Internal Medicine 203 432 0038
Student Health 203 432 0312
Mental Health & Counseling for Students 203 432 0290
Pharmacy 203 432 0033
Drug List
The Yale Health Drug List is subject to change.
| C/T & S/M & YPBA | M&P/Faculty | Students w/Prescription Plus | |
|---|---|---|---|
| Tier 1 | Generic $5 co-pay | Generic $5 co-pay | Generic $10 co-pay |
| Tier 2 | Preferred brand, $20 co-pay | Preferred brand, $25 co-pay | Preferred brand, $25 co-pay |
| Tier 3 | Non-preferred brand, $30 co-pay | Non-preferred brand, $50 co-pay | Non-preferred brand, $40 co-pay |
| NC | Not covered | Not covered | Not covered |
| $0 | Free | Free | Free |
Alphabetical Drug List
A
| Drug name | Tier | Restrictions | Mail order | |
|---|---|---|---|---|
| A/B OTIC | 1 | No | ||
| ABILIFY | 2 | No | ||
| ACARBOSE | 1 | Yes | ||
| ACCOLATE | 2 | Yes | ||
| ACCU-CHEK COMFORT CURVE TES COMFORT | 3 | Prior authorization, Quantity limit | No | |
| ACCU-CHEK COMPACT | 3 | Prior authorization, Quantity limit | No | |
| ACCUZYME | 2 | Quantity limit | No | |
| ACETAMINOPHEN/CODEINE #3 | 1 | No | ||
| ACETASAL HC | 1 | No | ||
| ACETAZOLAMIDE | 1 | Travel | Yes | |
| ACETIC ACID | 1 | No | ||
| ACETIC ACID/ALUMINUM | 1 | No | ||
| ACETYLCYSTEINE | 1 | No | ||
| ACIPHEX | 3 | Step therapy | No | |
| ACLARO EMU | 3 | Quantity limit | No | |
| ACTIQ LOZ | 3 | Prior authorization, Step therapy | No | |
| ACTONEL | 3 | Yes | ||
| ACTOPLUS MET | 2 | Yes | ||
| ACTOS | 2 | Yes | ||
| ACULAR | 3 | Yes | ||
| ACULAR LS | 3 | Yes | ||
| ACYCLOVIR | 1 | Yes | ||
| ACZONE | 2 | Prior authorization, Quantity limit, Step therapy | No | |
| ADDERALL | 3 | No | ||
| ADDERALL XR | 3 | No | ||
| ADOXA | 3 | Prior authorization, Step therapy | No | |
| ADVAIR DISKUS | 2 | Quantity limit | Yes | |
| ADVICOR | 2 | Quantity limit | Yes | |
| AEROBID AER | 2 | No | ||
| AEROCHAMBER MIS | NC | Prior authorization | No | |
| AGGRENOX | 2 | Yes | ||
| AK-PENTOLATE | 1 | No | ||
| AK-POLY-BAC | 1 | No | ||
| ALAMAG | NC | Over-the-counter | No | |
| ALAMAST | 3 | No | ||
| ALBENZA | 1 | No | ||
| ALBUTEROL SULFATE | 1 | Yes | ||
| ALCLOMETASONE DIPROPIONATE | 1 | Quantity limit | No | |
| ALDACTONE | 3 | Yes | ||
| ALDARA | 2 | Prior authorization, Quantity limit | No | |
| ALENDRONATE | 1 | Yes | ||
| ALINIA | 2 | No | ||
| ALKERAN | 3 | No | ||
| ALLANFILLENZYME | 2 | Quantity limit | No | |
| ALLOPURINOL | 1 | Yes | ||
| ALOCRIL | 3 | No | ||
| ALOMIDE | 3 | No | ||
| ALORA DIS | 3 | Yes | ||
| ALPHAGAN P | 3 | No | ||
| ALPHAQUIN HP | 2 | Quantity limit | No | |
| ALPRAZOLAM | 1 | No | ||
| ALPRAZOLAM ER | 1 | No | ||
| ALREX | 3 | Yes | ||
| ALTABAX | 2 | Prior authorization, Quantity limit | No | |
| ALTACE | 3 | Yes | ||
| AMANTADINE HCL | 1 | Yes | ||
| AMARYL | 3 | No | ||
| AMBIEN | 3 | Prior authorization, Quantity limit, Step therapy, Travel | No | |
| AMBIEN CR | 3 | Quantity limit, Step therapy, Travel | No | |
| AMCINONIDE | 1 | Quantity limit | No | |
| AMERGE | 3 | Quantity limit, Step therapy | Yes | |
| AMILORIDE | 1 | Yes | ||
| AMILORIDE/HYDROCHLOROTHIAZI | 1 | Yes | ||
| AMIODARONE HCL | 1 | Yes | ||
| AMITIZA | 2 | No | ||
| AMITRIPTYLINE | 1 | No | ||
| AMLACTIN | NC | Quantity limit | No | |
| AMLODIPINE | 1 | Yes | ||
| AMLODIPINE BESYLATE/BENAZEP | 1 | Yes | ||
| AMMONIUM LACTATE | NC | Quantity limit | No | |
| AMNESTEEM | 1 | Quantity limit | No | |
| AMOX/POT CLAV | 1 | No | ||
| AMOXICILLIN | 1 | Travel | No | |
| AMOXICILLIN/CLAV | 1 | No | ||
| AMOXICILLIN/CLAVU | 1 | No | ||
| AMPHETAMINE SALT COMBO | 1 | No | ||
| AMPHETAMINE/DEXTROAMPHETAMI | 1 | No | ||
| AMRIX CAP | 3 | Prior authorization, Step therapy | Yes | |
| ANAGRELIDE HYDROCHLORIDE | 1 | No | ||
| ANALPRAM-HC | 1 | Quantity limit | No | |
| ANASTROZOLE | 1 | No | ||
| ANDRODERM DIS | 2 | No | ||
| ANDROGEL | 2 | No | ||
| ANDROXY | 2 | No | ||
| ANGELIQ | 3 | No | ||
| ANTABUSE | 1 | Yes | ||
| ANTARA | 3 | Yes | ||
| ANTIPYRINE/BENZOCAINE | 1 | No | ||
| ANUCORT-HC | 1 | Quantity limit | Yes | |
| ANZEMET | 3 | Prior authorization | No | |
| APEXICON E | 3 | Prior authorization, Quantity limit, Step therapy | No | |
| APHTHASOL PST | 1 | Quantity limit | No | |
| APIDRA | 3 | No | ||
| ARANELLE | 1 | Yes | ||
| ARANESP | 2 | Prior authorization, Quantity limit | No | |
| ARAVA | 2 | Yes | ||
| ARICEPT | 2 | Yes | ||
| ARIMIDEX | 3 | No | ||
| ARIXTRA | 3 | Prior authorization | No | |
| ARMOUR THYROID | 1 | Yes | ||
| AROMASIN | 2 | Yes | ||
| ARTHROTEC | 2 | Yes | ||
| ARTHROTEC-50 | 2 | Yes | ||
| ASACOL | 2 | No | ||
| ASMANEX | 2 | Yes | ||
| ASTELIN | 3 | Prior authorization, Quantity limit | Yes | |
| ATACAND | 3 | Yes | ||
| ATACAND HCT | 3 | Yes | ||
| ATENOLOL | 1 | Yes | ||
| ATENOLOL/CHLORTHALIDONE | 1 | Yes | ||
| ATOVAQUONE | 1 | Travel | No | |
| ATRIPLA | 2 | Yes | ||
| ATROPINE | 1 | No | ||
| ATROVENT HFA AER | 2 | Yes | ||
| AUGMENTED BETAMETHASONE DIP | 1 | Quantity limit, Step therapy | No | |
| AUGMENTIN | 1 | No | ||
| AUGMENTIN XR | 3 | Prior authorization | No | |
| AVALIDE | 2 | Yes | ||
| AVANDAMET | 2 | Yes | ||
| AVANDARYL | 2 | Yes | ||
| AVANDIA | 2 | Yes | ||
| AVAPRO | 2 | Yes | ||
| AVC | 1 | No | ||
| AVELOX | 2 | No | ||
| AVINZA | 3 | No | ||
| AVODART | 2 | Yes | ||
| AVONEX | 2 | No | ||
| AXERT | 3 | Quantity limit, Step therapy | Yes | |
| AXID | 2 | Yes | ||
| AZASITE | 3 | No | ||
| AZATHIOPRINE | 2 | Yes | ||
| AZELEX | 3 | Quantity limit | No | |
| AZILECT | 2 | Yes | ||
| AZITHROMYCIN | 1 | Travel | No | |
| AZMACORT AER | 3 | No | ||
| AZOPT | 2 | No | ||
| AZURETTE | 1 | Yes |
B
| Drug name | Tier | Restrictions | Mail order | |
|---|---|---|---|---|
| B-D 3CC LUER-LOK SYRINGE/25 MIS 25GX1" | 1 | No | ||
| B-D GLUCOSE | NC | No | ||
| B-D INSLUIN SYRINGE ULTRAFI MIS 1CC/31G | 1 | No | ||
| B-D NEEDLE/27G X 1/2" MIS 27GX1/2" | 1 | No | ||
| B-D ULTRAFINE ORIGINAL PEN MIS PEN NEEDLE | 1 | No | ||
| BACITRACIN | 1 | No | ||
| BACLOFEN | 1 | Yes | ||
| BACTROBAN | 2 | Quantity limit | No | |
| BACTROBAN NASAL | 2 | Quantity limit | No | |
| BALSALAZIDE DIS | 1 | Yes | ||
| BALZIVA | 1 | Yes | ||
| BANZEL | 3 | No | ||
| BARACLUDE | 2 | No | ||
| BECONASE-AQ | 3 | Quantity limit, Step therapy | Yes | |
| BELLADONNA ALK/PHENOB | 1 | No | ||
| BENAZEPRIL HCL | 1 | Yes | ||
| BENAZEPRIL HCL/HYDROCHLOROT TAB | 1 | Yes | ||
| BENICAR | 3 | Yes | ||
| BENICAR HCT | 3 | Yes | ||
| BENPROX | 3 | Quantity limit | No | |
| BENZACLIN | 3 | Prior authorization, Quantity limit, Step therapy | No | |
| BENZAMYCIN GEL | 3 | Quantity limit, Step therapy | No | |
| BENZASHAVE | NC | Quantity limit | No | |
| BENZONATATE | 1 | No | ||
| BENZOYL PEROXIDE CREAMY WAS KIT WASH | 1 | Quantity limit, Step therapy | No | |
| BENZOYL PEROXIDE GEL | 1 | Quantity limit, Step therapy | No | |
| BENZOYL PEROXIDE PAD | 3 | Quantity limit, Step therapy | No | |
| BENZOYLE PEROXIDE WASH | 1 | Quantity limit | No | |
| BENZTROPINE MESYLATE | 1 | No | ||
| BETAMETHASONE DIPROPIONATE | 1 | Quantity limit | No | |
| BETAMETHASONE VALERATE | 1 | Quantity limit | No | |
