Drug List - A

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*