H2256_2025_12_C
Tufts Medicare Preferred HMO
Group Retiree 2024 Formulary
(List of Covered Drugs)
Tufts Medicare Preferred HMO Plans
PLEASE READ: This document contains information about the drugs
w
e cover in this plan
24517 Version 6
This formulary was updated on 09/01/2023. For more recent information
or other questions, please contact Tufts Medicare Preferred HMO
Member Services at 1-800-701-9000 (TTY users should call 711), 8:00
a.m. to 8:00 p.m., 7 days a week from October 1 to March 31 and
Monday–Friday from April 1 to September 30, or visit www.thpmp.org.
II
Tufts Medicare Preferred HMO Group Retiree
2024 Formulary (List of Covered Drugs)
Note to existing members: This formulary has changed since last year. Please review this
document to make sure that it still contains the drugs you take.
When this drug list (formulary) refers to “we,” “us,” or “our,” it means Tufts Health Plan. When it
refers to “plan” or “our plan,” it means Tufts Medicare Preferred HMO.
This document includes a list of the drugs (formulary) for our plan which is current as of
September 2023. For an updated formulary, please contact us. Our contact information, along
with the date we last updated the formulary, appears on the front and back cover pages.
You must generally use network pharmacies to use your prescription drug benefit. Benefits,
formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2025,
and from time to time during the year.
What is the Tufts Medicare Preferred HMO Formulary?
A formulary is a list of covered drugs selected by Tufts Medicare Preferred HMO in consultation
with a team of health care providers, which represents the prescription therapies believed to be a
necessary part of a quality treatment program. Tufts Medicare Preferred HMO will generally cover
the drugs listed in our formulary as long as the drug is medically necessary, the prescription is
filled at a Tufts Medicare Preferred HMO network pharmacy, and other plan rules are followed. For
more information on how to fill your prescriptions, please review your Evidence of Coverage.
Can the Formulary (drug list) change?
Most changes in drug coverage happen on January 1, but we may add or remove drugs on the
Drug List during the year, move them to different cost-sharing tiers, or add new restrictions. We
must follow Medicare rules in making these changes.
Changes that can affect you this year: In the below cases, you will be affected by coverage
changes during the year:
• New generic drugs. We may immediately remove a brand-name drug on our Drug List if we
are replacing it with a new generic drug that will appear on the same or lower cost-sharing
tier and with the same or fewer restrictions. Also, when adding the new generic drug, we
may decide to keep the brand-name drug on our Drug List, but immediately move it to a
different cost-sharing tier or add new restrictions. If you are currently taking that brand-
name drug, we may not tell you in advance before we make that change, but we will later
provide you with information about the specific change(s) we have made.
III
• If we make such a change, you or your prescriber can ask us to make an exception and
continue to cover the brand-name drug for you. The notice we provide you will also
include information on how to request an exception, and you can find information in
the section titled “How do I request an exception to the Tufts Medicare Preferred HMO
Formulary?”
• Drugs removed from the market. If the Food and Drug Administration deems a drug on our
formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we
will immediately remove the drug from our formulary and provide notice to members who
take the drug.
• Other changes. We may make other changes that affect members currently taking a drug.
For instance, we may add a generic drug that is not new to market to replace a brand-name
drug currently on the formulary; or add new restrictions to the brand-name drug or move
it to a different cost-sharing tier or both. Or we may make changes based on new clinical
guidelines. If we remove drugs from our formulary, add prior authorization, quantity limits
and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier, we
must notify affected members of the change at least 30 days before the change becomes
effective, or at the time the member requests a refill of the drug, at which time the member
will receive a 30-day supply of the drug.
• If we make these other changes, you or your prescriber can ask us to make an exception
and continue to cover the brand-name drug for you. The notice we provide you will also
include information on how to request an exception, and you can also find information in
the section below entitled “How do I request an exception to the Tufts Medicare Preferred
HMO Formulary?”
Changes that will not affect you if you are currently taking the drug. Generally, if you are
taking a drug on our 2024 formulary that was covered at the beginning of the year, we will not
discontinue or reduce coverage of the drug during the 2024 coverage year except as described
above. This means these drugs will remain available at the same cost-sharing and with no new
restrictions for those members taking them for the remainder of the coverage year. You will not
get direct notice this year about changes that do not affect you. However, on January 1 of the
next year, such changes would affect you, and it is important to check the Drug List for the new
benefit year for any changes to drugs.
The enclosed formulary is current as of September 2023. To get updated information about the
drugs covered by Tufts Medicare Preferred HMO, please contact us. Our contact information
appears on the front and back cover pages. In the event of a mid-year non-maintenance
formulary change, you will be notified via an errata sheet.
IV
How do I use the Formulary?
There are two ways to find your drug within the formulary:
Medical Condition
The formulary begins on page 1.
The drugs in this formulary are grouped into categories
depending on the type of medical conditions that they are used to treat. For example, drugs used
to treat a heart condition are listed under the category “Cardiovascular Drugs.” If you know what
your drug is used for, look for the category name in the list that begins on page 1. Then look
under the category name for your drug.
Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in the Index that
begins on page 61. The Index provides an alphabetical list of all of the drugs included in this
document. Both brand-name drugs and generic drugs are listed in the Index. Look in the Index
and find your drug. Next to your drug, you will see the page number where you can find coverage
information. Turn to the page listed in the Index and find the name of your drug in the first
column of the list.
What are generic drugs?
Tufts Medicare Preferred HMO covers both brand-name drugs and generic drugs. A generic drug
is approved by the FDA as having the same active ingredient as the brand-name drug. Generally,
generic drugs cost less than brand-name drugs.
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These
requirements and limits may include:
• Prior Authorization: Tufts Medicare Preferred HMO requires you or your physician to get
prior authorization for certain drugs. This means that you will need to get approval from
Tufts Medicare Preferred HMO before you fill your prescriptions. If you don’t get approval,
Tufts Medicare Preferred HMO may not cover the drug.
• Quantity Limits: For certain drugs, Tufts Medicare Preferred HMO limits the amount of the
drug that Tufts Medicare Preferred HMO will cover. For example, Tufts Medicare Preferred
HMO provides 30 tablets per prescription for ramelteon. This may be in addition to a
standard one-month or three-month supply.
• Step Therapy: In some cases, Tufts Medicare Preferred HMO requires you to first try certain
drugs to treat your medical condition before we will cover another drug for that condition.
For example, if Drug A and Drug B both treat your medical condition, Tufts Medicare
Preferred HMO may not cover Drug B unless you try Drug A first. If Drug A does not work for
you, Tufts Medicare Preferred HMO will then cover Drug B.
V
Y
ou can find out if your drug has any additional requirements or limits by looking in the
formulary that begins on page 1. You can also get more information about the restrictions
applied to specific covered drugs by visiting our website. We have posted online a document
that explains our prior authorization and step therapy restrictions. You may also ask us to send
you a copy. Our contact information, along with the date we last updated the formulary, appears
on the front and back cover pages.
You can ask Tufts Medicare Preferred HMO to make an exception to these restrictions or limits, or
for a list of other, similar drugs that may treat your health condition. See the section “How do I
request an exception to the Tufts Medicare Preferred HMO Formulary?” on page V for information
about how to request an exception.
What if my drug is not on the Formulary?
If your drug is not included in this formulary (list of covered drugs), you should first contact
Member
Services and ask if your drug is covered.
If you learn that Tufts Medicare Preferred HMO does not cover your drug, you have two options:
• You can ask Member Services for a list of similar drugs that are covered by Tufts Medicare
Preferred HMO. When you receive the list, show it to your doctor and ask them to prescribe
a similar drug that is covered by Tufts Medicare Preferred HMO.
• You can ask Tufts Medicare Preferred HMO to make an exception and cover your drug. See
below for information about how to request an exception.
How do I request an exception to the Tufts Medicare Preferred HMO
Formulary?
You can ask Tufts Medicare Preferred HMO to make an exception to our coverage rules. There are
several types of exceptions that you can ask us to make.
• You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will
be covered at a pre-determined cost-sharing level, and you would not be able to ask us to
provide the drug at a lower cost-sharing level.
• You can ask us to cover a formulary drug at a lower cost-sharing level.
• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain
drugs, Tufts Medicare Preferred HMO limits the amount of the drug that we will cover. If your
drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.
Generally, Tufts Medicare Preferred HMO will only approve your request for an exception if the
alternative drugs included on the plan’s formulary, the lower cost-sharing drug, or additional
VI
utilization restrictions would not be as effective in treating your condition and/or would cause
you to have adverse medical effects.
You should contact us to ask us for an initial coverage decision for a formulary, tier, or utilization
restriction exception. When you request a formulary, tier, or utilization restriction exception
you should submit a statement from your prescriber or physician supporting your request.
Generally, we must make our decision within 72 hours of getting your prescriber’s supporting
statement. You can request an expedited (fast) exception if you or your doctor believe that your
health could be seriously harmed by waiting up to 72 hours for a decision. If your request to
expedite is granted, we must give you a decision no later than 24 hours after we get a supporting
statement from your doctor or other prescriber.
What do I do before I can talk to my doctor about changing my drugs or
requesting an exception?
As a new or continuing member in our plan you may be taking drugs that are not on our
formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited.
For example, you may need a prior authorization from us before you can fill your prescription. You
should talk to your doctor to decide if you should switch to an appropriate drug that we cover
or request a formulary exception so that we will cover the drug you take. While you talk to your
doctor to determine the right course of action for you, we may cover your drug in certain cases
during the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited,
we will cover a temporary 30-day supply. If your prescription is written for fewer days, we’ll allow
refills to provide up to a maximum 30-day supply of medication. After your first one-month
supply, we will not pay for these drugs, even if you have been a member of the plan less than 90
days.
If you are a resident of a long-term care facility and you need a drug that is not on our formulary
or if your ability to get your drugs is limited, but you are past the first 90 days of membership
in our plan, we will cover a 31-day emergency supply of that drug while you pursue a formulary
exception.
As a current member, if you are admitted to or discharged from a long-term facility and
experience an unplanned drug change, you can request that we approve a one-time, temporary
fill of the non-covered medication to allow you time to discuss a transition plan with your
physician. Your physician can also request an exception to coverage for the non-covered drug
based on review for medical necessity following the standard exception process outlined
previously. The temporary “first fill” will generally be up to a 31-day supply, but may be extended
to allow you and your physician time to manage the complexities of multiple medications or
when special circumstances warrant. You can request a temporary prescription fill by calling the
Tufts Medicare Preferred HMO Member Services department.
VII
Fo
r more information
For more detailed information about your Tufts Medicare Preferred HMO prescription drug
coverage, please review your Evidence of Coverage and other plan materials.
If you have questions about Tufts Medicare Preferred HMO, please contact us. Our contact
information, along with the date we last updated the formulary, appears on the front and back
cover pages.
If you have general questions about Medicare prescription drug coverage, please call Medicare
at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call
1-877-486-2048. Or, visit www.medicare.gov.
Tufts Medicare Preferred HMO Formulary
The formulary that begins on page 1 provides coverage information about the drugs covered by
Tufts Medicare Preferred HMO. If you have trouble finding your drug in the list, turn to the Index
that begins on page 61.
The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g.,
ENTRESTO) and generic drugs are listed in lower-case italics (e.g., omeprazole).
The information in the Requirements/Limits column tells you if Tufts Medicare Preferred HMO
has any special requirements for coverage of your drug.
PA BvD: Medicare Part B or D
These drugs require prior authorization to determine appropriate coverage under Medicare Part B
or Part D.
QL: Quantity Limit Applies
Because of potential safety and utilization concerns, Tufts Medicare Preferred HMO has placed
dispensing limitations on a small number of prescription drugs. This means that the pharmacy
will only dispense a certain quantity of a drug within a given time period. These quantities
are based on recognized standards of care, such as U.S. Food and Drug Administration
recommendations for use. If your doctor believes you need a quantity greater than the program
limitation, your doctor can submit a request for coverage under the Medical Review Process.
The Medical Review Process allows you or your doctor to ask Tufts Medicare Preferred HMO to
make an exception to our coverage rules. See the section, “How do I request an exception to the
Tufts Medicare Preferred HMO Formulary?” on page V for information about how to request an
exception.
VIII
EC: Enhanced Coverage Drug
This prescription drug is not normally covered in a Medicare Prescription Drug Plan. The amount
you pay when you fill a prescription for this drug does not count towards your total drug costs
(that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if
you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for
this drug.
HI: Home Infusion Drug
This prescription drug may be covered under your medical benefit. For more information, please
call Tufts Medicare Preferred HMO Member Services at 1-800-701-9000 (TTY users should call
711), 8:00 a.m. to 8:00 p.m., 7 days a week from October 1 to March 31 and Monday - Friday from
April 1 to September 30, or visit www.thpmp.org.
PA: Prior Authorization Required
The Prior Authorization process encourages rational prescribing of drug products with significant
safety and/or financial concerns. A provider can submit a request for coverage based on a
member’s medical need for a particular drug. If approved, the member pays the designated tier
copayment. An appeal process exists for denied requests.
PA NSO: Prior Authorization for New Starts Only:
The Prior Authorization restriction only applies if you are a new member or have not taken this
drug before.
ST: Step Therapy Prior Authorization Applies
Step Therapy is an automated form of Prior Authorization, which uses claims history for approval
of a drug at the point of sale. Step Therapy Programs help encourage the clinically proven use
of first-line therapies and are designed to ensure the utilization of the most therapeutically
appropriate and cost-effective agents first, before other treatments may be covered.
Members who are currently on drugs that meet the initial Step Therapy criteria will automatically
be able to fill their prescriptions for a stepped medication. If the member does not meet the
initial Step Therapy criteria, the prescription will deny at the point of sale with a message
indicating that Prior Authorization (PA) is required. Physicians may submit Prior Authorization
requests to Tufts Medicare Preferred HMO for members who do not meet the Step Therapy
criteria at the point of sale under the Medical Review process. The Medical Review Process allows
you or your doctor to ask Tufts Medicare Preferred HMO to make an exception to our coverage
rules. See the section, “How do I request an exception to the Tufts Medicare Preferred HMO
Formulary?” on page V for information about how to request an exception.
IX
ST NSO: Step Therapy Prior Authorization Applies to New Starts Only
The Step Therapy Prior Authorization restriction only applies if you are a new member or have not taken
this drug before.
Part B Drug:
No copayment is required and the cost of the medication does not apply to your Part D benefit.
NEDS: Non-extended Day Supply Drug
In an effort to contain drug costs, certain high-cost drugs will be limited up to a 30-day supply per
fill.
SP: Available Through a Designated Special Pharmacy Provider
You have the option to obtain this drug through a designated Specialty Pharmacy provider. These
pharmacies specialize in supplying a select number of medications directly to our members. They
also provide free delivery to your home, educational support 24/7 by phone, support of nurses
and pharmacists, and will work closely with your doctor. Medications include, but are not limited
to, drugs used in the treatment of multiple sclerosis, hepatitis C, rheumatoid arthritis, and
cancers treated with oral medications. Optum Specialty Pharmacy: 1-800-265-1705
Additional coverage
Diabetic Testing Supplies: Diabetic testing supplies including blood glucose monitors, blood
glucose test strips, lancet devices, lancets, glucose control solutions, and Continuous Glucose
Monitoring Systems (CGMs) are covered under the plan’s medical benefit at participating retail or
mail-order pharmacies. Our preferred coverage is as follows:
• OneTouch Test Strips
• OneTouch Meters (Quantity Limit: 1 meter per 180 days)
• Covered therapeutic Continuous Glucose Monitors (CGMs) include Dexcom and FreeStyle
Libre products that are considered Durable Medical Equipment (DME) by Medicare (Requires
prior authorization)
Part B Vaccines: Certain vaccines are covered under the plan’s medical benefit and can be
obtained at participating retail pharmacies. Vaccines covered under Part B include:
• COVID-19 vaccines
• Flu vaccines
• Pneumonia vaccines (i.e. Pneumovax 23 & Prevnar 13)
X
Part B Oral Anti-Cancer Drugs: Certain oral anti-cancer drugs are covered under the plan’s
medical benefit at participating retail or mail-order pharmacies. Oral Anti-Cancer Drugs covered
under Part B include:
• Alkeran Tablet
• Capecitabine Tablet
• Etoposide Capsule
• Hycamtin Capsule
• Melphalan Tablet
• Myleran Tablet
• Temozolomide Capsule
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
1
Table of Contents
Anti-infective Agents ....................................................................................................................................... 2
Antihistamine Drugs ........................................................................................................................................ 8
Antineoplastic Agents ...................................................................................................................................... 9
Antitoxins, Immune Globulins, Toxoids, and Vaccines ................................................................................ 14
Autonomic Drugs ........................................................................................................................................... 16
Blood Formation,Coagulation & Thrombosis ................................................................................................ 17
Cardiovascular Drugs ..................................................................................................................................... 18
Central Nervous System Agents .................................................................................................................... 23
Devices ........................................................................................................................................................... 34
Electrolytic, Caloric, and Water Balance ....................................................................................................... 34
Enzymes ......................................................................................................................................................... 37
Eye, Ear, Nose & Throat Preparations ........................................................................................................... 38
Gastrointestinal Drugs .................................................................................................................................... 40
Gold Compounds............................................................................................................................................ 42
Heavy Metal Antagonists ............................................................................................................................... 42
Hormones and Synthetic Substitutes .............................................................................................................. 43
