Drug List

The Yale Health Drug List represents most covered items. If your drug is not listed, it may or may not be covered. To determine coverage of unlisted drugs or if you have questions about any of your prescriptions, please contact the pharmacy.

The Yale Health Drug List is subject of change.

  C/T & S/M & Security M&P/Faculty YPBA Students w/ Hospitalization/Specialty Care
Tier 1 Generic, $5 co-pay Generic, $5 co-pay Generic, $5 co-pay Generic, $10 co-pay
Tier 2 Preferred brand, $20 co-pay Preferred brand, $30 co-pay Preferred brand, $20 co-pay Preferred brand, $30 co-pay
Tier 3* Non-preferred brand, $35 co-pay Non-preferred brand, 40% coinsurance with a $50 minimum and $100 maximum Non-preferred brand, $30 co-pay Non-preferred brand, $45 co-pay
NC Not covered Not covered Not covered Not covered
$0 Free Free Free Free

1* Free for Yale Health members (excluding YPBA) and students with Yale Health Hospitalization/Specialty Coverage when filled at the Yale Health Pharmacy

*If a generic drug is available and a brand name is dispensed there may be additional charges depending on your employment status at the University.  Please see your applicable Schedule of Benefits.

A
Drug Name Tier Restrictions
ABACAVIR 1
ABILIFY 3 Prior Authorization
ACAMPRO CAL TAB 333MG 1
ACANYA 3
ACARBOSE 1
ACCOLATE 3 Prior Authorization
ACCU-CHEK COMFORT CURVE TES COMFORT 3 Prior authorization, Quantity limit
ACCU-CHEK COMPACT 3 Prior authorization, Quantity limit
ACCUZYME 2 Quantity limit
ACETAMINOPHEN WITH COD. SUSP 1
ACETAMINOPHEN WITH COD. TABS 1
ACETASAL HC 1
ACETAZOLAMIDE 1 Travel
ACETIC ACID 1
ACETIC ACID/ALUMINUM 1
ACETYLCYSTEINE 1
ACIPHEX NC
ACITRETIN CAP 25MG 1
ACLARO EMU 3 Quantity limit
ACTEMRA 3 Prior authorization, Step therapy
ACTICLATE 3 Prior authorization
ACTIQ LOZ 3 Prior authorization, Step therapy
ACTIVELLA 3 Prior authorization
ACTONEL 3 Prior authorization
ACTOPLUS MET 3 Prior authorization
ACTOS 3 Prior authorization
ACULAR 3 Prior authorization
ACULAR LS 3 Prior authorization
ACYCLOVIR 1
ACZONE 2 Prior authorization, Quantity limit, Step therapy
ADAPALENE 1
ADDERALL 3 Prior authorization
ADDERALL XR 3 Prior authorization
ADDYI 3 Prior authorization
ADLYXIN 3 Step therapy
ADOXA 3 Prior authorization, Step therapy
ADVAIR DISKUS 2 Quantity limit
ADVAIR HFA AER 2
ADVICOR 3
AEROBID AER 2
AEROCHAMBER MIS NC Prior authorization
AFINITOR TAB 5MG 3 Prior authorization
AGGRENOX 3 Prior authorization
AIRDUO RESPICLICK 3 Step therapy
AK-PENTOLATE 1
AK-POLY-BAC 1
ALAMAG NC Over-the-counter
ALAMAST 3
ALBENZA 1
ALBUTEROL SULFATE 1
ALCLOMETASONE DIPROPIONATE 1 Quantity limit
ALDACTAZIDE TAB 50/50 3
ALDACTONE 3 Prior Authorization
ALDARA 3 Quantity limit
ALENDRONATE 1
ALFUZOSIN 3 Prior authorization
ALINIA 2
ALKERAN 3
ALLANFILLENZYME 2 Quantity limit
ALLOPURINOL 1
ALMOTRIP MAL TAB 12.5MG 1
ALMOTRIPTAN 1 Quantity limit, Step therapy
ALOCRIL 3
ALOGLIPTIN 1 Step therapy
ALOGLIPTIN/METFORMIN 1 Step therapy
ALOGLIPTIN/PIOGLITAZONE 1 Step therapy
ALOMIDE 3
ALORA 3
ALPHAGAN P 3
ALPHAQUIN HP 2 Quantity limit
ALPRAZOLAM 1
ALPRAZOLAM ER 1
ALREX 3
ALTABAX 2 Prior authorization, Quantity limit
ALTACE 3 Prior authorization
ALVESCO 3
AMANTADINE HCL 1
AMARYL 3
AMBIEN 3 Prior authorization, Quantity limit, Step therapy, Travel
AMBIEN CR 3 Quantity limit, Step therapy, Travel
AMCINONIDE 1 Quantity limit
AMERGE 3 Prior authorizationQuantity limit, Step therapy
AMETHIA 1*
AMETHYST 1*
AMICAR 3 Prior authorization
AMILORIDE 1
AMILORIDE/HYDROCHLOROTHIAZI 1
AMINOCAPR AC INJ 1
AMIODARONE HCL 1
AMITIZA 2
AMITRIPTYLINE 1
AMLACTIN NC Quantity limit
AMLODIPINE/ATORVASTATIN 1
AMLODIPINE/BENAZEPRIL 1
AMMONIUM LACTATE NC Quantity limit
AMNESTEEM 1 Quantity limit
AMOXICILLIN 1 Travel
AMOXICILLIN/CLAVULANATE 1
AMPHETAMINE CAP ER 1
AMPHETAMINE SALT COMBO TABS 1
AMPHETAMINE XR COMBO CAPS 1
AMPYRA 3 Prior authorization
AMRIX CAP 3 Prior authorization, Step therapy
ANAGRELIDE HYDROCHLORIDE 1
ANALPRAM-HC 1 Quantity limit
ANASTROZOLE 1
ANDRODERM DIS 2
ANDROGEL 3
ANDROXY 2
ANGELIQ 3
ANORO ELLIPT AER 62.5-25 3 Prior authorization
ANTABUSE 1
ANTARA 3
ANTIPYRINE/BENZOCAINE 1
ANUCORT-HC 1 Quantity limit
ANZEMET 3 Prior authorization
APEXICON E 3 Prior authorization, Quantity limit, Step therapy
APHTHASOL PST 1 Quantity limit
APIDRA 3
APRACLONIDIN SOL 0.5% OP 1
APREPITANT 1 Quantity limit
APRI 1*
APTIOM TAB 200MG 3 Prior authorization
ARANELLE 1*
ARANESP 2 Prior authorization, Quantity limit
ARAVA 3
ARICEPT 3 Prior authorization
ARIMIDEX 3
ARIPIPRAZOLE 1
ARIXTRA 3 Prior authorization
ARMODAFINIL 1 Quantity limit
ARMOUR THYROID 1
AROMASIN 3 Prior authorization
ARTHROTEC EC 3 Prior authorization
ASACOL 2
ASACOL HD TAB 800MG 2
ASCOMP/COD CAP 30MG 1
ASMANEX 2
ASPIRIN 1*
ASPIRIN/DIPYRIDAMOLE EXT RELEASE 1
ASTELIN 3 Prior authorization, Quantity limit
ATACAND 3 Prior authorization
ATACAND HCT 3 Prior authorization
ATENOLOL 1
ATENOLOL/CHLORTHALIDONE 1
ATOMOXETINE 1
ATORVASTATIN 1
ATOVAQ/PROGU TAB 1 Travel
ATOVAQUONE 1 Travel
ATRALIN 3 Prior authorzation
ATRIPLA 2
ATROPINE 1
ATROPINE SUL SOL 1% OP 1
ATROVENT HFA AER 2
AUBAGIO 2 Prior authorization
AUGMENTED BETAMETHASONE DIP 1 Quantity limit, Step therapy
AUGMENTIN 3 Prior authorization
AUGMENTIN XR 3 Prior authorization
AUVI-Q 3 Prior authorization, Step therapy
AVALIDE 3 Prior authorization
AVANDAMET 3 Prior authorization
AVANDARYL 3 Prior authorization
AVANDIA 3 Prior authorization
AVAPRO 3 Prior authorization
AVC 1
AVELOX 3 Prior authorization
AVIANE 1*
AVINZA 3
AVODART 3 Prior authorization
AVONEX 2
AXERT 3 Quantity limit, Step therapy
AXID SOLUTION 3 Prior authorization
AXIRON SOL 30MG/ACT 3 Prior authorization
AZASITE 3
AZATHIOPRINE 2
AZELASTINE 1
AZELEX 3 Quantity limit
AZILECT 2
AZITHROMYCIN 1 Travel
AZOPT 2
AZOR 3 Prior authorization
AZURETTE 1*
B
Drug Name Tier Restrictions
B-D 3CC LUER-LOK SYRINGE/25 MIS 25GX1" 1
B-D GLUCOSE NC
B-D INSLUIN SYRINGE ULTRAFI MIS 1CC/31G 1
B-D NEEDLE/27G X 1/2" MIS 27GX1/2" 1
B-D ULTRAFINE ORIGINAL PEN MIS PEN NEEDLE 1
BACIT/POLYMY OIN OP 1
BACITRACIN OPTHAL 1
BACLOFEN 1
BACTROBAN 3 Prior authorization, Quantity limit
BACTROBAN NASAL 3 Quantity limit
BALSALAZIDE DIS 1
BALZIVA 1*
BANZEL 3
BARACLUDE 3 Prior authorization
BAYER CONTOR TES NEXT 3
BECONASE-AQ NC
BELBUCA MIS 3 Prior authorization
BELLADONNA ALK/PHENOB 1
BELSOMRA TAB 3 Prior authorization
BELVIQ 3 Prior authorization
