Formulary Abbreviations: F = Formulary, NF = Non-Formulary, PA = Prior Authorization, ST = Step Therapy, NC = Not Covered, SP = Specialty Drug, QL = Quantity Limit. MED = covered as a medical claim. A current formulary status is not shown for new medications. PRx = PreferredRx Drug Formulary, GA = GenericsAdvantageRx Drug Formulary. Drug Formulary Update, January 2022 Commercial Programs Updates to the HealthPartners Commercial Formularies (PreferredRx and GenericsAdvantageRx) are listed below. Please see www.healthpartners.com/formularies for details. Updates are effective by January 1, 2022. Updates include Drug name Current Status New Status Notes Canagliflozin (Invokana) F-QL NF-PA-QL Empagliflozin (Jardiance) remains on-formulary as the preferred alternative. This update also applies to canagliflozin/ metformin (Invokamet and Invokamet XR). Emtricitabine/ tenofovir (Descovy) F F-PA Generic Truvada is preferred. Descovy is reserved for patients with: 1. decreased bone mineral density due to osteopenia or osteoporosis, OR 2. decreased renal function (defined as creatinine clearance <60 mL/ min, or documentation of a significant decline), OR 3. 65 years of age and older Continuous glucose monitoring systems (Dexcom and Freestyle Libre) COV-PA-QL COV-ST-QL Coverage criteria have been updated, including a step-therapy from insulin. If you've used insulin within the previous 6 months, these will be covered. These are also available for patients with type 2 diabetes and one of the following: 1. documented hypoglycemia, or 2. documentation of considerable variability in glucose levels or inability to reach A1c goals despite frequent medication dose adjustments for 2 of more glucose lowering agents; or 3. documentation of barriers to glucose testing with glucose test strips (such as visual impairment, cognitive issues, and care giver assisting with care)
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Drug Formulary Update, January 2022 Commercial Programs
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Formulary Abbreviations: F = Formulary, NF = Non-Formulary, PA = Prior Authorization, ST = Step Therapy, NC = Not Covered, SP = Specialty Drug, QL = Quantity Limit. MED = covered as a medical claim. A current formulary status is not shown for new medications. PRx = PreferredRx Drug Formulary, GA = GenericsAdvantageRx Drug Formulary.
Drug Formulary Update, January 2022
Commercial Programs
Updates to the HealthPartners Commercial Formularies (PreferredRx and GenericsAdvantageRx) are listed below. Please see www.healthpartners.com/formularies for details. Updates are effective by January 1, 2022. Updates include
Drug name Current
Status New Status Notes
Canagliflozin (Invokana)
F-QL NF-PA-QL Empagliflozin (Jardiance) remains on-formulary as the preferred alternative.
This update also applies to canagliflozin/ metformin (Invokamet and Invokamet XR).
Emtricitabine/ tenofovir (Descovy)
F F-PA Generic Truvada is preferred. Descovy is reserved for patients with: 1. decreased bone mineral density due to
osteopenia or osteoporosis, OR 2. decreased renal function (defined as creatinine
clearance <60 mL/ min, or documentation of a significant decline), OR
3. 65 years of age and older
Continuous glucose monitoring systems (Dexcom and Freestyle Libre)
COV-PA-QL COV-ST-QL Coverage criteria have been updated, including a step-therapy from insulin.
If you've used insulin within the previous 6 months, these will be covered.
These are also available for patients with type 2 diabetes and one of the following:
1. documented hypoglycemia, or 2. documentation of considerable variability in
glucose levels or inability to reach A1c goals despite frequent medication dose adjustments for 2 of more glucose lowering agents; or
3. documentation of barriers to glucose testing with glucose test strips (such as visual impairment, cognitive issues, and care giver assisting with care)
Formulary Abbreviations: F = Formulary, NF = Non-Formulary, PA = Prior Authorization, ST = Step Therapy, NC = Not Covered, SP = Specialty Drug, QL = Quantity Limit. MED = covered as a medical claim. A current formulary status is not shown for new medications. PRx = PreferredRx Drug Formulary, GA = GenericsAdvantageRx Drug Formulary.
Drug name Current
Status New Status Notes
True Metrix glucose test strips
COV-QL NC-QL Accu-Chek remains as the preferred alternative.
Interferon beta (Rebif)
F-SP-QL F-SP-PA-QL Reserved for patients with an inadequate response or a medical contraindication to Avonex AND Plegridy
Weight loss medications, Saxenda and Wegovy
NF-PA NF-PA PA update. Phentermine/ topiramate (Qsymia) and naltrexone/ bupropion (Contrave) are preferred.
Mometasone/ formoterol (Dulera)
F-PA NF-PA Preferred alternatives include budesonide/ formoterol (Symbicort generic).
Salmeterol (Serevent)
F F-PA Olodaterol (Striverdi) remains on-formulary as the preferred alternative.
Ustekinumab (Stelara)
MED-PA F-PA-SP Ustekinumab (Stelara) is being added to HealthPartners’ self-administered drug list.
Medications on the self-administered drug list are processed through the pharmacy benefit.
