YOUR 2021 FORMULARY SIGNATUREVALUE 3-TIER - UNITEDHEALTHCARE
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Pharmacy | Formulary Your 2021 Formulary SignatureValue 3-Tier Effective May 1, 2021 This formulary is accurate as of May 1, 2021 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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Medication tips . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Reading your formulary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Anti-Infectives
Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Blood Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Cardiovascular/Heart Disease
Coagulation Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
High Blood Pressure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
High Cholesterol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Central Nervous System
Attention Deficit Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Migraine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Multiple Sclerosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Sedatives/Hypnotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Seizure Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Dermatology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Diabetes
Blood Glucose Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Non-Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Endocrine
Growth Hormone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Thyroid Hormone Replacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Eye Conditions
Allergies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Gastrointestinal
Acid Suppression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Nausea/Vomiting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
HIV/AIDS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Infertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Inflammatory Conditions: Rheumatoid Arthritis, Crohn’s Disease, Psoriasis,
Ulcerative Colitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Medications for Sexual Dysfunction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
2Men’s Health
Prostate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Testosterone Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Musculoskeletal
Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Pain Relief . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Overactive Bladder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Respiratory
Asthma/COPD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Nasal Allergies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Oral Allergies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Pulmonary Arterial Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Smoking Cessation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Transplant. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Vitamins/Electrolytes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Women’s Health
Contraceptives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Hormone Replacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Prenatal Vitamins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
3Understanding your formulary
What is a formulary?
This document is a list of the most commonly prescribed medications. It includes About this formulary
both brand-name and generic prescription medications approved by the Food and
Where differences exist between
Drug Administration (FDA). Medications are listed by common categories or classes
this formulary and your benefit
and placed in tiers that represent the cost you pay out-of-pocket. They are then
plan documents, the benefit
listed in alphabetical order.
plan documents rule. This
formulary is not a complete list
How do I use my formulary? of medications. Please look
You and your doctor can consult the formulary to help you select the most cost- at the benefit plan documents
effective prescription medications. This guide tells you if a medication is generic or provided by your employer
a brand name, and if there are coverage requirements or limits. Bring this list with or health plan to see which
you when you see your doctor. If your medication is not listed here, please visit your medications are covered under
plan’s member website or call the toll-free member phone number on your health your plan.
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.
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 PDL
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 ingredients (what makes the
(OTC) medications
medication work) as brand-name medications, but they often cost less. Once the An OTC medication may be
patent for a brand-name medication ends, the FDA can approve a generic version the right treatment option for
with the same active ingredients. These types of medications are known as generic some conditions. Talk to your
medications. Sometimes, the same company that makes a brand-name medication doctor about available OTC
also makes the generic version. options. Even though these
medications may not be covered
What if my doctor writes a brand-name prescription? by your pharmacy benefit,
they may cost less than a
If your doctor gives you a prescription for a brand-name medication, ask if a generic prescription medication.
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 $ Lower-cost Use Tier 1 drugs for the lowest
Medications that provide the highest overall value. Mostly out-of-pocket costs.
generic drugs. Some brand-name drugs may also be included.
Tier 2 $$ Mid-range cost Use Tier 2 drugs, instead of
Medications that provide good overall value of preferred Tier 3, to help reduce your
brand name drugs. out-of-pocket costs.
Tier 3 $$$ Highest-cost Ask your doctor if a Tier 1 or
Medications that provide the lowest overall value. Tier 2 option could work
Mostly brand-name drugs, as well as some generics. for you.
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 try one or more other medications before the medication you are requesting may
be covered.
6Reading your formulary (continued)
Coverage details
Some drug classes in this formulary 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.
Questions
For the most current list of covered medications or if you have questions:
Call the toll-free member phone number on your ID card.
And, if home delivery services
are included in your pharmacy
Visit your plan’s member website listed on your ID card to: benefit, you can also:
• View your pharmacy benefit and coverage information, • Refill prescriptions
including prescription history • Check the status of your order
• View medication interactions and side effects • Set up reminders for refills
• Locate a participating retail pharmacy by ZIP code • Manage your account
• Look up possible lower-cost medication alternatives
• Compare medication pricing and options
7Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
Anti-Infectives: Antibiotics g Nitrofurantoin 1
g Amoxicillin 1 g Nitrofurantoin Macrocrystal 1
g Amoxicillin/Potassium Clavulanate 1 B Nuzyra 3 QL
g Antipyrine/Benzocaine Otic 1 g Ofloxacin Otic 1
g Azithromycin 1 B Oracea 3 E
g Cefaclor Suspension 2 B Otovel 3 E
g Cefaclor Tablet 1 g Paromomycin 1
g Cefadroxil 1 QL g Penicillin VK 1
g Cefdinir 1 g Pentamidine 1 QL
g Cefpodoxime 1 g Pramoxine-HC Otic 1
g Cefprozil 1 g Pyrazinamide 1
g Cefuroxime 1 g Rifampin 1
g Cephalexin 1 B Solodyn 3 E
g Chloroxylenol/Hydrocortisone/ 1 B Solosec 3 ST
Pramoxine Otic g Sulfadiazine 1
g Ciprofloxacin 1 g Sulfamethoxazole/Trimethoprim, 1
g Clarithromycin IR/ER 1 Sulfamethoxazole/Trimethoprim DS
B Cleocin Vaginal Suppository 2 g Tetracycline 1
g Clindamycin Capsule 1 B TOBI Podhaler 3 PA, QL
g Clindamycin Vaginal Cream 1 g Trimethoprim 1
B Clindesse 3 B Xenleta 3
g Dapsone Tablet 1 B Ximino 3 E, PA
g Demeclocycline 1 B Zmax 2
g Dicloxacillin 1 Anti-Infectives: Antifungals
g Doxycycline Hyclate 1 g Clotrimazole Troche 1
g Doxycycline Monohydrate Tablet 1 QL B Cresemba 3
g Erythromycin 1 g Fluconazole 1
g Erythromycin/Sulfisoxazole 1 g Griseofulvin 1
g Ethambutol 1 g Itraconazole Capsule 1 PA
B Firvanq 1 B Jublia 3 PA
g Isoniazid 1 B Kerydin 3 PA, QL
g Levofloxacin 1 g Ketoconazole Cream 1 QL
g Linezolid Tablet 1 QL g Ketoconazole Shampoo 1
g Methenamine 1 g Metronidazole Vaginal Gel 1
g Metronidazole Tablet 1 g Nystatin 1 QL
g Minocycline Capsule 1 g Terbinafine 1 QL
B Mycobutin 2 g Terconazole 1
g Neomycin 1 g Vandazole Gel 1
g Neomycin/Polymixin/ 1
Hydrocortisone Otic
See page 6, 7 for coverage details.
8Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
Anti-Infectives: Antivirals g Capecitabine 1 QL
g Acyclovir 1 B Caprelsa 2 PA, QL
g Adefovir 1 B Cometriq 2 PA
g Amantadine Capsule, Syrup 1 B Cotellic 2 PA, QL
B Baraclude 3 E, QL g Cyclophosphamide 3
g Entecavir 1 QL B Daurismo 2 PA, QL
B Epclusa 2 PA, QL B Emcyt 2
B Epivir HBV Solution 2 g Etoposide 1
g Famciclovir 1 B Erivedge 2 PA, QL
B Harvoni 2 PA, QL B Erleada 2 PA, QL
g Lamivudine 1 g Exemestane 1
B Mavyret 2 PA, QL B Farydak 2 PA, QL
B Pegasys M g Flutamide 1
B Prevymis Tablet 2 PA B Hexalen 2
g Ribavirin Tablet 1 PA g Hydroxyurea 1
g Rimantidine 1 B Ibrance 2 PA, QL
g Valacyclovir 1 QL B Idhifa 2 QL
g Valganciclovir Solution 1 g Imatinib 1 PA, QL
g Valganciclovir Tablet 1 QL B Imbruvica 2 PA, QL
B Viekira Pak 3 PA, QL B Jakafi 2 PA, QL
B Vosevi 2 PA, QL B Koselugo 2 PA, QL
B Xofluza 3 QL g Letrozole 1 PA
B Zepatier 2 PA, QL g Leucovorin Calcium 1
B Zovirax Cream 3 E B Leukeran 2
B Zovirax Ointment 3 E g Lomustine 1
Blood Disorders B Lysodren 2
B Advate M B Lonsurf 2 PA, QL
B Adynovate M B Matulane 2
B Eloctate M g Melphalan 1
B Recombinate M g Mercaptopurine 1
B Retacrit M QL B Myleran 2
Cancer B Nerlynx 2 PA, QL
g Abiraterone 250 mg 1 PA, QL B Nexavar 2 PA
B Alunbrig 2 PA, QL B Nilandrone 2
B Balversa 2 PA, QL B Ninlaro 2 PA, QL
g Bicalutamide 1 B Nubeqa 2 PA, QL
B Bosulif 2 PA, QL B Odomzo 2 PA, QL
B Cabometyx 2 PA B Piqray 2 PA, QL
B Calquence 2 PA, QL B Rydapt 2 PA, QL
See page 6, 7 for coverage details.
9Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
B Sprycel 3 PA, QL g Amiloride/Hydrochlorothiazide 1
B Stivarga 2 PA g Amlodipine 1
B Sutent 2 PA g Amlodipine/Benazepril 1 QL
B Tabloid 2 g Atenolol 1
B Targretin Capsule 2 g Atenolol/Chlorthalidone 1
B Tasigna 2 PA, QL g Benazepril 1
g Temozolomide 1 PA g Benazepril/Hydrochlorothiazide 1
g Toremifene 1 g Betaxolol 1
B Trazimera M g Bisoprolol 1
g Tretinoin Capsule 1 g Bisoprolol/Hydrochlorothiazide 1
B Verzenio 2 PA, QL g Bumetanide 1
B Vitrakvi 2 PA, QL B Bystolic 3 E
B Xtandi 3 PA, QL B Byvalson 2
B Yonsa 3 E, PA, QL g Captopril 1
B Zejula 2 PA, QL g Captopril/Hydrochlorothiazide 1
B Zelboraf 2 PA g Cartia XT 1
B Zolinza 2 AE, QL g Carvedilol 1
B Zykadia 2 PA, QL g Chlorothiazide 1
Cardiovascular/Heart Disease: Coagulation Therapy g Chlorthalidone 1
B Aggrenox 3 g Clonidine Tablet 1
B Brilinta 2 g Diltiazem Sustained-Release 1
g Clopidogrel 1 Capsule
g Disopyramide 1
g Diltiazem Tablet 1
B Eliquis 2 QL
g Doxazosin 1
g Jantoven 1
B Edarbi 3 E
B Pradaxa 2 QL
B Edarbyclor 3 ST
g Prasugrel 1 QL
g Enalapril 1
B Savaysa 3 QL
g Enalapril/Hydrochlorothiazide 1
g Ticlopidine 1 QL
g Eprosartan 1 QL
g Warfarin 1
g Ezide 1
B Xarelto 2 QL
g Felodipine 1
B Zontivity 3 QL
g Fosinopril 1
Cardiovascular/Heart Disease: High Blood Pressure
g Fosinopril/Hydrochlorothiazide 1
g Acebutolol 1
g Furosemide 1
g Acetazolamide 1
g Guanfacine 1
g Acetazolamide ER 1
g Hydralazine 1
g Afeditab CR 1
g Hydrochlorothiazide 1
B Aldactazide 25/25 mg 2
g Indapamide 1
g Amiloride 1
g Irbesartan 1 QL
See page 6, 7 for coverage details.
10Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
g Irbesartan/Hydrochlorothiazide 1 QL B Tekturna HCT 3
g Isradipine 1 g Telmisartan 2 QL
g Labetalol 1 g Telmisartan/Hydrochlorothiazide 1 QL
g Lisinopril 1 g Terazosin 1 QL
g Lisinopril/Hydrochlorothiazide 1 g Timolol 1
g Losartan 1 g Torsemide 1
g Losartan/Hydrochlorothiazide 1 g Trandolapril/Verapamil CR 1
g Methazolamide 1 g Triamterene/Hydrochlorothiazide 1
g Methyclothia 1 g Valsartan 1 QL
g Methyldopa 1 g Valsartan/Hydrochlorothiazide 1 QL
g Methyldopa/Hydrochlorothiazide 1 g Verapamil Sustained-Release 1 QL
g Metolazone 1 Capsule
g Metoprolol Succinate ER 1
g Verapamil Sustained-Release Tablet 1
g Metoprolol Tartrate 1
g Verapamil Tablet 1
g Minoxidil 1 Cardiovascular/Heart Disease: High Cholesterol
g Moexipril 1
B Antara 3 QL
g Moexipril/Hydrochlorothiazide 1
g Atorvastatin 1 H-PA, QL
g Nadolol 1
g Cholestyramine 1
g Nicardipine 1
g Choline Fenofibrate Capsule 1 E
g Nifediac CC 1
g Colestipol 1
g Nifedical XL 1
g Ezetimibe 3 QL
g Nifedipine IR/ER 1
g Ezetimibe/Simvastatin 3 QL
g Olmesartan 1
g Fenofibrate 48 mg Tablet 1 E
g Olmesartan/Hydrochlorothiazide 1
g Fenofibrate 54, 160 mg Tablet 1
g Perindopril 1
g Fenofibrate Capsule 1
g Phenoxybenzamine 1
g Fenofibrate Micronized 1
g Pindolol 1
g Fluvastatin 1 QL
g Prazosin 1
g Gemfibrozil 1
g Propranolol/Hydrochlorothiazide 1
B Lipofen 3 E
g Propranolol IR/ER 1
B Livalo 3 E, QL
g Quinapril 1
g Lovastatin 1 H-PA
g Ramipril 1
B Nexletol 2 PA, QL
g Reserpine 1
B Nexlizet 2 PA, QL
g Sotalol 1
g Niacin ER 1 QL
g Sotalol AF 1
B Niaspan 3
g Spironolactone 1
g Omega-3-Acid Ethyl Esters Capsule 1
g Spironolactone/Hydrochlorothiazide 1
B Praluent M QL
g Taztia XT 1
g Pravastatin 1
B Tekturna 3
g Prevalite 1
See page 6, 7 for coverage details.
11Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
g Rosuvastatin 1 QL g Dextroamphetamine/Amphetamine 1 QL
g Simvastatin 1 H-PA g Dextroamphetamine/Amphetamine 3 AE, E, QL
B Vascepa 3 E, PA Extended-Release
B Welchol 2
g Dextroamphetamine Sulfate 1 QL
Extended-Release
Cardiovascular/Heart Disease: Other
g Dextroamphetamine Sulfate Tablet 1 AE, QL
g Amiodarone 1
B Evekeo ODT 3 E, QL
g Anagrelide 1
g Guanfacine ER 1 AE, QL
g Cilostazol 1
B Intuniv 3 AE, E, QL
g Corlanor 3 PA, QL
B Jornay PM 3 E, QL
g Digoxin 1
g Methylphenidate Controlled-Release 1 AE, QL
B Dilatrate SR 2 Capsule
g Disopyramide 1 g Methylphenidate Tablet 1 AE, QL
B Firazyr M QL B Vyvanse 3 AE, QL
g Flecainide 1 Central Nervous System: Depression
g Isochron 1 g Amitriptyline 1
g Isoditrate ER 1 g Amoxapine 1
g Isosorbide Dinitrate IR/ER 1 g Bupropion 1
g Isosorbide Mononitrate IR/ER 1 g Bupropion SR 1 H
g Isoxsuprine 1 g Bupropion XL 1 QL
g Mexiletine 1 g Citalopram 1
g Midodrine 1 g Clomipramine 3
B Multaq 3 PA B Cymbalta 3 E, QL
B NitroBid 2 g Desipramine 1
g Nitroglycerin ER 1 g Doxepin 1
g Nitroglycerin Tablet 1 g Duloxetine 20, 30, 60 mg 1 QL
g Nitrolingual Pump Spray 1 g Escitalopram 1
g NitroTime 1 g Fluoxetine Capsule (generic Prozac) 1
B Norpace CR 2 g Fluvoxamine 1
B Pacerone 3 B Forfivo XL 3 QL
g Pentoxifylline 1 g Imipramine 1
g Propafenone 1 g Maprotiline 1
g Quinidine IR/ER 1 g Mirtazapine, Mirtazapine ODT 1
g Ranolazine 1 g Nefazodone 1
g Sotalol 1 g Nortriptyline 1
Central Nervous System: Attention Deficit Disorder g Paroxetine Tablet (generic Paxil) 1
B Adderall XR 2 AE, QL g Paroxetine ER 1 QL
g Atomoxetine 3 QL B Paxil Suspension 2
B Concerta 2 AE, QL g Phenelzine 1
g Dexmethylphenidate 1 QL g Protriptyline 1
See page 6, 7 for coverage details.
12Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
g Sertraline 1 B Kesimpta M QL
g Tranylcypromine 1 B Mavenclad 3 PA, QL
g Trazodone 1 B Tecfidera 3 E, PA, QL
B Trintellix 3 QL, ST B Zeposia 3 PA, QL
g Venlafaxine 1 Central Nervous System: Other
g Venlafaxine Extended-Release 1 g Alprazolam IR/ER 1 QL
Capsule g Aripiprazole ODT 1 QL
g Venlafaxine Extended-Release 1 QL g Aripiprazole Solution, Tablet 1 QL
Tablet
B Aristada M
B Viibryd 3 QL
g Benztropine 1
Central Nervous System: Migraine
g Bromocriptine 1
g Acetaminophen/Butalbital/Caffeine 1 QL
g Buprenorphine/Naloxone Sublingual 1 QL
B Aimovig M QL Film
B Emgality M QL g Buprenorphine/Naloxone Sublingual 2 QL
g Isometheptene/Acetaminophen/ 1 Tablet
Dichloralphenazone g Buspirone 1
g Migragesic 1 g Carbidopa/Levodopa IR/ER 1
B Migranal 3 E, PA, QL g Chlordiazepoxide 1 QL
g Naratriptan 1 QL g Chlordiazepoxide/Amitriptyline 1
g Nodolor 1 g Chlorpromazine 1
B Phrenilin Forte 3 QL g Clorazepate 1 QL
B Reyvow 2 PA, QL g Clozapine 1 QL
g Rizatriptan 1 QL g Compro Suppository 1
g Sumatriptan Nasal Spray, Tablet 1 QL g Diazepam 1
B Sumavel DosePro M g Donepezil, Donepezil ODT 1
B Ubrelvy 2 PA, QL g Entaone 1
B Zecuity 3 E, QL g Ergoloid Mesylate 1
g Zolmitriptan 1 QL g Fluphenazine 1
Central Nervous System: Multiple Sclerosis g Galantamine IR/ER 1
B Ampyra 3 PA, QL g Galantamine Solution 1 QL
B Avonex M QL g Haloperidol 1
B Bafiertam 2 PA, QL g Hydroxyzine 1
B Betaseron M QL B Invega Sustenna, Invega Trinza M
B Copaxone M QL B Kynmobi 3 E, PA, QL
g Dalfampridine 1 PA, QL B Latuda 3 QL
g Dimethyl Fumarate 1 PA, QL g Lithium IR/ER 1
B Gilenya 3 PA, QL g Lorazepam 1 QL
g Glatiramer M QL g Loxapine 1
g Glatopa M QL g Memantine Solution, Tablet 1
See page 6, 7 for coverage details.
13Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
g Meprobamate 1 g Divalproex DR 1
B Namzaric 2 QL g Epidiolex 3 PA
g Olanzapine, Olanzapine ODT 1 QL g Epitol 1
g Oxazepam 1 QL g Ethosuximide 1
g Perphenazine/Amitriptyline 1 g Gabapentin 1
g Pramipexole 1 g Lamotrigine Chewable, Tablet 1
g Prochlorperazine 1 g Lamotrigine ER 1
g Quetiapine 1 QL g Lamotrigine ODT 3
g Quetiapine Extended-Release 1 QL g Levetiracetam ER 1
B Rexulti 3 PA, QL g Levetiracetam IR 1
g Risperidone, Risperidone ODT 1 QL B Lyrica Capsule 3 PA, QL
g Rivastigmine 1 B Lyrica Solution 3 PA, QL
g Ropinirole 1 g Oxcarbazepine 1
B Saphris 3 QL g Phenobarbital 1
g Thioridazine 1 g Phenytoin 1
g Thiothixene 1 g Pregabalin Capsule 1 QL
B Tiglutik 3 PA g Topiragen 1
g Trifluoperazine 1 g Topiramate 1
g Trihexyphenidyl 1 g Valproic Acid 1
B Wakix 3 PA, QL B Vimpat Injection M
B Xyrem 3 PA, QL B Vimpat Tablet, Solution 3 PA
B Zelapar 3 QL B Xcopri 3 PA
g Ziprasidone 1 QL g Zonisamide 1
B Zubsolv 1 QL Dermatology
Central Nervous System: Sedatives/Hypnotics B Absorica 3 PA
B Dayvigo 3 QL, ST B Absorica LD 3 E, PA
g Eszopiclone 1 QL g Acitretin 1
g Flurazepam 1 PA, QL g Acyclovir 1
B Silenor 3 QL B Aczone Gel 3
g Temazepam 1 QL g Ala Quin 1
g Triazolam 1 QL g Alclometasone 1
g Zaleplon 1 QL g Alphatrex 1
g Zolpidem 1 QL g Amnesteem 1
Central Nervous System: Seizure Disorders B Amzeeq 3 PA, QL
g Carbamazepine ER Capsules 1 g Azelaic Acid 1
g Carbamazepine IR 1 B Benzaclin 3 E, QL
g Clonazepam 1 g Betamethasone 1
g Clonazepam ODT 1 QL B Bryhali 3 E, QL
g Diazepam Gel 1 QL g Calcipotriene-Betamethasone 3 QL
See page 6, 7 for coverage details.
14Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
g Calcipotriene Ointment 1 QL g Imiquimod 1 QL
g Calcitriol Ointment 1 g Ivermectin Cream, Lotion 1
g Cerovel 1 g Laclotion 1
g Ciclodan 1 g Lidocaine 1
g Ciclopirox Cream, Gel, Lotion, 1 g Lidocaine/Prilocaine 1
Solution g Lindane 1
g Claravis 1 g Lokara 1
g Clindamycin Solution 1 QL B Metrogel 1% 3 E
g Clindamycin Swabs 1 g Metronidazole 0.75% Cream, Lotion 1
g Clobetasol, Clobetasol E 1 B Mirvaso 2 QL
B Clobex Lotion, Shampoo 3 E g Mometasone Furoate 1
B Clobex Spray 3 E, QL g Mupirocin Calcium Cream 1 QL
B Cloderm 3 E g Mupirocin Ointment 1
B Cloderm Pump 3 g Myorisan 1
g Cormax 1 g Nystatin 1 QL
g Crotan 1 g Nystop 1 QL
g Dermazene 1 B Onexton 3 E, QL
g Desonide Cream, Lotion, Ointment 1 B Otezla 2 PA, QL
g Desoximetasone Cream, Gel, 1 g Permethrin 1
Ointment
B Picato 3
B DrithoScalp 2
g Podofilox 1
B Dupixent M QL
g Pramcort 1
g Econazole 3
B Pramosone Cream, Ointment 3
B Enstilar 3 QL
B Pramosone E Cream 3
g Ery Pad 1
B Pramosone Lotion 3
g Erythromycin 1
B Protopic 3 AE, QL, ST
g Erythromycin/Benzoyl Peroxide 1
B Rhofade 3 PA, QL
g Ethyl Chloride 1
g Rosadan Cream 1
B Eucrisa 3 ST
g Selenium Sulfide 1
B Eurax 2
g Silver Nitrate 1
g Exoderm 1
g Silver Sulfadiazine 1
g Fluocinolone 1
B Soolantra 2
g Fluocinonide, Fluocinonide E 1
g Sulfacetamide Sodium 1
B Fluoroplex 3
g Sulfacetamide Sodium-Sulfur 1
g Fluorouracil Solution, 5% Cream 1
B Taclonex Ointment 3 E, QL
g Fluticasone 1
B Taclonex Suspension 3 QL
g Gentamicin 1 QL
g Tacrolimus Ointment 1 AE, QL
g Hydrocortisone 1
B Tazorac 3 AE, QL
g Hypercare 1
g Tretinoin Cream 3 AE, QL
See page 6, 7 for coverage details.
15Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
g Triamcinolone Acetonide Cream, 1 QL B Insulin Aspart FlexPen 2 E, ST
Lotion, Ointment, Paste B Insulin Aspart PenFill 2 E, ST
g Triderm 1 B Insulin Aspart Protamine/Insulin 2 E, ST
g Urea 40% Lotion 1 Aspart 70/30 FlexPen
B Vectical 3 E B Insulin Aspart Protamine/Insulin 2 E, ST
g Vitazol 1 Aspart 70/30 Vial
g Zenatane 1
B Insulin Aspart Vial 2 E, ST
B Zyclara Cream, Pump 3 QL
B Lantus 1 QL
Diabetes: Blood Glucose Monitoring
B Lantus SoloSTAR 1 QL
B Accu-Chek Test Strips 3 QL
B Levemir FlexTouch, Vials 3 E, QL
B Bayer Contour Next Test Strips 2 QL
B Lyumjev KwikPen 2 QL
B Bayer Contour Test Strips 3 PA, QL
B Lyumjev Vial 1 QL
B FreeStyle Test Strips 3 PA, QL
B Novolin 70/30 FlexPen 2 E
g Insulin Pen Needles 2
B Novolin N FlexPen 2 E
B Lancing Devices (Lifescan, Roche) 1 QL
B Novolin R FlexPen 2 E
B Lancets (Lifescan, Roche) 1 QL
B Novolin Vials (all formulations) 2 E
B Lancets 2 QL
B Novolog FlexPen, Vials (all 2 E
formulations)
B Novofine Autocover Pen Needles 2
B Soliqua 2 QL
B Novofine Pen Needles 2
B Toujeo Max SoloSTAR 2 QL
B Novofine Plus Pen Needles 2
B Toujeo SoloSTAR 2 QL
B Novotwist Pen Needles 2
B Tresiba 3 E, QL
B OneTouch Lancets 1 QL
B Tresiba FlexTouch 3 E, QL
B OneTouch Test Strips 1 QL
Diabetes: Non-Insulin
Diabetes: Insulin
g Acarbose 1
B Apidra Solostar, Vials 3 E, QL, ST
B Adlyxin, Adlyxin Starter Pack 3 QL, ST
B Humalog KwikPen 2
B Baqsimi 2 QL
B Humalog Mix 50-50 KwikPen 2
B Bydureon, Bydureon Bcise 2 QL, ST
B Humalog Mix 50-50 Vial 1
B Byetta 2 QL, ST
B Humalog Mix 75-25 KwikPen 2
g Chlorpropamide 1
B Humalog Mix 75-25 Vial 1
B Farxiga 3 E, QL, ST
B Humalog U-200 KwikPen 2
g Glimepiride 1
B Humalog Vial 1
g Glipizide IR/XL 1
B Humulin 70-30 KwikPen 2
g Glipizide/Metformin 1
B Humulin 70-30 Vial 1
B Glucagen 2 QL
B Humulin KwikPen 2
B Glucagon 2 QL
B Humulin N KwikPen 2
B Glumetza 3 PA
B Humulin N Vial 1
g Glyburide 1
B Humulin R U-500 KwikPen 2 QL
g Glyburide/Metformin 1
B Humulin R U-500 Vial 1
B Glyxambi 2 QL, ST
B Humulin R Vial 1
See page 6, 7 for coverage details.
16Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
B Gvoke HypoPen 2 QL Endocrine: Growth Hormone
B Gvoke PFS 2 QL B Lupron Depot M
B Invokamet, Invokamet XR 3 E, QL, ST B Nutropin AQ, Nutropin AQ NuSpin M
B Invokana 3 E, QL, ST Endocrine: Other
B Janumet 3 E, QL, ST B Asmalpred, Asmalpred Plus 2
B Janumet XR 3 E, QL, ST g Calcitriol 1
B Januvia 3 E, QL, ST g Cortisone 1
B Jardiance 2 QL, ST g Desmopressin 1
B Jentadueto 2 QL g Dexamethasone 1
B Jentadueto XR 2 QL g Fludrocortisone 1
B Juvisync 2 QL, ST g Hydrocortisone Tablet 1
B Kazano 2 QL B Medrol 2 mg 2
B Kombiglyze XR 2 QL g Methylprednisolone 1
g Metformin 1 g Millipred Tablet 1
g Metformin Extended-Release 1 B Nocdurna 3 PA, QL
(generic Glucophage XR) g Paricalcitol 1
g Metformin Oral Solution 3 g Prednisolone Solution, Tablet 1
g Metformin Tablet (generic 1 g Prednisone 1
Glucophage)
B TaperDex 3
g Nateglinide 1 QL
Endocrine: Thyroid Hormone Replacement
B Nesina 2 QL
g Levothyroxine Sodium 1
B Onglyza 2 QL
g Levoxyl 1
B Oseni 2 QL
g Liothyronine Sodium 1
B Ozempic 2 QL, ST
g Methimazole 1
g Pioglitazone 1 QL
g Propylthiouracil 1
g Pioglitazone/Glimepiride 1 QL, ST
B Tirosint 3
g Pioglitazone/Metformin 1 QL, ST
B Tirosint-SOL 3 PA
g Repaglinide 1 QL, ST
g Unithroid 1
B Rybelsus 2 QL, ST
Eye Conditions: Allergies
B Symlin 3 PA
g Azelastine 0.05% Solution 1
B Synjardy 2 QL
g Cromolyn 1
B Synjardy XR 2 QL
g Epinastine 1 E
B Tanzeum 2
B Lastacaft 3 QL
g Tolazamide 1 ST
g Naphazoline 0.1% 1
g Tolbutamide 1 ST
B Pazeo 3 E, QL
B Tradjenta 2 QL
g Phenylephrine 1
B Trijardy XR 2 QL
Eye Conditions: Antibiotics
B Trulicity 2 QL, ST
B Azasite 3
B Victoza (2 pen pack) 2 QL, ST
g Bacitracin 1
B Victoza (3 pen pack) 3 QL, ST
See page 6, 7 for coverage details.
17Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
g Bacitracin/Polymyxin 1 g Travoprost 1 QL
B Besivance 3 B Vyzulta 3 E, QL, ST
B Ciprodex 3 B Zioptan 3 QL
g Ciprofloxacin 1 Eye Conditions: Other
g Erythromycin 1 H-PA g Atropine 1
g Gentamicin 1 QL B Blephamide SOP 3
g Ilotycin 1 g Brimonidine 1
B Moxeza 3 g Cyclopentolate 1
B Natacyn 2 g Dexamethasone 1
g Neomycin/Bacitracin/Polymyxin 1 g Diclofenac 1
g Neomycin/Polymixin/Gramicidin 1 g Fluorometholone 1
g Ofloxacin 1 g Flurbiprofen 1
g Polymyxin B/Trimethoprim 1 g Homatropine 1
g Sulfacetamide Sodium 1 B Ilevro 3 E
B Tobradex Ointment 3 B Inveltys 3
g Tobramycin/Dexamethasone 1 B Iso Carbachol 2
g Tobramycin Ophth Solution 1 E B Iso Homatropine 2
B Tobrex 3 E g Ketorolac 1
g Trifluridine 1 g Neomycin/Bacitracin/Polymyxin/ 1
Eye Conditions: Glaucoma Hydrocortisone
B Alphagan P 2 QL
g Neomycin/Polymixin/ 1
Dexamethasone
B Azopt 2 QL
B Phospholine 2
g Betaxolol 1
B Pred Mild 3
B Betimol 3 QL
g Prednisolone Solution, Tablet 1
B Betoptic-S 3
g Proparacaine 1
g Carteolol 1
B Restasis 2 PA
B Combigan 2 QL
g Sulfacetamide Sodium/ 1
B Cosopt, Cosopt PF 3 Prednisolone
g Dorzolamide 1 QL g Tetracaine 1
g Dorzolamide/Timolol 1 g Tropicamide 1
g Latanoprost 1 B Xiidra 2 PA
g Levobunolol 1 Gastrointestinal: Acid Suppression
B Lumigan 2 QL g Cimetidine 1
g Metipranolol 1 B Dexilant 2 QL
B Rhopressa 3 QL g Misoprostol 1
B Rocklatan 3 QL g Nizatidine 1
B Simbrinza 2 QL B Omeclamox-Pak 2 QL
g Timolol Maleate 1 g Omeprazole 1 QL
B Timoptic Ocudose 0.25% 2
See page 6, 7 for coverage details.
18Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
g Pantoprazole Tablet (excludes 1 QL g Mesalamine Enema 1
tablets manufactured by Camber g Mesalamine Suppository 1 QL
Pharmaceuticals)
g Metoclopramide Solution, Tablet 1
B Pylera 2 QL
B Movantik 3 E, PA, QL
g Sucralfate 1
B Moviprep 3 QL
Gastrointestinal: Nausea/Vomiting
g Pancrelipase 1
B Akynzeo 3
g Paregoric Tincture 1
B Antivert 50 mg 2
B Pentasa 3 E
g Dronabinol 1
B Plenvu 3 QL
g Ondansetron 1 QL
g Polyethylene Glycol 3350 1 H, QL
g Ondansetron ODT 1
B Prepopik 3 QL
g Promethazine 1
g Propantheline 1
g Trimethobenzamide 1
g Sevelamer (generic Renvela) 1
B Varubi 3 E, QL
B Sucraid 2
Gastrointestinal: Other
g Sulfasalazine 1
B Analpram Advanced 3
B Suprep 3 QL
B Analpram-HC Cream 3
B Symproic 2 PA, QL
B Analpram-HC Lotion 3
g Trilyte 1 QL
B Analpram-HC Shingles 3
B Uceris Foam 2
B Apriso 2
B Uceris Tablet 3
B Auryxia 3
g Ursodiol 1
g B-donna 1
B Viberzi 3 PA, QL
g Belladonna Alkaloids/Phenobarbital 1
B Zelnorm 3 PA, QL
g Budesonide Delayed-Release 1
Capsule
B Zenpep 2
g Calcium Acetate 1 HIV/AIDS
B Clenpiq 3
g Abacavir 1
B Cortifoam 2
g Abacavir/Lamivudine 1
B Creon 2
B Aptivus 2
g Dicyclomine 1
g Atazanavir Capsule 1
B Dificid 3
B Atripla 3 E
B Digex NF 2
B Biktarvy 2
B Dipentum 3
B Cimduo 2
g Diphenoxylate/Atropine 1
B Complera 2
g Gavilyte 1 H, QL
B Crixivan 2
B Halflytely 3
B Delstrigo 2
g Hyoscyamine 1
B Descovy 2
g Lactulose Solution 1
g Didanosine 1
B Lialda 2
B Dovato 2
B Linzess 2 PA, QL
B Edurant 2
See page 6, 7 for coverage details.
19Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
g Efavirenz 1 B Viread Oral Powder 2
g Emtricitabine 1 B Vitekta 2
g Emtricitabine/Tenofovir 1 H B Zerit Solution 2
B Epivir Solution 2 g Zidovudine 1
B Evotaz 2 Infertility
g Fosamprenavir 1 B Cetrotide M QL
B Genvoya 2 g Clomiphene 1
B Intelence 2 B Endometrin 2
B Invirase 2 B Gonal-F M
B Isentress 2 B Gonal-F RFF M
B Juluca 2 B Ovidrel M
B Kaletra Tablet 2 Inflammatory Conditions: Rheumatoid Arthritis, Crohn’s
g Lamivudine 1 Disease, Psoriasis, Ulcerative Colitis
g Lamivudine/Zidovudine 1
B Actemra M
g Lopinavir-Ritonavir Solution 1
B Actemra ACTPen M QL
g Nevirapine 1
B Cimzia M QL
B Norvir Capsule, Powder Packet, 2
B Cosentyx M
Solution B D-Penamine 2
B Odefsey 2 B Depen 2
B Pifeltro 2 B Enbrel M QL
B Prezcobix 2 B Humira M QL
B Prezista 2 g Hydroxychloroquine Sulfate 1
B Rescriptor 2 B Kevzara M QL
B Retrovir 2 g Leflunomide 1 QL
B Reyataz Powder Packet 2 g Methotrexate 1
g Ritonavir Tablet 1 B Olumiant 2 PA, QL
B Selzentry 2 PA B Orencia M
g Stavudine Capsule 1 B Otrexup M
B Stribild 2 g Penicillamine 1
B Symfi 2 QL B Rasuvo M QL
B Symfi Lo 2 QL B Remicade M
B Symtuza 2 B Rheumatrex 3
B Temixys 2 B Rinvoq 2 PA, QL
g Tenofovir Tablet 1 B Simponi M QL
B Tivicay 2 B Skyrizi M
B Triumeq 2 B Stelara M QL
B Trizivir 3 B Trexall 3
B Truvada 3 E B Xeljanz 2 PA, QL
B Videx Solution 2 B Xeljanz XR 2 PA, QL
B Viracept 2
See page 6, 7 for coverage details.
20Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
Medications for Sexual Dysfunction B Cetylev 3
B Imvexxy 3 QL g Chloroquine 1
B Levitra 3 PA, QL g Citric Acid/Sodium Citrate 1
B Osphena 3 PA, QL B Cystagon 2
g Sildenafil Tablet (generic Viagra) 3 PA, QL g Danazol 1
g Tadalafil (generic Cialis) 3 PA, QL g Difil-G Forte Liquid 1
B Vyleesi M QL g Disulfiram 1
Men’s Health: Prostate B Easivent 2 QL
g Alfuzosin 1 B Emverm 3 PA, QL
g Doxazosin 1 g Epinephrine Auto-injector (generic 1 QL
g Dutasteride 1 Epipen, Epipen Jr)
g Dutasteride/Tamsulosin 1
B Epipen 3 E, QL
g Finasteride 1
B Epipen Jr 3 E, QL
g Tadalafil 2.5, 5 mg 3 PA, QL
g Ergocalciferol 50,000 Unit Capsule 1
g Tamsulosin 1
B Euflexxa M
g Terazosin 1
g Exemestane 1
Men’s Health: Testosterone Therapy
B EZ Spacer 2 QL
B Androderm 2 PA, QL
B Fosrenol 3 E
B Androgel 1% 3 PA, QL
B Granix M
g Androxy 1
g Guaifenesin/Codeine 1
B Testim 3 PA, QL
B Guanidine 2
g Testosterone 1% Gel Pump 1 PA, QL
g Hydrocodone/Homatropine 1 AE, QL
g Testosterone 1.62% Gel 1 PA, QL
g Hydrocortisone/Acetic Acid Otic 1
g Testosterone 2% Gel 3 PA, QL
g Hydrocortisone Pramoxine 1
B Testred 3
g Hydrocortisone Suppository 1
Miscellaneous
B Hypersal Nebs 2
g Acetic Acid Otic 1
B Impavido 2 PA
g Acetylcysteine 1
B Inspirease 2
B Aerochamber 2 QL
B Jynarque 2 PA, QL
g Albendazole 3 PA, QL
B Krintafel 1 QL
g Anastrozole 1
g Lidocaine Viscous 1
g Antipyrine/Benzocaine 1
B Lokelma 3 E, QL
g Anucort-HC 1
g Mebendazole 1
B Aranesp M
g Mefloquine 1
B Austedo 2 PA, QL
g Megestrol AC 1
g Benzocaine Otic 1
B Mephyton 2
g Benzonatate 1
g Methylergonovine 1 QL
g Bunavail 3 PA, QL
B Mulpleta 2 PA, QL
B Cerdelga 3 PA
B Multigen Folic 2
See page 6, 7 for coverage details.
21Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
B Multigen Plus 2 B Tuzistra XR 3 AE, E, QL
g Naltrexone 1 B Velphoro 2
B Narcan Nasal Spray 2 B Veltassa 3 PA, QL
B Nessi Spacer 2 QL B Vistogard 2
B Nityr 3 E, PA g Vitamin D 50,000 Unit 1
B Nuwiq M B Vortex 2 QL
B Optihaler 2 QL B Vyndamax 2 PA, QL
B Orfadin Capsules 2 PA B Vyndaqel 2 QL
B Orfadin Suspension 2 PA B WatchHaler 2 QL
B Orkambi 2 PA, QL B Xuriden 2 PA, QL
g Phenazopyridine 1 B Yodoxin 2
g Phytonadione 3 QL B Zarxio M
g Pilocarpine 1 B Zutripro 3 AE, E, QL
g Praziquantel 1 Musculoskeletal: Osteoporosis
g Primaquine 1 B Actonel 3 E
B Procrit M g Alendronate Oral Solution 1 QL
g Proctocream HC 1 g Alendronate Tablet 1 QL
B Proctofoam HC 2 B Binosto 3 QL
g Proctosol HC 1 g Calcitonin Spray 1 QL
g Proctozone HC 1 B Forteo M
g Promethazine/Codeine 1 AE, QL B Fortical 3 QL
g Promethazine/Dextromethorphan 1 g Ibandronate 1
g Promethazine Suppository 1 B Teriparatide (Recombinant) M
g Promethazine VC/Codeine 1 AE, QL Musculoskeletal: Other
B Pulmozyme 2 PA, QL g Allopurinol 1
g Pyridostigmine 1 g Baclofen 1
B Rezira 3 g Carisoprodol 1
B Ruzurgi 2 PA, QL g Colchicine 1
g Sodium Polystyrene Sulfonate 1 B Colcrys 2
Powder g Cyclobenzaprine 5, 10 mg Tablet 1
B SSKI 2 g Dantrolene 1
B Strensiq M g Febuxostat 1 QL, ST
B Symdeko 2 PA, QL B Lorzone 3
B Symjepi 2 QL g Methocarbamol 1
B Synarel 2 g Orphenadrine/Aspirin/Caffeine 1
B Synvisc M g Orphenadrine ER 1
B Synvisc One M g Probenecid 1
g Triamcinolone/Orabase 1 g Tizanidine Tablet 1
g Trientine 3 PA
See page 6, 7 for coverage details.
22Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
Musculoskeletal: Pain Relief g Morphine Sulfate Controlled- 1 PA, QL
g Acetaminophen/Caffeine/ 3 E, QL Release Tablet
Dihydrocodeine (generic Trezix) g Morphine Sulfate Immediate- 1
g Acetaminophen/Codeine 1 Release Tablet, Solution
g Ascomp/Codeine 1
g Nabumetone 1
B Belbuca 3 PA, QL
g Naproxen Suspension 1 PA
g Butalbital/Acetaminophen 1
g Naproxen Tablet 1
g Butalbital/Acetaminophen/Caffeine 1 QL
B Nucynta 3 QL
g Butalbital/Acetaminophen/Caffeine/ 1 QL
B Nucynta ER 3 PA, QL
Codeine g Oxaprozin 1
g Butalbital/Aspirin/Caffeine Capsule 1 g Oxycodone IR 1
g Butalbital/Aspirin/Caffeine/Codeine 1 g Oxycodone/Acetaminophen 1
g Celecoxib 3 QL B Oxycontin 3 E, PA, QL
g Choline Magnesium Trisalicylate 1 g Oxymorphone 1 QL
g Codeine 1 g Pentazocine/Naloxone 1
g Diclofenac Sodium 1 g Piroxicam 1
g Diflunisal 1 B Roxybond 3 E, QL
g Duraxin 1 g Salsalate 1
g Etodolac IR/ER 1 g Sulindac 1
g Fenoprofen 3 E, QL g Tolmetin 1
g Fentanyl Lozenge 1 PA, QL g Tramadol 50 mg 1
g Fentanyl Patch 12, 25, 50, 75, 100 1 PA, QL B Trezix 3 E, QL
mcg B Voltaren Gel 3 E
B Flector Patch 3 E, QL B Xtampza ER 2 PA, QL
g Flurbiprofen 1 B Zorvolex 3 E
g Fortigan 1 Overactive Bladder
B Gralise 3 QL, ST g Bethanechol 1
g Hydrocodone/Acetaminophen 1 B Myrbetriq 3 E
(generic Norco)
g Oxybutynin 1
g Hydrocodone/Ibuprofen 1
g Oxybutynin Extended-Release 1
g Hydromorphone IR 1 QL
g Solifenacin 3
g Ibuprofen 1
B Toviaz 3
B Indocin Suppository 2 QL
Respiratory: Asthma/COPD
g Indomethacin IR/ER 1
B Advair Diskus 3 QL
g Ketorolac 1 QL
B Advair HFA 3 QL
g Levorphanol 3 QL
B Aerospan 3 QL
g Meclofenamate 1
g Albuterol Sulfate ER 1
g Meloxicam Tablet 1
g Albuterol Sulfate HFA (generic 1 QL
g Meperidine 1 ProAir HFA or Proventil HFA)
g Methadone Tablet, Oral Solution 1 PA, QL
See page 6, 7 for coverage details.
23Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
g Albuterol Sulfate HFA (generic 3 E, QL, ST B Tudorza Pressair 3 E, QL
Ventolin HFA) B Ventolin HFA 3 E, QL
g Albuterol Sulfate Nebulization 1 B Xopenex HFA 3 QL
Solution
g Zafirlukast 1
g Albuterol Sulfate Syrup 1
Respiratory: Nasal Allergies
g Albuterol Sulfate Tablet 3 PA
g Azelastine-Fluticasone Propionate 1 E, QL
g Aminophylline 1 Spray
B Arnuity Ellipta 1 QL B Dymista Spray 3 E, QL
B Asmanex HFA 3 E, QL g Flunisolide 1 QL
B Asmanex Twisthaler 3 E, QL g Fluticasone Propionate 1 QL
B Atrovent HFA 3 QL g Ipratropium 1
B Bevespi Aerosphere 2 QL B Omnaris 3 E, QL
B Breo Ellipta 3 QL B QNasl 3 QL
g Budesonide Nebs 1 QL B Veramyst 3 E, QL
B Combivent Respimat 2 QL B Zetonna 3 E, QL
g Cromolyn Nebs 1 Respiratory: Oral Allergies
B Fasenra Pen M QL g Carbinoxamine Solution, 4 mg 1
B Flovent Diskus 1 QL Tablet
B Flovent HFA 1 QL g Clemastine 1
g Fluticasone/Salmeterol 55-14 mcg/ 2 QL g Cyproheptadine 1
act, 113-14 mcg/act, 232-14 mcg/act g Hydroxyzine 1
B Incruse Ellipta 3 E, QL g Levocetirizine 1
g Ipratropium 1 g Promethazine 1
g Ipratropium/Albuterol Nebs 1 Respiratory: Pulmonary Arterial Hypertension
B Lonhala Magnair 3 E, PA, QL g Ambrisentan 1 PA, QL
g Montelukast 1 QL B Adempas 2 PA, QL
B Perforomist 3 QL g Bosentan 1 PA, QL
B Proair HFA 3 E, QL B Opsumit 2 PA, QL
B Proair RespiClick 3 E, QL B Orenitram 3 PA, QL
B Pulmicort 3 E, QL g Sildenafil Tablet 20 mg (generic 1 QL
B Pulmicort Flexhaler 1 QL Revatio)
B QVAR RediHaler 3 E Smoking Cessation
B Serevent Diskus 2 QL g Bupropion Sustained-Release 1 H
B Spiriva HandiHaler, Respimat 2 QL Tablet
B Striverdi Respimat 2 QL
B Chantix Tablet 3 H
B Symbicort 3 QL
B Nicoderm CQ 3 H
g Terbutaline 1
B Nicorette Gum 3 H
g Theophylline SR 1
B Nicorette Lozenge 3 H
B Trelegy Ellipta 2 QL
B Nicorette Mini-Lozenge 3 H
See page 6, 7 for coverage details.
24Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
g Nicotine Gum 1 H g Camila 1 H
g Nicotine Lozenge 1 H B Caya 1 H
g Nicotine Patch 1 H g Caziant 1 H
B Nicotrol Inhaler 3 H g Chateal 1 H
B Nicotrol Nasal Spray 3 H g Chateal EQ 1 H
g Thrive Gum 1 H g Cryselle 1 H
Transplant g Cyclafem 1 H
g Azathioprine 1 g Cyred 1 H
g Cyclosporine, Cyclosporine 1 g Dasetta 1 H
Modified g Deblitane 1 H
g Gengraf 1 g Delyla 1 H
g Tacrolimus 1 B Depo-SubQ Provera 104 2 H, QL
Vitamins/Electrolytes g Desogestrel/Ethinyl Estradiol 1 H
g Fluoride Chewable Tablet, Drops 1 H g Drospirenone/Ethinyl Estradiol 1 H
g Folic Acid 1 mg 1 g Drospirenone/Ethinyl Estradiol/ 3 H
g Klor-Con 10 1 Levomefolate
g Klor-Con M10 1 g EContra EZ 1 H
g Klor-Con M20 1 g EContra One-Step 1 H
g Potassium Chloride 1 g Elinest 1 H
g Potassium Citrate 1 g Ella 1 H, QL
Women’s Health: Contraceptives g Emoquette 1 H
g Afirmelle 1 H g Enpresse 1 H
g Aftera 1 H g Enskyce 1 H
g Altavera 1 H g Errin 1 H
g Alyacen 1 H g Estarylla 1 H
g Apri 1 H g Ethynodiol Diacetate/Ethinyl 1 H
g Aranelle 1 H Estradiol
g Aubra 1 H
g Falmina 1 H
g Aubra EQ 1 H
g Femynor 1 H
g Aurovela 1 H
g Gianvi 1 H
g Aurovela FE 1 H
g Gildagia 1 H
g Aviane 1 H
g Hailey 1 H
g Ayuna 1 H
g Hailey Fe 1 H
g Azurette 1 H
g Heather 1 H
B Balcoltra 3 H
g Implanon 1 H
g Balziva 1 H
g Incassia 1 H
g Bekyree 1 H
g Introvale 1 H
g Blisovi FE 1 H
g Isibloom 1 H
g Briellyn 1 H
g Jasmiel 1 H
See page 6, 7 for coverage details.
25Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
g Jencycla 1 H g Necon 0.5/35, 1/50, 10/11 1 H
g Jolessa 1 H g New Day 1 H
g Juleber 1 H g Next Choice One Dose 1 H
g Junel 1 H g Nikki 1 H
g Junel Fe 1 H g Nora-BE 1 H
g Kalliga 1 H g Norethindrone 1 H
g Kariva 1 H g Norethindrone/Ethinyl Estradiol 1 H
g Kelnor 1/35, 1/50 1 H g Norgestimate/Ethinyl Estradiol 1 H
g Kimidess 1 H g Norethindrone/Ethinyl Estradiol/ 1 H
g Kurvelo 1 H Ferrous Fumarate
g Larin, Larin FE 1 H
g Norgestrel/Ethinyl Estradiol 1 H
g Larissia 1 H
g Norlyda 1 H
g Leena 1 H
g Norlyroc 1 H
g Lessina 1 H
g Nortrel 1 H
g Levonest 1 H
B Nuvaring 1 H
g Levonorgestrel 1 H, QL
g Ocella 1 H
g Levonorgestrel/Ethinyl Estradiol 1 H
g Ogestrel 1
g Levonorgestrel/Ethinyl Estradiol 3 H
g Opcicon One-Step 1 H
(generic Quartette) g Option 2 1 H
g Levora-28 1 H g Orsythia 1 H
g Lillow 1 H g Philith 1 H
B Lo Loestrin 3 H g Pimtrea 1 H
g Lo-Zumandimine 1 H B Plan B One Step 1 H
B Loestrin 2 g Portia 1 H
g Loryna 1 H g Previfem 1 H
g Low-Ogestrel 1 H g Primella 1 H
g Lutera 1 H g React 1 H
g Lyza 1 H g Reclipsen 1 H
g Marlissa 1 H g Setlakin 1 H
g Medroxyprogesterone Acetate 1 H, QL g Sharobel 1 H
Injection g Simliya 1 H
g Melodetta 24 FE 3 H B Slynd 3 H, PA
g Mibelas 24 FE 3 H g Sprintec 1 H
g Microgestin 1 H g Sronyx 1 H
g Microgestin FE 1 H g Syeda 1 H
g Mili 1 H g Take Action 1 H
g Mono-Linyah 1 H g Tarina FE 1 H
g My Choice 1 H g Tri Femynor 1 H
g My Way 1 H g Tri-Estarylla 1 H
B Natazia 2 H
See page 6, 7 for coverage details.
26Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
g Tri-Linyah 1 H g Estradiol Weekly Patch 1 QL
g Tri-Mili 1 H g Estrogen/Methyltestosterone, 1 QL
g Tri-Previfem 1 H Estrogen/Methyltestosterone HS
g Tri-Sprintec 1 H
g Estropipate 1
g Tri-Vylibra 1 H
B Evamist 3
g Trinessa 1 H
g Fyavolv 1
g Trinessa Lo 3 H
B Intrarosa 3
g Trivora-28 1 H
g Jinteli 1
g Tulana 1 H
g Lopreeza 1
g Tydemy 3 H
B Makena M
g Velivet 1 H
g Medroxyprogesterone 1
g Vestura 1 H
B Menest 2
g Vienva 1 H
g Mimvey 1
g Viorele 1 H
B Minivelle 3 E, QL
g Vyfemla 1 H
g Norethindrone 1
g Vylibra 1 H
g Norethindrone/Ethinyl Estradiol 1
g Wera 1 H
B Premarin 2
B Wide-Seal 1 H
B Premarin Vaginal Cream 2
g Xulane 1 H
B Premphase 2
B Yasmin 28 3 E, H
B Prempro 2
B Yaz 3 E, H
B Vivelle-Dot 2 QL
g Zarah 1 H
g Yuvafem 1
g Zovia 1 H Women’s Health: Miscellaneous
g Zumandimine 1 H
B Oriahnn 3 PA, QL
Women’s Health: Hormone Replacement
g Raloxifene 1 H-PA, QL
g Amabelz 1
g Tamoxifen 1 H-PA
B Bijuva 3 Women’s Health: Prenatal Vitamins
B Cenestin 3 QL
B Brand Prenatal Vitamins/Folic 2
Acid 1 mg
B Climara Pro 2 QL
g Generic Prenatal Vitamins/Folic 1
g Covaryx, Covaryx HS 1 QL Acid 1 mg
B Divigel 3
B Duavee 2 QL
B Elestrin 3
B Enjuvia 3
g Estradiol Tablet 1
g Estradiol Twice Weekly Patch 1 QL
(generic Minivelle)
g Estradiol Twice Weekly Patch 3 E, QL
(generic Vivelle-Dot)
See page 6, 7 for coverage details.
