Medications covered by MESSA Choices with 3-Tier Rx and MESSA ABC with 3-Tier Rx with and without mandatory mail 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; prior authorization (PA), step therapy (ST) or quantity limit (QL) requirements are noted where applicable. We encourage you to talk to your doctor to find the right drug therapies that your health plan covers. This chart contains tier information for Choices plans and ABC plans. Please refer to the appropriate column for medication details.

If your 3-Tier Rx plan includes mandatory mail, please refer to the list of long-term maintenance medications requiring home delivery to see if your drug requires home delivery.

Up to 34-day supply 90-day supply Specific preventive medications are covered 100 No cost to you No cost to you percent with no deductible required. Age and gender limits apply. ***ABC plans have a list of specific preventive medications in addition to those mandated by federal law. Tier 1 $10 copayment $25 copayment Generics Tier 2 20 percent coinsurance 20 percent coinsurance Most brand drugs with no generic equivalent $40 minimum - $80 maximum $100 minimum - $200 maximum Tier 3 20 percent coinsurance 20 percent coinsurance Most brand drugs with a generic equivalent or $60 minimum - $100 maximum $150 minimum - $250 maximum therapeutic alternative

Note: The amount you pay for brand name medications varies because coinsurance is based on the price of the drug when it is filled. If you obtain a Tier 3 drug when a Tier 1 drug is available, you will pay the Tier 3 coinsurance plus the difference in cost between the Tier 1 drug and the Tier 3 drug. These drugs are identified with an asterisk (*) in the list below. A drug may switch from one tier to another. Up to a 90-day supply of insulin may be obtained for the same payment as a 34-day supply from any in-network provider. This list is current as of November 13, 2017. It is subject to change without notice. If you have a question about any drug, call MESSA Member Services at 800.336.0013.

Drug name Category of drug Choices Tier ABC Tier Limits Generic equivalent if available 8-Mop* Antipsoriatic and antiseborrheic 3 3 None Methoxsalen Aa/Antpy/Bcaine/Polico/Al Acet Otic preparations 1 1 None This medication is generic Abacavir HIV 1 1 None This medication is generic Abacavir Sulfate Antiretrovirals 1 1 None This medication is generic Abacavir Sulfate/Lamivudine Antiretrovirals 1 1 None This medication is generic Abacavir/Lamivudine/Zidovudine Antiretrovirals 1 1 None This medication is generic Abilify* Antipsychotics 3 3 None Aripiprazole Absorica Acne treatment 3 3 ST No generic available Abstral Narcotics 3 3 PA, QL No generic available Acamprosate Calcium Miscellaneous CNS 1 Free As None This medication is generic Preventive Acanya Acne treatment 3 3 None No generic available Acarbose Non-insulin hypoglycemic agents 1 1 None This medication is generic

Accolate* Miscellaneous respiratory agents 3 3 QL Zafirlukast

Accuneb; Albuterol nebulizer solution* Inhaled beta-agonists 3 3 None Albuterol Sulfate

Accupril* ACE-Inhibitors and combinations 3 3 None Quinapril Hcl Accuretic* ACE-Inhibitors and combinations 3 3 None Quinapril/Hydrochlorothiazide Acebutolol Hcl Beta blockers and combinations 1 Free As None This medication is generic Preventive Aceon* ACE-Inhibitors and combinations 3 3 None Perindopril Erbumine Acetasol HC; Vosol HC* Otic preparations 3 3 None Acetic Acid/Hydrocortisone Acetazolamide Anticonvulsants/Diuretic 1 1 None This medication is generic Acetic Acid Otic preparations 1 1 None This medication is generic Acetic Acid/Aluminum Acetate Otic preparations 1 1 None This medication is generic Acetic Acid/Hydrocortisone Otic preparations 1 1 None This medication is generic Acetylcysteine Miscellaneous respiratory agents 1 1 None This medication is generic

Aciphex Sprinkle Proton Pump Inhibitors (PPI) 3 3 ST, QL No generic available Aciphex* Proton Pump Inhibitors (PPI) 3 3 None Rabeprazole Sodium Acitretin Antipsoriatic and antiseborrheic 1 1 None This medication is generic Aclovate* Corticosteroids - low potency 3 3 None Alclometasone Dipropionate Actemra syringe Non-Tumor Necrosis Factor (TNF) 3 3 PA, QL No generic available blocking agents Acthar H.P. Anticonvulsants 3 3 PA, QL No generic available Acticlate 150mg Tetracyclines, Acne Treatment 3 3 PA, QL Doxycycline Hyclate Acticlate 75mg Tetracyclines, Acne Treatment 3 3 PA, QL Doxycycline Hyclate Actigall* Bile acids 3 3 None Ursodiol Actimmune Interferons and MS therapy 2 2 None No generic available Actiq* Narcotics 3 3 PA, QL Fentanyl Citrate Activella* Estrogen and progestin combinations 3 3 None Estradiol/Norethindrone Acet

Updated 11/13/2017 Drug name Category of drug Choices Tier ABC Tier Limits Generic equivalent if available Actonel* Osteoporosis and bone resorption 3 3 ST, QL Risedronate Sodium

Actoplus MET XR Non-insulin hypoglycemic agents 3 3 None No generic available

Actoplus MET* Non-insulin hypoglycemic agents 3 3 None Pioglitazone Hcl/Metformin Hcl

Actos* Non-insulin hypoglycemic agents 3 3 None Pioglitazone Hcl

Acular, LS* Ophthalmic anti-inflammatory agents 3 3 None Ketorolac Tromethamine

Acuvail Ophthalmic anti-inflammatory agents 3 3 None No generic available

Acyclovir Antivirals 1 1 None This medication is generic Aczone 5% Acne treatment 3 3 None No generic available Adacel Vaccines Free As Free As None No generic available Preventive Preventive Vaccine Vaccine Adapalene Acne treatment 1 1 None This medication is generic Adapalene 0.1% lotion Acne treatment 3 3 None No generic available Adapalene-Benzoyl Peroxide Acne treatment 1 1 None This medication is generic Adapin; Sinequan* Antidepressants 3 3 None Doxepin Hcl Adcirca Pulmonary Hypertension Agents 2 2 PA, QL No generic available Adderall XR* CNS stimulants 3 3 QL Amphet Asp/Amphet/D-Amphet Adderall* CNS stimulants 3 3 QL Amphet Asp/Amphet/D-Amphet Addyi Sexual Dysfunction 3 3 PA, QL No generic available Adefovir Dipivoxil Antivirals 1 1 None This medication is generic Adempas Pulmonary Hypertension Agents 2 2 PA, QL No generic available Adipex, P* Weight Loss Preparations 3 3 None Phentermine Hcl Adoxa capsule* Tetracyclines/Acne treatment 3 3 PA Doxycycline Monohydrate Adoxa tablet* Tetracyclines/Acne treatment 3 3 PA Doxycycline Monohydrate Adrenalin chloride nasal Epinephrine 3 3 None No generic available Advair Inhaled steroid and beta-agonist 2 2 QL No generic available combinations Adzenys XR-ODT CNS stimulants 3 3 ST, QL No generic available Aerospan Inhaled steroids 3 3 QL No generic available Afinitor, Disperz Kinase inhibitors and molecular target 2 2 QL No generic available inhibitors Afluria, Quad Vaccines Free As Free As None No generic available Preventive Preventive Vaccine Vaccine Afrezza Insulins 3 3 PA No generic available Aggrenox* Anticoagulants and hemostasis agents 3 3 None Aspirin/Dipyridamole

Agrylin* Anticoagulants and hemostasis agents 3 3 None Anagrelide Hcl

Akynzeo Antiemetics 3 3 PA, QL No generic available Ala-Scalp HP* Corticosteroids - low potency 3 3 None Hydrocortisone Albalon* Miscellaneous ophthalmic agents 3 3 None Naphazoline Hcl

Albenza Antiparasitics and anthelmintics 2 2 QL No generic available Albuterol Sulfate Oral beta-agonists/inhaled beta- 1 1 None This medication is generic agonists Alclometasone Dipropionate Corticosteroids - low potency 1 1 None This medication is generic Aldactazide 50/50mg Diuretics 3 Free As None No generic available Preventive Aldactazide* Diuretics 3 3 None Spironolact/Hydrochlorothiazid Aldactone* Diuretics 3 3 None Spironolactone Aldara* Topical antineoplastic agents and 3 3 None Imiquimod immunomodulators Aldomet* Alpha-adrenergic agents 3 3 None Methyldopa Aldoril* Alpha-adrenergic agents 3 3 None Methyldopa/Hydrochlorothiazide Alecensa Kinase inhibitors and molecular target 2 2 PA, QL No generic available inhibitors Alendronate Sodium Osteoporosis and bone resorption 1 1 QL This medication is generic

Alesse, Levlite* Contraceptives-Monophasic 3 3 None Levonorgestrel-Eth Estra Alferon N Interferons and MS therapy 2 2 None No generic available Alfuzosin Hcl BPH Treatment 1 1 None This medication is generic Alinia Antiparasitics and anthelmintics 2 2 None No generic available Alkeran tablet Alkylating agents 2 2 None Melphalan tablet Allopurinol Gout therapy 1 1 None This medication is generic Almotriptan Malate Migraine therapy 1 1 ST, QL This medication is generic

Updated 11/13/2017 Drug name Category of drug Choices Tier ABC Tier Limits Generic equivalent if available Alocril Ophthalmic anti-allergy agents 2 2 None No generic available Alogliptin Non-insulin hypoglycemic agents 3 3 ST, QL No generic available

Alogliptin-metformin Non-insulin hypoglycemic agents 3 3 ST, QL No generic available

Alogliptin-pioglitazone Non-insulin hypoglycemic agents 3 3 ST, QL No generic available

Alomide Ophthalmic anti-allergy agents 2 2 None No generic available Alora Estrogens/Osteoporosis and hormonal 2 2 QL No generic available treatment Alosetron Hcl Miscellaneous gastrointestinal agents 1 1 None This medication is generic

Alphagan 0.2%, P 0.15%* Glaucoma agents 3 3 None Brimonidine Tartrate Alphagan P 0.1% Glaucoma agents 2 2 None No generic available Alprazolam Anxiolytics 1 1 None This medication is generic Alrex Ophthalmic steroids 3 3 None No generic available Alsuma* Migraine therapy 3 3 QL Sumatriptan Succinate Altabax Topical antibacterials 3 3 None No generic available Altace* ACE-Inhibitors and combinations 3 3 None Ramipril Aluminum Chloride Miscellaneous dermatologicals 1 1 None This medication is generic Alunbrig capsule Oncology 3 3 PA, QL No generic available Alupent* Oral beta-agonists 3 3 None Metaproterenol Sulfate Alvesco Inhaled steroids 2 2 QL No generic available Amantadine Hcl Parkinsons disease and related 1 1 None This medication is generic disorders/Antiviral Amaryl* Non-insulin hypoglycemic agents 3 3 None Glimepiride

Ambien CR* Sedative and hypnotics 3 3 QL Zolpidem Tartrate Ambien* Sedative and hypnotics 3 3 QL Zolpidem Tartrate Amcinonide Corticosteroids - high potency 1 1 None This medication is generic Amerge* Migraine therapy 3 3 QL Naratriptan Hcl Amicar Anticoagulants and hemostasis agents 2 2 None No generic available

Amiloride Hcl Diuretics 1 Free As None This medication is generic Preventive Amiloride/Hydrochlorothiazide Diuretics 1 Free As None This medication is generic Preventive Amiodarone Hcl Cardiovascular treatment 1 1 None This medication is generic Amitiza Miscellaneous gastrointestinal agents 3 3 PA No generic available

Amitrip Hcl/Chlordiazepoxide Antidepressants 1 1 None This medication is generic Amitriptyline Hcl Antidepressants 1 1 None This medication is generic Amitriptyline Hcl/Perphenazine Antidepressants/Antipsychotic 1 1 None This medication is generic Amlodipine Bes/Olmesartan Med Angiotensin II Receptor Blockers and 1 Free As None This medication is generic combinations Preventive Amlodipine Besylate Calcium channel blockers and 1 Free As None This medication is generic combinations Preventive Amlodipine Besylate/Benazepril ACE-Inhibitors and combinations 1 Free As None This medication is generic Preventive Amlodipine/Atorvastatin Cal Calcium channel blockers and 1 Free As QL This medication is generic combinations/Lipid Lowering Preventive Amlodipine/Valsartan Angiotensin II Receptor Blockers and 1 Free As None This medication is generic combinations Preventive Amlodipine/Valsartan/Hctz Angiotensin II Receptor Blockers and 1 Free As None This medication is generic combinations Preventive Amox Tr/Potassium Clavulanate Penicillins 1 1 None This medication is generic Amoxapine Antidepressants 1 1 None This medication is generic Amoxicillin Trihydrate Penicillins 1 1 None This medication is generic Amoxil* Penicillins 3 3 None Amoxicillin Trihydrate Amphet Asp/Amphet/D-Amphet CNS stimulants 1 1 QL This medication is generic Ampicillin Trihydrate Penicillins 1 1 None This medication is generic Ampicillin* Penicillins 3 3 None Ampicillin Trihydrate Ampyra Interferons and MS therapy 3 3 PA, QL No generic available Amrix Skeletal muscle relaxants 3 3 ST No generic available Anadrol-50 Androgens 3 3 PA No generic available Anafranil* Antidepressants 3 3 None Clomipramine Hcl Anagrelide Hcl Anticoagulants and hemostasis agents 1 1 None This medication is generic

Analpram HC cream Topical anti-Inflammatory agents 2 2 None No generic available

Analpram HC* Topical anti-Inflammatory agents 3 3 None Hydrocortisone/Pramoxine Hcl

Updated 11/13/2017 Drug name Category of drug Choices Tier ABC Tier Limits Generic equivalent if available Anamantle HC* Topical anti-Inflammatory agents 3 3 None Lidocaine Hcl/Hc

Anaprox, DS* Nonsteroidal anti-inflammatory drugs 3 3 None Naproxen Sodium

Anastrozole Hormonal agents 1 1 PA This medication is generic Ancobon* Antifungals 3 3 None Flucytosine Androderm Androgens 2 2 PA, QL No generic available Androgel 1%* Androgens 3 3 PA, QL Testosterone Androgel 1.62% Androgens 2 2 PA, QL No generic available Android; Testred* Androgens 3 3 None Methyltestosterone Androxy* Androgens 3 3 PA, QL Fluoxymesterone Angeliq Estrogen and progestin combinations 3 3 QL No generic available

Anoro Ellipta Inhaled beta-agonist and 3 3 QL No generic available anticholinergic Ansaid* Nonsteroidal anti-inflammatory drugs 3 3 None Flurbiprofen

Antabuse* Miscellaneous CNS 3 3 None Disulfiram Antara 30, 90mg Lipid-lowering agents 3 3 None No generic available Antara* Lipid-lowering agents 3 3 None Fenofibrate,Micronized Antivert* Antiemetics 3 3 None Meclizine Hcl Anusol HC* Topical anti-Inflammatory agents 3 3 None Hydrocortisone

Anzemet Antiemetics 3 3 None No generic available Apexicon, E* Corticosteroids - high potency 3 3 None Diflorasone Diacetate Apidra, Solostar Insulins 2 2 None No generic available Aplenzin Antidepressants 3 3 ST No generic available Apokyn Parkinsons disease and related 2 2 None No generic available disorders Apraclonidine Hcl Glaucoma agents 1 1 None This medication is generic Apresoline* Miscellaneous antihypertensives 3 3 None Hydralazine Hcl

Apriso 5-Aminosalicylic Acid (5-ASA) agents 3 3 None No generic available

Aptensio XR CNS stimulants 3 3 ST, QL No generic available Aptiom Anticonvulsants 3 3 ST, QL No generic available Aptivus Antiretrovirals 2 2 None No generic available Aralen* Antimalarials 3 3 None Chloroquine Phosphate Aranesp Adjuvant therapy/Hematopoietic 3 3 PA No generic available agents Arava* Miscellaneous rheumatologic agents 3 3 None Leflunomide

Arcalyst Immunomodulators 2 2 PA No generic available Arcapta Neohaler Inhaled beta-agonists 3 3 QL No generic available Aricept 23mg* Alzheimer's therapy 3 3 QL Donepezil Hcl Aricept, ODT* Alzheimer's therapy 3 3 None Donepezil Hcl Arimidex* Hormonal agents 3 3 PA Anastrozole Aripiprazole Antipsychotics 1 1 None This medication is generic Aristocort; Kenalog 0.5% cream* Corticosteroids - high potency 3 3 None Triamcinolone Acetonide Arixtra* Anticoagulants and hemostasis agents 3 3 None Fondaparinux Sodium

Armodafinil CNS stimulants 1 1 QL This medication is generic Armour Thyroid Thyroid hormones 3 3 None No generic available Armour Thyroid 15mg* Thyroid hormones 3 3 None Thyroid,Pork Arnuity Ellipta Inhaled steroids 3 3 QL No generic available Aromasin* Hormonal agents 3 3 PA Exemestane Artane* Parkinsons disease and related 3 3 None Trihexyphenidyl Hcl disorders Arthrotec* Nonsteroidal anti-inflammatory drugs 3 3 None Diclofenac Sodium/Misoprostol

Asacol HD 5-Aminosalicylic Acid (5-ASA) agents 2 2 None No generic available

Asmanex, HFA Inhaled steroids 2 2 QL No generic available Aspirin Salicylates Free As Free As None This medication is generic Preventive Preventive Aspirin, Ecotrin 81, 325mg* Salicylates Free As Free As None Aspirin Preventive Preventive Aspirin/Dipyridamole Anticoagulants and hemostasis agents 1 1 None This medication is generic

Astagraf XL Immunomodulators 3 3 None No generic available Astelin* Antihistamines/Nasal preparations 3 3 QL Azelastine Hcl

Updated 11/13/2017 Drug name Category of drug Choices Tier ABC Tier Limits Generic equivalent if available Astepro* Antihistamines/Nasal preparations 3 3 QL Azelastine Hcl

Atacand HCT* Angiotensin II Receptor Blockers and 3 3 None Candesartan/Hydrochlorothiazide combinations Atacand* Angiotensin II Receptor Blockers and 3 3 None Candesartan Cilexetil combinations Atarax; Vistaril* Antihistamines 3 3 None Hydroxyzine Atelvia* Osteoporosis and bone resorption 3 3 ST, QL Risedronate Sodium

Atenolol Beta blockers and combinations 1 Free As None This medication is generic Preventive Atenolol/Chlorthalidone Beta blockers and combinations 1 Free As None This medication is generic Preventive Ativan* Anxiolytics 3 3 None Lorazepam Atomoxetine ADHD 1 1 None This medication is generic Atorvastatin Calcium Lipid-lowering agents 1 Free As QL This medication is generic Preventive Atovaquone Antiparasitics and anthelmintics 1 1 None This medication is generic Atovaquone/Proguanil Hcl Antimalarials 1 1 None This medication is generic Atralin* Acne treatment 3 3 None Tretinoin Atripla Antiretrovirals 2 2 None No generic available Atropine Sulfate Cycloplegic mydriatics 1 1 None This medication is generic Atrovent HFA Inhaled anticholinergics 2 2 QL No generic available Atrovent nasal spray* Nasal preparations 3 3 QL Ipratropium Bromide Atrovent solution* Inhaled anticholinergics 3 3 None Ipratropium Bromide Aubagio Interferons and MS therapy 3 3 PA, QL No generic available Augmentin 125mg-31.25mg/5ml susp Penicillins 2 2 None No generic available

Augmentin, ES, XR* Penicillins 3 3 None Amox Tr/Potassium Clavulanate Auralgan* Otic preparations 3 3 None Aa/Antpy/Bcaine/Polico/Al Acet Auryxia Ion-Removing Agents 3 3 None No generic available Austedo Huntingtons disease 3 3 PA, QL No generic available Avalide* Angiotensin II Receptor Blockers and 3 3 None Irbesartan/Hydrochlorothiazide combinations Avandamet Non-insulin hypoglycemic agents 3 3 None No generic available

Avandia Non-insulin hypoglycemic agents 3 3 None No generic available

Avapro* Angiotensin II Receptor Blockers and 3 3 None Irbesartan combinations AVC Vaginal anti-infective and antifungal 3 3 None No generic available

Avelox ABC Quinolones 2 2 None No generic available Avelox* Quinolones 3 3 None Moxifloxacin Hcl Aventyl; Pamelor* Antidepressants 3 3 None Nortriptyline Hcl Avinza* Narcotics 3 3 None Morphine Sulfate Avita gel Acne treatment 3 3 None No generic available Avodart* BPH Treatment 3 3 None Dutasteride Avonex Interferons and MS therapy 2 2 None No generic available Axert* Migraine therapy 3 3 ST, QL Almotriptan Malate Axid (Rx Only)* H2-Receptor antagonists 3 3 None Nizatidine Axiron Androgens 3 3 PA, QL No generic available Aygestin* Progestins 3 3 None Norethindrone Acetate Azasan Miscellaneous rheumatologic 3 3 None No generic available agents/Immunomodulators Azasite Ophthalmic anti-infectives 3 3 None No generic available Azathioprine Immunomodulators 1 1 None This medication is generic Azelastine Hcl Antihistamines/Nasal Preperation 1 1 QL This medication is generic

Azelex Acne treatment 3 3 None No generic available Azilect Parkinsons disease and related 2 2 None No generic available disorders Azithromycin Macrolides 1 1 None This medication is generic Azopt Glaucoma agents 2 2 None No generic available Azor* Calcium channel blockers and 3 3 None Amlodipine Bes/Olmesartan Med combinations/5-Aminosalicylic Acid (5- ASA) agents Azulfidine, En-Tab* 5-Aminosalicylic Acid (5-ASA) 3 3 None Sulfasalazine agents/Miscellaneous rheumatologic agents Bacitracin Ophthalmic anti-infectives 1 1 None This medication is generic Bacitracin/Polymyxin B Sulfate Ophthalmic anti-infectives 1 1 None This medication is generic

Updated 11/13/2017 Drug name Category of drug Choices Tier ABC Tier Limits Generic equivalent if available Baclofen Skeletal muscle relaxants 1 1 None This medication is generic Bactrim, DS* Sulfonamides and combination 3 3 None Sulfamethoxazole/Trimethoprim Bactroban cream* Topical antibacterials 3 3 None Mupirocin Calcium Bactroban nasal Topical antibacterials 2 2 None No generic available Bactroban ointment* Topical antibacterials 3 3 None Mupirocin Balsalazide Disodium 5-Aminosalicylic Acid (5-ASA) agents 1 1 None This medication is generic

Banzel Anticonvulsants 2 2 None No generic available Baraclude solution Antivirals 2 2 None No generic available Baraclude tablet* Antivirals 3 3 None Entecavir Basaglar Insulins 3 3 None No generic available Baxdela tablet Antibiotic 3 3 None No generic available Beconase AQ Nasal preparations 3 3 ST, QL No generic available Belbuca Narcotic mixed agonist and antagonist 3 3 PA, QL No generic available

Belladonna & Opium* Narcotics 3 3 None Opium/Belladonna Alkaloids Belsomra Sedative and hypnotics 3 3 ST, QL No generic available Belviq, XR Weight Loss Preparations 3 Free As PA, QL No generic available Preventive Benadryl (Rx only)* Antihistamines 3 3 None Diphenhydramine Hcl Benazepril Hcl ACE-Inhibitors and combinations 1 Free As None This medication is generic Preventive Benazepril/Hydrochlorothiazide ACE-Inhibitors and combinations 1 Free As None This medication is generic Preventive Benicar HCT* Angiotensin II Receptor Blockers and 3 3 None Olmesartan/Hydrochlorothiazide combinations Benicar* Angiotensin II Receptor Blockers and 3 3 None Olmesartan Medoxomil combinations Bentyl* Antidiarrheals and antispasmodics 3 3 None Dicyclomine Hcl

Benzaclin* Acne treatment 3 3 None Clindamycin Phos/Benzoyl Perox Benzamycin* Acne treatment 3 3 None Erythromycin Base/Benz Per Benzonatate Antitussives 1 1 None This medication is generic Benzoyl Peroxide Acne treatment 1 1 None This medication is generic Benzphetamine Hcl Weight Loss Preparations 1 Free As None This medication is generic Preventive Benztropine Mesylate Parkinsons disease and related 1 1 None This medication is generic disorders Bepreve Ophthalmic anti-allergy agents 3 3 None No generic available Besivance Ophthalmic anti-infectives 3 3 None No generic available Betagan* Ophthalmic beta blockers 3 3 None Levobunolol Hcl Betamet Diprop/Prop Gly Corticosteroids - high potency/very 1 1 None This medication is generic high potency Betamethasone Dipropionate Corticosteroids - high potency 1 1 None This medication is generic Betamethasone Valerate Corticosteroids - medium potency/high 1 1 None This medication is generic potency Betapace, AF* Beta blockers and 3 3 None Sotalol Hcl combinations/Cardiovascular treatment Betaseron Interferons and MS therapy 3 3 None No generic available Betaxolol Hcl Beta blockers and combinations 1 Free As None This medication is generic Preventive Bethanechol Chloride Miscellaneous Urologicals 1 1 None This medication is generic Bethkis Miscellaneous anti-infectives/Cystic 3 3 PA, QL No generic available Fibrosis agents Betimol Ophthalmic beta blockers 2 2 None No generic available Betoptic S Ophthalmic beta blockers 2 2 None No generic available Betoptic solution* Ophthalmic beta blockers 3 3 None Betaxolol Hcl Bevespi Aerosphere Inhaled beta-agonist and 3 3 QL No generic available anticholinergic Bexarotene Miscellaneous antineoplastic agents 1 1 PA This medication is generic

Beyaz* Contraceptives-Monophasic 3 3 None Drospir/Eth Estra/Levomefol Ca Biaxin, XL* Macrolides 3 3 None Clarithromycin Bicalutamide Hormonal agents 1 1 None This medication is generic BiDil Nitrates and combinations 2 2 None No generic available Biltricide Antiparasitics and anthelmintics 2 2 None No generic available Bimatoprost Glaucoma agents 1 1 None This medication is generic Binosto Osteoporosis and bone resorption 3 3 ST, QL No generic available

Bisac/Nacl/Nahco3/Kcl/Peg 3350 Bowel preparation and cleansing 1 1 None This medication is generic agents

Updated 11/13/2017 Drug name Category of drug Choices Tier ABC Tier Limits Generic equivalent if available Bisac/Nacl/Nahco3/Kcl/Peg 3350 Bowel preparation and cleansing Free As Free As QL This medication is generic (Preventive) agents Preventive Preventive Bisacodyl Bowel preparation and cleansing Free As Free As QL This medication is generic agents Preventive Preventive Bisacodyl OTC* Bowel preparation and cleansing Free As Free As QL Bisacodyl agents Preventive Preventive Bisoprolol Fumarate Beta blockers and combinations 1 Free As None This medication is generic Preventive Bisoprolol/Hydrochlorothiazide Beta blockers and combinations 1 Free As None This medication is generic Preventive Bleph-10 drops Ophthalmic anti-infectives 3 3 None No generic available Bleph-10, Sodium sulamyde* Ophthalmic anti-infectives 3 3 None Sulfacetamide Sodium Blephamide Ophthalmic anti-infective and steroid 2 2 None No generic available

Blocadren* Beta blockers and combinations 3 3 None Timolol Maleate Boniva* Osteoporosis and bone resorption 3 3 QL Ibandronate Sodium

Bontril PDM* Weight Loss Preparations 3 3 None Phendimetrazine Tartrate Boostrix Vaccines Free As Free As None No generic available Preventive Preventive Vaccine Vaccine Bosulif Kinase inhibitors and molecular target 2 2 PA, QL No generic available inhibitors Bravelle Infertility treatment 2 2 None No generic available Breo Ellipta Inhaled steroid and beta-agonist 3 3 QL No generic available combinations Brevoxyl gel* Acne treatment 3 3 None Benzoyl Peroxide Brilinta Anticoagulants and hemostasis agents 2 2 None No generic available

