Tier BRAND NAME GENERIC NAMEPRIOR
AUTHORIZATION
QUANTITY LIMIT
INDICATOR
STEP THERAPY
INDICATOR2 1ST CHOICE LANCETS LANCETS
2 1ST TIER UNIFINE PENTIPS NEEDLES, INSULIN DISPOSABLE
2 1ST TIER UNIFINE PENTIPS PLUS NEEDLES, INSULIN DISPOSABLE
2 1ST TIER UNILET COMFORTOUCH LANCETS
2 8-MOP METHOXSALEN
1 ABACAVIR ABACAVIR SULFATE QL
1 ABACAVIR-LAMIVUDINE-ZIDOVUDINE ABACAVIR/LAMIVUDINE/ZIDOVUDINE PA
3 ABILIFY ARIPIPRAZOLE QL ST
Excluded ABSTRAL FENTANYL
2 ACANYA CLINDAMYCIN PHOS/BENZOYL PEROX
1 ACARBOSE ACARBOSE
3 ACCUPRIL QUINAPRIL HCL
3 ACCURETIC QUINAPRIL/HYDROCHLOROTHIAZIDE
1 ACEBUTOLOL HCL ACEBUTOLOL HCL
1 ACETAMINOPHEN-BUTALBITAL BUTALBITAL/ACETAMINOPHEN
1 ACETAMINOPHEN-CODEINE ACETAMINOPHEN WITH CODEINE
1 ACETASOL HC ACETIC ACID/HYDROCORTISONE
1 ACETAZOLAMIDE ACETAZOLAMIDE
1 ACETIC ACID ACETIC ACID
1 ACETIC ACID-ALUMINUM ACETIC ACID/ALUMINUM ACETATE
1 ACETYLCYSTEINE ACETYLCYSTEINE
1 ACITRETIN ACITRETIN
1 ACLOMETASONE DIPROPIONATE 0.05% CREAM, OINTMENT [LOW] ACLOMETASONE
3 ACTIGALL URSODIOL
2 ACTI-LANCE LANCETS
3 ACTOPLUS MET PIOGLITAZONE HCL/METFORMIN HCL ST
2 ACTOPLUS MET XR PIOGLITAZONE HCL/METFORMIN HCL ST
3 ACTOS PIOGLITAZONE HCL
3 ACULAR KETOROLAC TROMETHAMINE
3 ACULAR LS KETOROLAC TROMETHAMINE
1 ACYCLOVIR ACYCLOVIR
3 ADALAT CC NIFEDIPINE
2 ADAPALENE 0.05% GEL ADAPALENE
1 ADAPALENE 0.1% GEL ADAPALENE
2 ADAPALENE 0.1% LOTION ADAPALENE
2 ADAPALENE 0.3% GEL, GEL WIT HPUMP ADAPALENE
2 ADCIRCA TADALAFIL PA
3 ADDERALL DEXTROAMPHETAMINE/AMPHETAMINE QL
3 ADDERALL XR DEXTROAMPHETAMINE/AMPHETAMINE QL
Excluded ADDYI FLIBANSERIN
1 ADEFOVIR DIPIVOXIL ADEFOVIR DIPIVOXIL
2 ADEMPAS RIOCIGUAT PA
2 ADVAIR DISKUS FLUTICASONE/SALMETEROL QL
2 ADVAIR HFA FLUTICASONE/SALMETEROL QL
2 ADVANCED TRAVEL LANCETS LANCETS
2 ADVOCATE LANCET LANCETS
2 ADVOCATE LANCETS LANCETS
Tier BRAND NAME GENERIC NAMEPRIOR
AUTHORIZATION
QUANTITY LIMIT
INDICATOR
STEP THERAPY
INDICATOR2 ADVOCATE PEN NEEDLES NEEDLES, INSULIN DISPOSABLE
2 ADVOCATE SYRINGES SYRINGE & NEEDLE,INSULIN,1 ML
1 AFEDITAB CR NIFEDIPINE
2 AFINITOR EVEROLIMUS PA QL
2 AFINITOR DISPERZ EVEROLIMUS PA
3 AGRYLIN ANAGRELIDE HCL
1 AK-POLY-BAC BACITRACIN/POLYMYXIN B SULFATE
1 ALA-CORT HYDROCORTISONE
1 ALA-SCALP HYDROCORTISONE
1 ALBUTEROL SOLUTION FOR INHALATION ALBUTEROL
1 ALBUTEROL SULFATE ALBUTEROL SULFATE
1 ALCLOMETASONE DIPROPIONATE ALCLOMETASONE DIPROPIONATE
Excluded ALCORTIN-A IODOQUINAL-HYDROCORTISONE-ALOE
3 ALDACTONE SPIRONOLACTONE
3 ALDARA IMIQUIMOD PA QL
1 ALENDRONATE SODIUM ALENDRONATE SODIUM
1 ALFUZOSIN HCL ER ALFUZOSIN HCL
2 ALKERAN MELPHALAN
1 ALLOPURINOL ALLOPURINOL
2 ALMOTRIPTAN ALMOTRIPTAN
2 ALOCRIL NEDOCROMIL SODIUM
2 ALOMIDE LODOXAMIDE TROMETHAMINE
2 ALORA ESTRADIOL QL
3 ALPHAGAN P BRIMONIDINE TARTRATE
2 ALPRAZOLAM INTENSOL ALPRAZOLAM
VC ALPRAZOLAM IR TABS ALPRAZOLAM
2 ALPRAZOLAM ODT ALPRAZOLAM
2 ALREX LOTEPREDNOL ETABONATE
3 ALTACE RAMIPRIL
1 ALTAVERA LEVONORGESTREL-ETHIN ESTRADIOL
2 ALTERNATE SITE LANCETS LANCETS
Excluded ALTOPREV LOVASTATIN EXTENDED-RELEASE
Excluded ALVESCO CICLESONIDE
1 ALYACEN NORETHINDRONE-ETHINYL ESTRAD
1 AMANTADINE AMANTADINE HCL
3 AMARYL GLIMEPIRIDE
3 AMBIEN ZOLPIDEM TARTRATE QL
3 AMBIEN CR ZOLPIDEM TARTRATE QL ST
2 AMCINONIDE 0.1% CREAM, LOTION [HIGH] AMCINONIDE
3 AMERGE NARATRIPTAN HCL QL
1 AMIODARONE HCL AMIODARONE HCL
2 AMITIZA LUBIPROSTONE QL
1 AMITRIPTYLINE AMITRIPTYLINE
VC AMLODIPINE BESYLATE AMLODIPINE BESYLATE
1 AMLODIPINE BESYLATE-BENAZEPRIL AMLODIPINE BESYLATE/BENAZEPRIL
1 AMLODIPINE TABLET/ATORVASTATIN TABLET AMLOAMLODIPINE/ATORVASTATIN
2 AMLODIPINE/ATORVASTATIN COMBINATION TABLET QL
Tier BRAND NAME GENERIC NAMEPRIOR
AUTHORIZATION
QUANTITY LIMIT
INDICATOR
STEP THERAPY
INDICATOR2 AMLODIPINE/TELMISARTAN COMBINATION TABLET
1 AMLODIPINE/VALSARTAN COMBINATION 10 MG-320MG TABLET
2
AMLODIPINE/VALSARTAN COMBINATION TABLET (5/160, 5/320,
10/160) ST
2 AMLODIPINE/VALSARTAN/HCTZ COMINATION TABLET
1 AMNESTEEM ISOTRETINOIN
1 AMOX TR-POTASSIUM CLAVULANATE AMOXICILLIN/POTASSIUM CLAV
1 AMOXAPINE AMOXAPINE
VC AMOXICILLIN AMOXICILLIN
1 AMOXICILLIN-CLAVULANATE ER AMOXICILLIN/POTASSIUM CLAV
1 AMPHETAMINE SALT COMBO DEXTROAMPHETAMINE/AMPHETAMINE
2 AMPHETAMINE SALT COMBO ER DEXTROAMPHETAMINE/AMPHETAMINE QL
2 AMPHETAMINE/DEXTROAMPHETAMINE SALTS ER CAPSULE DEXTROAMPHETAMINE/AMPHETAMINE
1 AMPHETAMINE/DEXTROAMPHETAMINE SALTS TABLET DEXTROAMPHETAMINE/AMPHETAMINE
1 AMPICILLIN TRIHYDRATE AMPICILLIN TRIHYDRATE
Excluded AMRIX CYCLOBENZAPRINE EXTENDED-RELEASE
3 ANAFRANIL CLOMIPRAMINE HCL
1 ANAGRELIDE HCL ANAGRELIDE HCL
3 ANALPRAM HC HYDROCORTISONE/PRAMOXINE
3 ANAPROX NAPROXEN SODIUM
3 ANAPROX DS NAPROXEN SODIUM
3 ANASPAZ HYOSCYAMINE SULFATE
1 ANASTROZOLE ANASTROZOLE
3 ANDROGEL TESTOSTERONE PA
2 ANDROID METHYLTESTOSTERONE
1 ANDROXY FLUOXYMESTERONE QL
2 ANORO ELLIPTA UMECLIDINIUM BRM/VILANTEROL TR QL
3 ANTABUSE DISULFIRAM
Excluded ANTARA FENOFIBRATE
3 ANTIVERT MECLIZINE HCL
1 ANUCORT-HC HYDROCORTISONE ACETATE
3 ANUSOL-HC HYDROCORTISONE
2 APEXICON E DIFLORASONE DIACETATE/EMOLL
Excluded APIDRA INSULIN
1 APRI DESOGESTREL-ETHINYL ESTRADIOL
2 APRISO MESALAMINE
Excluded APTENSIO XR METHYLPHENIDATE EXTENDED-RELEASE
2 APTIVUS TIPRANAVIR/VITAMIN E TPGS PA
1 ARANELLE NORETHINDRONE-ETHINYL ESTRAD
3 ARAVA LEFLUNOMIDE
Excluded ARESTIN MINOCYCLINE
3 ARICEPT DONEPEZIL HCL
3 ARIMIDEX ANASTROZOLE
2 ARIPIPRAZOLE/ARIPIPRAZOLE ODT ARIPIPRAZOLE QL ST
3 ARIXTRA FONDAPARINUX SODIUM QL
2 ARMOUR THYROID THYROID,PORK
3 AROMASIN EXEMESTANE PA
Tier BRAND NAME GENERIC NAMEPRIOR
AUTHORIZATION
QUANTITY LIMIT
INDICATOR
STEP THERAPY
INDICATORExcluded ASACOL HD MESALAMINE DELAYED-RELEASE
1 ASCOMP WITH CODEINE CODEINE/BUTALBITAL/ASA/CAFFEIN
2 ASMANEX MOMETASONE FUROATE QL
2 ASMANEX HFA MOMETASONE FUROATE QL
2 ASSURE HAEMOLANCE PLUS BLADE LANCET, SAFETY
2 ASSURE ID INSULIN SAFETY SYRINGE,NEEDLE,INSULN,SAFE,1ML
2 ASSURE LANCE LANCETS
2 ASSURE LANCE PLUS LANCETS
3 ASTEPRO AZELASTINE HCL QL ST
VC ATENOLOL ATENOLOL
VC ATENOLOL-CHLORTHALIDONE ATENOLOL/CHLORTHALIDONE
3 ATIVAN LORAZEPAM
1 ATORVASTATIN CALCIUM ATORVASTATIN CALCIUM
2 ATRIPLA EFAVIRENZ/EMTRICITAB/TENOFOVIR QL
1 ATROPINE SULFATE ATROPINE SULFATE
3 ATROVENT IPRATROPIUM BROMIDE
2 ATROVENT HFA IPRATROPIUM BROMIDE QL
Excluded AUBAGIO TERIFLUNOMIDE
1 AUBRA LEVONORGESTREL-ETHIN ESTRADIOL
3 AUGMENTIN AMOXICILLIN/POTASSIUM CLAV
3 AUGMENTIN ES-600 AMOXICILLIN/POTASSIUM CLAV
3 AUGMENTIN XR AMOXICILLIN/POTASSIUM CLAV
2 AUTOSHIELD DUO PEN NEEDLE PEN NEEDLE, DIABETIC, SAFETY
2 AUTOSHIELD PEN NEEDLE NEEDLES, INSULIN DISP., SAFETY
Excluded AUVI-Q EPINEPHRINE INJECTION
3 AVALIDE IRBESARTAN/HYDROCHLOROTHIAZIDE
3 AVAPRO IRBESARTAN
2 AVC SULFANILAMIDE
3 AVELOX MOXIFLOXACIN HCL
3 AVELOX ABC PACK MOXIFLOXACIN HCL
1 AVIANE LEVONORGESTREL-ETHIN ESTRADIOL
2 AVODART DUTASTERIDE ST
2 AVONEX INTERFERON BETA-1A PA
2 AVONEX ADMINISTRATION PACK INTERFERON BETA-1A/ALBUMIN PA
2 AVONEX PEN INTERFERON BETA-1A PA
2 AXIRON TESTOSTERONE PA
3 AYGESTIN NORETHINDRONE ACETATE
1 AZATHIOPRINE AZATHIOPRINE
1 AZELASTINE 0.1% NASAL SPRAY
2 AZELASTINE 0.15% NASAL SPRAY
2 AZELASTINE HCL FLUTICASONE NASAL SPRAY QL
2 AZILECT RASAGILINE MESYLATE QL
1 AZITHROMYCIN AZITHROMYCIN
2 AZOPT BRINZOLAMIDE
3 AZULFIDINE SULFASALAZINE
1 AZURETTE DESOG-E.ESTRADIOL/E.ESTRADIOL
1 BACITRACIN BACITRACIN
Tier BRAND NAME GENERIC NAMEPRIOR
AUTHORIZATION
QUANTITY LIMIT
INDICATOR
STEP THERAPY
INDICATOR1 BACITRACIN-POLYMYXIN BACITRACIN/POLYMYXIN B SULFATE
1 BACLOFEN BACLOFEN
3 BACTRIM SULFAMETHOXAZOLE/TRIMETHOPRIM
3 BACTRIM DS SULFAMETHOXAZOLE/TRIMETHOPRIM
3 BACTROBAN MUPIROCIN
2 BACTROBAN NASAL MUPIROCIN CALCIUM
1 BALSALAZIDE DISODIUM BALSALAZIDE DISODIUM
3 BARACLUDE ENTECAVIR
Excluded BAYER (CONTOUR) TEST STRIPS/BAYER BLOOD GLUCOSE TEST STRIPS
2 BD MICROTAINER LANCETS LANCETS
2 BD ULTRA-FINE LANCETS
2 BD ULTRA-FINE II LANCETS
2 BD ULTRA-FINE PEN NEEDLE NEEDLES, INSULIN DISPOSABLE
Excluded BEAU RX
Excluded BECONASE AQ BECLOMETHASONE NASAL
Excluded BELBUCA BUPPRENORPHINE FILM
VC BENAZEPRIL BENAZEPRIL
1 BENAZEPRIL-HYDROCHLOROTHIAZIDE BENAZEPRIL/HYDROCHLOROTHIAZIDE
2 BENICAR OLMESARTAN MEDOXOMIL ST
2 BENICAR HCT OLMESARTAN/HYDROCHLOROTHIAZIDE ST
3 BENTYL DICYCLOMINE HCL
3 BENZACLIN CLINDAMYCIN PHOS/BENZOYL PEROX
Excluded BENZACLIN PUMP CLINDAMYCIN, BENZOYL PEROXIDE
3 BENZAMYCIN ERYTHROMYCIN/BENZOYL PEROXIDE
2 BENZAMYCINPAK ERYTHROMYCIN/BENZOYL PEROXIDE
1 BENZTROPINE MESYLATE BENZTROPINE MESYLATE
Excluded BEPREVE BEPOTASTINE BESILATE
2 BESIVANCE BESIFLOXACIN HCL
3 BETAGAN LEVOBUNOLOL HCL
2 BETAMETHASONE DIPROPIONATE BETAMETHASONE
1
BETAMETHASONE DIPROPIONATE 0.05% LOTION, OINTMENT [SUPER
HIGH], 0.05% CREAM, GEL, OINTMENT [HIGH] BETAMETHASONE
2 BETAMETHASONE VALERATE BETAMETHASONE
1
BETAMETHASONE VALERATE 0.1% OINTMENT [HIGH], [LOWER MID-
STRENGTH], 0.12% LOTION [LOW] BETAMETHASONE
3 BETAPACE SOTALOL HCL
3 BETAPACE AF SOTALOL HCL
Excluded BETASERON INTERFERON BETA-1B
1 BETAXOLOL HCL BETAXOLOL HCL
1 BETHANECHOL CHLORIDE BETHANECHOL CHLORIDE
2 BETIMOL TIMOLOL
2 BETOPTIC S BETAXOLOL HCL
1 BEXAROTENE BEXAROTENE PA
3 BIAXIN CLARITHROMYCIN
1 BICALUTAMIDE BICALUTAMIDE
2 BILTRICIDE PRAZIQUANTEL
2 BIMATOPROST DROPS BIMATOPROST QL
Tier BRAND NAME GENERIC NAMEPRIOR
AUTHORIZATION
QUANTITY LIMIT
INDICATOR
STEP THERAPY
INDICATORExcluded BINOSTO ALENDRONATE
VC BISOPROLOL BISOPROLOL
VC BISOPROLOL-HYDROCHLOROTHIAZIDE BISOPROLOL FUMARATE/HCTZ
1 BLEPH-10 SULFACETAMIDE SODIUM
2 BLEPHAMIDE SULFACETM NA/PREDNISOL AC
2 BLEPHAMIDE S.O.P. SULFACETM NA/PREDNISOL AC
3 BONIVA IBANDRONATE SODIUM
2 BOSULIF BOSUTINIB PA QL
1 BPO BENZOYL PEROXIDE
2 BREO ELLIPTA FLUTICASONE/VILANTEROL QL
1 BREVICON NORETHINDRONE-ETHINYL ESTRAD
2 BRILINTA TICAGRELOR QL
1 BRIMONIDINE TARTRATE BRIMONIDINE TARTRATE
2 BROMFENAC OPHTHALMIC SOLUTION BROMFENAC
1 BROMOCRIPTINE MESYLATE BROMOCRIPTINE MESYLATE
1 BUDESONIDE BUDESONIDE QL
1 BUDESONIDE EC BUDESONIDE
2 BUDESONIDE NASAL SPRAY BUDESONIDE
2 BULLSEYE MINI SAFETY LANCETS LANCETS
1 BUMETANIDE BUMETANIDE
3 BUPHENYL SODIUM PHENYLBUTYRATE
1 BUPRENORPHINE HCL BUPRENORPHINE HCL PA
1 BUPRENORPHINE-NALOXONE BUPRENORPHINE HCL/NALOXONE HCL PA
1 BUPROPION HCL BUPROPION HCL
1 BUPROPION HCL SR BUPROPION HCL
1 BUPROPION XL BUPROPION HCL
1 BUSPIRONE HCL BUSPIRONE HCL
1 BUTALBITAL COMPOUND-CODEINE CODEINE/BUTALBITAL/ASA/CAFFEINE
2
BUTALBITAL-ACETAMINOPHEN-CAFFEINE (500-300-40, 500-325-40)
CAPSULE BUTALB/ACETAMINOPHEN/CAFFEINE
1 BUTALBITAL-ACETAMINOPHEN-CAFFEINE 500-325-40 TABLET BUTALB/ACETAMINOPHEN/CAFFEINE
1 BUTALBITAL-ASPIRIN-CAFFEINE BUTALBITAL/ASPIRIN/CAFFEINE
1 BUTALBITAL-CAFFEINE-ACETAMINOPH-CODEINE BUTALBIT/ACETAMIN/CAFF/CODEINE
2 BUTRANS BUPRENORPHINE QL