| BETAXOLOL HCL | 1 | Yes | ||
| BETAXOLOL L | 1 | No | ||
| BETHANECHOL | 1 | Yes | ||
| BETIMOL | 3 | No | ||
| BETOPTIC-S | 3 | No | ||
| BIAFINE EMU | 2 | Quantity limit | No | |
| BILTRICIDE | 2 | No | ||
| BISOPROLOL FUMARATE | 1 | Yes | ||
| BISOPROLOL FUMARATE/HYDROCH | 1 | Yes | ||
| BLEPHAMIDE LIQUIFILM | 3 | No | ||
| BLEPHAMIDE-S.O.P. | 3 | No | ||
| BONIVA | 3 | Yes | ||
| BONIVA KIT | $0 | Prior authorization | Yes | |
| BOTOX INJ | $0 | Prior authorization | No | |
| BREVOXYL | 3 | Quantity limit, Step therapy | No | |
| BRIMONIDINE | 1 | Yes | ||
| BROMOCRIPTINE MESYLATE | 1 | Yes | ||
| BUDEPRIONSR | 1 | No | ||
| BUMETANIDE | 1 | Yes | ||
| BUPROPION HCL | 1 | No | ||
| BUPROPION HCL ER | 1 | No | ||
| BUPROPION HCL SR | 1 | No | ||
| BUPROPION HCL XL | 1 | No | ||
| BUTAL/ASA/CAFF | 1 | No | ||
| BUTALBITAL/APAP/CAFFEINE | 1 | No | ||
| BUTRANS PATCH | 3 | Prior authorization | No | |
| BYETTA INJ | 3 | No | ||
| BYSTOLIC | 3 | Prior authorization | Yes |
C
| Drug name | Tier | Restrictions | Mail order | |
|---|---|---|---|---|
| CADUET | 3 | Yes | ||
| CAL-NATE | 1 | No | ||
| CALAN | 3 | Yes | ||
| CALCIPOTRIENE | 1 | Prior authorization, Quantity limit | No | |
| CALCITRIOL | 1 | Yes | ||
| CAMILA | 1 | Yes | ||
| CAMPRAL | 2 | Yes | ||
| CANASA | 2 | No | ||
| CAPHOSOL | 1 | Quantity limit | No | |
| CAPTOPRIL | 1 | Yes | ||
| CAPTOPRIL/HYDROCHLOROTHIAZI | 1 | Yes | ||
| CARAC | 2 | Prior authorization, Quantity limit | No | |
| CARAFATE | 3 | Yes | ||
| CARBAMAZEPINE | 1 | Yes | ||
| CARBAMIDE PEROXIDE | 1 | No | ||
| CARBATROL | 2 | Yes | ||
| CARBIDOPA/LEVODOPA | 1 | Yes | ||
| CARBIDOPA/LEVODOPA ER | 1 | Yes | ||
| CARDIZEM CD | 3 | Yes | ||
| CARISOPRODOL | 1 | No | ||
| CARISOPRODOL/ASPIRIN | 1 | No | ||
| CARMOL 40 | 3 | Prior authorization, Quantity limit | No | |
| CARMOL-HC | 3 | Quantity limit | No | |
| CARTEOLOL HCL | 1 | Yes | ||
| CARTIA XT | 1 | Yes | ||
| CARVEDIOL | 1 | Yes | ||
| CASAMET | 3 | No | ||
| CASODEX | 2 | Yes | ||
| CATAPRES-TTS-3 DIS | 3 | No | ||
| CAVERJECT IMPULSE KIT | $0 | Prior authorization, Quantity limit | No | |
| CAZIANT | 1 | Yes | ||
| CEFACLOR | 1 | No | ||
| CEFADROXIL | 1 | No | ||
| CEFDINIR | 1 | No | ||
| CEFPODOXIME | 1 | No | ||
| CEFPROZIL | 1 | No | ||
| CEFTIN | 3 | No | ||
| CEFUROXIME | 1 | No | ||
| CELEBREX | 2 | Yes | ||
| CELESTONE-SOLUSPAN INJ | $0 | No | ||
| CELEXA | 3 | Prior authorization, Step therapy | No | |
| CELLECEPT | $0 | No | ||
| CENESTIN | 3 | Yes | ||
| CEPHALEXIN | 1 | Yes | ||
| CEREFOLIN | 3 | Yes | ||
| CERUMENEX | 3 | No | ||
| CETROTIDE KIT | 3 | No | ||
| CHANTIX | 2 | Quantity limit | Yes | |
| CHLORAL HYDRATE | 1 | No | ||
| CHLORDIAZEPOXIDE | 1 | No | ||
| CHLORDIAZEPOXIDE/CLID | 1 | No | ||
| CHLORHEXIDINE GLUC | 1 | Quantity limit | No | |
| CHLOROQUINE | 3 | Travel | Yes | |
| CHLORPROMAZINE | 1 | No | ||
| CHLORPROPAMIDE | 1 | Yes | ||
| CHLORTHALIDONE | 1 | Yes | ||
| CHLORZOXAZONE | 1 | No | ||
| CHOLESTYRAMINE | 1 | Yes | ||
| CHOLINE MAGNESIUM TRISALICY | 1 | No | ||
| CHORI GONADO INJ | 1 | No | ||
| CHROMAGEN | 2 | No | ||
| CHROMAGEN FA | 2 | No | ||
| CHROMAGEN FORTE | 2 | Yes | ||
| CIALIS | 2 | Quantity limit | Yes | |
| CICLOPIROX | 1 | Prior authorization, Quantity limit, Step therapy | No | |
| CILOSTAZOL | 1 | Yes | ||
| CILOXAN | 3 | Prior authorization | No | |
| CIMETIDINE | 1 | Yes | ||
| CIPRO | 1 | Travel | No | |
| CIPRO HC | 3 | No | ||
| CIPRO XR | 3 | Travel | No | |
| CIPRODEX | 3 | No | ||
| CIPROFLOXACIN | 1 | Travel | No | |
| CIPROFLOXACIN HCL | 1 | No | ||
| CITALOPRAM | 1 | No | ||
| CLARINEX | 3 | Prior authorization, Step therapy | No | |
| CLARITHROMYCIN | 1 | No | ||
| CLENIA | 3 | Quantity limit, Step therapy | No | |
| CLENIA FOAMING WASH EMU | 3 | Quantity limit, Step therapy | No | |
| CLEOCIN PED GRAN | 2 | No | ||
| CLEOCIN SUP | 2 | No | ||
| CLEOCIN-T | 3 | Prior authorization, Quantity limit, Step therapy | No | |
| CLIMARA DIS | 3 | Yes | ||
| CLINDAGEL | 3 | Prior authorization, Quantity limit, Step therapy | No | |
| CLINDAMYCIN HCL | 1 | No | ||
| CLINDAMYCIN PHOSPHATE | 1 | Quantity limit | No | |
| CLOBETASOL PROPIONATE | 1 | Quantity limit | No | |
| CLOBETASOL PROPIONATE AER | 3 | Prior authorization, Quantity limit, Step therapy | No | |
| CLOMIPHENE | 1 | No | ||
| CLOMIPRAMINE | 1 | No | ||
| CLONAZEPAM | 1 | No | ||
| CLONAZEPAM ORALLY DISINTEGR | 1 | No | ||
| CLONIDINE HCL | 1 | Yes | ||
| CLORAZEPATE DIPOTASSIUM | 1 | No | ||
| CLOTRIMAZOLE CRE 1% | NC | Quantity limit | No | |
| CLOTRIMAZOLE/BET | 1 | Quantity limit | No | |
| CLOZAPINE | 1 | No | ||
| CODEINE SULFATE | 1 | No | ||
| COLCRYS | 2 | Yes | ||
| COLESTIPOL HCL | 1 | Yes | ||
| COLOCORT ENE | 1 | Quantity limit | No | |
| COMBIGAN | 3 | Yes | ||
| COMBIPATCH DIS | 2 | No | ||
| COMBIVENT AER | 2 | Yes | ||
| COMBIVIR | 2 | Yes | ||
| COMMIT LOZ | NC | Over-the-counter | No | |
| COMPOUNDS | 3 | No | ||
| COMTAN | 3 | No | ||
| CONCERTA | 3 | Quantity limit | No | |
| CONDYLOX | 3 | Prior authorization, Quantity limit | No | |
| COPAXONE | 2 | No | ||
| CORDRAN TAPE | 3 | Quantity limit | No | |
| COREG CR | 3 | Yes | ||
| CORTEF | 3 | No | ||
| CORTISPORIN | 3 | Quantity limit | No | |
| COUMADIN | 3 | Yes | ||
| COZAAR | 3 | Prior authorization | Yes | |
| CREON | 2 | Yes | ||
| CRESTOR | 3 | Quantity limit | Yes | |
| CRINONE | 3 | No | ||
| CROMOLYN SODIUM | 1 | No | ||
| CRYSELLE | 1 | Yes | ||
| CUTIVATE | 3 | Quantity limit | No | |
| CYANOCOBALAMIN INJ | $0 | Yes | ||
| CYCLOCORT | 1 | Quantity limit | No | |
| CYCLOGYL | 1 | No | ||
| CYCLOPHOSPHAMIDE | 1 | No | ||
| CYCOLBENZAPRINE HCL | 1 | Yes | ||
| CYMBALTA | 2 | No | ||
| CYPROHEPTADINE | 1 | No | ||
| CYTOMEL | 3 | Yes | ||
| CYTRA-2 | 1 | No |
D
| Drug name | Tier | Restrictions | Mail order | |
|---|---|---|---|---|
| DANAZOL | 2 | No | ||
| DAPSONE | 1 | Yes | ||
| DDAVP | 3 | No | ||
| DELESTROGEN INJ | $0 | No | ||
| DEMECLOCYCLINE | 1 | No | ||
| DENAVIR | 2 | Quantity limit | No | |
| DENTA 5000 PLUS | 1 | Quantity limit | Yes | |
| DENTAGEL | 1 | Quantity limit | Yes | |
| DEPAKOTE | 3 | Yes | ||
| DEPAKOTE ER | 3 | Yes | ||
| DEPLIN | 2 | Yes | ||
| DEPO-MEDROL | $0 | No | ||
| DEPO-TESTOSTERONE INJ 200MG/ML | $0 | No | ||
| DERMA-SMOOTHE/FS | 3 | Prior authorization, Quantity limit, Step therapy | No | |
| DERMAZENE | 1 | Quantity limit | No | |
| DERMOTIC OIL | 2 | No | ||
| DESIPRAMINE HCL | 1 | No | ||
| DESMOPRESSINE ACETATE | 1 | No | ||
| DESONIDE | 1 | Quantity limit | No | |
| DESOXIMETASONE | 1 | Quantity limit | No | |
| DETROL | 3 | Yes | ||
| DETROL LA | 2 | Yes | ||
| DEXAMETHASONE | 1 | No | ||
| DEXAMETHASONE SODIUM PHOSPH | 1 | No | ||
| DEXAMETHASONE SODIUM PHOSPH INJ 4MG/ML UD | $0 | No | ||
| DEXEDRINE | 3 | No | ||
| DEXMETHYLPHENIDATE HCL | 1 | No | ||
| DEXTROAMPHETAMINE CR | 1 | No | ||
| DEXTROAMPHETAMINE SULFATE | 1 | No | ||
| DEXTROSTAT | 1 | No | ||
| DIALYVITE | 1 | Yes | ||
| DIALYVITE 3000 | 2 | Yes | ||
| DIAMOX | 3 | Travel | Yes | |
| DIASTAT | 3 | Prior authorization | No | |