Brimonidine Tartrate Glaucoma agents 1 1 None This medication is generic Brisdelle* Miscellaneous OB-GYN 3 3 ST, QL Paroxetine Briviact Anticonvulsants 3 3 PA, QL No generic available Bromday; Xibrom* Ophthalmic anti-inflammatory agents 3 3 None Bromfenac Sodium

Bromfed-DM* Antitussives 3 3 None D-Methorphan Hb/P-Epd Hcl/Bpm Bromfenac Sodium Ophthalmic anti-inflammatory agents 1 1 None This medication is generic

Bromocriptine Mesylate Parkinsons disease and related 1 1 None This medication is generic disorders Brovana Inhaled beta-agonists 3 3 None No generic available Budesonide Inhaled 1 1 None This medication is generic steroids/Corticosteroid/Diuretic Budesonide (nasal prep) Nasal preparations 1 1 ST, QL This medication is generic Bumetanide Diuretics 1 Free As None This medication is generic Preventive Bumex* Diuretics 3 3 None Bumetanide Bunavail Narcotic mixed agonist and antagonist 3 3 QL No generic available

Buphenyl powder* Urea cycle disorder agents 3 3 None Sodium Phenylbutyrate Buphenyl tablet Urea cycle disorder agents 2 2 PA, QL No generic available Buprenorphine Hcl Narcotic mixed agonist and antagonist 1 1 PA, QL This medication is generic

Buprenorphine Hcl/Naloxone Hcl Narcotic mixed agonist and antagonist 1 1 QL This medication is generic

Bupropion Hcl Antidepressants/Anxiolytics 1 1 None This medication is generic Bupropion Hcl (Preventive) Smoking Cessation Free As Free As QL This medication is generic Preventive Preventive Buspar* Anxiolytics 3 3 None Buspirone Hcl Butalb/Acetaminophen/Caffeine Narcotic and analgesic 1 1 None This medication is generic combinations/Migraine therapy Butalbit/Acetamin/Caff/Codeine Narcotic and analgesic 1 1 None This medication is generic combinations/Migraine therapy Butalbital/Acetaminophen Narcotic and analgesic 1 1 None This medication is generic combinations/Migraine therapy Butalbital/Aspirin/Caffeine Narcotic and analgesic 1 1 None This medication is generic combinations/Migraine therapy Butisol sodium Sedative and hypnotics 3 3 None No generic available Butorphanol Tartrate Narcotic mixed agonist and antagonist 1 1 None This medication is generic

Butrans Narcotic mixed agonist and antagonist 3 3 PA, QL No generic available

Updated 11/13/2017 Drug name Category of drug Choices Tier ABC Tier Limits Generic equivalent if available Bydureon, Pen Non-insulin hypoglycemic agents 2 2 PA, QL No generic available

Byetta Non-insulin hypoglycemic agents 3 3 PA, QL No generic available

Bystolic Beta blockers and combinations 3 Free As None No generic available Preventive Bystolic 20mg Beta blockers and combinations 3 Free As None No generic available Preventive Byvalson Angiotensin II Receptor Blockers and 3 3 ST, QL No generic available combinations/Beta blockers and combinations Cabergoline Miscellaneous endocrine 1 1 None This medication is generic Cabometyx Kinase inhibitors and molecular target 2 2 PA, QL No generic available inhibitors Caduet* Calcium channel blockers and 3 3 QL Amlodipine/Atorvastatin Cal combinations/Lipid-lowering agents

Cafcit* Miscellaneous CNS 3 3 None Caffeine Citrated Cafergot* Migraine therapy 2 2 None Ergotamine Tartrate/Caffeine Caffeine Citrated Miscellaneous CNS 1 1 None This medication is generic Calan SR; Isoptin SR* Calcium channel blockers and 3 3 None Verapamil Hcl combinations Calciferol* Vitamin D analogs/Vitamins and 3 3 None Ergocalciferol Minerals Calcipotriene Antipsoriatic and antiseborrheic 1 1 None This medication is generic Calcipotriene/Betamethasone Antipsoriatic and antiseborrheic 1 1 None This medication is generic Calcitonin,Salmon,Synthetic Miscellaneous endocrine/Osteoporosis 1 1 None This medication is generic and bone resorption

Calcitriol Antipsoriatic and 1 1 None This medication is generic antiseborrheic/Vitamin D analogs

Calcium + Vitamin D 600mg* Vitamins and Minerals Free As Free As None Calcium Carbonate/Vitamin D3 Preventive Preventive Calcium + Vitamin D capsule* Vitamins and Minerals Free As Free As None Calcium Carbonate/Vitamin D3 Preventive Preventive Calcium + Vitamin D chewable* Vitamins and Minerals Free As Free As None Calcium Carbonate/Vitamin D3 Preventive Preventive Calcium + Vitamin D tablet* Vitamins and Minerals Free As Free As None Calcium Carb & Cit/Vitamin D3 Preventive Preventive Calcium Acetate Ion-Removing Agents 1 1 None This medication is generic Calcium Carb & Cit/Vitamin D3 Vitamins and Minerals Free As Free As None This medication is generic Preventive Preventive Calcium Carbonate/Vitamin D3 Vitamins and Minerals Free As Free As None This medication is generic Preventive Preventive Calcium Citrate w/Vitamin D2* Vitamins and Minerals Free As Free As None Calcium Citrate/Vitamin D2 Preventive Preventive Calcium Citrate w/Vitamin D3* Vitamins and Minerals Free As Free As None Calcium Citrate/Vitamin D3 Preventive Preventive Calcium Citrate/Vitamin D2 Vitamins and Minerals Free As Free As None This medication is generic Preventive Preventive Calcium Citrate/Vitamin D3 Vitamins and Minerals Free As Free As None This medication is generic Preventive Preventive Calcium Phosphate Dibas/Vit D3 Vitamins and Minerals Free As Free As None This medication is generic Preventive Preventive Calvite P&D* Vitamins and Minerals Free As Free As None Calcium Phosphate Dibas/Vit D3 Preventive Preventive Cambia Migraine therapy/Nonsteroidal anti- 3 3 ST, QL No generic available inflammatory drugs Campral* Miscellaneous CNS 3 3 None Acamprosate Calcium Canasa 5-Aminosalicylic Acid (5-ASA) agents 2 2 None No generic available

Candesartan Cilexetil Angiotensin II Receptor Blockers and 1 Free As None This medication is generic combinations Preventive Candesartan/Hydrochlorothiazide Angiotensin II Receptor Blockers and 1 Free As None This medication is generic combinations Preventive Capecitabine Antimetabolites 1 1 None This medication is generic Capex shampoo Corticosteroids - low potency 2 2 None No generic available Capoten* ACE-Inhibitors and combinations 3 3 None Captopril Capozide* ACE-Inhibitors and combinations 3 3 None Captopril/Hydrochlorothiazide Caprelsa Kinase inhibitors and molecular target 2 2 QL No generic available inhibitors

Updated 11/13/2017 Drug name Category of drug Choices Tier ABC Tier Limits Generic equivalent if available Captopril ACE-Inhibitors and combinations 1 Free As None This medication is generic Preventive Captopril/Hydrochlorothiazide ACE-Inhibitors and combinations 1 Free As None This medication is generic Preventive Carac Topical antineoplastic agents and 3 3 PA, QL No generic available immunomodulators Carafate suspension Ulcer therapy 2 2 None No generic available Carafate* Ulcer therapy 3 3 None Sucralfate Carbaglu Urea cycle disorder agents 2 2 PA No generic available Carbamazepine Anticonvulsants 1 1 None This medication is generic Carbatrol* Anticonvulsants 3 3 None Carbamazepine Carbidopa Parkinsons disease and related 1 1 None This medication is generic disorders Carbidopa/Levodopa Parkinsons disease and related 1 1 None This medication is generic disorders Carbidopa/Levodopa/Entacapone Parkinsons disease and related 1 1 None This medication is generic disorders Cardene* Calcium channel blockers and 3 3 None Nicardipine Hcl combinations Cardizem LA 120mg Calcium channel blockers and 3 3 None No generic available combinations Cardizem, SR, CD, LA* Calcium channel blockers and 3 3 None Diltiazem Hcl combinations Cardura XL BPH Treatment 3 Free As None No generic available Preventive Cardura* Alpha-adrenergic agents/BPH 3 3 None Doxazosin Mesylate Treatment Carisoprodol Skeletal muscle relaxants 1 1 None This medication is generic Carisoprodol/Aspirin Skeletal muscle relaxants 1 1 None This medication is generic Carnitor SF solution Diagnostics and Other Miscellaneous 3 3 None No generic available

Carnitor* Diagnostics and Other Miscellaneous 3 3 None Levocarnitine

Carteolol Hcl Ophthalmic beta blockers 1 1 None This medication is generic Carvedilol Beta blockers and combinations 1 Free As None This medication is generic Preventive Casodex* Hormonal agents 3 3 None Bicalutamide Cataflam* Nonsteroidal anti-inflammatory drugs 3 3 None Diclofenac Potassium

Catapres TTS* Alpha-adrenergic agents 3 3 None Clonidine Hcl Catapres* Alpha-adrenergic agents 3 3 None Clonidine Hcl Caverject Sexual Dysfunction 2 2 QL No generic available Cayston Miscellaneous anti-infectives/Cystic 3 3 PA, QL No generic available Fibrosis agents Ceclor, ER* Cephalosporins 3 3 None Cefaclor Cedax* Cephalosporins 3 3 None Ceftibuten Dihydrate Cefaclor Cephalosporins 1 1 None This medication is generic Cefadroxil Hydrate Cephalosporins 1 1 None This medication is generic Cefdinir Cephalosporins 1 1 None This medication is generic Cefditoren Pivoxil Cephalosporins 1 1 None This medication is generic Cefixime Cephalosporins 1 1 None This medication is generic Cefpodoxime Proxetil Cephalosporins 1 1 None This medication is generic Cefprozil Cephalosporins 1 1 None This medication is generic Ceftibuten Dihydrate Cephalosporins 1 1 None This medication is generic Ceftin suspension Cephalosporins 2 2 None No generic available Ceftin tablet* Cephalosporins 3 3 None Cefuroxime Axetil Cefuroxime Axetil Cephalosporins 1 1 None This medication is generic Cefzil* Cephalosporins 3 3 None Cefprozil Celebrex* Nonsteroidal anti-inflammatory drugs 3 3 None Celecoxib

Celecoxib Nonsteroidal anti-inflammatory drugs 1 1 None This medication is generic

Celexa* Antidepressants 3 3 None Citalopram Hydrobromide Cellcept* Immunomodulators 3 3 None Mycophenolate Mofetil Celontin Anticonvulsants 3 3 None No generic available Cephalexin Monohydrate Cephalosporins 1 1 None This medication is generic Cerdelga Miscellaneous endocrine 3 3 PA, QL No generic available Cervarix Vaccines Free As Free As None No generic available Preventive Preventive Vaccine Vaccine Cesamet Antiemetics 3 3 None No generic available Cetraxal* Otic preparations 3 3 None Ciprofloxacin Hcl

Updated 11/13/2017 Drug name Category of drug Choices Tier ABC Tier Limits Generic equivalent if available Cetrotide Infertility treatment 2 2 None No generic available Cetylev Miscellaneous endocrine 3 3 None No generic available Cevimeline Hcl Miscellaneous gastrointestinal agents 1 1 None This medication is generic

Chantix Smoking Cessation Free As Free As ST, QL No generic available Preventive Preventive Chemet Chelating Agents 2 2 None No generic available Chenodal Bile acids 3 3 PA No generic available Chlordiazepoxide Hcl Anxiolytics 1 1 None This medication is generic Chlorhexidine Gluconate Miscellaneous anti-infectives 1 1 None This medication is generic Chloroquine Phosphate Antimalarials 1 1 None This medication is generic Chlorothiazide Diuretics 1 Free As None This medication is generic Preventive Chlorpromazine Hcl Antipsychotics 1 1 None This medication is generic Chlorpropamide Non-insulin hypoglycemic agents 1 1 None This medication is generic

Chlorthalidone Diuretics 1 Free As None This medication is generic Preventive Chlorzoxazone Skeletal muscle relaxants 1 1 None This medication is generic Cholbam Miscellaneous endocrine 2 2 PA, QL No generic available Cholecalciferol (Vitamin D3) Vitamins and Minerals Free As Free As None This medication is generic Preventive Preventive Cholestyramine Lipid-lowering agents 1 Free As None This medication is generic Preventive Cholestyramine light Lipid-lowering agents 1 Free As None This medication is generic Preventive Choline Magnesium Trisalicylate Salicylates 1 1 None This medication is generic Chorionic gonadotropin Infertility treatment 2 2 PA No generic available Cialis Sexual Dysfunction 2 2 QL No generic available Cialis 2.5, 5mg BPH Treatment 2 2 PA, QL No generic available Ciclopirox Topical antifungals 1 1 None This medication is generic Ciclopirox Olamine Topical antifungals 1 1 None This medication is generic Cilostazol Anticoagulants and hemostasis agents 1 1 None This medication is generic

Ciloxan drops* Ophthalmic anti-infectives 3 3 None Ciprofloxacin Hcl Ciloxan ointment Ophthalmic anti-infectives 2 2 None No generic available Cimetidine H2-Receptor antagonists 1 1 None This medication is generic Cimzia Syringe Tumor Necrosis Factor (TNF) blocking 3 3 PA, QL No generic available agents Cipro HC Otic preparations 3 3 None No generic available Cipro XR* Quinolones 3 3 None Ciprofloxacin Hcl-Betaine Comb Cipro* Quinolones 3 3 None Ciprofloxacin Hcl Ciprodex Otic preparations 2 2 None No generic available Ciprofloxacin Hcl Ophthalmic anti-infectives/Quinolones 1 1 None This medication is generic

Ciprofloxacin Hcl-Betaine Comb Quinolones 1 1 None This medication is generic Citalopram Hydrobromide Antidepressants 1 1 None This medication is generic Citrate of Magnesia OTC* Bowel preparation and cleansing Free As Free As QL Magnesium Citrate agents Preventive Preventive Claravis; Myorisan; Zenatane* Acne treatment 3 3 None Isotretinoin Clarinex syrup Antihistamines 3 3 None No generic available Clarinex tablet, Redi-tab* Antihistamines 3 3 QL Desloratadine Clarinex-D Antihistamines 3 3 QL No generic available Clarithromycin Macrolides 1 1 None This medication is generic Claritin Redi-tab Antihistamines 3 3 None No generic available Cleocin T* Acne treatment 3 3 None Clindamycin Phosphate Cleocin vaginal cream* Vaginal anti-infective and antifungal 3 3 None Clindamycin Phosphate

Cleocin vaginal ovules Vaginal anti-infective and antifungal 3 3 None No generic available

Cleocin* Miscellaneous anti-infectives 3 3 None Clindamycin Hcl Clidinium Br/Chlordiazepoxide Antidiarrheals and antispasmodics 1 1 None This medication is generic

Climara Pro Estrogen and progestin combinations 3 3 QL No generic available

Climara* Estrogens/Osteoporosis and hormonal 3 3 QL Estradiol treatment Clindagel Acne treatment 2 2 None No generic available Clindamycin Hcl Miscellaneous anti-infectives 1 1 None This medication is generic Clindamycin Phos/Benzoyl Perox Acne treatment 1 1 None This medication is generic Clindamycin Phosphate Vaginal anti-infective and 1 1 None This medication is generic antifungal/Acne treatment

Updated 11/13/2017 Drug name Category of drug Choices Tier ABC Tier Limits Generic equivalent if available Clindamycin Phosphate/Benz Per Acne treatment 1 1 None This medication is generic Clindamycin/Tretinoin Acne treatment 1 1 None This medication is generic Clindesse Vaginal anti-infective and antifungal 3 3 None No generic available

Clinoril* Nonsteroidal anti-inflammatory drugs 3 3 None Sulindac

Clobetasol Propionate Corticosteriods - very high potency 1 1 None This medication is generic

Clobetasol Propionate/Emoll Corticosteriods - very high potency 1 1 None This medication is generic

Clobevate; Temovate* Corticosteriods - very high potency 3 3 None Clobetasol Propionate

Clobex* Corticosteriods - very high potency 3 3 None Clobetasol Propionate

Clocortolone pivalate Corticosteroids - medium potency 2 2 None No generic available

Cloderm Corticosteroids - medium potency 2 2 None No generic available

Clomid* Infertility treatment 3 3 None Clomiphene Citrate Clomiphene Citrate Infertility treatment 1 1 None This medication is generic Clomipramine Hcl Antidepressants 1 1 None This medication is generic Clonazepam Anticonvulsants 1 1 None This medication is generic Clonidine Hcl Miscellaneous CNS 1 Free As QL This medication is generic Preventive Clonidine Hcl/Chlorthalidone Alpha-adrenergic agents 1 1 None This medication is generic Clopidogrel Bisulfate Anticoagulants and hemostasis agents 1 1 None This medication is generic

Clorazepate Dipotassium Anxiolytics 1 1 None This medication is generic Clorpres 0.3-15mg Alpha-adrenergic agents 3 3 None No generic available Clorpres* Alpha-adrenergic agents 3 3 None Clonidine Hcl/Chlorthalidone Clotrimazole Antifungals 1 1 None This medication is generic Clotrimazole/Betamet Diprop Topical antifungals 1 1 None This medication is generic Clozapine Antipsychotics 1 1 None This medication is generic Clozapine 200mg* Antipsychotics 3 3 None Clozapine Clozaril* Antipsychotics 3 3 None Clozapine Coartem Antimalarials 2 2 None No generic available Codeine Phos/Acetaminophen Narcotic and analgesic combinations 1 1 QL This medication is generic

Codeine Phos/Carisoprodol/Asa Skeletal muscle relaxants 1 1 None This medication is generic Codeine Sulfate Narcotics 1 1 None This medication is generic Codeine sulfate tablet* Narcotics 3 3 None Codeine Sulfate Codeine/Butalbital/Asa/Caffein Narcotic and analgesic 1 1 None This medication is generic combinations/Migraine therapy Codeine/Promethazine Hcl Antitussives 1 1 None This medication is generic Cogentin* Parkinsons disease and related 3 3 None Benztropine Mesylate disorders Colazal* 5-Aminosalicylic Acid (5-ASA) agents 3 3 None Balsalazide Disodium

Colbenemid* Gout therapy 3 3 None Colchicine/Probenecid Colchicine capsule Gout therapy 3 3 None No generic available Colchicine tablet Gout therapy 2 2 None No generic available Colchicine/Probenecid Gout therapy 1 1 None This medication is generic Colcrys Gout therapy 2 2 None No generic available Colestid granules, packet Lipid-lowering agents 3 3 None No generic available Colestid* Lipid-lowering agents 3 3 None Colestipol Hcl Colestipol Hcl Lipid-lowering agents 1 Free As None This medication is generic Preventive Coly-Mycin S Otic preparations 3 3 None No generic available Colyte (Preventive)* Bowel preparation and cleansing Free As Free As QL Sod Sulf/Sod/Nahco3/Kcl/Peg'S agents Preventive Preventive Colyte* Bowel preparation and cleansing 3 3 None Sod Sulf/Sod/Nahco3/Kcl/Peg'S agents Combigan Glaucoma agents 3 3 None No generic available Combipatch Estrogen and progestin combinations 3 3 QL No generic available

Combivent Respimat Inhaled beta-agonist and 2 2 None No generic available anticholinergic Combivir* Antiretrovirals 3 3 None Lamivudine/Zidovudine Cometriq Kinase inhibitors and molecular target 2 2 PA, QL No generic available inhibitors Commit lozenge OTC* Smoking Cessation Free As Free As QL Nicotine Polacrilex Preventive Preventive

Updated 11/13/2017 Drug name Category of drug Choices Tier ABC Tier Limits Generic equivalent if available Compazine suppositories* Antiemetics 3 3 None Prochlorperazine Compazine* Antiemetics 3 3 None Prochlorperazine Maleate Complera Antiretrovirals 2 2 QL No generic available Comtan* Parkinsons disease and related 3 3 None Entacapone disorders Conceptrol Contraceptives-Misc. Free As Free As QL No generic available Preventive Preventive Concerta* CNS stimulants 3 3 None Methylphenidate Hcl Condylox gel Miscellaneous dermatologicals 2 2 None No generic available Condylox solution* Miscellaneous dermatologicals 3 3 None Podofilox Contrave Weight Loss Preparations 3 Free As PA, QL No generic available Preventive Conzip Narcotic mixed agonist and antagonist 3 3 None No generic available

Copaxone Interferons and MS therapy 2 2 None No generic available Copegus* Antivirals 3 3 None Ribavirin Cordarone* Cardiovascular treatment 3 3 None Amiodarone Hcl Cordran cream* Corticosteroids - medium potency 3 3 None Flurandrenolide

Cordran ointment, tape Corticosteroids - medium potency 3 3 None No generic available

Coreg CR Beta blockers and combinations 3 Free As None No generic available Preventive Coreg immediate release* Beta blockers and combinations 3 3 None Carvedilol Corgard* Beta blockers and combinations 3 3 None Nadolol Corlanor Cardiovascular treatment 2 2 PA, QL No generic available Cortef; Hydrocortisone* Corticosteroids 3 3 None Hydrocortisone Cortenema* Topical anti-Inflammatory agents 3 3 None Hydrocortisone Acetate

Cortifoam Topical anti-Inflammatory agents 2 2 None No generic available

Cortisone Acetate Corticosteroids 1 1 None This medication is generic Cortisone Acetate* Corticosteroids 3 3 None Cortisone Acetate Cortisporin* Ophthalmic anti-infective and 3 3 None Neomy Sulf/Polymyx B Sulf/Hc steroid/Otic preparations Corzide* Beta blockers and combinations 3 3 None Nadolol/Bendroflumethiazide Cosentyx Antipsoriatic and antiseborrheic 3 3 PA, QL No generic available Cosopt PF Glaucoma agents 3 3 None No generic available Cosopt* Glaucoma agents 3 3 None Timolol Maleate/Dorzolam Hcl Cotellic Kinase inhibitors and molecular target 2 2 PA, QL No generic available inhibitors Coumadin* Anticoagulants and hemostasis agents 3 3 None Warfarin Sodium

Covaryx, H.S.* Miscellaneous OB-GYN/Osteoporosis 3 3 None Estrogen,Ester/Me-Testosterone and hormonal treatment

Cozaar* Angiotensin II Receptor Blockers and 3 3 None Losartan Potassium combinations Creon Digestive enzymes 2 2 None No generic available Cresemba capsule Antifungals 2 2 QL No generic available Crestor* Lipid-lowering agents 3 3 QL Rosuvastatin Calcium Crinone 4% Progestins 2 2 None No generic available Crinone 8% Infertility treatment 2 2 None No generic available Crixivan Antiretrovirals 2 2 None No generic available Cromolyn Sodium Miscellaneous gastrointestinal 1 1 None This medication is generic agents/Respiratory Cutivate* Corticosteroids - medium potency 3 3 None Fluticasone Propionate

Cuvposa Miscellaneous CNS 3 3 None No generic available Cyanocobalamin Vitamins and Minerals 1 1 None This medication is generic Cyanocobalamin injection* Vitamins and Minerals 3 3 None Cyanocobalamin Cyclessa* Contraceptives-Triphasic 3 3 None Desogestrel-Ethinyl Estradiol Cyclobenzaprine Hcl Skeletal muscle relaxants 1 1 None This medication is generic Cyclocort* Corticosteroids - high potency 3 3 None Amcinonide Cyclogyl 5ml Cycloplegic mydriatics 3 3 None No generic available Cyclogyl* Cycloplegic mydriatics 3 3 None Cyclopentolate Hcl Cyclopentolate Hcl Cycloplegic mydriatics 1 1 None This medication is generic Cyclophosphamide Alkylating agents 2 2 None No generic available Cycloserine Antituberculars 2 2 None No generic available Cycloset Non-insulin hypoglycemic agents 3 3 PA, QL No generic available

Cyclosporine Immunomodulators 1 1 None This medication is generic

Updated 11/13/2017 Drug name Category of drug Choices Tier ABC Tier Limits Generic equivalent if available Cyclosporine, Modified Immunomodulators 1 1 None This medication is generic Cymbalta* Antidepressants 3 3 None Duloxetine Hcl Cyproheptadine Hcl Antihistamines 1 1 None This medication is generic Cystadane Diagnostics and Other Miscellaneous 3 3 None No generic available

Cystagon Miscellaneous Urologicals 2 2 None No generic available Cystaran Miscellaneous ophthalmic agents 2 2 PA, QL No generic available

Cytomel* Thyroid hormones 3 3 None Liothyronine Sodium Cytotec* Ulcer therapy 3 3 None Misoprostol D.H.E.45* Migraine therapy 3 3 None Dihydroergotamine Mesylate Daklinza Antivirals 3 3 PA, QL No generic available Daliresp Miscellaneous respiratory agents 3 3 PA, QL No generic available

Dalmane* Sedative and hypnotics 3 3 QL Flurazepam Hcl D-Amphetamine Sulfate CNS stimulants 1 1 None This medication is generic Danazol Androgens 1 1 None This medication is generic Danocrine* Androgens 3 3 None Danazol Dantrium* Skeletal muscle relaxants 3 3 None Dantrolene Sodium Dantrolene Sodium Skeletal muscle relaxants 1 1 None This medication is generic Dapsone Miscellaneous anti-infectives 1 1 None This medication is generic Daraprim Antimalarials 2 2 None No generic available Darifenacin Hydrobromide Urinary Antispasmodics 1 1 QL This medication is generic Daypro* Nonsteroidal anti-inflammatory drugs 3 3 None Oxaprozin

Daytrana CNS stimulants 3 3 None No generic available DDAVP solution Miscellaneous endocrine 3 3 None No generic available DDAVP* Miscellaneous endocrine 3 3 None Desmopressin Acetate Decadron opthalmic* Ophthalmic steroids 3 3 None Dexamethasone Sod Phosphate Decadron* Corticosteroids 3 3 None Dexamethasone Declomycin* Tetracyclines 3 3 None Demeclocycline Hcl Deferoxamine Mesylate Chelating Agents 1 1 None This medication is generic Delatestryl* Androgens 3 3 None Testosterone Enanthate Delestrogen* Estrogens 3 3 None Estradiol Valerate Delzicol 5-Aminosalicylic Acid (5-ASA) agents 2 2 None No generic available

Demadex* Diuretics 3 3 None Torsemide Demeclocycline Hcl Tetracyclines 1 1 None This medication is generic Demerol* Narcotics 3 3 None Meperidine Hcl Demser Miscellaneous antihypertensives 3 Free As None No generic available Preventive Demulen* Contraceptives-Monophasic 3 3 None Ethynodiol D-Ethinyl Estradiol Denavir Topical antivirals 3 3 None No generic available Depakene* Anticonvulsants 3 3 None Valproate Sodium Depakote, ER, Sprinkles* Anticonvulsants 3 3 None Divalproex Sodium Depen Chelating Agents/Miscellaneous 2 2 None No generic available Urologicals/Miscellaneous rheumatologic agents Depo-Provera 150mg* Contraceptives-Misc. 3 3 None Medroxyprogesterone Acet Depo-Provera 400mg Hormonal agents 2 2 None No generic available Depo-Subq Provera 104 Contraceptives-Misc./Progestins 2 2 None No generic available Depo-Testosterone* Androgens 3 3 PA Testosterone Cypionate Dermacort; Hytone (Rx Only)* Corticosteroids - low potency 3 3 None Hydrocortisone Derma-Smoothe/FS* Corticosteroids - low potency 3 3 None Fluocinolone Acetonide Dermatop* Corticosteroids - medium potency 3 3 None Prednicarbate

