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Blue Cross of Idaho

Four-Tier Prescription Drug Formulary

If you cannot find a drug you are using on this formulary,

call the CVS Caremark Customer Care number on the back of

your member ID card or log onto bcidaho.com using your unique

login and password. Once you are logged in, clicking on

the Benefits & Coverage link under the Prescription Drugs menu,

and click Access My Benefits Now for access to additional

drug information. If you have questions about any of

your medications, please discuss them with your doctor

or pharmacist. You can also refer to your group’s contract

provisions for more information about the terms and

conditions of your prescription drug benefit.

This formulary is not an all-inclusive listing, and is

subject to change as new products and information

become available.

Things to know about Blue Cross of Idaho’s

Four-Tier Prescription Drug Formulary

The Blue Cross of Idaho formulary is a list of drugs approved for coverage under your pharmacy

benefit. The formulary includes brand name and generic drugs that have undergone rigorous testing

and are approved by the Food and Drug Administration (FDA).

How Does a Multi-Tier Formulary work?

In most cases you will be responsible for a portion of the cost of each prescription you have filled. The

portion you pay is your copay, and depending on the drug prescribed, your cost can vary. The Blue

Cross of Idaho formulary has multiple tiers, with the first tier costing you the least and the fourth tier

costing you the most. Asking your doctor to prescribe drugs listed in the first or second tier of the

formulary can save you money.

Tier Description

1 The first tier generally contains generic drugs. You will pay the least when your doctor

prescribes generic drugs. Some generic specialty drugs may be assigned a higher tier.

2 The second tier generally contains brand name drugs preferred by Blue Cross of Idaho.

3 The third tier generally contains brand name drugs that are not preferred by Blue Cross

of Idaho when compared to other drugs used to treat the same condition. However, the

third tier may also contain specialty drugs that are preferred over other specialty drugs

used to treat the same condition.

4 The fourth tier generally contains specialtydrugs, though not all specialty drugs are part

of the fourth tier. Some specialty drugs may be assigned a lower tier.

Additional Drug Descriptions

Affordable Care Act Preventive Drugs (*)

Some drugs in the formulary may be available at no cost under the regulations of the Affordable Care Act.

Examples of these drugs include aspirin, breast cancer prevention drugs, fluoride supplements, folic acid

supplements, iron supplements, tobacco cessation, vitamin D supplements, and some FDA approved

contraceptive methods. Not all ACA preventive drugs are listed in the formulary. When a drug in the formulary

may be eligible for coverage at no cost, the tier will be preceded by an asterisk (*). Example: *1($)

Some plans grandfathered under the Affordable Care Act may not be eligible for the ACA preventive drugs at

no cost. For these plans, the listed tier applies.

Mandatory Generic Substitution (GE)

You can save money by choosing generic prescription drugs. Brand name drugs with a generic alternative can be identified by the small, bold GE following the drug name. Most Blue Cross of Idaho prescription drug plans include a mandatory generic substitution requirement. If you or your physician requests the brand name medication when a generic equivalent is available, you are responsible to pay the difference between the contracted cost of the generic and brand name drug in addition to the tiered copayment. This cost difference does not apply to your deductible or out-of-pocket maximums.

Narrow Therapeutic Index (NTI)

Narrow therapeutic index medications are identified in the formulary by the small, bold NTI following the drug

name. The narrow therapeutic index medications will not be added to the generic listing or become available

under the generic initiative program, even if a generic equivalent becomes available.

Newly Approved Prescription Drugs

Any newly FDA approved prescription drug, biological agent, or other agent is excluded from coverage by

Blue Cross of Idaho until it has been reviewed and approved by Blue Cross of Idaho’s Pharmacy and

Therapeutics Committee. The Blue Cross of Idaho Pharmacy and Therapeutics Committee meets quarterly to

review newly approved drugs and older medications for coverage recommendations. The committee is

comprised of practicing board-certified physicians and licensed pharmacists from across the state of Idaho.

Prior authorization (PA)

Certain drugs found on the formulary require prior authorization. These can be identified by the small, bold PA

that follows the drug name. Your physician or pharmacist will tell you if your medication requires prior

authorization. If prior authorization is required, your physician must provide documentation showing that the

prescription is medically necessary. A determination will be made within 15 days of the request for prior

authorization, or a request for additional information will be made to your physician. If prior authorization is not

obtained, you may be held responsible for the entire cost of the drug. Please refer to the guidelines for prior

authorization found in your contract or policy for more information.

Quantity Limits QL

Certain drugs found on the formulary can only be dispensed in limited quantities. They can be identified by the

small, bold QL that follows the drug name. Your pharmacist can only dispense these drugs up to the

predetermined limit. These drugs have been found to be less effective or even dangerous when taken at higher

than normal doses. The quantity limit restrictions on these drugs are consistent with usage recommendations

from the manufacturers.

Specialty Pharmacy Exclusive (SP) Blue Cross of Idaho participates in the CVS specialty drug program to allow members to access high-cost medications at carefully controlled rates. NOT ALL EMPLOYERS CHOOSE TO PARTIPATE IN THE EXCLUSIVE SPECIALTY PHARMACY PROGRAM. When an employer has chosen to participate in the exclusive specialty pharmacy program, some drugs must be obtained by mail order through CVS Caremark specialty pharmacy in order to be covered. These can be identified in the formulary by the small, bold SP that follows the drug name.

Step Therapy (ST) You may need to use one or more alternative medications before Blue Cross of Idaho can authorize benefits for the use of another medication. Blue Cross of Idaho wants to ensure providers are trying equally or more effective, low-cost options before recommending effective, but higher cost treatments. Drugs requiring step therapy can be identified by the small, bold ST that follows the drug name. Your provider can send medical records to verify prior drug therapies utilizing the prior authorization process.

Covered Generic Drugs 1st Tier Copay ($)

Covered Preferred Brand Name Drugs 2nd Tier Copay ($$) Covered Non-Preferred Brand Name Drugs 3rd Tier Copay ($$$)

Covered Specialty Drugs 4th

Tier Copay ($$$$)

Multi-Tier Prescription Drug Formulary

Drug Name Tier Generic Alternative Drug Tier

ADHD/Anti-Narcolepsy Agents - Anti-Narcolepsy

Nuvigil 3($$$) Armodafinil 1($)

Provigil GE 3($$$) Modafinil 1($)

ADHD/Anti-Narcolepsy Agents - Attention-Deficit / Hyperactivity Disorder

Adderall GE 3($$$) Amphetamine/Dextroamphetamine 1($)

Adderall XR GE 3($$$) Amphetamine/Dextroamphetamine ER 1($)

Adzenys XR 3($$$)

Concerta GE 3($$$) Methylphenidate HCl SA (osmotic) 1($)

Daytrana 3($$$)

Desoxyn GE 3($$$) Methamphetamine HCl 1($)

Dextroamphetamine sulfate 1($)

Dyanavel XR QL 3($$$)

Focalin GE 3($$$) Dexmethylphenidate HCl 1($)

Focalin XR 20 mg, 25 mg & 35 mg GE 3($$$) Dexmethylphenidate HCl SR 1($)

Focalin XR 5 mg, 10 mg, 15 mg, 30 mg & 40

mg GE

3($$$) Dexmethylphenidate HCl SR 1($)

Intuniv GE 3($$$) Guanfacine ER 1($)

Metadate CD GE 3($$$) Methylphenidate HCl CR 1($)

Methylphenidate ER 1($)

Methylphenidate HCl CR 1($)

Quillichew 3($$$)

Quillivant XR 2($$)

Ritalin GE 3($$$) Methylphenidate HCl 1($)

Ritalin LA GE 3($$$) Methylphenidate HCl SR 1($)

Strattera 2($$)

Vyvanse 2($$)




Tier Copay ($$$$)



Anti-Infective Agents - Amebicides

Yodoxin 2($$)

Anti-Infective Agents - Aminoglycosides

Neomycin sulfate 1($)

TOBI GE SP 3($$$) Tobramycin SP 1($)

TOBI Podhaler SP 3($$$)

Anti-Infective Agents - Anthelmintics

Albenza 3($$$)

Biltricide 3($$$)

Anti-Infective Agents - Antibiotics - Cephalosporins

Cedax GE 3($$$) Ceftibuten dihydrate 1($)

Cefaclor 1($)

Cefaclor ER 3($$$)

Cefadroxil 1($)

Cefdinir 1($)

Cefixime Supsension 1($) 1($)

Cefpodoxime proxetil 1($)

Cefprozil 1($)

Ceftin GE 3($$$) Cefuroxime Suspension & Tablets 1($)

Keflex GE 3($$$) Cephalexin 1($)

Suprax GE 3($$$) Cefixime 1($)

Suprax Suspension GE 3($$$) Cefixime Suspension 1($)

Anti-Infective Agents - Antibiotics - Fluoroquinolones (Quinolones)

Avelox GE 3($$$) Moxifloxacin HCl 1($)

Cipro GE 3($$$) Ciprofloxacin 1($)

Cipro XR GE 3($$$) Ciprofloxacin XR 1($)

Factive 3($$$)

Levaquin GE 3($$$) Levofloxacin 1($)

Ocuflox GE 3($$$) Ofloxacin 1($)

Anti-Infective Agents - Antibiotics - Macrolides

Biaxin GE 3($$$) Clarithromycin 1($)

Biaxin XL GE 3($$$) Clarithromycin ER 1($)

Dificid PA ST 3($$$)

E.E.S. GE 3($$$) Erythromycin Ethylsuccinate 1($)




Tier Copay ($$$$)



Anti-Infective Agents - Antibiotics – Macrolides - Continued

Erythromycin 1($)

Erythromycin base 1($)

Erythromycin base EC 1($)

Erythromycin stearate 1($)

PCE 2($$)

Zithromax GE 3($$$) Azithromycin 1($)

Zmax 3($$$)

