Your 2022 Prescription Drug List - Traditional 3-Tier - United Healthcare
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Pharmacy | PDL Your 2022 Prescription Drug List Traditional 3-Tier Effective September 1, 2022 This Prescription Drug List (PDL) is accurate as of September 1, 2022 and is subject to change after this date. This PDL applies to members of our UnitedHealthcare, River Valley, Oxford, and Student Resources medical plans with a pharmacy benefit subject to the Traditional 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. . . . . . . . . . . . . . . . . . . . . . . . 10
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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Antifungals
Drugs for Fungal Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Antigout Agents
Drugs for Gout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Antimigraine Agents
Drugs for Migraines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Antineoplastics
Drugs for Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Antiparasitics
Drugs for Parasitic Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Anti-Parkinson’s Agents
Drugs for Parkinson’s Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Antiplatelets
Drugs for Heart Attack and Stroke Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Antipsychotics
Drugs for Mood Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Antivirals
Drugs for Viral Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Anxiolytics
Drugs for Anxiety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Drugs for Multiple Sclerosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Dental and Oral Agents
Drugs for Mouth and Throat Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
2Dermatological Agents
Drugs for Skin Conditions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Diabetes
Glucose Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Non-Insulin Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Drugs for Blood Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Drugs for Sexual Dysfunction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Electrolytes / Vitamins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Gastrointestinal Agents
Drugs for Acid Reflux and Ulcer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Drugs for Bowel, Intestine and Stomach Conditions . . . . . . . . . . . . . . . . . . . . . . . 28
Genetic or Enzyme Disorder
Drugs for Replacement, Modification, Treatment . . . . . . . . . . . . . . . . . . . . . . . . . 28
Genitourinary Agents
Drugs for Bladder, Genital and Kidney Conditions. . . . . . . . . . . . . . . . . . . . . . . . . 28
Drugs for Prostate Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Hormonal Agents
Hormone Replacement and Birth Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Oral Steroids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Testosterone Replacement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Thyroid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Immunological Agents
Drugs for Immune System Stimulation or Suppression. . . . . . . . . . . . . . . . . . . . . 33
Infertility Agents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Inflammatory Bowel Disease Agents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Metabolic Bone Disease Agents
Drugs for Osteoporosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Ophthalmic Agents
Drugs for Eye Allergy, Infection and Inflammation . . . . . . . . . . . . . . . . . . . . . . . . . 35
Drugs for Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Drugs for Miscellaneous Eye Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Otic Agents
Drugs for Ear Conditions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Respiratory
Drugs for Anaphylaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Respiratory Tract / Pulmonary Agents
Drugs for Allergies, Cough, Cold . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Drugs for Asthma and COPD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Drugs for Cystic Fibrosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Drugs for Pulmonary Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Skeletal Muscle Relaxants
Drugs for Muscle Pain and Spasm. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Sleep Disorder Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
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 documents provided by your
when you see your doctor. If your medication is not listed here, please visit your employer or health plan to see
plan’s member website or call the toll-free member phone number on your member 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 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)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 2 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.
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 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.
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 $$ Mid-range cost Use Tier 2 drugs, instead of
Medications that provide good overall value. Mainly preferred Tier 3, to help reduce your
brand-name drugs. out-of-pocket costs.
Tier 3 $$$ Highest-cost Ask your doctor if a Tier 1 or
Medications that provide the lowest overall value. Tier 2 option could work 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 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.
PA Prior Authorization (sometimes referred to as precertification)3 — Requires your doctor to provide
information about why you are taking a medication to determine how it may be covered by your plan.4
QL Quantity Limits — Specifies the largest quantity of medication covered per copayment or in a defined period
of time.
RS Refill and Save Program5 — Save money on your copayment when you refill your prescription on time as
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 Step Therapy (referred to as First Start in New Jersey) — Requires prior authorization and may require you to
try one or more other medications before the medication you are requesting may be covered.6
3 Depending on your benefit, you may have notification or medical necessity requirements for select medications.
4. For certain Student Resources plans, applies to specialty medications and topical retinoids only.
5. Not applicable to Oxford and Student Resources plans.
6. Not applicable to certain Student Resources 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 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
7Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
Analgesics - Drugs for Pain g lidocaine-prilocaine external cream 1
g acetaminophen-codeine 1 B LIDODERM E PA, QL
g acetaminophen-codeine #2 1 B LORTAB 3
g acetaminophen-codeine #3 1 g morphine sulfate (concentrate) oral 1
g acetaminophen-codeine #4 1 solution 100 mg/5ml, 20 mg/ml
g apap-caff-dihydrocodeine 1 QL
g morphine sulfate er oral capsule E PA, ST, QL
extended release 24 hour
g bac 1 QL
g morphine sulfate er oral tablet 1 PA, QL
B BELBUCA 3 PA, QL extended release
g butalbital-apap-caffeine 1 QL g morphine sulfate oral solution 1
B CONZIP E QL 10 mg/5ml
B DILAUDID ORAL 3 B MORPHINE SULFATE ORAL 3
B DUROLANE E SOLUTION 20 MG/5ML
g endocet 1 g morphine sulfate oral tablet 1
B ESGIC 3 QL g morphine sulfate rectal 1
B EUFLEXXA E B MS CONTIN 3 PA, ST, QL
g fentanyl transdermal patch 72 hour 1 PA, QL B NALOCET E QL
100 mcg/hr, 12 mcg/hr, 25 mcg/hr, B NUCYNTA 3 QL
50 mcg/hr, 75 mcg/hr B NUCYNTA ER 3 PA, QL
g fentanyl transdermal patch 72 hour E PA, ST, QL B OXAYDO E QL
37.5 mcg/hr, 62.5 mcg/hr,
87.5 mcg/hr
B OXYCODONE HCL ER E PA, ST, QL
B FIORICET 3 QL
g oxycodone hcl oral capsule 1
B GELSYN-3 E
g oxycodone hcl oral concentrate 1
100 mg/5ml
B HYALGAN E
g oxycodone hcl oral solution 1
g hydrocodone bitartrate er oral 1 PA, ST, QL
capsule extended release 12 hour
g oxycodone hcl oral tablet 10 mg, 1
15 mg, 20 mg, 30 mg
g hydrocodone bitartrate er oral E PA, ST, QL
tablet er 24 hour abuse-deterrent
g oxycodone hcl oral tablet 5 mg 1 QL
g hydrocodone-acetaminophen oral 1
B OXYCODONE-ACETAMINOPHEN E
solution 7.5-325 mg/15ml ORAL SOLUTION
g hydrocodone-acetaminophen oral E
B OXYCODONE-ACETAMINOPHEN E
tablet 10-300 mg, 5-300 mg, ORAL TABLET 10-300 MG,
7.5-300 mg 5-300 MG, 7.5-300 MG
g hydrocodone-acetaminophen oral 1
g oxycodone-acetaminophen oral 1
tablet 10-325 mg, 5-325 mg, tablet 10-325 mg, 2.5-325 mg,
7.5-325 mg 5-325 mg, 7.5-325 mg
g hydromorphone hcl er 1 PA, ST, QL
B OXYCODONE-ACETAMINOPHEN E QL
ORAL TABLET 2.5-300 MG
g hydromorphone hcl oral 1
B OXYCONTIN E PA, ST, QL
g hydromorphone hcl rectal 1
B PERCOCET E
B HYSINGLA ER E PA, ST, QL
g premium lidocaine 1 QL
g lidocaine external ointment 5 % 1 QL
B PROLATE E
g lidocaine external patch 5 % 1 PA, QL
B QDOLO E PA, 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).
8Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
B ROXICODONE ORAL TABLET E g ibuprofen oral suspension E
15 MG, 30 MG 100 mg/5ml
B ROXICODONE ORAL TABLET E QL g ibuprofen oral tablet 400 mg, 1
5 MG 600 mg, 800 mg
B SUBSYS E PA, QL B INDOCIN 3 PA
B SUPARTZ FX E g indomethacin er 1
g tramadol hcl er (biphasic) E (generic for B INDOMETHACIN ORAL CAPSULE E
Ryzolt), QL 20 MG
B TRAMADOL HCL ER ORAL E QL g indomethacin oral capsule 25 mg, 1
CAPSULE EXTENDED RELEASE 50 mg
24 HOUR B KETOROLAC TROMETHAMINE 3 ST, QL
g tramadol hcl er oral tablet extended 1 (generic for NASAL
release 24 hour Ultram ER), QL g ketorolac tromethamine oral 1
g tramadol hcl oral tablet 100 mg E B LODINE E
g tramadol hcl oral tablet 50 mg 1 B LOFENA E
B TREZIX 1 QL g meloxicam oral capsule E QL
B TRILURON E g meloxicam oral tablet 1
B ULTRAM E B MOBIC E
B VTOL LQ 2 PA, QL g nabumetone oral 1
B XTAMPZA ER 2 PA, QL B NAPRELAN E
B ZEBUTAL 3 QL B NAPROSYN ORAL SUSPENSION E PA
B ZTLIDO 3 PA, QL B NAPROSYN ORAL TABLET E
Analgesics - Drugs for Pain and Inflammation g naproxen oral suspension E PA
B ANAPROX DS E g naproxen oral tablet 1
B CATAFLAM E g naproxen oral tablet delayed 1
B CELEBREX E QL release
g celecoxib oral 1 QL g naproxen sodium er oral tablet E
g diclofenac potassium oral tablet E extended release 24 hour 375 mg,
25 mg 500 mg
g diclofenac potassium oral tablet 1
B NAPROXEN SODIUM ER ORAL E
50 mg TABLET EXTENDED RELEASE
24 HOUR 750 MG
g diclofenac sodium er 1
g naproxen sodium oral tablet 1
g diclofenac sodium external gel 1 % E 275 mg, 550 mg
g diclofenac sodium external solution E B PENNSAID E
g diclofenac sodium oral 1 B RELAFEN E
B EC-NAPROSYN ORAL TABLET 3 B RELAFEN DS E
DELAYED RELEASE 375 MG
B SPRIX 3 ST, QL
B EC-NAPROSYN ORAL TABLET 3
DELAYED RELEASE 500 MG
B TIVORBEX E
g ec-naproxen 1
B VIVLODEX E QL
g etodolac 1
B ZIPSOR E
g etodolac er 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).
9Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
Anti-Addiction / Substance Abuse Treatment Agents B DORYX E
g buprenorphine hcl sublingual 1 QL B DORYX MPC E
g buprenorphine hcl-naloxone hcl 1 QL g doxycycline hyclate oral capsule 1
B KLOXXADO 2 QL g doxycycline hyclate oral tablet 1
g naloxone hcl injection 1 100 mg, 20 mg
g naloxone hcl nasal 1 QL
g doxycycline hyclate oral tablet E
150 mg, 50 mg, 75 mg
g naltrexone hcl oral 1
g doxycycline hyclate oral tablet E
B NARCAN 2 QL delayed release 100 mg, 150 mg,
B SUBOXONE E PA, QL 200 mg, 50 mg, 75 mg
g varenicline tartrate 1 PA, H B DOXYCYCLINE HYCLATE ORAL E
B ZIMHI E TABLET DELAYED RELEASE
80 MG
B ZUBSOLV 1 QL
g doxycycline monohydrate oral 1
Antibacterials - Drugs for Infections
capsule 100 mg, 50 mg
B ACTICLATE E g doxycycline monohydrate oral E
g amoxicillin 1 capsule 150 mg, 75 mg
g amoxicillin-potassium clavulanate 1 g doxycycline monohydrate oral 1
g amoxicillin-potassium clavulanate er E suspension reconstituted
B AUGMENTIN E g doxycycline monohydrate oral 1
tablet
B AUGMENTIN ES-600 E
B FLAGYL 3
g avidoxy 1
g levofloxacin oral 1
g azithromycin oral 1
B LYMEPAK E
B BACTRIM 3
g metronidazole oral 1
B BACTRIM DS 3
g metronidazole vaginal 1
g cefadroxil 1
B MINOCYCLINE HCL ER ORAL E PA
g cefdinir 1
CAPSULE EXTENDED RELEASE
g cefuroxime axetil 1 24 HOUR
B CENTANY 3 QL g minocycline hcl er oral tablet E PA
B CENTANY AT E extended release 24 hour 105 mg,
g cephalexin 1 115 mg, 55 mg, 65 mg, 80 mg
B CIPRO ORAL TABLET 3
g minocycline hcl er oral tablet E PA
extended release 24 hour 135 mg,
g ciprofloxacin hcl oral 1 45 mg, 90 mg
g clarithromycin er 1 g minocycline hcl oral capsule 1
g clarithromycin oral 1 g minocycline hcl oral tablet E
B CLEOCIN ORAL CAPSULE 3 B MINOLIRA E PA
150 MG, 300 MG
g mondoxyne nl 1
B CLEOCIN ORAL CAPSULE 75 MG 2
g mupirocin calcium 1 QL
g clindamycin hcl oral 1
g mupirocin external 1 QL
B CLINDESSE 2
B NUVESSA E
g coremino E PA
B NUZYRA ORAL 3 QL
B DIFICID 3 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).
10Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
g penicillin v potassium 1 g divalproex sodium oral 1
B SOLODYN E PA B ELEPSIA XR E PA, ST
g sulfamethoxazole-trimethoprim oral 1 g epitol 1
g sulfatrim pediatric 1 B EPRONTIA E
B TARGADOX E g gabapentin oral capsule 1
g vandazole 1 g gabapentin oral solution 1
B VIBRAMYCIN ORAL CAPSULE 3 250 mg/5ml
B VIBRAMYCIN ORAL SUSPENSION 3
g gabapentin oral tablet 1
RECONSTITUTED B KEPPRA ORAL 3 PA, ST
B XENLETA ORAL 3 B KEPPRA XR 3 PA, ST
B XEPI 3 QL B LAMICTAL 3 PA, ST
B XIMINO E PA B LAMICTAL ODT ORAL KIT 21 X 3 PA, ST
B ZITHROMAX ORAL 3 25 MG & 7 X 50 MG, 42 X 50 MG &
14X100 MG
B ZITHROMAX TRI-PAK 3
B LAMICTAL ODT ORAL KIT 25 & 50 3 PA, ST
B ZITHROMAX Z-PAK 3 & 100 MG
Anticoagulants - Drugs to Treat or Prevent Blood Clots B LAMICTAL ODT ORAL TABLET 3 PA, ST
B ELIQUIS 2 QL DISPERSIBLE
B ELIQUIS DVT/PE STARTER PACK 2 QL B LAMICTAL STARTER 3 PA, ST
g enoxaparin sodium 1 QL B LAMICTAL XR 3 PA, ST
g jantoven 1 g lamotrigine er 1 PA, ST
B LOVENOX E QL g lamotrigine oral kit 1 PA, ST
B PRADAXA 2 QL g lamotrigine oral tablet 1
g warfarin sodium oral 1 g lamotrigine oral tablet chewable 1
B XARELTO ORAL SUSPENSION 2 g lamotrigine oral tablet dispersible 1 PA, ST
RECONSTITUTED g lamotrigine starter kit-blue 1
B XARELTO ORAL TABLET 2 QL g lamotrigine starter kit-green 1
B XARELTO STARTER PACK 2 QL g lamotrigine starter kit-orange 1
Anticonvulsants - Drugs for Seizures g levetiracetam er 1
B BRIVIACT ORAL SOLUTION 3 PA g levetiracetam oral 1
B BRIVIACT ORAL TABLET 3 PA B NAYZILAM 3 PA, QL
g carbamazepine er 1 B NEURONTIN 3 PA, ST
g carbamazepine oral 1 g oxcarbazepine 1
B CARBATROL 3 B OXTELLAR XR E ST
B DEPAKOTE 3 PA B QUDEXY XR E ST
B DEPAKOTE ER 3 PA, ST g roweepra 1
B DEPAKOTE SPRINKLES 3 PA, ST B SPRITAM E ST
B DIASTAT ACUDIAL 3 QL g subvenite 1
B DIASTAT PEDIATRIC 2 QL g subvenite starter kit-blue 1
g diazepam rectal 1 QL g subvenite starter kit-green 1
g divalproex sodium er 1 g subvenite starter kit-orange 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).
11Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
B TEGRETOL 3 g duloxetine hcl oral capsule delayed 1 QL
B TEGRETOL-XR 3 release particles 20 mg, 30 mg,
60 mg
B TOPAMAX 3 PA, ST
g duloxetine hcl oral capsule delayed E
B TOPAMAX SPRINKLE 3 PA, ST release particles 40 mg
g topiramate er E ST B EFFEXOR XR E
g topiramate oral 1 g escitalopram oxalate oral 1
B TRILEPTAL 3 PA, ST g fluoxetine hcl oral capsule 1
B TROKENDI XR E ST g fluoxetine hcl oral capsule delayed 1 QL
B VALTOCO 3 PA, QL release
B VIMPAT ORAL 3 PA g fluoxetine hcl oral solution 1
B XCOPRI 3 PA g fluoxetine hcl oral tablet 10 mg 1 QL
B ZONEGRAN 3 PA, ST g fluoxetine hcl oral tablet 20 mg 1
g zonisamide oral 1 g fluoxetine hcl oral tablet 60 mg E
Antidementia Agents - Drugs for Alzheimer's Disease g fluvoxamine maleate 1
and Dementia g fluvoxamine maleate er 1 QL
B ARICEPT E B FORFIVO XL E QL
g donepezil hcl oral tablet 10 mg, 1 B LEXAPRO E
5 mg
g mirtazapine oral 1
g donepezil hcl oral tablet 23 mg E
g nortriptyline hcl oral 1
g donepezil hcl oral tablet dispersible 1
B PAMELOR E
Antidepressants - Drugs for Depression
g paroxetine hcl 1
g amitriptyline hcl oral 1
g paroxetine hcl er 1 QL
g bupropion hcl er (sr) 1
B PAXIL CR E QL
g bupropion hcl er (xl) oral tablet 1
extended release 24 hour 150 mg,
B PAXIL ORAL SUSPENSION 3
300 mg B PAXIL ORAL TABLET E
B BUPROPION HCL ER (XL) ORAL E QL B PRISTIQ E QL
TABLET EXTENDED RELEASE B PROZAC E
24 HOUR 450 MG
B REMERON E
g bupropion hcl oral 1
B REMERON SOLTAB E
B CELEXA E
B SERTRALINE HCL ORAL CAPSULE E QL
B CITALOPRAM HYDROBROMIDE E
g sertraline hcl oral concentrate 1
ORAL CAPSULE
g citalopram hydrobromide oral 1
g sertraline hcl oral tablet 1
solution g trazodone hcl oral 1
g citalopram hydrobromide oral tablet 1 B TRINTELLIX 3 ST, QL
B CYMBALTA E QL g venlafaxine hcl 1
g desvenlafaxine succinate er 1 QL g venlafaxine hcl er oral capsule 1
g doxepin hcl oral capsule 1 extended release 24 hour
g venlafaxine hcl er oral tablet E QL
g doxepin hcl oral concentrate 1
extended release 24 hour
B DRIZALMA SPRINKLE 3 PA, 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).
12Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
B VIIBRYD 3 QL g nystatin external 1 QL
B VIIBRYD STARTER PACK 3 g nystatin mouth/throat 1
B WELLBUTRIN SR E g nystop 1 QL
B WELLBUTRIN XL E g terbinafine hcl oral 1 QL
B ZOLOFT E g terconazole 1
Antiemetics - Drugs for Nausea and Vomiting B XOLEGEL 3
B BONJESTA E PA Antigout Agents - Drugs for Gout
B DICLEGIS E PA g allopurinol oral 1
g doxylamine-pyridoxine E PA B COLCHICINE ORAL CAPSULE E
B GIMOTI E QL g colchicine oral tablet E
g metoclopramide hcl oral solution 1 B COLCRYS E
g metoclopramide hcl oral tablet 1 g febuxostat 1 ST, QL
g metoclopramide hcl oral tablet E B GLOPERBA 3 PA
dispersible B MITIGARE 2
g ondansetron hcl oral 1 B ULORIC E ST, QL
g ondansetron odt 1 B ZYLOPRIM 3
g prochlorperazine maleate oral 1 Antimigraine Agents - Drugs for Migraines
g promethazine hcl oral tablet 1 B AIMOVIG 2 PA, ST
g promethazine hcl rectal 1 B AIMOVIG SUBCUTANEOUS 2 PA, ST, QL
g promethegan 1 SOLUTION AUTO-INJECTOR
B REGLAN 3 140 MG/ML
g scopolamine 1
B AMERGE E QL
B TRANSDERM-SCOP E
g eletriptan hydrobromide 1 QL
B ZUPLENZ E QL
B EMGALITY 2 PA, ST, QL
Antifungals - Drugs for Fungal Infections
B EMGALITY (300 MG DOSE) 2 PA, ST, QL
g ciclodan 1
B IMITREX ORAL E QL
g ciclopirox external 1
B IMITREX STATDOSE REFILL E QL
g ciclopirox treatment E
B IMITREX STATDOSE SYSTEM E QL
B CRESEMBA ORAL 3
B MAXALT E QL
B DIFLUCAN E
B MAXALT-MLT E QL
B EXTINA 3 ST
g naratriptan hcl 1 QL
g fluconazole oral 1
B NURTEC ODT 2 PA, ST, QL
B GYNAZOLE-1 3
B ONZETRA XSAIL E QL
g ketoconazole external cream 1 QL
B RELPAX E QL
g ketoconazole external foam 1 ST
g rizatriptan benzoate 1 QL
g ketoconazole external shampoo 1
g sumatriptan succinate oral 1 QL
g ketodan external foam 1 ST
g sumatriptan succinate refill 1 QL
subcutaneous solution cartridge
B LOPROX EXTERNAL SHAMPOO E
g sumatriptan succinate 1 QL
g nyamyc 1 QL subcutaneous
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
B UBRELVY 2 PA, ST, QL B SOLTAMOX E
B ZEMBRACE SYMTOUCH E QL B STIVARGA 2 PA, QL, SP
B ZOLMITRIPTAN NASAL SOLUTION E QL g tamoxifen citrate oral tablet 10 mg 1
2.5 MG g tamoxifen citrate oral tablet 20 mg 1 H-PA
g zolmitriptan nasal solution 5 mg E QL B TARGRETIN EXTERNAL 3 QL, SP
g zolmitriptan oral 1 QL B TARGRETIN ORAL 1 SP
B ZOMIG NASAL SOLUTION 2.5 MG 3 QL B TASIGNA 2 PA, ST, QL, SP
B ZOMIG NASAL SOLUTION 5 MG 1 QL B UKONIQ 3 PA, QL, SP
B ZOMIG ORAL E QL B VERZENIO 2 PA, QL, SP
Antineoplastics - Drugs for Cancer B VITRAKVI 2 PA, QL, SP
B ALECENSA 2 PA, QL, SP B XELODA E QL, SP
B ALUNBRIG 2 PA, QL, SP B ZEJULA 2 PA, QL, SP
g anastrozole oral 1 H-PA Antiparasitics - Drugs for Parasitic Infections
B ARIMIDEX E B ARAKODA 3 QL
g bexarotene E SP g atovaquone-proguanil hcl 1
B CALQUENCE 2 PA, QL, SP g hydroxychloroquine sulfate oral 1
g capecitabine 1 QL, SP B KRINTAFEL 1 QL
B ERIVEDGE 2 PA, QL, SP B MALARONE 3
B ERLEADA 2 PA, QL, SP g permethrin external 1
B EXKIVITY 3 PA, QL, SP B PLAQUENIL E
B FEMARA E Antiparkinson Agents - Drugs for Parkinson's Disease
g fluorouracil external solution 1 B APOKYN 3 PA, QL, SP
B GAVRETO 3 PA, QL, SP g apomorphine hcl subcutaneous 1 PA, QL, SP
B IBRANCE 2 PA, QL, SP g carbidopa-levodopa 1
B ICLUSIG ORAL TABLET 10 MG, 3 PA, QL, SP g carbidopa-levodopa er 1
30 MG
B DHIVY E
B ICLUSIG ORAL TABLET 15 MG, 3 PA, QL, SP
45 MG
B DUOPA 3 PA
B IDHIFA 2 PA, QL, SP
B INBRIJA 3 PA, QL, SP
B KOSELUGO 3 PA, QL, SP
B KYNMOBI 3 PA, QL, SP
g lenalidomide 1 PA, QL, SP
B KYNMOBI TITRATION KIT 3 PA, SP
g letrozole oral 1 H-PA
B MIRAPEX ER E
B LYNPARZA 2 PA, QL, SP
B NOURIANZ 3 PA, QL
g mercaptopurine oral 1
g pramipexole dihydrochloride 1
B NUBEQA 2 PA, QL, SP
g pramipexole dihydrochloride er E
B ODOMZO 2 PA, QL, SP
g ropinirole hcl 1
B ORGOVYX 3 PA, QL, SP
g ropinirole hcl er E
B PURIXAN 3 PA, SP
B RYTARY E
B REVLIMID 2 PA, QL, SP
B SINEMET 3
B ROZLYTREK 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).
14Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
Antiplatelets - Drugs for Heart Attack and Stroke g emtricitabine-tenofovir df oral tablet 1 QL
Prevention 100-150 mg, 133-200 mg,
B BRILINTA 3 QL 167-250 mg
g clopidogrel bisulfate oral 1
g emtricitabine-tenofovir df oral tablet 1 QL, H
200-300 mg
B PLAVIX E
g entecavir 1 SP
B ZONTIVITY 3 QL
B EPCLUSA ORAL PACKET 2 PA, QL, SP
Antipsychotics - Drugs for Mood Disorders 150-37.5 MG
B ABILIFY E QL B EPCLUSA ORAL PACKET 2 PA, SP
g aripiprazole oral solution 1 200-50 MG
g aripiprazole oral tablet 1 QL B EPCLUSA ORAL TABLET 2 PA, QL, SP
g aripiprazole oral tablet dispersible 1 QL B GENVOYA 3 QL
g asenapine maleate E QL B HARVONI ORAL PACKET 2 QL
B GEODON ORAL E QL B HARVONI ORAL TABLET 2 PA, ST, QL, SP
B LATUDA 3 QL B ISENTRESS 2
g olanzapine oral 1 QL B ISENTRESS HD 2
g quetiapine fumarate 1 B JULUCA 2 QL
g quetiapine fumarate er 1 QL B LEDIPASVIR-SOFOSBUVIR 2 PA, ST, QL, SP
B RISPERDAL E B MAVYRET ORAL PACKET 2 QL, SP
g risperidone 1 B MAVYRET ORAL TABLET 2 PA, QL, SP
B SAPHRIS 1 QL B NORVIR ORAL PACKET 2
B SEROQUEL E B NORVIR ORAL SOLUTION 2
B SEROQUEL XR E QL B NORVIR ORAL TABLET E
B VRAYLAR 3 QL B ODEFSEY 3 QL
g ziprasidone hcl 1 QL g oseltamivir phosphate oral capsule 1
B ZYPREXA ORAL E QL g oseltamivir phosphate oral 1 QL
B ZYPREXA ZYDIS E QL suspension reconstituted
Antivirals - Drugs for Viral Infections B PREZCOBIX 2
g acyclovir oral 1
B PREZISTA 2
B ATRIPLA E ST, QL
g ritonavir 1
B BARACLUDE ORAL SOLUTION 2 SP
B RUKOBIA 3 PA
B BARACLUDE ORAL TABLET E SP
B SITAVIG E QL
B CIMDUO 2 QL B SOFOSBUVIR-VELPATASVIR 2 PA, QL, SP
B DESCOVY ORAL TABLET E PA, ST, QL
B STRIBILD 3 QL
200-25 MG B SYMFI 2 QL
B DESCOVY TABLET 120-15 MG E PA, ST B SYMFI LO 2 QL
ORAL B TAMIFLU ORAL CAPSULE E
B DOVATO 2 QL B TAMIFLU ORAL SUSPENSION E QL
g efavirenz-emtricitab-tenofovir 1 ST, QL RECONSTITUTED
g efavirenz-lamivudine-tenofovir 1 QL B TEMIXYS 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).
15Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
g tenofovir disoproxil fumarate 1 H-PA B VALIUM E
B TIVICAY 3 B VISTARIL 3
B TIVICAY PD 3 B XANAX E
B TRIUMEQ 2 QL B XANAX XR E
B TRUVADA ORAL TABLET 3 QL Bipolar Agents - Drugs for Mood Disorders
100-150 MG, 133-200 MG, g lithium carbonate er 1
167-250 MG
g lithium carbonate oral 1
B TRUVADA ORAL TABLET E QL
200-300 MG
B LITHOBID 3 PA
g valacyclovir hcl oral 1 QL Cardiovascular Agents - Drugs for Heart and Circulation
Conditions
B VALTREX E QL
B ACCUPRIL E
B VEMLIDY 3 ST, SP
g acetazolamide er 1
B VIREAD ORAL POWDER 3
g acetazolamide oral 1
B VIREAD ORAL TABLET 150 MG, 2
200 MG, 250 MG
B ALDACTONE E
B VIREAD ORAL TABLET 300 MG E
g aliskiren fumarate 1
B VOSEVI 2 PA, QL, SP
B ALTACE E
B XOFLUZA (40 MG DOSE) 3 QL
B ALTOPREV E
B XOFLUZA (80 MG DOSE) 3 QL
g amiodarone hcl oral 1
B ZEPATIER 2 PA, QL, SP
g amlodipine besylate oral 1
B ZOVIRAX ORAL 3
g amlodipine besylate-benazepril hcl 1
Anxiolytics - Drugs for Anxiety
g amlodipine besylate-valsartan 1
g alprazolam er 1
g atenolol oral 1
g alprazolam intensol 1
g atenolol-chlorthalidone 1
g alprazolam oral 1
g atorvastatin calcium oral tablet 1 QL, H-PA
10 mg, 20 mg
g alprazolam xr 1
g atorvastatin calcium oral tablet 1 QL
B ATIVAN ORAL E 40 mg, 80 mg
g buspirone hcl oral 1 B AVALIDE E
g clonazepam oral 1 B AVAPRO E
g diazepam intensol 1 g benazepril hcl oral 1
g diazepam oral 1 g benazepril-hydrochlorothiazide 1
B HALCION 3 B BENICAR E
g hydroxyzine hcl oral 1 B BENICAR HCT E
g hydroxyzine pamoate oral 1 B BETAPACE E
B KLONOPIN E B BIDIL 2
g lorazepam intensol 1 g bisoprolol fumarate oral 1
g lorazepam oral concentrate 1 g bisoprolol-hydrochlorothiazide 1
2 mg/ml
B BYSTOLIC E
g lorazepam oral tablet 1
B CALAN SR 3
B LOREEV XR E
B CARDIZEM E
g triazolam 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).
16Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
B CARDIZEM CD E g gemfibrozil oral 1
B CARDIZEM LA E B GONITRO E QL
B CARDURA 3 g guanfacine hcl 1
B CAROSPIR 3 PA B HEMANGEOL E
g cartia xt 1 g hydralazine hcl oral 1
g carvedilol 1 g hydrochlorothiazide oral 1
g chlorthalidone 1 B HYZAAR E
g clonidine hcl oral 1 g icosapent ethyl E PA
g colesevelam hcl E B INDERAL LA E
B COREG E g irbesartan 1
B CORGARD 3 g irbesartan-hydrochlorothiazide 1
B CORLANOR 3 PA, QL g isosorbide mononitrate 1
B COZAAR E g isosorbide mononitrate er 1
B CRESTOR E QL B KAPSPARGO SPRINKLE 3
g diltiazem hcl er 1 g labetalol hcl oral 1
g diltiazem hcl er coated beads 1 B LASIX 3
g diltiazem hcl oral 1 B LIPITOR E QL
g dilt-xr 1 B LIPOFEN E
B DIOVAN E g lisinopril oral 1
B DIOVAN HCT E g lisinopril-hydrochlorothiazide 1
g doxazosin mesylate oral 1 B LOPID 3
B EDARBI 3 B LOPRESSOR 3
B EDARBYCLOR 3 g losartan potassium oral 1
g enalapril maleate oral solution 1 PA g losartan potassium-hctz 1
g enalapril maleate oral tablet 1 B LOTENSIN 3
B EPANED 3 PA B LOTENSIN HCT 3
B EXFORGE E B LOTREL E
B EZALLOR SPRINKLE 3 PA g lovastatin oral 1 H
g ezetimibe 1 B LOVAZA E
g ezetimibe-simvastatin 1 g matzim la 1
g fenofibrate oral capsule 150 mg, E B MAXZIDE 3
50 mg B MAXZIDE-25 3
g fenofibrate oral tablet 120 mg, E g metoprolol succinate er 1
40 mg, 48 mg
g metoprolol tartrate oral tablet 1
g fenofibrate oral tablet 145 mg, 1 100 mg, 25 mg, 50 mg
160 mg, 54 mg
g metoprolol tartrate oral tablet E
B FENOGLIDE E 37.5 mg, 75 mg
g flecainide acetate 1 B MICARDIS E
B FLOLIPID 3 PA B MINIPRESS 3
g furosemide oral 1 B MULTAQ 3 PA
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 nadolol oral 1 B REPATHA PUSHTRONEX SYSTEM 2 PA, ST, QL
g nebivolol hcl E B REPATHA SURECLICK 2 PA, ST, QL
B NEXLETOL 2 PA, ST, QL g rosuvastatin calcium 1 QL
B NEXLIZET 2 PA, ST, QL g simvastatin oral tablet 10 mg, 1 H-PA
g niacin (antihyperlipidemic) E 20 mg, 40 mg, 5 mg
g niacin er (antihyperlipidemic) 1
g simvastatin oral tablet 80 mg 1
g niacor E
B SOAANZ E
B NIASPAN E
g sotalol hcl oral 1
g nifedipine er 1
B SOTYLIZE 3 PA
g nifedipine er osmotic release 1
g spironolactone oral 1
g nifedipine oral 1
B TEKTURNA 3
B NITRO-BID 2
B TEKTURNA HCT 3
B NITRO-DUR 3
g telmisartan 1
g nitroglycerin sublingual 1
B TENORETIC 100 E
g nitroglycerin transdermal 1
B TENORETIC 50 E
g nitroglycerin translingual E QL
B TENORMIN E
B NITROLINGUAL E QL
B THALITONE E
B NITROMIST 3 QL
B TOPROL XL E
B NITROSTAT 3
g torsemide 1
B NITRO-TIME 3
g triamterene-hctz 1
B NORVASC E
B TRICOR E
g olmesartan medoxomil oral 1
g valsartan 1
g olmesartan medoxomil-hctz 1
g valsartan-hydrochlorothiazide 1
g omega-3-acid ethyl esters 1
B VASCEPA E PA
B PACERONE ORAL TABLET 3
B VASOTEC E
100 MG, 400 MG g verapamil hcl er 1
B PACERONE ORAL TABLET 200 MG 3 g verapamil hcl oral 1
B PRALUENT E PA, ST, QL B VERELAN 3
g pravastatin sodium 1 B VERELAN PM 3
g prazosin hcl oral 1 B VERQUVO 3 PA, QL
B PROCARDIA XL E B VYTORIN E
g propranolol hcl er 1 B WELCHOL 1
g propranolol hcl oral 1 B ZESTORETIC E
B QBRELIS 3 PA B ZESTRIL E
g quinapril hcl 1 B ZETIA E
g ramipril 1 B ZIAC ORAL TABLET 10-6.25 MG, 3
B RANEXA E 2.5-6.25 MG
g ranolazine er 1
B ZIAC ORAL TABLET 5-6.25 MG 3
B REPATHA 2 PA, ST, QL
B ZOCOR 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).
18Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
Central Nervous System Agents - Drugs for Attention B PROCENTRA 3
Deficit Disorder B QUILLICHEW ER E QL
B ADDERALL E B QUILLIVANT XR E QL
B ADDERALL XR 1 QL g relexxii E QL
B ADHANSIA XR E QL B RITALIN E
g amphetamine-dextroamphetamine 1 B RITALIN LA E QL
g amphetamine-dextroamphetamine E QL B STRATTERA E QL
er
B VYVANSE 3 QL
B APTENSIO XR E QL
B ZENZEDI E
g atomoxetine hcl 1 QL
Central Nervous System Agents - Drugs for Multiple
B CONCERTA 1 QL Sclerosis
B DEXEDRINE E QL B AMPYRA E PA, QL, SP
g dexmethylphenidate hcl 1 B AUBAGIO 3 PA, QL, SP
g dexmethylphenidate hcl er 1 QL B AVONEX PEN 2 PA, QL, SP
g dextroamphetamine sulfate er 1 QL B AVONEX PREFILLED 2 PA, QL, SP
g dextroamphetamine sulfate oral 1 B BAFIERTAM 2 PA, QL, SP
solution
B BETASERON 2 PA, QL, SP
g dextroamphetamine sulfate oral E
tablet
B COPAXONE E PA, QL, SP
B FOCALIN 3
g dalfampridine er 1 PA, QL, SP
B FOCALIN XR E QL
B EXTAVIA E PA, ST, QL, SP
g guanfacine hcl er 1 QL
B GILENYA 3 PA, QL, SP
B INTUNIV E QL
g glatiramer acetate 1 PA, QL, SP
B JORNAY PM E QL
g glatopa 1 PA, QL, SP
B METHYLIN 3
B KESIMPTA 2 PA, QL, SP
g methylphenidate hcl er (cd) 1 QL
B MAVENCLAD 3 PA, ST, QL, SP
g methylphenidate hcl er (la) oral 1 QL
B MAYZENT 3 PA, QL, SP
capsule extended release 24 hour B PLEGRIDY INTRAMUSCULAR 3 PA, QL
10 mg, 20 mg, 30 mg, 40 mg B PLEGRIDY STARTER PACK 3 PA, QL, SP
g methylphenidate hcl er (la) oral 1 B PLEGRIDY SUBCUTANEOUS 3 PA, QL, SP
capsule extended release 24 hour B REBIF E PA, QL, SP
60 mg
B REBIF REBIDOSE E PA, QL, SP
g methylphenidate hcl er (xr) E QL
B REBIF REBIDOSE TITRATION E PA, QL, SP
g methylphenidate hcl er oral tablet 1 QL
PACK
extended release 10 mg, 20 mg
B REBIF TITRATION PACK E PA, QL, SP
g methylphenidate hcl er oral tablet E QL
extended release 18 mg, 27 mg, Central Nervous System Agents - Miscellaneous
36 mg, 54 mg, 72 mg B AUSTEDO 2 PA, QL, SP
g methylphenidate hcl er oral tablet E QL B EXSERVAN E PA, SP
extended release 24 hour B LYRICA 3 PA, ST, QL
g methylphenidate hcl oral 1 B LYRICA CR E ST, QL
B MYDAYIS E QL B NUEDEXTA 2 PA, 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).
19Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
g pregabalin 1 QL Dermatological Agents - Drugs for Skin Conditions
g pregabalin er E ST, QL B ABSORICA E PA
B RILUTEK E SP g accutane 1
g riluzole 1 SP B ACZONE 1 QL
B TIGLUTIK 3 PA B ALA SCALP 3
B ZEPOSIA 3 PA, ST, QL, SP g ala-cort external cream 1 % E
B ZEPOSIA 7-DAY STARTER PACK 3 PA, ST, QL, SP g ala-cort external cream 2.5 % 1
B ZEPOSIA STARTER KIT 3 PA, ST, QL, SP B ALDARA 3 QL
Dental and Oral Agents - Drugs for Mouth and Throat B ALTRENO E PA, QL
Conditions g amnesteem 1
g cavarest 1 B AMZEEQ 3 PA, QL
g chlorhexidine gluconate mouth/ 1 B ATRALIN E PA, QL
throat
B AVAR CLEANSER 3
B CLINPRO 5000 3
B AVAR LS CLEANSER E
B DENTA 5000 PLUS 3
B AVAR-E EMOLLIENT 3
B DENTAGEL 3
B AVAR-E GREEN 3
B FLUORIDEX 3
B AVAR-E LS 3
B FLUORIDEX ENHANCED 3
WHITENING
B AVITA E PA, QL
B FLUORIMAX 5000 3
g azelaic acid external 1
B JUST RIGHT 5000 3
g betamethasone dipropionate aug 1
g lidocaine hcl mouth/throat 1
g betamethasone dipropionate 1
external
g lidocaine viscous hcl 1
g bp 10-1 1
B NAFRINSE DAILY/NEUTRAL 2
g calcipotriene-betameth diprop E QL
B NAFRINSE WEEKLY 3 external ointment
B PERIDEX 3 g calcipotriene-betameth diprop E
g periogard 1 external suspension
B PREVIDENT 5000 BOOSTER PLUS 3 g calcitriol external 1 QL
B PREVIDENT 5000 DRY MOUTH 3 B CAPEX 2
B PREVIDENT 5000 ORTHO 3 B CARAC E
DEFENSE g claravis 1
B PREVIDENT 5000 PLUS 3 B CLENIA PLUS E
B PREVIDENT DENTAL 3 B CLEOCIN-T 3
B PREVIDENT MOUTH/THROAT 3 g clindacin etz external swab 1
g sf 1 g clindacin-p 1
g sf 5000 plus 1 B CLINDAGEL E QL
g sodium fluoride 5000 plus 1 g clindamycin phos-benzoyl perox 1 QL
g sodium fluoride 5000 ppm 1 external gel 1.2-5 %
g sodium fluoride dental 1 g clindamycin phosphate external 1
g sodium fluoride mouth/throat 1 foam
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 clindamycin phosphate external 1 B EFUDEX 3
lotion B ENSTILAR 3 QL
g clindamycin phosphate external 1 QL B EUCRISA 3 ST, QL
solution
B EVOCLIN 3
g clindamycin phosphate external 1
swab
B FINACEA 3
g clindamycin phosphate gel 1 % E QL
g fluocinolone acetonide body 1 QL
external g fluocinolone acetonide external 1 QL
g clindamycin phosphate gel 1 % 1 QL g fluocinolone acetonide scalp 1
external g fluocinonide external cream 0.05 % 1
g clobetasol propionate external 1 QL g fluocinonide external cream 0.1 % E QL
cream g fluocinonide external gel 1
g clobetasol propionate external foam E QL g fluocinonide external ointment 1
g clobetasol propionate external gel 1 QL g fluocinonide external solution 1
g clobetasol propionate external 1 QL B FLUOROPLEX 3
liquid
B FLUOROURACIL EXTERNAL E
g clobetasol propionate external E QL
CREAM 0.5 %
lotion
g fluorouracil external cream 5 % 1
g clobetasol propionate external 1 QL
ointment g hydrocortisone external cream 1 % E
g clobetasol propionate external E QL g hydrocortisone external cream 1
shampoo 2.5 %
g clobetasol propionate external 1 QL g hydrocortisone external lotion 2.5 % 1
solution g hydrocortisone external ointment 1
B CLOBEX E QL 1 %, 2.5 %
B CLOBEX SPRAY E QL g imiquimod external cream 3.75 % E QL
g clodan external shampoo E QL g imiquimod external cream 5 % 1 QL
g clotrimazole-betamethasone 1 QL g imiquimod pump E QL
external cream B IMPEKLO E QL
g clotrimazole-betamethasone 1 B IMPOYZ E QL
external lotion g isotretinoin capsule 10 mg oral E PA
g dapsone gel E QL g isotretinoin capsule 10 mg oral 1 (generic for
B DERMA-SMOOTHE/FS BODY 3 QL Absorica)
B DERMA-SMOOTHE/FS SCALP 3 g isotretinoin capsule 20 mg oral E PA
g desonide external cream 1 QL g isotretinoin capsule 20 mg oral 1 (generic for
g desonide external gel 1 ST, QL Absorica)
g desonide external lotion 1 QL g isotretinoin capsule 30 mg oral E PA
g desonide external ointment 1 QL g isotretinoin capsule 30 mg oral 1 (generic for
Absorica)
B DESOWEN 3 QL
g isotretinoin capsule 40 mg oral E PA
g desrx 1 ST, QL
g isotretinoin capsule 40 mg oral 1 (generic for
B DIPROLENE 3
Absorica)
B DUPIXENT 3 PA, ST, 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).
21Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
g isotretinoin oral capsule 25 mg, E PA g sulfacetamide sodium-sulfur E
35 mg external lotion 9.8-4.8 %
g ivermectin external cream E QL g sulfacetamide sodium-sulfur 1
B KENALOG EXTERNAL E QL external pad 10-4 %
B KLISYRI 3 ST, QL
g sulfacetamide sodium-sulfur E
external pad 9.8-4.8 %
B METROCREAM 3
g sulfacetamide sodium-sulfur 1
B METROGEL E external suspension 10-5 %
B METROLOTION 3 g sulfacetamide sodium-sulfur E
g metronidazole external cream 1 external suspension 8-4 %
g metronidazole external gel 0.75 % 1 g sulfacetamide sod-sulfur wash 1
g metronidazole external gel 1 % E B SULFACLEANSE 8/4 E
g metronidazole external lotion 1 g sulfamez wash 1
B MIRVASO 3 PA, QL B SUMADAN WASH E
g mometasone furoate external 1 B SUMAXIN 3
g myorisan 1 B SYNALAR E QL
g neuac external gel 1 QL B TACLONEX EXTERNAL OINTMENT E QL
B NORITATE E B TACLONEX EXTERNAL 1
B OLUX E QL SUSPENSION
B PICATO EXTERNAL GEL 0.015 %, 3 QL g tazarotene external cream 1 PA, QL
0.05 % B TAZORAC 3 PA, QL
B PLEXION E B TEMOVATE 3 QL
B PLEXION CLEANSER E B TEXACORT 2
B PLEXION CLEANSING CLOTH E g tretinoin external cream 1 QL
B RETIN-A E PA, QL g tretinoin external gel 0.01 %, E QL
B RHOFADE 3 PA, QL 0.025 %
g rosadan external cream 1 g tretinoin external gel 0.05 % E PA, QL
g rosadan external gel 1 g triamcinolone acetonide external 1 QL
aerosol solution
B SERNIVO E QL
g triamcinolone acetonide external 1
B SOOLANTRA 1 QL
cream 0.025 %, 0.1 %
g sss 10-5 1 g triamcinolone acetonide external 1 QL
g sulfacetamide sodium-sulfur 1 cream 0.5 %
external cream 10-2 %, 10-5 % g triamcinolone acetonide external 1
g sulfacetamide sodium-sulfur E lotion
external cream 9.8-4.8 % g triamcinolone acetonide external 1
g sulfacetamide sodium-sulfur E ointment 0.025 %, 0.1 %, 0.5 %
external liquid 10-2 %, 9.8-4.8 % g triamcinolone acetonide external E
g sulfacetamide sodium-sulfur 1 ointment 0.05 %
external liquid 10-5 %, 9-4 %, g triamcinolone in absorbase E
9-4.5 %
B TRIANEX E
g sulfacetamide sodium-sulfur 1
external lotion 10-5 % g triderm external cream 0.1 % 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).
22Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
g triderm external cream 0.5 % 1 QL B CONTOUR MONITOR KIT E
B TRIDESILON 1 QL W/DEVICE
g tritocin E
B CONTOUR NEXT BLOOD E
GLUCOSE METER
B VANOS E QL
B CONTOUR NEXT EZ KIT 2
B VECTICAL E QL W/DEVICE
B VERDESO E QL B CONTOUR NEXT LINK KIT E
B WYNZORA E QL W/DEVICE
g zenatane 1 B CONTOUR NEXT MONITOR KIT 2
B ZILXI 3 PA, ST, QL W/DEVICE
B ZYCLARA E QL B CONTOUR NEXT ONE DEVICE E
B ZYCLARA PUMP E QL B CONTOUR NEXT ONE KIT 2
Diabetes - Glucose Monitoring B CONTOUR NEXT TEST STRIPS 2 QL
B ACCU-CHEK AVIVA PLUS KIT E QL B CONTOUR TEST STRIPS E QL
W/DEVICE B CVS ADVANCED GLUCOSE TEST E QL
B ACCU-CHEK FASTCLIX LANCET 1 B CVS GLUCOSE METER TEST E QL
KIT STRIPS
B ACCU-CHEK FASTCLIX LANCETS 1 B D-CARE BLOOD GLUCOSE E QL
B ACCU-CHEK GUIDE BLOOD 3 B D-CARE GLUCOMETER E
GLUCOSE METER B DEXCOM G6 SENSOR 3 PA, QL
B ACCU-CHEK GUIDE KIT W/DEVICE 3 (Accu-Chek B EASY TOUCH TEST E QL
Guide Me)
B EASYMAX 15 TEST E QL
B ACCU-CHEK GUIDE TEST STRIPS 3 QL
B EASYMAX NG BLOOD GLUCOSE E
B ACCU-CHEK MULTICLIX LANCET 1
KIT
B EASYMAX V BLOOD GLUCOSE E
B ACCU-CHEK MULTICLIX LANCETS 1
B ENLITE GLUCOSE SENSOR 3 PA
B ACCU-CHEK SMARTVIEW TEST E QL
B EQ BLOOD GLUCOSE TEST E QL
STRIPS B FORTISCARE G1 TEST STRIP E QL
B ACCU-CHEK SOFT TOUCH 1 B FORTISCARE T1 GLUCOSE E
LANCETS SYSTEM
B ACCU-CHEK SOFTCLIX LANCET 1 B FORTISCARE TEST E QL
DEVICE KIT B FREESTYLE LIBRE 14 DAY 3 PA
B ACCU-CHEK SOFTCLIX LANCETS 1 READER
B ACCUTREND GLUCOSE E QL B FREESTYLE LIBRE 14 DAY 3 PA
g bd autoshield duo pen needles 2 SENSOR
g bd ultra-fine insulin syringes 2
B FREESTYLE LIBRE 2 READER 3 PA
g bd ultra-fine pen needles 2
B FREESTYLE LIBRE 2 SENSOR 3 PA
B BLOOD GLUCOSE TEST STRIPS E QL
B FREESTYLE LIBRE CONTINUOUS 3 PA
BLOOD GLUCOSE MONITOR
B CARETOUCH MONITOR SYSTEM E
B FREESTYLE LIBRE READER 3 PA, QL
B CARETOUCH TEST E QL
B FREESTYLE PRECISION NEO E
B CHEMSTRIP BG LOG BOOK 1 SYSTEM
B CONTOUR MONITOR DEVICE 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 FREESTYLE PRECISION NEO E QL B ONETOUCH VERIO IQ SYSTEM 1
TEST B ONETOUCH VERIO KIT W/DEVICE 1
B GUARDIAN REAL-TIME REPLACE 3 PA B ONETOUCH VERIO REFLECT KIT 1
PED W/DEVICE
B GUARDIAN SENSOR (3) 3 PA B ONETOUCH VERIO TEST STRIPS 1 QL
B IN TOUCH 3 B OPTIUMEZ TEST E QL
B INSULIN PEN NEEDLES 2 B PRECISION XTRA E
B MICRODOT TEST E QL B PRECISION XTRA BLOOD E QL
B MM EASY TOUCH GLUCOSE E GLUCOSE
METER B PREMIUM BLOOD GLUCOSE TEST E QL
B NEUTEK 2TEK TEST E QL B QUINTET AC BLOOD GLUCOSE E
B NOVOFINE AUTOCOVER PEN 2 B QUINTET AC BLOOD GLUCOSE E QL
NEEDLE TEST
B NOVOFINE PEN NEEDLE 2 B QUINTET BLOOD GLUCOSE E
B NOVOFINE PLUS PEN NEEDLE 2 SYSTEM
B NOVOTWIST 2 B QUINTET BLOOD GLUCOSE TEST E QL
B ONETOUCH CLUB LANCETS FINE 1 B RELION TRUE MET AIR GLUC E
PT METER
B ONETOUCH DELICA LANCETS 1 B RELION TRUE METRIX TEST E QL
30G STRIPS
B ONETOUCH DELICA LANCETS 1 B RELION ULTIMA GLUCOSE E
33G SYSTEM
B ONETOUCH DELICA LANCING 1 QL B RELION ULTIMA TEST E QL
DEV B SURESTEP PRO LINEARITY 1
B ONETOUCH DELICA PLUS 1 B TRUE FOCUS BLOOD GLUCOSE E QL
LANCET30G STRIP
B ONETOUCH DELICA PLUS 1 B TRUE METRIX AIR GLUCOSE E
LANCET33G METER
B ONETOUCH DELICA PLUS 1 QL B TRUE METRIX BLOOD GLUCOSE E QL
LANCING TEST
B ONETOUCH FINEPOINT LANCETS 1 B TRUE METRIX GO GLUCOSE E
B ONETOUCH SOLUTIONS E METER
STARTER KIT B TRUE METRIX METER KIT E
B ONETOUCH SURESOFT LANCING 1 B TRUE METRIX PRO BLOOD E QL
DEV GLUCOSE
B ONETOUCH ULTRA 2 KIT 1 B TRUETRACK BLOOD GLUCOSE E
W/DEVICE DEVICE
B ONETOUCH ULTRA MINI KIT 1 B TRUETRACK TEST E QL
W/DEVICE
B UNISTRIP1 GENERIC E QL
B ONETOUCH ULTRA TEST STRIPS 1 QL
Diabetes - Insulin
B ONETOUCH ULTRASOFT 1
LANCETS
B ADMELOG E QL
B ONETOUCH VERIO FLEX SYSTEM 1
B ADMELOG SOLOSTAR 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).
24Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
B AFREZZA E PA, QL B NOVOLIN N RELION E ST, QL
B BASAGLAR KWIKPEN E QL B NOVOLIN N VIAL E ST, QL
B HUMALOG KWIKPEN 2 QL B NOVOLIN R FLEXPEN E ST, QL
B HUMALOG MIX 50/50 KWIKPEN 2 QL B NOVOLIN R FLEXPEN RELION E ST, QL
B HUMALOG MIX 50/50 VIAL 1 QL B NOVOLIN R RELION E ST, QL
B HUMALOG MIX 75/25 KWIKPEN 2 QL B NOVOLIN R VIAL E ST, QL
B HUMALOG MIX 75/25 VIAL 1 QL B NOVOLOG FLEXPEN E ST, QL
B HUMALOG SUBCUTANEOUS 1 QL B NOVOLOG FLEXPEN RELION E ST, QL
SOLUTION B NOVOLOG PENFILL E ST, QL
B HUMALOG SUBCUTANEOUS 2 QL B NOVOLOG RELION E ST, QL
SOLUTION CARTRIDGE
B NOVOLOG U-100 VIAL E ST, QL
B HUMALOG U-100 JUNIOR 2 QL
KWIKPEN
B SEMGLEE E QL
B HUMULIN 70/30 KWIKPEN 2 QL
B TOUJEO MAX SOLOSTAR 2 QL
B HUMULIN 70/30 VIAL 1 QL
B TOUJEO SOLOSTAR 2 QL
B HUMULIN N KWIKPEN 2 QL
B TRESIBA E QL
B HUMULIN N VIAL 1 QL
B TRESIBA FLEXTOUCH E QL
B HUMULIN R U-500 KWIKPEN 2 QL Diabetes - Non-Insulin Agents
B HUMULIN R U-500 VIAL 1 QL
B ACTOS E QL
B HUMULIN R VIAL 1 QL
B ADLYXIN 3 PA, ST, QL
B INSULIN ASPART E ST, QL
B ADLYXIN STARTER PACK 3 PA, ST, QL
B INSULIN ASPART FLEXPEN E ST, QL
B ALOGLIPTIN BENZOATE E QL
B INSULIN ASPART PENFILL E ST, QL
B ALOGLIPTIN-METFORMIN HCL E QL
B INSULIN LISPRO E QL
B ALOGLIPTIN-PIOGLITAZONE E QL
B INSULIN LISPRO (1 UNIT DIAL) E QL
B AMARYL E
B INSULIN LISPRO JUNIOR E QL
B BAQSIMI ONE PACK 2 QL
KWIKPEN B BAQSIMI TWO PACK 2 QL
B INSULIN LISPRO PROT & LISPRO E QL B BYDUREON BCISE 2 PA, ST, QL
B LANTUS SOLOSTAR 1 QL AUTOINJECTOR
B LANTUS U-100 VIAL 1 QL
B BYETTA 10 MCG PEN 2 PA, ST, QL
B LEVEMIR U-100 FLEXTOUCH E PA, QL
B BYETTA 5 MCG PEN 2 PA, ST, QL
B LEVEMIR U-100 VIAL E PA, QL
B FARXIGA E ST, QL
B LYUMJEV KWIKPEN 2 QL
g glimepiride 1
B LYUMJEV VIAL 1 QL
g glipizide er 1
B NOVOLIN 70/30 FLEXPEN E ST, QL
g glipizide ir 1
B NOVOLIN 70/30 FLEXPEN RELION E ST, QL
g glipizide xl 1
B NOVOLIN 70/30 RELION E ST, QL
B GLUCAGON EMERGENCY KIT 1 (Fresenius), QL
1 MG INJECTION 1 MG
B NOVOLIN 70/30 VIAL E ST, QL
B GLUCOTROL XL 3
B NOVOLIN N FLEXPEN E ST, QL
B GLUMETZA E PA
B NOVOLIN N FLEXPEN RELION E ST, 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).
25Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
g glyburide oral 1 B AFSTYLA INTRAVENOUS KIT 1500 3 PA, SP
g glyburide-metformin 1 UNIT, 2500 UNIT
B GLYXAMBI 2 ST, QL
B ALPHANATE 2 SP
B JANUVIA E ST, QL
B ARANESP (ALBUMIN FREE) 2 QL, SP
B JARDIANCE 2 ST, QL
B DOPTELET 3 PA, ST, QL, SP
B JENTADUETO 2 QL
B ELOCTATE 3 PA, SP
B JENTADUETO XR 2 QL
B EMPAVELI 2 PA, QL, SP
B KAZANO 2 QL
B HEMOFIL M 2 SP
B KOMBIGLYZE XR 2 QL
B HUMATE-P 2 SP
g metformin hcl er 1
B JIVI 3 PA, SP
g metformin hcl er (mod) E PA
B KOATE 2 SP
g metformin hcl er (osm) E PA
B KOATE-DVI 2 SP
g metformin hcl ir 1
B KOGENATE FS 2 SP
B NESINA 2 QL
B KOVALTRY 2 SP
B ONGLYZA 2 QL
B MULPLETA 2 PA, QL, SP
B OSENI 2 QL
B NEULASTA 3 SP
B OZEMPIC 2 PA, ST, QL
B NEULASTA ONPRO E SP
g pioglitazone hcl 1 QL
B NOVOEIGHT 2 SP
B RIOMET E
B NUWIQ 2 SP
B RYBELSUS 2 PA, ST, QL
B RECOMBINATE 2 SP
B SOLIQUA 2 QL
B RETACRIT INJECTION SOLUTION 2 QL, SP
10000 UNIT/ML, 2000 UNIT/ML,
B SYMLINPEN 120 3 QL 3000 UNIT/ML, 4000 UNIT/ML,
B SYMLINPEN 60 3 QL 40000 UNIT/ML
B SYNJARDY 2 QL B RETACRIT INJECTION SOLUTION 2 SP
B SYNJARDY XR 2 QL 20000 UNIT/ML
B TRADJENTA 2 QL B TAVALISSE 3 PA, QL, SP
B TRIJARDY XR 2 QL B WILATE 2 SP
B TRULICITY 2 PA, ST, QL B ZARXIO 2 SP
B VICTOZA SOLUTION PEN- 2 PA, ST, (2 Pak), B ZIEXTENZO 3 SP
INJECTOR 18 MG/3ML QL Drugs for Sexual Dysfunction
SUBCUTANEOUS B ADDYI 3 PA, QL
B VICTOZA SOLUTION PEN- 3 PA, ST, (3 Pak), B CIALIS E QL
INJECTOR 18 MG/3ML QL
SUBCUTANEOUS
B IMVEXXY MAINTENANCE PACK 2 QL
B ZEGALOGUE 2 QL
B IMVEXXY STARTER PACK 2 QL
Drugs for Blood Disorders
B INTRAROSA 3 PA, QL
B ADVATE 2 SP
B OSPHENA 3 PA, QL
B ADYNOVATE 3 PA, SP
g sildenafil citrate oral tablet 100 mg, 1 QL
25 mg, 50 mg
B AFSTYLA INTRAVENOUS KIT 1000 3 PA, SP
UNIT, 2000 UNIT, 250 UNIT, 3000
B STENDRA 3 PA, QL
UNIT, 500 UNIT g tadalafil oral 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).
26Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
B VIAGRA E QL g potassium chloride er 1
B VYLEESI 3 PA, QL g potassium chloride oral packet 1
Electrolytes / Vitamins g potassium chloride oral solution 1
g cyanocobalamin injection solution 1 20 meq/15ml (10%), 40 meq/15ml
1000 mcg/ml (20%)
B CYANOCOBALAMIN INJECTION 3
g potassium citrate er 1
SOLUTION 2000 MCG/ML B PRENA1 PEARL 3
B DRISDOL 3 B QUFLORA PEDIATRIC 3
B ERGOCAL 3 B UROCIT-K 10 3
g ergocalciferol oral capsule 1 B UROCIT-K 15 3
B FLORIVA PLUS 3 B UROCIT-K 5 3
g folic acid oral tablet 1 mg 1 B VELTASSA 3 PA, QL
g klor-con 1 g vitamin d (ergocalciferol) oral 1
g klor-con 10 1 capsule 1.25 mg (50000 ut)
g klor-con m10 1
B VITAPEARL 3
g klor-con m15 3 Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer
g klor-con m20 1
B ACIPHEX E QL
B K-TAB 3
B CARAFATE E
B LOKELMA 3 PA, QL
B CYTOTEC 3
g multi-vitamin/fluoride 1
B DEXILANT E QL
g multivitamin/fluoride tablet 1
B DEXLANSOPRAZOLE E QL
chewable 0.25 mg oral (rx) B FIRST-OMEPRAZOLE 3 PA
B MULTIVITAMIN/FLUORIDE TABLET 3 g misoprostol oral 1
CHEWABLE 0.25 MG ORAL (RX) B OMECLAMOX-PAK 3 QL
g multivitamin/fluoride tablet 1 g omeprazole oral capsule delayed 1
chewable 0.5 mg oral release
B MULTIVITAMIN/FLUORIDE TABLET 3 B OMEPRAZOLE+SYRSPEND SF 3 PA
CHEWABLE 0.5 MG ORAL ALKA
g multivitamin/fluoride tablet 1 g pantoprazole sodium oral packet E
chewable 1 mg oral
g pantoprazole sodium oral tablet 1
B MULTIVITAMIN/FLUORIDE TABLET 3 delayed release
CHEWABLE 1 MG ORAL
B PROTONIX ORAL E
B MULTI-VIT-FLOR 3
B PYLERA 3 QL
B NASCOBAL 3
B RABEPRAZOLE SODIUM ORAL E QL
B POLY-VI-FLOR 3 CAPSULE SPRINKLE
g potassium chloride crys er oral 1 g rabeprazole sodium oral tablet 1 QL
tablet extended release 10 meq, delayed release
20 meq
g sucralfate oral 1
g potassium chloride crys er oral 3
tablet extended release 15 meq
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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