Yale Health

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 to change.

 C/T & S/M & SecurityM&P/FacultyYPBAStudents 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.

Alphabetical Drug List

All  
A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z

A

Drug name Tier Restrictions
ABACAVIR 1
ABILIFY 3
ACANYA 3
ACARBOSE 1
ACCOLATE 3
ACCU-CHEK COMFORT CURVE TES COMFORT 3 Prior authorization, Quantity limit
ACCU-CHEK COMPACT 3 Prior authorization, Quantity limit
ACCUZYME 2 Quantity limit
ACETAMINOPHEN/CODEINE #3 1
ACETASAL HC 1
ACETAZOLAMIDE 1 Travel
ACETIC ACID 1
ACETIC ACID/ALUMINUM 1
ACETYLCYSTEINE 1
ACIPHEX NC
ACLARO EMU 3 Quantity limit
ACTEMRA 3 Prior authorization, Step therapy
ACTIQ LOZ 3 Prior authorization, Step therapy
ACTONEL 3
ACTOPLUS MET 3
ACTOS 3
ACULAR 3
ACULAR LS 3
ACYCLOVIR 1
ACZONE 2 Prior authorization, Quantity limit, Step therapy
ADDERALL 3
ADDERALL XR 3
ADDYI 3 Prior authorization
ADOXA 3 Prior authorization, Step therapy
ADVAIR DISKUS 2 Quantity limit
ADVICOR 3
AEROBID AER 2
AEROCHAMBER MIS NC Prior authorization
AGGRENOX 2
AK-PENTOLATE 1
AK-POLY-BAC 1
ALAMAG NC Over-the-counter
ALAMAST 3
ALBENZA 1
ALBUTEROL SULFATE 1
ALCLOMETASONE DIPROPIONATE 1 Quantity limit
ALDACTONE 3
ALDARA 3 Quantity limit
ALENDRONATE 1
ALINIA 2
ALKERAN 3
ALLANFILLENZYME 2 Quantity limit
ALLOPURINOL 1
ALMOTRIPTAN 1 Quantity limit, Step therapy
ALOCRIL 3
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
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 Quantity limit, Step therapy
AMETHIA 1*
AMILORIDE 1
AMILORIDE/HYDROCHLOROTHIAZI 1
AMIODARONE HCL 1
AMITIZA 2
AMITRIPTYLINE 1
AMLACTIN NC Quantity limit
AMLODIPINE 1
AMLODIPINE/ATORVASTATIN 1
AMLODIPINE/BENAZEPRIL 1
AMMONIUM LACTATE NC Quantity limit
AMNESTEEM 1 Quantity limit
AMOXICILLIN 1 Travel
AMOXICILLIN/CLAVULANATE 1
AMPHETAMINE SALT COMBO 1
AMPHETAMINE/DEXTROAMPHETAMINE 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
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
APREPITANT 1 Quantity limit
APRI 1*
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
ARTHROTEC EC 3
ARTHROTEC-50 3
ASACOL 2
ASMANEX 2
ASPIRIN 1*
ASTELIN 3 Prior authorization, Quantity limit
ATACAND 3
ATACAND HCT 3
ATENOLOL 1
ATENOLOL/CHLORTHALIDONE 1
ATORVASTATIN 1
ATOVAQUONE 1 Travel
ATRALIN 3
ATRIPLA 2
ATROPINE 1
ATROVENT HFA AER 2
AUBAGIO 2 Prior authorization
AUGMENTED BETAMETHASONE DIP 1 Quantity limit, Step therapy
AUGMENTIN 3
AUGMENTIN XR 3 Prior authorization
AUVI-Q NC
AVALIDE 3 Prior authorization
AVANDAMET 3 Prior authorization
AVANDARYL 3 Prior authorization
AVANDIA 3 Prior authorization
AVAPRO 3 Prior authorization
AVC 1
AVELOX 3
AVIANE 1*
AVINZA 3
AVODART 3
AVONEX 2
AXERT 3 Quantity limit, Step therapy
AXID SOLUTION 3
AZASITE 3
AZATHIOPRINE 2
AZELEX 3 Quantity limit
AZILECT 2
AZITHROMYCIN 1 Travel
AZMACORT AER 3
AZOPT 2
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
BACITRACIN OPTHAL 1
BACLOFEN 1
BACTROBAN 3 Quantity limit
BACTROBAN NASAL 3 Quantity limit
BALSALAZIDE DIS 1
BALZIVA 1*
BANZEL 3
BARACLUDE 3
BECONASE-AQ NC
BELLADONNA ALK/PHENOB 1
BELVIQ 3 Prior authorization
BENAZEPRIL HCL 1
BENAZEPRIL HCL/HYDROCHLOROT TAB 1
BENICAR 3
BENICAR HCT 3
BENPROX 3 Quantity limit
BENZACLIN 3 Prior authorization, Quantity limit, Step therapy
BENZAMYCIN GEL 3 Quantity limit, Step therapy
BENZASHAVE NC Quantity limit
BENZEFOAM 3
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 1 Quantity limit
BENZTROPINE MESYLATE 1
BETAMETHASONE DIPROPIONATE 1 Quantity limit
BETAMETHASONE VALERATE 1 Quantity limit
BETASERON 3 Prior authorization, Step therapy
BETAXOLOL HCL 1
BETAXOLOL L 1
BETHANECHOL 1
BETIMOL 3
BETOPTIC-S 3
BIAFINE EMU 2 Quantity limit
BILTRICIDE 2
BISOPROLOL /HYDROCHLOROTHIAZIDE 1
BISOPROLOL FUMARATE 1
BLEPHAMIDE LIQUIFILM 3
BLEPHAMIDE-S.O.P. 3
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
BUDEPRION SR 1
BUDESONIDE NASAL SPRAY NC
BUDESONIDE INHALATION AMPULE 1
BUMETANIDE 1
BUPROPION HCL 1
BUPROPION HCL ER 1
BUPROPION HCL SR 1
BUPROPION HCL XL 1
BUTALBITAL/APAP/CAFFEINE 1
BUTALBITAL/ASA/CAFF 1
BUTRANS PATCH 3 Prior authorization
BYDUREON 3 Step therapy
BYETTA INJ 3 Step therapy
BYSTOLIC 3 Prior authorization

