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Essentials by MESSA Covererd Drug List

Essentials by MESSA Covererd Drug List

Medications covered under the Essentials by MESSA prescription plan

Use this list to find information about drug coverage and therapeutic options. This list is ordered alphabetically and includes generic and brand name drugs. Drugs are identified according to their tier placement. If a generic equivalent is available, the brand name drug will appear in grey font for informational purposes only as the brand name drug is not covered. Prior authorization (PA), step therapy (ST) or quantity limit (QL) requirements are noted where applicable.

● Prior Authorization (PA): plan approval is required for coverage - Member must meet clinical criteria or additional information must be provided before coverage is approved. ● Step therapy (ST): previous treatment with one or more preferred drugs is required before coverage is approved. ● Quantity limits (QL): prescriptions cannot exceed a specific quantity per fill - These limits are set based on clinical appropriateness and manufacturer-recommended dosing for particular drugs. We encourage you to talk to your doctor to find the right drug therapies covered by your health plan.

Note: The amount you pay for brand name medications varies because coinsurance is based on the price of the drug when it is filled. A drug may switch from one tier to another. Up to a 90-day supply of insulin may be obtained for the same amount as a 34-day supply from any in-network provider. All over the counter (OTC) medications are excluded from coverage unless mandated by the Affordable Care Act (ACA).

When a new generic version of a brand-names drug becomes available, the generic version is generally added to Tier 1. Once the generic drug is added, the original, brand-name version won’t be covered. This list is current as of 9/23/2021. It is subject to change without notice. If you have a question about any drug, call MESSA Member Services at 800.336.0013.

*If a generic equivalent is available, the brand name drug will appear in grey font for informational purposes only as the brand name drug is not covered and the tier applies to the generic* Specialty Drug name Generic name Tier Limits drug? Abilify aripiprazole 1 No Abiraterone 1 QL No Accolate zafirlukast 1 QL No Accrufer 3 PA,QL No Accupril quinapril hcl 1 No Accuretic quinapril/hydrochlorothiazide 1 No Accutane capsule 1 No Aceon perindopril erbumine 1 No Acetic Acid acetic acid 1 No Aciphex rabeprazole sodium 1 QL No Aclovate alclometasone dipropionate 1 No Actemra Actpen, syringe 2 PA, QL Yes

Updated 9/24/2021 1 Specialty Drug name Generic name Tier Limits drug? Actigall ursodiol 1 No Actimmune 2 Yes Actiq fentanyl citrate 1 PA, QL No Activella /norethindrone acet 1 No Actonel risedronate sodium 1 QL No Actoplus Met pioglitazone hcl/metformin hcl 1 No Actos pioglitazone hcl 1 No Acular, LS ketorolac tromethamine 1 No Free as Adacel QL No preventive Adalat CC; Procardia, XL nifedipine 1 No Adapin; Sinequan doxepin hcl 1 No Adcirca tadalafil, alyq 1 PA, QL Yes Adderall, XR dextroamphetamine/amphetamine 1 QL No Adempas 2 PA, QL Yes Adoxa tablet doxycycline monohydrate 1 PA No Advair Diskus fluticasone/salmeterol 1 QL No Advair HFA fluticasone/salmeterol, wixela inhub 2 QL No Afinitor, Disperz Everolimus 1 PA, QL Yes Free as Afluria QL No preventive Aggrenox aspirin/dipyridamole 1 No Agrylin anagrelide hcl 1 No Aimovig 2 PA, QL No Ajovy 2 PA, QL No Akynzeo 3 PA, QL No Albenza albendazole 1 QL No Albuterol nebulizer solution albuterol sulfate 1 No Aldactazide spironolact/hydrochlorothiazid 1 No Aldactazide 50/50mg 3 No Aldactone 1 No Aldara imiquimod 1 No Aldomet methyldopa 1 No Aldoril methyldopa/hydrochlorothiazide 1 No Alecensa 2 PA, QL Yes Free as Alesse; Levlite -ethin estradiol, afirmelle No preventive Alferon N 2 No Alinia Nitazoxanide 1 No Alkeran tablet melphalan 1 No Alocril 3 No Alomide 3 No Alora 2 No Alphagan 0.2%, P 0.15% brimonidine tartrate 1 No Alphagan P 0.1% 2 No Alrex 3 No Alsuma sumatriptan succinate 1 QL No Altace ramipril 1 No Altreno 3 QL No Alunbrig 2 PA, QL Yes Alupent metaproterenol sulfate 1 No Amaryl glimepiride 1 No Ambien zolpidem tartrate 1 QL No Ambien CR zolpidem tartrate 1 QL No Amerge naratriptan hcl 1 QL No Amicar aminocaproic acid 1 No

Updated 9/24/2021 2 Specialty Drug name Generic name Tier Limits drug? Amicar solution 2 No Amitiza 2 QL No Amnesteem; Claravis; Myorisan; Zenatane isotretinoin 1 QL No Amoxapine amoxapine 1 No Amoxil amoxicillin 1 No Ampicillin ampicillin trihydrate 1 No Ampyra dalfampridine 1 PA, QL Yes Anadrol-50 3 No Anafranil clomipramine hcl 1 No Analpram-HC 1-1% cream 2 No Analpram-HC cream 2.5-1%, 1-1% hydrocortisone/pramoxine 1 No Anamantle HC cream with lidocaine/hydrocortisone ac 1 No Anaprox, DS naproxen sodium 1 No Ancobon flucytosine 1 No Androderm 2 PA, QL No Androgel 1 PA, QL No Angeliq 3 No Anoro Ellipta 2 QL No Ansaid flurbiprofen 1 No Antabuse disulfiram 1 No Antara fenofibrate,micronized 1 No Antara 30, 90mg 3 No Apokyn 2 QL Yes Apresoline hydralazine hcl 1 No Apriso Mesalamine Er 1 No Aptivus 2 No Arakoda 3 QL No Aralen chloroquine phosphate 1 No Aranesp 3 PA Yes Arava leflunomide 1 No Arcalyst 2 PA Yes Arcapta Neohaler 3 QL No Aricept 5, 10mg; ODT donepezil hcl 1 No Arikayce 2 PA, QL Yes Free as Arimidex anastrozole PA No preventive Aristocort; Kenalog 0.5% triamcinolone acetonide 1 No Arixtra fondaparinux sodium 1 No Armour Thyroid thyroid,pork 1 No Armour Thyroid 15mg, 30mg, 60mg, 3 No Arnuity Ellipta 2 QL No Free as Aromasin PA No preventive Artane trihexyphenidyl hcl 1 No Asacol HD mesalamine 1 No Asmanex, HFA 2 QL No Free as Aspirin; Ecotrin 81mg, 325mg (OTC) aspirin No preventive Astagraf XL 3 Yes Astelin nasal spray azelastine hcl 1 QL No Atacand candesartan cilexetil 1 No Atacand HCT candesartan/hydrochlorothiazid 1 No Atarax hydroxyzine hcl 1 No Atelvia risedronate sodium 1 ST, QL No Ativan lorazepam 1 No

Updated 9/24/2021 3 Specialty Drug name Generic name Tier Limits drug? Atripla -Emtric-Tenof Disop 1 No Atrovent HFA 2 QL No Atrovent nasal spray ipratropium bromide 1 QL No Atrovent solution ipratropium bromide 1 QL No Aubagio 3 QL Yes Augmentin 125mg-31.25mg/ml suspension 2 No Augmentin, ES, XR amoxicillin/potassium clav 1 No Auryxia 3 No Austedo 3 PA, QL Yes Avalide irbesartan/hydrochlorothiazide 1 No Avandia 3 No Avapro irbesartan 1 No Avelox moxifloxacin hcl 1 No Aventyl; Pamelor nortriptyline hcl 1 No Avodart 1 No Avonex 2 QL Yes Axert almotriptan malate 1 ST, QL No Axid (Rx only) nizatidine 1 No Aygestin norethindrone acetate 1 No Ayvakit tablet 2 Yes Azasan 3 No Azasite 3 No Azilect rasagiline mesylate 1 No Azopt brinzolamide drops 1 No Azor amlodipine bes/olmesartan med 1 No Azulfidine, EN-tab sulfasalazine 1 No Bacitracin bacitracin 1 No Baciguent ointment 3 No Baclofen baclofen 1 No Baclofen 5mg 3 No Bactroban ointment mupirocin 1 No Balcoltra 3 No Banzel Rufinamide suspension 1 PA, QL No Baraclude entecavir 1 Yes Baraclude solution 2 Yes Basaglar Kwikpen U-100 3 No Baxdela tablet 3 No Belladonna & Opium opium/belladonna alkaloids 1 QL No Belversa 3 Yes capsule (Rx Only) diphenhydramine hcl 1 No Benicar olmesartan medoxomil 1 No Benicar HCT olmesartan/hydrochlorothiazide 1 No Benlysta 2 PA, QL Yes Bentyl dicyclomine hcl 1 No Benzaclin clindamycin phos/benzoyl perox 1 No Benzamycin erythromycin/benzoyl peroxide 1 No Benznidazole 2 QL No Bepreve bepotastine besilate drops 1 No Besivance 3 No Betagan levobunolol hcl 1 No Betapace, AF sotalol hcl 1 No Betaseron 3 QL Yes Betoptic S 2 No Betoptic solution betaxolol hcl 1 No Bevyxxa tablet 3 QL No

