2021 Formulary Reference Guide - MAIL ORDER AVAILABLE FOR CERTAIN PRESCRIPTIONS - Common Ground Healthcare Cooperative
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2021 Formulary
Reference Guide
MAIL ORDER AVAILABLE FOR CERTAIN PRESCRIPTIONSUnderstanding your formulary
What is a formulary?
A formulary is a list of prescribed medications or other About this formulary
pharmacy care products, services or supplies chosen Where differences between this
for their safety, cost, and effectiveness. Medications are formulary and your benefit plan
listed by categories or classes and are placed into cost exist, the benefit plan documents
levels known as tiers. It includes both brand and generic rule. This may not be a complete
prescription medications. list of medications that are covered
by your plan. Please review your
To create the list, OptumRx® is guided by the Pharmacy and
benefit plan for full details.
Therapeutics Committee. This group of doctors, nurses, and
pharmacists reviews which medications will be covered,
how well the drugs work, and overall value. They also make
sure there are safe and covered options.
How do I use my formulary?
You and your doctor can use the formulary to help you choose the most cost-effective prescription
medications. This guide tells you if a medication is generic or brand, and if special rules apply.
Bring this list with you when you see your doctor. If your medication is not listed here, please visit
your plan’s member website or call the number on your member ID card.
Some medications on your formulary have extra requirements before they can be covered. A
few of the most common coverage programs are prior authorization (PA), step therapy (ST) and
quantity limits (QL). We use programs like these to help make sure the medication you take is safe
and effective. Check your plan documents for more information. Some Affordable Care Act (ACA)
preventive medication may have coverage restrictions. If you want to learn more about these
programs or to see if you take a medication in one of these programs, please visit your plan’s
member website or call the number on your member ID card.
What are tiers?
Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, set by
your employer or plan sponsor. This is how much you will pay when you fill a prescription.
2Understanding your formulary
When does the formulary change?
• Medications may move to a lower tier at any time.
• Medications may move to a higher tier or be excluded from coverage on January 1 of each year.
When a medication changes tiers, you may have to pay a different amount for that medication.
Why are some medications excluded from coverage?
A medication may be excluded from coverage under your pharmacy benefit when it works the
same as or similar to another prescription or over-the-counter (OTC) medication.
What if I don’t agree with a decision about an excluded medication?
You or your authorized representative and your doctor can ask for a coverage request by calling
the number on your member ID card.
3Medication tips
What is the difference between brand-name and
generic medications? Over-the-counter medications
Generic medications contain the same active ingredients An over-the-counter (OTC)
(offers same effect) as brand-name medications, but they medication may be the right
often cost less. Once the patent for a brand-name medication treatment for some conditions.
ends, the FDA can approve a generic version with the same Talk to your doctor about
active ingredients. available OTC options. Even
though OTC medications may
What if my doctor writes a brand-name prescription? not be covered by your pharmacy
If your doctor gives you a prescription for a brand-name benefit, they may cost less than
medication, ask if a generic or lower-cost option could be right a prescription medication.
for you. Generic medications are usually your lowest-cost option.
What if I am taking a specialty medication?
Specialty medications are used to treat complex conditions. These high-cost medications may
be injected, infused or taken by mouth. Please note, not all specialty medications are listed in the
formulary. Our specialty pharmacy can provide most of your specialty medications along with helpful
programs and services. Call 1-855-427-4682 and have your prescriptions delivered right to your
home or doctor’s office.
4Reading your formulary
The formulary gives you choices so you and your doctor can decide your best course of treatment.
In this formulary, brand-name medications are shown in UPPERCASE (for example, CLOBEX).
Generic medications are shown in lowercase (for example, clobetasol).
Tier information
Using lower tier or preferred medications can help you pay your lowest out-of-pocket cost. Your
plan may have multiple or no tiers.
Drug Tier Includes Helpful Tips
Tier CM Oral Chemotherapy Oral chemotherapy drugs may have a designated
copayment or coinsurance based on state laws or
client preference.
Tier 1 $ Generic Use Tier 1 generic drugs instead of brand-name drugs to
help reduce your out-of-pocket costs.
Tier 2 $$ Preferred Preferred brand-name drugs will generally have lower
copayments than non-preferred brand-name drugs.
Tier 3 $$$ Non-Preferred Many Tier 3 drugs have lower-cost options in Tier 1 or 2.
Ask your doctor if they could work for you.
Tier 4 $$$$ Specialty Tier 4 is generally highest in copayment and cost.
These drugs are sometimes used for complex and chronic
conditions and may require special monitoring
and handling.
Drug list information
In this drug list, some medications are noted with letters next to them to help you see which ones
may have coverage requirements or limits. Your benefit plan decides how these medications may
be covered.
M Authorized generic or cobranded product
PA Prior Authorization – Your doctor is required to give OptumRx more information
to determine coverage.
PV Preventive drugs – May have coverage and no copayments when health care
reform requirements are met.
PV* Preventive drugs – Available at $0 if Health Care Reform copay waiver
is approved.
QL Quantity Limit – Medication may be limited to a certain quantity.
ST Step Therapy – Must try lower-cost medication(s) before a higher-cost medication
can be covered.
5Table of Contents
Analgesics......................................................................................................................................................... 7
Anesthetics........................................................................................................................................................ 9
Anti-Addiction/Substance Abuse Treatment Agents...................................................................................10
