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CHRISTUS Health Plan
2020 Formulary
Revised: July 31, 2020
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN
MC1794
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Note to members:
When this drug list (formulary) refers to “we,” “us”, or “our,” it means CHRISTUS Health Plan. When it
refers to “plan” or “our plan,” it means CHRISTUS Health Plan.
This document includes a list of the drugs (formulary) for our plan, which is current as of formulary revision
date.
You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary,
pharmacy network, and/or copayments/coinsurance may change on January 1, 2021, and from time to time
during the year.
What is the CHRISTUS Health Plan Formulary?
A formulary is a list of covered drugs selected by CHRISTUS Health Plan in consultation with a team of
health care providers, which represents the prescription therapies believed to be a necessary part of a quality
treatment program. CHRISTUS Health Plan will generally cover the drugs listed in our formulary as long
as the drug is medically necessary, the prescription is filled at a CHRISTUS Health Plan network
pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please
review your Evidence of Coverage.
Can the Formulary (drug list) change?
Generally, if you are taking a drug on our 2020 formulary that was covered at the beginning of the year,
we will not discontinue or reduce coverage of the drug during the 2020 coverage year except when a new,
less expensive generic drug becomes available or when new adverse information about the safety or
effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our
formulary, will not affect members who are currently taking the drug. It will remain available at the same
cost sharing for those members taking it for the remainder of the coverage year. We feel it is important that
you have continued access for the remainder of the coverage year to the formulary drugs that were available
when you chose our plan, except for cases in which you can save additional money or we can ensure your
safety.
If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy
restrictions on a drug, we must notify affected members of the change at least 60 days before the change
becomes effective, or at the time the member requests a refill of the drug, at which time the member will
receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary
to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove
the drug from our formulary and provide notice to members who take the drug. The enclosed formulary
is current as of August 01, 2020. To get updated information about the drugs covered by CHRISTUS
Health Plan, please contact our Member Services at 1-844-282-3025 or for TTY users, 711 or visit christushealthplan.org.
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How do I use the Formulary? There are two ways to find your drug within the formulary:
By Medical Condition:
The drugs in this formulary are grouped into categories depending on the type of medical conditions
that they are used to treat. For example, drugs used to treat a heart condition are listed under the
category, CARDIOVASCULAR, HYPERTENSION/LIPIDS. If you know, what your drug is used for,
look for the category name in the list that begins on page 8. Then look under the category name for
your drug.
By Alphabetical Listing:
If you are not sure what category to look under, you should look for your drug in the Index that begins
on page 101. The Index provides an alphabetical list of all of the drugs included in this document. Both
brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next
to your drug, you will see the page number where you can find coverage information. Turn to the page
listed in the Index and find the name of your drug in the first column of the list.
What are generic drugs?
CHRISTUS Health Plan covers both brand name drugs and generic drugs. A generic drug is approved by
the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less
than brand name drugs.
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements and
limits may include:
Prior Authorization: CHRISTUS Health Plan requires you or your physician to get prior
authorization for certain drugs. This means that you will need to get approval from CHRISTUS
Health Plan before you fill your prescriptions. If you do not get approval, CHRISTUS Health Plan
may not cover the drug.
Quantity Limits: For certain drugs, CHRISTUS Health Plan limits the amount of the drug that
CHRISTUS Health Plan will cover. For example, CHRISTUS Health Plan provides 30 per 30
days per prescription for AFINITOR.
Step Therapy: In some cases, CHRISTUS Health Plan requires you to first try certain drugs to
treat your medical condition before we will cover another drug for that condition. For example,
if Drug A and Drug B both treat your medical condition, CHRISTUS Health Plan may not cover
Drug B unless you try Drug A first. If Drug A does not work for you, CHRISTUS Health Plan
will then cover Drug B.
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You can find out if your drug has any additional requirements or limits by looking in the formulary that
begins on page 9. You can also get more information about the restrictions applied to specific covered
drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and
step therapy restrictions. You may also ask us to send you a copy.
You can ask CHRISTUS Health Plan to make an exception to these restrictions or limits or for a list of
other, similar drugs that may treat your health condition. See the section in your Evidence of Coverage
“Prescription Drugs/Medications.”
What if my drug is not on the Formulary?
If your drug is not included in this formulary (list of covered drugs), you should first contact Member
Services and ask if your drug is covered.
If you learn that CHRISTUS Health Plan does not cover your drug, you have two options:
You can ask Member Services for a list of similar drugs that are covered by CHRISTUS Health
Plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar
drug that is covered by CHRISTUS Health Plan.
You can ask CHRISTUS Health Plan to make an exception and cover your drug. See below for
information about how to request an exception.
How do I request an exception to the mandatory CHRISTUS Health Plan Formulary?
You can ask CHRISTUS Health Plan to make an exception to our coverage rules. There are several types
of exceptions that you can ask us to make.
You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will
be covered at a pre-determined cost-sharing level, and you would not be able to ask us to
provide the drug at a lower cost-sharing level.
You can ask us to waive coverage restrictions or limits on your drug. For example, for certain
drugs, CHRISTUS Health Plan limits the amount of the drug that we will cover. If your drug has a
quantity limit, you can ask us to waive the limit and cover a greater amount.
Generally, CHRISTUS Health Plan will only approve your request for an exception if the alternative drugs
included on the plan’s formulary, or additional utilization restrictions would not be as effective in treating
your condition and/or would cause you to have adverse medical effects.
For requests for benefits that do not involve exceptions, the Plan will provide notice of its decision within
24 hours after receiving an expedited request or 72 hours after receiving a standard request. For requests
for benefits that involve exceptions, the adjudication timeframes do not begin until the member’s prescriber
submits his or her supporting statement to the Plan for review. For payment requests, including payment
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requests that involve exceptions, CHRISTUS Health Plan will provide written notice of its decision (and
make payment when appropriate) within 14 calendar days after receiving a request.
If CHRISTUS Health Plan coverage determination is unfavorable, the decision will contain the
information needed to file a request for appeal/ redetermination with the Plan.
What do I do before I can talk to my doctor about changing my drugs or requesting an
exception?
As a new or continuing member in our plan, you may be taking drugs that are not on our formulary. Or,
you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you
may need a prior authorization from us before you can fill your prescription. You should talk to your
doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception
so that we will cover the drug you take. While you talk to your doctor to determine the right course of
action for you, we may cover your drug in certain cases during the first 90 days you are a member of our
plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we
will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you
go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you
have been a member of the plan less than 90 days.
For more information
For more detailed information about your CHRISTUS Health Plan prescription drug coverage, please
review your Evidence of Coverage and other plan materials.
If you have questions about CHRISTUS Health Plan, please contact our Member Services at
1-844-282-3025 or for TTY users, 711 or visit christushealthplan.org.
CHRISTUS Health Plan Formulary
The formulary that begins on page 9 provides coverage information about some of the drugs covered
by CHRISTUS Health Plan. If you have trouble finding your drug in the list, turn to the Index that
begins on page 101.
The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g.,
ACCUPRIL) and generic drugs are listed in lower-case italics (e.g. furosemide).
The information in the Requirements/Limits column tells you if CHRISTUS Health Plan has any special
requirements for coverage of your drug.
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Below is a list of abbreviations and that may appear on the following pages in the
Requirements/Limits column that tells you if there are any special requirements for coverage of your
drug.
List of Abbreviations
1: Preferred Generic
2: Non-Preferred Generic
3: Preferred Brand
4: Non-Preferred Brand
5: Specialty
ACA: Affordable Care Act.
LA: Limited Availability. This prescription may be available only at certain pharmacies. For more
information, please call Customer Service.
OTC: Over the Counter. An OTC drug is a non-prescription drug.
PA : Prior Authorization. The Plan requires you or your physician to get prior authorization for certain
drugs. This means that you will need to get approval before you fill your prescriptions. If you don’t get
approval, we may not cover the drug.
QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover.
ST: Step Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical
condition before we will cover another drug for that condition. For example, if Drug A and Drug B both
treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not
work for you, we will then cover Drug B.
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Legend:
Copay Amount by Drug Tier: You will pay either a copay or coinsurance amount for drugs in tiers 1
through 4. You will pay a coinsurance for tier 5. The amount you pay per prescription for drugs in tiers 1
through 5 may vary each time you fill a prescription. The copay and coinsurance amounts depend on the
plan and metal level you selected. The chart below shows the range of copays or coinsurance you may
pay. For your specific copay and coinsurance amounts please refer to your Summary of Benefits or visit
our website at www.christushealthplan.org
Tier
Number
Tier Name Copay for a one-month supply filled at a network
pharmacy with standard cost-sharing
0 ACA Drugs* $0
1 (Preventive) Preferred Generic Drugs
$0 or
40% after deductible
2 Non-Preferred Generic Drugs
$3-$25 or
40% after deductible
3 Preferred Brand Drugs
$20 or
$35-$100 after deductible or
40% after deductible
4 Non-Preferred Drugs
45% coinsurance or
$75-$95 after deductible or
40-50% after deductible
5 Specialty Drugs
45% coinsurance or
40-50% after deductible
Under $100 - $
$100 - $250 - $$
$251 - $500 - $$$
$501 - $1000 - $$$$
Over $1000 - $$$$$
*Preventive drugs (e.g. statins, aspirin, folic acid, fluoride, iron supplements, smoking cessation products
and FDA-approved contraceptives for women) are available at a zero-dollar cost share if prescribed under
certain medical criteria by your doctor.
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Table of Contents
ANTI - INFECTIVES ....................................................................................................................................... 9
ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS .................................................................... 16
AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH ...................................................................... 19
CARDIOVASCULAR, HYPERTENSION & LIPIDS ................................................................................ 34
DERMATOLOGICALS/TOPICAL THERAPY ......................................................................................... 42
DIAGNOSTICS & MISCELLANEOUS AGENTS ..................................................................................... 52
EAR, NOSE & THROAT MEDICATIONS ................................................................................................. 54
ENDOCRINE/DIABETES ............................................................................................................................. 55
GASTROENTEROLOGY .............................................................................................................................. 65
IMMUNOLOGY, VACCINES & BIOTECHNOLOGY ............................................................................. 71
MUSCULOSKELETAL & RHEUMATOLOGY ........................................................................................ 74
OBSTETRICS & GYNECOLOGY ............................................................................................................... 76
OPHTHALMOLOGY..................................................................................................................................... 82
RESPIRATORY, ALLERGY, COUGH & COLD ...................................................................................... 87
UROLOGICALS ............................................................................................................................................. 92
VITAMINS, HEMATINICS & ELECTROLYTES..................................................................................... 93
Index ................................................................................................................................................................. 99
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
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Drug Name Drug
Tier
Requirements
/ Limits
ANTI - INFECTIVES
ANTIFUNGAL AGENTS
ANCOBON 4
clotrimazole mucous
membrane
2
CRESEMBA ORAL 3 PA
DIFLUCAN ORAL
SUSPENSION FOR
RECONSTITUTIO
N
4
DIFLUCAN ORAL
TABLET 100 MG,
200 MG, 50 MG
4
DIFLUCAN ORAL
TABLET 150 MG
4 QL
fluconazole oral
suspension for
reconstitution
2
fluconazole oral
tablet 100 mg, 200
mg, 50 mg
2
fluconazole oral
tablet 150 mg
2 QL
flucytosine 2
griseofulvin
microsize
2
griseofulvin
ultramicrosize
2
itraconazole oral
capsule
2 QL
itraconazole oral
solution
2
ketoconazole oral 2
NOXAFIL ORAL
SUSPENSION
3 PA
nystatin oral
suspension
2
Drug Name Drug
Tier
Requirements
/ Limits
nystatin oral tablet 2
ONMEL 4 QL
ORAVIG 4
posaconazole oral
tablet,delayed
release (dr/ec)
3 PA
SPORANOX ORAL
SOLUTION
4
SPORANOX
PULSEPAK
4 QL
terbinafine hcl oral 2
VFEND 4 PA
voriconazole oral 2 PA
ANTIVIRALS
abacavir 2
abacavir-lamivudine 2
abacavir-
lamivudine-
zidovudine
2
acyclovir oral
capsule
2
acyclovir oral
suspension 200 mg/5
ml
2
acyclovir oral tablet 2
adefovir 2
amantadine hcl 2
APTIVUS 3
APTIVUS (WITH
VITAMIN E)
3
atazanavir 2
BARACLUDE
ORAL SOLUTION
3
BIKTARVY 3
CIMDUO 3
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
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Drug Name Drug
Tier
Requirements
/ Limits
COMBIVIR 4
CRIXIVAN ORAL
CAPSULE 200 MG,
400 MG
3
DESCOVY 3
didanosine oral
capsule,delayed
release(dr/ec) 250
mg, 400 mg
2
DOVATO 3
EDURANT 3
efavirenz 2
EMTRIVA 3
entecavir 2
EPCLUSA 5 PA; QL
EPIVIR 4
EPIVIR HBV
ORAL SOLUTION
3
EPIVIR HBV
ORAL TABLET
4
EPZICOM 4
EVOTAZ 4
famciclovir 2 QL
FLUMADINE
ORAL TABLET
4
fosamprenavir 2
FUZEON
SUBCUTANEOUS
RECON SOLN
5
GENVOYA 3
HARVONI ORAL
TABLET
5 PA; QL
HEPSERA 4
INTELENCE 3
Drug Name Drug
Tier
Requirements
/ Limits
INVIRASE ORAL
TABLET
3
ISENTRESS 3
ISENTRESS HD 3
JULUCA 3
KALETRA ORAL
SOLUTION
4 QL
KALETRA ORAL
TABLET
3 QL
lamivudine 2
lamivudine-
zidovudine
2
LEXIVA ORAL
SUSPENSION
3
LEXIVA ORAL
TABLET
4
lopinavir-ritonavir 2 QL
nevirapine 2
NORVIR ORAL
POWDER IN
PACKET
3
NORVIR ORAL
SOLUTION
3
NORVIR ORAL
TABLET
4
ODEFSEY 3
oseltamivir 2 QL
PREVYMIS ORAL 3 QL
PREZISTA ORAL
SUSPENSION
3
PREZISTA ORAL
TABLET 150 MG,
600 MG, 75 MG,
800 MG
3
RELENZA
DISKHALER
4 QL
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
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Drug Name Drug
Tier
Requirements
/ Limits
RETROVIR ORAL
CAPSULE
4
RETROVIR ORAL
SYRUP
4
REYATAZ ORAL
CAPSULE 150 MG,
200 MG, 300 MG
4
REYATAZ ORAL
POWDER IN
PACKET
3
ribavirin inhalation 2
rimantadine 2
ritonavir 2
SELZENTRY 3
stavudine oral
capsule
2
SUSTIVA 4
SYMFI 3
SYMFI LO 3
SYMTUZA 3
TAMIFLU 4 QL
TEMIXYS 3
tenofovir disoproxil
fumarate
2
TIVICAY 3
TIVICAY PD 4
TRIUMEQ 3
TRIZIVIR 4
TRUVADA 3
TYBOST 4
valacyclovir 2 QL
VALCYTE 4
valganciclovir 2
VEMLIDY 3
Drug Name Drug
Tier
Requirements
/ Limits
VIEKIRA PAK 5 PA; QL
VIRACEPT ORAL
TABLET
3
VIRAMUNE 4
VIRAMUNE XR
ORAL TABLET
EXTENDED
RELEASE 24 HR
400 MG
4
VIRAZOLE 4
VIREAD ORAL
POWDER
3
VIREAD ORAL
TABLET 150 MG,
200 MG, 250 MG
3
VIREAD ORAL
TABLET 300 MG
4
VOSEVI 5 PA; QL
XOFLUZA 4 QL
ZEPATIER 5 PA; QL
ZIAGEN 4
zidovudine 2
ZOVIRAX ORAL
SUSPENSION
4
CEPHALOSPORINS
cefaclor oral capsule 2
cefaclor oral
suspension for
reconstitution 125
mg/5 ml, 250 mg/5
ml, 375 mg/5 ml
2
cefaclor oral tablet
extended release 12
hr
2
cefadroxil oral
capsule
2
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
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Drug Name Drug
Tier
Requirements
/ Limits
cefadroxil oral
suspension for
reconstitution 250
mg/5 ml, 500 mg/5
ml
2
cefadroxil oral tablet 2
cefdinir 2
cefditoren pivoxil 2
cefixime 2
cefpodoxime 2
cefprozil 2
cefuroxime axetil
oral tablet
2
cephalexin 2
KEFLEX ORAL
CAPSULE
4
SPECTRACEF
ORAL TABLET
400 MG
4
SUPRAX ORAL
CAPSULE
4
SUPRAX ORAL
SUSPENSION FOR
RECONSTITUTIO
N
4
SUPRAX ORAL
TABLET,CHEWAB
LE
4
ERYTHROMYCINS & OTHER
MACROLIDES
azithromycin oral 2 QL
clarithromycin 2
DIFICID 4 QL
e.e.s. 400 oral tablet 2
E.E.S. GRANULES 4
ERYPED 200 4
Drug Name Drug
Tier
Requirements
/ Limits
ERYPED 400 4
ery-tab oral
tablet,delayed
release (dr/ec) 250
mg, 333 mg
2
ERY-TAB ORAL
TABLET,DELAYE
D RELEASE
(DR/EC) 500 MG
4
erythrocin (as
stearate) oral tablet
250 mg
2
erythromycin
ethylsuccinate oral
suspension for
reconstitution
2
erythromycin
ethylsuccinate oral
tablet
2
erythromycin oral 2
ZITHROMAX
ORAL PACKET
4 QL
ZITHROMAX
ORAL
SUSPENSION FOR
RECONSTITUTIO
N
4 QL
ZITHROMAX
ORAL TABLET
250 MG, 500 MG
4 QL
ZITHROMAX TRI-
PAK
4 QL
ZITHROMAX Z-
PAK
4 QL
MISCELLANEOUS
ANTIINFECTIVES
AEMCOLO 4 QL
albendazole 2
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
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Drug Name Drug
Tier
Requirements
/ Limits
ALBENZA 4 QL
ALINIA 3 QL
ARAKODA 4 QL
ARIKAYCE 5 PA
atovaquone 2
atovaquone-
proguanil
1 QL
BENZNIDAZOLE 3 QL
BETHKIS 5 PA; QL
BILTRICIDE 4
CAYSTON 5 LA; QL
chloroquine
phosphate
1 QL
CLEOCIN HCL 4
CLEOCIN
PEDIATRIC
4
clindamycin hcl 2
clindamycin
palmitate hcl
2
clindamycin
pediatric
2
COARTEM 3 QL
CYCLOSERINE 4
dapsone oral 2
DARAPRIM 5 PA
EMVERM 3 QL
ethambutol 2
FLAGYL 4
hydroxychloroquine 2 QL
IMPAVIDO 3 QL
isoniazid oral 2
ivermectin oral 2 QL
KITABIS PAK 5 PA; QL
Drug Name Drug
Tier
Requirements
/ Limits
KRINTAFEL 4 QL
linezolid 2 PA
MALARONE 4 QL
MALARONE
PEDIATRIC
4 QL
mefloquine 1 QL
MEPRON 4
metronidazole oral 2
MYAMBUTOL
ORAL TABLET
400 MG
4
MYCOBUTIN 4
NEBUPENT 4 QL
neomycin 2
paromomycin 2
PASER 4
pentamidine
inhalation
2 QL
praziquantel 2
PRETOMANID 4 PA
PRIFTIN 3
primaquine 1 QL
pyrazinamide 2
pyrimethamine 5 PA
QUALAQUIN 4 QL
quinine sulfate 2 QL
rifabutin 2
RIFADIN ORAL 4
RIFAMATE 4
rifampin oral 2
RIFATER 4
SIRTURO 3 PA; LA
SIVEXTRO ORAL 4 PA
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
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Drug Name Drug
Tier
Requirements
/ Limits
SOLOSEC 3 QL
STROMECTOL 4 QL
tinidazole 2 QL
TOBI PODHALER
INHALATION
CAPSULE,
W/INHALATION
DEVICE
5 PA; QL
tobramycin in 0.225
% nacl
5 PA; QL
TOBRAMYCIN
WITH NEBULIZER
5 PA; QL
TRECATOR 4
XENLETA ORAL 4
XIFAXAN ORAL
TABLET 550 MG
3 QL
ZYVOX ORAL 4 PA
PENICILLINS
amoxicillin oral
capsule
2
amoxicillin oral
suspension for
reconstitution
2
amoxicillin oral
tablet
2
amoxicillin oral
tablet,chewable 125
mg, 250 mg
2
amoxicillin-pot
clavulanate
2
ampicillin oral
capsule
2
AUGMENTIN ES-
600
4
Drug Name Drug
Tier
Requirements
/ Limits
AUGMENTIN
ORAL
SUSPENSION FOR
RECONSTITUTIO
N 125-31.25 MG/5
ML
3
AUGMENTIN
ORAL
SUSPENSION FOR
RECONSTITUTIO
N 250-62.5 MG/5
ML
4
AUGMENTIN
ORAL TABLET
500-125 MG, 875-
125 MG
4
AUGMENTIN XR 4
dicloxacillin 2
MOXATAG 4
penicillin v
potassium
2
QUINOLONES
BAXDELA ORAL 3 QL
CIPRO ORAL
SUSPENSION,MIC
ROCAPSULE
RECON
4
CIPRO ORAL
TABLET 250 MG,
500 MG
4
ciprofloxacin 2
ciprofloxacin hcl
oral
2
FACTIVE 4
LEVAQUIN ORAL
TABLET 500 MG,
750 MG
4
levofloxacin oral 2
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
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Drug Name Drug
Tier
Requirements
/ Limits
moxifloxacin oral 2
ofloxacin oral tablet
300 mg, 400 mg
2
SULFA'S & RELATED AGENTS
BACTRIM 4
BACTRIM DS 4
sulfadiazine 2
sulfamethoxazole-
trimethoprim oral
2
sulfatrim 2
TETRACYCLINES
ACTICLATE 4 ST
avidoxy 2
AVIDOXY DK 4 ST
coremino 2
demeclocycline 2
DORYX MPC 4 ST
DORYX ORAL
TABLET,DELAYE
D RELEASE
(DR/EC) 200 MG,
50 MG
4 ST
doxycycline hyclate
oral capsule
2
doxycycline hyclate
oral tablet
2
doxycycline hyclate
oral tablet,delayed
release (dr/ec) 100
mg, 150 mg, 200 mg,
50 mg, 75 mg
2
doxycycline
monohydrate oral
capsule
2
Drug Name Drug
Tier
Requirements
/ Limits
doxycycline
monohydrate oral
suspension for
reconstitution
2
doxycycline
monohydrate oral
tablet
2
minocycline oral
capsule
2
minocycline oral
tablet
2
minocycline oral
tablet extended
release 24 hr
2 ST
MINOLIRA ER 4 ST
mondoxyne nl oral
capsule 100 mg, 75
mg
2
MONODOX 4 ST
MORGIDOX 1X 50 4 ST
MORGIDOX 2X100 4 ST
morgidox oral
capsule 100 mg
2
ORACEA 3 ST
SEYSARA 4 PA
SOLODYN ORAL
TABLET
EXTENDED
RELEASE 24 HR
105 MG, 115 MG,
55 MG, 65 MG, 80
MG
4 ST
TARGADOX 4 ST
tetracycline 2
VIBRAMYCIN
ORAL CAPSULE
100 MG
4 ST
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
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Drug Name Drug
Tier
Requirements
/ Limits
VIBRAMYCIN
ORAL
SUSPENSION FOR
RECONSTITUTIO
N
4
VIBRAMYCIN
ORAL SYRUP
4
URINARY TRACT AGENTS
FURADANTIN 4
HIPREX 4
MACROBID 4
MACRODANTIN 4
methenamine
hippurate
2
methenamine
mandelate
2
MONUROL 4
nitrofurantoin 2
nitrofurantoin
macrocrystal
2
nitrofurantoin
monohyd/m-cryst
2
PRIMSOL 4
trimethoprim 2
VANCOMYCIN
FIRVANQ 4 QL
VANCOCIN 4 QL
vancomycin oral
capsule
2 QL
vancomycin oral
recon soln
2 QL
ANTINEOPLASTIC &
IMMUNOSUPPRESSANT
DRUGS
ADJUNCTIVE AGENTS
Drug Name Drug
Tier
Requirements
/ Limits
leucovorin calcium
oral
2
MESNEX ORAL 3
VISTOGARD 5 PA
XGEVA 5 PA
ANTINEOPLASTIC &
IMMUNOSUPPRESSANT DRUGS
abiraterone 5 PA; QL
AFINITOR 5 PA; QL
AFINITOR
DISPERZ
5 PA
ALKERAN 4
ALUNBRIG 5 PA; QL
anastrozole 2
AROMASIN 4
ASTAGRAF XL 4 ST
AYVAKIT 5 PA; LA; QL
AZASAN 4
azathioprine 2
BALVERSA 5 PA; LA
bexarotene 5 PA
bicalutamide 2
BOSULIF 5 PA; QL
BRAFTOVI 5 PA; QL
BRUKINSA 5 PA
CABOMETYX
ORAL TABLET 20
MG
5 PA; LA; QL
CABOMETYX
ORAL TABLET 40
MG, 60 MG
5 PA; LA
CALQUENCE 5 PA; LA; QL
capecitabine 5
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
17
Drug Name Drug
Tier
Requirements
/ Limits
CAPRELSA 5 PA; LA; QL
CASODEX 4
CELLCEPT 4
COMETRIQ 5 PA
COPIKTRA 5 PA; LA; QL
COTELLIC 5 PA; LA; QL
cyclophosphamide
oral capsule
2
cyclosporine
modified
2
cyclosporine oral
capsule
2
DAURISMO 5 PA; QL
DROXIA 3
ELIGARD 5 PA
ELIGARD (3
MONTH)
5 PA
ELIGARD (4
MONTH)
5 PA
ELIGARD (6
MONTH)
5 PA
EMCYT 3
ENVARSUS XR 4 ST
ERIVEDGE 5 PA; QL
ERLEADA 5 PA
erlotinib 5 PA; QL
etoposide oral 2
everolimus
(antineoplastic)
5 PA
everolimus
(immunosuppressive
)
2
exemestane 2
FARESTON 4
Drug Name Drug
Tier
Requirements
/ Limits
FARYDAK 5 PA; QL
FEMARA 4
flutamide 2
gengraf oral capsule
100 mg, 25 mg
2
gengraf oral solution 2
GILOTRIF 5 PA; QL
GLEOSTINE ORAL
CAPSULE 10 MG,
100 MG, 40 MG
3
GLIADEL WAFER 4
HYCAMTIN ORAL 5 PA
HYDREA 4
hydroxyurea 2
IBRANCE 5 PA; QL
ICLUSIG 5 PA; QL
IDHIFA 5 PA; LA; QL
imatinib 5 PA; QL
IMBRUVICA 5 PA; QL
IMURAN 4
INLYTA 5 PA; QL
IRESSA 5 PA; QL
JAKAFI 5 PA; QL
JELMYTO 5 PA
KOSELUGO 5 PA
LENVIMA 5 PA
letrozole 2
LEUKERAN 3
leuprolide
subcutaneous kit
5 PA
LONSURF 5 PA
LORBRENA 5 PA; QL
LUPRON DEPOT 5 PA
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
18
Drug Name Drug
Tier
Requirements
/ Limits
LUPRON DEPOT
(3 MONTH)
5 PA
LUPRON DEPOT
(4 MONTH)
5 PA
LUPRON DEPOT
(6 MONTH)
5 PA
LUPRON DEPOT-
PED
5 PA
LUPRON DEPOT-
PED (3 MONTH)
5 PA
LYNPARZA ORAL
TABLET
5 PA; QL
LYSODREN 3
MATULANE 5
megestrol oral
suspension 400
mg/10 ml (40
mg/ml), 625 mg/5 ml
(125 mg/ml)
2
megestrol oral tablet 2
MEKINIST 5 PA; QL
MEKTOVI 5 PA; QL
melphalan 2
mercaptopurine 2
methotrexate sodium 2
methotrexate sodium
(pf)
2
mycophenolate
mofetil
2
mycophenolate
sodium
2
MYFORTIC 4
MYLERAN 3
NEORAL 4
NERLYNX 5 PA; LA
Drug Name Drug
Tier
Requirements
/ Limits
NEXAVAR 5 PA; LA; QL
NILANDRON 4 PA
nilutamide 2 PA
NINLARO 5 PA; QL
NUBEQA 5 PA; LA
octreotide acetate 5
ODOMZO 5 PA; LA; QL
PEMAZYRE 5 PA; LA; QL
PROGRAF ORAL
CAPSULE
4
PROGRAF ORAL
GRANULES IN
PACKET
3
PURIXAN 5
RAPAMUNE 4
ROZLYTREK 5 PA; LA; QL
RUBRACA 5 PA; LA; QL
RYDAPT 5 PA
SANDIMMUNE
ORAL CAPSULE
4
SANDIMMUNE
ORAL SOLUTION
3
SANDOSTATIN
INJECTION
SOLUTION 100
MCG/ML, 50
MCG/ML, 500
MCG/ML
5
SIGNIFOR 5 PA
sirolimus 2
SOLTAMOX 4 ACA
SOMATULINE
DEPOT
5 PA
SPRYCEL 5 PA; QL
STIVARGA 5 PA; QL
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
19
Drug Name Drug
Tier
Requirements
/ Limits
SUPPRELIN LA 5 PA
SUTENT 5 PA; QL
SYNRIBO 5 PA
TABLOID 4
tacrolimus oral 2
TAFINLAR 5 PA; QL
TAGRISSO 5 PA; LA; QL
TALZENNA 5 PA; QL
tamoxifen 2 ACA
TARCEVA 5 PA; QL
TARGRETIN
TOPICAL
5 PA
TASIGNA 5 PA; QL
TAZVERIK 5 PA
TEMODAR ORAL 5 PA
temozolomide 5 PA
THALOMID 5 PA
TIBSOVO 5 PA
toremifene 2
tretinoin
(antineoplastic)
2
TREXALL 4
TUKYSA 5 PA; QL
TURALIO 5 PA; LA; QL
TYKERB 5 PA; LA; QL
VANTAS 5 PA
VENCLEXTA
ORAL TABLET 10
MG, 50 MG
5 PA
VENCLEXTA
ORAL TABLET
100 MG
5 PA; LA
Drug Name Drug
Tier
Requirements
/ Limits
VENCLEXTA
STARTING PACK
5 PA; QL
VERZENIO 5 PA; LA; QL
VITRAKVI 5 PA; LA
VIZIMPRO 5 PA; QL
VOTRIENT 5 PA; QL
XALKORI 5 PA; QL
XELODA 5
XERMELO 5 PA; QL
XOSPATA 5 PA; LA
XTANDI 5 PA; QL
YONSA 5 PA; QL
ZEJULA 5 PA; LA; QL
ZELBORAF 5 PA; QL
ZOLINZA 5 PA
ZORTRESS ORAL
TABLET 0.25 MG,
0.5 MG, 0.75 MG
4
ZORTRESS ORAL
TABLET 1 MG
3
ZYDELIG 5 PA; QL
ZYKADIA ORAL
TABLET
5 PA; QL
ZYTIGA ORAL
TABLET 500 MG
5 PA; QL
AUTONOMIC & CNS DRUGS,
NEUROLOGY & PSYCH
ANTICONVULSANTS
APTIOM 4
BANZEL 3 PA
BRIVIACT ORAL
SOLUTION
4 ST
BRIVIACT ORAL
TABLET 10 MG
4
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
20
Drug Name Drug
Tier
Requirements
/ Limits
BRIVIACT ORAL
TABLET 100 MG,
25 MG, 50 MG, 75
MG
4 ST
carbamazepine oral
capsule, er
multiphase 12 hr
2
carbamazepine oral
suspension 100 mg/5
ml
2
carbamazepine oral
tablet
2
carbamazepine oral
tablet extended
release 12 hr
2
carbamazepine oral
tablet,chewable
2
CARBATROL 4
CELONTIN ORAL
CAPSULE 300 MG
3
clobazam 1 PA
clonazepam 2
DEPAKOTE 4 ST
DEPAKOTE ER 4 ST
DEPAKOTE
SPRINKLES
4 ST
DIACOMIT 5 PA
DIASTAT 4
DIASTAT
ACUDIAL
4
diazepam rectal 2
DILANTIN 3
DILANTIN
EXTENDED
4
DILANTIN
INFATABS
4
Drug Name Drug
Tier
Requirements
/ Limits
DILANTIN-125 4
divalproex 2
EPIDIOLEX 5 PA
epitol 2
EQUETRO 4
ethosuximide 2
felbamate 2
FELBATOL 4
FYCOMPA ORAL
SUSPENSION
3
FYCOMPA ORAL
TABLET
3
gabapentin oral
capsule
2
gabapentin oral
solution 250 mg/5
ml, 300 mg/6 ml (6
ml)
2
gabapentin oral
tablet 600 mg, 800
mg
2
GABITRIL 4
GRALISE 4 ST
GRALISE 30-DAY
STARTER PACK
4 ST
KLONOPIN 4
LAMICTAL XR
STARTER (BLUE)
4 ST
LAMICTAL XR
STARTER
(GREEN)
4 ST
LAMICTAL XR
STARTER
(ORANGE)
4 ST
lamotrigine 2
levetiracetam oral 2
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
21
Drug Name Drug
Tier
Requirements
/ Limits
MYSOLINE 4
NAYZILAM 3 PA; QL
ONFI ORAL
SUSPENSION
4 PA
ONFI ORAL
TABLET 10 MG, 20
MG
4 PA
oxcarbazepine 2
OXTELLAR XR 4 ST
PEGANONE 3
phenobarbital 2
PHENYTEK 4
phenytoin oral
suspension
2
phenytoin oral
tablet,chewable
2
phenytoin sodium
extended
2
pregabalin 2
primidone 2
QUDEXY XR 3 ST
roweepra 2
roweepra xr 2
SABRIL 5 PA; LA
SPRITAM 4 ST
subvenite 2
subvenite starter
(blue) kit
2
subvenite starter
(green) kit
2
subvenite starter
(orange) kit
2
SYMPAZAN 4 PA
Drug Name Drug
Tier
Requirements
/ Limits
TEGRETOL ORAL
SUSPENSION
4
TEGRETOL ORAL
TABLET
4
TEGRETOL XR 4
tiagabine 2
topiramate oral
capsule, sprinkle
2
topiramate oral
tablet
2
TROKENDI XR 4 ST
valproic acid 2
valproic acid (as
sodium salt) oral
solution 250 mg/5
ml, 500 mg/10 ml
(10 ml)
2
VALTOCO 4 QL
vigabatrin 5 PA; LA
vigadrone 5 PA
VIMPAT ORAL
SOLUTION
3
VIMPAT ORAL
TABLET
3
XCOPRI 4 QL
XCOPRI
MAINTENANCE
PACK
4 QL
XCOPRI
TITRATION PACK
4 QL
ZARONTIN 4
zonisamide 2
ANTIPARKINSONISM AGENTS
APOKYN 5 LA
AZILECT 4 ST
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
22
Drug Name Drug
Tier
Requirements
/ Limits
benztropine oral 2
bromocriptine 2
carbidopa 2
carbidopa-levodopa 2
carbidopa-levodopa-
entacapone
2
COMTAN 4
DUOPA 5
entacapone 2
INBRIJA
INHALATION
CAPSULE,
W/INHALATION
DEVICE
5 PA
LODOSYN 4
MIRAPEX 4
MIRAPEX ER 4
NEUPRO 4
NOURIANZ 5 PA; LA; QL
PARLODEL 4
pramipexole 2
rasagiline 2
REQUIP ORAL
TABLET 0.25 MG,
3 MG, 5 MG
4
REQUIP XL ORAL
TABLET
EXTENDED
RELEASE 24 HR
12 MG, 2 MG, 6
MG
4
ropinirole 2
RYTARY 4
selegiline hcl 2
SINEMET 4
Drug Name Drug
Tier
Requirements
/ Limits
STALEVO 100 4
STALEVO 125 4
STALEVO 150 4
STALEVO 200 4
STALEVO 50 4
STALEVO 75 4
TASMAR ORAL
TABLET 100 MG
4
tolcapone 2
trihexyphenidyl 2
MIGRAINE & CLUSTER
HEADACHE THERAPY
AIMOVIG
AUTOINJECTOR
3 PA; QL
AJOVY
AUTOINJECTOR
3 PA
AJOVY SYRINGE 3 PA; QL
almotriptan malate 2 QL
AMERGE 4 ST; QL
CAFERGOT 4
D.H.E.45 4
dihydroergotamine
injection
2
dihydroergotamine
nasal
2 ST; QL
eletriptan 2 QL
EMGALITY PEN 3 PA; QL
EMGALITY
SYRINGE
3 PA; QL
ERGOMAR 4
ergotamine-caffeine 2
FROVA 4 ST
frovatriptan 2 QL
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
23
Drug Name Drug
Tier
Requirements
/ Limits
migergot 2
MIGRANAL 4 ST; QL
naratriptan 2 QL
NURTEC ODT 4 PA; QL
ONZETRA XSAIL 4 ST; QL
RELPAX 4 ST; QL
REYVOW 4 PA; QL
rizatriptan 2 QL
sumatriptan 2 QL
sumatriptan
succinate oral
2 QL
sumatriptan
succinate
subcutaneous
cartridge
2 QL
sumatriptan
succinate
subcutaneous pen
injector
2 QL
sumatriptan
succinate
subcutaneous
solution
2 QL
sumatriptan
succinate
subcutaneous
syringe 6 mg/0.5 ml
1 QL
sumatriptan-
naproxen
2 ST; QL
TOSYMRA 4 ST; QL
UBRELVY 4 PA; QL
ZEMBRACE
SYMTOUCH
4 ST; QL
zolmitriptan 2 QL
ZOMIG NASAL 3 ST; QL
Drug Name Drug
Tier
Requirements
/ Limits
MISCELLANEOUS
NEUROLOGICAL THERAPY
ARICEPT 4 ST
AUSTEDO 5 PA; LA; QL
dalfampridine 5 PA
donepezil oral tablet
10 mg, 5 mg
2
donepezil oral tablet
23 mg
2 ST
donepezil oral
tablet,disintegrating
2
EXELON
TRANSDERMAL
4 ST
FIRDAPSE 5 PA; LA
galantamine 2
HORIZANT 4 ST
KEVEYIS 5 PA
memantine oral
capsule,sprinkle,er
24hr
2
memantine oral
solution
2
memantine oral
tablet
2
MEMANTINE
ORAL
TABLETS,DOSE
PACK
4
NAMENDA ORAL
TABLET
4 ST
NAMENDA
TITRATION PAK
4
NAMENDA XR
ORAL
CAP,SPRINKLE,ER
24HR DOSE PACK
4
NAMZARIC 3 ST
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
24
Drug Name Drug
Tier
Requirements
/ Limits
NUEDEXTA 3 PA
RAZADYNE ER 4 ST
RAZADYNE ORAL
TABLET
4 ST
rivastigmine 2
rivastigmine tartrate 2
RUZURGI 5 PA
TEGSEDI 5 PA; LA
tetrabenazine 5 PA; QL
MUSCLE RELAXANTS &
ANTISPASMODIC THERAPY
baclofen oral tablet
10 mg, 20 mg
2
BACLOFEN ORAL
TABLET 5 MG
4
carisoprodol 2
carisoprodol-aspirin 2
carisoprodol-
aspirin-codeine
2
chlorzoxazone 2
cyclobenzaprine 2
DANTRIUM ORAL
CAPSULE 25 MG,
50 MG
4
dantrolene oral 2
FEXMID 4 ST
LORZONE 4 ST
meprobamate 2
MESTINON ORAL 4
MESTINON
TIMESPAN
4
metaxall 2
metaxalone 2
methocarbamol oral 2
Drug Name Drug
Tier
Requirements
/ Limits
NORGESIC FORTE 4
orphenadrine citrate
oral
2
pyridostigmine
bromide oral syrup
2
PYRIDOSTIGMINE
BROMIDE ORAL
TABLET 30 MG
4
pyridostigmine
bromide oral tablet
60 mg
2
pyridostigmine
bromide oral tablet
extended release
2
ROBAXIN-750 4
SKELAXIN 4
SOMA 4
tizanidine 2
vanadom 2
ZANAFLEX 4
NARCOTIC ANALGESICS
acetaminophen-caff-
dihydrocod oral
capsule
2
acetaminophen-caff-
dihydrocod oral
tablet 325-30-16 mg
2 ST
acetaminophen-
codeine oral solution
120-12 mg/5 ml, 300
mg-30 mg /12.5 ml
2
acetaminophen-
codeine oral tablet
2
ACTIQ 4 PA; QL
ALLZITAL 4 ST
ARYMO ER 4 ST; QL
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
25
Drug Name Drug
Tier
Requirements
/ Limits
ascomp with codeine 2
BELBUCA
BUCCAL FILM 150
MCG, 450 MCG,
750 MCG, 900
MCG
3 PA; QL
BELBUCA
BUCCAL FILM 300
MCG, 600 MCG, 75
MCG
3 ST; QL
buprenorphine 2 ST
buprenorphine hcl
sublingual
2
butalbital compound
w/codeine
2
butalbital-
acetaminop-caf-cod
2
butalbital-
acetaminophen
2
butalbital-
acetaminophen-caff
oral capsule
2
butalbital-
acetaminophen-caff
oral tablet 50-325-
40 mg
2
butalbital-aspirin-
caffeine
2
codeine sulfate oral
tablet
2
codeine-butalbital-
asa-caff
2 ST
DEMEROL ORAL
TABLET 100 MG
4
DILAUDID 4
diskets 2 PA
DOLOPHINE
ORAL
4 PA
Drug Name Drug
Tier
Requirements
/ Limits
DSUVIA 4
DURAGESIC 4 PA; ST; QL
dvorah 1 ST
endocet oral tablet
10-325 mg, 2.5-325
mg, 5-325 mg, 7.5-
325 mg
2
ESGIC 4 ST
fentanyl 2 PA; ST; QL
fentanyl citrate
buccal lozenge on a
handle
2 PA; QL
FIORICET ORAL
CAPSULE
4 ST
FIORICET WITH
CODEINE ORAL
CAPSULE 50-300-
40-30 MG
4 ST
FIORINAL 4 ST
FIORINAL-
CODEINE #3
4 ST
hydrocodone
bitartrate
2 ST; QL
hydrocodone-
acetaminophen oral
solution 10-325
mg/15 ml(15 ml)
1 ST
hydrocodone-
acetaminophen oral
solution 7.5-325
mg/15 ml
2 ST
hydrocodone-
acetaminophen oral
tablet 10-300 mg,
10-325 mg, 5-300
mg, 5-325 mg, 7.5-
300 mg, 7.5-325 mg
2
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
26
Drug Name Drug
Tier
Requirements
/ Limits
hydrocodone-
ibuprofen oral tablet
10-200 mg, 5-200
mg, 7.5-200 mg
2
hydromorphone oral
liquid
2
hydromorphone oral
tablet
2
hydromorphone oral
tablet extended
release 24 hr
2 PA; QL
hydromorphone
rectal
2
HYSINGLA ER 3 ST; QL
ibuprofen-oxycodone 2
KADIAN ORAL
CAPSULE,EXTEN
D.RELEASE
PELLETS 10 MG,
100 MG, 20 MG,
200 MG, 30 MG, 40
MG, 50 MG, 60
MG, 80 MG
4 ST; QL
levorphanol tartrate
oral tablet 2 mg
2
LEVORPHANOL
TARTRATE ORAL
TABLET 3 MG
4 ST
lorcet (hydrocodone) 2
lorcet hd 2
LORTAB ELIXIR
ORAL SOLUTION
10-300 MG/15 ML
4
meperidine oral 2
methadone oral
concentrate
2 PA
methadone oral
solution
2 PA
Drug Name Drug
Tier
Requirements
/ Limits
methadone oral
tablet
2 PA
methadone oral
tablet,soluble
2 PA
methadose oral
concentrate
2 PA
methadose oral
tablet,soluble
2 PA
morphine
concentrate oral
solution
2
morphine oral
capsule, er
multiphase 24 hr
2 PA; QL
morphine oral
capsule,extend.relea
se pellets
2 PA; QL
morphine oral
solution
2
morphine oral tablet 2
morphine oral tablet
extended release
2 PA; QL
morphine rectal 2
MS CONTIN 4 PA; QL
NALOCET 4
OXAYDO 4
oxycodone oral
capsule
2
oxycodone oral
concentrate
2
oxycodone oral
solution
2
oxycodone oral
tablet
2
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
27
Drug Name Drug
Tier
Requirements
/ Limits
oxycodone-
acetaminophen oral
tablet 10-325 mg,
2.5-325 mg, 5-325
mg, 7.5-325 mg
2
oxycodone-
acetaminophen oral
tablet 2.5-300 mg
2 ST
oxycodone-aspirin 2
OXYCONTIN
ORAL
TABLET,ORAL
ONLY,EXT.REL.12
HR
3 ST; QL
oxymorphone oral
tablet
2
oxymorphone oral
tablet extended
release 12 hr
2 PA; ST; QL
prolate 2 ST
ROXICODONE 4
tencon oral tablet
50-325 mg
2
TREZIX ORAL
CAPSULE 320.5-
30-16 MG
4
TYLENOL-
CODEINE #3
4
VANATOL LQ 4 ST
VANATOL S 4 ST
vtol lq 2
zebutal oral capsule
50-325-40 mg
2
ZOHYDRO ER
ORAL CAPSULE,
ORAL ONLY, ER
12HR
4 ST; QL
NON-NARCOTIC ANALGESICS
Drug Name Drug
Tier
Requirements
/ Limits
adult aspirin
regimen
1 ACA; OTC
ANAPROX DS 4 ST
ARTHROTEC 50 4 ST
ARTHROTEC 75 4 ST
aspir-81 1 ACA; OTC
aspirin low dose 1 ACA; OTC
aspirin oral tablet 1 ACA; OTC
aspirin oral
tablet,chewable
1 ACA; OTC
aspirin oral
tablet,delayed
release (dr/ec) 325
mg, 81 mg
1 ACA; OTC
aspir-trin 1 ACA; OTC
bayer aspirin 1 ACA; OTC
buprenorphine-
naloxone sublingual
tablet
2 QL
butorphanol tartrate
injection
2
butorphanol tartrate
nasal
2 QL
CAMBIA 4 ST; QL
celecoxib 2 ST
children's aspirin 1 ACA; OTC
choline,magnesium
salicylate
2
CONZIP 4 ST; QL
DAYPRO 4 ST
diclofenac potassium 2
diclofenac sodium
oral
2
diclofenac sodium
topical drops
2 QL
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
28
Drug Name Drug
Tier
Requirements
/ Limits
diclofenac sodium
topical gel 1 %
2 ST; QL
diclofenac-
misoprostol
2
diflunisal 2
DISALCID 4
DUEXIS 4 ST
e.c. prin 1 ACA; OTC
EC-NAPROSYN 4 ST
ecotrin 1 ACA; OTC
ecotrin low strength 1 ACA; OTC
etodolac 2
FELDENE 4 ST
fenoprofen oral
tablet
2 ST
FLECTOR 3 ST; QL
flurbiprofen oral
tablet 100 mg
2
ibu 2
ibuprofen oral
suspension
2
ibuprofen oral tablet
400 mg, 600 mg, 800
mg
2
INDOCIN RECTAL 4
indomethacin oral 2
ketoprofen oral
capsule 25 mg
2 ST
ketoprofen oral
capsule 50 mg, 75
mg
2
ketoprofen oral
capsule,ext rel.
