Prescription Drug List - Marin County

Prescription Drug ListFOR LARGE GROUP PLANS AND SMALL GROUP NON-ACA COMPLIANT PLANS
Note: The copayment for specialty medication is plan dependent and is specified in your Copayment Summary. Most specialty medications require a Prior Authorization and may be limited to a 30-day supply.
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Western Health Advantage complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.
Western Health Advantage does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
Western Health Advantage:
Provides free aids and services to people with disabilities to communicate effectively with us, such as: • Qualified sign language interpreters • Written information in other formats (large print, audio, accessible electronic formats, other formats)
Provides free language services to people whose primary language is not English, such as: • Qualified interpreters • Information written in other languages
If you need these services, contact the Member Services Manager.
If you believe that Western Health Advantage has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Member Services Manager, 2349 Gateway Oaks Drive, Suite 100, Sacramento, CA 95833, 888.563.2250 or 916.563.2250, 888.877.5378 (TTY), 916.568.0126 (fax), [email protected]. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Member Services Manager is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at:
Website: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Mail: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 Phone: 800.368.1019 or 800.537.7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
ENGLISH If you, or someone you’re helping, have questions about Western Health Advantage, you have the right to get help and information in your language at no cost. To talk to an interpreter, call 888.563.2250 or TTY 888.877.5378. SPANISH
Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca de Western Health Advantage, tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al 888.563.2250, o al TTY 888.877.5378 si tiene dificultades auditivas.
CHINESE
VIETNAMESE
Nu quý v, hay ngi mà quý v ang giúp , có câu hi v Western Health Advantage, quý v s có quyn c giúp và có thêm thông tin bng ngôn ng ca mình min phí. nói chuyn vi mt thông dch viên, xin gi s 888.563.2250, hoc gi ng dây TTY dành cho ngi khim thính ti s 888.877.5378.
TAGALOG Kung ikaw, o ang iyong tinutulangan, ay may mga katanungan tungkol sa Western Health Advantage, may karapatan ka na makakuha ng tulong at impormasyon sa iyong wika ng walang gastos. Upang makausap ang isang tagasalin, tumawag sa 888.563.2250 o TTY para sa may kapansanan sa pandinig sa 888.877.5378.
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KOREAN
Western Health Advantage . 888.563.2250 TTY 888.877.5378 .
ARMENIAN
Western Health Advantage- , 888.563.2250 TTY 888.877.5378
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888.877.5378 . 888.563.2250 . .
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JAPANESE
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HMONG
Yog koj, los yog tej tus neeg uas koj pab ntawd, muaj lus nug txog Western Health Advantage, koj muaj cai kom lawv muab cov ntshiab lus qhia uas tau muab sau ua koj hom lus pub dawb rau koj. Yog koj xav nrog ib tug neeg txhais lus tham, hu rau 888.563.2250 los sis TTY rau cov neeg uas tsis hnov lus zoo nyob ntawm 888.877.5378.
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1 FINASTERIDE 2 DUTASTERIDE AVODART 3 DUTASTERIDE/TAMSULOSIN HCL JALYN 3 FINASTERIDE PROSCAR
5-HT2C Receptor Antagonist / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes
3 LORCASERIN BELVIQ 5
5-HT3 Receptor Antagonists / ANTIEMETICS Tier Generic Name Brand Name Notes
1 GRANISETRON HCL 1 ONDANSETRON ONDANSETRON ODT 3 DOLASETRON ANZEMET 3 GRANISETRON SANCUSO 3 ONDANSETRON ZOFRAN ODT 4 GRANISETRON EXTENDED-RELEASE INJECTION SUSTOL 4
5-HT3 Receptor Antagonists / GASTROINTESTINAL OTHER Tier Generic Name Brand Name Notes
3 NETUPITANT/PALONOSETRON AKYNZEO 5
ADHD Amphetamines / CNS AGENTS Tier Generic Name Brand Name Notes
1 AMPHET ASP/AMPHET/D-AMPHET DEXTROAMPHETAMINE-AMPHETAMINE 1 AMPHET ASP/AMPHET/D-AMPHET AMPHETAMINE SALT COMBO 1 DEXTROAMPHETAMINE SULFATE 1 METHAMPHETAMINE HCL 3 AMPHET ASP/AMPHET/D-AMPHET ADDERALL 3 AMPHET ASP/AMPHET/D-AMPHET ADDERALL XR 3 DEXTROAMPHETAMINE SULFATE DEXEDRINE
ADHD Non-Amphetamine / CNS AGENTS Tier Generic Name Brand Name Notes
2 ATOMOXETINE HCL STRATTERA 3 CLONIDINE KAPVAY 3 GUANFACINE HCL INTUNIV
AMPA Receptor Antagonist / ANTICONVULSANTS Tier Generic Name Brand Name Notes
2 PERAMPANEL FYCOMPA
2 MILTEFOSINE CAPSULES IMPAVIDO
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3 POTASSIUM PHOSPHATE,MONOBASIC K-PHOS ORIGINAL
Adrenals / ENDOCRINE/DIABETES Tier Generic Name Brand Name Notes
1 CORTISONE ACETATE 1 DEXAMETHASONE 1 FLUDROCORTISONE ACETATE 1 METHYLPREDNISOLONE 1 PREDNISOLONE 1 PREDNISOLONE MILLIPRED 2 PREDNISOLONE SOD PHOSPHATE ORAPRED ODT 3 HYDROCORTISONE CORTEF 3 METHYLPREDNISOLONE MEDROL 3 PREDNISOLONE ACETATE FLO-PRED
Adrenals / GI AGENTS Tier Generic Name Brand Name Notes
1 BUDESONIDE BUDESONIDE EC 3 BUDESONIDE ENTOCORT EC
Adrenals / HORMONE: GLUCOCORTICOIDS/MINERALOCORTICOIDS Tier Generic Name Brand Name Notes
1 BETAMETHASONE DIPROPIONATE 1 BETAMETHASONE VALERATE BETA-VAL 1 BETAMETHASONE VALERATE 1 CLOTRIMAZOLE/BETAMETHASONE DIP CLOTRIMAZOLE-BETAMETHASONE 1 DEXAMETHASONE 1 HYDROCORTISONE VALERATE 1 PREDNISONE 2 DEXAMETHASONE DEXAMETHASONE INTENSOL 3 BENZOYL PEROXIDE/HYDROCORTISON VANOXIDE-HC 3 BETAMETHASONE VALERATE LUXIQ 3 CALCIPOTRIENE/BETAMETHASONE TACLONEX 3 DEXAMETHASONE MAXIDEX 3 HYDROCORTISONE BUTYRATE LOCOID 3 HYDROCORTISONE BUTYRATE/EMOLL LOCOID LIPOCREAM 3 HYDROCORTISONE/PRAMOXINE PRAMOSONE 3 HYDROCORTISONE/PRAMOXINE EPIFOAM 3 HYDROCORTISONE/PRAMOXINE/ALOE NOVACORT
Adrenocortical Insufficiency / ENDOCRINE/DIABETES Tier Generic Name Brand Name Notes
4 CORTICOTROPIN H.P. ACTHAR 5
Alcohol Deterrents / ANTI-ADDICTION/SUBSTANCE ABUSE Tier Generic Name Brand Name Notes
1 DISULFIRAM 3 ACAMPROSATE CALCIUM CAMPRAL 3 DISULFIRAM ANTABUSE
5 - Prior Authorization
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4 NALTREXONE HCL VIVITROL 5
Alkalinizing Agents / UROLOGICALS Tier Generic Name Brand Name Notes
1 CITRIC ACID/SODIUM CITRATE SODIUM CITRATE & CITRIC ACID 1 CITRIC ACID/SODIUM CITRATE CYTRA-2 1 POTASSIUM CITRATE 1 POTASSIUM CITRATE/CITRIC ACID CYTRA-K 1 POTASSIUM CITRATE/CITRIC ACID POTASSIUM CITRATE-CITRIC ACID 3 POTASSIUM CITRATE UROCIT-K
Alkylating Agent / ANTINEOPLASTICS Tier Generic Name Brand Name Notes
1 BUSULFAN 1 CARMUSTINE 1 CHLORAMBUCIL 1 CYCLOPHOSPHAMIDE 1 MECHLORETHAMINE 1 MELPHALAN 1 PROCARBAZINE 1 THIOTEPA 2 LOMUSTINE CEENU 3 MECHLORETHAMINE VALCHLOR 5 4 BENDAMUSTINE TREANDA 4 4 CISPLATIN 4
Allergen / IMMUNOLOGICAL AGENTS Tier Generic Name Brand Name Notes
3 GRASS POLLEN GRASTEK 3 GRASS POLLEN ORALAIR 3 RAGWEEK POLLEN RAGWITEK
