Standard Plan Four Tier Drug List€¦ · Tier 3. Higher Co-Pay or Co-Insurance Non-preferred brand...

Standard Plan Four Tier Drug List

Preferred Generic and Branded Medications

This Preferred Drug List is regularly updated, but it may not reflect your specific plan coverage. Please log-in to your member portal on www.prescryptive.com for the most up to date list using your fully searchable formulary tool for your specific benefit information, or call Prescryptive Member Services at the number on your Member ID card for coverage information.

PRESCRIPTION COVERAGE

Your plan covers drugs on the Standard Plan Four Tier Drug List. This list of covered, preferred medications provides a guide for plan members and their healthcare providers to finding more cost effective, FDA approved medications.

HOW MUCH WILL MY MEDICATION COST?

Please refer to your benefit plan summary for more information about your specific benefit. With the Four Tier Drug List, the covered prescription medications fall into one of four cost levels or tiers, as outlined below. What you pay will depend on which tier your medication is in. Your benefit summary documents will provide the cost to you for each of the four tiers. To help you save money, ask your healthcare provider to consider the following when selecting a course of treatment:

• Consider prescribing a generic medication (Tier 1) as a first option.• If there is no generic available, there may be more than one brand name

medication to treat a condition. When clinically appropriate, considerone of the preferred brand medications (Tier 2) identified on this list fora more cost-effective choice.

• Some Preventive Medications (Tier 0) including some over-the-counterdrugs, devices and other products approved by the Federal Food andDrug Administration are fully covered at no cost to you, the member,when purchased through a participating pharmacy with a writtenprescription. To learn more about Preventive Medication coverage visitour website at www.prescryptive.com.

Version 202002.2 Copyright 2020 Prescryptive Health, Inc.

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FOUR TIERS

Tier Level Description

Tier 1 Lowest Co-pay or

Co-insurance

Generic drugs. All generics in the Drug List arelisted in bolded italics.

Tier 2 Lower Co-Pay or

Co-insurance

Preferred brand drugs. Preferred brand drugs are listed in ALL-CAPS.

Tier 3 Higher Co-Pay or

Co-Insurance

Non-preferred brand drugs. Non-preferred brand drugs are not listed in this document.

Tier 4 Highest Co-pay or

Co-insurance

Specialty Medications usually have a higher co-pay than other brand name drugs. Specialty medications are high cost, self-administered drugs that are used to treat rare or complex medical conditions. Specialty drugs typically require prior authorization before they are covered and must be filled through our designated specialty pharmacy.

For more information about Specialty Medications, visit our website at www.prescryptive.com or contact Prescryptive Member Services at the number listed on the back of your Member ID card.

FILLING YOUR PRESCRIPTION AT A NETWORK PHARMACY

You have access to Prescryptive’s nationwide network with thousands of participating pharmacies. To have your medication covered, you will need to use a participating pharmacy and show your Member ID card before purchasing your prescription. If you go to a pharmacy not in the network, the cost of your prescription may be higher and not fully covered, and you may need to pay for the prescription in full, and then manually submit for reimbursement using the Direct Member Reimbursement Form.

Log-in to your member portal at www.prescryptive.com to use the searchable pharmacy tool to find a pharmacy that is part of the Prescryptive nationwide network. Or, call Prescryptive Member Services at the number on the back of your Member ID for assistance.


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Note: Tier 0 medications are covered at no cost to members ($0 co-pay) as mandated by the federal Affordable Care Act (ACA).


HOME DELIVERY/MAIL ORDER

Most retail pharmacies can fill up to a 90-day supply of maintenance medications. It is your choice to use home delivery as a convenient way to ensure you maintain your

supply of any maintenance medications you are taking. For more information about our

home delivery or mail order service visit our website or call Prescryptive MemberServices at the number on the back of your Member ID for assistance.

SPECIALTY MEDICATIONS

Specialty medications are listed as Tier 4 drugs on this Drug List. All specialty

medications are managed and dispensed by Prescryptive’s Specialty Pharmacy partner

and require a Prior Authorization before these medications are covered under your

benefit plan. With written approval, your plan will cover a portion of the cost of these

medications as detailed in your benefit plan document, along with the support services provided by the Specialty Pharmacy care team to help with your treatment success. To

learn more about Specialty Medications, the Prior Authorization process, or your

benefit coverage visit our website at www.prescryptive.com or call Prescryptive Member Services at the number on the back of your Member ID for assistance.

PREFERRED DRUG LIST

The following list provides the tier coverage of each preferred drug, along with any prior authorization requirements. If the medication you are looking for is not on this list, it is a Tier 3 or Tier 4 non-preferred medication. Refer to your Benefit Plan Summary to understand how much your cost will be for each medication based upon its Tier classification.