27Index
A Albuterol Sulfate Nebulization Anucort-HC . . . . . . . . . . . . . . . . . . . . 21
Solution . . . . . . . . . . . . . . . . . . . . . . . 24 Apidra Solostar, Vials . . . . . . . . . . . . 16
Abacavir . . . . . . . . . . . . . . . . . . . . . . . 19
Albuterol Sulfate Syrup . . . . . . . . . . . 24 Apri . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Abacavir/Lamivudine . . . . . . . . . . . . 19
Albuterol Sulfate Tablet. . . . . . . . . . . 24 Apriso . . . . . . . . . . . . . . . . . . . . . . . . . 19
Abiraterone 250 mg . . . . . . . . . . . . . . 9
Alclometasone . . . . . . . . . . . . . . . . . . 14 Aptivus . . . . . . . . . . . . . . . . . . . . . . . . 19
Absorica . . . . . . . . . . . . . . . . . . . . . . . 14
Aldactazide 25/25 mg . . . . . . . . . . . . 10 Aranelle . . . . . . . . . . . . . . . . . . . . . . . 25
Absorica LD . . . . . . . . . . . . . . . . . . . . 14
Alendronate Oral Solution . . . . . . . . 22 Aranesp . . . . . . . . . . . . . . . . . . . . . . . 21
Acarbose . . . . . . . . . . . . . . . . . . . . . . 16
Alendronate Tablet . . . . . . . . . . . . . . 22 Aripiprazole ODT . . . . . . . . . . . . . . . . 13
Accu-Chek Test Strips . . . . . . . . . . . 16
Alfuzosin . . . . . . . . . . . . . . . . . . . . . . . 21 Aripiprazole Solution, Tablet . . . . . . 13
Acebutolol . . . . . . . . . . . . . . . . . . . . . 10
Allopurinol . . . . . . . . . . . . . . . . . . . . . 22 Aristada . . . . . . . . . . . . . . . . . . . . . . . 13
Acetaminophen/Butalbital/
Caffeine . . . . . . . . . . . . . . . . . . . . . . . 13 Alphagan P . . . . . . . . . . . . . . . . . . . . . 18 Arnuity Ellipta . . . . . . . . . . . . . . . . . . . 24
Acetaminophen/Caffeine/ Alphatrex . . . . . . . . . . . . . . . . . . . . . . 14 Ascomp/Codeine . . . . . . . . . . . . . . . 23
Dihydrocodeine . . . . . . . . . . . . . . . . . 23 Alprazolam IR/ER . . . . . . . . . . . . . . . 13 Asmalpred, Asmalpred Plus . . . . . . . 17
Acetaminophen/Codeine . . . . . . . . . 23 Altavera. . . . . . . . . . . . . . . . . . . . . . . . 25 Asmanex HFA . . . . . . . . . . . . . . . . . . 24
Acetazolamide . . . . . . . . . . . . . . . . . . 10 Alunbrig . . . . . . . . . . . . . . . . . . . . . . . . 9 Asmanex Twisthaler . . . . . . . . . . . . . 24
Acetazolamide ER . . . . . . . . . . . . . . . 10 Alyacen . . . . . . . . . . . . . . . . . . . . . . . . 25 Atazanavir Capsule . . . . . . . . . . . . . . 19
Acetic Acid Otic . . . . . . . . . . . . . . . . . 21 Amabelz . . . . . . . . . . . . . . . . . . . . . . . 27 Atenolol . . . . . . . . . . . . . . . . . . . . . . . 10
Acetylcysteine . . . . . . . . . . . . . . . . . . 21 Amantadine Capsule, Syrup. . . . . . . . 9 Atenolol/Chlorthalidone . . . . . . . . . . 10
Acitretin . . . . . . . . . . . . . . . . . . . . . . . 14 Ambrisentan. . . . . . . . . . . . . . . . . . . . 24 Atomoxetine . . . . . . . . . . . . . . . . . . . . 12
Actemra . . . . . . . . . . . . . . . . . . . . . . . 20 Amiloride . . . . . . . . . . . . . . . . . . . . . . 10 Atorvastatin . . . . . . . . . . . . . . . . . . . . 11
Actemra ACTPen . . . . . . . . . . . . . . . . 20 Amiloride/Hydrochlorothiazide . . . . 10 Atripla . . . . . . . . . . . . . . . . . . . . . . . . . 19
Actonel . . . . . . . . . . . . . . . . . . . . . . . . 22 Aminophylline . . . . . . . . . . . . . . . . . . 24 Atropine . . . . . . . . . . . . . . . . . . . . 18, 19
Acyclovir . . . . . . . . . . . . . . . . . . . . . 9, 14 Amiodarone . . . . . . . . . . . . . . . . . . . . 12 Atrovent HFA . . . . . . . . . . . . . . . . . . . 24
Aczone Gel . . . . . . . . . . . . . . . . . . . . . 14 Amitriptyline . . . . . . . . . . . . . . . . . . 12-14 Aubra . . . . . . . . . . . . . . . . . . . . . . . . . 25
Adderall XR . . . . . . . . . . . . . . . . . . . . 12 Amlodipine . . . . . . . . . . . . . . . . . . . . . 10 Aubra EQ . . . . . . . . . . . . . . . . . . . . . . 25
Adefovir . . . . . . . . . . . . . . . . . . . . . . . . 9 Amlodipine/Benazepril . . . . . . . . . . . 10 Aurovela . . . . . . . . . . . . . . . . . . . . . . . 25
Adempas . . . . . . . . . . . . . . . . . . . . . . 24 Amnesteem . . . . . . . . . . . . . . . . . . . . 14 Aurovela FE . . . . . . . . . . . . . . . . . . . . 25
Adlyxin, Adlyxin Starter Pack . . . . . . 16 Amoxapine . . . . . . . . . . . . . . . . . . . . . 12 Auryxia . . . . . . . . . . . . . . . . . . . . . . . . 19
Advair Diskus . . . . . . . . . . . . . . . . . . . 23 Amoxicillin . . . . . . . . . . . . . . . . . . . . . . 8 Austedo . . . . . . . . . . . . . . . . . . . . . . . 21
Advair HFA . . . . . . . . . . . . . . . . . . . . . 23 Amoxicillin/Potassium Clavulanate . . 8 Aviane . . . . . . . . . . . . . . . . . . . . . . . . . 25
Advate . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Ampyra . . . . . . . . . . . . . . . . . . . . . . . . 13 Avonex . . . . . . . . . . . . . . . . . . . . . . . . 13
Adynovate . . . . . . . . . . . . . . . . . . . . . . 9 Amzeeq . . . . . . . . . . . . . . . . . . . . . . . 14 Ayuna . . . . . . . . . . . . . . . . . . . . . . . . . 25
Aerochamber . . . . . . . . . . . . . . . . . . . 21 Anagrelide . . . . . . . . . . . . . . . . . . . . . 12 Azasite . . . . . . . . . . . . . . . . . . . . . . . . 17
Aerospan . . . . . . . . . . . . . . . . . . . . . . 23 Analpram Advanced . . . . . . . . . . . . . 19 Azathioprine . . . . . . . . . . . . . . . . . . . . 25
Afeditab CR . . . . . . . . . . . . . . . . . . . . 10 Analpram-HC Cream . . . . . . . . . . . . . 19 Azelaic Acid . . . . . . . . . . . . . . . . . . . . 14
Afirmelle . . . . . . . . . . . . . . . . . . . . . . . 25 Analpram-HC Lotion . . . . . . . . . . . . . 19 Azelastine 0.05% Solution . . . . . . . . 17
Aftera . . . . . . . . . . . . . . . . . . . . . . . . . 25 Analpram-HC Shingles . . . . . . . . . . . 19 Azelastine-Fluticasone Propionate
Aggrenox . . . . . . . . . . . . . . . . . . . . . . 10 Anastrozole . . . . . . . . . . . . . . . . . . . . 21 Spray. . . . . . . . . . . . . . . . . . . . . . . . . . 24
Aimovig . . . . . . . . . . . . . . . . . . . . . . . . 13 Androderm . . . . . . . . . . . . . . . . . . . . . 21 Azithromycin . . . . . . . . . . . . . . . . . . . . 8
Akynzeo . . . . . . . . . . . . . . . . . . . . . . . 19 Androgel 1%. . . . . . . . . . . . . . . . . . . . 21 Azopt . . . . . . . . . . . . . . . . . . . . . . . . . 18
Ala Quin . . . . . . . . . . . . . . . . . . . . . . . 14 Androxy . . . . . . . . . . . . . . . . . . . . . . . 21 Azurette . . . . . . . . . . . . . . . . . . . . . . . 25
Albendazole . . . . . . . . . . . . . . . . . . . . 21 Antara . . . . . . . . . . . . . . . . . . . . . . . . . 11
B
Albuterol Sulfate ER . . . . . . . . . . . . . 23 Antipyrine/Benzocaine . . . . . . . . . 8, 21
Albuterol Sulfate HFA . . . . . . . . . 23, 24 Antipyrine/Benzocaine Otic . . . . . . . . 8 B-donna . . . . . . . . . . . . . . . . . . . . . . . 19
Antivert 50 mg . . . . . . . . . . . . . . . . . . 19 Bacitracin . . . . . . . . . . . . . . . . . . . 17, 18
28Bacitracin/Polymyxin . . . . . . . . . . . . 18 Budesonide Delayed-Release Carteolol . . . . . . . . . . . . . . . . . . . . . . . 18
