Your 2021 Prescription Drug List - Serve You Rx Select Formulary
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Your 2021
Prescription
Drug List
Serve You Rx
Select Formulary
Please read:
This document contains information
about the drugs covered under your
pharmacy benefit plan.
If you have questions:
Call customer service at
800-759-3203.
Visit serveyourx.com
• Locate a participating retail
pharmacy by ZIP code
• Perform drug cost comparisons
• Search the drug database for
generics, brand-names, generic
equivalents and other drug
information
• View quality and safety information
about prescription alternatives
Effective July 1, 2021Your Prescription Drug List (PDL)
The Prescription Drug List, or formulary, is a listing of the most commonly prescribed medications sorted by
therapeutic category. The PDL identifies the drugs available for certain conditions and organizes them into cost
levels, also known as tiers. It is intended to be used as a guide to help you and your doctor choose the best
course of treatment for you. Drug designation by category is for reference only and not clinical comparison.
The PDL is not intended to be a substitute for the clinical knowledge and judgement of the medical practitioner
in their choice of drug therapy. In all cases, the prescriber is expected to select appropriate drug therapy for the
individual patient and provide high-quality healthcare.
Please note:
• Where differences are noted between this PDL and your benefit plan documents, the benefit plan
documents will rule.
• This document is not intended to be a complete list of medications, and not all medications listed may be
covered under your plan. Please look at your benefit plan documents provided by your employer or plan
sponsor to see what medications are covered under your plan.
• You may also log on to serveyourx.com or call customer service at 800-759-3203 for more information.
At Serve You Rx, we are committed to helping you better understand
your medication options.
Your pharmacy benefit offers flexibility and choice in determining the right medication for you. To help you get
the most out of your pharmacy benefit, we’ve included some of the most commonly asked questions about the
PDL.
How do I use my Prescription Drug List?
Bring this PDL with you when you see your doctor. You and your doctor should consult it when choosing a
medication. It is organized by common medical conditions. Medications are then listed alphabetically and
identified as generic or brand, and if special rules apply. If your medication is not listed in this document,
please visit serveyourx.com or call customer service at 800-759-3203.
2What are tiers?
Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, which is determined by
your employer or plan sponsor. Tier 1 medications are your lowest-cost options. If your medication is placed in
Tier 2 or 3, look to see if there is a Tier 1 option available. Discuss these options with your doctor.
Check your benefit plan documents to find out your specific pharmacy plan costs.
$ DRUG TIER INCLUDES HELPFUL TIPS
Tier 1 Lower-cost, commonly Use Tier 1 drugs for the lowest
Lowest Cost used generic drugs out-of-pocket costs.
Tier 2 Many common brand- Use Tier 2 drugs, instead of Tier 3, to
Mid-Range name drugs, called help reduce your out-of-pocket costs.
Cost preferred brands
Tier 3 Mostly higher-cost brand Many Tier 3 drugs have lower-cost
Highest Cost drugs, also known as options in Tier 1 or 2. Ask your doctor
non-preferred brands if they could work for you.
Please note: Plans may have different tiers (4, none, etc.). If your plan has a Tier 4, specialty drugs are
included in this tier. If you have a high deductible plan, the tier cost levels may apply once you hit your
deductible. Refer to your enrollment and plan documents or call customer service at 800-759-3203 for more
information about your benefit plan.
When does the Prescription Drug List change?
• Medications may move to a lower tier at any time.
• Medications may move to a higher tier when its generic becomes available.
• Medications may move to a higher tier or be excluded from coverage on January 1 or July 1 of each year.
When a medication changes tiers, you may have to pay a different amount for that medication.
3Programs and Limits
Some medications are noted with letters or symbols next to them. The letters and symbols refer to pharmacy
benefit programs and are provided to help you check which medications may have a program or limit. Your
benefit plan determines how these medications may be covered for you.
Prior Authorization — Your doctor is required to provide additional information to
PA
determine coverage.
Step Therapy — Trial of lower cost medication(s) is required before a higher cost
ST medication is covered, based on continually updated, evidenced-based research and
widely accepted medical practices.
Quantity Limits — Amount of medication covered per copayment or in a specific time
QL period. For selected medications, may include conversion from twice-daily dosing to
one-time-daily dosing.
SP Specialty Medication — Medication is designated as a specialty pharmacy drug.
Excluded — May be excluded from coverage or subject to prior authorization. Lower-
E cost options are available and covered. Authorized Brand Alternatives (ABAs) are
excluded.
To learn more about a Serve You Rx Clinical Pharmacy Program, or to find out if it applies
to you, please visit serveyourx.com or call customer service at 800-759-3203.
4What is the difference between brand-name and generic medications?
Generic medications contain the same active ingredients (what makes the medication work) as brand-name
medications, but they often cost less. Once the patent of a brand-name medication ends, the FDA can approve
a generic version with the same active ingredients. These types of medications are known as generic
medications. Sometimes the same company that makes a brand-name medication also makes the generic
version.
Is it a generic or brand-name drug?
The drug list shows brand-name drugs in bold type (for example, Crestor) and generic drugs in plain type (for
example, rosuvastatin).
What if my doctor writes a brand-name prescription?
The next time your doctor gives you a prescription for a brand-name medication, ask if a generic equivalent or
lower-cost option is available and if it might be right for you. Generic medications are usually your lowest-cost
option, but not always. Visit the drug cost comparison tool in the Member Portal at serveyourx.com to be
sure.
Are you taking a specialty medication?
Specialty medications treat rare or complex conditions and are typically higher cost medications. Specialty
drugs have the following characteristics:
• Treat complex and often costly medical conditions such as cancer, rheumatoid arthritis, multiple sclerosis,
hepatitis C, and pulmonary hypertension
• Are often injected or infused (IV) medicines, but may also be taken orally
• Require close monitoring of response to drug therapy
• May require individualized dosing, medical devices to administer the medicine, and/or special handling and
delivery
• Require additional education for safe and cost-effective use
Please note, not all specialty medications are listed in the PDL.
Serve You DirectRxSM Specialty Pharmacy stocks most specialty medications and is committed to helping
patients navigate the complexity of specialty drug therapy with helpful programs, services, and enhanced
patient care. Call customer service at 800-759-3203 and have your prescriptions delivered right to your home
or office.
5Should I talk to my doctor about OTC medications?
An over-the-counter (OTC, no prescription required) medication may be the right treatment option for some
conditions. Talk to your doctor about available OTC options. Even though these medications may not be
covered under your pharmacy benefit, they may cost less than your out-of-pocket expense for prescription
medications.
How do I get updated information about my pharmacy benefit?
Since the PDL may change during your plan year, we encourage you to visit serveyourx.com or call customer
service at 800-759-3203 for more current information.
When you register at serveyourx.com, you can use the website’s helpful tools and features to:
• Perform drug cost comparisons;
• Learn how to use mail service for home delivery of your medications;
• View your medication history;
• Locate in-plan, out-of-plan, and 24-hour pharmacies near you;
• Refill your prescriptions;
• Search the drug database for generics, brand-names, generic equivalents, and other drug information;
• View quality and safety information about prescription alternatives; and
• View any plan-specific content.
More Information
If you have additional questions, please call customer
service at 800-759-3203 or visit serveyourx.com.
