Prescription Drug ListFOR LARGE GROUP PLANS AND SMALL GROUP NON-ACA
COMPLIANT PLANS
Note: The copayment for specialty medication is plan dependent and
is specified in your Copayment Summary. Most specialty medications
require a Prior Authorization and may be limited to a 30-day
supply.
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Western Health Advantage complies with applicable Federal civil
rights laws and does not discriminate on the basis of race, color,
national origin, age, disability, or sex.
Western Health Advantage does not exclude people or treat them
differently because of race, color, national origin, age,
disability, or sex.
Western Health Advantage:
Provides free aids and services to people with disabilities to
communicate effectively with us, such as: • Qualified sign language
interpreters • Written information in other formats (large print,
audio, accessible electronic formats, other formats)
Provides free language services to people whose primary language is
not English, such as: • Qualified interpreters • Information
written in other languages
If you need these services, contact the Member Services
Manager.
If you believe that Western Health Advantage has failed to provide
these services or discriminated in another way on the basis of
race, color, national origin, age, disability, or sex, you can file
a grievance with: Member Services Manager, 2349 Gateway Oaks Drive,
Suite 100, Sacramento, CA 95833, 888.563.2250 or 916.563.2250,
888.877.5378 (TTY), 916.568.0126 (fax),
[email protected]. You can file a grievance in
person or by mail, fax, or email. If you need help filing a
grievance, the Member Services Manager is available to help
you.
You can also file a civil rights complaint with the U.S. Department
of Health and Human Services, Office for Civil Rights,
electronically through the Office for Civil Rights Complaint
Portal, available at:
Website: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Mail: U.S.
Department of Health and Human Services 200 Independence Avenue, SW
Room 509F, HHH Building Washington, D.C. 20201 Phone: 800.368.1019
or 800.537.7697 (TDD)
Complaint forms are available at
http://www.hhs.gov/ocr/office/file/index.html.
ENGLISH If you, or someone you’re helping, have questions about
Western Health Advantage, you have the right to get help and
information in your language at no cost. To talk to an interpreter,
call 888.563.2250 or TTY 888.877.5378. SPANISH
Si usted, o alguien a quien usted está ayudando, tiene preguntas
acerca de Western Health Advantage, tiene derecho a obtener ayuda e
información en su idioma sin costo alguno. Para hablar con un
intérprete, llame al 888.563.2250, o al TTY 888.877.5378 si tiene
dificultades auditivas.
CHINESE
VIETNAMESE
Nu quý v, hay ngi mà quý v ang giúp , có câu hi v Western Health
Advantage, quý v s có quyn c giúp và có thêm thông tin bng ngôn ng
ca mình min phí. nói chuyn vi mt thông dch viên, xin gi s
888.563.2250, hoc gi ng dây TTY dành cho ngi khim thính ti s
888.877.5378.
TAGALOG Kung ikaw, o ang iyong tinutulangan, ay may mga katanungan
tungkol sa Western Health Advantage, may karapatan ka na makakuha
ng tulong at impormasyon sa iyong wika ng walang gastos. Upang
makausap ang isang tagasalin, tumawag sa 888.563.2250 o TTY para sa
may kapansanan sa pandinig sa 888.877.5378.
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KOREAN
Western Health Advantage . 888.563.2250 TTY 888.877.5378 .
ARMENIAN
Western Health Advantage- , 888.563.2250 TTY 888.877.5378
PERSIAN-FARSI ) ( Western Health Advantage
888.877.5378 . 888.563.2250 . .
RUSSIAN , , Western Health Advantage, . 888.563.2250 TTY
888.877.5378.
JAPANESE
888.563.2250TTY888.877.5378
ARABIC Western Health Advantage
.888.877.5378 )TTY( 888.563.2250 .
PUNJABI
(, " + , Western Health Advantage +,
, 888.563.2250 ‘ $ )$
888.877.5378 ‘
CAMBODIAN-MON-KHMER
!) ./0) /= Western Health Advantage , "$)$
"$%'($ "*+ %&*,/3 ( 888.563.2250 TTY "#"$* !
888.877.5378
HMONG
Yog koj, los yog tej tus neeg uas koj pab ntawd, muaj lus nug txog
Western Health Advantage, koj muaj cai kom lawv muab cov ntshiab
lus qhia uas tau muab sau ua koj hom lus pub dawb rau koj. Yog koj
xav nrog ib tug neeg txhais lus tham, hu rau 888.563.2250 los sis
TTY rau cov neeg uas tsis hnov lus zoo nyob ntawm
888.877.5378.
HINDI
" , & ) , Western Health Advantage ' () , , " + ,- 0 7 7,
888.563.2250 & ! % ) ++ 0 888.877.5378
THAI
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1 FINASTERIDE 2 DUTASTERIDE AVODART 3 DUTASTERIDE/TAMSULOSIN HCL
JALYN 3 FINASTERIDE PROSCAR
5-HT2C Receptor Antagonist / AUTONOMIC & CNS DRUGS, NEUROLOGY
& PSYCH Tier Generic Name Brand Name Notes
3 LORCASERIN BELVIQ 5
5-HT3 Receptor Antagonists / ANTIEMETICS Tier Generic Name Brand
Name Notes
1 GRANISETRON HCL 1 ONDANSETRON ONDANSETRON ODT 3 DOLASETRON
ANZEMET 3 GRANISETRON SANCUSO 3 ONDANSETRON ZOFRAN ODT 4
GRANISETRON EXTENDED-RELEASE INJECTION SUSTOL 4
5-HT3 Receptor Antagonists / GASTROINTESTINAL OTHER Tier Generic
Name Brand Name Notes
3 NETUPITANT/PALONOSETRON AKYNZEO 5
ADHD Amphetamines / CNS AGENTS Tier Generic Name Brand Name
Notes
1 AMPHET ASP/AMPHET/D-AMPHET DEXTROAMPHETAMINE-AMPHETAMINE 1 AMPHET
ASP/AMPHET/D-AMPHET AMPHETAMINE SALT COMBO 1 DEXTROAMPHETAMINE
SULFATE 1 METHAMPHETAMINE HCL 3 AMPHET ASP/AMPHET/D-AMPHET ADDERALL
3 AMPHET ASP/AMPHET/D-AMPHET ADDERALL XR 3 DEXTROAMPHETAMINE
SULFATE DEXEDRINE
ADHD Non-Amphetamine / CNS AGENTS Tier Generic Name Brand Name
Notes
2 ATOMOXETINE HCL STRATTERA 3 CLONIDINE KAPVAY 3 GUANFACINE HCL
INTUNIV
AMPA Receptor Antagonist / ANTICONVULSANTS Tier Generic Name Brand
Name Notes
2 PERAMPANEL FYCOMPA
2 MILTEFOSINE CAPSULES IMPAVIDO
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3 POTASSIUM PHOSPHATE,MONOBASIC K-PHOS ORIGINAL
Adrenals / ENDOCRINE/DIABETES Tier Generic Name Brand Name
Notes
1 CORTISONE ACETATE 1 DEXAMETHASONE 1 FLUDROCORTISONE ACETATE 1
METHYLPREDNISOLONE 1 PREDNISOLONE 1 PREDNISOLONE MILLIPRED 2
PREDNISOLONE SOD PHOSPHATE ORAPRED ODT 3 HYDROCORTISONE CORTEF 3
METHYLPREDNISOLONE MEDROL 3 PREDNISOLONE ACETATE FLO-PRED
Adrenals / GI AGENTS Tier Generic Name Brand Name Notes
1 BUDESONIDE BUDESONIDE EC 3 BUDESONIDE ENTOCORT EC
Adrenals / HORMONE: GLUCOCORTICOIDS/MINERALOCORTICOIDS Tier Generic
Name Brand Name Notes
1 BETAMETHASONE DIPROPIONATE 1 BETAMETHASONE VALERATE BETA-VAL 1
BETAMETHASONE VALERATE 1 CLOTRIMAZOLE/BETAMETHASONE DIP
CLOTRIMAZOLE-BETAMETHASONE 1 DEXAMETHASONE 1 HYDROCORTISONE
VALERATE 1 PREDNISONE 2 DEXAMETHASONE DEXAMETHASONE INTENSOL 3
BENZOYL PEROXIDE/HYDROCORTISON VANOXIDE-HC 3 BETAMETHASONE VALERATE
LUXIQ 3 CALCIPOTRIENE/BETAMETHASONE TACLONEX 3 DEXAMETHASONE
MAXIDEX 3 HYDROCORTISONE BUTYRATE LOCOID 3 HYDROCORTISONE
BUTYRATE/EMOLL LOCOID LIPOCREAM 3 HYDROCORTISONE/PRAMOXINE
PRAMOSONE 3 HYDROCORTISONE/PRAMOXINE EPIFOAM 3
HYDROCORTISONE/PRAMOXINE/ALOE NOVACORT
Adrenocortical Insufficiency / ENDOCRINE/DIABETES Tier Generic Name
Brand Name Notes
4 CORTICOTROPIN H.P. ACTHAR 5
Alcohol Deterrents / ANTI-ADDICTION/SUBSTANCE ABUSE Tier Generic
Name Brand Name Notes
1 DISULFIRAM 3 ACAMPROSATE CALCIUM CAMPRAL 3 DISULFIRAM
ANTABUSE
5 - Prior Authorization
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4 NALTREXONE HCL VIVITROL 5
Alkalinizing Agents / UROLOGICALS Tier Generic Name Brand Name
Notes
1 CITRIC ACID/SODIUM CITRATE SODIUM CITRATE & CITRIC ACID 1
CITRIC ACID/SODIUM CITRATE CYTRA-2 1 POTASSIUM CITRATE 1 POTASSIUM
CITRATE/CITRIC ACID CYTRA-K 1 POTASSIUM CITRATE/CITRIC ACID
POTASSIUM CITRATE-CITRIC ACID 3 POTASSIUM CITRATE UROCIT-K
Alkylating Agent / ANTINEOPLASTICS Tier Generic Name Brand Name
Notes
1 BUSULFAN 1 CARMUSTINE 1 CHLORAMBUCIL 1 CYCLOPHOSPHAMIDE 1
MECHLORETHAMINE 1 MELPHALAN 1 PROCARBAZINE 1 THIOTEPA 2 LOMUSTINE
CEENU 3 MECHLORETHAMINE VALCHLOR 5 4 BENDAMUSTINE TREANDA 4 4
CISPLATIN 4
Allergen / IMMUNOLOGICAL AGENTS Tier Generic Name Brand Name
Notes
3 GRASS POLLEN GRASTEK 3 GRASS POLLEN ORALAIR 3 RAGWEEK POLLEN
RAGWITEK
Allylamines / ANTIFUNGALS Tier Generic Name Brand Name Notes
1 TERBINAFINE HCL 3 TERBINAFINE HCL LAMISIL
Alpha- And Beta-Adrenergic Agonists / CARDIOVASCULAR Tier Generic
Name Brand Name Notes
3 DROXIDOPA NORTHERA 5
Alpha- And Beta-Adrenergic Agonists / RESPIRATORY AGENTS Tier
Generic Name Brand Name Notes
3 EPINEPHRINE TWINJECT
1 CLONIDINE
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Alpha-Adrenergic Agonists / CARDIOVASCULAR (cont.) Tier Generic
Name Brand Name Notes
1 DIHYDROERGOTAMINE MESYLATE 2 EPINEPHRINE EPIPEN 2 EPINEPHRINE
EPIPEN 2-PAK 2 EPINEPHRINE EPIPEN JR 2 EPINEPHRINE EPIPEN JR 2-PAK
3 CLONIDINE HCL KAPVAY 3 CLONIDINE HCL NEXICLON XR
Alpha-Adrenergic Agonists / DERMATOLOGICAL AGENTS Tier Generic Name
Brand Name Notes
3 BRIMONIDINE TOPICAL MIRVASO 3 OXYMETAZOLINE HCL 1% CREAM RHOFADE
5
Alpha-Adrenergic Agonists (Eent) / OPHTHALMOLOGY Tier Generic Name
Brand Name Notes
1 BRIMONIDINE TARTRATE 2 BRIMONIDINE TARTRATE ALPHAGAN P 3
BRIMONIDINE TARTRATE/TIMOLOL COMBIGAN
Alpha-Adrenergic Blocking Agents / ANTIMIGRAINE Tier Generic Name
Brand Name Notes
1 ERGOTAMINE TARTRATE/CAFFEINE MIGERGOT 3 DIHYDROERGOTAMINE
MESYLATE MIGRANAL
Alpha-Adrenergic Blocking Agents / CARDIOVASCULAR Tier Generic Name
Brand Name Notes
1 ALFUZOSIN HCL 1 DOXAZOSIN MESYLATE 1 PRAZOSIN HCL 1 TAMSULOSIN
HCL 1 TERAZOSIN HCL 2 DOXAZOSIN MESYLATE CARDURA XL 3 ALFUZOSIN HCL
UROXATRAL 3 PRAZOSIN HCL MINIPRESS 3 SILODOSIN RAPAFLO 3 TAMSULOSIN
HCL FLOMAX
Alpha-Glucosidase Inhibitors / BLOOD GLUCOSE REGULATORS Tier
Generic Name Brand Name Notes
1 ACARBOSE 3 MIGLITOL GLYSET
Amebicides / ANTI - INFECTIVES Tier Generic Name Brand Name
Notes
1 PAROMOMYCIN SULFATE 1 TINIDAZOLE
Aminoglycosides / ANTIBACTERIALS Tier Generic Name Brand Name
Notes
1 NEOMYCIN SULFATE
5 - Prior Authorization
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Aminoglycosides / ANTIBACTERIALS (cont.) Tier Generic Name Brand
Name Notes
3 TOBRAMYCIN IN 0.225% NACL TOBI 5 4 AMIKACIN 4 4 GENTAMICIN 4 4
KANAMYCIN 4 4 NETILMICIN NETROMYCIN 4 4 TOBRAMYCIN 4
Aminoglycosides / ANTIMYCOBACTERIALS - OTHER Tier Generic Name
Brand Name Notes
4 CAPREOMYCIN CAPASTAT 4
Aminosalicylates / INFLAMMATORY BOWEL AGENTS Tier Generic Name
Brand Name Notes
2 MESALAMINE ASACOL HD 2 MESALAMINE ASACOL 2 MESALAMINE PENTASA 3
MESALAMINE W/CLEANSING WIPES ROWASA
Ammonia Detoxicants / GI AGENTS Tier Generic Name Brand Name
Notes
1 LACTULOSE 1 LACTULOSE ENULOSE 1 LACTULOSE GENERLAC 2 LACTULOSE
KRISTALOSE
Amphetamines / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH
Tier Generic Name Brand Name Notes
3 LISDEXAMFETAMINE DIMESYLATE VYVANSE
Amylinomimetics / BLOOD GLUCOSE REGULATORS Tier Generic Name Brand
Name Notes
4 PRAMLINTIDE ACETATE SYMLINPEN 120 5 4 PRAMLINTIDE ACETATE
SYMLINPEN 60 5
Analgesics And Antipyretics- Misc. / ANTIMIGRAINE Tier Generic Name
Brand Name Notes
1 ISOMETHEPT/ACETAMINOP/DICHLPHN EPIDRIN 1
ISOMETHEPT/ACETAMINOP/DICHLPHN ISOMETHEPT-DICHLORALP-ACETAMIN
Analgesics And Antipyretics- Misc. / AUTONOMIC & CNS DRUGS,
NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes
1 BUTALB/ACETAMINOPHEN/CAFFEINE ZEBUTAL 1
BUTALB/ACETAMINOPHEN/CAFFEINE BUTALBITAL-ACETAMINOPHEN-CAFFE 3
BUTALB/ACETAMINOPHEN/CAFFEINE FIORICET 3 BUTALBITAL/ACETAMINOPHEN
PHRENILIN FORTE
4 - Office/Clinic Administration 5 - Prior Authorization
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1 DANAZOL
2 TESTOSTERONE ANDROGEL 3 TESTOSTERONE 3 TESTOSTERONE ANDRODERM 3
TESTOSTERONE NASAL GEL NATESTO 4 TESTOSTERONE CYPIONATE
DEPO-TESTOSTERONE 5
Angiotensin Ii Receptor Antagonists / CARDIOVASCULAR Tier Generic
Name Brand Name Notes
1 CANDESARTAN 7 1 CANDESARTAN/HYDROCHLOROTHIAZID
CANDESARTAN-HYDROCHLOROTHIAZID 7 1 IRBESARTAN 1
IRBESARTAN/HYDROCHLOROTHIAZIDE IRBESARTAN-HYDROCHLOROTHIAZIDE 1
LOSARTAN POTASSIUM 1 LOSARTAN/HYDROCHLOROTHIAZIDE
LOSARTAN-HYDROCHLOROTHIAZIDE 1 TELMISARTAN/AMLODIPINE 7 1 VALSARTAN
1 VALSARTAN/HYDROCHLOROTHIAZIDE VALSARTAN-HYDROCHLOROTHIAZIDE 2
CANDESARTAN CILEXETIL ATACAND 7 2 CANDESARTAN/HYDROCHLOROTHIAZID
ATACAND HCT 7 2 OLMESARTAN MEDOXOMIL BENICAR 7 2
OLMESARTAN/HYDROCHLOROTHIAZIDE BENICAR HCT 7 2 TELMISARTAN MICARDIS
7 2 TELMISARTAN/HYDROCHLOROTHIAZID MICARDIS HCT 7 3 AZILSARTAN
MED/CHLORTHALIDONE EDARBYCLOR 7 3 AZILSARTAN MEDOXOMIL EDARBI 7 3
IRBESARTAN AVAPRO 3 IRBESARTAN/HYDROCHLOROTHIAZIDE AVALIDE 3
LOSARTAN POTASSIUM COZAAR 3 OLMESARTAN MED/AMLODIPINE/HCTZ
TRIBENZOR 7 3 TELMISARTAN/AMLODIPINE TWYNSTA 7 3 VALSARTAN DIOVAN 3
VALSARTAN/HYDROCHLOROTHIAZIDE DIOVAN HCTZ
Angiotensin-Converting Enzyme Inhibitors / CARDIOVASCULAR Tier
Generic Name Brand Name Notes
1 BENAZEPRIL HCL 1 BENAZEPRIL/HYDROCHLOROTHIAZIDE
BENAZEPRIL-HYDROCHLOROTHIAZIDE 1 CAPTOPRIL 1
CAPTOPRIL/HYDROCHLOROTHIAZIDE CAPTOPRIL-HYDROCHLOROTHIAZIDE 1
ENALAPRIL MALEATE 1 ENALAPRIL/HYDROCHLOROTHIAZIDE
ENALAPRIL-HYDROCHLOROTHIAZIDE 1 FOSINOPRIL SODIUM 1
FOSINOPRIL/HYDROCHLOROTHIAZIDE FOSINOPRIL-HYDROCHLOROTHIAZIDE 1
LISINOPRIL 1 LISINOPRIL/HYDROCHLOROTHIAZIDE
LISINOPRIL-HYDROCHLOROTHIAZIDE
5 - Prior Authorization 7 - Step Therapy
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Angiotensin-Converting Enzyme Inhibitors / CARDIOVASCULAR (cont.)