pellets 24 hr 200 mg
2 ST
ketorolac oral 2 QL
Drug Name Drug
Tier
Requirements
/ Limits
lite coat aspirin 1 ACA; OTC
LODINE ORAL
TABLET
4 ST
meclofenamate 2
mefenamic acid 2
meloxicam oral
tablet 15 mg
2
meloxicam oral
tablet 7.5 mg
2 QL
MOBIC ORAL
TABLET 15 MG
4 ST
MOBIC ORAL
TABLET 7.5 MG
4 ST; QL
nabumetone 2
NALFON ORAL
TABLET
4 ST
naloxone injection
solution
2
naloxone injection
syringe
2
naltrexone 2
NAPRELAN CR 4 ST
NAPROSYN ORAL
SUSPENSION
4 ST
NAPROSYN ORAL
TABLET 500 MG
4 ST
naproxen oral
suspension
2 ST
naproxen oral tablet 2
naproxen oral
tablet,delayed
release (dr/ec)
2
naproxen sodium
oral tablet 275 mg,
550 mg
2
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
29
Drug Name Drug
Tier
Requirements
/ Limits
naproxen sodium
oral tablet, er
multiphase 24 hr
1 ST
naproxen-
esomeprazole
2 ST
NARCAN NASAL
SPRAY,NON-
AEROSOL 4
MG/ACTUATION
3 QL
NUCYNTA 3 QL
NUCYNTA ER 3 PA; QL
oxaprozin 2
pentazocine-
naloxone
2
piroxicam 2
salsalate 2
SPRIX 5 ST; QL
st joseph aspirin 1 ACA; OTC
st. joseph aspirin 1 ACA; OTC
sulindac 2
tolmetin oral capsule 2 ST
tolmetin oral tablet
200 mg
2
tolmetin oral tablet
600 mg
2 ST
TRAMADOL
ORAL
CAPSULE,ER
BIPHASE 24 HR
17-83
4 ST; QL
TRAMADOL
ORAL
CAPSULE,ER
BIPHASE 24 HR
25-75
4 ST; QL
Drug Name Drug
Tier
Requirements
/ Limits
TRAMADOL
ORAL TABLET
100 MG
4 ST
tramadol oral tablet
50 mg
2 QL
tramadol oral tablet
extended release 24
hr
2 PA; QL
tramadol oral tablet,
er multiphase 24 hr
2 ST; QL
tramadol-
acetaminophen
2 QL
ULTRACET 4 QL
ULTRAM 4 QL
VIMOVO 4 ST
VOLTAREN
TOPICAL
4 ST; QL
VOLTAREN-XR 4 ST
PSYCHOTHERAPEUTIC DRUGS
ABILIFY MYCITE 4 QL
ADASUVE 4
ADDERALL XR 4 PA; ST
ADDYI 4 PA
ADHANSIA XR 4 PA
ADZENYS ER 4 ST
ADZENYS XR-
ODT
4 ST
alprazolam 2
alprazolam intensol 2
amitriptyline 2
amitriptyline-
chlordiazepoxide
2
amoxapine 2
amphetamine sulfate 2 PA
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
30
Drug Name Drug
Tier
Requirements
/ Limits
ANAFRANIL 4
APLENZIN 4 ST; QL
APTENSIO XR 4 PA; ST
aripiprazole oral
solution
2
aripiprazole oral
tablet
2 QL
aripiprazole oral
tablet,disintegrating
2 QL
armodafinil 2 ST; QL
ATIVAN ORAL 4
atomoxetine 2 PA
BELSOMRA 4 ST; QL
bupropion hcl oral
tablet
2
bupropion hcl oral
tablet extended
release 24 hr 150
mg, 300 mg
2 QL
BUPROPION HCL
ORAL TABLET
EXTENDED
RELEASE 24 HR
450 MG
4 ST
bupropion hcl oral
tablet sustained-
release 12 hr
2 QL
buspirone 2
chlordiazepoxide hcl 2
chlorpromazine oral 2
citalopram oral
solution
1
citalopram oral
tablet
1 QL
clomipramine 2
Drug Name Drug
Tier
Requirements
/ Limits
clonidine hcl oral
tablet extended
release 12 hr
2 PA
clorazepate
dipotassium
2
clozapine oral tablet 2
clozapine oral
tablet,disintegrating
100 mg, 12.5 mg, 25
mg
2
CLOZAPINE
ORAL
TABLET,DISINTE
GRATING 150 MG,
200 MG
4
CLOZARIL 4
CONCERTA 4 PA; ST
COTEMPLA XR-
ODT
4 ST
DAYTRANA 3 PA; ST
desipramine 2
DESOXYN 4 ST
DESVENLAFAXIN
E ORAL TABLET
EXTENDED
RELEASE 24 HR
4 ST; QL
desvenlafaxine
succinate
2 ST; QL
DEXEDRINE
SPANSULE ORAL
CAPSULE,
EXTENDED
RELEASE 10 MG, 5
MG
4 ST
DEXEDRINE
SPANSULE ORAL
CAPSULE,
EXTENDED
RELEASE 15 MG
4 PA; ST
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
31
Drug Name Drug
Tier
Requirements
/ Limits
dexmethylphenidate 2 PA
dextroamphetamine 2 PA
dextroamphetamine-
amphetamine
2 PA
diazepam intensol 2
diazepam oral
solution 5 mg/5 ml
(1 mg/ml)
2
diazepam oral tablet 2
doxepin oral capsule 2
doxepin oral
concentrate
2
doxepin oral tablet 2 QL
duloxetine oral
capsule,delayed
release(dr/ec) 20
mg, 30 mg, 60 mg
2 QL
duloxetine oral
capsule,delayed
release(dr/ec) 40 mg
2 ST; QL
DYANAVEL XR 3 PA; ST
EDLUAR 4 ST; QL
EMSAM 4
ergoloid 2
escitalopram oxalate
oral solution
1
escitalopram oxalate
oral tablet
1 QL
estazolam 2
eszopiclone 2 QL
EVEKEO 4 PA
EVEKEO ODT 4 PA
FANAPT 4 QL
FETZIMA 3 ST; QL
Drug Name Drug
Tier
Requirements
/ Limits
fluoxetine oral
capsule 10 mg, 40
mg
1 QL
fluoxetine oral
capsule 20 mg
1
fluoxetine oral
capsule,delayed
release(dr/ec)
1 QL
fluoxetine oral
solution
1
fluoxetine oral tablet
10 mg
1 PA; QL
fluoxetine oral tablet
20 mg, 60 mg
1 PA
fluphenazine hcl oral 2
flurazepam 2
fluvoxamine oral
capsule,extended
release 24hr
1 PA; QL
fluvoxamine oral
tablet
1 QL
FORFIVO XL 4 ST; QL
GEODON ORAL 4 QL
guanfacine oral
tablet extended
release 24 hr
2 PA
guanidine 2
HALCION ORAL
TABLET 0.25 MG
4
haloperidol 2
haloperidol lactate
oral
2
HETLIOZ 5 PA; QL
imipramine hcl 2
imipramine pamoate 2
INTERMEZZO 4 ST; QL
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
32
Drug Name Drug
Tier
Requirements
/ Limits
INVEGA 4 QL
JORNAY PM 4 ST
KAPVAY 4 PA
KETAMINE
SUBLINGUAL
4
LATUDA 3 QL
lithium carbonate 2
lithium citrate oral
solution 8 meq/5 ml
2
LITHOBID 4
lorazepam intensol 2
lorazepam oral 2
loxapine succinate 2
maprotiline 2
MARPLAN 4
metadate er 2 PA
methamphetamine 2 PA
METHYLIN ORAL
SOLUTION
4 PA
methylphenidate hcl
oral capsule, er
biphasic 30-70
2 PA
methylphenidate hcl
oral capsule,er
biphasic 50-50
2 PA
methylphenidate hcl
oral solution
2 PA
methylphenidate hcl
oral tablet
2 PA
methylphenidate hcl
oral tablet extended
release
2 PA
methylphenidate hcl
oral tablet extended
release 24hr 18 mg,
27 mg, 36 mg, 54 mg
2 PA
Drug Name Drug
Tier
Requirements
/ Limits
METHYLPHENID
ATE HCL ORAL
TABLET
EXTENDED
RELEASE 24HR 72
MG
4 ST
methylphenidate hcl
oral tablet,chewable
2 PA
midazolam oral
syrup 2 mg/ml
1
mirtazapine 2
MKO
(MIDAZOLAM-
KETAMINE-
ONDAN)
4
modafinil 2 ST; QL
molindone 1
MYDAYIS 3 ST
NARDIL 4
nefazodone 2
NORPRAMIN
ORAL TABLET 10
MG, 25 MG
4
nortriptyline 2
NUPLAZID ORAL
CAPSULE
5 PA; QL
NUPLAZID ORAL
TABLET 10 MG
5 PA; QL
olanzapine oral 2 QL
olanzapine-
fluoxetine
2
oxazepam 2
paliperidone 2 QL
PAMELOR 4
PARNATE 4
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
33
Drug Name Drug
Tier
Requirements
/ Limits
paroxetine hcl oral
tablet
1 QL
paroxetine hcl oral
tablet extended
release 24 hr
1 PA; QL
paroxetine
mesylate(menop.sym
)
2 PA; QL
PAXIL CR 4 ST; QL
PAXIL ORAL
SUSPENSION
4 ST
PAXIL ORAL
TABLET
4 ST; QL
perphenazine 2
perphenazine-
amitriptyline
2
PEXEVA 4 ST; QL
phenelzine 2
pimozide 2
procentra 2 PA
protriptyline 2
QUAZEPAM 4
quetiapine 2 QL
QUILLICHEW ER 3 ST
QUILLIVANT XR 3 PA; ST
ramelteon 2 QL
RELEXXII 4 PA
REMERON ORAL
TABLET 15 MG, 30
MG
4
REMERON
SOLTAB
4
RESTORIL 4
REXULTI 4 QL
Drug Name Drug
Tier
Requirements
/ Limits
RISPERDAL ORAL
SOLUTION
4
RISPERDAL ORAL
TABLET 0.5 MG, 1
MG, 2 MG, 3 MG, 4
MG
4 QL
risperidone oral
solution
2
risperidone oral
tablet
2 QL
risperidone oral
tablet,disintegrating
2 QL
RITALIN 4 PA
RITALIN LA
ORAL
CAPSULE,ER
BIPHASIC 50-50 10
MG, 20 MG, 30
MG, 40 MG
4 PA; ST
SAPHRIS 4 QL
SARAFEM ORAL
TABLET 10 MG, 20
MG
4 ST; QL
seconal sodium 2 QL
SECUADO 4 QL
sertraline oral
concentrate
1
sertraline oral tablet 1 QL
SILENOR 4 ST; QL
SUNOSI 3 ST; QL
SYMBYAX ORAL
CAPSULE 12-50
MG, 3-25 MG, 6-25
MG, 6-50 MG
4
temazepam 2
thioridazine 2
thiothixene 2
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
34
Drug Name Drug
Tier
Requirements
/ Limits
TRANXENE T-
TAB ORAL
TABLET 7.5 MG
4
tranylcypromine 2
trazodone 2
triazolam 2
trifluoperazine 2
trimipramine 2
TRINTELLIX 4 ST; QL
venlafaxine oral
capsule,extended
release 24hr
2 QL
venlafaxine oral
tablet
2 QL
venlafaxine oral
tablet extended
release 24hr
2 ST; QL
VERSACLOZ 4
VIIBRYD ORAL
TABLET
3 QL
VIIBRYD ORAL
TABLETS,DOSE
PACK 10 MG (7)-
20 MG (23)
3 QL
VRAYLAR 4 QL
VYLEESI 5 PA; QL
VYVANSE ORAL
CAPSULE
3 PA; ST
VYVANSE ORAL
TABLET,CHEWAB
LE
3 ST
WAKIX 5 ST; LA; QL
WELLBUTRIN XL 4 ST; QL
XYREM 5 LA
zaleplon 2 QL
Drug Name Drug
Tier
Requirements
/ Limits
zenzedi oral tablet
10 mg, 5 mg
2 PA
ZENZEDI ORAL
TABLET 15 MG,
2.5 MG, 20 MG, 30
MG, 7.5 MG
4 PA
ziprasidone hcl 2 QL
zolpidem 2 QL
ZOLPIMIST 4 ST; QL
ZYPREXA ORAL 4 QL
ZYPREXA ZYDIS 4 QL
CARDIOVASCULAR,
HYPERTENSION & LIPIDS
ANTIARRHYTHMIC AGENTS
amiodarone oral 2
BETAPACE 4 ST
BETAPACE AF 4 ST
disopyramide
phosphate oral
capsule
2
dofetilide 2
flecainide 2
mexiletine 2
MULTAQ 4
NORPACE 4
NORPACE CR 4
pacerone oral tablet
100 mg, 200 mg, 400
mg
2
propafenone 2
quinidine gluconate
oral
2
quinidine sulfate
oral tablet
2
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
35
Drug Name Drug
Tier
Requirements
/ Limits
RYTHMOL SR 4
sotalol af 2
sotalol oral 2
SOTYLIZE 3
ANTIHYPERTENSIVE THERAPY
ACCUPRIL 4
ACCURETIC 4
acebutolol 1
ADALAT CC 4 ST
ALDACTAZIDE 4
ALDACTONE 4
aliskiren 2
ALTACE 4
amiloride 2
amiloride-
hydrochlorothiazide
2
amlodipine 1
amlodipine-
benazepril
1
amlodipine-
olmesartan
1
amlodipine-
valsartan
1
amlodipine-
valsartan-hcthiazid
1
atenolol 1
atenolol-
chlorthalidone
1
benazepril 1
benazepril-
hydrochlorothiazide
1
betaxolol oral 1
BIDIL 4
Drug Name Drug
Tier
Requirements
/ Limits
bisoprolol fumarate 1
bisoprolol-
hydrochlorothiazide
1
bumetanide oral 2
BYSTOLIC 3 ST
CALAN SR 4
candesartan 1
candesartan-
hydrochlorothiazid
1
captopril 1
captopril-
hydrochlorothiazide
1
CARDIZEM CD 4
CARDIZEM LA 4
CARDIZEM ORAL
TABLET 120 MG,
30 MG, 60 MG
4
CARDURA 4 ST; QL
CARDURA XL 4 ST; QL
CAROSPIR 4 ST
cartia xt 1
carvedilol 2
carvedilol phosphate 2
CATAPRES 4
CATAPRES-TTS-1 4 QL
CATAPRES-TTS-2 4 QL
CATAPRES-TTS-3 4 QL
chlorothiazide oral
tablet 500 mg
1
chlorthalidone oral
tablet 25 mg, 50 mg
1
clonidine 2 QL
clonidine hcl oral
tablet
2
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
36
Drug Name Drug
Tier
Requirements
/ Limits
CONSENSI 4
COREG CR 4 ST
CORGARD 4 ST
DEMSER 3 PA
DIBENZYLINE 4 PA
diltiazem hcl oral
capsule,ext.rel 24h
degradable 180 mg,
240 mg
1
diltiazem hcl oral
capsule,extended
release 12 hr
1
diltiazem hcl oral
capsule,extended
release 24 hr 180
mg, 240 mg, 300 mg,
360 mg, 420 mg
1
diltiazem hcl oral
capsule,extended
release 24hr
1
diltiazem hcl oral
tablet
1
diltiazem hcl oral
tablet extended
release 24 hr
1
dilt-xr 1
DIURIL 4
doxazosin 2 QL
DYAZIDE 4
DYRENIUM 4
EDARBI 3 ST
EDARBYCLOR 3 ST
EDECRIN 4
enalapril maleate 1
enalapril-
hydrochlorothiazide
1
Drug Name Drug
Tier
Requirements
/ Limits
eplerenone 2
eprosartan 1
ethacrynic acid 2
felodipine 1
fosinopril 1
fosinopril-
hydrochlorothiazide
1
furosemide oral
solution 10 mg/ml,
40 mg/5 ml (8
mg/ml)
2
furosemide oral
tablet
2
guanfacine oral
tablet
2
HEMANGEOL 5
hydralazine oral 2
hydrochlorothiazide 1
indapamide 1
INDERAL XL 4 ST
INNOPRAN XL 4 ST
INSPRA 4
irbesartan 1
irbesartan-
hydrochlorothiazide
1
isradipine 1
labetalol oral 2
LASIX 4
lisinopril 1
lisinopril-
hydrochlorothiazide
1
LOPRESSOR
ORAL
4 ST
losartan 1
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
37
Drug Name Drug
Tier
Requirements
/ Limits
losartan-
hydrochlorothiazide
1
LOTENSIN HCT 4
LOTENSIN ORAL
TABLET 10 MG, 20
MG, 40 MG
4
matzim la 1
MAXZIDE 4
MAXZIDE-25MG 4
methyldopa 2
methyldopa-
hydrochlorothiazide
2
metolazone 1
metoprolol succinate 1
metoprolol ta-
hydrochlorothiaz
1
metoprolol tartrate
oral
1
MINIPRESS 4
minoxidil oral 2
moexipril 1
nadolol 1
nadolol-
bendroflumethiazide
oral tablet 80-5 mg
1
nicardipine oral 1
nifedipine 1
nimodipine 2
nisoldipine 1
NYMALIZE ORAL
SYRINGE
4
olmesartan 1
olmesartan-
amlodipin-hcthiazid
1
Drug Name Drug
Tier
Requirements
/ Limits
olmesartan-
hydrochlorothiazide
1
ORENITRAM 5 PA
perindopril
erbumine
1
phenoxybenzamine 2 PA
pindolol 1
prazosin 2
PRESTALIA 4 ST
PRINIVIL ORAL
TABLET 10 MG, 20
MG
4
PROCARDIA 4 ST
PROCARDIA XL 4 ST
propranolol oral 1
propranolol-
hydrochlorothiazid
1
quinapril 1
quinapril-
hydrochlorothiazide
1
ramipril 1
spironolactone 2
spironolacton-
hydrochlorothiaz
2
SULAR ORAL
TABLET
EXTENDED
RELEASE 24 HR
17 MG, 34 MG, 8.5
MG
4 ST
TARKA ORAL
TABLET, IR - ER,
BIPHASIC 24HR 2-
180 MG, 2-240 MG,
4-240 MG
4
taztia xt 1
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
38
Drug Name Drug
Tier
Requirements
/ Limits
TEKTURNA 4
TEKTURNA HCT 3
telmisartan 1
telmisartan-
amlodipine
1
telmisartan-
hydrochlorothiazid
1
TENORETIC 100 4 ST
TENORETIC 50 4 ST
TENORMIN 4 ST
terazosin 2 QL
tiadylt er 1
TIAZAC 4
timolol maleate oral 1
torsemide oral 2
trandolapril 1
trandolapril-
verapamil
1
triamterene 2
triamterene-
hydrochlorothiazid
oral capsule 37.5-25
mg
2
triamterene-
hydrochlorothiazid
oral tablet
2
UPTRAVI 5 PA; LA
valsartan 1
valsartan-
hydrochlorothiazide
1
VASERETIC 4
VASOTEC 4
verapamil oral 1
VERELAN 4
Drug Name Drug
Tier
Requirements
/ Limits
VERELAN PM 4
ZESTORETIC 4
ZESTRIL 4
ZIAC 4 ST
CARDIAC GLYCOSIDES
digitek 2
digox 2
digoxin oral solution
50 mcg/ml (0.05
mg/ml)
2
digoxin oral tablet 2
LANOXIN ORAL
TABLET 125 MCG
(0.125 MG), 250
MCG (0.25 MG),
62.5 MCG (0.0625
MG)
4
COAGULATION THERAPY
ADVATE 5 PA
ADYNOVATE 5 PA
AFSTYLA 5 PA
ALPROLIX 5 PA
AMICAR 4
aminocaproic acid
oral solution
2
aminocaproic acid
oral tablet
1
ARIXTRA 5
aspirin-dipyridamole 1
ASPIRIN-
OMEPRAZOLE
4 PA
BENEFIX 5 PA
BEVYXXA 4 QL
BRILINTA 3
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
39
Drug Name Drug
Tier
Requirements
/ Limits
CABLIVI
INJECTION KIT
5 PA
CEPROTIN (BLUE
BAR)
5
CEPROTIN
(GREEN BAR)
5
cilostazol 2
clopidogrel 1
COAGADEX 5 PA
dipyridamole oral 1
DOPTELET (15
TAB PACK)
5 PA; QL
EFFIENT 4
ELIQUIS 3 PA
ELIQUIS DVT-PE
TREAT 30D
START
3 PA
ELOCTATE 5 PA
enoxaparin 5
ESPEROCT 5 PA
fondaparinux 5
FRAGMIN
SUBCUTANEOUS
SOLUTION
5
FRAGMIN
SUBCUTANEOUS
SYRINGE
5
HEMLIBRA 5 PA
hep flush-10 (pf) 2
Drug Name Drug
Tier
Requirements
/ Limits
HEPARIN
(PORCINE) IN
0.9% NACL
INTRAVENOUS
PARENTERAL
SOLUTION 2,500
UNIT/500 ML (5
UNIT/ML), 30,000
UNIT/1,000 ML,
5,000 UNIT/1,000
ML, 5,000
UNIT/500 ML (10
UNIT/ML)
4
heparin (porcine) in
5 % dex intravenous
parenteral solution
20,000 unit/500 ml
(40 unit/ml), 25,000
unit/250 ml(100
unit/ml), 25,000
unit/500 ml (50
unit/ml)
2
heparin (porcine) in
nacl (pf)
2
heparin (porcine)
injection cartridge
2
heparin (porcine)
injection solution
2
heparin (porcine)
injection syringe
5,000 unit/ml
2
heparin
flush(porcine)-
0.9nacl
2
heparin lock flush 2
heparin lock flush
(porcine)
intravenous solution
100 unit/ml
2
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
40
Drug Name Drug
Tier
Requirements
/ Limits
heparin
lockflush(porcine)(pf
)
2
HEPARIN(PORCIN
E) IN 0.45% NACL
INTRAVENOUS
PARENTERAL
SOLUTION 12,500
UNIT/250 ML
4
heparin(porcine) in
0.45% nacl
intravenous
parenteral solution
25,000 unit/250 ml,
25,000 unit/500 ml
2
heparin, porcine (pf)
injection solution
2
heparin, porcine (pf)
injection syringe
5,000 unit/0.5 ml
2
HEPARIN,
PORCINE (PF)
INJECTION
SYRINGE 5,000
UNIT/ML
4
heparin, porcine (pf)
intravenous solution
100 unit/ml (1 ml)
2
heparin, porcine (pf)
intravenous syringe
1 unit/ml, 100
unit/ml
2
HEPARIN,
PORCINE (PF)
SUBCUTANEOUS
4
IDELVION 5 PA
IXINITY 5 PA
jantoven 1
JIVI 5 PA
Drug Name Drug
Tier
Requirements
/ Limits
KOGENATE FS 5 PA
KOVALTRY 5 PA
MEPHYTON 4 QL
NOVOEIGHT 5 PA
NOVOSEVEN RT 5 PA
pentoxifylline 2
phytonadione
(vitamin k1)
injection solution
2
PHYTONADIONE
(VITAMIN K1)
INJECTION
SYRINGE
3
phytonadione
(vitamin k1) oral
tablet 5 mg
2 QL
prasugrel 1
PROMACTA 5 PA; LA
REBINYN 5 PA
RIXUBIS 5 PA
vitamin k 2
vitamin k1 injection 2
warfarin 1
WILATE
INTRAVENOUS
RECON SOLN
1,000-1,000 UNIT,
500-500 UNIT
5 PA
XARELTO 3 PA
YOSPRALA 4 ST
ZONTIVITY 4 PA
LIPID/CHOLESTEROL LOWERING
AGENTS
amlodipine-
atorvastatin
1 QL
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
41
Drug Name Drug
Tier
Requirements
/ Limits
ANTARA ORAL
CAPSULE 30 MG,
90 MG
4 ST
atorvastatin oral
tablet 10 mg, 20 mg
1 ACA; QL
atorvastatin oral
tablet 40 mg, 80 mg
1 QL
CADUET ORAL
TABLET 10-10
MG, 10-20 MG, 10-
40 MG, 10-80 MG,
5-10 MG, 5-20 MG,
5-40 MG, 5-80 MG
4 ST; QL
cholestyramine (with
sugar)
1
cholestyramine light 1
colesevelam 1
COLESTID
FLAVORED ORAL
PACKET
4 ST
COLESTID ORAL
GRANULES
4 PA; ST
COLESTID ORAL
PACKET
4 PA
COLESTID ORAL
TABLET
4 ST
colestipol 1
ezetimibe 1 ST
ezetimibe-
simvastatin
1 QL
fenofibrate
micronized
1
fenofibrate
nanocrystallized
oral tablet 145 mg,
48 mg
1
FENOFIBRATE
ORAL CAPSULE
4 ST
Drug Name Drug
Tier
Requirements
/ Limits
fenofibrate oral
tablet 120 mg, 40 mg
1 PA
fenofibrate oral
tablet 160 mg, 54 mg
1
fenofibric acid 1
fenofibric acid
(choline)
1
FENOGLIDE 4 ST
FIBRICOR 4 ST
FLOLIPID 4 ST; QL
fluvastatin 1 ACA; QL
gemfibrozil 1
JUXTAPID 5 PA; LA
LESCOL XL 4 ST; QL
LIPOFEN 3 ST
LIVALO 3 ST; QL
LOPID 4
lovastatin 1 ACA; QL
LOVAZA 4 PA
NEXLETOL 3 PA
niacin oral tablet
500 mg
1
niacin oral tablet
extended release 24
hr
1
NIASPAN
EXTENDED-
RELEASE
4
omega-3 acid ethyl
esters
2 PA
PRALUENT PEN 5 PA; QL
pravastatin 1 ACA; QL
prevalite 1
QUESTRAN 4 ST
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
42
Drug Name Drug
Tier
Requirements
/ Limits
QUESTRAN
LIGHT ORAL
POWDER
4 ST
REPATHA
PUSHTRONEX
3 PA; QL
REPATHA
SURECLICK
3 PA; QL
REPATHA
SYRINGE
3 PA; QL
rosuvastatin oral
tablet 10 mg, 5 mg
1 ACA; QL
rosuvastatin oral
tablet 20 mg, 40 mg
1 QL
simvastatin oral
tablet 10 mg, 20 mg,
40 mg, 5 mg
1 ACA; QL
simvastatin oral
tablet 80 mg
1 QL
TRIGLIDE ORAL
TABLET 160 MG
4 ST
TRILIPIX 4 ST
VASCEPA 3 PA
WELCHOL ORAL
POWDER IN
PACKET
4 PA
WELCHOL ORAL
TABLET
4 ST
ZYPITAMAG
ORAL TABLET 2
MG, 4 MG
4 ST; QL
MISCELLANEOUS
CARDIOVASCULAR AGENTS
CORLANOR 3 PA
ENTRESTO 3 PA; QL
ranolazine 2
VECAMYL 4
VYNDAMAX 5 PA
Drug Name Drug
Tier
Requirements
/ Limits
VYNDAQEL 5 PA
NITRATES
DILATRATE-SR 3
GONITRO 4
ISOCHRON 4
ISORDIL 4
ISORDIL
TITRADOSE
ORAL TABLET 5
MG
4
isosorbide dinitrate
oral
2
isosorbide
mononitrate
2
MINITRAN 4
nitro-bid 2
NITRO-DUR 4
nitroglycerin oral 2
nitroglycerin
sublingual
2
nitroglycerin
transdermal patch
24 hour
2
nitroglycerin
translingual
spray,non-aerosol
2
NITROLINGUAL 4
NITROMIST 4
NITROSTAT 4
nitro-time 2
DERMATOLOGICALS/TOPICA
L THERAPY
ANTIPSORIATIC /
ANTISEBORRHEIC
acitretin 2
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
43
Drug Name Drug
Tier
Requirements
/ Limits
ANALPRAM-HC
TOPICAL
4 ST
calcipotriene scalp 2 QL
calcipotriene topical
cream
2 QL
calcipotriene topical
ointment
2 QL
calcipotriene-
betamethasone
2 QL
calcitriol topical 2
COSENTYX 5 PA; QL
COSENTYX (2
SYRINGES)
5 PA; QL
COSENTYX PEN 5 PA; QL
COSENTYX PEN
(2 PENS)
5 PA; QL
DOVONEX
TOPICAL
4 QL
ENSTILAR 3 QL
EPIFOAM 4 ST
hydrocortisone-
pramoxine topical
2
OVACE 4
OVACE PLUS
SHAMPOO
4
OVACE PLUS
TOPICAL
CLEANSER
4
OVACE PLUS
TOPICAL CREAM
4
OVACE PLUS
TOPICAL FOAM
4
OVACE PLUS
TOPICAL LOTION
4
OVACE PLUS
WASH
4
Drug Name Drug
Tier
Requirements
/ Limits
PRAMOSONE 4 ST
selenium sulfide
topical lotion
2
selenium sulfide
topical shampoo
2.25 %, 2.3 %
2
SELRX 4
SKYRIZI
SUBCUTANEOUS
SYRINGE KIT
5 PA; QL
SORIATANE
ORAL CAPSULE
10 MG, 25 MG
4
SORILUX 4 QL
STELARA
SUBCUTANEOUS
5 PA; QL
sulfacetamide
sodium topical
2
TACLONEX
TOPICAL
OINTMENT
4 QL
TACLONEX
TOPICAL
SUSPENSION
3 QL
TERSI FOAM 4
TREMFYA 5 PA; QL
VECTICAL 4
BURN THERAPY
SILVADENE 4
silver sulfadiazine 2
ssd 2
KERATOLYTICS
INOVA 4-1 4 ST
INOVA 8-2 4 ST
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
44
Drug Name Drug
Tier
Requirements
/ Limits
MISCELLANEOUS
DERMATOLOGICALS
AMELUZ 4
ammonium lactate 2
CANTHARIDIN IN
ACETONE
4
CONDYLOX
TOPICAL GEL
4
CORTANE-B
TOPICAL
4
diclofenac sodium
topical gel 3 %
2 PA; QL
doxepin topical 2 PA; QL
DUPIXENT
SYRINGE
5 PA; QL
EFUDEX TOPICAL
CREAM
4
ESKATA 4
EUCRISA 4 ST; QL
FLUOROPLEX 4
fluorouracil topical
cream 5 %
2
fluorouracil topical
solution
2
iodine-sodium iodide
topical tincture 2 %
2
IODOFLEX 4
IODOSORB 4
LEVULAN 4
methoxsalen 2
methyl salicylate 2
methyl salicylate
topical liquid
2
OXSORALEN
ULTRA
4
Drug Name Drug
Tier
Requirements
/ Limits
PANRETIN 4
PICATO 3
pimecrolimus 2 QL
podofilox 2
PROTOPIC 4 ST; QL
prudoxin 2 PA; QL
QBREXZA 3 PA
REGRANEX 3 QL
SOLARAZE 4 PA; QL
tacrolimus topical 2 ST; QL
TOLAK 4
VALCHLOR 5 PA
VEREGEN 4 QL
wintergreen oil 2
ZONALON 4 PA; QL
THERAPY FOR ACNE
ABSORICA 4
ABSORICA LD 4
ACZONE 4 ST
adapalene topical
cream
2
adapalene topical
gel
2
adapalene topical
gel with pump
2
ADAPALENE
TOPICAL LOTION
4 ST
adapalene topical
solution
2
adapalene topical
swab
2
adapalene-benzoyl
peroxide
2
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
45
Drug Name Drug
Tier
Requirements
/ Limits
AKLIEF 4 ST
ALTRENO 4 PA
amnesteem 2
AMZEEQ 3 ST
AVAR LS 4 ST
avar topical cleanser 2
AVAR TOPICAL
PADS,
MEDICATED
4 ST
AVAR-E GREEN 4 ST
AVAR-E LS 4 ST
avita topical cream 2 PA
AVITA TOPICAL
GEL
4 PA
azelaic acid 2
AZELEX 4 ST
BENZACLIN 4 ST
BENZACLIN
PUMP
4 ST
BENZAMYCIN 4 ST
BENZEPRO
(MICROSPHERES)
4 ST
benzepro topical
towelette
2
benzoyl peroxide
topical cleanser 7 %
2
benzoyl peroxide
topical foam 9.8 %
2
bp 10-1 2 ST
claravis 2
CLEOCIN T
TOPICAL GEL
4 ST; QL
CLEOCIN T
TOPICAL LOTION
4 ST; QL
Drug Name Drug
Tier
Requirements
/ Limits
CLEOCIN T
TOPICAL
SOLUTION
4 ST; QL
CLINDACIN ETZ
TOPICAL KIT
4 ST
clindacin p 2
CLINDACIN PAC 4 ST
clindamycin
phosphate topical
foam
2 QL
clindamycin
phosphate topical
gel
2 QL
clindamycin
phosphate topical
lotion
2 QL
clindamycin
phosphate topical
solution
2 QL
clindamycin
phosphate topical
swab
2
clindamycin-benzoyl
peroxide
2
clindamycin-
tretinoin
2 PA
dapsone topical 2
DIFFERIN 4 ST
ENZOCLEAR 4 ST
ery pads 2
erygel 2
erythromycin with
ethanol topical gel
2
erythromycin with
ethanol topical
solution
2
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
46
Drug Name Drug
Tier
Requirements
/ Limits
erythromycin-
benzoyl peroxide
2
EVOCLIN 4 ST; QL
FABIOR 4 PA
FINACEA
TOPICAL FOAM
3 ST
FINACEA
TOPICAL GEL
4 ST
INOVA 4 ST
isotretinoin 2
ivermectin topical 2 QL
METROCREAM 4 ST
METROGEL
TOPICAL GEL 1 %
4 ST
METROGEL
TOPICAL GEL
WITH PUMP
4 ST
METROLOTION 4 ST
metronidazole
topical
2
MIRVASO 3 PA
myorisan 2
neuac 2
NEUAC KIT 4 ST
NORITATE 4 ST
ONEXTON
TOPICAL GEL
WITH PUMP
3 ST
PACNEX 4 ST
PLEXION 4 ST
PLEXION
CLEANSING
CLOTHS
4 ST
PR BENZOYL
PEROXIDE
4 ST
Drug Name Drug
Tier
Requirements
/ Limits
RETIN-A 4 PA
RETIN-A MICRO 4 PA
RETIN-A MICRO
PUMP
4 PA
RHOFADE 4 PA
rosadan topical
cream
2
rosadan topical gel 2
ROSADAN
TOPICAL KIT,
CLEANSER AND
GEL
4 ST
ROSADAN
TOPICAL
KIT,CLEANSER
AND CREAM
4 ST
ROSANIL 4 ST
ROSULA 4 ST
rosula cleansing
cloths
2
SOOLANTRA 4 ST; QL
sss 10-5 2
sulfacetamide
sodium-sulfur
topical cleanser
2
sulfacetamide
sodium-sulfur
topical cream
2
sulfacetamide
sodium-sulfur
topical lotion
2
sulfacetamide
sodium-sulfur
topical pads,
medicated 10-4 %
2
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
47
Drug Name Drug
Tier
Requirements
/ Limits
sulfacetamide
sodium-sulfur
topical suspension
10-5 %
2
sulfacetamide
sodium-sulfur
topical suspension 8-
4 %
2 ST
sulfacetamide-
sulfur-cleansr23
2
sulfacleanse 8-4 2 ST
SUMADAN 4 ST
SUMADAN XLT 4 ST
SUMAXIN 4 ST
SUMAXIN CP 4 ST
SUMAXIN TS 4 ST
tazarotene 2 PA
TAZORAC
TOPICAL CREAM
0.05 %
3 PA
TAZORAC
TOPICAL CREAM
0.1 %
4 PA
TAZORAC
TOPICAL GEL
3 PA
tretinoin 2 PA
tretinoin
microspheres
2 PA
TRETIN-X CREAM
KIT
4 PA
TRETIN-X
TOPICAL CREAM
0.075 %
4 PA
VANOXIDE-HC 4 ST
zenatane 2
ZIANA 4 PA; ST
Drug Name Drug
Tier
Requirements
/ Limits
TOPICAL ANESTHETICS
COCAINE NASAL 4
glydo 2 QL
GOPRELTO 4
lidocaine hcl
laryngotracheal
2
lidocaine hcl mucous
membrane jelly
2 QL
lidocaine hcl mucous
membrane jelly in
applicator
2 QL
lidocaine hcl mucous
membrane solution 4
% (40 mg/ml)
2
lidocaine hcl-
hydrocortison ac
topical
2
lidocaine topical
adhesive
patch,medicated 5 %
2 ST
lidocaine topical
ointment
2 QL
lidocaine viscous 2
lidocaine-prilocaine
topical cream
2 QL
lidocaine-prilocaine
topical kit
