2022 Premium Standard Formulary - Effective January 1, 2022 - Cornell HR
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2022 Premium Standard Formulary
Effective January 1, 2022
For the most current list of covered medications or if you have questions:
Call the number on your member ID card.
Visit your plan’s website on your member ID card or log on to the OptumRx app to:
• Find a participating retail pharmacy by ZIP code.
• Look up possible lower-cost medication alternatives.
• Compare medication pricing and options.Understanding your formulary
About this formulary
What is a formulary? Where differences exist between this list and your
A formulary is a list of prescribed medications or other benefit plan, the benefit plan documents rule. This is
pharmacy care products, services or supplies chosen for not a complete list of your covered medications. Please
their safety, cost, and effectiveness. Medications are review your benefit plan documents for full details. Not
listed by categories or classes and are placed into cost all formulary alternatives listed in this document may
levels known as tiers. It includes both brand and generic be appropriate for your specific condition. Please talk to
prescription medications. your doctor.
To create the list, OptumRx® is guided by the Pharmacy When does the formulary change?
and Therapeutics Committee. This group of doctors and
pharmacists reviews which medications will be covered, how • Medications may move to a lower tier at any time.
well the drugs work, and overall value. They also make sure • Medications may move to a higher tier when a generic
there are safe and covered options. equal becomes available.
• Medications may move to a higher tier or be excluded from
How do I use my formulary? coverage on January 1 or July 1 of each year.
You and your doctor can use the formulary to help you If a medication changes tiers, you may have to pay a different
choose the most cost-effective prescription medications. amount for that medication.
This guide tells you if a medication is generic or brand, and
if special rules apply. If your medication is not listed here, Why are some medications excluded
please visit your plan’s website or call the number on your from coverage?
member ID card. A medication may be excluded from coverage under your
pharmacy benefit when it works the same as or is similar to
What are tiers? another prescription or over-the-counter (OTC) medication.
Tiers are the different cost levels you pay for a medication.
Each tier is assigned a cost, set by your employer or What if I don’t agree with a decision about an
plan sponsor. excluded medication?
You, your authorized representative, or your doctor can
ask for a coverage request by calling the number on your
member ID card.
Medication tips
What is the difference between brand-name and generic medications?
Generic medications contain the same active ingredients (offer the same effect) as brand-name medications, but they
often cost less. In some situations, brand-name medications could be lower in cost.
What if my doctor writes a brand-name prescription?
If your doctor gives you a prescription for a brand-name medication, ask if a Over-the-counter
lower-cost option could be right for you. medications (OTC)
What if I am taking a specialty medication? Talk to your doctor about OTC
options. Even though OTC
Specialty medications are used to treat complex conditions and are generally higher
medications may not be covered
in cost. Please note, not all specialty medications are listed in the formulary. Our
by your pharmacy benefit,
specialty pharmacy can provide most of your specialty medications along with
they may cost less than a
helpful programs and services. Call 1-855-427-4682 and ask how you can have
prescription medication.
your prescriptions delivered right to your home or doctor’s office.
2Reading 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 lower your out-of-pocket cost. Your plan may have multiple or no tiers.
Please note: If you have a high-deductible plan, the tier cost levels will apply once you meet your deductible.
Drug tier Includes Helpful tips
Tier 1 $ Lower-cost Use tier 1 drugs for the lowest out-of-pocket costs.
generics and
some brand name
Tier 2 Mid-range cost
$$ Use tier 2 drugs instead of tier 3 to help reduce your
preferred brand out-of-pocket costs.
name
Tier 3 Higher-cost
$$$ Many tier 3 drugs have lower-cost options in tier 1 or 2.
brand name and Ask your doctor if they could work for you.
some generics
Tier E Excluded May not be covered or need prior authorization. Lower-cost options are
available and covered.
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.
QL Quantity limit – Medication may be limited to a certain quantity.
SP Specialty medication – Medication is designated as specialty.
ST Step therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered
3P Tier 3 preferred
++ Benefit design options – Coverage is determined by your prescription medication benefit plan.
3Premium Standard Formulary
Table of Contents
Analgesics - Drugs for Pain.................................................................................................................................6
Analgesics - Drugs for Pain and Inflammation.................................................................................................... 7
Anesthetics..........................................................................................................................................................7
Anti-Addiction / Substance Abuse Treatment Agents......................................................................................... 8
Antibacterials.......................................................................................................................................................8
Anticoagulants.....................................................................................................................................................9
Anticonvulsants - Drugs for Seizures.................................................................................................................. 9
Antidementia Agents - Drugs for Alzheimer's Disease and Dementia.............................................................. 10
Antidepressants.................................................................................................................................................10
Antiemetics - Drugs for Nausea and Vomiting.................................................................................................. 10
Antifungals.........................................................................................................................................................11
Antigout Agents................................................................................................................................................. 11
Antimigraine Agents.......................................................................................................................................... 11
Antineoplastics - Drugs for Cancer....................................................................................................................12
Antiparasitics..................................................................................................................................................... 12
Antiparkinson Agents........................................................................................................................................ 13
Antiplatelets.......................................................................................................................................................13
Antipsychotics - Drugs for Mood Disorders....................................................................................................... 13
Antivirals............................................................................................................................................................13
Anxiolytics - Drugs for Anxiety...........................................................................................................................14
Bipolar Agents - Drugs for Mood Disorders.......................................................................................................14
Blood Products and Modifiers - Drugs for Blood Disorders...............................................................................14
Cardiovascular Agents - Drugs for Heart and Circulation Conditions............................................................... 15
Central Nervous System Agents - Drugs for Attention Deficit Disorder............................................................ 17
Central Nervous System Agents - Drugs for Multiple Sclerosis........................................................................ 18
Central Nervous System Agents - Miscellaneous............................................................................................. 18
Dental and Oral Agents - Drugs for Mouth and Throat Conditions....................................................................18
Dermatological Agents - Drugs for Skin Conditions.......................................................................................... 18
Diabetes - Antidiabetic Agents.......................................................................................................................... 21
