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Drug FormularyFebruary 2018Drug Formulary
For the most up to date formulary coverage search, please use the searchable formulary website
1
lowercase italics= Generic drugs
UPPERCASE= Brand name
drugs
Tier T1= Formulary
T2= Non-Preferred Brand,
Generic Available
T3= Non-Formulary
T4= Specialty
Notes AL= Age limit applies
PA= PA Applies
QL= Quantity Limit
ST= ST applies
Drug Tier Notes
Antihistamine Drugs
Ethanolamine Derivatives
CHILDREN'S BENADRYL ALLERGY T1
dimenhydrinate T1
DIPHENHIST T1
diphenhydramine hcl injection T1 QL (20 ML per 25 days)
diphenhydramine hcl oral T1
SLEEP AID (DOXYLAMINE) T1
First Gen. Antihist. Derivatives, Misc.
cyproheptadine T1
First Generation Antihistamines
ALLER-CHLOR T1
CHILDREN'S BENADRYL ALLERGY T1
chlorpheniramine maleate T1
cyproheptadine T1
dimenhydrinate T1
DIPHENHIST T1
diphenhydramine hcl injection T1 QL (20 ML per 25 days)
diphenhydramine hcl oral T1
SLEEP AID (DOXYLAMINE) T1
Phenothiazine Derivatives
PHENERGAN T2
promethazine T1
PROMETHAZINE VC T1
2
Drug Tier Notes
PROMETHAZINE VC-CODEINE T1 QL (120 ML per 30 days); AL
Piperazine Derivatives
ANTIVERT T2
hydroxyzine hcl T1
hydroxyzine pamoate T1
meclizine T1
VISTARIL T2
Propylamine Derivatives
ALLER-CHLOR T1
chlorpheniramine maleate T1
M-END DMX T1
SUDOGEST COLD AND ALLERGY T1
ZODRYL AC 25 T1
ZODRYL AC 30 T1
ZODRYL AC 35 T1
ZODRYL AC 40 T1
ZODRYL AC 50 T1
ZODRYL AC 60 T1
ZODRYL AC 80 T1
Second Generation Antihistamines
ALAVERT T2
ALLEGRA-D 12 HOUR T3 PA
ALLEGRA-D 24 HOUR T3 PA
ALLERGY RELIEF (CETIRIZINE) T1 ST
cetirizine oral solution T1
cetirizine oral tablet T1
cetirizine oral tablet,chewable T3 PA
cetirizine-pseudoephedrine T1 ST
CHILDREN'S ZYRTEC ALLERGY T1 ST
CLARINEX T3 PA
CLARITIN T2
CLARITIN REDITABS T3 PA
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3
Drug Tier Notes
desloratadine T3 PA
fexofenadine oral suspension T1 ST; QL (10 ML per 1 day)
fexofenadine oral tablet 180 mg T1 ST
fexofenadine oral tablet 60 mg T3 PA
levocetirizine oral solution T3 PA
levocetirizine oral tablet T1
loratadine oral capsule T1 ST
loratadine oral solution T1 ST
loratadine oral tablet T1
loratadine oral tablet,disintegrating T1 ST
LORATADINE-D T3 PA
SEMPREX-D T3 PA
ZYRTEC T2
Anti-Infective Agents
1St Generation Cephalosporin Antibiotics
cefadroxil T1
cephalexin T1
KEFLEX T2
2Nd Generation Cephalosporin Antibiotics
cefaclor T1
cefprozil T1
CEFTIN ORAL SUSPENSION FOR
RECONSTITUTION
T1 QL (100 QY per 1 day)
CEFTIN ORAL TABLET T2
cefuroxime axetil oral suspension for
reconstitution
T1 QL (100 QY per 1 day)
cefuroxime axetil oral tablet 250 mg T1 QL (2 EA per 1 day)
cefuroxime axetil oral tablet 500 mg T1
3Rd Generation Cephalosporin Antibiotics
cefdinir T1
cefpodoxime T1
ceftriaxone T1
4
Drug Tier Notes
ZERBAXA T4 PA
5Th Generation Cephalosporin Antibiotics
TEFLARO T4 PA
Adamantane Antivirals
amantadine hcl T1
Allylamine Antifungals
LAMISIL T2 QL (90 DS per 365 DYs)
terbinafine hcl T1 QL (90 DS per 365 DYs)
Amebicides
FLAGYL T2
metronidazole T1
paromomycin T1 PA; QL (10 DS per 30 DYs)
YODOXIN T1
Aminoglycoside Antibiotics
ARIKAYCE T4 PA
BETHKIS T4 PA
paromomycin T1 PA; QL (10 DS per 30 DYs)
TOBI T4 PA
TOBI PODHALER T4 PA
tobramycin with nebulizer T4 PA
ZEMDRI T4 PA
Aminomethylcyclines
NUZYRA T4 PA
NUZYRA (7 DAY WITH LOAD DOSE) T4 PA
NUZYRA (7 DAY) T4 PA
Aminopenicillin Antibiotics
amoxicillin T1
amoxicillin-pot clavulanate T1
ampicillin T1
AUGMENTIN T2
Anthelmintics
albendazole T1
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Drug Tier Notes
EMVERM T1
ivermectin T1
praziquantel T1
STROMECTOL T2
Antifungals, Miscellaneous
griseofulvin microsize T1
griseofulvin ultramicrosize T1
GRIS-PEG (ULTRAMICROSIZE) T2
SSKI T1
Antimalarials
ARALEN T2
chloroquine phosphate T1
DARAPRIM T4 PA
hydroxychloroquine T1
mefloquine T1
PLAQUENIL T2
primaquine T1
quinidine sulfate T1
Antimycobacterials, Miscellaneous
dapsone T1
Antiprotozoals, Miscellaneous
atovaquone T1 PA
dapsone T1
FLAGYL T2
MEPRON T2 PA
metronidazole T1
NEBUPENT T4 PA
Antituberculosis Agents
AVELOX T2 QL (10 QY per 30 DYs)
AVELOX ABC PACK T2 QL (1 FL per 30 DYs)
BIAXIN T2 QL (1 FL per 30 DYs)
6
Drug Tier Notes
BIAXIN XL T2 QL (1 FL per 30 DYs)
CIPRO ORAL SUSPENSION,MICROCAPSULE
RECON
T2
CIPRO ORAL TABLET T2 QL (68 QY per 34 DYs)
ciprofloxacin T1
ciprofloxacin hcl oral tablet 100 mg T1 QL (28 EA per 30 DYs)
ciprofloxacin hcl oral tablet 250 mg T1 QL (68 EA per 34 DYs)
ciprofloxacin hcl oral tablet 500 mg T1 QL (68 QY per 34 DYs)
ciprofloxacin hcl oral tablet 750 mg T1 QL (28 QY per 14 DYs)
clarithromycin T1 QL (1 FL per 30 DYs)
ethambutol T1
isoniazid T1
LEVAQUIN ORAL SOLUTION T2 QL (1 FL per 30 DYs)
LEVAQUIN ORAL TABLET T2 QL (14 QY per 30 DYs)
levofloxacin oral solution T1 QL (1 FL per 30 DYs)
levofloxacin oral tablet T1 QL (14 QY per 30 DYs)
moxifloxacin T1 QL (10 QY per 30 DYs)
pyrazinamide T1
rifabutin T1
RIFADIN INTRAVENOUS T4 PA
RIFADIN ORAL T2
rifampin T1
Antivirals, Miscellaneous
PREVYMIS T4 PA
Azole Antifungals
CRESEMBA T4 PA
DIFLUCAN ORAL SUSPENSION FOR
RECONSTITUTION
T2
DIFLUCAN ORAL TABLET 100 MG, 200 MG,
50 MG
T2
DIFLUCAN ORAL TABLET 150 MG T2 QL (2 QY per 30 DYs)
fluconazole oral suspension for reconstitution T1
fluconazole oral tablet 100 mg, 200 mg, 50 mg T1
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7
Drug Tier Notes
fluconazole oral tablet 150 mg T1 QL (2 QY per 30 DYs)
ketoconazole T1
TOLSURA T4 PA
Carbapenem Antibiotics
INVANZ T4 PA
Chloramphenicol Antibiotics
chloramphenicol sod succinate T1
Cyclic Lipopeptide Antibiotics
CUBICIN T4 PA
daptomycin T4 PA
Erythromycin Antibiotics
ERYPED 400 T1
ERY-TAB T1
ERYTHROCIN (AS STEARATE) T1
erythromycin T1
erythromycin ethylsuccinate T1
erythromycin-sulfisoxazole T1
Glycopeptide Antibiotics
DALVANCE T4 PA
FIRVANQ T1
vancomycin T1
Glycylcycline Antibiotics
TYGACIL T4 PA
Hcv Polymerase Inhibitor Antivirals
EPCLUSA T4 PA
HARVONI T4 PA
ledipasvir-sofosbuvir T4 PA
sofosbuvir-velpatasvir T4 PA
SOVALDI T4 PA
VIEKIRA PAK T4 PA
VIEKIRA XR T4 PA
8
Drug Tier Notes
VOSEVI T4 PA
Hcv Protease Inhibitor Antivirals
MAVYRET T4 PA
OLYSIO T4 PA
TECHNIVIE T4 PA
VIEKIRA PAK T4 PA
VIEKIRA XR T4 PA
ZEPATIER T4 PA
Hcv Replication Complex Inhibitors
DAKLINZA T4 PA
EPCLUSA T4 PA
HARVONI T4 PA
ledipasvir-sofosbuvir T4 PA
MAVYRET T4 PA
sofosbuvir-velpatasvir T4 PA
TECHNIVIE T4 PA
VIEKIRA PAK T4 PA
VIEKIRA XR T4 PA
VOSEVI T4 PA
ZEPATIER T4 PA
Hiv Entry And Fusion Inhibitors
FUZEON T4 PA
SELZENTRY ORAL TABLET 150 MG T1 QL (2 EA per 1 day)
SELZENTRY ORAL TABLET 25 MG, 300 MG,
75 MG
T1
Hiv Integrase Inhibitor Antiretrovirals
BIKTARVY T1
GENVOYA T1
ISENTRESS T1
ISENTRESS HD T1
JULUCA T1
STRIBILD T1
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9
Drug Tier Notes
TIVICAY T1
TRIUMEQ T1
Hiv Nonnucleoside Rev.Transcrip. Inhib.
EDURANT T1
efavirenz oral capsule 200 mg T1
efavirenz oral capsule 50 mg T1 QL (3 EA per 1 day)
efavirenz oral tablet T1
INTELENCE ORAL TABLET 100 MG T1 QL (2 EA per 1 day)
INTELENCE ORAL TABLET 200 MG, 25 MG T1
JULUCA T1
nevirapine oral suspension T1
nevirapine oral tablet T1
nevirapine oral tablet extended release 24 hr 100
mg
T1 QL (4 EA per 1 day)
nevirapine oral tablet extended release 24 hr 400
mg
T1
ODEFSEY T1
RESCRIPTOR T1
SYMFI T1
SYMFI LO T1
Hiv Nucleoside, Nucleotide Rt Inhibitors
abacavir T1
abacavir-lamivudine T1
abacavir-lamivudine-zidovudine T1
BIKTARVY T1
CIMDUO T1
COMBIVIR T2
DESCOVY T1
didanosine T1
EMTRIVA T1
EPIVIR T2
EPIVIR HBV ORAL SOLUTION T1
10
Drug Tier Notes
EPIVIR HBV ORAL TABLET T2
EPZICOM T2
GENVOYA T1
lamivudine T1
lamivudine-zidovudine T1
ODEFSEY T1
RETROVIR T2
stavudine oral capsule 15 mg, 20 mg T1 QL (2 EA per 1 day)
stavudine oral capsule 30 mg, 40 mg T1
STRIBILD T1
SYMFI T1
SYMFI LO T1
tenofovir disoproxil fumarate T1
TRIZIVIR T2
TRUVADA T1
VIDEX 2 GRAM PEDIATRIC T1
VIDEX EC T2
ZERIT T2
zidovudine T1
Hiv Protease Inhibitor Antiretrovirals
APTIVUS T1
atazanavir T1
CRIXIVAN T1
fosamprenavir T1
INVIRASE T1
KALETRA ORAL SOLUTION T2
KALETRA ORAL TABLET T1
LEXIVA T1
lopinavir-ritonavir T1
NORVIR T1
PREZCOBIX T1
PREZISTA ORAL SUSPENSION T1
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11
Drug Tier Notes
PREZISTA ORAL TABLET 150 MG T1 QL (6 EA per 1 day)
PREZISTA ORAL TABLET 600 MG, 800 MG T1
PREZISTA ORAL TABLET 75 MG T1 QL (4 EA per 1 day)
REYATAZ T1
ritonavir T1
TECHNIVIE T4 PA
VIEKIRA PAK T4 PA
VIEKIRA XR T4 PA
VIRACEPT T1
Interferon Antivirals
ALFERON N T4 PA
INTRON A T4 PA
PEGASYS T4 PA
PEGASYS PROCLICK T4 PA
PEGINTRON T4 PA
PEGINTRON REDIPEN T4 PA
SYLATRON T4 PA
Lincomycin Antibiotics
CLEOCIN HCL T2
CLEOCIN PEDIATRIC T2
clindamycin hcl T1
clindamycin palmitate hcl T1
Macrolide Antibiotics
ERYPED 400 T1
ERY-TAB T1
ERYTHROCIN (AS STEARATE) T1
erythromycin T1
erythromycin ethylsuccinate T1
Monobactam Antibiotics
CAYSTON T4 PA
Monoclonal Antibody Antivirals
12
Drug Tier Notes
SYNAGIS T4 PA
Natural Penicillin Antibiotics
penicillin v potassium T1
Neuraminidase Inhibitor Antivirals
oseltamivir oral capsule T1 QL (1 Fill per 180 days)
oseltamivir oral suspension for reconstitution T1 QL (180 ML per 6 Months)
RELENZA DISKHALER T1 QL (1 FL per 180 DYs)
Nucleoside And Nucleotide Antivirals
acyclovir T1
adefovir T4 PA
BARACLUDE T4 PA
cidofovir T4 PA
COPEGUS T4 PA
CYTOVENE T4 PA
entecavir T1
HEPSERA T3 PA
MODERIBA DOSE PACK T4 PA
PREVYMIS T4 PA
REBETOL T4 PA
RIBASPHERE T4 PA
RIBASPHERE RIBAPAK T4 PA
valacyclovir oral tablet 1 gram T1
valacyclovir oral tablet 500 mg T1 QL (3 EA per 1 day)
VALCYTE T4 PA
valganciclovir T4 PA
VALTREX T2
VIRAZOLE T4 PA
ZOVIRAX T2
Other Macrolide Antibiotics
azithromycin oral packet T1 QL (1 FL per 30 DYs)
azithromycin oral suspension for reconstitution T1 QL (1 FL per 30 DYs)
azithromycin oral tablet 250 mg T1 QL (6 QY per 30 DYs)
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13
Drug Tier Notes
azithromycin oral tablet 500 mg T1 QL (1 FL per 30 DYs)
azithromycin oral tablet 600 mg T1 QL (8 QY per 24 DYs)
BIAXIN T2 QL (1 FL per 30 DYs)
BIAXIN XL T2 QL (1 FL per 30 DYs)
clarithromycin T1 QL (1 FL per 30 DYs)
DIFICID T1 PA
ZITHROMAX T2 QL (1 FL per 30 DYs)
ZITHROMAX TRI-PAK T2 QL (1 FL per 30 DYs)
ZMAX T1 QL (1 QY per 30 DYs)
Oxazolidinone Antibiotics
linezolid T3 PA
SIVEXTRO T4 PA
ZYVOX T3 PA
Penicillinase-Resistant Penicillins
dicloxacillin T1
Polyene Antifungals
nystatin T1
Polymyxin Antibiotics
colistin (colistimethate na) T4 PA
Pyrimidine Antifungals
flucytosine T4 PA
Quinolone Antibiotics
AVELOX T2 QL (10 QY per 30 DYs)
CIPRO ORAL SUSPENSION,MICROCAPSULE
RECON
T2
CIPRO ORAL TABLET T2 QL (68 QY per 34 DYs)
ciprofloxacin T1
ciprofloxacin hcl oral tablet 100 mg T1 QL (28 EA per 30 DYs)
ciprofloxacin hcl oral tablet 250 mg T1 QL (68 EA per 34 DYs)
ciprofloxacin hcl oral tablet 500 mg T1 QL (68 QY per 34 DYs)
ciprofloxacin hcl oral tablet 750 mg T1 QL (28 QY per 14 DYs)
LEVAQUIN T2 QL (14 QY per 30 DYs)
14
Drug Tier Notes
levofloxacin oral solution T1 QL (1 FL per 30 DYs)
levofloxacin oral tablet T1 QL (14 QY per 30 DYs)
moxifloxacin T1 QL (10 QY per 30 DYs)
Rifamycin Antibiotics
rifabutin T1
RIFADIN INTRAVENOUS T4 PA
RIFADIN ORAL T2
rifampin T1
Sulfonamide Antibiotics (Systemic)
AZULFIDINE T2
AZULFIDINE EN-TABS T2
BACTRIM T2
BACTRIM DS T2
erythromycin-sulfisoxazole T1
sulfadiazine T1
sulfamethoxazole-trimethoprim T1
sulfasalazine T1
Tetracycline Antibiotics
doxycycline monohydrate T1
minocycline T1
tetracycline T1
Urinary Anti-Infectives
MACROBID T2
MACRODANTIN T2
nitrofurantoin T1
nitrofurantoin macrocrystal T1
nitrofurantoin monohyd/m-cryst T1
trimethoprim T1
Antineoplastic Agents
Antineoplastic Agents
ABRAXANE T4 PA
ADCETRIS T4 PA
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15
Drug Tier Notes
ADRUCIL T4 PA
AFINITOR T4 PA
AFINITOR DISPERZ T4 PA
ALECENSA T4 PA
ALFERON N T4 PA
ALIMTA T4 PA
ALIQOPA T4 PA
ALKERAN T4 PA
ALKERAN (AS HCL) T4 PA
ALUNBRIG T4 PA
anastrozole T1
ARIMIDEX T2
AROMASIN T4 PA
arsenic trioxide T4 PA
ARZERRA T4 PA
AVASTIN T4 PA
azacitidine T4 PA
AZEDRA DOSIMETRIC T4 PA
AZEDRA THERAPEUTIC T4 PA
BAVENCIO T4 PA
BELEODAQ T4 PA
BENDEKA T4 PA
BESPONSA T4 PA
bicalutamide T1
BICNU T4 PA
bleomycin T4 PA
BLINCYTO T4 PA
bortezomib T4 PA
BOSULIF T4 PA
BRAFTOVI T4 PA
BUSULFEX T4 PA
CABOMETYX T4 PA
16
Drug Tier Notes
CALQUENCE T4 PA
CAMPTOSAR T4 PA
CAPRELSA T4 PA
carboplatin T4 PA
CASODEX T2
CEENU T1
cisplatin T4 PA
COMETRIQ T4 PA
COPIKTRA T4 PA
COSMEGEN T4 PA
COTELLIC T4 PA
cyclophosphamide intravenous T4 PA
cyclophosphamide oral T1
CYRAMZA T4 PA
cytarabine T4 PA
cytarabine (pf) T4 PA
dacarbazine T4 PA
DARZALEX T4 PA
daunorubicin T4 PA
DAURISMO T4 PA
decitabine T4 PA
DOCEFREZ T4 PA
docetaxel T4 PA
doxorubicin T4 PA
doxorubicin, peg-liposomal T4 PA
DROXIA T1
ELIGARD T4 PA
ELIGARD (3 MONTH) T4 PA
ELIGARD (4 MONTH) T4 PA
ELIGARD (6 MONTH) T4 PA
ELLENCE T4 PA
ELOXATIN T4 PA
ELZONRIS T4 PA
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17
Drug Tier Notes
EMCYT T1
EMPLICITI T4 PA
epirubicin T4 PA
ERBITUX T4 PA
ERIVEDGE T4 PA
ERLEADA T4 PA
ERWINAZE T4 PA
ETOPOPHOS T4 PA
etoposide T4 PA
EVOMELA T4 PA
FARESTON T1 ST
FARYDAK T4 PA
FASLODEX T4 PA
FEMARA T2 QL (1 QY per 1 DY)
FIRMAGON T4 PA
floxuridine T4 PA
fludarabine T4 PA
fluorouracil T4 PA
flutamide T1
FOLOTYN T4 PA
GAZYVA T4 PA
gemcitabine T4 PA
GEMZAR T4 PA
GILOTRIF T4 PA
GLEEVEC T4 PA
GLEOSTINE T4 PA
HALAVEN T4 PA
HERCEPTIN T4 PA
HEXALEN T4 PA
HYCAMTIN T4 PA
HYDREA T2
hydroxyurea T1
18
Drug Tier Notes
IBRANCE T4 PA
ICLUSIG T4 PA
IDAMYCIN PFS T4 PA
IDHIFA T4 PA
IFEX T4 PA
ifosfamide T4 PA
ifosfamide-mesna T4 PA
imatinib T4 PA
IMBRUVICA T4 PA
IMFINZI T4 PA
IMLYGIC T4 PA
INFUGEM T4 PA
INLYTA T4 PA
INTRON A T4 PA
IRESSA T4 PA
irinotecan T4 PA
ISTODAX T4 PA
IXEMPRA T4 PA
JAKAFI T4 PA
JEVTANA T4 PA
KADCYLA T4 PA
KEYTRUDA T4 PA
KISQALI T4 PA
KISQALI FEMARA CO-PACK T4 PA
KYMRIAH T4 PA
KYPROLIS T4 PA
LARTRUVO T4 PA
LENVIMA T4 PA
letrozole T1 QL (1 QY per 1 DY)
LEUKERAN T4 PA
leuprolide T4 PA
LIBTAYO T4 PA
lomustine T4 PA
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19
Drug Tier Notes
LONSURF T4 PA
LORBRENA T4 PA
LUMOXITI T4 PA
LUPANETA PACK (1 MONTH) T4 PA
LUPANETA PACK (3 MONTH) T4 PA
LUPRON DEPOT T4 PA
LUPRON DEPOT (3 MONTH) T4 PA
LUPRON DEPOT (4 MONTH) T4 PA
LUPRON DEPOT (6 MONTH) T4 PA
LUPRON DEPOT-PED T4 PA
LUPRON DEPOT-PED (3 MONTH) T4 PA
LYNPARZA T4 PA
LYSODREN T4 PA
MARQIBO T4 PA
MATULANE T4 PA
MEGACE T2
MEGACE ES T2 QL (150 QY per 30 DYs)
megestrol oral suspension 400 mg/10 ml (40
mg/ml)
T1
megestrol oral suspension 625 mg/5 ml T1 QL (150 ML per 30 DYs)
megestrol oral tablet T1
MEKINIST T4 PA
MEKTOVI T4 PA
mercaptopurine T1
methotrexate sodium (pf) T4 PA
methotrexate sodium injection T4 PA
methotrexate sodium oral T1
mitomycin T4 PA
mitoxantrone T4 PA
MUSTARGEN T4 PA
MYLERAN T1
MYLOTARG T4 PA
20
Drug Tier Notes
NERLYNX T4 PA
NEXAVAR T4 PA
nilutamide T4 PA
NINLARO T4 PA
NIPENT T4 PA
ODOMZO T4 PA
ONCASPAR T4 PA
ONIVYDE T4 PA
OPDIVO T4 PA
OTREXUP (PF) T4 PA
oxaliplatin T4 PA
paclitaxel T4 PA
PERJETA T4 PA
PHOTOFRIN T4 PA
POMALYST T4 PA
PORTRAZZA T4 PA
POTELIGEO T4 PA
PROLEUKIN T4 PA
REVLIMID T4 PA
RITUXAN T4 PA
RITUXAN HYCELA T4 PA
RUBRACA T4 PA
RYDAPT T4 PA
SPRYCEL T4 PA
STIVARGA T4 PA
SUPPRELIN LA T4 PA
SUTENT T4 PA
SYLATRON T4 PA
SYLVANT T4 PA
SYNRIBO T4 PA
TABLOID T4 PA
TAFINLAR T4 PA
TAGRISSO T4 PA
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21
Drug Tier Notes
TALZENNA T4 PA
tamoxifen T1
TARCEVA T4 PA
TARGRETIN T4 PA
TASIGNA T4 PA
TAXOTERE T4 PA
TECENTRIQ T4 PA
TEMODAR T4 PA
teniposide T4 PA
TEPADINA T4 PA
THERACYS T4 PA
thiotepa T4 PA
TIBSOVO T4 PA
TICE BCG T4 PA
TOPOSAR T4 PA
topotecan T4 PA
TREANDA T4 PA
TRELSTAR T4 PA
TRELSTAR DEPOT T4 PA
TRELSTAR LA T4 PA
tretinoin (chemotherapy) T4 PA
TREXALL ORAL TABLET 10 MG, 5 MG T4 PA
TREXALL ORAL TABLET 7.5 MG T1
TRIPTODUR T4 PA
TRISENOX T4 PA
TYKERB T4 PA
UNITUXIN T4 PA
VALSTAR T4 PA
VANTAS T4 PA
VECTIBIX T4 PA
VELCADE T4 PA
VENCLEXTA T4 PA
22
Drug Tier Notes
VENCLEXTA STARTING PACK T4 PA
VERZENIO T4 PA
vinblastine T4 PA
VINCASAR PFS T4 PA
vinorelbine T4 PA
VITRAKVI T4 PA
VIZIMPRO T4 PA
VOTRIENT T4 PA
VYXEOS T4 PA
XALKORI T4 PA
XELODA T4 PA
XOSPATA T4 PA
XTANDI T4 PA
YERVOY T4 PA
YESCARTA T4 PA
YONDELIS T4 PA
YONSA T4 PA
ZALTRAP T4 PA
ZEJULA T4 PA
ZELBORAF T4 PA
ZEVALIN (Y-90) T4 PA
ZOLADEX T4 PA
ZOLINZA T4 PA
ZYDELIG T4 PA
ZYKADIA T4 PA
ZYTIGA T4 PA
Antitoxins,Immune Glob,Toxoids,Vaccines
Allergenic Extracts (Therapeutic)
ORALAIR T4 PA
Antitoxins And Immune Globulins
BABYBIG T4 PA
BIVIGAM T4 PA
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23
Drug Tier Notes
CARIMUNE NF NANOFILTERED T4 PA
CUVITRU T4 PA
CYTOGAM T4 PA
FLEBOGAMMA DIF T4 PA
GAMASTAN S/D T4 PA
GAMMAGARD LIQUID T4 PA
GAMMAGARD S/D T4 PA
GAMMAPLEX T4 PA
GAMMAPLEX (WITH SORBITOL) T4 PA
GAMUNEX-C T4 PA
HEPAGAM B T4 PA
HIZENTRA T4 PA
HYPERHEP B S/D T4 PA
HYPERHEP B S-D NEONATAL T4 PA
HYPERRAB S/D (PF) T4 PA
HYPERRHO S/D T4 PA
HYPERTET S/D (PF) T4 PA
HYQVIA T4 PA
MICRHOGAM ULTRA-FILTERED PLUS T4 PA
NABI-HB T4 PA
OCTAGAM T4 PA
PANZYGA T4 PA
PRIVIGEN T4 PA
RHOGAM ULTRA-FILTERED PLUS T4 PA
RHOPHYLAC T4 PA
VARIZIG T4 PA
WINRHO SDF T4 PA