Allylamines / ANTIFUNGALS Tier Generic Name Brand Name Notes
1 TERBINAFINE HCL 3 TERBINAFINE HCL LAMISIL
Alpha- And Beta-Adrenergic Agonists / CARDIOVASCULAR Tier Generic Name Brand Name Notes
3 DROXIDOPA NORTHERA 5
Alpha- And Beta-Adrenergic Agonists / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes
3 EPINEPHRINE TWINJECT
1 CLONIDINE
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Alpha-Adrenergic Agonists / CARDIOVASCULAR (cont.) Tier Generic Name Brand Name Notes
1 DIHYDROERGOTAMINE MESYLATE 2 EPINEPHRINE EPIPEN 2 EPINEPHRINE EPIPEN 2-PAK 2 EPINEPHRINE EPIPEN JR 2 EPINEPHRINE EPIPEN JR 2-PAK 3 CLONIDINE HCL KAPVAY 3 CLONIDINE HCL NEXICLON XR
Alpha-Adrenergic Agonists / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name Notes
3 BRIMONIDINE TOPICAL MIRVASO 3 OXYMETAZOLINE HCL 1% CREAM RHOFADE 5
Alpha-Adrenergic Agonists (Eent) / OPHTHALMOLOGY Tier Generic Name Brand Name Notes
1 BRIMONIDINE TARTRATE 2 BRIMONIDINE TARTRATE ALPHAGAN P 3 BRIMONIDINE TARTRATE/TIMOLOL COMBIGAN
Alpha-Adrenergic Blocking Agents / ANTIMIGRAINE Tier Generic Name Brand Name Notes
1 ERGOTAMINE TARTRATE/CAFFEINE MIGERGOT 3 DIHYDROERGOTAMINE MESYLATE MIGRANAL
Alpha-Adrenergic Blocking Agents / CARDIOVASCULAR Tier Generic Name Brand Name Notes
1 ALFUZOSIN HCL 1 DOXAZOSIN MESYLATE 1 PRAZOSIN HCL 1 TAMSULOSIN HCL 1 TERAZOSIN HCL 2 DOXAZOSIN MESYLATE CARDURA XL 3 ALFUZOSIN HCL UROXATRAL 3 PRAZOSIN HCL MINIPRESS 3 SILODOSIN RAPAFLO 3 TAMSULOSIN HCL FLOMAX
Alpha-Glucosidase Inhibitors / BLOOD GLUCOSE REGULATORS Tier Generic Name Brand Name Notes
1 ACARBOSE 3 MIGLITOL GLYSET
Amebicides / ANTI - INFECTIVES Tier Generic Name Brand Name Notes
1 PAROMOMYCIN SULFATE 1 TINIDAZOLE
Aminoglycosides / ANTIBACTERIALS Tier Generic Name Brand Name Notes
1 NEOMYCIN SULFATE
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Aminoglycosides / ANTIBACTERIALS (cont.) Tier Generic Name Brand Name Notes
3 TOBRAMYCIN IN 0.225% NACL TOBI 5 4 AMIKACIN 4 4 GENTAMICIN 4 4 KANAMYCIN 4 4 NETILMICIN NETROMYCIN 4 4 TOBRAMYCIN 4
Aminoglycosides / ANTIMYCOBACTERIALS - OTHER Tier Generic Name Brand Name Notes
4 CAPREOMYCIN CAPASTAT 4
Aminosalicylates / INFLAMMATORY BOWEL AGENTS Tier Generic Name Brand Name Notes
2 MESALAMINE ASACOL HD 2 MESALAMINE ASACOL 2 MESALAMINE PENTASA 3 MESALAMINE W/CLEANSING WIPES ROWASA
Ammonia Detoxicants / GI AGENTS Tier Generic Name Brand Name Notes
1 LACTULOSE 1 LACTULOSE ENULOSE 1 LACTULOSE GENERLAC 2 LACTULOSE KRISTALOSE
Amphetamines / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes
3 LISDEXAMFETAMINE DIMESYLATE VYVANSE
Amylinomimetics / BLOOD GLUCOSE REGULATORS Tier Generic Name Brand Name Notes
4 PRAMLINTIDE ACETATE SYMLINPEN 120 5 4 PRAMLINTIDE ACETATE SYMLINPEN 60 5
Analgesics And Antipyretics- Misc. / ANTIMIGRAINE Tier Generic Name Brand Name Notes
1 ISOMETHEPT/ACETAMINOP/DICHLPHN EPIDRIN 1 ISOMETHEPT/ACETAMINOP/DICHLPHN ISOMETHEPT-DICHLORALP-ACETAMIN
Analgesics And Antipyretics- Misc. / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes
1 BUTALB/ACETAMINOPHEN/CAFFEINE ZEBUTAL 1 BUTALB/ACETAMINOPHEN/CAFFEINE BUTALBITAL-ACETAMINOPHEN-CAFFE 3 BUTALB/ACETAMINOPHEN/CAFFEINE FIORICET 3 BUTALBITAL/ACETAMINOPHEN PHRENILIN FORTE
4 - Office/Clinic Administration 5 - Prior Authorization
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1 DANAZOL
2 TESTOSTERONE ANDROGEL 3 TESTOSTERONE 3 TESTOSTERONE ANDRODERM 3 TESTOSTERONE NASAL GEL NATESTO 4 TESTOSTERONE CYPIONATE DEPO-TESTOSTERONE 5
Angiotensin Ii Receptor Antagonists / CARDIOVASCULAR Tier Generic Name Brand Name Notes
1 CANDESARTAN 7 1 CANDESARTAN/HYDROCHLOROTHIAZID CANDESARTAN-HYDROCHLOROTHIAZID 7 1 IRBESARTAN 1 IRBESARTAN/HYDROCHLOROTHIAZIDE IRBESARTAN-HYDROCHLOROTHIAZIDE 1 LOSARTAN POTASSIUM 1 LOSARTAN/HYDROCHLOROTHIAZIDE LOSARTAN-HYDROCHLOROTHIAZIDE 1 TELMISARTAN/AMLODIPINE 7 1 VALSARTAN 1 VALSARTAN/HYDROCHLOROTHIAZIDE VALSARTAN-HYDROCHLOROTHIAZIDE 2 CANDESARTAN CILEXETIL ATACAND 7 2 CANDESARTAN/HYDROCHLOROTHIAZID ATACAND HCT 7 2 OLMESARTAN MEDOXOMIL BENICAR 7 2 OLMESARTAN/HYDROCHLOROTHIAZIDE BENICAR HCT 7 2 TELMISARTAN MICARDIS 7 2 TELMISARTAN/HYDROCHLOROTHIAZID MICARDIS HCT 7 3 AZILSARTAN MED/CHLORTHALIDONE EDARBYCLOR 7 3 AZILSARTAN MEDOXOMIL EDARBI 7 3 IRBESARTAN AVAPRO 3 IRBESARTAN/HYDROCHLOROTHIAZIDE AVALIDE 3 LOSARTAN POTASSIUM COZAAR 3 OLMESARTAN MED/AMLODIPINE/HCTZ TRIBENZOR 7 3 TELMISARTAN/AMLODIPINE TWYNSTA 7 3 VALSARTAN DIOVAN 3 VALSARTAN/HYDROCHLOROTHIAZIDE DIOVAN HCTZ
Angiotensin-Converting Enzyme Inhibitors / CARDIOVASCULAR Tier Generic Name Brand Name Notes
1 BENAZEPRIL HCL 1 BENAZEPRIL/HYDROCHLOROTHIAZIDE BENAZEPRIL-HYDROCHLOROTHIAZIDE 1 CAPTOPRIL 1 CAPTOPRIL/HYDROCHLOROTHIAZIDE CAPTOPRIL-HYDROCHLOROTHIAZIDE 1 ENALAPRIL MALEATE 1 ENALAPRIL/HYDROCHLOROTHIAZIDE ENALAPRIL-HYDROCHLOROTHIAZIDE 1 FOSINOPRIL SODIUM 1 FOSINOPRIL/HYDROCHLOROTHIAZIDE FOSINOPRIL-HYDROCHLOROTHIAZIDE 1 LISINOPRIL 1 LISINOPRIL/HYDROCHLOROTHIAZIDE LISINOPRIL-HYDROCHLOROTHIAZIDE
5 - Prior Authorization 7 - Step Therapy
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Angiotensin-Converting Enzyme Inhibitors / CARDIOVASCULAR (cont.) Tier Generic Name Brand Name Notes
1 PERINDOPRIL ERBUMINE 1 QUINAPRIL HCL 1 RAMIPRIL 3 ENALAPRIL MALEATE VASOTEC 3 LISINOPRIL ZESTRIL 3 QUINAPRIL HCL ACCUPRIL 3 QUINAPRIL/HYDROCHLOROTHIAZIDE ACCURETIC 3 RAMIPRIL ALTACE 3 TRANDOLAPRIL/VERAPAMIL HCL TARKA
Anorex.-Respir.-Cerebral Stimulants-Misc / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes
1 METHYLPHENIDATE HCL METHYLPHENIDATE ER 1 METHYLPHENIDATE HCL METADATE ER 1 METHYLPHENIDATE HCL 1 METHYLPHENIDATE HCL METHYLPHENIDATE SR 1 MODAFINIL 2 METHYLPHENIDATE HCL RITALIN CAPSULE 10, 60 MG 3 ARMODAFINIL NUVIGIL 3 DEXMETHYLPHENIDATE HCL FOCALIN XR 3 DEXMETHYLPHENIDATE HCL FOCALIN 3 METHYLPHENIDATE DAYTRANA 3 METHYLPHENIDATE HCL CONCERTA 3 METHYLPHENIDATE HCL METHYLIN ER 3 METHYLPHENIDATE HCL METADATE CD 3 METHYLPHENIDATE HCL RITALIN 3 METHYLPHENIDATE HCL RITALIN LA CAPSULES 20, 30, 40 MG 3 METHYLPHENIDATE HCL METHYLIN 3 MODAFINIL PROVIGIL
Anthelmintics / ANTIPARASITICS Tier Generic Name Brand Name Notes
1 MEBENDAZOLE 2 IVERMECTIN STROMECTOL 3 ALBENDAZOLE ALBENZA 3 PRAZIQUANTEL BILTRICIDE
Anti HIV Other / ANTIVIRALS Tier Generic Name Brand Name Notes
2 COBICISTAT TYBOST 2 ELVITEGRAVIR/COBIC/EMT/TENOFOVIR STRIBILD
Anti-Cytomegalovirus / ANTIVIRALS Tier Generic Name Brand Name Notes
3 GANCICLOVIR ZIRGAN 3 VALGANCICLOVIR VALCYTE 4 CIDOFOVIR 4
Anti-HIV Other / ANTIVIRALS Tier Generic Name Brand Name Notes
2 DOLUTEGRAVIR TIVICAY
4 - Office/Clinic Administration
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Anti-HIV Other / ANTIVIRALS (cont.) Tier Generic Name Brand Name Notes
2 ELVITEGRAVIR/COBICISTAT/EMTRICITABINE/TEN OFOVIR ALAFENAMIDE
GENVOYA
2 RALTEGRAVIR POTASSIUM ISENTRESS 2 RITONAVIR NORVIR 4 ENFUVIRTIDE FUZEON 5
Anti-Inflammatory Agents (Gi Drugs) / GI AGENTS Tier Generic Name Brand Name Notes
1 BALSALAZIDE DISODIUM 1 MESALAMINE 2 MESALAMINE CANASA 2 MESALAMINE LIALDA 3 MESALAMINE APRISO