6Table of Contents
Endocrine: Thyroid Hormone Replacement...... 20
Acne/Rosacea .................................................... 8
Eye Conditions: Antibiotics ............................... 20
Addiction/Substance Abuse................................ 8
Eye Conditions: Glaucoma ............................... 20
Anti-Infectives: Antibiotics .................................. 8
Eye Conditions: Other ...................................... 20
Anti-Infectives: Antifungals ................................. 8
Gastrointestinal: Acid Suppression................... 21
Anti-Infectives: Antivirals .................................... 9
Gastrointestinal: Inflammatory Bowel Disease . 21
Blood Disorders.................................................. 9
Gastrointestinal: Nausea/Vomiting ................... 21
Cancer ............................................................... 9
Gastrointestinal: Other ..................................... 21
Cardiovascular/Heart Disease: Anticoagulants . 10
Gout ................................................................. 22
Cardiovascular/Heart Disease: High Blood
Pressure........................................................... 10 HIV/AIDS ......................................................... 22
Cardiovascular/Heart Disease: High Infertility ........................................................... 22
Cholesterol ....................................................... 11
Men’s Health: Erectile Dysfunction ................... 23
Cardiovascular/Heart Disease: Other ............... 12
Men’s Health: Prostate ..................................... 23
Cardiovascular/Heart Disease: Pulmonary
Men’s Health: Testosterone Therapy ............... 23
Arterial Hypertension ........................................ 12
Miscellaneous .................................................. 23
Central Nervous System: Alzheimer's/
Dementia.......................................................... 12 Musculoskeletal: Osteoarthritis ........................ 24
Central Nervous System: Antipsychotics .......... 12 Musculoskeletal: Osteoporosis......................... 24
Central Nervous System: Attention Deficit Musculoskeletal: Other..................................... 25
Disorder ........................................................... 12 Musculoskeletal: Pain Relief ............................ 25
Central Nervous System: Depression............... 13 Overactive Bladder .......................................... 26
Central Nervous System: Migraine ................... 13 Respiratory: Asthma/COPD ............................. 26
Central Nervous System: Multiple Sclerosis ..... 14 Respiratory: Nasal Allergies ............................. 27
Central Nervous System: Other ........................ 14 Respiratory: Oral Allergies ............................... 27
Central Nervous System: Parkinson’s Disease. 14 Transplant ........................................................ 27
Central Nervous System: Sedatives/Hypnotics. 14 Vitamins/Electrolytes ........................................ 27
Central Nervous System: Seizure Disorders .... 15 Weight Loss Management ............................... 27
Dermatology..................................................... 15 Women’s Health: Birth Control ......................... 28
Diabetes/Endocrine Blood: Glucose Monitoring 17 Women’s Health: Hormone Replacement ........ 28
Diabetes/Endocrine: Insulin .............................. 17 Women’s Health: Vaginal Anti-Infectives .......... 29
Diabetes/Endocrine: Non-Insulin ...................... 18
Endocrine: Growth Hormone ............................ 19
Endocrine: Other .............................................. 19
7DRUG PROGRAMS DRUG PROGRAMS
DRUG NAME DRUG NAME
TIER AND LIMITS TIER AND LIMITS
Acne/Rosacea Dificid 3
Doryx E
Absorica 3 PA
Doryx MPC E
Absorica LD 3 PA
Doxycycline Hyclate 1
Claravis 1
Doxycycline Hyclate
Minolira E
Tab 80mg (Dorxy E
Oracea E ABA)
Seysara 3 ST Doxycycline Monohydrate 1
Solodyn E Kitabis E SP
Addiction/Substance Abuse Levofloxacin Tab 1
Bunavail 3 QL Metronidazole Tab 1
Buprenorphine SL 1 QL Minocycline Cap 1
Buprenorphine/Naloxone 1 QL Neomycin/Polymyxin/
1
HC Otic
Chantix 3 QL
Nitrofurantoin
Naltrexone Tab 1 1
Macrocrystals
Narcan 2 Nitrofurantoin
Reset 2 Monohydrate 1
Reset-O 2 Macrocrystals
Suboxone E Nuzyra 3 PA
Zubsolv 2 QL Ofloxacin Otic Solution 1
Otovel 3
Anti-Infectives: Antibiotics
Penicillin VK 1
Acticlate E Solosec 3
Amoxicillin 1 Sulfamethoxazole-
1
Amoxicillin/Clavulanate 1 Trimethoprim
Azasite 3 Targadox E
Azithromycin 1 TOBI Nebulizer E SP
Bethkis E SP TOBI Podhaler 3 QL, SP
Cayston E SP Tobramycin
Cefdinir 1 Nebulization
E SP
Solution 300mg/5mL
Cefuroxime 1 (Kitabis ABA)
Cephalexin 1 Xenleta 3
Ciprodex E
Anti-Infectives: Antifungals
Ciprofloxacin/
1
Dexamethasone Otic Cresemba 3
Ciprofloxacin Tab 1 Fluconazole 1
Clarithromycin Tab 1 Jublia E
Clindamycin Cap 1 Kerydin 3 PA
______________________________________________________________________________________________________________________________________________________
Bold type = Brand name drug [Plain type = Generic drug]
E Excluded PA Prior Authorization ST Step Therapy QL Quantity Limits SP Specialty Program
8DRUG PROGRAMS DRUG PROGRAMS
DRUG NAME DRUG NAME
TIER AND LIMITS TIER AND LIMITS
Nystatin Suspension 1 Nivestym 2 PA, SP
Terbinafine Tab 1 QL Novoeight 2 SP
Tolsura E Nplate 3 PA, SP
Anti-Infectives: Antivirals Nuwiq 2 SP
Recombinate 2 SP
Acyclovir Tab 1
Procrit E SP
Baraclude E SP
Retacrit 2 PA, SP
Entecavir 1 QL, SP
Soliris 3 PA, SP
Epclusa 2 PA, QL, SP
Udenyca E SP
Harvoni 2 PA, QL, SP
Ultomiris 3 PA, SP
Ledipasvir/Sofosbuvir
E SP Wilate 2 SP
(Harvoni ABA)
Mavyret 2 PA, QL, SP Xyntha 2 SP
Sofosbuvir/Velpatasvir Zarxio 2 PA, SP
E SP
(Epclusa ABA) Ziextenzo 3 PA, SP
Tamiflu E Cancer
Valacyclovir 1 QL
Afinitor 2.5mg, 5mg, E
Valtrex E SP
7.5mg
Vemlidy 3 SP Alecensa 2 PA, SP
Vosevi 2 PA, QL, SP Alunbrig 2 PA, QL, SP
Xofluza 3 QL Anastrozole Tab 1
Zovirax E Arimidex E
Blood Disorders Belrapzo E SP
Advate 2 SP Cabometyx 2 PA, SP
Adynovate 3 SP Calquence 3 PA, SP
Afstyla 3 SP Capecitabine 1 SP
Aranesp 2 PA, SP Darzalex Faspro E SP
Eloctate 3 SP Erleada E SP
Epogen E SP Gleevec E SP
Esperoct E SP Herzuma E SP
Fulphila E SP Ibrance 3 PA, SP
Granix E SP Idhifa 3 PA, QL, SP
Jivi 3 SP Kanjinti 2 PA, SP
Koate 2 SP Keytruda 3 PA, SP
Mulpleta 2 PA, SP Letrozole 1
Neulasta 3 PA, SP Lynparza 2 PA, SP
Neulasta Onpro 3 PA, SP Mvasi 2 PA, SP
Neupogen E SP Nubeqa 3 PA, SP
______________________________________________________________________________________________________________________________________________________
Bold type = Brand name drug [Plain type = Generic drug]
E Excluded PA Prior Authorization ST Step Therapy QL Quantity Limits SP Specialty Program
9DRUG PROGRAMS DRUG PROGRAMS
DRUG NAME DRUG NAME
TIER AND LIMITS TIER AND LIMITS
Ogivri E SP Cardiovascular/Heart Disease: High Blood
Ontruzant E SP Pressure
Phesgo 2 PA, SP Altace E
Revlimid 2 PA, SP Amlodipine 1
Rozlytrek 3 PA, SP Amlodipine/Benazepril 1
Rubraca 2 PA, SP Amlodipine/Olmesartan 1
Amlodipine/Olmesartan/ 1
Ruxience 2 PA, SP
HCTZ
Sprycel 2 PA, SP Amlodipine/Valsartan 1
Tabrecta E SP Atacand E
Tagrisso 3 PA, SP Atenolol 1
Tamoxifen Tab 1 Atenolol/Chlorthalidone 1
Avapro E
Targretin Cap E SP
Azor E
Targretin Gel 3 PA, SP Benazepril 1
Tazverik E SP Benicar E
Trazimera 2 PA, SP Benicar HCT E
Treanda E SP Bisoprolol 1
Bisoprolol/HCTZ 1
Truxima E SP
Bumetanide 1