Toxoids
ADACEL(TDAP ADOLESN/ADULT)(PF) T1 AL
BOOSTRIX TDAP T1 AL
Vaccines
AFLURIA 2018-2019 T1 QL (0.5 ML per 180 days); AL
24
Drug Tier Notes
AFLURIA 2018-2019 (PF) T1 QL (0.5 ML per 180 days); AL
AFLURIA QUAD 2018-2019 T1 QL (0.5 ML per 180 days); AL
ENGERIX-B (PF) T1
ENGERIX-B PEDIATRIC (PF) T1
FLUAD 2018-2019 (65 YR UP)(PF) T1 QL (0.5 ML per 180 days); AL
FLUARIX QUAD 2018-2019 (PF) T1 QL (0.5 ML per 180 days); AL
FLUBLOK QUAD 2018-2019 (PF) T1 QL (0.5 ML per 180 days); AL
FLUCELVAX QUAD 2018-2019 T1 QL (0.5 ML per 180 days); AL
FLUCELVAX QUAD 2018-2019 (PF) T1 QL (0.5 ML per 180 days); AL
FLULAVAL QUAD 2018-2019 T1 QL (0.5 ML per 180 days); AL
FLULAVAL QUAD 2018-2019 (PF) T1 QL (0.5 ML per 180 days); AL
FLUMIST QUAD 2018-2019 T1 QL (0.2 EA per 180 days); AL
FLUZONE HIGH-DOSE 2018-19 (PF) T1 QL (0.5 ML per 180 days); AL
FLUZONE QUAD 2018-2019 T1 QL (0.5 ML per 180 days); AL
FLUZONE QUAD 2018-2019 (PF) T1 QL (0.5 ML per 180 days); AL
HAVRIX (PF) INTRAMUSCULAR
SUSPENSION 1,440 ELISA UNIT/ML
T1 AL
HAVRIX (PF) INTRAMUSCULAR
SUSPENSION 720 ELISA UNIT/0.5 ML
T1
HAVRIX (PF) INTRAMUSCULAR SYRINGE
1,440 ELISA UNIT/ML
T1 AL
HAVRIX (PF) INTRAMUSCULAR SYRINGE
720 ELISA UNIT/0.5 ML
T1
PNEUMOVAX 23 INJECTION SOLUTION T1 AL
PNEUMOVAX 23 INJECTION SYRINGE T1
PREVNAR 13 (PF) T1 AL
RECOMBIVAX HB (PF) INTRAMUSCULAR
SUSPENSION 10 MCG/ML, 40 MCG/ML
T1 AL
RECOMBIVAX HB (PF) INTRAMUSCULAR
SUSPENSION 5 MCG/0.5 ML
T1
RECOMBIVAX HB (PF) INTRAMUSCULAR
SYRINGE 10 MCG/ML
T1 AL
RECOMBIVAX HB (PF) INTRAMUSCULAR
SYRINGE 5 MCG/0.5 ML
T1
For the most up to date formulary coverage search, please use the searchable formulary website
25
Drug Tier Notes
SHINGRIX (PF) T1 QL (2 Doses Max Qty Per Fill Retail);
AL
THERACYS T4 PA
TICE BCG T4 PA
TWINRIX (PF) INTRAMUSCULAR
SUSPENSION
T1 AL
TWINRIX (PF) INTRAMUSCULAR SYRINGE T1
VAQTA (PF) INTRAMUSCULAR
SUSPENSION 25 UNIT/0.5 ML
T1
VAQTA (PF) INTRAMUSCULAR
SUSPENSION 50 UNIT/ML
T1 AL
VAQTA (PF) INTRAMUSCULAR SYRINGE 25
UNIT/0.5 ML
T1
VAQTA (PF) INTRAMUSCULAR SYRINGE 50
UNIT/ML
T1 AL
ZOSTAVAX (PF) T1 QL (1 QY per 365 DYs)
Autonomic Drugs
Alpha- And Beta-Adrenergic Agonists
ALLEGRA-D 12 HOUR T3 PA
ALLEGRA-D 24 HOUR T3 PA
BROMFED DM T1
BROTAPP DM T1
cetirizine-pseudoephedrine T1 ST
CHERATUSSIN DAC T1
CONGEST-EZE T1
epinephrine T1 QL (2 EA per 30 DYs)
LORATADINE-D T3 PA
M-END DMX T1
MUCINEX D MAXIMUM STRENGTH T1
pseudoephedrine hcl T1
pseudoephedrine-guaifenesin T1
SEMPREX-D T3 PA
SUDOGEST COLD AND ALLERGY T1
26
Drug Tier Notes
Alpha-Adrenergic Agonists
CATAPRES T2
CATAPRES-TTS-1 T2
CATAPRES-TTS-2 T2
CATAPRES-TTS-3 T2
CHILDREN'S STUFFY NOSE-COLD T1
clonidine T1
clonidine hcl T1
CLORPRES T1
ED BRON GP T1
methyldopa T1
methyldopa-hydrochlorothiazide T1
MUCUS RELIEF CONGESTION-COUGH T1
phenylephrine-chlophedianol-gg T1
PROMETHAZINE VC T1
PROMETHAZINE VC-CODEINE T1 QL (120 ML per 30 days); AL
ROBAFEN CF (PHENYLEPHRINE) T1
Antimuscarinics/Antispasmodics
ANORO ELLIPTA T1
ATROVENT HFA T1
BENTYL T2
COMBIVENT RESPIMAT T1
dicyclomine T1
diphenoxylate-atropine T1
glycopyrrolate T1
hydrocodone-homatropine T1
hyoscyamine sulfate T1
ipratropium bromide T1
LEVBID T2
LOMOTIL T2
propantheline T1
ROBINUL T2
For the most up to date formulary coverage search, please use the searchable formulary website
27
Drug Tier Notes
ROBINUL FORTE T2
SPIRIVA RESPIMAT T1 AL
STIOLTO RESPIMAT T1
TUSSIGON T1
Antiparkinsonian Agents
benztropine T1
trihexyphenidyl T1
Autonomic Drugs, Miscellaneous
CHANTIX T1 QL (360 QY per 365 DYs); AL
CHANTIX CONTINUING MONTH BOX T1 QL (360 EA per 365 DYs)
CHANTIX CONTINUING MONTH PAK T1 QL (360 EA per 365 DYs)
CHANTIX STARTING MONTH BOX T1 QL (360 QY per 365 DYs); AL
NICODERM CQ T2
NICORETTE T2
nicotine T1
nicotine (polacrilex) buccal gum T1
nicotine (polacrilex) buccal lozenge T1 QL (20 EA per 1 day)
nicotine (polacrilex) buccal mini lozenge T1 QL (20 EA per 1 day)
Centrally Acting Skeletal Muscle Relaxnt
carisoprodol T1
chlorzoxazone T1
cyclobenzaprine T1
methocarbamol T1
ROBAXIN T2
ROBAXIN-750 T2
SOMA T2
tizanidine T1
ZANAFLEX T2
Gaba-Derivative Skeletal Muscle Relaxant
baclofen T1
GABLOFEN T4 PA
28
Drug Tier Notes
LIORESAL T4 PA
Non-Sel. Beta-Adrenergic Blocking Agents
BETAPACE T2
BETAPACE AF T2
carvedilol T1
COREG T2
CORGARD T2
CORZIDE T2
INDERAL LA T2
labetalol T1
nadolol T1
nadolol-bendroflumethiazide T1
pindolol T1
propranolol T1
propranolol-hydrochlorothiazid T1
sotalol T1
SOTALOL AF T1
timolol maleate T1
TRANDATE T2
Non-Sel.Alpha-1-Adrenergic Blocking Agts
CARDURA T2
doxazosin T1
MINIPRESS T2
prazosin T1
terazosin T1
Non-Sel.Alpha-Adrenergic Blocking Agents
CAFERGOT T2
D.H.E.45 T2
DIBENZYLINE T2
dihydroergotamine injection T1 QL (12 ML per 30 days)
dihydroergotamine nasal T1 QL (1 QY per 30 DYs)
ERGOMAR T1 QL (20 EA per 30 days)
For the most up to date formulary coverage search, please use the searchable formulary website
29
Drug Tier Notes
ergotamine-caffeine T1
MIGRANAL T2 QL (1 QY per 30 DYs)
phenoxybenzamine T1 PA
Parasympathomimetic (Cholinergic Agents)
ARICEPT T2 AL
ARICEPT ODT T2 AL
bethanechol chloride T1
donepezil oral tablet 10 mg T1 AL
donepezil oral tablet 23 mg T1 ST; QL (1 EA per 1 day)
donepezil oral tablet 5 mg T1 QL (1 EA per 1 DY); AL
donepezil oral tablet,disintegrating T1 AL
EXELON ORAL T2 AL
EXELON TRANSDERMAL PATCH 24 HOUR
4.6 MG/24 HR
T2 QL (1 EA per 1 day); AL
EXELON TRANSDERMAL PATCH 24 HOUR
9.5 MG/24 HR
T2 AL
MESTINON T2
MESTINON TIMESPAN T2
PROSTIGMIN T1 AL
pyridostigmine bromide oral syrup T1
pyridostigmine bromide oral tablet T1 AL
pyridostigmine bromide oral tablet extended
release
T1 AL
rivastigmine tartrate oral capsule 1.5 mg, 3 mg T1 QL (2 EA per 1 day); AL
rivastigmine tartrate oral capsule 4.5 mg, 6 mg T1 AL
rivastigmine transdermal patch 24 hour 13.3
mg/24 hour
T1 AL
rivastigmine transdermal patch 24 hour 4.6 mg/24
hr
T1 QL (1 EA per 1 day)
rivastigmine transdermal patch 24 hour 9.5 mg/24
hr
T1
URECHOLINE T2
Selective Alpha-1-Adrenergic Block.Agent
alfuzosin T1
30
Drug Tier Notes
carvedilol T1
COREG T2
labetalol T1
tamsulosin T1
TRANDATE T2
Selective Beta-2-Adrenergic Agonists
albuterol sulfate inhalation hfa aerosol inhaler T1 QL (1 QY per 30 days)
albuterol sulfate inhalation solution for
nebulization
T1
albuterol sulfate oral T1
ANORO ELLIPTA T1
COMBIVENT RESPIMAT T1
DULERA T3 QL (13 QY per 30 DYs); AL
fluticasone propion-salmeterol inhalation aerosol
powdr breath activated
T1
fluticasone propion-salmeterol inhalation blister
with device
T1 QL (1 EA per 30 days)
levalbuterol tartrate T1 ST
SEREVENT DISKUS T1
STIOLTO RESPIMAT T1
terbutaline T1
WIXELA INHUB T1 QL (1 EA per 30 days)
Selective Beta-Adrenergic Blocking Agent
atenolol T1
atenolol-chlorthalidone T1
bisoprolol fumarate T1
bisoprolol-hydrochlorothiazide T1
LOPRESSOR T2
LOPRESSOR HCT T2
metoprolol succinate T1
metoprolol ta-hydrochlorothiaz T1
metoprolol tartrate T1
TENORMIN T2
For the most up to date formulary coverage search, please use the searchable formulary website
31
Drug Tier Notes
TOPROL XL T2
ZEBETA T2
ZIAC T2
Skeletal Muscle Relaxants, Miscellaneous
BOTOX T4 PA
BOTOX COSMETIC T4 PA
DYSPORT T4 PA
MYOBLOC T4 PA
XEOMIN T4 PA
Blood Formation, Coagulation, Thrombosis
Anticoagulants, Miscellaneous
ARIXTRA T4 PA
Antihemorrhagic Agents, Miscellaneous
ANDEXXA T4 PA
Antithrombotic Agents, Miscellaneous
CABLIVI T4 PA
Blood Form.,Coag,Thrombosis Agents Misc.
TAVALISSE T4 PA
Coumarin Derivatives
COUMADIN T2
warfarin T1
Direct Factor Xa Inhibitors
ARIXTRA T4 PA
ELIQUIS T1
XARELTO ORAL TABLET 10 MG, 15 MG, 20
MG
T1
XARELTO ORAL TABLET 2.5 MG T1 QL (60 EA per 30 days)
XARELTO ORAL TABLETS,DOSE PACK T1
Direct Thrombin Inhibitors
PRADAXA ORAL CAPSULE 110 MG, 150 MG T1
PRADAXA ORAL CAPSULE 75 MG T1 QL (2 EA per 1 day)
32
Drug Tier Notes
Hematopoietic Agents
ARANESP (IN ALBUMIN) T4 PA
ARANESP (IN POLYSORBATE) T4 PA
DOPTELET (10 TAB PACK) T4 PA
DOPTELET (15 TAB PACK) T4 PA
EPOGEN T4 PA
FULPHILA T4 PA
GRANIX T4 PA
LEUKINE T4 PA
MIRCERA T4 PA
MOZOBIL T4 PA
MULPLETA T4 PA
NEULASTA T4 PA
NEUMEGA T4 PA
NEUPOGEN T4 PA
NIVESTYM T4 PA
NPLATE T4 PA
PROCRIT T4 PA
PROMACTA T4 PA
RETACRIT T4 PA
UDENYCA T4 PA
ZARXIO T4 PA
Hemorrheologic Agents
pentoxifylline T1
Hemostatics
ADVATE T4 PA
ADYNOVATE T4 PA
AFSTYLA T4 PA
ALPHANATE T4 PA
ALPHANINE SD T4 PA
ALPROLIX T4 PA
AMICAR T1
For the most up to date formulary coverage search, please use the searchable formulary website
33
Drug Tier Notes
aminocaproic acid T1 PA
BEBULIN T4 PA
BENEFIX T4 PA
COAGADEX T4 PA
CORIFACT T4 PA
DDAVP NASAL T2 PA
DDAVP ORAL T2 PA; AL
desmopressin nasal T1 PA
desmopressin oral T1 PA; AL
ELOCTATE T4 PA
FEIBA NF T4 PA
HEMLIBRA T4 PA
HEMOFIL M HIGH T4 PA
HEMOFIL M LOW T4 PA
HEMOFIL M MID T4 PA
HEMOFIL M SUPER HIGH T4 PA
HUMATE-P T4 PA
IDELVION T4 PA
IXINITY T4 PA
JIVI T4 PA
KCENTRA T4 PA
KOATE-DVI T4 PA
KOGENATE FS T4 PA
MONOCLATE-P T4 PA
NOVOEIGHT T4 PA
NOVOSEVEN RT T4 PA
NUWIQ T4 PA
OBIZUR T4 PA
PROFILNINE T4 PA
REBINYN T4 PA
RECOMBINATE T4 PA
RIASTAP T4 PA
34
Drug Tier Notes
RIXUBIS T4 PA
STIMATE T1 PA
TRETTEN T4 PA
VONVENDI T4 PA
WILATE T4 PA
XYNTHA T4 PA
XYNTHA SOLOFUSE T4 PA
Heparins
enoxaparin subcutaneous solution T1 QL (3 ML per 1 day)
enoxaparin subcutaneous syringe 100 mg/ml, 150
mg/ml
T1 QL (2 ML per 1 day)
enoxaparin subcutaneous syringe 120 mg/0.8 ml,
80 mg/0.8 ml
T1 QL (1.6 ML per 1 day)
enoxaparin subcutaneous syringe 30 mg/0.3 ml T1 QL (0.6 ML per 1 day)
enoxaparin subcutaneous syringe 40 mg/0.4 ml T1 QL (0.8 ML per 1 day)
enoxaparin subcutaneous syringe 60 mg/0.6 ml T1 QL (1.2 ML per 1 day)
FRAGMIN T4 PA
heparin (porcine) T1
Iron Preparations
CADEAU DHA T1
CENTRUM COMPLETE T1
CERTAVITE-ANTIOXID (IRON GLUC) T2
CHILDREN'S CHEWABLE COMPLETE T1
CLASSIC PRENATAL T1
COMPETE T1
COMPLETE MULTIVITAMIN T1
COMPLETE MULTIVITAMIN-MINERAL T1
COMPLETE PREMIUM VITAMIN T1
COMPLETENATE T1
DAILY PRENATAL T1
DAILY VITES/IRON T1
FERAHEME T4 PA
FERRETTS T1
For the most up to date formulary coverage search, please use the searchable formulary website
35
Drug Tier Notes
FERRLECIT T4 PA
ferrous fumarate T1
ferrous gluconate T1
ferrous sulfate T1
HIGH POTENCY IRON T1
INFED T1
INJECTAFER T1
iron oral tablet T1
IRON ORAL TABLET EXTENDED RELEASE T1
MULTI-DELYN WITH IRON T1
MULTIGEN T1
MULTIGEN FOLIC T1
MULTIGEN PLUS T1
MULTI-VIT WITH FLUORIDE-IRON T1
MULTIVITAMIN WITH MINERALS T1
NUTRIVIT T1
OBSTETRIX DHA T1
OBTREX DHA T1
ONE DAILY PRENATAL T1
ONE-A-DAY WOMENS FORMULA T1
ONE-A-DAY WOMEN'S PRENATAL 1 T1
PERRY PRENATAL T1
pnv cmb#95-ferrous fumarate-fa T1
POLY-IRON 150 FORTE T1
polysaccharide iron complex T1
POLYVITAMIN WITH IRON T1 AL
POLY-VITAMIN WITH IRON T1 AL
PR NATAL 400 T1
PR NATAL 400 EC T1
PR NATAL 430 T1
PRENATA T1
PRENATAL + DHA T1
36
Drug Tier Notes
PRENATAL 19 T1
PRENATAL MULTI-DHA (ALGAL OIL) T1
PRENATAL PLUS T1
PRENATAL VITAMIN T1
PRENATAL VITAMIN PLUS LOW IRON T1
prenatal vit-iron fum-folic ac T1
PRORENAL QD T1
THERAPEUTIC-M T1
TRINATAL GT T1
TRIVEEN-DUO DHA T1
TRI-VI-SOL WITH IRON T1 AL
TRI-VIT WITH FLUORIDE AND IRON T1
VENOFER T1
WOMEN'S DAILY FORMULA T1
WOMEN'S PRENATAL PLUS DHA T1
Platelet-Aggregation Inhibitors
aspirin T1
aspirin-caffeine-dihydrocodein T3 AL
aspirin-dipyridamole T1
butalbital-aspirin-caffeine T1
cilostazol T1
clopidogrel T1
dipyridamole T1
PERSANTINE T2
PLAVIX T2
PLETAL T2
prasugrel oral tablet 10 mg T1
prasugrel oral tablet 5 mg T1 QL (1 EA per 1 day)
SYNALGOS-DC T3
ticlopidine T1
Thrombolytic Agents
ACTIVASE T4 PA
For the most up to date formulary coverage search, please use the searchable formulary website
37
Drug Tier Notes
aspirin T1
aspirin-caffeine-dihydrocodein T3 AL
butalbital-aspirin-caffeine T1
CATHFLO ACTIVASE T4 PA
SYNALGOS-DC T3
Cardiovascular Drugs
Alpha-Adrenergic Blocking Agents
CARDURA T2
carvedilol T1
COREG T2
doxazosin T1
labetalol T1
MINIPRESS T2
prazosin T1
terazosin T1
TRANDATE T2
Alpha-Adrenergic Blocking Agt.(Hypoten)
CARDURA T2
doxazosin T1
labetalol T1
MINIPRESS T2
prazosin T1
terazosin T1
TRANDATE T2
Angiotensin Ii Receptor Antagon.(Hypotn)
amlodipine-valsartan T1 ST
AVALIDE T2 ST
AVAPRO T2 ST
COZAAR T2
HYZAAR T2
irbesartan T1 ST
38
Drug Tier Notes
irbesartan-hydrochlorothiazide T1 ST
losartan T1
losartan-hydrochlorothiazide T1
olmesartan T1 ST
olmesartan-hydrochlorothiazide T1 ST
telmisartan T1 ST
valsartan T1 ST
valsartan-hydrochlorothiazide T1 ST
Angiotensin Ii Receptor Antagonists
amlodipine-valsartan T1 ST
AVALIDE T2 ST
AVAPRO T2 ST
COZAAR T2
ENTRESTO T1
HYZAAR T2
irbesartan T1 ST
irbesartan-hydrochlorothiazide T1 ST
losartan T1
losartan-hydrochlorothiazide T1
olmesartan T1 ST
olmesartan-hydrochlorothiazide T1 ST
telmisartan T1 ST
valsartan T1 ST
valsartan-hydrochlorothiazide T1 ST
Angiotensin-Convert.Enzyme Inhib(Hypotn)
ACCUPRIL T2
ACCURETIC T2
ACEON T2
benazepril oral tablet 10 mg, 20 mg, 5 mg T1 QL (2 EA per 1 day)
benazepril oral tablet 40 mg T1
benazepril-hydrochlorothiazide oral tablet 10-12.5
mg, 20-12.5 mg, 5-6.25 mg
T1 QL (2 EA per 1 day)
For the most up to date formulary coverage search, please use the searchable formulary website
39
Drug Tier Notes
benazepril-hydrochlorothiazide oral tablet 20-25
mg
T1
captopril T1
captopril-hydrochlorothiazide T1
enalapril maleate T1
enalapril-hydrochlorothiazide T1
fosinopril T1
lisinopril T1
lisinopril-hydrochlorothiazide T1
LOTENSIN T2
LOTENSIN HCT T2
MAVIK T2
moexipril T1
moexipril-hydrochlorothiazide T1
perindopril erbumine T1
PRINIVIL T2
quinapril T1
quinapril-hydrochlorothiazide T1
trandolapril T1
UNIRETIC T2
UNIVASC T2
VASERETIC T2
VASOTEC T2
ZESTORETIC T2
ZESTRIL T2
Angiotensin-Converting Enzyme Inhibitors
ACCUPRIL T2
ACCURETIC T2
ACEON T2
benazepril oral tablet 10 mg, 20 mg, 5 mg T1 QL (2 EA per 1 day)
benazepril oral tablet 40 mg T1
40
Drug Tier Notes
benazepril-hydrochlorothiazide oral tablet 10-12.5
mg, 20-12.5 mg, 5-6.25 mg
T1 QL (2 EA per 1 day)
benazepril-hydrochlorothiazide oral tablet 20-25
mg
T1
captopril T1
captopril-hydrochlorothiazide T1
enalapril maleate T1
enalapril-hydrochlorothiazide T1
fosinopril T1
lisinopril T1
lisinopril-hydrochlorothiazide T1
LOTENSIN T2
LOTENSIN HCT T2
MAVIK T2
moexipril T1
moexipril-hydrochlorothiazide T1
perindopril erbumine T1
PRINIVIL T2
quinapril T1
quinapril-hydrochlorothiazide T1
trandolapril T1
UNIRETIC T2
UNIVASC T2
VASERETIC T2
VASOTEC T2
ZESTORETIC T2
ZESTRIL T2
Antiarrhythmics, Miscellaneous
digoxin T1
LANOXIN T2
Antilipemic Agents, Miscellaneous
JUXTAPID T4 PA
KYNAMRO T4 PA
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41
Drug Tier Notes
niacin T1
NIACOR T1
Beta-Adrenergic Blocking Agents
atenolol T1
atenolol-chlorthalidone T1
BETAPACE T2
BETAPACE AF T2
bisoprolol fumarate T1
bisoprolol-hydrochlorothiazide T1
carvedilol T1
COREG T2
CORGARD T2
CORZIDE T2
INDERAL LA T2
labetalol T1
LOPRESSOR T2
LOPRESSOR HCT T2
metoprolol succinate T1
metoprolol ta-hydrochlorothiaz T1
metoprolol tartrate T1
nadolol T1
nadolol-bendroflumethiazide T1
pindolol T1
propranolol T1
propranolol-hydrochlorothiazid T1
sotalol T1
SOTALOL AF T1
TENORMIN T2
timolol maleate T1
TOPROL XL T2
TRANDATE T2
ZEBETA T2
42
Drug Tier Notes
ZIAC T2
Beta-Adrenergic Blocking Agt.(Hypoten)
atenolol T1
atenolol-chlorthalidone T1
BETAPACE T2
BETAPACE AF T2
bisoprolol fumarate T1
bisoprolol-hydrochlorothiazide T1
CORGARD T2
CORZIDE T2
INDERAL LA T2
labetalol T1
LOPRESSOR T2
LOPRESSOR HCT T2
metoprolol succinate T1
metoprolol ta-hydrochlorothiaz T1
metoprolol tartrate T1
nadolol T1
nadolol-bendroflumethiazide T1
pindolol T1
propranolol T1
propranolol-hydrochlorothiazid T1
sotalol T1
SOTALOL AF T1
TENORMIN T2
timolol maleate T1
TOPROL XL T2
TRANDATE T2
ZEBETA T2
ZIAC T2
Bile Acid Sequestrants
cholestyramine (with sugar) T1
For the most up to date formulary coverage search, please use the searchable formulary website
43
Drug Tier Notes
CHOLESTYRAMINE LIGHT T1
colesevelam oral powder in packet T1
colesevelam oral tablet T1 QL (6 EA per 1 day)
COLESTID T2
colestipol T1
PREVALITE T1
QUESTRAN T2
QUESTRAN LIGHT T2
WELCHOL T2
Calcium-Channel Block.Agt,Misc(Hypoten)
CALAN T2
CALAN SR T2
CARDIZEM T2
CARDIZEM CD T2
diltiazem hcl T1
DILT-XR T2
ISOPTIN SR T2
TAZTIA XT T1
TIAZAC T2
verapamil T1
VERELAN T2
Calcium-Channel Blocking Agents
ADALAT CC T2
amlodipine oral tablet 10 mg T1
amlodipine oral tablet 2.5 mg, 5 mg T1 QL (1 EA per 1 DY)
amlodipine-valsartan T1 ST
CALAN T2
CALAN SR T2
CARDIZEM T2
CARDIZEM CD T2
diltiazem hcl T1
DILT-XR T2
44
Drug Tier Notes
felodipine T1
ISOPTIN SR T2
NIFEDICAL XL T1
nifedipine oral capsule T1
nifedipine oral tablet extended release 24hr T1
nifedipine oral tablet extended release 30 mg T1 QL (1 EA per 1 day)
nifedipine oral tablet extended release 60 mg, 90
mg
T1
nisoldipine oral tablet extended release 24 hr 17
mg, 8.5 mg
T1 QL (1 EA per 1 day)
nisoldipine oral tablet extended release 24 hr 20
mg, 30 mg, 34 mg, 40 mg
T1
NORVASC T2
PROCARDIA T2
PROCARDIA XL T2
SULAR T2
TAZTIA XT T1
TIAZAC T2
verapamil T1
VERELAN T2
Calcium-Channel Blocking Agents(Hypoten)
CALAN T2
CALAN SR T2
CARDIZEM T2
CARDIZEM CD T2
diltiazem hcl T1
DILT-XR T2
ISOPTIN SR T2
TAZTIA XT T1
TIAZAC T2
verapamil T1
VERELAN T2
Calcium-Channel Blocking Agents, Misc.