ALIROCUMAB PRALUENT 150 MG/ML PEN NF PA QL NF PA NF PA QL
ALIROCUMAB PRALUENT 75 MG/ML PEN NF PA QL NF PA NF PA QL
ALITRETINOIN PANRETIN 0.1% GEL NF NF NF PA
Formulary Update, page 3 of 22
Formulary Abbreviations: F = Formulary, NF = Non-Formulary, PA = Prior Authorization, ST = Step Therapy, NC = Not Covered, SP = Specialty Drug, QL = Quantity Limit. MED = covered as a medical claim. A current formulary status is not shown for new medications. PRx = PreferredRx Drug Formulary, GA = GenericsAdvantageRx Drug Formulary.
GENERIC NAME Label Name PRx
Current GA Current New Status
ALMOTRIPTAN MALATE ALMOTRIPTAN MALATE 12.5 MG TAB
NF QL NF QL F-PA-QL
ALMOTRIPTAN MALATE ALMOTRIPTAN MALATE 6.25 MG TAB
NF QL NF QL F-PA-QL
ALPROSTADIL CAVERJECT 20 MCG VIAL NF EXCL NF
ALPROSTADIL CAVERJECT 40 MCG VIAL NF EXCL NF
ALPROSTADIL CAVERJECT IMPULSE 10 MCG KIT NF EXCL NF
ALPROSTADIL CAVERJECT IMPULSE 10 MCG SYRNG
NF EXCL NF
ALPROSTADIL CAVERJECT IMPULSE 20 MCG KIT NF EXCL NF
ALPROSTADIL CAVERJECT IMPULSE 20 MCG SYRNG
NF EXCL NF
ALPROSTADIL EDEX 10 MCG CARTRIDGE 2-PK KIT NF EXCL NF
ALPROSTADIL EDEX 10 MCG CARTRIDGE 6-PK KIT NF EXCL NF
ALPROSTADIL EDEX 20 MCG CARTRIDGE 2-PK KIT NF EXCL NF
ALPROSTADIL EDEX 20 MCG CARTRIDGE 6-PK KIT NF EXCL NF
ALPROSTADIL EDEX 40 MCG CARTRIDGE 2-PK KIT NF EXCL NF
ALPROSTADIL EDEX 40 MCG CARTRIDGE 6-PK KIT NF EXCL NF
ALPROSTADIL MUSE 1,000 MCG URETHRAL SUPP NF EXCL NF
ALPROSTADIL MUSE 125 MCG URETHRAL SUPPOS NF EXCL NF
ALPROSTADIL MUSE 250 MCG URETHRAL SUPPOS NF EXCL NF
ALPROSTADIL MUSE 500 MCG URETHRAL SUPPOS NF EXCL NF
APOMORPHINE HCL KYNMOBI 10 MG SL FILM S NF PA S NF PA S F PA
APOMORPHINE HCL KYNMOBI 15 MG SL FILM S NF PA S NF PA S F PA
Formulary Update, page 4 of 22
Formulary Abbreviations: F = Formulary, NF = Non-Formulary, PA = Prior Authorization, ST = Step Therapy, NC = Not Covered, SP = Specialty Drug, QL = Quantity Limit. MED = covered as a medical claim. A current formulary status is not shown for new medications. PRx = PreferredRx Drug Formulary, GA = GenericsAdvantageRx Drug Formulary.
GENERIC NAME Label Name PRx
Current GA Current New Status
APOMORPHINE HCL KYNMOBI 20 MG SL FILM S NF PA S NF PA S F PA
APOMORPHINE HCL KYNMOBI 25 MG SL FILM S NF PA S NF PA S F PA
APOMORPHINE HCL KYNMOBI 30 MG SL FILM S NF PA S NF PA S F PA
APOMORPHINE HCL KYNMOBI TITRATION KIT S NF PA S NF PA S F PA
Formulary Abbreviations: F = Formulary, NF = Non-Formulary, PA = Prior Authorization, ST = Step Therapy, NC = Not Covered, SP = Specialty Drug, QL = Quantity Limit. MED = covered as a medical claim. A current formulary status is not shown for new medications. PRx = PreferredRx Drug Formulary, GA = GenericsAdvantageRx Drug Formulary.
CETIRIZINE HCL ZERVIATE 0.24% EYE DROP NF PA NF PA F-PA
CETRORELIX ACETATE CETROTIDE 0.25 MG KIT F EXCL F
CHLOROTHIAZIDE DIURIL 250 MG/5 ML ORAL SUSP F NF F
CHLORPROMAZINE HCL CHLORPROMAZINE 10 MG TABLET NF F PA F PA
CHLORPROMAZINE HCL CHLORPROMAZINE 100 MG TABLET NF F PA F PA
CHLORPROMAZINE HCL CHLORPROMAZINE 200 MG TABLET NF F PA F PA
CHLORPROMAZINE HCL CHLORPROMAZINE 25 MG TABLET NF F PA F PA
CHLORPROMAZINE HCL CHLORPROMAZINE 50 MG TABLET NF F PA F PA
CHORIOGONADOTROPIN ALFA
OVIDREL 250 MCG/0.5 ML SYRG F EXCL F
CHORIONIC GONADOTROPIN, HUMAN
CHORIONIC GONAD 1 MILLION UNIT
NF EXCL NF
CHORIONIC GONADOTROPIN, HUMAN
CHORIONIC GONAD 10,000 UNIT VL F EXCL F
CHORIONIC GONADOTROPIN, HUMAN
CHORIONIC GONAD 12,000 UNIT VL F EXCL F
CHORIONIC GONADOTROPIN, HUMAN
CHORIONIC GONAD 2 MILLION UNIT
NF EXCL NF
CHORIONIC GONADOTROPIN, HUMAN
CHORIONIC GONAD 5 MILLION UNIT
NF EXCL NF
CHORIONIC GONADOTROPIN, HUMAN
CHORIONIC GONAD 50,000 UNIT VL NF EXCL NF
CHORIONIC GONADOTROPIN, HUMAN
CHORIONIC GONAD 6,000 UNIT VL F EXCL F
CHORIONIC GONADOTROPIN, HUMAN
CHORIONIC GONADOTROPIN POWDER
NF EXCL NF
CHORIONIC GONADOTROPIN, HUMAN
NOVAREL 10,000 UNITS VIAL F EXCL F
Formulary Update, page 6 of 22
Formulary Abbreviations: F = Formulary, NF = Non-Formulary, PA = Prior Authorization, ST = Step Therapy, NC = Not Covered, SP = Specialty Drug, QL = Quantity Limit. MED = covered as a medical claim. A current formulary status is not shown for new medications. PRx = PreferredRx Drug Formulary, GA = GenericsAdvantageRx Drug Formulary.
Formulary Abbreviations: F = Formulary, NF = Non-Formulary, PA = Prior Authorization, ST = Step Therapy, NC = Not Covered, SP = Specialty Drug, QL = Quantity Limit. MED = covered as a medical claim. A current formulary status is not shown for new medications. PRx = PreferredRx Drug Formulary, GA = GenericsAdvantageRx Drug Formulary.
GENERIC NAME Label Name PRx
Current GA Current New Status
DIHYDROERGOTAMINE MESYLATE
DIHYDROERGOTAMINE 4 MG/ML SPRY
NF PA QL NF PA QL F-PA-QL
DIMETHYL FUMARATE DIMETHYL FUMARATE 30D START PK
S F QL S F S F QL
DIMETHYL FUMARATE DIMETHYL FUMARATE DR 120 MG CP
S F QL S F S F QL
DIMETHYL FUMARATE DIMETHYL FUMARATE DR 240 MG CP
S F QL S F S F QL
DOXEPIN HCL DOXEPIN HCL 3 MG TABLET NF PA NF PA F-PA
DOXEPIN HCL DOXEPIN HCL 6 MG TABLET NF PA NF PA F-PA
DOXORUBICIN HCL ADRIAMYCIN 200 MG/100 ML VIAL MED NF MED
DOXYCYCLINE MONOHYDRATE
MONDOXYNE NL 100 MG CAPSULE NF PA F NF PA
DOXYCYCLINE MONOHYDRATE
MONDOXYNE NL 75 MG CAPSULE NF PA NF NF PA
DUPILUMAB DUPIXENT 300 MG/2 ML PEN S F PA QL S F PA S F PA QL
DUTASTERIDE/ TAMSULOSIN HCL
DUTASTERIDE-TAMSULOSIN 0.5-0.4 F NF F-PA
ECHOTHIOPHATE IODIDE PHOSPHOLINE IODIDE 0.125% F NF F
ELAGOLIX SODIUM ORILISSA 150 MG TABLET S-F PA QL S-F PA QL S-F PA QL
ELAGOLIX SODIUM ORILISSA 200 MG TABLET S-F PA QL S-F PA QL S-F PA QL
ELAGOLIX SODIUM/ ESTRADIOL/ NORETHINDRONE ACETATE
ORIAHNN 300-1-0.5MG/300MG CAPS
F PA QL S F PA QL S F PA QL
ELETRIPTAN HYDROBROMIDE ELETRIPTAN HBR 20 MG TABLET NF QL F PA QL F PA QL
ELETRIPTAN HYDROBROMIDE ELETRIPTAN HBR 40 MG TABLET NF QL F PA QL F PA QL
Formulary Abbreviations: F = Formulary, NF = Non-Formulary, PA = Prior Authorization, ST = Step Therapy, NC = Not Covered, SP = Specialty Drug, QL = Quantity Limit. MED = covered as a medical claim. A current formulary status is not shown for new medications. PRx = PreferredRx Drug Formulary, GA = GenericsAdvantageRx Drug Formulary.
FENTANYL CITRATE FENTANYL CIT 100 MCG BUCCAL TB NF PA NF NF PA
FENTANYL CITRATE FENTANYL CIT 200 MCG BUCCAL TB NF PA NF NF PA
FENTANYL CITRATE FENTANYL CIT 400 MCG BUCCAL TB NF PA NF NF PA
FENTANYL CITRATE FENTORA 100 MCG BUCCAL TABLET
NF PA NF NF PA
FENTANYL CITRATE FENTORA 200 MCG BUCCAL TABLET
NF PA NF NF PA
FENTANYL CITRATE FENTORA 400 MCG BUCCAL TABLET
NF PA NF NF PA
Formulary Update, page 9 of 22
Formulary Abbreviations: F = Formulary, NF = Non-Formulary, PA = Prior Authorization, ST = Step Therapy, NC = Not Covered, SP = Specialty Drug, QL = Quantity Limit. MED = covered as a medical claim. A current formulary status is not shown for new medications. PRx = PreferredRx Drug Formulary, GA = GenericsAdvantageRx Drug Formulary.
Formulary Abbreviations: F = Formulary, NF = Non-Formulary, PA = Prior Authorization, ST = Step Therapy, NC = Not Covered, SP = Specialty Drug, QL = Quantity Limit. MED = covered as a medical claim. A current formulary status is not shown for new medications. PRx = PreferredRx Drug Formulary, GA = GenericsAdvantageRx Drug Formulary.
GENERIC NAME Label Name PRx
Current GA Current New Status
GENTAMICIN SULFATE GENTAMICIN 0.3% EYE DROP NF NF F-PA
GENTAMICIN SULFATE/ PREDNISOLONE ACETATE
PRED-G 1% EYE DROPS NF NF F-PA
GENTAMICIN SULFATE/ PREDNISOLONE ACETATE
PRED-G S.O.P. EYE OINTMENT NF NF F-PA
GRANISETRON SANCUSO 3.1 MG/24 HR PATCH NF NF NF PA
GRANISETRON HCL GRANISETRON HCL 1 MG TABLET NF NF F PA
Formulary Abbreviations: F = Formulary, NF = Non-Formulary, PA = Prior Authorization, ST = Step Therapy, NC = Not Covered, SP = Specialty Drug, QL = Quantity Limit. MED = covered as a medical claim. A current formulary status is not shown for new medications. PRx = PreferredRx Drug Formulary, GA = GenericsAdvantageRx Drug Formulary.
IVERMECTIN IVERMECTIN 0.5% LOTION NF PA NF PA F-PA
KETAMINE HCL IN 0.9 % SODIUM CHLORIDE
KETAMINE 100 MG/100ML-0.9%NACL
MED PA MED MED PA
KETOPROFEN KETOPROFEN 25 MG CAPSULE NF NF F-PA
KETOPROFEN KETOPROFEN 50 MG CAPSULE NF NF F-PA
KETOPROFEN KETOPROFEN 75 MG CAPSULE NF NF F-PA
Formulary Update, page 12 of 22
Formulary Abbreviations: F = Formulary, NF = Non-Formulary, PA = Prior Authorization, ST = Step Therapy, NC = Not Covered, SP = Specialty Drug, QL = Quantity Limit. MED = covered as a medical claim. A current formulary status is not shown for new medications. PRx = PreferredRx Drug Formulary, GA = GenericsAdvantageRx Drug Formulary.
LOTEPREDNOL ETABONATE LOTEMAX 0.5% EYE OINTMENT F NF F
LOTEPREDNOL ETABONATE LOTEMAX SM 0.38% OPHTH GEL F NF F
LOTEPREDNOL ETABONATE LOTEPREDNOL 0.5% OPHTHALMC GEL
F NF F
Formulary Update, page 13 of 22
Formulary Abbreviations: F = Formulary, NF = Non-Formulary, PA = Prior Authorization, ST = Step Therapy, NC = Not Covered, SP = Specialty Drug, QL = Quantity Limit. MED = covered as a medical claim. A current formulary status is not shown for new medications. PRx = PreferredRx Drug Formulary, GA = GenericsAdvantageRx Drug Formulary.
METRONIDAZOLE NORITATE 1% CREAM NF PA NF PA maintain
MILNACIPRAN HCL SAVELLA 100 MG TABLET F PA QL NF PA QL F PA QL
MILNACIPRAN HCL SAVELLA 12.5 MG TABLET F PA QL NF PA QL F PA QL
MILNACIPRAN HCL SAVELLA 25 MG TABLET F PA QL NF PA QL F PA QL
MILNACIPRAN HCL SAVELLA 50 MG TABLET F PA QL NF PA QL F PA QL
MILNACIPRAN HCL SAVELLA TITRATION PACK F PA QL NF PA QL F PA QL
MITOTANE LYSODREN 500 MG TABLET NF PA F PA F-PA
Formulary Update, page 14 of 22
Formulary Abbreviations: F = Formulary, NF = Non-Formulary, PA = Prior Authorization, ST = Step Therapy, NC = Not Covered, SP = Specialty Drug, QL = Quantity Limit. MED = covered as a medical claim. A current formulary status is not shown for new medications. PRx = PreferredRx Drug Formulary, GA = GenericsAdvantageRx Drug Formulary.
GENERIC NAME Label Name PRx
Current GA Current New Status
MONOMETHYL FUMARATE BAFIERTAM DR 95 MG CAPSULE S-F PA QL S-F QL S-F PA QL
NYSTATIN NYSTATIN 100,000 UNIT/ML SUSP F QL F F QL
NYSTATIN/ TRIAMCINOLONE ACETONIDE
NYSTATIN-TRIAMCINOLONE CREAM
NF NF F-PA
NYSTATIN/ TRIAMCINOLONE ACETONIDE
NYSTATIN-TRIAMCINOLONE OINTM NF NF F-PA
OLOPATADINE HCL OLOPATADINE 665 MCG NASAL SPRY
NF NF F-PA
OLSALAZINE SODIUM DIPENTUM 250 MG CAPSULE NF PA NF PA F-PA
ONDANSETRON HCL ZOFRAN 4 MG TABLET NF NF NF PA
ONDANSETRON HCL ZOFRAN 8 MG TABLET NF NF NF PA
Formulary Update, page 15 of 22
Formulary Abbreviations: F = Formulary, NF = Non-Formulary, PA = Prior Authorization, ST = Step Therapy, NC = Not Covered, SP = Specialty Drug, QL = Quantity Limit. MED = covered as a medical claim. A current formulary status is not shown for new medications. PRx = PreferredRx Drug Formulary, GA = GenericsAdvantageRx Drug Formulary.
GENERIC NAME Label Name PRx
Current GA Current New Status
OPIUM/ BELLADONNA ALKALOIDS
BELLADONNA-OPIUM 16.2-30 SUPP NF NF QL NF QL
ORLISTAT ALLI 60 MG CAPSULE F PA F PA #REF!
ORLISTAT XENICAL 120 MG CAPSULE F PA F PA #REF!
OSPEMIFENE OSPHENA 60 MG TABLET NF EXCL NF
OXANDROLONE OXANDRIN 10 MG TABLET NF QL NF PA QL NF PA QL
OXANDROLONE OXANDRIN 2.5 MG TABLET NF QL NF PA QL NF PA QL
OXANDROLONE OXANDROLONE 10 MG TABLET NF QL F PA QL F PA QL
OXANDROLONE OXANDROLONE 2.5 MG TABLET NF QL F PA QL F PA QL
PAPAVERINE HCL/ PHENTOLAMINE MESYLATE/ ALPROSTADIL IN WATER
PPVRN 12MG-PHNT 1MG-ALPR 10MCG
NF EXCL NC
Formulary Update, page 16 of 22
Formulary Abbreviations: F = Formulary, NF = Non-Formulary, PA = Prior Authorization, ST = Step Therapy, NC = Not Covered, SP = Specialty Drug, QL = Quantity Limit. MED = covered as a medical claim. A current formulary status is not shown for new medications. PRx = PreferredRx Drug Formulary, GA = GenericsAdvantageRx Drug Formulary.
GENERIC NAME Label Name PRx
Current GA Current New Status
PAPAVERINE HCL/ PHENTOLAMINE MESYLATE/ ALPROSTADIL IN WATER
PEGFILGRASTIM NEULASTA 6 MG/0.6 ML SYRINGE S-NF PA S-NF PA NF-PA-SP
PEGFILGRASTIM NEULASTA ONPRO 6 MG/0.6 ML KIT
S-NF PA S-NF PA NF-PA-SP
PEGFILGRASTIM-APGF NYVEPRIA 6 MG/0.6 ML SYRINGE F F F-PA
PEGFILGRASTIM-BMEZ ZIEXTENZO 6 MG/0.6 ML SYRINGE F F F-PA
PEGFILGRASTIM-CBQV UDENYCA 6 MG/0.6 ML SYRINGE F F F-PA
PEGFILGRASTIM-JMDB FULPHILA 6 MG/0.6 ML SYRINGE F F F-PA
PEMBROLIZUMAB KEYTRUDA 100 MG/4 ML VIAL MED PA MED PA MED PA
PEMIGATINIB PEMAZYRE 4.5 MG TABLET F QL F PA QL F PA QL
PENCICLOVIR DENAVIR 1% CREAM NF NF F-PA
PENTAZOCINE HCL/ NALOXONE HCL
PENTAZOCINE-NALOXONE TABLET NF QL NF QL F-PA-QL
PERPHENAZINE/ AMITRIPTYLINE HCL
PERPHEN-AMITRIP 2 MG-10 MG TAB
NF AGE NF AGE F-PA-Age
PERPHENAZINE/ AMITRIPTYLINE HCL
PERPHEN-AMITRIP 2 MG-25 MG TAB
NF AGE NF AGE F-PA-Age
PERPHENAZINE/ AMITRIPTYLINE HCL
PERPHEN-AMITRIP 4 MG-10 MG TAB
NF AGE NF AGE F-PA-Age
PERPHENAZINE/ AMITRIPTYLINE HCL
PERPHEN-AMITRIP 4 MG-25 MG TAB
NF AGE NF AGE F-PA-Age
PERPHENAZINE/ AMITRIPTYLINE HCL
PERPHEN-AMITRIP 4 MG-50 MG TAB
NF AGE NF AGE F-PA-Age
PHENTERMINE HCL/ TOPIRAMATE
QSYMIA 11.25 MG-69 MG CAPSULE NF QL NF QL #REF!
PHENTERMINE HCL/ TOPIRAMATE
QSYMIA 15 MG-92 MG CAPSULE NF QL NF QL #REF!