Diabetes - Glucose Monitoring.......................................................................................................................... 21
Diabetes - Glycemic Agents.............................................................................................................................. 22
Diabetes - Insulins.............................................................................................................................................22
Electrolytes / Minerals / Metals / Vitamins.........................................................................................................24
Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer................................................................................24
Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions.................................................25
Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment............................................. 25
Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions.......................................................25
Genitourinary Agents - Drugs for Prostate Conditions...................................................................................... 26
Hormonal Agents - Adrenal............................................................................................................................... 26
Hormonal Agents - Men's Health.......................................................................................................................26
Hormonal Agents - Osteoporosis...................................................................................................................... 27
Hormonal Agents - Pituitary.............................................................................................................................. 27
Hormonal Agents - Sex Hormones and Birth Control........................................................................................28
Hormonal Agents - Thyroid............................................................................................................................... 29
Immunological Agents - Drugs for Immune System Stimulation or Suppression.............................................. 29
Inflammatory Bowel Disease Agents.................................................................................................................30
Metabolic Bone Disease Agents - Drugs for Osteoporosis............................................................................... 31
Metabolic Bone Disease Agents - Other........................................................................................................... 31
Miscellaneous Therapeutic Agents................................................................................................................... 31
Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation...........................................................31
4Ophthalmic Agents - Drugs for Glaucoma.........................................................................................................32
Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions......................................................................... 32
Otic Agents - Drugs for Ear Conditions............................................................................................................. 33
Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold........................................................33
Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions................................... 33
Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis.................................................................... 35
Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension.................................................... 35
Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm...................................................................... 35
Sleep Disorder Agents...................................................................................................................................... 36
Stimulation or Suppression............................................................................................................................... 36
5Drug Name Drug Tier Notes Drug Name Drug Tier Notes
Analgesics - Drugs DURAGESIC-50
for Pain TRANSDERMAL
E
acetaminophen- PATCH 72 HOUR 50
1 QL MCG/HR
codeine #2
acetaminophen- DURAGESIC-75
1 QL TRANSDERMAL
codeine #3 E
PATCH 72 HOUR 75
acetaminophen- MCG/HR
1 QL
codeine #4
fentanyl 1 PA; QL
acetaminophen-
codeine oral tablet 300- 1 QL FENTANYL CITRATE
E M
15 mg, 300-60 mg BUCCAL TABLET
APADAZ E FENTORA E
apap-caff- FIORICET E
dihydrocodeine oral 1 QL FIORICET/CODEINE E
capsule hydrocodone-
BELBUCA 2 PA; QL acetaminophen oral 1 QL
BENZHYDROCODON tablet
E
E-ACETAMINOPHEN hydromorphone hcl oral
1 QL
butalbital-apap-caffeine 1 tablet
BUTRANS HYSINGLA ER 2 PA; QL
TRANSDERMAL LAZANDA E
PATCH WEEKLY 10 MORPHINE SULFATE
E 3
MCG/HR, 15 MCG/HR, (BULK)
20 MCG/HR, 5
MCG/HR morphine sulfate
(concentrate) oral
CONZIP E 1 QL
solution 100 mg/5ml,
DILAUDID ORAL E 20 mg/ml
DURAGESIC-100 morphine sulfate er oral
1 PA; QL
TRANSDERMAL tablet extended release
E
PATCH 72 HOUR 100 morphine sulfate oral
MCG/HR 1 QL
solution
DURAGESIC-12 MS CONTIN E
TRANSDERMAL
E NUCYNTA E
PATCH 72 HOUR 12
MCG/HR NUCYNTA ER E
DURAGESIC-25 OXYCODONE HCL ER E M
TRANSDERMAL oxycodone hcl oral
E 1 QL
PATCH 72 HOUR 25 tablet
MCG/HR
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
6Drug Name Drug Tier Notes Drug Name Drug Tier Notes
OXYCODONE- etodolac oral tablet 1
ACETAMINOPHEN FLECTOR E
ORAL TABLET 10-300 3 QL
MG, 2.5-300 MG, 5-300 ibuprofen oral tablet 1
MG INDOMETHACIN
oxycodone- ORAL CAPSULE 20 3 ST
acetaminophen oral MG
tablet 10-325 mg, 2.5- 1 QL indomethacin oral
1
325 mg, 5-325 mg, 7.5- capsule 25 mg, 50 mg
325 mg KETOROLAC
OXYCONTIN 2 PA; QL TROMETHAMINE E M
PERCOCET E NASAL
QDOLO E ketorolac tromethamine
1 QL
oral
ROXICODONE E
LICART E
SUBSYS E
meloxicam oral tablet 1
TRAMADOL HCL ER
ORAL CAPSULE MOBIC E
E M
EXTENDED RELEASE nabumetone oral 1
24 HOUR NALFON E
tramadol hcl oral tablet NAPRELAN ORAL
1 QL
50 mg TABLET EXTENDED
3
TREZIX 3 QL RELEASE 24 HOUR
ULTRACET E 375 MG, 500 MG
ULTRAM E NAPRELAN ORAL
TABLET EXTENDED
XTAMPZA ER 2 PA; QL 3 PA
RELEASE 24 HOUR
Analgesics - Drugs 750 MG
for Pain and naproxen oral tablet 1
Inflammation
naproxen sodium oral
ARTHROTEC E 1
tablet
CAMBIA E PENNSAID E
CELEBREX E QMIIZ ODT E
celecoxib oral 1 QL RELAFEN E
DICLOFENAC CAP RELAFEN DS E
E M
35MG
SPRIX E
DICLOFENAC PATCH
E M VIMOVO E
1.3%
diclofenac sodium ZIPSOR E
1 QL
external gel 1 % ZORVOLEX E
diclofenac sodium oral 1 Anesthetics
DUEXIS E lidocaine external patch 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
lidocaine-prilocaine cephalexin oral
1
external cream suspension 1
LIDODERM E reconstituted
ZTLIDO E ciprofloxacin hcl oral
tablet 250 mg, 500 mg, 1
Anti-Addiction / 750 mg
Substance Abuse
Treatment Agents clarithromycin oral
1
tablet
buprenorphine hcl
1 QL CLEOCIN VAGINAL E
sublingual
buprenorphine hcl- clindamycin hcl oral 1
1 QL
naloxone hcl CLINDESSE 3
CHANTIX STARTING DIFICID 3
3 ++; QL
MONTH PAK DORYX E
LIFEMS NALOXONE E DORYX MPC E
naltrexone hcl oral 1 doxycycline hyclate oral
1
NARCAN 2 capsule
SUBOXONE E doxycycline hyclate oral
1
ZUBSOLV 2 QL tablet
Antibacterials DOXYCYCLINE
HYCLATE ORAL
ACTICLATE E E
TABLET DELAYED
amoxicillin oral capsule 1 RELEASE 80 MG
amoxicillin oral doxycycline
suspension 1 monohydrate oral 1
reconstituted capsule
amoxicillin oral tablet 1 doxycycline
1
amoxicillin-potassium monohydrate oral tablet
clavulanate oral levofloxacin oral tablet 1
1
suspension metronidazole oral
reconstituted 1
tablet
amoxicillin-potassium metronidazole vaginal 1
1
clavulanate oral tablet
minocycline hcl oral
azithromycin oral 1
capsule
suspension 1
reconstituted MINOLIRA E
azithromycin oral tablet 1 mupirocin external 1
cefdinir 1 nitrofurantoin
1
macrocrystal
cefuroxime axetil 1
nitrofurantoin
cephalexin oral capsule 1 monohydrate 1
macrocrystals
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
NUVESSA E DILANTIN ORAL
E
NUZYRA ORAL 3 CAPSULE 100 MG
penicillin v potassium DILANTIN ORAL
1 E
oral tablet SUSPENSION
SEYSARA 3 ST divalproex sodium er 1
SILVADENE E divalproex sodium oral
1
tablet delayed release
SOLODYN E
EPIDIOLEX 3 PA; SP
SOLOSEC 3
FYCOMPA 3
sulfamethoxazole-
1 gabapentin oral
trimethoprim oral tablet 1
capsule
TARGADOX E
gabapentin oral tablet 1
XENLETA 3
KEPPRA ORAL E
XEPI 3
KEPPRA XR E
XIMINO 3
LAMICTAL E
Anticoagulants
LAMICTAL ODT E
ELIQUIS 2 QL
LAMICTAL STARTER E
ELIQUIS DVT/PE
2 QL LAMICTAL XR ORAL
STARTER PACK
TABLET EXTENDED E
enoxaparin sodium 1 SP; QL RELEASE 24 HOUR
PRADAXA 2 QL lamotrigine er 1
warfarin sodium oral 1 lamotrigine oral tablet 1
XARELTO 2 QL levetiracetam oral
1
XARELTO STARTER tablet
2 QL
PACK NAYZILAM 3 QL
Anticonvulsants - NEURONTIN E
Drugs for Seizures
ONFI E
APTIOM 3
oxcarbazepine oral
BRIVIACT 1
3 tablet
INTRAVENOUS
OXTELLAR XR E
BRIVIACT ORAL 3 ST
QUDEXY XR E
carbamazepine oral
1 SABRIL E SP
tablet
CARBATROL E SYMPAZAN 3 PA
DEPAKOTE E TEGRETOL E
DEPAKOTE ER E TEGRETOL-XR E
DEPAKOTE TOPAMAX E
E
SPRINKLES TOPAMAX SPRINKLE E
DILANTIN INFATABS E topiramate 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.