Tier Generic Name Brand Name Notes
1 PERINDOPRIL ERBUMINE 1 QUINAPRIL HCL 1 RAMIPRIL 3 ENALAPRIL
MALEATE VASOTEC 3 LISINOPRIL ZESTRIL 3 QUINAPRIL HCL ACCUPRIL 3
QUINAPRIL/HYDROCHLOROTHIAZIDE ACCURETIC 3 RAMIPRIL ALTACE 3
TRANDOLAPRIL/VERAPAMIL HCL TARKA
Anorex.-Respir.-Cerebral Stimulants-Misc / AUTONOMIC & CNS
DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name
Notes
1 METHYLPHENIDATE HCL METHYLPHENIDATE ER 1 METHYLPHENIDATE HCL
METADATE ER 1 METHYLPHENIDATE HCL 1 METHYLPHENIDATE HCL
METHYLPHENIDATE SR 1 MODAFINIL 2 METHYLPHENIDATE HCL RITALIN
CAPSULE 10, 60 MG 3 ARMODAFINIL NUVIGIL 3 DEXMETHYLPHENIDATE HCL
FOCALIN XR 3 DEXMETHYLPHENIDATE HCL FOCALIN 3 METHYLPHENIDATE
DAYTRANA 3 METHYLPHENIDATE HCL CONCERTA 3 METHYLPHENIDATE HCL
METHYLIN ER 3 METHYLPHENIDATE HCL METADATE CD 3 METHYLPHENIDATE HCL
RITALIN 3 METHYLPHENIDATE HCL RITALIN LA CAPSULES 20, 30, 40 MG 3
METHYLPHENIDATE HCL METHYLIN 3 MODAFINIL PROVIGIL
Anthelmintics / ANTIPARASITICS Tier Generic Name Brand Name
Notes
1 MEBENDAZOLE 2 IVERMECTIN STROMECTOL 3 ALBENDAZOLE ALBENZA 3
PRAZIQUANTEL BILTRICIDE
Anti HIV Other / ANTIVIRALS Tier Generic Name Brand Name
Notes
2 COBICISTAT TYBOST 2 ELVITEGRAVIR/COBIC/EMT/TENOFOVIR
STRIBILD
Anti-Cytomegalovirus / ANTIVIRALS Tier Generic Name Brand Name
Notes
3 GANCICLOVIR ZIRGAN 3 VALGANCICLOVIR VALCYTE 4 CIDOFOVIR 4
Anti-HIV Other / ANTIVIRALS Tier Generic Name Brand Name
Notes
2 DOLUTEGRAVIR TIVICAY
4 - Office/Clinic Administration
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Anti-HIV Other / ANTIVIRALS (cont.) Tier Generic Name Brand Name
Notes
2 ELVITEGRAVIR/COBICISTAT/EMTRICITABINE/TEN OFOVIR
ALAFENAMIDE
GENVOYA
2 RALTEGRAVIR POTASSIUM ISENTRESS 2 RITONAVIR NORVIR 4 ENFUVIRTIDE
FUZEON 5
Anti-Inflammatory Agents (Gi Drugs) / GI AGENTS Tier Generic Name
Brand Name Notes
1 BALSALAZIDE DISODIUM 1 MESALAMINE 2 MESALAMINE CANASA 2
MESALAMINE LIALDA 3 MESALAMINE APRISO
Anti-Inflammatory Agents (Skin & Mucous) / DERMATOLOGICAL
AGENTS Tier Generic Name Brand Name Notes
1 ALCLOMETASONE DIPROPIONATE 1 CLOBETASOL PROPIONATE CORMAX 1
CLOBETASOL PROPIONATE 1 CLOBETASOL PROPIONATE/EMOLL CLOBETASOL
EMOLLIENT 1 DESONIDE 1 DESOXIMETASONE 1 FLUOCINOLONE ACETONIDE 1
FLUOCINONIDE/EMOLLIENT FLUOCINONIDE EMOLLIENT 1
FLUOCINONIDE/EMOLLIENT FLUOCINONIDE-E 1 HALOBETASOL PROPIONATE
CREAM AND
OINTMENT HALOBETASOL PROPIONATE
1 MOMETASONE FUROATE 1 PREDNICARBATE 1 TRIAMCINOLONE ACETONIDE 2
DESONIDE DESONATE 2 DESONIDE VERDESO 2 FLURANDRENOLIDE CORDRAN 2
FLUTICASONE PROPIONATE CUTIVATE 3 CLOBETASOL PROPIONATE OLUX 3
CLOBETASOL PROPIONATE CLOBEX 3 CLOBETASOL PROPIONATE/EMOLL OLUX-E 3
CLOCORTOLONE PIVALATE CLODERM 3 DESOXIMETASONE TOPICORT 3
FLUOCINOLONE ACETONIDE CAPEX SHAMPOO 3 FLUOCINOLONE ACETONIDE
DERMA-SMOOTHE-FS 3 FLUOCINONIDE VANOS 3 FLURANDRENOLIDE CORDRAN SP
3 HALCINONIDE HALOG 3 HALOBETASOL PROPIONATE CREAM AND
OINTMENT ULTRAVATE
3 HALOBETASOL PROPIONATE LOTION ULTRAVATE 5 3 MOMETASONE FUROATE
ELOCON 3 TRIAMCINOLONE ACETONIDE KENALOG
Anti-Inflammatory Agents (Skin & Mucous) / GI AGENTS Tier
Generic Name Brand Name Notes
1 HYDROCORTISONE COLOCORT
5 - Prior Authorization
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Anti-Inflammatory Agents (Skin & Mucous) / GI AGENTS (cont.)
Tier Generic Name Brand Name Notes
1 HYDROCORTISONE 1 HYDROCORTISONE PROCTOZONE-HC 1 HYDROCORTISONE
PROCTOSOL-HC 1 HYDROCORTISONE PROCTOCORT 1 HYDROCORTISONE ACETATE 1
HYDROCORTISONE ACETATE HEMRIL 1 HYDROCORTISONE ACETATE
SUPPOSITORIES ANUCORT-HC 5 1 HYDROCORTISONE/PRAMOXINE
HYDROCORTISONE-PRAMOXINE 2 HYDROCORTISONE ACETATE CORTIFOAM 2
HYDROCORTISONE/PRAMOXINE PROCTOFOAM-HC 3 HYDROCORTISONE ACETATE
SUPPOSITORIES ANUSOL-HC 5 3 HYDROCORTISONE/PRAMOXINE ANALPRAM
HC
Anti-Influenza / ANTIVIRALS Tier Generic Name Brand Name
Notes
1 AMANTADINE HCL AMANTADINE 2 OSELTAMIVIR PHOSPHATE TAMIFLU 6 3
ZANAMIVIR RELENZA 4 INFLUENZA VACCINE FLUZONE 4
Antiallergic Agents / NASAL STEROID Tier Generic Name Brand Name
Notes
1 OLOPATADINE HCL OLOPATADINE NASAL 3 OLOPATADINE HCL
PATANASE
Antiallergic Agents / OPHTHALMOLOGY Tier Generic Name Brand Name
Notes
1 AZELASTINE HCL 1 EPINASTINE HCL 2 LODOXAMIDE TROMETHAMINE ALOMIDE
3 ALCAFTADINE LASTACAFT 3 AZELASTINE HCL OPTIVAR 3 BEPOTASTINE
BESILATE BEPREVE 3 EPINASTINE HCL ELESTAT 3 OLOPATADINE HCL PATADAY
3 OLOPATADINE HCL PATANOL 3 PEMIROLAST POTASSIUM ALAMAST
Antiallergic Agents / RESPIRATORY AGENTS Tier Generic Name Brand
Name Notes
1 AZELASTINE 1 AZELASTINE HCL 3 AZELASTINE HCL ASTELIN 3 AZELASTINE
HCL ASTEPRO 3 AZELASTINE/FLUTICASONE DYMISTA
Antiandrogen / ANTINEOPLASTICS Tier Generic Name Brand Name
Notes
3 ENZALUTAMIDE XTANDI 5
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Antiangiogenic Agent / ANTINEOPLASTICS Tier Generic Name Brand Name
Notes
3 PAZOPANIB VOTRIENT 5 3 SORAFENIB NEXAVAR 5 3 SUNITINIB MALATE
SUTENT 4 BEVACIZUMAB AVASTIN 4
Antiarrhythmics / CARDIOVASCULAR Tier Generic Name Brand Name
Notes
1 AMIODARONE HCL 1 DIGOXIN 1 FLECAINIDE ACETATE 1 MEXILETINE HCL 1
PROPAFENONE HCL 1 QUINIDINE GLUCONATE 1 QUINIDINE SULFATE 2
AMIODARONE HCL PACERONE 2 DISOPYRAMIDE PHOSPHATE NORPACE CR 3
DIGOXIN LANOXIN 3 DOFETILIDE TIKOSYN 3 DRONEDARONE HCL MULTAQ 3
PROPAFENONE HCL RYTHMOL SR 4 ADENOSINE ADENOCARD 4
Antibacterials (Eent) / ANTIBACTERIALS Tier Generic Name Brand Name
Notes
1 NEOMYCIN/POLYMYXIN B SULF/HC NEOMYCIN-POLYMYXIN-HC 1
NEOMYCIN/POLYMYXIN B SULF/HC NEOMYCIN-POLYMYXIN-HYDROCORT 3
CIPROFLOXACIN HCL/DEXAMETH CIPRODEX 3 CIPROFLOXACIN/FLUOCINOLONE
ACETONIDE OTOVEL 3 CIPROFLOXACIN/HYDROCORTISONE CIPRO HC 3 NEOMY
SULF/COLIST SUL/HC/THONZ COLY-MYCIN S 3 NEOMY SULF/COLIST
SUL/HC/THONZ CORTISPORIN-TC
Antibacterials (Eent) / DENTAL AGENT Tier Generic Name Brand Name
Notes
3 MINOCYCLINE HCL MICROSPHERES ARESTIN 4
Antibacterials (Eent) / OPHTHALMOLOGY Tier Generic Name Brand Name
Notes
1 BACITRACIN 1 BACITRACIN/POLYMYXIN B SULFATE AK-POLY-BAC 1
CIPROFLOXACIN HCL 1 GENTAMICIN SULFATE 1 GENTAMICIN SULFATE GENTAK
1 LEVOFLOXACIN 1 NEO/POLYMYX B SULF/DEXAMETH
NEOMYCIN-POLYMYXIN-DEXAMETH 1 NEOMY SULF/BACITRA/POLYMYXIN B
NEO-POLYCIN 1 NEOMY SULF/BACITRA/POLYMYXIN B
NEOMYCIN-BACITRACIN-POLYMYXIN 1 NEOMY SULF/BACITRAC ZN/POLY/HC
NEO-POLYCIN HC
4 - Office/Clinic Administration 5 - Prior Authorization
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Antibacterials (Eent) / OPHTHALMOLOGY (cont.) Tier Generic Name
Brand Name Notes
1 NEOMY SULF/BACITRAC ZN/POLY/HC NEOMYCIN-BACITRACIN-POLY-HC 1
NEOMYCIN/POLYMYXN B/GRAMICIDIN NEOMYCIN-POLYMYXIN-GRAMICIDIN 1
OFLOXACIN 1 POLYMYXIN B SULF/TRIMETHOPRIM POLYMYXIN B
SUL-TRIMETHOPRIM 1 SULFACETAMIDE SODIUM SULFAMIDE 1 SULFACETAMIDE
SODIUM 1 SULFACETAMIDE/PREDNISOLONE SP SULFACETAMIDE-PREDNISOLONE 1
TOBRAMYCIN 1 TOBRAMYCIN/DEXAMETHASONE TOBRAMYCIN-DEXAMETHASONE 2
SULFACETAMIDE SODIUM BLEPH-10 2 TOBRAMYCIN TOBREX 2
TOBRAMYCIN/DEXAMETHASONE TOBRADEX ST 2 TOBRAMYCIN/DEXAMETHASONE
TOBRADEX OPTHALMIC OINTMENT 3 AZITHROMYCIN AZASITE 3 BESIFLOXACIN
HCL BESIVANCE 3 CIPROFLOXACIN HCL CILOXAN 3 GATIFLOXACIN ZYMAXID 3
GATIFLOXACIN ZYMAR 3 MOXIFLOXACIN HCL VIGAMOX 3 MOXIFLOXACIN HCL
MOXEZA 3 NEO/POLYMYX B SULF/DEXAMETH MAXITROL 3 POLYMYXIN B
SULF/TRIMETHOPRIM POLYTRIM 3 SULFACETM NA/PREDNISOL AC BLEPHAMIDE
S.O.P. 3 SULFACETM NA/PREDNISOL AC BLEPHAMIDE 3
TOBRAMYCIN/DEXAMETHASONE TOBRADEX 3 TOBRAMYCIN/LOTEPRED ETAB
ZYLET
Antibacterials (Eent) / RESPIRATORY AGENTS Tier Generic Name Brand
Name Notes
2 MUPIROCIN CALCIUM BACTROBAN NASAL
Antibacterials (Skin & Mucous Membrane) / DERMATOLOGICAL AGENTS
Tier Generic Name Brand Name Notes
1 CLINDAMYCIN PHOS/BENZOYL PEROX CLINDAMYCIN PHOS-BENZOYL PEROX 1
CLINDAMYCIN PHOS/BENZOYL PEROX CLINDAMYCIN-BENZOYL PEROXIDE 1
CLINDAMYCIN PHOSPHATE 1 ERYTHROMYCIN BASE/ETHANOL ERY 1
ERYTHROMYCIN/BENZOYL PEROXIDE ERYTHROMYCIN-BENZOYL PEROXIDE 1
MUPIROCIN 2 CLINDAMYCIN PHOS/BENZOYL PEROX ACANYA 2
ERYTHROMYCIN/BENZOYL PEROXIDE BENZAMYCINPAK 2 METRONIDAZOLE
METROGEL 2 METRONIDAZOLE NORITATE 3 CLINDAMYCIN PHOS/BENZOYL PEROX
DUAC 3 CLINDAMYCIN PHOS/BENZOYL PEROX BENZACLIN 3 CLINDAMYCIN
PHOSPHATE CLINDAGEL 3 CLINDAMYCIN/TRETINOIN ZIANA 5 3
CLINDAMYCIN/TRETINOIN VELTIN 5 3 ERYTHROMYCIN BASE AKNE-MYCIN 3
METRONIDAZOLE METROLOTION 3 MUPIROCIN BACTROBAN 3 RETAPAMULIN
ALTABAX
5 - Prior Authorization
14 of 104
Antibacterials (Skin & Mucous Membrane) / OBSTETRICS &
GYNECOLOGY Tier Generic Name Brand Name Notes
1 CLINDAMYCIN PHOSPHATE 1 METRONIDAZOLE VANDAZOLE 2 CLINDAMYCIN
PHOSPHATE CLEOCIN 3 METRONIDAZOLE METROGEL-VAGINAL
Antibacterials- Miscellaneous / ANTI - INFECTIVES Tier Generic Name
Brand Name Notes
1 CLINDAMYCIN HCL 1 CLINDAMYCIN PALMITATE HCL 1 CLINDAMYCIN
PALMITATE HCL CLEOCIN PALMITATE 1 VANCOMYCIN HCL 3 CLINDAMYCIN HCL
CLEOCIN HCL 3 LINEZOLID ZYVOX 5 3 RIFAXIMIN XIFAXAN 5 3 VANCOMYCIN
HCL VANCOCIN HCL
Antibacterials- Miscellaneous / GI AGENTS Tier Generic Name Brand
Name Notes
3 BISMUTH SAL/METRONID/TETRACYC HELIDAC 3
BISMUTH/METRONID/TETRACYCLINE PYLERA
Antibacterials- Miscellaneous / OFFICE ADMINISTERED Tier Generic
Name Brand Name Notes
4 BEZLOTOXUMAB INJECTION ZINPLAVA 4
Anticholinergics / ANTIPARKINSON AGENTS Tier Generic Name Brand
Name Notes
1 BENZTROPINE MESYLATE 1 TRIHEXYPHENIDYL HCL 3 TRIHEXYPHENIDYL HCL
ARTANE
Anticoagulants / BLOOD PRODUCT/MODIFIERS Tier Generic Name Brand
Name Notes
1 WARFARIN SODIUM 2 DABIGATRAN ETEXILATE MESYLATE PRADAXA 3
WARFARIN SODIUM COUMADIN 4 DALTEPARIN SODIUM,PORCINE FRAGMIN 5 4
DARBEPOETIN ALFA ARANESP 5 4 ENOXAPARIN SODIUM LOVENOX 5 4
ENOXAPARIN SODIUM 5 4 FONDAPARINUX SODIUM 5
Anticonvulsants- Miscellaneous / ANTICONVULSANTS Tier Generic Name
Brand Name Notes
1 FELBAMATE
15 of 104
Anticonvulsants- Miscellaneous / ANTICONVULSANTS (cont.) Tier
Generic Name Brand Name Notes
1 LEVETIRACETAM 2 TIAGABINE HCL GABITRIL 3 BRIVARACETAM ORAL
SOLUTION BRIVIACT 3 BRIVARACETAM TABLETS BRIVIACT 4 BRIVARACETAM
FOR INJECTION BRIVIACT 4
Anticonvulsants- Other / ANTICONVULSANTS Tier Generic Name Brand
Name Notes
1 CARBAMAZEPINE EPITOL 2 EZOGABINE POTIGA 2 METHSUXIMIDE CELONTIN 3
CARBAMAZEPINE EQUETRO 3 LACOSAMIDE VIMPAT
Antidepressants / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH
Tier Generic Name Brand Name Notes
1 DESVENLAFAXINE SUCCINATE 1 MIRTAZAPINE 1 NEFAZODONE HCL 1
OLANZAPINE/FLUOXETINE HCL OLANZAPINE-FLUOXETINE HCL 3
DESVENLAFAXINE SUCCINATE PRISTIQ ER 3 DOXEPIN HCL SILENOR 3
MIRTAZAPINE REMERON 3 OLANZAPINE/FLUOXETINE HCL SYMBYAX 3
VILAZODONE HYDROCHLORIDE VIIBRYD
Antidiarrhea Agents / GI AGENTS Tier Generic Name Brand Name
Notes
1 DIPHENOXYLATE HCL/ATROPINE DIPHENOXYLATE-ATROPINE 1 LOPERAMIDE