Anti-Inflammatory Agents (Skin & Mucous) / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name Notes
1 ALCLOMETASONE DIPROPIONATE 1 CLOBETASOL PROPIONATE CORMAX 1 CLOBETASOL PROPIONATE 1 CLOBETASOL PROPIONATE/EMOLL CLOBETASOL EMOLLIENT 1 DESONIDE 1 DESOXIMETASONE 1 FLUOCINOLONE ACETONIDE 1 FLUOCINONIDE/EMOLLIENT FLUOCINONIDE EMOLLIENT 1 FLUOCINONIDE/EMOLLIENT FLUOCINONIDE-E 1 HALOBETASOL PROPIONATE CREAM AND
OINTMENT HALOBETASOL PROPIONATE
1 MOMETASONE FUROATE 1 PREDNICARBATE 1 TRIAMCINOLONE ACETONIDE 2 DESONIDE DESONATE 2 DESONIDE VERDESO 2 FLURANDRENOLIDE CORDRAN 2 FLUTICASONE PROPIONATE CUTIVATE 3 CLOBETASOL PROPIONATE OLUX 3 CLOBETASOL PROPIONATE CLOBEX 3 CLOBETASOL PROPIONATE/EMOLL OLUX-E 3 CLOCORTOLONE PIVALATE CLODERM 3 DESOXIMETASONE TOPICORT 3 FLUOCINOLONE ACETONIDE CAPEX SHAMPOO 3 FLUOCINOLONE ACETONIDE DERMA-SMOOTHE-FS 3 FLUOCINONIDE VANOS 3 FLURANDRENOLIDE CORDRAN SP 3 HALCINONIDE HALOG 3 HALOBETASOL PROPIONATE CREAM AND
OINTMENT ULTRAVATE
3 HALOBETASOL PROPIONATE LOTION ULTRAVATE 5 3 MOMETASONE FUROATE ELOCON 3 TRIAMCINOLONE ACETONIDE KENALOG
Anti-Inflammatory Agents (Skin & Mucous) / GI AGENTS Tier Generic Name Brand Name Notes
1 HYDROCORTISONE COLOCORT
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Anti-Inflammatory Agents (Skin & Mucous) / GI AGENTS (cont.) Tier Generic Name Brand Name Notes
1 HYDROCORTISONE 1 HYDROCORTISONE PROCTOZONE-HC 1 HYDROCORTISONE PROCTOSOL-HC 1 HYDROCORTISONE PROCTOCORT 1 HYDROCORTISONE ACETATE 1 HYDROCORTISONE ACETATE HEMRIL 1 HYDROCORTISONE ACETATE SUPPOSITORIES ANUCORT-HC 5 1 HYDROCORTISONE/PRAMOXINE HYDROCORTISONE-PRAMOXINE 2 HYDROCORTISONE ACETATE CORTIFOAM 2 HYDROCORTISONE/PRAMOXINE PROCTOFOAM-HC 3 HYDROCORTISONE ACETATE SUPPOSITORIES ANUSOL-HC 5 3 HYDROCORTISONE/PRAMOXINE ANALPRAM HC
Anti-Influenza / ANTIVIRALS Tier Generic Name Brand Name Notes
1 AMANTADINE HCL AMANTADINE 2 OSELTAMIVIR PHOSPHATE TAMIFLU 6 3 ZANAMIVIR RELENZA 4 INFLUENZA VACCINE FLUZONE 4
Antiallergic Agents / NASAL STEROID Tier Generic Name Brand Name Notes
1 OLOPATADINE HCL OLOPATADINE NASAL 3 OLOPATADINE HCL PATANASE
Antiallergic Agents / OPHTHALMOLOGY Tier Generic Name Brand Name Notes
1 AZELASTINE HCL 1 EPINASTINE HCL 2 LODOXAMIDE TROMETHAMINE ALOMIDE 3 ALCAFTADINE LASTACAFT 3 AZELASTINE HCL OPTIVAR 3 BEPOTASTINE BESILATE BEPREVE 3 EPINASTINE HCL ELESTAT 3 OLOPATADINE HCL PATADAY 3 OLOPATADINE HCL PATANOL 3 PEMIROLAST POTASSIUM ALAMAST
Antiallergic Agents / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes
1 AZELASTINE 1 AZELASTINE HCL 3 AZELASTINE HCL ASTELIN 3 AZELASTINE HCL ASTEPRO 3 AZELASTINE/FLUTICASONE DYMISTA
Antiandrogen / ANTINEOPLASTICS Tier Generic Name Brand Name Notes
3 ENZALUTAMIDE XTANDI 5
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Antiangiogenic Agent / ANTINEOPLASTICS Tier Generic Name Brand Name Notes
3 PAZOPANIB VOTRIENT 5 3 SORAFENIB NEXAVAR 5 3 SUNITINIB MALATE SUTENT 4 BEVACIZUMAB AVASTIN 4
Antiarrhythmics / CARDIOVASCULAR Tier Generic Name Brand Name Notes
1 AMIODARONE HCL 1 DIGOXIN 1 FLECAINIDE ACETATE 1 MEXILETINE HCL 1 PROPAFENONE HCL 1 QUINIDINE GLUCONATE 1 QUINIDINE SULFATE 2 AMIODARONE HCL PACERONE 2 DISOPYRAMIDE PHOSPHATE NORPACE CR 3 DIGOXIN LANOXIN 3 DOFETILIDE TIKOSYN 3 DRONEDARONE HCL MULTAQ 3 PROPAFENONE HCL RYTHMOL SR 4 ADENOSINE ADENOCARD 4
Antibacterials (Eent) / ANTIBACTERIALS Tier Generic Name Brand Name Notes
1 NEOMYCIN/POLYMYXIN B SULF/HC NEOMYCIN-POLYMYXIN-HC 1 NEOMYCIN/POLYMYXIN B SULF/HC NEOMYCIN-POLYMYXIN-HYDROCORT 3 CIPROFLOXACIN HCL/DEXAMETH CIPRODEX 3 CIPROFLOXACIN/FLUOCINOLONE ACETONIDE OTOVEL 3 CIPROFLOXACIN/HYDROCORTISONE CIPRO HC 3 NEOMY SULF/COLIST SUL/HC/THONZ COLY-MYCIN S 3 NEOMY SULF/COLIST SUL/HC/THONZ CORTISPORIN-TC
Antibacterials (Eent) / DENTAL AGENT Tier Generic Name Brand Name Notes
3 MINOCYCLINE HCL MICROSPHERES ARESTIN 4
Antibacterials (Eent) / OPHTHALMOLOGY Tier Generic Name Brand Name Notes
1 BACITRACIN 1 BACITRACIN/POLYMYXIN B SULFATE AK-POLY-BAC 1 CIPROFLOXACIN HCL 1 GENTAMICIN SULFATE 1 GENTAMICIN SULFATE GENTAK 1 LEVOFLOXACIN 1 NEO/POLYMYX B SULF/DEXAMETH NEOMYCIN-POLYMYXIN-DEXAMETH 1 NEOMY SULF/BACITRA/POLYMYXIN B NEO-POLYCIN 1 NEOMY SULF/BACITRA/POLYMYXIN B NEOMYCIN-BACITRACIN-POLYMYXIN 1 NEOMY SULF/BACITRAC ZN/POLY/HC NEO-POLYCIN HC
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Antibacterials (Eent) / OPHTHALMOLOGY (cont.) Tier Generic Name Brand Name Notes
1 NEOMY SULF/BACITRAC ZN/POLY/HC NEOMYCIN-BACITRACIN-POLY-HC 1 NEOMYCIN/POLYMYXN B/GRAMICIDIN NEOMYCIN-POLYMYXIN-GRAMICIDIN 1 OFLOXACIN 1 POLYMYXIN B SULF/TRIMETHOPRIM POLYMYXIN B SUL-TRIMETHOPRIM 1 SULFACETAMIDE SODIUM SULFAMIDE 1 SULFACETAMIDE SODIUM 1 SULFACETAMIDE/PREDNISOLONE SP SULFACETAMIDE-PREDNISOLONE 1 TOBRAMYCIN 1 TOBRAMYCIN/DEXAMETHASONE TOBRAMYCIN-DEXAMETHASONE 2 SULFACETAMIDE SODIUM BLEPH-10 2 TOBRAMYCIN TOBREX 2 TOBRAMYCIN/DEXAMETHASONE TOBRADEX ST 2 TOBRAMYCIN/DEXAMETHASONE TOBRADEX OPTHALMIC OINTMENT 3 AZITHROMYCIN AZASITE 3 BESIFLOXACIN HCL BESIVANCE 3 CIPROFLOXACIN HCL CILOXAN 3 GATIFLOXACIN ZYMAXID 3 GATIFLOXACIN ZYMAR 3 MOXIFLOXACIN HCL VIGAMOX 3 MOXIFLOXACIN HCL MOXEZA 3 NEO/POLYMYX B SULF/DEXAMETH MAXITROL 3 POLYMYXIN B SULF/TRIMETHOPRIM POLYTRIM 3 SULFACETM NA/PREDNISOL AC BLEPHAMIDE S.O.P. 3 SULFACETM NA/PREDNISOL AC BLEPHAMIDE 3 TOBRAMYCIN/DEXAMETHASONE TOBRADEX 3 TOBRAMYCIN/LOTEPRED ETAB ZYLET
Antibacterials (Eent) / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes
2 MUPIROCIN CALCIUM BACTROBAN NASAL
Antibacterials (Skin & Mucous Membrane) / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name Notes
1 CLINDAMYCIN PHOS/BENZOYL PEROX CLINDAMYCIN PHOS-BENZOYL PEROX 1 CLINDAMYCIN PHOS/BENZOYL PEROX CLINDAMYCIN-BENZOYL PEROXIDE 1 CLINDAMYCIN PHOSPHATE 1 ERYTHROMYCIN BASE/ETHANOL ERY 1 ERYTHROMYCIN/BENZOYL PEROXIDE ERYTHROMYCIN-BENZOYL PEROXIDE 1 MUPIROCIN 2 CLINDAMYCIN PHOS/BENZOYL PEROX ACANYA 2 ERYTHROMYCIN/BENZOYL PEROXIDE BENZAMYCINPAK 2 METRONIDAZOLE METROGEL 2 METRONIDAZOLE NORITATE 3 CLINDAMYCIN PHOS/BENZOYL PEROX DUAC 3 CLINDAMYCIN PHOS/BENZOYL PEROX BENZACLIN 3 CLINDAMYCIN PHOSPHATE CLINDAGEL 3 CLINDAMYCIN/TRETINOIN ZIANA 5 3 CLINDAMYCIN/TRETINOIN VELTIN 5 3 ERYTHROMYCIN BASE AKNE-MYCIN 3 METRONIDAZOLE METROLOTION 3 MUPIROCIN BACTROBAN 3 RETAPAMULIN ALTABAX
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Antibacterials (Skin & Mucous Membrane) / OBSTETRICS & GYNECOLOGY Tier Generic Name Brand Name Notes
1 CLINDAMYCIN PHOSPHATE 1 METRONIDAZOLE VANDAZOLE 2 CLINDAMYCIN PHOSPHATE CLEOCIN 3 METRONIDAZOLE METROGEL-VAGINAL
Antibacterials- Miscellaneous / ANTI - INFECTIVES Tier Generic Name Brand Name Notes
1 CLINDAMYCIN HCL 1 CLINDAMYCIN PALMITATE HCL 1 CLINDAMYCIN PALMITATE HCL CLEOCIN PALMITATE 1 VANCOMYCIN HCL 3 CLINDAMYCIN HCL CLEOCIN HCL 3 LINEZOLID ZYVOX 5 3 RIFAXIMIN XIFAXAN 5 3 VANCOMYCIN HCL VANCOCIN HCL
Antibacterials- Miscellaneous / GI AGENTS Tier Generic Name Brand Name Notes
3 BISMUTH SAL/METRONID/TETRACYC HELIDAC 3 BISMUTH/METRONID/TETRACYCLINE PYLERA
Antibacterials- Miscellaneous / OFFICE ADMINISTERED Tier Generic Name Brand Name Notes