Formulary Update, page 17 of 22
Formulary Abbreviations: F = Formulary, NF = Non-Formulary, PA = Prior Authorization, ST = Step Therapy, NC = Not Covered, SP = Specialty Drug, QL = Quantity Limit. MED = covered as a medical claim. A current formulary status is not shown for new medications. PRx = PreferredRx Drug Formulary, GA = GenericsAdvantageRx Drug Formulary.
GENERIC NAME Label Name PRx
Current GA Current New Status
PHENTERMINE HCL/ TOPIRAMATE
QSYMIA 3.75 MG-23 MG CAPSULE NF QL NF QL #REF!
PHENTERMINE HCL/ TOPIRAMATE
QSYMIA 7.5 MG-46 MG CAPSULE NF QL NF QL #REF!
PIMOZIDE PIMOZIDE 1 MG TABLET NF AGE NF AGE F PA Age
PIMOZIDE PIMOZIDE 2 MG TABLET NF AGE NF AGE F PA Age
PIRFENIDONE ESBRIET 267 MG CAPSULE S-F PA S-F PA S-NF PA
PIRFENIDONE ESBRIET 267 MG TABLET S-F PA S-F PA S-NF PA
PIRFENIDONE ESBRIET 801 MG TABLET S-F PA S-F PA S-NF PA
PRAMIPEXOLE DI-HCL MIRAPEX ER 0.375 MG TABLET NF PA NF NF PA
PRAMIPEXOLE DI-HCL MIRAPEX ER 0.75 MG TABLET NF PA NF NF PA
PRAMIPEXOLE DI-HCL MIRAPEX ER 1.5 MG TABLET NF PA NF NF PA
PRAMIPEXOLE DI-HCL MIRAPEX ER 2.25 MG TABLET NF PA NF NF PA
PRAMIPEXOLE DI-HCL MIRAPEX ER 3 MG TABLET NF PA NF NF PA
PRAMIPEXOLE DI-HCL MIRAPEX ER 3.75 MG TABLET NF PA NF NF PA
PRAMIPEXOLE DI-HCL MIRAPEX ER 4.5 MG TABLET NF PA NF NF PA
PRAMIPEXOLE DI-HCL PRAMIPEXOLE ER 0.375 MG TABLET F PA NF NF
PRAMIPEXOLE DI-HCL PRAMIPEXOLE ER 0.75 MG TABLET F PA NF NF
PRAMIPEXOLE DI-HCL PRAMIPEXOLE ER 1.5 MG TABLET F PA NF NF
PRAMIPEXOLE DI-HCL PRAMIPEXOLE ER 2.25 MG TABLET F PA NF NF
PRAMIPEXOLE DI-HCL PRAMIPEXOLE ER 3 MG TABLET F PA NF NF
PRAMIPEXOLE DI-HCL PRAMIPEXOLE ER 3.75 MG TABLET F PA NF NF
PRAMIPEXOLE DI-HCL PRAMIPEXOLE ER 4.5 MG TABLET F PA NF NF
Formulary Abbreviations: F = Formulary, NF = Non-Formulary, PA = Prior Authorization, ST = Step Therapy, NC = Not Covered, SP = Specialty Drug, QL = Quantity Limit. MED = covered as a medical claim. A current formulary status is not shown for new medications. PRx = PreferredRx Drug Formulary, GA = GenericsAdvantageRx Drug Formulary.
GENERIC NAME Label Name PRx
Current GA Current New Status
QUININE SULFATE QUININE SULFATE 324 MG CAPSULE
NF NF F-PA
RETAPAMULIN ALTABAX 1% OINTMENT F STEP NF F STEP
RIBOCICLIB SUCCINATE KISQALI 200 MG DAILY DOSE F PA QL F PA F PA QL
RIBOCICLIB SUCCINATE KISQALI 400 MG DAILY DOSE F PA QL F PA F PA QL
RIBOCICLIB SUCCINATE KISQALI 600 MG DAILY DOSE F PA QL F PA F PA QL
RISEDRONATE SODIUM RISEDRONATE SODIUM 150 MG TAB
F NF F
RISEDRONATE SODIUM RISEDRONATE SODIUM 30 MG TAB F NF F
RISEDRONATE SODIUM RISEDRONATE SODIUM 35 MG TAB F NF F
RISEDRONATE SODIUM RISEDRONATE SODIUM 5 MG TABLET
F NF F
RIVASTIGMINE RIVASTIGMINE 13.3 MG/24HR PTCH
F NF F
RIVASTIGMINE RIVASTIGMINE 4.6 MG/24HR PATCH
F NF F
RIVASTIGMINE RIVASTIGMINE 9.5 MG/24HR PATCH
F NF F
ROPINIROLE HCL REQUIP XL 12 MG TABLET NF PA NF NF PA
ROPINIROLE HCL REQUIP XL 4 MG TABLET NF PA NF NF PA
ROPINIROLE HCL REQUIP XL 6 MG TABLET NF PA NF NF PA
ROPINIROLE HCL REQUIP XL 8 MG TABLET NF PA NF NF PA
ROPINIROLE HCL ROPINIROLE HCL ER 12 MG TABLET F PA NF F PA
ROPINIROLE HCL ROPINIROLE HCL ER 2 MG TABLET F PA NF F PA
ROPINIROLE HCL ROPINIROLE HCL ER 4 MG TABLET F PA NF F PA
ROPINIROLE HCL ROPINIROLE HCL ER 6 MG TABLET F PA NF F PA
ROPINIROLE HCL ROPINIROLE HCL ER 8 MG TABLET F PA NF F PA
SELEGILINE EMSAM 12 MG/24 HOURS PATCH F PA NF PA F PA
SELEGILINE EMSAM 6 MG/24 HOURS PATCH F PA NF PA F PA
SELEGILINE EMSAM 9 MG/24 HOURS PATCH F PA NF PA F PA
SELUMETINIB SULFATE/ VITAMIN E TPGS
KOSELUGO 10 MG CAPSULE F PA QL F PA F PA QL
SELUMETINIB SULFATE/ VITAMIN E TPGS
KOSELUGO 25 MG CAPSULE F PA QL F PA F PA QL
SEMAGLUTIDE WEGOVY 0.25 MG/0.5 ML PEN NF PA NF PA #REF!