Excluded BYDUREON EXENATIDE EXTENDED-RELEASE
Excluded BYETTA EXENATIDE
2 BYSTOLIC NEBIVOLOL HCL
1 CABERGOLINE CABERGOLINE
3 CADUET AMLODIPINE/ATORVASTATIN QL
2 CAFERGOT ERGOTAMINE TARTRATE/CAFFEINE QL
3 CALAN VERAPAMIL HCL
3 CALAN SR VERAPAMIL HCL
1 CALCIPOTRIENE CALCIPOTRIENE ST
1 CALCITRENE CALCIPOTRIENE ST
1 CALCITRIOL CALCITRIOL
1 CALCIUM ACETATE CALCIUM ACETATE
1 CAMILA NORETHINDRONE
Tier BRAND NAME GENERIC NAMEPRIOR
AUTHORIZATION
QUANTITY LIMIT
INDICATOR
STEP THERAPY
INDICATOR2 CANASA MESALAMINE
2 CANDESARTAN
2 CANDESARTAN/HCTZ COMBINATION TABLET
1 CAPECITABINE CAPECITABINE PA QL
2 CAPITAL W-CODEINE ACETAMINOPHEN WITH CODEINE
2 CAPTOPRIL CAPTOPRIL
2 CAPTOPRIL-HYDROCHLOROTHIAZIDE CAPTOPRIL/HYDROCHLOROTHIAZIDE
2 CARAFATE SUCRALFATE
1 CARBAMAZEPINE CARBAMAZEPINE
1 CARBAMAZEPINE ER CARBAMAZEPINE
1 CARBAMAZEPINE XR CARBAMAZEPINE
3 CARBATROL CARBAMAZEPINE
1 CARBIDOPA CARBIDOPA
1 CARBIDOPA-LEVODOPA CARBIDOPA/LEVODOPA
1 CARBIDOPA-LEVODOPA ER CARBIDOPA/LEVODOPA
1 CARBIDOPA-LEVODOPA-ENTACAPONE CARBIDOPA/LEVODOPA/ENTACAPONE
3 CARDIZEM DILTIAZEM HCL
3 CARDIZEM CD DILTIAZEM HCL
3 CARDURA DOXAZOSIN MESYLATE
2 CAREFINE PEN NEEDLE NEEDLES, INSULIN DISPOSABLE
2 CAREONE LANCETS
2 CARESENS LANCETS
1 CARISOPRODOL CARISOPRODOL
1 CARISOPRODOL COMPOUND CARISOPRODOL/ASPIRIN
1 CARISOPRODOL COMPOUND-CODEINE CODEINE/CARISOPRODOL/ASPIRIN
1 CARISOPRODOL-ASPIRIN CARISOPRODOL/ASPIRIN
1 CARISOPRODOL-ASPIRIN-CODEINE CODEINE/CARISOPRODOL/ASPIRIN
1 CARTEOLOL HCL CARTEOLOL HCL
1 CARTIA XT DILTIAZEM HCL
VC CARVEDILOL CARVEDILOL
3 CASODEX BICALUTAMIDE
3 CATAPRES CLONIDINE HCL
2 CAYSTON AZTREONAM LYSINE PA
1 CAZIANT DESOGESTREL-ETHINYL ESTRADIOL
1 CEFACLOR CEFACLOR
1 CEFACLOR ER CEFACLOR
1 CEFADROXIL CEFADROXIL
1 CEFDINIR CEFDINIR
1 CEFIXIME CEFIXIME
1 CEFPODOXIME PROXETIL CEFPODOXIME PROXETIL
1 CEFPROZIL CEFPROZIL
3 CEFTIN CEFUROXIME AXETIL
1 CEFUROXIME CEFUROXIME AXETIL
3 CELEBREX CELECOXIB
2 CELECOXIB CELECOXIB
3 CELEXA CITALOPRAM HYDROBROMIDE
3 CELLCEPT MYCOPHENOLATE MOFETIL
Tier BRAND NAME GENERIC NAMEPRIOR
AUTHORIZATION
QUANTITY LIMIT
INDICATOR
STEP THERAPY
INDICATOR3 CENTANY MUPIROCIN
1 CEPHALEXIN CEPHALEXIN
VC CETIRIZINE HCL CETIRIZINE HCL
2 CEVIMELINE CAPSULE CEVIMELINE
1 CEVIMELINE HCL TABLET CEVIMELINE
1 CHATEAL LEVONORGESTREL-ETHIN ESTRADIOL
1 CHERATUSSIN AC GUAIFENESIN/CODEINE PHOSPHATE
1 CHERATUSSIN DAC P-EPHED HCL/CODEINE/GUAIFEN
1 CHLORDIAZEPOXIDE HCL CHLORDIAZEPOXIDE HCL
1 CHLORDIAZEPOXIDE-CLIDINIUM CHLORDIAZEPOXIDE/CLIDINIUM BR
1 CHLORHEXIDINE GLUCONATE CHLORHEXIDINE GLUCONATE
1 CHLOROQUINE PHOSPHATE CHLOROQUINE PHOSPHATE
1 CHLOROQUINE TABLET CHLOROQUINE
1 CHLORPROMAZINE HCL CHLORPROMAZINE HCL
1 CHLORPROPAMIDE CHLORPROPAMIDE
VC CHLORTHALIDONE CHLORTHALIDONE
1 CHLORZOXAZONE CHLORZOXAZONE
1 CHOLESTYRAMINE CHOLESTYRAMINE (WITH SUGAR)
1 CHOLESTYRAMINE LIGHT CHOLESTYRAMINE/ASPARTAME
2 CIALIS (if covered, see your Benefit Summary) TADALAFIL QL
3 CICLODAN CICLOPIROX OLAMINE
2 CICLOPIROX 0.01% SHAMPOO CICLOPIROX OLAMINE
1 CICLOPIROX 0.77% CREAM CICLOPIROX OLAMINE
2 CICLOPIROX 0.77% GEL CICLOPIROX OLAMINE
1 CILOSTAZOL CILOSTAZOL
2 CILOXAN CIPROFLOXACIN HCL
1 CIMETIDINE CIMETIDINE
Excluded CIMZIA CERTOLIZUMAB PEGOL
3 CIPRO CIPROFLOXACIN HCL
2 CIPRODEX CIPROFLOXACIN HCL/DEXAMETH
1 CIPROFLOXACIN CIPROFLOXACIN
1 CIPROFLOXACIN HCL CIPROFLOXACIN HCL
VC CITALOPRAM HBR CITALOPRAM HBR
1 CLARAVIS ISOTRETINOIN
1 CLARITHROMYCIN CLARITHROMYCIN
1 CLARITHROMYCIN ER CLARITHROMYCIN
3 CLEOCIN PALMITATE CLINDAMYCIN PALMITATE HCL
3 CLEOCIN T CLINDAMYCIN PHOSPHATE
2 CLEVER CHEK LANCETS LANCETS
2 CLICKFINE NEEDLES, INSULIN DISPOSABLE
3 CLIMARA ESTRADIOL QL
3 CLINDACIN ETZ CLINDAMYCIN
3 CLINDACIN P CLINDAMYCIN
1 CLINDAMYCIN CAPSULE CLINDAMYCIN
1 CLINDAMYCIN HCL CLINDAMYCIN
1 CLINDAMYCIN PALMITATE HCL CLINDAMYCIN PALMITATE HCL
1 CLINDAMYCIN PEDIATRIC CLINDAMYCIN PALMITATE HCL
Tier BRAND NAME GENERIC NAMEPRIOR
AUTHORIZATION
QUANTITY LIMIT
INDICATOR
STEP THERAPY
INDICATOR2 CLINDAMYCIN PHOSPHATE FOAM CLINDAMYCIN PHOSPHATE
1 CLINDAMYCIN PHOSPHATE SOLUTION/GEL CLINDAMYCIN PHOSPHATE
2 CLINDAMYCIN PHOSPHATE/BENZOYL PEROXIDE GEL CLINDAMYCIN PHOSPHATE
2 CLINDAMYCIN-BENZOYL PEROXIDE CLINDAMYCIN PHOS/BENZOYL PEROX
1 CLOBETASOL EMOLLIENT CLOBETASOL PROPIONATE/EMOLL
2
CLOBETASOL PROPIONATE 0.05% CREAM, EMOLLIENT CREAM, FOAM,
GEL, LOTION, OINTMENT, SHAMPOO, SPRAY [SUPER HIGH] CLOBETASOL PROPIONATE
1
CLOBETASOL PROPIONATE 0.05% EMOLLIENT CREAM, SOLUTION [SUPER
HIGH] CLOBETASOL PROPIONATE
3 CLOBEX CLOBETASOL PROPIONATE
2 CLOCORTOLONE PIVALATE 0.1% CREAM [MEDIUM] CLOCORTOLONE
3 CLODAN CLOBETASOL PROPIONATE
2 CLOMIPRAMINE CLOMIPRAMINE
1 CLONAZEPAM CLONAZEPAM
1 CLONIDINE HCL CLONIDINE HCL
1 CLOPIDOGREL CLOPIDOGREL BISULFATE
1 CLORAZEPATE DIPOTASSIUM CLORAZEPATE DIPOTASSIUM
1 CLOTRIMAZOLE CLOTRIMAZOLE
1 CLOTRIMAZOLE-BETAMETHASONE 1% - 0.05% CREAM CLOTRIMAZOLE/BETAMETHASONE
2 CLOTRIMAZOLE-BETAMETHASONE DIPROPIONATE 2% - 0.05% LOTION CLOTRIMAZOLE/BETAMETHASONE
1 CLOZAPINE CLOZAPINE QL
3 CLOZARIL CLOZAPINE QL
2 COAGUCHEK LANCETS
1 CODEINE-GUAIFENESIN GUAIFENESIN/CODEINE PHOSPHATE
3 COLAZAL BALSALAZIDE DISODIUM
1 COLCHICINE COLCHICINE
3 COLCRYS COLCHICINE
3 COLESTID COLESTIPOL HCL
1 COLESTIPOL HCL COLESTIPOL HCL
1 COLOCORT HYDROCORTISONE
2 COLOR LANCETS LANCETS
3 COLYTE WITH FLAVOR PACKETS PEG 3350/NA SULF,BICARB,CL/KCL
2 COMBIGAN BRIMONIDINE TARTRATE/TIMOLOL
2 COMBIPATCH ESTRADIOL/NORETHINDRONE ACET QL
2 COMBIVENT RESPIMAT IPRATROPIUM/ALBUTEROL SULFATE
3 COMBIVIR LAMIVUDINE/ZIDOVUDINE QL
2 COMETRIQ CABOZANTINIB S-MALATE PA QL
2 COMFORT EZ NEEDLES, INSULIN DISPOSABLE
2 COMFORT LANCETS LANCETS
3 COMPAZINE PROCHLORPERAZINE MALEATE
2 COMPLERA EMTRICITAB/RILPIVIRINE/TENOFOV PA
1 COMPRO PROCHLORPERAZINE
3 COMTAN ENTACAPONE
3 CONCERTA METHYLPHENIDATE HCL QL
2 CONDYLOX PODOFILOX
1 CONSTULOSE LACTULOSE
Tier BRAND NAME GENERIC NAMEPRIOR
AUTHORIZATION
QUANTITY LIMIT
INDICATOR
STEP THERAPY
INDICATOR2 COPAXONE GLATIRAMER ACETATE PA
3 COPEGUS RIBAVIRIN
3 CORDARONE AMIODARONE HCL
2 CORDRAN FLURANDRENOLIDE
3 COREG CARVEDILOL
2 COREG CR CARVEDILOL PHOSPHATE
3 CORGARD NADOLOL
1 CORMAX CLOBETASOL PROPIONATE
3 CORTEF HYDROCORTISONE
3 CORTENEMA HYDROCORTISONE
1 CORTISONE ACETATE CORTISONE ACETATE
2 CORTISPORIN NEOMYCIN/BACITRA/POLYMYXIN/HC
3 COSENTYX SECUKINUMAB PA
3 COSOPT DORZOLAMIDE HCL/TIMOLOL MALEAT
2 COUMADIN WARFARIN SODIUM
1 COVARYX ESTROGEN,ESTER/ME-TESTOSTERONE
1 COVARYX H.S. ESTROGEN,ESTER/ME-TESTOSTERONE
3 COZAAR LOSARTAN POTASSIUM
3 CREON LIPASE/PROTEASE/AMYLASE
2 CRESTOR ROSUVASTATIN CALCIUM QL ST
2 CRIXIVAN INDINAVIR SULFATE
1 CROMOLYN SODIUM CROMOLYN SODIUM
1 CRYSELLE NORGESTREL-ETHINYL ESTRADIOL
2 CUPRIMINE PENICILLAMINE
3 CUTIVATE FLUTICASONE PROPIONATE
1 CYCLAFEM NORETHINDRONE-ETHINYL ESTRAD
3 CYCLESSA DESOGESTREL-ETHINYL ESTRADIOL ST
1 CYCLOBENZAPRINE TABLET CYCLOBENZAPRINE HCL
2 CYCLOGYL CYCLOPENTOLATE HCL
1 CYCLOPENTOLATE HCL CYCLOPENTOLATE HCL
2 CYCLOPHOSPHAMIDE CYCLOPHOSPHAMIDE
1 CYCLOSPORINE CYCLOSPORINE, MODIFIED
1 CYCLOSPORINE MODIFIED CYCLOSPORINE, MODIFIED
3 CYMBALTA DULOXETINE HCL QL
1 CYPROHEPTADINE HCL CYPROHEPTADINE HCL
2 CYSTARAN CYSTEAMINE HCL PA
3 CYTOMEL LIOTHYRONINE SODIUM
3 CYTOTEC MISOPROSTOL
2 DALIRESP ROFLUMILAST QL ST
1 DANAZOL DANAZOL
3 DANTRIUM DANTROLENE SODIUM
1 DANTROLENE SODIUM DANTROLENE SODIUM
1 DAPSONE DAPSONE
2 DARAPRIM PYRIMETHAMINE
1 DASETTA NORETHINDRONE-ETHINYL ESTRAD
3 DAYPRO OXAPROZIN
3 DDAVP DESMOPRESSIN ACETATE
Tier BRAND NAME GENERIC NAMEPRIOR
AUTHORIZATION
QUANTITY LIMIT
INDICATOR
STEP THERAPY
INDICATOR1 DEBLITANE NORETHINDRONE
3 DELATESTRYL TESTOSTERONE ENANTHATE PA
1 DELYLA LEVONORGESTREL-ETHIN ESTRADIOL
Excluded DELZICOL MESALAMINE
3 DEMADEX TORSEMIDE
Excluded DENAVIR CREAM PENCICLOVIR
1 DEPADE NALTREXONE HCL
3 DEPAKENE VALPROIC ACID
3 DEPAKOTE DIVALPROEX SODIUM
3 DEPAKOTE ER DIVALPROEX SODIUM
3 DEPAKOTE SPRINKLE DIVALPROEX SODIUM
2 DEPEN PENICILLAMINE
3 DEPO-PROVERA MEDROXYPROGESTERONE ACETATE QL
3 DEPO-TESTOSTERONE TESTOSTERONE CYPIONATE PA
Excluded DERMACINRX TRIAMCINOLONE 0.1%/DIMETHICONE 5%
Excluded DERMACINRX PUREFOLIX FOLIC ACID/VITAMIN D
Excluded DERMAPAK PLUS ZINC OXIDE/MENTHOL/TRETINOIN
Excluded DERMASILKRX TRIAMCINOLONE ACETONIDE CREAM/DIMETHICONE CREAM
1 DERMAZENE HYDROCORTISONE/IODOQUINOL
2 DESIPRAMINE DESIPRAMINE
2 DESLORATADINE ODT DESLORATADINE
1 DESMOPRESSIN ACETATE DESMOPRESSIN ACETATE
3 DESOGEN DESOGESTREL-ETHINYL ESTRADIOL ST
1 DESOGESTREL-ETHINYL ESTRADIOL DESOGESTREL-ETHINYL ESTRADIOL
1 DESOGESTR-ETH ESTRAD ETH ESTRA DESOG-E.ESTRADIOL/E.ESTRADIOL
2 DESONIDE DESONIDE
3 DESOWEN DESONIDE
1 DESOXIMETASONE 0.25% CREAM [HIGH] DESOXIMETASONE
2
DESOXIMETASONE 0.25% OINTMENT [HIGH], 0.05% GEL [HIGH], 0.05%
CREAM, OINTMENT [MEDIUM] DESOXIMETASONE
Excluded DESVENLAFAXINE ER TABLET DESVENLAFAXINE QL ST
3 DETROL TOLTERODINE TARTRATE ST
3 DETROL LA TOLTERODINE TARTRATE ST
Excluded DEUTETRABENAZINE
1 DEXAMETHASONE DEXAMETHASONE
3 DEXEDRINE DEXTROAMPHETAMINE SULFATE QL
Excluded DEXILANT DEXLANSOPRAZOLE
2 DEXMETHYLPHENIDATE ER CAPSULE
1 DEXMETHYLPHENIDATE HCL DEXMETHYLPHENIDATE HCL QL
2 DEXMETHYLPHENIDATE HCL ER DEXMETHYLPHENIDATE HCL QL
1 DEXMETHYLPHENIDATE TABLET DEXMETHYLPHENIDATE
2 DEXTROAMPHETAMINE ER CAPSULE
2 DEXTROAMPHETAMINE SULFATE DEXTROAMPHETAMINE SULFATE QL
2 DEXTROAMPHETAMINE SULFATE ER DEXTROAMPHETAMINE SULFATE QL
2 DEXTROAMPHETAMINE TABLET DEXTROAMPHETAMINE
2 DIABETA GLYBURIDE
3 DIAMOX SEQUELS ACETAZOLAMIDE
Tier BRAND NAME GENERIC NAMEPRIOR
AUTHORIZATION
QUANTITY LIMIT
INDICATOR
STEP THERAPY
INDICATOR2 DIASTAT DIAZEPAM QL
2 DIASTAT ACUDIAL DIAZEPAM QL
1 DIAZEPAM DIAZEPAM
2 DIBENZYLINE PHENOXYBENZAMINE HCL
1 DICLOFENAC SODIUM DICLOFENAC SODIUM
2 DICLOFENAC SODIUM 0.5%/1.5% TOPICAL SOLUTION DICLOFENAC SODIUM
2 DICLOFENAC SODIUM 1%/3% GEL DICLOFENAC SODIUM
1 DICLOFENAC SODIUM ER DICLOFENAC SODIUM
1 DICLOFENAC SODIUM OPHTHALMIC SOLUTION DICLOFENAC SODIUM
2 DICLOFENAC SODIUM/MISOPROSTOL COMBINATION TABLET DICLOFENAC SODIUM TABLET & MISOPROSTOL TABLET
Excluded DICLOPACK DICLOFENAC SODIUM
1 DICLOXACILLIN SODIUM DICLOXACILLIN SODIUM
1 DICYCLOMINE HCL DICYCLOMINE HCL
1 DIDANOSINE DIDANOSINE QL
3 DIFFERIN ADAPALENE
2 DIFICID FIDAXOMICIN QL ST
2 DIFLORASONE DIACETATE 0.05% OINTMENT, CREAM [HIGH] DIFLORASONE DIACETATE
3 DIFLUCAN FLUCONAZOLE
1 DIFLUNISAL DIFLUNISAL
1 DIGITEK DIGOXIN
1 DIGOX DIGOXIN
2 DIGOXIN DIGOXIN
2 DILANTIN PHENYTOIN
2 DILANTIN-125 PHENYTOIN
3 DILAUDID HYDROMORPHONE HCL
1 DILTIAZEM 12HR ER CAPSULE DILTIAZEM HCL
2 DILTIAZEM 24HR CD DILTIAZEM HCL
1 DILTIAZEM 24HR ER CAPSULE, 120 MG, 180 MG, 240 MG, 300 MG DILTIAZEM HCL
2 DILTIAZEM 24HR ER TABLET/ER CAPSULE 360 MG DILTIAZEM HCL