| DIATX ZN | 3 | No | ||
| DIAZEPAM | 1 | No | ||
| DICLOFENAC SODIUM | 1 | Yes | ||
| DICLOFENAC SODIUM ER | 1 | Yes | ||
| DICLOXACILLIN | 1 | No | ||
| DICYCLOMINE HCL | 1 | Yes | ||
| DIDRONEL | 1 | Yes | ||
| DIETHYLPROPION HCL | 1 | No | ||
| DIETHYLPROPION HCL ER | 1 | No | ||
| DIFFERIN | 2 | Prior authorization, Quantity limit | No | |
| DIFLORASONE DIACETATE | 1 | Quantity limit | No | |
| DIFLUNISAL | 1 | Yes | ||
| DILANTIN | 1 | Yes | ||
| DILT-XR | 1 | Yes | ||
| DILTIAZEM | 1 | Yes | ||
| DILTIAZEM HCL | 1 | Yes | ||
| DILTZAC | 1 | Yes | ||
| DIOVAN | 2 | Yes | ||
| DIOVAN HCT | 2 | Yes | ||
| DIPENTUM | 2 | Yes | ||
| DIPHENOXY/ATROP | 1 | No | ||
| DIPIVEFRIN HCL | 1 | Yes | ||
| DIPROLENE | 3 | Quantity limit | No | |
| DIPYRIDAMOLE | 1 | Yes | ||
| DISOPYRAMIDE PHOSPHATE | 1 | Yes | ||
| DITROPAN | 3 | Yes | ||
| DITROPAN XL | 3 | Yes | ||
| DIURIL | 2 | Yes | ||
| DIVALPROEX SODIUM | 1 | Yes | ||
| DOMEBORO | 1 | No | ||
| DORYX | 3 | Prior authorization, Step therapy | No | |
| DORZOLAMIDE | 1 | Yes | ||
| DORZOLAMIDE HCL/TIMOLOL MAL | 1 | Yes | ||
| DOSTINEX | 2 | Prior authorization | No | |
| DOVONEX | 2 | Prior authorization, Quantity limit | No | |
| DOXAZOSIN MESYLATE | 1 | Yes | ||
| DOXYCYCLINE HYC | 1 | Travel | Yes | |
| DRITHO-SCALP | 3 | Prior authorization, Quantity limit | No | |
| DRONABINOL | 1 | No | ||
| DUAC CS KIT | 3 | Prior authorization, Quantity limit, Step therapy | No | |
| DUET | 3 | No | ||
| DUET DHA PAK | 3 | No | ||
| DUETACT | 2 | No | ||
| DULERA | 2 | Yes | ||
| DURAGESIC DIS | 3 | Quantity limit | No | |
| DYAZIDE | 3 | Yes | ||
| DYNACIRC | 3 | Yes | ||
| DYNACIRC-CR | 3 | Yes | ||
| DYRENIUM | 3 | No |
E
| Drug name | Tier | Restrictions | Mail order | |
|---|---|---|---|---|
| E.E.S -200 | 1 | No | ||
| ECONAZOLE NITRATE | 1 | Quantity limit | No | |
| EDECRIN | 3 | Yes | ||
| EDEX KIT | $0 | Prior authorization, Quantity limit | No | |
| EFFEXOR | 3 | No | ||
| EFFEXOR XL | 3 | No | ||
| EFFEXOR XR | 3 | No | ||
| EFFIENT | 2 | Yes | ||
| EFUDEX | 3 | Prior authorization, Quantity limit | No | |
| ELDEPRYL | 3 | Yes | ||
| ELESTAT | 3 | No | ||
| ELIDEL | 2 | Prior authorization, Quantity limit | No | |
| ELOCON | 3 | Quantity limit | No | |
| EMADINE | 3 | No | ||
| EMCYT | 2 | No | ||
| EMEND | 2 | Prior authorization | No | |
| EMSAM DIS | 3 | Prior authorization, Step therapy | No | |
| ENABLEX | 3 | Yes | ||
| ENALAPRIL MALEATE | 1 | Yes | ||
| ENALAPRIL MALEATE/HYDROCHLO | 1 | Yes | ||
| ENBREL INJ 25MG UD | 2 | No | ||
| ENBREL INJ 50MG/ML UD | 2 | No | ||
| ENBREL SURECLICK INJ 50MG/ML/UD | 2 | No | ||
| ENDOCET | 1 | No | ||
| ENDOMETRIN SUPP. | 3 | No | ||
| ENJUVIA | 2 | Yes | ||
| ENPRESSE | 1 | Yes | ||
| ENTOCORT EC | 2 | Yes | ||
| EPIFOAM AER | 3 | Quantity limit | No | |
| EPIPENS | 2 | No | ||
| EPIQUIN MICRO | 2 | Quantity limit | No | |
| EPIVIR | 2 | Yes | ||
| EPIVIR HBV | 2 | Yes | ||
| EPLERENONE | 3 | No | ||
| EPZICOM | 3 | Prior authorization | No | |
| ERTACZO | 3 | Prior authorization, Quantity limit, Step therapy | No | |
| ERY PAD | 3 | Quantity limit | No | |
| ERY-TAB | 2 | No | ||
| ERYPED-200 | 1 | No | ||
| ERYTHRO/SULFISOX | 1 | No | ||
| ERYTHROCIN STE FILMTAB | 1 | No | ||
| ERYTHROMYCIN | 1 | No | ||
| ERYTHROMYCIN GEL 2% | 1 | Quantity limit | No | |
| ERYTHROMYCIN OIN OP | 1 | No | ||
| ERYTHROMYCIN/BENZOYL PEROXI GEL | 1 | Quantity limit, Step therapy | No | |
| ESCITALOPRAM | 1 | No | ||
| ESTRACE CRE | 2 | No | ||
| ESTRACE TAB | 3 | Yes | ||
| ESTRADERM DIS | 3 | Yes | ||
| ESTRADIOL | 1 | Yes | ||
| ESTRADIOL DIS | 1 | Yes | ||
| ESTRADIOL/NORET | 1 | Yes | ||
| ESTRATEST-H.S. | 3 | Yes | ||
| ESTRING MIS | 2 | Yes | ||
| ESTROGEL | 3 | No | ||
| ESTROSTEP FE | 3 | Yes | ||
| ETHAMBUTOL HCL | $0 | No | ||
| ETHEDENT | 1 | No | ||
| ETHOSUXIMIDE | 1 | Yes | ||
| ETODOLAC | 1 | Yes | ||
| ETODOLAC ER | 1 | Yes | ||
| EUFLEXXA INJ 10MG/ML UD | 3 | Quantity limit | No | |
| EURAX | 1 | Quantity limit | No | |
| EVISTA | 2 | Yes | ||
| EVOCLIN | 3 | Prior authorization, Quantity limit, Step therapy | No | |
| EVOXAC | 2 | Quantity limit | Yes | |
| EXELON | 2 | Yes | ||
| EXELON DIS | 2 | Yes | ||
| EXFORGE | 2 | Yes | ||
| EXFORGE HTC | 2 | No | ||
| EXTINA AE | 3 | Prior authorization, Quantity limit, Step therapy | No |
F
| Drug name | Tier | Restrictions | Mail order | |
|---|---|---|---|---|
| FABRAZYME INJ 35MG UD | $0 | Prior authorization | No | |
| FAMCICLOVIR | 1 | No | ||
| FAMOTIDINE | 1 | Yes | ||
| FAMVIR | 3 | No | ||
| FANAPT | 3 | Prior authorization | No | |
| FELODIPINE | 1 | Yes | ||
| FEMARA | 2 | Yes | ||
| FEMCON FE | 3 | Yes | ||
| FEMHRT | 2 | Yes | ||
| FEMHRT LOW | 2 | Yes | ||
| FENTANYL DIS | 1 | Quantity limit | No | |
| FEROTRINSIC | 1 | Over-the-counter | No | |
| FINACEA | 3 | Quantity limit | Yes | |
| FINASTERIDE | 1 | Yes | ||
| FIRST PROGESTONE VAG | 3 | No | ||
| FIRST-HYDROCORTISONE | 2 | Quantity limit | No | |
| FIRST-TESTOSTERONE MC COMPO | 2 | No | ||
| FLAREX | 3 | No | ||
| FLECAINIDE ACETATE | 1 | Yes | ||
| FLECTOR PAD | 2 | Prior authorization, Quantity limit | Yes | |
| FLOMAX | 3 | Yes | ||
| FLONASE SPR | 3 | Prior authorization, Quantity limit, Step therapy | Yes | |
| FLOVENT | 2 | Quantity limit | Yes | |
| FLOXIN OTIC | 3 | No | ||
| FLUCONAZOLE | 1 | No | ||
| FLUDROCORTISONE ACETATE | 1 | Yes | ||
| FLUOCINOLONE | 1 | Quantity limit | Yes | |
| FLUOCINOLONE ACETONIDE S | 1 | Quantity limit | Yes | |
| FLUOCINOLONE-E | 1 | Quantity limit | Yes | |
| FLUOR-A-DAY | 3 | Yes | ||
| FLUOROMETHOLONE | 1 | No | ||
| FLUOROPLEX | 2 | Prior authorization, Quantity limit | No | |
| FLUOXETINE | 1 | No | ||
| FLUPHENAZINE | 1 | No | ||
| FLURAZEPAM HCL | 1 | No | ||
| FLURBIPROFEN | 1 | Yes | ||
| FLUTAMIDE | 1 | Yes | ||
| FLUTICASONE PROPIONATE | 1 | Quantity limit | Yes | |
| FLUVOXAMINE MALEATE | 1 | No | ||
| FML FORTE | 3 | Yes | ||
| FML-S.O.P. | 3 | No | ||
| FOCALIN | 3 | No | ||
| FOCALIN XR | 3 | No | ||
| FOLBIC | 1 | Yes | ||
| FOLGARD OS | 2 | Yes | ||
| FOLGARD RX | 3 | Yes | ||
| FOLIC ACID | 1 | Yes | ||
| FOLLISTIM AQ INJ 900UNIT | 3 | No | ||
| FOLLISTIM INJ 75IU UD | 3 | No | ||
| FOLPLEX | 1 | Yes | ||
| FORADIL AEROLIZER | 2 | Quantity limit | No | |
| FOSAMAX | 3 | Prior authorization | Yes | |
| FOSAMAX PLUS D | 2 | Yes | ||
| FOSINOPRIL SODIUM | 1 | Yes | ||
| FOSINOPRIL SODIUM/HYDROCHOLO | 1 | No | ||
| FOSRENOL | 2 | Yes | ||
| FRAGMIN | 3 | Prior authorization, Quantity limit | No | |
| FREESTYLE LITE TEST STRIP AND LANCETS | 1 | Yes | ||
| FREESTYLE TEST STRIP AND LANCETS | 1 | Yes | ||
| FROVA | 3 | Quantity limit, Step therapy | Yes | |
| FURADANTIN | 2 | No | ||
| FUROSEMIDE | 1 | Yes |
G
| Drug name | Tier | Restrictions | Mail order | |
|---|---|---|---|---|
| GABAPENTIN | 1 | Yes | ||
| GABITRIL | 3 | No | ||
| GALANTAMINE ER | 1 | Yes | ||
| GARDASIL INJ UD | $0 | No | ||
| GASTROCROM CON | 1 | No | ||
| GELCLAIR | 1 | Quantity limit | No | |
| GEMFIBROZIL | 1 | Yes | ||
| GENOTROPIN | 3 | No | ||
| GENTAK | 1 | No | ||
