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Prescription Drug GuideOctober 2021Please consider talking to your doctor about prescribing preferred generic and brand medications, which may helpreduce your out-of-pocket costs. This list may help guide you and your doctor in selecting an appropriatemedication for you.ContentsTherapeutic Class Drug ListIntroduction . IMember Prescription Benefit . IPharmacy and Therapeutics (P&T) Committee . IBrand Drugs and Generic Drugs . IIClassification. IIGeneric Substitution . IISpecialty Drugs. IICompound Drugs. IIContraceptives . IIIUtilization Management . IIIPrior Authorization . IIIDispensing Limits. IIIStep Therapy . IIINotice . IIIAbbreviation Key. IVAnti-Infective Drugs .1Cancer Drugs .7Hormones, Diabetes and Related Drugs .13Heart and Circulatory Drugs .23Respiratory Agents.32Gastrointestinal Drugs.35Genitourinary Drugs .38Central Nervous System Drugs .39Pain Relief Drugs .47Neuromuscular Drugs .52Supplements .55Blood Modifying Drugs .56Topical Drugs .59Miscellaneous Categories .64Index.68To search for a drug name within this PDF document, use the Control and F keys on your keyboard, or go to Editin the drop-down menu and select Find/Search. Type in the word or phrase you are looking for and click onSearch.4157 AL Prime Therapeutics LLC 10/21
IntroductionThe Prescription Drug Guide includes all Preferred Brand drugs and a partial listing of Generic drugs. Brand namedrugs not listed in this Prescription Drug Guide are Non-Preferred Brands. A drug may not be added to the PreferredBrand tier for reasons including safety or effectiveness, or because a similar, more cost-effective drug is alreadyavailable as a Preferred Brand or Generic drug.Physicians are encouraged to prescribe drugs listed in this Prescription Drug Guide. Members are encouraged toshow this Prescription Drug Guide to their physician and pharmacist.Member Prescription BenefitThe prescription benefit is multi-tiered, placing prescription drugs into one of the following copayment levels.Tier 1 – Lowest copayment – Generic drugs and select Preferred Brand drugs– listed and unlisted generic drugsTier 2 – Middle copayment – Preferred Brand drugs – all shown in the Prescription Drug GuideTier 3 – Highest copayment – Non-Preferred Brand drugs – unlistedTier 4 – Specialty (if applicable)Coverage is limited to prescription products approved by the Food and Drug Administration (FDA) as evidenced by aNew Drug Application (NDA), Abbreviated New Drug Application (ANDA), or Biologics License Application (BLA) onfile. Any legal requirements or group specific benefits for coverage will supersede this (e.g., preventive drugs per theAffordable Care Act).The drug benefit includes most prescription drugs, although some restrictions and exclusions apply. Investigationaldrugs and drugs indicated for cosmetic purposes (e.g., Propecia for hair growth) are not covered. Coverage andcopayment levels vary depending on the plan. Drugs that require Prior Authorization, Step Therapy, or that haveDispensing Limits are noted in the Prescription Drug Guide.Covered insulin products may be capped at a cost share of 99 per 30 days' supply. Benefits will be provided inaccordance with all applicable laws. Call Customer Service using the number on the back of your ID card forquestions regarding your specific coverage.Pharmacy and Therapeutics (P&T) CommitteeThe P&T Committee is comprised of independent practicing physicians and pharmacists. The Committee meetsat least quarterly. Newly marketed prescription drugs may not be covered until the P&T Committee has had anopportunity to review the drug, to determine whether the drug will be covered and if so, which tier will apply basedon safety, efficacy, and the availability of other products within that class of drugs. If your physician feels that a newdrug is medically necessary prior to P&T Committee evaluation, a non-formulary exception request for coveragemay be submitted.Prescription Drug Guide October 2021I
Brand Drugs and Generic DrugsClassificationPrescription drugs are classified as either a Brand drug or a Generic drug. The Brand or Generic status providedis by a nationally recognized company providing drug product information. The Brand/Generic status for a specificdrug/specific marketer can sometimes change over the life of a product in the marketplace and change fromBrand to Generic (or Generic to Brand). Such changes might change your copayment share. Brand drug orGeneric drug status is never based upon a product having a trade name. Generic drugs often have trade names.Generic SubstitutionGeneric drug utilization is encouraged as a way to provide high quality drugs at a reduced cost. Generic drugs areas safe and effective as their brand counterparts, but are usually less expensive. Generic drugs are manufacturedunder the same strict requirements of FDA’s current Good Manufacturing Practice regulations required for Branddrugs and cover the manufacturing, and identity, strength, purity and quality.An FDA-approved Generic drug may be substituted for the Brand counterpart when it: Contains the same active ingredient(s) as the brand drug Is identical in strength, dosage form, and route of administration Is therapeutically equivalent and can be expected to have the same clinical effect and safety profile.To encourage use of Generic drugs, Tier 2 Preferred Brand drugs typically move to Tier 3 after an equivalentgeneric version becomes available.Specialty DrugsSpecialty drugs are used in the treatment of medical conditions such as hepatitis, multiple sclerosis andrheumatoid arthritis. Specialty drugs may be oral or injectable medications that can either be selfadministered or administered by a health care professional.Some members must obtain their specialty drugs from the Pharmacy Select Network as the preferredprovider. If the preferred provider is not utilized you may be responsible for up to 100 percent of the drugcost. Your plan may have a different coverage level for self-administered specialty drugs. If you havequestions about your coverage for specialty drugs or your prescription drug benefit, call the number on theback of your ID card.Compound DrugsCompound drugs are defined as a drug product made or modified to have characteristics that are specificallyprescribed for an individual patient when commercial drug products are not available or appropriate. To beeligible for coverage, compounded drugs must contain at least one FDA-approved prescription ingredient andmust not be a copy of a commercially available product. All compounded drugs are subject to review and mayrequire prior authorization. Drugs used in compounded drugs may be subject to additional coverage criteria andutilization management edits. Compounds are covered only when medically necessary. Compound drugs arealways classified as the highest cost-sharing non-specialty drug Tier.Prescription Drug Guide October 2021II
