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Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program Lower Case = generic drug INJ Injectable ST Step Therapy
Disclaimer: This information is confidential and proprietary and may not be reproduced or disclosed in whole or part unless authorized in
writing by an authorized representative of Pharmacy Data Management, Inc. v. 2019-01
Prime Detailed Formulary
Guide
v. 2019
2
Prime Detailed Formulary Guide
The Prime Formulary Guide outlines the tier coverage and suggested limitations of the most commonly prescribed medications. A formulary is the list of drugs available for certain conditions and organized by tiers (cost levels).
Drug Tier Types of Drugs Included Cost
1 Generic Drugs Lowest Copay
2 Preferred Brand Name Drugs Medium Copay
3 Non-Preferred Brand Name Drugs Higher Copay
Limits Description
INJ – Injectable Drug Product is administered via an injectable route of administration and may be subject to a separate benefit.
QL – Quantity Limit Drug is subject to a specific quantity per days supply due to patient safety or cost containment measures.
SP – Specialty Program Drug is designated as a specialty drug and may be subject to a separate specialty benefit.
ST – Step Therapy A more cost-effective option must be tried before a Step Therapy drug may be covered.
Preferred and non-preferred brand name medications are listed to help identify clinically appropriate and cost-effective options within drug categories. Unless specifically indicated, drug list products will include all dosage forms. This is not an all-inclusive list and does not guarantee coverage. Medications listed may change to a lower tier at any time. Medications may also be moved to non-preferred status twice a year on January 1 and July 1. A brand-name drug for which a generic product becomes available may be designated as a non-preferred option upon release of the generic product to the market. Products recently approved by the U.S. Food and Drug Administration (FDA) may not be covered upon release to the market. When a medication changes tiers, the member may have to pay a different amount for that medication. The member's specific prescription benefit plan design may not cover certain products or categories regardless of their appearance in this document. For the most up-to-date list call customer service at the toll-free member phone number on the ID card. Need assistance finding a drug on this formulary guide? An alphabetical index is included at the end of the formulary listing. You may also press Control + F to search for the product name.
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
3
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS
ADDERALL 3
ADDERALL XR 3
ADIPEX-P 3
ADZENYS ER 3
ADZENYS XR-ODT 3
amphetamine sulfate 1
amphetamine/dextroampheta 1
APTENSIO XR 3
armodafinil 1
atomoxetine 1
atomoxetine hydrochloride 1
BELVIQ 3
BELVIQ XR 3
caffeine citrate 1
clonidine hcl er 1
clonidine hydrochloride 1
clonidine hydrochloride e 1
CONCERTA 3
CONTRAVE 3
COTEMPLA XR-ODT 3
DAYTRANA 2
dexmethylphenidate hcl 1
dexmethylphenidate hcl er 1
dexmethylphenidate hydroc 1
dextroamphetamine sulfate 1
diethylpropion hcl 1
diethylpropion hcl er 1
DYANAVEL XR 3
EVEKEO 2
FOCALIN 3
FOCALIN XR 3
guanfacine er 1
guanfacine hydrochloride 1
INTUNIV 3
LOMAIRA 3
metadate er 1
methamphetamine hcl 1
METHYLIN 3
methylphenid cap 30mg er 1
METHYLPHENID CAP 60MG LA 2
modafinil 1
MYDAYIS 2
NUVIGIL 3
phendimetrazine tartrate 1
phentermine hcl 1
PROVIGIL 3
QSYMIA 3
QUILLICHEW ER 2
QUILLIVANT XR 2
RITALIN 3
RITALIN LA 3
SAXENDA 3 INJ
STRATTERA 3
VYVANSE 2
ZENZEDI 3
ALLERGENIC EXTRACTS/BIOLOGICALS MISC
GRASTEK 2
ODACTRA 2
RAGWITEK 2
Amebicides
SOLOSEC 3
Aminoglycosides
gentamicin sulfate 1 INJ
neomycin sulfate 1
paromomycin sulfate 1
TOBI PODHALER 2 SP
tobramycin 1 SP
ANALGESICS - ANTI-INFLAMMATORY
ACTEMRA 2 INJ SP
ARTHROTEC 75 3
CELEBREX 3
celecoxib 1
diclofenac potassium 1
diclofenac sodium dr 1
diclofenac sodium er 1
diclofenac sodium/misopro 1
DUEXIS 3
ENBREL 2 INJ SP
ENBREL MINI 2 INJ SP
ENBREL SURECLICK 2 INJ SP
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
4
etodolac 1
etodolac er 1
fenoprofen tab 600mg 1
FENOPROFEN CAP 400MG 3
FENORTHO 3
flurbiprofen 1
HUMIRA 2 INJ SP
HUMIRA PEDIATRIC CROHNS D 2 INJ SP
HUMIRA PEN 2 INJ SP
HUMIRA PEN-CD/UC/HS START 2 INJ SP
HUMIRA PEN-PS/UV STARTER 2 INJ SP
ibu 1
ibuprofen 1
ILARIS 2 INJ SP
INDOCIN 3
indomethacin 1
indomethacin er 1
KETOPROFEN 3
ketoprofen er 1
ketorolac tromethamine 1 QL
KEVZARA 3 INJ SP
KINERET 3 INJ SP
leflunomide 1
meclofenamate sodium 1
mefenamic acid 1
meloxicam 1
nabumetone 1
NAPRELAN 3
naproxen 1
naproxen dr 1
naproxen sodium 1
naproxen sodium cr 1
naproxen sodium er 1
OLUMIANT 3 SP
ORENCIA 3 INJ SP
ORENCIA CLICKJECT 3 INJ SP
OTEZLA 2 SP
OTREXUP 2 INJ
oxaprozin 1
piroxicam 1
RASUVO 2 INJ
RIDAURA 2
SIMPONI INJ 100MG/ML 2 INJ SP
SIMPONI INJ 50/0.5ML 3 INJ SP
SIMPONI ARIA 3 INJ SP
SPRIX 3
sulindac 1
TIVORBEX 3
tolmetin sodium 1
VIMOVO 3
VIVLODEX 3
XELJANZ 2 SP
XELJANZ XR 2 SP
ZIPSOR 3
ZORVOLEX 3
ANALGESICS - NonNarcotic
bupap 1
butalbital/acetaminophen 1
butalbital/acetaminophen/ 1
BUT/ASA/CAF TAB 2
diflunisal 1
esgic 1
FIORICET 3
FIORINAL 3
salsalate 1
VANATOL LQ 3
ANALGESICS - OPIOID
ABSTRAL 3
acetaminophen/caffeine/di 1
acetaminophen/codeine 1
acetaminophen/codeine #3 1
acetaminophen/codeine pho 1
ARYMO ER 3
ascomp/codeine 1
BELBUCA 2
BUNAVAIL 3
BUPRENORPHINE 3
buprenorphine hcl 1
buprenorphine hcl/naloxon 1
buprenorphine hydrochlori 1
but/asa/caf/ cap cod 30mg 1
butorphanol tartrate 1 QL
BUTRANS 2
codeine sulfate 1
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
5
CONZIP 3
DURAGESIC 3
EMBEDA 3
endocet 1
fentanyl 1
fentanyl citrate 1 INJ
fentanyl citrate oral tra 1
FENTORA 3
hydrocodone bitartrate/ac 1
hydrocodone/acetaminophen 1
hydrocodone/ibuprofen 1
hydromorphone hcl 1
hydromorphone hcl dosette 1 INJ
hydromorphone hcl er 1
HYSINGLA ER 2
IBUDONE 3
LEVORPHANOL TARTRATE 2
lorcet 1
lorcet hd 1
lorcet plus 1
LORTAB 3
meperidine hcl 1
METHADONE SOL 5MG/5ML 2
methadone tab 10mg 1
MORPHABOND ER 3
morphine sulfate 1
morphine sulfate er 1
NORCO 3
NUCYNTA 2
NUCYNTA ER 2
OXAYDO 3
oxycodone hcl 1
OXYCODONE HCL ER 3
oxycodone hydrochloride 1
oxycodone/acetaminophen 1
oxycodone/aspirin 1
OXYCONTIN 2
oxymorphone hydrochloride 1
pentazocine/naloxone hcl 1
PERCOCET 3
ROXICODONE 3
SUBOXONE 2
tramadol hcl 1
tramadol hcl tab 200mg er 1
TRAMADOL HCL CAP 150MG ER 3
tramadol hydrochloride/ac 1
TYLENOL/CODEINE #3 3
TYLENOL/CODEINE #4 3
ULTRAM 3
vicodin 1
vicodin es 1
vicodin hp 1
XTAMPZA ER 3
ZOHYDRO ER 3
ZUBSOLV 2
ANDROGENS-ANABOLIC
ANDRODERM 2
ANDROGEL GEL 1%(50MG) 3
ANDROGEL GEL 1.62% 2
ANDROGEL PUMP 2
AVEED 3 INJ SP
danazol 1
DEPO-TESTOSTERONE 3 INJ
FORTESTA 3
methyltestosterone 1
NATESTO 3
oxandrolone 1
STRIANT 3
TESTIM 3
TESTOPEL 3 INJ SP
testosterone cypionate 1 INJ
testosterone enanthate 1 INJ
