Transcription
2020 Performance Commercial Formulary
NotesST ST appliesDrugTierabacavir oral fy oral osateGPAacarboseGAccolateNPBAccu-Chek Aviva Control SolnAccu-Chek Aviva Plus MeterAccu-Chek Aviva Plus test strpAccu-Chek FastClix Lancing DevPBNPBPBNPBAccu-Chek GuidePBAccu-Chek Guide Glucose MeterPBAccu-Chek Guide L1-L2 Ctrl SolPBAccu-Chek Multiclix LancetPBAccu-Chek NanoNPBAccu-Chek SmartView Contrl SolPBAccu-Chek SmartView Test StripPBAccu-Chek Soft Dev LancetsPBAccu-Chek Softclix Lancet DevPBAccu-Chek Softclix LancetsPBAccuprilQLNPBacetaminophen-codeine oral solution 120-12 mg/5mLGacetaminophen-codeine oral tabletGStatusG Generic,NPB Non-Preferred Brand, P PreventativePB Preferred Brand,Female FemaleOnly,Male Male OnlyPA Prior Authorization,QL Quantity Limit,ST Step Therapy applies2
DrugTieracetazolamide oral capsule, extended releaseGacetazolamide oral tabletGacetazolamide sodiumNotesPASpecialtyacetic acid otic (ear)GacetylcysteineGAciphexNPBacitretinGPAActemra intravenousSpecialtyPAActhar H.P.SpecialtyPAActimmuneSpecialtyPAActivase intravenous recon soln 50 mgSpecialtyPAActivellaNPBActonel oral tablet 150 mg, 35 mg, 5 mgNPBActoplus METNPBActoplus Met XRNPBActosNPBacyclovir oral capsuleGacyclovir oral suspension 200 mg/5 mLGacyclovir oral tabletGacyclovir topical ointmentGAczone topical gelAdagenPANPBSpecialtyadapalene topical creamGadapalene topical gel 0.1 %GPAAdcetrisSpecialtyPAAdcircaSpecialtyPAAdderall XRadefovirAdrenalin nasalNPBSpecialtyPAPBAdriamycin intravenous solution 10 mg/5 mL, 20mg/10 mL, 50 mg/25 mLSpecialtyPAAdrucilSpecialtyPAStatusG Generic,NPB Non-Preferred Brand, P PreventativePB Preferred Brand,Female FemaleOnly,Male Male OnlyPA Prior Authorization,QL Quantity Limit,ST Step Therapy applies3
DrugTierAdvair DiskusPBAdvair HFAPBAdvateAerospanSpecialtyPANPBAfinitor oral tablet 10 mg, 2.5 mg, 5 mgSpecialtyAfinitor oral tablet 7.5 mgSpecialtyAggrenoxNotesPANPBAimovig AutoinjectorPBPAAimovig Autoinjector (2 Pack)PBPAAlavertGAlavert D-12 Allergy-SinusGAlawayGAlbenzaNPBalbuterol sulfate inhalation solution fornebulization 2.5 mg /3 mL (0.083 %), 5 mg/mLGalbuterol sulfate oral syrupGalbuterol sulfate oral tabletGAldactazide oral tablet 50-50 mgAldurazymealendronate oral tyAliniaNPBAlkeranNPBAllegra-D 24 Hourallopurinolallopurinol sodiumPAGAlferon NAlkeran (as eNPBAloraNPBStatusG Generic,NPB Non-Preferred Brand, P PreventativePB Preferred Brand,Female FemaleOnly,Male Male OnlyPA Prior Authorization,QL Quantity Limit,ST Step Therapy applies4
DrugTierAloxiSpecialtyAlphagan P ophthalmic (eye) drops 0.1 %NotesPANPBAlphanate intravenous recon soln 1,000 (400vWF) unit/10 mL, 1,500 (600 vWF) unit/10 mL,250 (100 vWF) unit/5 mL, 500 (200 vWF) unit/5mLSpecialtyPAAlphaNine SDSpecialtyPAalprazolam oral dine HCl oral capsuleGamantadine HCl oral solutionGAmbienNPBAmbien CRNPBPAAmBisomeSpecialtyPAamcinonide topical creamGamifostine crystallineSpecialtyPAamikacin injection solution 1,000 mg/4 mL, 500mg/2 deGaminocaproic acid intravenousSpecialtyPAaminophylline intravenous solution 250 mg/10 mLSpecialtyPAamiodarone oral tablet 200 poxideGamlodipineGamlodipine-benazepril oral capsule 10-20 mg, 1040 mg, 2.5-10 mgGamlodipine-valsartanGSTStatusG Generic,NPB Non-Preferred Brand, P PreventativePB Preferred Brand,Female FemaleOnly,Male Male OnlyPA Prior Authorization,QL Quantity Limit,ST Step Therapy applies5