Antibacterials...................................................................................................................................................10
Anticonvulsants.............................................................................................................................................. 13
Antidementia Agents...................................................................................................................................... 14
Antidepressants.............................................................................................................................................. 15
Antiemetics...................................................................................................................................................... 16
Antifungals.......................................................................................................................................................16
Antigout Agents.............................................................................................................................................. 17
Antimigraine Agents....................................................................................................................................... 17
Antimyasthenic Agents.................................................................................................................................. 17
Antimycobacterials......................................................................................................................................... 18
Antineoplastics................................................................................................................................................18
Antiparasitics...................................................................................................................................................21
Antiparkinson Agents..................................................................................................................................... 22
Antipsychotics.................................................................................................................................................22
Antivirals.......................................................................................................................................................... 23
Anxiolytics....................................................................................................................................................... 25
Bipolar Agents.................................................................................................................................................25
Blood Glucose Monitoring............................................................................................................................. 25
Blood Glucose Regulators............................................................................................................................. 26
Blood Products/Modifiers/Volume Expanders............................................................................................. 27
Cardiovascular Agents................................................................................................................................... 29
Central Nervous System Agents....................................................................................................................33
Dental and Oral Agents...................................................................................................................................33
Dermatological Agents................................................................................................................................... 34
Electrolytes/Minerals/Metals/Vitamins.......................................................................................................... 35
Gastrointestinal Agents..................................................................................................................................38
Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment............................................................ 39
Genitourinary Agents......................................................................................................................................40
Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)................................................................ 41
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)............................................................... 42
Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)................................................... 43
Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)................................... 43
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)................................................................ 47
Hormonal Agents, Suppressant (Adrenal)....................................................................................................47
Hormonal Agents, Suppressant (Pituitary)...................................................................................................47
Hormonal Agents, Suppressant (Thyroid).................................................................................................... 47
Immunological Agents....................................................................................................................................47
Inflammatory Bowel Disease Agents............................................................................................................ 50
Metabolic Bone Disease Agents.................................................................................................................... 50
Miscellaneous Therapeutic Agents............................................................................................................... 50
Ophthalmic Agents......................................................................................................................................... 52
Otic Agents...................................................................................................................................................... 55
Respiratory Tract/Pulmonary Agents............................................................................................................55
Skeletal Muscle Relaxants..............................................................................................................................57
Sleep Disorder Agents....................................................................................................................................57