Miscellaneous Therapeutic Agents ................................................................................................................ 49
Respiratory Tract Agents ............................................................................................................................... 53
Skin and Mucous Membrane Agents ............................................................................................................. 55
Skin and Mucous Membrane Preparations ..................................................................................................... 55
Smooth Muscle Relaxants .............................................................................................................................. 59
Vitamins ......................................................................................................................................................... 60
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
2
Drug Name
Drug
Tier
Requirements/Limits
Anti-infective Agents
Anthelmintics
albendazole tabs
3
NEDS
ivermectin tabs 3mg
1
praziquantel tabs
2
Antibacterials
amikacin sulfate inj 1gm/4ml, 500mg/2ml
3
HI
amoxicillin/clavulanate potassium
1
amoxicillin/clavulanate potassium er
1
amoxicillin chew 125mg, 250mg
1
amoxicillin caps, susr, tabs
1
ampicillin sodium inj
3
HI
ampicillin-sulbactam
3
HI
ampicillin caps 500mg
1
ARIKAYCE
3
PA; NEDS
AUGMENTIN SUSR 125MG/5ML; 31.25MG/5ML
3
AVYCAZ
3
NEDS; HI
azithromycin pack, susr, tabs
1
azithromycin inj 500mg
1
HI
aztreonam inj 1gm
1
HI
aztreonam inj 2gm
3
NEDS; HI
BAXDELA TABS
3
NEDS
BICILLIN C-R INJ 300000UNIT/ML; 300000UNIT/ML,
900000UNIT/2ML; 300000UNIT/2ML
2
BICILLIN L-A INJ 1200000UNIT/2ML,
2400000UNIT/4ML, 600000UNIT/ML
2
CAYSTON
3
PA; NEDS
cefaclor caps
1
cefaclor susr 125mg/5ml, 250mg/5ml, 375mg/5ml
1
cefadroxil
1
cefazolin sodium inj 10gm, 1gm, 500mg
1
HI
cefazolin inj 2gm, 3gm
1
HI
cefdinir
1
cefepime hydrochloride inj 2gm
3
HI
cefepime/dextrose inj 1gm/50ml; 5%
3
HI
cefepime inj 1gm/50ml, 1gm, 2gm
3
HI
cefixime
2
cefotetan inj 1gm, 2gm
1
HI
cefoxitin sodium inj 10gm, 1gm, 2gm
1
HI
cefpodoxime proxetil susr
2
cefpodoxime proxetil tabs 100mg
1
cefpodoxime proxetil tabs 200mg
2
cefprozil
1
ceftazidime inj 1gm, 2gm, 6gm
3
HI
ceftriaxone sodium inj 10gm, 1gm, 250mg, 2gm, 500mg
3
HI
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
3
Drug Name
Drug
Tier
Requirements/Limits
cefuroxime axetil tabs
1
cefuroxime sodium inj 1.5gm, 750mg
1
HI
cephalexin
1
ciprofloxacin hcl tabs 100mg, 750mg
1
ciprofloxacin hydrochloride tabs 250mg, 500mg
1
ciprofloxacin i.v.-in d5w
1
HI
ciprofloxacin susr 500mg/5ml, 5gm/100ml
3
clarithromycin er
2
clarithromycin tabs
1
clarithromycin susr
2
clindamycin hcl caps 300mg
1
clindamycin hydrochloride caps 150mg, 75mg
1
clindamycin palmitate hcl
2
clindamycin phosphate/dextrose
1
HI
clindamycin phosphate inj 300mg/2ml, 600mg/4ml,
9000mg/60ml, 900mg/6ml
1
HI
colistimethate sodium inj
3
NEDS; HI
DALVANCE
2
HI
daptomycin
3
HI
demeclocycline hcl tabs
3
dicloxacillin sodium
2
DIFICID
3
PA; NEDS
DOXY 100
2
HI
doxycycline
2
doxycycline hyclate dr tbec 100mg, 150mg, 200mg, 50mg,
75mg
2
doxycycline hyclate caps, tabs
1
doxycycline hyclate inj
2
HI
doxycycline monohydrate caps, tabs
1
ertapenem
3
HI
erythromycin base tabs
2
erythromycin dr
2
erythromycin ethylsuccinate susr, tabs
1
erythromycin cpep 250mg
1
FIRVANQ
3
gentamicin sulfate/0.9% sodium chloride inj 1.2mg/ml; 0.9%,
1.6mg/ml; 0.9%, 1mg/ml; 0.9%, 2mg/ml; 0.9%
1
HI
gentamicin sulfate inj 40mg/ml
3
HI
imipenem/cilastatin
1
HI
isotonic gentamicin inj 0.8mg/ml; 0.9%
1
HI
levofloxacin in d5w
1
HI
levofloxacin inj 25mg/ml
1
HI
levofloxacin oral soln 25mg/ml
2
levofloxacin tabs 250mg, 500mg, 750mg
1
linezolid tabs
3
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
4
Drug Name
Drug
Tier
Requirements/Limits
linezolid susr
3
NEDS
linezolid inj 600mg/300ml
1
HI
meropenem
3
HI
minocycline hcl caps 75mg
1
minocycline hcl tabs
3
minocycline hydrochloride caps 100mg, 50mg
1
mondoxyne nl caps 100mg
1
moxifloxacin hydrochloride/sodium hydrochloride
1
HI
moxifloxacin hydrochloride tabs 400mg
1
nafcillin sodium inj 10gm, 1gm, 2gm
1
HI
neomycin sulfate tabs
1
NUZYRA TABS
3
NEDS
ofloxacin tabs 300mg, 400mg
1
oxacillin sodium inj 1.5gm/50ml; 1gm/50ml, 10gm, 1gm, 2gm,
300mg/50ml; 2gm/50ml
1
HI
penicillin g potassium in iso-osmotic dextrose
1
HI
penicillin g potassium inj 20000000unit, 5000000unit
3
HI
PENICILLIN G SODIUM
3
NEDS; HI
penicillin v potassium
1
piperacillin sodium/tazobactam sodium
3
HI
SIVEXTRO TABS
3
NEDS
streptomycin sulfate inj 1gm
1
sulfadiazine tabs
1
sulfamethoxazole/trimethoprim ds
1
sulfamethoxazole/trimethoprim susp, tabs
1
sulfasalazine tabs, tbec
1
SUPRAX CHEW
3
SUPRAX SUSR 500MG/5ML
3
tazicef inj 1gm, 2gm, 6gm
3
HI
TEFLARO
3
NEDS; HI
tetracycline hydrochloride caps
2
TOBI PODHALER
3
NEDS; SP-Optum Specialty
tobramycin sulfate inj 1.2gm/30ml, 10mg/ml, 40mg/ml,
80mg/2ml
1
HI
tobramycin nebu 300mg/4ml, 300mg/5ml
3
PA BvD; NEDS; SP-Optum
Specialty
vancomycin hcl inj 100gm, 10gm
3
HI
vancomycin hydrochloride caps
2
vancomycin hydrochloride oral solr
3
vancomycin hydrochloride inj 1.25gm, 1.5gm, 1gm, 500mg,
5gm, 750mg
3
HI
VIBRAMYCIN SYRP
3
XENLETA TABS
3
NEDS
XIFAXAN TABS 200MG
3
XIFAXAN TABS 550MG
3
PA; NEDS
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
5
Drug Name
Drug
Tier
Requirements/Limits
ZERBAXA
3
NEDS; HI
ZOSYN INJ 1GM/50ML; 2GM/50ML; 0.25GM/50ML, 5%;
3GM/50ML; 0.375GM/50ML, 5%; 4GM/100ML;
0.5GM/100ML
2
HI
Antifungals
ABELCET
3
PA
amphotericin b liposome
3
PA; NEDS
amphotericin b inj
1
PA
caspofungin acetate inj 70mg
3
caspofungin acetate inj 50mg
3
NEDS
fluconazole in sodium chloride
1
fluconazole susr, tabs
1
flucytosine caps
3
NEDS
griseofulvin microsize susp
1
griseofulvin microsize tabs
2
griseofulvin ultramicrosize tabs 125mg, 250mg
2
itraconazole caps
1
itraconazole soln
2
ketoconazole tabs 200mg
1
micafungin inj 100mg
2
micafungin inj 50mg
3
NEDS
NOXAFIL PACK, SUSP
3
NEDS
nystatin susp 100000unit/ml
1
nystatin tabs 500000unit
1
posaconazole dr
3
NEDS
posaconazole susp
3
NEDS
terbinafine hcl tabs
1
QL(42 EA per 42 days)
voriconazole tabs
3
voriconazole susr
3
NEDS
voriconazole inj
3
PA; NEDS
Antimycobacterials
dapsone tabs
3
ethambutol hydrochloride
2
isoniazid syrp, tabs
1
PASER
3
PRIFTIN
2
pyrazinamide tabs
3
rifabutin
2
rifampin inj
1
rifampin caps
2
SIRTURO
3
PA; NEDS
TRECATOR
3
Antiprotozoals
atovaquone/proguanil hcl
3
atovaquone susp
3
NEDS
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
6
Drug Name
Drug
Tier
Requirements/Limits
BENZNIDAZOLE
3
chloroquine phosphate tabs
1
COARTEM
2
QL(24 EA per 3 days)
hydroxychloroquine sulfate tabs 200mg
1
IMPAVIDO
3
NEDS
mefloquine hcl
1
metronidazole caps 375mg
1
metronidazole inj 500mg/100ml
1
HI
metronidazole tabs 250mg, 500mg
1
nitazoxanide tabs
2
paromomycin sulfate caps
1
pentamidine isethionate inj
2
pentamidine isethionate inhalation solr
2
PA BvD
primaquine phosphate tabs
1
pyrimethamine tabs
3
quinine sulfate caps 324mg
3
PA
SOLOSEC
3
tinidazole tabs
1
Antivirals
abacavir
2
abacavir sulfate/lamivudine
2
abacavir sulfate/lamivudine/zidovudine
3
NEDS
acyclovir sodium inj 50mg/ml
3
PA
acyclovir caps 200mg
1
acyclovir susp 200mg/5ml
2
acyclovir tabs 400mg, 800mg
1
adefovir dipivoxil
3
APTIVUS CAPS
3
NEDS
atazanavir
3
atazanavir sulfate caps 300mg
3
BIKTARVY
3
NEDS
CIMDUO
3
NEDS
COMPLERA
3
NEDS
darunavir
3
NEDS
DELSTRIGO
2
DESCOVY
3
NEDS
DOVATO
3
NEDS
EDURANT
3
NEDS
efavirenz/emtricitabine/tenofovir disoproxil fumarate
3
NEDS
efavirenz/lamivudine/tenofovir disoproxil fumarate
3
NEDS
efavirenz caps
2
efavirenz tabs
3
emtricitabine
2
emtricitabine/tenofovir disoproxil
3
NEDS
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
7
Drug Name
Drug
Tier
Requirements/Limits
emtricitabine/tenofovir disoproxil fumarate tabs 200mg;
300mg
3
emtricitabine/tenofovir disoproxil fumarate tabs 100mg;
150mg, 133mg; 200mg
3
NEDS
EMTRIVA SOLN
2
entecavir
3
EPCLUSA
3
PA; NEDS; SP-Optum Specialty
etravirine tabs 100mg
2
etravirine tabs 200mg
3
NEDS
EVOTAZ
3
NEDS
famciclovir tabs
2
fosamprenavir calcium
3
NEDS
FUZEON
3
NEDS
GENVOYA
3
NEDS
HARVONI PACK
3
PA; NEDS; SP-Optum Specialty
HARVONI TABS 90MG; 400MG
3
PA; NEDS; SP-Optum Specialty
INTELENCE TABS 25MG
2
ISENTRESS HD
3
QL(60 EA per 30 days); NEDS
ISENTRESS PACK
2
ISENTRESS TABS
3
QL(120 EA per 30 days); NEDS
ISENTRESS CHEW 25MG
2
QL(720 EA per 30 days)
ISENTRESS CHEW 100MG
3
QL(180 EA per 30 days); NEDS
JULUCA
3
NEDS
lamivudine
1
lamivudine/zidovudine
3
LEXIVA SUSP
2
LIVTENCITY
3
PA; NEDS
lopinavir/ritonavir soln
2
lopinavir/ritonavir tabs 100mg; 25mg
2
lopinavir/ritonavir tabs 200mg; 50mg
3
maraviroc tabs 300mg
3
QL(120 EA per 30 days); NEDS
maraviroc tabs 150mg
3
QL(60 EA per 30 days); NEDS
MAVYRET
3
PA; NEDS; SP-Optum Specialty
nevirapine
1
nevirapine er
1
NORVIR PACK, SOLN
2
ODEFSEY
3
NEDS
oseltamivir phosphate caps, susr
1
PEGASYS
3
QL(4 ML per 28 days); NEDS; SP-
Optum Specialty
PIFELTRO
3
NEDS
PREVYMIS TABS
3
PA; NEDS
PREZCOBIX
3
NEDS
PREZISTA SUSP
3
NEDS
PREZISTA TABS 75MG
3
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
8
Drug Name
Drug
Tier
Requirements/Limits
PREZISTA TABS 150MG, 600MG, 800MG
3
NEDS
RELENZA DISKHALER
2
REYATAZ PACK
3
NEDS
ribavirin caps
1
SP-Optum Specialty
ribavirin tabs 200mg
1
SP-Optum Specialty
rimantadine hydrochloride
1
ritonavir
2
RUKOBIA
3
NEDS
SELZENTRY SOLN
2
QL(1800 ML per 30 days)
SELZENTRY TABS 25MG
3
SELZENTRY TABS 75MG
3
NEDS
STRIBILD
3
NEDS
SUNLENCA TBPK
3
NEDS
SYMTUZA
3
NEDS
TEMIXYS
3
NEDS
tenofovir disoproxil fumarate
2
TIVICAY PD
3
TIVICAY TABS 10MG
2
TIVICAY TABS 25MG, 50MG
3
NEDS
TRIUMEQ
3
NEDS
TRIUMEQ PD
3
NEDS
TRIZIVIR
3
NEDS
valacyclovir hcl tabs 1gm
2
valacyclovir hydrochloride tabs 500mg
1
valganciclovir
2
valganciclovir hydrochloride
3
NEDS
VEMLIDY
3
NEDS
VIRACEPT TABS 250MG
2
VIRACEPT TABS 625MG
3
NEDS
VIREAD POWD
3
NEDS
VIREAD TABS 150MG, 200MG, 250MG
3
NEDS
VOSEVI
3
PA; NEDS; SP-Optum Specialty
XOFLUZA TBPK 40MG, 80MG
2
QL(1 EA per 7 days)
XOFLUZA TBPK 20MG
2
QL(2 EA per 7 days)
zidovudine
1
Urinary Anti-infectives
fosfomycin tromethamine
2
methenamine hippurate
2
nitrofurantoin macrocrystals
1
nitrofurantoin monohydrate/macrocrystals
1
trimethoprim tabs
1
Antihistamine Drugs
First Generation Antihistamines
cyproheptadine hcl syrp
1
cyproheptadine hydrochloride tabs
1
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
9
Drug Name
Drug
Tier
Requirements/Limits
promethazine hcl plain
1
promethazine hcl tabs 12.5mg
1
promethazine hydrochloride tabs 25mg, 50mg
1
Second Generation Antihistamines
desloratadine
1
desloratadine odt
3
levocetirizine dihydrochloride tabs
1
Antineoplastic Agents
Antineoplastic Agents
abiraterone acetate
3
PA NSO; NEDS; SP-Optum
Specialty
ALECENSA
3
PA NSO; NEDS; SP-Optum
Specialty
ALUNBRIG
3
PA NSO; NEDS
AYVAKIT
3
QL(30 EA per 30 days); PA NSO;
NEDS
BALVERSA
3
PA NSO; NEDS
BESREMI
3
PA NSO; NEDS
bexarotene caps 75mg
3
NEDS; SP-Optum Specialty
bicalutamide
1
bortezomib inj 3.5mg/1.4ml
3
NEDS
BOSULIF TABS 100MG
3
QL(120 EA per 30 days); PA NSO;
NEDS; SP-Optum Specialty
BOSULIF TABS 400MG, 500MG
3
QL(30 EA per 30 days); PA NSO;
NEDS; SP-Optum Specialty
BRAFTOVI CAPS 75MG
3
PA NSO; NEDS; SP-Optum
Specialty
BRUKINSA
3
PA NSO; NEDS
CABOMETYX
3
PA NSO; NEDS; SP-Optum
Specialty
CALQUENCE TABS
3
PA NSO; NEDS
CALQUENCE CAPS
3
PA NSO; NEDS; SP-Optum
Specialty
CAPRELSA TABS 300MG
3
QL(30 EA per 30 days); PA NSO;
NEDS
CAPRELSA TABS 100MG
3
QL(60 EA per 30 days); PA NSO;
NEDS
COMETRIQ
3
PA NSO; NEDS; SP-Optum
Specialty
COPIKTRA
3
PA NSO; NEDS; SP-Optum
Specialty
COTELLIC
3
PA NSO; NEDS; SP-Optum
Specialty
cyclophosphamide tabs
2
PA BvD
cyclophosphamide caps
2
PA BvD; SP-Optum Specialty
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
10
Drug Name
Drug
Tier
Requirements/Limits
DAURISMO
3
PA NSO; NEDS; SP-Optum
Specialty
DROXIA
2
EMCYT
2
ERIVEDGE
3
PA NSO; NEDS; SP-Optum
Specialty
ERLEADA TABS 240MG
3
PA NSO; NEDS
ERLEADA TABS 60MG
3
PA NSO; NEDS; SP-Optum
Specialty
erlotinib hydrochloride tabs 150mg, 25mg
3
QL(30 EA per 30 days); NEDS; SP-
Optum Specialty
erlotinib hydrochloride tabs 100mg
3
QL(90 EA per 30 days); NEDS; SP-
Optum Specialty
everolimus tabs 10mg, 2.5mg, 5mg, 7.5mg
3
QL(30 EA per 30 days); PA NSO;
NEDS; SP-Optum Specialty
everolimus tbso 2mg, 3mg, 5mg
3
QL(60 EA per 30 days); PA NSO;
NEDS; SP-Optum Specialty
EXKIVITY
3
PA NSO; NEDS
flutamide
1
FOTIVDA
3
PA NSO; NEDS
GAVRETO
3
PA NSO; NEDS; SP-Optum
Specialty
gefitinib
3
PA NSO; NEDS
GILOTRIF
3
PA NSO; NEDS
GLEOSTINE CAPS 100MG, 10MG, 40MG
3
hydroxyurea caps
1
IBRANCE
3
PA NSO; NEDS; SP-Optum
Specialty
ICLUSIG
3
PA NSO; NEDS
IDHIFA
3
QL(30 EA per 30 days); PA NSO;
NEDS; SP-Optum Specialty
imatinib mesylate
3
NEDS; SP-Optum Specialty
IMBRUVICA SUSP
3
PA NSO; NEDS
IMBRUVICA CAPS, TABS
3
PA NSO; NEDS; SP-Optum
Specialty
INLYTA
3
PA NSO; NEDS; SP-Optum
Specialty
INQOVI
3
PA NSO; NEDS; SP-Optum
Specialty
INREBIC
3
PA NSO; NEDS; SP-Optum
Specialty
INTRON A INJ 10000000UNIT, 18000000UNIT,
50000000UNIT
2
SP-Optum Specialty
IRESSA
3
PA NSO; NEDS; SP-Optum
Specialty
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
11
Drug Name
Drug
Tier
Requirements/Limits
JAKAFI
3
PA NSO; NEDS; SP-Optum
Specialty
JAYPIRCA
3
PA NSO; NEDS
KISQALI
3
PA NSO; NEDS; SP-Optum
Specialty
KOSELUGO
3
PA NSO; NEDS
KRAZATI
3
PA NSO; NEDS
lapatinib ditosylate
3
QL(180 EA per 30 days); PA NSO;
NEDS; SP-Optum Specialty
lenalidomide caps 2.5mg, 20mg
3
PA NSO; NEDS
lenalidomide caps 10mg, 15mg, 25mg, 5mg
3
PA NSO; NEDS; SP-Optum
Specialty
LENVIMA 10 MG DAILY DOSE
3
PA NSO; NEDS; SP-Optum
Specialty
LENVIMA 12MG DAILY DOSE
3
PA NSO; NEDS; SP-Optum
Specialty
LENVIMA 14 MG DAILY DOSE
3
PA NSO; NEDS; SP-Optum
Specialty
LENVIMA 18 MG DAILY DOSE
3
PA NSO; NEDS; SP-Optum
Specialty
LENVIMA 20 MG DAILY DOSE
3
PA NSO; NEDS; SP-Optum
Specialty
LENVIMA 24 MG DAILY DOSE
3
PA NSO; NEDS; SP-Optum
Specialty
LENVIMA 4 MG DAILY DOSE
3
PA NSO; NEDS; SP-Optum
Specialty
LENVIMA 8 MG DAILY DOSE
3
PA NSO; NEDS; SP-Optum
Specialty
LEUKERAN
2
LONSURF
3
PA NSO; NEDS; SP-Optum
Specialty
LORBRENA
3
PA NSO; NEDS; SP-Optum
Specialty
LUMAKRAS TABS 320MG
3
PA NSO; NEDS
LUMAKRAS TABS 120MG
3
PA NSO; NEDS; SP-Optum
Specialty
LYNPARZA TABS
3
PA NSO; NEDS; SP-Optum
Specialty
LYSODREN
2
LYTGOBI
3
PA NSO; NEDS
MATULANE
3
NEDS
MEKINIST SOLR
3
PA NSO; NEDS
MEKINIST TABS
3
PA NSO; NEDS; SP-Optum
Specialty
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
12
Drug Name
Drug
Tier
Requirements/Limits
MEKTOVI
3
PA NSO; NEDS; SP-Optum
Specialty
mercaptopurine tabs
1
methotrexate sodium tabs
1
PA BvD
methotrexate sodium inj 1gm/40ml, 250mg/10ml, 50mg/2ml
1
PA BvD
methotrexate tabs
1
PA BvD
methotrexate inj 50mg/2ml
1
PA BvD
NERLYNX
3
PA NSO; NEDS; SP-Optum
Specialty
nilutamide
3
NEDS
NINLARO
3
PA NSO; NEDS; SP-Optum
Specialty
NUBEQA
3
PA NSO; NEDS; SP-Optum
Specialty
ODOMZO
3
PA NSO; NEDS; SP-Optum
Specialty
ONUREG
3
PA NSO; NEDS; SP-Optum
Specialty
ORSERDU
3
PA NSO; NEDS
PEMAZYRE
3
PA NSO; NEDS
PIQRAY 200MG DAILY DOSE
3
PA NSO; NEDS; SP-Optum
Specialty
PIQRAY 250MG DAILY DOSE
3
PA NSO; NEDS; SP-Optum
Specialty
PIQRAY 300MG DAILY DOSE
3
PA NSO; NEDS; SP-Optum
Specialty
POMALYST
3
PA NSO; NEDS; SP-Optum
Specialty
PURIXAN
3
NEDS
QINLOCK
3
PA NSO; NEDS
RETEVMO
3
PA NSO; NEDS; SP-Optum
Specialty
REZLIDHIA
3
PA NSO; NEDS
ROZLYTREK
3
PA NSO; NEDS; SP-Optum
Specialty
RUBRACA
3
QL(120 EA per 30 days); PA NSO;
NEDS; SP-Optum Specialty
RYDAPT
3
PA NSO; NEDS; SP-Optum
Specialty
SCEMBLIX
3
PA NSO; NEDS; SP-Optum
Specialty
sorafenib
3
QL(220 EA per 30 days); PA NSO;
NEDS
sorafenib tosylate tabs
3
QL(220 EA per 30 days); PA NSO;
NEDS
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
13
Drug Name
Drug
Tier
Requirements/Limits
SPRYCEL
3
PA NSO; NEDS; SP-Optum
Specialty
STIVARGA
3
QL(90 EA per 30 days); PA NSO;
NEDS; SP-Optum Specialty
sunitinib malate
3
PA NSO; NEDS; SP-Optum
Specialty
SYNRIBO
3
NEDS
TABLOID
2
SP-Optum Specialty
TABRECTA
3
PA NSO; NEDS; SP-Optum
Specialty
TAFINLAR TBSO
3
PA NSO; NEDS
TAFINLAR CAPS
3
PA NSO; NEDS; SP-Optum
Specialty
TAGRISSO
3
PA NSO; NEDS; SP-Optum
Specialty
TALZENNA CAPS 0.1MG, 0.35MG
3
PA NSO; NEDS
TALZENNA CAPS 0.25MG, 0.5MG, 0.75MG, 1MG
3
PA NSO; NEDS; SP-Optum
Specialty
TASIGNA
3
PA NSO; NEDS; SP-Optum
Specialty
TAZVERIK
3
PA NSO; NEDS
TEPMETKO
3
PA NSO; NEDS
TIBSOVO
3
PA NSO; NEDS; SP-Optum
Specialty
tretinoin caps 10mg
3
NEDS; SP-Optum Specialty
TREXALL
3
PA BvD
TRUSELTIQ
3
PA NSO; NEDS
TUKYSA
3
PA NSO; NEDS
TURALIO
3
PA NSO; NEDS
VENCLEXTA STARTING PACK
3
PA NSO; NEDS; SP-Optum
Specialty
VENCLEXTA TABS 10MG, 50MG
2
PA NSO; SP-Optum Specialty
VENCLEXTA TABS 100MG
3
PA NSO; NEDS; SP-Optum
Specialty
VERZENIO
3
PA NSO; NEDS; SP-Optum
Specialty
VITRAKVI
3
PA NSO; NEDS
VIZIMPRO
3
PA NSO; NEDS; SP-Optum
Specialty
VONJO
3
PA NSO; NEDS; SP-Optum
Specialty
VOTRIENT
3
QL(120 EA per 30 days); PA NSO;
NEDS; SP-Optum Specialty
WELIREG
3
PA NSO; NEDS
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
14
Drug Name
Drug
Tier
Requirements/Limits
XALKORI
3
PA NSO; NEDS; SP-Optum
Specialty
XATMEP
3
PA BvD
XOSPATA
3
PA NSO; NEDS
XPOVIO
3
PA NSO; NEDS
XPOVIO 100 MG ONCE WEEKLY
3
PA NSO; NEDS
XPOVIO 40 MG ONCE WEEKLY
3
PA NSO; NEDS
XPOVIO 40 MG TWICE WEEKLY
3
PA NSO; NEDS
XPOVIO 60 MG ONCE WEEKLY
3
PA NSO; NEDS
XPOVIO 60 MG TWICE WEEKLY
3
PA NSO; NEDS
XPOVIO 80 MG ONCE WEEKLY
3
PA NSO; NEDS
XPOVIO 80 MG TWICE WEEKLY
3
PA NSO; NEDS
XTANDI
3
PA NSO; NEDS; SP-Optum
Specialty
YONSA
3
PA NSO; NEDS; SP-Optum
Specialty
ZEJULA TABS
3
PA NSO; NEDS
ZEJULA CAPS
3
PA NSO; NEDS; SP-Optum
Specialty
ZELBORAF
3
PA NSO; NEDS; SP-Optum
Specialty
ZOLINZA
3
PA NSO; NEDS; SP-Optum
Specialty
ZYDELIG
3
PA NSO; NEDS; SP-Optum
Specialty
ZYKADIA TABS
3
PA NSO; NEDS; SP-Optum
Specialty
Antitoxins, Immune Globulins, Toxoids, and Vaccines
Antitoxins and Immune Globulins
BIVIGAM INJ 10%, 5GM/50ML
3
PA BvD; NEDS; HI
FLEBOGAMMA DIF
3
PA BvD; NEDS; HI
GAMMAGARD LIQUID
3
PA BvD; NEDS; HI
GAMMAKED INJ 10GM/100ML, 1GM/10ML,
20GM/200ML, 5GM/50ML
3
PA BvD; NEDS; HI
GAMMAPLEX INJ 10GM/100ML, 10GM/200ML,
20GM/200ML, 20GM/400ML, 5GM/100ML, 5GM/50ML
3
PA BvD; NEDS; HI
GAMUNEX-C
3
PA BvD; NEDS; HI
OCTAGAM
3
PA BvD; NEDS; HI
PANZYGA
3
PA BvD; NEDS; HI
PRIVIGEN
3
PA BvD; NEDS; HI
Toxoids
ADACEL
2
BOOSTRIX
2
DAPTACEL INJ 15LF/0.5ML; 23MCG/0.5ML; 5LF/0.5ML
2
diphtheria/tetanus toxoids adsorbed pediatric
2
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
15
Drug Name
Drug
Tier
Requirements/Limits
INFANRIX
2
KINRIX INJ 25LFU/0.5ML; 58MCG/0.5ML; 0;
10LFU/0.5ML
2
QUADRACEL
2
tdvax
2
TENIVAC
2
Vaccines
ABRYSVO
2
ACTHIB
2
AREXVY
2
BCG VACCINE INJ 50MG
2
BEXSERO
2
ENGERIX-B
2
PA BvD
GARDASIL 9
2
HAVRIX INJ 1440ELU/ML, 720ELU/0.5ML
2
HEPLISAV-B
2
PA BvD
HIBERIX
2
IMOVAX RABIES (H.D.C.V.)
2
IPOL INACTIVATED IPV
2
IXIARO
2
JYNNEOS
2
M-M-R II
2
MENACTRA
2
MENQUADFI
2
MENVEO
2
PEDIARIX INJ 25LFU/0.5ML; 10MCG/0.5ML;
58MCG/0.5ML; 0; 10LFU/0.5ML
2
PEDVAX HIB INJ 7.5MCG/0.5ML
2
PENTACEL
2
PREHEVBRIO
2
PA BvD
PRIORIX
2
PROQUAD
2
RABAVERT
2
RECOMBIVAX HB
2
PA BvD
ROTARIX
2
ROTATEQ SOLN
2
SHINGRIX
2
STAMARIL
2
TICOVAC
2
TRUMENBA
2
TWINRIX
2
TYPHIM VI
2
VAQTA
2
VARIVAX
2
YF-VAX
2
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
16
Drug Name
Drug
Tier
Requirements/Limits
Autonomic Drugs
Anticholinergic Agents
ANORO ELLIPTA
2
QL(180 EA per 90 days)
ATROVENT HFA
2
QL(77.4 GM per 90 days)
BEVESPI AEROSPHERE
2
QL(10.7 GM per 30 days)
dicyclomine hcl soln
1
dicyclomine hydrochloride caps, tabs
1
glycopyrrolate soln
2
glycopyrrolate tabs 1mg, 2mg
1
INCRUSE ELLIPTA
2
QL(30 EA per 30 days)
ipratropium bromide inhalation soln
1
PA BvD
ipratropium bromide nasal soln 0.03%
1
QL(180 ML per 90 days)
ipratropium bromide nasal soln 0.06%
1
QL(90 ML per 90 days)
LONHALA MAGNAIR REFILL KIT
3
NEDS
LONHALA MAGNAIR STARTER KIT
3
NEDS
SPIRIVA RESPIMAT
2
QL(12 GM per 90 days)
STIOLTO RESPIMAT
2
QL(12 GM per 90 days)
YUPELRI
3
PA BvD; NEDS
Autonomic Drugs, Miscellaneous
NICOTROL INHALER
2
NICOTROL NS
3
varenicline starting month box
2
QL(53 EA per 28 days)
varenicline tartrate
2
QL(60 EA per 30 days)
Parasympathomimetic (Cholinergic) Agents
bethanechol chloride tabs
2
cevimeline hydrochloride
2
donepezil hcl tbdp
1
donepezil hcl tabs 10mg
1
donepezil hcl tabs 23mg
2
donepezil hydrochloride tabs 5mg
1
galantamine hydrobromide er
1
galantamine hydrobromide tabs
1
galantamine hydrobromide soln
2
pilocarpine hydrochloride
1
pyridostigmine bromide er
3
pyridostigmine bromide tabs
1
pyridostigmine bromide soln
2
rivastigmine tartrate
1
rivastigmine transdermal system
2
Skeletal Muscle Relaxants
baclofen tabs
1
cyclobenzaprine hydrochloride tabs
2
dantrolene sodium caps
1
tizanidine hcl caps 4mg
2
tizanidine hcl tabs 2mg
1
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
17
Drug Name
Drug
Tier
Requirements/Limits
tizanidine hydrochloride caps 2mg, 6mg
2
tizanidine hydrochloride tabs 4mg
1
Sympatholytic (Adrenergic Blocking) Agents
alfuzosin hcl er
1
dihydroergotamine mesylate soln
3
QL(8 ML per 30 days); NEDS
ergoloid mesylates tabs
1
phenoxybenzamine hydrochloride
2
silodosin
2
tamsulosin hydrochloride
1
Sympathomimetic (Adrenergic) Agents
albuterol sulfate hfa aers 108mcg/act
1
QL(108 GM per 90 days)
albuterol sulfate hfa aers 108mcg/act
1
QL(40.2 GM per 90 days)
albuterol sulfate hfa aers 108mcg/act
1
QL(51 GM per 90 days)
albuterol sulfate syrp
1
albuterol sulfate nebu
1
PA BvD
albuterol sulfate tabs
2
arformoterol tartrate
2
PA BvD
COMBIVENT RESPIMAT
2
QL(24 GM per 90 days)
droxidopa
3
PA; NEDS
epinephrine inj 0.15mg/0.15ml, 0.15mg/0.3ml, 0.3mg/0.3ml
1
QL(2 EA per 1 days)
fluticasone propionate/salmeterol diskus
2
QL(180 EA per 90 days)
fluticasone propionate/salmeterol aepb 113mcg/act;
14mcg/act, 232mcg/act; 14mcg/act, 55mcg/act; 14mcg/act
1
QL(3 EA per 90 days)
formoterol fumarate nebu
2
PA BvD
ipratropium bromide/albuterol sulfate
1
PA BvD
levalbuterol hcl nebu
1
PA BvD
levalbuterol hydrochloride nebu 0.63mg/3ml
1
PA BvD
levalbuterol tartrate hfa
2
QL(90 GM per 90 days)
levalbuterol nebu
1
PA BvD
midodrine hcl
1
PROAIR RESPICLICK
2
QL(6 EA per 90 days)
SEREVENT DISKUS
2
QL(180 EA per 90 days)
STRIVERDI RESPIMAT
2
QL(12 GM per 90 days)
terbutaline sulfate tabs
1
wixela inhub
2
QL(180 EA per 90 days)
Blood Formation,Coagulation & Thrombosis
Antihemorrhagic Agents
tranexamic acid
1
Antithrombotic Agents
anagrelide hydrochloride
1
aspirin/dipyridamole er
2
BRILINTA
2
CABLIVI
3
NEDS
cilostazol
1
clopidogrel
1
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
18
Drug Name
Drug
Tier
Requirements/Limits
dabigatran etexilate
2
ELIQUIS
2
ELIQUIS STARTER PACK
2
enoxaparin sodium
2
fondaparinux sodium inj 2.5mg/0.5ml
3
fondaparinux sodium inj 10mg/0.8ml, 5mg/0.4ml, 7.5mg/0.6ml
3
NEDS
FRAGMIN INJ 10000UNIT/4ML, 2500UNIT/0.2ML,
5000UNIT/0.2ML
2
FRAGMIN INJ 10000UNIT/ML, 12500UNIT/0.5ML,
15000UNIT/0.6ML, 18000UNT/0.72ML, 7500UNIT/0.3ML,
95000UNIT/3.8ML
3
NEDS
heparin sodium
1
HEPARIN SODIUM/D5W
1
jantoven
1
prasugrel
2
warfarin sodium
1
XARELTO
2
XARELTO STARTER PACK
2
Blood Formation, Coagulation, and Thrombosis Agents Misc.