DrugTieramlodipine-valsartan-hcthiazid oral tablet 10-16025 mg, 10-320-25 mg, 5-160-12.5 mg, 5-160-25mgGammonium chlorideGammonium ansoprazGamoxicillin oral capsuleGamoxicillin oral suspension for reconstitutionGamoxicillin oral tabletGamoxicillin oral tablet,chewable 125 mg, 250 mgGamoxicillin-pot clavulanateGamphotericin Bampicillin oral capsuleNotesSTPASpecialtyGampicillin pyraSpecialtyPAAmrix oral capsule,extended release 24hr 15 BAndrodermNPBAndroGel transdermal gel in metered-dose pump20.25 mg/1.25 gram (1.62 %)PBMaleAndroGel transdermal gel in packetPBMaleAngeliqAnoro soPAFemaleNPBStatusG Generic,NPB Non-Preferred Brand, P PreventativePB Preferred Brand,Female FemaleOnly,Male Male OnlyPA Prior Authorization,QL Quantity Limit,ST Step Therapy applies6
DrugTierAptensio XR oral cap,ER sprinkle,biphasic 40-6030 mgNPBAptivusNPBAralast NPAranelle (28)SpecialtyPNotesPAFemaleAranesp (in polysorbate) injection solutionSpecialtyPAAranesp (in polysorbate) injection syringe 100mcg/0.5 mL, 150 mcg/0.3 mL, 200 mcg/0.4 mL,25 mcg/0.42 mL, 300 mcg/0.6 mL, 40 mcg/0.4mL, 500 mcg/mL, 60 mcg/0.3 mLSpecialtyPAArcalystSpecialtyPAArcapta NeohalerNPBArimidexNPBaripiprazole oral tabletGArmour ThyroidNPBArnuity ificial Tears (polyvin alc)Arzerra intravenous solution 100 mg/5 mLGSpecialtyAsmanex HFAPBAsmanex TwisthalerPBaspirin-dipyridamoleGAstepro nasal spray,non-aerosolNPBAtacandNPBAtacand HCT oral tablet 16-12.5 AStatusG Generic,NPB Non-Preferred Brand, P PreventativePB Preferred Brand,Female FemaleOnly,Male Male OnlyPA Prior Authorization,QL Quantity Limit,ST Step Therapy applies7
DrugTieratropine injection syringe 0.1 mg/mLGAtrovent HFAPBAubagioAubraSpecialtyPNotesPAFemaleAugmentin oral suspension for reconstitution 12531.25 mg/5 mLNPBAugmentin XRNPBAvageNPBAvalideNPBAvandamet oral tablet 2-1,000 mgNPBAvandia oral tablet 2 mg, 4 ePAvodartNPBSTFemaleAvonex (with albumin)SpecialtyPAAvonex intramuscular pen injector kitSpecialtyPAAvonex intramuscular syringe omycin n intramuscularSpecialtybacitracin ophthalmic (eye)QLGStatusG Generic,NPB Non-Preferred Brand, P PreventativePB Preferred Brand,Female FemaleOnly,Male Male OnlyPA Prior Authorization,QL Quantity Limit,ST Step Therapy applies8
DrugTierbacitracin-polymyxin B ophthalmic (eye)Gbaclofen oral tablet 10 mg, 20 mgGbalsalazideGBalziva (28)PBanophen oral liquidGBanzel oral suspensionNPBBanzel oral tabletNPBBaqsimi NasalBaracludeNotesFemalePAPBSpecialtyBasaglar KwikPen U-100 InsulinPBBD AutoShield Duo Pen NeedlePBBD Insulin Syringe Ultra-Fine syringe 0.3 mL 30gauge x 1/2", 0.3 mL 31 gauge x 5/16", 0.5 mL 30gauge x 1/2"PBBD Ultra-Fine Mini Pen NeedlePBBD Ultra-Fine Nano Pen NeedlePBBD Ultra-Fine Orig Pen NeedlePBBD Ultra-Fine Short Pen NeedlePBBeconase AQNPBBelbuca buccal film 150 mcg, 300 mcg, 450 mcg,600 mcg, 75 mcgNPBBelsomra oral tablet 10 mg, 15 mg, 20 azideGQLPABeneFIXSpecialtyPABenicarPBSTBenicar HCTPBSTSpecialtyPANPBPABenlysta intravenousBenzamycinbenzonatate oral capsule 100 mg, 200 mgGbenzoyl peroxide topical gel 10 %Gbenztropine oralGStatusG Generic,NPB Non-Preferred Brand, P PreventativePB Preferred Brand,Female FemaleOnly,Male Male OnlyPA Prior Authorization,QL Quantity Limit,ST Step Therapy applies9
