List of covered drugsThis is a list of covered drugs for MyPrioritySM and small business plans effective Jan. 1, 2015, or later.
Please read: This document contains information about the drugs we cover in this plan.
Important: Please read your Priority Health coverage documents and riders for details about
prescriptions covered by your plan.
This list changes frequently. For the most current information, please refer to the “Approved Drug
List” at priorityhealth.com.
Tips for getting the most out of your Priority Health prescription coverage:
• Show your Priority Health member ID card every time you fill a prescription. Even if the drug is
not covered, you’ll be able to take advantage of Priority Health discounts.
• The amount you pay depends on your plan and on what option is prescribed. Ask your
pharmacist if a less expensive option will work for you. Options include:
- Generic: The same active ingredients as brand-name drugs, but more affordable.
- Preferred brand: These drugs cost more than generics, but less than non-preferred
brands. Ask your doctor to select a preferred brand when no generic is available.
- Non-preferred brand: More expensive brand name drugs — usually these drugs have a
less costly option available.
- Preferred specialty: Drugs that treat chronic illnesses and rare or complex conditions.
You’ll usually pay less if your drug is on the “preferred” list.
- Non-preferred specialty: In general, non-preferred specialty drugs cost you more. Ask
your doctor if a preferred specialty drug will work for you.
Last updated: August 2014
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 1 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
Antihistamine Drugs
First Generation Antihistamines
carbinoxamine maleate SOLN Generic
carbinoxamine maleate TABS Generic
chlorpheniramine maleate TBCR Generic
CLEMASTINE FUMARATE SYRP Generic
clemastine fumarate TABS Generic
cyproheptadine hcl SYRP Generic
cyproheptadine hcl TABS Generic
diphenhydramine hcl CAPS Generic
PHENERGAN SOLN Medical Benefit-Non-Preferred
Specialty
promethazine hcl plain SYRP Generic
promethazine hcl SUPP Generic
promethazine hcl TABS Generic
PROMETHAZINE VC PLAIN SYRP Generic
PROMETHEGAN SUPP Generic
pyril d SUSP Non-Preferred Brand
pyrilamine-phenylephrine SUSP Generic
Second Generation Antihistamines
alavert allergy/sinus TB12 Excluded
alavert TABS Excluded
alavert TBDP Excluded
ALLEGRA ALLERGY CHILDRENS SUSP Excluded
ALLEGRA ALLERGY CHILDRENS TABS Excluded
ALLEGRA ALLERGY TABS Excluded
ALLEGRA-D 12 HOUR ALLERGY & CONGESTION
TB12 Excluded
ALLEGRA-D 24 HOUR ALLERGY & CONGESTION
TB24 Excluded
allergy relief/nasal decongestant TB24 Excluded
cetirizine hcl childrens allergy SYRP Excluded
cetirizine hcl/pseudoephedrine hcl er TB12 Excluded
cetirizine hcl CHEW Excluded
cetirizine hcl TABS Excluded
childrens loratadine SYRP Excluded
CLARINEX SYRP Excluded
CLARINEX TABS Excluded
CLARINEX-D 12 HOUR TB12 Excluded
CLARITIN REDITABS TBDP Excluded
CLARITIN CHEW Excluded
CLARITIN SYRP Excluded
CLARITIN TABS Excluded
CLARITIN-D 12 HOUR TB12 Excluded
CLARITIN-D 24 HOUR TB24 Excluded
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 2 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
desloratadine TABS Excluded
fexofenadine hcl TABS Excluded
levocetirizine dihydrochloride SOLN Excluded
levocetirizine dihydrochloride TABS Excluded
loratadine hives relief SOLN Excluded
loratadine TABS Excluded
loratadine-d 24hr TB24 Excluded
SEMPREX-D CAPS Non-Preferred Brand
XYZAL TABS Excluded
ZYRTEC ALLERGY TABS Excluded
ZYRTEC CHILDRENS ALLERGY CHEW Excluded
ZYRTEC CHILDRENS ALLERGY SYRP Excluded
ZYRTEC-D ALLERGY/CONGESTION TB12 Excluded
Anti-infective Agents
Anthelmintics
ALBENZA TABS Preferred Brand QL
STROMECTOL TABS Preferred Brand
Antibacterials
ADOXA CAPS Non-Preferred Brand
ADOXA TABS Non-Preferred Brand
amoxicillin/clavulanate potassium CHEW Generic
amoxicillin/clavulanate potassium SUSR Generic
amoxicillin/clavulanate potassium TABS Generic
amoxicillin CAPS Generic
AMOXICILLIN CHEW Generic
amoxicillin SUSR Generic
amoxicillin TABS Generic
ampicillin CAPS Generic
AMPICILLIN SUSR Preferred Brand
AUGMENTIN XR TB12 Non-Preferred Brand
AUGMENTIN SUSR Preferred Brand
AUGMENTIN TABS Non-Preferred Brand
AVELOX TABS Preferred Brand
AVELOX SOLN Medical Benefit
azithromycin SUSR Generic
azithromycin TABS Generic
AZULFIDINE EN-TABS TBEC Non-Preferred Brand
AZULFIDINE TABS Non-Preferred Brand
BACITRACIN SOLR Medical Benefit
BACTRIM DS TABS Non-Preferred Brand
BACTRIM TABS Non-Preferred Brand
BETHKIS NEBU Non-Preferred Specialty
PA
BIAXIN XL TB24 Non-Preferred Brand
BIAXIN SUSR Non-Preferred Brand
BIAXIN TABS Non-Preferred Brand
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 3 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
CAYSTON SOLR Preferred Specialty QL
CEDAX CAPS Non-Preferred Brand
CEDAX SUSR Non-Preferred Brand
CEFACLOR ER TB12 Preferred Brand
cefaclor CAPS Generic
cefadroxil CAPS Generic
cefadroxil SUSR Generic
cefadroxil TABS Generic
cefdinir CAPS Generic
cefdinir SUSR Generic
CEFDITOREN PIVOXIL TABS Generic
cefpodoxime proxetil SUSR Generic
cefpodoxime proxetil TABS Generic
cefprozil SUSR Generic
cefprozil TABS Generic
CEFTIN SUSR Non-Preferred Brand
CEFTIN TABS Non-Preferred Brand
cefuroxime axetil SUSR Generic
cefuroxime axetil TABS Generic
cephalexin CAPS Generic
cephalexin SUSR Generic
CEPHALEXIN TABS Preferred Brand
CIPRO SUSR Preferred Brand
CIPRO TABS Non-Preferred Brand
ciprofloxacin er TB24 Generic
ciprofloxacin hcl TABS Generic
clarithromycin er TB24 Generic
clarithromycin SUSR Generic
clarithromycin TABS Generic
CLEOCIN IN D5W SOLN Medical Benefit
CLEOCIN PEDIATRIC GRANULES SOLR Preferred Brand
CLEOCIN CAPS Preferred Brand
CLEOCIN CAPS Non-Preferred Brand
clindamycin hcl CAPS Generic
CUBICIN SOLR Medical Benefit
demeclocycline hcl TABS Generic
dicloxacillin sodium CAPS Generic
DIFICID TABS Non-Preferred Specialty
QL ST
DORYX TBEC Non-Preferred Brand ST
doxycycline hyclate dr TBEC Generic
doxycycline hyclate CAPS Generic
doxycycline hyclate TABS Generic
doxycycline hyclate SOLR Medical Benefit
doxycycline monohydrate CAPS Generic
doxycycline monohydrate TABS Generic
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 4 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
doxycycline CAPS Generic
doxycycline SUSR Generic
E.E.S. 400 TABS Generic
E.E.S. GRANULES SUSR Preferred Brand
ERYPED 200 SUSR Preferred Brand
ERYPED 400 SUSR Preferred Brand
ERY-TAB TBEC Preferred Brand
ERYTHROCIN STEARATE TABS Preferred Brand
ERYTHROMYCIN BASE TABS Preferred Brand
ERYTHROMYCIN ETHYLSUCCINATE TABS Generic
erythromycin/sulfisoxazole SUSR Generic
erythromycin CPEP Preferred Brand
FACTIVE TABS Non-Preferred Brand
INVANZ SOLR Medical Benefit
KEFLEX CAPS Non-Preferred Brand
KETEK TABS Non-Preferred Brand
LEVAQUIN SOLN Non-Preferred Brand
LEVAQUIN TABS Non-Preferred Brand
LEVAQUIN SOLN Medical Benefit
levofloxacin SOLN Generic
levofloxacin TABS Generic
MERREM SOLR Medical Benefit
MINOCIN CAPS Non-Preferred Brand
minocycline hcl CAPS Generic
minocycline hcl TABS Generic
MONODOX CAPS Non-Preferred Brand
MOXATAG TB24 Non-Preferred Brand
NOROXIN TABS Preferred Brand
ofloxacin TABS Generic
PCE TBEC Preferred Brand
penicillin v potassium SOLR Generic
penicillin v potassium TABS Generic
ROCEPHIN SOLR Medical Benefit
SPECTRACEF TABS Non-Preferred Brand
SULFADIAZINE TABS Generic
sulfamethoxazole/trimethoprim ds TABS Generic
sulfamethoxazole/trimethoprim SUSP Generic
sulfamethoxazole/trimethoprim TABS Generic
sulfasalazine TABS Generic
sulfazine ec TBEC Generic
SUPRAX CAPS Preferred Brand
SUPRAX CHEW Preferred Brand
SUPRAX SUSR Preferred Brand
SUPRAX TABS Preferred Brand
TEFLARO SOLR Medical Benefit-Non-Preferred
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 5 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
Specialty
TETRACYCLINE HCL CAPS Generic
TOBI PODHALER CAPS Non-Preferred Specialty
QL PA
TOBI NEBU Non-Preferred Specialty
QL PA
tobramycin NEBU Preferred Specialty QL PA
VANCOCIN HCL CAPS Non-Preferred Specialty
QL
vancomycin hcl CAPS Preferred Specialty QL
vancomycin hcl SOLR Medical Benefit
VIBATIV SOLR Medical Benefit-Non-Preferred
Specialty
PA
VIBRAMYCIN SYRP Preferred Brand
VIBRAMYCIN CAPS Non-Preferred Brand
VIBRAMYCIN SUSR Non-Preferred Brand
XIFAXAN TABS Preferred Brand QL
ZITHROMAX TRI-PAK TABS Non-Preferred Brand
ZITHROMAX Z-PAK TABS Non-Preferred Brand
ZITHROMAX PACK Preferred Brand
ZITHROMAX SUSR Non-Preferred Brand
ZITHROMAX TABS Non-Preferred Brand
ZMAX SUSR Non-Preferred Brand
ZOSYN SOLN Medical Benefit
ZOSYN SOLR Medical Benefit
ZYVOX SUSR Preferred Specialty QL PA
ZYVOX TABS Preferred Specialty QL PA
ZYVOX SOLN Medical Benefit-Preferred
Specialty
Antifungals
CANCIDAS SOLR Medical Benefit-Preferred
Specialty
DIFLUCAN SUSR Non-Preferred Brand
DIFLUCAN TABS Non-Preferred Brand
fluconazole SUSR Generic
fluconazole TABS Generic
GRIFULVIN V TABS Preferred Brand
griseofulvin microsize SUSP Generic
GRIS-PEG TABS Preferred Brand
itraconazole CAPS Generic QL
ketoconazole TABS Generic
LAMISIL TABS Non-Preferred Brand
MYCAMINE SOLR Medical Benefit-Preferred
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 6 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
Specialty
NOXAFIL SUSP Preferred Specialty QL ST
nystatin SUSP Generic
nystatin TABS Generic
SPORANOX PULSEPAK CAPS Non-Preferred Brand QL
SPORANOX SOLN Preferred Brand
SPORANOX CAPS Non-Preferred Brand QL
terbinafine hcl TABS Generic
VFEND IV SOLR Medical Benefit-Non-Preferred
Specialty
VFEND SUSR Non-Preferred Specialty
QL
VFEND TABS Non-Preferred Specialty
QL
voriconazole SUSR Preferred Specialty
voriconazole TABS Preferred Specialty QL
voriconazole SOLR Medical Benefit-Preferred
Specialty
Antimycobacterials
CYCLOSERINE CAPS Generic
DAPSONE TABS Preferred Brand
ethambutol hcl TABS Generic
isoniazid TABS Generic
ISONIAZID SYRP Preferred Brand
MYCOBUTIN CAPS Preferred Brand
PRIFTIN TABS Preferred Brand
pyrazinamide TABS Generic
RIFADIN CAPS Non-Preferred Brand
RIFADIN SOLR Medical Benefit-Non-Preferred
Specialty
rifampin CAPS Generic
rifampin SOLR Medical Benefit-Preferred
Specialty
SEROMYCIN CAPS Non-Preferred Brand
SIRTURO TABS Preferred Specialty
Antiprotozoals
ALINIA SUSR Preferred Brand
ALINIA TABS Preferred Brand
ARALEN TABS Non-Preferred Brand
atovaquone/proguanil hcl TABS Generic
chloroquine phosphate TABS Generic
DARAPRIM TABS Preferred Brand
FLAGYL ER TB24 Non-Preferred Brand ST
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 7 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
FLAGYL CAPS Non-Preferred Brand
FLAGYL TABS Non-Preferred Brand
hydroxychloroquine sulfate TABS Generic
MALARONE TABS Non-Preferred Brand
mefloquine hcl TABS Generic
MEPRON SUSP Preferred Brand
metronidazole TABS Generic
NEBUPENT SOLR Preferred Brand
paromomycin sulfate CAPS Generic
PENTAM 300 SOLR Medical Benefit
PLAQUENIL TABS Non-Preferred Brand
PRIMAQUINE PHOSPHATE TABS Preferred Brand
QUALAQUIN CAPS Non-Preferred Brand PA
quinine sulfate CAPS Generic
TINDAMAX TABS Non-Preferred Brand
tinidazole TABS Generic
Antivirals
abacavir sulfate/lamivudine/zidovudine TABS Preferred Specialty QL
abacavir TABS Generic
acyclovir sodium SOLR Medical Benefit
acyclovir CAPS Generic
acyclovir SUSP Generic
acyclovir TABS Generic
adefovir dipivoxil TABS Preferred Specialty QL
APTIVUS CAPS Preferred Specialty QL ST
APTIVUS SOLN Preferred Specialty QL ST
ATRIPLA TABS Preferred Specialty QL
BARACLUDE SOLN Non-Preferred Brand
BARACLUDE TABS Non-Preferred Brand
COMBIVIR TABS Non-Preferred Specialty
QL
COMPLERA TABS Preferred Specialty QL
COPEGUS TABS Non-Preferred Specialty
QL
CRIXIVAN CAPS Preferred Brand
CYTOVENE SOLR Medical Benefit
didanosine CPDR Generic
EDURANT TABS Preferred Brand
EMTRIVA CAPS Preferred Brand
EMTRIVA SOLN Preferred Brand
EPIVIR HBV SOLN Preferred Brand
EPIVIR HBV TABS Non-Preferred Brand
EPIVIR SOLN Preferred Brand
EPIVIR TABS Non-Preferred Brand
EPZICOM TABS Preferred Specialty QL
famciclovir TABS Generic QL
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 8 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
FAMVIR TABS Non-Preferred Brand QL
FOSCARNET SODIUM SOLN Medical Benefit-Preferred
Specialty
HEPSERA TABS Non-Preferred Specialty
QL
INCIVEK TABS Non-Preferred Specialty
QL PA
INFERGEN INJ Preferred Specialty QL PA
INTELENCE TABS Preferred Specialty QL
INVIRASE CAPS Preferred Specialty QL
INVIRASE TABS Preferred Specialty QL
ISENTRESS TABS Preferred Specialty QL
KALETRA SOLN Preferred Specialty QL
KALETRA TABS Preferred Specialty QL
lamivudine/zidovudine TABS Preferred Specialty QL
lamivudine TABS Generic
LEXIVA SUSP Preferred Specialty QL
LEXIVA TABS Preferred Specialty QL
nevirapine TABS Generic
NORVIR CAPS Preferred Brand
NORVIR SOLN Preferred Brand
OLYSIO CAPS Preferred Specialty QL PA
PEGASYS PROCLICK SOLN Non-Preferred Specialty
QL PA
PEGASYS KIT Non-Preferred Specialty
QL PA
PEGASYS SOLN Non-Preferred Specialty
QL PA
PEG-INTRON REDIPEN PAK 4 KIT Preferred Specialty QL
PEG-INTRON REDIPEN KIT Preferred Specialty QL
PEG-INTRON KIT Preferred Specialty QL
PREZISTA SUSP Preferred Specialty QL
PREZISTA TABS Preferred Specialty QL
REBETOL CAPS Non-Preferred Specialty
QL
REBETOL SOLN Non-Preferred Specialty
QL
RELENZA DISKHALER AEPB Non-Preferred Brand
RESCRIPTOR TABS Preferred Brand
RETROVIR CAPS Non-Preferred Brand
RETROVIR SYRP Non-Preferred Brand
REYATAZ CAPS Preferred Specialty QL
RIBAPAK TABS Non-Preferred Specialty
QL ST
ribasphere CAPS Non-Preferred Specialty
QL ST
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 9 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
ribasphere TABS Non-Preferred Specialty
QL ST
ribavirin CAPS Preferred Specialty QL
ribavirin TABS Preferred Specialty QL
rimantadine hcl TABS Generic
SELZENTRY TABS Preferred Specialty QL PA
SOVALDI TABS Preferred Specialty QL PA
stavudine CAPS Generic
STRIBILD TABS Preferred Specialty QL
SUSTIVA CAPS Preferred Brand
SUSTIVA TABS Preferred Brand
SYNAGIS SOLN Medical Benefit-Preferred
Specialty
PA
TAMIFLU CAPS Preferred Brand QL
TAMIFLU SUSR Preferred Brand QL
TIVICAY TABS Preferred Specialty QL
TRIZIVIR TABS Non-Preferred Specialty
QL
TRUVADA TABS Preferred Specialty QL
TYZEKA TABS Preferred Specialty QL ST
valacyclovir hcl TABS Generic
VALCYTE TABS Preferred Specialty QL
VALTREX TABS Preferred Brand
VALTREX TABS Non-Preferred Brand
VICTRELIS CAPS Non-Preferred Specialty
QL PA
VIDEX EC CPDR Non-Preferred Brand
VIDEX PEDIATRIC SOLR Preferred Brand
VIRACEPT TABS Preferred Specialty QL
VIRAMUNE XR TB24 Preferred Brand QL
VIRAMUNE SUSP Preferred Brand
VIRAMUNE TABS Non-Preferred Brand
VIRAZOLE SOLR Medical Benefit-Preferred
Specialty
VIREAD TABS Preferred Specialty QL
VISTIDE SOLN Medical Benefit-Preferred
Specialty
ZERIT CAPS Non-Preferred Brand
ZERIT SOLR Non-Preferred Brand
ZIAGEN SOLN Preferred Brand
ZIAGEN TABS Non-Preferred Brand
zidovudine CAPS Generic
zidovudine SYRP Generic
zidovudine TABS Generic
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 10 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
ZOVIRAX CAPS Non-Preferred Brand
ZOVIRAX SUSP Non-Preferred Brand
ZOVIRAX TABS Non-Preferred Brand
Urinary Anti-infectives
FURADANTIN SUSP Preferred Brand
hyophen TABS Generic
MACROBID CAPS Non-Preferred Brand
MACRODANTIN CAPS Preferred Brand
MACRODANTIN CAPS Non-Preferred Brand
methenamine hippurate TABS Generic
MONUROL PACK Preferred Brand QL
nitrofurantoin macrocrystals CAPS Generic
nitrofurantoin monohydrate CAPS Generic
PROSED/DS TABS Non-Preferred Brand
trimethoprim TABS Generic
URIBEL CAPS Non-Preferred Brand
Antineoplastic Agents
ABRAXANE SUSR Medical Benefit-Preferred
Specialty
ADCETRIS SOLR Medical Benefit-Preferred
Specialty
PA
adriamycin SOLN Medical Benefit
adriamycin SOLR Medical Benefit
adrucil SOLN Medical Benefit
AFINITOR DISPERZ TBSO Preferred Specialty QL PA
AFINITOR TABS Preferred Specialty QL PA
ALFERON N SOLN Medical Benefit-Preferred
Specialty
ALIMTA SOLR Medical Benefit-Preferred
Specialty
ALKERAN TABS Preferred Brand
ALKERAN SOLR Medical Benefit-Preferred
Specialty
anastrozole TABS Generic
