BlueShield of
Northeastern
New York
Formulary 2
Please bring this guide
with you the next time
you visit your doctor.
If you have questions about your prescription drug benefit,
visit the Pharmacy Services section of the BlueShield web site at
www.bsneny.com.
* M G 4 6 9 8 6 Y*
MG46986Y
(Revise Date 01/01/2017)
A Division of HealthNow New York Inc. An independent licensee of the BlueCross BlueShield Association. The Shield is a registered
trademark of the BlueCross BlueShield Association.
TABLE OF CONTENTS
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Understanding
the symbols used
throughout this book . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Using
iii
iii
this formulary book to help contain costs . iv
Save Money on Your Prescription Drugs. . . . . . . . . . . . . . . . .
iv
Finding Medications in the Guide . . . . . . . . . . . . . . . . . . . . . . .
iv
Section 1 — Therapeutic Drug Categories . . . . . . . . . .
1
Section II — Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7
ii
The BlueShield of Northeastern New York Formulary 2 is a list of drugs to help guide physicians and pharmacists to select the medication that provides the appropriate treatment for the best price.
Introduction
Blue Shield of Northeastern New York has established an independent committee of practicing physicians and a
pharmacist to help ensure that our formularies are medically sound and that they support your patients’ health.
This committee—called the Pharmacy and Therapeutics Committee—reviews and evaluates medications on the
formulary based on safety and efficacy to help maintain clinical integrity in all therapeutic categories.
Understanding
the symbols used throughout this book
Throughout this book, you will see certain symbols that indicate a management program is in place for selected
medications. The symbols are as follows:
Key
P=
step edit applies to this drug. Step therapy means that in order to receive the medication
A
with a step edit, a preferred medication must be tried first.
z =
Specific quantity limits apply. Quantity limits are in place to ensure members receive the
appropriate amount of medication not to exceed the maximum allowable daily dosage of
medication.
=
Prior authorization required. Prior authorization (also referred to as coverage review)
means that a healthcare professional must submit clinical documentation to obtain
approval for a member to receive the medication. Prior authorizations ensure medications
are being used appropriately.
=
Included
in tablet-splitting program. The medication can be cut in half to obtain the daily
u
dose of medication (i.e., 20mg daily of simvastatin can be obtained by 1/2 tablet of
simvastatin 40mg). A member will receive a 1-month supply for half their regular 1-month
copay.
+ =
Access restricted to specialty pharmacy. Medications must be obtained through a specialty
pharmacy.
o=Customer Home Delivery. The medication should be obtained through the mail service
pharmacy. The medication is subject to a retail refill allowance.
iii
Using
this formulary book to help contain costs
Many employers, benefit sponsors, and individuals may use the formulary to help manage the
overall cost of providing prescription drug benefits. The formulary offers a wide range of outpatient
medications.
Because there are over 40,000 Food and Drug Administration (FDA)-approved prescription drugs on
the market, not all tier 3 drugs can be listed in this formulary guide. We have included in this printed
formulary guide the drugs that are most commonly prescribed for our members. If you have any
questions regarding coverage of a drug, please call the customer service number on your card.
Save Money on Your Prescription Drugs
Here’s what you can do to save money:
1.
Bring this member guide to your doctor and review the cost-saving information below.
2.
Ask your doctor whether a drug listed in this guide is right for you.*
Tier 1
Tier 2
Tier 3
Lowest cost to you Highest cost to you
The amount you pay for a drug is determined by which medication you purchase and to what tier it is
assigned. Some drug plans exclude certain drugs or classes of drugs from coverage. Please check your
contract or other plan documents if you have a question about your specific drug coverage.
Please refer to your plan documents to confirm your cost share for diabetic drugs and supplies. Cost
share may vary by plan.
Customer Home Delivery: Members must obtain maintenance medications at mail-order after retail allowance is
exhausted for members with Customer Home Delivery Benefit.
Finding Medications in the Guide
This guide lists medications two different ways:
Section 1:Alphabetically by drug category (such as Diabetes, Heart or Pain/Arthritis)
Locate a category and drug on the guide and you will see the tier and copayment for that
drug—Tier 1, Tier 2 or Tier 3—which determines your copayment. To determine if a drug is a
generic or brand-name medication, look at the name of the drug. Generic medications are
lower case (e.g., amoxicillin), and brand-name medications are capitalized (e.g., Advair).
Section 2:Alphabetically by drug name. Use this list to find your drug.
Questions? Please call Pharmacy Services at 1 800 939-3751 if you have any questions about the
BlueShield of Northeastern New York Formulary 2. For the most up-to-date version of the Guide, visit the
Pharmacy Services section of our web site at www.bsneny.com.
* Some plan designs require that you use a Tier 1 generic drug if a generic is available.
Disclaimer: The BlueShield of Northeastern New York Medication Guide is subject to change, as we regularly review medications and existing therapies for inclusion in the BlueShield of Northeastern New York Formulary 2. The tier that a medication is currently in may change during the effective dates of the guides due to generic availability.
iv
Section I — Therapeutic drug categories
TIER
Allergy/Cough & Cold
Antihistamines & Decongestants
brompheniramine/ phenylephrine
1
brompheniramine/ pseudoephedrine
1
ocetirizine
1
clemastine
1
cyproheptadine
1
dexchlorpheniramine
1
diphenhydramine
1
zofexofenadine
1
zofexofenadine-D
1
hydroxyzine HCl
1
hydroxyzine pamoate
1
zolevocetirizine
1
loratadine
1
loratadine-D
1
pseudoephedrine
1
Semprex-D
2
zoClarinex-D
3
zodesloratadine
3
3
zGrastek
+zOralair
3
zRagwitek
3
Expectorant & Cough Products
benzonatate
1
guaifenesin/codeine
1
hydrocodone/chlorpheniramine 1
hydrocodone/homatropine
1
promethazine/codeine
1
promethazine/DM
1
promethazine/phenylephrine/ codeine 1
pseudoephedrine/codeine
1
Cardec/DM
3
Guaifenesin DM
3
Hycodan
3
Rondec DM/TR
3
Vituz
3
Mucolytic Agents
acetylcysteine inh soln.
1
Nasal Medications
azelastine nasal spray
1
Clarispray
1
Flonase Allergy Relief
1
zo
fluticasone nasal spray
1
ipratropium nasal spray
1
z
Nasacort OTC
1
Atrovent Nasal Spray
3
Pzo Beconase AQ
3
zo
flunisolide nasal spray
3
PzoOmnaris
3
Pz
mometasone nasal spray
3
Pzo Nasacort AQ
3
PzNasonex
3
PzoQnasl
3
Pzo Rhinocort Aqua
3
zo
triamcinolone acetonide nasal spray
3
PzoVeramyst
3
PzoZetonna
3
Alzheimer Agents
zodonepezil
ergoloid mesylates
zogalantamine
zo
galantamine ER
zomemantine
zorivastigmine
zo
rivastigmine patch
zo
Namenda XR
zNamzaric
Bladder/Kidney
Acidifiers
K-Phos
Alkalinizers
citric acid/sod citrate
potassium citrate
Oracit
Analgesics
phenazopyridine
Anticholinergics
oxybutynin
z
oxybutynin ER
KEY:
1
1
1
1
1
1
1
2
3
3
1
1
3
1
1
1
ztolterodine
z
tolterodine ER
ztrospium
z
trospium ER
zMyrbetriq
zToviaz
zVesicare
PzDetrol
Pz
Detrol LA
Pz
Ditropan XL
PzEnablex
PzGelnique
PzOxytrol
PzSanctura
Pz
Sanctura XR
Cholinergic Agents
Urecholine
TIER
1
1
1
1
2
2
2
3
3
3
3
3
3
3
3
3
Blood
Anticoagulants/antithrombotics
anagrelide
oclopidogrel
odipyridamole
enoxaparin
fondaparinux sodium
heparin
jantoven
oticlopidine
warfarin
oAggrenox
Coumadin
oEffient
Fragmin
zPradaxa
Xarelto
oBrilinta
zDurlaza
Eliquis
Innohep
zSavaysa
zoZontivity
Other Blood Modifiers
ocilostazol
pentoxifylline
+zActimmune
+Aranesp
+Exjade
+Jadenu
+Leukine
o
Miacalcin inj.
Neulasta
+Neupogen
+Procrit
+zPromacta
+zRevlimid
+Syprine
+Alprolix
+Eloctate
+Epogen
Ferriprox
+Granix
Mircera
+Neumega
Omontys
+Zarxio
1
1
2
2
2
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
Alkylating Agents
cyclophosphamide
Alkeran
CeeNu
Emcyt
Hexalen
Leukeran
Myleran
1
2
2
2
2
2
2
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
3
3
3
3
3
3
Cancer Drugs
P =A step edit applies to this drug.
z =Specific Quantity Limits Apply.
=Prior Authorization Required.
u = Included in Tablet-Splitting Program
+ = Access restricted to specialty pharmacy.
o = Home Service Delivery.
TIER
Antimetabolites
capecitabine
1
mercaptopurine
1
methotrexate
1
Purixan
2
Trexall
3
Hormones
bicalutamide
1
exemastine
1
flutamide
1
letrozole
1
leuprolide
1
megestrol
1
tamoxifen
1
anastrozole
1
Fareston
2
Miscellaneous
etoposide
1
hydroxyurea
1
+zimatinib
1
+temozolomide
1
+zAfinitor
2
zArcalyst
2
+zBosulif
2
+z Cabometyx2
zCaprelsa
2
zCometriq
2
+z Cotellic2
+zErivedge
2
+zFarydak
2
zGilotrif
2
+Hycamtin
2
+zIbrance
2
zIclusig
2
zImbruvica
2
+zInlyta
2
+
Intron A
2
zIressa
2
+zJakafi
2
zLenvima
2
+z Lonsurf2
zLynparza
2
Lysodren
2
Matulane
2
+zMekinist
2
Mesnex
2
+zNexavar
2
Nilandron
2
+z Ninlaro2
+zOdomzo
2
+zPomalyst
2
+zSprycel
2
+zStivarga
2
+zSutent
2
+zSylatron
2
+zSynribo
2
+zTafinlar
2
z
Tagrisso2
+zTarceva
2
+zTasigna
2
+Thalomid
2
+zTykerb
2
zValchlor
2
+zVotrient
2
+zXalkori
2
+zXtandi
2
+zZelboraf
2
+zZolinza
2
zZydelig
2
+zZykadia
2
+zZytiga
2
+z Alecensa3
+Temodar
3
z
Venclexta3
Rexinoids
+bexarotene
1
+
Targretin gel
2
Please refer to your plan documents to confirm your
cost share for diabetic drugs. Cost share may vary
by plan.
Antidiabetic Agents, Injectable
zBydureon
2
zByetta
2
Humalog insulin
2
Humulin (all types)
2
Lantus
2
zSymlin
2
Toujeo
2
zVictoza
2
z
Adlyxin 3
PApidra
3
PLevemir
3
PNovolin
3
PNovolog
3
zTanzeum
3
PTresiba
3
zTrulicity
3
Antidiabetic Agents, Glucose Elevating Agents
acarbose
1
chlorpropamide
1
zglimepiride
1
glipizide
1
z
glipizide ER
1
zglipizide/metformin
1
glyburide
1
glyburide micronized
1
metformin
1
z
metformin ER (generic Glucophage XR) 1
zmetformin/glyburide
1
znateglinide
1
zpioglitazone/metformin
1
zrepaglinide
1
tolazamide
1
tolbutamide
1
zAvandamet
2
zAvandaryl
2
zAvandia
2
zDuetact
2
Glucagon
2
zInvokamet
2
z
Invokamet XR
2
zInvokana
2
zJanumet
2
z
Janumet XR
2
zJanuvia
2
zJardiance
2
Jentadueto
2
z
Jentadueto XR
2
Juvisync
2
zSynjardy
2
Tradjenta
2
Afrezza
3
PzFarxiga
3
PzFortamet
3
PzGlumetza
3
zGlyxambi
3
PKazano
3
P
Kombiglyze XR
3
P
metformin ER (except generic
Glucophage XR)
3
miglitol
3
PNesina
3
POnglyza
3
POseni
3
repaglinide/metformin
3
Riomet solution
3
Pz
Xigduo XR
3
Diabetic Test Strips
Please refer to your plan documents to confirm your
cost share for diabetic supplies. Cost share may vary
by plan. Test strips other than OneTouch require
prior authorization.
OneTouch Test Strips
PAccu-Chek
Note: 1. * Please note that medications listed in the 3rd tier are considered
non-formulary and are not all-inclusive.