Descovy Antiretrovirals 2 2 QL No generic available Desferal* Chelating Agents 3 3 None Deferoxamine Mesylate Desipramine Hcl Antidepressants 1 1 None This medication is generic Desloratadine Antihistamines 1 1 QL This medication is generic Desmopressin Acetate Miscellaneous endocrine 1 1 None This medication is generic Desogen; Ortho-cept* Contraceptives-Monophasic 3 3 None Isibloom Desogestrel-Ethinyl Estradiol Contraceptives-Monophasic/Triphasic Free As Free As None This medication is generic Preventive Preventive Desog-Et Estra/Ethin Estra Contraceptives-Biphasic Free As Free As None This medication is generic Preventive Preventive Desonate Corticosteroids - low potency 3 3 None No generic available Desonide Corticosteroids - low potency 1 1 None This medication is generic Desowen* Corticosteroids - low potency 3 3 None Desonide Desoximetasone Corticosteroids - medium potency/High 1 1 None This medication is generic potency Desoxyn* CNS stimulants 3 3 None Methamphetamine Hcl

Updated 11/13/2017 Drug name Category of drug Choices Tier ABC Tier Limits Generic equivalent if available Desvenlafaxine ER Antidepressants 3 3 ST, QL No generic available Desvenlafaxine Fumarate ER Antidepressants 3 3 ST, QL No generic available Desyrel* Antidepressants 3 3 None Trazodone Hcl Detrol, LA* Urinary Antispasmodics 3 3 None Tolterodine Tartrate Dexamethasone Corticosteroids 1 1 None This medication is generic Dexamethasone Sod Phosphate Ophthalmic steroids 1 1 None This medication is generic Dexedrine* CNS stimulants 3 3 None D-Amphetamine Sulfate Dexilant Proton Pump Inhibitors (PPI) 3 3 ST No generic available Dexmethylphenidate Hcl CNS stimulants 1 1 None This medication is generic Dhcodeine Bt/Acetaminophn/Caff Narcotic and analgesic combinations 1 1 None This medication is generic

Diabeta; Micronase* Non-insulin hypoglycemic agents 3 3 None Glyburide

Diabinese* Non-insulin hypoglycemic agents 3 3 None Chlorpropamide

Diamox, Sequels* Diuretics/Anticonvulsants 3 3 None Acetazolamide Diastat 2.5mg Kit Anticonvulsants 2 2 None No generic available Diastat Acudial* Anticonvulsants 3 3 None Diazepam Diazepam Anxiolytics/Anticonvulsant/Skeletal 1 1 None This medication is generic muscle relaxants Dibenzyline* Alpha-adrenergic agents 3 3 PA, QL Phenoxybenzamine Hcl Diclegis Antiemetics/Miscellaneous OB-GYN 3 3 PA, QL No generic available

Diclofenac Potassium Nonsteroidal anti-inflammatory drugs 1 1 None This medication is generic

Diclofenac Sodium (generic Pennsaid 1.5%) Nonsteroidal anti-inflammatory drugs 1 1 QL This medication is generic

Diclofenac Sodium (generic Solaraze) Miscellaneous dermatologicals 1 1 PA, QL This medication is generic

Diclofenac Sodium (generic Voltaren Nonsteroidal anti-inflammatory 1 1 None This medication is generic drops/tablet/XR) drugs/Ophthalmic anti-inflammatory agents Diclofenac Sodium (generic Voltaren gel) Nonsteroidal anti-inflammatory drugs 1 1 PA, QL This medication is generic

Diclofenac Sodium/Misoprostol Nonsteroidal anti-inflammatory drugs 1 1 None This medication is generic

Dicloxacillin Sodium Penicillins 1 1 None This medication is generic Dicloxacillin* Penicillins 3 3 None Dicloxacillin Sodium Dicyclomine Hcl Antidiarrheals and antispasmodics 1 1 None This medication is generic

Didanosine Antiretrovirals 1 1 None This medication is generic Didrex* Weight Loss Preparations 3 3 None Benzphetamine Hcl Didronel* Osteoporosis and bone resorption 3 3 QL Etidronate Disodium

Diethylpropion Hcl Weight Loss Preparations 1 Free As None This medication is generic Preventive Diethylpropion hcl, ER* Weight Loss Preparations 3 3 None Diethylpropion Hcl Differin 0.1% lotion Acne treatment 3 3 None No generic available Differin* Acne treatment 3 3 None Adapalene Dificid Macrolides 3 3 QL No generic available Diflorasone Diacetate Corticosteroids - high potency 1 1 None This medication is generic Diflucan* Antifungals/Vaginal anti-infective and 3 3 None Fluconazole antifungal Diflunisal Salicylates 1 1 None This medication is generic Digoxin Cardiovascular treatment 1 1 None This medication is generic Dihydrocodeine/Aspirin/Caffein Narcotic and analgesic combinations 1 1 None This medication is generic

Dihydroergotamine Mesylate Migraine therapy 1 1 None This medication is generic Dihydroergotamine Mesylate (generic Migraine therapy 1 1 QL This medication is generic Migranal) Dilantin 30mg capsule Anticonvulsants 2 2 None No generic available Dilantin* Anticonvulsants 3 3 None Phenytoin Dilantin; Phenytek capsule 100mg* Anticonvulsants 3 3 None Phenytoin Sodium Extended Dilantin; Phenytek capsule 200mg, 300mg* Anticonvulsants 3 3 None Phenytoin Sodium Extended

Dilatrate-SR Nitrates and combinations 2 2 None No generic available Dilaudid* Narcotics 3 3 None Hydromorphone Hcl Diltiazem Hcl Calcium channel blockers and 1 Free As None This medication is generic combinations Preventive Diovan HCT* Angiotensin II Receptor Blockers and 3 3 None Valsartan/Hydrochlorothiazide combinations

Updated 11/13/2017 Drug name Category of drug Choices Tier ABC Tier Limits Generic equivalent if available Diovan* Angiotensin II Receptor Blockers and 3 3 None Valsartan combinations Dipentum 5-Aminosalicylic Acid (5-ASA) agents 3 3 None No generic available

Diphenhydramine Hcl Antihistamines 1 1 None This medication is generic Diphenoxylate Hcl/Atrop Sulf Antidiarrheals and antispasmodics 1 1 None This medication is generic

Diprolene AF, gel, cream, lotion* Corticosteroids - high potency 3 3 None Betamet Diprop/Prop Gly Diprolene ointment* Corticosteriods - very high potency 3 3 None Betamet Diprop/Prop Gly

Diprosone; Maxivate* Corticosteroids - high potency 3 3 None Betamethasone Dipropionate Dipyridamole Anticoagulants and hemostasis agents 1 1 None This medication is generic

Disalcid* Salicylates 3 3 None Salsalate Disopyramide Phosphate Cardiovascular treatment 1 1 None This medication is generic Disulfiram Miscellaneous CNS 1 Free as None This medication is generic preventive Ditropan, XL* Urinary Antispasmodics 3 3 None Oxybutynin Chloride Diuril capsule, tablet* Diuretics 3 3 None Chlorothiazide Diuril suspension Diuretics 3 3 None No generic available Divalproex Sodium Anticonvulsants 1 1 None This medication is generic Divigel Estrogens 3 3 QL No generic available D-Methorphan Hb/P-Epd Hcl/Bpm Antitussives 1 1 None This medication is generic D-Methorphan Hb/Prometh Hcl Antitussives 1 1 None This medication is generic Dofetilide Cardiovascular treatment 1 1 None This medication is generic Dolobid* Salicylates 3 3 None Diflunisal Domeboro Otic* Otic preparations 3 3 None Acetic Acid/Aluminum Acetate Donepezil Hcl Alzheimer's therapy 1 1 None This medication is generic Donepezil Hcl (generic Aricept 23mg) Alzheimer's therapy 1 1 QL This medication is generic

Donnatal, Extentabs Antidiarrheals and antispasmodics 3 3 None No generic available

Doral* Sedative and hypnotics 3 3 QL Quazepam Doryx MPC Tetracyclines/Acne treatment 3 3 PA No generic available Doryx* Tetracyclines/Acne treatment 3 3 PA Doxycycline Hyclate Dorzolamide Hcl Glaucoma agents 1 1 None This medication is generic Dostinex* Miscellaneous endocrine 3 3 None Cabergoline Dovonex* Antipsoriatic and antiseborrheic 3 3 None Calcipotriene Doxazosin Mesylate Alpha-adrenergic agents/BPH 1 Free As None This medication is generic treatment Preventive Doxepin Hcl Antidepressants/Misc. dermatologicals 1 1 None This medication is generic

Doxercalciferol Vitamin D analogs 1 1 None This medication is generic Doxycycline 20mg tablet* Acne treatment 3 3 None Doxycycline Hyclate Doxycycline Hyclate (generic Vibramycin) Tetracyclines 1 1 None This medication is generic

Doxycycline Hyclate 150 mg tablet Tetracyclines 1 1 PA, QL This medication is generic Doxycycline Hyclate 75 mg tablet Tetracyclines 1 1 PA This medication is generic Doxycycline Hyclate (generic Doryx) Tetracyclines/Acne treatment 1 1 PA This medication is generic Doxycycline IR-DR Tetracyclines/Acne treatment 3 3 PA No generic available Doxycycline Monohydrate Tetracyclines 1 1 None This medication is generic Doxycycline Monohydrate (generic Adoxa) Tetracyclines/Acne treatment 1 1 PA This medication is generic

Dronabinol Antiemetics 1 1 None This medication is generic Drospir/Eth Estra/Levomefol Ca Contraceptives-Monophasic Free As Free As None This medication is generic Preventive Preventive Droxia Miscellaneous antineoplastic agents 2 2 None No generic available

Drysol* Miscellaneous dermatologicals 3 3 None Aluminum Chloride Duac* Acne treatment 3 3 None Clindamycin Phosphate/Benz Per Duavee Miscellaneous OB-GYN/Osteoporosis 3 3 None No generic available and hormonal treatment

Duetact* Non-insulin hypoglycemic agents 3 3 None Pioglitazone/Glimepiride

Dulera Inhaled steroid and beta-agonist 2 2 QL No generic available combinations Duloxetine Hcl Antidepressants 1 1 None This medication is generic Duoneb* Inhaled beta-agonist and 3 3 None Ipratropium/Albuterol Sulfate anticholinergic Duopa Parkinsons disease and related 2 2 PA, QL No generic available disorders

Updated 11/13/2017 Drug name Category of drug Choices Tier ABC Tier Limits Generic equivalent if available Dupixent Miscellaneous dermatologicals 3 3 PA No generic available Duragesic* Narcotics 3 3 None Fentanyl Durezol Ophthalmic steroids 3 3 None No generic available Duricef* Cephalosporins 3 3 None Cefadroxil Hydrate Dutasteride BPH Treatment 1 1 None This medication is generic Dutasteride/Tamsulosin Hcl BPH Treatment 1 1 QL This medication is generic Dutoprol Beta blockers and 3 Free As None No generic available combinations/Diuretics Preventive Dyanavel XR CNS stimulants 3 3 PA, QL No generic available Dyazide, Maxzide* Diuretics 3 3 None Triamterene/Hydrochlorothiazide Dymista Nasal preparations 3 3 PA, QL No generic available Dynacirc* Calcium channel blockers and 3 3 None Isradipine combinations Dyrenium Diuretics 2 Free As None No generic available Preventive EC-Naprosyn* Nonsteroidal anti-inflammatory drugs 3 3 None Naproxen

Econazole Nitrate Topical antifungals 1 1 None This medication is generic Ecoza Topical antifungals 3 3 PA, QL No generic available Edarbi Angiotensin II Receptor Blockers and 3 Free As ST, QL No generic available combinations Preventive Edarbyclor Angiotensin II Receptor Blockers and 3 Free As ST, QL No generic available combinations Preventive Edecrin* Diuretics 3 3 None Ethacrynic Acid Edex Sexual Dysfunction 3 3 QL No generic available Edluar Sedative and hypnotics 3 3 ST, QL No generic available Edurant Antiretrovirals 2 2 QL No generic available Effexor, XR* Antidepressants 3 3 None Venlafaxine Hcl Effient* Anticoagulants and hemostasis agents 2 2 None Prasugrel

Efudex* Topical antineoplastic agents and 3 3 None Fluorouracil immunomodulators Egrifta Miscellaneous endocrine 3 3 PA, QL No generic available Elavil* Antidepressants 3 3 None Amitriptyline Hcl Eldepryl* Parkinsons disease and related 3 3 None Selegiline Hcl disorders Elestat* Ophthalmic anti-allergy agents 3 3 None Epinastine Hcl Elestrin Estrogens 3 3 QL No generic available Elidel Topical antineoplastic agents and 2 2 None No generic available immunomodulators Eligard Hormonal agents 3 3 None No generic available Elimite* Scabicides and pediculicides 3 3 None Permethrin Eliquis Anticoagulants and hemostasis agents 2 2 QL No generic available

Ella Contraceptives-Postcoital Free As Free As QL No generic available Preventive Preventive Elmiron Miscellaneous Urologicals 2 2 None No generic available Elocon cream, solution* Corticosteroids - medium potency 3 3 None Mometasone Furoate

Elocon ointment* Corticosteroids - high potency 3 3 None Mometasone Furoate Emadine Ophthalmic anti-allergy agents 3 3 None No generic available Embeda Narcotics 3 3 PA, QL No generic available Emcyt Alkylating agents 2 2 None No generic available Emend 40mg Antiemetics 2 2 None No generic available Emend 80, 125mg; dosepak capsule Antiemetics 2 2 None No generic available Emend suspension Antiemetics 2 2 PA, QL No generic available Emflaza suspension DMD 3 3 PA No generic available Emflaza tablet DMD 3 3 PA No generic available Emla* Topical anesthetics 3 3 None Lidocaine/Prilocaine Emsam Antidepressants 3 3 None No generic available Emtriva Antiretrovirals 2 2 None No generic available Emverm Antiparasitics and anthelmintics 3 3 QL No generic available Enablex* Urinary Antispasmodics 3 3 QL Darifenacin Hydrobromide Enalapril Maleate ACE-Inhibitors and combinations 1 Free As None This medication is generic Preventive Enalapril/Hydrochlorothiazide ACE-Inhibitors and combinations 1 Free As None This medication is generic Preventive Enbrel Tumor Necrosis Factor (TNF) blocking 2 2 PA, QL No generic available agents/Antipsoriatic and antiseborrheic

Endometrin Infertility treatment 2 2 None No generic available Enduron* Diuretics 3 3 None Methyclothiazide

Updated 11/13/2017 Drug name Category of drug Choices Tier ABC Tier Limits Generic equivalent if available Enoxaparin Sodium Anticoagulants and hemostasis agents 1 1 None This medication is generic

Enstilar Antipsoriatic and antiseborrheic 3 3 QL No generic available Entacapone Parkinsons disease and related 1 1 None This medication is generic disorders Entecavir Antivirals 1 1 None This medication is generic Entocort EC* Corticosteroids 3 3 None Budesonide Entresto Angiotensin II Receptor Blockers and 3 3 PA, QL No generic available combinations Envarsus XR Immunomodulators 3 3 None No generic available Epaned ACE-Inhibitors and combinations 3 3 None No generic available Epclusa Antivirals 2 2 PA, QL No generic available Epiduo* Acne treatment 3 3 None Adapalene-Benzoyl Peroxide Epiduo Forte Acne treatment 3 3 PA, QL No generic available Epifoam Topical anti-Inflammatory agents 3 3 None No generic available

Epinastine Hcl Ophthalmic anti-allergy agents 1 1 None This medication is generic Epinephrine auto-injector Epinephrine 2 2 QL No generic available Epivir HBV solution Antivirals 2 2 None No generic available Epivir HBV tablet* Antivirals 3 3 None Lamivudine Epivir* Antiretrovirals 3 3 None Lamivudine Eplerenone Diuretics 1 Free As None This medication is generic Preventive Epogen Adjuvant therapy/Hematopoietic 3 3 PA No generic available agents Eprosartan Mesylate Angiotensin II Receptor Blockers and 1 Free As None This medication is generic combinations Preventive Epzicom* Antiretrovirals 3 3 None Abacavir Sulfate/Lamivudine Equanil; Miltown* Anxiolytics 3 3 None Meprobamate Equetro Anticonvulsants/Antipsychotics 3 3 None No generic available Ergocalciferol Vitamins and Minerals 1 1 None This medication is generic Ergoloid Mesylates Miscellaneous CNS 1 1 None This medication is generic Ergotamine Tartrate/Caffeine Migraine therapy 1 1 None This medication is generic Erivedge Miscellaneous antineoplastic agents 2 2 PA, QL No generic available

Ertaczo Topical antifungals 3 3 None No generic available Eryped suspension 200mg/5ml, 400mg/5ml Macrolides 3 3 None No generic available

Eryped tablet* Macrolides 3 3 None Erythromycin Ethylsuccinate Ery-Tab 500mg Macrolides 3 3 None No generic available Ery-Tab* Macrolides 3 3 None Erythromycin Erythromycin Macrolides 1 1 None This medication is generic Erythromycin Base Macrolides 1 1 None This medication is generic Erythromycin Base/Benz Per Acne treatment 1 1 None This medication is generic Erythromycin Base/Ethanol Acne treatment 1 1 None This medication is generic Erythromycin Ethylsuccinate Macrolides 1 1 None This medication is generic Erythromycin Stearate Macrolides 1 1 None This medication is generic Erythromycin topical gel, solution Acne treatment 1 1 None This medication is generic Esbriet Miscellaneous respiratory agents 2 2 PA, QL No generic available

Escitalopram Oxalate Antidepressants 1 1 None This medication is generic Esgic* Migraine therapy/Narcotic and 3 3 None Butalb/Acetaminophen/Caffeine analgesic combinations Eskalith, CR* Miscellaneous CNS 3 3 None Lithium Carbonate Esomeprazole Magnesium Proton Pump Inhibitors (PPI) 1 1 ST This medication is generic Estazolam Sedative and hypnotics 1 1 QL This medication is generic Estrace tablet* Estrogens/Osteoporosis and hormonal 3 3 None Estradiol treatment Estrace vaginal cream Estrogens 3 3 None No generic available Estradiol Estrogens 1 1 None This medication is generic Estradiol (generic Climara) Estrogens/Osteoporosis and hormonal 1 1 QL This medication is generic treatment Estradiol (generic Vivelle-dot) Estrogens/Osteoporosis and hormonal 1 1 QL This medication is generic treatment Estradiol Valerate Estrogens 1 1 None This medication is generic Estradiol/Norethindrone Acet Estrogen and progestin combinations 1 1 None This medication is generic

Estring Estrogens 2 2 QL No generic available Estrogel Estrogens 3 3 QL No generic available Estrogen,Ester/Me-Testosterone Miscellaneous OB-GYN/Osteoporosis 1 1 None This medication is generic hormonal treatment

Updated 11/13/2017 Drug name Category of drug Choices Tier ABC Tier Limits Generic equivalent if available Estropipate Estrogens/Osteoporosis and hormonal 1 1 None This medication is generic treatment Estrostep Fe* Contraceptives-Triphasic 3 3 None Noreth A-Et Estra/Fe Fumarate Eszopiclone Sedative and hypnotics 1 1 QL This medication is generic Ethacrynic Acid Diuretics 1 Free As None This medication is generic Preventive Ethambutol Hcl Antituberculars 1 1 None This medication is generic Ethambutol* Antituberculars 3 3 None Ethambutol Hcl Ethinyl Estradiol/Drospirenone Contraceptives-Monophasic Free As Free As None This medication is generic Preventive Preventive Ethosuximide Anticonvulsants 1 1 None This medication is generic Ethynodiol D-Ethinyl Estradiol Contraceptives-Monophasic Free As Free As None This medication is generic Preventive Preventive Etidronate Disodium Osteoporosis and bone resorption 1 1 QL This medication is generic

Etodolac Nonsteroidal anti-inflammatory drugs 1 1 None This medication is generic

Etoposide Miscellaneous antineoplastic agents 1 1 None This medication is generic

Etrafon* Antidepressants/Antipsychotics 3 3 None Amitriptyline Hcl/Perphenazine Eulexin* Hormonal agents 3 3 None Flutamide Eurax Scabicides and pediculicides 2 2 None No generic available Evamist Estrogens 3 3 None No generic available Evekeo CNS stimulants 3 3 PA, QL No generic available Evista (Preventive)* Hormonal agents Free As Free As PA, QL Raloxifene Hcl Preventive Preventive Evista* Hormonal agents 3 3 PA, QL Raloxifene Hcl Evoclin foam* Acne treatment 3 3 None Clindamycin Phosphate Evotaz Antiretrovirals 2 2 QL No generic available Evoxac* Miscellaneous gastrointestinal agents 3 3 None Cevimeline Hcl

Exalgo* Narcotics 3 3 QL Hydromorphone Hcl Exelderm Topical antifungals 3 3 None No generic available Exelon capsule* Alzheimer's therapy 3 3 None Rivastigmine Tartrate Exelon patch* Alzheimer's therapy 3 3 None Rivastigmine Exemestane Hormonal agents 1 1 PA This medication is generic Exforge HCT* Angiotensin II Receptor Blockers and 3 3 None Amlodipine/Valsartan/Hctz combinations/Calcium channel blockers and combinations

Exforge* Angiotensin II Receptor Blockers and 3 3 None Amlodipine/Valsartan combinations/Calcium channel blockers and combinations

Exjade Chelating Agents 3 3 PA No generic available Extavia Interferons and MS therapy 3 3 None No generic available Extina* Topical antifungals 3 3 None Ketoconazole Ez Flu (Afluria) Vaccines Free As Free As None No generic available Preventive Preventive Vaccine Vaccine Ez Flu (Fluvirin) Vaccines Free As Free As None No generic available Preventive Preventive Vaccine Vaccine Ez Flu (Fluzone) Vaccines Free As Free As None No generic available Preventive Preventive Vaccine Vaccine Ezetimibe Lipid-lowering agents 1 Free As QL This medication is generic Preventive Fabior Acne treatment 3 3 ST, QL No generic available Factive Quinolones 3 3 None No generic available Famciclovir Antivirals 1 1 None This medication is generic Famotidine H2-Receptor antagonists 1 1 None This medication is generic Famvir* Antivirals 3 3 None Famciclovir Fanapt Antipsychotics 3 3 ST No generic available Fareston Hormonal agents 2 2 None No generic available Farxiga Non-insulin hypoglycemic agents 2 2 PA, QL No generic available

Farydak Miscellaneous antineoplastic agents 2 2 PA, QL No generic available

Faslodex Hormonal agents 3 3 None No generic available Fazaclo 150, 200mg Antipsychotics 3 3 None No generic available Fazaclo* Antipsychotics 3 3 None Clozapine

Updated 11/13/2017 Drug name Category of drug Choices Tier ABC Tier Limits Generic equivalent if available FC2 Female Condom Contraceptives-Misc. Free As Free As QL No generic available Preventive Preventive Felbamate Anticonvulsants 1 1 None This medication is generic Felbatol* Anticonvulsants 3 3 None Felbamate Feldene* Nonsteroidal anti-inflammatory drugs 3 3 None Piroxicam

Felodipine Calcium channel blockers and 1 Free As None This medication is generic combinations Preventive Femara* Hormonal agents 3 3 PA Letrozole Femcon Fe* Contraceptives-Monophasic 3 3 None Noreth-Ethinyl Estradiol/Iron FemHRT* Estrogen and progestin 3 3 None Norethindrone Ac-Eth Estradiol combinations/Osteoporosis and hormonal treatment Femring Estrogens 3 3 QL No generic available Fenofibrate Lipid-lowering agents 1 Free As None This medication is generic Preventive Fenofibrate capsule Lipid-lowering agents 3 3 None No generic available Fenofibrate Nanocrystallized Lipid-lowering agents 1 1 None This medication is generic Fenofibrate,Micronized Lipid-lowering agents 1 1 None This medication is generic Fenofibric Acid Lipid-lowering agents 1 Free As None This medication is generic Preventive Fenofibric Acid (Choline) Lipid-lowering agents 1 1 None This medication is generic Fenoglide* Lipid-lowering agents 3 3 None Fenofibrate Fenoprofen Calcium Nonsteroidal anti-inflammatory drugs 1 1 None This medication is generic

Fenoprofen Calcium 200mg, 400mg Nonsteroidal anti-inflammatory drugs 3 3 None No generic available

Fenortho Nonsteroidal anti-inflammatory drugs 3 3 None No generic available

Fentanyl Narcotics 1 1 None This medication is generic Fentanyl Citrate Narcotics 1 1 PA, QL This medication is generic Fentanyl patch 37.5, 62.5, 87.5mg Narcotics 3 3 None No generic available Fentora Narcotics 3 3 PA, QL No generic available Ferriprox Chelating Agents 3 3 PA, QL No generic available Fetzima Antidepressants 3 3 ST, QL No generic available Fexmid* Skeletal muscle relaxants 3 3 None Cyclobenzaprine Hcl Fibricor* Lipid-lowering agents 3 3 None Fenofibric Acid Finacea foam Miscellaneous dermatologicals 3 3 ST, QL No generic available Finacea gel Miscellaneous dermatologicals 3 3 None No generic available Finasteride BPH Treatment 1 1 None This medication is generic Fioricet 50/300/40mg capsule* Migraine therapy/Narcotic and 3 3 None Butalbit/Acetamin/Caff/Codeine analgesic combinations Fioricet w/codeine 50/300/30mg* Migraine therapy/Narcotic and 3 3 None Butalbit/Acetamin/Caff/Codeine analgesic combinations Fiorinal w/codeine* Migraine therapy/Narcotic and 3 3 None Codeine/Butalbital/Asa/Caffein analgesic combinations Fiorinal* Migraine therapy/Narcotic and 3 3 None Butalbital/Aspirin/Caffeine analgesic combinations Firazyr Miscellaneous immunology and 3 3 PA, QL No generic available hematology Flagyl ER Antiparasitics and anthelmintics 2 2 None No generic available Flagyl* Antiparasitics and anthelmintics 3 3 None Metronidazole Flavoxate Hcl Urinary Antispasmodics 1 1 None This medication is generic Flecainide Acetate Cardiovascular treatment 1 1 None This medication is generic Flector patch Nonsteroidal anti-inflammatory drugs 3 3 PA, QL No generic available

Flexeril* Skeletal muscle relaxants 3 3 None Cyclobenzaprine Hcl Flomax* BPH Treatment 3 3 None Tamsulosin Hcl Flonase (Rx only)* Nasal preparations 3 3 QL Fluticasone Propionate Florinef* Corticosteroids 3 3 None Fludrocortisone Acetate Florone; Psorcon* Corticosteroids - high potency 3 3 None Diflorasone Diacetate Flovent HFA, Diskus Inhaled steroids 2 2 QL No generic available Flowtuss Antitussives 3 3 QL No generic available Floxin Otic Singles Otic preparations 3 3 None No generic available Floxin Otic* Otic preparations 3 3 None Ofloxacin Floxin tablet* Quinolones 3 3 None Ofloxacin Fluad Vaccines Free As Free As None No generic available Preventive Preventive Vaccine Vaccine Fluarix Quad Vaccines Free As Free As None No generic available Preventive Preventive Vaccine Vaccine

Updated 11/13/2017 Drug name Category of drug Choices Tier ABC Tier Limits Generic equivalent if available Flublok 2016-2017 Vaccines Free As Free As None No generic available Preventive Preventive Vaccine Vaccine Fluconazole Vaginal anti-infective and antifungal 1 1 None This medication is generic

Flucytosine Antifungals 1 1 None This medication is generic Fludrocortisone Acetate Corticosteroids 1 1 None This medication is generic Flulaval Quad Vaccines Free As Free As None No generic available Preventive Preventive Vaccine Vaccine Flumadine* Antivirals 3 3 None Rimantadine Hcl Flunisolide 0.025% Spray Nasal preparations 1 1 QL This medication is generic Fluocinolone Acetonide Corticosteroids - low potency/medium 1 1 None This medication is generic potency Fluocinonide Corticosteroids - high potency/very 1 1 None This medication is generic high potency Fluoride 0.25, 0.5mg drops* Vitamins and Minerals Free As Free As None Sodium Fluoride Preventive Preventive Fluorometholone Ophthalmic steroids 1 1 None This medication is generic Fluoroplex Topical antineoplastic agents and 3 3 None No generic available immunomodulators Fluorouracil Topical antineoplastic agents and 1 1 None This medication is generic immunomodulators Fluorouracil 0.5% cream Topical antineoplastic agents and 3 3 PA, QL No generic available immunomodulators Fluoxetine 60mg Antidepressants 3 3 QL No generic available Fluoxetine Hcl Antidepressants 1 1 None This medication is generic Fluoxetine Hcl (generic Prozac weekly) Antidepressants 1 1 QL This medication is generic