ARIMIDEX TABS Non-Preferred Brand
AROMASIN TABS Non-Preferred Brand
ARZERRA CONC Medical Benefit-Non-Preferred
Specialty
PA
AVASTIN SOLN Medical Benefit-Preferred
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 11 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
Specialty
bicalutamide TABS Generic
BICNU SOLR Medical Benefit
bleomycin sulfate SOLR Medical Benefit
BOSULIF TABS Non-Preferred Specialty
QL PA
BUSULFEX SOLN Medical Benefit
CAMPTOSAR SOLN Medical Benefit-Preferred
Specialty
CAPRELSA TABS Preferred Specialty QL PA
carboplatin SOLN Medical Benefit
CASODEX TABS Non-Preferred Brand
CERUBIDINE SOLR Medical Benefit
cisplatin SOLN Medical Benefit-Preferred
Specialty
cladribine SOLN Medical Benefit
COMETRIQ KIT Preferred Specialty QL PA
COSMEGEN SOLR Medical Benefit-Preferred
Specialty
CYCLOPHOSPHAMIDE TABS Generic
CYCLOPHOSPHAMIDE SOLR Medical Benefit
cytarabine SOLR Generic
dacarbazine SOLR Medical Benefit
DACOGEN SOLR Medical Benefit-Preferred
Specialty
daunorubicin hcl SOLR Medical Benefit
DAUNOXOME INJ Medical Benefit
DEPOCYT SUSP Medical Benefit
DOCEFREZ SOLR Medical Benefit-Preferred
Specialty
DOCETAXEL CONC Medical Benefit-Preferred
Specialty
DOXIL INJ Medical Benefit-Preferred
Specialty
doxorubicin hcl SOLN Medical Benefit
ELIGARD KIT Medical Benefit-Preferred
Specialty
ELLENCE SOLN Medical Benefit-Preferred
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 12 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
Specialty
ELOXATIN SOLN Medical Benefit-Preferred
Specialty
ELSPAR SOLR Medical Benefit
EMCYT CAPS Preferred Brand
ERBITUX SOLN Medical Benefit-Preferred
Specialty
PA
ERIVEDGE CAPS Preferred Specialty QL PA
ERWINAZE SOLR Medical Benefit-Non-Preferred
Specialty
PA
ETOPOSIDE CAPS Generic
exemestane TABS Generic
FARESTON TABS Non-Preferred Brand QL ST
FASLODEX SOLN Medical Benefit-Preferred
Specialty
FEMARA TABS Non-Preferred Brand
FIRMAGON SOLR Medical Benefit-Non-Preferred
Specialty
floxuridine SOLR Medical Benefit
FLUDARA SOLR Medical Benefit
fludarabine phosphate SOLR Medical Benefit
flutamide CAPS Medical Benefit
FOLOTYN SOLN Medical Benefit-Preferred
Specialty
GAZYVA SOLN Medical Benefit-Preferred
Specialty
GEMZAR SOLR Medical Benefit-Preferred
Specialty
GILOTRIF TABS Preferred Specialty QL PA
GLEEVEC TABS Preferred Specialty QL PA
HALAVEN SOLN Medical Benefit-Non-Preferred
Specialty
HERCEPTIN SOLR Medical Benefit-Preferred
Specialty
HYCAMTIN CAPS Preferred Specialty QL
HYCAMTIN SOLR Medical Benefit-Preferred
Specialty
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 13 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
HYDREA CAPS Non-Preferred Brand
hydroxyurea CAPS Generic
ICLUSIG TABS Non-Preferred Specialty
QL PA
IDAMYCIN PFS SOLN Medical Benefit-Preferred
Specialty
idarubicin hcl SOLN Medical Benefit
IFEX SOLR Medical Benefit
ifosfamide SOLR Medical Benefit
IMBRUVICA CAPS Non-Preferred Specialty
QL PA
INLYTA TABS Preferred Specialty QL PA
INTRON-A W/DILUENT SOLR Preferred Specialty QL
INTRON-A SOLN Preferred Specialty QL
IXEMPRA KIT SOLR Medical Benefit-Non-Preferred
Specialty
JAKAFI TABS Preferred Specialty QL PA
JEVTANA SOLN Medical Benefit-Non-Preferred
Specialty
PA
KADCYLA SOLR Medical Benefit-Preferred
Specialty
PA
KYPROLIS SOLR Medical Benefit-Preferred
Specialty
letrozole TABS Generic
LEUKERAN TABS Preferred Brand
leuprolide acetate KIT Generic
LOMUSTINE CAPS Generic
LUPANETA PACK KIT Medical Benefit-Non-Preferred
Specialty
LUPRON DEPOT KIT Medical Benefit-Preferred
Specialty
LUPRON DEPOT-PED KIT Medical Benefit-Preferred
Specialty
LYSODREN TABS Preferred Specialty PA
MARQIBO SUSP Medical Benefit-Non-Preferred
Specialty
PA
MATULANE CAPS Preferred Specialty QL PA
MEGACE ORAL SUSP Non-Preferred Brand
megestrol acetate SUSP Generic
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 14 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
megestrol acetate TABS Generic
MEKINIST TABS Non-Preferred Specialty
QL PA
mercaptopurine TABS Generic
methotrexate sodium SOLN Generic
methotrexate sodium SOLR Generic
methotrexate TABS Generic
mitomycin SOLR Medical Benefit
mitoxantrone hcl CONC Medical Benefit
MUSTARGEN SOLR Medical Benefit
NAVELBINE SOLN Medical Benefit
NEXAVAR TABS Preferred Specialty QL PA
NIPENT SOLR Medical Benefit-Preferred
Specialty
ONCASPAR SOLN Medical Benefit-Preferred
Specialty
ONTAK SOLN Medical Benefit
paclitaxel CONC Medical Benefit
PERJETA SOLN Medical Benefit-Preferred
Specialty
PA
PHOTOFRIN SOLR Medical Benefit-Preferred
Specialty
POMALYST CAPS Non-Preferred Specialty
PA
PROLEUKIN SOLR Medical Benefit-Preferred
Specialty
REVLIMID CAPS Preferred Specialty QL
RHEUMATREX TABS Preferred Brand
RITUXAN CONC Medical Benefit-Preferred
Specialty
PA
SPRYCEL TABS Preferred Specialty QL PA
STIVARGA TABS Non-Preferred Specialty
QL PA
SUPPRELIN LA KIT Medical Benefit-Preferred
Specialty
SUTENT CAPS Preferred Specialty QL PA
SYLATRON KIT Preferred Specialty QL PA
SYNRIBO SOLR Medical Benefit-Non-Preferred
Specialty
ST
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 15 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
TABLOID TABS Preferred Brand
TAFINLAR CAPS Non-Preferred Specialty
QL PA
tamoxifen citrate TABS Generic
TARCEVA TABS Preferred Specialty QL PA
TARGRETIN CAPS Preferred Specialty QL PA
TASIGNA CAPS Preferred Specialty QL PA
TAXOTERE CONC Medical Benefit-Preferred
Specialty
TEMODAR CAPS Preferred Specialty QL
TENIPOSIDE SOLN Medical Benefit
THIOTEPA SOLR Medical Benefit
toposar SOLN Medical Benefit
TREANDA SOLR Medical Benefit-Preferred
Specialty
TRELSTAR DEPOT SUSR Medical Benefit-Preferred
Specialty
TRELSTAR LA SUSR Medical Benefit-Preferred
Specialty
TRELSTAR MIXJECT SUSR Medical Benefit-Preferred
Specialty
tretinoin CAPS Preferred Specialty QL PA
TRISENOX SOLN Medical Benefit-Preferred
Specialty
TYKERB TABS Preferred Specialty QL PA
VANTAS KIT Medical Benefit-Preferred
Specialty
VECTIBIX SOLN Medical Benefit-Preferred
Specialty
PA
VELCADE SOLR Medical Benefit-Preferred
Specialty
VINBLASTINE SULFATE SOLN Medical Benefit
vincasar pfs SOLN Medical Benefit
vincristine sulfate SOLN Medical Benefit
vinorelbine tartrate SOLN Medical Benefit
VOTRIENT TABS Preferred Specialty QL PA
XALKORI CAPS Preferred Specialty QL PA
XELODA TABS Preferred Specialty QL
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 16 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
XTANDI CAPS Non-Preferred Specialty
QL PA
YERVOY SOLN Medical Benefit-Preferred
Specialty
PA
ZALTRAP SOLN Medical Benefit-Non-Preferred
Specialty
ZANOSAR SOLR Medical Benefit
ZELBORAF TABS Preferred Specialty QL PA
ZEVALIN IN-111 KIT Medical Benefit-Preferred
Specialty
PA
ZEVALIN Y-90 KIT Medical Benefit-Preferred
Specialty
PA
ZOLADEX IMPL Medical Benefit-Preferred
Specialty
ZOLINZA CAPS Preferred Specialty QL PA
ZYTIGA TABS Preferred Specialty QL PA
Autonomic Drugs
Anticholinergic Agents
ANASPAZ TBDP Non-Preferred Brand
ATROPINE SULFATE SOLN Generic
ATROVENT HFA AERS Preferred Brand
ATROVENT SOLN Non-Preferred Brand
BELLADONNA & OPIUM SUPP Preferred Brand
BELLADONNA ALKALOIDS & OPIUM SUPP Preferred Brand
BENTYL CAPS Non-Preferred Brand
BENTYL TABS Non-Preferred Brand
CANTIL TABS Preferred Brand
chlordiazepoxide hcl/clidinium bromide CAPS Generic
CUVPOSA SOLN Non-Preferred Specialty
QL
dicyclomine hcl CAPS Generic
DICYCLOMINE HCL SOLN Generic
dicyclomine hcl TABS Generic
DONNATAL EXTENTABS TBCR Preferred Brand
DONNATAL ELIX Non-Preferred Brand
DONNATAL TABS Non-Preferred Brand
GLYCATE TABS Non-Preferred Brand
glycopyrrolate SOLN Generic
glycopyrrolate TABS Generic
hyomax-sl SUBL Generic
hyoscyamine sulfate er TB12 Generic
hyoscyamine sulfate ELIX Generic
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 17 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
hyoscyamine sulfate SOLN Generic
hyoscyamine sulfate SUBL Generic
hyoscyamine sulfate TABS Generic
hyoscyamine sulfate TBDP Generic
ipratropium bromide SOLN Generic
LEVSIN/SL SUBL Non-Preferred Brand
LEVSIN TABS Non-Preferred Brand
methscopolamine bromide TABS Generic
nulev TBDP Generic
oscimin sr TB12 Generic
PAMINE FORTE TABS Non-Preferred Brand
PROPANTHELINE BROMIDE TABS Generic
ROBINUL FORTE TABS Non-Preferred Brand
ROBINUL SOLN Non-Preferred Brand
ROBINUL TABS Non-Preferred Brand
SPIRIVA HANDIHALER CAPS Preferred Brand
SYMAX DUOTAB TBCR Non-Preferred Brand
TUDORZA PRESSAIR AEPB Preferred Brand
Autonomic Drugs, Miscellaneous
CHANTIX STARTING MONTH PAK TABS Preferred Brand
CHANTIX TABS Preferred Brand
COMMIT LOZG Preferred Brand
nicotine polacrilex GUM Generic
nicotine polacrilex LOZG Generic
nicotine PT24 Generic
NICOTROL INHALER INHA Preferred Brand QL
NICOTROL NS SOLN Preferred Brand
Parasympathomimetic (Cholinergic) Agents
ARICEPT ODT TBDP Non-Preferred Brand
ARICEPT TABS Non-Preferred Brand
bethanechol chloride TABS Generic
donepezil hcl TABS Generic
donepezil hcl TBDP Generic
EVOXAC CAPS Preferred Brand
EXELON PT24 Preferred Brand QL
EXELON SOLN Preferred Brand
EXELON CAPS Non-Preferred Brand
galantamine hydrobromide CP24 Generic
galantamine hydrobromide SOLN Generic
galantamine hydrobromide TABS Generic
MESTINON SYRP Preferred Brand
MESTINON TABS Non-Preferred Brand
pilocarpine hcl TABS Generic
pilocarpine hydrochloride TABS Generic
pyridostigmine bromide TABS Generic
RAZADYNE ER CP24 Non-Preferred Brand
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 18 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
RAZADYNE SOLN Non-Preferred Brand
RAZADYNE TABS Non-Preferred Brand
rivastigmine tartrate CAPS Generic
SALAGEN TABS Non-Preferred Brand
Skeletal Muscle Relaxants
AMRIX CP24 Non-Preferred Brand
baclofen TABS Generic
carisoprodol/aspirin/codeine TABS Generic
carisoprodol/aspirin TABS Generic
carisoprodol TABS Generic
chlorzoxazone TABS Generic
cyclobenzaprine hcl TABS Generic
DANTRIUM CAPS Non-Preferred Brand
dantrolene sodium CAPS Generic
LIORESAL INTRATHECAL SOLN Medical Benefit-Preferred
Specialty
LORZONE TABS Non-Preferred Brand QL ST
metaxalone TABS Generic
methocarbamol TABS Generic
orphenadrine citrate er TB12 Generic
PARAFON FORTE DSC TABS Non-Preferred Brand
ROBAXIN TABS Non-Preferred Brand
ROBAXIN-750 TABS Non-Preferred Brand
SKELAXIN TABS Non-Preferred Brand
SOMA TABS Non-Preferred Brand
tizanidine hcl CAPS Generic
tizanidine hcl TABS Generic
ZANAFLEX CAPS Non-Preferred Brand
ZANAFLEX TABS Non-Preferred Brand
Sympatholytic (Adrenergic Blocking) Agents
alfuzosin hcl er TB24 Generic
DIBENZYLINE CAPS Preferred Specialty QL
DIHYDROERGOTAMINE MESYLATE SOLN Generic
dihydroergotamine mesylate SOLN Medical Benefit
ERGOLOID MESYLATES TABS Generic
FLOMAX CAPS Non-Preferred Brand
MIGRANAL SOLN Non-Preferred Brand
RAPAFLO CAPS Non-Preferred Brand ST
tamsulosin hcl CAPS Generic
UROXATRAL TB24 Preferred Brand
Sympathomimetic (Adrenergic) Agents
ACCUNEB NEBU Non-Preferred Brand
ADRENACLICK SOAJ Non-Preferred Brand QL
ADVAIR DISKUS AEPB Non-Preferred Brand
ADVAIR HFA AERO Non-Preferred Brand
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 19 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
albuterol sulfate er TB12 Generic
albuterol sulfate NEBU Generic
albuterol sulfate SYRP Generic
albuterol sulfate TABS Generic
ARCAPTA NEOHALER CAPS Non-Preferred Brand
AUVI-Q SOAJ Non-Preferred Brand QL ST
BROVANA NEBU Preferred Brand
COMBIVENT RESPIMAT AERS Preferred Brand QL
COMBIVENT AERO Preferred Brand
DUONEB SOLN Non-Preferred Brand QL
EPINEPHRINE SOAJ Generic QL
EPIPEN 2-PAK SOAJ Preferred Brand QL
EPIPEN-JR 2-PAK SOAJ Preferred Brand QL
FORADIL AEROLIZER CAPS Preferred Brand
ipratropium bromide/albuterol sulfate SOLN Generic QL
levalbuterol hcl NEBU Generic
levalbuterol NEBU Generic
MAXAIR AUTOHALER AERB Non-Preferred Brand
METAPROTERENOL SULFATE SYRP Generic
METAPROTERENOL SULFATE TABS Generic
midodrine hcl TABS Generic
PERFOROMIST NEBU Preferred Brand
PROAIR HFA AERS Generic
PROVENTIL HFA AERS Non-Preferred Brand
SEREVENT DISKUS AEPB Preferred Brand
terbutaline sulfate TABS Generic
terbutaline sulfate SOLN Medical Benefit
VENTOLIN HFA AERS Preferred Brand
VOSPIRE ER TB12 Non-Preferred Brand
XOPENEX CONCENTRATE NEBU Non-Preferred Brand
XOPENEX HFA AERO Preferred Brand
XOPENEX NEBU Non-Preferred Brand
Blood Formation,Coagulation & Thrombosis
Antianemia Drugs
dexferrum SOLN Medical Benefit
FERAHEME SOLN Medical Benefit
FERREX 150 FORTE PLUS CAPS Excluded
ferrex 150 forte CAPS Excluded
FERREX 150 PLUS CAPS Excluded
ferrex 150 CAPS Excluded
FERREX 28 TABS Excluded
FERRLECIT SOLN Medical Benefit
ferrous sulfate SOLN Generic
infed SOLN Medical Benefit
INJECTAFER SOLN Medical Benefit-Non-Preferred
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 20 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
Specialty
MYKIDZ IRON 10 SUSP Preferred Brand
VENOFER SOLN Medical Benefit
VITAFOL SYRP Preferred Brand
wee care SUSP Generic
Antihemorrhagic Agents
ADVATE SOLR Preferred Specialty QL
ALPHANATE/VON WILLEBRAND FACTOR COMPLEX/HUMAN
SOLR Preferred Specialty QL
aminocaproic acid SYRP Generic
aminocaproic acid TABS Generic
BEBULIN VH SOLR Preferred Specialty QL
BEBULIN SOLR Preferred Specialty QL
BENEFIX SOLR Preferred Specialty QL
CORIFACT KIT Medical Benefit-Preferred
Specialty
FEIBA NF SOLR Preferred Specialty QL
HELIXATE FS KIT Preferred Specialty QL
HEMOFIL M SOLR Preferred Specialty QL
HUMATE-P SOLR Preferred Specialty QL
KOATE-DVI SOLR Preferred Specialty QL
KOGENATE FS BIO-SET KIT Preferred Specialty QL
KOGENATE FS KIT Preferred Specialty QL
LYSTEDA TABS Non-Preferred Brand
MONOCLATE-P KIT Preferred Specialty QL
MONONINE SOLR Preferred Specialty QL
NOVOSEVEN RT SOLR Preferred Specialty QL
RECOMBINATE SOLR Preferred Specialty QL
RIXUBIS SOLR Non-Preferred Specialty
tranexamic acid TABS Generic
WILATE SOLR Preferred Specialty QL
XYNTHA KIT Preferred Specialty QL
Antithrombotic Agents
AGGRENOX CP12 Preferred Brand
AGRYLIN CAPS Non-Preferred Brand
anagrelide hydrochloride CAPS Generic
ARIXTRA SOLN Non-Preferred Specialty
QL
BRILINTA TABS Preferred Brand
cilostazol TABS Generic
clopidogrel TABS Generic
COUMADIN TABS Preferred Brand
EFFIENT TABS Preferred Brand QL
ELIQUIS TABS Preferred Brand QL
enoxaparin sodium SOLN Generic
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 21 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
fondaparinux sodium SOLN Preferred Specialty QL
FRAGMIN SOLN Non-Preferred Specialty
QL
heparin sodium SOLN Generic
jantoven TABS Generic
LOVENOX SOLN Non-Preferred Specialty
QL
PLAVIX TABS Non-Preferred Brand
PLETAL TABS Non-Preferred Brand
PRADAXA CAPS Preferred Brand QL
THROMBATE III W/10 ML STERILE WATER SOLR Medical Benefit-Preferred
Specialty
ticlopidine hcl TABS Generic
warfarin sodium TABS Generic
XARELTO TABS Preferred Brand QL
Hematopoietic Agents
ARANESP ALBUMIN FREE SOLN Preferred Specialty QL
EPOGEN SOLN Non-Preferred Specialty
QL
GRANIX SOSY Generic
LEUKINE SOLR Medical Benefit-Preferred
Specialty
MOZOBIL SOLN Medical Benefit-Non-Preferred
Specialty
NEULASTA SOLN Preferred Specialty QL
NEUMEGA SOLR Preferred Specialty QL
NEUPOGEN SOLN Non-Preferred Specialty
QL
NPLATE SOLR Medical Benefit-Preferred
Specialty
PA
OMONTYS SOLN Non-Preferred Specialty
QL
PROCRIT SOLN Non-Preferred Specialty
QL
PROMACTA TABS Preferred Specialty QL PA
Hemorrheologic Agents
pentoxifylline er TBCR Generic
TRENTAL TBCR Non-Preferred Brand
Cardiovascular Drugs
alpha-Adrenergic Blocking Agents
CARDURA XL TB24 Non-Preferred Brand ST
CARDURA TABS Non-Preferred Brand
doxazosin mesylate TABS Generic
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 22 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
MINIPRESS CAPS Non-Preferred Brand
prazosin hcl CAPS Generic
terazosin hcl CAPS Generic
Antilipemic Agents
ADVICOR TB24 Preferred Brand
ALTOPREV TB24 Non-Preferred Brand ST
ANTARA CAPS Non-Preferred Brand
atorvastatin calcium TABS Generic
cholestyramine light PACK Generic
cholestyramine light POWD Generic
cholestyramine PACK Generic
cholestyramine POWD Generic
COLESTID GRAN Non-Preferred Brand
COLESTID PACK Non-Preferred Brand
COLESTID TABS Non-Preferred Brand
colestipol hcl for oral suspension PACK Generic
colestipol hcl GRAN Generic
