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WE CAN HELP YOU SAVE
fepblue.org AT THE PHARMACY.
2 0 2 1 A B B R E V I AT E D F O R M U L A RY
Blue Cross and Blue Shield Service Benefit Plan
2
REVIEW THIS ABBREVIATED FORMULARY TO LEARN HOW TO GET
THE MOST FROM YOUR PHARMACY BENEFIT SUCH AS:
■ Understanding the Formulary
■ How to use the Abbreviated Formulary
■ Abbreviated Formulary
■ Managed Not Covered” Drugs
■ Excluded Drug List
YOUR PHARMACY BENEFIT
The Blue Cross and Blue Shield Service Benefit Plan works
with Pharmacy Benefit Managers (PBMs) to administer your
pharmacy benefit.
■ Retail Pharmacy Program - CVS Caremark
■ Mail Service Pharmacy Program - CVS Caremark
■ Specialty Pharmacy Program - AllianceRx Walgreens Prime
NEW FOR 2021
■ Expanded Standard Option excluded drug list. See p. 42
■ Expanded Basic Option “Managed Not Covered” drug list. See p. 50
3
TABLE OF CONTENTS
UNDERSTANDING THE FORMULARY. . . . . . . . . . . . . . . . . . . . . . . . . . . 2
■ Formulary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
■ “Non-Covered” Drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
■ Quantity Limits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
■ Prior Approval. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
■ How Tiers Relate to Costs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
■ How Prescription Drugs are Assigned to Tiers. . . . . . . . . . . . . . . 5
COST SHARE TIERS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
■ Standard Option Cost Share Tiers. . . . . . . . . . . . . . . . . . . . . . . . . 6
■ Basic Option Cost Share Tiers. . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
■ FEP Blue Focus Cost Share Tiers . . . . . . . . . . . . . . . . . . . . . . . . 11
HOW TO USE THE ABBREVIATED FORMULARY. . . . . . . . . . . . . . . . . . 12
■ Program Options. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
■ Legend. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
ABBREVIATED FORMULARY (NON-SPECIALTY BY CONDITION) . . . . . . . . . 14
ABBREVIATED FORMULARY (ALPHABETIC INCLUDING SPECIALTY) . . . . . . 24
EXCLUDED DRUG LIST STANDARD OPTION. . . . . . . . . . . . . . . . . . . . . 42
“MANAGED NOT COVERED” DRUG LIST BASIC OPTION. . . . . . . . . . . 50
CHANGES FOR 2021 PHARMACY BENEFIT HIGHLIGHTS. . . . . . . . . . . 62
HOW TO CONTACT US . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
1
UNDERSTANDING THE FORMULARY
We continually review drugs in support of safe and appropriate
treatment. This helps to ensure that drugs in your benefit plan work well
and are cost-effective.
FORMULARY Basic Option has a managed
The formulary is a complete formulary. This means that we
list of your covered prescription cover most FDA-approved drugs.
drugs. It includes generic, brand There is a list of “Managed Not
name, and specialty drugs, as Covered” drugs that provides the
well as Preferred drugs that will Preferred alternatives that you
lower your out-of-pocket costs. may use. See p. 50–61
The Standard Option and Basic FEP Blue Focus has a limited
Option formularies have five tiers or closed formulary. This means
of drugs. The FEP Blue Focus that we only cover some FDA-
formulary has two tiers of drugs. approved drugs. Any drug not on
See p. 4 the FEP Blue Focus formulary is
not covered.
NON-COVERED DRUGS
If you buy a drug that is not
There are certain drugs approved
covered, you will pay full price.
by the U.S. Food and Drug
Administration (FDA) that we
don’t cover. We call these drugs QUANTITY LIMITS (QL)
“excluded” or “Managed Not Certain drugs on the formulary
Covered.” These drugs all have have quantity limits (for example,
Preferred alternatives that you number of pills). This means
can use. your pharmacy benefit will only
cover up to a specific amount per
Standard Option has a prescription or a limited amount
comprehensive formulary. This per year. Quantity limits help
means we cover almost all FDA ensure drugs are used safely and
approved drugs. There is a small appropriately. Drug quantities
list of excluded drugs that are are approved based on accepted
not covered. See p. 42–49 standards of healthcare practice
in the United States.
2
PRIOR APPROVAL (PA) ■ Drugs and supplies on the
Some prescription drugs and Prior Approval list may change
supplies need approval in throughout the year.
advance, or “prior approval” ■ Mail Service and Specialty
before we provide coverage for Programs will not fill
them. We need to confirm: prescriptions that need prior
■ Your use of the drug is related approval until you receive prior
to a service or condition approval.
covered under the Service ■ Preferred retail pharmacies
Benefit Plan. will fill your prescriptions, but
■ Your doctor prescribes it in a you will pay the full cost of
way that matches generally the drug until you get prior
accepted medical practices. approval. If you receive prior
approval, we’ll reimburse you
FACTS TO KNOW ABOUT for our portion of the drug cost
once you file a claim.
PRIOR APPROVAL
■ You will need to renew your
prior approval periodically.
HELP WITH PRIOR APPROVAL
Visit fepblue.org/priorapproval or call toll-free any
time at 1-800-624-5060 TTY/TDD 1-800-624-5077.
You will be able to:
■ See a list of drugs that need prior approval
■ Get a prior approval request form
Your doctor can submit requests for prior approval by:
■ Submitting an ePA (electronic prior approval)
■ Calling toll-free 1-877-727-3784
Filling out the Prior Approval Form found at
fepblue.org/priorapproval
3
UNDERSTANDING THE FORMULARY
HOW TIERS RELATE TO COSTS
The costs of drugs vary. How much you pay is your cost share. Look for
your drug in the formulary for your plan option. The tier level where your
drug type is listed determines your cost.
Standard and Basic Options
TIER DRUG TYPE
Tier 1 Generic Drugs: typically the most affordable, and are equal to their
brand name counterparts in quality, effectiveness and intended use.
Tier 2 Preferred Brand Name Drugs: proven to be safe, effective, and
favorably priced compared to Non-preferred brands.
Tier 3
Tier 4 Preferred Specialty Drugs: proven to be safe, effective, and
favorably priced compared to Non-preferred specialty drugs.
Tier 5
FEP Blue Focus
TIER DRUG TYPE
Tier 1
Tier 2 Preferred Brand Name Drugs and Preferred Specialty Drugs:
proven to be safe, effective, and favorably priced compared to
non-covered drug options.
4
HOW PRESCRIPTION DRUGS ARE ASSIGNED TO TIERS
The Pharmacy and Medical Policy Committee (PMPC) is an
independent group of doctors and pharmacists. This group
recommends drugs for each tier based on their:
■ Effectiveness
■ Safety
■ How they compare to other drugs in the same class
The PMPC meets every quarter to review new drugs and other
changes to the formulary. Based on that review, drugs may change
change tiers or be added or removed from the formulary. Check your
formulary often to be aware of any changes.
To see your 2021 cost share for a prescription drug:
- prior to January 1, 2021, visit fepblue.org/whatsnew
- after January 1, 2021, visit fepblue.org/formulary
- c all CVS Caremark for Retail or Mail Order drugs:
1-800-624-5060 TTY/TDD 1-800-624-5077
- c all AllianceRx Walgreens Prime for Specialty drugs:
1-888-346-3731 TTY/TDD 1-877-853-9549
5
UNDERSTANDING THE FORMULARY
STANDARD OPTION COST SHARE TIERS
Standard Option members save by using the Mail Service Pharmacy
and Preferred retail pharmacies for filling prescription drugs. Members
can also save by asking for generic and/or Preferred brand name drugs
when possible. Use the charts below to find your cost share.
Standard Option - GENERIC AND BRAND NAME DRUGS
Cost Share Based on Where You Fill Your Prescription
TIER MAIL SERVICE PREFERRED NON-PREFERRED
PHARMACY RETAIL RETAIL PHARMACY
PHARMACY
Tier 1: - $15* for up to a -$
7.50* for up to - 45% of the average
Generic 90-day supply a 30-day supply wholesale price
Drugs plus any difference
-$
22.50* for a 31
between our allowance
to 90-day supply
and the billed amount
Tier 2: - $90 for up - 3
0% of our - If you use a
Preferred to a 90-day allowance Non-preferred retail
Brand Name supply pharmacy, you need
Drugs to file a paper claim
for reimbursement
Tier 3: - $125 for up - 5
0% of our
Non- to a 90-day allowance
preferred supply
Brand Name
Drugs
*Lower cost shares are available to Standard Option members with Medicare Part B primary.
6
Standard Option - SPECIALTY DRUGS
Cost Share Based on Where You Fill Your Prescription
TIER SPECIALTY PREFERRED NON-PREFERRED
PHARMACY RETAIL PHARMACY RETAIL PHARMACY
Tier 4: - $65 for up to a - 3
0% of our - 45% of the average
Preferred 30-day supply allowance wholesale price
Specialty - $185 for a 31 to - W
hen you buy plus any difference
Drugs a 90-day supply between our
specialty drugs at
allowance and
-Y
ou are limited to a a Preferred retail
the billed amount
30-day supply for pharmacy, you
are limited to one - When you buy
the first 3 fills of
specialty drugs at
each specialty drug. 30-day supply for
a Non-preferred
You can get up to a each prescription.
retail pharmacy, you
90-day supply after You must get all
are limited to one
the third fill refills through the 30-day supply for
Specialty Pharmacy each prescription.
Tier 5: - $85 for up to a You must get all
Non- 30-day supply refills through the
preferred - $240 for a 31 to Specialty Pharmacy
Specialty a 90-day supply
Drugs
- Y
ou are limited to a
30-day supply for
the first 3 fills of
each specialty drug.
You can get up to a
90-day supply after
the third fill
To see 2021 Standard Option with Medicare Part B
primary cost shares:
- prior to January 1, 2021, visit fepblue.org/whatsnew
- after January 1, 2021, visit fepblue.org/formulary
- call CVS Caremark for Retail or Mail Order drugs:
1-800-624-5060 TTY/TDD 1-800-624-5077
- call AllianceRx Walgreens Prime for Specialty drugs:
1-888-346-3731 TTY/TDD 1-877-853-9549
7UNDERSTANDING THE FORMULARY
BASIC OPTION COST SHARE TIERS
Basic Option members must use a Preferred retail pharmacy and will
save by choosing generic drugs and Preferred brand name drugs when
possible. Use the charts below to find your cost share.
Basic Option - GENERIC AND BRAND NAME DRUGS
Cost Share Based on Where You Fill Your Prescription*
TIER PREFERRED RETAIL PHARMACY NON-PREFERRED
RETAIL PHARMACY
& MAIL SERVICE
PHARMACY
Tier 1: - $10 for up to a 30-day supply Not covered*
Generic - $30 for a 31 to 90-day supply
Drugs
Tier 2: - $55 for up to a 30-day supply
Preferred - $165 for a 31 to 90-day supply
Brand Name
Drugs
Tier 3: - 60% of our allowance with a $75
Non-preferred minimum for up to a 30-day supply
Brand Name and $210 minimum for a 31 to 90-
Drugs day supply
*Basic Option members with Medicare Part B primary coverage have Mail Service Pharmacy
benefits and some lower cost shares.