DrugTierNotesBepreveNPBPASpecialtyPABerinert intravenous kitBesivanceNPBbetamethasone dipropionateGbetamethasone valerate topical creamGbetamethasone valerate topical lotionGbetamethasone valerate topical ointmentGbetamethasone, augmented topical creamGbetamethasone, augmented topical lotionGbetamethasone, augmented topical ointmentGBetaseron subcutaneous kitSpecialtybetaxolol ophthalmic (eye)Gbethanechol chlorideGBetimol ophthalmic (eye) drops 0.5 %NPBbicalutamideGBicillin C-RSpecialtyBicillin bisoprolol cialtyPAbleomycinSpecialtyPABoniva intravenousSpecialtyPABoniva oralNPBBosulif oral tablet 100 mg, 500 mgSpecialtyBotoxSpecialtyPABotox Cosmetic intramuscularSpecialtyPABravelleSpecialtyPABreo ElliptaPBBrilintaPBStatusG Generic,NPB Non-Preferred Brand, P PreventativePB Preferred Brand,Female FemaleOnly,Male Male OnlyPA Prior Authorization,QL Quantity Limit,ST Step Therapy applies10
DrugTierbrimonidine ophthalmic (eye) drops 0.2 %GBromfed de inhalationGQLbudesonide nasalGPAbudesonide oral capsule,delayed,extend.releaseGPAbumetanide oralGBuphenyl oral tabletSpecialtybuprenorphine HCl sublingualGPAbuprenorphine-naloxone sublingual tabletGPAbupropion HCl oral tabletGbupropion HCl oral tablet extended release 24 hr150 mg, 300 mgGbupropion HCl oral tablet sustained-release 12 hrGbuspironeGBusulfexSpecialtyButalbital Compound W/CodeineGbutalbital-acetaminop-caf-cod oral capsule 50325-40-30 mgGbutalbital-acetaminophen oral tablet 50-325 mgGbutalbital-acetaminophen-caff oral tablet 50-32540 mgGbutorphanol tartrate nasalGButrans transdermal patch weekly 10 mcg/hour, 20mcg/hour, 5 mcg/hour, 7.5 mcg/hourPANPBBystolicPBcabergolineGCaduet oral tablet 10-10 mg, 10-20 mg, 10-40 mg,10-80 mg, 5-10 mg, 5-20 mg, 5-40 mg, 5-80 mgPANPBcaffeine citrate oralGcalcipotriene topical creamGStatusG Generic,NPB Non-Preferred Brand, P PreventativePB Preferred Brand,Female FemaleOnly,Male Male OnlyPA Prior Authorization,QL Quantity Limit,ST Step Therapy applies11
DrugTiercalcipotriene-betamethasoneGcalcitonin (salmon)Gcalcitriol intravenous solution 1 mcg/mLGcalcitriol oral capsuleGcalcitriol topicalGcalcium acetate oral capsuleGcalcium acetate oral tablet 667 ialtyPACaprelsaSpecialtyPACapastatcapsaicin topical cream 0.025 %GcaptoprilGcaptopril-hydrochlorothiazideGCarafate oral suspensionCarbagluNPBSpecialtycarbamazepine oral capsule, ER multiphase 12 hrGcarbamazepine oral suspension 100 mg/5 mLGcarbamazepine oral tabletGcarbamazepine oral tablet extended release 12 hr200 mg, 400 mgGcarbamazepine oral tablet,chewableGcarbidopaGcarbidopa-levodopa oral tabletGcarbidopa-levodopa oral tablet extended releaseGcarbinoxamine maleate oral tablet 4 mgGPAStatusG Generic,NPB Non-Preferred Brand, P PreventativePB Preferred Brand,Female FemaleOnly,Male Male OnlyPA Prior Authorization,QL Quantity Limit,ST Step Therapy applies12
DrugcarboplatinCardizem LAcarisoprodol oral tablet 350 mgTierSpecialtyGNPBCarnitor res-TTS-2NPBCatapres-TTS-3NPBCathflo ActivaseSpecialtyCaverject ImpulseNPBSpecialtycefaclor oral capsuleGcefadroxil oral capsuleGcefadroxil oral suspension for reconstitution 250mg/5 mL, 500 mg/5 mLGcefadroxil oral tabletGcefazolin injection recon soln 1 gram, 10 gram,500 mgPANPBCarnitor en pivoxil oral tablet 200 mgGPAPAPAcefepime in dextrose 5 %SpecialtyPAcefepime in dextrose,iso-osmSpecialtyPAcefepime injectionSpecialtyPAcefotaxime injection recon soln 1 gramSpecialtyPAcefotetanSpecialtyPAcefotetan in dextrose, iso-osmSpecialtyPAcefoxitin intravenous recon soln 1 tatusG Generic,NPB Non-Preferred Brand, P PreventativePB Preferred Brand,Female FemaleOnly,Male Male OnlyPA Prior Authorization,QL Quantity Limit,ST Step Therapy applies13