C

Drug name Tier Restrictions
CADUET 3
CAL-NATE 1
CALAN 3
CALCIPOTRIENE 1 Prior authorization, Quantity limit
CALCIPOTRIENE CREAM 1
CALCITRIOL 1
CAMILA 1*
CAMPRAL 3
CAMRESE 1*
CAMRESE LO 1*
CANASA 2
CANDESARTAN/HYDROCHLOROTHIAZIDE 1
CAPECITABINE 1
CAPHOSOL 1 Quantity limit
CAPTOPRIL 1
CAPTOPRIL/HYDROCHLOROTHIAZIDE 1
CARAC 2 Prior authorization, Quantity limit
CARAFATE 3
CARBAMAZEPINE 1
CARBAMIDE PEROXIDE 1
CARBATROL 3 Prior authorization
CARBIDOPA/ENTACAPONE/LEVODOPA 1
CARBIDOPA/LEVODOPA 1
CARBIDOPA/LEVODOPA ER 1
CARDIZEM CD 3
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
CASAMET 3
CASODEX 3 Prior authorization
CATAPRES-TTS-3 DIS 3
CAVERJECT 3 Prior authorization
CAZIANT 1*
CEFACLOR 1
CEFADROXIL 1
CEFDINIR 1
CEFPODOXIME 1
CEFPROZIL 1
CEFTIN 3
CEFUROXIME 1
CELEBREX 3
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
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 2
CHROMAGEN FORTE 2
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 HC 3
CIPRO XR 3 Travel
CIPRODEX 3
CIPROFLOXACIN 1 Travel
CITALOPRAM 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 DIS 3
CLINDAGEL 3 Prior authorization, Quantity limit, Step therapy
CLINDAMYCIN HCL 1
CLINDAMYCIN PHOSPHATE 1 Quantity limit
CLINDAMYCIN/BENZOYL PEROXIDE 1
CLOBETASOL PROPIONATE 1 Quantity limit
CLOBETASOL PROPIONATE AER 3 Prior authorization, Quantity limit, Step therapy
CLOMIPHENE 1
CLOMIPRAMINE 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
COLCRYS 2
COLESTIPOL HCL 1
COLOCORT ENE 1 Quantity limit
COMBIGAN 3
COMBIPATCH DIS 2
COMBIVENT AER 2
COMBIVIR 3 Prior authorization
COMMIT LOZ NC Over-the-counter
COMPOUNDS 3
COMTAN 3
CONCERTA 3 Quantity limit
CONDYLOX 3 Prior authorization, Quantity limit
CONTRAVE 3 Prior authorization
COPAXONE 2
CORDRAN TAPE 3 Quantity limit
COREG CR 3
CORLANOR 3 Prior authorization
CORTEF 3
CORTISPORIN 3 Quantity limit
COSENTYX 3 Prior authorization, Step therapy
COSYNTROPIN 2 Prior authorization
COUMADIN 3
COZAAR 3 Prior authorization
CREON 2
CRESTOR 3 Prior authorization
CRINONE 3
CROMOLYN SODIUM 1
CRYSELLE 1*
CUTIVATE 3 Quantity limit
CYANOCOBALAMIN INJ 1
CYCLOCORT 1 Quantity limit
CYCLOGYL 1
CYCLOPHOSPHAMIDE 1
CYCOLBENZAPRINE HCL 1
CYMBALTA 3
CYPROHEPTADINE 1
CYTOMEL 3
CYTRA-2 1

