YOUR 2022 FORMULARY SIGNATUREVALUE 3-TIER - UNITEDHEALTHCARE
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Pharmacy | Formulary Your 2022 Formulary SignatureValue 3-Tier Effective May 1, 2022 This formulary is accurate as of May 1, 2022 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.
Understanding 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 member your 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 member 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 member 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.
2Medication 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 member ID card or call the
toll-free phone number on your member 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 member
ID card to talk with a pharmacist about finding lower-cost options.
3Reading 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 UPPERCASE and generic medications in lowercase.
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.
4Reading 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 phone number on your member ID card
And, if home delivery services
are included in your pharmacy
Visit your plan’s member website listed on your member ID card to: benefit, you can also:
• View your pharmacy benefit and coverage information, including • Refill prescriptions
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
52022 SignatureValue Formulary
Table of Contents
Analgesics - Drugs for Pain.............................. 7 Genitourinary Agents - Drugs for Bladder,
Analgesics - Drugs for Pain and Inflammation. 8 Genital and Kidney Conditions..................... 35
Anti-Addiction / Substance Abuse Treatment Genitourinary Agents - Drugs for Prostate
Agents............................................................ 9 Conditions.................................................... 35
Antibacterials - Drugs for Infections..................9 Hormonal Agents - Hormone Replacement
Anticoagulants - Drugs to Treat or Prevent and Birth Control.......................................... 35
Blood Clots................................................... 11 Hormonal Agents - Oral Steroids....................39
Anticonvulsants - Drugs for Seizures............. 11 Hormonal Agents - Other................................39
Antidementia Agents - Drugs for Alzheimer's Hormonal Agents - Testosterone
Disease and Dementia................................. 12 Replacement................................................ 40
Antidepressants - Drugs for Depression.........12 Hormonal Agents - Thyroid.............................40
Antiemetics - Drugs for Nausea and Vomiting 13 Immunological Agents - Drugs for Immune
Antifungals - Drugs for Fungal Infections....... 14 System Stimulation or Suppression............. 40
Antigout Agents - Drugs for Gout................... 14 Infertility Agents.............................................. 42
Antimigraine Agents - Drugs for Migraines.....14 Inflammatory Bowel Disease Agents..............42
Antineoplastics - Drugs for Cancer.................15 Metabolic Bone Disease Agents - Drugs for
Antiparasitics - Drugs for Parasitic Infections. 15 Osteoporosis................................................ 43
Antiparkinson Agents - Drugs for Parkinson's Ophthalmic Agents - Drugs for Eye Allergy,
Disease ........................................................ 16 Infection and Inflammation........................... 43
Antiplatelets - Drugs for Heart Attack and Ophthalmic Agents - Drugs for Glaucoma......44
Stroke Prevention.........................................16 Ophthalmic Agents - Drugs for Miscellaneous
Antipsychotics - Drugs for Mood Disorders.... 16 Eye Conditions............................................. 45
Antivirals - Drugs for Viral Infections.............. 16 Otic Agents - Drugs for Ear Conditions.......... 45
Anxiolytics - Drugs for Anxiety........................17 Respiratory - Drugs for Anaphylaxis...............45
Bipolar Agents - Drugs for Mood Disorders....18 Respiratory Tract / Pulmonary Agents -
Cardiovascular Agents - Drugs for Heart and Drugs for Allergies, Cough, Cold..................45
Circulation Conditions.................................. 18 Respiratory Tract / Pulmonary Agents -
Central Nervous System Agents - Drugs for Drugs for Asthma and COPD....................... 46
Attention Deficit Disorder..............................21 Respiratory Tract / Pulmonary Agents -
Central Nervous System Agents - Drugs for Drugs for Cystic Fibrosis.............................. 48
Multiple Sclerosis......................................... 22 Respiratory Tract / Pulmonary Agents -
Central Nervous System Agents - Drugs for Pulmonary Hypertension.............. 48
Miscellaneous...............................................22 Skeletal Muscle Relaxants - Drugs for
Dental and Oral Agents - Drugs for Mouth Muscle Pain and Spasm...............................48
and Throat Conditions.................................. 23 Sleep Disorder Agents....................................49
Dermatological Agents - Drugs for Skin Index of Drugs................................................ 50
Conditions.................................................... 23
Diabetes - Glucose Monitoring....................... 26
Diabetes - Insulin............................................29
Diabetes - Non-Insulin Agents........................31
Drugs for Blood Disorders.............................. 31
Drugs for Sexual Dysfunction......................... 32
Electrolytes / Vitamins.................................... 32
Gastrointestinal Agents - Drugs for Acid
Reflux and Ulcer...........................................33
Gastrointestinal Agents - Drugs for Bowel,
Intestine and Stomach Conditions................33
Genetic or Enzyme Disorder - Drugs for
Replacement, Modification, Treatment.........34
6Requirem Requirem
Drug Drug
Drug Name ents & Drug Name ents &
Tier Tier
Limits Limits
Analgesics - Drugs for hydrocodone-
Pain acetaminophen oral 3
acetaminophen-codeine 1 tablet 10-300 mg, 5-300
mg, 7.5-300 mg
acetaminophen-codeine
1 hydrocodone-
#2
acetaminophen oral
acetaminophen-codeine 1
1 tablet 10-325 mg, 5-325
#3 mg, 7.5-325 mg