6Drug Name Drug Tier Notes Drug Name Drug Tier Notes
Analgesics diflunisal oral 1
butalbital- ec-naproxen 1
acetaminophen oral 1 etodolac 1
capsule
etodolac er 1
butalbital-
acetaminophen oral 1 fenoprofen calcium oral
3
tablet 50-325 mg capsule 400 mg
butalbital-apap-caffeine 1 fenoprofen calcium oral
3
tablet
butalbital-aspirin-
1 flurbiprofen oral 1
caffeine
duraxin 1 gnp aspirin low dose 1 PV
Nonsteroidal Anti- goodsense aspirin low
1 PV
inflammatory Drugs dose
adult aspirin regimen 1 PV ibu 1
aspirin adult 1 PV ibuprofen lysine 1
aspirin adult low ibuprofen oral
1
strength oral tablet 1 PV suspension
delayed release ibuprofen oral tablet
aspirin childrens 1 PV 400 mg, 600 mg, 800 1
mg
aspirin ec 1 PV
indomethacin er 1
aspirin ec low dose 1 PV
indomethacin oral
aspirin ec low strength 1 PV 1
capsule 25 mg, 50 mg
aspirin low dose 1 PV indomethacin sodium 1
aspirin oral tablet 1 PV ketoprofen er 1
aspirin oral tablet ketoprofen oral capsule
1 PV 1
delayed release 50 mg, 75 mg
BAYER ASPIRIN 3 PV ketorolac tromethamine
1
BAYER ASPIRIN EC injection
3 PV
LOW DOSE ketorolac tromethamine
1
celecoxib oral 1 QL intramuscular
diclofenac potassium 1 ketorolac tromethamine
1 QL
diclofenac sodium er 1 oral
diclofenac sodium oral 1 meclofenamate sodium
1
oral
diclofenac sodium
1 QL meloxicam oral 1
transdermal gel 1 %
diclofenac sodium nabumetone oral 1
1 PA
transdermal solution naproxen dr 1
diclofenac-misoprostol 1 naproxen oral tablet 1
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
7Drug Name Drug Tier Notes Drug Name Drug Tier Notes
naproxen sodium oral morphine sulfate er 1 PA; QL
1
tablet 275 mg, 550 mg morphine sulfate er
1 PA; QL
oxaprozin 1 beads
piroxicam oral 1 morphine sulfate
1
qc aspirin low dose oral intramuscular
1 PV
tablet delayed release NUCYNTA ER 3 PA; QL
ST JOSEPH LOW OXYCONTIN 2 PA; QL
DOSE ORAL TABLET 3 PV oxymorphone hcl er 1 PA; QL
DELAYED RELEASE
tramadol hcl er
sulindac oral 1 1 QL
(biphasic)
tolmetin sodium 1 tramadol hcl er oral
Opioid Analgesics, capsule extended 1 PA; QL
Long-acting release 24 hour 150 mg
buprenorphine tramadol hcl er oral
1 PA; QL
transdermal tablet extended release 1 QL
fentanyl 1 PA; QL 24 hour
hydrocodone bitartrate XTAMPZA ER 2 PA; QL
1 PA; QL Opioid Analgesics,
er
hydromorphone hcl er 1 PA; QL Short-acting
HYSINGLA ER 2 PA; QL acetaminophen-
1 QL
codeine
levorphanol tartrate oral
3 PA; QL acetaminophen-
tablet 2 mg 1 QL
codeine #2
methadone hcl injection 1
acetaminophen-
methadone hcl intensol 1 1 QL
codeine #3
methadone hcl oral acetaminophen-
1 1 QL
concentrate codeine #4
methadone hcl oral apap-caff-
1
solution dihydrocodeine oral 1 PA; QL
methadone hcl oral capsule
1 PA
tablet ascomp-codeine 1
methadone hcl oral butalbital-apap-caff-cod 1
1
tablet soluble
butalbital-asa-caff-
methadose oral 1
1 codeine
concentrate 10 mg/ml
butorphanol tartrate
methadose oral tablet 1
1 injection
soluble
butorphanol tartrate
methadose sugar-free 1 1 QL
nasal
mitigo 1 codeine sulfate 1 QL
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
8Drug Name Drug Tier Notes Drug Name Drug Tier Notes
duramorph 1 oxycodone-
endocet 1 QL acetaminophen oral
tablet 10-325 mg, 2.5- 1 QL
fentanyl citrate buccal 325 mg, 5-325 mg, 7.5-
1 PA; QL
lozenge on a handle 325 mg
hydrocodone- oxycodone-aspirin 1 QL
1 QL
acetaminophen
oxymorphone hcl 1 QL
hydrocodone-ibuprofen 1 QL
pentazocine-naloxone
hydromorphone hcl 1 QL
hcl
injection solution 1
1 tramadol hcl ir 1 QL
mg/ml, 2 mg/ml, 4
mg/ml tramadol-
1 QL
hydromorphone hcl oral 1 QL acetaminophen
hydromorphone hcl pf 1 Anesthetics
lorcet 1 QL Local Anesthetics
lorcet hd 1 QL ethyl chloride 1
morphine sulfate glydo 1
(concentrate) oral lidocaine external
1 QL 1
solution 100 mg/5ml, ointment
20 mg/ml lidocaine external patch
1
morphine sulfate (pf) 5%
1
injection lidocaine hcl external
1
morphine sulfate (pf) solution
intravenous solution 2 1 lidocaine hcl injection
mg/ml, 4 mg/ml 1
solution 2 %
morphine sulfate lidocaine hcl
injection solution 2 1
1 mouth/throat
mg/ml, 4 mg/ml, 5
mg/ml lidocaine hcl
1
urethral/mucosal
morphine sulfate oral 1 QL
lidocaine viscous hcl 1
oxycodone hcl oral
1 QL lidocaine-prilocaine
capsule 1
external cream
oxycodone hcl oral
concentrate 100 1 QL LIDOCAINE-
mg/5ml TETRACAINE
3
EXTERNAL CREAM 7-
oxycodone hcl oral 7%
1 QL
solution
oxycodone hcl oral
1 QL
tablet
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
9Drug Name Drug Tier Notes Drug Name Drug Tier Notes
Anti- NICORETTE
Addiction/Substance MOUTH/THROAT 3 PV; QL
Abuse Treatment GUM 2 MG
Agents nicotine polacrilex
1 PV; QL
Alcohol mouth/throat
Deterrents/Anti- nicotine step 1 1 PV; QL
craving
nicotine step 2 1 PV; QL
acamprosate calcium 1
nicotine step 3 1 PV; QL
disulfiram oral 1
NICOTROL 3 ST; PV; QL
naltrexone hcl oral 1
NICOTROL NS 3 ST; PV; QL
VIVITROL 4
Antibacterials
Opioid Dependence
Treatments Aminoglycosides
buprenorphine hcl amikacin sulfate
1 1
injection injection
buprenorphine hcl gentamicin in saline 1
1 QL
sublingual gentamicin sulfate
1
buprenorphine hcl- external
1 QL
naloxone hcl gentamicin sulfate
1
Opioid Reversal injection
Agents neomycin sulfate oral 1
naloxone hcl injection paromomycin sulfate
1 1
solution oral
naloxone hcl injection streptomycin sulfate
1 1
solution cartridge intramuscular
naloxone hcl injection tobramycin sulfate
1
solution prefilled 1 injection
syringe Antibacterials, Other
NARCAN 2 ALTABAX 3
Smoking Cessation
baciim 1
Agents
bacitracin intramuscular 1
bupropion hcl er
1 PV; QL chloramphenicol sod
(smoking det) 1
succinate
CHANTIX 3 ST; PV; QL
clindamycin hcl oral 1
CHANTIX
CONTINUING MONTH 3 ST; PV; QL clindamycin palmitate
1
PAK hcl
CHANTIX STARTING clindamycin phosphate
3 ST; PV; QL 1
MONTH PAK in d5w
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
10Drug Name Drug Tier Notes Drug Name Drug Tier Notes
clindamycin phosphate vancomycin hcl in
1
injection dextrose intravenous
clindamycin phosphate solution 1-5 gm/200ml- 1
1 %, 500-5 mg/100ml-%,
vaginal
750-5 mg/150ml-%
colistimethate sodium
1 vancomycin hcl in nacl
(cba)
intravenous solution 1-
CORTISPORIN 3 1
0.9 gm/200ml-%, 500-
daptomycin 1 0.9 mg/100ml-%
iodine tincture external VANCOMYCIN HCL IN
1
tincture 2 % NACL SOLUTION 750-
3
lincomycin hcl injection 1 0.9 MG/150ML-%
INTRAVENOUS
linezolid in sodium
1 vancomycin hcl in nacl
chloride
solution 750-0.9
linezolid intravenous 1 1
mg/150ml-%
linezolid oral 1 QL intravenous
mafenide acetate vancomycin hcl
1
external intravenous solution
methenamine hippurate 1 1000 mg/200ml, 1500
1
mg/300ml, 2000
metronidazole in nacl 1 mg/400ml, 500
metronidazole oral 1 mg/100ml
metronidazole vaginal 1 vancomycin hcl
mupirocin external 1 intravenous solution 1
reconstituted
NEO-SYNALAR
3 vancomycin hcl oral 1
EXTERNAL CREAM
