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Blue Cross Clinical Drug List - January 2021

Table of contents

Blue Cross Clinical Drug List (Formulary) introduction 6

How to read the Blue Cross Clinical Drug List 12

Anti-infectives

1A Antifungals 14

1B Antimalarials 14

1C Antiparasitics and antihelmintics 15

1D Antiretrovirals 16

1E Antituberculars 17

1F Antivirals 18

1G Cephalosporins 18

1H Macrolides 19

1I Penicillins 19

1J Quinolones 19

1K Sulfonamides and combinations 19

1L Tetracyclines 20

1M Urinary tract agents 20

1N Miscellaneous anti-infectives 21

Cardiovascular, hypertension, cholesterol

2A ACE-Inhibitors and combinations 22

2B Alpha-adrenergic agents 22

2C Angiotensin II Receptor Blockers and combinations 23

2D Anticoagulants and hemostasis agents 24

2E Beta blockers and combinations 25

2F Calcium channel blockers and combinations 26

2G Cardiovascular treatment 26

2H Diuretics 27

2I Lipid-lowering agents 28

2J Nitrates and combinations 29

2K Renin-inhibitors and combinations 29

2L Miscellaneous antihypertensives 29

Page 1

Central nervous system

3A Alzheimer's therapy 30

3B Anticonvulsants 31

3C Antidepressants 32

3D Antipsychotics 33

3E Anxiolytics 34

3F CNS stimulants 34

3G Migraine therapy 35

3H Myasthenia gravis 35

3I Narcotic antagonists and withdrawal management 35

3J Narcotic mixed agonist and antagonist 36

3K Narcotic and analgesic combinations 36

3L Narcotics 37

3M Nonsteroidal anti-inflammatory drugs 38

3N Parkinsons disease and related disorders 39

3O Salicylates 39

3P Sedative and hypnotics 40

3Q Skeletal muscle relaxants 40

3R Miscellaneous CNS 41

Gastrointestinal agents

4A 5-Aminosalicylic Acid (5-ASA) agents 42

4B Antidiarrheals and antispasmodics 42

4C Antiemetics 43

4D Bile acids 43

4E Bowel preparation and cleansing agents 44

4F Digestive enzymes 44

4G H2-Receptor antagonists 44

4H Proton Pump Inhibitors (PPI) 45

4I Topical anti-Inflammatory agents 45

4J Tumor Necrosis Factor (TNF) blocking agents 45

4K Ulcer therapy 46

4L Miscellaneous gastrointestinal agents 46

Obstetrics and gynecology

5A Contraceptives-Biphasic 47

5B Contraceptives-Misc. 47

5C Contraceptives-Monophasic 48

5D Contraceptives-Postcoital 48

5E Contraceptives-Triphasic 48

5F Estrogen and progestin combinations 49

5G Estrogens 49

5H Infertility treatment* 50

5I Progestins 50

5J Vaginal anti-infective and antifungal 50

5K Miscellaneous OB-GYN 51

Page 2

Rheumatology and musculoskeletal

6A Corticosteroids 52

6B Gout therapy 52

6C Non-Tumor Necrosis Factor (TNF) blocking agents 52

6D Osteoporosis and bone resorption 52

6E Osteoporosis and hormonal treatment 53

6F Salicylates 53

6G Tumor Necrosis Factor (TNF) blocking agents 53

6H Miscellaneous rheumatologic agents 53

Endocrinology

7A Androgens 54

7B Antithyroid agents 54

7C Corticosteroids 55

7D Growth Hormone and related products 55

7E Insulins 56

7F Non-insulin hypoglycemic agents 57

7G Somatostatin analogs 58

7H Thyroid hormones 58

7I Urea cycle disorder agents 58

7J Vitamin D analogs 58

7K Miscellaneous endocrine 59

Antineoplastics and immunosuppresants

8A Adjuvant therapy 60

8B Alkylating agents 60

8C Antimetabolites 60

8D Hormonal agents 61

8E Immunomodulators 62

8F Kinase inhibitors and molecular target inhibitors 63

8G Miscellaneous antineoplastic agents 64

Immunology and hematology

9A Hematopoietic agents 65

9B Immunoglobulins 65

9C Interferons and MS therapy 66

9D Miscellaneous immunology and hematology 66

Page 3

Dermatology

10A Acne treatment 67

10B Antipsoriatic and antiseborrheic 68

10C Corticosteroids - very high potency 68

10D Corticosteroids - high potency 69

10E Corticosteroids - medium potency 69

10F Corticosteroids - low potency 70

10G Scabicides and pediculicides 70

10H Topical anesthetics 70

10I Topical antibacterials 71

10J Topical antifungals 71

10K Topical antineoplastic agents and immunomodulators 72

10L Topical antivirals 72

10M Wound and burn therapy 72

10N Miscellaneous dermatologicals 73

Ophthalmology

11A Cycloplegic mydriatics 74

11B Glaucoma agents 74

11C Ophthalmic anti-allergy agents 75

11D Ophthalmic anti-infective and steroid combinations 75

11E Ophthalmic anti-infectives 76

11F Ophthalmic anti-inflammatory agents 76

11G Ophthalmic beta blockers 77

11H Ophthalmic steroids 77

11I Dry eye agents 77

11J Miscellaneous ophthalmic agents 78

Otic and nasal preparations

12A Nasal preparations 79

12B Otic preparations 79

Page 4

Respiratory, cough and cold

13A Antihistamine and decongestant combinations 80

13B Antihistamines 80

13C Antitussives 81

13D Cystic Fibrosis agents 81

13E Epinephrine 81

13F Inhaled anticholinergics 82

13G Inhaled beta-agonist and anticholinergic combinations 82

13H Inhaled beta-agonists 82

13I Inhaled steroid and beta-agonist combinations 83

13J Inhaled steroids 83

13K Intranasal steroids 83

13L Oral beta-agonists 83

13M Pulmonary Hypertension Agents 84

13N Theophyllines 84

13O Miscellaneous respiratory agents 84

Urology

14A BPH Treatment 85

14B Ion-Removing Agents 85

14C Urinary Antispasmodics 86

14D Miscellaneous Urologicals 86

Vitamins and supplements

15A Potassium Replacement 87

15B Vitamins and Minerals 87

Diagnostic and other miscellaneous

16A Chelating Agents 88

16B Diagnostics and Other Miscellaneous 89

16C Vaccines 90

Lifestyle modification

17A Sexual Dysfunction 91

17B Smoking Cessation 91

17C Weight Loss Preparations 91

Hemophilia

18A Antihemophilic Agents 92

Page 5

Blue Cross Clinical Drug List

Blue Cross Blue Shield of Michigan’s Clinical Drug List is a useful reference and educational tool for prescribers, pharmacists and members. We regularly update this list with medications approved by the U.S. Food and Drug Administration and reviewed by our Pharmacy and Therapeutics Committee. The list represents the clinical judgment of Michigan doctors, pharmacists and other experts in the diagnosis and treatment of disease and the promotion of health. The committee selects medications based on safety, clinical effectiveness and opportunity for cost savings. This is how the Clinical Drug List helps maintain quality of care and contain costs for our members.

About this drug list

Use this list to find information about drug coverage and therapeutic options for Blue Cross members. It’s divided by chapter into major drug classes or indication for use. Products approved for more than one use may be included in more than one chapter. Within each chapter, drugs are identified according to their tier placement. Refer to the “How to Read” section for details.

We encourage doctors to prescribe preferred medications whenever possible. Blue Cross respects the judgment of dispensing pharmacists and expects them to contact the prescriber when a drug or dose may not be appropriate for a member. We also encourage pharmacists to contact the prescriber to suggest an alternative when a Blue Cross member’s prescription is written for a nonpreferred or excluded drug.

Coverage and applicable copayments for drugs on the Blue Cross Clinical Drug List are based on a member’s drug plan. Not all drugs included in the drug list are covered by each member’s plan. Drugs not listed on the Clinical Drug List may not be covered.

Some medications excluded by a Blue Cross member’s pharmacy benefits may be covered under his or her medical benefits. These are medications that are generally administered in a doctor’s office under the supervision of appropriate health care personnel and aren’t normally dispensed to the member for self-administration. Drug list exclusions

Our goals are to provide you with safe, high-quality prescription drug therapies and keep your medical costs low. To accomplish this, we don’t cover some high-cost drugs that have comparable therapeutic alternatives with similar effectiveness, quality and safety, but at a fraction of the cost. For the most recent list of excluded drugs, refer to our Drug List Exclusions (PDF). If you have a question about a drug that isn’t covered and doesn’t appear on this list, call the Customer Service number on the back of your Blue Cross member ID card. Several drugs and drug categories are excluded from coverage under this drug list. These include:

• Prescription drugs for which there is an over-the-counter equivalent in both strength and dosage form (unless considered preventive by the United States Preventive Services Task Force)

• Drugs used for experimental or investigational purposes • Drugs prescribed for cosmetic purposes

http://www.bcbsm.com/content/dam/public/Consumer/Documents/help/documents-forms/pharmacy/drug-list-exclusions.pdf

• Products covered as a medical benefit (for example, injectable drugs and vaccines that are usually administered in a doctor’s office)

o Note: Most Blue Cross members can get multiple common vaccines at network retail pharmacies. Restrictions may apply.

• Compounded products, with some exceptions • Replacement prescriptions resulting from loss, theft or mishandling • Drugs not approved by the FDA

Specialty drugs For more information on specialty drugs, see the Specialty Drug Program Pharmacy Benefit Member Guide. Specialty drugs are limited to a 30-day supply. Select specialty drugs are managed by the 15-Day Specialty Drug Limitation Program. Drugs included on this list are limited to a 15-day supply for all fills. Members pay half their usual copayment for a 15-day supply. For more details, visit bcbsm.com/pharmacy.

Preventive drug coverage Under the Affordable Care Act, also known as national health care reform, most health care plans must cover certain preventive services and drugs with no cost-sharing. These drugs appear as a $0 tier on the drug list. For a complete list of preventive drugs and coverage requirements, please refer to Preventive Drug Coverage or visit bcbsm.com/pharmacy. How do I know what type of prescription coverage I have? For details about your prescription drug benefits, please call the Customer Service phone number on the back of your Blue Cross member ID card. If you have online access, log in to your account at bcbsm.com or the Blue Cross mobile app. You can also find general information about Blue Cross prescription coverage at bcbsm.com/pharmacy.

Tier descriptions

• Preferred generics Members pay the lowest copay for generics, making them the most cost-effective option for treatment.