Fluoxymesterone Androgens 1 1 PA, QL This medication is generic Fluphenazine Hcl Antipsychotics 1 1 None This medication is generic Flurandrenolide Corticosteroids - medium potency 1 1 None This medication is generic

Flurazepam Hcl Sedative and hypnotics 1 1 QL This medication is generic Flurbiprofen Nonsteroidal anti-inflammatory drugs 1 1 None This medication is generic

Flurbiprofen Sodium Ophthalmic anti-inflammatory agents 1 1 None This medication is generic

Flutamide Hormonal agents 1 1 None This medication is generic Fluticasone Propionate Corticosteroids - medium potency 1 1 None This medication is generic

Fluticasone Propionate (generic Flonase) Nasal preparations 1 1 QL This medication is generic

Fluvastatin Sodium Lipid-lowering agents 1 Free As QL This medication is generic Preventive Fluvirin Vaccines Free As Free As None No generic available Preventive Preventive Vaccine Vaccine Fluvoxamine Maleate Antidepressants 1 1 None This medication is generic Fluzone (all) Vaccines Free As Free As None No generic available Preventive Preventive Vaccine Vaccine Fluzone Quad (all) Vaccines Free As Free As None No generic available Preventive Preventive Vaccine Vaccine FML Forte, S.O.P. Ophthalmic steroids 2 2 None No generic available FML* Ophthalmic steroids 3 3 None Fluorometholone Focalin immediate release* CNS stimulants 3 3 None Dexmethylphenidate Hcl Focalin XR 25, 35mg CNS stimulants 3 3 None No generic available Focalin XR* CNS stimulants 3 3 None Dexmethylphenidate Hcl Folic Acid Vitamins and Minerals 1 1 None This medication is generic Folic Acid (Preventive) Vitamins and Minerals Free As Free As None This medication is generic Preventive Preventive Folic Acid 0.4, 0.8mg [OTC]* Vitamins and Minerals Free As Free As None Folic Acid Preventive Preventive Folic Acid 1mg* Vitamins and Minerals 3 3 None Folic Acid Follistim AQ Infertility treatment 3 3 PA No generic available Folvite* Vitamins and Minerals 3 3 None Folic Acid Fondaparinux Sodium Anticoagulants and hemostasis agents 1 1 None This medication is generic

Foradil Inhaled beta-agonists 2 2 QL No generic available Forfivo XL Antidepressants 3 3 ST, QL No generic available

Updated 11/13/2017 Drug name Category of drug Choices Tier ABC Tier Limits Generic equivalent if available Fortamet* Non-insulin hypoglycemic agents 3 3 None Metformin Hcl

Forteo Osteoporosis and hormonal treatment 3 3 PA, QL No generic available

Fortesta Androgens 3 3 PA, QL No generic available Fosamax Plus D Osteoporosis and bone resorption 3 3 ST, QL No generic available

Fosamax* Osteoporosis and bone resorption 3 3 QL Alendronate Sodium

Fosamprenavir Calcium HIV 1 1 None This medication is generic Fosinopril Sodium ACE-Inhibitors and combinations 1 Free As None This medication is generic Preventive Fosinopril/Hydrochlorothiazide ACE-Inhibitors and combinations 1 Free As None This medication is generic Preventive Fosrenol* Ion-Removing Agents 3 3 None Lanthanum Carbonate Fragmin Anticoagulants and hemostasis agents 3 3 None No generic available

Frova* Migraine therapy 3 3 ST, QL Frovatriptan Succinate Frovatriptan Succinate Migraine therapy 1 1 ST, QL This medication is generic Furadantin* Urinary tract agents 3 3 None Nitrofurantoin Furosemide Diuretics 1 Free As None This medication is generic Preventive Furosemide solution Diuretics 3 3 None No generic available Fuzeon Antiretrovirals 2 2 None No generic available Fycompa suspension Anticonvulsants 3 3 PA, QL No generic available Fycompa tablet Anticonvulsants 3 3 PA, QL No generic available Gabapentin Anticonvulsants 1 1 None This medication is generic Gabitril 12, 16mg Anticonvulsants 2 2 None No generic available Gabitril* Anticonvulsants 3 3 None Tiagabine Hcl Galantamine Hydrobromide Alzheimer's therapy 1 1 None This medication is generic Galzin Vitamins and Minerals 3 3 None No generic available Gammagard liquid Immunoglobulins 3 3 PA No generic available Gammaked liquid Immunoglobulins 3 3 PA No generic available Gamunex-C sub-q Immunoglobulins 3 3 PA No generic available Ganirelix Acetate Infertility treatment 2 2 None No generic available Garamycin* Ophthalmic anti-infectives 3 3 None Gentamicin Sulfate Gardasil, 9 Vaccines Free As Free As None No generic available Preventive Preventive Vaccine Vaccine Gastrocrom* Miscellaneous gastrointestinal agents 3 3 None Cromolyn Sodium

Gatifloxacin Ophthalmic anti-infectives 1 1 None This medication is generic Gattex Miscellaneous gastrointestinal agents 2 2 PA, QL No generic available

Gelnique packet Urinary Antispasmodics 3 3 ST, QL No generic available Gelnique pump Urinary Antispasmodics 3 3 ST, QL No generic available Gemfibrozil Lipid-lowering agents 1 Free As None This medication is generic Preventive Generess Fe* Contraceptives-Monophasic 3 3 None Noreth-Ethinyl Estradiol/Iron Gengraf; Neoral* Miscellaneous rheumatologic 3 3 None Cyclosporine, Modified agents/Immunomodulators Genotropin Growth Hormone and related products 2 2 PA No generic available

Gentamicin cream, ointment* Topical antibacterials 3 3 None Gentamicin Sulfate Gentamicin Sulfate Topical antibacterials 1 1 None This medication is generic Genvoya Antiretrovirals 2 2 QL No generic available Geodon* Antipsychotics 3 3 None Ziprasidone Hcl Giazo 5-Aminosalicylic Acid (5-ASA) agents 3 3 ST, QL No generic available

Gilenya Interferons and MS therapy 2 2 PA, QL No generic available Gilotrif Kinase inhibitors and molecular target 2 2 PA, QL No generic available inhibitors Glatiramer Acetate Interferons and MS therapy 1 1 None This medication is generic Glatopa* Interferons and MS therapy 3 3 None Glatiramer Acetate Gleevec* Kinase inhibitors and molecular target 3 3 None Imatinib Mesylate inhibitors Gleostine; Lomustine Alkylating agents 2 2 None No generic available Glimepiride Non-insulin hypoglycemic agents 1 1 None This medication is generic

Glipizide Non-insulin hypoglycemic agents 1 1 None This medication is generic

Updated 11/13/2017 Drug name Category of drug Choices Tier ABC Tier Limits Generic equivalent if available Glipizide/Metformin Hcl Non-insulin hypoglycemic agents 1 1 None This medication is generic

GlucaGen Miscellaneous endocrine 3 3 None No generic available Glucagon Emergency Kit Miscellaneous endocrine 2 2 None No generic available Glucophage, XR* Non-insulin hypoglycemic agents 3 3 None Metformin Hcl

Glucotrol, XL* Non-insulin hypoglycemic agents 3 3 None Glipizide

Glucovance* Non-insulin hypoglycemic agents 3 3 None Glyburide/Metformin Hcl

Glumetza* Non-insulin hypoglycemic agents 3 3 ST Metformin Hcl

Glyburide Non-insulin hypoglycemic agents 1 1 None This medication is generic

Glyburide,Micronized Non-insulin hypoglycemic agents 1 1 None This medication is generic

Glyburide/Metformin Hcl Non-insulin hypoglycemic agents 1 1 None This medication is generic

Glycolax OTC* Bowel preparation and cleansing Free As Free As QL Polyethylene Glycol 3350 agents Preventive Preventive Glycolax* Bowel preparation and cleansing 3 3 None Polyethylene Glycol 3350 agents Glycopyrrolate Ulcer therapy 1 1 None This medication is generic Glynase* Non-insulin hypoglycemic agents 3 3 None Glyburide,Micronized

Glyset* Non-insulin hypoglycemic agents 3 3 None Miglitol

Glyxambi Non-insulin hypoglycemic agents 3 3 PA, QL No generic available

Golytely (Preventive)* Bowel preparation and cleansing Free As Free As QL Peg 3350/Na Sulf,Bicarb,Cl/Kcl agents Preventive Preventive Golytely flavored Bowel preparation and cleansing 2 2 None No generic available agents Golytely* Bowel preparation and cleansing 3 3 None Peg 3350/Na Sulf,Bicarb,Cl/Kcl agents Gonal-F, RFF, Redi-Ject Infertility treatment 2 2 None No generic available GoNitro Nitrates and combinations 3 3 None No generic available Gralise Miscellaneous CNS 3 3 ST, QL No generic available Granisetron Hcl Antiemetics 1 1 None This medication is generic Granix Adjuvant therapy/Hematopoietic 2 2 None No generic available agents Grastek Miscellaneous respiratory agents 3 3 PA, QL No generic available

Grifulvin V* Antifungals 3 3 None Griseofulvin,Microsize Griseofulvin Ultramicrosize Antifungals 1 1 None This medication is generic Griseofulvin,Microsize Antifungals 1 1 None This medication is generic Gris-PEG* Antifungals 3 3 None Griseofulvin Ultramicrosize Guaifenesin/Codeine Phosphate Antitussives 1 1 None This medication is generic Guanfacine Hcl Alpha-adrenergic agents 1 Free As None This medication is generic Preventive Guanfacine Hcl (generic Intuniv) Miscellaneous CNS 1 1 QL This medication is generic Gynazole-1 Vaginal anti-infective and antifungal 3 3 None No generic available

Gynol II* Contraceptives-Misc. Free As Free As QL Nonoxynol 9 Preventive Preventive Halcion* Sedative and hypnotics 3 3 QL Triazolam Haldol liquid* Antipsychotics 3 3 None Haloperidol Lactate Haldol tablet* Antipsychotics 3 3 None Haloperidol Halflytely (Preventive)* Bowel preparation and cleansing Free As Free As QL Bisac/Nacl/Nahco3/Kcl/Peg 3350 agents Preventive Preventive Halflytely* Bowel preparation and cleansing 3 3 None Bisac/Nacl/Nahco3/Kcl/Peg 3350 agents Halobetasol Propionate Corticosteriods - very high potency 1 1 None This medication is generic

Halog Corticosteroids - high potency 3 3 None No generic available Haloperidol Antipsychotics 1 1 None This medication is generic Haloperidol Lactate Antipsychotics 1 1 None This medication is generic Harvoni Antivirals 3 3 PA, QL No generic available Hectorol* Vitamin D analogs 3 3 None Doxercalciferol Hemangeol Beta blockers and combinations 3 3 PA, QL No generic available Heparin Sodium,Porcine Anticoagulants and hemostasis agents 1 1 None This medication is generic

Updated 11/13/2017 Drug name Category of drug Choices Tier ABC Tier Limits Generic equivalent if available Heparin* Anticoagulants and hemostasis agents 3 3 None Heparin Sodium,Porcine

Hepsera* Antivirals 3 3 None Adefovir Dipivoxil Hetlioz Sedative and hypnotics 3 3 PA, QL No generic available Hexalen Miscellaneous antineoplastic agents 2 2 None No generic available

Hiprex/Urex* Urinary tract agents 3 3 None Methenamine Hippurate Hizentra Immunoglobulins 3 3 PA No generic available Horizant Miscellaneous CNS 3 3 ST, QL No generic available Humalog U-200 Insulins 2 2 None No generic available Humalog, Mix Insulins 2 2 None No generic available Humatin* Antiparasitics and anthelmintics 3 3 None Paromomycin Sulfate Humatrope Growth Hormone and related products 3 3 PA No generic available

Humira Tumor Necrosis Factor (TNF) blocking 2 2 PA, QL No generic available agents/Antipsoriatic and antiseborrheic

Humulin R U-500 (vial and KwikPen) Insulins 2 2 None No generic available Humulin N (all forms) Insulins 3 3 None Novolin N, Novolin 70/30, Novolin R

Humulin R (vial) Insulins 3 3 None Novolin N, Novolin 70/30, Novolin R

Humulin 70/30 (all forms) Insulins 3 3 None Novolin N, Novolin 70/30, Novolin R

Hycamtin capsule Miscellaneous antineoplastic agents 2 2 None No generic available

Hycet* Narcotic and analgesic combinations 3 3 None Hydrocodone Bit/Acetaminophen

Hycodan* Antitussives 3 3 None Hydrocodone Bit/Homatrop Me-Br Hycofenix Antitussives 3 3 QL No generic available Hydralazine Hcl Miscellaneous antihypertensives 1 Free As None This medication is generic Preventive Hydrea* Miscellaneous antineoplastic agents 3 3 None Hydroxyurea

Hydrochlorothiazide Diuretics 1 Free As None This medication is generic Preventive Hydrocodone Bit/Acetaminophen Narcotic and analgesic combinations 1 1 None This medication is generic

Hydrocodone Bit/Acetaminophen (generic Narcotic and analgesic combinations 1 1 QL This medication is generic Lortab; Norco; Vicodin; Xodol)

Hydrocodone Bit/Homatrop Me-Br Antitussives 1 1 None This medication is generic Hydrocodone/Chlorphen Polis Antitussives 1 1 None This medication is generic Hydrocodone/Ibuprofen Narcotic and analgesic combinations 1 1 None This medication is generic

Hydrocortisone Topical anti-Inflammatory 1 1 None This medication is generic agents/Corticosteroids Hydrocortisone Acetate Topical anti-Inflammatory agents 1 1 None This medication is generic

Hydrocortisone Butyrate Corticosteroids - medium potency 1 1 None This medication is generic

Hydrocortisone Butyrate/Emoll Corticosteroids - medium potency 1 1 None This medication is generic

Hydrocortisone Valerate Corticosteroids - medium potency 1 1 None This medication is generic

Hydrocortisone/Pramoxine Topical anti-Inflammatory agents 1 1 None This medication is generic

Hydrocortisone/Pramoxine Hcl Topical anti-Inflammatory agents 1 1 None This medication is generic

Hydrodiuril; Microzide* Diuretics 3 3 None Hydrochlorothiazide Hydromorphone Hcl Narcotics 1 1 None This medication is generic Hydromorphone Hcl (generic Exalgo) Narcotics 1 1 QL This medication is generic Hydroxychloroquine Sulfate Miscellaneous rheumatologic 1 1 None This medication is generic agents/Antimalarial Hydroxyurea Miscellaneous antineoplastic agents 1 1 None This medication is generic

Hydroxyzine Antihistamines 1 1 None This medication is generic Hygroton; Thalitone* Diuretics 3 3 None Chlorthalidone Hyoscyamine Sulfate Antidiarrheals and 1 1 None This medication is generic antispasmodics/Urinary Antispasmodics

Updated 11/13/2017 Drug name Category of drug Choices Tier ABC Tier Limits Generic equivalent if available Hyper-Sal Miscellaneous respiratory agents 3 3 None No generic available

HyQvia Immunoglobulins 3 3 PA No generic available Hysingla ER Narcotics 3 3 PA, QL No generic available Hytrin* Alpha-adrenergic agents/BPH 3 3 None Terazosin Hcl Treatment Hyzaar* Angiotensin II Receptor Blockers and 3 3 None Losartan/Hydrochlorothiazide combinations Ibandronate Sodium Osteoporosis and bone resorption 1 1 QL This medication is generic

Ibrance Kinase inhibitors and molecular target 2 2 PA, QL No generic available inhibitors Ibudone 5mg/200mg Narcotic and analgesic combinations 3 3 None No generic available

Ibudone* Narcotic and analgesic combinations 3 3 None Hydrocodone/Ibuprofen

Ibuprofen Nonsteroidal anti-inflammatory drugs 1 1 None This medication is generic

Iclusig Kinase inhibitors and molecular target 2 2 PA, QL No generic available inhibitors Idhifa Myeloid Leukemia 2 2 PA No generic available Ilevro Ophthalmic anti-inflammatory agents 3 3 None No generic available

Ilotycin* Ophthalmic anti-infectives 3 3 None Erythromycin Base Imatinib Mesylate Kinase inhibitors and molecular target 1 1 None This medication is generic inhibitors Imbruvica Kinase inhibitors and molecular target 2 2 PA, QL No generic available inhibitors Imdur* Nitrates and combinations 3 3 None Isosorbide Mononitrate Imipramine Hcl Antidepressants 1 1 None This medication is generic Imipramine Pamoate Antidepressants 1 1 None This medication is generic Imiquimod Topical antineoplastic agents and 1 1 None This medication is generic immunomodulators Imitrex (All Forms)* Migraine therapy 3 3 QL Sumatriptan Succinate Imodium* Antidiarrheals and antispasmodics 3 3 None Loperamide Hcl

Impavido Antiparasitics and anthelmintics 2 2 PA, QL No generic available Imuran* Miscellaneous rheumatologic 3 3 None Azathioprine agents/Immunomodulators Increlex Growth Hormone and related products 3 3 PA No generic available

Incruse Ellipta Inhaled anticholinergics 3 3 QL No generic available Indapamide Diuretics 1 Free As None This medication is generic Preventive Inderal XL Beta blockers and combinations 3 3 None No generic available Inderal, LA* Beta blockers and combinations 3 Free As None Propranolol Hcl Preventive Inderide* Beta blockers and combinations 3 3 None Propranolol/Hydrochlorothiazide Indocin suppository Nonsteroidal anti-inflammatory drugs 2 2 None No generic available

Indocin suspension Nonsteroidal anti-inflammatory drugs 3 3 None No generic available

Indocin, SR* Nonsteroidal anti-inflammatory drugs 3 3 None Indomethacin

Indomethacin Nonsteroidal anti-inflammatory drugs 1 1 None This medication is generic

Inflamase, Forte* Ophthalmic steroids 3 3 None Prednisolone Sod Phosphate Ingrezza Tardive dyskinesia 3 3 PA, QL No generic available Inlyta Kinase inhibitors and molecular target 2 2 PA, QL No generic available inhibitors Innopran XL Beta blockers and combinations 3 Free As None No generic available Preventive Inspra* Diuretics 3 3 None Eplerenone Intal solution* Miscellaneous respiratory agents 3 3 None Cromolyn Sodium

Intelence Antiretrovirals 2 2 None No generic available Intermezzo* Sedative and hypnotics 3 3 ST, QL Zolpidem Tartrate Intrarosa insert Steroid/post menopausal women 3 3 PA, QL No generic available

Intron A Interferons and MS therapy 2 2 None No generic available Intuniv* Miscellaneous CNS 3 3 QL Guanfacine Hcl Invega* Antipsychotics 3 3 QL Paliperidone

Updated 11/13/2017 Drug name Category of drug Choices Tier ABC Tier Limits Generic equivalent if available Invirase Antiretrovirals 2 2 None No generic available Invokamet Non-insulin hypoglycemic agents 2 2 PA, QL No generic available

Invokamet XR Non-insulin hypoglycemic agents 2 2 PA, QL No generic available

Invokana Non-insulin hypoglycemic agents 2 2 PA, QL No generic available

Iopidine droperette Glaucoma agents 3 3 None No generic available Iopidine drops* Glaucoma agents 3 3 None Apraclonidine Hcl Ipratropium Bromide Inhaled anticholinergics 1 1 None This medication is generic Ipratropium Bromide (generic Atrovent Nasal preparations 1 1 QL This medication is generic nasal spray) Ipratropium/Albuterol Sulfate Inhaled beta-agonist and 1 1 None This medication is generic anticholinergic Iprivask Anticoagulants and hemostasis agents 3 3 None No generic available

Irbesartan Angiotensin II Receptor Blockers and 1 Free As None This medication is generic combinations Preventive Irbesartan/Hydrochlorothiazide Angiotensin II Receptor Blockers and 1 Free As None This medication is generic combinations Preventive Iressa Kinase inhibitors and molecular target 2 2 PA, QL No generic available inhibitors Iron Ps Cmplx/Vit B12/Fa Vitamins and Minerals 1 1 None This medication is generic Isentress Antiretrovirals 2 2 None No generic available Isibloom Contraceptives-Monphasic Free As Free As None This medication is generic Preventive Preventive Isometheptene/Apap/Dichlphen Migraine therapy 1 1 None This medication is generic Isoniazid Antituberculars 1 1 None This medication is generic Isoniazid* Antituberculars 3 3 None Isoniazid Isopto Atropine* Cycloplegic mydriatics 3 3 None Atropine Sulfate Isordil 40mg Nitrates and combinations 3 3 None No generic available Isordil* Nitrates and combinations 3 3 None Isosorbide Dinitrate Isosorbide Dinitrate Nitrates and combinations 1 1 None This medication is generic Isosorbide Mononitrate Nitrates and combinations 1 1 None This medication is generic Isotretinoin Acne treatment 1 1 None This medication is generic Isoxsuprine Hcl Cardiovascular treatment 1 1 None This medication is generic Isradipine Calcium channel blockers and 1 Free As None This medication is generic combinations Preventive Istalol Ophthalmic beta blockers 3 3 None No generic available Itraconazole Antifungals 1 1 None This medication is generic Ivermectin Antiparasitics and anthelmintics 1 1 None This medication is generic Jadenu Chelating Agents 3 3 PA No generic available Jakafi Kinase inhibitors and molecular target 2 2 PA, QL No generic available inhibitors Jalyn* BPH Treatment 3 3 QL Dutasteride/Tamsulosin Hcl Janumet Non-insulin hypoglycemic agents 2 2 None No generic available

Janumet XR Non-insulin hypoglycemic agents 2 2 QL No generic available

Januvia Non-insulin hypoglycemic agents 2 2 QL No generic available

Jardiance Non-insulin hypoglycemic agents 3 3 PA, QL No generic available

Jentadueto Non-insulin hypoglycemic agents 3 3 ST, QL No generic available

Jentadueto XR Non-insulin hypoglycemic agents 3 3 ST, QL No generic available

Juxtapid Lipid-lowering agents 3 3 PA, QL No generic available Kadian 40, 200mg Narcotics 3 3 None No generic available Kadian* Narcotics 3 3 None Morphine Sulfate Kaletra Antiretrovirals 2 2 None No generic available Kalydeco Cystic Fibrosis agents 2 2 PA, QL No generic available Kapvay* Miscellaneous CNS 3 3 QL Clonidine Hcl Karbinal ER Antihistamines 3 3 ST, QL No generic available Kay Ciel, Kaon-Cl, Kaon Liquid* Potassium Replacement 3 3 None Potassium Chloride Kayexalate* Ion-Removing Agents 3 3 None Sodium Polystyrene Sulfonate Kazano Non-insulin hypoglycemic agents 3 3 ST, QL No generic available

Keflex* Cephalosporins 3 3 None Cephalexin Monohydrate Kenalog 0.025%* Corticosteroids - low potency 3 3 None Triamcinolone Acetonide Kenalog 0.1%* Corticosteroids - medium potency 3 3 None Triamcinolone Acetonide

Updated 11/13/2017 Drug name Category of drug Choices Tier ABC Tier Limits Generic equivalent if available Keppra XR* Anticonvulsants 3 3 None Levetiracetam Keppra* Anticonvulsants 3 3 None Levetiracetam Kerlone* Beta blockers and combinations 3 3 None Betaxolol Hcl Ketek Macrolides 3 3 None No generic available Ketoconazole Antifungals 1 1 None This medication is generic Ketoprofen Nonsteroidal anti-inflammatory drugs 1 1 None This medication is generic

Ketoprofen* Nonsteroidal anti-inflammatory drugs 3 3 None Ketoprofen

Ketorolac Tromethamine Nonsteroidal anti-inflammatory 1 1 None This medication is generic drugs/Ophthalmic anti-inflammatory agents Ketorolac Tromethamine (generic Toradol Nonsteroidal anti-inflammatory drugs 1 1 QL This medication is generic tablet) Keveyis Diagnostics and Other Miscellaneous 3 3 PA, QL No generic available

Khedezla Antidepressants 3 3 ST, QL No generic available Kineret Non-Tumor Necrosis Factor (TNF) 3 3 PA, QL No generic available blocking agents/Immunomodulators

Kisqali Breast cancer 2 2 PA, QL No generic available Kisqali Femara co-pack Breast cancer 2 2 PA, QL No generic available Klaron* Acne treatment 3 3 None Sulfacetamide Sodium Klonopin, Wafer* Anticonvulsants 3 3 None Clonazepam K-Lor, Klor-Con* Potassium Replacement 3 3 None Potassium Chloride Klor-con packet Potassium Replacement 3 3 None No generic available K-Lyte, Klor-Con/EF* Potassium Replacement 3 3 None Potassium Bicarbonate/Cit Ac Kombiglyze XR Non-insulin hypoglycemic agents 2 2 None No generic available

Korlym Miscellaneous endocrine 2 2 PA, QL No generic available Kristalose Miscellaneous gastrointestinal agents 3 3 None No generic available

K-Sol, potassium chloride* Potassium Replacement 3 3 None Potassium Chloride K-Tab, K-Dur, Slow-K, Kaon CL* Potassium Replacement 3 3 None Potassium Chloride Kuvan Miscellaneous endocrine 2 2 None No generic available Kynamro Lipid-lowering agents 2 2 PA, QL No generic available Kytril* Antiemetics 3 3 None Granisetron Hcl Labetalol Hcl Beta blockers and combinations 1 Free As None This medication is generic Preventive Lacrisert Miscellaneous ophthalmic agents 2 2 None No generic available

Lactulose Miscellaneous gastrointestinal agents 1 1 None This medication is generic

Lamictal dosepak Anticonvulsants 2 2 None No generic available Lamictal dosepak ODT* Anticonvulsants 3 3 None Lamotrigine Lamictal ODT* Anticonvulsants 3 3 None Lamotrigine Lamictal tablet, dispertabs* Anticonvulsants 3 3 None Lamotrigine Lamictal XR dosepak Anticonvulsants 3 3 None No generic available Lamictal XR* Anticonvulsants 3 3 None Lamotrigine Lamisil tablet* Antifungals 3 3 None Terbinafine Hcl Lamivudine Antiretrovirals/Anitvirals 1 1 None This medication is generic Lamivudine/Zidovudine Antiretrovirals 1 1 None This medication is generic Lamotrigine Anticonvulsants 1 1 None This medication is generic Lanoxin 62.5, 187.5mcg Cardiovascular treatment 3 3 None No generic available Lanoxin* Cardiovascular treatment 3 3 None Digoxin Lansoprazole Proton Pump Inhibitors (PPI) 1 1 None This medication is generic Lansoprazole/Amoxiciln/Clarith Ulcer therapy 1 1 None This medication is generic Lanthanum Carbonate Iron-removing agents 1 1 None This medication is generic Lantus, Solostar Insulins 2 2 None No generic available Lariam* Antimalarials 3 3 None Mefloquine Hcl Lasix* Diuretics 3 3 None Furosemide Lastacaft Ophthalmic anti-allergy agents 3 3 None No generic available Latanoprost Glaucoma agents 1 1 None This medication is generic Latuda Antipsychotics 3 3 ST, QL No generic available Lazanda Narcotics 3 3 PA, QL No generic available Leflunomide Miscellaneous rheumatologic agents 1 1 None This medication is generic

Lenvima Kinase inhibitors and molecular target 2 2 PA, QL No generic available inhibitors Lescol, XL* Lipid-lowering agents 3 3 QL Fluvastatin Sodium Letairis Pulmonary Hypertension Agents 2 2 PA, QL No generic available Letrozole Hormonal agents 1 1 PA This medication is generic

Updated 11/13/2017 Drug name Category of drug Choices Tier ABC Tier Limits Generic equivalent if available Leucovorin Calcium Adjuvant therapy 1 1 None This medication is generic Leucovorin tablet* Adjuvant therapy 3 3 None Leucovorin Calcium Leukeran Alkylating agents 2 2 None No generic available Leukine Adjuvant therapy 2 2 None No generic available Leukine Hematopoietic agents 2 2 None No generic available Leuprolide Acetate Infertility treatment/Hormonal agents 1 1 None This medication is generic

