2023 Select Standard Formulary
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2023
Select Standard Formulary
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 Optum Rx app to:
• Find a participating retail pharmacy by ZIP code.
• Look up possible lower-cost medication alternatives.
• Compare medication pricing and options.
Effective Jan. 1, 2023Understanding your formulary
What is a formulary?
A formulary is a list of prescribed medications or other pharmacy care products, services or supplies chosen for their
safety, cost, and effectiveness. Medications are listed by categories or classes and are placed into cost levels known as
tiers. It includes both brand and generic prescription medications.
To create the list, Optum Rx® is guided by the Pharmacy and Therapeutics Committee. This group of doctors and
pharmacists reviews which medications will be covered, how well the drugs work, and overall value. They also make sure
there are safe and covered options.
How do I use my formulary?
You and your doctor can use the formulary to help you choose the
most cost-effective prescription medications. This guide tells you
if a medication is generic or brand, and if special rules apply. If your
medication is not listed here, please visit your plan’s website or call the About this formulary
number on your member ID card.
Where differences exist between
What are tiers? this list and your benefit plan,
Tiers are the different cost levels you pay for a medication. Each tier is the benefit plan documents rule.
assigned a cost, set by your employer or plan sponsor. This is not a complete list of your
covered medications. Please review
When does the formulary change? your benefit plan documents
• Medications may move to a lower tier at any time. for full details. Not all formulary
• Medications may move to a higher tier when a generic equal alternatives listed in this document
becomes available. may be appropriate for your specific
• Medications may move to a higher tier or be excluded from coverage condition. Please talk to your doctor.
on January 1 or July 1 of each year.
If a medication changes tiers, you may have to pay a different amount
for that medication.
Why are some medications excluded from coverage?
A medication may be excluded from coverage under your pharmacy benefit when it works the same as or is similar to
another prescription or over-the-counter (OTC) medication.
What if I don’t agree with a decision about an 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?
Over-the-counter
If your doctor gives you a prescription for a brand-name medication, ask
if a lower-cost option could be right for you. medications (OTC)
Talk to your doctor about OTC
What if I am taking a specialty medication? options. Even though OTC
Specialty medications are used to treat complex conditions and are medications may not be covered by
generally higher in cost. Please note, not all specialty medications are your pharmacy benefit, they may cost
listed in the formulary. Our specialty pharmacy can provide most of your
less than a prescription medication.
specialty medications along with helpful programs and services. Call
1-855-427-4682 and ask how you can have 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
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.
PA Prior authorization – Your doctor is required to give Optum Rx 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.
3Select Standard Formulary
Table of Contents
Analgesics - Drugs for Pain.................................................................................................................................6
Analgesics - Drugs for Pain and Inflammation.................................................................................................... 6
Anesthetics..........................................................................................................................................................6
Anti-Addiction / Substance Abuse Treatment Agents......................................................................................... 6
Antibacterials.......................................................................................................................................................7
Anticoagulants.....................................................................................................................................................7
Anticonvulsants - Drugs for Seizures.................................................................................................................. 8
Antidementia Agents - Drugs for Alzheimer's Disease and Dementia................................................................ 8
Antidepressants...................................................................................................................................................8
Antiemetics - Drugs for Nausea and Vomiting.................................................................................................... 9
Antifungals...........................................................................................................................................................9
Antigout Agents................................................................................................................................................... 9
Antimigraine Agents............................................................................................................................................ 9
Antineoplastics - Drugs for Cancer....................................................................................................................10
Antiparasitics..................................................................................................................................................... 10
Antiparkinson Agents........................................................................................................................................ 11
Antiplatelets.......................................................................................................................................................11
Antipsychotics - Drugs for Mood Disorders....................................................................................................... 11
Antivirals............................................................................................................................................................11