VC DILTIAZEM HCL DILTIAZEM HCL IR
2 DILT-XR DILTIAZEM XR HCL
3 DIOVAN VALSARTAN
3 DIOVAN HCT VALSARTAN/HYDROCHLOROTHIAZIDE
Excluded DIPENTUM OLSALAZINE
1 DIPHENHYDRAMINE CREAM (OTC) DIPHENHYDRAMINE
1 DIPHENOXYLATE-ATROPINE DIPHENOXYLATE HCL/ATROPINE
3 DIPROLENE BETAMETHASONE/PROPYLENE GLYC
3 DIPROLENE AF BETAMETHASONE/PROPYLENE GLYC
1 DIPYRIDAMOLE DIPYRIDAMOLE
3 DISALCID SALSALATE
1 DISOPYRAMIDE PHOSPHATE DISOPYRAMIDE PHOSPHATE
1 DISULFIRAM DISULFIRAM
3 DITROPAN XL OXYBUTYNIN CHLORIDE
1 DIVALPROEX SODIUM DIVALPROEX SODIUM
1 DIVALPROEX SODIUM ER DIVALPROEX SODIUM
3 DOLOPHINE HCL METHADONE HCL
1 DONEPEZIL 10 MG TABLET DONEPEZIL
Tier BRAND NAME GENERIC NAMEPRIOR
AUTHORIZATION
QUANTITY LIMIT
INDICATOR
STEP THERAPY
INDICATOR2 DONEPEZIL 23 MG TABLET DONEPEZIL
1 DONEPEZIL HCL DONEPEZIL HCL
1 DONEPEZIL HCL ODT DONEPEZIL HCL
2 DONNATAL PHENOBARB/HYOSCY/ATROPINE/SCOP
1 DORZOLAMIDE HCL DORZOLAMIDE HCL
1 DORZOLAMIDE-TIMOLOL DORZOLAMIDE HCL/TIMOLOL MALEAT
3 DOVONEX CALCIPOTRIENE ST
1 DOXAZOSIN MESYLATE DOXAZOSIN MESYLATE
2 DOXEPIN 5% CREAM DOXEPIN
1 DOXYCYCLINE HYCLATE 20 MG TABLET DOXYCYCLINE HYCLATE
2 DOXYCYCLINE HYCLATE 75/150 DR TABLET DOXYCYCLINE HYCLATE QL ST
1 DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE/TABLET DOXYCYCLINE MONOHYDRATE QL
2 DOXYCYCLINE MONOHYDRATE 40 MG CAPSULE/BIPHASIC RELEASE DOXYCYCLINE MONOHYDRATE
2 DOXYCYCLINE MONOHYDRATE 75/150 MG CAPSULE DOXYCYCLINE MONOHYDRATE
1 DOXYCYCLINE MONOHYDRATE 75/150 MG TABLET DOXYCYCLINE MONOHYDRATE
3 DRISDOL ERGOCALCIFEROL (VITAMIN D2)
2 DRITHOCREME HP ANTHRALIN ST
2 DRONABINOL DRONABINOL QL ST
2 DROPLET LANCETS LANCETS
1 DROSPIRENONE-ETHINYL ESTRADIOL ETHINYL ESTRADIOL/DROSPIRENONE ST
2 DRYSOL ALUMINUM CHLORIDE
2 DUAVEE ESTROGENS,CONJ/BAZEDOXIFENE
3 DUETACT PIOGLITAZONE HCL/GLIMEPIRIDE ST
Excluded DUEXIS FAMOTIDINE/IBUPROFEN
2 DULERA MOMETASONE/FORMOTEROL QL
1 DULOXETINE 20 MG (2 CAPSULES) DULOXETINE QL
2 DULOXETINE 40 MG DULOXETINE
3 DURAGESIC FENTANYL PA QL
2 DUREZOL DIFLUPREDNATE
Excluded DURLAZA ASPRIN
3 DYAZIDE TRIAMTERENE/HYDROCHLOROTHIAZID
1 E.E.S. 200 ERYTHROMYCIN ETHYLSUCCINATE
1 E.E.S. 400 ERYTHROMYCIN ETHYLSUCCINATE
2 EASY COMFORT LANCETS
2 EASY COMFORT INSULIN SYRINGE SYRING W-NDL,DISP,INSUL,0.5 ML
2 EASY COMFORT PEN NEEDLES NEEDLES, INSULIN DISPOSABLE
2 EASY TOUCH LANCETS
2 EASY TOUCH INSULIN SAFETY SYRINGE,NEEDLE,INSULN,SF 0.5ML
2 EASY TOUCH INSULIN SYRINGE SYRINGE & NEEDLE,INSULIN,1 ML
2 EASY TOUCH LANCETS LANCETS
2 EASY TOUCH PEN NEEDLE NEEDLES, INSULIN DISPOSABLE
2 EASY TWIST & CAP LANCETS LANCETS
2 EASY-TOUCH INSULIN SYRINGE SYRINGE & NEEDLE,INSULIN,1 ML
2 ECLIPSE SYRINGE SYRINGE & NEEDLE,INSULIN,1 ML
3 EC-NAPROSYN NAPROXEN
2 ECONAZOLE NITRATE 0.01% CREAM ECONAZOLE
1 ECONTRA EZ LEVONORGESTREL
Tier BRAND NAME GENERIC NAMEPRIOR
AUTHORIZATION
QUANTITY LIMIT
INDICATOR
STEP THERAPY
INDICATORExcluded EDARBI AZILSARTAN MEDOXOMIL
Excluded EDARBYCLOR AZILSARTAN MEDOXOMIL AND CHLORTHALIDONE
Excluded EDLUAR ZOLPIDEM TARTRATE
1 ED-SPAZ HYOSCYAMINE SULFATE
2 EDURANT RILPIVIRINE HCL PA
1 EEMT ESTROGEN,ESTER/ME-TESTOSTERONE
1 EEMT H.S. ESTROGEN,ESTER/ME-TESTOSTERONE
1 EFFER-K POTASSIUM BICARBONATE/CIT AC
3 EFFEXOR XR VENLAFAXINE HCL
2 EFFIENT PRASUGREL HCL QL
3 EFUDEX FLUOROURACIL
3 ELDEPRYL SELEGILINE HCL
2 ELIGARD LEUPROLIDE ACETATE PA
3 ELIMITE PERMETHRIN
1 ELINEST NORGESTREL-ETHINYL ESTRADIOL
1 ELIPHOS CALCIUM ACETATE
2 ELIQUIS APIXABAN QL
1 ELIXOPHYLLIN THEOPHYLLINE ANHYDROUS
2 ELMIRON PENTOSAN POLYSULFATE SODIUM
3 ELOCON MOMETASONE FUROATE
Excluded EMADINE EMEDASTINE
2 EMBRACE LANCETS
2 EMCYT ESTRAMUSTINE PHOSPHATE SODIUM
2 EMEND APREPITANT QL
1 EMOQUETTE DESOGESTREL-ETHINYL ESTRADIOL
2 EMTRIVA EMTRICITABINE QL
VC ENALAPRIL MALEATE ENALAPRIL MALEATE
VC ENALAPRIL-HYDROCHLOROTHIAZIDE ENALAPRIL/HYDROCHLOROTHIAZIDE
2 ENBREL ETANERCEPT PA
1 ENDOCET OXYCODONE HCL/ACETAMINOPHEN QL
1 ENDODAN OXYCODONE HCL/ASPIRIN
1 ENOXAPARIN SODIUM ENOXAPARIN SODIUM QL
1 ENPRESSE LEVONORGESTREL-ETHIN ESTRADIOL
1 ENSKYCE DESOGESTREL-ETHINYL ESTRADIOL
1 ENTACAPONE ENTACAPONE
1 ENTECAVIR ENTECAVIR
3 ENTOCORT EC BUDESONIDE
1 ENULOSE LACTULOSE
1 EPINEPHRINE EPINEPHRINE
2 EPIPEN 2-PAK EPINEPHRINE
2 EPIPEN JR 2-PAK EPINEPHRINE
1 EPITOL CARBAMAZEPINE
3 EPIVIR LAMIVUDINE QL
3 EPIVIR HBV LAMIVUDINE
2 EPLERENONE EPLERENONE
Excluded EPROSARTAN EPROSARTAN
2 EPZICOM ABACAVIR SULFATE/LAMIVUDINE QL
Tier BRAND NAME GENERIC NAMEPRIOR
AUTHORIZATION
QUANTITY LIMIT
INDICATOR
STEP THERAPY
INDICATOR2 ERIVEDGE VISMODEGIB PA QL
1 ERRIN NORETHINDRONE
3 ERYGEL ERYTHROMYCIN BASE/ETHANOL
3 ERYPED 200 ERYTHROMYCIN ETHYLSUCCINATE
2 ERYPED 400 ERYTHROMYCIN ETHYLSUCCINATE
1 ERY-TAB ERYTHROMYCIN BASE
1 ERYTHROCIN STEARATE ERYTHROMYCIN STEARATE
VC ERYTHROMYCIN ERYTHROMYCIN BASE/ETHANOL
2 ERYTHROMYCIN BASE/BENZOYL PEROXIDE GEL ERYTHROMYCIN/BENZOYL PEROXIDE
1 ERYTHROMYCIN BASE/ETHANOL SOLUTION ERYTHROMYCIN/ETHANOL
1 ERYTHROMYCIN BASE/ETHANOL SOLUTION & BENZOYL PEROXIDE OTC ERYTHROMYCIN/ETHANOL
1 ERYTHROMYCIN ETHYLSUCCINATE ERYTHROMYCIN ETHYLSUCCINATE
1 ERYTHROMYCIN/BENZOYL PEROXIDE ERYTHROMYCIN/BENZOYL PEROXIDE
2 ESBRIET PIRFENIDONE PA
1 ESCITALOPRAM OXALATE ESCITALOPRAM OXALATE
3 ESGIC BUTALB/ACETAMINOPHEN/CAFFEINE
1 ESTARYLLA NORGESTIMATE-ETHINYL ESTRADIOL
1 ESTAZOLAM ESTAZOLAM
3 ESTRACE ESTRADIOL
1 ESTRADIOL ESTRADIOL
Excluded ESTROGEL ESTRADIOL
1 ESTROGEN & METHYLTESTOSTERONE ESTROGEN,ESTER/ME-TESTOSTERONE
1 ESTROPIPATE ESTROPIPATE
1 ESZOPICLONE ESZOPICLONE QL
1 ETHAMBUTOL HCL ETHAMBUTOL HCL
1 ETHOSUXIMIDE ETHOSUXIMIDE
2 ETIDRONATE ETIDRONATE
2 ETODOLAC ETODOLAC
1 ETODOLAC ER ETODOLAC
1 ETOPOSIDE ETOPOSIDE
2 EURAX CROTAMITON
Excluded EVEKEO AMPHETAMINE SULFATE
3 EVISTA RALOXIFENE HCL PA QL
3 EVOCLIN CLINDAMYCIN PHOSPHATE
2 EVOTAZ ATAZANAVIR SULFATE/COBICISTAT QL
3 EVOXAC CEVIMELINE HCL
2 EXELDERM SULCONAZOLE NITRATE
3 EXELON RIVASTIGMINE TARTRATE
1 EXEMESTANE EXEMESTANE PA
3 EXFORGE AMLODIPINE/VALSARTAN ST
3 EXFORGE HCT AMLODIPINE/VALSARTAN/HCTHIAZID ST
Excluded EXTAVIA INTERFERON BETA-1B
2 E-Z JECT LANCETS LANCETS
2 EZ SMART LANCETS LANCETS
2 E-ZJECT LANCETS LANCETS
1 FABB CYANOCOBALAMIN/FA/PYRIDOXINE
Tier BRAND NAME GENERIC NAMEPRIOR
AUTHORIZATION
QUANTITY LIMIT
INDICATOR
STEP THERAPY
INDICATOR2 FABIOR TAZAROTENE
1 FALLBACK SOLO LEVONORGESTREL
1 FALMINA LEVONORGESTREL-ETHIN ESTRADIOL
2 FAMOTIDINE ORAL SUSPENSION FAMOTIDINE
1 FAMOTIDINE TABLET OTC FAMOTIDINE
2 FARESTON TOREMIFENE CITRATE PA
Excluded FARXIGA DAPAGLIFLOZIN
2 FARYDAK PANOBINOSTAT LACTATE PA
3 FELDENE PIROXICAM
1 FELODIPINE ER FELODIPINE
3 FEMARA LETROZOLE
3 FEMHRT NORETHINDRONE AC-ETH ESTRADIOL
2 FENOFIBRATE (LIPOFEN/TRILIPIX DR/ANTARA/FENOGLIDE) FENOFIBRATE
1 FENOFIBRATE (LOFIBRA/TRICOR/LOFIBRA) FENOFIBRATE
2 FENOGLIDE FENOFIBRATE ST
2 FENOPROFEN CALCIUM TABLET FENOPROFEN CALCIUM
1 FENTANYL FENTANYL PA QL
1 FENTANYL CITRATE FENTANYL CITRATE PA
1
FENTANYL TRANSDERMAL PATCH 12 MCG/HR, 25 MCG/HR, 50 MCG/HR,
75 MCG/HR FENTANYL
2
FENTANYL TRANSDERMAL PATCH 37.5 MCG/HR, 62.5 MCG/HR, 87.5
MCG/HR FENTANYL
Excluded FENTORA FENTANYL CITRATE
Excluded FEXMID CYCLOBENZAPRINE
Excluded FEXOFENADINE HCL FEXOFENADINE HCL
2 FIFTY50 SAFETY SEAL LANCETS LANCETS
1 FINASTERIDE FINASTERIDE
2 FINE 30 UNIVERSAL LANCETS LANCETS
2 FINGERSTIX LANCETS
3 FIORINAL BUTALBITAL/ASPIRIN/CAFFEINE
3 FIORINAL WITH CODEINE #3 CODEINE/BUTALBITAL/ASA/CAFFEIN
2 FIRAZYR ICATIBANT ACETATE PA
3 FLAGYL METRONIDAZOLE
2 FLAGYL ER METRONIDAZOLE
2 FLAREX FLUOROMETHOLONE ACETATE
1 FLECAINIDE ACETATE FLECAINIDE ACETATE
Excluded FLECTOR PATCH DICLOFENAC
Excluded FLEXEPACX CYCLOBENZAPRINE
3 FLOMAX TAMSULOSIN HCL
Excluded FLOVENT DISKUS FLUTICASONE PROPIONATE
Excluded FLOVENT HFA FLUTICASONE PROPIONATE HFA
1 FLUCONAZOLE FLUCONAZOLE
1 FLUDROCORTISONE ACETATE FLUDROCORTISONE ACETATE
Excluded FLUMIST
1 FLUNISOLIDE FLUNISOLIDE QL
1 FLUOCINOLONE ACETONIDE 0.01% CREAM [LOW] FLUOCINOLONE ACETONIDE
2 FLUOCINOLONE ACETONIDE 0.01% SOLUTION [LOW] FLUOCINOLONE ACETONIDE
Tier BRAND NAME GENERIC NAMEPRIOR
AUTHORIZATION
QUANTITY LIMIT
INDICATOR
STEP THERAPY
INDICATOR
1
FLUOCINONIDE 0.05% CREAM, EMOLLIENT CREAM, GEL, OINTMENT
[HIGH] FLUOCINONIDE
2 FLUOCINONIDE 0.05% OINTMENT [HIGH], 0.1% CREAM [SUPER HIGH] FLUOCINONIDE
1 FLUORIDE SODIUM FLUORIDE
3 FLUORITAB SODIUM FLUORIDE
1 FLUOROMETHOLONE FLUOROMETHOLONE
1 FLUOROURACIL FLUOROURACIL
1 FLUOXETINE CAPSULE FLUOXETINE
1 FLUOXETINE DR FLUOXETINE
VC FLUOXETINE HCL CAPSULE FLUOXETINE
2 FLUOXETINE TABLET FLUOXETINE
1 FLUPHENAZINE HCL FLUPHENAZINE HCL
2 FLURA-DROPS SODIUM FLUORIDE
2 FLURANDRENOLIDE 0.05% CREAM [LOWER MID-STRENGTH]
1 FLURAZEPAM HCL FLURAZEPAM HCL
1 FLURBIPROFEN FLURBIPROFEN
1 FLURBIPROFEN SODIUM FLURBIPROFEN SODIUM
1 FLUTAMIDE FLUTAMIDE
VC FLUTICASONE NASAL SPRAY FLUTICASONE
1 FLUTICASONE PROPIONATE 0.05% CREAM [LOWER MID-STRENGTH] FLUTICASONE
2
FLUTICASONE PROPIONATE 0.05% LOTION [LOWER MID-STRENGTH],
0.005% OINTMENT [HIGH] FLUTICASONE QL
2 FLUVASTATIN
2 FLUVOXAMINE ER CAPSULE FLUVOXAMINE
1 FLUVOXAMINE MALEATE FLUVOXAMINE
1 FLUVOXAMINE TABLET FLUVOXAMINE
3 FML FLUOROMETHOLONE
2 FML FORTE FLUOROMETHOLONE
2 FML S.O.P. FLUOROMETHOLONE
3 FOCALIN DEXMETHYLPHENIDATE HCL QL
3 FOCALIN XR DEXMETHYLPHENIDATE HCL QL
3 FOLGARD RX CYANOCOBALAMIN/FA/PYRIDOXINE
1 FOLIC ACID FOLIC ACID
1 FONDAPARINUX SODIUM FONDAPARINUX SODIUM QL
2 FORACARE LANCETS LANCETS
Excluded FORFIVO XL BUPROPION HYDROCHLORIDE
2 FORTEO TERIPARATIDE QL
Excluded FORTESTA TESTOSTERONE
3 FOSAMAX ALENDRONATE SODIUM
2 FOSAMAX PLUS D ALENDRONATE SODIUM/VITAMIN D3
1 FOSINOPRIL SODIUM FOSINOPRIL SODIUM
1 FOSINOPRIL-HYDROCHLOROTHIAZIDE FOSINOPRIL/HYDROCHLOROTHIAZIDE
2 FRAGMIN DALTEPARIN SODIUM,PORCINE QL
1 FREESTYLE INSULINX BLOOD SUGAR DIAGNOSTIC
1 FREESTYLE INSULINX TEST STRIPS BLOOD SUGAR DIAGNOSTIC
1 FREESTYLE LANCETS LANCETS
Tier BRAND NAME GENERIC NAMEPRIOR
AUTHORIZATION
QUANTITY LIMIT
INDICATOR
STEP THERAPY
INDICATOR1 FREESTYLE LITE STRIPS BLOOD SUGAR DIAGNOSTIC
1 FREESTYLE PRECISION SYRINGE & NEEDLE,INSULIN,1 ML
1 FREESTYLE TEST STRIPS BLOOD SUGAR DIAGNOSTIC
1 FREESTYLE UNISTIK 2 LANCETS
Excluded FROVA FROVATRIPTAN
3 FURADANTIN NITROFURANTOIN
VC FUROSEMIDE FUROSEMIDE
2 FUZEON ENFUVIRTIDE QL ST
1 GABAPENTIN GABAPENTIN
1 GALANTAMINE HBR GALANTAMINE HBR QL
1 GALANTAMINE HYDROBROMIDE GALANTAMINE HBR QL
3 GARAMYCIN GENTAMICIN SULFATE
1 GATIFLOXACIN GATIFLOXACIN
2 GATTEX TEDUGLUTIDE PA
1 GAVILYTE-C PEG 3350/NA SULF,BICARB,CL/KCL
1 GAVILYTE-G PEG 3350/NA SULF,BICARB,CL/KCL
1 GAVILYTE-N SODIUM CHLORIDE/NAHCO3/KCL/PEG
1 GEMFIBROZIL TABLET GEMFIBROZIL
1 GENERLAC LACTULOSE
1 GENGRAF CYCLOSPORINE, MODIFIED
Excluded GENOTROPIN SOMATROPIN