For the most up to date formulary coverage search, please use the searchable formulary website
45
Drug Tier Notes
CALAN T2
CALAN SR T2
CARDIZEM T2
CARDIZEM CD T2
diltiazem hcl T1
DILT-XR T2
ISOPTIN SR T2
TAZTIA XT T1
TIAZAC T2
verapamil T1
VERELAN T2
Carbonic Anhydrase Inhibitors(Hypoten)
acetazolamide T1
DIAMOX SEQUELS T2 PA
Cardiotonic Agents
digoxin T1
LANOXIN T2
milrinone T4 PA
Central Alpha-Agonists
CATAPRES T2
CATAPRES-TTS-1 T2
CATAPRES-TTS-2 T2
CATAPRES-TTS-3 T2
clonidine T1
clonidine hcl T1
CLORPRES T1
guanfacine oral tablet T1
guanfacine oral tablet extended release 24 hr T1 AL
methyldopa T1
methyldopa-hydrochlorothiazide T1
TENEX T2
46
Drug Tier Notes
Cholesterol Absorption Inhibitors
ezetimibe T1
ezetimibe-simvastatin T1
Class Ia Antiarrhythmics
disopyramide phosphate T1
NORPACE T2
NORPACE CR T1
quinidine gluconate T1
quinidine sulfate T1
Class Ib Antiarrhythmics
DILANTIN T1
DILANTIN EXTENDED T1
DILANTIN INFATABS T2
DILANTIN-125 T2
mexiletine T1
phenytoin T1
phenytoin sodium extended T1
Class Ic Antiarrhythmics
flecainide T1
propafenone T1
RYTHMOL T2
Class Ii Antiarrhythmics
atenolol T1
atenolol-chlorthalidone T1
BETAPACE T2
BETAPACE AF T2
bisoprolol fumarate T1
bisoprolol-hydrochlorothiazide T1
carvedilol T1
COREG T2
CORGARD T2
CORZIDE T2
For the most up to date formulary coverage search, please use the searchable formulary website
47
Drug Tier Notes
INDERAL LA T2
labetalol T1
LOPRESSOR T2
LOPRESSOR HCT T2
metoprolol succinate T1
metoprolol ta-hydrochlorothiaz T1
metoprolol tartrate T1
nadolol T1
nadolol-bendroflumethiazide T1
pindolol T1
propranolol T1
propranolol-hydrochlorothiazid T1
sotalol T1
SOTALOL AF T1
TENORMIN T2
timolol maleate T1
TOPROL XL T2
TRANDATE T2
ZEBETA T2
ZIAC T2
Class Iii Antiarrhythmics
amiodarone T1
BETAPACE T2
BETAPACE AF T2
CORDARONE T2
MULTAQ T3 PA
sotalol T1
SOTALOL AF T1
Class Iv Antiarrhythmics
CALAN T2
CALAN SR T2
CARDIZEM T2
48
Drug Tier Notes
CARDIZEM CD T2
diltiazem hcl T1
DILT-XR T2
ISOPTIN SR T2
TAZTIA XT T1
TIAZAC T2
verapamil T1
VERELAN T2
Dihydropyridines
ADALAT CC T2
amlodipine oral tablet 10 mg T1
amlodipine oral tablet 2.5 mg, 5 mg T1 QL (1 EA per 1 DY)
amlodipine-valsartan T1 ST
felodipine T1
NIFEDICAL XL T1
nifedipine oral capsule T1
nifedipine oral tablet extended release 24hr T1
nifedipine oral tablet extended release 30 mg T1 QL (1 EA per 1 day)
nifedipine oral tablet extended release 60 mg, 90
mg
T1
nisoldipine oral tablet extended release 24 hr 17
mg, 8.5 mg
T1 QL (1 EA per 1 day)
nisoldipine oral tablet extended release 24 hr 20
mg, 30 mg, 34 mg, 40 mg
T1
NORVASC T2
PROCARDIA T2
PROCARDIA XL T2
SULAR T2
Dihydropyridines (Antihypertensive)
ADALAT CC T2
amlodipine oral tablet 10 mg T1
amlodipine oral tablet 2.5 mg, 5 mg T1 QL (1 EA per 1 DY)
amlodipine-valsartan T1 ST
For the most up to date formulary coverage search, please use the searchable formulary website
49
Drug Tier Notes
felodipine T1
NIFEDICAL XL T1
nifedipine oral capsule T1
nifedipine oral tablet extended release 24hr T1
nifedipine oral tablet extended release 30 mg T1 QL (1 EA per 1 day)
nifedipine oral tablet extended release 60 mg, 90
mg
T1
nisoldipine oral tablet extended release 24 hr 17
mg, 8.5 mg
T1 QL (1 EA per 1 day)
nisoldipine oral tablet extended release 24 hr 20
mg, 30 mg, 34 mg, 40 mg
T1
NORVASC T2
PROCARDIA T2
PROCARDIA XL T2
SULAR T2
Direct Vasodilators
BIDIL T1
hydralazine T1
minoxidil T1
Diuretics, Miscellaneous (Hypotensive)
THEO-24 T1
theophylline T1
Fibric Acid Derivatives
fenofibrate T1
fenofibrate micronized T1
fenofibrate nanocrystallized T1
gemfibrozil T1
LOFIBRA T2
LOPID T2
TRICOR T2
Hmg-Coa Reductase Inhibitors
atorvastatin oral tablet 10 mg T1 QL (1 EA per 1 DY)
50
Drug Tier Notes
atorvastatin oral tablet 20 mg, 40 mg, 80 mg T1
ezetimibe-simvastatin T1
fluvastatin T1 ST
LESCOL T2 ST
LESCOL XL T2 ST
LIPITOR T2
lovastatin oral tablet 10 mg, 20 mg T1 QL (3 EA per 1 day)
lovastatin oral tablet 40 mg T1
MEVACOR T2
PRAVACHOL T2 ST
pravastatin oral tablet 10 mg, 20 mg T1 ST; QL (1 EA per 1 day)
pravastatin oral tablet 40 mg T1 ST; QL (2 EA per 1 day)
pravastatin oral tablet 80 mg T1 ST
rosuvastatin T1
simvastatin T1
ZOCOR T2
Hypotensive Agents, Miscellaneous
ADALAT CC T2
amlodipine oral tablet 10 mg T1
amlodipine oral tablet 2.5 mg, 5 mg T1 QL (1 EA per 1 DY)
amlodipine-valsartan T1 ST
BETAPACE T2
BETAPACE AF T2
CARDURA T2
carvedilol T1
COREG T2
DIBENZYLINE T2
doxazosin T1
felodipine T1
INDERAL LA T2
NIFEDICAL XL T1
nifedipine oral capsule T1
For the most up to date formulary coverage search, please use the searchable formulary website
51
Drug Tier Notes
nifedipine oral tablet extended release 24hr T1
nifedipine oral tablet extended release 30 mg T1 QL (1 EA per 1 day)
nifedipine oral tablet extended release 60 mg, 90
mg
T1
nisoldipine oral tablet extended release 24 hr 17
mg, 8.5 mg
T1 QL (1 EA per 1 day)
nisoldipine oral tablet extended release 24 hr 20
mg, 30 mg, 34 mg, 40 mg
T1
NORVASC T2
phenoxybenzamine T1 PA
pindolol T1
PROCARDIA T2
PROCARDIA XL T2
propranolol T1
sotalol T1
SOTALOL AF T1
SULAR T2
terazosin T1
timolol maleate T1
Loop Diuretics (Hypotensive Agents)
bumetanide T1
DEMADEX T2
furosemide T1
LASIX T2
torsemide T1
Mineralocorticoid (Aldosterone) Antagnts
ALDACTAZIDE T2
ALDACTONE T2
spironolactone T1
spironolacton-hydrochlorothiaz T1
Mineralocorticoid(Aldoster.)Antag(Hypot)
ALDACTAZIDE T2
ALDACTONE T2
52
Drug Tier Notes
spironolactone T1
spironolacton-hydrochlorothiaz T1
Nitrates And Nitrites
BIDIL T1
ISORDIL T1
isosorbide dinitrate T1
isosorbide mononitrate T1
NITRO-BID T1
NITRO-DUR TRANSDERMAL PATCH 24
HOUR 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6
MG/HR
T2
NITRO-DUR TRANSDERMAL PATCH 24
HOUR 0.3 MG/HR, 0.8 MG/HR
T1
nitroglycerin T1
NITROSTAT T2
NITRO-TIME T1
Pcsk9 Inhibitors
PRALUENT PEN T4 PA
REPATHA PUSHTRONEX T4 PA
REPATHA SURECLICK T4 PA
REPATHA SYRINGE T4 PA
Peripheral Adrenergic Inhibitors
reserpine T1
Phosphodiesterase Type 5 Inhibitors
ADCIRCA T4 PA
cilostazol T1
PLETAL T2
REVATIO T4 PA
sildenafil (antihypertensive) T1 PA
Potassium-Sparing Diuretics (Hypoten)
ALDACTAZIDE T2
ALDACTONE T2
amiloride T1
For the most up to date formulary coverage search, please use the searchable formulary website
53
Drug Tier Notes
amiloride-hydrochlorothiazide T1
DYAZIDE T2
MAXZIDE T2
MAXZIDE-25MG T2
spironolactone T1
spironolacton-hydrochlorothiaz T1
triamterene-hydrochlorothiazid T1
Renin-Angioten.-Aldost. Sys. Inhib, Misc
ENTRESTO T1
Sclerosing Agents
STERITALC T4 PA
Thiazide Diuretics(Hypotensive Agents)
ACCURETIC T2
ALDACTAZIDE T2
amiloride-hydrochlorothiazide T1
AVALIDE T2 ST
benazepril-hydrochlorothiazide oral tablet 10-12.5
mg, 20-12.5 mg, 5-6.25 mg
T1 QL (2 EA per 1 day)
benazepril-hydrochlorothiazide oral tablet 20-25
mg
T1
bisoprolol-hydrochlorothiazide T1
captopril-hydrochlorothiazide T1
chlorothiazide T1
CORZIDE T2
DIURIL T1
DYAZIDE T2
enalapril-hydrochlorothiazide T1
hydrochlorothiazide T1
HYZAAR T2
irbesartan-hydrochlorothiazide T1 ST
lisinopril-hydrochlorothiazide T1
LOPRESSOR HCT T2
54
Drug Tier Notes
losartan-hydrochlorothiazide T1
LOTENSIN HCT T2
MAXZIDE T2
MAXZIDE-25MG T2
methyldopa-hydrochlorothiazide T1
metoprolol ta-hydrochlorothiaz T1
moexipril-hydrochlorothiazide T1
nadolol-bendroflumethiazide T1
olmesartan-hydrochlorothiazide T1 ST
propranolol-hydrochlorothiazid T1
quinapril-hydrochlorothiazide T1
spironolacton-hydrochlorothiaz T1
triamterene-hydrochlorothiazid T1
UNIRETIC T2
valsartan-hydrochlorothiazide T1 ST
VASERETIC T2
ZESTORETIC T2
ZIAC T2
Thiazide-Like Diuretics(Hypotensive Agt)
atenolol-chlorthalidone T1
chlorthalidone T1
CLORPRES T1
indapamide T1
metolazone T1
ZAROXOLYN T2
Vasodilating Agents, Miscellaneous
ADALAT CC T2
ADEMPAS T4 PA
ambrisentan T4 PA
amlodipine oral tablet 10 mg T1
amlodipine oral tablet 2.5 mg, 5 mg T1 QL (1 EA per 1 DY)
amlodipine-valsartan T1 ST
For the most up to date formulary coverage search, please use the searchable formulary website
55
Drug Tier Notes
aspirin-dipyridamole T1
CALAN T2
CALAN SR T2
CARDIZEM T2
CARDIZEM CD T2
diltiazem hcl T1
DILT-XR T2
dipyridamole T1
epoprostenol (glycine) T4 PA
felodipine T1
FLOLAN T4 PA
ISOPTIN SR T2
LETAIRIS T4 PA
NIFEDICAL XL T1
nifedipine oral capsule T1
nifedipine oral tablet extended release 24hr T1
nifedipine oral tablet extended release 30 mg T1 QL (1 EA per 1 day)
nifedipine oral tablet extended release 60 mg, 90
mg
T1
nisoldipine oral tablet extended release 24 hr 17
mg, 8.5 mg
T1 QL (1 EA per 1 day)
nisoldipine oral tablet extended release 24 hr 20
mg, 30 mg, 34 mg, 40 mg
T1
NORVASC T2
OPSUMIT T4 PA
ORENITRAM T4 PA
PERSANTINE T2
PROCARDIA T2
PROCARDIA XL T2
REMODULIN T4 PA
SULAR T2
TAZTIA XT T1
TIAZAC T2
56
Drug Tier Notes
TRACLEER T4 PA
TYVASO T4 PA
TYVASO REFILL KIT T4 PA
TYVASO STARTER KIT T4 PA
UPTRAVI T4 PA
VELETRI T4 PA
VENTAVIS T4 PA
verapamil T1
VERELAN T2
Cellular And Gene Therapy
Cellular And Gene Therapy
PROVENGE T4 PA
Cellular Therapy
PROVENGE T4 PA
Gene Therapy
KYMRIAH T4 PA
LUXTURNA T4 PA
YESCARTA T4 PA
Central Nervous System Agents
Adamantanes (Cns)
amantadine hcl T1
Amphetamines
ADDERALL T2
ADDERALL XR T2
DEXEDRINE SPANSULE T2
dextroamphetamine T1 PA; AL
dextroamphetamine-amphetamine T1 PA; AL
VYVANSE T1 AL
Analgesics And Antipyretics, Misc.