Anti-Infective Agents - Antibiotics - Penicillins

Amoxicillin 1($)

Ampicillin 1($)

Augmentin GE 3($$$) Amoxicillin/Potassium Clavulanate 1($)

Augmentin XR GE 3($$$) Amoxicillin/Potassium Clavulanate 1($)

Dicloxacillin sodium 1($)

Penicillin V potassium 1($)

Veetids 1($)

Anti-Infective Agents - Antibiotics - Tetracyclines

Demeclocycline HCl 1($)

Dynacin GE 3($$$) Minocycline HCl 1($)

Minocin GE 3($$$) Minocycline HCl 1($)

Oracea GE 3($$$) Doxycycline 1($)

Tetracycline HCl 1($)

Vibramycin GE 3($$$) Doxycycline calcium 1($)

Anti-Infective Agents - Antifungal Agents

Clotrimazole 1($)

Cresemba PA 3($$$)

Diflucan GE 3($$$) Fluconazole 1($)

Exoderm Lotion 3($$$)

Griseofulvin 1($)

Gris-Peg GE 3($$$) Griseofulvin 1($)

Ketoconazole 1($)

Lamisil GE 3($$$) Terbinafine 1($)

Nystatin 1($)

Sporanox GE 3($$$) Itraconazole 1($)

Vfend GE 3($$$) Voriconazole 1($)




Tier Copay ($$$$)



Anti-Infective Agents - Antimycobacterial Agents

Mycobutin GE 3($$$) Rifabutin 1($)

Anti-Infective Agents - Antivirals - Antiretrovirals

Aptivus 2($$)

Atripla 2($$)

Combivir GE 3($$$) Lamivudine/Zidovudine 1($)

Complera 2($$)

Crixivan 2($$)

Descovy 2($$)

Edurant 2($$)

Emtriva 2($$)

Envarsus XR 3($$$)

Epivir GE 3($$$) Lamivudine 1($)

Epivir Solution GE 3($$$) Lamivudine Solution 1($)

Epzicom SP GE 4($$$$) Abacavir/Lamivudine 1($)

Fuzeon Kit 2($$)

Genvoya 3($$$)

Intelence 2($$)

Invirase 2($$)

Isentress 2($$)

Kaletra 2($$)

Lexiva 2($$)

Norvir 2($$)

Odefsey 2($$)

Prezista 2($$)

Rescriptor 2($$)

Retrovir GE 3($$$) Zidovudine 1($)

Reyataz 2($$)

Selzentry 2($$)

Stribild 2($$)

Sustiva 2($$)

Tivicay 2($$)

Triumeq QL 3($$$)

Trizivir GE 3($$$) Abacavir/Lamivudine/Zidovudine 1($)

Truvada 2($$)

Videx EC GE 3($$$) Didanosine 1($)

Viracept 2($$)

Viramune GE 3($$$) Nevirapine 1($)

Viramune XR 100 mg 2($$)




Tier Copay ($$$$)



Anti-Infective Agents - Antivirals - Antiretrovirals

Viramune XR 400 mg GE 3($$$) Nevirapine Ext-Rel 400 mg 1($)

Viread 2($$)

Vitekta 3($$$)

Zerit GE 3($$$) Stavudine 1($)

Ziagen GE 3($$$) Abacavir 1($)

Anti-Infective Agents - Antivirals - Cytomegalovirus (CMV) Agents

Ganciclovir 1($)

Valcyte GE 3($$$) Valganciclovir 1($)

Anti-Infective Agents - Antivirals - Hepatitis Agents

Baraclude GE SP 4($$$$) Entecavir SP 4($$$$)

Copegus GE SP 4($$$$) Ribavirin SP 4($$$$)

Epclusa SP PA 3($$$)

Epivir HBV GE SP 4($$$$) Lamivudine SP 4($$$$)

Epivir HBV Solution SP 4($$$$)

Harvoni PA SP 3($$$)

Hepsera GE SP 4($$$$) Adefovir Dipivoxil SP 4($$$$)

Intron A SP 4($$$$)

Olysio PA ST QL 4($$$$)

Pegasys, Pegasys Proclick SP 3($$$)

Peg-Intron SP 4($$$$)

Rebetol GE SP 4($$$$) Ribavirin SP 4($$$$)

Ribatab, Ribapak, Ribasphere GE SP 4($$$$) Ribavirin SP 4($$$$)

Sovaldi PA ST QL SP 3($$$)

Anti-Infective Agents - Antivirals - Herpes Agents

Famvir GE 3($$$) Famciclovir 1($)

Valtrex GE 3($$$) Valacyclovir 1($)

Zovirax GE 3($$$) Acyclovir 1($)

Anti-Infective Agents - Antivirals - Influenza Agents

Amantadine 1($)

Flumadine GE 3($$$) Rimantadine 1($)

Relenza QL 3($$$)

Tamiflu QL Anti-Infective Agents - Other Anti-Infectives

2($$)

Bactrim GE 3($$$) Sulfamethoxazole/Trimethoprim (SMZ-TMP) 1($)

Cleocin GE 3($$$) Clindamycin 1($)

Eryped GE 3($$$) Erythromycin Ethylsuccinate 1($)

Metronidazole Tablets 1($)




Tier Copay ($$$$)



Anti-Infective Agents - Other Anti-Infectives - Continued

Mepron GE 3($$$) Atovaquone 1($)

Metrogel Vaginal GE 3($$$) Metronidazole Vaginal 1($)

Sirturo PA 3($$$)

Vancocin GE 3($$$) Vancomycin 1($)

Zortre 2($$)

Zyvox GE 3($$$) Linezolid 1($)




Tier Copay ($$$$)



Cancer and Transplant - Antineoplastic Agents (Cancer)

Afinitor PA SP 4($$$$)

Alecensa PA SP

4($$$$)

Arimidex GE 3($$$) Anastrozole 1($)

Cabometyx PA SP 4($$$$)

Caprelsa PA 3($$$)

Ceenu 3($$$) Lomustine 1($)

Cometriq PA 3($$$)

Cotellic PA SP 4($$$$)

Erivedge PA 4($$$$)

Fareston 2($$)

Gilotrif PA 4($$$$)

Farydak PA SP 4($$$$)

Gleevec PA SP 4($$$$)

Ibrance PA SP 4($$$$)

Imbruvica PA 3($$$)

Iressa PA 4($$$$)

Lenvima PA SP 4($$$$)

Lonsurf PA SP 4($$$$)

Lynparza PA 3($$$)

Mekinist PA SP 4($$$$)

Nexavar PA SP 4($$$$)

Nilandron GE 3($$$) Nilutamide 1($)

Ninlaro PA SP 4($$$$)

Odomzo PA SP 4($$$$)

Pomalyst PA SP 4($$$$)

Provenge PA 3($$$)

Revlimid PA SP 4($$$$)

Sutent PA SP 4($$$$)

Tafinlar PA SP 4($$$$)

Tagrisso PA 4($$$$)

Tamoxifen *1($)

Tarceva PA SP 4($$$$)

Tasigna PA SP 4($$$$)

Temodar PA GE SP 3($$$) Temozolomide PA SP 4($$$$)

Thalomid PA SP 4($$$$)

Tykerb PA SP 4($$$$)

Valchlor PA QL 3($$$)

Venclexta PA 4($$$$)

Vistogard SP 4($$$$)

Votrient PA SP 4($$$$)

Xalkori PA SP 4($$$$)

Xeloda PA GE SP 4($$$$) Capecitabine PA SP 4($$$$)

Xtandi PA SP 4($$$$)

Zelboraf PA SP 4($$$$)

Zolinza PA SP 4($$$$)




Tier Copay ($$$$)



Cancer and Transplant - Antineoplastic Agents (Cancer) - Continued

Zydelig PA 3($$$)

Zykadia PA SP 4($$$$)

Zytiga PA SP 4($$$$)

Cancer and Transplant - Immunosuppressives (Transplant)

CellCept NTI 2($$) Mycophenolate mofetil 1($)

Neoral NTI 2($$) Cyclosporine 1($)

Prograf GE 2($$) Tacrolimus 1($)

Rapamune NTI 2($$) Sirolimus 1($)

Sandimmune NTI 2($$) Cyclosporine 1($)

Zortress PA 2($$)




Tier Copay ($$$$)



Cardiovascular (Heart) - Antianginals

Imdur GE 3($$$) Isosorbide Mononitrate 1($)

Isordil 5 mg GE 3($$$) Isosorbide Dinitrate 5 mg 1($)

Isordil 40 mg 2($$)

Isosorbide Dinitrate (Oral/SL) 1($)

Minitran GE 3($$$) Nitroglycerin (Oral/SL/Topical/Patches) 1($)

Nitro-Bid Ointment 3($$$)

Nitro-Dur GE 3($$$) Nitroglycerin (Oral/SL/Topical/Patches) 1($)

Nitrolingual Spray GE 2($$) Nitroglycerin Spray 1($)

Nitromist 2($$)

NitroStat 3($$$) Nitroglycerin Sublingual Tablets 1($)

Cardiovascular (Heart) - Antiarrhythmics

Betapace GE 3($$$) Sotalol 1($)

Betapace AF NTI 3($$$) Sotalol AF 1($)

Cordarone NTI 2($$) Amiodarone 1($)

Norpace GE 3($$$) Disopyramide 1($)

Norpace CR 3($$$)

Pacerone NTI 1($) Amiodarone 1($)

Rythmol GE 3($$$) Propafenone 1($)

Rythmol SR GE 3($$$) Propafenone SR 1($)

Tikosyn GE 3($$$) Dofetilide 1($)

Cardiovascular (Heart) - Antihyperlipidemics - HMG CoA Reductase Inhibitors (Statins)

Crestor GE 3($$$) Rosuvastatin 1($)

Lescol GE 3($$$) Fluvastatin 1($)

Lescol XL 3($$$)

Lipitor GE 3($$$) Atorvastatin 1($)