1 GENTAK GENTAMICIN SULFATE
1 GENTAMICIN SULFATE GENTAMICIN SULFATE
3 GEODON ZIPRASIDONE HCL QL
1 GIANVI ETHINYL ESTRADIOL/DROSPIRENONE ST
1 GILDESS NORETHINDRONE AC-ETH ESTRADIOL
1 GILDESS FE NORETHINDRONE-E.ESTRADIOL-IRON
2 GILENYA FINGOLIMOD HCL PA
2 GILOTRIF AFATINIB DIMALEATE PA
1 GLATOPA GLATIRAMER ACETATE PA
2 GLEEVEC IMATINIB MESYLATE PA QL
3 GLEOSTINE LOMUSTINE
VC GLIMEPIRIDE GLIMEPIRIDE
VC GLIPIZIDE GLIPIZIDE
1 GLIPIZIDE ER GLIPIZIDE
1 GLIPIZIDE XL GLIPIZIDE
1 GLIPIZIDE-METFORMIN GLIPIZIDE/METFORMIN HCL
2 GLUCAGON EMERGENCY KIT GLUCAGON,HUMAN RECOMBINANT
2 GLUCOCOM LANCETS
2 GLUCOCOM LANCETS LANCETS
3 GLUCOPHAGE METFORMIN HCL
3 GLUCOPHAGE XR METFORMIN HCL
2 GLUCOSOURCE LANCETS
3 GLUCOTROL GLIPIZIDE
3 GLUCOTROL XL GLIPIZIDE
3 GLUCOVANCE GLYBURIDE/METFORMIN HCL
Excluded GLUMETZA METFORMIN
Tier BRAND NAME GENERIC NAMEPRIOR
AUTHORIZATION
QUANTITY LIMIT
INDICATOR
STEP THERAPY
INDICATORVC GLYBURIDE GLYBURIDE
VC GLYBURIDE-METFORMIN HCL GLYBURIDE/METFORMIN HCL
2 GLYXAMBI EMPAGLIFLOZIN/LINAGLIPTIN QL ST
2 GMATE LANCETS
3 GOLYTELY PEG 3350/NA SULF,BICARB,CL/KCL
Excluded GRALISE GABAPENTIN
2 GRANISETRON
2 GRASTEK GRASS POLLEN-TIMOTHY, STD PA
2 GRISEOFULVIN GRISEOFULVIN, MICROSIZE
2 GRISEOFULVIN MICROSIZE/ULTRAMICROSIZE GRISEOFULVIN ULTRAMICROSIZE
3 GRIS-PEG GRISEOFULVIN ULTRAMICROSIZE
1 GUAIATUSSIN AC GUAIFENESIN/CODEINE PHOSPHATE
1 GUAIFENESIN AC GUAIFENESIN/CODEINE PHOSPHATE
1 GUAIFENESIN DAC P-EPHED HCL/CODEINE/GUAIFEN
1 GUAIFENESIN-CODEINE GUAIFENESIN/CODEINE PHOSPHATE
1 GUANFACINE HCL GUANFACINE HCL
2 GYNAZOLE 1 BUTOCONAZOLE NITRATE
3 HALCION TRIAZOLAM
1 HALOBETASOL PROPIONATE HALOBETASOL PROPIONATE
1 HALOPERIDOL HALOPERIDOL
1 HALOPERIDOL LACTATE HALOPERIDOL LACTATE
2 HARVONI LEDIPASVIR/SOFOSBUVIR PA
2 HEALTHY ACCENTS UNIFINE PENTIP NEEDLES, INSULIN DISP., SAFETY
2 HEALTHY ACCENTS UNILET LANCET LANCETS
1 HEATHER NORETHINDRONE
1 HEPARIN FLUSH HEPARIN SODIUM,PORCINE/PF
1 HEPARIN LOCK HEPARIN SODIUM,PORCINE
1 HEPARIN SODIUM HEPARIN SODIUM,PORCINE
3 HEPSERA ADEFOVIR DIPIVOXIL
2 HEXALEN ALTRETAMINE
1 HOMATROPAIRE HOMATROPINE HBR
1 HOMATROPINE HYDROBROMIDE HOMATROPINE HBR
Excluded HORIZANT GABAPENTIN ENACARBIL EXTENDED-RELEASE
2 HUMALOG INSULIN LISPRO QL
2 HUMALOG KWIKPEN INSULIN LISPRO QL
2 HUMALOG MIX 50-50 INSULIN NPL/INSULIN LISPRO QL
2 HUMALOG MIX 50-50 KWIKPEN INSULIN NPL/INSULIN LISPRO QL
2 HUMALOG MIX 75-25 INSULIN NPL/INSULIN LISPRO QL
2 HUMALOG MIX 75-25 KWIKPEN INSULIN NPL/INSULIN LISPRO QL
Excluded HUMATROPE SOMATROPIN
2 HUMIRA ADALIMUMAB PA
2 HUMIRA CROHN'S ADALIMUMAB PA
2 HUMIRA PEDIATRIC CROHN'S ADALIMUMAB PA
2 HUMIRA PSORIASIS ADALIMUMAB PA
2 HUMULIN 70/30 KWIKPEN INSULIN NPH HUM/REG INSULIN HM QL
2 HUMULIN 70-30 INSULIN NPH HUM/REG INSULIN HM QL
2 HUMULIN N INSULIN NPH HUMAN ISOPHANE QL
Tier BRAND NAME GENERIC NAMEPRIOR
AUTHORIZATION
QUANTITY LIMIT
INDICATOR
STEP THERAPY
INDICATOR2 HUMULIN N KWIKPEN INSULIN NPH HUMAN ISOPHANE QL
2 HUMULIN R INSULIN REGULAR, HUMAN QL
2 HUMULIN R U-500 INSULIN REGULAR, HUMAN QL
2 HYCAMTIN TOPOTECAN HCL
3 HYCET HYDROCODONE/ACETAMINOPHEN QL
Excluded HYCOFENIX HYDROCODONE/PSEUDOEPHEDRINE/GUAIFENESIN
1 HYDRALAZINE HCL HYDRALAZINE HCL
3 HYDREA HYDROXYUREA
VC HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE
1 HYDROCODONE BT-HOMATROPINE MBR HYDROCODONE BIT/HOMATROP ME-BR
1 HYDROCODONE-ACETAMINOPHEN HYDROCODONE/ACETAMINOPHEN QL
1 HYDROCODONE-APAP (NORCO) HYDROCODONE
2 HYDROCODONE-APAP (VICODIN) HYDROCODONE
1 HYDROCODONE-CHLORPHENIRAMNE ER HYDROCODONE/CHLORPHEN P-STIREX
1 HYDROCODONE-HOMATROPINE MBR HYDROCODONE BIT/HOMATROP ME-BR
1 HYDROCORTISONE HYDROCORTISONE
1 HYDROCORTISONE ACETATE HYDROCORTISONE ACETATE
2
HYDROCORTISONE BUTYRATE 0.1% SOLUTION [LOWER MID-STRENGTH],
0.1% CREAM, OINTMENT, EMOLLIENT CREAM [LOWER MID-STRENGTH] HYDROCORTISONE BUTYRATE
2
HYDROCORTISONE VALERATE 0.2% CREAM [LOWER MID-STRENGTH],
0.2% OINTMENT [MEDIUM] HYDROCORTISONE VALERATE
1 HYDROCORTISONE-ACETIC ACID ACETIC ACID/HYDROCORTISONE
1 HYDROCORTISONE-IODOQUINOL HYDROCORTISONE/IODOQUINOL
1 HYDROCORTISONE-PRAMOXINE HYDROCORTISONE/PRAMOXINE
1 HYDROCORTISONE-PRAMOXINE HCL HYDROCORTISONE/PRAMOXINE
1 HYDROMET HYDROCODONE BIT/HOMATROP ME-BR
1 HYDROMORPHONE HCL HYDROMORPHONE HCL
1 HYDROXYCHLOROQUINE SULFATE HYDROXYCHLOROQUINE SULFATE
1 HYDROXYUREA HYDROXYUREA
1 HYDROXYZINE HCL HYDROXYZINE HCL
1 HYDROXYZINE PAMOATE HYDROXYZINE PAMOATE
1 HYOPHEN METHENAM/ME BLUE/BA/SALICY/HYO
1 HYOSCYAMINE SULFATE HYOSCYAMINE SULFATE
1 HYOSCYAMINE SULFATE ER HYOSCYAMINE SULFATE
1 HYOSCYAMINE SULFATE SR HYOSCYAMINE SULFATE
1 HYOSYNE HYOSCYAMINE SULFATE
3 HYPER-SAL SODIUM CHLORIDE FOR INHALATION
3 HYZAAR LOSARTAN/HYDROCHLOROTHIAZIDE
1 IBANDRONATE SODIUM IBANDRONATE SODIUM
2 IBRANCE PALBOCICLIB PA
VC IBUPROFEN IBUPROFEN
2 ICLUSIG PONATINIB HCL PA QL
2 ILEVRO NEPAFENAC
3 ILOTYCIN ERYTHROMYCIN BASE
2 IMBRUVICA IBRUTINIB PA
2 IMIPRAMINE IMIPRAMINE
Tier BRAND NAME GENERIC NAMEPRIOR
AUTHORIZATION
QUANTITY LIMIT
INDICATOR
STEP THERAPY
INDICATOR1 IMIQUIMOD IMIQUIMOD PA QL
3 IMITREX SUMATRIPTAN SUCCINATE QL
3 IMURAN AZATHIOPRINE
2 IN CONTROL PEN NEEDLE NEEDLES, INSULIN DISPOSABLE
1 INATAL ADVANCE PRENATAL VIT 15/IRON CB/FA/DSS
1 INATAL ULTRA PRENATAL VIT 18/IRON CB/FA/DSS
2 INCONTROL NEEDLES, INSULIN DISPOSABLE
2 INCONTROL SUPER THIN LANCETS LANCETS
2 INCONTROL ULTRA THIN LANCETS LANCETS
1 INDAPAMIDE INDAPAMIDE
3 INDERAL LA PROPRANOLOL HCL
2 INDOCIN INDOMETHACIN
1 INDOMETHACIN 25 MG/50 MG CASPSULE INDOMETHACIN
2 INDOMETHACIN 75 MG ER CAPSULE INDOMETHACIN
2 INJECT EASE LANCETS LANCETS
2 INLYTA AXITINIB PA QL
3 INSPRA EPLERENONE
2 INSULIN PEN NEEDLE NEEDLES, INSULIN DISPOSABLE
2 INSULIN SYRINGE SYRINGE & NEEDLE,INSULIN,1 ML
2 INSUPEN NEEDLES, INSULIN DISPOSABLE
2 INTEGRA SYRINGE SYRINGE & NEEDLE,INSULIN,1 ML
2 INTELENCE ETRAVIRINE PA
Excluded INTERMEZZO ZOLPIDEM TARTRATE
2 INTRON A INTERFERON ALFA-2B,RECOMB. PA
1 INTROVALE LEVONORGESTREL-ETHIN ESTRADIOL QL
2 INVACARE LANCETS LANCETS
2 INVIRASE SAQUINAVIR MESYLATE QL ST
2 INVOKAMET CANAGLIFLOZIN/METFORMIN HCL QL ST
2 INVOKANA CANAGLIFLOZIN QL ST
1 IOPHEN-C NR GUAIFENESIN/CODEINE PHOSPHATE
1 IPRATROPIUM BROMIDE IPRATROPIUM BROMIDE
1 IPRATROPIUM NASAL SPRAY IPRATROPIUM NASAL SPRAY
1 IPRATROPIUM-ALBUTEROL IPRATROPIUM/ALBUTEROL SULFATE
1 IRBESARTAN IRBESARTAN
1 IRBESARTAN-HYDROCHLOROTHIAZIDE IRBESARTAN/HYDROCHLOROTHIAZIDE
Excluded IRENKA DULOXETINE
2 IRESSA GEFITINIB PA
2 ISENTRESS RALTEGRAVIR POTASSIUM
3 ISOCHRON ISOSORBIDE DINITRATE
1 ISOMETHEPT-DICHLORALP-ACETAMIN ISOMETHEPT/DICHLPHN/ACETAMINOP
1 ISONIAZID ISONIAZID
3 ISOPTO ATROPINE ATROPINE SULFATE
3 ISOPTO CARPINE PILOCARPINE HCL
2 ISORDIL ISOSORBIDE DINITRATE
3 ISORDIL TITRADOSE ISOSORBIDE DINITRATE
1 ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE
1 ISOSORBIDE MONONITRATE ISOSORBIDE MONONITRATE
Tier BRAND NAME GENERIC NAMEPRIOR
AUTHORIZATION
QUANTITY LIMIT
INDICATOR
STEP THERAPY
INDICATOR1 ISOSORBIDE MONONITRATE ER ISOSORBIDE MONONITRATE
1 ISRADIPINE ISRADIPINE
1 ITRACONAZOLE ITRACONAZOLE
2 JAKAFI RUXOLITINIB PHOSPHATE PA QL
2 JALYN DUTASTERIDE/TAMSULOSIN HCL ST
1 JANTOVEN WARFARIN SODIUM
2 JANUMET SITAGLIPTIN PHOS/METFORMIN HCL QL
2 JANUMET XR SITAGLIPTIN PHOS/METFORMIN HCL QL
2 JANUVIA SITAGLIPTIN PHOSPHATE QL
Excluded JARDIANCE EMPAGLIFLOZIN
1 JENCYCLA NORETHINDRONE
2 JENTADUETO LINAGLIPTIN/METFORMIN HCL QL
1 JINTELI NORETHINDRONE AC-ETH ESTRADIOL
1 JOLESSA LEVONORGESTREL-ETHIN ESTRADIOL QL
1 JOLIVETTE NORETHINDRONE
1 JUNEL NORETHINDRONE AC-ETH ESTRADIOL
1 JUNEL FE NORETHINDRONE-E.ESTRADIOL-IRON
2 JUXTAPID LOMITAPIDE MESYLATE PA
1 K EFFERVESCENT POTASSIUM BICARBONATE/CIT AC
Excluded KADIAN MORPHINE
2 KALETRA LOPINAVIR/RITONAVIR QL
2 KALYDECO IVACAFTOR PA
1 KARIVA DESOG-E.ESTRADIOL/E.ESTRADIOL
3 KAYEXALATE SODIUM POLYSTYRENE SULFONATE
Excluded KAZANO ALOGLIPTIN AND METFORMIN
3 KEFLEX CEPHALEXIN
1 KELNOR 1-35 ETHYNODIOL D-ETHINYL ESTRADIOL
3 KENALOG TRIAMCINOLONE ACETONIDE
3 KEPPRA LEVETIRACETAM
2 KETEK TELITHROMYCIN
1 KETOCONAZOLE KETOCONAZOLE
2 KETOPROFEN SR CAPSULE KETOPROFEN
1 KETOROLAC TROMETHAMINE KETOROLAC TROMETHAMINE
1 KETOROLAC TROMETHAMINE OPHTHALMIC SOLUTION KETOROLAC TROMETHAMINE
VC KETOTIFEN EYE DROPS KETOTIFEN
Excluded KHEDEZLA DESVENLAFAXINE
1 KIMIDESS DESOG-E.ESTRADIOL/E.ESTRADIOL
2 KINNEY BRAND LANCETS LANCETS
1 KIONEX SODIUM POLYSTYRENE SULFONATE
3 KLARON SULFACETAMIDE SODIUM
2 KLONOPIN CLONAZEPAM
3 KLOR-CON POTASSIUM CHLORIDE
3 KLOR-CON 10 POTASSIUM CHLORIDE
3 KLOR-CON 8 POTASSIUM CHLORIDE
1 KLOR-CON M10 POTASSIUM CHLORIDE
1 KLOR-CON M20 POTASSIUM CHLORIDE
3 KLOR-CON-EF POTASSIUM BICARBONATE/CIT AC
Tier BRAND NAME GENERIC NAMEPRIOR
AUTHORIZATION
QUANTITY LIMIT
INDICATOR
STEP THERAPY
INDICATORExcluded KOMBIGLYZE XR SAXAGLIPTIN AND METFORMIN
2 KORLYM MIFEPRISTONE PA
2 KRISTALOSE LACTULOSE
3 K-SOL POTASSIUM CHLORIDE
3 K-TAB ER POTASSIUM CHLORIDE
1 KURVELO LEVONORGESTREL-ETHIN ESTRADIOL
2 KYNAMRO MIPOMERSEN SODIUM PA
1 LABETALOL HCL LABETALOL HCL
1 LACTULOSE LACTULOSE
2 LAMICTAL LAMOTRIGINE
2 LAMICTAL (BLUE) LAMOTRIGINE
2 LAMICTAL (GREEN) LAMOTRIGINE
2 LAMICTAL (ORANGE) LAMOTRIGINE
3 LAMISIL TERBINAFINE HCL
1 LAMIVUDINE LAMIVUDINE
1 LAMIVUDINE HBV LAMIVUDINE
1 LAMIVUDINE-ZIDOVUDINE LAMIVUDINE/ZIDOVUDINE QL
1 LAMOTRIGINE LAMOTRIGINE
2 LANCETS LANCETS
2 LANCETS THIN LANCETS
2 LANCETS ULTRA THIN LANCETS
2 LANOXIN DIGOXIN
1 LANSOPRAZOL-AMOXICIL-CLARITHRO LANSOPRAZOLE/AMOXICILN/CLARITH QL
1 LANSOPRAZOLE LANSOPRAZOLE
2 LANTUS INSULIN GLARGINE,HUM.REC.ANLOG QL
2 LANTUS SOLOSTAR INSULIN GLARGINE,HUM.REC.ANLOG QL
1 LARIN NORETHINDRONE AC-ETH ESTRADIOL
1 LARIN FE NORETHINDRONE-E.ESTRADIOL-IRON
3 LASIX FUROSEMIDE
Excluded LASTACAFT ALCAFTADINE
1 LATANOPROST LATANOPROST
Excluded LAZANDA FENTANYL CITRATE
Excluded LDO PLUS LIDOCAINE HCI
1 LEENA NORETHINDRONE-ETHINYL ESTRAD
1 LEFLUNOMIDE LEFLUNOMIDE
Excluded LEMTRADA ALEMTUZUMAB
2 LENVIMA LENVATINIB MESYLATE PA
Excluded LESCOL XL FLUVASTATIN
1 LESSINA LEVONORGESTREL-ETHIN ESTRADIOL
2 LETAIRIS AMBRISENTAN PA
1 LETROZOLE LETROZOLE
1 LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM
2 LEUKERAN CHLORAMBUCIL
2 LEUKINE SARGRAMOSTIM PA
2 LEVALBUTEROL SOLUTION FOR INHALATION
3 LEVAQUIN LEVOFLOXACIN
3 LEVBID HYOSCYAMINE SULFATE
Tier BRAND NAME GENERIC NAMEPRIOR
AUTHORIZATION
QUANTITY LIMIT
INDICATOR
STEP THERAPY
INDICATORExcluded LEVEMIR INSULIN DETEMIR
1 LEVETIRACETAM LEVETIRACETAM
Excluded LEVITRA VARDENAFIL
1 LEVOBUNOLOL HCL LEVOBUNOLOL HCL
1 LEVOCETIRIZINE DIHYDROCHLORIDE LEVOCETIRIZINE DIHYDROCHLORIDE
1 LEVOFLOXACIN LEVOFLOXACIN
1 LEVONEST LEVONORGESTREL-ETHIN ESTRADIOL
1 LEVONORGESTREL LEVONORGESTREL