testosterone topical solu 1
ANORECTAL AGENTS
ANALPRAM HC 3
ANALPRAM HC SINGLES 3
ANALPRAM-HC 3
anucort-hc 1
anusol-hc 1
colocort 1
CORTIFOAM 3
hemmorex-hc 1
hydrocortisone acetate 1
hydrocortisone acetate/pr 1
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
6
lidocaine hcl/hydrocortis 1
PROCTOCORT 3
PROCTOFOAM HC 3
procto-med hc 1
procto-pak 1
proctosol hc 1
proctozone-hc 1
RECTIV 2
UCERIS AER 2MG/ACT 3
Anthelmintics
albendazole 1
ALBENZA 2
BILTRICIDE 3
EMVERM 2
ivermectin 1
praziquantel 1
STROMECTOL 3
ANTIANGINAL AGENTS
isosorbide dinitrate 1
isosorbide mononitrate 1
isosorbide mononitrate er 1
NITRO-BID 2
NITRO-DUR 3
nitroglycerin 1
nitroglycerin er 1
nitroglycerin lingual 1
nitroglycerin transdermal 1
NITROSTAT 3
nitro-time 1
RANEXA 2
ANTIANXIETY AGENTS
alprazolam 1
alprazolam er 1
alprazolam odt 1
alprazolam xr 1
ATIVAN 3
buspirone hcl 1
buspirone hydrochloride 1
chlordiazepoxide hcl 1
clorazepate dipotassium 1
diazepam 1
diazepam intensol 1
hydroxyzine hcl 1
hydroxyzine hydrochloride 1
hydroxyzine pamoate 1
lorazepam 1
lorazepam intensol 1
oxazepam 1
VALIUM 3
XANAX 3
ANTIARRHYTHMICS
amiodarone hcl 1
amiodarone hydrochloride 1
disopyramide phosphate 1
dofetilide 1
flecainide acetate 1
mexiletine hcl 1
MULTAQ 3
NORPACE CR 3
pacerone 1
propafenone hcl 1
propafenone hcl er 1
propafenone hydrochloride 1
quinidine gluconate cr 1
RYTHMOL SR 3
TIKOSYN 3
ANTIASTHMATIC AND BRONCHODILATOR AGENTS
ADVAIR DISKUS 2
ADVAIR HFA 2
AIRDUO RESPICLICK 113/14 3
AIRDUO RESPICLICK 232/14 3
AIRDUO RESPICLICK 55/14 3
albuterol sulfate 1
albuterol sulfate er 1
ALVESCO 3
ANORO ELLIPTA 2
ARCAPTA NEOHALER 2
ARNUITY ELLIPTA 2
ASMANEX HFA 2
ASMANEX TWISTHALER 120 ME 2
ASMANEX TWISTHALER 14 MET 2
ASMANEX TWISTHALER 30 MET 2
ASMANEX TWISTHALER 60 MET 2
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
7
ATROVENT HFA 2
BEVESPI AEROSPHERE 2
BREO ELLIPTA 2
BROVANA 3
budesonide 1
COMBIVENT RESPIMAT 2
cromolyn sodium 1
DALIRESP 2
DULERA 2
FASENRA 2 INJ SP
FLOVENT DISKUS 2
FLOVENT HFA 2
FLUTICASONE PROPIONATE/SA 2
INCRUSE ELLIPTA 2
ipratropium bromide/albut 1
levalbuterol 1
levalbuterol hcl 1
levalbuterol hydrochlorid 1
LEVALBUTEROL TARTRATE HFA 3
montelukast sodium 1
NUCALA 2 INJ SP
PERFOROMIST 2
PROAIR HFA 2
PROAIR RESPICLICK 2
PROVENTIL HFA 3
PULMICORT 3
PULMICORT FLEXHALER 2
QVAR REDIHALER 2
SEEBRI NEOHALER 2
SEREVENT DISKUS 2
SINGULAIR 3
SPIRIVA HANDIHALER 2
SPIRIVA RESPIMAT 2
STIOLTO RESPIMAT 2
STRIVERDI RESPIMAT 2
SYMBICORT 2
terbutaline sulfate 1
THEO-24 3
theophylline er 1
TRELEGY ELLIPTA 2
TUDORZA PRESSAIR 2
UTIBRON NEOHALER 2
VENTOLIN HFA 2
XOLAIR 2 INJ SP
XOPENEX 3
XOPENEX HFA 3
zafirlukast 1
zileuton er 1
ZYFLO 3 ST
ZYFLO CR 3 ST
ANTICOAGULANTS
COUMADIN 3
ELIQUIS 2
ELIQUIS STARTER PACK 2
enoxaparin sodium 1 INJ
fondaparinux sodium 1 INJ SP
FRAGMIN 2 INJ SP
heparin lock flush 1 INJ
heparin lock flush/nacl f 1 INJ
heparin sodium 1 INJ
heparin sodium dcu 1 INJ
heparin sodium lock flush 1 INJ
HEPARIN SODIUM/SODIUM CHL 3 INJ
jantoven 1
LOVENOX 3 INJ
PRADAXA 3
SAVAYSA 3
warfarin sodium 1
XARELTO 2
XARELTO STARTER PACK 2
ANTICONVULSANTS
APTIOM 3
BANZEL 2
BRIVIACT 3
carbamazepine 1
carbamazepine er 1
CARBATROL 3
CELONTIN 2
clobazam 1
clonazepam 1
clonazepam odt 1
DEPAKOTE 3
DEPAKOTE ER 3
DIASTAT ACUDIAL 3
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
8
DIAZEPAM RECTAL GEL 2
DILANTIN CAP 100MG 3
DILANTIN CAP 30MG 2
DILANTIN INFATABS 3
divalproex sodium 1
divalproex sodium dr 1
divalproex sodium er 1
epitol 1
ethosuximide 1
felbamate 1
FYCOMPA 2
gabapentin 1
KEPPRA 3
KEPPRA XR 3
KLONOPIN 3
LAMICTAL 3
LAMICTAL ODT 3
LAMICTAL XR 3
lamotrigine 1
lamotrigine er 1
lamotrigine odt 1
lamotrigine starter kit/o 1
levetiracetam 1
levetiracetam er 1
LYRICA 2
MYSOLINE 3
NEURONTIN 3
ONFI 2
oxcarbazepine 1
OXTELLAR XR 3
PHENYTEK 3
phenytoin 1
phenytoin infatabs 1
phenytoin sodium extended 1
primidone 1
QUDEXY XR 2
SABRIL 2 SP
SPRITAM 3
subvenite 1
TEGRETOL 3
TEGRETOL-XR 3
tiagabine hydrochloride 1
TOPAMAX 3
TOPAMAX SPRINKLE 3
topiramate 1
TOPIRAMATE ER 3
TRILEPTAL 3
TROKENDI XR 3
valproic acid 1
vigabatrin 1 SP
VIMPAT 2
ZARONTIN 3
ZONEGRAN 3
zonisamide 1
ANTIDEPRESSANTS
amitriptyline hcl 1
amitriptyline hydrochlori 1
APLENZIN 3 ST
bupropion hcl 1
bupropion hcl er 1
bupropion hcl sr 1
bupropion hcl xl 1
bupropion hydrochloride 1
bupropion hydrochloride e 1
bupropion hydrochloride s 1
bupropion hydrochloride x 1
CELEXA 3
citalopram 1
citalopram hydrobromide 1
clomipramine hcl 1
CYMBALTA 3
desipramine hcl 1
desipramine hydrochloride 1
desvenlafax tab 100mg er 1
DESVENLAFAX TAB 50MG ER 3
doxepin hcl 1
duloxetine hcl 1
duloxetine hydrochloride 1
EFFEXOR XR 3
EMSAM 3
escitalopram oxalate 1
FETZIMA 2 ST
FETZIMA TITRATION PACK 2 ST
fluoxetine dr 1
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
9
fluoxetine hcl 1
fluoxetine tab 10mg 1
FLUOXETINE TAB 60MG 2
fluvoxamine maleate 1
fluvoxamine maleate er 1
FORFIVO XL 3
imipramine hcl 1
imipramine hydrochloride 1
imipramine pamoate 1
LEXAPRO 3
maprotiline hcl 1
MARPLAN 3
mirtazapine 1
mirtazapine odt 1
nefazodone hcl 1
nefazodone hydrochloride 1
nortriptyline hcl 1
paroxetine hcl 1
paroxetine hcl er 1
paroxetine hydrochloride 1
PAXIL 3
PAXIL CR 3
phenelzine sulfate 1
PRISTIQ 3
protriptyline hcl 1
PROZAC 3
REMERON 3
sertraline hcl 1
sertraline hydrochloride 1
tranylcypromine sulfate 1
trazodone hydrochloride 1
trimipramine maleate 1
TRINTELLIX 3 ST
venlafaxine hcl 1
venlafaxine hcl er 1
venlafaxine hydrochloride 1
VIIBRYD 2 ST
VIIBRYD STARTER PACK 2 ST
WELLBUTRIN SR 3
WELLBUTRIN XL 3
ZOLOFT 3
ANTIDIABETICS
acarbose 1
ACTOPLUS MET XR 3
ADLYXIN 3 INJ
ADLYXIN STARTER PACK 3 INJ
ADMELOG 3 INJ
ADMELOG SOLOSTAR 3 INJ
AFREZZA 3
ALOGLIPTIN 3 ST
ALOGLIPTIN/METFORMIN HCL 3 ST
ALOGLIPTIN/PIOGLITAZONE 3
AMARYL 3
APIDRA 3 INJ
APIDRA SOLOSTAR 3 INJ
AVANDIA 3
BASAGLAR KWIKPEN 3 INJ
BYDUREON 2 INJ
BYDUREON BCISE 2 INJ
BYDUREON PEN 2 INJ
BYETTA 2 INJ
chlorpropamide 1
CYCLOSET 3
FARXIGA 2
FIASP 2 INJ
FIASP FLEXTOUCH 2 INJ
glimepiride 1
glipizide 1
glipizide er 1
glipizide xl 1
glipizide/metformin hcl 1
GLUCAGEN HYPOKIT 2 INJ
GLUCAGON EMERGENCY KIT 2 INJ
GLUCOPHAGE 3
GLUCOPHAGE XR 3
GLUCOTROL XL 3
GLUMETZA 3
glyburide 1
glyburide micronized 1
glyburide/metformin hcl 1
GLYXAMBI 2
HUMALOG 2 INJ
HUMALOG JUNIOR KWIKPEN 2 INJ
HUMALOG KWIKPEN 2 INJ
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
10
HUMALOG MIX 50/50 KWIKPEN 2 INJ
HUMALOG MIX 75/25 2 INJ
HUMALOG MIX 75/25 KWIKPEN 2 INJ
HUMULIN R U-500 (CONCENTR 2 INJ
HUMULIN R U-500 KWIKPEN 2 INJ
INVOKAMET 2
INVOKAMET XR 2
INVOKANA 2
JANUMET 2
JANUMET XR 2
JANUVIA 2
JARDIANCE 2
JENTADUETO 2
JENTADUETO XR 2
KAZANO 3 ST
KOMBIGLYZE XR 3 ST
LANTUS 2 INJ
LANTUS SOLOSTAR 2 INJ
LEVEMIR 2 INJ
LEVEMIR FLEXTOUCH 2 INJ
metformin hcl 1
metformin hcl er 1
metformin hydrochloride 1
metformin hydrochloride e 1
miglitol 1
nateglinide 1
NESINA 3 ST
NOVOLOG 2 INJ
NOVOLOG FLEXPEN 2 INJ
NOVOLOG MIX 70/30 2 INJ
NOVOLOG MIX 70/30 PREFILL 2 INJ
