Transcription
Your 2021 Select Standard FormularyEffective January 1, 2021For the most current list of covered medications or if you have questions:Call the number on your member ID card.Visit your plan’s website on your member ID card to: Find a participating retail pharmacy by ZIP code. Look up possible lower-cost medication alternatives. Compare medication pricing and options.
Understanding your formularyWhat is a formulary?A formulary is a list of prescribed medications or otherpharmacy care products, services or supplies chosenfor their safety, cost, and effectiveness. Medications arelisted by categories or classes and are placed into costlevels known as tiers. It includes both brand and genericprescription medications.To create the list, OptumRx is guided by the Pharmacy andTherapeutics Committee. This group of doctors, nurses, andpharmacists reviews which medications will be covered,how well the drugs work, and overall value. They also makesure there are safe and covered options.About this formularyWhere differences between thisformulary and your benefit planexist, the benefit plan documentsrule. This may not be a completelist of medications that are coveredby your plan. Please review yourbenefit plan for full details.How do I use my formulary?You and your doctor can use the formulary to help you choose the most cost-effective prescriptionmedications. This guide tells you if a medication is generic or brand, and if special rules apply.Bring this list with you when you see your doctor. If your medication is not listed here, please visityour plan’s member website or call the number on your member ID card.What are tiers?Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, set byyour employer or plan sponsor. This is how much you will pay when you fill a prescription.When does the formulary change? Medications may move to a lower tier at any time. Medications may move to a higher tier when a generic equal becomes available. Medications may move to a higher tier or be excluded from coverage on January 1 or July 1 ofeach year.When a medication changes tiers, you may have to pay a different amount for that medication.Why are some medications excluded from coverage?A medication may be excluded from coverage under your pharmacy benefit when it works thesame as or similar to another prescription or over-the-counter (OTC) medication.What if I don’t agree with a decision about an excluded medication?You or your authorized representative and your doctor can ask for a coverage request by callingthe number on your member ID card.2
Medication tipsWhat is the difference between brand-name and genericmedications?Generic medications contain the same active ingredients(offer the same effect) as brand-name medications, but theyoften cost less. Once the patent for a brand-name medicationends, the FDA can approve a generic version with the sameactive ingredients.What if my doctor writes a brand-name prescription?If your doctor gives you a prescription for a brand-namemedication, ask if a generic or lower-cost option could be rightfor you. Generic medications are usually your lowest-cost option.Over-the-counter medicationsAn over-the-counter (OTC)medication may be the righttreatment for some conditions.Talk to your doctor aboutavailable OTC options. Eventhough OTC medications maynot be covered by your pharmacybenefit, they may cost less thana prescription medication.What if I am taking a specialty medication?Specialty medications are used to treat complex conditions. These high-cost medications maybe injected, infused or taken by mouth. Please note, not all specialty medications are listed in theformulary. Our specialty pharmacy can provide most of your specialty medications along with helpfulprograms and services.3