Baclofen . . . . . . . . . . . . . . . . . . . . . . . 22 Capsule . . . . . . . . . . . . . . . . . . . . . . . 19 Cartia XT . . . . . . . . . . . . . . . . . . . . . . 10
Bafiertam . . . . . . . . . . . . . . . . . . . . . . 13 Budesonide Nebs . . . . . . . . . . . . . . . 24 Carvedilol . . . . . . . . . . . . . . . . . . . . . . 10
Balcoltra . . . . . . . . . . . . . . . . . . . . . . . 25 Bumetanide . . . . . . . . . . . . . . . . . . . . 10 Caya . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Balversa . . . . . . . . . . . . . . . . . . . . . . . . 9 Bunavail . . . . . . . . . . . . . . . . . . . . . . . 21 Caziant . . . . . . . . . . . . . . . . . . . . . . . . 25
Balziva . . . . . . . . . . . . . . . . . . . . . . . . 25 Buprenorphine/Naloxone Cefaclor Suspension . . . . . . . . . . . . . . 8
Sublingual Film . . . . . . . . . . . . . . . . . 13
Baqsimi. . . . . . . . . . . . . . . . . . . . . . . . 16 Cefaclor Tablet. . . . . . . . . . . . . . . . . . . 8
Buprenorphine/Naloxone
Baraclude . . . . . . . . . . . . . . . . . . . . . . . 9 Sublingual Tablet . . . . . . . . . . . . . . . . 13 Cefadroxil . . . . . . . . . . . . . . . . . . . . . . . 8
Bayer Contour Next Test Strips . . . . 16 Bupropion . . . . . . . . . . . . . . . . . . 12, 24 Cefdinir . . . . . . . . . . . . . . . . . . . . . . . . . 8
Bayer Contour Test Strips. . . . . . . . . 16 Bupropion SR . . . . . . . . . . . . . . . . . . 12 Cefpodoxime . . . . . . . . . . . . . . . . . . . . 8
Bekyree . . . . . . . . . . . . . . . . . . . . . . . 25 Bupropion Sustained-Release Cefprozil . . . . . . . . . . . . . . . . . . . . . . . . 8
Belbuca . . . . . . . . . . . . . . . . . . . . . . . 23 Tablet . . . . . . . . . . . . . . . . . . . . . . . . . 24 Cefuroxime . . . . . . . . . . . . . . . . . . . . . . 8
Belladonna Alkaloids/ Bupropion XL . . . . . . . . . . . . . . . . . . . 12 Celecoxib . . . . . . . . . . . . . . . . . . . . . . 23
Phenobarbital . . . . . . . . . . . . . . . . . . 19 Buspirone . . . . . . . . . . . . . . . . . . . . . . 13 Cenestin . . . . . . . . . . . . . . . . . . . . . . . 27
Benazepril . . . . . . . . . . . . . . . . . . . . . 10 Butalbital/Acetaminophen . . . . . . . . 23 Cephalexin . . . . . . . . . . . . . . . . . . . . . . 8
Benazepril/Hydrochlorothiazide . . . 10 Butalbital/Acetaminophen/ Cerdelga . . . . . . . . . . . . . . . . . . . . . . . 21
Benzaclin . . . . . . . . . . . . . . . . . . . . . . 14 Caffeine . . . . . . . . . . . . . . . . . . . . . . . 23 Cerovel . . . . . . . . . . . . . . . . . . . . . . . . 15
Benzocaine Otic . . . . . . . . . . . . . . 8, 21 Butalbital/Acetaminophen/ Cetrotide. . . . . . . . . . . . . . . . . . . . . . . 20
Benzonatate . . . . . . . . . . . . . . . . . . . . 21 Caffeine/Codeine . . . . . . . . . . . . . . . 23
Cetylev . . . . . . . . . . . . . . . . . . . . . . . . 21
Benztropine . . . . . . . . . . . . . . . . . . . . 13 Butalbital/Aspirin/Caffeine
Chantix Tablet . . . . . . . . . . . . . . . . . . 24
Capsule . . . . . . . . . . . . . . . . . . . . . . . 23
Besivance . . . . . . . . . . . . . . . . . . . . . . 18 Chateal . . . . . . . . . . . . . . . . . . . . . . . . 25
Butalbital/Aspirin/Caffeine/
Betamethasone . . . . . . . . . . . . . . . . . 14 Chateal EQ . . . . . . . . . . . . . . . . . . . . . 25
Codeine . . . . . . . . . . . . . . . . . . . . . . . 23
Betaseron . . . . . . . . . . . . . . . . . . . . . . 13 Chlordiazepoxide . . . . . . . . . . . . . . . 13
Bydureon, Bydureon Bcise. . . . . . . . 16
Betaxolol . . . . . . . . . . . . . . . . . . . 10, 18 Chlordiazepoxide/Amitriptyline . . . . 13
Byetta . . . . . . . . . . . . . . . . . . . . . . . . . 16
Bethanechol . . . . . . . . . . . . . . . . . . . . 23 Chloroquine . . . . . . . . . . . . . . . . . . . . 21
Bystolic . . . . . . . . . . . . . . . . . . . . . . . . 10
Betimol . . . . . . . . . . . . . . . . . . . . . . . . 18 Chlorothiazide . . . . . . . . . . . . . . . . . . 10
Byvalson . . . . . . . . . . . . . . . . . . . . . . . 10
Betoptic-S . . . . . . . . . . . . . . . . . . . . . 18 Chloroxylenol/Hydrocortisone/
Bevespi Aerosphere . . . . . . . . . . . . . 24 C Pramoxine Otic . . . . . . . . . . . . . . . . . . 8
Bicalutamide . . . . . . . . . . . . . . . . . . . . 9 Cabometyx . . . . . . . . . . . . . . . . . . . . . . 9 Chlorpromazine . . . . . . . . . . . . . . . . . 13
Bijuva . . . . . . . . . . . . . . . . . . . . . . . . . 27 Calcipotriene Ointment . . . . . . . . . . . 15 Chlorpropamide. . . . . . . . . . . . . . . . . 16
Biktarvy . . . . . . . . . . . . . . . . . . . . . . . 19 Calcipotriene-Betamethasone . . . . . 14 Chlorthalidone . . . . . . . . . . . . . . . . . . 10
Binosto . . . . . . . . . . . . . . . . . . . . . . . . 22 Calcitonin Spray . . . . . . . . . . . . . . . . 22 Cholestyramine . . . . . . . . . . . . . . . . . 11
Bisoprolol . . . . . . . . . . . . . . . . . . . . . . 10 Calcitriol . . . . . . . . . . . . . . . . . . . . 15, 17 Choline Fenofibrate Capsule . . . . . . 11
Bisoprolol/Hydrochlorothiazide . . . . 10 Calcitriol Ointment. . . . . . . . . . . . . . . 15 Choline Magnesium Trisalicylate . . . 23
Blephamide SOP . . . . . . . . . . . . . . . . 18 Calcium Acetate . . . . . . . . . . . . . . . . 19 Cialis . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Blisovi FE . . . . . . . . . . . . . . . . . . . . . . 25 Calquence . . . . . . . . . . . . . . . . . . . . . . 9 Ciclodan . . . . . . . . . . . . . . . . . . . . . . . 15
Bosentan . . . . . . . . . . . . . . . . . . . . . . 24 Camila. . . . . . . . . . . . . . . . . . . . . . . . . 25 Ciclopirox Cream, Gel, Lotion,
Bosulif . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Capecitabine . . . . . . . . . . . . . . . . . . . . 9 Solution . . . . . . . . . . . . . . . . . . . . . . . 15
Brand Prenatal Vitamins/Folic Acid Caprelsa . . . . . . . . . . . . . . . . . . . . . . . . 9 Cilostazol . . . . . . . . . . . . . . . . . . . . . . 12
1 mg . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Captopril . . . . . . . . . . . . . . . . . . . . . . . 10 Cimduo . . . . . . . . . . . . . . . . . . . . . . . . 19
Breo Ellipta . . . . . . . . . . . . . . . . . . . . . 24 Captopril/Hydrochlorothiazide. . . . . 10 Cimetidine . . . . . . . . . . . . . . . . . . . . . 18
Briellyn . . . . . . . . . . . . . . . . . . . . . . . . 25 Carbamazepine ER Capsules . . . . . 14 Cimzia . . . . . . . . . . . . . . . . . . . . . . . . . 20
Brilinta. . . . . . . . . . . . . . . . . . . . . . . . . 10 Carbamazepine IR. . . . . . . . . . . . . . . 14 Ciprodex . . . . . . . . . . . . . . . . . . . . . . . 18
Brimonidine . . . . . . . . . . . . . . . . . . . . 18 Carbidopa/Levodopa IR/ER . . . . . . 13 Ciprofloxacin . . . . . . . . . . . . . . . . . 8, 18
Bromocriptine . . . . . . . . . . . . . . . . . . 13 Carbinoxamine Solution, Citalopram . . . . . . . . . . . . . . . . . . . . . 12
Bryhali. . . . . . . . . . . . . . . . . . . . . . . . . 14 4 mg Tablet . . . . . . . . . . . . . . . . . . . . 24 Citric Acid/Sodium Citrate . . . . . . . . 21
Carisoprodol . . . . . . . . . . . . . . . . . . . 22 Claravis . . . . . . . . . . . . . . . . . . . . . . . . 15
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