Anxiolytics - Drugs for Anxiety...........................................................................................................................12
Bipolar Agents - Drugs for Mood Disorders.......................................................................................................12
Blood Products and Modifiers - Drugs for Blood Disorders...............................................................................12
Cardiovascular Agents - Drugs for Heart and Circulation Conditions............................................................... 12
Central Nervous System Agents - Drugs for Attention Deficit Disorder............................................................ 14
Central Nervous System Agents - Drugs for Multiple Sclerosis........................................................................ 14
Central Nervous System Agents - Miscellaneous............................................................................................. 15
Dental and Oral Agents - Drugs for Mouth and Throat Conditions....................................................................15
Dermatological Agents - Drugs for Skin Conditions.......................................................................................... 15
Diabetes - Antidiabetic Agents.......................................................................................................................... 16
Diabetes - Glucose Monitoring.......................................................................................................................... 17
Diabetes - Glycemic Agents.............................................................................................................................. 18
Diabetes - Insulins.............................................................................................................................................18
Electrolytes / Minerals / Metals / Vitamins.........................................................................................................19
Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer................................................................................20
Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions.................................................20
Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment............................................. 20
Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions.......................................................21
Genitourinary Agents - Drugs for Prostate Conditions...................................................................................... 21
Hormonal Agents - Adrenal............................................................................................................................... 21
Hormonal Agents - Men's Health.......................................................................................................................21
Hormonal Agents - Pituitary.............................................................................................................................. 21
Hormonal Agents - Selective Estrogen Receptor Modifying Agents................................................................. 22
Hormonal Agents - Sex Hormones and Birth Control........................................................................................22
Hormonal Agents - Thyroid............................................................................................................................... 25
Immunological Agents - Drugs for Immune System Stimulation or Suppression.............................................. 25
Inflammatory Bowel Disease Agents.................................................................................................................26
Metabolic Bone Disease Agents - Drugs for Osteoporosis............................................................................... 27
Metabolic Bone Disease Agents - Other........................................................................................................... 27
Miscellaneous Therapeutic Agents................................................................................................................... 27
Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation...........................................................27
4Ophthalmic Agents - Drugs for Glaucoma.........................................................................................................28
Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions......................................................................... 28
Otic Agents - Drugs for Ear Conditions............................................................................................................. 28
Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold........................................................28
Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions................................... 29
Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis.................................................................... 30
Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension.................................................... 30
Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm...................................................................... 31
Sleep Disorder Agents...................................................................................................................................... 31
5Drug Name Drug Tier Notes Drug Name Drug Tier Notes
Analgesics - Drugs Analgesics - Drugs
for Pain for Pain and
acetaminophen- Inflammation
1 QL
codeine #2 celecoxib oral 1 QL
acetaminophen- diclofenac sodium oral 1
1 QL
codeine #3 ELYXYB 3 PA; QL
acetaminophen- etodolac oral tablet 1
1 QL
codeine #4
ibuprofen oral tablet
acetaminophen- 400 mg, 600 mg, 800 1
1 QL
codeine oral tablet mg
apap-caff- indomethacin oral
1 QL 1
dihydrocodeine capsule 25 mg, 50 mg
bac 1 ketorolac tromethamine
1 QL
BELBUCA 2 PA; QL oral
butalbital-apap-caffeine 1 meloxicam oral tablet 1
endocet 1 QL nabumetone oral 1
fentanyl 1 PA; QL NAPRELAN ORAL
hydrocodone- TABLET EXTENDED
3
acetaminophen oral 1 QL RELEASE 24 HOUR
tablet 375 MG, 500 MG
hydromorphone hcl oral NAPRELAN ORAL
1 QL TABLET EXTENDED
tablet 3 PA
RELEASE 24 HOUR
HYSINGLA ER 2 PA; QL 750 MG
morphine sulfate er oral naproxen oral tablet 1