Updated 9/24/2021 4 Specialty Drug name Generic name Tier Limits drug? Free as Beyaz drospir/eth estra/levomefol ca No preventive Biaxin, XL clarithromycin 1 No Bidil 2 No Biktarvy 2 QL No Biltricide praziquantel 1 No Free as Bisacodyl OTC bisacodyl QL No preventive Bleph-10, Sodium Sulamyde drops sulfacetamide sodium 1 No Blephamide 2 No Blocadren timolol maleate 1 No Boniva ibandronate sodium 1 QL No Free as Boostrix QL No preventive Bosulif 2 PA, QL Yes Braftovi 2 PA, QL Yes Breo Ellipta 2 QL No Brethine terbutaline sulfate 1 No Brilinta 2 No Briviact 3 PA, QL No Bromday; Xibrom bromfenac sodium 1 No Bronchitol capsule with device 3 PA, QL No Brovana arformoterol tartrate vial-neb 3 No Bryhali 3 QL No Bumex bumetanide 1 No Bunavail 3 QL No Buphenyl powder sodium phenylbutyrate 1 No Buphenyl tablet sodium phenylbutyrate 1 QL No Buprenorphine 7.5 MCG/HR patch 2 QL No Buspar buspirone hcl 1 No Butrans buprenorphine 2 QL No Butrans 7.5 MCG/HR 2 QL No Bystolic 2.5, 5, 10mg 3 ST No Bystolic 20mg 3 ST No Cabometyx 2 PA, QL Yes Caduet amlodipine/atorvastatin 1 QL No Cafcit caffeine citrate 1 No Cafergot ergotamine tartrate/caffeine 1 QL No Calan SR; Isoptin SR verapamil hcl 1 No Calciferol (Rx Only) ergocalciferol (vitamin d2) 1 No Calquence 2 PA, QL Yes Campral acamprosate 1 No Canasa mesalamine 1 No Capex shampoo 2 No Capoten captopril 1 No Capozide captopril/hydrochlorothiazide 1 No Caprelsa 2 PA, QL Yes Carafate sucralfate 1 No Carafate suspension 2 No Carbaglu 2 PA Yes Carbatrol carbamazepine 1 No Cardene nicardipine hcl 1 No Cardizem LA 120mg 3 No Cardizem, CD, LA, SR diltiazem hcl, diltiazem 24hr ER 1 No Cardura doxazosin mesylate 1 No Cardura XL 3 No

Updated 9/24/2021 5 Specialty Drug name Generic name Tier Limits drug? Carnitor levocarnitine 1 No Carnitor SF levocarnitine SF 1 No Carnitor solution levocarnitine (with sugar) 1 No Casodex 1 No Cataflam diclofenac potassium, Cataflam 1 No Catapres clonidine hcl 1 No Catapres-TTS clonidine 1 No Cayston 3 PA, QL Yes Ceclor, ER cefaclor 1 No Ceftin cefuroxime axetil 1 No Cefzil cefprozil 1 No Celebrex celecoxib 1 No Celexa citalopram hydrobromide 1 No Cellcept mycophenolate mofetil 1 Yes Celontin 3 No Cerdelga 3 PA, QL Yes Cesamet 3 No Cetraxal ciprofloxacin hcl 1 No Cetylev 3 No Chantix 2 QL No Free as Chantix ST, QL No preventive Chemet 2 No Chenodal 3 PA Yes Cholbam 2 PA, QL Yes Chorionic 3 PA, QL Yes Chorionic Gonadotropin vial 3 PA, QL Yes Ciloxan ciprofloxacin hcl 1 No Ciloxan ointment 2 No Cimduo 2 QL No Cimzia syringe 3 PA, QL Yes Cipro HC 3 No Cipro suspension ciprofloxacin 1 No Cipro tablet ciprofloxacin hcl 1 No Cipro XR ciprofloxacin/ciprofloxa hcl 1 No Ciprodex 2 No Ciprofloxacin HCL- Fluocinolone 2 No Free as Citrate of Magnesia OTC citrate QL No preventive Clenpiq 3 No Cleocin capsule clindamycin hcl 1 No Cleocin solution clindamycin palmitate hcl 1 No Cleocin vaginal cream clindamycin phosphate 1 No Cleocin vaginal ovules 3 No Cleocin-T swabs clindamycin phosphate 1 No Climara estradiol 1 No Climara Pro 3 No Clindesse 3 No Clinoril sulindac 1 No Clobevate; Temovate clobetasol propionate 1 No Clobex shampoo clobetasol propionate 1 No Clomid clomiphene citrate 1 QL No Clozapine 200mg clozapine 1 No Clozapine ODT clozapine ODT 1 No Clozaril clozapine 1 No Coartem 2 No

Updated 9/24/2021 6 Specialty Drug name Generic name Tier Limits drug? Codeine sulfate tablet codeine sulfate 1 QL No Cogentin benztropine mesylate 1 No Colazal balsalazide disodium 1 No Colbenemid colchicine/probenecid 1 No Colchicine tablet 2 No Colcrys 2 No Colestid colestipol hcl 1 No Colestid granules, packet 3 No Coly-Mycin S 3 No Colyte peg3350/sod sulf,bicarb,cl/kcl 1 No Free as Colyte peg3350/sod sulf,bicarb,cl/kcl QL No preventive Combipatch 3 No Combivent Respimat 2 No Combivir lamivudine/zidovudine 1 No Cometriq 2 PA, QL Yes Free as Commit Lozenge OTC nicotine polacrilex QL No preventive Compazine suppository prochlorperazine 1 No Compazine tablet prochlorperazine maleate 1 No Complera 2 QL No Comtan entacapone 1 No Free as Conceptrol QL No preventive Concerta methylphenidate hcl 1 No Condylox podofilox 1 No Condylox gel 2 No Copaxone glatiramer acetate 1 QL Yes Copegus ribavirin 1 Yes Copiktra 2 PA, QL Yes Cordarone; Pacerone amiodarone hcl 1 No Coreg immediate-release carvedilol 1 No Corgard nadolol 1 No Corlanor 2 PA, QL No Cortef; Hydrocortisone hydrocortisone 1 QL No Cortenema hydrocortisone 1 No Cortifoam 3 No Cortisone acetate cortisone acetate 1 No Cortisporin neomycin/polymyxin b sulf/hc 1 No Cortisporin cream 0.5% 3 No Cortisporin eye drops neomycin/polymyxin b sulf/hc 1 No Cortisporin eye ointment neomycin su/baci zn/poly/hc 1 No Cortisporin ointment 1% 3 No Corzide nadolol/bendroflumethiazide 1 No Cosopt dorzolamide hcl/timolol maleat 1 No Cosopt PF dorzolamide/timolol/pf 1 No Cotellic 2 PA, QL Yes Coumadin warfarin sodium 1 No Covaryx, H.S. ,ester/me-testosterone 1 No Coverject syringe 2 No Cozaar losartan potassium 1 No Creon 2 No Cresemba capsule 2 QL No Crestor rosuvastatin calcium 1 QL No Free as Crestor* 5mg, 10mg rosuvastatin calcium QL No preventive

Updated 9/24/2021 7 Specialty Drug name Generic name Tier Limits drug? Crotan crotamiton 1 No Cutaquig vial 3 PA Yes Cutivate fluticasone propionate, Beser 1 No Cuvitru vial 3 Yes Cuvposa 3 No Cyanocobalamin injection cyanocobalamin (vitamin b-12) 1 No Free as Cyclessa -ethinyl estradiol No preventive Cyclomydril 3 No Cyclophosphamide capsule cyclophosphamide 1 No Cyclophosphamide tablet 3 No Cycloserine 2 No Cycloset 3 PA, QL No Cymbalta duloxetine hcl 1 No Cystadane 3 Yes Cystagon 2 Yes Cystaran 2 PA, QL Yes Cytomel liothyronine sodium 1 No Cytotec misoprostol 1 No D.H.E.45 dihydroergotamine mesylate 1 QL No Daliresp 3 PA, QL No Dalmane flurazepam hcl 1 QL No Danocrine 1 No Dantrium dantrolene sodium 1 No Dapsone dapsone 1 No Daraprim 2 PA Yes Daurismo 3 PA, QL Yes Daypro oxaprozin 1 No Daytrana 3 No DDAVP desmopressin acetate 1 No Decadron dexamethasone 1 No Decadron ophthalmic dexamethasone sod phosphate 1 No Declomycin demeclocycline hcl 1 No Delatestryl 1 No Delestrogen 1 No Delestrogen 10mg/mL 3 No Delstrigo 2 QL No Deltasone 1 No Delzicol Mesalamine Dr 1 No Demadex torsemide 1 No Demser metyrosine 1 No Free as Demulen ethynodiol d-ethinyl estradiol No preventive Depakene capsule valproic acid 1 No Depakene solution valproic acid (as sodium salt) 1 No Depakote, ER, Sprinkles divalproex sodium 1 No Depen Penicillamine 1 No Free as Depo-Provera 150mg medroxyprogesterone acetate No preventive Depo-Provera 400mg 2 No Depo-subq Provera 104 2 No Depo-Testosterone 1 No Depot, LA 2 Yes Dermacort, Hytone 2.5% hydrocortisone 1 No Derma-smoothe-FS fluocinolone acetonide 1 No Descovy 2 PA, QL No