8Basic Option - SPECIALTY DRUGS
Cost Share Based on Where You Fill Your Prescription*
TIER SPECIALTY PHARMACY PREFERRED RETAIL
PHARMACY
Tier 4: - $85 for up to a 30-day supply - $65 for up to a
Preferred - $235 for a 31 to a 90-day 30-day supply only
Specialty supply - When you buy specialty
Drugs drugs at a Preferred retail
- You are limited to a 30-day
supply for the first 3 fills of pharmacy, you are limited
each specialty drug. You can to one 30-day supply for
get up to a 90-day supply each prescription. You
after the third fill must get all refills through
the Specialty Pharmacy
Tier 5: - $110 for up to a 30-day - $90 for up to a
Non-preferred supply 30-day supply only
Specialty - $300 for a 31 to a 90-day - When you buy specialty
Drugs supply drugs at a Preferred retail
- You are limited to a 30-day pharmacy, you are limited
supply for the first 3 fills of to one 30-day supply for
each specialty drug. You each prescription. You
can get up to a 90-day supply must get all refills through
after the third fill the Specialty Pharmacy
*Basic Option members with Medicare Part B primary coverage have some lower cost shares.
To see 2021 Basic Option with Medicare Part B
primary cost shares:
- prior to January 1, 2021, visit fepblue.org/whatsnew
- after January 1, 2021, visit fepblue.org/formulary
- c all CVS Caremark for Retail or Mail Order drugs:
1-800-624-5060 TTY/TDD 1-800-624-5077
- c all AllianceRx Walgreens Prime for Specialty drugs:
1-888-346-3731 TTY/TDD 1-877-853-9549
9UNDERSTANDING THE FORMULARY 10
FEP BLUE FOCUS COST SHARE TIERS
Members who use generic medications will benefit the most from
FEP Blue Focus. This plan has a limited or closed formulary of
covered drugs.
FEP Blue Focus
Cost Share Based on Where You Fill Your Prescription
TIER PREFERRED RETAIL PHARMACY AND
SPECIALTY PHARMACY
Tier 1: - $5 for up to a 30-day supply
Preferred Generic - $15 for a 31 to 90-day supply
Drugs
Tier 2: - 40% of our allowance up to $350 for up to a 30-day supply
Preferred Brand - 40% of our allowance up to $1,050 for a 31 to 90-day
Name Drugs supply
and Preferred
- You are limited to a 30-day supply for each specialty
Specialty Drugs
drug prescription.
To see 2021 FEP Blue Focus cost shares:
- prior to January 1, 2021, visit fepblue.org/whatsnew
- after January 1, 2021, visit fepblue.org/pharmacy
- c all CVS Caremark for Retail drugs: 1-800-624-5060
TTY/TDD 1-800-624-5077
- c all AllianceRx Walgreens Prime for Specialty drugs:
1-888-346-3731 TTY/TDD 1-877-853-9549
11HOW TO USE THE
ABBREVIATED FORMULARY
Use the abbreviated formulary to
find the most cost-effective drugs
for your condition.
1. F
ind the tier related to
your drug. The charts are
organized:
n By drug category for Non-
specialty drugs by condition
See p. 14–23
n lphabetically including
A
Specialty for all drugs
See p. 24–40
to prescribe a Preferred brand
2. S
ee if there are any limitations
name drug.
for your drug.
3. R
eview the cost share PROGRAM OPTIONS
charts to find your copay or The benefit for Standard Option
coinsurance. See p. 6–11 (SO), Basic Option (BO) and FEP
4. If your drug is in Tiers 2, 3 or Blue Focus (BF) varies. The charts
5, ask your doctor if there is list the SO, BO and BF tiers for
a generic drug to treat your each drug. In many cases the
condition. If there is not a tier is the same, but not in
generic drug, ask your doctor every case.
To see the 2021 full formularies:
- prior to January 1, 2021, visit fepblue.org/whatsnew
- after January 1, 2021, visit fepblue.org/pharmacy
- c all CVS Caremark for Retail or Mail Order drugs:
1-800-624-5060 TTY/TDD 1-800-624-5077
- c all AllianceRx Walgreens Prime for Specialty drugs:
1-888-346-3731 TTY/TDD 1-877-853-9549
12PROGRAM LEGEND
Some drugs are noted with letters or symbols in the columns next to
them. The letters describe any limitations.
‡
◊ Prior Approval: needs approval in advance before a drug is covered.
For certain drugs, this list shows uses for which the drug is
* prescribed. Some drugs are prescribed for more than one condition.
Generic oral contraceptives and select brand contraceptives are
** available to female members at no copay.
NC Not Covered
SO Standard Option
BO Basic Option
BF FEP Blue Focus
BOLD Bold type means there is a generic for this drug.
ITALIC Italic type means this is a specialty drug.
This abbreviated formulary lists the most commonly used drugs.
Please note: Before filling your prescription, please check the
Preferred/Non-preferred status of the drug. Other than changes
resulting from new drugs or safety issues, the Preferred drug list is
updated periodically during the year.
13ABBREVIATED FORMULARY
(NON-SPECIALTY BY CONDITION)
Bold Type means there is a generic version for this drug. Drugs that
are listed in CAPITAL LETTERS are brand name drugs, while those in
lowercase are generic versions.
SO BO BF SO BO BF
CONDITION/DRUG CONDITION/DRUG
TIER TIER TIER TIER TIER TIER
ALLERGY/COUGH & COLD ERTACZO ◊ 3 NC NC
azelastine 1 1 1 EXELDERM ◊ 3 3 NC
BECONASE AQ 3 NC NC fluconazole 1 1 1
benzonatate 1 1 1 JUBLIA ◊ 3 NC NC
CLARINEX 3 NC NC KERYDIN* ◊ 3 NC NC
CLARINEX-D 3 NC NC ketoconazole tabs ◊ 1 1 1
desloratadine 1 NC NC levofloxacin 1 1 1
flunisolide spray 1 1 1 LOPROX ‡ 3 NC NC
fluticasone spray 1 1 1 LOTRISONE* 3 NC NC
levocetirizine 1 NC NC LUZU ◊ 3 NC NC
NASONEX 3 NC NC MENTAX 3 NC NC
promethazine/codeine ‡ 1 1 1 metronidazole 1 1 1
VERAMYST 2 NC NC naftifine ‡ 1 1 1
ANTI-INFECTIVES/ ANTIBIOTICS/ NAFTIN ‡ 2 NC NC
ANTIFUNGAL/ANTIVIRAL
oseltamivir phosphate ‡ 1 1 1
amoxicillin 1 1 1
amoxicillin/ clavulanate OXISTAT ◊ 3 NC NC
1 1 1
potassium sulfamethoxazole/
1 1 1
azithromycin 1 1 1 trimethoprim
TAMIFLU CAPS ‡ 3 3 NC
cephalexin 1 1 1
valacyclovir 1 1 1
ciprofloxacin 1 1 1
clotrimazole/ VALTREX 3 3 NC
1 1 1
betamethasone
VUSION ‡ * 3 NC NC
doxycycline hyclate 1 1 1
XOFLUZA ‡ 3 3 2
14SO BO BF SO BO BF
CONDITION/DRUG CONDITION/DRUG
TIER TIER TIER TIER TIER TIER
ZOVIRAX 3 3 NC DESCOVY 2 2 2
ANTINEOPLASTICS AND didanosine delayed
1 1 1
IMMUNOSUPPRESSANTS release
anastrozole 1 1 1 DOVATO 2 2 2
ASTAGRAF XL 2 2 2 EDURANT 2 2 2
azathioprine 1 1 1 emtricitabine-TDF
1 1 1
200-300 mg
CELLCEPT 3 3 NC
EPIVIR 3 3 NC
cyclosporine 1 1 1
EPZICOM 3 3 NC
letrozole 1 1 1
GENVOYA 2 2 2
megestrol acetate 1 1 1
INTELENCE 2 2 2
mycophenolate mofetil 1 1 1
ISENTRESS 2 2 2
MYFORTIC 3 3 NC
lamivudine 1 1 1
NEORAL 3 3 NC
lamivudine/zidovudine 1 1 1
NILANDRON ◊ 3 3 NC
nevirapine ext-rel 1 1 1
PROGRAF 3 3 NC
PREZISTA 2 2 2
RAPAMUNE 3 3 NC
RETROVIR 3 3 NC
sirolimus 1 1 1
REYATAZ 3 3 NC
tacrolimus 1 1 1
stavudine 1 1 1
tamoxifen citrate 1 1 1
STRIBILD 2 2 2
ANTIVIRAL/HIV
SUSTIVA 3 3 NC
abacavir 1 1 1
TRIUMEQ 2 2 2
abacavir/ lamivudine/
1 1 1 TRIZIVIR 3 3 NC
zidovudine
APTIVUS 2 2 2 TRUVADA 200-300 mg 3 3 NC
ATRIPLA 3 3 NC TRUVADA
2 2 2
(except 200-300 mg)
BIKTARVI 2 2 2
VIRACEPT 2 2 2
COMBIVIR 3 3 NC
VIRAMUNE/XR 3 3 NC
15ABBREVIATED FORMULARY (NON-SPECIALTY BY CONDITION)
SO BO BF SO BO BF
CONDITION/DRUG CONDITION/DRUG
TIER TIER TIER TIER TIER TIER
ZIAGEN 3 3 NC SPIRIVA 2 2 2
zidovudine 1 1 1 STRIVERDI RESPIMAT 3 3 NC
ASTHMA COPD SYMBICORT 2 2 NC
ALVESCO 3 NC NC TRELEGY ELLIPTA 2 2 2
ACCOLATE 3 3 NC TUDORZA PRESSAIR 3 NC NC
ADVAIR DISKUS 3 3 NC VENTOLIN HFA 2 NC NC
ADVAIR HFA 2 2 2 XOPENEX HFA 3 NC NC
albuterol sulfate tablet/ XOPENEX/CONCEN-
1 1 1 3 3 NC
solution TRATE
albuterol sulfate, CFC- zafirlukast 1 1 1
1 1 1
free aerosol
CARDIOVASCULAR
ANORO ELLIPTA 2 2 2 DRUGS HIGH BLOOD
PRESSURE
ARNUITY ELLIPTA 2 2 2
amlodipine besylate/
1 1 1
ATROVENT HFA 2 3 NC benazepril hydrochloride
ATACAND/HCT 3 NC NC
BREO ELLIPTA 2 2 2
atenolol 1 1 1
budesonide/formoterol 1 1 1
COMBIVENT RE- AVALIDE 3 NC NC
3 3 NC
SPIMAT
AVAPRO 3 NC NC
DULERA 2 2 2
AZOR 3 3 NC
FLOVENT HFA 2 2 2
BENICAR/HCTZ 3 3 NC
fluticasone/salmeterol
1 1 1
diskus BREVIBLOC 3 3 NC
FORADIL 3 3 NC BYSTOLIC 2 2 2
INCRUSE ELLIPTA 3 NC NC candesartan/hctz 1 1 1
montelukast sodium 1 1 1 carvedilol 1 1 1
PERFOROMIST 3 3 NC clonidine 1 1 1
PROAIR HFA 2 2 NC COZAAR 3 NC NC
PROVENTIL HFA 2 NC NC diltiazem cd 1 1 1
QVAR 2 2 2 DIOVAN/HCT 3 NC NC
SINGULAIR 3 3 NC
16SO BO BF SO BO BF
CONDITION/DRUG CONDITION/DRUG
TIER TIER TIER TIER TIER TIER