1 PA; QL
tablet extended release
Anesthetics
NUCYNTA 3 QL
lidocaine external patch
oxycodone hcl oral 1
1 QL 5%
tablet
lidocaine-prilocaine
oxycodone- 1
external cream
acetaminophen oral
tablet 10-325 mg, 2.5- 1 QL ZTLIDO 3 ST
325 mg, 5-325 mg, 7.5- Anti-Addiction /
325 mg Substance Abuse
OXYCONTIN 2 PA; QL Treatment Agents
tramadol hcl oral tablet 1 QL buprenorphine hcl
1 QL
sublingual
TREZIX 3 QL
buprenorphine hcl-
XTAMPZA ER 2 PA; QL 1 QL
naloxone hcl
KLOXXADO 2
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
naloxone hcl nasal 1 DIFICID 3
naltrexone hcl oral 1 doxycycline hyclate oral
1
NARCAN 2 capsule
SUBLOCADE 3 SP doxycycline hyclate oral
1
tablet
varenicline tartrate oral
1 ++; QL doxycycline
tablet
monohydrate oral 1
ZIMHI 3 capsule
ZUBSOLV 2 QL doxycycline
1
Antibacterials monohydrate oral tablet
amoxicillin oral capsule 1 levofloxacin oral tablet 1
amoxicillin oral metronidazole oral
1
suspension 1 tablet
reconstituted metronidazole vaginal 1
amoxicillin oral tablet 1 minocycline hcl oral
1
amoxicillin-potassium capsule
clavulanate oral mondoxyne nl 1
1
suspension
reconstituted mupirocin external 1
amoxicillin-potassium nitrofurantoin
1 1
clavulanate oral tablet macrocrystal
avidoxy 1 nitrofurantoin
monohydrate 1
azithromycin oral macrocrystals
suspension 1
reconstituted NUZYRA ORAL 3
azithromycin oral tablet 1 penicillin v potassium
1
oral tablet
cefadroxil oral capsule 1
SEYSARA 3 ST
cefdinir 1
sulfamethoxazole-
cefuroxime axetil 1 1
trimethoprim oral tablet
cephalexin oral capsule 1 vandazole 1
cephalexin oral XENLETA 3
suspension 1
reconstituted XEPI 3
ciprofloxacin hcl oral 1 XIMINO 3
clarithromycin oral Anticoagulants
1
tablet ELIQUIS 2 QL
clindamycin hcl oral 1 ELIQUIS DVT/PE
2 QL
CLINDESSE 3 STARTER PACK
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
enoxaparin sodium TOPAMAX 3 ST
injection solution 1 QL TOPAMAX SPRINKLE 3 ST
prefilled syringe
topiramate oral tablet 1
jantoven 1
TROKENDI XR 3 ST
PRADAXA 2 QL
VALTOCO 3 QL
warfarin sodium oral 1
VIMPAT ORAL
XARELTO 2 QL 3 ST
TABLET
XARELTO STARTER XCOPRI 3 ST
2 QL
PACK
ZONEGRAN 3 ST
Anticonvulsants -
Drugs for Seizures zonisamide oral 1
APTIOM 3 Antidementia Agents
- Drugs for
BRIVIACT Alzheimer's Disease
3
INTRAVENOUS and Dementia
BRIVIACT ORAL 3 ST donepezil hcl oral tablet 1
carbamazepine oral memantine hcl oral
1 1
tablet tablet
divalproex sodium er 1 NAMZARIC 2 QL
divalproex sodium oral Antidepressants
1
tablet delayed release
amitriptyline hcl oral 1
EPIDIOLEX 3 PA; SP
bupropion hcl er (sr) 1 QL
epitol 1
bupropion hcl er (xl)
FYCOMPA 3 oral tablet extended
1 QL
gabapentin oral release 24 hour 150
1
capsule mg, 300 mg
gabapentin oral tablet bupropion hcl oral 1
1
600 mg, 800 mg citalopram
lamotrigine er 1 hydrobromide oral 1
lamotrigine oral tablet 1 tablet
levetiracetam oral desvenlafaxine
1 1 QL
tablet succinate er
NAYZILAM 3 QL doxepin hcl oral
1
capsule
oxcarbazepine oral
1 duloxetine hcl oral 1 QL
tablet
roweepra 1 escitalopram oxalate
1
oral tablet
subvenite 1
fluoxetine hcl oral
SYMPAZAN 3 PA 1
capsule
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
fluoxetine hcl oral tablet 1 ciclopirox external
1 ++
fluvoxamine maleate 1 solution
LYBALVI 3 ST; QL clotrimazole-
betamethasone 1
mirtazapine oral tablet 1 external cream
nortriptyline hcl oral CRESEMBA ORAL 3 PA
1
capsule
fluconazole oral tablet 1
paroxetine hcl oral
1 GYNAZOLE-1 3
tablet
sertraline hcl oral tablet 1 ketoconazole external
1
cream
SPRAVATO (56 MG
3 PA; SP ketoconazole external
DOSE) 1
shampoo
SPRAVATO (84 MG
3 PA; SP nystatin external cream 1
DOSE)
trazodone hcl oral 1 nystatin external
1
ointment
TRINTELLIX 3 ST; QL
nystatin mouth/throat 1
venlafaxine hcl 1
terbinafine hcl oral 1 QL
venlafaxine hcl er 1
terconazole vaginal
VIIBRYD 3 ST; QL 1
cream
Antiemetics - Drugs Antigout Agents
for Nausea and
Vomiting allopurinol oral 1
meclizine hcl oral tablet colchicine tablet 0.6 mg
1 ++ 1
25 mg oral
metoclopramide hcl colchicine tablet 0.6 mg
1 1 Made by Par
oral tablet oral
ondansetron hcl oral Antimigraine Agents
1 QL
tablet 24 mg AIMOVIG
ondansetron hcl oral SUBCUTANEOUS
1 SOLUTION AUTO- 2 PA; QL
tablet 4 mg, 8 mg
INJECTOR 140
ondansetron odt 1 MG/ML, 70 MG/ML
prochlorperazine AJOVY 2 PA; QL
1
maleate oral
eletriptan hydrobromide 1 QL
scopolamine 1
EMGALITY
VARUBI (180 MG SUBCUTANEOUS
3 QL 3 PA; QL
DOSE) SOLUTION AUTO-
Antifungals INJECTOR 120 MG/ML
ciclodan 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
EMGALITY KISQALI FEMARA 3 PA; SP
SUBCUTANEOUS KISQALI ORAL
SOLUTION 2 PA; QL TABLET THERAPY 3 PA; SP
PREFILLED SYRINGE PACK 200 MG
100 MG/ML
KOSELUGO 3 PA; SP
NURTEC 2 PA; QL
letrozole oral 1
QULIPTA 2 PA; QL
LUMAKRAS 3 PA; SP
rizatriptan benzoate 1 QL
LYNPARZA 2 PA; SP
sumatriptan succinate
1 QL MVASI 2 PA; SP
oral
UBRELVY 2 PA; QL NUBEQA 3 PA; SP
Antineoplastics - ODOMZO 3 PA; SP
Drugs for Cancer ORGOVYX 3 PA; SP
abiraterone acetate 1 PA; SP PANRETIN 3
ALECENSA 2 PA; SP PHESGO 2 PA; SP
ALUNBRIG 2 PA; SP; QL POMALYST 3 PA; SP
anastrozole oral 1 RETEVMO 3 PA; SP
CABOMETYX 2 PA; SP REVLIMID 2 PA; SP
CALQUENCE ORAL ROZLYTREK 3 PA; SP
3 PA; SP
CAPSULE RUXIENCE 2 PA; SP
capecitabine 1 PA; SP SPRYCEL 2 PA; SP
ERIVEDGE 3 PA; SP STIVARGA 3 PA; SP
ERLEADA 3 PA; SP TABRECTA 3 PA; SP
EXKIVITY 3 PA; SP TAGRISSO ORAL
3 PA; SP; QL
GAVRETO 3 PA; SP TABLET 40 MG
IBRANCE ORAL TAGRISSO ORAL
3 PA; SP 3 PA; SP
TABLET TABLET 80 MG
ICLUSIG ORAL tamoxifen citrate oral 1
TABLET 10 MG, 15 3 PA; SP; QL temozolomide 1 PA; SP
MG
TRAZIMERA 2 PA; SP
ICLUSIG ORAL
TABLET 30 MG, 45 3 PA; SP VITRAKVI 3 PA; SP
MG XTANDI 3 PA; SP
IDHIFA 3 PA; SP; QL ZEJULA 2 PA; SP
imatinib mesylate 1 PA; SP ZIRABEV 2 PA; SP
IMBRUVICA 3 PA; SP; QL Antiparasitics
KANJINTI 2 PA; SP ARAKODA 3
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
EMVERM 2 PERSERIS 3 ++
hydroxychloroquine quetiapine fumarate er 1 QL
1
sulfate oral quetiapine fumarate
Antiparkinson Agents oral tablet 100 mg, 200
1 QL
benztropine mesylate mg, 25 mg, 300 mg,
1 400 mg, 50 mg
oral
carbidopa-levodopa REXULTI 3 QL
1
oral tablet risperidone oral tablet 1 QL
INBRIJA 3 PA; SP VRAYLAR 3 QL
KYNMOBI 3 PA; SP; QL ziprasidone hcl 1 QL
KYNMOBI TITRATION Antivirals
3 PA; SP; QL
KIT acyclovir oral tablet 1
NEUPRO 3 ST BIKTARVY 3
NOURIANZ 3 PA CIMDUO 2
ONGENTYS 3 ST DESCOVY ORAL
3
pramipexole TABLET 120-15 MG
1
dihydrochloride DESCOVY ORAL
3 PA
ropinirole hcl 1 TABLET 200-25 MG
RYTARY 3 ST DOVATO 2
Antiplatelets emtricitabine-tenofovir
1
BRILINTA 2 df