Reading your formularyThe formulary gives you choices so you and your doctor can decide your best course of treatment.In this formulary, brand-name medications are shown in UPPERCASE (for example, CLOBEX).Generic medications are shown in lowercase (for example, clobetasol).Tier informationUsing lower tier or preferred medications can help you pay your lowest out-of-pocket cost. Yourplan may have multiple or no tiers. Please note: If you have a high-deductible plan, the tier costlevels will apply once you meet your deductible.Drug TierIncludesHelpful TipsTier 1 Lower-cost generics Use Tier 1 drugs for the lowest out-of-pocket costs.and some brand-nameTier 2 Mid-range costpreferred brand-nameUse Tier 2 drugs instead of Tier 3 to help reduce yourout-of-pocket costs.Tier 3 Highest-costnon-preferredMany Tier 3 drugs have lower-cost options in Tier 1 or 2.Ask your doctor if they could work for you.Drug list informationIn this drug list, some medications are noted with letters next to them to help you see which onesmay have coverage requirements or limits. Your benefit plan decides how these medications maybe covered.SPSpecialty Medication – Medication is designated as specialty.3PTier 3 preferred4
Table of ContentsAnalgesics - Drugs for Pain.7Analgesics - Drugs for Pain and Inflammation. 7Anesthetics.7Anti-Addiction / Substance Abuse Treatment Agents. 7Antibacterials.8Anticoagulants.8Anticonvulsants - Drugs for Seizures. 8Antidementia Agents - Drugs for Alzheimer's Disease and Dementia. 9Antidepressants.9Antiemetics - Drugs for Nausea and Vomiting. 10Antifungals.10Antigout Agents. 10Antimigraine Agents. 10Antineoplastics - Drugs for Cancer.10Antiparasitics. 11Antiparkinson Agents. 11Antiplatelets.11Antipsychotics - Drugs for Mood Disorders. 11Antivirals.11Anxiolytics - Drugs for Anxiety.12Bipolar Agents - Drugs for Mood Disorders.12Blood Products / Modifiers / Volume Expanders - Drugs for Bleeding Disorders.12Cardiovascular Agents - Drugs for Heart and Circulation Conditions. 12Central Nervous System Agents - Drugs for Attention Deficit Disorder. 14Central Nervous System Agents - Drugs for Multiple Sclerosis. 14Central Nervous System Agents - Miscellaneous. 15Dental and Oral Agents - Drugs for Mouth and Throat Conditions.15Dermatological Agents - Drugs for Skin Conditions. 15Diabetes - Antidiabetic Agents. 16Diabetes - Glucose Monitoring. 16Diabetes - Glycemic Agents. 17Diabetes - Insulins.17Electrolytes / Minerals / Metals / Vitamins.18Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer.18Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions.19Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment. 19Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions.19Genitourinary Agents - Drugs for Prostate Conditions. 20Hormonal Agents - Adrenal. 