OXBRYTA
3
NEDS
PYRUKYND
3
PA; NEDS; SP-Optum Specialty
PYRUKYND TAPER PACK
3
PA; NEDS; SP-Optum Specialty
TAVALISSE
3
QL(60 EA per 30 days); NEDS
Hematopoietic Agents
DOPTELET
3
PA; NEDS; SP-Optum Specialty
NEULASTA
3
NEDS; SP-Optum Specialty
PROCRIT INJ 2000UNIT/ML, 3000UNIT/ML,
4000UNIT/ML
2
SP-Optum Specialty
PROCRIT INJ 10000UNIT/ML, 20000UNIT/ML,
40000UNIT/ML
3
NEDS; SP-Optum Specialty
PROMACTA
3
PA; NEDS; SP-Optum Specialty
RETACRIT INJ 10000UNIT/ML, 20000UNIT/2ML,
20000UNIT/ML, 2000UNIT/ML, 3000UNIT/ML,
4000UNIT/ML
2
SP-Optum Specialty
RETACRIT INJ 40000UNIT/ML
3
NEDS; SP-Optum Specialty
UDENYCA INJ 6MG/0.6ML
3
NEDS
UDENYCA INJ 6MG/0.6ML
3
NEDS; SP-Optum Specialty
ZARXIO
3
NEDS; SP-Optum Specialty
ZIEXTENZO
3
NEDS; SP-Optum Specialty
Hemorrheologic Agents
pentoxifylline er
1
Cardiovascular Drugs
alpha-Adrenergic Blocking Agents
CARDURA XL
3
doxazosin mesylate tabs
1
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
19
Drug Name
Drug
Tier
Requirements/Limits
prazosin hydrochloride caps
1
terazosin hcl caps 10mg, 1mg, 5mg
1
terazosin hydrochloride caps 2mg
1
Antilipemic Agents
atorvastatin calcium tabs
1
cholestyramine light
2
cholestyramine pack
2
colesevelam hydrochloride tabs
2
colesevelam hydrochloride pack
3
colestipol hcl pack
1
colestipol hcl tabs
2
ezetimibe
1
ezetimibe/simvastatin
1
fenofibrate micronized caps 134mg, 200mg, 67mg
1
fenofibrate caps 130mg, 150mg, 43mg, 50mg
1
fenofibrate tabs 145mg, 160mg, 48mg, 54mg
1
fenofibrate tabs 120mg, 40mg
2
fenofibric acid dr
2
FLOLIPID
2
fluvastatin
1
fluvastatin sodium er
1
gemfibrozil tabs
1
icosapent ethyl
3
JUXTAPID CAPS 10MG, 20MG, 30MG, 5MG
3
PA; NEDS
LIVALO
2
lovastatin tabs
1
NEXLETOL
2
PA
NEXLIZET
2
PA
niacin er
2
omega-3-acid ethyl esters
1
PRALUENT
2
PA
pravastatin sodium
1
prevalite
2
REPATHA
2
PA
REPATHA PUSHTRONEX SYSTEM
2
PA
REPATHA SURECLICK
2
PA
rosuvastatin calcium
1
simvastatin tabs
1
VASCEPA
3
beta-Adrenergic Blocking Agents
acebutolol hydrochloride
1
atenolol/chlorthalidone
1
atenolol tabs
1
betaxolol hcl tabs 10mg, 20mg
1
bisoprolol fumarate/hydrochlorothiazide
1
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
20
Drug Name
Drug
Tier
Requirements/Limits
bisoprolol fumarate tabs
1
carvedilol
1
carvedilol phosphate er
3
labetalol hydrochloride tabs
1
metoprolol succinate er
1
metoprolol tartrate tabs 100mg, 25mg, 50mg
1
metoprolol tartrate tabs 37.5mg, 75mg
2
metoprolol/hydrochlorothiazide
1
nadolol tabs 20mg, 40mg, 80mg
1
nebivolol hydrochloride
2
pindolol
2
propranolol hcl er cp24 120mg, 160mg
2
propranolol hcl soln
1
propranolol hcl tabs 40mg
1
propranolol hydrochloride er cp24 60mg, 80mg
2
propranolol hydrochloride tabs 10mg, 20mg, 60mg, 80mg
1
sorine
1
sotalol hcl
1
sotalol hydrochloride (af)
1
timolol maleate tabs 10mg, 20mg, 5mg
1
Calcium-Channel Blocking Agents
amlodipine besylate/atorvastatin calcium
1
amlodipine besylate/benazepril hydrochloride
1
amlodipine besylate/valsartan
1
amlodipine besylate tabs
1
amlodipine/olmesartan medoxomil
1
cartia xt
1
dilt-xr
1
diltiazem hcl cd
1
diltiazem hcl er cp24 120mg, 180mg, 240mg, 420mg
1
diltiazem hcl er cp12, tb24
1
diltiazem hcl tabs 30mg, 60mg, 90mg
1
diltiazem hydrochloride er cp24
1
diltiazem hydrochloride er tb24 120mg, 180mg, 240mg,
300mg, 360mg
1
diltiazem hydrochloride tabs 120mg
1
felodipine er
1
isradipine
3
matzim la
1
nicardipine hcl caps
3
nifedipine er
1
nifedipine caps
1
nimodipine caps
3
nisoldipine er
3
NYMALIZE SOLN 6MG/ML
3
NEDS
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
21
Drug Name
Drug
Tier
Requirements/Limits
olmesartan medoxomil/amlodipine/hydrochlorothiazide
1
taztia xt
1
telmisartan/amlodipine
1
tiadylt er
1
trandolapril/verapamil hcl er
1
verapamil hcl er cp24 100mg, 300mg
2
verapamil hcl er tbcr 120mg, 240mg
1
verapamil hcl sr cp24
2
verapamil hcl tabs 40mg, 80mg
1
verapamil hydrochloride er cp24 200mg
2
verapamil hydrochloride er tbcr 180mg
1
verapamil hydrochloride tabs 120mg
1
Cardiac Drugs
amiodarone hydrochloride tabs 200mg
1
amiodarone hydrochloride tabs 100mg, 400mg
2
CAMZYOS
3
QL(30 EA per 30 days); PA; NEDS
CORLANOR
3
digitek tabs 0.125mg, 0.25mg
1
digox
1
digoxin oral soln
1
digoxin inj 0.25mg/ml
1
digoxin tabs 125mcg, 250mcg
1
digoxin tabs 62.5mcg
3
disopyramide phosphate
3
dofetilide
3
flecainide acetate
1
mexiletine hcl
1
MULTAQ
2
NORPACE CR
3
propafenone hcl
1
propafenone hydrochloride er
3
quinidine gluconate cr
2
quinidine sulfate tabs
1
ranolazine er
2
Hypotensive Agents
clonidine hcl ptwk
2
clonidine hydrochloride er
2
clonidine hydrochloride tabs
1
hydralazine hcl tabs 10mg
1
hydralazine hydrochloride tabs 100mg, 25mg, 50mg
1
minoxidil tabs
1
Renin-Angiotensin-Aldosterone Sys Inhib
aliskiren
1
benazepril hcl/hydrochlorothiazide
1
benazepril hcl tabs 10mg, 40mg, 5mg
1
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
22
Drug Name
Drug
Tier
Requirements/Limits
benazepril hydrochloride/hydrochlorothiazide tabs 10mg;
12.5mg, 20mg; 12.5mg, 20mg; 25mg
1
benazepril hydrochloride tabs 20mg
1
candesartan cilexetil
1
candesartan cilexetil/hydrochlorothiazide
1
captopril tabs
1
enalapril maleate/hydrochlorothiazide
1
enalapril maleate tabs
1
ENTRESTO
2
eplerenone
1
fosinopril sodium
1
fosinopril sodium/hydrochlorothiazide
1
irbesartan
1
irbesartan/hydrochlorothiazide
1
KERENDIA
3
PA
lisinopril/hydrochlorothiazide
1
lisinopril tabs
1
losartan potassium/hydrochlorothiazide
1
losartan potassium tabs
1
moexipril hcl
1
olmesartan medoxomil/hydrochlorothiazide
1
olmesartan medoxomil tabs
1
perindopril erbumine
1
quinapril hcl tabs 20mg, 40mg
1
quinapril hydrochloride
1
quinapril/hydrochlorothiazide
1
ramipril
1
spironolactone/hydrochlorothiazide
1
spironolactone tabs
1
TEKTURNA HCT
2
telmisartan
1
telmisartan/hydrochlorothiazide
1
trandolapril
1
valsartan/hydrochlorothiazide
1
valsartan tabs
1
Vasodilating Agents
alyq
3
PA; NEDS; SP-Optum Specialty
CAVERJECT IMPULSE
3
EC
CAVERJECT INJ 20MCG, 40MCG
3
EC
dipyridamole tabs
2
EDEX INJ 10MCG, 20MCG, 40MCG
3
EC
isosorbide dinitrate/hydralazine hydrochloride
2
isosorbide dinitrate tabs
1
isosorbide mononitrate
1
isosorbide mononitrate er
1
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
23
Drug Name
Drug
Tier
Requirements/Limits
MUSE
3
EC
NITRO-BID
3
nitroglycerin lingual soln
2
nitroglycerin transdermal
1
nitroglycerin subl 0.3mg, 0.4mg, 0.6mg
1
sildenafil citrate tabs 20mg
2
PA; SP-Optum Specialty
sildenafil citrate tabs 100mg, 25mg, 50mg
2
QL(4 EA per 30 days); EC
tadalafil tabs 2.5mg, 5mg
2
QL(30 EA per 30 days); PA
tadalafil tabs 10mg, 20mg
2
QL(4 EA per 30 days); EC
tadalafil tabs 20mg
3
PA; NEDS; SP-Optum Specialty
vardenafil hydrochloride odt
2
QL(4 EA per 30 days); EC
vardenafil hydrochloride tabs
2
QL(4 EA per 30 days); EC
VERQUVO
3
Central Nervous System Agents
Analgesics and Antipyretics
acetaminophen/codeine tabs
1
QL(240 EA per 30 days)
acetaminophen/codeine soln
1
QL(3600 ML per 30 days)
BELBUCA
3
QL(60 EA per 30 days)
buprenorphine hcl/naloxone hcl subl 2mg; 0.5mg
1
QL(360 EA per 30 days)
buprenorphine hcl/naloxone hcl subl 8mg; 2mg
1
QL(90 EA per 30 days)
buprenorphine hcl subl 2mg
1
QL(360 EA per 30 days)
buprenorphine hcl subl 8mg
1
QL(90 EA per 30 days)
buprenorphine hydrochloride/naloxone hydrochloride film
4mg; 1mg
1
QL(180 EA per 30 days)
buprenorphine hydrochloride/naloxone hydrochloride film
2mg; 0.5mg
1
QL(360 EA per 30 days)
buprenorphine hydrochloride/naloxone hydrochloride film
12mg; 3mg, 8mg; 2mg
1
QL(90 EA per 30 days)
buprenorphine ptwk
2
QL(4 EA per 28 days)
butorphanol tartrate soln
2
QL(7.5 ML per 30 days)
celecoxib caps 100mg, 200mg, 50mg
1
celecoxib caps 400mg
2
codeine sulfate tabs
2
QL(180 EA per 30 days)
diclofenac epolamine
2
QL(60 EA per 30 days); PA
diclofenac potassium tabs 50mg
2
diclofenac sodium dr
1
diclofenac sodium er
1
diclofenac sodium/misoprostol
3
diflunisal tabs 500mg
2
endocet tabs 325mg; 10mg, 325mg; 2.5mg, 325mg; 5mg,
325mg; 7.5mg
2
QL(240 EA per 30 days)
etodolac er
2
etodolac tabs
1
etodolac caps
2
fentanyl citrate oral transmucosal lpop 200mcg
3
QL(120 EA per 30 days); PA
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
24
Drug Name
Drug
Tier
Requirements/Limits
fentanyl citrate oral transmucosal lpop 1200mcg, 1600mcg,
400mcg, 600mcg, 800mcg
3
QL(120 EA per 30 days); PA; NEDS
fentanyl citrate tabs
3
QL(120 EA per 30 days); PA; NEDS
fentanyl pt72 100mcg/hr, 12mcg/hr, 25mcg/hr, 50mcg/hr,
75mcg/hr
1
QL(10 EA per 30 days)
flurbiprofen tabs 100mg
1
hydrocodone bitartrate er t24a
2
QL(60 EA per 30 days)
hydrocodone bitartrate/acetaminophen soln 325mg/15ml;
7.5mg/15ml
1
QL(3600 ML per 30 days)
hydrocodone bitartrate/acetaminophen tabs 300mg; 10mg,
300mg; 5mg, 300mg; 7.5mg, 325mg; 10mg, 325mg; 5mg
1
QL(240 EA per 30 days)
hydrocodone/acetaminophen tabs 325mg; 7.5mg
1
QL(240 EA per 30 days)
hydrocodone/ibuprofen tabs 10mg; 200mg, 5mg; 200mg,
7.5mg; 200mg
1
QL(240 EA per 30 days)
hydromorphone hcl er tb24 12mg, 16mg, 8mg
2
QL(30 EA per 30 days)
hydromorphone hcl liqd
1
QL(1350 ML per 30 days)
hydromorphone hcl tabs 8mg
1
QL(120 EA per 30 days)
hydromorphone hcl tabs 2mg, 4mg
1
QL(240 EA per 30 days)
hydromorphone hydrochloride er tb24 32mg
2
QL(30 EA per 30 days)
ibu
1
ibuprofen susp
1
ibuprofen tabs 400mg, 600mg, 800mg
1
indomethacin er
2
indomethacin caps 25mg, 50mg
1
ketoprofen er cp24 200mg
3
ketoprofen caps 25mg, 50mg
1
LAZANDA SOLN 400MCG/ACT
3
QL(15 EA per 30 days); PA; NEDS
LAZANDA SOLN 100MCG/ACT
3
QL(30 EA per 30 days); PA; NEDS
levorphanol tartrate tabs
3
QL(240 EA per 30 days); NEDS
meclofenamate sodium caps
3
mefenamic acid caps
3
meloxicam tabs
1
meloxicam caps
2
methadone hcl tabs
1
QL(120 EA per 30 days)
methadone hcl soln 5mg/5ml
1
QL(1200 ML per 30 days)
methadone hcl soln 10mg/5ml
1
QL(600 ML per 30 days)
morphine sulfate er cp24
3
QL(60 EA per 30 days)
morphine sulfate er tbcr 15mg
1
QL(60 EA per 30 days)
morphine sulfate er tbcr 100mg, 200mg, 30mg, 60mg
2
QL(60 EA per 30 days)
morphine sulfate tabs
1
QL(180 EA per 30 days)
morphine sulfate soln 20mg/ml
1
QL(180 ML per 30 days)
morphine sulfate soln 10mg/5ml, 20mg/5ml
1
QL(900 ML per 30 days)
nabumetone tabs
1
naproxen sodium cr
3
naproxen sodium er tb24 375mg
3
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
25
Drug Name
Drug
Tier
Requirements/Limits
naproxen sodium er tb24 500mg
3
NEDS
naproxen sodium tabs 275mg, 550mg
1
naproxen sodium tb24 750mg
3
naproxen tbec
1
naproxen susp
2
naproxen tabs 250mg, 375mg, 500mg
1
oxaprozin
3
oxycodone hcl er t12a
2
QL(60 EA per 30 days)
oxycodone hydrochloride er t12a 10mg, 20mg
2
QL(60 EA per 30 days)
oxycodone hydrochloride conc
1
QL(120 ML per 30 days)
oxycodone hydrochloride caps
1
QL(240 EA per 30 days)
oxycodone hydrochloride soln
1
QL(2400 ML per 30 days)
oxycodone hydrochloride tabs 20mg, 30mg
1
QL(120 EA per 30 days)
oxycodone hydrochloride tabs 10mg, 15mg
1
QL(180 EA per 30 days)
oxycodone hydrochloride tabs 5mg
1
QL(240 EA per 30 days)
oxycodone/acetaminophen tabs 325mg; 10mg, 325mg; 2.5mg,
325mg; 5mg, 325mg; 7.5mg
1
QL(240 EA per 30 days)
OXYCONTIN T12A
2
QL(60 EA per 30 days)
oxymorphone hydrochloride
1
QL(180 EA per 30 days)
oxymorphone hydrochloride er tb12 10mg, 15mg, 20mg,
30mg, 5mg, 7.5mg
1
QL(60 EA per 30 days)
oxymorphone hydrochlorideer
1
QL(60 EA per 30 days)
piroxicam caps
2
pregabalin er
2
SUBSYS
3
QL(120 EA per 30 days); PA; NEDS
sulindac tabs
1
tramadol hcl er cp24 100mg, 200mg, 300mg
1
QL(30 EA per 30 days)
tramadol hcl er tb24
2
QL(30 EA per 30 days)
tramadol hcl tabs
1
QL(240 EA per 30 days)
tramadol hydrochloride er
2
QL(30 EA per 30 days)
tramadol hydrochloride/acetaminophen
1
QL(240 EA per 30 days)
tramadol hydrochloride tabs 100mg
1
QL(120 EA per 30 days)
Anorexigenic Agents and Respiratory and CNS Stimulants
ADIPEX-P
3
EC; PA
amphetamine/dextroamphetamine
2
armodafinil
2
PA
CONTRAVE
3
PA
dexmethylphenidate hcl er cp24 20mg, 35mg
2
dexmethylphenidate hcl tabs 10mg, 5mg
1
dexmethylphenidate hydrochloride er cp24 10mg, 15mg,
30mg, 40mg, 5mg
2
dexmethylphenidate hydrochloride cp24
2
dexmethylphenidate hydrochloride tabs 2.5mg
1
dextroamphetamine sulfate er
2
dextroamphetamine sulfate tabs
2
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
26
Drug Name
Drug
Tier
Requirements/Limits
diethylpropion hcl
2
EC
diethylpropion hcl er
2
EC
methamphetamine hcl
1
PA
methylphenidate hydrochloride cd cpcr 10mg, 20mg, 30mg,
50mg, 60mg
2
methylphenidate hydrochloride er (la)
2
methylphenidate hydrochloride er cp24 10mg, 20mg, 30mg,
40mg
2
methylphenidate hydrochloride er cpcr 40mg
2
methylphenidate hydrochloride er tb24, tbcr
2
methylphenidate hydrochloride soln, tabs
1
methylphenidate hydrochloride chew
2
modafinil
1
PA
phendimetrazine tartrate
2
EC
phendimetrazine tartrate er
2
EC
phentermine hcl tabs 37.5mg
2
EC; PA
phentermine hydrochloride caps
2
EC; PA
QSYMIA
3
EC; PA
SUNOSI
3
PA
VYVANSE
3
PA
Anticonvulsants
APTIOM
3
BRIVIACT SOLN, TABS
3
NEDS
carbamazepine er
2
carbamazepine chew, tabs
1
carbamazepine susp
3
CELONTIN CAPS 300MG
3
clobazam susp
2
clobazam tabs
2
QL(60 EA per 30 days)
clonazepam odt
2
clonazepam tabs
1
DIACOMIT
3
PA NSO; NEDS
DILANTIN INFATABS
2
DILANTIN-125
2
DILANTIN CAPS
2
divalproex sodium dr
1
divalproex sodium er
2
divalproex sodium csdr
1
EPIDIOLEX
3
PA NSO
epitol
1
EPRONTIA
3
EQUETRO
3
ethosuximide soln
1
ethosuximide caps
2
felbamate susp
1
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
27
Drug Name
Drug
Tier
Requirements/Limits
felbamate tabs
2
FINTEPLA
3
PA NSO; NEDS
FYCOMPA
3
gabapentin caps, soln
1
gabapentin tabs 600mg, 800mg
1
HORIZANT
3
lacosamide inj, oral soln
3
lacosamide tabs 50mg
2
QL(60 EA per 30 days)
lacosamide tabs 100mg, 150mg, 200mg
3
QL(60 EA per 30 days)
lamotrigine er
2
lamotrigine odt
2
lamotrigine starter kit/blue
1
lamotrigine starter kit/green
1
lamotrigine starter kit/orange
1
lamotrigine titration
1
lamotrigine tabs
1
lamotrigine chew
2
levetiracetam er
1
levetiracetam oral soln, tabs
1
levetiracetam inj 500mg/5ml
1
magnesium sulfate inj 50%
1
methsuximide
2
NAYZILAM
3
QL(10 EA per 30 days); PA NSO
oxcarbazepine tabs
1
oxcarbazepine susp
2
phenytoin sodium extended
1
phenytoin chew, susp
1
pregabalin caps, soln
2
primidone tabs
1
roweepra tabs 500mg
1
rufinamide
2
SPRITAM
3
subvenite
1
subvenite starter kit/blue
1
subvenite starter kit/green
1
subvenite starter kit/orange
1
SYMPAZAN
3
tiagabine hydrochloride
3
topiramate er cs24
1
topiramate cpsp, tabs
1
valproic acid caps, soln
1
VALTOCO 10 MG DOSE
3
QL(10 EA per 30 days); PA NSO
VALTOCO 15 MG DOSE
3
QL(10 EA per 30 days); PA NSO
VALTOCO 20 MG DOSE
3
QL(10 EA per 30 days); PA NSO
VALTOCO 5 MG DOSE
3
QL(10 EA per 30 days); PA NSO
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
28
Drug Name
Drug
Tier
Requirements/Limits
vigabatrin
3
NEDS
vigadrone
3
NEDS
XCOPRI TABS
3
NEDS
XCOPRI TBPK 0
3
XCOPRI TBPK 0
3
NEDS
ZONISADE
3
zonisamide caps
1
ZTALMY
3
PA NSO; NEDS
Antimanic Agents
lithium carbonate er
1
lithium carbonate caps, tabs
1
Antimigraine Agents
AIMOVIG
2
QL(1 ML per 30 days); PA
almotriptan
3
eletriptan hydrobromide
2
EMGALITY INJ 120MG/ML
2
QL(2 ML per 30 days); PA
EMGALITY INJ 100MG/ML
2
QL(3 ML per 30 days); PA
frovatriptan succinate
3
naratriptan hcl
3
NURTEC
3
PA
rizatriptan benzoate
1
rizatriptan benzoate odt
1
sumatriptan succinate tabs
1
sumatriptan succinate inj 6mg/0.5ml
2
sumatriptan succinate inj 4mg/0.5ml, 6mg/0.5ml
3
sumatriptan soln
2
UBRELVY
3
PA
zolmitriptan odt
1
zolmitriptan tabs
3
zolmitriptan soln 5mg
2
Antiparkinsonian Agents
amantadine hcl caps, soln, tabs
1
benztropine mesylate tabs
1
bromocriptine mesylate caps, tabs
2
cabergoline
1
carbidopa/levodopa
1
carbidopa/levodopa er
1
carbidopa/levodopa odt
1
carbidopa/levodopa/entacapone
2
carbidopa tabs
1
EMSAM
3
ST NSO; NEDS
entacapone
1
GOCOVRI
3
PA
INBRIJA
3
NEDS
KYNMOBI
3
NEDS
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
29
Drug Name
Drug
Tier
Requirements/Limits
NEUPRO
3
QL(30 EA per 30 days)
ONGENTYS
3
pramipexole dihydrochloride
1
pramipexole dihydrochloride er
3
rasagiline mesylate tabs
3
ropinirole er
1
ropinirole hcl tabs 0.5mg, 1mg, 2mg, 4mg, 5mg
1
ropinirole hydrochloride tabs 0.25mg, 3mg
1
RYTARY
3
selegiline hcl caps
1
selegiline hcl tabs
2
trihexyphenidyl hcl soln
1
trihexyphenidyl hydrochloride
1
Anxiolytics, Sedatives, and Hypnotics
alprazolam er
1
alprazolam odt
2
alprazolam tabs
1
BELSOMRA
2
buspirone hcl tabs 15mg
1
buspirone hcl tabs 30mg
2
buspirone hydrochloride tabs 10mg, 5mg
1
buspirone hydrochloride tabs 7.5mg
2
clorazepate dipotassium tabs
3
DAYVIGO
3
diazepam intensol
1
diazepam rectal gel
1
diazepam soln, tabs
1
estazolam
1
eszopiclone
2
flurazepam hcl
1
HETLIOZ LQ
3
PA; NEDS
hydroxyzine hcl tabs 50mg
1
hydroxyzine hydrochloride syrp
1
hydroxyzine hydrochloride tabs 10mg, 25mg
1
hydroxyzine pamoate caps
1
lorazepam intensol
1
lorazepam tabs
1
oxazepam
2
phenobarbital elix 20mg/5ml
1
phenobarbital tabs 100mg, 15mg, 16.2mg, 30mg, 32.4mg,
60mg, 64.8mg, 97.2mg
1
ramelteon
2
QL(30 EA per 30 days)
tasimelteon
3
PA; NEDS
temazepam
1
triazolam
1
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