Velcade 2 PA, SP Bystolic 2
Vitrakvi 3 PA, SP Candesartan 1
Xtandi 3 PA, SP Cardizem LA 180mg,
Yonsa E SP 240mg, 300mg, E
360mg, 420mg
Zejula 2 PA, SP Cartia XT 1
Zirabev 2 PA, SP Carvedilol 1
Zytiga E SP Catapres-TTS E
Chlorthalidone 1
Cardiovascular/Heart Disease:
Clonidine Tab 1
Anticoagulants
Conjupri E
Aspirin/Omeprazole Consensi E
E
(Yosprala ABA) Coreg E
Brilinta 2 Coreg CR E
Clopidogrel 1 Cozaar E
Eliquis 2 QL Diltiazem ER 1
Enoxaparin 1 Diovan E
Plavix E Diovan HCT E
Pradaxa 2 QL Doxazosin 1
Prasugrel 1
Edarbi 3 ST
Warfarin 1
Xarelto 2 QL Edarbyclor 3 ST
Yosprala E Enalapril 1
Exforge E
______________________________________________________________________________________________________________________________________________________
Bold type = Brand name drug [Plain type = Generic drug]
E Excluded PA Prior Authorization ST Step Therapy QL Quantity Limits SP Specialty Program
10DRUG PROGRAMS DRUG PROGRAMS
DRUG NAME DRUG NAME
TIER AND LIMITS TIER AND LIMITS
Exforge HCT E Tekturna HCT 2 ST
Furosemide 1 Telmisartan 1
Guanfacine 1 Telmisartan/HCTZ 1
Hydralazine 1 Tenormin E
Hydrochlorothiazide 1 Toprol XL E
Hyzaar E Torsemide 1
Inderal LA E Triamterene/HCTZ 1
Inderal XL E Tribenzor E
Innopran XL E Valsartan 1
Irbesartan 1 Valsartan/HCTZ 1
Irbesartan/HCTZ 1 Verapamil ER 1
Kapspargo Sprinkle E Zestril E
Katerzia E Cardiovascular/Heart Disease: High
Labetalol 1 Cholesterol
Lasix E Antara 3
Lisinopril 1 Atorvastatin 1
Lisinopril/HCTZ 1 Colestid E
Losartan 1 Colestid Flavored E
Losartan/HCTZ 1 Crestor E
Lotrel E Ezetimibe 1
Metoprolol Succinate ER 1 Ezetimibe/Simvastatin 1
Metoprolol Tartrate 1 Fenofibrate 1
Micardis E Fenofibrate Micronized 1
Micardis HCT E Fenofibric Acid 1
Nadolol 1 Gemfibrozil 1
Nifedipine ER 1 Lescol XL E
Nifedipine ER Osmotic 1 Lipitor E
Norvasc E Livalo E
Olmesartan 1 Lovastatin 1
Olmesartan/HCTZ 1 Lovaza E
Prazosin 1 Niaspan E
Prinivil E Nexletol 2 PA, QL
Propranolol 1 Nexlizet 2 PA, QL
Propranolol ER 1 Omega-3 Acid 1
Ramipril 1 Praluent 2 PA, QL
Spironolactone 1 Pravastatin 1
Tekturna 2 ST Questran E
______________________________________________________________________________________________________________________________________________________
Bold type = Brand name drug [Plain type = Generic drug]
E Excluded PA Prior Authorization ST Step Therapy QL Quantity Limits SP Specialty Program
11DRUG PROGRAMS DRUG PROGRAMS
DRUG NAME DRUG NAME
TIER AND LIMITS TIER AND LIMITS
Questran Light E Central Nervous System:
Repatha 2 PA, QL Alzheimer's/Dementia
Rosuvastatin 1 Donepezil 1
Simvastatin 1 Memantine 1
Tricor E Namzaric 2 QL
Vascepa 2 Central Nervous System: Antipsychotics
Vytorin E
Abilify E
Welchol E
Abilify Maintena 3
Zetia E
Aripiprazole 1 QL
Zocor E
Aristada 3
Zypitamag E
Aristada Initio 3
Cardiovascular/Heart Disease: Other Invega Sustenna 3
Amiodarone 1 Invega Trinza 3
Corlanor 3 PA, QL Latuda 3 QL
Digoxin 1 Olanzapine 1
Entresto 2 QL Perseris 3
Flecainide 1 Quetiapine 1
Isosorbide Mononitrate Quetiapine ER 1 QL
1
ER Rexulti 3 QL
Multaq 3 Risperdal E
Nitroglycerin SL 1 Risperidone 1
Nitrostat E Saphris E
Ranexa E Secuado E
Ranolazine ER 1 Seroquel E
Sotalol 1 Seroquel XR E
Tikosyn E Vraylar 3 QL, ST
Cardiovascular/Heart Disease: Pulmonary Ziprasidone 1
Arterial Hypertension Zyprexa E
Adcirca E SP Central Nervous System: Attention Deficit
Adempas 2 PA, QL, SP Disorder
Letairis E SP Adderall E
Opsumit 2 PA, QL, SP Adderall XR E
Orenitram 3 PA, SP Adhansia XR E
Remodulin E SP Amphetamine/
1
Sildenafil Tab 20mg 1 PA, QL Dextroamphetamine
Tracleer
E SP
62.5mg, 125mg
______________________________________________________________________________________________________________________________________________________
Bold type = Brand name drug [Plain type = Generic drug]
E Excluded PA Prior Authorization ST Step Therapy QL Quantity Limits SP Specialty Program
12DRUG PROGRAMS DRUG PROGRAMS
DRUG NAME DRUG NAME
TIER AND LIMITS TIER AND LIMITS
Amphetamine/ Fluvoxamine 1
Dextroamphetamine 1 Forfivo XL E
ER
Lexapro E
Atomoxetine 1
Mirtazapine 1
Concerta E
Nortriptyline 1
Dexmethylphenidate 1
Paroxetine Tab 1
Dexmethylphenidate ER 1
Paxil CR E
Evekeo E
Paxil Tab E
Focalin E
Pristiq E
Focalin XR E
Prozac E
Guanfacine ER 1
Sertraline 1
Intuniv E
Trazodone 1
Jornay PM 3 ST
Trintellix 3 QL, ST
Methylphenidate ER 1
Venlafaxine 1
Methylphenidate ER (LA) 1
Venlafaxine ER 1
Methylphenidate ER (XR) 1
Viibryd 3 QL
Methylphenidate Tab 1
Wellbutrin SR E
Ritalin E
Wellbutrin XL E
Ritalin LA E
Zoloft E
Strattera E
Vyvanse 2 Central Nervous System: Migraine
Aimovig 2 PA, QL
Central Nervous System: Depression
Ajovy E
Amitriptyline 1
Butalbital/Acetaminophen
Bupropion 1 1
/Caffeine
Bupropion SR 1 QL Eletriptan 1 QL
Bupropion XL Emgality 2 PA, QL
1 QL
150mg, 300mg
Imitrex E
Bupropion XL 450mg
E Imitrex Statdose E
(Forfivo XL ABA)
Celexa E Maxalt E
Citalopram 1 Maxalt-MLT E
Cymbalta E Nurtec 2 PA, QL
Desvenlafaxine ER 1 QL Onzetra Xsail E
Doxepin 1 Relpax E
Duloxetine 1 QL Rizatriptan 1 QL
Effexor XR E Reyvow E
Escitalopram Tab 1 Sumatriptan Tab 1 QL
Fluoxetine 1 Tosymra E
______________________________________________________________________________________________________________________________________________________
Bold type = Brand name drug [Plain type = Generic drug]
E Excluded PA Prior Authorization ST Step Therapy QL Quantity Limits SP Specialty Program
13DRUG PROGRAMS DRUG PROGRAMS
DRUG NAME DRUG NAME
TIER AND LIMITS TIER AND LIMITS
Treximet E Modafinil 1
Ubrelvy 2 PA, QL Nuvigil E
Zembrace Symtouch E Provigil E
Zomig Tab E Sunosi 2 PA, QL
Zomig ZMT E Tegsedi 3 PA, SP
Central Nervous System: Multiple Sclerosis Tiglutik 3 PA, QL, SP
Valium E
Ampyra 3 PA, QL, SP
Wakix 3 PA, QL, SP
Aubagio 3 PA, QL, SP
Xanax E
Avonex 2 PA, QL, SP
Xanax ER E
Bafiertam 2 PA, QL, SP
Xyrem 3 PA, QL, SP
Betaseron 2 PA, QL, SP
Copaxone 2 PA, QL, SP Central Nervous System: Parkinson’s
Disease
Extavia E SP
Gilenya 3 PA, QL, SP Benztropine 1
Kesimpta 2 PA, QL, SP Carbidopa-Levodopa 1
Mavenclad 3 PA, SP Gocovri E
Mayzent 3 PA, QL, SP Inbrija 3 PA, SP
Plegridy E SP Kynmobi 3 PA, QL, SP
Rebif E SP Nourianz 3
Tecfidera E SP Ongentys 3 QL, ST
Vumerity 2 PA, QL, SP Osmolex ER E
Zeposia 3 PA, QL, SP Pramipexole 1
Ropinirole 1
Central Nervous System: Other
Rytary 3 ST
Alprazolam Tab 1 QL
Central Nervous System:
Armodafinil 1
Sedatives/Hypnotics
Ativan Tab E
Ambien E
Austedo 3 PA, QL, SP
Ambien CR E
Buspirone 1
Belsomra 3 QL, ST
Diazepam Tab 1
Dayvigo 3 QL, ST
Gralise 3 PA, QL, ST
Eszopiclone 1 QL
Horizant 3 PA, QL
Lunesta E
Hydroxyzine HCL 1
Restoril E
Hydroxyzine Pamoate 1
Silenor 3 QL
Lithium 1
Temazepam 1
Lithium ER 1
Triazolam 1 QL
Lorazepam Tab 1
Zolpidem 1 QL
______________________________________________________________________________________________________________________________________________________
Bold type = Brand name drug [Plain type = Generic drug]
E Excluded PA Prior Authorization ST Step Therapy QL Quantity Limits SP Specialty Program
14DRUG PROGRAMS DRUG PROGRAMS
DRUG NAME DRUG NAME
TIER AND LIMITS TIER AND LIMITS
Zolpidem ER 1 QL Tegretol E
Central Nervous System: Seizure Disorders Tegretol-XR E
Topamax E
Briviact 3 ST
Topamax Sprinkle E
Carbamazepine 1
Topiramate 1
Carbatrol E
Trileptal E
Clonazepam 1 QL
Trokendi XR 3
Depakote E
Valtoco 3 QL
Depakote ER E
Vimpat 3
Depakote Sprinkles E
Xcopri 3 ST
Dilantin Capsule E
Zonegran E
Dilantin Infatabs E
Zonisamide 1
Dilantin Suspension E
Divalproex DR 1 Dermatology
Divalproex ER 1 Acanya E