2
lta pre-attached 2
NUMBRINO 4
PLIAGLIS 4 ST; QL
SYNERA 4
ZTLIDO 3 PA
TOPICAL ANTIBACTERIALS
ALTABAX 4 ST; QL
CENTANY 4 ST; QL
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
48
Drug Name Drug
Tier
Requirements
/ Limits
CENTANY AT 4 ST; QL
CORTISPORIN
TOPICAL
4
gentamicin topical 2
KLARON 4 ST
lugols topical 2
mafenide acetate 2
mupirocin 2 QL
mupirocin calcium 2 ST; QL
NEO-SYNALAR 4
NEO-SYNALAR
KIT
4
strong iodine topical 2
sulfacetamide
sodium (acne)
2
SULFAMYLON
TOPICAL CREAM
3
SULFAMYLON
TOPICAL PACKET
4
XEPI 4 ST; QL
TOPICAL ANTIFUNGALS
CICLODAN KIT
TOPICAL COMBO
PACK
4
CICLODAN KIT
TOPICAL
SOLUTION
4 ST
ciclodan topical
cream
2 QL
ciclodan topical
solution
2
ciclopirox topical
cream
2 QL
ciclopirox topical
gel
2 QL
Drug Name Drug
Tier
Requirements
/ Limits
ciclopirox topical
shampoo
2 QL
ciclopirox topical
solution
2
ciclopirox topical
suspension
2 QL
ciclopirox-ure-
camph-menth-euc
2
clotrimazole topical 2 QL
clotrimazole-
betamethasone
2 QL
econazole 2 QL
ECOZA 4 QL
ERTACZO 4 QL
EXELDERM 4 QL
EXTINA 4 QL
JUBLIA 4 ST
KERYDIN 4 ST
ketoconazole topical 2 QL
ketodan 2 QL
ketodan kit 2
LOPROX (AS
OLAMINE)
4 QL
LOPROX KIT 4 QL
LOPROX TOPICAL
SHAMPOO
4 QL
LUZU 4 QL
MENTAX 4 QL
MICONAZOLE
NITRATE-ZINC
OX-PET
4 QL
naftifine 2 QL
NAFTIN TOPICAL
CREAM 2 %
4 QL
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
49
Drug Name Drug
Tier
Requirements
/ Limits
NAFTIN TOPICAL
GEL
4 QL
NIZORAL
TOPICAL
SHAMPOO
4 QL
nyamyc 2
nystatin topical
cream
2 QL
nystatin topical
ointment
2 QL
nystatin topical
powder
2
nystatin-
triamcinolone
2 QL
nystop 2
oxiconazole 2 QL
OXISTAT 4 QL
VUSION 4 QL
XOLEGEL 4 QL
TOPICAL ANTIVIRALS
acyclovir topical 2 PA; QL
DENAVIR 4
XERESE 4
ZOVIRAX
TOPICAL CREAM
4 PA; QL
TOPICAL CORTICOSTEROIDS
ala-cort topical
cream 1 %
2
alclometasone 2
amcinonide topical
cream
2 ST
amcinonide topical
lotion
2 ST
apexicon e 2 ST
beser 2
Drug Name Drug
Tier
Requirements
/ Limits
betamethasone
dipropionate
2
betamethasone
valerate topical
cream
2
betamethasone
valerate topical
foam
2 ST
betamethasone
valerate topical
lotion
2
betamethasone
valerate topical
ointment
2
betamethasone,
augmented
2
BRYHALI 4 ST
CAPEX 4 ST
clobetasol scalp 2 QL
clobetasol topical
cream
2 QL
clobetasol topical
foam
2 ST; QL
clobetasol topical
gel
2 QL
clobetasol topical
lotion
2 QL
clobetasol topical
ointment
2 QL
clobetasol topical
shampoo
2 ST; QL
clobetasol topical
spray,non-aerosol
2 ST; QL
clobetasol-emollient
topical cream
2 QL
clobetasol-emollient
topical foam
2 ST; QL
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
50
Drug Name Drug
Tier
Requirements
/ Limits
CLOBEX 4 ST; QL
clodan 2 ST; QL
CLODAN KIT 4 ST
CLODERM 4 ST
CORDRAN TAPE
LARGE ROLL
4 ST
CORDRAN
TOPICAL CREAM
4 ST; QL
CORDRAN
TOPICAL LOTION
4 ST; QL
CORDRAN
TOPICAL
OINTMENT
4 ST; QL
CUTIVATE
TOPICAL CREAM
4 ST
CUTIVATE
TOPICAL LOTION
4 ST
DERMA-
SMOOTHE/FS
BODY OIL
4 ST
DERMA-
SMOOTHE/FS
SCALP OIL
4 ST
DESONATE 4 ST
desonide topical
cream
2
desonide topical gel 2
desonide topical
lotion
2 ST
desonide topical
ointment
2
DESOWEN 4 ST
desoximetasone 2 ST
diflorasone 2 ST; QL
Drug Name Drug
Tier
Requirements
/ Limits
DIPROLENE
TOPICAL
OINTMENT
4 ST
DUOBRII 4 ST; QL
fluocinolone 2
fluocinolone and
shower cap
2
fluocinonide topical
cream 0.05 %
2 QL
fluocinonide topical
cream 0.1 %
2 ST; QL
fluocinonide topical
gel
2 QL
fluocinonide topical
ointment
2 QL
fluocinonide topical
solution
2 QL
fluocinonide-e 2 QL
flurandrenolide 2 QL
fluticasone
propionate topical
2
halcinonide 2
halobetasol
propionate topical
cream
2
HALOBETASOL
PROPIONATE
TOPICAL FOAM
4 ST
halobetasol
propionate topical
ointment
2
HALOG 4 ST
hydrocortisone
butyrate topical
cream
2 QL
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
51
Drug Name Drug
Tier
Requirements
/ Limits
hydrocortisone
butyrate topical
lotion
2 ST; QL
hydrocortisone
butyrate topical
ointment
2
hydrocortisone
butyrate topical
solution
2 QL
hydrocortisone
butyr-emollient
2 QL
hydrocortisone
topical cream 1 %,
2.5 %
2
hydrocortisone
topical lotion 2.5 %
2
hydrocortisone
topical ointment 1
%, 2.5 %
2
hydrocortisone
valerate
2
IMPOYZ 4 ST; QL
KENALOG
TOPICAL
4 ST; QL
LEXETTE 4 ST
LUXIQ 4 ST
mometasone topical 2
nolix 2 QL
NUCORT 4 ST
OLUX 4 ST; QL
OLUX-E 4 ST; QL
PANDEL 4 ST
prednicarbate 2
PROCTOCORT
TOPICAL
4 ST
PSORCON 4 ST; QL
Drug Name Drug
Tier
Requirements
/ Limits
scalacort 2
SCALACORT DK 4 ST
SERNIVO 4 ST
SYNALAR 4 ST
SYNALAR
CREAM KIT
4 ST
SYNALAR
OINTMENT KIT
4 ST
SYNALAR TS 4 ST
TEMOVATE
TOPICAL CREAM
4 ST; QL
TEMOVATE
TOPICAL
OINTMENT
4 ST; QL
TEXACORT 4 ST
TOPICORT
TOPICAL CREAM
4 ST
TOPICORT
TOPICAL GEL
4 ST
TOPICORT
TOPICAL
OINTMENT
4 ST
tovet emollient 2 ST; QL
triamcinolone
acetonide topical
aerosol
2 ST; QL
triamcinolone
acetonide topical
cream
2
triamcinolone
acetonide topical
lotion
2
triamcinolone
acetonide topical
ointment 0.025 %,
0.1 %, 0.5 %
2
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
52
Drug Name Drug
Tier
Requirements
/ Limits
triamcinolone
acetonide topical
ointment 0.05 %
2 ST
trianex 2 ST
triderm topical
cream 0.1 %
2
TRIDESILON 4 ST
ULTRAVATE
TOPICAL LOTION
4 ST
TOPICAL ENZYMES
SANTYL 3 QL
TOPICAL SCABICIDES /
PEDICULICIDES
crotan 2
ELIMITE 4
EURAX 4
lindane topical
shampoo
2
malathion 2
NATROBA 4
OVIDE 4
permethrin topical
cream
2
SKLICE 4
spinosad 2
ULESFIA 4
DIAGNOSTICS &
MISCELLANEOUS AGENTS
IRRIGATING SOLUTIONS
lactated ringers
irrigation
2
neomycin-polymyxin
b gu
2
PHYSIOLYTE 4
Drug Name Drug
Tier
Requirements
/ Limits
PHYSIOSOL
IRRIGATION
4
ringer's irrigation 2
SORBITOL
IRRIGATION
4
SORBITOL-
MANNITOL
4
tis-u-sol pentalyte 2
MISCELLANEOUS AGENTS
acamprosate 2
acetic acid irrigation 2
AGRYLIN 4
anagrelide 2
aqua care sodium
chloride
2
aqua care sterile
water
2
BUPHENYL 4
caffeine citrate oral 2
CARBAGLU 5 LA
CARNITOR
(SUGAR-FREE)
4
CARNITOR ORAL 4
cevimeline 2
CHEMET 3 PA
clovique 2 PA
deferasirox 5 PA
disulfiram 2
etidronate disodium
oral tablet 200 mg
2
EVOXAC 4
FERRIPROX 5 PA
GLASSIA 5 PA; LA
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
53
Drug Name Drug
Tier
Requirements
/ Limits
GLEOLAN 4
INCRELEX 5 PA; LA
INFASURF 4
levocarnitine (with
sugar)
2
levocarnitine oral
solution 100 mg/ml
2
levocarnitine oral
tablet
2
LITHOSTAT 4
METOPIRONE 4
midodrine 2
nitisinone 5 PA
NITYR 5 PA; LA
ORFADIN 5 PA; LA
pilocarpine hcl oral
tablet 5 mg
2
RADIOGARDASE 4
RAVICTI 5
RILUTEK 4 PA
riluzole 2 PA
risedronate oral
tablet 30 mg
1 QL
SALAGEN
(PILOCARPINE)
ORAL TABLET 5
MG
4
sodium chloride 0.9
%
2
sodium chloride 0.9
% (flush) injection
syringe
2
sodium chloride
injection
2
Drug Name Drug
Tier
Requirements
/ Limits
sodium chloride
irrigation
2
sodium
phenylbutyrate
2
SURVANTA 4
SYPRINE 4 PA
THIOLA 5
THIOLA EC 5
TIGLUTIK 4 PA
trientine 2 PA
water for irrigation,
sterile
2
XURIDEN 5
SMOKING DETERRENTS
bupropion hcl
(smoking deter)
1 ACA
CHANTIX 3 ACA
CHANTIX
CONTINUING
MONTH BOX
3 ACA
CHANTIX
STARTING
MONTH BOX
3 ACA
nicorette buccal gum
4 mg
1 ACA; OTC
nicotine (polacrilex) 1 ACA; OTC
nicotine transdermal
patch 24 hour 14
mg/24 hr, 21 mg/24
hr, 7 mg/24 hr
1 ACA; OTC
nicotine transdermal
patch, td daily,
sequential
1 ACA; OTC
NICOTROL 4 ACA
NICOTROL NS 4 ACA
quit 2 1 ACA; OTC
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
54
Drug Name Drug
Tier
Requirements
/ Limits
quit 4 1 ACA; OTC
stop smoking aid 1 ACA; OTC
EAR, NOSE & THROAT
MEDICATIONS
MISCELLANEOUS AGENTS
ARESTIN 5
azelastine nasal
aerosol,spray
2 QL
azelastine nasal
spray,non-aerosol
2
chlorhexidine
gluconate mucous
membrane
2
CLINPRO 5000 4
denta 5000 plus 1
dentagel 1
EPISIL 4
fluoride (sodium)
dental cream
1
fluoride (sodium)
dental gel
1
fluoride (sodium)
dental paste
2
FLUORIDEX
DAILY DEFENSE
DENTAL PASTE
4
FLUORIDEX
SENSITIVITY
RELIEF DENTAL
PASTE
4
GELCLAIR 4
GELX 4
ipratropium bromide
nasal
2 QL
MUGARD 4
Drug Name Drug
Tier
Requirements
/ Limits
olopatadine nasal 2 QL
oralone 2
ORAMAGICRX 4
paroex oral rinse 2
PATANASE 4 QL
PERIDEX 4
periogard 2
pilocarpine hcl oral
tablet 7.5 mg
2
PREVIDENT 4
PREVIDENT 5000
BOOSTER PLUS
4
PREVIDENT 5000
DRY MOUTH
4
PREVIDENT 5000
ENAMEL
PROTECT
4
PREVIDENT 5000
ORTHO DEFENSE
4
PREVIDENT 5000
PLUS
4
PREVIDENT 5000
SENSITIVE
4
PROTHELIAL 5
SALAGEN
(PILOCARPINE)
ORAL TABLET 7.5
MG
4
sf 1
sf 5000 plus 1
sodium fluoride
5000 plus
1
sodium fluoride-pot
nitrate
2
triamcinolone
acetonide dental
2
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
55
Drug Name Drug
Tier
Requirements
/ Limits
MISCELLANEOUS OTIC
PREPARATIONS
acetic acid otic (ear) 2
ciprofloxacin hcl
otic (ear)
2
DERMOTIC OIL 4
flac otic oil 2
fluocinolone
acetonide oil
2
hydrocortisone-
acetic acid
2
ofloxacin otic (ear) 2
OTIPRIO 4 QL
OTIC STEROID / ANTIBIOTIC
CIPRO HC 4
CIPRODEX 3
CORTISPORIN-TC 4
neomycin-
polymyxin-hc otic
(ear)
2
OTOVEL 3
ENDOCRINE/DIABETES
ADRENAL HORMONES
ACTHAR 5 PA
CORTEF 4
cortisone 2
decadron oral tablet 2
dexabliss 2 PA
dexamethasone
intensol
2
dexamethasone oral
elixir
2
dexamethasone oral
solution
2
Drug Name Drug
Tier
Requirements
/ Limits
dexamethasone oral
tablet
2
dexamethasone oral
tablets,dose pack
2 ST
DXEVO 4 PA
fludrocortisone 2
hidex 2 PA
hydrocortisone oral 2
MEDROL 4
MEDROL (PAK) 4
methylprednisolone 2
millipred dp 2
millipred oral tablet 2
ORAPRED ODT 4
PEDIAPRED 4
prednisolone oral
solution 15 mg/5 ml
2
prednisolone sodium
phosphate oral
solution 10 mg/5 ml,
15 mg/5 ml (3
mg/ml), 20 mg/5 ml
(4 mg/ml), 25 mg/5
ml (5 mg/ml), 5 mg
base/5 ml (6.7 mg/5
ml)
2
prednisolone sodium
phosphate oral
tablet,disintegrating
2
prednisone 2
prednisone intensol 2
RAYOS 4 ST
TAPERDEX ORAL
TABLETS,DOSE
PACK 1.5 MG (21
TABS), 1.5 MG (49
TABS)
4 ST
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
56
Drug Name Drug
Tier
Requirements
/ Limits
TAPERDEX ORAL
TABLETS,DOSE
PACK 1.5 MG (27
TABS)
4 PA
TRIESENCE (PF) 4
veripred 20 2
ANTITHYROID AGENTS
methimazole oral
tablet 10 mg, 5 mg
2
propylthiouracil 2
SSKI 4
TAPAZOLE 4
BLOOD GLUCOSE MONITORING
DEVICES & SUPPLIES
FREESTYLE
INSULINX STRIP
3 ST; OTC
FREESTYLE
INSULINX TEST
STRIPS
3 ST; OTC
FREESTYLE LITE
STRIPS
3 ST; OTC
FREESTYLE TEST 3 ST; OTC
ONETOUCH
ULTRA BLUE
TEST STRIP
3 OTC
ONETOUCH
VERIO TEST
STRIPS
3 OTC
PRECISION XTRA
TEST
3 ST; OTC
DIABETES, SUPPLIES, & DURABLE
MEDICAL EQUIPMENT
GLUCAGEN
DIAGNOSTIC KIT
3
GLUCAGON HCL 4
Drug Name Drug
Tier
Requirements
/ Limits
INSULIN
SYRINGE-
NEEDLE U-100
SYRINGE 0.5 ML
29 GAUGE X 1/2"
4
GLUCOSE ELEVATING AGENTS
BAQSIMI 3 QL
diazoxide 2
GLUCAGEN
HYPOKIT
3 QL
GLUCAGON
(HCL)
EMERGENCY KIT
3 QL
GLUCAGON
EMERGENCY KIT
(HUMAN)
3 QL
GVOKE HYPOPEN
2-PACK
3 QL
GVOKE PFS 2-
PACK SYRINGE
3 QL
PROGLYCEM 4
INSULIN
SYRINGES/MISCELLANEOUS
DURABLE MEDICAL EQU
ACCU-CHEK
GUIDE L1-L2
CTRL SOL
4 OTC
ACCU-CHEK
SMARTVIEW
CONTRL SOL
4 OTC
ACCUTREND
GLUCOSE
CONTROL
4 OTC
ADVOCATE LOW
CONTROL
4 OTC
ADVOCATE REDI-
CODE+ CTRL
LOW
4 OTC
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
57
Drug Name Drug
Tier
Requirements
/ Limits
AGAMATRIX
CONTROL HIGH
4 OTC
ASSURE 4
CONTROL
SOLUTION
4 OTC
ASSURE DOSE
NORMAL
CONTROL
4 OTC
ASSURE PRISM
CONTROL 1-2
SOLN
4 OTC
AT HOME A1C 4 OTC
AUTOJECT 2
INJECTION
DEVICE
3 OTC
AUTOPEN 1 TO 21
UNITS
3 OTC
AUTOSOFT 30 3
AUTOSOFT 90 3
AUTOSOFT XC
INFUSION SET 23"
3
BD INTEGRA
NEEDLE
3
BD
MICROTAINER
LANCET 30
GAUGE
3 OTC
BD SPECIALTY
USE NEEDLES
NEEDLE 30
GAUGE X 1/2"
3
BD ULTRA FINE
LANCETS
3 OTC
BD ULTRA-FINE
NANO PEN
NEEDLE
3 OTC
BLOOD GLUCOSE
CONTROL,
NORMAL
4 OTC
Drug Name Drug
Tier
Requirements
/ Limits
BREEZE 2
CONTROL
SOLUTION,HIGH
4 OTC
CARESENS
CONTROL A
NORMAL
4 OTC
CARTRIDGE
STAMPED IR 1200
3 OTC
CEQUR
SIMPLICITY
4
CLEO 90
INFUSION SET 24"
3
CLEVER CHOICE
LEVEL 2
CONTROL
4 OTC
COMFORT
INFUSION SET 43"
3
COMFORT SHORT
INSULIN PUMP
23"
3
CONTACT
DETACH INFUS
SET 23"
3
CONTOUR
CONTROL
SOLUTION, NML
4 OTC
CONTOUR NEXT
LEV 2 CONTROL
SOL
4 OTC
COOL CONTROL
A SOLUTION
4 OTC
DEXCOM G4
RECEIVER
3 PA
DEXCOM G5
RECEIVER
3 PA
DEXCOM G6
RECEIVER
3 PA
DEXCOM
RECEIVER
3 PA
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
58
Drug Name Drug
Tier
Requirements
/ Limits
DIATRUE
CONTROL SOLN
NORMAL
4 OTC
EASY PLUS II
HIGH CONTROL
4 OTC
EASY STEP HIGH
CONTROL SOLN
4 OTC
EASY TALK HIGH
CONTROL
4 OTC
EASY TRAK LOW
CONTROL
4 OTC
EASYGLUCO
PLUS NORMAL
CONTROL
4 OTC
EASYMAX LOW
CONTROL
4 OTC
EASYMAX
NORMAL
CONTROL
4 OTC
ECLIPSE NEEDLE
NEEDLE 27
GAUGE X 1/2"
4
ELEMENT
COMPACT
NORMAL
CONTROL
4 OTC
ELEMENT
NORMAL
CONTROL
4 OTC
EMBRACE EVO
LEVEL 1
4 OTC
EMBRACE
GLUCOSE
CONTROL LOW
4 OTC
EMBRACE TALK
CONTROL-LOW
(L1)
4 OTC
ENLITE SYSTEM 4 PA
Drug Name Drug
Tier
Requirements
/ Limits
EVERSENSE
SENSOR-HOLDER
4 PA
EVOLUTION
NORMAL
CONTROL
4 OTC
FORA GTEL
MULTI-FUNCTN
MONITOR
4 OTC
FORA NORMAL
CONTROL
4 OTC
FORACARE GDH
LOW CONTROL
4 OTC
FORTISCARE
NORMAL
4 OTC
FREESTYLE
CONTROL
3 OTC
FREESTYLE
FREEDOM
3 OTC
FREESTYLE
FREEDOM LITE
3 OTC
FREESTYLE
INSULINX
3 OTC
FREESTYLE
LIBRE 14 DAY
READER
3 PA
FREESTYLE
LIBRE 14 DAY
SENSOR
3 PA; QL
FREESTYLE LITE
METER
3 OTC
GE100 CONTROL
SOLUTION
NORMAL
4 OTC
GENTEEL
VACUUM
LANCING DEVICE
4 OTC
GLUCOCARD 01
NORMAL
CONTROL
4 OTC
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
59
Drug Name Drug
Tier
Requirements
/ Limits
GLUCOCOM
CONTROL
NORMAL
4 OTC
GLUCOSE
CONTROL
4 OTC
GOJJI GLUCOSE
CNTRL SOL-
NORMAL
4 OTC
GOJJI KETONE
CONTROL SOLN-
L1
4 OTC
GOJJI MULTI-
FUNCTIONAL
METER KIT
4 OTC
GUARDIAN
REAL-TIME GLU
MONITOR
4 PA
HEALTHPRO
HIGH-LOW
CONTROL
4 OTC
INFINITY
CONTROL
SOLUTION NORM
4 OTC
INFINITY VOICE
CTRL SOLN-LVL 2
4 OTC
INFUSION SET 43"
6MM
3 OTC
INPEN (FOR
HUMALOG)
4
INPEN (FOR
NOVOLOG OR
FIASP)
4
INSET 30
INFUSION SET 23"
3
INSET INFUSION
SET 23"
3
LANCETS 33
GAUGE
3 OTC
LANCING DEVICE 3 OTC
Drug Name Drug
Tier
Requirements
/ Limits
MEDISENSE 3 OTC
MEDISENSE
GLUCOSE
KETONE
3 OTC
MINIMED
INFUSION SET-
MMT 390
3
MINIMED MIO 32" 3
MINIMED MIO
ADVANCE INF
SET23"
3 OTC
MINIMED
SILHOUETTE 23"
3
MINIMED SURE T
32"
3
MIO INFUSION
SET
3
MYGLUCOHEALT
H CONTROL
SOLUTION
4 OTC
NOVA MAX
GLUCOSE
CONTROL
4 OTC
NOVAMAX PLUS
GLU-KET
4 OTC
NOVOPEN ECHO 4
OMNIPOD DASH 5
PACK POD
3
ON CALL
EXPRESS
CONTROL
4 OTC
ON CALL PLUS
CONTROL
4 OTC
ON CALL VIVID
CONTROL
4 OTC
ONETOUCH
ULTRA CONTROL
3 OTC
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
60
Drug Name Drug
Tier
Requirements
/ Limits
ONETOUCH
ULTRA2 METER
3 OTC
ONETOUCH
ULTRAMINI
3 OTC
ONETOUCH
VERIO FLEX
METER
3 OTC
ONETOUCH
VERIO IQ METER
3 OTC
ONETOUCH
VERIO METER
3 OTC
ONETOUCH
VERIO REFLECT
METER
3 OTC
PEN NEEDLE,
DIABETIC
NEEDLE 29
GAUGE X 1/2"
4 OTC
PRECISION XTRA
KETONE-
GLUCOSE
3 OTC
PRECISION XTRA
MONITOR
3 OTC
PRODIGY
CONTROL
SOLUTION, LOW
4 OTC
PRODIGY
CONTROL
SOLUTION,HIGH
4 OTC
QUICK-SET
PARADIGM
3
REFUAH PLUS
GLUCOSE
CONTROL
4 OTC
RIGHTEST
CONTROL
SOLUTION HIGH
4 OTC
SAFE-CLIP BY
3 OTC
Drug Name Drug
Tier
Requirements
/ Limits
SILHOUETTE
INFUSION SET
3
SMARTEST
CONTROL
4 OTC
SOLUS V2
CONTROL
SOLUTION,HIGH
4 OTC
SURE-T
PARADIGM
3
T:30 INFUSION
SET
3
T:90 INFUSION
SET 23"
3
T:SLIM 3
T:SLIM G4 3
TELCARE
CONTROL
4 OTC
TRUE METRIX
LEVEL 1
4 OTC
TRUECONTROL
LEVEL 0
4 OTC
TRUSTEEL
INFUSION SET 32"
3
UNISTRIP LOW
CONTROL
4 OTC
VARISOFT
INFUSION SET 43"
3
VERASENS
CONTROL SOLN-
LEVEL 1
4 OTC
V-GO 20 3
V-GO 30 3
V-GO 40 3
VIVAGUARD INO
CONTROL
SOLUTION
4 OTC
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
61
Drug Name Drug
Tier
Requirements
/ Limits
WAVESENSE
CONTROL
SOLUTION
4 OTC
INSULIN THERAPY
AFREZZA
INHALATION
CARTRIDGE
WITH INHALER 12
UNIT, 4 UNIT, 4
UNIT (90)/ 8 UNIT
(90), 4 UNIT/8
UNIT/ 12 UNIT
(60), 8 UNIT, 8
UNIT (90)/ 12 UNIT
(90)
4
BASAGLAR
KWIKPEN U-100
INSULIN
4
HUMALOG
JUNIOR KWIKPEN
U-100
3
HUMALOG
KWIKPEN
INSULIN
3
HUMALOG MIX
50-50 INSULN U-
100
3
HUMALOG MIX
50-50 KWIKPEN
3
HUMALOG MIX
75-25 KWIKPEN
3
HUMALOG MIX
75-25(U-
100)INSULN
3
HUMALOG U-100
INSULIN
3
HUMULIN 70/30
U-100 INSULIN
3
HUMULIN 70/30
U-100 KWIKPEN
3
Drug Name Drug
Tier
Requirements
/ Limits
HUMULIN N NPH
INSULIN
KWIKPEN
3
HUMULIN N NPH
U-100 INSULIN
3
HUMULIN R
REGULAR U-100
INSULN
3
HUMULIN R U-500
(CONC) INSULIN
3
HUMULIN R U-500
(CONC) KWIKPEN
3
LANTUS
SOLOSTAR U-100
INSULIN
3
LANTUS U-100
INSULIN
3
LEVEMIR
FLEXTOUCH U-
100 INSULN
3
LEVEMIR U-100
INSULIN
3
SOLIQUA 100/33 3 QL
TOUJEO MAX U-
300 SOLOSTAR
3
TOUJEO
SOLOSTAR U-300
INSULIN
3
TRESIBA
FLEXTOUCH U-
100
3
TRESIBA
FLEXTOUCH U-
200
3
TRESIBA U-100
INSULIN
3
XULTOPHY
100/3.6
3 QL
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
62
Drug Name Drug
Tier
Requirements
/ Limits
MISCELLANEOUS HORMONES
ANADROL-50 4
ANDRODERM 3 PA; QL
ANDROGEL
TRANSDERMAL
GEL IN
METERED-DOSE
PUMP 20.25
MG/1.25 GRAM
(1.62 %)
4 PA; QL
ANDROGEL
TRANSDERMAL
GEL IN PACKET
1.62 % (20.25
MG/1.25 GRAM),
1.62 % (40.5
MG/2.5 GRAM)
4 PA; QL
ANDROID 4 ST
cabergoline 2 QL
calcitonin (salmon) 2
calcitriol
intravenous solution
1 mcg/ml
2
calcitriol oral 2
CERDELGA 5 PA
cinacalcet 1 ST
danazol 2
DDAVP NASAL
SOLUTION
3
DDAVP NASAL
SPRAY WITH
PUMP
4
DDAVP ORAL 4
DEPO-
TESTOSTERONE
4 PA
desmopressin nasal
spray,non-aerosol
2
Drug Name Drug
Tier
Requirements
/ Limits
desmopressin oral 2
doxercalciferol oral 2
FORTESTA 4 PA; ST; QL
GALAFOLD 5 PA; QL
JYNARQUE ORAL
TABLET
5 PA; LA; QL
JYNARQUE ORAL
TABLETS,
SEQUENTIAL 15
MG (AM)/ 15 MG
(PM), 30 MG (AM)/
15 MG (PM)
5 PA; LA
JYNARQUE ORAL
TABLETS,
SEQUENTIAL 45
MG (AM)/ 15 MG
(PM), 60 MG (AM)/
30 MG (PM), 90
MG (AM)/ 30 MG
(PM)
5 PA; QL
KUVAN 5 PA
METHITEST 3
methyltestosterone
oral capsule
2
MIACALCIN
INJECTION
3
miglustat 5 PA
MYALEPT 5 PA; LA
NATESTO 3 PA; ST; QL
NATPARA 5 PA; LA
NOCDURNA
(MEN)
4 PA; QL
NOCDURNA
(WOMEN)
4 PA; QL
ORILISSA 3 PA; QL
OXANDRIN 4
oxandrolone 2
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
63
Drug Name Drug
Tier
Requirements
/ Limits
PALYNZIQ 5 PA; QL
paricalcitol
intravenous
2
paricalcitol oral 2
RAYALDEE 4
ROCALTROL 4
SAMSCA 5 PA; QL
SOMAVERT 5
STIMATE 5
STRENSIQ 5 PA; LA
SYNAREL 3
TESTOPEL 5 PA
testosterone
cypionate
intramuscular oil
100 mg/ml, 200
mg/ml
2 PA
testosterone
enanthate
2 PA
TESTOSTERONE
IMPLANT
4 PA
testosterone
transdermal gel
2 PA; QL
testosterone
transdermal gel in
metered-dose pump
10 mg/0.5 gram
/actuation
1 PA; ST; QL
testosterone
transdermal gel in
metered-dose pump
12.5 mg/ 1.25 gram
(1 %)
2 PA; QL
testosterone
transdermal gel in
metered-dose pump
20.25 mg/1.25 gram
(1.62 %)
2 PA
Drug Name Drug
Tier
Requirements
/ Limits
testosterone
transdermal gel in
packet 1 % (25
mg/2.5gram), 1 %
(50 mg/5 gram)
2 PA; QL
testosterone
transdermal gel in
packet 1.62 %
(20.25 mg/1.25
gram), 1.62 % (40.5
mg/2.5 gram)
2 PA
testosterone
transdermal solution
in metered pump
w/app
2 PA; QL
TESTRED 4 ST
tolvaptan 5 PA; QL
VOGELXO 4 PA; ST; QL
XYOSTED 4 PA
ZEMPLAR
INTRAVENOUS
4
ZEMPLAR ORAL
CAPSULE 1 MCG,
2 MCG
4
NON-INSULIN HYPOGLYCEMIC
AGENTS
acarbose 1
ACTOPLUS MET 4 ST; QL
ACTOPLUS MET
XR ORAL
TABLET, ER
MULTIPHASE 24
HR 15-1,000 MG
4 ST; QL
ACTOS 4 ST; QL
AMARYL 4
AVANDIA ORAL
TABLET 2 MG, 4
MG
4 ST; QL
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
64
Drug Name Drug
Tier
Requirements
/ Limits
BYDUREON
BCISE
3 PA; QL
BYDUREON
SUBCUTANEOUS
PEN INJECTOR
3 PA; QL
BYETTA 3 PA; QL
CYCLOSET 4
DUETACT 4 ST; QL
FARXIGA 3 ST; QL
FORTAMET 4 ST; QL
glimepiride 1
glipizide 1
glipizide-metformin 1
GLUCOTROL 4
GLUCOTROL XL 4
glyburide 1
glyburide
micronized
1
glyburide-metformin 1
GLYNASE 4
GLYSET 4
GLYXAMBI 3 ST; QL
INVOKAMET 3 ST; QL
INVOKAMET XR 3 ST; QL
INVOKANA 3 ST; QL
JANUMET 3 QL
JANUMET XR 3 QL
JANUVIA 3 QL
JARDIANCE 3 ST; QL
JENTADUETO 3 QL
JENTADUETO XR 3 QL
metformin oral
solution
1 ST
Drug Name Drug
Tier
Requirements
/ Limits
metformin oral
tablet
1
metformin oral
tablet extended
release 24 hr
1 QL
metformin oral
tablet extended
release 24hr
1 ST; QL
metformin oral
tablet,er
gast.retention 24 hr
1 ST; QL
miglitol 1
nateglinide 1
OSENI 4 QL
OZEMPIC 3 PA; QL
pioglitazone 1 QL
pioglitazone-
glimepiride
1 QL
pioglitazone-
metformin
1 QL
PRANDIN ORAL
TABLET 1 MG, 2
MG
4
PRECOSE 4
QTERN 4 ST
repaglinide 1
repaglinide-
metformin
1 QL
RIOMET 4 ST
RIOMET ER 4 ST
RYBELSUS 3 PA; QL
SEGLUROMET 3 ST; QL
STARLIX 4
STEGLATRO 3 ST; QL
STEGLUJAN 4 ST; QL
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
65
Drug Name Drug
Tier
Requirements
/ Limits
SYMLINPEN 120 3 PA; QL
SYMLINPEN 60 3 PA; QL
SYNJARDY 3 ST; QL
SYNJARDY XR 3 ST; QL
TRADJENTA 3 QL
TRULICITY 3 PA; QL
XIGDUO XR 3 ST; QL
THYROID HORMONES
ARMOUR
THYROID
3
euthyrox 2
levo-t 2
levothyroxine oral 2
levoxyl oral tablet
100 mcg, 112 mcg,
125 mcg, 137 mcg,
150 mcg, 175 mcg,
200 mcg, 25 mcg, 50
mcg, 75 mcg, 88 mcg
2
liothyronine oral 2
nature-throid 2
np thyroid 2
SYNTHROID 4
thyroid (pork) 2
THYROLAR-1 4
THYROLAR-1/2 4
THYROLAR-1/4 4
THYROLAR-2 4
THYROLAR-3 4
TIROSINT 4
TIROSINT-SOL 4
unithroid 2
Drug Name Drug
Tier
Requirements
/ Limits
westhroid oral tablet
130 mg, 195 mg,
32.5 mg, 65 mg, 97.5
mg
2
WP THYROID 4
GASTROENTEROLOGY
ANTIDIARRHEALS &
ANTISPASMODICS
anaspaz 2
belladonna
alkaloids-opium
2
chlordiazepoxide-
clidinium
2
CUVPOSA 4
dicyclomine oral
capsule
2
dicyclomine oral
solution
2
dicyclomine oral
tablet
2
diphenoxylate-
atropine
2
DONNATAL
ORAL ELIXIR
16.2-0.1037 -0.0194
MG/5 ML
4
DONNATAL
ORAL TABLET
4
ed-spaz 2
GLYCATE 4
glycopyrrolate oral 2
hyoscyamine sulfate
oral
2
hyoscyamine sulfate
sublingual
2
hyosyne 2
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
66
Drug Name Drug
Tier
Requirements
/ Limits
LEVBID 4
LEVSIN ORAL 4
LEVSIN/SL 4
LOMOTIL 4
loperamide oral
capsule
2
methscopolamine 2
MOTOFEN 4
MYTESI 4
NULEV 4
opium tincture 2
oscimin oral tablet 2
oscimin sl 2
oscimin sr 2
phenobarb-hyoscy-
atropine-scop oral
elixir 16.2-0.1037 -
0.0194 mg/5 ml
2
phenobarb-hyoscy-
atropine-scop oral
tablet
2
phenohytro 2
propantheline 2
SYMAX DUOTAB 4
symax fastabs 2
symax-sl 2
symax-sr 2
MISCELLANEOUS
GASTROINTESTINAL AGENTS
ACTIGALL 4
alophen (bisacodyl) 2 ACA; OTC
alosetron 2
AMITIZA 4 QL
Drug Name Drug
Tier
Requirements
/ Limits
ANA-LEX KIT 4
ANALPRAM-HC
RECTAL CREAM
4
ANALPRAM-HC
SINGLES RECTAL
CREAM 2.5-1 %
(4G)
4
anucort-hc 2
aprepitant 2 QL
APRISO 4
AURYXIA 4
AZULFIDINE 4 ST
AZULFIDINE EN-
TABS
4 ST
balsalazide 2
bisacodyl oral 2 ACA; OTC
bisa-lax (bisacodyl) 2 ACA; OTC
BONJESTA 4 QL
budesonide oral 2
calcium
acetate(phosphat
bind)
2
CANASA 4
CESAMET 4 QL
CHENODAL 5 PA; LA
CHOLBAM ORAL
CAPSULE 250 MG
5 PA
CHOLBAM ORAL
CAPSULE 50 MG
5 PA; QL
citrate of magnesia 2 ACA; OTC
citroma 2 ACA; OTC
clearlax 2 ACA; OTC
CLENPIQ 3
COLAZAL 4 ST
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
67
Drug Name Drug
Tier
Requirements
/ Limits
colocort 2
COMPAZINE 4
compro 2
constulose 2
CORTENEMA 4
CREON 3
cromolyn oral 2
CYSTADANE 5
DICLEGIS 4 QL
DIPENTUM 4 ST
doxylamine-
pyridoxine (vit b6)
2 QL
dronabinol 2 PA
ducodyl (bisacodyl) 2 ACA; OTC
ENTEREG 4
ENTOCORT EC 4
enulose 2
fleet laxative
(bisacodyl)
2 ACA; OTC
GASTROCROM 4
GATTEX 30-VIAL 5
gavilax oral powder 2 ACA; OTC
gavilyte-c 1 ACA
gavilyte-g 1 ACA
gavilyte-n 1 ACA
generlac 2
gentle laxative
(bisacodyl) oral
2 ACA; OTC
gentlelax 2 ACA; OTC
glycolax oral
powder
2 ACA; OTC
GOLYTELY 4
granisetron hcl oral 2 QL
Drug Name Drug
Tier
Requirements
/ Limits
healthylax 2 ACA; OTC
hemmorex-hc rectal
suppository 25 mg
2
hydrocortisone
acetate rectal
2
hydrocortisone
rectal
2
hydrocortisone
topical cream with
perineal applicator
2
hydrocortisone-
pramoxine rectal
2
kionex (with
sorbitol)
2
KRISTALOSE 4