4 BEZLOTOXUMAB INJECTION ZINPLAVA 4
Anticholinergics / ANTIPARKINSON AGENTS Tier Generic Name Brand Name Notes
1 BENZTROPINE MESYLATE 1 TRIHEXYPHENIDYL HCL 3 TRIHEXYPHENIDYL HCL ARTANE
Anticoagulants / BLOOD PRODUCT/MODIFIERS Tier Generic Name Brand Name Notes
1 WARFARIN SODIUM 2 DABIGATRAN ETEXILATE MESYLATE PRADAXA 3 WARFARIN SODIUM COUMADIN 4 DALTEPARIN SODIUM,PORCINE FRAGMIN 5 4 DARBEPOETIN ALFA ARANESP 5 4 ENOXAPARIN SODIUM LOVENOX 5 4 ENOXAPARIN SODIUM 5 4 FONDAPARINUX SODIUM 5
Anticonvulsants- Miscellaneous / ANTICONVULSANTS Tier Generic Name Brand Name Notes
1 FELBAMATE
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Anticonvulsants- Miscellaneous / ANTICONVULSANTS (cont.) Tier Generic Name Brand Name Notes
1 LEVETIRACETAM 2 TIAGABINE HCL GABITRIL 3 BRIVARACETAM ORAL SOLUTION BRIVIACT 3 BRIVARACETAM TABLETS BRIVIACT 4 BRIVARACETAM FOR INJECTION BRIVIACT 4
Anticonvulsants- Other / ANTICONVULSANTS Tier Generic Name Brand Name Notes
1 CARBAMAZEPINE EPITOL 2 EZOGABINE POTIGA 2 METHSUXIMIDE CELONTIN 3 CARBAMAZEPINE EQUETRO 3 LACOSAMIDE VIMPAT
Antidepressants / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes
1 DESVENLAFAXINE SUCCINATE 1 MIRTAZAPINE 1 NEFAZODONE HCL 1 OLANZAPINE/FLUOXETINE HCL OLANZAPINE-FLUOXETINE HCL 3 DESVENLAFAXINE SUCCINATE PRISTIQ ER 3 DOXEPIN HCL SILENOR 3 MIRTAZAPINE REMERON 3 OLANZAPINE/FLUOXETINE HCL SYMBYAX 3 VILAZODONE HYDROCHLORIDE VIIBRYD
Antidiarrhea Agents / GI AGENTS Tier Generic Name Brand Name Notes
1 DIPHENOXYLATE HCL/ATROPINE DIPHENOXYLATE-ATROPINE 1 LOPERAMIDE HCL LOPERAMIDE 3 CROFELEMER FULYZAQ 5 3 DIPHENOXYLATE HCL/ATROPINE LOMOTIL 3 OPIUM TINCTURE OPIUM
Antidotes / IMMUNOLOGICAL AGENTS Tier Generic Name Brand Name Notes
2 LEUCOVORIN CALCIUM
Antiemetics- Miscellaneous / GI AGENTS Tier Generic Name Brand Name Notes
3 SCOPOLAMINE TRANSDERM-SCOP 3 SCOPOLAMINE HYDROBROMIDE SCOPACE
Antiemetics- Miscellaneous / OBSTETRICS & GYNECOLOGY Tier Generic Name Brand Name Notes
3 DOXYLAMINE/PYRIDOXINE DICLEGIS
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1 TAMOXIFEN CITRATE
1 FLUCYTOSINE 1 GRISEOFULVIN ULTRAMICROSIZE 1 GRISEOFULVIN,MICROSIZE GRISEOFULVIN 1 NYSTATIN 3 GRISEOFULVIN ULTRAMICROSIZE GRIS-PEG 3 GRISEOFULVIN,MICROSIZE GRIFULVIN V
Antifungals (Eent) / OPHTHALMOLOGY Tier Generic Name Brand Name Notes
3 NATAMYCIN NATACYN
Antifungals (Skin & Mucous Membrane) / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name Notes
1 CICLOPIROX 1 CLOTRIMAZOLE 1 ECONAZOLE NITRATE 1 KETOCONAZOLE KETODAN 1 NYSTATIN NYSTOP 1 NYSTATIN NYAMYC 1 NYSTATIN/TRIAMCIN NYSTATIN-TRIAMCINOLONE 2 SULCONAZOLE NITRATE EXELDERM 3 CICLOPIROX/NAIL LACQ/FT DEOD#4 PEDIPIROX-4 3 KETOCONAZOLE NIZORAL 3 KETOCONAZOLE XOLEGEL 3 MICONAZOLE NITRATE/ZINC OX/PET VUSION 3 NAFTIFINE HCL NAFTIN 3 OXICONAZOLE NITRATE OXISTAT 3 SERTACONAZOLE NITRATE ERTACZO
Antifungals (Skin & Mucous Membrane) / OBSTETRICS & GYNECOLOGY Tier Generic Name Brand Name Notes
1 TERCONAZOLE
3 COAGULATION FACTOR IX RECOMBINANT FOR INJ
IDELVION 4
4 ANTIHEMOPHILIC FACTOR ELOCTATE 4 4 ANTIHEMOPHILIC FACTOR RECOMBINANT NUWIQ 4 4 ANTIHEMOPHYLIC FACTOR VIII, RECOMBINANT AFSTYLA 4 4 ANTIHEMOPHYLIC FACTOR [RECOMBINANT]
PEGYLATED INJECTION ADYNOVATE 4
4 COAGULATION FACTOR IX, RECOMBINANT IXINITY 4 4 COAGULATION FACTOR VIII, RECOMBINANT KOVALTRY 4 4 COAGULATION FACTOR X [HUMAN] FOR
INJECTION COAGADEX 4
4 - Office/Clinic Administration
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Antihemophilic / OFFICE ADMINISTERED (cont.) Tier Generic Name Brand Name Notes
4 VON WILLEBRAND FACTOR RECOMBINANT FOR INJ
VONVENDI 4
1 RIBAVIRIN RIBASPHERE 5 1 RIBAVIRIN RIBAPAK 5 1 RIBAVIRIN 5 2 LEDIPASVIR/SOFOSBUVIR HARVONI 5 2 SOFOSBUVIR/VELPATASVIR EPCLUSA 5 2 SOFOSBUVIR/VELPATASVIR/VOXILAPREVIR VOSEVI 5 3 BOCEPREVIR VICTRELIS 5 3 GLECAPREVIR/PIBRENTASVIR MAVYRET 5 3 GRAZOPREVIR/ELBASVIR ZEPATIER 5 3 PARITAPREVIR;/RITON/OMBITAS/DASA VIEKIRA PAK 5 3 RIBAVIRIN REBETOL 5 3 RIBAVIRIN COPEGUS 5 3 SIMEPREVIR OLYSIO 5 3 SOFOSBUVIR SOLVALDI 5 3 TELAPREVIR INCIVEK 5 4 DACLATASVIR DAKLINZA 5 4 OMBITASVIR/PARITAPREVIR/RITONAVIR TECHNIVIE 5 4 PEGINTERFERON ALFA-2A PEGASYS PROCLICK 5 4 PEGINTERFERON ALFA-2A PEGASYS 5 4 PEGINTERFERON ALFA-2B PEGINTRON REDIPEN 5
Antiherpetic / ANTIVIRALS Tier Generic Name Brand Name Notes
1 ACYCLOVIR 6 1 VALACYCLOVIR HCL VALACYCLOVIR 6 3 ACYCLOVIR ZOVIRAX 6 3 ACYCLOVIR SITAVIG 3 VALACYCLOVIR HCL VALTREX 6
Antihistamines (Gi Drugs) / GI AGENTS Tier Generic Name Brand Name Notes
1 MECLIZINE HCL 1 PROCHLORPERAZINE MALEATE COMPRO 1 PROCHLORPERAZINE MALEATE 1 TRIMETHOBENZAMIDE HCL 3 MECLIZINE HCL ANTIVERT
Antimalarial Agents / ANTI - INFECTIVES Tier Generic Name Brand Name Notes
1 CHLOROQUINE PHOSPHATE 1 HYDROXYCHLOROQUINE SULFATE
4 - Office/Clinic Administration 5 - Prior Authorization 6 - Quantity Limit
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Antimalarial Agents / ANTI - INFECTIVES (cont.) Tier Generic Name Brand Name Notes
1 MEFLOQUINE HCL 2 PRIMAQUINE PHOSPHATE PRIMAQUINE 2 PYRIMETHAMINE DARAPRIM 3 HYDROXYCHLOROQUINE SULFATE PLAQUENIL
Antimalarials / ANTI - INFECTIVES Tier Generic Name Brand Name Notes
1 ATOVAQUONE/PROGUANIL HCL ATOVAQUONE-PROGUANIL HCL 1 QUININE SULFATE 3 ATOVAQUONE/PROGUANIL HCL MALARONE
Antimetabolite / ANTINEOPLASTICS Tier Generic Name Brand Name Notes
1 MERCAPTOPURINE 1 THIOGUANINE 2 METHOTREXATE SODIUM TREXALL 4 METHOTREXATE SODIUM METHOTREXATE 5
Antimuscarinic/Beta Agonist / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes
2 UMECLIDINIUM/VILANTEROL ANORO ELLIPTA
1 CHLORDIAZEPOXIDE/CLIDINIUM BR CHLORDIAZEPOXIDE-CLIDINIUM 1 DICYCLOMINE HCL 1 GLYCOPYRROLATE 1 PROPANTHELINE BROMIDE
Antimuscarinics/Antispasmodics / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes
1 IPRATROPIUM BROMIDE 6 1 IPRATROPIUM/ALBUTEROL SULFATE IPRATROPIUM-ALBUTEROL 6 2 IPRATROPIUM BROMIDE ATROVENT HFA 6 2 TIOTROPIUM BROMIDE SPIRIVA 6 3 ACLIDINIUM BROMIDE TUDORZA PRESSAIR 3 GLYCOPYRROLATE INHALATION POWDER SEEBRI NEOHALER 3 IPRATROPIUM/ALBUTEROL SULFATE COMBIVENT 6 3 IPRATROPIUM/ALBUTEROL SULFATE COMBIVENT RESPIMAT 6
Antineoplastic Agents / ANTINEOPLASTICS Tier Generic Name Brand Name Notes
1 BICALUTAMIDE 1 HYDROXYUREA 1 IMATINIB MESYLATE 5 1 MEGESTROL ACETATE
5 - Prior Authorization 6 - Quantity Limit
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Antineoplastic Agents / ANTINEOPLASTICS (cont.) Tier Generic Name Brand Name Notes
2 MEGESTROL ACETATE MEGACE ES 2 THIOGUANINE TABLOID 2 TOREMIFENE CITRATE FARESTON 3 ABIRATERONE ACETATE ZYTIGA 3 CABOZANTINIB COMETRIQ 5 3 CABOZANTINIB CABOMETYX 5 3 CAPECITABINE XELODA 3 CRIZOTINIB XALKORI 3 DASATINIB SPRYCEL 3 ERLOTINIB HCL TARCEVA 5 3 EVEROLIMUS AFINITOR 3 IMATINIB MESYLATE GLEEVEC 5 3 LAPATINIB DITOSYLATE TYKERB 3 LETROZOLE FEMARA 3 NIRAPARIB CAPSULES ZEJULA 5 3 REGORAFENIB STIVARGA 3 TEMOZOLOMIDE TEMODAR 3 VISMODEGIB ERIVEDGE 5 4 LEUPROLIDE ACETATE 5 4 PONATINIB ICLUSIG 5 4 RADIUM RA 223 XOFIGO 5 4 TRIFLURIDINE/TIPIRACIL LONSURF 5