• Preferred brands This tier includes preferred brand-name specialty and nonspecialty drugs.

• Nonpreferred brands This tier includes nonpreferred brand-name specialty and nonspecialty drugs for which there’s a more cost-effective generic alternative or preferred brand-name drug available.

How do I fill my prescription?

The type of drug you take determines which pharmacy you may use.

• Specialty drugs o Local retail pharmacy

Walgreens is our preferred specialty pharmacy. Find a location at walgreens.com/pharmacy/*.

http://www.bcbsm.com/content/dam/public/Consumer/Documents/help/documents-forms/pharmacy/specialty-drug-program-member-guide.pdfhttp://www.bcbsm.com/content/dam/public/Consumer/Documents/help/documents-forms/pharmacy/15-day-specialty-drug-list.pdfhttp://www.bcbsm.com/content/dam/public/Consumer/Documents/help/documents-forms/pharmacy/15-day-specialty-drug-list.pdfhttp://www.bcbsm.com/index/health-insurance-help/faqs/plan-types/pharmacy.htmlhttp://www.bcbsm.com/preventivedruglisthttp://www.bcbsm.com/index/health-insurance-help/faqs/plan-types/pharmacy.htmlhttp://www.bcbsm.com/pharmacy

You can use any retail pharmacy in your applicable network. o Limited-distribution specialty drugs

Pharmacy options vary based on the drug. Refer to the Specialty Drug Program Pharmacy Benefit Member Guide, and search for the drug you take.

o Mail order for home delivery AllianceRx Walgreens Prime** Specialty Pharmacy Website: alliancerxwp.com* Telephone: 1-866-515-1355

• All other drugs o Local retail pharmacy — More than 2,400 retail pharmacies in Michigan and 70,000 retail

pharmacies outside of Michigan accept your member ID card. o Mail order for home delivery

Pharmacy: Express Scripts*** mail order pharmacy Telephone: 1-800-778-0735

If you have questions about which mail-order vendor to use, call the Customer Service number on the back of your Blue Cross member ID card or visit bcbsm.com/pharmacy.

*Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website.

**AllianceRx Walgreens Prime® is an independent company that provides specialty pharmacy benefit management services for Blue Cross.

***Express Scripts® is an independent company that provides pharmacy benefit management services for Blue Cross and BCN.

New generics

When a generic version of a brand-name drug becomes available, the generic version is generally added to Tier 1. The original branded version will move to a nonpreferred tier.

Generic drug substitution Generic drug substitution occurs when a pharmacist dispenses a generic equivalent in place of the brand-name product. Generics approved by the U.S. Food and Drug Administration are listed in the “Generic name” column to the right of the brand-name drug. Generic substitution is required for most Blue Cross members. If both the generic and brand names are listed, the tier number matches the available generic. The brand-name tier is always higher, reflecting the higher copayment when there’s an available generic. Members are encouraged to receive the generic equivalent if available. Some Blue Cross members, depending on their plan, may be required to pay the difference between the cost of the brand-name drug and its generic equivalent, in addition to the applicable brand-name copay, if they opt to not fill their prescription with the generic equivalent.

Authorized generics

Authorized generics are drugs that are considered brand-name drugs and don’t have generic equivalents. These drugs are the same as the brand-name drugs but are not true generic drugs. The respective brand copayment will apply for these medications. Some authorized generics may not be covered. For the most recent list of excluded drugs, refer to our Drug List Exclusions (PDF).

https://www.bcbsm.com/content/dam/public/Consumer/Documents/help/documents-forms/pharmacy/specialty-drug-program-member-guide.pdfhttps://www.bcbsm.com/content/dam/public/Consumer/Documents/help/documents-forms/pharmacy/specialty-drug-program-member-guide.pdfhttp://www.bcbsm.com/content/dam/public/Consumer/Documents/help/documents-forms/pharmacy/drug-list-exclusions.pdf

Vaccines

The following select vaccines are covered at pharmacies without cost-sharing for most members whose pharmacies participate with Blue Cross and are certified to administer vaccines.

Common name Vaccine Age restrictions

Flu Influenza virus None

Hepatitis A Havrix® None

Vaqta® None

Hepatitis A and B Twinrix® None

Hepatitis B

Energix-B® None

Recombivax HB® None

Heplisav-B® None

Human papillomavirus, or HPV Gardasil® 9 9 to 45 years old

Measles, mumps and rubella M-M-R- II® None

Meningitis

Bexsero® None

Menveo® None

Menactra® None

Menomune® None

Trumenba® None

Pneumonia Pneumovax® 23 None

Prevnar 13® 65 and older

Polio Ipol® None

Shingles Shingrix® 50 and older

Tetanus, diphtheria

Tenivac® None

TDVAX® None

Tetanus, diphtheria and whooping cough

Boostrix® None

Adacel® None

Chickenpox Varivax® None

How prior approval, step therapy and quantity limits work Prior approval

Prior approval may be necessary for coverage of certain medications. In these cases, the member must meet clinical criteria or additional information must be provided before coverage is approved. Clinical criteria are based on current medical information and approved by our Pharmacy and Therapeutics Committee.

Step therapy

Drugs subject to step therapy may require previous treatment with one or more preferred drugs before coverage is approved.

To view a current list of drugs requiring prior approval or step therapy, please see the Prior Authorization and Step Therapy Coverage Criteria and refer to the column labeled “Clinical Drug List.”

Quantity limits

Blue Cross sets quantity limits based on clinical appropriateness and manufacturer-recommended dosing for select drugs. For certain medications, Blue Cross limits the quantity that can be dispensed per fill.

To view a current list of drugs that have limits on the quantity that can be dispensed per fill, please see the Blue Cross Quantity Limit Program, and refer to the column labeled “BCBSM Clinical, Custom, Closed Drug Lists.”

How to request approval

For members:

Blue Cross members should consult their prescription drug benefit packet for information on how to get prior approval or request a review for coverage of a drug that isn’t included in their plan. Members can also call the Customer Service number on the back of their Blue Cross member ID card for more information. To request coverage of a drug:

• Fill out the Coverage Request Form online at bcbsm.com. • Write to:

Pharmacy Services — Mail Code 512C Blue Cross Blue Shield of Michigan 600 E. Lafayette Blvd. Detroit, MI 48226-2998

https://www.bcbsm.com/content/dam/public/Consumer/Documents/help/documents-forms/pharmacy/prior-authorization-and-step-therapy-guidelines.pdfhttps://www.bcbsm.com/content/dam/public/Consumer/Documents/help/documents-forms/pharmacy/prior-authorization-and-step-therapy-guidelines.pdfhttp://www.bcbsm.com/content/dam/public/Consumer/Documents/help/documents-forms/pharmacy/quantity-limit-program-drug-list.pdfhttp://www.bcbsm.com/index/health-insurance-help/faqs/plan-types/pharmacy/why-do-i-need-prior-authorization-for-prescription-drug/expedited-request-form.html

For doctors:

Doctors can request approval for Blue Cross and BCN members. We notify the doctor of approved requests and process the member’s claim accordingly. If a request isn’t approved, we’ll notify the member and doctor in writing. The notification includes the reason for the denial, an explanation of the member’s appeal rights and the appeals process.

Physicians can request approval one of four ways:

• Electronic prior authorization: Physicians can use their electronic health record or CoverMyMeds®

to submit electronic prior authorizations for commercial pharmacy members.

• Call: 1-800-437-3803

• Fax: 1-866-601-4425 • Write:

Pharmacy Services — Mail Code 512c Blue Cross Blue Shield of Michigan 600 E Lafayette Blvd. Detroit, MI 48226-2998

https://www.bcbsm.com/content/dam/public/Providers/Documents/help/electronic-prior-authorization-flyer.pdf

How to read the Clinical Drug List

This drug list shows each drug’s copayment status and whether the drug has special requirements for coverage. Drugs are listed alphabetically by brand name within each section. If a generic version is available, the name is included in the “Generic name” column next to the brand name in the “Trade name” column. The brand name is included for informational purposes. If only a brand name is listed, there isn’t a generic version available.

4

1

32

5

7

2

6

1 Drugs are organized based on drug class or

indication for use. 2 The generic drug raloxifene HCl is a

preferred generic drug, and quantity limits apply. Raloxifene is also a preventive drug and may be covered with no cost-sharing for members who meet criteria.

3 The generic drug fulvestrant is a preferred

generic drug and doesn’t have any restrictions on coverage.

4 Erleada is a preferred brand-name specialty

drug (). Prior approval and quantity limits apply.

5 Trelstar is a preferred brand-name specialty

drug () and doesn’t have any restrictions on coverage. The coverage requirements are the same for Trelstar, Trelstar Depot and Trelstar LA. Commas are used throughout

the drug list to indicate different strengths, formulations and dosage forms of the listed drug.

6 Soltamox is a nonpreferred brand-name drug that doesn’t have any restrictions on coverage.

7 Limits: This section lists information, such as prior approval, step therapy and quantity limits.

Prior approval: Plan approval is required for coverage (listed as PA in the chart).

Step therapy: Previous treatment with preferred drugs is required (listed as ST in the chart).

Quantity limits: Prescriptions can’t exceed a specific quantity per fill (listed as QL in the chart).

This document is current at the time of publication and subject to change. Go to bcbsm.com/pharmacy and click on Drug Lists for the most up-to-date information about the Clinical Drug List.

This content was developed to comply with applicable federal and state regulations. To learn more about your plan, go to bcbsm.com and type “How Health Insurance Works” in the search field.

Editor’s note: Please send us your comments and suggestions about the Blue Cross Clinical Drug List. Your input is vital to its continued success. We review and consider all responses. Please send your comments to: Drug Information Services — Mail Code 512C Blue Cross Blue Shield of Michigan 600 E. Lafayette Blvd. Detroit, MI 48226-2998

http://www.bcbsm.com/pharmacyhttp://www.bcbsm.com/index/health-insurance-help/faqs/topics/how-health-insurance-works.html

1. Anti-infectives

1A. Antifungals Trade name Generic name Limits

Preferred Generics Ancobon flucytosine Diflucan fluconazole Grifulvin V griseofulvin, microsize Gris-PEG griseofulvin ultramicrosize Lamisil tablet terbinafine hcl Mycelex Troche clotrimazole Nizoral ketoconazole Noxafil tablet posaconazole QL Nystatin nystatin Sporanox itraconazole Vfend voriconazole

Preferred Brands Cresemba capsule QL Noxafil suspension

Nonpreferred Brands Oravig QL

1B. Antimalarials Trade name Generic name Limits

Preferred Generics Aralen chloroquine phosphate QL Lariam mefloquine hcl Malarone atovaquone/proguanil hcl Plaquenil hydroxychloroquine sulfate QL Primaquine primaquine phosphate Qualaquin quinine sulfate

Preferred Brands Coartem Krintafel QL Primaquine

Nonpreferred Brands Arakoda QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug

ver. 1 Blue Cross Clinical Drug List - January 2021 Page 14

1C. Antiparasitics and antihelmintics Trade name Generic name Limits

Preferred Generics Albenza albendazole QL Alinia nitazoxanide Biltricide praziquantel Daraprim pyrimethamine PA Flagyl metronidazole Humatin paromomycin sulfate Mepron atovaquone Nebupent aerosol pentamidine isethionate Stromectol ivermectin Tindamax tinidazole

Preferred Brands Alinia suspension Benznidazole QL Impavido QL Mepron blister pak

Nonpreferred Brands Emverm QL Lampit QL



1D. Antiretrovirals Trade name Generic name Limits

Preventive Drugs Truvada 200mg/300mg emtricitabine/tenofovir (tdf) PA, QL

Preferred Generics Atripla efavirenz/emtricit/tenofovr df Combivir lamivudine/zidovudine Emtriva emtricitabine Epivir lamivudine Epzicom abacavir sulfate/lamivudine Kaletra lopinavir/ritonavir Lexiva fosamprenavir calcium Norvir ritonavir Retrovir zidovudine Reyataz atazanavir sulfate Sustiva efavirenz Symfi, Lo efavirenz/lamivu/tenofov disop QL Truvada emtricitabine/tenofovir (tdf) QL Viramune, XR nevirapine Viread tenofovir disoproxil fumarate Ziagen abacavir sulfate

Preferred Brands Aptivus Biktarvy QL Cimduo QL Complera QL Delstrigo QL Descovy ST, QL Dovato QL Edurant QL Emtriva solution Evotaz QL Fuzeon Genvoya QL Intelence Invirase Isentress Isentress HD Juluca QL Kaletra tablet Lexiva suspension Norvir solution, packet Odefsey QL Pifeltro QL Prezcobix QL Prezista Reyataz packet Rukobia PA, QL Selzentry Stribild QL Symtuza QL Temixys QL Tivicay Tivicay PD QL Triumeq QL Truvada 100/150mg, 133/200mg, 167/250mg QL



1D. Antiretrovirals (Continued) Trade name Generic name Limits

Tybost QL Vemlidy QL Viread 150mg, 200mg, 250mg tablet; powder

1E. Antituberculars Trade name Generic name Limits

Preferred Generics Ethambutol ethambutol hcl Isoniazid isoniazid Mycobutin rifabutin Pyrazinamide pyrazinamide Rifadin rifampin

Preferred Brands Cycloserine Pretomanid QL Sirturo PA, QL

Nonpreferred Brands Paser Priftin Rifamate Rifater Trecator



1F. Antivirals Trade name Generic name Limits

Preferred Generics Acyclovir acyclovir Baraclude entecavir Copegus ribavirin Epivir HBV lamivudine Famvir famciclovir Flumadine rimantadine hcl Hepsera adefovir dipivoxil Rebetol ribavirin Symmetrel amantadine hcl Tamiflu oseltamivir phosphate QL Valcyte valganciclovir hcl Valtrex valacyclovir hcl Zovirax capsule, suspension, tablet acyclovir

Preferred Brands Baraclude solution Epclusa PA, QL Epivir HBV solution Ledipasvir-sofosbuvir 90mg/400mg tablet (authorized generic of Harvoni)

PA, QL

Relenza QL Sofosbuvir-velpatasvir (authorized generic of Epclusa)

PA, QL

Zepatier PA, QL Nonpreferred Brands

Harvoni PA, QL Mavyret PA, QL Prevymis tablet QL Sitavig ST, QL Sovaldi PA, QL Vosevi PA, QL Xofluza QL

1G. Cephalosporins Trade name Generic name Limits

Preferred Generics Ceclor, ER cefaclor Ceftin cefuroxime axetil Cefzil cefprozil Duricef cefadroxil Keflex cephalexin Omnicef cefdinir Spectracef cefditoren pivoxil Suprax cefixime Vantin cefpodoxime proxetil

Nonpreferred Brands Suprax chew tablet, 500mg/5ml suspension



1H. Macrolides Trade name Generic name Limits

Preferred Generics Biaxin, XL clarithromycin E.E.S.; Eryped erythromycin ethylsuccinate Ery-tab erythromycin base Erythromycin Base erythromycin base Erythromycin Stearate erythromycin stearate Zithromax azithromycin

Nonpreferred Brands Dificid QL

1I. Penicillins Trade name Generic name Limits

Preferred Generics Amoxil amoxicillin Ampicillin ampicillin trihydrate Augmentin, ES, XR amoxicillin/potassium clav Dicloxacillin dicloxacillin sodium Penicillin VK penicillin v potassium

Preferred Brands Augmentin 125mg-31.25mg/ml suspension

Nonpreferred Brands Moxatag

1J. Quinolones Trade name Generic name Limits

Preferred Generics Avelox moxifloxacin hcl Cipro suspension ciprofloxacin Cipro tablet ciprofloxacin hcl Floxin tablet ofloxacin Levaquin levofloxacin

Nonpreferred Brands Baxdela tablet Factive

1K. Sulfonamides and combinations Trade name Generic name Limits

Preferred Generics Bactrim, DS; Septra, DS sulfamethoxazole/trimethoprim Sulfadiazine sulfadiazine



1L. Tetracyclines Trade name Generic name Limits

Preferred Generics Adoxa capsule doxycycline monohydrate PA Adoxa tablet doxycycline monohydrate Avidoxy 100mg doxycycline monohydrate Declomycin demeclocycline hcl Doryx doxycycline hyclate PA Dynacin minocycline hcl Minocin minocycline hcl Monodox doxycycline monohydrate Periostat doxycycline hyclate Tetracycline tetracycline hcl Vibramycin doxycycline hyclate Vibramycin suspension doxycycline monohydrate

Nonpreferred Brands Doryx MPC PA Doxycycline IR-DR (authorized generic of Oracea) PA Nuzyra tablet QL Oracea PA Vibramycin syrup

1M. Urinary tract agents Trade name Generic name Limits

Preferred Generics Furadantin nitrofurantoin Hiprex/Urex methenamine hippurate Macrobid nitrofurantoin monohyd/m-cryst Macrodantin nitrofurantoin macrocrystal Monurol fosfomycin tromethamine Trimethoprim trimethoprim

Nonpreferred Brands Primsol



-1N. Miscellaneous anti infectives Trade name Generic name Limits

Preferred Generics Bethkis tobramycin PA, QL Cleocin capsule clindamycin hcl Cleocin solution clindamycin palmitate hcl Dapsone dapsone Firvanq vancomycin hcl QL Neomycin neomycin sulfate Peridex chlorhexidine gluconate Tobi tobramycin in 0.225% sod chlor QL Vancocin vancomycin hcl Zyvox linezolid

Preferred Brands Arikayce PA, QL Sivextro QL Xifaxan 200mg QL

Nonpreferred Brands Aemcolo QL Cayston PA, QL Firvanq 25mg/mL QL Tobi Podhaler PA, QL Xenleta tablet QL



-

-

2. Cardiovascular, hypertension, cholesterol

2A. ACE Inhibitors and combinations Trade name Generic name Limits

Preferred Generics Accupril quinapril hcl Accuretic quinapril/hydrochlorothiazide Aceon perindopril erbumine Altace ramipril Capoten captopril Capozide captopril/hydrochlorothiazide Lotensin benazepril hcl Lotensin HCT benazepril/hydrochlorothiazide Lotrel amlodipine besylate/benazepril Mavik trandolapril Monopril fosinopril sodium Monopril HCT fosinopril/hydrochlorothiazide Prinivil; Zestril lisinopril Prinzide; Zestoretic lisinopril/hydrochlorothiazide Tarka trandolapril/verapamil hcl Univasc moexipril hcl Vaseretic enalapril/hydrochlorothiazide Vasotec enalapril maleate

Nonpreferred Brands Epaned Prestalia QL Qbrelis QL

2B. Alpha adrenergic agents Trade name Generic name Limits

Preferred Generics Aldomet methyldopa Aldoril methyldopa/hydrochlorothiazide Cardura doxazosin mesylate Catapres clonidine hcl Catapres-TTS clonidine Dibenzyline phenoxybenzamine hcl PA, QL Hytrin terazosin hcl Minipress prazosin hcl Tenex guanfacine hcl



2C. Angiotensin II Receptor Blockers and combinations Trade name Generic name Limits

Preferred Generics Atacand candesartan cilexetil Atacand HCT candesartan/hydrochlorothiazid Avalide irbesartan/hydrochlorothiazide Avapro irbesartan Azor amlodipine bes/olmesartan med Benicar olmesartan medoxomil Benicar HCT olmesartan/hydrochlorothiazide Cozaar losartan potassium Diovan valsartan Diovan HCT valsartan/hydrochlorothiazide Exforge amlodipine besylate/valsartan Exforge HCT amlodipine/valsartan/hcthiazid Hyzaar losartan/hydrochlorothiazide Micardis telmisartan Micardis HCT telmisartan/hydrochlorothiazid Teveten eprosartan mesylate Tribenzor olmesartan/amlodipin/hcthiazid QL Twynsta telmisartan/amlodipine

Preferred Brands Entresto QL

Nonpreferred Brands Edarbi QL Edarbyclor QL



2D. Anticoagulants and hemostasis agents Trade name Generic name Limits

Preferred Generics Aggrenox aspirin/dipyridamole Agrylin anagrelide hcl Amicar aminocaproic acid Arixtra fondaparinux sodium Coumadin warfarin sodium Effient prasugrel hcl QL Heparin heparin sodium,porcine/pf Heparin heparin sodium,porcine Lovenox enoxaparin sodium Mephyton phytonadione (vit k1) Persantine dipyridamole Plavix clopidogrel bisulfate Pletal cilostazol Trental pentoxifylline Vitamin K ampule phytonadione (vit k1)

Preferred Brands Brilinta QL Cablivi PA, QL Eliquis QL Xarelto, starter kit QL

Nonpreferred Brands Fragmin Pradaxa QL Savaysa QL Zontivity QL



2E. Beta blockers and combinations Trade name Generic name Limits

Preferred Generics Betapace, AF sotalol hcl Blocadren timolol maleate Coreg CR carvedilol phosphate QL Coreg immediate-release carvedilol Corgard nadolol Corzide nadolol/bendroflumethiazide Inderal, LA propranolol hcl Inderide propranolol/hydrochlorothiazid Kerlone betaxolol hcl Lopressor metoprolol tartrate Lopressor HCT metoprolol/hydrochlorothiazide Normodyne labetalol hcl Sectral acebutolol hcl Tenoretic atenolol/chlorthalidone Tenormin atenolol Toprol XL metoprolol succinate Visken pindolol Zebeta bisoprolol fumarate Ziac bisoprolol/hydrochlorothiazide

Preferred Brands Bystolic ST, QL

Nonpreferred Brands Dutoprol Hemangeol QL Sotylize



2F. Calcium channel blockers and combinations Trade name Generic name Limits

Preferred Generics Adalat CC; Procardia, XL nifedipine Azor amlodipine bes/olmesartan med Caduet amlodipine/atorvastatin QL Calan SR; Isoptin SR verapamil hcl Cardene nicardipine hcl Cardizem, CD, LA, SR diltiazem hcl Dynacirc isradipine Exforge amlodipine besylate/valsartan Exforge HCT amlodipine/valsartan/hcthiazid Lotrel amlodipine besylate/benazepril Norvasc amlodipine besylate Plendil felodipine Sular nisoldipine Tarka trandolapril/verapamil hcl Tiazac diltiazem hcl Tribenzor olmesartan/amlodipin/hcthiazid QL Twynsta telmisartan/amlodipine Verelan, PM verapamil hcl

Nonpreferred Brands Cardizem LA 120mg Katerzia QL Prestalia QL

2G. Cardiovascular treatment Trade name Generic name Limits

Preferred Generics Betapace, AF sotalol hcl Cordarone; Pacerone amiodarone hcl Lanoxin digoxin Mexitil mexiletine hcl Norpace disopyramide phosphate Proamatine midodrine hcl Quinidex quinidine sulfate Quinidine Gluconate SA quinidine gluconate Ranexa ranolazine Rythmol, SR propafenone hcl Tambocor flecainide acetate Tikosyn dofetilide

Preferred Brands Corlanor QL Multaq QL Norpace CR Vyndamax PA, QL Vyndaqel PA, QL

Nonpreferred Brands Lanoxin 62.5mcg, 187.5mcg Northera PA, QL Sotylize



2H. Diuretics Trade name Generic name Limits

Preferred Generics Aldactazide spironolact/hydrochlorothiazid Aldactone spironolactone Bumex bumetanide Demadex torsemide Diamox, Sequels acetazolamide Diuril chlorothiazide Dyazide; Maxzide triamterene/hydrochlorothiazid Dyrenium triamterene Edecrin ethacrynic acid Hydrodiuril; Microzide hydrochlorothiazide Hygroton; Thalitone chlorthalidone Inspra eplerenone Lasix furosemide Lozol indapamide Midamor amiloride hcl Moduretic amiloride/hydrochlorothiazide Zaroxolyn metolazone

Nonpreferred Brands Aldactazide 50/50mg Carospir Diuril suspension



-2I. Lipid lowering agents Trade name Generic name Limits

Preventive Drugs Crestor* 5mg, 10mg rosuvastatin calcium QL Lescol, XL* (all strengths) fluvastatin sodium QL Lipitor* 10mg, 20mg atorvastatin calcium QL Mevacor* (all strengths) lovastatin QL Pravachol* (all strengths) pravastatin sodium QL Zocor* 5mg, 10mg, 20mg, 40mg simvastatin QL

Preferred Generics Antara fenofibrate,micronized Caduet amlodipine/atorvastatin QL Colestid colestipol hcl Crestor rosuvastatin calcium QL Fenoglide fenofibrate Lescol, XL fluvastatin sodium QL Lipitor atorvastatin calcium QL Lofibra capsule fenofibrate,micronized Lofibra tablet fenofibrate Lopid gemfibrozil Lovaza omega-3 acid ethyl esters QL Mevacor lovastatin QL Niaspan niacin Pravachol pravastatin sodium QL Questran cholestyramine (with sugar) Questran Light cholestyramine/aspartame Tricor fenofibrate nanocrystallized Trilipix fenofibric acid (choline) Vascepa icosapent ethyl QL Vytorin ezetimibe/simvastatin QL Welchol colesevelam hcl Zetia ezetimibe QL Zocor simvastatin QL

Preferred Brands Lipofen Nexletol PA, QL Nexlizet PA, QL Praluent PA, QL Repatha PA, QL Vascepa QL

Nonpreferred Brands Antara 30mg, 90mg Colestid granules, packet Fenofibrate capsule (authorized generic of Lipofen) Juxtapid PA, QL Livalo QL

*Age restrictions apply.



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2J. Nitrates and combinations Trade name Generic name Limits

Preferred Generics Imdur; Ismo; Monoket isosorbide mononitrate Isordil isosorbide dinitrate Nitro-bid ointment nitroglycerin Nitro-Dur nitroglycerin Nitroglycerin capsule, patch nitroglycerin Nitrostat nitroglycerin

Preferred Brands Bidil Dilatrate-SR

Nonpreferred Brands GoNitro Minitran

2K. Renin inhibitors and combinations Trade name Generic name Limits

Preferred Generics Tekturna aliskiren hemifumarate

Nonpreferred Brands Tekturna HCT

2L. Miscellaneous antihypertensives Trade name Generic name Limits

Preferred Generics Apresoline hydralazine hcl Demser metyrosine Loniten minoxidil

Nonpreferred Brands Vecamyl PA, QL



3. Central nervous system

3A. Alzheimer's therapy Trade name Generic name Limits

Preferred Generics Aricept 23mg donepezil hcl QL Aricept 5, 10mg; ODT donepezil hcl Exelon capsule rivastigmine tartrate Exelon patch rivastigmine Namenda memantine hcl Namenda XR memantine hcl QL Razadyne, ER galantamine hbr

Preferred Brands Memantine hcl (authorized generic of Namenda dose pack)

QL

Namenda dose pack QL Nonpreferred Brands

Namenda XR dose pack QL Namzaric ST, QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met


3B. Anticonvulsants Trade name Generic name Limits

Preferred Generics Banzel suspension rufinamide Carbatrol carbamazepine Depakene capsule valproic acid Depakene solution valproic acid (as sodium salt) Depakote, ER, Sprinkles divalproex sodium Diamox, Sequels acetazolamide Diastat 2.5mg diazepam Diastat Acudial diazepam Dilantin phenytoin Dilantin; Phenytek capsule phenytoin sodium extended Felbatol felbamate Gabitril tiagabine hcl Keppra, XR levetiracetam Klonopin, Wafer clonazepam Lamictal ODT, XR lamotrigine Lamictal, dispertabs lamotrigine Lyrica pregabalin QL Mysoline primidone Neurontin gabapentin Onfi clobazam QL Phenobarbital phenobarbital Sabril vigabatrin PA, QL Tegretol, XR carbamazepine Topamax, Sprinkle topiramate Trileptal oxcarbazepine Zarontin ethosuximide Zonegran zonisamide

Preferred Brands Banzel tablet PA, QL Dilantin 30mg capsule Nayzilam QL Valtoco QL Vimpat solution Vimpat tablet PA, QL

Nonpreferred Brands Acthar H.P. PA, QL Aptiom PA, QL Briviact PA, QL Celontin Diacomit PA, QL Epidiolex PA, QL Equetro Fintepla PA, QL Fycompa QL Lamictal XR dose pack Lyrica CR PA, QL Oxtellar XR PA, QL Qudexy XR PA, QL Spritam PA, QL Sympazan PA, QL Topiramate ER (authorized generic of Qudexy XR) PA, QL Trokendi XR PA, QL



3B. Anticonvulsants (Continued) Trade name Generic name Limits

Xcopri PA, QL

3C. Antidepressants Trade name Generic name Limits

Preferred Generics Adapin; Sinequan doxepin hcl Amoxapine amoxapine Anafranil clomipramine hcl Aventyl; Pamelor nortriptyline hcl Celexa citalopram hydrobromide Cymbalta duloxetine hcl Desyrel trazodone hcl Effexor, XR; Venlafaxine hcl ER venlafaxine hcl Elavil amitriptyline hcl Etrafon perphenazine/amitriptyline hcl Fluoxetine 60mg fluoxetine hcl QL Irenka duloxetine hcl Lexapro escitalopram oxalate Limbitrol, DS amitriptyline/chlordiazepoxide Luvox, CR fluvoxamine maleate Maprotiline hcl maprotiline hcl Nardil phenelzine sulfate Norpramin desipramine hcl Parnate tranylcypromine sulfate Paxil, CR paroxetine hcl Pristiq desvenlafaxine succinate Prozac fluoxetine hcl Prozac weekly fluoxetine hcl QL Remeron mirtazapine Serzone nefazodone hcl Surmontil trimipramine maleate Tofranil imipramine hcl Tofranil-PM imipramine pamoate Vivactil protriptyline hcl Wellbutrin, SR, XL bupropion hcl Zoloft sertraline hcl

Nonpreferred Brands Desvenlafaxine ER ST, QL Emsam PA, QL Fetzima ST, QL Marplan Paxil suspension Pexeva ST, QL Trintellix ST, QL Viibryd, dose pack ST, QL



3D. Antipsychotics Trade name Generic name Limits

Preferred Generics Abilify aripiprazole Clozaril clozapine Etrafon perphenazine/amitriptyline hcl Fazaclo clozapine Fluphenazine decanoate fluphenazine decanoate Fluphenazine liquid fluphenazine hcl Geodon ziprasidone hcl Haldol decanoate haloperidol decanoate Haldol liquid haloperidol lactate Haldol tablet haloperidol Invega paliperidone QL Loxitane loxapine succinate Mellaril thioridazine hcl Molindone molindone hcl QL Navane thiothixene Orap pimozide Perphenazine perphenazine Prolixin fluphenazine hcl Risperdal, M-Tab risperidone Seroquel quetiapine fumarate Seroquel XR quetiapine fumarate QL Stelazine trifluoperazine hcl Symbyax olanzapine/fluoxetine hcl Thorazine chlorpromazine hcl Zyprexa, Zydis olanzapine

Preferred Brands Abilify Maintena Aristada QL Aristada Initio Invega Sustenna Invega Trinza QL Perseris QL Risperdal Consta Zyprexa Relprevv

Nonpreferred Brands Caplyta ST, QL Clozapine ODT 150mg (authorized generic of Fazaclo) Fanapt ST Latuda ST Nuplazid PA, QL Rexulti ST, QL Saphris ST, QL Secuado ST, QL Versacloz Vraylar ST, QL



3E. Anxiolytics Trade name Generic name Limits

Preferred Generics Ativan lorazepam Buspar buspirone hcl Equanil; Miltown meprobamate Librium chlordiazepoxide hcl Lorazepam intensol lorazepam Niravam alprazolam Serax oxazepam Tranxene T-Tab clorazepate dipotassium Valium diazepam Xanax, XR alprazolam

3F. CNS stimulants Trade name Generic name Limits

Preferred Generics Adderall, XR dextroamphetamine/amphetamine QL Aptensio XR methylphenidate hcl QL Concerta methylphenidate hcl QL Desoxyn methamphetamine hcl QL Dexedrine dextroamphetamine sulfate QL Evekeo amphetamine sulfate PA, QL Focalin, XR dexmethylphenidate hcl QL Metadate CD methylphenidate hcl QL Methylin, ER methylphenidate hcl QL Nuvigil armodafinil QL Procentra dextroamphetamine sulfate QL Provigil modafinil QL Ritalin, LA, SR methylphenidate hcl QL

Preferred Brands Daytrana QL Mydayis QL Vyvanse QL

Nonpreferred Brands Adzenys ER PA, QL Adzenys XR-ODT PA, QL Amphetamine ER suspension (authorized generic of Adzenys ER)

PA, QL

Dyanavel XR PA, QL Jornay PM PA, QL Methylphenidate ER 72mg QL Quillichew ER PA, QL Quillivant XR PA, QL Relexxii QL Zenzedi QL



3G. Migraine therapy Trade name Generic name Limits

Preferred Generics Alsuma sumatriptan succinate QL Amerge naratriptan hcl QL Axert almotriptan malate ST, QL Cafergot ergotamine tartrate/caffeine D.H.E.45 dihydroergotamine mesylate Esgic; Fioricet butalb/acetaminophen/caffeine Fioricet w/codeine butalbit/acetamin/caff/codeine QL Fiorinal butalbital/aspirin/caffeine Fiorinal w/codeine codeine/butalbital/asa/caffein QL Frova frovatriptan succinate ST, QL Imitrex sumatriptan succinate QL Imitrex nasal spray sumatriptan QL Maxalt, MLT rizatriptan benzoate QL Migranal dihydroergotamine mesylate QL Phrenilin 50mg/325mg butalbital/acetaminophen Relpax eletriptan hydrobromide ST, QL Treximet sumatriptan succ/naproxen sod PA, QL Zomig, ZMT zolmitriptan QL

Preferred Brands Aimovig PA, QL Ajovy PA, QL Emgality PA, QL Ergomar

Nonpreferred Brands Nurtec ODT PA, QL Onzetra Xsail ST, QL Reyvow PA, QL Ubrelvy PA, QL Zembrace Symtouch ST, QL Zomig nasal spray ST, QL

3H. Myasthenia gravis Trade name Generic name Limits

Preferred Generics Mestinon, Timespan pyridostigmine bromide

3I. Narcotic antagonists and withdrawal management Trade name Generic name Limits

Preferred Generics Naloxone hcl injection naloxone hcl Revia naltrexone hcl

Preferred Brands Lucemyra QL Narcan nasal spray QL



3J. Narcotic mixed agonist and antagonist Trade name Generic name Limits

Preferred Generics Butrans buprenorphine QL Ryzolt tramadol hcl QL Stadol NS butorphanol tartrate QL Suboxone buprenorphine hcl/naloxone hcl QL Subutex buprenorphine hcl QL Talwin NX pentazocine hcl/naloxone hcl QL Ultracet tramadol hcl/acetaminophen QL Ultram, ER tramadol hcl QL

Preferred Brands Zubsolv QL

Nonpreferred Brands Belbuca PA, QL Bunavail QL Tramadol 100mg QL

3K. Narcotic and analgesic combinations Trade name Generic name Limits

Preferred Generics Combunox ibuprofen/oxycodone hcl QL Esgic; Fioricet butalb/acetaminophen/caffeine Fioricet w/codeine butalbit/acetamin/caff/codeine QL Fiorinal butalbital/aspirin/caffeine Fiorinal w/codeine codeine/butalbital/asa/caffein QL Hycet hydrocodone/acetaminophen QL Ibudone hydrocodone/ibuprofen QL Norco; Vicodin; Xodol hydrocodone/acetaminophen QL Percocet oxycodone hcl/acetaminophen QL Percodan oxycodone hcl/aspirin QL Phrenilin 50mg/325mg butalbital/acetaminophen Trezix acetaminophen/caff/dihydrocod QL Tylenol w/codeine acetaminophen with codeine QL Vicoprofen hydrocodone/ibuprofen QL

Nonpreferred Brands Lortab solution QL Trezix QL



3L. Narcotics Trade name Generic name Limits

Preferred Generics Actiq fentanyl citrate PA, QL Avinza morphine sulfate QL Belladonna & Opium opium/belladonna alkaloids QL Codeine sulfate tablet codeine sulfate QL Demerol meperidine hcl QL Dilaudid hydromorphone hcl QL Duragesic fentanyl QL Exalgo hydromorphone hcl PA, QL Kadian morphine sulfate QL Levorphanol Tartrate levorphanol tartrate PA, QL Methadone methadone hcl QL MS Contin morphine sulfate QL MSIR morphine sulfate QL Nubain nalbuphine hcl QL Opana oxymorphone hcl QL Opana ER oxymorphone hcl PA, QL Oxycodone immediate release, solution oxycodone hcl QL RMS Suppository morphine sulfate QL Roxanol morphine sulfate QL Zohydro ER hydrocodone bitartrate PA, QL

Preferred Brands Nucynta PA, QL Oxycontin PA, QL

Nonpreferred Brands Fentanyl buccal tablet (authorized generic of Fentora) PA, QL Fentora PA, QL Hysingla ER PA, QL Kadian 200mg QL Levorphanol Tartrate 3mg PA, QL Nucynta ER PA, QL Oxycodone hcl ER (authorized generic of Oxycontin) PA, QL Subsys PA, QL



-3M. Nonsteroidal anti inflammatory drugs Trade name Generic name Limits

Preferred Generics Anaprox, DS naproxen sodium Ansaid flurbiprofen Arthrotec diclofenac sodium/misoprostol Cataflam diclofenac potassium Celebrex celecoxib Clinoril sulindac Daypro oxaprozin EC-Naprosyn naproxen Feldene piroxicam Indocin, SR indomethacin Ketoprofen (except 25mg) ketoprofen Ketoprofen 25mg ketoprofen PA, QL Lodine, XL etodolac Meclomen meclofenamate sodium Mobic meloxicam Motrin (Rx Only) ibuprofen Nalfon fenoprofen calcium QL Naprosyn (Rx Only) naproxen Pennsaid 1.5% diclofenac sodium Ponstel mefenamic acid Relafen nabumetone Tolectin, DS tolmetin sodium Toradol injection ketorolac tromethamine Toradol tablet ketorolac tromethamine QL Voltaren gel diclofenac sodium QL Voltaren, XR diclofenac sodium

Nonpreferred Brands Diclofenac 35mg capsule (authorized generic of Zorvolex 35mg)

PA, QL

Diclofenac epolamine (authorized generic of Flector patch)

PA, QL

Fenoprofen calcium 200mg (authorized generic of Fenortho 200mg)

PA, QL

Fenoprofen calcium 400mg (authorized generic of Nalfon 400mg)

PA, QL

Fenortho PA, QL Indocin suppository QL Indomethacin 20mg (authorized generic of Tivorbex 20mg)

ST, QL

Nalfon 400mg PA, QL Pennsaid 2% ST, QL Tivorbex ST, QL Vivlodex PA, QL Zipsor PA, QL Zorvolex PA, QL



3N. Parkinsons disease and related disorders Trade name Generic name Limits

Preferred Generics Artane trihexyphenidyl hcl Azilect rasagiline mesylate Cogentin benztropine mesylate Comtan entacapone Eldepryl selegiline hcl Lodosyn carbidopa Mirapex ER pramipexole di-hcl QL Mirapex immediate-release pramipexole di-hcl Parcopa carbidopa/levodopa Parlodel bromocriptine mesylate Requip, XL ropinirole hcl Sinemet, CR carbidopa/levodopa Stalevo carbidopa/levodopa/entacapone Symmetrel amantadine hcl Tasmar tolcapone

Preferred Brands Apokyn PA, QL Duopa PA, QL Kynmobi PA, QL

Nonpreferred Brands Inbrija PA, QL Neupro PA, QL Nourianz PA, QL Nuplazid PA, QL Ongentys PA, QL Rytary ST, QL Xadago QL Zelapar QL

3O. Salicylates Trade name Generic name Limits

Preventive Drugs Aspirin; Ecotrin 81mg, 325mg* (OTC) aspirin

Preferred Generics Disalcid salsalate Dolobid diflunisal




3P. Sedative and hypnotics Trade name Generic name Limits

Preferred Generics Ambien, CR zolpidem tartrate QL Dalmane flurazepam hcl QL Halcion triazolam QL Intermezzo zolpidem tartrate PA, QL Lunesta eszopiclone QL Prosom estazolam QL Restoril temazepam QL Rozerem ramelteon QL Seconal secobarbital sodium Silenor doxepin hcl ST, QL Sonata zaleplon QL Versed syrup midazolam hcl

Nonpreferred Brands Belsomra ST, QL Dayvigo ST, QL Edluar ST, QL Hetlioz PA, QL

3Q. Skeletal muscle relaxants Trade name Generic name Limits

Preferred Generics Baclofen baclofen Dantrium dantrolene sodium Fexmid cyclobenzaprine hcl Flexeril cyclobenzaprine hcl Norflex orphenadrine citrate Parafon Forte DSC 500mg chlorzoxazone Robaxin methocarbamol Skelaxin metaxalone Valium diazepam Zanaflex tizanidine hcl

Nonpreferred Brands Ozobax PA, QL



3R. Miscellaneous CNS Trade name Generic name Limits

Preferred Generics Antabuse disulfiram Cafcit caffeine citrate Campral acamprosate calcium Ergoloid Mesylates ergoloid mesylates Eskalith, CR; Lithobid lithium carbonate Guanidine hcl guanidine hcl Intuniv guanfacine hcl QL Kapvay clonidine hcl QL Lithium Citrate lithium citrate Nimotop nimodipine Rilutek riluzole Strattera atomoxetine hcl QL Xenazine tetrabenazine PA, QL

Preferred Brands Austedo PA, QL Enspryng PA, QL Evrysdi PA, QL Nuedexta PA, QL Ruzurgi PA, QL Tegsedi PA, QL

Nonpreferred Brands Cuvposa Gralise PA, QL Horizant PA, QL Ingrezza PA, QL Nymalize QL Savella PA, QL Sunosi PA, QL Tiglutik PA, QL Wakix PA, QL Xyrem PA, QL Xywav PA, QL



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4. Gastrointestinal agents

4A. 5 Aminosalicylic Acid (5 ASA) agents Trade name Generic name Limits

Preferred Generics Apriso mesalamine Asacol HD mesalamine Azulfidine, EN-tab sulfasalazine Canasa mesalamine Colazal balsalazide disodium Delzicol mesalamine Lialda mesalamine SfRowasa enema mesalamine

Preferred Brands Pentasa

Nonpreferred Brands Dipentum

4B. Antidiarrheals and antispasmodics Trade name Generic name Limits

Preferred Generics Bentyl dicyclomine hcl Imodium loperamide hcl Levbid hyoscyamine sulfate Levsin, SL hyoscyamine sulfate Librax chlordiazepoxide/clidinium br Lomotil diphenoxylate hcl/atropine

Preferred Brands Mytesi PA, QL

Nonpreferred Brands Motofen



4C. Antiemetics Trade name Generic name Limits

Preferred Generics Antivert meclizine hcl Compazine suppository prochlorperazine Compazine tablet prochlorperazine maleate Diclegis doxylamine succinate/vit b6 PA, QL Emend aprepitant QL Kytril granisetron hcl QL Marinol dronabinol Phenergan promethazine hcl Tigan trimethobenzamide hcl Transderm-Scop scopolamine Zofran ondansetron hcl QL Zofran ODT ondansetron QL

Preferred Brands Emend suspension QL

Nonpreferred Brands Akynzeo PA, QL Bonjesta PA, QL Cesamet Sancuso PA, QL Syndros Varubi tablet PA, QL

4D. Bile acids Trade name Generic name Limits

Preferred Generics Actigall ursodiol Urso; Forte ursodiol

Preferred Brands Ocaliva PA, QL

Nonpreferred Brands Chenodal PA



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4E. Bowel preparation and cleansing agents Trade name Generic name Limits

Preventive Drugs Bisacodyl OTC* bisacodyl QL Citrate of Magnesia OTC* magnesium citrate QL Colyte* peg3350/sod sulf,bicarb,cl/kcl QL Glycolax OTC * polyethylene glycol 3350 QL Golytely* peg3350/sod sulf,bicarb,cl/kcl QL Halflytely-Bisacodyl * bisac/nacl/nahco3/kcl/peg 3350 QL Milk of Magnesia OTC* magnesium hydroxide QL Moviprep* peg3350/sod sul/nacl/kcl/asb/c QL Nulytely* sodium chloride/nahco3/kcl/peg QL Oral Saline Laxative liquid OTC* sodium phosphate,mono-dibasic QL Peg-Prep* bisac/nacl/nahco3/kcl/peg 3350 QL

Preferred Generics Colyte peg3350/sod sulf,bicarb,cl/kcl Golytely peg3350/sod sulf,bicarb,cl/kcl Moviprep peg3350/sod sul/nacl/kcl/asb/c Nulytely sodium chloride/nahco3/kcl/peg Peg-Prep bisac/nacl/nahco3/kcl/peg 3350

Preferred Brands Golytely flavored Suprep

Nonpreferred Brands Clenpiq Nulytely Osmoprep Plenvu


4F. Digestive enzymes Trade name Generic name Limits

Preferred Brands Creon Viokace Zenpep

Nonpreferred Brands Pancreaze Pertzye

4G. H2 Receptor antagonists Trade name Generic name Limits

Preferred Generics Axid (Rx only) nizatidine Pepcid (Rx Only) famotidine Tagamet (Rx only) cimetidine Tagamet liquid (Rx only) cimetidine hcl



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4H. Proton Pump Inhibitors (PPI) Trade name Generic name Limits

Preferred Generics Aciphex tablet rabeprazole sodium Nexium esomeprazole magnesium Nexium suspension esomeprazole magnesium ST Prevacid capsule (Rx Only) lansoprazole Prevacid Solutab lansoprazole Prilosec capsule (Rx Only) omeprazole Protonix pantoprazole sodium

Nonpreferred Brands Aciphex Sprinkle ST, QL Dexilant ST Nexium 2.5mg, 5mg suspension ST Prilosec suspension

4I. Topical anti Inflammatory agents Trade name Generic name Limits

Preferred Generics Analpram-HC hydrocortisone/pramoxine Anamantle HC, Forte; Kit lidocaine/hydrocortisone ac Cortenema hydrocortisone Pramosone hydrocortisone/pramoxine Proctocort hydrocortisone Proctocort suppository hydrocortisone acetate Procto-pak hydrocortisone Proctosol-HC suppository hydrocortisone acetate

Preferred Brands Analpram-HC 1-1% cream Epifoam Pramosone lotion Proctofoam-HC

Nonpreferred Brands Cortifoam Pramosone cream, ointment Uceris foam ST

4J. Tumor Necrosis Factor (TNF) blocking agents Trade name Generic name Limits

Preferred Brands Cimzia syringe PA, QL Humira PA, QL

Nonpreferred Brands Simponi PA, QL



4K. Ulcer therapy Trade name Generic name Limits

Preferred Generics Carafate sucralfate Cytotec misoprostol Pamine, Forte methscopolamine bromide Prevpac lansoprazole/amoxiciln/clarith Pro-Banthine propantheline bromide Robinul tablet, Forte glycopyrrolate

Nonpreferred Brands Omeclamox-pak Talicia QL

4L. Miscellaneous gastrointestinal agents Trade name Generic name Limits

Preferred Generics Evoxac cevimeline hcl Gastrocrom cromolyn sodium Lactulose lactulose Lotronex alosetron hcl QL Metozolv ODT metoclopramide hcl Reglan metoclopramide hcl Salagen pilocarpine hcl

Preferred Brands Amitiza QL Gattex PA, QL Linzess QL Stelara 45mg, 90mg PA, QL Viberzi PA, QL Xeljanz, XR PA, QL Xifaxan 200mg QL Xifaxan 550mg PA, QL

Nonpreferred Brands Motegrity PA, QL Movantik PA, QL Rectiv QL Relistor tablet PA, QL Sucraid PA, QL Symproic PA, QL Zelnorm PA, QL Zorbtive PA



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5. Obstetrics and gynecology

5A. Contraceptives Biphasic Trade name Generic name Limits

Preventive Drugs Loseasonique l-norgest/e.estradiol-e.estrad QL Mircette desog-e.estradiol/e.estradiol Seasonique l-norgest/e.estradiol-e.estrad QL

Preferred Brands Lo Loestrin Fe

5B. Contraceptives Misc. Trade name Generic name Limits

Preventive Drugs Depo-Provera 150mg medroxyprogesterone acetate FC2 Female Condom QL Gynol II nonoxynol 9 QL Nuvaring etonogestrel/ethinyl estradiol QL Ortho Evra norelgestromin/ethin.estradiol QL Ortho Micronor; Nor-QD norethindrone Quartette l-norgest/e.estradiol-e.estrad QL Safyral drospir/eth estra/levomefol ca Today contraceptive sponge QL VCF film, gel QL VCF foam nonoxynol 9 QL

Preferred Brands Depo-subq Provera 104 Natazia

Nonpreferred Brands Slynd QL



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5C. Contraceptives Monophasic Trade name Generic name Limits

Preventive Drugs Alesse; Levlite levonorgestrel/ethin.estradiol Beyaz drospir/eth estra/levomefol ca Demulen ethynodiol d-ethinyl estradiol Desogen; Ortho-cept desogestrel-ethinyl estradiol Femcon Fe noreth-ethinyl estradiol/iron Generess Fe noreth-ethinyl estradiol/iron Levlen; Nordette levonorgestrel/ethin.estradiol Lo/Ovral norgestrel-ethinyl estradiol Loestrin norethindrone ac-eth estradiol Loestrin 24 Fe norethindrone-e.estradiol-iron Loestrin Fe norethindrone-e.estradiol-iron Lybrel levonorgestrel/ethin.estradiol Minastrin 24 Fe norethindrone-e.estradiol-iron Modicon norethindrone-ethin. estradiol Norinyl 1/35; Ortho-novum 1/35 norethindrone-ethin. estradiol Nortrel norethindrone-ethin. estradiol Ortho-Cyclen norgestimate-ethinyl estradiol Ovcon 35 norethindrone-ethin. estradiol Seasonale levonorgestrel/ethin.estradiol QL Taytulla norethindrone-e.estradiol-iron Yasmin 28 ethinyl estradiol/drospirenone Yaz ethinyl estradiol/drospirenone

Nonpreferred Brands Balcoltra

5D. Contraceptives Postcoital Trade name Generic name Limits

Preventive Drugs Ella QL Plan B One-step levonorgestrel QL

5E. Contraceptives Triphasic Trade name Generic name Limits

Preventive Drugs Cyclessa desogestrel-ethinyl estradiol Estrostep Fe norethindrone-e.estradiol-iron Ortho Tri-Cyclen norgestimate-ethinyl estradiol Ortho Tri-Cyclen Lo norgestimate-ethinyl estradiol Ortho-Novum 7/7/7 norethindrone-ethin. estradiol Trilevlen levonorgestrel/ethin.estradiol Tri-Norinyl norethindrone-ethin. estradiol



5F. Estrogen and progestin combinations Trade name Generic name Limits

Preferred Generics Activella estradiol/norethindrone acet FemHRT norethindrone ac-eth estradiol

Preferred Brands Climara Pro Combipatch Prempro, Low Dose; Premphase

Nonpreferred Brands Angeliq Bijuva QL Prefest

5G. Estrogens Trade name Generic name Limits

Preferred Generics Climara estradiol Delestrogen estradiol valerate Estrace estradiol Minivelle, Vivelle-Dot estradiol Vagifem estradiol

Preferred Brands Alora Estring Estrogel Premarin, cream, Low Dose

Nonpreferred Brands Delestrogen 10mg/ml Depo-estradiol Divigel Elestrin Evamist Femring Imvexxy Menest Menostar



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5H. Infertility treatment* Trade name Generic name Limits

Preferred Generics Clomid clomiphene citrate Ganirelix Acetate ganirelix acetate

Preferred Brands Cetrotide Crinone 8% Gonal-F, RFF, Redi-ject

Menopur Ovidrel

Pregnyl PA Nonpreferred Brands

Chorionic Gonadotropin PA Endometrin PA Follistim AQ PA Novarel PA

*Drugs used for the treatment of infertility may not be covered for select benefits.

5I. Progestins Trade name Generic name Limits

Preferred Generics Aygestin norethindrone acetate Progesterone In Oil (inj) progesterone Prometrium progesterone, micronized Provera medroxyprogesterone acetate

Preferred Brands Crinone 4% Depo-subq Provera 104

5J. Vaginal anti infective and antifungal Trade name Generic name Limits

Preferred Generics Cleocin vaginal cream clindamycin phosphate Diflucan fluconazole Metrogel-Vaginal metronidazole Monistat 3 miconazole nitrate Terazol- 3, 7 terconazole

Preferred Brands Gynazole-1

Nonpreferred Brands Cleocin vaginal ovules Clindesse Nuvessa



-5K. Miscellaneous OB GYN Trade name Generic name Limits

Preferred Generics Brisdelle paroxetine mesylate QL Covaryx, H.S. estrogen,ester/me-testosterone Diclegis doxylamine succinate/vit b6 PA, QL Lysteda tranexamic acid QL Methergine methylergonovine maleate QL

Preferred Brands Lupron Depot 3.75mg, 11.25mg Orilissa PA, QL

Nonpreferred Brands Bonjesta PA, QL Duavee Intrarosa Lupaneta Pack Oriahnn PA, QL Osphena Synarel



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6. Rheumatology and musculoskeletal

6A. Corticosteroids Trade name Generic name Limits

Corticosteroids See Chapter 7C

6B. Gout therapy Trade name Generic name Limits

Preferred Generics Colbenemid probenecid/colchicine Colcrys colchicine Probenecid probenecid Uloric febuxostat ST, QL Zyloprim allopurinol

Nonpreferred Brands Colchicine capsule (authorized generic of Mitigare) Mitigare

6C. Non Tumor Necrosis Factor (TNF) blocking agents Trade name Generic name Limits

Preferred Brands Actemra Actpen, syringe PA, QL Otezla PA, QL Rinvoq ER PA, QL Stelara 45mg, 90mg PA, QL Taltz PA, QL Xeljanz, XR PA, QL

Nonpreferred Brands Kevzara PA, QL Kineret PA, QL Olumiant PA, QL Orencia Clickject, sub-q PA, QL

6D. Osteoporosis and bone resorption Trade name Generic name Limits

Preferred Generics Actonel risedronate sodium QL Atelvia risedronate sodium ST, QL Boniva ibandronate sodium QL Didronel etidronate disodium QL Evista raloxifene hcl QL Fosamax alendronate sodium QL Miacalcin nasal spray calcitonin,salmon,synthetic

Preferred Brands Miacalcin injection

Nonpreferred Brands Binosto ST, QL Fosamax Plus D ST, QL



6E. Osteoporosis and hormonal treatment Trade name Generic name Limits

Preferred Generics Climara estradiol Estrace estradiol FemHRT norethindrone ac-eth estradiol Minivelle, Vivelle-Dot estradiol

Preferred Brands Alora Forteo PA, QL Premarin, cream, Low Dose Prempro, Low Dose; Premphase Tymlos PA, QL

Nonpreferred Brands Duavee Menest

6F. Salicylates Trade name Generic name Limits

Salicylates and NSAIDS See Chapters 3O & 3M

6G. Tumor Necrosis Factor (TNF) blocking agents Trade name Generic name Limits

Preferred Brands Cimzia syringe PA, QL Enbrel PA, QL Humira PA, QL

Nonpreferred Brands Simponi PA, QL

6H. Miscellaneous rheumatologic agents Trade name Generic name Limits

Preferred Generics Arava leflunomide Azulfidine, EN-tab sulfasalazine Depen penicillamine QL Gengraf; Neoral cyclosporine, modified Imuran azathioprine Methotrexate methotrexate sodium Methotrexate PF injection methotrexate sodium/pf Plaquenil hydroxychloroquine sulfate QL

Preferred Brands Ridaura Trexall

Nonpreferred Brands Azasan Otrexup PA, QL Rasuvo PA, QL Xatmep



7. Endocrinology

7A. Androgens Trade name Generic name Limits

Preferred Generics Androgel testosterone PA, QL Android, Testred methyltestosterone Axiron testosterone ST, QL Danocrine danazol Delatestryl testosterone enanthate Depo-Testosterone testosterone cypionate Fortesta testosterone ST, QL Oxandrin oxandrolone PA Testim testosterone ST, QL Testosterone 1% packet, pump testosterone PA, QL

Preferred Brands Androderm PA, QL

Nonpreferred Brands Anadrol-50 Depo-Testosterone Jatenzo PA, QL Methitest Natesto ST, QL Testosterone 1% (authorized generic of Vogelxo) ST, QL Vogelxo ST, QL Xyosted PA, QL

7B. Antithyroid agents Trade name Generic name Limits

Preferred Generics Propylthiouracil propylthiouracil Strong Iodine potassium iodide/iodine Tapazole methimazole

Nonpreferred Brands SSKI



7C. Corticosteroids Trade name Generic name Limits

Preferred Generics Cortef; Hydrocortisone hydrocortisone Cortisone acetate cortisone acetate Decadron dexamethasone Deltasone prednisone Dexpak dexamethasone Entocort EC budesonide Florinef fludrocortisone acetate Medrol, dose pack methylprednisolone Millipred solution prednisolone sodium phosphate Orapred ODT prednisolone sodium phosphate Orapred solution prednisolone sodium phosphate Pediapred solution prednisolone sodium phosphate Prednisolone solution, tablet prednisolone Prednisone prednisone Uceris tablet budesonide QL

Nonpreferred Brands Emflaza PA Medrol 2mg Rayos PA, QL Solu-cortef

7D. Growth Hormone and related products Trade name Generic name Limits

Preferred Brands Genotropin PA Norditropin FlexPro PA Nutropin AQ Nuspin PA

Nonpreferred Brands Humatrope PA Increlex PA Omnitrope PA Saizen, Saizenprep PA Serostim PA Zomacton PA



7E. Insulins Trade name Generic name Limits

Preferred Brands Fiasp, Flextouch, Penfill Humulin R U-500 (all forms) Lantus, Solostar Levemir, Flextouch Novolin (all NDC's ending in 00, 01, 11, and 15) Novolog, Mix (all forms) Soliqua 100-33 QL Toujeo, Max Solostar Tresiba, Flextouch Xultophy 100-3.6 QL

Nonpreferred Brands Afrezza PA Basaglar Kwikpen U-100 Insulin lispro junior (authorized generic of Humalog Junior Kwikpen)



-7F. Non insulin hypoglycemic agents Trade name Generic name Limits

Preferred Generics Actoplus Met pioglitazone hcl/metformin hcl Actos pioglitazone hcl Amaryl glimepiride Diabeta; Micronase glyburide Duetact pioglitazone hcl/glimepiride Fortamet metformin hcl PA Glucophage, XR metformin hcl Glucotrol, XL glipizide Glucovance glyburide/metformin hcl Glynase glyburide,micronized Glyset miglitol Metaglip glipizide/metformin hcl PrandiMet repaglinide/metformin hcl Prandin repaglinide Precose acarbose Riomet metformin hcl Starlix nateglinide

Preferred Brands Farxiga QL Glyxambi QL Invokamet, XR QL Invokana QL Janumet QL Janumet XR QL Januvia QL Jardiance QL Jentadueto, XR QL Ozempic QL Qtern QL Rybelsus QL Segluromet QL Steglatro QL Symlinpen Synjardy, XR QL Tradjenta QL Trijardy XR QL Trulicity QL Victoza QL Xigduo XR QL

Nonpreferred Brands Avandia QL Cycloset PA, QL Riomet ER QL



7G. Somatostatin analogs Trade name Generic name Limits

Preferred Generics Sandostatin octreotide acetate

Preferred Brands Sandostatin LAR Depot PA Signifor PA, QL Somatuline Depot PA, QL

Nonpreferred Brands Bynfezia PA, QL Mycapssa PA, QL Signifor LAR PA, QL

7H. Thyroid hormones Trade name Generic name Limits

Preferred Generics Cytomel liothyronine sodium NP Thyroid thyroid,pork Synthroid levothyroxine sodium Westhroid thyroid,pork

Preferred Brands Thyrolar

Nonpreferred Brands Armour Thyroid Levothyroxine sodium (authorized generic for Tirosint) Tirosint Tirosint-Sol

7I. Urea cycle disorder agents Trade name Generic name Limits

Preferred Generics Buphenyl powder sodium phenylbutyrate Buphenyl tablet sodium phenylbutyrate QL

Preferred Brands Carbaglu PA

Nonpreferred Brands Ravicti PA, QL

7J. Vitamin D analogs Trade name Generic name Limits

Preferred Generics Calciferol (Rx Only) ergocalciferol (vitamin d2) Hectorol doxercalciferol Rocaltrol calcitriol Zemplar paricalcitol

Nonpreferred Brands Rayaldee QL



7K. Miscellaneous endocrine Trade name Generic name Limits

Preferred Generics DDAVP desmopressin (nonrefrigerated) DDAVP desmopressin acetate Dostinex cabergoline Kuvan sapropterin dihydrochloride PA Miacalcin nasal spray calcitonin,salmon,synthetic Proglycem diazoxide Sensipar cinacalcet hcl Zavesca miglustat PA, QL

Preferred Brands Baqsimi QL Cerdelga PA, QL Cholbam PA, QL Dojolvi PA Galafold PA, QL GlucaGen HypoKit Glucagon Emergency Kit Gvoke QL Korlym PA, QL Lupron Depot-PED Miacalcin injection Natpara PA, QL Palynziq PA, QL Revcovi PA, QL Somavert PA Strensiq PA, QL Xermelo PA, QL

Nonpreferred Brands DDAVP solution Egrifta SV PA, QL Isturisa PA, QL Myalept PA, QL Synarel



8. Antineoplastics and immunosuppresants

8A. Adjuvant therapy Trade name Generic name Limits

Preferred Generics Leucovorin tablet leucovorin calcium

Preferred Brands Fulphila QL Leukine Mesnex tablet Neulasta QL Nivestym QL Procrit Retacrit Udenyca QL Zarxio

Nonpreferred Brands Aranesp Epogen

Granix Mircera QL Neupogen

Ziextenzo QL

8B. Alkylating agents Trade name Generic name Limits

Preferred Generics Alkeran tablet melphalan Cyclophosphamide capsule cyclophosphamide Temodar temozolomide

Preferred Brands Emcyt Gleostine; Lomustine Leukeran Matulane Myleran

8C. Antimetabolites Trade name Generic name Limits

Preferred Generics Methotrexate methotrexate sodium Methotrexate PF injection methotrexate sodium/pf Purinethol mercaptopurine Xeloda capecitabine

Preferred Brands Lonsurf PA, QL Onureg PA, QL Tabloid Trexall

Nonpreferred Brands Purixan Xatmep



8D. Hormonal agents Trade name Generic name Limits

Preventive Drugs Arimidex* anastrozole PA, QL Aromasin* exemestane PA, QL Evista * raloxifene hcl PA, QL Tamoxifen* tamoxifen citrate PA, QL

Preferred Generics Arimidex anastrozole QL Aromasin exemestane QL Casodex bicalutamide Eulexin flutamide Evista raloxifene hcl QL Fareston toremifene citrate Faslodex fulvestrant Femara letrozole Lupron leuprolide acetate Megace, ES megestrol acetate Nilandron nilutamide Tamoxifen tamoxifen citrate QL Zytiga 250mg abiraterone acetate QL

Preferred Brands Erleada PA, QL Kisqali Femara co-pack PA, QL Lupron Depot Trelstar, Depot, LA

Xtandi PA, QL Zoladex QL

Nonpreferred Brands Eligard Lupaneta Pack Soltamox




8E. Immunomodulators Trade name Generic name Limits

Preferred Generics Cellcept mycophenolate mofetil Gengraf; Neoral cyclosporine, modified Imuran azathioprine Myfortic mycophenolate sodium Prednisone prednisone Prograf tacrolimus Rapamune sirolimus Sandimmune capsule cyclosporine

Preferred Brands Arcalyst PA, QL Somatuline Depot PA, QL Thalomid

Nonpreferred Brands Astagraf XL Azasan Envarsus XR

Kineret PA, QL Pomalyst PA, QL Prograf granules

Revlimid QL Sandimmune solution



8F. Kinase inhibitors and molecular target inhibitors Trade name Generic name Limits

Preferred Generics Afinitor everolimus PA, QL Gleevec imatinib mesylate Tarceva erlotinib hcl PA, QL Tykerb lapatinib ditosylate PA Zortress everolimus

Preferred Brands Afinitor 10mg, Disperz PA, QL Alecensa PA, QL Alunbrig PA, QL Ayvakit PA, QL Balversa PA, QL Bosulif PA, QL Braftovi PA, QL Brukinsa PA, QL Cabometyx PA, QL Calquence PA, QL Caprelsa PA, QL Cometriq PA, QL Copiktra PA, QL Cotellic PA, QL Daurismo PA, QL Gavreto PA, QL Gilotrif PA, QL Ibrance PA, QL Iclusig PA, QL Idhifa PA, QL Imbruvica capsule; 280mg, 420mg, 560mg tablet PA, QL Inlyta PA, QL Inqovi PA, QL Iressa PA, QL Jakafi PA, QL Kisqali, Femara co-pack PA, QL Koselugo PA, QL Lenvima PA, QL Lorbrena PA, QL Lynparza PA, QL Mekinist PA, QL Mektovi PA, QL Nerlynx PA, QL Nexavar PA, QL Ninlaro PA, QL Nubeqa PA, QL Pemazyre PA, QL Piqray PA, QL Qinlock PA, QL Retevmo PA, QL Rozlytrek PA, QL Rubraca PA, QL Rydapt PA, QL Sprycel PA, QL Stivarga PA, QL Sutent PA, QL



8F. Kinase inhibitors and molecular target inhibitors (Continued) Trade name Generic name Limits

Tabrecta PA, QL Tafinlar PA, QL Tagrisso PA, QL Talzenna PA, QL Tasigna PA, QL Tazverik PA, QL Tibsovo PA, QL Tukysa PA, QL Turalio PA, QL Venclexta PA, QL Verzenio PA, QL Vitrakvi PA, QL Vizimpro PA, QL Votrient PA, QL Xalkori PA, QL Xospata PA, QL Zejula PA, QL Zelboraf PA, QL Zydelig PA, QL Zykadia PA, QL

Nonpreferred Brands Inrebic PA, QL Zortress 1mg

8G. Miscellaneous antineoplastic agents Trade name Generic name Limits

Preferred Generics Hydrea hydroxyurea Sandostatin octreotide acetate Targretin capsule bexarotene PA, QL Vepesid etoposide Vesanoid tretinoin

Preferred Brands Droxia Erivedge PA, QL Farydak PA, QL Hycamtin capsule Lysodren Odomzo PA, QL Sandostatin LAR Depot PA Synribo PA, QL Xpovio PA, QL Zolinza PA, QL



9. Immunology and hematology

9A. Hematopoietic agents Trade name Generic name Limits

Preferred Brands Doptelet PA, QL Fulphila QL Leukine

Neulasta QL Nivestym QL Procrit

Promacta PA Retacrit

Udenyca QL Zarxio

Nonpreferred Brands Aranesp

Epogen

Granix Mircera QL Neupogen Tavalisse PA, QL Ziextenzo QL

9B. Immunoglobulins Trade name Generic name Limits

Nonpreferred Brands Cutaquig PA Cuvitru PA Gammagard liquid PA Gammaked PA Gamunex-C sub-q PA Hizentra PA HyQvia PA Xembify PA



9C. Interferons and MS therapy Trade name Generic name Limits

Preferred Generics Ampyra dalfampridine QL Copaxone glatiramer acetate QL Glatopa glatiramer acetate QL Tecfidera dimethyl fumarate QL

Preferred Brands Actimmune Alferon N Avonex QL Gilenya QL Intron A

Mayzent QL Pegasys, Proclick QL Peg-Intron, Redipen QL Plegridy QL Rebif, Rebidose QL

Nonpreferred Brands Aubagio QL Bafiertam QL Betaseron QL Extavia QL Mavenclad QL Sylatron QL Vumerity QL Zeposia QL

9D. Miscellaneous immunology and hematology Trade name Generic name Limits

Preferred Generics Firazyr icatibant acetate PA, QL

Preferred Brands Benlysta PA, QL Haegarda PA, QL Palforzia packet PA, QL Takhzyro PA, QL

Nonpreferred Brands Oxbryta PA, QL Ruconest PA, QL Siklos PA



10. Dermatology

10A. Acne treatment Trade name Generic name Limits

Preferred Generics Acanya clindamycin phos/benzoyl perox Accutane; Amnesteem; Claravis; Myorisan; Zenatane isotretinoin QL Aczone 5% dapsone QL Adoxa capsule doxycycline monohydrate PA Adoxa tablet doxycycline monohydrate Atralin tretinoin Avar sulfacetamide sodium/sulfur Avar-E sulfacetamide sodium/sulfur Avidoxy 100mg doxycycline monohydrate Benzaclin clindamycin phos/benzoyl perox Benzamycin erythromycin/benzoyl peroxide Cleocin-T, swabs clindamycin phosphate Differin cream, gel adapalene Doryx doxycycline hyclate PA Duac clindamycin phos/benzoyl perox Dynacin minocycline hcl Epiduo adapalene/benzoyl peroxide Erythromycin topical gel, solution, swab erythromycin base in ethanol Klaron sulfacetamide sodium Minocin minocycline hcl Monodox doxycycline monohydrate Ovace sulfacetamide sodium Retin-A; Avita tretinoin Rosanil sulfacetamide sodium/sulfur Rosula Cleanser sulfacetamide sod/sulfur/urea Tazorac tazarotene Vibramycin doxycycline hyclate Vibramycin suspension doxycycline monohydrate

Preferred Brands Tazorac 0.05%; 0.1% gel

Nonpreferred Brands Adapalene 0.1% lotion (authorized generic for Differin) Altreno QL Amzeeq QL Avita gel Azelex Differin 0.1% lotion Doryx MPC PA Doxycycline IR-DR (authorized generic of Oracea) PA Epiduo Forte PA, QL Fabior ST, QL Noritate Oracea PA Tretin-X Vibramycin syrup



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10B. Antipsoriatic and antiseborrheic Trade name Generic name Limits

Preferred Generics Avar sulfacetamide sodium/sulfur Avar-E sulfacetamide sodium/sulfur Dovonex calcipotriene Klaron sulfacetamide sodium Ovace sulfacetamide sodium Oxsoralen-Ultra methoxsalen Rosanil sulfacetamide sodium/sulfur Selsun (Rx Only) selenium sulfide Soriatane acitretin Taclonex calcipotriene/betamethasone PA Tazorac tazarotene Vectical calcitriol

Preferred Brands Cimzia syringe PA, QL Duobrii QL Enbrel PA, QL Humira PA, QL Otezla PA, QL Skyrizi PA, QL Stelara 45mg, 90mg PA, QL Taltz PA, QL Tremfya PA, QL

Nonpreferred Brands Calcipotriene foam (authorized generic of Sorilux) Enstilar PA, QL Otrexup PA, QL Rasuvo PA, QL Siliq PA, QL Sorilux

10C. Corticosteroids very high potency Trade name Generic name Limits

Preferred Generics Clobevate; Temovate clobetasol propionate Clobex, spray clobetasol propionate Diprolene gel, ointment betamethasone dipropionate Olux clobetasol propionate Olux-E clobetasol propionate/emoll Temovate Emollient clobetasol propionate/emoll Ultravate cream, ointment halobetasol propionate Vanos fluocinonide QL

Preferred Brands Cordran tape Duobrii QL

Nonpreferred Brands Bryhali QL



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10D. Corticosteroids high potency Trade name Generic name Limits

Preferred Generics Apexicon E diflorasone diacetate/emoll Aristocort; Kenalog 0.5% triamcinolone acetonide Cyclocort amcinonide Diprolene cream, lotion; AF betamethasone/propylene glyc Diprosone cream, ointment betamethasone dipropionate Elocon ointment mometasone furoate Florone; Psorcon diflorasone diacetate Halog halcinonide Lidex fluocinonide Lidex E fluocinonide/emollient base Luxiq betamethasone valerate Topicort 0.25%; 0.05% gel desoximetasone Valisone ointment betamethasone valerate

Nonpreferred Brands Halog ointment, solution

10E. Corticosteroids medium potency Trade name Generic name Limits

Preferred Generics Cordran flurandren