DrugTierNotesceftriaxone in dextrose,iso-osSpecialtyPAceftriaxone injection recon soln 1 gram, 10 gram, 2gram, 250 mg, 500 mgSpecialtyPAceftriaxone intravenousSpecialtyPAcefuroxime axetil oral suspension forreconstitution 125 mg/5 mLGcefuroxime axetil oral tabletGcefuroxime sodium intravenous recon soln ne SoluspanNPBCellCeptNPBCellCept IntravenousCelontin oral capsule 300 mgSpecialtyNPBcephalexin oral capsule 250 mg, 500 mgGcephalexin oral suspension for reconstitutionGCerezyme intravenous recon soln 400 unitCesametSpecialtyPANPBcetirizine oral solution 1 mg/mLGcetirizine oral imelineGChantixPQLChantix Starting Month BoxPQLChateal (28)PFemaleChemetNPBchloramphenicol sod succinateGchlordiazepoxide HClGchlorhexidine gluconate mucous membraneGchloroquine phosphateGchlorothiazideGStatusG Generic,NPB Non-Preferred Brand, P PreventativePB Preferred Brand,Female FemaleOnly,Male Male OnlyPA Prior Authorization,QL Quantity Limit,ST Step Therapy applies14
DrugTierchlorpromazine oralGchlorpropamideGchlorthalidone oral tablet 25 mg, 50 mgGchlorzoxazone oral tablet 500 mgGcholestyramine (with sugar)GCholestyramine Light oral powder in packetGcholine,magnesium salicylateGchromium chlorideSpecialtyCialisPBciclopirox topical gelGciclopirox topical solutionGciclopirox topical suspensionGcidofovirGcilostazolGCiloxan ophthalmic (eye) ointmentNotesPANPBcimetidineGcimetidine HCl oralGCimziaSpecialtyPACimzia Powder for ReconstSpecialtyPACinryzeSpecialtyPACipro HCCipro in D5W intravenous piggyback 400 mg/200mLNPBSpecialtyPACipro oral suspension,microcapsule reconNPBCipro XRNPBCiprodexPBciprofloxacinGciprofloxacin HCl ophthalmic (eye)Gciprofloxacin HCl oral tablet 250 mg, 500 mg, 750mgGQLciprofloxacin in 5 % dextrose intravenouspiggyback 400 mg/200 mLSpecialtyPAcisplatinSpecialtyPAStatusG Generic,NPB Non-Preferred Brand, P PreventativePB Preferred Brand,Female FemaleOnly,Male Male OnlyPA Prior Authorization,QL Quantity Limit,ST Step Therapy applies15
ran injection recon soln 1 gram, 10 gram, 2gramSpecialtyPAClaforan intravenous recon solnSpecialtyPAGPAClarinex oral syrupNPBPAClarinex oral tabletNPBPAClarinex-D 12 HOURNPBPAGQLClaravisclarithromycinClaritin RediTabs oral tablet,disintegrating 5 mgclemastine oral tablet 2.68 mgNPBGCleocin injectionSpecialtyPACleocin intravenous solution 900 mg/6 mLSpecialtyPACleviprexSpecialtyClimaraNPBClimara ProNPBclindamycin HCl oral capsule 150 mg, 300 mgGclindamycin palmitate HClGclindamycin phosphate injectionSpecialtyPAclindamycin phosphate intravenous solution 900mg/6 mLSpecialtyPAclindamycin phosphate topical gelGclindamycin phosphate topical lotionGclindamycin phosphate topical solutionGclindamycin phosphate topical swabGclindamycin phosphate vaginalGclindamycin-benzoyl peroxide topical gel 1.2 %(1% base) -5 %GClinisol SF 15 %SpecialtyClinpro 5000Pclobetasol scalpGclobetasol topical creamGPAStatusG Generic,NPB Non-Preferred Brand, P PreventativePB Preferred Brand,Female FemaleOnly,Male Male OnlyPA Prior Authorization,QL Quantity Limit,ST Step Therapy applies16