clopidogrel bisulfate entecavir 1 QL
1
oral EPCLUSA 2 PA; SP; QL
prasugrel hcl 1 GENVOYA 3
Antipsychotics - HARVONI 2 PA; SP; QL
Drugs for Mood JULUCA 2
Disorders
MAVYRET 2 PA; SP; QL
ABILIFY MAINTENA 3 ++
ODEFSEY 3
aripiprazole oral tablet 1 QL
oseltamivir phosphate
ARISTADA 3 ++ 1 QL
oral
ARISTADA INITIO 3 ++ PREZCOBIX 2
INVEGA HAFYERA 3 ST; ++ RUKOBIA 2
INVEGA SUSTENNA 3 ++ SYMFI 2
INVEGA TRINZA 3 ++ SYMFI LO 2
LATUDA 3 QL SYMTUZA 3
olanzapine oral tablet 1 QL TIVICAY 2
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
TRIUMEQ 2 JIVI 3 SP
valacyclovir hcl oral 1 QL KOATE 2 SP
VEMLIDY 3 ST MULPLETA 2 PA; SP
VOSEVI 2 PA; SP; QL NEULASTA 3 PA; SP
XOFLUZA (40 MG NEULASTA ONPRO 3 PA; SP
3 QL
DOSE) NIVESTYM 2 PA; SP
XOFLUZA (80 MG NOVOEIGHT 2 SP
3 QL
DOSE)
NUWIQ 2 SP
Anxiolytics - Drugs
for Anxiety PROCRIT 2 PA; SP
alprazolam oral tablet 1 QL RECOMBINATE 2 SP
buspirone hcl oral 1 RETACRIT 2 PA; SP
clonazepam oral tablet 1 QL SOLIRIS 3 PA; SP
diazepam oral tablet 1 TAVALISSE 3 PA; SP
hydroxyzine hcl oral ULTOMIRIS 3 PA; SP
1
tablet WILATE 2 SP
hydroxyzine pamoate XYNTHA 2 SP
1
oral XYNTHA SOLOFUSE 2 SP
lorazepam oral tablet 1 QL ZARXIO 2 PA; SP
triazolam 1 QL ZIEXTENZO 3 PA; SP
Bipolar Agents - Cardiovascular
Drugs for Mood Agents - Drugs for
Disorders Heart and Circulation
lithium carbonate er 1 Conditions
lithium carbonate oral amiodarone hcl oral 1
1
capsule amlodipine besylate
Blood Products and 1
oral
Modifiers - Drugs for
amlodipine besylate-
Blood Disorders 1
benazepril hcl
ADVATE 2 SP amlodipine besylate-
1
ADYNOVATE 3 SP valsartan
AFSTYLA 3 SP amlodipine-olmesartan 1
ARANESP (ALBUMIN atenolol oral 1
2 PA; SP
FREE) atenolol-chlorthalidone 1
DOPTELET 3 PA; SP atorvastatin calcium
1
ELOCTATE 3 SP oral
EMPAVELI 3 PA; SP benazepril hcl oral 1
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
12Drug Name Drug Tier Notes Drug Name Drug Tier Notes
BIDIL 3 irbesartan 1
bisoprolol fumarate oral 1 irbesartan-
1
bisoprolol- hydrochlorothiazide
1
hydrochlorothiazide isosorbide mononitrate
1
bumetanide oral 1 er
candesartan cilexetil 1 labetalol hcl oral 1
cartia xt 1 lisinopril oral 1
carvedilol 1 lisinopril-
1
hydrochlorothiazide
chlorthalidone 1
LIVALO 3 ST
clonidine hcl oral 1
losartan potassium oral 1
CORLANOR 3 PA; QL
losartan potassium-hctz 1
digitek 1
lovastatin oral 1
digox 1
metoprolol succinate er 1
digoxin oral tablet 1
metoprolol tartrate oral 1
diltiazem hcl er coated
beads oral capsule MULTAQ 3
1
extended release 24 nadolol oral 1
hour nebivolol hcl 1
doxazosin mesylate NEXLETOL 2 PA; QL
1
oral
NEXLIZET 2 PA; QL
EDARBI 3 ST
nifedipine er 1
EDARBYCLOR 3 ST
nifedipine er osmotic
enalapril maleate oral 1
1 release
tablet
nitroglycerin sublingual 1
ENTRESTO 2 QL
olmesartan medoxomil
ezetimibe 1 1
oral
fenofibrate oral tablet 1 olmesartan medoxomil-
1
flecainide acetate 1 hctz
furosemide oral tablet 1 omega-3-acid ethyl
1
gemfibrozil oral 1 esters
guanfacine hcl 1 pravastatin sodium 1
HEMANGEOL 3 prazosin hcl oral 1
hydralazine hcl oral 1 propranolol hcl er 1
hydrochlorothiazide propranolol hcl oral
1 1
oral tablet
icosapent ethyl 1 PA ramipril 1
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
ranolazine er 1 dexmethylphenidate hcl
1 QL
REPATHA 2 PA; QL er
REPATHA guanfacine hcl er 1
PUSHTRONEX 2 PA; QL JORNAY PM 3 ST; QL
SYSTEM methylphenidate hcl er
1 QL
REPATHA (cd)
2 PA; QL
SURECLICK methylphenidate hcl er
1 QL
rosuvastatin calcium 1 (la)
simvastatin oral 1 methylphenidate hcl er
1 QL
SOAANZ 3 PA (osm)
spironolactone oral 1 methylphenidate hcl er
1 QL
(xr)
TEKTURNA 2
methylphenidate hcl er
TEKTURNA HCT 2 ST oral tablet extended 1 QL
telmisartan 1 release
telmisartan-hctz 1 methylphenidate hcl
1 QL
torsemide 1 oral tablet
triamterene-hctz 1 RELEXXII 3 ST; QL
valsartan oral tablet 1 VYVANSE 2 QL
Central Nervous
valsartan-
1 System Agents -
hydrochlorothiazide
Drugs for Multiple
VASCEPA 2 PA Sclerosis
verapamil hcl er oral AMPYRA 3 PA; SP; QL
1
tablet extended release
AUBAGIO 3 PA; SP; QL
VERQUVO 3 PA; QL
AVONEX PEN 2 PA; SP; QL
Central Nervous
System Agents - AVONEX PREFILLED 2 PA; SP; QL
Drugs for Attention BAFIERTAM 2 PA; SP; QL
Deficit Disorder BETASERON 2 PA; SP; QL
ADDERALL XR 1 QL COPAXONE 2 PA; SP; QL
amphetamine- dimethyl fumarate oral 1 PA; SP; QL
1 QL
dextroamphetamine
GILENYA 3 PA; SP; QL
amphetamine-
3 PA; QL glatiramer acetate 1 PA; SP; QL
dextroamphetamine er
atomoxetine hcl 1 QL glatopa 1 PA; SP; QL
AZSTARYS 3 ST; QL KESIMPTA 2 PA; SP; QL
dexmethylphenidate hcl 1 QL MAVENCLAD 3 PA; SP
MAYZENT 3 PA; SP; QL
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
MAYZENT STARTER Dental and Oral
PACK ORAL TABLET Agents - Drugs for
3 PA; SP; QL Mouth and Throat
THERAPY PACK 0.25
MG Conditions
REBIF 3 PA; SP; QL chlorhexidine gluconate
1
REBIF REBIDOSE 3 PA; SP; QL mouth/throat
REBIF REBIDOSE lidocaine hcl
3 PA; SP; QL 1
TITRATION PACK mouth/throat
REBIF TITRATION lidocaine viscous hcl 1
3 PA; SP; QL
PACK periogard 1
VUMERITY 2 PA; SP; QL Dermatological
ZEPOSIA 3 PA; SP; QL Agents - Drugs for
Skin Conditions
ZEPOSIA 7-DAY
3 PA; SP; QL ABSORICA LD 3 PA
STARTER PACK
ZEPOSIA STARTER accutane 1 PA
3 PA; SP; QL
KIT adapalene-benzoyl
1
Central Nervous peroxide external gel
System Agents - ADBRY 2 PA; SP; QL
Miscellaneous ala-cort external cream
1
ADDYI 3 PA; ++; QL 2.5 %
AUSTEDO 3 PA; SP; QL amnesteem 1 PA
GRALISE 3 ST; QL AMZEEQ 3
HORIZANT 3 PA; QL azelaic acid external 1
INGREZZA 3 PA; SP; QL betamethasone
phentermine hcl oral dipropionate external 1
1 PA; ++ cream
tablet
pregabalin oral capsule 1 QL CIBINQO 2 PA; SP
QSYMIA 3 PA; ++ claravis 1 PA
SAXENDA 3 PA; ++; QL clindacin etz external
1
swab
TEGSEDI 3 PA; SP
clindacin-p 1
TIGLUTIK 3 PA; QL
clindamycin phos-
VYLEESI 3 PA; ++; QL benzoyl perox external 1
WEGOVY 3 PA; ++; QL gel 1-5 %, 1.2-2.5 %
clindamycin phosphate
1
external gel
clindamycin phosphate
1
external lotion
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
clindamycin phosphate mometasone furoate
1 1
external solution external cream
clindamycin phosphate myorisan 1 PA
1
external swab ONEXTON 3
clobetasol propionate OPZELURA 2 ST; QL
1
external cream
QBREXZA 3 QL
clobetasol propionate
1 RETIN-A MICRO
external ointment
PUMP EXTERNAL 2 PA; ++
clobetasol propionate GEL 0.06 %, 0.08 %
1
external solution
RHOFADE 3
DUPIXENT 2 PA; SP; QL
rosadan external cream 1
ENSTILAR 3 QL
rosadan external gel 1
EPIDUO FORTE 3
SANTYL 3 QL
EUCRISA 2 ST
SOOLANTRA 3
FINACEA EXTERNAL
3 TACLONEX 3 QL
FOAM
FINACEA EXTERNAL tacrolimus external 1 QL