9Drug Name Drug Tier Notes Drug Name Drug Tier Notes
TRILEPTAL E duloxetine hcl oral 1 QL
TROKENDI XR 3 ST EFFEXOR XR E
VALTOCO 3 QL escitalopram oxalate
1
VIMPAT 3 oral tablet
XCOPRI 3 ST fluoxetine hcl oral
1
capsule
ZONEGRAN E
fluoxetine hcl oral tablet 1
zonisamide oral 1
fluvoxamine maleate 1
Antidementia Agents
- Drugs for FORFIVO XL E
Alzheimer's Disease LEXAPRO E
and Dementia mirtazapine oral tablet 1
donepezil hcl oral tablet nortriptyline hcl oral
1 1
10 mg, 23 mg capsule
memantine hcl oral paroxetine hcl 1
1
tablet 10 mg, 5 mg
PAXIL CR E
NAMZARIC 2 QL
PAXIL ORAL TABLET E
Antidepressants
PRISTIQ E
amitriptyline hcl oral 1
PROZAC E
BRISDELLE E
sertraline hcl oral tablet 1
bupropion hcl er (sr) 1 QL
trazodone hcl oral 1
bupropion hcl er (xl)
oral tablet extended TRINTELLIX 3 ST; QL
1 QL
release 24 hour 150 venlafaxine hcl 1
mg, 300 mg venlafaxine hcl er 1
BUPROPION HCL ER VIIBRYD 3 QL
(XL) ORAL TABLET
E M VIIBRYD STARTER
EXTENDED RELEASE 3 QL
24 HOUR 450 MG PACK
bupropion hcl oral 1 WELLBUTRIN SR E
CELEXA E WELLBUTRIN XL E
citalopram ZOLOFT E
hydrobromide oral 1 Antiemetics - Drugs
tablet for Nausea and
CYMBALTA E Vomiting
desvenlafaxine GIMOTI E
1 QL
succinate er meclizine hcl oral tablet 1 ++
doxepin hcl oral metoclopramide hcl
1
capsule 10 mg, 100 oral tablet 10 mg
1
mg, 25 mg, 50 mg, 75 ondansetron hcl oral
mg 1
tablet 4 mg, 8 mg
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
ondansetron odt 1 MITIGARE E
prochlorperazine Antimigraine Agents
1
maleate oral AIMOVIG
SANCUSO E SUBCUTANEOUS
scopolamine 1 SOLUTION AUTO- 2 PA; QL
INJECTOR 140
VARUBI (180 MG MG/ML, 70 MG/ML
3 QL
DOSE)
AJOVY E
Antifungals
eletriptan hydrobromide 1 QL
ciclopirox external
1 ++ EMGALITY 2 PA; QL
solution
clotrimazole external EMGALITY (300 MG
1 2 PA; QL
cream DOSE)
clotrimazole- IMITREX E
betamethasone 1 IMITREX STATDOSE
E
external cream REFILL
CRESEMBA ORAL 3 PA IMITREX STATDOSE
E
fluconazole oral tablet 1 SYSTEM
GYNAZOLE-1 3 MAXALT E
JUBLIA E MAXALT-MLT E
KERYDIN 3 PA; ++ NURTEC 2 PA; QL
ketoconazole external ONZETRA XSAIL E
1
cream RELPAX E
ketoconazole external REYVOW E
1
shampoo rizatriptan benzoate 1 QL
nystatin external cream 1 sumatriptan succinate
1 QL
nystatin mouth/throat 1 oral
terbinafine hcl oral 1 QL TOSYMRA E
terconazole vaginal TREXIMET E
1
cream UBRELVY 2 PA; QL
TOLSURA E ZEMBRACE
Antigout Agents E
SYMTOUCH
allopurinol oral 1 ZOMIG ORAL E
COLCHICINE ORAL ZOMIG ZMT ORAL
E M
CAPSULE TABLET
E
colchicine oral tablet 1 DISPERSIBLE 2.5 MG,
5 MG
COLCRYS E
febuxostat 1 ST
GLOPERBA E
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
Antineoplastics - PHESGO 2 PA; SP
Drugs for Cancer RETEVMO 3 PA; SP
AFINITOR ORAL REVLIMID 2 PA; SP
TABLET 2.5 MG, 5 E SP
MG, 7.5 MG RIABNI E SP
ALECENSA 2 PA; SP ROZLYTREK 3 PA; SP
ALUNBRIG 2 PA; SP; QL RUBRACA 2 PA; SP
anastrozole oral 1 RUXIENCE 2 PA; SP
ARIMIDEX E SPRYCEL 2 PA; SP
BELRAPZO E SP TABRECTA 3 PA; SP
CABOMETYX 2 PA; SP TAGRISSO ORAL
3 PA; SP; QL
TABLET 40 MG
CALQUENCE 3 PA; SP
TAGRISSO ORAL
capecitabine 1 PA; SP 3 PA; SP
TABLET 80 MG
DARZALEX FASPRO E SP tamoxifen citrate oral 1
ERIVEDGE 3 PA; SP TARGRETIN
3 PA; SP
ERLEADA E SP EXTERNAL
GAVRETO E SP TARGRETIN ORAL E SP
GLEEVEC E SP TAZVERIK E SP
HERZUMA E SP TEPMETKO E SP
IBRANCE ORAL TRAZIMERA 2 PA; SP
3 PA; SP
TABLET TREANDA E SP
IDHIFA 3 PA; SP; QL TRUXIMA E SP
INQOVI E SP UKONIQ 3 PA; SP
KANJINTI 2 PA; SP VELCADE 2 PA; SP
KEYTRUDA 3 PA; SP VITRAKVI 3 PA; SP
KISQALI FEMARA 3 PA; SP XTANDI 3 PA; SP
KISQALI ORAL YONSA E SP
TABLET THERAPY 3 PA; SP
PACK 200 MG ZEJULA 2 PA; SP
letrozole oral 1 ZIRABEV 2 PA; SP
LYNPARZA 2 PA; SP ZYTIGA E SP
MVASI 2 PA; SP Antiparasitics
NUBEQA 3 PA; SP ARAKODA 3
ODOMZO 3 PA; SP EMVERM 2
OGIVRI E SP hydroxychloroquine
sulfate oral tablet 200 1
ONTRUZANT E SP mg
ORGOVYX 3 PA; SP NATROBA E
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
PLAQUENIL E LATUDA 3 QL
Antiparkinson Agents olanzapine oral tablet 1 QL
benztropine mesylate PERSERIS 3
1
oral quetiapine fumarate 1 QL
carbidopa-levodopa quetiapine fumarate er 1 QL
1
oral tablet
REXULTI 3 QL
GOCOVRI E
RISPERDAL E
INBRIJA 3 PA; SP
risperidone oral tablet 1 QL
KYNMOBI 3 PA; SP; QL
SAPHRIS E
KYNMOBI TITRATION
3 PA; SP; QL SECUADO E
KIT
NEUPRO 3 ST SEROQUEL E
NOURIANZ 3 PA SEROQUEL XR E
ONGENTYS 3 ST VRAYLAR 3 ST; QL
OSMOLEX ER E ziprasidone hcl 1 QL
pramipexole ZYPREXA E
1
dihydrochloride Antivirals
ropinirole hcl 1 acyclovir oral tablet 1
RYTARY 3 ST ATRIPLA E
Antiplatelets BARACLUDE ORAL
E SP
ASPIRIN- TABLET
E M
OMEPRAZOLE BIKTARVY 3
BRILINTA 2 CABENUVA E
clopidogrel bisulfate CIMDUO 2
1
oral DESCOVY E
PLAVIX E DOVATO 2
prasugrel hcl 1 entecavir 1 SP; QL
YOSPRALA E EPCLUSA 2 PA; SP; QL
Antipsychotics -
GENVOYA 3
Drugs for Mood
Disorders HARVONI 2 PA; SP; QL
ABILIFY E JULUCA 2
ABILIFY MAINTENA 3 LEDIPASVIR-
E M; SP
SOFOSBUVIR
aripiprazole oral tablet 1 QL
MAVYRET 2 PA; SP; QL
ARISTADA 3
ODEFSEY 3
ARISTADA INITIO 3
PREZCOBIX 2
INVEGA SUSTENNA 3
RUKOBIA 2
INVEGA TRINZA 3
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
SOFOSBUVIR- XANAX E
E M; SP
VELPATASVIR XANAX XR E
SYMFI 2 Bipolar Agents -
SYMFI LO 2 Drugs for Mood
TAMIFLU E Disorders
TEMIXYS E lithium carbonate er 1
TIVICAY 2 lithium carbonate oral
1
capsule
TRIUMEQ 2
Blood Products and
TRUVADA E Modifiers - Drugs for
valacyclovir hcl oral 1 QL Blood Disorders
VALTREX E ADVATE 2 SP
VEMLIDY 3 SP ADYNOVATE 3 SP
VOCABRIA E AFSTYLA 3 SP
VOSEVI 2 PA; SP; QL ARANESP (ALBUMIN
2 PA; SP
XOFLUZA (40 MG FREE)
DOSE) ORAL TABLET ELOCTATE 3 SP
3 QL
THERAPY PACK 2 X EPOGEN E SP
