BLUECROSS BLUESHIELD OF WESTERN NEW YORK FORMULARY 2
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BlueCross BlueShield
of Western New York
Formulary 2
Please bring this guide
with you the next time
you visit your doctor.
If you have questions about your prescription drug benefit,
visit the Pharmacy Services section of the BlueCross BlueShield web site at
www.bcbswny.com.
CRP1906_0349 EME52266 MG_001203D
(Revise Date 01/01/2020)
A Division of HealthNow New York Inc. An independent licensee of the BlueCross BlueShield Association. The Cross and Shield
are registered trademarks of the BlueCross BlueShield Association.TABLE OF CONTENTS
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii
Understanding the symbols used
throughout this book . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii
Using this formulary book to help contain costs . iv
Save Money on Your Prescription Drugs. . . . . . . . . . . . . . . . . iv
Finding Medications in the Guide . . . . . . . . . . . . . . . . . . . . . . . . v
Section 1 — Therapeutic Drug Categories . . . . . . . . . . 1
Section II — Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
iiThe BlueCross BlueShield of Western New York Formulary 2 is a list of drugs to help guide physicians and
pharmacists to select the medication that provides the appropriate treatment for the best price.
Introduction
BlueCross Blue Shield of Western New York has established an independent committee of practicing physicians
and a pharmacist to help ensure that our formularies are medically sound and that they support your patients’
health. This committee—called the Pharmacy and Therapeutics Committee—reviews and evaluates medications
on the formulary based on safety and efficacy to help maintain clinical integrity in all therapeutic categories.
Understanding the symbols used throughout this book
Throughout this book, you will see certain symbols that indicate a management program is in place for selected
medications. The symbols are as follows:
Key
P = step edit applies to this drug. Step therapy means that in order to receive the medication
A
with a step edit, a preferred medication must be tried first.
z = Specific quantity limits apply. Quantity limits are in place to ensure members receive the
appropriate amount of medication not to exceed the maximum allowable daily dosage of
medication.
= Prior authorization required. Prior authorization (also referred to as coverage review)
means that a healthcare professional must submit clinical documentation to obtain
approval for a member to receive the medication. Prior authorizations ensure medications
are being used appropriately.
u = Included in tablet-splitting program. The medication can be cut in half to obtain the daily
dose of medication (i.e., 20mg daily of simvastatin can be obtained by 1/2 tablet of
simvastatin 40mg). A member will receive a 1-month supply for half their regular 1-month
copay.
+ = Access restricted to CVS Specialty pharmacy for members with an exclusive CVS Specialty
pharmacy network. Medications must be obtained through specialty pharmacy.
> = Access restricted to Accredo specialty pharmacy for members with an exclusive Accredo
specialty pharmacy network. Medications must be obtained through specialty pharmacy.
o = Custom Home Delivery. The medication should be obtained through the mail service
pharmacy. The medication is subject to a retail refill allowance.
= Affordable Care Act (ACA) Preventive Drug. The medication is included on the ACA
Preventive Drug List.
iiiUsing this formulary book to help contain costs
Many employers, benefit sponsors, and individuals may use the formulary to help manage the
overall cost of providing prescription drug benefits. The formulary offers a wide range of outpatient
medications.
Because there are over 40,000 Food and Drug Administration (FDA)-approved prescription drugs on
the market, not all tier 3 drugs can be listed in this formulary guide. We have included in this printed
formulary guide the drugs that are most commonly prescribed for our members. If you have any
questions regarding coverage of a drug, please call the customer service number on your card.
Save Money on Your Prescription Drugs
Here’s what you can do to save money:
Bring this member guide to your doctor and review the cost-saving information below.
1.
Ask your doctor whether a drug listed in this guide is right for you.*
2.
Tier 3
Tier 1 Tier 2
Lowest cost to you Highest cost to you
The amount you pay for a drug is determined by which medication you purchase and to what tier it is
assigned. Some drug plans exclude certain drugs or classes of drugs from coverage. Please check your
contract or other plan documents if you have a question about your specific drug coverage.
Please refer to your plan documents to confirm your cost share for diabetic drugs and supplies. Cost
share may vary by plan.
Affordable Care Act (ACA) Preventive Drug List
The Affordable Care Act (ACA) Preventive Drug List consists of medications that may be covered at $0.
They are not subject to any annual deductibles, coinsurance, or copayments. Please refer to your plan
documents to confirm if the ACA Preventive Drug List applies to you.
We’ve noted any drugs on the ACA Preventive Drug List within this guide. Please consult the key on
page iii. This list is reviewed periodically and is subject to change.
The presence of a drug on this list does not guarantee coverage. Drugs on this list may require prior
authorization, step-edits, and quantity limits. Restrictions may apply to certain brand-name ACA
medications with generic equivalents. Other restrictions may apply according to U.S. Preventive Services
Task Force (USPSTF) recommendations, which define ACA coverage requirements. These restrictions
may be based on age, dose, diagnosis, and others as recommended by USPSTF. Both prescription and
over-the-counter (OTC) products are eligible to be covered when prescribed by a licensed health care
provider and require a valid prescription.
* Some plan designs require that you use a Tier 1 generic drug if a generic is available.
Disclaimer: The BlueCross BlueShield of Western New York Medication Guide is subject to change, as we regularly review
medications and existing therapies for inclusion in the BlueCross BlueShield of Western New York Formulary 2. The tier
that a medication is currently in may change during the effective dates of the guides due to generic availability.
ivContraceptive Coverage under New York Insurance Law
Contraceptives (for members whose benefits align with contraceptive coverage requirements under
New York Insurance Law): All tier 1 contraceptives are covered at a $0 copayment. Brand-name
contraceptives without a generic equivalent are covered at a $0 copayment. Brand-name contraceptives
with a generic equivalent are covered at the copayment based on your plan design unless deemed
medically necessary by the prescriber. The prescriber must designate “DAW” (Dispense as Written) on
the prescription in order for the brand-name contraceptive with a generic equivalent to be considered
medically necessary and covered at a $0 copayment. Both prescription and over-the-counter (OTC)
products are covered only when prescribed by a licensed health care provider and require a valid
prescription. Please refer to your plan documents to confirm your cost share for contraceptives. Cost
share may vary by plan.
Contraceptives may include implantable rods, intrauterine devices (IUD), shots/injections, oral
contraceptives, patches, vaginal contraceptive rings, diaphragms, sponges, cervical caps, female
condoms, spermicides, and emergency contraceptives. Please see the “Women’s Health” section of this
guide for specific product examples.
Custom Home Delivery: Members must obtain maintenance medications at mail-order after retail allowance is
exhausted for members with Custom Home Delivery Benefit.
Finding Medications in the Guide
This guide lists medications two different ways:
Section 1: Alphabetically by drug category (such as Diabetes, Heart or Pain/Arthritis)
Locate a category and drug on the guide and you will see the tier and copayment for that
drug—Tier 1, Tier 2 or Tier 3—which determines your copayment. To determine if a drug is a
generic or brand-name medication, look at the name of the drug. Generic medications are
lower case (e.g., amoxicillin), and brand-name medications are capitalized (e.g., Advair).
Section 2: Alphabetically by drug name. Use this list to find your drug.
Questions? Please call Pharmacy Services at 1 800 939-3751 if you have any questions about the
BlueCross BlueShield of Western New York Formulary 2. For the most up-to-date version of the Guide,
visit the Pharmacy Services section of our web site at www.bcbswny.com.
vSection I — Therapeutic drug categories
TIER TIER TIER TIER
Allergy/Cough & Cold z tolterodine ER 1 Hexalen 2 +>z Idhifa 3
Antihistamines & Decongestants z trospium 1 Leukeran 2 +>z Inrebic 3
brompheniramine/ phenylephrine 1 z trospium ER 1 Myleran 2 +>z Kisqali 3
brompheniramine/ pseudoephedrine 1 z Myrbetriq 2 Antimetabolites +>z Kisqali Femara Co-Pack 3
o z Toviaz 2 +> capecitabine 1 +>z Lorbrena 3
Pz
cetirizine 1
Detrol 3 mercaptopurine 1 z Mektovi 3
Pz
clemastine 1
Detrol LA 3 methotrexate 1 +>z Nerlynx 3
Pz
cyproheptadine 1
Ditropan XL 3 Purixan 2 +>z Piqray 3
Pz
dexchlorpheniramine 1
Enablex 3 Trexall 3 +z Rozlytrek 3
Pz
diphenhydramine 1
Gelnique 3 z Xatmep 3 +>z Rubraca 3
Pz
hydroxyzine HCl 1
Oxytrol 3 Hormones z Rydapt 3
Pz
hydroxyzine pamoate 1
Sanctura 3 anastrozole 1 +>z Talzenna 3
Pz
levocetirizine 1
+>z
zo
Sanctura XR 3 bicalutamide 1 Tarceva 3
loratadine 1
loratadine-D 1 Cholinergic Agents exemestane 1 +> Temodar 3
pseudoephedrine 1 Urecholine 3 flutamide 1 z Tibsovo 3
Semprex-D 2 Miscellaneous letrozole 1 z Turalio 3
Clarinex-D 3 >z Jynarque 3 leuprolide 1 z Venclexta 3
+>z
zo
desloratadine 3 Blood megestrol 1 Verzenio 3
+>z
zo
Grastek 3 tamoxifen 1 Vitrakvi 3
+>z
z Anticoagulants/antithrombotics
z Odactra 3 anagrelide 1
Fareston 2 Vizimpro 3
+z Oralair 3
+z Nubeqa 3 + Xgeva 3
z
aspirin 325mg OTC 1 z Xospata 3
Ragwitek 3 Miscellaneous
aspirin 81mg OTC 1
+>z abiraterone acetate 250mg z Xpovio 3
o
Expectorant & Cough Products 1
aspirin-dipyridamole 1
+>z erlotinib +z Yonsa 3
o
benzonatate 1 1
clopidogrel 1 z Zejula 3
o
guaifenesin/codeine 1 etoposide 1
dipyridamole 1 Rexinoids
hydrocodone/chlorpheniramine 1 hydroxyurea 1
hydrocodone/homatropine 1
enoxaparin 1
+>z imatinib 1 +> bexarotene 1
promethazine/codeine 1
fondaparinux sodium 1
nilutamide 1 +> Targretin gel 2
+>
heparin 1
promethazine/DM 1 temozolomide 1 Diabetes
+>z Afinitor
jantoven 1
o
promethazine/phenylephrine/ codeine 1 2
+>z Arcalyst
prasugrel 1 Please refer to your plan documents to confirm your
o
pseudoephedrine/codeine 1 2
ticlopidine 1
Cardec/DM 3 +>z Bosulif 2 cost share for diabetic drugs. Cost share may vary
warfarin 1
+>z Cabometyx by plan.