BENAZEPRIL HCL 1
BENAZEPRIL HCL/HYDROCHLOROT TAB 1
BENICAR 3 Prior authorization
BENICAR HCT 3 Prior authorization
BENPROX 3 Quantity limit
BENZACLIN 3 Prior authorization, Quantity limit, Step therapy
BENZAMYCIN GEL 3 Quantity limit, Step therapy
BENZASHAVE NC
BENZEFOAM 3 Prior authorization
BENZONATATE 1
BENZOYL PEROXIDE CREAMY WAS KIT WASH 1 Quantity limit, Step therapy
BENZOYL PEROXIDE GEL 1 Quantity limit, Step therapy
BENZOYL PEROXIDE PAD 3 Quantity limit, Step therapy
BENZOYLE PEROXIDE WASH NC
BENZTROPINE MESYLATE 1
BETAMETHASONE DIPROPIONATE 1 Quantity limit
BETAMETHASONE VALERATE 1 Quantity limit
BETASERON 3 Prior authorization, Step therapy
BETASERON INJ 0.3MG 1 Prior authorization
BETAXOLOL HCL 1
BETAXOLOL L 1
BETHANECHOL 1
BETIMOL 3
BETOPTIC 3 Prior authorization
BEYAZ TAB 3
BIAFINE EMU 2 Quantity limit
BICALUTAMIDE TAB 50MG 1
BILTRICIDE 2
BISOPROLOL /HYDROCHLOROTHIAZIDE 1
BISOPROLOL FUMARATE 1
BLEPHAMIDE LIQUIFILM 3
BLEPHAMIDE-S.O.P. 3
BLISOVI FE TAB 1/20 1*
BONIVA 3 Prior authorization
BONIVA KIT $0 Prior authorization
BOTOX INJ 3
BREO ELLIPTA 2
BREVOXYL 3 Quantity limit, Step therapy
BRILINTA 2
BRIMONIDINE 1
BROMOCRIPTINE MESYLATE 1
BROVANA NEB 15MCG 3
BUDEPRION SR 1
BUDESONIDE INHALATION AMPULE 1
BUDESONIDE NASAL SPRAY NC
BUMETANIDE 1
BUNAVAIL MIS 4.2-0.7 1
BUPIVACAINE INJ 0.25% 1
BUPREN/NALOX SUB 1
BUPRENORPHIN SUB 1
BUPRENORPHINE TRANSDERMAL PATCH 1 Prior authorization
BUPROPION HCL 1
BUPROPION HCL ER 1
BUPROPION HCL SR 1
BUPROPION HCL XL 1
BUSPIRONE TAB 1
BUT/APAP/CAF CAP CODEINE 1
BUTALBITAL/APAP/CAFFEINE 1
BUTALBITAL/ASA/CAFF 1
BUTRANS PATCH 3 Prior authorization
BYDUREON 2 Step therapy
BYETTA INJ 2 Step therapy
BYSTOLIC 3 Prior authorization
C
Drug Name Tier Restrictions
CABERGOLINE TAB 0.5MG 1
CADUET 3 Prior authorization
CAL-NATE 1
CALAN 3 Prior authorizaton
CALC ACETATE CAP 667MG 1
CALCIFEROL DRO 8000/ML 1
CALCIPOTRIENE 1 Prior authorization, Quantity limit
CALCIPOTRIENE CREAM 1
CALCITRIOL 1
CAMBIA POW 50MG 3 Prior Authorization, Quantity limit
CAMILA 1*
CAMPRAL 3
CAMRESE 1*
CAMRESE LO 1*
CANASA 2
CANDESARTAN TAB 1
CANDESARTAN/HYDROCHLOROTHIAZIDE 1
CAPECITABINE 1
CAPHOSOL 1 Quantity limit
CAPTOPRIL 1
CAPTOPRIL/HYDROCHLOROTHIAZIDE 1
CARAC 2 Prior authorization, Quantity limit
CARAFATE 3 Prior authorization
CARBAMAZEPINE 1
CARBAMIDE PEROXIDE 1
CARBATROL 3 Prior authorization
CARBIDOPA/ENTACAPONE/LEVODOPA 1
CARBIDOPA/LEVODOPA 1
CARBIDOPA/LEVODOPA ER 1
CARDIZEM CD 3 Prior authorization
CARDURA XL TAB 4MG 3 Prior authorization
CARISOPRODOL 1
CARISOPRODOL/ASPIRIN 1
CARMOL 40 3 Prior authorization, Quantity limit
CARMOL-HC 3 Quantity limit
CARTEOLOL HCL 1
CARTIA XT 1
CARVEDIOL 1
CASODEX 3 Prior authorization
CATAPRES TABLETS 3 Prior authorization
CATAPRES-TTS-3 DIS 3 Prior authorization
CAVERJECT 3 Prior authorization
CAZIANT 1*
CEFACLOR 1
CEFADROXIL 1
CEFDINIR 1
CEFPODOXIME 1
CEFPROZIL 1
CEFTIN 3 Prior authorization
CEFTRIAXONE INJ 250MG 1
CEFUROXIME 1
CELEBREX 3 Prior authorization
CELECOXIB CAP 1
CELESTONE-SOLUSPAN INJ 3 Prior authorization
CELEXA 3 Prior authorization, Step therapy
CELLECEPT $0
CENESTIN 3
CEPHALEXIN 1
CEREFOLIN 3
CERUMENEX 3
CETROTIDE KIT 3
CEVIMELINE HCL 1
CHANTIX 2 Quantity limit
CHERATUSSIN SYP 100-10/5 1
CHLORAL HYDRATE 1
CHLORDIAZEPOXIDE 1
CHLORDIAZEPOXIDE/CLID 1
CHLORHEXIDINE GLUC 1 Quantity limit
CHLOROQUINE 3 Travel
CHLORPROMAZINE 1
CHLORPROPAMIDE 1
CHLORTHALIDONE 1
CHLORZOXAZONE 1
CHOLESTYRAMINE 1
CHOLINE MAGNESIUM TRISALICY 1
CHORI GONADO INJ 1
CHROMAGEN 2
CHROMAGEN FA 3 Prior authorization
CHROMAGEN FORTE 3 Prior authorization
CIALIS 2 Quantity limit
CICLOPIROX 1 Prior authorization, Quantity limit, Step therapy
CILOSTAZOL 1
CILOXAN 3 Prior authorization
CIMETIDINE NC
CIMZIA 3 Prior authorization, Step therapy
CIPRO (10%) SUS 500MG/5 3
CIPRO HC 3
CIPRO XR 3 Travel
CIPRODEX 3
CIPROFLOXACIN 1 Travel
CITALOPRAM 1
CITRIC ACID/ SOL SOD CITR 1
CLARAVIS CAP 1
CLARINEX 3 Prior authorization, Step therapy
CLARITHROMYCIN 1
CLENIA 3 Quantity limit, Step therapy
CLENIA FOAMING WASH EMU 3 Quantity limit, Step therapy
CLEOCIN PED GRAN 3 Prior authorization
CLEOCIN SUP 3 Prior authorization
CLEOCIN-T 3 Prior authorization, Quantity limit, Step therapy
CLIMARA PRO DIS 3
CLINDAGEL 3 Prior authorization, Quantity limit, Step therapy
CLINDAMYCIN HCL 1
CLINDAMYCIN PHOSPHATE 1 Quantity limit
CLINDAMYCIN/BENZOYL PEROXIDE 1
CLOBETASOL CREAM 1 Quantity limit
CLOBETASOL E CRE 0.05% 1
CLOBETASOL OINTMENT 1
CLOBETASOL PROPIONATE AER 3 Prior authorization, Quantity limit, Step therapy
CLOMIPHENE 1
CLOMIPRAMINE 1
CLONAZEP ODT TAB 1
CLONAZEPAM 1
CLONAZEPAM ODT 1
CLONIDINE HCL 1
CLOPIDROGEL 1
CLORAZEPATE DIPOTASSIUM 1
CLOTRIMAZOLE CRE 1% NC Quantity limit
CLOTRIMAZOLE/BETAMETHASONE 1 Quantity limit
CLOZAPINE 1
CODEINE SULFATE 1
COLCHICINE TAB 0.6MG 1
COLCRYS 2
COLESTIPOL HCL 1
COLOCORT ENE 1 Quantity limit
COLY-MYCIN S SUS OTIC 3
COMBIGAN 3
COMBIPATCH DIS 2
COMBIVENT AER 2
COMBIVIR 3 Prior authorization
COMMIT LOZ NC Over-the-counter
COMPLERA TAB 3 Prior authorization
COMPOUNDS 2
COMTAN 3
CONCERTA 3 Prior authorization,Quantity limit
CONDYLOX 3 Prior authorization, Quantity limit
CONTOUR TES SUPPLIES 3
CONTRAVE 3 Prior authorization
COPAXONE 2
CORDRAN TAPE 3 Quantity limit
COREG CR 3 Prior authorization
CORLANOR 3 Prior authorization
CORTEF 3 Prior authorization
CORTISPORIN 3 Quantity limit
COSENTYX 3 Prior authorization, Step therapy
COSYNTROPIN 2 Prior authorization
COUMADIN 3 Prior authorization
COZAAR 3 Prior authorization
CREON 2
CRESTOR 3 Prior authorization
CRINONE 3
CROMOLYN SODIUM 1
CRYSELLE 1*
CUTIVATE 3 Quantity limit
CYANOCOBALAMIN INJ 1
CYCLOBENZAPR TAB 1
CYCLOCORT 1 Quantity limit
CYCLOGYL 3 Prior authorization
CYCLOPENTOL SOL 1% OP 1
CYCLOPHOSPHAMIDE 1
CYCLOSPORINE CAP $0
CYCOLBENZAPRINE HCL 1
CYMBALTA 3 Prior authorization
CYPROHEPTADINE 1
CYTOMEL 3 Prior authorization
CYTRA-2 1
D
Drug Name Tier Restrictions
DALIRESP 3 Prior authorization
DANAZOL 2
DAPSONE 1
DDAVP 3 Prior authorization
DELESTROGEN INJ 3 Prior authorization
DELZICOL 2
DEMECLOCYCLINE 1
DENAVIR 2 Quantity limit
DENTA 5000 PLUS 1 Quantity limit
DENTAGEL 1 Quantity limit
DEPAKOTE 3
DEPAKOTE ER 3
DEPLIN 2
DEPO-MEDROL INJ 3 Prior authorization
DEPO-TESTOSTERONE INJ 200MG/ML 3
DERMA-SMOOTHE/FS 3 Prior authorization, Quantity limit, Step therapy
DERMAZENE 1 Quantity limit
DERMOTIC OIL 2
DESCOVY 2