2. * Some drugs are limited to 1 unit of use package per dispensing.
1
TIER
Diabetes
Section I — Therapeutic drug categories (cont’d)
P
Ascensia Breeze
PContour
PFreestyle
PPrecision
PTRUEtest
PTRUEtrack
TIER
Ear
Anti-infective Agents
acetic acid otic
acetic acid/aluminum acetate
ofloxacin otic
Domeboro
Xtoro
Anti-infective/Anti-inflammatory combinations
acetic acid HC otic
neomycin/polymyxin/HC otic
Ciprodex
Cipro HC
Eye
Antiallergy Agents (Eye)
azelastine ophth
cromolyn ophth
olopatadine ophth
Alomide
Bepreve
ketotifen opthalmic solution
Pataday
Pazeo
Zaditor
Anti-infective Agents
bacitracin ophth
bacitracin/polymyxin
ciprofloxacin ophth
erythromycin ophth
gatifloxacin
gentamicin ophth
neomycin/bacitracin/poly B
ofloxacin ophth
polymyxin B/TMP
sulfacetamide 10%
tobramycin soln
Tobrex ointment
Vigamox
Azasite
Besivance
Ciloxan
Tobrex solution
Anti-inflammatory
fluorometholone ophth
prednisolone acetate
prednisolone sod phosphate
FML Forte
FML S.O.P.
Lotemax
Pred Mild
Flarex
Maxidex
Anti-inflammatory/Anti-infective combinations
dexameth/neomycin/poly B
neomycin/bacitracin/poly B/HC
sulfacetamide/prednisolone ophth
tobramycin/dexameth
Tobradex ointment
Maxitrol ophth
Pred-G
Zylet
Antiviral
z
famciclovir ophth trifluridine
Beta-Blockers (Eye)
o
betaxolol HCl
ocarteolol
olevobunolol
ometipranolol
otimolol
oBetoptic-S
oIstalol
Carbonic Anhydrase Inhibitors
o
dorzolamide 2% eye drops
o
dorzolamide/timolol eye drops
oAzopt
KEY:
1
1
1
3
3
1
1
2
3
1
1
1
2
3
3
3
3
3
1
1
1
1
1
1
1
1
1
1
1
2
2
3
3
3
3
1
1
1
2
2
2
2
3
3
1
1
1
1
2
3
3
3
1
1
1
1
1
1
1
2
3
1
1
2
Miotics
opilocarpine
o
Isopto Carbachol 1.5%
Phospholine Iodide
o
Isopto Carbachol 3%
Miscellaneous
+Cystaran
zRestasis
zXiidra
Mydriatics
atropine sulfate ophth
homatropine
tropicamide
NSAIDs
bromfenac
diclofenac
flurbiprofen ophth
ketorolac tromethamine
Nevanac
Acular PF
Prolensa
Prostaglandin Analogues/Prostamines
olatanoprost
otravoprost
oLumigan
PIzba
PoRescula
Po Travatan Z
PoXalatan
PoZioptan
Sympathomimetics
obrimonidine
o
Alphagan P 0.1%
Vasoconstrictors
naphazoline
phenylephrine ophth
Gout
allopurinol
colchicine/probenecid
probenecid
Colcrys
zMitigare
PzUloric
PzZurampic
Heart
Angiotensin Converting Enzyme Inhibitors
obenazepril
ocaptopril
oenalapril
ofosinopril
olisinopril
omoexipril
operindopril
oquinapril
oramipril
otrandolapril
oEpaned
zQbrelis
Angiotensin II Antagonists
zo
eprosartan 600mg
zoirbesartan
zolosartan
zotelmisartan
zovalsartan
PzoAtacand
PzoAvapro
PzoBenicar
PzoCozaar
PzoDiovan
PzoEdarbi
PzoMicardis
PzoTeveten
Anti-Adrenergic Blockers Centrally Acting
o
clonidine, oral, patch
oguanabenz
oguanfacine
omethyldopa
midodrine
oDibenzyline
+zNorthera
P =A step edit applies to this drug.
z =Specific Quantity Limits Apply.
=Prior Authorization Required.
u = Included in Tablet-Splitting Program
+ = Access restricted to specialty pharmacy.
o = Home Service Delivery.
TIER
Anti-Adrenergic Blockers Peripheral
odoxazosin
oprazosin
oterazosin
o
Cardura XL
Antiarrhythmics
oamiodarone
digoxin
odisopyramide
oflecainide
omexiletine
procainamide
opropafenone
o
propafenone SR
o
quinidine gluconate
o
quinidine sulfate SR
osotalol
Lanoxin
oMultaq
oNorpace/CR
oTikosyn
Antilipidemics
zuo atorvastatin calcium
ocholestyramine
ocolestipol
ofenofibrate
o
fenofibric acid, tab
ogemfibrozil
zuolovastatin
o
niacin ER
zoniacin/simvastatin
zuopravastatin
zrosuvastatin
zuosimvastatin
oAdvicor
oColestid
+zKynamro
+zPraluent
+zRepatha
zoAltoprev
zEpanova
zo
fenofibric acid, capsule DR
zofluvastatin
zJuxtapid
zo
Lescol XL
oLiptruzet
oLivalo
z
omega-3 acid ethyl esters
zOmtryg
Vascepa
zoVytorin
oWelchol
zoZetia
Beta Blockers
oacebutolol
oatenolol
betaxolol
obisoprolol
ocarvedilol
olabetalol
ometoprolol
o
metoprolol ER
ometoprolol/HCTZ
onadolol
opindolol
opropranolol
otimolol
o
Coreg CR
o
Innopran XL
oBystolic
oCorgard
Hemangeol
Calcium Channel Blockers
oamlodipine
o
cartia XT
o
diltia XT
odiltiazem
o
diltiazem CD/SR/ER/XR
o
felodipine ER
oisradipine
onicardipine
o
nifediac CC
o
nifedical XL
1
2
2
3
2
2
3
1
1
1
1
1
1
1
2
3
3
1
1
2
3
3
3
3
3
1
2
1
1
1
1
1
2
3
3
3
1
1
1
1
1
1
1
1
1
1
3
3
1
1
1
1
1
3
3
3
3
3
3
3
3
1
1
1
1
1
2
2
TIER
1
1
1
3
1
1
1
1
1
1
1
1
1
1
1
2
2
2
3
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
3
3
3
1
1
1
1
1
1
1
1
1
1
Note: 1. * Please note that medications listed in the 3rd tier are considered
non-formulary and are not all-inclusive.
2. * Some drugs are limited to 1 unit of use package per dispensing.
2
TIER
onifedipine
1
o
nifedipine SR
1
onimodipine
1
onisoldipine
1
overapamil/SR
1
oDynacirc/CR
3
zoNymalize
3
Combination Anti-Hypertensive
zoamlodipine/atorvastatin
1
oamlodipine/benazepril
1
oatenolol/chlorthalidone
1
obenazepril/HCTZ
1
obisoprolol/HCTZ
1
Pzocandesartan/HCTZ
1
ocaptopril/HCTZ
1
oenalapril/HCTZ
1
ofosinopril/HCTZ
1
zoirbesartan/HCTZ
1
olisinopril/HCTZ
1
zolosartan/HCTZ
1
omethyldopa/HCTZ
1
ometoprolol/HCTZ
1
opropranolol/HCTZ
1
oquinapril/HCTZ
1
zotelmisartan/HCTZ
1
zovalsartan/HCTZ
1
PzoTekamlo
2
PzoTekturna
2
Pzo Tekturna HCT
2
zoamlodipine/valsartan
3
zoamlodipine/valsartan/HCTZ
3
PzoAmturnide
3
Pzo Atacand HCT
3
PzoAvalide
3
zoAzor
3
Pzo Benicar HCT
3
z
Byvalson3
Pzo Diovan HCT
3
PzoEdarbyclor
3
zo
Exforge HCT
3
PzoHyzaar
3
Pzo Micardis HCT
3
zoPrestalia
3
zotelmisartan/amlodipine
3
Pzo Teveten HCT
3
otrandolapril/verapamil
3
zoTribenzor
3
Diuretics
oacetazolamide
1
o
acetazolamide ER
1
oamiloride
1
oamiloride/HCTZ
1
obumetanide
1
ochlorothiazide
1
ochlorthalidone
1
ofurosemide
1
ohydrochlorothiazide
1
oindapamide
1
omethazolamide
1
omethyclothiazide
1
ometolazone
1
ospironolactone
1
ospironolactone/HCTZ
1
otorsemide
1
otriamterene/HCTZ
1
Miscellaneous Cardiovascular Agents
zoeplerenone
1
midodrine
1
+zBerinert
2
zCinryze
2
+zFirazyr
2
oRanexa
2
+zRuconest
2
+zSamsca
2
zoCorlanor
3
zoEntresto
3
Pulmonary Arterial Hypertension
+z sildenafil citrate
1
+zAdcirca
2
+zLetairis
2
+zTracleer
2
Section I — Therapeutic drug categories (cont’d)
zUptravi
zAdempas
epoprostenol
+zOpsumit
Orenitram
zTyvaso
veletri
zVentavis
Vasodilators
ohydralazine
o
isosorbide dinitrate
o
isosorbide mononitrate
o
isosorbide mononitrate SA
oisoxsuprine
o
minoxidil oral
nitroglycerin pumpspray
nitroglycerin SR
nitroglycerin transdermal patch
o
Dilatrate SR
Nitrostat SL tabs
Gonitro
Minitran
NitroDur patches
HIV - Antivirals
TIER
2
3
3
3
3
3
3
3
1
1
1
1
1
1
1
1
1
2
2
3
3
3
Non-Nucleoside Reverse Transcriptase Inhibitor
Atripla
2
Edurant
2
Intelence
2
Rescriptor
2
Sustiva
2
Viramune, XR
2
Nucleoside Analog Reverse Transcriptase Inhibitor
Combination
abacavir/lamivudine/zidovudine 1
lamivudine/zidovudine
1
Complera
2
Descovy
2
Dutrebis
2
Odefsey
2
Stribild
2
Triumeq
2
Truvada
2
Viread
2
Nucleoside Reverse Transcriptase Inhibitors
didanosine
1
lamivudine tabs
1
stavudine
1
zidovudine
1
Emtriva
2
Epivir solution
2
Epzicom
2
Videx
2
Ziagen
2
Other
+Fuzeon
2
Genvoya
2
Isentress
2
Selzentry
2
Tivicay
2
Tybost
2
Vitekta
2
Protease Inhibitors
Aptivus
2
Crixivan
2
Evotaz
2
Invirase
2
Lexiva
2
Norvir
2
Prezcobix
2
Prezista
2
Reyataz
2
Viracept
2
Protease Inhibitors Combinations
Kaletra
2
Huntington’s Disease
+zXenazine
2
azathioprine
cyclosporine
gengraf
mycophenolate mofetil
1
1
1
1
Immunosuppressants
KEY:
mycophenolic acid
sirolimus
tacrolimus
Astagraf XL
Cellcept
Neoral
Prograf
Rapamune solution
Sandimmune
Zortress
z
Envarsus XR
Infection
TIER
Antibacterial Agents/Antibiotics
amoxicillin
1
amoxicillin-clavulanate ER
1
ampicillin
1
azithromycin suspension
1
azithromycin tablets
1
cefaclor
1
cefadroxil
1
cefdinir
1
cefpodoxime
1
cefprozil
1
cefuroxime
1
cephalexin
1
ciprofloxacin
1
clarithromycin susp
1
clarithromycin tabs
1
clindamycin
1
dicloxacillin
1
doxycycline
1
erythromycin base
1
erythromycin ethylsuccinate
1
erythromycin stearate
1
erythromycin/sulfisoxazole
1
levofloxacin
1
minocycline
1
nitrofurantoin
1
ofloxacin
1
penicillin VK
1
sulfamethoxazole/trimethoprim 1
tetracycline
1
Ery-Tab
2
Ketek
2
Zmax
2
zActiclate
3
Biaxin XL
3
Ceftin
3
Cleocin
3
erythromycin estolate
3
Factive
3
Minocin
3
moxifloxacin
3
Noroxin
3
PCE
3
Spectracef
3
Suprax
3
Vibramycin
3
Antifungals
clotrimazole lozenge
1
fluconazole
1
flucytosine
1
griseofulvin
1
zitraconazole
1
ketoconazole
1
nystatin
1
zterbinafine
1
zvoriconazole
1
zNoxafil
2
z
Sporanox suspension
2
zCresemba
3
Ecoza
3
z
Lamisil Oral
3
Luzu
3
Oravig
3
Antimalarials
atovaquone/proguanil HCl
1
chloroquine phosphate
1
mefloquine
1
+Daraprim
2
Primaquine
2
P =A step edit applies to this drug.
z =Specific Quantity Limits Apply.