nitrofurantoin 1 XIFAXAN 3 PA
nitrofurantoin ZYVOX
1 INTRAVENOUS
macrocrystal oral 3
SOLUTION 200
nitrofurantoin MG/100ML
monohydrate 1
Beta-lactam,
macrocrystals
Cephalosporins
polymyxin b sulfate
1 cefaclor 1
injection
PRIMSOL 3 cefaclor er 1
silver sulfadiazine cefadroxil 1
1
external cefazolin sodium
1
tinidazole oral 1 injection
trimethoprim oral 1 cefazolin sodium
intravenous solution 1
reconstituted
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
11Drug Name Drug Tier Notes Drug Name Drug Tier Notes
cefazolin sodium- Beta-lactam,
1 Penicillins
dextrose
cefdinir 1 amoxicillin 1
cefditoren pivoxil 1 amoxicillin-potassium
1
cefepime hcl injection 1 clavulanate er
cefepime hcl amoxicillin-potassium
1 1
intravenous solution clavulanate oral
cefepime-dextrose 1 ampicillin 1
cefixime 1 ampicillin sodium 1
cefotaxime sodium 1 ampicillin-sulbactam
1
sodium
cefotetan disodium 1
AUGMENTIN ORAL
cefotetan disodium- SUSPENSION
1 3
dextrose RECONSTITUTED
cefoxitin sodium 1 125-31.25 MG/5ML
cefpodoxime proxetil 1 BICILLIN L-A 3
cefprozil 1 dicloxacillin sodium 1
ceftazidime and nafcillin sodium
1
dextrose injection solution
1
ceftazidime injection 1 reconstituted 1 gm, 2
gm
ceftriaxone sodium in
1 nafcillin sodium
dextrose 1
intravenous
ceftriaxone sodium
1 oxacillin sodium 1
injection
ceftriaxone sodium penicillin g potassium 1
1
intravenous penicillin g sodium 1
ceftriaxone sodium- penicillin v potassium 1
1
dextrose piperacillin sod-
cefuroxime axetil 1 tazobactam so
cephalexin 1 intravenous solution
reconstituted 2.25 (2- 1
tazicef injection 1 0.25) gm, 3.375 (3-
tazicef intravenous 0.375) gm, 4.5 (4-0.5)
1
solution reconstituted gm, 40.5 (36-4.5) gm
Beta-lactam, Other Macrolides
aztreonam 1 azithromycin
1
ertapenem sodium 1 intravenous
imipenem-cilastatin 1 azithromycin oral 1
meropenem 1 clarithromycin er 1
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
12Drug Name Drug Tier Notes Drug Name Drug Tier Notes
clarithromycin oral 1 doxycycline
DIFICID 3 monohydrate oral 1
capsule 100 mg, 50 mg
erythromycin base 1
doxycycline
erythromycin monohydrate oral
1 1
ethylsuccinate oral suspension
erythromycin oral 1 reconstituted
ZITHROMAX ORAL doxycycline
3 1
PACKET monohydrate oral tablet
Quinolones MINOCIN
3
BAXDELA ORAL 3 INTRAVENOUS
CIPRO ORAL minocycline hcl oral 1
SUSPENSION 3 mondoxyne nl oral
1
RECONSTITUTED capsule 100 mg
ciprofloxacin hcl oral 1 morgidox oral 1
ciprofloxacin in d5w 1 tetracycline hcl oral 1
levofloxacin in d5w 1 Anticonvulsants
levofloxacin Anticonvulsants,
1 Other
intravenous
levofloxacin oral 1 BRIVIACT ORAL 3 ST
moxifloxacin hcl in nacl 1 EPIDIOLEX 4 PA
moxifloxacin hcl oral 1 levetiracetam er 1
ofloxacin oral 1 levetiracetam in nacl 1
Sulfonamides levetiracetam
1
sulfadiazine oral 1 intravenous
sulfamethoxazole- levetiracetam oral 1
1
trimethoprim roweepra 1
sulfatrim pediatric 1 roweepra xr 1
Tetracyclines Calcium Channel
Modifying Agents
avidoxy 1
demeclocycline hcl 1 CELONTIN 3
doxy 100 1 ethosuximide oral 1
doxycycline hyclate zonisamide oral 1
1 Gamma-aminobutyric
intravenous
Acid (GABA)
doxycycline hyclate oral
1 Augmenting Agents
capsule
doxycycline hyclate oral clobazam 1 PA
1
tablet 100 mg, 20 mg DIACOMIT 4 PA
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
13Drug Name Drug Tier Notes Drug Name Drug Tier Notes
diazepam rectal 1 QL Sodium Channel
gabapentin oral 1 Agents
pentobarbital sodium BANZEL 3 PA
1
injection carbamazepine er 1
phenobarbital oral 1 carbamazepine oral 1
phenobarbital sodium DILANTIN ORAL
1 3
injection CAPSULE 30 MG
primidone oral 1 epitol 1
tiagabine hcl 1 fosphenytoin sodium 1
valproate sodium oxcarbazepine 1
1
intravenous PEGANONE 3
valproic acid oral 1 phenytoin infatabs 1
Glutamate Reducing phenytoin oral 1
Agents
phenytoin sodium
felbamate 1 1
extended
FYCOMPA 3 phenytoin sodium
1
lamotrigine er 1 injection
lamotrigine oral tablet 1 VIMPAT ORAL 3
lamotrigine oral tablet Antidementia Agents
1
chewable Cholinesterase
lamotrigine oral tablet Inhibitors
1
dispersible donepezil hcl 1
lamotrigine starter kit- galantamine
1 1
blue hydrobromide
lamotrigine starter kit- galantamine
1 1
green hydrobromide er
lamotrigine starter kit- rivastigmine 1
1
orange
rivastigmine tartrate 1
subvenite 1
N-methyl-D-aspartate
subvenite starter kit- (NMDA) Receptor
1
blue Antagonist
subvenite starter kit- memantine hcl er 1 QL
1
green
memantine hcl oral 1
subvenite starter kit-
1 NAMZARIC ORAL
orange
CAPSULE EXTENDED 2 QL
topiramate er 1 RELEASE 24 HOUR
topiramate oral 1
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
14Drug Name Drug Tier Notes Drug Name Drug Tier Notes
Antidepressants fluoxetine hcl oral
Antidepressants, capsule delayed 1 QL
Other release
APLENZIN 3 ST; QL fluoxetine hcl oral
1
solution
bupropion hcl er (sr) 1 QL
fluoxetine hcl oral tablet 1
bupropion hcl er (xl)
oral tablet extended fluvoxamine maleate 1
1 QL
release 24 hour 150 fluvoxamine maleate er 1 QL
mg, 300 mg maprotiline hcl 1
bupropion hcl oral 1 nefazodone hcl 3
chlordiazepoxide- paroxetine hcl 1
1
amitriptyline
paroxetine hcl er 1
mirtazapine oral 1
paroxetine mesylate 1 QL
olanzapine-fluoxetine
1 QL PAXIL ORAL
hcl 2 ST
SUSPENSION
perphenazine-
1 sertraline hcl oral 1
amitriptyline
Monoamine Oxidase trazodone hcl oral 1
Inhibitors TRINTELLIX 3 ST; QL
EMSAM 3 QL venlafaxine hcl 1
MARPLAN 3 venlafaxine hcl er oral
phenelzine sulfate oral 1 capsule extended 1
release 24 hour
tranylcypromine sulfate 1
venlafaxine hcl er oral
SSRI/SNRI (Selective tablet extended release 1
Serotonin Reuptake 24 hour 225 mg
Inhibitors/Serotonin
and Norepinephrine VIIBRYD 3 QL
Reuptake Inhibitors) VIIBRYD STARTER
3 QL
citalopram PACK
1
hydrobromide Tricyclics
desvenlafaxine amitriptyline hcl oral 1
1 QL
succinate er amoxapine 1
escitalopram oxalate 1 clomipramine hcl oral 1
FETZIMA 3 ST; QL desipramine hcl oral 1
FETZIMA TITRATION 3 ST; QL doxepin hcl oral
1
fluoxetine hcl (pmdd) 1 capsule
fluoxetine hcl oral doxepin hcl oral
1 1
capsule concentrate
imipramine hcl oral 1
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
15Drug Name Drug Tier Notes Drug Name Drug Tier Notes
imipramine pamoate 1 ondansetron hcl oral
1 QL
nortriptyline hcl oral 1 tablet 24 mg
protriptyline hcl 1 ondansetron hcl oral
1
tablet 4 mg, 8 mg
trimipramine maleate
1 ondansetron odt 1
oral
Antiemetics palonosetron hcl 1
Antiemetics, Other Antifungals
compro 1 ABELCET 3
dimenhydrinate AMBISOME 3
1
injection amphotericin b
1
droperidol injection 1 intravenous
meclizine hcl oral tablet 1 caspofungin acetate 1
metoclopramide hcl ciclodan 1
1
injection ciclopirox 1
metoclopramide hcl ciclopirox olamine
1 1
oral external
perphenazine oral 1 clotrimazole external 1
prochlorperazine 1 clotrimazole
1
prochlorperazine mouth/throat
1
edisylate injection clotrimazole-