| GENTAMICIN | 1 | Quantity limit | No | |
| GENTAMICIN SULFATE | 1 | No | ||
| GEODON | 2 | Yes | ||
| GIANVI | 1 | Yes | ||
| GILENYA | 3 | Prior authorization | No | |
| GLIMEPIRIDE | 1 | Yes | ||
| GLIPIZIDE | 1 | Yes | ||
| GLIPIZIDE ER | 1 | Yes | ||
| GLIPIZIDE XL | 1 | Yes | ||
| GLUCAGON EMERGENCY KIT 1MG UD | 2 | Yes | ||
| GLUCOPHAGE XR | 3 | Yes | ||
| GLUCOTROL XL | 3 | Yes | ||
| GLUCOVANCE | 3 | No | ||
| GLUMETZA | 2 | Prior authorization | No | |
| GLUTOSE | NC | Over-the-counter | No | |
| GLYBURIDE | 1 | Yes | ||
| GLYBURIDE/METFORMIN HCL | 1 | Yes | ||
| GLYCOLAX | NC | No | ||
| GLYCOPYRROLATE | 1 | Yes | ||
| GOLYTELY | 1 | No | ||
| GONAL-F INJ 1200IU | 3 | No | ||
| GONAL-F RFF PEN INJ 900 | 3 | No | ||
| GRANISETRON HCL | 1 | No | ||
| GRIFULVIN-V | 3 | Yes | ||
| GUANFACINE HCL | 1 | Yes | ||
| GYNAZOLE-1 | 1 | No |
H
| Drug name | Tier | Restrictions | Mail order | |
|---|---|---|---|---|
| HALFLYTELY BOWL PREP | 2 | No | ||
| HALOBETASOL PROP. | 1 | Quantity limit | No | |
| HALOPERIDOL | 1 | No | ||
| HALOPERIDOL DECANOATE INJ | $0 | No | ||
| HELIDAC MIS | NC | Prior authorization, Step therapy | No | |
| HEMATOGEN | 3 | No | ||
| HEPARIN SODIUM INJ 5000U/ML | 1 | No | ||
| HEPSERA | 2 | Yes | ||
| HIBICLENS | NC | Quantity limit | No | |
| HIPREX | 3 | Yes | ||
| HUMALOG MIX PEN | 3 | No | ||
| HUMALOG MIX VIAL | 2 | No | ||
| HUMALOG PEN | 3 | No | ||
| HUMALOG VIAL | 2 | No | ||
| HUMATROPE | 3 | No | ||
| HUMIRA | 2 | No | ||
| HUMULIN 70/30 VIAL | 1 | No | ||
| HUMULIN R U-500 | 1 | No | ||
| HUMULIN-N U-100 INJ | 1 | No | ||
| HUMULIN-N U-100 PEN | 3 | No | ||
| HYALGAN | $0 | Quantity limit | No | |
| HYDRALAZINE HC | 1 | Yes | ||
| HYDRO 40 FOAM | 3 | Prior authorization, Quantity limit | No | |
| HYDROCHLOROTHIAZIDE | 1 | Yes | ||
| HYDROCODONE/ACETAMINOPHEN | 1 | No | ||
| HYDROCODONE/HOMATROPINE | 1 | No | ||
| HYDROCODONE/IBUPROFEN | 1 | No | ||
| HYDROCODONE/IODO CRM | 1 | Quantity limit | No | |
| HYDROCORTISONE | 1 | Quantity limit | Yes | |
| HYDROCORTISONE 1% CREAM | NC | Over-the-counter, Quantity limit | No | |
| HYDROCORTISONE BUTYRATE | 1 | Quantity limit | Yes | |
| HYDROCORTISONE VALERATE | 1 | Quantity limit | Yes | |
| HYDROMET SYP 5-1.5/5 | 1 | No | ||
| HYDROMORPHONE HCL | 1 | No | ||
| HYDROQUINONE | NC | No | ||
| HYDROQUINONE/SUNSCREENS | NC | No | ||
| HYDROXYCHLOROQUINE | 1 | Yes | ||
| HYDROXYUREA | 1 | Quantity limit | Yes | |
| HYDROXYZINE HCL | 1 | Yes | ||
| HYDROXYZINE PAMOATE | 1 | Yes | ||
| HYOMAX-SR | 3 | Yes | ||
| HYOSCYAMINE SULFATE IR/HYOS | 1 | Yes | ||
| HYPER-SAL NEB UD | 1 | No | ||
| HYPERCARE | 1 | Quantity limit | Yes | |
| HYTRIN | 3 | Yes | ||
| HYZAAR | 3 | Prior authorization | Yes |
I
| Drug name | Tier | Restrictions | Mail order | |
|---|---|---|---|---|
| IBUPROFEN | 1 | Yes | ||
| IMDUR | 3 | Yes | ||
| IMITREX | 3 | Prior authorization, Quantity limit, Step therapy | Yes | |
| IMURAN | $0 | Yes | ||
| INCIVEK | 2 | Prior authorization | No | |
| INDAPAMIDE | 1 | Yes | ||
| INDERAL LA | 3 | Yes | ||
| INDOMETHACIN | 1 | Yes | ||
| INDOMETHACIN ER | 1 | No | ||
| INNOHEP INJ 20000/ML | 3 | No | ||
| INOVA PAD | 3 | Quantity limit, Step therapy | No | |
| INSPRA TAB | 3 | Yes | ||
| INTAL INHALER | 2 | Quantity limit | Yes | |
| INTRON-A INJ | 2 | Prior authorization, Quantity limit | No | |
| INVEGA | 3 | Prior authorization, Step therapy | No | |
| IPRATROPIUM | 1 | Quantity limit | Yes | |
| IPRATROPIUM BROMIDE SPR | 1 | Quantity limit | Yes | |
| IPRATROPIUM/ALBUTER | 1 | Quantity limit | Yes | |
| IRESSA | 2 | Prior authorization, Quantity limit | No | |
| ISENTRESS | 2 | Yes | ||
| ISOMETHEPTENE/DICHLORALPHEN | 1 | No | ||
| ISONIAZID | $0 | Yes | ||
| ISOPTIN SR | 3 | No | ||
| ISOPTO HOMATROPINE | 1 | Yes | ||
| ISOPTO HYOSCINE | 1 | No | ||
| ISORDIL TITRADOSE | 3 | Prior authorization | No | |
| ISOSORBIDE DINITRATE TA | 1 | Yes | ||
| ISOSORBIDE MONONITRATE ER | 1 | Yes | ||
| ISRADIPINE | 1 | No | ||
| ISTALOL | 3 | No | ||
| ITRACONAZOLE | 1 | Yes |
J
| Drug name | Tier | Restrictions | Mail order | |
|---|---|---|---|---|
| JANUMET | 2 | Yes | ||
| JANUVIA | 2 | Yes | ||
| JOLESSA | 1 | Yes | ||
| JUNEL FE | 1 | Yes |
K
| Drug name | Tier | Restrictions | Mail order | |
|---|---|---|---|---|
| K-EFFERVESCENT | 1 | Yes | ||
| K-TABS | 1 | Yes | ||
| KADIAN | 3 | No | ||
| KALETRA | 2 | Yes | ||
| KAON-CL-10 | 1 | Yes | ||
| KAPIDEX | 3 | Step therapy | No | |
| KARIVA 28 DAY | 1 | Yes | ||
| KENALOG-10 INJ | $0 | No | ||
| KEPPRA | 3 | Yes | ||
| KERAFOAM | 3 | Prior authorization, Quantity limit | No | |
| KERALAC | 3 | Prior authorization, Quantity limit | No | |
| KERALYT | 2 | Quantity limit | No | |
| KEROL EMU | 3 | Prior authorization, Quantity limit | No | |
| KETEK PAK | 2 | No | ||
| KETOCONAZOLE CREAM | 1 | Quantity limit | No | |
| KETOCONAZOLE TAB | 1 | No | ||
| KETOPROFEN | 1 | Yes | ||
| KETOROLAC TROMETHAMINE | 1 | Quantity limit | Yes | |
| KINERASE | 2 | Prior authorization, Quantity limit | No | |
| KLARON | 3 | Prior authorization, Quantity limit, Step therapy | No | |
| KLONOPIN | 3 | No | ||
| KLONOPIN WAFERS | 3 | Prior authorization, Step therapy | No | |
| KLOR-CON | 1 | Yes | ||
| KLOR-CON-8 | 1 | Yes | ||
| KLOR-CON/EF | 1 | Yes | ||
| KRISTALOSE PAK | 3 | No |
L
| Drug name | Tier | Restrictions | Mail order | |
|---|---|---|---|---|
| LABETALOL HCL | 1 | Yes | ||
| LAC-HYDRIN | NC | Over-the-counter | No | |
| LACTIC ACID | 1 | Quantity limit | No | |
| LACTIC ACID E | 1 | Quantity limit | No | |
| LACTINOL | 3 | Quantity limit | No | |
| LACTINOL-E | 3 | Quantity limit | No | |
| LACTULOSE | 1 | No | ||
| LAMICTAL | 3 | No | ||
| LAMICTAL ODT | 2 | No | ||
| LAMICTAL STARTER/NOT TAKING KIT | 3 | Prior authorization | No | |
| LAMICTAL XR | 2 | No | ||
| LAMOTRIGINE | 1 | No | ||
| LANOXIN | 1 | Yes | ||
| LANSOPRAZOLE 15 MG | 1 | Yes | ||
| LANSOPRAZOLE 30 MG | 1 | Yes | ||
| LANTANOPROST | 1 | Yes | ||
| LANTUS INJ 100U/ML | 2 | No | ||
| LANTUS SOLOSTAR INJ SOLOSTAR | 3 | No | ||
| LASIX | 3 | Yes | ||
| LAVOCLEN-4 CREAMY WASH LIQ CREM WSH | 3 | Quantity limit | No | |
| LAVOCLEN-8 CREAMY WASH LIQ CREM WSH | 3 | Quantity limit | No | |
| LAZERFORMALYDE | 2 | Quantity limit | No | |
| LEFLUNOMIDE | 1 | No | ||
| LESCOL | 3 | Quantity limit | Yes | |
| LESCOL XL | 3 | Quantity limit, Step therapy | Yes | |
| LESSINA | 1 | Quantity limit, Step therapy | Yes | |
| LEUCOVORIN | 1 | Quantity limit | No | |
| LEUKERAN | 1 | No | ||
| LEUKINE INJ | 2 | Prior authorization, Quantity limit | No | |
| LEUPROLIDE | 1 | No | ||
| LEVAQUIN | 3 | No | ||
| LEVBID | 2 | No | ||
| LEVEMIR INJ | 2 | No | ||
| LEVEMIR INJ FLEXPEN | 3 | No | ||
| LEVETIRACETAM | 1 | No | ||
| LEVITRA | 3 | Quantity limit | Yes | |
| LEVLITE-28 | 1 | Yes | ||
| LEVOBUNOLOL HCL | 1 | Yes | ||
| LEVOFLOXACIN | 1 | No | ||
| LEVORA | 1 | Yes | ||
| LEVOTHROID | 3 | Yes | ||
| LEVOTHYROXINE SODIUM INJ | $0 | No | ||
| LEVOTHYROXINE SODIUM TAB | 1 | No | ||
| LEVSIN | 2 | Yes | ||
| LEXAPRO | 3 | Prior authorization, Step therapy | No | |