D

Drug name Tier Restrictions
DALIRESP 3 Prior authorization
DANAZOL 2
DAPSONE 1
DDAVP 3
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
DESONIDE 1 Quantity limit
DESOXIMETASONE 1 Quantity limit
DETROL 3
DETROL LA 3
DEXAMETHASONE 1
DEXAMETHASONE SODIUM PHOSPH 1
DEXAMETHASONE SODIUM PHOSPH INJ 4MG/ML UD $0
DEXEDRINE 3
DEXILANT NC
DEXMETHYLPHENIDATE HCL 1
DEXTROAMPHETAMINE CR 1
DEXTROAMPHETAMINE SULFATE 1
DEXTROSTAT 1
DIALYVITE 1
DIALYVITE 3000 2
DIAMOX 3 Travel
DIASTAT 3 Prior authorization
DIATX ZN 3
DIAZEPAM 1
DICLEGIS 3 Prior authorization
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 2 Prior authorization, Quantity limit
DIFICID 3 Prior authorization
DIFLORASONE DIACETATE 1 Quantity limit
DIFLUNISAL 1
DIHYDROERGOTAMINE 1
DILANTIN 1
DILT-XR 1
DILTIAZEM 1
DILTIAZEM HCL 1
DILTZAC 1
DIOVAN 2
DIOVAN HCT 3 Prior authorization
DIPENTUM 2
DIPHENOXY/ATROP 1
DIPIVEFRIN HCL 1
DIPROLENE 3 Quantity limit
DIPYRIDAMOLE 1
DISOPYRAMIDE PHOSPHATE 1
DITROPAN 3
DITROPAN XL 3
DIURIL 2
DIVALPROEX SODIUM 1
DOMEBORO 1
DONEPEZIL 1
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
DOXYCYCLINE HYC 1 Travel
DRITHO-SCALP 3 Prior authorization, Quantity limit
DRONABINOL 1
DUAC CS KIT 3 Prior authorization, Quantity limit, Step therapy
DUET 3
DUET DHA PAK 3
DUETACT 3 Prior authorization
DUETACT 2
DUKE'S SOLUTION 1
DULERA 2
DULOXETINE DR 1
DURAGESIC DIS 3 Quantity limit
DUTASTERIDE 1
DYAZIDE 3
DYNACIN 3
DYNACIRC 3
DYNACIRC-CR 3
DYRENIUM 3