SEMAGLUTIDE WEGOVY 0.5 MG/0.5 ML PEN NF PA NF PA #REF!
SEMAGLUTIDE WEGOVY 1 MG/0.5 ML PEN NF PA NF PA #REF!
SEMAGLUTIDE WEGOVY 1.7 MG/0.75 ML PEN NF PA NF PA #REF!
SEMAGLUTIDE WEGOVY 2.4 MG/0.75 ML PEN NF PA NF PA #REF!
SILDENAFIL CITRATE REVATIO 10 MG/12.5 ML VIAL MED PA MED MED PA
Formulary Update, page 19 of 22
Formulary Abbreviations: F = Formulary, NF = Non-Formulary, PA = Prior Authorization, ST = Step Therapy, NC = Not Covered, SP = Specialty Drug, QL = Quantity Limit. MED = covered as a medical claim. A current formulary status is not shown for new medications. PRx = PreferredRx Drug Formulary, GA = GenericsAdvantageRx Drug Formulary.
GENERIC NAME Label Name PRx
Current GA Current New Status
SILDENAFIL CITRATE SILDENAFIL 100 MG TABLET F EXCL F
SILDENAFIL CITRATE SILDENAFIL 25 MG TABLET F EXCL F
SILDENAFIL CITRATE SILDENAFIL 50 MG TABLET F EXCL F
SILDENAFIL CITRATE VIAGRA 100 MG TABLET NF PA EXCL NF PA
SILDENAFIL CITRATE VIAGRA 25 MG TABLET NF PA EXCL NF PA
SILDENAFIL CITRATE VIAGRA 50 MG TABLET NF PA EXCL NF PA
SUMATRIPTAN SUCCINATE ONZETRA XSAIL 11 MG/NOSEPIECE NF PA QL NF QL NF PA QL
SUMATRIPTAN SUCCINATE/ NAPROXEN SODIUM
SUMATRIPTAN-NAPROXEN 85-500 MG
NF PA QL NF PA QL F-PA-QL
TADALAFIL CIALIS 10 MG TABLET NF PA EXCL NF PA
TADALAFIL CIALIS 20 MG TABLET NF PA EXCL NF PA
TADALAFIL TADALAFIL 10 MG TABLET F EXCL F
Formulary Update, page 20 of 22
Formulary Abbreviations: F = Formulary, NF = Non-Formulary, PA = Prior Authorization, ST = Step Therapy, NC = Not Covered, SP = Specialty Drug, QL = Quantity Limit. MED = covered as a medical claim. A current formulary status is not shown for new medications. PRx = PreferredRx Drug Formulary, GA = GenericsAdvantageRx Drug Formulary.
GENERIC NAME Label Name PRx
Current GA Current New Status
TADALAFIL TADALAFIL 2.5 MG TABLET F QL F PA QL F QL
TOCILIZUMAB ACTEMRA 162 MG/0.9 ML SYRINGE S F PA QL S F PA S F PA QL
TOLMETIN SODIUM TOLMETIN SODIUM 200 MG TAB NF F PA F PA
TOLMETIN SODIUM TOLMETIN SODIUM 400 MG CAP NF F PA F PA
TOLMETIN SODIUM TOLMETIN SODIUM 600 MG TAB NF F PA F PA
TOLVAPTAN JYNARQUE 15 MG TABLET S-NF PA S-NF PA S-NF PA
TOLVAPTAN JYNARQUE 15 MG-15 MG TABLET S-NF PA S-NF PA S-NF PA
TOLVAPTAN JYNARQUE 30 MG TABLET S-NF PA S-NF PA S-NF PA
TOLVAPTAN JYNARQUE 30 MG-15 MG TABLET S-NF PA S-NF PA S-NF PA
TOLVAPTAN JYNARQUE 45 MG-15 MG TABLET S-NF PA S-NF PA S-NF PA
TOLVAPTAN JYNARQUE 60 MG-30 MG TABLET S-NF PA S-NF PA S-NF PA
TOLVAPTAN JYNARQUE 90 MG-30 MG TABLET S-NF PA S-NF PA S-NF PA
TOLVAPTAN TOLVAPTAN 15 MG TABLET S NF PA S NF S NF PA
TOREMIFENE CITRATE FARESTON 60 MG TABLET NF NF NF PA
TOREMIFENE CITRATE TOREMIFENE CITRATE 60 MG TAB NF NF F PA
TRAMADOL HCL TRAMADOL ER 100 MG TABLET NF PA QL AGE
NF PA QL AGE
F-PA-QL-Age
TRAMADOL HCL TRAMADOL ER 200 MG TABLET NF PA QL AGE
NF PA QL AGE
F-PA-QL-Age
TRAMADOL HCL TRAMADOL ER 300 MG TABLET NF PA QL AGE
NF PA QL AGE
F-PA-QL-Age
Formulary Update, page 21 of 22
Formulary Abbreviations: F = Formulary, NF = Non-Formulary, PA = Prior Authorization, ST = Step Therapy, NC = Not Covered, SP = Specialty Drug, QL = Quantity Limit. MED = covered as a medical claim. A current formulary status is not shown for new medications. PRx = PreferredRx Drug Formulary, GA = GenericsAdvantageRx Drug Formulary.
GENERIC NAME Label Name PRx
Current GA Current New Status
TRAMADOL HCL TRAMADOL HCL ER 100 MG CAPSULE
NF PA NF PA F-PA
TRAMADOL HCL TRAMADOL HCL ER 100 MG TABLET NF PA NF PA F-PA
TRAMADOL HCL TRAMADOL HCL ER 150 MG CAPSULE
NF PA NF PA F-PA
TRAMADOL HCL TRAMADOL HCL ER 200 MG CAPSULE
NF PA NF PA F-PA
TRAMADOL HCL TRAMADOL HCL ER 200 MG TABLET NF PA NF PA F-PA
TRAMADOL HCL TRAMADOL HCL ER 300 MG CAPSULE
NF PA NF PA F-PA
TRAMADOL HCL TRAMADOL HCL ER 300 MG TABLET NF PA NF PA F-PA
TRASTUZUMAB HERCEPTIN 150 MG VIAL MED PA MED PA MED PA
TRASTUZUMAB-ANNS KANJINTI 150 MG VIAL MED PA MED PA MED PA
TRASTUZUMAB-ANNS KANJINTI 420 MG VIAL MED PA MED PA MED PA
TRASTUZUMAB-DKST OGIVRI 150 MG VIAL MED PA MED PA MED PA
TRASTUZUMAB-DKST OGIVRI 420 MG VIAL MED PA MED PA MED PA
TRASTUZUMAB-DTTB ONTRUZANT 150 MG VIAL MED PA MED PA MED PA
TRASTUZUMAB-DTTB ONTRUZANT 420 MG VIAL MED PA MED PA MED PA
TRASTUZUMAB-HYALURONIDASE-OYSK
HERCEPTIN HYLECTA 600MG-10,000
MED PA MED PA MED PA
TRASTUZUMAB-PKRB HERZUMA 150 MG VIAL MED PA MED PA MED PA
TRASTUZUMAB-PKRB HERZUMA 420 MG VIAL MED PA MED PA MED PA
TRASTUZUMAB-QYYP TRAZIMERA 150 MG VIAL MED PA MED PA MED PA
TRASTUZUMAB-QYYP TRAZIMERA 420 MG VIAL MED PA MED PA MED PA
VARDENAFIL HCL VARDENAFIL HCL 10 MG TABLET NF PA EXCL NF PA
VARDENAFIL HCL VARDENAFIL HCL 2.5 MG TABLET NF PA EXCL NF PA
VARDENAFIL HCL VARDENAFIL HCL 20 MG TABLET NF PA EXCL NF PA
VARDENAFIL HCL VARDENAFIL HCL 5 MG TABLET NF PA EXCL NF PA
Formulary Update, page 22 of 22
Formulary Abbreviations: F = Formulary, NF = Non-Formulary, PA = Prior Authorization, ST = Step Therapy, NC = Not Covered, SP = Specialty Drug, QL = Quantity Limit. MED = covered as a medical claim. A current formulary status is not shown for new medications. PRx = PreferredRx Drug Formulary, GA = GenericsAdvantageRx Drug Formulary.
GENERIC NAME Label Name PRx
Current GA Current New Status
VIGABATRIN SABRIL 500 MG TABLET S NF S NF PA S NF PA
ZAFIRLUKAST ZAFIRLUKAST 10 MG TABLET NF NF F-PA
ZAFIRLUKAST ZAFIRLUKAST 20 MG TABLET NF NF F-PA
ZILEUTON ZILEUTON ER 600 MG TABLET NF PA QL NF PA QL F-PA-QL
ZOLPIDEM TARTRATE ZOLPIDEM TART ER 12.5 MG TAB F STEP NF F STEP
ZOLPIDEM TARTRATE ZOLPIDEM TART ER 6.25 MG TAB F STEP NF F STEP