Please note: Pharmacy products and services covered by your benefit plan may change from time to time. Some products and services may not be covered under a specific member’s plan design. The information provided here is for general information purposes only and does not guarantee coverage. Some pharmacy products and services require prior authorization before they are covered. Only a written prior authorization approval will guarantee coverage for such products and services. To confirm your coverage, reference your specific plan documents within your member portal account at www.prescryptive.com or contact Prescryptive Member Services at the phone number on your Member ID card.


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Drug Tier Notes Drug Tier Notesabacavir sulfate

abacavir sulfate-lamivudine

abacavir-lamivudine-zidovudine

abaneu-sl

acamprosate calcium

acarbose

acebutolol

Acetaminophen-Caffeine-Dihydrocodeine

acetaminophen-codeine

acetazolamide, er

acetic acid

acetylcysteine

acitretin

acyclovir

adapalene

adapalene-benzoyl peroxide

adefovir dipivoxil

Adempas

Advair Diskus, HFA

Afinitor, Disperz

aftera

Aimovig

albendazole

albuterol, er

albuterol, hfa

alclometasone

Alecensa

alendronate

Alferon N

alfuzosin er

aliskiren

allopurinol

almotriptan

alosetron

alprazolam, er

altavera

Alunbrig

alyacen

amantadine

ambrisentan

Amcinonide

Ameluz

amethia, lo

amethyst

amiloride

amiloride-hydrochlorothiazide

aminoacetic acid

aminobenzoate potassium

aminocaproic acid

amiodarone

amitriptyline

amlodipine

amlodipine-benazepril

amlodipine -valsartan

amlodipine-atorvastatin

amlodipine-olmesartan

amlodipine-valsartan-hydrochlorothiazide

amnesteem

Amoxapine

amoxicillin

amoxicillin-clarithromycin-lansoprazole

amoxicillin-clavulanate, er

amphetamine, er

amphetamine-dextroamphetamine, er

ampicillin

anagrelide

anaspaz

anastrozole

annovera

Anoro Ellipta

anucort-hc

Apokyn

4

0

1

4

2

2

0

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1

1

1

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1

1

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4

Prior Authorization Required



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Drug Tier Notes Drug Tier Notesapraclonidine

aprepitant

apri

Aptiom

Aptivus

Arakoda

aranelle

Aranesp

Arcalyst

Arikayce

aripiprazole

armodafinil

Armour Thyroid

Arnuity Ellipta

ashlyna

aspirin low strength

aspirin-dipyridamole er

Astagraf XL

Atabex

atazanavir sulfate

atenolol

atenolol-chlorthalidone

atomoxetine

atorvastatin

atovaquone

atovaquone-proguanil

Atripla

atropine sulfate

Aubagio

aubra, eq

aurovela

aurovela 24 fe

aurovela fe

Auryxia

Austedo

aviane

avidoxy

avita

Avonex

ayuna

Ayvakit

Azasan

AzaSite

azathioprine

azelaic acid

azelastine

azelastine-fluticasone

azithromycin

azurette

bacitracin

bacitracin-neomycin-polymyxin b-hydrocortisone

bacitracin-polymyxin b

baclofen

balcoltra

balsalazide

Balversa

balziva

Banzel

Baqsimi

Basaglar

bekyree

Belladonna Alkaloids-Opium

benazepril

benazepril-hydrochlorothiazide

Benlysta

benznidazole

benzonatate

benzoyl peroxide-erythromycin

benzoyl peroxide-hydrocortisone

benztropine

betamethasone dipropionate

betamethasone dipropionate aug

1

1

4

0

4

2

2

1

1

1

1

1

0

1

1

1

1

1

1

4

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2

2

2

0

2

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1

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1

0

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1

1

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Drug Tier Notes Drug Tier Notesbetamethasone valerate

betaxolol

bethanechol

bexarotene

bicalutamide

Biktarvy

bimatoprost

Bio-Statin

bisoprolol

bisoprolol-hydrochlorothiazide

blanche

blisovi 24 fe

blisovi fe

bosentan

Bosulif

Braftovi

Breo Ellipta

briellyn

Brilinta

brimonidine

Brimonidine-Dorzolamide

Briviact

bromfed dm

bromfenac

bromocriptine

Brompheniramine

Brukinsa

budesonide

budesonide er

budesonide-formoterol fumarate

bumetanide

buprenorphine

buprenorphine-naloxone

bupropion, er (smoking det)