ACEPHEN T1
acetaminophen T1
acetaminophen-caff-dihydrocod T3 AL
For the most up to date formulary coverage search, please use the searchable formulary website
57
Drug Tier Notes
acetaminophen-codeine T1 AL
butalbital-acetaminop-caf-cod oral capsule 50-
300-40-30 mg
T3 AL
butalbital-acetaminop-caf-cod oral capsule 50-
325-40-30 mg
T1 AL
butalbital-acetaminophen T1
butalbital-acetaminophen-caff T1
CAPITAL WITH CODEINE T3 AL
CHILDREN'S ACETAMINOPHEN T1
ED-APAP T1
ENDOCET ORAL TABLET 10-325 MG, 2.5-325
MG, 7.5-325 MG
T3
ENDOCET ORAL TABLET 5-325 MG T1
ESGIC T2
FEVERALL T1
FIORICET WITH CODEINE T3 AL
gabapentin oral capsule 100 mg, 400 mg T1
gabapentin oral capsule 300 mg T1 QL (9 EA per 1 day)
gabapentin oral solution T1
gabapentin oral tablet T1
HORIZANT T4 PA
HYCET T3
hydrocodone-acetaminophen oral solution T1
hydrocodone-acetaminophen oral tablet 10-300
mg, 2.5-325 mg, 5-300 mg, 7.5-300 mg
T3
hydrocodone-acetaminophen oral tablet 10-325
mg, 5-325 mg, 5-500 mg, 7.5-325 mg, 7.5-500 mg,
7.5-750 mg
T1
LORTAB T2
LORTAB ELIXIR T2
MAPAP (ACETAMINOPHEN) T1
MARTEN-TAB T2
NEURONTIN T2
NON-ASPIRIN JR STRENGTH T1
58
Drug Tier Notes
NORTEMP T1
oxycodone-acetaminophen oral capsule T1
oxycodone-acetaminophen oral solution T3
oxycodone-acetaminophen oral tablet 10-325 mg,
2.5-325 mg, 7.5-325 mg
T3
oxycodone-acetaminophen oral tablet 5-325 mg T1
PAIN RELIEF T1
PERCOCET ORAL TABLET 10-325 MG, 2.5-
325 MG, 7.5-325 MG
T3
PERCOCET ORAL TABLET 5-325 MG T2
PRIALT T4 PA
PRIMLEV T3
Q-PAP T1
tramadol-acetaminophen T3 AL
TREZIX T3
TYLENOL-CODEINE #4 T2 AL
ULTRACET T3 AL
VERDROCET T3
VICODIN T3
VICODIN ES T3
VICODIN HP T3
XODOL 10/300 T3
XODOL 5/300 T3
XODOL 7.5/300 T3
Anticholinergic Agents (Cns)
benztropine T1
trihexyphenidyl T1
Anticonvulsants, Miscellaneous
BANZEL T1 ST; AL
carbamazepine T1
DEPAKENE T2
DEPAKOTE T2
DEPAKOTE ER T2
For the most up to date formulary coverage search, please use the searchable formulary website
59
Drug Tier Notes
DEPAKOTE SPRINKLES T2
divalproex oral capsule, delayed rel sprinkle T1
divalproex oral tablet extended release 24 hr 250
mg
T1 QL (3 EA per 1 day)
divalproex oral tablet extended release 24 hr 500
mg
T1
divalproex oral tablet,delayed release (dr/ec) T1
EPIDIOLEX T4 PA
gabapentin oral capsule 100 mg, 400 mg T1
gabapentin oral capsule 300 mg T1 QL (9 EA per 1 day)
gabapentin oral solution T1
gabapentin oral tablet T1
HORIZANT T4 PA
KEPPRA T2
LAMICTAL T2
lamotrigine oral tablet 100 mg T1 QL (5 EA per 1 day)
lamotrigine oral tablet 150 mg, 200 mg T1
lamotrigine oral tablet 25 mg T1 QL (3 EA per 1 day)
lamotrigine oral tablet, chewable dispersible 25
mg
T1 QL (3 EA per 1 day)
lamotrigine oral tablet, chewable dispersible 5 mg T1 QL (2 EA per 1 day)
lamotrigine oral tablets,dose pack T1
levetiracetam T1
NEURONTIN T2
oxcarbazepine T1
SABRIL T4 PA
TEGRETOL T2
TEGRETOL XR T2
TOPAMAX T2
topiramate oral capsule, sprinkle T1
topiramate oral tablet 100 mg, 200 mg, 25 mg T1
topiramate oral tablet 50 mg T1 QL (6 EA per 1 day)
valproic acid T1
60
Drug Tier Notes
valproic acid (as sodium salt) T1 QL (1000 ML per 30 days)
vigabatrin T4
Antidepressants, Miscellaneous
bupropion hcl T1
bupropion hcl (smoking deter) T1
mirtazapine oral tablet T1 QL (1 EA per 1 day)
mirtazapine oral tablet,disintegrating T1
REMERON T2
REMERON SOLTAB T2
SPRAVATO T4 PA
WELLBUTRIN T2
WELLBUTRIN SR T2
WELLBUTRIN XL T2
ZYBAN T2
Antimanic Agents
ABILIFY T2 AL
ABILIFY MAINTENA T4 PA
aripiprazole oral solution T1 AL
aripiprazole oral tablet 10 mg, 15 mg T1 QL (1 EA per 1 DY); AL
aripiprazole oral tablet 2 mg, 20 mg, 30 mg, 5 mg T1 AL
aripiprazole oral tablet,disintegrating 10 mg T1 QL (2 EA per 1 day); AL
aripiprazole oral tablet,disintegrating 15 mg T1 AL
ARISTADA T4 PA
ARISTADA INITIO T4 PA
carbamazepine T1
DEPAKENE T2
DEPAKOTE T2
DEPAKOTE ER T2
DEPAKOTE SPRINKLES T2
divalproex oral capsule, delayed rel sprinkle T1
divalproex oral tablet extended release 24 hr 250
mg
T1 QL (3 EA per 1 day)
For the most up to date formulary coverage search, please use the searchable formulary website
61
Drug Tier Notes
divalproex oral tablet extended release 24 hr 500
mg
T1
divalproex oral tablet,delayed release (dr/ec) T1
GEODON T2 AL
LAMICTAL T2
lamotrigine oral tablet 100 mg T1 QL (5 EA per 1 day)
lamotrigine oral tablet 150 mg, 200 mg T1
lamotrigine oral tablet 25 mg T1 QL (3 EA per 1 day)
lamotrigine oral tablet, chewable dispersible 25
mg
T1 QL (3 EA per 1 day)
lamotrigine oral tablet, chewable dispersible 5 mg T1 QL (2 EA per 1 day)
lamotrigine oral tablets,dose pack T1
lithium carbonate T1
lithium citrate T1
LITHOBID T2
olanzapine oral tablet 10 mg, 15 mg, 5 mg, 7.5 mg T1 QL (1 EA per 1 day); AL
olanzapine oral tablet 2.5 mg T1 QL (2 EA per 1 day); AL
olanzapine oral tablet 20 mg T1 AL
PERSERIS T4 PA
quetiapine oral tablet 100 mg, 200 mg, 25 mg, 50
mg
T1 QL (3 EA per 1 day); AL
quetiapine oral tablet 300 mg, 400 mg T1 AL
quetiapine oral tablet extended release 24 hr 150
mg
T1 QL (1 EA per 1 day); AL
quetiapine oral tablet extended release 24 hr 200
mg
T1 QL (1 EA per 1 day)
quetiapine oral tablet extended release 24 hr 300
mg, 400 mg, 50 mg
T1 AL
RISPERDAL T2 AL
RISPERDAL CONSTA T4 PA
risperidone oral solution T1 AL
risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2
mg
T1 QL (2 EA per 1 day); AL
risperidone oral tablet 3 mg, 4 mg T1 AL
62
Drug Tier Notes
SAPHRIS T1 AL
SAPHRIS (BLACK CHERRY) T1 QL (2 EA per 1 day); AL
SEROQUEL T2 AL
TEGRETOL T2
TEGRETOL XR T2
valproic acid T1
valproic acid (as sodium salt) T1 QL (1000 ML per 30 days)
ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg T1 QL (2 EA per 1 day); AL
ziprasidone hcl oral capsule 80 mg T1 AL
ZYPREXA INTRAMUSCULAR T4 PA
ZYPREXA ORAL T2 AL
ZYPREXA RELPREVV T4 PA
Antimigraine Agents, Miscellaneous
AIMOVIG AUTOINJECTOR T4 PA
AIMOVIG AUTOINJECTOR (2 PACK) T4 PA
AJOVY T4 PA
ASCOMP WITH CODEINE T3 AL
aspirin T1
aspirin-caffeine-dihydrocodein T3 AL
BUTALBITAL COMPOUND W/CODEINE T1 AL
BUTALBITAL COMPOUND-CODEINE T3 AL
butalbital-acetaminop-caf-cod oral capsule 50-
300-40-30 mg
T3 AL
butalbital-acetaminop-caf-cod oral capsule 50-
325-40-30 mg
T1 AL
butalbital-acetaminophen-caff T1
butalbital-aspirin-caffeine T1
CAFERGOT T2
codeine-butalbital-asa-caff T3 AL
D.H.E.45 T2
DEPAKENE T2
DEPAKOTE T2
DEPAKOTE ER T2
For the most up to date formulary coverage search, please use the searchable formulary website
63
Drug Tier Notes
DEPAKOTE SPRINKLES T2
dihydroergotamine injection T1 QL (12 ML per 30 days)
dihydroergotamine nasal T1 QL (1 QY per 30 DYs)
divalproex oral capsule, delayed rel sprinkle T1
divalproex oral tablet extended release 24 hr 250
mg
T1 QL (3 EA per 1 day)
divalproex oral tablet extended release 24 hr 500
mg
T1
divalproex oral tablet,delayed release (dr/ec) T1
EMGALITY PEN T4 PA
EMGALITY SYRINGE T4 PA
ERGOMAR T1 QL (20 EA per 30 days)
ergotamine-caffeine T1
ESGIC T2
FIORICET WITH CODEINE T3 AL
FIORINAL-CODEINE #3 T2 AL
INDERAL LA T2
MIGRANAL T2 QL (1 QY per 30 DYs)
propranolol T1
SYNALGOS-DC T3
timolol maleate T1
tramadol-acetaminophen T3 AL
ULTRACET T3 AL
valproic acid T1
valproic acid (as sodium salt) T1 QL (1000 ML per 30 days)
Antipsychotics, Miscellaneous
loxapine succinate T1 AL
pimozide T1 AL
Anxiolytics,Sedatives,And Hypnotics,Misc
AMBIEN T2
AMBIEN CR T3 PA
buspirone T1
64
Drug Tier Notes
droperidol T1
EDLUAR T3 PA
eszopiclone T1 ST
HETLIOZ T4 PA
hydroxyzine hcl T1
hydroxyzine pamoate T1
LUNESTA T3 PA
meprobamate T1
PHENERGAN T2
promethazine T1
SLEEP AID (DOXYLAMINE) T1
SONATA T2
VISTARIL T2
zaleplon oral capsule 10 mg T1 QL (14 EA per 25 days)
zaleplon oral capsule 5 mg T1 QL (1 EA per 1 day)
zolpidem T1
Atypical Antipsychotics
ABILIFY T2 AL
ABILIFY MAINTENA T4 PA
aripiprazole oral solution T1 AL
aripiprazole oral tablet 10 mg, 15 mg T1 QL (1 EA per 1 DY); AL
aripiprazole oral tablet 2 mg, 20 mg, 30 mg, 5 mg T1 AL
aripiprazole oral tablet,disintegrating 10 mg T1 QL (2 EA per 1 day); AL
aripiprazole oral tablet,disintegrating 15 mg T1 AL
ARISTADA T4 PA
ARISTADA INITIO T4 PA
clozapine oral tablet 100 mg, 200 mg, 50 mg T1 AL
clozapine oral tablet 25 mg T1 QL (3 EA per 1 day); AL
CLOZARIL T2 AL
GEODON T2 AL
INVEGA SUSTENNA T4 PA
INVEGA TRINZA T4 PA
For the most up to date formulary coverage search, please use the searchable formulary website
65
Drug Tier Notes
LATUDA ORAL TABLET 120 MG, 20 MG, 40
MG, 60 MG
T1 QL (1 EA per 1 day); AL
LATUDA ORAL TABLET 80 MG T1 QL (2 EA per 1 day); AL
NUPLAZID T4 PA
olanzapine oral tablet 10 mg, 15 mg, 5 mg, 7.5 mg T1 QL (1 EA per 1 day); AL
olanzapine oral tablet 2.5 mg T1 QL (2 EA per 1 day); AL
olanzapine oral tablet 20 mg T1 AL
PERSERIS T4 PA
quetiapine oral tablet 100 mg, 200 mg, 25 mg, 50
mg
T1 QL (3 EA per 1 day); AL
quetiapine oral tablet 300 mg, 400 mg T1 AL
quetiapine oral tablet extended release 24 hr 150
mg
T1 QL (1 EA per 1 day); AL
quetiapine oral tablet extended release 24 hr 200
mg
T1 QL (1 EA per 1 day)
quetiapine oral tablet extended release 24 hr 300
mg, 400 mg, 50 mg
T1 AL
RISPERDAL T2 AL
RISPERDAL CONSTA T4 PA
risperidone oral solution T1 AL
risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2
mg
T1 QL (2 EA per 1 day); AL
risperidone oral tablet 3 mg, 4 mg T1 AL
SAPHRIS T1 AL
SAPHRIS (BLACK CHERRY) T1 QL (2 EA per 1 day); AL
SEROQUEL T2 AL
ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg T1 QL (2 EA per 1 day); AL
ziprasidone hcl oral capsule 80 mg T1 AL
ZYPREXA INTRAMUSCULAR T4 PA
ZYPREXA ORAL T2 AL
ZYPREXA RELPREVV T4 PA
Barbiturates (Anticonvulsants)
MYSOLINE T2
phenobarbital T1
66
Drug Tier Notes
primidone T1
Barbiturates (Anxiolytic, Sedative/Hyp)
ASCOMP WITH CODEINE T3 AL
BUTALBITAL COMPOUND W/CODEINE T1 AL
BUTALBITAL COMPOUND-CODEINE T3 AL
butalbital-acetaminop-caf-cod oral capsule 50-
300-40-30 mg
T3 AL
butalbital-acetaminop-caf-cod oral capsule 50-
325-40-30 mg
T1 AL
butalbital-acetaminophen T1
butalbital-acetaminophen-caff T1
butalbital-aspirin-caffeine T1
codeine-butalbital-asa-caff T3 AL
ESGIC T2
FIORICET WITH CODEINE T3 AL
FIORINAL-CODEINE #3 T2 AL
MARTEN-TAB T2
phenobarbital T1
Benzodiazepines (Anticonvulsants)
ATIVAN T2
clobazam T1
clonazepam T1
clorazepate dipotassium T1
diazepam oral T1
diazepam rectal T1 QL (2 EA per 30 DYs)
KLONOPIN T2
lorazepam T1
SYMPAZAN T4 PA
TRANXENE T-TAB T2
Benzodiazepines (Anxiolytic,Sedativ/Hyp)
alprazolam T1 QL (4 EA per 1 day)
amitriptyline-chlordiazepoxide T1
ATIVAN T2
For the most up to date formulary coverage search, please use the searchable formulary website
67
Drug Tier Notes
chlordiazepoxide hcl T1
clobazam T1
clonazepam T1
clorazepate dipotassium T1
diazepam oral T1
diazepam rectal T1 QL (2 EA per 30 DYs)
estazolam T1
HALCION T2
KLONOPIN T2
lorazepam T1
oxazepam T1
RESTORIL T2
SYMPAZAN T4 PA
temazepam T1
TRANXENE T-TAB T2
triazolam T1
XANAX T2
Butyrophenones
haloperidol T1 AL
haloperidol decanoate T1
haloperidol lactate injection T1
haloperidol lactate oral T1 AL
Calcitonin Gene-Related Peptide Antag.
AIMOVIG AUTOINJECTOR T4 PA
AIMOVIG AUTOINJECTOR (2 PACK) T4 PA
AJOVY T4 PA
EMGALITY PEN T4 PA
EMGALITY SYRINGE T4 PA
Central Nervous System Agents, Misc.
atomoxetine T1 AL
AUSTEDO T4 PA
guanfacine oral tablet T1
68
Drug Tier Notes
guanfacine oral tablet extended release 24 hr T1 AL
INGREZZA T4 PA
memantine T1 AL
NAMENDA T2 AL
NAMENDA TITRATION PAK T2 AL
RADICAVA T4 PA
riluzole T4 PA
TENEX T2
TIGLUTIK T4 PA
XENAZINE T4 PA
XYREM T4 PA
Cyclooxygenase-2 (Cox-2) Inhibitors
celecoxib oral capsule 100 mg, 200 mg, 50 mg T1 QL (2 EA per 1 day)
celecoxib oral capsule 400 mg T1 QL (1 EA per 1 day)
Dopamine Precursors
carbidopa-levodopa T1
INBRIJA T4 PA
SINEMET T2
SINEMET CR T2
Ergot-Deriv. Dopamine Receptor Agonists
bromocriptine T1
cabergoline T1 ST new
PARLODEL T2
Fibromyalgia Agents
CYMBALTA T2
duloxetine oral capsule,delayed release(dr/ec) 20
mg
T1 QL (3 EA per 1 day)
duloxetine oral capsule,delayed release(dr/ec) 30
mg, 60 mg
T1 QL (2 EA per 1 day)
SAVELLA ORAL TABLET 100 MG T1
SAVELLA ORAL TABLET 12.5 MG, 25 MG, 50
MG
T1 QL (2 EA per 1 day)
SAVELLA ORAL TABLETS,DOSE PACK T1
For the most up to date formulary coverage search, please use the searchable formulary website
69
Drug Tier Notes
Hydantoins
DILANTIN T1
DILANTIN EXTENDED T1
DILANTIN INFATABS T2
DILANTIN-125 T2
phenytoin T1
phenytoin sodium extended T1
Monoamine Oxidase B Inhibitors
ELDEPRYL T2
selegiline hcl T1
Monoamine Oxidase Inhibitors
ELDEPRYL T2
NARDIL T2
PARNATE T2
phenelzine T1
selegiline hcl T1
tranylcypromine T1
Nonergot-Deriv.Dopamine Receptor Agonist
APOKYN T4 PA
MIRAPEX T2
pramipexole T1
REQUIP T2
ropinirole T1
Opiate Agonists
ABSTRAL T3
acetaminophen-caff-dihydrocod T3 AL
acetaminophen-codeine T1 AL
ACTIQ T3
ASCOMP WITH CODEINE T3 AL
aspirin-caffeine-dihydrocodein T3 AL
belladonna alkaloids-opium T3
70
Drug Tier Notes
BUTALBITAL COMPOUND W/CODEINE T1 AL
BUTALBITAL COMPOUND-CODEINE T3 AL
butalbital-acetaminop-caf-cod oral capsule 50-
300-40-30 mg
T3 AL
butalbital-acetaminop-caf-cod oral capsule 50-
325-40-30 mg
T1 AL
CAPITAL WITH CODEINE T3 AL
CHERATUSSIN AC T2
CHERATUSSIN DAC T1
codeine sulfate T3 AL
codeine-butalbital-asa-caff T3 AL
codeine-guaifenesin T1 QL (120 ML per 30 days); AL
DEMEROL T2
DILAUDID T2
DOLOPHINE T2
DSUVIA T4 PA
DURAGESIC T2 QL (10 QY per 30 DYs)
ENDOCET ORAL TABLET 10-325 MG, 2.5-325
MG, 7.5-325 MG
T3
ENDOCET ORAL TABLET 5-325 MG T1
fentanyl T1 PA; QL (10 QY per 30 DYs)
fentanyl citrate T3
FENTORA T3
FIORICET WITH CODEINE T3 AL
FIORINAL-CODEINE #3 T2 AL
HYCET T3
hydrocodone-acetaminophen oral solution T1
hydrocodone-acetaminophen oral tablet 10-300
mg, 2.5-325 mg, 5-300 mg, 7.5-300 mg
T3
hydrocodone-acetaminophen oral tablet 10-325
mg, 5-325 mg, 5-500 mg, 7.5-325 mg, 7.5-500 mg,
7.5-750 mg
T1
hydrocodone-homatropine T1
hydrocodone-ibuprofen T3
hydromorphone T1
For the most up to date formulary coverage search, please use the searchable formulary website
71
Drug Tier Notes
IBUDONE T3
ibuprofen-oxycodone T3
LAZANDA T3
levorphanol tartrate T3
LORTAB T2
LORTAB ELIXIR T2
meperidine T1
methadone oral concentrate T1
methadone oral solution T1
methadone oral tablet T1 PA
methadone oral tablet,soluble T1
morphine concentrate T1
morphine intramuscular T3
morphine oral capsule, er multiphase 24 hr T3 PA
morphine oral solution T1
morphine oral tablet T1
morphine oral tablet extended release T1 PA
MS CONTIN T2
NUCYNTA T3
OPANA T3
OXAYDO T3
oxycodone oral concentrate T1
oxycodone oral solution T1
oxycodone oral tablet 10 mg T1 QL (9 EA per 1 day)
oxycodone oral tablet 15 mg T1 QL (7 EA per 1 day)
oxycodone oral tablet 20 mg, 30 mg T1
oxycodone oral tablet 5 mg T1 QL (12 EA per 1 day)
oxycodone-acetaminophen oral capsule T1
oxycodone-acetaminophen oral solution T3
oxycodone-acetaminophen oral tablet 10-325 mg,
2.5-325 mg, 7.5-325 mg
T3
oxycodone-acetaminophen oral tablet 5-325 mg T1
72
Drug Tier Notes
oxymorphone T3
PERCOCET ORAL TABLET 10-325 MG, 2.5-
325 MG, 7.5-325 MG
T3
PERCOCET ORAL TABLET 5-325 MG T2
PRIMLEV T3
PROMETHAZINE VC-CODEINE T1 QL (120 ML per 30 days); AL
promethazine-codeine T1 QL (120 ML per 30 days); AL
REPREXAIN T3
ROXICODONE ORAL TABLET 15 MG, 30 MG T2
ROXICODONE ORAL TABLET 5 MG T3
SUBSYS T3
SYNALGOS-DC T3
tramadol T1 AL
tramadol-acetaminophen T3 AL