20Hormonal Agents - Men's Health.20Hormonal Agents - Osteoporosis. 20Hormonal Agents - Pituitary. 20Hormonal Agents - Sex Hormones and Birth Control.21Hormonal Agents - Thyroid. 22Immunological Agents - Drugs for Immune System Stimulation or Suppression. 22Inflammatory Bowel Disease Agents.23Metabolic Bone Disease Agents - Drugs for Osteoporosis. 23Metabolic Bone Disease Agents - Other. 24Miscellaneous Therapeutic Agents. 24Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation.24Ophthalmic Agents - Drugs for Glaucoma.245
Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions. 24Otic Agents - Drugs for Ear Conditions. 25Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold.25Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions. 25Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis. 26Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension. 26Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm. 26Sleep Disorder Agents. 266
Drug NameDrug Tier NotesDrug NameAnalgesics - Drugsfor PainDrug Tier Notesdiclofenac sodium oral1diclofenac sodiumtransdermal gel 1 %1etodolac oral tablet1acetaminophencodeine #21acetaminophencodeine #31ibuprofen oral tablet1acetaminophencodeine #41INDOMETHACINORAL CAPSULE 20MG3acetaminophencodeine oral tablet 30015 mg, 300-60 mg1indomethacin oralcapsule 25 mg, 50 mg1ketorolac tromethamineoral1meloxicam oral1apap-caffdihydrocodeine oralcapsule1BELBUCA2nabumetone ydrocodoneacetaminophen oraltabletnaproxen oral tabletAnesthetics1lidocaine external patch1hydromorphone hcl oraltablet1HYSINGLA ER2morphine sulfate er oraltablet extended release1NUCYNTA3oxycodone hcl ol hcl oral tablet50 mg1TREZIX3XTAMPZA ERAnalgesics - Drugsfor Pain andInflammation2celecoxib oral1lidocaine-prilocaineexternal creamAnti-Addiction /Substance AbuseTreatment Agents1BUNAVAIL3buprenorphine hclsublingual1buprenorphine hclnaloxone hcl1CHANTIX3CHANTIXCONTINUING MONTHPAK3CHANTIX STARTINGMONTH PAK3naltrexone hcl oral1NARCAN2ZUBSOLV2For more information regarding the tiers and designations in this drug list, please see the Reading yourformulary section of this booklet.7
Drug NameDrug Tier NotesDrug NameAntibacterialsamoxicillin oral capsule1Drug Tier Notesmetronidazole oraltablet1metronidazole vaginal1amoxicillin oralsuspensionreconstituted1minocycline hcl oralcapsule1amoxicillin oral tablet1mupirocin external1nitrofurantoinmacrocrystal oral1nitrofurantoinmonohydratemacrocrystals1NUZYRA ORAL3penicillin v potassiumoral anate lavulanate oral tablet1azithromycin oralsuspensionreconstituted1azithromycin oral tablet1cefdinir1cefuroxime axetil1sulfamethoxazoletrimethoprim oral tablet1cephalexin oral capsule1XENLETA3cephalexin oralsuspensionreconstituted1XEPI33ciprofloxacin hcl oraltablet 250 mg, 500 mg1XIMINOAnticoagulantsELIQUIS2clarithromycin oraltablet1ELIQUIS DVT/PESTARTER PACK2clindamycin hcl oral1enoxaparin sodium1CLINDESSE3PRADAXA2DIFICID3warfarin sodium oral1doxycycline hyclate oralcapsule1XARELTO2doxycycline hyclate oraltablet1doxycyclinemonohydrate oralcapsuleXARELTO STARTERPACKAnticonvulsants Drugs for Seizures1BRIVIACT3doxycyclinemonohydrate oral tablet1carbamazepine oraltablet1levofloxacin oral tablet1divalproex sodium er1SP2For more information regarding the tiers and designations in this drug list, please see the Reading yourformulary section of this booklet.8