E

Drug name Tier Restrictions
E.E.S -200 1
ECONAZOLE NITRATE 1 Quantity limit
EDECRIN 3
EDEX KIT 3 Prior authorization
EFFEXOR 3
EFFEXOR XL 3
EFFEXOR XR 3
EFFIENT 2
EFUDEX 3 Prior authorization, Quantity limit
ELDEPRYL 3
ELESTAT 3
ELIDEL 2 Prior authorization, Quantity limit
ELIGARD KIT 3 Prior authorization
ELIQUIS 3
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
ENPRESSE 1*
ENTOCORT EC 2
EPCLUSA 2 Prior authorization
EPIFOAM AER 3 Quantity limit
EPIPENS 2
EPIQUIN MICRO 2 Quantity limit
EPIVIR 2
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 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
ESTRACE CRE 2
ESTRACE TAB 3
ESTRADERM DIS 3
ESTRADIOL 1
ESTRADIOL DIS 1
ESTRADIOL/NORET 1
ESTRATEST-H.S. 3
ESTRING MIS 2
ESTROGEL 3
ESTROSTEP FE 3
ESZOPICLONE 1
ETHAMBUTOL HCL $0
ETHEDENT 1
ETHOSUXIMIDE 1
ETODOLAC 1
ETODOLAC ER 1
EUFLEXXA INJ 10MG/ML UD 3 Quantity limit, Step therapy
EURAX 1 Quantity limit
EVISTA 3
EVOCLIN 3 Prior authorization, Quantity limit, Step therapy
EVOXAC 3 Quantity limit
EXELON 3 Prior authorization
EXELON DIS 2
EXFORGE 2
EXFORGE HTC 2
EXTAVIA 3 Prior authorization, Step therapy
EXTINA AE 3 Prior authorization, Quantity limit, Step therapy
EYLEA 3
EZETIMIBE 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
FANAPT 3 Prior authorization
FELODIPINE 1
FEMARA 3
FEMCON FE 3
FEMHRT 2
FEMHRT LOW 2
FENOFIBRATE 1
FENTANYL DIS 1 Quantity limit
FEROTRINSIC 1 Over-the-counter
FERROUS SULFATE 1*
FINACEA 3 Quantity limit
FINASTERIDE 1MG NC
FINASTERIDE 5mg 1
FIRST PROGESTONE VAG 3
FIRST-HYDROCORTISONE 2 Quantity limit
FIRST-TESTOSTERONE MC COMPO 2
FLAREX 3
FLECAINIDE ACETATE 1
FLECTOR PAD 2 Prior authorization, Quantity limit
FLOMAX 3
FLONASE SPR NC
FLOVENT 2 Quantity limit
FLOXIN OTIC 3
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
FLUOROMETHOLONE 1
FLUOROPLEX 2 Prior authorization, Quantity limit
FLUOXETINE 1
FLUPHENAZINE DECANOATE INJ 1
FLURAZEPAM HCL 1
FLURBIPROFEN 1
FLUTAMIDE 1
FLUTICASONE PROPIONATE NC
FLUVASTATIN 1
FLUVOXAMINE CR 1
FLUVOXAMINE MALEATE 1
FML FORTE 3
FML-S.O.P. 3
FOCALIN 3
FOCALIN XR 3
FOLBIC 1
FOLGARD OS 2
FOLGARD RX 3
FOLIC ACID 1*
FOLLISTIM AQ INJ 3 Quantity limit
FOLPLEX 1
FORADIL AEROLIZER 2 Quantity limit
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
FURADANTIN 2
FUROSEMIDE 1

G

Drug name Tier Restrictions
GABAPENTIN 1
GABITRIL 3
GALANTAMINE ER 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
GIANVI 1*
GILENYA 2
GLIMEPIRIDE 1
GLIPIZIDE 1
GLIPIZIDE ER 1
GLIPIZIDE XL 1
GLUCAGON EMERGENCY KIT 1MG UD 2
GLUCOPHAGE XR 3
GLUCOTROL XL 3
GLUCOVANCE 3
GLUMETZA 3 Prior authorization
GLUTOSE NC Over-the-counter
GLYBURIDE 1
GLYBURIDE/METFORMIN HCL 1
GLYCOLAX NC
GLYCOPYRROLATE 1
GLYXAMBI 2
GOLYTELY 1*
GONAL-F RFF PEN INJ 3 Prior authorization, Step therapy
GRANISETRON HCL 1
GRIFULVIN-V 3
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
HELIDAC MIS NC Prior authorization, Step therapy
HEMATOGEN 3
HEPARIN SODIUM INJ 5000U/ML 1
HEPSERA 2
HIBICLENS NC Quantity limit
HIPREX 3
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
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
IBUPROFEN NC
IBUPROFEN 1
IMDUR 3
IMIQUIMOD 1 Quantity limit
IMITREX 3 Prior authorization, Quantity limit, Step therapy
IMURAN $0
INCIVEK 2 Prior authorization
INDAPAMIDE 1
INDERAL LA 3
INDOMETHACIN 1
INDOMETHACIN ER 1
INNOHEP INJ 20000/ML 3
INOVA PAD 3 Quantity limit, Step therapy
INSPRA TAB 3
INTAL INHALER 2 Quantity limit
INTERMEZZO 3
INTRON-A INJ 2 Prior authorization, Quantity limit
INTUNIV 3 Prior authorization, Step therapy
INVEGA 3 Prior authorization, Step therapy
INVOKANA 3
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
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 2
JANUVIA 2
JOLESSA 1*
JUBLIA NC
JUNEL 1*
JUVISYNC 2