=Prior Authorization Required.
u = Included in Tablet-Splitting Program
+ = Access restricted to specialty pharmacy.
o = Home Service Delivery.
TIER
quinine sulfate
3
Antituberculosis
oethambutol
1
oisoniazid
1
opyrazinamide
1
orifabutin
1
orifampin
1
Coartem
2
oRifater
2
oMyambutol
3
oRifadin
3
oRifamate
3
oSirturo
3
Antivirals
z
acyclovir oral
1
oamantadine
1
zfamciclovir
1
ganciclovir
1
+moderiba
1
+ribapak
1
+ribasphere
1
+ribavirin
1
rimantadine
1
zvalacyclovir
1
valganciclovir tablets
1
+PzDaklinza
2
Epivir-HBV solution
2
+zHarvoni
2
zHepsera
2
+zOlysio
2
+Pegasys
2
zRelenza
2
+zSovaldi
2
zTamiflu
2
+Victrelis
2
+PzViekira
2
+Pz Viekira XR
2
Baraclude solution
3
+Copegus
3
entecavir tablets
3
+PzEpclusa
3
+Infergen
3
+PPeg-Intron
3
+Rebetol
3
+Ribatab
3
zSitavig
3
+Pz Technivie3
zTyzeka
3
Valcyte
3
zValtrex
3
+Pz Zepatier3
Other Anti-Infectives
atovaquone
1
zlinezolid
1
methenamine combination
1
metronidazole
1
neomycin
1
nitrofurantoin
1
paromomycin
1
trimethoprim
1
tinidazole
1
+
tobramycin ampule/neb
1
vancomycin caps
1
Dapsone
2
Nebupent
2
zSivextro
2
+
Tobi Podhaler
2
+Bethkis
3
+Cayston
3
zDificid
3
Flagyl/ER
3
zImpavido
3
+z
Kitabis Pak
3
Macrodantin
3
+Tobi
3
Vancocin
3
zXifaxan
3
1
1
1
2
2
2
2
2
2
2
3
Impotence - possible contract exclusion; refer to
individual contract
yohimbine
zCaverject
zoCialis
zMUSE
zEdex
PzoLevitra
PzoStaxyn
PzoStendra
PzoViagra
Male Hormones

testosterone cypionate

testosterone enanthionate
Androderm patch
zAndrogel
Android
fluoxymesterone
PzAxiron
PzFortesta
PzNatesto
PStriant
PzTestim
Pz
Testosterone gel (brand)
PzVogelxo
Prostate Health
zoalfuzosin
zo
dutasteride odutasteride/tamsulosin
zo
finasteride 5mg
otamsulosin
oRapaflo
Mental Health
Antidepressants
amitriptyline
amitriptyline/ chlordiazepoxide
amitriptyline/perphenazine
amoxapine
bupropion
bupropion ER
bupropion XL
ucitalopram
clomipramine
desipramine
doxepin
duloxetine 20mg, 30mg, 60mg
uescitalopram
u
fluoxetine 10mg and 20mg tablet
fluoxetine capsule
u
fluvoxamine tablet
imipramine
maprotiline
umirtazapine
nefazodone
nortriptyline
uparoxetine
phenelzine
protriptyline
usertraline
tranylcypromine
trazodone
uvenlafaxine
venlafaxine ER
Pristiq ER
Viibryd
Desvenlafaxine ER
Desvenlafaxine Fumarate ER
duloxetine 40mg
Fetzima
fluoxetine 60mg tablet
fluvoxamine ER capsule
Forfivo
Khedezla
zu
Oleptro ER
Pexeva
Sarafem
Trintellix
Note: 1. * Please note that medications listed in the 3rd tier are considered
non-formulary and are not all-inclusive.
2. * Some drugs are limited to 1 unit of use package per dispensing.
3
TIER
Men’s Health
1
2
2
2
3
3
3
3
3
1
1
2
2
3
3
3
3
3
3
3
3
3
1
1
1
1
1
3
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
3
3
3
3
3
3
3
3
3
3
3
3
Section I — Therapeutic drug categories (cont’d)
TIER
Antimanic Agents
lithium carbonate
1
Antipsychotic Agents
aripiprazole
1
chlorpromazine
1
clozapine
1
fluphenazine
1
haloperidol
1
loxapine
1
zolanzapine
1
perphenazine
1
zquetiapine
1
zrisperidone
1
z
risperidone m-tab
1
thioridazine
1
thiothixene
1
trifluoperazine
1
z
ziprasidone caps
1
zLatuda
2
zSaphris
2
z
Seroquel XR
2
zFanapt
3
Fazaclo
3
+zNuplazid
3
zolanzapine/fluoxetine
3
z
paliperidone3
zRexulti
3
PVersacloz
3
zVraylar
3
zZyprexa
3
z
Zyprexa Zydis
3
Anxiolytics, Sedatives, and Hypnotics
alprazolam/ER
1
buspirone
1
chloral hydrate
1
chlordiazepoxide
1
clorazepate
1
diazepam
1
estazolam
1
flurazepam
1
lorazepam
1
meprobamate
1
oxazepam
1
temazepam
1
triazolam
1
zzaleplon
1
zzolpidem
1
z
zolpidem ER
1
+zHetlioz
2
PzAmbien
3
Pz
Ambien CR
3
Ativan
3
PzBelsomra
3
PzEdluar
3
Pzeszopiclone
3
PzIntermezzo
3
Librium
3
PzLunesta
3
PRozerem
3
PzSilenor
3
Somnote
3
PzSonata
3
Pz
zolpidem ER sublingual tablet
3
PzZolpimist
3
Cerebral Stimulants
dexmethylphenidate
1
dexmethylphenidate XR
1
dextroamphetamine tabs
1
generic Adderall
1
generic Adderall XR
1
generic Concerta
1
generic Dexedrine spansules
1
guanfacine ER
1
metadate ER
1
methylphenidate CD
1
methylphenidate/SR
1
zmodafinil
1
procentra
1
Ritalin LA 10mg, 60mg
2
KEY:
Strattera
Vyvanse
z
Adzenys XR ODT
zarmodafinil
z
Dyanavel XR
Focalin XR
z
Quillichew ER
Quillivant XR
Miscellaneous
TIER
Antidiuretic Agents
desmopressin solution
1
desmopressin tabs
1
Stimate
2
DDAVP nasal spray
3
DDAVP sol, tab
3
Other CNS
acamprosate calcium tablet EC
1
buprenorphine
1
disulfiram
1
naltrexone
1
riluzole
1
z
Narcan nasal spray
2
Suboxone film
2
PBunavail
3
Pbuprenorphine-naloxone
3
Campral dosepack
3
zEvzio
3
zGralise
3
PzHorizant
3
zNuedexta
3
Savella
3

Suboxone tablet
3
PZubsolv
3
Other Endocrine
danazol
1
fludrocortisone
1
+octreotide
1
+zCerdelga
2
+zEgrifta
2
+z HP Acthar Gel
2
zMyalept
2
+Norditropin
2
+Sensipar
2
Synarel
2
Zavesca
2
+PGenotropin
3
+PHumatrope
3
+Increlex
3
+Natpara
3
+PNutropin/AQ
3
+POmnitrope
3
+PSaizen
3
+Sandostatin
3
+
Sandostatin LAR
3
+PSerostim
3
+
Somatuline Depot
3
+zSomavert
3
+PTev-Tropin
3
+PZorbtive
3
Other Miscellaneous
z
Keveyis 2
zSignifor
2
Strensiq
2
Carbaglu
3
Cystadane
3
zKorlym
3
Procysbi
3
+Ravicti
3
+
sodium phenylbutyrate
3
+zVeltassa
3
zXuriden
3
Miscellaneous Immunologicals

Cuvitru3
+
Gammagard Liquid
3
+Gammaked
3
+Gamunex-C
3
+Hizentra
3
+HyQvia
3
Vivaglobin
3
P =A step edit applies to this drug.
z =Specific Quantity Limits Apply.
=Prior Authorization Required.
u = Included in Tablet-Splitting Program
+ = Access restricted to specialty pharmacy.
o = Home Service Delivery.
TIER
Multiple Sclerosis Agents
2
2
3
3
3
3
3
3
+zglatopa
+Avonex
+Rebif
+
Copaxone 40mg
+zGilenya
+zTecfidera
+Ampyra
+zAubagio
+PBetaseron
+
Copaxone 20mg
+PExtavia
+PzPlegridy
+zZinbryta
1
2
2
2
2
2
3
3
3
3
3
3
3
baclofen
carisoprodol
carisoprodol/ASA
chlorzoxazone
cyclobenzaprine
dantrolene sodium
metaxalone
methocarbamol
orphenadrine
tizanidine
1
1
1
1
1
1
1
1
1
1
zoalendronate
zocalcitonin-salmon
zo
fortical NS
zo
ibandronate tabs
zoraloxifene
+zForteo
PzoActonel
PzoAtelvia
PzoBinosto
PzoBoniva
PzoFosamax
Pzo Fosamax D
zo
risedronate 150mg
Pzo risedronate DR
1
1
1
1
1
2
3
3
3
3
3
3
3
3
Muscle Relaxants
Osteoporosis
Pain/Arthritis
Analgesics, Narcotic
acetaminophen w/codeine
belladonna & opium supp
butalbital/APAP/codeine
butalbital/aspirin/codeine
butorphanol NS
codeine sulfate
endocet
z
fentanyl lozenge
fentanyl patch
hydrocodone/APAP
hydrocodone/ibuprofen
hydromorphone
meperidine
methadone
morphine SR
z
morphine sulfate ER
morphine tab, soln, supp
oxycodone
oxycodone/acetaminophen
oxycodone/aspirin
oxycodone/ibuprofen
oxymorphone/ER
pentazocine/naloxone
Kadian (40mg, 70mg, 130mg, 150mg,
200mg) Oxycodone ER
Oxycontin
zAbstral
zBelbuca
Demerol
Embeda
fentanyl patch 37.5mcg/hr, 62.5mcg/hr,
and 87.5mcg/hr
zFentora
Fioricet/codeine
Fiorinal/codeine
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
3
3
3
3
3
3
3
3
Note: 1. * Please note that medications listed in the 3rd tier are considered
non-formulary and are not all-inclusive.
2. * Some drugs are limited to 1 unit of use package per dispensing.
4
TIER
hydromorphone ER
3
Hysingla ER
3
zLazanda
3
Nucynta/ER
3
Roxicet Soln
3
zSubsys
3
Targiniq ER
3
Trezix
3
Tylenol/codeine
3
Vicodin/ES
3
Xartemis XR
3
z
Xtampza ER3
Zohydro ER
3
Analgesics, Salicylates
o
choline mag. trisalicylate
1
odiflunisal
1
osalsalate
1
oEasprin
3
Anti-Rheumatic
ohydroxychloroquine
1
leflunomide
1
methotrexate
1
+zActemra
2
oCuprimine
2
+zEnbrel
2
+zHumira
2
zKineret
2
+zOtezla
2
oRidaura
2
+zXeljanz
2
+z Xeljanz XR 2
+PzCimzia
3
oDepen
3
+Pz Orencia SC
3
Otrexup
3
Rasuvo
3
+PzSimponi
3
Cox-2s
zocelecoxib
1
Migraine (Analgesics, Non-narcotic)
butalbital/APAP
1
butalbital/APAP/caffeine
1
butalbital/aspirin/caffeine
1
z
dihydroergotamine mesylate
1
ergotamine/caffeine
1
isometh/dichloralphen/APAP 1
znaratriptan
1
zrizatriptan
1
zsumatriptan
1
tramadol/ER tablet
1
tramadol/acetaminopen
1
zzolmitriptan
1
Ergomar
2
zRelpax
2
PzAmerge
3
PzAxert
3
Cafergot
3
zCambia
3
PzFrova
3
PzImitrex
3
PzMaxalt
3
Pz
Maxalt MLT
3
PzOnzetra
3
zSumavel
3
tramadol ER capsule
3
PzTreximet
3
+PzZecuity
3
PzZembrace
3
PzZomig
3
Pz
Zomig Nasal
3
Pz
Zomig ZMT
3
Nonsteroidal Anti-Inflammatory/Combination
Products
o
diclofenac potassium
1
o
diclofenac sodium
1
z
diclofenac sodium gel 1%
1
oetodolac
1
o
etodolac SA
1
ofenoprofen
1
Section I — Therapeutic drug categories (cont’d)
TIER
oflurbiprofen
oibuprofen
oindomethacin
oketoprofen
ketorolac inj.
z
ketorolac tab
omeclofenamate
o
mefenamic acid
omeloxicam
onabumetone
onaproxen/EC
ooxaprozin
opiroxicam
osulindac
otolmetin
diclofenac sodium 3% gel
o
diclofenac sodium/misoprostol
Pz
diclofenac sodium topical solution
PDuexis
PzFlector
oNaprosyn
PzPennsaid
zSprix
oTivorbex
PzoVimovo
PzVivlodex
oZorvolex
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
3
3
3
3
3
3
3
3
3
3
3
3
obenztropine
obromocriptine
ocarbidopa/levodopa
o
carbidopa/levodopa SA
oentacapone
opramipexole
oropinirole
zoselegiline
otrihexyphenidyl
+Apokyn
zDuopa
ocarbidopa
pergolide
o
pramipexole ER
o
ropinirole ER
oRytary
Tasmar
1
1
1
1
1
1
1
1
1
2
2
3
3
3
3
3
3
Parkinson’s Disease
Potassium
Potassium agents
o
potassium bicarb/potassium chloride
o
potassium bicarbonate
o
potassium chloride
oMicro-K
Potassium Removing agent
sod. polystyrene sulfonate
Kayexalate
Respiratory/Asthma
Adrenergic
epinephrine inj.