Antineoplastic Agents / OFFICE ADMINISTERED Tier Generic Name Brand Name Notes
4 LEUPROLIDE ACETATE LUPRON DEPOT 4
Antineoplastic Other / ANTINEOPLASTICS Tier Generic Name Brand Name Notes
4 DINUTUXIMAB FOR INJECTION UNITUXIN 4 4 OMACETAXINE MEPESUCCINATE FOR INJECTION SYNRIBO 4 4 SONIDEGIB CAPSULES ODOMZO 5 4 TRABECTEDIN FOR INJECTION YONDELIS 4 4 VINBLASTINE VELBAN 4 4 VINCRISTINE ONCOVIN 4 4 VINORELBINE NAVELBINE 4
Antiparkinsonian Agents / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes
1 CARBIDOPA 3 CARBIDOPA LODOSYN
Antiprotozoals / ANTIPARASITICS Tier Generic Name Brand Name Notes
1 CHLOROQUINE 1 METRONIDAZOLE 1 TINIDAZOLE 3 NITAZOXANIDE ALINIA
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3 TINIDAZOLE TINDAMAX
3 DOXEPIN HCL ZONALON 3 NORFLURANE/HFC 245FA PAIN EASE 3 TETRACAINE/BENZOCAINE/BUTAMBEN CETACAINE
Antipruritics And Local Anesthetics / UROLOGICALS Tier Generic Name Brand Name Notes
1 PHENAZOPYRIDINE HCL
1 DIDANOSINE 1 LAMIVUDINE 1 LAMIVUDINE/ZIDOVUDINE LAMIVUDINE-ZIDOVUDINE 1 NEVIRAPINE 2 EFAVIRENZ SUSTIVA 2 EFAVIRENZ/EMTRICITAB/TENOFOVIR ATRIPLA 2 EMTRICITAB/RILPIVIRINE/TENOFOV COMPLERA 2 EMTRICITABINE EMTRIVA 2 ETRAVIRINE INTELENCE 2 MARAVIROC SELZENTRY 2 NEVIRAPINE VIRAMUNE 2 TENOFOVIR ALAFENAMIDE TABLETS VEMLIDY 5 2 TENOFOVIR DISOPROXIL FUMARATE VIREAD 3 NEVIRAPINE VIRAMUNE XR
Antisense Oligonucleotide / OFFICE ADMINISTERED Tier Generic Name Brand Name Notes
4 ETEPLIRSEN INJECTION EXONDYS 51 4 4 NUSINERSEN INJECTION SPINRAZA 4
Antispasmodics / GI AGENTS Tier Generic Name Brand Name Notes
1 HYOSCYAMINE SULFATE HYOMAX-SR 1 HYOSCYAMINE SULFATE 1 HYOSCYAMINE SULFATE OSCIMIN 1 HYOSCYAMINE SULFATE OSCIMIN SR 1 HYOSCYAMINE SULFATE HYOMAX-SL 1 HYOSCYAMINE SULFATE HYOMAX-FT 1 HYOSCYAMINE SULFATE OSCIMIN SL 1 PHENOBARB/HYOSCY/ATROPINE/SCOP BELLADONNA-PHENOBARBITAL 1 PHENOBARB/HYOSCY/ATROPINE/SCOP QUADRAPAX 1 PHENOBARB/HYOSCY/ATROPINE/SCOP SE-DONNA PB HYOS 3 PHENOBARB/HYOSCY/ATROPINE/SCOP DONNATAL
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1 METHIMAZOLE 1 PROPYLTHIOURACIL 3 POTASSIUM IODIDE SSKI
Antituberculosis Agents / ANTIMYCOBACTERIALS Tier Generic Name Brand Name Notes
1 ETHAMBUTOL HCL MYAMBUTOL 1 ETHAMBUTOL HCL 1 ISONIAZID 1 PYRAZINAMIDE 1 RIFAMPIN 2 BEDAQUILINE SIRTURO 5 2 RIFABUTIN MYCOBUTIN 3 RIFAPENTINE PRIFTIN
Antitussives / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes
1 BENZONATATE 1 BROMPHENIRAMIN/PE/DEXTROMETHOR LOHIST-DM 1 CODEINE/PROMETHAZINE HCL PROMETHAZINE-CODEINE 1 D-METHORPHAN HB/PROMETH HCL PROMETHAZINE-DM 1 GUAIFENESIN/CODEINE PHOSPHATE IOPHEN-C NR 1 GUAIFENESIN/CODEINE PHOSPHATE CHERATUSSIN AC 1 GUAIFENESIN/CODEINE PHOSPHATE GUAIFENESIN AC 1 GUAIFENESIN/CODEINE PHOSPHATE GUAIFENESIN-CODEINE 1 GUAIFENESIN/CODEINE PHOSPHATE DEX-TUSS 1 HYDROCODONE BIT/HOMATROP ME-BR HYDROCODONE-HOMATROPINE MBR 1 HYDROCODONE BIT/HOMATROP ME-BR HYDROMET 1 HYDROCODONE/CHLORPHEN POLIS HYDROCODONE-CHLORPHENIRAMINE 1 P-EPHED HCL/CODEINE/GUAIFEN CHERATUSSIN DAC 1 P-EPHED HCL/CODEINE/GUAIFEN MYTUSSIN DAC 1 P-EPHED HCL/CODEINE/GUAIFEN GUAIFENESIN DAC 1 PHENYLEPHRINE HCL/COD/PROMETH PROMETHAZINE VC-CODEINE 3 D-METHORPHAN HB/P-EPD HCL/BPM BROMFED DM 3 HYDROCODONE/CHLORPHEN POLIS TUSSICAPS
Antivirals (Eent) / ANTIVIRALS Tier Generic Name Brand Name Notes
1 TRIFLURIDINE
Antivirals (Skin & Mucous Membrane) / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name Notes
3 ACYCLOVIR/HYDROCORTISONE XERESE 3 PENCICLOVIR DENAVIR
Antivirals- Miscellaneous / OFFICE ADMINISTERED Tier Generic Name Brand Name Notes
4 HUMAN PAPILLOMAVIRUS GARDASIL/CERVARIX 4
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Anxiolytics- Sedatives & Hypnotics-Misc. / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes
1 BUSPIRONE HCL 1 CHLORAL HYDRATE 1 ESZOPICLONE 6 1 ZALEPLON 6 1 ZOLPIDEM TARTRATE 6 1 ZOLPIDEM TARTRATE ZOLPIDEM TARTRATE ER 6 2 CHLORAL HYDRATE SOMNOTE 3 ESZOPICLONE LUNESTA 6 3 RAMELTEON ROZEREM 3 ZALEPLON SONATA 6 3 ZOLPIDEM TARTRATE EDLUAR 6 3 ZOLPIDEM TARTRATE AMBIEN 6 3 ZOLPIDEM TARTRATE INTERMEZZO 6 3 ZOLPIDEM TARTRATE AMBIEN CR 6
Anxiolytics- Sedatives & Hypnotics-Misc. / DIAGNOSTICS & MISCELLANEOUS AGENTS Tier Generic Name Brand Name Notes
3 DICHLORALPHENAZONE
1 HYDROXYZINE HCL 1 HYDROXYZINE PAMOATE
Aromatase Inhibitor / ANTINEOPLASTICS Tier Generic Name Brand Name Notes
1 ANASTROZOLE 1 EXEMESTANE 1 LETROZOLE 3 ANASTROZOLE ARIMIDEX
Astringents / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name Notes
1 ALUMINUM CHLORIDE HYPERCARE 3 ALUMINUM CHLORIDE XERAC AC 3 ALUMINUM CHLORIDE DRYSOL
Atypical/2nd Generation / ANTIPSYCHOTICS Tier Generic Name Brand Name Notes
1 OLANZAPINE OLANZAPINE ODT 1 OLANZAPINE 1 QUETIAPINE FUMARATE 1 RISPERIDONE RISPERIDONE ODT 1 RISPERIDONE 1 RISPERIDONE RISPERIDONE M-TAB 1 ZIPRASIDONE HCL 2 ARIPIPRAZOLE ABILIFY DISCMELT 2 ARIPIPRAZOLE ABILIFY 3 ASENAPINE MALEATE SAPHRIS
6 - Quantity Limit
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Atypical/2nd Generation / ANTIPSYCHOTICS (cont.) Tier Generic Name Brand Name Notes
3 BREXPIPRAZOLE REXULTI 3 CARIPRAZINE VRAYLAR 7 3 ILOPERIDONE FANAPT 3 LURASIDONE HCL LATUDA 3 OLANZAPINE ZYPREXA 3 OLANZAPINE ZYPREXA ZYDIS 3 PALIPERIDONE INVEGA 3 PIMAVANSERIN TABLETS NUPLAZID 5 3 QUETIAPINE FUMARATE SEROQUEL 3 QUETIAPINE FUMARATE SEROQUEL XR 3 ZIPRASIDONE HCL GEODON 4 PALIPERIDONE PALMITATE INVEGA SUSTENNA 5
Azoles / ANTIFUNGALS Tier Generic Name Brand Name Notes
1 CLOTRIMAZOLE 1 FLUCONAZOLE 1 ITRACONAZOLE 1 KETOCONAZOLE 1 VORICONAZOLE 5 3 EFINACONAZOLE JUBLIA 5 3 FLUCONAZOLE DIFLUCAN 3 ISAVUCONAZOMIUN CRESEMBA 5 3 LULICONAZOLE LUZU 3 POSACONAZOLE NOXAFIL
B-lymphocyte stimulator / MUSCULOSKELETAL & RHEUMATOLOGY Tier Generic Name Brand Name Notes
4 BELIMUMAB BENLYSTA 5
3 VENETOCLAX TABLETS VENCLEXTA 5
BILE ACID SYNTHESIS DISORDER / ENDOCRINE Tier Generic Name Brand Name Notes
4 CHOLIC ACID CAPSULES CHOLBAM 5
BPH / GI AGENTS Tier Generic Name Brand Name Notes
1 ALFUZOSIN 1 DOXAZOSIN MESYLATE DOXAZOSIN 1 TAMSULOSIN 1 TERAZOSIN HCL TERAZOSIN 3 SILODOSIN RAPAFLO 3 TAMSULOSIN FLOMAX
BRAF Inhibitor / ANTINEOPLASTICS Tier Generic Name Brand Name Notes
3 DABRAFENIB TAFINLAR 5
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BRAF Inhibitor / ANTINEOPLASTICS (cont.) Tier Generic Name Brand Name Notes
3 VEMURAFENIB ZELBORAF 5
1 PRIMIDONE
1 PHENOBARBITAL
Basic Lotions And Liniments / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name Notes
1 AMMONIUM LACTATE
Basic Ointments And Protectants / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name Notes
1 AMMONIUM LACTATE LAC-HYDRIN
Benzodiazepines (Anticonvulsants) / ANTICONVULSANTS Tier Generic Name Brand Name Notes
1 CLONAZEPAM 3 CLOBAZAM ONFI 3 CLONAZEPAM KLONOPIN 3 DIAZEPAM DIASTAT ACUDIAL
Benzodiazepines (Anxiolytic) / ANXIOLYTICS Tier Generic Name Brand Name Notes
1 ALPRAZOLAM ALPRAZOLAM ER 1 ALPRAZOLAM 1 ALPRAZOLAM ALPRAZOLAM ODT 1 ALPRAZOLAM ALPRAZOLAM XR 1 CHLORDIAZEPOXIDE HCL 1 CLORAZEPATE DIPOTASSIUM 1 DIAZEPAM 1 LORAZEPAM LORAZEPAM INTENSOL 1 LORAZEPAM 1 OXAZEPAM 3 ALPRAZOLAM XANAX 3 DIAZEPAM VALIUM 3 LORAZEPAM ATIVAN