Epidiolex 3 PA, SP Aczone Gel 5% E
Fycompa 3 Aczone Gel 7.5% 2
Gabapentin 1 Adapalene Gel 1 PA
Keppra E Aklief E
Keppra XR E Ala Scalp E
Klonopin E
Amzeeq 3
Lamictal E
Apexicon E E
Lamictal ODT E
Arazlo E
Lamictal Starter Kit E
Avita E
Lamictal XR E
Benzaclin E
Lamotrigine 1
Benzaclin Pump E
Lamotrigine ER 1
Benzamycin E
Levetiracetam 1
Betamethasone Cream 1
Lyrica E
Bryhali 3
Nayzilam 3 QL
Calcipotriene Foam
Neurontin E 0.005% (Sorilux E
Onfi E ABA)
Oxcarbazepine 1 Capex Shampoo E
Oxtellar XR E Ciclopirox Solution 1
Pregabalin 1 QL Clindagel E
Qudexy XR E Clindamycin Lotion,
1
Sabril E SP Solution, Swab
Sympazan 3 PA Clindamycin 1% Gel 1
______________________________________________________________________________________________________________________________________________________
Bold type = Brand name drug [Plain type = Generic drug]
E Excluded PA Prior Authorization ST Step Therapy QL Quantity Limits SP Specialty Program
15DRUG PROGRAMS DRUG PROGRAMS
DRUG NAME DRUG NAME
TIER AND LIMITS TIER AND LIMITS
Clindamycin 1% Gel Impoyz Cream E
E
(Clindagel ABA) Kenalog Spray E
Clindamycin/Benzoyl Ketoconazole Cream,
1 1
Peroxide Gel 1-5% Shampoo
Clobetasol Cream, Lexette E
1
Ointment, Solution
Lidocaine/Prilocaine
Clobex E 1
Cream
Cloderm Cream E Metrogel E
Clotrimazole/ Metronidazole Cream,
Betamethasone 1 1
Gel
Cream
Mirvaso Gel 3
Clotrimazole Cream 1
Mometasone Cream 1
Cordran Tape E
Mupirocin Cream,
Dapsone Gel 7.5% 1
E Ointment
(Aczone ABA)
Natroba E
Desonate Gel E
Noritate E
Differin Cream, Gel,
E Nystatin Cream 1
Lotion
Duobrii E Onexton 3
Elidel E Pandel Cream E
Enstilar 3 QL Pimecrolimus Cream 1
Epiduo E Psorcon Cream E
Epiduo Forte 3 Retin-A E
Eucrisa 2 ST Retin-A Micro 0.06%,
2 PA
0.08%
Fabior E
Retin-A-Micro 0.04%,
Finacea Gel 3 ST E
0.1%
Fluocinonide Cream, Rhofade 3 PA
1
Solution
Sernivo 3
Fluoroplex 3
Silvadene E
Fluorouracil Cream
2 Soolantra 3
0.5%
Fluorouracil Cream 5% 1 Sorilux E
Halobetasol Propionate Taclonex Ointment E
E
Foam (Lexette ABA) Taclonex Suspension 3 QL
Halog Cream, Ointment E Tacrolimus Ointment 1
Hydrocortisone Cream, Tazorac E
1
Ointment Topicort Spray E
Imiquimod Cream Tretinoin Cream 1 PA
E
3.75% (Zyclara ABA)
Triamcinolone Cream,
Imiquimod Cream 5% 1 1
Ointment
______________________________________________________________________________________________________________________________________________________
Bold type = Brand name drug [Plain type = Generic drug]
E Excluded PA Prior Authorization ST Step Therapy QL Quantity Limits SP Specialty Program
16DRUG PROGRAMS DRUG PROGRAMS
DRUG NAME DRUG NAME
TIER AND LIMITS TIER AND LIMITS
Trianex E Contour Next Monitor
2
Ultravate Lotion E Kit w/ Device
Vectical E Contour Next One Kit 2
Veltin E Contour Next Test
2
Strips
Verdeso Foam E
Contour Test Strips 2
Xepi 3
Dexcom G4 / G5 / G6
Ximino 3 Receiver,
Ziana E Transmitter, Sensor 2
Zilxi 3 ST (including Platinum,
Platinum Pediatric)
Zovirax E
FreeStyle Libre 2
Zyclara E E
Reader, Sensor
Zyclara Pump E Novofine Autocover
2
Diabetes/Endocrine Blood: Glucose Pen Needle
Monitoring Novofine Pen Needle 2
Accu-Chek FastClix Novofine Plus Pen
2 2
Lancet Kit Needle
Accu-Chek Guide Kit Novotwist Pen Needle 2
E
W/Device V-Go 20 2
Accu-Chek Guide Test V-Go 30 2
E
Strips
V-Go 40 2
Accu-Chek Softclix
2
Lancet Device Kit Diabetes/Endocrine: Insulin
BD Autoshield Duo Pen Admelog E
2
Needles
Admelog Solostar E
BD Ultra-Fine Insulin
2 Apidra E
Syringes
BD Ultra-Fine Pen Apidra Solostar E
2
Needles Basaglar KwikPen E
BD Veo Ultra-Fine Fiasp E
2
Insulin Syringes Fiasp FlexTouch E
Contour Control Fiasp Penfill E
2
Solution
Humalog Mix 50/50
Contour Monitor Device 2 2
Vials and KwikPen
Contour Monitor Kit w/ Humalog Mix 75/25
2 2
Device Vials and KwikPen
Contour Next Control Humalog U-100 Junior
2 2
Solution KwikPen
Contour Next EZ Kit w/ Humalog Vials and
2 2
Device KwikPen
______________________________________________________________________________________________________________________________________________________
Bold type = Brand name drug [Plain type = Generic drug]
E Excluded PA Prior Authorization ST Step Therapy QL Quantity Limits SP Specialty Program
17DRUG PROGRAMS DRUG PROGRAMS
DRUG NAME DRUG NAME
TIER AND LIMITS TIER AND LIMITS
Humulin 70/30 Vials and Novolin 70/30 FlexPen
2 E
KwikPen and FlexPen Relion
Humulin N Vials and Novolin 70/30 Relion E
2
KwikPen Novolin 70/30 Vials E
Humulin R U-500 Vials Novolin N Flexpen and
2 E
and KwikPen Flexpen Relion
Humulin R Vials 2 Novolin N Relion E
Insulin Aspart (Novolog Novolin N Vials E
E Novolin R Flexpen and
ABA) E
Flexpen Relion
Insulin Aspart Flexpen
(Novolog FlexPen E Novolin R Relion E
ABA) Novolin R Vials E
Insulin Aspart Mix 70/30 Novolog Flexpen E
(Novolog Mix 70/30 E Novolog Mix 70/30 Vials
E
ABA) and Flexpen
Insulin Aspart Mix 70/30 Novolog Penfill E
FlexPen (Novolog Novolog U-100 Vials E
E
Mix 70/30 FlexPen
Semglee E
ABA)
Soliqua 2 QL, ST
Insulin Aspart Penfill
(Novolog Penfill E Toujeo Max SoloStar 2
ABA) Toujeo SoloStar 2
Insulin Lispro (Humalog Tresiba E
E
ABA)
Tresiba FlexTouch E
Insulin Lispro Junior
KwikPen (Humalog Diabetes/Endocrine: Non-Insulin
E
Junior KwikPen Adlyxin E
ABA)
Alogliptin (Nesina ABA) E
Insulin Lispro KwikPen
(Humalog KwikPen E Alogliptin/Metformin
E
ABA) (Kazano ABA)
Insulin Lispro Mix 75/25 Alogliptin/Pioglitazone
E
KwikPen (Humalog (Oseni ABA)
E Baqsimi 2
Mix 75/25 KwikPen
ABA) Bydureon BCise 2 QL, ST
Lantus Solostar 2 Byetta 2 QL, ST
Lantus U-100 Vials 2 Farxiga 2 ST
Levemir U-100 Fortamet E
E
FlexTouch
Glimepiride 1
Levemir U-100 Vials E
Glipizide 1
Lyumjev Vials and
2 Glipizide ER 1
KwikPen
Glucagon Emergency Kit 1
______________________________________________________________________________________________________________________________________________________
Bold type = Brand name drug [Plain type = Generic drug]
E Excluded PA Prior Authorization ST Step Therapy QL Quantity Limits SP Specialty Program
18DRUG PROGRAMS DRUG PROGRAMS
DRUG NAME DRUG NAME
TIER AND LIMITS TIER AND LIMITS
Glucagon Emergency SymlinPen 3
Kit (Fresenius 2 Synjardy 2 ST
manufacturer)
Synjardy XR 2 ST
Glucagon Emergency
Kit (Lilly 3 Tradjenta 2 ST
manufacturer) Trijardy XR 2 ST
Glumetza E Trulicity 2 QL, ST
Glyburide 1 Victoza 2 QL, ST
Glyxambi 2 ST Xigduo XR 2 ST
Gvoke HypoPen 2 Endocrine: Growth Hormone
Gvoke PFS 2
Genotropin E SP
Invokamet E
Humatrope E SP
Invokamet XR E
Norditropin FlexPro 2 PA, SP
Invokana E
Nutropin AQ NuSpin 2 PA, SP
Janumet 2 ST
Omnitrope E SP
Janumet XR 2 ST
Saizen E SP
Januvia 2 ST
Zomacton E SP
Jardiance 2 ST
Jentadueto 2 ST
Endocrine: Other
Jentadueto XR 2 ST Acthar 2 PA, SP
Kazano E Alkindi Sprinkle E
Kombiglyze XR E Bynfezia Pen E SP
Metformin 1 Cabergoline 1
Metformin ER 1 Calcitriol Cap 1
Metformin ER Modified Cortef E
Release (generic E Dexamethasone Tab 1
Glumetza)
Fensolvi 3 PA, QL, SP
Metformin ER Osmotic
E Hemady E
(generic Fortamet)
Hydrocortisone Tab 1
Nesina E
Isturisa E SP
Onglyza E
Kenalog-40 E
Oseni E
Lupron Depot
Ozempic 2 QL, ST 2 PA, SP
7.5mg, 22.5mg,
Pioglitazone 1 30mg, 45mg
Qtern E Methylprednisolone Tab 1
Rybelsus 2 QL, ST Mycapssa E SP
Segluromet E Ortikos E
Steglatro E Osphena 3
Steglujan E Prednisone 1
______________________________________________________________________________________________________________________________________________________
Bold type = Brand name drug [Plain type = Generic drug]
E Excluded PA Prior Authorization ST Step Therapy QL Quantity Limits SP Specialty Program