Epipen/Jr.
Twinject
PAdrenaclick
PAuviQ
Corticosteroids
o
budesonide inh.
(0.25mg/2ml, 0.5mg/2ml)
zo
Arnuity Ellipta
zoAsmanex
zo
Flovent HFA/Diskus
zo
Pulmicort flexhaler/powder
o
Pulmicort respules (1mg/2ml)
zoQvar
zAerobid/M
oAlvesco
Leukotrienes
omontelukast
ozafirlukast
zoZyflo/CR
Other Agents
cromolyn inh. soln.
ipratropium inh. soln.
ipratropium/albuterol
KEY:
1
1
1
3
1
3
1
2
2
3
3
1
2
2
2
2
2
2
3
3
1
1
3
1
1
1
TIER
z
Advair diskus
Anoro Ellipta
z
Atrovent HFA
Breo Ellipta
z
Combivent Respimat
+zEsbriet
+zKalydeco
+zOfev
+zOrkambi
+Pulmozyme
zSpiriva
z
Spiriva Respimat
z
Stiolto Respimat
zSymbicort
zBevespi
oDaliresp
zDulera
+Glassia
z
Incruse Ellipta
zSeebri
Tudorza
zUtibron
Sympathomimetics
o
albuterol sulfate ER
o
albuterol tab, syr
o
metaproterenol syr
o
terbutaline tab
zForadil
z
Maxair Autohaler
z
ProAir HFA/RespiClick
z
Serevent Diskus
z
Ventolin HFA
Arcapta
z
Proventil HFA
z
Striverdi Respimat
Xopenex HFA
Xanthine Derivatives
oaminophylline
otheochron
o
theophylline/SR tabs, liquid
oTheo-24
oElixophyllin
Seizures
Barbiturates
mephobarbital
phenobarbital
Hydantoins
ophenytoin
oDilantin
oPeganone
Miscellaneous
ocarbamazepine
o
carbamazepine XR 200mg, 400mg
clonazepam
o
divalproex sodium/ER
felbamate
ogabapentin
olamotrigine
olevetiracetam
ooxcarbazepine
oprimidone
otopiramate
o
valproic acid
ozonisamide
o
Banzel tablets
o
Gabitril 12mg, 16mg
oTegretol
o
Tegretol XR 100mg
oAptiom
o
Banzel suspension
zBriviact
zFycompa
o
lamotrigine ER/ODT
Lyrica
o
Oxtellar XR
Potiga
o
Qudexy XR
Sabril
o
topiramate ER
o
Trokendi XR
Vimpat
P =A step edit applies to this drug.
z =Specific Quantity Limits Apply.
=Prior Authorization Required.
u = Included in Tablet-Splitting Program
+ = Access restricted to specialty pharmacy.
o = Home Service Delivery.
Succinimides
oethosuximide
oCelontin
2
2
2
2
2
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
Skin
TIER
1
2
Acne/Rosacea
adapalene
1
amnesteem
1
avita cream
1
benzoyl peroxide
1
claravis
1
clindamycin/benzoyl peroxide
1
clindamycin phospate
1
erythromycin/benz peroxide
1
minocycline
1
prascion RA
1
sodium sulfacetamide
1
sod. sulfacetamide/sulfur
emulsion cleanser
1
sod. sulfacetamide/sulfur lot
1
sotret
1
tretinoin cr/gel
1
PAbsorica
3
P
Acanya3
P
Aczone3
P
Adapalene lotion
3
P
Avar3
P
Avita gel
3
P
Azelex3
P
Benzaclin3
P
Benzamycin3
P
Cleocin T
3
P
Differin3
PDoryx
3
P
Duac3
P
doxycycline hyclate DR
3
P
Doxycycline IR-DR
3
P
Epiduo/Forte3
P
Evoclin3
PFabior
3
P
Finacea3
P
Metrogel topical 1%
3
P
minocycline HCl ER
3
PMirvaso
3
PNoritate
3
POnexton
3
POracea
3
P
Retin-A/Micro3
P
Rosula3
PSolodyn
3
Soolantra
3
PTazorac
3
P
tretinoin microsphere
3
P
Veltin gel
3
P
Ziana gel
3
Antibiotics (Topical)
clindamycin sol/swabs/gel/lotion
1
erythromycin sol/swabs/gel
1
gentamicin cr/oint
1
metronidazole cream/lotion/ 0.75% gel 1
mupirocin
1
Bactroban cream
3
Centany
3
Antipsoriatics
acitretin
1
calcipotriene
1
tacrolimus
1
+zCosentyx
2
Dritho-Scalp
2
Elidel
2
+zStelara
2
P
calcipotriene-betamethasone ointment 3
calcitriol ointment
3
PEnstilar
3
PTaclonex
3
+PzTaltz
3
Burn preparation
silver sulfadiazine
1
Fungicides
betamethasone/clotrimazole 1
ciclopirox cream
1
ciclopirox soln
1
1
1
1
1
2
2
2
2
2
3
3
3
3
1
1
1
2
3
1
1
1
2
3
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
Smoking Cessation
1
1
1
1
1
2
2
3
3
3
1
1
1
1
1
2
2
2
2
3
3
3
2
2
1
1
1
2
2
3
3
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
3
3
3
3
3
3
3
3
1
1
1
3
1
2
3
Members coverage varies by plan. Patient should be
in a smoking cessation program.
zbupropion
1
z
Nicorelief gum
1
z
Nicorelief lozenge
1
z
Nicotine Gum
1
Note: 1. * Please note that medications listed in the 3rd tier are considered
non-formulary and are not all-inclusive.
2. * Some drugs are limited to 1 unit of use package per dispensing.
5
TIER
econazole
ketoconazole
nystatin
nystatin/triamcinolone
nystop
Exelderm
Oxistat
zJublia
zKerydin
Naftin
Other Topicals
aluminum chloride 20%
fluorouracil
imiquimod 5% cream
podofilox
sodium chloride irrigating soln
Panretin
Phisohex
Picato
Regranex
Carac
Fluoroplex
Regenecare
Psoralens
8-MOP
Oxsoralen Ultra
Scabicides & Pediculicides
acticin
permethrin
spinosad
Lindane
Ulesfia
Eurax
Sklice
Topical Anti-Inflammatory Agents
alclometasone
amcinonide
aug. betamethasone diprop
betamethasone dipropionate
betamethasone valerate
clobetasol emol/emuls
clobetasol propionate
desonide
desoximetasone
diflorasone
fluocinolone acetonide
fluocinonide
fluticasone propionate
halobetasol
halobetasol propionate
hydrocortisone 2.5%
hydrocortisone valerate
hydrocortisone/iodoquinol
mometasone cr/oint
prednicarbate
triamcinolone acetonide
Cordran tape
betamethasone valerate foam
Capex Shampoo
clobetasol propionate shampoo
Cordran SP
fluocinonide cream (generic Vanos)
Halog
hydrocortisone butyrate/emoll cream
Kenalog/aerosol
Topical Antipruritics/Anesthetics
lidocaine
z
lidocaine patch
selenium sulf 2.5% suspension
Rectiv
Topical Antivirals
acyclovir ointment
Zovirax Cream
Denavir
Section I — Therapeutic drug categories (cont’d)
TIER
z
Nicotine lozenges
z
Nicotine patches various
zChantix
zCommit
z
Nicotrol Inhaler
z
Nicotrol NS
zZyban
Steroids
cortisone acetate
dexamethasone oral
hydrocortisone oral
methylprednisolone 4mg, 8mg,
16mg, 32mg prednisolone oral
prednisone oral
Medrol 2mg
Rayos
Stomach/Ulcer
1
1
2
2
2
2
3
1
1
1
1
1
1
2
3
Anorectal
hydrocortisone rectal cr. & supp.
1
hydrocortisone rectal enema
1
pramoxine/HC acetate 2.5%
1
Analpram-HC 1-1%
2
Cortifoam
2
Proctofoam-HC
2
Analpram-HC 2.5% cr/lot
3
Anticholinergics/Antispasmodic/GI Motility
belladonna/phenobarbital
1
chlordiazepoxide/clindinium 1
dicyclomine
1
glycopyrrolate
1
hyoscyamine/CR
1
metoclopramide
1
Donnatal tablet
2
Antidiarrheal
diphenoxylate/atropine
1
paregoric
1
zAlinia
2
Fulyzaq
2
Antiemetic/Antivertigo
zgranisetron
1
meclizine
1
zondansetron
1
prochlorperazine
1
promethazine
1
trimethobenzamide
1
Antivert 50mg
2
zAnzemet
2
zEmend
2
Transderm Scop
2
+PzAkynzeo
3
zDiclegis
3
zGranisol
3
zSancuso
3
zSyndros
3
zVarubi
3
zZuplenz
3
Bowel Evacuants
peg 3350/electrolyte
1
Trilyte
1
Halflytely
2
Nulytely
3
Prepopik
3
Suclear
3
Suprep
3
Digestants
oCreon
2
oZenpep
2
oPancreaze
3
oPertzye
3
oUltresa
3
oViokace
3
Gallstone Solubilizing Agents
oursodiol
1
+z Ocaliva3
H2 Antagonists
ocimetidine
1
ofamotidine
1
onizatidine
1
o
ranitidine (all)
1
KEY:
TIER
Other Antiulcer
omisoprostol
propantheline bromide
osucralfate
Helidac
lansoprazole/amox/clarith
Other GI Products
balsalazide
budesonide EC
o
cromolyn sodium
enulose
lactulose
mesalamine enema
osulfasalazine
o
sulfasalazine EC
Asacol HD
Canasa supp.
Cholbam
Delzicol
Dipentum
+Kuvan
Linzess
Pentasa
z
Relistor injection
z
Relistor tablets
alosetron
PzAmitiza
Apriso
oAzulfidine
+Gattex
Giazo
zMovantik
Uceris
Proton Pump Inhibitors
zolansoprazole
z
Nexium 24HR
zoomeprazole
zopantoprazole
z
Prevacid 24HR
zPrilosec-OTC
z
Zegerid OTC
zo
Nexium susp
zo
Prevacid Solutab
PzoAciphex
PzoDexilant
Pzo esomeprazole magnesium
PzoNexium
PzoPrevacid
PzoPrilosec
PzoProtonix
zorabeprazole
PzoZegerid
Thyroid
Antithyroid
omethimazole
opropylthiouracil
Thyroid
levothroid
olevothyroxine
olevoxyl
oliothyronine
othyroid
ounithroid
oSynthroid
o
Thyroid (Armour)
oThyrolar
Vitamins
ocalcitriol
o
calcitriol inj
calcium acetate
cholecalciferol
o
cyanocobalamin inj.
o
ergocalciferol capsule
oetidronate
o
folic acid Rx 1mg tab
leucovorin
levocarnitine
omultivitamin + fluoride
potassium aminobenzoate
P =A step edit applies to this drug.
z =Specific Quantity Limits Apply.