Benzodiazepines (Sedative/Hyp) / SLEEP DISORDERS Tier Generic Name Brand Name Notes
1 ESTAZOLAM 1 FLURAZEPAM HCL 6
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1 TEMAZEPAM 6 1 TRIAZOLAM 6
Beta-Adrenergic Agonists / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes
1 LEVALBUTEROL HCL LEVALBUTEROL 6 2 ALBUTEROL SULFATE VENTOLIN HFA 6 2 ALBUTEROL SULFATE PROVENTIL HFA 6 2 ALBUTEROL SULFATE PROAIR HFA 6 3 ARFORMOTEROL TARTRATE BROVANA 3 INDACATEROL MALEATE ARCAPTA NEOHALER 3 LEVALBUTEROL TARTRATE XOPENEX HFA 6
Beta-Adrenergic Blocking Agents / ANTIMIGRAINE PHOPHYLACTIC Tier Generic Name Brand Name Notes
1 PROPRANOLOL HCL
1 ATENOLOL 1 ATENOLOL/CHLORTHALIDONE ATENOLOL-CHLORTHALIDONE 1 BISOPROLOL FUMARATE 1 BISOPROLOL FUMARATE/HCTZ BISOPROLOL-HYDROCHLOROTHIAZIDE 1 CARVEDILOL 1 LABETALOL HCL 1 METOPROLOL SUCCINATE 1 METOPROLOL TARTRATE 1 METOPROLOL/HYDROCHLOROTHIAZIDE METOPROLOL-HYDROCHLOROTHIAZIDE 1 NADOLOL 1 PINDOLOL 1 PROPRANOLOL HCL 1 SOTALOL HCL SOTALOL 1 SOTALOL HCL SOTALOL AF 2 CARVEDILOL PHOSPHATE COREG CR 3 ATENOLOL TENORMIN 3 CARVEDILOL COREG 3 METOPROLOL SUCCINATE TOPROL XL 3 NADOLOL CORGARD 3 NEBIVOLOL HCL BYSTOLIC 3 PROPRANOLOL HCL HEMANGEOL 3 PROPRANOLOL HCL INDERAL LA 3 PROPRANOLOL HCL INNOPRAN XL
Beta-Adrenergic Blocking Agents (Eent) / OPHTHALMOLOGY Tier Generic Name Brand Name Notes
1 BETAXOLOL HCL 1 LEVOBUNOLOL HCL 1 TIMOLOL MALEATE 2 BETAXOLOL HCL BETOPTIC S 2 TIMOLOL MALEATE ISTALOL
6 - Quantity Limit
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Beta-Adrenergic Blocking Agents (Eent) / OPHTHALMOLOGY (cont.) Tier Generic Name Brand Name Notes
2 TIMOLOL MALEATE/PF TIMOPTIC OCUDOSE 3 TIMOLOL BETIMOL 3 TIMOLOL MALEATE TIMOPTIC
Beta-Lactam, Other / ANTIBACTERIALS Tier Generic Name Brand Name Notes
4 AZTREONAM AZACTAM 4 4 IMIPENEM PRIMAXIN 4 4 IMIPENEM/CILASTATN IMIPENEM/CILASTATIN 4 4 MEROPENEM 4
Biguanides / BLOOD GLUCOSE REGULATORS Tier Generic Name Brand Name Notes
1 METFORMIN HCL METFORMIN HCL ER 1 METFORMIN HCL 1 METFORMIN HCL ER (MOD) METFORMIN ER (MOD) 5 1 METFORMIN HCL ER (OSM) 2 METFORMIN HCL METFORMIN HYDROCHLORIDE 2 METFORMIN HCL RIOMET 3 METFORMIN HCL GLUCOPHAGE 3 METFORMIN HCL ER GLUCOPHAGE XR 3 METFORMIN HCL ER (MOD) GLUMETZA 5 3 METFORMIN HCL ER (OSM) FORTAMET
Bile Acid Sequestrants / CARDIOVASCULAR Tier Generic Name Brand Name Notes
1 CHOLESTYRAMINE (WITH SUGAR) CHOLESTYRAMINE 1 CHOLESTYRAMINE/ASPARTAME PREVALITE 1 CHOLESTYRAMINE/ASPARTAME CHOLESTYRAMINE LIGHT 1 COLESTIPOL HCL 3 COLESEVELAM HCL WELCHOL
Bipolar - Other / BIPOLAR AGENTS Tier Generic Name Brand Name Notes
1 ALPRAZOLAM 1 DIAZEPAM 1 OLANZAPINE 3 ARIPIPRAZOLE ABILIFY 3 LURASIDONE HCL LATUDA
Blood Formation Modifiers / ANTICONVULSANTS Tier Generic Name Brand Name Notes
3 EDOXABAN SAVAYSA
Blood Formation Modifiers / BLOOD PRODUCT/MODIFIERS Tier Generic Name Brand Name Notes
2 APIXABAN ELIQUIS 5
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2 RIVAROXABAN XARELTO 3 CLOPIDOGREL BISULFATE PLAVIX 4 FONDAPARINUX SODIUM ARIXTRA 5 4 HEPARIN 4
Bone Resorption Inhibitors / MUSCULOSKELETAL & RHEUMATOLOGY Tier Generic Name Brand Name Notes
1 ALENDRONATE SODIUM 1 IBANDRONATE SODIUM 1 RISEDRONATE 2 ALENDRONATE SODIUM/VITAMIN D3 FOSAMAX PLUS D 3 ALENDRONATE SODIUM FOSAMAX 3 ALENDRONATE SODIUM BINOSTO 3 IBANDRONATE SODIUM BONIVA 3 RISEDRONATE SODIUM ATELVIA 3 RISEDRONATE SODIUM ACTONEL
C1 Esterase Inhibitor / OFFICE ADMINISTERED Tier Generic Name Brand Name Notes
4 C1 ESTERASE INHIBITOR RUCONEST 4
CYSTIC FIBROSIS TRANSMEMBRANE REGULATOR PROTEIN / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes
4 LUMACAFTOR/IVACAFTOR ORKAMBI 5
Calcium Channel Agents / ANTICONVULSANTS Tier Generic Name Brand Name Notes
1 ETHOSUXIMIDE 1 LAMOTRIGINE 2 LAMOTRIGINE LAMICTAL (GREEN) 2 LAMOTRIGINE LAMICTAL (ORANGE) 3 LAMOTRIGINE LAMICTAL ODT (ORANGE) 3 LAMOTRIGINE LAMICTAL 3 LAMOTRIGINE LAMICTAL ODT 3 LAMOTRIGINE LAMICTAL XR 3 LEVETIRACETAM KEPPRA XR 3 LEVETIRACETAM KEPPRA
Calcium Channel Blocker/ARB / CARDIOVASCULAR Tier Generic Name Brand Name Notes
1 AMLODIPINE/VALSARTAN 7 3 AMLODIPINE/VALSARTAN EXFORGE 7 3 AMLODIPINE/VALSARTAN/HCTZ EXFORGE HCT 7
Calcium-Channel Blocking Agents- Misc. / CARDIOVASCULAR Tier Generic Name Brand Name Notes
1 DILTIAZEM HCL TAZTIA XT
4 - Office/Clinic Administration 5 - Prior Authorization 7 - Step Therapy
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Calcium-Channel Blocking Agents- Misc. / CARDIOVASCULAR (cont.) Tier Generic Name Brand Name Notes
1 DILTIAZEM HCL CARTIA XT 1 DILTIAZEM HCL DILTIAZEM 24HR CD 1 DILTIAZEM HCL DILT-XR 1 DILTIAZEM HCL MATZIM LA 1 DILTIAZEM HCL DILTIAZEM 24HR ER 1 DILTIAZEM HCL DILTIAZEM ER 1 DILTIAZEM HCL 1 VERAPAMIL HCL 1 VERAPAMIL HCL VERAPAMIL ER 1 VERAPAMIL HCL VERAPAMIL ER PM 3 DILTIAZEM HCL CARDIZEM CD 3 DILTIAZEM HCL CARDIZEM LA 3 DILTIAZEM HCL TIAZAC 3 VERAPAMIL HCL CALAN SR
Carbonic Anhydrase Inhibitors / CARDIOVASCULAR Tier Generic Name Brand Name Notes
1 ACETAZOLAMIDE 3 ACETAZOLAMIDE DIAMOX SEQUELS
Carbonic Anhydrase Inhibitors (Eent) / OPHTHALMOLOGY Tier Generic Name Brand Name Notes
1 ACETAZOLAMIDE 1 DORZOLAMIDE HCL 1 DORZOLAMIDE HCL/TIMOLOL MALEAT DORZOLAMIDE-TIMOLOL 1 METHAZOLAMIDE 2 BRINZOLAMIDE AZOPT 3 DORZOLAMIDE HCL/TIMOLOL MALEAT COSOPT 3 DORZOLAMIDE/TIMOLOL/PF COSOPT PF
Cardiac Drugs- Miscellaneous / CARDIOVASCULAR Tier Generic Name Brand Name Notes
2 Ivabradine HCL Corlanor 3 RANOLAZINE RANEXA 3 SACUBITRIL/VALSARTAN ENTRESTO 5
Cariostatic Agents / VITAMINS, HEMATINICS & ELECTROLYTES Tier Generic Name Brand Name Notes
1 SODIUM FLUORIDE RENAF 1 SODIUM FLUORIDE FLUORITAB 1 SODIUM FLUORIDE FLUORIDE 1 SODIUM FLUORIDE EPIFLUR 1 SODIUM FLUORIDE 1 SODIUM FLUORIDE LUDENT FLUORIDE 2 SODIUM FLUORIDE FLURA-DROPS 2 SODIUM FLUORIDE FLUORABON 2 SODIUM FLUORIDE FLUOR-A-DAY
Catechol-O-Methyltransferase(Comt)Inhib. / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes
1 ENTACAPONE
2 ENTACAPONE COMTAN
Cell Stimulants And Proliferants / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name Notes
1 TRETINOIN 5 2 TRETINOIN AVITA 5 2 TRETINOIN ATRALIN 5 2 TRETINOIN MICROSPHERES RETIN-A MICRO PUMP 5 2 TRETINOIN MICROSPHERES RETIN-A MICRO 5
Central Alpha-Agonists / CARDIOVASCULAR Tier Generic Name Brand Name Notes
1 GUANFACINE HCL 1 METHYLDOPA
Central Monoamine-Depleting Agent / CNS AGENTS Tier Generic Name Brand Name Notes
3 VALBENAZINE CAPSULES INGREZZA 5 4 DEUTETRABENAZINE TABLETS AUSTEDO 5
Central Nervous System Agents- Misc. / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes
3 DEXTROMETHORPHAN HBR/QUINIDINE NUEDEXTA 5
Central Nervous System Agents- Misc. / DIAGNOSTICS & MISCELLANEOUS AGENTS Tier Generic Name Brand Name Notes
3 RILUZOLE RILUTEK
Centrally Acting Skeletal Muscle Relaxnt / ANTISPASTICITY AGENTS Tier Generic Name Brand Name Notes
1 CARISOPRODOL 1 CHLORZOXAZONE 1 CYCLOBENZAPRINE HCL 1 METAXALONE 1 METHOCARBAMOL 1 TIZANIDINE HCL 3 CARISOPRODOL SOMA 3 CYCLOBENZAPRINE HCL AMRIX 3 METAXALONE SKELAXIN