bupropion, er, xl

buspirone

butalbital-acetaminophen

butalbital-acetaminophen-caffeine

butalbital-acetaminophen-caffeine-codeine

butalbital-aspirin-caffeine

butalbital-aspirin-caffeine-codeine

butorphanol tartrate

cabergoline

Cabometyx

caffeine citrate

calcipotriene

calcipotriene-betamethasone dipropionate

calcitonin

calcitrene

calcitriol

calcium acetate

Calquence

camila

camrese, lo

candesartan

candesartan-hydrochlorothiazide

capecitabine

Caprelsa

captopril

Captopril-hydrochlorothiazide

Carbaglu

carbamazepine, er

carbidopa

carbidopa-levodopa, er

carbidopa-levodopa-entacapone

carbinoxamine

carisoprodol

carisoprodol-aspirin

carisoprodol-aspirin-codeine

carteolol

carvedilol, er

cararest

1

1

1

1

1

1

1

4

1

1

1

1

1

1

1

4

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1

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1

1

0

1

1






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Drug Tier Notes Drug Tier Notesciclopirox

cilostazol

Cimduo

cimetidine

cinacalcet

ciprofloxacin

ciprofloxacin-fluocinolone

citalopram hydrobromide

claravis

clarithromycin, er

clemastine

clenpiq

clindamycin

clindamycin-benzoyl peroxide

clindamycin-tretinoin

clinpro 5000

clobazam

clobetasol,emollient

clobetasol,emulsion

clomipramine

clonazepam

clonidine, er

clopidogrel

clorazepate

clotrimazole

clotrimazole-betamethasone

clovique

clozapine

Coartem

codeine

colchicine

colchicine-probenecid

colesevelam

colestipol

coly-mycin s

Cometriq

1

1

2

1

1

1

1

1

1

1

1

0

1

1

1

1

1

1

1

1

1

1

1

1

1

1

4

1

2

1

1

1

1

1

1

4



caya

Cayston

caziant

cefaclor

Cefaclor ER

cefadroxil

cefdinir

Cefditoren

cefixime

cefpodoxime

cefprozil

cefuroxime

celecoxib

Celontin

cephalexin

Cerdelga

cerovel

cevimeline

chantix

chateal, eq

Chemet

Chenodal

chlordiazepoxide

Chlordiazepoxide-Amitriptyline

chlordiazepoxide-clidinium

chlorhexidine gluconate

chloroquine

chlorothiazide

chlorpromazine

chlorthalidone

chlorzoxazone

Cholbam

cholestyramine, light

choline-magnesium trisalicylate

Chondroitin Sulfate

ciclodan

0

4

0

1

2

1

1

2

1

1

1

1

1

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2

1

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1

1

1

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Drug Tier Notes Drug Tier Notesdeferasirox

Delstrigo

delyla

demeclocycline

Demser

Depo-Provera

Descovy

desipramine

desloratadine

desmopressin

desogestrel-ethinyl estradiol

desonide

desoximetasone

desvenlafaxine er

desvenlafaxine succinate er

dexamethasone

dexchlorpheniramine

dexmethylphenidate, er

dextroamphetamine, er

Diacomit

diazepam

diclofenac epolamine

diclofenac potassium

diclofenac sodium, er

diclofenac-misoprostol

dicloxacillin

dicyclomine

didanosine

Dificid

diflorasone

diflunisal

digoxin

dihydroergotamine

Dilatrate-SR

diltiazem, er

diphenoxylate-atropine

4

2

0

1

4

0

0

1

1

1

0

1

1

1

1

1

1

1

1

2

1

1

1

1

1

1

1

1

2

1

1

1

1

2

1

1



Complera

Copiktra

Cortisone Acetate

Corvita

Cosentyx

Cotellic

covaryx, hs

Creon

Crinone

Crixivan

cromolyn

cryselle-28

Crysvita

cyanocobalamin

cyclafem

cyclobenzaprine, er

cyclopentolate

cyclophosphamide

cycloserine

cyclosporine, modified

cyproheptadine

cyred, eq

Cystadane

Cystagon

Cystaran

dalfampridine er

Daliresp

danazol

dantrolene

dapsone

Daraprim

darifenacin er

dasetta

Daurismo

daysee

deblitane

2

4

2

2

4

4

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2

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Drug Tier Notes Drug Tier Noteseluryng

Emcyt

Emflaza

Emgality

emoquette

Emtriva

enalapril

enalapril-hydrochlorothiazide

Enbrel

Endari

enoxaparin

enpresse-28

enskyce

entacapone

entecavir

Entresto

Envarsus XR

Epidiolex

epinastine

epinephrine

eplerenone

Epogen

Eprosartan

Epzicom

Ergocal

ergocalciferol

ergoloid mesylates

Ergotamine-Caffeine

Erivedge

Erleada

erlotinib

errin

Erythrocin Stearate

erythromycin, base, stearate

Esbriet

escitalopram oxalate

0

4

4

4

0

2

1

1

4

4

4

0

0

1

1

2

2

4

1

1

1

4

2

2

2

1

1

2

4

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4

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1

4

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dipyridamole

disopyramide

disulfiram

divalproex, er

dofetilide

donepezil

Doptelet

dorzolamide

dorzolamide-timolol

dotti

Dovato

doxazosin

doxepin

doxercalciferol

doxycycline

doxylamine-pyridoxine

dronabinol

drospireninone-ethinyl estradiol-levomefol

drospirenone-ethinyl estradiol

Droxia

duloxetine

Dupixent

dutasteride

dutasteride-tamsulosin

dvorah

dxevo 11-day

E.E.S. 400

econazole

econtra ez, one step

Edurant

efavirenz

eletriptan

elinest

Eliquis

ella

Elmiron

1

1

0

1

1

1

4

1

1

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Drug Tier Notes Drug Tier Notesfenofibrate, micronized