20 MG
ESPEROCT E SP
XOFLUZA (80 MG
DOSE) ORAL TABLET FULPHILA E SP
3 QL
THERAPY PACK 2 X GRANIX E SP
40 MG JIVI 3 SP
ZOVIRAX E KOATE 2 SP
Anxiolytics - Drugs MULPLETA 2 PA; SP
for Anxiety
NEULASTA 3 PA; SP
alprazolam oral tablet 1 QL
NEULASTA ONPRO 3 PA; SP
ATIVAN ORAL E
NEUPOGEN E SP
buspirone hcl oral 1
NIVESTYM 2 PA; SP
clonazepam oral tablet 1 QL
NOVOEIGHT 2 SP
diazepam oral tablet 1
NPLATE 3 PA; SP
hydroxyzine hcl oral
1 NUWIQ 2 SP
tablet
hydroxyzine pamoate NYVEPRIA E SP
1
oral PROCRIT E SP
KLONOPIN E RECOMBINATE 2 SP
lorazepam oral tablet 1 QL RETACRIT 2 PA; SP
triazolam 1 QL SEVENFACT E SP
VALIUM E SOLIRIS 3 PA; SP
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
UDENYCA E SP CARDIZEM LA ORAL
ULTOMIRIS 3 PA; SP TABLET EXTENDED
RELEASE 24 HOUR E
WILATE 2 SP 180 MG, 240 MG, 300
XYNTHA 2 SP MG, 360 MG, 420 MG
XYNTHA SOLOFUSE 2 SP cartia xt 1
ZARXIO 2 PA; SP carvedilol 1
ZIEXTENZO 3 PA; SP CATAPRES-TTS-1 E
Cardiovascular CATAPRES-TTS-2 E
Agents - Drugs for CATAPRES-TTS-3 E
Heart and Circulation
Conditions chlorthalidone 1
ALTACE E clonidine hcl oral 1
amiodarone hcl oral 1 COLESTID E
amlodipine besylate COLESTID
1 E
oral FLAVORED
amlodipine besylate- CONJUPRI E
1
benazepril hcl CONSENSI E
amlodipine besylate- COREG E
1
valsartan COREG CR E
amlodipine-olmesartan 1 CORLANOR 3 PA; QL
ANTARA 3 PA COZAAR E
ATACAND E CRESTOR E
atenolol oral 1 digoxin oral tablet 1
atenolol-chlorthalidone 1 diltiazem hcl er coated
atorvastatin calcium beads oral capsule
1 1
oral extended release 24
AVAPRO E hour
AZOR E DIOVAN E
benazepril hcl oral 1 DIOVAN HCT E
BENICAR E doxazosin mesylate
1
oral
BENICAR HCT E
EDARBI 3 ST
BIDIL 3
EDARBYCLOR 3 ST
bisoprolol fumarate oral 1
enalapril maleate oral
bisoprolol- 1
1 tablet
hydrochlorothiazide
ENTRESTO 2 QL
bumetanide oral 1
EXFORGE E
BYSTOLIC E
EXFORGE HCT E
candesartan cilexetil 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
ezetimibe 1 losartan potassium-hctz 1
ezetimibe-simvastatin 1 LOTREL E
fenofibrate micronized lovastatin oral 1
oral capsule 134 mg, 1 LOVAZA E
200 mg, 67 mg
metoprolol succinate er 1
fenofibrate oral tablet 1
metoprolol tartrate oral 1
fenofibric acid oral
capsule delayed 1 MICARDIS E
release MICARDIS HCT E
flecainide acetate 1 MULTAQ 3
furosemide oral tablet 1 nadolol oral 1
gemfibrozil oral 1 NEXLETOL 2 PA; QL
guanfacine hcl 1 NEXLIZET 2 PA; QL
HEMANGEOL 3 NIASPAN E
hydralazine hcl oral 1 nifedipine er 1
hydrochlorothiazide nifedipine er osmotic
1 1
oral release
HYZAAR E nitroglycerin sublingual 1
INDERAL LA E NITROSTAT E
INDERAL XL E NORVASC E
INNOPRAN XL E olmesartan medoxomil
1
irbesartan 1 oral
irbesartan- olmesartan medoxomil-
1 1
hydrochlorothiazide hctz
isosorbide mononitrate olmesartan-amlodipine-
1 1
er hctz
KAPSPARGO omega-3-acid ethyl
E 1 PA
SPRINKLE esters
KATERZIA E PRALUENT E
labetalol hcl oral 1 pravastatin sodium 1
LASIX E prazosin hcl oral 1
LESCOL XL E PRINIVIL E
LIPITOR E propranolol hcl er 1
lisinopril oral 1 propranolol hcl oral
1
tablet
lisinopril-
1 QUESTRAN E
hydrochlorothiazide
LIVALO E QUESTRAN LIGHT E
losartan potassium oral 1 ramipril 1
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
RANEXA E Central Nervous
ranolazine er 1 System Agents -
Drugs for Attention
REPATHA 2 PA; QL Deficit Disorder
REPATHA ADDERALL E
PUSHTRONEX 2 PA; QL
SYSTEM ADDERALL XR E
REPATHA ADHANSIA XR E
2 PA; QL
SURECLICK amphetamine-
1 PA; QL
rosuvastatin calcium 1 dextroamphetamine
simvastatin oral 1 amphetamine-
1 PA; QL
dextroamphetamine er
sotalol hcl oral 1
atomoxetine hcl 1 QL
spironolactone oral 1
CONCERTA E
TEKTURNA 2
dexmethylphenidate hcl
TEKTURNA HCT 2 ST 1 PA; QL
er
telmisartan 1 dexmethylphenidate hcl
1 PA; QL
telmisartan-hctz 1 oral tablet 10 mg, 5 mg
TENORMIN E EVEKEO E
TIKOSYN E FOCALIN E
TOPROL XL E FOCALIN XR E
torsemide 1 guanfacine hcl er 1
triamterene-hctz 1 INTUNIV E
TRIBENZOR E JORNAY PM 3 PA; ST; QL
TRICOR E methylphenidate hcl er
valsartan 1 (la) oral capsule
extended release 24 1 PA; QL
valsartan- hour 10 mg, 20 mg, 30
1
hydrochlorothiazide mg, 40 mg
VASCEPA 2 PA methylphenidate hcl er
1 PA; QL
verapamil hcl er oral (xr)
1
tablet extended release methylphenidate hcl er
VERQUVO 3 PA; QL oral tablet extended 1 PA; QL
VYTORIN E release
WELCHOL E methylphenidate hcl
1 PA; QL
oral tablet
ZESTRIL E
RITALIN E
ZETIA E
RITALIN LA E
ZOCOR E
STRATTERA E
ZYPITAMAG E
VYVANSE 2 PA; QL
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
Central Nervous CONTRAVE E
System Agents - GRALISE 3 ST; QL
Drugs for Multiple
Sclerosis HORIZANT 3 PA; QL
AMPYRA 3 PA; SP; QL IMCIVREE E SP
AUBAGIO 3 PA; SP; QL INGREZZA 3 PA; SP; QL
AVONEX PEN 2 PA; SP; QL LYRICA E
AVONEX PREFILLED 2 PA; SP; QL LYRICA CR E
BAFIERTAM 2 PA; SP; QL phentermine hcl oral
1 PA; ++
tablet
BETASERON 2 PA; SP; QL
pregabalin oral capsule 1 QL
COPAXONE 2 PA; SP; QL
QSYMIA 3 PA; ++
EXTAVIA E SP
SAXENDA 3 PA; ++; QL
GILENYA 3 PA; SP; QL
TEGSEDI 3 PA; SP
KESIMPTA 2 PA; SP; QL
TIGLUTIK 3 PA; QL
MAVENCLAD 3 PA; SP
VYLEESI 3 PA; ++; QL
MAYZENT 3 PA; SP; QL
Dental and Oral
PLEGRIDY E SP Agents - Drugs for
PLEGRIDY STARTER Mouth and Throat
E SP Conditions
PACK
REBIF E SP chlorhexidine gluconate
1
REBIF REBIDOSE E SP mouth/throat
REBIF REBIDOSE lidocaine viscous hcl 1
E SP Dermatological
TITRATION PACK
REBIF TITRATION Agents - Drugs for
E SP Skin Conditions
PACK
TECFIDERA E SP ABSORICA E
VUMERITY 2 PA; SP; QL ABSORICA LD 3 PA
ZEPOSIA 3 PA; SP; QL ACANYA E
ZEPOSIA 7-DAY ACZONE EXTERNAL
3 PA; SP; QL E
STARTER PACK GEL 5 %
ZEPOSIA STARTER ACZONE EXTERNAL
3 PA; SP; QL 2