Levalbuterol Hcl Inhaled beta-agonists 1 1 None This medication is generic Levalbuterol Tartrate HFA Inhaled beta-agonists 3 3 QL No generic available Levaquin* Quinolones 3 3 None Levofloxacin Levatol Beta blockers and combinations 3 Free As None No generic available Preventive Levbid* Antidiarrheals and 3 3 None Hyoscyamine Sulfate antispasmodics/Urinary Antispasmodics Levemir, Flextouch Insulins 2 2 None No generic available Levetiracetam Anticonvulsants 1 1 None This medication is generic Levitra Sexual Dysfunction 3 3 QL No generic available Levlen; Nordette* Contraceptives-Monophasic 3 3 None Levonorgestrel-Eth Estra; Lillow Levobunolol Hcl Ophthalmic beta blockers 1 1 None This medication is generic Levocarnitine Diagnostics and Other Miscellaneous 1 1 None This medication is generic

Levocetirizine Dihydrochloride Antihistamines 1 1 QL This medication is generic Levofloxacin Quinolones/Ophthalmic anti-infectives 1 1 None This medication is generic

Levonorgestrel Contraceptives-Postcoital Free As Free As QL This medication is generic Preventive Preventive Levonorgestrel-Eth Estra Contraceptives-Monophasic/Triphasic Free As Free As None This medication is generic Preventive Preventive Levonorgestrel-Eth Estra (generic Contraceptives-Monophasic Free As Free As QL This medication is generic Seasonale) Preventive Preventive Levorphanol Tartrate Narcotics 1 1 None This medication is generic levorphanol tartrate* Narcotics 3 3 None Levorphanol Tartrate Levothyroxine Sodium Thyroid hormones 1 1 None This medication is generic Levsin, SL* Antidiarrheals and 3 3 None Hyoscyamine Sulfate antispasmodics/Urinary Antispasmodics Levsinex* Antidiarrheals and 3 3 None Hyoscyamine Sulfate antispasmodics/Urinary Antispasmodics Lexapro* Antidepressants 3 3 None Escitalopram Oxalate Lexiva* Antiretrovirals 2 2 None Fosamprenavir Calcium Lialda 5-Aminosalicylic Acid (5-ASA) agents 3 3 None Mesalamine

Librax* Antidiarrheals and antispasmodics 3 3 None Clidinium Br/Chlordiazepoxide

Librium* Anxiolytics 3 3 None Chlordiazepoxide Hcl Lidex, E* Corticosteroids - high potency 3 3 None Fluocinonide Lidocaine Topical anesthetics 1 1 None This medication is generic Lidocaine Hcl Topical anesthetics 1 1 None This medication is generic Lidocaine Hcl/Hc Topical anti-Inflammatory agents 1 1 None This medication is generic

Lidocaine/Prilocaine Topical anesthetics 1 1 None This medication is generic Lidoderm patch* Topical anesthetics 3 3 None Lidocaine Lillow Oral contraceptive 1 1 None This medication is generic Limbitrol, DS* Antidepressants 3 3 None Amitrip Hcl/Chlordiazepoxide Lindane Scabicides and pediculicides 1 1 None This medication is generic Linezolid Miscellaneous anti-infectives 1 1 None This medication is generic Linzess Miscellaneous gastrointestinal agents 3 3 PA, QL No generic available

Liothyronine Sodium Thyroid hormones 1 1 None This medication is generic Lipitor* Lipid-lowering agents 3 3 QL Atorvastatin Calcium Lipofen Lipid-lowering agents 3 Free As None No generic available Preventive Lisinopril ACE-Inhibitors and combinations 1 Free As None This medication is generic Preventive Lisinopril/Hydrochlorothiazide ACE-Inhibitors and combinations 1 Free As None This medication is generic Preventive Lithium Carbonate Miscellaneous CNS 1 1 None This medication is generic Lithium Citrate Miscellaneous CNS 1 1 None This medication is generic Lithobid* Miscellaneous CNS 3 3 None Lithium Carbonate

Updated 11/13/2017 Drug name Category of drug Choices Tier ABC Tier Limits Generic equivalent if available Livalo Lipid-lowering agents 3 Free As ST, QL No generic available Preventive L-Norgest-Eth Estr/Ethin Estra Contraceptives-Biphasic Free As Free As QL This medication is generic Preventive Preventive Lo Loestrin Fe Contraceptives-Biphasic 3 3 None No generic available Lo/Ovral* Contraceptives-Monophasic 3 3 None Norgestrel-Ethinyl Estradiol Locoid cream, ointment, solution* Corticosteroids - medium potency 3 3 None Hydrocortisone Butyrate

Locoid Lipocream* Corticosteroids - medium potency 3 3 None Hydrocortisone Butyrate/Emoll

Lodine, XL* Nonsteroidal anti-inflammatory drugs 3 3 None Etodolac

Lodosyn* Parkinsons disease and related 3 3 None Carbidopa disorders Loestrin 24 Fe* Contraceptives-Monophasic 3 3 None Noreth A-Et Estra/Fe Fumarate Loestrin, Fe* Contraceptives-Monophasic 3 3 None Norethindrone A-E Estradiol Lofibra* Lipid-lowering agents 3 3 None Fenofibrate,Micronized Lomaira Weight Loss Preparations 3 Free As None No generic available Preventive Lomotil* Antidiarrheals and antispasmodics 3 3 None Diphenoxylate Hcl/Atrop Sulf

Loniten* Miscellaneous antihypertensives 3 3 None Minoxidil

Lonsurf Antimetabolites 2 2 PA, QL No generic available Loperamide Hcl Antidiarrheals and antispasmodics 1 1 None This medication is generic

Lopid* Lipid-lowering agents 3 3 None Gemfibrozil Lopressor HCT* Beta blockers and combinations 3 3 None Metoprolol/Hydrochlorothiazide Lopressor* Beta blockers and combinations 3 3 None Metoprolol Tartrate Loprox* Topical antifungals 3 3 None Ciclopirox Olamine Lorazepam Anxiolytics 1 1 None This medication is generic Lortab solution Narcotic and analgesic combinations 3 3 None No generic available

Lortab; Norco; Vicodin; Xodol* Narcotic and analgesic combinations 3 3 QL Hydrocodone Bit/Acetaminophen

Lorzone Skeletal muscle relaxants 3 3 None No generic available Losartan Potassium Angiotensin II Receptor Blockers and 1 Free As None This medication is generic combinations Preventive Losartan/Hydrochlorothiazide Angiotensin II Receptor Blockers and 1 Free As None This medication is generic combinations Preventive Loseasonique* Contraceptives-Biphasic 3 3 QL L-Norgest-Eth Estr/Ethin Estra Lotemax Ophthalmic steroids 3 3 None No generic available Lotensin HCT* ACE-Inhibitors and combinations 3 3 None Benazepril/Hydrochlorothiazide Lotensin* ACE-Inhibitors and combinations 3 3 None Benazepril Hcl Lotrel* ACE-Inhibitors and 3 3 None Amlodipine Besylate/Benazepril combinations/Calcium channel blockers and combinations Lotrimin* Topical antifungals 3 3 None Clotrimazole Lotrisone* Topical antifungals 3 3 None Clotrimazole/Betamet Diprop Lotronex* Miscellaneous gastrointestinal agents 3 3 None Alosetron Hcl

Lovastatin Lipid-lowering agents 1 Free As QL This medication is generic Preventive Lovaza* Lipid-lowering agents 3 3 None Omega-3 Acid Ethyl Esters; Triklo Lovenox* Anticoagulants and hemostasis agents 3 3 None Enoxaparin Sodium

Loxapine Succinate Antipsychotics 1 1 None This medication is generic Loxitane* Antipsychotics 3 3 None Loxapine Succinate Lozol* Diuretics 3 3 None Indapamide Lumigan 0.01% Glaucoma agents 2 2 None No generic available Lumigan* Glaucoma agents 3 3 None Bimatoprost Lunesta* Sedative and hypnotics 3 3 QL Eszopiclone Lupaneta pack Miscellaneous OB-GYN/Hormonal 3 3 None No generic available agents Lupron Depot Miscellaneous OB-GYN/Hormonal 2 2 None No generic available agents Lupron Depot 45mg Miscellaneous OB-GYN 2 2 None No generic available Lupron Depot-Ped Miscellaneous endocrine 2 2 None No generic available Lupron* Infertility treatment/Hormonal agents 3 3 None Leuprolide Acetate

Luvox CR* Antidepressants 3 3 None Fluvoxamine Maleate Luvox* Antidepressants 3 3 None Fluvoxamine Maleate

Updated 11/13/2017 Drug name Category of drug Choices Tier ABC Tier Limits Generic equivalent if available Luxiq* Corticosteroids - medium potency 3 3 None Betamethasone Valerate

Luzu Topical antifungals 3 3 PA, QL No generic available Lybrel* Contraceptives-Monophasic 3 3 None Levonorgestrel-Eth Estra Lynparza Kinase inhibitors and molecular target 2 2 PA, QL No generic available inhibitors Lyrica Anticonvulsants 3 3 PA No generic available Lysodren Miscellaneous antineoplastic agents 2 2 None No generic available

Lysteda* Miscellaneous OB-GYN 3 3 QL Tranexamic Acid Macrobid* Urinary tract agents 3 3 None Nitrofurantoin Macrodantin* Urinary tract agents 3 3 None Nitrofurantoin Macrocrystal Magnesium Citrate Bowel preparation and cleansing Free As Free As QL This medication is generic agents Preventive Preventive Magnesium Hydroxide Bowel preparation and cleansing Free As Free As QL This medication is generic agents Preventive Preventive Malarone* Antimalarials 3 3 None Atovaquone/Proguanil Hcl Malathion Scabicides and pediculicides 1 1 None This medication is generic Maprotiline Hcl Antidepressants 1 1 None This medication is generic Marinol* Antiemetics 3 3 None Dronabinol Marplan Antidepressants 3 3 None No generic available Matulane Alkylating agents 2 2 None No generic available Mavik* ACE-Inhibitors and combinations 3 3 None Trandolapril Maxalt, MLT* Migraine therapy 3 3 QL Rizatriptan Benzoate Maxidex Ophthalmic steroids 3 3 None No generic available Maxitrol* Ophthalmic anti-infective and steroid 3 3 None Neo/Polymyx B Sulf/Dexameth

Maxofloxacin Ophthalmic antibiotics 1 1 None This medication is generic Meclizine Hcl Antiemetics 1 1 None This medication is generic Meclofenamate Sodium Nonsteroidal anti-inflammatory drugs 1 1 None This medication is generic

Meclomen* Nonsteroidal anti-inflammatory drugs 3 3 None Meclofenamate Sodium

Medrol 2mg Corticosteroids 3 3 None No generic available Medrol, Dosepak* Corticosteroids 3 3 None Methylprednisolone Medroxyprogesterone Acet Progestins 1 1 None This medication is generic Medroxyprogesterone Acet (Preventive) Contraceptives-Misc. Free As Free As None This medication is generic Preventive Preventive Mefenamic Acid Nonsteroidal anti-inflammatory drugs 1 1 None This medication is generic

Mefloquine Hcl Antimalarials 1 1 None This medication is generic Megace, ES* Hormonal agents 3 3 None Megestrol Acetate Megestrol Acetate Hormonal agents 1 1 None This medication is generic Mekinist Kinase inhibitors and molecular target 2 2 PA, QL No generic available inhibitors Mellaril* Antipsychotics 3 3 None Thioridazine Hcl Melodetta 24 FE Oral contraceptive 1 Free As None This medication is generic Preventive Meloxicam Nonsteroidal anti-inflammatory drugs 1 1 None This medication is generic

Melphalan tablet Oncology 1 1 None This medication is generic Memantine Hcl Alzheimer's therapy 1 1 None This medication is generic Memantine Hcl dosepack Alzheimer's therapy 2 2 None No generic available Menactra Vaccines Free As Free As None No generic available Preventive Preventive Vaccine Vaccine Menest Estrogens/Osteoporosis and hormonal 3 3 None No generic available treatment Menomune-A/C/Y/W-135 Vaccines Free As Free As None No generic available Preventive Preventive Vaccine Vaccine Menopur Infertility treatment 2 2 None No generic available Menostar Estrogens 3 3 QL No generic available Mentax Topical antifungals 2 2 None No generic available Menveo Vaccines Free As Free As None No generic available Preventive Preventive Vaccine Vaccine Meperidine Hcl Narcotics 1 1 None This medication is generic Mephyton Anticoagulants and hemostasis 2 2 None No generic available agents/Vitamins and Minerals Meprobamate Anxiolytics 1 1 None This medication is generic Mepron blister pak Antiparasitics and anthelmintics 2 2 None No generic available

Updated 11/13/2017 Drug name Category of drug Choices Tier ABC Tier Limits Generic equivalent if available Mepron* Antiparasitics and anthelmintics 3 3 None Atovaquone Mercaptopurine Antimetabolites 1 1 None This medication is generic Mesalamine 5-Aminosalicylic Acid (5-ASA) agents 1 1 None This medication is generic

Mesalamine ER 5-Aminosalicylic Acid (5-ASA) agents 3 3 None Asacol HD, Delzicol HD, Pentasa

Mesnex tablet Adjuvant therapy 2 2 None No generic available Mestinon Syrup Myesthenia gravis 2 2 None No generic available Mestinon Timespan* Myesthenia gravis 3 3 None Pyridostigmine Bromide Metadate CD* CNS stimulants 3 3 None Methylphenidate Hcl Metaglip* Non-insulin hypoglycemic agents 3 3 None Glipizide/Metformin Hcl

Metaproterenol solution* Inhaled beta-agonists 3 3 None Metaproterenol Sulfate Metaproterenol Sulfate Inhaled beta-agonists/Oral beta- 1 1 None This medication is generic agonists Metaxalone Skeletal muscle relaxants 1 1 None This medication is generic Metformin Hcl Non-insulin hypoglycemic agents 1 1 None This medication is generic

Metformin Hcl (generic Glumetza) Non-insulin hypoglycemic agents 1 1 ST This medication is generic

Methadone Hcl Narcotics 1 1 None This medication is generic Methadone* Narcotics 3 3 None Methadone Hcl Methamphetamine Hcl CNS stimulants 1 1 None This medication is generic Methenamine Hippurate Urinary tract agents 1 1 None This medication is generic Methergine tablet* Miscellaneous OB-GYN 3 3 None Methylergonovine Maleate Methimazole Antithyroid agents 1 1 None This medication is generic Methitest Androgens 3 3 None No generic available Methocarbamol Skeletal muscle relaxants 1 1 None This medication is generic Methotrexate Sodium Antimetabolites/Rheumatologic agents 1 1 None This medication is generic

Methotrexate tablet* Antimetabolites 3 3 None Methotrexate Sodium Methotrexate* Miscellaneous rheumatologic agents 3 3 None Methotrexate Sodium

Methoxsalen Antipsoriatic and antiseborrheic 1 1 None This medication is generic Methoxsalen, Rapid Antipsoriatic and antiseborrheic 1 1 None This medication is generic Methyclothiazide Diuretics 1 Free As None This medication is generic Preventive Methyldopa Alpha-adrenergic agents 1 Free As None This medication is generic Preventive Methyldopa/Hydrochlorothiazide Alpha-adrenergic agents 1 Free As None This medication is generic Preventive Methylergonovine Maleate Miscellaneous OB-GYN 1 1 None This medication is generic Methylin, ER* CNS stimulants 3 3 None Methylphenidate Hcl Methylphenidate Hcl CNS stimulants 1 1 None This medication is generic Methylprednisolone Corticosteroids 1 1 None This medication is generic Methyltestosterone Androgens 1 1 None This medication is generic Metipranolol Ophthalmic beta blockers 1 1 None This medication is generic Metoclopramide Hcl Miscellaneous gastrointestinal agents 1 1 None This medication is generic

Metolazone Diuretics 1 Free As None This medication is generic Preventive Metoprolol Succinate Beta blockers and combinations 1 Free As None This medication is generic Preventive Metoprolol Tartrate Beta blockers and combinations 1 Free As None This medication is generic Preventive Metoprolol/Hydrochlorothiazide Beta blockers and combinations 1 Free As None This medication is generic Preventive Metozolv ODT* Miscellaneous gastrointestinal agents 3 3 None Metoclopramide Hcl

Metrocream, gel, lotion* Miscellaneous dermatologicals 3 3 None Metronidazole Metrogel Topical 1%, pump* Miscellaneous dermatologicals 3 3 None Metronidazole Metrogel-Vaginal* Vaginal anti-infective and antifungal 3 3 None Metronidazole

Metronidazole Vaginal anti-infective and 1 1 None This medication is generic antifungal/Antiparasitics and anthelmintics Mevacor* Lipid-lowering agents 3 3 QL Lovastatin Mexiletine Hcl Cardiovascular treatment 1 1 None This medication is generic Mexitil* Cardiovascular treatment 3 3 None Mexiletine Hcl Miacalcin injection Osteoporosis and bone 2 2 None No generic available resorption/Miscellaneous endocrine

Updated 11/13/2017 Drug name Category of drug Choices Tier ABC Tier Limits Generic equivalent if available Miacalcin nasal spray* Osteoporosis and bone 3 3 None Calcitonin,Salmon,Synthetic resorption/Miscellaneous endocrine

Micardis HCT* Angiotensin II Receptor Blockers and 3 3 None Telmisartan/Hydrochlorothiazide combinations Micardis* Angiotensin II Receptor Blockers and 3 3 None Telmisartan combinations Miconazole Nitrate Vaginal anti-infective and antifungal 1 1 None This medication is generic

Micort-HC rectal Topical anti-Inflammatory agents 3 3 None No generic available

Micort-HC topical Topical anti-Inflammatory agents 3 3 None No generic available

Micro-K* Potassium Replacement 3 3 None Potassium Chloride Midamor* Diuretics 3 3 None Amiloride Hcl Midodrine Hcl Cardiovascular treatment 1 1 None This medication is generic Midrin* Migraine therapy 3 3 None Isometheptene/Apap/Dichlphen Miglitol Non-insulin hypoglycemic agents 1 1 None This medication is generic

Migranal* Migraine therapy 3 3 QL Dihydroergotamine Mesylate Milk of Magnesia OTC* Bowel preparation and cleansing Free As Free As QL Magnesium Hydroxide agents Preventive Preventive Minipress* Alpha-adrenergic agents 3 3 None Prazosin Hcl Minitran Nitrates and combinations 2 2 None No generic available Minivelle Estrogens/Osteoporosis and hormonal 3 3 QL No generic available treatment Minocin* Tetracyclines/Acne treatment 3 3 None Minocycline Hcl Minocycline Hcl Tetracyclines/Acne treatment 1 1 None This medication is generic Minocycline Hcl (generic Solodyn) Tetracyclines/Acne treatment 1 1 PA This medication is generic Minoxidil Miscellaneous antihypertensives 1 Free As None This medication is generic Preventive Mirapex ER* Parkinsons disease and related 3 3 PA, QL Pramipexole Di-Hcl disorders Mirapex immediate release* Parkinsons disease and related 3 3 None Pramipexole Di-Hcl disorders Mircera Adjuvant therapy/Hematopoietic 3 3 PA, QL No generic available agents Mircette* Contraceptives-Biphasic 3 3 None Desog-Et Estra/Ethin Estra Mirtazapine Antidepressants 1 1 None This medication is generic Misoprostol Ulcer therapy 1 1 None This medication is generic Mitigare Gout therapy 3 3 None No generic available Mobic* Nonsteroidal anti-inflammatory drugs 3 3 None Meloxicam

Modafinil CNS stimulants 1 1 QL This medication is generic Modicon* Contraceptives-Monophasic 3 3 None Norethindrone-Ethinyl Estrad Moduretic* Diuretics 3 3 None Amiloride/Hydrochlorothiazide Moexipril Hcl ACE-Inhibitors and combinations 1 Free As None This medication is generic Preventive Moexipril/Hydrochlorothiazide ACE-Inhibitors and combinations 1 Free As None This medication is generic Preventive Molindone Hcl Antipsychotics 1 1 None This medication is generic Molindone* Antipsychotics 3 3 None Molindone Hcl Mometasone Furoate Corticosteroids - medium potency/high 1 1 None This medication is generic potency Mometasone Furoate (generic Nasonex) Nasal preparations 1 1 ST, QL This medication is generic

Monistat 3* Vaginal anti-infective and antifungal 3 3 None Miconazole Nitrate

Monistat-Derm* Topical antifungals 3 3 None Miconazole Nitrate Monodox* Tetracyclines/Acne treatment 3 3 None Doxycycline Monohydrate Monopril HCT* ACE-Inhibitors and combinations 3 3 None Fosinopril/Hydrochlorothiazide Monopril* ACE-Inhibitors and combinations 3 3 None Fosinopril Sodium Montelukast Sodium Miscellaneous respiratory agents 1 1 QL This medication is generic

Monurol Urinary tract agents 3 3 None No generic available Morphine Sulfate Narcotics 1 1 None This medication is generic Motofen Antidiarrheals and antispasmodics 3 3 None No generic available

Motrin (Rx only)* Nonsteroidal anti-inflammatory drugs 3 3 None Ibuprofen

Movantik Miscellaneous gastrointestinal agents 3 3 PA, QL No generic available

Updated 11/13/2017 Drug name Category of drug Choices Tier ABC Tier Limits Generic equivalent if available Moviprep Bowel preparation and cleansing 3 3 None No generic available agents Moxatag Penicillins 3 3 None No generic available Moxeza Ophthalmic anti-infectives 2 2 None No generic available Moxifloxacin (generic Vigamox) Ophthalmic antibiotics 1 1 None This medication is generic Moxifloxacin Hcl Quinolones 1 1 None This medication is generic MS Contin* Narcotics 3 3 None Morphine Sulfate MSIR* Narcotics 3 3 None Morphine Sulfate Mucomyst* Miscellaneous respiratory agents 3 3 None Acetylcysteine

Multaq Cardiovascular treatment 2 2 QL No generic available Mupirocin Topical antibacterials 1 1 None This medication is generic Mupirocin Calcium Topical antibacterials 1 1 None This medication is generic Muse Sexual Dysfunction 2 2 QL No generic available Myalept Miscellaneous endocrine 3 3 PA, QL No generic available Mycelex Troche* Antifungals 3 3 None Clotrimazole Mycobutin* Antituberculars 3 3 None Rifabutin Mycophenolate Mofetil Immunomodulators 1 1 None This medication is generic Mycophenolate Sodium Immunomodulators 1 1 None This medication is generic Mycostatin* Topical antifungals 3 3 None Nystatin Mydriacyl* Cycloplegic mydriatics 3 3 None Tropicamide Myfortic* Immunomodulators 3 3 None Mycophenolate Sodium Myleran Alkylating agents 2 2 None No generic available Myrbetriq Urinary Antispasmodics 3 3 ST, QL No generic available Mysoline* Anticonvulsants 3 3 None Primidone Mytesi Antidiarrheals and antispasmodics 2 2 PA, QL No generic available

Na Phos,M-B/Na Phos,Di-Ba Bowel preparation and cleansing Free As Free As QL This medication is generic agents Preventive Preventive Nabumetone Nonsteroidal anti-inflammatory drugs 1 1 None This medication is generic

Nadolol Beta blockers and combinations 1 Free As None This medication is generic Preventive Nadolol/Bendroflumethiazide Beta blockers and combinations 1 Free As None This medication is generic Preventive Naftifine Hcl Topical antifungals 1 1 PA, QL This medication is generic Naftifine hcl 1% Topical antifungals 3 3 PA, QL No generic available Naftin gel Topical antifungals 3 3 PA, QL No generic available Naftin* Topical antifungals 3 3 PA, QL Naftifine Hcl Nalfon 400mg Nonsteroidal anti-inflammatory drugs 3 3 None No generic available

Nalfon* Nonsteroidal anti-inflammatory drugs 3 3 None Fenoprofen Calcium

Naloxone Hcl Narcotic antagonists 1 1 None This medication is generic Naloxone hcl injection* Narcotic antagonists 3 3 None Naloxone Hcl Naltrexone Hcl Narcotic antagonists 1 1 None This medication is generic Namenda dosepak Alzheimer's therapy 2 2 None No generic available Namenda XR Alzheimer's therapy 3 3 ST, QL No generic available Namenda* Alzheimer's therapy 3 3 None Memantine Hcl Namzaric Alzheimer's therapy 3 3 PA, QL No generic available Naphazoline Hcl Miscellaneous ophthalmic agents 1 1 None This medication is generic

Naprelan 750mg Nonsteroidal anti-inflammatory drugs 3 3 None No generic available

Naprelan* Nonsteroidal anti-inflammatory drugs 3 3 None Naproxen Sodium

Naprosyn (Rx only)* Nonsteroidal anti-inflammatory drugs 3 3 None Naproxen

Naproxen Nonsteroidal anti-inflammatory drugs 1 1 None This medication is generic

Naproxen Sodium Nonsteroidal anti-inflammatory drugs 1 1 None This medication is generic

Naratriptan Hcl Migraine therapy 1 1 QL This medication is generic Narcan nasal spray Narcotic antagonists 2 2 QL No generic available Nardil* Antidepressants 3 3 None Phenelzine Sulfate Nascobal Spray Vitamins and Minerals 3 3 None No generic available Nasonex* Nasal preparations 3 3 ST, QL Mometasone Furoate Natacyn Ophthalmic anti-infectives 2 2 None No generic available Natazia Contraceptives-Misc. 3 3 None No generic available Nateglinide Non-insulin hypoglycemic agents 1 1 None This medication is generic

Natesto Androgens 3 3 PA, QL No generic available

Updated 11/13/2017 Drug name Category of drug Choices Tier ABC Tier Limits Generic equivalent if available Natpara Miscellaneous endocrine 2 2 PA, QL No generic available Natroba* Scabicides and pediculicides 3 3 None Spinosad Nature-Throid* Thyroid hormones 3 3 None Thyroid,Pork Navane* Antipsychotics 3 3 None Thiothixene Nebupent aerosol Antiparasitics and anthelmintics 2 2 None No generic available Nebusal Miscellaneous respiratory agents 3 3 None No generic available

Necon 10/11* Contraceptives-Biphasic 3 3 None Norethindrone-Ethinyl Estrad Nefazodone Hcl Antidepressants 1 1 None This medication is generic Neo/Polymyx B Sulf/Dexameth Ophthalmic anti-infective and steroid 1 1 None This medication is generic

Neomy Sulf/Bacitra/Polymyxin B Ophthalmic anti-infectives 1 1 None This medication is generic Neomy Sulf/Polymyx B Sulf/Hc Otic preparations 1 1 None This medication is generic Neomycin Sulfate Miscellaneous anti-infectives 1 1 None This medication is generic Neomycin* Miscellaneous anti-infectives 3 3 None Neomycin Sulfate Neomycin/Gramicidin/Polymyxn B Ophthalmic anti-infectives 1 1 None This medication is generic Neosporin ophthalmic ointment* Ophthalmic anti-infectives 3 3 None Neomy Sulf/Bacitra/Polymyxin B Neosporin ophthalmic solution* Ophthalmic anti-infectives 3 3 None Neomycin/Gramicidin/Polymyxn B Neo-Synalar Corticosteroids - low potency/Topical 3 3 None No generic available antibacterials Neo-Synephrine* Miscellaneous ophthalmic agents 3 3 None Phenylephrine Hcl

Nesina Non-insulin hypoglycemic agents 3 3 ST, QL No generic available

Neulasta Adjuvant therapy/Hematopoietic 3 3 QL No generic available agents Neupogen Adjuvant therapy/Hematopoietic 2 2 None No generic available agents Neupro Parkinsons disease and related 3 3 PA, QL No generic available disorders Neurontin* Anticonvulsants 3 3 None Gabapentin Nevanac Ophthalmic anti-inflammatory agents 3 3 None No generic available