doxazosin mesylate 1 1 1 CRESTOR 3 NC NC
EDARBI 3 NC NC ezetimibe 1 1 1
EDARBYCLOR 3 NC NC fenofibrate 1 1 1
enalapril maleate 1 1 1 fenofibric acid 1 1 1
EXFORGE/HCTZ 3 3 NC gemfibrozil 1 1 1
furosemide 1 1 1 LESCOL/XL 3 NC NC
hydralazine 1 1 1 LIPITOR 3 NC NC
hydrochlorothiazide 1 1 1 LIVALO 3 NC NC
HYZAAR 3 NC NC lovastatin 1 1 1
irbesartan/hctz 1 1 1 LOVAZA 3 3 NC
LEVATOL 3 3 NC niacin er 1 1 1
lisinopril/hctz 1 1 1 omega-3 acid ethyl
1 1 1
esters
losartan/hctz 1 1 1
PRAVACHOL 3 NC NC
metoprolol succinate/
1 1 1 pravastatin sodium 1 1 1
tartrate
MICARDIS/HCT 3 NC NC rosuvastatin 1 1 1
propranolol 1 1 1 simvastatin 1 1 1
ramipril 1 1 1 TRIGLIDE 3 3 NC
spironolactone 1 1 1 VASCEPA 2 2 2
telmisartan/hctz 1 1 1 VYTORIN 3 NC NC
triamterene/hctz 1 1 1 WELCHOL 3 3 NC
valsartan/hctz 1 1 1 ZETIA 3 3 NC
verapamil/er 1 1 1 ZOCOR 3 NC NC
CARDIOVASCULAR DRUGS CARDIOVASCULAR DRUGS OTHER
HIGH CHOLESTEROL
AGGRASTAT 3 3 NC
amlodipine/atorvastatin 1 1 1
AGGRENOX 3 3 NC
atorvastatin calcium 1 1 1
clopidogrel 1 1 1
CADUET 3 NC NC
17ABBREVIATED FORMULARY (NON-SPECIALTY BY CONDITION)
SO BO BF SO BO BF
CONDITION/DRUG CONDITION/DRUG
TIER TIER TIER TIER TIER TIER
digoxin 1 1 1 sertraline 1 1 1
EFFIENT 3 3 NC trazodone 1 1 1
ELIQUIS 2 2 2 venlafaxine/er 1 1 1
enoxaparin sodium 1 1 1 WELLBUTRIN XL 3 3 NC
ENTRESTO ◊ 3 3 2 CENTRAL NERVOUS SYSTEM ATTENTION
DEFICIT DISORDER
isosorbide mononitrate
1 1 1 amphetamine salt
er 1 1 1
combo ◊
NITROSTAT 3 3 NC
DAYTRANA ◊ 3 3 NC
PLAVIX 3 3 NC dextro-amphetamine/
1 1 1
amphetamine salts ◊
PRADAXA 3 NC NC
FOCALIN XR ◊ 3 3 NC
warfarin 1 1 1
INTUNIV 3 3 NC
XARELTO 2 2 2
METHYLIN ◊ 3 3 NC
CENTRAL NERVOUS SYSTEM ANXIETY
AND DEPRESSION methylphenidate/er ◊
(except methylpheni-
alprazolam 1 1 1 1 1 1
date tab ER osmotic
amitriptyline 1 1 1 release 72 mg)
STRATTERA 3 3 NC
bupropion/xl 1 1 1
VYVANSE ◊ 2 2 2
citalopram 1 1 1
CENTRAL NERVOUS SYSTEM MIGRAINE
CYMBALTA 3 3 NC
AIMOVIG ◊ 2 2 2
diazepam 1 1 1
EMGALITY ◊ 2 2 2
duloxetine ER 1 1 1
NURTEC ODT ◊ 3 3 NC
EFFEXOR XR 3 3 NC
RELPAX ‡ 3 3 NC
escitalopram oxalate 1 1 1
rizatriptan ‡ 1 1 1
fluoxetine 1 1 1
sumatriptan succinate ‡ 1 1 1
LEXAPRO 3 3 NC
zolmitriptan ‡ 1 1 1
lorazepam 1 1 1
ZOMIG/ZMT ‡ 3 3 NC
paroxetine 1 1 1
CENTRAL NERVOUS SYSTEM OTHER
PRISTIQ 3 3 NC
ABILIFY 3 3 NC
18SO BO BF SO BO BF
CONDITION/DRUG CONDITION/DRUG
TIER TIER TIER TIER TIER TIER
AZILECT 3 3 NC SUBOXONE FILM ‡ 3 3 NC
baclofen 1 1 1 tramadol (except
1 1 1
100mg tab)/er ‡
carbidopa/levodopa
1 1 1 ZUBSOLV ‡ 2 2 2
& er
cyclobenzaprine 1 1 1 CENTRAL NERVOUS SYSTEM
SEIZURE DISORDERS
donepezil 1 1 1
clonazepam 1 1 1
EQUETRO 3 3 NC
gabapentin ‡ 1 1 1
EXELON 3 3 NC
lamotrigine 1 1 1
NAMENDA TABS 3 3 NC
levetiracetam 1 1 1
NEUPRO 2 2 2
LYRICA ‡ 3 NC NC
pramipexole dihydro-
1 1 1 pregabalin ‡ 1 1 1
chloride
quetiapine fumarate 1 1 1 topiramate 1 1 1
risperidone 1 1 1 CENTRAL NERVOUS SYSTEM
SLEEP AGENTS
ropinirole 1 1 1
AMBIEN/CR ‡ 3 NC NC
SAVELLA ‡ 3 3 NC
EDLUAR ‡ 3 NC NC
SEROQUEL XR 3 3 NC
eszopiclone ‡ 1 1 1
CENTRAL NERVOUS SYSTEM PAIN
INTERMEZZO ‡ 3 NC NC
buprenorphine patch ‡ 1 1 1
LUNESTA ‡ 3 NC NC
buprenorphine/
1 11 ROZEREM ‡ 3 NC NC
naloxone ‡
butalbital/APAP ‡ 1 1 1 temazepam ‡ 1 1 1
BUTRANS ‡ 3 3 NC zaleplon ‡ 1 1 1
EMBEDA ‡ 2 2 NC zolpidem/ER ‡ 1 1 1
fentanyl patch ‡ 1 1 1 CONTRACEPTIVES OTHER
hydrocodone/ NUVARING 3 3 NC
1 1 1
acetaminophen ‡
PARAGARD T 380A 2 2 2
hydromorphone ‡ 1 1 1
DERMATOLOGY
MORPHABOND ‡ 3 3 NC
BENZACLIN 3 3 NC
OXYCONTIN ‡ 3 NC NC
19ABBREVIATED FORMULARY (NON-SPECIALTY BY CONDITION)
SO BO BF SO BO BF
CONDITION/DRUG CONDITION/DRUG
TIER TIER TIER TIER TIER TIER
betamethasone ‡ 1 1 1 FARXIGA $ 2 2 2
CARAC 3 NC NC FORTAMET ◊ 3 NC NC
ciclopirox ‡ 1 1 1 glimepiride 1 1 1
clindamycin phosphate ‡ 1 1 1 glipizide/er/xl 1 1 1
clobetasol propionate ‡ 1 1 1 GLUCOPHAGE/XR 3 3 NC
CLOBEX ‡ 3 3 NC glyburide 1 1 1
doxepin crm ‡ 1 1 1 GLYSET 3 3 NC
EPIDUO ◊ 3 3 NC GVOKE 2 2 2
ERYGEL ‡ 3 3 NC INVOKANA ◊ 3 NC NC
fluorouracil cream 0.5% 1 NC NC JANUMET 2 2 2
lidocaine topical ‡ 1 1 1 JANUMET XR 2 2 2
methylprednisolone 1 1 1 JANUVIA 2 2 2
mupirocin ‡ 1 1 1 JARDIANCE $ 2 2 2
NORITATE 3 NC NC OZEMPIC 2 2 2
ORACEA 3 3 NC pioglitazone 1 1 1
TAZORAC ◊ 3 3 NC RYBELSUS 3 3 NC
tretinoin ◊ 1 1 1 TRULICITY 2 2 2
DIABETES BLOOD GLUCOSE MONITORING VICTOZA 2 2 2
ACCU CHEK TEST DIABETES INSULIN
2 2 2
STRIPS ‡
ONETOUCH TEST BASAGLAR 2 2 2
2 2 2
STRIPS ‡
FIASP 2 2 2
DIABETES DRUGS
HUMALOG/ MIX/KWIK-
2 NC NC
AFREZZA ◊ 3 3 NC PEN
HUMULIN U-500
BAQSIMI 2 2 2 2 2 2
CONCENTRATE
BYDUREON 3 NC NC HUMULIN/KWIKPEN
(EXCEPT HUMULIN 2 NC NC
BYETTA 3 NC NC U-500 CONCENTRATE)
§ Generic versions of GLUMETZA and FORTAMET (metformin ER ext-rel tabs) require
Prior Approval.
20SO BO BF SO BO BF
CONDITION/DRUG CONDITION/DRUG
TIER TIER TIER TIER TIER TIER
LANTUS 2 NC NC GASTROINTESTINAL DRUGS
LEVEMIR 2 2 2 ALOXI ◊ 3 3 NC
NOVOLIN 2 2 2 AMITIZA ◊ 3 3 NC
NOVOLOG MIX 70/30 2 2 2 ASACOL HD 3 NC NC
TOUJEO 2 NC NC DELZICOL 3 NC NC
TRESIBA 2 3 NC DEXILANT ‡ 3 NC NC
EYE/EAR dicyclomine 1 1 1
ALPHAGAN P (0.15%) 3 3 NC EMEND ‡ 3 3 NC
AZOPT 2 2 2 esomeprazole magne-
1 1 1
sium delayed-rel ‡
brimonidine tartrate 1 1 1
famotidine 40mg 1 1 1
CIPRODEX 3 3 NC
lansoprazole ‡ 1 1 1
COMBIGAN 2 2 2
LIALDA 3 3 NC
dorzolamide/timolol
1 1 1 LINZESS ◊ 2 2 2
maleate
DUREZOL 2 2 2 MOVIPREP 3 3 NC
erythromycin 1 1 1 omeprazole 1 1 1
latanoprost 1 1 1 omeprazole/sodium
1 NC NC
bicarbonate ‡
LUMIGAN 2 NC NC
ondansetron/odt ‡ 1 1 1
prednisolone acetate 1 1 1
pantoprazole sodium ‡ 1 1 1
RESTASIS ◊ 2 2 2 polyethylene glycol
1 1 1
3350
RHOPRESSA 3 3 NC
rabeprazole ‡ 1 1 1
ROCKLATAN 3 3 NC
RELISTOR ◊ 3 3 2
timolol maleate 1 1 1
sucralfate 1 1 1
TRAVATAN Z 3 3 NC
SUPREP BOWEL PREP
2 2 2
VIGAMOX 3 3 NC KIT
XIIDRA ◊ 2 2 2 VARUBI ‡ 2 2 2
ZIOPTAN 3 3 NC
21ABBREVIATED FORMULARY (NON-SPECIALTY BY CONDITION)
SO BO BF SO BO BF
CONDITION/DRUG CONDITION/DRUG
TIER TIER TIER TIER TIER TIER
HORMONE REPLACEMENT calcitriol 1 1 1
ANDRODERM ◊ 2 2 2 CHANTIX 2 2 2
ANDROGEL ◊ 3 NC NC COLCRYS 3 3 NC
ESTRACE 3 3 NC epinephrine injection 1 1 1
estradiol 1 1 1 EPIPEN 2 PAK 3 3 NC
FORTESTA ◊ 3 3 NC EVISTA 3 3 NC
MINIVELLE 3 3 NC febuxostat ◊ 1 1 1
PREFEST 3 3 NC naloxone 1 1 1
PREMARIN 2 2 2 NARCAN 1 1 1
PREMPRO 2 2 2 ORAL CONTRACEPTIVES BIPHASIC**
progesterone ◊ 1 1 1 MIRCETTE 3 3 NC
STRIANT ◊ 3 3 NC ORAL CONTRACEPTIVES MONOPHASIC**
TESTIM ◊ 3 NC NC cryselle 1 1 1
testosterone gianvi 1 1 1
1 1 1
cypionate ◊
LOESTRIN/FE 3 3 NC
testosterone gel ◊ 1 1 1
ORTHO-NOVUM 3 3 NC
VAGIFEM 3 3 NC
zovia 1 1 1
VIVELLE DOT 3 3 NC
ORAL CONTRACEPTIVES TRIPHASIC**
VOGELXO ◊ 3 NC NC
ORTHO TRI-CYCLEN 3 3 NC
INFLAMMATION - CORTICOSTEROIDS
ORTHO TRI-CYCLEN
CORTEF 3 NC NC 3 3 NC
LO
MEDROL 3 NC NC OSTEOPOROSIS/BONE DISEASES
ORAPRED ODT 3 NC NC ACTONEL 3 3 NC
prednisone 1 1 1 alendronate 1 1 1
RAYOS ◊ 3 NC NC ibandronate 1 1 1
MISCELLANEOUS risedronate 1 1 1
allopurinol 1 1 1 PSORIASIS
22SO BO BF SO BO BF
CONDITION/DRUG CONDITION/DRUG
TIER TIER TIER TIER TIER TIER
acitretin 1 1 1 levothyroxine 1 1 1
calcipotriene-betameth- SYNTHROID 2 2 2
1 1 1
asone ‡
UROLOGIC DISORDERS
RHEUMATOLOGY
AVODART 3 3 NC
ANAPROX DS 3 NC NC
finasteride 1 1 1
ARTHROTEC 3 NC NC
GELNIQUE 3 NC NC
CELEBREX ‡ 3 3 NC
JALYN 3 NC NC
celecoxib ‡ 1 1 1
MYRBETRIQ 2 2 NC
diclofenac tablets 1 1 1
oxybutynin/er 1 1 1
FELDENE 3 NC NC
phenazopyridine 1 1 1
ibuprofen 1 1 1
RAPAFLO 3 3 NC
meloxicam 1 1 1
silodosin 1 1 1
methotrexate inj 1 1 1
solifenacin 1 1 1
NAPROSYN 3 NC NC
tamsulosin 1 1 1
OTREXUP ◊ 3 3 NC
tolterodine/ER 1 1 1
RASUVO ◊ 3 3 NC
TOVIAZ 2 2 NC
THYROID MEDICATIONS
trospium/er 1 1 1
ARMOUR THYROID 3 3 NC
To see the 2021 full formularies:
-p
rior to January 1, 2021, visit
fepblue.org/whatsnew
- a fter January 1, 2021, visit
fepblue.org/formulary
- c all CVS Caremark for Retail or Mail Order drugs:
1-800-624-5060 TTY/TDD 1-800-624-5077
- c all AllianceRx Walgreens Prime for Specialty drugs:
1-888-346-3731 TTY/TDD 1-877-853-9549
23ABBREVIATED FORMULARY
(ALPHABETIC INCLUDING SPECIALTY)
Bold Type means there is a generic version for this drug. Italic Type
means this is a specialty drug. Drugs that are listed in CAPITAL LETTERS
are brand name drugs, while those in lowercase are generic versions.
