Drug List - X

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