DESIPRAMINE HCL 1
DESLORATADINE 1
DESMOPRESSINE ACETATE 1
DESOGEN-28 TAB 3 Prior authorization
DESONIDE 1 Quantity limit
DESOXIMETASONE 1 Quantity limit
DESVENLAFAX TAB ER 1
DETROL 3 Prior authorization
DETROL LA 3 Prior authorization
DEXAMETHASONE 1
DEXAMETHASONE SODIUM PHOSPH 1
DEXAMETHASONE SODIUM PHOSPH INJ 4MG/ML UD $0
DEXEDRINE 3 Prior authorization
DEXILANT NC
DEXMETHYLPHENIDATE HCL 1
DEXTROAMPHET CAP ER 1
DEXTROAMPHETAMINE CR 1
DEXTROAMPHETAMINE SULFATE 1
DEXTROSTAT 1
DIALYVITE 1
DIALYVITE 3000 2
DIAMOX 3 Travel, Prior authorization
DIASTAT 3 Prior authorization
DIATX ZN 3
DIAZEPAM 1
DICLEGIS 3 Prior authorization
DICLO/MISOPR TAB 75-0.2MG 1
DICLOFEN POT TAB 50MG 1
DICLOFENAC SODIUM 1
DICLOFENAC SODIUM ER 1
DICLOFENAC/MISOPROSTOL DR 1
DICLOXACILLIN 1
DICYCLOMINE HCL 1
DIDRONEL 1
DIETHYLPROPION HCL 1
DIETHYLPROPION HCL ER 1
DIFFERIN 3 Prior authorization, Quantity limit
DIFICID 3 Prior authorization
DIFLORASONE DIACETATE 1 Quantity limit
DIFLUNISAL 1
DIGOXIN 1
DIHYDROERGOTAMINE 1
DILANTIN 1
DILT-XR 1
DILTIAZEM 1
DILTIAZEM HCL 1
DILTZAC 1
DIOVAN 3 Prior authorizatoan
DIOVAN HCT 3 Prior authorization
DIPENTUM 2
DIPHENHYDRAM INJ 50MG/ML 1
DIPHENOXY/ATROP 1
DIPIVEFRIN HCL 1
DIPROLENE 3 Prior authorization, Quantity limit
DIPYRIDAMOLE 1
DISOPYRAMIDE PHOSPHATE 1
DISULFIRAM TAB 250MG 1
DITROPAN 3 Prior authorization
DITROPAN XL 3 Prior authorization
DIURIL 2
DIVALPROEX SODIUM 1
DIVIGEL GEL 1MG/GM 3
DOFETILIDE CAP 1
DOMEBORO 1
DONEPEZIL 1
DONNATAL 3
DORYX 3 Prior authorization, Step therapy
DORZOLAMIDE 1
DORZOLAMIDE HCL/TIMOLOL MAL 1
DOSTINEX 2 Prior authorization
DOVONEX CREAM 3 Prior authorization, Quantity limit
DOXAZOSIN MESYLATE 1
DOXEPIN HCL 1
DOXYCYCLINE HYC 1 Travel
DOXYCYCLINE MONO 1
DRITHO-SCALP 3 Prior authorization, Quantity limit
DRONABINOL 1
DROSPIR/ETHI TAB 3-0.03MG 1*
DRYSOL SOL 20% 2
DUAC CS KIT 3 Prior authorization, Quantity limit, Step therapy
DUET 3
DUET DHA PAK 3
DUETACT 3 Prior authorization
DUKE'S SOLUTION 1
DULERA 2
DULERA AER 2
DULOXETINE DR 1
DUPIXENT 3 Prior authorization, minimum age 18 or older
DURAGESIC DIS 3 Quantity limit
DUREZOL EMU 0.05% 3
DUTASTERIDE 1
DYAZIDE 3 Prior authorization
DYMISTA SPR 137-50 3
DYNACIN 3 Prior authorization
DYNACIRC 3 Prior authorization
DYRENIUM 3 Prior authorization
E
Drug Name Tier Restrictions
E.E.S -200 1
ECONAZOLE NITRATE 1 Quantity limit
EDECRIN 3
EDEX KIT 3 Prior authorization
EFFEXOR 3 Prior authorization
EFFEXOR XR 3 Prior authorization
EFFIENT 2
EFUDEX 3 Prior authorization, Quantity limit
ELDEPRYL 3
ELESTAT 3 Prior authorization
ELIDEL 2 Prior authorization, Quantity limit
ELIGARD KIT 3 Prior authorization
ELIQUIS 2
ELLA TAB 30MG NC Quantity limit
ELOCON 3 Quantity limit
EMADINE 3
EMCYT 2
EMEND 3 Prior authorization
EMSAM DIS 3 Prior authorization, Step therapy
ENABLEX 3
ENALAPRIL MALEATE 1
ENALAPRIL MALEATE/HYDROCHLO 1
ENBREL 2
ENDOCET 1
ENDOMETRIN SUPP. 3
ENJUVIA 2
ENOXAPARIN INJ 1
ENPRESSE 1*
ENTECAVIR TAB 0.5MG 1
ENTOCORT EC 2
ENTRESTO TAB 49-51MG 3 Prior authorization
EPCLUSA 2 Prior authorization
EPIDUO GEL 0.1-2.5% 3 Prior Authorization
EPIDUO FORTE GEL 0.3-2.5% 3 Prior
EPIFOAM AER 3 Quantity limit
EPINASTINE DROP 0.05% 1
EPINEPHRINE 1
EPIPENS 3 Prior Authorization
EPIQUIN MICRO 2 Quantity limit
EPIVIR 3 Prior authorization
EPIVIR HBV 2
EPLERENONE 3
EPZICOM 3 Prior authorization
ERRIN 1*
ERTACZO 3 Prior authorization, Quantity limit, Step therapy
ERY PAD 3 Quantity limit
ERY-TAB 2
ERYPED-200 1
ERYTHRO/SULFISOX 1
ERYTHROCIN 1
ERYTHROCIN STE FILMTAB 1
ERYTHROMYCIN 1
ERYTHROMYCIN GEL 2% 1 Quantity limit
ERYTHROMYCIN OIN OP 1
ERYTHROMYCIN/BENZOYL PEROXI GEL 1 Quantity limit, Step therapy
ESCITALOPRAM 1
EST ESTROGEN TAB MTEST HS 1
ESTAZOLAM TAB 1MG
ESTRACE CRE 2
ESTRACE TAB 3 Prior authorization
ESTRADERM DIS 3 Prior authorization
ESTRADIOL 1
ESTRADIOL DIS 1
ESTRADIOL/NORET 1
ESTRATEST-H.S. 3
ESTRING MIS 2
ESTROG/MTEST TAB 1.25-2.5 1
ESTROGEL 3
ESTROSTEP FE 3 Prior authorization
ESZOPICLONE 1
ETHAMBUTOL HCL $0
ETHEDENT 1
ETHOSUXIMIDE 1
ETHYL CHLOR AER MIST 1
ETODOLAC 1
ETODOLAC ER 1
EUFLEXXA INJ 10MG/ML UD 3 Quantity limit, Step therapy
EURAX 1 Quantity limit
EVAMIST SPR 1.53MG 3
EVISTA 3
EVOCLIN 3 Prior authorization, Quantity limit, Step therapy
EVOXAC 3 Quantity limit
EXELON 3 Prior authorization
EXELON DIS 2
EXEMESTANE TAB 25MG 1
EXFORGE 2
EXFORGE HTC 2
EXTAVIA 3 Prior authorization, Step therapy
EXTINA AE 3 Prior authorization, Quantity limit, Step therapy
EYLEA 3
EZETIMIBE 1
EZETIMIDE/SIMVASTATIN 1
F
Drug Name Tier Restrictions
FABRAZYME INJ 35MG UD $0 Prior authorization
FAMCICLOVIR 1
FAMOTIDINE NC
FAMOTIDINE 40MG/5ML ORAL SUSPENSION (AGE RESTRICTION 4-12 YEARS OLD) 1
FAMVIR 3 Prior authorization
FANAPT 3 Prior authorization
FARXIGA TAB 10MG 3 Step therapy
FASTCLIX MIS LANCETS 1
FELBAMATE TAB 1
FELODIPINE 1
FEMARA 3 Prior authorization
FEMCON FE 3
FEMHRT 3 Prior authorization
FEMHRT LOW 3 Prior authorization
FENOFIBRATE 1
FENTANYL DIS 1 Quantity limit
FEROTRINSIC 1 Over-the-counter
FERREX 150 CAP FORTE 1
FERREX 28 TAB 1
FERROUS SULFATE 1*
FETZIMA CAP 80MG 3
FINACEA 3 Quantity limit
FINASTERIDE 1MG NC
FINASTERIDE 5mg 1
FIRST PROGESTONE VAG 3
FIRST-HYDROCORTISONE 2 Quantity limit
FIRST-TESTOS OIN 2% 2
FIRST-TESTOSTERONE MC COMPO 2
FLAREX 3
FLECAINIDE ACETATE 1
FLECTOR PAD 2 Prior authorization, Quantity limit
FLOMAX 3 Prior authorization
FLONASE SPR NC
FLOVENT 2 Quantity limit
FLOVENT DISK AER 2
FLUCONAZOLE 1
FLUDROCORTISONE ACETATE 1
FLUNISOLIDE NC
FLUOCINOLONE 1 Quantity limit
FLUOCINOLONE ACETONIDE S 1 Quantity limit
FLUOCINOLONE-E 1 Quantity limit
FLUOCINONIDE 0.1% CR 1
FLUOR-A-DAY 3 Prior authorization
FLUORIDE CHW 1MG F $0
FLUOROMETHOLONE 1
FLUOROPLEX 2 Prior authorization, Quantity limit
FLUOROURACIL CRE 5% 1
FLUOXETINE 1
FLUPHENAZINE DECANOATE INJ 1
FLUPHENAZINE TABS 1
FLURAZEPAM HCL 1
FLURBIPROFEN 1
FLUTAMIDE 1
FLUTIC/SALMET INH 1
FLUTICASONE SPRAY NC
FLUVASTATIN 1
FLUVOXAMINE CR 1
FLUVOXAMINE MALEATE 1
FML FORTE 3 Prior authorization
FML-S.O.P. 3 Prior authorization
FOCALIN 3 Prior authorization
FOCALIN XR 3 Prior authorization
FOLBIC 1
FOLGARD OS 2
FOLGARD RX 3 Prior authorization
FOLIC ACID 1*
FOLLISTIM AQ INJ 3 Quantity limit
FOLPLEX 1
FORADIL AEROLIZER 2 Quantity limit
FORFIVO XL TAB 450MG 3 Prior Authorization
FORTEO SOL 600/2.4 3 Prior Authorization
FORTICAL SPR 200/ACT 3 Prior authorization
FORVIVO 3 Prior authorization