Updated 9/24/2021 8 Specialty Drug name Generic name Tier Limits drug? Desferal deferoxamine mesylate 1 No Free as Desogen; Ortho-cept desogestrel-ethinyl estradiol, kalliga No preventive Desowen desonide 1 No Desoxyn methamphetamine hcl 1 No Desyrel trazodone hcl 1 No Detrol, LA tolterodine tartrate 1 No Dexedrine dextroamphetamine sulfate 1 No Dexpak dexamethasone 1 No Diabeta; Micronase glyburide 1 No Diabinese chlorpropamide 1 No Diacomit capsule 3 Yes Diacomit powder pack 3 Yes Diamox, Sequels acetazolamide 1 No Diastat 2.5mg diazepam 1 No Diastat 2.5mg 2 No Diastat Acudial diazepam 1 No Dibenzyline phenoxybenzamine hcl 1 PA, QL No Dicloxacillin dicloxacillin sodium 1 No Didronel etidronate disodium 1 QL No Differin 0.1% cream, gel adapalene 1 No Dificid 3 QL No Diflucan fluconazole 1 No Dilacor XR diltiazem 24hr ER 1 No Dilantin 1 No Dilantin 30mg capsule 2 No Dilantin; Phenytek capsule phenytoin sodium extended 1 No Dilatrate-SR 2 No Dilaudid hydromorphone hcl 1 QL No Diovan valsartan 1 No Diovan HCT valsartan/hydrochlorothiazide 1 No Dipentum 3 No Diprolene cream, lotion; AF betamethasone/propylene glyc 1 No Diprolene gel, ointment betamethasone/propylene glyc/diprop A 1 No Diprolene ointment betamethasone dipropionate Augmented 1 No Diprosone cream, ointment; Maxivate betamethasone dipropionate 1 No Diprosone lotion betamethasone dipropionate 1 No Disalcid salsalate 1 No Ditropan, XL oxybutynin chloride 1 No Diuril chlorothiazide 1 No Diuril suspension 3 No Divigel 3 No Dolobid diflunisal 1 No Doptelet 3 PA, QL Yes Dostinex cabergoline 1 No Dovato tablet 3 No Dovonex calcipotriene 1 No Droxia 2 No Drysol 2 No Duavee 3 No Duetact pioglitazone hcl/glimepiride 1 No Dulera 2 QL No Dulera HFA 2 QL No Duoneb ipratropium/albuterol sulfate 1 QL No Duopa 2 PA, QL Yes

Updated 9/24/2021 9 Specialty Drug name Generic name Tier Limits drug? Dupixent 3 PA, QL Yes Duragesic fentanyl 1 QL No Durezol 3 No Duricef cefadroxil 1 No Dutoprol 3 No Dyazide; Maxzide triamterene/hydrochlorothiazid 1 No Dynacirc isradipine 1 No Dyrenium Triamterene capsule 1 No E.E.S. erythromycin ethylsuccinate 1 No EC-Naproxyn naproxen 1 No Edarbi 3 ST, QL No Edarbyclor 3 ST, QL No Edecrin ethacrynic acid 1 No Edurant 2 QL No Effexor venlafaxine hcl 1 No Effexor XR; Venlafaxine hcl ER capsule venlafaxine hcl 1 No Effexor XR; Venlafaxine hcl ER tablet venlafaxine hcl 1 No Effient prasugrel hcl 1 No Efudex fluorouracil 1 No Elavil amitriptyline hcl 1 No Eldepryl selegiline hcl 1 No Elestat epinastine hcl 1 No Elestrin 3 No Elidel pimecrolimus 1 No Elimite permethrin 1 No Eliquis 2 QL No Free as Ella QL No preventive Elmiron 2 No Elocon cream, lotion, solution mometasone furoate 1 No Elocon ointment mometasone furoate 1 No Emadine 3 No Embeda 3 PA, QL No Emcyt 2 No Emend 40mg aprepitant 1 QL No Emend 80mg, 125mg, 125mg-80mg aprepitant 1 QL No Emend suspension 2 QL No Emflaza 3 PA Yes Emgality 2 PA, QL No Emla lidocaine/prilocaine 1 No Emsam 3 PA, QL No Emtriva Emtricitabine 1 No Enbrel 2 PA, QL Yes Endari 3 PA, QL No Enduron methyclothiazide 1 No Entocort EC budesonide 1 No Entresto 2 QL No Envarsus XR 3 Yes Epclusa 2 PA, QL Yes Epidiolex 3 PA, QL Yes Epifoam 2 No Epinephrine auto-injector 2 QL No Epipen 0.3mg auto-injector epinephrine 1 QL No Epivir lamivudine 1 No Epivir HBV lamivudine 1 No

Updated 9/24/2021 10 Specialty Drug name Generic name Tier Limits drug? Epivir HBV solution 2 No Epogen 3 PA Yes Epzicom abacavir sulfate/lamivudine 1 No Equanil; Miltown meprobamate 1 No Equetro 3 No Ergoloid Mesylates ergoloid mesylates 1 No Erivedge 2 PA, QL Yes Erleada 2 PA, QL Yes Eryped 200mg/5ml 3 No Eryped 400mg/5ml erythromycin ethylsuccinate 1 No Ery-tab erythromycin base 1 No Ery-tab 500mg erythromycin 1 No Erythromycin Base erythromycin base 1 No Erythromycin Stearate erythromycin stearate 1 No Esbriet 2 PA, QL Yes Esgic; Fioricet 50/325/40mg butalb/acetaminophen/caffeine 1 QL No Eskalith, CR; Lithobid lithium carbonate 1 No Estrace estradiol 1 No Estring 2 No Estrogel 2 No Free as Estrostep Fe norethindrone-e.estradiol-iron No preventive Ethambutol ethambutol hcl 1 No Etrafon perphenazine/amitriptyline hcl 1 No Eulexin 1 No Eurax 2 No Evamist 3 No Evista hcl 1 QL No Free as Evista raloxifene hcl PA, QL No preventive Evotaz 2 QL No Evoxac cevimeline hcl 1 No Exalgo hydromorphone hcl 1 QL No Exelderm 3 No Exelon capsule rivastigmine tartrate 1 No Exelon patch rivastigmine 1 No Exforge amlodipine besylate/valsartan 1 No Exforge HCT amlodipine/valsartan/hcthiazid 1 No Exjade deferasirox 1 PA, QL Yes Exservan film 3 Yes Extavia 3 QL Yes Extina 1 No Free as Ez Flu (flucelvax) QL No preventive Factive 3 No Famvir famciclovir 1 No Fanapt 3 ST No Fareston citrate 1 No Farxiga 2 QL No Farydak 2 PA, QL Yes Faslodex 1 No Fazaclo clozapine 1 No Fazaclo 150, 200mg 3 No Free as FC2 female condom QL No preventive Felbatol felbamate 1 No

Updated 9/24/2021 11 Specialty Drug name Generic name Tier Limits drug? Feldene piroxicam 1 No Femara letrozole 1 No Free as Femcon Fe noreth-ethinyl estradiol/iron No preventive FemHRT norethindrone ac-eth estradiol 1 No Femring 3 No Fenobibric acid 1 No Ferriprox Deferiprone table 1 PA, QL Yes Fiasp, Flextouch, penfill 2 No Fibricor fenofibric acid 1 No Finacea gel 1 No Fioricet 50/300/40mg butalb/acetaminophen/caffeine 1 No Fioricet w/codeine 50/325/30mg butalbit/acetamin/caff/codeine 1 QL No Fiorinal butalbital/aspirin/caffeine 1 No Fiorinal w/codeine codeine/butalbital/asa/caffein 1 QL No Firazyr icatibant, Sajazir 1 PA, QL Yes Firvanq 3 QL No Flagyl metronidazole 1 No Flexeril cyclobenzaprine hcl 1 No Flomax tamsulosin hcl 1 No Flonase (Rx Only) fluticasone propionate 1 QL No Florinef fludrocortisone acetate 1 No Flovent HFA, Diskus 2 QL No Floxin Otic ofloxacin 1 No Floxin tablet ofloxacin 1 No Free as Fluad QL No preventive Free as Fluarix QL No preventive Free as Flublok Quad QL No preventive Free as Flucelvax Quad QL No preventive Free as Flulaval QL No preventive Flumadine rimantadine hcl 1 No Free as Flumist QL No preventive Fluoroplex 3 No Fluoxetine 60mg fluoxetine hcl 1 QL No Free as Fluzone QL No preventive Free as Fluzone High-dose QL No preventive FML fluorometholone 1 No FML Forte, S.O.P. 2 No Focalin dexmethylphenidate hcl 1 No Focalin XR dexmethylphenidate hcl 1 QL No Free as Folic Acid 0.4mg, 0.8mg (OTC) folic acid No preventive Follistim AQ 3 PA, QL Yes Forteo 2 PA, QL Yes Fosamax alendronate sodium 1 QL No Fosrenol tablet lanthanum carbonate 1 No Fragmin 3 No Frova frovatriptan succinate 1 ST, QL No