=Prior Authorization Required.
u = Included in Tablet-Splitting Program
+ = Access restricted to specialty pharmacy.
o = Home Service Delivery.
1
1
1
3
3
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
TIER
o
pre-natal vitamins
sevelamer
o
sodium fluoride chewable tab & drops
o
vit A,D,C + fluoride
o
vit A,D,C + fluoride and iron
Galzin
oMephyton
oNascobal
Orfadin
ophytonadione
o
Prenate Elite
Renagel
Renvela
zAuryxia
Fosrenol
paricalcitol
oPoly-Vi-Flor + Iron
zRayaldee
oTri-Vi-Flor
Velphoro
1
1
1
1
1
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
benzphetamine
diethylpropion
phentermine
Belviq
z
Belviq XR
zContrave
zQsymia
zSaxenda

Suprenza ODT
Xenical
1
1
1
3
3
3
3
3
3
3
Weight Loss - possible contract exclusion;
refer to individual contract
Women’s Health
1
1
1
1
1
1
1
2
2
3
3
3
3
3
3
3
3
3
Contraceptives - Other
oxulane
Mirena
oNuvaRing
Skyla
o
Depo-SubQ Provera
Liletta
Paragard
Fertility Induction Agents - possible contract
exclusion; refer to individual contract

chorionic gonadotropin 10000 unit vial
clomiphene

progesterone in oil
serophene
Bravelle
Cetrotide

Follistim AQ
Novarel
Ovidrel
Repronex
Ganirelix
P Gonal F
Menopur
Pregnyl
Hormones
zo
estradiol/noreth ac
zo
estradiol oral
zo
estradiol patches
zoestropipate
zoestrogen/methyltesterone
zojinteli
omedroxyprogesterone
onorethindrone
o
progesterone, micronized
zoAlora
oCenestin
zoCombipatch
oEnjuvia
o
Estrace Vag. Cream
zoEstraderm
zoEstring
oEvamist
oMenest
oPremarin
Premarin vag cream
1
1
1
1
1
1
1
1
2
2
2
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
3
3
3
1
1
1
1
2
2
2
2
2
2
3
3
3
3
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
oPremphase
Prempro
oVagifem
zo
Climara Pro
o
Crinone 8%
Duavee
zo
Estrasorb packet
zoEstrogel
zoFemring
zoMenostar
Ortho-Est
Osphena
zoPrefest
Miscellaneous
zAddyi
Brisdelle
Oral Contraceptives
oamethia
oamethyst
oapri
oaranelle
oaviane
obalziva
ocamila
ocamrese
ocesia
ocryselle
oenpresse
oerrin
ojolessa
ojolivette
ojunel/FE
okariva
olessina
olevora
olow-ogestrel
olutera
omicrogestin/FE
omononessa
onecon
onora-BE
o
norethindrone a-e estradiol/
ferrous fumarate
onortrel
oocella
oogestrel
oportia
oprevifem
oquasense
osolia
osprintec
otri-sprintec
otrinessa
otriprevifem
otrivora
ovelivet
ozarah
ozenchent
ozovia
o
Ortho Tri-Cyclen Lo
oOvcon-50
oBeyaz
Oxytocic Agents
methylergonovine maleate
Methergine
Vaginal Preparations
miconazole vag supp
nystatin vag tab
terconazole
vandazole vag
Cleocin Vag/Ovules
Clindesse
Gynazole-1
Note: 1. * Please note that medications listed in the 3rd tier are considered
non-formulary and are not all-inclusive.
2. * Some drugs are limited to 1 unit of use package per dispensing.
6
TIER
2
2
2
3
3
3
3
3
3
3
3
3
3
3
3
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
3
1
3
1
1
1
1
3
3
3
Section II — Index
DRUG NAME TIER PAGE DRUG NAME A
abacavir/lamivudine/
zidovudine
13
PAbsorica
35
zAbstral
34
acamprosate calcium
tablet EC
1
4
PAcanya
35
acarbose
11
PAccu-Chek1
oacebutolol
12
acetaminophen w/codeine1 4
oacetazolamide
12
oacetazolamide ER
1
2
acetic acid HC otic
1
2
acetic acid otic
1
2
acetic acid/aluminum acetate1
2
acetylcysteine inh soln. 1
1
PzoAciphex
36
acitretin
15
+zActemra
24
acticin
15
zActiclate
33
+zActimmune
21
PzoActonel
34
Acular PF
3
2
acyclovir ointment
1
5
zacyclovir oral
1
3
PAczone
35
adapalene
15
PAdapalene lotion
3
5
+zAdcirca
22
zAddyi
36
zAdempas
33
zAdlyxin 3
1
PAdrenaclick
35
oAdvicor
22
zAdzenys XR ODT
3
4
zAerobid/M
35
+zAfinitor
21
Afrezza
31
oAggrenox
21
+PzAkynzeo
36
oalbuterol sulfate ER
1
5
oalbuterol tab, syr
1
5
alclometasone
15
+zAlecensa
31
zoalendronate
14
zoalfuzosin
13
zAlinia
26
Alkeran
21
allopurinol
12
Alomide
22
zoAlora
26
alosetron
36
oAlphagan P 0.1%
2
2
alprazolam/ER
14
+Alprolix
31
zoAltoprev
32
aluminum chloride 20% 1
5
oAlvesco
35
oamantadine
13
PzAmbien
34
PzAmbien CR
3
4
amcinonide
15
PzAmerge
34
oamethia
16
oamethyst
16
oamiloride
12
oamiloride/HCTZ 12
oaminophylline
15
oamiodarone
12
PzAmitiza
36
amitriptyline
13
amitriptyline/chlordiazepoxide1
3
amitriptyline/perphenazine1 3
oamlodipine
12
zoamlodipine/atorvastatin1 2
oamlodipine/benazepril1 2
zoamlodipine/valsartan3 2
zoamlodipine/
valsartan/HCTZ
32
amnesteem
15
amoxapine
13
amoxicillin
13
amoxicillin-clavulanate ER1 3
ampicillin
13
+Ampyra
34
PzoAmturnide
32
anagrelide
11
Analpram-HC 1-1%
2
6
KEY:
TIER PAGE DRUG NAME TIER PAGE DRUG NAME Analpram-HC 2.5% cr/lot3 6
anastrozole
11
Androderm patch
2
3
zAndrogel
23
Android
33
Antivert 50mg
2
6
zAnzemet
26
PApidra
31
+Apokyn
25
oapri
16
Apriso
36
oAptiom
35
Aptivus
23
oaranelle
16
+Aranesp
21
zArcalyst
21
Arcapta
35
aripiprazole
14
zarmodafinil
34
zoArnuity Ellipta
2
5
Asacol HD
2
6
PAscensia Breeze
2
zoAsmanex
25
Astagraf XL
2
3
PzoAtacand
32
PzoAtacand HCT
3
2
PzoAtelvia
34
oatenolol
12
oatenolol/chlorthalidone1 2
Ativan
34
zuoatorvastatin calcium1 2
atovaquone
13
atovaquone/proguanil HCl1 3
Atripla
23
atropine sulfate ophth
1
2
Atrovent Nasal Spray
3
1
+zAubagio
34
aug. betamethasone diprop1 5
zAuryxia
36
PAuviQ
35
PzoAvalide
32
zAvandamet
21
zAvandaryl
21
zAvandia
21
PzoAvapro
32
PAvar
35
oaviane
16
avita cream
1
5
PAvita gel
3
5
+Avonex
24
PzAxert
34
PzAxiron
33
Azasite
32
azathioprine
13
azelastine nasal spray
1
1
azelastine ophth
1
2
PAzelex
35
azithromycin suspension 1
3
azithromycin tablets
1
3
oAzopt
22
zoAzor
32
oAzulfidine
36
B
bacitracin ophth
1
2
bacitracin/polymyxin 12
baclofen
14
Bactroban cream
3
5
balsalazide
16
obalziva
16
oBanzel suspension
3
5
oBanzel tablets
2
5
Baraclude solution
3
3
PzoBeconase AQ
3
1
zBelbuca
34
belladonna & opium supp1 4
belladonna/phenobarbital1
6
PzBelsomra
34
Belviq
36
zBelviq XR
3
6
obenazepril
12
obenazepril/HCTZ 12
PzoBenicar
32
PzoBenicar HCT
3
2
PBenzaclin
35
PBenzamycin
35
benzonatate
11
benzoyl peroxide
1
5
benzphetamine 16
obenztropine
15
Bepreve
32
+zBerinert
22
P =A step edit applies to this drug.
z =Specific Quantity Limits Apply.
=Prior Authorization Required.
u = Included in Tablet-Splitting Program
+ = Access restricted to specialty pharmacy.
o = Home Service Delivery.
Besivance
32
betamethasone dipropionate1
5
betamethasone valerate 1
5
betamethasone valerate foam3
5
betamethasone/clotrimazole1 5
+PBetaseron
34
betaxolol
12
obetaxolol HCl
1
2
+Bethkis
33
oBetoptic-S
22
+bexarotene
11
zBevespi
35
oBeyaz
36
Biaxin XL
3
3
bicalutamide
11
PzoBinosto
34
obisoprolol
12
obisoprolol/HCTZ 12
PzoBoniva
34
+zBosulif
21
Bravelle
26
oBrilinta
31
obrimonidine
12
Brisdelle
36
zBriviact
35
bromfenac
12
obromocriptine
15
brompheniramine/
phenylephrine
11
brompheniramine/
pseudoephedrine 11
budesonide EC
1
6
obudesonide inh.
(0.25mg/2ml, 0.5mg/2ml)1
5
obumetanide
12
PBunavail
34
buprenorphine
14
Pbuprenorphine-naloxone3 4
bupropion
13
zbupropion
15
bupropion ER
1
3
bupropion XL
1
3
buspirone
14
butalbital/APAP
14
butalbital/APAP/caffeine1 4
butalbital/APAP/codeine1 4
butalbital/aspirin/caffeine1
4
butalbital/aspirin/codeine1
4
butorphanol NS
1
4
zBydureon
21
zByetta
21
zByvalson
32
oBystolic
32
C
+zCabometyx
21
Cafergot
34
calcipotriene
15
Pcalcipotrienebetamethasone ointment3 5
zocalcitonin-salmon1 4
ocalcitriol
16
ocalcitriol inj
1
6
calcitriol ointment
3
5
calcium acetate
1
6
zCambia
34
ocamila
16
Campral dosepack
3
4
ocamrese
16
Canasa supp.