3 ST
GEL tretinoin external cream 1 PA; ++
fluocinonide external triamcinolone acetonide
1 1
solution external cream
fluorouracil external triamcinolone acetonide
1 1
cream 5 % external ointment
hydrocortisone external triamcinolone in
1 1
cream 2.5 % absorbase
hydrocortisone external triderm 1
1
ointment 2.5 % tritocin 1
imiquimod external WYNZORA 3 PA; QL
1 ST
cream 3.75 %
zenatane 1 PA
imiquimod external
1 ZILXI 3 ST
cream 5 %
imiquimod pump 1 ST Diabetes -
Antidiabetic Agents
isotretinoin oral 1 PA
BYDUREON BCISE
KLISYRI 3 ST 2 PA; QL
AUTOINJECTOR
metronidazole external BYETTA 10 MCG PEN 2 PA; QL
1
cream
BYETTA 5 MCG PEN 2 PA; QL
metronidazole external
1 FARXIGA 2 ST
gel
MIRVASO 3 glimepiride 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
glipizide er 1 Diabetes - Glucose
glipizide ir 1 Monitoring
glipizide xl 1 ACCU-CHEK
FASTCLIX LANCET 2 ++
glyburide oral 1 KIT
GLYXAMBI 2 ST ACCU-CHEK
JANUMET 2 ST SOFTCLIX LANCET 2 ++
JANUMET XR 2 ST DEVICE KIT
JANUVIA 2 ST CEQUR SIMPLICITY
2 ++
2U KIT
JARDIANCE 2 ST
CEQUR SIMPLICITY
JENTADUETO 2 ST 2 ++
STARTER KIT
JENTADUETO XR 2 ST CONTOUR MONITOR
2 ++
metformin hcl er 1 KIT W/DEVICE
metformin hcl er (mod) 1 PA CONTOUR NEXT EZ
2 ++
metformin hcl er (osm) 1 KIT W/DEVICE
metformin hcl oral CONTOUR NEXT GEN
2 ++
tablet 1000 mg, 500 1 MONITOR
mg, 850 mg CONTOUR NEXT LINK
2 ++
metformin hcl oral KIT W/DEVICE
1 PA
tablet 625 mg CONTOUR NEXT
OZEMPIC 2 PA; QL MONITOR KIT 2 ++
W/DEVICE
pioglitazone hcl 1
CONTOUR NEXT ONE
RYBELSUS 2 PA; QL 2 ++
KIT
SOLIQUA 2 ST; QL CONTOUR NEXT
2 ++; QL
SYMLINPEN 120 3 PA TEST STRIPS
SYMLINPEN 60 3 PA CONTOUR TEST
2 ++; QL
SYNJARDY 2 ST STRIPS
SYNJARDY XR 2 ST DEXCOM G6
2 PA; ++
RECEIVER
TRADJENTA 2 ST
DEXCOM G6 SENSOR 2 PA; ++
TRIJARDY XR 2 ST
DEXCOM G6
TRULICITY 2 PA; QL 2 PA; ++
TRANSMITTER
VICTOZA 2 PA; QL FREESTYLE LIBRE 14
2 PA; ++
XIGDUO XR 2 ST DAY READER
FREESTYLE LIBRE 14
2 PA; ++
DAY SENSOR
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
FREESTYLE LIBRE 2 GLUCAGON
2 PA; ++
READER EMERGENCY KIT
Made by
FREESTYLE LIBRE 2 INJECTION 2
2 PA; ++ Fresenius
SENSOR SOLUTION
RECONSTITUTED
FREESTYLE LIBRE 3
2 PA; ++ ZEGALOGUE 2
SENSOR
GHT BLOOD Diabetes - Insulins
3 PA; ++
GLUCOSE MONITOR ADMELOG 3 ST; ++
GUARDIAN CONNECT ADMELOG
3 PA; ++ 3 ST; ++
TRANSMITTER SOLOSTAR
GUARDIAN LINK 3 BASAGLAR KWIKPEN 3 ST; ++
3 PA; ++
TRANSMITTER BD ULTRA-FINE
GUARDIAN SENSOR INSULIN SYRINGES
3 PA; ++
(3) 30G X 1/2" 0.3 ML,
GUARDIAN SENSOR 30G X 1/2" 0.5 ML,
3 PA; ++ 30G X 1/2" 1 ML, 31G 2 ++
3
X 15/64" 1 ML, 31G X
ONETOUCH ULTRA 5/16" 0.3 ML, 31G X
2 ++; QL
TEST STRIPS 5/16" 0.5 ML, 31G X
ONETOUCH ULTRA 2 5/16" 1 ML
2 ++
KIT W/DEVICE HUMALOG 2 ++
ONETOUCH ULTRA HUMALOG KWIKPEN 2 ++
2 ++
MINI KIT W/DEVICE
HUMALOG MIX 50/50
ONETOUCH VERIO 2 ++
2 ++ KWIKPEN
FLEX SYSTEM
HUMALOG MIX 50/50
ONETOUCH VERIO 2 ++
2 ++; QL VIAL
TEST STRIPS
HUMALOG MIX 75/25
ONETOUCH VERIO IQ 2 ++
2 ++ KWIKPEN
SYSTEM
HUMALOG MIX 75/25
ONETOUCH VERIO 2 ++
VIAL
REFLECT KIT 2 ++
W/DEVICE HUMALOG U-100
2 ++
JUNIOR KWIKPEN
Diabetes - Glycemic
Agents HUMULIN 70/30
2 ++
KWIKPEN
BAQSIMI ONE PACK 2
HUMULIN 70/30 VIAL 2 ++
BAQSIMI TWO PACK 2
HUMULIN N KWIKPEN 2 ++
HUMULIN N VIAL 2 ++
HUMULIN R U-500
2 ++
KWIKPEN
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
HUMULIN R U-500 NOVOLOG PENFILL 2 ++
2 ++
VIAL NOVOLOG RELION 3 PA; ++
HUMULIN R VIAL 2 ++ NOVOLOG U-100 VIAL 2 ++
INSULIN ASPART 2 PA; ++ TOUJEO MAX
2 ++
INSULIN ASPART SOLOSTAR
2 PA; ++
FLEXPEN TOUJEO SOLOSTAR 2 ++
INSULIN GLARGINE 3 PA; ++ TRESIBA 2 ++
INSULIN GLARGINE TRESIBA
3 PA; ++ 2 ++
SOLOSTAR FLEXTOUCH
INSULIN LISPRO 2 PA; ++ Electrolytes / Minerals
INSULIN LISPRO (1 / Metals / Vitamins
2 PA; ++
UNIT DIAL) ACCRUFER 3 ST
INSULIN LISPRO cyanocobalamin
2 PA; ++
JUNIOR KWIKPEN injection solution 1000 1 ++
INSULIN LISPRO mcg/ml
2 PA; ++
PROT & LISPRO ergocalciferol oral
1 ++
LANTUS SOLOSTAR 2 ++ capsule
LANTUS U-100 VIAL 2 ++ klor-con 10 1
LEVEMIR U-100 klor-con m10 1
2 ++
FLEXTOUCH klor-con m15 1
LEVEMIR U-100 VIAL 2 ++ klor-con m20 1
LYUMJEV KWIKPEN 2 ++ klor-con oral tablet
1
LYUMJEV VIAL 2 ++ extended release
NOVOLIN 70/30 LOKELMA 3
2 ++
FLEXPEN NASCOBAL 3 ++
NOVOLIN 70/30 VIAL 2 ++ potassium chloride crys
1
NOVOLIN N FLEXPEN 2 ++ er
NOVOLIN N VIAL 2 ++ potassium chloride er 1
NOVOLIN R FLEXPEN 2 ++ potassium citrate er 1
NOVOLIN R VIAL 2 ++ VELTASSA 3
NOVOLOG FLEXPEN 2 ++ vitamin d
NOVOLOG FLEXPEN (ergocalciferol) oral
3 PA; ++ 1 ++
RELION capsule 1.25 mg
(50000 ut), 50000 unit
NOVOLOG MIX 70/30
2 ++
FLEXPEN
NOVOLOG MIX 70/30
2 ++
VIAL
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
Gastrointestinal glycopyrrolate oral
Agents - Drugs for 1 QL
tablet 1 mg, 2 mg
Acid Reflux and Ulcer hyoscyamine sulfate sl 1
DEXILANT 2 ++; QL hyoscyamine sulfate
1
famotidine oral sublingual
suspension 1 ++ lactulose oral solution 1
reconstituted
LINZESS 2 ST; QL
famotidine oral tablet
1 ++ MOTEGRITY 3 ST; QL
40 mg
lansoprazole oral MOVANTIK 2 ST; QL
capsule delayed 1 ++; QL OMECLAMOX-PAK 2
release 30 mg peg 3350-kcl-na bicarb-
1
misoprostol oral 1 nacl
omeprazole oral peg-3350/electrolytes 1
capsule delayed 1 QL PYLERA 2
release 10 mg, 40 mg
SUPREP BOWEL
pantoprazole sodium 3
PREP KIT
oral tablet delayed 1 QL
release SUTAB 3
rabeprazole sodium SYMPROIC 2 ST; QL
oral tablet delayed 1 ++; QL TALICIA 3
release TRULANCE 3 ST; QL
sucralfate oral 1 VIBERZI 3 PA; QL
Gastrointestinal Genetic or Enzyme
Agents - Drugs for Disorder - Drugs for
Bowel, Intestine and Replacement,
Stomach Conditions Modification,
CLENPIQ 3 Treatment
constulose 1 CERDELGA 3 PA; SP
dicyclomine hcl oral CREON 2
1
capsule NITYR 3 PA; SP
dicyclomine hcl oral ORFADIN 3 PA; SP
1
tablet
PANCREAZE 3 ST
diphenoxylate-atropine
1 PERTZYE 3 ST
oral tablet
gavilyte-g 1 STRENSIQ 2 PA; SP
gavilyte-n with flavor ZENPEP 2
pack oral solution 1 ZOLGENSMA 3 PA; SP
reconstituted 420 gm
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
Genitourinary Agents hydrocortisone oral 1
- Drugs for Bladder, methylprednisolone
Genital and Kidney 1
oral
Conditions
prednisolone oral 1
DEPEN TITRATABS 2 SP
prednisolone sodium
MYRBETRIQ 2 1
phosphate oral solution
oxybutynin chloride er 1 prednisone oral tablet 1
oxybutynin chloride oral prednisone oral tablet
1 1
tablet therapy pack
phenazo oral tablet 200 Hormonal Agents -
1
mg Men's Health
phenazopyridine hcl ANDRODERM 2 PA
oral tablet 100 mg, 200 1
mg testosterone cypionate
1 PA
intramuscular
sildenafil citrate oral
tablet 100 mg, 25 mg, 1 ++; QL testosterone