DrugTierclobetasol topical gelGclobetasol topical ointmentGclobetasol-emollient topical epam oral tabletGclonidineGclonidine (PF) epidural solution 1,000 mcg/10 mL(100 mcg/mL)Gclonidine HCl oral tabletGclopidogrelGclorazepate dipotassiumGClorpresGclotrimazole topicalGclotrimazole-betamethasone topical creamGclotrimazole-betamethasone topical lotionGclozapine oral tabletGGcolchicine oral tabletGcolestipol oral tabletQLNPBcodeine sulfate oral tabletColcrysPANPBclotrimazole mucous membraneCoartemNotesNPBPAGcolistin (colistimethate Na)SpecialtyPAColy-Mycin M ParenteralSpecialtyPAColy-Mycin SNPBCombiganNPBCombiPatchNPBCombivent RespimatPBCometriqSpecialtyCompleraPBStatusG Generic,NPB Non-Preferred Brand, P PreventativePB Preferred Brand,Female FemaleOnly,Male Male OnlyPA Prior Authorization,QL Quantity Limit,ST Step Therapy applies17
DrugCompleteNateTierNotesPFemaleComtanNPBCondylox topical gelNPBContraveConZip oral capsule,ER biphase 24 hr 25-75 100mgCopaxone subcutaneous syringePBPANPBSpecialtyCordran topical cream 0.05 %NPBCordran topical lotionNPBCoreg CRNPBCorifactSpecialtycortisoneGCortisporin ltyPACosentyx (2 Syringes)SpecialtyPACosentyx PenSpecialtyPACosentyx Pen (2 Pens)SpecialtyPACosmegenSpecialtyPAcosyntropin oneNPBCrixivan oral capsule 200 mg, 400 mgPBcromolyn inhalationGcromolyn ophthalmic (eye)Gcromolyn oralGCryselle (28)PCubicinCupriminecyclobenzaprine oral tablet 10 mg, 5 mgSpecialtyFemalePANPBGStatusG Generic,NPB Non-Preferred Brand, P PreventativePB Preferred Brand,Female FemaleOnly,Male Male OnlyPA Prior Authorization,QL Quantity Limit,ST Step Therapy applies18
Drugcyclopentolate ophthalmic (eye) drops 2 %TierGcyclophosphamide intravenousSpecialtycyclophosphamide oral capsuleGcycloserineGCyclosetcyclosporine intravenousSpecialtyGcyclosporine oral capsuleGcyproheptadinePANPBcyclosporine modified oral capsule 100 mg, 25 cytarabineSpecialtyPAcytarabine (PF) injection solutionSpecialtyPACytoGam intravenous solution 50 mg/mLSpecialtyPACytomelNPBCytoveneSpecialtyPAD5 %-0.45 % sodium ecialtyPADaklinza oral tablet 30 mg, 60 mgSpecialtyPADalirespPBdanazolGdantroleneGdapsone oralGDaraprimPBdaunorubicin intravenous yDelzicolPBdemeclocyclineGDemserPAPANPBStatusG Generic,NPB Non-Preferred Brand, P PreventativePB Preferred Brand,Female FemaleOnly,Male Male OnlyPA Prior Authorization,QL Quantity Limit,ST Step Therapy applies19
DrugTierNotesDenavirNPBQLDepo-Provera intramuscular suspension 150mg/mLNPBDepo-Provera intramuscular suspension 400mg/mLNPBDepo-Provera intramuscular syringeNPBDermacea Non-Woven topical sponge 4 X 4 "DermOtic OilDesferalFemalePBNPBSpecialtyPAdesipramine oral tablet 10 mg, 150 mg, 25 mg, 50mgGdesloratadineGPAdesmopressin nasal spray,non-aerosolGPAdesmopressin oralGPAdesonide topical ointmentGdesoximetasone topical creamGDetrol LANPBDexamethasone IntensolGdexamethasone oral elixirGdexamethasone oral solutionGdexamethasone oral tabletGdexamethasone sodium phos (PF)Gdexamethasone sodium phosphate ophthalmic(eye)GDexilantPBdexmethylphenidate oral capsule,ER biphasic 5050 10 mg, 15 mg, 20 mg, 30 mg, 5 mgGDexPak 6 Daydexrazoxane HClNPBSpecialtydextroamphetamine oral capsule, extended releaseGdextroamphetamine oral tabletGdextrose 70 % in water (D70W)Specialtydiazepam oral tabletSTPAPAGStatusG Generic,NPB Non-Preferred Brand, P PreventativePB Preferred Brand,Female FemaleOnly,Male Male OnlyPA Prior Authorization,QL Quantity Limit,ST Step Therapy applies20