o
Guaifenesin DM 3 2
Brilinta 2
Hycodan 3 z Caprelsa 2 Antidiabetic Agents, Injectable
Coumadin 2
Rondec DM/TR 3 Eliquis 2 +>z Cometriq 2 Basaglar 2
Vituz 3 Fragmin 2 +>z Cotellic 2 z Bydureon 2
Mucolytic Agents Pradaxa 2 +>z Erivedge 2 z Byetta 2
+>z Farydak
z Humalog insulin 2
acetylcysteine inh soln. 1 Xarelto 2 2
Nasal Medications Bevyxxa 3 >z Gilotrif 2 Humulin (all types) 2
+> Hycamtin 2 Lantus 2
azelastine nasal spray 1 zo Durlaza 3
+>z Ibrance 2 z Symlin 2
budesonide nasal spray 1 Innohep 3
z Iclusig 2 Toujeo 2
Clarispray 1 Savaysa 3
z
z Trulicity 2
Zontivity 3 Imbruvica 2 z
Flonase Allergy Relief 1
+>z Inlyta
zo Victoza 2
2 z
Flonase Sensimist 1
+>
Other Blood Modifiers Adlyxin 3
o
Intron A 2 z
zo fluticasone nasal spray 1 cilostazol 1
+>z Iressa 2 P Admelog 3
ipratropium nasal spray 1 +> deferasirox 1
+>z Jakafi 2 P Apidra 3
z Nasacort Allergy 24HR 1 pentoxifylline 1
+>z Lenvima P Fiasp 3
z
2
Rhinocort Allergy 1 trientine 1
+>z Lonsurf P Insulin Lispro 3
+>z Actimmune
2
triamcinolone nasal spray 1 2
+>z Lynparza P Levemir 3
+>
2
Atrovent Nasal Spray 3 Aranesp 2 P
Pzo Beconase AQ
Lysodren 2 Novolin 3
3 +> Jadenu 2 P Novolog 3
Dymista 3 +> Leukine 2 Matulane 2
o Miacalcin inj. 2 +>z Mekinist 2 z Ozempic 3
zo flunisolide nasal spray 3
Pzo mometasone nasal spray
Soliqua 3
> Mesnex 2 z
3 Neulasta 2
+>z Nexavar
Pzo Nasacort AQ
Tanzeum 3
+> 2 z
3 Neupogen 2
+>z Ninlaro P
Pzo Omnaris
Tresiba 3
+> Procrit 2 2
+>z Odomzo
3
Pzo Qnasl
Xultophy 3
+>z Promacta 2 z
2
+>z Pomalyst
3
+>z Revlimid
Antidiabetic Agents, Glucose Elevating Agents
z 2 2
+>z Sprycel
Xhance 3
Pzo Zetonna
2 acarbose 1
Alprolix 3
+>z Stivarga
3 +>
z 2 chlorpropamide 1
Cablivi 3
Alzheimer Agents
+>z Doptelet 3 +>z Sutent 2 z glimepiride 1
zo donepezil 1 +> Eloctate 3 +>z Sylatron 2 glipizide 1
ergoloid mesylates 1 z Endari 3 z Synribo 2 z glipizide ER 1
zo galantamine 1 +> Epogen 3 +>z Tafinlar 2 z glipizide/metformin 1
zo galantamine ER 1 +> Exjade 3 +>z Tagrisso 2 glyburide 1
zo memantine 1 Ferriprox 3 +>z Tasigna 2 glyburide micronized 1
zo memantine ER 1 Fulphila 3 +> Thalomid 2 metformin 1
zo rivastigmine 1 +> Granix 3 +>z Tykerb 2 z metformin ER (generic Glucophage XR) 1
zo rivastigmine patch 1 +> Hemlibra 3 >z Valchlor 2 z metformin/glyburide 1
z Namzaric 2 Mircera 3 +>z Votrient 2 z nateglinide 1
Bladder/Kidney +>z Mulpleta 3 +>z Xalkori 2 z pioglitazone/metformin 1
+> Nivestym 3 +>z Xtandi 2 z repaglinide 1
Acidifiers
Omontys 3 +>z Zelboraf 2 tolazamide 1
K-Phos 3
+> Retacrit 3 +>z Zolinza 2 tolbutamide 1
Alkalinizers
z Tavalisse 3 +z Zydelig 2 z Avandamet 2
potassium citrate 1
> Udenyca 3 +>z Zykadia 2 z Avandaryl 2
Oracit 3
+> Zarxio 3 +>z Zytiga 500mg 2 z Avandia 2
Analgesics Zontivity 3 +>z Alecensa 3 z Duetact 2
+>z Alunbrig
z
phenazopyridine 1 3 Glucagon 2
Anticholinergics Cancer Drugs z Balversa 3 z Glyxambi 2
z oxybutynin 1 Alkylating Agents z Braftovi 3 z Invokamet 2
z oxybutynin ER 1 cyclophosphamide 1 z Calquence 3 z Invokamet XR 2
z Oxytrol for Women 1 Alkeran 2 z Copiktra 3 z Invokana 2
z solifenacin 1 CeeNu 2 +>z Daurismo 3 z Janumet 2
z tolterodine 1 Emcyt 2 +>z Erleada 3 z Janumet XR 2
KEY: P = A step edit applies to this drug. + = Access restricted to CVS Specialty pharmacy if applicable.
z = Specific Quantity Limits Apply. > = Access restricted to Accredo specialty pharmacy if applicable.
= Prior Authorization Required. o = Custom Home Delivery.
u = Included in Tablet-Splitting Program = ACA Preventive Drug
1Section I — Therapeutic drug categories (cont’d)
TIER TIER TIER TIER
z Januvia 2 Tobrex solution 3 z Gloperba 3 Fenofibrate (brand) 3
z Jardiance 2 Anti-inflammatory Pz Uloric 3 zo fenofibric acid, capsule DR 3
Jentadueto 2 fluorometholone ophth 1 z Zurampic 3 zo fluvastatin 3
z Jentadueto XR 2 loteprednol etabonate susp 1 Heart >z Juxtapid 3
Juvisync 2 prednisolone acetate 1 zuo Lescol 3
Synjardy 2 Angiotensin Converting Enzyme Inhibitors Lescol XL 3
o
z prednisolone sod phosphate 1 zo
Tradjenta 2 FML Forte 2 benazepril 1 zuo Lipitor 3
Afrezza 3 FML S.O.P. 2 o captopril 1 o Livalo 3
Baqsimi 3 Lotemax gel, ointment 2 o enalapril 1 Nikita 3
o
z
Pz Farxiga 3 Pred Mild 2 fosinopril 1 omega-3 acid ethyl esters 3
o
z
Pz Fortamet 3 Flarex 3 lisinopril 1 Omtryg 3
o
z
Pz Glumetza 3 Maxidex 3 moexipril 1 zuo Pravachol 3
P Kazano 3 o perindopril 1 Vascepa 3
o
Anti-inflammatory/Anti-infective combinations
P Kombiglyze XR 3 quinapril 1 zuo Zocor 3
o
dexameth/neomycin/poly B 1
P metformin ER (except generic ramipril 1 Zypitamag 3
o
neomycin/bacitracin/poly B/HC 1 zo
Glucophage XR) 3 sulfacetamide/prednisolone ophth 1 trandolapril 1 Beta Blockers
miglitol 3 tobramycin/dexameth 1 zo Epaned 3 o acebutolol 1
P Nesina 3 Tobradex ointment 2 zo Qbrelis 3 o atenolol 1
z Qtern 3 Maxitrol ophth 3 Angiotensin II Antagonists betaxolol 1
P Onglyza 3 Pred-G 3 zo eprosartan 600mg 1 o bisoprolol 1
P Oseni 3 Zylet 3 zo irbesartan 1 o carvedilol 1
repaglinide/metformin 3 Antiviral zo losartan 1 o carvedilol ER 1
Riomet solution 3 z famciclovir ophth 1 zo olmesartan 1 o labetalol 1
Rybelsus 3 trifluridine 1 zo telmisartan 1 o metoprolol 1
Pz Segluromet 3 Beta-Blockers (Eye) zo valsartan 1 o metoprolol ER 1
Pz Steglatro 3 o Pzo Atacand 3 o metoprolol/HCTZ 1
Pzo Avapro
betaxolol HCl 1
z Steglujan 3 o 3 o nadolol 1
Pzo Benicar
carteolol 1
Pz Xigduo XR 3 o 3 o pindolol 1
Pzo Cozaar
levobunolol 1
Diabetic Test Strips o 3 o propranolol 1
Pzo Diovan
metipranolol 1
o
Please refer to your plan documents to confirm your o
3 timolol 1
Pzo Edarbi
timolol 1
o 3 o Bystolic 2
Pzo Micardis
Betoptic-S 2
cost share for diabetic supplies. Cost share may vary
o 3 o Innopran XL 2
Pz
Istalol 3
by plan. Test strips other than OneTouch require Prexxartan 3 Hemangeol 3
Carbonic Anhydrase Inhibitors
prior authorization. o dorzolamide 2% eye drops 1 Anti-Adrenergic Blockers Centrally Acting Calcium Channel Blockers
OneTouch Test Strips o o clonidine, oral, patch 1 o amlodipine 1
P
dorzolamide/timolol eye drops 1
Accu-Chek o o guanfacine 1 o cartia XT 1
P
Azopt 2
Ascensia Breeze o methyldopa 1 o diltia XT 1
P
Miotics
Contour
o midodrine 1 o diltiazem 1
P
pilocarpine 1
Freestyle +>z Northera 2 o diltiazem CD/SR/ER/XR 1
P
Phospholine Iodide 2
Precision Anti-Adrenergic Blockers Peripheral o felodipine ER 1
P TRUEtest Miscellaneous
o doxazosin 1 o isradipine 1
P TRUEtrack Cystaran 2
o prazosin 1 o nicardipine 1
o
Restasis 2
o
z
Ear terazosin 1 nifediac CC 1
o
Xiidra 2
o
z
Cequa 3 Cardura XL 3 nifedical XL 1
Anti-infective Agents
o
z
> Oxervate 3 Antiarrhythmics nifedipine 1
o
acetic acid otic 1
o
z
acetic acid/aluminum acetate 1 Po Rhopressa 3 amiodarone 1 nifedipine SR 1
1 oz Rocklatan 3 digoxin 1 o nimodipine 1
o
ciprofloxacin otic
ofloxacin otic 1 Mydriatics disopyramide 1 o nisoldipine 1
atropine sulfate ophth 1 dofetilide 1 o verapamil/SR 1
o
Domeboro 3
homatropine 1 flecainide 1 Dynacirc/CR 3
o
Xtoro 3
tropicamide 1 mexiletine 1 P Katerzia 3
o
Anti-infective/Anti-inflammatory combinations
procainamide 1 Nymalize 3
o
acetic acid HC otic 1 NSAIDs
propafenone 1 Combination Anti-Hypertensive
o
neomycin/polymyxin/HC otic 1 bromfenac 1
propafenone SR 1 o aliskiren 1
o
Ciprodex 2 diclofenac 1
Cipro HC 3 flurbiprofen ophth 1 quinidine gluconate 1 zo amlodipine/atorvastatin 1
quinidine sulfate SR 1 o amlodipine/benazepril 1
o
Eye Nevanac 2
Acular PF 3 sotalol 1 zo amlodipine/valsartan 1
Antiallergy Agents (Eye) Lanoxin 2 o atenolol/chlorthalidone 1
o
Prolensa 3
azelastine ophth 1 Prostaglandin Analogues/Prostamines Multaq 2 o benazepril/HCTZ 1
cromolyn ophth 1 bimatoprost 0.03% 1 o Norpace CR 3 o bisoprolol/HCTZ 1