HCL LOPERAMIDE 3 CROFELEMER FULYZAQ 5 3 DIPHENOXYLATE HCL/ATROPINE
LOMOTIL 3 OPIUM TINCTURE OPIUM
Antidotes / IMMUNOLOGICAL AGENTS Tier Generic Name Brand Name
Notes
2 LEUCOVORIN CALCIUM
Antiemetics- Miscellaneous / GI AGENTS Tier Generic Name Brand Name
Notes
3 SCOPOLAMINE TRANSDERM-SCOP 3 SCOPOLAMINE HYDROBROMIDE
SCOPACE
Antiemetics- Miscellaneous / OBSTETRICS & GYNECOLOGY Tier
Generic Name Brand Name Notes
3 DOXYLAMINE/PYRIDOXINE DICLEGIS
16 of 104
1 TAMOXIFEN CITRATE
1 FLUCYTOSINE 1 GRISEOFULVIN ULTRAMICROSIZE 1
GRISEOFULVIN,MICROSIZE GRISEOFULVIN 1 NYSTATIN 3 GRISEOFULVIN
ULTRAMICROSIZE GRIS-PEG 3 GRISEOFULVIN,MICROSIZE GRIFULVIN V
Antifungals (Eent) / OPHTHALMOLOGY Tier Generic Name Brand Name
Notes
3 NATAMYCIN NATACYN
Antifungals (Skin & Mucous Membrane) / DERMATOLOGICAL AGENTS
Tier Generic Name Brand Name Notes
1 CICLOPIROX 1 CLOTRIMAZOLE 1 ECONAZOLE NITRATE 1 KETOCONAZOLE
KETODAN 1 NYSTATIN NYSTOP 1 NYSTATIN NYAMYC 1 NYSTATIN/TRIAMCIN
NYSTATIN-TRIAMCINOLONE 2 SULCONAZOLE NITRATE EXELDERM 3
CICLOPIROX/NAIL LACQ/FT DEOD#4 PEDIPIROX-4 3 KETOCONAZOLE NIZORAL 3
KETOCONAZOLE XOLEGEL 3 MICONAZOLE NITRATE/ZINC OX/PET VUSION 3
NAFTIFINE HCL NAFTIN 3 OXICONAZOLE NITRATE OXISTAT 3 SERTACONAZOLE
NITRATE ERTACZO
Antifungals (Skin & Mucous Membrane) / OBSTETRICS &
GYNECOLOGY Tier Generic Name Brand Name Notes
1 TERCONAZOLE
3 COAGULATION FACTOR IX RECOMBINANT FOR INJ
IDELVION 4
4 ANTIHEMOPHILIC FACTOR ELOCTATE 4 4 ANTIHEMOPHILIC FACTOR
RECOMBINANT NUWIQ 4 4 ANTIHEMOPHYLIC FACTOR VIII, RECOMBINANT
AFSTYLA 4 4 ANTIHEMOPHYLIC FACTOR [RECOMBINANT]
PEGYLATED INJECTION ADYNOVATE 4
4 COAGULATION FACTOR IX, RECOMBINANT IXINITY 4 4 COAGULATION FACTOR
VIII, RECOMBINANT KOVALTRY 4 4 COAGULATION FACTOR X [HUMAN]
FOR
INJECTION COAGADEX 4
4 - Office/Clinic Administration
17 of 104
Antihemophilic / OFFICE ADMINISTERED (cont.) Tier Generic Name
Brand Name Notes
4 VON WILLEBRAND FACTOR RECOMBINANT FOR INJ
VONVENDI 4
1 RIBAVIRIN RIBASPHERE 5 1 RIBAVIRIN RIBAPAK 5 1 RIBAVIRIN 5 2
LEDIPASVIR/SOFOSBUVIR HARVONI 5 2 SOFOSBUVIR/VELPATASVIR EPCLUSA 5
2 SOFOSBUVIR/VELPATASVIR/VOXILAPREVIR VOSEVI 5 3 BOCEPREVIR
VICTRELIS 5 3 GLECAPREVIR/PIBRENTASVIR MAVYRET 5 3
GRAZOPREVIR/ELBASVIR ZEPATIER 5 3 PARITAPREVIR;/RITON/OMBITAS/DASA
VIEKIRA PAK 5 3 RIBAVIRIN REBETOL 5 3 RIBAVIRIN COPEGUS 5 3
SIMEPREVIR OLYSIO 5 3 SOFOSBUVIR SOLVALDI 5 3 TELAPREVIR INCIVEK 5
4 DACLATASVIR DAKLINZA 5 4 OMBITASVIR/PARITAPREVIR/RITONAVIR
TECHNIVIE 5 4 PEGINTERFERON ALFA-2A PEGASYS PROCLICK 5 4
PEGINTERFERON ALFA-2A PEGASYS 5 4 PEGINTERFERON ALFA-2B PEGINTRON
REDIPEN 5
Antiherpetic / ANTIVIRALS Tier Generic Name Brand Name Notes
1 ACYCLOVIR 6 1 VALACYCLOVIR HCL VALACYCLOVIR 6 3 ACYCLOVIR ZOVIRAX
6 3 ACYCLOVIR SITAVIG 3 VALACYCLOVIR HCL VALTREX 6
Antihistamines (Gi Drugs) / GI AGENTS Tier Generic Name Brand Name
Notes
1 MECLIZINE HCL 1 PROCHLORPERAZINE MALEATE COMPRO 1
PROCHLORPERAZINE MALEATE 1 TRIMETHOBENZAMIDE HCL 3 MECLIZINE HCL
ANTIVERT
Antimalarial Agents / ANTI - INFECTIVES Tier Generic Name Brand
Name Notes
1 CHLOROQUINE PHOSPHATE 1 HYDROXYCHLOROQUINE SULFATE
4 - Office/Clinic Administration 5 - Prior Authorization 6 -
Quantity Limit
18 of 104
Antimalarial Agents / ANTI - INFECTIVES (cont.) Tier Generic Name
Brand Name Notes
1 MEFLOQUINE HCL 2 PRIMAQUINE PHOSPHATE PRIMAQUINE 2 PYRIMETHAMINE
DARAPRIM 3 HYDROXYCHLOROQUINE SULFATE PLAQUENIL
Antimalarials / ANTI - INFECTIVES Tier Generic Name Brand Name
Notes
1 ATOVAQUONE/PROGUANIL HCL ATOVAQUONE-PROGUANIL HCL 1 QUININE
SULFATE 3 ATOVAQUONE/PROGUANIL HCL MALARONE
Antimetabolite / ANTINEOPLASTICS Tier Generic Name Brand Name
Notes
1 MERCAPTOPURINE 1 THIOGUANINE 2 METHOTREXATE SODIUM TREXALL 4
METHOTREXATE SODIUM METHOTREXATE 5
Antimuscarinic/Beta Agonist / RESPIRATORY AGENTS Tier Generic Name
Brand Name Notes
2 UMECLIDINIUM/VILANTEROL ANORO ELLIPTA
1 CHLORDIAZEPOXIDE/CLIDINIUM BR CHLORDIAZEPOXIDE-CLIDINIUM 1
DICYCLOMINE HCL 1 GLYCOPYRROLATE 1 PROPANTHELINE BROMIDE
Antimuscarinics/Antispasmodics / RESPIRATORY AGENTS Tier Generic
Name Brand Name Notes
1 IPRATROPIUM BROMIDE 6 1 IPRATROPIUM/ALBUTEROL SULFATE
IPRATROPIUM-ALBUTEROL 6 2 IPRATROPIUM BROMIDE ATROVENT HFA 6 2
TIOTROPIUM BROMIDE SPIRIVA 6 3 ACLIDINIUM BROMIDE TUDORZA PRESSAIR
3 GLYCOPYRROLATE INHALATION POWDER SEEBRI NEOHALER 3
IPRATROPIUM/ALBUTEROL SULFATE COMBIVENT 6 3 IPRATROPIUM/ALBUTEROL
SULFATE COMBIVENT RESPIMAT 6
Antineoplastic Agents / ANTINEOPLASTICS Tier Generic Name Brand
Name Notes
1 BICALUTAMIDE 1 HYDROXYUREA 1 IMATINIB MESYLATE 5 1 MEGESTROL
ACETATE
5 - Prior Authorization 6 - Quantity Limit
19 of 104
Antineoplastic Agents / ANTINEOPLASTICS (cont.) Tier Generic Name
Brand Name Notes
2 MEGESTROL ACETATE MEGACE ES 2 THIOGUANINE TABLOID 2 TOREMIFENE
CITRATE FARESTON 3 ABIRATERONE ACETATE ZYTIGA 3 CABOZANTINIB
COMETRIQ 5 3 CABOZANTINIB CABOMETYX 5 3 CAPECITABINE XELODA 3
CRIZOTINIB XALKORI 3 DASATINIB SPRYCEL 3 ERLOTINIB HCL TARCEVA 5 3
EVEROLIMUS AFINITOR 3 IMATINIB MESYLATE GLEEVEC 5 3 LAPATINIB
DITOSYLATE TYKERB 3 LETROZOLE FEMARA 3 NIRAPARIB CAPSULES ZEJULA 5
3 REGORAFENIB STIVARGA 3 TEMOZOLOMIDE TEMODAR 3 VISMODEGIB ERIVEDGE
5 4 LEUPROLIDE ACETATE 5 4 PONATINIB ICLUSIG 5 4 RADIUM RA 223
XOFIGO 5 4 TRIFLURIDINE/TIPIRACIL LONSURF 5
Antineoplastic Agents / OFFICE ADMINISTERED Tier Generic Name Brand
Name Notes
4 LEUPROLIDE ACETATE LUPRON DEPOT 4
Antineoplastic Other / ANTINEOPLASTICS Tier Generic Name Brand Name
Notes
4 DINUTUXIMAB FOR INJECTION UNITUXIN 4 4 OMACETAXINE MEPESUCCINATE
FOR INJECTION SYNRIBO 4 4 SONIDEGIB CAPSULES ODOMZO 5 4 TRABECTEDIN
FOR INJECTION YONDELIS 4 4 VINBLASTINE VELBAN 4 4 VINCRISTINE
ONCOVIN 4 4 VINORELBINE NAVELBINE 4
Antiparkinsonian Agents / AUTONOMIC & CNS DRUGS, NEUROLOGY
& PSYCH Tier Generic Name Brand Name Notes
1 CARBIDOPA 3 CARBIDOPA LODOSYN
Antiprotozoals / ANTIPARASITICS Tier Generic Name Brand Name
Notes
1 CHLOROQUINE 1 METRONIDAZOLE 1 TINIDAZOLE 3 NITAZOXANIDE
ALINIA
4 - Office/Clinic Administration 5 - Prior Authorization
20 of 104
3 TINIDAZOLE TINDAMAX
3 DOXEPIN HCL ZONALON 3 NORFLURANE/HFC 245FA PAIN EASE 3
TETRACAINE/BENZOCAINE/BUTAMBEN CETACAINE
Antipruritics And Local Anesthetics / UROLOGICALS Tier Generic Name
Brand Name Notes
1 PHENAZOPYRIDINE HCL
1 DIDANOSINE 1 LAMIVUDINE 1 LAMIVUDINE/ZIDOVUDINE
LAMIVUDINE-ZIDOVUDINE 1 NEVIRAPINE 2 EFAVIRENZ SUSTIVA 2
EFAVIRENZ/EMTRICITAB/TENOFOVIR ATRIPLA 2
EMTRICITAB/RILPIVIRINE/TENOFOV COMPLERA 2 EMTRICITABINE EMTRIVA 2
ETRAVIRINE INTELENCE 2 MARAVIROC SELZENTRY 2 NEVIRAPINE VIRAMUNE 2
TENOFOVIR ALAFENAMIDE TABLETS VEMLIDY 5 2 TENOFOVIR DISOPROXIL
FUMARATE VIREAD 3 NEVIRAPINE VIRAMUNE XR
Antisense Oligonucleotide / OFFICE ADMINISTERED Tier Generic Name
Brand Name Notes
4 ETEPLIRSEN INJECTION EXONDYS 51 4 4 NUSINERSEN INJECTION SPINRAZA
4
Antispasmodics / GI AGENTS Tier Generic Name Brand Name Notes
1 HYOSCYAMINE SULFATE HYOMAX-SR 1 HYOSCYAMINE SULFATE 1 HYOSCYAMINE
SULFATE OSCIMIN 1 HYOSCYAMINE SULFATE OSCIMIN SR 1 HYOSCYAMINE
SULFATE HYOMAX-SL 1 HYOSCYAMINE SULFATE HYOMAX-FT 1 HYOSCYAMINE
SULFATE OSCIMIN SL 1 PHENOBARB/HYOSCY/ATROPINE/SCOP
BELLADONNA-PHENOBARBITAL 1 PHENOBARB/HYOSCY/ATROPINE/SCOP QUADRAPAX
1 PHENOBARB/HYOSCY/ATROPINE/SCOP SE-DONNA PB HYOS 3
PHENOBARB/HYOSCY/ATROPINE/SCOP DONNATAL
4 - Office/Clinic Administration 5 - Prior Authorization
21 of 104
1 METHIMAZOLE 1 PROPYLTHIOURACIL 3 POTASSIUM IODIDE SSKI
Antituberculosis Agents / ANTIMYCOBACTERIALS Tier Generic Name
Brand Name Notes
1 ETHAMBUTOL HCL MYAMBUTOL 1 ETHAMBUTOL HCL 1 ISONIAZID 1
PYRAZINAMIDE 1 RIFAMPIN 2 BEDAQUILINE SIRTURO 5 2 RIFABUTIN
MYCOBUTIN 3 RIFAPENTINE PRIFTIN
Antitussives / RESPIRATORY AGENTS Tier Generic Name Brand Name
Notes
1 BENZONATATE 1 BROMPHENIRAMIN/PE/DEXTROMETHOR LOHIST-DM 1
CODEINE/PROMETHAZINE HCL PROMETHAZINE-CODEINE 1 D-METHORPHAN
HB/PROMETH HCL PROMETHAZINE-DM 1 GUAIFENESIN/CODEINE PHOSPHATE
IOPHEN-C NR 1 GUAIFENESIN/CODEINE PHOSPHATE CHERATUSSIN AC 1
GUAIFENESIN/CODEINE PHOSPHATE GUAIFENESIN AC 1 GUAIFENESIN/CODEINE
PHOSPHATE GUAIFENESIN-CODEINE 1 GUAIFENESIN/CODEINE PHOSPHATE
DEX-TUSS 1 HYDROCODONE BIT/HOMATROP ME-BR HYDROCODONE-HOMATROPINE
MBR 1 HYDROCODONE BIT/HOMATROP ME-BR HYDROMET 1
HYDROCODONE/CHLORPHEN POLIS HYDROCODONE-CHLORPHENIRAMINE 1 P-EPHED
HCL/CODEINE/GUAIFEN CHERATUSSIN DAC 1 P-EPHED HCL/CODEINE/GUAIFEN
MYTUSSIN DAC 1 P-EPHED HCL/CODEINE/GUAIFEN GUAIFENESIN DAC 1
PHENYLEPHRINE HCL/COD/PROMETH PROMETHAZINE VC-CODEINE 3
D-METHORPHAN HB/P-EPD HCL/BPM BROMFED DM 3 HYDROCODONE/CHLORPHEN
POLIS TUSSICAPS
Antivirals (Eent) / ANTIVIRALS Tier Generic Name Brand Name
Notes
1 TRIFLURIDINE
Antivirals (Skin & Mucous Membrane) / DERMATOLOGICAL AGENTS
Tier Generic Name Brand Name Notes
3 ACYCLOVIR/HYDROCORTISONE XERESE 3 PENCICLOVIR DENAVIR
Antivirals- Miscellaneous / OFFICE ADMINISTERED Tier Generic Name
Brand Name Notes
4 HUMAN PAPILLOMAVIRUS GARDASIL/CERVARIX 4
4 - Office/Clinic Administration 5 - Prior Authorization
22 of 104
Anxiolytics- Sedatives & Hypnotics-Misc. / AUTONOMIC & CNS
DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name
Notes
1 BUSPIRONE HCL 1 CHLORAL HYDRATE 1 ESZOPICLONE 6 1 ZALEPLON 6 1
ZOLPIDEM TARTRATE 6 1 ZOLPIDEM TARTRATE ZOLPIDEM TARTRATE ER 6 2
CHLORAL HYDRATE SOMNOTE 3 ESZOPICLONE LUNESTA 6 3 RAMELTEON ROZEREM
3 ZALEPLON SONATA 6 3 ZOLPIDEM TARTRATE EDLUAR 6 3 ZOLPIDEM
TARTRATE AMBIEN 6 3 ZOLPIDEM TARTRATE INTERMEZZO 6 3 ZOLPIDEM
TARTRATE AMBIEN CR 6
Anxiolytics- Sedatives & Hypnotics-Misc. / DIAGNOSTICS &
MISCELLANEOUS AGENTS Tier Generic Name Brand Name Notes
3 DICHLORALPHENAZONE
1 HYDROXYZINE HCL 1 HYDROXYZINE PAMOATE
Aromatase Inhibitor / ANTINEOPLASTICS Tier Generic Name Brand Name
Notes
1 ANASTROZOLE 1 EXEMESTANE 1 LETROZOLE 3 ANASTROZOLE ARIMIDEX
Astringents / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name
Notes
1 ALUMINUM CHLORIDE HYPERCARE 3 ALUMINUM CHLORIDE XERAC AC 3
ALUMINUM CHLORIDE DRYSOL
Atypical/2nd Generation / ANTIPSYCHOTICS Tier Generic Name Brand
Name Notes
1 OLANZAPINE OLANZAPINE ODT 1 OLANZAPINE 1 QUETIAPINE FUMARATE 1
RISPERIDONE RISPERIDONE ODT 1 RISPERIDONE 1 RISPERIDONE RISPERIDONE
M-TAB 1 ZIPRASIDONE HCL 2 ARIPIPRAZOLE ABILIFY DISCMELT 2
ARIPIPRAZOLE ABILIFY 3 ASENAPINE MALEATE SAPHRIS
6 - Quantity Limit
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Atypical/2nd Generation / ANTIPSYCHOTICS (cont.) Tier Generic Name
Brand Name Notes
3 BREXPIPRAZOLE REXULTI 3 CARIPRAZINE VRAYLAR 7 3 ILOPERIDONE
FANAPT 3 LURASIDONE HCL LATUDA 3 OLANZAPINE ZYPREXA 3 OLANZAPINE
ZYPREXA ZYDIS 3 PALIPERIDONE INVEGA 3 PIMAVANSERIN TABLETS NUPLAZID
5 3 QUETIAPINE FUMARATE SEROQUEL 3 QUETIAPINE FUMARATE SEROQUEL XR