fenofibric acid

fenoprofen

fentanyl

Ferriprox

Fiasp

finasteride

flac

flavoxate

flecainide acetate

Flovent Diskus, HFA

fluconazole

flucytosine

fludrocortisone

flunisolide

fluocinolone, body, scalp

fluocinonide, emulsified base

fluoride

fluoridex

fluoritab

fluorometholone

fluorouracil

fluoxetine

fluphenazine

flurandrenolide

Flurazepam

flurbiprofen

flutamide

fluticasone

fluvastatin, er

fluvoxamine, er

folic acid

Folivane-OB

fondaparinux

Forteo

fosamprenavir

1

1

1

1

4

2

1

1

1

1

2

1

1

1

1

1

1

1

1

1

1

1

1

1

1

2

1

1

1

1

1

1

2

4

4

1




esgic

esomeprazole magnesium

estarylla

estazolam

estirified estrogens-methyltestosterone, hs

estradiol

estradiol-norethindrone

estrostep fe

eszopiclone

ethacrynic acid

ethambutol

ethosuximide

ethynodiol-ethinyl estradiol

etodolac, er

etonogestrel-ethinyl estradiol

etoposide

euthyrox

Evenity

everolimus

Evotaz

exemestane

ezetimibe

ezetimibe-simvastatin

falessa

falmina

famciclovir

famotidine

Farydak

Fasenra

fayosim

febuxostat

felbamate

felodipine er

femcap

Femring

femynor

1

1

0

1

1

1

0

0

1

1

1

1

0

1

0

4

1

4

4

2

1

1

1

0

0

1

1

4

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1

1

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Drug Tier Notes Drug Tier Noteshailey 24 fe

halcinonide

halobetasol propionate

haloperidol

heather

Hemlibra

homatropine hbr

Humira

HumuLIN R U-500

Hycamtin

hydralazine

hydrochlorothiazide

hydrocodone-chlorpheniramine er

hydrocodone er

hydrocodone-acetaminophen

hydrocodone-homatropine

hydrocodone-ibuprofen

hydrocortisone

hydrocortisone acetate-pramoxine

hydrocortisone acetate

hydrocortisone butyrate, lipo base

hydrocortisone valerate

hydrocortisone-acetic acid

hydrocortisone-iodoquinol

hydromorphone

hydroquinone

hydroxychloroquine

hydroxyprogesterone caproate

hydroxyurea

hydroxyzine HCl, pamoate

hyoscyamine sulfate, sl, er

ibandronate

Ibrance

ibuprofen

Iclusig

0

1

1

1

0

4

1

4

2

4

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

4

1

4

4







fosinopril

fosinopril-hydrochlorothiazide

frovatriptan succinate

Fulphila

furosemide

Fuzeon

Fycompa

gabapentin

Galafold

galantamine, er

gatifloxacin

Gattex

gemfibrozil

gengraf

gentamicin

Genvoya

gialax

gianvi

Gilenya

Gilotrif

glatiramer

glimepiride

glipizide, er

glipizide-metformin

Glucagon Emergency

glyburide, micronized

glyburide-metformin

glycine

glycopyrrolate

granisetron

Granix

griseofulvin microsize, ultramicrosize

guanfacine, er

Guanidine

Haegarda

hailey

1

1

1

4

1

2

2

1

4

1

1

4

1

1

1

2

0

0

4

4

4

1

1

1

2

1

1

1

1

1

4

1

1

2

4

0









IDHIFA


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Drug Tier Notes Drug Tier Notesisoxsuprine