Nevirapine Antiretrovirals 1 1 None This medication is generic Nexavar Kinase inhibitors and molecular target 2 2 QL No generic available inhibitors Nexium suspension Proton Pump Inhibitors (PPI) 3 3 ST No generic available Nexium* Proton Pump Inhibitors (PPI) 3 3 ST Esomeprazole Magnesium Niacin Lipid-lowering agents 1 Free As None This medication is generic Preventive Niacor Lipid-lowering agents 3 Free As None No generic available Preventive Niaspan* Lipid-lowering agents 3 3 None Niacin Nicardipine Hcl Calcium channel blockers and 1 Free As None This medication is generic combinations Preventive Nicotine Smoking Cessation Free As Free As QL This medication is generic Preventive Preventive Nicotine gum, Nicorette* Smoking Cessation Free As Free As QL Nicotine Polacrilex Preventive Preventive Nicotine patch* Smoking Cessation Free As Free As QL Nicotine Preventive Preventive Nicotine Polacrilex Smoking Cessation Free As Free As QL This medication is generic Preventive Preventive Nicotrol, NS Smoking Cessation Free As Free As ST, QL No generic available Preventive Preventive Nifedipine Calcium channel blockers and 1 Free As None This medication is generic combinations Preventive Niferex-150 Forte* Vitamins and Minerals 3 3 None Iron Ps Cmplx/Vit B12/Fa Nilandron* Hormonal agents 3 3 None Nilutamide Nilutamide Hormonal agents 1 1 None This medication is generic Nimodipine Miscellaneous CNS 1 Free As None This medication is generic Preventive Nimotop* Miscellaneous CNS 3 3 None Nimodipine Ninlaro Kinase inhibitors and molecular target 2 2 PA, QL No generic available inhibitors Niravam* Anxiolytics 3 3 None Alprazolam Nisoldipine Calcium channel blockers and 1 Free As None This medication is generic combinations Preventive Nitro-Bid ointment* Nitrates and combinations 3 3 None Nitroglycerin Nitro-Dur Nitrates and combinations 3 3 None No generic available Nitro-Dur 0.3mg, 0.8mg Nitrates and combinations 3 3 None No generic available Nitrofurantoin Urinary tract agents 1 1 None This medication is generic

Updated 11/13/2017 Drug name Category of drug Choices Tier ABC Tier Limits Generic equivalent if available Nitrofurantoin Macrocrystal Urinary tract agents 1 1 None This medication is generic Nitroglycerin Nitrates and combinations 1 1 None This medication is generic Nitroglycerin capsule, patch, spray, tablet* Nitrates and combinations 3 3 None Nitroglycerin

Nitromist* Nitrates and combinations 3 3 None Nitroglycerin Nitrostat* Nitrates and combinations 3 3 None Nitroglycerin Nityr Tyrosinemia 3 3 None No generic available Nizatidine H2-Receptor antagonists 1 1 None This medication is generic Nizoral cream, shampoo 2%* Topical antifungals 3 3 None Ketoconazole Nizoral* Antifungals 3 3 None Ketoconazole Nonoxynol 9 Contraceptives-Misc. Free As Free As QL This medication is generic Preventive Preventive Norditropin Flexpro Growth Hormone and related products 3 3 PA No generic available

Norelgestromin/Ethin.Estradiol Contraceptives-Misc. Free As Free As QL This medication is generic Preventive Preventive Noreth A-Et Estra/Fe Fumarate Contraceptives-Monophasic/Triphasic Free As Free As None This medication is generic Preventive Preventive Noreth-Ethinyl Estradiol/Iron Contraceptives-Monophasic Free As Free As None This medication is generic Preventive Preventive Norethindrone Contraceptives-Misc. Free As Free As None This medication is generic Preventive Preventive Norethindrone Acetate Progestins 1 1 None This medication is generic Norethindrone Ac-Eth Estradiol Estrogen and progestin combinations 1 1 None This medication is generic

Norethindrone A-E Estradiol Contraceptives-Monophasic Free As Free As None This medication is generic Preventive Preventive Norethindrone-Ethinyl Estrad Contraceptives- Free As Free As None This medication is generic Monophasic/Biphasic/Triphasic Preventive Preventive Norethindrone-Mestranol Contraceptives-Monophasic Free As Free As None This medication is generic Preventive Preventive Norflex* Skeletal muscle relaxants 3 3 None Orphenadrine Citrate Norgesic, Forte* Skeletal muscle relaxants 3 3 None Orphenadrine/Aspirin/Caffeine Norgestimate-Ethinyl Estradiol Contraceptives-Monophasic/Triphasic 3 3 None This medication is generic

Norgestrel-Ethinyl Estradiol Contraceptives-Monophasic 3 3 None This medication is generic Norinyl/Ortho-Novum 1/35* Contraceptives-Monophasic 3 3 None Norethindrone-Mestranol Norinyl/Ortho-Novum 1/50* Contraceptives-Monophasic 3 3 None Norethindrone-Ethinyl Estrad Noritate Acne treatment 3 3 None No generic available Norlyda Contraceptives Free As Free As None This medication is generic Preventive Preventive Normodyne; Trandate* Beta blockers and combinations 3 3 None Labetalol Hcl Norpace CR Cardiovascular treatment 2 2 None No generic available Norpace* Cardiovascular treatment 3 3 None Disopyramide Phosphate Norpramin* Antidepressants 3 3 None Desipramine Hcl Nor-QD; Ortho Micronor* Contraceptives-Misc. 3 3 None Norethindrone, Norlyda Northera Cardiovascular treatment 3 3 PA, QL No generic available Nortriptyline Hcl Antidepressants 1 1 None This medication is generic Norvasc* Calcium channel blockers and 3 3 None Amlodipine Besylate combinations Norvir Antiretrovirals 2 2 None No generic available Novarel Infertility treatment 2 2 PA No generic available Novolin (all forms) Insulins 2 2 None No generic available Novolog (all forms) Insulins 2 2 None No generic available Noxafil suspension Antifungals 2 2 None No generic available Noxafil tablet Antifungals 2 2 QL No generic available NP Thyroid* Thyroid hormones 1 1 None This medication is generic Nucynta, ER Narcotics 3 3 PA, QL No generic available Nuedexta Miscellaneous CNS 2 2 PA, QL No generic available Nulytely (Preventive)* Bowel preparation and cleansing Free As Free As QL Sod Sulf/Sod/Nahco3/Kcl/Peg'S agents Preventive Preventive Nulytely* Bowel preparation and cleansing 3 3 None Sod Sulf/Sod/Nahco3/Kcl/Peg'S agents Nuplazid Antipsychotics/Parkinsons disease and 3 3 PA, QL No generic available related disorders Nutropin AQ, Nuspin Growth Hormone and related products 2 2 PA No generic available

Nuvaring Contraceptives-Misc. Free As Free As QL No generic available Preventive Preventive Nuvessa Vaginal anti-infective and antifungal 3 3 None No generic available

Nuvigil* CNS stimulants 3 3 QL Armodafinil

Updated 11/13/2017 Drug name Category of drug Choices Tier ABC Tier Limits Generic equivalent if available Nymalize Miscellaneous CNS 3 3 QL No generic available Nystatin Vaginal anti-infective and antifungal 1 1 None This medication is generic

Nystatin w/triamcinolone* Topical antifungals 3 3 None Nystatin/Triamcin Nystatin/Triamcin Topical antifungals 1 1 None This medication is generic Obredon Antitussives 3 3 QL No generic available Ocaliva Bile acids 2 2 PA, QL No generic available Octreotide Acetate Somatostatin analogs/antineoplastic 1 1 PA This medication is generic agents Ocufen* Ophthalmic anti-inflammatory agents 3 3 None Flurbiprofen Sodium

Ocuflox* Ophthalmic anti-infectives 3 3 None Ofloxacin Ocupress* Ophthalmic beta blockers 3 3 None Carteolol Hcl Odefsey Antiretrovirals 2 2 QL No generic available Odomzo Miscellaneous antineoplastic agents 2 2 PA, QL No generic available

Ofev Miscellaneous respiratory agents 3 3 PA, QL No generic available

Ofloxacin Quinolones/Otic 1 1 None This medication is generic preparations/Ophthalmic anti- infectives Ogen* Estrogens/Osteoporosis and hormonal 3 3 None Estropipate treatment Olanzapine Antipsychotics 1 1 None This medication is generic Olanzapine/Fluoxetine Hcl Antipsychotics 1 1 None This medication is generic Olmesartan Medoxomil Angiotensin II Receptor Blockers and 1 Free As None This medication is generic combinations Preventive Olmesartan/Amlodipin/Hcthiazid Angiotensin II Receptor Blockers and 1 Free As QL This medication is generic combinations Preventive Olmesartan/Hydrochlorothiazide Angiotensin II Receptor Blockers and 1 Free As None This medication is generic combinations Preventive Olopatadine drops Ophthalmic anti-allergy agents 1 1 None This medication is generic Olopatadine Hcl Antihistamines 1 1 QL This medication is generic Olopatadine Hcl (generic Patanase) Nasal preparations 1 1 QL This medication is generic Olopatadine Hcl (generic Patanol) Ophthalmic anti-allergy agents 1 1 None This medication is generic Olux* Corticosteriods - very high potency 3 3 None Clobetasol Propionate

Olux-E* Corticosteriods - very high potency 3 3 None Clobetasol Propionate/Emoll

Olysio Antivirals 3 3 PA, QL No generic available Omega-3 Acid Ethyl Esters Lipid-lowering agents 1 1 None This medication is generic Omeprazole (Rx only) Proton Pump Inhibitors (PPI) 1 1 None This medication is generic Omeprazole/Sodium Bicarbonate Proton Pump Inhibitors (PPI) 1 1 ST, QL This medication is generic Omnaris Nasal preparations 3 3 ST, QL No generic available Omnicef* Cephalosporins 3 3 None Cefdinir Omnitrope Growth Hormone and related products 3 3 PA No generic available

Ondansetron Antiemetics 1 1 None This medication is generic Onexton Acne treatment 3 3 ST, QL No generic available Onfi Anticonvulsants 3 3 PA, QL No generic available Onglyza Non-insulin hypoglycemic agents 2 2 QL No generic available

Onzetra Xsail Migraine therapy 3 3 ST, QL No generic available Opana ER* Narcotics 3 3 PA, QL Oxymorphone Hcl Opana* Narcotics 3 3 QL Oxymorphone Hcl Opium/Belladonna Alkaloids Narcotics 1 1 None This medication is generic Opsumit Pulmonary Hypertension Agents 2 2 PA, QL No generic available Opticrom* Ophthalmic anti-allergy agents 3 3 None Cromolyn Sodium Optipranolol* Ophthalmic beta blockers 3 3 None Metipranolol Optivar* Ophthalmic anti-allergy agents 3 3 None Azelastine Hcl Oracea Tetracyclines/Acne treatment 3 3 PA No generic available Oral saline laxative liquid OTC* Bowel preparation and cleansing Free As Free As QL Na Phos,M-B/Na Phos,Di-Ba agents Preventive Preventive Oralair Miscellaneous respiratory agents 3 3 PA, QL No generic available

Oralone paste* Corticosteroids - medium potency 3 3 None Triamcinolone Acetonide

Orap* Antipsychotics 3 3 None Pimozide Orapred ODT* Corticosteroids 3 3 None Prednisolone Sod Phosphate Orapred solution 15mg/5ml* Corticosteroids 3 3 None Prednisolone Sod Phosphate Oravig Antifungals 3 3 QL No generic available

Updated 11/13/2017 Drug name Category of drug Choices Tier ABC Tier Limits Generic equivalent if available Orencia Clickject, sub-q Non-Tumor Necrosis Factor (TNF) 3 3 PA, QL No generic available blocking agents Orenitram ER Pulmonary Hypertension Agents 2 2 PA, QL No generic available Orfadin Diagnostics and Other Miscellaneous 2 2 None No generic available

Orinase* Non-insulin hypoglycemic agents 3 3 None Tolbutamide

Orkambi Cystic Fibrosis agents 2 2 PA, QL No generic available Orphenadrine Citrate Skeletal muscle relaxants 1 1 None This medication is generic Orphenadrine/Aspirin/Caffeine Skeletal muscle relaxants 1 1 None This medication is generic Ortho Evra* Contraceptives-Misc. 3 3 QL Norelgestromin/Ethin.Estradiol Ortho Tri-Cyclen Lo* Contraceptives-Triphasic 3 3 None Norgestimate-Ethinyl Estradiol Ortho Tri-Cyclen* Contraceptives-Triphasic 3 3 None Norgestimate-Ethinyl Estradiol Ortho-Cyclen* Contraceptives-Monophasic 3 3 None Norgestimate-Ethinyl Estradiol Ortho-Novum 7/7/7* Contraceptives-Triphasic 3 3 None Norethindrone-Ethinyl Estrad Oseltamivir Phosphate Antivirals 1 1 QL This medication is generic Oseni Non-insulin hypoglycemic agents 3 3 ST, QL No generic available

Osmoprep Bowel preparation and cleansing 3 3 None No generic available agents Osphena Miscellaneous OB-GYN 3 3 None No generic available Otezla Non-Tumor Necrosis Factor (TNF) 3 3 PA, QL No generic available blocking agents/Antipsoriatic and antiseborrheic

Otovel Otic preparations 3 3 None No generic available Otrexup Miscellaneous rheumatologic 3 3 PA, QL No generic available agents/Antipsoriatic and antiseborrheic

Ovace, Plus* Antipsoriatic and antiseborrheic 3 3 None Sulfacetamide Sodium Ovcon 35* Contraceptives-Monophasic 3 3 None Norethindrone-Ethinyl Estrad Ovide* Scabicides and pediculicides 3 3 None Malathion Ovidrel Infertility treatment 2 2 None No generic available Ovral* Contraceptives-Monophasic 3 3 None Norgestrel-Ethinyl Estradiol Oxandrin* Androgens 3 3 PA Oxandrolone Oxandrolone Androgens 1 1 PA This medication is generic Oxaprozin Nonsteroidal anti-inflammatory drugs 1 1 None This medication is generic

Oxazepam Anxiolytics 1 1 None This medication is generic Oxcarbazepine Anticonvulsants 1 1 None This medication is generic Oxiconazole Nitrate Topical antifungals 1 1 PA, QL This medication is generic Oxistat lotion Topical antifungals 3 3 PA, QL No generic available Oxistat* Topical antifungals 3 3 PA, QL Oxiconazole Nitrate Oxsoralen-Ultra* Antipsoriatic and antiseborrheic 3 3 None Methoxsalen, Rapid Oxtellar XR Anticonvulsants 3 3 PA, QL No generic available Oxybutynin Chloride Urinary Antispasmodics 1 1 None This medication is generic Oxycodone Hcl Narcotics 1 1 QL This medication is generic Oxycodone hcl ER Narcotics 3 3 PA, QL No generic available Oxycodone Hcl/Acetaminophen Narcotic and analgesic combinations 1 1 QL This medication is generic

Oxycodone Hcl/Aspirin Narcotic and analgesic combinations 1 1 None This medication is generic

Oxycodone immediate release* Narcotics 3 3 QL Oxycodone Hcl Oxycontin Narcotics 3 3 PA, QL No generic available Oxymorphone Hcl (generic Opana ER) Narcotics 1 1 PA, QL This medication is generic

Oxymorphone Hcl (generic Opana) Narcotics 1 1 QL This medication is generic Oxytrol Urinary Antispasmodics 3 3 ST, QL No generic available Paliperidone Antipsychotics 1 1 QL This medication is generic Pancreaze Digestive enzymes 3 3 None Creon, Zenpep Pandel Corticosteroids - medium potency 3 3 None No generic available

Panretin Topical antineoplastic agents and 2 2 None No generic available immunomodulators Pantoprazole Sodium Proton Pump Inhibitors (PPI) 1 1 None This medication is generic Parafon Forte DSC* Skeletal muscle relaxants 3 3 None Chlorzoxazone Parcopa* Parkinsons disease and related 3 3 None Carbidopa/Levodopa disorders Paregoric Antidiarrheals and antispasmodics 1 1 None This medication is generic

Paregoric* Antidiarrheals and antispasmodics 3 3 None Paregoric

Updated 11/13/2017 Drug name Category of drug Choices Tier ABC Tier Limits Generic equivalent if available Paricalcitol Vitamin D analogs 1 1 None This medication is generic Parlodel* Parkinsons disease and related 3 3 None Bromocriptine Mesylate disorders Parnate* Antidepressants 3 3 None Tranylcypromine Sulfate Paromomycin Sulfate Antiparasitics and anthelmintics 1 1 None This medication is generic Paroxetine Hcl Antidepressants 1 1 None This medication is generic Paser Antituberculars 3 3 None No generic available Pataday Ophthalmic anti-allergy agents 3 3 None Olopatadine drops Patanase* Nasal preparations/Antihistamines 3 3 QL Olopatadine Hcl

Patanol* Ophthalmic anti-allergy agents 3 3 None Olopatadine Hcl Paxil CR* Antidepressants 3 3 None Paroxetine Hcl Paxil suspension Antidepressants 3 3 None No generic available Paxil* Antidepressants 3 3 None Paroxetine Hcl Pazeo Ophthalmic anti-allergy agents 3 3 QL No generic available Peg 3350/Na Sulf,Bicarb,Cl/Kcl Bowel preparation and cleansing 1 1 None This medication is generic agents Peg 3350/Na Sulf,Bicarb,Cl/Kcl (Preventive) Bowel preparation and cleansing Free As Free As QL This medication is generic agents Preventive Preventive Peganone Anticonvulsants 2 2 None No generic available Pegasys, Proclick Interferons and MS therapy 2 2 QL No generic available Peg-Intron, Redipen Interferons and MS therapy 2 2 QL No generic available Penicillin V Potassium Penicillins 1 1 None This medication is generic Penicillin VK* Penicillins 3 3 None Penicillin V Potassium Penlac* Topical antifungals 3 3 None Ciclopirox Pennsaid 1.5%* Nonsteroidal anti-inflammatory drugs 3 3 QL Diclofenac Sodium

Pennsaid 2% Nonsteroidal anti-inflammatory drugs 3 3 PA, QL No generic available

Pentasa 5-Aminosalicylic Acid (5-ASA) agents 2 2 None No generic available

Pentazocine Hcl/Naloxone Hcl Narcotic mixed agonist and antagonist 1 1 None This medication is generic

Pentoxifylline Anticoagulants and hemostasis agents 1 1 None This medication is generic

Pepcid (Rx Only)* H2-Receptor antagonists 3 3 None Famotidine Percocet* Narcotic and analgesic combinations 3 3 QL Oxycodone Hcl/Acetaminophen

Percodan* Narcotic and analgesic combinations 3 3 None Oxycodone Hcl/Aspirin

Perforomist Inhaled beta-agonists 3 3 None No generic available Periactin* Antihistamines 3 3 None Cyproheptadine Hcl Peridex* Miscellaneous anti-infectives 3 3 None Chlorhexidine Gluconate Perindopril Erbumine ACE-Inhibitors and combinations 1 Free As None This medication is generic Preventive Periostat* Tetracyclines 3 3 None Doxycycline Hyclate Permethrin Scabicides and pediculicides 1 1 None This medication is generic Persantine* Anticoagulants and hemostasis agents 3 3 None Dipyridamole

Pertzye Digestive enzymes 3 3 None No generic available Pexeva Antidepressants 3 3 ST No generic available Phendimetrazine Tartrate Weight Loss Preparations 1 Free As None This medication is generic Preventive Phenelzine Sulfate Antidepressants 1 1 None This medication is generic Phenergan DM* Antitussives 3 3 None D-Methorphan Hb/Prometh Hcl Phenergan VC w/Codeine* Antihistamines 3 3 None Promethazine/Phenyleph/Codeine

Phenergan VC* Antihistamines 3 3 None Phenylephrine Hcl/Prometh Hcl Phenergan w/Codeine* Antitussives 3 3 None Codeine/Promethazine Hcl Phenergan* Antiemetics/Antihistamines 3 3 None Promethazine Hcl Phenobarbital Anticonvulsants 1 1 None This medication is generic Phenoxybenzamine Hcl Alpha-adrenergic agents 1 Free As PA, QL This medication is generic Preventive Phentermine Hcl Weight Loss Preparations 1 Free As None This medication is generic Preventive Phenylephrine Hcl Miscellaneous ophthalmic agents 1 1 None This medication is generic

Phenylephrine Hcl/Prometh Hcl Antihistamines 1 1 None This medication is generic Phenytoin Anticonvulsants 1 1 None This medication is generic Phenytoin Sodium Extended Anticonvulsants 1 1 None This medication is generic Phoslo* Ion-Removing Agents 3 3 None Calcium Acetate Phoslyra Ion-Removing Agents 3 3 None No generic available

Updated 11/13/2017 Drug name Category of drug Choices Tier ABC Tier Limits Generic equivalent if available Phospholine Iodide Glaucoma agents 2 2 None No generic available Phrenilin tablet* Migraine therapy/Narcotic and 3 3 None Butalbital/Acetaminophen analgesic combinations Phytonadione Anticoagulants and hemostasis 1 1 None This medication is generic agents/Vitamins and Minerals Picato Topical antineoplastic agents and 3 3 PA, QL No generic available immunomodulators Pilocar; Isopto-Carpine* Glaucoma agents 3 3 None Pilocarpine Hcl Pilocarpine Hcl Miscellaneous gastrointestinal 1 1 None This medication is generic agents/Glaucoma agents Pimozide Antipsychotics 1 1 None This medication is generic Pindolol Beta blockers and combinations 1 Free As None This medication is generic Preventive Pioglitazone Hcl Non-insulin hypoglycemic agents 1 1 None This medication is generic

Pioglitazone Hcl/Metformin Hcl Non-insulin hypoglycemic agents 1 1 None This medication is generic

Pioglitazone/Glimepiride Non-insulin hypoglycemic agents 1 1 None This medication is generic

Piroxicam Nonsteroidal anti-inflammatory drugs 1 1 None This medication is generic

Plan B, One-Step* Contraceptives-Postcoital 3 3 QL Levonorgestrel Plaquenil* Antimalarials/Miscellaneous 3 3 None Hydroxychloroquine Sulfate rheumatologic agents Plavix* Anticoagulants and hemostasis agents 3 3 None Clopidogrel Bisulfate

Plegridy Interferons and MS therapy 3 3 PA, QL No generic available Plendil* Calcium channel blockers and 3 3 None Felodipine combinations Pletal* Anticoagulants and hemostasis agents 3 3 None Cilostazol

Plexion, TS* Acne treatment 3 3 None Sulfacetamide Sodium/Sulfur Pneumovax 23 Vaccines Free As Free As None No generic available Preventive Preventive Vaccine Vaccine Pnv Combo#47/Iron/Fa #1/Dha Vitamins and Minerals 1 1 None This medication is generic Pnv With Ca,No.72/Iron/Fa Vitamins and Minerals 1 1 None This medication is generic Podofilox Miscellaneous dermatologicals 1 1 None This medication is generic Polyethylene Glycol 3350 Bowel preparation and cleansing 1 1 None This medication is generic agents Polyethylene Glycol 3350 (Preventive) Bowel preparation and cleansing Free As Free As QL This medication is generic agents Preventive Preventive Polymyxin B Sulfate/Tmp Ophthalmic anti-infectives 1 1 None This medication is generic Polysporin* Ophthalmic anti-infectives 3 3 None Bacitracin/Polymyxin B Sulfate Polytrim* Ophthalmic anti-infectives 3 3 None Polymyxin B Sulfate/Tmp Poly-Vi-Flor Vitamins and Minerals 3 3 None No generic available Pomalyst Immunomodulators 3 3 PA, QL No generic available Ponstel* Nonsteroidal anti-inflammatory drugs 3 3 None Mefenamic Acid

Potassium Bicarbonate/Cit Ac Potassium Replacement 1 1 None This medication is generic Potassium Chloride Potassium Replacement 1 1 None This medication is generic Potassium Citrate Miscellaneous Urologicals 1 1 None This medication is generic Potiga Anticonvulsants 3 3 None No generic available Pradaxa Anticoagulants and hemostasis agents 3 3 QL Warfarin

Praluent Lipid-lowering agents 3 3 PA, QL No generic available Pramipexole Di-Hcl Parkinsons disease and related 1 1 None This medication is generic disorders Pramipexole Di-Hcl (generic Mirapex ER) Parkinsons disease and related 1 1 PA, QL This medication is generic disorders Pramosone cream* Topical anti-Inflammatory agents 3 3 None Hydrocortisone/Pramoxine

Pramosone lotion, ointment Topical anti-Inflammatory agents 3 3 None No generic available

PrandiMet* Non-insulin hypoglycemic agents 3 3 None Repaglinide/Metformin Hcl

Prandin* Non-insulin hypoglycemic agents 3 3 None Repaglinide

Prasugrel Anticoagulants and hemostasis agents 1 1 None This medication is generic

Pravachol* Lipid-lowering agents 3 3 QL Pravastatin Sodium

Updated 11/13/2017 Drug name Category of drug Choices Tier ABC Tier Limits Generic equivalent if available Pravastatin Sodium Lipid-lowering agents 1 Free As QL This medication is generic Preventive Prazosin Hcl Alpha-adrenergic agents 1 Free As None This medication is generic Preventive Precose* Non-insulin hypoglycemic agents 3 3 None Acarbose

Pred Forte* Ophthalmic steroids 3 3 None Prednisolone Acetate Pred Mild Ophthalmic steroids 2 2 None No generic available Pred-G Ophthalmic anti-infective and steroid 3 3 None No generic available

Prednicarbate Corticosteroids - medium potency 1 1 None This medication is generic

Prednisolone Corticosteroids 1 1 None This medication is generic Prednisolone Acetate Ophthalmic steroids 1 1 None This medication is generic Prednisolone Sod Phosphate Corticosteroids/Ophthalmic steroids 1 1 None This medication is generic

Prednisolone, tablet, syrup* Corticosteroids 3 3 None Prednisolone Prednisone Corticosteroids/Immunomodulators 1 1 None This medication is generic

Prefest Estrogen and progestin combinations 3 3 None No generic available

Pregnyl Infertility treatment 2 2 PA No generic available Premarin, Low Dose, cream Estrogens/Osteoporosis and hormonal 2 2 None No generic available treatment Prempro, Low Dose; Premphase Estrogen and progestin 2 2 None No generic available combinations/Osteoporosis and hormonal treatment Prenatal Plus, Tricare* Vitamins and Minerals 3 3 None Pnv With Ca,No.72/Iron/Fa Prenatal Vit/Iron,Carb/Doss/Fa Vitamins and Minerals 1 1 None This medication is generic Prenatal Vitamins* Vitamins and Minerals 3 3 None Prenatal Vit/Iron,Carb/Doss/Fa Prepopik Bowel preparation and cleansing 3 3 None No generic available agents Prestalia ACE-Inhibitors and 3 3 ST, QL No generic available combinations/Calcium channel blockers and combinations Prevacid capsule* Proton Pump Inhibitors (PPI) 3 3 None Lansoprazole Prevacid Solutab Proton Pump Inhibitors (PPI) 2 2 None No generic available Prevident* Vitamins and Minerals 3 3 None Sodium Fluoride Prevnar 13 Vaccines Free As Free As None No generic available Preventive Preventive Vaccine Vaccine Prevpac* Ulcer therapy 3 3 None Lansoprazole/Amoxiciln/Clarith Prezcobix Antiretrovirals 2 2 QL No generic available Prezista Antiretrovirals 2 2 None No generic available Priftin Antituberculars 3 3 None No generic available Prilosec capsule* (Rx only) Proton Pump Inhibitors (PPI) 3 3 None Omeprazole Prilosec suspension Proton Pump Inhibitors (PPI) 3 3 None No generic available Primaquine Antimalarials 2 2 None No generic available Primidone Anticonvulsants 1 1 None This medication is generic Primsol Urinary tract agents 3 3 None No generic available Prinivil; Zestril* ACE-Inhibitors and combinations 3 3 None Lisinopril Prinzide; Zestoretic* ACE-Inhibitors and combinations 3 3 None Lisinopril/Hydrochlorothiazide Pristiq Antidepressants 3 3 ST No generic available Proair HFA, Respiclick; Ventolin HFA Inhaled beta-agonists 2 2 QL No generic available Proamatine* Cardiovascular treatment 3 3 None Midodrine Hcl Pro-Banthine* Antidiarrheals and 3 3 None Propantheline Bromide antispasmodics/Urinary Antispasmodics Probenecid Gout therapy 1 1 None This medication is generic Procardia, XL; Adalat CC* Calcium channel blockers and 3 3 None Nifedipine combinations Procentra* CNS stimulants 3 3 None D-Amphetamine Sulfate Prochlorperazine Antiemetics 1 1 None This medication is generic Prochlorperazine Maleate Antiemetics 1 1 None This medication is generic Procrit Adjuvant therapy/Hematopoietic 2 2 PA No generic available agents Proctocort* Topical anti-Inflammatory agents 3 3 None Hydrocortisone Acetate