SO BO BF SO BO BF
NAME NAME
TIER TIER TIER TIER TIER TIER
abacavir 1 1 1 AFINITOR 2.5 mg, 5 mg,
5 NC NC
7.5 mg ◊
abacavir/ lamivudine/
1 1 1 AFINITOR DISPERZ
zidovudine 4 4 NC
TAB ◊
ABILIFY 3 3 NC
AFREZZA ◊ 3 3 NC
ABIRATERONE ◊ 4 4 2
AFSTYLA 4 4 NC
ABRAXANE 4 4 NC
AGGRASTAT 3 3 NC
ACCOLATE 3 3 NC
AGGRENOX 3 3 NC
ACCU CHEK TEST
2 2 2 AIMOVIG ◊ 2 2 2
STRIPS ‡
acitretin 1 1 1 albuterol sulfate tablet/
1 1 1
solution
ACTEMRA ◊ 4 4 2 albuterol sulfate, CFC-
1 1 1
free aerosol
ACTHAR HP ◊ 5 5 NC
ALDURAZYME ◊ 4 4 NC
ACTONEL 3 3 NC
ALECENSA ◊ 5 5 2
ADCETRIS ◊ 4 4 2
alendronate 1 1 1
ADCIRCA ◊ 5 NC NC
ALIMTA 4 4 2
ADEFOVIR 4 4 2
ALKERAN INJ 5 5 NC
ADEMPAS ◊ 5 5 2
ALKERAN TAB 5 5 NC
ADRIAMYCIN PFS 4 4 NC
allopurinol 1 1 1
ADRUCIL 4 4 2
ALOXI ◊ 3 3 NC
ADVAIR DISKUS 3 3 NC
ALPHAGAN P (0.15%) 3 3 NC
ADVAIR HFA 2 2 2
ALPHANATE 4 4 2
ADVATE 4 4 NC
ALPHANINE SD 4 4 NC
ADYNOVATE 5 5 NC
alprazolam 1 1 1
AFINITOR 10 mg ◊ 4 4 2
ALPROLIX 4 4 2
24SO BO BF SO BO BF
NAME NAME
TIER TIER TIER TIER TIER TIER
ALVESCO 3 NC NC ARZERRA ◊ 4 4 NC
AMBIEN/CR ‡ 3 NC NC ASACOL HD 3 NC NC
AMBRISENTAN ◊ 4 4 2 ASTAGRAF XL 2 2 2
AMIFOSTINE 4 4 2 ATACAND/HCT 3 NC NC
AMITIZA ◊ 3 3 NC atenolol 1 1 1
amitriptyline 1 1 1 atorvastatin calcium 1 1 1
amlodipine besylate/ ATRIPLA 3 3 NC
1 1 1
benazepril hydrochloride
ATROVENT HFA 2 3 NC
amlodipine/atorvastatin 1 1 1
AUBAGIO ◊ 4 4 2
amoxicillin 1 1 1
amoxicillin/ clavulanate AVALIDE 3 NC NC
1 1 1
potassium
AVAPRO 3 NC NC
amphetamine salt
1 1 1
combo ◊ AVASTIN ◊ 5 5 NC
ANAPROX DS 3 NC NC AVODART 3 3 NC
anastrozole 1 1 1 AVONEX ◊ 4 4 2
ANDRODERM ◊ 2 2 2 AZACITIDINE 4 4 NC
ANDROGEL ◊ 3 NC NC azathioprine 1 1 1
ANORO ELLIPTA 2 2 2 azelastine 1 1 1
APOKYN 4 4 2 AZILECT 3 3 NC
APTIVUS 2 2 2 azithromycin 1 1 1
ARALAST /NP ◊ 4 4 2 AZOPT 2 2 2
ARANESP ◊ 4 4 2 AZOR 3 3 NC
ARCALYST ◊ 4 4 2 baclofen 1 1 1
ARMOUR THYROID 3 3 NC BAQSIMI 2 2 2
ARNUITY ELLIPTA 2 2 2 BARACLUDE SOLN 4 4 2
ARRANON 4 4 2 BARACLUDE TABS ◊ 5 NC NC
ARTHROTEC 3 NC NC BASAGLAR 2 2 2
25ABBREVIATED FORMULARY (ALPHABETIC INCLUDING SPECIALTY)
SO BO BF SO BO BF
NAME NAME
TIER TIER TIER TIER TIER TIER
BEBULIN 4 4 2 BUPHENYL ◊ 5 5 NC
BECONASE AQ 3 NC NC buprenorphine patch ‡ 1 1 1
BELEODAQ ◊ 4 4 NC buprenorphine/naloxone ‡ 1 1 1
BENDEKA ◊ 4 4 NC bupropion/xl 1 1 1
BENEFIX 4 4 2 butalbital/APAP ‡ 1 1 1
BENICAR/HCTZ 3 3 NC BUTRANS ‡ 3 3 NC
BENLYSTA ◊ 4 4 NC BYDUREON 3 NC NC
BENZACLIN 3 3 NC BYETTA 3 NC NC
benzonatate 1 1 1 BYSTOLIC 2 2 2
BERINERT ◊ 4 4 2 CADUET 3 NC NC
betamethasone ‡ 1 1 1 calcipotriene-
1 1 1
betamethasone ‡
BETASERON ◊ 4 4 2
calcitriol 1 1 1
BETHKIS 5 5 NC
CALQUENCE ◊ 4 4 2
BEXAROTENE ◊ 4 4 2
candesartan/hctz 1 1 1
BICNU 5 5 NC
CARAC 3 NC NC
BIKTARVI 2 2 2
carbidopa/levodopa & er 1 1 1
BIVIGAM ◊ 4 4 NC
carvedilol 1 1 1
BLEOMYCIN 4 4 2
CELEBREX ‡ 3 3 NC
BLINCYTO ◊ 4 4 2
celecoxib ‡ 1 1 1
BOSENTAN ◊ 4 4 2
CELLCEPT 3 3 NC
BOSULIF ◊ 4 4 2
cephalexin 1 1 1
BOTOX ◊ 4 4 2
CEPROTIN ◊ 4 4 NC
BRAFTOVI ◊ 5 5 NC
CERDELGA ◊ 4 4 2
BREO ELLIPTA 2 2 2
CEREZYME ◊ 4 4 2
BREVIBLOC 3 3 NC
CETROTIDE ◊ 4 4 2
brimonidine tartrate 1 1 1
CHANTIX 2 2 2
budesonide/formoterol 1 1 1
26SO BO BF SO BO BF
NAME NAME
TIER TIER TIER TIER TIER TIER
CHORIONIC GONADO- CORIFACT 4 4 NC
4 4 2
TROPIN ◊
CORTEF 3 NC NC
ciclopirox ‡ 1 1 1
COSENTYX ◊ 5 5 NC
CIMZIA ◊ 5 5 NC
COSMEGEN 5 5 NC
CINACALCET ◊ 4 4 2
COZAAR 3 NC NC
CINRYZE ◊ 4 4 2
CRESTOR 3 NC NC
CIPRODEX 3 3 NC
cryselle 1 1 1
ciprofloxacin 1 1 1
CUVITRU ◊ 5 5 2
CISPLATIN 4 4 2
cyclobenzaprine 1 1 1
citalopram 1 1 1
CYCLOPHOSPHAMIDE 4 4 2
CLADRIBINE 4 4 2
cyclosporine 1 1 1
CLARINEX 3 NC NC
CYMBALTA 3 3 NC
CLARINEX-D 3 NC NC
CYSTAGON 4 4 2
clindamycin phosphate ‡ 1 1 1
CYTARABINE 4 4 2
clobetasol propionate ‡ 1 1 1
CYTOGAM 4 4 2
CLOBEX ‡ 3 3 NC
CYTOVENE 5 5 NC
CLOLAR 5 5 NC
DACARBAZINE 4 4 2
clonazepam 1 1 1
DACOGEN 5 5 NC
clonidine 1 1 1
DACTINOMYCIN 4 4 2
clopidogrel 1 1 1
clotrimazole/ DALFAMPRIDINE ER ◊ 4 4 2
1 1 1
betamethasone ‡
DARZALEX ◊ 4 4 NC
COAGADEX 4 4 NC
DAUNORUBICIN HCL 4 4 2
COLCRYS 3 3 NC
DAYTRANA ◊ 3 3 NC
COMBIGAN 2 2 2
DECITABINE 4 4 2
COMBIVENT RESPIMAT 3 3 NC
DEFERASIROX ◊ 4 4 2
COMBIVIR 3 3 NC
DEFEROXAMINE 4 4 2
COPAXONE ◊ 5 NC NC
DELZICOL 3 NC NC
27ABBREVIATED FORMULARY (ALPHABETIC INCLUDING SPECIALTY)
SO BO BF SO BO BF
NAME NAME
TIER TIER TIER TIER TIER TIER
DESCOVY 2 2 2 DUREZOL 2 2 2
DESFERAL 5 5 NC DYSPORT ◊ 4 4 2
desloratadine 1 NC NC EDARBI 3 NC NC
DEXILANT ‡ 3 NC NC EDARBYCLOR 3 NC NC
dextro-amphetamine/ EDLUAR ‡ 3 NC NC
1 1 1
amphetamine salts ◊
EDURANT 2 2 2
diazepam 1 1 1
EFFEXOR XR 3 3 NC
diclofenac tablets 1 1 1
EFFIENT 3 3 NC
dicyclomine 1 1 1
didanosine delayed EGRIFTA ◊ 4 4 2
1 1 1
release
ELAPRASE ◊ 4 4 NC
digoxin 1 1 1
ELIGARD ◊ 4 4 2
diltiazem cd 1 1 1
ELIQUIS 2 2 2
DIMETHYL FUMARATE ◊ 4 4 2
ELITEK 4 4 2
DIOVAN/HCT 3 NC NC
ELLENCE 5 5 NC
DOCETAXEL 4 4 2
ELOCTATE 4 4 2
DOFETILIDE 4 4 2
EMBEDA ‡ 2 2 NC
donepezil 1 1 1
EMEND ‡ 3 3 NC
DOPTELET ◊ 5 5 NC
EMGALITY ◊ 2 2 2
dorzolamide/timolol
1 1 1
maleate EMPLICITI ◊ 4 4 NC
DOVATO 2 2 2 emtricitabine-TDF
1 1 1
200-300 mg
doxazosin mesylate 1 1 1
enalapril maleate 1 1 1
doxepin crm ‡ 1 1 1
ENBREL ◊ 4 4 2
DOXIL 5 5 NC
enoxaparin sodium 1 1 1
DOXORUBICIN HCL 4 4 NC
ENTECAVIR 4 4 2
doxycycline hyclate 1 1 1
ENTRESTO ◊ 3 3 2
DULERA 2 2 2
ENTYVIO ◊ 5 5 NC
duloxetine ER 1 1 1
28SO BO BF SO BO BF
NAME NAME
TIER TIER TIER TIER TIER TIER
EPCLUSA ◊ 4 4 2 EVEROLIMUS ◊ 4 4 2
EPIDUO ◊ 3 3 NC EVISTA 3 3 NC
epinephrine injection 1 1 1 EXELDERM ◊ 3 3 NC
EPIPEN 2 PAK 3 3 NC EXELON 3 3 NC
EPIRUBICIN 4 4 NC EXFORGE/HCTZ 3 3 NC
EPIVIR 3 3 NC EXJADE ◊ 5 NC NC
EPOGEN ◊ 5 5 NC EXONDYS 51 ◊ 5 5 NC
EPZICOM 3 3 NC EXTAVIA ◊ 5 5 NC
EQUETRO 3 3 NC EYLEA ◊ 4 4 2
ERBITUX ◊ 4 4 NC ezetimibe 1 1 1
ERIVEDGE ◊ 4 4 2 FABRAZYME ◊ 4 4 2
ERLEADA ◊ 5 5 NC famotidine 40mg 1 1 1
ERLOTINIB ◊ 4 4 2 FARXIGA $ 2 2 2
ERTACZO ◊ 3 NC NC FARYDAK ◊ 5 5 2
ERYGEL ‡ 3 3 NC FASLODEX ◊ 5 NC NC
erythromycin 1 1 1 febuxostat ◊ 1 1 1
ESBRIET ◊ 4 4 2 FEIBA 4 4 NC
escitalopram oxalate 1 1 1 FELDENE 3 NC NC