isradipine

itraconazole

ivermectin

Jadenu Sprinkle

jaimiess

Jakafi

Jantoven

Janumet, XR

Januvia

Jardiance

jasmiel

jencycla

jolessa

juleber

Juluca

junel

junel fe

junel fe 24

Juxtapid

Jynarque

kaitlib fe

Kalbitor

Kaletra

kalliga

Kalydeco

kariva

kelnor

ketoconazole

ketoprofen

Ketoprofen ER

ketorolac

Ketostix

Keveyis

kinrix

1

1

1

1

4

0

4

1

2

2

2

0

0

0

0

2

0

0

0

4

4

0

4

2

0

4

0

0

1

1

2

1

2

4

0








IDHIFA

Ilaris

imatinib

Imbruvica

imipramine HCl, pamoate

imiquimod

Inbrija

incassia

Increlex

Incruse Ellipta

indapamide

indomethacin, er

Ingrezza

Inlyta

Inrebic

Intelence

Intron A

introvale

Invirase

Invokamet, XR

Invokana

Iodine Strong

iodoquimez-hydrocortisone

iodoquinol-hydrocortisone-aloe

ipratropium bromide

ipratropium-albuterol

irbesartan

irbesartan-hydrochlorothiazide

Iressa

Isentress

isibloom

isoniazid

isosorbide dinitrate

isosorbide mononitrate, er

isotretinoin

4

4

4

4

1

1

4

0

4

2

1

1

4

4

4

2

4

0

2

2

2

2

1

1

1

1

1

1

4

2

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1

1

1

1













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Drug Tier Notes Drug Tier NotesLeukeran

levalbuterol

Levemir FlexTouch

levetiracetam, er

levobunolol

levocarnitine

levofloxacin

levonest

levonorgestrel

levonorgestrel-ethinyl estradiol

levora

levo-t

levothyroxine

levoxyl

Lexiva

lidocaine

lidocaine viscous

lidocaine-hydrocortisone ace

lidocaine-prilocaine

liletta

lillow

lindane

linezolid

Linzess

liothyronine

lisinopril

lisinopril-hydrochlorothiazide

Lithium

lithium carbonate, er

Lo Loestrin Fe

lojaimiess

Lokelma

Lonsurf

lopinavir-ritonavir

llorazepam

Lorbrena

2

1

2

1

1

1

1

0

0

0

0

1

1

1

2

1

1

1

1

0

0

1

1

2

1

1

1

2

1

0

0

4

4

1

1

4




kionex

Kisqali

Kisqali Femara

kitabis (tobramycin)

Klarity-A

klor-con

Korlym

K-Phos

Krintafel

k-tab

kurvelo

Kuvan

kyleena

labetalol

lactic acid

lactulose

lamivudine

lamivudine-zidovudine

lamotrigine, er

lansoprazole

lanthanum carbonate

larin

larin 24 fe

larin fe

larissia

latanoprost

Latanoprost-Timolol Maleate

Latuda

layolis fe

Ledipasvir-Sofosbuvir

leena

leflunomide

Lenvima

lessina

letrozole

leucovorin calcium

1

4

4

4

2

1

4

2

2

1

0

4

0

1

1

1

1

1

1

1

1

0

0

0

0

1

2

2

0

4

0

1

4

0

1

1









14 of 23

Drug Tier Notes Drug Tier Notesmemantine, er

meperidine

meprobamate

mercaptopurine

mesalamine, er

Mesnex

Metaproterenol

metaxalone

metformin, er (non-osm, non-mod)

methadone

methamphetamine

methazolamide

methenamine hippurate

methenamine mandelate

methimazole

methocarbamol

methotrexate

methscopolamine bromide

methyldopa

Methyldopa-hydrochlorothiazide

methylergonovine maleate

methylphenidate, er

methylprednisolone

methyltestosterone

metoclopramide

metolazone

Metopirone

metoprolol succinate er

metoprolol tartrate

metoprolol-hydrochlorothiazide

metronidazole

mexiletine

mibelas 24 fe

miconazole-zinc oxide-petrolatum

microgestin

microgestin fe

1

1

1

1

1

4

2

1

1

1

1

1

1

1

1

1

1

1

1

2

1

1

1

1

1

1

2

1

1

1

1

1

0

1

0

0


loryna

losartan

losartan-hydrochlorothiazide

loteprednol

lovastatin

low-ogestrel

loxapine

lo-zumandimine

Lucemyra

ludent

Luliconazole

lutera

Lynparza

Lysodren

lyza

mafenide acetate

Makena

Maprotiline

marlissa

Marplan

Matulane

Mavenclad

Mavyret

Maxidex

Mayzent

Meclofenamate

Medrol

medroxyprogesterone

mefenamic acid

mefloquine

megestrol

Mekinist

Mektovi

melodetta 24 fe

meloxicam

melphalan

0

1

1

1

1

0

1

0

4

1

2

0

4

4

0

1

4

2

0

2

4

4

4

2

4

2

2

0

1

1

1

4

4

0

1

1












15 of 23

Drug Tier Notes Drug Tier Notesnabumetone

nadolol

naftifine

naltrexone

naproxen, er, dr

naratriptan

Narcan

Natacyn

natazia

nateglinide

Natpara

Nature-Throid

necon

nefazodone

neomycin sulfate

neomycin-bacitracin-polymyxin

neomycin-polymyxin-dexamethasone

neomycin-polymyxin-gramicidin

neomycin-polymyxin-hydrocortisone

Nerlynx

nevirapine, er

new day

NexAVAR

Nexletol

nexplanon

niacin, er (antihyperlipidemic)