KIT GEL 7.5 %
Central Nervous adapalene external gel 1 PA; ++
System Agents - AKLIEF E
Miscellaneous ALA SCALP E
ADDYI 3 PA; ++; QL AMZEEQ 3
ADIPEX-P E APEXICON E E
AUSTEDO 3 PA; SP; QL ARAZLO E
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
AVITA E DAPSONE EXTERNAL
E M
BENZACLIN E GEL 7.5 %
BENZACLIN WITH DESONATE E
E
PUMP DIFFERIN EXTERNAL
E
BENZAMYCIN E CREAM
betamethasone DIFFERIN EXTERNAL
E
dipropionate external 1 GEL 0.3 %
cream DIFFERIN EXTERNAL
E
BRYHALI 3 PA LOTION
CALCIPOTRIENE DUOBRII E
E M
EXTERNAL FOAM DUPIXENT
CAPEX E SUBCUTANEOUS
SOLUTION PEN- 2 PA; SP; QL
claravis 1 PA INJECTOR 300
CLINDAGEL E MG/2ML
clindamycin phosphate- DUPIXENT
benzoyl peroxide 1 SUBCUTANEOUS
2 PA; SP; QL
external gel 1-5 % SOLUTION
clindamycin phosphate PREFILLED SYRINGE
1
external lotion ELIDEL E
clindamycin phosphate ENSTILAR 3 PA; QL
1
external solution EPIDUO E
clindamycin phosphate EPIDUO FORTE 3
1
external swab
EUCRISA 2 ST
CLINDAMYCIN
PHOSPHATE GEL 1 % E M FABIOR E
EXTERNAL FINACEA EXTERNAL
3
clindamycin phosphate FOAM
1
gel 1 % external FINACEA EXTERNAL
3 ST
clobetasol propionate GEL
1
external cream fluocinonide external
1
clobetasol propionate cream
1
external ointment fluocinonide external
1
clobetasol propionate solution
1
external solution FLUOROPLEX 3
CLOBEX E FLUOROURACIL
CLOBEX SPRAY E EXTERNAL CREAM 2
0.5 %
CLODERM E
fluorouracil external
CORDRAN 1
E cream 5 %
EXTERNAL TAPE
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
HALOBETASOL RETIN-A MICRO GEL
E
PROPIONATE E M 0.04 %, 0.1 %
EXTERNAL FOAM RETIN-A MICRO
HALOG EXTERNAL PUMP EXTERNAL E
E
CREAM GEL 0.04 %, 0.1 %
HALOG EXTERNAL RETIN-A MICRO
E
OINTMENT PUMP EXTERNAL 2 PA; ++
hydrocortisone external GEL 0.06 %, 0.08 %
1
cream RHOFADE 3
hydrocortisone external SERNIVO 3
1
ointment 1 %, 2.5 % SOOLANTRA 3
imiquimod external SORILUX E
1 ST
cream 3.75 %
TACLONEX
imiquimod external EXTERNAL E
1
cream 5 % OINTMENT
IMIQUIMOD PUMP E M TACLONEX
IMPEKLO E EXTERNAL 3 QL
IMPOYZ E SUSPENSION
KENALOG EXTERNAL E tacrolimus external 1
KLISYRI 3 ST TAZAROTENE
E
EXTERNAL FOAM
LEXETTE E
TAZORAC E
METROGEL E
TOPICORT SPRAY E
metronidazole external
1 tretinoin external cream 1 PA; ++
cream
metronidazole external triamcinolone acetonide
1 1
gel external cream
MIRVASO 3 triamcinolone acetonide
external ointment 0.025 1
mometasone furoate %, 0.1 %, 0.5 %
1
external cream
triamcinolone acetonide
NORITATE E external ointment 0.05 1 PA
ONEXTON 3 %
ORACEA E TRIANEX E
PANDEL E ULTRAVATE E
pimecrolimus 1 ST VECTICAL E
PROPECIA E VELTIN E
PSORCON E VERDESO E
QBREXZA 3 QL WINLEVI E
RETIN-A E WYNZORA E
ZIANA E
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
ZILXI 3 ST metformin hcl er (mod) E
ZYCLARA E metformin hcl er (osm) E
ZYCLARA PUMP E metformin hcl oral
1
Diabetes - tablet
Antidiabetic Agents NESINA E
ADLYXIN E ONGLYZA E
ADLYXIN STARTER OSENI E
E
PACK OZEMPIC 2 ST; QL
ALOGLIPTIN pioglitazone hcl 1
E M
BENZOATE
QTERN E
ALOGLIPTIN-
E M RYBELSUS 2 ST; QL
METFORMIN HCL
ALOGLIPTIN- SEGLUROMET E
E M
PIOGLITAZONE SOLIQUA 2 ST; QL
BYDUREON BCISE STEGLATRO E
2 ST; QL
AUTOINJECTOR STEGLUJAN E
BYETTA 10 MCG PEN 2 ST; QL SYMLINPEN 120 3 PA
BYETTA 5 MCG PEN 2 ST; QL SYMLINPEN 60 3 PA
FARXIGA 2 ST SYNJARDY 2 ST
glimepiride 1 SYNJARDY XR 2 ST
glipizide er 1 TRADJENTA 2 ST
glipizide ir 1 TRIJARDY XR 2 ST
GLUMETZA E TRULICITY 2 ST; QL
glyburide oral 1 VICTOZA 2 ST; QL
GLYXAMBI 2 ST XIGDUO XR 2 ST
INVOKAMET E Diabetes - Glucose
INVOKAMET XR E Monitoring
INVOKANA E ACCU-CHEK
JANUMET 2 ST FASTCLIX LANCET 2 ++
KIT
JANUMET XR 2 ST
ACCU-CHEK GUIDE
JANUVIA 2 ST E
TEST STRIPS
JARDIANCE 2 ST ACCU-CHEK GUIDE
E
JENTADUETO 2 ST KIT W/DEVICE
JENTADUETO XR 2 ST ACCU-CHEK
KAZANO E SOFTCLIX LANCET 2 ++
DEVICE KIT
KOMBIGLYZE XR E
CONTOUR MONITOR
metformin hcl er 1 2 ++
KIT W/DEVICE
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
CONTOUR NEXT EZ ONETOUCH VERIO
2 ++ E
KIT W/DEVICE KIT W/DEVICE
CONTOUR NEXT LINK ONETOUCH VERIO
2 ++ E
KIT W/DEVICE FLEX SYSTEM
CONTOUR NEXT ONETOUCH VERIO
E
MONITOR KIT 2 ++ TEST STRIPS
W/DEVICE ONETOUCH VERIO IQ
E
CONTOUR NEXT ONE SYSTEM
2 ++
KIT ONETOUCH VERIO
E
CONTOUR NEXT REFLECT
2 ++; QL
TEST STRIPS ONETOUCH VERIO
E
CONTOUR TEST SYNC SYSTEM
2 ++; QL
STRIPS V-GO 20 2 ++
DEXCOM G4 / G5 / G6 V-GO 30 2 ++
RECEIVER,
TRANSMITTER, V-GO 40 2 ++
SENSOR (INCLUDING 2 PA; ++ Diabetes - Glycemic
PLATINUM, Agents
PLATINUM BAQSIMI ONE PACK 2
PEDIATRIC) DEVICE
BAQSIMI TWO PACK 2
FREESTYLE LIBRE 14
E GLUCAGON
DAY READER
EMERGENCY KIT
FREESTYLE LIBRE 14 Made by
E INJECTION 2
DAY SENSOR Fresenius
SOLUTION
FREESTYLE LIBRE 2 RECONSTITUTED
E
READER GVOKE HYPOPEN 1-
2
FREESTYLE LIBRE 2 PACK
E
SENSOR GVOKE HYPOPEN 2-
2
GHT BLOOD PACK
E
GLUCOSE MONITOR GVOKE PFS 2
GUARDIAN CONNECT Diabetes - Insulins
3 PA; ++
TRANSMITTER
ADMELOG E
GUARDIAN LINK 3
3 PA; ++ ADMELOG
TRANSMITTER E
SOLOSTAR
GUARDIAN SENSOR
3 PA; ++ APIDRA SOLOSTAR E
(3)
ONETOUCH ULTRA APIDRA VIAL E
E
TEST STRIPS BASAGLAR KWIKPEN E
ONETOUCH ULTRA 2 BD AUTOSHIELD DUO
E 2 ++
KIT W/DEVICE PEN NEEDLES
ONETOUCH ULTRA BD ULTRA-FINE
E 2 ++
MINI KIT W/DEVICE INSULIN SYRINGES
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
BD ULTRA-FINE PEN INSULIN LISPRO
2 ++ E M
NEEDLES JUNIOR KWIKPEN
FIASP E INSULIN LISPRO
E M
FIASP FLEXTOUCH E PROT & LISPRO
FIASP PENFILL E LANTUS SOLOSTAR 2 ++
HUMALOG 2 ++ LANTUS U-100 VIAL 2 ++
HUMALOG KWIKPEN 2 ++ LEVEMIR U-100
E
FLEXTOUCH
HUMALOG MIX 50/50
2 ++ LEVEMIR U-100 VIAL E
KWIKPEN
HUMALOG MIX 50/50 LYUMJEV KWIKPEN 2 ++
2 ++
VIAL LYUMJEV VIAL 2 ++
HUMALOG MIX 75/25 NOVOFINE