esomeprazole fenofibrate 1 1 1
1 1 1
magnesium delayed-rel ‡
fenofibric acid 1 1 1
ESTRACE 3 3 NC
fentanyl patch ‡ 1 1 1
estradiol 1 1 1
FIASP/FLEXTOUCH 2 2 2
eszopiclone ‡ 1 1 1
finasteride 1 1 1
ETHYOL 5 5 NC
FIRAZYR ◊ 5 NC NC
ETOPOPHOS 4 4 NC
FIRMAGON ◊ 4 4 2
ETOPOSIDE 4 4 2
FLOVENT HFA 2 2 2
EUFLEXXA ◊ 5 5 NC
FLOXURIDINE 4 4 2
29ABBREVIATED FORMULARY (ALPHABETIC INCLUDING SPECIALTY)
SO BO BF SO BO BF
NAME NAME
TIER TIER TIER TIER TIER TIER
fluconazole 1 1 1 GANCICLOVIR 4 4 2
FLUDARABINE 4 4 2 GANIRELIX ACETATE ◊ 4 4 2
flunisolide spray 1 1 1 GATTEX ◊ 4 4 2
fluorouracil cream 0.5% 1 NC NC GAZYVA ◊ 4 4 NC
FLUOROURACIL INJ 4 4 2 GELNIQUE 3 NC NC
fluoxetine 1 1 1 GEL-ONE ◊ 4 4 2
fluticasone spray 1 1 1 GELSYN-3 ◊ 4 4 2
fluticasone/salmeterol GEMCITABINE 4 4 2
1 1 1
diskus
gemfibrozil 1 1 1
FOCALIN XR ◊ 3 3 NC
GENOTROPIN ◊ 5 NC NC
FOLLISTIM /AQ ◊ 4 4 2
GENVOYA 2 2 2
FOLOTYN 4 4 2
gianvi 1 1 1
FORADIL 3 3 NC
GILENYA ◊ 4 4 2
FORTAMET ◊ 3 NC NC
GLASSIA ◊ 4 4 2
FORTEO ◊ 4 4 2
GLATIRAMER ◊ 4 4 2
FORTESTA ◊ 3 3 NC
GLEEVEC ◊ 5 NC NC
FULPHILA ◊ 4 4 2
glimepiride 1 1 1
FULVESTRANT 4 4 2
glipizide/er/xl 1 1 1
furosemide 1 1 1
GLUCOPHAGE/XR 3 3 NC
FUZEON 4 4 2
glyburide 1 1 1
gabapentin ‡ 1 1 1
GLYSET 3 3 NC
GAMASTAN S/D ◊ 4 4 NC
GONAL-F ◊ 5 5 NC
GAMMAGARD ◊ 4 4 2
GONAL-F RFF ◊ 5 5 NC
GAMMAKED ◊ 4 4 2
GRANIX ◊ 4 4 2
GAMMAPLEX ◊ 4 4 2
GVOKE 2 2 2
GAMUNEX-C ◊ 4 4 2
HALAVEN ◊ 4 4 2
§ Generic versions of FORTAMET (metformin ER ext-rel tabs) require Prior Approval.
30SO BO BF SO BO BF
NAME NAME
TIER TIER TIER TIER TIER TIER
HARVONI ◊ 4 4 2 IBRANCE ◊ 4 4 2
HEMOFIL M 4 4 NC ibuprofen 1 1 1
HEPAGAM B 4 4 2 ICATIBANT ◊ 4 4 2
HEPSERA ◊ 5 NC NC ICLUSIG ◊ 4 4 2
HERCEPTIN ◊ 5 5 NC IDAMYCIN PFS 5 5 NC
HERZUMA ◊ 4 4 2 IDARUBICIN HCL 4 4 2
HIZENTRA ◊ 4 4 2 IDELVION 4 4 NC
HUMALOG/ MIX/ IFEX 5 5 NC
2 NC NC
KWIKPEN
IFOSFAMIDE 4 4 2
HUMATE-P 4 4 2
ILARIS ◊ 4 4 2
HUMATROPE ◊ 5 NC NC
IMATINIB ◊ 4 4 2
HUMIRA ◊ 4 4 2
HUMULIN U-500 IMBRUVICA ◊ 4 4 2
2 2 2
CONCENTRATE
INCRELEX ◊ 4 4 2
HUMULIN/KWIKPEN
(EXCEPT HUMULIN 2 NC NC INCRUSE ELLIPTA 3 NC NC
U-500 CONCENTRATE)
INLYTA ◊ 4 4 2
HYALGAN ◊ 4 4 2
INTELENCE 2 2 2
HYCAMTIN CAP 4 4 2
INTERMEZZO ‡ 3 NC NC
HYCAMTIN INJ 5 5 NC
INTRON-A ◊ 4 4 2
hydralazine 1 1 1
INTUNIV 3 3 NC
hydrochlorothiazide 1 1 1
INVOKANA ◊ 3 NC NC
hydrocodone/
1 1 1
acetaminophen ‡ irbesartan/hctz 1 1 1
hydromorphone ‡ 1 1 1
IRESSA ◊ 5 5 2
HYPERHEP B 4 4 2
IRINOTECAN 4 4 2
HYPERRHO S/D 4 4 2
ISENTRESS 2 2 2
HYQVIA ◊ 4 4 2
isosorbide mononitrate er 1 1 1
HYZAAR 3 NC NC
ISTODAX ◊ 5 5 NC
ibandronate 1 1 1
IXEMPRA 4 4 NC
31ABBREVIATED FORMULARY (ALPHABETIC INCLUDING SPECIALTY)
SO BO BF SO BO BF
NAME NAME
TIER TIER TIER TIER TIER TIER
IXINITY 4 4 NC lamotrigine 1 1 1
JADENU ◊ 5 5 NC lansoprazole ‡ 1 1 1
JAKAFI ◊ 4 4 2 LANTUS 2 NC NC
JALYN 3 NC NC latanoprost 1 1 1
JANUMET 2 2 2 LEDIPASVIR/
4 4 2
SOFOSBUVIR ◊
JANUMET XR 2 2 2
LEMTRADA ◊ 5 5 2
JANUVIA 2 2 2
LESCOL/XL 3 NC NC
JARDIANCE $ 2 2 2
LETAIRIS ◊ 5 NC NC
JEVTANA ◊ 4 4 2
letrozole 1 1 1
JUBLIA ◊ 3 NC NC
LEUKINE ◊ 5 5 NC
JYNARQUE ◊ 4 4 2
LEUPROLIDE ◊ 4 4 2
KADCYLA ◊ 4 4 NC
LEVATOL 3 3 NC
KALBITOR ◊ 4 4 2
LEVEMIR 2 2 2
KALYDECO ◊ 4 4 2
levetiracetam 1 1 1
KANJINTI ◊ 4 4 2
levocetirizine 1 NC NC
KEPIVANCE ◊ 4 4 2
levofloxacin 1 1 1
KERYDIN* ◊ 3 NC NC
levothyroxine 1 1 1
ketoconazole tabs ◊ 1 1 1
LEXAPRO 3 3 NC
KEYTRUDA ◊ 4 4 2
LIALDA 3 3 NC
KINERET ◊ 5 5 2
lidocaine topical ‡ 1 1 1
KOATE-DVI 4 4 NC
LILETTA 5 5 NC
KOGENATE FS 4 4 2
LINZESS ◊ 2 2 2
KRYSTEXXA ◊ 5 5 NC
LIPITOR 3 NC NC
KUVAN ◊ 5 5 NC
lisinopril/hctz 1 1 1
KYPROLIS ◊ 5 5 2
LIVALO 3 NC NC
lamivudine 1 1 1
LOESTRIN/FE 3 3 NC
lamivudine/zidovudine 1 1 1
32SO BO BF SO BO BF
NAME NAME
TIER TIER TIER TIER TIER TIER
LOPROX 3 NC NC methotrexate inj 1 1 1
lorazepam 1 1 1 METHYLIN ◊ 3 3 NC
losartan/hctz 1 1 1 methylphenidate/er ◊
(except methylphenidate
1 1 1
LOTRISONE* 3 NC NC tab ER osmotic release
72 mg)
lovastatin 1 1 1
methylprednisolone 1 1 1
LOVAZA 3 3 NC
metoprolol succinate/
1 1 1
LUCENTIS ◊ 4 4 2 tartrate
metronidazole 1 1 1
LUMIGAN 2 NC NC
MICARDIS/HCT 3 NC NC
LUMIZYME ◊ 4 4 2
MICRHOGAM 4 4 2
LUNESTA ‡ 3 NC NC
MIGLUSTAT ◊ 4 4 2
LUPANETA PACK 4 4 2
MINIVELLE 3 3 NC
LUPRON DEPOT ◊ 4 4 2
MIRCETTE 3 3 NC
LUZU ◊ 3 NC NC
MIRENA 4 4 2
LYNPARZA ◊ 4 4 2
MITOMYCIN 4 4 2
LYRICA ‡ 3 NC NC
MITOXANTRONE 4 4 2
MACUGEN ◊ 5 5 NC
MONONINE 4 4 NC
MEDROL 3 NC NC
MONOVISC ◊ 5 5 NC
megestrol acetate 1 1 1
montelukast sodium 1 1 1
MEKINIST ◊ 4 4 2
MORPHABOND ‡ 3 3 NC
MEKTOVI ◊ 5 5 NC
MOVIPREP 3 3 NC
meloxicam 1 1 1
MOZOBIL ◊ 4 4 2
MELPHALAN HCL 4 4 2
mupirocin ‡ 1 1 1
MENOPUR ◊ 4 4 2
MUSTARGEN 4 4 2
MENTAX 3 NC NC
MVASI ◊ 4 4 2
MESNA 4 4 2
mycophenolate mofetil 1 1 1
MESNEX INJ 5 5 NC
MYFORTIC 3 3 NC
MESNEX TAB 4 4 2
33ABBREVIATED FORMULARY (ALPHABETIC INCLUDING SPECIALTY)
SO BO BF SO BO BF
NAME NAME
TIER TIER TIER TIER TIER TIER
MYOBLOC ◊ 4 4 2 NOVOLOG MIX 70/30 2 2 2
MYRBETRIQ 2 2 NC NOVOSEVEN RT 4 4 2
NABI-HB 4 4 NC NPLATE ◊ 4 4 2
naftifine ‡ 1 1 1 NUCALA ◊ 5 5 NC
NAFTIN ‡ 2 NC NC NULOJIX 4 4 NC
NAGLAZYME ◊ 4 4 NC NURTEC ODT ◊ 3 3 NC
naloxone 1 1 1 NUTROPIN AQ ◊ 5 NC NC
NAMENDA TABS 3 3 NC NUVARING 3 3 NC
NAPROSYN 3 NC NC NUWIQ 4 4 NC
NARCAN 1 1 1 OCALIVA ◊ 5 5 2
NASONEX 3 NC NC OCTAGAM ◊ 4 4 NC
NAVELBINE 5 5 NC OCTREOTIDE 4 4 2
NEORAL 3 3 NC OFEV ◊ 4 4 2
NEULASTA ◊ 5 NC NC OLUMIANT ◊ 5 5 NC
NEUPOGEN ◊ 5 NC NC omega-3 acid ethyl esters 1 1 1
NEUPRO 2 2 2 omeprazole 1 1 1
nevirapine ext-rel 1 1 1 omeprazole/sodium
1 NC NC
bicarbonate ‡
NEXAVAR ◊ 4 4 2
OMNITROPE ◊ 5 NC NC
niacin er 1 1 1
ondansetron/odt ‡ 1 1 1
NILANDRON ◊ 3 3 NC ONETOUCH TEST
2 2 2
STRIPS ‡
NIPENT 4 4 2
ONIVYDE ◊ 5 5 NC
NITROSTAT 3 3 NC
ONTRUZANT ◊ 4 4 2
NORDITROPIN ◊ 4 4 2
OPDIVO ◊ 4 4 2
NORITATE 3 NC NC
OPSUMIT ◊ 4 4 2
NORTHERA ◊ 5 5 NC
ORACEA 3 3 NC
NOVAREL ◊ 4 4 2
ORALAIR ◊ 5 5 2
NOVOLIN 2 2 2
34SO BO BF SO BO BF
NAME NAME
TIER TIER TIER TIER TIER TIER
ORAPRED ODT 3 NC NC phenazopyridine 1 1 1
ORENCIA ◊ 5 5 NC pioglitazone 1 1 1
ORENITRAM ◊ 4 4 2 PLAVIX 3 3 NC