olopatadine ophth 1 o latanoprost 1 Antilipidemics Pzo candesartan/HCTZ 1
Alomide 2 o travoprost 1 zuo atorvastatin calcium 1 o captopril/HCTZ 1
Bepreve 3 o Lumigan 0.01% 2 o cholestyramine 1 o enalapril/HCTZ 1
ketotifen opthalmic solution 3 o Xelpros 2 o colestipol 1 o fosinopril/HCTZ 1
olopatadine 0.2% drop 3 P Izba 3 zo ezetimibe 1 zo irbesartan/HCTZ 1
Pazeo 3 P Rescula 3 o fenofibrate (generic) 1 o lisinopril/HCTZ 1
Zaditor 3 Po Travatan Z 3 o fenofibric acid, tab 1 zo losartan/HCTZ 1
Zerviate 3 Po Vyzulta 3 o gemfibrozil 1 o methyldopa/HCTZ 1
Anti-infective Agents Po Xalatan 3 zuo lovastatin 1 o metoprolol/HCTZ 1
bacitracin ophth 1 Po Zioptan 3 o niacin ER 1 zo olmesartan/HCTZ 1
bacitracin/polymyxin 1 Sympathomimetics zo niacin/simvastatin 1 o propranolol/HCTZ 1
ciprofloxacin ophth 1 o brimonidine 1 zuo pravastatin 1 o quinapril/HCTZ 1
erythromycin ophth 1 o Alphagan P 0.1% 2 zo rosuvastatin 1 zo telmisartan/HCTZ 1
gatifloxacin 1 Vasoconstrictors zuo simvastatin 1 zo valsartan/HCTZ 1
gentamicin ophth 1 Advicor 2 Pzo Tekturna HCT 2
o
naphazoline 1
neomycin/bacitracin/poly B 1 phenylephrine ophth 1 Colestid 2 zo amlodipine/olmesartan 3
ofloxacin ophth 1 +>z Kynamro 2 zo amlodipine/valsartan/HCTZ 3
polymyxin B/TMP 1 Gout zo Praluent 2 Pz Amturnide 3
sulfacetamide 10% 1 allopurinol 1 zo Repatha 2 Pzo Atacand HCT 3
tobramycin soln 1 colchicine/probenecid 1 zo Altoprev 3 Pzo Avalide 3
Tobrex ointment 2 probenecid 1 zuo Crestor 3 zo Azor 3
Vigamox 2 Colcrys 2 o colesevelam 3 Pzo Benicar HCT 3
Azasite 3 z Mitigare 2 z Epanova 3 zo Byvalson 3
Besivance 3 z Duzallo 3 zo Ezallor 3 Pzo Diovan HCT 3
Ciloxan 3 Pz febuxostat 3 zo ezetimibe-simvastatin 3 Pzo Edarbyclor 3
KEY: P = A step edit applies to this drug. + = Access restricted to CVS Specialty pharmacy if applicable.
z = Specific Quantity Limits Apply. > = Access restricted to Accredo specialty pharmacy if applicable.
= Prior Authorization Required. o = Custom Home Delivery.
u = Included in Tablet-Splitting Program = ACA Preventive Drug
2Section I — Therapeutic drug categories (cont’d)
TIER TIER TIER TIER
zo Exforge HCT 3 Nucleoside Analog Reverse Transcriptase Inhibitor cephalexin 1 z valacyclovir 1
Pzo Hyzaar 3 Combination ciprofloxacin 1 valganciclovir tablets 1
Pzo Micardis HCT 3 abacavir/lamivudine/zidovudine 1 clarithromycin susp 1 +>Pz Daklinza 2
zo olmesartan/amlodipine/HCTZ 3 lamivudine/zidovudine 1 clarithromycin tabs 1 +>z Epclusa 2
zo Prestalia 3 tenofovir 300mg 1 clindamycin 1 Epivir-HBV solution 2
Pzo Tekturna 3 Biktarvy 2 dicloxacillin 1 +>z Harvoni 2
zo telmisartan/amlodipine 3 Cimduo 2 doxycycline 1 z Hepsera 2
o trandolapril/verapamil 3 Complera 2 ery-tab 250mg, 333mg 1 +z Olysio 2
zo Tribenzor 3 Descovy 2 erythromycin base 1 +>z Mavyret 2
Diuretics Dutrebis 2 erythromycin DR 1 +> Pegasys 2
o acetazolamide 1 Odefsey 2 erythromycin ethylsuccinate 1 Relenza 2
o acetazolamide ER 1 Stribild 2 erythromycin stearate 1 +>z Sovaldi 2
o amiloride 1 Symfi 2 erythromycin/sulfisoxazole 1 + Victrelis 2
o amiloride/HCTZ 1 Symfi Lo 2 levofloxacin 1 +>Pz Viekira 2
o bumetanide 1 Triumeq 2 minocycline 1 +>Pz Viekira XR 2
o chlorothiazide 1 Truvada 2 nitrofurantoin 1 Baraclude solution 3
o chlorthalidone 1 Viread 150mg, 200mg, 250mg, 40mg/ ofloxacin 1 entecavir tablets 3
o furosemide 1 scoop powder 2 penicillin VK 1 +>Pz Ledipasvir/Sofosbuvir 3
o hydrochlorothiazide 1 Nucleoside Reverse Transcriptase Inhibitors sulfamethoxazole/trimethoprim 1 +>P Peg-Intron 3
o indapamide 1 abacavir-lamivudine 1 tetracycline 1 z Prevymis tablets 3
o methazolamide 1 didanosine 1 Ketek 2 +> Rebetol 3
o methyclothiazide 1 lamivudine tabs 1 Zmax 2 + Ribatab 3
o metolazone 1 stavudine 1 Baxdela 3 Sitavig 3
o
z
spironolactone 1 zidovudine 1 Biaxin XL 3 +>Pz Sofosbuvir/Velpatasvir 3
o spironolactone/HCTZ 1 Emtriva 2 cefixime 3 +>Pz Technivie 3
o torsemide 1 Epivir solution 2 Ceftin 3 z Tyzeka 3
triamterene/HCTZ 1 Videx 2 Cleocin 3 valganciclovir solution 3
zo Carospir 3 Ziagen 2 z doxycycline hyclate 75mg, 150mg tab 3 z Valtrex 3
Miscellaneous Cardiovascular Agents Other erythromycin estolate 3 z Vemlidy 3
zo eplerenone 1 + Fuzeon 2 erythromycin suspension 3 +>z Vosevi 3
+>z icatibant 1 Factive 3 Xofluza 3
o
Genvoya 2 z
ranolazine ER 1 Isentress 2 z Lymepak 3 +>Pz Zepatier 3
+>z Berinert 2 Juluca 2 Minocin 3 Other Anti-Infectives
+>z Cinryze 2 Selzentry 2 moxifloxacin 3 atovaquone 1
zo Entresto 2 Tivicay 2 Noroxin 3 dapsone tablets 1
+>z Ruconest 2 Tybost 2 PCE 3 linezolid 1
+>z Samsca
z
2 Spectracef 3
Pz
Vitekta 2 methenamine combination 1
Consensi 3 Vibramycin 3 metronidazole 1
zo
Protease Inhibitors
Corlanor 3 Antifungals neomycin 1
+>z Firazyr
atazanavir 1
3 clotrimazole lozenge 1 nitrofurantoin 1
z
ritonavir tablet 1
Haegarda 3 fluconazole 1
o
Aptivus 2 paromomycin 1
Ranexa 3 flucytosine 1
+>z Takhzyro
Crixivan 2 trimethoprim 1
3 griseofulvin 1
Evotaz 2 tinidazole 1
Vecamyl 3 z itraconazole 1
+z Invirase 2 +> tobramycin ampule/neb 1
Vyndamax 3 ketoconazole 1
+>z Vyndaqel 3 Lexiva 2
nystatin 1
vancomycin caps 1
Norvir capsule, solution 2 Firvanq 2
Pulmonary Arterial Hypertension z terbinafine 1
+>z alyq
Prezcobix 2 Nebupent 2
1 z voriconazole 1
+>z ambrisentan
Prezista 2 z Sivextro 2
1 z Noxafil 2
+>z bosentan
Viracept 2 +> Tobi Podhaler 2
1 z Posaconazole 2
+>z sildenafil 20mg tab, oral susp 1 Protease Inhibitors Combinations
z Sporanox suspension 2
+ Bethkis 3
+>z tadalafil (generic Adcirca) 1 Kaletra 2
z Cresemba 3
+> Cayston 3
+>z Letairis 2 Huntington’s Disease Ecoza 3
z Dificid 3
+>z Tracleer 2 +>z tetrabenazine 1 z Lamisil Oral 3
Flagyl/ER 3
+>z Uptravi 2 +>z Austedo 3 Luzu 3
z Impavido 3
+>z Adempas 3 z Ingrezza 3 Oravig 3
+>z Kitabis Pak 3
+> epoprostenol 3 Tolsura 3
Macrodantin 3
+>z Opsumit 3 Immunosuppressants z +> Tobi 3
Antimalarials
+> Orenitram 3 azathioprine 1 Vancocin 3
+>z Tyvaso 3 cyclosporine 1 atovaquone/proguanil HCl 1 z Xifaxan 3
chloroquine phosphate 1
+> veletri 3 gengraf 1
mefloquine 1 Men’s Health
+>z Ventavis 3 mycophenolate mofetil 1
Daraprim 2 Impotence
Vasodilators mycophenolic acid 1
sildenafil citrate 25mg, 50mg, 100mg 1
o sirolimus 1 Primaquine 2 zo
hydralazine 1 tadalafil (generic Cialis) 1
o tacrolimus 1 quinine sulfate 3 zo
isosorbide dinitrate 1 vardenafil 1
o
Antituberculosis zo
o
isosorbide mononitrate 1 Astagraf XL 2
vardenafil ODT 1
o
ethambutol 1 zo
o
isosorbide mononitrate SA 1 Cellcept 2
o
isoniazid 1 z Caverject 2
o
isoxsuprine 1 Neoral 2
o
pyrazinamide 1 z MUSE 2
o Pzo Cialis
minoxidil oral 1 Prograf 2
rifabutin 1 3
o
nitroglycerin pumpspray 1 Sandimmune 2
rifampin 1 z Edex 3
Pz
nitroglycerin SR 1 Zortress 2
Coartem 2 Levitra 3
o Pzo Staxyn
nitroglycerin transdermal patch 1 z Envarsus XR 3
o
Rifater 2 3
Dilatrate SR 2 Infection o Rifamate 3 Pzo Stendra 3
Nitrostat SL tabs 2
Antibacterial Agents/Antibiotics o Sirturo 3 Pzo Viagra 3
Gonitro 3
Minitran 3 amoxicillin 1 Antivirals Male Hormones
amoxicillin-clavulanate ER 1 z acyclovir oral 1 testosterone cypionate 1
o
NitroDur patches 3
ampicillin 1 amantadine 1 testosterone enanthate 1
HIV - Antivirals azithromycin suspension 1 z famciclovir 1 z testosterone gel 1
Non-Nucleoside Reverse Transcriptase Inhibitor azithromycin tablets 1 ganciclovir 1 z testosterone pump 1
efavirenz 1 cefaclor 1 +> moderiba 1 Androderm patch 2
Atripla 2 cefadroxil 1 oseltamivir 1 Android 3
Edurant 2 cefdinir 1 +> ribapak 1 fluoxymesterone 3
Intelence 2 cefpodoxime 1 +> ribasphere 1 Pz Axiron 3
Rescriptor 2 cefprozil 1 +> ribavirin 1 Pz Fortesta 3
Viramune, XR 2 cefuroxime 1 rimantadine 1 Pz Natesto 3
KEY: P = A step edit applies to this drug. + = Access restricted to CVS Specialty pharmacy if applicable.