NOVOLOG PENFILL 2 INJ
ONGLYZA 3 ST
OSENI 3
OZEMPIC 2 INJ
pioglitazone hcl 1
pioglitazone hcl/metformi 1
PROGLYCEM 2
QTERN 3
repaglinide 1
RIOMET 3
SEGLUROMET 2
SOLIQUA 100/33 2 INJ
STEGLATRO 2
STEGLUJAN 3
SYMLINPEN 120 2 INJ
SYMLINPEN 60 2 INJ
SYNJARDY 2
SYNJARDY XR 2
TOUJEO MAX SOLOSTAR 2 INJ
TOUJEO SOLOSTAR 2 INJ
TRADJENTA 2
TRESIBA FLEXTOUCH 2 INJ
TRULICITY 2 INJ
VICTOZA 2 INJ
XIGDUO XR 2
XULTOPHY 100/3.6 2 INJ
ANTIDIARRHEAL/PROBIOTIC AGENTS
diphenoxylate/atropine 1
loperamide hcl 1
MOTOFEN 3
MYTESI 3
opium 1
opium tincture 1
paregoric 1
RESTORA RX 3
VSL#3 DS 3
Antidotes and Specific Antagonists
CHEMET 2
EXJADE 2 SP
JADENU 2 SP
JADENU SPRINKLE 2 SP
naloxone hcl 1 INJ
naltrexone hcl 1
NARCAN 2
VIVITROL 2 INJ SP
ANTIEMETICS
AKYNZEO 2
aprepitant 1 QL
BONJESTA 3
DICLEGIS 3
dronabinol 1
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
11
EMEND 3 QL
granisetron hcl 1
meclizine hcl 1
meclizine hydrochloride 1
ondansetron hcl 1
ondansetron hydrochloride 1
ondansetron odt 1
SANCUSO 2
TRANSDERM-SCOP 3
trimethobenzamide hcl 1
VARUBI 2
ZOFRAN 3
ZUPLENZ 3
Antifungals
ABELCET 2 INJ
amphotericin b 1 INJ
CRESEMBA 2 SP
DIFLUCAN 3
fluconazole 1
griseofulvin microsize 1
griseofulvin ultramicrosi 1
itraconazole 1
ketoconazole 1
NOXAFIL 2
nystatin 1
SPORANOX 2
terbinafine hcl 1
terbinafine hydrochloride 1
voriconazole 1 INJ
ANTIHISTAMINES
carbinoxamine maleate 1
CLARINEX 3
clemastine fumarate 1
cyproheptadine hcl 1
desloratadine 1
desloratadine odt 1
diphenhydramine hcl 1
levocetirizine dihydrochl 1
phenadoz 1
promethazine hcl 1
promethazine hcl plain 1
promethazine hydrochlorid 1
promethegan 1
ryvent 1
ANTIHYPERLIPIDEMICS
ANTARA 3
atorvastatin calcium 1
cholestyramine 1
cholestyramine light 1
colesevelam hydrochloride 1
COLESTID 3
colestipol hcl 1
CRESTOR 3
ezetimibe 1
ezetimibe/simvastatin 1
fenofibrate tab 48mg 1
FENOFIBRATE CAP 50MG 3
fenofibrate micronized 1
FENOFIBRIC ACID 2
fenofibric acid dr 1
fluvastatin 1
fluvastatin sodium er 1
gemfibrozil 1
LESCOL XL 3
LIPITOR 3
LIPOFEN 2
LIVALO 2 ST
lovastatin 1
LOVAZA 3
niacin er 1
NIACOR 3
NIASPAN 3
omega-3-acid ethyl esters 1
PRALUENT 2 INJ SP
PRAVACHOL 3
pravastatin sodium 1
prevalite 1
QUESTRAN LIGHT 3
REPATHA 2 INJ SP
REPATHA PUSHTRONEX SYSTEM 2 INJ SP
REPATHA SURECLICK 2 INJ SP
rosuvastatin calcium 1
simvastatin 1
TRICOR 3
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
12
TRIGLIDE 3
TRILIPIX 3
VASCEPA 2
VYTORIN 3
WELCHOL 3
ZETIA 3
ANTIHYPERTENSIVES
ACCUPRIL 3
amlodipine besylate/benaz 1
amlodipine besylate/valsa 1
amlodipine/olmesartan med 1
amlodipine/valsartan/hctz 1
atenolol/chlorthalidone 1
AVAPRO 3
AZOR 3
benazepril hcl 1
benazepril hcl/hydrochlor 1
BENICAR 3
BENICAR HCT 3
bisoprolol fumarate/hydro 1
BYVALSON 2 ST
candesartan cilexetil 1
candesartan cilexetil/hyd 1
captopril 1
captopril/hydrochlorothia 1
CATAPRES-TTS-1 3
CATAPRES-TTS-3 3
clonidine hcl 1
COZAAR 3
DIOVAN 3
DIOVAN HCT 3
doxazosin mesylate 1
DUTOPROL 3
EDARBI 2 ST
EDARBYCLOR 2 ST
enalapril maleate 1
enalapril maleate/hydroch 1
EPANED 3
eplerenone 1
eprosartan mesylate 1
fosinopril sodium 1
fosinopril sodium/hydroch 1
guanfacine hcl 1
hydralazine hcl 1
HYZAAR 3
irbesartan 1
irbesartan/hydrochlorothi 1
lisinopril 1
lisinopril/hydrochlorothi 1
losartan potassium 1
losartan potassium/hydroc 1
LOTREL 3
methyldopa 1
methyldopa/hydrochlorothi 1
metoprolol/hydrochlorothi 1
MICARDIS 3
MICARDIS HCT 3
minoxidil 1
moexipril hcl 1
nadolol/bendroflumethiazi 1
olmesartan medoxomil 1
olmesartan medoxomil/amlo 1
olmesartan medoxomil/hydr 1
perindopril erbumine 1
prazosin hcl 1
propranolol/hydrochloroth 1
QBRELIS 3
quinapril hcl 1
quinapril hydrochloride 1
quinapril/hydrochlorothia 1
ramipril 1
TEKTURNA 2
TEKTURNA HCT 2
telmisartan 1
telmisartan/amlodipine 1
telmisartan/hydrochloroth 1
terazosin hcl 1
trandolapril 1
trandolapril/verapamil hc 1
TRIBENZOR 3
valsartan 1
valsartan/hydrochlorothia 1
ZESTRIL 3
Anti-infective Agents - Misc.
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
13
ALINIA 2
atovaquone 1
CAYSTON 2
clindamycin hcl 1
clindamycin hydrochloride 1
clindamycin palmitate hcl 1
dapsone 1
FIRST-METRONIDAZOLE 100 3
FIRST-METRONIDAZOLE 50 3
FIRST-VANCOMYCIN 25 3
FIRST-VANCOMYCIN 50 3
FIRVANQ 3
LINCOCIN 3 INJ
linezolid 1
meropenem 1 INJ
SIVEXTRO 3 SP
sulfamethoxazole/trimetho 1
sulfatrim pediatric 1
tinidazole 1
trimethoprim 1
vancomycin hcl 1 INJ
XIFAXAN 2
Antimalarials
atovaquone/proguanil hcl 1
chloroquine phosphate 1
COARTEM 2
hydroxychloroquine sulfat 1
MALARONE 3
mefloquine hcl 1
PLAQUENIL 3
quinine sulfate 1
Antimyasthenic/Cholinergic Agents
MESTINON TIMESPAN 3
pyridostigmine bromide 1
pyridostigmine bromide er 1
Antimycobacterial Agents
ethambutol hcl 1
isoniazid 1
PRIFTIN 2
rifabutin 1
rifampin 1
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES
AFINITOR 2 SP
ALECENSA 2 SP
ALUNBRIG 3 SP
anastrozole 1
AROMASIN 3
AVASTIN 2 INJ SP
azacitidine 1 INJ SP
bicalutamide 1
BOSULIF 2 SP
BRAFTOVI 3 SP
CABOMETYX 2 SP
capecitabine 1 SP
CAPRELSA 2 SP
CYCLOPHOSPH CAP 25MG 2
cyclophosph cap 50mg 1
ELIGARD 2 INJ SP
ERIVEDGE 2 SP
etoposide 1 SP
exemestane 1
FASLODEX 2 INJ SP
flutamide 1
GLEEVEC 3 SP
GLEOSTINE 2 SP
HERCEPTIN 2 INJ SP
hydroxyurea 1
IBRANCE 2 SP
ICLUSIG 2 SP
imatinib mesylate 1 SP
IMBRUVICA 2 SP
INLYTA 2 SP
INTRON A 2 INJ SP
JAKAFI 2 SP
KEYTRUDA 2 INJ SP
KISQALI 3 SP
KISQALI FEMARA 600 DOSE 3 SP
LENVIMA 12MG DAILY DOSE 2 SP
letrozole 1
leucovor ca tab 5mg 1
LEUCOVOR CA TAB 10MG 2
LEUKERAN 2
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
14
leuprolide acetate 1 INJ SP
LONSURF 2 SP
LUPRON DEPOT INJ 3.75MG 2 INJ SP
LUPRON DEPOT INJ 7.5MG 3 INJ SP
LUPRON DEPOT INJ 22.5MG 3 INJ SP
LUPRON DEPOT INJ 11.25MG 2 INJ SP
LUPRON DEPOT (4-MONTH) 3 INJ SP
LUPRON DEPOT (6-MONTH) 3 INJ SP
LYNPARZA 2 SP
MATULANE 2 SP
megestrol acetate 1
MEKINIST 2 SP
MEKTOVI 3 SP
mercaptopurine 1 SP
methotrexate 1
methotrexate sodium 1 INJ
NERLYNX 2 SP
NEXAVAR 2 SP
NINLARO 2 SP
OPDIVO 2 INJ SP
PERJETA 2 INJ SP
POMALYST 2 SP
PURIXAN 2 SP
RITUXAN 2 INJ SP
RUBRACA 2 SP
RYDAPT 2 SP
SPRYCEL 2 SP
STIVARGA 2 SP
SUTENT 2 SP
TABLOID 2 SP
TAFINLAR 2 SP
TAGRISSO 2 SP
TALZENNA 3 SP
tamoxifen citrate 1
TARCEVA 2 SP
TASIGNA 2 SP
temozolomide 1 SP
TREXALL 3
VELCADE 2 INJ SP
VENCLEXTA 2 SP
VENCLEXTA STARTING PACK 2 SP
VERZENIO 2 SP
VOTRIENT 2 SP
XALKORI 2 SP
XTANDI 2 SP
ZEJULA 2 SP
ZELBORAF 2 SP
ZOLADEX 2 INJ SP
ZYTIGA 2 SP
ANTIPARKINSON AND RELATED THERAPY AGENTS
amantadine hcl 1
APOKYN 2 INJ SP
AZILECT 3
benztropine mesylate 1
bromocriptine mesylate 1
carbidopa 1
carbidopa/levodopa 1
carbidopa/levodopa er 1
carbidopa/levodopa odt 1
CARB/LEVO 75 TAB /ENTACAP 2
carb/levo100 tab /entacap 1
entacapone 1
GOCOVRI 3 SP
MIRAPEX 3
NEUPRO 3
pramipexole dihydrochlori 1
rasagiline mesylate 1
REQUIP 3
REQUIP XL 3
ropinirole er 1
ropinirole hcl 1
RYTARY 3
selegiline hcl 1
trihexyphenidyl hcl 1
ANTIPSYCHOTICS/ANTIMANIC AGENTS
ABILIFY 3
ABILIFY MAINTENA 2 INJ
aripiprazole 1
aripiprazole odt 1
ARISTADA 2 INJ SP