1
prochlorperazine betamethasone
1
maleate oral CRESEMBA 3
scopolamine 1 econazole nitrate
1
Emetogenic Therapy external
Adjuncts fluconazole in sodium
1
AKYNZEO ORAL 3 QL chloride
ANZEMET 3 QL fluconazole oral 1
aprepitant 1 QL flucytosine oral 1
dronabinol 1 PA; QL griseofulvin microsize
1
oral
fosaprepitant
1 griseofulvin
dimeglumine 1
ultramicrosize
granisetron hcl
1 GYNAZOLE-1 3
intravenous
granisetron hcl oral 1 QL itraconazole oral 1 PA
ondansetron hcl KERYDIN 3 PA
1
injection ketoconazole external
1
ondansetron hcl oral cream
1 QL
solution
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
16Drug Name Drug Tier Notes Drug Name Drug Tier Notes
ketoconazole external Prophylactic
1
shampoo AIMOVIG 2 PA; QL
ketoconazole oral 1 EMGALITY 2 PA; QL
micafungin sodium 1 EMGALITY (300 MG
2 PA; QL
miconazole 3 vaginal DOSE)
1
suppository Serotonin (5-HT)
naftifine hcl 1 1b/1d Receptor
nyamyc 1 Agonists
nystatin external 1 almotriptan malate 1 QL
nystatin mouth/throat 1 eletriptan hydrobromide 1 QL
nystatin oral 1 naratriptan hcl 1 QL
nystatin-triamcinolone 1 rizatriptan benzoate 1 QL
nystop 1 sumatriptan nasal 1 QL
oxiconazole nitrate 3 sumatriptan succinate
1 QL
oral
OXISTAT EXTERNAL
3 sumatriptan succinate
LOTION 1 QL
refill
posaconazole 1
sumatriptan succinate
terbinafine hcl oral 1 QL 1 QL
subcutaneous
terconazole 1 sumatriptan-naproxen
3 QL
voriconazole sodium
1
intravenous zolmitriptan oral 1 QL
voriconazole oral 1 ZOMIG NASAL 3 ST; QL
Antigout Agents Antimyasthenic
allopurinol oral 1 Agents
allopurinol sodium 1 Parasympathomimeti
cs
colchicine oral tablet 1
colchicine-probenecid 1 GUANIDINE HCL 3
febuxostat 1 ST neostigmine
methylsulfate
probenecid 1 1
intravenous solution 10
Antimigraine Agents mg/10ml, 5 mg/10ml
Ergot Alkaloids pyridostigmine bromide
1
dihydroergotamine er
1 PA; QL
mesylate injection pyridostigmine bromide
1
dihydroergotamine oral
1 PA; QL
mesylate nasal
ergotamine-caffeine 1
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
17Drug Name Drug Tier Notes Drug Name Drug Tier Notes
Antimycobacterials MYLERAN CM
Antimycobacterials, oxaliplatin 4
Other paraplatin intravenous
dapsone oral 1 solution 150 mg/15ml,
4
rifabutin 1 450 mg/45ml, 50
mg/5ml, 600 mg/60ml
Antituberculars
TEMODAR
CAPASTAT SULFATE 3 4
INTRAVENOUS
cycloserine oral 1 temozolomide CM PA
ethambutol hcl oral 1 ZANOSAR 4
isoniazid injection 1 Antiandrogens
isoniazid oral 1 abiraterone acetate CM PA
PASER 3 bicalutamide CM
PRIFTIN 3 flutamide CM
pyrazinamide oral 1 nilutamide CM
rifampin intravenous 1 XTANDI CM PA
rifampin oral 1 Antiangiogenic
SIRTURO 3 Agents
TRECATOR 3 POMALYST CM PA
Antineoplastics REVLIMID CM PA
Alkylating Agents THALOMID CM PA
BENDEKA 4 PA Antiestrogens/Modifie
rs
busulfan 4
carboplatin 4 EMCYT CM
carmustine 4 fulvestrant 4
cisplatin intravenous SOLTAMOX CM PV*
4
solution tamoxifen citrate oral
CM
cyclophosphamide tablet 10 mg
4
injection tamoxifen citrate oral
CM PV*
cyclophosphamide oral CM tablet 20 mg
dacarbazine 4 toremifene citrate CM
Antimetabolites
GLEOSTINE CM
ifosfamide 4 ALIMTA 4
LEUKERAN CM capecitabine CM PA
MATULANE CM cladribine 4
melphalan CM clofarabine 4
melphalan hcl 4 cytarabine 4
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
18Drug Name Drug Tier Notes Drug Name Drug Tier Notes
cytarabine (pf) 4 fluorouracil external
1
decitabine 4 PA cream 5 %
DROXIA 3 fluorouracil external
4
solution
floxuridine injection 4
HALAVEN 4 PA
fludarabine phosphate 4
HERCEPTIN
fluorouracil intravenous 4 4 PA
HYLECTA
FOLOTYN 4 PA idarubicin hcl 4
gemcitabine hcl 4 irinotecan hcl 4
hydroxyurea oral CM ISTODAX (OVERFILL) 4 PA
mercaptopurine oral CM IXEMPRA KIT 4
NIPENT 4 leucovorin calcium
1
TABLOID CM injection
Antineoplastics, leucovorin calcium oral CM
Other levoleucovorin calcium 4
ABRAXANE 4 levoleucovorin calcium
4
adriamycin 4 pf
ARRANON 4 LONSURF CM PA
arsenic trioxide MARQIBO 4
4
intravenous mitomycin intravenous 4
azacitidine 4 mitoxantrone hcl 4 PA
bleomycin sulfate 4 mutamycin 4
dactinomycin 4 NINLARO CM PA
daunorubicin hcl 4 ONCASPAR 4
dexrazoxane hcl 4 ONIVYDE 4
diclofenac sodium paclitaxel intravenous
1 ST; QL
transdermal gel 3 % concentrate 100
docetaxel 4 mg/16.7ml, 150 4
doxorubicin hcl 4 mg/25ml, 30 mg/5ml,
300 mg/50ml
doxorubicin hcl
4 PICATO 3 ST
liposomal
epirubicin hcl 4 PIQRAY (200 MG
CM PA
DAILY DOSE)
ETHYOL 4
PIQRAY (250 MG
FLUOROPLEX 3 CM PA
DAILY DOSE)
FLUOROURACIL PIQRAY (300 MG
EXTERNAL CREAM 2 CM PA
DAILY DOSE)
0.5 %
PROLEUKIN 4
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
19Drug Name Drug Tier Notes Drug Name Drug Tier Notes
ROZLYTREK CM PA COMETRIQ (140 MG
CM PA
SYNRIBO 4 PA DAILY DOSE)
teniposide 4 COMETRIQ (60 MG
CM PA
DAILY DOSE)
TOTECT 4
COTELLIC CM PA
VELCADE 4 PA
ERIVEDGE CM PA
vinblastine sulfate 4
erlotinib hcl oral tablet
vincristine sulfate 4 CM PA
100 mg, 150 mg
vinorelbine tartrate 4 erlotinib hcl oral tablet
CM PA; QL
VYXEOS 4 PA 25 mg
ZALTRAP 4 PA everolimus oral tablet
CM PA; QL
ZOLINZA CM PA 2.5 mg, 5 mg, 7.5 mg
Aromatase Inhibitors, FARYDAK CM PA
3rd Generation GILOTRIF CM PA; QL
anastrozole oral CM PV* IBRANCE CM PA
exemestane CM PV* ICLUSIG ORAL
CM PA; QL
letrozole oral CM TABLET 15 MG
Enzyme Inhibitors ICLUSIG ORAL
CM PA
TABLET 45 MG
etoposide intravenous 4
imatinib mesylate CM PA
etoposide oral CM
IMBRUVICA CM PA
HYCAMTIN ORAL CM
INLYTA CM PA
KYPROLIS 4 PA
JAKAFI ORAL TABLET
RUBRACA CM PA CM PA; QL
10 MG
toposar 4 JAKAFI ORAL TABLET
topotecan hcl 4 15 MG, 20 MG, 25 MG, CM PA
Molecular Target 5 MG
Inhibitors JEVTANA 4 PA
AFINITOR DISPERZ CM PA KOSELUGO CM PA
BELEODAQ 4 PA LENVIMA (10 MG
CM PA
BOSULIF CM PA DAILY DOSE)
CABOMETYX CM PA LENVIMA (12 MG
CM PA
DAILY DOSE)
CAPRELSA ORAL
CM PA; QL LENVIMA (14 MG
TABLET 100 MG CM PA
DAILY DOSE)
CAPRELSA ORAL
CM PA LENVIMA (18 MG
TABLET 300 MG CM PA
DAILY DOSE)
COMETRIQ (100 MG
CM PA LENVIMA (20 MG
DAILY DOSE) CM PA
DAILY DOSE)
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
20Drug Name Drug Tier Notes Drug Name Drug Tier Notes
LENVIMA (24 MG CYRAMZA 4 PA
CM PA
DAILY DOSE) DARZALEX 4 PA
LENVIMA (4 MG EMPLICITI 4 PA
CM PA
DAILY DOSE)
ENHERTU 4 PA
LENVIMA (8 MG
CM PA ERBITUX 4 PA
DAILY DOSE)
LYNPARZA CM PA GAZYVA 4 PA
MEKINIST CM PA HERCEPTIN 4 PA
NEXAVAR CM PA KADCYLA 4 PA
RYDAPT CM PA KANJINTI 4 PA
SPRYCEL CM PA MVASI 4 PA
STIVARGA CM PA OPDIVO 4 PA
SUTENT CM PA PADCEV 4 PA
TAFINLAR CM PA PERJETA 4 PA
TAGRISSO ORAL POLIVY 4 PA
CM PA; QL
TABLET 40 MG RITUXAN 4 PA
TAGRISSO ORAL RITUXAN HYCELA 4 PA
CM PA
TABLET 80 MG RUXIENCE 4 PA
TASIGNA CM PA TECENTRIQ 4 PA
TURALIO CM PA TRAZIMERA 4 PA
TYKERB CM PA UNITUXIN 4 PA
VENCLEXTA CM PA YERVOY 4 PA
VENCLEXTA ZIRABEV 4 PA
CM PA
STARTING PACK
Retinoids
VOTRIENT CM PA
bexarotene CM PA
XALKORI CM PA
PANRETIN 3
ZELBORAF CM PA
TARGRETIN
