Your 2023 Prescription Drug List - Advantage 4-Tier
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Pharmacy | PDL Your 2023 Prescription Drug List Advantage 4-Tier Effective May 1, 2023 This Prescription Drug List (PDL) is accurate as of May 1, 2023 and is subject to change after this date. This PDL applies to members of our UnitedHealthcare, Neighborhood Health Plan, UnitedHealthcare Freedom Plans, River Valley, All Savers and Oxford medical plans with a pharmacy benefit subject to the Advantage 4-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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Anti-Addiction / Substance Abuse Treatment Agents. . . . . . . . . . . . . . . . . . . . . . . . . 8
Antibacterials
Drugs for Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Anticoagulants
Drugs to Treat or Prevent Blood Clots . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Anticonvulsants
Drugs for Seizures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Antidepressants
Drugs for Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Antiemetics
Drugs for Nausea and Vomiting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Antifungals
Drugs for Fungal Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Antigout Agents
Drugs for Gout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Antimigraine Agents
Drugs for Migraines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Antineoplastics
Drugs for Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Antiparasitics
Drugs for Parasitic Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Antiparkinson Agents
Drugs for Parkinson’s Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Antiplatelets
Drugs for Heart Attack and Stroke Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Antipsychotics
Drugs for Mood Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Antivirals
Drugs for Viral Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Anxiolytics
Drugs for Anxiety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Bipolar Agents
Drugs for Mood Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Cardiovascular Agents
Drugs for Heart and Circulation Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Central Nervous System Agents
Drugs for Attention Deficit Disorder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Drugs for Multiple Sclerosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Dental and Oral Agents
Drugs for Mouth and Throat Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Dermatological Agents
Drugs for Skin Conditions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
2Diabetes
Glucose Monitoring and Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Non-Insulin Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Drugs for Blood Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Drugs for Pregnancy Termination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Drugs for Sexual Dysfunction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Electrolytes / Vitamins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Gastrointestinal Agents
Drugs for Acid Reflux and Ulcer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Drugs for Bowel, Intestine and Stomach Conditions . . . . . . . . . . . . . . . . . . . . . . . 22
Genetic or Enzyme Disorder
Drugs for Replacement, Modification, Treatment . . . . . . . . . . . . . . . . . . . . . . . . . 22
Genitourinary Agents
Drugs for Bladder, Genital and Kidney Conditions. . . . . . . . . . . . . . . . . . . . . . . . . 22
Drugs for Prostate Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Hormonal Agents
Hormone Replacement and Birth Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Oral Steroids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Testosterone Replacement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Thyroid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Immunological Agents
Drugs for Immune System Stimulation or Suppression. . . . . . . . . . . . . . . . . . . . . 26
Drugs for Vaccination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Infertility Agents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Inflammatory Bowel Disease Agents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Metabolic Bone Disease Agents
Drugs for Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Ophthalmic Agents
Drugs for Eye Allergy, Infection and Inflammation . . . . . . . . . . . . . . . . . . . . . . . . . 27
Drugs for Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Drugs for Miscellaneous Eye Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Otic Agents
Drugs for Ear Conditions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Respiratory
Drugs for Anaphylaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Respiratory Tract / Pulmonary Agents
Drugs for Allergies, Cough, Cold . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Drugs for Asthma and COPD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Drugs for Cystic Fibrosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Drugs for Pulmonary Fibrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Drugs for Pulmonary Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Skeletal Muscle Relaxants
Drugs for Muscle Pain and Spasm. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Sleep Disorder Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
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 two or more manufacturers, but greatly vary in cost. In these instances, only the lower-cost
product may be covered.
You should review your benefit plan documents to confirm if any medications are excluded from your plan. You can log in to
the member website listed on your member ID card at any time to check your medication coverage. Talk to your doctor to see if
there are lower-cost options or over-the-counter medications available.
Who decides which medications are covered?
Thousands of medications are already available and more come to the market regularly. Often, several medications are available
to treat the same condition. The UnitedHealthcare® Pharmacy and Therapeutics Committee, which includes both internal and
external doctors and pharmacists, meets regularly to provide clinical reviews of all medications. Using this information, the PDL
Management Committee, which includes senior UnitedHealth Group® doctors and business leaders, meets to evaluate overall
health care value. They also set coverage and tier status for all medications.
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 An OTC medication may be the
the patent for a brand-name medication ends, the FDA can approve a generic right treatment option for some
version with the same active ingredients. These types of medications are conditions. Talk to your doctor
known as generic medications. Sometimes, the same company that makes a about available OTC options.
brand-name medication also makes the generic version. Even though these medications
may not be covered by your
What if my doctor writes a brand-name prescription? pharmacy benefit, they may
cost less than a prescription
If your doctor gives you a prescription for a brand-name medication, ask if a medication.
generic 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.
Tiers $$ Mid-range cost Use Tier 2 or Tier 3 drugs,
2 and 3 Medications that provide good overall value. A mix of brand instead of Tier 4, to help reduce
name and generic drugs. your out-of-pocket costs.
Tier 4 $$$ Highest-cost Many Tier 4 drugs have lower-cost
Medications that provide the lowest overall value. Mostly options in Tiers 1, 2 or 3. Ask your
brand-name drugs, as well as some generics. doctor if they 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. May be subject to Prior Authorization for fully insured benefit plans
governed by state law 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.
QL Quantity Limits — Specifies the largest quantity of medication covered per copayment or in a defined period
of time.
RS Refill and Save Program4 — 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.
3. Depending on your benefit, you may have notification or medical necessity requirements for select medications.
4. Not applicable to Neighborhood Health Plan, some UnitedHealthcare Freedom Plans, Golden Rule, Oxford and UnitedHealthOne.
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.
• Central nervous system: sedatives/hypnotics
Coverage is set by the consumer’s prescription drug benefit plan. Please consult plan documents regarding benefit
coverage and cost-share.
• 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.
• Termination of pregnancy
Coverage under the prescription drug benefit is set by the consumer’s medical benefit plan. Please consult plan
documents regarding benefit coverage, exclusions and cost-sharing. More information will be available on myuhc.com in
early 2023. Additionally, more information is available by calling the number on the back of your ID card.
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 B ROXICODONE E
g acetaminophen-codeine #2 1 g tramadol hcl oral tablet 100 mg E
g acetaminophen-codeine #3 1 g tramadol hcl oral tablet 50 mg 1
g acetaminophen-codeine #4 1 B TREZIX 4 QL
g acetaminophen-codeine oral tablet 1 B XTAMPZA ER 4 PA, QL
g apap-caff-dihydrocodeine 4 QL B ZTLIDO 3 PA, QL
g bac 1 QL Analgesics - Drugs for Pain and Inflammation
B BELBUCA 3 PA, QL B CELEBREX E QL
g butalbital-apap-caffeine oral tablet 1 QL g celecoxib oral 2 QL
B DILAUDID ORAL TABLET E g diclofenac sodium oral 1
g endocet 1 B DUROLANE E
B ESGIC ORAL TABLET 4 QL B EUFLEXXA E
B GEN7T EXTERNAL PATCH E B GELSYN-3 E
g hydrocodone-acetaminophen oral E B HYALGAN INTRA-ARTICULAR E
tablet 10-300 mg, 5-300 mg, SOLUTION PREFILLED SYRINGE
7.5-300 mg g ibuprofen oral tablet 400 mg, 1
g hydrocodone-acetaminophen oral 1 600 mg, 800 mg
tablet 10-325 mg, 5-325 mg, B INDOMETHACIN ORAL CAPSULE E
7.5-325 mg 20 MG
g hydromorphone hcl oral tablet 1 g indomethacin oral capsule 25 mg, 1
g lidocaine external patch 5 % 3 PA, QL 50 mg
B LIDODERM E PA, QL g ketorolac tromethamine oral 1
g morphine sulfate er oral tablet 1 PA, QL g meloxicam oral tablet 1
extended release g nabumetone oral 1
B MS CONTIN E PA, QL B NAPROSYN ORAL TABLET E
B NALOCET E QL g naproxen oral tablet 1
B NUCYNTA 4 QL B RELAFEN E
B NUCYNTA ER 3 PA, QL B RELAFEN DS E
B OXAYDO E QL B SUPARTZ FX E
g oxycodone hcl oral tablet 10 mg, 1 B SYNOJOYNT E
15 mg, 20 mg, 30 mg
B TRILURON E
g oxycodone hcl oral tablet 5 mg 1 QL
Anti-Addiction / Substance Abuse Treatment Agents
B OXYCODONE-ACETAMINOPHEN E
ORAL TABLET 10-300 MG,
g buprenorphine hcl sublingual 1 QL
5-300 MG, 7.5-300 MG g buprenorphine hcl-naloxone hcl 2 QL
g oxycodone-acetaminophen oral 1 B KLOXXADO 2 QL
tablet 10-325 mg, 2.5-325 mg, g naloxone hcl injection solution 1
5-325 mg, 7.5-325 mg prefilled syringe
B OXYCODONE-ACETAMINOPHEN E QL g naloxone hcl nasal 1 QL
ORAL TABLET 2.5-300 MG g naltrexone hcl oral 1
B PERCOCET E B NARCAN 2 QL
B PROLATE ORAL TABLET 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).
8Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
B SUBOXONE E PA, QL g doxycycline monohydrate oral 1
B ZIMHI 2 QL capsule 100 mg, 50 mg
B ZUBSOLV 2 QL
g doxycycline monohydrate oral E
capsule 150 mg, 75 mg
Antibacterials - Drugs for Infections
g doxycycline monohydrate oral 1
B ACTICLATE E tablet
g amoxicillin oral capsule 1 g levofloxacin oral tablet 1
g amoxicillin oral suspension 1 B LYMEPAK E
reconstituted
B MACROBID 4
g amoxicillin oral tablet 1
B MACRODANTIN 4
g amoxicillin-potassium clavulanate 1
oral suspension reconstituted
g metronidazole oral tablet 1
g amoxicillin-potassium clavulanate 1
g metronidazole vaginal 2
oral tablet g minocycline hcl oral capsule 1
B AUGMENTIN E g mondoxyne nl 1
B AUGMENTIN ES-600 E g mupirocin external 1 QL
g avidoxy 1 g nitrofurantoin macrocrystal 1
g azithromycin oral suspension 1 g nitrofurantoin monohydrate 1
reconstituted macrocrystals
g azithromycin oral tablet 1 B NUVESSA E
B BACTRIM 4 B NUZYRA ORAL 4 QL
B BACTRIM DS 4 g penicillin v potassium oral tablet 1
g cefdinir 1 g sulfamethoxazole-trimethoprim oral 1
g cefuroxime axetil 1 tablet
B CENTANY 4 QL
B TARGADOX E
g cephalexin oral capsule 1
g vandazole 4
g cephalexin oral suspension 1
B VIBRAMYCIN ORAL CAPSULE 4
reconstituted B XENLETA ORAL 3
B CIPRO ORAL TABLET 4 B ZITHROMAX ORAL SUSPENSION 4
g ciprofloxacin hcl oral 1 RECONSTITUTED
B CLEOCIN ORAL CAPSULE 4
B ZITHROMAX ORAL TABLET 4
150 MG, 300 MG B ZITHROMAX TRI-PAK 4
B CLEOCIN ORAL CAPSULE 75 MG 2 B ZITHROMAX Z-PAK 4
g clindamycin hcl oral 1 Anticoagulants - Drugs to Treat or Prevent Blood Clots
B CLINDESSE 2 g dabigatran etexilate mesylate 1 QL
B DIFICID ORAL TABLET 3 QL B ELIQUIS 2 QL
g doxycycline hyclate oral capsule 2 B ELIQUIS DVT/PE STARTER PACK 2 QL
g doxycycline hyclate oral tablet 2 g enoxaparin sodium 2 QL
100 mg g jantoven 1
g doxycycline hyclate oral tablet E B LOVENOX E QL
150 mg, 50 mg, 75 mg
B PRADAXA 2 QL
g doxycycline hyclate oral tablet 1
20 mg
g warfarin sodium 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).
9Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
B XARELTO 2 QL B BUPROPION HCL ER (XL) ORAL E QL
B XARELTO STARTER PACK 2 QL TABLET EXTENDED RELEASE
24 HOUR 450 MG
Anticonvulsants - Drugs for Seizures
g bupropion hcl oral 1
B APTIOM 3 PA
B CELEXA E
B BRIVIACT ORAL TABLET 3 PA
g citalopram hydrobromide oral tablet 1
B DEPAKOTE 4 PA
B CYMBALTA E
B DEPAKOTE ER 4 PA
g desvenlafaxine succinate er 3 QL
g divalproex sodium er 2
g doxepin hcl oral capsule 1
g divalproex sodium oral tablet 1
delayed release
g duloxetine hcl oral capsule delayed 2
release particles 20 mg, 30 mg,
B EPIDIOLEX 3 PA, SP 60 mg
g gabapentin oral capsule 1 g duloxetine hcl oral capsule delayed E
B GABAPENTIN ORAL TABLET E PA release particles 40 mg
25 MG, 50 MG B EFFEXOR XR E
g gabapentin oral tablet 600 mg, 1 g escitalopram oxalate oral tablet 1
800 mg
g fluoxetine hcl oral capsule 1
B KEPPRA ORAL TABLET 4 PA
g fluoxetine hcl oral tablet 10 mg 3 QL
B LAMICTAL ORAL TABLET 4 PA
g fluoxetine hcl oral tablet 20 mg 3
g lamotrigine oral tablet 1
g fluoxetine hcl oral tablet 60 mg E
g levetiracetam oral tablet 1
g fluvoxamine maleate 1
B NAYZILAM 3 PA, QL
B FORFIVO XL E QL
B NEURONTIN ORAL CAPSULE 4 PA
B LEXAPRO E
B NEURONTIN ORAL TABLET 4 PA
g mirtazapine oral tablet 1
g oxcarbazepine oral tablet 1
g nortriptyline hcl oral capsule 1
g roweepra 1
B PAMELOR E
g subvenite 1
g paroxetine hcl oral tablet 1
B TOPAMAX 4 PA
B PAXIL ORAL TABLET E
g topiramate oral tablet 1
B PRISTIQ E QL
B TRILEPTAL ORAL TABLET 4 PA
B PROZAC E
B VALTOCO NASAL LIQUID 3 PA, QL
10 MG/0.1ML, 5 MG/0.1ML
B REMERON E
B XCOPRI ORAL TABLET 100 MG, 3 PA
g sertraline hcl oral tablet 1
150 MG, 200 MG, 50 MG g trazodone hcl oral 1
B ZONEGRAN 4 PA B TRINTELLIX 4 ST, QL
g zonisamide oral 1 g venlafaxine hcl 1
Antidepressants - Drugs for Depression g venlafaxine hcl er oral capsule 1
g amitriptyline hcl oral 1 extended release 24 hour
g bupropion hcl er (sr) 1
B VIIBRYD E QL
g bupropion hcl er (xl) oral tablet 1
B VIIBRYD STARTER PACK 4
extended release 24 hour 150 mg, g vilazodone hcl 3 QL
300 mg B WELLBUTRIN SR 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).
10Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
B WELLBUTRIN XL E B IMITREX ORAL E QL
B ZOLOFT ORAL TABLET E B MAXALT E QL
Antiemetics - Drugs for Nausea and Vomiting B NURTEC 2 PA, ST, QL
g metoclopramide hcl oral tablet 1 B RELPAX E QL
g ondansetron hcl oral tablet 1 g rizatriptan benzoate 1 QL
g ondansetron odt 1 g sumatriptan succinate oral 1 QL
g prochlorperazine maleate oral 1 B UBRELVY 2 PA, ST, QL
g promethazine hcl oral tablet 1 B ZOLMITRIPTAN NASAL SOLUTION E QL
B REGLAN 4 2.5 MG
g scopolamine 3
B ZOMIG NASAL SOLUTION 2.5 MG 3 QL
B TRANSDERM-SCOP E
B ZOMIG NASAL SOLUTION 5 MG 2 QL
Antifungals - Drugs for Fungal Infections Antineoplastics - Drugs for Cancer
g ciclodan 1
B ALECENSA 2 PA, QL, SP
g ciclopirox external solution 1
B ALUNBRIG 2 PA, QL, SP
B CRESEMBA ORAL 3
g anastrozole oral 1 H-PA
B DIFLUCAN ORAL TABLET E
B ARIMIDEX E
g fluconazole oral tablet 1
g bexarotene external E QL, SP
B GYNAZOLE-1 3
B CALQUENCE 2 PA, QL, SP
g ketoconazole external cream 1 QL
B ERIVEDGE 2 PA, QL, SP
g ketoconazole external shampoo 1
B ERLEADA 2 PA, QL, SP
g nystatin external cream 1 QL
B EXKIVITY 4 PA, QL, SP
g nystatin mouth/throat 1
B FEMARA E
g terbinafine hcl oral 1 QL
B GAVRETO 4 PA, QL, SP
B VIVJOA E PA
B IBRANCE ORAL CAPSULE 2 PA, QL, SP
Antigout Agents - Drugs for Gout
B ICLUSIG ORAL TABLET 10 MG, 3 PA, QL, SP
30 MG
g allopurinol oral tablet 100 mg, 1
300 mg
B ICLUSIG ORAL TABLET 15 MG, 3 PA, QL, SP
45 MG
B ALLOPURINOL ORAL TABLET E
200 MG
B IDHIFA 2 PA, QL, SP
B COLCHICINE ORAL CAPSULE E
B IMBRUVICA 2 PA, QL, SP
B MITIGARE 2
B KOSELUGO 3 PA, QL, SP
B ZYLOPRIM 4
g lenalidomide oral capsule 10 mg, 2 PA, QL, SP
15 mg, 25 mg, 5 mg
Antimigraine Agents - Drugs for Migraines
g lenalidomide oral capsule 2.5 mg, 1 PA, QL, SP
B AIMOVIG 2 PA, ST 20 mg
B AIMOVIG SUBCUTANEOUS 2 PA, ST, QL g letrozole oral 1 H-PA
SOLUTION AUTO-INJECTOR
140 MG/ML
B LUMAKRAS 4 PA, QL, SP
g eletriptan hydrobromide 2 QL
B LYNPARZA 2 PA, QL, SP
B EMGALITY SUBCUTANEOUS 2 PA, ST, QL
B NUBEQA 2 PA, QL, SP
SOLUTION AUTO-INJECTOR B ODOMZO 2 PA, QL, SP
120 MG/ML B ORGOVYX 3 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).
11Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
B POMALYST 3 PA, QL, SP B REXULTI 4 PA, ST, QL
B REVLIMID 2 PA, QL, SP B RISPERDAL ORAL TABLET E
B STIVARGA 2 PA, QL, SP g risperidone oral tablet 1
B TABRECTA 4 PA, QL, SP B SAPHRIS 3 QL
B TAGRISSO 3 PA, QL, SP B SEROQUEL E
g tamoxifen citrate oral tablet 10 mg 1 B VRAYLAR ORAL CAPSULE 4 QL
g tamoxifen citrate oral tablet 20 mg 1 H-PA B ZYPREXA ORAL E
B TARGRETIN EXTERNAL 3 QL, SP Antivirals - Drugs for Viral Infections
B TARGRETIN ORAL 2 SP g acyclovir oral tablet 1
B TASIGNA 2 PA, ST, QL, SP B BIKTARVY 4 QL
B VERZENIO 2 PA, QL, SP B CIMDUO 2 QL
B VITRAKVI 2 PA, QL, SP B DESCOVY E PA, ST, QL
B ZEJULA 2 PA, QL, SP B DOVATO 2 QL
Antiparasitics - Drugs for Parasitic Infections g emtricitabine-tenofovir df oral tablet 1 QL
B ARAKODA 4 QL 100-150 mg, 133-200 mg,
167-250 mg
g hydroxychloroquine sulfate oral 1
g emtricitabine-tenofovir df oral tablet 1 QL, H
B KRINTAFEL 1 QL 200-300 mg
B PLAQUENIL E B EPCLUSA ORAL TABLET 2 PA, QL, SP
Antiparkinson Agents - Drugs for Parkinson's Disease B HARVONI ORAL TABLET 2 PA, ST, QL, SP
B INBRIJA 3 PA, QL, SP B JULUCA 2 QL
B KYNMOBI 3 PA, QL, SP B LEDIPASVIR-SOFOSBUVIR 2 PA, ST, QL, SP
B NEUPRO 3 B MAVYRET ORAL PACKET 2 QL, SP
B NOURIANZ 3 PA, QL g oseltamivir phosphate oral capsule 2
g pramipexole dihydrochloride 1 B PAXLOVID (150/100) 3
g ropinirole hcl 1 B PAXLOVID (300/100) 3
Antiplatelets - Drugs for Heart Attack and Stroke B PREZCOBIX 2
Prevention
B RUKOBIA 4 PA
B BRILINTA 4 QL
B SITAVIG E QL
g clopidogrel bisulfate oral 1
B SOFOSBUVIR-VELPATASVIR 2 PA, QL, SP
B PLAVIX E
B SYMFI 2 QL
Antipsychotics - Drugs for Mood Disorders
B SYMFI LO 2 QL
B ABILIFY E
B TAMIFLU ORAL CAPSULE E
g aripiprazole oral tablet 2
B TIVICAY 3
B LATUDA 4 QL
B TRIUMEQ 2 QL
g olanzapine oral tablet 1
B TRUVADA ORAL TABLET 4 QL
g quetiapine fumarate oral tablet 1 100-150 MG, 133-200 MG,
100 mg, 200 mg, 25 mg, 300 mg, 167-250 MG
400 mg, 50 mg
B TRUVADA ORAL TABLET E QL
g quetiapine fumarate oral tablet E 200-300 MG
150 mg
g valacyclovir hcl 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).
12Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
B VALTREX E QL B AVALIDE E
B VOSEVI 2 PA, QL, SP B AVAPRO E
B XOFLUZA (40 MG DOSE) 3 QL g benazepril hcl oral 1
B XOFLUZA (80 MG DOSE) 3 QL B BENICAR E
Anxiolytics - Drugs for Anxiety B BENICAR HCT E
g alprazolam oral tablet 1 B BIDIL 2
B ATIVAN ORAL E g bisoprolol fumarate oral 1
g buspirone hcl oral 1 g bisoprolol-hydrochlorothiazide 1
g clonazepam oral tablet 1 B CALAN SR 4
g diazepam oral tablet 1 B CARDIZEM CD E
B HALCION 4 B CARDURA 4
g hydroxyzine hcl oral tablet 1 g cartia xt 2
g hydroxyzine pamoate oral 1 g carvedilol 1
B KLONOPIN E g chlorthalidone 1
g lorazepam oral tablet 1 g clonidine hcl oral 1
g triazolam 1 B COREG E
B VALIUM E B CORLANOR 3 PA, QL
B VISTARIL 4 B COZAAR E
B XANAX E B CRESTOR E
Bipolar Agents - Drugs for Mood Disorders g diltiazem hcl er coated beads oral 2
g lithium carbonate er 1 capsule extended release 24 hour
g lithium carbonate oral capsule 1
B DIOVAN E
B LITHOBID 4 PA
B DIOVAN HCT E
Cardiovascular Agents - Drugs for Heart and Circulation
g doxazosin mesylate oral 1
Conditions B EDARBI 3
B ALDACTONE E B EDARBYCLOR 3
g aliskiren fumarate 3 g enalapril maleate oral tablet 1
B ALTACE E B ENTRESTO 4 PA, QL
g amiodarone hcl oral 1 g ezetimibe 2
g amlodipine besylate oral 1 g fenofibrate oral tablet 120 mg, E
g amlodipine besylate-benazepril hcl 1 40 mg
g amlodipine besylate-valsartan 2
g fenofibrate oral tablet 145 mg, 2
160 mg, 48 mg, 54 mg
g amlodipine besylate-valsartan- E
hydrochlorothiazide
B FENOGLIDE E
g atenolol oral 1
g flecainide acetate 1
g atenolol-chlorthalidone 1
g furosemide oral tablet 1
g atorvastatin calcium oral tablet 1 H-PA
g gemfibrozil oral 1
10 mg, 20 mg g hydralazine hcl oral 1
g atorvastatin calcium oral tablet 1 g hydrochlorothiazide oral 1
40 mg, 80 mg B HYZAAR 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).
13Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
B INDERAL LA E g olmesartan medoxomil-hctz 2
g irbesartan 1 g omega-3-acid ethyl esters 2
g irbesartan-hydrochlorothiazide 1 B PACERONE ORAL TABLET 3
g isosorb dinitrate-hydralazine 2 100 MG, 400 MG
g isosorbide mononitrate er 1
B PACERONE ORAL TABLET 200 MG 4
g labetalol hcl oral 1
g pravastatin sodium 1
B LASIX 4
g prazosin hcl oral 1
B LIPITOR E
B PROCARDIA XL E
g lisinopril oral 1
g propranolol hcl er 2
g lisinopril-hydrochlorothiazide 1
g propranolol hcl oral tablet 1
B LOPID 4
g ramipril 1
B LOPRESSOR 4
B REPATHA 2 PA, ST, QL
g losartan potassium oral 1
B REPATHA PUSHTRONEX SYSTEM 2 PA, ST, QL
g losartan potassium-hctz 1
B REPATHA SURECLICK 2 PA, ST, QL
B LOTENSIN 4
g rosuvastatin calcium 2
B LOTREL E
g simvastatin oral tablet 10 mg, 1 H-PA
20 mg, 40 mg, 5 mg
g lovastatin oral 1 H
g simvastatin oral tablet 80 mg 1
B LOVAZA E
B SOAANZ E QL
B MAXZIDE 4
g spironolactone oral 1
B MAXZIDE-25 4
B TEKTURNA 3
g metoprolol succinate er oral tablet 2
extended release 24 hour 100 mg,
B TEKTURNA HCT 3
200 mg, 50 mg g telmisartan 2
g metoprolol succinate er oral tablet 1 B TENORETIC 100 E
extended release 24 hour 25 mg B TENORETIC 50 E
g metoprolol tartrate oral tablet 1 B TENORMIN E
100 mg, 25 mg, 50 mg
B THALITONE E
g metoprolol tartrate oral tablet E
37.5 mg, 75 mg
B TOPROL XL E
B MICARDIS E
g torsemide 1
B MINIPRESS 4
g triamterene-hctz 1
B MULTAQ 4 PA
B TRICOR E
B NEXLETOL 2 PA, ST, QL
g valsartan oral tablet 2
B NEXLIZET 2 PA, ST, QL
g valsartan-hydrochlorothiazide 1
g nifedipine er 1
B VASOTEC E
g nifedipine er osmotic release 1
g verapamil hcl er oral tablet 1
extended release
g nitroglycerin sublingual 1
B VERQUVO 4 PA, QL
B NITROSTAT 4
B ZESTORETIC E
B NORLIQVA 4 PA
B ZESTRIL E
B NORVASC E
B ZETIA E
g olmesartan medoxomil oral 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).
14Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
B ZIAC ORAL TABLET 10-6.25 MG, 3 Central Nervous System Agents - Drugs for Multiple
2.5-6.25 MG Sclerosis
B ZIAC ORAL TABLET 5-6.25 MG 4 B AUBAGIO 3 PA, QL, SP
B ZOCOR E B AVONEX PEN 2 PA, QL, SP
Central Nervous System Agents - Drugs for Attention B AVONEX PREFILLED 2 PA, QL, SP
Deficit Disorder B BAFIERTAM 2 PA, QL, SP
B ADDERALL E B BETASERON 2 PA, QL, SP
B ADDERALL XR 2 QL B COPAXONE E PA, QL, SP
B ADHANSIA XR E QL B EXTAVIA E PA, ST, QL, SP
g amphetamine-dextroamphetamine 1 g fingolimod hcl 2 PA, QL, SP
g amphetamine-dextroamphetamine E QL g glatiramer acetate 2 PA, QL, SP
er
g glatopa 2 PA, QL, SP
B APTENSIO XR E QL
B KESIMPTA 2 PA, QL, SP
g atomoxetine hcl 3 QL
B MAVENCLAD 3 PA, ST, QL, SP
B CONCERTA 2 QL
B MAYZENT STARTER PACK ORAL 4 PA, QL, SP
g dexmethylphenidate hcl 1 TABLET THERAPY PACK 0.25 MG
g dexmethylphenidate hcl er 3 QL B MAYZENT STARTER PACK ORAL 3 PA, QL, SP
B FOCALIN 4 TABLET THERAPY PACK 12 X
B FOCALIN XR E QL 0.25 MG
g guanfacine hcl er 2
B PLEGRIDY INTRAMUSCULAR 3 PA, QL, SP
B INTUNIV E
B PLEGRIDY STARTER PACK 3 PA, QL, SP
B JORNAY PM E QL
B PLEGRIDY SUBCUTANEOUS 3 PA, QL, SP
g methylphenidate hcl er (cd) 2 QL Central Nervous System Agents - Miscellaneous
g methylphenidate hcl er (la) oral 2 QL
B AUSTEDO 2 PA, QL, SP
capsule extended release 24 hour B LYRICA ORAL CAPSULE 4 PA
10 mg, 20 mg, 30 mg, 40 mg g pregabalin oral capsule 2 QL
g methylphenidate hcl er (la) oral 2 B TIGLUTIK 4 PA
capsule extended release 24 hour
60 mg
B ZEPOSIA 3 PA, ST, QL, SP
g methylphenidate hcl er (osm) E QL
B ZEPOSIA 7-DAY STARTER PACK 3 PA, ST, QL, SP
g methylphenidate hcl er (xr) E QL
B ZEPOSIA STARTER KIT 3 PA, ST, QL, SP
g methylphenidate hcl er oral tablet 4 QL Dental and Oral Agents - Drugs for Mouth and Throat
extended release Conditions
g methylphenidate hcl oral tablet 1
g chlorhexidine gluconate mouth/ 1
throat
B MYDAYIS E QL
g lidocaine hcl mouth/throat 1
B RELEXXI E QL
g lidocaine viscous hcl 1
B RITALIN E
B PERIDEX 4
B RITALIN LA E QL
g periogard 1
B STRATTERA E QL
B VYVANSE 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).
15Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
Dermatological Agents - Drugs for Skin Conditions B ENSTILAR 4 QL
B ABSORICA E PA B EUCRISA 3 ST, QL
g accutane 2 B FINACEA 4
g ala-cort external cream 1 % E B FLUOROPLEX 4
g ala-cort external cream 2.5 % 1 B FLUOROURACIL EXTERNAL E
g amnesteem 2 CREAM 0.5 %
B AMZEEQ 4 PA, QL
g fluorouracil external cream 5 % 1
B AVITA EXTERNAL CREAM E PA, QL
g hydrocortisone external cream 1 % E
B CARAC E
g hydrocortisone external cream 1
2.5 %
B CIBINQO 2 PA, QL, SP
g hydrocortisone external ointment 1
g claravis 2 1 %, 2.5 %
B CLEOCIN-T 4 B IMPOYZ E QL
g clindacin etz external swab 1 g isotretinoin capsule 10 mg oral E PA
g clindacin-p 1 g isotretinoin capsule 10 mg oral 2
B CLINDAGEL E QL g isotretinoin capsule 20 mg oral E PA
g clindamycin phosphate external 3 g isotretinoin capsule 20 mg oral 2
lotion
g isotretinoin capsule 30 mg oral E PA
g clindamycin phosphate external 1
solution
g isotretinoin capsule 30 mg oral 2
g clindamycin phosphate external 1
g isotretinoin capsule 40 mg oral E PA
swab g isotretinoin capsule 40 mg oral 2
g clindamycin phosphate gel 1 % E QL g isotretinoin oral capsule 25 mg, E PA
external 35 mg
g clindamycin phosphate gel 1 % 3 QL B KLISYRI 4 ST, QL
external B METROCREAM 4
g clobetasol propionate external 2 QL g metronidazole external cream 1
cream
B MIRVASO 4 PA, QL
g clobetasol propionate external 2 QL
ointment
g myorisan 2
g clobetasol propionate external 1 QL
B NORITATE E
solution B OPZELURA 4 PA, QL, SP
g clotrimazole-betamethasone 1 QL B PICATO 3 QL
external cream B PROTOPIC E ST, QL
B DAZOMON E PA B RETIN-A EXTERNAL CREAM E PA, QL
B DUPIXENT SUBCUTANEOUS 2 PA, QL, SP B RHOFADE 4 PA, QL
SOLUTION PEN-INJECTOR g rosadan external cream 1
B DUPIXENT SUBCUTANEOUS 2 PA, QL B SANTYL 3 QL
SOLUTION PREFILLED SYRINGE
100 MG/0.67ML B SOOLANTRA 4 QL
B DUPIXENT SUBCUTANEOUS 2 PA, QL, SP B TACLONEX EXTERNAL OINTMENT E QL
SOLUTION PREFILLED SYRINGE g tacrolimus external 2 ST, QL
200 MG/1.14ML, 300 MG/2ML g tretinoin external cream 3 QL
B EFUDEX 4
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 triamcinolone acetonide external 1 g bd veo ultra-fine insulin syringes 2 QL
cream 0.025 %, 0.1 % B BLOOD GLUCOSE TEST STRIPS E QL
g triamcinolone acetonide external 1 QL B CARETOUCH MONITOR SYSTEM E
cream 0.5 %
B CARETOUCH TEST E QL
g triamcinolone acetonide external 1
ointment 0.025 %, 0.1 %, 0.5 %
B CONTOUR MONITOR KIT E
W/DEVICE
g triamcinolone acetonide external E
ointment 0.05 %
B CONTOUR NEXT EZ KIT E
W/DEVICE
g triamcinolone in absorbase E
B CONTOUR NEXT GEN MONITOR E
B TRIANEX E
B CONTOUR NEXT LINK KIT 4
g triderm external cream 0.1 % 1 W/DEVICE
g triderm external cream 0.5 % 1 QL B CONTOUR NEXT LINK KIT E (Contour Next
g tritocin E W/DEVICE Link 24 )
B VTAMA 4 PA, QL B CONTOUR NEXT MONITOR KIT 2
B XEPI 3 QL W/DEVICE
g zenatane 2
B CONTOUR NEXT ONE KIT 2
B ZILXI 4 PA, ST, QL
B CONTOUR NEXT TEST STRIPS 2 QL
Diabetes - Glucose Monitoring and Supplies
B CONTOUR TEST STRIPS E QL
B ACCU-CHEK AVIVA PLUS TEST E QL
B CVS ADVANCED GLUCOSE TEST E QL
STRIPS B CVS GLUCOSE METER TEST E QL
B ACCU-CHEK FASTCLIX LANCET 1 STRIPS
KIT B D-CARE BLOOD GLUCOSE E QL
B ACCU-CHEK FASTCLIX LANCETS 1 B D-CARE GLUCOMETER E
B ACCU-CHEK GUIDE KIT W/DEVICE 3 (Accu-Chek B DEXCOM G6 RECEIVER 3 PA, QL
Guide Me) B DEXCOM G6 SENSOR 3 PA, QL
B ACCU-CHEK GUIDE KIT W/DEVICE 3 B DEXCOM G6 TRANSMITTER 3 PA, QL
B ACCU-CHEK GUIDE TEST STRIPS 3 QL B DIABETES MONITOR DIGIT E
B ACCU-CHEK MULTICLIX LANCET 1 ADD-ON
KIT B DIABETES MONITOR DIGIT SOLN E
B ACCU-CHEK MULTICLIX LANCETS 1 B EASY TOUCH TEST E QL
B ACCU-CHEK SMARTVIEW TEST E QL B EASYGLUCO E
STRIPS
B EASYMAX 15 TEST E QL
B ACCU-CHEK SOFT TOUCH 1
LANCETS
B EASYMAX NG BLOOD GLUCOSE E
KIT
B ACCU-CHEK SOFTCLIX LANCET 1
DEVICE KIT
B ENLITE GLUCOSE SENSOR 3 PA
B ACCU-CHEK SOFTCLIX LANCETS 1
B EQ BLOOD GLUCOSE TEST E QL
B ACCUTREND GLUCOSE E QL
B EVERSENSE SENSOR/HOLDER 3 PA
g bd autoshield duo pen needles 2 QL
B EVERSENSE SMART 3 PA
TRANSMITTER
g bd U-500 insulin syringes 2 QL
B FORTISCARE G1 TEST STRIP E QL
g bd ultra-fine insulin syringes 2 QL
B FORTISCARE TEST E QL
g bd ultra-fine pen needles 2 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).
17Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
B FREESTYLE LIBRE 14 DAY 3 PA, QL B ONETOUCH DELICA LANCETS 1
READER 30G
B FREESTYLE LIBRE 14 DAY 3 PA, QL B ONETOUCH DELICA LANCETS 1
SENSOR 33G
B FREESTYLE LIBRE 2 READER 3 PA, QL B ONETOUCH DELICA PLUS 1
B FREESTYLE LIBRE 2 SENSOR 3 PA LANCET30G
B FREESTYLE LIBRE 3 SENSOR 3 PA
B ONETOUCH DELICA PLUS 1
LANCET33G
B FREESTYLE LIBRE CONTINUOUS 3 PA
BLOOD GLUCOSE MONITOR
B ONETOUCH FINEPOINT LANCETS 1
SYSTEM B ONETOUCH SOLUTIONS 4
B FREESTYLE LIBRE READER 3 PA, QL STARTER KIT
B FREESTYLE PRECISION NEO E
B ONETOUCH ULTRA 2 KIT 1
SYSTEM W/DEVICE
B FREESTYLE PRECISION NEO E QL
B ONETOUCH ULTRA MINI KIT 1
TEST W/DEVICE
B FREESTYLE TEST E QL
B ONETOUCH ULTRA TEST STRIPS 1 QL
B GLUCOCARD EXPRESSION TEST E QL
B ONETOUCH ULTRASOFT 1
LANCETS
B GLUCOCARD SHINE TEST E QL