2 ++
KWIKPEN AUTOCOVER PEN 2 ++
HUMALOG MIX 75/25 NEEDLE 30G X 8 MM
2 ++
VIAL NOVOFINE PEN
2 ++
HUMALOG U-100 NEEDLE 32G X 6 MM
2 ++
JUNIOR KWIKPEN NOVOFINE PLUS PEN
2 ++
HUMULIN 70/30 NEEDLE 32G X 4 MM
2 ++
KWIKPEN NOVOLIN 70/30
E
HUMULIN 70/30 VIAL 2 ++ FLEXPEN
HUMULIN N KWIKPEN 2 ++ NOVOLIN 70/30
E
FLEXPEN RELION
HUMULIN N VIAL 2 ++
NOVOLIN 70/30
HUMULIN R U-500 E
2 ++ RELION
KWIKPEN
NOVOLIN 70/30 VIAL E
HUMULIN R U-500
2 ++ NOVOLIN N FLEXPEN E
VIAL
HUMULIN R VIAL 2 ++ NOVOLIN N FLEXPEN
E
RELION
INSULIN ASP PROT &
E M NOVOLIN N RELION E
ASP FLEXPEN
INSULIN ASPART E M NOVOLIN N VIAL E
INSULIN ASPART NOVOLIN R FLEXPEN E
E M
FLEXPEN NOVOLIN R FLEXPEN
E
INSULIN ASPART RELION
E M
PENFILL NOVOLIN R RELION E
INSULIN ASPART NOVOLIN R VIAL E
E M
PROT & ASPART NOVOLOG 70/30
E
INSULIN LISPRO E M FLEXPEN RELION
INSULIN LISPRO (1 NOVOLOG FLEXPEN E
E M
UNIT DIAL)
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
NOVOLOG FLEXPEN potassium citrate er 1
E
RELION sodium fluoride oral
1 ++
NOVOLOG MIX 70/30 tablet chewable
E
FLEXPEN VELTASSA 3
NOVOLOG MIX 70/30 vitamin d
E
RELION (ergocalciferol) oral
1 ++
NOVOLOG MIX 70/30 capsule 1.25 mg
E
VIAL (50000 ut)
NOVOLOG PENFILL E Gastrointestinal
Agents - Drugs for
NOVOLOG RELION E
Acid Reflux and Ulcer
NOVOLOG U-100 VIAL E
ACIPHEX E
NOVOTWIST PEN
2 ++ CARAFATE ORAL
NEEDLE 32G X 5 MM E
TABLET
SEMGLEE E
DEXILANT 2 ++; QL
TOUJEO MAX
2 ++ esomeprazole
SOLOSTAR
magnesium oral
TOUJEO SOLOSTAR 2 ++ 1 ++; QL
capsule delayed
TRESIBA E release
TRESIBA famotidine oral 1 ++
E
FLEXTOUCH lansoprazole oral
Electrolytes / Minerals capsule delayed 1 ++; QL
/ Metals / Vitamins release
CARNITOR ORAL E misoprostol oral 1
CARNITOR SF E NEXIUM ORAL
cyanocobalamin CAPSULE DELAYED E
injection solution 1000 1 ++ RELEASE
mcg/ml omeprazole oral
ergocalciferol oral capsule delayed 1 QL
1 ++ release
capsule
folic acid oral tablet 1 ++ omeprazole-sodium
E
bicarbonate
klor-con m20 1
pantoprazole sodium
K-TAB E oral tablet delayed 1 QL
LOKELMA 3 release
NASCOBAL 3 ++ PREVACID E
potassium chloride crys PREVACID SOLUTAB E
er oral tablet extended PROTONIX ORAL
1
release 10 meq, 20 TABLET DELAYED E
meq RELEASE
potassium chloride er 1
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
RABEPRAZOLE peg 3350-kcl-na bicarb-
1
SODIUM ORAL E M nacl
CAPSULE SPRINKLE PLENVU E
rabeprazole sodium PYLERA 2
oral tablet delayed 1 ++; QL
release RELISTOR E
sucralfate oral tablet 1 RELTONE E
ZEGERID E SUPREP BOWEL
3
PREP KIT
Gastrointestinal
Agents - Drugs for SUTAB 3
Bowel, Intestine and SYMPROIC 2 ST; QL
Stomach Conditions
TALICIA 3
AMITIZA E TRULANCE E
CLENPIQ 3 VIBERZI 3 PA; QL
dicyclomine hcl oral ZELNORM 3 PA; QL
1
capsule
Genetic or Enzyme
dicyclomine hcl oral Disorder - Drugs for
1
tablet Replacement,
diphenoxylate-atropine Modification,
1
oral tablet Treatment
glycopyrrolate oral CERDELGA 3 PA; SP
1
tablet 1 mg, 2 mg CREON 2
GLYCOPYRROLATE EXONDYS 51 E SP
3 PA
ORAL TABLET 1.5 MG
KUVAN E SP
GOLYTELY E
NITYR 3 PA; SP
hyoscyamine sulfate sl 1
ORFADIN 3 PA; SP
hyoscyamine sulfate
1 PANCREAZE E
sublingual
lactulose oral solution 1 PERTZYE E
LINZESS 2 ST; QL STRENSIQ 2 PA; SP
LUBIPROSTONE E M VIOKACE E
MOTEGRITY 3 ST; QL VYONDYS 53 E SP
MOTOFEN E ZENPEP 2
MOVANTIK E ZOLGENSMA 3 PA; SP
MOVIPREP E Genitourinary Agents
- Drugs for Bladder,
NULYTELY LEMON- Genital and Kidney
E
LIME Conditions
OMECLAMOX-PAK 2 AURYXIA 3
OSMOPREP E CIALIS E
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
CUPRIMINE E SP terazosin hcl oral
DEPEN TITRATABS 2 SP capsule 1 mg, 10 mg, 5 1
mg
ELMIRON E
Hormonal Agents -
GEMTESA E Adrenal
MYRBETRIQ ORAL ALKINDI SPRINKLE E
TABLET EXTENDED 2
RELEASE 24 HOUR CORTEF E
oxybutynin chloride er 1 dexamethasone oral
tablet 0.5 mg, 0.75 mg, 1 PA
oxybutynin chloride oral 4 mg, 6 mg
1
tablet
dexamethasone oral
penicillamine oral tablet 1 mg, 1.5 mg, 2 1
E SP
capsule mg
phenazopyridine hcl HEMADY E
oral tablet 100 mg, 200 1
mg hydrocortisone oral 1
RENAGEL E KENALOG INJECTION
SUSPENSION 40 E
sildenafil citrate oral MG/ML
tablet 100 mg, 25 mg, 1 ++; QL
50 mg methylprednisolone
1
oral tablet therapy pack
solifenacin succinate 1
prednisolone sodium
STENDRA E 1
phosphate oral solution
tadalafil oral 1 ++; QL prednisone oral tablet 1
tolterodine tartrate er 1 prednisone oral tablet
1
TOVIAZ 3 therapy pack
VELPHORO 3 RAYOS E
VESICARE E TAPERDEX 12-DAY 3 PA
VESICARE LS E TAPERDEX 6-DAY 3 PA
VIAGRA E TAPERDEX 7-DAY 3 PA
Genitourinary Agents Hormonal Agents -
- Drugs for Prostate Men's Health
Conditions ANDRODERM 2 PA
alfuzosin hcl er 1 ANDROGEL E
AVODART E ANDROGEL PUMP E
dutasteride oral 1 AVEED E
finasteride oral tablet 5 DEPO-
1 E
mg TESTOSTERONE
FLOMAX E FORTESTA E
tamsulosin hcl 1 JATENZO E
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
NATESTO E LUPRON DEPOT (1-
TESTIM E MONTH)
2 PA; SP
INTRAMUSCULAR KIT
TESTOPEL E 7.5 MG
testosterone cypionate LUPRON DEPOT (3-
1 PA
intramuscular MONTH)
2 PA; SP
testosterone INTRAMUSCULAR KIT
transdermal gel 1.62 %, 22.5 MG
10 mg/act (2%), 20.25 LUPRON DEPOT (4-
mg/1.25gm (1.62%), MONTH)
20.25 mg/act (1.62%), 1 PA 2 PA; SP
INTRAMUSCULAR KIT
25 mg/2.5gm (1%), 30MG
40.5 mg/2.5gm
(1.62%), 50 mg/5gm LUPRON DEPOT (6-
(1%) MONTH)
2 PA; SP
INTRAMUSCULAR KIT
VOGELXO E 45MG
VOGELXO PUMP E MYCAPSSA E SP
XYOSTED 3 PA NOCDURNA 3
Hormonal Agents - NORDITROPIN
Osteoporosis 2 PA; ++; SP
FLEXPRO
OSPHENA 3 NUTROPIN AQ
2 PA; ++; SP
Hormonal Agents - NUSPIN 10
Pituitary NUTROPIN AQ
2 PA; ++; SP
ACTHAR 2 PA; SP NUSPIN 20
cabergoline 1 NUTROPIN AQ
2 PA; ++; SP
CETROTIDE E SP NUSPIN 5