ORKAMBI ◊ 4 4 2 PLEGRIDY /PEN ◊ 4 4 2
ORTHO TRI-CYCLEN 3 3 NC polyethylene glycol 3350 1 1 1
ORTHO TRI-CYCLEN LO 3 3 NC POMALYST ◊ 5 5 2
ORTHO-NOVUM 3 3 NC PRADAXA 3 NC NC
ORTHOVISC ◊ 5 5 NC PRALUENT ◊ 5 NC NC
oseltamivir phosphate ‡ 1 1 1 pramipexole
1 1 1
dihydrochloride
OTEZLA ◊ 4 4 2
PRAVACHOL 3 NC NC
OTREXUP ◊ 3 3 NC
pravastatin sodium 1 1 1
OVIDREL ◊ 4 4 2
prednisolone acetate 1 1 1
OXALIPLATIN 4 4 2
prednisone 1 1 1
OXISTAT ◊ 3 NC NC
PREFEST 3 3 NC
oxybutynin/er 1 1 1
pregabalin ‡ 1 1 1
OXYCONTIN ‡ 3 NC NC
PREGNYL ◊ 4 4 2
OZEMPIC 2 2 2
PREMARIN 2 2 2
PACLITAXEL 4 4 2
PREMPRO 2 2 2
PALYNZIQ ◊ 5 5 NC
PREVYMIS ◊ 4 4 2
PAMIDRONATE 4 4 2
PREZISTA 2 2 2
pantoprazole sodium ‡ 1 1 1
PRISTIQ 3 3 NC
PARAGARD T 380A 2 2 2
PRIVIGEN ◊ 4 4 NC
paroxetine 1 1 1
PROAIR HFA 2 2 NC
PEGASYS ◊ 4 4 2
PROCRIT ◊ 5 NC NC
PEGINTRON ◊ 4 4 2
PROFILNINE SD 4 4 NC
PERFOROMIST 3 3 NC
progesterone ◊ 1 1 1
PERJETA ◊ 4 4 2
35ABBREVIATED FORMULARY (ALPHABETIC INCLUDING SPECIALTY)
SO BO BF SO BO BF
NAME NAME
TIER TIER TIER TIER TIER TIER
PROGRAF 3 3 NC RETROVIR 3 3 NC
PROLEUKIN 4 4 2 REVATIO ◊ 5 NC NC
PROLIA ◊ 4 4 2 REVLIMID ◊ 4 4 2
PROMACTA ◊ 4 4 2 REYATAZ 3 3 NC
promethazine/codeine ‡ 1 1 1 RHOGAM PLUS 4 4 2
propranolol 1 1 1 RHOPHYLAC 4 4 NC
PROVENTIL HFA 2 NC NC RHOPRESSA 3 3 NC
PULMOZYME ◊ 4 4 2 RIASTAP 4 4 NC
quetiapine fumarate 1 1 1 RIBAVIRIN ◊ 4 4 2
QVAR 2 2 2 risedronate 1 1 1
rabeprazole ‡ 1 1 1 risperidone 1 1 1
ramipril 1 1 1 RITUXAN ◊ 5 5 NC
RAPAFLO 3 3 NC RIXUBIS 4 4 2
RAPAMUNE 3 3 NC rizatriptan ‡ 1 1 1
RASUVO ◊ 3 3 NC ROCKLATAN 3 3 NC
RAVICTI ◊ 4 4 2 ROMIDEPSIN ◊ 4 4 NC
RAYOS ◊ 3 NC NC ropinirole 1 1 1
REBIF ◊ 4 4 2 rosuvastatin 1 1 1
REBINYN 4 4 NC ROZEREM ‡ 3 NC NC
RECLAST ◊ 5 NC NC RUXIENCE ◊ 4 4 2
RECOMBINATE 4 4 2 RYBELSUS 3 3 NC
RELISTOR ◊ 3 3 2 SABRIL ◊ 5 NC NC
RELPAX ‡ 3 3 NC SAIZEN ◊ 5 NC NC
REMODULIN ◊ 5 5 NC SAMSCA ◊ 4 4 2
REPATHA ◊ 4 4 2 SANDOSTATIN LAR ◊ 4 4 2
RESTASIS ◊ 2 2 2 SAPROPTERIN ◊ 4 4 2
RETACRIT ◊ 4 4 2 SAVELLA ‡ 3 3 NC
36SO BO BF SO BO BF
NAME NAME
TIER TIER TIER TIER TIER TIER
SENSIPAR ◊ 5 NC NC STRATTERA 3 3 NC
SEROQUEL XR 3 3 NC STRIANT ◊ 3 3 NC
SEROSTIM ◊ 4 4 2 STRIBILD 2 2 2
sertraline 1 1 1 STRIVERDI RESPIMAT 3 3 NC
SIKLOS ◊ 5 5 NC SUBLOCADE ◊ 5 5 2
SILDENAFIL (PAH)◊ 4 4 2 SUBOXONE FILM ‡ 3 3 NC
silodosin 1 1 1 sucralfate 1 1 1
simvastatin 1 1 1 sulfamethoxazole/
1 1 1
trimethoprim
SINGULAIR 3 3 NC
sumatriptan succinate ‡ 1 1 1
sirolimus 1 1 1
SUPARTZ ◊ 4 4 2
SKYLA 4 4 2
SUPPRELIN LA ◊ 4 4 2
SODIUM
4 4 2 SUPREP BOWEL
PHENYLBUTYRATE ◊ 2 2 2
PREP KIT
SOFOSBUVIR/
4 4 2 SUSTIVA 3 3 NC
VELPATASVIR ◊
SOLESTA 4 4 2 SUTENT ◊ 4 4 2
solifenacin 1 1 1 SYMBICORT 2 2 NC
SOLIRIS ◊ 4 4 NC SYMDEKO ◊ 4 4 2
SOMATULINE DEPOT ◊ 4 4 2 SYNAGIS ◊ 4 4 2
SOMAVERT 4 4 2 SYNTHROID 2 2 2
SOVALDI ◊ 4 4 2 SYNVISC ◊ 5 5 NC
SPIRIVA 2 2 2 SYNVISC ONE ◊ 5 5 NC
spironolactone 1 1 1 tacrolimus 1 1 1
SPRYCEL ◊ 4 4 2 TADALAFIL (PAH) ◊ 4 4 2
stavudine 1 1 1 TAFINLAR ◊ 4 4 2
STELARA ◊ 4 4 NC TAMIFLU CAPS ‡ 3 3 NC
STIMATE 4 4 2 tamoxifen citrate 1 1 1
STIVARGA ◊ 4 4 2 tamsulosin 1 1 1
37ABBREVIATED FORMULARY (ALPHABETIC INCLUDING SPECIALTY)
SO BO BF SO BO BF
NAME NAME
TIER TIER TIER TIER TIER TIER
TARCEVA ◊ 5 NC NC TOPOTECAN 4 4 2
TARGRETIN CAPS ◊ 5 NC NC TOTECT 5 5 NC
TASIGNA ◊ 5 5 2 TOUJEO 2 NC NC
TAVALISSE ◊ 5 5 NC TOVIAZ 2 2 NC
TAXOTERE 5 5 NC TRACLEER ◊ 5 5 NC
TAZORAC ◊ 3 3 NC tramadol (except 100mg
1 1 1
tab)/er ‡
TECFIDERA ◊ 5 5 NC
TRAVATAN Z 3 3 NC
telmisartan/hctz 1 1 1
trazodone 1 1 1
temazepam ‡ 1 1 1
TREANDA ◊ 5 5 NC
TEMODAR ◊ 5 NC NC
TRELEGY ELLIPTA 2 2 2
TEMOZOLOMIDE 4 4 2
TRELSTAR ◊ 4 4 2
TESTIM ◊ 3 NC NC
TRESIBA 2 3 NC
testosterone cypionate ◊ 1 1 1
tretinoin ◊ 1 1 1
testosterone gel ◊ 1 1 1
TRETTEN 4 4 NC
TETRABENAZINE ◊ 4 4 2
triamterene/hctz 1 1 1
THALOMID 4 4 2
TRIGLIDE 3 3 NC
THERACYS 4 4 2
TRIKAFTA ◊ 4 4 2
THIOTEPA 4 4 2
TRISENOX 5 5 NC
THYROGEN 4 4 2
TRIUMEQ 2 2 2
TICE BCG 4 4 2
TRIZIVIR 3 3 NC
TIKOSYN ◊ 5 NC NC
TROGARZO ◊ 5 5 2
timolol maleate 1 1 1
trospium/er 1 1 1
TOBI 5 5 NC
TRULICITY 2 2 2
TOBI PODHALER 4 4 NC
TRUVADA 200-300 mg 3 3 NC
TOBRAMYCIN INH SOLN 4 4 2 TRUVADA
2 2 2
(except 200-300 mg)
tolterodine/ER 1 1 1
TRUXIMA ◊ 4 4 2
topiramate 1 1 1
38SO BO BF SO BO BF
NAME NAME
TIER TIER TIER TIER TIER TIER
TUDORZA PRESSAIR 3 NC NC VIGAMOX 3 3 NC
TYKERB ◊ 5 5 NC VIMIZIM ◊ 4 4 NC
TYSABRI ◊ 4 4 2 VINBLASTINE 4 4 2
TYVASO ◊ 5 5 NC VINCRISTINE 4 4 2
TYZEKA 4 4 2 VINORELBINE 4 4 2
UDENYCA ◊ 4 4 2 VIRACEPT 2 2 2
VAGIFEM 3 3 NC VIRAMUNE/XR 3 3 NC
valacyclovir 1 1 1 VISUDYNE 4 4 2
valsartan/hctz 1 1 1 VIVELLE DOT 3 3 NC
VALTREX 3 3 NC VIVITROL 4 4 2
VANTAS ◊ 4 4 2 VOGELXO ◊ 3 NC NC
VARIZIG 4 4 2 VOTRIENT ◊ 4 4 2
VARUBI ‡ 2 2 2 VPRIV ◊ 4 4 2
VASCEPA 2 2 2 VUSION ‡ * 3 NC NC
VECTIBIX ◊ 4 4 NC VYEPTI ◊ 5 5 NC
VELCADE ◊ 5 5 NC VYTORIN 3 NC NC
VELETRI ◊ 5 5 NC VYVANSE ◊ 2 2 2
VEMLIDY 4 4 2 warfarin 1 1 1
venlafaxine/er 1 1 1 WELCHOL 3 3 NC
VENTAVIS ◊ 4 4 2 WELLBUTRIN XL 3 3 NC
VENTOLIN HFA 2 NC NC WILATE 4 4 NC
VERAMYST 2 NC NC WINRHO SDF 4 4 NC
verapamil/er 1 1 1 XALKORI ◊ 4 4 2
VERZENIO ◊ 4 4 2 XARELTO 2 2 2
VICTOZA 2 2 2 XELJANZ / XR ◊ 4 4 NC
VIDAZA 5 5 NC XELODA ◊ 5 NC NC
VIGABATRIN ◊ 4 4 2 XENAZINE ◊ 5 NC NC
39ABBREVIATED FORMULARY (ALPHABETIC INCLUDING SPECIALTY)
SO BO BF SO BO BF
NAME NAME
TIER TIER TIER TIER TIER TIER
XEOMIN ◊ 4 4 2 ZIAGEN 3 3 NC
XGEVA ◊ 4 4 2 zidovudine 1 1 1
XIAFLEX ◊ 4 4 2 ZINECARD 5 5 NC
XIIDRA ◊ 2 2 2 ZIOPTAN 3 3 NC
XOLAIR ◊ 4 4 2 ZOCOR 3 NC NC
XOPENEX HFA 3 NC NC ZOLADEX ◊ 4 4 2
XOPENEX/CONCEN- ZOLEDRONIC ACID 4 4 2
3 3 NC
TRATE
ZOLINZA ◊ 4 4 2
XTANDI ◊ 4 4 2
zolmitriptan ‡ 1 1 1
XYNTHA 4 4 NC
zolpidem/ER ‡ 1 1 1
XYNTHA SOLOFUSE 4 4 NC
ZOMACTON ◊ 5 NC NC
YERVOY ◊ 4 4 NC
ZOMIG/ZMT ‡ 3 3 NC
YONSA ◊ 5 5 2
ZORBTIVE ◊ 4 4 2
zafirlukast 1 1 1
ZORTRESS 4 4 2
zaleplon ‡ 1 1 1
zovia 1 1 1
ZALTRAP ◊ 4 4 2
ZOVIRAX 3 3 NC
ZANOSAR 4 4 2
ZUBSOLV ‡ 2 2 2
ZARXIO ◊ 4 4 2
ZYKADIA ◊ 4 4 2
ZELBORAF ◊ 4 4 2
ZYTIGA ◊ 5 NC NC
ZEMAIRA ◊ 4 4 2
ZETIA 3 3 NC
4041
EXCLUDED DRUG LIST
STANDARD OPTION