19DRUG PROGRAMS DRUG PROGRAMS
DRUG NAME DRUG NAME
TIER AND LIMITS TIER AND LIMITS
Prednisolone Sodium Tobramycin/
1
Phosphate Solution Dexamethasone 1
Rayos E Ophthalmic
Signifor E SP Vigamox E
Somatuline Depot 3 PA, SP Eye Conditions: Glaucoma
Supprelin LA 2 PA, QL, SP Alphagan P 0.1% 2
TaperDex 6-Day 3 Alphagan P 0.15% E
TaperDex 7-Day 3 Azopt 2
TaperDex 12-Day 3 Betimol 3
Triptodur 3 PA, QL, SP Brimonidine Ophthalmic 1
Endocrine: Thyroid Hormone Replacement Combigan 2
Armour Thyroid 3 ST Cosopt E
Cytomel E Cosopt PF E
Euthyrox 1 Dorzolamide/Timolol 1
Levothyroxine 1 Latanoprost 1 QL
Levothyroxine Cap Lumigan 2 QL
E
(Tirosint ABA) Rhopressa 3
Levoxyl 1 Rocklatan 3 QL
Liothyronine 1 Simbrinza 2
Methimazole 1 Timolol Ophthalmic 1
NP Thyroid 1 Timoptic E
Synthroid E Timoptic Ocudose E
Thyquidity E Timoptic-XE E
Tirosint E Vyzulta E
Eye Conditions: Antibiotics Xalatan E
Zioptan E
Besivance 3
Ciprofloxacin Ophthalmic 1 Eye Conditions: Other
Erythromycin Ophthalmic 1 Bepreve E
Moxeza 2 Bromsite E
Moxifloxacin Cequa E
3
Intraocular Solution Flarex 3
Moxifloxacin Ophthalmic 1 Ilevro E
Ofloxacin Ophthalmic 1 Inveltys 3
Polymyxin B/ Ketorolac Ophthalmic 1
Trimethoprim 1
Ophthalmic Lastacaft E
Tobradex E Latisse E
Lotemax Gel, Ointment 3
______________________________________________________________________________________________________________________________________________________
Bold type = Brand name drug [Plain type = Generic drug]
E Excluded PA Prior Authorization ST Step Therapy QL Quantity Limits SP Specialty Program
20DRUG PROGRAMS DRUG PROGRAMS
DRUG NAME DRUG NAME
TIER AND LIMITS TIER AND LIMITS
Lotemax Suspension E Vimovo E
Lotemax SM 3 Zegerid E
Neomycin/Polymyxin/ Gastrointestinal: Inflammatory Bowel
Dexamethasone 1 Disease
Ophthalmic
Nevanac E Apriso 2
Olopatadine Ophthalmic 1 Asacol HD E
Pred Forte E Canasa E
Prednisolone Ophthalmic 1 Delzicol E
Prolensa 2 QL Dipentum E
Restasis 2 PA Hydrocortisone (Perianal) 1
Restasis Multidose 2 PA Lialda E
Tobradex ST 3 Mesalamine DR 1
Xiidra 2 PA Pentasa 3
Zerviate E Proctofoam-HC 2
Sulfasalazine 1
Gastrointestinal: Acid Suppression
Uceris Rectal 3
Aciphex E Uceris Tab E
Carafate Tab E
Gastrointestinal: Nausea/Vomiting
Dexilant 2 QL
Duexis E Gimoti E
Esomeprazole Meclizine 1
1 QL
Magnesium (Rx only) Metoclopramide 1
Famotidine (Rx only) 1 Ondansetron ODT 1
Lansoprazole (Rx only) 1 QL Ondansetron Tab
1
Misoprostol 1 4mg, 8mg
Nexium Cap E Prochlorperazine 1
Omeprazole (Rx only) 1 QL Sancuso E
Omeprazole/Sodium Scopolamine 1
E
Bicarbonate Varubi 3 QL
Pantoprazole 1 QL Gastrointestinal: Other
Prevacid E
Amitiza E
Prevacid SoluTab E
Clenpiq 3
Protonix Tab E
Creon 2
Rabeprazole 1 QL
Dicyclomine 1
Rabeprazole Sprinkle
(Aciphex Sprinkle E Diphenoxylate/Atropine 1
ABA) Glycopyrrolate Tab 1
Sucralfate Tab 1 1mg, 2mg
______________________________________________________________________________________________________________________________________________________
Bold type = Brand name drug [Plain type = Generic drug]
E Excluded PA Prior Authorization ST Step Therapy QL Quantity Limits SP Specialty Program
21DRUG PROGRAMS DRUG PROGRAMS
DRUG NAME DRUG NAME
TIER AND LIMITS TIER AND LIMITS
Glycopyrrolate Tab 3 Mitigare E
1.5mg
HIV/AIDS
Golytely E
Hyoscyamine Sulfate SL 1 Atripla E
Lactulose 1 Biktarvy 3
Linzess 2 QL, ST Cimduo 2
Lubiprostone (Amitiza Descovy E
E Dovato 2
ABA)
Motegrity 3 QL, ST Genvoya 3
Motofen E Juluca 2
Movantik E Odefsey 3
Moviprep E Prezcobix 2
Nulytely w/ Flavor Rukobia 2
E
Packs 2
Symfi
Omeclamox-Pak 2
Symfi Lo 2
OsmoPrep E
Temixys E
Pancreaze E
Tivicay 2
PEG 3350-KCl-Na
1 Triumeq 2
Bicarb-NaCl
Pertzye E Truvada E
Plenvu E Infertility
Pylera 2
Cetrotide E SP
Relistor E
Clomiphene Citrate 1
Suprep Bowel Prep 3
Follistim AQ 2 PA, SP
Symproic 2 QL, ST
Ganirelix 1 SP
Trulance E
Gonal-f E SP
Viberzi 3 PA, QL
Gonal-f RFF E SP
Viokace E
Zelnorm 3 PA, QL Inflammatory Conditions
Zenpep 2 Actemra+ 3 PA, SP
Gout Avsola 2 PA, SP
Cimzia 2 PA, SP
Allopurinol 1
Cosentyx E SP
Colchicine Capsule
E Enbrel 3 PA, SP
(Mitigare ABA)
Colchicine Tab 1 Humira 2 PA, SP
Colcrys E Hydroxychloroquine 1
Febuxostat 1 Inflectra 2 PA, SP
Gloperba E Leflunomide 1
______________________________________________________________________________________________________________________________________________________
Bold type = Brand name drug [Plain type = Generic drug]
E Excluded PA Prior Authorization ST Step Therapy QL Quantity Limits SP Specialty Program
22DRUG PROGRAMS DRUG PROGRAMS
DRUG NAME DRUG NAME
TIER AND LIMITS TIER AND LIMITS
Methotrexate 1 Men’s Health: Testosterone Therapy
Olumiant E SP
Androderm 2 PA
Orencia+ 3 PA, SP
Androgel E
Otezla 2 PA, SP
Aveed E
Plaquenil E
Depo-Testosterone E
Rasuvo 2 PA, QL
Fortesta E
Remicade E SP
Jatenzo E
Renflexis E SP
Natesto E
Rinvoq 2 PA, SP
Testim E
Simponi 2 PA, SP
Testopel E
Skyrizi 2 PA, SP
Testosterone Cypionate
Stelara 2 PA, QL, SP 1 PA
IM Injection
Taltz+ 3 PA, SP Testosterone Gel
1 PA
Tremfya 2 PA, SP 1%, 1.62%, 2%
Xeljanz 2 PA, SP Vogelxo E
Xeljanz XR 2 PA, SP Xyosted 3 PA
+ Tier 3 Preferred Miscellaneous
Men’s Health: Erectile Dysfunction Addyi 3 PA, QL
Cialis E Arakoda 3
Levitra E Asceniv E SP
Sildenafil 25mg, Auryxia 3
1 QL
50mg, 100mg Auvi-Q 0.15mg, 0.3mg E
Staxyn E Benzonatate 1
Stendra E Beovu E SP
Tadalafil 1 QL Botox (non-cosmetic) 2 PA, SP
Viagra E Brisdelle E
Men’s Health: Prostate Cerdelga 3 PA, SP
Alfuzosin ER 1 Chlorhexidine 1
Avodart E Clarinex E
Cialis 2.5mg, 5mg E Clarinex-D E
Dutasteride 1 Cutaquig E SP
Finasteride 5mg 1 Depen Titratabs 2 SP
Flomax E Dojolvi E
Tamsulosin 1 Dupixent 2 PA, QL, SP
Terazosin 1 Elmiron E
Emverm 2
Endari 3 PA
______________________________________________________________________________________________________________________________________________________
Bold type = Brand name drug [Plain type = Generic drug]
E Excluded PA Prior Authorization ST Step Therapy QL Quantity Limits SP Specialty Program
23DRUG PROGRAMS DRUG PROGRAMS
DRUG NAME DRUG NAME
TIER AND LIMITS TIER AND LIMITS
Epinephrine Auto-Injector 1 Strensiq 2 PA, SP
Epipen 3 ST Symjepi 3
Epipen Jr E Takhzyro 3 PA, SP
Exondys 51 E SP Trikafta 3 PA, QL, SP
Fasenra 2 PA, SP Velphoro 3
Firazyr 3 PA, QL, SP Vyleesi 3 PA, QL
Firdapse E SP Vyondys 53 E SP
Gammagard 3 PA, SP Xembify 3 PA, SP
Haegarda 3 PA, SP Xgeva 2 PA, SP
Hemangeol 3 Xhance E
Ingrezza 3 PA, QL, SP Zolgensma 3 SP
Kuvan E SP Musculoskeletal: Osteoarthritis
Lidocaine Viscous 1
Durolane 2 PA, SP
Makena 2 PA, SP
Euflexxa 2 PA, SP
Nityr 3 PA, SP
Gelsyn-3 2 PA, SP
Nocdurna 3
Gel-One E SP
Nucala 2 PA, QL, SP
Genvisc 850 E SP
Orfadin 3 PA, SP
Hyalgan E SP
Oriahnn 2 PA, QL
Hymovis E SP
Orilissa 2 PA, QL
Monovisc E SP
Oxbryta E SP
Orthovisc E SP
Palforzia E SP
Supartz FX E SP
Panzyga E SP
Synvisc E SP
Phenazopyridine
1 Synvisc-One E SP
(Rx only)
Promethazine 1 Triluron E SP
Promethazine DM 1 TriVisc E SP
Visco-3 E SP
Promethazine/Codeine 1 QL
Propecia E Musculoskeletal: Osteoporosis
Pseudoephedrine/ Alendronate Tab 1 QL
1
Brompheniramine/DM
Binosto 3 QL
Pulmozyme 2 PA, SP
Forteo E SP
Qbrexza 3 QL
Ibandronate 1 QL
Rayaldee 3
Prolia 2 PA, QL, SP
Renagel E
Teriparatide
Ruconest 3 PA, SP 2 PA, QL, SP
(Recombinant)
Sandostatin E SP Tymlos 2 PA, SP
Sensipar E
______________________________________________________________________________________________________________________________________________________
Bold type = Brand name drug [Plain type = Generic drug]