TREZIX T3
TUSSIGON T1
TYLENOL-CODEINE #4 T2 AL
ULTRACET T3 AL
ULTRAM T2 AL
VERDROCET T3
VICODIN T3
VICODIN ES T3
VICODIN HP T3
VICOPROFEN T3
XODOL 10/300 T3
XODOL 5/300 T3
XODOL 7.5/300 T3
XYLON 10 T3
ZODRYL AC 25 T1
ZODRYL AC 30 T1
ZODRYL AC 35 T1
ZODRYL AC 40 T1
ZODRYL AC 50 T1
For the most up to date formulary coverage search, please use the searchable formulary website
73
Drug Tier Notes
ZODRYL AC 60 T1
ZODRYL AC 80 T1
Opiate Antagonists
naloxone T1
naltrexone T1
NARCAN T1
REVIA T2
VIVITROL T1 QL (1 EA per 30 days)
Opiate Partial Agonists
buprenorphine T3 PA
buprenorphine hcl T3 PA
buprenorphine-naloxone sublingual tablet 2-0.5
mg
T1 QL (4 EA per 1 day)
buprenorphine-naloxone sublingual tablet 8-2 mg T1 QL (2 EA per 1 day)
nalbuphine T1
SUBLOCADE T1 PA
ZUBSOLV T3 PA
Other Nonsteroidal Anti-Inflam. Agents
ANAPROX T2
ANAPROX DS T2
CATAFLAM T2
CHILDREN'S IBUPROFEN T2
diclofenac potassium T1
diclofenac sodium oral T1
diclofenac sodium topical T1 ST
EC-NAPROSYN T2
FELDENE T2
flurbiprofen T1
hydrocodone-ibuprofen T3
IBUDONE T3
ibuprofen T1
ibuprofen-oxycodone T3
74
Drug Tier Notes
indomethacin T1
INFANT'S IBUPROFEN T1
ketoprofen T1
meloxicam oral tablet 15 mg T1
meloxicam oral tablet 7.5 mg T1 QL (1 EA per 1 DY)
MOBIC T2
NAPROSYN T2
naproxen T1
naproxen sodium T1
piroxicam T1
REPREXAIN T3
sulindac T1
VICOPROFEN T3
XYLON 10 T3
Phenothiazines
chlorpromazine T1 AL
fluphenazine decanoate T1
fluphenazine hcl injection T1
fluphenazine hcl oral T1 AL
perphenazine T1 AL
perphenazine-amitriptyline T1 AL
prochlorperazine T1
prochlorperazine edisylate T1 QL (20 ML per 30 days)
prochlorperazine maleate T1 AL
thioridazine T1 AL
trifluoperazine T1 AL
Respiratory And Cns Stimulants
acetaminophen-caff-dihydrocod T3 AL
ASCOMP WITH CODEINE T3 AL
aspirin-caffeine-dihydrocodein T3 AL
BUTALBITAL COMPOUND W/CODEINE T1 AL
BUTALBITAL COMPOUND-CODEINE T3 AL
For the most up to date formulary coverage search, please use the searchable formulary website
75
Drug Tier Notes
butalbital-acetaminop-caf-cod oral capsule 50-
300-40-30 mg
T3 AL
butalbital-acetaminop-caf-cod oral capsule 50-
325-40-30 mg
T1 AL
butalbital-acetaminophen-caff T1
butalbital-aspirin-caffeine T1
CAFCIT T2
caffeine citrate T1
codeine-butalbital-asa-caff T3 AL
CONCERTA T2 PA; AL
dexmethylphenidate oral capsule,er biphasic 50-
50 10 mg, 15 mg, 5 mg
T1 PA; QL (1 EA per 1 day); AL
dexmethylphenidate oral capsule,er biphasic 50-
50 20 mg
T1 PA; QL (2 EA per 1 day); AL
dexmethylphenidate oral capsule,er biphasic 50-
50 25 mg, 30 mg, 35 mg, 40 mg
T1 PA; AL
dexmethylphenidate oral tablet 10 mg T1 PA; AL
dexmethylphenidate oral tablet 2.5 mg T1 QL (4 EA per 1 day); AL
dexmethylphenidate oral tablet 5 mg T1 QL (4 EA per 1 day)
ESGIC T2
FIORICET WITH CODEINE T3 AL
FIORINAL-CODEINE #3 T2 AL
FOCALIN XR T2 PA; AL
methylphenidate hcl oral capsule, er biphasic 30-
70
T1 AL
methylphenidate hcl oral solution T1 AL
methylphenidate hcl oral tablet T1 PA; AL
methylphenidate hcl oral tablet extended release T1 PA; AL
methylphenidate hcl oral tablet extended release
24hr 18 mg, 27 mg, 54 mg
T1 PA; QL (1 EA per 1 day); AL
methylphenidate hcl oral tablet extended release
24hr 36 mg
T1 PA; QL (2 EA per 1 day); AL
methylphenidate hcl oral tablet,chewable T1 AL
RITALIN T2 PA; AL
76
Drug Tier Notes
RITALIN SR T2 PA; AL
SYNALGOS-DC T3
TREZIX T3
Salicylates
ARTHRITIS T1
ASCOMP WITH CODEINE T3 AL
aspirin T1
aspirin-caffeine-dihydrocodein T3 AL
aspirin-dipyridamole T1
BUTALBITAL COMPOUND W/CODEINE T1 AL
BUTALBITAL COMPOUND-CODEINE T3 AL
butalbital-aspirin-caffeine T1
choline,magnesium salicylate T1
codeine-butalbital-asa-caff T3 AL
FIORINAL-CODEINE #3 T2 AL
salsalate T1
SYNALGOS-DC T3
Sel.Serotonin,Norepi Reuptake Inhibitor
CYMBALTA T2
duloxetine oral capsule,delayed release(dr/ec) 20
mg
T1 QL (3 EA per 1 day)
duloxetine oral capsule,delayed release(dr/ec) 30
mg, 60 mg
T1 QL (2 EA per 1 day)
EFFEXOR XR T2
SAVELLA ORAL TABLET 100 MG T1
SAVELLA ORAL TABLET 12.5 MG, 25 MG, 50
MG
T1 QL (2 EA per 1 day)
SAVELLA ORAL TABLETS,DOSE PACK T1
venlafaxine oral capsule,extended release 24hr
150 mg
T1
venlafaxine oral capsule,extended release 24hr
37.5 mg, 75 mg
T1 QL (1 EA per 1 day)
venlafaxine oral tablet 100 mg T1
For the most up to date formulary coverage search, please use the searchable formulary website
77
Drug Tier Notes
venlafaxine oral tablet 25 mg, 37.5 mg, 50 mg, 75
mg
T1 QL (3 EA per 1 day)
venlafaxine oral tablet extended release 24hr T1
Selective Serotonin Agonists
AMERGE T3 PA; QL (12 QY per 30 DYs)
eletriptan T3 PA; QL (12 EA per 30 days)
FROVA T3 PA; QL (12 QY per 30 DYs)
IMITREX ORAL T2 QL (12 QY per 30 DYs)
IMITREX STATDOSE PEN T2 QL (2 QY per 30 DYs)
IMITREX STATDOSE REFILL T2 QL (2 QY per 30 DYs)
IMITREX SUBCUTANEOUS T2 QL (4 QY per 30 DYs)
MAXALT T2 QL (12 QY per 30 DYs)
MAXALT-MLT T2 QL (12 QY per 30 DYs)
rizatriptan T1 QL (12 QY per 30 DYs)
sumatriptan nasal spray,non-aerosol 20
mg/actuation
T1 QL (6 QY per 30 DYs)
sumatriptan nasal spray,non-aerosol 5
mg/actuation
T1 QL (6 EA per 30 days)
sumatriptan succinate oral T1 QL (12 QY per 30 DYs)
sumatriptan succinate subcutaneous cartridge T1 QL (2 QY per 30 DYs)
sumatriptan succinate subcutaneous pen injector T1 QL (2 QY per 30 DYs)
sumatriptan succinate subcutaneous solution T1 QL (4 QY per 30 DYs)
ZOMIG T3 PA; QL (1 QY per 30 DYs)
Selective-Serotonin Reuptake Inhibitors
CELEXA T2
citalopram T1
escitalopram oxalate T1
fluoxetine T1
fluvoxamine T1
LEXAPRO T2
paroxetine hcl oral tablet T1 QL (1 EA per 1 day)
paroxetine hcl oral tablet extended release 24 hr
12.5 mg
T1 QL (1 EA per 1 day)
78
Drug Tier Notes
paroxetine hcl oral tablet extended release 24 hr
25 mg, 37.5 mg
T1 QL (2 EA per 1 day)
PAXIL T2
PROZAC T2
sertraline oral concentrate T1
sertraline oral tablet 100 mg T1
sertraline oral tablet 25 mg, 50 mg T1 QL (45 EA per 30 days)
ZOLOFT T2
Serotonin Modulators
nefazodone T1
trazodone T1
Succinimides
ethosuximide T1
ZARONTIN T2
Thioxanthenes
thiothixene T1 AL
Tricyclics, Other Norepi-Ru Inhibitors
amitriptyline T1
amitriptyline-chlordiazepoxide T1
amoxapine T1
ANAFRANIL T2
clomipramine T1
desipramine T1
doxepin T1
imipramine hcl T1
maprotiline T1
NORPRAMIN T2
nortriptyline T1
PAMELOR T2
perphenazine-amitriptyline T1
TOFRANIL T2
Vesicular Monoamine Transport2 Inhibitor
For the most up to date formulary coverage search, please use the searchable formulary website
79
Drug Tier Notes
AUSTEDO T4 PA
INGREZZA T4 PA
XENAZINE T4 PA
Devices
Devices
ACCU-CHEK AVIVA CONTROL SOLN T1
ACCU-CHEK FASTCLIX LANCET DRUM T1
ACCU-CHEK GUIDE GLUCOSE METER T1
ACCU-CHEK GUIDE L1-L2 CTRL SOL T1
ACCU-CHEK GUIDE ME GLUCOSE MTR T1
ACCU-CHEK MULTICLIX LANCET T1
ACCU-CHEK SMARTVIEW CONTRL SOL T1
ACCU-CHEK SOFT DEV LANCETS T1
ACCU-CHEK SOFTCLIX LANCET DEV T1
ACCU-CHEK SOFTCLIX LANCETS T1
BD AUTOSHIELD DUO PEN NEEDLE T1 QL (200 EA per 34 days)
BD INSULIN SYRINGE HALF UNIT T1 QL (200 EA per 34 days)
BD INSULIN SYRINGE U-500 T1 QL (200 EA per 34 days)
BD INSULIN SYRINGE ULTRA-FINE T1 QL (200 EA per 34 days)
BD NANO 2ND GEN PEN NEEDLE T1 QL (200 EA per 34 days)
BD ULTRA-FINE MICRO PEN NEEDLE T1 QL (200 EA per 34 days)
BD ULTRA-FINE MINI PEN NEEDLE T1 QL (200 EA per 34 days)
BD ULTRA-FINE NANO PEN NEEDLE T1 QL (200 EA per 34 days)
BD ULTRA-FINE ORIG PEN NEEDLE T1 QL (200 EA per 34 days)
BD ULTRA-FINE SHORT PEN NEEDLE T1 QL (200 EA per 34 days)
BD VEO INSULIN SYR HALF UNIT T1 QL (200 EA per 34 days)
BD VEO INSULIN SYRINGE UF T1 QL (200 EA per 34 days)
EUFLEXXA T4 PA
GEL-ONE T4 PA
GELSYN-3 T4 PA
GENVISC 850 T4 PA
HYALGAN T4 PA
80
Drug Tier Notes
NEUROPEN T1 QL (1 EA per 365 days)
NEUROTIPS T1 QL (1 EA per 365 days)
ORTHOVISC T4 PA
sodium chloride T1
SOFT TOUCH LANCETS T1
SOLESTA T4 PA
SUPARTZ FX T4 PA
SYNVISC T4 PA
SYNVISC-ONE T4 PA
Diagnostic Agents
Adrenocortical Insufficiency
ACTHAR H.P. T4 PA
ACTHREL T4 PA
Diabetes Mellitus
ACCU-CHEK AVIVA PLUS TEST STRP T1
ACCU-CHEK GUIDE T1
ACCU-CHEK SMARTVIEW TEST STRIP T1
Ketones
KETOSTIX T1
Pituitary Function
ACTHREL T4 PA
MACRILEN T4 PA
Protein
ALBUSTIX REAGENT T1
Roentgenography And Other Imaging Agents
AZEDRA DOSIMETRIC T4 PA
AZEDRA THERAPEUTIC T4 PA
Thyroid Function
THYROGEN T4 PA
Urine And Feces Contents
KETO-DIASTIX T1
For the most up to date formulary coverage search, please use the searchable formulary website
81
Drug Tier Notes
Electrolytic, Caloric, And Water Balance
Alkalinizing Agents
potassium citrate T1
sodium citrate-citric acid T1
UROCIT-K 10 T1
UROCIT-K 5 T2
Ammonia Detoxicants
CARBAGLU T4 PA
lactulose T1
RAVICTI T4 PA
sodium phenylbutyrate T4 PA
Caloric Agents
glucose T1
Carbonic Anhydrase Inhibitors
acetazolamide T1
DIAMOX SEQUELS T2 PA
Diuretics, Miscellaneous
THEO-24 T1
theophylline T1
Electrolytic,Caloric,Water Balance Misc,
CRYSVITA T4 PA
Irrigating Solutions
SEA-CLENS WOUND CLEANSER T1
water for irrigation, sterile T1
Loop Diuretics
bumetanide T1
DEMADEX T2
furosemide T1
LASIX T2
torsemide T1
Phosphate-Removing Agents
82
Drug Tier Notes
calcium acetate T1
lanthanum T1
PHOSLO T2
sevelamer carbonate T1
Potassium-Removing Agents
LOKELMA T3 PA
SPS (WITH SORBITOL) T1
VELTASSA T3 PA
Potassium-Sparing Diuretics
ALDACTAZIDE T2
ALDACTONE T2
amiloride T1
amiloride-hydrochlorothiazide T1
DYAZIDE T2
MAXZIDE T2
MAXZIDE-25MG T2
spironolactone T1
spironolacton-hydrochlorothiaz T1
triamterene-hydrochlorothiazid T1
Replacement Preparations
CALCI-MIX T1
CALCITRATE T1
CALCIUM 600 T1
CALCIUM 600 + D(3) T1
CALCIUM 600 + MINERALS T1
CALCIUM ANTACID T1
calcium carbonate T1
calcium carbonate-vitamin d2 T1
calcium carbonate-vitamin d3 T1
calcium citrate T1
calcium citrate-vitamin d3 T1
calcium gluconate T1
For the most up to date formulary coverage search, please use the searchable formulary website
83
Drug Tier Notes
calcium lactate T1
CITRACAL + D3 (CALCIUM PHOS) T1
CITRUS CALCIUM T1
CORAL CALCIUM T1
DAILY PRENATAL T1
FOSFREE T1
KLOR-CON T1
KLOR-CON M10 T2
KLOR-CON M20 T2
LIQUID CALCIUM WITH VITAMIN D T1
magnesium chloride T1
ONE DAILY PRENATAL T1
ONE-A-DAY WOMENS FORMULA T1
ONE-A-DAY WOMEN'S PRENATAL 1 T1
OYSTER SHELL CALCIUM 500 T1
OYSTER SHELL CALCIUM-VIT D2 T1
OYSTER SHELL CALCIUM-VIT D3 T1
PEDIATRIC ELECTROLYTE T1
PERRY PRENATAL T1
potassium chloride T1
PR NATAL 400 T1
PR NATAL 400 EC T1
PR NATAL 430 T1
PRENATAL PLUS T1
PRENATAL VITAMIN T1
PRENATAL VITAMIN PLUS LOW IRON T1
prenatal vit-iron fum-folic ac T1
sodium chloride T1
THERAPEUTIC-M T1
TRIVEEN-DUO DHA T1
TUMS T2
TUMS ULTRA T2
84
Drug Tier Notes
Thiazide Diuretics
ACCURETIC T2
ALDACTAZIDE T2
amiloride-hydrochlorothiazide T1
AVALIDE T2 ST
benazepril-hydrochlorothiazide oral tablet 10-12.5
mg, 20-12.5 mg, 5-6.25 mg
T1 QL (2 EA per 1 day)
benazepril-hydrochlorothiazide oral tablet 20-25
mg
T1
bisoprolol-hydrochlorothiazide T1
captopril-hydrochlorothiazide T1
chlorothiazide T1
CORZIDE T2
DIURIL T1
DYAZIDE T2
enalapril-hydrochlorothiazide T1
hydrochlorothiazide T1
HYZAAR T2
irbesartan-hydrochlorothiazide T1 ST
lisinopril-hydrochlorothiazide T1
LOPRESSOR HCT T2
losartan-hydrochlorothiazide T1
LOTENSIN HCT T2
MAXZIDE T2
MAXZIDE-25MG T2
methyldopa-hydrochlorothiazide T1
metoprolol ta-hydrochlorothiaz T1
moexipril-hydrochlorothiazide T1
nadolol-bendroflumethiazide T1
olmesartan-hydrochlorothiazide T1 ST
propranolol-hydrochlorothiazid T1
quinapril-hydrochlorothiazide T1
spironolacton-hydrochlorothiaz T1
For the most up to date formulary coverage search, please use the searchable formulary website
85
Drug Tier Notes
triamterene-hydrochlorothiazid T1
UNIRETIC T2
valsartan-hydrochlorothiazide T1 ST
VASERETIC T2
ZESTORETIC T2
ZIAC T2
Thiazide-Like Diuretics
atenolol-chlorthalidone T1
chlorthalidone T1
CLORPRES T1
indapamide T1
metolazone T1
ZAROXOLYN T2
Uricosuric Agents
probenecid T1
probenecid-colchicine T1
Vasopressin Antagonists
JYNARQUE T4 PA
SAMSCA T4 PA
Enzymes
Enzymes
ACTIVASE T4 PA
ADAGEN T4 PA
ALDURAZYME T4 PA
BRINEURA T4 PA
CATHFLO ACTIVASE T4 PA
CEREZYME T4 PA
ELAPRASE T4 PA
ELELYSO T4 PA
ELITEK T4 PA
FABRAZYME T4 PA
86
Drug Tier Notes
KANUMA T4 PA
MEPSEVII T4 PA
MYOZYME T4 PA
NAGLAZYME T4 PA
PALYNZIQ T4 PA
PULMOZYME T4 PA
REVCOVI T4 PA
STRENSIQ T4 PA
SUCRAID T4 PA
VIMIZIM T4 PA
VORAXAZE T4 PA
VPRIV T4 PA
XIAFLEX T4 PA
Eye, Ear, Nose And Throat (Eent) Preps.
Alpha-Adrenergic Agonists (Eent)
ALPHAGAN P T2
brimonidine T1
Antiallergic Agents
ALAWAY T2 QL (1 QY per 30 DYs)
ASTELIN T2
ASTEPRO T2
azelastine nasal T1
azelastine ophthalmic (eye) T1 ST
cromolyn T1
ketotifen fumarate T1 QL (1 QY per 30 DYs)
olopatadine T1 ST
ZADITOR T2 QL (1 QY per 30 DYs)
Antibacterials (Eent)
bacitracin T1
bacitracin-polymyxin b T1
BLEPH-10 T2
CILOXAN T2
For the most up to date formulary coverage search, please use the searchable formulary website
87
Drug Tier Notes
CIPRODEX T3 PA
ciprofloxacin hcl T1 QL (10 ML per 25 days)
erythromycin T1 QL (3.5 GM per 25 days)
GENTAK T1 QL (4 GM per 30 days)
gentamicin T1
MAXITROL T2
MOXEZA T1
moxifloxacin T1 QL (3 ML per 30 days)
neomycin-bacitracin-poly-hc T1 QL (3.5 GM per 25 days)
neomycin-bacitracin-polymyxin T1 QL (4 GM per 30 days)
neomycin-polymyxin b-dexameth ophthalmic (eye)
drops,suspension
T1 QL (5 ML per 30 days)
neomycin-polymyxin b-dexameth ophthalmic (eye)
ointment
T1 QL (4 GM per 30 days)
neomycin-polymyxin-gramicidin T1 QL (10 ML per 25 days)
neomycin-polymyxin-hc T1
NEOSPORIN (NEO-POLYM-GRAMICID) T2
OCUFLOX T2
ofloxacin ophthalmic (eye) T1 QL (10 ML per 25 days)
ofloxacin otic (ear) T1
polymyxin b sulf-trimethoprim T1 QL (10 ML per 30 days)
POLYTRIM T2
sulfacetamide sodium T1
sulfacetamide-prednisolone T1
TOBRADEX T2
tobramycin T1 QL (5 ML per 25 days)
tobramycin-dexamethasone T1
TOBREX OPHTHALMIC (EYE) DROPS T2
TOBREX OPHTHALMIC (EYE) OINTMENT T1 QL (4 GM per 30 days)
Antivirals (Eent)
trifluridine T1 QL (8 ML per 25 days)
VIROPTIC T2
88
Drug Tier Notes
Beta-Adrenergic Blocking Agents (Eent)
BETAGAN T2
carteolol T1
COSOPT T2
dorzolamide-timolol T1
levobunolol T1
timolol maleate T1
TIMOPTIC T2
TIMOPTIC OCUDOSE (PF) T1
TIMOPTIC-XE T2
Carbonic Anhydrase Inhibitors (Eent)
acetazolamide T1
COSOPT T2
DIAMOX SEQUELS T2 PA
dorzolamide T1
dorzolamide-timolol T1
TRUSOPT T2
Corticosteroids (Eent)
ACETASOL HC T2
CIPRODEX T3 PA
dexamethasone sodium phosphate T1
fluorometholone T1
fluticasone propionate T1
FML FORTE T1
FML LIQUIFILM T2
FML S.O.P. T1
hydrocortisone-acetic acid T1
ILUVIEN T4 PA
MAXIDEX T1
MAXITROL T2
neomycin-bacitracin-poly-hc T1 QL (3.5 GM per 25 days)
neomycin-polymyxin b-dexameth ophthalmic (eye)
drops,suspension
T1 QL (5 ML per 30 days)
For the most up to date formulary coverage search, please use the searchable formulary website
89
Drug Tier Notes
neomycin-polymyxin b-dexameth ophthalmic (eye)
ointment
T1 QL (4 GM per 30 days)
neomycin-polymyxin-hc T1
OMNARIS T3 PA
OZURDEX T4 PA
PRED FORTE T2
PRED MILD T1
prednisolone acetate T1
prednisolone sodium phosphate T1 QL (10 ML per 30 days)
RETISERT T4 PA
TOBRADEX T2
tobramycin-dexamethasone T1
triamcinolone acetonide T1 ST
Eent Anti-Infectives, Miscellaneous
ACETASOL HC T2
acetic acid T1
acetic acid-aluminum acetate T1
carbamide peroxide T1
chlorhexidine gluconate T1
hydrocortisone-acetic acid T1
PERIOGARD T2
Eent Anti-Inflammatory Agents, Misc.