lactulose oral packet 2
lactulose oral
solution 10 gram/15
ml, 20 gram/30 ml
2
lanthanum 2
laxaclear 2 ACA; OTC
laxative (bisacodyl)
oral
2 ACA; OTC
laxative peg 3350
oral powder
2 ACA; OTC
LIALDA 4 ST
lidocaine hcl-
hydrocortison ac
rectal cream 3-0.5 %
2
LIDOCAINE HCL-
HYDROCORTISO
N AC RECTAL
GEL
4
lidocaine hcl-
hydrocortison ac
rectal kit
2
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
68
Drug Name Drug
Tier
Requirements
/ Limits
lidocaine-
hydrocortisone-aloe
rectal gel
2
lidocaine-
hydrocortisone-aloe
rectal kit 3-2.5 % (7
gram)
2
LINZESS 3 QL
LOKELMA 3 QL
LOTRONEX 4
magnesium citrate
oral solution
2 ACA; OTC
MARINOL 4 PA
meclizine oral tablet
12.5 mg, 25 mg
2
mesalamine oral
capsule (with del rel
tablets)
2
mesalamine oral
capsule,extended
release 24hr
2
mesalamine oral
tablet,delayed
release (dr/ec) 1.2
gram
2
mesalamine oral
tablet,delayed
release (dr/ec) 800
mg
1 ST
mesalamine rectal
enema
2
mesalamine rectal
suppository
1
mesalamine with
cleansing wipe
2
metoclopramide hcl
oral
2
milk of magnesia 2 ACA; OTC
Drug Name Drug
Tier
Requirements
/ Limits
milk of magnesia
concentrated
2 ACA; OTC
miralax oral powder
in packet
2 ACA; OTC
MOTEGRITY 4 QL
MOVANTIK 3 QL
MOVIPREP 4
natura-lax 2 ACA; OTC
NULYTELY WITH
FLAVOR PACKS
4
OCALIVA 5 PA; LA; QL
ondansetron 2 QL
ondansetron hcl oral 2 QL
oral saline laxative
oral liquid
2 ACA; OTC
peg 3350-
electrolytes oral
recon soln 236-
22.74-6.74 -5.86
gram
1 ACA
peg-electrolyte soln 1 ACA
peg-prep 1 ACA
PENTASA 3
PHOSLYRA 3
phosphate laxative
oral liquid
2 ACA; OTC
PLENVU 4
polyethylene glycol
3350
2 ACA; OTC
powderlax 2 ACA; OTC
PREPOPIK 3
prochlorperazine 2
prochlorperazine
maleate
2
PROCORT 4
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
69
Drug Name Drug
Tier
Requirements
/ Limits
PROCTOCORT
RECTAL
4 ST
PROCTOFOAM HC 4
procto-med hc 2
procto-pak 2
proctosol hc topical 2
proctozone-hc 2
purelax 2 ACA; OTC
RECTIV 3
REGLAN ORAL 4
RELISTOR ORAL 3 ST
RELISTOR
SUBCUTANEOUS
SOLUTION
3 ST
RELISTOR
SUBCUTANEOUS
SYRINGE
3 ST
RENVELA 4
ROWASA RECTAL
ENEMA KIT
4
SANCUSO 4 QL
scopolamine base 2
sevelamer carbonate 2
sevelamer hcl 2
SFROWASA 4
smoothlax 2 ACA; OTC
sodium polystyrene
(sorb free)
2
sodium polystyrene
sulfonate oral
powder
2
SOLESTA 5
sps (with sorbitol) 2
SUCRAID 5
Drug Name Drug
Tier
Requirements
/ Limits
sulfasalazine 2
SUPREP BOWEL
PREP KIT
3
SYMPROIC 3
SYNDROS 4 PA
TIGAN ORAL
CAPSULE 300 MG
4
trilyte with flavor
packets
1 ACA
trimethobenzamide
oral
2
TRULANCE 3
UCERIS ORAL 4
UCERIS RECTAL 3
URSO 250 4
URSO FORTE 4
ursodiol 2
VARUBI ORAL 3 QL
VELPHORO 3
VIBERZI 3
VIOKACE 3
women's gentle
laxative(bisac)
2 ACA; OTC
women's laxative
(bisacodyl)
2 ACA; OTC
ZELNORM 4
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
70
Drug Name Drug
Tier
Requirements
/ Limits
ZENPEP ORAL
CAPSULE,DELAY
ED
RELEASE(DR/EC)
10,000-32,000 -
42,000 UNIT,
15,000-47,000 -
63,000 UNIT,
20,000-63,000-
84,000 UNIT,
25,000-79,000-
105,000 UNIT,
3,000-10,000 -
14,000-UNIT,
40,000-126,000-
168,000 UNIT,
5,000-17,000-
24,000 UNIT
3
ZOFRAN ORAL
TABLET
4 QL
ZUPLENZ 4 QL
ULCER THERAPY
amoxicil-
clarithromy-
lansopraz
2 QL
CARAFATE 4
cimetidine 2
cimetidine hcl oral 2
CYTOTEC 4
DEXILANT 4 ST; QL
esomeprazole
magnesium oral
capsule,delayed
release(dr/ec) 20 mg
2 QL
esomeprazole
magnesium oral
capsule,delayed
release(dr/ec) 40 mg
2
Drug Name Drug
Tier
Requirements
/ Limits
esomeprazole
magnesium oral
granules dr for susp
in packet 10 mg, 20
mg
2 ST; QL
esomeprazole
magnesium oral
granules dr for susp
in packet 40 mg
2 ST
famotidine oral
suspension
2
famotidine oral
tablet 20 mg, 40 mg
2
lansoprazole oral
capsule,delayed
release(dr/ec) 15 mg
2 QL
lansoprazole oral
capsule,delayed
release(dr/ec) 30 mg
2
lansoprazole oral
tablet,disintegrat,
delay rel 15 mg
2 QL
lansoprazole oral
tablet,disintegrat,
delay rel 30 mg
2
misoprostol 2
NEXIUM ORAL
CAPSULE,DELAY
ED
RELEASE(DR/EC)
20 MG
4 ST; QL
NEXIUM ORAL
CAPSULE,DELAY
ED
RELEASE(DR/EC)
40 MG
4 ST
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
71
Drug Name Drug
Tier
Requirements
/ Limits
NEXIUM PACKET
ORAL GRANULES
DR FOR SUSP IN
PACKET 10 MG, 20
MG
4 ST; QL
NEXIUM PACKET
ORAL GRANULES
DR FOR SUSP IN
PACKET 2.5 MG, 5
MG
3 ST; QL
NEXIUM PACKET
ORAL GRANULES
DR FOR SUSP IN
PACKET 40 MG
4 ST
nizatidine 2
OMECLAMOX-
PAK
4 QL
omeprazole oral
capsule,delayed
release(dr/ec) 10 mg
2 QL
omeprazole oral
capsule,delayed
release(dr/ec) 20
mg, 40 mg
2
omeprazole-sodium
bicarbonate oral
capsule 20-1.1 mg-
gram
2 ST; QL
omeprazole-sodium
bicarbonate oral
capsule 40-1.1 mg-
gram
2 ST
omeprazole-sodium
bicarbonate oral
packet 20-1,680 mg
2 ST; QL
omeprazole-sodium
bicarbonate oral
packet 40-1,680 mg
2 ST
Drug Name Drug
Tier
Requirements
/ Limits
pantoprazole oral
tablet,delayed
release (dr/ec) 20
mg
2 QL
pantoprazole oral
tablet,delayed
release (dr/ec) 40
mg
2
PEPCID ORAL
TABLET
4
rabeprazole oral
tablet,delayed
release (dr/ec)
2
ranitidine hcl oral
syrup
2
ranitidine hcl oral
tablet 150 mg, 300
mg
2
sucralfate 2
TALICIA 3 QL
IMMUNOLOGY, VACCINES &
BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
FULPHILA 5 PA; QL
LEUKINE
INJECTION
RECON SOLN
5
MACRILEN 5 QL
MOZOBIL 5
NEULASTA 5 PA; QL
NIVESTYM 5 PA
PROCRIT 5 PA
RETACRIT 5 PA
UDENYCA 5 PA; QL
ZARXIO 5 PA
ZIEXTENZO 5 PA
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
72
Drug Name Drug
Tier
Requirements
/ Limits
GROWTH HORMONES
EGRIFTA
SUBCUTANEOUS
RECON SOLN 1
MG
5 PA
EGRIFTA SV 5 PA
GENOTROPIN 5 PA
GENOTROPIN
MINIQUICK
5 PA
NORDITROPIN
FLEXPRO
5 PA
SEROSTIM
SUBCUTANEOUS
RECON SOLN 4
MG, 5 MG, 6 MG
5 PA
ZORBTIVE 5 PA
INTERFERONS
AVONEX
INTRAMUSCULA
R PEN INJECTOR
KIT
5 PA; QL
AVONEX
INTRAMUSCULA
R SYRINGE KIT
5 PA; QL
BETASERON
SUBCUTANEOUS
KIT
5 QL
COPAXONE
SUBCUTANEOUS
SYRINGE 20
MG/ML
5 ST; QL
COPAXONE
SUBCUTANEOUS
SYRINGE 40
MG/ML
5 QL
GILENYA ORAL
CAPSULE 0.5 MG
5 PA
glatiramer 5 QL
Drug Name Drug
Tier
Requirements
/ Limits
glatopa 5 QL
MAVENCLAD (10
TABLET PACK)
5 PA; QL
MAVENCLAD (4
TABLET PACK)
5 PA; QL
MAVENCLAD (5
TABLET PACK)
5 PA; QL
MAVENCLAD (6
TABLET PACK)
5 PA; QL
MAVENCLAD (7
TABLET PACK)
5 PA; QL
MAVENCLAD (8
TABLET PACK)
5 PA; QL
MAVENCLAD (9
TABLET PACK)
5 PA; QL
MAYZENT 5 PA; QL
PEGASYS 5 PA; QL
PEGINTRON
SUBCUTANEOUS
KIT 50 MCG/0.5
ML
5 PA; QL
PLEGRIDY 5 PA; QL
POMALYST 5 PA
REBIF (WITH
ALBUMIN)
5 PA; QL
REBIF REBIDOSE 5 PA; QL
REBIF TITRATION
PACK
5 PA; QL
REVLIMID 5 PA; LA
ribavirin oral
capsule
5 PA
ribavirin oral tablet
200 mg
5 PA
SYLATRON
SUBCUTANEOUS
KIT 200 MCG, 300
MCG
5 PA
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
73
Drug Name Drug
Tier
Requirements
/ Limits
TECFIDERA 5 PA
VUMERITY 5 PA
ZEPOSIA 5
ZEPOSIA
STARTER KIT
5
ZEPOSIA
STARTER PACK
5
INTERLEUKINS
ACTIMMUNE 5
ALDARA 4
ALFERON N 3
ARCALYST 5 PA
imiquimod topical
cream in packet
2
INTRON A
INJECTION
5
PROLEUKIN 5 PA
VACCINES & MISCELLANEOUS
IMMUNOLOGICALS
ACTHIB (PF) 3 ACA
ADACEL(TDAP
ADOLESN/ADULT
)(PF)
3 ACA
BCG VACCINE,
LIVE (PF)
3 ACA
BEXSERO 3 ACA
BIOTHRAX 3 ACA
BOOSTRIX TDAP 3 ACA
BOTOX
INJECTION
RECON SOLN 100
UNIT
5 PA
DAPTACEL (DTAP
PEDIATRIC) (PF)
3 ACA
ENGERIX-B (PF) 3 ACA
Drug Name Drug
Tier
Requirements
/ Limits
ENGERIX-B
PEDIATRIC (PF)
INTRAMUSCULA
R SYRINGE
3 ACA
GARDASIL 9 (PF) 3 ACA
HAVRIX (PF)
INTRAMUSCULA
R SUSPENSION
1,440 ELISA
UNIT/ML
3 ACA
HAVRIX (PF)
INTRAMUSCULA
R SYRINGE
3 ACA
HEPLISAV-B (PF)
INTRAMUSCULA
R SYRINGE
4 ACA
HIBERIX (PF) 3 ACA
IMOVAX RABIES
VACCINE (PF)
3 ACA
INFANRIX (DTAP)
(PF)
3 ACA
IPOL 3 ACA
IXIARO (PF) 3 ACA
KINRIX (PF) 4 ACA
MENACTRA (PF)
INTRAMUSCULA
R SOLUTION
3 ACA
MENVEO A-C-Y-
W-135-DIP (PF)
4 ACA
M-M-R II (PF) 3 ACA
PEDIARIX (PF) 3 ACA
PEDVAX HIB (PF) 3 ACA
PENTACEL (PF) 3 ACA
PENTACEL
ACTHIB
COMPONENT (PF)
3 ACA
PNEUMOVAX-23 3 ACA
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
74
Drug Name Drug
Tier
Requirements
/ Limits
PREVNAR 13 (PF) 3 ACA
PROQUAD (PF) 3 ACA
QUADRACEL (PF) 3 ACA
RABAVERT (PF) 3 ACA
RECOMBIVAX HB
(PF)
3 ACA
ROTARIX 4 ACA
ROTATEQ
VACCINE
3 ACA
SHINGRIX (PF) 3 ACA
STAMARIL (PF) 3 ACA
TDVAX 3 ACA
TENIVAC (PF) 4 ACA
TETANUS,DIPHTH
ERIA TOX
PED(PF)
3 ACA
TRUMENBA 3 ACA
TWINRIX (PF)
INTRAMUSCULA
R SYRINGE
3 ACA
TYPHIM VI 3 ACA
VAQTA (PF) 4 ACA
VARIVAX (PF) 3 ACA
VARIZIG
INTRAMUSCULA
R SOLUTION
3 ACA
VAXCHORA
VACCINE
3 ACA
VIVOTIF 3 ACA
YF-VAX (PF) 3 ACA
ZOSTAVAX (PF) 4 ACA
MUSCULOSKELETAL &
RHEUMATOLOGY
GOUT THERAPY
Drug Name Drug
Tier
Requirements
/ Limits
allopurinol 2
colchicine oral
tablet
2
COLCRYS 4
febuxostat 2 ST
GLOPERBA 4
MITIGARE 3
probenecid 2
probenecid-
colchicine
2
ZYLOPRIM 4
OSTEOPOROSIS THERAPY
ACTONEL ORAL
TABLET 150 MG,
35 MG, 5 MG
4 ST; QL
alendronate oral
solution
1 QL
alendronate oral
tablet 10 mg, 35 mg,
5 mg, 70 mg
1 QL
ATELVIA 4 ST; QL
BINOSTO 4 ST; QL
BONIVA ORAL 4 ST; QL
EVISTA 4
FORTEO 5 PA; QL
FOSAMAX ORAL
TABLET 70 MG
4 ST; QL
FOSAMAX PLUS
D
4 ST; QL
ibandronate oral 1 QL
raloxifene 1 ACA
risedronate oral
tablet 150 mg, 35
mg, 5 mg
1 QL
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
75
Drug Name Drug
Tier
Requirements
/ Limits
risedronate oral
tablet,delayed
release (dr/ec)
1 QL
TERIPARATIDE 5 PA
TYMLOS 5 PA; QL
OTHER RHEUMATOLOGICALS
ACTEMRA
ACTPEN
5 PA; QL
ACTEMRA
SUBCUTANEOUS
5 PA; QL
ARAVA 4 QL
BENLYSTA
SUBCUTANEOUS
5 PA; QL
DEPEN
TITRATABS
4 PA
D-PENAMINE 3 PA
ENBREL 5 PA; QL
ENBREL MINI 5 PA; QL
ENBREL
SURECLICK
5 PA; QL
HUMIRA 5 PA; QL
HUMIRA PEN 5 PA; QL
HUMIRA PEN
CROHNS-UC-HS
START
5 PA; QL
HUMIRA PEN
PSOR-UVEITS-
ADOL HS
5 PA; QL
HUMIRA(CF) 5 PA; QL
HUMIRA(CF) PEDI
CROHNS
STARTER
5 PA; QL
HUMIRA(CF) PEN
CROHNS-UC-HS
5 PA; QL
Drug Name Drug
Tier
Requirements
/ Limits
HUMIRA(CF) PEN
PSOR-UV-ADOL
HS
5 PA; QL
HUMIRA(CF) PEN
SUBCUTANEOUS
PEN INJECTOR
KIT 40 MG/0.4 ML
5 PA; QL
KEVZARA 5 PA; QL
leflunomide 2 QL
OTEZLA 5 PA; QL
OTEZLA
STARTER
5 PA; QL
OTREXUP (PF)
SUBCUTANEOUS
AUTO-INJECTOR
10 MG/0.4 ML, 12.5
MG/0.4 ML, 15
MG/0.4 ML, 17.5
MG/0.4 ML, 20
MG/0.4 ML, 22.5
MG/0.4 ML, 25
MG/0.4 ML
3 ST
penicillamine 2 PA
RASUVO (PF)
SUBCUTANEOUS
AUTO-INJECTOR
10 MG/0.2 ML, 12.5
MG/0.25 ML, 15
MG/0.3 ML, 17.5
MG/0.35 ML, 20
MG/0.4 ML, 22.5
MG/0.45 ML, 25
MG/0.5 ML, 30
MG/0.6 ML, 7.5
MG/0.15 ML
3 ST
RIDAURA 3
RINVOQ 5 PA; QL
SAVELLA 3 ST; QL
SIMPONI ARIA 5 PA
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
76
Drug Name Drug
Tier
Requirements
/ Limits
SIMPONI
SUBCUTANEOUS
PEN INJECTOR
100 MG/ML
5 PA; QL
SIMPONI
SUBCUTANEOUS
SYRINGE 100
MG/ML
5 PA; QL
XELJANZ 5 PA; QL
XELJANZ XR 5 PA; QL
OBSTETRICS &
GYNECOLOGY
DIAPHRAGMS AND OTHER NON-
ORAL CONTRACEPTIVES
CAYA
CONTOURED
4 ACA
FC2 FEMALE
CONDOM
3 ACA; OTC
FEMCAP
VAGINAL DEVICE
22 MM
3 ACA
KYLEENA 5 ACA
LILETTA 5 ACA
MIRENA 5 ACA
PARAGARD T
380A
5 ACA
SKYLA 5 ACA
WIDE-SEAL
DIAPHRAGM
4 ACA
ESTROGENS & PROGESTINS
ACTIVELLA 4
ALORA 4 QL
amabelz 2
ANGELIQ 4
AYGESTIN 4
Drug Name Drug
Tier
Requirements
/ Limits
BIJUVA 4
camila 2 ACA
CLIMARA 4 QL
COMBIPATCH 3
covaryx 2
covaryx h.s. 2
CRINONE
VAGINAL GEL 4
%
3
deblitane 2 ACA
DELESTROGEN 4
DEPO-ESTRADIOL 3
DEPO-PROVERA
INTRAMUSCULA
R SUSPENSION
150 MG/ML
4 ACA; QL
DEPO-PROVERA
INTRAMUSCULA
R SYRINGE
4 ACA; QL
DEPO-SUBQ
PROVERA 104
4 ACA; QL
DIVIGEL
TRANSDERMAL
GEL IN PACKET
0.25 MG/0.25
GRAM (0.1 %), 0.5
MG/0.5 GRAM (0.1
%), 0.75 MG/0.75
GRAM (0.1%), 1
MG/GRAM (0.1 %)
3 QL
DIVIGEL
TRANSDERMAL
GEL IN PACKET
1.25 MG/1.25
GRAM (0.1 %)
3
dotti 2 QL
DUAVEE 3
eemt 2
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
77
Drug Name Drug
Tier
Requirements
/ Limits
eemt hs 2
ELESTRIN 4 QL
errin 2 ACA
ESTRACE 4
estradiol oral 2
estradiol
transdermal
2 QL
estradiol vaginal 2
estradiol valerate
intramuscular oil 20
mg/ml, 40 mg/ml
2
estradiol-
norethindrone acet
2
ESTRING 3
estrogens-
methyltestosterone
2
EVAMIST 4 QL
FEMHRT LOW
DOSE
4
fyavolv 2
heather 2 ACA
IMVEXXY
MAINTENANCE
PACK
4 QL
IMVEXXY
STARTER PACK
4 QL
incassia 2
jencycla 2 ACA
jinteli 2
lopreeza oral tablet
1-0.5 mg
2
lyza 2 ACA
medroxyprogesteron
e intramuscular
2 ACA; QL
Drug Name Drug
Tier
Requirements
/ Limits
medroxyprogesteron
e oral
2
MENEST 4
MENOSTAR 4 QL
mimvey 2
MINIVELLE 4 QL
nora-be 2 ACA
norethindrone
(contraceptive)
2 ACA
norethindrone
acetate
2
norethindrone ac-eth
estradiol oral tablet
0.5-2.5 mg-mcg, 1-5
mg-mcg
2
norlyda 2 ACA
PREFEST 4
PREMARIN ORAL 3
PREMARIN
VAGINAL
3
PREMPHASE 3
PREMPRO 3
progesterone 5
progesterone
micronized
2
PROMETRIUM 4
PROVERA 4
sharobel 2 ACA
tulana 2
yuvafem 2
MISCELLANEOUS OB/GYN
ANNOVERA 4 QL
CERVIDIL 4
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
78
Drug Name Drug
Tier
Requirements
/ Limits
CLEOCIN
VAGINAL
4
clindamycin
phosphate vaginal
2
CLINDESSE 4
eluryng 2
etonogestrel-ethinyl
estradiol
2
fem ph 2
GYNAZOLE-1 4 QL
gynol ii 2 ACA; OTC
INTRAROSA 4
isoxsuprine 2
LUPANETA PACK
(1 MONTH)
5 PA
LUPANETA PACK
(3 MONTH)
5 PA
LYSTEDA 4
METROGEL
VAGINAL
4
metronidazole
vaginal
2
miconazole-3
vaginal suppository
2
NEXPLANON 5 ACA
NUVARING 4 ACA
NUVESSA 4
OSPHENA 4
PREPIDIL 4
PROSTIN E2 4
RELAGARD 4
terconazole 2
Drug Name Drug
Tier
Requirements
/ Limits
TODAY
CONTRACEPTIVE
SPONGE
3 ACA; OTC
tranexamic acid oral 2
TRIMO-SAN
JELLY
3
vaginal
contraceptive foam
2 ACA; OTC
vandazole 2
VCF
CONTRACEPTIVE
FILM
3 ACA; OTC
VCF
CONTRACEPTIVE
GEL
3 ACA; OTC
xulane 2 ACA
ORAL CONTRACEPTIVES &
RELATED AGENTS
afirmelle 2
AFTERA 4 ACA; OTC;
QL
altavera (28) 2 ACA
alyacen 1/35 (28) 2 ACA
alyacen 7/7/7 (28) 2 ACA
amethia 2 ACA
amethia lo 2 ACA
amethyst (28) 2 ACA
apri 2 ACA
aranelle (28) 2 ACA
ashlyna 2 ACA
aubra 2 ACA
aubra eq 2
aurovela 1.5/30 (21) 2
aurovela 1/20 (21) 2
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
79
Drug Name Drug
Tier
Requirements
/ Limits
aurovela 24 fe 2
aurovela fe 1.5/30
(28)
2
aurovela fe 1-20
(28)
2
aviane 2 ACA
ayuna 2
azurette (28) 2 ACA
BALCOLTRA 4
balziva (28) 2 ACA
bekyree (28) 2 ACA
BEYAZ 4 ACA
blisovi 24 fe 2 ACA
blisovi fe 1.5/30 (28) 2 ACA
blisovi fe 1/20 (28) 2 ACA
briellyn 2 ACA
camrese 2 ACA
camrese lo 2 ACA
caziant (28) 2 ACA
chateal (28) 2 ACA
chateal eq (28) 2
cryselle (28) 2 ACA
cyclafem 1/35 (28) 2 ACA
cyclafem 7/7/7 (28) 2 ACA
cyred 2 ACA
cyred eq 2
dasetta 1/35 (28) 2 ACA
dasetta 7/7/7 (28) 2 ACA
daysee 2 ACA
desog-
e.estradiol/e.estradio
l
2 ACA
Drug Name Drug
Tier
Requirements
/ Limits
desogestrel-ethinyl
estradiol
2 ACA
drospirenone-
e.estradiol-lm.fa
oral tablet 3-0.02-
0.451 mg (24) (4)
2 ACA
drospirenone-
e.estradiol-lm.fa
oral tablet 3-0.03-
0.451 mg (21) (7)
2
drospirenone-ethinyl
estradiol oral tablet
3-0.02 mg
2 ACA
drospirenone-ethinyl
estradiol oral tablet
3-0.03 mg
2
econtra ez 2 ACA; OTC;
QL
econtra one-step 2 OTC; QL
elinest 2 ACA
ELLA 4 ACA; QL
emoquette 2 ACA
enpresse 2 ACA
enskyce 2 ACA
estarylla 2 ACA
ESTROSTEP FE-28 4 ACA
ethynodiol diac-eth
estradiol
2 ACA
falmina (28) 2 ACA
fayosim 2 ACA
femynor 2 ACA
GENERESS FE 4 ACA
gianvi (28) 2 ACA
hailey 2
hailey 24 fe 2
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
80
Drug Name Drug
Tier
Requirements
/ Limits
hailey fe 1.5/30 (28) 2
hailey fe 1/20 (28) 2
introvale 2 ACA
isibloom 2 ACA
jaimiess 2
jasmiel (28) 2
jolessa 2 ACA
juleber 2 ACA
junel 1.5/30 (21) 2 ACA
junel 1/20 (21) 2 ACA
junel fe 1.5/30 (28) 2 ACA
junel fe 1/20 (28) 2 ACA
junel fe 24 2 ACA
kaitlib fe 2 ACA
kalliga 2
kariva (28) 2 ACA
kelnor 1/35 (28) 2 ACA
kelnor 1-50 2
kurvelo (28) 2 ACA
l norgest/e.estradiol-
e.estrad
2 ACA
larin 1.5/30 (21) 2 ACA
larin 1/20 (21) 2 ACA
larin 24 fe 2 ACA
larin fe 1.5/30 (28) 2 ACA
larin fe 1/20 (28) 2 ACA
larissia 2 ACA
layolis fe 2 ACA
leena 28 2 ACA
lessina 2 ACA
levonest (28) 2 ACA
Drug Name Drug
Tier
Requirements
/ Limits
levonorgestrel oral
tablet 1.5 mg
2 OTC
levonorgestrel-
ethinyl estrad
2 ACA
levonorg-eth estrad
triphasic
2 ACA
levora-28 2 ACA
lillow (28) 2 ACA
LO LOESTRIN FE 3 ACA
lojaimiess 2
loryna (28) 2 ACA
LOSEASONIQUE 4 ACA
low-ogestrel (28) 2 ACA
lo-zumandimine (28) 2
lutera (28) 2 ACA
marlissa (28) 2 ACA
melodetta 24 fe 2 ACA
mibelas 24 fe 2 ACA
microgestin 1.5/30
(21)
2 ACA
microgestin 1/20
(21)
2 ACA
microgestin fe 1.5/30
(28)
2 ACA
microgestin fe 1/20
(28)
2 ACA
mili 2
MIRCETTE (28) 4 ACA
mono-linyah 2 ACA
my choice 2 ACA; OTC;
QL
my way 2 ACA; OTC;
QL
NATAZIA 4 ACA
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
81
Drug Name Drug
Tier
Requirements
/ Limits
necon 0.5/35 (28) 2 ACA
new day 2 OTC; QL
nikki (28) 2 ACA
noreth-ethinyl
estradiol-iron
2 ACA
norethindrone ac-eth
estradiol oral tablet
1.5-30 mg-mcg
2
norethindrone ac-eth
estradiol oral tablet
1-20 mg-mcg
2 ACA
norethindrone-
e.estradiol-iron oral
tablet 1 mg-20 mcg
(21)/75 mg (7)
2 ACA
norethindrone-
e.estradiol-iron oral
tablet 1.5 mg-30 mcg
(21)/75 mg (7)
2
norethindrone-
e.estradiol-iron oral
tablet,chewable
2 ACA
norgestimate-ethinyl
estradiol
2 ACA
nortrel 0.5/35 (28) 2 ACA
nortrel 1/35 (21) 2
nortrel 1/35 (28) 2 ACA
nortrel 7/7/7 (28) 2 ACA
ocella 2 ACA
opcicon one-step 2 ACA; OTC;
QL
option-2 2 ACA; OTC;
QL
orsythia 2 ACA
philith 2 ACA
pimtrea (28) 2 ACA
Drug Name Drug
Tier
Requirements
/ Limits
pirmella 2 ACA
PLAN B ONE-STEP 3 ACA; OTC;
QL
portia 28 2 ACA
previfem 2 ACA
QUARTETTE 4 ACA
reclipsen (28) 2 ACA
rivelsa 2 ACA
SAFYRAL 4 ACA
SEASONIQUE 4 ACA
setlakin 2 ACA
simliya (28) 2
simpesse 2
SLYND 4
sprintec (28) 2 ACA
sronyx 2 ACA
syeda 2
TAKE ACTION 4 ACA; OTC;
QL
tarina 24 fe 2
tarina fe 1/20 (28) 2 ACA
TAYTULLA 3 ACA
tilia fe 2 ACA
tri femynor 2 ACA
tri-estarylla 2 ACA
tri-legest fe 2 ACA
tri-linyah 2 ACA
tri-lo-estarylla 2 ACA
tri-lo-marzia 2 ACA
tri-lo-mili 2
tri-lo-sprintec 2 ACA
tri-mili 2
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
82
Drug Name Drug
Tier
Requirements
/ Limits
tri-previfem (28) 2 ACA
tri-sprintec (28) 2 ACA
trivora (28) 2 ACA
tri-vylibra 2 ACA
tri-vylibra lo 2
tydemy 2
velivet triphasic
regimen (28)
2 ACA
vienva 2 ACA
viorele (28) 2 ACA
volnea (28) 2
vyfemla (28) 2 ACA
vylibra 2 ACA
wera (28) 2 ACA
wymzya fe 2 ACA
YAZ (28) 4 ACA
zarah 2 ACA
zovia 1/35e (28) 2 ACA
zumandimine (28) 2
OXYTOCICS
methergine 2 ST; QL
methylergonovine
oral
2 ST; QL
OPHTHALMOLOGY
ANTIBIOTICS
ak-poly-bac 2
AZASITE 3
bacitracin
ophthalmic (eye)
2
bacitracin-
polymyxin b
ophthalmic (eye)
2
BESIVANCE 4
Drug Name Drug
Tier
Requirements
/ Limits
BETADINE
OPHTHALMIC
PREP
4
CILOXAN 4
ciprofloxacin hcl
ophthalmic (eye)
2
erythromycin
ophthalmic (eye)
2
gatifloxacin 2
gentak ophthalmic
(eye) ointment
2
gentamicin
ophthalmic (eye)
drops
2
levofloxacin
ophthalmic (eye)
2
MOXEZA 4
MOXIFLOXACIN
(PF)-BSS
INTRAVITREAL
SOLUTION
4
moxifloxacin
ophthalmic (eye)
2
MOXIFLOXACIN-
SOD
CHLOR,ISO(PF)
4
NATACYN 3
neomycin-
bacitracin-
polymyxin
2
neomycin-
polymyxin-
gramicidin
2
neo-polycin 2
OCUFLOX 4
ofloxacin ophthalmic
(eye)
2
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
83
Drug Name Drug
Tier
Requirements
/ Limits
polycin 2
polymyxin b sulf-
trimethoprim
2
POLYTRIM 4
tobramycin 2
TOBREX 4
VIGAMOX 4
ZYMAXID 4
ANTIVIRALS
trifluridine 2
ZIRGAN 4
BETA-BLOCKERS
betaxolol ophthalmic
(eye)
2
BETIMOL 4
BETOPTIC S 4
carteolol 2
levobunolol
ophthalmic (eye)
drops 0.5 %
2
metipranolol 2
timolol maleate
ophthalmic (eye)
2
TIMOPTIC 4
TIMOPTIC-XE 4
CHOLINESTERASE INHIBITOR
MIOTICS
PHOSPHOLINE
IODIDE
3
CYCLOPLEGIC MYDRIATICS
atropine ophthalmic
(eye) drops
2
Drug Name Drug
Tier
Requirements
/ Limits
ATROPINE
OPHTHALMIC
(EYE) DROPS,
EMULSION
4
atropine ophthalmic
(eye) ointment
2
CYCLOGYL 4
cyclopentolate 2
CYCLOPEN-
TROPIC-
PHENYLEPH-
WATR
4
homatropaire 2
ISOPTO
ATROPINE
4
MYDRIACYL 4
PAREMYD 4
PHENYLEPH-
TROPICAMIDE IN
WATER
4
tropicamide 2
DIRECT ACTING MIOTICS
ISOPTO CARPINE 4
MIOCHOL-E 4
pilocarpine hcl
ophthalmic (eye)
drops 1 %, 2 %, 4 %
2
MISCELLANEOUS
OPHTHALMOLOGICS
AKTEN (PF) 4
ALCAINE 4
ALOCRIL 4 ST
ALOMIDE 4 ST
altacaine 2
ALTAFLUOR
BENOX
4
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
84
Drug Name Drug
Tier
Requirements
/ Limits
azelastine
ophthalmic (eye)
2
BEOVU 5 PA
BEPREVE 3 ST
BEVACIZUMAB
INTRAVITREAL
SYRINGE 2.5
MG/0.1 ML
4 PA
BEVACIZUMAB
INTRAVITREAL
SYRINGE 3.25
MG/0.13 ML, 3.75
MG/0.15 ML
4
CEQUA 4 PA
cromolyn
ophthalmic (eye)
2
CYCLOSPORINE
IN KLARITY
4
CYSTARAN 5
DEXAMET-
MOXIFL-
KETORO-
NACL(PF)
4
epinastine 2
EYLEA
INTRAVITREAL
SOLUTION
5 PA
EYLEA
INTRAVITREAL
SYRINGE
5
fluorescein-
proparacaine
2
KLARITY-A
(AZITHRO-
CHONDR)(PF)
4
KLARITY-B
(BETAMETH-
CHOND)(PF)
4
Drug Name Drug
Tier
Requirements
/ Limits
KLARITY-L
(LOTEPRED-
CHOND)(PF)
4
LACRISERT 4
LASTACAFT 4 ST
LIDOCAINE-
PHENYLEPHRIN-
BSS(PF)
4
lidocaine-
phenylephrn in
water
2
LUCENTIS 5 PA
MACUGEN 5 PA
MYDRIATIC4(TRO
P-PROP-PE-
KTRLC)
4
olopatadine
ophthalmic (eye)
2
OMIDRIA 4
OXERVATE 5 PA
PAZEO 3 ST
PHOTREXA
CROSS-LINKING
KIT
4
PHOTREXA
VISCOUS
4
PREDNISOL ACE-
GATIFLOX-
BROMFEN
4
PREDNISOLN SP-
GATIFLOX-
BROMFEN
4
PREDNISOLN SP-
MOXIFLOX-
BROMFEN
4
PREDNISOLONE
ACETATE-
NEPAFENAC
4
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
85
Drug Name Drug
Tier
Requirements
/ Limits
PREDNISOLONE
SOD PH-
BROMFENAC
4
PREDNISOLONE-
MOXIFLO-
NEPAFENAC
4
PREDNISOLONE-
MOXIFLOX-
BROMFEN
4
proparacaine 2
RACEPINEPH-
LIDOCAINE-BSS
7(PF)
4
RESTASIS 3 PA; QL
RESTASIS
MULTIDOSE
3 PA; QL
tetracaine hcl 2
TETRACAINE
HCL (PF)
OPHTHALMIC
(EYE)
4
XIIDRA 3 PA; QL
ZERVIATE 4 ST
NON-STEROIDAL ANTI-
INFLAMMATORY AGENTS
ACULAR 4
ACULAR LS 4
bromfenac 2
BROMSITE 4
diclofenac sodium
ophthalmic (eye)
2
flurbiprofen sodium 2
ILEVRO 3
ketorolac
ophthalmic (eye)
2
PROLENSA 3
Drug Name Drug
Tier
Requirements
/ Limits
ORAL DRUGS FOR GLAUCOMA
acetazolamide 2
methazolamide 2
OTHER GLAUCOMA DRUGS
AZOPT 4
bimatoprost
ophthalmic (eye)
2 PA
BRIMONIDINE-
DORZOLAMIDE
(PF)
4
COMBIGAN 3
COSOPT (PF) 4
dorzolamide 2
DORZOLAMIDE
(PF)
4
dorzolamide-timolol 2
dorzolamide-timolol
(pf) ophthalmic (eye)
dropperette
2
DORZOLAMIDE-
TIMOLOL (PF)
OPHTHALMIC
(EYE) DROPS
4
latanoprost 2 PA
LATANOPROST
(PF)
4
LUMIGAN
OPHTHALMIC
(EYE) DROPS 0.01
%
3 PA; ST
miostat 2
MITOSOL 4
RHOPRESSA 3
ROCKLATAN 4 ST
SIMBRINZA 4
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
86
Drug Name Drug
Tier
Requirements
/ Limits
TIMOL-BRIMON-
DORZO-
LATANOP(PF)
4
TIMOLOL-
BRIMONIDI-
DORZOLAM(PF)
4
TIMOLOL-
DORZOLAMID-
LATANOP(PF)
4
TIMOLOL-
LATANOPROST(P
F)
4
TRAVATAN Z 4 ST
travoprost 2 ST
TRUSOPT 4
VYZULTA 4 ST
ZIOPTAN (PF) 3 ST
STEROID-ANTIBIOTIC
COMBINATIONS
DEXAMETH-
MOXIFLOX(PF)-
NACL,ISO
4
MAXITROL 4
neomycin-
bacitracin-poly-hc
2
neomycin-polymyxin
b-dexameth
2
neomycin-
polymyxin-hc
ophthalmic (eye)
2
neo-polycin hc 2
PRED-G 4
PRED-G S.O.P. 4
PREDNISOLONE
ACET-
GATIFLOXACIN
4
Drug Name Drug
Tier
Requirements
/ Limits
PREDNISOLONE
SOD PH-
MOXIFLOX
4
PREDNISOLONE-
MOXIFLOXACIN
HCL
4
TOBRADEX
OPHTHALMIC
(EYE)
DROPS,SUSPENSI
ON
4
TOBRADEX
OPHTHALMIC
(EYE) OINTMENT
3
TOBRADEX ST 3
tobramycin-
dexamethasone
2
TRIAMCINOLON-
MOXIFLOX-
WATR(PF)
4
ZYLET 3
STEROIDS
ALREX 3 ST
dexamethasone
sodium phosphate
ophthalmic (eye)
2
DEXTENZA 4
DEXYCU (PF) 4
DUREZOL 4
FLAREX 4
fluorometholone 2
FML LIQUIFILM 4
ILUVIEN 5
INVELTYS 3 ST
LOTEMAX
OPHTHALMIC
(EYE) DROPS,GEL
3
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
87
Drug Name Drug
Tier
Requirements
/ Limits
LOTEMAX
OPHTHALMIC
(EYE)
DROPS,SUSPENSI
ON
4
LOTEMAX
OPHTHALMIC
(EYE) OINTMENT
3
LOTEMAX SM 3
loteprednol
etabonate
2
OZURDEX 5
PRED FORTE 4
prednisolone acetate 2
PREDNISOLONE
ACETATE (PF)
4
prednisolone sodium
phosphate
ophthalmic (eye)
2
RETISERT 5
YUTIQ 5
STEROID-SULFONAMIDE
COMBINATIONS
BLEPHAMIDE 4
BLEPHAMIDE
S.O.P.