Drug NameDrug Tier Notesdivalproex sodium oraltablet delayed release1EPIDIOLEX3FYCOMPA3gabapentin oralcapsule1gabapentin oral tablet1lamotrigine er1lamotrigine oral tablet1levetiracetam oraltablet1NAYZILAM3oxcarbazepine oraltablet1SYMPAZAN3topiramate oral tablet1TROKENDI XRDrug Namememantine hcl oraltablet 10 mg, 5 mg1NAMZARICAntidepressants2amitriptyline hcl oral1bupropion hcl er (sr)1bupropion hcl er (xl)oral tablet extendedrelease 24 hour 150mg, 300 mg1BUPROPION HCL ER(XL) ORAL TABLETEXTENDED RELEASE24 HOUR 450 MG3bupropion hcl oral113citalopramhydrobromide oraltabletVALTOCO 10 MGDOSE3desvenlafaxinesuccinate er1VALTOCO 15 MGDOSE3doxepin hcl oralcapsule1VALTOCO 20 MGDOSE3duloxetine hcl oral1VALTOCO 5 MGDOSE13escitalopram oxalateoral tabletVIMPAT3fluoxetine hcl oralcapsule1XCOPRI3fluoxetine hcl oral tablet1XCOPRI (250 MGDAILY DOSE)3fluvoxamine maleate1FORFIVO XL3XCOPRI (350 MGDAILY DOSE)3mirtazapine oral tablet1nortriptyline hcl oralcapsule1paroxetine hcl1sertraline hcl oral tablet1trazodone hcl oral1TRINTELLIX3venlafaxine hcl1zonisamide oralAntidementia Agents- Drugs forAlzheimer's Diseaseand Dementiadonepezil hcl oral tablet10 mg, 23 mgSPDrug Tier Notes11For more information regarding the tiers and designations in this drug list, please see the Reading yourformulary section of this booklet.9
Drug NameDrug Tier Notesvenlafaxine hcl er1VIIBRYD3VIIBRYD STARTERPACKAntiemetics - Drugsfor Nausea andVomitingterconazole vaginalcreamAntigout Agents3meclizine hcl oral tablet1metoclopramide hcloral tablet 10 mg1ondansetron hcl oraltablet 4 mg, 8 mg1ondansetron odt1prochlorperazinemaleate oral1scopolamine1VARUBI (180 MGDOSE)AntifungalsDrug Name3Drug Tier Notes1allopurinol oral1colchicine oral tablet1febuxostatAntimigraine Agents1AIMOVIG2eletriptan hydrobromide1EMGALITY2EMGALITY (300 MGDOSE)2NURTEC2rizatriptan benzoate1sumatriptan succinateoral1UBRELVYAntineoplastics Drugs for Cancer2anastrozole oral1CABOMETYX2SPcapecitabine1SPIBRANCE ORALCAPSULE3SPIDHIFA3SPimatinib mesylate1SPciclopirox externalsolution1clotrimazole externalcream1clotrimazolebetamethasoneexternal cream1CRESEMBA ORAL3fluconazole oral tablet1GYNAZOLE-13IMBRUVICA ORALTABLET3SPKERYDIN3KANJINTI2SPketoconazole externalcream1letrozole oral1ketoconazole externalshampooLYNPARZA2SP1MVASI2SPnystatin external cream1NUBEQA3SPnystatin mouth/throat1REVLIMID2SPterbinafine hcl oral1RUBRACA2SPRUXIENCE2SPFor more information regarding the tiers and designations in this drug list, please see the Reading yourformulary section of this booklet.10
Drug NameDrug Tier NotesSPRYCEL2tamoxifen citrate g NameINVEGA TRINZA3LATUDA3olanzapine oral tablet1PERSERIS3SPquetiapine fumarate12SPquetiapine fumarate er1XTANDI3SPREXULTI3ZEJULA2SPrisperidone oral KODA32ziprasidone hclAntivirals1EMVERM1acyclovir oral capsule1acyclovir oral e oralAntiparkinson AgentsSPDrug Tier Notesbenztropine mesylateoral1carbidopa-levodopaoral 1ropinirole LINTA2clopidogrel bisulfateoral11oseltamivir phosphateoralPREZCOBIX2SYMFI2SYMFI LO2TAMIFLU ORALCAPSULE 75 MG3TIVICAY2TRIUMEQ2TRUVADA3prasugrel hclAntipsychotics Drugs for MoodDisorders1aripiprazole oral tablet1ARISTADA3ARISTADA INITIO3INVEGA SUSTENNA3SPSPSPFor more information regarding the tiers and designations in this drug list, please see the Reading yourformulary section of this booklet.11