Mevacor GE 3($$$) Lovastatin 1($)

Pravachol GE 3($$$) Pravastatin 1($)

Zocor GE 3($$$) Simvastatin 1($)

Cardiovascular (Heart) - Antihyperlipidemics - Miscellaneous

Advicor 3($$$)

Antara GE 3($$$) Fenofibrate 1($)

Colestid GE 3($$$) Colestipol 1($)

Fenoglide GE 3($$$) Fenofibrate 1($)




Tier Copay ($$$$)



Cardiovascular (Heart) - Antihyperlipidemics - Miscellaneous

Fibricor GE 3($$$) Fenofibric Acid 1($)

Lipofen GE 3($$$) Fenofibrate 1($)

Lopid GE 3($$$) Gemfibrozil 1($)

Niaspan GE 3($$$) Niacin Extended-Release 1($)

Questran GE 3($$$) Cholestyramine 1($)

Simcor 3($$$)

Tricor GE 3($$$) Fenofibrate 1($)

Trilipix GE 3($$$) Choline Fenofibrate 1($)

Welchol 3($$$)

Zetia 2($$)

Cardiovascular (Heart) - Antihypertensives - Angiotensin Converting Enzyme (ACE) Inhibitors

Accupril GE 3($$$) Quinapril 1($)

Aceon GE 3($$$) Perindopril Erbumine 1($)

Altace GE 3($$$) Ramipril 1($)

Captopril 1($)

Fosinopril 1($)

Lotensin GE 3($$$) Benazepril 1($)

Mavik GE 3($$$) Trandolapril 1($)

Prinivil GE 3($$$) Lisinopril 1($)

Univasc GE 3($$$) Moexipril 1($)

Vasotec GE 3($$$) Enalapril 1($)

Zestril GE 3($$$) Lisinopril 1($)

Cardiovascular (Heart) - Antihypertensives - Angiotensin II Receptor Blockers (ARB)

Atacand GE 3($$$) Candesartan 1($)

Avapro GE 3($$$) Irbesartan 1($)

Benicar 2($$)

Cozaar GE 3($$$) Losartan 1($)

Diovan GE 3($$$) Valsartan 1($)

Edarbi 3($$$)

Micardis GE 3($$$) Telmisartan 1($)

Teveten 600 mg GE 3($$$) Eprosartan Mesylate 600 mg 1($)

Cardiovascular (Heart) - Antihypertensives - Antiadrenergic Blockers

Cardura GE 3($$$) Doxazosin 1($)

Cardura XL 3($$$)

Catapres tablets GE 3($$$) Clonidine tablets 1($)

\




Tier Copay ($$$$)



Cardiovascular (Heart) - Antihypertensives - Antiadrenergic Blockers

Catapres TTS patches GE 3($$$) Clonidine patches 1($)

Methyldopa 1($)

Minipress GE 3($$$) Prazosin 1($)

Cardiovascular (Heart) - Antihypertensives - Combinations

Accuretic GE 3($$$) Quinapril/HCTZ 1($)

Amturnide 3($$$)

Atacand HCT GE 3($$$) Candesartan-HCTZ 1($)

Avalide GE 3($$$) Irbesartan/HCTZ 1($)

Azor 2($$)

Benicar HCT 2($$)

Captopril/HCTZ 1($)

Diovan HCT GE 3($$$) Valsartan-HCTZ 1($)

Dutoprol 2($$)

Edarbyclor 3($$$)

Entresto PA 3($$$) 1($)

Exforge GE 3($$$) Amlodipine/Valsartan 1($)

Exforge HCT GE 3($$$) Amlodipine/Valsartan/HCTZ 1($)

Fosinopril/HCTZ 1($)

Hyzaar GE 3($$$) Losartan/HCTZ 1($)

Lopressor HCT GE 3($$$) Metoprolol/HCTZ 1($)

Lotensin HCT GE 3($$$) Benazepril/HCTZ 1($)

Lotrel GE 3($$$) Amlodipine/Benazepril 1($)

Micardis HCT GE 3($$$) Telmisartan/HCTZ 1($)

Prinzide GE 3($$$) Lisinopril/HCTZ 1($)

Propranolol/HCTZ 1($)

Tarka GE 3($$$) Trandolapril/Verapamil CR 1($)

Tekamlo 3($$$)

Tekturna HCT 3($$$)

Tenoretic GE 3($$$) Atenolol/Chlorthalidone 1($)

Teveten HCT 3($$$)

Tribenzor 2($$)

Twynsta GE 3($$$) Telmisartan/Amlodipine 1($)

Uniretic GE 3($$$) Moexipril/HCTZ 1($)

Vaseretic GE 3($$$) Enalapril/HCTZ 1($)




Tier Copay ($$$$)



Cardiovascular (Heart) - Antihypertensives - Combinations

Zestoretic GE 3($$$) Lisinopril/HCTZ 1($)

Ziac GE 3($$$) Bisoprolol/HCTZ 1($)

Cardiovascular (Heart) - Antihypertensives - Direct Renin Inhibitors

Tekturna 3($$$)

Cardiovascular (Heart) - Antihypertensives - Selective Aldosterone Receptor Antagonists (SARAs)

Aldactone GE 3($$$) Spironolactone 1($)

Inspra GE 3($$$) Eplerenon 1($)

Cardiovascular (Heart) - Antihypertensives - Vasodilators

Hydralazine 1($)

Minoxidil 1($)

Cardiovascular (Heart) - Beta Blockers

Bystolic 3($$$)

Coreg GE 3($$$) Carvedilol 1($)

Coreg CR 2($$)

Hemangeol PA 3($$$)

Inderal LA GE 3($$$) Propranolol SA 1($)

Innopran XL 2($$)

Labetalol 1($)

Lopressor GE 3($$$) Metoprolol 1($)

Pindolol 1($)

Propranolol 1($)

Sectral GE 3($$$) Acebutolol 1($)

Tenormin GE 3($$$) Atenolol 1($)

Toprol XL GE 3($$$) Metoprolol XL 1($)

Zebeta GE 3($$$) Bisoprolol 1($)

Cardiovascular (Heart) - Calcium Channel Blockers

Adalat CC GE 3($$$) Nifedipine CC 1($)

Calan GE 3($$$) Verapamil 1($)

Calan SR GE 3($$$) Verapamil SR 1($)

Cardizem GE 3($$$) Diltiazem 1($)

Cardizem CD GE 3($$$) Diltiazem SA 1($)

Cardizem LA GE 3($$$) Diltiazem 24HR ER 1($)

Dilacor XR 3($$$)

Felodipine 1($)




Tier Copay ($$$$)



Cardiovascular (Heart) - Calcium Channel Blockers - Continued

Isoptin SR GE 3($$$) Verapamil SR 1($)

Norvasc GE 3($$$) Amlodipine 1($)

Procardia GE 3($$$) Nifedipine 1($)

Procardia XL GE 3($$$) Nifedipine XL 1($)

Sular GE 3($$$) Nisoldipine 1($)

Tiazac GE 3($$$) Diltiazem SA 1($)

Verelan GE 3($$$) Verapamil 1($)

Verelan PM GE 3($$$) Verapamil 1($)

Cardiovascular (Heart) - Cardiotonics

Lanoxin NTI 2($$) Digoxin 1($)

Cardiovascular (Heart) - Cardiovascular Agents - Miscellaneous

Adcirca PA SP 4($$$$)

Adempas PA QLSP 4($$$$)

Caduet GE 3($$$) Amlodipine/Atorvastatin 1($)

Letairis SP 3($$$)

Opsumit PA QL SP 4($$$$)

Orenitram PA SP 4($$$$)

Repatha PA SP 4($$$$)

Revatio PA SP 4($$$$) Sildenafil PA SP 4($$$$)

Tracleer SP 3($$$)

Tyvaso PA SP 4($$$$)

Uptravi PA SP 4($$$$)

Cardiovascular (Heart) - Diuretics

Bumex GE 3($$$) Bumetanide 1($)

Demadex GE 3($$$) Torsemide 1($)

Diamox Sequels GE 3($$$) Acetazolamide 1($)

Dyazide GE 3($$$) Triamterene/HCTZ 1($)

Edecrin GE 3($$$) Ethacrynic Acid 1($)

Indapamide 1($)

Lasix GE 3($$$) Furosemide 1($)

Maxzide GE 3($$$) Triamterene/HCTZ 1($)

Microzide GE 3($$$) Hydrochlorothiazide (HCTZ) 1($)

Zaroxolyn GE 3($$$) Metolazone 1($)

Cardiovascular (Heart) - Vasopressors

Adrenaclick 2($$)

Epipen 2($$)

EpiPen Jr. 2($$)




Tier Copay ($$$$)



Central Nervous System - Antianxiety Agents

Ativan GE 3($$$) Lorazepam 1($)

Buspirone 1($)

Chlordiazepoxide 1($)

Meprobamate 1($)

Oxazepam 1($)

Tranxene T-Tab GE 3($$$) Clorazepate 1($)

Valium GE 3($$$) Diazepam 1($)

Xanax GE 3($$$) Alprazolam 1($)

Central Nervous System - Antidepressants - Miscellaneous

Aplenzin 3($$$)

Brintellix PA ST 3($$$)

Emsam 3($$$)

Nefazodone 1($)

Remeron GE 3($$$) Mirtazapine 1($)

Trazodone 1($)

Viibryd PA ST QL 3($$$)

Wellbutrin GE 3($$$) Bupropion 1($)

Wellbutrin SR/ XL GE 3($$$) Bupropion SR / XL 1($)

Central Nervous System - Antidepressants - Selective Serotonin Reuptake Inhibitors (SSRIs)

Celexa GE 3($$$) Citalopram 1($)

Lexapro GE 3($$$) Escitalopram 1($)

Luvox CR GE 3($$$) Fluvoxamine ER 1($)

Paxil GE 3($$$) Paroxetine 1($)