FOSAMAX 3 Prior authorization
FOSAMAX PLUS D 2
FOSINOPRIL SODIUM 1
FOSINOPRIL SODIUM/HYDROCHOLO 1
FOSRENOL 2
FRAGMIN 3 Prior authorization, Quantity limit
FREESTYLE LITE TEST STRIP AND LANCETS 1
FREESTYLE TEST STRIP AND LANCETS 1
FROVA 3 Quantity limit, Step therapy
FROVATRIPTAN TAB 1
FURADANTIN 2
FUROSEMIDE 1
G
Drug Name Tier Restrictions
GABAPENTIN 1
GABITRIL 3 Prior authorization
GALANTAMINE ER 1
GANIRELIX AC INJ 1
GARDASIL INJ UD $0
GASTROCROM CON 1
GATIFLOXACIN 1
GELCLAIR 1 Quantity limit
GEMFIBROZIL 1
GENOTROPIN 3 Prior authorization, Step therapy
GENTAK 1
GENTAMICIN 1 Quantity limit
GENTAMICIN SULFATE 1
GENVOYA 2
GEODON 3 Prior authorization
GG/CODEINE SOL 100-10/5 1
GIANVI 1*
GILENYA 2
GLEEVEC TAB 400MG 3 Prior Authorization
GLIMEPIRIDE 1
GLIP/METFORM TAB 5-500MG 1
GLIPIZIDE 1
GLIPIZIDE ER 1
GLIPIZIDE XL 1 Prior authorization
GLUCAGON EMERGENCY KIT 1MG UD 2
GLUCOPHAGE XR 3 Prior authorization
GLUCOTROL XL 3 Prior authorization
GLUCOVANCE 3 Prior authorization
GLUMETZA 3 Prior authorization
GLUTOSE NC Over-the-counter
GLYB/METFORM TAB 1
GLYBURIDE 1
GLYBURIDE/METFORMIN HCL 1
GLYCOLAX NC
GLYCOPYRROLATE 1
GLYXAMBI 2 Step therapy
GOLYTELY 1*
GONAL-F RFF PEN INJ 3 Prior authorization, Step therapy
GRANISETRON 1
GRANISETRON HCL 1
GRASTEK 3
GRIFULVIN-V 3
GRISEOFULVIN SUS 125/5ML 1
GUANFACINE HCL 1
GYNAZOLE-1 1
H
Drug Name Tier Restrictions
HALFLYTELY BOWL PREP 2
HALOBETASOL PROP. 1 Quantity limit
HALOPERIDOL 1
HALOPERIDOL DECANOATE INJ 1
HARVONI 3 Prior authorization
HC BUTYRATE CRE 0.1% 1
HC PRAMOXINE CRE 1
HC VALERATE 1
HC/ACET ACID SOL OTIC 1
HELIDAC MIS NC Prior authorization, Step therapy
HEMATOGEN 3
HEPARIN SOD INJ 5000/ML 1
HEPARIN SODIUM INJ 5000U/ML 1
HEPSERA 2
HIBICLENS NC Quantity limit
HIPREX 3
HIZENTRA INJ 3 Prior Authorization
HOMATROPINE DROPS 1
HORIZANT 3 Prior authorization
HUMALOG MIX PEN 2
HUMALOG MIX VIAL 2
HUMALOG PEN 2
HUMALOG VIAL 2
HUMATROPE 3 Prior authorization, Step therapy
HUMIRA 2
HUMULIN 70/30 VIAL 1
HUMULIN R U-500 1
HUMULIN-N U-100 INJ 1
HUMULIN-N U-100 PEN 2
HYALGAN INJ 3 Quantity limit, Step therapy
HYDRALAZINE HC 1
HYDRO 40 FOAM 3 Prior authorization, Quantity limit
HYDROCHLOROTHIAZIDE 1
HYDROCODONE/ACETAMINOPHEN 1
HYDROCODONE/HOMATROPINE 1
HYDROCODONE/IBUPROFEN 1
HYDROCODONE/IODO CRM 1 Quantity limit
HYDROCORTISONE 1 Quantity limit
HYDROCORTISONE 1% CREAM NC Over-the-counter, Quantity limit
HYDROCORTISONE BUTYRATE 1 Quantity limit
HYDROCORTISONE VALERATE 1 Quantity limit
HYDROMET SYP 5-1.5/5 1
HYDROMORPHONE HCL 1
HYDROQUINONE NC
HYDROQUINONE/SUNSCREENS NC
HYDROXYCHLOROQUINE 1
HYDROXYUREA 1 Quantity limit
HYDROXYZINE HCL 1
HYDROXYZINE PAMOATE 1
HYOMAX-SR 3 Prior authorization
HYOSCYAMINE SULFATE IR/HYOS 1
HYPER-SAL NEB UD 1
HYPERCARE 1 Quantity limit
HYTRIN 3
HYZAAR 3 Prior authorization
I
Drug Name Tier Restrictions
IBANDRONATE 1
IBRANCE CAP 125MG 3 Prior Authorization
IBUPROFEN 1
ILARIS INJ 180MG 3 Prior authorization
IMBRUVICA CAP 140MG 3 Prior Authorization
IMDUR 3 Prior authorization
IMIPRAMINE 1
IMIQUIMOD 1 Quantity limit
IMITREX 3 Prior authorization, Quantity limit, Step therapy
IMURAN $0
INCIVEK 2 Prior authorization
INCRUSE ELPT INH 62.5MCG 3 Prior authorizaton
INDAPAMIDE 1
INDERAL LA 3 Prior authorization
INDOMETHACIN 1
INDOMETHACIN ER 1
INNOHEP INJ 20000/ML 3
INOVA PAD 3 Quantity limit, Step therapy
INSPRA TAB 3 Prior authorization
INTAL INHALER 2 Quantity limit
INTERMEZZO 3 Prior authorization
INTRON-A INJ 2 Prior authorization, Quantity limit
INTUNIV 3 Prior authorization, Step therapy
INVEGA 3 Prior authorization, Step therapy
INVOKAMET 2 Step therapy
INVOKANA 2 Step therapy
IOPHEN C-NR LIQ 100-10/5 1
IPRATROPIUM 1 Quantity limit
IPRATROPIUM BROMIDE SPR 1 Quantity limit
IPRATROPIUM/ALBUTER 1 Quantity limit
IRBESARTAN 1
IRBESARTAN/HCTZ 1
IRESSA 2 Prior authorization, Quantity limit
ISENTRESS 2
ISOMETHEPTENE/DICHLORALPHEN 1
ISONIAZID $0
ISOPTIN SR 3 Prior authorization
ISOPTO HOMATROPINE 1
ISOPTO HYOSCINE 1
ISORDIL TITRADOSE 3 Prior authorization
ISOSORBIDE DINITRATE TA 1
ISOSORBIDE MONONITRATE ER 1
ISRADIPINE 1
ISTALOL 3
ITRACONAZOLE 1
J
Drug Name Tier Restrictions
JANUMET 3 Step therapy
JANUVIA 3 Step therapy
JARDIANCE TAB 2 Step therapy
JENTADUETO 2 Step therapy
JINTELI TAB 1MG-5MCG 1*
JOLESSA 1*
JUBLIA NC
JUNEL 1*
JUNEL FE TAB 1*
JUVISYNC 2
K
Drug Name Tier Restrictions
K CITRATE SOL CITR ACD 1
K-EFFERVESCENT 1
K-TABS 1
KADIAN 3
KADIAN CAP 40MG ER 3
KALETRA 2
KAON-CL-10 1
KAPIDEX 3 Step therapy
KARIVA 1*
KAZANO 3 Step therapy
KELNOR TAB 1/35 1*
KENALOG INJ 2
KEPPRA 3
KERAFOAM 3 Prior authorization, Quantity limit
KERALAC 3 Prior authorization, Quantity limit
KERALYT 2 Quantity limit
KEROL EMU 3 Prior authorization, Quantity limit
KERYDIN NC
KETEK PAK 2
KETOCONAZOLE CREAM 1 Quantity limit
KETOCONAZOLE TAB 1
KETOPROFEN 1
KETOROLAC TROMETHAMINE 1 Quantity limit
KINERASE 2 Prior authorization, Quantity limit
KINERET 3 Prior authorization, Step therapy
KLARON 3 Prior authorization, Quantity limit, Step therapy
KLONOPIN 3 Prior authorization
KLONOPIN WAFERS 3 Prior authorization, Step therapy
KLOR-CON 1
KLOR-CON-8 1
KLOR-CON/EF 1
KOMBIGLYZE XR 3 Step therapy
KRISTALOSE PAK 3
L
Drug Name Tier Restrictions
L-METHYL- TAB B6-B12 1
L-METHYLFOLA CAP FORTE 1
LABETALOL HCL 1
LAC-HYDRIN NC Over-the-counter
LACTIC ACID 1 Quantity limit
LACTIC ACID E 1 Quantity limit
LACTINOL 3 Quantity limit
LACTINOL-E 3 Quantity limit
LACTULOSE 1
LAMICTAL 3
LAMICTAL ODT 3
LAMICTAL STARTER/NOT TAKING KIT 3 Prior authorization
LAMICTAL XR 3 Prior authorization
LAMIVUDINE/ZIDOVUDINE 1
LAMOTRIGINE 1
LAMOTRIGINE EXTENDED RELEASE 1
LAMOTRIGINE ODT 1
LANOXIN 1
LANSOPR/AMOX MIS /CLARITH 1
LANSOPRAZOLE 15 MG NC
LANSOPRAZOLE 30 MG NC
LANSOPRAZOLE 3MG/ML SOLUTION (AGE RESTRICTION 4-12 YEARS OLD) 1
LANTANOPROST 1
LANTUS INJ 100U/ML 2
LANTUS SOLOSTAR INJ SOLOSTAR 2
LARIN 24 TAB FE 1/20 1*
LASIX 3 Prior authorization
LATANOPROST SOL 0.005% 1
LATUDA 3 Prior authorization
LAVOCLEN-4 CREAMY WASH LIQ CREM WSH 3 Quantity limit
LAVOCLEN-8 CREAMY WASH LIQ CREM WSH 3 Quantity limit
LAZERFORMALYDE 2 Quantity limit
LEFLUNOMIDE 1
LESCOL 3 Quantity limit
LESCOL XL 3 Quantity limit, Step therapy
LESSINA 1* Quantity limit, Step therapy
LETROZOLE 1
LEUCOVORIN 1 Quantity limit
LEUKERAN 1
LEUKINE INJ 2 Prior authorization, Quantity limit
LEUPROLIDE 1
LEVALBUTEROL INHAL. SOLN. 1
LEVAQUIN 3 Prior authorization