30
Drug Name
Drug
Tier
Requirements/Limits
zaleplon
1
zolpidem tartrate er
3
zolpidem tartrate tabs
1
zolpidem tartrate subl
2
Central Nervous System Agents, Misc
acamprosate calcium dr
1
ADDYI
3
EC
atomoxetine hydrochloride caps 10mg, 25mg
3
QL(60 EA per 30 days)
atomoxetine caps 100mg, 80mg
3
QL(30 EA per 30 days)
atomoxetine caps 18mg, 40mg, 60mg
3
QL(60 EA per 30 days)
EXSERVAN
3
NEDS
guanfacine er tb24 2mg
2
QL(90 EA per 90 days)
guanfacine hydrochloride tb24 1mg, 3mg, 4mg
2
QL(90 EA per 90 days)
memantine hcl titration pak
1
memantine hydrochloride er
2
memantine hydrochloride tabs
1
memantine hydrochloride soln
2
NAMZARIC
2
NOURIANZ
3
QL(30 EA per 30 days); NEDS
NUEDEXTA
2
PA
RADICAVA ORS
3
PA; NEDS; SP-Optum Specialty
RADICAVA ORS STARTER KIT
3
PA; NEDS; SP-Optum Specialty
RELYVRIO
3
QL(60 EA per 30 days); PA; NEDS
riluzole
2
SODIUM OXYBATE
3
PA; NEDS
Fibromyalgia Agents
SAVELLA
2
SAVELLA TITRATION PACK
2
Opiate Antagonists
naloxone hcl inj 2mg/2ml, 4mg/10ml
1
naloxone hydrochloride liqd
2
QL(4 EA per 30 days)
naloxone hydrochloride inj 0.4mg/ml, 4mg/10ml
1
naltrexone hcl tabs
1
VIVITROL
3
NEDS
Psychotherapeutic Agents
ABILIFY ASIMTUFII
3
NEDS
ABILIFY MAINTENA
3
NEDS
ABILIFY MYCITE
3
QL(30 EA per 30 days); PA NSO;
NEDS
ABILIFY MYCITE MAINTENANCE KIT
3
QL(30 EA per 30 days); PA NSO;
NEDS
ABILIFY MYCITE STARTER KIT
3
QL(30 EA per 30 days); PA NSO;
NEDS
amitriptyline hcl tabs 100mg, 150mg, 25mg, 75mg
1
amitriptyline hydrochloride tabs 10mg, 50mg
1
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
31
Drug Name
Drug
Tier
Requirements/Limits
amoxapine
1
APLENZIN TB24 174MG, 348MG
3
ST NSO
APLENZIN TB24 522MG
3
ST NSO; NEDS
aripiprazole
2
aripiprazole odt
2
ARISTADA
3
NEDS
ARISTADA INITIO
3
NEDS
asenapine maleate sl
2
ST NSO
AUVELITY
3
bupropion hcl tabs 100mg
1
bupropion hydrochloride er (sr)
1
bupropion hydrochloride er (xl)
1
bupropion hydrochloride tabs 75mg
1
CAPLYTA
3
QL(30 EA per 30 days); PA NSO;
NEDS
chlordiazepoxide/amitriptyline
1
chlorpromazine hcl tabs
3
chlorpromazine hydrochloride conc, tabs
3
citalopram hydrobromide tabs
1
citalopram hydrobromide caps, soln
2
clomipramine hydrochloride
2
clozapine odt
1
clozapine tabs 100mg, 200mg, 25mg, 50mg
1
desipramine hydrochloride
1
desvenlafaxine er
1
doxepin hcl caps 75mg
2
doxepin hcl conc
1
doxepin hydrochloride caps 100mg, 10mg, 150mg, 25mg,
50mg
2
doxepin hydrochloride tabs 3mg, 6mg
3
QL(30 EA per 30 days)
DRIZALMA SPRINKLE CSDR 20MG, 60MG
3
QL(60 EA per 30 days)
DRIZALMA SPRINKLE CSDR 30MG, 40MG
3
QL(90 EA per 30 days)
duloxetine hcl cpep 40mg
3
QL(90 EA per 30 days)
duloxetine hydrochloride cpep 20mg, 60mg
1
QL(60 EA per 30 days)
duloxetine hydrochloride cpep 30mg
1
QL(90 EA per 30 days)
escitalopram oxalate tabs
1
escitalopram oxalate soln
3
FANAPT
3
ST NSO
FANAPT TITRATION PACK
3
ST NSO
FETZIMA
3
ST NSO
FETZIMA TITRATION PACK
3
ST NSO
fluoxetine dr
1
fluoxetine hcl caps 20mg
1
fluoxetine hcl soln
2
fluoxetine hydrochloride caps 10mg, 40mg
1
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
32
Drug Name
Drug
Tier
Requirements/Limits
fluoxetine hydrochloride soln
2
fluoxetine hydrochloride tabs
3
fluphenazine decanoate inj
2
fluphenazine hcl conc, inj
1
fluphenazine hcl tabs
2
fluphenazine hydrochloride elix
1
fluvoxamine maleate
1
fluvoxamine maleate er
3
haloperidol decanoate inj
1
haloperidol lactate
1
haloperidol conc, tabs
1
imipramine hcl tabs 25mg, 50mg
1
imipramine hydrochloride tabs 10mg
1
imipramine pamoate
3
INVEGA HAFYERA
3
NEDS
INVEGA SUSTENNA INJ 39MG/0.25ML
3
INVEGA SUSTENNA INJ 117MG/0.75ML, 156MG/ML,
234MG/1.5ML, 78MG/0.5ML
3
NEDS
INVEGA TRINZA
3
NEDS
loxapine
1
lurasidone hydrochloride tabs 120mg, 20mg, 40mg, 60mg
3
QL(30 EA per 30 days)
lurasidone hydrochloride tabs 80mg
3
QL(60 EA per 30 days)
LYBALVI
3
PA NSO; NEDS
MARPLAN
3
mirtazapine odt
1
mirtazapine tabs
1
molindone hydrochloride
2
nefazodone hydrochloride
1
nortriptyline hcl caps 25mg, 75mg
1
nortriptyline hcl soln
1
nortriptyline hydrochloride caps 10mg, 50mg
1
NUPLAZID CAPS
3
QL(60 EA per 30 days); PA NSO;
NEDS
NUPLAZID TABS 10MG
3
QL(60 EA per 30 days); PA NSO;
NEDS
olanzapine
1
olanzapine odt
1
olanzapine/fluoxetine
1
paliperidone er
3
paroxetine
1
paroxetine hcl er
3
paroxetine hcl tabs 30mg, 40mg
1
paroxetine hydrochloride susp
2
paroxetine hydrochloride tabs 10mg, 20mg
1
perphenazine/amitriptyline
2
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
33
Drug Name
Drug
Tier
Requirements/Limits
perphenazine tabs
1
PERSERIS
3
NEDS
phenelzine sulfate tabs
1
pimozide
3
prochlorperazine maleate tabs
1
prochlorperazine supp 25mg
2
protriptyline hcl
2
quetiapine fumarate er
2
quetiapine fumarate tabs 100mg, 150mg, 200mg, 300mg,
400mg
1
quetiapine fumarate tabs 25mg, 50mg
1
QL(60 EA per 30 days)
REXULTI
3
NEDS
RISPERDAL CONSTA INJ 12.5MG
3
RISPERDAL CONSTA INJ 25MG, 37.5MG, 50MG
3
NEDS
risperidone
1
risperidone odt
1
SECUADO
3
NEDS
sertraline hcl conc
1
sertraline hcl tabs 25mg, 50mg
1
sertraline hydrochloride tabs 100mg
1
thioridazine hcl tabs 100mg, 10mg, 25mg, 50mg
1
thiothixene caps 10mg, 1mg, 2mg, 5mg
2
tranylcypromine sulfate
1
trazodone hydrochloride
1
trifluoperazine hcl tabs 10mg, 2mg, 5mg
1
trifluoperazine hydrochloride tabs 1mg
1
trimipramine maleate caps
1
TRINTELLIX
3
venlafaxine besylate er
1
venlafaxine hcl er cp24 150mg, 37.5mg
1
venlafaxine hcl er tb24 37.5mg
2
venlafaxine hydrochloride
1
venlafaxine hydrochloride er cp24 75mg
1
venlafaxine hydrochloride er tb24
2
VERSACLOZ
3
NEDS
VIIBRYD STARTER PACK
3
vilazodone hydrochloride
2
VRAYLAR CPPK
3
VRAYLAR CAPS
3
NEDS
ziprasidone hcl
1
ziprasidone mesylate
2
ZYPREXA RELPREVV INJ 210MG
2
ZYPREXA RELPREVV INJ 300MG, 405MG
3
NEDS
Vesicular Monoamine Transporter 2 (VMAT2) Inhibitors
AUSTEDO
3
PA; NEDS; SP-Optum Specialty
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
34
Drug Name
Drug
Tier
Requirements/Limits
INGREZZA
3
PA; NEDS
tetrabenazine
3
PA; NEDS; SP-Optum Specialty
Devices
Devices
alcohol prep pads
1
b-d insulin syringe ultrafine ii/0.3ml/31g x 5/16"
1
bd insulin syringe safetyglide/1ml/29g x 1/2"
1
bd insulin syringe ultra-fine/0.5ml/30g x 12.7mm
1
bd insulin syringe ultra-fine/1ml/31g x 8mm
1
bd insulin syringe/u-100/1ml/27g x 1/2"
1
bd insulin syringe/u-500/0.5ml/31g x 6mm
1
bd pen needle/original/ultra-fine/29g x 12.7mm
1
curity gauze pads 2"x2" 12 ply
1
gauze pads 2"x2"
1
gnp insulin syringe/0.3ml/30g x 5/16"
1
gnp insulin syringe/0.5ml/30g x 5/16"
1
OMNIPOD 5 G6 INTRO KIT (GEN 5)
3
OMNIPOD 5 G6 PODS (GEN 5)
3
OMNIPOD CLASSIC PDM STARTER KIT (GEN 3)
3
OMNIPOD CLASSIC PODS (GEN 3)
3
OMNIPOD DASH INTRO KIT (GEN 4)
3
OMNIPOD DASH PDM KIT (GEN 4)
3
OMNIPOD DASH PODS (GEN 4)
3
OMNIPOD GO 10 UNITS/DAY
3
OMNIPOD GO 15 UNITS/DAY
3
OMNIPOD GO 20 UNITS/DAY
3
OMNIPOD GO 25 UNITS/DAY
3
OMNIPOD GO 30 UNITS/DAY
3
OMNIPOD GO 35 UNITS/DAY
3
OMNIPOD GO 40 UNITS/DAY
3
techlite insulin syringe u-100/0.5ml/30g x 1/2"
1
techlite pen needles 29g x 10mm
1
trueplus insulin syringe /u-100/1ml/29g x 1/2"
1
trueplus pen needles 29gx12mm
1
Electrolytic, Caloric, and Water Balance
Alkalinizing Agents
potassium citrate er
1
Ammonia Detoxicants
carglumic acid
3
PA; NEDS
constulose
1
enulose
1
generlac
1
KRISTALOSE
2
lactulose soln
1
lactulose pack
2
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
35
Drug Name
Drug
Tier
Requirements/Limits
sodium phenylbutyrate powd, tabs
3
NEDS
Caloric Agents
AMINOSYN II INJ 107.6MEQ/L; 1490MG/100ML;
1527MG/100ML; 1050MG/100ML; 1107MG/100ML;
750MG/100ML; 450MG/100ML; 990MG/100ML;
1500MG/100ML; 1575MG/100ML; 258MG/100ML;
405MG/100ML; 447MG/100ML; 1083MG/100ML;
795MG/100ML; 50MEQ/L; 600MG/100ML; 300MG/100ML;
750MG/100ML
2
PA BvD
AMINOSYN-PF 7% INJ 32.5MEQ/L; 490MG/100ML;
861MG/100ML; 370MG/100ML; 576MG/100ML;
270MG/100ML; 220MG/100ML; 534MG/100ML;
831MG/100ML; 475MG/100ML; 125MG/100ML;
300MG/100ML; 570MG/100ML; 347MG/100ML;
50MG/100ML; 360MG/100ML; 125MG/100ML;
44MG/100ML; 452MG/100ML
2
PA BvD
CLINIMIX 4.25%/DEXTROSE 10%
2
PA BvD
CLINIMIX 4.25%/DEXTROSE 5%
2
PA BvD
CLINIMIX 5%/DEXTROSE 15%
2
PA BvD
CLINIMIX 5%/DEXTROSE 20%
2
PA BvD
CLINIMIX 6/5
2
PA BvD
CLINIMIX 8/10
2
PA BvD
CLINIMIX E 2.75%/DEXTROSE 5%
2
PA BvD
CLINIMIX E 4.25%/DEXTROSE 10%
2
PA BvD
CLINIMIX E 4.25%/DEXTROSE 5%
2
PA BvD
CLINIMIX E 5%/DEXTROSE 15%
2
PA BvD
CLINIMIX E 5%/DEXTROSE 20%
2
PA BvD
CLINIMIX E 8/10
2
PA BvD
CLINISOL SF 15%
2
PA BvD
dextrose 10%
1
dextrose 5%
1
dextrose 50%
1
dextrose 70%
1
FREAMINE III INJ 89MEQ/L; 710MG/100ML;
950MG/100ML; 3MEQ/L; 24MG/100ML; 1400MG/100ML;
280MG/100ML; 690MG/100ML; 910MG/100ML;
730MG/100ML; 530MG/100ML; 560MG/100ML;
10MMOLE/L; 120MG/100ML; 1120MG/100ML;
590MG/100ML; 10MEQ/L; 400MG/100ML; 150MG/100ML;
660MG/100ML
2
PA BvD
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
36
Drug Name
Drug
Tier
Requirements/Limits
HEPATAMINE INJ 62MEQ/L; 770MG/100ML;
600MG/100ML; 3MEQ/L; 20MG/100ML; 900MG/100ML;
240MG/100ML; 900MG/100ML; 1100MG/100ML;
610MG/100ML; 100MG/100ML; 100MG/100ML;
115MG/100ML; 800MG/100ML; 500MG/100ML;
450MG/100ML; 66MG/100ML; 840MG/100ML
2
PA BvD
INTRALIPID INJ 20GM/100ML, 30GM/100ML
2
PA BvD
NUTRILIPID
2
PA BvD
PLENAMINE
2
PA BvD
PREMASOL INJ 52MEQ/L; 1760MG/100ML;
880MG/100ML; 34MEQ/L; 1760MG/100ML;
372MG/100ML; 406MG/100ML; 526MG/100ML;
492MG/100ML; 492MG/100ML; 526MG/100ML;
356MG/100ML; 356MG/100ML; 390MG/100ML;
34MG/100ML; 152MG/100ML
2
PA BvD
PROSOL
2
PA BvD
TRAVASOL INJ 52MEQ/L; 1760MG/100ML;
880MG/100ML; 34MEQ/L; 1760MG/100ML;
372MG/100ML; 406MG/100ML; 526MG/100ML;
492MG/100ML; 492MG/100ML; 526MG/100ML;
356MG/100ML; 500MG/100ML; 356MG/100ML;
390MG/100ML; 34MG/100ML; 152MG/100ML
2
PA BvD
TROPHAMINE INJ 0.54GM/100ML; 1.2GM/100ML;
0.32GM/100ML; 0; 0; 0.5GM/100ML; 0.36GM/100ML;
0.48GM/100ML; 0.82GM/100ML; 1.4GM/100ML;
1.2GM/100ML; 0.34GM/100ML; 0.48GM/100ML;
0.68GM/100ML; 0.38GM/100ML; 5MEQ/L;
0.025GM/100ML; 0.42GM/100ML; 0.2GM/100ML;
0.24GM/100ML; 0.78GM/100ML
2
PA BvD
Diuretics
amiloride hcl tabs
1
amiloride/hydrochlorothiazide
1
bumetanide
1
chlorthalidone tabs 25mg, 50mg
1
ethacrynic acid tabs
3
furosemide inj, oral soln, tabs
1
hydrochlorothiazide caps, tabs
1
indapamide
1
metolazone
1
torsemide tabs
1
triamterene/hydrochlorothiazide caps 25mg; 37.5mg
1
triamterene/hydrochlorothiazide tabs
1
Ion-removing Agents
AURYXIA
3
PA; NEDS
LOKELMA
2
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
37
Drug Name
Drug
Tier
Requirements/Limits
sevelamer carbonate tabs
2
sevelamer carbonate pack
3
sevelamer hydrochloride
3
sodium polystyrene sulfonate powd
1
sps
1
VELPHORO
3
NEDS
VELTASSA
2
Irrigating Solutions
sodium chloride 0.9%
2
Replacement Preparations
calcium acetate caps
1
dextrose 10%/nacl 0.45%
1
dextrose 10%/nacl 0.2%
1
dextrose 2.5%/nacl 0.45%
1
dextrose 5%/nacl 0.2%
1
dextrose 5%/nacl 0.3%
1
dextrose 5%/nacl 0.33%
1
dextrose 5%/nacl 0.45%
1
dextrose 5%/nacl 0.9%
1
dextrose/sodium chloride
1
kcl 0.075%/d5w/nacl 0.45% inj 5%; 10meq/l; 0.45%
1
kcl 0.15%/d5w/nacl 0.2%
1
kcl 0.15%/d5w/nacl 0.45% inj 5%; 20meq/l; 0.45%
1
kcl 0.15%/d5w/nacl 0.9% inj 5%; 20meq/l; 0.9%
1
kcl 0.3%/d5w/nacl 0.45% inj 5%; 40meq/l; 0.45%
1
kcl 0.3%/d5w/nacl 0.9% inj 5%; 40meq/l; 0.9%
1
klor-con
1
klor-con 10
1
klor-con 8
1
klor-con m10
1
klor-con m15
1
klor-con m20
1
potassium chloride er
1
potassium chloride/dextrose/sodium chloride inj 5%; 10meq/l;
0.45%, 5%; 20meq/l; 0.45%, 5%; 20meq/l; 0.9%, 5%;
30meq/l; 0.45%, 5%; 40meq/l; 0.45%, 5%; 40meq/l; 0.9%
1
potassium chloride pack, oral soln
1
potassium chloride inj 10meq/100ml, 10meq/50ml,
20meq/100ml, 20meq/50ml, 2meq/ml, 40meq/100ml
1
sodium chloride 0.45%
1
sodium chloride inj 0.9%, 2.5meq/ml, 3%, 4meq/ml, 5%
1
Uricosuric Agents
probenecid/colchicine
1
probenecid tabs
1
Enzymes
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
38
Drug Name
Drug
Tier
Requirements/Limits
Enzymes
REVCOVI
3
NEDS
SUCRAID
3
NEDS
Eye, Ear, Nose & Throat Preparations
Anti-infectives
AZASITE
3
bacitracin
3
bacitracin/polymyxin b
1
BESIVANCE
3
chlorhexidine gluconate
1
ciprofloxacin hydrochloride soln 0.3%
1
ciprofloxacin soln 0.2%
1
erythromycin oint 5mg/gm
1
gatifloxacin
3
gentak oint
1
gentamicin sulfate ophthalmic soln 0.3%
1
levofloxacin ophthalmic soln 0.5%, 1.5%
2
moxifloxacin hydrochloride soln 0.5%
1
NATACYN
3
neo-polycin
1
neomycin/bacitracin/polymyxin
1
neomycin/polymyxin/gramicidin
1
ofloxacin ophthalmic soln 0.3%
1
ofloxacin otic soln 0.3%
2
periogard
1
polycin
1
polymyxin b sulfate/trimethoprim sulfate
1
sulfacetamide sodium oint 10%
1
sulfacetamide sodium soln 10%
1
tobramycin soln 0.3%
1
trifluridine soln
1
ZIRGAN
3
Anti-inflammatory Agents
ALREX
2
bromfenac
2
BROMSITE
3
ciprofloxacin/dexamethasone
2
cyclosporine emul 0.05%
2
dexamethasone sodium phosphate soln
1
diclofenac sodium ophthalmic soln 0.1%
1
difluprednate
2
flac
1
FLAREX
2
flunisolide soln 0.025%
2
QL(150 ML per 90 days)
fluocinolone acetonide oil 0.01%
1
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
39
Drug Name
Drug
Tier
Requirements/Limits
fluorometholone susp
1
flurbiprofen sodium
1
fluticasone propionate susp 50mcg/act
1
QL(48 GM per 90 days)
FML
2
FML FORTE
3
hydrocortisone/acetic acid
1
ILEVRO
2
INVELTYS
3
ketorolac tromethamine
1
LOTEMAX OINT
3
loteprednol etabonate
2
MAXIDEX SUSP
3
mometasone furoate susp 50mcg/act
2
QL(102 GM per 90 days)
neo-polycin hc
1
neomycin/polymyxin/bacitracin/hydrocortisone
1
neomycin/polymyxin/dexamethasone
1
neomycin/polymyxin/hc
1
neomycin/polymyxin/hydrocortisone ophthalmic susp, otic
susp
1
PRED MILD
2
prednisolone acetate
2
prednisolone sodium phosphate ophthalmic soln 1%
1
PROLENSA
2
RESTASIS
2
RESTASIS MULTIDOSE
2
sulfacetamide sodium/prednisolone sodium phosphate
1
TOBRADEX ST
2
TOBRADEX OINT
2
tobramycin/dexamethasone
2
ZYLET
2
Antiallergic Agents
ALOCRIL
3
ALOMIDE
3
azelastine hcl ophthalmic soln
1
azelastine hcl nasal soln 0.15%
1
QL(120 ML per 90 days)
azelastine hydrochloride soln 0.1%
1
QL(120 ML per 90 days)
bepotastine besilate
2
cromolyn sodium soln 4%
1
epinastine hcl
3
olopatadine hcl ophthalmic soln
2
olopatadine hcl nasal soln
2
QL(91.5 GM per 90 days)
olopatadine hydrochloride soln 0.2%
2
Antiglaucoma Agents
acetazolamide er
2
acetazolamide tabs
1
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
40
Drug Name
Drug
Tier
Requirements/Limits
ALPHAGAN P SOLN 0.1%
2
betaxolol hcl soln 0.5%
2
BETIMOL
3
BETOPTIC-S
2
bimatoprost soln
1
brimonidine tartrate/timolol maleate
2
brimonidine tartrate soln 0.2%
1
brimonidine tartrate soln 0.15%
3
brinzolamide
2
carteolol hcl
1
dorzolamide hcl/timolol maleate
1
dorzolamide hydrochloride/timolol maleate pf
3
dorzolamide hydrochloride soln
1
latanoprost soln
1
levobunolol hcl soln 0.5%
1
LUMIGAN
2
methazolamide tabs
3
pilocarpine hcl soln 1%, 2%, 4%
1
RHOPRESSA
2
ROCKLATAN
2
SIMBRINZA
2
tafluprost
2
timolol maleate ophthalmic gel forming
2
timolol maleate soln 0.25%, 0.5%
1
timolol maleate soln 0.25%, 0.5%
2
travoprost
2
VYZULTA
2
EENT Drugs, Miscellaneous
acetic acid
1
apraclonidine
2
CYSTARAN
2
OXERVATE
3
PA; NEDS
Local Anesthetics
lidocaine hydrochloride viscous
1
lidocaine viscous
1
Mydriatics
atropine sulfate soln 1%
1
Gastrointestinal Drugs
Anti-inflammatory Agents
alosetron hydrochloride
3
NEDS
balsalazide disodium
2
mesalamine dr
3
mesalamine er
3
mesalamine enem, kit, supp
3
Antidiarrhea Agents
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
41
Drug Name
Drug
Tier
Requirements/Limits
loperamide hcl caps
1
XERMELO
3
PA; NEDS; SP-Optum Specialty
Antiemetics
aprepitant caps 0, 40mg, 80mg
2
PA BvD
aprepitant caps 125mg
3
PA BvD; NEDS
dronabinol
3
PA BvD
granisetron hydrochloride tabs
2
PA BvD
meclizine hcl tabs
1
ondansetron hcl soln
1
PA BvD
ondansetron hcl tabs 24mg
1
PA BvD
ondansetron hydrochloride tabs
1
PA BvD
ondansetron odt
1
PA BvD
scopolamine
2
Antiulcer Agents and Acid Suppressants
bismuth subcitrate pot/metronidazole/tetracycline hydrochlo
1
cimetidine tabs
2
DEXLANSOPRAZOLE
2
esomeprazole magnesium cpdr
2
esomeprazole magnesium pack
3
famotidine susr
3
famotidine tabs 20mg, 40mg
1
lansoprazole/amoxicillin/clarithromycin thpk
2
lansoprazole cpdr
1
lansoprazole tbdd
3
misoprostol tabs
1
nizatidine soln
1
omeprazole dr cpdr 10mg
1
omeprazole/sodium bicarbonate caps
3
omeprazole/sodium bicarbonate pack
3
NEDS
omeprazole cpdr 20mg, 40mg
1
pantoprazole sodium dr tbec 20mg
1
pantoprazole sodium tbec
1
pantoprazole sodium pack
3
PYLERA
2
rabeprazole sodium
2
sucralfate tabs
1
sucralfate susp
2
Cathartics and Laxatives
CLENPIQ
2
gavilyte-c
1
gavilyte-g
1
gavilyte-n/flavor pack
1
OSMOPREP
3
peg-3350/electrolytes
1
peg-3350/electrolytes/ascorbate
2
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
42
Drug Name
Drug
Tier
Requirements/Limits
peg-3350/nacl/na bicarbonate/kcl
1
peg-3350/sodium sulf/naclpotassium cl/na ascorbate/ascorbic
2
sodium sulfate/potassium sulfate/magnesium sulfate
2
Cholelitholytic Agents
ursodiol caps 300mg
2
ursodiol caps 200mg
3
ursodiol tabs
3
Digestants
CREON CPEP 120000UNIT; 24000UNIT; 76000UNIT,
15000UNIT; 3000UNIT; 9500UNIT, 180000UNIT;
36000UNIT; 114000UNIT, 30000UNIT; 6000UNIT;
19000UNIT, 60000UNIT; 12000UNIT; 38000UNIT