z = Specific Quantity Limits Apply. > = Access restricted to Accredo specialty pharmacy if applicable.
= Prior Authorization Required. o = Custom Home Delivery.
u = Included in Tablet-Splitting Program = ACA Preventive Drug
3Section I — Therapeutic drug categories (cont’d)
TIER TIER TIER TIER
P Striant 3 P Versacloz 3 z Narcan nasal spray 2 carisoprodol 1
Pz Testim 3 z Vraylar 3 Zubsolv 2 carisoprodol/ASA 1
Pz Testosterone gel (brand) 3 z Zyprexa 3 Bunavail 3 chlorzoxazone 1
Pz Vogelxo 3 z Zyprexa Zydis 3 Campral dosepack 3 cyclobenzaprine 1
Pz Xyosted 3 Anxiolytics, Sedatives, and Hypnotics z Evzio 3 dantrolene sodium 1
Prostate Health alprazolam/ER 1 z Gralise 3 metaxalone 1
zo alfuzosin 1 buspirone 1 Pz Horizant 3 methocarbamol 1
zo dutasteride 1 chloral hydrate 1 Lucemyra 3 orphenadrine 1
o dutasteride/tamsulosin 1 chlordiazepoxide 1 z Nuedexta 3 tizanidine 1
zo finasteride 5mg 1 clorazepate 1 Savella 3 cyclobenzaprine ER 3
o tamsulosin 1 diazepam 1 >z Tegsedi 3 Osteoporosis
o silodosin 3 estazolam 1 Pz Tiglutik 3
eszopiclone 1 Other Endocrine zo alendronate 1
Mental Health z
flurazepam 1 o cinacalcet 1 zo calcitonin-salmon 1
Antidepressants lorazepam 1 danazol 1 zo fortical NS 1
amitriptyline 1 meprobamate 1 fludrocortisone 1 zo ibandronate tabs 1
amitriptyline/ chlordiazepoxide 1 oxazepam 1 +> miglustat 1 zo raloxifene 1
amitriptyline/perphenazine 1 temazepam 1 +> octreotide 1 +>z Forteo 2
amoxapine 1 triazolam 1 +>z Cerdelga 2 +>z Tymlos 2
bupropion 1 z zaleplon 1 +>z Egrifta 2 Pzo Actonel 3
bupropion 12HR 1 z zolpidem 1 +>z HP Acthar Gel 2 Pzo Atelvia 3
bupropion 24HR 1 z zolpidem ER 1 >z Myalept 2 Pzo Binosto 3
u citalopram 1 >z Hetlioz 2 +> Norditropin 2 Pzo Boniva 3
clomipramine 1 z Xyrem 2 +>o Sensipar 2 Pzo Fosamax 3
desipramine 1 Pz Ambien 3 z Synarel 2 Pzo Fosamax D 3
desvenlafaxine succinate ER 1 Pz Ambien CR 3 > Zavesca 2 zo risedronate 150mg 3
doxepin 1 Ativan 3 +>P Genotropin 3 Pzo risedronate DR 3
duloxetine 1 Pz Belsomra 3 +>P Humatrope 3 Pain/Arthritis
u escitalopram 1 Pz Edluar 3 +> Increlex 3
u fluoxetine 10mg and 20mg tablet 1 Pz Intermezzo 3 +>z Natpara 3
Analgesics, Opioid - Medications listed under this
+>P Nutropin/AQ
fluoxetine capsule 1 Librium 3 category may require additional review for coverage
3
u fluvoxamine tablet 1 P ramelteon 3 +>P Omnitrope 3 based on recommendations from the Centers for
imipramine 1 P Rozerem 3 +>P Saizen 3 Disease Control and Prevention (CDC).
maprotiline 1 Pz Silenor 3 +> Sandostatin 3 z acetaminophen w/codeine 1
u mirtazapine 1 Somnote 3 z belladonna & opium supp 1
+> Sandostatin LAR 3
nefazodone 1 Pz Sonata 3 +>P Serostim 3 buprenorphine TD patch (generic) 1
nortriptyline 1 Pz zolpidem ER sublingual tablet 3 +> Somatuline Depot 3 z butalbital/APAP/codeine 1
u paroxetine 1 Pz Zolpimist 3 +>z Somavert 3 z butalbital/aspirin/codeine 1
+>P Tev-Tropin
phenelzine 1 Cerebral Stimulants z butorphanol NS 1
3
+>P Zorbtive
protriptyline 1 z armodafinil 1 codeine sulfate 1
u sertraline 1 3 z
atomoxetine 1 Other Miscellaneous z endocet 1
tranylcypromine 1 dexmethylphenidate 1 zo Keveyis 2 z fentanyl lozenge 1
trazodone 1 dexmethylphenidate XR 1 >z Signifor 2 fentanyl patch 1
venlafaxine 1
u dextroamphetamine tabs 1 z hydrocodone/APAP 1
venlafaxine ER 1 Strensiq 2
Viibryd 2
generic Adderall 1 > Carbaglu 3 z hydrocodone/ibuprofen 1
generic Adderall XR 1 Cystadane 3 z hydromorphone 1
Desvenlafaxine ER 3 generic Concerta 1 + Cystagon 3 z meperidine 1
Desvenlafaxine Fumarate ER 3
P Drizalma Sprinkle 3
generic Dexedrine spansules 1 z Firdapse 3 methadone 1
guanfacine ER 1 >z Galafold 3 morphine SR 1
Fetzima 3 metadate ER 1 z Korlym 3 z morphine sulfate ER 1
fluoxetine 60mg tablet 3 methylphenidate CD 1 > Nityr 3 morphine tab, soln, supp 1
fluvoxamine ER capsule 3
Forfivo 3
methylphenidate/SR 1 > Procysbi 3 z oxycodone 1
Khedezla 3
z modafinil 1 +> Ravicti 3 z oxycodone/acetaminophen 1
zu Oleptro ER 3
procentra 1 Revcovi 3 z oxycodone/aspirin 1
Pexeva 3
z Mydayis 2 z Ruzurgi 3 z oxycodone/ibuprofen 1
Sarafem 3
Vyvanse 2 + sodium phenylbutyrate 3 oxymorphone/ER 1
Trintellix 3
z Adhansia XR 3 Tegsedi 3 z pentazocine/naloxone 1
Antimanic Agents
z Adzenys 3 z Veltassa 3 Kadian (40mg, 70mg, 130mg, 150mg,
lithium carbonate 1
z Cotempla XR 3 z Xuriden 3 200mg) 2
Antipsychotic Agents
z Dyanavel XR 3 Miscellaneous Immunologicals Oxycodone ER 2
aripiprazole 1
Focalin XR 3 +> Cuvitru 3 Oxycontin 2
chlorpromazine 1
z Jornay PM 3 +> Gammagard Liquid 3 z Abstral 3
clozapine 1
Methylphenidate ER (brand) 3 +> Gammaked 3 z Belbuca 3
fluphenazine 1
z Quillichew ER 3 +> Gamunex-C 3 Buprenorphine 7.5mg TD patch 3
haloperidol 1
Quillivant XR 3 +> Hizentra 3 Butrans 3
Miscellaneous +> HyQvia 3 Demerol 3
z
loxapine 1 z
Sunosi 3 Xembify 3 Embeda 3
z olanzapine 1 +>z Wakix 3 z Fentanyl buccal tablet 3
perphenazine 1 Multiple Sclerosis Agents
Miscellaneous fentanyl patch 37.5mcg/hr, 62.5mcg/hr,
z quetiapine 1 +> glatiramer acetate 1 and 87.5mcg/hr 3
z quetiapine fumarate ER 1 Antidiuretic Agents +>z glatopa 1 z Fentora 3
z risperidone 1 desmopressin solution 1 +> Avonex 2 Fioricet/codeine 3
desmopressin tabs 1 +>
z risperidone m-tab 1 z
Rebif 2 Fiorinal/codeine 3
Stimate 2 +>z
thioridazine 1 z
Gilenya 2
+>z
thiothixene 1 DDAVP nasal spray 3 hydromorphone ER 3
Plegridy 2
+>z
trifluoperazine 1 DDAVP sol, tab 3 Hysingla ER 3
z
Tecfidera 2
z ziprasidone caps 1 z Nocdurna 3 +>z
Lazanda 3
Aubagio 3
z Latuda 2 z Noctiva 3 +>P Betaseron 3
Nucynta/ER 3
+>
z Saphris 2 Other CNS z Roxicet Soln 3
Copaxone 3
z z
Abilify Mycite 3 acamprosate calcium tablet EC 1 +>z dalfampridine ER 3 Subsys 3
z Fanapt 3 buprenorphine 1 +>P Extavia 3 z Trezix 3
Fazaclo 3 buprenorphine-naloxone 1 +>z Mavenclad 3 z Tylenol/codeine 3
+>z Nuplazid 3 buprenorphine/naloxone film 1 +>z Mayzent 3 z Vicodin/ES 3
z olanzapine/fluoxetine 3 disulfiram 1 Xartemis XR 3
z paliperidone 3 naltrexone 1 Muscle Relaxants z Xtampza ER 3
z Rexulti 3 riluzole 1 baclofen 1 Zohydro ER 3
KEY: P = A step edit applies to this drug. + = Access restricted to CVS Specialty pharmacy if applicable.