3 ZIPRASIDONE HCL GEODON 4 PALIPERIDONE PALMITATE INVEGA SUSTENNA
5
Azoles / ANTIFUNGALS Tier Generic Name Brand Name Notes
1 CLOTRIMAZOLE 1 FLUCONAZOLE 1 ITRACONAZOLE 1 KETOCONAZOLE 1
VORICONAZOLE 5 3 EFINACONAZOLE JUBLIA 5 3 FLUCONAZOLE DIFLUCAN 3
ISAVUCONAZOMIUN CRESEMBA 5 3 LULICONAZOLE LUZU 3 POSACONAZOLE
NOXAFIL
B-lymphocyte stimulator / MUSCULOSKELETAL & RHEUMATOLOGY Tier
Generic Name Brand Name Notes
4 BELIMUMAB BENLYSTA 5
3 VENETOCLAX TABLETS VENCLEXTA 5
BILE ACID SYNTHESIS DISORDER / ENDOCRINE Tier Generic Name Brand
Name Notes
4 CHOLIC ACID CAPSULES CHOLBAM 5
BPH / GI AGENTS Tier Generic Name Brand Name Notes
1 ALFUZOSIN 1 DOXAZOSIN MESYLATE DOXAZOSIN 1 TAMSULOSIN 1 TERAZOSIN
HCL TERAZOSIN 3 SILODOSIN RAPAFLO 3 TAMSULOSIN FLOMAX
BRAF Inhibitor / ANTINEOPLASTICS Tier Generic Name Brand Name
Notes
3 DABRAFENIB TAFINLAR 5
24 of 104
BRAF Inhibitor / ANTINEOPLASTICS (cont.) Tier Generic Name Brand
Name Notes
3 VEMURAFENIB ZELBORAF 5
1 PRIMIDONE
1 PHENOBARBITAL
Basic Lotions And Liniments / DERMATOLOGICAL AGENTS Tier Generic
Name Brand Name Notes
1 AMMONIUM LACTATE
Basic Ointments And Protectants / DERMATOLOGICAL AGENTS Tier
Generic Name Brand Name Notes
1 AMMONIUM LACTATE LAC-HYDRIN
Benzodiazepines (Anticonvulsants) / ANTICONVULSANTS Tier Generic
Name Brand Name Notes
1 CLONAZEPAM 3 CLOBAZAM ONFI 3 CLONAZEPAM KLONOPIN 3 DIAZEPAM
DIASTAT ACUDIAL
Benzodiazepines (Anxiolytic) / ANXIOLYTICS Tier Generic Name Brand
Name Notes
1 ALPRAZOLAM ALPRAZOLAM ER 1 ALPRAZOLAM 1 ALPRAZOLAM ALPRAZOLAM ODT
1 ALPRAZOLAM ALPRAZOLAM XR 1 CHLORDIAZEPOXIDE HCL 1 CLORAZEPATE
DIPOTASSIUM 1 DIAZEPAM 1 LORAZEPAM LORAZEPAM INTENSOL 1 LORAZEPAM 1
OXAZEPAM 3 ALPRAZOLAM XANAX 3 DIAZEPAM VALIUM 3 LORAZEPAM
ATIVAN
Benzodiazepines (Sedative/Hyp) / SLEEP DISORDERS Tier Generic Name
Brand Name Notes
1 ESTAZOLAM 1 FLURAZEPAM HCL 6
5 - Prior Authorization 6 - Quantity Limit
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1 TEMAZEPAM 6 1 TRIAZOLAM 6
Beta-Adrenergic Agonists / RESPIRATORY AGENTS Tier Generic Name
Brand Name Notes
1 LEVALBUTEROL HCL LEVALBUTEROL 6 2 ALBUTEROL SULFATE VENTOLIN HFA
6 2 ALBUTEROL SULFATE PROVENTIL HFA 6 2 ALBUTEROL SULFATE PROAIR
HFA 6 3 ARFORMOTEROL TARTRATE BROVANA 3 INDACATEROL MALEATE ARCAPTA
NEOHALER 3 LEVALBUTEROL TARTRATE XOPENEX HFA 6
Beta-Adrenergic Blocking Agents / ANTIMIGRAINE PHOPHYLACTIC Tier
Generic Name Brand Name Notes
1 PROPRANOLOL HCL
1 ATENOLOL 1 ATENOLOL/CHLORTHALIDONE ATENOLOL-CHLORTHALIDONE 1
BISOPROLOL FUMARATE 1 BISOPROLOL FUMARATE/HCTZ
BISOPROLOL-HYDROCHLOROTHIAZIDE 1 CARVEDILOL 1 LABETALOL HCL 1
METOPROLOL SUCCINATE 1 METOPROLOL TARTRATE 1
METOPROLOL/HYDROCHLOROTHIAZIDE METOPROLOL-HYDROCHLOROTHIAZIDE 1
NADOLOL 1 PINDOLOL 1 PROPRANOLOL HCL 1 SOTALOL HCL SOTALOL 1
SOTALOL HCL SOTALOL AF 2 CARVEDILOL PHOSPHATE COREG CR 3 ATENOLOL
TENORMIN 3 CARVEDILOL COREG 3 METOPROLOL SUCCINATE TOPROL XL 3
NADOLOL CORGARD 3 NEBIVOLOL HCL BYSTOLIC 3 PROPRANOLOL HCL
HEMANGEOL 3 PROPRANOLOL HCL INDERAL LA 3 PROPRANOLOL HCL INNOPRAN
XL
Beta-Adrenergic Blocking Agents (Eent) / OPHTHALMOLOGY Tier Generic
Name Brand Name Notes
1 BETAXOLOL HCL 1 LEVOBUNOLOL HCL 1 TIMOLOL MALEATE 2 BETAXOLOL HCL
BETOPTIC S 2 TIMOLOL MALEATE ISTALOL
6 - Quantity Limit
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Beta-Adrenergic Blocking Agents (Eent) / OPHTHALMOLOGY (cont.) Tier
Generic Name Brand Name Notes
2 TIMOLOL MALEATE/PF TIMOPTIC OCUDOSE 3 TIMOLOL BETIMOL 3 TIMOLOL
MALEATE TIMOPTIC
Beta-Lactam, Other / ANTIBACTERIALS Tier Generic Name Brand Name
Notes
4 AZTREONAM AZACTAM 4 4 IMIPENEM PRIMAXIN 4 4 IMIPENEM/CILASTATN
IMIPENEM/CILASTATIN 4 4 MEROPENEM 4
Biguanides / BLOOD GLUCOSE REGULATORS Tier Generic Name Brand Name
Notes
1 METFORMIN HCL METFORMIN HCL ER 1 METFORMIN HCL 1 METFORMIN HCL ER
(MOD) METFORMIN ER (MOD) 5 1 METFORMIN HCL ER (OSM) 2 METFORMIN HCL
METFORMIN HYDROCHLORIDE 2 METFORMIN HCL RIOMET 3 METFORMIN HCL
GLUCOPHAGE 3 METFORMIN HCL ER GLUCOPHAGE XR 3 METFORMIN HCL ER
(MOD) GLUMETZA 5 3 METFORMIN HCL ER (OSM) FORTAMET
Bile Acid Sequestrants / CARDIOVASCULAR Tier Generic Name Brand
Name Notes
1 CHOLESTYRAMINE (WITH SUGAR) CHOLESTYRAMINE 1
CHOLESTYRAMINE/ASPARTAME PREVALITE 1 CHOLESTYRAMINE/ASPARTAME
CHOLESTYRAMINE LIGHT 1 COLESTIPOL HCL 3 COLESEVELAM HCL
WELCHOL
Bipolar - Other / BIPOLAR AGENTS Tier Generic Name Brand Name
Notes
1 ALPRAZOLAM 1 DIAZEPAM 1 OLANZAPINE 3 ARIPIPRAZOLE ABILIFY 3
LURASIDONE HCL LATUDA
Blood Formation Modifiers / ANTICONVULSANTS Tier Generic Name Brand
Name Notes
3 EDOXABAN SAVAYSA
Blood Formation Modifiers / BLOOD PRODUCT/MODIFIERS Tier Generic
Name Brand Name Notes
2 APIXABAN ELIQUIS 5
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2 RIVAROXABAN XARELTO 3 CLOPIDOGREL BISULFATE PLAVIX 4 FONDAPARINUX
SODIUM ARIXTRA 5 4 HEPARIN 4
Bone Resorption Inhibitors / MUSCULOSKELETAL & RHEUMATOLOGY
Tier Generic Name Brand Name Notes
1 ALENDRONATE SODIUM 1 IBANDRONATE SODIUM 1 RISEDRONATE 2
ALENDRONATE SODIUM/VITAMIN D3 FOSAMAX PLUS D 3 ALENDRONATE SODIUM
FOSAMAX 3 ALENDRONATE SODIUM BINOSTO 3 IBANDRONATE SODIUM BONIVA 3
RISEDRONATE SODIUM ATELVIA 3 RISEDRONATE SODIUM ACTONEL
C1 Esterase Inhibitor / OFFICE ADMINISTERED Tier Generic Name Brand
Name Notes
4 C1 ESTERASE INHIBITOR RUCONEST 4
CYSTIC FIBROSIS TRANSMEMBRANE REGULATOR PROTEIN / RESPIRATORY
AGENTS Tier Generic Name Brand Name Notes
4 LUMACAFTOR/IVACAFTOR ORKAMBI 5
Calcium Channel Agents / ANTICONVULSANTS Tier Generic Name Brand
Name Notes
1 ETHOSUXIMIDE 1 LAMOTRIGINE 2 LAMOTRIGINE LAMICTAL (GREEN) 2
LAMOTRIGINE LAMICTAL (ORANGE) 3 LAMOTRIGINE LAMICTAL ODT (ORANGE) 3
LAMOTRIGINE LAMICTAL 3 LAMOTRIGINE LAMICTAL ODT 3 LAMOTRIGINE
LAMICTAL XR 3 LEVETIRACETAM KEPPRA XR 3 LEVETIRACETAM KEPPRA
Calcium Channel Blocker/ARB / CARDIOVASCULAR Tier Generic Name
Brand Name Notes
1 AMLODIPINE/VALSARTAN 7 3 AMLODIPINE/VALSARTAN EXFORGE 7 3
AMLODIPINE/VALSARTAN/HCTZ EXFORGE HCT 7
Calcium-Channel Blocking Agents- Misc. / CARDIOVASCULAR Tier
Generic Name Brand Name Notes
1 DILTIAZEM HCL TAZTIA XT
4 - Office/Clinic Administration 5 - Prior Authorization 7 - Step
Therapy
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Calcium-Channel Blocking Agents- Misc. / CARDIOVASCULAR (cont.)
Tier Generic Name Brand Name Notes
1 DILTIAZEM HCL CARTIA XT 1 DILTIAZEM HCL DILTIAZEM 24HR CD 1
DILTIAZEM HCL DILT-XR 1 DILTIAZEM HCL MATZIM LA 1 DILTIAZEM HCL
DILTIAZEM 24HR ER 1 DILTIAZEM HCL DILTIAZEM ER 1 DILTIAZEM HCL 1
VERAPAMIL HCL 1 VERAPAMIL HCL VERAPAMIL ER 1 VERAPAMIL HCL
VERAPAMIL ER PM 3 DILTIAZEM HCL CARDIZEM CD 3 DILTIAZEM HCL
CARDIZEM LA 3 DILTIAZEM HCL TIAZAC 3 VERAPAMIL HCL CALAN SR
Carbonic Anhydrase Inhibitors / CARDIOVASCULAR Tier Generic Name
Brand Name Notes
1 ACETAZOLAMIDE 3 ACETAZOLAMIDE DIAMOX SEQUELS
Carbonic Anhydrase Inhibitors (Eent) / OPHTHALMOLOGY Tier Generic
Name Brand Name Notes
1 ACETAZOLAMIDE 1 DORZOLAMIDE HCL 1 DORZOLAMIDE HCL/TIMOLOL MALEAT
DORZOLAMIDE-TIMOLOL 1 METHAZOLAMIDE 2 BRINZOLAMIDE AZOPT 3
DORZOLAMIDE HCL/TIMOLOL MALEAT COSOPT 3 DORZOLAMIDE/TIMOLOL/PF
COSOPT PF
Cardiac Drugs- Miscellaneous / CARDIOVASCULAR Tier Generic Name
Brand Name Notes
2 Ivabradine HCL Corlanor 3 RANOLAZINE RANEXA 3
SACUBITRIL/VALSARTAN ENTRESTO 5
Cariostatic Agents / VITAMINS, HEMATINICS & ELECTROLYTES Tier
Generic Name Brand Name Notes
1 SODIUM FLUORIDE RENAF 1 SODIUM FLUORIDE FLUORITAB 1 SODIUM
FLUORIDE FLUORIDE 1 SODIUM FLUORIDE EPIFLUR 1 SODIUM FLUORIDE 1
SODIUM FLUORIDE LUDENT FLUORIDE 2 SODIUM FLUORIDE FLURA-DROPS 2
SODIUM FLUORIDE FLUORABON 2 SODIUM FLUORIDE FLUOR-A-DAY
Catechol-O-Methyltransferase(Comt)Inhib. / AUTONOMIC & CNS
DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name
Notes
1 ENTACAPONE
2 ENTACAPONE COMTAN
Cell Stimulants And Proliferants / DERMATOLOGICAL AGENTS Tier
Generic Name Brand Name Notes
1 TRETINOIN 5 2 TRETINOIN AVITA 5 2 TRETINOIN ATRALIN 5 2 TRETINOIN
MICROSPHERES RETIN-A MICRO PUMP 5 2 TRETINOIN MICROSPHERES RETIN-A
MICRO 5
Central Alpha-Agonists / CARDIOVASCULAR Tier Generic Name Brand
Name Notes
1 GUANFACINE HCL 1 METHYLDOPA
Central Monoamine-Depleting Agent / CNS AGENTS Tier Generic Name
Brand Name Notes
3 VALBENAZINE CAPSULES INGREZZA 5 4 DEUTETRABENAZINE TABLETS
AUSTEDO 5
Central Nervous System Agents- Misc. / AUTONOMIC & CNS DRUGS,
NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes
3 DEXTROMETHORPHAN HBR/QUINIDINE NUEDEXTA 5
Central Nervous System Agents- Misc. / DIAGNOSTICS &
MISCELLANEOUS AGENTS Tier Generic Name Brand Name Notes
3 RILUZOLE RILUTEK
Centrally Acting Skeletal Muscle Relaxnt / ANTISPASTICITY AGENTS
Tier Generic Name Brand Name Notes
1 CARISOPRODOL 1 CHLORZOXAZONE 1 CYCLOBENZAPRINE HCL 1 METAXALONE 1
METHOCARBAMOL 1 TIZANIDINE HCL 3 CARISOPRODOL SOMA 3
CYCLOBENZAPRINE HCL AMRIX 3 METAXALONE SKELAXIN
Cephalosporins / ANTIBACTERIALS Tier Generic Name Brand Name
Notes
1 CEFACLOR 1 CEFADROXIL HYDRATE CEFADROXIL 1 CEFAZOLIN 1 CEFDINIR 1
CEFPROZIL
5 - Prior Authorization
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Cephalosporins / ANTIBACTERIALS (cont.) Tier Generic Name Brand
Name Notes
1 CEFUROXIME AXETIL CEFUROXIME 1 CEPHALEXIN 3 CEFIXIME SUPRAX 3
CEFRADINE VELOSEF 3 CEFTIBUTEN CEDAX 3 CEFTIBUTEN DIHYDRATE CEDAX 3
CEFUROXIME AXETIL CEFTIN 3 CEPHALEXIN KEFLEX 4 CEFEPIME MAXIPIME 4
4 CEFOTAXIME CLAFORAN 4 4 CEFOTETAN CEFOTAN 4 4 CEFOXITAN MEFOXIN
4
Chelator / CARDIOVASCULAR Tier Generic Name Brand Name Notes
3 DEFERASIROX EXJADE 5
Cholelitholytic Agents / GI AGENTS Tier Generic Name Brand Name
Notes
1 URSODIOL 3 URSODIOL ACTIGALL
Cholesterol Absorption Inhibitors / CARDIOVASCULAR Tier Generic
Name Brand Name Notes
3 LOMITAPIDE JUXTAPID 5 4 MIPOMERSEN KYNAMRO 5
Cholinesterase Inhibitors / ANTIDEMENTIA AGENTS Tier Generic Name
Brand Name Notes
1 DONEPEZIL HCL 1 GALANTAMINE 1 RIVASTIGMINE 3 RIVASTIGMINE EXELON
PATCH
Coagulant - Vitamin K / BLOOD PRODUCT/MODIFIERS Tier Generic Name
Brand Name Notes
2 PHYTONADIONE MEPHYTON
Complement Inhibitors / RESPIRATORY AGENTS Tier Generic Name Brand
Name Notes
4 ICATIBANT ACETATE FIRAZYR 5
Contraceptives / OBSTETRICS & GYNECOLOGY Tier Generic Name
Brand Name Notes
1 DESOG-ET ESTRA/ETHIN ESTRA KARIVA 3
3 - No copay 4 - Office/Clinic Administration 5 - Prior
Authorization
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Contraceptives / OBSTETRICS & GYNECOLOGY (cont.) Tier Generic
Name Brand Name Notes
1 DESOG-ET ESTRA/ETHIN ESTRA VIORELE 1 DESOG-ET ESTRA/ETHIN ESTRA
AZURETTE 3 1 DESOGESTREL-ETHINYL ESTRADIOL RECLIPSEN 3 1
DESOGESTREL-ETHINYL ESTRADIOL APRI 3 1 DESOGESTREL-ETHINYL
ESTRADIOL VELIVET 1 DESOGESTREL-ETHINYL ESTRADIOL CAZIANT 3 1