2
ZENPEP CPEP 105000UNIT; 25000UNIT; 79000UNIT,
14000UNIT; 3000UNIT; 10000UNIT, 168000UNIT;
40000UNIT; 126000UNIT, 24000UNIT; 5000UNIT;
17000UNIT, 42000UNIT; 10000UNIT; 32000UNIT,
63000UNIT; 15000UNIT; 47000UNIT, 84000UNIT;
20000UNIT; 63000UNIT
2
GI Drugs, Miscellaneous
BYLVAY
3
PA; NEDS; SP-Optum Specialty
BYLVAY (PELLETS)
3
PA; NEDS; SP-Optum Specialty
CHOLBAM
3
PA; NEDS
GATTEX
3
PA; NEDS
LINZESS
2
LIVMARLI
3
PA; NEDS
lubiprostone
2
MOVANTIK
2
RELISTOR
3
NEDS
SKYRIZI INJ 180MG/1.2ML
3
QL(1.2 ML per 28 days); PA;
NEDS; SP-Optum Specialty
SKYRIZI INJ 360MG/2.4ML
3
QL(2.4 ML per 28 days); PA; NEDS
XENICAL
3
EC
Prokinetic Agents
metoclopramide hcl inj, oral soln
1
metoclopramide hcl tabs 5mg
1
metoclopramide hydrochloride tabs 10mg
1
metoclopramide odt
1
Gold Compounds
Gold Compounds
RIDAURA
3
NEDS
Heavy Metal Antagonists
Heavy Metal Antagonists
CHEMET
3
deferasirox pack
3
NEDS; SP-Optum Specialty
deferasirox tabs 90mg
2
SP-Optum Specialty
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
43
Drug Name
Drug
Tier
Requirements/Limits
deferasirox tabs 180mg, 360mg
3
NEDS; SP-Optum Specialty
deferasirox tbso 125mg
2
SP-Optum Specialty
deferasirox tbso 250mg, 500mg
3
NEDS; SP-Optum Specialty
deferiprone
3
NEDS
penicillamine tabs
2
penicillamine caps
3
NEDS
trientine hydrochloride
3
NEDS
Hormones and Synthetic Substitutes
Adrenals
BREO ELLIPTA
2
QL(180 EA per 90 days)
BREYNA
2
QL(30.9 GM per 90 days)
BREZTRI AEROSPHERE
2
QL(32.1 GM per 90 days)
budesonide er
3
NEDS
budesonide/formoterol fumarate dihydrate
2
QL(30.6 GM per 90 days)
budesonide cpep 3mg
2
budesonide susp 0.25mg/2ml, 0.5mg/2ml, 1mg/2ml
1
PA BvD
dexamethasone 10-day dose pack
1
dexamethasone 13-day dose pack
1
dexamethasone 6-day dose pack
1
dexamethasone elix
1
dexamethasone tabs 0.5mg, 0.75mg, 1.5mg, 1mg, 2mg, 4mg,
6mg
1
FLOVENT DISKUS AEPB 100MCG/BLIST, 50MCG/BLIST
3
QL(180 EA per 90 days); ST
FLOVENT DISKUS AEPB 250MCG/BLIST
3
QL(720 EA per 90 days); ST
fludrocortisone acetate tabs
1
fluticasone propionate hfa aero 44mcg/act
3
QL(63.6 GM per 90 days); ST
fluticasone propionate hfa aero 110mcg/act, 220mcg/act
3
QL(72 GM per 90 days); ST
hydrocortisone tabs 10mg, 20mg, 5mg
1
INTRAROSA
3
MEDROL TABS 2MG
3
methylprednisolone dose pack tbpk
1
methylprednisolone tabs
1
MILLIPRED TABS
3
prednisolone sodium phosphate odt
2
prednisolone sodium phosphate oral soln 10mg/5ml,
15mg/5ml, 20mg/5ml, 25mg/5ml, 5mg/5ml
1
prednisolone soln, tabs
1
prednisone soln, tbpk
1
prednisone tabs 10mg, 1mg, 2.5mg, 20mg, 50mg, 5mg
1
QVAR REDIHALER
2
QL(63.6 GM per 90 days)
TRELEGY ELLIPTA
2
QL(180 EA per 90 days)
Androgens
AVEED
3
danazol caps
3
testosterone cypionate inj 100mg/ml, 200mg/ml
1
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
44
Drug Name
Drug
Tier
Requirements/Limits
testosterone enanthate inj
1
testosterone pump
2
testosterone gel 10mg/act, 20.25mg/1.25gm, 25mg/2.5gm,
40.5mg/2.5gm, 50mg/5gm
2
testosterone soln
3
XYOSTED
3
Antidiabetic Agents
acarbose tabs
1
BYDUREON BCISE
2
PA
BYETTA
3
PA
CYCLOSET
2
FARXIGA
2
glimepiride
1
glipizide er
1
glipizide/metformin hydrochloride
1
glipizide tabs
1
glyburide micronized
1
glyburide/metformin hydrochloride
1
glyburide tabs 1.25mg, 2.5mg, 5mg
1
GLYXAMBI
2
HUMALOG
2
HUMALOG JUNIOR KWIKPEN
2
HUMALOG KWIKPEN
2
HUMALOG MIX 50/50
2
HUMALOG MIX 50/50 KWIKPEN
2
HUMALOG MIX 75/25
2
HUMALOG MIX 75/25 KWIKPEN
2
HUMULIN 70/30
2
HUMULIN 70/30 KWIKPEN
2
HUMULIN N
2
HUMULIN N KWIKPEN
2
HUMULIN R
2
HUMULIN R U-500 (CONCENTRATED)
2
HUMULIN R U-500 KWIKPEN
2
JANUMET
2
JANUMET XR
2
JANUVIA
2
JARDIANCE
2
JENTADUETO
2
JENTADUETO XR
2
KORLYM
3
QL(120 EA per 30 days); PA; NEDS
LANTUS
2
LANTUS SOLOSTAR
2
LEVEMIR
2
LEVEMIR FLEXPEN
2
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
45
Drug Name
Drug
Tier
Requirements/Limits
LEVEMIR FLEXTOUCH
2
metformin hydrochloride er tb24 500mg, 750mg
1
metformin hydrochloride soln
1
metformin hydrochloride tabs 1000mg, 500mg, 850mg
1
miglitol
1
MOUNJARO
2
PA
nateglinide
1
OZEMPIC
2
PA
pioglitazone hcl-glimepiride
1
pioglitazone hcl/metformin hcl
1
pioglitazone hcl tabs 45mg
1
pioglitazone hydrochloride tabs 15mg, 30mg
1
repaglinide
1
RYBELSUS
2
PA
SAXENDA
3
EC
SYMLINPEN 120
2
SYMLINPEN 60
2
SYNJARDY
2
SYNJARDY XR
2
TOUJEO MAX SOLOSTAR
2
TOUJEO SOLOSTAR
2
TRADJENTA
2
TRESIBA
2
TRESIBA FLEXTOUCH
2
TRULICITY
2
PA
VICTOZA
2
PA
WEGOVY
3
EC
XIGDUO XR
2
Antihypoglycemic Agents
BAQSIMI ONE PACK
2
BAQSIMI TWO PACK
2
diazoxide susp
2
GLUCAGEN HYPOKIT
2
GLUCAGON EMERGENCY KIT
2
GLUCAGON EMERGENCY KIT FOR LOW BLOOD
SUGAR INJ 1MG
2
GVOKE HYPOPEN 1-PACK
2
GVOKE HYPOPEN 2-PACK
2
GVOKE KIT
2
GVOKE PFS
2
Contraceptives
amethia
1
apri
1
ashlyna
1
aviane
1
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
46
Drug Name
Drug
Tier
Requirements/Limits
balziva
1
briellyn
1
camila
1
deblitane
1
desogestrel/ethinyl estradiol tabs 0; 0
1
drospirenone/ethinyl estradiol tabs 3mg; 0.03mg
1
eluryng
2
errin
1
etonogestrel/ethinyl estradiol
2
falmina
1
finzala
1
haloette
2
iclevia
1
introvale
1
junel 1.5/30
1
junel 1/20
1
junel fe 1.5/30
1
junel fe 1/20
1
junel fe 24
1
kariva
1
kelnor 1/35
1
larin 1.5/30
1
larin 1/20
1
larin fe 1.5/30
1
larin fe 1/20
1
lessina
1
levonest
1
levonorgestrel and ethinyl estradiol tabs 20mcg; 90mcg
1
levonorgestrel/ethinyl estradiol
1
levora 0.15/30-28
1
LO LOESTRIN FE
3
marlissa
1
mibelas 24 fe
1
microgestin 1.5/30
1
microgestin 1/20
1
microgestin fe 1.5/30
1
microgestin fe 1/20
1
necon 0.5/35-28
1
nikki
1
norethindrone & ethinyl estradiol ferrous fumarate
1
norethindrone acetate/ethinyl estradiol/ferrous fumarate tabs
0; 75mg; 1mg
1
nortrel 0.5/35 (28)
1
nortrel 1/35
1
nortrel 7/7/7
1
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
47
Drug Name
Drug
Tier
Requirements/Limits
portia-28
1
sharobel
1
tarina fe 1/20 eq
1
tri-sprintec
1
trivora-28
1
tyblume
1
velivet
1
vyfemla
1
zovia 1/35
1
Estrogens and Antiestrogens
amabelz
1
anastrozole
1
COMBIPATCH
3
DEPO-ESTRADIOL
2
dotti
2
ELESTRIN
3
estradiol valerate
1
estradiol/norethindrone acetate
1
estradiol oral tabs
1
estradiol crea, gel, pttw, ptwk, vaginal tabs
2
ESTRING
2
EVAMIST
3
exemestane
2
FEMRING
2
fyavolv
2
IMVEXXY MAINTENANCE PACK
2
IMVEXXY STARTER PACK
2
jinteli
1
KISQALI FEMARA 200 DOSE
3
PA NSO; NEDS; SP-Optum
Specialty
KISQALI FEMARA 400 DOSE
3
PA NSO; NEDS; SP-Optum
Specialty
KISQALI FEMARA 600 DOSE
3
PA NSO; NEDS; SP-Optum
Specialty
letrozole
1
MENEST
3
MENOSTAR
3
mimvey
1
norethindrone acetate/ethinyl estradiol
1
OSPHENA
3
PREMARIN CREA
2
PREMARIN TABS
3
PREMPHASE
3
PREMPRO
3
raloxifene hydrochloride
1
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
48
Drug Name
Drug
Tier
Requirements/Limits
SOLTAMOX
2
tamoxifen citrate
1
toremifene citrate
2
yuvafem
2
Gonadotropins and Antigonadotropins
ELIGARD
2
FIRMAGON INJ 80MG
2
FIRMAGON INJ 120MG/VIAL
3
NEDS
leuprolide acetate inj 1mg/0.2ml
1
SP-Optum Specialty
LUPRON DEPOT (1-MONTH)
3
NEDS
LUPRON DEPOT (3-MONTH)
3
NEDS
LUPRON DEPOT (4-MONTH)
3
NEDS
LUPRON DEPOT (6-MONTH)
3
NEDS
MYFEMBREE
3
QL(28 EA per 28 days); PA; NEDS
ORGOVYX
3
PA NSO; NEDS
ORILISSA TABS 150MG
3
QL(30 EA per 30 days); PA; NEDS
ORILISSA TABS 200MG
3
QL(60 EA per 30 days); PA; NEDS
SYNAREL
3
NEDS
TRELSTAR MIXJECT INJ 22.5MG, 3.75MG
3
TRELSTAR MIXJECT INJ 11.25MG
3
NEDS
Parathyroid and Antiparathyroid Agents
CALCITONIN SALMON INJ
2
calcitonin-salmon soln
1
cinacalcet hydrochloride tabs 30mg, 60mg
3
cinacalcet hydrochloride tabs 90mg
3
NEDS
FORTEO INJ 600MCG/2.4ML
3
PA; NEDS
NATPARA
3
QL(2 EA per 28 days); PA; NEDS
teriparatide
3
PA; NEDS
TYMLOS
3
PA; NEDS
Pituitary
CORTROPHIN
3
PA; NEDS; SP-Optum Specialty
desmopressin acetate tabs
1
desmopressin acetate soln 0.01%
1
Progestins
DEPO-SUBQ PROVERA 104
2
medroxyprogesterone acetate inj, tabs
1
megestrol acetate tabs
1
megestrol acetate susp 40mg/ml
1
megestrol acetate susp 625mg/5ml
3
norethindrone acetate tabs
1
progesterone caps
1
Somatostatin Agonists and Antagonists
octreotide acetate
1
SP-Optum Specialty
SIGNIFOR
3
QL(60 ML per 30 days); PA; NEDS
Somatotropin Agonists and Antagonists
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
49
Drug Name
Drug
Tier
Requirements/Limits
EGRIFTA SV
3
PA; NEDS; SP-Optum Specialty
GENOTROPIN
3
PA; NEDS; SP-Optum Specialty
GENOTROPIN MINIQUICK INJ 0.2MG
2
PA; SP-Optum Specialty
GENOTROPIN MINIQUICK INJ 0.4MG, 0.6MG, 0.8MG,
1.2MG, 1.4MG, 1.6MG, 1MG, 2MG
3
PA; NEDS; SP-Optum Specialty
genotropin miniquick inj 1.8mg
3
PA; NEDS; SP-Optum Specialty
INCRELEX
3
PA; NEDS; SP-Optum Specialty
NORDITROPIN FLEXPRO
3
PA; NEDS; SP-Optum Specialty
NUTROPIN AQ NUSPIN 10
3
PA; NEDS; SP-Optum Specialty
NUTROPIN AQ NUSPIN 20
3
PA; NEDS; SP-Optum Specialty
NUTROPIN AQ NUSPIN 5
3
PA; NEDS; SP-Optum Specialty
OMNITROPE
3
PA; NEDS; SP-Optum Specialty
SEROSTIM INJ 4MG, 5MG, 6MG
3
PA; NEDS; SP-Optum Specialty
SOMAVERT
3
PA; NEDS; SP-Optum Specialty
ZORBTIVE
3
PA; NEDS; SP-Optum Specialty
Thyroid and Antithyroid Agents
ARMOUR THYROID
3
euthyrox tabs 100mcg, 112mcg, 125mcg, 137mcg, 150mcg,
175mcg, 200mcg, 25mcg, 50mcg, 75mcg, 88mcg
1
levo-t
1
levothyroxine sodium tabs
1
levothyroxine sodium caps
2
levoxyl tabs 100mcg, 112mcg, 125mcg, 137mcg, 150mcg,
175mcg, 200mcg, 25mcg, 50mcg, 75mcg, 88mcg
1
liothyronine sodium tabs
1
methimazole tabs 10mg, 5mg
1
NIVA THYROID
3
np thyroid 120
1
np thyroid 15
1
np thyroid 30
1
np thyroid 60
1
np thyroid 90
1
propylthiouracil tabs
1
SYNTHROID TABS
3
THYQUIDITY
3
THYROID TABS 120MG, 15MG, 30MG, 60MG, 90MG
3
TIROSINT-SOL
3
unithroid
1
Miscellaneous Therapeutic Agents
5-alpha-Reductase Inhibitors
dutasteride/tamsulosin hydrochloride
2
dutasteride caps
1
finasteride tabs
1
Alcohol Deterrents
disulfiram tabs
1
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
50
Drug Name
Drug
Tier
Requirements/Limits
Antidotes
acetylcysteine soln
1
PA BvD
leucovorin calcium tabs
1
Antigout Agents
allopurinol tabs 100mg, 300mg
1
colchicine tabs
1
colchicine caps
2
febuxostat
2
ST
GLOPERBA
3
Antisense Oligonucleotides
TEGSEDI
3
QL(6 ML per 30 days); PA; NEDS
Bone Anabolic Agents
EVENITY
3
PA; NEDS
Bone Resorption Inhibitors
alendronate sodium soln
2
alendronate sodium tabs 10mg, 35mg, 70mg
1
ibandronate sodium tabs
1
PROLIA
3
PA
risedronate sodium
2
risedronate sodium dr
2
XGEVA
3
PA; NEDS
Carbonic Anhydrase Inhibitors
dichlorphenamide
3
PA; NEDS
Disease-modifying Antirheumatic Drugs
COSENTYX
3
PA; NEDS; SP-Optum Specialty
COSENTYX SENSOREADY PEN
3
PA; NEDS; SP-Optum Specialty
COSENTYX UNOREADY
3
PA; NEDS
ENBREL MINI
3
QL(8 ML per 28 days); PA; NEDS;
SP-Optum Specialty
ENBREL SURECLICK
3
QL(8 ML per 28 days); PA; NEDS;
SP-Optum Specialty
ENBREL INJ 25MG
3
QL(8 EA per 28 days); PA; NEDS;
SP-Optum Specialty
ENBREL INJ 50MG/ML
3
QL(8 ML per 28 days); PA; NEDS;
SP-Optum Specialty
ENBREL INJ 25MG/0.5ML
3
QL(8.16 ML per 28 days); PA;
NEDS; SP-Optum Specialty
HUMIRA PEDIATRIC CROHNS DISEASE STARTER
PACK INJ 0, 80MG/0.8ML
3
PA; NEDS; SP-Optum Specialty
HUMIRA PEN-CD/UC/HS STARTER
3
PA; NEDS; SP-Optum Specialty
HUMIRA PEN-PEDIATRIC UC STARTER PACK
3
PA; NEDS; SP-Optum Specialty
HUMIRA PEN-PS/UV STARTER
3
PA; NEDS; SP-Optum Specialty
HUMIRA PEN INJ 80MG/0.8ML
3
QL(4 EA per 28 days); PA; NEDS;
SP-Optum Specialty
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
51
Drug Name
Drug
Tier
Requirements/Limits
HUMIRA PEN INJ 40MG/0.4ML, 40MG/0.8ML
3
QL(6 EA per 28 days); PA; NEDS;
SP-Optum Specialty
HUMIRA INJ 10MG/0.1ML, 20MG/0.2ML, 40MG/0.4ML,
40MG/0.8ML
3
QL(6 EA per 28 days); PA; NEDS;
SP-Optum Specialty
KINERET
3
QL(20.1 ML per 28 days); PA;
NEDS
leflunomide tabs
1
ORENCIA CLICKJECT
3
QL(4 ML per 28 days); PA; NEDS
ORENCIA INJ 50MG/0.4ML
3
QL(1.6 ML per 28 days); PA; NEDS
ORENCIA INJ 87.5MG/0.7ML
3
QL(2.8 ML per 28 days); PA; NEDS
ORENCIA INJ 125MG/ML
3
QL(4 ML per 28 days); PA; NEDS
OTEZLA TBPK
3
QL(110 EA per 365 days); PA;
NEDS
OTEZLA TABS
3
QL(60 EA per 30 days); PA; NEDS
RASUVO INJ 10MG/0.2ML, 12.5MG/0.25ML,
15MG/0.3ML, 17.5MG/0.35ML, 20MG/0.4ML,
22.5MG/0.45ML, 25MG/0.5ML, 30MG/0.6ML,
7.5MG/0.15ML
3
RINVOQ
3
QL(30 EA per 30 days); PA; NEDS;
SP-Optum Specialty
XELJANZ XR
3
QL(30 EA per 30 days); PA; NEDS;
SP-Optum Specialty
XELJANZ SOLN
3
QL(300 ML per 30 days); PA;
NEDS; SP-Optum Specialty
XELJANZ TABS
3
QL(60 EA per 30 days); PA; NEDS;
SP-Optum Specialty
Immunomodulatory Agents
ACTIMMUNE
3
NEDS; SP-Optum Specialty
AUBAGIO
3
NEDS; SP-Optum Specialty
AVONEX PEN
3
NEDS; SP-Optum Specialty
AVONEX INJ 30MCG/0.5ML
3
NEDS; SP-Optum Specialty
BAFIERTAM
3
NEDS; SP-Optum Specialty
BETASERON
3
NEDS; SP-Optum Specialty
COPAXONE
3
NEDS; SP-Optum Specialty
dimethyl fumarate starterpack
3
NEDS; SP-Optum Specialty
dimethyl fumarate cpdr
3
NEDS; SP-Optum Specialty
EXTAVIA
3
NEDS; SP-Optum Specialty
fingolimod
3
NEDS
KESIMPTA
3
PA; NEDS; SP-Optum Specialty
MAYZENT
3
NEDS; SP-Optum Specialty
MAYZENT STARTER PACK TBPK 0.25MG
3
NEDS; SP-Optum Specialty
MAYZENT STARTER PACK TBPK 0.25MG
3
SP-Optum Specialty
PLEGRIDY
3
NEDS; SP-Optum Specialty
PLEGRIDY STARTER PACK
3
NEDS; SP-Optum Specialty
REBIF
3
NEDS; SP-Optum Specialty
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
52
Drug Name
Drug
Tier
Requirements/Limits
REBIF REBIDOSE
3
NEDS; SP-Optum Specialty
REBIF REBIDOSE TITRATION PACK
3
NEDS; SP-Optum Specialty
REBIF TITRATION PACK
3
NEDS; SP-Optum Specialty
teriflunomide
3
THALOMID
3
NEDS; SP-Optum Specialty
VUMERITY
3
NEDS; SP-Optum Specialty
Immunosuppressive Agents
azathioprine tabs 50mg
1
PA BvD
azathioprine tabs 100mg, 75mg
2
PA BvD
BENLYSTA INJ 200MG/ML
3
PA; NEDS; SP-Optum Specialty
cyclosporine modified soln
1
PA BvD
cyclosporine modified caps
2
PA BvD
cyclosporine caps 100mg, 25mg
3
PA BvD
ENVARSUS XR
3
PA BvD
everolimus tabs 0.25mg, 0.5mg, 0.75mg, 1mg
3
QL(60 EA per 30 days); PA BvD;
NEDS
GENGRAF SOLN
1
PA BvD
gengraf caps 100mg, 25mg
2
PA BvD
mycophenolate mofetil caps, tabs
1
PA BvD
mycophenolate mofetil susr
3
PA BvD; NEDS
mycophenolic acid dr
3
PA BvD
PROGRAF PACK
3
PA BvD
sirolimus soln, tabs
2
PA BvD
tacrolimus caps 0.5mg, 1mg, 5mg
1
PA BvD
Kallikrein-Kinin System Inhibitors
BERINERT
3
PA; NEDS
CINRYZE
3
PA; NEDS
HAEGARDA
3
PA; NEDS; SP-Optum Specialty
icatibant acetate
3
QL(18 ML per 30 days); PA; NEDS;
SP-Optum Specialty
SAJAZIR
3
QL(18 ML per 30 days); PA; NEDS;
SP-Optum Specialty
TAVNEOS
3
PA; NEDS
Other Miscellaneous Therapeutic Agents
ARCALYST
3
PA; NEDS
betaine anhydrous
3
NEDS
CERDELGA
3
PA; NEDS; SP-Optum Specialty
CYSTAGON
3
dalfampridine er
2
SP-Optum Specialty
ELMIRON
3
ENDARI
3
NEDS
EVRYSDI
3
PA; NEDS
FIRDAPSE
3
PA; NEDS
GALAFOLD
3
PA; NEDS
levocarnitine tabs
2
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
53
Drug Name
Drug
Tier
Requirements/Limits
metyrosine
3
NEDS
miglustat
3
PA; NEDS; SP-Optum Specialty
nitisinone caps 20mg
3
PA; NEDS
nitisinone caps 10mg, 2mg, 5mg
3
PA; NEDS; SP-Optum Specialty
ORFADIN SUSP
3
PA; NEDS
ORFADIN CAPS 20MG
3
PA; NEDS
REZUROCK
3
PA; NEDS
sapropterin dihydrochloride
3
PA; NEDS; SP-Optum Specialty
THIOLA EC
3
NEDS
TYBOST
2
VIJOICE TBPK 125MG, 50MG
3
QL(28 EA per 28 days); PA; NEDS;
SP-Optum Specialty
VIJOICE TBPK 0
3
QL(56 EA per 28 days); PA; NEDS;
SP-Optum Specialty
VOXZOGO
3
PA; NEDS; SP-Optum Specialty
VYNDAMAX
3
QL(30 EA per 30 days); PA; NEDS;
SP-Optum Specialty
VYNDAQEL
3
QL(120 EA per 30 days); PA;
NEDS; SP-Optum Specialty
Protective Agents
MESNEX TABS
3
NEDS
Respiratory Tract Agents
Anti-inflammatory Agents
cromolyn sodium conc 100mg/5ml
3
cromolyn sodium nebu 20mg/2ml
3
PA BvD
DUPIXENT INJ 100MG/0.67ML, 200MG/1.14ML
3
PA; NEDS; SP-Optum Specialty
FASENRA
3
PA; NEDS
FASENRA PEN
3
PA; NEDS; SP-Optum Specialty
montelukast sodium chew, pack, tabs
1
NUCALA INJ 100MG, 40MG/0.4ML
3
PA; NEDS
NUCALA INJ 100MG/ML
3
PA; NEDS; SP-Optum Specialty
zafirlukast
2
zileuton er
3
NEDS
Antifibrotic Agents
ESBRIET CAPS
3
QL(270 EA per 30 days); PA;
NEDS; SP-Optum Specialty
ESBRIET TABS 267MG
3
QL(270 EA per 30 days); PA;
NEDS; SP-Optum Specialty
ESBRIET TABS 801MG
3
QL(90 EA per 30 days); PA; NEDS;
SP-Optum Specialty
OFEV
3
QL(60 EA per 30 days); PA; NEDS;
SP-Optum Specialty
pirfenidone caps
3
QL(270 EA per 30 days); PA; NEDS
pirfenidone tabs 534mg
3
QL(135 EA per 30 days); PA; NEDS
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
54
Drug Name
Drug
Tier
Requirements/Limits
pirfenidone tabs 267mg
3
QL(270 EA per 30 days); PA;
NEDS; SP-Optum Specialty
pirfenidone tabs 801mg
3
QL(90 EA per 30 days); PA; NEDS;
SP-Optum Specialty
Antitussives
benzonatate
2
EC
hydrocodone bitartrate/homatropine methylbromide soln, tabs
2
EC
promethazine dm
2
EC
promethazine vc/codeine
2
EC
promethazine/codeine syrp
2
EC
Cystic Fibrosis Transmembrane Conductance Regulator
Modulators
KALYDECO TABS
3
QL(56 EA per 28 days); PA; NEDS;
SP-Optum Specialty
KALYDECO PACK 13.4MG
3
QL(56 EA per 28 days); PA; NEDS
KALYDECO PACK 25MG, 50MG, 75MG
3
QL(56 EA per 28 days); PA; NEDS;
SP-Optum Specialty
ORKAMBI TABS
3
QL(112 EA per 28 days); PA;
NEDS; SP-Optum Specialty
ORKAMBI PACK 94MG; 75MG
3
QL(56 EA per 28 days); PA; NEDS
ORKAMBI PACK 125MG; 100MG, 188MG; 150MG
3
QL(56 EA per 28 days); PA; NEDS;
SP-Optum Specialty
SYMDEKO
3