ZYDELIG CM PA 4 PA
EXTERNAL
ZYKADIA CM PA tretinoin oral CM
Monoclonal Treatment Adjuncts
Antibody/Antibody-
Drug Conjugate ELITEK 4
ADCETRIS 4 PA mesna 4
ARZERRA 4 PA MESNEX ORAL CM
AVASTIN 4 PA Antiparasitics
BAVENCIO 4 PA Anthelmintics
BLINCYTO 4 PA albendazole oral 1 PA
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
21Drug Name Drug Tier Notes Drug Name Drug Tier Notes
EMVERM 2 entacapone 1
ivermectin oral 1 tolcapone 1
praziquantel oral 1 Dopamine Agonists
SKLICE 3 APOKYN 4 PA; QL
Antiprotozoals bromocriptine mesylate
3
ALINIA 2 oral
atovaquone oral 1 NEUPRO 3 ST
atovaquone-proguanil pramipexole
1 1
hcl dihydrochloride
BENZNIDAZOLE 3 pramipexole
1
dihydrochloride er
chloroquine phosphate
1 QL ropinirole hcl 1
oral
COARTEM 3 ropinirole hcl er 1
hydroxychloroquine Dopamine
1 QL Precursors/L-Amino
sulfate oral
Acid Decarboxylase
IMPAVIDO 3 Inhibitors
mefloquine hcl 1 carbidopa oral 1
pentamidine isethionate 1 carbidopa-levodopa 1
primaquine phosphate 1 carbidopa-levodopa er 1
pyrimethamine oral 4 PA carbidopa-levodopa-
1
quinine sulfate oral 1 PA entacapone
Pediculicides/Scabici Monoamine Oxidase
des B (MAO-B) Inhibitors
crotan 1 rasagiline mesylate oral 1
lindane 3 selegiline hcl oral 1
malathion 1 Antipsychotics
permethrin external 1 1st
Generation/Typical
spinosad 1
sulfurated lime 1 chlorpromazine hcl
1
injection
Antiparkinson Agents
chlorpromazine hcl oral 1
Anticholinergics
fluphenazine
benztropine mesylate 1 1
decanoate injection
trihexyphenidyl hcl 1 fluphenazine hcl 1
Antiparkinson haloperidol decanoate
Agents, Other 1
intramuscular
amantadine hcl oral 1 haloperidol lactate 1
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
22Drug Name Drug Tier Notes Drug Name Drug Tier Notes
haloperidol oral 1 ganciclovir sodium 1
loxapine succinate 1 valganciclovir hcl 1
molindone hcl 1 Anti-hepatitis B (HBV)
pimozide 1 Agents
thioridazine hcl oral 1 adefovir dipivoxil 4
thiothixene 1 BARACLUDE ORAL
4 QL
SOLUTION
trifluoperazine hcl 1
entecavir 4 QL
2nd
Generation/Atypical EPIVIR HBV ORAL
4
SOLUTION
ABILIFY MAINTENA 3
lamivudine oral tablet
aripiprazole 1 QL 4
100 mg
FANAPT 3 ST; QL VEMLIDY 4
FANAPT TITRATION Anti-hepatitis C (HBV)
3 ST; QL
PACK Agents
INVEGA SUSTENNA 3 EPCLUSA 4 PA; QL
INVEGA TRINZA 3 HARVONI 4 PA; QL
LATUDA 3 QL MAVYRET 4 PA; QL
olanzapine ZEPATIER 4 PA; QL
1
intramuscular
Anti-hepatitis C (HCV)
olanzapine oral 1 QL Agents
paliperidone er 1 QL PEGASYS 4 PA
quetiapine fumarate 1 QL PEGASYS PROCLICK 4 PA
quetiapine fumarate er 1 QL ribavirin oral 4
REXULTI 3 QL Anti-hepatitis C (HCV)
RISPERDAL CONSTA 3 Agents, Other
risperidone 1 QL INTRON A 4 PA
SAPHRIS 2 QL Antiherpetic Agents
ziprasidone hcl 1 QL acyclovir external 1
ziprasidone mesylate 1 acyclovir oral 1
ZYPREXA RELPREVV 3 acyclovir sodium 1
Treatment-Resistant DENAVIR 3
clozapine 1 QL famciclovir oral 1
Antivirals valacyclovir hcl oral 1 QL
Anti-cytomegalovirus
(CMV) Agents
cidofovir intravenous 1
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
23Drug Name Drug Tier Notes Drug Name Drug Tier Notes
Anti-HIV Agents, didanosine 1
Integrase Inhibitors EMTRIVA 2
(INSTI)
lamivudine oral solution 1
GENVOYA 3
lamivudine oral tablet
ISENTRESS 2 1
150 mg, 300 mg
ISENTRESS HD 2 lamivudine-zidovudine 1
STRIBILD 3 RETROVIR
2
TIVICAY 2 INTRAVENOUS
TIVICAY PD 2 stavudine 1
TRIUMEQ 2 tenofovir disoproxil
1 PV*
TYBOST 2 fumarate
Anti-HIV Agents, Non- TRUVADA 2 PV*
nucleoside Reverse VIREAD ORAL
Transcriptase 2
POWDER
Inhibitors (NNRTI) VIREAD ORAL
COMPLERA 2 TABLET 150 MG, 200 2
EDURANT 2 MG, 250 MG
efavirenz 1 zidovudine 1
INTELENCE 2 Anti-HIV Agents,
Other
JULUCA 2
FUZEON 2
nevirapine 1
SELZENTRY 2 PA
nevirapine er 1
Anti-HIV Agents,
ODEFSEY 3 Protease Inhibitors
SYMFI 2 APTIVUS 2
SYMFI LO 2 atazanavir sulfate 1
Anti-HIV Agents, CRIXIVAN 2
Nucleoside and
Nucleotide Reverse EVOTAZ 2
Transcriptase fosamprenavir calcium 1
Inhibitors (NRTI)
INVIRASE 2
abacavir sulfate 1 KALETRA ORAL
2
abacavir sulfate- TABLET
1
lamivudine LEXIVA ORAL
2
abacavir-lamivudine- SUSPENSION
1
zidovudine lopinavir-ritonavir 1
BIKTARVY 3 NORVIR ORAL
2
CIMDUO 2 PACKET
DESCOVY 3 PA; PV*
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
24Drug Name Drug Tier Notes Drug Name Drug Tier Notes
NORVIR ORAL lorazepam intensol 1 QL
2
SOLUTION lorazepam oral
1 QL
PREZCOBIX 2 concentrate 2 mg/ml
PREZISTA 2 lorazepam oral tablet 1 QL
REYATAZ ORAL oxazepam 1 QL
2
PACKET triazolam 1 QL
ritonavir 1 Bipolar Agents
VIRACEPT 2 Mood Stabilizers
Anti-influenza Agents divalproex sodium er 1
oseltamivir phosphate divalproex sodium oral 1
1 QL
oral
lithium 1
RELENZA DISKHALER 3 QL
lithium carbonate er 1
rimantadine hcl 1
lithium carbonate oral 1
Anxiolytics
Blood Glucose
Anxiolytics, Other Monitoring
buspirone hcl oral 1 ACCU-CHEK
hydroxyzine hcl FASTCLIX LANCET 2
1
intramuscular KIT
hydroxyzine hcl oral 1 ACCU-CHEK
hydroxyzine pamoate MULTICLIX LANCET 2
1 DEVICE KIT
oral
Benzodiazepines ACCU-CHEK
SOFTCLIX LANCET 2
alprazolam er 1 QL DEVICE KIT
alprazolam intensol 1 QL BAYER CONTOUR
2
alprazolam oral tablet 1 QL LINK 2.4
alprazolam xr 1 QL CEQUR SIMPLICITY
3
chlordiazepoxide hcl 1 QL 2U
clonazepam oral 1 QL CHEMSTRIP UGK 3
clorazepate CONTOUR CONTROL 2
1 QL
dipotassium CONTOUR NEXT
2
diazepam injection 1 CONTROL
diazepam intensol 1 CONTOUR NEXT LINK 2
diazepam CONTOUR NEXT
1 2
intramuscular MONITOR
diazepam oral 1 CONTOUR NEXT
2 QL
TEST
estazolam 1 QL
CONTOUR TEST 2 QL
lorazepam injection 1
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
25Drug Name Drug Tier Notes Drug Name Drug Tier Notes
INPEN 100-BLUE- glyburide-metformin 1
3
LILLY GLYXAMBI 2 ST
INPEN 100-BLUE- JANUMET 2 ST
3
NOVO
JANUMET XR 2 ST
INPEN 100-GRAY-
3 JANUVIA 2 ST
LILLY
INPEN 100-GREY- JARDIANCE 2 ST
3
NOVO JENTADUETO 2 ST
INPEN 100-PINK- JENTADUETO XR 2 ST
3
LILLY metformin hcl er 1
INPEN 100-PINK- metformin hcl ir 1
3
NOVO
miglitol 1
KETONE TEST 3
nateglinide 1
KETOSTIX 3
OZEMPIC 2 ST; QL
LANCETS 2
pioglitazone hcl 1
NOVOPEN ECHO 3
pioglitazone hcl-
ONETOUCH DELICA 1
3 glimepiride
LANCING DEV
pioglitazone hcl-
ONETOUCH DELICA 1
3 metformin hcl
PLUS LANCING
repaglinide 1
Blood Glucose
Regulators SYNJARDY 2 ST
Antidiabetic Agents SYNJARDY XR 2 ST
acarbose oral 1 TRADJENTA 2 ST
BYDUREON 2 ST; QL TRULICITY
SUBCUTANEOUS
BYDUREON BCISE SOLUTION PEN-
2 ST; QL 2 ST; QL
AUTOINJECTOR INJECTOR 0.75
BYETTA 10 MCG PEN 2 ST; QL MG/0.5ML, 1.5
BYETTA 5 MCG PEN 2 ST; QL MG/0.5ML
FARXIGA 2 ST VICTOZA 2 ST; QL
glimepiride 1 XIGDUO XR 2 ST
glipizide er 1 Glycemic Agents
glipizide ir 1 diazoxide oral 1
glipizide xl 1 GLUCAGON
2 Made by Lilly
EMERGENCY KIT
glipizide-metformin hcl 1
GLUCAGON Made by
glyburide micronized 1 2
EMERGENCY KIT Fresenius
glyburide oral 1
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
26Drug Name Drug Tier Notes Drug Name Drug Tier Notes