| LIALDA | 3 | Yes | ||
| LIDAMANTLE | 2 | Quantity limit | No | |
| LIDAZONE HC | 1 | Quantity limit | No | |
| LIDEX | 3 | Prior authorization, Quantity limit | No | |
| LIDOCAINE HCL | 1 | Quantity limit | No | |
| LIDOCAINE VISCOUS | 1 | Quantity limit | No | |
| LIDOCAINE/PRILOCAINE | 1 | Quantity limit | No | |
| LIDODERM DIS | 2 | Quantity limit | Yes | |
| LIMBREL | 3 | Prior authorization | No | |
| LINDALE | 3 | Quantity limit | No | |
| LIPITOR | 2 | Yes | ||
| LISINOPRIL | 1 | Yes | ||
| LISINOPRIL/HYDROCHLOROTHIAZ | 1 | Yes | ||
| LITHIUM CARBONATE | 1 | No | ||
| LITHIUM CARBONATE ER | 1 | No | ||
| LITHOBID | 3 | No | ||
| LOCOID | 3 | Quantity limit | No | |
| LOCOID LIPOCREAM | 3 | Prior authorization, Quantity limit, Step therapy | No | |
| LOESTRIN 24 FE | 3 | Yes | ||
| LOESTRIN FE1/20 | 3 | Yes | ||
| LOFIBRA | 3 | Yes | ||
| LOPERAMIDE HCL | NC | No | ||
| LOPROX GEL | 3 | Prior authorization, Quantity limit, Step therapy | No | |
| LOPROX SHAMPOO | 3 | Prior authorization, Quantity limit, Step therapy | No | |
| LORATADINE | NC | No | ||
| LORAZEPAM | 1 | Travel | No | |
| LOSARTAN | 1 | Yes | ||
| LOSARTAN/HCTZ | 1 | Yes | ||
| LOTEMAX | 3 | Yes | ||
| LOTENSIN | 3 | Yes | ||
| LOTENSIN HCT | 3 | Yes | ||
| LOTREL | 3 | Yes | ||
| LOVASTATIN | 1 | Quantity limit | Yes | |
| LOVAZA | 3 | Quantity limit | Yes | |
| LOVENEX INJ | 2 | Quantity limit | No | |
| LOW OGESTREL | 1 | Yes | ||
| LUGOL'S SOL | 1 | No | ||
| LUGOL'S SOL BP | 1 | No | ||
| LUMIGAN SOL 0.03% | 2 | No | ||
| LUNESTA | 3 | Quantity limit, Step therapy | No | |
| LUPRON DEPOT | 3 | No | ||
| LUSTRA | NC | Quantity limit | No | |
| LUSTRA-ULTRA | NC | Quantity limit | No | |
| LUVERIS INJ 75UNIT UD | 3 | No | ||
| LUVOX CR | 3 | No | ||
| LUXIQ | 3 | Prior authorization, Quantity limit | Yes | |
| LYRICA | 2 | No |
M
| Drug name | Tier | Restrictions | Mail order | |
|---|---|---|---|---|
| M-OXY | 1 | No | ||
| MACRODANTIN | 3 | Yes | ||
| MAG-OX 400 | NC | Over-the-counter | No | |
| MALARONE | 3 | Travel | No | |
| MARPLAN TAB | 3 | No | ||
| MAXAIR AUTOHALER | 3 | Prior authorization, Quantity limit | Yes | |
| MAXALT | 2 | Quantity limit | Yes | |
| MAXZIDE-25 | 3 | No | ||
| MEBENDAZOLE | 2 | No | ||
| MEDERMA GEL | 2 | Quantity limit | No | |
| MEDROXYPROG INJ | 1 | Yes | ||
| MEFENAMIC ACID | 1 | No | ||
| MEFLOQUINE HCL | 3 | Travel | No | |
| MEGACE | 3 | No | ||
| MEGESTROL ACETATE | 1 | Yes | ||
| MELOXICAM | 1 | Yes | ||
| MENEST | 2 | Yes | ||
| MENOPUR INJ 75UNIT UD | 3 | No | ||
| MENOSTAR DIS | 3 | No | ||
| MENTAX | 3 | Prior authorization, Quantity limit, Step therapy | No | |
| MEPERIDINE HCL | 1 | No | ||
| MEPHYTON | 1 | No | ||
| MEPRON | 2 | No | ||
| MERCAPTOPURINE | 1 | Yes | ||
| MESALAMINE ENE | 1 | No | ||
| MESTINON | 2 | No | ||
| METADATE CD | 3 | Prior authorization | No | |
| METANX | 3 | No | ||
| METFORMIN HCL | 1 | Yes | ||
| METHADONE HCL | 1 | No | ||
| METHADOSE | 1 | No | ||
| METHAZOLAMIDE | 1 | No | ||
| METHENAMINE HIP | 1 | Yes | ||
| METHENAMINE MAN E | 1 | No | ||
| METHERGINE | 1 | No | ||
| METHIMAZOLE | 1 | Yes | ||
| METHOCARBAMOL | 1 | Yes | ||
| METHOTREXATE | 1 | No | ||
| METHYLDOPA | 1 | Yes | ||
| METHYLIN ER | 1 | No | ||
| METHYLIN SOL | 2 | No | ||
| METHYLIN TAB | 1 | No | ||
| METHYLPREDNISOLONE PAK | 1 | Yes | ||
| METHYLPREDNISOLONE SODIUMSU INJ | $0 | No | ||
| METHYLPREDNISOLONE/ESTE | 1 | No | ||
| METOCLOPRAMIDE | 1 | Yes | ||
| METOCLOPRAMIDE HCL | 1 | No | ||
| METOLAZONE | 1 | Yes | ||
| METOPROLOL | 1 | Yes | ||
| METOPROLOL/HYDROCHLOROTHIAZ | 1 | Yes | ||
| METROGEL GEL | 3 | Quantity limit | No | |
| METRONIDAZOLE TABLETS | 1 | Quantity limit | Yes | |
| MEXILETINE HCL | 1 | Yes | ||
| MIACALCIN | 2 | No | ||
| MICARDIS | 3 | Yes | ||
| MICARDIS HCT | 3 | Yes | ||
| MICROGESTIN FE | 1 | Yes | ||
| MIDODRINE HCL | 1 | No | ||
| MIDRIN | 3 | No | ||
| MIMYX | 2 | Prior authorization, Quantity limit | No | |
| MINITRAN DIS | 1 | No | ||
| MINOCIN | 3 | Prior authorization | No | |
| MINOCYCLINE HCL | 1 | Yes | ||
| MINOXIDIL | 1 | Yes | ||
| MIRAPEX | 3 | Yes | ||
| MIRCETTE 28 | 3 | Yes | ||
| MIRENA IUD SYSTEM | 2 | No | ||
| MIRTAZAPINE | 1 | No | ||
| MISOPROSTOL | 1 | Yes | ||
| MOBIC | 3 | Yes | ||
| MODICON 28 | 3 | Yes | ||
| MOEXIPRIL HCL | 1 | Yes | ||
| MOEXIPRIL/HYDROCHLOROTHIAZI | 1 | Yes | ||
| MOMETASONE FUROATE | 1 | Quantity limit | No | |
| MONOPRIL | 3 | Yes | ||
| MORPHINE SULFATE | 1 | No | ||
| MOTRIN TAB | 3 | Prior authorization | Yes | |
| MOVIPREP | 2 | No | ||
| MULTAQ | 3 | No | ||
| MULTI VITA-BETS/FLUORIDE | 1 | Yes | ||
| MULTIGEN | 2 | Yes | ||
| MUPIROCIN | 1 | Quantity limit | No | |
| MUSE | 3 | Prior authorization, Quantity limit | No | |
| MYAMBUTOL | 1 | No | ||
| MYCOPHENOLATE | $0 | Yes | ||
| MYDRIACYL | 3 | No | ||
| MYFORTIC | $0 | No |
N
| Drug name | Tier | Restrictions | Mail order | |
|---|---|---|---|---|
| NA BICARBONATE | 1 | Yes | ||
| NABUMETONE | 1 | Yes | ||
| NADOLOL | 1 | Yes | ||
| NAFTIN | 3 | Quantity limit, Step therapy | No | |
| NALTREXONE HCL | 1 | No | ||
| NAMENDA | 2 | Yes | ||
| NAMENDA TITRATION PAK | 3 | No | ||
| NAPROXEN EC | 1 | Yes | ||
| NARDIL | 2 | No | ||
| NASACORT-AQ | 3 | Quantity limit, Step therapy | Yes | |
| NASCOBAL | 3 | Prior authorization, Step therapy | No | |
| NASONEX | 2 | Quantity limit | Yes | |
| NECON 1/35 | 1 | Yes | ||
| NECON 7/7/7 | 1 | Yes | ||
| NEFAZODONE HCL | 1 | Yes | ||
| NEO/POLY/CORT | 1 | No | ||
| NEOBENZ MICRO | 3 | Prior authorization, Step therapy | No | |
| NEOCATE | 2 | No | ||
| NEOMYCIN SULFATE | 1 | No | ||
| NEOMYCIN/POLYMIXIN/DEXAMETH | 1 | No | ||
| NEOMYCIN/POLYMYXIN/HYDROCOR | 1 | No | ||
| NEORAL | $0 | No | ||
| NEULASTA INJ 6MG/0.6M | 2 | Prior authorization, Quantity limit | No | |
| NEUPOGEN PFS | 2 | Prior authorization, Quantity limit | No | |
| NEUPRO DIS | 2 | Prior authorization | No | |
| NEURONTIN | 3 | Yes | ||
| NEUTRA PHOS-K | 3 | No | ||
| NEUTRA-PHOS | 3 | No | ||
| NEVANAC | 3 | Yes | ||
| NEXIUM | 3 | Step therapy | Yes | |
| NIASPAN | 2 | Quantity limit | Yes | |
| NICOTINAMIDE W/ZINC OXIDE/C | 3 | Prior authorization | No | |
| NICOTINE POLACRILEX GUM | NC | Over-the-counter | No | |
| NICOTINE TRANSDERMAL SYSTEM | NC | Over-the-counter | No | |
| NICOTROL INHALER | 3 | Prior authorization | No | |
| NIFEDICAL XL | 1 | Yes | ||
| NIFEDIPINE | 1 | Yes | ||
| NIFEDIPINE ER | 1 | Yes | ||
| NIFEREX GOLD | 2 | Yes | ||
| NIFEREX-150 | 2 | Yes | ||
| NIFEREX-150 FORTE | 2 | Yes | ||
| NILANDRON | 2 | No | ||
| NITRO-DUR DIS | 3 | Yes | ||
| NITROBID | 2 | No | ||
| NITROFURAN MACROCRYSTAL | 1 | Yes | ||
| NITROFURAN MONOHY | 1 | No | ||
| NITROGLYCERIN TRANSDERMAL | 1 | No | ||
| NITROLINGUAL PUMPSPRAY | 3 | Step therapy | Yes | |
| NITROSTAT SUB | 1 | Yes | ||
| NIZATIDINE CAP | 1 | No | ||
| NOR-BE | 1 | Yes | ||
| NORITATE | 3 | Quantity limit | No | |
| NORPACE CR | 3 | Yes | ||
| NORPRAMIN | 3 | Prior authorization, Step therapy | No | |
| NORTREL 0.5/35 | 1 | Yes | ||
| NORTREL 7/7/7 | 1 | Yes | ||
| NORTRIPTYLINE HCL | 1 | No | ||