PA; NEDS; SP-Optum Specialty
TRIKAFTA THPK
3
QL(56 EA per 28 days); PA; NEDS
TRIKAFTA TBPK
3
QL(84 EA per 28 days); PA; NEDS;
SP-Optum Specialty
Mucolytic Agents
PULMOZYME
3
PA BvD; NEDS; SP-Optum
Specialty
Phosphodiesterase Type 4 Inhibitors
roflumilast
2
Respiratory Tract Agents, Miscellaneous
BRONCHITOL
3
NEDS
PROLASTIN-C
3
PA; NEDS
XOLAIR INJ 150MG, 75MG/0.5ML
3
PA; NEDS
XOLAIR INJ 150MG/ML
3
PA; NEDS; SP-Optum Specialty
Vasodilating Agents
ADEMPAS
3
PA; NEDS
ambrisentan
3
PA; NEDS; SP-Optum Specialty
bosentan
3
PA; NEDS; SP-Optum Specialty
OPSUMIT
3
PA; NEDS
ORENITRAM TITRATION KIT MONTH 1
3
PA; NEDS
ORENITRAM TITRATION KIT MONTH 2
3
PA; NEDS
ORENITRAM TITRATION KIT MONTH 3
3
PA; NEDS
ORENITRAM TBCR 0.125MG, 0.25MG, 1MG, 2.5MG
3
PA
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
55
Drug Name
Drug
Tier
Requirements/Limits
ORENITRAM TBCR 5MG
3
PA; NEDS
TRACLEER TBSO
3
PA; NEDS; SP-Optum Specialty
UPTRAVI TITRATION PACK
3
PA; NEDS
UPTRAVI TABS
3
PA; NEDS
VENTAVIS
3
PA; NEDS
Skin and Mucous Membrane Agents
Anti-inflammatory Agents
kourzeq
1
Cell Stimulants and Proliferants
RETIN-A MICRO GEL 0.06%
3
PA
Skin and Mucous Membrane Preparations
Anti-infectives
acyclovir crea 5%
2
ciclopirox nail lacquer
2
ciclopirox olamine
1
ciclopirox gel, susp
1
ciclopirox sham
3
CLEOCIN
3
clindacin
3
clindacin etz pledgets
1
clindacin-p
1
clindamycin phosphate/benzoyl peroxide
3
clindamycin phosphate crea 2%
1
clindamycin phosphate foam 1%
3
clindamycin phosphate gel 1%
1
clindamycin phosphate lotn 1%
3
clindamycin phosphate external soln 1%
1
clindamycin phosphate swab 1%
1
clindamycin/benzoyl peroxide
3
clotrimazole/betamethasone dipropionate crea
2
clotrimazole/betamethasone dipropionate lotn
3
clotrimazole soln, troc
1
clotrimazole crea
2
econazole nitrate
2
ery
1
erythromycin/benzoyl peroxide
3
erythromycin gel 2%
1
erythromycin soln 2%
1
gentamicin sulfate crea 0.1%
2
gentamicin sulfate oint 0.1%
2
GYNAZOLE-1
3
ivermectin crea 1%
3
ketoconazole crea 2%
2
QL(120 GM per 30 days)
ketoconazole foam 2%
3
ketoconazole sham 2%
1
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
56
Drug Name
Drug
Tier
Requirements/Limits
KETODAN
3
malathion
3
MENTAX
3
metronidazole vaginal
2
metronidazole crea 0.75%
1
metronidazole gel 0.75%, 1%
1
metronidazole lotn 0.75%
3
miconazole 3
1
mupirocin oint
1
QL(44 GM per 30 days)
mupirocin crea
2
QL(180 GM per 30 days)
naftifine hcl
2
naftifine hydrochloride
2
NEUAC
3
NUVESSA
3
nyamyc
1
nystatin crea 100000unit/gm
1
nystatin oint 100000unit/gm
1
nystatin powd 100000unit/gm
1
nystop
1
oxiconazole nitrate
3
QL(90 GM per 30 days)
penciclovir
3
permethrin
2
rosadan
1
selenium sulfide
1
silver sulfadiazine
1
ssd
1
sulfacetamide sodium lotn 10%
2
SULFAMYLON
3
terconazole crea
1
terconazole supp
2
Anti-inflammatory Agents
ala-cort
1
alclometasone dipropionate oint
1
alclometasone dipropionate crea
3
amcinonide lotn
1
amcinonide crea
3
betamethasone dipropionate augmented crea, oint
1
betamethasone dipropionate augmented gel, lotn
3
betamethasone dipropionate lotn
1
betamethasone dipropionate crea, oint
3
betamethasone valerate crea, lotn, oint
1
betamethasone valerate foam
3
budesonide foam 2mg
2
calcipotriene/betamethasone dipropionate oint
3
calcipotriene/betamethasone dipropionate susp
3
NEDS
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
57
Drug Name
Drug
Tier
Requirements/Limits
clobetasol propionate e
2
QL(240 GM per 30 days)
clobetasol propionate emollient
3
QL(200 GM per 30 days)
clobetasol propionate soln
2
QL(200 ML per 30 days)
clobetasol propionate gel, oint
2
QL(240 GM per 30 days)
clobetasol propionate foam
3
QL(200 GM per 30 days)
clobetasol propionate lotn, sham
3
QL(236 ML per 30 days)
clobetasol propionate crea
3
QL(240 GM per 30 days)
clobetasol propionate liqd
3
QL(250 ML per 30 days)
clocortolone pivalate
3
clodan
2
QL(236 ML per 30 days)
CORDRAN
3
desonide
3
desoximetasone
3
DESRX
3
diclofenac sodium gel 3%
2
QL(200 GM per 30 days)
diclofenac sodium gel 1%
2
QL(960 GM per 30 days)
diclofenac sodium external soln 1.5%
3
QL(300 ML per 30 days)
diflorasone diacetate
3
EUCRISA
3
PA
fluocinolone acetonide body
3
fluocinolone acetonide scalp
2
fluocinolone acetonide crea 0.01%, 0.025%
2
fluocinolone acetonide oint 0.025%
2
fluocinolone acetonide soln 0.01%
3
fluocinonide emulsified base
3
fluocinonide crea
2
fluocinonide gel, oint, soln
3
fluticasone propionate crea 0.05%
1
fluticasone propionate lotn 0.05%
3
fluticasone propionate oint 0.005%
1
halcinonide
2
halobetasol propionate
3
hydrocortisone butyrate lotn
1
hydrocortisone butyrate crea, oint, soln
3
hydrocortisone valerate
3
hydrocortisone crea 1%, 2.5%
1
hydrocortisone enem 100mg/60ml
3
hydrocortisone lotn 2.5%
1
hydrocortisone oint 1%, 2.5%
1
mometasone furoate crea 0.1%
1
mometasone furoate oint 0.1%
1
mometasone furoate soln 0.1%
1
nystatin/triamcinolone crea
1
nystatin/triamcinolone oint
2
oralone dental paste
1
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
58
Drug Name
Drug
Tier
Requirements/Limits
prednicarbate
1
procto-med hc
1
procto-pak
1
proctosol hc
1
proctozone-hc
1
TOVET
3
QL(200 GM per 30 days)
triamcinolone acetonide dental paste
1
triamcinolone acetonide crea, lotn
1
triamcinolone acetonide aers
3
triamcinolone acetonide oint 0.025%, 0.1%, 0.5%
1
triamcinolone acetonide oint 0.05%
2
TRIANEX
2
triderm
1
TRITOCIN
2
UCERIS
3
Antipruritics and Local Anesthetics
doxepin hydrochloride crea 5%
3
QL(90 GM per 30 days)
hydrocortisone acetate/pramoxine
1
lidocaine hcl
1
QL(100 ML per 30 days)
lidocaine/prilocaine
2
QL(60 GM per 30 days)
lidocaine oint
2
QL(100 GM per 30 days)
lidocaine ptch
2
QL(90 EA per 30 days); PA
premium lidocaine
2
QL(100 GM per 30 days)
Cell Stimulants and Proliferants
avita
1
PA
RETIN-A MICRO PUMP
3
PA
tretinoin microsphere
3
PA
tretinoin crea 0.025%, 0.05%, 0.1%
1
PA
tretinoin gel 0.01%, 0.025%, 0.05%
3
PA
Emollients, Demulcents, and Protectants
ammonium lactate lotn
1
ammonium lactate crea
2
Skin and Mucous Membrane Agents, Misc
accutane
3
acitretin
3
adapalene
3
PA
amnesteem
1
azelaic acid
2
AZELEX
3
bexarotene gel 1%
3
PA NSO; NEDS
calcipotriene crea
2
QL(120 GM per 30 days)
calcipotriene oint
3
QL(120 GM per 30 days)
calcipotriene soln
3
QL(120 ML per 30 days)
calcitriol oint 3mcg/gm
2
claravis
3
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
59
Drug Name
Drug
Tier
Requirements/Limits
CONDYLOX
3
DUPIXENT INJ 200MG/1.14ML, 300MG/2ML
3
PA; NEDS; SP-Optum Specialty
fluorouracil crea
1
fluorouracil soln
3
HYFTOR
3
PA; NEDS
imiquimod pump
3
imiquimod crea 5%
2
imiquimod crea 3.75%
3
isotretinoin
3
KLISYRI
3
PA; NEDS
MYORISAN
3
PANRETIN
3
NEDS
pimecrolimus
2
podofilox
1
RECTIV
3
QL(30 GM per 30 days)
REGRANEX
2
SANTYL
2
SKYRIZI PEN
3
QL(1 ML per 28 days); PA; NEDS;
SP-Optum Specialty
SKYRIZI INJ 75MG/0.83ML
3
QL(1 EA per 28 days); PA; NEDS;
SP-Optum Specialty
SKYRIZI INJ 150MG/ML
3
QL(1 ML per 28 days); PA; NEDS;
SP-Optum Specialty
STELARA INJ 45MG/0.5ML
3
QL(1 ML per 28 days); PA; NEDS
STELARA INJ 45MG/0.5ML, 90MG/ML
3
QL(1 ML per 28 days); PA; NEDS;
SP-Optum Specialty
tacrolimus oint 0.03%, 0.1%
2
tazarotene crea, gel
2
PA
tazarotene foam
3
PA
TAZORAC
3
PA
VALCHLOR
3
NEDS; SP-Optum Specialty
WINLEVI
3
PA
ZENATANE
3
Smooth Muscle Relaxants
Genitourinary Smooth Muscle Relaxants
darifenacin hydrobromide er
3
fesoterodine fumarate er
3
flavoxate hcl
1
GEMTESA
3
MYRBETRIQ
2
oxybutynin chloride er
1
oxybutynin chloride soln, syrp
1
oxybutynin chloride tabs 5mg
1
oxybutynin chloride tabs 2.5mg
2
solifenacin succinate
2
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
60
Drug Name
Drug
Tier
Requirements/Limits
tolterodine tartrate
2
tolterodine tartrate er
2
trospium chloride
2
trospium chloride er
3
Respiratory Smooth Muscle Relaxants
elixophyllin
1
theophylline er tb24
1
theophylline er tb12 300mg, 450mg
1
theophylline elix
1
Vitamins
Multivitamin Preparations
prenatal tabs 120mg; 0; 200mg; 10mcg; 2mg; 12mcg; 27mg;
1mg; 20mg; 10mg; 1200mcg; 3mg; 1.84mg; 10mg; 25mg
1
Vitamin B Complex
cyanocobalamin inj 1000mcg/ml
2
EC
folic acid inj
2
EC
folic acid tabs 1mg
2
EC
NASCOBAL SOLN
3
EC
niacin tabs 500mg
1
niacor
1
Vitamin D
calcitriol caps 0.25mcg, 0.5mcg
1
calcitriol soln 1mcg/ml
1
doxercalciferol caps
3
paricalcitol caps
1
RAYALDEE
3
vitamin d caps 50000unit
2
EC
Vitamin K Activity
phytonadione tabs
2
EC
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
61
Index of Drugs
Drug Name
Page #
abacavir
6
abacavir sulfate/lamivudine
6
abacavir sulfate/lamivudine/zidovudine
6
ABELCET
5
ABILIFY ASIMTUFII
30
ABILIFY MAINTENA
30
ABILIFY MYCITE
30
ABILIFY MYCITE MAINTENANCE KIT
30
ABILIFY MYCITE STARTER KIT
30
abiraterone acetate
9
ABRYSVO
15
acamprosate calcium dr
30
acarbose
44
accutane
58
acebutolol hydrochloride
19
acetaminophen/codeine
23
acetazolamide
39
acetazolamide er
39
acetic acid
40
acetylcysteine
50
acitretin
58
ACTHIB
15
ACTIMMUNE
51
acyclovir
6
acyclovir
55
acyclovir sodium
6
ADACEL
14
adapalene
58
ADDYI
30
adefovir dipivoxil
6
ADEMPAS
54
ADIPEX-P
25
AIMOVIG
28
ala-cort
56
albendazole
2
albuterol sulfate
17
albuterol sulfate hfa
17
alclometasone dipropionate
56
alcohol prep pads
34
ALECENSA
9
alendronate sodium
50
alfuzosin hcl er
17
aliskiren
21
Drug Name
Page #
allopurinol
50
almotriptan
28
ALOCRIL
39
ALOMIDE
39
alosetron hydrochloride
40
ALPHAGAN P
40
alprazolam
29
alprazolam er
29
alprazolam odt
29
ALREX
38
ALUNBRIG
9
alyq
22
amabelz
47
amantadine hcl
28
ambrisentan
54
amcinonide
56
amethia
45
amikacin sulfate
2
amiloride hcl
36
amiloride/hydrochlorothiazide
36
AMINOSYN II
35
AMINOSYN-PF 7%
35
amiodarone hydrochloride
21
amitriptyline hcl
30
amitriptyline hydrochloride
30
amlodipine besylate
20
amlodipine besylate/atorvastatin calcium
20
amlodipine besylate/benazepril
hydrochloride
20
amlodipine besylate/valsartan
20
amlodipine/olmesartan medoxomil
20
ammonium lactate
58
amnesteem
58
amoxapine
31
amoxicillin
2
amoxicillin/clavulanate potassium
2
amoxicillin/clavulanate potassium er
2
amphetamine/dextroamphetamine
25
amphotericin b
5
amphotericin b liposome
5
ampicillin
2
ampicillin sodium
2
ampicillin-sulbactam
2
anagrelide hydrochloride
17
anastrozole
47
ANORO ELLIPTA
16
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
62
Drug Name
Page #
APLENZIN
31
apraclonidine
40
aprepitant
41
apri
45
APTIOM
26
APTIVUS
6
ARCALYST
52
AREXVY
15
arformoterol tartrate
17
ARIKAYCE
2
aripiprazole
31
aripiprazole odt
31
ARISTADA
31
ARISTADA INITIO
31
armodafinil
25
ARMOUR THYROID
49
asenapine maleate sl
31
ashlyna
45
aspirin/dipyridamole er
17
atazanavir
6
atazanavir sulfate
6
atenolol
19
atenolol/chlorthalidone
19
atomoxetine
30
atomoxetine hydrochloride
30
atorvastatin calcium
19
atovaquone
5
atovaquone/proguanil hcl
5
atropine sulfate
40
ATROVENT HFA
16
AUBAGIO
51
AUGMENTIN
2
AURYXIA
36
AUSTEDO
33
AUVELITY
31
AVEED
43
aviane
45
avita
58
AVONEX
51
AVONEX PEN
51
AVYCAZ
2
AYVAKIT
9
AZASITE
38
azathioprine
52
azelaic acid
58
azelastine hcl
39
Drug Name
Page #
azelastine hydrochloride
39
AZELEX
58
azithromycin
2
aztreonam
2
bacitracin
38
bacitracin/polymyxin b
38
baclofen
16
BAFIERTAM
51
balsalazide disodium
40
BALVERSA
9
balziva
46
BAQSIMI ONE PACK
45
BAQSIMI TWO PACK
45
BAXDELA
2
BCG VACCINE
15
bd insulin syringe safetyglide/1ml/29g x
1/2"
34
b-d insulin syringe ultrafine ii/0.3ml/31g x
5/16"
34
bd insulin syringe ultra-fine/0.5ml/30g x
12.7mm
34
bd insulin syringe ultra-fine/1ml/31g x 8mm
34
bd insulin syringe/u-100/1ml/27g x 1/2"
34
bd insulin syringe/u-500/0.5ml/31g x 6mm
34
bd pen needle/original/ultra-fine/29g x
12.7mm
34
BELBUCA
23
BELSOMRA
29
benazepril hcl
21
benazepril hcl/hydrochlorothiazide
21
benazepril hydrochloride
22
benazepril
hydrochloride/hydrochlorothiazide
22
BENLYSTA
52
BENZNIDAZOLE
6
benzonatate
54
benztropine mesylate
28
bepotastine besilate
39
BERINERT
52
BESIVANCE
38
BESREMI
9
betaine anhydrous
52
betamethasone dipropionate
56
betamethasone dipropionate augmented
56
betamethasone valerate
56
BETASERON
51
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
63
Drug Name
Page #
betaxolol hcl
19
betaxolol hcl
40
bethanechol chloride
16
BETIMOL
40
BETOPTIC-S
40
BEVESPI AEROSPHERE
16
bexarotene
9
bexarotene
58
BEXSERO
15
bicalutamide
9
BICILLIN C-R
2
BICILLIN L-A
2
BIKTARVY
6
bimatoprost
40
bismuth subcitrate
pot/metronidazole/tetracycline hydrochlo
41
bisoprolol fumarate
20
bisoprolol fumarate/hydrochlorothiazide
19
BIVIGAM
14
BOOSTRIX
14
bortezomib
9
bosentan
54
BOSULIF
9
BRAFTOVI
9
BREO ELLIPTA
43
BREYNA
43
BREZTRI AEROSPHERE
43
briellyn
46
BRILINTA
17
brimonidine tartrate
40
brimonidine tartrate/timolol maleate
40
brinzolamide
40
BRIVIACT
26
bromfenac
38
bromocriptine mesylate
28
BROMSITE
38
BRONCHITOL
54
BRUKINSA
9
budesonide
43
budesonide
56
budesonide er
43
budesonide/formoterol fumarate dihydrate
43
bumetanide
36
buprenorphine
23
buprenorphine hcl
23
buprenorphine hcl/naloxone hcl
23
Drug Name
Page #
buprenorphine hydrochloride/naloxone
hydrochloride
23
bupropion hcl
31
bupropion hydrochloride
31
bupropion hydrochloride er (sr)
31
bupropion hydrochloride er (xl)
31
buspirone hcl
29
buspirone hydrochloride
29
butorphanol tartrate
23
BYDUREON BCISE
44
BYETTA
44
BYLVAY
42
BYLVAY (PELLETS)
42
cabergoline
28
CABLIVI
17
CABOMETYX
9
calcipotriene
58
calcipotriene/betamethasone dipropionate
56
CALCITONIN SALMON
48
calcitonin-salmon
48
calcitriol
58
calcitriol
60
calcium acetate
37
CALQUENCE
9
camila
46
CAMZYOS
21
candesartan cilexetil
22
candesartan cilexetil/hydrochlorothiazide
22
CAPLYTA
31
CAPRELSA
9
captopril
22
carbamazepine
26
carbamazepine er
26
carbidopa
28
carbidopa/levodopa
28
carbidopa/levodopa er
28
carbidopa/levodopa odt
28
carbidopa/levodopa/entacapone
28
CARDURA XL
18
carglumic acid
34
carteolol hcl
40
cartia xt
20
carvedilol
20
carvedilol phosphate er
20
caspofungin acetate
5
CAVERJECT
22
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
64
Drug Name
Page #
CAVERJECT IMPULSE
22
CAYSTON
2
cefaclor
2
cefadroxil
2
cefazolin
2
cefazolin sodium
2
cefdinir
2
cefepime
2
cefepime hydrochloride
2
cefepime/dextrose
2
cefixime
2
cefotetan
2
cefoxitin sodium
2
cefpodoxime proxetil
2
cefprozil
2
ceftazidime
2
ceftriaxone sodium
2
cefuroxime axetil
3
cefuroxime sodium
3
celecoxib
23
CELONTIN
26
cephalexin
3
CERDELGA
52
cevimeline hydrochloride
16
CHEMET
42
chlordiazepoxide/amitriptyline
31
chlorhexidine gluconate
38
chloroquine phosphate
6
chlorpromazine hcl
31
chlorpromazine hydrochloride
31
chlorthalidone
36
CHOLBAM
42
cholestyramine
19
cholestyramine light
19
ciclopirox
55
ciclopirox nail lacquer
55
ciclopirox olamine
55
cilostazol
17
CIMDUO
6
cimetidine
41
cinacalcet hydrochloride
48
CINRYZE
52
ciprofloxacin
3
ciprofloxacin
38
ciprofloxacin hcl
3
ciprofloxacin hydrochloride
3
Drug Name
Page #
ciprofloxacin hydrochloride
38
ciprofloxacin i.v.-in d5w
3
ciprofloxacin/dexamethasone
38
citalopram hydrobromide
31
claravis
58
clarithromycin
3
clarithromycin er
3
CLENPIQ
41
CLEOCIN
55
clindacin
55
clindacin etz pledgets
55
clindacin-p
55
clindamycin hcl
3
clindamycin hydrochloride
3
clindamycin palmitate hcl
3
clindamycin phosphate
3
clindamycin phosphate
55
clindamycin phosphate/benzoyl peroxide
55
clindamycin phosphate/dextrose
3
clindamycin/benzoyl peroxide
55
CLINIMIX 4.25%/DEXTROSE 10%
35
CLINIMIX 4.25%/DEXTROSE 5%
35
CLINIMIX 5%/DEXTROSE 15%
35
CLINIMIX 5%/DEXTROSE 20%
35
CLINIMIX 6/5
35
CLINIMIX 8/10
35
CLINIMIX E 2.75%/DEXTROSE 5%
35
CLINIMIX E 4.25%/DEXTROSE 10%
35
CLINIMIX E 4.25%/DEXTROSE 5%
35
CLINIMIX E 5%/DEXTROSE 15%
35
CLINIMIX E 5%/DEXTROSE 20%
35
CLINIMIX E 8/10
35
CLINISOL SF 15%
35
clobazam
26
clobetasol propionate
57
clobetasol propionate e
57
clobetasol propionate emollient
57
clocortolone pivalate
57
clodan
57
clomipramine hydrochloride
31
clonazepam
26
clonazepam odt
26
clonidine hcl
21
clonidine hydrochloride
21
clonidine hydrochloride er
21
clopidogrel
17
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
65
Drug Name
Page #
clorazepate dipotassium
29
clotrimazole
55
clotrimazole/betamethasone dipropionate
55
clozapine
31
clozapine odt
31
COARTEM
6
codeine sulfate
23
colchicine
50
colesevelam hydrochloride
19
colestipol hcl
19
colistimethate sodium
3
COMBIPATCH
47
COMBIVENT RESPIMAT
17
COMETRIQ
9
COMPLERA
6
CONDYLOX
59
constulose
34
CONTRAVE
25
COPAXONE
51
COPIKTRA
9
CORDRAN
57
CORLANOR
21
CORTROPHIN
48
COSENTYX
50
COSENTYX SENSOREADY PEN
50
COSENTYX UNOREADY
50
COTELLIC
9
CREON
42
cromolyn sodium
39
cromolyn sodium
53
curity gauze pads 2"x2" 12 ply
34
cyanocobalamin
60
cyclobenzaprine hydrochloride
16
cyclophosphamide
9
CYCLOSET
44
cyclosporine
38
cyclosporine
52
cyclosporine modified
52
cyproheptadine hcl
8
cyproheptadine hydrochloride
8
CYSTAGON
52
CYSTARAN
40
dabigatran etexilate
18
dalfampridine er
52
DALVANCE
3
danazol
43
Drug Name
Page #
dantrolene sodium
16
dapsone
5
DAPTACEL
14
daptomycin
3
darifenacin hydrobromide er
59
darunavir
6
DAURISMO
10
DAYVIGO
29
deblitane
46
deferasirox
42
deferiprone
43
DELSTRIGO
6
demeclocycline hcl
3
DEPO-ESTRADIOL
47
DEPO-SUBQ PROVERA 104
48
DESCOVY
6
desipramine hydrochloride
31
desloratadine