1 PA
50 mg transdermal gel
solifenacin succinate 1 XYOSTED 3 PA
STENDRA 3 ++; QL Hormonal Agents -
Pituitary
tadalafil oral 1 ++; QL
ACTHAR 2 PA; SP
THIOLA 3 SP
cabergoline 1
THIOLA EC 3 SP
clomiphene citrate oral 1 ++
tolterodine tartrate er 1
CORTROPHIN 2 PA; SP
VELPHORO 3
FOLLISTIM AQ 2 PA; ++; SP
Genitourinary Agents
- Drugs for Prostate PA; Made by
Conditions ganirelix acetate 1 Organon/Merc
k; ++; SP
alfuzosin hcl er 1
LUPRON DEPOT (1-
dutasteride oral 1 MONTH)
2 PA; SP
finasteride oral tablet 5 INTRAMUSCULAR KIT
1
mg 7.5 MG
tamsulosin hcl 1 LUPRON DEPOT (3-
Hormonal Agents - MONTH)
2 PA; SP
Adrenal INTRAMUSCULAR KIT
22.5 MG
dexamethasone oral
1 LUPRON DEPOT (4-
tablet
MONTH)
fludrocortisone acetate 2 PA; SP
1 INTRAMUSCULAR KIT
oral 30MG
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
LUPRON DEPOT (6- aurovela 1/20 1 ++
MONTH) aurovela 24 fe 1 ++
2 PA; SP
INTRAMUSCULAR KIT
45MG aurovela fe 1.5/30 1 ++
NOCDURNA 3 aurovela fe 1/20 1 ++
NORDITROPIN aviane 1 ++
2 PA; ++; SP
FLEXPRO ayuna 1 ++
NUTROPIN AQ BALCOLTRA 3 ++
2 PA; ++; SP
NUSPIN 10 balziva 1 ++
NUTROPIN AQ BIJUVA 3
2 PA; ++; SP
NUSPIN 20
blisovi 24 fe 1 ++
NUTROPIN AQ
2 PA; ++; SP blisovi fe 1.5/30 1 ++
NUSPIN 5
ORILISSA 2 PA; QL blisovi fe 1/20 1 ++
OVIDREL 3 PA; ++; SP briellyn 1 ++
SOMATULINE DEPOT 3 PA; SP camila 1 ++
SUPPRELIN LA 2 PA; SP; QL camrese 1 ++; QL
TRIPTODUR 3 PA; SP; QL camrese lo 1 ++; QL
Hormonal Agents - chateal 1 ++
Selective Estrogen chateal eq 1 ++
Receptor Modifying
CLIMARA PRO 2
Agents
cryselle-28 1 ++
OSPHENA 3
cyred 1 ++
Hormonal Agents -
Sex Hormones and cyred eq 1 ++
Birth Control dasetta 1/35 1 ++
afirmelle 1 ++ daysee 1 ++; QL
altavera 1 ++ deblitane 1 ++
alyacen 1/35 1 ++ delyla 1 ++
amabelz 1 desogestrel-ethinyl
amethia 1 ++; QL estradiol oral tablet 1 ++
0.15-30 mg-mcg
ANNOVERA 3 ++; QL
DIVIGEL 3
apri 1 ++
dotti 1
ashlyna 1 ++; QL
drospirenone-ethinyl
aubra 1 ++ 1 ++
estradiol
aubra eq 1 ++ DUAVEE 2
aurovela 1.5/30 1 ++ ELESTRIN 3
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
elinest 1 ++ jolessa 1 ++; QL
eluryng 1 ++ juleber 1 ++
emoquette 1 ++ junel 1.5/30 1 ++
ENDOMETRIN 2 ++ junel 1/20 1 ++
enskyce 1 ++ junel fe 1.5/30 1 ++
errin 1 ++ junel fe 1/20 1 ++
estarylla 1 ++ junel fe 24 1 ++
estradiol oral 1 kalliga 1 ++
estradiol transdermal 1 kurvelo 1 ++
estradiol vaginal 1 larin 1.5/30 1 ++
estradiol-norethindrone larin 1/20 1 ++
1
acet larin 24 fe 1 ++
ESTROGEL 3 larin fe 1.5/30 1 ++
etonogestrel-ethinyl larin fe 1/20 1 ++
1 ++
estradiol
larissia oral tablet 0.1-
EVAMIST 3 1 ++
20 mg-mcg
falmina 1 ++ lessina 1 ++
fayosim 1 ++; QL levonorgest-eth est &
1 ++; QL
femynor 1 ++ eth est
hailey 1.5/30 1 ++ levonorgest-eth estrad
1 ++; QL
hailey 24 fe 1 ++ 91-day
hailey fe 1.5/30 1 ++ levonorgestrel-ethinyl
estrad oral tablet 0.1-20
hailey fe 1/20 1 ++ 1 ++
mg-mcg, 0.15-30 mg-
heather 1 ++ mcg
iclevia 1 ++; QL levora 0.15/30 (28) 1 ++
IMVEXXY LO LOESTRIN FE 3 ++
2
MAINTENANCE PACK lojaimiess 1 ++; QL
IMVEXXY STARTER loryna 1 ++
2
PACK
low-ogestrel 1 ++
incassia 1 ++
lo-zumandimine 1 ++
introvale 1 ++; QL
lutera 1 ++
isibloom 1 ++
lyleq 1 ++
jaimiess 1 ++; QL
lyllana 1
jasmiel 1 ++
lyza 1 ++
jencycla 1 ++
MAKENA 2 PA; SP
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
marlissa 1 ++ nymyo 1 ++
medroxyprogesterone ocella 1 ++
1 ++; QL
acetate intramuscular ORIAHNN 2 PA; QL
medroxyprogesterone philith 1 ++
1
acetate oral
pirmella 1/35 1 ++
microgestin 1.5/30 1 ++
portia-28 1 ++
microgestin 1/20 1 ++
PREMARIN ORAL 2
microgestin 24 fe 1 ++
PREMARIN VAGINAL 2
microgestin fe 1.5/30 1 ++
PREMPHASE 2
microgestin fe 1/20 1 ++
PREMPRO 2
mili 1 ++
progesterone oral 1
mimvey 1
reclipsen 1 ++
MIRENA (52 MG) 3 ++
rivelsa 1 ++; QL
mono-linyah 1 ++
setlakin 1 ++; QL
MYFEMBREE 2 PA; QL
sharobel 1 ++
NATAZIA 2 ++
simpesse 1 ++; QL
necon 0.5/35 (28) 1 ++
sprintec 28 1 ++
NEXTSTELLIS 3 ++
sronyx 1 ++
nikki 1 ++
syeda 1 ++
nora-be 1 ++
tarina 24 fe 1 ++
norethin ace-eth
1 ++ tarina fe 1/20 1 ++
estrad-fe oral tablet
norethindrone acetate tarina fe 1/20 eq 1 ++
1
oral tri femynor 1 ++
norethindrone acet- tri-estarylla 1 ++
1 ++
ethinyl est tri-linyah 1 ++
norethindrone oral 1 ++ tri-lo-estarylla 1 ++
norgestimate-eth tri-lo-marzia 1 ++
1 ++
estradiol
tri-lo-mili 1 ++
norgestimate-ethinyl
1 ++ tri-lo-sprintec 1 ++
estradiol triphasic
norlyroc 1 ++ tri-mili 1 ++
nortrel 0.5/35 (28) 1 ++ tri-nymyo 1 ++
nortrel 1/35 (21) 1 ++ tri-sprintec 1 ++
nortrel 1/35 (28) 1 ++ tri-vylibra 1 ++
nylia 1/35 1 ++ tri-vylibra lo 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
vestura 1 ++ BENLYSTA
vienva 1 ++ SUBCUTANEOUS
3 PA; SP
SOLUTION AUTO-
vyfemla 1 ++ INJECTOR
vylibra 1 ++ CIMZIA 2 PA; SP
wera 1 ++ CIMZIA PREFILLED
2 PA; SP
xulane 1 ++ KIT
yuvafem 1 CIMZIA STARTER KIT 2 PA; SP
zafemy 1 ++ COSENTYX (300 MG
3 PA; SP
zumandimine 1 ++ DOSE)
Hormonal Agents - COSENTYX 150
3 PA; SP
Thyroid MG/ML
ARMOUR THYROID 3 ST COSENTYX
SENSOREADY (300 3 PA; SP
euthyrox 1 MG)
levo-t 1 COSENTYX
3 PA; SP
levothyroxine sodium SENSOREADY PEN
1
oral tablet cyclosporine modified
1
levoxyl 1 oral capsule
liothyronine sodium oral 1 ENBREL 2 PA; SP
methimazole oral 1 ENBREL MINI 2 PA; SP
np thyroid 1 ENBREL SURECLICK 2 PA; SP
SYNTHROID 3 ST ENVARSUS XR 3
TIROSINT 3 gengraf oral capsule 1
TIROSINT-SOL 3 HAEGARDA 3 PA; SP
unithroid 1 HUMIRA 2 PA; SP
Immunological HUMIRA PEDIATRIC
2 PA; SP
Agents - Drugs for CROHNS START
Immune System HUMIRA PEN 2 PA; SP
Stimulation or
Suppression HUMIRA PEN-
2 PA; SP
CD/UC/HS STARTER
ACTEMRA ACTPEN 3 PA; 3P; SP
HUMIRA PEN-
ACTEMRA PEDIATRIC UC 2 PA; SP
3 PA; 3P; SP
SUBCUTANEOUS START
AVSOLA 2 PA; SP HUMIRA PEN-
azathioprine oral 1 PS/UV/ADOL HS 2 PA; SP
START
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
HUMIRA PEN- TAKHZYRO
PSOR/UVEIT 2 PA; SP SUBCUTANEOUS 3 PA; SP
STARTER SOLUTION
INFLECTRA 2 PA; SP TALTZ 3 PA; 3P; SP
leflunomide oral 1 TREMFYA 2 PA; SP
LUPKYNIS 3 PA; SP; QL TREXALL 3
methotrexate oral 1 XELJANZ 2 PA; SP
methotrexate sodium XELJANZ XR 2 PA; SP
1
oral XEMBIFY 3 PA; SP
mycophenolate mofetil Inflammatory Bowel
1
oral capsule Disease Agents
mycophenolate mofetil APRISO 1
1
oral tablet
CORTIFOAM 3
mycophenolate sodium 1
DIPENTUM 3
ORENCIA 3 PA; 3P; SP
hydrocortisone
ORENCIA CLICKJECT 3 PA; 3P; SP 1
(perianal)
ORLADEYO 3 PA; SP; QL LIALDA 1
OTEZLA 2 PA; SP mesalamine er oral
3 PA
RASUVO 2 PA; QL capsule 0.375 gm
REDITREX 3 PA; QL mesalamine oral tablet
3 PA
RINVOQ 2 PA; SP delayed release 1.2 gm