chlorpromazine hcl 1 INJ
clozapine 1
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
15
CLOZAPINE TAB 200/ODT 3
clozapine tab 25mg odt 1
compro 1
FANAPT 3 ST
fluphenazine decanoate 1 INJ
fluphenazine hcl 1
GEODON 3
haloperidol 1
haloperidol decanoate 1 INJ
haloperidol lactate 1 INJ
INVEGA 3
INVEGA SUSTENNA 3 INJ
INVEGA TRINZA 3 INJ
LATUDA 2 ST
lithium carbonate 1
lithium carbonate er 1
loxapine 1
loxapine succinate 1
olanzapine 1
olanzapine odt 1
paliperidone er 1
perphenazine 1
prochlorperazine 1
prochlorperazine maleate 1
quetiapine fumarate 1
quetiapine fumarate er 1
REXULTI 3
RISPERDAL 3
RISPERDAL CONSTA 2 INJ
risperidone 1
risperidone odt 1
SAPHRIS 3
SEROQUEL 3
SEROQUEL XR 3
thioridazine hcl 1
thiothixene 1
trifluoperazine hcl 1
VRAYLAR 3 SP ST
ziprasidone hcl 1
ZYPREXA 3
ZYPREXA ZYDIS 3
Antiseptics & Disinfectants
formaldehyde 1
HYDROGEN PEROXIDE 2
ANTIVIRALS
abacavir 1 SP
abacavir/lamivudine 1 SP
acyclovir 1
atazanavir 1 SP
atazanavir sulfate 1 SP
ATRIPLA 2 SP
BARACLUDE 3 SP
BIKTARVY 2 SP
cidofovir 1 INJ SP
COMPLERA 2 SP
DESCOVY 2 SP
EDURANT 2 SP
efavirenz 1 SP
entecavir 1 SP
EPCLUSA 2 SP
EVOTAZ 3 SP
famciclovir 1
GENVOYA 2 SP
HARVONI 2 SP
ISENTRESS 2 SP
JULUCA 3 SP
KALETRA 2 SP
lamivudine 1 SP
lamivudine/zidovudine 1 SP
MAVYRET 2 SP
NORVIR 3 SP
ODEFSEY 2 SP
oseltamivir phosphate 1 QL
PEGASYS 2 INJ SP
PREZCOBIX 3 SP
PREZISTA 2 SP
RELENZA DISKHALER 2 QL
REYATAZ 3 SP
ribavirin 1 SP
ritonavir 1 SP
SITAVIG 3
STRIBILD 2 SP
SUSTIVA 3 SP
TAMIFLU 3 QL
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
16
tenofovir disoproxil fuma 1 SP
TIVICAY 2 SP
TRIUMEQ 2 SP
TRUVADA 2 SP
valacyclovir hcl 1
valacyclovir hydrochlorid 1
VALCYTE 3 SP
valganciclovir 1 SP
valganciclovir hydrochlor 1 SP
VALTREX 3
VEMLIDY 2 SP
VIREAD 3 SP
VOSEVI 2 SP
ZEPATIER 2 SP
zidovudine 1 SP
BETA BLOCKERS
acebutolol hcl 1
acebutolol hydrochloride 1
atenolol 1
BETAPACE 3
betaxolol hcl 1
bisoprolol fumarate 1
BYSTOLIC 2 ST
carvedilol 1
carvedilol phosphate 1
COREG 3
COREG CR 3
CORGARD 3
INDERAL LA 3
INDERAL XL 3 ST
INNOPRAN XL 3 ST
labetalol hcl 1
labetalol hydrochloride 1
metoprolol succinate er 1
metoprol tar tab 25mg 1
METOPROLOL TAB 75MG 2
nadolol 1
pindolol 1
propranolol hcl 1
propranolol hcl er 1
propranolol hydrochloride 1
sotalol hcl 1
sotalol hcl (af) 1
sotalol hydrochloride (af 1
sotalol hydrocholride 1
SOTYLIZE 2
TENORMIN 3
timolol maleate 1
TOPROL XL 3
Calcium Channel Blockers
amlodipine besylate 1
CARDIZEM LA 3
cartia xt 1
diltiazem hcl 1
diltiazem hcl cd 1
diltiazem hcl er 1
diltiazem hydrochloride e 1
dilt-xr 1
felodipine er 1
isradipine 1
matzim la 1
nifedipine 1
nifedipine er 1
nimodipine 1
nisoldipine er 1
NORVASC 3
PROCARDIA XL 3
taztia xt 1
TIAZAC 3
verapamil hcl 1
verapamil hcl er 1
verapamil hcl sr 1
verapamil hydrochloride 1
CARDIOTONICS
digitek 1
digox 1
digoxin 1
CARDIOVASCULAR AGENTS - MISC.
ADCIRCA 3 SP
ADEMPAS 2 SP
amlodipine besylate/atorv 1
BIDIL 3
CADUET 3
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
17
CAVERJECT IMPULSE 2 INJ QL
CIALIS 2 QL
CORLANOR 2
EDEX 3 INJ QL
ENTRESTO 2
LETAIRIS 2 SP
LEVITRA 3 QL ST
MUSE 2 QL
OPSUMIT 2 SP
ORENITRAM 3 SP
papaverine hcl 1 INJ
REMODULIN 2 INJ SP
REVATIO 3 SP
sildenafil 1 SP
sildenafil citrate 1 QL
STAXYN 3 QL ST
STENDRA 3 QL ST
tadalafil 1 QL
TRACLEER 2 SP
TYVASO 2 SP
TYVASO REFILL 2 SP
UPTRAVI 2 SP
vardenafil hydrochloride 1 QL
VIAGRA 3 QL
CEPHALOSPORINS
cefaclor 1
cefadroxil 1
cefdinir 1
cefepime 1 INJ
cefixime 1
cefpodoxime proxetil 1
cefprozil 1
ceftriaxone sodium 1 INJ
cefuroxime axetil 1
CEPHALEXIN TAB 250MG 2
cephalexin tab 500mg 1
SUPRAX 3
TEFLARO 2 INJ
CONTRACEPTIVES
altavera 1
alyacen 1/35 1
alyacen 7/7/7 1
amethia 1
amethia lo 1
amethyst 1
apri 1
aranelle 1
ashlyna 1
aubra 1
aubra eq 1
aviane 1
azurette 1
BALCOLTRA 3
balziva 1
bekyree 1
BEYAZ 3
blisovi 24 fe 1
blisovi fe 1.5/30 1
blisovi fe 1/20 1
briellyn 1
camila 1
camrese 1
camrese lo 1
caziant 1
chateal 1
cryselle-28 1
cyclafem 1/35 1
cyclafem 7/7/7 1
cyred 1
cyred eq 1
dasetta 1/35 1
dasetta 7/7/7 1
daysee 1
deblitane 1
DEPO-PROVERA CONTRACEPTIV 3 INJ
DEPO-SUBQ PROVERA 104 3 INJ
desogestrel/ethinyl estra 1
drospirenone/ethinyl estr 1
elinest 1
ELLA 3
emoquette 1
enpresse-28 1
enskyce 1
errin 1
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
18
estarylla 1
ESTROSTEP FE 3
ethynodiol diacetate/ethi 1
falmina 1
fayosim 1
femynor 1
GENERESS FE 3
gianvi 1
heather 1
introvale 1
isibloom 1
jencycla 1
jolessa 1
jolivette 1
juleber 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
kaitlib fe 1
kariva 1
kelnor 1/35 1
kelnor 1/50 1
kurvelo 1
KYLEENA 2
larin 1.5/30 1
larin 1/20 1
larin 24 fe 1
larin fe 1.5/30 1
larin fe 1/20 1
larissia 1
layolis fe 1
leena 1
lessina 1
levonest 1
levonorgestrel and ethiny 1
levonorgestrel/ethinyl es 1
levora 0.15/30-28 1
LILETTA 3
lillow 1
LO LOESTRIN FE 2
LOESTRIN 1.5/30-21 3
LOESTRIN 1/20-21 3
LOESTRIN FE 1.5/30 3
LOESTRIN FE 1/20 3
loryna 1
LOSEASONIQUE 3
low-ogestrel 1
lutera 1
lyza 1
marlissa 1
medroxyprogesterone aceta 1 INJ
melodetta 24 fe 1
mibelas 24 fe 1
microgestin 1.5/30 1
microgestin 1/20 1
microgestin fe 1
microgestin fe 1.5/30 1
mili 1
MINASTRIN 24 FE 3
MIRCETTE 3
MIRENA 2
mono-linyah 1
mononessa 1
myzilra 1
NATAZIA 3
necon 0.5/35-28 1
NEXPLANON 2 INJ
nikki 1
nora-be 1
norethindrone 1
norethindrone & ethinyl e 1
norethindrone acetate/eth 1
norethindrone/ethinyl est 1
norgestimate/ethinyl estr 1
norlyda 1
nortrel 0.5/35 (28) 1
nortrel 1/35 1
nortrel 7/7/7 1
NUVARING 2
ocella 1
ogestrel 1
orsythia 1
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
19
ORTHO MICRONOR 3
ORTHO TRI-CYCLEN LO 3
ORTHO-CYCLEN 3
ORTHO-NOVUM 1/35 3
PARAGARD INTRAUTERINE COP 3
philith 1
pimtrea 1
pirmella 1/35 1
pirmella 7/7/7 1
portia-28 1
previfem 1
QUARTETTE 3
quasense 1
rajani 1
reclipsen 1
rivelsa 1
SAFYRAL 3
SEASONIQUE 3
setlakin 1
sharobel 1
SKYLA 2
sprintec 28 1
sronyx 1
syeda 1
tarina fe 1/20 1
tarina fe 1/20 eq 1
TAYTULLA 2
tilia fe 1
tri femynor 1
tri-estarylla 1
tri-legest fe 1
tri-linyah 1
tri-lo-estarylla 1
tri-lo-marzia 1
tri-lo-sprintec 1
tri-previfem 1
tri-sprintec 1
trivora-28 1
tri-vylibra 1
tulana 1
tydemy 1
velivet 1
vienva 1
viorele 1
vyfemla 1
vylibra 1
wera 1
wymzya fe 1
XULANE 2
YASMIN 28 3
YAZ 3
zarah 1
zovia 1/35e 1
CORTICOSTEROIDS
betamethasone sodium phos 1 INJ
budesonide er 1
BUPIVILOG KIT 3 INJ
CORTEF 3
DEPO-MEDROL 3 INJ
DEXAMETHASON SOL 0.5/5ML 2
dexamethason tab 0.75mg 1
DEXAMETHASONE INTENSOL 2
DEXPAK 10 DAY 3
DEXPAK 6 DAY 3
EMFLAZA 3 SP
ENTOCORT EC 3
fludrocortisone acetate 1
hydrocortisone 1
KENALOG-10 3 INJ
KENALOG-40 3 INJ
MEDROL 3
MEDROL DOSEPAK 3
methylprednisolone 1
methylprednisolone acetat 1 INJ
methylprednisolone dose p 1
methylprednisolone sodium 1 INJ
MILLIPRED TAB 5MG 2
MILLIPRED SOL 10MG/5ML 3
ORAPRED ODT 3
PHYSICIANS EZ USE JOINT T 3
PHYSICIANS EZ USE M-PRED 3 INJ
prednisolone 1
prednisolone sol 15mg/5ml 1
PREDNISOLONE SOL 25MG/5ML 2
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
20