E Excluded PA Prior Authorization ST Step Therapy QL Quantity Limits SP Specialty Program
24DRUG PROGRAMS DRUG PROGRAMS
DRUG NAME DRUG NAME
TIER AND LIMITS TIER AND LIMITS
Musculoskeletal: Other Duragesic E
Etodolac 1
Amrix E
Fentanyl Citrate Buccal
Baclofen Tab 1 E
Tablet (Fentora ABA)
Carisoprodol 1 Fentanyl Patch 1 PA, QL
Cyclobenzaprine Tab 1 Fentora E
Lorzone 3 Fiorcet E
Metaxalone 1
Fioricet/Codeine E
Methocarbamol 1
Flector E
Ozobax E
Hydrocodone/
Skelaxin E 1 QL
Acetaminophen
Soma E Hydromorphone Tab 1 QL
Tizanidine Tab 1 Hysingla ER 2 PA, QL
Vanadom E Ibuprofen Tab (Rx only) 1
Zanaflex E Indomethacin Cap
3
20mg
Musculoskeletal: Pain Relief
Indomethacin Cap 25mg,
Acetaminophen 1
1 QL 50mg
w/ Codeine
Ketorolac Tab 1 QL
Acetaminophen
1 QL Ketorolac
w/ Codeine #2, #3, #4
Tromethamine Nasal E
Acetaminophen/Caffeine/ Spray (Sprix ABA)
1 QL
Dihydrocodeine
Lazanda E
Apadaz E
Licart E
Arthrotec E
Lidocaine Patch 1
Belbuca 2 PA, QL
Lidoderm E
Benzhydrocodone/
1
E QL Meloxicam 1
Acetaminophen
Mobic E
Butrans E
Morphine Sulfate ER 1 PA, QL
Cambia E
Morphine Sulfate Solution 1 QL
Celebrex E
MS Contin E
Celecoxib 1 QL
Nabumetone 1
Conzip E
Nalfon E
Diclofenac Cap 35mg
E Naprelan 3
(Zorvolex ABA)
Diclofenac Gel 1% 1 QL Naproxen (Rx only) 1
Diclofenac Patch 1.3% Norgesic Forte E
E E
(Flector ABA) Nucynta
Diclofenac Tab 1 Nucynta ER E
Dilaudid E
______________________________________________________________________________________________________________________________________________________
Bold type = Brand name drug [Plain type = Generic drug]
E Excluded PA Prior Authorization ST Step Therapy QL Quantity Limits SP Specialty Program
25DRUG PROGRAMS DRUG PROGRAMS
DRUG NAME DRUG NAME
TIER AND LIMITS TIER AND LIMITS
Orphengesic Forte Solifenacin 1
(Norgesic Forte E Tolterodine ER 1
ABA)
Toviaz 3
Oxycodone
w/ Acetaminophen Vesicare E
Tab 2.5/325mg, 1 QL Respiratory: Asthma/COPD
5/325mg, 7.5/325mg,
10/325mg Advair Diskus 2 QL
Oxycodone w/ Advair HFA 2 QL
Acetaminophen Tab AirDuo Digihaler E
3 QL
2.5/300mg, 5/300mg,
AirDuo RespiClick E
10/300mg
Albuterol HFA 1 QL
Oxycodone ER
E Albuterol HFA (Ventolin
(Oxycontin ABA) E
HFA ABA)
Oxycodone Tab 1 QL
Albuterol Inhalation
Oxycontin 2 PA, QL 1 QL
Solution
Pennsaid E
Alvesco E
Percocet E
Anoro Ellipta 2 QL
Qdolo E
ArmonAir Digihaler E
Qmiiz ODT E
Arnuity Ellipta 2 QL
Relafen E
Asmanex E
Relafen DS E
Asmanex HFA E
Roxicodone E
Atrovent HFA 3 QL
Sprix E
Bevespi Aerosphere E
Subsys E
Breo Ellipta 2 QL
Tramadol 1 QL
Breztri Aerosphere 2 QL
Trezix 3 QL
Budesonide Inhalation
Ultracet E 1 QL
Suspension
Ultram E Budesonide/Formoterol
E
Voltaren Gel 1% E (Symbicort ABA)
Xtampza ER 2 PA, QL Combivent Respimat 2 QL
Zipsor E Duaklir Pressair E
Zohydro ER E Dulera E
Zorvolex E Flovent Diskus 2 QL
ZTlido E Flovent HFA 2 QL
Fluticasone/Salmeterol 1 QL
Overactive Bladder
Incruse Ellipta E
Myrbetriq 2
Ipratropium/Albuterol 1 QL
Oxybutynin 1
Levalbuterol HFA
Oxybutynin ER 1 E
(Xopenex HFA ABA)
______________________________________________________________________________________________________________________________________________________
Bold type = Brand name drug [Plain type = Generic drug]
E Excluded PA Prior Authorization ST Step Therapy QL Quantity Limits SP Specialty Program
26DRUG PROGRAMS DRUG PROGRAMS
DRUG NAME DRUG NAME
TIER AND LIMITS TIER AND LIMITS
Lonhala Magnair 3 QL QNasl 3 QL
Montelukast 1 Zetonna 3 QL
Perforomist 3 QL Respiratory: Oral Allergies
ProAir Digihaler E
Cetirizine Solution 1
ProAir HFA 2 QL
Cyproheptadine Tab 1
ProAir RespiClick 2 QL
Levocetirizine 1
Proventil HFA E
Pulmicort Flexhaler 2 QL
Transplant
Pulmicort Suspension E Azathioprine Tab 1
Qvar RediHaler E Cyclosporine Modified
1
Cap
Seebri Neohaler E
Mycophenolate Mofetil 1
Serevent Diskus 2 QL
Mycophenolate Sodium 1
Singulair E
Tacrolimus Cap 1
Spiriva HandiHaler 2 QL
Spiriva Respimat 2 QL Vitamins/Electrolytes
Stiolto Respimat 2 QL Carnitor E
Striverdi Respimat 2 QL Carnitor SF E
Symbicort 2 QL Cyanocobalamin Injection
1
Trelegy Ellipta 2 QL 1000mcg/mL
Tudorza Pressair E Feonyx E
Utibron Neohaler E Folic Acid 1mg (Rx only) 1
Ventolin HFA 2 QL Foltrexyl E
Wixela Inhub 1 QL K-Tab E
Xolair 2 PA, SP Klor-Con m20 1
Xopenex HFA E Lokelma 3
Yupelri 3 QL Nascobal 3
Potassium Chloride Crys
Respiratory: Nasal Allergies 1
ER
Azelastine Nasal Spray 1 QL Potassium Chloride ER 1
Azelastine/Fluticasone Potassium Citrate ER 1
1 QL
Nasal Spray
Sodium Fluoride
Dymista Spray 2 QL 1
Chewable Tab
Fluticasone Nasal Spray 1 Veltassa 3
Ipratropium Nasal Spray 1 Vitamin D (ergocalciferol)
1
Mometasone Nasal (Rx only)
1 QL
Spray
Weight Loss Management
Nasonex E
Adipex-P E
Omnaris 3 QL
Contrave E
______________________________________________________________________________________________________________________________________________________
Bold type = Brand name drug [Plain type = Generic drug]
E Excluded PA Prior Authorization ST Step Therapy QL Quantity Limits SP Specialty Program
27DRUG PROGRAMS DRUG PROGRAMS
DRUG NAME DRUG NAME
TIER AND LIMITS TIER AND LIMITS
Phentermine 1 PA Minastrin 24 Fe E
Qsymia 3 PA Mirena 3
Saxenda 3 PA Mono-Linyah 1
Women’s Health: Birth Control Natazia 2
Nikki 1
Annovera E
Norethindrone 1
Apri 1
Norethindrone Acetate 1
Aurovela Fe 1/20 1
Norethindrone
Aviane 1
Acetate/Ethinyl 1
Beyaz E Estradiol
Blisovi 24 Fe 1 Norethindrone
Blisovi Fe 1 Acetate/Ethinyl 1
Estradiol/Fe
Cryselle-28 1
Norgestimate/Ethinyl
Drospirenone/Ethinyl 1
1 Estradiol
Estradiol
Nortrel 1
Eluryng 1
Ortho Micronor E
Enskyce 1
Phexxi E
Estarylla 1
Safyral E
Etonogestrel/Ethinyl
1 Seasonique E
Estradiol
Generess Fe E Slynd E
Isibloom 1 Sprintec 28 1
Junel 1 Syeda 1
Junel Fe 1 Tri Femynor 1
Kurvelo 1 Tri-Estarylla 1
Larin Fe 1/20 1 Tri-Lo-Marzia 1
Larissia 1 Tri-Lo-Mili 1
Lessina 1 Tri-Lo-Sprintec 1
Levonorgestrel/Ethinyl Tri-Sprintec 1
1
Estradiol Twirla E
Levonorgestrel/Ethinyl Vienva 1
Estradiol and Ethinyl 1 Xulane 1
Estradiol
Yasmin 28 E
Lo Loestrin Fe E
Yaz E
Loestrin E
Loestrin Fe E Women’s Health: Hormone Replacement
Loryna 1 Bijuva 3
Medroxyprogesterone Climara E
1 QL
Acetate Injection Climara Pro 2
______________________________________________________________________________________________________________________________________________________
Bold type = Brand name drug [Plain type = Generic drug]
E Excluded PA Prior Authorization ST Step Therapy QL Quantity Limits SP Specialty Program
28DRUG PROGRAMS DRUG PROGRAMS
DRUG NAME DRUG NAME
TIER AND LIMITS TIER AND LIMITS
Delestrogen E Premarin Vaginal
2
Divigel 3 Cream
Dotti 1 Premphase 2
Duavee 2 Prempro 2
Elestrin Gel 3 Progesterone Micronized 1
Endometrin 2 Prometrium E
Estrace E Vagifem E
Estradiol Patch, Tab, Vivelle-Dot E
1
Vaginal Cream Women’s Health: Vaginal Anti-Infectives
EstroGel 3
Clindesse 3
Evamist 3
Gynazole-1 Vaginal
Imvexxy 3 3
Cream
Medroxyprogesterone Metronidazole
1 1
Acetate Tab Vaginal Gel
Premarin Tab 2 Terconazole
1
Vaginal Cream
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Bold type = Brand name drug [Plain type = Generic drug]
E Excluded PA Prior Authorization ST Step Therapy QL Quantity Limits SP Specialty Program
29Index
Albuterol HFA (Ventolin HFA ABA) .. 26 Arazlo ............................................... 15
A Albuterol Inhalation Solution........... 26 Arimidex ............................................ 9
Abilify ...............................................12 Alecensa ............................................. 9 Aripiprazole ..................................... 12