ContraceptivesSome or all of the contraceptive methods or prescription drugs listed in this Prescription Drug Guide may not becovered under your plan because of your employer’s religious beliefs. To find out if contraceptive methods andprescription drugs are excluded, you may find this information in the exclusions section of your benefit booklet oryou may contact your group administrator.Utilization ManagementYour Plan is committed to supporting proper selection and use of drugs for its members. To help assure thesegoals are met, several programs have been developed to promote drug selection that encourages botheffectiveness and safety. Preferred generic or brand drugs requiring Prior Authorization or Step Therapy, or drugswith Dispensing Limits will be noted in the Therapeutic Class Drug List portion of the Prescription Drug Guide.Prior AuthorizationSome drugs require Prior Authorization (PA) because of their high potential for misuse or overuse. Drugs selectedfor Prior Authorization may require that specific clinical criteria are met before the drugs will be covered under amember’s prescription benefit. Approval is required for claims to process at network pharmacies.Dispensing LimitsDispensing Limits (DL) identify gender or age restrictions, and/or the maximum quantity that can be dispensedover a specific period of time. Limits are in place to encourage appropriate drug utilization, enhance memberoutcomes, and reduce drug benefit costs. Limits are typically developed based upon FDA-approved drug labeling.Step TherapyStep Therapy (ST) programs help manage the cost of expensive drugs by redirecting members to safe, effectiveand less expensive alternatives. Drugs included in the Step Therapy program require a more cost-effectiveprerequisite drug be tried before the Step Therapy drug will be approved for coverage. If the member meets theprerequisite requirement, the requested drug will be covered automatically without requiring review. If prerequisitedrugs are not found in the claims history, Prior Authorization may be required. Drugs and drug categories includedin the Step Therapy program are subject to change.NoticeThe purpose of the Prescription Drug Guide is to provide a guide to coverage. The Prescription Drug Guide is notintended to dictate to physicians how to practice medicine. Physicians should exercise their medical judgment inproviding the care they feel is most appropriate for their patients.Neither this Prescription Drug Guide, nor the successful adjudication of a pharmacy claim, is guarantee ofpayment.Prescription Drug Guide October 2021III
Abbreviation Keyaer. aerosolnebu . nebulizercap .capsulesodt. .orally disintegrating tabschew .chewableoint . ointmentconc . concentrateophth . ophthalmiccr. controlled releaseosm . osmotic releasedr . delayed releasepack . packetsec . enteric coatedpowd . powderequiv . equivalentpttw . twice-weekly patcher. extended releasesl . sublingualgm.gramsoln . solutioninhal . inhalersuppos . suppositoriesinj .injectionsusp . suspensionliqd. liquidtab . tabletsmg. milligramtd .transdermalml . milliliterw/ . withPrescription Drug Guide October 2021IV