nicardipine

nicotine

nifedipine, er

nikki

nilutamide

nimodipine

Ninlaro

nisoldipine er

nitisinone

nitrofurantoin

1

1

1

1

1

1

2

2

0

1

4

2

0

1

1

1

1

1

1

4

1

0

4

2

0

1

1

0

1

0

1

1

4

1

4

1






midazolam

midodrine

mifepristone

miglitol

miglustat

mili

minitran

minocycline

minoxidil

Mircera

mirena

mirtazapine

misoprostol

modafinil

moexipril

Molindone

mometasone

mono-linyah

montelukast

morphine sulfate, er

Movantik

moviprep

moxifloxacin

Mozobil

Mucotrol

Mulpleta

multivitamins/fluoride

multivitamins/fluoride/iron

mupirocin

my choice

my way

Myalept

mycophenolate mofetil

mycophenolate

Myleran

myorisan

1

1

1

1

4

0

1

1

1

4

0

1

1

1

1

2

1

0

1

1

4

0

1

4

2

4

1

1

1

0

0

4

1

1

2

1








16 of 23

Drug Tier Notes Drug Tier NotesOcaliva

ocella

octreotide acetate

Odefsey

Odomzo

Ofev

ofloxacin

ogestrel

olanzapine

olanzapine-fluoxetine

olmesartan

olmesartan-amlodipine-hydrochlorothiazide

olmesartan-hydrochlorothiazide

olopatadine

omega-3-acid ethyl esters

omeprazole

omeprazole-bicarbonate

omniflex diaphragm

ondansetron

OneTouch Ultra 2

OneTouch Ultra Blue

OneTouch Ultra Mini

OneTouch Verio

opcicon one-step

opium

Opsumit

option 2

OraMagicRx

Orenitram

Orfadin

Orilissa

Orkambi

orphenadrine citrate er

orphenadrine-aspirin-caffeine

orsythia

oscimin, sr

4

0

4

2

4

4

1

0

1

1

1

1

1

1

1

1

1

0

1

2

2

2

2

0

1

4

0

2

4

4

4

4

1

1

0

1










nitroglycerin

Nityr

Niva-Plus

Nivestym

nizatidine

nolix

nora-be

Norditropin

norethindrone

norethindrone acetate

norethindrone-ethinyl estradiol

norethindrone-ethinyl estradiol-fe

norgestimate-ethinyl estradiol

norlyda

norlyroc

Northera

nortrel

nortriptyline

Nourianz

NovoLIN 70/30

NovoLIN N

NovoLIN R

NovoLOG

NovoLOG Mix 70/30

Noxafil

NP Thyroid

Nplate

Nubeqa

Nucala

Nuedexta

nufol

nulev

Nuplazid

nuvaring

nystatin

nystatin-triamcinolone

1

4

2

4

1

1

0

4

0

1

0

0

0

0

0

4

0

1

4

2

2

2

2

2

4

2

4

4

4

4

1

1

4

0

1

1













17 of 23

Drug Tier Notes Drug Tier Notespentazocine-naloxon

pentoxifylline er

Perforomist

perindopril

periogard

permethrin

perphenazine

Perphenazine-Amitriptyline

phenazopyridine

phenelzine

phenobarbital

phenobarbital-belladonna alk

phenoxybenzamine

phenylbutyrate

phenylephrine

phenytoin

philith

phosphorous

phytonadione

Picato

Pifeltro

pilocarpine

pimecrolimus

Pimozide

pimtrea

pindolol

pioglitazone

pioglitazone-glimepiride

pioglitazone-metformin

Piqray

pirmella

piroxicam

plan b one-step

Plegridy

podofilox

polycin

1

1

2

1

1

1

1

2

1

1

1

1

4

4

1

1

0

1

1

4

2

1

1

2

0

1

1

1

1

4

0

1

0

4

1

1






oseltamivir phosphate

Osmolex ER

Otezla

Otrexup

oxandrolone

oxaprozin

oxazepam

Oxbryta

oxcarbazepine

oxiconazole

oxybutynin, er

oxycodone, er

oxycodone-acetaminophen

oxycodone-aspirin

oxymorphone, er

Ozempic

pacerone

Palforzia

paliperidone er

Palynziq

Panretin

pantoprazole

paragard intrauterine copper

Paregoric

paricalcitol

paroex

paromomycin sulfate

paroxetine, er

paroxetine, mesylate

Paser

peg-3350/electrolytes

Peganone

Pegasys

PegIntron

penicillamine

penicillin v potassium

1

2

4

2

1

1

1

4

1

1

1

1

1

1

1

2

1

4

1

4

4

1

0

2

1

1

1

1

1

2

0

2

4

4

4

1










18 of 23

Drug Tier Notes Drug Tier NotesProcrit

Procysbi

progesterone micronized

Proglycem

Prolia

Promacta

promethazine

promethazine-codeine

promethazine-dextromethorphan