LEVBID 2
LEVEMIR INJ 2
LEVEMIR INJ FLEXPEN 2
LEVETIRACETAM 1
LEVITRA 3 Quantity limit
LEVLITE-28 1
LEVOBUNOLOL HCL 1
LEVOCARNITIN
LEVOCETIRIZINE 1
LEVOFLOXACIN 1
LEVONOR/ETHI TAB ESTRADIO 1
LEVORA 1*
LEVOTHROID 3
LEVOTHYROXINE SODIUM TAB 1
LEVOXYL 3 Prior authorization
LEVSIN 2
LEXAPRO 3 Prior authorization, Step therapy
LIALDA 3
LIDAMANTLE 2 Quantity limit
LIDAZONE HC 1 Quantity limit
LIDEX 3 Prior authorization, Quantity limit
LIDOCAINE HCL 1 Quantity limit
LIDOCAINE PATCH 1 Quantity limit
LIDOCAINE VISCOUS 1 Quantity limit
LIDOCAINE/PRILOCAINE 1 Quantity limit
LIDODERM 3 Quantity limit
LIMBREL 3 Prior authorization
LINDALE 3 Quantity limit
LINEZOLID 1
LINZESS CAP
LIOTHYRONINE TAB 1
LIPITOR 3 Prior authorization
LIPTRUZET 3 Step therapy
LISINOPRIL 1
LISINOPRIL/HYDROCHLOROTHIAZ 1
LITHIUM CARBONATE 1
LITHIUM CARBONATE ER 1
LITHOBID 3 Prior authorization
LIVALO TAB 2MG 3
LO LOESTRIN TAB 3
LOCOID 3 Quantity limit
LOCOID LIPOCREAM 3 Prior authorization, Quantity limit, Step therapy
LOESTRIN 21 TAB 1.5/30 1* Prior authorization
LOESTRIN 24 FE 3 Prior authorization
LOESTRIN FE1/20 3 Prior authorization
LOFIBRA 3
LOMEDIA 24 TAB FE 1*
LOPERAMIDE HCL NC
LOPREEZA 1
LOPROX GEL 3 Prior authorization, Quantity limit, Step therapy
LOPROX SHAMPOO 3 Prior authorization, Quantity limit, Step therapy
LORATADINE NC
LORAZEPAM 1 Travel
LORYNA TAB 3-0.02MG 1
LORZONE TAB 750MG 3 Prior authorization
LOSARTAN 1
LOSARTAN/HCTZ 1
LOTEMAX 3
LOTENSIN 3 Prior authorizaton
LOTENSIN HCT 3 Prior authorization
LOTREL 3 Prior authorization
LOVASTATIN 1
LOVAZA 3 Prior authorization, Quantity limit
LOVENOX INJ 3 Quantity limit
LOW OGESTREL 1*
LUDENT CHW 1*
LUGOL'S SOL 1
LUGOL'S SOL BP 1
LUMIGAN SOL 0.03% 2
LUNESTA 3 Quantity limit, Step therapy
LUPR DEP-PED INJ 3
LUPRON DEPOT 3
LUSTRA NC Quantity limit
LUSTRA-ULTRA NC Quantity limit
LUTERA TAB 1*
LUVERIS INJ 75UNIT UD 3
LUVOX CR 3 Prior authorization
LUXIQ 3 Prior authorization, Quantity limit
LYRICA 2
LYSTEDA 3 Prior authorization
M
Drug Name Tier Restrictions
M-OXY 1
MACRODANTIN 3 Prior authorization
MAG-OX 400 NC Over-the-counter
MAGIC MOUTHWASH SOLUTION 2
MAKENA 3 Prior Authorization
MALARONE 3 Travel
MALATHION LOT 0.5% 1
MARPLAN TAB 3
MATZIM LA TAB 240MG/24 3 Prior Authorization
MAXAIR AUTOHALER 3 Prior authorization, Quantity limit
MAXALT 3 Quantity limit
MAXALT-MLT 3 Quantity limit
MAXZIDE-25 3 Prior authorization
MEBENDAZOLE 2
MEDERMA GEL 2 Quantity limit
MEDROXYPROG INJ 1
MEFENAMIC ACID 1
MEFLOQUINE HCL 3 Travel
MEGACE 3 Prior authorization
MEGESTROL ACETATE 1
MEKINIST 3 Prior authorization
MELOXICAM 1
MEMANTINE 1
MENEST 2
MENOPUR INJ 75UNIT UD 3
MENOSTAR DIS 3
MENTAX 3 Prior authorization, Quantity limit, Step therapy
MEPERIDINE HCL 1
MEPHYTON 1
MEPRON 2
MERCAPTOPURINE 1
MESALAMINE ENE 1
MESTINON 2
METADATE CD 3 Prior authorization
METANX 3
METAXALONE TAB 800MG 1
METFORMIN EXTENDED RELEASE 1
METFORMIN HCL 1
METFORMIN/PIOGLITAZONE 1
METFORMIN/ROSIGLITAZONE 1
METHADONE HCL 1
METHADOSE 1
METHAZOLAMIDE 1
METHENAMINE HIP 1
METHENAMINE MAN E 1
METHERGINE 1
METHIMAZOLE 1
METHOCARBAMOL 1
METHOTREXATE 1
METHYLDOPA 1
METHYLERGON TAB 0.2MG 1
METHYLIN ER 1
METHYLIN SOL 2
METHYLIN TAB 1
METHYLPREDNISOLONE INJ 1
METHYLPREDNISOLONE PAK 1
METHYLPREDNISOLONE/ESTE 1
METOCLOPRAMIDE 1
METOCLOPRAMIDE HCL 1
METOLAZONE 1
METOPROLOL 1
METOPROLOL/HYDROCHLOROTHIAZ 1
METROGEL GEL 3 Quantity limit
METRONIDAZOL GEL 1
METRONIDAZOLE TABLETS 1 Quantity limit
MEXILETINE HCL 1
MIACALCIN 2
MICARDIS 2 Prior authorization
MICARDIS HCT 3 Prior authorization
MICROGESTIN 1*
MIDODRINE HCL 1
MIDRIN 3 Prior authorization
MIGRANAL 3 Prior authorizaton
MIMYX 2 Prior authorization, Quantity limit
MINASTRIN 24 CHW FE 3
MINITRAN DIS 1
MINIVELLE DIS 0.0375MG 3
MINOCIN 3 Prior authorization
MINOCYCLINE HCL 1
MINOXIDIL 1
MIRAPEX 3 Prior authorization
MIRCETTE 28 3
MIRENA IUD SYSTEM $0
MIRTAZAPINE 1
MIRVASO GEL 0.33% 3
MISOPROSTOL 1
MOBIC 3
MODAFINIL 1
MODICON 28 3 Prior authorization
MOEXIPRIL HCL 1
MOEXIPRIL/HYDROCHLOROTHIAZI 1
MOMETASONE CREAM 1
MOMETASONE FUROATE NASAL SPRAY NC
MONODOX 3 Prior authorization
MONOPRIL 3 Prior authorization
MONOVISC INJ 2 Quantity limit
MONTELUKAST 1
MONUROL PAK GRANULES 2
MORPHINE SULFATE 1
MOTRIN TAB 3 Prior authorization
MOVANTIK TAB 25MG 3
MOVIPREP NC
MOXEZA SOL 0.5% 3
MOXIFLOXACIN 1
MULTAQ 3
MULTI VITAMINE/FLUORIDE 1*
MULTIGEN 2
MUPIROCIN 1 Quantity limit
MUSE 3 Prior authorization, Quantity limit
MY WAY TAB 1.5MG
MYAMBUTOL 1
MYCOPHENOLATE $0
MYDRIACYL 3 Prior authorization
MYFORTIC $0
MYORISAN CAP 1
MYRBETRIQ 3
MYZILRA TAB 3
N
Drug Name Tier Restrictions
NA BICARBONATE 1
NABUMETONE 1
NAFTIFINE CRE HCL
NAFTIN 3 Prior authorization, Quantity limit, Step therapy
NAFTIN GEL 3 Quantity limit, Step therapy
NALOXONE INJ 0.4MG/ML 1
NALTREXONE HCL 1
NAMENDA 3 Prior authorization
NAMENDA TITRATION PAK 3 Prior authorization
NAPROXEN NC
NARATRIPTAN TAB 1
NARCAN SPR 3
NARDIL 3 Prior authorization
NASACORT NC
NASAREL NC
NASCOBAL 3 Prior authorization, Step therapy
NASCOBAL SPR 500MCG 3 Prior Authorization
NASONEX NC
NATEGLINIDE TAB 60MG 1
NATURE-THROI TAB 1
NECON 0.5/35MG 2 1*
NECON 1/35 1*
NECON 7/7/7 1*
NEEDLES (VARIOUS) 1
NEFAZODONE HCL 1
NEO/POLY/CORT 1
NEO/POLY/DEX 1
NEOBENZ MICRO 3 Prior authorization, Step therapy
NEOMYCIN 1
NEOMYCIN SULFATE 1
NEOMYCIN/POLYMIXIN/DEXAMETH 1
NEOMYCIN/POLYMYXIN/HYDROCOR 1
NEORAL $0
NESINA $3 Step therapy
NEULASTA INJ 6MG/0.6M 2 Quantity limit
NEUPOGEN PFS 2 Prior authorization, Quantity limit
NEUPRO DIS 2 Prior authorization
NEURONTIN 3
NEUTRA PHOS-K 3
NEUTRA-PHOS 3
NEVANAC 3
NEVIRAPINE 1
NEXIUM NC
NEXPLANON IMP 68MG 3*
NIACIN ER 1
NIASPAN 3
NICORELIEF GUM NC* Over-the-counter
NICORETTE LOZ 4MG MINT NC*
NICOTINAMIDE W/ZINC OXIDE/C 3 Prior authorization
NICOTINE POL GUM ORIG NC*
NICOTINE POLACRILEX GUM NC* Over-the-counter
NICOTINE TRANSDERMAL SYSTEM NC* Over-the-counter
NICOTROL INHALER 3 Prior authorization
NIFEDICAL XL 1
NIFEDIPINE 1
NIFEDIPINE ER 1
NIFEREX GOLD 2
NIFEREX-150 2
NIFEREX-150 FORTE 2
NILANDRON 2
NINLARO CAP 3MG 3 Prior authorization
NISOLDIPINE 1
NITRO-DUR DIS 3 Prior authorization
NITROBID 2
NITROFURAN MACROCRYSTAL 1
NITROFURAN MONOHY 1
NITROGLYCERIN TRANSDERMAL 1
NITROLINGUAL PUMPSPRAY 3 Step therapy
NITROSTAT SUB 2
NIZATIDINE CAP 1
NORA-BE 1*
NORDITROPIN 2 Prior authorization
NORETHINDRON TAB 0.35MG 1*
NORETHINDRONE 5MG 1
NORGEST/ETHI TAB ESTRADIO 1