z = Specific Quantity Limits Apply. > = Access restricted to Accredo specialty pharmacy if applicable.
= Prior Authorization Required. o = Custom Home Delivery.
u = Included in Tablet-Splitting Program = ACA Preventive Drug
4Section I — Therapeutic drug categories (cont’d)
TIER TIER TIER TIER
Analgesics, Salicylates o meclofenamate 1 z fluticasone-salmeterol (Prasco) 1 o Tegretol XR 100mg 2
o choline mag. trisalicylate 1 o mefenamic acid 1 ipratropium inh. soln. 1 o Aptiom 3
o diflunisal 1 o meloxicam 1 ipratropium/albuterol 1 o Banzel suspension 3
o salsalate 1 o nabumetone 1 z wixela inhub 1 z Briviact 3
zo Yosprala 3 o naproxen/EC 1 Advair HFA 2 z Diacomit 3
Anti-Rheumatic o oxaprozin 1 Anoro Ellipta 2 +> Epidiolex 3
o hydroxychloroquine 1 o piroxicam 1 z Atrovent HFA 2 z Fycompa 3
leflunomide 1 o sulindac 1 Breo Ellipta 2 o lamotrigine ER/ODT 3
methotrexate 1 o tolmetin 1 z Combivent Respimat 2 Pz Lyrica CR 3
z penicillamine 1 Pz Diclofenac Epolamine patch 3 +>z Esbriet 2 o Oxtellar XR 3
+>Pz Actemra 2 Pz diclofenac sodium 3% gel 3 z Fluticasone-Salmeterol (Teva) 2 Potiga 3
+>z Enbrel 2 o diclofenac sodium/misoprostol 3 z Incruse Ellipta 2 o Qudexy XR 3
+>z Humira 2 Pz diclofenac sodium topical solution 3 >z Kalydeco 2 +> Sabril 3
z Kineret 2 Pz Duexis 3 +>z Ofev 2 Pz Sympazan 3
+>z Otezla 2 Pz Flector 3 >z Orkambi 2 o topiramate ER 3
o Ridaura 2 Pz Licart 3 +> Pulmozyme 2 o Trokendi XR 3
+>z Rinvoq 2 naproxen CR 375mg tablet 3 z Spiriva 2 +> vigabatrin oral powder 3
+>Pz Xeljanz 2 Pz Pennsaid 3 z Spiriva Respimat 2 Vimpat 3
+>z Xeljanz XR 2 Pzo Qmiiz ODT 3 z Stiolto Respimat 2 Succinimides
+>Pz Cimzia 3 z Sprix 3 z Symbicort 2 o ethosuximide 1
oz Cuprimine 3 o Tivorbex 3 z Symdeko 2 o Celontin 2
oz D-Penamine 3 Pzo Vimovo 3 z Trelegy Ellipta 2 Skin
oz Depen 3 Pzo Vivlodex 3 z AirDuo 3
+>z Kevzara 3 Pz Zipsor 3 z Bevespi 3 Acne/Rosacea
+>Pz Olumiant 3 o Zorvolex 3 o Daliresp 3 adapalene/benzoyl peroxide 1
+>Pz Orencia SC z Duaklir Pressair 3 adapalene cream/gel 1
3 Parkinson’s Disease z Dulera 3 amnesteem 1
o
Otrexup 3
benztropine 1 +> Glassia 3 avita cream 1
o
Rasuvo 3
+>Pz Simponi bromocriptine 1 z Lonhala Magnair 3 benzoyl peroxide 1
o
3
carbidopa/levodopa 1 z Nucala syringe/auto-inject 3 claravis 1
o
Cox-2s
carbidopa/levodopa SA 1 > Orkambi granules 3 clindamycin/benzoyl peroxide
o
zo celecoxib 1 1.2%-2.5% gel 1
entacapone 1 z Seebri 3
o
Migraine (Miscellaneous)
z
pramipexole 1 > Trikafta 3 clindamycin/benzoyl peroxide 1-5% gel 1
o
Aimovig 2 clindamycin/benzoyl peroxide
ropinirole 1
z Ajovy 2 Tudorza 3
1-5% pump 1
Pz
zo selegiline 1 z Utibron 3
o
Emgality 3
trihexyphenidyl 1 Pz Yupelri 3 clindamycin phospate 1
Migraine (Analgesics, Non-opioid) +>z Apokyn 2 Sympathomimetics erythromycin/benz peroxide 1
butalbital/APAP 50mg-325mg 1 >z Duopa 2 o albuterol sulfate ER 1 minocycline 1
butalbital/APAP/caffeine 1 o carbidopa 3 o albuterol tab, syr 1 prascion RA 1
z o
butalbital/aspirin/caffeine 1 Gocovri 3 sodium sulfacetamide 1
metaproterenol syr 1
+>z o
z dihydroergotamine mesylate 1 Inbrija 3 sod. sulfacetamide/sulfur
terbutaline tab 1
z eletriptan 1 Pzo Osmolex ER 3 z Foradil 2 emulsion cleanser 1
ergotamine/caffeine 1 pergolide 3 sod. sulfacetamide/sulfur lot 1
z Maxair Autohaler 2
isometh/dichloralphen/APAP 1 o pramipexole ER 3 z ProAir HFA/RespiClick 2 sotret 1
z naratriptan 1 rasagiline 3 tretinoin cr/gel 1
zo Serevent Diskus 2
P
z
z rizatriptan 1 o ropinirole ER 3 z Ventolin HFA 2 Tazorac gel 2
z sumatriptan 1 o Rytary 3 Albuterol Sulfate HFA 3 Absorica 3
tramadol/ER tablet 1 tolcapone 3 Arcapta 3 P Acanya 3
tramadol/acetaminopen 1 zo Xadago 3 Levalbuterol Tartrate HFA 3 P Aczone 3
z zolmitriptan 1 P Adapalene lotion 3
Pz Potassium z Proventil HFA 3
Amerge 3 adapalene solution 3
Pz
Striverdi Respimat 3
P
z
Axert 3 Potassium agents Xopenex HFA 3 Altreno 3
butalbital/APAP 50mg-300mg 3 o potassium bicarb/potassium chloride 1 P Avar 3
o
Xanthine Derivatives
Cafergot 3 potassium bicarbonate 1 o P Avita gel 3
Pz o
aminophylline 1
o
Cambia 3 potassium chloride 1 azelaic acid gel 3
theochron 1
z Ergomar 3 Potassium Removing agent o P Azelex 3
Pz
theophylline/SR tabs, liquid 1
Frova 3 sod. polystyrene sulfonate 1 o Theo-24 2 P Benzaclin 3
z frovatriptan 3
Respiratory/Asthma o P Benzamycin 3
Pz
Elixophyllin 3
Imitrex 3 P Cleocin T 3
Pz Maxalt 3 Adrenergic Seizures clindamycin/benzoyl peroxide
Pz Maxalt MLT 3 epinephrine auto-injector 1 Barbiturates 1.2%-2.5% pump 3
Pz Onzetra 3 Epinephrine (Impax) 2 mephobarbital 1 dapsone 5% 3
Pz Relpax 3 Epinephrine 0.15mg/0.3ml (Mylan) 2 phenobarbital 1 P Differin 3
z Sumavel 3 P Adrenaclick 3 Hydantoins P Doryx 3
Pz Tosymra 3 P AuviQ 3 o phenytoin 1 P Duac 3
tramadol ER capsule 3 P Epipen/Jr. 3 o Dilantin 2 P doxycycline hyclate DR 3
Pz Treximet 3 P Symjepi 3 o Peganone 3 P Doxycycline IR-DR 3
+Pz Zecuity 3 Corticosteroids Miscellaneous P Epiduo/Forte 3
Pz Zembrace 3 o budesonide inh. o carbamazepine 1 P Evoclin 3
Pz Zomig 3 (0.25mg/2ml, 0.5mg/2ml) 1 o carbamazepine XR 200mg, 400mg 1 P Fabior 3
Pz Zomig Nasal 3 zo Arnuity Ellipta 2 clobazam 1 P Finacea 3
Pz Zomig ZMT 3 zo Asmanex 2 clonazepam 1 P Metrogel topical 1% 3
Nonsteroidal Anti-Inflammatory/Combination zo Flovent HFA/Diskus 2 o divalproex sodium/ER 1 P minocycline HCl ER 3
Products zo Pulmicort flexhaler/powder 2 felbamate 1 Pz Minolira ER 3
o diclofenac potassium 1 o Pulmicort respules (1mg/2ml) 2 o gabapentin 1 P Mirvaso 3
o diclofenac sodium 1 zo Qvar 2 o lamotrigine 1 P Noritate 3
z diclofenac sodium gel 1% 1 z Aerobid/M 3 o levetiracetam 1 P Onexton 3
o etodolac 1 o Alvesco 3 o oxcarbazepine 1 P Oracea 3
o etodolac SA 1 zo ArmonAir 3 pregabalin 1 P Retin-A/Micro 3
o fenoprofen 1 Leukotrienes o primidone 1 P Rhofade 3
o flurbiprofen 1 o montelukast 1 o tiagabine 1 P Rosula 3
o ibuprofen 1 o zafirlukast 1 o topiramate 1 Pz Seysara 3
o indomethacin 1 zo zileuton ER 3 o valproic acid 1 P Solodyn 3
o ketoprofen 1 zo Zyflo 3 o zonisamide 1 Soolantra 3
ketorolac inj. 1 Other Agents o Banzel tablets 2 P tazarotene cream 3
z ketorolac tab 1 cromolyn inh. soln. 1 o Tegretol 2 P Tazorac cream 3
KEY: P = A step edit applies to this drug. + = Access restricted to CVS Specialty pharmacy if applicable.
z = Specific Quantity Limits Apply. > = Access restricted to Accredo specialty pharmacy if applicable.