RUCONEST 3 PA; SP; QL mesalamine oral tablet
delayed release 800 1
SIMPONI 2 PA; SP mg
SIMPONI ARIA 2 PA; SP PENTASA ORAL
sirolimus oral tablet 1 CAPSULE EXTENDED 3
SKYRIZI (150 MG RELEASE 250 MG
2 PA; SP
DOSE) PROCTOFOAM HC 2
SKYRIZI PEN 2 PA; SP procto-med hc 1
SKYRIZI procto-pak 1
SUBCUTANEOUS proctosol hc 1
2 PA; SP
SOLUTION
PREFILLED SYRINGE proctozone-hc 1
STELARA sulfasalazine oral tablet 1
2 PA; SP
INTRAVENOUS UCERIS RECTAL 3
STELARA
2 PA; SP; QL
SUBCUTANEOUS
tacrolimus oral 1
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
26Drug Name Drug Tier Notes Drug Name Drug Tier Notes
Metabolic Bone OMNIPOD 5 G6
Disease Agents - 2 ++
INTRO (GEN 5)
Drugs for OMNIPOD 5 G6 POD
Osteoporosis 2 ++
(GEN 5)
alendronate sodium OMNIPOD CLASSIC
1 2 ++
oral tablet 10 mg, 5 mg PDM (GEN 3)
alendronate sodium OMNIPOD CLASSIC
oral tablet 35 mg, 70 1 QL 2 ++
PODS (GEN 3)
mg
OMNIPOD DASH
ibandronate sodium 2 ++
1 QL INTRO (GEN 4)
oral
OMNIPOD DASH PDM
PROLIA 2 PA; SP; QL 2 ++
(GEN 4)
TERIPARATIDE OMNIPOD DASH
2 PA; SP 2 ++
(RECOMBINANT) PODS (GEN 4)
TYMLOS 2 PA; SP V-GO 20 2 ++
Metabolic Bone V-GO 30 2 ++
Disease Agents -
Other V-GO 40 2 ++
calcitriol oral capsule 1 VYVGART 3 PA; SP
RAYALDEE 3 Ophthalmic Agents -
Drugs for Eye Allergy,
Miscellaneous Infection and
Therapeutic Agents Inflammation
BD ULTRA-FINE PEN AZASITE 3
2 ++
NEEDLES
BESIVANCE 3
PA; Non-
BOTOX 2 ciprofloxacin hcl
Cosmetic 1
ophthalmic
DUROLANE 2 PA
erythromycin
ENDARI 3 PA 1
ophthalmic
EUFLEXXA 2 PA EYSUVIS 3 PA
GELSYN-3 2 PA FLAREX 3
KERENDIA 3 PA; QL INVELTYS 3
NOVOFINE ketorolac tromethamine
AUTOCOVER PEN 2 ++ 1
ophthalmic
NEEDLE
LOTEMAX SM 3
NOVOFINE PEN
2 ++ moxifloxacin hcl
NEEDLE 1
ophthalmic solution
NOVOFINE PLUS PEN
2 ++
NEEDLE
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
neomycin-polymyxin- ZIOPTAN 3 QL
dexameth ophthalmic 1 Ophthalmic Agents -
ointment Drugs for
neomycin-polymyxin- Miscellaneous Eye
dexameth ophthalmic Conditions
1
suspension 3.5-10000- cyclosporine
0.1 3 PA
ophthalmic
ofloxacin ophthalmic 1 polymyxin b-
1
prednisolone acetate trimethoprim
1
ophthalmic POLYTRIM 3
PROLENSA 2 QL RESTASIS 1 PA
TOBRADEX ST 3 RESTASIS
2 PA
tobramycin- MULTIDOSE
1
dexamethasone XIIDRA 2 PA
TYRVAYA 3 PA; QL ZYLET 3
Ophthalmic Agents - Otic Agents - Drugs
Drugs for Glaucoma for Ear Conditions
ALPHAGAN P 2 ciprofloxacin-
1
BETIMOL 3 dexamethasone
brimonidine tartrate neomycin-polymyxin-hc
1 1
ophthalmic otic suspension
COMBIGAN 3 ST ofloxacin otic 1
dorzolamide hcl-timolol OTOVEL 3 PA
1
mal Respiratory Tract /
dorzolamide hcl-timolol Pulmonary Agents -
1 Drugs for Allergies,
mal pf
latanoprost ophthalmic 1 Cough, Cold
LUMIGAN 2 QL azelastine hcl nasal
solution 0.1 %, 137 1 QL
RHOPRESSA 3 QL mcg/spray
ROCKLATAN 3 QL azelastine-fluticasone 1 QL
SIMBRINZA 2 benzonatate 1
timolol maleate (once- cyproheptadine hcl oral
1 1
daily) tablet
timolol maleate DYMISTA 2 QL
1
ocudose
FASENRA 2 PA; SP
timolol maleate
1 FASENRA PEN 2 PA; SP
ophthalmic solution
timolol maleate pf 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
ipratropium bromide albuterol sulfate hfa
1
nasal aerosol solution 108
1 QL
mometasone furoate (90 base) mcg/act
1 ++; QL inhalation
nasal
NUCALA albuterol sulfate hfa
SUBCUTANEOUS aerosol solution 108 Made by Par;
2 PA; SP; QL 1
SOLUTION AUTO- (90 base) mcg/act QL
INJECTOR inhalation
NUCALA albuterol sulfate hfa
SUBCUTANEOUS aerosol solution 108 Made by Teva;
1
SOLUTION 2 PA; SP; QL (90 base) mcg/act QL
PREFILLED SYRINGE inhalation
100 MG/ML ALBUTEROL
NUCALA SULFATE HFA
SUBCUTANEOUS AEROSOL SOLUTION ST; Made by
2 PA; SP; QL 3
SOLUTION 108 (90 BASE) Prasco; QL
RECONSTITUTED MCG/ACT
INHALATION
OMNARIS 3 ++; QL
albuterol sulfate
promethazine hcl oral 1 QL
1 inhalation
tablet
ALVESCO 3 ST; QL
promethazine-codeine 1 PA; QL
ANORO ELLIPTA 2 QL
promethazine-dm 1
ARNUITY ELLIPTA 2 QL
pseudoephedrine-
1 ATROVENT HFA 3 QL
bromphen-dm
QNASL 3 ++; QL AUVI-Q INJECTION
SOLUTION AUTO-
QNASL CHILDRENS 3 ++; QL 3 QL
INJECTOR 0.1
XHANCE 3 ST; ++; QL MG/0.1ML
XOLAIR 2 PA; SP BREO ELLIPTA 2 QL
ZETONNA 3 ++; QL BREZTRI
2 QL
Respiratory Tract / AEROSPHERE
Pulmonary Agents - budesonide inhalation 1 QL
Drugs for Asthma and BUDESONIDE-
Other Lung FORMOTEROL 3 PA; QL
Conditions FUMARATE
ADVAIR DISKUS 1 QL COMBIVENT
2 QL
ADVAIR HFA 2 QL RESPIMAT
epinephrine injection
solution auto-injector 1
0.15 mg/0.15ml
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
epinephrine solution PERFOROMIST 3 QL
auto-injector 0.15 1 Made by Mylan PROAIR HFA 3 ST; QL
mg/0.3ml injection
PROVENTIL HFA 3 ST; QL
epinephrine solution
auto-injector 0.15 1 PULMICORT
2 QL
mg/0.3ml injection FLEXHALER
epinephrine solution QVAR REDIHALER 2 QL
auto-injector 0.3 1 Made by Mylan SEREVENT DISKUS 2 QL
mg/0.3ml injection SPIRIVA
2 QL
epinephrine solution HANDIHALER
auto-injector 0.3 1 SPIRIVA RESPIMAT 2 QL
mg/0.3ml injection
STIOLTO RESPIMAT 2 QL
EPIPEN 2-PAK 3 ST
STRIVERDI
EPIPEN JR 2-PAK 3 ST 2 QL
RESPIMAT
ESBRIET 3 PA; SP SYMBICORT 2 QL
FLOVENT DISKUS 2 QL SYMJEPI 3
FLOVENT HFA 2 QL TRELEGY ELLIPTA 2 QL
FLUTICASONE VENTOLIN HFA 3 ST; QL
FUROATE- 3 PA; QL
VILANTEROL wixela inhub 3 PA; QL
FLUTICASONE YUPELRI 3 QL
3 PA; QL
PROPIONATE HFA Respiratory Tract /
fluticasone-salmeterol Pulmonary Agents -
inhalation aerosol Drugs for Cystic
powder breath Fibrosis
activated 100-50 3 PA; QL BRONCHITOL 3 PA; QL
mcg/act, 250-50 PULMOZYME 2 PA; SP
mcg/act, 500-50
mcg/act TOBI PODHALER 3 SP; QL
ipratropium-albuterol 1 QL TRIKAFTA 3 PA; SP; QL
LONHALA MAGNAIR Respiratory Tract /
3 QL Pulmonary Agents -
REFILL KIT
Drugs for Pulmonary
LONHALA MAGNAIR Hypertension
3 QL
STARTER KIT
ADEMPAS 2 PA; SP; QL
montelukast sodium
1 OPSUMIT 2 PA; SP; QL
oral tablet
montelukast sodium ORENITRAM 3 PA; SP
1
oral tablet chewable sildenafil citrate oral
1 PA; SP; QL
OFEV 3 PA; SP tablet 20 mg
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
Skeletal Muscle
Relaxants - Drugs for
Muscle Pain and
Spasm
baclofen oral tablet 1
carisoprodol oral 1
cyclobenzaprine hcl
1
oral
LORZONE 3
metaxalone 1
methocarbamol oral 1
tizanidine hcl oral 1
Sleep Disorder
Agents
armodafinil 1 PA; QL
BELSOMRA 3 ST; QL
DAYVIGO 3 ST; QL
eszopiclone 1 QL
modafinil 1 PA; 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
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
31Index of Drugs
ABILIFY MAINTENA................. 11 amlodipine besylate-valsartan.. 12 azelastine hcl............................ 28
abiraterone acetate................... 10 amlodipine-olmesartan..............12 azelastine-fluticasone............... 28