prednisone tab 20mg 1
PREDNISONE PAK 5MG 2
PREDNISONE INTENSOL 2
RAYOS 3
SOLU-CORTEF 2 INJ
SOLU-MEDROL 3 INJ
TAPERDEX 6-DAY 3
UCERIS TAB 9MG 2
VERIPRED 20 2
COUGH/COLD/ALLERGY
acetylcysteine 1
benzonatate 1
bromfed dm 1
bromphen/pseudoephedrine 1
CLARINEX-D 12 HOUR 3
GILTUSS TR 3
hydrocodone bitartrate/ch 1
hydrocodone bitartrate/ho 1
hydrocodone polistirex/ch 1
hydrocodone/homatropine 1
hydromet 1
HYPERSAL 3
nebusal 1
promethazine/codeine 1
promethazine/dextromethor 1
promethazine/phenylephrin 1
promethazine-dm 1
SEMPREX-D 3
SSKI 3
TUZISTRA XR 3
DERMATOLOGICALS
ABSORICA 2
ACANYA 2
acitretin 1 SP
ACUICYN DAILY EYELID & EY 2
ACZONE 3
adapalene 1
adapalene pump 1
adapalene/benzoyl peroxid 1
AKTIPAK 3
ALA SCALP 3
ALA-QUIN 3
alclometasone dipropionat 1
ALCORTIN A 3
ALDARA 3
ALEVICYN ANTIPRURITIC SG 3
ALTABAX 3
amcinonide 1
amnesteem 1
ARZOL SILVER NITRATE APP 2
ASTERO 3
augmented betamethasone d 1
avar cleanser 1
AVAR LS 3
AVAR LS CLEANSER 3
avar-e green 1
AVAR-E LS 3
AVENOVA 3
avita 1
AZELEX 3
BENSAL HP 3
BENZACLIN 3
BENZACLIN WITH PUMP 3
BENZEFOAM 3
BENZEFOAM ULTRA 3
benzepro 1
benzepro creamy wash 1
benzepro foaming cloths 1
benzepro short contact 1
betamethasone dipropionat 1
betamethasone valerate 1
BIAFINE 3
bimatoprost 1
BIONECT 3
BOTOX COSMETIC 3 INJ SP
bp 10-1 1
bp foam 1
bp wash 1
BPO 2
calcipotriene 1
calcipotriene/betamethaso 1
calcitrene 1
CAPEX 3
celacyn 1
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
21
CERACADE 3
ceramax 1
ciclopirox 1
ciclopirox nail lacquer 1
ciclopirox olamine 1
claravis 1
CLINDACIN PAC 3
CLINDAGEL 3
clindamycin phosphate 1
CLINDAMYCIN PHOSPHATE/BEN 3
clindamycin phosphate/tre 1
clindamycin/benzoyl perox 1
clobetasol propionate 1
clobetasol propionate e 1
clobetasol propionate emo 1
CLOBEX 3
CLOCORTOLONE PIVALATE 3
CLOCORTOLONE PIVALATE PUM 3
clodan 1
CLODERM 3
CLODERM PUMP 3
clotrimazole/betamethason 1
COAL TAR 2
CONDYLOX 3
CORDRAN 3
CORTISPORIN 3
COSENTYX 2 INJ SP
COSENTYX SENSOREADY PEN 2 INJ SP
DENAVIR 3
DERMACINRX LEXITRAL PHARM 3
dermacinrx prizopak 1
DERMACINRX ZRM PAK 3
DERMA-SMOOTHE/FS SCALP 3
DERMASORB HC 3
DERMASORB XM 3
dermazene 1
DESONATE 3
desonide 1
desoximetasone 1
diclofenac sodium 1
DIFFERIN 3
diflorasone diacetate 1
doxepin hydrochloride 1
DOXYCYCLINE CAP 40MG 3
DRITHO-CREME HP 2
DRYSOL 3
DUAC 3
DUPIXENT 2 INJ SP
econazole nitrate 1
ECOZA 3
EFUDEX 3
ELETONE 2
ELETONE TWINPACK 2
ELIDEL 2
ELOCON 3
EMULSION SB 2
ENSTILAR 2
ENTTY SPRAY EMULSION 3
EPICERAM 3
EPIDUO 3
EPIDUO FORTE 2
EPIFOAM 3
ERTACZO 3 ST
ery 1
erythromycin 1
erythromycin/benzoyl pero 1
ethyl chloride/medium jet 1
ethyl chloride/medium str 1
EUCRISA 3
FABIOR 3
FINACEA 2
FLECTOR 2
fluocinolone acetonide 1
fluocinolone acetonide bo 1
fluocinolone acetonide sc 1
fluocinonide 1
fluocinonide emulsified 1
fluocinonide emulsified b 1
FLUOROPLEX 3
fluorouracil 1
flurandrenolide 1
GENADUR 3
halobetasol propionate 1
HALOG 3
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
22
HPR PLUS 2
HPR PLUS HYDROGEL KIT 2
HYCLODEX 3
hydrocortisone acetate & 1
hydrocortisone butyrate 1
hydrocortisone butyrate ( 1
hydrocortisone valerate 1
hydrocortisone/iodoquinol 1
hydroquinone 1
hydroquinone time release 1
HYLATOPIC PLUS 3
imiquimod 1
IMIQUIMOD PUMP 3
IMPOYZ 3
isotretinoin 1
JUBLIA 3 ST
KAMDOY 3
KERALAC 3
KERALYT 3
KERALYT SCALP 3
KERYDIN 3 ST
LATISSE 3
LEVICYN 3
levicyn dermal spray 1
LEVULAN KERASTICK 3
lidocaine 1
LIDOCAINE AND TETRACAINE 3
lidocaine hcl 1
lidocaine hcl jelly 1
lidocaine/prilocaine 1
lidocaine-prilocaine-crea 1
LIDODERM 3
lidopril 1
LIDORX 3
LIDOTRAL 3
lidozion 1
LOCOID 3
LOYON 3
LULICONAZOLE 3 ST
LUXAMEND 2
LUXIQ 3
LUZU 3 ST
malathion 1
MENTAX 3
methoxsalen 1
METROGEL 3
metronidazole 1
MICORT-HC 3
MIRVASO 2
mometasone furoate 1
mupirocin 1
myorisan 1
naftifine hcl 1
naftifine hydrochloride 1
NAFTIN 3 ST
NATROBA 3
NEO-SYNALAR 3
NEUAC KIT 3
NIVATOPIC PLUS 2
nolix 1
NORITATE 3
NUVAIL 3
nyamyc 1
nystatin/triamcinolone 1
nystatin/triamcinolone ac 1
nystop 1
OLUX-E 3
ONEXTON 2
ORACEA 2
OVACE PLUS 3
OVACE PLUS WASH 3
OVACE WASH 3
oxiconazole nitrate 1
OXISTAT 3 ST
PENLAC NAIL LACQUER 3
PENNSAID 3
permethrin 1
PICATO 2
PLEXION 3
PLEXION CLEANSER 3
PODOCON 25 IN BENZOIN TIN 3
podofilox 1
PRAMOSONE 3
prednicarbate 1
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
23
PROMISEB 3
PROPECIA 3
PROTOPIC 3
PRUMYX 2
PSORCON 3
QBREXZA 3
RECEDO 2
REGENECARE 3
REGRANEX 2
RENOVA 3
RETIN-A 3
RETIN-A MICRO 3
RETIN-A MICRO PUMP 3
RHOFADE 3
RIAX 3
rosadan 1
SALEX 3
SALEX CREAM 3
SALEX LOTION 3
salicylic acid 1
salicylic acid er 1
salicylic acid wart remov 1
SANTYL 2
selenium sulfide 1
selenium sulfide shampoo 1
SERNIVO 3
SILIQ 3 INJ SP
SIL-K PAD/LARGE 3
SILVADENE 3
SILVASORB 2
silver sulfadiazine 1
SKLICE 3
sodium sulfacetamide wash 1
SOD SUL/SULF EMU 10-5% 2
sod sul/sulf pad 10-4% 1
SOOLANTRA 2
SORILUX 3
SPINOSAD 2
ssd 1
SSS 10-5 2
STELARA INJ 45MG/0.5 2 INJ SP
sulfacetamid lot 10% 1
sulfacetamide sodium/sulf 1
sulfacleanse 8/4 1
SUMADAN WASH 3
SUMAXIN 3
SYNALAR 3
SYNERA 3
SYNERDERM 3
TACLONEX 2
tacrolimus 1
TALTZ 3 INJ SP
tazarotene 1
TAZORAC GEL 0.1% 2
TAZORAC CRE 0.1% 3
TEMOVATE 3
TETRIX 3
TEXACORT 3
TOLAK 3
TOPICORT 3
TREMFYA 2 INJ SP
tretinoin 1
tretinoin microsphere 1
tretinoin microsphere pum 1
triamcinolone acetonide 1
TRIANEX 2
triderm 1
TRIDESILON 3
TRI-LUMA 3
ULESFIA 3
ULTRAVATE 3
urea 1
urea nail 1
URE-K 3
UTOPIC 3
VANIQA 3
vanoxide-hc 1
VECTICAL 3
VELTIN 3
VENELEX 3
VERDESO 3
VEREGEN 3
VIRASAL 3
VOLTAREN 3
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
24
VUSION 3
VYTONE 3
XERAC AC 3
XERESE 3
XEROFORM OCCLUSIVE PETROL 2
XOLEGEL 3 ST
XRYLIX 3
ZIANA 3
ZITHRANOL 3
ZONALON 3
ZOVIRAX 2
ZTLIDO 3
ZYCLARA 3
ZYCLARA PUMP 3
DIAGNOSTIC PRODUCTS
THYROGEN 2 INJ SP
TUBERSOL 2 INJ
DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS
CEREFOLIN NAC 3
DEPLIN 15 3
DEPLIN 7.5 3
ELFOLATE TAB 15MG 3
ELFOLATE TAB 7.5MG 2
ENLYTE 3
ENTERAGAM 3
folbic 1
FOLBIC RF 3
FOLTANX 2
FOLTANX RF 3
FOLTX 3
FOSTEUM PLUS 3
LEVOMEFOLATE CALCIUM ALGA 3
LEVOMEFOLATE CALCIUM/N-AC 3
LEVOMEFOLATE CALCIUM/PYRI 3
LIMBREL 3
L-METHYL-B6-B12 2
L-METHYLFOLATE 2
L-METHYLFOLATE CA/S-ALGAL 3
L-METHYLFOLATE CALCIUM 2
L-METHYLFOLATE FORTE 3
L-METHYL-MC NAC 2
MEBOLIC 3
METAFOLBIC PLUS 2
METAFOLBIC PLUS RF 3
METANX 3
NICAPRIN 3
niva-fol 1
PODIAPN 3
RHEUMATE 3
VASCULERA 3
VAYARIN 3
VAYARIN PLUS 3
VISBIOME 3
XYZBAC 3
ZYVIT 3
DIGESTIVE AIDS
CREON 2
PANCREAZE 3
PERTZYE 3
SUCRAID 2 SP
VIOKACE 2
ZENPEP 2
DIURETICS
acetazolamide 1
acetazolamide er 1
ALDACTAZIDE 3
ALDACTONE 3
amiloride hcl 1
amiloride/hydrochlorothia 1
bumetanide 1
CAROSPIR 3
chlorothiazide 1
chlorthalidone 1
DIURIL 3
DYAZIDE 3
DYRENIUM 3
ethacrynic acid 1
furosemide 1
hydrochlorothiazide 1
indapamide 1
LASIX 3
MAXZIDE 3
methazolamide 1
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
25
methyclothiazide 1
metolazone 1
spironolactone 1
spironolactone/hydrochlor 1
torsemide 1
triamterene/hydrochloroth 1
ENDOCRINE AND METABOLIC AGENTS - MISC.