Proctofoam-HC Topical anti-Inflammatory agents 2 2 None No generic available

Procto-Pak* Topical anti-Inflammatory agents 3 3 None Hydrocortisone

Updated 11/13/2017 Drug name Category of drug Choices Tier ABC Tier Limits Generic equivalent if available Proctosol-HC suppository* Topical anti-Inflammatory agents 3 3 None Hydrocortisone Acetate

Procysbi Miscellaneous Urologicals 3 3 PA No generic available Progesterone Progestins 1 1 None This medication is generic Progesterone in Oil (Inj)* Progestins 3 3 None Progesterone Progesterone,Micronized Progestins 1 1 None This medication is generic Proglycem Miscellaneous endocrine 2 2 None No generic available Prograf * Immunomodulators 3 3 None Tacrolimus Anhydrous Prolensa Ophthalmic anti-inflammatory agents 3 3 None No generic available

Prolixin* Antipsychotics 3 3 None Fluphenazine Hcl Promacta Hematopoietic agents 2 2 PA No generic available Promethazine Hcl Antiemetics/Antihistamines 1 1 None This medication is generic Promethazine/Phenyleph/Codeine Antihistamines 1 1 None This medication is generic Prometrium* Progestins 3 3 None Progesterone,Micronized Propafenone Hcl Cardiovascular treatment 1 1 None This medication is generic Propantheline Bromide Antidiarrheals and 1 1 None This medication is generic antispasmodics/Urinary Antispasmodics Propranolol Hcl Beta blockers and combinations 1 Free As None This medication is generic Preventive Propranolol/Hydrochlorothiazide Beta blockers and combinations 1 Free As None This medication is generic Preventive Propylthiouracil Antithyroid agents 1 1 None This medication is generic Proscar* BPH Treatment 3 3 None Finasteride Prosom* Sedative and hypnotics 3 3 QL Estazolam Protonix suspension Proton Pump Inhibitors (PPI) 3 3 None No generic available Protonix tablet* Proton Pump Inhibitors (PPI) 3 3 None Pantoprazole Sodium Protopic* Topical antineoplastic agents and 3 3 None Tacrolimus immunomodulators Protriptyline Hcl Antidepressants 1 1 None This medication is generic Proventil HFA Inhaled beta-agonists 3 3 QL No generic available Proventil solution* Oral beta-agonists 3 3 None Albuterol Sulfate Provera* Progestins 3 3 None Medroxyprogesterone Acet Provigil* CNS stimulants 3 3 QL Modafinil Prozac Weekly* Antidepressants 3 3 QL Fluoxetine Hcl Prozac* Antidepressants 3 3 None Fluoxetine Hcl Pseudoephed/Hydrocodone/Cpm Antitussives 1 1 QL This medication is generic Pulmicort Flexhaler Inhaled steroids 2 2 QL No generic available Pulmicort solution* Inhaled steroids 3 3 None Budesonide Pulmozyme Cystic Fibrosis agents 2 2 None No generic available Purinethol* Antimetabolites 3 3 None Mercaptopurine Purixan Antimetabolites 3 3 PA No generic available Pylera Ulcer therapy 3 3 None No generic available Pyrazinamide Antituberculars 1 1 None This medication is generic Pyridostigmine Bromide Myesthenia gravis 1 1 None This medication is generic Qbrelis ACE-Inhibitors and combinations 3 Free As QL No generic available Preventive Qnasl Nasal preparations 3 3 ST, QL No generic available Qsymia Weight Loss Preparations 3 Free As PA, QL No generic available Preventive Qualaquin* Antimalarials 3 3 None Quinine Sulfate Quartette Contraceptives-Misc. 3 3 QL L-Norgest-Eth Estr/Ethin Estra Quazepam Sedative and hypnotics 1 1 QL This medication is generic Qudexy XR Anticonvulsants 3 3 PA, QL No generic available Questran* Lipid-lowering agents 3 3 None Cholestyramine Questran Light* Lipid-lowering agents 3 3 None Cholestyramine light Quetiapine Fumarate Antipsychotics 1 1 None This medication is generic Quetiapine Fumarate (generic Seroquel XR) Antipsychotics 1 1 ST, QL This medication is generic

Quillichew ER CNS stimulants 3 3 PA, QL No generic available Quillivant XR CNS stimulants 3 3 PA, QL No generic available Quinapril Hcl ACE-Inhibitors and combinations 1 Free As None This medication is generic Preventive Quinapril/Hydrochlorothiazide ACE-Inhibitors and combinations 1 Free As None This medication is generic Preventive Quinidex* Cardiovascular treatment 3 3 None Quinidine Sulfate Quinidine Gluconate Cardiovascular treatment 1 1 None This medication is generic Quinidine gluconate SA* Cardiovascular treatment 3 3 None Quinidine Gluconate Quinidine Sulfate Cardiovascular treatment 1 1 None This medication is generic Quinine Sulfate Antimalarials 1 1 None This medication is generic Quixin* Ophthalmic anti-infectives 3 3 None Levofloxacin

Updated 11/13/2017 Drug name Category of drug Choices Tier ABC Tier Limits Generic equivalent if available Qvar Inhaled steroids 2 2 QL No generic available Rabeprazole Sodium Proton Pump Inhibitors (PPI) 1 1 None This medication is generic Radiogardase Diagnostics and Other Miscellaneous 2 2 None No generic available

Ragwitek Miscellaneous respiratory agents 3 3 PA, QL No generic available

Raloxifene Hcl Osteoporosis and bone 1 1 QL This medication is generic resorption/Hormonal agents Raloxifene Hcl (Preventive) Hormonal agents Free As Free As PA, QL This medication is generic Preventive Preventive Ramipril ACE-Inhibitors and combinations 1 Free As None This medication is generic Preventive Ranexa Cardiovascular treatment 3 3 None No generic available Ranitidine Hcl H2-Receptor antagonists 1 1 None This medication is generic Rapaflo BPH Treatment 3 3 QL No generic available Rapamune solution Immunomodulators 2 2 None No generic available Rapamune tablet* Immunomodulators 3 3 None Sirolimus Rasuvo Miscellaneous rheumatologic 3 3 PA, QL No generic available agents/Antipsoriatic and antiseborrheic

Ravicti Urea cycle disorder agents 3 3 PA, QL No generic available Rayos Corticosteroids/Immunomodulators 3 3 PA, QL No generic available

Razadyne, ER* Alzheimer's therapy 3 3 None Galantamine Hydrobromide Rebetol capsule* Antivirals 3 3 None Ribavirin Rebetol solution Antivirals 2 2 None No generic available Rebif, Rebidose Interferons and MS therapy 2 2 None No generic available Rectiv Miscellaneous gastrointestinal agents 3 3 QL No generic available

Regimex Weight Loss Preparations 3 3 None No generic available Reglan* Miscellaneous gastrointestinal agents 3 3 None Metoclopramide Hcl

Regranex Wound and burn therapy 3 3 None No generic available Relafen* Nonsteroidal anti-inflammatory drugs 3 3 None Nabumetone

Relenza Antivirals 2 2 QL No generic available Relistor syringe Narcotic antagonists/Miscellaneous 2 2 PA, QL No generic available gastrointestinal agents

Relistor tablet Narcotic antagonists/Miscellaneous 3 3 PA, QL No generic available gastrointestinal agents

Relistor vial Narcotic antagonists/Miscellaneous 2 2 PA No generic available gastrointestinal agents

Relpax Migraine therapy 3 3 ST, QL No generic available Remeron* Antidepressants 3 3 None Mirtazapine Remodulin Pulmonary Hypertension Agents 3 3 None No generic available Renacidin Miscellaneous Urologicals 2 2 None No generic available Renagel Ion-Removing Agents 2 2 None No generic available Renvela Ion-Removing Agents 2 2 None No generic available Repaglinide Non-insulin hypoglycemic agents 1 1 None This medication is generic

Repaglinide/Metformin Hcl Non-insulin hypoglycemic agents 1 1 None This medication is generic

Repatha Lipid-lowering agents 3 3 PA, QL No generic available Requip, XL* Parkinsons disease and related 3 3 None Ropinirole Hcl disorders Rescriptor Antiretrovirals 2 2 None No generic available Reserpine Alpha-adrenergic agents 1 Free As None This medication is generic Preventive Restasis, multidose Miscellaneous ophthalmic agents 2 2 None No generic available

Restoril* Sedative and hypnotics 3 3 QL Temazepam Retin-A Micro pump 0.08% Acne treatment 3 3 None No generic available Retin-A Micro, pump* Acne treatment 3 3 None Tretinoin Microspheres Retin-A* Acne treatment 3 3 None Tretinoin Retrovir* Antiretrovirals 3 3 None Zidovudine Revatio suspension Pulmonary Hypertension Agents 2 2 PA, QL No generic available Revatio* Pulmonary Hypertension Agents 3 3 QL Sildenafil Citrate Revia* Narcotic antagonists 3 3 None Naltrexone Hcl Revlimid Immunomodulators 3 3 QL No generic available

Updated 11/13/2017 Drug name Category of drug Choices Tier ABC Tier Limits Generic equivalent if available Rexulti Antipsychotics 3 3 PA, QL No generic available Reyataz Antiretrovirals 2 2 None No generic available Rezira Antitussives 3 3 QL No generic available Rhinocort Aqua* Nasal preparations 3 3 ST, QL Budesonide Ribasphere, Ribapak* Antivirals 3 3 None Ribavirin Ribatab* Antivirals 3 3 None Ribavirin Ribavirin Antivirals 1 1 None This medication is generic Ridaura Miscellaneous rheumatologic agents 2 2 None No generic available

Rifabutin Antituberculars 1 1 None This medication is generic Rifadin* Antituberculars 3 3 None Rifampin Rifampin Antituberculars 1 1 None This medication is generic Rifater Antituberculars 3 3 None No generic available Rilutek* Miscellaneous CNS 3 3 None Riluzole Riluzole Miscellaneous CNS 1 1 None This medication is generic Rimantadine Hcl Antivirals 1 1 None This medication is generic Riomet Non-insulin hypoglycemic agents 3 3 None No generic available

Risedronate Sodium Osteoporosis and bone resorption 1 1 ST, QL This medication is generic

Risperdal, M-Tab, solution* Antipsychotics 3 3 None Risperidone Risperidone Antipsychotics 1 1 None This medication is generic Ritalin LA 10mg, 60mg CNS stimulants 3 3 None No generic available Ritalin, LA, SR* CNS stimulants 3 3 None Methylphenidate Hcl Rivastigmine Alzheimer's therapy 1 1 None This medication is generic Rivastigmine Tartrate Alzheimer's therapy 1 1 None This medication is generic Rizatriptan Benzoate Migraine therapy 1 1 QL This medication is generic RMS suppository* Narcotics 3 3 None Morphine Sulfate Robaxin* Skeletal muscle relaxants 3 3 None Methocarbamol Robinul, Forte* Ulcer therapy 3 3 None Glycopyrrolate Robitussin AC* Antitussives 3 3 None Guaifenesin/Codeine Phosphate Rocaltrol* Vitamin D analogs 3 3 None Calcitriol Ropinirole Hcl Parkinsons disease and related 1 1 None This medication is generic disorders Rosula medicated pad* Acne treatment 3 3 None Sulfacetamide Sod/Sulfur/Urea Rosuvastatin Calcium Lipid-lowering agents 1 Free As QL This medication is generic Preventive Rowasa enema; SfRowasa enema* 5-Aminosalicylic Acid (5-ASA) agents 3 3 None Mesalamine

Roxanol* Narcotics 3 3 None Morphine Sulfate Rozerem Sedative and hypnotics 3 3 QL No generic available Rubraca Ovarian cancer 2 2 PA, QL No generic available Ruconest Miscellaneous immunology and 3 3 PA, QL No generic available hematology Rulavite DHA* Vitamins and Minerals 3 3 None Pnv Combo#47/Iron/Fa #1/Dha Rydapt Oncology 2 2 PA, QL No generic available Rytary Parkinsons disease and related 3 3 ST, QL No generic available disorders Rythmol, SR* Cardiovascular treatment 3 3 None Propafenone Hcl Ryzolt* Narcotic mixed agonist and antagonist 3 3 None Tramadol Hcl

Sabril* Anticonvulsants 2 2 None Vigabatrin Safyral Contraceptives-Misc. 3 3 None No generic available Saizen Growth Hormone and related products 3 3 PA No generic available

Salagen* Miscellaneous gastrointestinal agents 3 3 None Pilocarpine Hcl

Salsalate Salicylates 1 1 None This medication is generic Samsca Diagnostics and Other Miscellaneous 2 2 QL No generic available

Sanctura XR* Urinary Antispasmodics 3 3 QL Trospium Chloride Sanctura* Urinary Antispasmodics 3 3 QL Trospium Chloride Sancuso Antiemetics 3 3 PA, QL No generic available Sandimmune capsule* Immunomodulators 3 3 None Cyclosporine Sandimmune solution Immunomodulators 3 3 None No generic available Sandostatin LAR, Depot Somatostatin analogs/Miscellaneous 2 2 PA No generic available antineoplastic agents

Sandostatin* Somatostatin analogs/Miscellaneous 3 3 PA Octreotide Acetate antineoplastic agents

Santyl Wound and burn therapy 2 2 None No generic available

Updated 11/13/2017 Drug name Category of drug Choices Tier ABC Tier Limits Generic equivalent if available Saphris Antipsychotics 3 3 ST, QL No generic available Sarafem Antidepressants 3 3 None No generic available Savaysa Anticoagulants and hemostasis agents 3 3 QL No generic available

Savella Miscellaneous CNS 3 3 PA, QL No generic available Saxenda Weight Loss Preparations 3 Free As PA, QL No generic available Preventive Scopolamine Antiemetic/antivertigo agent 1 1 None This medication is generic Seasonale* Contraceptives-Monophasic 3 3 QL Levonorgestrel-Eth Estra Seasonique* Contraceptives-Biphasic 3 3 QL L-Norgest-Eth Estr/Ethin Estra Secobarbital Sodium Sedative and hypnotics 1 1 None This medication is generic Seconal* Sedative and hypnotics 3 3 None Secobarbital Sodium Sectral* Beta blockers and combinations 3 3 None Acebutolol Hcl Selegiline Hcl Parkinsons disease and related 1 1 None This medication is generic disorders Selenium Sulfide Antipsoriatic and antiseborrheic 1 1 None This medication is generic Selsun 2.5% (Rx Only)* Antipsoriatic and antiseborrheic 3 3 None Selenium Sulfide Selzentry Antiretrovirals 2 2 None No generic available Semprex-D Antihistamines 3 3 None No generic available Sensipar Miscellaneous endocrine 2 2 None No generic available Serax* Anxiolytics 3 3 None Oxazepam Serevent Diskus Inhaled beta-agonists 2 2 QL No generic available Seroquel XR* Antipsychotics 3 3 ST, QL Quetiapine Fumarate Seroquel* Antipsychotics 3 3 None Quetiapine Fumarate Serostim Growth Hormone and related products 3 3 PA No generic available

Sertraline Hcl Antidepressants 1 1 None This medication is generic Serzone* Antidepressants 3 3 None Nefazodone Hcl Signifor Somatostatin analogs 2 2 PA, QL No generic available Signifor LAR Somatostatin analogs 3 3 PA, QL No generic available Sildenafil Citrate Pulmonary Hypertension Agents 1 1 QL This medication is generic Silenor Sedative and hypnotics 3 3 ST, QL No generic available Silvadene* Wound and burn therapy 3 3 None Silver Sulfadiazine Silver Sulfadiazine Wound and burn therapy 1 1 None This medication is generic Simbrinza Glaucoma agents 3 3 None No generic available Simponi Tumor Necrosis Factor (TNF) blocking 3 3 PA, QL No generic available agents Simvastatin Lipid-lowering agents 1 Free As QL This medication is generic Preventive Sinemet, CR* Parkinsons disease and related 3 3 None Carbidopa/Levodopa disorders Singulair* Miscellaneous respiratory agents 3 3 QL Montelukast Sodium

Sirolimus Immunomodulators 1 1 None This medication is generic Sirturo Antituberculars 2 2 PA No generic available Sitavig Antivirals 3 3 ST, QL No generic available Sivextro Miscellaneous anti-infectives 2 2 QL No generic available Skelaxin* Skeletal muscle relaxants 3 3 None Metaxalone Sklice Scabicides and pediculicides 3 3 QL No generic available Sod Sulf/Sod/Nahco3/Kcl/Peg'S Bowel preparation and cleansing 1 1 None This medication is generic agents Sod Sulf/Sod/Nahco3/Kcl/Peg'S (Preventive) Bowel preparation and cleansing Free As Free As QL This medication is generic agents Preventive Preventive Sodium Chloride For Inhalation Miscellaneous respiratory agents 1 1 None This medication is generic

Sodium Fluoride Vitamins and Minerals 1 Free As None This medication is generic Preventive Sodium Fluoride (Preventive) Vitamins and Minerals Free As Free As None This medication is generic Preventive Preventive Sodium Phenylbutyrate Urea cycle disorder agents 1 1 None This medication is generic Sodium Polystyrene Sulfonate Ion-Removing Agents 1 1 None This medication is generic Solaraze* Miscellaneous dermatologicals 3 3 PA, QL Diclofenac Sodium Solodyn 55, 65, 80, 105, 115mg Tetracyclines/Acne treatment 3 3 PA No generic available Solodyn* Tetracyclines/Acne treatment 3 3 PA Minocycline Hcl Soltamox Hormonal agents 3 3 None No generic available Soma Compound w/codeine* Skeletal muscle relaxants 3 3 None Codeine Phos/Carisoprodol/Asa Soma Compound* Skeletal muscle relaxants 3 3 None Carisoprodol/Aspirin Soma* Skeletal muscle relaxants 3 3 None Carisoprodol Somatuline Depot Somatostatin 2 2 PA, QL No generic available analogs/Immunomodulators Somavert Miscellaneous endocrine 2 2 PA No generic available Sonata* Sedative and hypnotics 3 3 QL Zaleplon

Updated 11/13/2017 Drug name Category of drug Choices Tier ABC Tier Limits Generic equivalent if available Soolantra Miscellaneous dermatologicals 3 3 ST, QL No generic available Soriatane* Antipsoriatic and antiseborrheic 3 3 None Acitretin Sorilux Antipsoriatic and antiseborrheic 3 3 None No generic available Sotalol Hcl Beta blockers and 1 Free As None This medication is generic combinations/Cardiovascular Preventive treatment Sotylize Beta blockers and 3 3 PA No generic available combinations/Cardiovascular treatment Sovaldi Antivirals 3 3 PA, QL No generic available Spectazole* Topical antifungals 3 3 None Econazole Nitrate Spectracef* Cephalosporins 3 3 None Cefditoren Pivoxil Spinosad Scabicides and pediculicides 1 1 None This medication is generic Spiriva, Respimat Inhaled anticholinergics 2 2 QL No generic available Spironolactone/Hydrochlorothiazid Diuretics 1 Free As None This medication is generic Preventive Spironolactone Diuretics 1 Free As None This medication is generic Preventive Sporanox capsule* Antifungals 3 3 None Itraconazole Sporanox solution Antifungals 2 2 None No generic available Spritam Anticonvulsants 3 3 PA, QL No generic available Sprix Nonsteroidal anti-inflammatory drugs 3 3 QL No generic available

Sprycel Kinase inhibitors and molecular target 2 2 QL No generic available inhibitors SPS* Ion-Removing Agents 3 3 None Sodium Polystyrene Sulfonate SSKI Antithyroid agents 3 3 None No generic available Stadol, NS* Narcotic mixed agonist and antagonist 3 3 None Butorphanol Tartrate

Stalevo* Parkinsons disease and related 3 3 None Carbidopa/Levodopa/Entacapone disorders Starlix* Non-insulin hypoglycemic agents 3 3 None Nateglinide

Stavudine Antiretrovirals 1 1 None This medication is generic Staxyn Sexual Dysfunction 3 3 QL No generic available Stelara Miscellaneous gastrointestinal 3 3 PA, QL No generic available agents/Antipsoriatic and antiseborrheic

Stelazine* Antipsychotics 3 3 None Trifluoperazine Hcl Stendra Sexual Dysfunction 3 3 QL No generic available Stimate Miscellaneous endocrine 2 2 None No generic available Stiolto Respimat Inhaled beta-agonist and 2 2 QL No generic available anticholinergic Stivarga Kinase inhibitors and molecular target 2 2 PA, QL No generic available inhibitors Strattera Miscellaneous CNS 3 3 None Atomoxetine Strensiq Miscellaneous endocrine 2 2 PA, QL No generic available Striant Androgens 3 3 PA, QL No generic available Stribild Antiretrovirals 2 2 QL No generic available Striverdi Respimat Inhaled beta-agonists 3 3 QL No generic available Stromectol* Antiparasitics and anthelmintics 3 3 None Ivermectin Suboxone Film Narcotic mixed agonist and antagonist 2 2 QL No generic available

Suboxone* Narcotic mixed agonist and antagonist 3 3 QL Buprenorphine Hcl/Naloxone Hcl

Subsys Narcotics 3 3 PA, QL No generic available Subutex* Narcotic mixed agonist and antagonist 3 3 PA, QL Buprenorphine Hcl

Sucraid Miscellaneous gastrointestinal agents 3 3 None No generic available

Sucralfate Ulcer therapy 1 1 None This medication is generic Sular* Calcium channel blockers and 3 3 None Nisoldipine combinations Sulfacetamide Sod/Sulfur/Urea Acne treatment 1 1 None This medication is generic Sulfacetamide Sodium Acne treatment/Antipsoriatic and 1 1 None This medication is generic antiseborrheic/Ophthalmic anti- infectives Sulfacetamide Sodium/Sulfur Acne treatment 1 1 None This medication is generic Sulfacetamide/Prednisolone Sp Ophthalmic anti-infective and steroid 1 1 None This medication is generic

Sulfacet-R* Acne treatment 3 3 None Sulfacetamide Sodium/Sulfur Sulfadiazine Sulfonamides and combination 1 1 None This medication is generic

Updated 11/13/2017 Drug name Category of drug Choices Tier ABC Tier Limits Generic equivalent if available Sulfadiazine* Sulfonamides and combination 3 3 None Sulfadiazine Sulfamethoxazole/Trimethoprim Sulfonamides and combination 1 1 None This medication is generic Sulfasalazine 5-Aminosalicylic Acid (5-ASA) 1 1 None This medication is generic agents/Miscellaneous rheumatologic agents Sulindac Nonsteroidal anti-inflammatory drugs 1 1 None This medication is generic

Sumatriptan Succinate Migraine therapy 1 1 QL This medication is generic Sumavel Dosepro Migraine therapy 3 3 ST, QL No generic available Supervite Vitamins and Minerals 3 3 None No generic available Suprax chew, capsule, tablet Cephalosporins 3 3 None No generic available Suprax suspension 100mg/5ml, Cephalosporins 3 3 None Cefixime 200mg/5ml* Suprax suspension 500mg/5ml Cephalosporins 3 3 None No generic available Suprep Bowel preparation and cleansing 3 3 None No generic available agents Surmontil* Antidepressants 3 3 None Trimipramine Maleate Sustiva Antiretrovirals 2 2 None No generic available Sutent Kinase inhibitors and molecular target 2 2 QL No generic available inhibitors Sylatron Interferons and MS therapy 3 3 QL No generic available Symbicort Inhaled steroid and beta-agonist 2 2 QL No generic available combinations Symbyax* Antipsychotics 3 3 None Olanzapine/Fluoxetine Hcl Symlinpen Non-insulin hypoglycemic agents 3 3 None No generic available

Symmetrel* Parkinsons disease and related 3 3 None Amantadine Hcl disorders Synalar 0.01%* Corticosteroids - low potency 3 3 None Fluocinolone Acetonide Synalar 0.025%* Corticosteroids - medium potency 3 3 None Fluocinolone Acetonide

Synalgos-DC* Narcotic and analgesic combinations 3 3 None Dihydrocodeine/Aspirin/Caffein

Synarel Miscellaneous OB-GYN/Miscellaneous 2 2 None No generic available endocrine Syndros solution Antiemetic/antivertigo agent 3 3 None No generic available Synjardy Non-insulin hypoglycemic agents 3 3 PA, QL No generic available

Synthroid, Levoxyl* Thyroid hormones 3 3 None Levothyroxine Sodium Syprine Chelating Agents 3 3 PA, QL No generic available Tabloid Antimetabolites 2 2 None No generic available Taclonex ointment* Antipsoriatic and antiseborrheic 3 3 None Calcipotriene/Betamethasone Taclonex topical solution Antipsoriatic and antiseborrheic 3 3 None No generic available Tacrolimus Topical antineoplastic agents and 1 1 None This medication is generic immunomodulators Tacrolimus Anhydrous Immunomodulators 1 1 None This medication is generic Tafinlar Kinase inhibitors and molecular target 2 2 PA, QL No generic available inhibitors Tagamet (Rx Only)* H2-Receptor antagonists 3 3 None Cimetidine Tagrisso Kinase inhibitors and molecular target 2 2 PA, QL No generic available inhibitors Taltz Antipsoriatic and antiseborrheic 3 3 PA, QL No generic available Talwin NX* Narcotic mixed agonist and antagonist 3 3 None Pentazocine Hcl/Naloxone Hcl

Tambocor* Cardiovascular treatment 3 3 None Flecainide Acetate Tamiflu suspension Antivirals 2 2 QL No generic available Tamiflu* Antivirals 3 3 QL Oseltamivir Phosphate Tamoxifen Citrate Hormonal agents 1 1 QL This medication is generic Tamoxifen Citrate (Preventive) Hormonal agents Free As Free As PA, QL This medication is generic Preventive Preventive Tamsulosin Hcl BPH Treatment 1 1 None This medication is generic Tanzeum Non-insulin hypoglycemic agents 3 3 PA, QL No generic available

Tapazole* Antithyroid agents 3 3 None Methimazole Tarceva Kinase inhibitors and molecular target 2 2 QL No generic available inhibitors Targretin capsule* Miscellaneous antineoplastic agents 3 3 PA Bexarotene

Targretin gel Topical antineoplastic agents and 3 3 None No generic available immunomodulators

Updated 11/13/2017 Drug name Category of drug Choices Tier ABC Tier Limits Generic equivalent if available Tarka* ACE-Inhibitors and 3 3 None Trandolapril/Verapamil Hcl combinations/Calcium channel blockers and combinations Tasigna Kinase inhibitors and molecular target 2 2 None No generic available inhibitors Tasmar* Parkinsons disease and related 3 3 None Tolcapone disorders Taytulla Contraceptives-Monophasic 3 Free As None No generic available Preventive Tazorac Acne treatment 2 2 None No generic available Tecfidera Interferons and MS therapy 2 2 PA, QL No generic available Technivie Antivirals 3 3 PA, QL No generic available Tegretol, XR* Anticonvulsants 3 3 None Carbamazepine Tekamlo Calcium channel blockers and 3 3 QL No generic available combinations/Renin-inhibitors and combinations Tekturna Renin-inhibitors and combinations 3 Free As PA No generic available Preventive Tekturna HCT Renin-inhibitors and combinations 3 Free As None No generic available Preventive Telmisartan Angiotensin II Receptor Blockers and 1 Free As None This medication is generic combinations Preventive Telmisartan/Amlodipine Angiotensin II Receptor Blockers and 1 1 None This medication is generic combinations Telmisartan/Hydrochlorothiazide Angiotensin II Receptor Blockers and 1 Free As None This medication is generic combinations Preventive Temazepam Sedative and hypnotics 1 1 QL This medication is generic Temodar* Alkylating agents 3 3 None Temozolomide Temozolomide Alkylating agents 1 1 None This medication is generic Tenex* Alpha-adrenergic agents 3 3 None Guanfacine Hcl Tenoretic* Beta blockers and combinations 3 3 None Atenolol/Chlorthalidone Tenormin* Beta blockers and combinations 3 3 None Atenolol Terazol-3, 7* Vaginal anti-infective and antifungal 3 3 None Terconazole