1 LEVONORGESTREL-ETH ESTRADIOL LEVONORGESTREL-ETHIN ESTRADIOL
1 LEVORA-28 LEVONORGESTREL-ETHIN ESTRADIOL
Excluded LEVORPHANOL
1 LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM
2 LEVOXYL LEVOTHYROXINE SODIUM
3 LEVSIN HYOSCYAMINE SULFATE
3 LEVSIN-SL HYOSCYAMINE SULFATE
3 LEXAPRO ESCITALOPRAM OXALATE
2 LEXIVA FOSAMPRENAVIR CALCIUM PA
3 LIBRAX CHLORDIAZEPOXIDE/CLIDINIUM BR
1 LIDOCAINE HCL VISCOUS LIDOCAINE HCL
Excluded LIDORX KIT LIDOCAINE
1 LINDANE LINDANE
1 LINEZOLID LINEZOLID PA
2 LINZESS LINACLOTIDE QL
1 LIOTHYRONINE SODIUM LIOTHYRONINE SODIUM
3 LIPITOR ATORVASTATIN CALCIUM
VC LISINOPRIL LISINOPRIL
VC LISINOPRIL-HYDROCHLOROTHIAZIDE LISINOPRIL/HYDROCHLOROTHIAZIDE
2 LITE TOUCH SYRING W-NDL,DISP,INSUL,0.5 ML
1 LITHIUM LITHIUM CITRATE
1 LITHIUM CARBONATE LITHIUM CARBONATE
1 LITHIUM CARBONATE ER LITHIUM CARBONATE
2 LITHOBID LITHIUM CARBONATE
Excluded LIVALO PITAVASTATIN
2 LO LOESTRIN FE NORETHINDRONE-E.ESTRADIOL-IRON ST
3 LOCOID HYDROCORTISONE BUTYRATE
3 LOCOID LIPOCREAM HYDROCORTISONE BUTYRATE/EMOLL
3 LODOSYN CARBIDOPA
3 LOESTRIN NORETHINDRONE AC-ETH ESTRADIOL ST
3 LOESTRIN FE NORETHINDRONE-E.ESTRADIOL-IRON ST
3 LOFIBRA FENOFIBRATE MICRONIZED
3 LOMOTIL DIPHENOXYLATE HCL/ATROPINE
1 LOMUSTINE LOMUSTINE
3 LOPID GEMFIBROZIL
3 LOPRESSOR METOPROLOL TARTRATE
3 LOPROX CICLOPIROX
VC LORATADINE LORATADINE
VC LORATADINE-PSEUDOEPHEDRINE LORATADINE-PSEUDOEPHEDRINE
Tier BRAND NAME GENERIC NAMEPRIOR
AUTHORIZATION
QUANTITY LIMIT
INDICATOR
STEP THERAPY
INDICATOR1 LORAZEPAM LORAZEPAM
1 LORAZEPAM INTENSOL LORAZEPAM
1 LORCET HYDROCODONE/ACETAMINOPHEN QL
1 LORCET HD HYDROCODONE/ACETAMINOPHEN QL
1 LORCET PLUS HYDROCODONE/ACETAMINOPHEN QL
3 LORTAB HYDROCODONE/ACETAMINOPHEN QL
1 LORTUSS EX P-EPHED HCL/CODEINE/GUAIFEN
1 LORYNA ETHINYL ESTRADIOL/DROSPIRENONE ST
VC LOSARTAN LOSARTAN
1 LOSARTAN-HYDROCHLOROTHIAZIDE COMBINATION TABLET LOSARTAN/HYDROCHLOROTHIAZIDE
2 LOTEMAX LOTEPREDNOL ETABONATE
3 LOTENSIN BENAZEPRIL HCL
3 LOTENSIN HCT BENAZEPRIL/HYDROCHLOROTHIAZIDE
3 LOTREL AMLODIPINE BESYLATE/BENAZEPRIL
3 LOTRISONE CLOTRIMAZOLE/BETAMETHASONE DIP
VC LOVASTATIN LOVASTATIN
3 LOVAZA OMEGA-3 ACID ETHYL ESTERS QL
3 LOVENOX ENOXAPARIN SODIUM QL
1 LOW-OGESTREL NORGESTREL-ETHINYL ESTRADIOL
1 LOXAPINE LOXAPINE SUCCINATE
3 LUDENT FLUORIDE SODIUM FLUORIDE
2 LUER-LOK SYRINGE SYRINGE W-O NEEDL,INSULIN,1 ML
2 LUMIGAN BIMATOPROST QL
3 LUNESTA ESZOPICLONE QL
1 LUTERA LEVONORGESTREL-ETHIN ESTRADIOL
2 LYNPARZA OLAPARIB PA QL
2 LYRICA PREGABALIN
2 LYSODREN MITOTANE
1 LYZA NORETHINDRONE
3 MACROBID NITROFURANTOIN MONOHYD/M-CRYST
2 MACRODANTIN NITROFURANTOIN MACROCRYSTAL
2 MAGELLAN INSULIN SAFETY SYRNG SYRINGE,NEEDLE,INSULN,SAFE,1ML
2 MAGELLAN INSULIN SYRINGE SYRINGE,NEEDLE,INSULN,SF,0.3ML
1 MALATHION MALATHION
2 MALATHION LOTION MALATHION
1 MAPROTILINE HCL MAPROTILINE HCL
3 MARINOL DRONABINOL QL ST
1 MARLEXATE SODIUM POLYSTYRENE SULFONATE
1 MARLISSA LEVONORGESTREL-ETHIN ESTRADIOL
1 MARTEN-TAB BUTALBITAL/ACETAMINOPHEN
2 MATULANE PROCARBAZINE HCL
3 MAVIK TRANDOLAPRIL
3 MAXALT RIZATRIPTAN BENZOATE QL
3 MAXALT MLT RIZATRIPTAN BENZOATE QL
2 MAXI-COMFORT SYRING W-NDL,DISP,INSUL,0.5 ML
3 MAXITROL NEO/POLYMYX B SULF/DEXAMETH
3 MAXZIDE TRIAMTERENE/HYDROCHLOROTHIAZID
Tier BRAND NAME GENERIC NAMEPRIOR
AUTHORIZATION
QUANTITY LIMIT
INDICATOR
STEP THERAPY
INDICATOR3 MAXZIDE-25 MG TRIAMTERENE/HYDROCHLOROTHIAZID
1 MECLIZINE HCL MECLIZINE HCL
2 MECLOFENAMATE SODIUM CAPSULE MECLOFENAMATE SODIUM
2 MEDI-LANCE LANCETS
2 MEDISENSE THIN LANCETS LANCETS
2 MEDLANCE PLUS LANCETS
2 MEDLANCE PLUS SPECIAL BLADE BLADE LANCET, SAFETY
2 MEDROL METHYLPREDNISOLONE
1 MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE ACETATE
2 MEFENAMIC ACID CAPSULE MEFENAMIC ACID
2 MEFLOQUINE HCL MEFLOQUINE HCL
3 MEGACE MEGESTROL ACETATE
2 MEGACE ES MEGESTROL ACETATE
1 MEGESTROL ACETATE MEGESTROL ACETATE
2 MEKINIST TRAMETINIB DIMETHYL SULFOXIDE PA
VC MELOXICAM MELOXICAM
1 MEMANTINE HCL MEMANTINE HCL QL
2 MENEST ESTROGENS,ESTERIFIED
2 MEPHYTON PHYTONADIONE
2 MEPROBAMATE MEPROBAMATE
1 MERCAPTOPURINE MERCAPTOPURINE
1 MESALAMINE MESALAMINE
3 MESTINON PYRIDOSTIGMINE BROMIDE
3 METADATE CD METHYLPHENIDATE HCL QL
1 METADATE ER METHYLPHENIDATE HCL QL
1 METAPROTERENOL SULFATE METAPROTERENOL SULFATE
2 METAXALONE METAXALONE
2 METFORMIN ER TABLET 500/1000 (FORTAMET/GLUMETZA) METFORMIN
1 METFORMIN ER TABLET 500/750 (GLUCOPHAGE XR GENERIC) METFORMIN
VC METFORMIN HCL METFORMIN
1 METHADONE HCL METHADONE HCL
2 METHAZOLAMIDE METHAZOLAMIDE
1 METHIMAZOLE METHIMAZOLE
2 METHITEST METHYLTESTOSTERONE
1 METHOCARBAMOL METHOCARBAMOL
1 METHOTREXATE METHOTREXATE
1 METHOXSALEN METHOXSALEN, RAPID
1 METHYLDOPA METHYLDOPA
1 METHYLERGONOVINE MALEATE METHYLERGONOVINE MALEATE
3 METHYLIN METHYLPHENIDATE HCL
1 METHYLPHENIDATE METHYLPHENIDATE
2 METHYLPHENIDATE ER METHYLPHENIDATE HCL QL
1 METHYLPHENIDATE HCL METHYLPHENIDATE HCL QL
2 METHYLPHENIDATE HCL CD METHYLPHENIDATE HCL QL
2 METHYLPHENIDATE LA METHYLPHENIDATE HCL QL
1 METHYLPREDNISOLONE METHYLPREDNISOLONE
1 METIPRANOLOL METIPRANOLOL
Tier BRAND NAME GENERIC NAMEPRIOR
AUTHORIZATION
QUANTITY LIMIT
INDICATOR
STEP THERAPY
INDICATOR1 METOCLOPRAMIDE HCL METOCLOPRAMIDE HCL
1 METOLAZONE METOLAZONE
1 METOPROLOL ER TABLET METOPROLOL TARTRATE
1 METOPROLOL SUCCINATE METOPROLOL SUCCINATE
VC METOPROLOL TARTRATE 25 MG, 50 MG, 100 MG METOPROLOL TARTRATE
2 METOPROLOL TARTRATE 37.5 MG, 75 MG METOPROLOL TARTRATE
VC METOPROLOL-HYDROCHLOROTHIAZIDE METOPROLOL/HYDROCHLOROTHIAZIDE
3 METROCREAM METRONIDAZOLE
3 METROGEL-VAGINAL METRONIDAZOLE
3 METROLOTION METRONIDAZOLE
1 METRONIDAZOLE METRONIDAZOLE
1 MEXILETINE HCL MEXILETINE HCL
1 MICONAZOLE 3 MICONAZOLE NITRATE
2 MICRO THIN LANCETS LANCETS
1 MICROGESTIN NORETHINDRONE AC-ETH ESTRADIOL
1 MICROGESTIN FE NORETHINDRONE-E.ESTRADIOL-IRON
2 MICROLET LANCETS
2 MICROTAINER LANCETS BLADE LANCET, SAFETY
3 MICROZIDE HYDROCHLOROTHIAZIDE
1 MIDODRINE HCL MIDODRINE HCL
2 MIGERGOT ERGOTAMINE TARTRATE/CAFFEINE QL
1 MIGRAGESIC IDA ISOMETHEPT/DICHLPHN/ACETAMINOP
2 MILLIPRED PREDNISOLONE
2 MILLIPRED DP PREDNISOLONE
2 MINI ULTRA-THIN II NEEDLES, INSULIN DISPOSABLE
3 MINIPRESS PRAZOSIN HCL
1 MINITRAN NITROGLYCERIN
2 MINIVELLE ESTRADIOL QL
3 MINOCIN MINOCYCLINE HCL
2 MINOCYCLINE 24HR SR TABLET MINOCYCLINE
1 MINOCYCLINE CAPSULE MINOCYCLINE
1 MINOCYCLINE HCL MINOCYCLINE HCL
3 MIRAPEX PRAMIPEXOLE DI-HCL
3 MIRCETTE DESOG-E.ESTRADIOL/E.ESTRADIOL ST
1 MIRTAZAPINE MIRTAZAPINE
1 MISOPROSTOL MISOPROSTOL
Excluded MITIGARE COLCHICINE
3 MOBIC MELOXICAM
2 MODAFINIL TABLET MODAFINIL
3 MODERIBA RIBAVIRIN
3 MODICON NORETHINDRONE-ETHINYL ESTRAD ST
1 MOEXIPRIL HCL MOEXIPRIL HCL
1 MOEXIPRIL-HYDROCHLOROTHIAZIDE MOEXIPRIL/HYDROCHLOROTHIAZIDE
1 MOMETASONE FUROATE MOMETASONE FUROATE
2 MONOJECT SYRING W-NDL,DISP,INSUL,0.5 ML
2 MONOJECT INSULIN SAFETY SYRNG SYRINGE W-NDL, DISP., INSULIN
2 MONOJECT INSULIN SYRINGE SYRINGE & NEEDLE,INSULIN,1 ML
Tier BRAND NAME GENERIC NAMEPRIOR
AUTHORIZATION
QUANTITY LIMIT
INDICATOR
STEP THERAPY
INDICATOR1 MONOJECT PREFILL HEPARIN SODIUM,PORCINE/PF
1 MONOJECT PREFILL ADVANCED HEPARIN SODIUM,PORCINE/PF
2 MONOLET LANCETS LANCETS
2 MONOLET THIN LANCETS LANCETS
1 MONO-LINYAH NORGESTIMATE-ETHINYL ESTRADIOL
1 MONONESSA NORGESTIMATE-ETHINYL ESTRADIOL
1 MONTELUKAST SODIUM MONTELUKAST SODIUM
3 MORGIDOX DOXYCYCLINE HYCLATE QL ST
2 MORPHINE SULFATE MORPHINE SULFATE
1 MORPHINE SULFATE ER MORPHINE SULFATE QL
2 MOVANTIK NALOXEGOL OXALATE QL
2 MOXEZA MOXIFLOXACIN HCL
1 MOXIFLOXACIN HCL MOXIFLOXACIN HCL
3 MS CONTIN MORPHINE SULFATE QL
2 MULTAQ DRONEDARONE HCL
1 MULTIVITAMIN AND FLUORIDE PEDI MULTIVIT NO.2 W-FLUORIDE
1 MULTI-VITAMIN W-FLUORIDE PEDI MULTIVIT NO.2 W-FLUORIDE
1 MULTI-VITAMIN W-FLUORIDE-IRON PEDI MV #45/FLUORIDE/IRON
1 MULTI-VITAMIN WITH FLUORIDE PEDI M.VIT NO.17 WITH FLUORIDE
1 MULTIVITAMINS W-FLUORIDE-IRON PEDI MV #75/FLUORIDE/IRON
1 MULTIVITAMINS WITH FLUORIDE PEDI MVI NO.82 WITH FLUORIDE
2 MUPIROCIN CREAM MUPIROCIN
1 MUPIROCIN OINTMENT MUPIROCIN
1 MY WAY LEVONORGESTREL
3 MYAMBUTOL ETHAMBUTOL HCL
1 MYCOPHENOLATE MOFETIL MYCOPHENOLATE MOFETIL
2 MYGLUCOHEALTH LANCETS LANCETS
2 MYLERAN BUSULFAN
1 MYNATAL PNV/IRON,CARBONYL/DOCUSATE/FA
1 MYNATAL ADVANCE PRENATAL VIT 15/IRON CB/FA/DSS
1 MYORISAN ISOTRETINOIN
3 MYSOLINE PRIMIDONE
1 MYZILRA LEVONORGESTREL-ETHIN ESTRADIOL
1 NABUMETONE NABUMETONE
2 NADOLOL TABLET NADOLOL
2 NAFTIFINE 1%, 2% CREAM NAFTIFINE HCL
1 NAFTIFINE HCL NAFTIFINE HCL
2 NAFTIN NAFTIFINE HCL
3 NALFON FENOPROFEN CALCIUM
1 NALTREXONE HCL NALTREXONE HCL
3 NAMENDA MEMANTINE HCL QL
2 NAMENDA XR MEMANTINE HCL QL
2 NAMZARIC MEMANTINE HCL/DONEPEZIL HCL QL ST
Excluded NAPRELAN NAPROXEN
Excluded NAPROPACK COOL NAPROXEN
Excluded NAPROPAX NAPROXEN
3 NAPROSYN NAPROXEN
Tier BRAND NAME GENERIC NAMEPRIOR
AUTHORIZATION
QUANTITY LIMIT
INDICATOR
STEP THERAPY
INDICATORVC NAPROXEN NAPROXEN
2 NAPROXEN SODIUM (ANAPROX DS/NAPRELAN CR) NAPROXEN
1 NAPROXEN TABLET (NAPROSYN/EC-NAPROSYN) NAPROXEN
2 NARATRIPTAN NARATRIPTAN HCL QL
1 NARATRIPTAN HCL NARATRIPTAN HCL QL
3 NARDIL PHENELZINE SULFATE
2 NASONEX MOMETASONE FUROATE QL
1 NATEGLINIDE NATEGLINIDE
Excluded NATESTO TESTOSTERONE
1 NATURE-THROID THYROID,PORK
2 NEBUPENT PENTAMIDINE ISETHIONATE
1 NECON NORETHINDRONE-ETHINYL ESTRAD
2 NEEDLES NEEDLES, INSULIN DISPOSABLE
2 NEFAZONDONE NEFAZODONE
1 NEOMYCIN SULFATE NEOMYCIN SULFATE
1 NEOMYCIN-BACITRACIN-POLY-HC NEOMYCIN SU/BACI ZN/POLY/HC
1 NEOMYCIN-BACITRACIN-POLYMYXIN NEOMYCIN SU/BACITRA/POLYMYXIN
1 NEOMYCIN-POLYMYXIN-DEXAMETH NEO/POLYMYX B SULF/DEXAMETH
1 NEOMYCIN-POLYMYXIN-GRAMICIDIN NEOMYCIN/POLYMYXN B/GRAMICIDIN
1 NEOMYCIN-POLYMYXIN-HC NEOMYCIN/POLYMYXIN B SULF/HC
1 NEOMYCIN-POLYMYXIN-HYDROCORT NEOMYCIN/POLYMYXIN B SULF/HC
1 NEO-POLYCIN NEOMYCIN SU/BACITRA/POLYMYXIN
1 NEO-POLYCIN HC NEOMYCIN SU/BACI ZN/POLY/HC
2 NEORAL CYCLOSPORINE, MODIFIED
3 NEOSPORIN NEOMYCIN/POLYMYXN B/GRAMICIDIN
3 NEPTAZANE METHAZOLAMIDE
Excluded NESINA ALOGLIPTIN
2 NEULASTA PEGFILGRASTIM PA
2 NEUPOGEN FILGRASTIM PA
2 NEUPRO ROTIGOTINE QL ST
2 NEURONTIN GABAPENTIN
2 NEVANAC NEPAFENAC
1 NEVIRAPINE NEVIRAPINE QL
1 NEVIRAPINE ER NEVIRAPINE
2 NEXAVAR SORAFENIB TOSYLATE PA QL
2 NEXIUM ESOMEPRAZOLE MAGNESIUM QL ST
1 NEXT CHOICE ONE DOSE LEVONORGESTREL
1 NIACIN ER NIACIN ST
3 NIASPAN NIACIN ST
1 NICARDIPINE HCL NICARDIPINE HCL
1 NIFEDICAL XL NIFEDIPINE
1 NIFEDIPINE NIFEDIPINE
1 NIFEDIPINE ER NIFEDIPINE
1 NIKKI ETHINYL ESTRADIOL/DROSPIRENONE ST
2 NILANDRON NILUTAMIDE QL
1 NIMODIPINE NIMODIPINE
2 NISOLDIPINE ER TABLET NISOLDIPINE
Tier BRAND NAME GENERIC NAMEPRIOR
AUTHORIZATION
QUANTITY LIMIT
INDICATOR
STEP THERAPY
INDICATOR2 NITRO-BID NITROGLYCERIN
2 NITRO-DUR NITROGLYCERIN