K

Drug name Tier Restrictions
K-EFFERVESCENT 1
K-TABS 1
KADIAN 3
KALETRA 2
KAON-CL-10 1
KAPIDEX 3 Step therapy
KARIVA 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
KLONOPIN WAFERS 3 Prior authorization, Step therapy
KLOR-CON 1
KLOR-CON-8 1
KLOR-CON/EF 1
KRISTALOSE PAK 3

L

Drug name Tier Restrictions
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 2
LAMIVUDINE/ZIDOVUDINE 1
LAMOTRIGINE 1
LAMOTRIGINE ODT 1
LANOXIN 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
LASIX 3
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
LEVBID 2
LEVEMIR INJ 2
LEVEMIR INJ FLEXPEN 2
LEVETIRACETAM 1
LEVITRA 3 Quantity limit
LEVLITE-28 1
LEVOBUNOLOL HCL 1
LEVOCETIRIZINE 1
LEVOFLOXACIN 1
LEVORA 1*
LEVOTHROID 3
LEVOTHYROXINE SODIUM INJ $0
LEVOTHYROXINE SODIUM TAB 1
LEVOXYL 2
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
LIPITOR 3 Prior authorization
LIPTRUZET 3 Step therapy
LISINOPRIL 1
LISINOPRIL/HYDROCHLOROTHIAZ 1
LITHIUM CARBONATE 1
LITHIUM CARBONATE ER 1
LITHOBID 3
LOCOID 3 Quantity limit
LOCOID LIPOCREAM 3 Prior authorization, Quantity limit, Step therapy
LOESTRIN 24 FE 3
LOESTRIN FE1/20 3
LOFIBRA 3
LOPERAMIDE HCL NC
LOPROX GEL 3 Prior authorization, Quantity limit, Step therapy
LOPROX SHAMPOO 3 Prior authorization, Quantity limit, Step therapy
LORATADINE NC
LORAZEPAM 1 Travel
LOSARTAN 1
LOSARTAN/HCTZ 1
LOTEMAX 3
LOTENSIN 3
LOTENSIN HCT 3
LOTREL 3
LOVASTATIN 1 Quantity limit
LOVAZA 3 Prior authorization, Quantity limit
LOVENOX INJ 3 Quantity limit
LOW OGESTREL 1*
LUGOL'S SOL 1
LUGOL'S SOL BP 1
LUMIGAN SOL 0.03% 2
LUNESTA 3 Quantity limit, Step therapy
LUPRON DEPOT 3
LUSTRA NC Quantity limit
LUSTRA-ULTRA NC Quantity limit
LUVERIS INJ 75UNIT UD 3
LUVOX CR 3
LUXIQ 3 Prior authorization, Quantity limit
LYRICA 2
LYSTEDA 3

M

Drug name Tier Restrictions
M-OXY 1
MACRODANTIN 3
MAG-OX 400 NC Over-the-counter
MAGIC MOUTHWASH SOLUTION 1
MALARONE 3 Travel
MARPLAN TAB 3
MAXAIR AUTOHALER 3 Prior authorization, Quantity limit
MAXALT 3 Quantity limit
MAXALT-MLT 3 Quantity limit
MAXZIDE-25 3
MEBENDAZOLE 2
MEDERMA GEL 2 Quantity limit
MEDROXYPROG INJ 1
MEFENAMIC ACID 1
MEFLOQUINE HCL 3 Travel
MEGACE 3
MEGESTROL ACETATE 1
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
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
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
METRONIDAZOLE TABLETS 1 Quantity limit
MEXILETINE HCL 1
MIACALCIN 2
MICARDIS 3
MICARDIS HCT 3
MICROGESTIN 1*
MIDODRINE HCL 1
MIDRIN 3
MIGRANAL 3
MIMYX 2 Prior authorization, Quantity limit
MINITRAN DIS 1
MINOCIN 3 Prior authorization
MINOCYCLINE HCL 1
MINOXIDIL 1
MIRAPEX 3
MIRCETTE 28 3
MIRENA IUD SYSTEM $0
MIRTAZAPINE 1
MISOPROSTOL 1
MOBIC 3
MODAFINIL 1
MODICON 28 3
MOEXIPRIL HCL 1
MOEXIPRIL/HYDROCHLOROTHIAZI 1
MOMETASONE FUROATE NASAL SPRAY NC
MONODOX 3
MONOPRIL 3
MONOVISC INJ 2 Quantity limit
MONTELUKAST 1
MORPHINE SULFATE 1
MOTRIN TAB 3 Prior authorization
MOVIPREP NC
MOVIPREP NC
MOXIFLOXACIN 1
MULTAQ 3
MULTI VITAMINE/FLUORIDE 1*
MULTIGEN 2
MUPIROCIN 1 Quantity limit
MUSE 3 Prior authorization, Quantity limit
MYAMBUTOL 1
MYCOPHENOLATE $0
MYDRIACYL 3
MYFORTIC $0
MYRBETRIQ 3