ANTI-INFECTIVE DRUGSCEPHALOSPORINSPENICILLINScefadroxil cap 500 mgamoxicillin (trihydrate) cap250 mgamoxicillin (trihydrate) cap500 mgamoxicillin (trihydrate) for susp125 mg/5mlamoxicillin (trihydrate) for susp200 mg/5mlamoxicillin (trihydrate) for susp250 mg/5mlamoxicillin (trihydrate) for susp400 mg/5mlamoxicillin (trihydrate) tab500 mgamoxicillin (trihydrate) tab875 mgamoxicillin & k clavulanate forsusp 200-28.5 mg/5ml11cefadroxil for susp 250 mg/5mlcefadroxil for susp 500 mg/5mlcefdinir cap 300 mg1111cefixime for susp 200 mg/5ml(Suprax)11cefpodoxime proxetil for susp50 mg/5ml1cefpodoxime proxetil for susp100 mg/5ml1cefpodoxime proxetil tab 100 mgcefpodoxime proxetil tab 200 mgcefprozil for susp 125 mg/5mlcefprozil tab 500 mgamoxicillin & k clavulanatefor susp 600-42.9 mg/5ml(Augmentin es-600)1ceftriaxone sodium for inj250 mgamoxicillin & k clavulanate tab250-125 mg1penicillin v potassium tab250 mgpenicillin v potassium tab500 mgPrescription Drug Guide October 2021cefprozil for susp 250 mg/5mlcefprozil tab 250 mg1ceftriaxone sodium for inj500 mg (Rocephin)111111111ceftriaxone sodium for inj 1 gm(Rocephin)1ceftriaxone sodium for inj 2 gm111cefuroxime axetil tab 500 mg(Ceftin)1cephalexin cap 250 mg (Keflex)11cephalexin cap 500 mg (Keflex)cephalexin for susp 125 mg/5mlcephalexin for susp 250 mg/5mlDispensing Limits1cefuroxime axetil tab 250 mg(Ceftin)1Step Therapy111Prior Authorization1cefixime for susp 100 mg/5ml(Suprax)1dicloxacillin sodium cap 500 mg1cefixime cap 400 mg (Suprax)amoxicillin & k clavulanate forsusp 400-57 mg/5mldicloxacillin sodium cap 250 mg11amoxicillin & k clavulanatefor susp 250-62.5 mg/5ml(Augmentin)amoxicillin & k clavulanate tab875-125 mg (Augmentin)1cefdinir for susp 125 mg/5ml1amoxicillin & k clavulanate tab500-125 mg (Augmentin)11cefdinir for susp 250 mg/5mlSpecialtyDrug NameTier DesignationDispensing LimitsStep TherapyPrior AuthorizationSpecialtyDrug NameTier Designation20211111
SUPRAX – cefixime for susp 500mg/5ml2SUPRAX – cefixime chew tab 100 2mgSUPRAX – cefixime chew tab 200 2mgdoxycycline monohydrate tab100 mg (Adoxa pak 1/100)doxycycline monohydrate tab150 mg (Adoxa pak 1/150)11minocycline hcl cap 75 mg(Minocin)11minocycline hcl cap 100 mg(Minocin)1azithromycin tab 250 mg(Zithromax)1tetracycline hcl cap 250 mg(Tetracycline hcl)1azithromycin tab 500 mg(Zithromax)1tetracycline hcl cap 500 mg(Tetracycline hcl)azithromycin tab 600 mg(Zithromax)1clarithromycin tab er 24hr500 mg1CIPRO – ciprofloxacin for oralsusp 500 mg/5ml (10%) (10gm/100ml)clarithromycin tab 250 mg(Biaxin)1ciprofloxacin hcl tab 250 mg(base equiv) (Cipro)clarithromycin tab 500 mg(Biaxin)1ciprofloxacin hcl tab 500 mg(base equiv) (Cipro)azithromycin for susp200 mg/5ml (Zithromax)TETRACYCLINESdemeclocycline hcl tab 150 mgdemeclocycline hcl tab 300 mgdoxycycline hyclate cap 50 mgciprofloxacin hcl tab 750 mg(base equiv)doxycycline monohydrate tab75 mg (Adoxa)Prescription Drug Guide October 2021levofloxacin tab 500 mg(Levaquin)11levofloxacin tab 750 mg(Levaquin)11ofloxacin tab 400 mg11AMINOGLYCOSIDESneomycin sulfate tab 500 mg1paromomycin sulfate cap250 mg1tobramycin nebu soln300 mg/5ml (Tobi)Dispensing Limits1111doxycycline monohydrate tab50 mg (Adoxa)1levofloxacin tab 250 mg(Levaquin)1doxycycline hyclate tab 20 mgdoxycycline monohydrate cap100 mg (Monodox)111doxycycline monohydrate cap50 mg2levofloxacin oral soln 25 mg/ml(Levaquin)1doxycycline hyclate cap 100 mg(Vibramycin)doxycycline hyclate tab 100 mgFLUOROQUINOLONESStep Therapy11azithromycin for susp100 mg/5ml (Zithromax)Prior Authorization1minocycline hcl cap 50 mg(Minocin)MACROLIDESSpecialtyDrug NameTier DesignationDispensing LimitsStep TherapyPrior AuthorizationSpecialtyDrug NameTier Designation2021111 TUBERCULOSIS2