ALENDRONATE TAB 40MG 2
alendronate tab 35mg 1
BONIVA 3
cabergoline 1
calcitonin salmon 1
calcitonin-salmon 1
calcitriol 1
CARNITOR 3
CETROTIDE 2 INJ SP
chorionic gonadotropin 1 INJ SP
clomiphene citrate 1
desmopressin acetate 1
doxercalciferol 1 SP
EVISTA 3
FABRAZYME 2 INJ SP
FOLLISTIM AQ 3 INJ SP
FORTEO 2 INJ SP
FOSAMAX PLUS D 3 ST
GANIRELIX ACETATE 3 INJ SP
GENOTROPIN 2 INJ SP
GENOTROPIN MINIQUICK 2 INJ SP
GONAL-F 2 INJ SP
GONAL-F RFF REDIJECT 2 INJ SP
H.P. ACTHAR 3 INJ SP
HUMATROPE 2 INJ SP
ibandronate sodium 1
KUVAN 2 SP
levocarnitine 1
LUPANETA PACK 3 SP
LUPRON DEPOT-PED (1-MONTH 2 INJ SP
LUPRON DEPOT-PED (3-MONTH 2 INJ SP
MENOPUR 2 INJ SP
NATPARA 2 INJ SP
NOCTIVA 3
NORDITROPIN FLEXPRO 2 INJ SP
NOVAREL 2 INJ SP
NUTROPIN AQ NUSPIN 10 3 INJ SP
NUTROPIN AQ NUSPIN 20 3 INJ SP
octreotide acetate 1 INJ SP
OMNITROPE 3 INJ SP
ORILISSA 3
OSPHENA 3
OVIDREL 2 INJ SP
paricalcitol 1 SP
PREGNYL W/DILUENT BENZYL 3 INJ SP
PROLIA 3 INJ SP
raloxifene hydrochloride 1
RAVICTI 2 SP
RAYALDEE 3
risedronate sodium 1
risedronate sodium dr 1
ROCALTROL 3
SANDOSTATIN LAR DEPOT 2 INJ SP
SENSIPAR 2 SP
SOMATULINE DEPOT 2 INJ SP
SOMAVERT 2 INJ SP
STIMATE 2 SP
SUPPRELIN LA 3 INJ SP
SYNAREL 2 SP
TYMLOS 2 INJ SP
XGEVA 2 INJ SP
zoledronic acid 1 INJ SP
ZOMACTON 3 INJ SP
Estrogens
ALORA 3
amabelz 1
ANGELIQ 3
CLIMARA 3
CLIMARA PRO 3
COMBIPATCH 2
DELESTROGEN 3 INJ
DEPO-ESTRADIOL 2 INJ
DIVIGEL 2
DUAVEE 2
eemt 1
eemt hs 1
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
26
esterified estrogens/meth 1
estradiol valerate 1 INJ
estradiol/norethindrone a 1
ESTROGEL 3
EVAMIST 3
fyavolv 1
jevantique lo 1
jinteli 1
lopreeza 1
MENEST 3
MENOSTAR 3
mimvey 1
MINIVELLE 2
PREMARIN 2
PREMPHASE 2
PREMPRO 2
VIVELLE-DOT 3
Fluoroquinolones
BAXDELA 3
CIPRO 3
ciprofloxacin er 1
ciprofloxacin hcl 1
ciprofloxacin hydrochlori 1
LEVAQUIN 3
levofloxacin 1
levofloxacin in d5w 1 INJ
moxifloxacin hcl 1
GASTROINTESTINAL AGENTS - MISC.
alosetron hydrochloride 1
AMITIZA 2
APRISO 3
ASACOL HD 2
AURYXIA 3
AZULFIDINE EN-TABS 3
balsalazide disodium 1
calcium acetate 1
CANASA 2
CIMZIA 3 INJ SP
CIMZIA STARTER KIT 3 INJ SP
DELZICOL 2
DIPENTUM 3
ENTYVIO 2 INJ SP
enulose 1
FOSRENOL 3
generlac 1
INFLECTRA 3 INJ SP
lanthanum carbonate 1
LIALDA 3
LINZESS 2
mesalamine 1
mesalamine dr 1
metoclopramide hcl 1
metoclopramide hydrochlor 1
METOCLOPRAMIDE ODT 2
MOVANTIK 2
OCALIVA 2 SP
PENTASA 2
RELISTOR 3 SPQL
REMICADE 2 INJ SP
RENAGEL 3
RENVELA 3
sevelamer carbonate 1
STELARA INJ 5MG/ML 3 INJ SP
sulfasalazine 1
SYMPROIC 2
TRULANCE 3
URSO 250 3
URSO FORTE 3
ursodiol 1
VELPHORO 2 SP
VIBERZI 2
XERMELO 2 SP
GENERAL ANESTHETICS
ketamine hcl 1 INJ
GENITOURINARY AGENTS - MISCELLANEOUS
acetic acid 0.25% 1
alfuzosin hcl er 1
AVODART 3 QL
CARDURA XL 3
dutasteride 1 QL
dutasteride/tamsulosin hc 1
dutasteride/tamsulosin hy 1
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
27
ELMIRON 2
finasteride 1
FLOMAX 3
JALYN 3
K-PHOS NO 2 3
ORACIT 3
phenazopyridine hcl 1
phenazopyridine hydrochlo 1
potassium citrate er 1
potassium citrate/citric 1
PROSCAR 3
PYRIDIUM 3
RAPAFLO 2
RIMSO-50 3 INJ
sodium chloride 0.9% 1
sodium chloride 0.9% 1
sodium citrate/citric aci 1
tamsulosin hcl 1
tamsulosin hydrochloride 1
THIOLA 3
tricitrates 1
UROCIT-K 10 3
Gout Agents
allopurinol 1
COLCHICINE CAP 0.6MG 3
COLCHICINE TAB 0.6MG 2
COLCRYS 2
KRYSTEXXA 2 INJ SP
MITIGARE 2
probenecid 1
probenecid/colchicine 1
ULORIC 2 ST
HEMATOLOGICAL AGENTS - MISC.
ADVATE 2 INJ SP
AGGRENOX 3
anagrelide hydrochloride 1
aspirin/dipyridamole 1
BENEFIX 2 INJ SP
BRILINTA 2
cilostazol 1
clopidogrel 1
dipyridamole 1
EFFIENT 3
ELOCTATE 3 INJ SP
FIRAZYR 2 INJ SP
IDELVION 3 INJ SP
pentoxifylline er 1
PLAVIX 3
prasugrel 1
RUCONEST 2 INJ SP
TAVALISSE 3 SP
YOSPRALA 3
ZONTIVITY 2
HEMATOPOIETIC AGENTS
ARANESP ALBUMIN FREE 2 INJ SP
CENTRATEX 2
CERDELGA 2 SP
chromagen 1
corvita 150 1
CORVITE FE 3
cyanocobalamin 1 INJ
DROXIA 2
EPOGEN 3 INJ SP
fabb 1
FERAHEME 2 INJ
FERIVA 21/7 3
ferocon 1
FERRALET 90 3
FERRAPLUS 90 2
folbee 1
folic acid/vitamin b-6/vi 1
FOLIVANE-F 2
FOLIVANE-PLUS 2
FUSION PLUS 3
GRANIX 2 INJ SP
HEMATOGEN FA 2
hematogen forte 1
HEMOCYTE PLUS 3
hemocyte-f 1
hydroxocobalamin 1 INJ
iferex 150 forte 1
INTEGRA F 3
INTEGRA PLUS 3
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
28
IROSPAN 24/6 3
MULPLETA 3 SP
MULTIGEN 2
MULTIGEN PLUS 2
NASCOBAL 2
NEULASTA 2 INJ SP
NEULASTA ONPRO KIT 2 INJ SP
NEUPOGEN 2 INJ SP
NIFEREX 3
NOXIFOL-D 3
PHYSICIANS EZ USE B-12 CO 3 INJ
poly-iron 150 forte 1
PROCRIT 2 INJ SP
PROMACTA 2 SP
REVESTA 3
se-tan plus 1
tl gard rx 1
trigels-f forte 1
VENOFER 2 INJ SP
virt-gard 1
VPRIV 3 INJ SP
ZARXIO 2 INJ SP
HEMOSTATICS
AMICAR 2
tranexamic acid 1
HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS
AMBIEN 3 QL
AMBIEN CR 3 QL
BELSOMRA 3 QL ST
DORAL 3
EDLUAR 3 QL ST
estazolam 1
eszopiclone 1 QL
flurazepam hcl 1
HALCION 3 QL
INTERMEZZO 3 QL
LUNESTA 3 QL
midazolam hcl 1
phenobarbital 1
ROZEREM 2 QL ST
SILENOR 3 ST
temazepam 1
triazolam 1 QL
zaleplon 1 QL
zolpidem tartrate 1 QL
zolpidem tartrate er 1 QL
LAXATIVES
CLENPIQ 2
COLYTE-FLAVOR PACKS 3
constulose 1
gavilyte-c 1
gavilyte-g 1
gavilyte-n/flavor pack 1
GOLYTELY 3
KRISTALOSE 3
lactulose 1
MOVIPREP 3
NULYTELY/FLAVOR PACKS 3
OSMOPREP 3
peg-3350/electrolytes 1
peg-3350/nacl/na bicarbon 1
PLENVU 3
polyethylene glycol 3350 1
PREPOPIK 2
SUPREP BOWEL PREP KIT 2
trilyte 1
LOCAL ANESTHETICS-Parenteral
bupivacaine hcl 1 INJ
MARCAINE 3 INJ
MARLIDO KIT 3 INJ
XYLOCAINE 3 INJ
XYLOCAINE-MPF 3 INJ
MACROLIDES
azithromycin sus 200/5ml 1
AZITHROMYCIN POW 1GM PAK 2
clarithromycin 1
clarithromycin er 1
DIFICID 3
e.e.s. 400 1
E.E.S. GRANULES 3
ERYPED 400 3
ERY-TAB 2
ERYTHROCIN STEARATE 2
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
29
erythromycin base 1
erythromycin ethylsuccina 1
ZITHROMAX 3
ZITHROMAX Z-PAK 3
MEDICAL DEVICES AND SUPPLIES
CAYA 3
Migraine Products
AIMOVIG 2 INJ QL
AJOVY 3 INJ QL
almotriptan 1 QL
almotriptan malate 1 QL
CAMBIA 3 QL
dihydroergot inj 1mg/ml 1 INJ QL
DIHYDROERGOT SPR 4MG/ML 2 QL
eletriptan hydrobromide 1 QL
EMGALITY 3 INJ
