Drug List - C

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