4
sulfacetamide-
prednisolone
2
SULFONAMIDES
BLEPH-10 4
sulfacetamide
sodium ophthalmic
(eye)
2
SYMPATHOMIMETICS
Drug Name Drug
Tier
Requirements
/ Limits
ALPHAGAN P
OPHTHALMIC
(EYE) DROPS 0.1
%
3
ALPHAGAN P
OPHTHALMIC
(EYE) DROPS 0.15
%
4
apraclonidine 2
brimonidine 2
IOPIDINE
OPHTHALMIC
(EYE)
DROPPERETTE
4
VASOCONSTRICTOR
DECONGESTANTS
CYCLOMYDRIL 4
phenylephrine hcl
ophthalmic (eye)
2
RESPIRATORY, ALLERGY,
COUGH & COLD
ANTIHISTAMINE &
ANTIALLERGENIC AGENTS
carbinoxamine
maleate oral liquid
2
carbinoxamine
maleate oral tablet 4
mg
2
carbinoxamine
maleate oral tablet 6
mg
2 ST
cetirizine oral
solution 1 mg/ml
2
CLARINEX ORAL
TABLET
4 QL
clemastine oral
tablet 2.68 mg
2
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
88
Drug Name Drug
Tier
Requirements
/ Limits
cyproheptadine 2
desloratadine 2 QL
dexchlorpheniramin
e maleate oral
solution
1
DIPHEN ORAL
ELIXIR
4
epinephrine
injection auto-
injector 0.15 mg/0.3
ml, 0.3 mg/0.3 ml
2 QL
EPIPEN 2-PAK 3 QL
EPIPEN JR 2-PAK 3 QL
hydroxyzine hcl oral
solution 10 mg/5 ml
2
hydroxyzine hcl oral
tablet
2
hydroxyzine
pamoate
2
KARBINAL ER 4 ST
levocetirizine oral
solution
2
levocetirizine oral
tablet
2 QL
promethazine oral 2
promethazine rectal 2
promethegan 2
RYCLORA 4
RYVENT 4 ST
SYMJEPI 3 QL
VISTARIL 4
COUGH & COLD THERAPY
benzonatate 2
BROMFED DM 4
Drug Name Drug
Tier
Requirements
/ Limits
brompheniramine-
pseudoeph-dm oral
syrup
2
CAPCOF 4
CLARINEX-D 12
HOUR
4 QL
codeine-guaifenesin 2
CODITUSSIN AC 4
CODITUSSIN DAC 4
g tussin ac 2
guaiatussin ac 2
guaifenesin dac 2
HISTEX-AC 4
hydrocodone-
chlorpheniramine
2
hydrocodone-
homatropine oral
syrup 5-1.5 mg/5 ml
2
hydrocodone-
homatropine oral
tablet
2
hydromet 2
lortuss ex oral syrup 2
MAR-COF CG 4
MAXI-TUSS CD 4
m-clear wc 2
M-END PE 4
NINJACOF-XG 4
OBREDON 4 ST
POLY-TUSSIN AC
ORAL LIQUID 4-
10-10 MG/5 ML
4
promethazine-
codeine
2
promethazine-dm 2
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
89
Drug Name Drug
Tier
Requirements
/ Limits
promethazine-
phenyleph-codeine
2
promethazine-
phenylephrine
2
RESPA-AR 4
SEMPREX-D 4
TESSALON
PERLES
4
TUSSICAPS ORAL
CAPSULE,EXTEN
DED RELEASE 12
HR 10-8 MG
4 ST
TUXARIN ER 4
TUZISTRA XR 4 ST
virtussin ac 2
virtussin dac 2
Z-TUSS AC 4
PULMONARY AGENTS
ACCOLATE 4
acetylcysteine 1
ADEMPAS 5 PA; LA
ADRENALIN
NASAL
4
ADVAIR DISKUS 4 ST; QL
ADVAIR HFA 3 ST; QL
AIRDUO
RESPICLICK
4 ST; QL
albuterol sulfate
inhalation hfa
aerosol inhaler
1 QL
albuterol sulfate
inhalation solution
for nebulization
1
albuterol sulfate oral 1
ALVESCO 4 ST; QL
Drug Name Drug
Tier
Requirements
/ Limits
alyq 2 PA; QL
ambrisentan 5 PA
ANORO ELLIPTA 3 QL
ARCAPTA
NEOHALER
4 QL
ARMONAIR
RESPICLICK
INHALATION
AEROSOL POWDR
BREATH
ACTIVATED 232
MCG/ACTUATION
, 55
MCG/ACTUATION
3 QL
ARNUITY
ELLIPTA
3 QL
ASMANEX HFA 3 QL
ASMANEX
TWISTHALER
INHALATION
AEROSOL POWDR
BREATH
ACTIVATED 110
MCG/
ACTUATION (30),
220 MCG/
ACTUATION (120),
220 MCG/
ACTUATION (14),
220 MCG/
ACTUATION (30),
220 MCG/
ACTUATION (60)
3 QL
ATROVENT HFA 4 QL
azelastine-
fluticasone
2 PA; QL
BEVESPI
AEROSPHERE
3 QL
bosentan 5 PA
BREO ELLIPTA 3 PA; QL
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
90
Drug Name Drug
Tier
Requirements
/ Limits
BROVANA 4 QL
budesonide
inhalation
1 QL
COMBIVENT
RESPIMAT
3 QL
cromolyn inhalation 1
CUROSURF 4
DALIRESP ORAL
TABLET 250 MCG
3 PA; QL
DALIRESP ORAL
TABLET 500 MCG
3 PA
DULERA
INHALATION HFA
AEROSOL
INHALER 100-5
MCG/ACTUATION
, 200-5
MCG/ACTUATION
3 PA; QL
DULERA
INHALATION HFA
AEROSOL
INHALER 50-5
MCG/ACTUATION
3 ST; QL
DYMISTA 3 ST; QL
ELIXOPHYLLIN
ORAL ELIXIR 80
MG/15 ML
4
ESBRIET ORAL
CAPSULE
5 PA; QL
ESBRIET ORAL
TABLET 267 MG
5 PA; QL
ESBRIET ORAL
TABLET 801 MG
5 PA
FASENRA PEN 5 PA
FLOVENT DISKUS 3 QL
FLOVENT HFA 3 QL
Drug Name Drug
Tier
Requirements
/ Limits
flunisolide nasal
spray,non-aerosol
25 mcg (0.025 %)
2 QL
fluticasone
propionate nasal
2 QL
FLUTICASONE
PROPION-
SALMETEROL
INHALATION
AEROSOL POWDR
BREATH
ACTIVATED
3 ST; QL
fluticasone propion-
salmeterol
inhalation blister
with device
1 ST; QL
HAEGARDA 5 PA; LA
HYPER-SAL 4
icatibant 5 PA
INCRUSE
ELLIPTA
3 QL
ipratropium bromide
inhalation
1
ipratropium-
albuterol
1 QL
KALYDECO ORAL
GRANULES IN
PACKET 25 MG
5 PA
KALYDECO ORAL
GRANULES IN
PACKET 50 MG, 75
MG
5 PA; QL
KALYDECO ORAL
TABLET
5 PA; QL
levalbuterol hcl 1
LONHALA
MAGNAIR REFILL
4 QL
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
91
Drug Name Drug
Tier
Requirements
/ Limits
LONHALA
MAGNAIR
STARTER
4 QL
metaproterenol oral
syrup
1
mometasone nasal 2 QL
montelukast 1
nebusal inhalation
solution for
nebulization 3 %
2
NEBUSAL
INHALATION
SOLUTION FOR
NEBULIZATION 6
%
4
NUCALA
SUBCUTANEOUS
AUTO-INJECTOR
5 PA; LA; QL
NUCALA
SUBCUTANEOUS
SYRINGE
5 PA; LA; QL
OFEV 5 PA; QL
OPSUMIT 5 PA; LA
ORKAMBI 5 PA; QL
PERFOROMIST 3 QL
PROAIR HFA 3 QL
PROAIR
RESPICLICK
3 QL
PULMICORT
FLEXHALER
3 QL
pulmosal 2
PULMOZYME 5
QNASL 3 QL
QVAR
REDIHALER
3 QL
REVATIO ORAL 5 PA; ST; QL
Drug Name Drug
Tier
Requirements
/ Limits
RUCONEST 5 PA
SEEBRI
NEOHALER
4 QL
SEREVENT
DISKUS
3 QL
sildenafil
(pulm.hypertension)
oral
5 PA; QL
SINUVA 5
sodium chloride
inhalation
2
SPIRIVA
RESPIMAT
3 QL
SPIRIVA WITH
HANDIHALER
3 QL
STIOLTO
RESPIMAT
3 QL
SURFAXIN 4
SYMBICORT 3 PA; QL
SYMDEKO 5 PA; QL
tadalafil (pulm.
hypertension)
5 PA; QL
TAKHZYRO 5 PA
terbutaline oral 1
THEO-24 4
theochron oral tablet
extended release 12
hr 100 mg, 200 mg
1
theophylline oral
elixir
1
theophylline oral
solution
1
theophylline oral
tablet extended
release 12 hr
1
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
92
Drug Name Drug
Tier
Requirements
/ Limits
theophylline oral
tablet extended
release 24 hr
1
TRACLEER 5 PA; LA
TRELEGY
ELLIPTA
3 QL
TRIKAFTA 5 PA
TYVASO 5 PA
TYVASO REFILL
KIT
5 PA
TYVASO
STARTER KIT
5 PA
UTIBRON
NEOHALER
4 QL
VENTAVIS 5 PA; ST
VENTOLIN HFA 3 QL
wixela inhub 1 ST; QL
XHANCE 4 ST; QL
XOLAIR 5 PA; LA; QL
XOPENEX 4
XOPENEX
CONCENTRATE
4
YUPELRI 3 QL
zafirlukast 1
zileuton 1 ST
ZYFLO 4 ST
UROLOGICALS
ANTICHOLINERGICS &
ANTISPASMODICS
darifenacin 2
DITROPAN XL
ORAL TABLET
EXTENDED
RELEASE 24HR 10
MG, 5 MG
4 ST
Drug Name Drug
Tier
Requirements
/ Limits
flavoxate 2
GELNIQUE
TRANSDERMAL
GEL IN PACKET
3 QL
MYRBETRIQ 3
oxybutynin chloride 2
OXYTROL 4 ST; QL
solifenacin 2
tolterodine 2
TOVIAZ 3
trospium 2
BENIGN PROSTATIC
HYPERPLASIA (BPH) THERAPY
alfuzosin 2
dutasteride 2 PA
dutasteride-
tamsulosin
2 ST
finasteride oral
tablet 5 mg
2
FLOMAX 4 ST
JALYN 4 ST
PROSCAR 4 ST
silodosin 1
tadalafil oral tablet
2.5 mg, 5 mg
2 PA; QL
tamsulosin 2
CHOLINERGIC STIMULANTS
bethanechol chloride 2
URECHOLINE
ORAL TABLET 25
MG, 50 MG
4
MISCELLANEOUS UROLOGICALS
CAVERJECT 3 PA; QL
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
93
Drug Name Drug
Tier
Requirements
/ Limits
CAVERJECT
IMPULSE
3 PA; QL
CYSTAGON 5 LA
EDEX 4 PA; QL
ELMIRON 3
hyophen 2
IFE-BIMIX 30/1 4
IFE-PG20 4
K-PHOS NO 2 4
K-PHOS
ORIGINAL
3
LEVITRA ORAL
TABLET 10 MG, 20
MG
4 PA; QL
methen-sod phos-
meth blue-hyos
2
ORACIT 4
phosphasal 2
potassium citrate 2
RENACIDIN
IRRIGATION
SOLUTION 1980.6
MG-59.4 MG-
980.4MG/30ML
3
SHOHL'S
MODIFIED
4
sildenafil 2 PA; QL
STAXYN 4 PA; QL
STENDRA 4 PA; QL
tadalafil oral tablet
10 mg, 20 mg
2 PA; QL
TRI-MIX
(PAPAVRN-
PHNTLMN-PGE1)
4
URELLE 4
Drug Name Drug
Tier
Requirements
/ Limits
uretron d-s oral
tablet 81.6-10.8-40.8
mg
2
URIBEL 4
urimar-t 2
urin ds 2
uro-458 2
UROCIT-K 10 4
UROCIT-K 15 4
UROCIT-K 5 4
urogesic-blue 2
uro-mp 2
UROQID-ACID
NO.2
4
uryl 2
ustell 2
utira-c 2
vardenafil 1 PA; QL
vilamit mb 2
vilevev mb 2
URINARY ANESTHETICS
phenazopyridine
oral tablet 100 mg,
200 mg
2
PYRIDIUM 4
VITAMINS, HEMATINICS &
ELECTROLYTES
ELECTROLYTES
calcium 500 + d oral
tablet,chewable
1 ACA; OTC
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
94
Drug Name Drug
Tier
Requirements
/ Limits
calcium 600 + d(3)
oral tablet 600
mg(1,500mg) -200
unit, 600
mg(1,500mg) -400
unit
1 ACA; OTC
calcium citrate-
vitamin d3 oral
tablet 315 mg- 250
unit
1 OTC
calcium citrate-
vitamin d3 oral
tablet 315 mg-5 mcg
(200 unit)
1 ACA; OTC
EFFER-K ORAL
TABLET,
EFFERVESCENT
10 MEQ, 20 MEQ
4
effer-k oral tablet,
effervescent 25 meq
2
GALZIN 4
klor-con 2
klor-con 10 2
klor-con 8 2
klor-con m10 2
klor-con m15 2
klor-con m20 2
klor-con/ef 2
K-TAB ORAL
TABLET
EXTENDED
RELEASE 10 MEQ,
20 MEQ
4
k-tab oral tablet
extended release 8
meq
2
lugols oral 2
oyster shell + d3 1 ACA; OTC
Drug Name Drug
Tier
Requirements
/ Limits
oyster shell calcium-
vit d3 oral tablet 500
mg(1,250mg) -400
unit
1 ACA; OTC
POTABA ORAL
CAPSULE
4
potassium chloride
oral
2
strong iodine oral 2
VITAMINS & HEMATINICS
b complex 1 (with
folic acid)
2 ACA; OTC
b complex-vitamin
b12
2 ACA; OTC
b complex-vitamin c-
folic acid oral tablet
2 ACA; OTC
balanced b-100
complex oral tablet
extended release 100
mg
2 ACA; OTC
balanced b-100 oral
tablet 0.4 mg
2 ACA; OTC
balanced b-50 oral
tablet
2 ACA; OTC
bal-care dha 1
BAL-CARE DHA
ESSENTIAL
4
b-complex with
vitamin c oral tablet
2 ACA; OTC
cholecalciferol
(vitamin d3) oral
capsule 25 mcg
(1,000 unit)
1 ACA; OTC
cholecalciferol
(vitamin d3) oral
tablet 25 mcg (1,000
unit)
2 OTC
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
95
Drug Name Drug
Tier
Requirements
/ Limits
CITRANATAL
(DUAL-IRON)
4
CITRANATAL 90
DHA (ALGAL OIL)
4
CITRANATAL
ASSURE ORAL
COMBO PACK 35
MG IRON-1 MG -
50 MG-300 MG
4
CITRANATAL B-
CALM (FE GLUC)
4
CITRANATAL
BLOOM
4
CITRANATAL
DHA (ALGAL OIL)
4
CITRANATAL
HARMONY (IRON
FUM)
4
classic prenatal 1 ACA; OTC
c-nate dha 1
complete natal dha 1
complex b-100 oral
tablet extended
release
2 ACA; OTC
CONCEPT DHA 4
CONCEPT OB 4
cyanocobalamin
(vitamin b-12)
injection
2
dialyvite 800 oral
tablet
2 ACA; OTC
DRISDOL ORAL
CAPSULE
4
DUET DHA
BALANCED ORAL
COMBO PACK 25
MG IRON-1 MG -
267 MG-233 MG
4
Drug Name Drug
Tier
Requirements
/ Limits
DUET DHA WITH
OMEGA-3 ORAL
COMBO PACK 25
MG IRON-1 MG -
400 MG
4
elite-ob 1
ENBRACE HR 4
ergocalciferol
(vitamin d2) oral
capsule 1,250 mcg
(50,000 unit)
2
FLORIVA
(FLUORIDE-
VITAMIN D3)
4 OTC
FLUORABON 4 OTC
fluoride (sodium)
oral drops
1 ACA; OTC
fluoride (sodium)
oral tablet,chewable
1 ACA; OTC
fluoritab oral
tablet,chewable
1 ACA; OTC
FLURA-DROPS 4 OTC
FOLET ONE 4
folic acid oral tablet
400 mcg, 800 mcg
1 ACA; OTC
folivane-ob 1
foltabs 800 2 ACA; OTC
full spectrum b-
vitamin c
2 ACA; OTC
hydroxocobalamin 2
kobee 2 ACA; OTC
KOSHER
PRENATAL PLUS
IRON
4
kpn oral tablet 1 ACA; OTC
ludent fluoride 1 ACA; OTC
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
96
Drug Name Drug
Tier
Requirements
/ Limits
MARNATAL-F 4
MECOBALAMIN
(VITAMIN B12)
INJECTION
4
m-natal plus 1
multi-vitamin with
fluoride
1 ACA; OTC
multivitamins with
fluoride
1 ACA; OTC
mvc-fluoride 1 ACA; OTC
mynatal 1
mynatal advance 1
mynatal plus 1
mynatal-z 1
mynate 90 plus 1
NASCOBAL 3
NATACHEW (FE
BIS-GLYCINATE)
4
natural b-100
complex
2 ACA; OTC
NEEVODHA
(WITH ALGAL
OIL)
4
NESTABS 4
NESTABS ABC 4
NESTABS DHA 4
NESTABS ONE 4
newgen 1
OB COMPLETE
ONE
4
OB COMPLETE
ORAL TABLET
4
OB COMPLETE
PETITE
4
Drug Name Drug
Tier
Requirements
/ Limits
OB COMPLETE
PREMIER
4
OB COMPLETE
WITH DHA
4
obstetrix dha 1
OBSTETRIX EC 4
OBSTETRIX ONE 4
OBTREX DHA 4
O-CAL
PRENATAL
4
one daily prenatal
oral combo pack 28-
800-440 mg-mcg-mg
1 ACA; OTC
perry prenatal 1 ACA; OTC
pnv 29-1 1
pnv-dha 1
pnv-dha + docusate 1
pnv-omega 1
pnv-select 1
pr natal 400 1
pr natal 400 ec 1
pr natal 430 1
pr natal 430 ec 1
PREGENNA 4
prena1 chew 1
prena1 pearl 1
prena1 true 1
prenaissance 1
prenaissance plus 1
PRENATA 4
prenatabs fa 1
prenatabs rx 1
prenatal complete 1 ACA; OTC
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
97
Drug Name Drug
Tier
Requirements
/ Limits
prenatal formula
oral tablet 28 mg
iron- 800 mcg
1 ACA; OTC
prenatal multi-dha
(algal oil)
1 ACA; OTC
prenatal one daily 1 ACA; OTC
prenatal oral tablet
28 mg iron- 800 mcg
1 ACA; OTC
prenatal plus 1
prenatal plus
(calcium carb)
1
PRENATAL PLUS
DHA ORAL
COMBO PACK
4
prenatal vitamin
oral tablet 27 mg
iron- 0.8 mg
2 ACA; OTC
prenatal vitamin
plus low iron
1
prenatal vitamin
with minerals
1 ACA; OTC
prenatal vits96-iron
fum-folic
1 ACA; OTC
prenatal-u 1
PRENATE AM 4
PRENATE
CHEWABLE
4
PRENATE DHA
(FERR ASP
GLYCIN)
4
PRENATE ELITE
(IRON ASP GLYC)
4
PRENATE
ENHANCE
4
PRENATE
ESSENTIAL(IRON-
ASP-GL)
4
Drug Name Drug
Tier
Requirements
/ Limits
PRENATE MINI
(FERR ASP
GLYCIN)
4
PRENATE PIXIE 4
PRENATE
RESTORE
4
PRENATE STAR 4
preplus 1
pretab 1
PRIMACARE 4
PROVIDA OB 4
PUREFE OB PLUS 4
rena-vite 2 ACA; OTC
R-NATAL OB 4
SELECT-OB 4
SELECT-OB
(FOLIC ACID)
4
SELECT-OB +
DHA
4
se-natal 19 chewable 1
se-natal-19 1
stress formula 2 ACA; OTC
stress formula with
iron
2 ACA; OTC
stress formula with
iron(sulf)
2 ACA; OTC
super b complex-
vitamin c
2 ACA; OTC
super b maxi
complex
2 ACA; OTC
super quints 2 ACA; OTC
super quints b-50 2 ACA; OTC
taron-c dha 1
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
98
Drug Name Drug
Tier
Requirements
/ Limits
taron-prex prenatal-
dha
1
THRIVITE RX 4
total b/c 2 ACA; OTC
TRICARE 4
TRIFERIC 4
trinatal rx 1 1
trinate 1
TRINAZ 4
TRISTART DHA 4
triveen-duo dha 1
tri-vitamin with
fluoride
1 ACA; OTC
VINATE DHA RF 4
virt-c dha 1
virt-nate dha 1
virt-pn dha 1
virt-pn plus 1
VITAFOL FE PLUS 4
VITAFOL FE+
(WITH
DOCUSATE)
4
VITAFOL
GUMMIES
4
VITAFOL NANO 4
VITAFOL ULTRA 4
VITAFOL-OB 4
Drug Name Drug
Tier
Requirements
/ Limits
VITAFOL-
OB+DHA
4
VITAFOL-ONE 4
VITAMED MD
ONE RX
4
VITAMEDMD
REDICHEW RX
4
vitamin b complex
oral tablet
2 ACA; OTC
vitamin b complex-
folic acid oral tablet
2 ACA; OTC
vitamin d3 oral
capsule 10 mcg (400
unit)
1 ACA; OTC
vitamin d3 oral
tablet 10 mcg (400
unit)
1 ACA; OTC
vitamin d3 oral
tablet,chewable 25
mcg (1,000 unit)
1 ACA; OTC
vitamins a,c,d and
fluoride
1 ACA; OTC
VITAPEARL 4
VITATRUE 4
vp-ch-pnv 1
VP-PNV-DHA 4
zatean-pn dha 1
zatean-pn plus 1
zingiber 1
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
99
Index
A abacavir .................................. 9
abacavir-lamivudine ............... 9
abacavir-lamivudine-
zidovudine .......................... 9
ABILIFY MYCITE .............. 29
abiraterone ............................ 16
ABSORICA .......................... 44
ABSORICA LD ................... 44
acamprosate .......................... 52
acarbose ................................ 63
ACCOLATE......................... 89
ACCU-CHEK GUIDE L1-L2
CTRL SOL ....................... 56
ACCU-CHEK SMARTVIEW
CONTRL SOL ................. 56
ACCUPRIL .......................... 35
ACCURETIC ....................... 35
ACCUTREND GLUCOSE
CONTROL ....................... 56
acebutolol ............................. 35
acetaminophen-caff-
dihydrocod ........................ 24
acetaminophen-codeine ........ 24
acetazolamide ....................... 85
acetic acid ....................... 52, 55
acetylcysteine ....................... 89
acitretin ................................. 42
ACTEMRA .......................... 75
ACTEMRA ACTPEN .......... 75
ACTHAR ............................. 55
ACTHIB (PF) ....................... 73
ACTICLATE ........................ 15
ACTIGALL .......................... 66
ACTIMMUNE ..................... 73
ACTIQ .................................. 24
ACTIVELLA ....................... 76
ACTONEL ........................... 74
ACTOPLUS MET ................ 63
ACTOPLUS MET XR ......... 63
ACTOS ................................. 63
ACULAR ............................. 85
ACULAR LS ........................ 85
acyclovir ........................... 9, 49
ACZONE .............................. 44
ADACEL(TDAP
ADOLESN/ADULT)(PF) 73
ADALAT CC ....................... 35
adapalene .............................. 44
ADAPALENE ...................... 44
adapalene-benzoyl peroxide . 44
ADASUVE ........................... 29
ADDERALL XR .................. 29
ADDYI ................................. 29
adefovir ................................... 9
ADEMPAS ........................... 89
ADHANSIA XR................... 29
ADRENALIN ....................... 89
adult aspirin regimen ............ 27
ADVAIR DISKUS ............... 89
ADVAIR HFA ..................... 89
ADVATE.............................. 38
ADVOCATE LOW
CONTROL ....................... 56
ADVOCATE REDI-CODE+
CTRL LOW ...................... 56
ADYNOVATE ..................... 38
ADZENYS ER ..................... 29
ADZENYS XR-ODT ........... 29
AEMCOLO .......................... 12
AFINITOR ........................... 16
AFINITOR DISPERZ .......... 16
afirmelle................................ 78
AFREZZA ............................ 61
AFSTYLA ............................ 38
AFTERA .............................. 78
AGAMATRIX CONTROL
HIGH ................................ 57
AGRYLIN ............................ 52
AIMOVIG AUTOINJECTOR
.......................................... 22
AIRDUO RESPICLICK....... 89
AJOVY AUTOINJECTOR .. 22
AJOVY SYRINGE............... 22
AKLIEF ................................ 45
ak-poly-bac ........................... 82
AKTEN (PF) ........................ 83
ala-cort .................................. 49
albendazole ........................... 12
ALBENZA ........................... 13
albuterol sulfate .................... 89
ALCAINE ............................. 83
alclometasone ....................... 49
ALDACTAZIDE .................. 35
ALDACTONE ...................... 35
ALDARA ............................. 73
alendronate ........................... 74
ALFERON N ........................ 73
alfuzosin ............................... 92
ALINIA ................................ 13
aliskiren ................................ 35
ALKERAN ........................... 16
allopurinol ............................. 74
ALLZITAL ........................... 24
almotriptan malate ................ 22
ALOCRIL ............................. 83
ALOMIDE ............................ 83
alophen (bisacodyl) .............. 66
ALORA ................................ 76
alosetron ............................... 66
ALPHAGAN P ..................... 87
alprazolam ............................ 29
alprazolam intensol ............... 29
ALPROLIX .......................... 38
ALREX ................................. 86
ALTABAX ........................... 47
altacaine ................................ 83
ALTACE .............................. 35
ALTAFLUOR BENOX ........ 83
altavera (28) .......................... 78
ALTRENO ........................... 45
ALUNBRIG ......................... 16
ALVESCO ............................ 89
alyacen 1/35 (28) .................. 78
alyacen 7/7/7 (28) ................. 78
alyq ....................................... 89
amabelz ................................. 76
amantadine hcl ........................ 9
AMARYL ............................. 63
ambrisentan ........................... 89
amcinonide ........................... 49
AMELUZ ............................. 44
AMERGE ............................. 22
amethia ................................. 78
amethia lo ............................. 78
amethyst (28) ........................ 78
AMICAR .............................. 38
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
100
amiloride............................... 35
amiloride-hydrochlorothiazide
.......................................... 35
aminocaproic acid ................ 38
amiodarone ........................... 34
AMITIZA ............................. 66
amitriptyline ......................... 29
amitriptyline-chlordiazepoxide
.......................................... 29
amlodipine ............................ 35
amlodipine-atorvastatin ........ 40
amlodipine-benazepril .......... 35
amlodipine-olmesartan ......... 35
amlodipine-valsartan ............ 35
amlodipine-valsartan-hcthiazid
.......................................... 35
ammonium lactate ................ 44
amnesteem ............................ 45
amoxapine ............................ 29
amoxicil-clarithromy-lansopraz
.......................................... 70
amoxicillin ............................ 14
amoxicillin-pot clavulanate .. 14
amphetamine sulfate ............. 29
ampicillin .............................. 14
AMZEEQ ............................. 45
ANADROL-50 ..................... 62
ANAFRANIL ....................... 30
anagrelide ............................. 52
ANA-LEX KIT .................... 66
ANALPRAM-HC........... 43, 66
ANALPRAM-HC SINGLES66
ANAPROX DS .................... 27
anaspaz ................................. 65
anastrozole ............................ 16
ANCOBON ............................ 9
ANDRODERM .................... 62
ANDROGEL ........................ 62
ANDROID ........................... 62
ANGELIQ ............................ 76
ANNOVERA ....................... 77
ANORO ELLIPTA .............. 89
ANTARA ............................. 41
anucort-hc ............................. 66
apexicon e ............................. 49
APLENZIN .......................... 30
APOKYN ............................. 21
apraclonidine ........................ 87
aprepitant .............................. 66
apri ........................................ 78
APRISO ................................ 66
APTENSIO XR .................... 30
APTIOM ............................... 19
APTIVUS ............................... 9
APTIVUS (WITH VITAMIN
E) ........................................ 9
aqua care sodium chloride .... 52
aqua care sterile water .......... 52
ARAKODA .......................... 13
aranelle (28) .......................... 78
ARAVA ................................ 75
ARCALYST ......................... 73
ARCAPTA NEOHALER ..... 89
ARESTIN ............................. 54
ARICEPT ............................. 23
ARIKAYCE ......................... 13
aripiprazole ........................... 30
ARIXTRA ............................ 38
armodafinil ........................... 30
ARMONAIR RESPICLICK 89
ARMOUR THYROID ......... 65
ARNUITY ELLIPTA ........... 89
AROMASIN ......................... 16
ARTHROTEC 50 ................. 27
ARTHROTEC 75 ................. 27
ARYMO ER ......................... 24
ascomp with codeine ............ 25
ashlyna .................................. 78
ASMANEX HFA ................. 89
ASMANEX TWISTHALER 89
aspir-81 ................................. 27
aspirin ................................... 27
aspirin low dose .................... 27
aspirin-dipyridamole ............ 38
ASPIRIN-OMEPRAZOLE .. 38
aspir-trin ............................... 27
ASSURE 4 CONTROL
SOLUTION ...................... 57
ASSURE DOSE NORMAL
CONTROL ....................... 57
ASSURE PRISM CONTROL
1-2 SOLN ......................... 57
ASTAGRAF XL................... 16
AT HOME A1C ................... 57
atazanavir................................ 9
ATELVIA ............................. 74
atenolol ................................. 35
atenolol-chlorthalidone ......... 35
ATIVAN ............................... 30
atomoxetine .......................... 30
atorvastatin ........................... 41
atovaquone ............................ 13
atovaquone-proguanil ........... 13
atropine ................................. 83
ATROPINE .......................... 83
ATROVENT HFA ................ 89
aubra ..................................... 78
aubra eq ................................ 78
AUGMENTIN ...................... 14
AUGMENTIN ES-600 ......... 14
AUGMENTIN XR ............... 14
aurovela 1.5/30 (21) .............. 78
aurovela 1/20 (21) ................. 78
aurovela 24 fe ....................... 79
aurovela fe 1.5/30 (28) ......... 79
aurovela fe 1-20 (28) ............ 79
AURYXIA ............................ 66
AUSTEDO ........................... 23
AUTOJECT 2 INJECTION
DEVICE ........................... 57
AUTOPEN 1 TO 21 UNITS 57
AUTOSOFT 30 .................... 57
AUTOSOFT 90 .................... 57
AUTOSOFT XC INFUSION
SET 23 .............................. 57
AVANDIA ........................... 63
avar ....................................... 45
AVAR ................................... 45
AVAR LS ............................. 45
AVAR-E GREEN ................. 45
AVAR-E LS ......................... 45
aviane .................................... 79
avidoxy ................................. 15
AVIDOXY DK ..................... 15
avita ...................................... 45
AVITA .................................. 45
AVONEX ............................. 72
AYGESTIN .......................... 76
ayuna ..................................... 79
AYVAKIT ............................ 16
AZASAN .............................. 16
AZASITE ............................. 82
azathioprine .......................... 16
azelaic acid ........................... 45
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
101
azelastine ........................ 54, 84
azelastine-fluticasone ........... 89
AZELEX .............................. 45
AZILECT ............................. 21
azithromycin ......................... 12
AZOPT ................................. 85
AZULFIDINE ...................... 66
AZULFIDINE EN-TABS .... 66
azurette (28).......................... 79
B b complex 1 (with folic acid) 94
b complex-vitamin b12......... 94
b complex-vitamin c-folic acid
.......................................... 94
bacitracin .............................. 82
bacitracin-polymyxin b ........ 82
baclofen ................................ 24
BACLOFEN ......................... 24
BACTRIM ............................ 15
BACTRIM DS...................... 15
balanced b-100 ..................... 94
balanced b-100 complex....... 94
balanced b-50 ....................... 94
bal-care dha .......................... 94
BAL-CARE DHA
ESSENTIAL..................... 94
BALCOLTRA ...................... 79
balsalazide ............................ 66
BALVERSA ......................... 16
balziva (28) ........................... 79
BANZEL .............................. 19
BAQSIMI ............................. 56
BARACLUDE ....................... 9
BASAGLAR KWIKPEN U-
100 INSULIN ................... 61
BAXDELA ........................... 14
bayer aspirin ......................... 27
BCG VACCINE, LIVE (PF) 73
b-complex with vitamin c ..... 94
BD INTEGRA NEEDLE ..... 57
BD MICROTAINER
LANCET .......................... 57
BD SPECIALTY USE
NEEDLES ........................ 57
BD ULTRA FINE LANCETS
.......................................... 57
BD ULTRA-FINE NANO
PEN NEEDLE .................. 57
bekyree (28) .......................... 79
BELBUCA ........................... 25
belladonna alkaloids-opium . 65
BELSOMRA ........................ 30
benazepril ............................. 35
benazepril-hydrochlorothiazide
.......................................... 35
BENEFIX ............................. 38
BENLYSTA ......................... 75
BENZACLIN ....................... 45
BENZACLIN PUMP ........... 45
BENZAMYCIN ................... 45
benzepro ............................... 45
BENZEPRO
(MICROSPHERES) ......... 45
BENZNIDAZOLE ............... 13
benzonatate ........................... 88
benzoyl peroxide .................. 45
benztropine ........................... 22
BEOVU ................................ 84
BEPREVE ............................ 84
beser...................................... 49
BESIVANCE........................ 82
BETADINE OPHTHALMIC
PREP ................................ 82
betamethasone dipropionate . 49
betamethasone valerate......... 49
betamethasone, augmented ... 49
BETAPACE ......................... 34
BETAPACE AF ................... 34
BETASERON ...................... 72
betaxolol ......................... 35, 83
bethanechol chloride............. 92
BETHKIS ............................. 13
BETIMOL ............................ 83
BETOPTIC S ........................ 83
BEVACIZUMAB ................. 84
BEVESPI AEROSPHERE ... 89
BEVYXXA .......................... 38
bexarotene ............................ 16
BEXSERO ............................ 73
BEYAZ ................................. 79
bicalutamide ......................... 16
BIDIL ................................... 35
BIJUVA ................................ 76
BIKTARVY ........................... 9
BILTRICIDE ........................ 13
bimatoprost ........................... 85
BINOSTO ............................. 74
BIOTHRAX ......................... 73
bisacodyl ............................... 66
bisa-lax (bisacodyl) .............. 66
bisoprolol fumarate ............... 35
bisoprolol-hydrochlorothiazide
.......................................... 35
BLEPH-10 ............................ 87
BLEPHAMIDE .................... 87
BLEPHAMIDE S.O.P. ......... 87
blisovi 24 fe .......................... 79
blisovi fe 1.5/30 (28) ............ 79
blisovi fe 1/20 (28) ............... 79
BLOOD GLUCOSE
CONTROL, NORMAL .... 57
BONIVA ............................... 74
BONJESTA .......................... 66
BOOSTRIX TDAP ............... 73
bosentan ................................ 89
BOSULIF ............................. 16
BOTOX ................................ 73
bp 10-1 .................................. 45
BRAFTOVI .......................... 16
BREEZE 2 CONTROL
SOLUTION,HIGH ........... 57
BREO ELLIPTA .................. 89
briellyn .................................. 79
BRILINTA ........................... 38
brimonidine ........................... 87
BRIMONIDINE-
DORZOLAMIDE (PF) ..... 85
BRIVIACT ..................... 19, 20
BROMFED DM ................... 88
bromfenac ............................. 85
bromocriptine ....................... 22
brompheniramine-pseudoeph-
dm ..................................... 88
BROMSITE .......................... 85
BROVANA .......................... 90
BRUKINSA .......................... 16
BRYHALI ............................ 49
budesonide ...................... 66, 90
bumetanide ........................... 35
BUPHENYL ......................... 52
buprenorphine ....................... 25
buprenorphine hcl ................. 25
buprenorphine-naloxone ....... 27
bupropion hcl ........................ 30
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
102
BUPROPION HCL .............. 30
bupropion hcl (smoking deter)
.......................................... 53
buspirone .............................. 30
butalbital compound w/codeine
.......................................... 25
butalbital-acetaminop-caf-cod
.......................................... 25
butalbital-acetaminophen ..... 25
butalbital-acetaminophen-caff
.......................................... 25
butalbital-aspirin-caffeine .... 25
butorphanol tartrate .............. 27
BYDUREON ........................ 64
BYDUREON BCISE ........... 64
BYETTA .............................. 64
BYSTOLIC .......................... 35
C cabergoline ........................... 62
CABLIVI .............................. 39
CABOMETYX..................... 16
CADUET .............................. 41
CAFERGOT ......................... 22
caffeine citrate ...................... 52
CALAN SR .......................... 35
calcipotriene ......................... 43
calcipotriene-betamethasone 43
calcitonin (salmon) ............... 62
calcitriol .......................... 43, 62
calcium 500 + d .................... 93
calcium 600 + d(3) ............... 94
calcium acetate(phosphat bind)
.......................................... 66
calcium citrate-vitamin d3 .... 94
CALQUENCE ...................... 16
CAMBIA .............................. 27
camila ................................... 76
camrese ................................. 79
camrese lo ............................. 79
CANASA ............................. 66
candesartan ........................... 35
candesartan-hydrochlorothiazid
.......................................... 35
CANTHARIDIN IN
ACETONE ....................... 44
CAPCOF .............................. 88
capecitabine .......................... 16
CAPEX ................................. 49
CAPRELSA.......................... 17
captopril ................................ 35
captopril-hydrochlorothiazide
.......................................... 35
CARAFATE ......................... 70
CARBAGLU ........................ 52
carbamazepine ...................... 20
CARBATROL ...................... 20
carbidopa .............................. 22
carbidopa-levodopa .............. 22
carbidopa-levodopa-
entacapone ........................ 22
carbinoxamine maleate ......... 87
CARDIZEM ......................... 35
CARDIZEM CD................... 35
CARDIZEM LA ................... 35
CARDURA .......................... 35
CARDURA XL .................... 35
CARESENS CONTROL A
NORMAL ......................... 57
carisoprodol .......................... 24
carisoprodol-aspirin .............. 24
carisoprodol-aspirin-codeine 24
CARNITOR.......................... 52
CARNITOR (SUGAR-FREE)
.......................................... 52
CAROSPIR .......................... 35
carteolol ................................ 83
cartia xt ................................. 35
CARTRIDGE STAMPED IR
1200 .................................. 57
carvedilol .............................. 35
carvedilol phosphate ............. 35
CASODEX ........................... 17
CATAPRES.......................... 35
CATAPRES-TTS-1 .............. 35
CATAPRES-TTS-2 .............. 35
CATAPRES-TTS-3 .............. 35
CAVERJECT ....................... 92
CAVERJECT IMPULSE ..... 93
CAYA CONTOURED ......... 76
CAYSTON ........................... 13
caziant (28) ........................... 79
cefaclor ................................. 11
cefadroxil ........................ 11, 12
cefdinir.................................. 12
cefditoren pivoxil ................. 12
cefixime ................................ 12
cefpodoxime ......................... 12
cefprozil ................................ 12
cefuroxime axetil .................. 12
celecoxib ............................... 27
CELLCEPT .......................... 17
CELONTIN .......................... 20
CENTANY ........................... 47
CENTANY AT ..................... 48
cephalexin ............................. 12
CEPROTIN (BLUE BAR) ... 39
CEPROTIN (GREEN BAR) 39
CEQUA ................................ 84
CEQUR SIMPLICITY ......... 57
CERDELGA ......................... 62
CERVIDIL ........................... 77
CESAMET ........................... 66
cetirizine ............................... 87
cevimeline ............................. 52
CHANTIX ............................ 53
CHANTIX CONTINUING
MONTH BOX .................. 53
CHANTIX STARTING
MONTH BOX .................. 53
chateal (28) ........................... 79
chateal eq (28) ...................... 79
CHEMET .............................. 52
CHENODAL ........................ 66
children's aspirin ................... 27
chlordiazepoxide hcl ............. 30
chlordiazepoxide-clidinium .. 65
chlorhexidine gluconate ........ 54
chloroquine phosphate .......... 13
chlorothiazide ....................... 35
chlorpromazine ..................... 30
chlorthalidone ....................... 35
chlorzoxazone ....................... 24
CHOLBAM .......................... 66
cholecalciferol (vitamin d3) . 94
cholestyramine (with sugar) . 41
cholestyramine light ............. 41
choline,magnesium salicylate
.......................................... 27
ciclodan ................................. 48
CICLODAN KIT .................. 48
ciclopirox .............................. 48
ciclopirox-ure-camph-menth-
euc ..................................... 48
cilostazol ............................... 39
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
103
CILOXAN ............................ 82
CIMDUO ................................ 9
cimetidine ............................. 70
cimetidine hcl ....................... 70
cinacalcet .............................. 62
CIPRO .................................. 14
CIPRO HC............................ 55
CIPRODEX .......................... 55
ciprofloxacin......................... 14
ciprofloxacin hcl ....... 14, 55, 82
citalopram ............................. 30
CITRANATAL (DUAL-
IRON) ............................... 95
CITRANATAL 90 DHA
(ALGAL OIL) .................. 95
CITRANATAL ASSURE .... 95
CITRANATAL B-CALM (FE
GLUC) .............................. 95
CITRANATAL BLOOM ..... 95
CITRANATAL DHA
(ALGAL OIL) .................. 95
CITRANATAL HARMONY
(IRON FUM) .................... 95
citrate of magnesia ............... 66
citroma .................................. 66
claravis ................................. 45
CLARINEX .......................... 87
CLARINEX-D 12 HOUR .... 88
clarithromycin ...................... 12
classic prenatal ..................... 95
clearlax ................................. 66
clemastine ............................. 87
CLENPIQ ............................. 66
CLEO 90 INFUSION SET 24
.......................................... 57
CLEOCIN............................. 78
CLEOCIN HCL.................... 13
CLEOCIN PEDIATRIC ....... 13
CLEOCIN T ......................... 45
CLEVER CHOICE LEVEL 2
CONTROL ....................... 57
CLIMARA ........................... 76
CLINDACIN ETZ................ 45
clindacin p ............................ 45
CLINDACIN PAC ............... 45
clindamycin hcl .................... 13
clindamycin palmitate hcl .... 13
clindamycin pediatric ........... 13
clindamycin phosphate ... 45, 78
clindamycin-benzoyl peroxide
.......................................... 45
clindamycin-tretinoin ........... 45
CLINDESSE ........................ 78