DESOGESTREL-ETHINYL ESTRADIOL EMOQUETTE 3 1 ETHYNODIOL D-ETHINYL
ESTRADIOL ZOVIA 1-35E 3 1 ETHYNODIOL D-ETHINYL ESTRADIOL ZOVIA
1-50E 3 1 ETHYNODIOL D-ETHINYL ESTRADIOL KELNOR 1-35 3 1
L-NORGEST-ETH ESTR/ETHIN ESTRA AMETHIA 3 1 L-NORGEST-ETH ESTR/ETHIN
ESTRA AMETHIA LO 3 1 L-NORGEST-ETH ESTR/ETHIN ESTRA LEVONORG-ETH
ESTRAD ETH ESTRAD 3 1 L-NORGEST-ETH ESTR/ETHIN ESTRA CAMRESE LO 3 1
L-NORGEST-ETH ESTR/ETHIN ESTRA CAMRESE 3 1 LEVONORGESTREL NEXT
CHOICE 3 1 LEVONORGESTREL-ETH ESTRADIOL LESSINA 3 1
LEVONORGESTREL-ETH ESTRADIOL AVIANE 3 1 LEVONORGESTREL-ETH
ESTRADIOL MYZILRA 3 1 LEVONORGESTREL-ETH ESTRADIOL AMETHYST 3 1
LEVONORGESTREL-ETH ESTRADIOL ENPRESSE 3 1 LEVONORGESTREL-ETH
ESTRADIOL ALTAVERA 1 LEVONORGESTREL-ETH ESTRADIOL JOLESSA 3 1
LEVONORGESTREL-ETH ESTRADIOL TRIVORA-28 3 1 LEVONORGESTREL-ETH
ESTRADIOL SRONYX 3 1 LEVONORGESTREL-ETH ESTRADIOL QUASENSE 3 1
LEVONORGESTREL-ETH ESTRADIOL PORTIA 3 1 LEVONORGESTREL-ETH
ESTRADIOL LUTERA 3 1 LEVONORGESTREL-ETH ESTRADIOL ORSYTHIA 3 1
LEVONORGESTREL-ETH ESTRADIOL INTROVALE 3 1 LEVONORGESTREL-ETH
ESTRADIOL LEVORA-28 3 1 NORELGESTROMIN/ETHIN.ESTRADIOL
NORELGESTROMIN/ETH ESTRADIOL 3 1 NORETH A-ET ESTRA/FE FUMARATE
JUNEL FE 3 1 NORETH A-ET ESTRA/FE FUMARATE GILDESS FE 3 1 NORETH
A-ET ESTRA/FE FUMARATE TILIA FE 3 1 NORETH A-ET ESTRA/FE FUMARATE
MICROGESTIN FE 3 1 NORETH A-ET ESTRA/FE FUMARATE TRI-LEGEST FE 3 1
NORETH-ETHINYL ESTRADIOL/IRON WYMZYA FE 3 1 NORETH-ETHINYL
ESTRADIOL/IRON ZENCHENT FE 3 1 NORETH-ETHINYL ESTRADIOL/IRON ZEOSA
3 1 NORETHINDRONE CAMILA 1 NORETHINDRONE HEATHER 1 NORETHINDRONE
JOLIVETTE 3 1 NORETHINDRONE NORA-BE 3 1 NORETHINDRONE 1
NORETHINDRONE ERRIN 1 NORETHINDRONE A-E ESTRADIOL MICROGESTIN 3 1
NORETHINDRONE A-E ESTRADIOL GILDESS 3 1 NORETHINDRONE A-E ESTRADIOL
JUNEL 3 1 NORETHINDRONE-ETHINYL ESTRAD BRIELLYN 3 1
NORETHINDRONE-ETHINYL ESTRAD ARANELLE 3 1 NORETHINDRONE-ETHINYL
ESTRAD LEENA 3 1 NORETHINDRONE-ETHINYL ESTRAD CYCLAFEM 3 1
NORETHINDRONE-ETHINYL ESTRAD ZENCHENT 3
3 - No copay
32 of 104
Contraceptives / OBSTETRICS & GYNECOLOGY (cont.) Tier Generic
Name Brand Name Notes
1 NORETHINDRONE-ETHINYL ESTRAD NECON 3 1 NORETHINDRONE-ETHINYL
ESTRAD NORTREL 3 1 NORETHINDRONE-ETHINYL ESTRAD ALYACEN 1
NORETHINDRONE-ETHINYL ESTRAD DASETTA 3 1 NORETHINDRONE-ETHINYL
ESTRAD BALZIVA 3 1 NORGESTIMATE-ETHINYL ESTRADIOL TRI-SPRINTEC 3 1
NORGESTIMATE-ETHINYL ESTRADIOL TRI-PREVIFEM 3 1
NORGESTIMATE-ETHINYL ESTRADIOL TRINESSA 3 1 NORGESTIMATE-ETHINYL
ESTRADIOL SPRINTEC 3 1 NORGESTIMATE-ETHINYL ESTRADIOL PREVIFEM 3 1
NORGESTIMATE-ETHINYL ESTRADIOL 3 1 NORGESTIMATE-ETHINYL ESTRADIOL
MONONESSA 3 1 NORGESTREL-ETHINYL ESTRADIOL LOW-OGESTREL 3 1
NORGESTREL-ETHINYL ESTRADIOL NORGESTREL-ETHINY ESTRA 3 1
NORGESTREL-ETHINYL ESTRADIOL CRYSELLE 3 1 NORGESTREL-ETHINYL
ESTRADIOL ELINEST 3 1 NORGESTREL-ETHINYL ESTRADIOL OGESTREL 3 2
DESOGESTREL-ETHINYL ESTRADIOL ORTHO-CEPT 2 ETONOGESTREL/ETHINYL
ESTRADIOL NUVARING 2 NORETH A-ET ESTRA/FE FUMARATE LO LOESTRIN FE 2
NORETH A-ET ESTRA/FE FUMARATE LOESTRIN 24 FE 2 NORETH-ETHINYL
ESTRADIOL/IRON GENERESS FE 2 NORGESTIMATE-ETHINYL ESTRADIOL ORTHO
TRI-CYCLEN LO 3 DESOG-ET ESTRA/ETHIN ESTRA MIRCETTE 3
DESOGESTREL-ETHINYL ESTRADIOL DESOGEN 3 DROSPIR/ETH ESTRA/LEVOMEFOL
CA BEYAZ 3 DROSPIR/ETH ESTRA/LEVOMEFOL CA SAFYRAL 3 ESTRADIOL
VALERATE/DIENOGEST NATAZIA 3 ETHINYL ESTRADIOL/DROSPIRENONE YAZ 3
ETHINYL ESTRADIOL/DROSPIRENONE YASMIN 28 3 L-NORGEST-ETH ESTR/ETHIN
ESTRA SEASONIQUE 3 LEVONORGESTREL-ETH ESTRADIOL SEASONALE 3
LEVONORGESTREL-ETH ESTRADIOL LYBREL 3 LEVONORGESTREL-ETH ESTRADIOL
NORDETTE-28 3 NORELGESTROMIN/ETHIN.ESTRADIOL ORTHO EVRA 3 NORETH
A-ET ESTRA/FE FUMARATE ESTROSTEP FE 3 NORETH A-ET ESTRA/FE FUMARATE
LOESTRIN FE 3 NORETH-ETHINYL ESTRADIOL/IRON FEMCON FE 3
NORETHINDRONE MICRONOR 3 NORETHINDRONE A-E ESTRADIOL LOESTRIN 3
NORETHINDRONE-ETHINYL ESTRAD OVCON-35 3 NORETHINDRONE-ETHINYL
ESTRAD ORTHO-NOVUM 3 NORETHINDRONE-ETHINYL ESTRAD BREVICON 3
NORGESTIMATE-ETHINYL ESTRADIOL ORTHO-CYCLEN 3 NORGESTIMATE-ETHINYL
ESTRADIOL ORTHO TRI-CYCLEN 3 NORGESTREL-ETHINYL ESTRADIOL
LO-OVRAL-28 3 ULIPRISTAL ACETATE ELLA 4 LEVONORGESTREL-RELEASING
INTRAUTERINE
SYSTEM KYLEENA 4
3 DIAPHRAGMS, ARC-SPRING ORTHO ALL-FLEX
3 - No copay 4 - Office/Clinic Administration
33 of 104
Corticosteroids / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH
Tier Generic Name Brand Name Notes
3 DEFLAZACORT EMFLAZA 5 4 CORTICOTROPIN ACTHAR H.P. 5
Corticosteroids (Eent) / EAR, NOSE & THROAT MEDICATIONS Tier
Generic Name Brand Name Notes
3 FLUOCINOLONE ACETONIDE OIL DERMOTIC
Corticosteroids (Eent) / GI AGENTS Tier Generic Name Brand Name
Notes
3 BUDESONIDE UCERIS 5
1 FLUOROMETHOLONE 1 PREDNISOLONE ACETATE 1 PREDNISOLONE SOD
PHOSPHATE PREDNISOLONE SODIUM PHOSPHATE 2 FLUOROMETHOLONE FML FORTE
2 FLUOROMETHOLONE FML S.O.P. 2 PREDNISOLONE ACETATE PRED MILD 3
DIFLUPREDNATE DUREZOL 3 FLUOROMETHOLONE ACETATE FLAREX 3
LOTEPREDNOL ETABONATE ALREX 3 LOTEPREDNOL ETABONATE LOTEMAX 3
PREDNISOLONE ACETATE PRED FORTE 3 RIMEXOLONE VEXOL
Corticosteroids (Eent) / RESPIRATORY AGENTS Tier Generic Name Brand
Name Notes
1 FLUNISOLIDE 1 FLUTICASONE PROPIONATE 2 BECLOMETHASONE
DIPROPIONATE BECONASE AQ 3 BECLOMETHASONE DIPROPIONATE QNASL 3
BUDESONIDE RHINOCORT AQUA 3 CICLESONIDE OMNARIS 3 CICLESONIDE
ZETONNA 3 FLUTICASONE FUROATE VERAMYST 3 FLUTICASONE PROPIONATE
FLONASE 3 MOMETASONE FUROATE NASONEX 3 TRIAMCINOLONE ACETONIDE
NASACORT AQ
Corticosteroids (Respiratory Tract) / RESPIRATORY AGENTS Tier
Generic Name Brand Name Notes
1 BUDESONIDE 2 BECLOMETHASONE DIPROPIONATE QVAR 2 BUDESONIDE
PULMICORT FLEXHALER 2 BUDESONIDE/FORMOTEROL FUMARATE SYMBICORT 2
FLUTICASONE FUROATE ARNUITY ELLIPTA 2 FLUTICASONE PROPIONATE
FLOVENT HFA 2 FLUTICASONE PROPIONATE FLOVENT DISKUS
5 - Prior Authorization
34 of 104
2 FLUTICASONE/SALMETEROL ADVAIR HFA 6 2 FLUTICASONE/VILANTEROL BREO
ELLIPTA 2 MOMETASONE FUROATE ASMANEX 3 BUDESONIDE PULMICORT 3
CICLESONIDE ALVESCO 3 MOMETASONE/FORMOTEROL DULERA
Cystine depleting agent / GENETIC DISORDERS Tier Generic Name Brand
Name Notes
3 CYSTEAMINE PROCYSBI 5
Cystine depleting agent / OPHTHALMOLOGY Tier Generic Name Brand
Name Notes
3 CYSTEAMINE CYSTARAN 5
Devices / BLOOD GLUCOSE REGULATORS Tier Generic Name Brand Name
Notes
2 NEEDLES, INSULIN DISPOSABLE NOVOTWIST 2 SYR W-NDL,INS 0.3 ML HALF
MARK INSULIN SYRINGE 2 SYRING W-NDL,DISP,INSUL,0.3ML ULTICARE 2
SYRING W-NDL,DISP,INSUL,0.3ML INSULIN SYRINGE 2 SYRING
W-NDL,DISP,INSUL,0.5ML INSULIN SYRINGE 2 SYRING
W-NDL,DISP,INSUL,0.5ML ULTRA COMFORT 2 SYRINGE &
NEEDLE,INSULIN,1 ML INSULIN SYRINGE 3 INSULIN ADMIN. SUPPLIES
HUMAPEN LUXURA HD 3 SYRINGE & NEEDLE,INSULIN,1 ML INSULIN
SYRINGE
Devices / DIAGNOSTICS & MISCELLANEOUS AGENTS Tier Generic Name
Brand Name Notes
3 SALIVA SUBSTITUTION COMBO NO.2 CAPHOSOL
Devices / EAR, NOSE & THROAT MEDICATIONS Tier Generic Name
Brand Name Notes
3 GLY/CARB HOMOPOLY A/POT HYDROX MUGARD
Devices / ENDOCRINE/DIABETES Tier Generic Name Brand Name
Notes
2 INHALER, ASSIST DEVICES BREATHERITE 2 INHALER, ASSIST DEVICES
OPTICHAMBER 2 INHALER, ASSIST DEVICES OPTIHALER 2 INHALER, ASSIST
DEVICES EASIVENT 2 INHALER, ASSIST DEVICES MICROCHAMBER 2 INHALER,
ASSIST DEVICES VORTEX 2 INHALER, ASSIST DEVICES E-Z SPACER 2
INHALER, ASSIST DEVICES PROCHAMBER 2 INHALER,ASSIST DEVICE,ACCESORY
OPTICHAMBER DIAMOND
5 - Prior Authorization 6 - Quantity Limit
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2 NEEDLES, INSULIN DISPOSABLE PEN NEEDLE 2 SYRING
W-NDL,DISP,INSUL,0.3ML SURE COMFORT 2 SYRING W-NDL,DISP,INSUL,0.5ML
EASY TOUCH 2 SYRINGE & NEEDLE,INSULIN,1 ML PRECISION 2 SYRINGE
& NEEDLE,INSULIN,1 ML MONOJECT INSULIN SYRINGE 3 BISMUTH
TRIBROMOPH/PETROLATUM XEROFORM PETROLATUM DRESSING 3 NEEDLES,
DISPOSABLE SPECIALTY USE NEEDLES 3 NEEDLES, DISPOSABLE REGULAR
BEVEL NEEDLES 3 NEEDLES, DISPOSABLE NEEDLE 3 NEEDLES, DISPOSABLE
NEEDLES
Devices / RESPIRATORY AGENTS Tier Generic Name Brand Name
Notes
2 INHALER, ASSIST DEVICES AEROCHAMBER Z-STAT PLUS 2 INHALER, ASSIST
DEVICES AEROCHAMBER MAX 2 INHALER, ASSIST DEVICES AEROCHAMBER 2
INHALER, ASSIST DEVICES AEROCHAMBER MV 2 INHALER, ASSIST DEVICES
AEROCHAMBER PLUS 2 INHALER, ASSIST DEVICES AEROCHAMBER WITH
FLOWSIGNAL
Digestants / GI AGENTS Tier Generic Name Brand Name Notes
1 LIPASE/PROTEASE/AMYLASE PANCRELIPASE 5,000 2
LIPASE/PROTEASE/AMYLASE ZENPEP 2 LIPASE/PROTEASE/AMYLASE CREON 5 2
LIPASE/PROTEASE/AMYLASE PANCREAZE
Dihydropyridines / CARDIOVASCULAR Tier Generic Name Brand Name
Notes
1 AMLODIPINE BESYLATE 1 AMLODIPINE BESYLATE/BENAZEPRIL AMLODIPINE
BESYLATE-BENAZEPRIL 1 FELODIPINE FELODIPINE ER 1 NIFEDIPINE
NIFEDIPINE ER 1 NIFEDIPINE AFEDITAB CR 1 NIFEDIPINE NIFEDIAC CC 1
NIFEDIPINE NIFEDICAL XL 1 NIFEDIPINE 1 NISOLDIPINE 3 AMLODIPINE
BES/OLMESARTAN MED AZOR 7 3 AMLODIPINE BESYLATE NORVASC 3
AMLODIPINE BESYLATE/BENAZEPRIL LOTREL 3 NICARDIPINE HCL CARDENE SR
3 NIFEDIPINE ADALAT CC 3 NISOLDIPINE SULAR
Dipeptidyl Peptidase-4(Dpp-4) Inhibitors / BLOOD GLUCOSE REGULATORS
Tier Generic Name Brand Name Notes
2 SAXAGLIPTIN HCL ONGLYZA
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2 SAXAGLIPTIN HCL/METFORMIN HCL KOMBIGLYZE XR 2 SITAGLIPTIN
PHOS/METFORMIN HCL JANUMET 2 SITAGLIPTIN PHOS/METFORMIN HCL JANUMET
XR 2 SITAGLIPTIN PHOSPHATE JANUVIA 3 ALOGLIPTIN NESINA 3
LINAGLIPTIN TRADJENTA 3 LINAGLIPTIN/METFORMIN HCL JENTADUETO
Direct Vasodilators / CARDIOVASCULAR Tier Generic Name Brand Name
Notes
1 HYDRALAZINE HCL 1 MINOXIDIL
Direct-Acting Skeletal Muscle Relaxants / AUTONOMIC & CNS
DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name
Notes
1 DANTROLENE SODIUM
Disease-Modifying Antirheumatic Agents / MUSCULOSKELETAL &
RHEUMATOLOGY Tier Generic Name Brand Name Notes
1 LEFLUNOMIDE 3 ANAKINRA KINERET 3 LEFLUNOMIDE ARAVA 4 ABATACEPT
ORENCIA 5 4 ADALIMUMAB HUMIRA 5 4 ADALIMUMAB HUMIRA PEDIATRIC
CROHNS 5 4 ETANERCEPT ENBREL 5 4 GOLIMUMAB SIMPONI 5
Disease-Modifying Antirheumatic Agents / OFFICE ADMINISTERED Tier
Generic Name Brand Name Notes
4 INFLIXIMAB FOR INJECTION REMICADE 4
Dopamine Agonists / ANTIPARKINSON AGENTS Tier Generic Name Brand
Name Notes
1 AMANTADINE HCL AMANTADINE 1 BROMOCRIPTINE MESYLATE 1 PRAMIPEXOLE
DI-HCL PRAMIPEXOLE DIHYDROCHLORIDE 1 ROPINIROLE HCL 3 AMANTADINE
HCL SYMMETREL 3 BROMOCRIPTINE MESYLATE CYCLOSET 3 PRAMIPEXOLE
DI-HCL MIRAPEX ER 3 PRAMIPEXOLE DI-HCL MIRAPEX 3 ROPINIROLE HCL
REQUIP 3 ROPINIROLE HCL REQUIP XL 3 ROTIGOTINE NEUPRO
Dopamine Antagonist / ANTIEMETICS Tier Generic Name Brand Name
Notes
1 PROCLORPERAZINE
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Dopamine Antagonist / ANTIEMETICS (cont.) Tier Generic Name Brand
Name Notes