ERGOMAR 3
ergotamine tartrate/caffe 1
FROVA 3 QL
frovatriptan succinate 1 QL
IMITREX 3 QL
IMITREX STATDOSE REFILL 3 INJ QL
IMITREX STATDOSE SYSTEM 3 INJ QL
MAXALT 3 QL
MAXALT-MLT 3 QL
naratriptan hcl 1 QL
ONZETRA XSAIL 3 QL ST
RELPAX 3 QL
rizatriptan benzoate 1 QL
rizatriptan benzoate odt 1 QL
sumatriptan 1 QL
sumatriptan succinate 1 INJ QL
sumatriptan succinate ref 1 INJ QL
sumatriptan/naproxen sodi 1 QL
TREXIMET 3 QL
ZEMBRACE SYMTOUCH 3 INJ QL ST
zolmitriptan 1 QL
zolmitriptan odt 1 QL
ZOMIG TAB 5MG 3 QL
ZOMIG SPR 5MG 2 QL
ZOMIG ZMT 3 QL
MINERALS AND ELECTROLYTES
bd posiflush 1 INJ
effer-k tab 25meq ef 1
EFFER-K TAB 20MEQ 3
effervescent pot chloride 1
FLUORABON 3
fluoride 1
FLURA-DROPS 3
GALZIN 3
iodine strong 1
k-effervescent 1
klor-con 1
klor-con 10 1
klor-con 8 1
klor-con m10 1
KLOR-CON M15 2
klor-con m20 1
klor-con sprinkle 1
klor-con/ef 1
K-PHOS 2
K-TAB TAB 8MEQ CR 2
K-TAB TAB 20MEQ 3
k-vescent 1
lactated ringers 1 INJ
ludent 1
monoject pharma grade flu 1 INJ
normal saline flush 1 INJ
normal saline flush for f 1 INJ
normal saline i.v. flush 1 INJ
phospha 250 neutral 1
phosphorous 1
phospho-trin 250 neutral 1
potassium chloride 1
potassium chloride cr 1
pot chloride tab 10meq er 1
POT CHLORIDE TAB 20MEQ ER 2
potassium chloride sr 1
saline flush 1 INJ
sodium chloride flush 1 INJ
sodium fluoride 1
virt-phos 250 neutral 1
Miscellaneous Therapeutic Classes
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
30
ASTAGRAF XL 3 SP
AZASAN 3 SP
azathioprine 1
BENLYSTA 2 INJ SP
CELLCEPT 3 SP
cyclosporine 1
cyclosporine cap 25mg mod 1
CYCLOSPORINE CAP 50MG MOD 2
ENVARSUS XR 3 SP
gengraf 1
HYLAFEM 3
HYLENEX 3 INJ
kionex 1
mycophenolate mofetil 1 SP
mycophenolic acid dr 1 SP
MYFORTIC 3 SP
NEORAL 3
PROGRAF 3 SP
PROSTIN VR PEDIATRIC 3 INJ
RAPAMUNE TAB 1MG 3 SP
RAPAMUNE SOL 1MG/ML 2 SP
REVLIMID 2 SP
SANDIMMUNE 2
sirolimus 1 SP
sodium polystyrene sulfon 1
sps 1
sterile water irrigation 1
SYPRINE 3
trientine hydrochloride 1
VELTASSA 2
XIAFLEX 2 INJ SP
ZORTRESS 2 SP
MOUTH/THROAT/DENTAL AGENTS
ARESTIN 3
CAPHOSOL 3
cevimeline hcl 1
chlorhexidine gluconate 1
clinpro 5000 1
clotrimazole 1
DEBACTEROL 3
denta 5000 plus 1
dentagel 1
FIRST-MOUTHWASH BLM 2
GELCLAIR 3
lidocaine viscous 1
MUGARD 3
NEUTRASAL 3
ORAMAGICRX 3
paroex 1
pilocarpine hcl 1
pilocarpine hydrochloride 1
PREVIDENT 5000 BOOSTER PL 3
PREVIDENT 5000 DRY MOUTH 3
PREVIDENT 5000 ENAMEL PRO 3
PREVIDENT 5000 PLUS 3
PREVIDENT 5000 SENSITIVE 3
PREVIDENT FLUORIDE 3
PREVIDENT RINSE 3
SALAGEN 3
SALIVAMAX 3
sf 1
sf 5000 plus 1
triamcinolone acetonide d 1
MULTIVITAMINS
CITRANATAL 90 DHA 3
CITRANATAL ASSURE 3
CITRANATAL B-CALM 3
CITRANATAL BLOOM 3
CITRANATAL DHA 3
CITRANATAL HARMONY 3
CITRANATAL RX 3
complete natal dha 1
completenate 1
CONCEPT DHA 3
CONCEPT OB 3
dialyvite 1
DIALYVITE/ZINC 2
elite-ob 1
ENBRACE HR 3
FLORIVA PLUS 3
folbee plus 1
FOLGARD OS 3
multi-vit/iron/fluoride 1
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
31
multivitamin with fluorid 1
multivit/fl dro 0.25mg 1
MULTIVIT/FL CHW 0.5MG 3
MULTIVIT/FL CHW 0.25MG 2
multi-vitamin/fluoride dr 1
multi-vitamin/fluoride/ir 1
NEEVO DHA 3
NEPHRO-VITE RX 2
NESTABS DHA 3
NESTABS ONE 3
NICADAN 3
NICOMIDE 3
NIVA-PLUS 3
OB COMPLETE ONE 3
OB COMPLETE PETITE 3
OB COMPLETE PREMIER 3
OB COMPLETE/DHA 3
PNV PRENATAL TAB PLUS 2
PRENATAL PLS MIS MV + DHA 3
PNV TABS 29-1 2
pnv-dha 1
PNV-DHA+DOCUSATE 2
POLY-VI-FLOR 3
PRENA 1 TRUE 2
PRENA1 PEARL 2
PRENAISSANCE 2
PRENATA 3
prenatabs rx 1
PRENATAL 2
PRENATAL 19 TAB 29-1MG 3
prenatal 19 chw tab 1
PRENATAL PLUS 2
PRENATAL PLUS IRON 2
PRENATAL VITAMINS PLUS LO 2
PRENATE 3
PRENATE DHA 3
PRENATE ELITE 3
PRENATE ENHANCE 3
PRENATE ESSENTIAL 3
PRENATE MINI 3
PRENATE PIXIE 3
PRENATE RESTORE 3
PREPLUS 2
PRIMACARE 3
PROVIDA DHA 3
PROVIDA OB 3
renal caps 1
reno caps 1
SELECT-OB+DHA 3
se-natal 19 1
TARON-C DHA 2
THRIVITE RX 3
TL G-FOL OS 2
TRICARE PRENATAL DHA ONE/ 3
trinatal rx 1 1
triphrocaps 1
TRISTART DHA 3
tri-vitamin/fluoride 1
ultimatecare one 1
v-c forte 1
VINATE M 2
vinate one 1
VIRT-C DHA 2
virt-caps 1
VIRT-PN 2
VIRT-PN DHA 2
VITAFOL 3
VITAFOL FE+ 3
VITAFOL GUMMIES 3
VITAFOL ULTRA 3
VITAFOL-NANO 3
VITAFOL-OB 3
VITAFOL-OB+DHA 3
VITAFOL-ONE 3
VITAMEDMD ONE RX/QUATREFO 3
VITAMEDMD REDICHEW RX 3
vitamins a/c/d/fluoride 1
VITAPEARL 3
VITATRUE 3
VOL-PLUS 2
VOL-TAB RX 2
VP-PNV-DHA 3
ZATEAN-PN DHA 2
ZATEAN-PN PLUS 2
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
32
MUSCULOSKELETAL THERAPY AGENTS
AMRIX 3 QL
baclofen tab 20mg 1
BACLOFEN TAB 5MG 3
carisoprodol 1
chlorzoxazon tab 500mg 1
CHLORZOXAZON TAB 250MG 2
cyclobenzaprine hcl 1
cyclobenzaprine hydrochlo 1
dantrolene sodium 1
EUFLEXXA 2 INJ SP
FIRST-BACLOFEN 5 2
GABLOFEN 2 INJ
GEL-ONE 3 INJ SP
HYALGAN 3 INJ SP
HYMOVIS 3 INJ SP
LORZONE 3
METAXALONE TAB 400MG 2
metaxalone tab 800mg 1
methocarbamol 1
MONOVISC 2 INJ SP
orphenadrine citrate er 1
ORTHOVISC 2 INJ SP
ROBAXIN-750 3
SOMA 3
SUPARTZ FX 3 INJ SP
SYNVISC 3 INJ SP
SYNVISC ONE 3 INJ SP
tizanidine hcl 1
tizanidine hydrochloride 1
NASAL AGENTS - SYSTEMIC AND TOPICAL
ADRENALIN SOL 1:1000 3
ASTEPRO 3
azelastine hcl 1
azelastine hydrochloride 1
BECONASE AQ 3 ST
DYMISTA 2 ST
FLONASE 3
flunisolide 1
fluticasone propionate 1
ipratropium bromide 1
NASONEX 3
PATANASE 3 ST
QNASL 2 ST
QNASL CHILDRENS 2 ST
SINUVA 3 SP
XHANCE 3
ZETONNA 3 ST
NEUROMUSCULAR AGENTS
BOTOX 2 INJ SP
DYSPORT 3 INJ SP
MYOBLOC 2 INJ SP
riluzole 1 SP
SPINRAZA 2 INJ SP
NUTRIENTS
dextrose 20% 1 INJ
dextrose 5% 1 INJ
intralipid 1 INJ
OPHTHALMIC AGENTS
ACULAR 3
ACULAR LS 3
ACUVAIL 3
ALOCRIL 3
ALPHAGAN P SOL 0.15% 3
ALPHAGAN P SOL 0.1% 2
ALREX 2
apraclonidine 1
atropine sulfate 1
AZASITE 2
AZOPT 3
BACITRACIN 2
bacitracin/polymyxin b 1
BEPREVE 2
BESIVANCE 3
BETIMOL 3
BETOPTIC-S 3
BLEPHAMIDE 3
BLEPHAMIDE S.O.P. 3
brimonidine tartrate 1
bromfenac 1
BROMSITE 3
carteolol hcl 1
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
33
CILOXAN 3
COMBIGAN 2
COSOPT 3
COSOPT PF 3
CYCLOMYDRIL 3
cyclopentolate hcl 1
cyclopentolate hydrochlor 1
dorzolamide hcl 1
dorzolamide hcl/timolol m 1