acetaminophen-codeine 1 hydromorphone hcl er 3 PA; QL; E
#4
hydromorphone hcl oral
apap-caff-dihydrocodeine 3 QL; E 3
liquid
bac 1 QL
hydromorphone hcl oral 1
BELBUCA 3 PA; QL tablet
butalbital-apap-caffeine 1 QL hydromorphone hcl rectal 1
CONZIP 3 PA; QL HYSINGLA ER 3 PA; QL; E
DILAUDID ORAL 3 lidocaine external 1
DUROLANE M ointment 5 %
endocet 1 lidocaine external patch 5 3 PA; QL
%
ESGIC 3 QL
lidocaine-prilocaine 1
EUFLEXXA M
external cream
fentanyl transdermal LIDODERM 3 PA; QL
patch 72 hour 100
mcg/hr, 12 mcg/hr, 25 1 PA; QL LORTAB 3
mcg/hr, 50 mcg/hr, 75 morphine sulfate
mcg/hr (concentrate) oral
1
fentanyl transdermal solution 100 mg/5ml, 20
patch 72 hour 37.5 mg/ml
3 PA; QL; E
mcg/hr, 62.5 mcg/hr, morphine sulfate er oral
87.5 mcg/hr capsule extended 3 PA; QL; E
FIORICET 3 QL; E release 24 hour
GELSYN-3 M morphine sulfate er oral 1 PA; QL
tablet extended release
HYALGAN M
morphine sulfate oral 1
hydrocodone bitartrate er
oral capsule extended 3 PA; QL morphine sulfate rectal 1
release 12 hour MS CONTIN 3 PA; QL
hydrocodone bitartrate er NALOCET 3 QL; E
oral tablet er 24 hour 3 PA; QL; E 3 QL
NUCYNTA
abuse-deterrent
NUCYNTA ER 3 PA; QL
hydrocodone-
acetaminophen oral 3 OXAYDO 3 QL; E
solution 7.5-325 mg/15ml OXYCODONE HCL ER 3 PA; QL; E
oxycodone hcl oral 1
capsule
7Requirem Requirem
Drug Drug
Drug Name ents & Drug Name ents &
Tier Tier
Limits Limits
oxycodone hcl oral (generic for
3
concentrate 100 mg/5ml tramadol hcl er oral tablet 3 Ultram
extended release 24 hour ER); QL
oxycodone hcl oral 3
solution tramadol hcl oral tablet 3 E
oxycodone hcl oral tablet 100 mg
10 mg, 15 mg, 20 mg, 30 1 tramadol hcl oral tablet 1
mg 50 mg
oxycodone hcl oral tablet TREZIX 3 QL; E
3 QL; E
5 mg TRILURON M
OXYCODONE- ULTRAM 3 E
ACETAMINOPHEN 3 E
VTOL LQ 3 QL
ORAL SOLUTION
XTAMPZA ER 2 PA; QL
OXYCODONE-
ACETAMINOPHEN ZEBUTAL 3 QL
ORAL TABLET 10-300 3 QL; E 3 PA; QL
ZTLIDO
MG, 2.5-300 MG, 5-300
MG Analgesics - Drugs for
Pain and Inflammation
oxycodone-
CATAFLAM 3 E
acetaminophen oral
tablet 10-325 mg, 2.5- 1 CELEBREX 3 QL; E
325 mg, 5-325 mg, 7.5- celecoxib oral 3 QL
325 mg
diclofenac potassium oral 3 E
OXYCONTIN 3 PA; QL; E tablet 25 mg
PERCOCET 3 E diclofenac potassium oral 1
premium lidocaine 1 tablet 50 mg
PROLATE ORAL diclofenac sodium er 1
3 E
SOLUTION diclofenac sodium 3 E
PROLATE ORAL external gel 1 %
3 QL; E
TABLET diclofenac sodium
3 E
QDOLO 3 PA; QL; E external solution
ROXICODONE ORAL diclofenac sodium oral 1
3 E
TABLET 15 MG, 30 MG EC-NAPROSYN 3
ROXICODONE ORAL ec-naproxen 1
3 QL; E
TABLET 5 MG
etodolac er 1
SUBSYS 3 PA; QL; E
etodolac oral capsule 1 QL
SUPARTZ FX M
etodolac oral tablet 400
(generic for 3 E
mg
3 Ryzolt);
tramadol hcl er (biphasic) QL; E etodolac oral tablet 500
1
mg
TRAMADOL HCL ER PA;
(generic for ibu 1
ORAL CAPSULE 3
EXTENDED RELEASE Conzip); ibuprofen oral
3 E
24 HOUR QL suspension
8Requirem Requirem
Drug Drug
Drug Name ents & Drug Name ents &
Tier Tier
Limits Limits
ibuprofen oral tablet 400 naproxen sodium oral
1 1
mg, 600 mg, 800 mg tablet 275 mg, 550 mg
INDOCIN 3 PA PENNSAID 3 E
indomethacin er 1 RELAFEN 3 E
INDOMETHACIN ORAL RELAFEN DS 3 E
3 E
CAPSULE 20 MG SPRIX 3 ST; QL
indomethacin oral 1 TIVORBEX 3 E
capsule 25 mg, 50 mg
VIVLODEX 3 QL; E
KETOROLAC
TROMETHAMINE 3 ST; QL ZIPSOR 3 E
NASAL Anti-Addiction /
Substance Abuse
ketorolac tromethamine
1 QL Treatment Agents
oral
LODINE 3 E buprenorphine hcl 3 QL
sublingual
meloxicam oral capsule 3 QL; E
buprenorphine hcl-
meloxicam oral tablet 1 naloxone hcl sublingual 1 QL
MOBIC 3 E film 12-3 mg, 4-1 mg, 8-2
nabumetone oral 1 mg
NAPRELAN ORAL buprenorphine hcl-
naloxone hcl sublingual 1 PA; QL
TABLET EXTENDED
3 film 2-0.5 mg
RELEASE 24 HOUR 375
MG, 500 MG buprenorphine hcl-
naloxone hcl sublingual 2 QL
NAPRELAN ORAL
TABLET EXTENDED tablet sublingual
3 E
RELEASE 24 HOUR 750 KLOXXADO 2 QL
MG naloxone hcl injection M
NAPROSYN ORAL naltrexone hcl oral 1
3 PA; E
SUSPENSION
NARCAN 3
NAPROSYN ORAL
3 E SUBOXONE
TABLET
SUBLINGUAL FILM 12-3 3 QL
naproxen oral 3 E MG, 4-1 MG, 8-2 MG
suspension
SUBOXONE
naproxen oral tablet 1 SUBLINGUAL FILM 2- 3 PA; QL
naproxen oral tablet 0.5 MG
1
delayed release varenicline tartrate 3 H
naproxen sodium er oral ZUBSOLV 1 QL
tablet extended release 3
Antibacterials - Drugs
24 hour 375 mg, 500 mg
for Infections
NAPROXEN SODIUM
ACTICLATE 3 E
ER ORAL TABLET
3
EXTENDED RELEASE amoxicillin oral capsule 1
24 HOUR 750 MG amoxicillin oral
1
suspension reconstituted
9Requirem Requirem
Drug Drug
Drug Name ents & Drug Name ents &
Tier Tier
Limits Limits
amoxicillin oral tablet 1 doxycycline hyclate oral
1
AMOXICILLIN ORAL tablet 100 mg, 20 mg
2
TABLET CHEWABLE doxycycline hyclate oral
amoxicillin-pot tablet 150 mg, 50 mg, 75 3 E
1 mg
clavulanate
amoxicillin-pot doxycycline hyclate oral
1 tablet delayed release
clavulanate er 3 E
100 mg, 150 mg, 200
AUGMENTIN 3 E mg, 50 mg, 75 mg
AUGMENTIN ES-600 3 E DOXYCYCLINE
avidoxy 3 HYCLATE ORAL 3 E
azithromycin oral 1 TABLET DELAYED
RELEASE 80 MG
BACTRIM 3
doxycycline monohydrate
BACTRIM DS 3 oral capsule 100 mg, 50 1
cefadroxil oral capsule 1 QL mg, 75 mg
cefadroxil oral doxycycline monohydrate
1 3 QL; E
suspension reconstituted oral capsule 150 mg
cefadroxil oral tablet 1 QL doxycycline monohydrate
1 oral suspension 3
cefdinir
reconstituted
cefuroxime axetil 1
doxycycline monohydrate 3
CENTANY 3 oral tablet
CENTANY AT 3 FLAGYL 3
cephalexin 1 levofloxacin oral 1
CIPRO ORAL TABLET 3 LYMEPAK 3 E
ciprofloxacin hcl oral 1 metronidazole oral 3
clarithromycin er 1 capsule
clarithromycin oral 1 metronidazole oral tablet 1
CLEOCIN ORAL metronidazole vaginal 1
3
CAPSULE MINOCYCLINE HCL ER
clindamycin hcl oral 1 ORAL CAPSULE
3 PA; E
CLINDESSE 3 EXTENDED RELEASE
24 HOUR
coremino 3 E
minocycline hcl er oral
DIFICID ORAL tablet extended release 3 E
SUSPENSION 3 QL 24 hour
RECONSTITUTED
minocycline hcl oral 1
DIFICID ORAL TABLET 3 capsule 100 mg, 50 mg
DORYX 3 E minocycline hcl oral
3
DORYX MPC 3 E capsule 75 mg
doxycycline hyclate oral minocycline hcl oral
1 3 E
capsule tablet
MINOLIRA 3 PA; E
10Requirem Requirem
Drug Drug
Drug Name ents & Drug Name ents &
Tier Tier
Limits Limits
mondoxyne nl 1 Anticonvulsants -
1 QL Drugs for Seizures