NORITATE 3 Quantity limit
NORPACE CR 3 Prior authorization
NORPRAMIN 3 Prior authorization, Step therapy
NORTREL 0.5/35 2 1*
NORTREL 7/7/7 1*
NORTRIPTYLINE HCL 1
NORVASC 3 Prior authorization
NORVIR 2
NOTREL 1/35 1*
NOVAREL INJ 10000U 3 Prior authorization
NOVOFINE MIS 1
NOVOLIN 70/30 PEN 2
NOVOLIN-70/30 VIALS 2
NOVOLIN-N VIALS 2
NOVOLIN-R PEN 2
NOVOLIN-R VIAL 2
NOVOLOG INJ FLEXPEN 2
NOVOLOG MIX 70/30 2
NOVOLOG MIX 70/30 PEN 2
NOVOLOG VIALS 2
NP THYROID TAB 30MG 1
NUCALA INJ 100MG 3 Prior authorization
NUCYNTA TAB 3
NUEDEXTA CAP 20-10MG 3 Prior authorization
NULYTELY 3 Prior authorization
NUQUIN HP 1 Quantity limit
NUTRINATE 3
NUTROPIN 3 Prior authorization, Step therapy
NUVARING MIS 2
NUVIGIL 3 Prior authorization
NYSTATIN CREAM 1 Quantity limit
NYSTATIN SUSPENSION 1 Quantity limit
NYSTATIN TABLETS 1
NYSTATIN/TRIAMCINOLONE 1 Quantity limit
NYSTOP 1 Quantity limit
O
Drug Name Tier Restrictions
OCELLA 28S 1*
OCTREOTIDE INJ 1
ODEFSEY 2
OFLOXACIN 1
OGESTREL 1
OLANZIPINE 1
OLM MED/HCTZ TAB 40-12.5 1
OLMESA MEDOX TAB 1
OLMESARTAN 1
OLMESARTAN/AMLODIPINE 1
OLMESARTAN/AMLODIPINE/HCTZ 1
OLMESARTAN/HCTZ 1
OLOPATADINE 0.1% 1
OLUX AER 3 Prior authorization, Quantity limit, Step therapy
OLYSIO 3 Prior authorization
OMEGA-3-ACID ETHYL ESTERS 1
OMEPRAZOLE NC
OMEPRAZOLE 2 MG/ML ORAL SUSPENSION (AGE RESTRICTION 4-12 YEARS OLD) 1
OMINTROPE 3 Prior authorization, Step therapy
OMNARIS SPR NC
OMNICEF 3 Prior authorization
OMNIFLEX DPR 3*
ONDANSETRON 1
ONE TOUCH TEST STRIPS 3 Prior authorization, Quantity limit
ONETOUCH 3 Prior authorization, Quantity limit
ONFI 3
ONGLYZA TAB 5MG 3 Step therapy
OPANA 3 Prior authorization
OPANA ER 3 Prior authorizaton
OPTIHALER MIS 3 Prior authorization
OPTIPRIO 3 Prior authorization
OPTIVAR DRO 3
ORACEA 3 Quantity limit
ORAPRED ODT TAB 2
ORAPRED SOL 15MG/5ML 3
ORENCIA 3 Prior authorization, Step therapy
ORPHENADRINE CITRATE ER 1
ORTHO DIAPHRAGM ALL-FLEX DRP KIT 3*
ORTHO EVRA DIS 24HR 3*
ORTHO TRI-CYCLEN 3 Prior authorization
ORTHO TRI-CYCLEN LO 3 Prior authorizaton
ORTHO-CEPT 28 3 Prior authorization
ORTHO-CYCLEN 3
ORTHO-NOVUM 3
ORTHOVISC INJ 3 Quantity limit, Step therapy
OSCIMIN SR TAB 0.375MG 1
OSCION CLEANSER 2 Quantity limit, Step therapy
OSELTAMIVIR 1 Quantity limit
OSENI TAB 25-30MG 3
OSMOPREP 2
OSPHENA 3 Step therapy
OTEZLA 3 Prior authorization, Step therapy
OTREXUP 3 Prior authorization, Step therapy
OVACE PLUS 3
OVCON-35 3 Prior authorization
OVIDE 2 Quantity limit
OVIDREL INJ UD 3
OXAPROZIN 1
OXAZEPAM 1
OXCARBAZEPINE 1
OXICONAZOLE CRE NITRATE 1 Prior authorizaton, Qunatity limit
OXISTAT 2 Prior authorization, Quantity limit
OXSORALEN LOT 1% 2 Prior authorization, Quantity limit
OXSORALEN ULTRA CAP 10MG 3 Prior authorization, Quantity limit
OXTELLAR XR TAB 600MG 3 Prior authorization
OXYBUTYNIN 1
OXYBUTYNIN ER 1
OXYCODONE HCL 1
OXYCODONE/ACETAMINOPHEN 1
OXYCONTIN 2
OXYMORPHONE TAB 1
OXYTROL 3
P
Drug Name Tier Restrictions
PAMELOR 3 Prior authorization, Step therapy
PANCREAZE 2
PANCRELIPASE CAP 5000UNIT 1
PANDEL 3 Quantity limit
PANTOPRAZOLE SODIUM NC
PARAGARD INTRAUTERINE COPPE IUD $0
PARI TREK COMBO PAK NC
PARI TREK S COMPACT COMPRESS NC Prior authorization
PARI TREK S PORTABLE POWER KIT POWER NC Prior authorization
PARICALCITOL CAP 1
PARLODEL 3 Prior authorization
PAROMOMYCIN SULFATE 1
PAROXETINE ER 1
PAROXETINE HCL 1
PATADAY SOL 3 Prior authorization
PATANESE 3 Prior authorization, Quantity limit
PATANOL 3 Prior authorization
PAXIL 3 Prior authorization
PAZEO DRO 0.7% 3
PEG 3350 SOL ELECTROL 1
PEG-INTRON KIT 2
PEG-INTRON REDIPEN PAK 4 KIT 80MCG RP UD 2
PEGASYS INJ 180MCG/M UD 2
PEGASYS KIT 2
PENICILLIN V POTASSIUM 1
PENTASA 2
PENTAZOCINE/ACETAMINOPHEN 1
PENTOXIFYLLINE ER 1
PEPCID TAB 40MG NC
PERCOCET 3 Prior authorizaton
PERIDEX RINSE 3 Quantity limit
PERINDOPRIL TAB
PERMAX 2
PERMETHRIN 1 Quantity limit
PERPHENAZINE 1
PHENAZOPYRIDINE 1
PHENELZINE TAB 15MG 1
PHENOBARBITAL 1
PHENTERMINE HCL 1
PHENYLERPHRINE 1
PHENYTEK 1
PHENYTOIN 1
PHOS FLUR 1 Quantity limit
PHOS-NAK 1
PHOSLO 2
PILOCARPINE HCL 1
PILOPINE HS 3 Prior authorization
PINDOLOL 1
PIOGLITAZONE 1
PIOGLITAZONE/GLIMEPIRIDE 1
PIROXICAM 1
PLAVIX 3 Prior authorization
PLEGRIDY 2
PLENDIL 3 Prior authorizaton
PLEXION 3 Quantity limit
PODOFILOX SOL 0.5% 1
POLY-VITAMIN/FLUORIDE 1*
POLY-VITAMIN/IRON/FLUORIDE DRO 1*
POLYETHYLENE GLYCOL NC
POLYMYXIN B/ SOL TRIMETHP 1
POMALYST 3 Prior authorizaton
PONSTEL 3 Prior authorizaton
PORTIA-28 1*
POT CITRATE TAB 1080MG 1
POTASSIUM CHLORIDE 1
POTASSIUM CHLORIDE ER 1
PRADAXA 3
PRALUENT 3 Prior authorization
PRAMIPEXOLE TAB 1
PRAMOSONE 1 Quantity limit
PRANDIN 3
PRASCION EMU 1 Quantity limit
PRAVACHOL 3 Prior authorization
PRAVASTATIN SODIUM 1 Quantity limit
PRAZOSIN HCL 1
PRECARE CHW 3
PRECARE PREMIER 3
PRED FORTE 3 Prior authorization
PRED MILD 3
PRED SOD PHO SOL 1% OP 1
PRED-G 3
PRED-G-S.O.P. 3
PREDNICARBATE 1 Quantity limit
PREDNISOLONE 1
PREDNISOLONE ACETATE 1
PREDNISOLONE SODIUM PHOSPHA 1
PREDNISONE 1
PREFEST TAB 3
PREMARIN 3
PREMARIN W/APP CREAM 2
PREMPHASE 3
PREMPRO 3
PRENATAL 19 1
PRENATAL DHA 3
PRENATAL ELITE 3 Prior authorization
PRENATAL PLUS 1*
PRENATE CAP ENHANCE 3
PREVACID NC
PREVACID SOLUTAB (AGE RESTRICTION 4-12 YEARS OLD) 2
PREVALITE 1
PREVIDENT 3 Prior authorization, Quantity limit
PREVIFEM 1
PREVPAC NC Prior authorization, Step therapy
PREZCOBIX TAB 800-150 3 Prior authorization
PREZISTA 2
PRILOSEC NC
PRIMACARE ONE 3
PRIMAQUINE PHOSPHATE 3
PRIMIDONE 1
PRINIVIL 3
PRINZIDE 3
PRISTIQ 3
PROAIR MDI 3 Prior authorization, Step therapy
PROAMATINE 3
PROBENECID 1
PROCAINAMIDE HCL 1
PROCARDIA 3
PROCARDIA XL 3 Prior authorizaton
PROCHLORPERAZINE 1
PROCRIT INJ 2000U/ML UD 2 Prior authorization, Quantity limit
PROCTOFOAM-HC AER 3 Quantity limit
PROCTOFOAM-NS AER 3 Quantity limit
PROCTOZONE-HC 1 Quantity limit
PROGESTERONE IN OIL 3
PROGRAF $0
PROGUANIL 1 Travel
PROLENSA SOL 0.07% 3
PROMETHAZINE 1
PROMETHAZINE/CODEINE 1
PROMETRIUM 2
PRONEB ULTRA II ADULT $0
PRONEB ULTRA II PEDI $0
PROPAFENONE HCL 1
PROPANTHELINE 1
PROPARACAINE HCL 1
PROPECIA NC Quantity limit
PROPIMEX-2 2
PROPRANOLOL 1
PROSCAR 3 Prior authorization
PROSED EC 3
PROTONIX NC
PROTOPIC 3 Prior authorization, Quantity limit
PROTRIPTYLINE
PROVENT 3
PROVENTIL AER HFA 3 Prior authorization, Quantity limit
PROVIGIL 3 Prior authorization
PROZAC 3 Prior authorization
PROZAC WEEKLY 3 Prior authorization, Step therapy