1 NITROFURANTOIN NITROFURANTOIN
1 NITROFURANTOIN MACROCRYSTAL CAPSULE NITROFURANTOIN
1 NITROFURANTOIN MONO-MACRO NITROFURANTOIN
2 NITROFURANTOIN ORAL SUSPENSION NITROFURANTOIN
1 NITROGLYCERIN NITROGLYCERIN
1 NITROGLYCERIN PATCH NITROGLYCERIN
1 NITROGLYCERIN SUBLINGUAL TABLET NITROGLYCERIN
2 NITROGLYCERINE TRANSLINGUAL SPRAY NITROGLYCERIN
3 NITROLINGUAL NITROGLYCERIN SUBLINGUAL TABLET
2 NITROSTAT NITROGLYCERIN
1 NIZATIDINE NIZATIDINE
3 NIZORAL KETOCONAZOLE
1 NODOLOR ISOMETHEPT/DICHLPHN/ACETAMINOP
1 NORA-BE NORETHINDRONE
3 NORCO HYDROCODONE/ACETAMINOPHEN QL
Excluded NORDITROPIN SOMATROPIN
1 NORETHINDRONE NORETHINDRONE
1 NORETHINDRONE ACETATE NORETHINDRONE ACETATE
1 NORETHINDRON-ETHINYL ESTRADIOL NORETHINDRONE AC-ETH ESTRADIOL
1 NORETHIN-ETH ESTRA FERROUS FUM NORETHINDRONE-E.ESTRADIOL-IRON
1 NORGESTIMATE-ETHINYL ESTRADIOL NORGESTIMATE-ETHINYL ESTRADIOL
1 NORINYL 1+35 NORETHINDRONE-ETHINYL ESTRAD
3 NORINYL 1+50 NORETHINDRONE-MESTRANOL ST
Excluded NORITATE METRONIDAZOLE
1 NORLYROC NORETHINDRONE
3 NORPACE DISOPYRAMIDE PHOSPHATE
2 NORPACE CR DISOPYRAMIDE PHOSPHATE
3 NORPRAMIN DESIPRAMINE HCL
3 NOR-Q-D NORETHINDRONE ST
1 NORTREL NORETHINDRONE-ETHINYL ESTRAD
1 NORTRIPTYLINE NORTRIPTYLINE
3 NORVASC AMLODIPINE BESYLATE
2 NORVIR RITONAVIR QL
2 NOVA SAFETY LANCETS LANCETS
2 NOVA SUREFLEX LANCETS
2 NOVOFINE NEEDLES, INSULIN DISPOSABLE
2 NOVOFINE 32 NEEDLES, INSULIN DISPOSABLE
2 NOVOFINE AUTOCOVER NEEDLES, INSULIN DISP., SAFETY
2 NOVOFINE PLUS NEEDLES, INSULIN DISPOSABLE
Excluded NOVOLIN INSULIN
Excluded NOVOLOG INSULIN
2 NOVOTWIST NEEDLES, INSULIN DISPOSABLE
1 NP THYROID THYROID,PORK
Excluded NUCALA MEPOLIZUMAB
2 NUCYNTA TAPENTADOL HCL QL
Tier BRAND NAME GENERIC NAMEPRIOR
AUTHORIZATION
QUANTITY LIMIT
INDICATOR
STEP THERAPY
INDICATOR2 NUCYNTA ER TAPENTADOL HCL QL
3 NULEV HYOSCYAMINE SULFATE
3 NULYTELY WITH FLAVOR PACKS SODIUM CHLORIDE/NAHCO3/KCL/PEG
Excluded NUPLAZID PIMAVANSERIN
Excluded NUTROPIN SOMATROPIN
Excluded NUTROPIN AQ SOMATROPIN
2 NUVARING ETONOGESTREL/ETHINYL ESTRADIOL QL ST
Excluded NUVIGIL ARMODAFINIL
1 NYAMYC NYSTATIN
1 NYSTATIN NYSTATIN
2 NYSTATIN-TRIAMCINOLONE 100,000 - 0.1% CREAM/OINTMENT NYSTATIN/TRIAMCIN
1 NYSTOP NYSTATIN
1 OCELLA ETHINYL ESTRADIOL/DROSPIRENONE ST
1 OCTREOTIDE ACETATE OCTREOTIDE ACETATE
3 OCUFEN FLURBIPROFEN SODIUM
3 OCUFLOX OFLOXACIN
2 OFEV NINTEDANIB ESYLATE PA
1 OFLOXACIN OFLOXACIN
1 OGESTREL NORGESTREL-ETHINYL ESTRADIOL
2 OLANZAPINE ODT OLANZAPINE
1 OLANZAPINE TABLET OLANZAPINE QL
2 OLANZAPINE-FLUOXETINE COMBINATION CAPSULE
2 OLANZAPINE-FLUOXETINE HCL QL
2 OLOPATADINE NASAL SPRAY
3 OLUX CLOBETASOL PROPIONATE
2 OMEGA-3 ACID ETHYL ESTERS OMEGA-3 ACID ETHYL ESTERS QL
VC OMEPRAZOLE OMEPRAZOLE
1 OMEPRAZOLE 40 MG, ANTACIDS OTC OMEPRAZOLE
1 OMEPRAZOLE OTC, ANTACIDS OTC OMEPRAZOLE
Excluded OMEPRAZOLE-SODIUM BICARBONATE OMEPRAZOLE
Excluded OMNARIS CICLESONIDE
3 OMNIPRED PREDNISOLONE ACETATE
2 OMNITROPE SOMATROPIN PA
2 ON CALL LANCET LANCETS
2 ON CALL PLUS LANCET LANCETS
1 ONDANSETRON HCL ONDANSETRON QL
1 ONDANSETRON ODT ONDANSETRON
1 ONETOUCH DELICA LANCETS
1 ONETOUCH FINEPOINT LANCETS LANCETS
1 ONETOUCH LANCETS LANCETS
1 ONETOUCH SURESOFT LANCETS
1 ONETOUCH ULTRA TEST STRIPS BLOOD SUGAR DIAGNOSTIC
1 ONETOUCH VERIO BLOOD SUGAR DIAGNOSTIC
Excluded ONGLYZA SAXAGLIPTIN
Excluded ONSOLIS FENTANYL CITRATE
2 ON-THE-GO LANCETS
1 OPCICON ONE-STEP LEVONORGESTREL
Tier BRAND NAME GENERIC NAMEPRIOR
AUTHORIZATION
QUANTITY LIMIT
INDICATOR
STEP THERAPY
INDICATOR2 OPSUMIT MACITENTAN PA
Excluded ORACEA DOXYCYCLINE ER
2 ORALAIR GR POL-ORC/SW VER/RYE/KENT/TIM PA
1 ORALONE TRIAMCINOLONE ACETONIDE
1 ORPHENADRINE CITRATE ORPHENADRINE CITRATE
1 ORSYTHIA LEVONORGESTREL-ETHIN ESTRADIOL
3 ORTHO EVRA NORELGESTROMIN/ETHIN.ESTRADIOL QL ST
3 ORTHO MICRONOR NORETHINDRONE ST
3 ORTHO TRI-CYCLEN NORGESTIMATE-ETHINYL ESTRADIOL ST
2 ORTHO TRI-CYCLEN LO NORGESTIMATE-ETHINYL ESTRADIOL ST
3 ORTHO-CEPT DESOGESTREL-ETHINYL ESTRADIOL ST
3 ORTHO-CYCLEN NORGESTIMATE-ETHINYL ESTRADIOL ST
3 ORTHO-NOVUM NORETHINDRONE-ETHINYL ESTRAD ST
1 OSCIMIN HYOSCYAMINE SULFATE
1 OSCIMIN SL HYOSCYAMINE SULFATE
1 OSCIMIN SR HYOSCYAMINE SULFATE
Excluded OSENI ALOGLIPTIN AND PIOGLITAZONE
3 OTEZLA APREMILAST PA
2 OVACE PLUS SULFACETAMIDE SODIUM
3 OVIDE MALATHION
2 OXAPROZIN OXAPROZIN
1 OXAZEPAM OXAZEPAM
1 OXCARBAZEPINE OXCARBAZEPINE
2 OXICONAZOLE NITRATE 1% CREAM OXICONAZOLE
2 OXSORALEN METHOXSALEN
3 OXSORALEN-ULTRA METHOXSALEN, RAPID
1 OXYBUTYNIN OXYBUTYNIN
1 OXYBUTYNIN ER OXYBUTYNIN
1 OXYCODONE HCL OXYCODONE HCL
1 OXYCODONE HCL ER OXYCODONE HCL QL
1 OXYCODONE HCL-ASPIRIN OXYCODONE HCL/ASPIRIN
1 OXYCODONE-ACETAMINOPHEN OXYCODONE HCL/ACETAMINOPHEN QL
3 OXYCONTIN OXYCODONE HCL QL
1 PACERONE AMIODARONE HCL
3 PAMELOR NORTRIPTYLINE HCL
Excluded PANCREAZE LIPASE/PROTEASE/AMYLASE
1 PANCRELIPASE 5,000 LIPASE/PROTEASE/AMYLASE
2 PANDEL HYDROCORTISONE PROBUTATE
VC PANTOPRAZOLE SODIUM PANTOPRAZOLE SODIUM
3 PARAFON FORTE DSC CHLORZOXAZONE
1 PARICALCITOL PARICALCITOL
3 PARLODEL BROMOCRIPTINE MESYLATE
3 PARNATE TRANYLCYPROMINE SULFATE
1 PAROEX CHLORHEXIDINE GLUCONATE
1 PAROMOMYCIN SULFATE PAROMOMYCIN SULFATE
2 PAROXETINE HCL PAROXETINE
2 PAROXETINE SR TABLETS PAROXETINE
Tier BRAND NAME GENERIC NAMEPRIOR
AUTHORIZATION
QUANTITY LIMIT
INDICATOR
STEP THERAPY
INDICATOR1 PAROXETINE TABLET PAROXETINE
2 PATADAY OLOPATADINE HCL
2 PATANOL OLOPATADINE HCL
2 PAXIL PAROXETINE HCL
2 PCE ERYTHROMYCIN BASE
Excluded PEDIAPALM LANOLIN, AMMONIUM LACTATE, GLYCERIN
3 PEDIAPRED PREDNISOLONE SOD PHOSPHATE
Excluded PEDIPAK CICLOPIROX
1 PEG 3350-ELECTROLYTE PEG 3350/NA SULF,BICARB,CL/KCL
1 PEG-3350 SODIUM CHLORIDE/NAHCO3/KCL/PEG
1 PEG-3350 WITH FLAVOR PACKS SODIUM CHLORIDE/NAHCO3/KCL/PEG
2 PEGASYS PEGINTERFERON ALFA-2A PA
2 PEGASYS PROCLICK PEGINTERFERON ALFA-2A PA
2 PEN NEEDLE NEEDLES, INSULIN DISPOSABLE
2 PEN NEEDLES NEEDLES, INSULIN DISPOSABLE
1 PENICILLIN VK PENICILLIN V POTASSIUM
Excluded PENNSAID DICLOFENAC
2 PENTIPS NEEDLES, INSULIN DISPOSABLE
1 PENTOXIFYLLINE PENTOXIFYLLINE
3 PEPCID FAMOTIDINE
3 PERCOCET OXYCODONE HCL/ACETAMINOPHEN QL
2 PERFOROMIST FORMOTEROL FUMARATE QL
3 PERIDEX CHLORHEXIDINE GLUCONATE
1 PERIOGARD CHLORHEXIDINE GLUCONATE
1 PERMETHRIN CREAM PERMETHRIN
1 PERPHENAZINE PERPHENAZINE
3 PERSANTINE DIPYRIDAMOLE
Excluded PERTZYE LIPASE/PROTEASE/AMYLASE
Excluded PEXEVA PAROXETINE MESYLATE
1 PHENADOZ PROMETHAZINE HCL
1 PHENAZOPYRIDINE HCL PHENAZOPYRIDINE HCL
1 PHENELZINE SULFATE PHENELZINE SULFATE
3 PHENERGAN PROMETHAZINE HCL
1 PHENOBARBITAL PHENOBARBITAL
1 PHENYLHISTINE DH P-EPHED HCL/COD/CHLORPHENIR
3 PHENYTEK PHENYTOIN SODIUM EXTENDED
1 PHENYTOIN PHENYTOIN
1 PHENYTOIN SODIUM EXTENDED RELEASE RELEASEPHENYTOIN SODIUM EXTENDED
3 PHOSLO CALCIUM ACETATE
2 PHOSPHASAL MTH/ME BLUE/SOD PHOS/PHEN/HYOS
2 PICATO INGENOL MEBUTATE QL
1 PILOCARPINE HCL PILOCARPINE HCL
1 PIMTREA DESOG-E.ESTRADIOL/E.ESTRADIOL
1 PINDOLOL PINDOLOL
1 PIOGLITAZONE HCL PIOGLITAZONE HCL
2 PIOGLITAZONE-GLIMEPIRIDE COMBINATION TABLET PIOGLITAZONE/GLIMEPIRIDE ST
2 PIOGLITAZONE-METFORMIN COMBINATION TABLET PIOGLITAZONE/METFORMIN ST
Tier BRAND NAME GENERIC NAMEPRIOR
AUTHORIZATION
QUANTITY LIMIT
INDICATOR
STEP THERAPY
INDICATOR1 PIRMELLA NORETHINDRONE-ETHINYL ESTRAD
2 PIROXICAM PIROXICAM
3 PLAN B ONE-STEP LEVONORGESTREL
3 PLAQUENIL HYDROXYCHLOROQUINE SULFATE
3 PLAVIX CLOPIDOGREL BISULFATE
2 PLEGRIDY PEGINTERFERON BETA-1A PA
2 PLEGRIDY PEN PEGINTERFERON BETA-1A PA
3 PLETAL CILOSTAZOL
1 PODOFILOX PODOFILOX
1 POLYCIN BACITRACIN/POLYMYXIN B SULFATE
1 POLYETHYLENE GLYCOL 3350 POLYETHYLENE GLYCOL 3350
1 POLYMYXIN B SUL-TRIMETHOPRIM POLYMYXIN B SULF/TRIMETHOPRIM
3 POLYTRIM POLYMYXIN B SULF/TRIMETHOPRIM
2 POMALYST POMALIDOMIDE PA
1 PORTIA LEVONORGESTREL-ETHIN ESTRADIOL
1 POTASSIUM BICARBONATE POTASSIUM BICARBONATE/CIT AC
1 POTASSIUM CHLORIDE POTASSIUM CHLORIDE
Excluded PRALUENT ALIROCUMAB
3 PRAMCORT HYDROCORTISONE/PRAMOXINE
1 PRAMIPEXOLE DIHYDROCHLORIDE PRAMIPEXOLE DI-HCL
2 PRAMOSONE HYDROCORTISONE/PRAMOXINE
2 PRANDIMET REPAGLINIDE/METFORMIN HCL
3 PRANDIN REPAGLINIDE
3 PRAVACHOL PRAVASTATIN SODIUM
1 PRAVASTATIN PRAVASTATIN
1 PRAZOSIN HCL PRAZOSIN HCL
2 PRECISION XTRA BLOOD SUGAR DIAGNOSTIC
3 PRECOSE ACARBOSE
3 PRED FORTE PREDNISOLONE ACETATE
2 PRED MILD PREDNISOLONE ACETATE
1 PREDNISOLONE PREDNISOLONE
1 PREDNISOLONE ACETATE PREDNISOLONE ACETATE
1 PREDNISOLONE SODIUM PHOSPHATE PREDNISOLONE SOD PHOSPHATE
1 PREDNISONE PREDNISONE
2 PREDNISONE INTENSOL PREDNISONE
2 PREMARIN ESTROGENS, CONJUGATED
2 PREMPHASE ESTROGEN,CON/M-PROGEST ACET
2 PREMPRO ESTROGEN,CON/M-PROGEST ACET
2 PRESSURE ACTIVATED LANCETS LANCETS
Excluded PRESTALIA AMLODIPINE/PERONDOPRIL
3 PREVACID LANSOPRAZOLE
1 PREVALITE CHOLESTYRAMINE/ASPARTAME
1 PREVIFEM NORGESTIMATE-ETHINYL ESTRADIOL
3 PREVPAC LANSOPRAZOLE/AMOXICILN/CLARITH QL
2 PREZCOBIX DARUNAVIR/COBICISTAT QL
2 PREZISTA DARUNAVIR ETHANOLATE QL
3 PRILOSEC OMEPRAZOLE
Tier BRAND NAME GENERIC NAMEPRIOR
AUTHORIZATION
QUANTITY LIMIT
INDICATOR
STEP THERAPY
INDICATOR2 PRIMAQUINE PRIMAQUINE PHOSPHATE
1 PRIMIDONE PRIMIDONE
2 PRIMSOL TRIMETHOPRIM
3 PRINIVIL LISINOPRIL
2 PRISTIQ ER DESVENLAFAXINE SUCCINATE QL ST
2 PROAIR HFA ALBUTEROL SULFATE
2 PROAIR RESPICLICK ALBUTEROL SULFATE
1 PROBENECID PROBENECID
1 PROBENECID-COLCHICINE COLCHICINE/PROBENECID
3 PROCARDIA NIFEDIPINE
3 PROCARDIA XL NIFEDIPINE
1 PROCHLORPERAZINE PROCHLORPERAZINE
2 PROCRIT EPOETIN ALFA PA
3 PROCTOCORT HYDROCORTISONE
2 PROCTOFOAM-HC HYDROCORTISONE/PRAMOXINE
1 PROCTO-PAK HYDROCORTISONE
1 PROCTOSOL-HC HYDROCORTISONE
1 PROCTOZONE-HC HYDROCORTISONE
2 PRODIGY INSULIN SYRINGE SYRINGE & NEEDLE,INSULIN,1 ML
2 PRODIGY LANCETS LANCETS
2 PRODIGY TWIST TOP LANCET LANCETS
1 PROGESTERONE PROGESTERONE,MICRONIZED
2 PROGRAF TACROLIMUS
2 PROMACTA ELTROMBOPAG OLAMINE PA
1 PROMETHAZINE HCL PROMETHAZINE HCL
1 PROMETHAZINE VC PHENYLEPHRINE HCL/PROMETH HCL
1 PROMETHAZINE VC-CODEINE PROMETHAZINE/PHENYLEPH/CODEINE
1 PROMETHAZINE-CODEINE PROMETHAZINE HCL/CODEINE
1 PROMETHAZINE-DM D-METHORPHAN HB/PROMETH HCL
1 PROMETHEGAN PROMETHAZINE
3 PROMETRIUM PROGESTERONE,MICRONIZED
1 PROPAFENONE HCL PROPAFENONE
1 PROPAFENONE HCL ER PROPAFENONE
2 PROPRANOLOL ER CAPSULE PROPRANOLOL
VC PROPRANOLOL HCL PROPRANOLOL
1 PROPRANOLOL-HYDROCHLOROTHIAZIDE PROPRANOLOL/HYDROCHLOROTHIAZIDE
1 PROPYLTHIOURACIL PROPYLTHIOURACIL
3 PROSCAR FINASTERIDE
2 PROSED-DS METHENAM/ME BLUE/BA/SALICY/HYO
3 PROTONIX PANTOPRAZOLE SODIUM
3 PROTOPIC TACROLIMUS ST
2 PROTRIPTYLINE
Excluded PROVENTIL HFA ALBUTEROL SULFATE
3 PROVERA MEDROXYPROGESTERONE ACETATE
3 PROZAC FLUOXETINE HCL
3 PROZAC WEEKLY FLUOXETINE HCL
3 PSORCON DIFLORASONE DIACETATE
Tier BRAND NAME GENERIC NAMEPRIOR