2
6
Pzocandesartan/HCTZ1
2
capecitabine
11
Capex Shampoo
3
5
zCaprelsa
21
ocaptopril
12
ocaptopril/HCTZ 12
Carac
35
Carbaglu
34
ocarbamazepine 15
ocarbamazepine XR
200mg, 400mg
1
5
ocarbidopa
35
ocarbidopa/levodopa1 5
ocarbidopa/levodopa SA1 5
Cardec/DM
31
oCardura XL
3
2
carisoprodol
14
carisoprodol/ASA 14
ocarteolol
12
ocartia XT
1
2
ocarvedilol
12
zCaverject
23
TIER PAGE DRUG NAME +Cayston
33
CeeNu
21
cefaclor
13
cefadroxil
13
cefdinir
13
cefpodoxime
13
cefprozil
13
Ceftin
33
cefuroxime
13
zocelecoxib
14
Cellcept
23
oCelontin
25
oCenestin
26
Centany
35
cephalexin
13
24
+zCerdelga
ocesia
16
ocetirizine
11
Cetrotide
26
zChantix
26
chloral hydrate
1
4
chlordiazepoxide
14
chlordiazepoxide/clindinium1 6
chloroquine phosphate 1
3
ochlorothiazide
12
chlorpromazine
14
chlorpropamide
11
ochlorthalidone
12
chlorzoxazone
14
Cholbam
26
cholecalciferol
16
ocholestyramine 12
ocholine mag. trisalicylate1 4
chorionic gonadotropin
10000 unit vial
1
6
zoCialis
23
ciclopirox cream
1
5
ciclopirox soln
1
5
ocilostazol
11
Ciloxan
32
ocimetidine
16
34
+PzCimzia
zCinryze
22
Cipro HC
3
2
Ciprodex
22
ciprofloxacin
13
ciprofloxacin ophth
1
2
ucitalopram
13
citric acid/sod citrate
1
1
claravis
15
zoClarinex-D
31
Clarispray
11
clarithromycin susp
1
3
clarithromycin tabs
1
3
clemastine
11
Cleocin
33
PCleocin T
3
5
Cleocin Vag/Ovules
3
6
zoClimara Pro
3
6
clindamycin
13
clindamycin phospate
1
5
clindamycin sol/
swabs/gel/lotion
15
clindamycin/benzoyl peroxide1
5
Clindesse
36
clobetasol emol/emuls
1
5
clobetasol propionate
1
5
clobetasol propionate
shampoo
35
clomiphene
16
clomipramine
13
clonazepam
15
oclonidine, oral, patch 1
2
oclopidogrel
11
clorazepate
14
clotrimazole lozenge
1
3
clozapine
14
Coartem
23
codeine sulfate
1
4
colchicine/probenecid1 2
Colcrys
22
oColestid
22
ocolestipol
12
zoCombipatch
26
zCometriq
21
zCommit
26
Complera
23
PContour2
zContrave
36
3
4
+Copaxone 20mg
2
4
+Copaxone 40mg
33
+Copegus
TIER PAGE DRUG NAME TIER PAGE
odisopyramide
12
disulfiram
14
PzDitropan XL
3
1
odivalproex sodium/ER 1
5
Domeboro
32
zodonepezil
11
Donnatal tablet
2
6
PDoryx
35
odorzolamide 2%
eye drops
1
2
odorzolamide/timolol
eye drops
1
2
odoxazosin
12
doxepin
13
doxycycline
13
Pdoxycycline hyclate DR3 5
PDoxycycline IR-DR
3
5
Dritho-Scalp
25
PDuac
35
Duavee
36
zDuetact
21
PDuexis
35
duloxetine
20mg, 30mg, 60mg
1
3
duloxetine 40mg
3
3
zDuopa
25
zDurlaza
31
zodutasteride 1
3
D
odutasteride/tamsulosin1
3
+PzDaklinza
23 Dutrebis
23
danazol
14 zDyanavel XR
3
4
dantrolene sodium
1
4 oDynacirc/CR
32
Dapsone
23
E
+Daraprim
23
34
DDAVP nasal spray
3
4 oEasprin
econazole
15
DDAVP sol, tab
3
4
Ecoza
33
Delzicol
26
32
Demerol
34 PzoEdarbi
Denavir
35 PzoEdarbyclor 32
z
Edex
33
oDepen
34
34
oDepo-SubQ Provera
3
6 PzEdluar
23
Descovy
23 Edurant
oEffient
21
desipramine
13
+

z
Egrifta
24
zodesloratadine 31
25
desmopressin solution 1
4 8-MOP

Elidel
25
desmopressin tabs
1
4
Eliquis
31
desonide
15
oElixophyllin
35
desoximetasone
15
+Eloctate
31
Desvenlafaxine ER
3
3
Embeda
34
Desvenlafaxine Fumarate ER3
3
Emcyt
21
PzDetrol
31
zEmend
26
PzDetrol LA
3
1
Emtriva
23
dexameth/neomycin/poly B1 2
PzEnablex
31
dexamethasone oral
1
6 oenalapril
12
dexchlorpheniramine11 oenalapril/HCTZ
12
PzoDexilant
36 +zEnbrel
24
dexmethylphenidate 14 endocet
14
dexmethylphenidate XR 1
4 oEnjuvia
26
dextroamphetamine tabs 1
4 enoxaparin
11
diazepam
14 oenpresse
16
oDibenzyline
22 PEnstilar
35
zDiclegis
36 oentacapone
15
diclofenac
12 entecavir tablets
3
3
odiclofenac potassium 1
4 zoEntresto
32
odiclofenac sodium
1
4 enulose
16
diclofenac sodium 3% gel3 5 zEnvarsus XR
3
3
zdiclofenac sodium gel 1%1 4 oEpaned
32
Pzdiclofenac sodium
zEpanova
32
topical solution
3
5 +PzEpclusa
33
odiclofenac sodium/
PEpiduo/Forte
35
misoprostol
35 epinephrine inj.
1
5
dicloxacillin
13 Epipen/Jr.
25
dicyclomine
16 Epivir solution
2
3
didanosine
13 Epivir-HBV solution
2
3
diethylpropion
16 zoeplerenone
12
PDifferin
35 +Epogen
31
zDificid
33 epoprostenol
33
diflorasone
15 zoeprosartan 600mg
1
2
odiflunisal
14 Epzicom
23
digoxin
12 oergocalciferol capsule 1
6
zdihydroergotamine mesylate1
4 ergoloid mesylates
1
1
oDilantin
25 Ergomar
24
oDilatrate SR
2
3 ergotamine/caffeine 14
odiltia XT
1
2 +zErivedge
21
odiltiazem
12 oerrin
16
odiltiazem CD/SR/ER/XR1 2 Ery-Tab
23
PzoDiovan
32 erythromycin base
1
3
PzoDiovan HCT
3
2 erythromycin estolate
3
3
Dipentum
26 erythromycin ethylsuccinate1
3
diphenhydramine 11 erythromycin ophth
1
2
diphenoxylate/atropine1 6 erythromycin sol/swabs/gel1 5
odipyridamole
11 erythromycin stearate
1
3
Cordran SP
Cordran tape
oCoreg CR
oCorgard
zoCorlanor
Cortifoam
cortisone acetate
+zCosentyx
+zCotellic
Coumadin
PzoCozaar
oCreon
zCresemba
oCrinone 8%
Crixivan
cromolyn ophth
ocromolyn sodium
ocryselle
oCuprimine
Cuvitru
ocyanocobalamin inj.
cyclobenzaprine
cyclophosphamide
cyclosporine
cyproheptadine
Cystadane
+Cystaran
3
5
2
5
2
2
32
32
26
1
6
25
21
21
32
26
33
3
6
23
1
2
1
6
16
24
34
1
6
14
11
13
11
34
22
Note: 1. * Please note that medications listed in the 3rd tier are considered
non-formulary and are not all-inclusive.
2. * Some drugs are limited to 1 unit of use package per dispensing.
7
Section II — Index (cont’d)
DRUG NAME TIER PAGE DRUG NAME erythromycin/benz peroxide1 5
erythromycin/sulfisoxazole1 3
uescitalopram
13
Pzoesomeprazole
magnesium
36
estazolam
14
oEstrace Vag. Cream
2
6
zoEstraderm
26
zoestradiol oral
1
6
zoestradiol patches
1
6
zoestradiol/noreth ac 1
6
zoEstrasorb packet
3
6
zoEstring
26
zoEstrogel
36
zoestrogen/methyltesterone1 6
zoestropipate
16
Pzeszopiclone
34
oethambutol
13
oethosuximide
15
oetidronate
16
oetodolac
14
oetodolac SA
1
4
etoposide
11
Eurax
35
oEvamist
26
PEvoclin
35
Evotaz
23
zEvzio
34
Exelderm
25
exemastine
11
zoExforge HCT
3
2
+Exjade
21
+PExtavia
34
F
PFabior
35
Factive
33
zfamciclovir
13
zfamciclovir ophth 1
2
ofamotidine
16
zFanapt
34
Fareston
21
PzFarxiga
31
+zFarydak
21
Fazaclo
34
felbamate
15
ofelodipine ER
1
2
zoFemring
36
ofenofibrate
12
zofenofibric acid,
capsule DR
3
2
ofenofibric acid, tab
1
2
ofenoprofen
14
zfentanyl lozenge
1
4
fentanyl patch
1
4
fentanyl patch
37.5mcg/hr, 62.5mcg/hr,
and 87.5mcg/hr
3
4
zFentora
34
Ferriprox
31
Fetzima
33
zofexofenadine
11
zofexofenadine-D 11
PFinacea
35
zofinasteride 5mg
1
3
Fioricet/codeine
34
Fiorinal/codeine
34
+zFirazyr
22
Flagyl/ER
33
Flarex
32
oflecainide
12
PzFlector
35
Flonase Allergy Relief
1
1
zoFlovent HFA/Diskus 2
5
fluconazole
13
flucytosine
13
fludrocortisone
14
zoflunisolide nasal spray3 1
fluocinolone acetonide
1
5
fluocinonide
15
fluocinonide cream
(generic Vanos)
3
5
fluorometholone ophth 1
2
Fluoroplex
35
fluorouracil
15
ufluoxetine 10mg and
20mg tablet
13
fluoxetine 60mg tablet
3
3
fluoxetine capsule
1
3
fluoxymesterone
33
fluphenazine
14
flurazepam
14
KEY:
TIER PAGE DRUG NAME oflurbiprofen
14
flurbiprofen ophth
1
2
flutamide
11
zofluticasone nasal spray1 1
fluticasone propionate
1
5
zofluvastatin
32
fluvoxamine ER capsule 3
3
ufluvoxamine tablet
1
3
FML Forte
2
2
FML S.O.P.
2
2
Focalin XR
3
4
1
6
ofolic acid Rx 1mg tab
Follistim AQ
2
6
fondaparinux sodium
1
1
zForadil
25
Forfivo
33
31
PzFortamet
24
+zForteo
33
PzFortesta
zofortical NS
1
4
34
PzoFosamax
3
4
PzoFosamax D
ofosinopril
12
ofosinopril/HCTZ 12
Fosrenol
36
Fragmin
21
PFreestyle2
34
PzFrova
Fulyzaq
26
ofurosemide
12
+Fuzeon
23
zFycompa
35
G
ogabapentin
15
oGabitril 12mg, 16mg 2
5
zogalantamine
11
zogalantamine ER
1
1
Galzin
26
4
+Gammagard Liquid 3
34
+Gammaked
34
+Gamunex-C
ganciclovir
13
Ganirelix
36
gatifloxacin
12
36
+Gattex
31
PzGelnique
ogemfibrozil
12
generic Adderall
1
4
generic Adderall XR
1
4
generic Concerta
1
4
generic Dexedrine spansules1
4
gengraf
13
+PGenotropin 34
gentamicin cr/oint
1
5
gentamicin ophth
1
2
Genvoya
23
Giazo
36
24
+zGilenya
zGilotrif
21
+Glassia
35
14
+zglatopa
zglimepiride
11
glipizide
11
zglipizide ER
1
1
zglipizide/metformin 11
Glucagon
21
31
PzGlumetza
glyburide
11
glyburide micronized
1
1
glycopyrrolate
16
zGlyxambi
31
PGonal F
3
6
Gonitro
33
zGralise
34
zgranisetron
16
zGranisol
36
31
+Granix
31
_zGrastek
griseofulvin
13
Guaifenesin DM
3
1
guaifenesin/codeine 11
oguanabenz
12
oguanfacine
12
guanfacine ER
1
4
Gynazole-1
36
H
Halflytely
halobetasol
halobetasol propionate
Halog
haloperidol
14
23
+zHarvoni
Helidac
36
Hemangeol
32
heparin
11
zHepsera
23
24
+zHetlioz
Hexalen
21
34
+Hizentra
homatropine
12
PzHorizant
34
2
4
+zHP Acthar Gel
Humalog insulin
2
1
+PHumatrope 34
24
+zHumira
Humulin (all types)
2
1
+Hycamtin
21
Hycodan
31
ohydralazine
13
ohydrochlorothiazide1 2
hydrocodone/APAP 14
hydrocodone/
chlorpheniramine 11
hydrocodone/homatropine1 1
hydrocodone/ibuprofen1 4
hydrocortisone 2.5%
1
5
hydrocortisone butyrate/
emoll cream
3
5
hydrocortisone oral
1
6
hydrocortisone rectal
cr. & supp.
1
6
hydrocortisone rectal enema 1
6
hydrocortisone valerate 1
5
hydrocortisone/iodoquinol1 5
hydromorphone
14
hydromorphone ER
3
4
ohydroxychloroquine1 4
hydroxyurea
11
hydroxyzine HCl
1
1
hydroxyzine pamoate
1
1
hyoscyamine/CR
16
34
+HyQvia
Hysingla ER
3
4
32
PzoHyzaar
I
zoibandronate tabs
+zIbrance
1
4
21
oibuprofen
15
zIclusig
21
11
+zimatinib
zImbruvica
21
imipramine
13
imiquimod 5% cream
1
5
34
PzImitrex
zImpavido
33
34
+Increlex
oindapamide
12
oindomethacin
15
33
+Infergen
21
+zInlyta
Innohep
31
oInnopran XL
2
2
Intelence
23
34
PzIntermezzo
2
1
+Intron A
Invirase
23
zInvokamet
21
zInvokamet XR
2
1
zInvokana
21
ipratropium nasal spray 1
1
zoirbesartan
12
zoirbesartan/HCTZ 12
zIressa
21
Isentress
23
isometh/dichloralphen/APAP1
4
oisoniazid
13
oIsopto Carbachol 1.5% 2
2
oIsopto Carbachol 3% 3
2
oisosorbide dinitrate
1
3
oisosorbide mononitrate 1
3
3
oisosorbide mononitrate SA1
oisoxsuprine
13
oisradipine
12
oIstalol
32
zitraconazole
13
PIzba
32
J
26
15 +Jadenu
1
5 +zJakafi
35 jantoven
P =A step edit applies to this drug.
z =Specific Quantity Limits Apply.