CLINPRO 5000 .................... 54
clobazam ............................... 20
clobetasol .............................. 49
clobetasol-emollient ............. 49
CLOBEX .............................. 50
clodan ................................... 50
CLODAN KIT ...................... 50
CLODERM .......................... 50
clomipramine ........................ 30
clonazepam ........................... 20
clonidine ............................... 35
clonidine hcl ................... 30, 35
clopidogrel ............................ 39
clorazepate dipotassium ....... 30
clotrimazole ...................... 9, 48
clotrimazole-betamethasone . 48
clovique ................................ 52
clozapine ............................... 30
CLOZAPINE ........................ 30
CLOZARIL .......................... 30
c-nate dha ............................. 95
COAGADEX........................ 39
COARTEM .......................... 13
COCAINE ............................ 47
codeine sulfate ...................... 25
codeine-butalbital-asa-caff ... 25
codeine-guaifenesin .............. 88
CODITUSSIN AC ................ 88
CODITUSSIN DAC ............. 88
COLAZAL ........................... 66
colchicine.............................. 74
COLCRYS............................ 74
colesevelam .......................... 41
COLESTID ........................... 41
COLESTID FLAVORED .... 41
colestipol .............................. 41
colocort ................................. 67
COMBIGAN ........................ 85
COMBIPATCH .................... 76
COMBIVENT RESPIMAT . 90
COMBIVIR .......................... 10
COMETRIQ ......................... 17
COMFORT INFUSION SET
43 ...................................... 57
COMFORT SHORT INSULIN
PUMP 23 .......................... 57
COMPAZINE ....................... 67
complete natal dha ................ 95
complex b-100 ...................... 95
compro .................................. 67
COMTAN ............................. 22
CONCEPT DHA .................. 95
CONCEPT OB ..................... 95
CONCERTA ......................... 30
CONDYLOX ........................ 44
CONSENSI ........................... 36
constulose ............................. 67
CONTACT DETACH INFUS
SET 23 .............................. 57
CONTOUR CONTROL
SOLUTION, NML ........... 57
CONTOUR NEXT LEV 2
CONTROL SOL ............... 57
CONZIP ................................ 27
COOL CONTROL A
SOLUTION ...................... 57
COPAXONE ........................ 72
COPIKTRA .......................... 17
CORDRAN ........................... 50
CORDRAN TAPE LARGE
ROLL ................................ 50
COREG CR .......................... 36
coremino ............................... 15
CORGARD ........................... 36
CORLANOR ........................ 42
CORTANE-B ....................... 44
CORTEF ............................... 55
CORTENEMA ..................... 67
cortisone ............................... 55
CORTISPORIN .................... 48
CORTISPORIN-TC ............. 55
COSENTYX ......................... 43
COSENTYX (2 SYRINGES)
.......................................... 43
COSENTYX PEN ................ 43
COSENTYX PEN (2 PENS) 43
COSOPT (PF) ....................... 85
COTELLIC ........................... 17
COTEMPLA XR-ODT ........ 30
covaryx ................................. 76
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
104
covaryx h.s. .......................... 76
CREON ................................ 67
CRESEMBA .......................... 9
CRINONE ............................ 76
CRIXIVAN .......................... 10
cromolyn................... 67, 84, 90
crotan .................................... 52
cryselle (28) .......................... 79
CUROSURF ......................... 90
CUTIVATE .......................... 50
CUVPOSA ........................... 65
cyanocobalamin (vitamin b-12)
.......................................... 95
cyclafem 1/35 (28) ............... 79
cyclafem 7/7/7 (28) .............. 79
cyclobenzaprine .................... 24
CYCLOGYL ........................ 83
CYCLOMYDRIL................. 87
cyclopentolate....................... 83
CYCLOPEN-TROPIC-
PHENYLEPH-WATR ..... 83
cyclophosphamide ................ 17
CYCLOSERINE .................. 13
CYCLOSET ......................... 64
cyclosporine ......................... 17
CYCLOSPORINE IN
KLARITY ........................ 84
cyclosporine modified .......... 17
cyproheptadine ..................... 88
cyred ..................................... 79
cyred eq ................................ 79
CYSTADANE ...................... 67
CYSTAGON ........................ 93
CYSTARAN ........................ 84
CYTOTEC ........................... 70
D D.H.E.45 ............................... 22
dalfampridine ....................... 23
DALIRESP ........................... 90
danazol ................................. 62
DANTRIUM ........................ 24
dantrolene ............................. 24
dapsone ........................... 13, 45
DAPTACEL (DTAP
PEDIATRIC) (PF)............ 73
DARAPRIM ......................... 13
darifenacin ............................ 92
dasetta 1/35 (28) ................... 79
dasetta 7/7/7 (28) .................. 79
DAURISMO ......................... 17
DAYPRO.............................. 27
daysee ................................... 79
DAYTRANA........................ 30
DDAVP ................................ 62
deblitane ............................... 76
decadron ............................... 55
deferasirox ............................ 52
DELESTROGEN ................. 76
demeclocycline ..................... 15
DEMEROL ........................... 25
DEMSER .............................. 36
DENAVIR ............................ 49
denta 5000 plus ..................... 54
dentagel ................................ 54
DEPAKOTE ......................... 20
DEPAKOTE ER ................... 20
DEPAKOTE SPRINKLES .. 20
DEPEN TITRATABS .......... 75
DEPO-ESTRADIOL ............ 76
DEPO-PROVERA................ 76
DEPO-SUBQ PROVERA 104
.......................................... 76
DEPO-TESTOSTERONE .... 62
DERMA-SMOOTHE/FS
BODY OIL ....................... 50
DERMA-SMOOTHE/FS
SCALP OIL ...................... 50
DERMOTIC OIL ................. 55
DESCOVY ........................... 10
desipramine .......................... 30
desloratadine ......................... 88
desmopressin ........................ 62
desog-e.estradiol/e.estradiol . 79
desogestrel-ethinyl estradiol . 79
DESONATE ......................... 50
desonide ................................ 50
DESOWEN .......................... 50
desoximetasone .................... 50
DESOXYN ........................... 30
DESVENLAFAXINE .......... 30
desvenlafaxine succinate ...... 30
dexabliss ............................... 55
dexamethasone ..................... 55
dexamethasone intensol ........ 55
dexamethasone sodium
phosphate .......................... 86
DEXAMETH-
MOXIFLOX(PF)-
NACL,ISO ........................ 86
DEXAMET-MOXIFL-
KETORO-NACL(PF) ....... 84
dexchlorpheniramine maleate
.......................................... 88
DEXCOM G4 RECEIVER .. 57
DEXCOM G5 RECEIVER .. 57
DEXCOM G6 RECEIVER .. 57
DEXCOM RECEIVER ........ 57
DEXEDRINE SPANSULE .. 30
DEXILANT .......................... 70
dexmethylphenidate .............. 31
DEXTENZA ......................... 86
dextroamphetamine .............. 31
dextroamphetamine-
amphetamine ..................... 31
DEXYCU (PF) ..................... 86
DIACOMIT .......................... 20
dialyvite 800 ......................... 95
DIASTAT ............................. 20
DIASTAT ACUDIAL .......... 20
DIATRUE CONTROL SOLN
NORMAL ......................... 58
diazepam ......................... 20, 31
diazepam intensol ................. 31
diazoxide ............................... 56
DIBENZYLINE ................... 36
DICLEGIS ............................ 67
diclofenac potassium ............ 27
diclofenac sodium .... 27, 28, 44,
85
diclofenac-misoprostol ......... 28
dicloxacillin .......................... 14
dicyclomine .......................... 65
didanosine ............................. 10
DIFFERIN ............................ 45
DIFICID ............................... 12
diflorasone ............................ 50
DIFLUCAN ............................ 9
diflunisal ............................... 28
digitek ................................... 38
digox ..................................... 38
digoxin .................................. 38
dihydroergotamine ................ 22
DILANTIN ........................... 20
DILANTIN EXTENDED ..... 20
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
105
DILANTIN INFATABS ...... 20
DILANTIN-125 ................... 20
DILATRATE-SR ................. 42
DILAUDID .......................... 25
diltiazem ............................... 36
dilt-xr .................................... 36
DIPENTUM ......................... 67
DIPHEN ............................... 88
diphenoxylate-atropine ......... 65
DIPROLENE ........................ 50
dipyridamole......................... 39
DISALCID ........................... 28
diskets ................................... 25
disopyramide phosphate ....... 34
disulfiram ............................. 52
DITROPAN XL ................... 92
DIURIL ................................ 36
divalproex ............................. 20
DIVIGEL .............................. 76
dofetilide............................... 34
DOLOPHINE ....................... 25
donepezil .............................. 23
DONNATAL ........................ 65
DOPTELET (15 TAB PACK)
.......................................... 39
DORYX ................................ 15
DORYX MPC ...................... 15
dorzolamide .......................... 85
DORZOLAMIDE (PF) ........ 85
dorzolamide-timolol ............. 85
dorzolamide-timolol (pf) ...... 85
DORZOLAMIDE-TIMOLOL
(PF) ................................... 85
dotti....................................... 76
DOVATO ............................. 10
DOVONEX .......................... 43
doxazosin .............................. 36
doxepin ........................... 31, 44
doxercalciferol ...................... 62
doxycycline hyclate .............. 15
doxycycline monohydrate .... 15
doxylamine-pyridoxine (vit b6)
.......................................... 67
D-PENAMINE ..................... 75
DRISDOL............................. 95
dronabinol............................. 67
drospirenone-e.estradiol-lm.fa
.......................................... 79
drospirenone-ethinyl estradiol
.......................................... 79
DROXIA .............................. 17
DSUVIA ............................... 25
DUAVEE.............................. 76
ducodyl (bisacodyl) .............. 67
DUET DHA BALANCED ... 95
DUET DHA WITH OMEGA-3
.......................................... 95
DUETACT ........................... 64
DUEXIS ............................... 28
DULERA .............................. 90
duloxetine ............................. 31
DUOBRII ............................. 50
DUOPA ................................ 22
DUPIXENT SYRINGE ........ 44
DURAGESIC ....................... 25
DUREZOL ........................... 86
dutasteride ............................ 92
dutasteride-tamsulosin .......... 92
dvorah ................................... 25
DXEVO ................................ 55
DYANAVEL XR ................. 31
DYAZIDE ............................ 36
DYMISTA ............................ 90
DYRENIUM ........................ 36
E e.c. prin ................................. 28
e.e.s. 400 ............................... 12
E.E.S. GRANULES.............. 12
EASY PLUS II HIGH
CONTROL ....................... 58
EASY STEP HIGH
CONTROL SOLN ............ 58
EASY TALK HIGH
CONTROL ....................... 58
EASY TRAK LOW
CONTROL ....................... 58
EASYGLUCO PLUS
NORMAL CONTROL ..... 58
EASYMAX LOW CONTROL
.......................................... 58
EASYMAX NORMAL
CONTROL ....................... 58
ECLIPSE NEEDLE .............. 58
EC-NAPROSYN .................. 28
econazole .............................. 48
econtra ez .............................. 79
econtra one-step .................... 79
ecotrin ................................... 28
ecotrin low strength .............. 28
ECOZA ................................. 48
EDARBI ............................... 36
EDARBYCLOR ................... 36
EDECRIN ............................. 36
EDEX ................................... 93
EDLUAR .............................. 31
ed-spaz .................................. 65
EDURANT ........................... 10
eemt ...................................... 76
eemt hs .................................. 77
efavirenz ............................... 10
effer-k ................................... 94
EFFER-K .............................. 94
EFFIENT .............................. 39
EFUDEX .............................. 44
EGRIFTA ............................. 72
EGRIFTA SV ....................... 72
ELEMENT COMPACT
NORMAL CONTROL ..... 58
ELEMENT NORMAL
CONTROL ....................... 58
ELESTRIN ........................... 77
eletriptan ............................... 22
ELIGARD ............................. 17
ELIGARD (3 MONTH) ....... 17
ELIGARD (4 MONTH) ....... 17
ELIGARD (6 MONTH) ....... 17
ELIMITE .............................. 52
elinest .................................... 79
ELIQUIS ............................... 39
ELIQUIS DVT-PE TREAT
30D START ...................... 39
elite-ob .................................. 95
ELIXOPHYLLIN ................. 90
ELLA .................................... 79
ELMIRON ............................ 93
ELOCTATE ......................... 39
eluryng .................................. 78
EMBRACE EVO LEVEL 1 . 58
EMBRACE GLUCOSE
CONTROL LOW ............. 58
EMBRACE TALK
CONTROL-LOW (L1) ..... 58
EMCYT ................................ 17
EMGALITY PEN ................. 22
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
106
EMGALITY SYRINGE ....... 22
emoquette ............................. 79
EMSAM ............................... 31
EMTRIVA ............................ 10
EMVERM ............................ 13
enalapril maleate .................. 36
enalapril-hydrochlorothiazide
.......................................... 36
ENBRACE HR ..................... 95
ENBREL .............................. 75
ENBREL MINI .................... 75
ENBREL SURECLICK ....... 75
endocet ................................. 25
ENGERIX-B (PF) ................ 73
ENGERIX-B PEDIATRIC
(PF) ................................... 73
ENLITE SYSTEM ............... 58
enoxaparin ............................ 39
enpresse ................................ 79
enskyce ................................. 79
ENSTILAR........................... 43
entacapone ............................ 22
entecavir ............................... 10
ENTEREG ............................ 67
ENTOCORT EC .................. 67
ENTRESTO ......................... 42
enulose .................................. 67
ENVARSUS XR .................. 17
ENZOCLEAR ...................... 45
EPCLUSA ............................ 10
EPIDIOLEX ......................... 20
EPIFOAM ............................ 43
epinastine .............................. 84
epinephrine ........................... 88
EPIPEN 2-PAK .................... 88
EPIPEN JR 2-PAK ............... 88
EPISIL .................................. 54
epitol ..................................... 20
EPIVIR ................................. 10
EPIVIR HBV........................ 10
eplerenone ............................ 36
eprosartan ............................. 36
EPZICOM ............................ 10
EQUETRO ........................... 20
ergocalciferol (vitamin d2) ... 95
ergoloid................................. 31
ERGOMAR .......................... 22
ergotamine-caffeine .............. 22
ERIVEDGE .......................... 17
ERLEADA ........................... 17
erlotinib ................................ 17
errin ...................................... 77
ERTACZO............................ 48
ery pads................................. 45
erygel .................................... 45
ERYPED 200 ....................... 12
ERYPED 400 ....................... 12
ery-tab ................................... 12
ERY-TAB ............................. 12
erythrocin (as stearate) ......... 12
erythromycin .................. 12, 82
erythromycin ethylsuccinate. 12
erythromycin with ethanol.... 45
erythromycin-benzoyl peroxide
.......................................... 46
ESBRIET .............................. 90
escitalopram oxalate ............. 31
ESGIC .................................. 25
ESKATA .............................. 44
esomeprazole magnesium..... 70
ESPEROCT .......................... 39
estarylla ................................ 79
estazolam .............................. 31
ESTRACE ............................ 77
estradiol ................................ 77
estradiol valerate................... 77
estradiol-norethindrone acet . 77
ESTRING ............................. 77
estrogens-methyltestosterone 77
ESTROSTEP FE-28 ............. 79
eszopiclone ........................... 31
ethacrynic acid ...................... 36
ethambutol ............................ 13
ethosuximide ........................ 20
ethynodiol diac-eth estradiol 79
etidronate disodium .............. 52
etodolac ................................ 28
etonogestrel-ethinyl estradiol78
etoposide ............................... 17
EUCRISA ............................. 44
EURAX ................................ 52
euthyrox ................................ 65
EVAMIST ............................ 77
EVEKEO .............................. 31
EVEKEO ODT ..................... 31
everolimus (antineoplastic) .. 17
everolimus
(immunosuppressive) ....... 17
EVERSENSE SENSOR-
HOLDER .......................... 58
EVISTA ................................ 74
EVOCLIN ............................. 46
EVOLUTION NORMAL
CONTROL ....................... 58
EVOTAZ .............................. 10
EVOXAC ............................. 52
EXELDERM ........................ 48
EXELON .............................. 23
exemestane ........................... 17
EXTINA ............................... 48
EYLEA ................................. 84
ezetimibe ............................... 41
ezetimibe-simvastatin ........... 41
F FABIOR ............................... 46
FACTIVE ............................. 14
falmina (28) .......................... 79
famciclovir ............................ 10
famotidine ............................. 70
FANAPT ............................... 31
FARESTON ......................... 17
FARXIGA ............................ 64
FARYDAK ........................... 17
FASENRA PEN ................... 90
fayosim ................................. 79
FC2 FEMALE CONDOM ... 76
febuxostat ............................. 74
felbamate .............................. 20
FELBATOL .......................... 20
FELDENE ............................ 28
felodipine .............................. 36
fem ph ................................... 78
FEMARA ............................. 17
FEMCAP .............................. 76
FEMHRT LOW DOSE ........ 77
femynor ................................. 79
fenofibrate ............................. 41
FENOFIBRATE ................... 41
fenofibrate micronized .......... 41
fenofibrate nanocrystallized . 41
fenofibric acid ....................... 41
fenofibric acid (choline) ....... 41
FENOGLIDE ........................ 41
fenoprofen ............................. 28
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
107
fentanyl ................................. 25
fentanyl citrate ...................... 25
FERRIPROX ........................ 52
FETZIMA............................. 31
FEXMID............................... 24
FIBRICOR ........................... 41
FINACEA............................. 46
finasteride ............................. 92
FIORICET ............................ 25
FIORICET WITH CODEINE
.......................................... 25
FIORINAL ........................... 25
FIORINAL-CODEINE #3 ... 25
FIRDAPSE ........................... 23
FIRVANQ ............................ 16
flac otic oil ............................ 55
FLAGYL .............................. 13
FLAREX .............................. 86
flavoxate ............................... 92
flecainide .............................. 34
FLECTOR ............................ 28
fleet laxative (bisacodyl) ...... 67
FLOLIPID ............................ 41
FLOMAX ............................. 92
FLORIVA (FLUORIDE-
VITAMIN D3) ................. 95
FLOVENT DISKUS ............ 90
FLOVENT HFA ................... 90
fluconazole ............................. 9
flucytosine .............................. 9
fludrocortisone ..................... 55
FLUMADINE ...................... 10
flunisolide ............................. 90
fluocinolone .......................... 50
fluocinolone acetonide oil .... 55
fluocinolone and shower cap 50
fluocinonide .......................... 50
fluocinonide-e....................... 50
FLUORABON ..................... 95
fluorescein-proparacaine ...... 84
fluoride (sodium) ............ 54, 95
FLUORIDEX DAILY
DEFENSE ........................ 54
FLUORIDEX SENSITIVITY
RELIEF ............................ 54
fluoritab ................................ 95
fluorometholone ................... 86
FLUOROPLEX .................... 44
fluorouracil ........................... 44
fluoxetine .............................. 31
fluphenazine hcl ................... 31
FLURA-DROPS ................... 95
flurandrenolide ..................... 50
flurazepam ............................ 31
flurbiprofen ........................... 28
flurbiprofen sodium .............. 85
flutamide ............................... 17
fluticasone propionate .... 50, 90
fluticasone propion-salmeterol
.......................................... 90
FLUTICASONE PROPION-
SALMETEROL................ 90
fluvastatin ............................. 41
fluvoxamine .......................... 31
FML LIQUIFILM ................ 86
FOLET ONE ........................ 95
folic acid ............................... 95
folivane-ob............................ 95
foltabs 800 ............................ 95
fondaparinux ......................... 39
FORA GTEL MULTI-
FUNCTN MONITOR ...... 58
FORA NORMAL CONTROL
.......................................... 58
FORACARE GDH LOW
CONTROL ....................... 58
FORFIVO XL....................... 31
FORTAMET ........................ 64
FORTEO .............................. 74
FORTESTA .......................... 62
FORTISCARE NORMAL ... 58
FOSAMAX .......................... 74
FOSAMAX PLUS D ............ 74
fosamprenavir ....................... 10
fosinopril .............................. 36
fosinopril-hydrochlorothiazide
.......................................... 36
FRAGMIN............................ 39
FREESTYLE CONTROL .... 58
FREESTYLE FREEDOM .... 58
FREESTYLE FREEDOM
LITE ................................. 58
FREESTYLE INSULINX ... 56,
58
FREESTYLE INSULINX
TEST STRIPS .................. 56
FREESTYLE LIBRE 14 DAY
READER .......................... 58
FREESTYLE LIBRE 14 DAY
SENSOR ........................... 58
FREESTYLE LITE METER 58
FREESTYLE LITE STRIPS 56
FREESTYLE TEST ............. 56
FROVA ................................. 22
frovatriptan ........................... 22
full spectrum b-vitamin c ...... 95
FULPHILA ........................... 71
FURADANTIN .................... 16
furosemide ............................ 36
FUZEON .............................. 10
fyavolv .................................. 77
FYCOMPA ........................... 20
G g tussin ac ............................. 88
gabapentin ............................. 20
GABITRIL ........................... 20
GALAFOLD ......................... 62
galantamine ........................... 23
GALZIN ............................... 94
GARDASIL 9 (PF) ............... 73
GASTROCROM .................. 67
gatifloxacin ........................... 82
GATTEX 30-VIAL .............. 67
gavilax .................................. 67
gavilyte-c .............................. 67
gavilyte-g .............................. 67
gavilyte-n .............................. 67
GE100 CONTROL
SOLUTION NORMAL .... 58
GELCLAIR .......................... 54
GELNIQUE .......................... 92
GELX ................................... 54
gemfibrozil ........................... 41
GENERESS FE .................... 79
generlac ................................. 67
gengraf .................................. 17
GENOTROPIN ..................... 72
GENOTROPIN MINIQUICK
.......................................... 72
gentak ................................... 82
gentamicin ...................... 48, 82
GENTEEL VACUUM
LANCING DEVICE ........ 58
gentle laxative (bisacodyl) .... 67
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
108
gentlelax ............................... 67
GENVOYA .......................... 10
GEODON ............................. 31
gianvi (28) ............................ 79
GILENYA ............................ 72
GILOTRIF ............................ 17
GLASSIA ............................. 52
glatiramer ............................. 72
glatopa .................................. 72
GLEOLAN ........................... 53
GLEOSTINE ........................ 17
GLIADEL WAFER.............. 17
glimepiride ........................... 64
glipizide ................................ 64
glipizide-metformin .............. 64
GLOPERBA ......................... 74
GLUCAGEN DIAGNOSTIC
KIT ................................... 56
GLUCAGEN HYPOKIT ..... 56
GLUCAGON (HCL)
EMERGENCY KIT ......... 56
GLUCAGON EMERGENCY
KIT (HUMAN) ................ 56
GLUCAGON HCL .............. 56
GLUCOCARD 01 NORMAL
CONTROL ....................... 58
GLUCOCOM CONTROL
NORMAL......................... 59
GLUCOSE CONTROL........ 59
GLUCOTROL ...................... 64
GLUCOTROL XL ............... 64
glyburide............................... 64
glyburide micronized............ 64
glyburide-metformin ............ 64
GLYCATE ........................... 65
glycolax ................................ 67
glycopyrrolate....................... 65
glydo ..................................... 47
GLYNASE ........................... 64
GLYSET............................... 64
GLYXAMBI ........................ 64
GOJJI GLUCOSE CNTRL
SOL-NORMAL ................ 59
GOJJI KETONE CONTROL
SOLN-L1 .......................... 59
GOJJI MULTI-FUNCTIONAL
METER ............................ 59
GOLYTELY......................... 67
GONITRO ............................ 42
GOPRELTO ......................... 47
GRALISE ............................. 20
GRALISE 30-DAY STARTER
PACK ............................... 20
granisetron hcl ...................... 67
griseofulvin microsize ............ 9
griseofulvin ultramicrosize ..... 9
guaiatussin ac ....................... 88
guaifenesin dac ..................... 88
guanfacine ...................... 31, 36
guanidine .............................. 31
GUARDIAN REAL-TIME
GLU MONITOR .............. 59
GVOKE HYPOPEN 2-PACK
.......................................... 56
GVOKE PFS 2-PACK
SYRINGE ......................... 56
GYNAZOLE-1 ..................... 78
gynol ii .................................. 78
H HAEGARDA........................ 90
hailey .................................... 79
hailey 24 fe ........................... 79
hailey fe 1.5/30 (28) ............. 80
hailey fe 1/20 (28) ................ 80
halcinonide ........................... 50
HALCION ............................ 31
halobetasol propionate .......... 50
HALOBETASOL
PROPIONATE ................. 50
HALOG ................................ 50
haloperidol ............................ 31
haloperidol lactate ................ 31
HARVONI............................ 10
HAVRIX (PF) ...................... 73
HEALTHPRO HIGH-LOW
CONTROL ....................... 59
healthylax ............................. 67
heather .................................. 77
HEMANGEOL ..................... 36
HEMLIBRA ......................... 39
hemmorex-hc ........................ 67
hep flush-10 (pf) ................... 39
heparin (porcine) .................. 39
HEPARIN (PORCINE) IN
0.9% NACL ...................... 39
heparin (porcine) in 5 % dex 39
heparin (porcine) in nacl (pf) 39
heparin flush(porcine)-0.9nacl
.......................................... 39
heparin lock flush ................. 39
heparin lock flush (porcine) .. 39
heparin lockflush(porcine)(pf)
.......................................... 40
heparin(porcine) in 0.45% nacl
.......................................... 40
HEPARIN(PORCINE) IN
0.45% NACL .................... 40
heparin, porcine (pf) ............. 40
HEPARIN, PORCINE (PF).. 40
HEPLISAV-B (PF) ............... 73
HEPSERA ............................ 10
HETLIOZ ............................. 31
HIBERIX (PF) ...................... 73
hidex ..................................... 55
HIPREX ................................ 16
HISTEX-AC ......................... 88
homatropaire ......................... 83
HORIZANT .......................... 23
HUMALOG JUNIOR
KWIKPEN U-100 ............ 61
HUMALOG KWIKPEN
INSULIN .......................... 61
HUMALOG MIX 50-50
INSULN U-100 ................ 61
HUMALOG MIX 50-50
KWIKPEN ........................ 61
HUMALOG MIX 75-25
KWIKPEN ........................ 61
HUMALOG MIX 75-25(U-
100)INSULN .................... 61
HUMALOG U-100 INSULIN
.......................................... 61
HUMIRA .............................. 75
HUMIRA PEN ..................... 75
HUMIRA PEN CROHNS-UC-
HS START ....................... 75
HUMIRA PEN PSOR-
UVEITS-ADOL HS ......... 75
HUMIRA(CF) ...................... 75
HUMIRA(CF) PEDI
CROHNS STARTER ....... 75
HUMIRA(CF) PEN .............. 75
HUMIRA(CF) PEN
CROHNS-UC-HS ............. 75
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
109
HUMIRA(CF) PEN PSOR-
UV-ADOL HS.................. 75
HUMULIN 70/30 U-100
INSULIN .......................... 61
HUMULIN 70/30 U-100
KWIKPEN ....................... 61
HUMULIN N NPH INSULIN
KWIKPEN ....................... 61
HUMULIN N NPH U-100
INSULIN .......................... 61
HUMULIN R REGULAR U-
100 INSULN .................... 61
HUMULIN R U-500 (CONC)
INSULIN .......................... 61
HUMULIN R U-500 (CONC)
KWIKPEN ....................... 61
HYCAMTIN ........................ 17
hydralazine ........................... 36
HYDREA ............................. 17
hydrochlorothiazide .............. 36
hydrocodone bitartrate.......... 25
hydrocodone-acetaminophen 25
hydrocodone-chlorpheniramine
.......................................... 88
hydrocodone-homatropine ... 88
hydrocodone-ibuprofen ........ 26
hydrocortisone .......... 51, 55, 67
hydrocortisone acetate .......... 67
hydrocortisone butyrate .. 50, 51
hydrocortisone butyr-emollient
.......................................... 51
hydrocortisone valerate ........ 51
hydrocortisone-acetic acid.... 55
hydrocortisone-pramoxine .. 43,
67
hydromet............................... 88
hydromorphone .................... 26
hydroxocobalamin ................ 95
hydroxychloroquine ............. 13
hydroxyurea .......................... 17
hydroxyzine hcl .................... 88
hydroxyzine pamoate ........... 88
hyophen ................................ 93
hyoscyamine sulfate ............. 65
hyosyne................................. 65
HYPER-SAL ........................ 90
HYSINGLA ER ................... 26
I ibandronate ........................... 74
IBRANCE ............................ 17
ibu ......................................... 28
ibuprofen .............................. 28
ibuprofen-oxycodone............ 26
icatibant ................................ 90
ICLUSIG .............................. 17
IDELVION ........................... 40
IDHIFA ................................ 17
IFE-BIMIX 30/1 ................... 93
IFE-PG20.............................. 93
ILEVRO ............................... 85
ILUVIEN .............................. 86
imatinib ................................. 17
IMBRUVICA ....................... 17
imipramine hcl ...................... 31
imipramine pamoate ............. 31
imiquimod ............................ 73
IMOVAX RABIES VACCINE
(PF) ................................... 73
IMPAVIDO .......................... 13
IMPOYZ ............................... 51
IMURAN .............................. 17
IMVEXXY MAINTENANCE
PACK ............................... 77
IMVEXXY STARTER PACK
.......................................... 77
INBRIJA ............................... 22
incassia ................................. 77
INCRELEX .......................... 53
INCRUSE ELLIPTA ............ 90
indapamide ........................... 36
INDERAL XL ...................... 36
INDOCIN ............................. 28
indomethacin ........................ 28
INFANRIX (DTAP) (PF) ..... 73
INFASURF ........................... 53
INFINITY CONTROL
SOLUTION NORM ......... 59
INFINITY VOICE CTRL
SOLN-LVL 2 ................... 59
INFUSION SET 43 .............. 59
INLYTA ............................... 17
INNOPRAN XL ................... 36
INOVA ................................. 46
INOVA 4-1 ........................... 43
INOVA 8-2 ........................... 43
INPEN (FOR HUMALOG) . 59
INPEN (FOR NOVOLOG OR
FIASP) .............................. 59
INSET 30 INFUSION SET 23
.......................................... 59
INSET INFUSION SET 23 .. 59
INSPRA ................................ 36
INSULIN SYRINGE-
NEEDLE U-100 ............... 56
INTELENCE ........................ 10
INTERMEZZO ..................... 31
INTRAROSA ....................... 78
INTRON A ........................... 73
introvale ................................ 80
INVEGA ............................... 32
INVELTYS ........................... 86
INVIRASE ........................... 10
INVOKAMET ...................... 64
INVOKAMET XR ............... 64
INVOKANA ......................... 64
iodine-sodium iodide ............ 44
IODOFLEX .......................... 44
IODOSORB .......................... 44
IOPIDINE ............................. 87
IPOL ..................................... 73
ipratropium bromide ....... 54, 90
ipratropium-albuterol ............ 90
irbesartan .............................. 36
irbesartan-hydrochlorothiazide
.......................................... 36
IRESSA ................................ 17
ISENTRESS ......................... 10
ISENTRESS HD .................. 10
isibloom ................................ 80
ISOCHRON .......................... 42
isoniazid ................................ 13
ISOPTO ATROPINE ........... 83
ISOPTO CARPINE .............. 83
ISORDIL .............................. 42
ISORDIL TITRADOSE ....... 42
isosorbide dinitrate ............... 42
isosorbide mononitrate ......... 42
isotretinoin ............................ 46
isoxsuprine ............................ 78
isradipine .............................. 36
itraconazole ............................. 9
ivermectin ....................... 13, 46
IXIARO (PF) ........................ 73
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
110
IXINITY ............................... 40
J jaimiess ................................. 80
JAKAFI ................................ 17
JALYN ................................. 92
jantoven ................................ 40
JANUMET ........................... 64
JANUMET XR ..................... 64
JANUVIA............................. 64
JARDIANCE ........................ 64
jasmiel (28) ........................... 80
JELMYTO ............................ 17
jencycla................................. 77
JENTADUETO .................... 64
JENTADUETO XR.............. 64
jinteli..................................... 77
JIVI ....................................... 40
jolessa ................................... 80
JORNAY PM ....................... 32
JUBLIA ................................ 48
juleber ................................... 80
JULUCA............................... 10
junel 1.5/30 (21) ................... 80
junel 1/20 (21) ...................... 80
junel fe 1.5/30 (28) ............... 80
junel fe 1/20 (28) .................. 80
junel fe 24 ............................. 80
JUXTAPID ........................... 41
JYNARQUE ......................... 62
K KADIAN .............................. 26
kaitlib fe................................ 80
KALETRA ........................... 10
kalliga ................................... 80
KALYDECO ........................ 90
KAPVAY ............................. 32
KARBINAL ER ................... 88
kariva (28) ............................ 80
KEFLEX............................... 12
kelnor 1/35 (28) .................... 80
kelnor 1-50 ........................... 80
KENALOG........................... 51
KERYDIN ............................ 48
KETAMINE ......................... 32
ketoconazole ..................... 9, 48
ketodan ................................. 48
ketodan kit ............................ 48
ketoprofen............................. 28