9
desloratadine odt
9
desmopressin acetate
48
desogestrel/ethinyl estradiol
46
desonide
57
desoximetasone
57
DESRX
57
desvenlafaxine er
31
dexamethasone
43
dexamethasone 10-day dose pack
43
dexamethasone 13-day dose pack
43
dexamethasone 6-day dose pack
43
dexamethasone sodium phosphate
38
DEXLANSOPRAZOLE
41
dexmethylphenidate hcl
25
dexmethylphenidate hcl er
25
dexmethylphenidate hydrochloride
25
dexmethylphenidate hydrochloride er
25
dextroamphetamine sulfate
25
dextroamphetamine sulfate er
25
dextrose 10%/nacl 0.45%
37
dextrose 10%
35
dextrose 10%/nacl 0.2%
37
dextrose 2.5%/nacl 0.45%
37
dextrose 5%
35
dextrose 5%/nacl 0.2%
37
dextrose 5%/nacl 0.3%
37
dextrose 5%/nacl 0.33%
37
dextrose 5%/nacl 0.45%
37
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
66
Drug Name
Page #
dextrose 5%/nacl 0.9%
37
dextrose 50%
35
dextrose 70%
35
dextrose/sodium chloride
37
DIACOMIT
26
diazepam
29
diazepam intensol
29
diazepam rectal gel
29
diazoxide
45
dichlorphenamide
50
diclofenac epolamine
23
diclofenac potassium
23
diclofenac sodium
38
diclofenac sodium
57
diclofenac sodium dr
23
diclofenac sodium er
23
diclofenac sodium/misoprostol
23
dicloxacillin sodium
3
dicyclomine hcl
16
dicyclomine hydrochloride
16
diethylpropion hcl
26
diethylpropion hcl er
26
DIFICID
3
diflorasone diacetate
57
diflunisal
23
difluprednate
38
digitek
21
digox
21
digoxin
21
dihydroergotamine mesylate
17
DILANTIN
26
DILANTIN INFATABS
26
DILANTIN-125
26
diltiazem hcl
20
diltiazem hcl cd
20
diltiazem hcl er
20
diltiazem hydrochloride
20
diltiazem hydrochloride er
20
dilt-xr
20
dimethyl fumarate
51
dimethyl fumarate starterpack
51
diphtheria/tetanus toxoids adsorbed
pediatric
14
dipyridamole
22
disopyramide phosphate
21
disulfiram
49
Drug Name
Page #
divalproex sodium
26
divalproex sodium dr
26
divalproex sodium er
26
dofetilide
21
donepezil hcl
16
donepezil hydrochloride
16
DOPTELET
18
dorzolamide hcl/timolol maleate
40
dorzolamide hydrochloride
40
dorzolamide hydrochloride/timolol maleate
pf
40
dotti
47
DOVATO
6
doxazosin mesylate
18
doxepin hcl
31
doxepin hydrochloride
31
doxepin hydrochloride
58
doxercalciferol
60
DOXY 100
3
doxycycline
3
doxycycline hyclate
3
doxycycline hyclate dr
3
doxycycline monohydrate
3
DRIZALMA SPRINKLE
31
dronabinol
41
drospirenone/ethinyl estradiol
46
DROXIA
10
droxidopa
17
duloxetine hcl
31
duloxetine hydrochloride
31
DUPIXENT
53
DUPIXENT
59
dutasteride
49
dutasteride/tamsulosin hydrochloride
49
econazole nitrate
55
EDEX
22
EDURANT
6
efavirenz
6
efavirenz/emtricitabine/tenofovir disoproxil
fumarate
6
efavirenz/lamivudine/tenofovir disoproxil
fumarate
6
EGRIFTA SV
49
ELESTRIN
47
eletriptan hydrobromide
28
ELIGARD
48
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
67
Drug Name
Page #
ELIQUIS
18
ELIQUIS STARTER PACK
18
elixophyllin
60
ELMIRON
52
eluryng
46
EMCYT
10
EMGALITY
28
EMSAM
28
emtricitabine
6
emtricitabine/tenofovir disoproxil
6
emtricitabine/tenofovir disoproxil fumarate
7
EMTRIVA
7
enalapril maleate
22
enalapril maleate/hydrochlorothiazide
22
ENBREL
50
ENBREL MINI
50
ENBREL SURECLICK
50
ENDARI
52
endocet
23
ENGERIX-B
15
enoxaparin sodium
18
entacapone
28
entecavir
7
ENTRESTO
22
enulose
34
ENVARSUS XR
52
EPCLUSA
7
EPIDIOLEX
26
epinastine hcl
39
epinephrine
17
epitol
26
eplerenone
22
EPRONTIA
26
EQUETRO
26
ergoloid mesylates
17
ERIVEDGE
10
ERLEADA
10
erlotinib hydrochloride
10
errin
46
ertapenem
3
ery
55
erythromycin
3
erythromycin
38
erythromycin
55
erythromycin base
3
erythromycin dr
3
Drug Name
Page #
erythromycin ethylsuccinate
3
erythromycin/benzoyl peroxide
55
ESBRIET
53
escitalopram oxalate
31
esomeprazole magnesium
41
estazolam
29
estradiol
47
estradiol valerate
47
estradiol/norethindrone acetate
47
ESTRING
47
eszopiclone
29
ethacrynic acid
36
ethambutol hydrochloride
5
ethosuximide
26
etodolac
23
etodolac er
23
etonogestrel/ethinyl estradiol
46
etravirine
7
EUCRISA
57
euthyrox
49
EVAMIST
47
EVENITY
50
everolimus
10
everolimus
52
EVOTAZ
7
EVRYSDI
52
exemestane
47
EXKIVITY
10
EXSERVAN
30
EXTAVIA
51
ezetimibe
19
ezetimibe/simvastatin
19
falmina
46
famciclovir
7
famotidine
41
FANAPT
31
FANAPT TITRATION PACK
31
FARXIGA
44
FASENRA
53
FASENRA PEN
53
febuxostat
50
felbamate
26
felodipine er
20
FEMRING
47
fenofibrate
19
fenofibrate micronized
19
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
68
Drug Name
Page #
fenofibric acid dr
19
fentanyl
24
fentanyl citrate
24
fentanyl citrate oral transmucosal
23
fesoterodine fumarate er
59
FETZIMA
31
FETZIMA TITRATION PACK
31
finasteride
49
fingolimod
51
FINTEPLA
27
finzala
46
FIRDAPSE
52
FIRMAGON
48
FIRVANQ
3
flac
38
FLAREX
38
flavoxate hcl
59
FLEBOGAMMA DIF
14
flecainide acetate
21
FLOLIPID
19
FLOVENT DISKUS
43
fluconazole
5
fluconazole in sodium chloride
5
flucytosine
5
fludrocortisone acetate
43
flunisolide
38
fluocinolone acetonide
38
fluocinolone acetonide
57
fluocinolone acetonide body
57
fluocinolone acetonide scalp
57
fluocinonide
57
fluocinonide emulsified base
57
fluorometholone
39
fluorouracil
59
fluoxetine dr
31
fluoxetine hcl
31
fluoxetine hydrochloride
31
fluphenazine decanoate
32
fluphenazine hcl
32
fluphenazine hydrochloride
32
flurazepam hcl
29
flurbiprofen
24
flurbiprofen sodium
39
flutamide
10
fluticasone propionate
39
fluticasone propionate
57
Drug Name
Page #
fluticasone propionate hfa
43
fluticasone propionate/salmeterol
17
fluticasone propionate/salmeterol diskus
17
fluvastatin
19
fluvastatin sodium er
19
fluvoxamine maleate
32
fluvoxamine maleate er
32
FML
39
FML FORTE
39
folic acid
60
fondaparinux sodium
18
formoterol fumarate
17
FORTEO
48
fosamprenavir calcium
7
fosfomycin tromethamine
8
fosinopril sodium
22
fosinopril sodium/hydrochlorothiazide
22
FOTIVDA
10
FRAGMIN
18
FREAMINE III
35
frovatriptan succinate
28
furosemide
36
FUZEON
7
fyavolv
47
FYCOMPA
27
gabapentin
27
GALAFOLD
52
galantamine hydrobromide
16
galantamine hydrobromide er
16
GAMMAGARD LIQUID
14
GAMMAKED
14
GAMMAPLEX
14
GAMUNEX-C
14
GARDASIL 9
15
gatifloxacin
38
GATTEX
42
gauze pads 2"x2"
34
gavilyte-c
41
gavilyte-g
41
gavilyte-n/flavor pack
41
GAVRETO
10
gefitinib
10
gemfibrozil
19
GEMTESA
59
generlac
34
GENGRAF
52
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
69
Drug Name
Page #
GENOTROPIN
49
GENOTROPIN MINIQUICK
49
gentak
38
gentamicin sulfate
3
gentamicin sulfate
38
gentamicin sulfate
55
gentamicin sulfate/0.9% sodium chloride
3
GENVOYA
7
GILOTRIF
10
GLEOSTINE
10
glimepiride
44
glipizide
44
glipizide er
44
glipizide/metformin hydrochloride
44
GLOPERBA
50
GLUCAGEN HYPOKIT
45
GLUCAGON EMERGENCY KIT
45
GLUCAGON EMERGENCY KIT FOR
LOW BLOOD SUGAR
45
glyburide
44
glyburide micronized
44
glyburide/metformin hydrochloride
44
glycopyrrolate
16
GLYXAMBI
44
gnp insulin syringe/0.3ml/30g x 5/16"
34
gnp insulin syringe/0.5ml/30g x 5/16"
34
GOCOVRI
28
granisetron hydrochloride
41
griseofulvin microsize
5
griseofulvin ultramicrosize
5
guanfacine er
30
guanfacine hydrochloride
30
GVOKE HYPOPEN 1-PACK
45
GVOKE HYPOPEN 2-PACK
45
GVOKE KIT
45
GVOKE PFS
45
GYNAZOLE-1
55
HAEGARDA
52
halcinonide
57
halobetasol propionate
57
haloette
46
haloperidol
32
haloperidol decanoate
32
haloperidol lactate
32
HARVONI
7
HAVRIX
15
Drug Name
Page #
heparin sodium
18
HEPARIN SODIUM/D5W
18
HEPATAMINE
36
HEPLISAV-B
15
HETLIOZ LQ
29
HIBERIX
15
HORIZANT
27
HUMALOG
44
HUMALOG JUNIOR KWIKPEN
44
HUMALOG KWIKPEN
44
HUMALOG MIX 50/50
44
HUMALOG MIX 50/50 KWIKPEN
44
HUMALOG MIX 75/25
44
HUMALOG MIX 75/25 KWIKPEN
44
HUMIRA
51
HUMIRA PEDIATRIC CROHNS
DISEASE STARTER PACK
50
HUMIRA PEN
50
HUMIRA PEN-CD/UC/HS STARTER
50
HUMIRA PEN-PEDIATRIC UC
STARTER PACK
50
HUMIRA PEN-PS/UV STARTER
50
HUMULIN 70/30
44
HUMULIN 70/30 KWIKPEN
44
HUMULIN N
44
HUMULIN N KWIKPEN
44
HUMULIN R
44
HUMULIN R U-500 (CONCENTRATED)
44
HUMULIN R U-500 KWIKPEN
44
hydralazine hcl
21
hydralazine hydrochloride
21
hydrochlorothiazide
36
hydrocodone bitartrate er
24
hydrocodone bitartrate/acetaminophen
24
hydrocodone bitartrate/homatropine
methylbromide
54
hydrocodone/acetaminophen
24
hydrocodone/ibuprofen
24
hydrocortisone
43
hydrocortisone
57
hydrocortisone acetate/pramoxine
58
hydrocortisone butyrate
57
hydrocortisone valerate
57
hydrocortisone/acetic acid
39
hydromorphone hcl
24
hydromorphone hcl er
24
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
70
Drug Name
Page #
hydromorphone hydrochloride er
24
hydroxychloroquine sulfate
6
hydroxyurea
10
hydroxyzine hcl
29
hydroxyzine hydrochloride
29
hydroxyzine pamoate
29
HYFTOR
59
ibandronate sodium
50
IBRANCE
10
ibu
24
ibuprofen
24
icatibant acetate
52
iclevia
46
ICLUSIG
10
icosapent ethyl
19
IDHIFA
10
ILEVRO
39
imatinib mesylate
10
IMBRUVICA
10
imipenem/cilastatin
3
imipramine hcl
32
imipramine hydrochloride
32
imipramine pamoate
32
imiquimod
59
imiquimod pump
59
IMOVAX RABIES (H.D.C.V.)
15
IMPAVIDO
6
IMVEXXY MAINTENANCE PACK
47
IMVEXXY STARTER PACK
47
INBRIJA
28
INCRELEX
49
INCRUSE ELLIPTA
16
indapamide
36
indomethacin
24
indomethacin er
24
INFANRIX
15
INGREZZA
34
INLYTA
10
INQOVI
10
INREBIC
10
INTELENCE
7
INTRALIPID
36
INTRAROSA
43
INTRON A
10
introvale
46
INVEGA HAFYERA
32
Drug Name
Page #
INVEGA SUSTENNA
32
INVEGA TRINZA
32
INVELTYS
39
IPOL INACTIVATED IPV
15
ipratropium bromide
16
ipratropium bromide/albuterol sulfate
17
irbesartan
22
irbesartan/hydrochlorothiazide
22
IRESSA
10
ISENTRESS
7
ISENTRESS HD
7
isoniazid
5
isosorbide dinitrate
22
isosorbide dinitrate/hydralazine
hydrochloride
22
isosorbide mononitrate
22
isosorbide mononitrate er
22
isotonic gentamicin
3
isotretinoin
59
isradipine
20
itraconazole
5
ivermectin
2
ivermectin
55
IXIARO
15
JAKAFI
11
jantoven
18
JANUMET
44
JANUMET XR
44
JANUVIA
44
JARDIANCE
44
JAYPIRCA
11
JENTADUETO
44
JENTADUETO XR
44
jinteli
47
JULUCA
7
junel 1.5/30
46
junel 1/20
46
junel fe 1.5/30
46
junel fe 1/20
46
junel fe 24
46
JUXTAPID
19
JYNNEOS
15
KALYDECO
54
kariva
46
kcl 0.075%/d5w/nacl 0.45%
37
kcl 0.15%/d5w/nacl 0.2%
37
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
71
Drug Name
Page #
kcl 0.15%/d5w/nacl 0.45%
37
kcl 0.15%/d5w/nacl 0.9%
37
kcl 0.3%/d5w/nacl 0.45%
37
kcl 0.3%/d5w/nacl 0.9%
37
kelnor 1/35
46
KERENDIA
22
KESIMPTA
51
ketoconazole
5
ketoconazole
55
KETODAN
56
ketoprofen
24
ketoprofen er
24
ketorolac tromethamine
39
KINERET
51
KINRIX
15
KISQALI
11
KISQALI FEMARA 200 DOSE
47
KISQALI FEMARA 400 DOSE
47
KISQALI FEMARA 600 DOSE
47
KLISYRI
59
klor-con
37
klor-con 10
37
klor-con 8
37
klor-con m10
37
klor-con m15
37
klor-con m20
37
KORLYM
44
KOSELUGO
11
kourzeq
55
KRAZATI
11
KRISTALOSE
34
KYNMOBI
28
labetalol hydrochloride
20
lacosamide
27
lactulose
34
lamivudine
7
lamivudine/zidovudine
7
lamotrigine
27
lamotrigine er
27
lamotrigine odt
27
lamotrigine starter kit/blue
27
lamotrigine starter kit/green
27
lamotrigine starter kit/orange
27
lamotrigine titration
27
lansoprazole
41
lansoprazole/amoxicillin/clarithromycin
41
Drug Name
Page #
LANTUS
44
LANTUS SOLOSTAR
44
lapatinib ditosylate
11
larin 1.5/30
46
larin 1/20
46
larin fe 1.5/30
46
larin fe 1/20
46
latanoprost
40
LAZANDA
24
leflunomide
51
lenalidomide
11
LENVIMA 10 MG DAILY DOSE
11
LENVIMA 12MG DAILY DOSE
11
LENVIMA 14 MG DAILY DOSE
11
LENVIMA 18 MG DAILY DOSE
11
LENVIMA 20 MG DAILY DOSE
11
LENVIMA 24 MG DAILY DOSE
11
LENVIMA 4 MG DAILY DOSE
11
LENVIMA 8 MG DAILY DOSE
11
lessina
46
letrozole
47
leucovorin calcium
50
LEUKERAN
11
leuprolide acetate
48
levalbuterol
17
levalbuterol hcl
17
levalbuterol hydrochloride
17
levalbuterol tartrate hfa
17
LEVEMIR
44
LEVEMIR FLEXPEN
44
LEVEMIR FLEXTOUCH
45
levetiracetam
27
levetiracetam er
27
levobunolol hcl
40
levocarnitine
52
levocetirizine dihydrochloride
9
levofloxacin
3
levofloxacin
38
levofloxacin in d5w
3
levonest
46
levonorgestrel and ethinyl estradiol
46
levonorgestrel/ethinyl estradiol
46
levora 0.15/30-28
46
levorphanol tartrate
24
levo-t
49
levothyroxine sodium
49
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
72
Drug Name
Page #
levoxyl
49
LEXIVA
7
lidocaine
58
lidocaine hcl
58
lidocaine hydrochloride viscous
40
lidocaine viscous
40
lidocaine/prilocaine
58
linezolid
3
LINZESS
42
liothyronine sodium
49
lisinopril
22
lisinopril/hydrochlorothiazide
22
lithium carbonate
28
lithium carbonate er
28
LIVALO
19
LIVMARLI
42
LIVTENCITY
7
LO LOESTRIN FE
46
LOKELMA
36
LONHALA MAGNAIR REFILL KIT
16
LONHALA MAGNAIR STARTER KIT
16
LONSURF
11
loperamide hcl
41
lopinavir/ritonavir
7
lorazepam
29
lorazepam intensol
29
LORBRENA
11
losartan potassium
22
losartan potassium/hydrochlorothiazide
22
LOTEMAX
39
loteprednol etabonate
39
lovastatin
19
loxapine
32
lubiprostone
42
LUMAKRAS
11
LUMIGAN
40
LUPRON DEPOT (1-MONTH)
48
LUPRON DEPOT (3-MONTH)
48
LUPRON DEPOT (4-MONTH)
48
LUPRON DEPOT (6-MONTH)
48
lurasidone hydrochloride
32
LYBALVI
32
LYNPARZA
11
LYSODREN
11
LYTGOBI
11
magnesium sulfate
27
Drug Name
Page #
malathion
56
maraviroc
7
marlissa
46
MARPLAN
32
MATULANE
11
matzim la
20
MAVYRET
7
MAXIDEX
39
MAYZENT
51
MAYZENT STARTER PACK
51
meclizine hcl
41
meclofenamate sodium
24
MEDROL
43
medroxyprogesterone acetate
48
mefenamic acid
24
mefloquine hcl
6
megestrol acetate
48
MEKINIST
11
MEKTOVI
12
meloxicam
24
memantine hcl titration pak
30
memantine hydrochloride
30
memantine hydrochloride er
30
MENACTRA
15
MENEST
47
MENOSTAR
47
MENQUADFI
15
MENTAX
56
MENVEO
15
mercaptopurine
12
meropenem
4
mesalamine
40
mesalamine dr
40
mesalamine er
40
MESNEX
53
metformin hydrochloride
45
metformin hydrochloride er
45
methadone hcl
24
methamphetamine hcl
26
methazolamide
40
methenamine hippurate
8
methimazole
49
methotrexate
12
methotrexate sodium
12
methsuximide
27
methylphenidate hydrochloride
26
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
73
Drug Name
Page #
methylphenidate hydrochloride cd
26
methylphenidate hydrochloride er
26
methylphenidate hydrochloride er (la)
26
methylprednisolone
43
methylprednisolone dose pack
43
metoclopramide hcl
42
metoclopramide hydrochloride
42
metoclopramide odt
42
metolazone
36
metoprolol succinate er
20
metoprolol tartrate
20
metoprolol/hydrochlorothiazide
20
metronidazole
6
metronidazole
56
metronidazole vaginal
56
metyrosine
53
mexiletine hcl
21
mibelas 24 fe
46
micafungin
5
miconazole 3
56
microgestin 1.5/30
46
microgestin 1/20
46
microgestin fe 1.5/30
46
microgestin fe 1/20
46
midodrine hcl
17
miglitol
45
miglustat
53
MILLIPRED
43
mimvey
47
minocycline hcl
4
minocycline hydrochloride
4
minoxidil
21
mirtazapine
32
mirtazapine odt
32
misoprostol
41
M-M-R II
15
modafinil
26
moexipril hcl
22
molindone hydrochloride
32
mometasone furoate
39
mometasone furoate
57
mondoxyne nl
4
montelukast sodium
53
morphine sulfate
24
morphine sulfate er
24
MOUNJARO
45
Drug Name
Page #
MOVANTIK
42
moxifloxacin hydrochloride/sodium
hydrochloride
4
moxifloxacin hydrochloride
4
moxifloxacin hydrochloride
38
MULTAQ
21
mupirocin
56
MUSE
23
mycophenolate mofetil
52
mycophenolic acid dr
52
MYFEMBREE
48
MYORISAN
59
MYRBETRIQ
59
nabumetone
24
nadolol
20
nafcillin sodium
4
naftifine hcl
56
naftifine hydrochloride
56
naloxone hcl
30
naloxone hydrochloride
30
naltrexone hcl
30
NAMZARIC
30
naproxen
25
naproxen sodium
25
naproxen sodium cr
24
naproxen sodium er
24
naratriptan hcl
28
NASCOBAL
60
NATACYN
38
nateglinide
45
NATPARA
48
NAYZILAM
27
nebivolol hydrochloride
20
necon 0.5/35-28
46
nefazodone hydrochloride
32
neomycin sulfate
4
neomycin/bacitracin/polymyxin
38
neomycin/polymyxin/bacitracin/hydrocortis
one
39
neomycin/polymyxin/dexamethasone
39
neomycin/polymyxin/gramicidin
38
neomycin/polymyxin/hc
39
neomycin/polymyxin/hydrocortisone
39
neo-polycin
38
neo-polycin hc
39
NERLYNX
12
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
74
Drug Name
Page #
NEUAC
56
NEULASTA
18
NEUPRO
29
nevirapine
7
nevirapine er
7
NEXLETOL
19
NEXLIZET
19
niacin
60
niacin er
19
niacor
60
nicardipine hcl
20
NICOTROL INHALER
16
NICOTROL NS
16
nifedipine
20
nifedipine er
20
nikki
46
nilutamide
12
nimodipine
20
NINLARO
12
nisoldipine er
20
nitazoxanide
6
nitisinone
53
NITRO-BID
23
nitrofurantoin macrocrystals
8
nitrofurantoin monohydrate/macrocrystals
8
nitroglycerin
23
nitroglycerin lingual
23
nitroglycerin transdermal
23
NIVA THYROID
49
nizatidine
41
NORDITROPIN FLEXPRO
49
norethindrone & ethinyl estradiol ferrous
fumarate
46
norethindrone acetate
48
norethindrone acetate/ethinyl estradiol
47
norethindrone acetate/ethinyl
estradiol/ferrous fumarate
46
NORPACE CR
21
nortrel 0.5/35 (28)
46
nortrel 1/35
46
nortrel 7/7/7
46
nortriptyline hcl
32
nortriptyline hydrochloride
32
NORVIR
7
NOURIANZ
30
NOXAFIL
5
Drug Name
Page #
np thyroid 120
49
np thyroid 15
49
np thyroid 30
49
np thyroid 60
49
np thyroid 90
49
NUBEQA
12
NUCALA
53
NUEDEXTA
30
NUPLAZID
32
NURTEC
28
NUTRILIPID
36
NUTROPIN AQ NUSPIN 10
49
NUTROPIN AQ NUSPIN 20
49
NUTROPIN AQ NUSPIN 5
49
NUVESSA
56
NUZYRA
4
nyamyc
56
NYMALIZE
20
nystatin
5
nystatin
56
nystatin/triamcinolone
57
nystop
56
OCTAGAM
14
octreotide acetate
48
ODEFSEY
7
ODOMZO
12
OFEV
53
ofloxacin
4
ofloxacin
38
olanzapine
32
olanzapine odt
32
olanzapine/fluoxetine
32
olmesartan medoxomil
22
olmesartan
medoxomil/amlodipine/hydrochlorothiazide
21
olmesartan medoxomil/hydrochlorothiazide
22
olopatadine hcl
39
olopatadine hydrochloride
39
omega-3-acid ethyl esters