Terazosin Hcl Alpha-adrenergic agents/BPH 1 Free As None This medication is generic Treatment Preventive Terbinafine Hcl Antifungals 1 1 None This medication is generic Terbutaline Sulfate Oral beta-agonists 1 1 None This medication is generic Terconazole Vaginal anti-infective and antifungal 1 1 None This medication is generic

Tessalon, Perles; Zonatuss* Antitussives 3 3 None Benzonatate Testim Androgens 3 3 PA, QL No generic available Testosterone Androgens 1 1 PA, QL This medication is generic Testosterone Cypionate Androgens 1 1 None This medication is generic Testosterone Enanthate Androgens 1 1 None This medication is generic Tetrabenazine Miscellaneous CNS 1 1 PA, QL This medication is generic Tetracycline Hcl Tetracyclines 1 1 None This medication is generic Tetracycline* Tetracyclines 3 3 None Tetracycline Hcl Teveten* Angiotensin II Receptor Blockers and 3 3 None Eprosartan Mesylate combinations Thalomid Immunomodulators 2 2 None No generic available Theo-24 Theophyllines 2 2 None No generic available Theophylline Anhydrous Theophyllines 1 1 None This medication is generic Theophylline Anhydrous* Theophyllines 3 3 None Theophylline Anhydrous Thiola Miscellaneous Urologicals 3 3 PA No generic available Thioridazine Hcl Antipsychotics 1 1 None This medication is generic Thiothixene Antipsychotics 1 1 None This medication is generic Thorazine* Antipsychotics 3 3 None Chlorpromazine Hcl Thyroid,Pork Thyroid hormones 1 1 None This medication is generic Thyrolar Thyroid hormones 2 2 None No generic available Tiagabine Hcl Anticonvulsants 1 1 None This medication is generic Tiazac* Calcium channel blockers and 3 3 None Diltiazem Hcl combinations Ticlid* Anticoagulants and hemostasis agents 3 3 None Ticlopidine Hcl

Ticlopidine Hcl Anticoagulants and hemostasis agents 1 1 None This medication is generic

Tigan* Antiemetics 3 3 None Trimethobenzamide Hcl Tikosyn* Cardiovascular treatment 3 3 None Dofetilide Timolol Maleate Beta blockers and 1 Free As None This medication is generic combinations/Ophthalmic beta Preventive blockers

Updated 11/13/2017 Drug name Category of drug Choices Tier ABC Tier Limits Generic equivalent if available Timolol Maleate/Dorzolam Hcl Glaucoma agents 1 1 None This medication is generic Timoptic Ocudose Ophthalmic beta blockers 3 3 None No generic available Timoptic, - XE* Ophthalmic beta blockers 3 3 None Timolol Maleate Tindamax* Antiparasitics and anthelmintics 3 3 None Tinidazole Tinidazole Antiparasitics and anthelmintics 1 1 None This medication is generic Tirosint Thyroid hormones 3 3 None No generic available Tivicay Antiretrovirals 2 2 None No generic available Tivorbex Nonsteroidal anti-inflammatory drugs 3 3 PA, QL No generic available

Tizanidine Hcl Skeletal muscle relaxants 1 1 None This medication is generic Tobi Podhaler Miscellaneous anti-infectives/Cystic 3 3 PA, QL No generic available Fibrosis agents Tobi* Miscellaneous anti-infectives/Cystic 3 3 QL Tobramycin/0.25 Normal Saline Fibrosis agents Tobradex ointment Ophthalmic anti-infective and steroid 2 2 None No generic available

Tobradex ST Ophthalmic anti-infective and steroid 3 3 None No generic available

Tobradex suspension* Ophthalmic anti-infective and steroid 3 3 None Tobramycin Sulfate/Dexameth

Tobramycin Sulfate Ophthalmic anti-infectives 1 1 None This medication is generic Tobramycin Sulfate/Dexameth Ophthalmic anti-infective and steroid 1 1 None This medication is generic

Tobramycin/0.25 Normal Saline Miscellaneous anti-infectives/Cystic 1 1 QL This medication is generic Fibrosis agents Tobrex drops* Ophthalmic anti-infectives 3 3 None Tobramycin Sulfate Tobrex ointment Ophthalmic anti-infectives 3 3 None No generic available Today Contraceptive Sponge Contraceptives-Misc. Free As Free As QL No generic available Preventive Preventive Tofranil* Antidepressants 3 3 None Imipramine Hcl Tofranil-PM* Antidepressants 3 3 None Imipramine Pamoate Tolak Topical antineoplastic agents and 3 3 QL No generic available immunomodulators Tolazamide Non-insulin hypoglycemic agents 1 1 None This medication is generic

Tolbutamide Non-insulin hypoglycemic agents 1 1 None This medication is generic

Tolcapone Parkinsons disease and related 1 1 None This medication is generic disorders Tolectin, DS* Nonsteroidal anti-inflammatory drugs 3 3 None Tolmetin Sodium

Tolinase* Non-insulin hypoglycemic agents 3 3 None Tolazamide

Tolmetin Sodium Nonsteroidal anti-inflammatory drugs 1 1 None This medication is generic

Tolterodine Tartrate Urinary Antispasmodics 1 1 None This medication is generic Topamax* Anticonvulsants 3 3 None Topiramate Topicort cream, gel, ointment* Corticosteroids - high potency 3 3 None Desoximetasone Topicort LP* Corticosteroids - medium potency 3 3 None Desoximetasone

Topicort spray Corticosteroids - high potency 3 3 None No generic available Topiramate Anticonvulsants 1 1 None This medication is generic Topiramate ER Anticonvulsants 3 3 PA, QL No generic available Toprol XL* Beta blockers and combinations 3 3 None Metoprolol Succinate Toradol injection* Nonsteroidal anti-inflammatory drugs 3 3 None Ketorolac Tromethamine

Toradol tablet* Nonsteroidal anti-inflammatory drugs 3 3 QL Ketorolac Tromethamine

Torsemide Diuretics 1 Free As None This medication is generic Preventive Toujeo Solostar Insulins 2 2 None No generic available Toviaz Urinary Antispasmodics 3 3 ST, QL No generic available Tracleer Pulmonary Hypertension Agents 2 2 PA, QL No generic available Tradjenta Non-insulin hypoglycemic agents 3 3 ST, QL No generic available

Tramadol Hcl Narcotic mixed agonist and antagonist 1 1 None This medication is generic

Tramadol Hcl/Acetaminophen Narcotic mixed agonist and antagonist 1 1 None This medication is generic

Trandolapril ACE-Inhibitors and combinations 1 Free As None This medication is generic Preventive

Updated 11/13/2017 Drug name Category of drug Choices Tier ABC Tier Limits Generic equivalent if available Trandolapril/Verapamil Hcl ACE-Inhibitors and 1 Free As None This medication is generic combinations/Calcium channel Preventive blockers and combinations Tranexamic Acid Miscellaneous OB-GYN 1 1 QL This medication is generic Transderm-Scop* Antiemetics 2 2 None Scopolamine Tranxene T-Tab* Anxiolytics 3 3 None Clorazepate Dipotassium Tranylcypromine Sulfate Antidepressants 1 1 None This medication is generic Travatan Z Glaucoma agents 2 2 None No generic available Trazodone Hcl Antidepressants 1 1 None This medication is generic Trecator Antituberculars 3 3 None No generic available Trelstar, Depot, LA Hormonal agents 2 2 None No generic available Tremfya Plaque Psoriasis 3 3 PA, QL No generic available Trental* Anticoagulants and hemostasis agents 3 3 None Pentoxifylline

Tresiba Flextouch Insulins 2 2 None No generic available Tretinoin Miscellaneous antineoplastic 1 1 None This medication is generic agents/Acne treatment Tretinoin Microspheres Acne treatment 1 1 None This medication is generic Tretin-X Acne treatment 3 3 None No generic available Trexall Antimetabolites/Miscellaneous 2 2 None No generic available rheumatologic agents Treximet Migraine therapy 3 3 PA, QL No generic available Trezix* Narcotic and analgesic combinations 3 3 None Dhcodeine Bt/Acetaminophn/Caff

Triamcinolone Acetonide Corticosteroids - Low/Medium/High 1 1 None This medication is generic potency Triamterene/Hydrochlorothiazide Diuretics 1 Free As None This medication is generic Preventive Triazolam Sedative and hypnotics 1 1 QL This medication is generic Tribenzor* Angiotensin II Receptor Blockers and 3 3 QL Olmesartan/Amlodipin/Hcthiazid combinations/Calcium channel blockers and combinations

Tricor* Lipid-lowering agents 3 3 None Fenofibrate Nanocrystallized Trifluoperazine Hcl Antipsychotics 1 1 None This medication is generic Trifluridine Ophthalmic anti-infectives 1 1 None This medication is generic Triglide Lipid-lowering agents 3 Free As None No generic available Preventive Trihexyphenidyl Hcl Parkinsons disease and related 1 1 None This medication is generic disorders Triklo Lipid-lowering agents 1 1 None This medication is generic Trileptal* Anticonvulsants 3 3 None Oxcarbazepine Trilevlen; Triphasil* Contraceptives-Triphasic 3 3 None Levonorgestrel-Eth Estra Trilipix* Lipid-lowering agents 3 3 None Fenofibric Acid (Choline) Trilisate* Salicylates 3 3 None Choline Magnesium Trisalicylate Trimethobenzamide Hcl Antiemetics 1 1 None This medication is generic Trimethoprim Urinary tract agents 1 1 None This medication is generic Trimethoprim* Urinary tract agents 3 3 None Trimethoprim Trimipramine Maleate Antidepressants 1 1 None This medication is generic Tri-Norinyl* Contraceptives-Triphasic 3 3 None Norethindrone-Ethinyl Estrad Trintellix Antidepressants 3 3 ST, QL No generic available Triumeq Antiretrovirals 2 2 QL No generic available Trizivir* Antiretrovirals 3 3 None Abacavir/Lamivudine/Zidovudine Trokendi XR Anticonvulsants 3 3 PA, QL No generic available Tropicamide Cycloplegic mydriatics 1 1 None This medication is generic Trospium Chloride Urinary Antispasmodics 1 1 QL This medication is generic Trulicity Non-insulin hypoglycemic agents 3 3 PA, QL No generic available

Trusopt* Glaucoma agents 3 3 None Dorzolamide Hcl Truvada Antiretrovirals 2 2 None No generic available Tudorza Pressair Inhaled anticholinergics 3 3 QL No generic available Tussicaps Antitussives 2 2 QL No generic available Tussionex* Antitussives 3 3 None Hydrocodone/Chlorphen Polis Tuzistra XR Antitussives 3 3 QL No generic available Twynsta* Angiotensin II Receptor Blockers and 3 3 None Telmisartan/Amlodipine combinations Twynsta* Calcium channel blockers and 3 3 None Telmisartan/Amlodipine combinations Tybost Antiretrovirals 2 2 QL No generic available Tykerb Kinase inhibitors and molecular target 2 2 None No generic available inhibitors

Updated 11/13/2017 Drug name Category of drug Choices Tier ABC Tier Limits Generic equivalent if available Tylenol w/Codeine* Narcotic and analgesic combinations 3 3 QL Codeine Phos/Acetaminophen

Tymlos pen injector Parkinsons disease 3 3 PA, QL No generic available Tyvaso Pulmonary Hypertension Agents 2 2 PA, QL No generic available Tyzine Nasal preparations 2 2 None No generic available Uceris foam Topical anti-Inflammatory agents 3 3 ST No generic available

Uceris tablet Corticosteroids 3 3 PA, QL No generic available Ulesfia Scabicides and pediculicides 3 3 None No generic available Uloric Gout therapy 2 2 ST, QL No generic available Ultracet* Narcotic mixed agonist and antagonist 3 3 None Tramadol Hcl/Acetaminophen

Ultram, ER* Narcotic mixed agonist and antagonist 3 3 None Tramadol Hcl

Ultravate* Corticosteriods - very high potency 3 3 None Halobetasol Propionate

Uniretic* ACE-Inhibitors and combinations 3 3 None Moexipril/Hydrochlorothiazide Univasc* ACE-Inhibitors and combinations 3 3 None Moexipril Hcl Uptravi Pulmonary Hypertension Agents 2 2 PA, QL No generic available Urecholine* Miscellaneous Urologicals 3 3 None Bethanechol Chloride Urispas* Urinary Antispasmodics 3 3 None Flavoxate Hcl Urocit-K* Miscellaneous Urologicals 3 3 None Potassium Citrate Uroxatral* BPH Treatment 3 3 None Alfuzosin Hcl Urso, Urso Forte* Bile acids 3 3 None Ursodiol Ursodiol Bile acids 1 1 None This medication is generic Vagifem* Estrogens 3 3 None Estradiol Valacyclovir Hcl Antivirals 1 1 None This medication is generic Valchlor Topical antineoplastic agents and 3 3 PA No generic available immunomodulators Valcyte* Antivirals 3 3 None Valganciclovir Hcl Valganciclovir Hcl Antivirals 1 1 None This medication is generic Valisone* Corticosteroids - high potency 3 3 None Betamethasone Valerate Valium* Anxiolytics/Skeletal muscle relaxants 3 3 None Diazepam

Valproate Sodium Anticonvulsants 1 1 None This medication is generic Valsartan Angiotensin II Receptor Blockers and 1 Free As None This medication is generic combinations Preventive Valsartan/Hydrochlorothiazide Angiotensin II Receptor Blockers and 1 Free As None This medication is generic combinations Preventive Valtrex* Antivirals 3 3 None Valacyclovir Hcl Vancocin hcl* Miscellaneous anti-infectives 3 3 None Vancomycin Hcl Vancomycin Hcl Miscellaneous anti-infectives 1 1 None This medication is generic Vanos* Corticosteriods - very high potency 3 3 None Fluocinonide

Vantin* Cephalosporins 3 3 None Cefpodoxime Proxetil Varubi Antiemetics 3 3 PA, QL No generic available Vascepa Lipid-lowering agents 3 Free As PA, QL No generic available Preventive Vaseretic* ACE-Inhibitors and combinations 3 3 None Enalapril/Hydrochlorothiazide Vasocidin* Ophthalmic anti-infective and steroid 3 3 None Sulfacetamide/Prednisolone Sp

Vasodilan* Cardiovascular treatment 3 3 None Isoxsuprine Hcl Vasotec* ACE-Inhibitors and combinations 3 3 None Enalapril Maleate VCF film, gel Contraceptives-Misc. Free As Free As QL No generic available Preventive Preventive VCF foam* Contraceptives-Misc. Free As Free As QL Nonoxynol 9 Preventive Preventive Vecamyl Miscellaneous antihypertensives 3 3 PA, QL No generic available

Vectical* Antipsoriatic and antiseborrheic 3 3 None Calcitriol Velphoro Ion-Removing Agents 3 3 None No generic available Veltassa Ion-Removing Agents 2 2 PA, QL No generic available Veltin Acne treatment 3 3 None No generic available Venclexta Kinase inhibitors and molecular target 2 2 PA, QL No generic available inhibitors Venlafaxine Hcl Antidepressants 1 1 None This medication is generic Venlafaxine hcl ER* Antidepressants 3 3 None Venlafaxine Hcl Ventavis Pulmonary Hypertension Agents 2 2 PA, QL No generic available Vepesid* Miscellaneous antineoplastic agents 3 3 None Etoposide

Veramyst Nasal preparations 3 3 ST, QL No generic available

Updated 11/13/2017 Drug name Category of drug Choices Tier ABC Tier Limits Generic equivalent if available Verapamil Hcl Calcium channel blockers and 1 Free As None This medication is generic combinations Preventive Verdeso Corticosteroids - low potency 3 3 None No generic available Veregen Topical antineoplastic agents and 3 3 None No generic available immunomodulators Verelan PM* Calcium channel blockers and 3 3 None Verapamil Hcl combinations Versacloz Antipsychotics 3 3 ST No generic available Vesanoid* Miscellaneous antineoplastic agents 3 3 None Tretinoin

Vesicare Urinary Antispasmodics 3 3 ST, QL No generic available Vfend* Antifungals 3 3 None Voriconazole Viagra Sexual Dysfunction 2 2 QL No generic available Viberzi Miscellaneous gastrointestinal agents 3 3 PA, QL No generic available

Vibramycin syrup Tetracyclines/Acne treatment 3 3 None No generic available Vibramycin* Tetracyclines/Acne treatment 3 3 None Doxycycline Hyclate Vicoprofen* Narcotic and analgesic combinations 3 3 None Hydrocodone/Ibuprofen

Victoza Non-insulin hypoglycemic agents 2 2 PA, QL No generic available

Videx Antiretrovirals 2 2 None No generic available Videx EC* Antiretrovirals 3 3 None Didanosine Vigabatrin Anticonvulsants 1 1 None This medication is generic Vigamox* Ophthalmic anti-infectives 2 2 None Maxofloxacin Viibryd Antidepressants 3 3 ST, QL No generic available Vimpat Anticonvulsants 2 2 None No generic available Viokace Digestive enzymes 2 2 None No generic available Viracept Antiretrovirals 2 2 None No generic available Viramune, XR* Antiretrovirals 3 3 None Nevirapine Viread Antiretrovirals 2 2 None No generic available Viroptic* Ophthalmic anti-infectives 3 3 None Trifluridine Visken* Beta blockers and combinations 3 3 None Pindolol Vistogard Diagnostics and Other Miscellaneous 2 2 QL No generic available

Vitamin D3 (1000IU or less)* Vitamins and Minerals Free As Free As None Cholecalciferol (Vitamin D3) Preventive Preventive Vitamin K ampule* Anticoagulants and hemostasis 3 3 None Phytonadione agents/Vitamins and Minerals Vituz Antitussives 3 3 QL No generic available Vivactil* Antidepressants 3 3 None Protriptyline Hcl Vivelle-Dot* Estrogens/Osteoporosis and hormonal 3 3 QL Estradiol treatment Vivlodex Nonsteroidal anti-inflammatory drugs 3 3 PA, QL No generic available

Vogelxo Androgens 3 3 PA, QL No generic available Voltaren drops* Ophthalmic anti-inflammatory agents 3 3 None Diclofenac Sodium

Voltaren gel* Nonsteroidal anti-inflammatory drugs 3 3 PA, QL Diclofenac Sodium

Voltaren tablet* Nonsteroidal anti-inflammatory drugs 3 3 None Diclofenac Sodium

Voltaren XR* Nonsteroidal anti-inflammatory drugs 3 3 None Diclofenac Sodium

Voriconazole Antifungals 1 1 None This medication is generic Vosol* Otic preparations 3 3 None Acetic Acid Vospire ER* Oral beta-agonists 3 3 None Albuterol Sulfate Votrient Kinase inhibitors and molecular target 2 2 QL No generic available inhibitors Vraylar Antipsychotics 3 3 ST, QL No generic available Vusion Topical antifungals 3 3 None No generic available Vytorin Lipid-lowering agents 3 3 ST, QL No generic available Vyvanse CNS stimulants 3 3 PA, QL No generic available Warfarin Sodium Anticoagulants and hemostasis agents 1 1 None This medication is generic

Welchol Lipid-lowering agents 2 Free As None No generic available Preventive Wellbutrin, SR, XL* Antidepressants 3 3 None Bupropion Hcl Westcort* Corticosteroids - medium potency 3 3 None Hydrocortisone Valerate

Westhroid* Thyroid hormones 3 3 None Thyroid,Pork WP Thyroid Thyroid hormones 3 3 None No generic available

Updated 11/13/2017 Drug name Category of drug Choices Tier ABC Tier Limits Generic equivalent if available Xadago Parkinsons disease 3 3 QL No generic available Xalatan* Glaucoma agents 3 3 None Latanoprost Xalkori Kinase inhibitors and molecular target 2 2 PA, QL No generic available inhibitors Xanax, XR* Anxiolytics 3 3 None Alprazolam Xarelto Anticoagulants and hemostasis agents 2 2 QL No generic available

Xartemis XR Narcotic and analgesic combinations 3 3 PA, QL No generic available

Xeljanz, XR Non-Tumor Necrosis Factor (TNF) 3 3 PA, QL No generic available blocking agents Xeloda* Antimetabolites 3 3 None Capecitabine Xenazine* Miscellaneous CNS 3 3 PA, QL Tetrabenazine Xenical Weight Loss Preparations 3 Free As None No generic available Preventive Xerese Topical antivirals 3 3 None No generic available Xifaxan 200mg Miscellaneous anti-infectives 3 3 None No generic available Xifaxan 200mg Miscellaneous gastrointestinal agents 3 3 None No generic available

Xifaxan 550mg Miscellaneous gastrointestinal agents 3 3 PA, QL No generic available

Xigduo XR Non-insulin hypoglycemic agents 2 2 PA, QL No generic available

Xiidra Miscellaneous ophthalmic agents 3 3 None No generic available

Xolegel Topical antifungals 3 3 PA, QL No generic available Xopenex HFA Inhaled beta-agonists 3 3 QL No generic available Xopenex nebulizer solution* Inhaled beta-agonists 3 3 None Levalbuterol Hcl Xtandi Hormonal agents 2 2 PA, QL No generic available Xuriden Miscellaneous Urologicals 2 2 PA, QL No generic available Xylocaine, Viscous (Rx only)* Topical anesthetics 3 3 None Lidocaine Hcl Xyrem Miscellaneous CNS 3 3 PA, QL No generic available Xyzal solution* Antihistamines 3 3 QL Levocetirizine Dihydrochloride Xyzal tablet* Antihistamines 3 3 QL Levocetirizine Dihydrochloride Yasmin 28* Contraceptives-Monophasic 3 3 None Ethinyl Estradiol/Drospirenone Yaz* Contraceptives-Monophasic 3 3 None Ethinyl Estradiol/Drospirenone Zafirlukast Miscellaneous respiratory agents 1 1 QL This medication is generic

Zaleplon Sedative and hypnotics 1 1 QL This medication is generic Zanaflex capsule* Skeletal muscle relaxants 3 3 None Tizanidine Hcl Zanaflex tablet* Skeletal muscle relaxants 3 3 None Tizanidine Hcl Zantac (Rx Only)* H2-Receptor antagonists 3 3 None Ranitidine Hcl Zarontin* Anticonvulsants 3 3 None Ethosuximide Zaroxolyn* Diuretics 3 3 None Metolazone Zarxio Adjuvant therapy/Hematopoietic 3 3 None No generic available agents Zavesca Miscellaneous endocrine 3 3 PA, QL No generic available Zebeta* Beta blockers and combinations 3 3 None Bisoprolol Fumarate Zegerid Rx* Proton Pump Inhibitors (PPI) 3 3 ST, QL Omeprazole/Sodium Bicarbonate Zejula Oncology 2 2 PA, QL No generic available Zelapar Parkinsons disease and related 3 3 None No generic available disorders Zelboraf Kinase inhibitors and molecular target 2 2 PA, QL No generic available inhibitors Zembrace Symtouch Migraine therapy 3 3 ST, QL No generic available Zemplar* Vitamin D analogs 3 3 None Paricalcitol Zenpep Digestive enzymes 2 2 None No generic available Zenzedi CNS stimulants 3 3 None No generic available Zepatier Antivirals 2 2 PA, QL No generic available Zerit* Antiretrovirals 3 3 None Stavudine Zetia* Lipid-lowering agents 3 3 QL Ezetimibe Zetonna Nasal preparations 3 3 ST, QL No generic available Ziac* Beta blockers and combinations 3 3 None Bisoprolol/Hydrochlorothiazide Ziagen solution Antiretrovirals 2 2 None No generic available Ziagen tablet* Antiretrovirals 3 3 None Abacavir Sulfate Ziana* Acne treatment 3 3 None Clindamycin/Tretinoin Zidovudine Antiretrovirals 1 1 None This medication is generic Zinbryta Interferons and MS therapy 3 3 PA, QL No generic available Zioptan Glaucoma agents 3 3 None No generic available Ziprasidone Hcl Antipsychotics 1 1 None This medication is generic Zipsor Nonsteroidal anti-inflammatory drugs 3 3 ST, QL No generic available

Updated 11/13/2017 Drug name Category of drug Choices Tier ABC Tier Limits Generic equivalent if available Zirgan Ophthalmic anti-infectives 2 2 None No generic available Zithromax* Macrolides 3 3 None Azithromycin Zmax Macrolides 3 3 None No generic available Zocor* Lipid-lowering agents 3 3 QL Simvastatin Zofran, ODT* Antiemetics 3 3 None Ondansetron Zohydro ER Narcotics 3 3 PA, QL No generic available Zoladex Hormonal agents 2 2 QL No generic available Zolinza Miscellaneous antineoplastic agents 2 2 None No generic available

Zolmitriptan Migraine therapy 1 1 ST, QL This medication is generic Zoloft* Antidepressants 3 3 None Sertraline Hcl Zolpidem Tartrate (generic Ambien) Sedative and hypnotics 1 1 QL This medication is generic Zolpidem Tartrate (generic Intermezzo) Sedative and hypnotics 1 1 ST, QL This medication is generic

Zolpimist Sedative and hypnotics 3 3 ST No generic available Zomacton Growth Hormone and related products 3 3 PA No generic available

Zomig nasal spray Migraine therapy 3 3 ST, QL No generic available Zomig, ZMT* Migraine therapy 3 3 ST, QL Zolmitriptan Zonalon* Miscellaneous dermatologicals 3 3 None Doxepin Hcl Zonegran* Anticonvulsants 3 3 None Zonisamide Zonisamide Anticonvulsants 1 1 None This medication is generic Zontivity Anticoagulants and hemostasis agents 3 3 PA, QL No generic available

Zorbtive Miscellaneous gastrointestinal agents 3 3 PA No generic available

Zortress Kinase inhibitors and molecular target 3 3 None No generic available inhibitors Zorvolex Nonsteroidal anti-inflammatory drugs 3 3 PA, QL No generic available

Zostavax Vaccines Free As Free As None No generic available Preventive Preventive Vaccine Vaccine Zovirax cream Topical antivirals 2 2 None No generic available Zovirax ointment* Topical antivirals 3 3 None Acyclovir Zovirax* Antivirals 3 3 None Acyclovir Zubsolv Narcotic mixed agonist and antagonist 3 3 QL No generic available

Zuplenz Antiemetics 3 3 PA No generic available Zurampic Gout therapy 3 3 PA, QL No generic available Zutripro* Antitussives 3 3 QL Pseudoephed/Hydrocodone/Cpm Zyban* Smoking Cessation Free As Free As QL Bupropion Hcl Preventive Preventive Zyclara Topical antineoplastic agents and 3 3 PA, QL No generic available immunomodulators Zydelig Kinase inhibitors and molecular target 2 2 PA, QL No generic available inhibitors Zyflo Miscellaneous respiratory agents 3 3 QL No generic available

Zyflo CR Miscellaneous respiratory agents 3 3 QL No generic available

Zykadia Kinase inhibitors and molecular target 2 2 PA, QL No generic available inhibitors Zylet Ophthalmic anti-infective and steroid 3 3 None No generic available

Zyloprim* Gout therapy 3 3 None Allopurinol Zymaxid* Ophthalmic anti-infectives 3 3 None Gatifloxacin Zyprexa, Zydis* Antipsychotics 3 3 None Olanzapine Zytiga Hormonal agents 2 2 QL No generic available Zyvox* Miscellaneous anti-infectives 3 3 None Linezolid

Updated 11/13/2017