1 PROMETHAZINE HCL PROMETHEGAN 4 DROPERIDOL INAPSINE 4
Dopamine Precursors/AA Decarbox Inhibitor / ANTIPARKINSON AGENTS
Tier Generic Name Brand Name Notes
1 CARBIDOPA/LEVODOPA CARBIDOPA-LEVODOPA 1
CARBIDOPA/LEVODOPA/ENTACAPONE CARBIDOPA-LEVODOPA-ENTACAPONE 3
CARBIDOPA/LEVODOPA RYTARY 3 CARBIDOPA/LEVODOPA/ENTACAPONE STALEVO 4
CARBIDOPA/LEVODOPA DUOPA 1
Dopamine Receptor Agonists / EMETOGENIC THERAPY Tier Generic Name
Brand Name Notes
4 APOMORPHINE APOKYN 4
Dopamine Receptor Agonists / ENDOCRINE/DIABETES Tier Generic Name
Brand Name Notes
1 CABERGOLINE
Dopamine Reuptake Blocker / AUTONOMIC & CNS DRUGS, NEUROLOGY
& PSYCH Tier Generic Name Brand Name Notes
1 METHYLPHENIDATE HCL METHYLPHENIDATE HCL CD
Dyslipidemics, Other / CARDIOVASCULAR Tier Generic Name Brand Name
Notes
1 EZETIMIBE 1 EZETIMIBE/SIMVASTATIN 2 NIACIN NIASPAN 2
NIACIN/LOVASTATIN ADVICOR 2 NIACIN/SIMVASTATIN SIMCOR 3 EZETIMIBE
ZETIA 3 EZETIMIBE/SIMVASTATIN VYTORIN 3 NIACIN NIACOR 3 OMEGA-3
ACID ETHYL ESTERS LOVAZA
Eent Anti-Infectives- Miscellaneous / EAR, NOSE & THROAT
MEDICATIONS Tier Generic Name Brand Name Notes
1 CHLORHEXIDINE GLUCONATE
Eent Anti-Inflammatory Agents- Misc. / OPHTHALMOLOGY Tier Generic
Name Brand Name Notes
3 CYCLOSPORINE RESTASIS 3 LIFITEGRAST OPTH SOLUTION XIIDRA 5
1 - Home Health 4 - Office/Clinic Administration 5 - Prior
Authorization
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Eent Drugs- Miscellaneous / EAR, NOSE & THROAT MEDICATIONS Tier
Generic Name Brand Name Notes
3 AMLEXANOX APHTHASOL
Eent Drugs- Miscellaneous / OPHTHALMOLOGY Tier Generic Name Brand
Name Notes
3 EYE LUBRICANT COMBINATION NO.1 FRESHKOTE 3 HYDROXYPROPYL
CELLULOSE LACRISERT
Eent Nonsteroidal Anti-Inflam. Agents / OPHTHALMOLOGY Tier Generic
Name Brand Name Notes
1 BROMFENAC SODIUM 2 BROMFENAC SODIUM BROMDAY 2 KETOROLAC
TROMETHAMINE/PF ACUVAIL 2 NEPAFENAC NEVANAC 3 BROMFENAC SODIUM
XIBROM 3 KETOROLAC TROMETHAMINE ACULAR LS 3 KETOROLAC TROMETHAMINE
ACULAR
Emollients / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name
Notes
1 EMOLLIENT COMBINATION NO.53 HPR PLUS 3 EMOLLIENT COMBINATION
NO.10 BIAFINE 3 EMOLLIENT COMBINATION NO.32 EPICERAM 3 EMOLLIENT
COMBINATION NO.35 MIMYX 3 EMOLLIENT COMBINATION NO.43 PROMISEB 3
EMOLLIENT COMBINATION NO.44 HYLATOPIC 3 EMOLLIENT COMBINATION NO.53
HYLATOPIC PLUS 3 EMOLLIENT COMBINATION NO.60 ATRAPRO HYDROGEL 3
VITE AC/GRAPE/HYALURONIC ACID ATOPICLAIR
Endothelin Receptor Antagonist / OFFICE ADMINISTERED Tier Generic
Name Brand Name Notes
4 RAMUCIRUMAB CYRAMZA 4
Endothelin Receptor Antagonist / RESPIRATORY AGENTS Tier Generic
Name Brand Name Notes
3 MACITENTAN OPSUMIT 5
Enzyme Replacement / ENZYME REPLACEMENT Tier Generic Name Brand
Name Notes
3 ELIGLUSTAT CERDELGA 5 4 AGALSIDASE BETA FABRAZYME 4
Enzyme Replacement / OFFICE ADMINISTERED Tier Generic Name Brand
Name Notes
4 ELOSULFASE ALFA VIMIZIM 4
4 - Office/Clinic Administration 5 - Prior Authorization
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3 DORNASE ALFA PULMOZYME 5
Ergot Alkaloids / ANTIMIGRAINE Tier Generic Name Brand Name
Notes
1 DIHYDROERGOTAMINE MESYLATE 2 ERGOTAMINE TARTRATE ERGOMAR 2
ERGOTAMINE TARTRATE/CAFFEINE CAFERGOT
Estrogen Agonist-Antagonists / HORMONE: ER RECEPTOR MODIFIER Tier
Generic Name Brand Name Notes
1 RALOXIFENE 3 ESTROGEN/BAZEDOXIFENE DUAVEE 3 OSPEMIFENE OSPHENA 3
RALOXIFENE EVISTA 4 CLOMIPHENE CITRATE 2
Estrogens / HORMONE: ESTROGENS Tier Generic Name Brand Name
Notes
1 ESTRADIOL 1 ESTRADIOL/NORETHINDRONE ACET ESTRADIOL-NORETHINDRONE
ACETAT 1 ESTROPIPATE 2 ESTRADIOL ALORA 2 ESTRADIOL ESTRACE 0.01%
CREAM 2 ESTRADIOL MICRONIZED ESTRADIOL 3 ESTRADIOL DIVIGEL 3
ESTRADIOL EVAMIST 3 ESTRADIOL ESTROGEL 3 ESTRADIOL ELESTRIN 3
ESTRADIOL ESTRING 3 ESTRADIOL CLIMARA 3 ESTRADIOL ESTRACE TABLETS 3
ESTRADIOL ACETATE FEMRING 3 ESTRADIOL/NORETHINDRONE ACET ACTIVELLA
3 ESTROGENS,CONJ.,SYNTHETIC A CENESTIN 3 ESTROGENS,CONJ.,SYNTHETIC
B ENJUVIA 3 NORETHIND AC/ETHINYL ESTRADIOL FEMHRT
Estrogens / OBSTETRICS & GYNECOLOGY Tier Generic Name Brand
Name Notes
1 ESTRADIOL/NORETHINDRONE ACET MIMVEY 1 NORETHIND AC/ETHINYL
ESTRADIOL JINTELI 1 NORETHIND AC/ETHINYL ESTRADIOL JEVANTIQUE 2
ESTRADIOL VAGIFEM 2 ESTRADIOL/LEVONORGESTREL CLIMARA PRO 2
ESTRADIOL/NORGESTIMATE PREFEST 2 ESTROGEN,CON/M-PROGEST ACET
PREMPRO 2 ESTROGEN,CON/M-PROGEST ACET PREMPHASE 2 ESTROGENS,
CONJUGATED PREMARIN
2 - Infertility 5 - Prior Authorization
40 of 104
Estrogens / OBSTETRICS & GYNECOLOGY (cont.) Tier Generic Name
Brand Name Notes
3 DROSPIRENONE/ESTRADIOL ANGELIQ 3 ESTRADIOL MENOSTAR 3 ESTRADIOL
VIVELLE-DOT 3 ESTRADIOL/NORETHINDRONE ACET COMBIPATCH 3
ESTROGENS,ESTERIFIED MENEST 4 ESTRADIOL CYPIONATE DEPO-ESTRADIOL
5
Ethanolamine Derivatives / RESPIRATORY AGENTS Tier Generic Name
Brand Name Notes
1 DIPHENHYDRAMINE HCL
Farnesoid X Receptor Agonists / GI AGENTS Tier Generic Name Brand
Name Notes
3 OBETICHOLIC ACID TABLETS OCALIVA 5
Fibric Acid Derivatives / CARDIOVASCULAR Tier Generic Name Brand
Name Notes
1 FENOFIBRATE NANOCRYSTALLIZED FENOFIBRATE 1 FENOFIBRIC ACID
(CHOLINE) FENOFIBRIC ACID 1 GEMFIBROZIL 3 FENOFIBRATE FENOGLIDE 3
FENOFIBRATE LIPOFEN 3 FENOFIBRATE NANOCRYSTALLIZED TRIGLIDE 3
FENOFIBRATE NANOCRYSTALLIZED TRICOR 3 FENOFIBRATE,MICRONIZED ANTARA
3 FENOFIBRIC ACID (CHOLINE) TRILIPIX
Fibromyalgia Agents / CNS AGENTS Tier Generic Name Brand Name
Notes
1 GABAPENTIN 3 MILNACIPRAN HCL SAVELLA 3 PREGABALIN LYRICA
First Gen. Antihist. Derivatives- Misc. / RESPIRATORY AGENTS Tier
Generic Name Brand Name Notes
1 CYPROHEPTADINE HCL
4 METHOTREXATE OTREXUP 5
GABA Augmenting Agents / AANTICONVULSANTS Tier Generic Name Brand
Name Notes
3 GABAPENTIN ENACARBIL HORIZANT
GABA Augmenting Agents / ANTICONVULSANTS Tier Generic Name Brand
Name Notes
1 DIVALPROEX SODIUM
5 - Prior Authorization
41 of 104
GABA Augmenting Agents / ANTICONVULSANTS (cont.) Tier Generic Name
Brand Name Notes
1 DIVALPROEX SODIUM DIVALPROEX SODIUM ER 1 VALPROATE SODIUM
VALPROIC ACID 3 DIVALPROEX SODIUM DEPAKOTE 3 DIVALPROEX SODIUM
DEPAKOTE ER 3 DIVALPROEX SODIUM DEPAKOTE SPRINKLE 3 GABAPENTIN
GRALISE 3 TIAGABINE GABITRIL 3 VIGABATRIN SABRIL 5
GLP-2 analog / GI AGENTS Tier Generic Name Brand Name Notes
4 TEDUGLUTIDE GATTEX 5
1 BACLOFEN
Genitourinary Smooth Muscle Relaxants / UROLOGICALS Tier Generic
Name Brand Name Notes
1 FLAVOXATE HCL 1 OXYBUTYNIN CHLORIDE 1 OXYBUTYNIN CHLORIDE
OXYBUTYNIN CHLORIDE ER 1 TOLTERODINE TARTRATE 3 DARIFENACIN
HYDROBROMIDE ENABLEX 3 FESOTERODINE FUMARATE TOVIAZ 3 MIRABEGRON
MYRBETRIQ 3 OXYBUTYNIN GELNIQUE 3 SOLIFENACIN SUCCINATE VESICARE 3
TOLTERODINE TARTRATE DETROL LA 3 TOLTERODINE TARTRATE DETROL 3
TROSPIUM CHLORIDE SANCTURA XR
Gi Drugs- Miscellaneous / GI AGENTS Tier Generic Name Brand Name
Notes
3 CERTOLIZUMAB PEGOL CIMZIA 5 3 ELUXADOLINE TABLETS VIBERZI 3
LINACLOTIDE LINZESS 3 PLECANATIDE TABLETS TRULANCE 5
Glutamate Reducing Agents / ANTICONVULSANTS Tier Generic Name Brand
Name Notes
1 GABAPENTIN 3 GABAPENTIN NEURONTIN
Glycogenolytic Agents / BLOOD GLUCOSE REGULATORS Tier Generic Name
Brand Name Notes
3 GLUCAGON,HUMAN RECOMBINANT GLUCAGON EMERGENCY KIT 3
GLUCAGON,HUMAN RECOMBINANT GLUCAGEN
5 - Prior Authorization
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4 CETRORELIX ACETATE CETROTIDE 2 4 GANIRELIX ACETATE 2
Gonadotropins / ENDOCRINE/DIABETES Tier Generic Name Brand Name
Notes
4 CHORIONIC GONADOTROPIN, HUMAN CHORIONIC GONADOTROPIN 2 4
CHORIONIC GONADOTROPIN, HUMAN PREGNYL 2 4 FOLLITROPIN ALFA, RECOMB
GONAL-F RFF 2 4 FOLLITROPIN ALFA, RECOMB GONAL-F 2 4 FOLLITROPIN
BETA,RECOMB FOLLISTIM AQ 2 4 HCG ALPHA,RECOMBINANT OVIDREL 2 4
MENOTROPINS MENOPUR 2 4 UROFOLLITROPIN BRAVELLE 2
Gonadotropins / OBSTETRICS & GYNECOLOGY Tier Generic Name Brand
Name Notes
4 CHORIONIC GONADOTROPIN NOVAREL 2
Growth Hormone Releasing Factor / DIAGNOSTICS & MISCELLANEOUS
AGENTS Tier Generic Name Brand Name Notes
4 TESAMORELIN EGRIFTA 5
HER2 Targeted Antibody / ANTINEOPLASTICS Tier Generic Name Brand
Name Notes
4 ADO-TRASTUZUMAB KADCYLA 5 4 TRASTUZUMAB HERCEPTIN 5
HYPOPHOSPHATASIA / ENDOCRINE Tier Generic Name Brand Name
Notes
4 ASFOTASE ALFA INJECTION STRENSIQ 5
Hematopoietic Agents / ANTINEOPLASTICS Tier Generic Name Brand Name
Notes
4 TBO-FILGRASTIM GRANIX 5
Hematopoietic Agents / IMMUNOLOGICAL AGENTS Tier Generic Name Brand
Name Notes
4 EPOETIN ALFA PROCRIT 5 4 PEGFILGRASTIM NEULASTA 5
2 - Infertility 5 - Prior Authorization
43 of 104
Hematopoietic Agents / IMMUNOLOGICAL AGENTS (cont.) Tier Generic
Name Brand Name Notes
4 PLERIXAFOR MOZOBIL 5
Hematopoietic Agents / OFFICE ADMINISTERED Tier Generic Name Brand
Name Notes
4 EPOETIN ALFA EPOGEN 4 4 FILGRASTIM NEUPOGEN 4
Hemorrheologic Agents / CARDIOVASCULAR Tier Generic Name Brand Name
Notes
1 PENTOXIFYLLINE
Hemostatic / OFFICE ADMINISTERED Tier Generic Name Brand Name
Notes
4 COAGULATION FACTOR IX ALPROLIX 4 4 COAGULATION FACTOR IX RIXUBIS
4 4 COAGULATION FACTOR XIII TRETTEN 4
Hemostatics / CARDIOVASCULAR Tier Generic Name Brand Name
Notes
3 AMINOCAPROIC ACID 4 ANTIHEMOPH.FVIII PLAS/ALB FREE ADVATE 5
Hemostatics / OBSTETRICS & GYNECOLOGY Tier Generic Name Brand
Name Notes
1 TRANEXAMIC ACID 3 TRANEXAMIC ACID LYSTEDA
Hereditary Tyrosinemia / ENDOCRINE Tier Generic Name Brand Name
Notes
3 NITISINONE ORFADIN 5
1 AMOXAPINE 1 MAPROTILINE HCL 1 MIRTAZAPINE
Histamine H2-Antagonists / GI AGENTS Tier Generic Name Brand Name
Notes
1 CIMETIDINE 1 FAMOTIDINE 1 NIZATIDINE 1 RANITIDINE HCL 3
FAMOTIDINE PEPCID
4 - Office/Clinic Administration 5 - Prior Authorization
44 of 104
Histamine H2-Antagonists / GI AGENTS (cont.) Tier Generic Name
Brand Name Notes
3 RANITIDINE HCL ZANTAC 25
Histone inhibitor / ANTINEOPLASTICS Tier Generic Name Brand Name
Notes
3 PANOBINOSTAT FARYDAK 5 3 VORINOSTAT ZOLINZA 5
Histone inhibitor / OFFICE ADMINISTERED Tier Generic Name Brand
Name Notes
4 BELINOSTAT BELEODAQ 4
Hmg-Coa Reductase Inhibitors / CARDIOVASCULAR Tier Generic Name
Brand Name Notes
1 AMLODIPINE/ATORVASTATIN AMLODIPINE-ATORVASTATIN 1 ATORVASTATIN
CALCIUM 1 FLUVASTATIN SODIUM 1 LOVASTATIN 1 PRAVASTATIN SODIUM 1
SIMVASTATIN 3 ATORVASTATIN CALCIUM LIPITOR 3 FLUVASTATIN SODIUM
LESCOL XL 3 FLUVASTATIN SODIUM LESCOL 3 LOVASTATIN ALTOPREV 3
PITAVASTATIN CALCIUM LIVALO 3 PRAVASTATIN SODIUM PRAVACHOL 3
ROSUVASTATIN CALCIUM CRESTOR 3 SIMVASTATIN ZOCOR
Human Leptin / GENETIC DISORDERS Tier Generic Name Brand Name
Notes
4 METRELEPTN MYALEPT 5
4 IXEKIZUMAB FOR SUBCUTANEOUS INJ TALTZ 5
Immunomodulator / IMMUNOLOGICAL AGENTS Tier Generic Name Brand Name
Notes
3 APREMILAST OTEZLA 5 3 LENALIDOMIDE REVLIMID 5 3 POMALIDOMIDE
POMALYST 5 3 THALIDOMIDE THALOMID 5 3 TOFACITINIB XELJANZ 5 4