Updated 9/24/2021 12 Specialty Drug name Generic name Tier Limits drug? Furadantin nitrofurantoin 1 No Fuzeon 2 No Fycompa suspension 3 QL No Fycompa tablet 3 QL No Gabitril tiagabine hcl 1 No Galafold 2 PA, QL Yes Galzin 3 No Gammagard liquid 3 PA Yes Gammaked 3 PA Yes Gamunex-C sub-q 3 PA Yes Garamycin gentamicin sulfate 1 No Free as Gardasil, 9* QL No preventive Gastrocrom cromolyn sodium 1 No Gattex 2 PA, QL Yes Free as Generess Fe noreth-ethinyl estradiol/iron No preventive Gengraf; Neoral cyclosporine, modified 1 Yes Genotropin 2 PA Yes Gentamicin cream, ointment gentamicin sulfate 1 No Genvoya 2 QL No Geodon ziprasidone hcl 1 No Gilenya 2 QL Yes Gilotrif 2 PA, QL Yes Glassia 2 PA, QL Yes Glatopa glatiramer acetate 1 QL Yes Gleevec imatinib mesylate 1 QL Yes Gleostine; Lomustine 2 No GlucaGen HypoKit 2 No Glucagon Emergency Kit 1 No Glucophage, XR metformin hcl 1 No Glucotrol, XL glipizide 1 No Glucovance glyburide/metformin hcl 1 No Free as Glycolax OTC polyethylene glycol 3350 QL No preventive Glynase glyburide,micronized 1 No Glyset miglitol 1 No Glyxambi 2 QL No Golytely peg 3350/na sulf,bicarb,cl/kcl 1 No Free as Golytely peg 3350/na sulf,bicarb,cl/kcl QL No preventive Golytely flavored 2 No Gonal-F, RFF, Redi-ject 2 PA, QL Yes Granix 3 Yes Grifulvin V griseofulvin, microsize 1 No Gris-PEG griseofulvin ultramicrosize 1 No Guanidine hcl guanidine hcl 1 No Gvoke Hypogen auto injector 2 No Gynazole-1 3 No Free as Gynol II nonoxynol 9 QL No preventive Haegarda 2 PA Yes Halcion triazolam 1 QL No Haldol liquid lactate 1 No Haldol tablet haloperidol 1 No Harvoni 3 PA, QL Yes

Updated 9/24/2021 13 Specialty Drug name Generic name Tier Limits drug? Free as Havrix QL No preventive Hectorol doxercalciferol 1 No Heparin heparin sodium,porcine 1 No Heparin Sodium syringe 3 Yes Hepsera adefovir dipivoxil 1 Yes Hetlioz 3 PA, QL Yes Hetlioz Lq 3 PA, QL Yes Hiprex/Urex methenamine hippurate 1 No Hizentra vial and syringe 3 PA Yes Humatin paromomycin sulfate 1 No Humatrope 3 PA Yes Humira 2 PA, QL Yes Humira Pen pediatric 2 PA, QL Yes Humulin R U-500 2 No Hycamtin capsule 2 Yes Hycet hydrocodone/acetaminophen 1 QL No Hydrea hydroxyurea 1 No Hydrodiuril; Microzide hydrochlorothiazide 1 No Hydroxocobalamin hydroxocobalamin 1 No Hygroton; Thalitone chlorthalidone 1 No Hyper-Sal 3 No HyQvia 3 PA Yes Hytrin terazosin hcl 1 No Hyzaar losartan/hydrochlorothiazide 1 No Ibrance 2 PA, QL Yes Iclusig 2 PA, QL Yes Idhifa 2 PA, QL Yes Ilotycin erythromycin base 1 No Imbruvica capsules; 280mg, 420mg, 560mg 2 PA, QL Yes tablets Imdur; Ismo; Monoket isosorbide mononitrate 1 No Imitrex sumatriptan succinate 1 QL No Imitrex nasal spray sumatriptan 1 QL No Impavido 2 QL No Imuran azathioprine 1 No Imvexxy 3 QL No Inbrija capsule 3 QL No Increlex 3 PA Yes Inderal, LA propranolol hcl 1 No Inderide propranolol/hydrochlorothiazid 1 No Indocin suppository 3 No Indocin, SR indomethacin 1 No Inflamase, Forte sod phosphate 1 No Ingrezza 3 PA, QL Yes Ingrezza initiation pack 3 PA, QL Yes Inlyta 2 PA, QL Yes Inqovi tablet 2 Yes Inspra eplerenone 1 No Insulin Lispro Junior Kwikpen 3 No Intal solution cromolyn sodium 1 No Intelence etravirine 1 No Intrarosa 3 QL No Intron A 2 Yes Intuniv guanfacine hcl 1 PA, QL No Invega paliperidone 1 QL No

Updated 9/24/2021 14 Specialty Drug name Generic name Tier Limits drug? Invirase 2 No Invokamet 2 QL No Invokamet XR 2 QL No Invokana 2 QL No Iopidine droperette 3 No Iopidine drops apraclonidine hcl 1 No Iressa 2 PA, QL Yes Isentress 2 No Isentress HD 2 No Isoniazid isoniazid 1 No Isopto Atropine atropine sulfate 1 No Isopto-Carpine; Pilocar pilocarpine hcl 1 No Isordil isosorbide dinitrate 1 No Isordil 40mg 3 No Isturisa tablet 3 PA, QL Yes Jakafi 2 PA, QL Yes Jalyn dutasteride/tamsulosin hcl 1 QL No Janumet 2 No Janumet XR 2 QL No Januvia 2 QL No Jardiance 2 QL No Jentadueto 2 QL No Jentadueto XR 2 QL No Juluca 3 QL No Jynarque 2 PA, QL Yes Kaletra lopinavir/ritonavir 1 No Kaletra tablet 2 No Kalydeco 2 PA, QL Yes Kapvay clonidine hcl 1 QL No Kayexalate sodium polystyrene sulfonate 1 No Keflex cephalexin 1 No Kenalog 0.025% cream, lotion triamcinolone acetonide 1 No Kenalog 0.025% ointment, 0.05%, triamcinolone acetonide 1 No Kenalog spray triamcinolone acetonide 1 No Keppra, XR levetiracetam 1 No Kerlone betaxolol hcl 1 No Ketoprofen ketoprofen 1 PA, QL No Keveyis 3 PA, QL Yes Kevzara 3 PA, QL Yes Kineret 3 PA, QL Yes Kisqali Femara co-pack 2 PA, QL Yes Kisqali, Femara co-pack 2 PA, QL Yes Klonopin, Wafer clonazepam 1 No K-Lor; Klor-Con packet potassium chloride 1 No Klor-Con M15 potassium chloride 1 No Kloxxado spray 2 QL No K-Lyte; Klor-con/EF potassium bicarbonate/cit ac 1 No Korlym 2 PA, QL Yes Krintafel 2 QL No K-Sol; Potassium Chloride potassium chloride 1 No K-Tab; K-Dur; Slow-K; Kaon CL; Klor-con potassium chloride 1 No Kuvan Sapropterin Dihydrochloride powder pack and tablet 1 PA Yes Kytril granisetron hcl 1 QL No Lac-Hydrin ammonium lactate 1 No Lacrisert 2 No

Updated 9/24/2021 15 Specialty Drug name Generic name Tier Limits drug? Lactulose lactulose 1 No Lamictal dose pack lamotrigine 1 No Lamictal ODT, XR lamotrigine 1 No Lamictal XR dose pack 3 No Lamictal, dispertabs lamotrigine 1 No Lamisil tablet terbinafine hcl 1 No Lanoxin solution; 125mcg, 250mcg tablets digoxin 1 No Lantus, Solostar 2 No Lariam mefloquine hcl 1 No Lasix furosemide 1 No Lastacaft 3 No Latuda 3 ST No Ledipasvir-sofosbuvir 2 PA, QL Yes Lenvima 2 PA, QL Yes Lescol, XL fluvastatin sodium 1 QL No Free as Lescol, XL* (all strengths) fluvastatin sodium QL No preventive Letairis Ambrisentan 1 PA, QL Yes Leucovorin tablet leucovorin calcium 1 No Leukeran 2 No Leukine 2 Yes Levalbuterol Tartrate HFA; Xopenex 3 QL No Levaquin levofloxacin, isotretinoin 1 No Levbid hyoscyamine sulfate 1 No Levemir, Flextouch 2 No Free as Levlen; Nordette levonorgestrel-ethin estradiol, ayuna No preventive Levorphanol Tartrate levorphanol tartrate 1 QL No Levorphanol Tartrate 3mg 3 QL No Levoxyl; Synthroid levothyroxine sodium 1 No Levsin, SL hyoscyamine sulfate 1 No Lexapro escitalopram oxalate 1 No Lexiva fosamprenavir calcium 1 No Lexiva suspension 2 No Lialda mesalamine 1 QL No Librax chlordiazepoxide/clidinium br 1 No Librium chlordiazepoxide hcl 1 No Lidex fluocinonide 1 QL No Lidex E fluocinonide/emollient base 1 QL No Limbitrol, DS amitrip hcl/chlordiazepoxide 1 No Lindane lindane 1 No Linzess 2 QL No Lipitor atorvastatin calcium 1 QL No Free as Lipitor* 10mg, 20mg atorvastatin calcium QL No preventive Lithium Citrate lithium citrate 1 No Lithostat 3 No Livalo 3 ST, QL No Lo Loestrin Fe 3 No Free as Lo/Ovral -ethinyl estradiol No preventive Locoid cream, ointment, solution hydrocortisone butyrate 1 No Lodine, XL etodolac 1 No Lodosyn carbidopa 1 No