Paxil CR GE 3($$$) Paroxetine CR 1($)

Prozac GE 3($$$) Fluoxetine 1($)

Prozac Weekly 90mg GE QL 3($$$) Fluoxetine 90 mg Weekly QL 1($)

Sarafem 3($$$)

Zoloft GE 3($$$) Sertraline 1($)

Central Nervous System - Antidepressants - Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)

Cymbalta GE 3($$$) Duloxetine 1($)

Effexor GE 3($$$) Venlafaxine (Venlafaxine ER Tablets by Upstate P 1($)

Effexor XR GE 3($$$) Venlafaxine ER Capsules (Venlafaxine ER Tablets

1($)

Pristiq 3($$$)




Tier Copay ($$$$)



Central Nervous System - Antidepressants - Tricyclic Agents (TCAs)

Amitriptyline 1($)

Doxepin 1($)

Norpramin GE 3($$$) Desipramine 1($)

Pamelor GE 3($$$) Nortriptyline 1($)

Protriptyline 1($)

Tofranil GE 3($$$) Imipramine 1($)

Central Nervous System - Antipsychotics/Antimanic Agents

Abilify GE 3($$$) Aripiprazole 1($)

Abilify Discmelt GE 3($$$) Ariprazole ODT 1($)

Aristada PA 3($$$)

Chlorpromazine 1($)

Clozaril NTI 2($$) Clozapine 1($)

Fanapt 3($$$)

FazaClo ODT GE 3($$$) Clozapine ODT 1($)

Fluphenazine 1($)

Geodon GE 3($$$) Ziprasidone 1($)

Haloperidol 1($)

Invega Oral Tablets 3($$$)

Invega Sustenna PA 3($$$)

Latuda 3($$$)

Lithium Carbonate/SR NTI 1($)

Lithium Citrate 1($)

Lithobid NTI 2($$) Lithium Carbonate SA 1($)

Loxitane GE 3($$$) Loxapine 1($)

Orap GE 3($$$) Pimozide 1($)

Perphenazine 1($)

Prochlorperazine 1($)

Risperdal Consta PA 2($$)

Risperdal M-Tab GE 3($$$) Risperidone ODT 1($)

Risperdal Oral Tablets GE 3($$$) Risperidone 1($)

Saphris 3($$$)

Seroquel GE 3($$$) Quetiapine Fumarate 1($)

Seroquel XR 2($$)

Thioridazine 1($)

Thiothixene 1($)

Trifluoperazine 1($)




Tier Copay ($$$$)



Central Nervous System - Antipsychotics/Antimanic Agents

Vraylar QL 3($$$)

Zyprexa GE 3($$$) Olanzapine 1($)

Zyprexa Zydis GE 3($$$) Olanzapine ODT 1($)

Central Nervous System - Hypnotics (Sleep Agents)

Ambien GE QL 3($$$) Zolpidem QL 1($)

Flurazepam QL 1($)

Halcion GE QL 3($$$) Triazolam QL 1($)

Lunesta GE QL 3($$$) Eszopiclone QL 1($)

Prosom GE QL 3($$$) Estazolam QL 1($)

Restoril GE QL 3($$$) Temazepam QL 1($)

Sonata GE QL 3($$$) Zaleplon QL 1($)

Compounded Medications

Compounded Medications 3($$$) Refer to Medical Policy 5.01.150




Tier Copay ($$$$)



Endocrine and Hormones - Androgens

Androderm 2($$)

Axiron 2($$)

Testosterone TD Gel 1($)

Endocrine and Hormones - Antidiabetics - Insulins and other Injectables

Bydureon PA ST 3($$$)

Byetta PA ST 3($$$)

Glucagen 2($$)

Lantus 2($$)

Levemir FlexTouch 2($$)

*Novolin 70-30 2($$) *Novolin Relion not covered

*Novolin N/R 2($$) *Novolin Relion not covered

Novolog 2($$)

Novolog Mix 70-30 2($$)

SymlinPen 3($$$)

Toujeo 2($$)

Tresiba 2($$)

Trulicity PA ST QL 2($$)

Veltassa ST QL 3($$$)

Victoza PA ST 2($$)

Endocrine and Hormones - Antidiabetics - Oral

Actoplus Met GE 3($$$) Pioglitazone/Metformin 1($)

Actoplus Met XR 2($$)

Actos GE 3($$$) Pioglitazone 1($)

Amaryl GE 3($$$) Glimepiride 1($)

Diabeta GE 3($$$) Glyburide 1($)

DuetAct GE 3($$$) Pioglitazone/Glimepiride 1($)

Farxiga PA 2($$)

Fortamet (Extended Release) GE 3($$$) Metformin ER 1($)

Glucophage GE 3($$$) Metformin 1($)

Glucophage XR GE 3($$$) Metformin XL 1($)

Glucotrol GE 3($$$) Glipizide 1($)




Tier Copay ($$$$)



Endocrine and Hormones - Antidiabetics - Oral

Glucotrol XL GE 3($$$) Glipizide ER 1($)

Glyxambi PA 2($$)

Glucovance GE 3($$$) Glyburide/Metformin 1($)

Glynase GE 3($$$) Glyburide (Micronized) 1($)

Glyset 1($)

Janumet 2($$)

Janumet XR 2($$)

Januvia 2($$)

Jardiance PA 2($$)

Jentadueto 2($$)

Metaglip GE 3($$$) Glipizide/Metformin 1($)

Prandimet 3($$$)

Prandin GE 3($$$) Repaglinide 1($)

Precose GE 3($$$) Acarbose 1($)

Starlix GE 3($$$) Nateglinide 1($)

Tradjenta 2($$)

Xigduo PA 2($$)

Endocrine and Hormones - Antidiabetics - Other

Glucagen Hypokit 3($$$)

Glucagon 2($$)

Proglycem 2($$)

Endocrine and Hormones - Bone Density Regulators (Osteoporosis)

Actonel GE 3($$$) Risedronate 1($)

Atelvia DR 2($$)

Boniva GE 3($$$) Ibandronate 1($)

Evista GE 3($$$) Raloxifene *1($)

Forteo PA QL 4($$$$)

Fosamax 35 mg and 70 mg GE QL 3($$$) Alendronate 35mg and 70mg QL 1($)

Fosamax Plus D 3($$$)

Miacalcin Injection 2($$)

Miacalcin Nasal Spray GE 3($$$) Calcitonin-Salmon Spray 1($)




Tier Copay ($$$$)



Endocrine and Hormones – Contraceptives – Please See Women’s Health

Endocrine and Hormones - Corticosteroids (Steroids)

Dexamethasone 1($)

Fludrocortisone 1($)

Medrol GE 3($$$) Methylprednisolone 1($)

Orapred GE 3($$$) Prednisolone 1($)

Prednisolone 1($)

Prednisone 1($)

Prelone GE 3($$$) Prednisolone 1($)

Endocrine and Hormones - Diabetic Supplies

Accu-Chek QL 2($$) PREFERRED

Ascensia QL 3($$$)

Bayer QL 3($$$)

BD 3($$$)

Fast Take QL 2($$)

Freestyle QL 3($$$)

Glucometer Brand Test Strips 3($$$)

Insulin Pen Needle 2($$)

One Touch QL 2($$) PREFERRED

Precision QL 3($$$)

Prestige QL 3($$$)

True Track QL 3($$$)

Endocrine and Hormones - Endocrine and Metabolic Agents - Miscellaneous

DDAVP GE 3($$$) Desmopressin 1($)

Lupron Depot PA SP 4($$$$)

Samsca SP 4($$$$)

Sensipar SP 4($$$$)

Signifor PA 3($$$)

Synarel 2($$)




Tier Copay ($$$$)



Endocrine and Hormones - Estrogens

Activella GE 3($$$) Estradiol/Norethindrone 1($)

Alora 3($$$)

Cenestin 2($$)

Climara GE 3($$$) Estradiol Patch 1($)

Climara Pro 2($$)

Combipatch 3($$$)

Divigel 3($$$)

Enjuvia 3($$$)

Estrace GE 3($$$) Estradiol 1($)

Estradiol 1($)

Estring 2($$)

Estrogel 2($$)

Estropipate 1($)

Evamist 3($$$)

FemHRT GE 3($$$) Ethinyl Estradiol and Norethindrone 1($)

Femring 3($$$)

Menest 2($$)

Minivelle 3($$$)

Osphena 3($$$)

Prefest 2($$)

Premarin 2($$)

Premarin Vaginal Cream 2($$)

Premphase 2($$)

Prempro 2($$)

Vivelle-Dot GE 3($$$) Estradiol Transdermal System 1($)

Endocrine and Hormones - Growth Hormone Receptor Antagonists

Somavert PA SP 4($$$$)

Endocrine and Hormones - Growth Hormone Releasing Hormones (GHRH)

Egrifta PA SP 4($$$$)

Endocrine and Hormones - Growth Hormones

Humatrope, Norditropin, PA SP 3($$$)

Endocrine and Hormones – Insulin-Like Growth Factors

Increlex PA SP 4($$$$)




Tier Copay ($$$$)



Endocrine and Hormones - Progestins

Aygestin GE 3($$$) Norethindrone 1($)

Crinone PA 3($$$)

Makena PA SP 4($$$$)

Prometrium GE 3($$$) Progesterone 1($)

Provera GE 3($$$) Medroxyprogesterone 1($)

Endocrine and Hormones - Thyroid Agents - Antithyroid agents

Propylthiouracil 1($)

Tapazole GE 3($$$) Methimazole 1($)

Endocrine and Hormones - Thyroid Agents - Thyroid hormones

Armour Thyroid 2($$)

Cytomel GE 3($$$) Liothyronine Sodium 1($)

Levoxyl 1($)

Natpara PA 4($$$$)

Synthroid NTI 2($$) Levothyroxine 1($)

Tirosint 2($$)

Unithroid 1($)

;