mupirocin calcium
mupirocin external 1 carbamazepine er oral
capsule extended 1
NUVESSA 3 E release 12 hour
NUZYRA ORAL 3 QL carbamazepine er oral
penicillin v potassium 1 tablet extended release 3
SOLODYN 3 E 12 hour
sulfamethoxazole- carbamazepine oral
1 3
trimethoprim oral suspension
sulfatrim pediatric 1 carbamazepine oral
3
tablet
TARGADOX 3 E
carbamazepine oral 1
vandazole 1 tablet chewable
VIBRAMYCIN ORAL CARBATROL 3
3
CAPSULE
DEPAKOTE 3 E
VIBRAMYCIN ORAL
3 DEPAKOTE ER 3 E
SUSPENSION
RECONSTITUTED DEPAKOTE SPRINKLES 3 E
XENLETA ORAL 3 DIASTAT ACUDIAL 3 QL
XEPI 3 QL DIASTAT PEDIATRIC 3 QL
XIMINO 3 PA; E diazepam rectal 1 QL
ZITHROMAX ORAL 3 divalproex sodium er 3
ZITHROMAX TRI-PAK 3 divalproex sodium oral 1
ZITHROMAX Z-PAK 3 ELEPSIA XR 3 PA; E
Anticoagulants - Drugs epitol 3
to Treat or Prevent gabapentin oral capsule 1
Blood Clots
gabapentin oral solution
ELIQUIS 2 QL 1
250 mg/5ml
ELIQUIS DVT/PE 2 QL gabapentin oral tablet 1
STARTER PACK
KEPPRA ORAL 3 E
enoxaparin sodium M QL
KEPPRA XR 3
jantoven 1
LAMICTAL 3 E
LOVENOX M QL
LAMICTAL ODT ORAL
PRADAXA 2 QL 3 QL
KIT
warfarin sodium oral 1 LAMICTAL ODT ORAL
3
XARELTO ORAL 2 QL TABLET DISPERSIBLE
TABLET LAMICTAL STARTER
XARELTO STARTER 2 QL ORAL KIT 35 X 25 MG, 3
PACK 42 X 25 MG & 7 X 100
MG
11Requirem Requirem
Drug Drug
Drug Name ents & Drug Name ents &
Tier Tier
Limits Limits
LAMICTAL STARTER topiramate er 3 ST
ORAL KIT 84 X 25 MG & 3 QL topiramate oral 1
14X100 MG
TRILEPTAL 3 PA
LAMICTAL XR ORAL 3
KIT TROKENDI XR 3 ST
LAMICTAL XR ORAL VALTOCO 10 MG DOSE 3 ST; QL
TABLET EXTENDED 3 E VALTOCO 15 MG DOSE 3 ST; QL
RELEASE 24 HOUR VALTOCO 20 MG DOSE 3 ST; QL
lamotrigine er 3 VALTOCO 5 MG DOSE 3 ST; QL
lamotrigine oral kit 3 QL VIMPAT ORAL 3 PA
lamotrigine oral tablet 1 XCOPRI 3 PA
lamotrigine oral tablet XCOPRI (250 MG DAILY
1 3 PA
chewable DOSE)
lamotrigine oral tablet XCOPRI (350 MG DAILY
3 3 PA
dispersible DOSE)
lamotrigine starter kit- ZONEGRAN 3 PA
1
blue
zonisamide oral 1
lamotrigine starter kit- 1 QL Antidementia Agents -
green
Drugs for Alzheimer's
lamotrigine starter kit- 1 Disease and Dementia
orange
ARICEPT 3 E
levetiracetam er 1
donepezil hcl oral tablet
levetiracetam oral 1 1
10 mg, 5 mg
NAYZILAM 3 PA; ST; QL donepezil hcl oral tablet 3 E
NEURONTIN 3 E 23 mg
oxcarbazepine 1 donepezil hcl oral tablet 1
OXTELLAR XR 3 ST; E dispersible
3 ST Antidepressants -
QUDEXY XR
Drugs for Depression
roweepra 1
amitriptyline hcl oral 1
SPRITAM 3 E
bupropion hcl er (sr) 1
subvenite 1
bupropion hcl er (xl) oral
subvenite starter kit-blue 1 tablet extended release 1 QL
subvenite starter kit- 24 hour 150 mg, 300 mg
1 QL
green BUPROPION HCL ER
subvenite starter kit- (XL) ORAL TABLET 1 QL
1
orange EXTENDED RELEASE
TEGRETOL 3 24 HOUR 450 MG
3 bupropion hcl oral 1
TEGRETOL-XR
3 E CELEXA 3
TOPAMAX
3 E citalopram hydrobromide 1
TOPAMAX SPRINKLE
CYMBALTA 3 QL; E
12Requirem Requirem
Drug Drug
Drug Name ents & Drug Name ents &
Tier Tier
Limits Limits
desvenlafaxine succinate PAXIL ORAL
3 QL 3
er SUSPENSION
doxepin hcl oral capsule 1 PAXIL ORAL TABLET 3 E
doxepin hcl oral PRISTIQ 3 QL; E
1
concentrate PROZAC 3 E
DRIZALMA SPRINKLE 3 QL; AE REMERON 3 E
duloxetine hcl oral REMERON SOLTAB 3 E
capsule delayed release 1 QL
particles 20 mg, 30 mg, SERTRALINE HCL
3 E
60 mg ORAL CAPSULE
duloxetine hcl oral sertraline hcl oral
1
capsule delayed release 3 E concentrate
particles 40 mg sertraline hcl oral tablet 1
EFFEXOR XR 3 E trazodone hcl oral 1
escitalopram oxalate oral TRINTELLIX 3 ST; QL
3
solution venlafaxine hcl 1
escitalopram oxalate oral 1 venlafaxine hcl er oral
tablet capsule extended 1
fluoxetine hcl oral 1 release 24 hour
capsule venlafaxine hcl er oral
fluoxetine hcl oral tablet extended release 3 QL
3 QL
capsule delayed release 24 hour
fluoxetine hcl oral VIIBRYD 3 QL
1
solution VIIBRYD STARTER
3 QL
fluoxetine hcl oral tablet PACK
3
10 mg, 20 mg WELLBUTRIN SR 3
fluoxetine hcl oral tablet WELLBUTRIN XL 3 QL; E
3 E
60 mg
ZOLOFT 3 E
fluvoxamine maleate 1
Antiemetics - Drugs for
fluvoxamine maleate er 3 Nausea and Vomiting
FORFIVO XL 3 QL BONJESTA 3 PA; E
LEXAPRO 3 E DICLEGIS 3 PA; QL; E
mirtazapine oral 1 doxylamine-pyridoxine 3 PA; QL; E
nortriptyline hcl oral 1 GIMOTI 3 QL; E
PAMELOR 3 E metoclopramide hcl oral
1
paroxetine hcl er 1 QL solution
paroxetine hcl oral metoclopramide hcl oral
3 1
suspension tablet
paroxetine hcl oral tablet 1 metoclopramide hcl oral
3
PAXIL CR 3 QL; E tablet dispersible
ondansetron 1
13Requirem Requirem
Drug Drug
Drug Name ents & Drug Name ents &
Tier Tier
Limits Limits
ondansetron hcl oral nystatin mouth/throat 1
1
solution nystop 1 QL
ondansetron hcl oral 1 QL terbinafine hcl oral 1 QL
tablet 24 mg
terconazole 1
ondansetron hcl oral 1
tablet 4 mg, 8 mg XOLEGEL 3
Antigout Agents -
prochlorperazine maleate 1 Drugs for Gout
oral
allopurinol oral 1
promethazine hcl oral 1
tablet COLCHICINE ORAL
3 E
promethazine hcl rectal 1 CAPSULE
promethegan 1 colchicine tablet 0.6 mg
1
oral
REGLAN 3
colchicine tablet 0.6 mg 3 ST; E
scopolamine 3 oral
TRANSDERM-SCOP 3 E COLCRYS 3
ZUPLENZ 3 QL febuxostat 1 ST; QL
Antifungals - Drugs for GLOPERBA 3 PA
Fungal Infections
MITIGARE 3 E
ciclodan 1
ULORIC 3 ST; QL; E
ciclopirox external 1
ZYLOPRIM 3
ciclopirox treatment 3
Antimigraine Agents -
CRESEMBA ORAL 3 Drugs for Migraines
DIFLUCAN 3 E AIMOVIG
EXTINA 3 ST SUBCUTANEOUS M QL
fluconazole oral 1 SOLUTION AUTO-
INJECTOR 140 MG/ML
GYNAZOLE-1 3
AIMOVIG
ketoconazole external 1 QL SUBCUTANEOUS
cream M
SOLUTION AUTO-
ketoconazole external INJECTOR 70 MG/ML
3 ST
foam AMERGE 3 QL; E
ketoconazole external 1 eletriptan hydrobromide 3 QL
shampoo
EMGALITY (300 MG M QL
ketodan external foam 3 ST DOSE)
LOPROX EXTERNAL EMGALITY
3 E
SHAMPOO SUBCUTANEOUS M QL
nyamyc 1 QL SOLUTION AUTO-
nystatin external cream 1 QL INJECTOR
nystatin external EMGALITY
1 QL SUBCUTANEOUS
ointment M
SOLUTION PREFILLED
nystatin external powder 1 SYRINGE
14Requirem Requirem
Drug Drug
Drug Name ents & Drug Name ents &
Tier Tier
Limits Limits
IMITREX ORAL 3 QL; E capecitabine 1 QL
IMITREX STATDOSE ERIVEDGE 2 PA; QL
M QL
REFILL ERLEADA 2 PA; QL
IMITREX STATDOSE FEMARA 3 E
M QL
SYSTEM
fluorouracil external
MAXALT 3 QL; E 1
solution
MAXALT-MLT 3 QL; E IBRANCE 2 PA; QL
naratriptan hcl 1 QL IDHIFA 2 PA; QL
ONZETRA XSAIL 3 QL; E KOSELUGO 2 PA; QL
RELPAX 3 QL; E letrozole oral 1
REYVOW 2 PA; QL LYNPARZA 2 PA; QL
rizatriptan benzoate 1 QL mercaptopurine oral 1
sumatriptan succinate NUBEQA 2 PA; QL
1 QL
oral
ODOMZO 2 PA; QL
sumatriptan succinate M QL ORGOVYX 3 PA; QL
refill
PURIXAN 3 PA
sumatriptan succinate M QL
subcutaneous REVLIMID 3 PA; QL
UBRELVY 2 PA; QL ROZLYTREK 3 PA; QL
ZEMBRACE SOLTAMOX 3
M QL
SYMTOUCH tamoxifen citrate oral 1
ZOLMITRIPTAN NASAL 3 QL; E tablet 10 mg
SOLUTION 2.5 MG tamoxifen citrate oral 1 H-PA
zolmitriptan nasal tablet 20 mg
3 QL; E
solution 5 mg TARGRETIN EXTERNAL 3
zolmitriptan oral tablet 1 QL TARGRETIN ORAL 2
zolmitriptan oral tablet TASIGNA 2 PA; QL
3 QL
dispersible
UKONIQ 3 PA; QL
ZOMIG NASAL
3 QL VERZENIO 2 PA; QL
SOLUTION 2.5 MG
VITRAKVI 2 PA; QL
ZOMIG NASAL 2 QL
SOLUTION 5 MG XELODA 3 QL; E
ZOMIG ORAL 3 QL; E ZEJULA 2 PA; QL
Antineoplastics - Drugs Antiparasitics - Drugs
for Cancer for Parasitic Infections
ALECENSA 3 PA; QL ARAKODA 3 QL
ALUNBRIG 2 PA; QL atovaquone-proguanil hcl 3
anastrozole oral 1 hydroxychloroquine 1
ARIMIDEX 3 sulfate oral
3 E KRINTAFEL 1 QL
bexarotene
2 PA; QL MALARONE 3
CALQUENCE
15Requirem Requirem
Drug Drug
Drug Name ents & Drug Name ents &
Tier Tier
Limits Limits
permethrin external 1 ABILIFY MYCITE
PLAQUENIL 3 E STARTER KIT ORAL 3 QL; E
TABLET 10 MG, 15 MG,
Antiparkinson Agents -
2 MG, 20 MG, 5 MG
Drugs for Parkinson's
Disease ABILIFY MYCITE
STARTER KIT ORAL 3 E
APOKYN M QL
TABLET 30 MG
carbidopa-levodopa er 1 1 QL
aripiprazole
carbidopa-levodopa oral 1 asenapine maleate 3 QL; E
tablet
GEODON ORAL 3 QL; E
carbidopa-levodopa oral 3
tablet dispersible LATUDA 3 QL
DUOPA 3 PA olanzapine oral 1 QL
INBRIJA 3 PA; QL PERSERIS M
KYNMOBI 3 PA; QL quetiapine fumarate 1 QL
KYNMOBI TITRATION quetiapine fumarate er 1 QL
3 PA; E
KIT RISPERDAL 3 QL; E
MIRAPEX ER 3 E risperidone 1 QL
NOURIANZ 3 PA; QL SAPHRIS 3 QL
pramipexole SEROQUEL 3 QL; E
1
dihydrochloride SEROQUEL XR 3 QL; E
pramipexole 3 E VRAYLAR 3 QL
dihydrochloride er
ziprasidone hcl 1 QL
ropinirole hcl 1
ZYPREXA ORAL 3 QL; E
ropinirole hcl er 3 E
ZYPREXA ZYDIS 3 QL
RYTARY 3 E
Antivirals - Drugs for
SINEMET 3 Viral Infections
Antiplatelets - Drugs 1
acyclovir oral
for Heart Attack and
Stroke Prevention ATRIPLA 3 E
BRILINTA 2 BARACLUDE ORAL 3 QL
SOLUTION
clopidogrel bisulfate oral 1
BARACLUDE ORAL 3 QL; E
PLAVIX 3
TABLET
ZONTIVITY 3 QL 2
CIMDUO
Antipsychotics - Drugs 2 H-PA
DESCOVY
for Mood Disorders
DOVATO 2
ABILIFY 3 QL; E
efavirenz-emtricitab- 1
ABILIFY MYCITE 3 PA; QL; E
tenofovir
ABILIFY MYCITE efavirenz-lamivudine-
3 QL; E 1 QL
MAINTENANCE KIT tenofovir
16Requirem Requirem
Drug Drug
Drug Name ents & Drug Name ents &
Tier Tier
Limits Limits
emtricitabine-tenofovir df STRIBILD 2
oral tablet 100-150 mg, 1 SYMFI 3 QL
133-200 mg, 167-250 mg
SYMFI LO 3 QL
emtricitabine-tenofovir df 1 H-PA
oral tablet 200-300 mg TAMIFLU ORAL
3
CAPSULE
entecavir 1 QL
TAMIFLU ORAL
EPCLUSA ORAL 2 PA; QL SUSPENSION 3 QL; E
PACKET 150-37.5 MG RECONSTITUTED
EPCLUSA ORAL 2 PA TEMIXYS 2
PACKET 200-50 MG
tenofovir disoproxil 1 H-PA
EPCLUSA ORAL fumarate
2 PA; QL
TABLET
TIVICAY 2
GENVOYA 2
TIVICAY PD 2
HARVONI ORAL
3 QL; E TRIUMEQ 2
PACKET
HARVONI ORAL TRUVADA ORAL
2 PA; QL TABLET 100-150 MG,
TABLET 3
133-200 MG, 167-250
ISENTRESS 2 MG
ISENTRESS HD 2 TRUVADA ORAL
3 E; H-PA
JULUCA 2 TABLET 200-300 MG
LEDIPASVIR- valacyclovir hcl oral 1 QL
2 PA; QL
SOFOSBUVIR VALTREX 3 QL; E
MAVYRET ORAL 2 PA; QL VEMLIDY 3 ST
TABLET
VIREAD ORAL TABLET
NORVIR ORAL PACKET 2 2
150 MG, 200 MG, 250
NORVIR ORAL 2 MG
SOLUTION VIREAD ORAL TABLET 3 E
NORVIR ORAL TABLET 3 300 MG
ODEFSEY 2 VOSEVI 2 PA; QL
oseltamivir phosphate 3 XOFLUZA (40 MG 3 QL
oral capsule DOSE)
oseltamivir phosphate XOFLUZA (80 MG 3 QL
oral suspension 3 QL DOSE)
reconstituted ZEPATIER 2 PA; QL
PREZCOBIX 2 ZOVIRAX ORAL 3
PREZISTA 2 Anxiolytics - Drugs for
ritonavir 1 Anxiety
RUKOBIA 2 alprazolam er 1 QL
SITAVIG 3 alprazolam intensol 3 QL
SOFOSBUVIR- alprazolam oral tablet 1 QL
2 PA; QL
VELPATASVIR
17Requirem Requirem
Drug Drug
Drug Name ents & Drug Name ents &
Tier Tier
Limits Limits
alprazolam oral tablet ALDACTONE 3 E
3 QL
dispersible aliskiren fumarate 3
alprazolam xr 1 QL ALTACE 3 E
ATIVAN ORAL 3 QL; E ALTOPREV 3 E
buspirone hcl oral 1 amiodarone hcl oral 1
clonazepam oral tablet 1 amlodipine besy-
1
clonazepam oral tablet benazepril hcl
1 QL
dispersible amlodipine besylate oral 1
diazepam intensol 3 amlodipine besylate-
3 QL; E
diazepam oral valsartan
3
concentrate atenolol oral 1
diazepam oral solution 3 atenolol-chlorthalidone 1
diazepam oral tablet 1 atorvastatin calcium oral
1 QL; H-PA
HALCION 3 QL tablet 10 mg, 20 mg
hydroxyzine hcl oral 1 atorvastatin calcium oral 1 QL
hydroxyzine pamoate tablet 40 mg, 80 mg
1
oral AVALIDE 3 E
KLONOPIN ORAL AVAPRO 3 E
3 E
TABLET 1 MG benazepril hcl oral 1
lorazepam intensol 3 QL
benazepril- 1
lorazepam oral 3 QL hydrochlorothiazide
concentrate 2 mg/ml BENICAR 3 E
lorazepam oral tablet 1 QL 3 E
BENICAR HCT
LOREEV XR 3 E 3 E
BETAPACE
triazolam 1 QL 3
BIDIL
VALIUM 3 1
bisoprolol fumarate oral
VISTARIL 3 bisoprolol-
1
XANAX 3 QL hydrochlorothiazide
XANAX XR 3 QL BYSTOLIC 3 E
Bipolar Agents - Drugs CALAN SR 3
for Mood Disorders 3 E
CARDIZEM
lithium carbonate er 1 PA 3 E
CARDIZEM CD
lithium carbonate oral 1
CARDIZEM LA ORAL
LITHOBID 3 PA TABLET EXTENDED 3
Cardiovascular Agents RELEASE 24 HOUR 120
- Drugs for Heart and MG
Circulation Conditions CARDIZEM LA ORAL
ACCUPRIL 3 E TABLET EXTENDED
RELEASE 24 HOUR 180 3 E
acetazolamide er 1
MG, 240 MG, 300 MG,
acetazolamide oral 1 360 MG, 420 MG
18Requirem Requirem
Drug Drug
Drug Name ents & Drug Name ents &
Tier Tier
Limits Limits
CARDURA 3 EZALLOR SPRINKLE 3 PA
CAROSPIR 3 PA ezetimibe 3
cartia xt 1 ezetimibe-simvastatin 3
carvedilol 1 fenofibrate oral capsule
1
chlorthalidone 1 150 mg, 50 mg
clonidine hcl oral 1 fenofibrate oral tablet 120
3 E
mg
colesevelam hcl oral
3 QL; E fenofibrate oral tablet 145
packet 3
mg
colesevelam hcl oral
3 E fenofibrate oral tablet 160
tablet 1
mg, 48 mg, 54 mg
COREG 3 E
fenofibrate oral tablet 40 3 QL; E
CORGARD 3 mg
CORLANOR 3 PA; QL FENOGLIDE ORAL 3 E
COZAAR 3 E TABLET 120 MG
CRESTOR 3 QL; E FENOGLIDE ORAL
3 QL; E
diltiazem hcl er 1 TABLET 40 MG
diltiazem hcl er coated flecainide acetate 1
beads oral capsule FLOLIPID 3 PA
extended release 24 hour 1 furosemide oral 1
120 mg, 180 mg, 240
mg, 300 mg gemfibrozil oral 1
diltiazem hcl er coated guanfacine hcl 1
beads oral capsule HEMANGEOL 3
3
extended release 24 hour hydralazine hcl oral 1
360 mg
hydrochlorothiazide oral 1
diltiazem hcl er coated
3 HYZAAR 3 E
beads oral tablet
extended release 24 hour icosapent ethyl 3 PA; E
diltiazem hcl oral 1 INDERAL LA 3 E
dilt-xr 1 irbesartan 1
DIOVAN 3 QL; E irbesartan- 1
DIOVAN HCT 3 QL; E hydrochlorothiazide
1 isosorbide mononitrate 1
doxazosin mesylate oral
3 E isosorbide mononitrate er 1
EDARBI
EDARBYCLOR 3 ST KAPSPARGO 3
SPRINKLE
enalapril maleate oral 3 PA labetalol hcl oral 1
solution
LASIX 3
enalapril maleate oral 1
tablet LIPITOR 3 QL; E
EPANED 3 PA LIPOFEN 3 E
EXFORGE 3 QL; E lisinopril oral 1
19Requirem Requirem
Drug Drug
Drug Name ents & Drug Name ents &
Tier Tier
Limits Limits
lisinopril- nitroglycerin sublingual 1
1
hydrochlorothiazide nitroglycerin transdermal 3
LOPID 3 nitroglycerin translingual 3
LOPRESSOR 3 NITROLINGUAL 3
losartan potassium oral 1 NITROMIST 3
losartan potassium-hctz 1 NITROSTAT 3
LOTENSIN 3 NITRO-TIME 2
LOTENSIN HCT 3 NORVASC 3 E
LOTREL 3 E olmesartan medoxomil 1
lovastatin oral 1 H-PA oral
LOVAZA 3 E olmesartan medoxomil-
1
matzim la 3 hctz
MAXZIDE 3 omega-3-acid ethyl
1
esters
MAXZIDE-25 3
PACERONE 3
metoprolol succinate er 1
PRALUENT M QL
metoprolol tartrate oral
tablet 100 mg, 25 mg, 50 1 pravastatin sodium 1
mg prazosin hcl oral 1
metoprolol tartrate oral PROCARDIA XL 3 E
3 E
tablet 37.5 mg, 75 mg propranolol hcl er 1
MICARDIS 3 QL; E propranolol hcl oral 1
MINIPRESS 3 QBRELIS 3 E
MULTAQ 3 PA quinapril hcl 1
nadolol oral 1 ramipril 1
nebivolol hcl 3 E RANEXA 3 E
NEXLETOL 2 PA; QL ranolazine er 1
NEXLIZET 2 QL REPATHA M QL
niacin REPATHA
3 E M QL
(antihyperlipidemic) PUSHTRONEX SYSTEM
niacin er REPATHA SURECLICK M QL
1
(antihyperlipidemic)
rosuvastatin calcium 1 QL
niacor 3 E
simvastatin oral tablet 10 1 H-PA
NIASPAN 3 E mg, 20 mg, 40 mg, 5 mg
nifedipine er 1 simvastatin oral tablet 80
1
nifedipine er osmotic mg
1
release sotalol hcl oral 1
nifedipine oral 1 SOTYLIZE 3
NITRO-BID 2 spironolactone oral 1
NITRO-DUR 3 TEKTURNA 3
20Requirem Requirem
Drug Drug
Drug Name ents & Drug Name ents &
Tier Tier
Limits Limits
TEKTURNA HCT 3 amphetamine-
3 QL; E
telmisartan 1 QL dextroamphet er
TENORETIC 100 3 E amphetamine- 1 QL
dextroamphetamine
TENORETIC 50 3 E
APTENSIO XR 3 QL; E
TENORMIN 3 E
atomoxetine hcl 3 QL
THALITONE 3 E
CONCERTA 2 QL
TOPROL XL 3 E
DEXEDRINE 3 QL; E
torsemide 1
dexmethylphenidate hcl 1 QL
triamterene-hctz 1
dexmethylphenidate hcl
TRICOR ORAL TABLET 1 QL
3 E er
145 MG
dextroamphetamine 1 QL
TRICOR ORAL TABLET sulfate er
3
48 MG
dextroamphetamine 3 QL
valsartan 1 QL sulfate oral solution
valsartan- dextroamphetamine
1 QL 3 E
hydrochlorothiazide sulfate oral tablet
VASCEPA 3 PA; E FOCALIN 3 QL
VASOTEC 3 E FOCALIN XR 3 ST; QL
verapamil hcl er 1 guanfacine hcl er 1 QL
verapamil hcl oral 1 INTUNIV 3 QL; E
VERELAN 3 JORNAY PM 3 QL; E
VERELAN PM 3 METHYLIN 3 ST; QL
VERQUVO 3 PA; QL
methylphenidate hcl er 1 QL
VYTORIN 3 E (cd)
WELCHOL ORAL 2 QL methylphenidate hcl er
PACKET (la) oral capsule
WELCHOL ORAL extended release 24 hour 1 QL
2 10 mg, 20 mg, 30 mg, 40
TABLET
mg
ZESTORETIC 3 E
methylphenidate hcl er
ZESTRIL 3 E (la) oral capsule 3 QL
ZETIA 3 E extended release 24 hour
ZIAC 3 60 mg
ZOCOR 3 E methylphenidate hcl er
3 QL; E
(xr)
Central Nervous
System Agents - Drugs methylphenidate hcl er
for Attention Deficit oral tablet extended 3 QL
Disorder release 10 mg, 20 mg
ADDERALL 3 QL; E
ADDERALL XR 2 QL; AE
ADHANSIA XR 3 QL; E
21Requirem Requirem
Drug Drug
Drug Name ents & Drug Name ents &
Tier Tier
Limits Limits
methylphenidate hcl er KESIMPTA M QL
oral tablet extended 3 QL; E MAVENCLAD (10 TABS) 3 PA; QL
release 18 mg, 27 mg, 36
mg, 54 mg MAVENCLAD (4 TABS) 3 PA; QL
methylphenidate hcl er MAVENCLAD (5 TABS) 3 PA; QL
oral tablet extended 3 ST; QL; AE MAVENCLAD (6 TABS) 3 PA; QL
release 24 hour MAVENCLAD (7 TABS) 3 PA; QL
methylphenidate hcl er MAVENCLAD (8 TABS) 3 PA; QL
oral tablet extended 3 ST; QL; E
MAVENCLAD (9 TABS) 3 PA; QL
release 72 mg
MAYZENT 3 PA; QL
methylphenidate hcl oral 3 QL
solution PLEGRIDY M QL
methylphenidate hcl oral INTRAMUSCULAR
1
tablet PLEGRIDY STARTER
M
methylphenidate hcl oral PACK
3 QL
tablet chewable PLEGRIDY
M
MYDAYIS 3 ST; QL; E SUBCUTANEOUS
PROCENTRA 3 ST; QL REBIF M QL
QUILLICHEW ER 3 ST; QL; E REBIF REBIDOSE M QL
QUILLIVANT XR 3 ST; QL REBIF REBIDOSE
M QL
TITRATION PACK
relexxii 3 ST; QL; E
REBIF TITRATION M QL
RITALIN 3 E
PACK
RITALIN LA 3 ST; QL Central Nervous
STRATTERA 3 QL; E System Agents -
3 QL Miscellaneous
VYVANSE
3 ST; E AUSTEDO 2 PA; QL
ZENZEDI
Central Nervous EXSERVAN 3 PA; E
System Agents - Drugs LYRICA 3 PA; QL
for Multiple Sclerosis LYRICA CR 3 ST; QL; E
AMPYRA 3 PA; QL; E 3 PA; QL
NUEDEXTA
AUBAGIO 3 PA; QL 3 ST; QL; E
pregabalin er
AVONEX PEN M QL 1 QL
pregabalin oral capsule
AVONEX PREFILLED M QL 3 QL
pregabalin oral solution
BAFIERTAM 2 PA; QL 3 E
RILUTEK
BETASERON M 3
riluzole
COPAXONE M QL 3 PA
TIGLUTIK
dalfampridine er 1 PA; QL 3 PA; QL
ZEPOSIA
EXTAVIA M ZEPOSIA 7-DAY
3 PA; QL
GILENYA 3 PA; QL STARTER PACK
glatiramer acetate M QL ZEPOSIA STARTER KIT 3 PA; QL
glatopa M QL
22Requirem Requirem
Drug Drug
Drug Name ents & Drug Name ents &
Tier Tier
Limits Limits
Dental and Oral Agents calcipotriene-betameth
- Drugs for Mouth and diprop external 3 QL
Throat Conditions suspension
chlorhexidine gluconate calcitriol external 1
3
mouth/throat CAPEX 3
lidocaine hcl 3 CARAC 3 E
mouth/throat
claravis 1
lidocaine viscous hcl 1
CLEOCIN-T 3
PERIDEX 3
clindacin etz external 1
periogard 3
swab
Dermatological Agents 1
clindacin-p
- Drugs for Skin
Conditions CLINDAGEL 3 E
ABSORICA 3 PA clindamycin phos-
benzoyl perox external 3 QL; E
accutane oral capsule 20 gel 1.2-5 %
1
mg, 30 mg, 40 mg
clindamycin phosphate 3
ACZONE 3
external foam
ALA SCALP 3
clindamycin phosphate
3
ala-cort 3 E external gel
ALDARA 3 QL clindamycin phosphate
3
ALTRENO 3 QL; E; AE external lotion
amnesteem 1 clindamycin phosphate
1 QL
external solution
AMZEEQ 3 PA; QL
clindamycin phosphate 1
ATRALIN 3 QL; E; AE
external swab
AVAR CLEANSER 3
clobetasol propionate 1
AVAR LS CLEANSER 3 external cream
AVAR-E EMOLLIENT 3 clobetasol propionate 3 QL
AVAR-E GREEN 3 external foam
AVAR-E LS 3 clobetasol propionate 1
external gel
AVITA EXTERNAL 3 E; AE
CREAM clobetasol propionate
3 QL
external liquid
AVITA EXTERNAL GEL 3 PA; QL; E
clobetasol propionate
azelaic acid external 1 3
external lotion
betamethasone 1 clobetasol propionate
dipropionate aug 1
external ointment
betamethasone 1 clobetasol propionate
dipropionate external 3
external shampoo
bp 10-1 3
clobetasol propionate 1
calcipotriene-betameth external solution
3 QL; E
diprop external ointment CLOBEX 3 E
23Requirem Requirem
Drug Drug
Drug Name ents & Drug Name ents &
Tier Tier
Limits Limits
CLOBEX SPRAY 3 QL; E fluocinolone acetonide
1
clodan external shampoo 3 external
clotrimazole- fluocinolone acetonide 1
3 scalp
betamethasone
dapsone external gel 5 % 3 PA; E fluocinonide external 1
cream 0.05 %
DAPSONE EXTERNAL
3 E fluocinonide external
GEL 7.5 % 3
cream 0.1 %
DERMA-SMOOTHE/FS 3 fluocinonide external gel 1
BODY
DERMA-SMOOTHE/FS fluocinonide external 1
3 ointment
SCALP
desonide external cream 1 fluocinonide external
1
solution
desonide external gel 3
FLUOROPLEX 3
desonide external lotion 1
FLUOROURACIL
desonide external 1 EXTERNAL CREAM 0.5 3 E
ointment %
DESOWEN 3
fluorouracil external 1
desrx 3 cream 5 %
DIPROLENE 3 hydrocortisone external 3 E
DIPROLENE AF 3 cream 1 %
DUPIXENT hydrocortisone external 1
SUBCUTANEOUS cream 2.5 %
M QL
SOLUTION PEN- hydrocortisone external
1
INJECTOR lotion 2.5 %
DUPIXENT hydrocortisone external
3
SUBCUTANEOUS ointment 1 %
SOLUTION PREFILLED M hydrocortisone external
SYRINGE 100 1
ointment 2.5 %
MG/0.67ML
imiquimod external 3 QL
DUPIXENT cream 3.75 %
SUBCUTANEOUS
SOLUTION PREFILLED imiquimod external 1 QL
M QL cream 5 %
SYRINGE 200
MG/1.14ML, 300 IMIQUIMOD PUMP 3 QL
MG/2ML IMPEKLO 3 QL; E
EFUDEX 3 3 QL; E
IMPOYZ
ENSTILAR 3 QL
isotretinoin capsule 10 1
EUCRISA 3 ST mg oral
EVOCLIN 3 isotretinoin capsule 10 3 PA
FINACEA 3 ST mg oral
fluocinolone acetonide isotretinoin capsule 20
1 1
body mg oral
24Requirem Requirem
Drug Drug
Drug Name ents & Drug Name ents &
Tier Tier
Limits Limits
isotretinoin capsule 20 RETIN-A EXTERNAL
3 PA 3 PA; E
mg oral GEL
isotretinoin capsule 30 RHOFADE 3 PA; QL
1
mg oral rosadan external cream 1
isotretinoin capsule 30 3 PA rosadan external gel 3
mg oral
SERNIVO 3 E
isotretinoin capsule 40 1
mg oral SOOLANTRA 3 QL
isotretinoin capsule 40 sss 10-5 3
3 PA
mg oral sulfacetamide sodium-
3
isotretinoin oral capsule sulfur external cream
3 PA
25 mg, 35 mg sulfacetamide sodium-
3
ivermectin external sulfur external liquid
3 QL; E
cream sulfacetamide sodium-
KENALOG EXTERNAL 3 QL; E sulfur external lotion 10-5 1
%
KLISYRI 3 ST; QL
sulfacetamide sodium-
METROCREAM 3 sulfur external lotion 9.8- 3
METROGEL 3 E 4.8 %
METROLOTION 3 sulfacetamide sodium-
metronidazole external sulfur external pad 10-4 3
1 %
cream
metronidazole external sulfacetamide sodium-
3 sulfur external pad 9.8- 3 E
gel 0.75 %
4.8 %
metronidazole external 3 E
gel 1 % sulfacetamide sodium-
sulfur external 3
metronidazole external 1 suspension
lotion
sulfacetamide sod-sulfur
MIRVASO 2 QL 3
wash
mometasone furoate 1 SULFACLEANSE 8/4 3
external
sulfamez wash 3
myorisan 1
SUMADAN WASH 3
neuac external gel 3 QL; E
SUMAXIN 3
NORITATE 3
SYNALAR 3 E
OLUX 3 QL; E
TACLONEX EXTERNAL
PLEXION 3 3 QL; E
OINTMENT
PLEXION CLEANSER 3 TACLONEX EXTERNAL
3 QL
PLEXION CLEANSING 3 SUSPENSION
CLOTH tazarotene external 3 QL; AE
RETIN-A EXTERNAL 3 QL; E; AE cream
CREAM TAZORAC 3 QL; AE
TEMOVATE 3
25Requirem Requirem
Drug Drug
Drug Name ents & Drug Name ents &
Tier Tier
Limits Limits
TEXACORT 3 ACCU-CHEK FASTCLIX
1
tretinoin external cream 3 QL LANCET
tretinoin external gel 0.01 ACCU-CHEK FASTCLIX (Lifescan,
3 E; AE 1
%, 0.025 % LANCETS Roche); QL
tretinoin external gel 0.05 ACCU-CHEK GUIDE 3
3 QL; E; AE
% ACCU-CHEK GUIDE IN 3 QL
triamcinolone acetonide VITRO
3 QL
external aerosol solution ACCU-CHEK GUIDE ME 3
triamcinolone acetonide ACCU-CHEK (Lifescan,
1
external cream 0.025 %, 1 MULTICLIX LANCETS Roche); QL
0.1 % ACCU-CHEK SAFE-T (Lifescan,
1
triamcinolone acetonide PRO LANCETS Roche); QL
1 QL
external cream 0.5 % ACCU-CHEK
3 PA; QL
triamcinolone acetonide SMARTVIEW
1
external lotion ACCU-CHEK SOFTCLIX
1
triamcinolone acetonide LANCET DEV
1
external ointment ACCU-CHEK SOFTCLIX (Lifescan,
1
triamcinolone in LANCETS Roche); QL
1
absorbase ACCUTREND 3 PA; QL
TRIANEX 2 GLUCOSE
triderm external cream 1 ADVANCED MOBILE 2 QL
0.1 % LANCET
triderm external cream 1 QL AIMSCO TWIST 2 QL
0.5 % LANCETS 32G
TRIDESILON 3 AIMSCO TWIST 2 QL
tritocin 1 LANCETS 33G
VANOS 3 AQUALANCE LANCETS
2 QL
30G
VECTICAL 3 E
ASSURE COMFORT
VERDESO 3 2 QL
LANCETS 28G
WYNZORA 3 QL; E
AUTOLET LANCING 3
zenatane 1 DEVICE
ZILXI 3 PA; QL BD AUTOSHIELD DUO 2
ZYCLARA 3 QL; E BD INSULIN SYRINGE 2 QL
ZYCLARA PUMP 3 QL U-500
Diabetes - Glucose BD PEN NEEDLE 2
Monitoring MICRO U/F
ACCU-CHEK AVIVA CAREFINE PEN 2
3 PA; QL NEEDLES
PLUS IN VITRO
ACCU-CHEK COMPACT CARETOUCH INSULIN
3 PA; QL 2 QL
PLUS SYRINGE
26Requirem Requirem
Drug Drug
Drug Name ents & Drug Name ents &
Tier Tier
Limits Limits
CARETOUCH EASYMAX 15 TEST 3 PA; QL
3
LANCING/EJECTOR EASYMAX TEST 3 PA; QL
CARETOUCH PEN 2 EQ BLOOD GLUCOSE
NEEDLES 3 PA; QL
TEST
CARETOUCH SAFETY 2 QL FINGERSTIX LANCETS 2 QL
LANCETS
FORTISCARE G1 TEST
CARETOUCH SAFETY 3 PA; QL
2 QL STRIP
LANCETS 26G
FORTISCARE TEST 3 PA; QL
CARETOUCH TEST 3 PA; QL
FREESTYLE 3 PA; QL
CARETOUCH TWIST 2 QL PRECISION NEO TEST
LANCETS 28G
GENTLE-LET GP 2 QL
CARETOUCH TWIST LANCETS
2 QL
LANCETS 30G
GENTLE-LET LANCETS 2 QL
CARETOUCH TWIST
2 QL GENTLE-LET
LANCETS 33G 3 QL
PLATFORMS
(Lifescan,
1 GLUCOPRO INSULIN
COAGUCHEK LANCETS Roche); QL 2 QL
SYRINGE
COMFORT TOUCH 2
INSULIN PEN NEED KROGER LANCETS
2 QL
ULTRATHIN 30G
COMFORT TOUCH 2 QL
LANCETS 31G LANCET
3 QL
TRANSPORTER CASE
COMFORT TOUCH 2 QL
PLUS LANCETS 30G LANCETS MICRO THIN
2 QL
33G
CONTOUR NEXT TEST
2 QL LANCETS SUPER THIN
STRIP IN VITRO 2 QL
28G
CONTOUR NEXT TEST
3 PA; QL LEADER UNIFINE
STRIP IN VITRO
PENTIPS PLUS 31G X 5 2
CONTOUR TEST 3 PA; QL MM , 31G X 8 MM
CVS ADVANCED (Lifescan,
3 PA; QL 1
GLUCOSE TEST LIFESCAN UNISTIK 2 Roche); QL
CVS GLUCOSE METER 3 PA; QL LIFESCAN UNISTIK II (Lifescan,
TEST STRIPS 1
LANCETS Roche); QL
CVS LANCETS 2 QL MAXICOMFORT II PEN
ORIGINAL 2
NEEDLE
CVS LANCETS THIN 2 QL MAXI-COMFORT
26G 2 QL
INSULIN SYRINGE
CVS LANCING DEVICE 3
MAXI-COMFORT 2
CVS ULTRA THIN 2 QL SAFETY PEN NEEDLE
LANCETS MAXICOMFORT SYR 2 QL
D-CARE BLOOD 27G X 1/2"
3 PA; QL
GLUCOSE MICRODOT PEN
2
EASY TOUCH TEST 3 PA; QL NEEDLE
27Requirem Requirem
Drug Drug
Drug Name ents & Drug Name ents &
Tier Tier
Limits Limits
MICRODOT TEST 3 PA; QL ONETOUCH FINEPOINT (Lifescan,
1
MICROLET LANCETS 2 QL LANCETS Roche); QL
MICROLET NEXT ONETOUCH
3 SURESOFT LANCING 1 QL
LANCING DEVICE
DEV
MINI LANCING DEVICE 3
ONETOUCH ULTRA 1 QL
MM INSULIN
(Onetouch
SYRINGE/NEEDLE 30G
Ultrasoft
X 5/16" 0.3 ML, 30G X 2 QL
5/16" 0.5 ML, 31G X Plus
1
5/16" 0.3 ML, 31G X lancets)
5/16" 0.5 ML ONETOUCH (Lifescan,
ULTRASOFT LANCETS Roche); QL
MM LANCING DEVICE 3
ONETOUCH VERIO IN 1 QL
MM PEN NEEDLES 2 VITRO STRIP
MM TWIST LANCETS 2 QL OPTIUMEZ TEST 3 PA; QL
NEUTEK 2TEK TEST 3 PA; QL PEN NEEDLES 1/2" 2
NOVOFINE PEN NEEDLES 31G X 6
AUTOCOVER PEN 2 2
MM
NEEDLE
PEN NEEDLES 5/16" 2
NOVOFINE PEN 2
NEEDLE PENLET II BLOOD 1
SAMPLER
NOVOFINE PLUS PEN 2
NEEDLE PENLET II
1 QL
REPLACEMENT CAP
NOVOTWIST PEN 2
NEEDLE PENTIPS 29G X 12MM ,
31G X 5 MM , 31G X 8 2
ONETOUCH CLUB (Lifescan,
1 MM , 32G X 4 MM
LANCETS FINE PT Roche); QL
PRECISION SURE- 2 QL
ONETOUCH DELICA (Lifescan, DOSE SYRINGE
1
LANCETS 30G Roche); QL
PRECISION THINS GP 2 QL
ONETOUCH DELICA (Lifescan, LANCETS
1
LANCETS 33G Roche); QL
PRECISION XTRA 3 PA; QL
ONETOUCH DELICA 1 BLOOD GLUCOSE
LANCING DEV
PREMIUM BLOOD
(Onetouch 3 PA; QL
GLUCOSE TEST
Delica Plus
1 Lancets) PREVENT DROPSAFE
2
ONETOUCH DELICA (Lifescan, PEN NEEDLES
PLUS LANCET30G Roche); QL PREVENT SAFETY PEN 2
(Onetouch NEEDLES
Delica Plus PSS SELECT GP 2 QL
1 Lancets) LANCETS
ONETOUCH DELICA (Lifescan,
PSS SELECT 3 QL
PLUS LANCET33G Roche); QL PLATFORMS
ONETOUCH DELICA
1
PLUS LANCING
28Requirem Requirem
Drug Drug
Drug Name ents & Drug Name ents &
Tier Tier
Limits Limits
PSS SELECT SAFETY TRUEPLUS LANCETS
2 QL 2 QL
LANCETS 30G
QUINTET AC BLOOD 3 PA; QL TRUEPLUS LANCETS 2 QL
GLUCOSE TEST 33G
QUINTET BLOOD 3 PA; QL TRUEPLUS PEN 2
GLUCOSE TEST NEEDLES
RA INSULIN SYRINGE 2 QL TRUEPLUS SAFETY 2 QL
RA PEN NEEDLES 2 LANCETS 28G
TRUETRACK TEST 3 PA; QL
RELION INSULIN
SYRINGE 31G X 15/64" 2 QL ULTRA THIN PEN 2
0.3 ML, 31G X 15/64" 0.5 NEEDLES
ML ULTRA-THIN II INS SYR
2 QL
RELION TRUE METRIX SHORT
3 PA; QL
TEST STRIPS ULTRA-THIN II INSULIN
2 QL
RELION ULTIMA TEST 3 PA; QL SYRINGE
RELION ULTRA THIN ULTRA-THIN II
2 QL 2 QL
LANCETS 30G LANCETS
SAFE-T-LANCE 2 QL ULTRA-THIN II MINI 2
SAFE-T-LANCE PLUS 2 QL PEN NEEDLE
SB INSULIN SYRINGE ULTRA-THIN II PEN 2
29G X 1/2" 0.5 ML, 30G 2 QL NEEDLE SHORT
X 5/16" 0.5 ML ULTRA-THIN II PEN 2
SINGLE-LET 2 QL NEEDLES
THINLETS GP UNIFINE PENTIPS 29G
2 QL 2
LANCETS X 12MM
TRUE FOCUS BLOOD UNIFINE PENTIPS
3 PA; QL PLUS 31G X 5 MM , 31G
GLUCOSE STRIP
X 6 MM , 31G X 8 MM , 2
TRUE METRIX BLOOD 32G X 4 MM , 33G X 4
3 PA; QL
GLUCOSE TEST MM
TRUE METRIX PRO UNILET MICRO-THIN
3 PA; QL 2 QL
BLOOD GLUCOSE 33G
TRUEDRAW LANCING 3 UNILET SUPER-THIN
DEVICE 2 QL
30G
TRUEPLUS 5-BEVEL 2 UNISTRIP1 GENERIC 3 PA; QL
PEN NEEDLES
Diabetes - Insulin
TRUEPLUS INSULIN 2 QL ADMELOG SOLOSTAR 3 ST; E
SYRINGE
TRUEPLUS LANCETS ADMELOG SOLUTION
2 QL 100 UNIT/ML 3 QL; E
26G
SUBCUTANEOUS
TRUEPLUS LANCETS
2 QL ADMELOG SOLUTION
28G
100 UNIT/ML 3 ST; E
SUBCUTANEOUS
29Requirem Requirem
Drug Drug
Drug Name ents & Drug Name ents &
Tier Tier
Limits Limits
AFREZZA INHALATION INSULIN LISPRO
3 E
POWDER 12 UNIT, 4 & JUNIOR KWIKPEN
8 & 12 UNIT, 4 UNIT, 8 3 PA; QL
INSULIN LISPRO PROT 3 E
UNIT, 90 X 4 UNIT & & LISPRO
90X8 UNIT
LANTUS 1 QL
AFREZZA INHALATION
POWDER 90 X 8 UNIT & 3 QL LANTUS SOLOSTAR 1 QL
90X12 UNIT LEVEMIR 3 QL; E
BASAGLAR KWIKPEN 3 QL; E LEVEMIR FLEXTOUCH 3 QL; E
HUMALOG JUNIOR LYUMJEV 1 QL
2
KWIKPEN LYUMJEV KWIKPEN 2 QL
HUMALOG KWIKPEN 2 NOVOLIN 70/30 3 QL; E
HUMALOG MIX 50/50 1 NOVOLIN 70/30
3 QL; E
HUMALOG MIX 50/50 2 FLEXPEN
KWIKPEN NOVOLIN 70/30 3 QL; E
HUMALOG MIX 75/25 1 FLEXPEN RELION
HUMALOG MIX 75/25 NOVOLIN 70/30 RELION 3 QL; E
2
KWIKPEN NOVOLIN N 3 QL; E
HUMALOG NOVOLIN N FLEXPEN 3 QL; E
SUBCUTANEOUS 1
SOLUTION NOVOLIN N FLEXPEN 3 QL; E
RELION
HUMALOG
SUBCUTANEOUS 2 NOVOLIN N RELION 3 QL; E
SOLUTION CARTRIDGE NOVOLIN R 3 QL; E
HUMULIN 70/30 1 NOVOLIN R FLEXPEN 3 QL; E
HUMULIN 70/30 NOVOLIN R FLEXPEN
2 3 QL; E
KWIKPEN RELION
HUMULIN N 1 NOVOLIN R RELION 3 QL; E
HUMULIN N KWIKPEN 2 NOVOLOG 3 QL; E
HUMULIN R 1 NOVOLOG FLEXPEN 3 QL; E
HUMULIN R U-500 1 NOVOLOG FLEXPEN 3 QL; E
(CONCENTRATED) RELION
HUMULIN R U-500 NOVOLOG PENFILL 3 QL; E
2 QL
KWIKPEN NOVOLOG RELION 3 QL; E
INSULIN ASPART 3 QL; E 3 QL; E
SEMGLEE
INSULIN ASPART 3 QL; E TOUJEO MAX
FLEXPEN 2 QL
SOLOSTAR
INSULIN ASPART 3 ST; E TOUJEO SOLOSTAR 2 QL
PENFILL
TRESIBA 3 QL; E
INSULIN LISPRO 3 QL; E
TRESIBA FLEXTOUCH 3 QL; E
INSULIN LISPRO (1
3 QL; E
UNIT DIAL)
30Requirem Requirem
Drug Drug
Drug Name ents & Drug Name ents &
Tier Tier
Limits Limits
Diabetes - Non-Insulin JENTADUETO 2 QL
Agents 2 QL
JENTADUETO XR
ACTOS 3 QL; E 2 QL
KAZANO
ADLYXIN 3 PA; QL 2 QL
KOMBIGLYZE XR
ADLYXIN STARTER metformin hcl er 1
3 PA; QL
PACK
metformin hcl er (mod) 3 PA
ALOGLIPTIN 3 QL; E
BENZOATE metformin hcl er (osm) 3 PA
ALOGLIPTIN- metformin hcl oral 3
3 QL; E solution
METFORMIN HCL
ALOGLIPTIN- metformin hcl oral tablet 1
3 QL; E
PIOGLITAZONE NESINA 2 QL
AMARYL 3 E ONGLYZA 2 QL
BAQSIMI ONE PACK 2 QL OSENI 2 QL
BAQSIMI TWO PACK 2 QL OZEMPIC (0.25 OR 0.5 2 PA; QL
BYDUREON BCISE 2 PA MG/DOSE)
BYETTA 10 MCG PEN 2 PA; QL OZEMPIC (1 MG/DOSE) 2 PA; QL
BYETTA 5 MCG PEN 2 PA; QL pioglitazone hcl 1 QL
FARXIGA 3 ST; QL; E RIOMET 3 E
glimepiride 1 RYBELSUS 2 PA; QL
glipizide er 1 SOLIQUA 2 QL
glipizide oral 1 SYMLINPEN 120 3 PA
glipizide xl 1 SYMLINPEN 60 3 PA
glucagon emergency kit SYNJARDY 2 QL
1 QL
1 mg injection SYNJARDY XR 2 QL
GLUCAGON TRADJENTA 2 QL
EMERGENCY KIT 1 MG 3 QL; E 2 QL
TRIJARDY XR
INJECTION
TRULICITY 2 PA; QL