Abilify Maintena ...............................12 Alendronate Tab .............................. 24 Aristada ........................................... 12
Absorica .............................................8 Alfuzosin ER ..................................... 23 Aristada Initio .................................. 12
Absorica LD ........................................8 Alkindi Sprinkle ................................ 19 Armodafinil ...................................... 14
Acanya..............................................15 Allopurinol ....................................... 22 ArmonAir Digihaler .......................... 26
Accu-Chek FastClix Lancet Kit ..........17 Alogliptin (Nesina ABA) .................... 18 Armour Thyroid ............................... 20
Accu-Chek Guide Kit /Device ...........17 Alogliptin/Metformin (Kazano ABA) 18 Arnuity Ellipta .................................. 26
Accu-Chek Guide Test Strips ............17 Alogliptin/Pioglitazone (Oseni ABA) 18 Arthrotec ......................................... 25
Accu-Chek Softclix Lancet Device Alphagan P 0.1% .............................. 20 Asacol HD......................................... 21
Kit.................................................17 Alphagan P 0.15% ............................ 20 Asceniv............................................. 23
Acetaminophen w/ Codeine ............25 Alprazolam Tab ................................ 14 Asmanex .......................................... 26
Acetaminophen w/ Codeine #2, #3, Altace ............................................... 10 Asmanex HFA ................................... 26
#4 .................................................25 Alunbrig ............................................. 9 Aspirin/Omeprazole (Yosprala ABA) 10
Acetaminophen/Caffeine/ Alvesco ............................................. 26 Atacand............................................ 10
Dihydrocodeine ...........................25 Ambien............................................. 14 Atenolol ........................................... 10
Aciphex ............................................21 Ambien CR ....................................... 14 Atenolol/Chlorthalidone .................. 10
Actemra............................................22 Amiodarone ..................................... 12 Ativan Tab ........................................ 14
Acthar...............................................19 Amitiza ............................................. 21 Atomoxetine .................................... 13
Acticlate .............................................8 Amitriptyline .................................... 13 Atorvastatin ..................................... 11
Acyclovir Tab ......................................9 Amlodipine....................................... 10 Atripla .............................................. 22
Aczone Gel 5%..................................15 Amlodipine/Benazepril .................... 10 Atrovent HFA ................................... 26
Aczone Gel 7.5% ..............................15 Amlodipine/Olmesartan .................. 10 Aubagio ............................................ 14
Adapalene Gel ..................................15 Amlodipine/Valsartan ...................... 10 Aurovela Fe 1/20 ............................. 28
Adcirca .............................................12 Amoxicillin ......................................... 8 Auryxia ............................................. 23
Adderall ............................................12 Amoxicillin/Clavulanate ..................... 8 Austedo ........................................... 14
Adderall XR.......................................12 Amphetamine/ Auvi-Q 0.15mg, 0.3mg ..................... 23
Addyi ................................................23 Dextroamphetamine ................... 12 Avapro ............................................. 10
Adempas ..........................................12 Amphetamine/Dextroamphetamine Aveed ............................................... 23
Adhansia XR .....................................12 ER................................................. 13 Aviane .............................................. 28
Adipex-P ...........................................27 Ampyra ............................................ 14 Avita................................................. 15
Adlyxin .............................................18 Amrix................................................ 25 Avodart ............................................ 23
Admelog ...........................................17 Amzeeq ............................................ 15 Avonex ............................................. 14
Admelog Solostar .............................17 Anastrozole Tab ................................. 9 Avsola .............................................. 22
Advair Diskus....................................26 Androderm ...................................... 23 Azasite ............................................... 8
Advair HFA .......................................26 Androgel .......................................... 23 Azathioprine Tab ............................. 27
Advate ................................................9 Annovera ......................................... 28 Azelastine Nasal Spray ..................... 27
Adynovate ..........................................9 Anoro Ellipta .................................... 26 Azelastine/Fluticasone Nasal Spray . 27
Afinitor 2.5mg, 5mg, 7.5mg ...............9 Antara .............................................. 11 Azithromycin...................................... 8
Afstyla ................................................9 Apadaz ............................................. 25 Azopt ............................................... 20
Aimovig ............................................13 Apexicon E ....................................... 15 Azor.................................................. 10
AirDuo Digihaler ...............................26 Apidra .............................................. 17
AirDuo RespiClick .............................26 Apidra Solostar ................................ 17 B
Ajovy ................................................13 Apri .................................................. 28
Baclofen Tab .................................... 25
Aklief ................................................15 Apriso ............................................... 21
Bafiertam ......................................... 14
Ala Scalp ...........................................15 Arakoda............................................ 23
Baqsimi ............................................ 18
Albuterol HFA ...................................26 Aranesp .............................................. 9
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Bold type = Brand name drug [Plain type = Generic drug]
E Excluded PA Prior Authorization ST Step Therapy QL Quantity Limits SP Specialty Program
30Baraclude ...........................................9 Bupropion ........................................ 13 Chlorthalidone ................................. 10
Basaglar KwikPen .............................17 Bupropion SR ................................... 13 Cialis................................................. 23
BD Autoshield Duo Pen Needles ......17 Bupropion XL 450mg (Forfivo XL Cialis 2.5mg, 5mg ............................. 23