colestipol hcl TABS Generic
CRESTOR TABS Preferred Brand
fenofibrate micronized CAPS Generic
fenofibrate CAPS Generic
fenofibrate TABS Generic
fenofibric acid dr CPDR Generic
FENOFIBRIC ACID TABS Generic
FENOGLIDE TABS Non-Preferred Brand ST
FIBRICOR TABS Non-Preferred Brand
fluvastatin CAPS Generic
gemfibrozil TABS Generic
JUXTAPID CAPS Non-Preferred Specialty
PA
KYNAMRO SOLN Non-Preferred Brand PA
LESCOL XL TB24 Non-Preferred Brand ST
LESCOL CAPS Non-Preferred Brand
LIPITOR TABS Non-Preferred Brand
LIPOFEN CAPS Non-Preferred Brand ST
LIPTRUZET TABS Non-Preferred Brand QL ST
LIVALO TABS Non-Preferred Brand ST
LOFIBRA CAPS Non-Preferred Brand
LOFIBRA TABS Non-Preferred Brand
LOPID TABS Non-Preferred Brand
lovastatin TABS Generic
LOVAZA CAPS Preferred Brand PA
MEVACOR TABS Non-Preferred Brand
niacin er TBCR Generic
NIASPAN TBCR Non-Preferred Brand
PRAVACHOL TABS Non-Preferred Brand
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 23 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
pravastatin sodium TABS Generic
prevalite PACK Generic
prevalite POWD Generic
QUESTRAN LIGHT POWD Non-Preferred Brand
QUESTRAN POWD Non-Preferred Brand
SIMCOR TB24 Preferred Brand QL
simvastatin TABS Generic
TRICOR TABS Non-Preferred Brand
TRIGLIDE TABS Non-Preferred Brand
TRILIPIX CPDR Non-Preferred Brand
VASCEPA CAPS Non-Preferred Brand PA
VYTORIN TABS Non-Preferred Brand ST
WELCHOL TABS Preferred Brand
ZETIA TABS Preferred Brand
ZOCOR TABS Non-Preferred Brand QL
beta-Adrenergic Blocking Agents
acebutolol hcl CAPS Generic
atenolol/chlorthalidone TABS Generic
atenolol TABS Generic
BETAPACE TABS Non-Preferred Brand
betaxolol hcl TABS Generic
bisoprolol fumarate/hydrochlorothiazide TABS Generic
bisoprolol fumarate TABS Generic
BYSTOLIC TABS Non-Preferred Brand ST
carvedilol TABS Generic
COREG CR CP24 Preferred Brand ST
COREG TABS Non-Preferred Brand
CORGARD TABS Non-Preferred Brand
CORZIDE TABS Non-Preferred Brand
INDERAL LA CP24 Non-Preferred Brand
INNOPRAN XL CP24 Non-Preferred Brand ST
KERLONE TABS Non-Preferred Brand
labetalol hcl TABS Generic
LEVATOL TABS Preferred Brand
LOPRESSOR HCT TABS Non-Preferred Brand
LOPRESSOR TABS Non-Preferred Brand
LOPRESSOR SOLN Medical Benefit-Non-Preferred
Specialty
metoprolol succinate er TB24 Generic
metoprolol tartrate TABS Generic
metoprolol/hydrochlorothiazide TABS Generic
nadolol/bendroflumethiazide TABS Generic
nadolol TABS Generic
pindolol TABS Generic
propranolol hcl er CP24 Generic
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 24 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
PROPRANOLOL HCL SOLN Generic
propranolol hcl TABS Generic
PROPRANOLOL/HYDROCHLOROTHIAZIDE TABS Generic
SECTRAL CAPS Non-Preferred Brand
sorine TABS Generic
sotalol hcl TABS Generic
TENORETIC 100 TABS Non-Preferred Brand
TENORETIC 50 TABS Non-Preferred Brand
TENORMIN TABS Non-Preferred Brand
TIMOLOL MALEATE TABS Generic
TOPROL XL TB24 Non-Preferred Brand
TRANDATE TABS Non-Preferred Brand
ZEBETA TABS Non-Preferred Brand
ZIAC TABS Non-Preferred Brand
Calcium-Channel Blocking Agents
ADALAT CC TB24 Non-Preferred Brand
afeditab cr TB24 Generic
amlodipine besylate/atorvastatin calcium TABS Generic
amlodipine besylate/benazepril hcl CAPS Generic
amlodipine besylate/benazepril hcl CAPS Preferred Brand
amlodipine besylate/benazepril hydrochloride CAPS Generic
amlodipine besylate TABS Generic
AZOR TABS Non-Preferred Brand ST
CADUET TABS Non-Preferred Brand
CALAN SR TBCR Non-Preferred Brand
CALAN TABS Non-Preferred Brand
CARDENE SR CP12 Non-Preferred Brand ST
CARDIZEM CD CP24 Non-Preferred Brand
CARDIZEM LA TB24 Preferred Brand
CARDIZEM LA TB24 Non-Preferred Brand
CARDIZEM TABS Non-Preferred Brand
cartia xt CP24 Generic
DILACOR XR CP24 Non-Preferred Brand
dilt-cd CP24 Generic
diltiazem cd CP24 Generic
diltiazem hcl er CP12 Generic
diltiazem hcl er CP24 Generic
diltiazem hcl TABS Generic
dilt-xr CP24 Generic
diltzac CP24 Generic
EXFORGE HCT TABS Preferred Brand ST
EXFORGE TABS Preferred Brand ST
felodipine er TB24 Generic
ISOPTIN SR TBCR Non-Preferred Brand
ISRADIPINE CAPS Generic
LOTREL CAPS Non-Preferred Brand
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 25 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
matzim la TB24 Generic
nicardipine hcl CAPS Generic
nifediac cc TB24 Generic
nifedipine er TB24 Generic
nifedipine CAPS Generic
nimodipine CAPS Preferred Specialty QL
NISOLDIPINE ER TB24 Generic
nisoldipine TB24 Generic
NORVASC TABS Non-Preferred Brand
NYMALIZE SOLN Non-Preferred Specialty
QL ST
PROCARDIA XL TB24 Non-Preferred Brand
SULAR TB24 Non-Preferred Brand
TARKA TBCR Preferred Brand
TARKA TBCR Non-Preferred Brand
telmisartan/amlodipine TABS Generic
TIAZAC CP24 Non-Preferred Brand
TRIBENZOR TABS Non-Preferred Brand ST
TWYNSTA TABS Non-Preferred Brand
verapamil hcl er CP24 Generic
verapamil hcl er TBCR Generic
verapamil hcl TABS Generic
VERELAN PM CP24 Non-Preferred Brand
VERELAN CP24 Non-Preferred Brand
Cardiac Drugs
amiodarone hcl TABS Generic
CORDARONE TABS Non-Preferred Brand
digox TABS Generic
DIGOXIN SOLN Preferred Brand
disopyramide phosphate CAPS Generic
flecainide acetate TABS Generic
LANOXIN PEDIATRIC SOLN Medical Benefit-Non-Preferred
Specialty
LANOXIN TABS Non-Preferred Brand
mexiletine hcl CAPS Generic
MULTAQ TABS Preferred Brand
NORPACE CR CP12 Preferred Brand
NORPACE CAPS Non-Preferred Brand
pacerone TABS Generic
pacerone TABS Preferred Brand
propafenone hcl er CP12 Generic
propafenone hcl TABS Generic
quinidine gluconate cr TBCR Generic
QUINIDINE SULFATE ER TBCR Generic
QUINIDINE SULFATE TABS Generic
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 26 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
RANEXA TB12 Preferred Brand
RYTHMOL SR CP12 Non-Preferred Brand QL
RYTHMOL TABS Non-Preferred Brand
TAMBOCOR TABS Non-Preferred Brand
TIKOSYN CAPS Preferred Brand
Hypotensive Agents
CATAPRES TABS Non-Preferred Brand
CATAPRES-TTS-1 PTWK Non-Preferred Brand
CATAPRES-TTS-2 PTWK Non-Preferred Brand
CATAPRES-TTS-3 PTWK Non-Preferred Brand
clonidine hcl er TB12 Generic
clonidine hcl PTWK Generic
clonidine hcl TABS Generic
CLORPRES TABS Generic
guanfacine hcl TABS Generic
hydralazine hcl TABS Generic
KAPVAY TB12 Non-Preferred Brand
METHYLDOPA/HYDROCHLOROTHIAZIDE TABS Generic
methyldopa TABS Generic
minoxidil TABS Generic
RESERPINE TABS Generic
TENEX TABS Non-Preferred Brand
VECAMYL TABS Preferred Specialty
Renin-Angiotensin-Aldosterone Sys Inhib
ACCUPRIL TABS Non-Preferred Brand
ACCURETIC TABS Non-Preferred Brand
ALDACTAZIDE TABS Preferred Brand
ALDACTAZIDE TABS Non-Preferred Brand
ALDACTONE TABS Non-Preferred Brand
ALTACE CAPS Non-Preferred Brand
AMTURNIDE TABS Preferred Brand QL
ATACAND HCT TABS Non-Preferred Brand
ATACAND TABS Non-Preferred Brand
AVALIDE TABS Non-Preferred Brand
AVAPRO TABS Non-Preferred Brand
benazepril hcl/hydrochlorothiazide TABS Generic
benazepril hcl TABS Generic
BENICAR HCT TABS Non-Preferred Brand ST
BENICAR TABS Non-Preferred Brand ST
candesartan cilexetil/hydrochlorothiazide TABS Generic
candesartan cilexetil TABS Generic
CAPTOPRIL/HYDROCHLOROTHIAZIDE TABS Generic
captopril TABS Generic
COZAAR TABS Non-Preferred Brand
DIOVAN HCT TABS Non-Preferred Brand
DIOVAN TABS Preferred Brand QL ST
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 27 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
EDARBI TABS Non-Preferred Brand ST
EDARBYCLOR TABS Non-Preferred Brand ST
enalapril maleate/hydrochlorothiazide TABS Generic
enalapril maleate TABS Generic
EPANED SOLR Non-Preferred Brand
eplerenone TABS Generic
fosinopril sodium/hydrochlorothiazide TABS Generic
fosinopril sodium TABS Generic
HYZAAR TABS Non-Preferred Brand
INSPRA TABS Non-Preferred Brand
irbesartan/hydrochlorothiazide TABS Generic
irbesartan TABS Generic
lisinopril/hydrochlorothiazide TABS Generic
lisinopril TABS Generic
losartan potassium/hydrochlorothiazide TABS Generic
losartan potassium TABS Generic
LOTENSIN HCT TABS Non-Preferred Brand
LOTENSIN TABS Non-Preferred Brand
MAVIK TABS Non-Preferred Brand
MICARDIS HCT TABS Non-Preferred Brand
MICARDIS TABS Non-Preferred Brand
moexipril hcl TABS Generic
moexipril/hydrochlorothiazide TABS Generic
perindopril erbumine TABS Generic
PRINIVIL TABS Non-Preferred Brand
quinapril hcl TABS Generic
quinapril/hydrochlorothiazide TABS Generic
ramipril CAPS Generic
spironolactone/hydrochlorothiazide TABS Generic
spironolactone TABS Generic
TEKAMLO TABS Preferred Brand ST
TEKTURNA HCT TABS Preferred Brand ST
TEKTURNA TABS Preferred Brand ST
telmisartan/hydrochloroth TABS Generic
telmisartan/hydrochlorothiazide TABS Generic
telmisartan TABS Generic
TEVETEN HCT TABS Non-Preferred Brand ST
TEVETEN TABS Non-Preferred Brand ST
trandolapril TABS Generic
UNIRETIC TABS Non-Preferred Brand
UNIVASC TABS Non-Preferred Brand
valsartan/hydrochlorothiazide TABS Generic
VASERETIC TABS Non-Preferred Brand
VASOTEC TABS Non-Preferred Brand
ZESTORETIC TABS Non-Preferred Brand
ZESTRIL TABS Non-Preferred Brand
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 28 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
Vasodilating Agents
ADCIRCA TABS Preferred Specialty QL PA
ADEMPAS TABS Preferred Specialty QL PA
BIDIL TABS Preferred Brand
CAVERJECT IMPULSE KIT Excluded
CAVERJECT SOLR Excluded
CIALIS TABS Excluded
CIALIS TABS Excluded ST
dipyridamole TABS Generic
EDEX KIT Preferred Brand QL
epoprostenol sodium SOLR Medical Benefit-Preferred
Specialty
FLOLAN SOLR Medical Benefit-Non-Preferred
Specialty
isoditrate er TBCR Generic
ISORDIL TITRADOSE TABS Preferred Brand
ISORDIL TITRADOSE TABS Non-Preferred Brand
isosorbide dinitrate er TBCR Generic
ISOSORBIDE DINITRATE SUBL Generic
isosorbide dinitrate TABS Generic
isosorbide mononitrate er TB24 Generic
isosorbide mononitrate TABS Generic
LETAIRIS TABS Non-Preferred Specialty
QL
LEVITRA TABS Excluded
minitran PT24 Generic
MUSE PLLT Preferred Brand QL
NITRO-BID OINT Preferred Brand
NITRO-DUR PT24 Preferred Brand
NITRO-DUR PT24 Non-Preferred Brand
nitroglycerin er CPCR Generic
nitroglycerin transdermal PT24 Generic
NITROLINGUAL PUMPSPRAY SOLN Preferred Brand
NITROSTAT SUBL Generic
nitro-time CPCR Generic
OPSUMIT TABS Non-Preferred Specialty
QL PA
PERSANTINE TABS Non-Preferred Brand
REMODULIN SOLN Medical Benefit-Preferred
Specialty
PA
REVATIO TABS Non-Preferred Specialty
QL PA
sildenafil citrate TABS Generic PA
STAXYN TBDP Excluded
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 29 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
STENDRA TABS Excluded
TRACLEER TABS Preferred Specialty QL
TYVASO SOLN Preferred Specialty QL PA
VENTAVIS SOLN Preferred Brand PA
VIAGRA TABS Excluded
Cellular Therapy
PROVENGE SUSP Medical Benefit-Non-Preferred
Specialty
PA
Central Nervous System Agents
Analgesics and Antipyretics
ABSTRAL SUBL Non-Preferred Brand PA
acetaminophen/codeine #3 TABS Generic
acetaminophen/codeine SOLN Generic
acetaminophen/codeine TABS Generic
ACTIQ LPOP Non-Preferred Specialty
QL PA
ANAPROX DS TABS Non-Preferred Brand
ANAPROX TABS Non-Preferred Brand
ARTHROTEC 50 TBEC Non-Preferred Brand
ARTHROTEC 75 TBEC Non-Preferred Brand
ASCRIPTIN TABS Generic
aspirin ec low dose TBEC Generic
aspirin ec TBEC Generic
aspirin CHEW Generic
ASPIRIN-CAFFEINE-DIHYDROCODEINE CAPS Generic
AVINZA CP24 Preferred Brand QL ST
buffered aspirin TABS Generic
BUFFERIN LOW DOSE TABS Non-Preferred Brand
BUFFERIN TABS Non-Preferred Brand
BUPRENEX SOLN Medical Benefit
buprenorphine hcl/naloxone hcl SUBL Generic QL
buprenorphine hcl SUBL Generic QL
butalbital/acetaminophen/caffeine/codeine CAPS Generic QL
butalbital/acetaminophen/caffeine TABS Generic
butalbital/acetaminophen TABS Generic
butalbital/apap/caffeine CAPS Generic QL
butalbital/asa/caffeine CAPS Generic
BUTALBITAL/ASPIRIN/CAFFEINE TABS Generic
butorphanol tartrate SOLN Generic
BUTRANS PTWK Non-Preferred Brand QL
CAMBIA PACK Non-Preferred Brand ST
CAPITAL/CODEINE SUSP Preferred Brand
CATAFLAM TABS Non-Preferred Brand
CELEBREX CAPS Preferred Brand PA
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 30 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
choline magnesium trisalicylate LIQD Generic
choline magnesium trisalicylate TABS Generic
CLINORIL TABS Non-Preferred Brand
CODEINE PHOSPHATE SOLN Medical Benefit
CODEINE SULFATE TABS Generic
CONZIP CP24 Non-Preferred Brand QL ST
DAYPRO TABS Non-Preferred Brand
diclofenac potassium TABS Generic
diclofenac sodium dr TBEC Generic
diclofenac sodium er TB24 Generic
diclofenac sodium/misoprostol TBEC Generic
diflunisal TABS Generic
DILAUDID TABS Non-Preferred Brand QL
DILAUDID SOLN Medical Benefit-Non-Preferred
Specialty
DOANS REGULAR STRENGTH TABS Generic
DOLOPHINE HCL TABS Non-Preferred Brand
DOLOPHINE TABS Non-Preferred Brand
DUEXIS TABS Non-Preferred Brand QL ST
DURAGESIC PT72 Non-Preferred Brand QL
EC-NAPROSYN TBEC Non-Preferred Brand
ESGIC TABS Non-Preferred Brand
etodolac er TB24 Generic
etodolac CAPS Generic
etodolac TABS Generic
EXALGO T24A Non-Preferred Brand QL ST
FELDENE CAPS Non-Preferred Brand
fentanyl citrate oral transmucosal LPOP Preferred Specialty QL PA
fentanyl PT72 Generic QL
FENTORA TABS Preferred Specialty QL PA
FIORICET/CODEINE CAPS Non-Preferred Brand QL
FIORICET CAPS Non-Preferred Brand QL
FIORINAL/CODEINE #3 CAPS Non-Preferred Brand
FIORINAL CAPS Non-Preferred Brand
flurbiprofen TABS Generic
GRALISE STARTER MISC Non-Preferred Brand ST
GRALISE TABS Non-Preferred Brand QL ST
HALFPRIN TBEC Preferred Brand
HYCET SOLN Non-Preferred Brand
hydrocodone bitartrate/acetaminophen SOLN Generic
HYDROCODONE BITARTRATE/ACETAMINOPHEN
TABS Generic
hydrocodone bitartrate/acetaminophen TABS Excluded
hydrocodone/acetaminophen SOLN Generic
hydrocodone/acetaminophen TABS Generic
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 31 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
hydrocodone/ibuprofen TABS Generic
HYDROMORPHONE HCL SUPP Generic
hydromorphone hcl TABS Generic QL
hydromorphone hcl SOLN Medical Benefit
ibuprofen TABS Generic
ILARIS SOLR Medical Benefit-Non-Preferred
Specialty
PA
INDOCIN SUSP Preferred Brand
indomethacin er CPCR Generic
indomethacin CAPS Generic
KADIAN CP24 Non-Preferred Brand QL
KETOPROFEN ER CP24 Generic
ketoprofen CAPS Generic
ketorolac tromethamine TABS Generic QL
LAZANDA SOLN Non-Preferred Specialty
QL PA
LEVORPHANOL TARTRATE TABS Generic
LORCET 10/650 TABS Non-Preferred Brand
LORCET PLUS TABS Non-Preferred Brand
LORTAB TABS Non-Preferred Brand
mefenamic acid CAPS Generic
meloxicam TABS Generic
MEPERIDINE HCL SOLN Generic
meperidine hcl TABS Generic
meperidine hcl SOLN Medical Benefit
methadone hcl intensol CONC Generic
methadone hcl CONC Generic
methadone hcl TABS Generic
METHADONE HCL SOLN Preferred Brand
METHADOSE CONC Generic
MOBIC TABS Non-Preferred Brand
morphine sulfate er CP24 Generic QL
morphine sulfate er TBCR Generic
morphine sulfate SOLN Generic
MORPHINE SULFATE SUPP Generic
MORPHINE SULFATE TABS Generic
morphine sulfate SOLN Preferred Brand
MS CONTIN TBCR Non-Preferred Brand
nabumetone TABS Generic
NAPRELAN TB24 Non-Preferred Brand
NAPROSYN SUSP Non-Preferred Brand
NAPROSYN TABS Non-Preferred Brand
naproxen dr TBEC Generic
naproxen sodium TABS Generic
naproxen SUSP Generic
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 32 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
naproxen TABS Generic
NORCO TABS Non-Preferred Brand
NUCYNTA ER TB12 Non-Preferred Brand QL
NUCYNTA TABS Non-Preferred Brand
OFIRMEV SOLN Medical Benefit
ONSOLIS FILM Non-Preferred Brand PA
OPANA ER (CRUSH RESISTANT) T12A Non-Preferred Brand QL ST
OPANA TABS Non-Preferred Brand ST
orphenadrine/asa/caffeine TABS Generic
oxaprozin TABS Generic
OXECTA TABA Non-Preferred Brand PA
oxycodone hcl CAPS Generic
oxycodone hcl TABS Generic
oxycodone/acetaminophen TABS Generic
oxycodone/aspirin TABS Generic
OXYCONTIN T12A Preferred Brand QL
oxymorphone hydrochloride er TB12 Generic QL
oxymorphone hydrochloride TABS Generic
pentazocine/acetaminophen TABS Generic
pentazocine/naloxone hcl TABS Generic
PERCOCET TABS Non-Preferred Brand
PHRENILIN FORTE CAPS Preferred Brand
piroxicam CAPS Generic
PONSTEL CAPS Non-Preferred Brand
PRIALT SOLN Medical Benefit
roxicet TABS Generic
salsalate TABS Generic
SPRIX SOLN Non-Preferred Brand QL ST
SUBOXONE FILM Preferred Brand QL
SUBOXONE SUBL Non-Preferred Brand QL
sulindac TABS Generic
SYNALGOS-DC CAPS Non-Preferred Brand
tolmetin sodium CAPS Generic
TOLMETIN SODIUM TABS Generic
tramadol hcl er TB24 Generic QL
tramadol hcl TABS Generic
tramadol hydrochloride/acetaminophen TABS Generic
TREZIX CAPS Generic QL
TYLENOL/CODEINE #3 TABS Non-Preferred Brand
TYLENOL/CODEINE #4 TABS Non-Preferred Brand
ULTRACET TABS Non-Preferred Brand
ULTRAM ER TB24 Non-Preferred Brand QL
ULTRAM TABS Non-Preferred Brand
vicodin es TABS Excluded
vicodin hp TABS Excluded
vicodin TABS Excluded
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 33 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
VICOPROFEN TABS Non-Preferred Brand
VIMOVO TBEC Excluded
VOLTAREN-XR TB24 Non-Preferred Brand
zebutal CAPS Generic
ZIPSOR CAPS Non-Preferred Brand ST
ZORVOLEX CAPS Non-Preferred Brand QL ST
ZUBSOLV SUBL Non-Preferred Brand QL
Anorexigenic Agents and Respiratory and CNS Stimulants
ADDERALL XR CP24 Preferred Brand QL
ADDERALL TABS Non-Preferred Brand
amphetamine/dextroamphetamine CP24 Generic QL
amphetamine/dextroamphetamine TABS Generic
BELVIQ TABS Excluded
CONCERTA TBCR Non-Preferred Brand QL
DAYTRANA PTCH Non-Preferred Brand QL
DEXEDRINE CP24 Non-Preferred Brand
dexmethylphenidate hcl TABS Generic
dextroamphetamine sulfate er CP24 Generic
dextroamphetamine sulfate TABS Generic
FOCALIN XR CP24 Non-Preferred Brand QL
FOCALIN TABS Non-Preferred Brand
METADATE CD CPCR Non-Preferred Brand QL
metadate er TBCR Generic
methamphetamine hcl TABS Generic QL
METHYLIN CHEW Non-Preferred Brand
METHYLIN SOLN Non-Preferred Brand
methylphenidate hcl cd CPCR Generic QL
methylphenidate hcl er CP24 Generic QL
methylphenidate hcl er TBCR Generic QL
methylphenidate hcl sr TBCR Generic
methylphenidate hcl TABS Generic
methylphenidate hydrochloride SOLN Generic
modafinil TABS Generic QL PA
NUVIGIL TABS Non-Preferred Brand PA
phentermine hcl CAPS Excluded
phentermine hcl TABS Excluded
PROVIGIL TABS Non-Preferred Brand QL PA
QSYMIA CP24 Excluded
QUILLIVANT XR SUSR Non-Preferred Brand QL ST
RITALIN LA CP24 Non-Preferred Brand QL
RITALIN SR TBCR Non-Preferred Brand
RITALIN TABS Non-Preferred Brand
SUPRENZA TBDP Excluded
VYVANSE CAPS Preferred Brand QL
zenzedi TABS Generic QL
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 34 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
ZENZEDI TABS Non-Preferred Brand QL ST
Anticonvulsants
BANZEL TABS Preferred Brand PA
carbamazepine er TB12 Generic
carbamazepine CHEW Generic
carbamazepine SUSP Generic
carbamazepine TABS Generic
CARBATROL CP12 Preferred Brand
CELONTIN CAPS Preferred Brand
clonazepam odt TBDP Generic
clonazepam TABS Generic
DEPACON SOLN Medical Benefit
DEPAKENE CAPS Non-Preferred Brand
DEPAKENE SYRP Non-Preferred Brand
DEPAKOTE ER TB24 Non-Preferred Brand
DEPAKOTE SPRINKLES CPSP Non-Preferred Brand
DEPAKOTE TBEC Non-Preferred Brand
DILANTIN INFATABS CHEW Preferred Brand
DILANTIN CAPS Preferred Brand
DILANTIN CAPS Non-Preferred Brand
DILANTIN SUSP Non-Preferred Brand
divalproex sodium dr TBEC Generic
divalproex sodium er TB24 Generic
divalproex sodium CPSP Generic
epitol TABS Generic
EQUETRO CP12 Non-Preferred Brand
ethosuximide CAPS Generic
ethosuximide SOLN Generic
felbamate SUSP Generic
felbamate TABS Generic
FELBATOL SUSP Non-Preferred Brand
FELBATOL TABS Non-Preferred Brand
FYCOMPA TABS Non-Preferred Brand QL ST
gabapentin CAPS Generic
gabapentin SOLN Generic
gabapentin TABS Generic
GABITRIL TABS Preferred Brand
GABITRIL TABS Non-Preferred Brand
HORIZANT TB24 Non-Preferred Brand QL ST
KEPPRA XR TB24 Non-Preferred Brand
KEPPRA SOLN Non-Preferred Brand
KEPPRA TABS Non-Preferred Brand
KLONOPIN TABS Non-Preferred Brand
LAMICTAL CHEWABLE DISPERSIBLE CHEW Non-Preferred Brand
LAMICTAL ODT KIT Non-Preferred Brand ST
LAMICTAL ODT TBDP Non-Preferred Brand ST
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 35 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
LAMICTAL STARTER/NOT TAKING CARBAMAZEPINE
KIT Non-Preferred Brand
LAMICTAL STARTER/TAKING CARBAMAZEPINE/NOT TAKING VALPROATE
KIT Non-Preferred Brand
LAMICTAL STARTER/TAKING VALPROATE KIT Non-Preferred Brand
LAMICTAL XR KIT Non-Preferred Brand
LAMICTAL XR TB24 Non-Preferred Brand
LAMICTAL TABS Non-Preferred Brand
lamotrigine er TB24 Generic
lamotrigine CHEW Generic
lamotrigine TABS Generic
levetiracetam er TB24 Generic
levetiracetam SOLN Generic
levetiracetam TABS Generic
LYRICA CAPS Preferred Brand ST
MYSOLINE TABS Non-Preferred Brand
NEURONTIN CAPS Non-Preferred Brand
NEURONTIN SOLN Non-Preferred Brand
NEURONTIN TABS Non-Preferred Brand
ONFI SUSP Preferred Brand
ONFI TABS Preferred Brand QL ST
oxcarbazepine TABS Generic
OXTELLAR XR TB24 Non-Preferred Brand
PHENYTEK CAPS Preferred Brand
phenytoin sodium extended CAPS Generic
phenytoin SUSP Generic
POTIGA TABS Non-Preferred Brand QL ST
primidone TABS Generic
SABRIL TABS Non-Preferred Specialty
QL
STAVZOR CPDR Non-Preferred Brand ST
TEGRETOL SUSP Non-Preferred Brand
TEGRETOL TABS Non-Preferred Brand
TEGRETOL-XR TB12 Preferred Brand
TEGRETOL-XR TB12 Non-Preferred Brand
tiagabine hydrochloride TABS Generic
TOPAMAX SPRINKLE CPSP Non-Preferred Brand
TOPAMAX TABS Non-Preferred Brand
topiramate CPSP Generic
topiramate TABS Generic
TRILEPTAL SUSP Non-Preferred Brand
TRILEPTAL TABS Non-Preferred Brand
TROKENDI XR CP24 Non-Preferred Brand QL ST
valproic acid CAPS Generic
valproic acid SYRP Generic
VIMPAT SOLN Preferred Brand ST
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 36 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
VIMPAT TABS Preferred Brand ST
ZARONTIN CAPS Non-Preferred Brand
ZARONTIN SOLN Non-Preferred Brand
ZONEGRAN CAPS Non-Preferred Brand
zonisamide CAPS Generic
Antimanic Agents
lithium carbonate er TBCR Generic
lithium carbonate CAPS Generic
LITHIUM CITRATE SOLN Generic
LITHOBID TBCR Non-Preferred Brand
Antimigraine Agents
ALSUMA SOAJ Non-Preferred Brand
AMERGE TABS Non-Preferred Brand
AXERT TABS Non-Preferred Brand QL ST
CAFERGOT TABS Non-Preferred Brand
FROVA TABS Non-Preferred Brand QL ST
IMITREX STATDOSE REFILL SOCT Preferred Brand
IMITREX STATDOSE SYSTEM SOAJ Preferred Brand
IMITREX SOLN Preferred Brand
IMITREX SOLN Non-Preferred Brand
IMITREX TABS Non-Preferred Brand
isometheptene/dichloralphenazone/acetaminophen CAPS Generic
MAXALT TABS Non-Preferred Brand
MAXALT-MLT TBDP Non-Preferred Brand
MIGERGOT SUPP Generic
naratriptan hcl TABS Generic
RELPAX TABS Non-Preferred Brand QL ST
rizatriptan benzoate odt TBDP Generic
rizatriptan benzoate TABS Generic
sumatriptan succinate SOAJ Generic
sumatriptan succinate TABS Generic
SUMATRIPTAN SOLN Generic
SUMAVEL DOSEPRO SOTJ Non-Preferred Brand QL ST
TREXIMET TABS Non-Preferred Brand QL ST
zolmitriptan odt TBDP Generic
zolmitriptan TABS Generic
ZOMIG NASAL SPRAY SOLN Preferred Brand QL ST
ZOMIG ZMT TBDP Non-Preferred Brand
ZOMIG TABS Non-Preferred Brand
Antiparkinsonian Agents
amantadine hcl CAPS Generic
amantadine hcl SYRP Generic
AMANTADINE HCL TABS Generic
AZILECT TABS Non-Preferred Brand ST
benztropine mesylate TABS Generic
bromocriptine mesylate CAPS Generic
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 37 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
bromocriptine mesylate TABS Generic
cabergoline TABS Generic
carbidopa/levodopa er TBCR Generic
carbidopa/levodopa odt TBDP Generic
CARBIDOPA/LEVODOPA/ENTACAPONE TABS Generic
carbidopa/levodopa TABS Generic
COGENTIN SOLN Medical Benefit-Non-Preferred
Specialty
COMTAN TABS Non-Preferred Brand
ELDEPRYL CAPS Non-Preferred Brand
EMSAM PT24 Non-Preferred Brand ST
entacapone TABS Generic
MIRAPEX ER TB24 Non-Preferred Brand ST
MIRAPEX TABS Preferred Brand
MIRAPEX TABS Non-Preferred Brand
NEUPRO PT24 Non-Preferred Brand QL ST
PARCOPA TBDP Non-Preferred Brand
PARLODEL CAPS Non-Preferred Brand
PARLODEL TABS Non-Preferred Brand
pramipexole dihydrochloride TABS Generic
REQUIP XL TB24 Non-Preferred Brand
REQUIP TABS Non-Preferred Brand
ropinirole er TB24 Generic
ropinirole hcl TABS Generic
selegiline hcl TABS Preferred Brand
SINEMET CR TBCR Non-Preferred Brand
STALEVO 100 TABS Non-Preferred Brand
STALEVO 125 TABS Non-Preferred Brand
STALEVO 150 TABS Non-Preferred Brand
STALEVO 200 TABS Non-Preferred Brand
STALEVO 50 TABS Non-Preferred Brand
STALEVO 75 TABS Non-Preferred Brand
TASMAR TABS Preferred Brand
trihexyphenidyl hcl ELIX Generic
trihexyphenidyl hcl TABS Generic
Anxiolytics, Sedatives, and Hypnotics
alprazolam er TB24 Generic QL
ALPRAZOLAM INTENSOL CONC Generic QL
alprazolam odt TBDP Generic
alprazolam TABS Generic
AMBIEN CR TBCR Non-Preferred Brand QL
AMBIEN TABS Non-Preferred Brand QL
ATIVAN TABS Non-Preferred Brand
ATIVAN SOLN Medical Benefit-Non-Preferred
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 38 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
Specialty
buspirone hcl TABS Generic
chlordiazepoxide hcl CAPS Generic
clorazepate dipotassium TABS Generic
DIASTAT ACUDIAL GEL Preferred Brand
DIASTAT PEDIATRIC GEL Preferred Brand
DIAZEPAM INTENSOL CONC Preferred Brand
DIAZEPAM GEL Generic
diazepam TABS Generic
EDLUAR SUBL Non-Preferred Brand QL ST
estazolam TABS Generic
flurazepam hcl CAPS Generic QL
HALCION TABS Non-Preferred Brand
hydroxyzine hcl SYRP Generic
hydroxyzine hcl TABS Generic
hydroxyzine pamoate CAPS Generic
INTERMEZZO SUBL Non-Preferred Brand ST
LORAZEPAM INTENSOL CONC Generic
lorazepam TABS Generic
lorazepam SOLN Medical Benefit
LUNESTA TABS Preferred Brand QL ST
meprobamate TABS Generic
midazolam hcl SYRP Generic
NIRAVAM TBDP Non-Preferred Brand
oxazepam CAPS Generic
phenobarbital ELIX Generic
phenobarbital TABS Generic
PHENOBARBITAL TABS Preferred Brand
RESTORIL CAPS Non-Preferred Brand QL
ROZEREM TABS Non-Preferred Brand QL ST
SECONAL CAPS Non-Preferred Brand QL
SONATA CAPS Non-Preferred Brand QL
temazepam CAPS Generic QL
TRANXENE T TABS Non-Preferred Brand
triazolam TABS Generic QL
VALIUM TABS Non-Preferred Brand
VISTARIL CAPS Non-Preferred Brand
XANAX XR TB24 Non-Preferred Brand QL
XANAX TABS Non-Preferred Brand
zaleplon CAPS Generic QL
zolpidem tartrate er TBCR Generic QL
zolpidem tartrate TABS Generic QL
ZOLPIMIST SOLN Non-Preferred Brand QL ST
Central Nervous System Agents, Misc
acamprosate calcium dr TBEC Generic
CAMPRAL TBEC Non-Preferred Brand
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 39 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
INTUNIV TB24 Non-Preferred Brand QL ST
NAMENDA TITRATION PAK TABS Preferred Brand
NAMENDA XR TITRATION PACK CP24 Non-Preferred Brand
NAMENDA XR CP24 Non-Preferred Brand
NAMENDA SOLN Preferred Brand QL
NAMENDA TABS Preferred Brand QL
NUEDEXTA CAPS Non-Preferred Brand PA
RILUTEK TABS Non-Preferred Specialty
QL
riluzole TABS Generic
STRATTERA CAPS Preferred Brand QL
XENAZINE TABS Preferred Specialty QL
XYREM SOLN Preferred Specialty QL PA
Fibromyalgia Agents
SAVELLA TITRATION PACK MISC Preferred Brand QL ST
SAVELLA TABS Preferred Brand QL ST
General Anesthetics
ketamine hcl SOLN Excluded
Opiate Antagonists
naltrexone hcl TABS Generic
REVIA TABS Non-Preferred Brand
VIVITROL SUSR Medical Benefit-Preferred
Specialty
Psychotherapeutic Agents
ABILIFY DISCMELT TBDP Non-Preferred Brand QL ST
ABILIFY MAINTENA SUSR Medical Benefit-Non-Preferred
Specialty
ABILIFY SOLN Non-Preferred Brand ST
ABILIFY TABS Non-Preferred Brand QL ST
amitriptyline hcl TABS Generic
AMOXAPINE TABS Generic
APLENZIN TB24 Non-Preferred Brand ST
BRINTELLIX TABS Non-Preferred Brand ST
BRISDELLE CAPS Non-Preferred Brand QL ST
budeprion sr TB12 Generic QL
buproban TB12 Generic
bupropion hcl sr TB12 Generic QL
bupropion hcl xl TB24 Generic QL
bupropion hcl TABS Generic
CELEXA TABS Non-Preferred Brand
CHLORDIAZEPOXIDE/AMITRIPTYLINE TABS Generic
chlorpromazine hcl TABS Generic
citalopram hydrobromide SOLN Generic
citalopram hydrobromide TABS Generic QL
clomipramine hcl CAPS Generic
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 40 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
CLOZAPINE ODT TBDP Generic
clozapine TABS Generic
CLOZARIL TABS Non-Preferred Brand
compro SUPP Generic
CYMBALTA CPEP Non-Preferred Brand QL
desipramine hcl TABS Generic
DESVENLAFAXINE ER TB24 Generic
doxepin hcl CAPS Generic
doxepin hcl CONC Generic
duloxetine hcl CPEP Generic QL
EFFEXOR XR CP24 Non-Preferred Brand
escitalopram oxalate TABS Generic
FANAPT TITRATION PACK TABS Non-Preferred Brand QL ST
FANAPT TABS Non-Preferred Brand QL ST
FAZACLO TBDP Preferred Brand ST
FETZIMA TITRATION PACK C4PK Non-Preferred Brand QL ST
FETZIMA CP24 Non-Preferred Brand QL ST
fluoxetine dr CPDR Generic
fluoxetine hcl CAPS Generic
fluoxetine hcl SOLN Generic
fluoxetine hcl TABS Generic
FLUPHENAZINE DECANOATE SOLN Generic
fluphenazine hcl TABS Generic
fluvoxamine maleate er CP24 Generic QL
fluvoxamine maleate TABS Generic
FORFIVO XL TB24 Non-Preferred Brand ST
GEODON CAPS Non-Preferred Brand ST
GEODON SOLR Medical Benefit
HALDOL DECANOATE 100 SOLN Medical Benefit-Non-Preferred
Specialty
HALDOL DECANOATE 50 SOLN Medical Benefit-Non-Preferred
Specialty
HALDOL SOLN Medical Benefit-Non-Preferred
Specialty
haloperidol decanoate SOLN Medical Benefit
haloperidol lactate SOLN Generic
haloperidol TABS Generic
imipramine hcl TABS Generic
imipramine pamoate CAPS Generic
INVEGA SUSTENNA SUSP Medical Benefit
INVEGA SUSTENNA SUSP Medical Benefit-Preferred
Specialty
INVEGA TB24 Non-Preferred Brand ST
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 41 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
KHEDEZLA TB24 Non-Preferred Brand QL ST
LATUDA TABS Non-Preferred Brand QL ST
LEXAPRO SOLN Non-Preferred Brand
LEXAPRO TABS Non-Preferred Brand
loxapine succinate CAPS Generic
loxapine CAPS Generic
LOXITANE CAPS Non-Preferred Brand
LUVOX CR CP24 Non-Preferred Brand QL
MAPROTILINE HCL TABS Generic
MARPLAN TABS Preferred Brand QL
mirtazapine odt TBDP Generic
mirtazapine TABS Generic
mirtazapine TBDP Generic
NARDIL TABS Non-Preferred Brand
nefazodone hcl TABS Generic
NORPRAMIN TABS Non-Preferred Brand
nortriptyline hcl CAPS Generic
olanzapine odt TBDP Generic
olanzapine TABS Generic
olanzapine SOLR Medical Benefit
ORAP TABS Preferred Brand QL
PAMELOR CAPS Non-Preferred Brand
PARNATE TABS Non-Preferred Brand
paroxetine hcl er TB24 Generic QL
paroxetine hcl TABS Generic
PAXIL CR TB24 Non-Preferred Brand QL
PAXIL SUSP Non-Preferred Brand
PAXIL TABS Non-Preferred Brand
PERPHENAZINE/AMITRIPTYLINE TABS Generic
perphenazine TABS Generic
PEXEVA TABS Non-Preferred Brand QL ST
phenelzine sulfate TABS Generic
PRISTIQ TB24 Non-Preferred Brand QL ST
prochlorperazine edisylate SOLN Generic
prochlorperazine maleate TABS Generic
prochlorperazine SUPP Generic
protriptyline hcl TABS Generic
PROZAC WEEKLY CPDR Non-Preferred Brand
PROZAC CAPS Non-Preferred Brand
quetiapine fumarate TABS Generic
REMERON SOLTAB TBDP Non-Preferred Brand
REMERON TABS Non-Preferred Brand
RISPERDAL CONSTA SUSR Medical Benefit-Preferred
Specialty
RISPERDAL M-TAB TBDP Non-Preferred Brand
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 42 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
RISPERDAL SOLN Non-Preferred Brand
RISPERDAL TABS Non-Preferred Brand
risperidone m-tab TBDP Generic
risperidone SOLN Generic
risperidone TABS Generic
SAPHRIS SUBL Non-Preferred Brand QL ST
SARAFEM TABS Non-Preferred Brand
SEROQUEL XR TB24 Preferred Brand QL ST
SEROQUEL TABS Non-Preferred Brand
sertraline hcl CONC Generic
sertraline hcl TABS Generic QL
SILENOR TABS Non-Preferred Brand QL ST
SURMONTIL CAPS Non-Preferred Brand
SYMBYAX CAPS Non-Preferred Brand ST
thioridazine hcl TABS Generic
thiothixene CAPS Generic
TOFRANIL TABS Non-Preferred Brand
TOFRANIL-PM CAPS Non-Preferred Brand
tranylcypromine sulfate TABS Generic
trazodone hcl TABS Generic
trifluoperazine hcl TABS Generic
trimipramine maleate CAPS Generic
venlafaxine hcl er CP24 Generic
venlafaxine hcl er TB24 Generic
VENLAFAXINE HCL ER TB24 Preferred Brand
venlafaxine hcl TABS Generic
VERSACLOZ SUSP Non-Preferred Specialty
QL ST
VIIBRYD KIT Non-Preferred Brand ST
VIIBRYD TABS Non-Preferred Brand QL ST
VIVACTIL TABS Non-Preferred Brand
WELLBUTRIN SR TB12 Non-Preferred Brand QL
WELLBUTRIN XL TB24 Non-Preferred Brand QL
WELLBUTRIN TABS Non-Preferred Brand
ziprasidone hcl CAPS Generic
ZOLOFT CONC Non-Preferred Brand
ZOLOFT TABS Non-Preferred Brand QL
ZYBAN TB12 Non-Preferred Brand
ZYPREXA RELPREVV SUSR Medical Benefit-Preferred
Specialty
ZYPREXA ZYDIS TBDP Non-Preferred Brand
ZYPREXA TABS Non-Preferred Brand
ZYPREXA SOLR Medical Benefit
Contraceptives
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 43 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
ORTHO DIAPHRAGM ALL-FLEX/65MM DPRH Preferred Brand
ORTHO DIAPHRAGM ALL-FLEX/70MM DPRH Preferred Brand
ORTHO DIAPHRAGM ALL-FLEX/75MM DPRH Preferred Brand
ORTHO DIAPHRAGM ALL-FLEX/80MM DPRH Preferred Brand
ORTHO DIAPHRAGM COIL SPRING KIT 100 KIT Preferred Brand
ORTHO DIAPHRAGM COIL SPRING KIT 105 KIT Preferred Brand
ORTHO DIAPHRAGM COIL SPRING KIT 50 KIT Preferred Brand
ORTHO DIAPHRAGM FLAT SPRING KIT 55 KIT Preferred Brand
ORTHO DIAPHRAGM FLAT SPRING KIT 60 KIT Preferred Brand
ORTHO DIAPHRAGM FLAT SPRING KIT 65 KIT Preferred Brand
ORTHO DIAPHRAGM FLAT SPRING KIT 70 KIT Preferred Brand
ORTHO DIAPHRAGM FLAT SPRING KIT 75 KIT Preferred Brand
ORTHO DIAPHRAGM FLAT SPRING KIT 80 KIT Preferred Brand
ORTHO DIAPHRAGM FLAT SPRING KIT 85 KIT Preferred Brand
ORTHO DIAPHRAGM FLAT SPRING KIT 90 KIT Preferred Brand
ORTHO DIAPHRAGM FLAT SPRING KIT 95 KIT Preferred Brand
Devices
AEROCHAMBER PLUS FLOW-VU/LARGE MASK MISC Preferred Brand QL
AEROCHAMBER PLUS FLOW-VU/MASK MISC Preferred Brand QL
AEROCHAMBER PLUS FLOW-VU/SMALL MASK MISC Preferred Brand QL
AEROCHAMBER PLUS FLOW-VU MISC Preferred Brand QL
BD INSULIN SYRINGE MICROFINE IV/U-100/0.5ML/28G X 1/2"
MISC Preferred Brand
BD INSULIN SYRINGE MICROFINE/U-100/0.3ML/28G X 1/2"
MISC Preferred Brand
BD INSULIN SYRINGE ULTRAFINE/1ML/30G X 1/2"
MISC Preferred Brand
BREATHERITE COLLAPSIBLE ADULT SPACER W/MASK
MISC Preferred Brand QL
BREATHERITE COLLAPSIBLE CHILD SPACER W/MASK
MISC Preferred Brand QL
BREATHERITE COLLAPSIBLE INFANT SPACER W/MASK
MISC Preferred Brand QL
BREATHERITE COLLAPSIBLE SMALL CHILD SPACER W/MASK
MISC Preferred Brand QL
BREATHERITE COLLAPSIBLE SPACER W/ NEONATE MASK
MISC Preferred Brand QL
BREATHERITE RIGID SPACER W/MASK MISC Preferred Brand QL
BREATHERITE W/LARGE MASK MISC Preferred Brand QL
BREATHERITE W/MEDIUM MASK MISC Preferred Brand QL
BREATHERITE W/SMALL MASK MISC Preferred Brand QL
BREATHERITE MISC Preferred Brand QL
EASIVENT/MASK-LARGE MISC Preferred Brand QL
EASIVENT/MASK-MEDIUM MISC Preferred Brand QL
EASIVENT/MASK-SMALL MISC Preferred Brand QL
EASIVENT MISC Preferred Brand QL
LANCETS MISC Generic
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 44 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
OPTICHAMBER ADVANTAGE/LARGE MASK MISC Preferred Brand QL
OPTICHAMBER ADVANTAGE/MEDIUM FACE MASK
MISC Preferred Brand QL
OPTICHAMBER ADVANTAGE/SMALL FACE MASK
MISC Preferred Brand QL
OPTICHAMBER ADVANTAGE MISC Preferred Brand QL
OPTICHAMBER DIAMOND MISC Preferred Brand
OPTICHAMBER FACE MASK/LARGE MISC Preferred Brand QL
OPTICHAMBER FACE MASK/MEDIUM MISC Preferred Brand QL
OPTICHAMBER FACE MASK/SMALL MISC Preferred Brand QL
ULTICARE INSULIN SYRINGE ULTRAFINE U-100/1ML/31G X 5/16"
MISC Preferred Brand
VALVED HOLDING CHAMBER DEVI Generic
V-GO 20 KIT Preferred Brand
V-GO 30 KIT Preferred Brand
V-GO 40 KIT Preferred Brand
Diagnostic Agents
Diabetes Mellitus
ACCU-CHEK ACTIVE STRIPS STRP Generic
ACCU-CHEK AVIVA STRP Generic
ACCU-CHEK COMFORT CURVE TEST STRIPS STRP Generic
ACCU-CHEK COMPACT PLUS STRP Generic
ACCU-CHEK COMPACT TEST DRUM STRP Generic
ACCU-CHEK SMARTVIEW STRIPS STRP Generic
AGAMATRIX AMP NO CODE TEST STRIPS STRP Non-Preferred Brand
ASCENSIA AUTODISC TEST STRIPS DISK Non-Preferred Brand
BAYER BREEZE 2 TEST DISC DISK Non-Preferred Brand
BAYER CONTOUR BLOOD GLUCOSE TEST STRIPS
STRP Non-Preferred Brand
BAYER CONTOUR NEXT BLOOD GLUCOSE TEST
STRP Non-Preferred Brand
ECLIPSE TEST STRIPS STRP Non-Preferred Brand
FASTTAKE TEST STRIPS STRP Preferred Brand
FREESTYLE LITE TEST STRIPS STRP Non-Preferred Brand
FREESTYLE TEST STRIPS STRP Non-Preferred Brand
GLUCOCARD 01 SENSOR STRP Non-Preferred Brand
GLUCOCARD 01 TEST STRIPS STRP Non-Preferred Brand
GLUCOCARD EXPRESSION BLOOD GLUCOSE TEST STRIPS
STRP Non-Preferred Brand
GLUCOCARD VITAL TEST STRIPS STRP Non-Preferred Brand
GLUCOCARD X-SENSOR STRP Non-Preferred Brand
ONETOUCH BASIC/PROFILE TEST STRIPS STRP Generic
ONETOUCH ULTRA BLUE STRP Generic
ONETOUCH VERIO TEST STRIPS STRP Generic
PRECISION PCX PLUS TEST STRIPS STRP Non-Preferred Brand
PRECISION POINT OF CARE TEST STRIPS STRP Non-Preferred Brand
PRECISION QID TEST STRIPS STRP Non-Preferred Brand
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 45 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
PRECISION XTRA BLOOD GLUCOSE TEST STRIPS
STRP Non-Preferred Brand
SURESTEP TEST STRIPS STRP Non-Preferred Brand
TRUETRACK TEST STRP Non-Preferred Brand
UNISTRIP1 GENERIC STRP Non-Preferred Brand
Pituitary Function
ACTHREL SOLR Medical Benefit
Thyroid Function
THYROGEN SOLR Medical Benefit-Preferred
Specialty
Electrolytic, Caloric, and Water Balance
Alkalinizing Agents
cytra k crystals PACK Generic
cytra-2 SOLN Generic
CYTRA-3 SYRP Generic
CYTRA-K SOLN Generic
POTASSIUM CITRATE ER TBCR Generic
POTASSIUM CITRATE TBCR Generic
SODIUM CITRATE GRAN Generic
TRICITRATES SOLN Generic
UROCIT-K 10 TBCR Non-Preferred Brand
UROCIT-K 15 TBCR Non-Preferred Brand
UROCIT-K 5 TBCR Non-Preferred Brand
Ammonia Detoxicants
BUPHENYL TABS Preferred Specialty QL PA
BUPHENYL POWD Non-Preferred Specialty
PA
CARBAGLU TABS Preferred Specialty QL PA
enulose SOLN Generic
generlac SOLN Generic
KRISTALOSE PACK Preferred Brand
lactulose SOLN Generic
RAVICTI LIQD Preferred Specialty PA
sodium phenylbutyrate POWD Preferred Specialty PA
Diuretics
amiloride hcl TABS Generic
amiloride/hydrochlorothiazide TABS Generic
bumetanide TABS Generic
chlorothiazide TABS Generic
CHLORTHALIDONE TABS Generic
CHLORTHALIDONE TABS Preferred Brand
DEMADEX TABS Non-Preferred Brand
DIURIL SUSP Non-Preferred Brand
DYAZIDE CAPS Non-Preferred Brand
DYRENIUM CAPS Preferred Brand
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 46 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
EDECRIN TABS Preferred Brand
furosemide SOLN Generic
furosemide TABS Generic
hydrochlorothiazide CAPS Generic
hydrochlorothiazide TABS Generic
indapamide TABS Generic
LASIX TABS Non-Preferred Brand
MAXZIDE-25 TABS Non-Preferred Brand
METHYCLOTHIAZIDE TABS Generic
metolazone TABS Generic
MICROZIDE CAPS Non-Preferred Brand
SAMSCA TABS Preferred Specialty QL PA
torsemide TABS Generic
triamterene/hydrochlorothiazide CAPS Generic
triamterene/hydrochlorothiazide TABS Generic
ZAROXOLYN TABS Non-Preferred Brand
Ion-removing Agents
FOSRENOL CHEW Non-Preferred Specialty
QL
kionex SUSP Generic
RENAGEL TABS Preferred Brand QL
RENVELA TABS Preferred Specialty QL
sodium polystyrene sulfonate POWD Generic
sodium polystyrene sulfonate SUSP Generic
SPS SUSP Non-Preferred Brand
Irrigating Solutions
sodium chloride 0.9% SOLN Generic
Replacement Preparations
calcium acetate CAPS Generic
effervescent pot chloride TBEF Generic
GALZIN CAPS Preferred Brand
k-effervescent TBEF Generic
klor-con 10 TBCR Generic
KLOR-CON 25 PACK Non-Preferred Brand
klor-con 8 TBCR Non-Preferred Brand
klor-con m10 TBCR Generic
KLOR-CON M15 TBCR Generic
klor-con m20 TBCR Generic
K-TAB TBCR Non-Preferred Brand
PHOSLO CAPS Non-Preferred Brand
PHOSLYRA SOLN Non-Preferred Specialty
ST
potassium bicarbonate TBEF Generic
potassium chloride er CPCR Generic
potassium chloride er TBCR Generic
potassium chloride sr TBCR Generic
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 47 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
potassium chloride LIQD Generic
Uricosuric Agents
probenecid TABS Generic
Enzymes
ALDURAZYME SOLN Medical Benefit-Preferred
Specialty
CEREZYME SOLR Medical Benefit-Preferred
Specialty
ELELYSO SOLR Medical Benefit-Preferred
Specialty
ELITEK SOLR Medical Benefit-Preferred
Specialty
FABRAZYME SOLR Medical Benefit-Preferred
Specialty
PA
LUMIZYME SOLR Medical Benefit-Preferred
Specialty
NAGLAZYME SOLN Medical Benefit-Preferred
Specialty
SUCRAID SOLN Preferred Specialty QL
VPRIV SOLR Medical Benefit-Preferred
Specialty
XIAFLEX SOLR Medical Benefit-Preferred
Specialty
PA
Eye, Ear, Nose & Throat Preparations
Antiallergic Agents
alaway SOLN Generic
ALOCRIL SOLN Non-Preferred Brand ST
ALOMIDE SOLN Preferred Brand
ASTELIN SOLN Non-Preferred Brand
ASTEPRO SOLN Non-Preferred Brand
azelastine hcl SOLN Generic
BEPREVE SOLN Non-Preferred Brand ST
cromolyn sodium SOLN Generic
DYMISTA SUSP Non-Preferred Brand ST
ELESTAT SOLN Non-Preferred Brand
EMADINE SOLN Preferred Brand ST
epinastine hcl SOLN Generic
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 48 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
ketotifen fumarate SOLN Generic
LASTACAFT SOLN Non-Preferred Brand QL ST
OPTIVAR SOLN Non-Preferred Brand
PATADAY SOLN Preferred Brand ST
PATANASE SOLN Non-Preferred Brand ST
PATANOL SOLN Preferred Brand ST
ZADITOR SOLN Generic
Antiglaucoma Agents
acetazolamide er CP12 Generic
acetazolamide TABS Generic
ALPHAGAN P SOLN Non-Preferred Brand
AZOPT SUSP Preferred Brand
BETAGAN SOLN Non-Preferred Brand
betaxolol hcl SOLN Preferred Brand
BETIMOL SOLN Non-Preferred Brand
BETOPTIC-S SUSP Preferred Brand
brimonidine tartrate SOLN Generic
carteolol hcl SOLN Generic
COMBIGAN SOLN Preferred Brand
COSOPT SOLN Non-Preferred Brand
DIAMOX CP12 Non-Preferred Brand
dorzolamide hcl/timolol maleate SOLN Generic
dorzolamide hcl SOLN Generic
ISOPTO CARBACHOL SOLN Preferred Brand
ISOPTO CARPINE SOLN Non-Preferred Brand
ISTALOL SOLN Non-Preferred Brand ST
latanoprost SOLN Generic
levobunolol hcl SOLN Generic
LUMIGAN SOLN Preferred Brand
metipranolol SOLN Generic
OPTIPRANOLOL SOLN Non-Preferred Brand
PHOSPHOLINE IODIDE SOLR Preferred Brand
pilocarpine hcl SOLN Generic
PILOPINE HS GEL Preferred Brand
SIMBRINZA SUSP Preferred Brand
timolol maleate ophthalmic gel forming SOLG Generic
timolol maleate SOLN Generic
TIMOPTIC SOLN Non-Preferred Brand
TIMOPTIC-XE SOLG Non-Preferred Brand
TRAVATAN Z SOLN Non-Preferred Brand
TRAVOPROST SOLN Generic
TRUSOPT SOLN Non-Preferred Brand
XALATAN SOLN Non-Preferred Brand
ZIOPTAN SOLN Non-Preferred Brand
Anti-infectives
AZASITE SOLN Non-Preferred Brand ST
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 49 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
bacitracin/polymyxin b OINT Generic
BESIVANCE SUSP Non-Preferred Brand
BLEPH-10 SOLN Non-Preferred Brand
CETRAXAL SOLN Non-Preferred Brand
chlorhexidine gluconate SOLN Generic
CILOXAN OINT Preferred Brand
CILOXAN SOLN Non-Preferred Brand
ciprofloxacin hcl SOLN Generic
erythromycin OINT Generic
gatifloxacin SOLN Generic
gentak OINT Generic
gentamicin sulfate SOLN Generic
levofloxacin SOLN Generic
MOXEZA SOLN Preferred Brand
neomycin/bacitracin/polymyxin OINT Generic
neomycin/polymyxin/gramicidin SOLN Generic
NEOSPORIN SOLN Non-Preferred Brand
OCUFLOX SOLN Non-Preferred Brand
ofloxacin SOLN Generic
PERIDEX SOLN Non-Preferred Brand
polymyxin b sulfate/trimethoprim sulfate SOLN Generic
POLYTRIM SOLN Non-Preferred Brand
sodium sulfacetamide SOLN Generic
SULFACETAMIDE SODIUM OINT Generic
tobramycin sulfate SOLN Generic
TOBREX OINT Preferred Brand
TOBREX SOLN Non-Preferred Brand
trifluridine SOLN Generic
VIGAMOX SOLN Preferred Brand
VIROPTIC SOLN Non-Preferred Brand
ZIRGAN GEL Non-Preferred Brand
ZYMAXID SOLN Non-Preferred Brand ST
Anti-inflammatory Agents
ACULAR LS SOLN Non-Preferred Brand
ACULAR SOLN Non-Preferred Brand
ACUVAIL SOLN Non-Preferred Brand
ALREX SUSP Non-Preferred Brand ST
BECONASE AQ SUSP Non-Preferred Brand ST
BLEPHAMIDE S.O.P. OINT Preferred Brand
BLEPHAMIDE SUSP Preferred Brand
BROMFENAC SOLN Generic
CIPRO HC SUSP Preferred Brand
CIPRODEX SUSP Preferred Brand
COLY-MYCIN S SUSP Non-Preferred Brand
CORTANE-B-OTIC SOLN Non-Preferred Brand
CORTISPORIN SOLN Non-Preferred Brand
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 50 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
CORTISPORIN-TC SUSP Non-Preferred Brand
diclofenac sodium SOLN Generic
DUREZOL EMUL Non-Preferred Brand ST
FLAREX SUSP Preferred Brand
FLONASE SUSP Non-Preferred Brand
FLUNISOLIDE SOLN Generic
fluorometholone SUSP Generic
flurbiprofen sodium SOLN Generic
fluticasone propionate SUSP Generic
FML FORTE SUSP Preferred Brand
FML LIQUIFILM SUSP Non-Preferred Brand
FML OINT Preferred Brand
ILEVRO SUSP Non-Preferred Brand QL ST
ketorolac tromethamine SOLN Generic
LOTEMAX SUSP Preferred Brand
LOTEMAX GEL Non-Preferred Brand
LOTEMAX OINT Non-Preferred Brand
MAXITROL OINT Non-Preferred Brand
MAXITROL SUSP Non-Preferred Brand
NASACORT AQ AERS Non-Preferred Brand
NASONEX SUSP Non-Preferred Brand ST
neomycin/polymyxin/bacitracin/hydrocortisone OINT Generic
neomycin/polymyxin/dexamethasone OINT Generic
neomycin/polymyxin/dexamethasone SUSP Generic
neomycin/polymyxin/hydrocortisone SOLN Generic
NEVANAC SUSP Non-Preferred Brand ST
OMNARIS SUSP Preferred Brand ST
oto-end 10 SOLN Generic
OZURDEX IMPL Medical Benefit-Preferred
Specialty
PRED FORTE SUSP Non-Preferred Brand
PRED MILD SUSP Preferred Brand
PRED-G SUSP Preferred Brand
prednisolone acetate SUSP Generic
PREDNISOLONE SODIUM PHOSPHATE SOLN Preferred Brand
PROLENSA SOLN Non-Preferred Brand ST
QNASL AERS Non-Preferred Brand ST
RESTASIS EMUL Preferred Brand QL
RETISERT IMPL Medical Benefit-Preferred
Specialty
PA
RHINOCORT AQUA SUSP Non-Preferred Brand ST
sulfacetamide sodium/prednisolone sodium phosphate
SOLN Generic
TOBRADEX OINT Preferred Brand
TOBRADEX SUSP Non-Preferred Brand
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 51 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
tobramycin/dexamethasone SUSP Generic
triamcinolone acetonide INHA Generic
VERAMYST SUSP Non-Preferred Brand ST
VEXOL SUSP Preferred Brand
ZETONNA AERS Non-Preferred Brand ST
ZYLET SUSP Non-Preferred Brand ST
EENT Drugs, Miscellaneous
ACETIC ACID/ALUMINUM ACETATE SOLN Generic
acetic acid SOLN Generic
APHTHASOL PSTE Preferred Brand QL
apraclonidine SOLN Generic
CYSTARAN SOLN Preferred Specialty QL
EYLEA SOLN Medical Benefit-Non-Preferred
Specialty
PA
HEALON SOLN Medical Benefit
IOPIDINE SOLN Non-Preferred Brand
JETREA SOLN Medical Benefit-Preferred
Specialty
LACRISERT INST Non-Preferred Brand
LUCENTIS SOLN Medical Benefit-Non-Preferred
Specialty
PA
MACUGEN SOLN Medical Benefit-Preferred
Specialty
PA
PROVISC SOLN Medical Benefit
VISUDYNE SOLR Medical Benefit-Preferred
Specialty
Local Anesthetics
antipyrine/benzocaine SOLN Generic
lidocaine viscous SOLN Generic
TREAGAN OTIC SOLN Preferred Brand
Mydriatics
atropine sulfate SOLN Generic
CYCLOGYL SOLN Preferred Brand
CYCLOGYL SOLN Non-Preferred Brand
cyclopentolate hcl SOLN Generic
homatropaire SOLN Generic
ISOPTO ATROPINE SOLN Non-Preferred Brand
ISOPTO HOMATROPINE SOLN Preferred Brand
ISOPTO HOMATROPINE SOLN Non-Preferred Brand
Vasoconstrictors
NAPHAZOLINE HCL SOLN Generic
phenylephrine hcl SOLN Generic
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 52 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
Gastrointestinal Drugs
Antidiarrhea Agents
DIPHENOXYLATE/ATROPINE LIQD Generic
diphenoxylate/atropine TABS Generic
FULYZAQ TBEC Non-Preferred Brand ST
LOMOTIL TABS Non-Preferred Brand
loperamide hcl CAPS Generic
OPIUM TINCTURE (PAREGORIC) TINC Generic
opium tincture TINC Generic
Antiemetics
ALOXI SOLN Medical Benefit
ANTIVERT TABS Non-Preferred Brand
ANZEMET TABS Non-Preferred Brand QL
ANZEMET SOLN Medical Benefit
CESAMET CAPS Non-Preferred Brand
DICLEGIS TBEC Excluded
dronabinol CAPS Generic QL
dronabinol CAPS Preferred Specialty QL
EMEND CAPS Preferred Brand QL
granisetron hcl TABS Generic QL
granisetron hcl SOLN Medical Benefit
MARINOL CAPS Non-Preferred Specialty
QL
meclizine hcl TABS Generic
ondansetron hcl SOLN Generic
ondansetron hcl TABS Generic
ondansetron hcl SOLN Medical Benefit
ondansetron odt TBDP Generic
SANCUSO PTCH Non-Preferred Brand QL ST
TIGAN CAPS Non-Preferred Brand
TRANSDERM-SCOP PT72 Preferred Brand
trimethobenzamide hcl CAPS Generic
trimethobenzamide hcl SOLN Generic
ZOFRAN ODT TBDP Non-Preferred Brand
ZOFRAN SOLN Non-Preferred Brand
ZOFRAN TABS Non-Preferred Brand
ZOFRAN SOLN Medical Benefit-Non-Preferred
Specialty
ZUPLENZ FILM Non-Preferred Brand QL ST
Anti-inflammatory Agents
APRISO CP24 Non-Preferred Brand QL
ASACOL HD TBEC Preferred Brand QL
balsalazide disodium CAPS Generic
CANASA SUPP Preferred Brand
COLAZAL CAPS Non-Preferred Brand
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 53 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
DELZICOL CPDR Preferred Brand
DIPENTUM CAPS Non-Preferred Brand
GIAZO TABS Non-Preferred Specialty
QL
LIALDA TBEC Non-Preferred Brand QL
LOTRONEX TABS Preferred Brand
mesalamine ENEM Generic
PENTASA CPCR Non-Preferred Brand QL
ROWASA KIT Non-Preferred Brand
SFROWASA ENEM Non-Preferred Brand QL
Antiulcer Agents and Acid Suppressants
ACIPHEX SPRINKLE CPSP Excluded
ACIPHEX TBEC Excluded
AXID CAPS Non-Preferred Brand
AXID SOLN Non-Preferred Brand
CARAFATE SUSP Non-Preferred Brand
CARAFATE TABS Non-Preferred Brand
cimetidine hcl SOLN Generic
cimetidine TABS Generic
CYTOTEC TABS Non-Preferred Brand
DEXILANT CPDR Excluded
ESOMEPRAZOLE STRONTIUM CPDR Excluded
famotidine TABS Generic
famotidine SOLN Medical Benefit
FIRST-LANSOPRAZOLE SUSP Generic
FIRST-OMEPRAZOLE SUSP Generic
HELIDAC MISC Non-Preferred Brand
lansoprazole/amoxicillin/clarithromycin MISC Generic
lansoprazole CPDR Generic
misoprostol TABS Generic
NEXIUM CPDR Excluded
nizatidine CAPS Generic
nizatidine SOLN Generic
omeprazole/sodium bicarbonate CAPS Generic
omeprazole CPDR Generic
OMEPRAZOLE TBEC Generic
pantoprazole sodium TBEC Generic
PEPCID SUSR Preferred Brand
PEPCID TABS Non-Preferred Brand
PREVACID 24HR CPDR Generic
PREVACID SOLUTAB TBDP Excluded
PREVACID CPDR Excluded
PREVPAC MISC Non-Preferred Brand
PRILOSEC OTC TBEC Generic
PRILOSEC CPDR Excluded
PROTONIX PACK Excluded
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 54 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
PROTONIX TBEC Excluded
PYLERA CAPS Non-Preferred Brand
rabeprazole sodium TBEC Generic
ranitidine 75 TABS Generic
ranitidine hcl CAPS Generic
ranitidine hcl SYRP Generic
ranitidine hcl TABS Generic
SUCRALFATE SUSP Generic
sucralfate TABS Generic
ZANTAC SYRP Non-Preferred Brand
ZANTAC TABS Non-Preferred Brand
ZANTAC SOLN Medical Benefit-Non-Preferred
Specialty
ZEGERID OTC CAPS Generic
ZEGERID CAPS Excluded
ZEGERID PACK Excluded
Cathartics and Laxatives
COLYTE-FLAVOR PACKS SOLR Non-Preferred Brand
enemeez mini ENEM Non-Preferred Brand QL
enemeez plus ENEM Non-Preferred Brand QL
gavilyte-c SOLR Generic
gavilyte-g SOLR Generic
gavilyte-n/flavor pack SOLR Generic
GOLYTELY SOLR Preferred Brand
GOLYTELY SOLR Non-Preferred Brand
HALFLYTELY BOWEL PREP/FLAVOR PACKS KIT Preferred Brand
MIRALAX POWD Non-Preferred Brand
MOVIPREP SOLR Non-Preferred Brand
NULYTELY/FLAVOR PACKS SOLR Non-Preferred Brand
OSMOPREP TABS Non-Preferred Brand
peg 3350/electrolytes SOLR Generic
peg 3350 POWD Generic
peg-3350/electrolytes SOLR Generic
polyethylene glycol 3350 POWD Generic
PREPOPIK PACK Non-Preferred Brand
smooth lax POWD Generic
SUCLEAR KIT Non-Preferred Brand
SUPREP BOWEL PREP SOLN Non-Preferred Brand
trilyte SOLR Generic
Cholelitholytic Agents
ACTIGALL CAPS Non-Preferred Brand
URSO 250 TABS Non-Preferred Brand
URSO FORTE TABS Non-Preferred Brand
ursodiol CAPS Generic
ursodiol TABS Generic
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 55 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
Digestants
CREON CPEP Preferred Brand
PANCREAZE CPEP Preferred Specialty
PERTZYE CPEP Non-Preferred Specialty
QL
ULTRESA CPEP Preferred Specialty
VIOKACE TABS Non-Preferred Specialty
QL
ZENPEP CPEP Preferred Brand
GI Drugs, Miscellaneous
AMITIZA CAPS Non-Preferred Brand QL
GATTEX KIT Non-Preferred Specialty
PA
LINZESS CAPS Non-Preferred Brand
RELISTOR KIT Non-Preferred Brand PA
RELISTOR SOLN Non-Preferred Brand PA
XENICAL CAPS Excluded
Prokinetic Agents
metoclopramide hcl SOLN Generic
metoclopramide hcl TABS Generic
METOZOLV ODT TBDP Non-Preferred Brand ST
REGLAN TABS Non-Preferred Brand
Gold Compounds
RIDAURA CAPS Preferred Brand
Heavy Metal Antagonists
CHEMET CAPS Preferred Brand
CUPRIMINE CAPS Preferred Brand
deferoxamine mesylate SOLR Medical Benefit
DESFERAL SOLR Medical Benefit
EXJADE TBSO Preferred Specialty QL
FERRIPROX TABS Preferred Specialty QL
Hormones and Synthetic Substitutes
Adrenals
ALVESCO AERS Preferred Brand QL
ASMANEX 120 METERED DOSES AEPB Non-Preferred Brand
ASMANEX 14 METERED DOSES AEPB Non-Preferred Brand
ASMANEX 30 METERED DOSES AEPB Non-Preferred Brand
ASMANEX 60 METERED DOSES AEPB Non-Preferred Brand
BREO ELLIPTA AEPB Non-Preferred Brand ST
budesonide SUSP Generic
CORTEF TABS Non-Preferred Brand
CORTISONE ACETATE TABS Generic
DEPO-MEDROL SUSP Medical Benefit
DEXAMETHASONE INTENSOL CONC Preferred Brand
dexamethasone ELIX Generic
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 56 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
dexamethasone TABS Generic
DEXAMETHASONE SOLN Preferred Brand
DEXAMETHASONE TABS Preferred Brand
DULERA AERO Generic
ENTOCORT EC CP24 Preferred Brand
FLOVENT DISKUS AEPB Non-Preferred Brand
FLOVENT HFA AERO Non-Preferred Brand
fludrocortisone acetate TABS Generic
hydrocortisone TABS Generic
MEDROL TABS Preferred Brand
MEDROL TABS Non-Preferred Brand
methylprednisolone dose pack TABS Generic
methylprednisolone TABS Generic
ORAPRED ODT TBDP Preferred Brand QL
ORAPRED SOLN Non-Preferred Brand
prednisolone sodium phosphate SOLN Generic
prednisolone SOLN Generic
PREDNISONE INTENSOL CONC Preferred Brand
prednisone TABS Generic
PREDNISONE SOLN Preferred Brand
PREDNISONE TABS Preferred Brand
PRELONE SYRP Non-Preferred Brand
PULMICORT FLEXHALER AEPB Generic
PULMICORT SUSP Preferred Brand QL
PULMICORT SUSP Non-Preferred Brand
QVAR AERS Generic
RAYOS TBEC Non-Preferred Brand ST
SYMBICORT AERO Generic
UCERIS TB24 Non-Preferred Specialty
QL ST
Androgens
ANDRODERM PT24 Preferred Brand PA
ANDROGEL PUMP GEL Preferred Brand PA
ANDROGEL GEL Preferred Brand PA
ANDROID CAPS Non-Preferred Brand
AXIRON SOLN Preferred Brand PA
danazol CAPS Generic
DEPO-TESTOSTERONE OIL Non-Preferred Brand
FIRST-TESTOSTERONE MC COMPOUNDING KIT
CREA Non-Preferred Brand PA
FIRST-TESTOSTERONE OINT Non-Preferred Brand PA
FORTESTA GEL Non-Preferred Brand QL PA
METHITEST TABS Preferred Brand
STRIANT MISC Non-Preferred Brand PA
TESTIM GEL Non-Preferred Brand PA
TESTOPEL PLLT Medical Benefit PA
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 57 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
testosterone cypionate OIL Generic
testosterone enanthate OIL Generic
TESTRED CAPS Non-Preferred Brand PA
Antidiabetic Agents
acarbose TABS Generic
ACTOPLUS MET XR TB24 Preferred Brand
ACTOPLUS MET TABS Non-Preferred Brand
ACTOS TABS Non-Preferred Brand
AMARYL TABS Non-Preferred Brand
APIDRA SOLOSTAR SOPN Non-Preferred Brand ST
APIDRA SOLN Non-Preferred Brand ST
AVANDAMET TABS Preferred Brand
AVANDARYL TABS Preferred Brand
AVANDIA TABS Preferred Brand
BYDUREON SUSR Preferred Brand
BYETTA SOPN Preferred Brand
CHLORPROPAMIDE TABS Generic
CYCLOSET TABS Non-Preferred Brand
DIABETA TABS Non-Preferred Brand
DUETACT TABS Non-Preferred Brand
FARXIGA TABS Non-Preferred Brand QL
FORTAMET TB24 Non-Preferred Brand ST
glimepiride TABS Generic
glipizide er TB24 Generic
glipizide xl TB24 Generic
glipizide/metformin hcl TABS Generic
glipizide TABS Generic
GLUCOPHAGE XR TB24 Non-Preferred Brand
GLUCOPHAGE TABS Non-Preferred Brand
GLUCOTROL XL TB24 Non-Preferred Brand
GLUCOTROL TABS Non-Preferred Brand
GLUCOVANCE TABS Non-Preferred Brand
GLUMETZA TB24 Non-Preferred Brand ST
glyburide micronized TABS Generic
glyburide/metformin hcl TABS Generic
glyburide TABS Generic
GLYNASE TABS Non-Preferred Brand
GLYSET TABS Non-Preferred Brand
HUMALOG KWIKPEN SOPN Generic
HUMALOG MIX 50/50 KWIKPEN SUPN Generic
HUMALOG MIX 50/50 SUSP Generic
HUMALOG MIX 75/25 KWIKPEN SUPN Generic
HUMALOG MIX 75/25 SUSP Generic
HUMALOG SOLN Generic
HUMULIN 70/30 PEN SUPN Generic
HUMULIN 70/30 SUSP Generic
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 58 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
HUMULIN N U-100 PEN SUPN Generic
HUMULIN N SUSP Generic
HUMULIN R U-500 (CONCENTRATED) SOLN Generic
HUMULIN R SOLN Generic
INVOKANA TABS Preferred Brand QL
JANUMET XR TB24 Preferred Brand
JANUMET TABS Preferred Brand
JANUVIA TABS Preferred Brand QL
JENTADUETO TABS Non-Preferred Brand
JUVISYNC TABS Preferred Brand QL
KAZANO TABS Non-Preferred Brand QL
KOMBIGLYZE XR TB24 Preferred Brand QL
KORLYM TABS Non-Preferred Specialty
QL PA
LANTUS SOLOSTAR SOPN Generic
LANTUS SOLN Generic
LEVEMIR FLEXPEN SOPN Non-Preferred Brand ST
LEVEMIR SOLN Non-Preferred Brand ST
METAGLIP TABS Non-Preferred Brand
metformin hcl er TB24 Generic
metformin hcl TABS Generic
nateglinide TABS Generic
NESINA TABS Non-Preferred Brand
NOVOLIN 70/30 SUSP Non-Preferred Brand ST
NOVOLIN N SUSP Non-Preferred Brand ST
NOVOLIN R SOLN Non-Preferred Brand ST
NOVOLOG FLEXPEN SOPN Non-Preferred Brand ST
NOVOLOG MIX 70/30 PREFILLED FLEXPEN SUPN Non-Preferred Brand ST
NOVOLOG MIX 70/30 SUSP Non-Preferred Brand ST
NOVOLOG PENFILL SOCT Non-Preferred Brand ST
NOVOLOG SOLN Non-Preferred Brand ST
ONGLYZA TABS Preferred Brand QL
OSENI TABS Non-Preferred Brand QL
pioglitazone hcl/metformin hcl TABS Generic
pioglitazone hcl TABS Generic
pioglitazone hcl-glimepiride TABS Generic
PRANDIMET TABS Non-Preferred Brand
PRANDIN TABS Non-Preferred Brand
PRECOSE TABS Non-Preferred Brand
repaglinide TABS Generic
STARLIX TABS Non-Preferred Brand
SYMLINPEN 120 SOPN Preferred Brand
SYMLINPEN 60 SOPN Preferred Brand
tolazamide TABS Preferred Brand
TOLBUTAMIDE TABS Preferred Brand
TRADJENTA TABS Non-Preferred Brand QL
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 59 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
VICTOZA SOPN Preferred Brand
Antihypoglycemic Agents
GLUCAGEN HYPOKIT SOLR Preferred Brand
GLUCAGON EMERGENCY KIT KIT Preferred Brand
Contraceptives
altavera TABS Non-Preferred Brand
amethia lo TABS Generic
amethia TABS Generic
apri TABS Generic
aviane TABS Generic
azurette TABS Generic
balziva TABS Generic
BEYAZ TABS Non-Preferred Brand
camila TABS Generic
camrese lo TABS Generic
camrese TABS Generic
cryselle-28 TABS Generic
cyclafem 1/35 TABS Generic
cyclafem 7/7/7 TABS Generic
DESOGEN TABS Non-Preferred Brand
ELLA TABS Non-Preferred Brand
emoquette TABS Generic
enpresse-28 TABS Generic
errin TABS Generic
ESTROSTEP FE TABS Non-Preferred Brand
FEMCON FE CHEW Non-Preferred Brand
GENERESS FE CHEW Non-Preferred Brand
gianvi TABS Generic
gildess fe 1.5/30 TABS Generic
gildess fe 1/20 TABS Generic
introvale TABS Generic
jolessa TABS Generic
jolivette TABS Generic
junel 1.5/30 TABS Generic
junel 1/20 TABS Generic
junel fe 1.5/30 TABS Generic
junel fe 1/20 TABS Generic
kariva TABS Generic
levonorgestrel and ethinyl estradiol TABS Generic
levonorgestrel TABS Generic
levora 0.15/30-28 TABS Generic
LO LOESTRIN FE TABS Non-Preferred Brand
LO MINASTRIN FE THPK Non-Preferred Brand
LOESTRIN 24 FE TABS Non-Preferred Brand
LOESTRIN FE 1.5/30 TABS Non-Preferred Brand
LOESTRIN FE 1/20 TABS Non-Preferred Brand
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 60 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
LOMEDIA 24 FE TABS Generic
LOSEASONIQUE TABS Non-Preferred Brand
low-ogestrel TABS Generic
lutera TABS Generic
microgestin 1.5/30 TABS Generic
microgestin 1/20 TABS Generic
microgestin fe 1.5/30 TABS Generic
microgestin fe TABS Generic
MINASTRIN 24 FE CHEW Non-Preferred Brand
MIRCETTE TABS Non-Preferred Brand
mononessa TABS Generic
NATAZIA TABS Non-Preferred Brand
necon 0.5/35-28 TABS Generic
necon 1/35 TABS Generic
NECON 1/50-28 TABS Generic
NECON 10/11-28 TABS Generic
necon 7/7/7 TABS Generic
NEXPLANON IMPL Medical Benefit
next choice one dose TABS Generic
nora-be TABS Generic
NORINYL 1+50 TABS Non-Preferred Brand
NOR-QD TABS Non-Preferred Brand
nortrel 1/35 TABS Generic
nortrel 7/7/7 TABS Generic
NUVARING RING Non-Preferred Brand
ocella TABS Generic
OGESTREL TABS Generic
ORTHO EVRA PTWK Non-Preferred Brand
ORTHO MICRONOR TABS Non-Preferred Brand
ORTHO TRI-CYCLEN LO TABS Preferred Brand
ORTHO TRI-CYCLEN TABS Non-Preferred Brand
ORTHO-CEPT TABS Non-Preferred Brand
ORTHO-CYCLEN TABS Non-Preferred Brand
ORTHO-NOVUM 1/35 TABS Non-Preferred Brand
ORTHO-NOVUM 7/7/7 TABS Non-Preferred Brand
OVCON-35 TABS Non-Preferred Brand
PLAN B ONE-STEP TABS Non-Preferred Brand
PLAN B TABS Non-Preferred Brand
portia-28 TABS Generic
previfem TABS Generic
QUARTETTE TABS Non-Preferred Brand
quasense TABS Generic
reclipsen TABS Generic
SAFYRAL TABS Non-Preferred Brand
SEASONIQUE TABS Non-Preferred Brand
SKYLA IUD Medical Benefit
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 61 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
solia TABS Generic
sprintec 28 TABS Generic
sronyx TABS Generic
tri-estarylla TABS Generic
tri-legest fe TABS Generic
trinessa TABS Generic
TRI-NORINYL 28 TABS Non-Preferred Brand
tri-previfem TABS Generic
tri-sprintec TABS Generic
trivora-28 TABS Generic
velivet TABS Generic
YASMIN 28 TABS Non-Preferred Brand
YAZ TABS Non-Preferred Brand
zenchent TABS Generic
zovia 1/35e TABS Generic
ZOVIA 1/50E TABS Generic
Estrogens and Antiestrogens
ACTIVELLA TABS Non-Preferred Brand
ALORA PTTW Preferred Brand
ANGELIQ TABS Non-Preferred Brand ST
CENESTIN TABS Preferred Brand
CLIMARA PRO PTWK Preferred Brand
CLIMARA PTWK Non-Preferred Brand
CLOMID TABS Non-Preferred Brand
clomiphene citrate TABS Generic
COMBIPATCH PTTW Preferred Brand
DELESTROGEN OIL Non-Preferred Brand
DEPO-ESTRADIOL OIL Preferred Brand
DIVIGEL GEL Preferred Brand QL
DUAVEE TABS Non-Preferred Brand QL
ELESTRIN GEL Non-Preferred Brand
ENJUVIA TABS Non-Preferred Brand QL
esterified estrogens/methyltestosterone ds TABS Generic
esterified estrogens/methyltestosterone hs TABS Generic
ESTRACE CREA Preferred Brand
ESTRACE TABS Non-Preferred Brand
estradiol valerate OIL Generic
estradiol/norethindrone acetate TABS Generic
estradiol PTWK Generic
estradiol TABS Generic
ESTRASORB EMUL Preferred Brand
ESTRING RING Preferred Brand
ESTROGEL GEL Preferred Brand QL
estropipate TABS Generic
EVAMIST SOLN Preferred Brand
EVISTA TABS Non-Preferred Brand
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 62 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
FEMHRT LOW DOSE TABS Preferred Brand
FEMRING RING Preferred Brand
JINTELI TABS Generic
MENEST TABS Preferred Brand
MENOSTAR PTWK Non-Preferred Brand QL
MINIVELLE PTTW Non-Preferred Brand
ortho-est TABS Non-Preferred Brand
OSPHENA TABS Preferred Brand PA
PREFEST TABS Non-Preferred Brand
PREMARIN CREA Preferred Brand
PREMARIN TABS Preferred Brand QL
PREMPHASE TABS Preferred Brand
PREMPRO TABS Preferred Brand
raloxifene hydrochloride TABS Generic
serophene TABS Generic
VAGIFEM TABS Preferred Brand
VIVELLE-DOT PTTW Generic
Gonadotropins
BRAVELLE SOLR Preferred Brand
FOLLISTIM AQ SOLN Non-Preferred Brand ST
GONAL-F RFF PEN SOLN Preferred Brand
GONAL-F RFF SOLR Preferred Brand
GONAL-F SOLR Preferred Brand
MENOPUR SOLR Preferred Brand
novarel SOLR Preferred Brand
OVIDREL INJ Preferred Brand
pregnyl w/diluent benzyl alcohol/nacl SOLR Generic
REPRONEX SOLR Preferred Brand
SYNAREL SOLN Preferred Brand
Parathyroid
calcitonin-salmon SOLN Generic
FORTEO SOLN Preferred Specialty QL PA
FORTICAL SOLN Generic
MIACALCIN SOLN Non-Preferred Brand
Pituitary
ACTHAR HP GEL Preferred Specialty QL PA
DDAVP SOLN Non-Preferred Brand
DDAVP TABS Non-Preferred Brand
DDAVP SOLN Medical Benefit
desmopressin acetate SOLN Generic
desmopressin acetate TABS Generic
STIMATE SOLN Preferred Brand
Progestins
AYGESTIN TABS Non-Preferred Brand
CRINONE GEL Preferred Brand QL
DEPO-PROVERA CONTRACEPTIVE SUSP Non-Preferred Brand
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 63 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
DEPO-PROVERA SUSP Medical Benefit
DEPO-SUBQ PROVERA 104 SUSP Non-Preferred Brand
ENDOMETRIN INST Preferred Brand
MAKENA OIL Excluded
medroxyprogesterone acetate SUSP Generic
medroxyprogesterone acetate TABS Generic
MEGACE ES SUSP Non-Preferred Brand ST
norethindrone acetate TABS Generic
progesterone CAPS Generic
progesterone OIL Generic
PROMETRIUM CAPS Non-Preferred Brand
PROVERA TABS Non-Preferred Brand
Somatostatin Agonists and Antagonists
octreotide acetate SOLN Preferred Specialty QL
SANDOSTATIN LAR DEPOT KIT Medical Benefit
SANDOSTATIN SOLN Non-Preferred Specialty
QL
SIGNIFOR SOLN Non-Preferred Specialty
PA
SOMATULINE DEPOT SOLN Preferred Specialty QL
Somatotropin Agonists and Antagonists
GENOTROPIN MINIQUICK SOLR Non-Preferred Specialty
QL PA
GENOTROPIN SOLR Non-Preferred Specialty
QL PA
HUMATROPE COMBO PACK SOLR Non-Preferred Specialty
QL PA
HUMATROPE SOLR Non-Preferred Specialty
QL PA
INCRELEX SOLN Preferred Specialty QL PA
NORDITROPIN FLEXPRO SOLN Preferred Specialty QL PA
NORDITROPIN NORDIFLEX PEN SOLN Preferred Specialty QL PA
NUTROPIN AQ NUSPIN 10 SOLN Non-Preferred Specialty
QL PA
NUTROPIN AQ NUSPIN 5 SOLN Non-Preferred Specialty
QL PA
NUTROPIN AQ PEN SOLN Non-Preferred Specialty
QL PA
NUTROPIN SOLR Non-Preferred Specialty
QL PA
OMNITROPE SOLN Non-Preferred Specialty
QL PA
OMNITROPE SOLR Non-Preferred Specialty
QL PA
SAIZEN CLICK.EASY SOLR Non-Preferred Specialty
QL PA
SAIZEN SOLR Non-Preferred QL PA
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 64 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
Specialty
SEROSTIM SOLR Non-Preferred Specialty
QL PA
SOMAVERT SOLR Preferred Specialty QL PA
TEV-TROPIN SOLR Non-Preferred Specialty
QL PA
ZORBTIVE SOLR Non-Preferred Specialty
QL PA
Thyroid and Antithyroid Agents
ARMOUR THYROID TABS Preferred Brand
CYTOMEL TABS Non-Preferred Brand
levothroid TABS Generic
LEVOTHYROXINE SODIUM SOLR Generic
levothyroxine sodium TABS Generic
LEVOTHYROXINE SODIUM SOLR Non-Preferred Specialty
QL
levoxyl TABS Generic
liothyronine sodium TABS Generic
methimazole TABS Generic
NATURE-THROID TABS Preferred Brand
propylthiouracil TABS Generic
SYNTHROID TABS Non-Preferred Brand
TAPAZOLE TABS Non-Preferred Brand
THYROLAR-1/2 TABS Preferred Brand
THYROLAR-1/4 TABS Preferred Brand
THYROLAR-1 TABS Preferred Brand
THYROLAR-2 TABS Preferred Brand
THYROLAR-3 TABS Preferred Brand
TIROSINT CAPS Non-Preferred Brand
unithroid TABS Generic
WESTHROID TABS Generic
Local Anesthetics
EXPAREL SUSP Medical Benefit
Miscellaneous Therapeutic Agents
5-alpha-Reductase Inhibitors
AVODART CAPS Non-Preferred Brand ST
finasteride TABS Generic
JALYN CAPS Non-Preferred Brand ST
PROSCAR TABS Non-Preferred Brand
Alcohol Deterrents
ANTABUSE TABS Non-Preferred Brand
disulfiram TABS Generic
Antidotes
acetylcysteine SOLN Generic
FUSILEV SOLR Medical Benefit
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 65 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
leucovorin calcium TABS Generic
LEUCOVORIN CALCIUM TABS Preferred Brand
VORAXAZE SOLR Medical Benefit-Preferred
Specialty
Antigout Agents
allopurinol TABS Generic
COLCRYS TABS Preferred Brand QL
KRYSTEXXA SOLN Medical Benefit-Preferred
Specialty
PA
ULORIC TABS Preferred Brand ST
ZYLOPRIM TABS Non-Preferred Brand
Bone Resorption Inhibitors
ACTONEL TABS Preferred Brand ST
ALENDRONATE SODIUM SOLN Generic
alendronate sodium TABS Generic
ATELVIA TBEC Non-Preferred Brand ST
BINOSTO TBEF Non-Preferred Brand ST
BONIVA TABS Non-Preferred Brand
BONIVA SOLN Medical Benefit-Non-Preferred
Specialty
PA
ETIDRONATE DISODIUM TABS Generic
FOSAMAX PLUS D TABS Non-Preferred Brand QL ST
FOSAMAX TABS Non-Preferred Brand
ibandronate sodium TABS Generic
pamidronate disodium SOLR Medical Benefit
PROLIA SOLN Medical Benefit-Preferred
Specialty
PA
RECLAST SOLN Medical Benefit-Non-Preferred
Specialty
SKELID TABS Preferred Specialty QL
XGEVA SOLN Medical Benefit-Preferred
Specialty
PA
zoledronic acid CONC Medical Benefit-Non-Preferred
Specialty
PA
zoledronic acid SOLN Medical Benefit-Non-Preferred
Specialty
ZOMETA CONC Medical Benefit-Preferred
Specialty
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 66 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
Cariostatic Agents
cavarest GEL Generic
cavirinse SOLN Generic
controlrx CREA Generic
denta 5000 plus CREA Generic
dentagel GEL Generic
FLUORABON SOLN Preferred Brand
fluor-a-day SOLN Preferred Brand
fluoridex daily defense GEL Generic
LURIDE CHEW Non-Preferred Brand
LURIDE SOLN Non-Preferred Brand
neutragard advanced GEL Generic
phos-flur GEL Generic
PREVIDENT 5000 BOOSTER PSTE Non-Preferred Brand
PREVIDENT 5000 PLUS CREA Non-Preferred Brand
PREVIDENT FLUORIDE GEL Non-Preferred Brand
PREVIDENT SOLN Non-Preferred Brand
sf 5000 plus CREA Generic
sf GEL Generic
sodium fluoride CHEW Generic
sodium fluoride SOLN Generic
Complement Inhibitors
BERINERT KIT Medical Benefit-Non-Preferred
Specialty
CINRYZE SOLR Medical Benefit-Preferred
Specialty
QL
FIRAZYR SOLN Non-Preferred Specialty
QL PA
KALBITOR SOLN Medical Benefit-Preferred
Specialty
SOLIRIS SOLN Medical Benefit-Preferred
Specialty
PA
Disease-modifying Antirheumatic Drugs
ACTEMRA SOSY Non-Preferred Specialty
ACTEMRA SOLN Medical Benefit-Preferred
Specialty
PA
ARAVA TABS Non-Preferred Specialty
QL
CIMZIA KIT Non-Preferred Specialty
QL PA
ENBREL SURECLICK SOLN Preferred Specialty QL PA
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 67 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
ENBREL KIT Preferred Specialty QL PA
ENBREL SOLN Preferred Specialty QL PA
HUMIRA PEN KIT Preferred Specialty QL PA
HUMIRA PEN-CROHNS DISEASESTARTER KIT Preferred Specialty QL PA
HUMIRA PEN-PSORIASIS STARTER KIT Preferred Specialty QL PA
HUMIRA KIT Preferred Specialty QL PA
KINERET SOLN Preferred Specialty QL PA
leflunomide TABS Preferred Specialty QL
ORENCIA SOLN Non-Preferred Specialty
QL PA
ORENCIA SOLR Medical Benefit-Non-Preferred
Specialty
PA
OTREXUP SOAJ Non-Preferred Brand ST
REMICADE SOLR Medical Benefit-Non-Preferred
Specialty
PA
SIMPONI ARIA SOLN Medical Benefit-Non-Preferred
Specialty
QL PA
SIMPONI SOLN Non-Preferred Specialty
QL PA
XELJANZ TABS Non-Preferred Specialty
PA
Gonadotropin-releasing Hormone Antagonists
CETROTIDE KIT Preferred Brand
GANIRELIX ACETATE SOLN Preferred Brand
Immunomodulatory Agents
ACTIMMUNE SOLN Preferred Specialty QL
AUBAGIO TABS Non-Preferred Specialty
QL PA
AVONEX PEN KIT Preferred Specialty QL
AVONEX KIT Preferred Specialty QL
BETASERON KIT Non-Preferred Specialty
QL PA
COPAXONE KIT Preferred Specialty QL
EXTAVIA KIT Non-Preferred Specialty
QL PA
GILENYA CAPS Non-Preferred Specialty
QL PA
REBIF REBIDOSE TITRATION PACK SOLN Preferred Specialty QL
REBIF REBIDOSE SOLN Preferred Specialty QL
REBIF TITRATION PACK SOLN Preferred Specialty QL
REBIF SOLN Preferred Specialty QL
TECFIDERA STARTER PACK MISC Preferred Specialty QL
TECFIDERA CPDR Preferred Specialty QL
THALOMID CAPS Preferred Specialty QL
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 68 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
TYSABRI CONC Medical Benefit-Non-Preferred
Specialty
PA
Immunosuppressive Agents
ASTAGRAF XL CP24 Non-Preferred Specialty
ST
ATGAM INJ Medical Benefit
AZASAN TABS Non-Preferred Brand
azathioprine TABS Generic
BENLYSTA SOLR Medical Benefit-Preferred
Specialty
PA
CELLCEPT SUSR Preferred Brand
CELLCEPT CAPS Non-Preferred Brand
CELLCEPT TABS Non-Preferred Brand
cyclosporine modified CAPS Generic
cyclosporine modified SOLN Generic
CYCLOSPORINE MODIFIED CAPS Preferred Brand
cyclosporine CAPS Generic
gengraf CAPS Generic
gengraf SOLN Generic
IMURAN TABS Non-Preferred Brand
mycophenolate mofetil CAPS Generic
mycophenolate mofetil TABS Generic
MYFORTIC TBEC Non-Preferred Brand QL
NEORAL CAPS Non-Preferred Brand
NEORAL SOLN Non-Preferred Brand
NULOJIX SOLR Medical Benefit-Non-Preferred
Specialty
PA
PROGRAF CAPS Non-Preferred Brand
PROGRAF SOLN Medical Benefit-Preferred
Specialty
RAPAMUNE SOLN Preferred Specialty QL
RAPAMUNE TABS Preferred Specialty QL
RAPAMUNE TABS Non-Preferred Specialty
QL
SANDIMMUNE CAPS Non-Preferred Brand
SANDIMMUNE SOLN Non-Preferred Brand
SANDIMMUNE SOLN Medical Benefit
SIMULECT SOLR Medical Benefit
sirolimus TABS Preferred Specialty QL
tacrolimus CAPS Generic
ZORTRESS TABS Preferred Brand
ZORTRESS TABS Preferred Specialty QL
Other Miscellaneous Therapeutic Agents
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 69 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
AMPYRA TB12 Non-Preferred Specialty
QL PA
ARCALYST SOLR Preferred Specialty QL
BOTOX SOLR Medical Benefit-Preferred
Specialty
PA
CARNITOR SOLN Non-Preferred Brand
CARNITOR TABS Non-Preferred Brand
CARNITOR SOLN Medical Benefit
CARTICEL IMPL Medical Benefit
COENZYME Q10 POWD Preferred Brand
coenzyme q-10 CAPS Excluded
DYSPORT SOLR Medical Benefit-Preferred
Specialty
PA
ELMIRON CAPS Preferred Brand QL
EUFLEXXA SOLN Medical Benefit-Preferred
Specialty
HYALGAN SOLN Medical Benefit-Non-Preferred
Specialty
PA
KUVAN TBSO Preferred Specialty QL
levocarnitine SOLN Generic
levocarnitine TABS Generic
levocarnitine SOLN Medical Benefit
MYOBLOC SOLN Medical Benefit-Preferred
Specialty
PA
ORTHOVISC SOLN Medical Benefit-Non-Preferred
Specialty
PA
PROCYSBI CPDR Excluded
RIMSO-50 SOLN Medical Benefit
SENSIPAR TABS Preferred Specialty QL
SUPARTZ SOLN Medical Benefit-Non-Preferred
Specialty
PA
SYNVISC ONE SOSY Medical Benefit-Non-Preferred
Specialty
PA
SYNVISC SOSY Medical Benefit-Non-Preferred
Specialty
PA
XEOMIN SOLR Medical Benefit-Preferred
Specialty
PA
Protective Agents
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 70 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
dexrazoxane SOLR Medical Benefit
ETHYOL SOLR Medical Benefit-Preferred
Specialty
mesna SOLN Medical Benefit
MESNEX TABS Preferred Specialty QL
ZINECARD SOLR Medical Benefit
Oxytocics
methylergonovine maleate TABS Generic
methylergonovine maleate SOLN Medical Benefit
Radioactive Agents
XOFIGO SOLN Medical Benefit-Non-Preferred
Specialty
Respiratory Tract Agents
Anti-inflammatory Agents
ACCOLATE TABS Non-Preferred Brand
cromolyn sodium NEBU Generic
GASTROCROM CONC Preferred Brand
montelukast sodium CHEW Generic
montelukast sodium TABS Generic
SINGULAIR PACK Preferred Brand
SINGULAIR CHEW Non-Preferred Brand
SINGULAIR TABS Non-Preferred Brand
zafirlukast TABS Generic
ZYFLO CR TB12 Non-Preferred Brand ST
ZYFLO TABS Non-Preferred Brand ST
Antitussives
benzonatate CAPS Generic
bromfed dm SYRP Generic
cheratussin ac SYRP Generic
cheratussin dac SOLN Generic
hydrocodone polistirex/chlorpheniramine polistirex LQCR Generic
hydrocodone/homatropine SYRP Generic
hydromet SYRP Generic
promethazine/codeine SYRP Generic
promethazine/dextromethorphan SYRP Generic
REZIRA SOLN Excluded
TESSALON PERLES CAPS Non-Preferred Brand
tussigon TABS Preferred Brand
TUSSIONEX PENNKINETIC EXTENDED RELEASE
LQCR Non-Preferred Brand
VITUZ SOLN Excluded
ZUTRIPRO SOLN Excluded
Cystic Fibrosis Transmembrane Conductance Regulator Modulators
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 71 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
KALYDECO TABS Preferred Specialty QL PA
Expectorants
donatussin LIQD Non-Preferred Brand
phenylephrine/guaifenesin LIQD Generic
Mucolytic Agents
HYPER-SAL NEBU Preferred Brand QL
PULMOZYME SOLN Preferred Specialty QL PA
sodium chloride NEBU Generic
Phosphodiesterase Type 4 Inhibitors
DALIRESP TABS Non-Preferred Brand PA
Respiratory Tract Agents, Miscellaneous
ARALAST NP SOLR Medical Benefit-Preferred
Specialty
PA
GLASSIA SOLN Medical Benefit-Preferred
Specialty
PA
XOLAIR SOLR Medical Benefit-Preferred
Specialty
PA
ZEMAIRA SOLR Medical Benefit-Preferred
Specialty
PA
Serums, Toxoids and Vaccines
Serums
ANASCORP SOLR Medical Benefit-Preferred
Specialty
CARIMUNE NANOFILTERED SOLR Medical Benefit-Preferred
Specialty
PA
FLEBOGAMMA DIF SOLN Medical Benefit-Preferred
Specialty
PA
FLEBOGAMMA SOLN Medical Benefit-Preferred
Specialty
PA
GAMASTAN S/D INJ Medical Benefit
GAMMAGARD LIQUID SOLN Medical Benefit-Preferred
Specialty
PA
GAMMAGARD S/D IGA LESS THAN 1MCG/ML SOLR Medical Benefit-Preferred
Specialty
PA
GAMMAGARD S/D SOLR Medical Benefit-Preferred
Specialty
PA
GAMUNEX SOLN Medical PA
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 72 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
Benefit-Preferred Specialty
HIZENTRA SOLN Medical Benefit-Preferred
Specialty
PA
HYPERHEP B S/D SOLN Medical Benefit
HYPERRAB S/D INJ Medical Benefit
HYPERRHO S/D INJ Medical Benefit
HYPERTET S/D INJ Medical Benefit
IMOGAM RABIES-HT INJ Medical Benefit
MICRHOGAM ULTRA-FILTERED PLUS INJ Medical Benefit
NABI-HB SOLN Medical Benefit
PRIVIGEN SOLN Medical Benefit-Preferred
Specialty
PA
RHOGAM ULTRA-FILTERED PLUS INJ Medical Benefit
RHOPHYLAC SOLN Medical Benefit
WINRHO SDF SOLN Medical Benefit
Toxoids
ADACEL SUSP Medical Benefit QL
BOOSTRIX SUSP Medical Benefit QL
DAPTACEL SUSP Medical Benefit
TENIVAC INJ Medical Benefit
TETANUS TOXOID ADSORBED SOLN Medical Benefit
TETANUS/DIPHTHERIA TOXOIDS-ADSORBED ADULT
SUSP Medical Benefit
Vaccines
CERVARIX SUSP Medical Benefit QL
COMVAX SUSP Medical Benefit
ENGERIX-B SUSP Medical Benefit QL
FLUBLOK 2013-2014 SOLN Medical Benefit
FLUMIST QUADRIVALENT SUSP Medical Benefit
FLUZONE HIGH-DOSE PF 2013-2014 SUSP Medical Benefit
FLUZONE INTRADERMAL DEVI Excluded
FLUZONE PEDIATRIC PF 2013-2014 SUSP Excluded
FLUZONE PF 2013-2014 SUSP Medical Benefit
FLUZONE SPLIT 2013-2014 INJ Medical Benefit
GARDASIL SUSP Medical Benefit QL
HAVRIX SUSP Medical Benefit QL
IMOVAX RABIES (H.D.C.V.) INJ Medical Benefit
IPOL INACTIVATED IPV INJ Medical Benefit QL
IXIARO SUSP Excluded
JE-VAX SOLR Excluded
MEDICAL PROVIDER EZ FLU SHOT 2013-2014 KIT Excluded
MENACTRA INJ Medical Benefit QL
MENOMUNE-A/C/Y/W-135 INJ Medical Benefit QL
MENVEO SOLR Medical Benefit QL
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 73 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
M-M-R II W/DILUENT 10 DOSE INJ Medical Benefit QL
PEDIARIX SUSP Medical Benefit
PNEUMOVAX 23/1 DOSE INJ Medical Benefit QL
PNEUMOVAX 23/5 DOSE INJ Medical Benefit QL
PREVNAR 13 SUSP Medical Benefit QL
PROQUAD INJ Medical Benefit
RABAVERT SUSR Medical Benefit
RECOMBIVAX HB SUSP Medical Benefit QL
ROTATEQ SOLN Medical Benefit
THERACYS SUSR Medical Benefit
TICE BCG SUSR Medical Benefit
TWINRIX SUSP Medical Benefit QL
TYPHIM VI SOLN Excluded
VAQTA SUSP Medical Benefit QL
VARIVAX INJ Medical Benefit
VIVOTIF BERNA CPDR Excluded
YF-VAX INJ Excluded
ZOSTAVAX SOLR Preferred Brand QL
Skin and Mucous Membrane Preparations
Anti-infectives
ACANYA GEL Non-Preferred Brand
acne medication 10 GEL Generic
acne medication 5 GEL Generic
acticin CREA Non-Preferred Brand
acyclovir OINT Generic QL
ALTABAX OINT Non-Preferred Brand ST
BACTROBAN NASAL OINT Preferred Brand
BACTROBAN CREA Non-Preferred Brand
BACTROBAN OINT Non-Preferred Brand
BENZACLIN WITH PUMP GEL Non-Preferred Brand
BENZACLIN GEL Non-Preferred Brand
BENZAMYCIN GEL Non-Preferred Brand
BENZEFOAM FOAM Non-Preferred Brand
BPO CREAMY WASH COMPLETE PACK KIT Generic QL
BPO GEL Generic
CENTANY OINT Non-Preferred Brand
ciclopirox nail lacquer SOLN Generic
ciclopirox olamine CREA Generic
ciclopirox GEL Generic
ciclopirox SUSP Generic
CLEOCIN SUPP Preferred Brand
CLEOCIN CREA Non-Preferred Brand
CLEOCIN-T GEL Non-Preferred Brand
CLEOCIN-T LOTN Non-Preferred Brand
CLEOCIN-T SOLN Non-Preferred Brand
CLEOCIN-T SWAB Non-Preferred Brand
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 74 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
CLINDAGEL GEL Non-Preferred Brand
clindamycin phosphate CREA Generic
clindamycin phosphate GEL Generic
clindamycin phosphate LOTN Generic
clindamycin phosphate SOLN Generic
clindamycin phosphate SWAB Generic
clindamycin/benzoyl peroxide GEL Generic
clotrimazole/betamethasone dipropionate CREA Generic
clotrimazole/betamethasone dipropionate LOTN Generic
clotrimazole CREA Generic
clotrimazole SOLN Generic
clotrimazole TROC Generic
DENAVIR CREA Preferred Brand
DESQUAM-X WASH LIQD Non-Preferred Brand
DUAC GEL Non-Preferred Brand
econazole nitrate CREA Generic
ECOZA FOAM Non-Preferred Brand QL
ERTACZO CREA Non-Preferred Brand
ery PADS Generic
erythromycin/benzoyl peroxide GEL Generic
erythromycin GEL Generic
erythromycin SOLN Generic
EURAX CREA Preferred Brand
EURAX LOTN Preferred Brand
EXELDERM CREA Non-Preferred Brand ST
EXELDERM SOLN Non-Preferred Brand ST
GENTAMICIN SULFATE CREA Generic
GENTAMICIN SULFATE OINT Generic
GYNAZOLE-1 CREA Non-Preferred Brand
ketoconazole CREA Generic
ketoconazole SHAM Generic
KLARON LOTN Non-Preferred Brand
LAMISIL SPRAY SOLN Non-Preferred Brand
lavoclen-4 acne wash kit KIT Generic
lavoclen-8 acne wash kit KIT Generic
lindane LOTN Generic
lindane SHAM Generic
LOPROX GEL Non-Preferred Brand
LOTRISONE CREA Non-Preferred Brand
malathion LOTN Generic
MENTAX CREA Non-Preferred Brand
METROCREAM CREA Non-Preferred Brand
METROGEL GEL Non-Preferred Brand
METROGEL-VAGINAL GEL Non-Preferred Brand
METROLOTION LOTN Non-Preferred Brand
metronidazole vaginal GEL Generic
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 75 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
metronidazole CREA Generic
metronidazole GEL Generic
metronidazole LOTN Generic
mexar wash LIQD Generic
mupirocin CREA Generic
mupirocin OINT Generic
NAFTIN CREA Non-Preferred Brand ST
NAFTIN GEL Non-Preferred Brand
NATROBA SUSP Non-Preferred Brand ST
NIZORAL SHAM Non-Preferred Brand
NORITATE CREA Preferred Brand
nystatin CREA Generic
nystatin OINT Generic
nystop POWD Generic
oscion cleanser LOTN Generic
OVACE PLUS WASH LIQD Non-Preferred Brand
OVACE WASH LIQD Non-Preferred Brand
OXISTAT CREA Preferred Brand
OXISTAT LOTN Preferred Brand
panoxyl wash LIQD Generic
PENLAC NAIL LACQUER SOLN Non-Preferred Brand
permethrin CREA Generic
permethrin LOTN Excluded
RIAX FOAM Non-Preferred Brand QL
selenium sulfide LOTN Generic
SELENIUM SULFIDE SHAM Generic
SELRX SHAM Non-Preferred Brand QL
SELSUN SHAMPOO LOTN Non-Preferred Brand
SILVADENE CREA Non-Preferred Brand
silver sulfadiazine CREA Generic
SKLICE LOTN Non-Preferred Brand
sodium sulfacetamide wash LIQD Generic
sulfacetamide sodium SUSP Generic
SULFAMYLON CREA Non-Preferred Brand
SULFAMYLON PACK Non-Preferred Brand
TERAZOL 3 SUPP Non-Preferred Brand
TERAZOL 7 CREA Non-Preferred Brand
terconazole CREA Generic
terconazole SUPP Generic
ULESFIA LOTN Preferred Brand
vandazole GEL Generic
VYTONE CREA Non-Preferred Brand QL
XERESE CREA Non-Preferred Brand ST
XOLEGEL GEL Non-Preferred Brand ST
ZOVIRAX CREA Preferred Brand QL ST
ZOVIRAX OINT Non-Preferred Brand QL
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 76 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
Anti-inflammatory Agents
ACLOVATE CREA Non-Preferred Brand
alclometasone dipropionate CREA Generic
alclometasone dipropionate OINT Generic
amcinonide CREA Generic
AMCINONIDE LOTN Preferred Brand
AMCINONIDE OINT Preferred Brand
ANUSOL-HC SUPP Non-Preferred Brand
APEXICON E CREA Generic ST
aquanil hc LOTN Generic
augmented betamethasone dipropionate CREA Generic
augmented betamethasone dipropionate GEL Generic
augmented betamethasone dipropionate LOTN Generic
augmented betamethasone dipropionate OINT Generic
betamethasone dipropionate CREA Generic
betamethasone dipropionate LOTN Generic
betamethasone dipropionate OINT Generic
betamethasone valerate CREA Generic
betamethasone valerate FOAM Generic
betamethasone valerate LOTN Generic
betamethasone valerate OINT Generic
CAPEX SHAM Non-Preferred Brand ST
clobetasol propionate emollient FOAM Generic
clobetasol propionate CREA Generic
clobetasol propionate FOAM Generic
clobetasol propionate GEL Generic
clobetasol propionate LOTN Generic
clobetasol propionate OINT Generic
clobetasol propionate SHAM Generic
clobetasol propionate SOLN Generic
CLOBEX LIQD Non-Preferred Brand
CLOBEX LOTN Non-Preferred Brand
CLOBEX SHAM Non-Preferred Brand
CLODERM PUMP CREA Non-Preferred Brand
CLODERM CREA Non-Preferred Brand
CORDRAN SP CREA Non-Preferred Brand
CORDRAN TAPE TAPE Preferred Brand
CORDRAN LOTN Non-Preferred Brand
CORTANE-B LOTN Non-Preferred Brand
CORTENEMA ENEM Non-Preferred Brand
CORTIFOAM FOAM Preferred Brand
CORTISPORIN CREA Preferred Brand
CORTISPORIN OINT Preferred Brand
CUTIVATE CREA Non-Preferred Brand
CUTIVATE OINT Non-Preferred Brand
DERMA-SMOOTHE/FS BODY OIL Non-Preferred Brand
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 77 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
DERMA-SMOOTHE/FS SCALP OIL Non-Preferred Brand
DESONATE GEL Non-Preferred Brand ST
desonide CREA Generic
desonide LOTN Generic
desonide OINT Generic
desoximetasone CREA Generic
desoximetasone GEL Generic
desoximetasone OINT Generic
DIFLORASONE DIACETATE CREA Generic
diflorasone diacetate OINT Generic
DIPROLENE AF CREA Non-Preferred Brand
DIPROLENE LOTN Non-Preferred Brand
DIPROLENE OINT Non-Preferred Brand
ELOCON CREA Non-Preferred Brand
ELOCON LOTN Non-Preferred Brand
ELOCON OINT Non-Preferred Brand
EPIFOAM FOAM Preferred Brand
fluocinolone acetonide body OIL Generic
fluocinolone acetonide scalp OIL Generic
fluocinolone acetonide CREA Generic
fluocinolone acetonide OINT Generic
fluocinolone acetonide SOLN Generic
fluocinonide CREA Generic
fluocinonide GEL Generic
fluocinonide OINT Generic
fluocinonide SOLN Generic
fluticasone propionate CREA Generic
fluticasone propionate OINT Generic
halobetasol propionate CREA Generic
halobetasol propionate OINT Generic
HALOG CREA Non-Preferred Brand ST
HALOG OINT Non-Preferred Brand ST
hydrocortisone butyrate CREA Generic
hydrocortisone butyrate OINT Generic
hydrocortisone butyrate SOLN Generic
hydrocortisone valerate CREA Generic
hydrocortisone valerate OINT Generic
hydrocortisone CREA Generic
hydrocortisone ENEM Generic
hydrocortisone LOTN Generic
hydrocortisone OINT Generic
LOCOID LIPOCREAM CREA Non-Preferred Brand
LOCOID CREA Non-Preferred Brand
LOCOID OINT Non-Preferred Brand
LOCOID SOLN Non-Preferred Brand
LUXIQ FOAM Non-Preferred Brand
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 78 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
mometasone furoate CREA Generic
mometasone furoate OINT Generic
mometasone furoate SOLN Generic
nystatin/triamcinolone CREA Generic
nystatin/triamcinolone OINT Generic
OLUX FOAM Non-Preferred Brand
OLUX-E FOAM Non-Preferred Brand
oralone PSTE Non-Preferred Brand
PANDEL CREA Non-Preferred Brand
PRAMOSONE CREA Preferred Brand
PRAMOSONE LOTN Preferred Brand
PRAMOSONE OINT Preferred Brand
prednicarbate CREA Generic
prednicarbate OINT Generic
proctosol hc CREA Generic
TACLONEX OINT Non-Preferred Brand ST
TACLONEX SUSP Non-Preferred Brand ST
TEMOVATE GEL Non-Preferred Brand
TEMOVATE OINT Non-Preferred Brand
TEMOVATE SOLN Non-Preferred Brand
TOPICORT CREA Non-Preferred Brand
TOPICORT GEL Non-Preferred Brand
TOPICORT LIQD Non-Preferred Brand
TOPICORT OINT Non-Preferred Brand
triamcinolone acetonide CREA Generic
triamcinolone acetonide LOTN Generic
triamcinolone acetonide OINT Generic
triamcinolone acetonide PSTE Generic
triamcinolone in orabase PSTE Generic
ULTRAVATE X KIT Non-Preferred Brand
ULTRAVATE CREA Non-Preferred Brand
VANOS CREA Non-Preferred Brand ST
VANOXIDE-HC LOTN Non-Preferred Brand
VERDESO FOAM Non-Preferred Brand ST
WESTCORT OINT Non-Preferred Brand
Antipruritics and Local Anesthetics
ANALPRAM-HC SINGLES CREA Non-Preferred Brand
ANALPRAM-HC LOTN Preferred Brand
ANALPRAM-HC CREA Non-Preferred Brand
ETHYL CHLORIDE/MIST AERO Generic
hydrocortisone acetate/pramoxine CREA Generic
lidocaine hcl jelly GEL Generic
lidocaine hcl SOLN Generic
lidocaine/prilocaine CREA Generic
lidocaine OINT Generic
lidocaine PTCH Generic PA
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 79 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
LIDODERM PTCH Non-Preferred Brand PA
phenazopyridine hcl TABS Generic
PROCTOFOAM HC FOAM Preferred Brand QL
PRUDOXIN CREA Non-Preferred Brand
PYRIDIUM TABS Non-Preferred Brand
URELIEF PLUS TABS Generic
ZONALON CREA Non-Preferred Brand ST
Astringents
DOMEBORO PACK Excluded
DRYSOL SOLN Non-Preferred Brand
hypercare SOLN Generic
XERAC AC SOLN Non-Preferred Brand ST
Cell Stimulants and Proliferants
ATRALIN GEL Non-Preferred Brand ST
avita CREA Non-Preferred Brand
avita GEL Non-Preferred Brand
KEPIVANCE SOLR Medical Benefit
RETIN-A MICRO PUMP GEL Non-Preferred Brand
RETIN-A MICRO GEL Non-Preferred Brand
RETIN-A CREA Non-Preferred Brand
RETIN-A GEL Non-Preferred Brand
tretinoin microsphere pump GEL Generic
tretinoin microsphere GEL Generic
tretinoin CREA Generic
tretinoin GEL Generic
TRETIN-X KIT Non-Preferred Brand ST
Depigmenting and Pigmenting Agents
ELDOPAQUE FORTE CREA Non-Preferred Brand
hydroquinone CREA Generic
LUSTRA CREA Non-Preferred Brand
melpaque hp CREA Generic
OXSORALEN ULTRA CAPS Preferred Brand
TRI-LUMA CREA Non-Preferred Brand ST
Emollients, Demulcents, and Protectants
ammonium lactate CREA Generic
ammonium lactate LOTN Generic
HPR PLUS/MB HYDROGEL KIT Excluded
HPR PLUS FOAM Excluded
HPR FOAM Excluded
LAC-HYDRIN CREA Non-Preferred Brand
LAC-HYDRIN LOTN Non-Preferred Brand
Keratolytic Agents
prascion fc PADS Generic
prascion ra with sunscreens CREA Generic
SALEX CREAM KIT Non-Preferred Brand
SALEX LOTION KIT Non-Preferred Brand
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 80 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
SALEX SHAM Non-Preferred Brand
salicylic acid cream KIT Generic
salicylic acid lotion KIT Generic
salicylic acid CREA Generic
salicylic acid LOTN Generic
salicylic acid SHAM Generic
SALVAX FOAM Non-Preferred Brand
sodium sulfacetamide/sulfur LOTN Generic
sulfacetamide sodium/sulfur cleanser EMUL Generic
SUMADAN KIT KIT Non-Preferred Brand
SUMADAN WASH LIQD Non-Preferred Brand
urea CREA Generic
urea GEL Generic
urea LOTN Generic
UTOPIC CREA Non-Preferred Brand QL
Keratoplastic Agents
COAL TAR SOLN Preferred Brand
Skin and Mucous Membrane Agents, Misc
ABSORICA CAPS Non-Preferred Specialty
ST
acitretin CAPS Preferred Specialty
ACZONE GEL Non-Preferred Brand ST
adapalene CREA Generic
adapalene GEL Generic
ALDARA CREA Non-Preferred Brand
amnesteem CAPS Generic
AZELEX CREA Preferred Brand QL
calcipotriene OINT Generic QL
calcipotriene SOLN Generic
calcitrene OINT Generic QL
CARAC CREA Preferred Brand
claravis CAPS Generic
CONDYLOX GEL Preferred Brand
CONDYLOX SOLN Non-Preferred Brand
DIFFERIN GEL Preferred Brand
DIFFERIN CREA Non-Preferred Brand
DIFFERIN GEL Non-Preferred Brand
DIFFERIN LOTN Non-Preferred Brand
DOVONEX CREA Preferred Brand
EFUDEX CREA Non-Preferred Brand
ELIDEL CREA Preferred Brand
EPIDUO GEL Non-Preferred Brand
FABIOR FOAM Non-Preferred Brand QL
FINACEA GEL Non-Preferred Brand
finasteride TABS Excluded
FLECTOR PTCH Preferred Brand ST
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 81 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
FLUOROPLEX CREA Preferred Brand
fluorouracil CREA Generic
fluorouracil SOLN Generic
imiquimod CREA Generic
LATISSE SOLN Excluded
minocycline hcl er TB24 Generic
MIRVASO GEL Non-Preferred Brand QL
ORACEA CPDR Non-Preferred Brand ST
PENNSAID SOLN Non-Preferred Brand ST
PICATO GEL Non-Preferred Brand QL ST
podofilox SOLN Generic
PROTOPIC OINT Preferred Brand
QUTENZA KIT Medical Benefit-Non-Preferred
Specialty
PA
RECTIV OINT Non-Preferred Brand QL
REGRANEX GEL Preferred Specialty ST
SANTYL OINT Non-Preferred Brand
SOLODYN TB24 Non-Preferred Brand ST
SORIATANE CAPS Non-Preferred Specialty
QL
SORILUX FOAM Non-Preferred Brand
STELARA SOLN Preferred Specialty PA
TARGRETIN GEL Preferred Specialty QL PA
TAZORAC CREA Preferred Brand
TAZORAC GEL Preferred Brand
VALCHLOR GEL Preferred Specialty QL PA
vasolex OINT Generic
VECTICAL OINT Preferred Brand ST
VELTIN GEL Non-Preferred Brand
VOLTAREN GEL Non-Preferred Brand QL
zenatane CAPS Generic
ZIANA GEL Non-Preferred Brand
ZYCLARA CREA Non-Preferred Brand ST
Smooth Muscle Relaxants
Genitourinary Smooth Muscle Relaxants
DETROL LA CP24 Non-Preferred Brand QL ST
DETROL TABS Non-Preferred Brand
DITROPAN XL TB24 Non-Preferred Brand
ENABLEX TB24 Preferred Brand
flavoxate hcl TABS Generic
GELNIQUE GEL Non-Preferred Brand ST
MYRBETRIQ TB24 Non-Preferred Brand ST
oxybutynin chloride er TB24 Generic
oxybutynin chloride SYRP Generic
oxybutynin chloride TABS Generic
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 82 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
OXYTROL PTTW Excluded
SANCTURA XR CP24 Non-Preferred Brand
SANCTURA TABS Non-Preferred Brand
tolterodine tartrate TABS Generic
TOVIAZ TB24 Non-Preferred Brand QL ST
trospium chloride er CP24 Generic
trospium chloride TABS Generic
VESICARE TABS Preferred Brand
Respiratory Smooth Muscle Relaxants
ELIXOPHYLLIN ELIX Non-Preferred Brand
THEO-24 CP24 Preferred Brand
theophylline er TB12 Generic
theophylline er TB24 Generic
Vitamins
Multivitamin Preparations
CAVAN PRENATAL/EC CALCIUM TBEC Generic
CITRANATAL ASSURE MISC Non-Preferred Brand
CITRANATAL HARMONY CAPS Non-Preferred Brand
COMPLETE NATAL DHA MISC Generic
COMPLETENATE CHEW Generic
DUET DHA BALANCED MISC Preferred Brand
folbee plus TABS Preferred Brand
GESTICARE DHA MISC Preferred Brand
INATAL ADVANCE TABS Generic
INATAL GT TABS Generic
INATAL ULTRA TABS Generic
INFANATE BALANCE CAPS Non-Preferred Brand
MISSION PRENATAL HP TABS Preferred Brand
MISSION PRENATAL/FOLIC ACID TABS Preferred Brand
MISSION PRENATAL TABS Preferred Brand
multi vitamin/fluoride CHEW Generic
multi-vit/fluoride SOLN Generic
MULTI-VIT/IRON/FLUORIDE SOLN Generic
multivitamin with fluoride CHEW Generic
multivitamin/fluoride CHEW Generic
multivitamins/fluoride CHEW Generic
M-VIT TABS Generic
MYNATAL ADVANCE TABS Generic
MYNATAL PLUS TABS Generic
MYNATAL ULTRACAPLET TABS Generic
MYNATAL-Z TABS Generic
MYNATE 90 PLUS TBCR Generic
NEEVO DHA CAPS Non-Preferred Brand
NESTABS ABC MISC Non-Preferred Brand
OB-NATAL ONE CAPS Generic
PNV FOLIC ACID + IRON MULTIVITAMIN TABS Generic
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 83 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
PNV-FIRST CAPS Generic
PR NATAL 400 EC MISC Generic
PR NATAL 400 MISC Generic
PR NATAL 430 EC MISC Generic
PR NATAL 430 MISC Generic
PREFERA OB TABS Non-Preferred Brand
PREFERAOB ONE CAPS Non-Preferred Brand
PRENAFIRST TABS Generic
PRENAPLUS TABS Generic
PRENATABS FA TABS Generic
PRENATABS OBN TABS Generic
PRENATABS RX TABS Generic
PRENATAL 19 CHEW Non-Preferred Brand
PRENATAL 19 TABS Non-Preferred Brand
PRENATAL AD TABS Generic
PRENATAL AND IRON TABS Generic
PRE-NATAL FORMULA TABS Generic
PRENATAL FORTE TABS Generic
PRENATAL LOW IRON TABS Generic
PRENATAL PLUS TABS Generic
PRENATAL VITAMINS TABS Generic
PRENATAL TABS Generic
PRENATE AM TABS Non-Preferred Brand
PROVIDA OB CAPS Non-Preferred Brand
SELECT-OB CHEW Generic
TARON EC CALCIUM MISC Generic
TARON-PREX CAPS Preferred Brand
TL-CARE DHA CAPS Generic
TRIADVANCE TABS Generic
TRICARE PRENATAL COMPLEAT MISC Non-Preferred Brand
TRICARE PRENATAL DHA ONE CAPS Non-Preferred Brand
TRICARE TABS Generic
TRIMESIS RX TABS Generic
TRINATAL RX 1 TABS Generic
TRINATE TABS Preferred Brand
TRIVEEN-DUO DHA MISC Generic
TRI-VIT/FLUORIDE/IRON SOLN Generic
tri-vit/fluoride SOLN Generic
tri-vitamin/fluoride SOLN Generic
ULTRA TABS TABS Generic
urosex TABS Preferred Brand
VINATE AZ TABS Generic
VINATE DHA CAPS Non-Preferred Brand
VINATE GT TABS Generic
VINATE IC CAPS Generic
VINATE M TABS Generic
*Requirements/Limits: PA- Prior Authorization ST- Step Therapy QL- Quantity Limits Page 84 of 85
Drug Name Dosage Form
Drug Tier Requirements/
Limits
VINATE ONE TABS Generic
VINATE PN CARE TABS Generic
VINATE ULTRA TABS Generic
vitacel TABS Generic
VITAFOL-OB TABS Preferred Brand
VITAFOL-ONE CAPS Non-Preferred Brand
VITAFOL-PN TABS Preferred Brand
VOL-TAB RX TABS Generic
VP-HEME ONE CAPS Generic
Vitamin B Complex
cyanocobalamin SOLN Generic
folbee TABS Generic
folbic TABS Generic
folic acid TABS Generic
FOLIC ACID SOLN Medical Benefit
FOLTX TABS Non-Preferred Brand
LMTHF/PYRIDOXINE HCL/CYANOCOBALAMIN TABS Generic
NASCOBAL SOLN Preferred Brand
NIACOR TABS Generic
Vitamin D
calcitriol CAPS Generic
calcitriol SOLN Generic
calcitriol SOLN Medical Benefit
DRISDOL CAPS Non-Preferred Brand
HECTOROL CAPS Preferred Brand
paricalcitol CAPS Generic
ROCALTROL CAPS Non-Preferred Brand
ROCALTROL SOLN Non-Preferred Brand
vitamin d CAPS Generic
vitamin d TABS Generic
vitamin d3 CAPS Generic
vitamin d3 LIQD Generic
ZEMPLAR CAPS Non-Preferred Brand
Vitamin K Activity
MEPHYTON TABS Preferred Brand
© 2014 Priority Health 8294H 8/14