YOUR 2020 FORMULARY SIGNATUREVALUE 3-TIER - EFFECTIVE ...
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Your 2020 Formulary SignatureValue 3-Tier Effective September 1, 2020 This formulary is accurate as of September 1, 2020 and is subject to change after this date. This formulary applies to members of our UnitedHealthcare West HMO medical plans with a pharmacy benefit. Your estimated coverage and copayment/coinsurance may vary based on the benefit plan you choose and the effective date of the plan.
Table of Contents
Understanding your formulary . . . . . . . . . 3 Gastrointestinal
Medication tips . . . . . . . . . . . . . . . . . . . . . . 5 Acid Suppression. . . . . . . . . . . . . . . . . . . . . 22
Nausea/Vomiting. . . . . . . . . . . . . . . . . . . . . 22
Reading your formulary. . . . . . . . . . . . . . . 6 Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . 9
HIV/AIDS. . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Drugs by category . . . . . . . . . . . . . . . . . . 10
Infertility. . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Anti-Infectives Inflammatory Conditions: Rheumatoid
Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Arthritis, Crohn’s Disease, Psoriasis,
Antifungals. . . . . . . . . . . . . . . . . . . . . . . . . . 11 Ulcerative Colitis. . . . . . . . . . . . . . . . . . . . 24
Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Medications for Sexual Dysfunction. . . . 25
Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Men’s Health
Cardiovascular/Heart Disease Prostate. . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Coagulation Therapy. . . . . . . . . . . . . . . . . . 12 Testosterone Therapy. . . . . . . . . . . . . . . . . 25
High Blood Pressure. . . . . . . . . . . . . . . . . . 12
High Cholesterol . . . . . . . . . . . . . . . . . . . . . 14 Miscellaneous. . . . . . . . . . . . . . . . . . . . . . 25
Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Musculoskeletal
Central Nervous System Osteoporosis. . . . . . . . . . . . . . . . . . . . . . . . 27
Attention Deficit Disorder. . . . . . . . . . . . . . . 15 Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Depression . . . . . . . . . . . . . . . . . . . . . . . . . 15 Pain Relief. . . . . . . . . . . . . . . . . . . . . . . . . . 27
Migraine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Overactive Bladder. . . . . . . . . . . . . . . . . . 28
Multiple Sclerosis. . . . . . . . . . . . . . . . . . . . . 16
Respiratory
Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Asthma/COPD. . . . . . . . . . . . . . . . . . . . . . . 28
Sedatives/Hypnotics . . . . . . . . . . . . . . . . . . 17
Nasal Allergies. . . . . . . . . . . . . . . . . . . . . . . 29
Seizure Disorders . . . . . . . . . . . . . . . . . . . . 17
Oral Allergies. . . . . . . . . . . . . . . . . . . . . . . . 29
Dermatology . . . . . . . . . . . . . . . . . . . . . . . 17 Pulmonary Arterial Hypertension. . . . . . . . 29
Diabetes Smoking Cessation. . . . . . . . . . . . . . . . . . 29
Blood Glucose Monitoring. . . . . . . . . . . . . . 19
Transplant . . . . . . . . . . . . . . . . . . . . . . . . . 29
Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Non-Insulin . . . . . . . . . . . . . . . . . . . . . . . . . 20 Vitamins/Electrolytes. . . . . . . . . . . . . . . . 29
Endocrine Women’s Health
Growth Hormone. . . . . . . . . . . . . . . . . . . . . 20 Contraceptives. . . . . . . . . . . . . . . . . . . . . . . 29
Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Hormone Replacement. . . . . . . . . . . . . . . . 32
Thyroid Hormone Replacement. . . . . . . . . . 21 Miscellaneous. . . . . . . . . . . . . . . . . . . . . . . 32
Prenatal Vitamins . . . . . . . . . . . . . . . . . . . . 32
Eye Conditions
Allergies. . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
2Understanding your formulary
What is a formulary?
This document is a list of the most commonly About this formulary
prescribed medications. It includes both brand-name Where differences exist between
and generic prescription medications approved by the this formulary and your benefit
Food and Drug Administration (FDA). Medications are plan documents, the benefit plan
listed by common categories or classes and placed documents rule. This formulary is
in tiers that represent the cost you pay out-of-pocket. not a complete list of medications.
They are then listed in alphabetical order. Please look at the benefit plan
documents provided by your
How do I use my formulary? employer or health plan to see
You and your doctor can consult the formulary to which medications are covered
help you select the most cost-effective prescription under your plan.
medications. This guide tells you if a medication is
generic or a brand name, and if there are coverage
requirements or limits. Bring this list with you when
you see your doctor. If your medication is not listed
here, please visit your plan’s member website or call
the toll-free member phone number on your health
plan ID card.
What are tiers?
Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, set by
your employer or benefit plan. This is how much you will pay when you fill a prescription.
See page 6 for more information.
When does the formulary change?
Formulary changes including tier status changes resulting in higher copayments of maintenance
medications occur 2-3 times per contract or plan year. Tier changes that result in a lower
copayment may occur at any time. You can log in to the member website listed on your ID card at
any time to check your medication coverage and lower-cost options.
3Understanding your formulary (continued)
Why are some medications excluded from coverage?
We review medications based on their total value, including effectiveness and safety, how
much they cost, and the availability of alternative medications to treat the same or similar
medical conditions. Certain medications may be excluded from coverage or be subject to prior
authorization (sometimes referred to as precertification) if similar alternatives are available at
a lower cost. Examples include medications that work the same way, but one is much more
expensive than the other, or options that are available without a prescription (also referred to as
over-the-counter medications). There are also some instances where the same product can be
made by two or more manufacturers, but greatly vary in cost. In these instances, only the
lower-cost product may be covered.
You should review your benefit plan documents to confirm if any medications are excluded from
your plan. You can log in to the member website listed on your ID card at any time to check your
medication coverage. Talk to your doctor to see if there are lower-cost options or over-the-counter
medications available.
Who decides which medications are covered?
Thousands of medications are already available and more come to the market regularly.
Often, several medications are available to treat the same condition. The UnitedHealthcare®
Pharmacy and Therapeutics Committee, which includes both internal and external doctors and
pharmacists, meets regularly to provide clinical reviews of all medications. Using this information,
the Prescription Drug List Management Committee, which includes senior UnitedHealth Group®
doctors and business leaders, meets to evaluate overall health care value. They also set coverage
and tier status for all medications.
4Medication tips
What is the difference between brand-name and
generic medications? Over-the-counter
Generic medications contain the same active (OTC) medications
ingredients (what makes the medication work) as An OTC medication may be
brand-name medications, but they often cost less. the right treatment option for
Once the patent for a brand-name medication ends, some conditions. Talk to your
the FDA can approve a generic version with the same doctor about available OTC
active ingredients. These types of medications are options. Even though these
known as generic medications. Sometimes, the same medications may not be
company that makes a brand-name medication also covered by your pharmacy
makes the generic version. benefit, they may cost less
than a prescription medication.
What if my doctor writes a brand-name prescription?
If your doctor gives you a prescription for a brand-name
medication, ask if a generic equivalent or lower-cost
option is available and could be right for you. Generic
medications are usually your lowest-cost option, but not
always. For some benefit plans, if a brand-name drug is
prescribed and a generic equal is available, your cost-
share may be the copayment PLUS the cost difference
between the brand-name drug and the
generic equivalent.
What if I am taking a specialty medication?
Specialty medications are high-cost and are used to treat rare or complex conditions that require
additional care and support. For most plans, these medications are managed through the specialty
pharmacy program. Take advantage of personalized support designed to help you get the most out
of your treatment plan. Visit the member website listed on your ID card or call the toll-free phone
number on your ID card to learn more.
Please note, not all specialty medications are listed here. If you’re taking a specialty medication that
is on a higher tier, call the toll-free phone number on your ID card to talk with a pharmacist about
finding lower-cost options.
5Reading your formulary
The formulary gives you choices so you and your doctor can decide your best course of treatment.
In this formulary, brand-name medications are shown in bold type and generic medications in
plain type.
Tier information.
Using lower-tier medications can help you pay your lowest out-of-pocket cost. Your plan may have
multiple or no tiers. Please note: If you have a high deductible plan, the tier cost levels may apply
once you hit your deductible.
In the chart below, overall value indicates medications’ effectiveness and safety, cost, and the
availability of alternative medications to treat the same or similar medical condition(s).