Insulins NOVOLIN N RELION 3
HUMALOG KWIKPEN 2 NOVOLIN N VIAL 3
HUMALOG MIX 50/50 NOVOLIN R FLEXPEN 3
2
KWIKPEN NOVOLIN R FLEXPEN
3
HUMALOG MIX 50/50 RELION
2
VIAL NOVOLIN R RELION 3
HUMALOG MIX 75/25 NOVOLIN R VIAL 3
2
KWIKPEN
NOVOLOG FLEXPEN 3
HUMALOG MIX 75/25
2 NOVOLOG MIX 70/30
VIAL 3
FLEXPEN
HUMALOG U-100
2 NOVOLOG MIX 70/30
JUNIOR KWIKPEN 3
VIAL
HUMALOG VIAL 2
NOVOLOG PENFILL 3
HUMULIN 70/30
2 NOVOLOG U-100 VIAL 3
KWIKPEN
HUMULIN 70/30 VIAL 2 TOUJEO MAX
2
SOLOSTAR
HUMULIN N KWIKPEN 2
TOUJEO SOLOSTAR 2
HUMULIN N VIAL 2
TRESIBA 3
HUMULIN R U-500
2 TRESIBA
KWIKPEN 3
FLEXTOUCH
HUMULIN R U-500
2 Blood
VIAL
Products/Modifiers/V
HUMULIN R VIAL 2 olume Expanders
LANTUS SOLOSTAR 2 CEPROTIN 4
LANTUS U-100 VIAL 2 SOLIRIS 4 PA
LEVEMIR U-100 Anticoagulants
2
FLEXTOUCH
acd formula a 1
LEVEMIR U-100 VIAL 2
anticoagulant cit dext
NOVOLIN 70/30 1
3 soln a
FLEXPEN
argatroban 1
NOVOLIN 70/30
3 bivalirudin
FLEXPEN RELION 1
trifluoroacetate
NOVOLIN 70/30
3 ELIQUIS 2 QL
RELION
NOVOLIN 70/30 VIAL 3 ELIQUIS DVT/PE
2 QL
STARTER PACK
NOVOLIN N FLEXPEN 3
enoxaparin sodium 1 QL
NOVOLIN N FLEXPEN
3 fondaparinux sodium 1 QL
RELION
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
27Drug Name Drug Tier Notes Drug Name Drug Tier Notes
heparin (porcine) in COAGADEX 4
nacl intravenous 1 CORIFACT 4
solution
ELOCTATE 4
heparin sod (porcine) in
1 FEIBA 4
d5w
heparin sodium HEMLIBRA 4
1
(porcine) HEMOFIL M 4
heparin sodium HUMATE-P 4
1
(porcine) pf KOATE 4
jantoven 1 KOATE-DVI 4
PRADAXA 2 QL KOGENATE FS 4
SAVAYSA 3 QL KOVALTRY 4
THROMBATE III 4 NOVOSEVEN RT 4
warfarin sodium oral 1 NUWIQ 4
XARELTO 2 QL OBIZUR 4
XARELTO STARTER PROFILNINE 4
2 QL
PACK
PROFILNINE SD 4
ZONTIVITY 3
protamine sulfate
Blood Formation 1
intravenous
Modifiers
RECOMBINATE 4
ADAKVEO 4 PA
RIASTAP 4
anagrelide hcl 1
RIXUBIS 4
ARANESP (ALBUMIN
4 PA tranexamic acid oral 1
FREE)
MOZOBIL 4 PA; QL VONVENDI 4
NEULASTA 4 PA XYNTHA 4
NEULASTA ONPRO 4 PA XYNTHA SOLOFUSE 4
NIVESTYM 4 PA Platelet Modifying
Agents
PROMACTA 4 PA
aspirin-dipyridamole er 1
REBLOZYL 4 PA
BRILINTA 2
RETACRIT 4 PA
CABLIVI 4 PA; QL
Hemostasis Agents
cilostazol 1
ADVATE 4
clopidogrel bisulfate
aminocaproic acid 1
1 oral
intravenous
dipyridamole oral 1
aminocaproic acid oral 1
eptifibatide 1
BENEFIX 4
prasugrel hcl 1
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
28Drug Name Drug Tier Notes Drug Name Drug Tier Notes
Cardiovascular olmesartan medoxomil-
Agents 1
hctz
Alpha-adrenergic olmesartan-amlodipine-
1
Agonists hctz
clonidine 1 telmisartan 1
clonidine hcl oral 1 telmisartan-amlodipine 1
guanfacine hcl 1 telmisartan-hctz 1
methyldopa 1 valsartan 1
methyldopa- valsartan-
1 1
hydrochlorothiazide hydrochlorothiazide
midodrine hcl 1 Angiotensin-
Alpha-adrenergic converting Enzyme
Blocking Agents (ACE) Inhibitors
doxazosin mesylate amlodipine besylate-
1 1
oral benazepril hcl
phenoxybenzamine hcl benazepril hcl oral 1
1
oral benazepril-
1
phentolamine mesylate hydrochlorothiazide
1
injection captopril oral 1
prazosin hcl oral 1 captopril-
1
Angiotensin II hydrochlorothiazide
Receptor Antagonists enalapril maleate oral 1
amlodipine besylate- enalaprilat 1
1
valsartan enalapril-
1
amlodipine-olmesartan 1 hydrochlorothiazide
amlodipine-valsartan- fosinopril sodium 1
1
hctz fosinopril sodium-hctz 1
candesartan cilexetil 1 lisinopril oral 1
candesartan cilexetil- lisinopril-
1 1
hctz hydrochlorothiazide
irbesartan 1 moexipril hcl 1
irbesartan- perindopril erbumine 1
1
hydrochlorothiazide
quinapril hcl 1
losartan potassium oral 1
quinapril-
losartan potassium-hctz 1 1
hydrochlorothiazide
olmesartan medoxomil ramipril 1
1
oral
trandolapril 1
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
29Drug Name Drug Tier Notes Drug Name Drug Tier Notes
trandolapril-verapamil BYSTOLIC 2
1
hcl er carvedilol 1
Antiarrhythmics carvedilol phosphate er 1
adenosine intravenous esmolol hcl intravenous
solution 12 mg/4ml, 6 1 1
solution 100 mg/10ml
mg/2ml
esmolol hcl-sodium
amiodarone hcl 1 1
chloride
disopyramide labetalol hcl
1 1
phosphate intravenous solution
dofetilide 1 labetalol hcl oral 1
flecainide acetate 1 metoprolol succinate er 1
ibutilide fumarate 1 metoprolol tartrate
1
lidocaine hcl (cardiac) 1 intravenous
lidocaine hcl (cardiac) metoprolol tartrate
1
pf intravenous solution 1
lidocaine in d5w cartridge 5 mg/5ml
intravenous solution 4- metoprolol tartrate oral 1
1
5 mg/ml-%, 8-5 mg/ml- metoprolol-
% 1
hydrochlorothiazide
mexiletine hcl oral 1 pindolol 1
procainamide hcl propranolol hcl er 1
1
injection
propranolol hcl
propafenone hcl 1 1
intravenous
propafenone hcl er 1 propranolol hcl oral 1
quinidine gluconate er 1 propranolol-hctz 1
quinidine sulfate 1 timolol maleate oral 1
sorine 1 Calcium Channel
sotalol hcl (af) 1 Blocking Agents
sotalol hcl oral 1 amlodipine besylate
1
Beta-adrenergic oral
Blocking Agents cartia xt 1
acebutolol hcl oral 1 diltiazem hcl er beads 1
atenolol oral 1 diltiazem hcl er coated
1
atenolol-chlorthalidone 1 beads
betaxolol hcl oral 1 diltiazem hcl er oral
capsule extended 1
bisoprolol fumarate 1 release 12 hour
bisoprolol-
1
hydrochlorothiazide
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
30Drug Name Drug Tier Notes Drug Name Drug Tier Notes
diltiazem hcl ENTRESTO 2 QL
1
intravenous ephedrine sulfate
1
diltiazem hcl oral 1 intravenous solution
dilt-xr 1 epinephrine injection
felodipine er 1 solution prefilled 1
syringe
matzim la 1
epinephrine pf 1
nicardipine hcl
1 metyrosine 1
intravenous
nifedipine er 1 milrinone lactate 1
nifedipine er osmotic milrinone lactate in
1 1
release dextrose
nimodipine oral 1 norepinephrine
1
bitartrate intravenous
nisoldipine er 1
pentoxifylline er 1
taztia xt 1
phenylephrine hcl
tiadylt er 1 1
intravenous solution
verapamil hcl er 1 ranolazine er 1
verapamil hcl spironolactone-hctz 1
1
intravenous
triamterene-hctz 1
verapamil hcl oral 1
VYNDAMAX 4 PA; QL
Cardiovascular
Agents, Other Diuretics, Carbonic
Anhydrase Inhibitors
aliskiren fumarate 1
acetazolamide er 1
alprostadil injection 1
acetazolamide oral 1
amiloride-
1 acetazolamide sodium 1
hydrochlorothiazide
amlodipine-atorvastatin 1 methazolamide oral 1
CORLANOR 3 PA; QL Diuretics, Loop
DEMSER 3 bumetanide 1
digitek 1 ethacrynate sodium 1
digox 1 ethacrynic acid 1
digoxin injection 1 furosemide injection 1
digoxin oral 1 furosemide oral 1
dobutamine hcl 1 torsemide 1
dobutamine in d5w 1 Diuretics, Potassium-
sparing
dopamine hcl
1 amiloride hcl oral 1
intravenous
dopamine in d5w 1 eplerenone 1
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
31Drug Name Drug Tier Notes Drug Name Drug Tier Notes
spironolactone oral 1 cholestyramine oral 1
triamterene oral 1 colesevelam hcl 1
Diuretics, Thiazide colestipol hcl 1
chlorthalidone 1 ezetimibe 1