RESTASIS T1 ST
RESTASIS MULTIDOSE T1 ST
XIIDRA T1 ST
Eent Drugs, Miscellaneous
apraclonidine T1
ARTIFICIAL TEARS (POLYVIN ALC) T2
ARTIFICIAL TEARS(GLYCERIN-PEG) T1
ATROVENT T2
bevacizumab T4 PA
CYSTARAN T4 PA
90
Drug Tier Notes
EYLEA T4 PA
IOPIDINE OPHTHALMIC (EYE)
DROPPERETTE
T1
IOPIDINE OPHTHALMIC (EYE) DROPS T2
ipratropium bromide T1
ISOPTO TEARS T1
JETREA (PF) T4 PA
LUBRICATING PLUS T1
LUCENTIS T4 PA
MACUGEN T4 PA
NASAL MIST T1
OXERVATE T4 PA
PHOTREXA T4 PA
PHOTREXA CROSS-LINKING KIT T4 PA
PHOTREXA VISCOUS T4 PA
polyvinyl alcohol T1
REFRESH CLASSIC (PF) T1
REFRESH OPTIVE T1
REFRESH REPAIR T1
REFRESH TEARS T1
SALINE NASAL MIST T1
sodium chloride T1
TEARS NATURALE FREE (PF) T1
TEARS NATURALE II T1
ULTRA FRESH PM T1
VISUDYNE T4 PA
Eent Nonsteroidal Anti-Inflam. Agents
ACULAR T2
ACULAR LS T2
flurbiprofen sodium T1 QL (2.5 ML per 30 days)
ketorolac ophthalmic (eye) drops 0.4 % T1 QL (5 ML per 30 days)
ketorolac ophthalmic (eye) drops 0.5 % T1 QL (20 ML per 25 days)
OCUFEN T2
For the most up to date formulary coverage search, please use the searchable formulary website
91
Drug Tier Notes
Local Anesthetics (Eent)
lidocaine hcl T1
LIDOCAINE VISCOUS T1
XYLOCAINE T2
Miotics
PHOSPHOLINE IODIDE T1
pilocarpine hcl T1
PILOPINE HS T1
Mydriatics
atropine T1
cyclopentolate T1
HOMATROPAIRE T1
Prostaglandin Analogs
latanoprost T1 QL (6 ML per 30 days)
travoprost (benzalkonium) T1 ST; QL (5 ML per 30 days)
XALATAN T2
Vasoconstrictors
ADRENALIN T1
MYDFRIN T2
naphazoline T1
NASAL DECONGESTANT (OXYMETAZL) T1
NEO-SYNEPHRINE (PHENYLEPHRINE) T1
NEO-SYNEPHRINE 12 H SPR (OXYM) T1
phenylephrine hcl T1
Gastrointestinal Drugs
5-Ht3 Receptor Antagonists
ALOXI T4 PA
granisetron (pf) T4 PA
granisetron hcl intravenous T4 PA
granisetron hcl oral T1 ST
ondansetron T1
92
Drug Tier Notes
ondansetron hcl intravenous T4 PA
ondansetron hcl oral T1
SUSTOL T4 PA
ZOFRAN T2
ZOFRAN ODT T2
Antacids And Adsorbents
ACID GONE ANTACID T1
aluminum hydroxide gel T1
ANTACID PLUS ANTI-GAS T1
BISMUTH MAXIMUM STRENGTH T1
bismuth subsalicylate T1
CALCIUM ANTACID T1
calcium carbonate T1
FOAMING ANTACID T1
magnesium oxide T1
PEPTO-BISMOL T2
PINK BISMUTH T1
RI-MAG T1
sodium bicarbonate T1
TUMS T2
TUMS ULTRA T2
URO-MAG T1
Antidiarrhea Agents
BISMUTH MAXIMUM STRENGTH T1
bismuth subsalicylate T1
diphenoxylate-atropine T1
LOMOTIL T2
loperamide T1
PEPTO-BISMOL T2
PINK BISMUTH T1
XERMELO T4 PA
Antiemetics, Miscellaneous
For the most up to date formulary coverage search, please use the searchable formulary website
93
Drug Tier Notes
doxylamine-pyridoxine (vit b6) T1 PA
scopolamine base T3 PA
Antiflatulents
ANTACID PLUS ANTI-GAS T1
ANTI-GAS MAXIMUM STRENGTH T1
simethicone T1
Antihistamines (Gi Drugs)
ANTIVERT T2
dimenhydrinate T1
doxylamine-pyridoxine (vit b6) T1 PA
meclizine T1
prochlorperazine T1
prochlorperazine edisylate T1 QL (20 ML per 30 days)
prochlorperazine maleate T1
TIGAN T1
trimethobenzamide T1
Anti-Inflammatory Agents (Gi Drugs)
AZULFIDINE T2
AZULFIDINE EN-TABS T2
balsalazide T1
CANASA T1
COLAZAL T2
mesalamine T1
PENTASA ORAL CAPSULE, EXTENDED
RELEASE 250 MG
T1 QL (6 EA per 1 day)
PENTASA ORAL CAPSULE, EXTENDED
RELEASE 500 MG
T1
sulfasalazine T1
Cathartics And Laxatives
AMITIZA ORAL CAPSULE 24 MCG T1
AMITIZA ORAL CAPSULE 8 MCG T1 QL (2 EA per 1 day)
bisacodyl T1
94
Drug Tier Notes
calcium polycarbophil T1
COL-RITE T1
COLYTE WITH FLAVOR PACKS T2
docusate calcium T1
docusate sodium T1
DOCUSOL T1
ENEMA T1
FIBER T1
FIBER (DEXTRIN) T1
FIBER (WITH ASPARTAME) T1
FLEET BISACODYL T1
FLEET LAXATIVE T1
GAVILYTE-G T1
glycerin (adult) T1
glycerin (child) T1
GOLYTELY T2
LAXATIVE (SENNOSIDES) T1
magnesium citrate T1
METAMUCIL (WITH SUGAR) T1
MILK OF MAGNESIA T1
mineral oil T1
MINERAL OIL LAXATIVE T1
MIRALAX T2
NATURAL FIBER LAXATIVE (SUGAR) T1
NATURAL FIBER LAXATIVE THERAPY T1
NULYTELY WITH FLAVOR PACKS T2
PEDIA-LAX T1
peg 3350-electrolytes T1
peg-electrolyte soln T1
polyethylene glycol 3350 T1
SENNA T1
sennosides T1
sennosides-docusate sodium T1
For the most up to date formulary coverage search, please use the searchable formulary website
95
Drug Tier Notes
SILACE T2
STOOL SOFTENER T1
TRILYTE WITH FLAVOR PACKETS T2
Cholelitholytic Agents
ACTIGALL T2
URSO 250 T2
URSO FORTE T2
ursodiol T1
Digestants
CREON T1
lactase T1
ZENPEP T1
Gi Drugs, Miscellaneous
CHOLBAM T4 PA
CIMZIA T4 PA
CIMZIA POWDER FOR RECONST T4 PA
ENDARI T4 PA
ENTYVIO T4 PA
GATTEX 30-VIAL T4 PA
HUMIRA T4 PA
HUMIRA PEDIATRIC CROHNS START T4 PA
HUMIRA PEN T4 PA
HUMIRA PEN CROHNS-UC-HS START T4 PA
HUMIRA PEN PSOR-UVEITS-ADOL HS T4 PA
HUMIRA(CF) T4 PA
HUMIRA(CF) PEDI CROHNS STARTER T4 PA
HUMIRA(CF) PEN T4 PA
HUMIRA(CF) PEN CROHNS-UC-HS T4 PA
HUMIRA(CF) PEN PSOR-UV-ADOL HS T4 PA
INFLECTRA T4 PA
LINZESS ORAL CAPSULE 145 MCG, 290 MCG T1 AL
LINZESS ORAL CAPSULE 72 MCG T1
96
Drug Tier Notes
OCALIVA T4 PA
REMICADE T4 PA
RENFLEXIS T4 PA
SIMPONI T4 PA
SIMPONI ARIA T4 PA
Histamine H2-Antagonists
cimetidine T1
cimetidine hcl T1
famotidine T1
nizatidine oral capsule 150 mg T1 QL (2 EA per 1 day)
nizatidine oral capsule 300 mg T1
PEPCID T2
ranitidine hcl T1
ZANTAC T2
Lipotropic Agents
choline bitartrate T1
Neurokinin-1 Receptor Antagonists
aprepitant oral capsule 125 mg, 80 mg T1
aprepitant oral capsule 40 mg T1 QL (1 QY per 30 days)
aprepitant oral capsule,dose pack T1
CINVANTI T4 PA
EMEND INTRAVENOUS T4 PA
EMEND ORAL CAPSULE 125 MG, 80 MG T2
EMEND ORAL CAPSULE 40 MG T2 QL (1 QY per 30 DYs)
EMEND ORAL CAPSULE,DOSE PACK T2
VARUBI T4 PA
Prokinetic Agents
metoclopramide hcl T1
REGLAN T2
Prostaglandins
CYTOTEC T2
misoprostol T1
For the most up to date formulary coverage search, please use the searchable formulary website
97
Drug Tier Notes
Protectants
CARAFATE ORAL SUSPENSION T1 QL (1200 ML per 30 days)
CARAFATE ORAL TABLET T2
sucralfate T1
Proton-Pump Inhibitors
esomeprazole magnesium T1 ST; QL (2 EA per 1 day)
lansoprazole T1 ST; QL (2 EA per 1 day)
NEXIUM 24HR T1 ST; QL (2 EA per 1 day)
NEXIUM PACKET T3 PA
omeprazole T1 QL (2 EA per 1 day)
omeprazole-sodium bicarbonate T1 ST
pantoprazole T1 QL (2 EA per 1 day)
PRILOSEC T1 QL (2 EA per 1 day); AL
PRILOSEC OTC T3 PA
PROTONIX ORAL GRANULES DR FOR SUSP
IN PACKET
T3 PA
PROTONIX ORAL TABLET,DELAYED
RELEASE (DR/EC)
T2
rabeprazole T1 ST
ZEGERID T3 PA
ZEGERID OTC T2 ST
Heavy Metal Antagonists
Heavy Metal Antagonists
CHEMET T1
CUPRIMINE T4 PA
deferoxamine T4 PA
DEPEN TITRATABS T4 PA
EXJADE T4 PA
FERRIPROX T4 PA
GALZIN T4 PA
JADENU T4 PA
JADENU SPRINKLE T4 PA
98
Drug Tier Notes
trientine T4 PA
Hormones And Synthetic Substitutes
Adrenals
ARMONAIR RESPICLICK T1
ARNUITY ELLIPTA INHALATION BLISTER
WITH DEVICE 100 MCG/ACTUATION, 200
MCG/ACTUATION
T1 QL (1 EA per 30 days)
ARNUITY ELLIPTA INHALATION BLISTER
WITH DEVICE 50 MCG/ACTUATION
T1 QL (1 EA per 30 DYs)
ASMANEX HFA T1
ASMANEX TWISTHALER INHALATION
AEROSOL POWDR BREATH ACTIVATED 110
MCG (30 DOSES), 220 MCG (120 DOSES), 220
MCG (30 DOSES), 220 MCG (60 DOSES)
T1 QL (1 QY per 30 DYs)
ASMANEX TWISTHALER INHALATION
AEROSOL POWDR BREATH ACTIVATED 110
MCG (7 DOSES)
T1 QL (1 QY per 7 DYs)
ASMANEX TWISTHALER INHALATION
AEROSOL POWDR BREATH ACTIVATED 220
MCG (14 DOSES)
T1 QL (1 QY per 14 DYs)
budesonide inhalation suspension for nebulization
0.25 mg/2 ml
T1 QL (60 QY per 30 DYs); AL
budesonide inhalation suspension for nebulization
0.5 mg/2 ml
T1 QL (120 QY per 30 DYs); AL
budesonide inhalation suspension for nebulization
1 mg/2 ml
T1 QL (60 ML per 30 DYs); AL
CORTEF T2
cortisone T1
dexamethasone T1
DEXAMETHASONE INTENSOL T1
dexamethasone sodium phos (pf) T1
dexamethasone sodium phosphate T1
DULERA T3 QL (13 QY per 30 DYs); AL
EMFLAZA T4 PA
ENTOCORT EC T3 PA
FLOVENT DISKUS INHALATION BLISTER
WITH DEVICE 100 MCG/ACTUATION
T1 QL (120 QY per 30 DYs)
For the most up to date formulary coverage search, please use the searchable formulary website
99
Drug Tier Notes
FLOVENT DISKUS INHALATION BLISTER
WITH DEVICE 250 MCG/ACTUATION
T1 QL (240 QY per 30 DYs)
FLOVENT DISKUS INHALATION BLISTER
WITH DEVICE 50 MCG/ACTUATION
T1 QL (60 QY per 30 DYs)
FLOVENT HFA INHALATION HFA AEROSOL
INHALER 110 MCG/ACTUATION
T1 QL (12 QY per 30 DYs)
FLOVENT HFA INHALATION HFA AEROSOL
INHALER 220 MCG/ACTUATION
T1 QL (24 QY per 30 DYs)
FLOVENT HFA INHALATION HFA AEROSOL
INHALER 44 MCG/ACTUATION
T1 QL (10.6 QY per 30 DYs)
fludrocortisone T1
fluticasone propion-salmeterol inhalation aerosol
powdr breath activated
T1
fluticasone propion-salmeterol inhalation blister
with device
T1 QL (1 EA per 30 days)
hydrocortisone T1
INTRAROSA T1
MEDROL (PAK) T2
MEDROL ORAL TABLET 16 MG, 32 MG, 4
MG, 8 MG
T2
MEDROL ORAL TABLET 2 MG T1
methylprednisolone T1
ORAPRED T2
prednisolone T1
prednisolone sodium phosphate T1
prednisone T1
PREDNISONE INTENSOL T1
PRELONE T2
PULMICORT INHALATION SUSPENSION
FOR NEBULIZATION 0.25 MG/2 ML
T2 QL (60 QY per 30 DYs); AL
PULMICORT INHALATION SUSPENSION
FOR NEBULIZATION 0.5 MG/2 ML
T2 QL (120 QY per 30 DYs); AL
QVAR INHALATION AEROSOL 40
MCG/ACTUATION
T1 QL (8.7 QY per 30 DYs)
QVAR INHALATION AEROSOL 80
MCG/ACTUATION
T1 QL (17.4 QY per 30 DYs)
100
Drug Tier Notes
QVAR REDIHALER INHALATION HFA
AEROSOL BREATH ACTIVATED 40
MCG/ACTUATION
T1 QL (10.6 GM per 30 days)
QVAR REDIHALER INHALATION HFA
AEROSOL BREATH ACTIVATED 80
MCG/ACTUATION
T1 QL (21.2 GM per 30 days)
WIXELA INHUB T1 QL (1 EA per 30 days)
Androgens
AVEED T4 PA
danazol T1 PA
fluoxymesterone T1 PA
TESTOPEL T4 PA
testosterone T1 PA
testosterone cypionate intramuscular oil 100
mg/ml
T1 QL (10 ML per 70 days)
testosterone cypionate intramuscular oil 200
mg/ml
T1 QL (4 ML per 28 days)
testosterone enanthate T1 QL (5 QY per 30 DYs)
Antidiabetic Agents, Miscellaneous
colesevelam oral powder in packet T1
colesevelam oral tablet T1 QL (6 EA per 1 day)
WELCHOL T2
Antiestrogens
anastrozole T1
ARIMIDEX T2
AROMASIN T4 PA
FEMARA T2 QL (1 QY per 1 DY)
KISQALI FEMARA CO-PACK T4 PA
letrozole T1 QL (1 QY per 1 DY)
Antigonadtropins
FIRMAGON T4 PA
ganirelix T4 PA
ORILISSA T1 PA
Antiparathyroid Agents
For the most up to date formulary coverage search, please use the searchable formulary website
101
Drug Tier Notes
calcitonin (salmon) T1
MIACALCIN INJECTION T4 PA
MIACALCIN NASAL T2
PARSABIV T4 PA
Antithyroid Agents
methimazole T1
propylthiouracil T1
SSKI T1
TAPAZOLE T2
Biguanides
alogliptin-metformin T1 ST
glipizide-metformin oral tablet 2.5-250 mg T1 QL (3 EA per 1 day)
glipizide-metformin oral tablet 2.5-500 mg, 5-500
mg
T1
GLUCOPHAGE T2
GLUCOPHAGE XR T2
GLUCOVANCE T2
glyburide-metformin oral tablet 1.25-250 mg T1 QL (3 EA per 1 day)
glyburide-metformin oral tablet 2.5-500 mg, 5-500
mg
T1
JANUMET T1 ST
JANUMET XR T1 ST
metformin oral tablet T1
metformin oral tablet extended release 24 hr 500
mg
T1
metformin oral tablet extended release 24 hr 750
mg
T1 QL (2 EA per 1 day)
pioglitazone-metformin T1 ST
SEGLUROMET T1 ST
Contraceptives
ARANELLE (28) T1
BALCOLTRA T1
BALZIVA (28) T1
102
Drug Tier Notes
CAMILA T2
CAMRESE T1
CRYSELLE (28) T1
CYCLESSA (28) T2
desog-e.estradiol/e.estradiol T1
DESOGEN T2
desogestrel-ethinyl estradiol T2
drospirenone-e.estradiol-lm.fa T1
drospirenone-ethinyl estradiol T1
ELLA T1
ENPRESSE T1
ERRIN T2
ESTROSTEP FE-28 T1
FEMCON FE T2
INTROVALE T2
JOLESSA T2
JOLIVETTE T2
JUNEL 1.5/30 (21) T1
JUNEL 1/20 (21) T1
JUNEL FE 1.5/30 (28) T1
JUNEL FE 1/20 (28) T1
KARIVA (28) T1
KELNOR 1/35 (28) T1
KURVELO (28) T1
KYLEENA T1
l norgest/e.estradiol-e.estrad T1
LEENA 28 T1
LESSINA T2
levonorgestrel-ethinyl estrad T1
LEVORA-28 T2
LILETTA T1
LO LOESTRIN FE T1
LOESTRIN 1.5/30 (21) T2
For the most up to date formulary coverage search, please use the searchable formulary website
103
Drug Tier Notes
LOESTRIN 1/20 (21) T2
LOESTRIN 24 FE T2
LOESTRIN FE 1.5/30 (28-DAY) T1
LOESTRIN FE 1/20 (28-DAY) T2
LOW-OGESTREL (28) T1
LUTERA (28) T2
MICROGESTIN 1.5/30 (21) T1
MICROGESTIN 1/20 (21) T2
MICROGESTIN FE 1.5/30 (28) T1
MICROGESTIN FE 1/20 (28) T2
MIRCETTE (28) T2
MIRENA T1
MODICON (28) T2
MONONESSA (28) T2
NATAZIA T1
NECON 1/35 (28) T1
NECON 1/50 (28) T1
NECON 7/7/7 (28) T1
NEXPLANON T1
NORA-BE T2
noreth-ethinyl estradiol-iron T1
norethindrone (contraceptive) T1
norethindrone ac-eth estradiol T1
norethindrone-e.estradiol-iron T1
norgestimate-ethinyl estradiol T1
NORINYL 1/35 (28) T2
NORTREL 0.5/35 (28) T1
NORTREL 1/35 (21) T1
NORTREL 1/35 (28) T1
NORTREL 7/7/7 (28) T1
NUVARING T1 QL (1 EA per 28 DYs)
OCELLA T2
104
Drug Tier Notes
OGESTREL (28) T1
ORTHO TRI-CYCLEN (28) T2
ORTHO TRI-CYCLEN LO (28) T2
ORTHO-NOVUM 1/35 (28) T2
PARAGARD T 380A T1
PLAN B ONE-STEP T1
PORTIA 28 T2
QUASENSE T2
RECLIPSEN (28) T1
SEASONIQUE T2
SKYLA T1
SPRINTEC (28) T2
SRONYX T2
TAYTULLA T1
TRINESSA (28) T1
TRI-NORINYL (28) T2
TRI-SPRINTEC (28) T2
TRIVORA (28) T1
VELIVET TRIPHASIC REGIMEN (28) T1
XULANE T1 QL (3 EA per 28 days)
YASMIN (28) T2
ZENCHENT FE T1
ZOVIA 1/35E (28) T1
ZOVIA 1/50E (28) T1
Dipeptidyl Peptidase-4(Dpp-4) Inhibitors
alogliptin T1 ST
alogliptin-metformin T1 ST
alogliptin-pioglitazone T1 ST
JANUMET T1 ST
JANUMET XR T1 ST
JANUVIA T1 ST
Estrogen Agonist-Antagonists
For the most up to date formulary coverage search, please use the searchable formulary website
105
Drug Tier Notes
FARESTON T1 ST
raloxifene T1
tamoxifen T1
Estrogens
CLIMARA T2
COMBIPATCH T1
estradiol T1
estropipate T1
FEMHRT LOW DOSE T2
JINTELI T1
MENEST T1
norethindrone ac-eth estradiol T1
PREMARIN T1
PREMPHASE T1
PREMPRO T1
Glycogenolytic Agents
GLUCAGEN HYPOKIT T1 QL (2 QY per 30 DYs)
GLUCAGON EMERGENCY KIT (HUMAN) T1 QL (2 QY per 30 DYs)
Gonadotropins
BRAVELLE T4 PA
chorionic gonadotropin, human T4 PA
ELIGARD T4 PA
ELIGARD (3 MONTH) T4 PA
ELIGARD (4 MONTH) T4 PA
ELIGARD (6 MONTH) T4 PA
FOLLISTIM AQ T4 PA
GONAL-F T4 PA
GONAL-F RFF T4 PA
GONAL-F RFF REDI-JECT T4 PA
leuprolide T4 PA
LUPANETA PACK (1 MONTH) T4 PA
LUPANETA PACK (3 MONTH) T4 PA
106
Drug Tier Notes
LUPRON DEPOT T4 PA
LUPRON DEPOT (3 MONTH) T4 PA
LUPRON DEPOT (4 MONTH) T4 PA
LUPRON DEPOT (6 MONTH) T4 PA
LUPRON DEPOT-PED T4 PA
LUPRON DEPOT-PED (3 MONTH) T4 PA
MENOPUR T4 PA
NOVAREL T4 PA
OVIDREL T4 PA
SUPPRELIN LA T4 PA
TRELSTAR T4 PA
TRELSTAR DEPOT T4 PA
TRELSTAR LA T4 PA
TRIPTODUR T4 PA
VANTAS T4 PA
ZOLADEX T4 PA
Gonadotropins And Antigonadotropins
BRAVELLE T4 PA
chorionic gonadotropin, human T4 PA
ELIGARD T4 PA
ELIGARD (3 MONTH) T4 PA
ELIGARD (4 MONTH) T4 PA
ELIGARD (6 MONTH) T4 PA
FOLLISTIM AQ T4 PA
GONAL-F T4 PA
GONAL-F RFF T4 PA
GONAL-F RFF REDI-JECT T4 PA
leuprolide T4 PA
LUPANETA PACK (1 MONTH) T4 PA
LUPANETA PACK (3 MONTH) T4 PA
LUPRON DEPOT T4 PA
LUPRON DEPOT (3 MONTH) T4 PA
For the most up to date formulary coverage search, please use the searchable formulary website
107
Drug Tier Notes
LUPRON DEPOT (4 MONTH) T4 PA
LUPRON DEPOT (6 MONTH) T4 PA
LUPRON DEPOT-PED T4 PA
LUPRON DEPOT-PED (3 MONTH) T4 PA
MENOPUR T4 PA
NOVAREL T4 PA
OVIDREL T4 PA
SUPPRELIN LA T4 PA
TRIPTODUR T4 PA
VANTAS T4 PA
ZOLADEX T4 PA
Incretin Mimetics
OZEMPIC T1 ST
TRULICITY T1 ST
VICTOZA 2-PAK T1 ST
VICTOZA 3-PAK T1 ST
Insulins
ADMELOG SOLOSTAR U-100 INSULIN T1 QL (30 ML per 30 days)
ADMELOG U-100 INSULIN LISPRO T1 QL (30 ML per 30 days)
BASAGLAR KWIKPEN U-100 INSULIN T1 QL (30 ML per 30 DYs)
HUMALOG JUNIOR KWIKPEN U-100 T1 QL (30 ML per 30 days)
HUMALOG MIX 50-50 INSULN U-100 T1 QL (3 QY per 30 DYs)
HUMALOG MIX 50-50 KWIKPEN T1 QL (2 QY per 30 DYs)
HUMALOG MIX 75-25 KWIKPEN T1 QL (2 QY per 30 DYs)
HUMALOG MIX 75-25(U-100)INSULN T1 QL (3 QY per 30 DYs)
HUMULIN 70/30 U-100 INSULIN T1 QL (3 QY per 30 DYs)
HUMULIN 70/30 U-100 KWIKPEN T1
HUMULIN N NPH INSULIN KWIKPEN T1
HUMULIN N NPH U-100 INSULIN T1 QL (3 QY per 30 DYs)
HUMULIN R REGULAR U-100 INSULN T1 QL (3 QY per 30 DYs)
HUMULIN R U-500 (CONC) INSULIN T1
Intermediate-Acting Insulins
108
Drug Tier Notes
HUMALOG MIX 50-50 INSULN U-100 T1 QL (3 QY per 30 DYs)
HUMALOG MIX 50-50 KWIKPEN T1 QL (2 QY per 30 DYs)
HUMALOG MIX 75-25 KWIKPEN T1 QL (2 QY per 30 DYs)
HUMALOG MIX 75-25(U-100)INSULN T1 QL (3 QY per 30 DYs)
HUMULIN 70/30 U-100 INSULIN T1 QL (3 QY per 30 DYs)
HUMULIN 70/30 U-100 KWIKPEN T1
HUMULIN N NPH INSULIN KWIKPEN T1
HUMULIN N NPH U-100 INSULIN T1 QL (3 QY per 30 DYs)
Leptins
MYALEPT T4 PA
Long-Acting Insulins
BASAGLAR KWIKPEN U-100 INSULIN T1 QL (30 ML per 30 DYs)
Parathyroid Agents
FORTEO T4 PA
TYMLOS T4 PA
Parathyroid And Antiparathyroid Agents
calcitonin (salmon) T1
FORTEO T4 PA
MIACALCIN INJECTION T4 PA
MIACALCIN NASAL T2
TYMLOS T4 PA
Pituitary
ACTHAR H.P. T4 PA
DDAVP NASAL T2 PA
DDAVP ORAL T2 PA; AL
desmopressin nasal T1 PA
desmopressin oral T1 PA; AL
GENOTROPIN T4 PA
GENOTROPIN MINIQUICK T4 PA
HUMATROPE T4 PA
NORDITROPIN FLEXPRO T4 PA
NORDITROPIN NORDIFLEX T4 PA