Drug NameDrug Tier Notesvalacyclovir hcl oral1VEMLIDY3VOSEVI2XOFLUZA (40 MGDOSE)3XOFLUZA (80 MGDOSE)Anxiolytics - Drugsfor AnxietyDrug NameDrug Tier NotesMULPLETA2SPSPNEULASTA3SPSPNEULASTA ULTOMIRIS3SP3alprazolam oral tablet1ZARXIO2SPbuspirone hcl oral13SPclonazepam oral tablet1diazepam oral tablet1hydroxyzine hcl oraltablet1ZIEXTENZOCardiovascularAgents - Drugs forHeart and CirculationConditionsamiodarone hcl oral1hydroxyzine pamoateoral1amlodipine besylateoral1lorazepam oral tablet1triazolamBipolar Agents Drugs for MoodDisorders1amlodipine besylatebenazepril hcl1amlodipine besylatevalsartan1amlodipine-olmesartan1lithium carbonate er1atenolol oral11atenolol-chlorthalidone1atorvastatin calciumoral1benazepril hcl oral1bisoprolol fumarate1bisoprololhydrochlorothiazide1bumetanide oral1BYSTOLIC2candesartan cilexetil1cartia xt1carvedilol1lithium carbonate oralcapsuleBlood Products /Modifiers / VolumeExpanders - Drugs forBleeding DisordersADYNOVATE3SPAFSTYLAINTRAVENOUS KIT1000 UNIT, 2000 UNIT,250 UNIT, 3000 UNIT,500 UNIT3SPARANESP lonidine hcl oral1For more information regarding the tiers and designations in this drug list, please see the Reading yourformulary section of this booklet.12
Drug NameDrug Tier NotesCORLANOR3digoxin oral tablet1Drug NameDrug Tier Noteslisinoprilhydrochlorothiazide1LIVALO3losartan potassium oral1losartan potassium-hctz1lovastatin1metoprolol succinate er1diltiazem hcl er coatedbeads oral capsuleextended release 24hour1dilt-xr1doxazosin mesylateoral1metoprolol tartrate oral1EDARBI3MULTAQ3EDARBYCLOR3nadolol oral1enalapril maleate ne er1ezetimibe-simvastatin11fenofibrate micronizedoral capsule 134 mg,200 mg, 67 mgnifedipine er osmoticrelease1nitroglycerin sublingual1fenofibrate oral tablet1olmesartan medoxomiloral1fenofibric acid oralcapsule delayedrelease1olmesartan medoxomilhctz1flecainide acetate1olmesartan-amlodipinehctz1furosemide oral tablet11gemfibrozil oral1omega-3-acid ethylestersguanfacine hcl1PRALUENT2HEMANGEOL3pravastatin sodium1hydralazine hcl oral1prazosin hcl oral1hydrochlorothiazideoralpropranolol hcl er111irbesartan1propranolol hcl anolazine er1isosorbide mononitrateer1REPATHA2SPlabetalol hcl oral12SPlisinopril oral1REPATHAPUSHTRONEXSYSTEMSPFor more information regarding the tiers and designations in this drug list, please see the Reading yourformulary section of this booklet.13
Drug NameDrug Tier NotesREPATHASURECLICK2rosuvastatin calcium1simvastatin oral1sotalol hcl oral1spironolactone oral1TEKTURNA2TEKTURNA ASCEPA2verapamil hcl er oralcapsule extendedrelease 24 hour 120mg, 180 mg, 240 mg,360 mg1verapamil hcl er oraltablet extended releaseCentral NervousSystem Agents Drugs for AttentionDeficit DisorderDrug NameSP1Drug Tier Notesguanfacine hcl er1JORNAY PM3methylphenidate hcl er(la) oral capsuleextended release 24hour 10 mg, 20 mg, 30mg, 40 mg1METHYLPHENIDATEHCL ER (XR)3methylphenidate hcl eroral tablet extendedrelease1methylphenidate hcloral tablet1VYVANSECentral NervousSystem Agents Drugs for MultipleSclerosis2AMPYRA3SPAUBAGIO3SPAVONEX PEN2SPAVONEX ENYA33P; SPADDERALL XR3glatiramer acetate1SPamphetaminedextroamphetamine1MAVENCLAD (10TABS)33P; SPamphetaminedextroamphetamine er1MAVENCLAD (4TABS)33P; SPatomoxetine hcl133P; SPdexmethylphenidate hclerMAVENCLAD (5TABS)133P; SPdexmethylphenidate hcloral tablet 10 mg, 5 mgMAVENCLAD (6TABS)133P; SPEVEKEO ODT3MAVENCLAD (7TABS)For more information regarding the tiers and designations in this drug list, please see the Reading yourformulary section of this booklet.14