ketorolac ......................... 28, 85
KEVEYIS ............................. 23
KEVZARA ........................... 75
KINRIX (PF) ........................ 73
kionex (with sorbitol) ........... 67
KITABIS PAK ..................... 13
KLARITY-A (AZITHRO-
CHONDR)(PF) ................. 84
KLARITY-B (BETAMETH-
CHOND)(PF) ................... 84
KLARITY-L (LOTEPRED-
CHOND)(PF) ................... 84
KLARON ............................. 48
KLONOPIN.......................... 20
klor-con ................................ 94
klor-con 10 ........................... 94
klor-con 8 ............................. 94
klor-con m10 ........................ 94
klor-con m15 ........................ 94
klor-con m20 ........................ 94
klor-con/ef ............................ 94
kobee .................................... 95
KOGENATE FS ................... 40
KOSELUGO ........................ 17
KOSHER PRENATAL PLUS
IRON ................................ 95
KOVALTRY ........................ 40
K-PHOS NO 2 ...................... 93
K-PHOS ORIGINAL ........... 93
kpn ........................................ 95
KRINTAFEL ........................ 13
KRISTALOSE...................... 67
k-tab ...................................... 94
K-TAB .................................. 94
kurvelo (28) .......................... 80
KUVAN................................ 62
KYLEENA ........................... 76
L l norgest/e.estradiol-e.estrad . 80
labetalol ................................ 36
LACRISERT ........................ 84
lactated ringers ..................... 52
lactulose ................................ 67
LAMICTAL XR STARTER
(BLUE) ............................. 20
LAMICTAL XR STARTER
(GREEN) .......................... 20
LAMICTAL XR STARTER
(ORANGE) ....................... 20
lamivudine ............................ 10
lamivudine-zidovudine ......... 10
lamotrigine ............................ 20
LANCETS ............................ 59
LANCING DEVICE ............ 59
LANOXIN ............................ 38
lansoprazole .......................... 70
lanthanum ............................. 67
LANTUS SOLOSTAR U-100
INSULIN .......................... 61
LANTUS U-100 INSULIN .. 61
larin 1.5/30 (21) .................... 80
larin 1/20 (21) ....................... 80
larin 24 fe .............................. 80
larin fe 1.5/30 (28) ................ 80
larin fe 1/20 (28) ................... 80
larissia ................................... 80
LASIX .................................. 36
LASTACAFT ....................... 84
latanoprost ............................ 85
LATANOPROST (PF) ......... 85
LATUDA .............................. 32
laxaclear ................................ 67
laxative (bisacodyl) .............. 67
laxative peg 3350 .................. 67
layolis fe ............................... 80
leena 28 ................................. 80
leflunomide ........................... 75
LENVIMA ............................ 17
LESCOL XL ......................... 41
lessina ................................... 80
letrozole ................................ 17
leucovorin calcium ............... 16
LEUKERAN ......................... 17
LEUKINE ............................. 71
leuprolide .............................. 17
levalbuterol hcl ..................... 90
LEVAQUIN ......................... 14
LEVBID ............................... 66
LEVEMIR FLEXTOUCH U-
100 INSULN .................... 61
LEVEMIR U-100 INSULIN 61
levetiracetam ......................... 20
LEVITRA ............................. 93
levobunolol ........................... 83
levocarnitine ......................... 53
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
111
levocarnitine (with sugar)..... 53
levocetirizine ........................ 88
levofloxacin .................... 14, 82
levonest (28) ......................... 80
levonorgestrel ....................... 80
levonorgestrel-ethinyl estrad 80
levonorg-eth estrad triphasic 80
levora-28............................... 80
levorphanol tartrate .............. 26
LEVORPHANOL
TARTRATE ..................... 26
levo-t..................................... 65
levothyroxine ........................ 65
levoxyl .................................. 65
LEVSIN ................................ 66
LEVSIN/SL .......................... 66
LEVULAN ........................... 44
LEXETTE ............................ 51
LEXIVA ............................... 10
LIALDA ............................... 67
lidocaine ............................... 47
lidocaine hcl ......................... 47
lidocaine hcl-hydrocortison ac
.................................... 47, 67
LIDOCAINE HCL-
HYDROCORTISON AC . 67
lidocaine viscous .................. 47
lidocaine-hydrocortisone-aloe
.......................................... 68
LIDOCAINE-
PHENYLEPHRIN-BSS(PF)
.......................................... 84
lidocaine-phenylephrn in water
.......................................... 84
lidocaine-prilocaine .............. 47
LILETTA ............................. 76
lillow (28) ............................. 80
lindane .................................. 52
linezolid ................................ 13
LINZESS .............................. 68
liothyronine .......................... 65
LIPOFEN ............................. 41
lisinopril ............................... 36
lisinopril-hydrochlorothiazide
.......................................... 36
lite coat aspirin ..................... 28
lithium carbonate .................. 32
lithium citrate ....................... 32
LITHOBID ........................... 32
LITHOSTAT ........................ 53
LIVALO ............................... 41
LO LOESTRIN FE ............... 80
LODINE ............................... 28
LODOSYN ........................... 22
lojaimiess .............................. 80
LOKELMA .......................... 68
LOMOTIL ............................ 66
LONHALA MAGNAIR
REFILL ............................ 90
LONHALA MAGNAIR
STARTER ........................ 91
LONSURF ............................ 17
loperamide ............................ 66
LOPID .................................. 41
lopinavir-ritonavir ................ 10
lopreeza ................................ 77
LOPRESSOR ....................... 36
LOPROX .............................. 48
LOPROX (AS OLAMINE) .. 48
LOPROX KIT ...................... 48
lorazepam ............................. 32
lorazepam intensol ................ 32
LORBRENA ........................ 17
lorcet (hydrocodone) ............ 26
lorcet hd ................................ 26
LORTAB ELIXIR ................ 26
lortuss ex............................... 88
loryna (28) ............................ 80
LORZONE ........................... 24
losartan ................................. 36
losartan-hydrochlorothiazide 37
LOSEASONIQUE................ 80
LOTEMAX .................... 86, 87
LOTEMAX SM .................... 87
LOTENSIN .......................... 37
LOTENSIN HCT ................. 37
loteprednol etabonate ........... 87
LOTRONEX ........................ 68
lovastatin .............................. 41
LOVAZA.............................. 41
low-ogestrel (28) .................. 80
loxapine succinate ................ 32
lo-zumandimine (28) ............ 80
lta pre-attached ..................... 47
LUCENTIS ........................... 84
ludent fluoride ...................... 95
lugols .............................. 48, 94
LUMIGAN ........................... 85
LUPANETA PACK (1
MONTH) .......................... 78
LUPANETA PACK (3
MONTH) .......................... 78
LUPRON DEPOT ................ 17
LUPRON DEPOT (3
MONTH) .......................... 18
LUPRON DEPOT (4
MONTH) .......................... 18
LUPRON DEPOT (6
MONTH) .......................... 18
LUPRON DEPOT-PED ....... 18
LUPRON DEPOT-PED (3
MONTH) .......................... 18
lutera (28) ............................. 80
LUXIQ .................................. 51
LUZU ................................... 48
LYNPARZA ......................... 18
LYSODREN ......................... 18
LYSTEDA ............................ 78
lyza ....................................... 77
M MACRILEN ......................... 71
MACROBID ......................... 16
MACRODANTIN ................ 16
MACUGEN .......................... 84
mafenide acetate ................... 48
magnesium citrate ................. 68
MALARONE ....................... 13
MALARONE PEDIATRIC .. 13
malathion .............................. 52
maprotiline ............................ 32
MAR-COF CG ..................... 88
MARINOL ........................... 68
marlissa (28) ......................... 80
MARNATAL-F .................... 96
MARPLAN ........................... 32
MATULANE ........................ 18
matzim la .............................. 37
MAVENCLAD (10 TABLET
PACK) .............................. 72
MAVENCLAD (4 TABLET
PACK) .............................. 72
MAVENCLAD (5 TABLET
PACK) .............................. 72
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
112
MAVENCLAD (6 TABLET
PACK) .............................. 72
MAVENCLAD (7 TABLET
PACK) .............................. 72
MAVENCLAD (8 TABLET
PACK) .............................. 72
MAVENCLAD (9 TABLET
PACK) .............................. 72
MAXITROL ......................... 86
MAXI-TUSS CD.................. 88
MAXZIDE ........................... 37
MAXZIDE-25MG ................ 37
MAYZENT .......................... 72
m-clear wc ............................ 88
meclizine .............................. 68
meclofenamate ..................... 28
MECOBALAMIN (VITAMIN
B12) .................................. 96
MEDISENSE ....................... 59
MEDISENSE GLUCOSE
KETONE .......................... 59
MEDROL ............................. 55
MEDROL (PAK) ................. 55
medroxyprogesterone ........... 77
mefenamic acid .................... 28
mefloquine ............................ 13
megestrol .............................. 18
MEKINIST ........................... 18
MEKTOVI ........................... 18
melodetta 24 fe ..................... 80
meloxicam ............................ 28
melphalan ............................. 18
memantine ............................ 23
MEMANTINE ..................... 23
MENACTRA (PF) ............... 73
M-END PE ........................... 88
MENEST .............................. 77
MENOSTAR ........................ 77
MENTAX ............................. 48
MENVEO A-C-Y-W-135-DIP
(PF) ................................... 73
meperidine ............................ 26
MEPHYTON ........................ 40
meprobamate ........................ 24
MEPRON ............................. 13
mercaptopurine ..................... 18
mesalamine ........................... 68
mesalamine with cleansing
wipe .................................. 68
MESNEX.............................. 16
MESTINON ......................... 24
MESTINON TIMESPAN .... 24
metadate er ........................... 32
metaproterenol ...................... 91
metaxall ................................ 24
metaxalone............................ 24
metformin ............................. 64
methadone ............................ 26
methadose ............................. 26
methamphetamine ................ 32
methazolamide...................... 85
methenamine hippurate ........ 16
methenamine mandelate ....... 16
methen-sod phos-meth blue-
hyos .................................. 93
methergine ............................ 82
methimazole ......................... 56
METHITEST ........................ 62
methocarbamol ..................... 24
methotrexate sodium ............ 18
methotrexate sodium (pf) ..... 18
methoxsalen .......................... 44
methscopolamine .................. 66
methyl salicylate ................... 44
methyldopa ........................... 37
methyldopa-
hydrochlorothiazide .......... 37
methylergonovine ................. 82
METHYLIN ......................... 32
methylphenidate hcl ............. 32
METHYLPHENIDATE HCL
.......................................... 32
methylprednisolone .............. 55
methyltestosterone ................ 62
metipranolol.......................... 83
metoclopramide hcl .............. 68
metolazone............................ 37
METOPIRONE .................... 53
metoprolol succinate............. 37
metoprolol ta-hydrochlorothiaz
.......................................... 37
metoprolol tartrate ................ 37
METROCREAM .................. 46
METROGEL ........................ 46
METROGEL VAGINAL ..... 78
METROLOTION ................. 46
metronidazole ........... 13, 46, 78
mexiletine ............................. 34
MIACALCIN ....................... 62
mibelas 24 fe ......................... 80
MICONAZOLE NITRATE-
ZINC OX-PET .................. 48
miconazole-3 ........................ 78
microgestin 1.5/30 (21) ........ 80
microgestin 1/20 (21) ........... 80
microgestin fe 1.5/30 (28) .... 80
microgestin fe 1/20 (28) ....... 80
midazolam ............................ 32
midodrine .............................. 53
migergot ................................ 23
miglitol ................................. 64
miglustat ............................... 62
MIGRANAL ......................... 23
mili ........................................ 80
milk of magnesia .................. 68
milk of magnesia concentrated
.......................................... 68
millipred ............................... 55
millipred dp .......................... 55
mimvey ................................. 77
MINIMED INFUSION SET-
MMT 390 .......................... 59
MINIMED MIO 32 .............. 59
MINIMED MIO ADVANCE
INF SET23 ........................ 59
MINIMED SILHOUETTE 23
.......................................... 59
MINIMED SURE T 32 ........ 59
MINIPRESS ......................... 37
MINITRAN .......................... 42
MINIVELLE ........................ 77
minocycline .......................... 15
MINOLIRA ER .................... 15
minoxidil ............................... 37
MIO INFUSION SET ........... 59
MIOCHOL-E ........................ 83
miostat .................................. 85
miralax .................................. 68
MIRAPEX ............................ 22
MIRAPEX ER ...................... 22
MIRCETTE (28) .................. 80
MIRENA .............................. 76
mirtazapine ........................... 32
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
113
MIRVASO ........................... 46
misoprostol ........................... 70
MITIGARE .......................... 74
MITOSOL ............................ 85
MKO (MIDAZOLAM-
KETAMINE-ONDAN) .... 32
M-M-R II (PF) ...................... 73
m-natal plus .......................... 96
MOBIC ................................. 28
modafinil .............................. 32
moexipril .............................. 37
molindone ............................. 32
mometasone .................... 51, 91
mondoxyne nl ....................... 15
MONODOX ......................... 15
mono-linyah ......................... 80
montelukast .......................... 91
MONUROL .......................... 16
morgidox .............................. 15
MORGIDOX 1X 50 ............. 15
MORGIDOX 2X100 ............ 15
morphine............................... 26
morphine concentrate ........... 26
MOTEGRITY ...................... 68
MOTOFEN........................... 66
MOVANTIK ........................ 68
MOVIPREP .......................... 68
MOXATAG ......................... 14
MOXEZA ............................. 82
moxifloxacin................... 15, 82
MOXIFLOXACIN (PF)-BSS
.......................................... 82
MOXIFLOXACIN-SOD
CHLOR,ISO(PF) .............. 82
MOZOBIL ............................ 71
MS CONTIN ........................ 26
MUGARD ............................ 54
MULTAQ ............................. 34
multi-vitamin with fluoride .. 96
multivitamins with fluoride .. 96
mupirocin ............................. 48
mupirocin calcium ................ 48
mvc-fluoride ......................... 96
my choice ............................. 80
my way ................................. 80
MYALEPT ........................... 62
MYAMBUTOL .................... 13
MYCOBUTIN ...................... 13
mycophenolate mofetil ......... 18
mycophenolate sodium ......... 18
MYDAYIS ........................... 32
MYDRIACYL ...................... 83
MYDRIATIC4(TROP-PROP-
PE-KTRLC)...................... 84
MYFORTIC ......................... 18
MYGLUCOHEALTH
CONTROL SOLUTION .. 59
MYLERAN .......................... 18
mynatal ................................. 96
mynatal advance ................... 96
mynatal plus ......................... 96
mynatal-z .............................. 96
mynate 90 plus...................... 96
myorisan ............................... 46
MYRBETRIQ ...................... 92
MYSOLINE ......................... 21
MYTESI ............................... 66
N nabumetone .......................... 28
nadolol .................................. 37
nadolol-bendroflumethiazide 37
naftifine ................................ 48
NAFTIN ......................... 48, 49
NALFON .............................. 28
NALOCET ........................... 26
naloxone ............................... 28
naltrexone ............................. 28
NAMENDA.......................... 23
NAMENDA TITRATION
PAK .................................. 23
NAMENDA XR ................... 23
NAMZARIC ......................... 23
NAPRELAN CR .................. 28
NAPROSYN ........................ 28
naproxen ............................... 28
naproxen sodium ............ 28, 29
naproxen-esomeprazole ........ 29
naratriptan ............................. 23
NARCAN ............................. 29
NARDIL ............................... 32
NASCOBAL ........................ 96
NATACHEW (FE BIS-
GLYCINATE) .................. 96
NATACYN .......................... 82
NATAZIA ............................ 80
nateglinide ............................ 64
NATESTO ............................ 62
NATPARA ........................... 62
NATROBA ........................... 52
natural b-100 complex .......... 96
natura-lax .............................. 68
nature-throid ......................... 65
NAYZILAM ......................... 21
NEBUPENT ......................... 13
nebusal .................................. 91
NEBUSAL ............................ 91
necon 0.5/35 (28) .................. 81
NEEVODHA (WITH ALGAL
OIL) .................................. 96
nefazodone ............................ 32
neomycin .............................. 13
neomycin-bacitracin-poly-hc 86
neomycin-bacitracin-
polymyxin ......................... 82
neomycin-polymyxin b gu .... 52
neomycin-polymyxin b-
dexameth ........................... 86
neomycin-polymyxin-
gramicidin ......................... 82
neomycin-polymyxin-hc . 55, 86
neo-polycin ........................... 82
neo-polycin hc ...................... 86
NEORAL .............................. 18
NEO-SYNALAR .................. 48
NEO-SYNALAR KIT .......... 48
NERLYNX ........................... 18
NESTABS ............................ 96
NESTABS ABC ................... 96
NESTABS DHA ................... 96
NESTABS ONE ................... 96
neuac ..................................... 46
NEUAC KIT ......................... 46
NEULASTA ......................... 71
NEUPRO .............................. 22
nevirapine ............................. 10
new day ................................. 81
newgen .................................. 96
NEXAVAR ........................... 18
NEXIUM .............................. 70
NEXIUM PACKET .............. 71
NEXLETOL ......................... 41
NEXPLANON ...................... 78
niacin .................................... 41
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
114
NIASPAN EXTENDED-
RELEASE ........................ 41
nicardipine ............................ 37
nicorette ................................ 53
nicotine ................................. 53
nicotine (polacrilex) ............. 53
NICOTROL .......................... 53
NICOTROL NS.................... 53
nifedipine .............................. 37
nikki (28) .............................. 81
NILANDRON ...................... 18
nilutamide ............................. 18
nimodipine ............................ 37
NINJACOF-XG ................... 88
NINLARO ............................ 18
nisoldipine ............................ 37
nitisinone .............................. 53
nitro-bid ................................ 42
NITRO-DUR ........................ 42
nitrofurantoin ........................ 16
nitrofurantoin macrocrystal .. 16
nitrofurantoin monohyd/m-
cryst .................................. 16
nitroglycerin ......................... 42
NITROLINGUAL ................ 42
NITROMIST ........................ 42
NITROSTAT ........................ 42
nitro-time .............................. 42
NITYR .................................. 53
NIVESTYM ......................... 71
nizatidine .............................. 71
NIZORAL ............................ 49
NOCDURNA (MEN) ........... 62
NOCDURNA (WOMEN) .... 62
nolix ...................................... 51
nora-be .................................. 77
NORDITROPIN FLEXPRO 72
noreth-ethinyl estradiol-iron . 81
norethindrone (contraceptive)
.......................................... 77
norethindrone acetate ........... 77
norethindrone ac-eth estradiol
.................................... 77, 81
norethindrone-e.estradiol-iron
.......................................... 81
NORGESIC FORTE ............ 24
norgestimate-ethinyl estradiol
.......................................... 81
NORITATE .......................... 46
norlyda .................................. 77
NORPACE ........................... 34
NORPACE CR ..................... 34
NORPRAMIN ...................... 32
nortrel 0.5/35 (28)................. 81
nortrel 1/35 (21).................... 81
nortrel 1/35 (28).................... 81
nortrel 7/7/7 (28) .................. 81
nortriptyline .......................... 32
NORVIR ............................... 10
NOURIANZ ......................... 22
NOVA MAX GLUCOSE
CONTROL ....................... 59
NOVAMAX PLUS GLU-KET
.......................................... 59
NOVOEIGHT ...................... 40
NOVOPEN ECHO ............... 59
NOVOSEVEN RT ............... 40
NOXAFIL .............................. 9
np thyroid ............................. 65
NUBEQA ............................. 18
NUCALA ............................. 91
NUCORT.............................. 51
NUCYNTA .......................... 29
NUCYNTA ER .................... 29
NUEDEXTA ........................ 24
NULEV ................................ 66
NULYTELY WITH FLAVOR
PACKS ............................. 68
NUMBRINO ........................ 47
NUPLAZID .......................... 32
NURTEC ODT ..................... 23
NUVARING ......................... 78
NUVESSA............................ 78
nyamyc ................................. 49
NYMALIZE ......................... 37
nystatin ............................. 9, 49
nystatin-triamcinolone .......... 49
nystop ................................... 49
O OB COMPLETE .................. 96
OB COMPLETE ONE ......... 96
OB COMPLETE PETITE .... 96
OB COMPLETE PREMIER 96
OB COMPLETE WITH DHA
.......................................... 96
OBREDON ........................... 88
obstetrix dha ......................... 96
OBSTETRIX EC .................. 96
OBSTETRIX ONE ............... 96
OBTREX DHA .................... 96
O-CAL PRENATAL ............ 96
OCALIVA ............................ 68
ocella ..................................... 81
octreotide acetate .................. 18
OCUFLOX ........................... 82
ODEFSEY ............................ 10
ODOMZO ............................. 18
OFEV .................................... 91
ofloxacin ................... 15, 55, 82
olanzapine ............................. 32
olanzapine-fluoxetine ........... 32
olmesartan ............................. 37
olmesartan-amlodipin-
hcthiazid ........................... 37
olmesartan-
hydrochlorothiazide .......... 37
olopatadine ..................... 54, 84
OLUX ................................... 51
OLUX-E ............................... 51
OMECLAMOX-PAK ........... 71
omega-3 acid ethyl esters ..... 41
omeprazole ........................... 71
omeprazole-sodium
bicarbonate ....................... 71
OMIDRIA ............................. 84
OMNIPOD DASH 5 PACK
POD .................................. 59
ON CALL EXPRESS
CONTROL ....................... 59
ON CALL PLUS CONTROL
.......................................... 59
ON CALL VIVID CONTROL
.......................................... 59
ondansetron ........................... 68
ondansetron hcl ..................... 68
one daily prenatal ................. 96
ONETOUCH ULTRA BLUE
TEST STRIP ..................... 56
ONETOUCH ULTRA
CONTROL ....................... 59
ONETOUCH ULTRA2
METER ............................. 60
ONETOUCH ULTRAMINI . 60
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
115
ONETOUCH VERIO FLEX
METER ............................ 60
ONETOUCH VERIO IQ
METER ............................ 60
ONETOUCH VERIO METER
.......................................... 60
ONETOUCH VERIO
REFLECT METER .......... 60
ONETOUCH VERIO TEST
STRIPS ............................. 56
ONEXTON........................... 46
ONFI..................................... 21
ONMEL .................................. 9
ONZETRA XSAIL .............. 23
opcicon one-step ................... 81
opium tincture ...................... 66
OPSUMIT ............................ 91
option-2 ................................ 81
ORACEA ............................. 15
ORACIT ............................... 93
oral saline laxative ................ 68
oralone .................................. 54
ORAMAGICRX................... 54
ORAPRED ODT .................. 55
ORAVIG ................................ 9
ORENITRAM ...................... 37
ORFADIN ............................ 53
ORILISSA ............................ 62
ORKAMBI ........................... 91
orphenadrine citrate .............. 24
orsythia ................................. 81
oscimin ................................. 66
oscimin sl.............................. 66
oscimin sr ............................. 66
oseltamivir ............................ 10
OSENI .................................. 64
OSPHENA ........................... 78
OTEZLA .............................. 75
OTEZLA STARTER............ 75
OTIPRIO .............................. 55
OTOVEL .............................. 55
OTREXUP (PF) ................... 75
OVACE ................................ 43
OVACE PLUS ..................... 43
OVACE PLUS SHAMPOO . 43
OVACE PLUS WASH......... 43
OVIDE ................................. 52
OXANDRIN......................... 62
oxandrolone .......................... 62
oxaprozin .............................. 29
OXAYDO ............................. 26
oxazepam .............................. 32
oxcarbazepine ....................... 21
OXERVATE ........................ 84
oxiconazole ........................... 49
OXISTAT ............................. 49
OXSORALEN ULTRA ....... 44
OXTELLAR XR .................. 21
oxybutynin chloride .............. 92
oxycodone ............................ 26
oxycodone-acetaminophen ... 27
oxycodone-aspirin ................ 27
OXYCONTIN ...................... 27
oxymorphone ........................ 27
OXYTROL ........................... 92
oyster shell + d3 ................... 94
oyster shell calcium-vit d3 ... 94
OZEMPIC ............................ 64
OZURDEX ........................... 87
P pacerone................................ 34
PACNEX .............................. 46
paliperidone .......................... 32
PALYNZIQ .......................... 63
PAMELOR ........................... 32
PANDEL .............................. 51
PANRETIN .......................... 44
pantoprazole ......................... 71
PARAGARD T 380A ........... 76
PAREMYD .......................... 83
paricalcitol ............................ 63
PARLODEL ......................... 22
PARNATE............................ 32
paroex oral rinse ................... 54
paromomycin ........................ 13
paroxetine hcl ....................... 33
paroxetine
mesylate(menop.sym)....... 33
PASER.................................. 13
PATANASE ......................... 54
PAXIL .................................. 33
PAXIL CR ............................ 33
PAZEO ................................. 84
PEDIAPRED ........................ 55
PEDIARIX (PF) ................... 73
PEDVAX HIB (PF) .............. 73
peg 3350-electrolytes ............ 68
PEGANONE ......................... 21
PEGASYS ............................ 72
peg-electrolyte soln .............. 68
PEGINTRON ....................... 72
peg-prep ................................ 68
PEMAZYRE ......................... 18
PEN NEEDLE, DIABETIC . 60
penicillamine ........................ 75
penicillin v potassium ........... 14
PENTACEL (PF) .................. 73
PENTACEL ACTHIB
COMPONENT (PF) ......... 73
pentamidine .......................... 13
PENTASA ............................ 68
pentazocine-naloxone ........... 29
pentoxifylline ........................ 40
PEPCID ................................ 71
PERFOROMIST ................... 91
PERIDEX ............................. 54
perindopril erbumine ............ 37
periogard ............................... 54
permethrin ............................. 52
perphenazine ......................... 33
perphenazine-amitriptyline ... 33
perry prenatal ........................ 96
PEXEVA .............................. 33
phenazopyridine ................... 93
phenelzine ............................. 33
phenobarb-hyoscy-atropine-
scop ................................... 66
phenobarbital ........................ 21
phenohytro ............................ 66
phenoxybenzamine ............... 37
phenylephrine hcl ................. 87
PHENYLEPH-
TROPICAMIDE IN
WATER ............................ 83
PHENYTEK ......................... 21
phenytoin .............................. 21
phenytoin sodium extended .. 21
philith .................................... 81
PHOSLYRA ......................... 68
phosphasal ............................ 93
phosphate laxative ................ 68
PHOSPHOLINE IODIDE .... 83
PHOTREXA CROSS-
LINKING KIT .................. 84
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
116
PHOTREXA VISCOUS ...... 84
PHYSIOLYTE ..................... 52
PHYSIOSOL IRRIGATION 52
phytonadione (vitamin k1) ... 40
PHYTONADIONE
(VITAMIN K1) ................ 40
PICATO ............................... 44
pilocarpine hcl .......... 53, 54, 83
pimecrolimus ........................ 44
pimozide ............................... 33
pimtrea (28) .......................... 81
pindolol................................. 37
pioglitazone .......................... 64
pioglitazone-glimepiride ...... 64
pioglitazone-metformin ........ 64
pirmella................................. 81
piroxicam .............................. 29
PLAN B ONE-STEP ............ 81
PLEGRIDY .......................... 72
PLENVU .............................. 68
PLEXION ............................. 46
PLEXION CLEANSING
CLOTHS .......................... 46
PLIAGLIS ............................ 47
PNEUMOVAX-23 ............... 73
pnv 29-1................................ 96
pnv-dha ................................. 96
pnv-dha + docusate .............. 96
pnv-omega ............................ 96
pnv-select ............................. 96
podofilox .............................. 44
polycin .................................. 83
polyethylene glycol 3350 ..... 68
polymyxin b sulf-trimethoprim
.......................................... 83
POLYTRIM ......................... 83
POLY-TUSSIN AC.............. 88
POMALYST ........................ 72
portia 28................................ 81
posaconazole .......................... 9
POTABA .............................. 94
potassium chloride................ 94
potassium citrate ................... 93
powderlax ............................. 68
PR BENZOYL PEROXIDE. 46
pr natal 400 ........................... 96
pr natal 400 ec ...................... 96
pr natal 430 ........................... 96
pr natal 430 ec ...................... 96
PRALUENT PEN................. 41
pramipexole .......................... 22
PRAMOSONE ..................... 43
PRANDIN ............................ 64
prasugrel ............................... 40
pravastatin ............................ 41
praziquantel .......................... 13
prazosin ................................ 37
PRECISION XTRA
KETONE-GLUCOSE ...... 60
PRECISION XTRA
MONITOR ....................... 60
PRECISION XTRA TEST ... 56
PRECOSE ............................ 64
PRED FORTE ...................... 87
PRED-G................................ 86
PRED-G S.O.P. .................... 86
prednicarbate ........................ 51
PREDNISOL ACE-
GATIFLOX-BROMFEN . 84
PREDNISOLN SP-
GATIFLOX-BROMFEN . 84
PREDNISOLN SP-
MOXIFLOX-BROMFEN 84
prednisolone ......................... 55
prednisolone acetate ............. 87
PREDNISOLONE ACETATE
(PF) ................................... 87
PREDNISOLONE ACETATE-
NEPAFENAC .................. 84
PREDNISOLONE ACET-
GATIFLOXACIN ............ 86
PREDNISOLONE SOD PH-
BROMFENAC ................. 85
PREDNISOLONE SOD PH-
MOXIFLOX ..................... 86
prednisolone sodium phosphate
.................................... 55, 87
PREDNISOLONE-
MOXIFLO-NEPAFENAC
.......................................... 85
PREDNISOLONE-
MOXIFLOXACIN HCL .. 86
PREDNISOLONE-
MOXIFLOX-BROMFEN 85
prednisone ............................ 55
prednisone intensol ............... 55
PREFEST ............................. 77
pregabalin ............................. 21
PREGENNA ......................... 96
PREMARIN ......................... 77
PREMPHASE ....................... 77
PREMPRO ........................... 77
prena1 chew .......................... 96
prena1 pearl .......................... 96
prena1 true ............................ 96
prenaissance .......................... 96
prenaissance plus .................. 96
PRENATA ............................ 96
prenatabs fa ........................... 96
prenatabs rx .......................... 96
prenatal ................................. 97
prenatal complete .................. 96
prenatal formula .................... 97
prenatal multi-dha (algal oil) 97
prenatal one daily ................. 97
prenatal plus .......................... 97
prenatal plus (calcium carb) . 97
PRENATAL PLUS DHA ..... 97
prenatal vitamin .................... 97
prenatal vitamin plus low iron
.......................................... 97
prenatal vitamin with minerals
.......................................... 97
prenatal vits96-iron fum-folic
.......................................... 97
prenatal-u .............................. 97
PRENATE AM ..................... 97
PRENATE CHEWABLE ..... 97
PRENATE DHA (FERR ASP
GLYCIN) .......................... 97
PRENATE ELITE (IRON ASP
GLYC) .............................. 97
PRENATE ENHANCE ........ 97
PRENATE
ESSENTIAL(IRON-ASP-
GL) ................................... 97
PRENATE MINI (FERR ASP
GLYCIN) .......................... 97
PRENATE PIXIE ................. 97
PRENATE RESTORE ......... 97
PRENATE STAR ................. 97
PREPIDIL ............................. 78
preplus .................................. 97
PREPOPIK ........................... 68
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
117
PRESTALIA ........................ 37
pretab .................................... 97
PRETOMANID .................... 13
prevalite ................................ 41
PREVIDENT ........................ 54
PREVIDENT 5000 BOOSTER
PLUS ................................ 54
PREVIDENT 5000 DRY
MOUTH ........................... 54
PREVIDENT 5000 ENAMEL
PROTECT ........................ 54
PREVIDENT 5000 ORTHO
DEFENSE ........................ 54
PREVIDENT 5000 PLUS .... 54
PREVIDENT 5000
SENSITIVE ...................... 54
previfem ............................... 81
PREVNAR 13 (PF) .............. 74
PREVYMIS .......................... 10
PREZISTA ........................... 10
PRIFTIN ............................... 13
PRIMACARE....................... 97
primaquine ............................ 13
primidone ............................. 21
PRIMSOL............................. 16
PRINIVIL ............................. 37
PROAIR HFA ...................... 91
PROAIR RESPICLICK ....... 91
probenecid ............................ 74
probenecid-colchicine .......... 74
PROCARDIA ....................... 37
PROCARDIA XL ................ 37
procentra ............................... 33
prochlorperazine ................... 68
prochlorperazine maleate ..... 68
PROCORT ........................... 68
PROCRIT ............................. 71
PROCTOCORT ............. 51, 69
PROCTOFOAM HC ............ 69
procto-med hc ....................... 69
procto-pak............................. 69
proctosol hc .......................... 69
proctozone-hc ....................... 69
PRODIGY CONTROL