These drugs are not covered under Standard Option. If you use any of
these Excluded Drugs, you will pay the full cost of the drug(s).
If you are using a non-covered drug, ask your doctor to prescribe one of
the covered generic or brand name options.
CATEGORY* DRUG NOT COVERED IN
COVERED OPTIONS**
DRUG CLASS* 2021 FOR STANDARD OPTION
Acne MINOLIRA azithromycin, doxycycline
Oral Antibiotics (except 20 mg), minocycline,
minocycline ext-rel,
sulfamethoxazole/trimethoprim,
MINOCIN, SOLODYN,
VIBRAMYCIN, ZITHROMAX
Acne adapalene pad, adapalene adapalene crm, adapalene gel,
Topical soln 0.1% DIFFERIN
ABSORICA LD isotretinoin, ABSORICA
Allergies carbinoxamine 6 mg, desloratadine, levocetirizine
Antihistamines RYVENT (Rx), montelukast, zafirlukast,
ACCOLATE, CLARINEX,
CLARINEX-D, SINGULAIR
Anaphylaxis Treatment AUVI-Q epinephrine injection/auto-
injector (0.15 mg, 0.30 mg),
EPIPEN, EPIPEN JR., SYMJEPI
Antidiarrheals opium tincture diphenoxylate/
atropine, loperamide
Antifungals TOLSURA fluconazole, itraconazole,
ketoconazole, posaconazole
delayed-rel tabs, voriconazole,
DIFLUCAN, NOXAFIL susp,
NOXAFIL tabs, SPORANOX,
VFEND
Anti-Inflammatories fenoprofen cap 200 mg, diclofenac DR/ER, diclofenac
Nonsteroidal Anti- indomethacin caps 20 mg, gel/soln, etodolac/ER,
Inflammatories (NSAIDs) 40 mg, naproxen sodium flurbiprofen, ibuprofen,
ext-rel tablets, CAMBIA, indomethacin/ER (except
FENORTHO, NAPRELAN, indomethacin caps 20 mg,
PENNSAID 2%, QMIIZ, 40 mg), ketoprofen/ER,
TIVORBEX, VIVLODEX, meloxicam, nabumetone,
ZIPSOR, ZORVOLEX naproxen, oxaprozin, piroxicam,
sulindac
42CATEGORY* DRUG NOT COVERED IN
COVERED OPTIONS**
DRUG CLASS* 2021 FOR STANDARD OPTION
Anti-Inflammatories naproxen/esomeprazole diclofenac/misoprostol,
Nonsteroidal Anti- magnesium tabs DR, esomeprazole magnesium
Inflammatories (NSAIDs) DUEXIS, VIMOVO delayed-rel, famotidine,
Combinations ibuprofen, naproxen
CONSENSI celecoxib, CELEBREX, AND
amlodipine tabs, NORVASC
Antirheumatics penicillamine caps, azathioprine,
CUPRIMINE hydroxychloroquine,
leflunomide,
methotrexate, penicillamine
tabs, DEPEN
Antispasmodics LIBRAX clidinium/chlordiazepoxide,
dicyclomine, hyoscyamine
DONNATAL atropine/hyoscyamine/
scopolamine/phenobarbital
Asthma zileuton ext-rel, ZYFLO CR montelukast, zafirlukast,
Leukotriene Modulators ACCOLATE, SINGULAIR
Benign Prostatic UROXATRAL alfuzosin ext-rel, dutasteride,
Hyperplasia (BPH) dutasteride/tamsulosin,
finasteride, silodosin, tadalafil
(2.5mg, 5mg), tamsulosin,
AVODART, CIALIS (2.5mg,
5mg), JALYN, PROSCAR,
RAPAFLO, FLOMAX
Bladder Agents DETROL, DETROL LA, darifenacin ext-rel, oxybutynin,
ENABLEX, OXYTROL, oxybutynin ext-rel, solifenacin,
VESICARE tolterodine, tolterodine ext-rel,
trospium, trospium ext-rel,
DITROPAN XL, GELNIQUE,
MYRBETRIQ, TOVIAZ
Cardiovascular BETAPACE, BETAPACE AF sotalol, sotalol AF
Antiarrhythmics
Cardiovascular aspirin/omeprazole delayed- aspirin*** and esomeprazole
Heart rel tabs, YOSPRALA magnesium delayed-rel,
lansoprazole, omeprazole,
pantoprazole, rabeprazole
Central Nervous System SYMBYAX olanzapine/fluoxetine
Antidepressant
Combinations
CONTINUED ON NEXT PAGE
43EXCLUDED DRUG LIST STANDARD OPTION
CATEGORY* DRUG NOT COVERED IN
COVERED OPTIONS**
DRUG CLASS* 2021 FOR STANDARD OPTION
Central Nervous System methylphenidate tab ER amphetamine/
Miscellaneous osmotic release 72 mg, dextroamphetamine mixed
DESOXYN, JORNAY PM, salts/ER, amphetamine ext-rel
RELEXXII susp, amphetamine sulfate,
dexmethylphenidate/
ER, dextroamphetamine/
ER, methylphenidate/ER
(except methylphenidate
tab ER osmotic release
72 mg), ADDERALL,
ADDERALL XR, ADZENYS ER
SUSP, ADZENYS XR-ODT,
APTENSIO XR, CONCERTA,
DAYTRANA, DEXEDRINE,
EVEKEO, EVEKEO ODT,
FOCALIN, FOCALIN XR,
METHYLIN, PROCENTRA,
QUILLIVANT XR, RITALIN,
RITALIN LA, VYVANSE,
ZENZEDI
Cotricosteroids MILLIPRED cortisone acetate,
Oral dexamethasone,
fludrocortisone, hydrocortisone,
methylprednisolone,
prednisolone, prednisone,
CORTEF, MEDROL, ORAPRED
ODT, RAYOS
Dermatology ALCORTIN-A, XOLEGEL ciclopirox, clotrimazole,
Antifungal hydrocortisone/iodoquinol,
hydrocortisone/iodoquinol/
aloe, ketoconazole 2% cream,
naftifine, nystatin, terbinafine,
ECOZA, NAFTIN
Dermatology halobetasol propionate betamethasone dipropionate
Corticosteroids topical foam, triamcinolone (crm, lotion, oint),
oint 0.05%, BRYHALI, betamethasone dipropionate
LEXETTE, NOVACORT, augmented (crm, lotion, gel,
OLUX/OLUX-E, PSORCON, oint), clobetasol propionate,
TRIANEX, VANOS diflorasone diacetate,
fluocinonide (crm, gel, oint,
soln), halobetasol propionate
crm, triamcinolone acetonide
(except triamcinolone oint
0.05%), APEXICON E,
CLOBEX, DIPROLENE,
DIPROLENE AF, HALOG,
KENALOG SPRAY, SERNIVO,
TEMOVATE, TOPICORT,
ULTRAVATE
44CATEGORY* DRUG NOT COVERED IN
COVERED OPTIONS**
DRUG CLASS* 2021 FOR STANDARD OPTION
Dermatology XERESE acyclovir, hydrocortisone
Miscellaneous
VEREGEN imiquimod, ALDARA, ZYCLARA
EXTINA ketoconazole foam 2%
OVACE, OVACE PLUS sulfacetamide sodium
Dermatology calcipotriene foam 0.005%, acitretin, betamethasone
Psoriasis SORIATANE, TACLONEX dipropionate/calcipotriene (oint,
susp), calcitriol, methoxsalen,
DOVONEX, OXSORALEN
ULTRA, SORILUX
Diabetes JENTADUETO, alogliptin, alogliptin/metformin,
Dipeptidyl Peptidase-4 JENTADUETO XR, KAZANO, alogliptin/pioglitazone,
(DPP-4) Inhibitors/ KOMBIGLYZE XR, NESINA, JANUMET, JANUMET XR,
Combinations ONGLYZA, OSENI, JANUVIA
TRADJENTA
Diabetes GLUMETZA, RIOMET ER metformin oral soln,
Metformin FORTAMET, GLUCOPHAGE XR
(metformin ER), RIOMET IR
Diabetes CYCLOSET alogliptin, alogliptin/metformin,
Other alogliptin/pioglitazone,
bromocriptine mesylate,
glimepiride, glipizide,
glyburide, glyburide/metformin,
pioglitazone, repaglinide
H2 Receptor Antagonists PEPCID cimetidine, famotidine 40mg,
nizatidine
High Blood Pressure DUTOPROL metoprolol succinate ext-rel,
Beta-Blockers/ hydrochlorothiazide
Combinations
High Cholesterol FENOGLIDE fenofibrate, fenofibric acid
Fibrates del-rel, gemfibrozil, ANTARA,