= Prior Authorization Required. o = Custom Home Delivery.
u = Included in Tablet-Splitting Program = ACA Preventive Drug
5Section I — Therapeutic drug categories (cont’d)
TIER TIER TIER TIER
P tretinoin microsphere 3 betamethasone valerate 1 z Alinia 2 Proton Pump Inhibitors
P Veltin gel 3 clobetasol emol/emuls 1 Fulyzaq 2 zo esomeprazole magnesium 1
P Ximino 3 clobetasol proprionate Antiemetic/Antivertigo zo lansoprazole 1
P Ziana gel 3 foam/gel/oint/cr/sol 1 z aprepitant 1 Pz lansoprazole DR ODT 1
Antibiotics (Topical) desonide 1 z granisetron 1 z Nexium 24HR 1
clindamycin sol/swabs/gel/lotion 1 desoximetasone 1 meclizine 1 zo omeprazole 1
erythromycin sol/swabs/gel 1 diflorasone 1 z ondansetron 1 zo pantoprazole 1
gentamicin cr/oint 1 fluocinolone acetonide 1 prochlorperazine 1 z Prevacid 24HR 1
metronidazole cream/lotion/ 0.75% gel 1 fluocinonide 1 promethazine 1 z Prilosec-OTC 1
mupirocin 1 fluticasone propionate 1 scopolamine patch 1 zo rabeprazole 1
Bactroban cream 3 halobetasol 1 trimethobenzamide 1 z Zegerid OTC 1
Centany 3 halobetasol propionate 1 Antivert 50mg 2 zo Nexium susp 2
P Xepi 3 hydrocortisone 2.5% 1 z Anzemet 2 Pzo Aciphex 3
Antipsoriatics hydrocortisone valerate 1 z Emend 2 Pzo Dexilant 3
acitretin 1 hydrocortisone/iodoquinol 1 Pz Akynzeo 3 Pzo Nexium 3
calcipotriene 1 mometasone cr/oint 1 z Bonjesta 3 Pzo omeprazole/sodium bicarbonate 3
tacrolimus 1 prednicarbate 1 z doxylamine-pyridoxine 3 Pzo Prevacid 3
+>z Cosentyx 2 triamcinolone acetonide 1 z Granisol 3 Pzo Prilosec 3
Dritho-Scalp 2 Cordran tape 2 z Sancuso 3 Pzo Protonix 3
Elidel 2 betamethasone valerate foam 3 z Syndros 3 Pzo Zegerid 3
+>z Skyrizi 2 Capex Shampoo 3 z Varubi 3
+>z Stelara 2 clobetasol propionate z Zuplenz 3
Thyroid
+>z Tremfya 2 lotion/shampoo/spray 3 Bowel Evacuants Antithyroid
P calcipotriene-betamethasone ointment 3 Cordran ointment 3 peg 3350/electrolyte 1 o methimazole 1
calcitriol ointment 3 Pz Duobrii 3 Trilyte 1 o propylthiouracil 1
P Enstilar 3 fluocinonide cream (generic Vanos) 3 Moviprep 3 Thyroid
+>Pz Siliq 3 flurandrenolide cream 3 Nulytely 3 levothroid 1
P Taclonex 3 halcinonide cream 3 Prepopik 3 o levothyroxine 1
+>Pz Taltz 3 hydrocortisone butyrate/emoll cream 3 Suprep 3 o levoxyl 1
Burn preparation P Impoyz 3 Digestants o liothyronine 1
silver sulfadiazine 1 Kenalog/aerosol 3 o Creon 2 o thyroid 1
Fungicides Topical Antipruritics/Anesthetics o Zenpep 2 o unithroid 1
betamethasone/clotrimazole 1 lidocaine 1 o Pancreaze 3 o Synthroid 2
ciclopirox cream 1 z lidocaine patch 1 o Pertzye 3 o Thyroid (Armour) 2
ciclopirox soln 1 selenium sulf 2.5% suspension 1 Sucraid 3 o Thyrolar 2
econazole 1 Rectiv 3 Ultresa 3 o Tirosint 3
ketoconazole 1 Topical Antivirals o Viokace 3 Vaccines
nystatin 1 acyclovir cream 1 Gallstone Solubilizing Agents
o
Adacel 2
nystatin/triamcinolone 1 acyclovir ointment 1 ursodiol 1 Bexsero 2
nystop 1 Denavir 3 +>z Ocaliva 3 Boostrix 2
oxiconazole nitrate cream 1 Smoking Cessation H2 Antagonists
o
Daptacel 2
Exelderm 2
cimetidine 1
o
bupropion 1 Diphtheria-Tetanus Toxoids-Ped 2
Oxistat lotion 2
famotidine 1
o
Nicorelief gum 1 Infanrix 2
Jublia 3
z nizatidine 1
o
Nicorelief lozenge 1 Influenza 2
Kerydin 3
z ranitidine (all) 1
Nicotine Gum 1 Menactra 2
naftifine 3
Other Antiulcer
o
Miscellaneous Nicotine lozenges 1 Menhibrix 2
misoprostol 1
aluminum chloride 20% 1 Nicotine patches various 1 Menomune-A-C-Y-W-135 2
propantheline bromide 1
z doxepin cream 1 Chantix 2 o Menveo A-C-Y-W-135-Dip 2
sucralfate 1
fluorouracil 5% cr/sol 1 Commit 2 Pneumovax 23 2
Helidac 3
fluorouracil 2% sol 1 Nicotrol Inhaler 2 Prevnar 13 2
lansoprazole/amox/clarith 3
imiquimod 5% cream 1 Nicotrol NS 2 Shingrix 2
Other GI Products
ivermectin 1 Zyban 3
balsalazide 1 Tetanus Diphtheria Toxoids 2
podofilox 1 Steroids budesonide EC 1 Tenivac 2
z prudoxin 1 cortisone acetate 1 o cromolyn sodium 1 Trumenba 2
sodium chloride irrigating soln 1 dexamethasone oral 1 enulose 1 Zostavax 2
Carac 2 hydrocortisone oral 1 lactulose 1
Panretin 2 mesalamine DR capsule 400mg 1
Vitamins
methylprednisolone 4mg, 8mg,
Phisohex 2 16mg, 32mg 1 mesalamine DR tablet 800mg 1 o calcitriol 1
Picato 2 prednisolone oral 1 mesalamine enema 1 o calcitriol inj 1
Regranex 2 prednisone oral 1 mesalamine suppository 1 calcium acetate 1
+>z Benlysta SC 3 Medrol 2mg 2 o sulfasalazine 1 cholecalciferol 1
+>z Dupixent 3 z Emflaza 3 o sulfasalazine EC 1 o cyanocobalamin inj. 1
Eucrisa 3 Rayos 3 Cholbam 2 o ergocalciferol capsule 1
Fluoroplex 3 +> Kuvan 2 o etidronate 1
Fluorouracil 0.5% cr 3 Stomach/Ulcer Linzess 2 o fluoride drops OTC 1
Pz Qbrexza 3 Anorectal Pentasa 2 o fluoride tablets OTC 1
Regenecare 3 hydrocortisone rectal cr. & supp. 1 z Relistor injection 2 o folic acid Rx 1mg tab 1
z Zonalon 3 hydrocortisone rectal enema 1 z Relistor tablets 2 folic acid tablets OTC 1
Psoralens pramoxine/HC acetate 2.5% 1 alosetron 3 leucovorin 1
methoxsalen capsule 1 Analpram-HC 1-1% 2 Pz Amitiza 3 levocarnitine 1
8-MOP 2 Cortifoam 2 Apriso 3 o multivitamin +> fluoride (Rx-only) 1
Scabicides & Pediculicides Proctofoam-HC 2 o Azulfidine 3 nitisinone 1
acticin 1 Analpram-HC 2.5% cr/lot 3 budesonide ER tablet 3 potassium aminobenzoate 1
permethrin 1 Anticholinergics/Antispasmodic/GI Motility z Dipentum 3 o pre-natal vitamins (Rx-only) 1
spinosad 1 belladonna/phenobarbital 1 +> Gattex 3 sevelamer 1
Lindane 2 chlordiazepoxide/clindinium 1 Giazo 3 o Pediatric sodium fluoride chewable tab &
Ulesfia 2 dicyclomine 1 mesalamine DR tablet 1.2g 3 drops 1
Eurax 3 glycopyrrolate 1 z Motegrity 3 o vit A,D,C +> fluoride (Rx-only) 1
Sklice 3 hyoscyamine/CR 1 z Movantik 3 o vit A,D,C +> fluoride and iron (Rx-only) 1
Topical Anti-Inflammatory Agents metoclopramide 1 +>z Palynziq 3 Galzin 2
alclometasone 1 Donnatal tablet 2 z Symproic 3 o Mephyton 2
amcinonide 1 Antidiarrheal Pz Trulance 3 o Nascobal 2
aug. betamethasone diprop 1 diphenoxylate/atropine 1 Uceris 3 o phytonadione 2
betamethasone dipropionate 1 paregoric 1 z Xermelo 3 o Prenate Elite 2
KEY: P = A step edit applies to this drug. + = Access restricted to CVS Specialty pharmacy if applicable.
z = Specific Quantity Limits Apply. > = Access restricted to Accredo specialty pharmacy if applicable.