ethambutol hcl tab 100 mg(Myambutol)1voriconazole for susp 40 mg/ml(Vfend)1ethambutol hcl tab 400 mg(Myambutol)1voriconazole tab 50 mg (Vfend)1isoniazid tab 300 mg1PRIFTIN – rifapentine tab 150 mg 21pyrazinamide tab 500 mgrifabutin cap 150 mg (Mycobutin)rifampin cap 150 mg (Rifadin)rifampin cap 300 mg (Rifadin)FUNGAL INFECTIONS111voriconazole tab 200 mg (Vfend)Cytomegalovirusvalganciclovir hcl for soln50 mg/ml (base equiv) (Valcyte)valganciclovir hcl tab 450 mg(base equivalent) (Valcyte)Hepatitis11fluconazole for susp 40 mg/ml(Diflucan)1BARACLUDE – entecavir oralsoln 0.05 mg/ml2fluconazole tab 50 mg (Diflucan)1entecavir tab 0.5 mg (Baraclude)1entecavir tab 1 mg (Baraclude)1EPCLUSA – sofosbuvirvelpatasvir tab 200-50 mg1flucytosine cap 250 mg(Ancobon)1EPCLUSA – sofosbuvirvelpatasvir tab 400-100 mgflucytosine cap 500 mg(Ancobon)1HARVONI – ledipasvirsofosbuvir tab 45-200 mggriseofulvin microsize susp125 mg/5ml1HARVONI – ledipasvirsofosbuvir tab 90-400 mggriseofulvin microsize tab500 mg (Grifulvin v)1HARVONI – ledipasvirsofosbuvir pellet pack33.75-150 mgitraconazole cap 100 mg(Sporanox)1itraconazole oral soln 10 mg/ml(Sporanox)1HARVONI – ledipasvirsofosbuvir pellet pack 45-200mgNOXAFIL – posaconazole susp40 mg/ml2INTRON A – interferon alfa-2b inj6000000 unit/ml1INTRON A – interferon alfa-2b inj10000000 unit/mlnystatin tab 500000 unitposaconazole tab delayedrelease 100 mg (Noxafil)terbinafine hcl tab 250 mg(Lamisil)Prescription Drug Guide October 2021Dispensing Limits1adefovir dipivoxil tab 10 mg(Hepsera)fluconazole tab 200 mg (Diflucan)Step TherapyVIRAL INFECTIONS1fluconazole tab 150 mg (Diflucan)Prior Authorization1fluconazole for susp 10 mg/ml(Diflucan)fluconazole tab 100 mg (Diflucan)SpecialtyDrug NameTier DesignationDispensing LimitsStep TherapyPrior AuthorizationSpecialtyDrug NameTier Designation2021112 2 2 2 2 2 2 2 1lamivudine tab 100 mg (hbv)(Epivir hbv)11LEDIPASVIR/SOFOSBUVIR –ledipasvir-sofosbuvir tab90-400 mg2 3
MAVYRET – glecaprevirpibrentasvir tab 100-40 mgPEGASYS – peginterferonalfa-2a inj 180 mcg/mlPEGASYS – peginterferonalfa-2a inj 180 mcg/0.5mlribavirin cap 200 mg (Rebetol)ribavirin tab 200 mg (Copegus)SOFOSBUVIR/VELPATASVIR– sofosbuvir-velpatasvir tab400-100 mgSOVALDI – sofosbuvir tab 200mgSOVALDI – sofosbuvir tab 400mgSOVALDI – sofosbuvir pelletpack 150 mgSOVALDI – sofosbuvir pelletpack 200 mgVOSEVI – sofosbuvirvelpatasvir-voxilaprevir tab400-100-100 mgHerpesacyclovir cap 200 mg (Zovirax)2 12 2 atazanavir sulfate cap 300 mg(base equiv) (Reyataz)2 2 BIKTARVY – bictegraviremtricitabine-tenofovir af tab50-200-25 mg2 2 1 1 abacavir sulfate-lamivudinezidovudine tab 300-150-300 mg(Trizivir)1 atazanavir sulfate cap 150 mg(base equiv) (Reyataz)1 1 1 2 2 2 2 2 11 1 1 1 abacavir sulfate tab 300 mg(base equiv) (Ziagen)abacavir sulfate-lamivudine tab600-300 mg (Epzicom)atazanavir sulfate cap 200 mg(base equiv) (Reyataz)CIMDUO – lamivudine-tenofovirdisoproxil fumarate tab300-300 mgDELSTRIGO – doravirinelamivudine-tenofovir df tab100-300-300 mgDESCOVY – emtricitabinetenofovir alafenamide fumaratetab 200-25 