Drug Tier Includes Helpful Tips
Tier 1 $ ower-cost
L
Medications that provide the highest Use Tier 1 drugs for the
overall value. Mostly generic drugs. Some lowest out-of-pocket costs.
brand-name drugs may also be included.
Tier 2 id-range cost
$$ M Use Tier 2 drugs, instead of
Medications that provide good overall value Tier 3, to help reduce your
of preferred brand name drugs. out-of-pocket costs.
Tier 3 ighest-cost
$$$ H
Medications that provide the lowest
Ask your doctor if a Tier 1 or
overall value. Mostly non-preferred
Tier 2 option could work for you.
brand-name drugs, as well as some
non-preferred generics.
6Reading your formulary (continued)
Drug list information.
In this drug list, some medications are noted with letters next to them to help you see which ones
may have coverage requirements or limits. Your benefit plan sets how these medications may be
covered for you.
AE Age Edit
This medication applies to a specific age group. Members outside of this age
group need to meet specific criteria for approval.
E Exceptions required for select markets in California and Oklahoma
Your doctor is required to provide additional information to UnitedHealthcare to
verify medical necessity of certain medications.
H Health Care Reform Preventive
This medication is part of a health care reform preventive benefit and may be
available at no additional cost to you.
H-PA Health Care Reform Preventive with Prior Authorization
May be part of health care reform preventive and available at no additional cost
to you if prior authorization criteria is met.
M Medical
The medication may be covered under medical with prior authorization.
Certain medications may process through the pharmacy claims system.
Check with your doctor for more information.
PA Prior Authorization
Requires your doctor to provide information about why you are taking
a medication to determine how it may be covered by your plan.
QL Quantity Limits
Specifies the largest quantity of medication covered per copayment or in a
defined period of time.
ST Step Therapy
Requires you to try one or more other medications before the medication you
are requesting may be covered.
7Reading your formulary (continued)
Coverage details.
Some drug classes in this PDL have additional/important coverage details. Review this list to see
if drug classes that apply to you are noted.
Infertility
Coverage is set by the consumer’s prescription drug benefit plan. Please consult plan
documents regarding benefit coverage and cost-share.
Medications for Sexual Dysfunction
Coverage is set by the consumer’s prescription drug benefit plan. Please consult plan
documents regarding benefit coverage and cost-share.
8Questions
For the most current list of covered medications or if you have questions:
all the toll-free member phone number
C
on your ID card.
isit your plan’s member website listed
V And, if home delivery services
on your ID card to: are included in your pharmacy
benefit, you can also:
• View your pharmacy benefit and coverage
information, including prescription history • Refill prescriptions
• View medication interactions and side effects • Check the status of your order
• Locate a participating retail pharmacy • Set up reminders for refills
by ZIP code
• Manage your account
• Look up possible lower-cost medication
alternatives
• Compare medication pricing and options
9Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Anti-Infectives: Antibiotics Isoniazid 1
Amoxicillin 1 Levofloxacin 1
Amoxicillin/Potassium Linezolid Tablet 1 QL
1
Clavulanate
Methenamine 1
Antipyrine/Benzocaine Otic 1
Metronidazole Tablet 1
Azithromycin 1
Minocycline Capsule 1
Bethkis 2 PA, QL
Mycobutin 2
Cayston 2 PA, QL
Neomycin 1
Cefaclor Suspension 2
Neomycin/Polymixin/
Cefaclor Tablet 1 1
Hydrocortisone Otic
Cefadroxil 1 QL Nitrofurantoin 1
Cefdinir 1 Nitrofurantoin Macrocrystal 1
Cefpodoxime 1 Nuzyra 3 QL
Cefprozil 1 Ofloxacin Otic 1
Cefuroxime 1 Oracea 3 E
Cephalexin 1 Otovel 3 E
Chloroxylenol/Hydrocortisone/ Paromomycin 1
1
Pramoxine Otic
Penicillin VK 1
Ciprofloxacin 1
Pentamidine 1 QL
Clarithromycin IR/ER 1
Pramoxine-HC Otic 1
Cleocin Vaginal Suppository 2
Pyrazinamide 1
Clindamycin Capsule 1
Rifampin 1
Clindamycin Vaginal Cream 1
Solodyn 3 E
Clindesse 3
Solosec 3 ST
Dapsone Tablet 1
Sulfadiazine 1
Demeclocycline 1
Sulfamethoxazole/Trimethoprim,
Dicloxacillin 1 Sulfamethoxazole/Trimethoprim 1
Doxycycline Hyclate 1 DS
Tetracycline 1
Doxycycline Monohydrate Tablet 1 QL
TOBI Podhaler 3 PA, QL
Erythromycin 1
Trimethoprim 1
Erythromycin/Sulfisoxazole 1
Xenleta 3
Ethambutol 1
Zmax 2
Firvanq 1
See page 8 for coverage details.
10Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Anti-Infectives: Antifungals Valacyclovir 1 QL
Clotrimazole Troche 1 Valganciclovir Solution 1
Cresemba 3 Valganciclovir Tablet 1 QL
Fluconazole 1 Viekira Pak 3 PA, QL
Griseofulvin 1 Vosevi 2 PA, QL
Itraconazole Capsule 1 PA Xofluza 3 QL
Jublia 3 PA Zepatier 2 PA, QL
Kerydin 3 PA Zovirax Cream 3 E
Ketoconazole Cream 1 QL Zovirax Ointment 3 E
Ketoconazole Shampoo 1 Cancer
Metronidazole Vaginal Gel 1 Alunbrig 2 PA, QL
Nystatin 1 Balversa 2 PA, QL
Terbinafine 1 QL Bicalutamide 1
Terconazole 1 Bosulif 2 PA, QL
Vandazole Gel 1 Cabometyx 2 PA
Anti-Infectives: Antivirals Calquence 2 PA, QL
Acyclovir 1 Capecitabine 1
Adefovir 1 Caprelsa 2 PA, QL
Amantadine Capsule, Syrup 1 Cometriq 2 PA
Baraclude 3 E, QL Cotellic 2 PA, QL
Daklinza 3 PA Cyclophosphamide 3
Entecavir 1 QL Daurismo 2 PA, QL
Epclusa 2 PA, QL Emcyt 2
Epivir HBV Solution 2 Etoposide 1
Famciclovir 1 Erivedge 2 PA, QL
Harvoni 2 PA, QL Erleada 2 PA, QL
Lamivudine 1 Exemestane 1
Mavyret 2 PA, QL Farydak 2 PA, QL
Pegasys M Flutamide 1
Prevymis Tablet 2 PA Hexalen 2
Ribavirin Tablet 1 PA Hydroxyurea 1
Rimantidine 1 Ibrance 2 PA, QL
Sovaldi 3 PA Idhifa 2 QL
See page 8 for coverage details.
11Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Imatinib 1 PA, QL Xeloda 3 E
Imbruvica 2 PA, QL Xtandi 3 PA, QL
Jakafi 2 PA, QL Yonsa 3 E, PA, QL
Letrozole 1 PA Zejula 2 PA, QL
Leucovorin Calcium 1 Zelboraf 2 PA
Leukeran 2 Zolinza 2 QL
Lomustine 1 Zykadia 2 PA, QL
Lysodren 2 Zytiga 2 PA
Lonsurf 2 PA, QL Cardiovascular/Heart Disease: Coagulation Therapy
Matulane 2 Aggrenox 3
Melphalan 1 Brilinta 2
Mercaptopurine 1 Clopidogrel 1
Myleran 2 Disopyramide 1
Nerlynx 2 PA, QL Eliquis 2 QL
Nexavar 2 PA Jantoven 1
Nilandrone 2 Pradaxa 2 QL
Ninlaro 2 PA, QL Prasugrel 1 QL
Nubeqa 2 PA, QL Savaysa 3 QL
Odomzo 2 PA, QL Ticlopidine 1 QL
Piqray 2 PA, QL Warfarin 1
Rydapt 2 PA, QL Xarelto 2 QL
Sprycel 3 PA, QL Zontivity 3 QL
Stivarga 2 PA Cardiovascular/Heart Disease: High Blood Pressure
Sutent 2 PA Acebutolol 1
Tabloid 2 Acetazolamide 1
Targretin Capsule 2 Acetazolamide ER 1
Tasigna 2 PA, QL Afeditab CR 1
Temozolomide 1 PA Aldactazide 25/25 mg 2
Toremifene 1 Amiloride 1
Tretinoin Capsule 1 Amiloride/Hydrochlorothiazide 1
Tykerb 2 PA Amlodipine 1
Verzenio 2 PA, QL Amlodipine/Benazepril 1 QL
Vitrakvi 2 PA, QL Atenolol 1
See page 8 for coverage details.
12Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Atenolol/Chlorthalidone 1 Irbesartan 1 QL
Benazepril 1 Irbesartan/Hydrochlorothiazide 1 QL
Benazepril/Hydrochlorothiazide 1 Isradipine 1
Betaxolol 1 Labetalol 1
Bisoprolol 1 Lisinopril 1
Bisoprolol/Hydrochlorothiazide 1 Lisinopril/Hydrochlorothiazide 1
Bumetanide 1 Losartan 1
Bystolic 2 Losartan/Hydrochlorothiazide 1
Byvalson 2 Methazolamide 1
Captopril 1 Methyclothia 1
Captopril/Hydrochlorothiazide 1 Methyldopa 1
Cartia XT 1 Methyldopa/Hydrochlorothiazide 1
Carvedilol 1 Metolazone 1
Chlorothiazide 1 Metoprolol Succinate ER 1
Chlorthalidone 1 Metoprolol Tartrate 1
Clonidine Tablet 1 Minoxidil 1
Diltiazem Sustained-Release Moexipril 1
1
Capsule
Moexipril/Hydrochlorothiazide 1
Diltiazem Tablet 1
Nadolol 1
Doxazosin 1
Nicardipine 1
Edarbi 3 E
Nifediac CC 1
Edarbyclor 3 ST
Nifedical XL 1
Enalapril 1
Nifedipine IR/ER 1
Enalapril/Hydrochlorothiazide 1
Olmesartan 1
Eprosartan 1 QL
Olmesartan/Hydrochlorothiazide 1
Ezide 1
Perindopril 1
Felodipine 1
Phenoxybenzamine 1
Fosinopril 1
Pindolol 1
Fosinopril/Hydrochlorothiazide 1
Prazosin 1
Furosemide 1
Propranolol/Hydrochlorothiazide 1
Guanfacine 1
Propranolol IR/ER 1
Hydralazine 1
Quinapril 1
Hydrochlorothiazide 1
Ramipril 1
Indapamide 1
See page 8 for coverage details.
13Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Reserpine 1 Fluvastatin 1 QL
Sotalol 1 Gemfibrozil 1
Sotalol AF 1 Lipofen 3 E
Spironolactone 1 Livalo 3 E, QL
Spironolactone/ Lovastatin 1 H-PA
1
Hydrochlorothiazide
Niacin ER 1 QL
Taztia XT 1
Niaspan 3
Tekturna 3
Omega-3-Acid Ethyl Esters
Tekturna HCT 3 1 PA, QL
Capsule
Telmisartan 2 QL Praluent M QL
Telmisartan/Hydrochlorothiazide 1 QL Pravastatin 1
Terazosin 1 QL Prevalite 1
Timolol 1 Rosuvastatin 1 QL
Torsemide 1 Simvastatin 1 H-PA
Trandolapril/Verapamil CR 1 Vascepa 2
Triamterene/Hydrochlorothiazide 1 Welchol 2
Valsartan 1 QL Cardiovascular/Heart Disease: Other
Valsartan/Hydrochlorothiazide 1 QL Amiodarone 1
Verapamil Sustained-Release Anagrelide 1
1 QL
Capsule
Cilostazol 1
Verapamil Sustained-Release
1
Tablet Corlanor 3 PA, QL
Verapamil Tablet 1 Digoxin 1
Cardiovascular/Heart Disease: High Cholesterol Dilatrate SR 2
Antara 3 QL Disopyramide 1
Atorvastatin 1 H-PA, QL Firazyr M QL
Cholestyramine 1 Flecainide 1
Choline Fenofibrate Capsule 1 E Isochron 1
Colestipol 1 Isoditrate ER 1
Ezetimibe 3 QL Isordil 2
Ezetimibe/Simvastatin 3 QL Isosorbide Dinitrate IR/ER 1
Fenofibrate 48, 145 mg Tablet 1 E Isosorbide Mononitrate IR/ER 1
Fenofibrate 54, 160 mg Tablet 1 Isoxsuprine 1
Fenofibrate Capsule 1 Mexiletine 1
Fenofibrate Micronized 1 Midodrine 1
See page 8 for coverage details.
14Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Multaq 3 PA Bupropion SR 1 H
NitroBid 2 Bupropion XL 1 QL
Nitroglycerin ER 1 Citalopram 1
Nitroglycerin Tablet 1 Clomipramine 3
Nitrolingual Pump Spray 1 Cymbalta 3 E, QL
NitroTime 1 Desipramine 1
Norpace CR 2 Doxepin 1
Pacerone 3 Duloxetine 20, 30, 60 mg 1 QL
Pentoxifylline 1 Escitalopram 1
Propafenone 1 Fluoxetine Capsule (generic
1
Prozac)
Quinidine IR/ER 1
Fluvoxamine 1
Ranolazine 1
Forfivo XL 3 QL
Sotalol 1
Imipramine 1
Central Nervous System: Attention Deficit Disorder
Maprotiline 1
Adderall XR 2 AE, QL
Mirtazapine, Mirtazapine ODT 1
Atomoxetine 3 QL
Nefazodone 1
Concerta 2 AE, QL
Nortriptyline 1
Dextroamphetamine/
1 AE, QL Paroxetine Tablet (generic Paxil) 1
Amphetamine
Dextroamphetamine/ Paroxetine ER 1 QL
3 AE, E, QL
Amphetamine Extended-Release
Paxil Suspension 2
Dextroamphetamine Sulfate
1 AE
Extended-Release Phenelzine 1
Dextroamphetamine Sulfate Protriptyline 1
1 AE, QL
Tablet
Sertraline 1
Evekeo ODT 3 AE, E, QL
Tranylcypromine 1
Guanfacine ER 1 AE, QL
Trazodone 1
Intuniv 3 AE, E, QL
Trintellix 3 QL, ST
Methylphenidate Controlled-
1 AE, QL
Release Capsule Venlafaxine 1
Methylphenidate Tablet 1 AE, QL Venlafaxine Extended-Release
1
Capsule
Vyvanse 3 AE, QL
Venlafaxine Extended-Release
Central Nervous System: Depression 1 QL
Tablet
Amitriptyline 1 Viibryd 3 QL
Amoxapine 1
Bupropion 1
See page 8 for coverage details.
15Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Central Nervous System: Migraine Buprenorphine/Naloxone
1 QL
Sublingual Film
Acetaminophen/Butalbital/
1 QL Buprenorphine/Naloxone
Caffeine 2 QL
Sublingual Tablet
Emgality M QL
Buspirone 1
Isometheptene/Acetaminophen/
1 Carbidopa/Levodopa IR/ER 1
Dichloralphenazone
Migragesic 1 Chlordiazepoxide 1 QL
Migranal 3 E, PA, QL Chlordiazepoxide/Amitriptyline 1
Naratriptan 1 QL Chlorpromazine 1
Nodolor 1 Clorazepate 1 QL
Phrenilin Forte 3 QL Clozapine 1 QL
Rizatriptan 1 QL Compro Suppository 1
Sumatriptan Nasal Spray, Tablet 1 QL Diazepam 1
Sumavel DosePro M Donepezil, Donepezil ODT 1
Zecuity 3 E, QL Entaone 1
Zolmitriptan 1 QL Ergoloid Mesylate 1
Central Nervous System: Multiple Sclerosis Fluphenazine 1
Ampyra 3 PA, QL Galantamine IR/ER 1
Avonex M QL Galantamine Solution 1 QL
Betaseron M QL Haloperidol 1
Copaxone M QL Hydroxyzine 1
Dalfampridine 1 PA, QL Invega Sustenna, Invega Trinza M
Gilenya 3 PA, QL Latuda 3 QL
Glatiramer M QL Lithium IR/ER 1
Glatopa M QL Lorazepam 1 QL
Mavenclad 3 PA, QL Loxapine 1
Tecfidera 2 PA, QL Memantine Solution, Tablet 1
Central Nervous System: Other Meprobamate 1
Alprazolam IR/ER 1 QL Namzaric 2 QL
Aripiprazole ODT 1 QL Olanzapine, Olanzapine ODT 1 QL
Aripiprazole Solution, Tablet 1 QL Oxazepam 1 QL
Aristada M Perphenazine/Amitriptyline 1
Benztropine 1 Pramipexole 1
Bromocriptine 1 Prochlorperazine 1
See page 8 for coverage details.
16Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Quetiapine 1 QL Ethosuximide 1
Rexulti 3 PA, QL Gabapentin 1
Risperidone, Risperidone ODT 1 QL Lamotrigine Chewable, Tablet 1
Rivastigmine 1 Lamotrigine ER 1
Ropinirole 1 Lamotrigine ODT 3
Saphris 2 QL Levetiracetam ER 1
Thioridazine 1 Levetiracetam IR 1
Thiothixene 1 Lyrica Capsule 3 PA, QL
Tiglutik 3 PA Lyrica Solution 3 PA, QL
Trifluoperazine 1 Oxcarbazepine 1
Trihexyphenidyl 1 Phenobarbital 1
Wakix 3 PA, QL Phenytoin 1
Xyrem 3 PA, QL Pregabalin Capsule 1 QL
Zelapar 3 QL Topiragen 1
Ziprasidone 1 QL Topiramate 1
Zubsolv 1 QL Valproic Acid 1
Central Nervous System: Sedatives/Hypnotics Vimpat Injection M
Eszopiclone 1 QL Vimpat Tablet, Solution 3 PA
Flurazepam 1 PA, QL Zonisamide 1
Silenor 3 QL Dermatology
Temazepam 1 QL Absorica 3 PA
Triazolam 1 QL Absorica LD 3 E, PA
Zaleplon 1 QL Acitretin 1
Zolpidem 1 QL Acyclovir 1
Central Nervous System: Seizure Disorders Aczone Gel 3
Carbamazepine ER Capsules 1 Ala Quin 1
Carbamazepine IR 1 Alclometasone 1
Clonazepam 1 Alphatrex 1
Clonazepam ODT 1 QL Amnesteem 1
Diazepam Gel 1 QL Azelaic Acid 1
Divalproex DR 1 Benzaclin 3 E, QL
Epidiolex 3 PA Betamethasone 1
Epitol 1 Bryhali 3 E, QL
See page 8 for coverage details.
17Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Calcipotriene-Betamethasone 2 QL Fluoroplex 3
Calcipotriene Ointment 1 QL Fluorouracil Solution, 5% Cream 1
Calcitriol Ointment 1 Fluticasone 1
Cerovel 1 Gentamicin 1
Ciclodan 1 Hydrocortisone 1
Ciclopirox Cream, Gel, Lotion, Hypercare 1
1
Solution
Imiquimod 1 QL
Claravis 1
Ivermectin Cream 1
Clindamycin Solution 1 QL
Laclotion 1
Clindamycin Swabs 1
Lidocaine 1
Clobetasol, Clobetasol E 1
Lidocaine/Prilocaine 1
Clobex Lotion, Shampoo 3 E
Lindane 1
Clobex Spray 3 E, QL
Lokara 1
Cloderm 3 E
Metrogel 1% 3 E
Cloderm Pump 3
Metronidazole 0.75% Cream,
Cormax 1 1
Lotion
Crotan 1 Mirvaso 2 QL
Dermazene 1 Mometasone Furoate 1
Desonide 1 Mupirocin Calcium Cream 1 QL
Desoximetasone Cream, Gel, Mupirocin Ointment 1
1
Ointment
Myorisan 1
DrithoScalp 2
Nystatin 1
Dupixent M QL
Nystop 1
Econazole 3
Onexton 3 E, QL
Elidel 3 QL, ST
Otezla 2 PA, QL
Enstilar 3 QL
Permethrin 1
Ery Pad 1
Picato 3
Erythromycin 1
Podofilox 1
Erythromycin/Benzoyl Peroxide 1
Pramcort 1
Ethyl Chloride 1
Pramosone Cream, Ointment 3
Eurax 2
Pramosone E Cream 3
Exoderm 1
Pramosone Lotion 3
Fluocinolone 1
Protopic 3 AE, QL, ST
Fluocinonide, Fluocinonide E 1
Rhofade 3 PA, QL
See page 8 for coverage details.
18Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Rosadan Cream 1 Novotwist Pen Needles 2
Selenium Sulfide 1 OneTouch Lancets 1 QL
Silver Nitrate 1 OneTouch Test Strips 1 QL
Silver Sulfadiazine 1 Diabetes: Insulin
Soolantra 3 Apidra Solostar, Vials 3 E, QL, ST
Sulfacetamide Sodium 1 Humalog KwikPen 2
Sulfacetamide Sodium-Sulfur 1 Humalog Mix 50-50 KwikPen 2
Taclonex Ointment 3 E, QL Humalog Mix 50-50 Vial 1
Taclonex Scalp 3 QL Humalog Mix 75-25 KwikPen 2
Taclonex Suspension 3 QL Humalog Mix 75-25 Vial 1
Tacrolimus Ointment 1 AE, QL Humalog U-200 KwikPen 2
Tazorac 3 AE, QL Humalog Vial 1
Tretinoin Cream 3 AE, QL Humulin 70-30 KwikPen 2
Triamcinolone Acetonide Cream, Humulin 70-30 Vial 1
1 QL
Lotion, Ointment, Paste
Humulin KwikPen 2
Triderm 1
Humulin N KwikPen 2
Urea 40% Lotion 1
Humulin N Vial 1
Vectical 3 E
Humulin R U-500 KwikPen 2 QL
Vitazol 1
Humulin R U-500 Vial 1
Zenatane 1
Humulin R Vial 1
Zyclara Cream, Pump 3 QL
Insulin Aspart FlexPen 2 E, ST
Diabetes: Blood Glucose Monitoring
Insulin Aspart PenFill 2 E, ST
Accu-Chek Test Strips 3 PA, QL
Insulin Aspart Protamine/
Bayer Contour Next Test Strips 2 QL 2 E, ST
Insulin Aspart 70/30 FlexPen
Bayer Contour Test Strips 3 PA, QL Insulin Aspart Protamine/
2 E, ST
Insulin Aspart 70/30 Vial
FreeStyle Test Strips 3 PA, QL
Insulin Aspart Vial 2 E, ST
Insulin Pen Needles 2
Lantus 1 QL
Lancing Devices (Lifescan,
1 QL Lantus SoloSTAR 1 QL
Roche)
Lancets (Lifescan, Roche) 1 QL Levemir FlexTouch, Vials 3 E, QL
Lancets 2 QL Novolin 70/30 FlexPen 2 E
Novofine Autocover Pen Novolin N FlexPen 2 E
2
Needles
Novolin R FlexPen 2 E
Novofine Pen Needles 2
Novolin Vials (all formulations) 2 E
Novofine Plus Pen Needles 2
See page 8 for coverage details.
19Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Novolog FlexPen, Vials Juvisync 2 QL, ST
2 E
(all formulations)
Kazano 2 QL
Soliqua 2 QL
Kombiglyze XR 2 QL
Toujeo Max SoloSTAR 2 QL
Metformin 1
Toujeo SoloSTAR 2 QL
Metformin Extended-Release
Tresiba 3 E, QL 1
(generic Glucophage XR)
Tresiba FlexTouch 3 E, QL Nateglinide 1 QL
Diabetes: Non-Insulin Nesina 2 QL
Acarbose 1 Onglyza 2 QL
Adlyxin, Adlyxin Starter Pack 3 QL, ST Oseni 2 QL
Baqsimi 2 QL Ozempic 2 QL, ST
Bydureon, Bydureon Bcise 2 QL, ST Pioglitazone 1 QL
Byetta 2 QL, ST Pioglitazone/Glimepiride 1 QL, ST
Chlorpropamide 1 Pioglitazone/Metformin 1 QL, ST
Farxiga 3 E, QL, ST Repaglinide 1 QL, ST
Glimepiride 1 Rybelsus 2 QL, ST
Glipizide IR/XL 1 Symlin 3 PA
Glipizide/Metformin 1 Synjardy 2 QL
Glucagen 2 QL Synjardy XR 2 QL
Glucagon 2 QL Tanzeum 2
Glumetza 3 PA Tolazamide 1 ST
Glyburide 1 Tolbutamide 1 ST
Glyburide/Metformin 1 Tradjenta 2 QL
Glyxambi 2 QL, ST Trulicity 2 QL, ST
Gvoke HypoPen 2 Victoza (2 pen pack) 2 QL, ST
Gvoke PFS 2 QL Victoza (3 pen pack) 3 QL, ST
Invokamet, Invokamet XR 3 E, QL, ST Endocrine: Growth Hormone
Invokana 3 E, QL, ST Lupron Depot M
Janumet 3 E, QL Nutropin AQ, Nutropin AQ
M
NuSpin
Janumet XR 3 E, QL
Endocrine: Other
Januvia 3 E, QL
Asmalpred, Asmalpred Plus 2
Jardiance 2 QL, ST
Calcitriol 1
Jentadueto 2 QL
Cortisone 1
Jentadueto XR 2 QL
See page 8 for coverage details.
20Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Desmopressin 1 Besivance 3
Dexamethasone 1 Ciprodex 3
Fludrocortisone 1 Ciprofloxacin 1
Hydrocortisone Tablet 1 Erythromycin 1 H-PA
Medrol 2 mg 2 Gentamicin 1
Methylprednisolone 1 Ilotycin 1
Millipred Tablet 1 Moxeza 2
Nocdurna 3 PA, QL Natacyn 2
Paricalcitol 1 Neomycin/Bacitracin/Polymyxin 1
Prednisolone Solution, Tablet 1 Neomycin/Polymixin/Gramicidin 1
Prednisone 1 Ofloxacin 1
TaperDex 3 Polymyxin B/Trimethoprim 1
Endocrine: Thyroid Hormone Replacement Sulfacetamide Sodium 1
Levothyroxine Sodium 1 Tobradex Ointment 3
Levoxyl 1 Tobramycin/Dexamethasone 1
Liothyronine Sodium 1 Tobramycin Ophth Solution 1 E
Methimazole 1 Tobrex 3 E
Propylthiouracil 1 Trifluridine 1
Tirosint 3 Eye Conditions: Glaucoma
Tirosint-SOL 3 PA Alphagan P 2 QL
Unithroid 1 Azopt 2 QL
Eye Conditions: Allergies Betaxolol 1
Azelastine 0.05% Solution 1 Betimol 3 QL
Cromolyn 1 Betoptic-S 3
Epinastine 1 E Carteolol 1
Lastacaft 3 QL Combigan 2 QL
Naphazoline 0.1% 1 Cosopt, Cosopt PF 3
Pataday 3 E Dorzolamide 1 QL
Phenylephrine 1 Dorzolamide/Timolol 1
Eye Conditions: Antibiotics Latanoprost 1
Azasite 3 Levobunolol 1
Bacitracin 1 Lumigan 2 QL
Bacitracin/Polymyxin 1 Metipranolol 1
See page 8 for coverage details.
21Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Rhopressa 3 QL Tetracaine 1
Rocklatan 3 QL Tropicamide 1
Simbrinza 2 QL Xiidra 2 PA
Timolol Maleate 1 Gastrointestinal: Acid Suppression
Timoptic Ocudose 2 Cimetidine 1
Travatan Z 3 QL Dexilant 2 QL
Travoprost 1 QL Misoprostol 1
Vyzulta 3 E, QL, ST Nizatidine 1
Zioptan 3 QL Omeclamox-Pak 2 QL
Eye Conditions: Other Omeprazole 1 QL
Atropine 1 Pantoprazole 1 QL
Blephamide SOP 3 Pylera 2 QL
Brimonidine 1 Sucralfate 1
Cyclopentolate 1 Gastrointestinal: Nausea/Vomiting
Dexamethasone 1 Akynzeo 3
Diclofenac 1 Antivert 50 mg 2
Fluorometholone 1 Dronabinol 1
Flurbiprofen 1 Ondansetron 1 QL
Homatropine 1 Ondansetron ODT 1
Inveltys 3 Promethazine 1
Iso Carbachol 2 Trimethobenzamide 1
Iso Homatropine 2 Varubi 3 QL
Ketorolac 1 Gastrointestinal: Other
Neomycin/Bacitracin/Polymyxin/ Amitiza 3 PA, QL
1
Hydrocortisone
Analpram Advanced 3
Neomycin/Polymixin/
1
Dexamethasone Analpram-HC Cream 3
Phospholine 2 Analpram-HC Lotion 3
Pred Mild 3 Analpram-HC Shingles 3
Prednisolone Solution, Tablet 1 Apriso 2
Proparacaine 1 Auryxia 3
Restasis 2 PA B-donna 1
Sulfacetamide Sodium/ Belladonna Alkaloids/
1 1
Prednisolone Phenobarbital
See page 8 for coverage details.
22Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Budesonide Delayed-Release Trilyte 1 QL
1
Capsule
Uceris Foam 2
Calcium Acetate 1
Uceris Tablet 3
Clenpiq 3
Ursodiol 1
Cortifoam 2
Viberzi 3 PA, QL
Creon 2
Zelnorm 3 PA, QL
Dicyclomine 1
Zenpep 2
Dificid 3
HIV/AIDS
Digex NF 2
Abacavir 1
Dipentum 3
Abacavir/Lamivudine 1
Diphenoxylate/Atropine 1
Aptivus 2
Gavilyte 1 H, QL
Atazanavir Capsule 1
Halflytely 3
Atripla 2
Hyoscyamine 1
Biktarvy 2
Lactulose Solution 1
Cimduo 2
Lialda 2
Complera 2
Linzess 2 PA, QL
Crixivan 2
Mesalamine Enema, Suppository 1
Delstrigo 2
Metoclopramide Solution, Tablet 1
Descovy 2
Movantik 3 E, PA, QL
Didanosine 1
Moviprep 3 QL
Dovato 2
Pancrelipase 1
Edurant 2
Paregoric Tincture 1
Efavirenz 1
Pentasa 3 E
Emtriva 2
Plenvu 3
Epivir Solution 2
Polyethylene Glycol 3350 1 H, QL
Evotaz 2
Prepopik 3 QL
Fosamprenavir 1
Propantheline 1
Fuzeon 2 QL
Sevelamer (generic Renvela) 1
Genvoya 2
Sucraid 2
Intelence 2
Sulfasalazine 1
Invirase 2
Suprep 3 QL
Isentress 2
Symproic 2 PA, QL
Juluca 2
See page 8 for coverage details.
23Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Kaletra Tablet 2 Infertility
Lamivudine 1 Cetrotide M QL
Lamivudine/Zidovudine 1 Clomiphene 1
Lopinavir-Ritonavir Solution 1 Endometrin 2 PA
Nevirapine 1 Gonal-F M
Norvir Capsule, Powder Gonal-F RFF M
2
Packet, Solution
Ovidrel M
Odefsey 2
Inflammatory Conditions: Rheumatoid Arthritis,
Pifeltro 2 Crohn’s Disease, Psoriasis, Ulcerative Colitis
Prezcobix 2 Cimzia M QL
Prezista 2 Cosentyx M
Rescriptor 2 D-Penamine 2
Retrovir 2 Depen 2
Reyataz Powder Packet 2 Humira M QL
Ritonavir Tablet 1 Hydroxychloroquine Sulfate 1
Selzentry 2 PA Kevzara M QL
Stavudine Capsule 1 Leflunomide 1 QL
Stribild 2 Methotrexate 1
Symfi 2 Olumiant 2 PA, QL
Symfi Lo 2 Orencia M
Symtuza 2 Otrexup M
Temixys 2 Penicillamine 1
Tenofovir Tablet 1 Rasuvo M
Tivicay 2 Remicade M
Triumeq 2 Rheumatrex 3
Trizivir 3 Rinvoq 2 PA, QL
Truvada 2 Simponi M QL
Videx Solution 2 Skyrizi M
Viracept 2 Stelara M QL
Viread Oral Powder 2 Trexall 3
Vitekta 2 Xeljanz 2 PA, QL
Zerit Solution 2 Xeljanz XR 2 PA
Zidovudine 1
See page 8 for coverage details.
24Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Medications for Sexual Dysfunction Aranesp M
Imvexxy 3 QL Austedo 2 PA, QL
Levitra 3 PA, QL Benznidazole 2 PA, QL
Osphena 3 PA, QL Benzocaine Otic 1
Sildenafil Tablet (generic Viagra) 3 PA, QL Benzonatate 1
Tadalafil (generic Cialis) 3 PA, QL Bunavail 3 PA, QL
Vyleesi M QL Cerdelga 3 PA
Men’s Health: Prostate Cetylev 3
Alfuzosin 1 Chloroquine 1
Doxazosin 1 Citric Acid/Sodium Citrate 1
Dutasteride 1 Cystagon 2
Dutasteride/Tamsulosin 1 Danazol 1
Finasteride 1 Daraprim 3 PA
Tadalafil 2.5, 5 mg 3 PA, QL Difil-G Forte Liquid 1
Tamsulosin 1 Disulfiram 1
Terazosin 1 Easivent 2 QL
Men’s Health: Testosterone Therapy Elmiron 2
Androderm 2 PA, QL Emverm 3 PA, QL
Androgel 1% 3 PA, QL Epinephrine Auto-injector
1 QL
(generic Epipen, Epipen Jr)
Androxy 1
Epipen Jr 3 E, QL
Testim 3 PA, QL
Ergocalciferol 50,000 Unit
1
Testosterone 1% Gel Pump 1 PA, QL Capsule
Testosterone 1.62% Gel 1 PA, QL Euflexxa M
Testosterone 2% Gel 3 PA, QL Exemestane 1
Testred 3 EZ Spacer 2 QL
Miscellaneous Firazyr M
Acetic Acid Otic 1 Fosrenol 3 E
Acetylcysteine 1 Granix M
Aerochamber 2 QL Guaifenesin/Codeine 1
Albendazole 3 PA, QL Guanidine 2
Alinia 2 Hydrocodone/Homatropine 1 AE, QL
Anastrozole 1 Hydrocortisone/Acetic Acid Otic 1
Antipyrine/Benzocaine 1 Hydrocortisone Pramoxine 1
Anucort-HC 1 Hydrocortisone Suppository 1
See page 8 for coverage details.
25Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Hypersal Nebs 2 Proctozone HC 1
Impavido 2 PA Proglycem 2
Inspirease 2 Promethazine/Codeine 1 AE, QL
Jynarque 2 PA, QL Promethazine/Dextromethorphan 1
Krintafel 1 QL Promethazine Suppository 1
Kuvan 2 PA, QL Promethazine VC/Codeine 1 AE, QL
Letrozole 1 Pulmozyme 2 PA, QL
Lidocaine Viscous 1 Pyridostigmine 1
Lokelma 3 E, QL Rezira 3
Mebendazole 1 Ruzurgi 2 PA, QL
Mefloquine 1 Samsca 2 PA, QL
Megestrol AC 1 Sodium Polystyrene Sulfonate
1
Powder
Mephyton 2
SSKI 2
Methylergonovine 1 QL
Strensiq M
Mulpleta 2 PA, QL
Symdeko 2 PA, QL
Multigen Folic 2
Symjepi 2 QL
Multigen Plus 2
Synarel 2
Naltrexone 1
Synvisc M
Narcan Nasal Spray 2
Synvisc One M
Nessi Spacer 2 QL
Triamcinolone/Orabase 1
Nityr 2 PA
Tuzistra XR 3 AE, E, QL
Nuwiq M
Velphoro 2
Optihaler 2 QL
Veltassa 3 PA, QL
Orkambi 2 PA, QL
Vistogard 2
Phenazopyridine 1
Vitamin D 50,000 Unit 1
Phytonadione 3 QL
Vortex 2 QL
Pilocarpine 1
Vyndamax 2 PA, QL
Praziquantel 1
Vyndaqel 2 QL
Primaquine 1
WatchHaler 2 QL
Procrit M
Xuriden 2 PA, QL
Proctocream HC 1
Yodoxin 2
Proctofoam HC 2
Zarxio M
Proctosol HC 1
Zutripro 3 AE, E, QL
See page 8 for coverage details.
26Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Musculoskeletal: Osteoporosis Butalbital/Aspirin/Caffeine/
1
Codeine
Actonel 3 E
Celecoxib 3 QL
Alendronate Oral Solution 1 QL
Choline Magnesium Trisalicylate 1
Alendronate Tablet 1 QL
Codeine 1
Binosto 3 QL
Diclofenac Sodium 1
Calcitonin Spray 1 QL
Diflunisal 1
Forteo M
Duraxin 1
Fortical 3 QL
Etodolac IR/ER 1
Ibandronate 1
Fenoprofen 3 E, QL
Musculoskeletal: Other
Fentanyl Lozenge 1 PA, QL
Allopurinol 1
Fentanyl Patch 12, 25, 50, 75,
1 PA, QL
Baclofen 1 100 mcg
Carisoprodol 1 Flector Patch 3 E, QL
Colchicine 1 Flurbiprofen 1
Colcrys 2 Fortigan 1
Cyclobenzaprine Tablet 1 Gralise 3 QL, ST
Dantrolene 1 Hydrocodone/Acetaminophen
1
(generic Norco)
Febuxostat 1 QL, ST
Hydrocodone/Ibuprofen 1
Lorzone 3
Hydromorphone IR 1 QL
Methocarbamol 1
Ibuprofen 1
Orphenadrine/Aspirin/Caffeine 1
Indocin Suppository 2 QL
Orphenadrine ER 1
Indomethacin IR/ER 1
Probenecid 1
Ketorolac 1 QL
Tizanidine Tablet 1
Levorphanol 3 QL
Musculoskeletal: Pain Relief
Meclofenamate 1
Acetaminophen/Codeine 1
Meloxicam 1
Ascomp/Codeine 1
Meperidine 1
Belbuca 3 PA, QL
Methadone Tablet, Oral Solution 1 PA, QL
Butalbital/Acetaminophen 1
Morphine Sulfate Controlled-
Butalbital/Acetaminophen/ 1 PA, QL
Release Tablet
1 QL
Caffeine Morphine Sulfate Immediate-
1
Butalbital/Acetaminophen/ Release Tablet, Solution
1 QL
Caffeine/Codeine Nabumetone 1
Butalbital/Aspirin/Caffeine
1 Naproxen Suspension 1 PA
Capsule
See page 8 for coverage details.
27Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Naproxen Tablet 1 Atrovent HFA 3 QL
Nucynta 3 QL Bevespi Aerosphere 2 QL
Nucynta ER 3 PA, QL Breo Ellipta 3 QL
Oxaprozin 1 Budesonide Nebs 1 QL
Oxycodone IR 1 Combivent Respimat 2 QL
Oxycodone/Acetaminophen 1 Cromolyn Nebs 1
Oxymorphone 1 QL Flovent Diskus 1 QL
Pentazocine/Naloxone 1 Flovent HFA 1 QL
Piroxicam 1 Fluticasone/Salmeterol
55-14 mcg/act, 113-14 mcg/act, 2 QL
Roxybond 3 E, QL 232-14 mcg/act
Salsalate 1 Foradil 2 QL
Sulindac 1 Incruse Ellipta 2 QL
Tivorbex 3 E Ipratropium 1
Tolmetin 1 Ipratropium/Albuterol Nebs 1
Tramadol 50 mg 1 Lonhala Magnair 3 E, PA, QL
Trezix 3 E, QL Montelukast 1 QL
Vivlodex 3 E, QL Perforomist 3 QL
Voltaren Gel 2 QL Proair HFA 3 QL, ST
Xtampza ER 2 PA, QL Proair RespiClick 3 QL
Zorvolex 3 E Pulmicort 3 E, QL
Overactive Bladder Pulmicort Flexhaler 1 QL
Bethanechol 1 QVAR RediHaler 3 E
Myrbetriq 3 E Serevent 2 QL
Oxybutynin 1 Spiriva HandiHaler, Respimat 2 QL
Oxybutynin Extended-Release 1 Striverdi Respimat 2 QL
Toviaz 3 Symbicort 3 QL
Respiratory: Asthma/COPD Terbutaline 1
Advair Diskus 3 QL Theophylline SR 1
Advair HFA 3 QL Trelegy Ellipta 2 QL
Aerospan 3 QL Tudorza Pressair 3 E, QL
Albuterol Sulfate 1 Ventolin HFA 2 QL
Aminophylline 1 Xopenex HFA 3 QL
Arcapta Neohaler 3 QL Zafirlukast 1
Arnuity Ellipta 1 QL
See page 8 for coverage details.
28Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Respiratory: Nasal Allergies Nicotine Patch 1 H
Dymista Spray 2 E, QL Nicotrol Inhaler 3 H
Flunisolide 1 QL Nicotrol Nasal Spray 3 H
Fluticasone Propionate 1 QL Thrive Gum 1 H
Ipratropium 1 Transplant
Omnaris 3 E, QL Azathioprine 1
QNasl 3 QL Cyclosporine, Cyclosporine
1
Modified
Veramyst 3 E, QL
Gengraf 1
Zetonna 3 E, QL
Tacrolimus 1
Respiratory: Oral Allergies
Vitamins/Electrolytes
Carbinoxamine Solution, 4 mg
1 Fluoride Chewable Tablet, Drops 1 H
Tablet
Clemastine 1 Folic Acid 1 mg 1
Cyproheptadine 1 Klor-Con 10 1
Hydroxyzine 1 Klor-Con M10 1
Levocetirizine 1 Klor-Con M20 1
Promethazine 1 Potassium Chloride 1
Respiratory: Pulmonary Arterial Hypertension Potassium Citrate 1
Ambrisentan 1 PA, QL Women’s Health: Contraceptives
Adempas 2 PA, QL Afirmelle 1 H
Bosentan 1 PA, QL Aftera 1 H
Opsumit 2 PA, QL Altavera 1 H
Orenitram 3 PA, QL Alyacen 1 H
Sildenafil Tablet 20 mg (generic Apri 1 H
1 QL
Revatio)
Aranelle 1 H
Smoking Cessation
Aubra 1 H
Bupropion Sustained-Release
1 H
Tablet Aubra EQ 1 H
Chantix Tablet 3 H Aurovela 1 H
Nicoderm CQ 3 H Aurovela FE 1 H
Nicorette Gum 3 H Aviane 1 H
Nicorette Lozenge 3 H Ayuna 1 H
Nicorette Mini-Lozenge 3 H Azurette 1 H
Nicotine Gum 1 H Balcoltra 3 H
Nicotine Lozenge 1 H Balziva 1 H
See page 8 for coverage details.
29Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Bekyree 1 H Implanon 1 H
Blisovi FE 1 H Incassia 1 H
Briellyn 1 H Introvale 1 H
Camila 1 H Isibloom 1 H
Caya 1 H Jasmiel 1 H
Caziant 1 H Jencycla 1 H
Chateal 1 H Jolessa 1 H
Chateal EQ 1 H Jolivette 1 H
Cryselle 1 H Juleber 1 H
Cyclafem 1 H Junel 1 H
Cyred 1 H Junel Fe 1 H
Dasetta 1 H Kalliga 1 H
Deblitane 1 H Kariva 1 H
Delyla 1 H Kelnor 1/35, 1/50 1 H
Depo-SubQ Provera 104 2 H, QL Kimidess 1 H
Desogestrel/Ethinyl Estradiol 1 H Kurvelo 1 H
Drospirenone/Ethinyl Estradiol 1 H Larin, Larin FE 1 H
Drospirenone/Ethinyl Estradiol/ Larissia 1 H
3 H
Levomefolate
Leena 1 H
EContra EZ 1 H
Lessina 1 H
EContra One-Step 1 H
Levonest 1 H
Elinest 1 H
Levonorgestrel 1 H, QL
Ella 1 H, QL
Levonorgestrel/Ethinyl Estradiol 1 H
Emoquette 1 H
Levonorgestrel/Ethinyl Estradiol
Enpresse 1 H 3 H
(generic Quartette)
Enskyce 1 H Levora-28 1 H
Errin 1 H Lillow 1 H
Estarylla 1 H Lo Loestrin 3 H
Ethynodiol Diacetate/Ethinyl Lo-Zumandimine 1 H
1 H
Estradiol
Loestrin 2
Falmina 1 H
Loryna 1 H
Femynor 1 H
Low-Ogestrel 1 H
Gianvi 1 H
Lutera 1 H
Gildagia 1 H
Lyza 1 H
Heather 1 H
See page 8 for coverage details.
30Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Marlissa 1 H Pimtrea 1 H
Medroxyprogesterone Acetate Plan B One Step 1 H
1 H, QL
Injection
Portia 1 H
Melodetta 24 FE 3 H
Previfem 1 H
Mibelas 24 FE 3 H
Primella 1 H
Microgestin 1 H
React 1 H
Microgestin FE 1 H
Reclipsen 1 H
Mili 1 H
Setlakin 1 H
Mono-Linyah 1 H
Sharobel 1 H
MonoNessa 1 H
Simliya 1 H
My Choice 1 H
Slynd 3 H, PA
My Way 1 H
Sprintec 1 H
Myzilra 1 H
Sronyx 1 H
Natazia 2 H
Syeda 1 H
Necon 0.5/35, 1/50, 10/11 1 H
Take Action 1 H
New Day 1 H
Tarina FE 1 H
Next Choice One Dose 1 H
Taytulla 3 H
Nikki 1 H
Tri Femynor 1 H
Nora-BE 1 H
Tri-Estarylla 1 H
Norethindrone 1 H
Tri-Linyah 1 H
Norethindrone/Ethinyl Estradiol 1 H
Tri-Mili 1 H
Norgestimate/Ethinyl Estradiol 1 H
Tri-Previfem 1 H
Norethindrone/Ethinyl Estradiol/
1 H
Ferrous Fumarate Tri-Sprintec 1 H
Norgestrel/Ethinyl Estradiol 1 H Tri-Vylibra 1 H
Norlyda 1 H Trinessa 1 H
Norlyroc 1 H Trinessa Lo 3 H
Nortrel 1 H Trivora-28 1 H
Nuvaring 1 H Tulana 1 H
Ocella 1 H Tydemy 3 H
Ogestrel 1 Velivet 1 H
Opcicon One-Step 1 H Vestura 1 H
Option 2 1 H Vienva 1 H
Orsythia 1 H Viorele 1 H
Philith 1 H Vyfemla 1 H
See page 8 for coverage details.
31Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Vylibra 1 H Makena M
Wera 1 H Medroxyprogesterone 1
Wide-Seal 1 H Menest 2
Xulane 1 H Mimvey 1
Yasmin 28 3 E, H Minivelle 3 E, QL
Yaz 3 E, H Norethindrone 1
Zarah 1 H Norethindrone/Ethinyl Estradiol 1
Zovia 1 H Premarin 2
Zumandimine 1 H Premarin Vaginal Cream 2
Women’s Health: Hormone Replacement Premphase 2
Amabelz 1 Prempro 2
Bijuva 3 Vivelle-Dot 2 QL
Cenestin 3 QL Yuvafem 1
Climara Pro 2 QL Women’s Health: Miscellaneous
Covaryx, Covaryx HS 1 QL Raloxifene 1 H-PA, QL
Divigel 3 Tamoxifen 1 H-PA
Duavee 2 QL Women’s Health: Prenatal Vitamins
Elestrin 3 Brand Prenatal Vitamins/Folic
2
Acid 1 mg
Enjuvia 3
Generic Prenatal Vitamins/Folic
Estradiol Tablet 1 1
Acid 1 mg
Estradiol Twice Weekly Patch
1 QL
(generic Minivelle)
Estradiol Twice Weekly Patch
3 E, QL
(generic Vivelle-Dot)
Estradiol Weekly Patch 1 QL
Estrogen/Methyltestosterone,
1 QL
Estrogen/Methyltestosterone HS
Estropipate 1
Evamist 3
Fyavolv 1
Intrarosa 3
Jinteli 1
Lopreeza 1
See page 8 for coverage details.
