2022 High Performance Formulary - (List of Covered Drugs) - The Health Plan
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2022 High Performance Formulary
(List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION
ABOUT THE DRUGS WE COVER IN THIS PLAN
This formulary was updated on 4/1/2022. For more recent information or other questions,
please contact The Health Plan Pharmacy Services at 1.800.624.6961 extension 7914, or
visit www.heathplan.org.Pharmacy Benefit Programs How to Use Your Prescription Benefit
Prescription drugs are an integral component of a Please present The Health Plan ID card to the
comprehensive health maintenance plan. pharmacist with your prescription. You will be
Pharmacy benefit programs at The Health Plan are required to pay a copayment (“copay”) at the time
developed through recommendations of of service based on the prescription plan in which
participating physicians and pharmacists. This you are enrolled. Your copayment levels are found
group of professional health care providers, under the pharmacy benefit section Pharmacy
known as the Pharmacy and Therapeutics Benefit of your Summary of Benefits. Your ID
Committee, evaluates therapeutic classes of drugs card also contains important information to allow
and recommends coverage guidelines for our the pharmacy to correctly submit your claim.
pharmacy benefit programs. The committee uses Please take it with you to the pharmacy.
current medical and pharmaceutical literature
along with recommendations of experts in various Specialty Pharmacy Program
clinical specialties in its evaluation of our Specialty drugs are high-cost medications
pharmacy benefit programs. The result is a list of including drugs manufactured by biotechnology.
drugs (formulary) to allow for the availability of Specialty drugs may be administered by injection,
appropriate medications for our members’ needs. oral, transdermal, or inhaled. Specialty drugs are
Also, the formulary and coverage guidelines allow used to treat very specific diseases and require
prescription costs and your premium to be extensive management for safety and
maintained at affordable levels. effectiveness. Dosages need to be monitored for
effect and adjustments might be needed for
Definitions
adequate response to effectively treat the disease.
Prescription – Drugs which can only be
Specialty drug require prior authorization to assure
dispensed upon order (prescription) by a qualified
appropriate candidate for the drug. Additionally,
provider of care. Additionally, only drugs which
oversight is an integral part of the prior
are labeled “Caution: Federal law prohibits
authorization process. Dispensing might be limited
dispensing without prescription” will be
to pharmacies with specific skills and distribution
considered eligible.
programs to assure proper delivery of these
Generic Drug – A drug available as a chemically medications. Diseases targeted to receive therapy
and therapeutically equivalent copy of a brand- are, but not limited to, rheumatoid arthritis, severe
name drug. It is usually available from several chronic psoriasis, multiple sclerosis, hepatitis C,
manufacturers. hemophilia, certain cancers, growth deficiency,
cystic fibrosis, Crohn’s disease and organ
Brand Drug – A prescription item only available transplant.
from a single-source supplier.
Coverage for these agents are provided under your
Multi-Source Brand Drugs – Brand-name drugs Specialty Pharmacy Benefit. The list of specialty
which are manufactured by more than one drugs is available
producer. These agents are usually available as at www.healthplan.org/personal/products-and-
generic equivalents. services.Drugs Requiring Prior Authorization exception request can be made by the member,
Certain medications are eligible for coverage only member’s representative or physician. To request
after a patient-specific approval has been an exception please contact pharmacy services at
authorized. Patient-specific criteria may include 1.800.624.6961, ext. 7914. Standard requests for
age, gender, and clinical conditions determined by exceptions will be processed within 15 calendar
the physician for authorization to be granted for a days of receipt of the request. Requests for non-
specific drug. A coverage determination request urgent coverage determinations received after 5pm
can be made by the member, member’s will be processed the next business day. Urgent
representative or physician. To request a coverage requests for coverage determinations will be
determination please contact pharmacy services at processed within 24 hours or receipt.
1.800.624.6961, ext. 7914. Standard requests for
Generic Difference Policy
coverage determinations will be processed within
(copayment policy for multi-source drugs)
72 hours. Requests for non-urgent coverage
If a prescription order specifies that a brand-name
determinations received after 5pm will be
drug must be dispensed when the generic
processed the next business day. Urgent requests
equivalent is available, or the prescription order
for coverage determinations will be processed
allows for generic substitution and the member
within 24 hours.
elects to have the prescription filled with a brand-
Quantity Per Dispensing Event (QPC rules) name drug instead, the member must pay the
Generally, The Health Plan allows dispensing of brand copayment plus the difference between The
approved medications up to a 34-day supply per Health Plan cost of a brand-name and its generic
co-pay at the retail pharmacy network. Quantity equivalent (i.e., The Health Plan only pays for the
per dispensing event rules (QPC) set thresholds generic cost). Please note: Non-formulary brand
that reduce exposure to unnecessary cost, without versions of generic drugs require coverage review
creating obstacles to access for most members. as outlined above.
Drugs that are subject to QPC rules usually have
Out-of-Area Emergencies
specific limitations for use approved by the FDA.
In situations of emergency need for a prescription
Examples include drugs to treat migraine
outside The Health Plan service area, please
headaches. These drugs, known as “triptans,” are
contact The Health Plan for the location of a
to be used in specific doses up to a defined
participating pharmacy in that area. Present The
number of headaches per month. The QPC rules
Health Plan ID card with the emergency
allow this specific number of triptan medications
prescription and pay your copayment. If no
to be dispensed per 34-day benefit period. To
pharmacy in the area participates with The Health
inquire about QPC limits to request an exemption,
Plan, purchase the emergency prescription and
have your provider contact pharmacy services at
send your receipt to The Health Plan. You will be
1.800.624.6961, ext. 7914.
reimbursed in full, less your applicable
Non-Formulary Coverage Review copayment, for the prescription provided the
Certain non-formulary medications are eligible for prescription meets the guidelines specified in this
coverage only after a patient-specific approval has document.
been authorized. Patient-specific criteria may
include age, gender, and clinical conditions
determined by the physician for authorization to
be granted for a specific drug. A non-formularyExclusions and Limitations •Charges for lost or stolen prescription drugs
The following will not be covered or paid for by unless noted within your Summary of Benefits.
The Health Plan: Please contact The Health plan for details.
• The charge for any prescription refill other than • Certain legend drugs when any version or
the number set by the prescriber. Additionally, no strength become available over the counter.
refills dispensed more than one year from the date
Pain Management Program and Opiate/
or the original prescription.
Opioid Management
• The charge for any prescription, oral or topical, Pain Management Program will apply to plans
that is prescribed for cosmetic purposes. within the value program.
• The charge for any medications not FDA- The acute use of opioid medications for moderate
approved for use in the general population. to severe pain from acute injury, medical
treatment or surgical procedure will be limited.
• Off label use of a drug which is not medically
The first fill of an opioid medication will be
accepted. The Health Plan uses the same
limited to a 5 day supply. This limit is for the first
guidelines as CMS for determining whether a
fill of an opioid medication for a member who has
proposed use in medically accepted.
no history of opioid usage in the past 130 days.
• The charge for a drug not prescribed by a Health
For those members needing further management
Plan qualified provider except in an emergency
of their pain, a prior authorization will be required
situation.
if:
• The charge for any medication covered by any • The opioid exceeds 80 morphine milligram
Worker’s Compensation or occupational disease equivalents
laws, any other group policy, or government
program which is not The Health Plan’s program. • Is taken for greater than 90 consecutive days
• Dental-related prescriptions such as, but not • Is a long acting opioid
limited to, oral fluorides, dental mouth washes, • Is being taken with a medication that could cause
devices used in dental therapy. Certain oral respiratory depression.
fluoride products may be covered as a
A pharmacist will review the case to evaluate that
preventative medication.
the opioid is being utilized safely and
• The charge for prescription drugs or devices used appropriately. Additionally, the member can be
to promote weight loss. limited to one prescriber and one pharmacy, if
needed.
• Prescriptions used to treat sexual dysfunction,
either oral or topical, or devices used for Formulary medications will be preferred over non-
impotence. formulary medications. Step therapy rules will be
applied when reviewing a request for non-
• Appliances and therapeutic devices which may formulary medications. Also, dosing and
require a prescription are not covered. These quantities may be limited.
include, but are not limited to, garments, splints,
bandages, or braces regardless of intended use.Table of Contents
ANTI - INFECTIVES ........................................................................................................................................ 3
ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS ....................................................................... 6
AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH ......................................................................... 9
CARDIOVASCULAR, HYPERTENSION & LIPIDS ................................................................................. 15
DERMATOLOGICALS/TOPICAL THERAPY .......................................................................................... 19
DIAGNOSTICS & MISCELLANEOUS AGENTS ...................................................................................... 22
EAR, NOSE & THROAT MEDICATIONS .................................................................................................. 24
ENDOCRINE/DIABETES .............................................................................................................................. 24
GASTROENTEROLOGY .............................................................................................................................. 29
IMMUNOLOGY, VACCINES & BIOTECHNOLOGY ............................................................................. 32
MUSCULOSKELETAL & RHEUMATOLOGY ......................................................................................... 34
OBSTETRICS & GYNECOLOGY................................................................................................................ 35
OPHTHALMOLOGY ..................................................................................................................................... 39
RESPIRATORY, ALLERGY, COUGH & COLD ....................................................................................... 41
UROLOGICALS .............................................................................................................................................. 43
VITAMINS, HEMATINICS & ELECTROLYTES ..................................................................................... 44
Index .................................................................................................................................................................. 46
1List of Abbreviations
ACA: Affordable Care Act.