clomiphene citrate oral 1 ++ OMNITROPE E SP
FENSOLVI (6 MONTH) 3 PA; SP; QL ORILISSA 2 PA; QL
FOLLISTIM AQ 2 PA; ++; SP SAIZEN E SP
PA; Made by SAIZENPREP E SP
ganirelix acetate 1 Organon; ++; SANDOSTATIN E SP
SP SIGNIFOR E SP
GENOTROPIN E SP SOMATULINE DEPOT 3 PA; SP
GENOTROPIN SUPPRELIN LA 2 PA; SP; QL
E SP
MINIQUICK
TRIPTODUR 3 PA; SP; QL
GONAL-F E SP
ZOMACTON E SP
GONAL-F RFF E SP
ZOMACTON (FOR
GONAL-F RFF E SP
E SP ZOMA-JET 10)
REDIJECT
HUMATROPE E SP
ISTURISA E SP
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
Hormonal Agents - GENERESS FE E
Sex Hormones and IMVEXXY
Birth Control 3
MAINTENANCE PACK
ANNOVERA E IMVEXXY STARTER
3
apri 1 ++ PACK
aurovela fe 1/20 1 ++ isibloom 1 ++
aviane 1 ++ junel 1.5/30 1 ++
BEYAZ E junel 1/20 1 ++
BIJUVA 3 junel fe 1.5/30 1 ++
blisovi 24 fe 1 ++ junel fe 1/20 1 ++
blisovi fe 1.5/30 1 ++ junel fe 24 1 ++
blisovi fe 1/20 1 ++ kurvelo 1 ++
CLIMARA E larin fe 1/20 1 ++
CLIMARA PRO 2 larissia 1 ++
cryselle-28 1 ++ lessina 1 ++
DELESTROGEN levonorgest-eth est &
1 ++; QL
INTRAMUSCULAR OIL E eth est
20 MG/ML, 40 MG/ML levonorgest-eth estrad
DIVIGEL 3 91-day oral tablet 0.15-
1 ++; QL
dotti 1 0.03 &0.01 mg, 0.15-
0.03 mg
drospirenone-ethinyl
1 ++ levonorgestrel-ethinyl
estradiol
estrad oral tablet 0.1-20
DUAVEE 2 1 ++
mg-mcg, 0.15-30 mg-
ELESTRIN 3 mcg
eluryng 1 ++ LO LOESTRIN FE E
ENDOMETRIN 2 ++ LOESTRIN 1.5/30 (21) E
enskyce 1 ++ LOESTRIN 1/20 (21) E
estarylla 1 ++ LOESTRIN FE 1.5/30 E
ESTRACE E LOESTRIN FE 1/20 E
estradiol oral 1 loryna 1 ++
estradiol transdermal 1 MAKENA 2 PA; SP
estradiol vaginal 1 medroxyprogesterone
1 ++; QL
estradiol-norethindrone acetate intramuscular
1
acet medroxyprogesterone
1
ESTROGEL 3 acetate oral
etonogestrel-ethinyl MINASTRIN 24 FE E
1 ++
estradiol MIRENA (52 MG) 3 ++
EVAMIST 3 mono-linyah 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
NATAZIA 2 ++ Hormonal Agents -
nikki 1 ++ Thyroid
norethin ace-eth ARMOUR THYROID 3 ST
1 ++
estrad-fe oral tablet CYTOMEL E
norethindrone acetate euthyrox 1
1
oral LEVOTHYROXINE
norethindrone acet- SODIUM ORAL E M
1 ++
ethinyl est CAPSULE
norethindrone oral 1 ++ levothyroxine sodium
1
norgestimate-ethinyl oral tablet
1 ++
estradiol triphasic levoxyl 1
nortrel 1/35 (21) 1 ++ liothyronine sodium oral 1
nortrel 1/35 (28) 1 ++ methimazole oral 1
ORIAHNN 2 PA; QL np thyroid oral tablet 30
1
PREMARIN ORAL 2 mg, 60 mg
PREMARIN VAGINAL 2 SYNTHROID E
PREMPHASE 2 THYQUIDITY E
PREMPRO 2 TIROSINT E
PROMETRIUM E TIROSINT-SOL E
SAFYRAL E Immunological
Agents - Drugs for
SEASONIQUE E Immune System
SLYND E Stimulation or
Suppression
sprintec 28 1 ++
syeda 1 ++ ACTEMRA ACTPEN 3 PA; 3P; SP
tri femynor 1 ++ ACTEMRA
3 PA; 3P; SP
SUBCUTANEOUS
tri-estarylla 1 ++
ASCENIV E SP
tri-lo-marzia 1 ++
AVSOLA 2 PA; SP
tri-lo-mili 1 ++
azathioprine oral 1
tri-lo-sprintec 1 ++
CIMZIA 2 PA; SP
tri-sprintec 1 ++
CIMZIA PREFILLED
TWIRLA E 2 PA; SP
KIT
VAGIFEM E CIMZIA STARTER KIT 2 PA; SP
vienva 1 ++ COSENTYX (300 MG
E SP
VIVELLE-DOT E DOSE)
xulane 1 ++ COSENTYX 150
E SP
YASMIN 28 E MG/ML
YAZ E
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
COSENTYX mycophenolate mofetil
1 SP
SENSOREADY (300 E SP oral tablet
MG) mycophenolate sodium 1 SP
COSENTYX OLUMIANT E SP
E SP
SENSOREADY PEN
ORENCIA 3 PA; 3P; SP
CUTAQUIG E SP
ORENCIA CLICKJECT 3 PA; 3P; SP
cyclosporine modified
1 SP ORLADEYO 3 PA; SP; QL
oral capsule
ENBREL MINI 3 PA; SP OTEZLA 2 PA; SP
ENBREL OTREXUP E
SUBCUTANEOUS PANZYGA E SP
3 PA; SP
SOLUTION RASUVO 2 PA; QL
PREFILLED SYRINGE
REDITREX E
ENBREL SURECLICK 3 PA; SP
REMICADE E SP
FIRAZYR E SP
RENFLEXIS E SP
GAMMAGARD 3 PA; SP
RINVOQ 2 PA; SP
HAEGARDA 3 PA; SP
RUCONEST 3 PA; SP; QL
HUMIRA 2 PA; SP
SIMPONI 2 PA; SP
HUMIRA PEDIATRIC
2 PA; SP SIMPONI ARIA 2 PA; SP
CROHNS START
HUMIRA PEN 2 PA; SP SKYRIZI 2 PA; SP
HUMIRA PEN- SKYRIZI (150 MG
2 PA; SP 2 PA; SP
CD/UC/HS STARTER DOSE)
HUMIRA PEN- SKYRIZI PEN 2 PA; SP
PEDIATRIC UC 2 PA; SP STELARA
2 PA; SP
START INTRAVENOUS
HUMIRA PEN- STELARA
2 PA; SP; QL
PS/UV/ADOL HS 2 PA; SP SUBCUTANEOUS
START tacrolimus oral 1 SP
HUMIRA PEN- TALTZ 3 PA; 3P; SP
PSOR/UVEIT 2 PA; SP
STARTER TREMFYA 2 PA; SP
INFLECTRA 2 PA; SP TREXALL 3
leflunomide oral 1 XELJANZ 2 PA; SP
LUPKYNIS E SP XELJANZ XR 2 PA; SP
methotrexate oral 1 XEMBIFY 3 PA; SP
methotrexate sodium Inflammatory Bowel
1 Disease Agents
oral
mycophenolate mofetil APRISO 2
1 SP
oral capsule ASACOL HD E
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
CANASA E Metabolic Bone
CORTIFOAM 3 Disease Agents -
Other
DELZICOL E
calcitriol oral capsule 1
DIPENTUM E
SENSIPAR E
hydrocortisone
1 Miscellaneous
(perianal)
Therapeutic Agents
LIALDA E
PA; Non-
mesalamine er oral BOTOX 2
1 Cosmetic; SP
capsule 0.375 gm
DOJOLVI E
mesalamine oral tablet
1 DUROLANE 2 PA; SP
delayed release
ORTIKOS E ENDARI 3 PA
PENTASA 3 EUFLEXXA 2 PA; SP
PROCTOFOAM HC 2 FIRDAPSE E SP
sulfasalazine oral tablet 1 GEL-ONE E SP
UCERIS ORAL E GELSYN-3 2 PA; SP
UCERIS RECTAL 3 GENVISC 850 E SP
Metabolic Bone HYALGAN E SP
Disease Agents - HYMOVIS E SP
Drugs for MONOVISC E SP
Osteoporosis
ORTHOVISC E SP
alendronate sodium
1 OXBRYTA E SP
oral tablet 10 mg, 5 mg
alendronate sodium PALFORZIA E SP
oral tablet 35 mg, 70 1 QL PHEXXI E
mg SUPARTZ FX E SP
BINOSTO 3 QL SYNVISC E SP
FORTEO E SP SYNVISC ONE E SP
ibandronate sodium TRILURON E SP
1 QL
oral
TRIVISC E SP
PROLIA 2 PA; SP; QL
VILTEPSO E SP
RAYALDEE 3
VISCO-3 E SP
TERIPARATIDE
2 PA; SP Ophthalmic Agents -
(RECOMBINANT)
Drugs for Eye Allergy,
TYMLOS 2 PA; SP Infection and
XGEVA 2 PA; SP Inflammation
AZASITE 3