N

Drug name Tier Restrictions
NA BICARBONATE 1
NABUMETONE 1
NADOLOL 1
NAFTIN 3 Quantity limit, Step therapy
NALTREXONE HCL 1
NAMENDA 3
NAMENDA TITRATION PAK 3
NAPROXEN NC
NARCAN 2
NARDIL 2
NASACORT NC
NASAREL NC
NASCOBAL 3 Prior authorization, Step therapy
NASONEX NC
NECON 0.5/35MG 2 1*
NECON 1/35 1*
NECON 7/7/7 1*
NEFAZODONE HCL 1
NEO/POLY/CORT 1
NEOBENZ MICRO 3 Prior authorization, Step therapy
NEOMYCIN SULFATE 1
NEOMYCIN/POLYMIXIN/DEXAMETH 1
NEOMYCIN/POLYMYXIN/HYDROCOR 1
NEORAL $0
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
NIACIN ER 1
NIASPAN 3
NICOTINAMIDE W/ZINC OXIDE/C 3 Prior authorization
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
NITRO-DUR DIS 3
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
NORITATE 3 Quantity limit
NORPACE CR 3
NORPRAMIN 3 Prior authorization, Step therapy
NORTREL 0.5/35 2 1*
NORTREL 7/7/7 1*
NORTRIPTYLINE HCL 1
NORVASC 3
NORVIR 2
NOTREL 1/35 1*
NOVAREL INJ 10000U 3
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
NULYTELY 3
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
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
ONDANSETRON 1
ONE TOUCH TEST STRIPS 3 Prior authorization, Quantity limit
ONETOUCH 3 Prior authorization, Quantity limit
OPANA 3
OPANA ER 3
OPTIHALER MIS 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
ORTHO TRI-CYCLEN LO 3
ORTHO-CEPT 28 3
ORTHO-CYCLEN 3
ORTHO-NOVUM 3
ORTHOVISC INJ 3 Quantity limit, Step therapy
OSCION CLEANSER 2 Quantity limit, Step therapy
OSELTAMIVIR 1 Quantity limit
OSMOPREP 2
OSPHENA 3 Step therapy
OTEZLA 3 Prior authorization, Step therapy
OTREXUP 3 Prior authorization, Step therapy
OVCON-35 3
OVIDE 2 Quantity limit
OVIDREL INJ UD 3
OXAPROZIN 1
OXAZEPAM 1
OXCARBAZEPINE 1
OXISTAT 2 Prior authorization, Quantity limit
OXSORALEN LOT 1% 2 Prior authorization, Quantity limit
OXSORALEN ULTRA CAP 10MG 3 Prior authorization, Quantity limit
OXYBUTYNIN 1
OXYBUTYNIN ER 1
OXYCODONE HCL 1
OXYCODONE/ACETAMINOPHEN 1
OXYCONTIN 2
OXYTROL 3

P

Drug name Tier Restrictions
PAMELOR 3 Prior authorization, Step therapy
PANCREAZE 2
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
PARLODEL 3
PAROMOMYCIN SULFATE 1
PAROXETINE ER 1
PAROXETINE HCL 1
PATADAY SOL 3 Prior authorization
PATANESE 3 Prior authorization, Quantity limit
PATANOL 1
PAXIL 3
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
PERIDEX RINSE 3 Quantity limit
PERMAX 2
PERMETHRIN 1 Quantity limit
PERPHENAZINE 1
PHENAZOPYRIDINE 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
PINDOLOL 1
PIOGLITAZONE 1
PIOGLITAZONE/GLIMEPIRIDE 1
PIROXICAM 1
PLAVIX 3
PLEGRIDY 2
PLENDIL 3
PLEXION 3 Quantity limit
POLY-VITAMIN/FLUORIDE 1*
POLY-VITAMIN/IRON/FLUORIDE DRO 1*
POLYETHYLENE GLYCOL NC
PONSTEL 3
PORTIA-28 1*
POTASSIUM CHLORIDE 1
POTASSIUM CHLORIDE ER 1
PRADAXA 3 Prior authorization
PRALUENT 3 Prior authorization
PRAMOSONE 1 Quantity limit
PRANDIN 3
PRASCION EMU 1 Quantity limit
PRAVACHOL 3 Quantity limit
PRAVASTATIN SODIUM 1 Quantity limit
PRAZOSIN HCL 1
PRECARE CHW 3
PRECARE PREMIER 3
PRED FORTE 3
PRED MILD 3
PRED-G 3
PRED-G-S.O.P. 3
PREDNICARBATE 1 Quantity limit
PREDNISOLONE 1
PREDNISOLONE ACETATE 1
PREDNISOLONE SODIUM PHOSPHA 1
PREDNISONE 1
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*
PRENATAL S 1
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
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
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
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
PROSED EC 3
PROTONIX NC
PROTOPIC 3 Prior authorization, Quantity limit
PROVENT 3
PROVENTIL AER HFA 3 Quantity limit
PROVIGIL 3 Prior authorization
PROZAC 3
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
PYRAZINAMIDE $0
PYRIDOSTIGMINE 1
PYRIDOXINE $0