| NORVASC | 3 | Yes | ||
| NORVIR | 2 | Yes | ||
| NOTREL 1/35 | 1 | Yes | ||
| NOVAREL INJ 10000U | 3 | No | ||
| NOVOLIN 70/30 PEN | 3 | No | ||
| NOVOLIN-70/30 VIALS | 1 | No | ||
| NOVOLIN-N U-100 VIALS | 1 | No | ||
| NOVOLIN-R U-100 PEN | 3 | No | ||
| NOVOLIN-R U-100 PEN | 3 | No | ||
| NOVOLIN-R U-100 VIALS | 1 | No | ||
| NOVOLOG INJ 100U/ML | 2 | No | ||
| NOVOLOG INJ FLEXPEN | 3 | No | ||
| NOVOLOG MIX 70/30 | 2 | No | ||
| NOVOLOG MIX 70/30 PREFILLED INJ SYRINGE | 3 | No | ||
| NULYTELY | 3 | No | ||
| NUQUIN HP | 1 | Quantity limit | No | |
| NUTRINATE | 3 | No | ||
| NUTROPIN | 3 | No | ||
| NUVARING MIS | 2 | No | ||
| NUVIGIL | 2 | No | ||
| NYSTATIN CREAM | 1 | Quantity limit | No | |
| NYSTATIN SUSPENSION | 1 | Quantity limit | No | |
| NYSTATIN TABLETS | 1 | No | ||
| NYSTATIN/TRIAMCINOLONE | 1 | Quantity limit | No | |
| NYSTOP | 1 | Quantity limit | No |
O
| Drug name | Tier | Restrictions | Mail order | |
|---|---|---|---|---|
| OCELLA | 1 | Yes | ||
| OFLOXACIN | 1 | No | ||
| OGESTREL | 1 | No | ||
| OLANZIPINE | 1 | No | ||
| OLUX AER | 3 | Prior authorization, Quantity limit, Step therapy | No | |
| OMEPRAZOLE | 1 | Yes | ||
| OMINTROPE | 3 | No | ||
| OMNARIS SPR | 3 | Quantity limit, Step therapy | Yes | |
| OMNICEF | 3 | No | ||
| ONDANSETRON | 1 | Yes | ||
| ONE TOUCH TEST STRIPS | 3 | Prior authorization, Quantity limit | Yes | |
| ONETOUCH | 3 | Prior authorization, Quantity limit | Yes | |
| OPANA | 3 | No | ||
| OPANA ER | 3 | No | ||
| OPTIHALER MIS | 3 | Prior authorization | No | |
| OPTIVAR DRO | 3 | No | ||
| ORACEA | 3 | Quantity limit | No | |
| ORAPRED ODT TAB | 2 | No | ||
| ORAPRED SOL 15MG/5ML | 3 | No | ||
| ORPHENADRINE CITRATE ER | 1 | No | ||
| ORTHO DIAPHRAGM ALL-FLEX DRP KIT | 3 | No | ||
| ORTHO EVRA DIS 24HR | 3 | Yes | ||
| ORTHO TRI-CYCLEN | 3 | Yes | ||
| ORTHO TRI-CYCLEN LO | 2 | No | ||
| ORTHO-CEPT 28 | 3 | Yes | ||
| ORTHO-CYCLEN | 3 | Yes | ||
| ORTHO-NOVUM | 3 | Yes | ||
| ORTHOVISC INJ 15MG/ML UD | 3 | Quantity limit | No | |
| OSCION CLEANSER | 2 | Quantity limit, Step therapy | No | |
| OSMOPREP | 2 | No | ||
| OVCON-35 | 3 | Yes | ||
| OVIDE | 2 | Quantity limit | No | |
| OVIDREL INJ UD | 3 | No | ||
| OXAPROZIN | 1 | Yes | ||
| OXAZEPAM | 1 | No | ||
| OXCARBAZEPINE | 1 | Yes | ||
| OXISTAT | 2 | Prior authorization, Quantity limit | No | |
| OXSORALEN LOT 1% | 2 | Prior authorization, Quantity limit | No | |
| OXSORALEN ULTRA CAP 10MG | 3 | Prior authorization, Quantity limit | No | |
| OXYBUTYNIN | 1 | Yes | ||
| OXYBUTYNIN ER | 1 | Yes | ||
| OXYCODONE HCL | 1 | No | ||
| OXYCODONE/ACETAMINOPHEN | 1 | No | ||
| OXYCONTIN | 2 | No | ||
| OXYTROL | 3 | Yes |
P
| Drug name | Tier | Restrictions | Mail order | |
|---|---|---|---|---|
| PAMELOR | 3 | Prior authorization, Step therapy | No | |
| PANCREAZE | 2 | Yes | ||
| PANDEL | 3 | Quantity limit | No | |
| PANTOPRAZOLE SODIUM | 1 | Step therapy | Yes | |
| PARAGARD INTRAUTERINE COPPE IUD | 2 | No | ||
| PARI TREK COMBO PAK | NC | No | ||
| PARI TREK S COMPACT COMPRESS | NC | Prior authorization | No | |
| PARI TREK S PORTABLE POWER KIT POWER | NC | Prior authorization | No | |
| PARLODEL | 3 | No | ||
| PAROMOMYCIN SULFATE | 1 | No | ||
| PAROXETINE ER | 1 | No | ||
| PAROXETINE HCL | 1 | No | ||
| PATADAY SOL | 3 | Prior authorization | No | |
| PATANESE | 3 | Prior authorization, Quantity limit | Yes | |
| PATANOL | 3 | Prior authorization | Yes | |
| PAXIL | 3 | No | ||
| PEG-INTRON KIT | 2 | No | ||
| PEG-INTRON REDIPEN PAK 4 KIT 80MCG RP UD | 2 | No | ||
| PEGASYS INJ 180MCG/M UD | 2 | No | ||
| PEGASYS KIT | 2 | No | ||
| PENICILLIN V POTASSIUM | 1 | No | ||
| PENTASA | 2 | Yes | ||
| PENTAZOCINE/ACETAMINOPHEN | 1 | No | ||
| PENTOXIFYLLINE ER | 1 | Yes | ||
| PEPCID SUS 40MG/5ML | 3 | No | ||
| PEPCID TAB 40MG | 3 | Prior authorization | No | |
| PERCOCET | 3 | No | ||
| PERIDEX RINSE | 3 | Quantity limit | Yes | |
| PERMAX | 2 | Yes | ||
| PERMETHRIN | 1 | Quantity limit | No | |
| PERPHENAZINE | 1 | No | ||
| PHENOBARBITAL | 1 | No | ||
| PHENTERMINE HCL | 1 | No | ||
| PHENYLERPHRINE | 1 | No | ||
| PHENYTEK | 1 | No | ||
| PHENYTOIN | 1 | Yes | ||
| PHOS FLUR | 1 | Quantity limit | No | |
| PHOS-NAK | 1 | No | ||
| PHOSLO | 2 | No | ||
| PILOCARPINE HCL | 1 | No | ||
| PILOPINE HS | 3 | No | ||
| PINDOLOL | 1 | Yes | ||
| PIROXICAM | 1 | Yes | ||
| PLAVIX | 2 | Yes | ||
| PLENDIL | 3 | Yes | ||
| PLEXION | 3 | Quantity limit | No | |
| POLY-VI-FLOR DROPS | 3 | No | ||
| POLY-VITAMIN/FLUORIDE | 1 | Yes | ||
| POLY-VITAMIN/IRON/FLUORIDE DRO | 1 | Yes | ||
| POLYETHYLENE GLYCOL | NC | No | ||
| PONSTEL | 3 | No | ||
| PORTIA-28 | 1 | Yes | ||
| POTASSIUM CHLORIDE | 1 | No | ||
| POTASSIUM CHLORIDE ER | 1 | Yes | ||
| PRADAXA | 3 | Prior authorization | Yes | |
| PRAMOSONE | 1 | Quantity limit | No | |
| PRANDIN | 2 | Yes | ||
| PRASCION EMU | 1 | Quantity limit | No | |
| PRAVACHOL | 3 | Quantity limit | Yes | |
| PRAVASTATIN SODIUM | 1 | Quantity limit | Yes | |
| PRAZOSIN HCL | 1 | No | ||
| PRECARE CHW | 3 | No | ||
| PRECARE PREMIER | 3 | No | ||
| PRED FORTE | 3 | Yes | ||
| PRED MILD | 3 | Yes | ||
| PRED-G | 3 | No | ||
| PRED-G-S.O.P. | 3 | No | ||
| PREDNICARBATE | 1 | Quantity limit | No | |
| PREDNISOLONE | 1 | No | ||
| PREDNISOLONE ACETATE | 1 | Yes | ||
| PREDNISOLONE SODIUM PHOSPHA | 1 | No | ||
| PREDNISONE | 1 | Yes | ||
| PREMARIN | 3 | Yes | ||
| PREMARIN W/APP CREAM | 2 | Yes | ||
| PREMPHASE | 3 | Yes | ||
| PREMPRO | 3 | Yes | ||
| PRENATAL 19 | 1 | Yes | ||
| PRENATAL DHA | 3 | Yes | ||
| PRENATAL ELITE | 3 | Prior authorization | Yes | |
| PRENATAL PLUS | 1 | Yes | ||
| PRENATAL S | 1 | Yes | ||
| PRESISTA | 2 | No | ||
| PREVACID | 3 | Step therapy | No | |
| PREVACID SOLUTAB | 3 | Step therapy | No | |
| PREVACID-DR | 3 | Step therapy | No | |
| PREVALITE | 1 | No | ||
| PREVIDENT | 3 | Prior authorization, Quantity limit | Yes | |
| PREVIFEM | 1 | Yes | ||
| PREVPAC | NC | Prior authorization, Step therapy | No | |
| PRILOSEC | NC | Step therapy | Yes | |
| PRIMACARE ONE | 3 | No | ||
| PRIMAQUINE PHOSPHATE | 3 | No | ||
| PRIMIDONE | 1 | Yes | ||
| PRINIVIL | 3 | Yes | ||
| PRINZIDE | 3 | No | ||
| PRISTIQ | 3 | No | ||
| PROAMATINE | 3 | No | ||
| PROBENECID | 1 | Yes | ||
| PROCAINAMIDE HCL | 1 | Yes | ||
| PROCARDIA | 3 | Yes | ||
| PROCARDIA XL | 3 | Yes | ||
| PROCHLORPERAZINE | 1 | No | ||
| PROCRIT INJ 2000U/ML UD | 2 | Prior authorization, Quantity limit | No | |
| PROCTOFOAM-HC AER | 3 | Quantity limit | No | |
| PROCTOFOAM-NS AER | 3 | Quantity limit | No | |
| PROCTOZONE-HC | 1 | Quantity limit | Yes | |
| PROGESTERONE IN OIL | 3 | No | ||
| PROGRAF | $0 | No | ||
| PROGUANIL | 1 | Travel | No | |
| PROMETHAZINE/CODEINE | 1 | No | ||
| PROMETRIUM | 2 | Yes | ||
| PRONEB ULTRA II ADULT | $0 | No | ||
| PRONEB ULTRA II PEDI | $0 | No | ||
| PROPAFENONE HCL | 1 | Yes | ||
| PROPANTHELINE | 1 | No | ||
| PROPARACAINE HCL | 1 | No | ||
| PROPECIA | NC | Quantity limit | Yes | |
| PROPIMEX-2 | 2 | No | ||
| PROPRANOLOL | 1 | Yes | ||
| PROSCAR | 3 | Yes | ||
| PROSED EC | 3 | No | ||
| PROTOPIC | 2 | Prior authorization, Quantity limit | No | |
| PROVENTIL AER HFA | 3 | Quantity limit | Yes | |
| PROVIGIL | 2 | No | ||
| PROZAC | 3 | No | ||
| PROZAC WEEKLY | 3 | Prior authorization, Step therapy | No | |
| PRUDOXIN | 2 | Prior authorization, Quantity limit, Step therapy | No | |
| PSORCON E | 3 | Prior authorization, Quantity limit, Step therapy | No | |
| PULMICORT FLEXHALER | 2 | Quantity limit | Yes | |
| PULMOZYME | 2 | No | ||
| PURALUBE TEARS | 1 | No | ||
| PYRAZINAMIDE | $0 | No | ||
| PYRIDOSTIGMINE | 1 | No | ||
| PYRIDOXINE | $0 | No |
Q
| Drug name | Tier | Restrictions | Mail order | |
|---|---|---|---|---|
| QUALAQUIN | 2 | Yes | ||
| QUASENSE | 1 | Yes | ||
| QUESTREN LIGHT | 3 | Yes | ||
| QUINAPRIL HCL | 1 | Yes | ||
| QUINAPRIL/HYDROCHLOROTHIAZI | 1 | Yes | ||
| QUINIDINE SULFATE | 1 | Yes | ||
| QUIXIN | 3 | No | ||
| QVAR AER | 2 | Quantity limit | Yes |
R
| Drug name | Tier | Restrictions | Mail order | |
|---|---|---|---|---|
| RABAVART INJ UD | $0 | No | ||
| RAMIPRIL | 1 | Yes | ||
| RANEXA | 3 | Prior authorization | No | |
| RANITIDINE HCL | 1 | Yes | ||
| RAPAMUNE | $0 | Yes | ||
| RAZADYNE | 3 | Yes | ||
| RE-SA | 2 | Quantity limit | No | |
| REBIF | 2 | No | ||
| RECLAST | $0 | No | ||
| RECLIPSEN | 1 | Yes | ||
| RELENZA DISKHALER | 2 | No | ||
| RELPAX | 3 | Quantity limit, Step therapy | Yes | |
| REMERON | 3 | No | ||
| REMINYL | 2 | No | ||
| RENA-VITE | 1 | Yes | ||
| RENAGEL | 2 | Yes | ||
| RENAL CAP SOFTGEL | 3 | Prior authorization | Yes | |
| RENAX | 2 | No | ||
| RENOVA | NC | Quantity limit | No | |
| RENVELA | 2 | Yes | ||
| REPRONEX INJ 75IU UD | 3 | No | ||
| REQUIP XL | 2 | Yes | ||
| RESERPINE | 1 | Yes | ||
| RESTASIS EMU | 3 | Yes | ||
| RESTORIL | 3 | No | ||
| RETIN-A | 3 | Quantity limit | No | |
| RETIN-A MICRO | 3 | Prior authorization, Quantity limit, Step therapy | No | |
| RETROVIR | 3 | Yes | ||
| REVATIO | 3 | Quantity limit | No | |
| REVLIMID CAP | 3 | Prior authorization | No | |
| REYATAZ | 2 | Yes | ||
| RHINOCORT AQUA | 2 | Prior authorization, Quantity limit, Step therapy | Yes | |
| RIBAPAK TAB 800/DAY | 2 | No | ||
| RIBAVIRIN TAB 200MG | 1 | Yes | ||
| RIFADIN CAP | 2 | No | ||
| RIFAMPIN CAP 150MG | 1 | Yes | ||
| RILUTEK | 2 | Yes | ||
| RIMANTADINE HCL | 1 | No | ||
| RIMSO-50 | 3 | No | ||
| RISPERDAL | 3 | No | ||
| RISPERDAL CONSTA INJ | $0 | Prior authorization | No | |
| RISPERDAL M-TAB | 3 | No | ||
| RISPERIDONE | 1 | No | ||
| RITALIN | 3 | No | ||
| RITALIN LA | 3 | Step therapy | No | |
| ROPINIROLE HCL | 1 | Yes | ||
| ROSAC | 3 | Quantity limit | No | |
| ROSADERM EMU CLEANSER | 1 | Quantity limit | No | |
| ROSANIL CLEANSER EMU | 3 | Quantity limit, Step therapy | No | |
| ROSULA | 3 | Prior authorization, Quantity limit, Step therapy | No | |
| ROXICET | 1 | No | ||
| ROXICODONE | 1 | No | ||
| ROZEREM | 3 | Prior authorization, Quantity limit, Step therapy | No | |
| RYTHMOL SR | 3 | No |
S
| Drug name | Tier | Restrictions | Mail order | |
|---|---|---|---|---|
| SALAGEN | 2 | Prior authorization, Quantity limit | Yes | |
| SALEX | 3 | Quantity limit | No | |
| SALSALATE | 1 | Yes | ||
| SANCTURA | 3 | No | ||
| SANCTURA XR | 3 | No | ||
| SANDOSTATIN INJ 0.1MG/ML | $0 | No | ||
| SANDOSTATIN LAR DEPOT KIT LAR 30MG UD | $0 | No | ||
| SANTYL | 2 | Quantity limit | No | |
| SAPHRIS | 3 | No | ||
| SARNA LOT | NC | Quantity limit | No | |
| SEASONALE | 3 | Quantity limit | Yes | |
| SEASONIQUE | 3 | Quantity limit | Yes | |
| SELEGILINE HCL | 1 | Yes | ||
| SELENIUM SULFIDE LOTION | 1 | Quantity limit | Yes | |
| SELENIUM SULFIDE SHA | 3 | Prior authorization, Quantity limit, Step therapy | No | |
| SENSIPAR | 2 | Prior authorization | Yes | |
| SEREVENT MIS | 2 | Quantity limit | No | |
| SEROQUEL | 2 | No | ||
| SEROQUEL XR | 2 | No | ||
| SERTRALINE HCL | 1 | No | ||
| SF 5000 PLUS | 1 | Quantity limit | Yes | |
| SILVER NITRATE | 1 | Quantity limit | No | |
| SIMCOR | 2 | Yes | ||
| SIMVASTATIN | 1 | Quantity limit | Yes | |
| SINGULAIR | 2 | Yes | ||
| SKELAXIN | 3 | Step therapy | No | |
| SODIUM CHLORIDE INJ 0.9% UD | $0 | No | ||
| SODIUM FLUORIDE | 1 | Yes | ||
| SODIUM SULFACETAMIDE | 1 | Quantity limit | No | |
| SODIUM SULFACETAMIDE AND SU EMU SULFUR | 1 | Quantity limit | No | |
| SODIUM SULFACETAMIDE/SULFUR | 1 | Quantity limit | No | |
| SOLODYN | 3 | Prior authorization, Step therapy | No | |
| SOLU-CORTEF INJ 100MG UD | $0 | No | ||
| SOLU-MEDROL INJ 1000MG UD | $0 | No | ||
| SOLU-MEDROL INJ-40MG UD | $0 | No | ||
| SOLU-MEDROL-ACT-O-VIAL-INJ 1000MG | $0 | No | ||
| SOMA | 3 | No | ||
| SONATA CAP | 3 | Quantity limit, Step therapy | No | |
| SORBITOL | 1 | No | ||
| SORIATANE CK KIT | 3 | Prior authorization, Quantity limit | No | |
| SOTALOL HCL | 1 | Yes | ||
| SPIRIVA | 2 | Quantity limit | Yes | |
| SPIRONOLACTONE | 1 | Yes | ||
| SPIRONOLACTONE/HYDROCHLOROT | 1 | Yes | ||
| SPRINTEC | 1 | Yes | ||
| SRONYX | 1 | Yes | ||
| SSKI | 1 | No | ||
| STALEVO | 2 | Yes | ||
| STARLIX | 2 | Yes | ||
| STAVUDINE | 1 | No | ||
| STRATTERA | 2 | Yes | ||
| STROMECTOL | 2 | No | ||
| STRONGSTART CHW | 3 | No | ||
| SUBOXONE SUB | 2 | No | ||
| SUBUTEX SUB | 2 | No | ||
| SUCRALFATE | 1 | Yes | ||
| SULFACET-R LOT TINT-FRE | 3 | Quantity limit | No | |
| SULFACETAMIDE SODIUM | 1 | No | ||
| SULFACETAMIDE SODIUM OIN | 1 | No | ||
| SULFACETAMIDE SODIUM/SULFUR | 1 | Quantity limit | No | |
| SULFADIAZINE | 1 | Yes | ||
| SULFATOL | 3 | Quantity limit | No | |
| SULFAZINE EC | 1 | Yes | ||
| SULFUR SUBLIMED | 1 | Quantity limit | No | |
| SULINDAC | 1 | Yes | ||
| SUMATRIPTAN | 1 | Quantity limit | Yes | |
| SUPARTZ INJ 25MG UD | $0 | Quantity limit | No | |
| SUPRAX | 2 | No | ||
| SUSTIVA | 2 | Yes | ||
| SUTENT | 2 | Prior authorization, Quantity limit | No | |
| SYMAX FASTABS | 3 | Prior authorization | No | |
| SYMBICORT | 2 | Quantity limit | Yes | |
| SYMLIN INJ 0.6MG/ML | 2 | No | ||
| SYNALAR | 3 | Quantity limit | No | |
| SYNTHROID | 1 | Yes | ||
| SYNVISC INJ 8MG/ML UD | $0 | Prior authorization, Quantity limit | No | |
| SYPRINE | 2 | Prior authorization | No |
T
| Drug name | Tier | Restrictions | Mail order | |
|---|---|---|---|---|
| TACLONEX OIN | 2 | Prior authorization, Quantity limit | No | |
| TAMIFLU | 2 | No | ||
| TAMOXIFEN CITRATE | 1 | Yes | ||
| TAMSOLUSIN | 1 | Yes | ||
| TARCEVA | 3 | Prior authorization | No | |
| TAZORAC | 2 | Prior authorization, Quantity limit | No | |
| TEGRETOL | 3 | No | ||
| TEGRETOL-XR | 2 | Yes | ||
| TEKTURNA | 2 | Yes | ||
| TEKTURNA HTC | 2 | No | ||
| TEKTURNA-XR | 2 | Yes | ||
| TEMAZEPAM | 1 | No | ||
| TEMODAR | 2 | No | ||
| TENORMIN | 3 | Prior authorization | Yes | |
| TERAZOSIN HCL | 1 | Yes | ||
| TERBINAFINE HCL | 1 | Yes | ||
| TERBUTALINE SULFATE | 1 | No | ||
| TERCONAZOLE | 1 | Yes | ||
| THALOMID | 2 | Prior authorization, Quantity limit | No | |
| THEOPHYLLINE ER | 1 | No | ||
| THERMAZENE | 1 | Quantity limit | No | |
| THEROBEC TAB PLUS | 1 | No | ||
| THIOTHIXENE | 1 | No | ||
| THYROID | 1 | Yes | ||