mg1acyclovir susp 200 mg/5ml(Zovirax)1acyclovir tab 400 mg (Zovirax)1DOVATO – dolutegravir sodiumlamivudine tab 50-300 mg(base eq)1efavirenz cap 50 mg (Sustiva)1efavirenz cap 200 mg (Sustiva)1efavirenz tab 600 mg (Sustiva)1efavirenz-emtricitabine-tenofovirdf tab 600-200-300 mg (Atripla)acyclovir tab 800 mg (Zovirax)famciclovir tab 125 mg (Famvir)famciclovir tab 250 mg (Famvir)famciclovir tab 500 mg (Famvir)valacyclovir hcl tab 500 mg(Valtrex)1valacyclovir hcl tab 1 gm(Valtrex)1HIV/AIDSabacavir sulfate soln 20 mg/ml(base equiv) (Ziagen)Prescription Drug Guide October 20211efavirenz-lamivudine-tenofovir dftab 400-300-300 mg (Symfi lo)efavirenz-lamivudine-tenofovir dftab 600-300-300 mg (Symfi) Dispensing Limits Step Therapy2Prior Authorization Specialty21 Drug NameTier DesignationDispensing LimitsStep TherapyPrior AuthorizationSpecialtyDrug NameTier Designation2021emtricitabine-tenofovirdisoproxil fumarate tab100-150 mg (Truvada)114
emtricitabine-tenofovirdisoproxil fumarate tab133-200 mg (Truvada)emtricitabine-tenofovirdisoproxil fumarate tab167-250 mg (Truvada)emtricitabine-tenofovirdisoproxil fumarate tab200-300 mg (Truvada)etravirine tab 100 mg (Intelence)etravirine tab 200 mg (Intelence)EVOTAZ – atazanavir sulfatecobicistat tab 300-150 mg(base equiv)GENVOYA – elvitegrav-cobicemtricitab-tenofov af tab150-150-200-10 mgINTELENCE – etravirine tab 25mgINTELENCE – etravirine tab 100mgINTELENCE – etravirine tab 200mgISENTRESS – raltegravirpotassium packet for susp 100mg (base equiv)ISENTRESS – raltegravirpotassium tab 400 mg (baseequiv)ISENTRESS – raltegravirpotassium chew tab 25 mg(base equiv)ISENTRESS – raltegravirpotassium chew tab 100 mg(base equiv)ISENTRESS HD – raltegravirpotassium tab 600 mg (baseequiv)JULUCA – dolutegravir sodiumrilpivirine hcl tab 50-25 mg(base eq)Prescription Drug Guide October 2021111 Dispensing LimitsStep TherapyPrior AuthorizationSpecialty Drug NameTier DesignationDispensing LimitsStep TherapyPrior AuthorizationSpecialtyDrug NameTier Designation20212 2 lamivudine oral soln 10 mg/ml(Epivir)1 lamivudine tab 150 mg (Epivir)11 KALETRA – lopinavir-ritonavirtab 100-25 mgKALETRA – lopinavir-ritonavirtab 200-50 mglamivudine tab 300 mg (Epivir)1lamivudine-zidovudine tab150-300 mg (Combivir)2 lopinavir-ritonavir soln400-100 mg/5ml (80-20 mg/ml)(Kaletra)1 2 lopinavir-ritonavir tab 100-25 mg(Kaletra)1 lopinavir-ritonavir tab 200-50 mg(Kaletra)1 nevirapine susp 50 mg/5ml(Viramune)1 nevirapine tab er 24hr 400 mg(Viramune xr)1 nevirapine tab 200 mg (Viramune) 12NORVIR – ritonavir oral soln 80mg/ml2NORVIR – ritonavir powderpacket 100 mg2ODEFSEY – emtricitabinerilpivirine-tenofovir af tab200-25-25 mg2PREZCOBIX – darunavircobicistat tab 800-150 mg2PREZISTA – darunavirethanolate susp 100 mg/ml(base equiv)2PREZISTA – darunavirethanolate tab 75 mg (baseequiv)2PREZISTA – darunavirethanolate tab 150 mg (baseequiv) 112 2 2 2 2 2 2 2 2 5