AUTHORIZATION
QUANTITY LIMIT
INDICATOR
STEP THERAPY
INDICATOR3 PULMICORT BUDESONIDE QL
2 PULMICORT FLEXHALER BUDESONIDE QL
3 PULMOSAL SODIUM CHLORIDE FOR INHALATION
2 PULMOZYME DORNASE ALFA PA
2 PURIXAN MERCAPTOPURINE ST
2 PUSH BUTTON SAFETY LANCETS LANCETS
1 PYRAZINAMIDE PYRAZINAMIDE
3 PYRIDIUM PHENAZOPYRIDINE HCL
1 PYRIDOSTIGMINE BROMIDE PYRIDOSTIGMINE BROMIDE
1 PYRIDOSTIGMINE BROMIDE ER PYRIDOSTIGMINE BROMIDE
2 QNASL BECLOMETHASONE DIPROPIONATE QL ST
2 QNASL CHILDREN BECLOMETHASONE DIPROPIONATE QL ST
Excluded QSYMIA PHENTERMINE AND TOPIRATMATE EXTENDED-RELEASE
3 QUALAQUIN QUININE SULFATE
1 QUASENSE LEVONORGESTREL-ETHIN ESTRADIOL QL
3 QUESTRAN CHOLESTYRAMINE (WITH SUGAR)
3 QUESTRAN LIGHT CHOLESTYRAMINE/ASPARTAME
1 QUETIAPINE FUMARATE QUETIAPINE QL
1 QUETIAPINE TABLET QUETIAPINE
2 QUILLIVANT XR METHYLPHENIDATE HCL QL ST
1 QUINAPRIL HCL QUINAPRIL HCL
1 QUINAPRIL-HYDROCHLOROTHIAZIDE QUINAPRIL/HYDROCHLOROTHIAZIDE
1 QUINIDINE GLUCONATE QUINIDINE GLUCONATE
1 QUINIDINE SULFATE QUINIDINE SULFATE
1 QUININE SULFATE QUININE SULFATE
2 QVAR BECLOMETHASONE DIPROPIONATE QL
2 RAGWITEK WEED POLLEN-SHORT RAGWEED PA
1 RALOXIFENE HCL RALOXIFENE HCL PA QL
VC RAMIPRIL RAMIPRIL
2 RANEXA RANOLAZINE QL
1 RANITIDINE HCL RANITIDINE HCL
1 RANITIDINE SYRUP RANITIDINE
2 RAPAMUNE SIROLIMUS
Excluded RAYOS PREDNISONE
3 REBETOL RIBAVIRIN
2 REBIF INTERFERON BETA-1A/ALBUMIN PA
2 REBIF REBIDOSE INTERFERON BETA-1A/ALBUMIN PA
Excluded RECLAST-ZOLEDRONIC ACID (Brand Excluded - Generic Covered) ZOLEDRONIC ACID PA
1 RECLIPSEN DESOGESTREL-ETHINYL ESTRADIOL
3 REGLAN METOCLOPRAMIDE HCL
2 REGRANEX BECAPLERMIN
2 RELIAMED LANCETS
2 RELIAMED SAFETY SEAL LANCETS LANCETS
2 RELION PEN NEEDLES NEEDLES, INSULIN DISPOSABLE
2 RELION THIN LANCETS
2 RELISTOR METHYLNALTREXONE BROMIDE PA
3 REMERON MIRTAZAPINE
Tier BRAND NAME GENERIC NAMEPRIOR
AUTHORIZATION
QUANTITY LIMIT
INDICATOR
STEP THERAPY
INDICATOR2 RENAGEL SEVELAMER HCL
2 RENVELA SEVELAMER CARBONATE
2 REPAGLINIDE REPAGLINIDE
Excluded REPATHA EVOLOCUMAB
3 REQUIP ROPINIROLE HCL
3 REQUIP XL ROPINIROLE HCL QL ST
2 RESCRIPTOR DELAVIRDINE MESYLATE
1 RESERPINE RESERPINE
2 RESTASIS CYCLOSPORINE QL
3 RESTORIL TEMAZEPAM
3 RETROVIR ZIDOVUDINE QL
3 REVATIO SILDENAFIL CITRATE QL
3 REVIA NALTREXONE HCL
2 REVLIMID LENALIDOMIDE PA QL
2 REYATAZ ATAZANAVIR SULFATE
2 RHEUMATREX METHOTREXATE SODIUM
1 RIBASPHERE RIBAVIRIN
1 RIBAVIRIN RIBAVIRIN
3 RIFADIN RIFAMPIN
2 RIFAMATE RIFAMPIN/ISONIAZID
1 RIFAMPIN RIFAMPIN
2 RIGHTEST GL300 LANCETS LANCETS
2 RIOMET METFORMIN HCL
2 RISEDRONATE RISEDRONATE
3 RISPERDAL RISPERIDONE QL
3 RISPERDAL M-TAB RISPERIDONE QL
2 RISPERIDONE ODT RISPERIDONE QL
1 RISPERIDONE TABLET RISPERIDONE QL
3 RITALIN METHYLPHENIDATE HCL QL
3 RITALIN LA METHYLPHENIDATE HCL QL
1 RIVASTIGMINE RIVASTIGMINE TARTRATE
1 RIZATRIPTAN RIZATRIPTAN BENZOATE QL
3 ROBAXIN METHOCARBAMOL
3 ROBAXIN-750 METHOCARBAMOL
3 ROCALTROL CALCITRIOL
Excluded ROCHE (ACCU-CHEK) TEST STRIPS/BLOOD GLUCOSE TEST STRIPS
1 ROPINIROLE HCL ROPINIROLE HCL
1 ROSADAN METRONIDAZOLE
3 ROWASA MESALAMINE W/CLEANSING WIPES
3 ROXICODONE OXYCODONE HCL
Excluded ROZEREM RAMELTEON
3 RYTHMOL PROPAFENONE HCL
3 RYTHMOL SR PROPAFENONE HCL
Excluded SABRIL VIGABATRIN
2 SAFESNAP INSULIN SYRINGE SYR,NDL,INS,SAFE,DISP UN,0.3ML
2 SAFETY LANCETS LANCETS
2 SAFETY SEAL LANCETS LANCETS
Tier BRAND NAME GENERIC NAMEPRIOR
AUTHORIZATION
QUANTITY LIMIT
INDICATOR
STEP THERAPY
INDICATOR2 SAFETYGLIDE INSULIN SYRINGE SYRING W-NDL,DISP,INSUL,0.5 ML
2 SAFETYGLIDE SYRINGE SYRINGE & NEEDLE,INSULIN,1 ML
2 SAFETY-LET LANCETS
Excluded SAIZEN SOMATROPIN
3 SALAGEN PILOCARPINE HCL
2 SALICYLIC ACID FOAM SALICYCLIC ACID
1 SALICYLIC ACID GEL SALICYLIC ACID
2 SALICYLIC ACID/CERAMIDES KIT, CLEANSER & CREAM SALICYCLIC ACID
VC SALSALATE SALSALATE
2 SANDIMMUNE CYCLOSPORINE
3 SANDOSTATIN OCTREOTIDE ACETATE
Excluded SARILUMAB SARILUMAB
2 SAVELLA MILNACIPRAN HCL
3 SCALACORT HYDROCORTISONE
2 SCALACORT DK HYDROCORT/SAL ACID/SULF/SHMP#1
3 SECTRAL ACEBUTOLOL HCL
Excluded SEEBRI NEOHALER GLYCOPYRROLATE
1 SELEGILINE HCL SELEGILINE HCL
1 SELENIUM SULFIDE SELENIUM SULFIDE
2 SELZENTRY MARAVIROC PA
1 SE-NATAL 19 PNV119/IRON FUMARATE/FA/DSS
2 SEREVENT DISKUS SALMETEROL XINAFOATE QL
3 SEROQUEL QUETIAPINE FUMARATE QL
2 SEROQUEL XR QUETIAPINE FUMARATE QL ST
1 SERTRALINE SERTRALINE
3 SFROWASA MESALAMINE
1 SHAROBEL NORETHINDRONE
Excluded SILAPAK TRIAMCINOLONE 0.1%/DIMETHICONE 5%
Excluded SILAZONE TRIAMCINOLONE 0.1%/DIMETHICONE 5%
1 SILDENAFIL SILDENAFIL CITRATE QL
Excluded SILIQ BRODALUMAB
3 SILVADENE SILVER SULFADIAZINE
1 SILVER SULFADIAZINE SILVER SULFADIAZINE
2 SIMBRINZA BRINZOLAMIDE/BRIMONIDINE TART
2 SIMCOR NIACIN/SIMVASTATIN QL ST
Excluded SIMPONI GROLIMUMAB
VC SIMVASTATIN SIMVASTATIN
Excluded SINELEE PATCH CAPSAICIN-MENTHOL
3 SINEMET 10-100 CARBIDOPA/LEVODOPA
3 SINEMET 25-100 CARBIDOPA/LEVODOPA
3 SINEMET 25-250 CARBIDOPA/LEVODOPA
3 SINEMET CR CARBIDOPA/LEVODOPA
2 SINGLE-LET LANCETS
3 SINGULAIR MONTELUKAST SODIUM
1 SIROLIMUS SIROLIMUS
2 SIVEXTRO TEDIZOLID PHOSPHATE PA
3 SKELAXIN METAXALONE
Tier BRAND NAME GENERIC NAMEPRIOR
AUTHORIZATION
QUANTITY LIMIT
INDICATOR
STEP THERAPY
INDICATOR2 SMART SENSE LANCETS
2 SMART SENSE LANCETS LANCETS
2 SMARTEST LANCET LANCETS
1 SODIUM CHLORIDE SODIUM CHLORIDE FOR INHALATION
1 SODIUM FLUORIDE SODIUM FLUORIDE
1 SODIUM PHENYLBUTYRATE SODIUM PHENYLBUTYRATE
1 SODIUM POLYSTYRENE SULFONATE SODIUM POLYSTYRENE SULFONATE
1 SODIUM SULFACETAMIDE SULFACETAMIDE SODIUM
2 SOFT TOUCH LANCETS
2 SOFTCLIX LANCETS
2 SOLTAMOX TAMOXIFEN CITRATE
2 SOLUS V2 LANCETS
2 SOLUS V2 LANCETS LANCETS
3 SOMA CARISOPRODOL
2 SOMAVERT PEGVISOMANT
3 SONATA ZALEPLON QL
3 SORIATANE ACITRETIN
1 SORINE SOTALOL HCL
1 SOTALOL SOTALOL HCL
1 SOTALOL AF SOTALOL HCL
2 SOVALDI SOFOSBUVIR PA
2 SPINOSAD SUSPENSION SPINOSAD
2 SPIRIVA TIOTROPIUM BROMIDE QL
2 SPIRIVA RESPIMAT TIOTROPIUM BROMIDE QL
1 SPIRONOLACTONE SPIRONOLACTONE
3 SPORANOX ITRACONAZOLE
1 SPRINTEC NORGESTIMATE-ETHINYL ESTRADIOL
2 SPRYCEL DASATINIB PA QL
1 SPS SODIUM POLYSTYRENE SULFONATE
1 SRONYX LEVONORGESTREL-ETHIN ESTRADIOL
1 SSD SILVER SULFADIAZINE
1 SSKI POTASSIUM IODIDE
3 STALEVO 50, 75, 100, 125,150, 200 CARBIDOPA/LEVODOPA/ENTACAPONE
3 STARLIX NATEGLINIDE
1 STAVUDINE STAVUDINE QL
Excluded STAXYN VARDENAFIL
3 STELARA USEKINUMAB PA
Excluded STENDRA AVANAFIL
2 STERILANCE TL LANCETS
2 STIVARGA REGORAFENIB PA QL
2 STRATTERA ATOMOXETINE HCL QL
2 STRIBILD ELVITEGR/COBICIST/EMTRIC/TENOF QL
2 SUBOXONE BUPRENORPHINE HCL/NALOXONE HCL PA
Excluded SUBSYS FENTANYL CITRATE
1 SUCRALFATE SUCRALFATE
2 SULFACETAMIDE 10% SHAMPOO, WASH, CLEANSING GEL SULFACETAMIDE SODIUM
1 SULFACETAMIDE LOTION SULFACETAMIDE SODIUM
Tier BRAND NAME GENERIC NAMEPRIOR
AUTHORIZATION
QUANTITY LIMIT
INDICATOR
STEP THERAPY
INDICATOR1 SULFACETAMIDE SODIUM SULFACETAMIDE SODIUM
1 SULFACETAMIDE/PREDNISOLONE SULFACETAMIDE/PREDNISOLONE SP
2 SULFACETAMIDE/SULFUR SUSPENSION SULFACETAMIDE SODIUM
1 SULFADIAZINE SULFADIAZINE
1 SULFAMETHOXAZOLE-TRIMETHOPRIM SULFAMETHOXAZOLE/TRIMETHOPRIM
1 SULFASALAZINE DR SULFASALAZINE
1 SULFATRIM SULFAMETHOXAZOLE/TRIMETHOPRIM
1 SULFAZINE SULFASALAZINE
1 SULFAZINE EC SULFASALAZINE
1 SULINDAC SULINDAC
2 SUMATRIPTAN NASAL SPRAY SUMATRIPTAN
2 SUMATRIPTAN SUBCUTANEOUS PEN INJECTOR SUMATRIPTAN
1 SUMATRIPTAN SUCCINATE SUMATRIPTAN SUCCINATE QL
1 SUMATRIPTAN TABLET SUMATRIPTAN QL
2 SUPER THIN LANCETS LANCETS
2 SUPRAX CEFIXIME
2 SURE COMFORT NEEDLES, INSULIN DISPOSABLE
2 SURE COMFORT LANCETS LANCETS
2 SURE-FINE PEN NEEDLES NEEDLES, INSULIN DISPOSABLE
2 SURE-JECT INSULIN SYRINGE SYRINGE & NEEDLE,INSULIN,1 ML
2 SURE-LANCE LANCETS
2 SURE-TOUCH LANCETS
2 SUSTIVA EFAVIRENZ
2 SUTENT SUNITINIB MALATE PA QL
1 SYEDA ETHINYL ESTRADIOL/DROSPIRENONE ST
3 SYMAX HYOSCYAMINE SULFATE
3 SYMAX-SL HYOSCYAMINE SULFATE
3 SYMAX-SR HYOSCYAMINE SULFATE
Excluded SYMBICORT BUDESONIDE/FORMOTEROL FUMARATE
3 SYMBYAX OLANZAPINE/FLUOXETINE HCL QL
2 SYMLINPEN 120 PRAMLINTIDE ACETATE
2 SYMLINPEN 60 PRAMLINTIDE ACETATE
3 SYNALAR FLUOCINOLONE ACETONIDE
2 SYNTHROID LEVOTHYROXINE SODIUM
2 TABLOID THIOGUANINE
1 TACROLIMUS TACROLIMUS ST
2 TAFINLAR DABRAFENIB MESYLATE PA
2 TAMIFLU OSELTAMIVIR PHOSPHATE QL
1 TAMOXIFEN CITRATE TAMOXIFEN CITRATE
1 TAMSULOSIN HCL TAMSULOSIN HCL
Excluded TANZEUM ALBIGLUTIDE
3 TAPAZOLE METHIMAZOLE
2 TARCEVA ERLOTINIB HCL PA QL
2 TARGRETIN BEXAROTENE PA
1 TARINA FE NORETHINDRONE-E.ESTRADIOL-IRON
2 TASIGNA NILOTINIB HCL PA QL
2 TAZORAC TAZAROTENE
Tier BRAND NAME GENERIC NAMEPRIOR
AUTHORIZATION
QUANTITY LIMIT
INDICATOR
STEP THERAPY
INDICATOR1 TAZTIA XT DILTIAZEM HCL
2 TECFIDERA DIMETHYL FUMARATE PA
2 TECHLITE LANCETS LANCETS
3 TEGRETOL CARBAMAZEPINE
2 TEGRETOL XR CARBAMAZEPINE
2 TELCARE LANCETS
2 TELMISARTAN/HCTZ COMBINATION TABLET
VC TEMAZEPAM TEMAZEPAM
3 TEMODAR TEMOZOLOMIDE PA
3 TEMOVATE CLOBETASOL PROPIONATE
3 TEMOVATE EMOLLIENT CLOBETASOL PROPIONATE/EMOLL
1 TEMOZOLOMIDE TEMOZOLOMIDE PA
1 TENCON BUTALBITAL/ACETAMINOPHEN
3 TENEX GUANFACINE HCL
3 TENORETIC 100 ATENOLOL/CHLORTHALIDONE
3 TENORETIC 50 ATENOLOL/CHLORTHALIDONE
3 TENORMIN ATENOLOL
1 TERAZOSIN HCL TERAZOSIN HCL
1 TERBINAFINE HCL TERBINAFINE HCL
1 TERBUTALINE SULFATE TERBUTALINE SULFATE
1 TERFINAFINE TERFINAFINE
2 TERUMO INSULIN SYRINGE SYRING W-NDL,DISP,INSUL,0.3 ML
Excluded TESTIM TESTOSTERONE
1 TESTOSTERONE TESTOSTERONE PA
1 TESTOSTERONE CYPIONATE TESTOSTERONE CYPIONATE PA
1 TESTOSTERONE ENANTHATE TESTOSTERONE ENANTHATE PA
2 TESTRED METHYLTESTOSTERONE
1 TETRACYCLINE HCL TETRACYCLINE HCL
Excluded TEVETEN EPROSARTAN
Excluded TEVETEN HCT EPROSARTAN/HYDROCHLOROTHIAZIDE
Excluded TEV-TROPIN SOMATROPIN
2 TEXACORT HYDROCORTISONE
2 THALOMID THALIDOMIDE PA QL
2 THEO-24 THEOPHYLLINE ANHYDROUS
1 THEOCHRON THEOPHYLLINE ANHYDROUS
1 THEOPHYLLINE THEOPHYLLINE ANHYDROUS
1 THEOPHYLLINE ANHYDROUS THEOPHYLLINE ANHYDROUS
1 THERAPEUTIC VITAMIN W-MINERALS MULTIVITAMINS WITH MIN NO.7/FA
3 THERMAZENE SILVER SULFADIAZINE
2 THIN LANCETS LANCETS
2 THINPRO INSULIN SYRINGE SYRING W-NDL,DISP,INSUL,0.3 ML
1 THIORIDAZINE HCL THIORIDAZINE HCL
1 THIOTHIXENE THIOTHIXENE
1 THRIVITE 19 PNV119/IRON FUMARATE/FA/DSS
3 TIAZAC DILTIAZEM HCL
2 TIKOSYN DOFETILIDE
1 TIMOLOL MALEATE TIMOLOL
Tier BRAND NAME GENERIC NAMEPRIOR
AUTHORIZATION
QUANTITY LIMIT
INDICATOR
STEP THERAPY
INDICATOR2 TIMOLOL TABLET TIMOLOL
3 TIMOPTIC TIMOLOL MALEATE
3 TIMOPTIC-XE TIMOLOL MALEATE
2 TINADAZOLE TABLET TINADAZOLE
Excluded TIROSINT LEVOTHYROXINE
2 TIVICAY DOLUTEGRAVIR SODIUM PA
Excluded TIVORBEX INDOMETHACIN
2 TIZANIDINE CAPSULE TIZANIDINE HCL
1 TIZANIDINE TABLET TIZANIDINE HCL
1 TL GARD RX CYANOCOBALAMIN/FA/PYRIDOXINE
3 TOBI TOBRAMYCIN IN 0.225% NACL PA