DrugTierDibenzylineNPBdiclofenac potassiumGdiclofenac sodium ophthalmic (eye)Gdiclofenac sodium oral tablet,delayed release(DR/EC)Gdiclofenac sodium topical gel 3 %GdicloxacillinGdicyclomine oral capsuleGdicyclomine oral solutionGdicyclomine oral tabletGdidanosineGDifferin topical lotionNPBDificidNPBdiflorasone topical creamGDiflucan oral suspension for reconstitutionNPBDiflucan oral tablet 100 mg, 200 mg, 50 mgNPBDiflucan oral tablet 150 mgNPBdiflunisalGDigoxGdigoxin oral tabletGdihydroergotamine injectionGdihydroergotamine nasalGDilantinPBDilantin InfatabsQLQLNPBdiltiazem HCl oral capsule,ext.rel 24h degradableGdiltiazem HCl oral capsule,extended release 12 hr120 mg, 60 mgGdiltiazem HCl oral capsule,extended release 24 hrGdiltiazem HCl oral capsule,extended release 24hr120 mg, 180 mg, 240 mg, 300 mgGdiltiazem HCl oral tabletGDILT-XRGDiovanNotesNPBSTStatusG Generic,NPB Non-Preferred Brand, P PreventativePB Preferred Brand,Female FemaleOnly,Male Male OnlyPA Prior Authorization,QL Quantity Limit,ST Step Therapy applies21
DrugTierDiovan HCTNPBdiphenhydramine HCl injection solution 50mg/mLGdiphenhydramine HCl injection syringeGdiphenhydramine HCl oral capsuleGdiphenhydramine HCl oral tablet 25 mgGdiphenoxylate-atropineGdipyridamole oralGdisopyramide phosphate oral capsuleGdisulfiramGDiurildivalproexDivigel transdermal gel in packet 0.25 mg/0.25gram (0.1 %), 0.5 mg/0.5 gram (0.1 %), 1mg/gram (0.1 %)NotesNPBGNPBDocefrezSpecialtyPAdocetaxel intravenous solution 160 mg/16 mL (10mg/mL), 160 mg/8 mL (20 mg/mL), 20 mg/2 mL(10 mg/mL), 20 mg/mL (1 mL), 80 mg/4 mL (20mg/mL), 80 mg/8 mL (10 mg/mL)SpecialtyPAdonepezil oral tablet 10 mg, 5 mgGdonepezil oral tablet,disintegratingGDoryx oral tablet,delayed release (DR/EC) 200mg, 50 epin oral capsule 10 mg, 100 mg, 25 mg, 50mg, 75 mgGdoxepin oral concentrateGdoxercalciferol oralSpecialtydoxorubicin intravenous solutionSpecialtydoxorubicin, peg-liposomalGdoxycycline monohydrate oral capsule 100 mg, 50mgGPAStatusG Generic,NPB Non-Preferred Brand, P PreventativePB Preferred Brand,Female FemaleOnly,Male Male OnlyPA Prior Authorization,QL Quantity Limit,ST Step Therapy applies22
Drugdoxycycline monohydrate oral tablet 100 mg, 50mgDrithocreme HPTierGNPBdronabinol oral capsule 2.5 mgGdroperidol injection solutionGdrospirenone-ethinyl estradiol oral tablet 3-0.03mgPDroxiaNPBDuacNPBDuaveeDUETACTduloxetine oral capsule,delayed release(DR/EC)20 mg, 30 mg, 60 mgDuraclon (PF) epidural solution 1,000 mcg/10 mL(100 yreniumNPBDysportNotesSpecialtyEasy Touch needle 31 gauge x inNPBEdluarNPBEdurantPBEEMT HSGefavirenz oral capsuleGPAEgrifta subcutaneous recon soln 1 etriptanElidelGQLNPBPAStatusG Generic,NPB Non-Preferred Brand, P PreventativePB Preferred Brand,Female FemaleOnly,Male Male OnlyPA Prior Authorization,QL Quantity Limit,ST Step Therapy applies23
DrugTierNotesEligardSpecialtyPAEligard (3 month)SpecialtyPAEligard (4 month)SpecialtyPAEligard (6 daPBEmcytNPBEmend oral capsule 125 mg, 80 mgNPBEmend oral capsule 40 mgNPBEmend oral capsule,dose packNPBQLEmgality PenPBPAEmgality SyringePBPAEmsamNPBEmtrivaPBEnablexNPBenalapril maleateenalaprilat intravenous EnbrelSpecialtyPAEnbrel MiniSpecialtyPAEnbrel SureClickSpecialtyPAEndocet oral tablet 5-325 ePFemaleentacaponeGPAentecavirSpecialtyStatusG Generic,NPB Non-Preferred Brand, P PreventativePB Preferred Brand,Female FemaleOnly,Male Male OnlyPA Prior Authorization,QL Quantity Limit,ST Step Therapy applies24