Promethazine-Phenylephrine

promethazine-phenylephrine-codeine

propafenone, er

propranolol, er

Propranolol-hydrochlorothiazide

propylthiouracil

protriptyline

prudoxin

pseudoephdrine-brompheniramine-dextromethorphan

pulmosal

Pulmozyme

pyrazinamide

pyridostigmine bromide, er

Pyrimethamine-Leucovorin

Pyrogallic Acid

quartette

quetiapine, er

QuilliChew ER

Quillivant XR

quinapril

quinapril-hydrochlorothiazide

quinidine gluconate er

quinidine sulfate

quinine sulfate

rabeprazole

raloxifene

ramelteon

4

4

1

2

4

4

1

1

1

2

1

1

1

2

1

1

1

1

1

4

1

1

2

2

0

1

2

2

1

1

1

1

1

1

1

1






poly-iron 150 forte

polymyxin b-trimethoprim

polysaccharide iron forte

polystyrene sulfonate

Pomalyst

portia-28

posaconazole

potassium & sodium citrates-citric acid

potassium bicarbonate

potassium bicarbonate-potassium chloride

potassium chloride, er

potassium citrate, er

potassium citrate-citric acid

Praluent

pramipexole, er

prasugrel

pravastatin

praziquantel

prazosin

prednicarbate

prednisolone

prednisone

prednisone Intensol

pregabalin

premium lidocaine

Pretomanid

preventeza

previfem

Prevymis

Prezcobix

Prezista

Priftin

primaquine phosphate

primidone

probenecid

prochlorperazine

1

1

1

1

4

0

4

1

1

1

1

1

1

4

1

1

1

1

1

1

1

1

2

1

1

2

0

0

2

2

2

2

1

1

1

1





19 of 23

Drug Tier Notes Drug Tier Notesramipril

ranitidine

ranolazine er

rasagiline mesylate

Rasuvo

Ravicti

Rayaldee

react

Rebif

Reblozyl

reclipsen

repaglinide

Repatha

Retacrit

Revlimid

Reyataz

ribavirin

rifabutin

Rifamate

rifampin

Rifater

riluzole

rimantadine

Rinvoq

risedronate

risperidone

ritonavir

rivastigmine

rivelsa

rizatriptan benzoate

ropinirole, er

rosadan

rosuvastatin

Rozlytrek

Rubraca

Ruzurgi

1

1

1

1

2

4

4

0

4

4

0

1

4

4

4

2

1

1

2

1

2

1

1

4

1

1

1

1

0

1

1

1

1

4

4

4












Rybelsus

RyClora

Rydapt

SaliCept

salicylic acid

salsalate

Samsca

Sancuso

Savella

scopolamine

selegiline

selenium sulfide

Selzentry

Serevent Diskus

sertraline

setlakin

sevelamer

sevelamer carbonate

sharobel

Siklos

sildenafil

silodosin

Silver Nitrate

silver sulfadiazine

simliya

simpesse

simvastatin

sirolimus

Sirturo

skyla

Skyrizi

slynd

sodium citrate-citric acid

Sofosbuvir-Velpatasvir

solifenacin succinate

Somavert

2

2

4

2

1

1

4

4

2

1

1

1

2

2

1

0

4

1

0

4

1

1

2

1

0

0

1

1

4

0

4

0

1

4

1

4











20 of 23

Drug Tier Notes Drug Tier NotesSoriatane

sorine

sotalol

spironolactone

spironolactone-hydrochlorothiazide

sprintec 28

Sprycel

sronyx

stavudine

Stivarga

Strensiq

Stribild

Strovite Forte

Sucraid

sucralfate

sulconazole nitrate

sulfacetamide

sulfacetamide-sulfur

sulfacetamide-prednisolone

sulfADIAZINE

sulfamethoxazole-trimethoprim

sulfasalazine

sulindac

sumatriptan

sumatriptan-naproxen

Sutent

syeda

Sylatron

Symdeko

Symfi, Lo

Symlin

Symproic

Symtuza

Synarel

Synjardy, XR

Synribo

4

1

1

1

1

0

4

0

1

4

4

2

2

4

1

1

1

1

1

2

1

1

1

1

1

4

0

4

4

2

2

2

2

4

2

4











Tabloid

tacrolimus

tadalafil

Tafinlar

Tagrisso

take action

Takhzyro

Talzenna

tamoxifen citrate

tamsulosin

Targretin

tarina 24 fe

tarina fe, eq

Tasigna

Tavalisse

taytulla

tazarotene

Tazveril

Tecfidera

Tegsedi

telmisartan

telmisartan-amlodipine

telmisartan-hydrochlorothiazide

temazepam

Temixys

temozolomide

tenofovir disoproxil fumarate

terazosin

terbinafine

terbutaline

terconazole

testosterone (topical)