Drug NameDrug Tier NotesMAVENCLAD (8TABS)33P; SPMAVENCLAD (9TABS)33P; SPMAYZENT3REBIFDrug NameDrug Tier NotesDermatologicalAgents - Drugs forSkin ConditionsABSORICA33P; SPABSORICA LD33SPREBIF REBIDOSE3SPACZONE EXTERNALGEL 7.5 %2REBIF REBIDOSETITRATION PACK3SPAMZEEQ3REBIF TITRATIONPACK3SPbetamethasonedipropionate vis12SPclindamycin phosphatebenzoyl peroxideexternal gel 1-5 %1clindamycin phosphateexternal lotion1clindamycin phosphateexternal solution1clindamycin phosphateexternal swab1CLINDAMYCINPHOSPHATE GEL 1 %EXTERNAL3clindamycin phosphategel 1 % external1clobetasol propionateexternal cream1clobetasol propionateexternal ointment1clobetasol propionateexternal solution1DUPIXENTSUBCUTANEOUSSOLUTIONPREFILLED SYRINGE2ENSTILAR3EPIDUO FORTE3EUCRISA2VUMERITY(STARTER)Central NervousSystem Agents rmine hcl oraltablet1pregabalin oral IDental and OralAgents - Drugs forMouth and ThroatConditions3chlorhexidine gluconatemouth/throat1lidocaine viscous hcl1SPSPFor more information regarding the tiers and designations in this drug list, please see the Reading yourformulary section of this booklet.15
Drug NameDrug Tier NotesFINACEA3fluocinonide externalcream1FLUOROPLEX3hydrocortisone externalcream1hydrocortisone externalointment1metronidazole externalcream1metronidazole externalgel1MIRVASO3mometasone furoateexternal cream1ONEXTON3QBREXZA3RETIN-A MICROPUMP EXTERNALGEL 0.06 %, 0.08 %Drug NameDrug Tier NotesFARXIGA2glimepiride1glipizide er1glipizide ir1glyburide oral1GLYXAMBI2INVOKANA3JANUMET2JANUMET XR2JANUVIA2JARDIANCE2JENTADUETO2JENTADUETO XR2metformin hcl er1metformin hcl er (mod)1metformin hcl er (osm)12metformin hcl oraltablet1RHOFADE3OZEMPIC2SERNIVO3pioglitazone hcl1SOOLANTRA3RYBELSUS2TACLONEX3SOLIQUA2tacrolimus externalointment1SYMLINPEN 1203SYMLINPEN 603tretinoin external cream1SYNJARDY2triamcinolone acetonideexternal cream1SYNJARDY XR2TRADJENTA2TRIJARDY XR2TRULICITY2VICTOZA2XIGDUO XRDiabetes - GlucoseMonitoring2triamcinolone acetonideexternal ointmentDiabetes Antidiabetic Agents1BYDUREON2BYDUREON BCISEAUTOINJECTOR2BYETTA 10 MCG PEN2BYETTA 5 MCG PEN2ACCU-CHEKFASTCLIX LANCETKIT2For more information regarding the tiers and designations in this drug list, please see the Reading yourformulary section of this booklet.16
Drug NameDrug Tier NotesACCU-CHEK GUIDETEST STRIPS3ACCU-CHEKSOFTCLIX LANCETDEVICE KIT2CONTOUR MONITOR2CONTOUR CONTROLDrug NameDrug Tier NotesV-GO 40Diabetes - GlycemicAgents2BAQSIMI ONE PACK2BAQSIMI TWO PACK22GLUCAGONEMERGENCY KIT2Made by LillyCONTOUR NEXTCONTROL2GLUCAGONEMERGENCY KIT2Made byFreseniusCONTOUR NEXTMONITOR2CONTOUR NEXTTESTGVOKE PFSDiabetes - Insulins22CONTOUR TEST2BD AUTOSHIELD DUOPEN NEEDLESBD ULTRA-FINEINSULIN SYRINGES2BD ULTRA-FINE PENNEEDLES2BD VEO INSULIN SYRU/F 1/2UNIT2HUMALOG KWIKPEN2HUMALOG MIX 50/50KWIKPEN2HUMALOG MIX 50/50VIAL2HUMALOG MIX 75/25KWIKPEN2DEXCOM G4 / G5 / G6RECEIVER,TRANSMITTER,SENSOR (INCLUDINGPLATINUM,PLATINUMPEDIATRIC)22DEXCOM G4 / G5 / G6RECEIVER,TRANSMITTER,SENSOR (INCLUDINGPLATINUM,PLATINUMPEDIATRIC) DEVICE2FREESTYLE LIBRE 14DAY READER2HUMALOG MIX 75/25VIAL2FREESTYLE LIBRE 14DAY SENSOR2HUMALOG U-100JUNIOR KWIKPEN2FREESTYLE LIBREREADER2HUMALOG VIAL2FREESTYLE LIBRESENSOR SYSTEM22HUMULIN 70/30KWIKPENHUMULIN 70/30 VIAL2ONETOUCH ULTRA3HUMULIN N KWIKPEN2ONETOUCH VERIOTEST STRIPS3HUMULIN N VIAL2V-GO 202HUMULIN R U-500KWIKPEN2V-GO 302For more information regarding the tiers and designations in this drug list, please see the Reading yourformulary section of this booklet.17
Drug NameDrug Tier NotesHUMULIN R U-500VIAL2HUMULIN R VIAL2LANTUS SOLOSTAR2LANTUS U-100 VIAL2LEVEMIR U-100FLEXTOUCH2LEVEMIR U-100 VIAL2NOVOFINEAUTOCOVER PENNEEDLEDrug NameDrug Tier NotesElectrolytes / Minerals/ Metals / Vitaminscyanocobalamininjection solution 1000mcg/ml1ergocalciferol oralcapsule1folic acid oral tablet1klor-con m2012LOKELMA3NOVOFINE PENNEEDLE2multivitamin/fluorideoral tablet chewable0.25 mg, 0.5 mg, 1 mg1NOVOFINE PLUS PENNEEDLE2NASCOBAL3NOVOLIN 70/30FLEXPEN12potassium chloride cryserpotassium chloride er1NOVOLIN 70/30 VIAL2potassium citrate er1NOVOLIN N FLEXPEN2NOVOLIN N VIAL2sodium fluoride oraltablet chewable1NOVOLIN R FLEXPEN2VELTASSA3NOVOLIN R VIAL2NOVOLOG FLEXPEN2NOVOLOG MIX 70/30FLEXPEN2NOVOLOG MIX 70/30VIAL2vitamin d(ergocalciferol) oralcapsule 1.25 mg(50000 ut)GastrointestinalAgents - Drugs forAcid Reflux and UlcerNOVOLOG PENFILL2DEXILANT2NOVOLOG U-100 VIAL2NOVOTWIST PENNEEDLE21TOUJEO MAXSOLOSTAResomeprazolemagnesium oralcapsule delayedrelease2famotidine oral tablet1TOUJEO SOLOSTAR2TRESIBA2lansoprazole oralcapsule delayedrelease1TRESIBAFLEXTOUCH2omeprazole oralcapsule delayedrelease11For more information regarding the tiers and designations in this drug list, please see the Reading yourformulary section of this booklet.18
Drug NameDrug Tier Notespantoprazole sodiumoral tablet delayedrelease1rabeprazole sodiumoral tablet delayedrelease1sucralfate oral tabletGastrointestinalAgents - Drugs forBowel, Intestine andStomach Conditions1CLENPIQ3dicyclomine hcl oralcapsule1dicyclomine hcl oraltablet1diphenoxylate-atropineoral tabletDrug NameDrug Tier NotesGenetic or EnzymeDisorder - Drugs N2NITYR3SPSTRENSIQSUBCUTANEOUSSOLUTION 28MG/0.7ML, 40 MG/ML,80 MG/0.8ML2SP21ZENPEPGenitourinary Agents- Drugs for Bladder,Genital and KidneyConditionsgavilyte-g1AURYXIA3glycopyrrolate oraltablet 1 mg, 2 mg1DEPEN TITRATABS2MYRBETRIQ2GLYCOPYRROLATEORAL TABLET 1.5 MG3oxybutynin chloride er1hyoscyamine sulfate sl1oxybutynin chloride oraltablet1hyoscyamine sulfatesublingual11lactulose oral solution1phenazopyridine hcloral tablet 100 mg, 200mgLINZESS2MOTEGRITY3sildenafil citrate oraltablet 100 mg, 25 mg,50 mg1MOVANTIK2solifenacin succinate1OMECLAMOX-PAK2STENDRA3PYLERA2tadalafil oral1SUPREP BOWELPREP KIT3tolterodine tartrate RM3SPSPFor more information regarding the tiers and designations in this drug list, please see the Reading yourformulary section of this booklet.19
Drug NameDrug Tier NotesDrug NameGenitourinary Agents- Drugs for ProstateConditionsalfu
Your 2021 Select Standard Formulary Effective January 1, 2021. For the most current list of covered medications or if you have questions: Call the number on your member ID card. Visit your plan’s website on your member ID card to: Find a participating retail pharmacy by ZIP cod