PREZISTA – darunavirethanolate tab 600 mg (baseequiv)PREZISTA – darunavirethanolate tab 800 mg (baseequiv)ritonavir tab 100 mg (Norvir)SYMTUZA – darunavir-cobicemtricitab-tenofov af tab800-150-200-10 mgTEMIXYS – lamivudine-tenofovirdisoproxil fumarate tab300-300 mgtenofovir disoproxil fumarate tab300 mg (Viread)TIVICAY – dolutegravir sodiumtab 10 mg (base equiv)TIVICAY – dolutegravir sodiumtab 25 mg (base equiv)TIVICAY – dolutegravir sodiumtab 50 mg (base equiv)TIVICAY PD – dolutegravirsodium tab for oral susp 5 mg(base equiv)TRIUMEQ – abacavirdolutegravir-lamivudine tab600-50-300 mgVIREAD – tenofovir disoproxilfumarate oral powder 40 mg/gmVIREAD – tenofovir disoproxilfumarate tab 150 mgVIREAD – tenofovir disoproxilfumarate tab 200 mgVIREAD – tenofovir disoproxilfumarate tab 250 mg2212 oseltamivir phosphate cap45 mg (base equiv) (Tamiflu)oseltamivir phosphate cap75 mg (base equiv) (Tamiflu)oseltamivir phosphate for susp6 mg/ml (base equiv) (Tamiflu)MALARIA2 1 2 2 2 2 22 2 2 2 1zidovudine syrup 10 mg/ml(Retrovir)1 zidovudine tab 300 mg1 zidovudine cap 100 mg (Retrovir)oseltamivir phosphate cap30 mg (base equiv) (Tamiflu)atovaquone-proguanil hcl tab62.5-25 mg (Malarone)atovaquone-proguanil hcl tab250-100 mg (Malarone)chloroquine phosphate tab250 mghydroxychloroquine sulfate tab200 mg (Plaquenil)MEFLOQUINE HCL – mefloquinehcl tab 250 mg 1 1 111121albendazole tab 200 mg(Albenza)1BENZNIDAZOLE – benznidazoletab 12.5 mg2praziquantel tab 600 mg(Biltricide)OTHER ANTI-INFECTIVESALINIA – nitazoxanide for susp100 mg/5mlatovaquone susp 750 mg/5ml(Mepron)Dispensing Limits1pyrimethamine tab 25 mg(Daraprim)ivermectin tab 3 mg (Stromectol)Step Therapy 1BENZNIDAZOLE – benznidazoletab 100 mgPrior Authorization1primaquine phosphate tab26.3 mg (15 mg base)(Primaquine phosphate)WORM INFECTIONSSpecialty Drug NameTier DesignationDispensing LimitsStep TherapyPrior AuthorizationSpecialtyDrug NameTier Designation20212112 1InfluenzaPrescription Drug Guide October 20216
clindamycin hcl cap 75 mg(Cleocin)1clindamycin hcl cap 150 mg(Cleocin)1clindamycin hcl cap 300 mg(Cleocin)1clindamycin palmitate hcl forsoln 75 mg/5ml (base equiv)(Cleocin pediatric gr)1dapsone tab 25 mg1dapsone tab 100 mgIMPAVIDO – miltefosine cap 50mgsulfamethoxazole-trimethoprimtab 400-80 mg (Bactrim)sulfamethoxazole-trimethoprimtab 800-160 mg (Bactrim ds)trimethoprim tab 100 mgvancomycin hcl cap 125 mg(base equivalent) (Vancocin hcl)vancomycin hcl cap 250 mg(base equivalent) (Vancocin hcl)XIFAXAN – rifaximin tab 550 mg1JANSSEN COVID-19 VACCINE– covid-19 (sars-cov-2) ad26vector vaccine-janssen im 0.5ml2linezolid for susp 100 mg/5ml(Zyvox)1linezolid tab 600 mg (Zyvox)1metronidazole tab 250 mg(Flagyl)1metronidazole tab 500 mg(Flagyl)1nitazoxanide tab 500 mg (Alinia)1MODERNA COVID-19 VACCINE– covid-19 (sars-cov-2)mrnavacc-moderna im susp 100mcg/0.5ml PFIZER-BIONTECH COVID-19– covid-19 (sars-cov-2)mrna vacc-pfizer im susp 30mcg/0.3mlDispensing LimitsStep TherapyPrior AuthorizationSpecialtyDrug NameTier DesignationDispensing LimitsStep TherapyPrior AuthorizationSpecialtyDrug NameTier Designation20211111122221CANCER DRUGS1abiraterone acetate tab 250 mg(Zytiga)1 1abiraterone acetate tab 500 mg(Zytiga)1 ACTIMMUNE – interferongamma-1b inj 100 mcg/0.5ml(2000000 unit/0.5ml)2nitrofurantoin monohydratemacrocrystalline cap 100 mg(Macrobid)1 AFINITOR – everolimus tab 10mg2nitrofurantoin susp 25 mg/5ml1 AFINITOR DISPERZ – everolimus 2tab for oral susp 2 mgAFINITOR DISPERZ – everolimus 2tab for oral susp 3 mgAFINITOR DISPERZ – everolimus 2tab for oral susp 5 mg2ALECENSA – alectinib hcl cap150 mg (base equivalent) nitrofurantoin macrocrystallinecap 25 mg (Macrodantin)nitrofurantoin macrocrystallinecap 50 mg (Macrodantin)nitrofurantoin macrocrystallinecap 100 mg (Macrodantin)pentamidine isethionate fornebulization soln 300 mg(Nebupent)1SOLOSEC – secnidazolegranules packet 2 gm2SULFADIAZINE – sulfadiazine tab 2500 mg1sulfamethoxazole-trimethoprimsusp 200-40 mg/5mlPrescription Drug Guide October 20217