LIPOFEN, LOPID, TRICOR,
TRIGLIDE, TRIPLEX
High Cholesterol simvastatin susp, ALTOPREV, atorvastatin, ezetimibe/
Statins FLOLIPID, ZYPITAMAG simvastatin, fluvastatin,
fluvastatin ext-rel, lovastatin,
pravastatin, rosuvastatin,
simvastatin, CRESTOR,
LESCOL XL, LIPITOR, LIVALO,
PRAVACHOL, VYTORIN,
ZOCOR
Influenza Agents FLUMADINE oseltamivir, rimantadine,
RELENZA, TAMIFLU, XOFLUZA
CONTINUED ON NEXT PAGE
45EXCLUDED DRUG LIST STANDARD OPTION
CATEGORY* DRUG NOT COVERED IN
COVERED OPTIONS**
DRUG CLASS* 2021 FOR STANDARD OPTION
Laxatives LACTULOSE PAK 10MG, lactulose solution, PEG
PCP 100 3350/electrolytes, COLYTE,
GOLYTELY, KRISTALOSE,
MOVIPREP, NULYTELY,
OSMOPREP, PLENVU,
PREPOPIK, SUPREP
Migraine Agents AJOVY AIMOVIG, EMGALITY 120 mg/
Calcitonin Gene-Related mL, VYEPTI
Peptide (CGRP) Inhibitors
UBRELVY NURTEC ODT
Migraine Agents REYVOW almotriptan, eletriptan,
Selective Serotonin frovatriptan, naratriptan,
Agonists rizatriptan, sumatriptan,
zolmitriptan, AMERGE, FROVA,
IMITREX, MAXALT, MAXALT-
MLT, RELPAX, TOSYMRA,
ZOMIG, ZOMIG-ZMT
Movement Disorders TASMAR amantadine, benztropine,
bromocriptine, carbidopa/
levodopa, entacapone,
pramipexole, rasagiline,
ropinirole/ER, selegiline,
tolcapone, APOKYN, AZILECT,
COMTAN, DUOPA, GOCOVRI,
MIRAPEX, MIRAPEX XR,
NEUPRO, OSMOLEX ER,
PARLODEL, REQUIP,
REQUIP XL, RYTARY, SINEMET,
STALEVO, XADAGO, ZELAPAR
Multiple Sclerosis AMPYRA dalfampridine ER
Muscle Relaxant cyclobenzaprine ext-rel, baclofen, cyclobenzaprine
AMRIX, FEXMID
Musculoskeletal Agents chlorzoxazone tab (250mg, chlorzoxazone tab 500mg
Miscellaneous 375mg, 750mg), LORZONE
Nausea And Vomiting ANZEMET, ZUPLENZ granisetron, ondansetron,
Therapy palonosetron, promethazine,
(5HT-3 Blocker) ALOXI, SANCUSO, ZOFRAN
Ophthalmology BACIGUENT bacitracin ophthalmic
Anti-Infectives
Ophthalmology atropine sulfate eye ointment atropine ophthalmic solution,
Miscellaneous cyclopentolate ophthalmic
solution
Pain Medications GRALISE, HORIZANT, gabapentin, pregabalin, LYRICA,
Neuropathic Pain LYRICA CR NEURONTIN
46CATEGORY* DRUG NOT COVERED IN
COVERED OPTIONS**
DRUG CLASS* 2021 FOR STANDARD OPTION
Pain Medications benzhydrocodone/ codeine/acetaminophen,
Opioids acetaminophen, hydrocodone/acetaminophen,
hydrocodone- oxycodone/acetaminophen
acetaminophen sol 10-325 (except 2.5 mg - 300 mg, 5
mg/15 mL, oxycodone/ mg- 300 mg, 10 mg -300mg
acetaminophen tab (2.5 mg tabs), tramadol/acetaminophen,
- 300 mg, 5 mg- 300 mg, ENDOCET, LORCET, LORCET
10 mg -300mg), APADAZ, HD, LORTAB, NORCO,
NALOCET, PRIMLEV, PERCOCET
PROLATE
LAZANDA fentanyl buccal, fentanyl
sublingual, fentanyl
transmucosal, ABSTRAL,
ACTIQ, FENTORA, SUBSYS
levorphanol hydromorphone, morphine,
oxycodone, tramadol (except
100mg tab), DILAUDID,
NUCYNTA, OPANA,
ROXICODONE
tramadol 100 mg tabs, tramadol (except 100 mg tabs),
CONZIP tramadol ext-rel, tramadol/
acetaminophen, ULTRAM,
ULTRAM ER
Pain Medications ZTLIDO lidocaine cream, lidocaine
Topical gel, lidocaine lotion, lidocaine
ointment, lidocaine patch 5%,
LIDODERM PATCH, QUTENZA
PATCH, XYLOCAINE
Proton Pump Inhibitors esomeprazole strontium, esomeprazole magnesium
ACIPHEX, FIRST- delayed-rel, lansoprazole
LANSOPRAZOLE, NEXIUM, delayed-rel, omeprazole
PREVACID, PREVACID delayed-rel, omeprazole/sodium
SOLUTAB, PRILOSEC, bicarbonate, pantoprazole
PROTONIX, ZEGERID delayed-rel, rabeprazole
delayed-rel, DEXILANT
Sleep Agents SECONAL estazolam, eszopiclone,
flurazepam, ramelteon,
temazepam, triazolam,
zaleplon, zolpidem/ER,
AMBIEN, AMBIEN CR,
BELSOMRA, EDLUAR,
INTERMEZZO, LUNESTA,
ROZEREM, ZOLPIMIST
CONTINUED ON NEXT PAGE
47EXCLUDED DRUG LIST STANDARD OPTION
CATEGORY* DRUG NOT COVERED IN
COVERED OPTIONS**
DRUG CLASS* 2021 FOR STANDARD OPTION
Ulcerative Colitis COLAZAL balsalazide, mesalamine
delayed-rel (caps, tabs),
mesalamine ext-rel caps,
sulfasalazine, sulfasalazine
delayed, rel, ASACOL HD,
APRISO, AZULFIDINE,
DELZICOL, DIPENTIUM,
LIALDA, PENTASA
Ulcer Therapy CARAFATE sucralfate
Miscellaneous
*This list shows uses for which the drug is prescribed. Some drugs are prescribed for
more than one condition.
**For more covered options, view the 2021 Standard Option formulary.
***Low dose aspirin (81 mg) is covered for men age 45 through 79 and women age 12 through
79 and for pregnant women at risk of preeclampsia.
48EXCLUDED DRUG LIST
STANDARD OPTION (ALPHABETIC)
ABSORICA LD DONNATAL MINOLIRA SECONAL
ACIPHEX DUEXIS NALOCET simvastatin susp
adapalene pad DUTOPROL NAPRELAN SORIATANE
adapalene soln 0.1% ENABLEX naproxen sodium SYMBYAX
ext-rel tablets
AJOVY esomeprazole strontium TACLONEX
naproxen/esomeprazole
ALCORIN-A EXTINA TASMAR
magnesium tabs D
ALTOPREV FENOGLIDE TOLSURA
NESINA
AMPYRA fenoprofen cap 200 mg TRADJENTA
NEXIUM
AMRIX FENORHO tramadol 100 mg tabs
NOVACORT
ANZEMET FEXMID triamcinolone oint 0.05%
OLUX/OLUX-E
APADAZ FIRST-LANSOPRAZOLE TRIANEX
ONGLYZA
aspirin/omeprazole FLOLIPID UBRELVY
opium tincture
delayed-rel tabs
FLUMADINE UROXATRAL
OSENI
atropine sulfate
GLUMETZA VANOS
eye ointment OVACE/PLUS
GRALISE VEREGEN
AUVI-Q oxycodone/acetamino-
halobetasol propionate phen tab (2.5 mg-300 mg, VESICARE
BACIGUENT
topical foam 5 mg-300 mg,
10 mg-300mg) VIMOVO
benzhydrocodone/
HORIZANT
acetaminophen VIVLODEX
OXYTROL
hydrocodone-acetamino-
BETAPACE/AF XERESE
phen sol 10-325 mg/mL PCP 100
BRYHALI XOLEGEL
indomethacin caps 20 penicillamine
calcipotriene foam mg, 40 mg YOSPRALA
PENNSAID 2%
0.005%
JENTADUETO/XR ZEGERID
PEPCID
CAMBIA
JORNAY PM zileuton ext-rel
PREVACID/SOLUTAB
CARAFATE
KAZANO ZIPSOR
PRILOSEC
carbinoxamine 6 mg
KOMBIGLYZE XR ZORVOLEX
PRIMLEV
chlorzoxazone tab
LACTULOSE PAK 10MG ZTLIDO
PROLATE
COLAZAL
LAZANDA ZUPLENZ
PROTONIX
CONSENSI
levorphanol ZYFLO CR
PSORCON
CONZIP
LEXETTE ZYPITAMAG
QMIIZ
CUPRIMINE
LIBRAX
RELEXXII
cyclobenzaprine ext-rel
LYRICA CR
REYVOW
CYCLOSET
methylphenidate tab ER
RIOMET ER
DESOXYN osmotic release 72 mg
RYVENT
DETROL/LA MILLIPRED
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