PRUDOXIN 2 Prior authorization, Quantity limit, Step therapy
PSORCON E 3 Prior authorization, Quantity limit, Step therapy
PULMICORT FLEXHALER 2 Quantity limit
PULMICORT RESPULES 2
PULMOZYME 2
PURALUBE TEARS 1
PYLERA CAP 3 Prior Authorization
PYRAZINAMIDE $0
PYRIDOSTIGMINE 1
PYRIDOXINE $0
Q
Drug Name Tier Restrictions
QNASL NC
QSYMIA CAP 3 Prior authorization
QUALAQUIN 2
QUASENSE 1*
QUDEXY XR CAP 50/24HR 3
QUESTREN LIGHT 3 Prior authorization
QUETIAPINE 1
QUETIAPINE ER 1
QUILLICHEW 3
QUILLIVANT SUS 25MG/5ML 3
QUINAPRIL HCL 1
QUINAPRIL/HCTZ TAB 20-12.5 1
QUINAPRIL/HYDROCHLOROTHIAZI 1
QUINIDINE SULFATE 1
QUIXIN 3
QVAR AER 2 Quantity limit
R
Drug Name Tier Restrictions
RABAVART INJ 3
RABEPRAZOLE NC
RAGWITEK SUB 3
RALOXIFENE 1
RAMIPRIL 1
RANEXA 3 Prior authorization
RANITIDINE 15MG/ML ORAL SOLUTION (AGE RESTRICTION 4-12 YEARS OLD) 1
RANITIDINE HCL NC
RAPAFLO CAP 3 Prior authorization
RAPAMUNE $0
RASUVO 3 Prior authorization, Step therapy
RAZADYNE 3 Prior authorization
RE-SA 2 Quantity limit
REBIF 3 Prior authorization, Step therapy
RECLAST $0
RECLIPSEN 1*
RELENZA DISKHALER 2
RELPAX 3 Quantity limit, Step therapy
REMERON 3 Prior authorization
REMINYL 2
RENA-VITE 1
RENAGEL 2
RENAL CAP SOFTGEL 3 Prior authorization
RENAX 2
RENOVA NC Quantity limit
RENVELA 2
REPAGLINIDE 1
REPATHA 3 Prior authorization
REPRONEX INJ 75IU UD 3
REQUIP XL 3
RESERPINE 1
RESTASIS EMU 3
RESTORIL 3 Prior authorization
RETIN-A 3 Quantity limit
RETIN-A MICRO 3 Prior authorization, Quantity limit, Step therapy
RETROVIR 3 Prior authorization
REVATIO 3 Quantity limit
REVLIMID CAP 3 Prior authorization
REXULTI TAB 3 Prior authorization
REYATAZ 2
RHINOCORT AQUA NC
RIBAPAK TAB 800/DAY 2
RIBAVIRIN TAB 200MG 1
RIFADIN CAP 2
RIFAMPIN CAP 150MG 1
RILUTEK 3 Prior authorization
RILUZOLE 1
RIMANTADINE HCL 1
RIMSO-50 3
RISEDRONATE TAB 1
RISPERDAL 3
RISPERDAL CONSTA INJ 3 Prior authorization
RISPERDAL M-TAB 3 Prior authorization
RISPERIDONE 1
RITALIN 3 Prior authorization
RITALIN LA 3 Prior authorization, Step therapy
RIVASTIGMINE 1
RIZATRIPTAN 1 Quantity limit
RIZATRIPTAN-MLT 1 Quantity limit
ROPINIROLE EXTENDED RELEASE 1
ROPINIROLE HCL 1
ROSAC 3 Quantity limit
ROSADERM EMU CLEANSER 1 Quantity limit
ROSANIL CLEANSER EMU 3 Quantity limit, Step therapy
ROSIGLITAZONE 1
ROSIGLITAZONE/GLIMEPIRIDE 1
ROSULA 3 Prior authorization, Quantity limit, Step therapy
ROSUVASTATIN 1
ROXICET 1
ROXICODONE 1
ROZEREM 3 Prior authorization, Quantity limit, Step therapy
RYTARY CAP 3
RYTHMOL SR 3 Prior authorization
S
Drug Name Tier Restrictions
SABRIL TAB 500MG 3 Prior Authorization
SAIZEN 3 Prior authorization, Step therapy
SALAGEN 2 Prior authorization, Quantity limit
SALEX 3 Quantity limit
SALSALATE 1
SANCTURA 3 Prior authorization
SANCTURA XR 3 Prior authorization
SANDOSTATIN INJ 3 Prior authorization
SANDOSTATIN LAR DEPOT KIT 3 Prior authorization
SANTYL 2 Quantity limit
SAPHRIS 3
SARNA LOT NC Quantity limit
SAVELLA 2
SAXENDA 3 Prior authorization
SEASONALE 3 Quantity limit
SEASONIQUE 3 Quantity limit
SELEGILINE HCL 1
SELENIUM SULFIDE LOTION 1 Quantity limit
SELENIUM SULFIDE SHA 3 Prior authorization, Quantity limit, Step therapy
SENSIPAR 2 Prior authorization
SEREVENT MIS 2 Quantity limit
SEROQUEL 3 Prior authorization
SEROQUEL XR 3 Prior authorization
SEROSTIM 3 Prior authorization, Step therapy
SERTRALINE HCL 1
SF 5000 PLUS 1 Quantity limit
SILDENAFIL 1 Quantity limit
SILENOR TAB 3 Prior authorization
SILVER NITRATE 1 Quantity limit
SILVER SULFA CRE 1% 1
SIMBRINZA SUS 1-0.2% 3
SIMCOR 2
SIMPONI 3 Prior authorization, Step therapy
SIMVASTATIN 1 Quantity limit
SINGULAIR 3 Prior authorization
SKELAXIN 3 Step therapy
SKLICE LOT 0.5% 3
SKYLA IUD $0
SMZ/TMP 1
SODIUM CHLORIDE INJ 1
SODIUM FLUORIDE 1*
SODIUM SULFACETAMIDE 1 Quantity limit
SODIUM SULFACETAMIDE AND SU EMU SULFUR 1 Quantity limit
SODIUM SULFACETAMIDE/SULFUR 1 Quantity limit
SOLODYN 3 Prior authorization, Step therapy
SOLU-CORTEF INJ 100MG UD $0
SOLU-MEDROL INJ 3 Prior authorization
SOLVADI 3 Prior authorization
SOMA 3 Prior authorization
SONATA CAP 3 Quantity limit, Step therapy
SOOLANTRA CRE 1% 3
SORBITOL 1
SORIATANE CK KIT 3 Prior authorization, Quantity limit
SOTALOL HCL 1
SPIRIVA 2 Quantity limit
SPIRONOLACTONE 1
SPIRONOLACTONE/HYDROCHLOROT 1
SPORANOX SOL 10MG/ML 3
SPRINTEC 1*
SPRYCEL 3 Prior authorization, Quantity limit, Step therapy
SRONYX 1*
SSKI 1
STALEVO 3 Prior authorization
STARLIX 2
STAVUDINE 1
STELARA 3 Prior authorization, Step therapy
STENDRA 3
STIMATE SOL 1.5MG/ML 3
STIOLTO AER 2.5-2.5 3
STRATTERA 3 Prior authorization
STRIBILD 2 Prior authorization
STROMECTOL 2
STRONGSTART CHW 3
SUBOXONE FILM 3
SUBOXONE SUB 3 Prior authorization
SUBUTEX SUB 2 Prior authorization
SUCRALFATE 1
SULAR 3 Prior authorization
SULFACET-R LOT TINT-FRE 3 Quantity limit
SULFACETAMIDE SODIUM 1
SULFACETAMIDE SODIUM OIN 1
SULFACETAMIDE SODIUM/SULFUR 1 Quantity limit
SULFADIAZINE 1
SULFATOL 3 Quantity limit
SULFAZINE EC 1
SULFUR SUBLIMED 1 Quantity limit
SULINDAC 1
SUMATRIPTAN 1 Quantity limit
SUPARTZ INJ 3 Quantity limit
SUPRAX 2
SUPREP 2
SURE COMFORT MIS LANCETS 1
SUSTIVA 2
SUTENT 2 Prior authorization, Quantity limit
SYMAX FASTABS 3 Prior authorization
SYMBICORT 2 Quantity limit
SYMLIN INJ 0.6MG/ML 2
SYNALAR 3 Quantity limit
SYNJARDY 2 Step therapy
SYNTHROID 1
SYNVISC INJ 2 Quantity limit
SYNVISC ONE INJ 2 Quantity limit
SYPRINE 2 Prior authorization
SYRINGES (VARIOUS) 1
T
Drug Name Tier Restrictions
TACLONEX OIN 2 Prior authorization, Quantity limit
TACROLIMUS OINT 1
TAFINLAR CAP 75MG 3 Prior authorization
TAGAMET NC
TAMIFLU 3 Prior authorization
TAMOXIFEN CITRATE 1
TAMSOLUSIN 1
TANZEUM 3 Step therapy
TARCEVA 3 Prior authorization
TASIGNA CAP 3 Prior authorization
TAZAROTENE 1 Prior authorization, Quantity limit
TAZORAC 3 Prior authorization, Quantity limit
TECFIDERA 2
TEGRETOL 3
TEGRETOL-XR 2
TEKTURNA 2
TEKTURNA HTC 2
TEKTURNA-XR 2
TELMISARTAN 1
TELMISARTAN/HCTZ 1
TEMAZEPAM 1
TEMODAR 3 Prior authorization
TEMOZOLOMIDE 1
TENORMIN 3 Prior authorization
TERAZOSIN HCL 1
TERBINAFINE HCL 1
TERBUTALINE SULFATE 1
TERCONAZOLE 1
TESFIDERA 3 Prior authorization
TESTERONE ENANTHATE INJ 1
TESTOSTERONE CYPIONATE INJ 1
TESTOSTERONE GEL 1
TETRACYCLINE CAP 1
TEV-TROPIN 3 Prior authorization, Step therapy
TEVETEN 3
THALOMID 2 Prior authorization, Quantity limit
THEOPHYLLINE ER 1
THERMAZENE 1 Quantity limit
THEROBEC TAB PLUS 1
THIOTHIXENE 1