DrugTierEnteregNPBEntocort ECNPBEntrestoPBEnuloseGEpclusaSpecialtyEpiduo topical gel with pumpNotesPAPANPBepinastineGepinephrine injection auto-injector 0.15 mg/0.3mL, 0.3 mg/0.3 mLGepinephrine injection solutionGepinephrine injection syringe 0.1 mg/mLGQLEpiPenNPBQLEpiPen 2-PakNPBQLEpiPen JrNPBQLEpiPen Jr 2-PakNPBQLepirubicin intravenous recon soln 50 mgSpecialtyPAepirubicin intravenous solutionSpecialtyPAEpivirNPBEpivir HBVSpecialtyeplerenoneGPAEpogen injection solution 10,000 unit/mL, 2,000unit/mL, 20,000 unit/2 mL, 20,000 unit/mL, 3,000unit/mL, 4,000 unit/mLSpecialtyPAepoprostenol (glycine)SpecialtyPAeprosartanGPAEpzicomPBEquetro oral capsule, ER multiphase 12 hr 100 mgNPBEraxis(Water l (vitamin D2) oral capsule 50,000unitGergoloidGErgomarNPBStatusG Generic,NPB Non-Preferred Brand, P PreventativePB Preferred Brand,Female FemaleOnly,Male Male OnlyPA Prior Authorization,QL Quantity Limit,ST Step Therapy applies25
DrugErivedgeErrinErtaczoTierSpecialtyPSpecialtyEry PadsGEryPed 200NPBEryPed 400NPBEry-TabNPBGerythromycin ethylsuccinate oral tabletGerythromycin ophthalmic (eye)Gerythromycin oral capsule,delayed release(DR/EC)Gerythromycin with ethanol topical gelGerythromycin with ethanol topical solutionGerythromycin-benzoyl peroxideGescitalopram oxalateGestazolamGestradiol oralGestradiol transdermalGestradiol-norethindrone ate disodiumGetodolac oral tablet 500 yErythrocin (as stearate) oral tablet 250 mgestradiol valerate intramuscular oil 40 atusG Generic,NPB Non-Preferred Brand, P PreventativePB Preferred Brand,Female FemaleOnly,Male Male OnlyPA Prior Authorization,QL Quantity Limit,ST Step Therapy applies26
DrugetoposideEucrisaEuflexxaEurax topical staNPBEvotazPBEvoxacNPBExelderm topical creamNPBExelon transdermal patch 24 hour 4.6 mg/24 hr,9.5 mg/24 hrNPBexemestaneNotesFemalePAGExforgeNPBSTExforge HCTNPBSTExjadeSpecialtyPAExtavia subcutaneous FactiveNPBfamciclovirGfamotidine oral tablet 20 mg, 40 mgGFanapt oral tablet 1 mg, 2 mg, 6 mgNPBFarestonNPBPAFaslodexSpecialtyPAFE C PlusPFeiba NFSpecialtyfelbamate oral tabletGfelodipineGFemaraNPBFemhrt Low DoseNPBFemringNPBPAFemaleStatusG Generic,NPB Non-Preferred Brand, P PreventativePB Preferred Brand,Female FemaleOnly,Male Male OnlyPA Prior Authorization,QL Quantity Limit,ST Step Therapy applies27
DrugTierNotesfenofibrate micronized oral capsule 134 mg, 200mg, 67 mgGfenofibrate oral tablet 160 mg, 54 mgGfenoprofen oral tabletGfentanyl citrate (PF) injectionGfentanyl transdermal patch 72 hour 100 mcg/hr, 12mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hrGQLFerahemeSpecialtyPAFerriprox oral tabletSpecialtyPAFerrlecitSpecialtyPAfexofenadine oral suspensionGSTfexofenadine oral tablet 180 mgGSTFinacea topical gelfinasterideNPBGFirazyrSpecialtyPAFirmagon subcutaneous recon soln 120 mgSpecialtyPAFlarexflavoxateFlebogamma DIF intravenous solution 5 lovent DiskusPBFlovent HFAPBPAPAfloxuridineSpecialtyPAfluconazole in dextrose(iso-o) intravenouspiggyback 400 mg/200 mLSpecialtyPAfluconazole in NaCl (iso-osm) intravenouspiggyback 200 mg/100 mL, 400 mg/200 mLSpecialtyPAfluconazole oral suspension for reconstitutionGfluconazole oral tablet 100 mg, 200 mg, 50 mgGfluconazole oral tablet 150 mgGflucytosineGQLStatusG Generic,NPB Non-Preferred Brand, P PreventativePB Preferred Brand,Female FemaleOnly,Male Male OnlyPA Prior Authorization,QL Quantity Limit,ST Step Therapy applies28