Updated 9/24/2021 16 Specialty Drug name Generic name Tier Limits drug? Free as Loestrin norethindrone ac-eth estradiol, Aurovela, Hailey No preventive Free as Loestrin 24 Fe norethindrone-e.estradiol-iron, Hailey 24 Fe No preventive Free as Loestrin Fe norethindrone-e.estradiol-iron, Aurovela Fe, Hailey Fe No preventive Lofibra capsule fenofibrate,micronized 1 No Lofibra tablet fenofibrate 1 No Lokelma 3 PA, QL No Lomotil diphenoxylate hcl/atropine 1 No Lonhala Magnair 3 QL No Loniten minoxidil 1 No Lonsurf 2 PA, QL Yes Lopid gemfibrozil 1 No Lopressor metoprolol tartrate 1 No Lopressor HCT metoprolol/hydrochlorothiazide 1 No Loprox cream, suspension ciclopirox olamine 1 No Loprox gel, shampoo ciclopirox 1 No Lorazepam intensol lorazepam 1 No Lorbrena 3 PA, QL Yes Free as Loseasonique l-norgest/e.estradiol-e.estrad, Lojaimiess tablet QL No preventive Lotemax Loteprednol Etabonate 1 No Lotensin benazepril hcl 1 No Lotensin HCT benazepril/hydrochlorothiazide 1 No Lotrel amlodipine besylate/benazepril 1 No Lotrimin clotrimazole 1 No Lotrisone clotrimazole/betamethasone dip 1 No Lotronex alosetron hcl 1 No Lovaza omega-3 acid ethyl esters 1 QL No Lovenox enoxaparin sodium 1 No Loxitane loxapine succinate 1 No Lozol indapamide 1 No Lucemyra 2 QL No Lumigan bimatoprost 1 No Lumigan 0.01% 2 No Lunesta eszopiclone 1 QL No Lupron leuprolide acetate 1 Yes Lupron Depot 3.75mg, 11.25mg 2 Yes Lupron Depot-PED 2 Yes Luvox fluvoxamine maleate 1 No Luvox CR fluvoxamine maleate 1 No Free as Lybrel levonorgestrel-ethin estradiol, dolishale No preventive Lynparza 2 PA, QL Yes Lyrica pregabalin 1 PA, QL No Lysodren 2 No Lysteda tranexamic acid 1 PA, QL No Macrobid nitrofurantoin monohyd/m-cryst 1 No Macrodantin nitrofurantoin macrocrystal 1 No Malarone atovaquone/proguanil hcl 1 No Maprotiline hcl maprotiline hcl 1 No Marinol dronabinol 1 No Marplan 3 No Matulane 2 Yes Mavenclad tablet 3 Yes

Updated 9/24/2021 17 Specialty Drug name Generic name Tier Limits drug? Mavik trandolapril 1 No Mavyret 3 PA, QL Yes Maxalt, MLT rizatriptan benzoate 1 QL No Maxidex 3 No Maxitrol neo/polymyx b sulf/dexameth 1 No Mayzent tablet 3 Yes Meclomen meclofenamate sodium 1 No Medrol 2mg 3 No Medrol, dose pack , methylpred dp 1 No Megace, ES 1 No Mekinist 2 PA, QL Yes Mektovi 2 PA, QL Yes Mellaril thioridazine hcl 1 No Free as Menactra QL No preventive Menest 3 No Menostar 3 No Free as Menveo QL No preventive Mephyton phytonadione (vit k1) 1 No Mepron atovaquone 1 No Mesnex tablet 2 No Mestinon syrup pyridostigmine bromide syrup 1 No Mestinon, Timespan pyridostigmine bromide 1 No Metadate CD methylphenidate hcl 1 No Metaglip glipizide/metformin hcl 1 No Methadone methadone hcl 1 QL No Methergine methylergonovine maleate 1 QL No Methitest 3 QL No Methotrexate methotrexate sodium 1 No Methotrexate PF injection methotrexate sodium/pf 1 No Methylin, ER methylphenidate hcl 1 No Metrocream, gel, lotion 0.75% metronidazole 1 No Metrogel-Vaginal metronidazole 1 No Mevacor lovastatin 1 QL No Free as Mevacor* (all strengths) lovastatin QL No preventive Mexitil mexiletine hcl 1 No Miacalcin injection 2 No Miacalcin nasal spray calcitonin,salmon,synthetic 1 No Micardis telmisartan 1 No Micardis HCT telmisartan/hydrochlorothiazid 1 No Micro-K potassium chloride 1 No Midamor amiloride hcl 1 No Migergot ergotamine tartrate/caffeine 1 No Free as Milk of Magnesia OTC magnesium hydroxide QL No preventive Millipred solution prednisolone sod phosphate 1 No Millipred tablet, dose pack prednisolone 1 No Free as Minastrin 24 FE norethindrone-e.estradiol-iron, charlotte 24 Fe No preventive Minipress prazosin hcl 1 No Minivelle, Vivelle-Dot estradiol, dotti/Lyllana transdermal patch 1 No Minocin capsule minocycline hcl 1 No Mirapex immediate-release pramipexole di-hcl 1 WL No

Updated 9/24/2021 18 Specialty Drug name Generic name Tier Limits drug? Free as Mircette desog-e.estradiol/e.estradiol, Simliya, Volnea tablet No preventive Mobic meloxicam 1 No Free as Modicon norethindrone-ethinyl estrad No preventive Moduretic amiloride/hydrochlorothiazide 1 No Monistat 3 miconazole nitrate 1 No Monodox doxycycline monohydrate 1 No Monopril fosinopril sodium 1 No Monopril HCT fosinopril/hydrochlorothiazide 1 No Monurol Fosfomycin Tromethamine 1 No Motrin (Rx Only) ibuprofen 1 No Moviprep Peg3350-Sod Sul-Nacl-K powder pack 1 No Moxeza Moxifloxacin drops 1 No MS Contin morphine sulfate 1 QL No MSIR morphine sulfate 1 QL No Mucomyst acetylcysteine 1 No Mulpleta 2 PA, QL Yes Multaq 2 QL No Myalept 3 PA, QL Yes Mycelex Troche clotrimazole 1 No Mycobutin rifabutin 1 No Mycostatin nystatin 1 No Mydriacyl tropicamide 1 No Myfortic mycophenolate sodium 1 Yes Myleran 2 No Myrbetriq 3 PA, ST, QL No Mysoline primidone 1 No Mytesi 2 PA, QL No Nalfon 600mg fenoprofen calcium 1 PA, QL No Naloxone hcl injection naloxone hcl 1 No Namenda memantine hcl 1 QL No Namenda dose pack 2 QL No Naprosyn suspension (Rx Only) naproxen 1 No Naprosyn tablet (Rx Only) naproxen 1 No Narcan nasal spray 2 QL No Nardil phenelzine sulfate 1 No Natacyn 2 No Natazia 3 No Natpara 2 PA, QL Yes Natroba spinosad 1 No Nature-Throid thyroid,pork 1 No Navane thiothixene 1 No Nayzalim spray 2 No Nebupent aerosol 2 No Neomycin neomycin sulfate 1 No Neosporin ophthalmic ointment neomycin su/bacitra/polymyxin 1 No Neosporin ophthalmic solution neomycin/polymyxn b/gramicidin 1 No Neo-Synephrine phenylephrine hcl 1 No Neptazane methazolamide 1 No Nerlynx 2 PA, QL Yes Neulasta 3 QL Yes Neupogen 3 Yes Neurontin gabapentin 1 No Nevanac 3 No

Updated 9/24/2021 19 Specialty Drug name Generic name Tier Limits drug? Nexavar 2 PA, QL Yes Nexlizet 3 No Niaspan 1 No Free as lozenge nicotine polacrilex QL No preventive Free as Nicotine gum; Nicorette nicotine polacrilex QL No preventive Free as Nicotine patch nicotine QL No preventive Nicotrol, NS 3 QL No Free as Nicotrol, NS ST, QL No preventive Nilandron 1 PA, QL No Nimotop nimodipine 1 No Ninlaro 2 PA, QL Yes Niravam alprazolam 1 No Nitro-bid ointment nitroglycerin 1 No Nitro-Dur nitroglycerin 2 No Nitroglycerin capsule, patch nitroglycerin 1 No Nitrostat nitroglycerin 1 No Nityr 3 PA Yes Nizoral ketoconazole 1 No Nizoral cream, shampoo 2% ketoconazole 1 No Norco; Vicodin; Xodol hydrocodone/acetaminophen 1 QL No Norditropin FlexPro 2 PA Yes Norflex orphenadrine citrate 1 No Free as Norinyl 1/35; Ortho-novum 1/35 norethindrone-ethinyl estrad, Nortrel, Nylia No preventive Normodyne labetalol hcl 1 No Norpace disopyramide phosphate 1 No Norpace CR 2 No Norpramin desipramine hcl 1 No Norvasc amlodipine besylate 1 No Norvir ritonavir 1 No Norvir capsule, packet, solution 2 No Novarel 3 PA, QL Yes Novolin; 70/30 vial 2 No Novolog, Mix (all forms) 2 No Noxafil suspension 2 QL No Noxafil tablet Posaconazole tablet 1 QL No NP Thyroid thyroid,pork 1 No Nucynta, ER 3 PA, QL No Nuedexta 2 PA, QL No Nulytely sodium chloride/nahco3/kcl/peg 1 No Free as Nulytely sodium chloride/nahco3/kcl/peg QL No preventive Nulytely Soln Recon $3 No Nuplazid tablet 3 PA, QL No Nutropin AQ NuSpin 2 PA Yes Free as Nuvaring Eluryng, -Ethinyl E QL No preventive Nuvigil armodafinil 1 QL No Nuzyra tablet 3 QL No Nymalize 3 QL No Nystatin nystatin 1 No Nystatin w/Triamcinolone nystatin/triamcin 1 No