THYROGEN INJ 2
THYROID 1
TIAGABINE HCL 1
TIAZAC 3 Prior authorization
TICLOPIDINE HCL 1
TICOSYN 3 Prior authorization
TIGAN 3 Prior authorization
TIKOSYN CAP 250MCG 3 Prior authorization
TILIA FE 1*
TIMOLOL MALEATE OP 1
TIMOLOL OP 1
TIMOPTIC 3 Prior authorization
TIMOPTIC-XE OP 2
TINDAMAX 2
TINIDAZOLE TAB 1
TIROSINT CAP 3 Prior authorization
TIVICAY TAB 50MG 3 Prior authorization
TIZANIDINE HCL 1
TOBI NEB 300/5ML 2
TOBRA/DEXAME SUS 0.3-0.1%
TOBRADEX 3 Prior authorization
TOBRAMYCIN SULFATE 1
TOBREX 3 Prior authorization
TOLAK 4% CREAM 2
TOLBUTAMIDE 1
TOLMETIN SODIUM 1
TOLTERODINE 1
TOPAMAX 3
TOPICORT 3 Prior authorization
TOPIRAMATE TAB 1
TOPROL XL 3 Prior authorization
TORSEMIDE 1
TOUJEO SOLO INJ 300IU/ML 3
TOVIAZ 3
TRADJENTA TAB 5MG 2 Step therapy
TRAMADOL HCL 1
TRAMADOL HYDROCHLORIDE/ACET 1
TRANDOLAPRIL TAB 2MG 1
TRANEXAMIC ACID 1
TRANSDERM-SCOP DIS 2 Travel
TRANYLCYPROMINE SULFATE 1
TRAVATAN Z 2
TRAZODONE HC 1
TRENTAL 3 Prior authorization
TRESIBA FLEX INJ 3 Prior authorization
TRETINOIN CRE 1 Quantity limit
TRETINOIN EMOLLIENT NC Quantity limit
TRETINOIN GEL & CREAM 1 Quantity limit
TREXIMET NC
TRI-LEGEST FE 1*
TRI-LO-SPRINTEC 1*
TRI-LUMA NC Quantity limit
TRI-PREVIFEM 1
TRI-SPRINTEC 1*
TRI-VITAMIN/FLUORIDE 1
TRIAMCINOLONE
TRIAMCINOLONE IN ORABASE 1 Quantity limit
TRIAMTERENE/HYDROCHLOROTHIA 1
TRIAZ 3 Quantity limit
TRIAZOLAM 1 Quantity limit
TRIBENZOR 3 Prior authorization
TRICON CAP 1
TRICOR 3 Step therapy
TRIFLUOPERAZINE 1
TRIFLURIDINE 1
TRIGLIDE 3
TRIHEXYPHENIDYL HCL 1
TRILEPTAL 3
TRILYTE 3 Prior authorization
TRIMETHOBENZAMIDE HCL 1
TRIMETHOPRIM 1
TRIMETHOPRIM SULFATE 1
TRINESSA 1*
TRINESSA LO 1*
TRINTELLIX TAB 3
TRIUMEQ TAB 3 Prior authorization
TRIVORA 1
TRIZIVIR 2
TROKENDI XR CAP 100MG 3 Prior authorization
TROPICAMIDE 1
TROSPIUM CHLORIDE ER 1
TRULICITY 2 Step therapy
TRUVADA 2
TUDORZA PRES AER 400/ACT 3
TYKOSIN 3 Prior authorization
TYLENOL/CODEINE #3 3 Prior authorization
U
Drug Name Tier Restrictions
ULESFIA LOT 5% 3 Prior authorization
ULORIC 3 Prior authorization
ULTRA NATALCARE 3
ULTRACET 3 Prior authorizaton
ULTRAM 3 Prior authorization
ULTRAVATE 3 Quantity limit
UMECTA EMU 3 Prior authorization, Quantity limit, Step therapy
UMECTA MOUSSE AER 3 Prior authorization, Quantity limit
UMECTA NAIL FILM 3 Prior authorization, Quantity limit, Step therapy
UNIRETIC 3 Prior authorization
UNIVASC 3 Prior authorization
UREA 1 Quantity limit
UREA NAIL STK 50% 2 Prior authorization, Quantity limit
UREALAC LOTION 1 Quantity limit
UREALAC NAIL GEL 3 Prior authorization, Quantity limit
URIBEL CAP 118MG 3
URIMAX 3
URISED 1
UROQID 1
URSO 2
URSO FORTE 2
URSODIL 1
USEPT 1
V
Drug Name Tier Restrictions
VAGIFEM 2
VALACYCLOVIR 1
VALCYTE 3 Prior authorization, Quantity limit, Step therapy
VALGANCICLOV TAB 450MG 1
VALPROIC 1
VALPROIC ACD SYP 250/5ML 1
VALSARTAN TAB 1
VALSARTAN/HCTZ 1
VALTREX 3 Prior authorization
VANCOCIN HCL 3 Prior authorization
VANCOMYCIN CAP 1
VANDAZOLE 2
VANIQA NC
VANOS 3 Prior authorization, Quantity limit, Step therapy
VASOTEC 3 Prior authorization
VAXCHORA 3
VELIVET PAK 1*
VELTIN 3
VEMLIDY 2
VENLAFAXINE ER CAP 1
VENLAFAXINE ER TAB 1
VENLAFAXINE HCL 1
VENTOLIN HFA AER 1 Quantity limit
VEPESID 3 Prior authorization, Quantity limit
VERALEN SR 3 Prior authorization
VERAMYST NC
VERAPAMIL HCL 1
VERELAN PM 3 Prior authorization
VESICARE 2
VESTURA TAB 3-0.02MG 1*
VFEND 2
VIAGRA 2 Quantity limit
VIBRAMYCIN 3 Prior authorization
VICODIN ES 3 Prior authorization
VICTOZA 2 Step therapy
VICTRELIS 2 Prior authorization
VIEKIRA PAK 3 Prior authorization
VIGAMOX 3 Prior authorization
VIIBRYD TAB 3
VIMPAT TAB 3
VINATAL FORTE 3
VIOKACE TAB 20880 3
VIRACEPT 2
VIRAMUNE 3 Prior authorization
VIREAD 2
VISICOL 2
VISTARIL 3 Prior authorization
VITAFOL-OB 3
VITAMIN D 1
VITAMIN D3 CAP 50000UNT 1
VIVACTIL 2
VIVAGLOBIN 3 Prior authorization
VIVELLE-DOT 3 Prior authorization
VIVITROL INJ 3
VIVOTIF BERNA 3 Travel
VOL-CARE RX TAB 1
VOLTAREN GEL 2 Prior authorization, Quantity limit
VOLTAREN SOL 0.1% OP 3 Prior authorization
VOLTAREN TAB 75MG EC 3 Prior authorizaton
VORICONAZOLE TAB 200MG 1
VORTEX CHAMBER 1
VOSPIRE ER TAB 4 MG 2 Quantity limit
VSL#3 NC
VYTORIN 3 Prior authorization, Quantity limit
VYVANSE 3
W
Drug Name Tier Restrictions
WARFARIN SODIUM 1
WELCHOL 3 Prior authorization
WELLBUTRIN 3 Prior authorization
WELLBUTRIN XL 3 Prior authorization
WELLBUTRIN-SR 3 Prior authorization
WP THYROID TAB 3
WYMZYA FE CHW 0.4MG-35 3
X
Drug Name Tier Restrictions
XALATAN 3 Prior authorization
XANAX 3 Prior authorization, Step therapy
XARELTO 2
XELJANZ 3 Prior authorization, Step therapy
XELODA 3 Prior Authorization
XENADERM 2 Quantity limit
XENICAL NC Over-the-counter
XEOMIN 3 Prior authorization
XERAC AC 1 Quantity limit
XIAFLEX INJ 0.9MG 3 Prior authorization
XIBROM 3 Prior authorization
XIFAXAN 3 Travel
XIGDUO XR 3 Step therapy
XIIDRA OPTHAL SOLN 3 Prior authorization, Step therapy
XOLAIR 2 Prior authorization
XOLEGEL 3 Prior authorization, Quantity limit, Step therapy
XOPENEX INHAL. SOLN. 3 Prior authorization
XULANE DIS 150-35 1*
XYREM 2
XYZAL NC
Y
Drug Name Tier Restrictions
YALE HEALTH H. PYLORI 1
YASMIN 3 Prior authorization
YAZ 3 Prior authorization
YODOXIN 1
YOHIMBINE HCL 1
YUVAFEM TAB 10MCG 3
Z
Drug Name Tier Restrictions
ZACLIR CLEANSING 2 Quantity limit, Step therapy
ZADITOR NC
ZAFIRKULAST 1
ZALEPLON CAP 5MG 1
ZANAFLEX CAP 6MG 3
ZANTAC NC
ZARELTO 3
ZAROXOLYN 3
ZEGERID 3 Prior authorization, Step therapy
ZELAPAR 2
ZEMPLAR CAP 2
ZENCHENT FE 1*
ZENPEP 2
ZEPATIER 2 Prior authorization
ZESTORETIC 3 Prior authorization
ZESTRIL 3 Prior authorization
ZETIA 3 Prior authorization
ZETONNA NC
ZIAGEN 3 Prior authorization
ZIANA 3 Quantity limit, Step therapy
ZIDOVUDINE 1
ZINC OXIDE NC Quantity limit
ZIOPTAN 3 Prior authorization
ZIPRASIDONE 1
ZIRGAN GEL 0.15% 3
ZITHROMAX 3 Travel
ZODERM 3 Quantity limit, Step therapy
ZOFRAN 3 Prior authorization, Step therapy
ZOLADEX IMP 3
ZOLENE HC 3
ZOLINZA TAB 3 Prior authorization, Quantity limit
ZOLMITRIPTAN 1 Quantity limit
ZOLOFT 3
ZOLPIDEM TARTRATE 1 Travel
ZOMIG 3 Quantity limit
ZONALON 3 Prior authorization, Quantity limit, Step therapy
ZONISAMIDE 1
ZORBTIVE 3 Prior authorization, Step therapy
ZOVIA 1*
ZOVIRAX 2 Quantity limit
ZUBSOLV 2
ZYFLO CR 2
ZYLET 3
ZYMAXID 3 Prior authorization
ZYPREXA 3 Prior authorization
ZYTIGA TAB 250MG 3 Prior Authorization
ZYVOX 3 Prior authorization