= Prior Authorization Required. o = Custom Home Delivery.
u = Included in Tablet-Splitting Program = ACA Preventive Drug
6Section I — Therapeutic drug categories (cont’d)
TIER TIER TIER TIER
Renagel 2 o Enjuvia 2 o ethynodiol-ethinyl estradiol 1 o orsythia 1
z Auryxia 3 zo Estraderm 2 fallback solo 1 o philith 1
lanthanum carbonate tablet 3 zo Estring 2 o falmina 1 o pimtrea 1
paricalcitol 3 o Evamist 2 o femynor 1 o pirmella 1
o Poly-Vi-Flor +> Iron 3 o Menest 2 o gianvi 1 o portia 1
z Rayaldee 3 o Premarin 2 o gildagia 1 o previfem 1
Tri-Vi-Flor 3 Premarin vag cream 2 o gildess 1 o quasense 1
Velphoro 3 o Premphase 2 o gildess 24 fe 1 react 1
Weight Loss Prempro 2 o gildess fe 1 o reclipsen 1
Climara Pro 3 o hailey 24 Fe 1 o setlakin 1
zo
benzphetamine 1 o Crinone 3 o heather 1 o sharobel 1
diethylpropion 1 Duavee 3 o incassia 1 simliya 1
phentermine 1 zo Estrasorb packet 3 o introvale 1 simpesse 1
Belviq 3 zo Estrogel 3 o isibloom 1 o sprintec 1
z Belviq XR 3 zo Femring 3 o jasmiel 1 o sronyx 1
z Contrave 3 z Imvexxy 3 o jencycla 1 o syeda 1
z Lomaira 3 z Intrarosa 3 o jolessa 1 o tarina fe 1
z Qsymia 3 zo Menostar 3 o jolivette 1 o tarina 24 Fe 1
z Saxenda 3 z Orilissa 3 o juleber 1 o tarina Fe 1-20 eq 1
Suprenza ODT 3 Ortho-Est 3 o junel 1 o tilia fe 1
Xenical 3 Osphena 3 o junel fe 1 o tri femynor 1
Women’s Health zo Prefest 3 o kaitlib fe 1 o tri-estarylla 1
kalliga 1 o tri-legest fe 1
Please refer to your plan documents to confirm your Miscellaneous
paroxetine 7.5mg 1 o kariva 1 o tri-linyah 1
cost share for contraceptives. Cost share may vary
z Addyi 3 o kelnor 1-35 1 o tri-lo-estarylla 1
by plan.
z Vyleesi 3 o kelnor 1-50 1 o tri-lo-marzia 1
Contraceptives - Other o kimidess 1 tri-lo-mili 1
o 1 Oral Contraceptives o o
xulane kurvelo 1 tri-lo-sprintec 1
afirmelle 1
+ Mirena 2
o o larin 1 o tri-mili 1
o
altavera 1
NuvaRing 2
o alyacen 1 o larin fe 1 o tri-vylibra lo 1
+ Skyla 2
o o larissia 1 o trinessa 1
amethia 1
Caya Contoured Diaphragm 3
o o layolis fe 1 o trinessa lo 1
amethia lo 1
Conceptrol 3
o o leena 1 o tri-previfem 1
o
amethyst 1
Depo-SubQ Provera 3
o o lessina 1 o tri-sprintec 1
apri 1
FC2 Female Condom 3
o o levonest 1 trivora 1
aranelle 1
Femcap 3
o levonorgestrel 1 o tri-vylibra 1
ashlyna 1
gynol II 3
o aubra 1 o levonorgestrel-eth estradiol 1 o tulana 1
+ Kyleena 3
o aubra eq 1 o levonorg-eth estrad eth estrad 1 o tydemy 1
> Liletta 3 aurovela 1 levora 1 o velivet 1
+> Nexplanon 3 o o lillow 1 o vestura 1
aurovela 24 Fe 1
Paragard 3 o o lomedia 24 fe 1 o vienva 1
aviane 1
Today Contraceptive Sponge 3 o loryna 1 o viorele 1
ayuna 1
VCF 3 o azurette 1 o low-ogestrel 1 o vyfemla 1
Fertility Induction Agents o balziva 1 lo-zumandimine 1 o vylibra 1
clomiphene 1 o bekyree 1 o lutera 1 o wera 1
progesterone in oil 1 o blisovi 24 fe 1 o lyza 1 o wymzya fe 1
serophene 1 o blisovi fe 1 o marlissa 1 o zarah 1
Bravelle 2 o briellyn 1 o melodetta 24 fe 1 o zenchent 1
Cetrotide 2 o camila 1 o mibelas 24 fe 1 o zenchent fe 1
Follistim AQ 2 o camrese 1 o microgestin 1 zeosa 1
Novarel 2 o camrese lo 1 o microgestin fe 1 zovia 1
Ovidrel 2 o caziant 1 o mili 1 zumandimine 1
Repronex 2 o chateal 1 o mono-linyah 1 o Lo Loestrin Fe 2
Chorionic gonadotropin 3 o chateal eq 1 o mononessa 1 o Natazia 2
Ganirelix 3 o cryselle 1 my choice 1 o Balcoltra 3
P Gonal F 3 o cyclafem 1 my way 1 o drospirenone-eth estra-levomef 3
Menopur 3 o cyred 1 o myzilra 1 Ella 3
Pregnyl 3 o cyred eq 1 o necon 1 o fayosim 3
Hormones o dasetta 1 new day 1 o rajani 3
dotti 1 o daysee 1 next choice one dose 1 o rivelsa 3
zo estradiol/noreth ac 1 o deblitane 1 o nikki 1 Slynd 3
o estradiol 0.01% cream 1 o delyla 1 o nora-be 1 o Taytulla 3
zo estradiol oral 1 o desogestrel-ethinyl estradiol 1 o norethindrone acetate 1 Oxytocic Agents
zo estradiol patches 1 o desogestr-eth estrad eth estra 1 o norethindrone-ethin estradiol 1 methylergonovine maleate 1
zo estropipate 1 o drospirenone-ethinyl estradiol 1 o norethin-eth estra ferrous fum 1 Methergine 3
zo estrogen/methyltesterone 1 econtra ez 1 o norgestimate-ethinyl estradiol 1 Vaginal Preparations
zo jinteli 1 econtra one-step 1 o norgestrel-ethiny estra 1 miconazole vag supp 1
o medroxyprogesterone 1 o elinest 1 o norlyda 1 nystatin vag tab 1
o norethindrone 1 o emoquette 1 o norlyroc 1 terconazole 1
o progesterone, micronized 1 o enpresse 1 o nortrel 1 vandazole vag 1
o yuvafem 1 o enskyce 1 o ocella 1 Cleocin Vag/Ovules 3
zo Alora 2 o errin 1 o ogestrel 1 Clindesse 3
Cenestin 2 o estarylla 1 opcicon one-step 1 Gynazole-1 3
zo Combipatch 2 option 2 1
KEY: P = A step edit applies to this drug. + = Access restricted to CVS Specialty pharmacy if applicable.
z = Specific Quantity Limits Apply. > = Access restricted to Accredo specialty pharmacy if applicable.
= Prior Authorization Required. o = Custom Home Delivery.
u = Included in Tablet-Splitting Program = ACA Preventive Drug
7Section II — Index
DRUG NAME PAGE` DRUG NAME PAGE DRUG NAME PAGE DRUG NAME PAGE DRUG NAME PAGE DRUG NAME PAGE
A amlodipine/valsartan/HCTZ 2 Baqsimi 2 calcipotriene-betamethasone Cleocin Vag/Ovules 7 Denavir 6
abacavir-lamivudine 3 amnesteem 5 Baraclude solution 3 ointment 6 Climara Pro 7 Depen 5
abacavir/lamivudine/zidovudine 3 amoxapine 4 Basaglar 1 calcitonin-salmon 4 clindamycin 3 Depo-SubQ Provera 7
Abilify Mycite 4 amoxicillin 3 Baxdela 3 calcitriol 6 clindamycin phospate 5 Descovy 3
abiraterone acetate 250mg 1 amoxicillin-clavulanate ER 3 Beconase AQ 1 calcitriol inj 6 clindamycin sol/swabs/gel/lotion 6 desipramine 4
Absorica 5 ampicillin 3 bekyree 7 calcitriol ointment 6 clindamycin/benzoyl peroxide desloratadine 1
Abstral 4 Amturnide 2 Belbuca 4 calcium acetate 6 1.2%-2.5% gel 5 desmopressin solution 4
acamprosate calcium tablet EC 4 anagrelide 1 belladonna & opium supp 4 Calquence 1 clindamycin/benzoyl peroxide desmopressin tabs 4
Analpram-HC 1-1% 6 belladonna/phenobarbital 6 Cambia 5 1.2%-2.5% pump 5 desogestr-eth estrad eth estra 7
Acanya 5
Analpram-HC 2.5% cr/lot 6 Belsomra 4 camila 7 clindamycin/benzoyl peroxide desogestrel-ethinyl estradiol 7
acarbose 1
anastrozole 1 Belviq 7 Campral dosepack 4 1-5% gel 5 desonide 6
Accu-Chek 2
Androderm patch 3 Belviq XR 7 camrese 7 clindamycin/benzoyl peroxide desoximetasone 6
acebutolol 2 1-5% pump 5
acetaminophen w/codeine 4 Android 3 benazepril 2 camrese lo 7 Desvenlafaxine ER 4
Anoro Ellipta 5 benazepril/HCTZ 2 candesartan/HCTZ 2 Clindesse 7 Desvenlafaxine Fumarate ER 4
acetazolamide 3 clobazam 5
acetazolamide ER 3 Antivert 50mg 6 Benicar 2 capecitabine 1 desvenlafaxine succinate ER 4
Anzemet 6 Benicar HCT 2 Capex Shampoo 6 clobetasol emol/emuls 6 Detrol 1
acetic acid HC otic 2 clobetasol propionate lotion/
acetic acid otic 2 Apidra 1 Benlysta SC 6 Caprelsa 1 Detrol LA 1
Benzaclin 5 captopril 2 shampoo/spray 6 dexameth/neomycin/poly B 2
acetic acid/aluminum acetate 2 Apokyn 5
Benzamycin 5 captopril/HCTZ 2 clobetasol proprionate foam/gel/ dexamethasone oral 6
acetylcysteine inh soln. 1 aprepitant 6
benzonatate 1 oint/cr/sol 6
Aciphex 6 apri 7 Carac 6 dexchlorpheniramine 1