=Prior Authorization Required.
u = Included in Tablet-Splitting Program
+ = Access restricted to specialty pharmacy.
o = Home Service Delivery.
TIER PAGE DRUG NAME 21
21
11
TIER PAGE DRUG NAME zJanumet
zJanumet XR
zJanuvia
zJardiance
Jentadueto
zJentadueto XR
zojinteli
ojolessa
ojolivette
zJublia
ojunel/FE
Juvisync
zJuxtapid
K
loratadine
loratadine-D
lorazepam
zolosartan
zolosartan/HCTZ
Lotemax
zuolovastatin
olow-ogestrel
loxapine
oLumigan
PzLunesta
olutera
Luzu
zLynparza
Lyrica
31 Lysodren
21
2
1
21
21
21
2
1
16
16
16
35
16
21
32
K-Phos
Kadian (40mg, 70mg,
130mg, 150mg, 200mg) 2
4
Kaletra
23
okariva
16
Kayexalate
35
PKazano
31
Kenalog/aerosol
35
zKerydin
35
Ketek
23
ketoconazole
13
ketoconazole
15
oketoprofen
15
ketorolac inj.
1
5
zketorolac tab
1
5
ketorolac tromethamine 1
2
ketotifen opthalmic solution3 2
zKeveyis 2
4
Khedezla
33
zKineret
24
3
3
+zKitabis Pak
PKombiglyze XR
3
1
zKorlym
34
26
+Kuvan
22
+zKynamro
L
TIER PAGE DRUG NAME olabetalol
12
lactulose
16
zLamisil Oral
3
3
lamivudine tabs
1
3
lamivudine/zidovudine1 3
olamotrigine
15
olamotrigine ER/ODT
3
5
Lanoxin
22
zolansoprazole
16
lansoprazole/amox/clarith3 6
Lantus
21
olatanoprost
12
zLatuda
24
zLazanda
34
leflunomide
14
zLenvima
21
zoLescol XL
3
2
olessina
16
22
+zLetairis
letrozole
11
leucovorin
16
Leukeran
21
21
+Leukine
leuprolide
11
PLevemir
31
olevetiracetam
15
33
PzoLevitra
olevobunolol
12
levocarnitine
16
zolevocetirizine 11
levofloxacin
13
olevora
16
levothroid
16
olevothyroxine
16
olevoxyl
16
Lexiva
23
Librium
34
lidocaine
15
zlidocaine patch
1
5
Liletta
36
Lindane
25
zlinezolid
13
Linzess
26
oliothyronine
16
oLiptruzet
32
olisinopril
12
olisinopril/HCTZ 12
lithium carbonate
1
4
oLivalo
32
21
+zLonsurf
11
11
14
12
12
22
12
16
14
22
34
16
33
21
35
21
M
Macrodantin
33
maprotiline
13
Matulane
21
zMaxair Autohaler
2
5
PzMaxalt
34
PzMaxalt MLT
3
4
Maxidex
32
Maxitrol ophth
3
2
meclizine
16
omeclofenamate 15
Medrol 2mg
2
6
omedroxyprogesterone1 6
omefenamic acid
1
5
mefloquine
13
megestrol
11
+zMekinist
21
omeloxicam
15
zomemantine
11
oMenest
26
Menopur
36
zoMenostar
36
meperidine
14
mephobarbital
15
oMephyton
26
meprobamate
14
mercaptopurine
11
mesalamine enema
1
6
Mesnex
21
metadate ER
1
4
ometaproterenol syr
1
5
metaxalone
14
metformin
11
Pmetformin ER (except
generic Glucophage XR)3 1
zmetformin ER (generic
Glucophage XR)
1
1
zmetformin/glyburide1 1
methadone
14
omethazolamide 12
methenamine combination1 3
Methergine
36
omethimazole
16
methocarbamol
14
methotrexate
11
methotrexate
14
omethyclothiazide 12
omethyldopa
12
omethyldopa/HCTZ 12
methylergonovine maleate 1
6
methylphenidate CD
1
4
methylphenidate/SR 14
methylprednisolone 4mg,
8mg, 16mg, 32mg 1
6
ometipranolol
12
metoclopramide
16
ometolazone
12
ometoprolol
12
ometoprolol ER
1
2
ometoprolol/HCTZ 12
ometoprolol/HCTZ 12
PMetrogel topical 1% 3
5
metronidazole
13
metronidazole cream/
lotion/ 0.75% gel
1
5
omexiletine
12
oMiacalcin inj.
2
1
PzoMicardis
32
PzoMicardis HCT
3
2
miconazole vag supp
1
6
oMicro-K
35
omicrogestin/FE 16
midodrine
12
midodrine
12
miglitol
31
TIER PAGE
Minitran
33
Minocin
33
minocycline
13
minocycline
15
Pminocycline HCl ER 3
5
ominoxidil oral
1
3
Mircera
31
Mirena
26
umirtazapine
13
PMirvaso
35
omisoprostol
16
zMitigare
32
zmodafinil
14
+moderiba
13
omoexipril
12
mometasone cr/oint
1
5
Pzmometasone nasal spray3
1
omononessa
16
omontelukast
15
morphine SR
1
4
zmorphine sulfate ER
1
4
morphine tab, soln, supp 1
4
zMovantik
36
moxifloxacin
33
oMultaq
22
omultivitamin V fluoride
1
6
mupirocin
15
zMUSE
23
zMyalept
24
oMyambutol
33
mycophenolate mofetil 1
3
mycophenolic acid
1
3
Myleran
21
zMyrbetriq
21
N
onabumetone
15
onadolol
12
Naftin
35
naltrexone
14
zoNamenda XR
2
1
zNamzaric
31
naphazoline
12
oNaprosyn
35
onaproxen/EC
15
znaratriptan
14
zNarcan nasal spray
2
4
PzoNasacort AQ
3
1
zNasacort OTC
1
1
oNascobal
26
PzNasonex
31
znateglinide
11
PzNatesto
33
+Natpara
34
Nebupent
23
onecon
16
nefazodone
13
neomycin
13
neomycin/bacitracin/poly B1 2
neomycin/bacitracin/
poly B/HC
1
2
neomycin/polymyxin/
HC otic
1
2
Neoral
23
PNesina
31
Neulasta
21
+Neumega
31
+Neupogen
21
Nevanac
22
+zNexavar
21
PzoNexium
36
zNexium 24HR
1
6
zoNexium susp
2
6
oniacin ER
1
2
zoniacin/simvastatin1 2
onicardipine
12
zNicorelief gum
1
5
zNicorelief lozenge
1
5
zNicotine Gum
1
5
zNicotine lozenges
1
6
zNicotine patches various1 6
zNicotrol Inhaler
2
6
zNicotrol NS
2
6
onifediac CC
1
2
onifedical XL
1
2
onifedipine
12
onifedipine SR
1
2
Nilandron
21
onimodipine
12
+zNinlaro
21
onisoldipine
12
NitroDur patches
3
3
Note: 1. * Please note that medications listed in the 3rd tier are considered
non-formulary and are not all-inclusive.
2. * Some drugs are limited to 1 unit of use package per dispensing.
8
Section II — Index (cont’d)
DRUG NAME TIER PAGE DRUG NAME nitrofurantoin
13
nitrofurantoin
13
nitroglycerin pumpspray 1
3
nitroglycerin SR
1
3
nitroglycerin
transdermal patch
1
3
Nitrostat SL tabs
2
3
onizatidine
16
onora-BE
16
+Norditropin
24
onorethindrone
16
onorethindrone a-e
estradiol/ferrous fumarate1 6
PNoritate
35
Noroxin
33
oNorpace/CR
22
+zNorthera
22
onortrel
16
nortriptyline
13
Norvir
23
Novarel
26
PNovolin
31
PNovolog
31
zNoxafil
23
Nucynta/ER
34
zNuedexta
34
Nulytely
36
+zNuplazid
34
+PNutropin/AQ 34
oNuvaRing
26
zoNymalize
32
nystatin
13
nystatin
15
nystatin vag tab
1
6
nystatin/triamcinolone1 5
nystop
15
O
+zOcaliva
36
oocella
16
+octreotide
14
Odefsey
23
+zOdomzo
21
ofloxacin
13
ofloxacin ophth
1
2
ofloxacin otic
1
2
oogestrel
16
zolanzapine
14
zolanzapine/fluoxetine3 4
zuOleptro ER
3
3
olopatadine ophth
1
2
+zOlysio
23
zomega-3 acid ethyl esters3
2
zoomeprazole
16
PzoOmnaris
31
+POmnitrope 34
Omontys
31
zOmtryg
32
zondansetron
16
OneTouch Test Strips
1
POnexton
35
POnglyza
31
PzOnzetra
34
+zOpsumit
33
POracea
35
Oracit
31
+zOralair
31
Oravig
33
+PzOrencia SC
3
4
Orenitram
33
Orfadin
26
orphenadrine
14
oOrtho Tri-Cyclen Lo
2
6
Ortho-Est
36
POseni
31
Osphena
36
+zOtezla
24
Otrexup
34
oOvcon-50
26
Ovidrel
26
ooxaprozin
15
oxazepam
14
ooxcarbazepine
15
Oxistat
25
Oxsoralen Ultra
2
5
oOxtellar XR
3
5
oxybutynin
11
zoxybutynin ER
1
1
oxycodone
14
Oxycodone ER
2
4
oxycodone/acetaminophen1 4
oxycodone/aspirin 14
KEY:
TIER PAGE DRUG NAME TIER PAGE DRUG NAME oxycodone/ibuprofen14
Oxycontin
24
oxymorphone/ER 14
PzOxytrol
31
P
zpaliperidone
34
oPancreaze
36
Panretin
25
zopantoprazole
16
Paragard
36
paregoric
16
paricalcitol
36
paromomycin
13
uparoxetine
13
Pataday
32
Pazeo
32
PCE
33
peg 3350/electrolyte
1
6
+PPeg-Intron 33
oPeganone
35
+Pegasys
23
penicillin VK
1
3
PzPennsaid
35
Pentasa
26
pentazocine/naloxone1 4
pentoxifylline
11
pergolide
35
operindopril
12
permethrin
15
perphenazine
14
oPertzye
36
Pexeva
33
phenazopyridine
11
phenelzine
13
phenobarbital
15
phentermine
16
phenylephrine ophth
1
2
ophenytoin
15
Phisohex
25
Phospholine Iodide
2
2
ophytonadione
26
Picato
25
opilocarpine
12
opindolol
12
zpioglitazone/metformin1 1
opiroxicam
15
+PzPlegridy
34
podofilox
15
oPoly-Vi-Flor V Iron
3
6
polymyxin B/TMP
1
2
+zPomalyst
21
oportia
16
potassium aminobenzoate 1
6
opotassium bicarb/
potassium chloride
1
5
opotassium bicarbonate 1
5
opotassium chloride
1
5
potassium citrate
1
1
Potiga
35
zPradaxa
21
+zPraluent
22
opramipexole
15
opramipexole ER
3
5
pramoxine/HC acetate 2.5% 1
6
prascion RA
1
5
zuopravastatin 12
oprazosin
12
opre-natal vitamins
1
6
PPrecision2
Pred Mild
2
2
Pred-G
32
prednicarbate
15
prednisolone acetate
1
2
prednisolone oral
1
6
prednisolone sod phosphate1
2
prednisone oral
1
6
zoPrefest
36
Pregnyl
36
oPremarin
26
Premarin vag cream
2
6
oPremphase
26
Prempro
26
oPrenate Elite
2
6
Prepopik
36
zoPrestalia
32
PzoPrevacid
36
zPrevacid 24HR
1
6
zoPrevacid Solutab
2
6
oprevifem
16
Prezcobix
23
P =A step edit applies to this drug.
z =Specific Quantity Limits Apply.
=Prior Authorization Required.
u = Included in Tablet-Splitting Program
+ = Access restricted to specialty pharmacy.
o = Home Service Delivery.