19
omeprazole
41
omeprazole dr
41
omeprazole/sodium bicarbonate
41
OMNIPOD 5 G6 INTRO KIT (GEN 5)
34
OMNIPOD 5 G6 PODS (GEN 5)
34
OMNIPOD CLASSIC PDM STARTER
KIT (GEN 3)
34
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
75
Drug Name
Page #
OMNIPOD CLASSIC PODS (GEN 3)
34
OMNIPOD DASH INTRO KIT (GEN 4)
34
OMNIPOD DASH PDM KIT (GEN 4)
34
OMNIPOD DASH PODS (GEN 4)
34
OMNIPOD GO 10 UNITS/DAY
34
OMNIPOD GO 15 UNITS/DAY
34
OMNIPOD GO 20 UNITS/DAY
34
OMNIPOD GO 25 UNITS/DAY
34
OMNIPOD GO 30 UNITS/DAY
34
OMNIPOD GO 35 UNITS/DAY
34
OMNIPOD GO 40 UNITS/DAY
34
OMNITROPE
49
ondansetron hcl
41
ondansetron hydrochloride
41
ondansetron odt
41
ONGENTYS
29
ONUREG
12
OPSUMIT
54
oralone dental paste
57
ORENCIA
51
ORENCIA CLICKJECT
51
ORENITRAM
54
ORENITRAM TITRATION KIT MONTH
1
54
ORENITRAM TITRATION KIT MONTH
2
54
ORENITRAM TITRATION KIT MONTH
3
54
ORFADIN
53
ORGOVYX
48
ORILISSA
48
ORKAMBI
54
ORSERDU
12
oseltamivir phosphate
7
OSMOPREP
41
OSPHENA
47
OTEZLA
51
oxacillin sodium
4
oxaprozin
25
oxazepam
29
OXBRYTA
18
oxcarbazepine
27
OXERVATE
40
oxiconazole nitrate
56
oxybutynin chloride
59
oxybutynin chloride er
59
Drug Name
Page #
oxycodone hcl er
25
oxycodone hydrochloride
25
oxycodone hydrochloride er
25
oxycodone/acetaminophen
25
OXYCONTIN
25
oxymorphone hydrochloride
25
oxymorphone hydrochloride er
25
oxymorphone hydrochlorideer
25
OZEMPIC
45
paliperidone er
32
PANRETIN
59
pantoprazole sodium
41
pantoprazole sodium dr
41
PANZYGA
14
paricalcitol
60
paromomycin sulfate
6
paroxetine
32
paroxetine hcl
32
paroxetine hcl er
32
paroxetine hydrochloride
32
PASER
5
PEDIARIX
15
PEDVAX HIB
15
peg-3350/electrolytes
41
peg-3350/electrolytes/ascorbate
41
peg-3350/nacl/na bicarbonate/kcl
42
peg-3350/sodium sulf/naclpotassium cl/na
ascorbate/ascorbic
42
PEGASYS
7
PEMAZYRE
12
penciclovir
56
penicillamine
43
penicillin g potassium
4
penicillin g potassium in iso-osmotic
dextrose
4
PENICILLIN G SODIUM
4
penicillin v potassium
4
PENTACEL
15
pentamidine isethionate
6
pentoxifylline er
18
perindopril erbumine
22
periogard
38
permethrin
56
perphenazine
33
perphenazine/amitriptyline
32
PERSERIS
33
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
76
Drug Name
Page #
phendimetrazine tartrate
26
phendimetrazine tartrate er
26
phenelzine sulfate
33
phenobarbital
29
phenoxybenzamine hydrochloride
17
phentermine hcl
26
phentermine hydrochloride
26
phenytoin
27
phenytoin sodium extended
27
phytonadione
60
PIFELTRO
7
pilocarpine hcl
40
pilocarpine hydrochloride
16
pimecrolimus
59
pimozide
33
pindolol
20
pioglitazone hcl
45
pioglitazone hcl/metformin hcl
45
pioglitazone hcl-glimepiride
45
pioglitazone hydrochloride
45
piperacillin sodium/tazobactam sodium
4
PIQRAY 200MG DAILY DOSE
12
PIQRAY 250MG DAILY DOSE
12
PIQRAY 300MG DAILY DOSE
12
pirfenidone
53
piroxicam
25
PLEGRIDY
51
PLEGRIDY STARTER PACK
51
PLENAMINE
36
podofilox
59
polycin
38
polymyxin b sulfate/trimethoprim sulfate
38
POMALYST
12
portia-28
47
posaconazole
5
posaconazole dr
5
potassium chloride
37
potassium chloride er
37
potassium chloride/dextrose/sodium
chloride
37
potassium citrate er
34
PRALUENT
19
pramipexole dihydrochloride
29
pramipexole dihydrochloride er
29
prasugrel
18
pravastatin sodium
19
Drug Name
Page #
praziquantel
2
prazosin hydrochloride
19
PRED MILD
39
prednicarbate
58
prednisolone
43
prednisolone acetate
39
prednisolone sodium phosphate
39
prednisolone sodium phosphate
43
prednisolone sodium phosphate odt
43
prednisone
43
pregabalin
27
pregabalin er
25
PREHEVBRIO
15
PREMARIN
47
PREMASOL
36
premium lidocaine
58
PREMPHASE
47
PREMPRO
47
prenatal
60
prevalite
19
PREVYMIS
7
PREZCOBIX
7
PREZISTA
7
PRIFTIN
5
primaquine phosphate
6
primidone
27
PRIORIX
15
PRIVIGEN
14
PROAIR RESPICLICK
17
probenecid
37
probenecid/colchicine
37
prochlorperazine
33
prochlorperazine maleate
33
PROCRIT
18
procto-med hc
58
procto-pak
58
proctosol hc
58
proctozone-hc
58
progesterone
48
PROGRAF
52
PROLASTIN-C
54
PROLENSA
39
PROLIA
50
PROMACTA
18
promethazine dm
54
promethazine hcl
9
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
77
Drug Name
Page #
promethazine hcl plain
9
promethazine hydrochloride
9
promethazine vc/codeine
54
promethazine/codeine
54
propafenone hcl
21
propafenone hydrochloride er
21
propranolol hcl
20
propranolol hcl er
20
propranolol hydrochloride
20
propranolol hydrochloride er
20
propylthiouracil
49
PROQUAD
15
PROSOL
36
protriptyline hcl
33
PULMOZYME
54
PURIXAN
12
PYLERA
41
pyrazinamide
5
pyridostigmine bromide
16
pyridostigmine bromide er
16
pyrimethamine
6
PYRUKYND
18
PYRUKYND TAPER PACK
18
QINLOCK
12
QSYMIA
26
QUADRACEL
15
quetiapine fumarate
33
quetiapine fumarate er
33
quinapril hcl
22
quinapril hydrochloride
22
quinapril/hydrochlorothiazide
22
quinidine gluconate cr
21
quinidine sulfate
21
quinine sulfate
6
QVAR REDIHALER
43
RABAVERT
15
rabeprazole sodium
41
RADICAVA ORS
30
RADICAVA ORS STARTER KIT
30
raloxifene hydrochloride
47
ramelteon
29
ramipril
22
ranolazine er
21
rasagiline mesylate
29
RASUVO
51
RAYALDEE
60
Drug Name
Page #
REBIF
51
REBIF REBIDOSE
52
REBIF REBIDOSE TITRATION PACK
52
REBIF TITRATION PACK
52
RECOMBIVAX HB
15
RECTIV
59
REGRANEX
59
RELENZA DISKHALER
8
RELISTOR
42
RELYVRIO
30
repaglinide
45
REPATHA
19
REPATHA PUSHTRONEX SYSTEM
19
REPATHA SURECLICK
19
RESTASIS
39
RESTASIS MULTIDOSE
39
RETACRIT
18
RETEVMO
12
RETIN-A MICRO
55
RETIN-A MICRO PUMP
58
REVCOVI
38
REXULTI
33
REYATAZ
8
REZLIDHIA
12
REZUROCK
53
RHOPRESSA
40
ribavirin
8
RIDAURA
42
rifabutin
5
rifampin
5
riluzole
30
rimantadine hydrochloride
8
RINVOQ
51
risedronate sodium
50
risedronate sodium dr
50
RISPERDAL CONSTA
33
risperidone
33
risperidone odt
33
ritonavir
8
rivastigmine tartrate
16
rivastigmine transdermal system
16
rizatriptan benzoate
28
rizatriptan benzoate odt
28
ROCKLATAN
40
roflumilast
54
ropinirole er
29
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
78
Drug Name
Page #
ropinirole hcl
29
ropinirole hydrochloride
29
rosadan
56
rosuvastatin calcium
19
ROTARIX
15
ROTATEQ
15
roweepra
27
ROZLYTREK
12
RUBRACA
12
rufinamide
27
RUKOBIA
8
RYBELSUS
45
RYDAPT
12
RYTARY
29
SAJAZIR
52
SANTYL
59
sapropterin dihydrochloride
53
SAVELLA
30
SAVELLA TITRATION PACK
30
SAXENDA
45
SCEMBLIX
12
scopolamine
41
SECUADO
33
selegiline hcl
29
selenium sulfide
56
SELZENTRY
8
SEREVENT DISKUS
17
SEROSTIM
49
sertraline hcl
33
sertraline hydrochloride
33
sevelamer carbonate
37
sevelamer hydrochloride
37
sharobel
47
SHINGRIX
15
SIGNIFOR
48
sildenafil citrate
23
silodosin
17
silver sulfadiazine
56
SIMBRINZA
40
simvastatin
19
sirolimus
52
SIRTURO
5
SIVEXTRO
4
SKYRIZI
42
SKYRIZI
59
SKYRIZI PEN
59
Drug Name
Page #
sodium chloride
37
sodium chloride 0.45%
37
sodium chloride 0.9%
37
SODIUM OXYBATE
30
sodium phenylbutyrate
35
sodium polystyrene sulfonate
37
sodium sulfate/potassium sulfate/magnesium
sulfate
42
solifenacin succinate
59
SOLOSEC
6
SOLTAMOX
48
SOMAVERT
49
sorafenib
12
sorafenib tosylate
12
sorine
20
sotalol hcl
20
sotalol hydrochloride (af)
20
SPIRIVA RESPIMAT
16
spironolactone
22
spironolactone/hydrochlorothiazide
22
SPRITAM
27
SPRYCEL
13
sps
37
ssd
56
STAMARIL
15
STELARA
59
STIOLTO RESPIMAT
16
STIVARGA
13
streptomycin sulfate
4
STRIBILD
8
STRIVERDI RESPIMAT
17
SUBSYS
25
subvenite
27
subvenite starter kit/blue
27
subvenite starter kit/green
27
subvenite starter kit/orange
27
SUCRAID
38
sucralfate
41
sulfacetamide sodium
38
sulfacetamide sodium
56
sulfacetamide sodium/prednisolone sodium
phosphate
39
sulfadiazine
4
sulfamethoxazole/trimethoprim
4
sulfamethoxazole/trimethoprim ds
4
SULFAMYLON
56
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
79
Drug Name
Page #
sulfasalazine
4
sulindac
25
sumatriptan
28
sumatriptan succinate
28
sunitinib malate
13
SUNLENCA
8
SUNOSI
26
SUPRAX
4
SYMDEKO
54
SYMLINPEN 120
45
SYMLINPEN 60
45
SYMPAZAN
27
SYMTUZA
8
SYNAREL
48
SYNJARDY
45
SYNJARDY XR
45
SYNRIBO
13
SYNTHROID
49
TABLOID
13
TABRECTA
13
tacrolimus
52
tacrolimus
59
tadalafil
23
TAFINLAR
13
tafluprost
40
TAGRISSO
13
TALZENNA
13
tamoxifen citrate
48
tamsulosin hydrochloride
17
tarina fe 1/20 eq
47
TASIGNA
13
tasimelteon
29
TAVALISSE
18
TAVNEOS
52
tazarotene
59
tazicef
4
TAZORAC
59
taztia xt
21
TAZVERIK
13
tdvax
15
techlite insulin syringe u-100/0.5ml/30g x
1/2"
34
techlite pen needles 29g x 10mm
34
TEFLARO
4
TEGSEDI
50
TEKTURNA HCT
22
Drug Name
Page #
telmisartan
22
telmisartan/amlodipine
21
telmisartan/hydrochlorothiazide
22
temazepam
29
TEMIXYS
8
TENIVAC
15
tenofovir disoproxil fumarate
8
TEPMETKO
13
terazosin hcl
19
terazosin hydrochloride
19
terbinafine hcl
5
terbutaline sulfate
17
terconazole
56
teriflunomide
52
teriparatide
48
testosterone
44
testosterone cypionate
43
testosterone enanthate
44
testosterone pump
44
tetrabenazine
34
tetracycline hydrochloride
4
THALOMID
52
theophylline
60
theophylline er
60
THIOLA EC
53
thioridazine hcl
33
thiothixene
33
THYQUIDITY
49
THYROID
49
tiadylt er
21
tiagabine hydrochloride
27
TIBSOVO
13
TICOVAC
15
timolol maleate
20
timolol maleate
40
timolol maleate ophthalmic gel forming
40
tinidazole
6
TIROSINT-SOL
49
TIVICAY
8
TIVICAY PD
8
tizanidine hcl
16
tizanidine hydrochloride
17
TOBI PODHALER
4
TOBRADEX
39
TOBRADEX ST
39
tobramycin
4
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
80
Drug Name
Page #
tobramycin
38
tobramycin sulfate
4
tobramycin/dexamethasone
39
tolterodine tartrate
60
tolterodine tartrate er
60
topiramate
27
topiramate er
27
toremifene citrate
48
torsemide
36
TOUJEO MAX SOLOSTAR
45
TOUJEO SOLOSTAR
45
TOVET
58
TRACLEER
55
TRADJENTA
45
tramadol hcl
25
tramadol hcl er
25
tramadol hydrochloride
25
tramadol hydrochloride er
25
tramadol hydrochloride/acetaminophen
25
trandolapril
22
trandolapril/verapamil hcl er
21
tranexamic acid
17
tranylcypromine sulfate
33
TRAVASOL
36
travoprost
40
trazodone hydrochloride
33
TRECATOR
5
TRELEGY ELLIPTA
43
TRELSTAR MIXJECT
48
TRESIBA
45
TRESIBA FLEXTOUCH
45
tretinoin
13
tretinoin
58
tretinoin microsphere
58
TREXALL
13
triamcinolone acetonide
58
triamcinolone acetonide dental paste
58
triamterene/hydrochlorothiazide
36
TRIANEX
58
triazolam
29
triderm
58
trientine hydrochloride
43
trifluoperazine hcl
33
trifluoperazine hydrochloride
33
trifluridine
38
trihexyphenidyl hcl
29
Drug Name
Page #
trihexyphenidyl hydrochloride
29
TRIKAFTA
54
trimethoprim
8
trimipramine maleate
33
TRINTELLIX
33
tri-sprintec
47
TRITOCIN
58
TRIUMEQ
8
TRIUMEQ PD
8
trivora-28
47
TRIZIVIR
8
TROPHAMINE
36
trospium chloride
60
trospium chloride er
60
trueplus insulin syringe /u-100/1ml/29g x
1/2"
34
trueplus pen needles 29gx12mm
34
TRULICITY
45
TRUMENBA
15
TRUSELTIQ
13
TUKYSA
13
TURALIO
13
TWINRIX
15
tyblume
47
TYBOST
53
TYMLOS
48
TYPHIM VI
15
UBRELVY
28
UCERIS
58
UDENYCA
18
unithroid
49
UPTRAVI
55
UPTRAVI TITRATION PACK
55
ursodiol
42
valacyclovir hcl
8
valacyclovir hydrochloride
8
VALCHLOR
59
valganciclovir
8
valganciclovir hydrochloride
8
valproic acid
27
valsartan
22
valsartan/hydrochlorothiazide
22
VALTOCO 10 MG DOSE
27
VALTOCO 15 MG DOSE
27
VALTOCO 20 MG DOSE
27
VALTOCO 5 MG DOSE
27
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
81
Drug Name
Page #
vancomycin hcl
4
vancomycin hydrochloride
4
VAQTA
15
vardenafil hydrochloride
23
vardenafil hydrochloride odt
23
varenicline starting month box
16
varenicline tartrate
16
VARIVAX
15
VASCEPA
19
velivet
47
VELPHORO
37
VELTASSA
37
VEMLIDY
8
VENCLEXTA
13
VENCLEXTA STARTING PACK
13
venlafaxine besylate er
33
venlafaxine hcl er
33
venlafaxine hydrochloride
33
venlafaxine hydrochloride er
33
VENTAVIS
55
verapamil hcl
21
verapamil hcl er
21
verapamil hcl sr
21
verapamil hydrochloride
21
verapamil hydrochloride er
21
VERQUVO
23
VERSACLOZ
33
VERZENIO
13
VIBRAMYCIN
4
VICTOZA
45
vigabatrin
28
vigadrone
28
VIIBRYD STARTER PACK
33
VIJOICE
53
vilazodone hydrochloride
33
VIRACEPT
8
VIREAD
8
vitamin d
60
VITRAKVI
13
VIVITROL
30
VIZIMPRO
13
VONJO
13
voriconazole
5
VOSEVI
8
VOTRIENT
13
VOXZOGO
53
Drug Name
Page #
VRAYLAR
33
VUMERITY
52
vyfemla
47
VYNDAMAX
53
VYNDAQEL
53
VYVANSE
26
VYZULTA
40
warfarin sodium
18
WEGOVY
45
WELIREG
13
WINLEVI
59
wixela inhub
17
XALKORI
14
XARELTO
18
XARELTO STARTER PACK
18
XATMEP
14
XCOPRI
28
XELJANZ
51
XELJANZ XR
51
XENICAL
42
XENLETA
4
XERMELO
41
XGEVA
50
XIFAXAN
4
XIGDUO XR
45
XOFLUZA
8
XOLAIR
54
XOSPATA
14
XPOVIO
14
XPOVIO 100 MG ONCE WEEKLY
14
XPOVIO 40 MG ONCE WEEKLY
14
XPOVIO 40 MG TWICE WEEKLY
14
XPOVIO 60 MG ONCE WEEKLY
14
XPOVIO 60 MG TWICE WEEKLY
14
XPOVIO 80 MG ONCE WEEKLY
14
XPOVIO 80 MG TWICE WEEKLY
14
XTANDI
14
XYOSTED
44
YF-VAX
15
YONSA
14
YUPELRI
16
yuvafem
48
zafirlukast
53
zaleplon
30
ZARXIO
18
ZEJULA
14
Formulary ID: 24517, Version: 6, Effective Date: 01/01/2024
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
82
Drug Name
Page #
ZELBORAF
14
ZENATANE
59
ZENPEP
42
ZERBAXA
5
zidovudine
8
ZIEXTENZO
18
zileuton er
53
ziprasidone hcl
33
ziprasidone mesylate
33
ZIRGAN
38
ZOLINZA
14
zolmitriptan
28
zolmitriptan odt
28
zolpidem tartrate
30
zolpidem tartrate er
30
ZONISADE
28
zonisamide
28
ZORBTIVE
49
ZOSYN
5
zovia 1/35
47
ZTALMY
28
ZYDELIG
14
ZYKADIA
14
ZYLET
39
ZYPREXA RELPREVV
33
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Nous proposons des services gratuits d'interprétation pour répondre à toutes
vos questions relatives à notre régime de santé ou d'assurance-médicaments. Pour
accéder au service d'interprétation, il vous suffit de nous appeler au 1-800-701-9000.
Un interlocuteur parlant Français pourra vous aider. Ce service est gratuit.
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Chúng tôi có dịch vụ thông dịch miễn phí để trả lời các câu hỏi về chương
sức khỏe và chương trình thuốc men. Nếu quí vị cần thông dịch viên xin gọi 1-800-701-
9000 sẽ có nhân viên nói tiếng Việt giúp đỡ quí vị. Đây là dịch vụ miễn phí .
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Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem
Gesundheits- und Arzneimittelplan. Unsere Dolmetscher erreichen Sie unter 1-800-701-
9000. Man wird Ihnen dort auf Deutsch weiterhelfen. Dieser Service ist kostenlos.
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당사는 의료 보험 또는 약품 보험에 관한 질문에 답해 드리고자 무료 통역 서비스를
제공하고 있습니다. 통역 서비스를 이용하려면 전화 1-800-701-9000 번으로 문의해 주십시오.
한국어를 하는 담당자가 도와 드릴 것입니다. 이 서비스는 무료로 운영됩니다.
Form CMS-10802
(Expires 12/31/25)
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Если у вас возникнут вопросы относительно страхового или
медикаментного плана, вы можете воспользоваться нашими бесплатными услугами
переводчиков. Чтобы воспользоваться услугами переводчика, позвоните нам по
телефону 1-800-701-9000. Вам окажет помощь сотрудник, который говорит по-
pусски. Данная услуга бесплатная.
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ودﻷا لودﺟ وأ ﺔﺣﺻﻟﺎﺑ ﻖﻠﻌﺗﺗ ﺔﻠﺋﺳأ يأ نﻋ ﺔﺑﺎﺟﻺﻟ ﺔﯾﻧﺎﺟﻣﻟا يروﻔﻟا مﺟرﺗﻣﻟا تﺎﻣدﺧ مدﻘﻧ ﺎﻧﻧإ ،يروﻓ مﺟرﺗﻣ ﻰﻠﻋ لوﺻﺣﻠﻟ .ﺎﻧﯾدﻟ ﺔﯾ
ﻰﻠﻋ ﺎﻧﺑ لﺎﺻﺗﻻا ىوﺳ كﯾﻠﻋ سﯾﻟ
1-800 -701-9000 .ﺔﯾﻧﺎﺟﻣ ﺔﻣدﺧ هذھ .كﺗدﻋﺎﺳﻣﺑ ﺔﯾﺑرﻌﻟا ثدﺣﺗﯾ ﺎﻣ صﺧﺷ موﻘﯾﺳ .
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1-800-701-9000
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È disponibile un servizio di interpretariato gratuito per rispondere a eventuali
domande sul nostro piano sanitario e farmaceutico. Per un interprete, contattare il
numero 1-800-701-9000. Un nostro incaricato che parla Italianovi fornirà l'assistenza
necessaria. È un servizio gratuito.
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Dispomos de serviços de interpretação gratuitos para responder a qualquer
questão que tenha acerca do nosso plano de saúde ou de medicação. Para obter um
intérprete, contacte-nos através do número 1-800-701-9000. Irá encontrar alguém que
fale o idioma Português para o ajudar. Este serviço é gratuito.
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Nou genyen sèvis entèprèt gratis pou reponn tout kesyon ou ta genyen
konsènan plan medikal oswa dwòg nou an. Pou jwenn yon entèprèt, jis rele nou nan 1-
800-701-9000. Yon moun ki pale Kreyòl kapab ede w. Sa a se yon sèvis ki gratis.
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Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego, który pomoże w
uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania leków. Aby
skorzystać z pomocy tłumacza znającego język polski, należy zadzwonić pod numer 1-
800-701-9000. Ta usługa jest bezpłatna.
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当社の健康 健康保険と薬品 処方薬プランに関するご質問にお答えするため に、無料の
通訳サービスがありますございます。通訳をご用命になるには、1-800-701-9000 にお電話くださ
い。日本語を話す人 者 が支援いたします。これは無料のサー ビスです。
Y0065_2023_1_C
1 Wellness Way
Canton, MA 02021
This formulary was updated on 09/01/2023. For more recent information or other questions,
please contact Tufts Medicare Preferred HMO Member Services at 1-800-701-9000 (TTY users
should call 711), 8:00 a.m. to 8:00 p.m., 7 days a week from October 1 to March 31 and Monday–
Friday from April 1 to September 30, or visit www.thpmp.org.
Tufts Health Plan complies with applicable Federal civil rights laws and does not discriminate on the basis
of race, color, national origin, age, disability, or sex (including pregnancy, sexual orientation, and gender
identity). ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.
Llame al 1-800-701-9000 (TTY: 711).