LA: Limited Availability. This prescription may be available only at certain pharmacies. For more
information, please call Customer Service.
OTC: Over the Counter. An OTC drug is a non-prescription drug.
PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs.
This means that you will need to get approval before you fill your prescriptions. If you don’t get approval, we
may not cover the drug.
QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover.
ST: Step Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical
condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat
your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for
you, we will then cover Drug B.
1: Preferred Generic
2: Preferred Brand
3: Non-preferred Drug
4: Specialty Drug
2Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
ANTI - INFECTIVES didanosine 1
ANTIFUNGAL AGENTS DOVATO 2
clotrimazole 1 EDURANT 2
CRESEMBA 2 efavirenz 1
fluconazole 1 efavirenz- 1
emtricitabin-tenofov
flucytosine 1
efavirenz-lamivu- 1
griseofulvin 1 tenofov disop
microsize
emtricitabine 1
griseofulvin 1
ultramicrosize emtricitabine- 1
tenofovir (tdf) oral
itraconazole 1 tablet 100-150 mg,
ketoconazole 1 133-200 mg, 167-
250 mg
NOXAFIL 2
emtricitabine- 6 ACA
nystatin 1 tenofovir (tdf) oral
posaconazole 1 tablet 200-300 mg
terbinafine hcl 1 EMTRIVA 2
voriconazole 1 entecavir 1
ANTIVIRALS EPCLUSA 4 PA
abacavir 1 EPIVIR HBV 2
abacavir-lamivudine 1 etravirine 1
abacavir- 1 EVOTAZ 3
lamivudine- famciclovir 1 QL
zidovudine
fosamprenavir 1
acyclovir 1
foscarnet 3 PA
adefovir 1
FUZEON 2 PA
amantadine hcl 1
GENVOYA 2
APTIVUS 2
HARVONI 4 PA
atazanavir 1
INTELENCE 2
BARACLUDE 2
INVIRASE 2
BIKTARVY 2
ISENTRESS 2
CIMDUO 2
ISENTRESS HD 2
DESCOVY 2
JULUCA 2
You can find information on what the symbols and abbreviations on this table mean by going to the
beginning of this table.
3Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
lamivudine 1 VIRACEPT 2
lamivudine- 1 VIREAD 2
zidovudine ZEPATIER 4 PA
LEXIVA 2 zidovudine 1
lopinavir-ritonavir 1
CEPHALOSPORINS
maraviroc 1
cefaclor 1
MOLNUPIRAVIR 2 QL
cefadroxil 1
nevirapine 1
cefdinir 1
NORVIR 2
cefditoren pivoxil 1
ODEFSEY 2
cefixime 1
oseltamivir 1 QL
cefpodoxime 1
PAXLOVID (EUA) 2 QL
cefprozil 1
PREVYMIS 2 QL
cefuroxime axetil 1
PREZISTA 2
cephalexin 1
RELENZA 3 QL
DISKHALER ERYTHROMYCINS & OTHER
MACROLIDES
REYATAZ 2
azithromycin 1
ribavirin 1 PA
clarithromycin 1
rimantadine 1
DIFICID 3 QL
ritonavir 1
e.e.s. 400 1
SELZENTRY 2
ery-tab 1
stavudine 1
erythrocin (as 1
SYNAGIS 4 PA; LA stearate)
TEMIXYS 2 erythromycin 1
tenofovir disoproxil 1 erythromycin 1
fumarate ethylsuccinate
TIVICAY 2 MISCELLANEOUS
TIVICAY PD 2 ANTIINFECTIVES
TRIUMEQ 2 albendazole 1 QL
TROGARZO 4 PA ALINIA 2 QL
valacyclovir 1 QL ARIKAYCE 4 PA; LA
valganciclovir 1 atovaquone 1
VEMLIDY 2
You can find information on what the symbols and abbreviations on this table mean by going to the
beginning of this table.
4Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
atovaquone- 1 QL SIVEXTRO 3 PA
proguanil tinidazole 1 QL
BENZNIDAZOLE 2 QL tobramycin 4 PA
CAYSTON 4 PA; LA tobramycin in 0.225 4 PA
chloroquine 1 % nacl
phosphate TRECATOR 3
clindamycin hcl 1 XIFAXAN 2 QL
clindamycin 1
PENICILLINS
pediatric
amoxicillin 1
COARTEM 2 QL
amoxicillin-pot 1
CYCLOSERINE 3
clavulanate
dapsone 1
ampicillin 1
EMVERM 2 QL
AUGMENTIN 2
ethambutol 1
dicloxacillin 1
hydroxychloroquine 1
penicillin v 1
IMPAVIDO 2 QL potassium
isoniazid 1 QUINOLONES
ivermectin 1 QL ciprofloxacin 1
KITABIS PAK 4 PA ciprofloxacin hcl 1
linezolid 1 PA FACTIVE 3
mefloquine 1 QL levofloxacin 1
metronidazole 1 moxifloxacin 1
neomycin 1 ofloxacin 1
nitazoxanide 1 QL SULFA'S & RELATED AGENTS
paromomycin 1 sulfadiazine 1
pentamidine 1 QL sulfamethoxazole- 1
praziquantel 1 trimethoprim
PRIFTIN 2 sulfatrim 1
pyrazinamide 1 TETRACYCLINES
quinine sulfate 1 QL avidoxy 1
rifabutin 1 demeclocycline 1
rifampin 1 doxycycline hyclate 1
SIRTURO 2 LA
You can find information on what the symbols and abbreviations on this table mean by going to the
beginning of this table.
5Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
doxycycline 1 ADAKVEO 4
monohydrate ADCETRIS 4 PA
minocycline 1 ALECENSA 4 PA
mondoxyne nl 1 ALIQOPA 4 PA; LA
morgidox 1 ALUNBRIG 4 PA
tetracycline 1 anastrozole 1
URINARY TRACT AGENTS azacitidine 4 PA
fosfomycin 1 azathioprine 1
tromethamine
BALVERSA 4 PA; LA
methenamine 1
hippurate BAVENCIO 4 PA; LA
methenamine 1 BENDEKA 4 PA
mandelate BESPONSA 4 PA
nitrofurantoin 1 bexarotene 4 PA
nitrofurantoin 1 bicalutamide 1
macrocrystal
BLINCYTO 4 PA
nitrofurantoin 1
BOSULIF 4 PA
monohyd/m-cryst
CABOMETYX 4 PA; LA
trimethoprim 1
CALQUENCE 4 PA; LA
VANCOMYCIN
capecitabine 4 PA
vancomycin 1 QL
CAPRELSA 4 PA; LA
ANTINEOPLASTIC &
COMETRIQ 4 PA
IMMUNOSUPPRESSANT
COTELLIC 4 PA; LA
DRUGS
cyclophosphamide 1
ADJUNCTIVE AGENTS
cyclosporine 1
KEPIVANCE 4 PA
cyclosporine 1
leucovorin calcium 1 modified
MESNEX 2 CYRAMZA 4 PA
VISTOGARD 4 PA DARZALEX 4 PA; LA
XGEVA 4 PA decitabine 4 PA
ANTINEOPLASTIC & DROXIA 2
IMMUNOSUPPRESSANT DRUGS
ELIGARD 4 PA
abiraterone 4 PA
ELIGARD (3 4 PA
ABRAXANE 4 PA MONTH)
You can find information on what the symbols and abbreviations on this table mean by going to the
beginning of this table.
6Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
ELIGARD (4 4 PA IMBRUVICA 4 PA
MONTH) IMFINZI 4 PA; LA
ELIGARD (6 4 PA INLYTA 4 PA
MONTH)
IRESSA 4 PA
ELZONRIS 4 PA
ISTODAX 4 PA
EMCYT 2
IXEMPRA 4 PA
ENSPRYNG 4 PA
JAKAFI 4 PA
ERBITUX 4 PA
KADCYLA 4 PA
ERIVEDGE 4 PA
KANJINTI 4 PA
ERLEADA 4 PA
KEYTRUDA 4 PA
erlotinib 4 PA
KYMRIAH 4 PA
etoposide 1
KYPROLIS 4 PA
everolimus 4 PA
(antineoplastic) lapatinib 4 PA
everolimus 1 LENVIMA 4 PA
(immunosuppressive letrozole 1
)
LEUKERAN 2
exemestane 1
leuprolide 4 PA
fludarabine 1
LIBTAYO 4 PA
flutamide 1
LONSURF 4 PA
FOLOTYN 4 PA
LORBRENA 4 PA
GAMIFANT 4 PA
LUPRON DEPOT 4 PA
GAVRETO 4 LA
LUPRON DEPOT 4 PA
GAZYVA 4 PA (3 MONTH)
gengraf 1 LUPRON DEPOT- 4 PA
GILOTRIF 4 PA PED
GLEOSTINE 2 LUPRON DEPOT- 4 PA
PED (3 MONTH)
HALAVEN 4 PA
LYNPARZA 4 PA
HYCAMTIN 4 PA
LYSODREN 4
hydroxyurea 1
MARQIBO 4 PA
IBRANCE 4 PA
MATULANE 4 PA
ICLUSIG 4 PA
megestrol 1
IDHIFA 4 PA; LA
MEKINIST 4 PA
imatinib 4 PA
You can find information on what the symbols and abbreviations on this table mean by going to the
beginning of this table.
7Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
melphalan 1 sirolimus 1
mercaptopurine 1 SOLTAMOX 3
methotrexate sodium 1 SOMATULINE 4 PA
methotrexate sodium 1 DEPOT
(pf) SPRYCEL 4 PA
mitoxantrone 4 PA STIVARGA 4 PA
mycophenolate 1 sunitinib 4 PA
mofetil SYLVANT 4 PA
mycophenolate 1 TABRECTA 4 PA
sodium
tacrolimus 1
MYLERAN 2
TAFINLAR 4 PA
MYLOTARG 4 PA; LA
TAGRISSO 4 PA; LA
nelarabine 4 PA
TALZENNA 4 PA
NERLYNX 4 PA; LA
tamoxifen 1
NEXAVAR 4 PA; LA
TARGRETIN 4 PA
nilutamide 1
TASIGNA 4 PA
NINLARO 4 PA
TECENTRIQ 4 PA; LA
NUBEQA 4 PA; LA
TEMODAR 4 PA
octreotide acetate 4 PA
temozolomide 4 PA
ODOMZO 4 PA; LA
temsirolimus 4 PA
ONIVYDE 4 PA
THALOMID 4 PA
OPDIVO 4 PA
TIBSOVO 4 PA
PEMAZYRE 4 PA; LA
topotecan 4 PA
PERJETA 4 PA
toremifene 1
POTELIGEO 4 PA
TRAZIMERA 4 PA
PROGRAF 2
TREANDA 4 PA
PURIXAN 4 PA
tretinoin 1
ROZLYTREK 4 PA; LA (antineoplastic)
RUBRACA 4 PA; LA TRIPTODUR 4 PA
RUXIENCE 4 UNITUXIN 4 PA
RYDAPT 4 PA VANTAS 4 PA
SANDIMMUNE 2 VECTIBIX 4 PA
SIGNIFOR 4 PA VELCADE 4 PA
You can find information on what the symbols and abbreviations on this table mean by going to the
beginning of this table.
8Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
VENCLEXTA 4 PA; LA DILANTIN 2
VENCLEXTA 4 PA divalproex 1
STARTING PACK EPIDIOLEX 4 PA; LA
VERZENIO 4 PA; LA epitol 1
VITRAKVI 4 PA; LA ethosuximide 1
VIZIMPRO 4 PA felbamate 1
VOTRIENT 4 PA gabapentin 1
VYXEOS 4 PA lamotrigine 1
XALKORI 4 PA levetiracetam 1
XERMELO 4 PA; LA NAYZILAM 2 QL
XOSPATA 4 PA; LA oxcarbazepine 1
YERVOY 4 PA phenobarbital 1
YESCARTA 4 PA phenytoin 1
YONDELIS 4 PA phenytoin sodium 1
YONSA 4 PA extended
ZEJULA 4 PA; LA pregabalin 1
ZELBORAF 4 PA primidone 1
ZIRABEV 4 PA roweepra 1
ZOLADEX 4 PA rufinamide 1
ZOLINZA 4 PA subvenite 1
ZYDELIG 4 PA subvenite starter 1
ZYKADIA 4 PA (blue) kit
subvenite starter 1
AUTONOMIC & CNS DRUGS, (green) kit
NEUROLOGY & PSYCH subvenite starter 1
ANTICONVULSANTS (orange) kit
APTIOM 3 tiagabine 1
carbamazepine 1 topiramate 1
CELONTIN 2 valproic acid 1
clobazam 1 valproic acid (as 1
sodium salt)
clonazepam 1
vigabatrin 4 PA; LA
DIACOMIT 4 PA
vigadrone 4 PA
diazepam 1
VIMPAT 2
You can find information on what the symbols and abbreviations on this table mean by going to the
beginning of this table.
9Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
zonisamide 1 sumatriptan 1 QL
succinate oral
ANTIPARKINSONISM AGENTS
sumatriptan 1 PA; QL
benztropine 1
succinate
bromocriptine 1 subcutaneous
carbidopa 1 sumatriptan- 1 QL
carbidopa-levodopa 1 naproxen
carbidopa-levodopa- 1 zolmitriptan 1 QL
entacapone MISCELLANEOUS
entacapone 1 NEUROLOGICAL THERAPY
INBRIJA 4 PA; QL dalfampridine 4 PA
KYNMOBI 2 PA; QL donepezil 1
NEUPRO 3 FIRDAPSE 4 PA; LA
pramipexole 1 galantamine 1
rasagiline 1 memantine 1
ropinirole 1 NUEDEXTA 2
selegiline hcl 1 RADICAVA 4 PA
tolcapone 1 rivastigmine 1
trihexyphenidyl 1 rivastigmine tartrate 1
MIGRAINE & CLUSTER TEGSEDI 4 PA; LA
HEADACHE THERAPY tetrabenazine 4 PA; QL
almotriptan malate 1 QL TYSABRI 4 PA; LA
dihydroergotamine 1 PA ZEPOSIA 4 PA
injection
ZEPOSIA 4 PA
dihydroergotamine 1 QL STARTER KIT
nasal
ZEPOSIA 4 PA
eletriptan 1 QL STARTER PACK
ergotamine-caffeine 1 ZOLGENSMA 4 PA
frovatriptan 1 QL MUSCLE RELAXANTS &
migergot 1 ANTISPASMODIC THERAPY
naratriptan 1 QL baclofen 1
rizatriptan 1 QL carisoprodol 3
sumatriptan 1 QL chlorzoxazone 1
cyclobenzaprine 1
You can find information on what the symbols and abbreviations on this table mean by going to the
beginning of this table.
10Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
dantrolene 1 fentanyl 1 QL
meprobamate 3 fentanyl citrate 1 PA; QL
metaxalone 1 hydrocodone 1 QL
methocarbamol 1 bitartrate
orphenadrine citrate 1 hydrocodone- 1 ST; QL
acetaminophen
orphenadrine-asa- 1
caffeine hydrocodone- 1 ST; QL
ibuprofen
orphengesic forte 1
hydromorphone oral 1 ST; QL
pyridostigmine 1 liquid
bromide
hydromorphone oral 1 ST; QL
tizanidine 1 tablet
NARCOTIC ANALGESICS hydromorphone oral 1 PA; QL
acetaminophen-caff- 1 ST; QL tablet extended
dihydrocod release 24 hr
acetaminophen- 1 ST; QL hydromorphone 1 ST; QL
codeine rectal
ascomp with codeine 1 levorphanol tartrate 1 ST; QL
buprenorphine 1 methadone injection 1
buprenorphine hcl 1 methadone oral 1 PA
butalbital compound 1 methadose 1 PA
w/codeine morphine 1 ST; QL
butalbital- 1 concentrate
acetaminop-caf-cod morphine oral 1 PA; QL
butalbital- 1 capsule, er
acetaminophen multiphase 24 hr
butalbital- 1 morphine oral 1 PA; QL
acetaminophen-caff capsule,extend.relea
se pellets
butalbital-aspirin- 1
caffeine morphine oral 1 ST; QL
solution
codeine sulfate 1 ST; QL
morphine oral tablet 1 ST; QL
codeine-butalbital- 1
asa-caff morphine oral tablet 1 PA; QL
extended release
diskets 1 PA
morphine rectal 1 ST; QL
dvorah 1 ST; QL
oxycodone 1 ST; QL
endocet 1 ST; QL
You can find information on what the symbols and abbreviations on this table mean by going to the
beginning of this table.
11Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
oxycodone- 1 ST; QL choline,magnesium 1
acetaminophen salicylate
OXYCONTIN 3 PA; QL diclofenac potassium 1
oxymorphone oral 1 ST; QL diclofenac sodium 1
tablet oral
oxymorphone oral 1 PA; QL diclofenac sodium 1 QL
tablet extended topical
release 12 hr diclofenac- 1
prolate 1 ST; QL misoprostol
SUBLOCADE 4 PA diflunisal 1
tencon 1 ecotrin 6 ACA; OTC
vtol lq 1 ecotrin low strength 6 ACA; OTC
zebutal 1 etodolac 1
NON-NARCOTIC ANALGESICS fenoprofen 1
aspirin 6 ACA; OTC flurbiprofen 1
aspirin low dose 6 ACA; OTC ibu 1
aspir-trin 6 ACA; OTC ibuprofen 1
bayer aspirin 6 ACA; OTC indomethacin 1
buprenorphine- 1 ketoprofen 1
naloxone sublingual ketorolac 1
film 12-3 mg
KLOXXADO 2 QL
buprenorphine- 1 QL
naloxone sublingual lofena 1
film 2-0.5 mg, 4-1 meclofenamate 1
mg, 8-2 mg
mefenamic acid 1
buprenorphine- 1 QL
meloxicam 1
naloxone sublingual
tablet 2-0.5 mg meloxicam 1
submicronized
buprenorphine- 1
naloxone sublingual nabumetone 1
tablet 8-2 mg naloxone injection 1 PA
butorphanol 1 PA; QL naloxone nasal 1 QL
cataflam 1 naltrexone 1
celecoxib 1 naproxen 1
children's aspirin 6 ACA; OTC naproxen sodium 1
NUCYNTA 3 ST; QL
You can find information on what the symbols and abbreviations on this table mean by going to the
beginning of this table.
12Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
NUCYNTA ER 3 PA; QL aripiprazole oral 1 QL
oxaprozin 1 tablet
pentazocine- 3 ST; QL aripiprazole oral 1 QL
naloxone tablet,disintegrating
piroxicam 1 ARISTADA 2
salsalate 1 ARISTADA INITIO 2
st joseph aspirin 6 ACA; OTC armodafinil 1 PA
sulindac 1 asenapine maleate 3 QL
tolmetin 1 atomoxetine 1
tramadol 1 ST; QL BELSOMRA 3
tramadol- 1 ST; QL bupropion hcl 1
acetaminophen buspirone 1
VISCO-3 4 PA chlordiazepoxide hcl 1
VIVITROL 4 chlorpromazine 1
ZUBSOLV 2 QL citalopram 1
SUBLINGUAL clomipramine 1
TABLET 0.7-0.18
MG, 1.4-0.36 MG, clonidine hcl 1
2.9-0.71 MG, 5.7- clorazepate 1
1.4 MG, 8.6-2.1 MG dipotassium
ZUBSOLV 2 clozapine 1
SUBLINGUAL
TABLET 11.4-2.9 desipramine 1
MG desvenlafaxine 1
PSYCHOTHERAPEUTIC DRUGS succinate
dexmethylphenidate 1
ABILIFY 2
MAINTENA dextroamphetamine 1
alprazolam 1 dextroamphetamine- 1
amphetamine
alprazolam intensol 1
diazepam 1
amitriptyline 1
diazepam intensol 1
amitriptyline- 1
chlordiazepoxide DORAL 2
amoxapine 1 doxepin 1
amphetamine sulfate 1 duloxetine 1
aripiprazole oral 1 ergoloid 1
solution escitalopram oxalate 1
You can find information on what the symbols and abbreviations on this table mean by going to the
beginning of this table.
13Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
estazolam 1 paroxetine 1
eszopiclone 1 mesylate(menop.sym
)
FETZIMA 3
perphenazine 1
fluoxetine 1
perphenazine- 1
fluphenazine hcl 1 amitriptyline
flurazepam 1 phenelzine 1
fluvoxamine 1 pimozide 1
guanfacine 1 procentra 1
haloperidol 1 protriptyline 1
haloperidol lactate 1 QUAZEPAM 3
imipramine hcl 1 quetiapine 1 QL
imipramine pamoate 1 ramelteon 1
LATUDA 3 QL REXULTI 3 QL
lithium carbonate 1 RISPERDAL 2
lorazepam 1 CONSTA
lorazepam intensol 1 risperidone oral 1
solution
loxapine succinate 1
risperidone oral 1 QL
maprotiline 1 tablet
MARPLAN 3 risperidone oral 1 QL
methamphetamine 1 tablet,disintegrating
methylphenidate hcl 1 sertraline 1
midazolam 1 SUNOSI 2
mirtazapine 1 temazepam 3
modafinil 1 PA thioridazine 1
molindone 1 thiothixene 1
nortriptyline 1 tranylcypromine 1
olanzapine 1 QL trazodone 1
olanzapine- 1 triazolam 1
fluoxetine trifluoperazine 1
oxazepam 3 trimipramine 1
paliperidone 1 QL TRINTELLIX 3 PA
paroxetine hcl 1 venlafaxine 1
You can find information on what the symbols and abbreviations on this table mean by going to the
beginning of this table.
14Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
VIIBRYD 3 PA amlodipine 1
XYREM 4 PA; LA; QL amlodipine- 1
XYWAV 4 PA; LA; QL benazepril
zaleplon 1 amlodipine- 1
olmesartan
zenzedi 1
amlodipine- 1
ziprasidone hcl 1 QL valsartan
zolpidem 1 amlodipine- 1
ZULRESSO 4 PA valsartan-hcthiazid
atenolol 1
CARDIOVASCULAR,
HYPERTENSION & LIPIDS atenolol- 1
chlorthalidone
ANTIARRHYTHMIC AGENTS
benazepril 1
amiodarone 1
benazepril- 1
disopyramide 3 hydrochlorothiazide
phosphate
betaxolol 1
dofetilide 1
bisoprolol fumarate 1
flecainide 1
bisoprolol- 1
mexiletine 1 hydrochlorothiazide
MULTAQ 3 bumetanide 1
pacerone 1 candesartan 1
propafenone 1 candesartan- 1
quinidine gluconate 1 hydrochlorothiazid
quinidine sulfate 1 captopril 1
sorine 1 captopril- 1
hydrochlorothiazide
sotalol 1
cartia xt 1
sotalol af 1
carvedilol 1
SOTYLIZE 2
carvedilol phosphate 1
ANTIHYPERTENSIVE THERAPY
chlorthalidone 1
acebutolol 1
clonidine 1
aliskiren 3
clonidine hcl 1
amiloride 1
diltiazem 1
amiloride- 1
dilt-xr 1
hydrochlorothiazide
doxazosin 1
You can find information on what the symbols and abbreviations on this table mean by going to the
beginning of this table.
15Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
enalapril maleate 1 metolazone 1
enalapril- 1 metoprolol succinate 1
hydrochlorothiazide metoprolol ta- 1
eplerenone 1 hydrochlorothiaz
epoprostenol 4 PA metoprolol tartrate 1
epoprostenol 4 PA metyrosine 1
(glycine) minoxidil 1
eprosartan 1 moexipril 1
ethacrynic acid 1 nadolol 1
felodipine 1 nebivolol 1
fosinopril 1 nicardipine 1
fosinopril- 1 nifedipine 1
hydrochlorothiazide
nimodipine 1
furosemide 1
nisoldipine 1
guanfacine 1
olmesartan 1
hydralazine 1
olmesartan- 1
hydrochlorothiazide 1 amlodipin-hcthiazid
indapamide 1 olmesartan- 1
irbesartan 1 hydrochlorothiazide
irbesartan- 1 ORENITRAM 4 PA
hydrochlorothiazide perindopril 1
isradipine 1 erbumine
KERENDIA 2 phenoxybenzamine 1
labetalol 1 pindolol 1
lisinopril 1 prazosin 1
lisinopril- 1 propranolol 1
hydrochlorothiazide propranolol- 1
losartan 1 hydrochlorothiazid
losartan- 1 quinapril 1
hydrochlorothiazide quinapril- 1
matzim la 1 hydrochlorothiazide
methyldopa 1 ramipril 1
methyldopa- 1 spironolactone 1
hydrochlorothiazide
You can find information on what the symbols and abbreviations on this table mean by going to the
beginning of this table.
16Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
spironolacton- 1 ALPHANATE 4 PA
hydrochlorothiaz ALPROLIX 4 PA
taztia xt 1 aminocaproic acid 1
TEKTURNA HCT 3 aspirin-dipyridamole 1
telmisartan 1 BENEFIX 4 PA
telmisartan- 1 BRILINTA 2
amlodipine
CABLIVI 4 PA; LA
telmisartan- 1
hydrochlorothiazid CEPROTIN (BLUE 4 PA
BAR)
terazosin 1
CEPROTIN 4 PA
tiadylt er 1 (GREEN BAR)
timolol maleate 1 cilostazol 1
torsemide 1 clopidogrel 1
trandolapril 1 COAGADEX 4 PA
trandolapril- 1 CORIFACT 4 PA
verapamil
dipyridamole 1
treprostinil sodium 4 PA
DOPTELET (15 4 PA; LA
triamterene 1 TAB PACK)
triamterene- 1 ELIQUIS 2
hydrochlorothiazid
ELIQUIS DVT-PE 2
UPTRAVI 4 PA; LA TREAT 30D
valsartan 1 START
valsartan- 1 ELOCTATE 4 PA
hydrochlorothiazide enoxaparin 4 PA
veletri 4 PA ESPEROCT 4 PA
verapamil 1 FEIBA NF 4 PA
CARDIAC GLYCOSIDES fondaparinux 4 PA
digitek 1 HEMLIBRA 4 PA
digox 1 HEMOFIL M HIGH 4 PA
digoxin 1 HEMOFIL M LOW 4 PA
COAGULATION THERAPY HEMOFIL M MID 4 PA
ADVATE 4 PA HEMOFIL M 4 PA
ADYNOVATE 4 PA SUPER HIGH
AFSTYLA 4 PA hep flush-10 (pf) 1 PA
You can find information on what the symbols and abbreviations on this table mean by going to the
beginning of this table.
17Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
heparin (porcine) 1 PA vitamin k 1 PA
heparin (porcine) in 1 PA vitamin k1 1 PA
5 % dex VONVENDI 4 PA
heparin (porcine) in 1 PA warfarin 1
nacl (pf)
XARELTO 2
heparin 1 PA
flush(porcine)- XARELTO DVT-PE 2
0.9nacl TREAT 30D
START
heparin lock flush 1 PA
(porcine) ZONTIVITY 3
heparin 1 PA LIPID/CHOLESTEROL LOWERING
lockflush(porcine)(pf AGENTS
)
amlodipine- 1
heparin(porcine) in 1 PA atorvastatin
0.45% nacl
atorvastatin oral 6 ACA
heparin, porcine (pf) 1 PA tablet 10 mg, 20 mg
HUMATE-P 4 PA atorvastatin oral 1
IXINITY 4 PA tablet 40 mg, 80 mg
jantoven 1 cholestyramine (with 1
sugar)
JIVI 4 PA
cholestyramine light 1
KOGENATE FS 4 PA
colesevelam 1
KOVALTRY 4 PA
colestipol 1
NOVOEIGHT 4 PA
ezetimibe 1
NPLATE 4 PA
ezetimibe- 1
OBIZUR 4 PA simvastatin
pentoxifylline 1 fenofibrate 1
phytonadione 1 PA fenofibrate 1
(vitamin k1) micronized
prasugrel 1 fenofibrate 1
PROFILNINE 4 PA nanocrystallized
PROMACTA 4 PA; LA fenofibric acid 1
RIASTAP 4 PA fluvastatin 6 ACA
SEVENFACT 4 gemfibrozil 1
TAVALISSE 4 PA; LA icosapent ethyl 1 PA
TRETTEN 4 PA JUXTAPID 4 PA; LA
You can find information on what the symbols and abbreviations on this table mean by going to the
beginning of this table.
18Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
lovastatin 6 ACA nitroglycerin 1
niacin 1 nitro-time 1
omega-3 acid ethyl 1 PA DERMATOLOGICALS/TOPICA
esters
L THERAPY
pravastatin 6 ACA
ANTIPSORIATIC /
prevalite 1 ANTISEBORRHEIC
REPATHA 2 PA acitretin 1
PUSHTRONEX
calcipotriene 1
REPATHA 2 PA
SURECLICK calcipotriene- 1
betamethasone
REPATHA 2 PA
SYRINGE calcitriol 1
rosuvastatin oral 6 ACA COSENTYX 4 PA
tablet 10 mg, 5 mg COSENTYX (2 4 PA
rosuvastatin oral 1 SYRINGES)
tablet 20 mg, 40 mg COSENTYX PEN 4 PA
simvastatin oral 6 ACA COSENTYX PEN 4 PA
tablet 10 mg, 20 mg, (2 PENS)
40 mg, 5 mg
hydrocortisone- 1
simvastatin oral 1 pramoxine
tablet 80 mg
selenium sulfide 1
VASCEPA 2 PA
SKYRIZI 4 PA
MISCELLANEOUS
STELARA 4 PA
CARDIOVASCULAR AGENTS
sulfacetamide 1
CORLANOR 2 sodium
ENTRESTO 2 TALTZ 4 PA
ranolazine 1 AUTOINJECTOR
VERQUVO 2 TALTZ 4 PA
AUTOINJECTOR
VYNDAMAX 4 PA
(2 PACK)
VYNDAQEL 4 PA
TALTZ 4 PA
NITRATES AUTOINJECTOR
isosorbide dinitrate 1 (3 PACK)
isosorbide 1 TALTZ SYRINGE 4 PA
mononitrate TREMFYA 4 PA
nitro-bid 1 BURN THERAPY
You can find information on what the symbols and abbreviations on this table mean by going to the
beginning of this table.
19Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
silver sulfadiazine 1 clindacin p 1
ssd 1 clindamycin 1 QL
phosphate topical
MISCELLANEOUS
foam
DERMATOLOGICALS
clindamycin 1 QL
ammonium lactate 1 phosphate topical
doxepin 1 gel
DUPIXENT PEN 4 PA clindamycin 1 QL
phosphate topical
DUPIXENT 4 PA
gel, once daily
SYRINGE
clindamycin 1 QL
fluorouracil 1
phosphate topical
iodine-sodium iodide 1 lotion
methoxsalen 1 clindamycin 1 QL
methyl salicylate 1 phosphate topical
solution
pimecrolimus 3
clindamycin 1
podofilox 1 phosphate topical
prudoxin 1 swab
REGRANEX 2 clindamycin-benzoyl 1
peroxide
tacrolimus 1
clindamycin- 1
VALCHLOR 4 PA tretinoin
VEREGEN 3 dapsone 1
wintergreen oil 1 ery pads 1
THERAPY FOR ACNE erygel 1
accutane 1 erythromycin with 1
adapalene-benzoyl 1 ethanol
peroxide erythromycin- 1
amnesteem 1 benzoyl peroxide
avar 1 isotretinoin 1
avita 1 ivermectin 1
benzepro 1 metronidazole 1
benzoyl peroxide 1 myorisan 1
bp 10-1 1 neuac 1
claravis 1 rosadan 1
clindacin etz 1
You can find information on what the symbols and abbreviations on this table mean by going to the
beginning of this table.
20Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
rosula cleansing 1 lidocaine-prilocaine 1
cloths topical kit
sss 10-5 1 lidocort 1
sulfacetamide 1 lta pre-attached 1
sodium-sulfur ZTLIDO 2
sulfacetamide- 1
TOPICAL ANTIBACTERIALS
sulfur-cleansr23
gentamicin 1 QL
sulfacleanse 8-4 1
lugols 1
tazarotene 1
mafenide acetate 1
TAZORAC 2
mupirocin 1 QL
tretinoin 1
strong iodine 1
tretinoin 1
microspheres sulfacetamide 1
sodium (acne)
zenatane 1
SULFAMYLON 2
TOPICAL ANESTHETICS
TOPICAL ANTIFUNGALS
glydo 1 QL
ciclodan 1
lidocaine hcl 1
laryngotracheal ciclopirox 1
lidocaine hcl mucous 1 QL ciclopirox-ure- 1
membrane jelly camph-menth-euc
lidocaine hcl mucous 1 QL clotrimazole 1
membrane jelly in clotrimazole- 1
applicator betamethasone
lidocaine hcl mucous 1 econazole 1
membrane solution
ERTACZO 3
lidocaine hcl- 1
hydrocortison ac EXELDERM 3
lidocaine topical 1 JUBLIA 3
adhesive ketoconazole 1
patch,medicated
ketodan 1
lidocaine topical 1 QL
ointment ketodan kit 1
lidocaine viscous 1 LULICONAZOLE 3
lidocaine-prilocaine 1 QL LUZU 2
topical cream MENTAX 3
naftifine 1
You can find information on what the symbols and abbreviations on this table mean by going to the
beginning of this table.
21Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
nyamyc 1 fluocinonide 1
nystatin 1 fluocinonide-e 1
nystatin- 1 flurandrenolide 1
triamcinolone fluticasone 1
nystop 1 propionate
oxiconazole 1 halcinonide 3
tavaborole 1 halobetasol 1
propionate
TOPICAL ANTIVIRALS
hydrocortisone 1
acyclovir 1 QL
hydrocortisone 1
XERESE 3
butyrate
TOPICAL CORTICOSTEROIDS hydrocortisone 1
ala-cort 1 butyr-emollient
alclometasone 1 hydrocortisone 1
valerate
amcinonide 1
mometasone 1
apexicon e 1
nolix 1
beser 1
prednicarbate 1
betamethasone 1
dipropionate scalacort 1
betamethasone 1 tovet emollient 1
valerate triamcinolone 1
betamethasone, 1 acetonide
augmented trianex 1
clobetasol 1 triderm 1
clobetasol-emollient 1 tritocin 1
clocortolone 1
TOPICAL ENZYMES
pivalate
SANTYL 2
clodan 1
desonide 1
TOPICAL SCABICIDES /
PEDICULICIDES
desoximetasone 1
crotan 1
desrx 1
ivermectin 1
diflorasone 1
lindane 1
fluocinolone 1
malathion 1
fluocinolone and 1
shower cap permethrin 1
You can find information on what the symbols and abbreviations on this table mean by going to the
beginning of this table.
22Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
spinosad 1 INCRELEX 4 PA; LA
ULESFIA 3 levocarnitine 1
DIAGNOSTICS & levocarnitine (with 1
sugar)
MISCELLANEOUS AGENTS
midodrine 1
IRRIGATING SOLUTIONS
nitisinone 4 PA; LA
lactated ringers 1
NITYR 4 PA; LA
neomycin-polymyxin 1
b gu pilocarpine hcl 1
ringer's 1 PROLASTIN-C 4 PA; LA
tis-u-sol pentalyte 1 RAVICTI 4 PA
MISCELLANEOUS AGENTS REVCOVI 4 PA
acamprosate 1 riluzole 1 PA
acetic acid 1 risedronate 1
anagrelide 1 sodium chloride 0.9 1 PA
%
aqua care sodium 1
chloride sodium chloride 0.9 1 PA
% (flush)
aqua care sterile 1
water sodium chloride 1 PA
injection
ARALAST NP 4 PA; LA
sodium chloride 1
caffeine citrate 1 irrigation
CARBAGLU 4 PA; LA sodium 1
carglumic acid 4 PA phenylbutyrate
cevimeline 1 SOLIRIS 4 PA
CHEMET 2 tiopronin 4 PA
deferasirox 4 PA trientine 1
deferiprone oral 1 water for irrigation, 1
tablet 1,000 mg sterile
deferiprone oral 4 XURIDEN 4 PA
tablet 500 mg ZEMAIRA 4 PA; LA
disulfiram 1 zoledronic acid- 4 PA
EMPAVELI 4 PA mannitol-water
FERRIPROX 4 PA SMOKING DETERRENTS
GLASSIA 4 PA; LA bupropion hcl 6 ACA
(smoking deter)
You can find information on what the symbols and abbreviations on this table mean by going to the
beginning of this table.
23Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
nicorette buccal gum 6 ACA; OTC flac otic oil 1 QL
NICORETTE 2 OTC fluocinolone 1 QL
BUCCAL acetonide oil
LOZENGE hydrocortisone- 1 QL
NICORETTE 2 OTC acetic acid
BUCCAL MINI ofloxacin 1 QL
LOZENGE
OTIC STEROID / ANTIBIOTIC
nicotine 6 ACA; OTC
CIPRO HC 3
nicotine (polacrilex) 6 ACA; OTC
ciprofloxacin- 1
quit 2 6 ACA; OTC
dexamethasone
quit 4 6 ACA; OTC
CORTISPORIN-TC 3
stop smoking aid 6 ACA; OTC
neomycin- 1
varenicline 6 ACA polymyxin-hc
EAR, NOSE & THROAT ENDOCRINE/DIABETES
MEDICATIONS ADRENAL HORMONES
MISCELLANEOUS AGENTS decadron 1
azelastine nasal 1 QL dexabliss 1
aerosol,spray
dexamethasone 1
azelastine nasal 1
spray,non-aerosol dexamethasone 1
intensol
chlorhexidine 1
gluconate fludrocortisone 1
ipratropium bromide 1 QL hydrocortisone 1
olopatadine 1 QL methylprednisolone 1
oralone 1 millipred 1
paroex oral rinse 1 millipred dp 1
periogard 1 prednisolone 1
pilocarpine hcl 1 prednisolone sodium 1
phosphate
triamcinolone 1
acetonide prednisone 1
MISCELLANEOUS OTIC prednisone intensol 1
PREPARATIONS ANTITHYROID AGENTS
acetic acid 1 methimazole 1
ciprofloxacin hcl 1 propylthiouracil 1
You can find information on what the symbols and abbreviations on this table mean by going to the
beginning of this table.
24Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
BLOOD GLUCOSE MONITORING OPTICHAMBER 2
DEVICES & SUPPLIES DIAMOND VHC
ONETOUCH 2 POCKET 2
ULTRA TEST CHAMBER
ONETOUCH 2 PRIMEAIRE 2
VERIO TEST PROCHAMBER 2
STRIPS
RITEFLO 2
DIABETES, SUPPLIES, & DURABLE AEROCHAMBER
MEDICAL EQUIPMENT SPACE CHAMBER 2
ACE AEROSOL 2 TRIJARDY XR 2 ST
CLOUD
ENHANCER VORTEX 2
HOLDING
AEROCHAMBER 2
CHAMBER
MINI
AEROCHAMBER 2
GLUCOSE ELEVATING AGENTS
PLUS FLOW-VU BAQSIMI 2
AEROCHAMBER 2 diazoxide 1
PLUS Z STAT GLUCAGEN 2
AEROTRACH 2 HYPOKIT
PLUS GLUCAGON 2
AEROVENT PLUS 2 (HCL)
EMERGENCY KIT
BREATHERITE 2
MDI SPACER glucagon emergency 1
kit (human)
COMPACT SPACE 2
CHAMBER GVOKE 2
EASIVENT 2 GVOKE HYPOPEN 2
HOLDING 2-PACK
CHAMBER GVOKE PFS 2- 2
FLEXICHAMBER 2 PACK SYRINGE
GLUCAGEN 2 INSULIN
DIAGNOSTIC KIT SYRINGES/MISCELLANEOUS
INSPIRACHAMBE 2 DURABLE MEDICAL EQU
R BD INTEGRA 2
LITEAIRE MDI 2 NEEDLE
CHAMBER BD 2 OTC
MICROCHAMBER 2 MICROTAINER
LANCET
MICROSPACER 2
You can find information on what the symbols and abbreviations on this table mean by going to the
beginning of this table.
25Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
BD SPECIALTY 2 V-GO 40 2
USE NEEDLES
INSULIN THERAPY
BD ULTRA FINE 2 OTC
APIDRA 3
LANCETS
SOLOSTAR U-100
BD ULTRA-FINE 2 OTC INSULIN
NANO PEN
APIDRA U-100 3
NEEDLE
INSULIN
LANCETS 2 OTC
BASAGLAR 2
LANCING DEVICE 2 OTC KWIKPEN U-100
MEDISENSE 2 OTC INSULIN
MEDISENSE 2 OTC HUMALOG 2
GLUCOSE JUNIOR KWIKPEN
KETONE U-100
OMNIPOD DASH 2 PA HUMALOG 2
INSULIN POD KWIKPEN
INSULIN
OMNIPOD 2 PA
INSULIN HUMALOG MIX 2
MANAGEMENT 50-50 INSULN U-
100
ONETOUCH 2
ULTRA CONTROL HUMALOG MIX 2
50-50 KWIKPEN
ONETOUCH 2 QL
ULTRA2 METER HUMALOG MIX 2
75-25 KWIKPEN
ONETOUCH 2 QL
ULTRAMINI HUMALOG MIX 2
75-25(U-
ONETOUCH 2 QL 100)INSULN
VERIO FLEX
METER HUMALOG U-100 2
INSULIN
ONETOUCH 2 QL
VERIO IQ METER HUMULIN 70/30 2
U-100 INSULIN
ONETOUCH 2 QL
VERIO METER HUMULIN 70/30 2
U-100 KWIKPEN
PRECISION XTRA 2 OTC
KETONE- HUMULIN N NPH 2
GLUCOSE INSULIN
KWIKPEN
SAFE-CLIP BY 2 OTC
MAIL HUMULIN N NPH 2
U-100 INSULIN
V-GO 20 2
V-GO 30 2
You can find information on what the symbols and abbreviations on this table mean by going to the
beginning of this table.
26Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
HUMULIN R 2 RELION NOVOLIN 3
REGULAR U-100 R
INSULN SEMGLEE(INSULI 2
HUMULIN R U-500 2 N GLARGINE-
(CONC) INSULIN YFGN)
HUMULIN R U-500 2 SEMGLEE(INSULI 2
(CONC) KWIKPEN N GLARG-
LEVEMIR 3 YFGN)PEN
FLEXTOUCH U- TOUJEO MAX U- 2
100 INSULN 300 SOLOSTAR
LEVEMIR U-100 3 TOUJEO 2
INSULIN SOLOSTAR U-300
LYUMJEV 2 INSULIN
KWIKPEN U-100 MISCELLANEOUS HORMONES
INSULIN
ALDURAZYME 4 PA
LYUMJEV 2
BRINEURA 4 PA
KWIKPEN U-200
INSULIN cabergoline 1
LYUMJEV U-100 2 calcitonin (salmon) 1 PA
INSULIN injection
NOVOLOG 3 calcitonin (salmon) 1
FLEXPEN U-100 nasal
INSULIN calcitriol 1 PA
NOVOLOG MIX 3 CERDELGA 4 PA
70-30 U-100
INSULN CEREZYME 4 PA
NOVOLOG MIX 3 cinacalcet 1 PA
70-30FLEXPEN U- clomiphene citrate 3
100
CRYSVITA 4 PA
NOVOLOG 3
PENFILL U-100 danazol 1
INSULIN desmopressin nasal 1 PA
NOVOLOG U-100 3 desmopressin oral 1
INSULIN ASPART
doxercalciferol 1
RELION NOVOLIN 3
ELAPRASE 4 PA
70/30
FABRAZYME 4 PA
RELION NOVOLIN 3
N KANUMA 4 PA
LUMIZYME 4 PA
You can find information on what the symbols and abbreviations on this table mean by going to the
beginning of this table.
27Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
MEPSEVII 4 PA glimepiride 1
METHITEST 2 PA glipizide 1
methyltestosterone 1 PA glipizide-metformin 1
miglustat 4 PA; LA glyburide 1
MYALEPT 4 PA; LA glyburide 1
NAGLAZYME 4 PA; LA micronized
NATPARA 4 PA; LA glyburide-metformin 1
ORILISSA 2 PA GLYXAMBI 2 ST
oxandrolone 1 JANUMET 2 ST
PALYNZIQ 4 PA; LA JANUMET XR 2 ST
paricalcitol 1 PA JANUVIA 2 ST
intravenous JARDIANCE 2 ST
paricalcitol oral 1 metformin 1
SAMSCA 4 PA miglitol 1
sapropterin 4 PA nateglinide 1
SOMAVERT 4 PA pioglitazone 1
STRENSIQ 4 PA; LA pioglitazone- 1
testosterone 1 PA glimepiride
testosterone 1 PA pioglitazone- 1
cypionate metformin
testosterone 1 PA repaglinide 1
enanthate repaglinide- 1
tolvaptan 4 PA; LA metformin
VIMIZIM 4 PA SEGLUROMET 2 ST
zoledronic acid 4 PA STEGLATRO 2 ST
zoledronic acid- 4 PA STEGLUJAN 2 ST
mannitol-water SYMLINPEN 120 2 PA
NON-INSULIN HYPOGLYCEMIC SYMLINPEN 60 2 PA
AGENTS SYNJARDY 2 ST
acarbose 1 SYNJARDY XR 2 ST
BYDUREON 2 PA TRULICITY 2 PA
BCISE
XIGDUO XR 2 ST
BYETTA 2 PA
THYROID HORMONES
FARXIGA 2 ST
You can find information on what the symbols and abbreviations on this table mean by going to the
beginning of this table.
28Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
ARMOUR 2 symax-sl 1
THYROID symax-sr 1
euthyrox 1
MISCELLANEOUS
levo-t 1 GASTROINTESTINAL AGENTS
levothyroxine 1 alosetron 1
levoxyl 1 alvimopan 1
liothyronine 1 anucort-hc 1
np thyroid 1 aprepitant 1
unithroid 1 balsalazide 1
westhroid 1 betaine 4 PA
GASTROENTEROLOGY budesonide 1
ANTIDIARRHEALS & calcium 1
ANTISPASMODICS acetate(phosphat
bind)
anaspaz 1
CHENODAL 4 PA; LA
belladonna 1 ST; QL
alkaloids-opium CHOLBAM 4 PA
chlordiazepoxide- 1 citrate of magnesia 6 ACA; OTC
clidinium citroma 6 ACA; OTC
dicyclomine 1 clearlax 6 ACA; OTC
diphenoxylate- 1 compro 1
atropine
CREON 2
ed-spaz 1
cromolyn 1
glycopyrrolate 1
CYSTADANE 4 PA
hyoscyamine sulfate 1
DIPENTUM 3
hyosyne 1
dronabinol 1
loperamide 1
dulcolax 6 ACA; OTC
methscopolamine 3 (magnesium
opium tincture 1 hydroxide)
oscimin 1 ENTYVIO 4 PA
oscimin sl 1 enulose 1
phenobarb-hyoscy- 1 gavilyte-c 6 ACA
atropine-scop gavilyte-g 6 ACA
phenohytro 1 gavilyte-n 6 ACA
symax fastabs 1
You can find information on what the symbols and abbreviations on this table mean by going to the
beginning of this table.
29Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
generlac 1 peg 3350- 6 ACA
granisetron hcl 1 electrolytes
hemmorex-hc 1 peg3350-sod sul- 6 ACA
nacl-kcl-asb-c
hydrocortisone 1
peg-electrolyte soln 6 ACA
hydrocortisone 1
acetate peg-prep 6 ACA
hydrocortisone- 1 PENTASA 2
pramoxine phosphate laxative 6 ACA; OTC
INFLECTRA 4 PA powderlax 6 ACA; OTC
lactulose 1 prochlorperazine 1
lanthanum 1 prochlorperazine 1
laxative peg 3350 6 ACA; OTC maleate
lidocaine hcl- 1 procto-med hc 1
hydrocortison ac procto-pak 1
lidocaine- 1 proctosol hc 1
hydrocortisone-aloe proctozone-hc 1
LOKELMA 2 RECTIV 2
magnesium citrate 6 ACA; OTC RELISTOR 2 PA
meclizine 1 scopolamine base 1
mesalamine 1 sevelamer carbonate 1
mesalamine with 1 sevelamer hcl 1
cleansing wipe
sodium polystyrene 1
metoclopramide hcl 1 sulfonate
milk of magnesia 6 ACA; OTC sps (with sorbitol) 1
milk of magnesia 6 ACA; OTC SUCRAID 4 PA
concentrated
sulfasalazine 1
MOVANTIK 2
SUPREP BOWEL 6 ACA
natura-lax 6 ACA; OTC PREP KIT
OCALIVA 4 PA; LA trimethobenzamide 1
ondansetron 1 TRULANCE 2
ondansetron hcl 1 UCERIS 2
oral saline laxative 6 ACA; OTC ursodiol 1
PANCREAZE 2 VARUBI 2
VELPHORO 3
You can find information on what the symbols and abbreviations on this table mean by going to the
beginning of this table.
30Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
VIBERZI 2 lansoprazole oral 1
VIOKACE 2 capsule,delayed
release(dr/ec) 30 mg
women's gentle 6 ACA; OTC
laxative(bisac) lansoprazole oral 1 QL
tablet,disintegrat,
ULCER THERAPY delay rel 15 mg
amoxicil- 1 QL lansoprazole oral 1
clarithromy- tablet,disintegrat,
lansopraz delay rel 30 mg
cimetidine 1 misoprostol 1
cimetidine hcl 1 nizatidine 1
DEXILANT ORAL 3 PA; QL omeprazole oral 1 QL
CAPSULE,BIPHAS capsule,delayed
E DELAYED release(dr/ec) 10 mg
RELEAS 30 MG
omeprazole oral 1
DEXILANT ORAL 3 PA capsule,delayed
CAPSULE,BIPHAS release(dr/ec) 20
E DELAYED mg, 40 mg
RELEAS 60 MG
pantoprazole oral 1
esomeprazole 1 QL granules dr for susp
magnesium oral in packet
capsule,delayed
pantoprazole oral 1 QL
release(dr/ec) 20 mg
tablet,delayed
esomeprazole 1 release (dr/ec) 20
magnesium oral mg
capsule,delayed
pantoprazole oral 1
release(dr/ec) 40 mg
tablet,delayed
esomeprazole 1 PA; QL release (dr/ec) 40
magnesium oral mg
granules dr for susp
rabeprazole 1
in packet 10 mg, 20
mg sucralfate 1
esomeprazole 1 PA IMMUNOLOGY, VACCINES &
magnesium oral BIOTECHNOLOGY
granules dr for susp
in packet 40 mg BIOTECHNOLOGY DRUGS
famotidine 1 FULPHILA 4 PA
lansoprazole oral 1 QL LEUKINE 4 PA
capsule,delayed MOZOBIL 4 PA
release(dr/ec) 15 mg
NIVESTYM 4 PA
You can find information on what the symbols and abbreviations on this table mean by going to the
beginning of this table.
31Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
PROCRIT 4 PA ribavirin 4 PA
RETACRIT 4 PA VUMERITY 4 PA
ZARXIO 4 PA INTERLEUKINS
ZIEXTENZO 4 PA ACTIMMUNE 4 PA
GROWTH HORMONES ALFERON N 2 PA
EGRIFTA SV 4 PA ILARIS (PF) 4 PA; LA
OMNITROPE 4 PA imiquimod 1
INTERFERONS INTRON A 4 PA
AVONEX 4 PA PROLEUKIN 4 PA
BAFIERTAM 4 VACCINES & MISCELLANEOUS
BETASERON 4 PA IMMUNOLOGICALS
dimethyl fumarate 4 PA ADACEL(TDAP 6 ACA
ADOLESN/ADULT
GILENYA 4 PA )(PF)
glatiramer 4 PA AFLURIA QD 6 ACA
glatopa 4 PA 2021-22(3YR
UP)(PF)
KESIMPTA PEN 4 PA
AFLURIA QD 6 ACA
MAYZENT 4 PA 2021-22(6-
MAYZENT 4 PA 35MO)(PF)
STARTER PACK AFLURIA QUAD 6 ACA
OCREVUS 4 PA 2021-2022(6MO
UP)
PEGASYS 4 PA
BEXSERO 6 ACA
PLEGRIDY 4 PA
BIOTHRAX 2
POMALYST 4 PA; LA
BOOSTRIX TDAP 6 ACA
PONVORY 4 PA
BOTOX 4 PA
PONVORY 14- 4 PA
DAY STARTER DAPTACEL (DTAP 6 ACA
PACK PEDIATRIC) (PF)
REBIF (WITH 4 PA DENGVAXIA (PF) 2
ALBUMIN) ENGERIX-B (PF) 6 ACA
REBIF REBIDOSE 4 PA ENGERIX-B 6 ACA
REBIF TITRATION 4 PA PEDIATRIC (PF)
PACK FLUAD QUAD 6 ACA
REVLIMID 4 PA; LA 2021-22(65Y
UP)(PF)
You can find information on what the symbols and abbreviations on this table mean by going to the
beginning of this table.
32Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
FLUARIX QUAD 6 ACA IXIARO (PF) 2
2021-2022 (PF) JANSSEN COVID- 6 ACA
FLUBLOK QUAD 6 ACA 19 VACCINE
2021-2022 (PF) (EUA)
FLUCELVAX 6 ACA MENACTRA (PF) 6 ACA
QUAD 2021-2022 M-M-R II (PF) 6 ACA
FLUCELVAX 6 ACA MODERNA 6 ACA
QUAD 2021-2022 COVID-19
(PF) VACCINE (EUA)
FLULAVAL QUAD 6 ACA ODACTRA 2
2021-2022 (PF)
PEDVAX HIB (PF) 6 ACA
FLUMIST QUAD 6 ACA
2021-2022 PFIZER COVID-19 6 ACA
TRIS VACCN(PF)
FLUZONE 6 ACA
HIGHDOSE QUAD PFIZER COVID-19 6 ACA
21-22 PF VACCINE (EUA)
FLUZONE QUAD 6 ACA PNEUMOVAX-23 6 ACA
2021-2022 PREVNAR 13 (PF) 6 ACA
FLUZONE QUAD 6 ACA PREVNAR 20 (PF) 2
2021-2022 (PF)
PROQUAD (PF) 6 ACA
GAMASTAN 4 PA
PROVENGE 4 PA
GAMASTAN S/D 4 PA
QUADRACEL (PF) 6 ACA
GAMMAGARD 4 PA
LIQUID RABAVERT (PF) 2
GAMMAGARD S- 4 PA RAGWITEK 2
D (IGA < 1 RECOMBIVAX HB 6 ACA
MCG/ML) (PF)
GAMUNEX-C 4 PA ROTATEQ 6 ACA
GARDASIL 9 (PF) 6 ACA VACCINE
GRASTEK 2 SHINGRIX (PF) 6 ACA
HAVRIX (PF) 6 ACA STAMARIL (PF) 2
HIBERIX (PF) 6 ACA TDVAX 6 ACA
IMOVAX RABIES 2 TETANUS,DIPHTH 6 ACA
VACCINE (PF) ERIA TOX
PED(PF)
INFANRIX (DTAP) 6 ACA
(PF) TICOVAC 2
IPOL 6 ACA TRUMENBA 6 ACA
You can find information on what the symbols and abbreviations on this table mean by going to the
beginning of this table.
33Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
TWINRIX (PF) 6 ACA ENBREL 4 PA
TYPHIM VI 2 ENBREL MINI 4 PA
VARIVAX (PF) 6 ACA ENBREL 4 PA
VARIZIG 2 SURECLICK
VAXNEUVANCE 2 HUMIRA 4 PA
XEMBIFY 4 PA HUMIRA PEN 4 PA
YF-VAX (PF) 2 HUMIRA PEN 4 PA
CROHNS-UC-HS
MUSCULOSKELETAL & START
RHEUMATOLOGY HUMIRA PEN 4 PA
PSOR-UVEITS-
GOUT THERAPY
ADOL HS
allopurinol 1
HUMIRA(CF) 4 PA
colchicine 1
HUMIRA(CF) PEDI 4 PA
febuxostat 1 CROHNS
KRYSTEXXA 4 PA STARTER
MITIGARE 2 HUMIRA(CF) PEN 4 PA
probenecid 1 HUMIRA(CF) PEN 4 PA
CROHNS-UC-HS
probenecid- 1
colchicine HUMIRA(CF) PEN 4 PA
PEDIATRIC UC
OSTEOPOROSIS THERAPY
HUMIRA(CF) PEN 4 PA
alendronate 1 PSOR-UV-ADOL
FOSAMAX PLUS 3 HS
D leflunomide 1
ibandronate 4 PA OTEZLA 4 PA
intravenous
OTEZLA 4 PA
ibandronate oral 1 STARTER
raloxifene 1 penicillamine 1
risedronate 1 RIDAURA 2
TYMLOS 4 PA RINVOQ 4 PA
OTHER RHEUMATOLOGICALS SAVELLA 2
ACTEMRA 4 PA XELJANZ 4 PA
ACTEMRA 4 PA XELJANZ XR 4 PA
ACTPEN
OBSTETRICS &
BENLYSTA 4 PA
GYNECOLOGY
You can find information on what the symbols and abbreviations on this table mean by going to the
beginning of this table.
34Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
DIAPHRAGMS AND OTHER NON- jencycla 6 ACA
ORAL CONTRACEPTIVES jinteli 1
CAYA 6 ACA lyleq 6 ACA
CONTOURED
lyllana 1
FC2 FEMALE 6 ACA; OTC
CONDOM lyza 6 ACA
FEMCAP 6 ACA medroxyprogesteron 6 ACA
e intramuscular
MIRENA 6 ACA
medroxyprogesteron 1
PARAGARD T 6 ACA e oral
380A
mimvey 1
ESTROGENS & PROGESTINS
nora-be 6 ACA
amabelz 1
norethindrone 6 ACA
camila 6 ACA (contraceptive)
covaryx 1 norethindrone 1
covaryx h.s. 1 acetate
deblitane 6 ACA norethindrone ac-eth 1
estradiol
dotti 1
norlyda 6 ACA
DUAVEE 3
progesterone 4 PA
eemt 1
progesterone 1
eemt hs 1 micronized
errin 6 ACA sharobel 6 ACA
estradiol 1 tulana 6 ACA
estradiol valerate 1 yuvafem 1
estradiol- 1 MISCELLANEOUS OB/GYN
norethindrone acet
clindamycin 1
estrogens- 1 phosphate
methyltestosterone
eluryng 6 ACA
fyavolv 1
etonogestrel-ethinyl 6 ACA
heather 6 ACA estradiol
hydroxyprogest(pf)(p 4 PA fem ph 1
reg presv)
GYNAZOLE-1 3
hydroxyprogesterone 4 PA
cap(ppres) gynol ii 6 ACA; OTC
incassia 6 ACA isoxsuprine 1
You can find information on what the symbols and abbreviations on this table mean by going to the
beginning of this table.
35Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
metronidazole 1 aubra 6 ACA
miconazole-3 1 aubra eq 6 ACA
MYFEMBREE 2 aurovela 1.5/30 (21) 6 ACA
NEXPLANON 6 ACA aurovela 1/20 (21) 6 ACA
ORIAHNN 2 aurovela 24 fe 6 ACA
OSPHENA 3 PA aurovela fe 1.5/30 6 ACA
terconazole 1 (28)
TODAY 6 ACA; OTC aurovela fe 1-20 6 ACA
CONTRACEPTIVE (28)
SPONGE aviane 6 ACA
tranexamic acid 1 ayuna 6 ACA
TRIMO-SAN 2 azurette (28) 6 ACA
JELLY balziva (28) 6 ACA
vandazole 1 blisovi 24 fe 6 ACA
VCF 2 OTC blisovi fe 1.5/30 (28) 6 ACA
CONTRACEPTIVE
FILM blisovi fe 1/20 (28) 6 ACA
VCF 2 OTC briellyn 6 ACA
CONTRACEPTIVE camrese 6 ACA
GEL
camrese lo 6 ACA
xulane 6 ACA
caziant (28) 6 ACA
zafemy 6 ACA
charlotte 24 fe 6 ACA
ORAL CONTRACEPTIVES &
chateal (28) 6 ACA
RELATED AGENTS
chateal eq (28) 6 ACA
afirmelle 6 ACA
cryselle (28) 6 ACA
after pill 6 ACA; OTC
cyclafem 1/35 (28) 6 ACA
altavera (28) 6 ACA
cyclafem 7/7/7 (28) 6 ACA
alyacen 1/35 (28) 6 ACA
cyred 6 ACA
alyacen 7/7/7 (28) 6 ACA
cyred eq 6 ACA
amethia 6 ACA
dasetta 1/35 (28) 6 ACA
amethyst (28) 6 ACA
dasetta 7/7/7 (28) 6 ACA
apri 6 ACA
daysee 6 ACA
aranelle (28) 6 ACA
ashlyna 6 ACA
You can find information on what the symbols and abbreviations on this table mean by going to the
beginning of this table.
36Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
desog- 6 ACA junel fe 1.5/30 (28) 6 ACA
e.estradiol/e.estradio junel fe 1/20 (28) 6 ACA
l
junel fe 24 6 ACA
desogestrel-ethinyl 6 ACA
estradiol kaitlib fe 6 ACA
dolishale 6 ACA kalliga 6 ACA
drospirenone- 6 ACA kariva (28) 6 ACA
e.estradiol-lm.fa kelnor 1/35 (28) 6 ACA
drospirenone-ethinyl 6 ACA kelnor 1-50 (28) 6 ACA
estradiol
kurvelo (28) 6 ACA
econtra ez 6 ACA; OTC
l norgest/e.estradiol- 6 ACA
econtra one-step 6 ACA; OTC e.estrad
elinest 6 ACA larin 1.5/30 (21) 6 ACA
ELLA 6 ACA larin 1/20 (21) 6 ACA
enpresse 6 ACA larin 24 fe 6 ACA
enskyce 6 ACA larin fe 1.5/30 (28) 6 ACA
estarylla 6 ACA larin fe 1/20 (28) 6 ACA
ethynodiol diac-eth 6 ACA larissia 6 ACA
estradiol
layolis fe 6 ACA
falmina (28) 6 ACA
leena 28 6 ACA
femynor 6 ACA
lessina 6 ACA
gemmily 6 ACA
levonest (28) 6 ACA
hailey 6 ACA
levonorgestrel 6 ACA; OTC
hailey 24 fe 6 ACA
levonorgestrel- 6 ACA
hailey fe 1.5/30 (28) 6 ACA ethinyl estrad
hailey fe 1/20 (28) 6 ACA levonorg-eth estrad 6 ACA
iclevia 6 ACA triphasic
isibloom 6 ACA levora-28 6 ACA
jaimiess 6 ACA lillow (28) 6 ACA
jasmiel (28) 6 ACA lojaimiess 6 ACA
jolessa 6 ACA loryna (28) 6 ACA
juleber 6 ACA low-ogestrel (28) 6 ACA
junel 1.5/30 (21) 6 ACA lo-zumandimine (28) 6 ACA
junel 1/20 (21) 6 ACA lutera (28) 6 ACA
You can find information on what the symbols and abbreviations on this table mean by going to the
beginning of this table.
37Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
marlissa (28) 6 ACA opcicon one-step 6 ACA; OTC
merzee 6 ACA option-2 6 ACA; OTC
mibelas 24 fe 6 ACA orsythia 6 ACA
microgestin 1.5/30 6 ACA philith 6 ACA
(21) pimtrea (28) 6 ACA
microgestin 1/20 6 ACA pirmella 6 ACA
(21)
portia 28 6 ACA
microgestin fe 1.5/30 6 ACA
(28) previfem 6 ACA
microgestin fe 1/20 6 ACA reclipsen (28) 6 ACA
(28) rivelsa 6 ACA
mili 6 ACA setlakin 6 ACA
mono-linyah 6 ACA simliya (28) 6 ACA
my choice 6 ACA; OTC simpesse 6 ACA
my way 6 ACA; OTC sprintec (28) 6 ACA
necon 0.5/35 (28) 6 ACA sronyx 6 ACA
new day 6 ACA; OTC syeda 6 ACA
nikki (28) 6 ACA tarina 24 fe 6 ACA
noreth-ethinyl 6 ACA tarina fe 1/20 (28) 6 ACA
estradiol-iron
taysofy 6 ACA
norethindrone ac-eth 6 ACA
estradiol tilia fe 6 ACA
norethindrone- 6 ACA tri femynor 6 ACA
e.estradiol-iron tri-estarylla 6 ACA
norgestimate-ethinyl 6 ACA tri-legest fe 6 ACA
estradiol
tri-linyah 6 ACA
nortrel 0.5/35 (28) 6 ACA
tri-lo-estarylla 6 ACA
nortrel 1/35 (21) 6 ACA
tri-lo-marzia 6 ACA
nortrel 1/35 (28) 6 ACA
tri-lo-mili 6 ACA
nortrel 7/7/7 (28) 6 ACA
tri-lo-sprintec 6 ACA
nylia 1/35 (28) 6 ACA
tri-mili 6 ACA
nylia 7/7/7 (28) 6 ACA
tri-nymyo 6 ACA
nymyo 6 ACA
tri-previfem (28) 6 ACA
ocella 6 ACA
tri-sprintec (28) 6 ACA
You can find information on what the symbols and abbreviations on this table mean by going to the
beginning of this table.
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