Updated 9/24/2021 20 Specialty Drug name Generic name Tier Limits drug? Ocaliva 2 PA, QL Yes Ocufen flurbiprofen sodium 1 No Ocuflox ofloxacin 1 No Ocupress carteolol hcl 1 No Odefsey 2 QL No Odomzo 2 PA, QL Yes Ofev 2 PA, QL Yes Olumiant 3 PA, QL Yes Omnicef cefdinir 1 No Omnitrope 3 PA Yes Onfi clobazam 1 QL No Ongentys capsule 3 PA, QL No Opsumit 2 PA, QL Yes Opticrom cromolyn sodium 1 No Optipranolol metipranolol 1 No Optivar azelastine hcl 1 No Free as Oral Saline Laxative liquid OTC sodium phosphate,mono-dibasic QL No preventive Oralone paste triamcinolone acetonide 1 No Orap pimozide 1 No Orapred solution prednisolone sod phosphate 1 No Orencia Clickject, sub-q 3 PA, QL Yes Orenitram ER 2 PA, QL Yes Orfadin Nitisinone 1 PA Yes Orilissa 3 PA, QL No Orinase tolbutamide 1 No Orkambi 2 PA, QL Yes Free as Ortho Evra /ethin.estradiol/zafemy QL No preventive Free as Ortho Micronor; Nor-QD norethindrone, Lyleq No preventive Free as Ortho Tri-Cyclen -ethinyl estradiol, Tri-Nymyo No preventive Free as Ortho Tri-Cyclen Lo norgestimate-ethinyl estradiol, Tri-Lo-Mili No preventive Free as Ortho-Cyclen norgestimate-ethinyl estradiol, nymyo No preventive Free as Ortho-Novum 7/7/7 norethindrone-ethinyl estrad, Nortrel, Nylia No preventive Osphena 3 No Otezla 2 PA, QL Yes Otovel 2 No Free as Ovcon 35 norethindrone-ethinyl estrad No preventive Ovide malathion 1 No Ovidrel 2 PA, QL Yes Free as Ovral norgestrel-ethinyl estradiol No preventive Oxandrin 1 PA No Oxervate 2 PA, QL Yes Oxsoralen-Ultra methoxsalen, rapid 1 No Oxycodone hcl ER 3 PA, QL No Oxycodone immediate release, solution oxycodone hcl 1 QL No Oxycontin 3 PA, QL No Ozempic 2 QL No

Updated 9/24/2021 21 Specialty Drug name Generic name Tier Limits drug? Palynziq 2 PA, QL Yes Pamine, Forte methscopolamine bromide 1 No Panretin 2 No Parafon Forte DSC 500mg chlorzoxazone 1 No Parcopa carbidopa/levodopa 1 No Paremyd 3 No Parlodel bromocriptine mesylate 1 No Parnate tranylcypromine sulfate 1 No Paser 3 No Pataday olopatadine hcl 1 No Patanol olopatadine hcl 1 No Paxil paroxetine hcl 1 No Paxil CR paroxetine hcl 1 No Paxil suspension 3 No Pediapred solution prednisolone sod phosphate 1 No Peganone 2 No Pegasys, Proclick 2 QL Yes Peg-Intron, Redipen 2 QL Yes Peg-Prep bisac/nacl/nahco3/kcl/peg 3350 1 No Free as Peg-Prep bisac/nacl/nahco3/kcl/peg 3350 QL No preventive Penicillin VK penicillin v potassium 1 No Penlac ciclopirox 1 No Pentasa 2 No Pepcid (Rx Only) famotidine 1 No Percocet oxycodone hcl/acetaminophen 1 QL No Percodan oxycodone hcl/aspirin 1 QL No Perforomist formoterol fumarate vial-neb 1 No Periactin tablet, 2mg/5 ml syrup hcl 1 No Periostat doxycycline hyclate 1 No Perphenazine perphenazine 1 No Persantine dipyridamole 1 No Pexeva 3 ST No Phenergan promethazine hcl 1 No Phenobarbital phenobarbital 1 No Phoslo calcium acetate 1 No Phoslyra 3 No Phospholine Iodide 2 No Phrenilin 50mg/325mg butalbital/acetaminophen 1 No Picato 3 PA, QL No Pifeltro 2 QL No Free as Plan B One-step levonorgestrel, After Pill QL No preventive Plaquenil hydroxychloroquine sulfate 1 No Plavix clopidogrel bisulfate 1 No Plegridy 2 QL Yes Plendil felodipine 1 No Pletal cilostazol 1 No Free as Pneumovax 23 QL No preventive Polysporin bacitracin/polymyxin b sulfate 1 No Polytrim polymyxin b sulf/trimethoprim 1 No Pomalyst 3 PA, QL Yes Posaconazole (authorized generic) 2 No Potassium Chloride effervescent pot chloride/pot bicarb/cit ac 1 No Pradaxa 3 QL No

Updated 9/24/2021 22 Specialty Drug name Generic name Tier Limits drug? Praluent 2 PA, QL No Pramosone cream hydrocortisone/pramoxine 1 No PrandiMet repaglinide/metformin hcl 1 No Prandin repaglinide 1 No Pravachol pravastatin sodium 1 QL No Free as Pravachol* (all strengths) pravastatin sodium QL No preventive Precose acarbose 1 No Pred Forte prednisolone acetate 1 No Pred Mild 2 No Pred-G 3 No Prednisolone solution prednisolone 1 No Prednisone prednisone 1 No Prefest 3 No Pregnyl 2 PA, QL Yes Premarin, cream, Low Dose 2 No Prempro, Low Dose; Premphase 2 No Pretomanid tablet 2 No Prevacid capsule (Rx Only) lansoprazole 1 QL No Free as Prevnar 13* QL No preventive Prevymis tablet 3 QL No Prezcobix 2 QL No Prezista 2 No Priftin 3 No Prilosec capsule (Rx Only) omeprazole 1 QL No Primaquine (branded version) 2 No Primaquine (generic version) 1 No Primsol 3 No Prinivil; Zestril lisinopril 1 No Prinzide; Zestoretic lisinopril/hydrochlorothiazide 1 No Pristiq desvenlafaxine succinate 1 QL No ProAir HFA; 2 QL No Proamatine midodrine hcl 1 No Pro-Banthine propantheline bromide 1 No Probenecid probenecid 1 No Procentra dextroamphetamine sulfate 1 No Procrit 2 PA Yes Proctocort hydrocortisone 1 No Proctocort suppository hydrocortisone acetate 1 No Proctofoam-HC 2 No Procto-Pak hydrocortisone 1 No Proctosol-HC suppository hydrocortisone acetate 1 No Progesterone In Oil (inj) progesterone 1 No Proglycem Diazoxide suspension 1 No Prograf tacrolimus 1 Yes Prograf granule 3 No Prolixin fluphenazine hcl 1 No Promacta 2 PA Yes Prometrium progesterone,micronized 1 No Propylthiouracil propylthiouracil 1 No Proscar 1 No Prosom estazolam 1 QL No Protonix tablet pantoprazole sodium 1 QL No Protopic tacrolimus 1 No Proventil HFA 3 QL No

Updated 9/24/2021 23 Specialty Drug name Generic name Tier Limits drug? Proventil solution albuterol sulfate 1 No Proventil albuterol sulfate 1 No Provera medroxyprogesterone acetate 1 No Provigil modafinil 1 QL No Prozac fluoxetine hcl 1 QL No Prozac Weekly fluoxetine hcl 1 QL No Prudoxin, Zonalon doxepin hcl 1 PA, QL No Pulmicort Flexhaler 2 QL No Pulmicort solution budesonide 1 No Pulmozyme 2 PA Yes Purinethol mercaptopurine 1 No Purixan 3 Yes Pyrazinamide pyrazinamide 1 No Qtern 2 QL No Qualaquin quinine sulfate 1 No Free as Quartette l-norgest-eth estr/ethin estra QL No preventive Questran cholestyramine (with sugar) 1 No Questran Light cholestyramine/aspartame 1 No Quinidex quinidine sulfate 1 No Quinidine Gluconate SA quinidine gluconate 1 No Quixin levofloxacin 1 No Qvar RediHaler 2 QL No Radiogardase 2 No Ranexa ranolazine ER 1 No Rapaflo silodosin 1 QL No Rapamune sirolimus 1 Yes Ravicti 3 PA, QL Yes Razadyne, ER galantamine hbr 1 No Rebetol ribavirin 1 Yes Rebetol solution 2 Yes Rebif, Rebidose 2 QL Yes Rectiv 3 QL No Reglan hcl 1 No Regranex 3 QL No Relafen nabumetone 1 No Relenza 2 QL No Relpax eletriptan hbr 1 ST, QL No Remeron mirtazapine 1 No Renacidin 2 No Renagel sevelamer hcl 1 No Renvela sevelamer carbonate 1 No Repatha 2 PA, QL No Requip ropinirole hcl 1 No Requip XL ropinirole hcl 1 No Restasis 2 No Restoril temazepam 1 QL No Retacrit vial 2 No Retin-A; Avita tretinoin 1 No Retrovir zidovudine 1 No Revatio sildenafil citrate 1 PA, QL No Revatio suspension 2 PA, QL No Revia naltrexone hcl 1 No Revlimid 3 QL Yes Reyataz atazanavir sulfate 1 No Reyataz packet 2 No