INTERFERON ALFACON 1 INFERGEN 5
Immunosuppressive Agents / IMMUNOLOGICAL AGENTS Tier Generic Name
Brand Name Notes
1 AZATHIOPRINE
45 of 104
1 CYCLOSPORINE 1 CYCLOSPORINE, MODIFIED GENGRAF 1 CYCLOSPORINE,
MODIFIED CYCLOSPORINE MODIFIED 1 MYCOPHENOLATE MOFETIL 1 TACROLIMUS
2 CYCLOSPORINE SANDIMMUNE 2 CYCLOSPORINE, MODIFIED NEORAL 2
MYCOPHENOLATE SODIUM MYFORTIC 2 SIROLIMUS RAPAMUNE 3 MYCOPHENOLATE
MOFETIL CELLCEPT 3 TACROLIMUS PROGRAF 4 TOCILIZUMAB ACTEMRA SQ 5 4
TOCILIZUMAB ACTEMRA 5
Incretin Mimetics / BLOOD GLUCOSE REGULATORS Tier Generic Name
Brand Name Notes
2 EXENATIDE BYETTA 5 2 EXENATIDE EXTENDED RELEASE BYDUREON BCISE 5
2 EXENATIDE MICROSPHERES BYDUREON 5 2 LIRAGLUTIDE VICTOZA 2-PAK 5 2
LIRAGLUTIDE VICTOZA 3-PAK 5 3 ALBIGLUTIDE TANZEUM 5 3 DULAGLUTIDE
TRULICITY 5 3 LIXISENATIDE INJECTION ADLYXIN 5
Incretin Mimetics / OBESITY Tier Generic Name Brand Name
Notes
4 LIRAGLUTIDE SAXENDA 5
Inhibit DNA polymerases / ANTINEOPLASTICS Tier Generic Name Brand
Name Notes
1 TEMOZOLOMIDE
Inhibit DNA polymerases / ANTIVIRALS Tier Generic Name Brand Name
Notes
3 GANCICLOVIR CYTOVENE 5
Inhibit Protein Synthesis / ANTIFUNGALS Tier Generic Name Brand
Name Notes
3 TAVABOROLE KERYDIN 5
Inhibit Protein Synthesis / ANTINEOPLASTICS Tier Generic Name Brand
Name Notes
4 OMACETAXINE SYNRIBO 5
Inhibit Protein Synthesis / GENETIC DISORDERS Tier Generic Name
Brand Name Notes
3 MIGLUSTAT ZAVESCA 5
Insulins / BLOOD GLUCOSE REGULATORS Tier Generic Name Brand Name
Notes
2 HUM INSULIN NPH/REG INSULIN HM HUMULIN 70-30 2 HUM INSULIN
NPH/REG INSULIN HM NOVOLIN 70-30 2 INSULIN GLARGINE,HUM.REC.ANLOG
LANTUS 2 INSULIN GLARGINE,HUM.REC.ANLOG LANTUS SOLOSTAR 2 INSULIN
GLARGINE,HUM.REC.ANLOG TOUJEO 2 INSULIN LISPRO HUMALOG 2 INSULIN
NPL/INSULIN LISPRO HUMALOG MIX 50-50 2 INSULIN NPL/INSULIN LISPRO
HUMALOG MIX 75-25 2 INSULIN REGULAR, HUMAN HUMULIN R 2 INSULIN
REGULAR, HUMAN NOVOLIN R 2 NPH, HUMAN INSULIN ISOPHANE HUMULIN N 2
NPH, HUMAN INSULIN ISOPHANE NOVOLIN N 3 INSULIN ASPART NOVOLOG 7 3
INSULIN ASPART NOVOLOG FLEXPEN 7 3 INSULIN DEGLUDEC INJECTION
TRESIBA 7 3 INSULIN DETEMIR LEVEMIR FLEXTOUCH 7 3 INSULIN DETEMIR
LEVEMIR 7 3 INSULIN GLARGINE,HUM.REC.ANLOG Basaglar KwikPen 7 3
INSULIN GLULISINE APIDRA SOLOSTAR 3 INSULIN GLULISINE APIDRA 3
INSULIN INHALED AFREZZA 3 INSULN ASP PRT/INSULIN ASPART NOVOLOG MIX
70-30 7 3 INSULN ASP PRT/INSULIN ASPART NOVOLOG MIX 70-30 FLEXPEN
7
Integrase Strand Inhibitor / ANTIVIRALS Tier Generic Name Brand
Name Notes
2 ELVITEGRAVIR VITEKTA
4 INTERFERON ALFA-2B,RECOMB. INTRON A 5 4 INTERFERON
ALFA-2B,RECOMB. PEG-INTRON 5 4 INTERFERON ALFA-2B,RECOMB. SYLATRON
5
Interleukin / CARDIOVASCULAR Tier Generic Name Brand Name
Notes
4 OPRELVEKIN NEUMEGA 5
4 SECUKINUMAB COSENTYX 5
4 SILTUXIMAB SYLVANT 4
47 of 104
4 OCRIPLASMIN JETREA 5
Keratolytic Agents / DERMATOLOGICAL AGENTS Tier Generic Name Brand
Name Notes
1 BENZOYL PEROXIDE LAVOCLEN-4 1 BENZOYL PEROXIDE BENZEPRO 1 BENZOYL
PEROXIDE 1 BENZOYL PEROXIDE BP WASH 1 BENZOYL PEROXIDE BPO 1
BENZOYL PEROXIDE BP WASH ACNE TREATMENT 1 SALICYLIC ACID 1 SULFACET
SOD/SULFUR/WITCH HAZ SE 10-5 SS 1 SULFACETAMIDE SODIUM/SULFUR
ZENCIA 1 SULFACETAMIDE SODIUM/SULFUR SULFACETAMIDE SODIUM-SULFUR 1
SULFACETAMIDE SODIUM/SULFUR SODIUM SULFACETAMIDE-SULFUR 1
SULFACETAMIDE SODIUM/SULFUR PRASCION 1 SULFACETAMIDE SODIUM/SULFUR
PRASCION FC 1 SULFACETAMIDE SODIUM/SULFUR BP 10-1 1 UREA 2 BENZOYL
PEROXIDE BENZEFOAM ULTRA 2 BENZOYL PEROXIDE BENZAC AC 2
SULFACETAMIDE SODIUM/SULFUR CLARIFOAM EF 3 SALICYLIC ACID KERALYT 3
SALICYLIC ACID/CERAMIDE CMB #1 SALEX 3 SULFACETAMIDE SODIUM/SULFUR
CLENIA
Keratoplastic Agents / DERMATOLOGICAL AGENTS Tier Generic Name
Brand Name Notes
1 ANTHRALIN DRITHOCREME HP 3 COAL TAR
Kinase Inhibitor / ANTINEOPLASTICS Tier Generic Name Brand Name
Notes
3 CERITINIB ZYKADIA 5 3 IDELALISIB ZYDELIG 5 3 LENVATINIB LENVIMA 5
3 RIBOCICLIB TABLETS KISQALI 5 3 RUXOLITINIB JAKAFI 5 3 TRAMETINIB
MEKINIST 5
LIPOSOMAL ACID LIPASE DEFICIENCY / ENDOCRINE Tier Generic Name
Brand Name Notes
4 SEBELIPASE ALFA INJECTION KANUMA 4
Laxatives / GI AGENTS Tier Generic Name Brand Name Notes
1 PEG 3350/NA SULF,BICARB,CL/KCL PEG 3350-ELECTROLYTE
4 - Office/Clinic Administration 5 - Prior Authorization
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Laxatives / GI AGENTS (cont.) Tier Generic Name Brand Name
Notes
1 PEG 3350/NA SULF,BICARB,CL/KCL PEG-3350 AND ELECTROLYTES 1 PEG
3350/NA SULF,BICARB,CL/KCL GAVILYTE 1 POLYETHYLENE GLYCOL 3350 2
NAPHOS M-B M-H/NA PHOS,DI-BA OSMOPREP 2 PEG 3350/NA
SULF,BICARB,CL/KCL GOLYTELY PACKETS 3 BISAC/NACL/NAHCO3/KCL/PEG
3350 HALFLYTELY-BISACODYL 3 LUBIPROSTONE AMITIZA 3 PEG 3350/NA
SULF,BICARB,CL/KCL GOLYTELY 3 PEG 3350/NA SULF,BICARB,CL/KCL COLYTE
WITH FLAVOR PACKETS 3 PEG3350/SOD SUL/NACL/ASB/C/KCL MOVIPREP 3 SOD
PICOSULF/MAG OX/CITRIC AC PREPOPIK 3 SODIUM,POTASSIUM,&MAG
SULFATES SUPREP
Leprosy / ANTIMYCOBACTERIALS - OTHER Tier Generic Name Brand Name
Notes
2 DAPSONE 3 CLOFAZIMINE LAMPRENE
Leukotriene Modifiers / RESPIRATORY AGENTS Tier Generic Name Brand
Name Notes
1 MONTELUKAST SODIUM 1 ZAFIRLUKAST 3 MONTELUKAST SODIUM SINGULAIR 3
ZAFIRLUKAST ACCOLATE 3 ZILEUTON ZYFLO CR 5
Local Anesthetics / ANESTHETICS Tier Generic Name Brand Name
Notes
1 HYDROCORTISONE AC/LIDOCAINE LIDOCAINE-HYDROCORTISONE 1 LIDOCAINE
HCL 1 LIDOCAINE HCL LIDOCAINE HCL VISCOUS 1 LIDOCAINE/PRILOCAINE
LIDOCAINE-PRILOCAINE 3 LIDOCAINE LIDODERM
Local Anesthetics (Eent) / OTIC AGENTS Tier Generic Name Brand Name
Notes
1 ANTIPYRINE/BENZOCAINE/GLYCERIN AURODEX 1
ANTIPYRINE/BENZOCAINE/GLYCERIN ANTIPYRINE-BENZOCAINE 3
ANTIPY/BENZOCAINE/POLICOS NO.1 OTIC CARE 3 ANTIPYRINE/BENZOCAINE
AURAX
Local Anti-Infectives- Miscellaneous / DERMATOLOGICAL AGENTS Tier
Generic Name Brand Name Notes
1 HYDROCORTISONE/IODOQUINOL HYDROCORTISONE-IODOQUINOL 1 SELENIUM
SULFIDE 1 SILVER SULFADIAZINE SSD 1 SILVER SULFADIAZINE THERMAZENE
1 SILVER SULFADIAZINE 1 SULFACETAMIDE SOD/SULFUR/UREA CLEANSING
WASH
5 - Prior Authorization
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1 SULFACETAMIDE SOD/SULFUR/UREA SODIUM SULFACETAMIDE-SULFUR 1
SULFACETAMIDE SODIUM SEB-PREV 1 SULFACETAMIDE SODIUM SODIUM
SULFACETAMIDE 1 SULFACETM NA/AVOBENZONE/SULFUR PRASCION RA 2
SELENIUM SULFIDE TERSI FOAM 3 HEXACHLOROPHENE PHISOHEX 3 SILVER
SULFADIAZINE SILVADENE
Loop Diuretics / CARDIOVASCULAR Tier Generic Name Brand Name
Notes
1 BUMETANIDE 1 FUROSEMIDE 1 TORSEMIDE 2 ETHACRYNIC ACID EDECRIN 3
FUROSEMIDE LASIX
MAO Inhibitor / ANTIDEPRESSANTS Tier Generic Name Brand Name
Notes
1 PHENELZINE SULFATE 1 TRANYLCYPROMINE SULFATE
MEK Inhibitor / ANTINEOPLASTICS Tier Generic Name Brand Name
Notes
4 COBIMETINIB TABLETS COTELLIC 5
MIXED 5HT1A AGONIST HT2A ANTAGONIST / CNS AGENTS Tier Generic Name
Brand Name Notes
4 FLIBANSERIN ADDYI 5
MS / CNS AGENTS Tier Generic Name Brand Name Notes
2 GLATIRAMER ACETATE GLATOPA 5 3 DALFAMPRIDINE AMPYRA 5 3 DIMETHYL
FUMARATE TECFIDERA 5 3 TERIFLUNOMIDE AUBAGIO 5 4 GLATIRAMER ACETATE
COPAXONE 5 4 INTERFERON BETA-1A AVONEX 5 4 INTERFERON BETA-1A
AVONEX PEN 5 4 INTERFERON BETA-1A/ALBUMIN REBIF 5 4 INTERFERON
BETA-1A/ALBUMIN AVONEX ADMINISTRATION PACK 5 4 INTERFERON BETA-1B
BETASERON 5
Macrolides / ANTIBACTERIALS Tier Generic Name Brand Name
Notes
1 AZITHROMYCIN 1 CLARITHROMYCIN CLARITHROMYCIN ER 1 CLARITHROMYCIN
1 ERYTHROMYCIN BASE ERYTHROMYCIN
5 - Prior Authorization
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1 ERYTHROMYCIN ETHYLSUCCINATE E.E.S. 400 1 ERYTHROMYCIN
ETHYLSUCCINATE 1 ERYTHROMYCIN STEARATE ERYTHROCIN STEARATE 2
ERYTHROMYCIN BASE ERY-TAB 2 ERYTHROMYCIN ETHYLSUCCINATE E.E.S. 200
2 ERYTHROMYCIN ETHYLSUCCINATE ERYPED 400 2 ERYTHROMYCIN
ETHYLSUCCINATE ERYPED 200 3 AZITHROMYCIN ZITHROMAX 3 AZITHROMYCIN
ZMAX
Mast-Cell Stabilizers / OPHTHALMOLOGY Tier Generic Name Brand Name
Notes
1 CROMOLYN SODIUM 3 NEDOCROMIL SODIUM ALOCRIL
Mast-Cell Stabilizers / RESPIRATORY AGENTS Tier Generic Name Brand
Name Notes
1 CROMOLYN SODIUM
Meglitinides / BLOOD GLUCOSE REGULATORS Tier Generic Name Brand
Name Notes
1 NATEGLINIDE 3 NATEGLINIDE STARLIX
Meglitinides / ENDOCRINE/DIABETES Tier Generic Name Brand Name
Notes
1 REPAGLINIDE 3 REPAGLINIDE PRANDIN
Melatonin Receptor Agonist / AUTONOMIC & CNS DRUGS, NEUROLOGY
& PSYCH Tier Generic Name Brand Name Notes
3 TASIMELTEON HETLIOZ 5
1 PILOCARPINE HCL
1 ACETIC ACID/HYDROCORTISONE HYDROCORTISONE-ACETIC ACID
Miscellaneous Anti-Infectives (Eent) / OTIC AGENTS Tier Generic
Name Brand Name Notes
1 ACETIC ACID 1 ACETIC ACID/HYDROCORTISONE ACETASOL HC
Miscellaneous Anti-Infectives (Systemic) / ANTI - INFECTIVES Tier
Generic Name Brand Name Notes
1 SULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE-TRIMETHOPRIM
5 - Prior Authorization
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3 METRONIDAZOLE FLAGYL ER 3 METRONIDAZOLE FLAGYL
Miscellaneous B-Lactam Antibiotics / ANTI - INFECTIVES Tier Generic
Name Brand Name Notes
3 AZTREONAM LYSINE CAYSTON
Miscellaneous Gi Drugs / GI AGENTS Tier Generic Name Brand Name
Notes
3 ALOSETRON HCL LOTRONEX 4 OCTREOTIDE ACETATE SANDOSTATIN 5
Monoamine Oxidase B Inhibitors / ANTIPARKINSON AGENTS Tier Generic
Name Brand Name Notes
1 SELEGILINE HCL 3 SELEGILINE EMSAM
Monoamine Oxidase B Inhibitors / AUTONOMIC & CNS DRUGS,
NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes
3 RASAGILINE MESYLATE AZILECT
3 TETRABENAZINE XENAZINE 5
Monoclonal Antibody / ANTINEOPLASTICS Tier Generic Name Brand Name
Notes
4 ATEZOLIZUMAB FOR INJECTION TECENTRIQ 4 4 AVELUMAB INJECTION
BAVENCIO 4 4 BRENTUXIMAB ADCETRIS 4 4 CANAKINUMAB ILARIS 5 4
DARATUMUMAB INJECTION DARZALEX 4 4 DENOSUMAB XGEVA 5 4 ELOTUZUMAB
INJECTION EMPLICITI 4 4 NECITUMUMAB FOR INJECTION PORTRAZZA 4 4
OLARATUMAB INJECTION LARTRUVO 4 4 PEMBROLIZUMAB KEYTRUDA 4
Monoclonal Antibody / DERMATOLOGICAL AGENTS Tier Generic Name Brand
Name Notes
4 DUPILUMAB SUBCUTANEOUS INJECTION DUPIXENT 5
Monoclonal Antibody / MUSCULOSKELETAL & RHEUMATOLOGY Tier
Generic Name Brand Name Notes
4 DENOSUMAB PROLIA 4
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Monoclonal Antibody / OFFICE ADMINISTERED Tier Generic Name Brand
Name Notes
3 RESLIZUMAB INJECTION CINQAIR 4 4 MEPOLIZUMAB INJECTION NUCALA 4 4
OMALIZUMAB XOLAIR 4 4 RITUXIMAB RITUXAN 4 4 SYNAGIS PALIVIZUMAB
4
Mood Stabilizers / BIPOLAR AGENTS Tier Generic Name Brand Name
Notes
1 CARBAMAZEPINE 1 LAMOTRIGINE 1 LITHIUM CARBONATE 1 LITHIUM CITRATE
LITHIUM 1 VALPROATE SODIUM VALPROIC ACID 3 LITHIUM CARBONATE
LITHOBID
Mucolytic Agents / RESPIRATORY AGENTS Tier Generic Name Brand Name
Notes
1 ACETYLCYSTEINE
Multiple Sclerosis / CNS AGENTS Tier Generic Name Brand Name