benzoyl peroxide 5 clomiphene 7
acitretin 6 Apriso 6 Carbaglu 4 Dexilant 6
benzphetamine 7 clomipramine 4
Actemra 5 Aptiom 5 carbamazepine 5 dexmethylphenidate 4
benztropine 5 clonazepam 5
acticin 6 Aptivus 3 carbamazepine XR 200mg, 400mg 5 dexmethylphenidate XR 4
Bepreve 2 clonidine, oral, patch 2
Actimmune 1 aranelle 7 carbidopa 5 dextroamphetamine tabs 4
Berinert 3 clopidogrel 1
Actonel 4 Aranesp 1 carbidopa/levodopa 5 Diacomit 5
Besivance 2 clorazepate 4
Acular PF 2 Arcalyst 1 carbidopa/levodopa SA 5 diazepam 4
betamethasone dipropionate 6 clotrimazole lozenge 3
acyclovir cream 6 Arcapta 5 Cardec/DM 1 diclofenac 2
betamethasone valerate 6 clozapine 4
acyclovir ointment 6 aripiprazole 4 Cardura XL 2 Diclofenac Epolamine patch 5
betamethasone valerate foam 6 Coartem 3
acyclovir oral 3 armodafinil 4 carisoprodol 4 diclofenac potassium 5
betamethasone/clotrimazole 6 codeine sulfate 4
Aczone 5 ArmonAir 5 carisoprodol/ASA 4 diclofenac sodium 5
Betaseron 4 colchicine/probenecid 2
Adacel 6 Arnuity Ellipta 5 Carospir 3 diclofenac sodium 3% gel 5
betaxolol 2 Colcrys 2
adapalene/benzoyl peroxide 5 Ascensia Breeze 2 carteolol 2 diclofenac sodium gel 1% 5
betaxolol HCl 2 colesevelam 2
adapalene cream/gel 5 ashlyna 7 cartia XT 2 diclofenac sodium
Bethkis 3 Colestid 2
Adapalene lotion 5 Asmanex 5 carvedilol 2 topical solution 5
Betoptic-S 2 colestipol 2
adapalene solution 5 aspirin 325mg OTC 1 carvedilol ER 2 diclofenac sodium/misoprostol 5
Bevespi 5 Combipatch 7
Addyi 7 aspirin 81mg OTC 1 Caverject 3 dicloxacillin 3
Bevyxxa 1 Combivent Respimat 5
Adempas 3 aspirin-dipyridamole 1 Caya Contoured Diaphragm 7 dicyclomine 6
bexarotene 1 Cometriq 1
Adhansia XR 4 Astagraf XL 3 Cayston 3 didanosine 3
Bexsero 6 Commit 6
Adlyxin 1 Atacand 2 caziant 7 diethylpropion 7
Biaxin XL 3 Complera 3
Admelog 1 Atacand HCT 2 CeeNu 1 Differin 5
bicalutamide 1 Conceptrol 7
Adrenaclick 5 atazanavir 3 cefaclor 3 Dificid 3
Biktarvy 3 Consensi 3
Advair HFA 5 Atelvia 4 cefadroxil 3 diflorasone 6
bimatoprost 0.03% 2 Contour 2
Advicor 2 atenolol 2 cefdinir 3 diflunisal 5
Binosto 4 Contrave 7
Adzenys 4 atenolol/chlorthalidone 2 cefixime 3 digoxin 2
bisoprolol 2 Copaxone 4
Aerobid/M 5 Ativan 4 cefpodoxime 3 dihydroergotamine mesylate 5
bisoprolol/HCTZ 2 Copiktra 1
Afinitor 1 atomoxetine 4 cefprozil 3 Dilantin 5
blisovi 24 fe 7 Cordran ointment 6
afirmelle 7 atorvastatin calcium 2 Ceftin 3 Dilatrate SR 3
blisovi fe 7 Cordran tape 6
Afrezza 2 atovaquone 3 cefuroxime 3 diltia XT 2
Boniva 4 Corlanor 3
Aimovig 5 atovaquone/proguanil HCl 3 celecoxib 5 diltiazem 2
Bonjesta 6 Cortifoam 6
AirDuo 5 Atripla 3 Cellcept 3 diltiazem CD/SR/ER/XR 2
Boostrix 6 cortisone acetate 6
Ajovy 5 atropine sulfate ophth 2 Celontin 5 Diovan 2
bosentan 3 Cosentyx 6
Akynzeo 6 Atrovent HFA 5 Cenestin 7 Diovan HCT 2
Bosulif 1 Cotellic 1
albuterol sulfate ER 5 Atrovent Nasal Spray 1 Centany 6 Dipentum 6
Braftovi 1 Cotempla XR 4
Albuterol Sulfate HFA 5 Aubagio 4 cephalexin 3 diphenhydramine 1
Bravelle 7 Coumadin 1
albuterol tab, syr 5 aubra 7 Cequa 2 diphenoxylate/atropine 6
Breo Ellipta 5 Cozaar 2
alclometasone 6 aubra eq 7 Cerdelga 4 Diphtheria-Tetanus Toxoids-Ped 6
briellyn 7 Creon 6
Alecensa 1 aug. betamethasone diprop 6 cetirizine 1 dipyridamole 1
Brilinta 1 Cresemba 3
alendronate 4 aurovela 7 Cetrotide 7 Crestor 2 disopyramide 2
brimonidine 2 Chantix 6 disulfiram 4
alfuzosin 4 aurovela 24 Fe 7 Crinone 7
Briviact 5 chateal 7 Ditropan XL 1
Alinia 6 Auryxia 7 Crixivan 3
bromfenac 2 chateal eq 7 divalproex sodium/ER 5
aliskiren 2 Austedo 3 cromolyn inh. soln. 5
bromocriptine 5 chloral hydrate 4 dofetilide 2
Alkeran 1 AuviQ 5 cromolyn ophth 2
brompheniramine/phenylephrine 1 chlordiazepoxide 4 Domeboro 2
allopurinol 2 Avalide 2 cromolyn sodium 6
brompheniramine/ chlordiazepoxide/clindinium 6 donepezil 1
Alomide 2 Avandamet 1 pseudoephedrine 1 cryselle 7
Alora 7 Avandaryl 1 chloroquine phosphate 3 Cuprimine 5 Donnatal tablet 6
budesonide EC 6
alosetron 6 Avandia 1 chlorothiazide 3 Cuvitru 4 Doptelet 1
budesonide ER tablet 6
Alphagan P 0.1% 2 Avapro 2 chlorpromazine 4 cyanocobalamin inj. 6 Doryx 5
budesonide inh. (0.25mg/2ml,
alprazolam/ER 4 Avar 5 chlorpropamide 1 cyclafem 7 dorzolamide 2% eye drops 2
0.5mg/2ml) 5
Alprolix 1 aviane 7 chlorthalidone 3 cyclobenzaprine 4 dorzolamide/timolol eye drops 2
budesonide nasal spray 1
altavera 7 avita cream 5 chlorzoxazone 4 cyclobenzaprine ER 4 dotti 7
bumetanide 3
Altoprev 2 Avita gel 5 Cholbam 6 cyclophosphamide 1 doxazosin 2
Bunavail 4
Altreno 5 Avonex 4 cholecalciferol 6 cyclosporine 3 doxepin 4
buprenorphine 4
aluminum chloride 20% 6 Axert 5 Buprenorphine 7.5mg TD patch 4 cholestyramine 2 cyproheptadine 1 doxepin cream 6
Alunbrig 1 Axiron 3 buprenorphine TD patch (generic) 4 choline mag. trisalicylate 5 cyred 7 doxycycline 3
Alvesco 5 ayuna 7 buprenorphine-naloxone 4 Chorionic gonadotropin 7 cyred eq 7 doxycycline hyclate 75mg, 150mg tab 3
alyacen 7 Azasite 2 buprenorphine/naloxone film 4 Cialis 3 Cystadane 4 doxycycline hyclate DR 5
alyq 3 azathioprine 3 bupropion 4 ciclopirox cream 6 Cystagon 4 Doxycycline IR-DR 5
amantadine 3 azelaic acid gel 5 bupropion 6 ciclopirox soln 6 Cystaran 2 doxylamine-pyridoxine 6
Ambien 4 azelastine nasal spray 1 bupropion 12HR 4 cilostazol 1 Dritho-Scalp 6
Ambien CR 4 azelastine ophth 2 Ciloxan 2 D Drizalma Sprinkle 4
bupropion 24HR 4
ambrisentan 3 Azelex 5 buspirone 4 Cimduo 3 D-Penamine 5 drospirenone-eth estra-levomef 7
amcinonide 6 azithromycin suspension 3 butalbital/APAP 50mg-300mg 5 cimetidine 6 Daklinza 3 drospirenone-ethinyl estradiol 7
Amerge 5 azithromycin tablets 3 butalbital/APAP 50mg-325mg 5 Cimzia 5 dalfampridine ER 4 Duac 5
amethia 7 Azopt 2 butalbital/APAP/caffeine 5 cinacalcet 4 Daliresp 5 Duaklir Pressair 5
amethia lo 7 Azor 2 butalbital/APAP/codeine 4 Cinryze 3 danazol 4 Duavee 7
amethyst 7 Azulfidine 6 butalbital/aspirin/caffeine 5 Cipro HC 2 dantrolene sodium 4 Duetact 1
amiloride 3 azurette 7 butalbital/aspirin/codeine 4 Ciprodex 2 dapsone 5% 5 Duexis 5
amiloride/HCTZ 3 butorphanol NS 4 ciprofloxacin 3 dapsone tablets 3 Dulera 5
aminophylline 5 B ciprofloxacin ophth 2 Daptacel 6 duloxetine 4
Butrans 4
amiodarone 2 bacitracin ophth 2 Bydureon 1 ciprofloxacin otic 2 Daraprim 3 Duobrii 6
Amitiza 6 bacitracin/polymyxin 2 Byetta 1 citalopram 4 dasetta 7 Duopa 5
amitriptyline 3 baclofen 4 Bystolic 2 claravis 5 Daurismo 1 Dupixent 6
amitriptyline/ chlordiazepoxide 4 Bactroban cream 6 Byvalson 2 Clarinex-D 1 daysee 7 Durlaza 1
amitriptyline/perphenazine 4 Balcoltra 7 Clarispray 1 DDAVP nasal spray 4 dutasteride 4
amlodipine 2 balsalazide 6 C clarithromycin susp 3 DDAVP sol, tab 4 dutasteride/tamsulosin 4
amlodipine/atorvastatin 2 Balversa 1 Cablivi 1 clarithromycin tabs 3 deblitane 7 Dutrebis 3
amlodipine/benazepril 2 balziva 7 Cabometyx 1 clemastine 1 deferasirox 1 Duzallo 2
amlodipine/olmesartan 2 Banzel suspension 5 Cafergot 5 Cleocin 3 delyla 7 Dyanavel XR 4
amlodipine/valsartan 2 Banzel tablets 5 calcipotriene 6 Cleocin T 5 Demerol 4 Dymista 1
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