Updated 9/24/2021 24 Specialty Drug name Generic name Tier Limits drug? Ribapak; Ribatab ribavirin 1 Yes Ribasphere Ribapak tablet ribavirin 1 Yes Ridaura 2 No Rifadin rifampin 1 No Rifamate 3 No Rifater 3 No Rilutek riluzole 1 No Rinvoq 2 No Risperdal, M-Tab 1 No Ritalin, LA, SR methylphenidate hcl 1 No RMS Suppository morphine sulfate 1 QL No Robaxin methocarbamol 1 No Robinul tablet, Forte glycopyrrolate 1 No Rocaltrol calcitriol 1 No Roxanol morphine sulfate 1 QL No Rozorem ramelteon 1 ST, QL No Rubraca 2 PA, QL Yes Ruconest 3 PA, QL Yes Ruzurgi tablet 3 Yes Rydapt 2 PA, QL Yes Rythmol, SR propafenone hcl 1 No Ryzolt tramadol hcl 1 QL No Sabril packet vigabatrin 1 PA, QL Yes Sabril tablet vigabatrin 1 ST, QL Yes Free as Safyral drospir/eth estra/levomefol ca No preventive Saizen, Saizenprep 3 PA Yes Salagen pilocarpine hcl 1 No Samsca tolvaptan 2 QL Yes Sanctura trospium chloride 1 QL No Sanctura XR trospium chloride 1 QL No Sancuso 3 PA, QL No Sandimmune capsule cyclosporine 1 Yes Sandimmune solution 3 Yes Sandostatin octreotide acetate 1 Yes Sandostatin LAR Depot 2 PA Yes Santyl 2 No Saphris Asenapine Maleate sublingual tablets 1 ST, QL No Savaysa 3 QL No Savella 3 PA, QL No Savella dose pack 3 PA No Free as Seasonale levonorgestrel-ethin estradiol, iclevia QL No preventive Free as Seasonique l-norgest/e.estradiol-e.estrad, simpesse, Jaimiess tablet QL No preventive Sectral acebutolol hcl 1 No Secuado patch 3 PA, QL No Selsun 2.5% (Rx Only) selenium sulfide 1 No Selzentry 2 No Sensipar 2 Yes Serax oxazepam 1 No Serevent Diskus 2 QL No Seroquel quetiapine fumarate 1 No Seroquel XR quetiapine fumarate 1 QL No Serostim 3 PA Yes Serzone nefazodone hcl 1 No

Updated 9/24/2021 25 Specialty Drug name Generic name Tier Limits drug? Sevenfact vial 2 No SfRowasa enema mesalamine 1 No Free as Shingrix* QL No preventive Signifor 2 PA, QL Yes Siklos 3 PA No Silvadene silver sulfadiazine 1 No Simponi 3 PA, QL Yes Sinemet, CR carbidopa/levodopa 1 No Singulair montelukast sodium 1 QL No Sirturo 2 PA, QL No Sivextro 2 QL No Skelaxin metaxalone 1 No Sklice Ivermectin lotion 1 QL No Skyrizi pen and syringe kit 2 Yes Sodium chloride inhalation sodium chloride for inhalation 1 No Sodium Fluoride 0.25mg, 0.5mg, fluoride (sodium) 1 No Free as Sodium Fluoride 0.25mg, 0.5mg, 1mg fluoride (sodium) No preventive Sofosbuvir-velpatasvir 2 PA, QL Yes Solaraze diclofenac sodium 1 PA, QL No Soltamox 3 No Solu-cortef hydrocortisone sod succinate 1 No Solu-cortef (pf) 3 No Soma carisoprodol 1 No Soma vanadom 1 No Somatuline Depot 2 PA, QL Yes Somavert 2 PA Yes Sonata zaleplon 1 QL No Soolantra * ivermectin cream 1 No Soriatane acitretin 1 No Sovaldi 3 PA, QL Yes Spectazole econazole nitrate 1 No Spectracef cefditoren pivoxil 1 QL No Spiriva, Respimat 2 QL No Sporanox itraconazole 1 No Sprycel 2 PA, QL Yes SPS sodium polystyrene sulfonate 1 No SPS (sorbitol free) sodium polystyrene sulfon/sorb 1 No SPS 50g/200ml enema 3 No SSKI 3 No Stadol NS butorphanol tartrate 1 QL No Stalevo carbidopa/levodopa/entacapone 1 No Starlix nateglinide 1 No Stelara 45mg, 90mg 2 PA, QL Yes Stelazine trifluoperazine hcl 1 No Stimate 2 Yes Stiolto Respimat 2 QL No Stivarga 2 PA, QL Yes Strattera atomoxetine hcl 1 No Strensiq 2 PA, QL Yes Stribild 2 QL No Stromectol ivermectin 1 No Strong Iodine potassium iodide/iodine 1 No Suboxone buprenorphine hcl/naloxone hcl 1 QL No Suboxone film buprenorphine hcl/naloxone hcl film 2 QL No

Updated 9/24/2021 26 Specialty Drug name Generic name Tier Limits drug? Subutex buprenorphine hcl 1 PA, QL No Sucraid 3 PA, QL Yes Sular nisoldipine 1 No Sulconazole Nitrate cream and solution 3 No Sulfadiazine sulfadiazine 1 No Sunosi tablet 3 PA, QL No Suprax cefixime 1 No Suprax capsule, chew tablet, 500mg/5ml 3 No suspension Suprep 3 No Surmontil trimipramine maleate 1 No Sustiva efavirenz 1 No Sutent sunitinib 1 PA, QL Yes Sylatron 3 QL Yes Symbicort 2 QL No Symbyax olanzapine/fluoxetine hcl 1 No Symdeko 2 PA, QL Yes Symfi Efavirenz-Lamivu-Tenofov Disop 1 QL No Symfi Lo Efavirenz-Lamivu-Tenofov Disop 1 QL No Symjepi 2 QL No Symlinpen 3 No Symmetrel amantadine hcl 1 No Symtuza 2 QL No Synalar 0.01% fluocinolone acetonide 1 No Synalar 0.025% fluocinolone acetonide 1 No Synarel 2 No Synjardy, XR 2 QL No Syprine trientine hcl, clorique 1 PA, QL Yes Tabloid 2 No Taclonex ointment calcipotriene/betamethasone 3 PA No Taclonex topical suspension 3 PA No Tafinlar 2 PA, QL Yes Tagamet (Rx only) 1 No Tagamet liquid (Rx only) cimetidine hcl 1 No Tagrisso 2 PA, QL Yes Takhzyro 3 PA, QL Yes Talwin NX pentazocine hcl/naloxone hcl 1 QL No Talzenna 3 PA, QL Yes Tambocor flecainide acetate 1 No Tamiflu oseltamivir phosphate 1 QL No tamoxifen citrate 1 QL No Free as Tamoxifen tamoxifen citrate PA, QL No preventive Tapazole methimazole 1 No Tarceva Erlotinib 1 PA, QL Yes Targretin capsule bexarotene 1 PA, QL Yes Targretin gel 3 PA Yes Tarka trandolapril/verapamil hcl 1 No Tasigna 2 PA, QL Yes Tasmar tolcapone 1 No Tavalisse 3 PA, QL Yes Tavist tablet (Rx Only) clemastine fumarate 1 No Gemmily capsule/Noresthin-Eth-Estra-Ferrous Fum, Free as Taytulla No Merzee, Taysofy preventive Tazorac tazarotene 1 No Tazorac 0.1%, 0.5% gel 2 No

Updated 9/24/2021 27 Specialty Drug name Generic name Tier Limits drug? Tecfidera Dimethyl Fumarate 1 QL Yes Technivie 3 PA, QL Yes Tegretol carbamazepine 1 No Tegretol XR carbamazepine 1 No Tekturna, HCT aliskiren 1 No Temixys tablet 2 No Temodar temozolomide 1 Yes Temovate Emollient clobetasol propionate/emoll 1 No Tenex guanfacine hcl 1 No Tenoretic atenolol/chlorthalidone 1 No Tenormin atenolol 1 No Terazol- 3, 7 terconazole 1 No Tetracycline tetracycline hcl 1 No Teveten eprosartan mesylate 1 No Thalomid 2 Yes Theo-24 2 No Theophylline anhydrous theophylline anhydrous 1 No Thiola* tiopronin 1 PA No Thorazine hcl 1 No Thyrolar 2 No Tiazac diltiazem hcl 1 No Tiazac Tiadylt Er 1 No Tibsovo 2 PA, QL Yes Tigan trimethobenzamide hcl 1 No Tiglutik 3 PA, QL Yes Tikosyn dofetilide 1 No Timoptic, XE timolol maleate 1 No Tindamax tinidazole 1 QL No Tirosint capsule 3 No Tirosint-Sol solution 3 No Tivicay 2 No Tobi tobramycin in 0.225% nacl 1 QL Yes Tobradex ointment 2 No Tobradex ST 3 No Tobradex suspension tobramycin/dexamethasone 1 No Tobrex drops tobramycin 1 No Tobrex ointment 3 No Free as Today contraceptive sponge QL No preventive Tofranil imipramine hcl 1 No Tofranil-PM imipramine pamoate 1 No Tolak 2 QL No Tolectin, DS tolmetin sodium 1 No Tolinase tolazamide 1 No Topamax, Sprinkle topiramate 1 No Toprol XL metoprolol succinate 1 No Toradol injection ketorolac tromethamine 1 No Toradol tablet ketorolac tromethamine 1 QL No Toujeo, Max Solostar 2 No Tracleer Bosentan 1 PA, QL Yes Tracleer tablet for suspension 2 PA Yes Tradjenta 2 QL No Transderm-Scop scopolamine 1 No Tranxene T-Tab clorazepate dipotassium 1 No Travatan Z Travoprost 1 No Trecator 3 No