| TIAZAC | 3 | No | ||
| TICLOPIDINE HCL | 1 | Yes | ||
| TILIA FE | 1 | Yes | ||
| TIMOLOL MALEATE OP | 1 | Yes | ||
| TIMOLOL OP | 1 | Yes | ||
| TIMOPTIC | 3 | Yes | ||
| TIMOPTIC-XE OP | 2 | Yes | ||
| TINDAMAX | 2 | No | ||
| TIZANIDINE HCL | 1 | Yes | ||
| TOBI NEB 300/5ML | 2 | No | ||
| TOBRADEX | 3 | No | ||
| TOBRAMYCIN SULFATE | 1 | No | ||
| TOBREX | 3 | Prior authorization | No | |
| TOLBUTAMIDE | 1 | Yes | ||
| TOLMETIN SODIUM | 1 | Yes | ||
| TOPAMAX | 3 | No | ||
| TOPROL XL | 3 | Yes | ||
| TORSEMIDE | 1 | Yes | ||
| TOVIAZ | 2 | No | ||
| TRAMADOL HCL | 1 | Yes | ||
| TRAMADOL HYDROCHLORIDE/ACET | 1 | Yes | ||
| TRANSDERM-SCOP DIS | 2 | Travel | No | |
| TRANYLCYPROMINE SULFATE | 1 | No | ||
| TRAVATAN | 2 | Yes | ||
| TRAVATAN Z | 2 | Yes | ||
| TRAZODONE HC | 1 | No | ||
| TRENTAL | 3 | No | ||
| TRETINOIN CRE | 1 | Quantity limit | No | |
| TRETINOIN EMOLLIENT | NC | Quantity limit | No | |
| TRETINOIN GEL | 1 | Quantity limit | No | |
| TREXIMET | 3 | Prior authorization, Quantity limit | No | |
| TRI-LEGEST FE | 1 | Yes | ||
| TRI-LO-SPRINTEC | 1 | Yes | ||
| TRI-LUMA | NC | Quantity limit | No | |
| TRI-PREVIFEM | 1 | Yes | ||
| TRI-SPRINTEC | 1 | Yes | ||
| TRI-VITAMIN/FLUORIDE | 1 | Yes | ||
| TRIAMCINOLONE IN ORABASE | 1 | Quantity limit | No | |
| TRIAMTERENE/HYDROCHLOROTHIA | 1 | Yes | ||
| TRIAZ | 3 | Quantity limit | No | |
| TRIAZOLAM | 1 | Quantity limit | No | |
| TRICOR | 3 | Step therapy | Yes | |
| TRIFLUOPERAZINE | 1 | No | ||
| TRIFLURIDINE | 1 | No | ||
| TRIGLIDE | 3 | No | ||
| TRIHEXYPHENIDYL HCL | 1 | No | ||
| TRILEPTAL | 3 | No | ||
| TRILYTE | 3 | No | ||
| TRIMETHOBENZAMIDE HCL | 1 | No | ||
| TRIMETHOPRIM | 1 | Yes | ||
| TRIMETHOPRIM SULFATE | 1 | No | ||
| TRIVORA | 1 | Yes | ||
| TRIZIVIR | 2 | Yes | ||
| TROPICAMIDE | 1 | No | ||
| TRUVADA | 2 | Yes | ||
| TYKOSIN | 3 | Prior authorization | No | |
| TYLENOL/CODEINE #3 | 3 | No |
U
| Drug name | Tier | Restrictions | Mail order | |
|---|---|---|---|---|
| ULORIC | 3 | Prior authorization | No | |
| ULTRA NATALCARE | 3 | No | ||
| ULTRACET | 3 | Yes | ||
| ULTRAM | 3 | Yes | ||
| ULTRAVATE | 3 | Quantity limit | No | |
| UMECTA EMU | 3 | Prior authorization, Quantity limit, Step therapy | No | |
| UMECTA MOUSSE AER | 3 | Prior authorization, Quantity limit | No | |
| UMECTA NAIL FILM | 3 | Prior authorization, Quantity limit, Step therapy | No | |
| UNIRETIC | 3 | Yes | ||
| UNIVASC | 3 | Yes | ||
| UREA | 1 | Quantity limit | No | |
| UREA NAIL STK 50% | 2 | Prior authorization, Quantity limit | No | |
| UREALAC LOTION | 1 | Quantity limit | No | |
| UREALAC NAIL GEL | 3 | Prior authorization, Quantity limit | No | |
| URIMAX | 3 | No | ||
| URISED | 1 | No | ||
| UROQID | 1 | No | ||
| URSO | 2 | Yes | ||
| URSO FORTE | 2 | Yes | ||
| URSODIL | 1 | No | ||
| USEPT | 1 | No |
V
| Drug name | Tier | Restrictions | Mail order | |
|---|---|---|---|---|
| VAGIFEM | 2 | Yes | ||
| VALACYCLOVIR | 1 | Yes | ||
| VALCYTE | 3 | Prior authorization, Quantity limit, Step therapy | Yes | |
| VALPROIC | 1 | Yes | ||
| VALTREX | 3 | Yes | ||
| VANCOCIN HCL | 2 | No | ||
| VANDAZOLE | 2 | No | ||
| VANIQA | NC | No | ||
| VANOS | 3 | Prior authorization, Quantity limit, Step therapy | No | |
| VASOTEC | 3 | Yes | ||
| VELIVET PAK | 3 | No | ||
| VENLAFAXINE ER CAP | 1 | No | ||
| VENLAFAXINE ER TAB | 1 | No | ||
| VENLAFAXINE HCL | 1 | No | ||
| VENTOLIN HFA AER | 1 | Quantity limit | Yes | |
| VEPESID | 3 | Prior authorization, Quantity limit | No | |
| VERALEN SR | 3 | Prior authorization | No | |
| VERAMYST | 2 | Quantity limit, Step therapy | Yes | |
| VERAPAMIL HCL | 1 | Yes | ||
| VERELAN PM | 3 | Prior authorization | No | |
| VESICARE | 2 | Yes | ||
| VFEND | 2 | No | ||
| VIAGRA | 2 | Quantity limit | Yes | |
| VIBRAMYCIN | 3 | No | ||
| VICODIN ES | 3 | No | ||
| VICTOZA | 3 | No | ||
| VICTRELIS | 2 | Prior authorization | No | |
| VIGAMOX | 3 | Yes | ||
| VINATAL FORTE | 3 | No | ||
| VIRACEPT | 2 | Yes | ||
| VIRAMUNE | 2 | No | ||
| VIREAD | 2 | Yes | ||
| VISICOL | 2 | No | ||
| VISTARIL | 3 | Prior authorization | No | |
| VITAFOL-OB | 3 | No | ||
| VITAMIN D | 1 | No | ||
| VIVACTIL | 2 | No | ||
| VIVAGLOBIN | 3 | Prior authorization | No | |
| VIVELLE-DOT | 3 | Yes | ||
| VIVOTIF BERNA | 3 | Travel | No | |
| VOLTAREN GEL | 2 | Prior authorization, Quantity limit | Yes | |
| VOLTAREN SOL 0.1% OP | 3 | Prior authorization | No | |
| VOLTAREN TAB 75MG EC | 3 | Yes | ||
| VORTEX CHAMBER | 1 | Yes | ||
| VOSPIRE ER TAB 4 MG | 2 | Quantity limit | No | |
| VYTORIN | 2 | Prior authorization, Quantity limit | Yes | |
| VYVANSE | 3 | No |
W
| Drug name | Tier | Restrictions | Mail order | |
|---|---|---|---|---|
| WARFARIN SODIUM | 1 | Yes | ||
| WELCHOL | 3 | Yes | ||
| WELLBUTRIN | 3 | No | ||
| WELLBUTRIN XL | 3 | No | ||
| WELLBUTRIN-SR | 3 | No |
X
| Drug name | Tier | Restrictions | Mail order | |
|---|---|---|---|---|
| XALATAN | 3 | No | ||
| XANAX | 3 | Prior authorization, Step therapy | No | |
| XELODA | 2 | Quantity limit | No | |
| XENADERM | 2 | Quantity limit | No | |
| XENICAL | NC | Over-the-counter | No | |
| XERAC AC | 1 | Quantity limit | No | |
| XIBROM | 3 | Prior authorization | No | |
| XIFAXAN | 3 | Travel | No | |
| XOLAIR | 2 | Prior authorization | No | |
| XOLEGEL | 3 | Prior authorization, Quantity limit, Step therapy | No | |
| XOPENEX | 2 | Prior authorization, Quantity limit | Yes | |
| XYREM | 2 | No | ||
| XYZAL | 3 | No |
Y
| Drug name | Tier | Restrictions | Mail order | |
|---|---|---|---|---|
| YALE HEALTH H. PYLORI | 1 | No | ||
| YASMIN | 3 | Prior authorization | Yes | |
| YAZ | 3 | Yes | ||
| YODOXIN | 1 | No | ||
| YOHIMBINE HCL | 1 | No |
Z
| Drug name | Tier | Restrictions | Mail order | |
|---|---|---|---|---|
| ZACLIR CLEANSING | 2 | Quantity limit, Step therapy | No | |
| ZADITOR | NC | No | ||
| ZALEPLON CAP 5MG | 1 | No | ||
| ZANAFLEX CAP 6MG | 3 | Yes | ||
| ZANTAC | 3 | Prior authorization | Yes | |
| ZAROXOLYN | 3 | Yes | ||
| ZEGERID | 3 | Prior authorization, Step therapy | No | |
| ZELAPAR | 2 | Yes | ||
| ZEMPLAR CAP | 2 | No | ||
| ZENPEP | 2 | Yes | ||
| ZESTORETIC | 3 | Yes | ||
| ZESTRIL | 3 | Yes | ||
| ZETIA | 2 | Quantity limit | Yes | |
| ZIAGEN | 2 | Yes | ||
| ZIANA | 3 | Quantity limit, Step therapy | No | |
| ZIDOVUDINE | 1 | Yes | ||
| ZINC OXIDE | NC | Quantity limit | No | |
| ZITHROMAX | 2 | Travel | No | |
| ZODERM | 3 | Quantity limit, Step therapy | No | |
| ZOFRAN | 3 | Prior authorization, Step therapy | Yes | |
| ZOLADEX IMP | 3 | No | ||
| ZOLENE HC | 3 | No | ||
| ZOLINZA TAB | 3 | Prior authorization, Quantity limit | No | |
| ZOLOFT | 3 | No | ||
| ZOLPIDEM TARTRATE | 1 | Travel | No | |
| ZOMIG | 3 | Quantity limit | Yes | |
| ZONALON | 3 | Prior authorization, Quantity limit, Step therapy | No | |
| ZONISAMIDE | 1 | Yes | ||
| ZOVIA | 1 | Yes | ||
| ZOVIRAX | 2 | Quantity limit | Yes | |
| ZYFLO CR | 2 | Yes | ||
| ZYLET | 3 | No | ||
| ZYMAXID | 3 | No | ||
| ZYPREXA | 3 | No | ||
| ZYVOX | 3 | Prior authorization | No |