ABSORICA LD..........................15 amnesteem............................... 15 azithromycin................................7
ACCRUFER.............................. 19 amoxicillin................................... 7 AZSTARYS............................... 14
ACCU-CHEK FASTCLIX amoxicillin-potassium bac.............................................. 6
LANCET KIT............................. 17 clavulanate..................................7 baclofen.................................... 31
ACCU-CHEK SOFTCLIX amphetamine- BAFIERTAM............................. 14
LANCET DEVICE KIT...............17 dextroamphetamine.................. 14 BALCOLTRA.............................22
accutane................................... 15 amphetamine- balziva.......................................22
acetaminophen-codeine..............6 dextroamphetamine er.............. 14 BAQSIMI ONE PACK............... 18
acetaminophen-codeine #2.........6 AMPYRA...................................14 BAQSIMI TWO PACK...............18
acetaminophen-codeine #3.........6 AMZEEQ...................................15 BASAGLAR KWIKPEN............. 18
acetaminophen-codeine #4.........6 anastrozole............................... 10 BD ULTRA-FINE INSULIN
ACTEMRA................................ 25 ANDRODERM.......................... 21 SYRINGES............................... 18
ACTEMRA ACTPEN.................25 ANNOVERA..............................22 BD ULTRA-FINE PEN
ACTHAR................................... 21 ANORO ELLIPTA..................... 29 NEEDLES................................. 27
acyclovir.................................... 11 apap-caff-dihydrocodeine........... 6 BELBUCA................................... 6
adapalene-benzoyl peroxide.....15 apri............................................ 22 BELSOMRA.............................. 31
ADBRY......................................15 APRISO.................................... 26 benazepril hcl............................12
ADDERALL XR......................... 14 APTIOM...................................... 8 BENLYSTA............................... 25
ADDYI....................................... 15 ARAKODA................................ 10 benzonatate.............................. 28
ADEMPAS................................ 30 ARANESP (ALBUMIN FREE)... 12 benztropine mesylate................11
ADMELOG................................ 18 aripiprazole............................... 11 BESIVANCE............................. 27
ADMELOG SOLOSTAR........... 18 ARISTADA................................ 11 betamethasone dipropionate.... 15
ADVAIR DISKUS...................... 29 ARISTADA INITIO.................... 11 BETASERON............................14
ADVAIR HFA............................ 29 armodafinil................................ 31 BETIMOL.................................. 28
ADVATE....................................12 ARMOUR THYROID.................25 BIDIL......................................... 13
ADYNOVATE............................12 ARNUITY ELLIPTA...................29 BIJUVA..................................... 22
afirmelle.................................... 22 ashlyna......................................22 BIKTARVY................................ 11
AFSTYLA.................................. 12 atenolol..................................... 12 bisoprolol fumarate................... 13
AIMOVIG.....................................9 atenolol-chlorthalidone..............12 bisoprolol-hydrochlorothiazide.. 13
AJOVY........................................ 9 atomoxetine hcl.........................14 blisovi 24 fe............................... 22
ala-cort...................................... 15 atorvastatin calcium.................. 12 blisovi fe 1.5/30......................... 22
albuterol sulfate.........................29 ATROVENT HFA...................... 29 blisovi fe 1/20............................ 22
albuterol sulfate hfa...................29 AUBAGIO..................................14 BOTOX..................................... 27
ALBUTEROL SULFATE HFA... 29 aubra.........................................22 BREO ELLIPTA........................ 29
ALECENSA...............................10 aubra eq....................................22 BREZTRI AEROSPHERE.........29
alendronate sodium.................. 27 aurovela 1.5/30......................... 22 briellyn.......................................22
alfuzosin hcl er.......................... 21 aurovela 1/20............................ 22 BRILINTA..................................11
allopurinol....................................9 aurovela 24 fe........................... 22 brimonidine tartrate................... 28
ALPHAGAN P........................... 28 aurovela fe 1.5/30..................... 22 BRIVIACT................................... 8
alprazolam................................ 12 aurovela fe 1/20........................ 22 BRONCHITOL.......................... 30
altavera..................................... 22 AUSTEDO.................................15 budesonide............................... 29
ALUNBRIG................................10 AUVI-Q......................................29 BUDESONIDE-
ALVESCO................................. 29 aviane....................................... 22 FORMOTEROL FUMARATE.... 29
alyacen 1/35..............................22 avidoxy........................................7 bumetanide............................... 13
amabelz.................................... 22 AVONEX PEN...........................14 buprenorphine hcl....................... 6
amethia..................................... 22 AVONEX PREFILLED.............. 14 buprenorphine hcl-naloxone
amiodarone hcl......................... 12 AVSOLA....................................25 hcl............................................... 6
amitriptyline hcl........................... 8 ayuna........................................ 22 bupropion hcl.............................. 8
amlodipine besylate.................. 12 AZASITE................................... 27 bupropion hcl er (sr)....................8
amlodipine besylate-benazepril azathioprine.............................. 25 bupropion hcl er (xl).................... 8
hcl............................................. 12 azelaic acid............................... 15 buspirone hcl.............................12
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