Updated 9/24/2021 28 Specialty Drug name Generic name Tier Limits drug? Trelegy Ellipta 2 QL No Tremfya auto injector 3 PA, QL Yes Tremfya syringe 3 PA, QL Yes Trental pentoxifylline 1 No Tresiba, Flextouch 2 No Trexall 2 No Tribenzor olmesartan/amlodipin/hcthiazid 1 QL No Tricor fenofibrate nanocrystallized 1 No Trikafta 3 PA, QL Yes Trileptal suspension oxcarbazepine 1 No Trileptal tablet oxcarbazepine 1 No Free as Trilevlen levonorgestrel-ethin estradiol No preventive Trilipix fenofibric acid (choline) 1 No Trimethoprim trimethoprim 1 No Trimpex 3 No Free as Tri-Norinyl norethindrone-ethinyl estrad No preventive Trintellix 3 ST, QL No Tritocin Kenalog ointment 1 No Triumeq 2 QL No Trulicity 2 QL No Trusopt dorzolamide hcl 1 No Truvada Emtricitabine-Tenofovir Disop 1 PA, QL No Free as Truvada 200mg/300mg PA, QL No preventive Tudorza Pressair 3 QL No Turalio capsule 3 Yes Tuxarin ER tablet 3 No Free as Twinrix QL No preventive Twynsta telmisartan/amlodipine 1 No Tybost 2 QL No Tykerb Lapatinib 1 PA Yes w/codeine acetaminophen with codeine 1 QL No Tylenol w/codeine solution acetaminophen with codeine 1 QL No Tymlos 2 PA, QL No Tyvaso 2 PA, QL Yes Ulesfia 3 No Uloric febuxostat 1 ST, QL No Ultracet tramadol hcl/acetaminophen 1 QL No Ultram, ER tramadol hcl 1 QL No Ultravate cream, ointment halobetasol propionate 1 No Univasc moexipril hcl 1 No Upneeq dropperette 2 No Uptravi 2 PA, QL Yes Urecholine bethanechol chloride 1 No Urispas flavoxate hcl 1 No Urocit-K potassium citrate, potassium citrate ER 1 No Uroxatral alfuzosin hcl 1 No Urso; Forte ursodiol 1 No Vagifem estradiol 1 No Valchlor 3 PA, QL Yes Valcyte valganciclovir hcl 1 No Valisone lotion betamethasone valerate 1 No Valisone ointment betamethasone valerate 1 No

Updated 9/24/2021 29 Specialty Drug name Generic name Tier Limits drug? Valium diazepam 1 No Valtrex valacyclovir hcl 1 No Vancocin vancomycin hcl 1 No Vantin cefpodoxime proxetil 1 No Free as Vaqta QL No preventive Varenicline Tartrate $2 QL No Vascepa Icosapent Ethyl capsule 1 PA, QL No Vaseretic enalapril/hydrochlorothiazide 1 No Vasocidin sulfacetamide/prednisolone sp 1 No Vasotec enalapril maleate 1 No Free as VCF film, gel QL No preventive Free as VCF foam nonoxynol 9 QL No preventive Vectical calcitriol 1 No Veltassa 2 QL No Vemlidy 2 QL Yes Venclexta 2 PA, QL Yes Ventavis 2 PA, QL Yes Vepesid etoposide 1 No Veregen 3 No Verelan, PM verapamil hcl 1 No Versed syrup midazolam hcl 1 No Verzenio 2 PA, QL Yes Vesanoid tretinoin 1 No Vesicare Solifenacin Succinate 1 ST, QL No Vfend voriconazole 1 No Vibramycin doxycycline hyclate 1 No Vibramycin suspension doxycycline monohydrate 1 No Vibramycin syrup 3 No Vicoprofen hydrocodone/ibuprofen 1 QL No Victoza 2 QL No Vigamox moxifloxacin hcl 1 No Viibryd, dose pack 3 ST, QL No Vimpat 2 PA, QL No Viramune, XR nevirapine 1 No Viread tenofovir disoproxil fumarate 1 No Viread 150mg, 200mg, 250mg tablet; 2 No packet Viroptic trifluridine 1 No Visken pindolol 1 No Vistaril hydroxyzine pamoate 1 No Vistogard 2 QL Yes Vitamin K ampule phytonadione 1 No Vitrakvi 3 PA, QL Yes Vivactil protriptyline hcl 1 No Vizimpro 2 PA, QL Yes Voltaren gel diclofenac sodium 1 QL No Voltaren ophthalmic solution diclofenac sodium 1 No Voltaren tablet diclofenac sodium 1 No Voltaren-XR diclofenac sodium 1 No Vosevi 3 PA, QL Yes Vosol acetic acid 1 No Vospire ER albuterol sulfate 1 No Votrient 2 PA, QL Yes

Updated 9/24/2021 30 Specialty Drug name Generic name Tier Limits drug? Vraylar 3 ST, QL No Vyndamax capsule 2 No Vytorin ezetimibe/simvastatin 1 QL No Vyvanse 3 QL No Welchol colesevelam hcl 1 No Wellbutrin, SR, XL bupropion hcl, bupropion xl 1 No Westcort hydrocortisone valerate 1 No Westhroid thyroid,pork 1 No WP Thyroid thyroid,pork 1 No WP Thyroid 32.5mg, 65mg, 3 No Xadago 3 QL No Xalatan latanoprost 1 No Xalkori 2 PA, QL Yes Xanax, XR alprazolam 1 No Xarelto, starter kit 2 QL No Xatmep 3 Yes Xcopri tablet 3 PA, QL Xeljanz, XR 2 PA, QL Yes Xeloda capecitabine 1 Yes Xembify 3 PA, QL Yes Xenazine tetrabenazine 1 PA, QL Yes Xenleta 3 QL No Xermelo 2 PA, QL Yes Xifaxan 200mg 3 No Xifaxan 550mg 3 PA, QL No Xigduo XR 2 QL No Xiidra 2 QL No Xofluza 3 QL No Xolair 3 PA, QL Yes Xopenex solution levalbuterol hcl 1 No Xospata 3 PA, QL No Xpovio tablet 2 QL Yes Xtandi 2 PA, QL Yes Xultophy 100-3.6 2 QL No Xuriden 2 PA, QL Yes Xylocaine Viscous solution (Rx Only) lidocaine hcl 1 No Xyntha Solofuse 2 No Xyrem 3 PA, QL Yes Free as Yasmin 28 ethinyl estradiol/, zumandimine No preventive ethinyl estradiol/drospirenone, Jasmiel, lo- Free as Yaz No zumandimine preventive Zanaflex tizanidine hcl 1 No Zantac (Rx Only) ranitidine hcl 1 No Zarontin ethosuximide 1 No Zaroxolyn metolazone 1 No Zarxio 3 Yes Zavesca miglustat 1 PA, QL Yes Zebeta bisoprolol fumarate 1 No Zejula 2 PA, QL Yes Zelboraf 2 PA, QL Yes Zemplar paricalcitol 1 No Zenpep 2 No Zenzedi dextroamphetamine sulfate 1 No Zepatier 2 PA, QL Yes Zetia ezetimibe 1 QL No

Updated 9/24/2021 31 Specialty Drug name Generic name Tier Limits drug? Ziac bisoprolol fumarate/hctz 1 No Ziagen abacavir sulfate 1 No Zioptan 3 No Zirgan 2 No Zithromax azithromycin 1 No Zocor simvastatin 1 QL No Free as Zocor* 5mg, 10mg, 20mg, 40mg simvastatin QL No preventive Zofran ondansetron hcl 1 QL No Zofran ODT ondansetron 1 QL No Zohydro ER Hydrocodone Bitartrate 1 PA, QL No Zolinza 2 PA, QL Yes Zoloft sertraline hcl 1 No Zomacton 3 PA Yes Zomig nasal spray 3 ST, QL No Zomig, ZMT zolmitriptan 1 QL No Zonalon 30g 3 PA, QL No Zonegran zonisamide 1 No Zontivity 3 QL No Zorbtive 3 PA Yes Zortress Everolimus 2 Yes Zovirax capsule, solution, tablet acyclovir 1 No Zovirax ointment acyclovir 1 No Zubsolv 2 QL No Free as Zyban bupropion hcl QL No preventive Zydelig 2 PA, QL Yes Zyflo 3 QL No Zyflo CR zileuton 1 QL No Zykadia 2 PA, QL Yes Zylet 3 No Zyloprim allopurinol 1 No Zymaxid gatifloxacin 1 No Zyprexa, Zydis olanzapine 1 No Zyvox linezolid 1 No

Updated 9/24/2021 32

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