Q

Drug name Tier Restrictions
QNASL NC
QUALAQUIN 2
QUASENSE 1*
QUESTREN LIGHT 3
QUETIAPINE 1
QUETIAPINE ER 1
QUINAPRIL HCL 1
QUINAPRIL/HYDROCHLOROTHIAZI 1
QUINIDINE SULFATE 1
QUIXIN 3
QVAR AER 2 Quantity limit

R

Drug name Tier Restrictions
RABAVART INJ 3
RABEPRAZOLE NC
RALOXIFENE 1
RAMIPRIL 1
RANEXA 3 Prior authorization
RANITIDINE 15MG/ML ORAL SOLUTION (AGE RESTRICTION 4-12 YEARS OLD) 1
RANITIDINE HCL NC
RAPAMUNE $0
RASUVO 3 Prior authorization, Step therapy
RAZADYNE 3
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
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
RETIN-A 3 Quantity limit
RETIN-A MICRO 3 Prior authorization, Quantity limit, Step therapy
RETROVIR 3
REVATIO 3 Quantity limit
REVLIMID CAP 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
RILUZOLE 1
RIMANTADINE HCL 1
RIMSO-50 3
RISPERDAL 3
RISPERDAL CONSTA INJ 3 Prior authorization
RISPERDAL M-TAB 3
RISPERIDONE 1
RITALIN 3
RITALIN LA 3 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
RYTHMOL SR 3

S

Drug name Tier Restrictions
SAIZEN 3 Prior authorization, Step therapy
SALAGEN 2 Prior authorization, Quantity limit
SALEX 3 Quantity limit
SALSALATE 1
SANCTURA 3
SANCTURA XR 3
SANDOSTATIN INJ 3 Prior authorization
SANDOSTATIN LAR DEPOT KIT 3 Prior authorization
SANTYL 2 Quantity limit
SAPHRIS 3
SARNA LOT NC Quantity limit
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
SILVER NITRATE 1 Quantity limit
SIMCOR 2
SIMPONI 3 Prior authorization, Step therapy
SIMVASTATIN 1 Quantity limit
SINGULAIR 3
SKELAXIN 3 Step therapy
SKYLA IUD $0
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
SONATA CAP 3 Quantity limit, Step therapy
SORBITOL 1
SORIATANE CK KIT 3 Prior authorization, Quantity limit
SOTALOL HCL 1
SPIRIVA 2 Quantity limit
SPIRONOLACTONE 1
SPIRONOLACTONE/HYDROCHLOROT 1
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
STRATTERA 2
STRIBILD 2 Prior authorization
STROMECTOL 2
STRONGSTART CHW 3
SUBOXONE SUB 3
SUBUTEX SUB 2
SUCRALFATE 1
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
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
SYNTHROID 1
SYNVISC INJ 2 Quantity limit
SYNVISC ONE INJ 2 Quantity limit
SYPRINE 2 Prior authorization