olide nasal spray,non-aerosol 25 mcg (0.025%)Gfluocinolone acetonide oilGfluocinolone and shower capGfluocinolone topical creamGfluocinolone topical ointmentGfluocinonide topical cream 0.05 %Gfluocinonide topical gelGfluocinonide topical ointmentGfluocinonide topical solutionGFluocinonide-EGfluoride (sodium) oral dropsPfluoride (sodium) oral tablet,chewablePfluorometholoneGfluorouracil intravenousSpecialtyfluorouracil topical cream 5 %Gfluorouracil topical solution 2 %Gfluoxetine oral capsule 10 mg, 20 mgGfluoxetine oral capsule 40 mgGfluoxetine oral solutionGfluphenazine decanoateGfluphenazine HCl injectionGfluphenazine HCl oral tabletGflurbiprofen oral tablet 100 mgGflurbiprofen sodiumGflutamideGfluticasone propionateGfluvoxamine oral tabletGFML ForteNPBFML S.O.P.NPBNotesPAPAPAMaleStatusG Generic,NPB Non-Preferred Brand, P PreventativePB Preferred Brand,Female FemaleOnly,Male Male OnlyPA Prior Authorization,QL Quantity Limit,ST Step Therapy applies29
DrugTierFocalin XR oral capsule,ER biphasic 50-50 10 mg,15 mg, 20 mg, 30 mg, 40 mg, 5 mgNPBFocalin XR oral capsule,ER biphasic 50-50 25 mg,35 mgPBfolic acid oral tablet 1 mgGFolotynfondaparinux subcutaneous syringe 10 mg/0.8 mLSpecialtyNotesPAGFortaz injection recon soln 1 gramSpecialtyPAFortaz intravenousSpecialtyPAForteoSpecialtyPAFosamax oral tablet 70 mgNPBFosamax Plus henytoinGFragmin subcutaneous solutionNPBFrovaNPBfurosemide oral solution 10 mg/mL, 40 mg/5 mL(8 mg/mL)Gfurosemide oral tabletGFusilevPA; QLSpecialtyPAFuzeon subcutaneous recon solnPBPAgabapentin oral capsuleGgabapentin oral solution 250 mg/5 mLGgabapentin oral tablet 600 mg, 800 mgGgalantamine oral capsule,ext rel. pellets 24 hr 24mgGGalzinSpecialtyPAGamaSTAN S/DSpecialtyPAGammagard LiquidSpecialtyPAGammaplex (with sorbitol)SpecialtyPAStatusG Generic,NPB Non-Preferred Brand, P PreventativePB Preferred Brand,Female FemaleOnly,Male Male OnlyPA Prior Authorization,QL Quantity Limit,ST Step Therapy applies30
DrugGamunex-C injection solution 1 gram/10 mL (10%), 10 gram/100 mL (10 %), 2.5 gram/25 mL (10%), 20 gram/200 mL (10 %), 5 gram/50 mL (10%)gatifloxacinTierSpecialtyNotesPAGGattex 30-VialSpecialtyPAGattex One-VialSpecialtyPAgemcitabine intravenous recon solnSpecialtyPAgemcitabine intravenous solution 1 gram/26.3 mL(38 mg/mL), 2 gram/52.6 mL (38 mg/mL), 200mg/5.26 mL (38 mg/mL)SpecialtyPAgemfibrozilGGengraf oral capsule 100 mg, 25 mgGGenotropinSpecialtyPAGenotropin MiniQuickSpecialtyPAGentak ophthalmic (eye) ointmentGgentamicin in NaCl (iso-osm) intravenouspiggyback 100 mg/100 mL, 100 mg/50 mL, 80mg/100 mL, 80 mg/50 mLSpecialtyPAgentamicin injectionSpecialtyPAgentamicin ophthalmic (eye) dropsgentamicin sulfate (PF) intravenous solution 100mg/10 mL, 60 mg/6 mLGSpecialtyPAgentamicin yPAGleevecSpecialtyPAGliadel tforminGGlucaGen HypoKitPBQLGlucagon Emergency Kit (human)PBQLStatusG Generic,NPB No
apraclonidine G Apri P Female Apriso NPB . Botox Specialty PA Botox Cosmetic intramuscular Specialty PA Bravelle Specialty PA Breo Ellipta PB Brilinta PB . StatusG Generic,NPB Non-Preferred Brand, P PreventativePB Preferred Brand,Female Female Only,Male Male OnlyPA Prior Authorization,QL Quantity Limit,ST Step Therapy .