For the most up to date formulary coverage search, please use the searchable formulary website
109
Drug Tier Notes
NUTROPIN AQ T4 PA
NUTROPIN AQ NUSPIN T4 PA
OMNITROPE T4 PA
SAIZEN T4 PA
SAIZEN CLICK.EASY T4 PA
SEROSTIM T4 PA
STIMATE T1 PA
ZOMACTON T4 PA
Progestins
AYGESTIN T2
COMBIPATCH T1
DEPO-PROVERA INTRAMUSCULAR
SUSPENSION 150 MG/ML
T2
DEPO-PROVERA INTRAMUSCULAR
SUSPENSION 400 MG/ML
T1
DEPO-SUBQ PROVERA 104 T1
FEMHRT LOW DOSE T2
hydroxyprogest(pf)(preg presv) T4 PA
hydroxyprogesterone cap(ppres) T4 PA
hydroxyprogesterone caproate T4 PA
JINTELI T1
LUPANETA PACK (1 MONTH) T4 PA
LUPANETA PACK (3 MONTH) T4 PA
MAKENA T4 PA
MAKENA (PF) T4 PA
medroxyprogesterone intramuscular suspension T1 QL (1 ML per 30 days)
medroxyprogesterone intramuscular syringe T1 QL (1 ML per 30 DYs)
medroxyprogesterone oral T1
MEGACE T2
MEGACE ES T2 QL (150 QY per 30 DYs)
megestrol oral suspension 400 mg/10 ml (40
mg/ml)
T1
megestrol oral suspension 625 mg/5 ml T1 QL (150 ML per 30 DYs)
110
Drug Tier Notes
megestrol oral tablet T1
norethindrone acetate T1
norethindrone ac-eth estradiol T1
PROVERA T2
Rapid-Acting Insulins
ADMELOG SOLOSTAR U-100 INSULIN T1 QL (30 ML per 30 days)
ADMELOG U-100 INSULIN LISPRO T1 QL (30 ML per 30 days)
HUMALOG JUNIOR KWIKPEN U-100 T1 QL (30 ML per 30 days)
HUMALOG MIX 50-50 INSULN U-100 T1 QL (3 QY per 30 DYs)
HUMALOG MIX 50-50 KWIKPEN T1 QL (2 QY per 30 DYs)
HUMALOG MIX 75-25 KWIKPEN T1 QL (2 QY per 30 DYs)
HUMALOG MIX 75-25(U-100)INSULN T1 QL (3 QY per 30 DYs)
Short-Acting Insulins
HUMULIN 70/30 U-100 INSULIN T1 QL (3 QY per 30 DYs)
HUMULIN 70/30 U-100 KWIKPEN T1
HUMULIN R REGULAR U-100 INSULN T1 QL (3 QY per 30 DYs)
HUMULIN R U-500 (CONC) INSULIN T1
Sodium-Gluc Cotransport 2 (Sglt2) Inhib
SEGLUROMET T1 ST
STEGLATRO T1 ST
Somatostatin Agonists
octreotide acetate T4 PA
SANDOSTATIN T4 PA
SANDOSTATIN LAR DEPOT T4 PA
SIGNIFOR T4 PA
SIGNIFOR LAR T4 PA
SOMATULINE DEPOT T4 PA
Somatotropin Agonists
EGRIFTA T4 PA
INCRELEX T4 PA
Somatotropin Antagonists
SOMAVERT T4 PA
For the most up to date formulary coverage search, please use the searchable formulary website
111
Drug Tier Notes
Sulfonylureas
AMARYL T2
DIABETA T2
glimepiride oral tablet 1 mg, 2 mg T1 QL (3 EA per 1 day)
glimepiride oral tablet 4 mg T1
glipizide oral tablet 10 mg T1
glipizide oral tablet 5 mg T1 QL (5 EA per 1 day)
glipizide oral tablet extended release 24hr 10 mg T1
glipizide oral tablet extended release 24hr 2.5 mg,
5 mg
T1 QL (3 EA per 1 day)
glipizide-metformin oral tablet 2.5-250 mg T1 QL (3 EA per 1 day)
glipizide-metformin oral tablet 2.5-500 mg, 5-500
mg
T1
GLUCOTROL T2
GLUCOTROL XL T2
GLUCOVANCE T2
glyburide micronized oral tablet 1.5 mg, 3 mg T1 QL (3 EA per 1 day)
glyburide micronized oral tablet 6 mg T1
glyburide oral tablet 1.25 mg, 2.5 mg T1 QL (3 EA per 1 day)
glyburide oral tablet 5 mg T1
glyburide-metformin oral tablet 1.25-250 mg T1 QL (3 EA per 1 day)
glyburide-metformin oral tablet 2.5-500 mg, 5-500
mg
T1
GLYNASE T2
Thiazolidinediones
alogliptin-pioglitazone T1 ST
pioglitazone T1 ST
pioglitazone-metformin T1 ST
Thyroid Agents
ARMOUR THYROID ORAL TABLET 120 MG,
15 MG, 30 MG, 60 MG, 90 MG
T2
ARMOUR THYROID ORAL TABLET 180 MG,
240 MG, 300 MG
T1
112
Drug Tier Notes
CYTOMEL T2
levothyroxine T1
liothyronine T1
NATURE-THROID T1
SYNTHROID T2
thyroid (pork) T1
THYROLAR-1 T1
THYROLAR-1/2 T1
THYROLAR-1/4 T1
THYROLAR-2 T1
THYROLAR-3 T1
UNITHROID T2
Miscellaneous Therapeutic Agents
5-Alpha-Reductase Inhibitors
dutasteride T1
finasteride T1
PROSCAR T2
Alcohol Deterrents
ANTABUSE T2
disulfiram T1
naltrexone T1
REVIA T2
VIVITROL T1 QL (1 EA per 30 days)
Antidotes
CHEMET T1
deferoxamine T4 PA
FUSILEV T4 PA
GLUCAGEN HYPOKIT T1 QL (2 QY per 30 DYs)
GLUCAGON EMERGENCY KIT (HUMAN) T1 QL (2 QY per 30 DYs)
KHAPZORY T4 PA
lanthanum T1
leucovorin calcium T4 PA
For the most up to date formulary coverage search, please use the searchable formulary website
113
Drug Tier Notes
naloxone T1
NARCAN T1
phytonadione (vitamin k1) T1
sevelamer carbonate T1
SPS (WITH SORBITOL) T1
SSKI T1
VISTOGARD T4 PA
VORAXAZE T4 PA
Antigout Agents
allopurinol oral tablet 100 mg T1
allopurinol oral tablet 300 mg T1 QL (2 EA per 1 day)
ANAPROX T2
ANAPROX DS T2
colchicine T1 ST; QL (60 EA per 30 days)
EC-NAPROSYN T2
indomethacin T1
KRYSTEXXA T4 PA
NAPROSYN T2
naproxen T1
naproxen sodium T1
probenecid T1
probenecid-colchicine T1
ZYLOPRIM T2
Antisense Oligonucleotides
EXONDYS 51 T4 PA
KYNAMRO T4 PA
SPINRAZA (PF) T4 PA
TEGSEDI T4 PA
Bone Anabolic Agents
FORTEO T4 PA
TYMLOS T4 PA
114
Drug Tier Notes
Bone Resorption Inhibitors
alendronate T1
BONIVA T4 PA
calcitonin (salmon) T1
DIDRONEL T2
etidronate disodium T1
FOSAMAX T2
MIACALCIN INJECTION T4 PA
MIACALCIN NASAL T2
pamidronate T4 PA
PROLIA T4 PA
raloxifene T1
RECLAST T4 PA
XGEVA T4 PA
zoledronic acid T4 PA
zoledronic ac-mannitol-0.9nacl T4 PA
ZOMETA T4 PA
Cariostatic Agents
CLINPRO 5000 T1 AL
fluoride (sodium) T1 AL
FLUORITAB T1 AL
FLURA-DROPS T1 AL
MULTI-VIT WITH FLUORIDE-IRON T1
MULTI-VITAMIN WITH FLUORIDE T1
MULTIVITAMINS WITH FLUORIDE T1
MVC-FLUORIDE T1
PHOS-FLUR T1 AL
PREVIDENT 5000 ENAMEL PROTECT T1 AL
PREVIDENT 5000 PLUS T2 AL
PREVIDENT DENTAL GEL T2 AL
PREVIDENT DENTAL SOLUTION T1 AL
SF T1 AL
For the most up to date formulary coverage search, please use the searchable formulary website
115
Drug Tier Notes
SF 5000 PLUS T1 AL
TRI-VIT WITH FLUORIDE AND IRON T1
TRI-VITAMIN WITH FLUORIDE T1
Complement Inhibitors
BERINERT T4 PA
CINRYZE T4 PA
FIRAZYR T4 PA
HAEGARDA T4 PA
KALBITOR T4 PA
RUCONEST T4 PA
SOLIRIS T4 PA
TAKHZYRO T4 PA
ULTOMIRIS T4 PA
Disease-Modifying Antirheumatic Agents
ACTEMRA T4 PA
ACTEMRA ACTPEN T4 PA
ARAVA T2
azathioprine T1
AZULFIDINE T2
AZULFIDINE EN-TABS T2
CIMZIA T4 PA
CIMZIA POWDER FOR RECONST T4 PA
CUPRIMINE T4 PA
cyclosporine T1
cyclosporine modified T1
DEPEN TITRATABS T4 PA
ENBREL T4 PA
ENBREL MINI T4 PA
ENBREL SURECLICK T4 PA
GENGRAF T1
HUMIRA T4 PA
HUMIRA PEDIATRIC CROHNS START T4 PA
116
Drug Tier Notes
HUMIRA PEN T4 PA
HUMIRA PEN CROHNS-UC-HS START T4 PA
HUMIRA PEN PSOR-UVEITS-ADOL HS T4 PA
HUMIRA(CF) T4 PA
HUMIRA(CF) PEDI CROHNS STARTER T4 PA
HUMIRA(CF) PEN T4 PA
HUMIRA(CF) PEN CROHNS-UC-HS T4 PA
HUMIRA(CF) PEN PSOR-UV-ADOL HS T4 PA
hydroxychloroquine T1
IMURAN T2
INFLECTRA T4 PA
KEVZARA T4 PA
KINERET T4 PA
leflunomide T1
methotrexate sodium (pf) T4 PA
methotrexate sodium injection T4 PA
methotrexate sodium oral T1
NEORAL T2
OLUMIANT T4 PA
ORENCIA T4 PA
ORENCIA (WITH MALTOSE) T4 PA
ORENCIA CLICKJECT T4 PA
OTEZLA T4 PA
OTEZLA STARTER T4 PA
OTREXUP (PF) T4 PA
PLAQUENIL T2
REMICADE T4 PA
RENFLEXIS T4 PA
SANDIMMUNE ORAL CAPSULE T2
SANDIMMUNE ORAL SOLUTION T1
SIMPONI T4 PA
SIMPONI ARIA T4 PA
STELARA T4 PA
For the most up to date formulary coverage search, please use the searchable formulary website
117
Drug Tier Notes
sulfasalazine T1
TREXALL ORAL TABLET 10 MG, 5 MG T4 PA
TREXALL ORAL TABLET 7.5 MG T1
XELJANZ T4 PA
XELJANZ XR T4 PA
Gonadotropin-Releasing Hormone Antagnts
FIRMAGON T4 PA
ganirelix T4 PA
Immunomodulatory Agents
ACTEMRA T4 PA
ACTEMRA ACTPEN T4 PA
ACTIMMUNE T4 PA
ARAVA T2
AUBAGIO T4 PA
AVONEX T4 PA
AVONEX (WITH ALBUMIN) T4 PA
azathioprine T1
AZULFIDINE T2
AZULFIDINE EN-TABS T2
BETASERON T4 PA
CIMZIA T4 PA
CIMZIA POWDER FOR RECONST T4 PA
COPAXONE T4 PA
cyclosporine T1
cyclosporine modified T1
ENBREL T4 PA
ENBREL MINI T4 PA
ENBREL SURECLICK T4 PA
ENTYVIO T4 PA
EXTAVIA T4 PA
GENGRAF T1
GILENYA T4 PA
118
Drug Tier Notes
glatiramer T4 PA
GLATOPA T4 PA
HUMIRA T4 PA
HUMIRA PEDIATRIC CROHNS START T4 PA
HUMIRA PEN T4 PA
HUMIRA PEN CROHNS-UC-HS START T4 PA
HUMIRA PEN PSOR-UVEITS-ADOL HS T4 PA
HUMIRA(CF) T4 PA
HUMIRA(CF) PEDI CROHNS STARTER T4 PA
HUMIRA(CF) PEN T4 PA
HUMIRA(CF) PEN CROHNS-UC-HS T4 PA
HUMIRA(CF) PEN PSOR-UV-ADOL HS T4 PA
hydroxychloroquine T1
IMURAN T2
INFLECTRA T4 PA
INTRON A T4 PA
KEVZARA T4 PA
KINERET T4 PA
leflunomide T1
LEMTRADA T4 PA
MAYZENT T4 PA
MAYZENT STARTER PACK T4 PA
methotrexate sodium (pf) T4 PA
methotrexate sodium injection T4 PA
methotrexate sodium oral T1
NEORAL T2
OCREVUS T4 PA
OLUMIANT T4 PA
ORENCIA T4 PA
ORENCIA (WITH MALTOSE) T4 PA
ORENCIA CLICKJECT T4 PA
OTEZLA T4 PA
OTEZLA STARTER T4 PA
For the most up to date formulary coverage search, please use the searchable formulary website
119
Drug Tier Notes
OTREXUP (PF) T4 PA
PLAQUENIL T2
PLEGRIDY T4 PA
POMALYST T4 PA
PROLEUKIN T4 PA
REBIF (WITH ALBUMIN) T4 PA
REBIF REBIDOSE T4 PA
REBIF TITRATION PACK T4 PA
REMICADE T4 PA
RENFLEXIS T4 PA
REVLIMID T4 PA
SANDIMMUNE ORAL CAPSULE T2
SANDIMMUNE ORAL SOLUTION T1
SIMPONI T4 PA
SIMPONI ARIA T4 PA
STELARA T4 PA
sulfasalazine T1
TECFIDERA T4 PA
THALOMID T4 PA
TREXALL ORAL TABLET 10 MG, 5 MG T4 PA
TREXALL ORAL TABLET 7.5 MG T1
TYSABRI T4 PA
XELJANZ T4 PA
XELJANZ XR T4 PA
Immunosuppressive Agents
ASTAGRAF XL T4 PA
ATGAM T4 PA
azathioprine T1
BENLYSTA T4 PA
CELLCEPT T2
CELLCEPT INTRAVENOUS T4 PA
cyclophosphamide intravenous T4 PA
120
Drug Tier Notes
cyclophosphamide oral T1
cyclosporine T1
cyclosporine modified T1
ELIDEL T1 PA
ENVARSUS XR T4 PA
GAMIFANT T4 PA
GENGRAF T1
IMURAN T2
mercaptopurine T1
methotrexate sodium (pf) T4 PA
methotrexate sodium injection T4 PA
methotrexate sodium oral T1
mycophenolate mofetil T1
NEORAL T2
NULOJIX T4 PA
OTREXUP (PF) T4 PA
PROGRAF INTRAVENOUS T4 PA
PROGRAF ORAL T2
RAPAMUNE T4 PA
SANDIMMUNE ORAL CAPSULE T2
SANDIMMUNE ORAL SOLUTION T1
SIMULECT T4 PA
tacrolimus T1
THYMOGLOBULIN T4 PA
TREXALL ORAL TABLET 10 MG, 5 MG T4 PA
TREXALL ORAL TABLET 7.5 MG T1
ZORTRESS T4 PA
Other Miscellaneous Therapeutic Agents
acetylcysteine T1
AMPYRA T4 PA
ARCALYST T4 PA
BOTOX T4 PA
For the most up to date formulary coverage search, please use the searchable formulary website
121
Drug Tier Notes
BOTOX COSMETIC T4 PA
CARNITOR T2
CARNITOR (SUGAR-FREE) T4 PA
CERDELGA T4 PA
choline dihydrogen citrate T1
CYSTADANE T4 PA
DEMSER T4 PA
DYSPORT T4 PA
ENDARI T4 PA
EXONDYS 51 T4 PA
FIRDAPSE T4 PA
GALAFOLD T4 PA
ILARIS (PF) T4 PA
KUVAN T4 PA
levocarnitine T1
MYOBLOC T4 PA
NITYR T4 PA
octreotide acetate T4 PA
ONPATTRO T4 PA
ORALAIR T4 PA
ORFADIN T4 PA
PANHEMATIN T4 PA
PARSABIV T4 PA
PREZCOBIX T1
PROCYSBI T4 PA
REMICADE T4 PA
SANDOSTATIN T4 PA
SANDOSTATIN LAR DEPOT T4 PA
SPINRAZA (PF) T4 PA
THIOLA T4 PA
XEOMIN T4 PA
ZAVESCA T4 PA
122
Drug Tier Notes
Protective Agents
amifostine crystalline T4 PA
dexrazoxane hcl T4 PA
ELMIRON T1 QL (3 EA per 1 day)
MESNEX T4 PA
TOTECT T4 PA
Oxytocics
Oxytocics
METHERGINE T1 QL (28 EA per 7 days)
Pharmaceutical Aids
Pharmaceutical Aids
DILUENT FOR EPOPROSTENOL/FLOLA T4 PA
Radioactive Agents
Radioactive Agents
AZEDRA DOSIMETRIC T4 PA
AZEDRA THERAPEUTIC T4 PA
XOFIGO T4 PA
Respiratory Tract Agents
Alpha And Beta Adrenergic Agonist(Respr)
ALLEGRA-D 12 HOUR T3 PA
ALLEGRA-D 24 HOUR T3 PA
BROMFED DM T1
BROTAPP DM T1
cetirizine-pseudoephedrine T1 ST
CHERATUSSIN DAC T1
CONGEST-EZE T1
epinephrine T1 QL (2 EA per 30 DYs)
LORATADINE-D T3 PA
M-END DMX T1
MUCINEX D MAXIMUM STRENGTH T1
pseudoephedrine hcl T1
pseudoephedrine-guaifenesin T1
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123
Drug Tier Notes
SEMPREX-D T3 PA
SUDOGEST COLD AND ALLERGY T1
Anticholinergic Agents (Respir.Tract)
ANORO ELLIPTA T1
ATROVENT HFA T1
COMBIVENT RESPIMAT T1
diphenoxylate-atropine T1
ipratropium bromide T1
LOMOTIL T2
SPIRIVA RESPIMAT T1 AL
Antifibrotic Agents
ESBRIET T4 PA
OFEV T4 PA
Anti-Inflammatory Agents (Respiratory)
NUCALA T4 PA
Antitussives
aspirin-caffeine-dihydrocodein T3 AL
benzonatate T1
BROMFED DM T1
BROTAPP DM T1
CHERATUSSIN AC T2
CHERATUSSIN DAC T1
codeine sulfate T3 AL
codeine-guaifenesin T1 QL (120 ML per 30 days); AL
hydrocodone-homatropine T1
M-END DMX T1
MUCUS DM T1
MUCUS RELIEF CONGESTION-COUGH T1
phenylephrine-chlophedianol-gg T1
PROMETHAZINE VC-CODEINE T1 QL (120 ML per 30 days); AL
promethazine-codeine T1 QL (120 ML per 30 days); AL
124
Drug Tier Notes
promethazine-dm T1
ROBAFEN CF (PHENYLEPHRINE) T1
ROBAFEN DM T1
ROBITUSSIN PEDIATRIC T1
SYNALGOS-DC T3
TESSALON PERLES T2
TUSSIGON T1
ZODRYL AC 25 T1
ZODRYL AC 30 T1
ZODRYL AC 35 T1
ZODRYL AC 40 T1
ZODRYL AC 50 T1
ZODRYL AC 60 T1
ZODRYL AC 80 T1
Cystic Fibrosis (Cftr) Correctors
ORKAMBI T4 PA
SYMDEKO T4 PA
Cystic Fibrosis (Cftr) Potentiators
KALYDECO T4 PA
ORKAMBI T4 PA
SYMDEKO T4 PA
Expectorants
CHERATUSSIN AC T2
CHERATUSSIN DAC T1
CHILDREN'S STUFFY NOSE-COLD T1
codeine-guaifenesin T1 QL (120 ML per 30 days); AL
CONGEST-EZE T1
ED BRON GP T1
guaifenesin T1
MUCINEX D MAXIMUM STRENGTH T1
MUCUS DM T1
MUCUS RELIEF CONGESTION-COUGH T1
For the most up to date formulary coverage search, please use the searchable formulary website
125
Drug Tier Notes
phenylephrine-chlophedianol-gg T1
pseudoephedrine-guaifenesin T1
ROBAFEN CF (PHENYLEPHRINE) T1
ROBAFEN DM T1
SSKI T1
First Generation Antihist.(Respir Tract)
ALLER-CHLOR T1
BROMFED DM T1
BROTAPP DM T1
CHILDREN'S BENADRYL ALLERGY T1
chlorpheniramine maleate T1
cyproheptadine T1
dimenhydrinate T1
DIPHENHIST T1
diphenhydramine hcl injection T1 QL (20 ML per 25 days)
diphenhydramine hcl oral T1
doxylamine-pyridoxine (vit b6) T1 PA
M-END DMX T1
PHENERGAN T2
promethazine T1
PROMETHAZINE VC T1
PROMETHAZINE VC-CODEINE T1 QL (120 ML per 30 days); AL
promethazine-codeine T1 QL (120 ML per 30 days); AL
promethazine-dm T1
SLEEP AID (DOXYLAMINE) T1
SUDOGEST COLD AND ALLERGY T1
ZODRYL AC 25 T1
ZODRYL AC 30 T1
ZODRYL AC 35 T1
ZODRYL AC 40 T1
ZODRYL AC 50 T1
ZODRYL AC 60 T1
126
Drug Tier Notes
ZODRYL AC 80 T1
Interleukin Antagonists
CINQAIR T4 PA
DUPIXENT T4 PA
FASENRA T4 PA
NUCALA T4 PA
Leukotriene Modifiers
montelukast oral granules in packet T1 QL (1 EA per 1 day); AL
montelukast oral tablet T1 QL (1 EA per 1 day)
montelukast oral tablet,chewable T1 QL (1 EA per 1 day)
SINGULAIR ORAL GRANULES IN PACKET T2 AL
SINGULAIR ORAL TABLET T2
SINGULAIR ORAL TABLET,CHEWABLE T2
Mast-Cell Stabilizers
cromolyn T1
Mucolytic Agents
acetylcysteine T1
PULMOZYME T4 PA
Nasal Preparations (Steroids)
fluticasone propionate T1
OMNARIS T3 PA
triamcinolone acetonide T1 ST
Orally Inhaled Preparations (Steroids)
ARMONAIR RESPICLICK T1
ARNUITY ELLIPTA INHALATION BLISTER
WITH DEVICE 100 MCG/ACTUATION, 200
MCG/ACTUATION
T1 QL (1 EA per 30 days)
ARNUITY ELLIPTA INHALATION BLISTER
WITH DEVICE 50 MCG/ACTUATION
T1 QL (1 EA per 30 DYs)
ASMANEX HFA T1
ASMANEX TWISTHALER INHALATION
AEROSOL POWDR BREATH ACTIVATED 110
MCG (30 DOSES), 220 MCG (120 DOSES), 220
MCG (30 DOSES), 220 MCG (60 DOSES)
T1 QL (1 QY per 30 DYs)
For the most up to date formulary coverage search, please use the searchable formulary website
127
Drug Tier Notes
ASMANEX TWISTHALER INHALATION
AEROSOL POWDR BREATH ACTIVATED 110
MCG (7 DOSES)
T1 QL (1 QY per 7 DYs)
ASMANEX TWISTHALER INHALATION
AEROSOL POWDR BREATH ACTIVATED 220
MCG (14 DOSES)
T1 QL (1 QY per 14 DYs)
budesonide inhalation suspension for nebulization
0.25 mg/2 ml
T1 QL (60 QY per 30 DYs); AL
budesonide inhalation suspension for nebulization
0.5 mg/2 ml
T1 QL (120 QY per 30 DYs); AL
budesonide inhalation suspension for nebulization
1 mg/2 ml
T1 QL (60 ML per 30 DYs); AL
DULERA T3 QL (13 QY per 30 DYs); AL
FLOVENT DISKUS INHALATION BLISTER
WITH DEVICE 100 MCG/ACTUATION
T1 QL (120 QY per 30 DYs)
FLOVENT DISKUS INHALATION BLISTER
WITH DEVICE 250 MCG/ACTUATION
T1 QL (240 QY per 30 DYs)
FLOVENT DISKUS INHALATION BLISTER
WITH DEVICE 50 MCG/ACTUATION
T1 QL (60 QY per 30 DYs)
FLOVENT HFA INHALATION HFA AEROSOL
INHALER 110 MCG/ACTUATION
T1 QL (12 QY per 30 DYs)
FLOVENT HFA INHALATION HFA AEROSOL
INHALER 220 MCG/ACTUATION
T1 QL (24 QY per 30 DYs)
FLOVENT HFA INHALATION HFA AEROSOL
INHALER 44 MCG/ACTUATION
T1 QL (10.6 QY per 30 DYs)
fluticasone propion-salmeterol inhalation aerosol
powdr breath activated
T1
fluticasone propion-salmeterol inhalation blister
with device
T1 QL (1 EA per 30 days)
PULMICORT INHALATION SUSPENSION
FOR NEBULIZATION 0.25 MG/2 ML
T2 QL (60 QY per 30 DYs); AL
PULMICORT INHALATION SUSPENSION
FOR NEBULIZATION 0.5 MG/2 ML
T2 QL (120 QY per 30 DYs); AL
QVAR INHALATION AEROSOL 40
MCG/ACTUATION
T1 QL (8.7 QY per 30 DYs)
QVAR INHALATION AEROSOL 80
MCG/ACTUATION
T1 QL (17.4 QY per 30 DYs)
128
Drug Tier Notes
QVAR REDIHALER INHALATION HFA
AEROSOL BREATH ACTIVATED 40
MCG/ACTUATION
T1 QL (10.6 GM per 30 days)
QVAR REDIHALER INHALATION HFA
AEROSOL BREATH ACTIVATED 80
MCG/ACTUATION
T1 QL (21.2 GM per 30 days)
WIXELA INHUB T1 QL (1 EA per 30 days)
Phosphodiesterase Type 4 Inhibitors
DALIRESP T1 ST
Respiratory Tract Agents, Miscellaneous
ARALAST NP T4 PA
GLASSIA T4 PA
XOLAIR T4 PA
ZEMAIRA T4 PA
Second Generation Antihist(Respir Tract)
ALAVERT T2
ALLEGRA-D 12 HOUR T3 PA
ALLEGRA-D 24 HOUR T3 PA