dorzolamide hydrochloride 1
DUREZOL 3
epinastine hcl 1
EYLEA 2 SP
fluorometholone 1
flurbiprofen sodium 1
FML 3
FML FORTE 3
FML LIQUIFILM 3
gatifloxacin 1
GENTAK 2
homatropine hbr 1
ILEVRO 2
IOPIDINE 3
ISTALOL 3
LACRISERT 3
LASTACAFT 3
latanoprost 1
levobunolol hcl 1
LOTEMAX 2
LUMIGAN 2
MAXIDEX 3
MOXEZA 2
moxifloxacin hydrochlorid 1
NATACYN 2
neomycin/bacitracin/polym 1
neomycin/polymyxin/bacitr 1
neomycin/polymyxin/dexame 1
neomycin/polymyxin/gramic 1
neo-polycin 1
neo-polycin hc 1
NEOSPORIN 3
NEVANAC 2
OCUFLOX 3
ofloxacin 1
olopatadine hcl 1
olopatadine hydrochloride 1
OZURDEX 2 SP
PATADAY 3
PATANOL 3
PAZEO 2
PHOSPHOLINE IODIDE 2
polycin 1
polymyxin b sulfate/trime 1
POLYTRIM 3
PRED FORTE 3
PRED MILD 3
PRED-G S.O.P. 3
prednisolone acetate 1
PROLENSA 2
proparacaine hcl 1
RESTASIS 2
RESTASIS MULTIDOSE 2
RHOPRESSA 2
SIMBRINZA 3
sodium sulfacetamide 1
SULFACET SOD OIN 10% OP 2
sulfacetamide sodium/pred 1
tetracaine hcl 1
tetracaine hydrochloride 1
TIMOLOL GEL SOL 0.5% OP 3
timolol gel sol 0.25% op 1
TIMOPTIC 3
TIMOPTIC OCUDOSE 3
TOBRADEX SUS 0.3-0.1% 3
TOBRADEX OIN 0.3-0.1% 2
TOBRADEX ST 2
tobramycin sulfate 1
tobramycin/dexamethasone 1
TOBREX 3
TRAVATAN Z 2
trifluridine 1
trimethoprim sulfate/poly 1
tropicamide 1
TRUSOPT 3
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
34
VIGAMOX 3
VYZULTA 3
XALATAN 3
XIIDRA 2
ZIOPTAN 3
ZIRGAN 3
ZYLET 2
ZYMAXID 3
OTIC AGENTS
acetic acid 1
CIPRO HC 3
CIPRODEX 2
CIPROFLOXACIN 2
COLY-MYCIN S 3
hydrocortisone/acetic aci 1
neomycin/polymyxin/hc 1
neomycin/polymyxin/hydroc 1
OTOVEL 2
Oxytocics
methergine 1
methylergonovine maleate 1
PASSIVE IMMUNIZING AND TREATMENT AGENTS
FLEBOGAMMA DIF 3 INJ SP
HIZENTRA 2 INJ SP
HYPERRHO S/D 2 INJ SP
RHOGAM ULTRA-FILTERED PLU 3 INJ SP
SYNAGIS 2 INJ SP
PENICILLINS
amoxicillin 1
amoxicillin/clavulanate p 1
ampicillin 1
AUGMENTIN 2
BICILLIN L-A 2 INJ
dicloxacillin sodium 1
MOXATAG 3
penicillin v potassium 1
piperacillin/tazobactam 1 INJ
Progestins
hydroxyprogesterone capro 1 INJ SP
MAKENA INJ 250MG/ML 2 INJ SP
MAKENA INJ 275MG 3 INJ SP
norethindrone acetate 1
progesterone 1
PROMETRIUM 3
PROVERA 3
Psychotherapeutic and Neurological Agents - Misc.
acamprosate calcium dr 1
ADDYI 3 SP
AMPYRA 2 SP
AUBAGIO 3 SP
AUSTEDO 3 SP
AVONEX 2 INJ SP
AVONEX PEN 2 INJ SP
BETASERON 2 INJ SP
BRISDELLE 3
CHANTIX 2 QL
CHANTIX CONTINUING MONTH 2 QL
CHANTIX STARTING MONTH PA 2 QL
chlordiazepoxide/amitript 1
COPAXONE INJ 40MG/ML 2 INJ SP
COPAXONE INJ 20MG/ML 3 INJ SP
dalfampridine er 1 SP
disulfiram 1
donepezil hcl 1
donepezil hydrochloride 1
EXTAVIA 2 INJ SP
fluoxetine 1
galantamine hydrobromide 1
GILENYA 2 SP
glatiramer acetate 1 INJ SP
glatopa 1 INJ SP
GRALISE 2
GRALISE STARTER 2
HORIZANT 3
INGREZZA 3 SP
LYRICA CR 3
memantine hcl 1
memantine hcl titration p 1
memantine hydrochloride 1
memantine hydrochloride e 1
NAMENDA 3
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
35
NAMENDA XR 3
NAMZARIC 2
NICOTROL INHALER 3
NICOTROL NS 3
NUEDEXTA 2
OCREVUS 2 INJ SP
olanzapine/fluoxetine 1
ORAP 3
paroxetine 1
perphenazine/amitriptylin 1
pimozide 1
PLEGRIDY 2 INJ SP
REBIF 2 INJ SP
REBIF REBIDOSE 2 INJ SP
REBIF REBIDOSE TITRATION 2 INJ SP
rivastigmine tartrate 1
rivastigmine transdermal 1
SAVELLA 2
SAVELLA TITRATION PACK 2
TECFIDERA 2 SP
TECFIDERA STARTER PACK 2 SP
tetrabenazine 1 SP
TYSABRI 2 INJ SP
XENAZINE 3 SP
XYREM 2 SP
Respiratory Agents - Misc.
ESBRIET 2 SP
OFEV 2 SP
ORKAMBI 2 SP
PROLASTIN-C 2 INJ SP
PULMOZYME 2 SP
SYMDEKO 2 SP
Tetracyclines
ACTICLATE 3
demeclocycline hcl 1
DORYX MPC 3
doxycycline sus 25mg/5ml 1
doxycycline hyclate 1
doxycycline hyclate dr 1
doxycycline monohydrate 1
minocycline hcl 1
minocycline hcl er 1
minocycline hydrochloride 1
okebo 1
SOLODYN 2
TARGADOX 3
tetracycline hydrochlorid 1
VIBRAMYCIN 3
XIMINO 3
THYROID AGENTS
ARMOUR THYROID 2
CYTOMEL 3
levothyroxine sodium 1
levothyroxine/liothyronin 1
levoxyl 1
liothyronine sodium 1
methimazole 1
NATURE-THROID 2
NATURE-THROID NT-2.5 2
np thyroid 120 1
np thyroid 15 1
np thyroid 30 1
np thyroid 60 1
np thyroid 90 1
propylthiouracil 1
SYNTHROID 3
TIROSINT 3
unithroid 1
WESTHROID 2
WP THYROID 3
Toxoids
ADACEL 2 INJ
BOOSTRIX 2 INJ
INFANRIX 2 INJ
TENIVAC 3 INJ
TETANUS/DIPHTHERIA TOXOID 2 INJ
ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS
ACIPHEX 3 QL
belladonna & opium 1
belladonna alkaloids & op 1
CARAFATE 2
chlordiazepoxide hcl/clid 1
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
36
cimetidine 1
cimetidine hcl 1
CUVPOSA 3
CYTOTEC 3
DEXILANT 3 QL ST
dicyclomine hcl 1
dicyclomine hydrochloride 1
DONNATAL 3
esomeprazole magnesium 1 QL
esomeprazole magnesium dr 1 QL
ESOMEPRAZOLE STRONTIUM 3
famotidine 1
FIRST-LANSOPRAZOLE 2 QL
FIRST-OMEPRAZOLE 2 QL
glycopyrrolate 1
hyoscyamine sulfate 1
hyoscyamine sulfate er 1
hyoscyamine sulfate odt 1
hyoscyamine sulfate sr 1
hyosyne 1
lansoprazole 1 QL
lansoprazole/amoxicillin/ 1
LEVSIN 3
LEVSIN/SL 3
methscopolamine bromide 1
misoprostol 1
NEXIUM GRA 10MG DR 2 QL
NEXIUM CAP 40MG 3 QL
nizatidine cap 150mg 1
NIZATIDINE SOL 15MG/ML 2
OMECLAMOX-PAK 3
omeprazole 1 QL
omeprazole dr 1 QL
omeprazole/sodium bicarbo 1
oscimin 1
oscimin sr 1
pantoprazole sodium 1 QL
pantoprazole sodium dr 1 QL
phenohytro 1
PREVACID 3 QL
PREVACID SOLUTAB 3 QL
PRILOSEC 3 QL
propantheline bromide 1
PROTONIX 3 QL
PYLERA 2
rabeprazole sodium 1 QL
ranitidine hcl 1
ranitidine hydrochloride 1
sucralfate tab 1gm 1
SUCRALFATE SUS 1GM/10ML 2
SYMAX DUOTAB 3
ZEGERID 3
Urinary Anti-infectives
HYOPHEN 2
MACROBID 3
MACRODANTIN 3
me/naphos/mb/hyo 1 1
methenamine hippurate 1
methenamine mandelate 1
MONUROL 3
nitrofurantoin 1
nitrofurantoin macrocryst 1
nitrofurantoin monohydrat 1
phosphasal 1
urelle 1
uribel 1
URIMAR-T 2
uro-458 1
UROGESIC-BLUE 2
uro-mp 1
ustell 1
vilamit mb 1
Urinary Antispasmodics
bethanechol chloride 1
darifenacin hydrobromide 1 QL
DETROL 3 QL
DETROL LA 3 QL
flavoxate hcl 1
GELNIQUE 2
MYRBETRIQ 2
oxybutynin chloride 1
oxybutynin chloride er 1 QL
tolterodine tartrate 1 QL
tolterodine tartrate er 1 QL
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy