YOUR 2022 PRESCRIPTION DRUG LIST - ACCESS 3-TIER - UNITEDHEALTHCARE
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Pharmacy | PDL Your 2022 Prescription Drug List Access 3-Tier Effective January 1, 2022 This Prescription Drug List (PDL) is accurate as of January 1, 2022 and is subject to change after this date. This PDL applies to members of our UnitedHealthcare, Neighborhood Health Plan, River Valley and Oxford medical plans with a pharmacy benefit subject to the Access 3-Tier PDL. Your estimated coverage and copayment/coinsurance may vary based on the benefit plan you choose and the effective date of the plan.
Table of contents
Understanding your Prescription Drug List (PDL). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Medication tips . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Reading your PDL. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Analgesics
Drugs for Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Drugs for Pain and Inflammation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Anti-Addiction / Substance Abuse Treatment Agents. . . . . . . . . . . . . . . . . . . . . . . . . . 9
Antibacterials
Drugs for Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Anticoagulants
Drugs to Treat or Prevent Blood Clots. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Anticonvulsants
Drugs for Seizures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Antidementia Agents
Drugs for Alzheimer’s Disease and Dementia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Antidepressants
Drugs for Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Antiemetics
Drugs for Nausea and Vomiting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Antifungals
Drugs for Fungal Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Antigout Agents
Drugs for Gout. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Antimigraine Agents
Drugs for Migraines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Antineoplastics
Drugs for Cancer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Antiparasitics
Drugs for Parasitic Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Antiparkinson Agents
Drugs for Parkinson’s Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Antiplatelets
Drugs for Heart Attack and Stroke Prevention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Antipsychotics
Drugs for Mood Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Antivirals
Drugs for Viral Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Anxiolytics
Drugs for Anxiety. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Bipolar Agents
Drugs for Mood Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Cardiovascular Agents
Drugs for Heart and Circulation Conditions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Central Nervous System Agents
Drugs for Attention Deficit Disorder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Drugs for Multiple Sclerosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Dental and Oral Agents
Drugs for Mouth and Throat Conditions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
2Dermatological Agents
Drugs for Skin Conditions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Diabetes
Glucose Monitoring. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Insulin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Non-Insulin Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Drugs for Blood Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Drugs for Sexual Dysfunction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Electrolytes / Vitamins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Gastrointestinal Agents
Drugs for Acid Reflux and Ulcer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Drugs for Bowel, Intestine and Stomach Conditions. . . . . . . . . . . . . . . . . . . . . . . . 25
Genetic or Enzyme Disorder
Drugs for Replacement, Modification, Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Genitourinary Agents
Drugs for Bladder, Genital and Kidney Conditions. . . . . . . . . . . . . . . . . . . . . . . . . 26
Drugs for Prostate Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Hormonal Agents
Hormone Replacement and Birth Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Oral Steroids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Testosterone Replacement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Thyroid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Immunological Agents
Drugs for Immune System Stimulation or Suppression. . . . . . . . . . . . . . . . . . . . . . 31
Infertility Agents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Inflammatory Bowel Disease Agents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Metabolic Bone Disease Agents
Drugs for Osteoporosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Ophthalmic Agents
Drugs for Eye Allergy, Infection and Inflammation. . . . . . . . . . . . . . . . . . . . . . . . . . 33
Drugs for Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Drugs for Miscellaneous Eye Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Otic Agents
Drugs for Ear Conditions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Respiratory
Drugs for Anaphylaxis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Respiratory Tract / Pulmonary Agents
Drugs for Allergies, Cough, Cold. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Drugs for Asthma and COPD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Drugs for Cystic Fibrosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Drugs for Pulmonary Hypertension. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Skeletal Muscle Relaxants
Drugs for Muscle Pain and Spasm. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Sleep Disorder Agents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
3Understanding your Prescription Drug List (PDL)
What is a PDL?
This document is a list of the most commonly prescribed medications. It includes About this PDL
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 PDL and your benefit plan
and placed in tiers that represent the cost you pay out-of-pocket. They are then
documents, the benefit plan
listed in alphabetical order.
documents rule. This PDL is not
a complete list of medications,
How do I use my PDL? and not all medications listed
You and your doctor can consult the PDL to help you select the most cost-effective may be covered by your plan.
prescription medications. This guide tells you if a medication is generic or a brand Please look at the benefit plan
name, and if there are coverage requirements or limits. Bring this list with you when documents provided by your
you see your doctor. If your medication is not listed here, please visit your plan’s employer or health plan to see
member website or call the toll-free member phone number on your health plan which medications are covered
ID card. under your plan.
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 PDL change?
PDL changes typically occur 2-3 times per year. However, changes that have a positive impact for you — such as coverage for
new medications or cost savings — may occur at any time. You can log in to the member website listed on your health plan 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)1 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 medications2). 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 health plan 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.
1. Depending on your benefit, you may have notification or medical necessity requirements for select medications.
2. For New York and New Jersey plans, a prescription drug product that is therapeutically equal to an over-the-counter
drug may be covered if it is determined to be medically necessary.
4Medication tips
What is the difference between brand-name and
generic medications? Over-the-counter
Generic medications contain the same active ingredients (what makes the
(OTC) medications
medication work) as brand-name medications, but they often cost less. Once the An OTC medication may be
patent for a brand-name medication ends, the FDA can approve a generic version the right treatment option for
with the same active ingredients. These types of medications are known as generic some conditions. Talk to your
medications. Sometimes, the same company that makes a brand-name medication doctor about available OTC
also makes the generic version. options. Even though these
medications may not be covered
What if my doctor writes a brand-name prescription? by your pharmacy benefit,
they may cost less than a
If your doctor gives you a prescription for a brand-name medication, ask if a generic prescription medication.
equivalent or lower-cost option is available and could be right for you. Generic
medications are usually your lowest-cost option, but not always. For some benefit
plans, if a brand-name drug is prescribed and a generic equal is available, your
cost-share may be the copayment PLUS the cost difference between the brand-
name drug and the generic equivalent.
What if I am taking a specialty medication?
Specialty medications are high-cost and are used to treat rare or complex
conditions that require additional care and support. For most plans, these
medications are managed through the specialty pharmacy program. Take
advantage of personalized support designed to help you get the most out of your
treatment plan. Visit the member website listed on your ID card or call the toll-free
phone number on your ID card to learn more.
Please note, not all specialty medications are listed here. If you’re taking a specialty
medication that is on a higher tier, call the toll-free phone number on your health
plan ID card to talk with a pharmacist about finding lower-cost options.
5Reading your PDL
The PDL gives you choices so you and your doctor can decide your best course of treatment. In this PDL, 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
Medications that provide the highest overall value. Mostly
lowest out-of-pocket costs.
generic drugs. Some brand-name drugs may also be included.
Tier 2 $$ M
id-range cost Use Tier 2 drugs, instead of
Medications that provide good overall value. A mix of brand Tier 3, to help reduce your
name and generic drugs. out-of-pocket costs.
Tier 3 $$$ H
ighest-cost Ask your doctor if a Tier 1 or
Medications that provide the lowest overall value. Tier 2 option could work 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.
E May be excluded from coverage or subject to Prior Authorization in Connecticut, New Jersey and New
York. (Referred to as First Start in New Jersey) — Lower-cost options are available and covered.
H ealth Care Reform Preventive — This medication is part of a health care reform preventive benefit and may
H
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.
PA rior Authorization (sometimes referred to as precertification)3 — Requires your doctor to provide
P
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.
RS efill and Save Program4 — Save money on your copayment when you refill your prescription on time as
R
prescribed. Program eligibility may vary.
SP Specialty Medication — Specialty medications treat complex or rare conditions and may require special
storage and handling. You may be required to obtain these medications from a specialty pharmacy.
ST tep Therapy (referred to as First Start in New Jersey) — Requires prior authorization and may require you to
S
try one or more other medications before the medication you are requesting may be covered.
3. Depending on your benefit, you may have notification or medical necessity requirements for select medications.
4. Not applicable to Neighborhood Health Plan and Oxford plans.
6Reading your PDL (continued)
Coverage details
Some drug classes in this PDL have additional/important coverage details. Review this list to see if drug classes that apply
to you are noted.
• Diabetes: blood glucose monitoring; insulin; non-insulin
Diabetic supplies and prescription medications may be subject to different cost-share arrangements for Oxford plans.
Please see your Summary of Benefits and Coverage (SBC) for specifics.
• Diabetes: continuous glucose monitors, sensors
Coverage is set by the consumer’s prescription drug benefit plan. Please consult plan documents regarding benefit
coverage and cost-share. Diabetic self-management items, including continuous glucose monitors, may be covered
under the consumer pharmacy and/or medical plan depending on the benefit.
• Endocrine: growth hormone
Coverage is set by the consumer’s prescription drug benefit plan. Please consult plan documents regarding benefit
coverage and cost-share.
• Infertility
Coverage is set by the consumer’s prescription drug benefit plan. Please consult plan documents regarding benefit
coverage and cost-share. Prior authorization (sometimes referred to as precertification) may be required for Oxford plans
or where a state mandates infertility drug coverage. This is not a covered benefit for Neighborhood Health Plan.
• 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 member phone number on your health plan ID card
And, if home delivery services
are included in your pharmacy
Visit your plan’s member website listed on your health plan 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
7Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
Analgesics - Drugs for Pain g morphine sulfate er oral capsule 1 PA, ST, QL
g acetaminophen-codeine 1 extended release 24 hour
g acetaminophen-codeine #2 1
g morphine sulfate er oral tablet 1 PA, QL
extended release
g acetaminophen-codeine #3 1
g morphine sulfate oral 1
g acetaminophen-codeine #4 1
g morphine sulfate rectal 1
g apap-caff-dihydrocodeine 1
B MS CONTIN 3 PA, ST, QL
g bac 1 QL
B NALOCET E QL
B BELBUCA 3 PA, QL
B NUCYNTA 2 QL
g butalbital-apap-caffeine 1 QL
B NUCYNTA ER 3 PA, QL
B CONZIP 3 QL
B OXAYDO E QL
B DILAUDID ORAL 3
B OXYCODONE HCL ER E PA, QL
B DURAGESIC-100 E PA, QL
g oxycodone hcl oral capsule 1
B DURAGESIC-12 E PA, QL
g oxycodone hcl oral concentrate 1
B DURAGESIC-25 E PA, QL 100 mg/5ml
B DURAGESIC-50 E PA, QL g oxycodone hcl oral solution 1
B DURAGESIC-75 E PA, QL g oxycodone hcl oral tablet 10 mg, 1
g endocet 1 15 mg, 20 mg, 30 mg
B ESGIC 3 QL g oxycodone hcl oral tablet 5 mg 1 QL
g fentanyl 1 PA, QL B OXYCODONE-ACETAMINOPHEN E
B FIORICET 3 QL ORAL SOLUTION
g hydrocodone bitartrate er oral 1 PA, ST, QL B OXYCODONE-ACETAMINOPHEN E
capsule extended release 12 hour ORAL TABLET 10-300 MG,
5-300 MG
g hydrocodone bitartrate er oral tablet E PA, QL
er 24 hour abuse-deterrent g oxycodone-acetaminophen oral 1
tablet 10-325 mg, 2.5-325 mg,
g hydrocodone-acetaminophen oral 1
5-325 mg, 7.5-325 mg
solution 10-325 mg/15ml,
7.5-325 mg/15ml B OXYCODONE-ACETAMINOPHEN E QL
ORAL TABLET 2.5-300 MG
g hydrocodone-acetaminophen oral 1
tablet B OXYCONTIN E PA, QL
g hydromorphone hcl er 1 PA, ST, QL B PERCOCET E
g hydromorphone hcl oral 1 g premium lidocaine 1 QL
g hydromorphone hcl rectal 1 B PROLATE E
B HYSINGLA ER E PA, QL B QDOLO E QL
g lidocaine external ointment 5 % 1 QL B ROXICODONE ORAL TABLET E
15 MG, 30 MG
g lidocaine external patch 5 % 1 PA, QL
B ROXICODONE ORAL TABLET 5 MG E QL
g lidocaine-prilocaine external cream 1
B SUBSYS SUBLINGUAL LIQUID E PA, QL
B LIDODERM E PA, QL
400 MCG, 600 MCG, 800 MCG
B LORTAB 3 g tramadol hcl er (biphasic) 1 (generic for
g morphine sulfate (concentrate) oral 1 Ryzolt), QL
solution 100 mg/5ml, 20 mg/ml
See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as
First Start in New Jersey).
8Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
B TRAMADOL HCL ER ORAL 3 QL B KETOROLAC TROMETHAMINE 3 ST
CAPSULE EXTENDED RELEASE NASAL
24 HOUR g ketorolac tromethamine oral 1
g tramadol hcl er oral tablet extended 1 QL B LODINE E
release 24 hour
g meloxicam oral capsule E QL
g tramadol hcl ir 1
g meloxicam oral tablet 1
B TREZIX 1
B MOBIC E
B ULTRAM E
g nabumetone oral 1
B VTOL LQ 2
B NAPRELAN E
B XTAMPZA ER 2 PA, QL
B NAPROSYN E
B ZEBUTAL 3 QL
g naproxen oral 1
B ZOHYDRO ER E PA, ST, QL
g naproxen sodium er oral tablet 1
B ZTLIDO 3 PA, QL extended release 24 hour 375 mg,
Analgesics - Drugs for Pain and Inflammation 500 mg
B CATAFLAM E B NAPROXEN SODIUM ER ORAL E
B CELEBREX E QL TABLET EXTENDED RELEASE
24 HOUR 750 MG
g celecoxib oral 1 QL
g naproxen sodium oral tablet 1
g diclofenac potassium 1 275 mg, 550 mg
g diclofenac sodium er 1 B PENNSAID E
g diclofenac sodium external gel 1 % E B QMIIZ ODT 3
g diclofenac sodium external solution E B RELAFEN E
g diclofenac sodium oral 1 B RELAFEN DS E
B DUROLANE E B SPRIX 3 ST
B EC-NAPROSYN ORAL TABLET 3 B TIVORBEX 3
DELAYED RELEASE 375 MG
B VIVLODEX E QL
B EC-NAPROSYN ORAL TABLET 3
DELAYED RELEASE 500 MG
B ZIPSOR 3
g ec-naproxen 1 Anti-Addiction / Substance Abuse Treatment Agents
g etodolac 1
B BUNAVAIL E PA, QL
g etodolac er 1
g buprenorphine hcl sublingual 1 QL
B EUFLEXXA E
g buprenorphine hcl-naloxone hcl 1 QL
B GELSYN-3 E
B CHANTIX 2 PA, H
g ibuprofen 1
B CHANTIX CONTINUING MONTH 2 PA, H
PAK
g ibuprofen oral suspension E
B CHANTIX STARTING MONTH PAK 2 PA, H
B INDOCIN 3
g naloxone hcl injection 1
g indomethacin er 1
g naltrexone hcl oral 1
B INDOMETHACIN ORAL CAPSULE 3
20 MG
B NARCAN 2
g indomethacin oral capsule 25 mg, 1
B SUBOXONE E PA, QL
50 mg B ZUBSOLV 1 QL
See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as
First Start in New Jersey).
9Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
Antibacterials - Drugs for Infections g doxycycline hyclate oral tablet 1
B ACTICLATE E 100 mg, 150 mg, 20 mg, 75 mg
g amoxicillin 1
g doxycycline hyclate oral tablet E
50 mg
g amoxicillin-potassium clavulanate er 1
g doxycycline hyclate oral tablet 1
g amoxicillin-potassium clavulanate 1 delayed release 100 mg, 150 mg,
oral 200 mg, 50 mg, 75 mg
B AUGMENTIN ES-600 E B DOXYCYCLINE HYCLATE ORAL 3
B AUGMENTIN ORAL SUSPENSION 3 TABLET DELAYED RELEASE 80 MG
RECONSTITUTED g doxycycline monohydrate oral 1
125-31.25 MG/5ML
B FLAGYL 3
B AUGMENTIN ORAL SUSPENSION E
RECONSTITUTED
B KEFLEX 3
250-62.5 MG/5ML g levofloxacin oral 1
B AUGMENTIN ORAL TABLET E g metronidazole oral 1
g avidoxy 1 g metronidazole vaginal 1
g azithromycin oral 1 B MINOCYCLINE HCL ER ORAL 3
B BACTRIM 3 CAPSULE EXTENDED RELEASE
24 HOUR
B BACTRIM DS 3
g minocycline hcl er oral tablet E
g cefadroxil 1 extended release 24 hour
g cefdinir 1 g minocycline hcl oral 1
g cefuroxime axetil 1 B MINOLIRA E
B CENTANY 3 g mondoxyne nl 1
B CENTANY AT 3 g morgidox oral 1
g cephalexin 1 g mupirocin calcium 1
B CIPRO ORAL TABLET 3 g mupirocin external 1
g ciprofloxacin hcl oral 1 B NUZYRA ORAL 3
g clarithromycin er 1 g penicillin v potassium 1
g clarithromycin oral 1 B SOLODYN E
B CLEOCIN ORAL CAPSULE 150 MG, 3 g sulfamethoxazole-trimethoprim oral 1
300 MG
g sulfatrim pediatric 1
B CLEOCIN ORAL CAPSULE 75 MG 2
B TARGADOX E
g clindamycin hcl oral 1
g vandazole 1
B CLINDESSE 2
B VIBRAMYCIN ORAL CAPSULE 3
g coremino E
B VIBRAMYCIN ORAL SUSPENSION 3
B DIFICID 3 QL RECONSTITUTED
B DORYX MPC 3 B XENLETA ORAL 3
B DORYX ORAL TABLET DELAYED E B XEPI 3
RELEASE 200 MG, 50 MG
B XIMINO 3
B DORYX ORAL TABLET DELAYED 3
RELEASE 80 MG
B ZITHROMAX ORAL 3
g doxycycline hyclate oral capsule 1
B ZITHROMAX TRI-PAK 3
B ZITHROMAX Z-PAK 3
See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as
First Start in New Jersey).
10Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
Anticoagulants - Drugs to Treat or Prevent Blood Clots g lamotrigine oral kit 1 ST
B ELIQUIS 2 QL g lamotrigine oral tablet 1
B ELIQUIS DVT/PE STARTER PACK 2 QL g lamotrigine oral tablet chewable 1
g enoxaparin sodium 1 g lamotrigine oral tablet dispersible 1 ST
g jantoven 1 g lamotrigine starter kit-blue 1
B LOVENOX E g lamotrigine starter kit-green 1
B PRADAXA 2 QL g lamotrigine starter kit-orange 1
g warfarin sodium oral 1 g levetiracetam er 1
B XARELTO 2 QL g levetiracetam oral 1
B XARELTO STARTER PACK 2 QL B NAYZILAM 3 PA
Anticonvulsants - Drugs for Seizures B NEURONTIN 3 ST
g carbamazepine er 1 g oxcarbazepine 1
g carbamazepine oral 1 B OXTELLAR XR E ST
B CARBATROL 3 B QUDEXY XR 3 ST
B DEPAKOTE 3 g roweepra 1
B DEPAKOTE ER 3 ST B SPRITAM 3 ST
B DEPAKOTE SPRINKLES 3 g subvenite 1
B DIASTAT ACUDIAL 3 g subvenite starter kit-blue 1
B DIASTAT PEDIATRIC 2 g subvenite starter kit-green 1
g diazepam rectal 1 g subvenite starter kit-orange 1
g divalproex sodium er 1 B TEGRETOL 3
g divalproex sodium oral 1 B TEGRETOL-XR 3
g epitol 1 B TOPAMAX 3 ST
g gabapentin oral capsule 1 B TOPAMAX SPRINKLE 3 ST
g gabapentin oral solution 1 g topiramate er 1 ST
250 mg/5ml g topiramate oral 1
g gabapentin oral tablet 1 B TRILEPTAL 3 ST
B KEPPRA ORAL 3 ST B TROKENDI XR E ST
B KEPPRA XR 3 ST B VALTOCO 3 PA
B LAMICTAL 3 ST B VIMPAT ORAL 2 PA
B LAMICTAL ODT ORAL KIT 21 X 3 ST B XCOPRI ORAL TABLET 100 MG, 3 PA
25 MG & 7 X 50 MG, 42 X 50 MG & 150 MG, 200 MG, 50 MG
14X100 MG
B XCOPRI ORAL TABLET THERAPY 3 PA
B LAMICTAL ODT ORAL KIT 25 & 50 3 ST PACK 14 X 12.5 MG & 14 X 25 MG,
& 100 MG 14 X 150 MG & 14 X200 MG, 14 X 50
B LAMICTAL ODT ORAL TABLET 3 ST MG & 14 X100 MG, 150 & 200 MG,
DISPERSIBLE 50 & 200 MG
B LAMICTAL STARTER 3 ST B ZONEGRAN 3 ST
B LAMICTAL XR 3 ST g zonisamide oral 1
g lamotrigine er 1 ST
See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as
First Start in New Jersey).
11Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
Antidementia Agents - Drugs for Alzheimer's Disease g paroxetine hcl 1
and Dementia g paroxetine hcl er 1 QL
B ARICEPT E B PAXIL CR E QL
g donepezil hcl 1 B PAXIL ORAL SUSPENSION 3
Antidepressants - Drugs for Depression B PAXIL ORAL TABLET E
g amitriptyline hcl oral 1 B PRISTIQ E QL
g bupropion hcl er (sr) 1 B PROZAC E
g bupropion hcl er (xl) oral tablet 1 B REMERON E
extended release 24 hour 150 mg,
300 mg
B REMERON SOLTAB E
B BUPROPION HCL ER (XL) ORAL 3 QL
g sertraline hcl oral 1
TABLET EXTENDED RELEASE g trazodone hcl oral 1
24 HOUR 450 MG B TRINTELLIX 3 ST, QL
g bupropion hcl oral 1 g venlafaxine hcl 1
B CELEXA E g venlafaxine hcl er oral capsule 1
g citalopram hydrobromide 1 extended release 24 hour
B CYMBALTA E QL g venlafaxine hcl er oral tablet 1 QL
g desvenlafaxine succinate er 1 QL extended release 24 hour
g doxepin hcl oral capsule 1
B VIIBRYD 2 QL
g doxepin hcl oral concentrate 1
B VIIBRYD STARTER PACK 2
B DRIZALMA SPRINKLE 3 QL
B WELLBUTRIN SR E
g duloxetine hcl oral capsule delayed 1 QL
B WELLBUTRIN XL E
release particles 20 mg, 30 mg, B ZOLOFT E
60 mg Antiemetics - Drugs for Nausea and Vomiting
g duloxetine hcl oral capsule delayed 1 B BONJESTA 2
release particles 40 mg B DICLEGIS E
B EFFEXOR XR E g doxylamine-pyridoxine 1
g escitalopram oxalate 1 B GIMOTI E QL
g fluoxetine hcl oral capsule 1 g metoclopramide hcl oral 1
g fluoxetine hcl oral capsule delayed 1 QL g ondansetron hcl oral 1
release
g ondansetron odt 1
g fluoxetine hcl oral solution 1
g prochlorperazine maleate oral 1
g fluoxetine hcl oral tablet 10 mg 1 QL
g promethazine hcl oral tablet 1
g fluoxetine hcl oral tablet 20 mg, 1
60 mg g promethazine hcl rectal 1
g fluvoxamine maleate 1 g promethegan 1
g fluvoxamine maleate er 1 QL B REGLAN 3
B FORFIVO XL 3 QL g scopolamine 1
B LEXAPRO E B TRANSDERM SCOP (1.5 MG) E
g mirtazapine oral 1 B TRANSDERM-SCOP (1.5 MG) E
g nortriptyline hcl oral 1 B ZOFRAN E
B PAMELOR E B ZUPLENZ 3
See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as
First Start in New Jersey).
12Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
Antifungals - Drugs for Fungal Infections B IMITREX STATDOSE SYSTEM E
g ciclodan 1 B IMITREX SUBCUTANEOUS E
g ciclopirox external 1 B MAXALT E
g ciclopirox treatment 1 B MAXALT-MLT E
B CRESEMBA ORAL 3 g naratriptan hcl 1
B DIFLUCAN E B ONZETRA XSAIL 3
B EXTINA 3 B RELPAX E
g fluconazole oral 1 B REYVOW 2 PA
B GYNAZOLE-1 3 g rizatriptan benzoate 1
g ketoconazole external 1 g sumatriptan succinate oral 1
g ketodan external foam 1 g sumatriptan succinate refill 1
B LOPROX EXTERNAL SHAMPOO E g sumatriptan succinate 1
g nyamyc 1 subcutaneous
g nystatin external 1
B UBRELVY 2 PA, ST, QL
g nystatin mouth/throat 1
B ZEMBRACE SYMTOUCH 3
g nystop 1
B ZOLMITRIPTAN NASAL E
g terbinafine hcl oral 1 QL
g zolmitriptan oral 1
g terconazole 1
B ZOMIG NASAL 2
B XOLEGEL 3
B ZOMIG ORAL E
Antigout Agents - Drugs for Gout
B ZOMIG ZMT E
g allopurinol oral 1 Antineoplastics - Drugs for Cancer
B COLCHICINE ORAL CAPSULE E
B ALECENSA 2 PA, QL
g colchicine oral tablet E
B ALUNBRIG 2 PA, QL, SP
B COLCRYS E
g anastrozole oral 1
g febuxostat 1 QL
B ARIMIDEX E
B GLOPERBA 3
g bexarotene E SP
B MITIGARE 2
B CALQUENCE 2 PA, QL, SP
B ULORIC E QL
g capecitabine 1 SP
B ZYLOPRIM 3
B ERIVEDGE 2 PA, QL, SP
Antimigraine Agents - Drugs for Migraines
B ERLEADA 2 PA, QL, SP
B AIMOVIG SUBCUTANEOUS 2 PA, QL
B FEMARA E
SOLUTION AUTO-INJECTOR g fluorouracil external solution 1
140 MG/ML, 70 MG/ML B GLEEVEC E PA, QL, SP
B AMERGE E B IBRANCE 2 PA, QL, SP
g eletriptan hydrobromide 1 B IDHIFA 2 PA, QL, SP
B EMGALITY 2 PA, QL g imatinib mesylate 1 PA, QL, SP
B EMGALITY (300 MG DOSE) 2 PA, QL B KOSELUGO 3 PA, QL, SP
B IMITREX ORAL E g letrozole oral 1
B IMITREX STATDOSE REFILL E B LYNPARZA 2 PA, QL, SP
See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as
First Start in New Jersey).
13Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
g mercaptopurine oral 1 g ropinirole hcl 1
B NUBEQA 2 PA, QL, SP g ropinirole hcl er 1
B ODOMZO 2 PA, QL, SP B RYTARY E
B ORGOVYX 3 PA, QL, SP B SINEMET 3
B PURIXAN 3 PA, SP Antiplatelets - Drugs for Heart Attack and Stroke
B REVLIMID 2 PA, SP Prevention
B ROZLYTREK 2 PA, QL, SP
B BRILINTA 2 QL
B SOLTAMOX 3
g clopidogrel bisulfate oral 1
g tamoxifen citrate oral tablet 10 mg 1
B PLAVIX E
g tamoxifen citrate oral tablet 20 mg 1 H-PA
B ZONTIVITY 3 QL
B TARGRETIN EXTERNAL 3 SP Antipsychotics - Drugs for Mood Disorders
B TARGRETIN ORAL 1 SP
B ABILIFY E QL
B TASIGNA 2 PA, ST, QL, SP
g aripiprazole oral solution 1
B UKONIQ 3 PA, QL, SP
g aripiprazole oral tablet 1 QL
B VERZENIO 2 PA, QL, SP
g aripiprazole oral tablet dispersible 1 QL
B VITRAKVI 2 PA, QL, SP
g asenapine maleate E QL
B XELODA E SP
B GEODON ORAL E QL
B ZEJULA 2 PA, QL, SP
B LATUDA 2 QL
Antiparasitics - Drugs for Parasitic Infections
g olanzapine oral 1 QL
B ARAKODA 3 QL
g quetiapine fumarate 1
g atovaquone-proguanil hcl 1
g quetiapine fumarate er 1 QL
g hydroxychloroquine sulfate oral 1
B RISPERDAL E
B KRINTAFEL 1
g risperidone 1
B MALARONE 3
B SAPHRIS 1 QL
g permethrin external 1
B SEROQUEL E
B PLAQUENIL E
B SEROQUEL XR E QL
Antiparkinson Agents - Drugs for Parkinson's Disease
B VRAYLAR 3 QL
B APOKYN 3 PA, QL, SP
g ziprasidone hcl 1 QL
g carbidopa-levodopa 1
B ZYPREXA ORAL E QL
g carbidopa-levodopa er 1
B ZYPREXA ZYDIS E QL
B DUOPA 3 Antivirals - Drugs for Viral Infections
B INBRIJA 3 PA, QL, SP
g acyclovir oral 1
B KYNMOBI 3 PA, QL, SP
B ATRIPLA E QL
B KYNMOBI TITRATION KIT 3 PA, SP
B BARACLUDE ORAL SOLUTION 2 SP
B MIRAPEX 3
B BARACLUDE ORAL TABLET E SP
B MIRAPEX ER E
B CIMDUO 2 QL
B NOURIANZ 3 QL
B DESCOVY E ST, QL
g pramipexole dihydrochloride 1
B DOVATO 2 QL
g pramipexole dihydrochloride er E
g efavirenz-emtricitab-tenofovir E QL
See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as
First Start in New Jersey).
14Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
g efavirenz-lamivudine-tenofovir 1 QL B TIVICAY 3
g emtricitabine-tenofovir df oral tablet 1 QL B TIVICAY PD 3
100-150 mg, 133-200 mg, B TRIUMEQ 2 QL
167-250 mg
B TRUVADA ORAL TABLET 3 QL
g emtricitabine-tenofovir df oral tablet 1 QL, H 100-150 MG, 133-200 MG,
200-300 mg 167-250 MG
g entecavir 1 SP B TRUVADA ORAL TABLET E QL
B EPCLUSA ORAL TABLET 2 PA, QL 200-300 MG
200-50 MG g valacyclovir hcl oral 1
B EPCLUSA ORAL TABLET 2 PA, QL, SP B VALTREX E
400-100 MG
B VEMLIDY 3 ST, SP
B GENVOYA 3 QL
B VIREAD ORAL POWDER 3
B HARVONI ORAL PACKET 2 QL
B VIREAD ORAL TABLET 150 MG, 2
B HARVONI ORAL TABLET 2 PA, ST, QL, SP 200 MG, 250 MG
B ISENTRESS 2 B VIREAD ORAL TABLET 300 MG E
B ISENTRESS HD 2 B VOSEVI 2 PA, QL, SP
B JULUCA 2 QL B XOFLUZA (40 MG DOSE) 3 QL
B LEDIPASVIR-SOFOSBUVIR 2 PA, ST, QL, SP B XOFLUZA (80 MG DOSE) 3 QL
B MAVYRET 2 PA, QL, SP B ZEPATIER 2 PA, QL, SP
B NORVIR ORAL PACKET 2 B ZOVIRAX ORAL 3
B NORVIR ORAL SOLUTION 2 Anxiolytics - Drugs for Anxiety
B NORVIR ORAL TABLET E g alprazolam er 1
B ODEFSEY 3 QL g alprazolam intensol 1
g oseltamivir phosphate oral capsule 1 g alprazolam oral 1
g oseltamivir phosphate oral 1 QL g alprazolam xr 1
suspension reconstituted
B ATIVAN ORAL E
B PREZCOBIX 2
g buspirone hcl oral 1
B PREZISTA 2
g clonazepam oral 1
g ritonavir 1
g diazepam intensol 1
B RUKOBIA 3 PA
g diazepam oral 1
B SITAVIG E
B HALCION 3
B SOFOSBUVIR-VELPATASVIR 2 PA, QL, SP
g hydroxyzine hcl oral 1
B STRIBILD 3 QL
g hydroxyzine pamoate oral 1
B SYMFI 2 QL
B KLONOPIN E
B SYMFI LO 2 QL
g lorazepam intensol 1
B TAMIFLU ORAL CAPSULE E
g lorazepam oral concentrate 2 mg/ml 1
B TAMIFLU ORAL SUSPENSION E QL
RECONSTITUTED
g lorazepam oral tablet 1
B TEMIXYS E QL
g triazolam 1
g tenofovir disoproxil fumarate 1 H-PA
B VALIUM E
See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as
First Start in New Jersey).
15Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
B VISTARIL 3 B CARDIZEM E
B XANAX E B CARDIZEM CD E
B XANAX XR E B CARDIZEM LA E
Bipolar Agents - Drugs for Mood Disorders B CARDURA 3
g lithium carbonate er 1 B CAROSPIR 3
g lithium carbonate oral 1 g cartia xt 1
B LITHOBID 3 g carvedilol 1
Cardiovascular Agents - Drugs for Heart and Circulation g chlorthalidone 1
Conditions g clonidine hcl oral 1
B ACCUPRIL E g colesevelam hcl E
g acetazolamide er 1 B COREG E
g acetazolamide oral 1 B CORGARD 3
B ALDACTONE E B CORLANOR 3 PA, QL
g aliskiren fumarate 1 B COZAAR E
B ALTACE E B CRESTOR E QL
B ALTOPREV 3 g diltiazem hcl er 1
g amiodarone hcl oral 1 g diltiazem hcl er coated beads 1
g amlodipine besylate oral 1 g diltiazem hcl oral 1
g amlodipine besylate-benazepril hcl 1 g dilt-xr 1
g amlodipine besylate-valsartan 1 B DIOVAN E
g atenolol oral 1 B DIOVAN HCT E
g atenolol-chlorthalidone 1 g doxazosin mesylate oral 1
g atorvastatin calcium oral tablet 1 QL, H-PA B EDARBI 2
10 mg, 20 mg
B EDARBYCLOR 2
g atorvastatin calcium oral tablet 1 QL
40 mg, 80 mg
g enalapril maleate oral 1
B AVALIDE E
B EPANED 3
B AVAPRO E
B EXFORGE E
g benazepril hcl oral 1
B EZALLOR SPRINKLE 3
g benazepril-hydrochlorothiazide 1
g ezetimibe 1
B BENICAR E
g ezetimibe-simvastatin 1
B BENICAR HCT E
g fenofibrate oral capsule 150 mg, 1
50 mg
B BETAPACE E
g fenofibrate oral tablet 1
B BIDIL 2
B FENOGLIDE E
g bisoprolol fumarate oral 1
g flecainide acetate 1
g bisoprolol-hydrochlorothiazide 1
B FLOLIPID 3
B BYSTOLIC 3
g furosemide oral 1
B CALAN SR ORAL TABLET 3
EXTENDED RELEASE 120 MG,
g gemfibrozil oral 1
180 MG B GONITRO 3
See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as
First Start in New Jersey).
16Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
g guanfacine hcl 1 g niacin er (antihyperlipidemic) 1
B HEMANGEOL E g niacor E
g hydralazine hcl oral 1 B NIASPAN E
g hydrochlorothiazide oral 1 g nifedipine er 1
B HYZAAR E g nifedipine er osmotic release 1
g icosapent ethyl E PA g nifedipine oral 1
B INDERAL LA E B NITRO-BID 2
g irbesartan 1 B NITRO-DUR 3
g irbesartan-hydrochlorothiazide 1 g nitroglycerin sublingual 1
g isosorbide mononitrate 1 g nitroglycerin transdermal 1
g isosorbide mononitrate er 1 g nitroglycerin translingual 1
B KAPSPARGO SPRINKLE 3 B NITROLINGUAL E
g labetalol hcl oral 1 B NITROMIST 3
B LASIX 3 B NITROSTAT 3
B LIPITOR E QL B NITRO-TIME 3
B LIPOFEN 3 B NORVASC E
g lisinopril oral 1 g olmesartan medoxomil oral 1
g lisinopril-hydrochlorothiazide 1 g olmesartan medoxomil-hctz 1
B LOPID 3 g omega-3-acid ethyl esters 1
B LOPRESSOR 3 B PACERONE ORAL TABLET 3
g losartan potassium oral 1 100 MG, 400 MG
g losartan potassium-hctz 1
B PACERONE ORAL TABLET 200 MG 3
B LOTENSIN 3
B PRALUENT E PA, QL
B LOTENSIN HCT 3
g pravastatin sodium 1
B LOTREL E
g prazosin hcl oral 1
g lovastatin oral 1 H
B PRINIVIL 3
g matzim la 1
B PROCARDIA XL E
B MAXZIDE 3
g propranolol hcl er 1
B MAXZIDE-25 3
g propranolol hcl oral 1
g metoprolol succinate er 1
B QBRELIS 3
g metoprolol tartrate oral 1
g quinapril hcl 1
B MICARDIS E
g ramipril 1
B MINIPRESS 3
B RANEXA E
g minitran 1
g ranolazine er 1
B MULTAQ 3 PA
B REPATHA 2 PA, QL
g nadolol oral 1
B REPATHA PUSHTRONEX SYSTEM 2 PA, QL
B NEXLETOL 2 QL
B REPATHA SURECLICK 2 PA, QL
B NEXLIZET 2 QL
g rosuvastatin calcium 1 QL
g niacin (antihyperlipidemic) E
g simvastatin oral tablet 10 mg, 1 H-PA
20 mg, 40 mg, 5 mg
See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as
First Start in New Jersey).
17Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
g simvastatin oral tablet 80 mg 1 B APTENSIO XR 3 QL
g sotalol hcl oral 1 g atomoxetine hcl 1 QL
B SOTYLIZE 3 B CONCERTA 1 QL
g spironolactone oral 1 B DEXEDRINE E QL
B TEKTURNA 3 g dexmethylphenidate hcl 1
B TEKTURNA HCT 3 g dexmethylphenidate hcl er 1 QL
g telmisartan 1 g dextroamphetamine sulfate 1
B TENORETIC 100 E g dextroamphetamine sulfate er 1 QL
B TENORETIC 50 E B FOCALIN 3
B TENORMIN E B FOCALIN XR E QL
B TOPROL XL E g guanfacine hcl er 1 QL
g torsemide 1 B INTUNIV E QL
g triamterene-hctz 1 B JORNAY PM 3 PA, QL
B TRICOR E B METHYLIN 3
g valsartan 1 g methylphenidate hcl er (cd) 1 QL
g valsartan-hydrochlorothiazide 1 g methylphenidate hcl er (la) oral 1 QL
B VASCEPA E PA capsule extended release 24 hour
10 mg, 20 mg, 30 mg, 40 mg
B VASOTEC E
g methylphenidate hcl er (la) oral 1
g verapamil hcl er 1 capsule extended release 24 hour
g verapamil hcl oral 1 60 mg
B VERELAN 3 g methylphenidate hcl er (xr) 1 QL
B VERELAN PM 3 g methylphenidate hcl er oral tablet 1 QL
B VERQUVO E PA, QL extended release 10 mg, 20 mg
B VYTORIN E g methylphenidate hcl er oral tablet E QL
extended release 18 mg, 27 mg,
B WELCHOL 1
36 mg, 54 mg, 72 mg
B ZESTORETIC E g methylphenidate hcl er oral tablet E QL
B ZESTRIL E extended release 24 hour
B ZETIA E g methylphenidate hcl oral 1
B ZIAC ORAL TABLET 10-6.25 MG, 3 B MYDAYIS 2 QL
2.5-6.25 MG B PROCENTRA 3
B ZIAC ORAL TABLET 5-6.25 MG 3 B QUILLICHEW ER 3 QL
B ZOCOR E B QUILLIVANT XR 3 QL
Central Nervous System Agents - Drugs for Attention g relexxii E QL
Deficit Disorder
B RITALIN E
B ADDERALL E
B RITALIN LA E QL
B ADDERALL XR 1 QL
B STRATTERA E QL
B ADHANSIA XR 3 QL
B VYVANSE 2 QL
g amphetamine-dextroamphetamine 1
B ZENZEDI E
g amphetamine-dextroamphetamine E QL
er
See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as
First Start in New Jersey).
18Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
Central Nervous System Agents - Drugs for Multiple Dental and Oral Agents - Drugs for Mouth and Throat
Sclerosis Conditions
B AMPYRA E PA, QL, SP g cavarest 1
B AUBAGIO 3 PA, QL, SP g chlorhexidine gluconate mouth/ 1
B AVONEX PEN 2 PA, QL, SP throat
B AVONEX PREFILLED 2 PA, QL, SP
B CLINPRO 5000 3
B BAFIERTAM 2 PA, QL, SP
B DENTA 5000 PLUS 3
B BETASERON 2 PA, QL, SP
B DENTAGEL 3
B COPAXONE E PA, QL, SP
B FLUORIDEX 3
g dalfampridine er 1 PA, QL, SP
B FLUORIDEX ENHANCED 3
WHITENING
B EXTAVIA E PA, ST, QL, SP
g lidocaine hcl mouth/throat 1
B GILENYA 3 PA, QL, SP
g lidocaine viscous hcl 1
g glatiramer acetate 1 PA, QL, SP
B NAFRINSE DAILY/NEUTRAL 2
g glatopa 1 PA, QL, SP
B NAFRINSE WEEKLY 3
B KESIMPTA 2 PA, QL, SP
B PERIDEX 3
B MAVENCLAD 3 PA, ST, QL, SP
g periogard 1
B MAYZENT 3 PA, QL, SP
B PREVIDENT 5000 BOOSTER PLUS 3
B PLEGRIDY INTRAMUSCULAR 3 PA, QL
B PREVIDENT 5000 DRY MOUTH 3
B PLEGRIDY STARTER PACK 3 PA, QL, SP
B PREVIDENT 5000 ORTHO 3
B PLEGRIDY SUBCUTANEOUS 3 PA, QL, SP DEFENSE
B REBIF E PA, ST, QL, SP B PREVIDENT 5000 PLUS 3
B REBIF REBIDOSE E PA, ST, QL, SP B PREVIDENT DENTAL 3
B REBIF REBIDOSE TITRATION PACK E PA, ST, QL, SP B PREVIDENT MOUTH/THROAT 3
B REBIF TITRATION PACK E PA, ST, QL, SP g sf 1
Central Nervous System Agents - Miscellaneous g sf 5000 plus 1
B AUSTEDO 2 PA, QL, SP g sodium fluoride 5000 plus 1
B LYRICA 3 QL g sodium fluoride 5000 ppm 1
B LYRICA CR E QL g sodium fluoride dental 1
B NUEDEXTA 2 PA Dermatological Agents - Drugs for Skin Conditions
g pregabalin oral 1 QL B ABSORICA E
B RILUTEK 3 SP g accutane 1
g riluzole 1 SP B ACZONE 2
B TIGLUTIK 3 PA B ALA SCALP 3
B ZEPOSIA 3 PA, QL, SP g ala-cort external cream 1 % E
B ZEPOSIA 7-DAY STARTER PACK 3 PA, QL, SP g ala-cort external cream 2.5 % 1
B ZEPOSIA STARTER KIT 3 PA, QL, SP B ALDARA 3
B ALTRENO 3 PA
g amnesteem 1
See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as
First Start in New Jersey).
19Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
B AMZEEQ 3 B CLOBEX SPRAY E
B ATRALIN E PA g clodan external shampoo 1
B AVAR CLEANSER 3 g clotrimazole-betamethasone 1
B AVAR LS CLEANSER 3 g dapsone external gel 5 % E
B AVAR-E EMOLLIENT 3 B DAPSONE EXTERNAL GEL 7.5 % 3
B AVAR-E GREEN 3 B DERMA-SMOOTHE/FS BODY 3
B AVAR-E LS 3 B DERMA-SMOOTHE/FS SCALP 3
B AVITA E PA B DESONATE 3
g azelaic acid external 1 g desonide external 1
g betamethasone dipropionate aug 1 B DESOWEN 3
g betamethasone dipropionate 1 B DIPROLENE 3
external B DIPROLENE AF 3
g bp 10-1 1 B DUPIXENT 3 PA, ST, QL, SP
g calcipotriene-betameth diprop 1 B EFUDEX 3
external ointment
B ENSTILAR 3
g calcipotriene-betameth diprop E
external suspension
B EUCRISA 3 ST
g calcitriol external 1
B EVOCLIN 3
B CAPEX 2
B FINACEA EXTERNAL FOAM 2
B CARAC E
B FINACEA EXTERNAL GEL 3
g claravis 1
g fluocinolone acetonide body 1
B CLEOCIN-T 3
g fluocinolone acetonide external 1
g clindacin etz external swab 1
g fluocinolone acetonide scalp 1
g clindacin-p 1
g fluocinonide external 1
B CLINDAGEL 3
B FLUOROPLEX 3
g clindamycin phos-benzoyl perox 1 QL
B FLUOROURACIL EXTERNAL E
external gel 1.2-5 % CREAM 0.5 %
g clindamycin phosphate external 1
g fluorouracil external cream 5 % 1
foam g hydrocortisone external cream 1 % E
g clindamycin phosphate external 1 g hydrocortisone external cream 1
lotion 2.5 %
g clindamycin phosphate external 1 g hydrocortisone external lotion 2.5 % 1
solution g hydrocortisone external ointment 1
g clindamycin phosphate external 1 1 %, 2.5 %
swab g imiquimod external cream 3.75 % E
B CLINDAMYCIN PHOSPHATE GEL 3 g imiquimod external cream 5 % 1
1 % EXTERNAL B IMIQUIMOD PUMP E
g clindamycin phosphate gel 1 % 1 B IMPEKLO E
external
B IMPOYZ 3
g clobetasol propionate external 1
g isotretinoin oral capsule 10 mg, 1
B CLOBEX E
20 mg, 30 mg, 40 mg
See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as
First Start in New Jersey).
20Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
g ivermectin external cream E B SUMAXIN WASH 3
B KENALOG EXTERNAL E B SYNALAR 3
B KLISYRI E B TACLONEX EXTERNAL OINTMENT E
B METROCREAM 3 B TACLONEX EXTERNAL 3
B METROGEL E SUSPENSION
B METROLOTION 3
g tazarotene external cream E PA
g metronidazole external 1
B TAZORAC EXTERNAL CREAM 3 PA
B MIRVASO 3 PA
B TAZORAC EXTERNAL GEL 0.05 % 2 PA
g mometasone furoate external 1
B TAZORAC EXTERNAL GEL 0.1 % 3 PA
g myorisan 1
B TEMOVATE 3
g neuac external gel 1 QL
B TEXACORT 2
B NORITATE E
g tretinoin external cream 1
B OLUX E
g tretinoin external gel 0.01 %, 1
0.025 %
B PLEXION 3
g tretinoin external gel 0.05 % 1 PA
B PLEXION CLEANSER 3
g triamcinolone acetonide external 1
B PLEXION CLEANSING CLOTH 3 aerosol solution
B RETIN-A E PA g triamcinolone acetonide external 1
B RHOFADE 3 PA cream
g rosadan external cream 1 g triamcinolone acetonide external 1
g rosadan external gel 1 lotion
B SERNIVO 3 g triamcinolone acetonide external 1
ointment 0.025 %, 0.1 %, 0.5 %
B SOOLANTRA 1
g triamcinolone acetonide external E
g sss 10-5 1
ointment 0.05 %
g sulfacetamide sodium-sulfur 1 B TRIANEX E
external cream
g triderm 1
g sulfacetamide sodium-sulfur 1
external emulsion B TRIDESILON 1
g sulfacetamide sodium-sulfur 1 B VANOS E
external liquid B VECTICAL E
g sulfacetamide sodium-sulfur 1 B VERDESO 3
external lotion B WYNZORA E
g sulfacetamide sodium-sulfur 1 g zenatane 1
external pad 10-4 %
B ZILXI 3 PA, ST
g sulfacetamide sodium-sulfur 1
external suspension
B ZYCLARA E
g sulfacetamide sod-sulfur wash 1
B ZYCLARA PUMP E
B SULFACLEANSE 8/4 3 Diabetes - Glucose Monitoring
g sulfamez wash 1
B ACCU-CHEK FASTCLIX LANCET 1
KIT
B SUMADAN WASH E
B ACCU-CHEK FASTCLIX LANCETS 1
B SUMAXIN 3
See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as
First Start in New Jersey).
21Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
g accu-chek guide kit w/device 3 (Accu-Chek B ONETOUCH ULTRA 2 KIT 1
Guide Me) W/DEVICE
B ACCU-CHEK GUIDE TEST STRIPS 3 B ONETOUCH ULTRA BLUE TEST 1
B ACCU-CHEK GUIDE TEST STRIPS 3 QL STRIPS IN VITRO STRIP
B ACCU-CHEK SOFTCLIX LANCET 1
B ONETOUCH ULTRA MINI KIT 1
DEVICE KIT W/DEVICE
B ACCU-CHEK SOFTXLIX LANCETS 1
B ONETOUCH ULTRASOFT 1
LANCETS
g bd autoshield duo pen needles 2
B ONETOUCH VERIO FLEX SYSTEM 1
g bd ultra-fine insulin syringes 2 KIT W/DEVICE
g bd ultra-fine pen needles 2 B ONETOUCH VERIO IQ SYSTEM 1
B CONTOUR NEXT EZ KIT W/DEVICE 2 B ONETOUCH VERIO KIT W/DEVICE 1
B CONTOUR NEXT MONITOR KIT 2 B ONETOUCH VERIO REFLECT 1
W/DEVICE
B ONETOUCH VERIO TEST STRIPS 1 QL
B CONTOUR NEXT ONE KIT 2
Diabetes - Insulin
B CONTOUR NEXT TEST STRIPS 2 QL
B ADMELOG E
B DEXCOM G4 / G5 / G6 RECEIVER, 3 PA, QL
TRANSMITTER, SENSOR
B ADMELOG SOLOSTAR E
(INCLUDING PLATINUM, B AFREZZA 3
PLATINUM PEDIATRIC) B BASAGLAR KWIKPEN E
B DEXCOM G4 / G5 / G6 RECEIVER, 3 PA, QL B HUMALOG KWIKPEN 2
TRANSMITTER, SENSOR
(INCLUDING PLATINUM,
B HUMALOG MIX 50/50 KWIKPEN 2
PLATINUM PEDIATRIC) DEVICE B HUMALOG MIX 50/50 VIAL 1
B FREESTYLE LIBRE 14 DAY 3 PA B HUMALOG MIX 75/25 KWIKPEN 2
READER B HUMALOG MIX 75/25 VIAL 1
B FREESTYLE LIBRE 14 DAY 3 PA B HUMALOG U-100 JUNIOR 2
SENSOR KWIKPEN
B FREESTYLE LIBRE 2 READER 3 PA B HUMALOG VIAL SUBCUTANEOUS 1
B FREESTYLE LIBRE 2 SENSOR 3 PA SOLUTION 100 UNIT/ML
B FREESTYLE LIBRE READER 3 PA, QL B HUMALOG VIAL SUBCUTANEOUS 2
B FREESTYLE LIBRE SENSOR 3 PA SOLUTION CARTRIDGE
SYSTEM 100 UNIT/ML
B INSULIN SYRINGE AND PEN 2
B HUMULIN 70/30 KWIKPEN 2
NEEDLES B HUMULIN 70/30 VIAL 1
B LANCETS 3 B HUMULIN N KWIKPEN 2
B NOVOFINE AUTOCOVER PEN 2 B HUMULIN N VIAL 1
NEEDLE B HUMULIN R U-500 KWIKPEN 2
B NOVOFINE PEN NEEDLE 2 B HUMULIN R U-500 VIAL 1
B NOVOFINE PLUS PEN NEEDLE 2 B HUMULIN R VIAL 1
B NOVOTWIST 2 B INSULIN ASPART E
B ONETOUCH DELICA PLUS 1 B INSULIN ASPART FLEXPEN E ST
LANCETS B INSULIN ASPART PENFILL E ST
See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as
First Start in New Jersey).
22Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
B INSULIN LISPRO E B BAQSIMI ONE PACK 2
B INSULIN LISPRO (1 UNIT DIAL) E B BAQSIMI TWO PACK 2
B INSULIN LISPRO JUNIOR E B BYDUREON BCISE 2 PA, ST, QL
KWIKPEN AUTOINJECTOR
B INSULIN LISPRO PROT & LISPRO E B BYETTA 10 MCG PEN 2 PA, ST, QL
B LANTUS SOLOSTAR 1 B BYETTA 5 MCG PEN 2 PA, ST, QL
B LANTUS U-100 VIAL 1 B FARXIGA E ST, QL
B LEVEMIR U-100 FLEXTOUCH E B FORTAMET E
B LEVEMIR U-100 VIAL E g glimepiride 1
B LYUMJEV KWIKPEN 2 g glipizide er 1
B LYUMJEV VIAL 1 g glipizide ir 1
B NOVOLIN 70/30 FLEXPEN E g glipizide xl 1
B NOVOLIN 70/30 FLEXPEN RELION E B GLUCAGON EMERGENCY KIT 2 (Eli Lilly)
B NOVOLIN 70/30 RELION E 1 MG INJECTION 1 MG
B NOVOLIN 70/30 VIAL E
B GLUCAGON EMERGENCY KIT 2 (Fresenius)
1 MG INJECTION 1 MG
B NOVOLIN N FLEXPEN E
B GLUCOTROL XL 3
B NOVOLIN N FLEXPEN RELION E
B GLUMETZA E
B NOVOLIN N RELION E
g glyburide oral 1
B NOVOLIN N VIAL E
g glyburide-metformin 1
B NOVOLIN R FLEXPEN E
B GLYXAMBI 2 ST, QL
B NOVOLIN R FLEXPEN RELION E
B GVOKE HYPOPEN 1-PACK 2
B NOVOLIN R RELION E
B GVOKE HYPOPEN 2-PACK 2
B NOVOLIN R VIAL E
B GVOKE PFS 2
B NOVOLOG FLEXPEN E ST
B JANUVIA E ST, QL
B NOVOLOG PENFILL E ST
B JARDIANCE 2 ST, QL
B NOVOLOG U-100 VIAL E
B JENTADUETO 2 QL
B SEMGLEE E
B JENTADUETO XR 2 QL
B TOUJEO MAX SOLOSTAR 2
B KAZANO 2 QL
B TOUJEO SOLOSTAR 2
B KOMBIGLYZE XR 2 QL
B TRESIBA E
g metformin hcl er 1
B TRESIBA FLEXTOUCH E
g metformin hcl er (mod) E
Diabetes - Non-Insulin Agents
g metformin hcl er (osm) E
B ACTOS E QL
g metformin hcl ir 1
B ADLYXIN 3 PA, ST, QL
B NESINA 2 QL
B ADLYXIN STARTER PACK 3 PA, ST, QL
B ONGLYZA 2 QL
B ALOGLIPTIN BENZOATE E QL
B OSENI 2 QL
B ALOGLIPTIN-METFORMIN HCL E QL
B OZEMPIC 2 PA, ST, QL
B ALOGLIPTIN-PIOGLITAZONE E QL
g pioglitazone hcl 1 QL
B AMARYL E
See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as
First Start in New Jersey).
23Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
B RIOMET E B RETACRIT INJECTION SOLUTION 2
B RYBELSUS 2 PA, ST, QL 20000 UNIT/ML
B SOLIQUA 2 QL
B ZARXIO 2
B SYMLINPEN 120 3 QL
B ZIEXTENZO 3 SP
B SYMLINPEN 60 3 QL Drugs for Sexual Dysfunction
B SYNJARDY 2 QL
B ADDYI 3 QL
B SYNJARDY XR 2 QL
B CIALIS E QL
B TRADJENTA 2 QL
B IMVEXXY MAINTENANCE PACK 2 QL
B TRIJARDY XR 2 QL
B IMVEXXY STARTER PACK 2 QL
B TRULICITY 2 PA, ST, QL
B INTRAROSA 3 PA, QL
B VICTOZA SOLUTION PEN- 2 PA, ST, (2 Pak),
B OSPHENA 2 PA, QL
INJECTOR 18 MG/3ML QL g sildenafil citrate oral tablet 100 mg, 1 QL
SUBCUTANEOUS 25 mg, 50 mg
B VICTOZA SOLUTION PEN- 3 PA, ST, (3 Pak), B STENDRA 2 QL
INJECTOR 18 MG/3ML QL g tadalafil oral 1 QL
SUBCUTANEOUS
B VIAGRA E QL
Drugs for Blood Disorders
B VYLEESI 3 PA, QL
B ADVATE 2 SP
Electrolytes / Vitamins
B ADYNOVATE 3 PA, SP
g cyanocobalamin injection solution 1
B AFSTYLA INTRAVENOUS KIT 1000 3 PA 1000 mcg/ml
UNIT, 2000 UNIT, 250 UNIT, 3000
UNIT, 500 UNIT
B CYANOCOBALAMIN INJECTION 3
SOLUTION 2000 MCG/ML
B AFSTYLA INTRAVENOUS KIT 1500 3 PA, SP
UNIT, 2500 UNIT
B DRISDOL 3
B ALPHANATE 2 SP
B ERGOCAL 3
B ARANESP (ALBUMIN FREE) 2 QL, SP
g ergocalciferol oral capsule 1
B ELOCTATE 3 PA, SP
B FLORIVA PLUS 3
B JIVI 3 PA, SP
g folic acid oral tablet 1 mg 1
B KOATE 2 SP
g klor-con 1
B KOATE-DVI 2 SP
g klor-con 10 1
B KOGENATE FS 2 SP
g klor-con m10 1
B KOVALTRY 2 SP
B KLOR-CON M15 3
B MULPLETA 2 PA, SP
g klor-con m20 1
B NEULASTA 3 SP
B K-TAB 3
B NOVOEIGHT 2 SP
B LOKELMA 3 QL
B NUWIQ 2 SP
g multi-vitamin/fluoride 1
B RECOMBINATE 2 SP
g multivitamin/fluoride oral solution 1
B RETACRIT INJECTION SOLUTION 2 QL, SP
g multivitamin/fluoride oral tablet 1
10000 UNIT/ML, 2000 UNIT/ML, chewable 0.25 mg, 0.5 mg, 1 mg
3000 UNIT/ML, 4000 UNIT/ML, B NASCOBAL 3
40000 UNIT/ML
See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as
First Start in New Jersey).
24Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
B POLY-VI-FLOR 3 B PROTONIX ORAL TABLET E
g potassium chloride crys er oral 1 DELAYED RELEASE
tablet extended release 10 meq, B PYLERA 3 QL
20 meq B RABEPRAZOLE SODIUM ORAL 3 QL
g potassium chloride er 1 CAPSULE SPRINKLE
g potassium chloride oral packet 1 g rabeprazole sodium oral tablet 1 QL
g potassium chloride oral solution 1 delayed release
20 meq/15ml (10%), 40 meq/15ml g sucralfate oral 1
(20%) Gastrointestinal Agents - Drugs for Bowel, Intestine and
g potassium citrate er 1 Stomach Conditions
B QUFLORA PEDIATRIC 3 B ANASPAZ 2
B UROCIT-K 10 3 B CLENPIQ 2
B UROCIT-K 15 3 g dicyclomine hcl oral 1
B UROCIT-K 5 3 g diphenoxylate-atropine 1
B VELTASSA 3 QL B ED-SPAZ 3
g vitamin d (ergocalciferol) oral 1 g gavilyte-c 1 H
capsule 1.25 mg (50000 ut) g gavilyte-g 1 H
Gastrointestinal Agents - Drugs for Acid Reflux and B GOLYTELY 3
Ulcer
g hyoscyamine sulfate er 1
B ACIPHEX E QL
g hyoscyamine sulfate oral 1
B ACIPHEX SPRINKLE 3 QL
g hyoscyamine sulfate sl 1
B CARAFATE E
g hyoscyamine sulfate sublingual 1
B CYTOTEC 3
g hyosyne 1
B DEXILANT 2 QL
B LEVBID 3
B FIRST-OMEPRAZOLE 3 PA
B LEVSIN ORAL 3
g misoprostol oral 1
B LEVSIN/SL 3
B OMECLAMOX-PAK 3 QL
B LINZESS 2 PA, QL
g omeprazole oral capsule delayed 1
release
B LOMOTIL 3
B OMEPRAZOLE+SYRSPEND SF 3 PA
B MOTEGRITY 3 PA, QL
ALKA B MOVIPREP 2
g pantoprazole sodium oral packet 1 B NULEV 3
g pantoprazole sodium tablet delayed 1 g oscimin 1
release 20 mg oral g oscimin sr 1
g pantoprazole sodium tablet delayed E g peg-3350/electrolytes 1 H
release 20 mg oral g peg-3350/electrolytes/ascorbat 1
g pantoprazole sodium tablet delayed E g peg-kcl-nacl-nasulf-na asc-c 1
release 40 mg oral
B PLENVU 2
g pantoprazole sodium tablet delayed 1
release 40 mg oral B SUPREP BOWEL PREP KIT 2
B PROTONIX ORAL PACKET 3 B SUTAB 2
See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as
First Start in New Jersey).
25Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
B SYMAX DUOTAB 3 Genitourinary Agents - Drugs for Bladder, Genital and
B SYMAX-SL 3 Kidney Conditions
B SYMAX-SR 3
B AURYXIA 3
B SYMPROIC 2 PA, QL
B DITROPAN XL E
B TRULANCE 3 PA, ST, QL
B GELNIQUE 3
B URSO 250 E
g oxybutynin chloride er 1
B URSO FORTE E
g oxybutynin chloride oral 1
g ursodiol oral 1
g phenazo oral tablet 200 mg 1
B VIBERZI 3 QL
g phenazopyridine hcl oral tablet 1
100 mg, 200 mg
B XIFAXAN ORAL TABLET 200 MG 3
B PYRIDIUM 3
B XIFAXAN ORAL TABLET 550 MG 3 QL
B TOVIAZ 2
B ZELNORM 3 PA, QL
B VELPHORO 2
Genetic or Enzyme Disorder - Drugs for Replacement,
Modification, Treatment Genitourinary Agents - Drugs for Prostate Conditions
B CERDELGA 2 PA, SP
g alfuzosin hcl er 1
g clovique 1 PA, SP
g finasteride oral tablet 5 mg 1
B CREON 2
B FLOMAX E
B CUPRIMINE E SP
B PROSCAR E
B DEPEN TITRATABS 2 SP
g tamsulosin hcl 1
B ENDARI 3 QL
g terazosin hcl 1
g nitisinone E PA, SP
B UROXATRAL E
B NITYR E PA, SP Hormonal Agents - Hormone Replacement and Birth
Control
B ORFADIN ORAL CAPSULE 1 PA, SP
g afirmelle 1 H
B ORFADIN ORAL SUSPENSION 2 PA, SP
B ALORA 3 QL
B PANCREAZE ORAL CAPSULE 3 ST
DELAYED RELEASE PARTICLES
g altavera 1 H
10500-35500 UNIT, 16800-56800 g alyacen 1/35 1 H
UNIT, 21000-54700 UNIT, 2600- g amethia 1 H
8800 UNIT, 4200-14200 UNIT
g apri 1 H
g penicillamine oral 1 SP
g ashlyna 1 H
B PERTZYE 3 ST
g aubra 1 H
B STRENSIQ 2 PA, QL, SP
g aubra eq 1 H
B SYPRINE E PA, SP
g aurovela 1.5/30 1 H
B TEGSEDI 2 PA, QL, SP
g aurovela 1/20 1 H
g trientine hcl 1 PA, SP
g aurovela 24 fe 1 H
B VIOKACE ORAL TABLET 20880- 3 ST
78300 UNIT
g aurovela fe 1.5/30 1 H
B ZENPEP 2
g aurovela fe 1/20 1 H
g aviane 1 H
See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as
First Start in New Jersey).
26Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
B AYGESTIN 3 B ELESTRIN 3
g ayuna 1 H g elinest 1 H
g azurette 1 H g eluryng E
g balziva 1 H g emoquette 1 H
g bekyree 1 H g enskyce 1 H
B BEYAZ E g errin 1 H
B BIJUVA 3 g estarylla 1 H
g blisovi 24 fe 1 H B ESTRACE E
g blisovi fe 1.5/30 1 H g estradiol oral 1
g blisovi fe 1/20 1 H g estradiol patch twice weekly 1 (generic for
g briellyn 1 H 0.025 mg/24hr transdermal Minivelle), QL
g camila 1 H
g estradiol patch twice weekly E (generic for
0.025 mg/24hr transdermal Vivelle-Dot), QL
g camrese 1 H
g estradiol patch twice weekly 1 (generic for
g camrese lo 1 H 0.0375 mg/24hr transdermal Minivelle), QL
g charlotte 24 fe 1 g estradiol patch twice weekly E (generic for
g chateal 1 H 0.0375 mg/24hr transdermal Vivelle-Dot), QL
g chateal eq 1 H g estradiol patch twice weekly 1 (generic for
B CLIMARA E QL 0.05 mg/24hr transdermal Minivelle), QL
B CLIMARA PRO 2 QL g estradiol patch twice weekly E (generic for
0.05 mg/24hr transdermal Vivelle-Dot), QL
g cryselle-28 1 H
g estradiol patch twice weekly 1 (generic for
g cyclafem 1/35 1 H
0.075 mg/24hr transdermal Minivelle), QL
g cyred 1 H g estradiol patch twice weekly E (generic for
g cyred eq 1 H 0.075 mg/24hr transdermal Vivelle-Dot), QL
g dasetta 1/35 1 H g estradiol patch twice weekly 1 (generic for
g daysee 1 H 0.1 mg/24hr transdermal Minivelle), QL
g deblitane 1 H g estradiol patch twice weekly E (generic for
0.1 mg/24hr transdermal Vivelle-Dot), QL
g delyla 1 H
g estradiol transdermal patch weekly 1 (generic for
B DEPO-PROVERA 3 QL
Climara), QL
INTRAMUSCULAR SUSPENSION
g estradiol vaginal 1
B DEPO-PROVERA 3
INTRAMUSCULAR SUSPENSION B ESTRING 2 QL
PREFILLED SYRINGE B ESTROGEL 3 QL
B DEPO-SUBQ PROVERA 104 2 QL g etonogestrel-ethinyl estradiol E
g desogestrel-ethinyl estradiol 1 H B EVAMIST 2
B DIVIGEL 2 g falmina 1 H
g dotti E QL g fayosim 1
g drospiren-eth estrad-levomefol 1 g femynor 1 H
g drospirenone-ethinyl estradiol 1 H g gemmily 1
B DUAVEE 3 QL g hailey 1.5/30 1 H
See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as
First Start in New Jersey).
27Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
g hailey 24 fe 1 H B LOESTRIN FE 1/20 E
g hailey fe 1.5/30 1 H g lojaimiess 1 H
g hailey fe 1/20 1 H g loryna 1 H
g heather 1 H B LOSEASONIQUE 3
g iclevia 1 H g low-ogestrel 1 H
g incassia 1 H g lo-zumandimine 1 H
g introvale 1 H g lutera 1 H
g isibloom 1 H g lyleq 1 H
g jaimiess 1 H g lyllana E QL
g jasmiel 1 H g lyza 1 H
g jencycla 1 H g marlissa 1 H
g jolessa 1 H g medroxyprogesterone acetate 1 QL, H
g juleber 1 H intramuscular suspension
g junel 1.5/30 1 H
g medroxyprogesterone acetate 1 H
intramuscular suspension prefilled
g junel 1/20 1 H syringe
g junel fe 1.5/30 1 H g medroxyprogesterone acetate oral 1
g junel fe 1/20 1 H B MENOSTAR 3 QL
g junel fe 24 1 H g merzee 1
g kalliga 1 H g mibelas 24 fe 1
g kariva 1 H g microgestin 1.5/30 1 H
g kurvelo 1 H g microgestin 1/20 1 H
g larin 1.5/30 1 H g microgestin 24 fe 1 H
g larin 1/20 1 H g microgestin fe 1.5/30 1 H
g larin 24 fe 1 H g microgestin fe 1/20 1 H
g larin fe 1.5/30 1 H g mili 1 H
g larin fe 1/20 1 H B MINASTRIN 24 FE E
g larissia 1 H B MINIVELLE E QL
g lessina 1 H B MIRCETTE E
g levonorgest-eth est & eth est 1 g mono-linyah 1 H
g levonorgest-eth estrad 91-day 1 H B NATAZIA 2
g levonorgestrel-ethinyl estrad oral 1 H g necon 0.5/35 (28) 1 H
tablet 0.1-20 mg-mcg,
0.15-30 mg-mcg
g nikki 1 H
g levora 0.15/30 (28) 1 H
g nora-be 1 H
g lillow 1 H
g norethin ace-eth estrad-fe oral 1
capsule
B LO LOESTRIN FE 2
g norethin ace-eth estrad-fe oral tablet 1 H
B LOESTRIN 1.5/30 (21) E
g norethin ace-eth estrad-fe oral tablet 1
B LOESTRIN 1/20 (21) E chewable
B LOESTRIN FE 1.5/30 E g norethindrone acetate oral 1
See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as
First Start in New Jersey).
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