Tier Copay ($$$$)



Gastrointestinal (GI) Agents - Antidiarrheals

Lomotil GE 3($$$) Diphenoxylate/Atropine 1($)

Restora RX 3($$$)

Gastrointestinal (GI) Agents - Antiemetics

Antivert GE 3($$$) Meclizine 1($)

Emend QL 2($$)

Granisetron QL 1($)

Marinol GE QL 3($$$) Dronabinol QL 1($)

Prochlorperazine 1($)

Promethazine 1($)

Sancuso Patch QL 3($$$)

Tigan GE 3($$$) Trimethobenzamide 1($)

Zofran GE QL 3($$$) Ondansetron QL 1($)

Zofran ODT GE QL 3($$$) Ondansetron ODT QL 1($)

Varubi QL PA ST 3($$$)

Zuplenz 3($$$)

Gastrointestinal (GI) Agents - Digestive Enzymes

Creon 2($$)

Pancreaze 2($$)

Zenpep GE 3($$$) Pancrelipase Delayed-Rel 1($)

Gastrointestinal (GI) Agents - Laxatives

Bowel Evacuants (Colyte, GoLYTELY, Nulytely) GE

3($$$) PEG 3350/Electrolytes *1($)

Movantik 3($$$)

Moviprep 3($$$)

Polyethylene Glycol 1($)

Trilyte 1($)

Gastrointestinal (GI) Agents - Miscellaneous GI - Gallstone Solubilizing Agents

Actigall GE 3($$$) Ursodiol 1($)

URSO GE 3($$$) Ursodiol 1($)

URSO Forte GE 3($$$) Ursodiol 1($)

Gastrointestinal (GI) Agents - Miscellaneous GI - Inflammatory Bowel Agents

Apriso 2($$)

Asacol HD GE 2($$) Mesalamine Delayed Release 1($)

Azulfidine GE 3($$$) Sulfasalazine 1($)

Canasa 2($$)




Tier Copay ($$$$)



Gastrointestinal (GI) Agents - Miscellaneous GI - Inflammatory Bowel Agents - Continued

Colazal GE 3($$$) Balsalazide 1($)

Cortifoam 2($$)

Delzicol 2($$)

Dipentum 3($$$)

Entocort EC GE 3($$$) Budesonide EC 1($)

Lialda 2($$)

Pentasa 2($$)

Rowasa Enema GE 3($$$) Mesalamine 1($)

Gastrointestinal (GI) Agents - Miscellaneous GI - Irritable Bowel Syndrome (IBS) Agents

Linzess PA 2($$)

Viberzi PA 3($$$)

Gastrointestinal (GI) Agents - Miscellaneous GI - Phosphate Binder Agents

Eliphos GE 3($$$) Calcium Acetate 1($)

Fosrenol 2($$)

PhosLo GE 3($$$) Calcium Acetate 1($)

Renagel 2($$)

Renvela 2($$)

Velphoro PA 3($$$)

Gastrointestinal (GI) Agents - Ulcer Drugs - Antispasmodics

Bentyl GE 3($$$) Dicyclomine 1($)

Donnatal 3($$$)

Hyoscyamine Sulfate 1($)

Levbid GE 3($$$) Hyoscyamine Sulfate 1($)

Levsin GE 3($$$) Hyoscyamine Sulfate 1($)

Librax GE 3($$$) Clidinium/Chlordiazepoxide 1($)

Propantheline 15mg 1($)

Reglan GE 3($$$) Metoclopramide 1($)

Relistor 3($$$)

Gastrointestinal (GI) Agents - Ulcer Drugs - H-2 Antagonists

Axid GE 3($$$) Nizatidine 1($)

Cimetidine 300 mg, 400 mg & $00 mg 1($)

Gastrointestinal (GI) Agents - Ulcer Drugs - Miscellaneous

Carafate GE 3($$$) Sucralfate 1($)

Cytotec GE 3($$$) Misoprostol 1($)

Prevpac GE 3($$$) Lansoprazole/Amoxicillin/Clarithromycin 1($)




Tier Copay ($$$$)



Gastrointestinal (GI) Agents - Ulcer Drugs - Proton Pump Inhibitors (PPI)

First Lansoprazole 3mg/ML Compounding Kit 2($$)

First Omperazole 2mg/ML Compounding Kit 2($$)

Omeprazole 20 mg & 40 mg Delayed Release 1($)

Pantoprazole 1($)

Prevacid 30 mg GE 3($$$) Lansoprazole 30 mg 1($)

Genitourinary Agents (Bladder and Kidney) - Genitourinary Agents - Miscellaneous

Pyridium GE 3($$$) Phenazopyridine 1($)

Genitourinary Agents (Bladder and Kidney) - Prostatic Hypertrophy Agents (BPH)

Avodart 2($$)

Cardura GE 3($$$) Doxazosin 1($)

Flomax GE 3($$$) Tamsulosin 1($)

Jalyn 2($$)

Proscar GE QL 3($$$) Finasteride QL 1($)

Rapaflo 3($$$)

Terazosin 1($)

Uroxatral GE 3($$$) Alfuzosin ER 1($)

Genitourinary Agents (Bladder and Kidney) - Urinary Anti-Infectives

Macrobid GE 3($$$) Nitrofurantoin 1($)

Macrodantin GE 3($$$) Nitrofurantoin Macrocrystal 1($)

Genitourinary Agents (Bladder and Kidney) - Urinary Antispasmodics

Detrol GE 3($$$) Tolterodine 1($)

Detrol LA GE 3($$$) Tolterodine ER 1($)

Ditropan XL GE 3($$$) Oxybutynin XL 1($)

Enablex 3($$$)

Flavoxate 1($)

Gelnique 3($$$)

Oxybutynin 1($)

Oxytrol 3($$$)

Sanctura GE 3($$$) Trospium 1($)

Toviaz 3($$$)

Trospium ER 1($)

Urecholine GE 3($$$) Bethanechol 1($)

VESIcare 2($$)




Tier Copay ($$$$)



Genitourinary Agents (Bladder and Kidney) - Vaginal Products

Vagifem GE 3($$$) Estradiol Vaginal 1($)

Hematological Agents - Anticoagulants

Arixtra GE 3($$$) Fondaparinux 1($)

Coumadin NTI 2($$) Warfarin 1($)

Eliquis 3($$$)

Lovenox GE 3($$$) Enoxaparin 1($)

Pradaxa 2($$)

Xarelto 2($$)

Hematological Agents - Hematological Agents - Miscellaneous

Aggrenox 2($$)

Agrylin GE 3($$$) Anagrelide 1($)

Brilinta 3($$$)

Effient 3($$$)

Jadenu PA SP 4($$$$) 1($)

Mircera 3($$$) 1($)

Pentoxifylline 1($)

Persantine GE 3($$$) Dipyridamole 1($)

Plavix GE 3($$$) Clopidogrel 1($)

Pletal GE 3($$$) Cilostazol 1($)

Ticlopidine 1($)

Zontivity QL 3($$$)

Hematological Agents - Hematopoietic Agents

Aranesp 4($$$$)

Epogen 4($$$$)

Leukine 4($$$$)

Neulasta 4($$$$)

Neupogen 4($$$$)

Procrit 3($$$)

Zarxio 4($$$$)




Tier Copay ($$$$)



Miscellaneous Medications

Aubagio PA SP 4($$$$)

Buphenyl GE PA SP 4($$$$) Sodium Phenylbutrate PA SP 4($$$$)

Cayston PA 4($$$$)

Cerdelga PA SP 4($$$$)

Cholbam PA 3($$$)

Evzio ST QL 3($$$)

Firazyr PA SP 4($$$$)

Ferriprox Tablets, Ferriprox Solution PA SP 4($$$$)

Hectorol GE 3($$$) Doxercalciferol 1($)

Incivek PA SP 4($$$$)

Jakafi PA SP 4($$$$)

Kalydeco PA SP 4($$$$)

Keveyis PA 4($$$$)

Korlym PA 3($$$)

Kuvan PA SP 4($$$$)

Naloxone QL 1($)

Narcan Nasal Spray QL 2($$)

Orencia PA SP 3($$$)

Orfadin PA 3($$$)

Orfadin Suspension PA 3($$$)

Orkambi PA SP 4($$$$)

Pulmozyme SP 4($$$$)

Strensiq PA 3($$$)

Sylatron Kit PA SP 4($$$$)

Xenazine GE PA SP 4($$$$) Tetrabenazine PA SP 4($$$$)




Tier Copay ($$$$)



Musculoskeletal and Pain - Analgesics - Non-Narcotic

Choline Mag Trisalicylate 1($)

Probenecid 1($)

Salsalate 1($)

Musculoskeletal and Pain - Analgesics - Opioid

Abstral PA 3($$$)

Actiq Lozenge PA GE 3($$$) Fentanyl Lozenge 1($)

Avinza GE 3($$$) Morphine Extended Rel 1($)

Butorphanol Nasal Spray 1($)

Butrans 3($$$)

Codeine 1($)

Dilaudid GE 3($$$) Hydromorphone 1($)

Dolophine GE 3($$$) Methadone 1($)

Duragesic GE 3($$$) Fentanyl Patch 1($)

Embeda 3($$$)

Fentora PA 3($$$)

Hydrocodone/Acetaminophen (APAP) 1($)

Kadian GE 3($$$) Morphine Sulfate ER 1($)

Levorphanol 1($)

Lortab GE 3($$$) Hydrocodone/Acetaminophen (APAP) 1($)

Morphine 1($)

MS Contin GE 3($$$) Morphine Sulfate SA 1($)

Norco GE 3($$$) Hydrocodone/Acetaminophen (APAP) 1($)

Nucynta 3($$$)

Nucynta ER 3($$$)

Opana GE 3($$$) Oxymorphone 1($)

Opana ER 3($$$)

Oxycodone 1($)

Oxycodone HCL SR 1($)