32Index
A Amantadine Capsule, Syrup...........11 Atropine.................................... 22, 23
Abacavir......................................... 23 Ambrisentan................................... 29 Atrovent HFA.................................. 28
Abacavir/Lamivudine...................... 23 Amiloride........................................ 12 Aubra.............................................. 29
Absorica......................................... 17 Amiloride/Hydrochlorothiazide....... 12 Aubra EQ........................................ 29
Absorica LD.................................... 17 Aminophylline................................. 28 Aurovela......................................... 29
Acarbose........................................ 20 Amiodarone.................................... 14 Aurovela FE.................................... 29
Accu-Chek Test Strips.................... 19 Amitiza............................................ 22 Auryxia........................................... 22
Acebutolol....................................... 12 Amitriptyline...............................15, 16 Austedo.......................................... 25
Acetaminophen/Butalbital/ Amlodipine...................................... 12 Aviane............................................. 29
Caffeine....................................... 16 Amlodipine/Benazepril................... 12 Avonex............................................ 16
Acetaminophen/Codeine................ 27 Amnesteem.................................... 17 Ayuna............................................. 29
Acetazolamide................................ 12 Amoxapine..................................... 15 Azasite............................................ 21
Acetazolamide ER.......................... 12 Amoxicillin...................................... 10 Azathioprine................................... 29
Acetic Acid Otic.............................. 25 Amoxicillin/Potassium Azelaic Acid.................................... 17
Acetylcysteine................................ 25 Clavulanate................................. 10 Azelastine 0.05% Solution............. 21
Acitretin.......................................... 17 Ampyra........................................... 16 Azithromycin................................... 10
Actonel........................................... 27 Anagrelide...................................... 14 Azopt.............................................. 21
Acyclovir.................................... 11, 17 Analpram Advanced....................... 22 Azurette.......................................... 29
Aczone Gel..................................... 17 Analpram-HC Cream...................... 22
Analpram-HC Lotion....................... 22 B
Adderall XR.................................... 15
Adefovir...........................................11 Analpram-HC Shingles.................. 22 B-donna.......................................... 22
Adempas........................................ 29 Anastrozole.................................... 25 Bacitracin.................................. 21, 22
Adlyxin, Adlyxin Starter Pack......... 20 Androderm...................................... 25 Bacitracin/Polymyxin................ 21, 22
Advair Diskus................................. 28 Androgel 1%................................... 25 Baclofen......................................... 27
Advair HFA..................................... 28 Androxy.......................................... 25 Balcoltra......................................... 29
Aerochamber.................................. 25 Antara............................................. 14 Balversa..........................................11
Aerospan........................................ 28 Antipyrine/Benzocaine............. 10, 25 Balziva............................................ 29
Afeditab CR.................................... 12 Antipyrine/Benzocaine Otic............ 10 Baqsimi........................................... 20
Afirmelle......................................... 29 Antivert 50 mg................................ 22 Baraclude........................................11
Aftera.............................................. 29 Anucort-HC.................................... 25 Bayer Contour Next Test Strips...... 19
Aggrenox........................................ 12 Apidra Solostar, Vials..................... 19 Bayer Contour Test Strips.............. 19
Akynzeo.......................................... 22 Apri................................................. 29 Bekyree.......................................... 30
Ala Quin.......................................... 17 Apriso............................................. 22 Belbuca.......................................... 27
Albendazole.................................... 25 Aptivus............................................ 23 Belladonna Alkaloids/
Albuterol Sulfate............................. 28 Aranelle.......................................... 29 Phenobarbital.............................. 22
Alclometasone................................ 17 Aranesp.......................................... 25 Benazepril.................................12, 13
Aldactazide 25/25 mg..................... 12 Arcapta Neohaler........................... 28 Benazepril/Hydrochlorothiazide..... 13
Alendronate Oral Solution.............. 27 Aripiprazole ODT............................ 16 Benzaclin........................................ 17
Alendronate Tablet......................... 27 Aripiprazole Solution, Tablet.......... 16 Benznidazole.................................. 25
Alfuzosin......................................... 25 Aristada.......................................... 16 Benzocaine Otic....................... 10, 25
Alinia............................................... 25 Arnuity Ellipta................................. 28 Benzonatate................................... 25
Allopurinol...................................... 27 Ascomp/Codeine............................ 27 Benztropine.................................... 16
Alphagan P..................................... 21 Asmalpred, Asmalpred Plus........... 20 Besivance....................................... 21
Alphatrex........................................ 17 Atazanavir Capsule........................ 23 Betamethasone.............................. 17
Alprazolam IR/ER........................... 16 Atenolol.....................................12, 13 Betaseron....................................... 16
Altavera.......................................... 29 Atenolol/Chlorthalidone.................. 13 Betaxolol....................................13, 21
Alunbrig...........................................11 Atomoxetine.................................... 15 Bethanechol................................... 28
Alyacen........................................... 29 Atorvastatin.................................... 14 Bethkis............................................ 10
Amabelz......................................... 32 Atripla............................................. 23 Betimol........................................... 21
33Betoptic-S....................................... 21 Calcipotriene Ointment................... 18 Choline Fenofibrate Capsule.......... 14
Bevespi Aerosphere....................... 28 Calcipotriene-Betamethasone........ 18 Choline Magnesium Trisalicylate.... 27
Bicalutamide....................................11 Calcitonin Spray............................. 27 Cialis............................................... 25
Bijuva.............................................. 32 Calcitriol................................... 18, 20 Ciclodan......................................... 18
Biktarvy.......................................... 23 Calcitriol Ointment.......................... 18 Ciclopirox Cream, Gel, Lotion,
Binosto........................................... 27 Calcium Acetate............................. 23 Solution....................................... 18
Bisoprolol........................................ 13 Calquence.......................................11 Cilostazol........................................ 14
Bisoprolol/Hydrochlorothiazide...... 13 Camila............................................ 30 Cimduo........................................... 23
Blephamide SOP............................ 22 Capecitabine...................................11 Cimetidine...................................... 22
Blisovi FE....................................... 30 Caprelsa..........................................11 Cimzia............................................ 24
Bosentan........................................ 29 Captopril......................................... 13 Ciprodex......................................... 21
Bosulif..............................................11 Captopril/Hydrochlorothiazide........ 13 Ciprofloxacin............................. 10, 21
Brand Prenatal Vitamins/ Carbamazepine ER Capsules........ 17 Citalopram...................................... 15
Folic Acid 1 mg............................ 32 Carbamazepine IR......................... 17 Citric Acid/Sodium Citrate.............. 25
Breo Ellipta..................................... 28 Carbidopa/Levodopa IR/ER........... 16 Claravis.......................................... 18
Briellyn............................................ 30 Carbinoxamine Solution, Clarithromycin IR/ER...................... 10
Brilinta............................................ 12 4 mg Tablet.................................. 29 Clemastine..................................... 29
Brimonidine.................................... 22 Carisoprodol................................... 27 Clenpiq........................................... 23
Bromocriptine................................. 16 Carteolol......................................... 21 Cleocin Vaginal Suppository.......... 10
Bryhali............................................ 17 Cartia XT........................................ 13 Climara Pro.................................... 32
Budesonide Delayed-Release Carvedilol....................................... 13 Clindamycin Capsule...................... 10
Capsule....................................... 23 Caya............................................... 30 Clindamycin Solution...................... 18
Budesonide Nebs........................... 28 Cayston.......................................... 10 Clindamycin Swabs........................ 18
Bumetanide.................................... 13 Caziant........................................... 30 Clindamycin Vaginal Cream........... 10
Bunavail.......................................... 25 Cefaclor Suspension...................... 10 Clindesse........................................ 10
Buprenorphine/Naloxone Cefaclor Tablet............................... 10 Clobetasol, Clobetasol E................ 18
Sublingual Film............................ 16 Cefadroxil....................................... 10 Clobex Lotion, Shampoo................ 18
Buprenorphine/Naloxone Cefdinir........................................... 10 Clobex Spray.................................. 18
Sublingual Tablet......................... 16 Cefpodoxime.................................. 10 Cloderm.......................................... 18
Bupropion................................. 15, 29 Cefprozil......................................... 10 Cloderm Pump............................... 18
Bupropion SR................................. 15 Cefuroxime..................................... 10 Clomiphene.................................... 24
Bupropion Sustained-Release Celecoxib........................................ 27 Clomipramine................................. 15
Tablet........................................... 29 Cenestin......................................... 32 Clonazepam................................... 17
Bupropion XL.................................. 15 Cephalexin..................................... 10 Clonazepam ODT........................... 17
Buspirone....................................... 16 Cerdelga......................................... 25 Clonidine Tablet.............................. 13
Butalbital/Acetaminophen.............. 27 Cerovel........................................... 18 Clopidogrel..................................... 12
Butalbital/Acetaminophen/ Cetrotide......................................... 24 Clorazepate.................................... 16
Caffeine....................................... 27 Cetylev........................................... 25 Clotrimazole Troche........................11
Butalbital/Acetaminophen/ Chantix Tablet................................. 29 Clozapine....................................... 16
Caffeine/Codeine........................ 27 Chateal........................................... 30 Codeine..................................... 25-27
Butalbital/Aspirin/Caffeine Chateal EQ..................................... 30 Colchicine....................................... 27
Capsule....................................... 27 Chlordiazepoxide............................ 16 Colcrys........................................... 27
Butalbital/Aspirin/Caffeine/ Chlordiazepoxide/Amitriptyline....... 16 Colestipol........................................ 14
Codeine....................................... 27 Chloroquine.................................... 25 Combigan....................................... 21
Bydureon, Bydureon Bcise............. 20 Chlorothiazide................................ 13 Combivent Respimat...................... 28
Byetta............................................. 20 Chloroxylenol/Hydrocortisone/ Cometriq..........................................11
Bystolic........................................... 13 Pramoxine Otic............................ 10 Complera........................................ 23
Byvalson......................................... 13 Chlorpromazine.............................. 16 Compro Suppository...................... 16
Chlorpropamide.............................. 20 Concerta......................................... 15
C Chlorthalidone................................ 13 Copaxone....................................... 16
Cabometyx......................................11 Cholestyramine.............................. 14 Corlanor.......................................... 14
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