GLUCOTROL XL 3
VICTOZA SOLUTION
GLUMETZA 3 PA PA; (2
PEN-INJECTOR 18 2
glyburide oral 1 MG/3ML Pak); QL
glyburide-metformin 1 SUBCUTANEOUS
GLYXAMBI 2 ST; QL VICTOZA SOLUTION
PEN-INJECTOR 18 PA; (3
GVOKE HYPOPEN 1- 3
3 QL; E MG/3ML Pak); QL
PACK SUBCUTANEOUS
GVOKE HYPOPEN 2- 3 QL; E Drugs for Blood
PACK Disorders
GVOKE PFS 3 QL; E ADVATE M
JANUVIA 3 ST; QL; E M
ADYNOVATE
JARDIANCE 2 ST; QL M
AFSTYLA
31Requirem Requirem
Drug Drug
Drug Name ents & Drug Name ents &
Tier Tier
Limits Limits
ALPHANATE M CIALIS ORAL TABLET
3 PA; QL
ARANESP (ALBUMIN 10 MG, 20 MG
M
FREE) CIALIS ORAL TABLET 3 PA; QL; E
ELOCTATE M 2.5 MG, 5 MG
HEMOFIL M M IMVEXXY 2 QL
MAINTENANCE PACK
HUMATE-P M
IMVEXXY STARTER 2 QL
JIVI M PACK
KOATE M INTRAROSA 3 PA; QL
KOATE-DVI M OSPHENA 3 PA; QL
KOGENATE FS M sildenafil citrate oral
KOVALTRY M tablet 100 mg, 25 mg, 50 3 PA; QL
MULPLETA 3 PA; QL; E mg
NEULASTA M STENDRA 3 PA; QL
NOVOEIGHT M tadalafil oral 3 PA; QL
NUWIQ INTRAVENOUS VIAGRA 3 PA; QL
KIT 1000 UNIT, 2000 VYLEESI M QL
UNIT, 250 UNIT, 2500 M Electrolytes / Vitamins
UNIT, 3000 UNIT, 4000
UNIT, 500 UNIT cyanocobalamin injection M
solution 1000 mcg/ml
NUWIQ INTRAVENOUS
SOLUTION CYANOCOBALAMIN
INJECTION SOLUTION M
RECONSTITUTED 1000
UNIT, 2000 UNIT, 250 M 2000 MCG/ML
UNIT, 2500 UNIT, 3000 DRISDOL 3
UNIT, 4000 UNIT, 500 ergocalciferol oral
UNIT 1
capsule
RECOMBINATE M folic acid injection M
RETACRIT INJECTION folic acid oral tablet 1 mg 1
SOLUTION 10000
klor-con 1
UNIT/ML, 2000 UNIT/ML,
M QL
3000 UNIT/ML, 4000 klor-con 10 1
UNIT/ML, 40000 klor-con m10 1
UNIT/ML
klor-con m15 1
RETACRIT INJECTION
M klor-con m20 1
SOLUTION 20000
UNIT/ML K-TAB 3
WILATE M LOKELMA 3 PA; QL
ZARXIO M potassium chloride crys
1
ZIEXTENZO M er
Drugs for Sexual potassium chloride er 1
Dysfunction
ADDYI 3 PA; QL
32Requirem Requirem
Drug Drug
Drug Name ents & Drug Name ents &
Tier Tier
Limits Limits
potassium chloride oral pantoprazole sodium
solution 20 meq/15ml tablet delayed release 20 1 QL
1
(10%), 40 meq/15ml mg oral
(20%) pantoprazole sodium
potassium citrate er oral tablet delayed release 40 1
tablet extended release mg oral
1
10 meq (1080 mg), 5 pantoprazole sodium
meq (540 mg) tablet delayed release 40 1 QL
potassium citrate er oral mg oral
tablet extended release 3 PROTONIX ORAL
15 meq (1620 mg) 3 E
PACKET
PRENA1 PEARL 2
PROTONIX ORAL
UROCIT-K 10 3 TABLET DELAYED 3 QL; E
UROCIT-K 15 3 RELEASE
3 PYLERA 2 QL
UROCIT-K 5
VELTASSA 3 PA; QL RABEPRAZOLE
SODIUM ORAL 3 QL; E
vitamin d (ergocalciferol) CAPSULE SPRINKLE
oral capsule 1.25 mg 1
(50000 ut) rabeprazole sodium oral
3 ST; QL
tablet delayed release
VITAPEARL 2
sucralfate oral 1
Gastrointestinal Agents
- Drugs for Acid Reflux Gastrointestinal Agents
and Ulcer - Drugs for Bowel,
Intestine and Stomach
ACIPHEX 3 QL; E Conditions
ACIPHEX SPRINKLE ANASPAZ 3
ORAL CAPSULE 3 QL; E
CLENPIQ 3
SPRINKLE 10 MG, 5 MG
3 E dicyclomine hcl oral 1
CARAFATE
2 diphenoxylate-atropine 1
CYTOTEC
3 QL; E ED-SPAZ 3
DEXILANT
FIRST-OMEPRAZOLE 3 PA; ST; QL gavilyte-c 1 H
misoprostol oral 1 gavilyte-g 1 QL; H
OMECLAMOX-PAK 2 QL GOLYTELY 3 QL
omeprazole oral capsule hyoscyamine sulfate er 1
1 QL
delayed release hyoscyamine sulfate oral 1
OMEPRAZOLE+SYRSP elixir
3 PA; ST; QL
END SF ALKA hyoscyamine sulfate oral 1
pantoprazole sodium oral solution
3 E
packet hyoscyamine sulfate oral 1
pantoprazole sodium tablet
tablet delayed release 20 1 hyoscyamine sulfate oral 3
mg oral tablet dispersible
33Requirem Requirem
Drug Drug
Drug Name ents & Drug Name ents &
Tier Tier
Limits Limits
hyoscyamine sulfate sl 1 ZELNORM 3 PA; QL
hyoscyamine sulfate Genetic or Enzyme
1
sublingual Disorder - Drugs for
hyosyne 1 Replacement,
Modification, Treatment
LEVBID 2
CERDELGA 3 PA
LEVSIN ORAL 2
CREON 2
LEVSIN/SL 2
CUPRIMINE 3 PA; E
LINZESS ORAL
2 PA; QL DEPEN TITRATABS 2
CAPSULE 145 MCG,
290 MCG ENDARI 3 PA; QL
LINZESS ORAL nitisinone 3 PA; E
2 PA
CAPSULE 72 MCG NITYR 3 PA; E
LOMOTIL 3 ORFADIN ORAL
MOTEGRITY 3 PA; QL CAPSULE 10 MG, 2 MG, 2 PA
MOVIPREP 3 QL 5 MG
NULEV 3 ORFADIN ORAL 3 PA; E
CAPSULE 20 MG
OSCIMIN 2
ORFADIN ORAL
peg-3350/electrolytes 1 QL; H 2 PA
SUSPENSION
peg- PANCREAZE ORAL
3350/electrolytes/ascorb 3 QL CAPSULE DELAYED
at RELEASE PARTICLES
peg-kcl-nacl-nasulf-na 10500-35500 UNIT, 3 ST
3 QL
asc-c 16800-56800 UNIT,
PLENVU 3 QL 21000-54700 UNIT,
2600-8800 UNIT, 4200-
RELTONE 3 E 14200 UNIT
SUPREP BOWEL PREP 3 QL PANCREAZE ORAL
KIT CAPSULE DELAYED 3 E
SUTAB 3 RELEASE PARTICLES
SYMPROIC 2 PA; QL 37000-97300 UNIT
TRULANCE 3 PA; QL; E penicillamine oral
3 PA; E
capsule
URSO 250 3 E
penicillamine oral tablet 1
URSO FORTE 3 E
PERTZYE 3 ST
URSODIOL ORAL
3 E STRENSIQ M
CAPSULE 200 MG, 400
MG SYPRINE 3 PA; E
ursodiol oral capsule 300 TEGSEDI M QL
1
mg trientine hcl 3 PA
ursodiol oral tablet 1 VIOKACE 3 ST
VIBERZI 3 PA; QL
XIFAXAN 3 PA
34Requirem Requirem
Drug Drug
Drug Name ents & Drug Name ents &
Tier Tier
Limits Limits
ZENPEP ORAL alyacen 1/35 1 H
CAPSULE DELAYED amethia 3 QL; H
RELEASE PARTICLES
10000-32000 UNIT, apri 1 H
15000-47000 UNIT, 2 ashlyna 3 QL; H
20000-63000 UNIT, aubra 1 H
25000-79000 UNIT,
40000-126000 UNIT, aubra eq 1 H
5000-24000 UNIT aurovela 1.5/30 1 H
Genitourinary Agents - aurovela 1/20 1 H
Drugs for Bladder, 3 H
aurovela 24 fe
Genital and Kidney
Conditions aurovela fe 1.5/30 1 H
AURYXIA 3 aurovela fe 1/20 1 H
DITROPAN XL 3 E aviane 1 H
GELNIQUE 3 E AYGESTIN 3
oxybutynin chloride er 1 ayuna 1 H
oxybutynin chloride oral 1 azurette 1 H
phenazo oral tablet 200 balziva 1 H
1
mg BEYAZ 3 E
phenazopyridine hcl oral BIJUVA 3
1
tablet 100 mg, 200 mg blisovi 24 fe 3 H
PYRIDIUM 2 1 H
blisovi fe 1.5/30
TOVIAZ 3 E 1 H
blisovi fe 1/20
VELPHORO 2 1 H
briellyn
Genitourinary Agents - 1 H
camila
Drugs for Prostate
Conditions camrese 3 QL; H
alfuzosin hcl er 1 camrese lo 3 QL; H
finasteride oral tablet 5 charlotte 24 fe 3 H
1
mg chateal 1 H
FLOMAX 3 QL chateal eq 1 H
PROSCAR 3 E CLIMARA 3 QL; E
tamsulosin hcl 1 QL CLIMARA PRO 2 QL
terazosin hcl 1 cryselle-28 1 H
UROXATRAL 3 E cyclafem 1/35 1 H
Hormonal Agents - cyred 1 H
Hormone Replacement 1 H
cyred eq
and Birth Control
dasetta 1/35 1 H
afirmelle 1 H
daysee 3 QL; H
ALORA 3 QL
deblitane 1 H
altavera 1 H
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