BEPREVE E
BESIVANCE 3
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
BROMSITE E Ophthalmic Agents -
ciprofloxacin hcl Drugs for Glaucoma
1
ophthalmic ALPHAGAN P
erythromycin OPHTHALMIC 2
1 SOLUTION 0.1 %
ophthalmic
EYSUVIS 3 PA ALPHAGAN P
OPHTHALMIC E
FLAREX 3 SOLUTION 0.15 %
ILEVRO E AZOPT E
INVELTYS 3 BETIMOL 3
ketorolac tromethamine brimonidine tartrate
1 1
ophthalmic ophthalmic
LOTEMAX COMBIGAN 2
3 PA; QL
OPHTHALMIC GEL
COSOPT E
LOTEMAX
OPHTHALMIC 3 PA; QL COSOPT PF E
OINTMENT dorzolamide hcl-timolol
1
LOTEMAX mal
OPHTHALMIC E latanoprost ophthalmic 1
SUSPENSION LUMIGAN 2 QL
LOTEMAX SM 3 RHOPRESSA 3 QL
MOXEZA 2 ROCKLATAN 3 QL
MOXIFLOXACIN HCL SIMBRINZA 2
INTRAOCULAR 3
SOLUTION timolol maleate
1
ophthalmic solution
moxifloxacin hcl
1 timolol maleate pf 1
ophthalmic solution
NEVANAC E TIMOPTIC E
ofloxacin ophthalmic 1 TIMOPTIC OCUDOSE E
olopatadine hcl TIMOPTIC-XE E
1
ophthalmic TRAVATAN Z E
PRED FORTE E VYZULTA E
prednisolone acetate XALATAN E
1
ophthalmic ZIOPTAN E
PROLENSA 2 QL Ophthalmic Agents -
VIGAMOX E Drugs for
ZERVIATE E Miscellaneous Eye
Conditions
BEOVU E SP
CEQUA E
LASTACAFT E
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
LATISSE E CLARINEX-D 12
E
neomycin-polymyxin- HOUR
dexameth ophthalmic cyproheptadine hcl oral
1 1
suspension 3.5-10000- tablet
0.1 DYMISTA 2 QL
polymyxin b- FASENRA 2 PA; SP
1
trimethoprim
FASENRA PEN 2 PA; SP
RESTASIS 2 PA
fluticasone propionate
RESTASIS 1 ++
2 PA nasal
MULTIDOSE
ipratropium bromide
TOBRADEX 1
nasal
OPHTHALMIC E
SUSPENSION levocetirizine
dihydrochloride oral 1 ++
TOBRADEX ST 3 tablet
tobramycin- mometasone furoate
1 1 ++; QL
dexamethasone nasal
XIIDRA 2 PA NASONEX E
ZYLET 3 NUCALA 2 PA; SP; QL
Otic Agents - Drugs OMNARIS 3 ++; QL
for Ear Conditions
promethazine hcl oral
CIPRODEX E 1
tablet
ciprofloxacin- promethazine-dm 1
1
dexamethasone
pseudoephedrine-
neomycin-polymyxin-hc 1
1 bromphen-dm
otic
QNASL 3 ++; QL
ofloxacin otic 1
QNASL CHILDRENS 3 ++; QL
OTOVEL 3 PA
XHANCE E
Respiratory Tract /
Pulmonary Agents - XOLAIR 2 PA; SP
Drugs for Allergies, ZETONNA 3 ++; QL
Cough, Cold Respiratory Tract /
allergy relief oral tablet Pulmonary Agents -
1 ++
5 mg Drugs for Asthma and
azelastine hcl nasal 1 QL Other Lung
Conditions
azelastine-fluticasone 1 QL
ADVAIR DISKUS 2 QL
benzonatate 1
ADVAIR HFA 2 QL
cetirizine hcl oral
1 ++ AIRDUO DIGIHALER E
solution
CLARINEX E AIRDUO RESPICLICK
E
113/14
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
AIRDUO RESPICLICK BREZTRI
E 2 QL
232/14 AEROSPHERE
AIRDUO RESPICLICK budesonide inhalation 1 QL
E
55/14 BUDESONIDE-
albuterol sulfate hfa FORMOTEROL E M
aerosol solution 108 FUMARATE
1 QL
(90 base) mcg/act COMBIVENT
inhalation 2 QL
RESPIMAT
ALBUTEROL DUAKLIR PRESSAIR E
SULFATE HFA
AEROSOL SOLUTION DULERA E
E M
108 (90 BASE) epinephrine injection
1
MCG/ACT solution auto-injector
INHALATION EPIPEN 2-PAK 3 ST
albuterol sulfate EPIPEN JR 2-PAK E
1 QL
inhalation
ESBRIET 3 PA; SP
ALVESCO E
FLOVENT DISKUS 2 QL
ANORO ELLIPTA 2 QL
FLOVENT HFA 2 QL
ARMONAIR
E fluticasone-salmeterol
DIGIHALER
inhalation aerosol
ARNUITY ELLIPTA 2 QL powder breath
ASMANEX (120 activated 100-50 1 QL
E
METERED DOSES) mcg/dose, 250-50
ASMANEX (14 mcg/dose, 500-50
E mcg/dose
METERED DOSES)
ASMANEX (30 INCRUSE ELLIPTA E
E
METERED DOSES) ipratropium-albuterol 1 QL
ASMANEX (60 LEVALBUTEROL HFA
E
METERED DOSES) INHALATION
E M
ASMANEX (7 AEROSOL 45
E MCG/ACT
METERED DOSES)
ASMANEX HFA E LONHALA MAGNAIR
3 QL
REFILL KIT
ATROVENT HFA 3 QL
LONHALA MAGNAIR
AUVI-Q INJECTION 3 QL
STARTER KIT
SOLUTION AUTO-
INJECTOR 0.15 E montelukast sodium
1
MG/0.15ML, 0.3 oral tablet
MG/0.3ML montelukast sodium
1
BEVESPI oral tablet chewable
E
AEROSPHERE OFEV 3 PA; SP
BREO ELLIPTA 2 QL PERFOROMIST 3 QL
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
PROAIR DIGIHALER E TOBRAMYCIN
PROAIR HFA E NEBULIZATION
E M; SP
SOLUTION 300
PROAIR RESPICLICK E MG/5ML INHALATION
PROVENTIL HFA E TRIKAFTA 3 PA; SP; QL
PULMICORT Respiratory Tract /
2 QL
FLEXHALER Pulmonary Agents -
PULMICORT Drugs for Pulmonary
E Hypertension
SUSPENSION
QVAR REDIHALER E ADCIRCA E SP
SEREVENT DISKUS 2 QL ADEMPAS 2 PA; SP; QL
SINGULAIR E LETAIRIS E SP
SPIRIVA OPSUMIT 2 PA; SP; QL
2 QL
HANDIHALER ORENITRAM 3 PA; SP
SPIRIVA RESPIMAT 2 QL REMODULIN E SP
STIOLTO RESPIMAT 2 QL sildenafil citrate oral
1 PA; SP; QL
STRIVERDI tablet 20 mg
2 QL
RESPIMAT TRACLEER 62.5 MG,
E SP
SYMBICORT 2 QL 125 MG
SYMJEPI 3 Skeletal Muscle
Relaxants - Drugs for
TRELEGY ELLIPTA 2 QL
Muscle Pain and
TUDORZA PRESSAIR E Spasm
VENTOLIN HFA E AMRIX E
wixela inhub E baclofen oral 1
XOPENEX HFA E carisoprodol oral 1
YUPELRI 3 QL cyclobenzaprine hcl
1
Respiratory Tract / oral
Pulmonary Agents - LORZONE 3
Drugs for Cystic
Fibrosis metaxalone 1
BETHKIS E SP methocarbamol oral 1
BRONCHITOL E NORGESIC FORTE E
CAYSTON E SP ORPHENGESIC
E M
FORTE
KITABIS PAK E SP
OZOBAX E
PULMOZYME 2 PA; SP
SKELAXIN E
TOBI NEBULIZER E SP
SOMA E
TOBI PODHALER 3 SP; QL
tizanidine hcl oral tablet 1
VANADOM E
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
ZANAFLEX E
Sleep Disorder
Agents
AMBIEN E
AMBIEN CR E
armodafinil 1 PA; QL
BELSOMRA 3 ST; QL
DAYVIGO 3 ST; QL
eszopiclone 1 QL
LUNESTA E
modafinil 1 PA; QL
NUVIGIL E
PROVIGIL E
RESTORIL E
SILENOR 3 QL
SUNOSI 2 PA; QL
temazepam 1 QL
WAKIX 3 PA; SP; QL
XYREM 3 PA; SP; QL
XYWAV 3 PA; SP; QL
zolpidem tartrate er 1 QL
zolpidem tartrate oral 1 QL
Stimulation or
Suppression
TAKHZYRO 3 PA; SP
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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