Notes
3 FINGOLIMOD HCL GILENYA 5 4 PEGINTERFERON ALFA-1A PLEGRIDY 5
Multiple Sclerosis / OFFICE ADMINISTERED Tier Generic Name Brand
Name Notes
4 ALEMTUZUMAB LEMTRADA 4 4 NATALIZUMAB TYSABRI 4 4 OCRELIZUMAB
INJECTION OCREVUS 4
Multivitamin Preparations / VITAMINS, HEMATINICS & ELECTROLYTES
Tier Generic Name Brand Name Notes
1 FLUORIDE/IRON/VIT A,C TRI-VIT WITH FLUORIDE-IRON 1
FLUORIDE/VITAMINS A,C,AND D TRIPHLUORIVIT 1 MULTIVITAMINS WITH
FLUORIDE MULTI-VITAMIN WITH FLUORIDE 1 MULTIVITAMINS WITH FLUORIDE
PHLUORIVIT 1 MULTIVITS WITH IRON & FLUORIDE MULTI-VITAMIN
W-FLUORIDE-IRON 1 PED MV A,C,D3 #21 W-FLUORIDE TRIPLE-VITAMIN
W-FLUORIDE 1 PED MV A,C,D3 #21 W-FLUORIDE VITAMINS A,C,D &
FLUORIDE 1 PED MV A,C,D3 #21 W-FLUORIDE TRI-VITAMIN WITH FLUORIDE 1
PEDI MVI NO.12/SODIUM FLUORIDE MVC-FLUORIDE 1 PNV COMBO
#22/IRON/FA/OM3/DHA HEMENATAL OB + DHA 1 PNV NO.22/IRON
CBN&GLUC/FA/DSS VINACAL 1 PNV W-O CA NO5/FE FUMARATE/FA
PRENATAL-U 3 1 PNV WITH CA,NO.72/IRON,CARB/FA PRENATAL PLUS 3
3 - No copay 4 - Office/Clinic Administration 5 - Prior
Authorization
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Multivitamin Preparations / VITAMINS, HEMATINICS & ELECTROLYTES
(cont.) Tier Generic Name Brand Name Notes
1 PNV66/IRON FUMARATE/FA/DSS/DHA PNV-DHA + DOCUSATE 1 PNV66/IRON
FUMARATE/FA/DSS/DHA FOLCAL DHA 1 PNV66/IRON FUMARATE/FA/DSS/DHA
VEMAVITE-PRX 2 1 PNV77/SOD IRON EDTA& PS/FA/OM3 VENATAL
COMPLETE DHA 1 PRENATAL NO.25/IRON/FA #6/DHA PRENA1 1 PRENATAL VIT
15/IRON CB/FA/DSS TRIADVANCE 3 1 PRENATAL VIT 15/IRON CB/FA/DSS
PRENATAL AD 3 1 PRENATAL VIT 16/IRON CB/FA/DSS VINATE GT 1 PRENATAL
VIT 18/IRON CB/FA/DSS VINATE ULTRA 3 1 PRENATAL VIT NO.78/IRON/FA
PRENATABS FA 3 1 PRENATAL VIT/IRON FUMARATE/FA PRENATAL 19 1
PRENATAL VITAMINS#21, IRON, FA HEMENATAL OB 3 PED MV A,C,D3 #38
W-FLUORIDE TRI-VI-FLOR 3 PEDI MULTIVIT #37 W-FLUORIDE POLY-VI-FLOR
3 PN W-CA64/IRON CB&GL/FA/DSS/DH CITRANATAL 90 DHA 3 PNV
#38/IRON FUM/FOLATE/DHA PRENATE DHA 3 PNV 18/FE,CARB/FA/DSS/UBI/DHA
PREQUE 10 3 PNV COMBO #19/IRON/FOL AC/DHA PREFERA-OB ONE 3 PNV
COMBO #22/IRON/FA/OM3/DHA PREFERA-OB PLUS DHA 3 PNV WITH
CA,NO.71/IRON/FA VOL-PLUS 3 PNV WITH CA,NO63/IRON/FA/B6 CITRANATAL
B-CALM 3 PNV#79/IRON/FA/LMFOLATE CA/DHA NEEVO DHA 3
PNV/FA/B6/CALCIUM PHOS/GINGER B-NEXA 3 PNV22/IRON
CBN&GLUC/FA/DSS/DHA CITRANATAL DHA 3 PNV38/IRON
CBN&GLUC/FA/DSS/DHA CITRANATAL ASSURE 3 PNV53/IRON
FUM/FA/DOCUSATE/DHA NEXA PLUS 3 PNV66/IRON FUMARATE/FA/DSS/DHA
PRENEXA 3 PNV69/IRON,CARBONYL/FA/DSS/DHA CITRANATAL HARMONY 3
PNV80/IRON FUMARATE/FA/DSS/DHA NEXA SELECT 3 PRENATAL NO.25/IRON/FA
#6/DHA VITAMEDMD ONE RX 3 PRENATAL NO.39/IRON/FA #6/DHA VITAMEDMD
PLUS RX 3 PRENATAL VIT #76/IRON,CARB/FA VOL-TAB RX 3 PRENATAL VIT
NO.44/IRON/FA/DHA PRENATE MINI 3 PRENATAL VIT NO.78/IRON/FA
VENATAL-FA 3 PRENATAL VIT#36/IRON/FA CMB#6 PRENATE ELITE 3 PRENATAL
VIT#42/FA CMB#6 VITAMEDMD REDICHEW RX 3 PRENATAL VITAMINS#21, IRON,
FA PREFERA OB
Mydriatics / OPHTHALMOLOGY Tier Generic Name Brand Name Notes
1 ATROPINE SULFATE ATROPINE CARE 1 ATROPINE SULFATE/PF ATROPINE
SULFATE 1 CYCLOPENTOLATE HCL 1 HOMATROPINE HBR HOMATROPAIRE 2
CYCLOPENTOLATE HCL CYCLOGYL 2 SCOPOLAMINE HYDROBROMIDE ISOPTO
HYOSCINE 3 HOMATROPINE HBR ISOPTO HOMATROPINE
NMDA Receptor Blocker / ANTIDEMENTIA AGENTS Tier Generic Name Brand
Name Notes
3 MEMANTINE HCL NAMENDA
3 CYSTEAMINE PROCYSBI 5
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4 ONABOTULINUMTOXINA BOTOX 4
Nitrates And Nitrites / CARDIOVASCULAR Tier Generic Name Brand Name
Notes
1 ISOSORBIDE DINITRATE 1 ISOSORBIDE MONONITRATE ISOSORBIDE
MONONITRATE ER 1 NITROGLYCERIN NITRO-BID 2 NITROGLYCERIN NITROMIST
2 NITROGLYCERIN NITROSTAT 2 NITROGLYCERIN NITRO-DUR 3 ISOSORBIDE
MONONITRATE IMDUR
Nitrogen Binding Agent / UROLOGICALS Tier Generic Name Brand Name
Notes
3 GLYCEROL PHENYLBUTYRATE RAVICTI 5
Non-Nucleoside Reverse Transcriptase Inhibitor / ANTIVIRALS Tier
Generic Name Brand Name Notes
1 NEVIRAPINE 2 DELAVIRDINE RESCRIPTOR 2 EFAVIRENZ SUSTIVA 2
ETRAVIRINE INTELENCE 2 RILPIVIRINE EDURANT 3 NEVIRAPINE
VIRAMUNE
Nonsteroidal Anti-Inflammatory Agents /
ANALGESICS/ANTI-INFLAMMATORY Tier Generic Name Brand Name
Notes
1 BUTALBITAL/ASPIRIN/CAFFEINE BUTALBITAL-ASPIRIN-CAFFEINE 1
CELECOXIB 7 1 DICLOFENAC SODIUM 1 DICLOFENAC SODIUM/MISOPROSTOL
DICLOFENAC SODIUM-MISOPROSTOL 1 ETODOLAC 1 IBUPROFEN 1 INDOMETHACIN
1 KETOPROFEN 1 KETOROLAC TROMETHAMINE 1 MELOXICAM 1 NABUMETONE 1
NAPROXEN 1 OXAPROZIN 1 PIROXICAM 1 SALSALATE 1 SULINDAC 2 NAPROXEN
SODIUM NAPRELAN 3 ASPIRIN EXTENDED-RELEASE CAPSULES DURLAZA 5 3
BUTALBITAL/ASPIRIN/CAFFEINE FIORINAL
4 - Office/Clinic Administration 5 - Prior Authorization 7 - Step
Therapy
55 of 104
Nonsteroidal Anti-Inflammatory Agents /
ANALGESICS/ANTI-INFLAMMATORY (cont.) Tier Generic Name Brand Name
Notes
3 CELECOXIB CELEBREX 7 3 DICLOFENAC EPOLAMINE FLECTOR 5 3
DICLOFENAC POTASSIUM CAMBIA 3 DICLOFENAC POTASSIUM ZIPSOR 3
DICLOFENAC SODIUM PENNSAID 5 3 DICLOFENAC SODIUM VOLTAREN 3
DICLOFENAC SODIUM/MISOPROSTOL ARTHROTEC 75 3 DICLOFENAC
SODIUM/MISOPROSTOL ARTHROTEC 50 3 INDOMETHACIN INDOCIN 3 KETOROLAC
TROMETHAMINE SPRIX 3 MELOXICAM MOBIC 3 OXAPROZIN DAYPRO
Nucleoside/Nucleotide RT Inhibitors / ANTIVIRALS Tier Generic Name
Brand Name Notes
1 ABACAVIR SULFATE ABACAVIR 1 LAMIVUDINE 1 ZIDOVUDINE 1
ZIDOVUDINE/LAMIVUDINE 2 ABACAVIR SULFATE/LAMIVUDINE EPZICOM 2
ABACAVIR/LAMIVUDINE/ZIDOVUDINE TRIZIVIR 2
EMTRICITABINE/RILPIVIRINE/TENOFOVIR ODFESEY 2
EMTRICITABINE/TENOFOVIR TRUVADA 2 LAMIVUDINE EPIVIR HBV 3 ABACAVIR
SULFATE ZIAGEN 3 LAMIVUDINE/ZIDOVUDINE COMBIVIR 3 ZIDOVUDINE
RETROVIR
Nucleosides And Nucleotides / ANTIVIRALS Tier Generic Name Brand
Name Notes
1 ENTECAVIR 1 FAMCICLOVIR 2 ADEFOVIR DIPIVOXIL HEPSERA 2
TELBIVUDINE TYZEKA 3 ENTECAVIR BARACLUDE 3 FAMCICLOVIR FAMVIR 3
VALGANCICLOVIR HCL VALCYTE
ONCOLYTIC VIRUS / ANTINEOPLASTICS Tier Generic Name Brand Name
Notes
4 TALIMOGENE LAHERPAREPVEC IMLYGIC 4
Ophthalmic Antiinflammatory / OPHTHALMOLOGY Tier Generic Name Brand
Name Notes
4 DESAMETHASONE INTRAVITREAL OZURDEX 4
Opiate Agonists, Short Acting / ANALGESICS Tier Generic Name Brand
Name Notes
1 ACETAMINOPHEN WITH CODEINE ACETAMINOPHEN-CODEINE
4 - Office/Clinic Administration 5 - Prior Authorization 7 - Step
Therapy
56 of 104
Opiate Agonists, Short Acting / ANALGESICS (cont.) Tier Generic
Name Brand Name Notes
1 BUTALBIT/ACETAMIN/CAFF/CODEINE BUTALB-CAFF-ACETAMINOPH-CODEIN 1
CODEINE/BUTALBITAL/ASA/CAFFEIN BUTALBITAL COMPOUND-CODEINE 1
CODEINE/BUTALBITAL/ASA/CAFFEIN ASCOMP WITH CODEINE 1 HYDROCODONE
BIT/ACETAMINOPHEN HYDROCODONE-ACETAMINOPHEN 1 HYDROCODONE/IBUPROFEN
HYDROCODONE BIT-IBUPROFEN 1 HYDROCODONE/IBUPROFEN
HYDROCODONE-IBUPROFEN 1 HYDROMORPHONE HCL 1 MEPERIDINE HCL 1
MORPHINE SULFATE 1 OXYCODONE HCL OXYCODONE CONCENTRATE 1 OXYCODONE
HCL 1 OXYCODONE HCL/ACETAMINOPHEN OXYCODONE-ACETAMINOPHEN 1
OXYCODONE HCL/ACETAMINOPHEN ENDOCET 1 OXYCODONE HCL/ASPIRIN ENDODAN
1 OXYCODONE HCL/OXYCODON TER/ASA OXYCODONE-ASPIRIN 1 OXYMORPHONE
HCL 1 TRAMADOL HCL 1 TRAMADOL HCL/ACETAMINOPHEN TRAMADOL
HCL-ACETAMINOPHEN 2 HYDROMORPHONE HCL DILAUDID 2 METHADONE HCL 2
MORPHINE SULFATE AVINZA 2 MORPHINE SULFATE KADIAN 2 OXYCODONE
HCL/ACETAMINOPHEN ROXICET 3 ACETAMINOPHEN WITH CODEINE
TYLENOL-CODEINE NO.3 3 FENTANYL DURAGESIC 3 FENTANYL CITRATE
FENTORA 3 FENTANYL CITRATE ABSTRAL 3 HYDROCODONE BIT/ACETAMINOPHEN
VICODIN HP 3 HYDROCODONE BIT/ACETAMINOPHEN LORTAB 3 HYDROCODONE
BIT/ACETAMINOPHEN NORCO 3 HYDROCODONE BIT/ACETAMINOPHEN VICODIN 3
HYDROCODONE BITARTRATE ZOHYDRO 3 HYDROCODONE BITARTRATE 3
HYDROCODONE/IBUPROFEN IBUDONE 3 HYDROCODONE/IBUPROFEN REPREXAIN 3
HYDROCODONE/IBUPROFEN VICOPROFEN 3 HYDROMORPHONE HCL EXALGO 3
OXYCODONE HCL/ACETAMINOPHEN PERCOCET 3 TAPENTADOL HCL NUCYNTA 3
TRAMADOL HCL RYBIX ODT 3 TRAMADOL HCL ULTRAM
Opiate Agonists,Long Acting / ANALGESICS Tier Generic Name Brand
Name Notes
1 FENTANYL TRANSDERMAL FENTANYL 1 HYDROMORPHONE ER 1 MORPHINE
SULFATE MORPHINE SULFATE ER 2 OXYCODONE HCL OXYCONTIN 3 HYDROCODONE
BITARTRATE HYSINGLA ER 3 MORPHINE SULFATE MS CONTIN 3 OXYCODONE HCL
XARTEMIS XR 3 OXYMORPHONE HCL OPANA ER 3 TAPENTADOL HCL NUCYNTA ER
3 TRAMADOL HCL ULTRAM ER
Opiate Antagonists / ANTI-ADDICTION/SUBSTANCE ABUSE Tier Generic
Name Brand Name Notes
1 NALOXONE
4 NALOXONE EVZIO 5
Opiate Antagonists / AUTONOMIC & CNS DRUGS, NEUROLOGY &
PSYCH Tier Generic Name Brand Name Notes
3 NALTREXONE HCL
Opiate Antagonists / GASTROINTESTINAL OTHER Tier Generic Name Brand
Name Notes
3 METHYLNALTREXONE BROMIDE TABLETS RELISTOR 5
Opiate Antagonists / GI AGENTS Tier Generic Name Brand Name
Notes
3 NALOXEGOL MOVANTIK 5
3 NALOXONE/BUPROPION CONTRAVE 5
Opiate Partial Agonists / ANALGESICS Tier Generic Name Brand Name
Notes
3 BUPRENORPHINE BUTRANS 3 BUPRENORPHINE BUCCAL FILM BELBUCA
Opiate Partial Agonists / ANTI-ADDICTION/SUBSTANCE ABUSE Tier
Generic Name Brand Name Notes
1 BUPRENORPHINE HCL/NALOXONE HCL BUPRENORPHINE/NALOXONE SL TABS 5 3
BUPRENORPHINE HCL/NALOXONE HCL SUBOXONE SL TABS 5 4 BUPRENORPHINE
IMPLANT PROBUPHINE 4
Other Miscellaneous Therapeutic Agents / ANTINEOPLASTICS Tier
Generic Name Brand Name Notes
4 OCTREOTIDE ACETATE 5
1 LEVOCARNITINE (WITH SUGAR) LEVOCARNITINE 3 LEVOCARNITINE CARNITOR
SF 3 LEVOCARNITINE CARNITOR
Other Miscellaneous Therapeutic Agents / ENDOCRINE/DIABETES Tier
Generic Name Brand Name Notes
3 CINACALCET HCL SENSIPAR 5 3 SAPROPTERIN DIHYDROCHLORIDE
KUVAN
4 - Office/Clinic Administration 5 - Prior Authorization
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Other Miscellaneous Therapeutic Agents / UROLOGICALS Tier Generic
Name Brand Name Notes
3 PENTOSAN POLYSULFATE SODIUM ELMIRON
Other Miscellaneous Therapeutic Agents / VITAMINS, HEMATINICS &
ELECTROLYTES Tier Generic Name Brand Name Notes
3 BAICALIN/CATECHIN/CITRATED ZNC LIMBREL250
3 TEDIZOLID SIVEXTRO
1 METHYLERGONOVINE MALEATE 3 METHYLERGONOVINE MALEATE
METHERGINE
PCSK9 INHIBITOR / CARDIOVASCULAR Tier Generic Name Brand Name
Notes
4 ALIROCUMAB PRALUENT 5 4 EVOLOCUMAB REPATHA 5
PO4 scavengers / GENETIC DISORDERS Tier Generic Name Brand Name
Notes
3 CARGLUMIC ACID CARBAGLU 5
Parasympathomimetic (Cholinergic Agents) / AUTONOMIC & CNS
DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name
Notes
1 PYRIDOSTIGMINE BROMIDE 2 PYRIDOSTIGMINE BROMIDE MESTINON
Parasympathomimetic (Cholinergic Agents) / DIAGNOSTICS &
MISCELLANEOUS AGENTS Tier Generic Name Brand Name Notes
1 CEVIMELINE HCL 2 CEVIMELINE HCL EVOXAC
Parasympathomimetic (Cholinergic Agents) / UROLOGICALS Tier Generic
Name Brand Name Notes
1 BETHANECHOL CHLORIDE
1 NEOSTIGMINE 1 PYRIDOSTIGMINE
4 PARATHYROID HORMONE FOR INJEC