Prezista
23
36
PzoPrilosec
zPrilosec-OTC
16
Primaquine
23
oprimidone
15
Pristiq ER
2
3
zProAir HFA/RespiClick 2
5
probenecid
12
procainamide
12
procentra
14
prochlorperazine
16
21
+Procrit
Proctofoam-HC
26
Procysbi
34
progesterone in oil
1
6
6
oprogesterone, micronized 1
Prograf
23
Prolensa
32
21
+zPromacta
promethazine
16
promethazine/codeine1 1
promethazine/DM 11
promethazine/
phenylephrine/codeine1 1
opropafenone
12
opropafenone SR
1
2
propantheline bromide 1
6
opropranolol
12
opropranolol/HCTZ 12
opropylthiouracil 16
36
PzoProtonix
protriptyline
13
zProventil HFA
3
5
pseudoephedrine
11
pseudoephedrine/codeine1
1
zoPulmicort flexhaler/
powder
25
oPulmicort respules
(1mg/2ml)
25
Purixan
21
opyrazinamide
13
zQbrelis
Q
PzoQnasl
zQsymia
oquasense
oQudexy XR
zquetiapine
zQuillichew ER
Quillivant XR
oquinapril
oquinapril/HCTZ
oquinidine gluconate
oquinidine sulfate SR
quinine sulfate
zoQvar
R
zorabeprazole
zRagwitek
zoraloxifene
32
31
36
16
3
5
14
3
4
3
4
12
12
1
2
1
2
3
3
25
36
31
14
oramipril
12
oRanexa
22
oranitidine (all)
1
6
oRapaflo
33
Rapamune solution
2
3
Rasuvo
34
34
+Ravicti
zRayaldee
36
Rayos
36
33
+Rebetol
24
+Rebif
Rectiv
35
Regenecare
35
Regranex
25
zRelenza
23
zRelistor injection
2
6
zRelistor tablets
2
6
zRelpax
24
Renagel
26
Renvela
26
zrepaglinide
11
repaglinide/metformin3 1
22
+zRepatha
Repronex
26
Rescriptor
23
PoRescula
32
zRestasis
22
PRetin-A/Micro
35
21
+zRevlimid
zRexulti
34
TIER PAGE DRUG NAME Reyataz
PzoRhinocort Aqua
+ribapak
+ribasphere
+Ribatab
+ribavirin
oRidaura
orifabutin
oRifadin
oRifamate
orifampin
oRifater
riluzole
rimantadine
Riomet solution
zorisedronate 150mg
Pzorisedronate DR
zrisperidone
zrisperidone m-tab
Ritalin LA 10mg, 60mg
zorivastigmine
zorivastigmine patch
zrizatriptan
Rondec DM/TR
oropinirole
oropinirole ER
PRosula
zrosuvastatin
Roxicet Soln
PRozerem
+zRuconest
oRytary
23
3
1
13
13
33
13
24
13
33
33
13
23
14
13
3
1
3
4
3
4
14
1
4
2
4
11
1
1
14
3
1
15
3
5
35
12
3
4
34
22
35
S
Sabril
35
+PSaizen
34
osalsalate
14
+zSamsca
22
PzSanctura
31
PzSanctura XR
3
1
zSancuso
36
Sandimmune
23
+Sandostatin
34
+Sandostatin LAR
3
4
zSaphris
24
Sarafem
33
zSavaysa
31
Savella
34
zSaxenda
36
zSeebri
35
zoselegiline
15
selenium sulf
2.5% suspension
1
5
Selzentry
23
Semprex-D
21
+Sensipar
24
zSerevent Diskus
2
5
serophene
16
zSeroquel XR
2
4
+PSerostim
34
usertraline
13
sevelamer
16
zSignifor
24
+zsildenafil citrate
1
2
PzSilenor
34
silver sulfadiazine
1
5
+PzSimponi
34
zuosimvastatin 12
sirolimus
13
oSirturo
33
zSitavig
33
zSivextro
23
Sklice
35
Skyla
26
sod. polystyrene sulfonate1 5
sod. sulfacetamide/sulfur
emulsion cleanser
1
5
sod. sulfacetamide/sulfur lot1
5
sodium chloride
irrigating soln
1
5
osodium fluoride chewable
tab & drops
1
6
+sodium phenylbutyrate 3
4
sodium sulfacetamide
1
5
osolia
16
PSolodyn
35
+Somatuline Depot
3
4
+zSomavert
34
Somnote
34
PzSonata
34
Soolantra
35
osotalol
12
TIER PAGE DRUG NAME sotret
15
+zSovaldi
23
Spectracef
33
spinosad
15
ospironolactone 12
ospironolactone/HCTZ1 2
zSporanox suspension 2
3
osprintec
16
zSprix
35
+zSprycel
21
stavudine
13
PzoStaxyn
33
+zStelara
25
PzoStendra
33
Stimate
24
+zStivarga
21
Strattera
24
Strensiq
24
PStriant
33
Stribild
23
zStriverdi Respimat
3
5
Suboxone film
2
4
Suboxone tablet
3
4
zSubsys
34
Suclear
36
osucralfate
16
sulfacetamide 10%
1
2
sulfacetamide/
prednisolone ophth
1
2
sulfamethoxazole/
trimethoprim
13
osulfasalazine
16
osulfasalazine EC
1
6
osulindac
15
zsumatriptan
14
zSumavel
34
Suprax
33
Suprenza ODT
3
6
Suprep
36
Sustiva
23
+zSutent
21
+zSylatron
21
zSymlin
21
Synarel
24
zSyndros
36
zSynjardy
21
+zSynribo
21
oSynthroid
26
+Syprine
21
T
TIER PAGE
+Thalomid
21
oTheo-24
25
otheochron
15
otheophylline/
SR tabs, liquid
1
5
thioridazine
14
thiothixene
14
othyroid
16
oThyroid (Armour)
2
6
oThyrolar
26
oticlopidine
11
oTikosyn
32
otimolol
12
otimolol
12
tinidazole
13
Tivicay
23
oTivorbex
35
tizanidine
14
+Tobi
33
+Tobi Podhaler
2
3
Tobradex ointment
2
2
+tobramycin ampule/neb 1
3
tobramycin soln
1
2
tobramycin/dexameth1 2
Tobrex ointment
2
2
Tobrex solution
3
2
tolazamide
11
tolbutamide
11
otolmetin
15
ztolterodine
11
ztolterodine ER
1
1
otopiramate
15
otopiramate ER
3
5
otorsemide
12
Toujeo
21
zToviaz
21
+zTracleer
22
Tradjenta
21
tramadol ER capsule
3
4
tramadol/acetaminopen1 4
tramadol/ER tablet
1
4
otrandolapril
12
otrandolapril/verapamil3 2
Transderm Scop
2
6
tranylcypromine
13
PoTravatan Z
3
2
otravoprost
12
trazodone
13
PTresiba
31
tretinoin cr/gel
1
5
Ptretinoin microsphere3 5
Trexall
31
PzTreximet
34
Trezix
34
otri-sprintec
16
oTri-Vi-Flor
36
triamcinolone acetonide 1
5
zotriamcinolone
acetonide nasal spray 3
1
otriamterene/HCTZ 12
triazolam
14
zoTribenzor
32
trifluoperazine
14
trifluridine
12
otrihexyphenidyl 15
Trilyte
16
trimethobenzamide 16
trimethoprim
13
otrinessa
16
Trintellix
33
otriprevifem
16
Triumeq
23
otrivora
16
oTrokendi XR
3
5
tropicamide
12
ztrospium
11
ztrospium ER
1
1
PTRUEtest2
PTRUEtrack2
zTrulicity
31
Truvada
23
Twinject
25
Tybost
23
+zTykerb
21
Tylenol/codeine
34
zTyvaso
33
zTyzeka
33
PTaclonex
35
tacrolimus
13
tacrolimus
15
+zTafinlar
21
zTagrisso
21
+PzTaltz
35
zTamiflu
23
tamoxifen
11
otamsulosin
13
zTanzeum
31
+zTarceva
21
Targiniq ER
3
4
+Targretin gel
2
1
+zTasigna
21
Tasmar
35
PTazorac
35
+zTecfidera
24
+PzTechnivie 33
oTegretol
25
oTegretol XR 100mg
2
5
PzoTekamlo
22
PzoTekturna
22
PzoTekturna HCT
2
2
zotelmisartan
12
zotelmisartan/amlodipine3 2
zotelmisartan/HCTZ12
temazepam
14
+Temodar
31
+temozolomide 11
oterazosin
12
zterbinafine
13
oterbutaline tab
1
5
terconazole
16
PzTestim
33
testosterone cypionate 1
3
testosterone enanthionate1
3
PzTestosterone gel (brand)3
3
U
tetracycline
13
+PTev-Tropin 34 Uceris
PzoTeveten
32 Ulesfia
PzoTeveten HCT
3
2 PzUloric
Note: 1. * Please note that medications listed in the 3rd tier are considered
non-formulary and are not all-inclusive.
2. * Some drugs are limited to 1 unit of use package per dispensing.
9
36
25
32
Section II — Index (cont’d)
DRUG NAME TIER PAGE DRUG NAME oUltresa
ounithroid
zUptravi
Urecholine
oursodiol
zUtibron
36
16
23
31
16
35
V
oVagifem
zvalacyclovir
zValchlor
Valcyte
valganciclovir tablets
ovalproic acid
zovalsartan
zovalsartan/HCTZ
zValtrex
Vancocin
vancomycin caps
vandazole vag
Vascepa
veletri
ovelivet
KEY:
26
13
21
33
1
3
1
5
12
12
33
33
1
3
1
6
32
33
16
Velphoro
+zVeltassa
PVeltin gel
uvenlafaxine
venlafaxine ER
zVentolin HFA
PzoVeramyst
overapamil/SR
PVersacloz
zVesicare
PzoViagra
Vibramycin
Vicodin/ES
+Victrelis
Videx
+PzViekira
+PzViekira XR
Vigamox
Viibryd
PzoVimovo
Vimpat
oViokace
TIER PAGE DRUG NAME TIER PAGE DRUG NAME 36
34
3
5
13
1
3
2
5
31
12
34
21
33
33
34
23
23
23
2
3
22
23
35
35
36
P =A step edit applies to this drug.
z =Specific Quantity Limits Apply.
=Prior Authorization Required.
u = Included in Tablet-Splitting Program
+ = Access restricted to specialty pharmacy.
o = Home Service Delivery.
Viracept
Viramune, XR
Viread
ovit A,D,C V fluoride
ovit A,D,C V fluoride
and iron
Vitekta
Vituz
Vivaglobin
PzVivlodex
PzVogelxo
zVraylar
zoVytorin
Vyvanse
W
warfarin
oWelchol
X
PoXalatan
Xarelto
Xartemis XR
23
2
3
23
1
6
+zXeljanz
+zXeljanz XR Xenical
PzXigduo XR
zXiidra
Xopenex HFA
zXtampza ER
Xtoro
oxulane
1
6
23
31
34
35
Y
33
34 yohimbine
32
Z
24
Zaditor
ozafirlukast
11 zzaleplon
32 ozarah
+Zarxio
Zavesca
32 +PzZecuity
21 PzoZegerid
3
4 zZegerid OTC
TIER PAGE DRUG NAME 24
2
4
36
3
1
32
3
5
3
4
32
16
13
32
15
14
16
31
24
34
36
1
6
PzZembrace
ozenchent
oZenpep
+PzZepatier
zoZetia
PzoZetonna
Ziagen
PZiana gel
zidovudine
PoZioptan
zziprasidone caps
Zmax
Zohydro ER
zzolmitriptan
zzolpidem
zzolpidem ER
Pzzolpidem ER
sublingual tablet
PzZolpimist
PzZomig
PzZomig Nasal
PzZomig ZMT
ozonisamide
TIER PAGE DRUG NAME 34
16
26
33
32
31
23
3
5
13
32
1
4
23
3
4
14
14
1
4
TIER PAGE
zoZontivity
+PZorbtive
Zortress
oZorvolex
ozovia
Zovirax Cream
PZubsolv
PzZurampic
zZyban
zoZyflo/CR
Zylet
+zZinbryta
zZyprexa
zZyprexa Zydis
34
34
34
3
4
3
4
15
Note: 1. * Please note that medications listed in the 3rd tier are considered
non-formulary and are not all-inclusive.
2. * Some drugs are limited to 1 unit of use package per dispensing.
10
31
34
23
35
16
2
5
34
32
36
35
32
34
34
3
4