B ONETOUCH VERIO FLEX SYSTEM 1
B GLUCOCARD VITAL TEST E QL
B ONETOUCH VERIO IQ SYSTEM 1
B GUARDIAN CONNECT 3 PA, QL
TRANSMITTER
B ONETOUCH VERIO KIT W/DEVICE 1
B GUARDIAN LINK 3 TRANSMITTER 3 PA, QL
B ONETOUCH VERIO REFLECT KIT 1
W/DEVICE
B GUARDIAN REAL-TIME REPLACE 3 PA
PED
B ONETOUCH VERIO TEST STRIPS 1 QL
B GUARDIAN SENSOR (3) 3 PA, QL
B OPTIUMEZ TEST E QL
B INSULIN PEN NEEDLES 2 QL
B PARADIGM REAL-TIME 3 PA
TRANSMITTER
B MICRODOT TEST E QL
B PRECISION XTRA E
B MINILINK REAL-TIME 3 PA
TRANSMITTER
B PRECISION XTRA BLOOD E QL
GLUCOSE
B MINIMED 630G GUARDIAN PRESS 3 PA
B PREMIUM BLOOD GLUCOSE TEST E QL
B MM EASY TOUCH GLUCOSE E
METER
B PTS PANELS EGLU TEST E QL
B NEUTEK 2TEK TEST E QL
B QUINTET AC BLOOD GLUCOSE E QL
TEST
B NOVOFINE AUTOCOVER PEN 2 QL
NEEDLE
B QUINTET BLOOD GLUCOSE TEST E QL
B NOVOFINE PEN NEEDLE 2 QL
B RELION TRUE MET AIR GLUC E
METER
B NOVOFINE PLUS PEN NEEDLE 2 QL
B RELION TRUE METRIX TEST E QL
B NOVOTWIST 2 STRIPS
B OMNIPOD 5 G6 INTRO (GEN 5) 2 PA, QL B RELION ULTIMA GLUCOSE E
B OMNIPOD 5 G6 POD (GEN 5) 2 PA, QL SYSTEM
B ONETOUCH CLUB LANCETS FINE 1 B RELION ULTIMA TEST E QL
PT
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
B TECHLITE (ARKAY) INSULIN 2 QL B INSULIN LISPRO JUNIOR E QL
SYRINGES KWIKPEN
B TECHLITE (ARKAY) PEN NEEDLES 2 QL B INSULIN LISPRO KWIKPEN E
B TRUE FOCUS BLOOD GLUCOSE E QL B INSULIN LISPRO PROT & LISPRO E QL
STRIP B LANTUS SOLOSTAR 1 QL
B TRUE METRIX AIR GLUCOSE E B LANTUS U-100 VIAL 1 QL
METER KIT
B LYUMJEV KWIKPEN 2 QL
B TRUE METRIX BLOOD GLUCOSE E QL
TEST
B LYUMJEV VIAL 1 QL
B TRUE METRIX GO GLUCOSE E
B NOVOLIN 70/30 FLEXPEN E ST, QL
METER B NOVOLIN 70/30 FLEXPEN RELION E ST, QL
B TRUE METRIX METER KIT E B NOVOLIN 70/30 RELION E ST, QL
B TRUE METRIX PRO BLOOD E QL B NOVOLIN 70/30 VIAL E ST, QL
GLUCOSE B NOVOLIN N FLEXPEN E ST, QL
B TRUETRACK TEST E QL B NOVOLIN N FLEXPEN RELION E ST, QL
B UNISTRIP1 GENERIC E QL B NOVOLIN N RELION E ST, QL
Diabetes - Insulin B NOVOLIN N VIAL E ST, QL
B ADMELOG E QL B NOVOLIN R FLEXPEN E ST, QL
B ADMELOG SOLOSTAR E QL B NOVOLIN R FLEXPEN RELION E ST, QL
B BASAGLAR KWIKPEN E QL B NOVOLIN R RELION E ST, QL
B HUMALOG INJECTION 1 QL B NOVOLIN R VIAL E ST, QL
B HUMALOG KWIKPEN 2 QL B TOUJEO MAX SOLOSTAR 2 QL
B HUMALOG MIX 50/50 KWIKPEN 2 QL B TOUJEO SOLOSTAR 2 QL
B HUMALOG MIX 50/50 VIAL 1 QL Diabetes - Non-Insulin Agents
B HUMALOG MIX 75/25 KWIKPEN 2 QL B ACTOS E QL
B HUMALOG MIX 75/25 VIAL 1 QL B ADLYXIN 4 PA, ST, QL
B HUMALOG SUBCUTANEOUS 2 QL B ADLYXIN STARTER PACK 4 PA, ST, QL
B HUMALOG U-100 JUNIOR 2 QL B ALOGLIPTIN BENZOATE E QL
KWIKPEN B ALOGLIPTIN-METFORMIN HCL E QL
B HUMULIN 70/30 KWIKPEN 2 QL B ALOGLIPTIN-PIOGLITAZONE E QL
B HUMULIN 70/30 VIAL 1 QL B AMARYL E
B HUMULIN N KWIKPEN 2 QL B BAQSIMI ONE PACK 2 QL
B HUMULIN N VIAL 1 QL B BAQSIMI TWO PACK 2 QL
B HUMULIN R U-500 KWIKPEN 2 QL B BYDUREON BCISE 2 PA, ST, QL
B HUMULIN R U-500 VIAL 1 QL B BYDUREON PEN 2 PA, ST, QL
B HUMULIN R VIAL 1 QL B BYETTA 10 MCG PEN 2 PA, ST, QL
B INSULIN GLARGINE E QL B BYETTA 5 MCG PEN 2 PA, ST, QL
B INSULIN GLARGINE SOLOSTAR E QL g glimepiride 1
B INSULIN LISPRO E QL g glipizide er 1
B INSULIN LISPRO (1 UNIT DIAL) E QL g glipizide ir 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
g glipizide xl 1 B VICTOZA SOLUTION PEN- 3 PA, ST, (3 Pak),
B GLUCAGON EMERGENCY 2 QL INJECTOR 18 MG/3ML QL
KIT INJECTION SOLUTION SUBCUTANEOUS
RECONSTITUTED B ZEGALOGUE SUBCUTANEOUS 2 QL
B GLUCOTROL XL 4 SOLUTION AUTO-INJECTOR
B GLUMETZA E PA Drugs for Blood Disorders
g glyburide oral 1
B ADVATE 2 SP
B GLYXAMBI 2 ST, QL
B ADYNOVATE 4 PA, SP
B GVOKE HYPOPEN 1-PACK 2 QL
B AFSTYLA INTRAVENOUS KIT 1000 4 PA
UNIT, 2000 UNIT, 250 UNIT, 3000
B GVOKE HYPOPEN 2-PACK 2 QL UNIT, 500 UNIT
B GVOKE PREFILLED SYRINGE 2 QL B AFSTYLA INTRAVENOUS KIT 1500 4 PA, SP
B JARDIANCE 2 QL UNIT, 2500 UNIT
B JENTADUETO 2 QL B ALPHANATE 2 SP
B JENTADUETO XR 2 QL B ARANESP (ALBUMIN FREE) 2 QL, SP
B KAZANO 2 QL B DOPTELET 4 PA, QL, SP
B KOMBIGLYZE XR 2 QL B ELOCTATE 4 PA, SP
g metformin hcl er 1 B HEMLIBRA 2 PA, SP
g metformin hcl er (mod) E PA B HEMOFIL M 2 SP
g metformin hcl er (osm) E PA B HUMATE-P 2 SP
g metformin hcl oral tablet 1000 mg, 1 B JIVI 4 PA, SP
500 mg, 850 mg B KOATE 2 SP
g metformin hcl oral tablet 625 mg E B KOATE-DVI 2 SP
B MOUNJARO 2 PA, ST, QL 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
B OZEMPIC 2 PA, ST, QL B NOVOEIGHT 2 SP
g pioglitazone hcl 1 QL B NUWIQ INTRAVENOUS KIT 1000 2 SP
B RYBELSUS 2 PA, ST, QL UNIT, 2000 UNIT, 250 UNIT, 2500
B SOLIQUA 2 QL UNIT, 3000 UNIT, 4000 UNIT, 500
UNIT
B SYMLINPEN 120 3 QL
B NUWIQ INTRAVENOUS KIT 1500 2
B SYMLINPEN 60 3 QL
UNIT
B SYNJARDY 2 QL B RECOMBINATE 2 SP
B SYNJARDY XR 2 QL B RETACRIT INJECTION SOLUTION 2 QL, SP
B TRADJENTA 2 QL 10000 UNIT/ML, 2000 UNIT/ML,
B TRIJARDY XR 2 QL 3000 UNIT/ML, 4000 UNIT/ML,
40000 UNIT/ML
B TRULICITY 2 PA, ST, QL
B RETACRIT INJECTION SOLUTION 2
B VICTOZA SOLUTION PEN- 2 PA, ST, (2 Pak),
20000 UNIT/ML
INJECTOR 18 MG/3ML QL
SUBCUTANEOUS B TAVALISSE 4 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).
20Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
B WILATE 2 B MULTIVITAMIN/FLUORIDE TABLET 3
B ZARXIO 2 CHEWABLE 0.5 MG ORAL (RX)
B ZIEXTENZO 3 SP
g multivitamin/fluoride tablet 1
chewable 1 mg oral (rx)
Drugs for Pregnancy Termination
B MULTIVITAMIN/FLUORIDE TABLET 3
g mifepristone 1 CHEWABLE 1 MG ORAL (RX)
Drugs for Sexual Dysfunction B MULTI-VIT-FLOR 3
B ADDYI 4 PA, QL B NASCOBAL 3
B CIALIS E QL B POLY-VI-FLOR ORAL TABLET 3
B IMVEXXY MAINTENANCE PACK 2 QL CHEWABLE
B IMVEXXY STARTER PACK 2 QL g potassium chloride crys er oral 1
B OSPHENA 3 PA, QL tablet extended release 10 meq,
20 meq
g sildenafil citrate oral tablet 100 mg, 2 QL
25 mg, 50 mg g potassium chloride crys er oral 3
tablet extended release 15 meq
B STENDRA 4 PA, QL
g potassium chloride er 1
g tadalafil oral 2 QL
g potassium citrate er 1
B VIAGRA E QL
B QUFLORA GUMMIES E
B VYLEESI 4 PA, QL
B QUFLORA PEDIATRIC ORAL 3
Electrolytes / Vitamins
TABLET CHEWABLE
g cyanocobalamin injection solution 1 B UROCIT-K 10 4
1000 mcg/ml
B UROCIT-K 15 4
B CYANOCOBALAMIN INJECTION 3
SOLUTION 2000 MCG/ML
B UROCIT-K 5 4
B DODEX 4
B VELTASSA 3 PA, QL
B DRISDOL 4 g vitamin d (ergocalciferol) oral 1
capsule 1.25 mg (50000 ut), 50000
g ergocalciferol oral capsule 1
unit
g folic acid oral tablet 1 mg 1
Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer
g klor-con 10 1 B ACIPHEX E QL
g klor-con m10 1 B CARAFATE ORAL TABLET E
g klor-con m15 3 B CYTOTEC 4
g klor-con m20 1 B DEXILANT E QL
g klor-con oral tablet extended 1 B DEXLANSOPRAZOLE E QL
release
g famotidine oral suspension 1
B K-TAB 3
reconstituted
B LOKELMA 3 PA, QL g misoprostol oral 1
g multivitamin/fluoride tablet 1 B OMECLAMOX-PAK 3 QL
chewable 0.25 mg oral (rx)
g omeprazole oral capsule delayed 1
B MULTIVITAMIN/FLUORIDE TABLET 3
release
CHEWABLE 0.25 MG ORAL (RX)
g pantoprazole sodium oral tablet 1
g multivitamin/fluoride tablet 1
delayed release
chewable 0.5 mg oral (rx)
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
B PROTONIX ORAL TABLET E B TEGSEDI 2 PA, QL, SP
DELAYED RELEASE B ZENPEP 2
B PYLERA 3 QL Genitourinary Agents - Drugs for Bladder, Genital and
g rabeprazole sodium oral tablet 2 QL Kidney Conditions
delayed release B DITROPAN XL E
g sucralfate oral tablet 1 g oxybutynin chloride er 2
Gastrointestinal Agents - Drugs for Bowel, Intestine and g oxybutynin chloride oral tablet 1
Stomach Conditions
g phenazo oral tablet 200 mg 1
B CLENPIQ 3
g phenazopyridine hcl oral tablet 1
g dicyclomine hcl oral capsule 1 100 mg, 200 mg
g dicyclomine hcl oral tablet 1 B PYRIDIUM 3
B GLYCATE E g solifenacin succinate 3
g glycopyrrolate oral tablet 1 mg, 1 B THIOLA 4 SP
2 mg
B THIOLA EC 3 SP
B GLYCOPYRROLATE ORAL TABLET E
1.5 MG
B VELPHORO 2
B LINZESS 2 PA, QL
B VESICARE E
B MOTEGRITY 3 PA, QL Genitourinary Agents - Drugs for Prostate Conditions
B MOVIPREP 3 QL
g alfuzosin hcl er 1
g peg 3350-kcl-na bicarb-nacl 1 QL, H
g finasteride oral tablet 5 mg 1
g peg-3350/electrolytes/ascorbat 3 QL
B FLOMAX E
g peg-kcl-nacl-nasulf-na asc-c 3 QL
B PROSCAR E
B PLENVU 3 QL
g tamsulosin hcl 1
B ROBINUL E
B UROXATRAL E
B ROBINUL-FORTE E Hormonal Agents - Hormone Replacement and Birth
Control
g sodium sulfate-potassium sulfate- 3 QL
magnesium sulfate
g afirmelle 1 H
B SUTAB 3
B ALORA 3 QL
B SYMPROIC 2 PA, QL
g altavera 1 H
B VIBERZI 3 PA, QL
B ANNOVERA 3 QL
B ZELNORM 3 PA, ST, QL
g apri 1 H
Genetic or Enzyme Disorder - Drugs for Replacement,
g aubra 1 H
Modification, Treatment g aubra eq 1 H
B CERDELGA 2 PA, SP g aurovela 1.5/30 1 H
B CREON 2 g aurovela 1/20 1 H
B DEPEN TITRATABS 2 SP g aurovela 24 fe 1 H
B ORFADIN 2 PA, SP g aurovela fe 1.5/30 1 H
B PANCREAZE 3 ST g aurovela fe 1/20 1 H
B PERTZYE 4 ST g aviane 1 H
B STRENSIQ 2 PA, QL, SP B AYGESTIN 4
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 ayuna 1 H g estradiol patch twice weekly 2 QL
B BIJUVA 3 0.075 mg/24hr transdermal
g blisovi 24 fe 1 H
g estradiol patch twice weekly 2 QL
0.075 mg/24hr transdermal
g blisovi fe 1.5/30 1 H
g estradiol patch twice weekly 2 QL
g blisovi fe 1/20 1 H 0.1 mg/24hr transdermal
g camila 1 H g estradiol transdermal gel 3
g chateal 1 H g estradiol transdermal patch weekly 1 (generic for
g chateal eq 1 H Climara), QL
B CLIMARA E QL g estradiol vaginal cream 3
B CLIMARA PRO 3 QL g estradiol vaginal tablet 2
g cryselle-28 1 H B ESTRING 2 QL
g cyred 1 H B ESTROGEL 3 QL
g cyred eq 1 H g etonogestrel-ethinyl estradiol 1 H
g deblitane 1 H B EVAMIST 2
g delyla 1 H g falmina 1 H
B DEPO-PROVERA 4 QL g femynor 1 H
INTRAMUSCULAR SUSPENSION g hailey 1.5/30 1 H
PREFILLED SYRINGE
g hailey 24 fe 1 H
B DEPO-SUBQ PROVERA 104 2 QL
g hailey fe 1.5/30 1 H
g desogestrel-ethinyl estradiol oral 1 H
tablet 0.15-30 mg-mcg
g hailey fe 1/20 1 H
B DIVIGEL 3
g heather 1 H
g dotti 2 QL
g incassia 1 H
g drospirenone-ethinyl estradiol 3
g isibloom 1 H
B DUAVEE 3 QL
g jasmiel 3
B ELESTRIN 3
g jencycla 1 H
g elinest 1 H
g juleber 1 H
g eluryng 1 H
g junel 1.5/30 1 H
g enskyce 1 H
g junel 1/20 1 H
g errin 1 H
g junel fe 1.5/30 1 H
g estarylla 1 H
g junel fe 1/20 1 H
B ESTRACE E
g junel fe 24 1 H
g estradiol oral 1
g kalliga 1 H
g estradiol patch twice weekly 2 QL
g kurvelo 1 H
0.025 mg/24hr transdermal g larin 1.5/30 1 H
g estradiol patch twice weekly 2 QL g larin 1/20 1 H
0.0375 mg/24hr transdermal g larin 24 fe 1 H
g estradiol patch twice weekly 2 QL g larin fe 1.5/30 1 H
0.05 mg/24hr transdermal
g larin fe 1/20 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).
23Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
g lessina 1 H g norethindrone oral 1 H
g levonorgestrel-ethinyl estrad oral 1 H g norgestimate-eth estradiol 1 H
tablet 0.1-20 mg-mcg, g norgestimate-ethinyl estradiol 2
0.15-30 mg-mcg triphasic oral tablet 0.18/0.215/
g levora 0.15/30 (28) 1 H 0.25 mg-25 mcg
B LO LOESTRIN FE 1 H g norgestimate-ethinyl estradiol 1 H
B LOESTRIN 1.5/30 (21) E triphasic oral tablet 0.18/0.215/
0.25 mg-35 mcg
B LOESTRIN 1/20 (21) E
g norlyroc 1 H
B LOESTRIN FE 1.5/30 E
B NUVARING E
B LOESTRIN FE 1/20 E
g nymyo 1 H
g loryna 3
g ocella 3
g low-ogestrel 1 H
g portia-28 1 H
g lo-zumandimine 3
B PREMARIN ORAL 3
g lutera 1 H
B PREMARIN VAGINAL 3
g lyleq 1 H
B PREMPHASE 3
g lyllana 4 QL
B PREMPRO 3
g lyza 1 H
g progesterone oral 2
g marlissa 1 H
B PROMETRIUM E
g medroxyprogesterone acetate 1 QL, H
intramuscular suspension prefilled
B PROVERA 4
syringe g reclipsen 1 H
g medroxyprogesterone acetate oral 1 g sharobel 1 H
B MENOSTAR 3 QL g sprintec 28 1 H
g microgestin 1.5/30 1 H g sronyx 1 H
g microgestin 1/20 1 H g syeda 3
g microgestin 24 fe 1 H g tarina 24 fe 1 H
g microgestin fe 1.5/30 1 H g tarina fe 1/20 1 H
g microgestin fe 1/20 1 H g tarina fe 1/20 eq 1 H
g mili 1 H g tri femynor 1 H
B MINIVELLE E QL g tri-estarylla 1 H
g mono-linyah 1 H g tri-linyah 1 H
B MYFEMBREE 2 PA, QL g tri-lo-estarylla 2
B NATAZIA 2 g tri-lo-marzia 2
g nikki 3 g tri-lo-mili 2
g nora-be 1 H g tri-lo-sprintec 2
g norethin ace-eth estrad-fe oral 1 H g tri-mili 1 H
tablet g tri-nymyo 1 H
g norethindrone acetate oral 1 g tri-sprintec 1 H
g norethindrone acet-ethinyl est 1 H g tri-vylibra 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).
24Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
g tri-vylibra lo 2 B TAPERDEX 7-DAY 3
B VAGIFEM E B ZCORT 7-DAY E
g vestura 3 Hormonal Agents - Other
g vienva 1 H B ELIGARD SUBCUTANEOUS KIT 3 PA
B VIVELLE-DOT E QL 7.5 MG
g vylibra 1 H
B LANREOTIDE ACETATE E SP
g xulane 3 H
g leuprolide acetate injection 1 PA
B YASMIN 28 2
B LUPRON DEPOT (1-MONTH) E
B YAZ 2
B NOCDURNA 3 PA, QL
g yuvafem 2
B NORDITROPIN FLEXPRO 2 PA, QL, SP
g zafemy 3 H
B NUTROPIN AQ NUSPIN 10 2 PA, QL, SP
g zumandimine 3
B NUTROPIN AQ NUSPIN 20 2 PA, QL, SP
Hormonal Agents - Oral Steroids
B NUTROPIN AQ NUSPIN 5 2 PA, QL, SP
B CORTEF 4
B ORIAHNN 2 PA, QL
B DEXABLISS E
B ORILISSA 2 PA, QL
g dexamethasone oral tablet 1
B SOMATULINE DEPOT 4 SP
g dexamethasone oral tablet therapy 3 Hormonal Agents - Testosterone Replacement
pack B ANDRODERM 2 PA, QL
B DXEVO 11-DAY E B ANDROGEL E PA, QL
B HEMADY E B ANDROGEL PUMP E PA, QL
B HIDEX 6-DAY E B DEPO-TESTOSTERONE 3
g hydrocortisone oral 1 INTRAMUSCULAR SOLUTION
100 MG/ML
B MEDROL ORAL TABLET THERAPY 4
PACK
B DEPO-TESTOSTERONE 4
INTRAMUSCULAR SOLUTION
g methylprednisolone oral tablet 1 200 MG/ML
therapy pack
B FORTESTA E PA, QL
B PEDIAPRED 2
B NATESTO E PA, QL
g prednisolone sodium phosphate E
oral solution 10 mg/5ml,
B TESTIM 2 PA, QL
25 mg/5ml, 6.7 (5 base) mg/5ml B TESTOSTERONE CYPIONATE E
g prednisolone sodium phosphate 1 INJECTION
oral solution 15 mg/5ml g testosterone cypionate 1
g prednisolone sodium phosphate E QL intramuscular
oral solution 20 mg/5ml B VOGELXO E PA, QL
g prednisone oral tablet 1 B VOGELXO PUMP E PA, QL
g prednisone oral tablet therapy pack 1 Hormonal Agents - Thyroid
B TAPERDEX 12-DAY 3 B ARMOUR THYROID 3
B TAPERDEX 6-DAY ORAL TABLET 4 B CYTOMEL E
THERAPY PACK 1.5 MG g euthyrox 1
B TAPERDEX 6-DAY ORAL TABLET 3 g levo-t 1
THERAPY PACK 1.5 MG (21)
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 levothyroxine sodium oral tablet 1 B ENBREL SURECLICK 2 PA, QL, SP
g levoxyl 2 B FIRAZYR E PA, QL, SP
g liothyronine sodium oral 2 B HAEGARDA 2 PA, QL, SP
g methimazole oral 1 B HUMIRA 2 PA, QL, SP
g np thyroid 1 B HUMIRA PEDIATRIC CROHNS 2 PA, QL, SP
B SYNTHROID E START
B THYQUIDITY E PA
B HUMIRA PEN 2 PA, QL, SP
B TIROSINT-SOL 2 PA
B HUMIRA PEN-CD/UC/HS STARTER 2 PA, QL, SP
g unithroid 1
B HUMIRA PEN-PEDIATRIC UC 2 PA, QL, SP
START
Immunological Agents - Drugs for Immune System
Stimulation or Suppression
B HUMIRA PEN-PS/UV/ADOL HS 2 PA, QL, SP
START
B ACTEMRA ACTPEN 3 PA, ST, QL, SP
B HUMIRA PEN-PSOR/UVEIT 2 PA, QL, SP
B ACTEMRA SUBCUTANEOUS 3 PA, ST, QL, SP STARTER
B ADBRY 2 PA, SP B IMURAN E
B AZASAN 4 g methotrexate oral 1
g azathioprine oral tablet 100 mg, 3 g methotrexate sodium oral 1
75 mg
g mycophenolate mofetil oral tablet 1
g azathioprine oral tablet 50 mg 1
B OLUMIANT ORAL TABLET 1 MG, 2 PA, QL, SP
B BENLYSTA SUBCUTANEOUS 2 PA, QL, SP 4 MG
SOLUTION AUTO-INJECTOR
B OLUMIANT ORAL TABLET 2 MG 2 PA, QL, SP
B CELLCEPT ORAL TABLET E
B ORENCIA CLICKJECT 3 PA, ST, QL, SP
B CIMZIA E PA
B ORENCIA SUBCUTANEOUS 3 PA, ST, QL, SP
B CIMZIA PREFILLED KIT 2 PA, QL, SP
B OTEZLA ORAL TABLET 2 PA, QL, SP
B CIMZIA STARTER KIT 2 PA, QL, SP
B OTREXUP E QL
B CINRYZE E PA, QL, SP
B PROGRAF ORAL CAPSULE 4
B COSENTYX (300 MG DOSE) 3 PA, ST, QL, SP
B RASUVO 2 QL
B COSENTYX 150 MG/ML 3 PA, ST, QL, SP
SUBCUTANEOUS SOLUTION
B RINVOQ 2 PA, QL, SP
PREFILLED SYRINGE 150 MG/ML B RUCONEST 4 PA, QL, SP
B COSENTYX 150 MG/ML 3 PA, ST, QL, SP B SIMPONI 2 PA, QL, SP
SUBCUTANEOUS SOLUTION B SKYRIZI PEN 2 PA, QL, SP
PREFILLED SYRINGE
75 MG/0.5ML
B SKYRIZI SUBCUTANEOUS 2 PA, QL, SP
SOLUTION PREFILLED SYRINGE
B COSENTYX SENSOREADY 3 PA, ST, QL, SP
(300 MG)
B STELARA SUBCUTANEOUS 2 PA, QL, SP
B COSENTYX SENSOREADY PEN 3 PA, ST, QL, SP
g tacrolimus oral 1
B EMPAVELI 2 PA, QL, SP
B TAKHZYRO SUBCUTANEOUS 2 PA, QL, SP
SOLUTION
B ENBREL MINI 2 PA, QL, SP
B TALTZ SUBCUTANEOUS E PA, ST, QL, SP
B ENBREL SUBCUTANEOUS 2 PA, QL, SP SOLUTION AUTO-INJECTOR
SOLUTION
B TREMFYA 2 PA, QL, SP
B ENBREL SUBCUTANEOUS 2 PA, QL, SP
SOLUTION PREFILLED SYRINGE
B TREXALL 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).
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