BD Ultra-Fine Insulin Syringes ..........17 ABA) ............................................. 13 Ciclopirox Solution ........................... 15
BD Ultra-Fine Pen Needles ...............17 Buspirone ......................................... 14 Cimduo ............................................ 22
BD Veo Ultra-Fine Insulin Syringes ...17 Butalbital/Acetaminophen/Caffeine 13 Cimzia .............................................. 22
Belbuca ............................................25 Butrans............................................. 25 Ciprodex ............................................ 8
Belrapzo .............................................9 Bydureon ......................................... 18 Ciprofloxacin Ophthalmic ................ 20
Belsomra ..........................................14 Bydureon BCise ................................ 18 Ciprofloxacin Tab ............................... 8
Benazepril ........................................10 Byetta............................................... 18 Ciprofloxacin/Dexamethasone Otic ... 8
Benicar .............................................10 Bynfezia Pen .................................... 19 Citalopram ....................................... 13
Benicar HCT ......................................10 Bystolic............................................. 10 Claravis .............................................. 8
Benzaclin ..........................................15 Clarinex ............................................ 23
Benzaclin Pump ................................15 C Clarinex-D ........................................ 23
Benzamycin ......................................15 Clarithromycin Tab ............................ 8
Cabergoline ...................................... 19
Benzhydrocodone/Acetaminophen .25 Clenpiq ............................................. 21
Cabometyx ......................................... 9
Benzonatate .....................................23 Climara............................................. 28
Calcipotriene Foam 0.005% (Sorilux
Benztropine......................................14 Climara Pro ...................................... 28
ABA) ............................................. 15
Beovu ...............................................23 Clindagel .......................................... 15
Calcitriol Cap .................................... 19
Bepreve ............................................20 Clindamycin 1% Gel ......................... 15
Calquence .......................................... 9
Besivance .........................................20 Clindamycin 1% Gel (Clindagel ABA) 16
Cambia ............................................. 25
Betamethasone Cream ....................15 Clindamycin Cap ................................ 8
Canasa.............................................. 21
Betaseron .........................................14 Clindamycin Lotion, Solution, Swab 15
Candesartan ..................................... 10
Bethkis ...............................................8 Clindamycin/Benzoyl Peroxide Gel
Capecitabine ...................................... 9
Betimol .............................................20 1-5% ............................................ 16
Capex Shampoo ............................... 15
Bevespi Aerosphere .........................26 Clindesse .......................................... 29
Carafate Tab..................................... 21
Beyaz ................................................28 Clobetasol Cream, Ointment,
Carbamazepine ................................ 15
Bijuva ...............................................28 Solution ....................................... 16
Carbatrol .......................................... 15
Biktarvy ............................................22 Clobex .............................................. 16
Carbidopa-Levodopa........................ 14
Binosto .............................................24 Cloderm Cream ................................ 16
Cardizem LA 180mg, 240mg, 300mg,
Bisoprolol .........................................10 Clomiphene Citrate .......................... 22
360mg, 420mg ............................. 10
Bisoprolol/HCTZ ...............................10 Clonazepam ..................................... 15
Carisoprodol .................................... 25
Blisovi 24 Fe…………………..………………28 Clonidine Tab ................................... 10
Carnitor ............................................ 27
Blisovi Fe ..........................................28 Clopidogrel ...................................... 10
Carnitor SF ....................................... 27
Botox (non-cosmetic) .......................23 Clotrimazole Cream ......................... 16
Cartia XT ........................................... 10
Breo Ellipta .......................................26 Colchicine Capsule (Mitigare ABA) .. 22
Carvedilol ......................................... 10
Breztri Aerosphere ...........................26 Colchicine Tab .................................. 22
Catapres-TTS .................................... 10
Brilinta ..............................................10 Colcrys ............................................. 22
Cayston .............................................. 8
Brimonidine Ophthalmic ..................20 Colestid ............................................ 11
Cefdinir .............................................. 8
Brisdelle ...........................................23 Colestid Flavored ............................. 11
Cefuroxime ........................................ 8
Briviact .............................................15 Combigan ......................................... 20
Celebrex ........................................... 25
Bromsite ...........................................20 Combivent Respimat ....................... 26
Celecoxib .......................................... 25
Bryhali ..............................................15 Concerta .......................................... 13
Celexa .............................................. 13
Budesonide Inhalation Suspension ..26 Conjupri ........................................... 10
Cephalexin ......................................... 8
Budesonide/Formoterol (Symbicort Consensi .......................................... 10
Cequa ............................................... 20
ABA) .............................................26 Contour Control Solution................. 17
Cerdelga ........................................... 23
Bumetanide......................................10 Contour Monitor Device .................. 17
Cetirizine Solution ............................ 27
Bunavail .............................................8 Contour Monitor Kit w/ Device ....... 17
Cetrotide .......................................... 22
Buprenorphine ...................................8 Contour Next Control Solution ........ 17
Chantix ............................................... 8
Buprenorphine SL ..............................8 Contour Next EZ Kit w/ Device ........ 17
Chlorhexidine ................................... 23
Buprenorphine/Naloxone ..................8
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Bold type = Brand name drug [Plain type = Generic drug]
E Excluded PA Prior Authorization ST Step Therapy QL Quantity Limits SP Specialty Program
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