hydrochlorothiazide ezetimibe-simvastatin 1
1
oral NEXLETOL 2 PA; QL
indapamide 1 NEXLIZET 2 PA; QL
metolazone 1 niacin er
1
Dyslipidemics, Fibric (antihyperlipidemic)
Acid Derivatives omega-3-acid ethyl
1 PA
fenofibrate micronized 1 esters
fenofibrate oral capsule 1 PRALUENT 2 PA; QL
fenofibrate oral tablet prevalite 1
145 mg, 160 mg, 48 1 REPATHA 2 PA; QL
mg, 54 mg
REPATHA
fenofibric acid oral PUSHTRONEX 2 PA; QL
capsule delayed 1 SYSTEM
release
REPATHA
gemfibrozil oral 1 2 PA; QL
SURECLICK
Dyslipidemics, HMG Vasodilators, Direct-
CoA Reductase acting Arterial
Inhibitors
hydralazine hcl
atorvastatin calcium 1
injection
oral tablet 10 mg, 20 1 PV*
mg hydralazine hcl oral 1
atorvastatin calcium minoxidil oral 1
oral tablet 40 mg, 80 1 Vasodilators, Direct-
mg acting
LIVALO 3 ST Arterial/Venous
lovastatin 1 PV DILATRATE-SR 3
pravastatin sodium 1 isosorbide dinitrate oral
tablet 10 mg, 20 mg, 30 1
rosuvastatin calcium 1 mg, 5 mg
simvastatin oral tablet isosorbide mononitrate 1
10 mg, 20 mg, 40 mg, 5 1 PV*
mg isosorbide mononitrate
1
er
simvastatin oral tablet
1 NITRO-BID 3
80 mg
Dyslipidemics, Other nitroglycerin 1
cholestyramine light 1 nitroglycerin in d5w 1
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
32Drug Name Drug Tier Notes Drug Name Drug Tier Notes
NITROMIST 3 relexxii 1 PA; QL
nitroprusside sodium 1 Central Nervous
RECTIV 3 System, Other
Central Nervous caffeine citrate 1
System Agents GRALISE 3 ST; QL
Attention Deficit riluzole 1 PA; QL
Hyperactivity tetrabenazine 4 PA
Disorder Agents,
Amphetamines Fibromyalgia Agents
amphetamine sulfate 1 PA; QL duloxetine hcl oral 1 QL
amphetamine- pregabalin oral 1 QL
1 PA; QL
dextroamphetamine SAVELLA 3 ST; QL
amphetamine- SAVELLA TITRATION
1 PA; QL 3 ST; QL
dextroamphetamine er PACK
dextroamphetamine Multiple Sclerosis
1 PA; QL
sulfate Agents
dextroamphetamine AVONEX PEN 4 PA; QL
1 PA; QL
sulfate er AVONEX PREFILLED 4 PA; QL
VYVANSE 2 PA; QL BAFIERTAM 4 PA; QL
Attention Deficit
BETASERON 4 PA; QL
Hyperactivity
Disorder Agents, COPAXONE 4 PA; QL
Non-amphetamines dalfampridine er 4 PA; QL
atomoxetine hcl 1 QL GILENYA 4 PA; QL
clonidine hcl er 1 glatiramer acetate 4 PA; QL
DAYTRANA 3 ST; PA; QL glatopa 4 PA; QL
dexmethylphenidate hcl 1 PA; QL MAYZENT 4 PA; QL
dexmethylphenidate hcl MAYZENT STARTER
1 PA; QL 4 PA; QL
er PACK
guanfacine hcl er 1 TECFIDERA 4 PA; QL
metadate er 1 PA; QL TYSABRI 4 PA; QL
methylphenidate hcl er 1 PA; QL Dental and Oral
methylphenidate hcl er Agents
1 PA; QL
(cd) cavarest 1
methylphenidate hcl er cevimeline hcl 1
1 PA; QL
(la) chlorhexidine gluconate
1
methylphenidate hcl mouth/throat
1 PA; QL
oral CLINPRO 5000 3
QUILLIVANT XR 3 ST; PA; QL
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
33Drug Name Drug Tier Notes Drug Name Drug Tier Notes
DEBACTEROL 3 AZELEX 3
DENTA 5000 PLUS 3 benzoyl peroxide-
1
DENTAGEL 3 erythromycin
easygel 1 calcipotriene external
1
cream
FLUORIDEX 3
calcipotriene external
fluoridex daily renewal 1 1
ointment
FLUORIDEX calcipotriene external
ENHANCED 3 1
solution
WHITENING
calcipotriene-betameth
FLUORIDEX diprop external 1 QL
3
SENSITIVITY RELIEF suspension
neutral sodium fluoride 1 calcitriol external 1
oralone 1 claravis 1 PA
paroex 1 clindacin etz external
1
periogard 1 swab
pilocarpine hcl oral 1 clindacin-p 1
prevident mouth/throat 1 clindamycin phosphate-
1
sodium fluoride 5000 benzoyl peroxide
1
plus clindamycin phosphate
1
sodium fluoride 5000 external
1
ppm clindamycin-tretinoin 1
sodium fluoride 5000 coal tar external 1
1
sensitive CONDYLOX 3
sodium fluoride dental 1 dapsone external gel 5
1
triamcinolone acetonide %
1
mouth/throat doxepin hcl external 3
Dermatological DUPIXENT 4 PA; QL
Agents
EPIDUO FORTE 3
acitretin 1
ery 1
adapalene external
1 PA erythromycin external 1
cream
adapalene external gel 1 PA imiquimod external 1
adapalene-benzoyl isotretinoin oral 1 PA
1
peroxide lactic acid e 1
ammonium lactate lactic acid external 1
1
external methoxsalen rapid 1
amnesteem 1 PA metronidazole external 1
azelaic acid external 1
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
34Drug Name Drug Tier Notes Drug Name Drug Tier Notes
MIRVASO 2 CARBAGLU 4
myorisan 1 PA chromic chloride
1
neuac external gel 1 intravenous
pimecrolimus 1 corvita 150 1
podofilox external 1 dextrose in lactated
1
ringers
REGRANEX 3 PA
dextrose intravenous 1
rosadan external cream 1
dextrose-nacl 1
rosadan external gel 1
dextrose-sodium
SANTYL 3 1
chloride
selenium sulfide effer-k oral tablet
1 1
external lotion effervescent 25 meq
STELARA ferocon 1
4 PA
INTRAVENOUS
ferotrinsic 1
STELARA
4 PA; QL ferraplus 90 1
SUBCUTANEOUS
sulfacetamide sodium ferrocite plus 1
1
(acne) fluoritab 1 PV
tacrolimus external foltrin 1
1
ointment hemocyte-f 1
TALTZ 4 PA hemocyte-plus 1
tazarotene external 1 iodine strong oral 1
TAZORAC EXTERNAL kcl in dextrose-nacl 1
3
CREAM 0.05 %
kcl-lactated ringers-d5w 1
TAZORAC EXTERNAL
3 klor-con 1
GEL
TREMFYA 4 PA klor-con 10 1
tretinoin external 1 PA klor-con m10 1
tretinoin microsphere 1 PA KLOR-CON M15 3
tretinoin microsphere klor-con m20 1
1 PA
pump klor-con sprinkle 1
zenatane 1 PA klor-con/ef 1
Electrolytes/Minerals/ k-prime 1
Metals/Vitamins
k-tan plus 1
Electrolyte/Mineral
lactated ringers
Replacement 1
intravenous
calcium chloride 1 levocarnitine oral
1
calcium gluconate solution
1
intravenous
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
35Drug Name Drug Tier Notes Drug Name Drug Tier Notes
levocarnitine oral tablet 1 potassium chloride oral 1
levocarnitine sf 1 potassium citrate er 1
ludent 1 PV potassium
1
magnesium chloride phosphates(71 meq k)
1
injection purevit dualfe plus 1
magnesium sulfate in ringers 1
1
d5w se-tan plus 1
magnesium sulfate sod citrate-citric acid 1
1
injection
sodium acetate
magnesium sulfate 1
intravenous
intravenous solution 2
gm/50ml, 20 gm/500ml, sodium bicarbonate
1 1
4 gm/100ml, 4 intravenous
gm/50ml, 40 sodium chloride (pf) 1
gm/1000ml sodium chloride
1
na ferric gluc cplx in injection
1
sucrose sodium chloride
1
nafrinse 1 PV intravenous
nafrinse drops 1 PV sodium fluoride oral 1 PV
nutrilipid 1 sodium phosphates 1
phosphorous 1 tl-hem 150 1
phospho-trin 250 trigels-f forte 1
1
neutral virt-phos 250 neutral 1
polysaccharide iron Electrolyte/Mineral/Me
1
forte tal Modifiers
pot bicarb-pot chloride 1 CHEMET 3
potassium acetate clovique 4 PA
1
intravenous
deferasirox 1 PA
potassium bicarbonate
1 kionex 1
oral
potassium chloride crys sodium polystyrene
1 1
er sulfonate
potassium chloride er 1 sps 1
potassium chloride in trientine hcl 4 PA
1
dextrose VELTASSA 3
potassium chloride in Phosphate Binders
1
nacl calcium acetate (phos
1
potassium chloride binder)
1
intravenous
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
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