ALLERGY RELIEF (CETIRIZINE) T1 ST
cetirizine oral solution T1
cetirizine oral tablet T1
cetirizine oral tablet,chewable T3 PA
cetirizine-pseudoephedrine T1 ST
CHILDREN'S ZYRTEC ALLERGY T1 ST
CLARINEX T3 PA
CLARITIN T2
CLARITIN REDITABS T3 PA
desloratadine T3 PA
fexofenadine oral suspension T1 ST; QL (10 ML per 1 day)
fexofenadine oral tablet 180 mg T1 ST
fexofenadine oral tablet 60 mg T3 PA
levocetirizine oral solution T3 PA
levocetirizine oral tablet T1
loratadine oral capsule T1 ST
For the most up to date formulary coverage search, please use the searchable formulary website
129
Drug Tier Notes
loratadine oral solution T1 ST
loratadine oral tablet T1
loratadine oral tablet,disintegrating T1 ST
LORATADINE-D T3 PA
SEMPREX-D T3 PA
ZYRTEC T2
Select.Beta-2-Adrenergic Agonist(Respir)
albuterol sulfate inhalation hfa aerosol inhaler T1 QL (1 QY per 30 days)
albuterol sulfate inhalation solution for
nebulization
T1
albuterol sulfate oral T1
ANORO ELLIPTA T1
COMBIVENT RESPIMAT T1
DULERA T3 QL (13 QY per 30 DYs); AL
fluticasone propion-salmeterol inhalation aerosol
powdr breath activated
T1
fluticasone propion-salmeterol inhalation blister
with device
T1 QL (1 EA per 30 days)
levalbuterol tartrate T1 ST
SEREVENT DISKUS T1
terbutaline T1
WIXELA INHUB T1 QL (1 EA per 30 days)
Vasodilating Agents (Respiratory Tract)
ADCIRCA T4 PA
ADEMPAS T4 PA
ambrisentan T4 PA
epoprostenol (glycine) T4 PA
FLOLAN T4 PA
LETAIRIS T4 PA
OPSUMIT T4 PA
ORENITRAM T4 PA
REMODULIN T4 PA
REVATIO T4 PA
130
Drug Tier Notes
sildenafil (antihypertensive) T1 PA
TRACLEER T4 PA
TYVASO T4 PA
TYVASO REFILL KIT T4 PA
TYVASO STARTER KIT T4 PA
UPTRAVI T4 PA
VELETRI T4 PA
VENTAVIS T4 PA
Xanthine Derivatives
THEO-24 T1
theophylline T1
Skin And Mucous Membrane Agents
Antibacterials (Skin, Mucous Membrane)
ANTIBIOTIC (NEOMY-BACIT-POLYM) T1
ANTIBIOTIC-PAIN RELIEF (BACIT) T1
bacitracin T1
bacitracin-polymyxin b T1
BENZAMYCIN T2
CLEOCIN T T2
clindamycin phosphate T1
ERY PADS T1
erythromycin with ethanol T1
erythromycin-benzoyl peroxide T1
gentamicin T1
METROGEL T2
METROGEL VAGINAL T2
metronidazole T1
mupirocin T1
POLYSPORIN T2
Anti-Inflammatory Agents (Skin, Mucous)
amcinonide T1 QL (15 GM per 30 days)
betamethasone dipropionate T1
For the most up to date formulary coverage search, please use the searchable formulary website
131
Drug Tier Notes
betamethasone valerate T1
betamethasone, augmented T1
CAPEX T1
clobetasol T1
clobetasol-emollient T1
clotrimazole-betamethasone T1 QL (15 QY per 34 DYs)
desonide T1
desoximetasone T1
diflorasone topical cream T1 QL (15 GM per 25 days)
diflorasone topical ointment T1 QL (15 GM per 30 days)
DIPROLENE T2
DIPROLENE AF T2
ELOCON TOPICAL CREAM T2 QL (45 QY per 30 DYs)
ELOCON TOPICAL OINTMENT T2 QL (45 QY per 30 DYs)
ELOCON TOPICAL SOLUTION T2
fluocinolone T1
fluocinonide T1
FLUOCINONIDE-E T1
hydrocortisone T1
hydrocortisone acetate T1
hydrocortisone valerate T1
hydrocortisone-min oil-wht pet T1
LOTRISONE T1 QL (15 QY per 34 DYs)
mometasone topical cream T1 QL (45 QY per 30 DYs)
mometasone topical ointment T1 QL (45 QY per 30 DYs)
mometasone topical solution T1
PROCTOFOAM HC T1
TEMOVATE T2
TEMOVATE E T2
TOPICORT T2
triamcinolone acetonide T1
TRIANEX T1
132
Drug Tier Notes
WESTCORT T2
Antipruritics And Local Anesthetics
dibucaine T1
lidocaine T3 PA
lidocaine hcl T1
lidocaine-prilocaine T1 QL (30 QY per 30 DYs)
LIDODERM T3 PA
NUPERCAINAL T1
phenazopyridine T1
PRAX T1
PROCTOFOAM HC T1
PYRIDIUM T2
Antivirals (Skin And Mucous Membrane)
ABREVA T1
ZOVIRAX T3 PA
Astringents
DRYSOL DAB-O-MATIC T1
PEDI-BORO SOAK T1
Azoles (Skin And Mucous Membrane)
clotrimazole T1
CLOTRIMAZOLE-3 T1
clotrimazole-betamethasone T1 QL (15 QY per 34 DYs)
GYNAZOLE-1 T1
ketoconazole T1
LOTRIMIN AF (CLOTRIMAZOLE) T2
LOTRISONE T1 QL (15 QY per 34 DYs)
miconazole nitrate T1
MICONAZOLE-3 T1
NIZORAL A-D T1
ZEASORB (MICONAZOLE) T1
Basic Lotions And Liniments
AMLACTIN T1
For the most up to date formulary coverage search, please use the searchable formulary website
133
Drug Tier Notes
ammonium lactate T1
LAC-HYDRIN FIVE T1
Basic Ointments And Protectants
ammonium lactate T1
LAC-HYDRIN T2
Benzylamines (Skin And Mucous Membrane)
LOTRIMIN ULTRA T1
MENTAX T2
Cell Stimulants And Proliferants
KEPIVANCE T4 PA
tretinoin T1 AL
tretinoin microspheres T1 AL
Corticosteroids (Skin, Mucous Membrane)
amcinonide T1 QL (15 GM per 30 days)
betamethasone dipropionate T1
betamethasone valerate T1
betamethasone, augmented T1
CAPEX T1
clobetasol T1
clobetasol-emollient T1
clotrimazole-betamethasone T1 QL (15 QY per 34 DYs)
desonide T1
desoximetasone T1
diflorasone topical cream T1 QL (15 GM per 25 days)
diflorasone topical ointment T1 QL (15 GM per 30 days)
DIPROLENE T2
DIPROLENE AF T2
ELOCON TOPICAL CREAM T2 QL (45 QY per 30 DYs)
ELOCON TOPICAL OINTMENT T2 QL (45 QY per 30 DYs)
ELOCON TOPICAL SOLUTION T2
fluocinolone T1
134
Drug Tier Notes
fluocinonide T1
FLUOCINONIDE-E T1
hydrocortisone T1
hydrocortisone acetate T1
hydrocortisone valerate T1
hydrocortisone-min oil-wht pet T1
LOTRISONE T1 QL (15 QY per 34 DYs)
mometasone topical cream T1 QL (45 QY per 30 DYs)
mometasone topical ointment T1 QL (45 QY per 30 DYs)
mometasone topical solution T1
PROCTOFOAM HC T1
TEMOVATE T2
TEMOVATE E T2
TOPICORT T2
triamcinolone acetonide T1
TRIANEX T1
WESTCORT T2
Keratolytic Agents
benzoyl peroxide T1
COMPOUND W T1
DESQUAM-X T2
NEUTROGENA ON THE SPOT T2
NEUTROGENA T-GEL CONDITNER(SA) T1
SELSUN BLUE (SALICYLIC ACID) T1
sulfacetamide sodium-sulfur T1
TARGETED ACNE SPOT TREATMENT T1
urea T1
Keratoplastic Agents
DRITHOCREME HP T1
Local Anti-Infectives, Miscellaneous
alcohol swabs T1
ANTI-DANDRUFF T1
For the most up to date formulary coverage search, please use the searchable formulary website
135
Drug Tier Notes
KLARON T2
selenium sulfide T1
SILVADENE T2
silver sulfadiazine T1
sulfacetamide sodium (acne) T1
sulfacetamide sodium-sulfur T1
Nonsteroidal Anti-Inflammat.Agents(Skin)
diclofenac sodium T1 ST
Pigmenting Agents
8-MOP T4 PA
OXSORALEN ULTRA T4 PA
Polyenes (Skin And Mucous Membrane)
nystatin T1
nystatin-triamcinolone T1
Scabicides And Pediculicides
CUTTER BACKWOODS T1 QL (170 GM per 6 days)
CUTTER SKINSATIONS T1 QL (177 ML per 6 days)
LICE BEDDING SPRAY T1 QL (142 GM per 5 days)
LICE KILLING T1 QL (120 QY per 30 DYs)
OFF ACTIVE T1 QL (170 GM per 6 days)
OFF DEEP WOODS T1 QL (170 GM per 6 days)
OFF DEEP WOODS DRY T1 QL (113 GM per 4 days)
OFF FAMILYCARE (WITH DEET) T1 QL (71 GM per 2 days)
permethrin topical cream T1 QL (60 QY per 1 PD)
permethrin topical liquid T1 QL (118 QY per 30 DYs)
REPEL SPORTSMEN T1 QL (184 GM per 6 days)
REPEL SPORTSMEN MAX T1 QL (184 GM per 6 days)
RID COMPLETE LICE ELIM KIT T1 QL (141.8 GM per 5 days)
SKLICE T1
STOP LICE T1 QL (142 GM per 5 days)
Skin And Mucous Membrane Agents, Misc.
136
Drug Tier Notes
ABSORICA T3 PA
ALDARA T2 QL (24 QY per 30 DYs)
AMNESTEEM T1 PA
ARTHRITIS PAIN RELIEF(CAPSAIC) T1
capsaicin T1
CAPZASIN-HP T1
CAVILON SKIN CLEANSER T1
CLARAVIS T1 PA; QL (1 EA per 1 day)
CONDYLOX T2
COSENTYX T4 PA
COSENTYX (2 SYRINGES) T4 PA
COSENTYX PEN T4 PA
COSENTYX PEN (2 PENS) T4 PA
CUTTER BACKWOODS T1 QL (170 GM per 6 days)
CUTTER SKINSATIONS T1 QL (177 ML per 6 days)
diclofenac sodium T1 ST
DUPIXENT T4 PA
ELIDEL T1 PA
ENBREL T4 PA
ENBREL MINI T4 PA
ENBREL SURECLICK T4 PA
HIGH POTENCY CAPSAICIN T1
HUMIRA T4 PA
HUMIRA PEDIATRIC CROHNS START T4 PA
HUMIRA PEN T4 PA
HUMIRA PEN CROHNS-UC-HS START T4 PA
HUMIRA PEN PSOR-UVEITS-ADOL HS T4 PA
HUMIRA(CF) T4 PA
HUMIRA(CF) PEDI CROHNS STARTER T4 PA
HUMIRA(CF) PEN T4 PA
HUMIRA(CF) PEN CROHNS-UC-HS T4 PA
HUMIRA(CF) PEN PSOR-UV-ADOL HS T4 PA
ILUMYA T4 PA
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137
Drug Tier Notes
imiquimod T1 QL (24 QY per 30 DYs)
INFLECTRA T4 PA
INSECT REPELLENT (PICARIDIN) T1 QL (118 GM per 4 days)
MYORISAN T1 PA; QL (1 EA per 1 day)
NATRAPEL T1 QL (177 ML per 6 days)
OFF ACTIVE T1 QL (170 GM per 6 days)
OFF DEEP WOODS T1 QL (170 GM per 6 days)
OFF DEEP WOODS DRY T1 QL (113 GM per 4 days)
OFF FAMILYCARE (WITH DEET) T1 QL (71 GM per 2 days)
OTEZLA T4 PA
OTEZLA STARTER T4 PA
podofilox T1
PROTOPIC T2 PA
REMICADE T4 PA
RENFLEXIS T4 PA
REPEL SPORTSMEN T1 QL (184 GM per 6 days)
REPEL SPORTSMEN MAX T1 QL (184 GM per 6 days)
SANTYL T1
SILIQ T4 PA
STELARA T4 PA
tacrolimus T1 PA
TALTZ AUTOINJECTOR T4 PA
TALTZ AUTOINJECTOR (2 PACK) T4 PA
TALTZ AUTOINJECTOR (3 PACK) T4 PA
TALTZ SYRINGE T4 PA
TALTZ SYRINGE (2 PACK) T4 PA
TALTZ SYRINGE (3 PACK) T4 PA
TARGRETIN T4 PA
TREMFYA T4 PA
TRIXAICIN HP T1
ZENATANE T1 PA; QL (1 EA per 1 day)
ZOSTRIX-HP FOOT T1
138
Drug Tier Notes
ZOSTRIX-HP TOPICAL CREAM 0.075 % T2
ZOSTRIX-HP TOPICAL CREAM 0.1 % T1
Thiocarbamates(Skin And Mucous Membrane)
tolnaftate T1
Smooth Muscle Relaxants
Antimuscarinics
DETROL T2
flavoxate T1
oxybutynin chloride T1
OXYTROL FOR WOMEN T1
tolterodine oral capsule,extended release 24hr 2
mg
T1 QL (1 EA per 1 day)
tolterodine oral capsule,extended release 24hr 4
mg
T1
tolterodine oral tablet 1 mg T1 QL (2 EA per 1 day)
tolterodine oral tablet 2 mg T1
trospium T1
Respiratory Smooth Muscle Relaxants
THEO-24 T1
theophylline T1
Vitamins
Multivitamin Preparations
ANTIOXIDANT VITAMINS T1
CADEAU DHA T1
CENTRAL VITE WITH LUTEIN T1
CENTRUM COMPLETE T1
CERTAVITE-ANTIOXID (IRON GLUC) T2
CHILDREN'S CHEWABLE COMPLETE T1
CHILDREN'S CHEWABLE VITAMIN T1
CHILDREN'S CHEWABLES T1
CHILDREN'S MULTI-VIT GUMMIES T1
CHILD'S VITAMIN WITH IRON T1
CHILDS/IRON T1
For the most up to date formulary coverage search, please use the searchable formulary website
139
Drug Tier Notes
CLASSIC PRENATAL T1
COMPETE T1
COMPLETE MULTIVITAMIN T1
COMPLETE MULTIVITAMIN-MINERAL T1
COMPLETE NATAL DHA T1
COMPLETE PREMIUM VITAMIN T1
COMPLETENATE T1
DAILY PRENATAL T1
DAILY VITES/IRON T1
FLINTSTONES COMPLETE (IRON) T1
GERAVIM T1
MULTI-DELYN WITH IRON T1
MULTI-VIT WITH FLUORIDE-IRON T1
multivitamin T1
MULTI-VITAMIN WITH FLUORIDE T1
MULTIVITAMIN WITH MINERALS ORAL
LIQUID
T1
multivitamin with minerals oral tablet T1
MULTIVITAMINS WITH FLUORIDE T1
MVC-FLUORIDE T1
mv-min-folic acid-lutein T1
MY FAVORITE MULTIPLE T1
MY-VITALIFE T1
NUTRIVIT T1
OBSTETRIX DHA T1
OBTREX DHA T1
ONE DAILY PLUS MINERALS T2
ONE DAILY PRENATAL T1
ONE-A-DAY WOMENS FORMULA T1
ONE-A-DAY WOMEN'S PRENATAL 1 T1
PEDIA POLY-VITE T1
PEDIAVIT T1
140
Drug Tier Notes
PERRY PRENATAL T1
pnv cmb#95-ferrous fumarate-fa T1
POLY-VI-SOL T2 AL
POLY-VITAMIN T1 AL
POLYVITAMIN WITH IRON T1 AL
POLY-VITAMIN WITH IRON T1 AL
PR NATAL 400 T1
PR NATAL 400 EC T1
PR NATAL 430 T1
PRENA1 CHEW (QUATREFOLIC) T1
PRENATA T1
PRENATAL + DHA T1
PRENATAL 19 T1
PRENATAL GUMMY T1
PRENATAL MULTI-DHA (ALGAL OIL) T1
PRENATAL PLUS T1
PRENATAL VITAMIN T1
PRENATAL VITAMIN PLUS LOW IRON T1
prenatal vit-iron fum-folic ac T1
PRORENAL QD T1
SENTRY SENIOR T1
TAB-A-VITE-MINERALS T1
THERAPEUTIC LIQUID T1
THERAPEUTIC-M T1
THERA-TABS T1
THERATRUM COMPLETE 50 PLUS T1
TRINATAL GT T1
TRIVEEN-DUO DHA T1
TRI-VI-SOL WITH IRON T1 AL
TRI-VIT WITH FLUORIDE AND IRON T1
TRI-VITAMIN T1 AL
TRI-VITAMIN WITH FLUORIDE T1
TRUST NATAL DHA T1
For the most up to date formulary coverage search, please use the searchable formulary website
141
Drug Tier Notes
VITRUM SENIOR T1
WOMEN'S DAILY FORMULA T1
WOMEN'S PRENATAL PLUS DHA T1
Vitamin A
beta carotene T1
TRI-VI-SOL WITH IRON T1 AL
TRI-VITAMIN T1 AL
TRI-VITAMIN WITH FLUORIDE T1
vitamin a T1
Vitamin B Complex
B COMPLEX-VITAMIN B12 T1
b complex-vitamin c-folic acid T1
biotin T1
CADEAU DHA T1
CENTRAL VITE WITH LUTEIN T1
CENTRUM COMPLETE T1
CHILDREN'S CHEWABLE COMPLETE T1
CHILDREN'S CHEWABLES T1
CHILDREN'S MULTI-VIT GUMMIES T1
CLASSIC PRENATAL T1
COMPLETE MULTIVITAMIN-MINERAL T1
COMPLETENATE T1
cyanocobalamin (vitamin b-12) injection T1
cyanocobalamin (vitamin b-12) oral T1
cyanocobalamin (vitamin b-12) sublingual T1 AL
DAILY PRENATAL T1
doxylamine-pyridoxine (vit b6) T1 PA
ELDERTONIC T1
folic acid T1
MULTIGEN FOLIC T1
MULTIGEN PLUS T1
mv-min-folic acid-lutein T1
142
Drug Tier Notes
niacinamide T1
NICOMIDE T1
NUTRIVIT T1
OBSTETRIX DHA T1
OBTREX DHA T1
ONE DAILY PRENATAL T1
ONE-A-DAY WOMENS FORMULA T1
pantothenic acid (vit b5) T1
PERRY PRENATAL T1
pnv cmb#95-ferrous fumarate-fa T1
POLY-IRON 150 FORTE T1
PR NATAL 400 T1
PR NATAL 400 EC T1
PR NATAL 430 T1
PRENA1 CHEW (QUATREFOLIC) T1
PRENATA T1
PRENATAL + DHA T1
PRENATAL 19 T1
PRENATAL GUMMY T1
PRENATAL MULTI-DHA (ALGAL OIL) T1
PRENATAL PLUS T1
PRENATAL VITAMIN T1
PRENATAL VITAMIN PLUS LOW IRON T1
prenatal vit-iron fum-folic ac T1
PRORENAL QD T1
PYRI 500 T1
pyridoxine (vitamin b6) T1
riboflavin (vitamin b2) T1 AL
SENTRY SENIOR T1
STRESS B-COMPLEX T1
THERAPEUTIC-M T1
thiamine hcl (vitamin b1) oral tablet 100 mg T1 AL
thiamine hcl (vitamin b1) oral tablet 250 mg T1
For the most up to date formulary coverage search, please use the searchable formulary website
143
Drug Tier Notes
thiamine mononitrate (vit b1) T1
TRINATAL GT T1
TRIVEEN-DUO DHA T1
vitamin b complex-folic acid T1
VITAMIN B-1 ORAL TABLET 100 MG T1 AL
VITAMIN B-1 ORAL TABLET 250 MG, 50 MG T1
VITAMIN B-12 ORAL T1
VITAMIN B-12 SUBLINGUAL T1 AL
VITAMIN B-2 ORAL TABLET 100 MG, 25 MG T1
VITAMIN B-2 ORAL TABLET 50 MG T1 AL
VITAMIN B-6 T1
VITAMINS B COMPLEX T1
WOMEN'S PRENATAL PLUS DHA T1
Vitamin C
ascorbic acid (vitamin c) oral tablet T1 AL
ascorbic acid (vitamin c) oral tablet extended
release 1,500 mg
T1
ascorbic acid (vitamin c) oral tablet extended
release 500 mg
T1 AL
b complex-vitamin c-folic acid T1
MULTIGEN FOLIC T1
MULTIGEN PLUS T1
STRESS B-COMPLEX T1
TRI-VI-SOL WITH IRON T1 AL
TRI-VITAMIN T1 AL
TRI-VITAMIN WITH FLUORIDE T1
VITAMIN C ORAL SYRUP T1
VITAMIN C ORAL TABLET 1,000 MG, 500
MG
T1
VITAMIN C ORAL TABLET 250 MG T1 AL
VITAMIN C ORAL TABLET EXTENDED
RELEASE
T1 AL
VITAMIN C ORAL TABLET,CHEWABLE T1
144
Drug Tier Notes
Vitamin D
calcitriol T1
CALCIUM 600 + D(3) T1
CALCIUM 600 + MINERALS T1
calcium carbonate-vitamin d2 T1
calcium carbonate-vitamin d3 T1
calcium citrate-vitamin d3 T1
cholecalciferol (vitamin d3) T1
CITRACAL + D3 (CALCIUM PHOS) T1
CITRUS CALCIUM T1
DRISDOL T2
ergocalciferol (vitamin d2) T1
JUST D T2
LIQUID CALCIUM WITH VITAMIN D T1
ONE-A-DAY WOMEN'S PRENATAL 1 T1
OYSTER SHELL CALCIUM-VIT D2 T1
OYSTER SHELL CALCIUM-VIT D3 T1
PRORENAL QD T1
ROCALTROL T2
TRI-VI-SOL WITH IRON T1 AL
TRI-VITAMIN T1 AL
TRI-VITAMIN WITH FLUORIDE T1
VITAMIN D3 T1
Vitamin E
vitamin e T1
vitamin e (dl, acetate) T1
vitamin e mixed T1
Vitamin K Activity
phytonadione (vitamin k1) T1
Keystone First complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, creed, religious affiliation, ancestry, sex gender, gender identity or expression, or sexual orientation.
Keystone First does not exclude people or treat them differently because of race, color, national origin, age, disability, creed, religious affiliation, ancestry, sex gender, gender identity or expression, or sexual orientation.
Keystone First provides free aids and services to people with disabilities to communicate effectively with us, such as:
• Qualified sign language interpreters • Written information in other formats (large print, audio, accessible electronic formats, other formats)
Keystone First provides free language services to people whose primary language is not English, such as:
• Qualified interpreters • Information written in other languages
If you need these services, contact Keystone First at 1-800-521-6860 (TTY 1-800-684-5505).
If you believe that Keystone First has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, creed, religious affiliation, ancestry, sex gender, gender identity or expression, or sexual orientation, you can file a complaint with:
Keystone First, Member Complaints Department, Attention: Member Advocate, 200 Stevens Drive Philadelphia, PA 19113-1570 Phone: 1-800-521-6860, TTY 1-800-684-5505, Fax: 215-937-5367, or Email: [email protected]
The Bureau of Equal Opportunity, Room 223, Health and Welfare Building, P.O. Box 2675, Harrisburg, PA 17105-2675, Phone: (717) 787-1127, TTY/PA Relay 711, Fax: (717) 772-4366, or Email: [email protected]
You can file a complaint in person or by mail, fax, or email. If you need help filing a complaint, Keystone First and the Bureau of Equal Opportunity are available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services, 200 Independence Avenue S.W., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TDD).
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
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ATTENTION: If you speak English, language assistance services, free of charge, are available to you.
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