tetrabenazine

tetracycline

Thalomid

theophylline, er

2

1

1

4

4

0

4

4

1

1

4

0

0

4

4

0

1

4

4

4

1

1

1

1

2

1

1

1

1

1

1

1

4

1

4

1













21 of 23

Drug Tier Notes Drug Tier NotesThiola, EC

thioridazine

thiothixene

thyroid

tiadylt er

tiagabine

Tibsovo

Tiglutik

tilia fe

timolol maleate

Timolol-Brimonidine-Dorzolamide

Timolol-Brimonidine-Dorzolamide-Latanoprost

Timolol-Dorzolamide-Latanoprost

tinidazole

Tivicay

tizanidine

Tobi Podhaler

tobramycin

tobramycin-dexamethasone

TOLBUTamide

tolcapone

Tolmetin

tolterodine, er

topiramate

Topiramate ER

toremifene citrate

torsemide

tramadol, er

tramadol-acetaminophen

trandolapril

trandolapril-verapamil er

tranexamic acid

tranylcypromine sulfate

travoprost

trazodone

Trecator

Trelegy Ellipta

Tremfya

Tresiba

tretinoin

tretinoin microsphere

tri femynor

triamcinolone acetonide

triamterene

triamterene-hydrochlorothiazide

triazolam

Tri-Chlor

trientine

tri-estarylla

trifluoperazine

trifluridine

trihexyphenidyl

Trikafta

tri-legest fe

tri-linyah

tri-lo-estarylla

tri-lo-marzia

tri-lo-mili

tri-lo-sprintec

trilyte

trimethobenzamide

trimethoprim

tri-mili

trimipramine maleate

tri-previfem

tri-sprintec

Triumeq

tri-vitamin/fluoride

trivora

tri-vylibra, lo

Trizivir

tropicamide

4

4

2

1

1

0

1

1

1

1

2

4

0

1

1

1

4

0

0

0

0

0

0

0

1

1

0

1

0

0

2

1

0

0

2

1





4

1

1

1

1

1

4

4

0

1

2

2

2

1

2

1

4

1

1

2

1

2

1

1

2

1

1

1

1

1

1

1

1

1

1

2






22 of 23

Drug Tier Notes Drug Tier Notestrospium, er

Trulicity

trumenba

Truvada

tulana

Turalio

Tybost

tydemy

Tykerb

Tymlos

Tyvaso

Udenyca

umecta

unithroid

Uptravi

urea

ursodiol

valacyclovir

Valchlor

valganciclovir

valproic acid

valsartan

valsartan-hydrochlorothiazide

vancomycin

vanoxide-hc

Vascepa

Vecamyl

velivet

Velphoro

Veltassa

Vemlidy

Venclexta

venlafaxine, er

Ventavis

verapamil, er

Viberzi

Victoza

Videx

vienva

vigabatrin

Vimpat

viorele

Viracept

Viread

vitamin d (ergocalciferol)

Vitrakvi

Vizimpro

volnea

voriconazole

Vosevi

Votrient

Vraylar

Vumerity

vyfemla

vylibra

Vyndamax

Vyndaqel

Vyvanse

warfarin

Westhroid

wide-seal diaphragm

wymzya fe

Xadago

Xalkori

Xarelto

Xeljanz, XR

Xenleta

Xermelo

Xgeva

Xiidra

Xolair

Xospata

2

2

0

1

2

0

2

2

1

4

4

0

1

4

4

2

4

0

0

4

4

2

1

2

0

0

4

4

2

4

4

4

4

2

4

4
















1

2

0

0

0

4

2

0

4

4

4

4

1

1

4

1

1

1

4

1

1

1

1

1

1

2

4

0

4

4

2

4

1

4

1

4















23 of 23

Drug Tier NotesXpovio

Xtandi

xulane

Xultophy

Xuriden

Xyrem

zafirlukast

zaleplon

zarah

Zarxio

Zejula

Zelapar

Zelboraf

Zenpep

Ziagen

zidovudine

Ziextenzo

zileuton ER

ziprasidone

Zolinza

zolmitriptan

zolpidem, er

zonisamide

Zontivity

Zortress

zovia

zumandimine

Zydelig

Zykadia

Zytiga

4

4

0

2

4

4

1

1

0

4

4

4

4

2

2

1

4

4

1

4

1

1

1

2

2

0

0

4

4

4














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Standard Plan Four Tier Drug List€¦ · Tier 3. Higher Co-Pay or Co-Insurance Non-preferred brand...

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Transcript of Standard Plan Four Tier Drug List€¦ · Tier 3. Higher Co-Pay or Co-Insurance Non-preferred brand...