anastrozole tab 1 mg (Arimidex)AYVAKIT – avapritinib tab 25 mgAYVAKIT – avapritinib tab 50 mg2122AYVAKIT – avapritinib tab 100 mg 2AYVAKIT – avapritinib tab 200 mg 2AYVAKIT – avapritinib tab 300 mg 2bexarotene cap 75 mg (Targretin) 1bicalutamide tab 50 mg(Casodex)1BOSULIF – bosutinib tab 100 mg2BOSULIF – bosutinib tab 400 mgBOSULIF – bosutinib tab 500 mgCABOMETYX – cabozantinibs-malate tab 20 mg (baseequivalent)CABOMETYX – cabozantinibs-malate tab 40 mg (baseequivalent)CABOMETYX – cabozantinibs-malate tab 60 mg (baseequivalent)22222CAPRELSA – vandetanib tab 300mgCOMETRIQ – cabozantinib smalate cap 3 x 20 mg (60 mgdose) kitPrescription Drug Guide October 2021 COTELLIC – cobimetinibfumarate tab 20 mg (baseequivalent) 2 2 2 2 2 2 2 1 1 1 1cyclophosphamide cap 50 mg(Cyclophosphamide)1EMCYT – estramustinephosphate sodium cap 140 mg2ERIVEDGE – vismodegib cap150 mg 2cyclophosphamide cap 25 mg(Cyclophosphamide)ERLEADA – apalutamide tab 60mgerlotinib hcl tab 25 mg (baseequivalent) (Tarceva)erlotinib hcl tab 100 mg (baseequivalent) (Tarceva)erlotinib hcl tab 150 mg (baseequivalent) (Tarceva)ETOPOSIDE – etoposide cap 50mgeverolimus tab 2.5 mg (Afinitor)everolimus tab 5 mg (Afinitor)capecitabine tab 150 mg (Xeloda) 1capecitabine tab 500 mg (Xeloda) 1CAPRELSA – vandetanib tab 100mg COMETRIQ – cabozantinib s-malcap 1 x 80 mg & 3 x 20 mg (140dose) kiteverolimus tab 7.5 mg (Afinitor)Dispensing Limits COMETRIQ – cabozantinib s-malcap 1 x 80 mg & 1 x 20 mg (100dose) kitStep TherapyALUNBRIG – brigatinib tab 30 mg 2ALUNBRIG – brigatinib tab 90 mg 2ALUNBRIG – brigatinib tab 180mg Prior Authorization Specialty2ALUNBRIG – brigatinib tabinitiation therapy pack 90 mg &180 mgDrug NameTier DesignationDispensing LimitsStep TherapyPrior AuthorizationSpecialtyDrug NameTier Designation2021 2111exemestane tab 25 mg(Aromasin)1FARYDAK – panobinostat lactatecap 10 mg (base equivalent)2 2 2 FARYDAK – panobinostat lactatecap 15 mg (base equivalent)FARYDAK – panobinostat lactatecap 20 mg (base equivalent)8
FIRMAGON – degarelix acetatefor inj 120 mg/vial (240 mgdose)floxuridine for inj 0.5 gm2ICLUSIG – ponatinib hcl tab 30mg (base equiv)ICLUSIG – ponatinib hcl tab 45mg (base equiv)1fulvestrant inj 250 mg/5ml(Faslodex)1GILOTRIF – afatinib dimaleatetab 20 mg (base equivalent)2 2 2 GILOTRIF – afatinib dimaleatetab 30 mg (base equivalent)GILOTRIF – afatinib dimaleatetab 40 mg (base equivalent)GLEOSTINE – lomustine cap 10mgGLEOSTINE – lomustine cap 40mgGLEOSTINE – lomustine cap 100mg222HYCAMTIN – topotecan hcl cap 1 2mg (base equiv)1hydroxyurea cap 500 mg(Hydrea)2IBRANCE – palbociclib cap 75mg2IBRANCE – palbociclib cap 100mg2IBRANCE – palbociclib cap 125mgIBRANCE – palbociclib tab 75 mg 2 IBRANCE – palbociclib tab 125mgICLUSIG – ponatinib hcl tab 10mg (base equiv)ICLUSIG – ponatinib hcl tab 15mg (base equiv)Prescription Drug Guide October 2021imatinib mesylate tab 400 mg(base equivalent) (Gleevec)IMBRUVICA – ibrutinib cap 70mgIMBRUVI
The Prescription Drug Guide includes all Preferred Brand drugs and a partial listing of Generic drugs. Brand name drugs not listed in this Prescription Drug Guide are Non-Preferred Brands. A drug may not be added to the Preferred Brand tier for reasons including safety or effectiveness, or because a simi