Oxycodone/Ibuprofen 1($)

Oxycontin 2($$)

Oxycontin 10 mg & 20 mg GE 2($$) Oxycodone ER 12 HR 1($)

Percocet GE 3($$$) Oxycodone/Acetaminophen (APAP) 1($)

Percodan GE 3($$$) Oxycodone/Aspirin (ASA) 1($)

Reprexain 1($)




Tier Copay ($$$$)



Musculoskeletal and Pain - Analgesics – Opioid - Continued

Roxicodone GE 3($$$) Oxycodone 1($)

Tylenol/Codeine GE 3($$$) Acetaminophen (APAP) / Codeine 1($)

Ultracet GE 3($$$) Tramadol/Acetaminophen (APAP) 1($)

Ultram GE 3($$$) Tramadol 1($)

Ultram ER GE 3($$$) Tramadol ER 1($)

Vicodin 1($)

Vicodin ES 1($)

Vicodin HP 1($)

Vicoprofen GE 3($$$) Hydrocodone/Ibuprofen 1($)

Musculoskeletal and Pain - Anticonvulsants (Seizures)

Aptiom PA 4 ($$$$)

Banzel 2($$)

Carbatrol NTI 2($$) Carbamazepine ER 1($)

Depakene NTI 2($$) Valproic Acid 1($)

Depakote NTI 2($$) Divalproex 1($)

Depakote ER NTI 2($$) Divalproex ER 1($)

Depakote Sprinkle NTI 2($$) Divalproex ER 1($)

Dilantin NTI 2($$) Phenytoin 1($)

Felbatol GE 3($$$) Felbamate 1($)

Fycompa PA 3($$$)

Gabitril 12 mg & 16 mg 2($$)

Gabitril 2 mg & 4 mg GE 3($$$) Tiagabine 2 mg & 4 mg 1($)

Keppra GE 3($$$) Levetiracetam 1($)

Keppra XR GE

3($$$) Levetiracetam ER 1($)

Klonopin GE 3($$$) Clonazepam 1($)

Lamictal NTI 2($$) Lamotrigine 1($)

Lamictal chewable NTI 2($$) Lamotrigine chewable 1($)

Lamictal ODT NTI 2($$)

Lamictal XR NTI 2($$) Lamotrigine ER 1($)

Lyrica 2($$)

Mysoline GE 3($$$) Primidone 1($)

Neurontin GE 3($$$) Gabapentin 1($)

Onfi PA 3($$$)

Phenobarbital 1($)

Phenytek NTI 2($$) Phenytoin 1($)




Tier Copay ($$$$)



Musculoskeletal and Pain - Anticonvulsants (Seizures) - Continued

Stavzor 3($$$)

Tegretol NTI 2($$) Carbamazepine 1($)

Tegretol XR NTI 2($$) Carbamazepine ER 1($)

Topamax NTI 2($$) Topiramate 1($)

Trileptal NTI 2($$) Oxcarbazepine 1($)

Vimpat 3($$$)

Zarontin NTI 2($$) Ethosuximide 1($)

Zonegran NTI 2($$) Zonisamide 1($)

Musculoskeletal and Pain - Anti-Inflammatory - Miscellaneous

Arava GE QL 3($$$) Leflunomide QL 1($)

Azulfidine GE 3($$$) Sulfasalazine 1($)

Cimzia PA SP 4($$$$)

Cosentyx PA SP 4($$$$)

Enbrel PA SP 3($$$)

Humira PA SP 3($$$)

Imuran GE 3($$$) Azathioprine 1($)

Kineret PA 4($$$$)

Otezla PA SP 4($$$$)

Plaquenil GE 3($$$) Hydroxychloroquine 1($)

Rheumatrex GE 3($$$) Methotrexate 1($)

Ridaura 2($$)

Simponi PA SP 4($$$$)

Stelara PA SP 4($$$$)

Xeljanz PA SP 4($$$$)

Musculoskeletal and Pain - Anti-Inflammatory - Nonsteroidal Anti-Inflammatory Agents (NSAIDs)

Anaprox GE 3($$$) Naproxen Sodium 1($)

Arthrotec GE 3($$$) Diclofenac-Misoprostol 1($)

Celebrex GE QL 3($$$) Celecoxib QL 1($)

Clinoril GE 3($$$) Sulindac 1($)

Daypro GE 3($$$) Oxaprozin 1($)

Diflunisal 1($)

Etodolac 1($)

Etodolac SR 1($)

Feldene GE 3($$$) Piroxicam 1($)

Flurbiprofen 1($)




Tier Copay ($$$$)



Musculoskeletal and Pain - Anti-Inflammatory - Nonsteroidal Anti-Inflammatory Agents (NSAIDs) - Continued

Ibuprofen 1($)

Indomethacin 1($)

Indomethacin SR 1($)

Ketoprofen 1($)

Ketorolac QL 2($$)

Mobic GE 3($$$) Meloxicam 1($)

Nabumetone 1($)

Nalfon GE 3($$$) Fenoprofen 1($)

Naprosyn GE 3($$$) Naproxen 1($)

Tolectin GE 3($$$) Tolmetin 1($)

Voltaren GE 3($$$) Diclofenac 1($)

Voltaren XR GE 3($$$) Diclofenac XR 1($)

Musculoskeletal and Pain - Antiparkinson Agents

Amantadine 1($)

Apokyn SP 4($$$$)

Benztropine 1($)

Carbidopa/Levodopa 1($)

Comtan GE 3($$$) Entacapone 1($)

Eldepryl Capsules GE 3($$$) Selegiline Capsules 1($)

Lodosyn GE 3($$$) Carbidopa 1($)

Mirapex GE 3($$$) Pramipexole 1($)

Mirapex ER GE 3($$$) Pramipexole ER 1($)

Neupro 2($$)

Parlodel GE 3($$$) Bromocriptine 1($)

Pergolide 1($)

Pramipexole 1($) 1($)

Pramipexole ER 1($) 1($)

Requip GE 3($$$) Ropinirole 1($)

Requip XL GE 3($$$) Ropinirole XL 1($)

Sabril SP 4($$$$)

Selegiline Tablet 1($)

Sinemet GE 3($$$) Carbidopa/Levodopa 1($)

Sinemet CR GE 3($$$) Carbidopa/Levodopa SR 1($)

Stalevo GE 3($$$) Carbidopa/Levodopa/Entacapone 1($)

Trihexyphenidyl 1($)




Tier Copay ($$$$)



Musculoskeletal and Pain - Gout Agents

Colcrys GE 3($$$) Colchicine 1($)

Mitigare 3($$$)

Uloric 3($$$)

Zurampic ST 3($$$) Lesinurad 1($)

Zyloprim GE 3($$$) Allopurinol 1($)

Musculoskeletal and Pain - Migraine Products

Alsuma GE QL 3($$$) Sumatriptan Succinate Injectable QL 1($)

Amerge GE QL 3($$$) Naratriptan QL 1($)

Axert GE QL 3($$$) Almotriptan QL 1($)

Cafergot 3($$$)

Esgic GE 3($$$) Acetaminophen(APAP)/Caffeine/Butalbital 1($)

Fioricet/Codeine GE 3($$$) Acetaminophen(APAP)/Caffeine/Butalbital/Codein 1($)

Fiorinal/Codeine QL 3($$$)

Frova GE QL 3($$$) Frovatriptan Succinate QL 1($)

Imitrex GE QL 3($$$) Sumatriptan Succinate QL 1($)

Imitrex Injectable GE QL 3($$$) Sumatriptan Succinate Injectable QL 1($)

Imitrex Nasal Spray GE QL 3($$$) Sumatriptan Succinate Nasal Spray QL 1($)

Maxalt GE QL 3($$$) Rizatriptan Benzoate QL 1($)

Maxalt MLT GE QL 3($$$) Rizatriptan Benzoate ODT QL 1($)

Midrin GE 3($$$) Acetaminophen(APAP)/Isometheptene/Dichlphena

1($)

Migranal GE QL 3($$$) Dihydroergotamine Mesylate Spray QL 1($)

Relpax 2($$)

Zomig GE QL 3($$$) Zolmitriptan QL 1($)

Zomig Nasal Spray QL 2($$)

Zomig ZMT GE QL 3($$$) Zolmitriptan ODT QL 1($)

Musculoskeletal and Pain - Muscle Relaxants

Dantrium GE 3($$$) Dantrolene 1($)

Flexeril GE 3($$$) Cyclobenzaprine 1($)

Lioresal GE 3($$$) Baclofen 1($)

Lorzone 3($$$)

Norflex Oral GE 3($$$) Orphenadrine Oral 1($)

Parafon Forte DSC GE 3($$$) Chlorzoxazone 1($)

Robaxin GE 3($$$) Methocarbamol 1($)

Skelaxin GE 3($$$) Metaxalone 1($)

Soma GE 3($$$) Carisoprodol 1($)

Zanaflex GE 3($$$) Tizanidine 1($)




Tier Copay ($$$$)



Musculoskeletal and Pain - Neuromuscular Agents

Nuedexta 3($$$)

Rilutek GE 3($$$) Riluzole 1($)

Psychotherapeutic and Neurological Agents - Agents for Chemical Dependency

Buprenorphine/Naloxone Tablets 1($)

Disulfiram 1($)

Suboxone Film 2($$)

Psychotherapeutic and Neurological Agents - Antidementia (Alzheimer's) Agents

Aricept GE 3($$$) Donepezil 1($)

Exelon GE 3($$$)

Rivastigmine 1($)

Exelon Patch GE 3($$$) Rivastigmine Transdermal Patch 1($)

Namenda GE 3($$$) Memantine 1($)

Namenda XR 2($$)

Namenda Oral Solution GE 3($$$) Memantine Oral Solution 1($)

Razadyne GE 3($$$) Galantamine 1($)

Razadyne ER GE 3($$$) Galantamine 24hr cap 1($)

Psychotherapeutic and Neurological Agents - Miscellaneous

Savella 3($$$)

Symbyax GE 3($$$) Olanzapine-Fluoxetine 1($)

Psychotherapeutic and Neurological Agents - Multiple Sclerosis Agents

Ampyra SP 4($$$$)

Avonex SP 3($$$)

Betaseron PA ST SP 4($$$$)

Copaxone 20 mg GE SP 4($$$$) Glatopa SP 4($$$$)

Copaxone 40 mg SP 3($$$)

Extavia PA ST SP 4($$$$)

Gilenya ST SP 4($$$$)

Rebif SP 4($$$$)

Tecfidera QL SP 4($$$$)

Psychotherapeutic and Neurological Agents - Smoking (Tobacco) Cessation

Bupropion (Generic for Zyban) *1($)

Chantix *2($$)

Generic Nicotine Replacements (Patches, gum, etc) *1($)




Tier Copay ($$$$)



Respiratory Agents - Antihistamines

Hydroxyzine HCL 1($)

Promethazine 1($)

Promethazine/Codeine 1($)

Vistaril GE 3($$$) Hydroxyzine Pamoate 1($)

Respiratory Agents - Bronchodilators - Anticholinergics

Arcapta Neohaler 3($$$)

Atrovent HFA 2($$)

Brovana 3($$$)

Combivent Respimat 2($$)

Daliresp 3($$$)

Duoneb GE 3($$$) Albuterol sulfate/Ipratropium 1($)

Ipratropium solution 1($)

Perforomist 2($$)

Spiriva 2($$)

Stiolto Respimat 3($$$)

Tudorza Pressair 3($$$)

Respiratory Agents - Cough / Cold / Allergy

Tessalon GE 3($$$) Benzonatate 1($)

Respiratory Agents - Leukotriene Modulators

Accolate GE 3($$$) Zafirlukast 1($)

Singulair GE 3($$$) Montelukast 1($)

Respiratory Agents - Nasal Agents - Systemic and Topical

Astepro GE 3($$$) Azelastine Nasal Spray 1($)

Atrovent Nasal Spray GE 3($$$) Ipratropium Spray 1($)

Azelastine 1($)

Beconase AQ 3($$$)

Dymista 3($$$)

Flonase GE 3($$$) Fluticasone Spray 1($)

Flunisolide 1($)

Nasonex GE 3($$$) Mometasone Furoate Nasal Spray 1($)

Omnaris 3($$$)

Patanase GE 3($$$) Olopatadine Nasal Spray 1($)

Rhinocort Aqua GE 3($$$) Budesonide Nasal 1($)

Triamcinolone Nasal Spray 1($)

Veramyst 3($$$)




Tier Copay ($$$$)



Respiratory Agents - Nasal Agents - Systemic and Topical

Zetonna 3($$$)

Respiratory Agents - Respiratory Agents - Miscellaneous

Cromolyn solution 1($)

Nucala PA SP 4($$$$)

Xolair PA SP 4($$$$)

Respiratory Agents - Steroid Inhalants

Alvesco 3($$$)

Asmanex 2($$)

Flovent Diskus 2($$)

Flovent HFA 2($$)

Pulmicort Flexhaler 2($$)

Pulmicort Inhalation Suspension GE 3($$$) Budesonide Inhalation Suspension 1($)

Qnasl 3($$$)

QVAR 2($$)

Respiratory Agents - Sympathomimetics

Advair Diskus 2($$)

Advair HFA 2($$)

Albuterol (oral, solution) 1($)

Dulera 3($$$)

Foradil 2($$)

Levalbuterol 1($)

Perforomist 2($$)

ProAir HFA 2($$)

ProAir Respiclick 2($$) 1($)

Proventil HFA 3($$$)

Serevent Diskus 2($$)

Symbicort 2($$)

Ventolin HFA 2($$)

Vospire ER GE 3($$$) Albuterol 1($)

Xopenex HFA GE 3($$$) Levalbuterol 1($)

Respiratory Agents - Xanthines

Theo-24 NTI

2($$)

Theophylline NTI

1($)




Tier Copay ($$$$)



Topical Products - Acne Products

Atralin 3($$$)

Avita 3($$$)

Azelex 3($$$)

Benzaclin GE 3($$$) Clindamycin/Benzoyl Peroxide 1($)

Benzamycin GE 3($$$) Erythromycin/Benzoyl Peroxide 1($)

Cleocin T GE 3($$$) Clindamycin 1($)

Differin 0.1% Cream GE 3($$$) Adapalene 0.1% Cream 1($)

Differin 0.1% Gel GE 3($$$) Adapalene 0.1% Gel 1($)

Differin 0.1% Lotion GE 3($$$) Adapalene 0.1% Lotion 1($)

Differin 0.3% Gel GE 3($$$) Adapalene 0.3% Gel 1($)

Duac Gel GE 3($$$) Clindamycin/Benzoyl Peroxide 1($)

Erycette GE 3($$$) Erythromycin Pledgets 1($)

Isotretinoin (Amnesteem, Claravis) 1($)

Klaron 3($$$)

Peroxin GE 3($$$) Benzoyl Peroxide 1($)

Retin-A GE 3($$$) Tretinoin 1($)

Retin-A Micro GE 3($$$) Tretinoin 1($)

Retin-A Micro Pump GE 3($$$) Tretinoin 1($)

Rosanil Kit 3($$$)

Sodium Sulfacetamide/Sulfur 1($)

Tazorac 2($$)

Ziana Gel GE 3($$$) Clindamycin-tretinoin external gel

1($)

Topical Products - Anorectal Agents

Proctocort Cream GE 3($$$) Hydrocortisone 1($)

Proctocort Suppository 3($$$)

Proctofoam 3($$$)

Topical Products - Antibiotics - Topical

Aczone Gel 7.5% 3($$$)

Bactroban GE 3($$$) Mupirocin ointment 1($)

Bactroban Cream GE 3($$$) Mupirocin cream 1($)

Silvadene GE 3($$$) Silver Sulfadiazine 1($)

Topical Products - Antifungals - Topical

Econazole 1($)

Ertaczo 3($$$)

Exelderm 3($$$)

Extina GE 3($$$) Ketoconazole 1($)




Tier Copay ($$$$)



Topical Products - Antifungals - Topical

Ketoconazole Cream 1($)

Lamisil Spray 3($$$)

Loprox Gel GE 3($$$) Ciclopirox gel 1($)

Loprox Shampoo GE 3($$$) Ciclopirox shampoo 1($)

Oxistat 3($$$)

Topical Products - Antineoplastic or Premalignant Lesion Agents - Topical

Carac GE 3($$$) Fluorouracil 1($)

Efudex GE 3($$$) Fluorouracil 1($)

Metvixia Cream photodynamic therapy 3($$$)

Solaraze GE PA 3($$$) Diclofenac gel 3% 1($)

Topical Products - Antipsoriatics

Dovonex GE 3($$$) Calcipotriene 1($)

Oxsoralen (oral medication) GE 3($$$) Methoxsalen Rapid Cap 1($)

Soriatane (oral medication) GE 3($$$) Acitretin 1($)

Taclonex 3($$$)

Tazorac 2($$)

Topical Products - Corticosteroids - Topical

Aclovate GE 3($$$) Alclometasone 1($)

Capex Shampoo 2($$)

Cloderm GE 3($$$) Clocortolone 1($)

Cordan Cream 0.05% GE 3($$$) Flurandrenolide Cream 0.05% 1($)

Cutivate GE 3($$$) Fluticasone 1($)

Desonide 1($)

Desowen GE 3($$$) Desonide 1($)

Desoximetasone 1($)

Diflorasone 1($)

Diprolene AF GE 3($$$) Betamethasone 1($)

Elocon GE 3($$$) Mometasone 1($)

Fluocinolone 1($)

Fluocinonide 1($)

Fluocinonide emollient 1($)

Hydrocortisone (RX strength) 1($)

Kenalog Spray 3($$$) Triamcinolone Acetonide 1($)

Luxiq GE 3($$$) Betamethasone Valerate 1($)

Olux GE 3($$$) Clobetasol 1($)




Tier Copay ($$$$)



Topical Products - Corticosteroids - Topical

Olux-E GE 3($$$) Clobetasol emulsion 1($)

Taclonex Scalp 3($$$)

Temovate GE 3($$$) Clobetasol Propionate 1($)

Topicort GE 3($$$) Desoximetasone 1($)

Triamcinolone 1($)

Triamcinolone Acetonide 1($) 1($)

Triamcinolone HP 1($)

Ultravate GE 3($$$) Halobetasol 1($)

Voltaren Gel 3($$$)

Topical Products - Immunosuppressive Agents - Topical

Elidel 3($$$)

Protopic GE 3($$$) Tacrolimus 1($)

Topical Products - Ophthalmic - Anti-Allergic/Anti-Inflammatory Agents

Acular GE 3($$$) Ketorolac 1($)

Alomide 3($$$)

Bepreve 3($$$)

Bromfenac 1($)

Durezol 3($$$)

Elestat GE 3($$$) Epinastine 1($)

FML GE 3($$$) Fluorometholone 1($)

FML Forte 3($$$)

Lastacaft 3($$$)

Lotemax 2($$)

Optivar GE 3($$$) Azelastine 1($)

Pataday 2($$)

Patanol 2($$)

Voltaren GE 3($$$) Diclofenac Sodium 1($)

Topical Products - Ophthalmic - Anti-Glaucoma Agents

Alphagan P 0.1% 2($$)

Alphagan P 0.15% GE 3($$$) Brimonidine Tartrate 0.15% 1($)

Azopt 2($$)

Betagan GE 3($$$) Levobunolol 1($)




Tier Copay ($$$$)



Topical Products - Ophthalmic - Anti-Glaucoma Agents - Continued

Betoptic GE 3($$$) Betaxolol 1($)

Betoptic S 3($$$)

Brimonidine Tartrate 0.2% 1($)

Combigan 3($$$)

Cosopt GE 3($$$) Timolol/Dorzolamide 1($)

Lumigan 3($$$)

Pilocarpine 1($)

Simbrinza 2($$)

Timoptic GE 3($$$) Timolol 1($)

Timoptic XE GE 3($$$) Timolol XE 1($)

Travatan Z 2($$)

Travoprost 1($)

Trusopt GE 3($$$) Dorzolamide 1($)

Xalatan GE 3($$$) Latanoprost 1($)

Topical Products - Ophthalmic - Anti-Infective Agents

Azasite 3($$$)

Besivance 3($$$)

Ciloxan Ointment 3($$$)

Ciloxan Solution GE 3($$$) Ciprofloxacin Solution 1($)

Erythromycin 1($)

Gentamicin 1($)

Moxeza 2($$)

Ocuflox GE 3($$$) Ofloxacin 1($)

Tobradex GE 3($$$) Tobramycin/Dexamethasone 1($)

Tobrex GE 3($$$) Tobramycin 1($)

Vigamox 3($$$)

Xifaxan 2($$)

Zymaxid GE 3($$$) Gatifloxacin 1($)

Topical Products - Otic Agents

Acetic Acid/HC 1($)

Antipyrine/Benz/Glycerin 1($)

Cetraxal GE 3($$$) Ciprofloxacin 1($)

Cipro HC 3($$$)

Ciprodex 2($$)




Tier Copay ($$$$)



Topical Products - Otic Agents - Continued

Coly-Mycin S 3($$$)

Cortisporin solution GE 3($$$) Polymyxin-B/Neomycin/HC 1($)

Cortisporin suspension GE 3($$$) Polymyxin-B/Neomycin/HC 1($)

Cortisporin-TC 3($$$)

Ofloxacin 1($)

Lacrisert Insert 2($$)

Topical Products - Topicals - Miscellaneous

Aldara GE 3($$$) Imiquimod 1($)

Condylox Solution GE 3($$$) Podofilox solution 1($)

Denavir 2($$)

Drysol Slution 3($$$) 1($)

Emla GE 3($$$) Lidocaine/Prilocaine 1($)

Finacea 2($$)

LidoRx 3($$$)

Lidovir 3($$$)

Metrocream GE 3($$$) Metronidazole cream 1($)

MetroGel GE 3($$$) Metronidazole gel 1($)

Metrolotion GE 3($$$) Metronidazole lotion 1($)

Noritate 2($$)

Penlac 8% solution GE 3($$$) Ciclopirox 8% solution 1($)

Regranex PA 2($$)

Sodium Sulfacetamide/Sulfur 1($)

Taclonex Oint GE 3($$$) Calcipotriene/Betamethasone Dipropionate ointme 1($)

Vaccines - Vaccines

Influenza (flu) * *Available at no cost when obtained from vaccine network pharmacy

Pneumococcal (pneumonia) * *Available at no cost when obtained from vaccine network pharmacy

Zostavax (shingles) * *Available at no cost when obtained from vaccine network pharmacy




Tier Copay ($$$$)



Vitamins and Minerals - Minerals and Electrolytes

Folene 3($$$)

K-Tab GE 3($$$) Potassium Chloride (KCL) SA 1($)

Micro-K 10 GE 3($$$) Potassium Chloride (KCL) 1($)

Potassium Chloride (KCL) SA 1($)

Urocit-K GE 3($$$) Potassium Citrate SA 1($)

Vitamins and Minerals - Prenatal Vitamins

Duet DHA 3($$$)

Duet Stuart Natal 3($$$)

Nestabs RX GE 3($$$) Natatab 1($)

Prenatal Advantage 1($)

Prenatal Optima Advance 1($)

Provida 3($$$) 1($)

Stuart Natal 3 GE 3($$$) Prenatal Formula 3 1($)

Tricare GE 3($$$) Prenatal Plus 1($)

Vitafol Chw Gummies 3($$$)




Tier Copay ($$$$)



*Certain preventive drugs may be available at no cost under the Affordable Care Act.

Contraceptives - Generic Injection

Medroxyprogesterone Injection *1($)

Contraceptives - Generic Patch

Xulane *1($)

Contraceptive - Vaginal Ring

Nuvaring *2($$)

Contraceptives – Emergency (Oral)

Ella *3($$$)

Levonorgestrel *1($)

Plan B One-Step GE *3($$$) Next Choice One Dose *$(1)

Contraceptives - Generic Oral Contraceptives

All Generic Oral Contraceptives *1($)

All generic oral contraceptives are covered under the formulary. Due to the vast number of available generic oral contraceptives, not all may be listed.

Altavera *1($)

Alyacen 1-35, Alyacen 7-7-7 *1($)

Amethia 0.15-0.03-0.01 *1($)

Amethia Lo *1($)

Amethyst 90-20 mcg *1($)

Apri *1($)

Aranelle *1($)

Aviane *1($)

Azurette *1($)

Balziva *1($)

Briellyn *1($)

Camila *1($)

Camrese 0.15-0.03-0.01 *1($)

Camrese Lo *1($)

Caziant *1($)

Cesia *1($)

Cryselle *1($)

Cyclafem 1-35, Cyclafem 7-7-7 *1($)

Emoquette *1($)

Enpresse *1($)

Errin *1($)

Gianvi 3-0.02 *1($)




Tier Copay ($$$$)



Contraceptives - Generic Oral - Continued

Gildess FE 1.5-30, Gildess FE 1-20 *1($)

Introvale 0.15-0.03 *1($)

Jolessa 0.15-0.03 *1($)

Junel 1.5-30 *1($)

Junel 1-20 *1($)

Junel FE 1.5-30 *1($)

Junel FE 1-20 *1($)

Kariva *1($)

Kelnor 1/35 *1($)

Leena *1($)

Lessina *1($)

Levora *1($)

Loryna 3-0.02 *1($)

Low-Ogestrel *1($)

Lutera *1($)

Marlissa *1($)

Microgestin 21 1.5-30 *1($)

Microgestin 21 1-20 *1($)

Microgestin FE 1.5-30 *1($)

Microgestin FE 1-20 *1($)

Mononessa *1($)

Myzilra *1($)

Necon 0.5-35 *1($)

Necon 10-11 *1($)

Necon 1-35 *1($)

Necon 1-50 *1($)

Necon 7-7-7 *1($)

Nora-BE *1($)

Nortrel 0.5-35 *1($)

Nortrel 1-35 *1($)

Nortrel 7-7-7 *1($)

Ocella 3-0.03 *1($)

Ogestrel *1($)

Orsythia *1($)

Philith 0.4-0.0.35 *1($)




Tier Copay ($$$$)



Contraceptives – Generic Oral - Continued

Portia *1($)

Previfem *1($)

Quasense 0.15-0.03 *1($)

Reclipsen *1($)

Solia 0.15-0.03 *1($)

Sprintec *1($)

Sronyx 0.10-0.02 *1($)

Syeda *1($)

Tilia FE *1($)

Tri-Legest FE *1($)

Trinessa *1($)

Tri-Previfem *1($)

Tri-Sprintec *1($)

Trivora *1($)

Velivet *1($)

Viorele *1($)

Wymzya Chewable *1($)

Zarah *1($)

Zenchent 0.4-35 *1($)

Zovia 1-35 *1($)

Zovia 1-50 *1($)

Contraceptives – Brand Oral

Beyaz 3($$$)

Brevicon GE 3($$$) Nortrel *1($)

Desogen GE 3($$$) Solia *1($)

Estrostep/FE GE 3($$$) Tilia FE, Tri-Legest FE *1($)

Lo Loestrin FE 1-10 3($$$)

Loestrin FE GE 3($$$) Microgestin FE *1($)

Loseasonique GE 3($$$) Amethia Lo *1($)

Mircette GE 3($$$) Kariva, Azurette *1($)

Modicon GE 3($$$) Nortrel *1($)

Natazia 3($$$)

Nordette GE 3($$$) Levora *1($)

Norinyl GE 3($$$) Nortrel, Necon *1($)




Tier Copay ($$$$)



Contraceptives – Brand Oral - Continued

Nor-Q-D GE 3($$$) Camila, Errin, Jolivette *1($)

Ortho Evra Patch GE 3($$$) Norelgestromin-Ethinyl Estradiol Patch *1($)

Ortho Micronor GE 3($$$) Camila, Errin, Jolivette *1($)

Ortho-Cyclen GE 3($$$) Mononessa, Sprintec *1($)

Ortho-Novum 1/35 GE 3($$$) Necon *1($)

Ortho-Novum 777 GE 3($$$) Necon *1($)

Ortho-Tri-Cyclen GE 3($$$) Trinessa *1($)

Ortho-Tri-Cyclen Lo 3($$$)

Ovcon-35 GE 3($$$) Balziva, Zenchent *1($)

Safyral 3($$$)

Seasonique GE 3($$$) Amethia, Camrese *1($)

Tri-Norinyl GE 3($$$) Leena, Junel *1($)

Yasmin GE 3($$$) Ocella *1($)

Yaz GE 3($$$) Gianvi, Loryna *1($)

Contraceptives - Cervical Caps

Femcap Vaginal Device 26 MM, 30 MM *1($)

Prentif Cavity-Rim Cerv Cap *1($)

Contraceptives - Condoms-Female

FC FEmale Condom *1($)

Contraceptives - Diaphragms

Coilspring *1($)

Flatspring *1($)

Omniflex *1($)

Ortho All-Flex *1($)

Contraceptives- Spermicides

Encare Vaginal Suppository *1($)

Options Conceptrol *1($)

Options Gynol II Contraceptive *1($)

Shur-Seal Contraceptive *1($)

Today Sponge *1($)

VCF Vaginal Contraceptive *1($)

blue cross of idaho four-tier prescription drug formulary tier... · four-tier prescription drug...

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