2 TOBI PODHALER TOBRAMYCIN PA
3 TOBRADEX TOBRAMYCIN/DEXAMETHASONE
1 TOBRAMYCIN TOBRAMYCIN IN 0.225% NACL PA
1 TOBRAMYCIN-DEXAMETHASONE TOBRAMYCIN/DEXAMETHASONE
3 TOBREX TOBRAMYCIN
3 TOFRANIL IMIPRAMINE HCL
2 TOLAZAMIDE 500 MG TABLET TOLAZAMIDE
1 TOLBUTAMIDE TOLBUTAMIDE
2 TOLMETIN SODIUM TABLET TOLMETIN SODIUM TABLET
2 TOLTERODINE TOLTERODINE TARTRATE
2 TOLTERODINE ER TOLTERODINE TARTRATE ST
3 TOPAMAX TOPIRAMATE
2 TOPCARE CLICKFINE NEEDLES, INSULIN DISPOSABLE
2 TOPCARE ULTRA COMFORT SYRING W-NDL,DISP,INSUL,0.3 ML
2 TOPCARE UNIVERSAL THIN LANCET LANCETS
3 TOPICORT DESOXIMETASONE
1 TOPIRAMATE TOPIRAMATE
3 TOPROL XL METOPROLOL SUCCINATE
1 TORSEMIDE TORSEMIDE
2 TOUJEO SOLOSTAR INSULIN GLARGINE,HUM.REC.ANLOG QL
2 TOVIAZ FESOTERODINE FUMARATE ST
2 TRACLEER BOSENTAN PA
2 TRADJENTA LINAGLIPTIN QL
1 TRAMADOL HCL TRAMADOL HCL
1 TRAMADOL HCL-ACETAMINOPHEN TRAMADOL HCL/ACETAMINOPHEN
3 TRANDATE LABETALOL HCL
1 TRANDOLAPRIL TRANDOLAPRIL
3 TRANXENE T-TAB CLORAZEPATE DIPOTASSIUM
1 TRANYLCYPROMINE SULFATE TRANYLCYPROMINE SULFATE
2 TRAVATAN Z TRAVOPROST QL
2 TRAVOPROST DROPS TRAVOPROST QL
1 TRAZODONE HCL TRAZODONE HCL
Excluded TRESIBA INSULIN DEGLUDEC INJECTION
2 TRETINOIN TRETINOIN
1 TRETINOIN 0.05% CREAM/EMOLLIENT CREAM TRETINOIN
2 TRETINOIN 0.05% GEL TRETINOIN
Tier BRAND NAME GENERIC NAMEPRIOR
AUTHORIZATION
QUANTITY LIMIT
INDICATOR
STEP THERAPY
INDICATOR2 TRETINOIN 0.1%/0.04% GEL MICRO TUBE, GEL MICRO WITH PUMP TRETINOIN
1 TRETINOIN 0.1/0.025% CREAM/GEL TRETINOIN
2 TREXALL METHOTREXATE SODIUM
Excluded TREXIMET SUMATRIPTAN-NAPROXEN
1 TRIADVANCE PRENATAL VIT 15/IRON CB/FA/DSS
2 TRIAMCINOLONE 0.147% MG/G TOPICAL SPRAY [MEDIUM] TRIAMCINOLONE
VC TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE QL
2 TRIAMCINOLONE ACETONIDE 0.05% ABSORBASE OINTMENT[MEDIUM] TRIAMCINOLONE
2 TRIAMCINOLONE ACETONIDE/DIMETHICONE 0.1%-5% KIT TRIAMCINOLONE
2 TRIAMCINOLONE NASAL SPRAY TRIAMCINOLONE
1 TRIAMTERENE-HYDROCHLOROTHIAZID TRIAMTERENE/HYDROCHLOROTHIAZID
1 TRIANEX TRIAMCINOLONE ACETONIDE
1 TRIAZOLAM TRIAZOLAM
3 TRICOR FENOFIBRATE NANOCRYSTALLIZED
1 TRIDERM TRIAMCINOLONE ACETONIDE
1 TRI-ESTARYLLA NORGESTIMATE-ETHINYL ESTRADIOL
1 TRIFLUOPERAZINE HCL TRIFLUOPERAZINE HCL
1 TRIFLURIDINE TRIFLURIDINE
2 TRIGLIDE FENOFIBRATE NANOCRYSTALLIZED ST
1 TRIHEXYPHENIDYL HCL TRIHEXYPHENIDYL HCL
3 TRILEPTAL OXCARBAZEPINE
1 TRI-LINYAH NORGESTIMATE-ETHINYL ESTRADIOL
1 TRILYTE WITH FLAVOR PACKETS SODIUM CHLORIDE/NAHCO3/KCL/PEG
2 TRIMETHOBENZAMIDE CAPSULE
1 TRIMETHOPRIM TRIMETHOPRIM
1 TRINATAL GT PRENATAL VIT 16/IRON CB/FA/DSS
1 TRINESSA NORGESTIMATE-ETHINYL ESTRADIOL
3 TRI-NORINYL NORETHINDRONE-ETHINYL ESTRAD ST
1 TRIPLE-VITAMIN W-FLUORIDE PED MV A,C,D3 #21 W-FLUORIDE
1 TRI-PREVIFEM NORGESTIMATE-ETHINYL ESTRADIOL
1 TRI-SPRINTEC NORGESTIMATE-ETHINYL ESTRADIOL
2 TRIUMEQ ABACAVIR/DOLUTEGRAVIR/LAMIVUDI QL
1 TRI-VIT WITH FLUORIDE-IRON FLUORIDE/IRON/VIT A,C&D
1 TRI-VITAMIN WITH FLUORIDE PED MV A,C,D3 #21 W-FLUORIDE
1 TRIVORA-28 LEVONORGESTREL-ETHIN ESTRADIOL
3 TRIZIVIR ABACAVIR/LAMIVUDINE/ZIDOVUDINE PA
2 TROSPIUM TROSPIUM
2 TRUEPLUS INSULIN SYRINGE SYRING W-NDL,DISP,INSUL,0.5 ML
2 TRUEPLUS LANCETS LANCETS
2 TRULICITY DULAGLUTIDE QL ST
3 TRUSOPT DORZOLAMIDE HCL
2 TRUVADA EMTRICITABINE/TENOFOVIR QL
Excluded TUDORZA ACLIDINIUM BROMIDE
3 TUSNEL C P-EPHED HCL/CODEINE/GUAIFEN
3 TUSSIGON HYDROCODONE BIT/HOMATROP ME-BR
3 TUSSIONEX HYDROCODONE/CHLORPHEN P-STIREX
Tier BRAND NAME GENERIC NAMEPRIOR
AUTHORIZATION
QUANTITY LIMIT
INDICATOR
STEP THERAPY
INDICATOR2 TYBOST COBICISTAT PA
2 TYKERB LAPATINIB DITOSYLATE PA
3 TYLENOL-CODEINE NO.3 ACETAMINOPHEN WITH CODEINE
3 TYLENOL-CODEINE NO.4 ACETAMINOPHEN WITH CODEINE
2 TYZEKA TELBIVUDINE
1 U-CORT HYDROCORTISONE ACETATE/UREA
2 ULORIC FEBUXOSTAT QL ST
2 ULTICARE SYRNGE&NEEDLE,INSLN,1ML&SHARPS
2 ULTILET BASIC LANCETS
2 ULTILET CLASSIC LANCETS
2 ULTILET INSULIN SYRINGE SYRINGE & NEEDLE,INSULIN,1 ML
2 ULTILET LANCETS LANCETS
2 ULTILET PEN NEEDLE NEEDLES, INSULIN DISPOSABLE
2 ULTILET SAFETY LANCETS
2 ULTRA COMFORT SYRING W-NDL,DISP,INSUL,0.5 ML
2 ULTRA THIN LANCETS LANCETS
2 ULTRA THIN PLUS LANCETS
2 ULTRA THIN PLUS LANCETS LANCETS
2 ULTRALANCE LANCETS
3 ULTRAM TRAMADOL HCL
2 ULTRA-THIN II SYRING W-NDL,DISP,INSUL,0.5 ML
2 ULTRATLC LANCETS LANCETS
3 ULTRAVATE HALOBETASOL PROPIONATE
2 UNIFINE PENTIPS NEEDLES, INSULIN DISPOSABLE
2 UNIFINE PENTIPS PLUS PEN NEEDLE, DIABETIC,DISP UNIT
2 UNILET COMFORTOUCH LANCETS
2 UNILET EXCELITE LANCETS
2 UNILET EXCELITE II LANCETS
2 UNILET GP LANCET LANCETS
2 UNILET LANCET LANCETS
2 UNILET LANCETS LANCETS
2 UNISTIK 3 LANCETS
2 UNISTIK 3 EXTRA LANCETS
2 UNISTIK CZT LANCETS
2 UNISTIK SAFETY LANCETS
2 UNITHROID LEVOTHYROXINE SODIUM
2 UNIVERSAL 1 LANCETS
1 UR N-C MTH/ME BLUE/SOD PHOS/PHEN/HYOS
3 URECHOLINE BETHANECHOL CHLORIDE
2 URETRON D-S MTH/ME BLUE/SOD PHOS/PHEN/HYOS
2 URIN D.S. MTH/ME BLUE/SOD PHOS/PHEN/HYOS
3 UROXATRAL ALFUZOSIN HCL
3 URSO URSODIOL
3 URSO FORTE URSODIOL
1 URSODIOL URSODIOL
Excluded UTIBRON INDACATEROL/GLYCOPYRROLATE
2 VAGIFEM ESTRADIOL
Tier BRAND NAME GENERIC NAMEPRIOR
AUTHORIZATION
QUANTITY LIMIT
INDICATOR
STEP THERAPY
INDICATOR1 VALACYCLOVIR VALACYCLOVIR HCL
2 VALCHLOR MECHLORETHAMINE HCL PA
2 VALIUM DIAZEPAM
1 VALPROIC ACID VALPROIC ACID (AS SODIUM SALT)
1 VALSARTAN VALSARTAN
1 VALSARTAN-HYDROCHLOROTHIAZIDE COMBINATION TABLET VALSARTAN/HYDROCHLOROTHIAZIDE
3 VALTREX VALACYCLOVIR HCL
3 VANCOCIN HCL VANCOMYCIN HCL QL
1 VANCOMYCIN HCL VANCOMYCIN HCL QL
2 VANDAZOLE METRONIDAZOLE
2 VANISHPOINT SYRINGE & NEEDLE,INSULIN,1 ML
3 VANOS FLUOCINONIDE
2 VANOXIDE-HC BENZOYL PEROXIDE/HYDROCORTISON
2 VASCEPA ICOSAPENT ETHYL QL
3 VASERETIC ENALAPRIL/HYDROCHLOROTHIAZIDE
3 VASOTEC ENALAPRIL MALEATE
1 V-C FORTE MULTIVITAMINS WITH MIN NO.7/FA
3 VECTICAL CALCITRIOL ST
1 VELIVET DESOGESTREL-ETHINYL ESTRADIOL
Excluded VELTIN CLINDAMYCIN/TRETINOIN
1 VENLAFAXINE ER CAPSULE VENLAFAXINE
2 VENLAFAXINE ER TABLET VENLAFAXINE
1 VENLAFAXINE HCL VENLAFAXINE
1 VENLAFAXINE HCL ER VENLAFAXINE
2 VENTOLIN HFA ALBUTEROL SULFATE
Excluded VERAMYST FLUTICASONE FUROATE
1 VERAPAMIL ER VERAPAMIL HCL
1 VERAPAMIL ER PM VERAPAMIL HCL
1 VERAPAMIL HCL VERAPAMIL HCL
VC VERAPAMIL SR VERAPAMIL HCL
3 VERELAN VERAPAMIL HCL
3 VERELAN PM VERAPAMIL HCL
2 VESICARE SOLIFENACIN SUCCINATE ST
1 VESTURA ETHINYL ESTRADIOL/DROSPIRENONE ST
3 VFEND VORICONAZOLE
2 VIAGRA (if covered, see your Benefit Summary) SILDENAFIL CITRATE QL
3 VIBRAMYCIN DOXYCYCLINE HYCLATE QL ST
1 VIC-FORTE MULTIVITAMINS WITH MIN NO.7/FA
1 VICODIN HP HYDROCODONE/ACETAMINOPHEN QL
2 VICTOZA 2-PAK LIRAGLUTIDE QL ST
2 VICTOZA 3-PAK LIRAGLUTIDE QL ST
2 VIDEX DIDANOSINE QL
3 VIDEX EC DIDANOSINE QL
Excluded VIEKIRA PAK
OMBITASVIR/PARITAPREVIR/RITONAVIR TABLETS CO-PACKAGED WITH DASABUVIR
TABLETS
2 VIGAMOX MOXIFLOXACIN HCL
Excluded VIMOVO NAPROXEN/ESOMEPRAZOLE
Tier BRAND NAME GENERIC NAMEPRIOR
AUTHORIZATION
QUANTITY LIMIT
INDICATOR
STEP THERAPY
INDICATOR1 VINATE GT PRENATAL VIT 16/IRON CB/FA/DSS
1 VINATE ULTRA PRENATAL VIT 18/IRON CB/FA/DSS
1 VIORELE DESOG-E.ESTRADIOL/E.ESTRADIOL
2 VIRACEPT NELFINAVIR MESYLATE
3 VIRAMUNE NEVIRAPINE QL
3 VIRAMUNE XR NEVIRAPINE
2 VIRAZOLE RIBAVIRIN
2 VIREAD TENOFOVIR DISOPROXIL FUMARATE QL
3 VIROPTIC TRIFLURIDINE
1 VIRT-ADVANCE PRENATAL VIT 15/IRON CB/FA/DSS
1 VIRTUSSIN AC GUAIFENESIN/CODEINE PHOSPHATE
1 VIRTUSSIN DAC P-EPHED HCL/CODEINE/GUAIFEN
1 VIRT-VITE GT PRENATAL VIT 16/IRON CB/FA/DSS
3 VISTARIL HYDROXYZINE PAMOATE
1 VITAMIN D2 ERGOCALCIFEROL (VITAMIN D2)
1 VITAMINS A,C,D & FLUORIDE PED MV A,C,D3 #21 W-FLUORIDE
2 VITEKTA ELVITEGRAVIR QL ST
3 VIVELLE-DOT ESTRADIOL QL
Excluded VOGELXO TESTOSTERONE
2 VOLTAREN DICLOFENAC SODIUM
3 VOLTAREN-XR DICLOFENAC SODIUM
2 VORICONAZOLE VORICONAZOLE
2 VOTRIENT PAZOPANIB HCL PA QL
2 VYVANSE LISDEXAMFETAMINE DIMESYLATE QL ST
1 WARFARIN SODIUM WARFARIN SODIUM
2 WELCHOL COLESEVELAM HCL
3 WELLBUTRIN BUPROPION HCL
3 WELLBUTRIN SR BUPROPION HCL
3 WELLBUTRIN XL BUPROPION HCL
1 WERA NORETHINDRONE-ETHINYL ESTRAD
1 WESTHROID THYROID,PORK
Excluded WHYTEDERMTD PAK TRIAMCINOLONE 0.1%/DIMETHICONE 5%
1 WP THYROID THYROID,PORK
3 XALATAN LATANOPROST
2 XALKORI CRIZOTINIB PA QL
3 XANAX ALPRAZOLAM
2 XARELTO RIVAROXABAN QL
3 XELODA CAPECITABINE PA QL
Excluded XENAZINE TETRABENAZINE
2 XIFAXAN RIFAXIMIN QL ST
Excluded XIGDUO XR DAPAGLIFLOZIN/METFORMIN
3 XODOL 10-300 HYDROCODONE/ACETAMINOPHEN QL
Excluded XOPENEX HFA LEVALBUTEROL
2 XTANDI ENZALUTAMIDE PA QL
1 XULANE NORELGESTROMIN/ETHIN.ESTRADIOL QL
3 XYZAL LEVOCETIRIZINE DIHYDROCHLORIDE
3 YASMIN 28 ETHINYL ESTRADIOL/DROSPIRENONE ST
Tier BRAND NAME GENERIC NAMEPRIOR
AUTHORIZATION
QUANTITY LIMIT
INDICATOR
STEP THERAPY
INDICATOR3 YAZ ETHINYL ESTRADIOL/DROSPIRENONE ST
2 ZAFIRLUKAST ZAFIRLUKAST
1 ZALEPLON ZALEPLON QL
3 ZANAFLEX TIZANIDINE HCL
3 ZANTAC RANITIDINE HCL
1 ZARAH ETHINYL ESTRADIOL/DROSPIRENONE ST
2 ZARONTIN ETHOSUXIMIDE
3 ZEBETA BISOPROLOL FUMARATE
2 ZELBORAF VEMURAFENIB PA QL
3 ZEMPLAR PARICALCITOL
1 ZENATANE ISOTRETINOIN
3 ZENPEP LIPASE/PROTEASE/AMYLASE
2 ZENZEDI DEXTROAMPHETAMINE SULFATE QL ST
3 ZERIT STAVUDINE QL
3 ZESTORETIC LISINOPRIL/HYDROCHLOROTHIAZIDE
3 ZESTRIL LISINOPRIL
2 ZETIA EZETIMIBE QL
Excluded ZETONNA CICLESONIDE
3 ZIAC BISOPROLOL FUMARATE/HCTZ
3 ZIAGEN ABACAVIR SULFATE QL
2 ZIANA CLINDAMYCIN/TRETINOIN
1 ZIDOVUDINE ZIDOVUDINE QL
Excluded ZINBRYTA DACLIZUMAB
Excluded ZIOPTAN TAFLUPROST OPTHALMIC
2 ZIPRASIDONE HCL ZIPRASIDONE HCL QL
Excluded ZIPSOR DICLOFENAC
2 ZIRGAN GANCICLOVIR
3 ZITHROMAX AZITHROMYCIN
3 ZITHROMAX TRI-PAK AZITHROMYCIN
2 ZMAX AZITHROMYCIN
3 ZOCOR SIMVASTATIN ST
3 ZOFRAN ONDANSETRON HCL
3 ZOFRAN ODT ONDANSETRON
2 ZOLINZA VORINOSTAT
2 ZOLMITRIPTAN ZOLMITRIPTAN QL ST
2 ZOLMITRIPTAN ODT ZOLMITRIPTAN QL ST
3 ZOLOFT SERTRALINE HCL
2 ZOLPIDEM ER TABLET ZOLPIDEM TARTRATE QL
1 ZOLPIDEM TABLET ZOLPIDEM TARTRATE
1 ZOLPIDEM TARTRATE ZOLPIDEM TARTRATE QL
1 ZOLPIDEM TARTRATE ER ZOLPIDEM TARTRATE QL ST
Excluded ZOLPIMIST ZOLPIDEM TARTRATE
Excluded ZOMACTON SOMATROPIN (rDNA ORIGIN)
3 ZOMIG ZOLMITRIPTAN QL ST
3 ZOMIG ZMT ZOLMITRIPTAN QL ST
3 ZONEGRAN ZONISAMIDE
1 ZONISAMIDE ZONISAMIDE
Tier BRAND NAME GENERIC NAMEPRIOR
AUTHORIZATION
QUANTITY LIMIT
INDICATOR
STEP THERAPY
INDICATOR2 ZORTRESS EVEROLIMUS
Excluded ZORVOLEX DICLOFENAC
1 ZOVIA 1-35E ETHYNODIOL D-ETHINYL ESTRADIOL
1 ZOVIA 1-50E ETHYNODIOL D-ETHINYL ESTRADIOL
3 ZOVIRAX ACYCLOVIR
Excluded ZUBSOLV BUPRENORPHINE/NALOXONE
Excluded ZUPLENZ ONDANSETRON
2 ZYDELIG IDELALISIB PA
2 ZYKADIA CERITINIB PA
2 ZYLET TOBRAMYCIN/LOTEPRED ETAB
3 ZYLOPRIM ALLOPURINOL
3 ZYMAXID GATIFLOXACIN
3 ZYPREXA OLANZAPINE QL
2 ZYTIGA ABIRATERONE ACETATE PA QL
3 ZYVOX LINEZOLID PA