T

Drug name Tier Restrictions
TACLONEX OIN 2 Prior authorization, Quantity limit
TAGAMET NC
TAMIFLU 3
TAMOXIFEN CITRATE 1*
TAMSOLUSIN 1
TANZEUM 3 Step therapy
TARCEVA 3 Prior authorization
TAZORAC 2 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
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
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
TICLOPIDINE HCL 1
TICOSYN 3
TILIA FE 1*
TIMOLOL MALEATE OP 1
TIMOLOL OP 1
TIMOPTIC 3
TIMOPTIC-XE OP 2
TINDAMAX 2
TIZANIDINE HCL 1
TOBI NEB 300/5ML 2
TOBRADEX 3
TOBRAMYCIN SULFATE 1
TOBREX 3 Prior authorization
TOLAK 4% CREAM 2
TOLBUTAMIDE 1
TOLMETIN SODIUM 1
TOLTERODINE 1
TOPAMAX 3
TOPROL XL 3
TORSEMIDE 1
TOVIAZ 3
TRAMADOL HCL 1
TRAMADOL HYDROCHLORIDE/ACET 1
TRANEXAMIC ACID 1
TRANSDERM-SCOP DIS 2 Travel
TRANYLCYPROMINE SULFATE 1
TRAVATAN 2
TRAVATAN Z 2
TRAZODONE HC 1
TRENTAL 3
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 IN ORABASE 1 Quantity limit
TRIAMTERENE/HYDROCHLOROTHIA 1
TRIAZ 3 Quantity limit
TRIAZOLAM 1 Quantity limit
TRIBENZOR 3
TRICOR 3 Step therapy
TRICOR 3
TRIFLUOPERAZINE 1
TRIFLURIDINE 1
TRIGLIDE 3
TRIHEXYPHENIDYL HCL 1
TRILEPTAL 3
TRILYTE 3
TRIMETHOBENZAMIDE HCL 1
TRIMETHOPRIM 1
TRIMETHOPRIM SULFATE 1
TRINESSA 1*
TRINESSA LO 1*
TRIVORA 1
TRIZIVIR 2
TROPICAMIDE 1
TROSPIUM CHLORIDE ER 1
TRULICITY 2
TRUVADA 2
TYKOSIN 3 Prior authorization
TYLENOL/CODEINE #3 3

U

Drug name Tier Restrictions
ULORIC 3 Prior authorization
ULTRA NATALCARE 3
ULTRACET 3
ULTRAM 3
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
UNIVASC 3
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
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
VALPROIC 1
VALSARTAN/HCTZ 1
VALTREX 3
VANCOCIN HCL 2
VANDAZOLE 2
VANIQA NC
VANOS 3 Prior authorization, Quantity limit, Step therapy
VASOTEC 3
VAXCHORA 3
VELIVET PAK 3
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 3 Prior authorization, Quantity limit, Step therapy
VERAPAMIL HCL 1
VERELAN PM 3 Prior authorization
VESICARE 2
VFEND 2
VIAGRA 2 Quantity limit
VIBRAMYCIN 3
VICODIN ES 3
VICTOZA 2
VICTRELIS 2 Prior authorization
VIEKIRA PAK 3 Prior authorization
VIGAMOX 3
VINATAL FORTE 3
VIRACEPT 2
VIRAMUNE 3 Prior authorization
VIREAD 2
VISICOL 2
VISTARIL 3 Prior authorization
VITAFOL-OB 3
VITAMIN D 1
VIVACTIL 2
VIVAGLOBIN 3 Prior authorization
VIVELLE-DOT 3
VIVITROL INJ 3
VIVOTIF BERNA 3 Travel
VOLTAREN GEL 2 Prior authorization, Quantity limit
VOLTAREN SOL 0.1% OP 3 Prior authorization
VOLTAREN TAB 75MG EC 3
VORTEX CHAMBER 1
VOSPIRE ER TAB 4 MG 2 Quantity limit
VSL#3 NC
VYTORIN 2 Prior authorization, Quantity limit
VYVANSE 3

W

Drug name Tier Restrictions
WARFARIN SODIUM 1
WELCHOL 3
WELLBUTRIN 3
WELLBUTRIN XL 3
WELLBUTRIN-SR 3

X

Drug name Tier Restrictions
XALATAN 3
XANAX 3 Prior authorization, Step therapy
XARELTO 3
XELJANZ 3 Prior authorization, Step therapy
XELODA 3
XENADERM 2 Quantity limit
XENICAL NC Over-the-counter
XEOMIN 3 Prior authorization
XERAC AC 1 Quantity limit
XIBROM 3 Prior authorization
XIFAXAN 3 Travel
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
XYREM 2
XYZAL 3

Y

Drug name Tier Restrictions
YALE HEALTH H. PYLORI 1
YASMIN 3 Prior authorization
YAZ 3
YODOXIN 1
YOHIMBINE HCL 1

Z

Drug name Tier Restrictions
ZACLIR CLEANSING 2 Quantity limit, Step therapy
ZADITOR NC
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
ZESTRIL 3
ZETIA 3
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
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
ZYPREXA 3
ZYVOX 3 Prior authorization