SOLUTION, LOW ........... 60
PRODIGY CONTROL
SOLUTION,HIGH ........... 60
progesterone ......................... 77
progesterone micronized ...... 77
PROGLYCEM ..................... 56
PROGRAF............................ 18
prolate ................................... 27
PROLENSA ......................... 85
PROLEUKIN ....................... 73
PROMACTA ........................ 40
promethazine ........................ 88
promethazine-codeine .......... 88
promethazine-dm .................. 88
promethazine-phenyleph-
codeine.............................. 89
promethazine-phenylephrine 89
promethegan ......................... 88
PROMETRIUM ................... 77
propafenone .......................... 34
propantheline ........................ 66
proparacaine ......................... 85
propranolol ........................... 37
propranolol-hydrochlorothiazid
.......................................... 37
propylthiouracil .................... 56
PROQUAD (PF)................... 74
PROSCAR ............................ 92
PROSTIN E2 ........................ 78
PROTHELIAL ..................... 54
PROTOPIC ........................... 44
protriptyline .......................... 33
PROVERA ........................... 77
PROVIDA OB ...................... 97
prudoxin................................ 44
PSORCON............................ 51
PULMICORT FLEXHALER
.......................................... 91
pulmosal ............................... 91
PULMOZYME ..................... 91
PUREFE OB PLUS .............. 97
purelax .................................. 69
PURIXAN ............................ 18
pyrazinamide ........................ 13
PYRIDIUM .......................... 93
pyridostigmine bromide ....... 24
PYRIDOSTIGMINE
BROMIDE........................ 24
pyrimethamine ...................... 13
Q QBREXZA ........................... 44
QNASL ................................. 91
QTERN ................................. 64
QUADRACEL (PF) ............. 74
QUALAQUIN ...................... 13
QUARTETTE ....................... 81
QUAZEPAM ........................ 33
QUDEXY XR ....................... 21
QUESTRAN ......................... 41
QUESTRAN LIGHT ............ 42
quetiapine ............................. 33
QUICK-SET PARADIGM ... 60
QUILLICHEW ER ............... 33
QUILLIVANT XR ............... 33
quinapril ................................ 37
quinapril-hydrochlorothiazide
.......................................... 37
quinidine gluconate .............. 34
quinidine sulfate ................... 34
quinine sulfate ...................... 13
quit 2 ..................................... 53
quit 4 ..................................... 54
QVAR REDIHALER ........... 91
R RABAVERT (PF) ................ 74
rabeprazole ........................... 71
RACEPINEPH-LIDOCAINE-
BSS 7(PF) ......................... 85
RADIOGARDASE ............... 53
raloxifene .............................. 74
ramelteon .............................. 33
ramipril ................................. 37
ranitidine hcl ......................... 71
ranolazine ............................. 42
RAPAMUNE ........................ 18
rasagiline ............................... 22
RASUVO (PF) ...................... 75
RAVICTI .............................. 53
RAYALDEE ......................... 63
RAYOS ................................. 55
RAZADYNE ........................ 24
RAZADYNE ER .................. 24
REBIF (WITH ALBUMIN) . 72
REBIF REBIDOSE .............. 72
REBIF TITRATION PACK . 72
REBINYN ............................ 40
reclipsen (28) ........................ 81
RECOMBIVAX HB (PF) ..... 74
RECTIV ................................ 69
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
118
REFUAH PLUS GLUCOSE
CONTROL ....................... 60
REGLAN .............................. 69
REGRANEX ........................ 44
RELAGARD ........................ 78
RELENZA DISKHALER .... 10
RELEXXII ........................... 33
RELISTOR ........................... 69
RELPAX .............................. 23
REMERON .......................... 33
REMERON SOLTAB .......... 33
RENACIDIN ........................ 93
rena-vite ................................ 97
RENVELA ........................... 69
repaglinide ............................ 64
repaglinide-metformin .......... 64
REPATHA PUSHTRONEX 42
REPATHA SURECLICK .... 42
REPATHA SYRINGE ......... 42
REQUIP ............................... 22
REQUIP XL ......................... 22
RESPA-AR........................... 89
RESTASIS ........................... 85
RESTASIS MULTIDOSE ... 85
RESTORIL ........................... 33
RETACRIT .......................... 71
RETIN-A .............................. 46
RETIN-A MICRO ................ 46
RETIN-A MICRO PUMP .... 46
RETISERT ........................... 87
RETROVIR .......................... 11
REVATIO ............................ 91
REVLIMID .......................... 72
REXULTI ............................. 33
REYATAZ ........................... 11
REYVOW ............................ 23
RHOFADE ........................... 46
RHOPRESSA ....................... 85
ribavirin .......................... 11, 72
RIDAURA ............................ 75
rifabutin ................................ 13
RIFADIN .............................. 13
RIFAMATE ......................... 13
rifampin ................................ 13
RIFATER ............................. 13
RIGHTEST CONTROL
SOLUTION HIGH ........... 60
RILUTEK ............................. 53
riluzole .................................. 53
rimantadine ........................... 11
ringer's .................................. 52
RINVOQ .............................. 75
RIOMET ............................... 64
RIOMET ER......................... 64
risedronate ................ 53, 74, 75
RISPERDAL ........................ 33
risperidone ............................ 33
RITALIN .............................. 33
RITALIN LA ........................ 33
ritonavir ................................ 11
rivastigmine .......................... 24
rivastigmine tartrate .............. 24
rivelsa ................................... 81
RIXUBIS .............................. 40
rizatriptan.............................. 23
R-NATAL OB ...................... 97
ROBAXIN-750 .................... 24
ROCALTROL ...................... 63
ROCKLATAN ..................... 85
ropinirole .............................. 22
rosadan.................................. 46
ROSADAN ........................... 46
ROSANIL ............................. 46
ROSULA .............................. 46
rosula cleansing cloths.......... 46
rosuvastatin ........................... 42
ROTARIX ............................ 74
ROTATEQ VACCINE......... 74
ROWASA ............................. 69
roweepra ............................... 21
roweepra xr ........................... 21
ROXICODONE.................... 27
ROZLYTREK ...................... 18
RUBRACA ........................... 18
RUCONEST ......................... 91
RUZURGI ............................ 24
RYBELSUS.......................... 64
RYCLORA ........................... 88
RYDAPT .............................. 18
RYTARY.............................. 22
RYTHMOL SR .................... 35
RYVENT .............................. 88
S SABRIL ................................ 21
SAFE-CLIP BY MAIL ........ 60
SAFYRAL ............................ 81
SALAGEN (PILOCARPINE)
.................................... 53, 54
salsalate ................................. 29
SAMSCA .............................. 63
SANCUSO ........................... 69
SANDIMMUNE ................... 18
SANDOSTATIN .................. 18
SANTYL .............................. 52
SAPHRIS .............................. 33
SARAFEM ........................... 33
SAVELLA ............................ 75
scalacort ................................ 51
SCALACORT DK ................ 51
scopolamine base .................. 69
SEASONIQUE ..................... 81
seconal sodium ..................... 33
SECUADO ........................... 33
SEEBRI NEOHALER .......... 91
SEGLUROMET ................... 64
SELECT-OB ......................... 97
SELECT-OB (FOLIC ACID)
.......................................... 97
SELECT-OB + DHA ............ 97
selegiline hcl ......................... 22
selenium sulfide .................... 43
SELRX ................................. 43
SELZENTRY ....................... 11
SEMPREX-D ....................... 89
se-natal 19 chewable ............. 97
se-natal-19 ............................ 97
SEREVENT DISKUS .......... 91
SERNIVO ............................. 51
SEROSTIM .......................... 72
sertraline ............................... 33
setlakin .................................. 81
sevelamer carbonate ............. 69
sevelamer hcl ........................ 69
SEYSARA ............................ 15
sf 54
sf 5000 plus ........................... 54
SFROWASA ........................ 69
sharobel ................................. 77
SHINGRIX (PF) ................... 74
SHOHL'S MODIFIED ......... 93
SIGNIFOR ............................ 18
sildenafil ............................... 93
sildenafil (pulm.hypertension)
.......................................... 91
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
119
SILENOR ............................. 33
SILHOUETTE ..................... 60
silodosin ............................... 92
SILVADENE ....................... 43
silver sulfadiazine ................. 43
SIMBRINZA ........................ 85
simliya (28) .......................... 81
simpesse ............................... 81
SIMPONI ............................. 76
SIMPONI ARIA ................... 75
simvastatin ............................ 42
SINEMET............................. 22
SINUVA ............................... 91
sirolimus ............................... 18
SIRTURO ............................. 13
SIVEXTRO .......................... 13
SKELAXIN .......................... 24
SKLICE ................................ 52
SKYLA................................. 76
SKYRIZI .............................. 43
SLYND................................. 81
SMARTEST CONTROL ..... 60
smoothlax ............................. 69
sodium chloride .............. 53, 91
sodium chloride 0.9 % .......... 53
sodium chloride 0.9 % (flush)
.......................................... 53
sodium fluoride 5000 plus .... 54
sodium fluoride-pot nitrate ... 54
sodium phenylbutyrate ......... 53
sodium polystyrene (sorb free)
.......................................... 69
sodium polystyrene sulfonate
.......................................... 69
SOLARAZE ......................... 44
SOLESTA ............................ 69
solifenacin ............................ 92
SOLIQUA 100/33 ................ 61
SOLODYN ........................... 15
SOLOSEC ............................ 14
SOLTAMOX ........................ 18
SOLUS V2 CONTROL
SOLUTION,HIGH ........... 60
SOMA .................................. 24
SOMATULINE DEPOT ...... 18
SOMAVERT ........................ 63
SOOLANTRA ...................... 46
SORBITOL .......................... 52
SORBITOL-MANNITOL .... 52
SORIATANE ....................... 43
SORILUX ............................. 43
sotalol ................................... 35
sotalol af ............................... 35
SOTYLIZE ........................... 35
SPECTRACEF ..................... 12
spinosad ................................ 52
SPIRIVA RESPIMAT .......... 91
SPIRIVA WITH
HANDIHALER ................ 91
spironolactone ...................... 37
spironolacton-hydrochlorothiaz
.......................................... 37
SPORANOX .......................... 9
SPORANOX PULSEPAK ..... 9
sprintec (28) .......................... 81
SPRITAM ............................. 21
SPRIX ................................... 29
SPRYCEL ............................ 18
sps (with sorbitol) ................. 69
sronyx ................................... 81
ssd ......................................... 43
SSKI ..................................... 56
sss 10-5 ................................. 46
st joseph aspirin .................... 29
st. joseph aspirin ................... 29
STALEVO 100 ..................... 22
STALEVO 125 ..................... 22
STALEVO 150 ..................... 22
STALEVO 200 ..................... 22
STALEVO 50 ....................... 22
STALEVO 75 ....................... 22
STAMARIL (PF) ................. 74
STARLIX ............................. 64
stavudine ............................... 11
STAXYN .............................. 93
STEGLATRO ....................... 64
STEGLUJAN ....................... 64
STELARA ............................ 43
STENDRA............................ 93
STIMATE ............................. 63
STIOLTO RESPIMAT......... 91
STIVARGA .......................... 18
stop smoking aid ................... 54
STRENSIQ ........................... 63
stress formula ....................... 97
stress formula with iron ........ 97
stress formula with iron(sulf)97
STROMECTOL ................... 14
strong iodine ................... 48, 94
subvenite ............................... 21
subvenite starter (blue) kit .... 21
subvenite starter (green) kit .. 21
subvenite starter (orange) kit 21
SUCRAID ............................. 69
sucralfate ............................... 71
SULAR ................................. 37
sulfacetamide sodium ..... 43, 87
sulfacetamide sodium (acne) 48
sulfacetamide sodium-sulfur 46,
47
sulfacetamide-prednisolone .. 87
sulfacetamide-sulfur-cleansr23
.......................................... 47
sulfacleanse 8-4 .................... 47
sulfadiazine ........................... 15
sulfamethoxazole-trimethoprim
.......................................... 15
SULFAMYLON ................... 48
sulfasalazine ......................... 69
sulfatrim ................................ 15
sulindac ................................. 29
SUMADAN .......................... 47
SUMADAN XLT ................. 47
sumatriptan ........................... 23
sumatriptan succinate ........... 23
sumatriptan-naproxen ........... 23
SUMAXIN ........................... 47
SUMAXIN CP ...................... 47
SUMAXIN TS ...................... 47
SUNOSI ................................ 33
super b complex-vitamin c ... 97
super b maxi complex ........... 97
super quints ........................... 97
super quints b-50 .................. 97
SUPPRELIN LA .................. 19
SUPRAX .............................. 12
SUPREP BOWEL PREP KIT
.......................................... 69
SURE-T PARADIGM .......... 60
SURFAXIN .......................... 91
SURVANTA ........................ 53
SUSTIVA ............................. 11
SUTENT ............................... 19
syeda ..................................... 81
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
120
SYLATRON......................... 72
SYMAX DUOTAB .............. 66
symax fastabs ....................... 66
symax-sl ............................... 66
symax-sr ............................... 66
SYMBICORT....................... 91
SYMBYAX .......................... 33
SYMDEKO .......................... 91
SYMFI .................................. 11
SYMFI LO ........................... 11
SYMJEPI .............................. 88
SYMLINPEN 120 ................ 65
SYMLINPEN 60 .................. 65
SYMPAZAN ........................ 21
SYMPROIC ......................... 69
SYMTUZA........................... 11
SYNALAR ........................... 51
SYNALAR CREAM KIT .... 51
SYNALAR OINTMENT KIT
.......................................... 51
SYNALAR TS ..................... 51
SYNAREL ........................... 63
SYNDROS ........................... 69
SYNERA .............................. 47
SYNJARDY ......................... 65
SYNJARDY XR .................. 65
SYNRIBO ............................ 19
SYNTHROID ....................... 65
SYPRINE ............................. 53
T T
30 INFUSION SET .......... 60
90 INFUSION SET 23 ..... 60
SLIM ................................ 60
SLIM G4 .......................... 60
TABLOID ............................ 19
TACLONEX ........................ 43
tacrolimus ....................... 19, 44
tadalafil ........................... 92, 93
tadalafil (pulm. hypertension)
.......................................... 91
TAFINLAR .......................... 19
TAGRISSO .......................... 19
TAKE ACTION ................... 81
TAKHZYRO ........................ 91
TALICIA .............................. 71
TALZENNA......................... 19
TAMIFLU ............................ 11
tamoxifen .............................. 19
tamsulosin ............................. 92
TAPAZOLE ......................... 56
TAPERDEX ................... 55, 56
TARCEVA ........................... 19
TARGADOX........................ 15
TARGRETIN ....................... 19
tarina 24 fe ............................ 81
tarina fe 1/20 (28) ................. 81
TARKA ................................ 37
taron-c dha ............................ 97
taron-prex prenatal-dha ........ 98
TASIGNA ............................ 19
TASMAR ............................. 22
TAYTULLA ......................... 81
tazarotene.............................. 47
TAZORAC ........................... 47
taztia xt ................................. 37
TAZVERIK .......................... 19
TDVAX ................................ 74
TECFIDERA ........................ 73
TEGRETOL ......................... 21
TEGRETOL XR ................... 21
TEGSEDI ............................. 24
TEKTURNA ........................ 38
TEKTURNA HCT ............... 38
TELCARE CONTROL ........ 60
telmisartan ............................ 38
telmisartan-amlodipine ......... 38
telmisartan-hydrochlorothiazid
.......................................... 38
temazepam ............................ 33
TEMIXYS ............................ 11
TEMODAR .......................... 19
TEMOVATE ........................ 51
temozolomide ....................... 19
tencon ................................... 27
TENIVAC (PF) .................... 74
tenofovir disoproxil fumarate
.......................................... 11
TENORETIC 100 ................. 38
TENORETIC 50 ................... 38
TENORMIN ......................... 38
terazosin................................ 38
terbinafine hcl ......................... 9
terbutaline ............................. 91
terconazole............................ 78
TERIPARATIDE ................. 75
TERSI FOAM ...................... 43
TESSALON PERLES .......... 89
TESTOPEL ........................... 63
testosterone ........................... 63
TESTOSTERONE ................ 63
testosterone cypionate .......... 63
testosterone enanthate ........... 63
TESTRED ............................. 63
TETANUS,DIPHTHERIA
TOX PED(PF) .................. 74
tetrabenazine ......................... 24
tetracaine hcl ......................... 85
TETRACAINE HCL (PF) .... 85
tetracycline ........................... 15
TEXACORT ......................... 51
THALOMID ......................... 19
THEO-24 .............................. 91
theochron .............................. 91
theophylline .................... 91, 92
THIOLA ............................... 53
THIOLA EC ......................... 53
thioridazine ........................... 33
thiothixene ............................ 33
THRIVITE RX ..................... 98
thyroid (pork) ........................ 65
THYROLAR-1 ..................... 65
THYROLAR-1/2 .................. 65
THYROLAR-1/4 .................. 65
THYROLAR-2 ..................... 65
THYROLAR-3 ..................... 65
tiadylt er ................................ 38
tiagabine ............................... 21
TIAZAC ............................... 38
TIBSOVO ............................. 19
TIGAN .................................. 69
TIGLUTIK ........................... 53
tilia fe .................................... 81
TIMOL-BRIMON-DORZO-
LATANOP(PF) ................ 86
timolol maleate ............... 38, 83
TIMOLOL-BRIMONIDI-
DORZOLAM(PF) ............ 86
TIMOLOL-DORZOLAMID-
LATANOP(PF) ................ 86
TIMOLOL-
LATANOPROST(PF) ...... 86
TIMOPTIC ........................... 83
TIMOPTIC-XE ..................... 83
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
121
tinidazole .............................. 14
TIROSINT ............................ 65
TIROSINT-SOL ................... 65
tis-u-sol pentalyte ................. 52
TIVICAY ............................. 11
TIVICAY PD ....................... 11
tizanidine .............................. 24
TOBI PODHALER .............. 14
TOBRADEX ........................ 86
TOBRADEX ST .................. 86
tobramycin ............................ 83
tobramycin in 0.225 % nacl . 14
TOBRAMYCIN WITH
NEBULIZER .................... 14
tobramycin-dexamethasone .. 86
TOBREX .............................. 83
TODAY CONTRACEPTIVE
SPONGE .......................... 78
TOLAK ................................ 44
tolcapone .............................. 22
tolmetin................................. 29
tolterodine............................. 92
tolvaptan ............................... 63
TOPICORT .......................... 51
topiramate ............................. 21
toremifene............................. 19
torsemide .............................. 38
TOSYMRA .......................... 23
total b/c ................................. 98
TOUJEO MAX U-300
SOLOSTAR ..................... 61
TOUJEO SOLOSTAR U-300
INSULIN .......................... 61
tovet emollient ...................... 51
TOVIAZ ............................... 92
TRACLEER ......................... 92
TRADJENTA ....................... 65
tramadol ................................ 29
TRAMADOL ....................... 29
tramadol-acetaminophen ...... 29
trandolapril ........................... 38
trandolapril-verapamil .......... 38
tranexamic acid .................... 78
TRANXENE T-TAB............ 34
tranylcypromine ................... 34
TRAVATAN Z .................... 86
travoprost .............................. 86
trazodone .............................. 34
TRECATOR ......................... 14
TRELEGY ELLIPTA........... 92
TREMFYA ........................... 43
TRESIBA FLEXTOUCH U-
100 .................................... 61
TRESIBA FLEXTOUCH U-
200 .................................... 61
TRESIBA U-100 INSULIN . 61
tretinoin ................................ 47
tretinoin (antineoplastic)....... 19
tretinoin microspheres .......... 47
TRETIN-X............................ 47
TRETIN-X CREAM KIT ..... 47
TREXALL ............................ 19
TREZIX ................................ 27
tri femynor ............................ 81
triamcinolone acetonide 51, 52,
54
TRIAMCINOLON-
MOXIFLOX-WATR(PF) . 86
triamterene ............................ 38
triamterene-hydrochlorothiazid
.......................................... 38
trianex ................................... 52
triazolam ............................... 34
TRICARE ............................. 98
triderm .................................. 52
TRIDESILON ...................... 52
trientine ................................. 53
TRIESENCE (PF) ................ 56
tri-estarylla............................ 81
TRIFERIC ............................ 98
trifluoperazine ...................... 34
trifluridine ............................. 83
TRIGLIDE............................ 42
trihexyphenidyl ..................... 22
TRIKAFTA .......................... 92
tri-legest fe ............................ 81
tri-linyah ............................... 81
TRILIPIX ............................. 42
tri-lo-estarylla ....................... 81
tri-lo-marzia .......................... 81
tri-lo-mili .............................. 81
tri-lo-sprintec ........................ 81
trilyte with flavor packets ..... 69
trimethobenzamide ............... 69
trimethoprim ......................... 16
tri-mili ................................... 81
trimipramine ......................... 34
TRI-MIX (PAPAVRN-
PHNTLMN-PGE1) ........... 93
TRIMO-SAN JELLY ........... 78
trinatal rx 1 ........................... 98
trinate .................................... 98
TRINAZ ............................... 98
TRINTELLIX ....................... 34
tri-previfem (28) ................... 82
tri-sprintec (28) ..................... 82
TRISTART DHA ................. 98
TRIUMEQ ............................ 11
triveen-duo dha ..................... 98
tri-vitamin with fluoride ....... 98
trivora (28) ............................ 82
tri-vylibra .............................. 82
tri-vylibra lo .......................... 82
TRIZIVIR ............................. 11
TROKENDI XR ................... 21
tropicamide ........................... 83
trospium ................................ 92
TRUE METRIX LEVEL 1 ... 60
TRUECONTROL LEVEL 0 60
TRULANCE ......................... 69
TRULICITY ......................... 65
TRUMENBA ........................ 74
TRUSOPT ............................ 86
TRUSTEEL INFUSION SET
32 ...................................... 60
TRUVADA ........................... 11
TUKYSA .............................. 19
tulana .................................... 77
TURALIO ............................. 19
TUSSICAPS ......................... 89
TUXARIN ER ...................... 89
TUZISTRA XR .................... 89
TWINRIX (PF) ..................... 74
TYBOST ............................... 11
tydemy .................................. 82
TYKERB .............................. 19
TYLENOL-CODEINE #3 .... 27
TYMLOS .............................. 75
TYPHIM VI .......................... 74
TYVASO .............................. 92
TYVASO REFILL KIT ........ 92
TYVASO STARTER KIT ... 92
U UBRELVY ........................... 23
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
122
UCERIS ................................ 69
UDENYCA .......................... 71
ULESFIA ............................. 52
ULTRACET ......................... 29
ULTRAM ............................. 29
ULTRAVATE ...................... 52
UNISTRIP LOW CONTROL
.......................................... 60
unithroid ............................... 65
UPTRAVI............................. 38
URECHOLINE .................... 92
URELLE............................... 93
uretron d-s ............................ 93
URIBEL ............................... 93
urimar-t ................................. 93
urin ds ................................... 93
uro-458 ................................. 93
UROCIT-K 10 ...................... 93
UROCIT-K 15 ...................... 93
UROCIT-K 5 ........................ 93
urogesic-blue ........................ 93
uro-mp .................................. 93
UROQID-ACID NO.2 ......... 93
URSO 250 ............................ 69
URSO FORTE...................... 69
ursodiol ................................. 69
uryl ....................................... 93
ustell ..................................... 93
UTIBRON NEOHALER...... 92
utira-c ................................... 93
V vaginal contraceptive foam .. 78
valacyclovir .......................... 11
VALCHLOR ........................ 44
VALCYTE ........................... 11
valganciclovir ....................... 11
valproic acid ......................... 21
valproic acid (as sodium salt)
.......................................... 21
valsartan ............................... 38
valsartan-hydrochlorothiazide
.......................................... 38
VALTOCO ........................... 21
vanadom ............................... 24
VANATOL LQ .................... 27
VANATOL S ....................... 27
VANCOCIN ......................... 16
vancomycin .......................... 16
vandazole .............................. 78
VANOXIDE-HC .................. 47
VANTAS .............................. 19
VAQTA (PF) ........................ 74
vardenafil .............................. 93
VARISOFT INFUSION SET
43 ...................................... 60
VARIVAX (PF) ................... 74
VARIZIG.............................. 74
VARUBI ............................... 69
VASCEPA ............................ 42
VASERETIC ........................ 38
VASOTEC............................ 38
VAXCHORA VACCINE..... 74
VCF CONTRACEPTIVE
FILM ................................ 78
VCF CONTRACEPTIVE GEL
.......................................... 78
VECAMYL .......................... 42
VECTICAL .......................... 43
velivet triphasic regimen (28)
.......................................... 82
VELPHORO ......................... 69
VEMLIDY............................ 11
VENCLEXTA ...................... 19
VENCLEXTA STARTING
PACK ............................... 19
venlafaxine ........................... 34
VENTAVIS .......................... 92
VENTOLIN HFA ................. 92
verapamil .............................. 38
VERASENS CONTROL
SOLN-LEVEL 1............... 60
VEREGEN ........................... 44
VERELAN ........................... 38
VERELAN PM..................... 38
veripred 20 ............................ 56
VERSACLOZ ...................... 34
VERZENIO .......................... 19
VFEND ................................... 9
V-GO 20 ............................... 60
V-GO 30 ............................... 60
V-GO 40 ............................... 60
VIBERZI .............................. 69
VIBRAMYCIN .............. 15, 16
VIEKIRA PAK..................... 11
vienva ................................... 82
vigabatrin .............................. 21
vigadrone .............................. 21
VIGAMOX ........................... 83
VIIBRYD ............................. 34
vilamit mb ............................. 93
vilevev mb ............................ 93
VIMOVO .............................. 29
VIMPAT ............................... 21
VINATE DHA RF ................ 98
VIOKACE ............................ 69
viorele (28) ........................... 82
VIRACEPT ........................... 11
VIRAMUNE ......................... 11
VIRAMUNE XR .................. 11
VIRAZOLE .......................... 11
VIREAD ............................... 11
virt-c dha ............................... 98
virt-nate dha .......................... 98
virt-pn dha ............................ 98
virt-pn plus ............................ 98
virtussin ac ............................ 89
virtussin dac .......................... 89
VISTARIL ............................ 88
VISTOGARD ....................... 16
VITAFOL FE PLUS ............. 98
VITAFOL FE+ (WITH
DOCUSATE) ................... 98
VITAFOL GUMMIES ......... 98
VITAFOL NANO ................ 98
VITAFOL ULTRA ............... 98
VITAFOL-OB ...................... 98
VITAFOL-OB+DHA ........... 98
VITAFOL-ONE ................... 98
VITAMED MD ONE RX .... 98
VITAMEDMD REDICHEW
RX ..................................... 98
vitamin b complex ................ 98
vitamin b complex-folic acid 98
vitamin d3 ............................. 98
vitamin k ............................... 40
vitamin k1 ............................. 40
vitamins a,c,d and fluoride ... 98
VITAPEARL ........................ 98
VITATRUE .......................... 98
VITRAKVI ........................... 19
VIVAGUARD INO
CONTROL SOLUTION .. 60
VIVOTIF .............................. 74
VIZIMPRO ........................... 19
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
123
VOGELXO........................... 63
volnea (28)............................ 82
VOLTAREN ........................ 29
VOLTAREN-XR ................. 29
voriconazole ........................... 9
VOSEVI ............................... 11
VOTRIENT .......................... 19
vp-ch-pnv ............................. 98
VP-PNV-DHA ..................... 98
VRAYLAR........................... 34
vtol lq.................................... 27
VUMERITY ......................... 73
VUSION ............................... 49
vyfemla (28) ......................... 82
VYLEESI ............................. 34
vylibra................................... 82
VYNDAMAX ...................... 42
VYNDAQEL ........................ 42
VYVANSE ........................... 34
VYZULTA ........................... 86
W WAKIX ................................ 34
warfarin ................................ 40
water for irrigation, sterile .... 53
WAVESENSE CONTROL
SOLUTION ...................... 61
WELCHOL .......................... 42
WELLBUTRIN XL.............. 34
wera (28) .............................. 82
westhroid .............................. 65
WIDE-SEAL DIAPHRAGM
.......................................... 76
WILATE............................... 40
wintergreen oil...................... 44
wixela inhub ......................... 92
women's gentle laxative(bisac)
.......................................... 69
women's laxative (bisacodyl)69
WP THYROID ..................... 65
wymzya fe ............................ 82
X XALKORI ............................ 19
XARELTO ........................... 40
XCOPRI ............................... 21
XCOPRI MAINTENANCE
PACK ............................... 21
XCOPRI TITRATION PACK
.......................................... 21
XELJANZ ............................ 76
XELJANZ XR ...................... 76
XELODA.............................. 19
XENLETA............................ 14
XEPI ..................................... 48
XERESE ............................... 49
XERMELO ........................... 19
XGEVA ................................ 16
XHANCE ............................. 92
XIFAXAN ............................ 14
XIGDUO XR ........................ 65
XIIDRA ................................ 85
XOFLUZA ........................... 11
XOLAIR ............................... 92
XOLEGEL............................ 49
XOPENEX ........................... 92
XOPENEX CONCENTRATE
.......................................... 92
XOSPATA............................ 19
XTANDI ............................... 19
xulane ................................... 78
XULTOPHY 100/3.6 ........... 61
XURIDEN ............................ 53
XYOSTED ........................... 63
XYREM................................ 34
Y YAZ (28) .............................. 82
YF-VAX (PF) ....................... 74
YONSA ................................ 19
YOSPRALA ......................... 40
YUPELRI ............................. 92
YUTIQ.................................. 87
yuvafem ................................ 77
Z zafirlukast ............................. 92
zaleplon ................................ 34
ZANAFLEX ......................... 24
zarah ..................................... 82
ZARONTIN.......................... 21
ZARXIO ............................... 71
zatean-pn dha ........................ 98
zatean-pn plus ....................... 98
zebutal .................................. 27
ZEJULA ............................... 19
ZELBORAF ......................... 19
ZELNORM ........................... 69
ZEMBRACE SYMTOUCH . 23
ZEMPLAR ........................... 63
zenatane ................................ 47
ZENPEP ............................... 70
zenzedi .................................. 34
ZENZEDI ............................. 34
ZEPATIER ........................... 11
ZEPOSIA .............................. 73
ZEPOSIA STARTER KIT ... 73
ZEPOSIA STARTER PACK
.......................................... 73
ZERVIATE ........................... 85
ZESTORETIC ...................... 38
ZESTRIL .............................. 38
ZIAC ..................................... 38
ZIAGEN ............................... 11
ZIANA .................................. 47
zidovudine ............................ 11
ZIEXTENZO ........................ 71
zileuton ................................. 92
zingiber ................................. 98
ZIOPTAN (PF) ..................... 86
ziprasidone hcl ...................... 34
ZIRGAN ............................... 83
ZITHROMAX ...................... 12
ZITHROMAX TRI-PAK ..... 12
ZITHROMAX Z-PAK ......... 12
ZOFRAN .............................. 70
ZOHYDRO ER .................... 27
ZOLINZA ............................. 19
zolmitriptan ........................... 23
zolpidem ............................... 34
ZOLPIMIST ......................... 34
ZOMIG ................................. 23
ZONALON ........................... 44
zonisamide ............................ 21
ZONTIVITY ......................... 40
ZORBTIVE .......................... 72
ZORTRESS .......................... 19
ZOSTAVAX (PF) ................ 74
zovia 1/35e (28) .................... 82
ZOVIRAX ...................... 11, 49
ZTLIDO ................................ 47
Z-TUSS AC .......................... 89
zumandimine (28) ................. 82
ZUPLENZ ............................ 70
ZYDELIG ............................. 19
ZYFLO ................................. 92
ZYKADIA ............................ 19
ZYLET ................................. 86
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
124
ZYLOPRIM ......................... 74
ZYMAXID ........................... 83
ZYPITAMAG ...................... 42
ZYPREXA............................ 34
ZYPREXA ZYDIS ............... 34
ZYTIGA ............................... 19
ZYVOX ................................ 14