Cephalosporins / ANTIBACTERIALS Tier Generic Name Brand Name Notes
1 CEFACLOR 1 CEFADROXIL HYDRATE CEFADROXIL 1 CEFAZOLIN 1 CEFDINIR 1 CEFPROZIL
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Cephalosporins / ANTIBACTERIALS (cont.) Tier Generic Name Brand Name Notes
1 CEFUROXIME AXETIL CEFUROXIME 1 CEPHALEXIN 3 CEFIXIME SUPRAX 3 CEFRADINE VELOSEF 3 CEFTIBUTEN CEDAX 3 CEFTIBUTEN DIHYDRATE CEDAX 3 CEFUROXIME AXETIL CEFTIN 3 CEPHALEXIN KEFLEX 4 CEFEPIME MAXIPIME 4 4 CEFOTAXIME CLAFORAN 4 4 CEFOTETAN CEFOTAN 4 4 CEFOXITAN MEFOXIN 4
Chelator / CARDIOVASCULAR Tier Generic Name Brand Name Notes
3 DEFERASIROX EXJADE 5
Cholelitholytic Agents / GI AGENTS Tier Generic Name Brand Name Notes
1 URSODIOL 3 URSODIOL ACTIGALL
Cholesterol Absorption Inhibitors / CARDIOVASCULAR Tier Generic Name Brand Name Notes
3 LOMITAPIDE JUXTAPID 5 4 MIPOMERSEN KYNAMRO 5
Cholinesterase Inhibitors / ANTIDEMENTIA AGENTS Tier Generic Name Brand Name Notes
1 DONEPEZIL HCL 1 GALANTAMINE 1 RIVASTIGMINE 3 RIVASTIGMINE EXELON PATCH
Coagulant - Vitamin K / BLOOD PRODUCT/MODIFIERS Tier Generic Name Brand Name Notes
2 PHYTONADIONE MEPHYTON
Complement Inhibitors / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes
4 ICATIBANT ACETATE FIRAZYR 5
Contraceptives / OBSTETRICS & GYNECOLOGY Tier Generic Name Brand Name Notes
1 DESOG-ET ESTRA/ETHIN ESTRA KARIVA 3
3 - No copay 4 - Office/Clinic Administration 5 - Prior Authorization
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Contraceptives / OBSTETRICS & GYNECOLOGY (cont.) Tier Generic Name Brand Name Notes
1 DESOG-ET ESTRA/ETHIN ESTRA VIORELE 1 DESOG-ET ESTRA/ETHIN ESTRA AZURETTE 3 1 DESOGESTREL-ETHINYL ESTRADIOL RECLIPSEN 3 1 DESOGESTREL-ETHINYL ESTRADIOL APRI 3 1 DESOGESTREL-ETHINYL ESTRADIOL VELIVET 1 DESOGESTREL-ETHINYL ESTRADIOL CAZIANT 3 1 DESOGESTREL-ETHINYL ESTRADIOL EMOQUETTE 3 1 ETHYNODIOL D-ETHINYL ESTRADIOL ZOVIA 1-35E 3 1 ETHYNODIOL D-ETHINYL ESTRADIOL ZOVIA 1-50E 3 1 ETHYNODIOL D-ETHINYL ESTRADIOL KELNOR 1-35 3 1 L-NORGEST-ETH ESTR/ETHIN ESTRA AMETHIA 3 1 L-NORGEST-ETH ESTR/ETHIN ESTRA AMETHIA LO 3 1 L-NORGEST-ETH ESTR/ETHIN ESTRA LEVONORG-ETH ESTRAD ETH ESTRAD 3 1 L-NORGEST-ETH ESTR/ETHIN ESTRA CAMRESE LO 3 1 L-NORGEST-ETH ESTR/ETHIN ESTRA CAMRESE 3 1 LEVONORGESTREL NEXT CHOICE 3 1 LEVONORGESTREL-ETH ESTRADIOL LESSINA 3 1 LEVONORGESTREL-ETH ESTRADIOL AVIANE 3 1 LEVONORGESTREL-ETH ESTRADIOL MYZILRA 3 1 LEVONORGESTREL-ETH ESTRADIOL AMETHYST 3 1 LEVONORGESTREL-ETH ESTRADIOL ENPRESSE 3 1 LEVONORGESTREL-ETH ESTRADIOL ALTAVERA 1 LEVONORGESTREL-ETH ESTRADIOL JOLESSA 3 1 LEVONORGESTREL-ETH ESTRADIOL TRIVORA-28 3 1 LEVONORGESTREL-ETH ESTRADIOL SRONYX 3 1 LEVONORGESTREL-ETH ESTRADIOL QUASENSE 3 1 LEVONORGESTREL-ETH ESTRADIOL PORTIA 3 1 LEVONORGESTREL-ETH ESTRADIOL LUTERA 3 1 LEVONORGESTREL-ETH ESTRADIOL ORSYTHIA 3 1 LEVONORGESTREL-ETH ESTRADIOL INTROVALE 3 1 LEVONORGESTREL-ETH ESTRADIOL LEVORA-28 3 1 NORELGESTROMIN/ETHIN.ESTRADIOL NORELGESTROMIN/ETH ESTRADIOL 3 1 NORETH A-ET ESTRA/FE FUMARATE JUNEL FE 3 1 NORETH A-ET ESTRA/FE FUMARATE GILDESS FE 3 1 NORETH A-ET ESTRA/FE FUMARATE TILIA FE 3 1 NORETH A-ET ESTRA/FE FUMARATE MICROGESTIN FE 3 1 NORETH A-ET ESTRA/FE FUMARATE TRI-LEGEST FE 3 1 NORETH-ETHINYL ESTRADIOL/IRON WYMZYA FE 3 1 NORETH-ETHINYL ESTRADIOL/IRON ZENCHENT FE 3 1 NORETH-ETHINYL ESTRADIOL/IRON ZEOSA 3 1 NORETHINDRONE CAMILA 1 NORETHINDRONE HEATHER 1 NORETHINDRONE JOLIVETTE 3 1 NORETHINDRONE NORA-BE 3 1 NORETHINDRONE 1 NORETHINDRONE ERRIN 1 NORETHINDRONE A-E ESTRADIOL MICROGESTIN 3 1 NORETHINDRONE A-E ESTRADIOL GILDESS 3 1 NORETHINDRONE A-E ESTRADIOL JUNEL 3 1 NORETHINDRONE-ETHINYL ESTRAD BRIELLYN 3 1 NORETHINDRONE-ETHINYL ESTRAD ARANELLE 3 1 NORETHINDRONE-ETHINYL ESTRAD LEENA 3 1 NORETHINDRONE-ETHINYL ESTRAD CYCLAFEM 3 1 NORETHINDRONE-ETHINYL ESTRAD ZENCHENT 3
3 - No copay
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Contraceptives / OBSTETRICS & GYNECOLOGY (cont.) Tier Generic Name Brand Name Notes
1 NORETHINDRONE-ETHINYL ESTRAD NECON 3 1 NORETHINDRONE-ETHINYL ESTRAD NORTREL 3 1 NORETHINDRONE-ETHINYL ESTRAD ALYACEN 1 NORETHINDRONE-ETHINYL ESTRAD DASETTA 3 1 NORETHINDRONE-ETHINYL ESTRAD BALZIVA 3 1 NORGESTIMATE-ETHINYL ESTRADIOL TRI-SPRINTEC 3 1 NORGESTIMATE-ETHINYL ESTRADIOL TRI-PREVIFEM 3 1 NORGESTIMATE-ETHINYL ESTRADIOL TRINESSA 3 1 NORGESTIMATE-ETHINYL ESTRADIOL SPRINTEC 3 1 NORGESTIMATE-ETHINYL ESTRADIOL PREVIFEM 3 1 NORGESTIMATE-ETHINYL ESTRADIOL 3 1 NORGESTIMATE-ETHINYL ESTRADIOL MONONESSA 3 1 NORGESTREL-ETHINYL ESTRADIOL LOW-OGESTREL 3 1 NORGESTREL-ETHINYL ESTRADIOL NORGESTREL-ETHINY ESTRA 3 1 NORGESTREL-ETHINYL ESTRADIOL CRYSELLE 3 1 NORGESTREL-ETHINYL ESTRADIOL ELINEST 3 1 NORGESTREL-ETHINYL ESTRADIOL OGESTREL 3 2 DESOGESTREL-ETHINYL ESTRADIOL ORTHO-CEPT 2 ETONOGESTREL/ETHINYL ESTRADIOL NUVARING 2 NORETH A-ET ESTRA/FE FUMARATE LO LOESTRIN FE 2 NORETH A-ET ESTRA/FE FUMARATE LOESTRIN 24 FE 2 NORETH-ETHINYL ESTRADIOL/IRON GENERESS FE 2 NORGESTIMATE-ETHINYL ESTRADIOL ORTHO TRI-CYCLEN LO 3 DESOG-ET ESTRA/ETHIN ESTRA MIRCETTE 3 DESOGESTREL-ETHINYL ESTRADIOL DESOGEN 3 DROSPIR/ETH ESTRA/LEVOMEFOL CA BEYAZ 3 DROSPIR/ETH ESTRA/LEVOMEFOL CA SAFYRAL 3 ESTRADIOL VALERATE/DIENOGEST NATAZIA 3 ETHINYL ESTRADIOL/DROSPIRENONE YAZ 3 ETHINYL ESTRADIOL/DROSPIRENONE YASMIN 28 3 L-NORGEST-ETH ESTR/ETHIN ESTRA SEASONIQUE 3 LEVONORGESTREL-ETH ESTRADIOL SEASONALE 3 LEVONORGESTREL-ETH ESTRADIOL LYBREL 3 LEVONORGESTREL-ETH ESTRADIOL NORDETTE-28 3 NORELGESTROMIN/ETHIN.ESTRADIOL ORTHO EVRA 3 NORETH A-ET ESTRA/FE FUMARATE ESTROSTEP FE 3 NORETH A-ET ESTRA/FE FUMARATE LOESTRIN FE 3 NORETH-ETHINYL ESTRADIOL/IRON FEMCON FE 3 NORETHINDRONE MICRONOR 3 NORETHINDRONE A-E ESTRADIOL LOESTRIN 3 NORETHINDRONE-ETHINYL ESTRAD OVCON-35 3 NORETHINDRONE-ETHINYL ESTRAD ORTHO-NOVUM 3 NORETHINDRONE-ETHINYL ESTRAD BREVICON 3 NORGESTIMATE-ETHINYL ESTRADIOL ORTHO-CYCLEN 3 NORGESTIMATE-ETHINYL ESTRADIOL ORTHO TRI-CYCLEN 3 NORGESTREL-ETHINYL ESTRADIOL LO-OVRAL-28 3 ULIPRISTAL ACETATE ELLA 4 LEVONORGESTREL-RELEASING INTRAUTERINE
SYSTEM KYLEENA 4
3 DIAPHRAGMS, ARC-SPRING ORTHO ALL-FLEX
3 - No copay 4 - Office/Clinic Administration
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Corticosteroids / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes
3 DEFLAZACORT EMFLAZA 5 4 CORTICOTROPIN ACTHAR H.P. 5
Corticosteroids (Eent) / EAR, NOSE & THROAT MEDICATIONS Tier Generic Name Brand Name Notes
3 FLUOCINOLONE ACETONIDE OIL DERMOTIC
Corticosteroids (Eent) / GI AGENTS Tier Generic Name Brand Name Notes
3 BUDESONIDE UCERIS 5
1 FLUOROMETHOLONE 1 PREDNISOLONE ACETATE 1 PREDNISOLONE SOD PHOSPHATE PREDNISOLONE SODIUM PHOSPHATE 2 FLUOROMETHOLONE FML FORTE 2 FLUOROMETHOLONE FML S.O.P. 2 PREDNISOLONE ACETATE PRED MILD 3 DIFLUPREDNATE DUREZOL 3 FLUOROMETHOLONE ACETATE FLAREX 3 LOTEPREDNOL ETABONATE ALREX 3 LOTEPREDNOL ETABONATE LOTEMAX 3 PREDNISOLONE ACETATE PRED FORTE 3 RIMEXOLONE VEXOL
Corticosteroids (Eent) / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes
1 FLUNISOLIDE 1 FLUTICASONE PROPIONATE 2 BECLOMETHASONE DIPROPIONATE BECONASE AQ 3 BECLOMETHASONE DIPROPIONATE QNASL 3 BUDESONIDE RHINOCORT AQUA 3 CICLESONIDE OMNARIS 3 CICLESONIDE ZETONNA 3 FLUTICASONE FUROATE VERAMYST 3 FLUTICASONE PROPIONATE FLONASE 3 MOMETASONE FUROATE NASONEX 3 TRIAMCINOLONE ACETONIDE NASACORT AQ
Corticosteroids (Respiratory Tract) / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes
1 BUDESONIDE 2 BECLOMETHASONE DIPROPIONATE QVAR 2 BUDESONIDE PULMICORT FLEXHALER 2 BUDESONIDE/FORMOTEROL FUMARATE SYMBICORT 2 FLUTICASONE FUROATE ARNUITY ELLIPTA 2 FLUTICASONE PROPIONATE FLOVENT HFA 2 FLUTICASONE PROPIONATE FLOVENT DISKUS
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2 FLUTICASONE/SALMETEROL ADVAIR HFA 6 2 FLUTICASONE/VILANTEROL BREO ELLIPTA 2 MOMETASONE FUROATE ASMANEX 3 BUDESONIDE PULMICORT 3 CICLESONIDE ALVESCO 3 MOMETASONE/FORMOTEROL DULERA
Cystine depleting agent / GENETIC DISORDERS Tier Generic Name Brand Name Notes
3 CYSTEAMINE PROCYSBI 5
Cystine depleting agent / OPHTHALMOLOGY Tier Generic Name Brand Name Notes
3 CYSTEAMINE CYSTARAN 5
Devices / BLOOD GLUCOSE REGULATORS Tier Generic Name Brand Name Notes
2 NEEDLES, INSULIN DISPOSABLE NOVOTWIST 2 SYR W-NDL,INS 0.3 ML HALF MARK INSULIN SYRINGE 2 SYRING W-NDL,DISP,INSUL,0.3ML ULTICARE 2 SYRING W-NDL,DISP,INSUL,0.3ML INSULIN SYRINGE 2 SYRING W-NDL,DISP,INSUL,0.5ML INSULIN SYRINGE 2 SYRING W-NDL,DISP,INSUL,0.5ML ULTRA COMFORT 2 SYRINGE & NEEDLE,INSULIN,1 ML INSULIN SYRINGE 3 INSULIN ADMIN. SUPPLIES HUMAPEN LUXURA HD 3 SYRINGE & NEEDLE,INSULIN,1 ML INSULIN SYRINGE
Devices / DIAGNOSTICS & MISCELLANEOUS AGENTS Tier Generic Name Brand Name Notes
3 SALIVA SUBSTITUTION COMBO NO.2 CAPHOSOL
Devices / EAR, NOSE & THROAT MEDICATIONS Tier Generic Name Brand Name Notes
3 GLY/CARB HOMOPOLY A/POT HYDROX MUGARD
Devices / ENDOCRINE/DIABETES Tier Generic Name Brand Name Notes
2 INHALER, ASSIST DEVICES BREATHERITE 2 INHALER, ASSIST DEVICES OPTICHAMBER 2 INHALER, ASSIST DEVICES OPTIHALER 2 INHALER, ASSIST DEVICES EASIVENT 2 INHALER, ASSIST DEVICES MICROCHAMBER 2 INHALER, ASSIST DEVICES VORTEX 2 INHALER, ASSIST DEVICES E-Z SPACER 2 INHALER, ASSIST DEVICES PROCHAMBER 2 INHALER,ASSIST DEVICE,ACCESORY OPTICHAMBER DIAMOND
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2 NEEDLES, INSULIN DISPOSABLE PEN NEEDLE 2 SYRING W-NDL,DISP,INSUL,0.3ML SURE COMFORT 2 SYRING W-NDL,DISP,INSUL,0.5ML EASY TOUCH 2 SYRINGE & NEEDLE,INSULIN,1 ML PRECISION 2 SYRINGE & NEEDLE,INSULIN,1 ML MONOJECT INSULIN SYRINGE 3 BISMUTH TRIBROMOPH/PETROLATUM XEROFORM PETROLATUM DRESSING 3 NEEDLES, DISPOSABLE SPECIALTY USE NEEDLES 3 NEEDLES, DISPOSABLE REGULAR BEVEL NEEDLES 3 NEEDLES, DISPOSABLE NEEDLE 3 NEEDLES, DISPOSABLE NEEDLES
Devices / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes
2 INHALER, ASSIST DEVICES AEROCHAMBER Z-STAT PLUS 2 INHALER, ASSIST DEVICES AEROCHAMBER MAX 2 INHALER, ASSIST DEVICES AEROCHAMBER 2 INHALER, ASSIST DEVICES AEROCHAMBER MV 2 INHALER, ASSIST DEVICES AEROCHAMBER PLUS 2 INHALER, ASSIST DEVICES AEROCHAMBER WITH FLOWSIGNAL
Digestants / GI AGENTS Tier Generic Name Brand Name Notes
1 LIPASE/PROTEASE/AMYLASE PANCRELIPASE 5,000 2 LIPASE/PROTEASE/AMYLASE ZENPEP 2 LIPASE/PROTEASE/AMYLASE CREON 5 2 LIPASE/PROTEASE/AMYLASE PANCREAZE
Dihydropyridines / CARDIOVASCULAR Tier Generic Name Brand Name Notes
1 AMLODIPINE BESYLATE 1 AMLODIPINE BESYLATE/BENAZEPRIL AMLODIPINE BESYLATE-BENAZEPRIL 1 FELODIPINE FELODIPINE ER 1 NIFEDIPINE NIFEDIPINE ER 1 NIFEDIPINE AFEDITAB CR 1 NIFEDIPINE NIFEDIAC CC 1 NIFEDIPINE NIFEDICAL XL 1 NIFEDIPINE 1 NISOLDIPINE 3 AMLODIPINE BES/OLMESARTAN MED AZOR 7 3 AMLODIPINE BESYLATE NORVASC 3 AMLODIPINE BESYLATE/BENAZEPRIL LOTREL 3 NICARDIPINE HCL CARDENE SR 3 NIFEDIPINE ADALAT CC 3 NISOLDIPINE SULAR
Dipeptidyl Peptidase-4(Dpp-4) Inhibitors / BLOOD GLUCOSE REGULATORS Tier Generic Name Brand Name Notes
2 SAXAGLIPTIN HCL ONGLYZA
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2 SAXAGLIPTIN HCL/METFORMIN HCL KOMBIGLYZE XR 2 SITAGLIPTIN PHOS/METFORMIN HCL JANUMET 2 SITAGLIPTIN PHOS/METFORMIN HCL JANUMET XR 2 SITAGLIPTIN PHOSPHATE JANUVIA 3 ALOGLIPTIN NESINA 3 LINAGLIPTIN TRADJENTA 3 LINAGLIPTIN/METFORMIN HCL JENTADUETO
Direct Vasodilators / CARDIOVASCULAR Tier Generic Name Brand Name Notes
1 HYDRALAZINE HCL 1 MINOXIDIL
Direct-Acting Skeletal Muscle Relaxants / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes
1 DANTROLENE SODIUM
Disease-Modifying Antirheumatic Agents / MUSCULOSKELETAL & RHEUMATOLOGY Tier Generic Name Brand Name Notes
1 LEFLUNOMIDE 3 ANAKINRA KINERET 3 LEFLUNOMIDE ARAVA 4 ABATACEPT ORENCIA 5 4 ADALIMUMAB HUMIRA 5 4 ADALIMUMAB HUMIRA PEDIATRIC CROHNS 5 4 ETANERCEPT ENBREL 5 4 GOLIMUMAB SIMPONI 5
Disease-Modifying Antirheumatic Agents / OFFICE ADMINISTERED Tier Generic Name Brand Name Notes
4 INFLIXIMAB FOR INJECTION REMICADE 4
Dopamine Agonists / ANTIPARKINSON AGENTS Tier Generic Name Brand Name Notes
1 AMANTADINE HCL AMANTADINE 1 BROMOCRIPTINE MESYLATE 1 PRAMIPEXOLE DI-HCL PRAMIPEXOLE DIHYDROCHLORIDE 1 ROPINIROLE HCL 3 AMANTADINE HCL SYMMETREL 3 BROMOCRIPTINE MESYLATE CYCLOSET 3 PRAMIPEXOLE DI-HCL MIRAPEX ER 3 PRAMIPEXOLE DI-HCL MIRAPEX 3 ROPINIROLE HCL REQUIP 3 ROPINIROLE HCL REQUIP XL 3 ROTIGOTINE NEUPRO
Dopamine Antagonist / ANTIEMETICS Tier Generic Name Brand Name Notes
1 PROCLORPERAZINE
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Dopamine Antagonist / ANTIEMETICS (cont.) Tier Generic Name Brand Name Notes
1 PROMETHAZINE HCL PROMETHEGAN 4 DROPERIDOL INAPSINE 4
Dopamine Precursors/AA Decarbox Inhibitor / ANTIPARKINSON AGENTS Tier Generic Name Brand Name Notes
1 CARBIDOPA/LEVODOPA CARBIDOPA-LEVODOPA 1 CARBIDOPA/LEVODOPA/ENTACAPONE CARBIDOPA-LEVODOPA-ENTACAPONE 3 CARBIDOPA/LEVODOPA RYTARY 3 CARBIDOPA/LEVODOPA/ENTACAPONE STALEVO 4 CARBIDOPA/LEVODOPA DUOPA 1
Dopamine Receptor Agonists / EMETOGENIC THERAPY Tier Generic Name Brand Name Notes
4 APOMORPHINE APOKYN 4
Dopamine Receptor Agonists / ENDOCRINE/DIABETES Tier Generic Name Brand Name Notes
1 CABERGOLINE
Dopamine Reuptake Blocker / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes
1 METHYLPHENIDATE HCL METHYLPHENIDATE HCL CD
Dyslipidemics, Other / CARDIOVASCULAR Tier Generic Name Brand Name Notes
1 EZETIMIBE 1 EZETIMIBE/SIMVASTATIN 2 NIACIN NIASPAN 2 NIACIN/LOVASTATIN ADVICOR 2 NIACIN/SIMVASTATIN SIMCOR 3 EZETIMIBE ZETIA 3 EZETIMIBE/SIMVASTATIN VYTORIN 3 NIACIN NIACOR 3 OMEGA-3 ACID ETHYL ESTERS LOVAZA
Eent Anti-Infectives- Miscellaneous / EAR, NOSE & THROAT MEDICATIONS Tier Generic Name Brand Name Notes
1 CHLORHEXIDINE GLUCONATE
Eent Anti-Inflammatory Agents- Misc. / OPHTHALMOLOGY Tier Generic Name Brand Name Notes
3 CYCLOSPORINE RESTASIS 3 LIFITEGRAST OPTH SOLUTION XIIDRA 5
1 - Home Health 4 - Office/Clinic Administration 5 - Prior Authorization
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Eent Drugs- Miscellaneous / EAR, NOSE & THROAT MEDICATIONS Tier Generic Name Brand Name Notes
3 AMLEXANOX APHTHASOL
Eent Drugs- Miscellaneous / OPHTHALMOLOGY Tier Generic Name Brand Name Notes
3 EYE LUBRICANT COMBINATION NO.1 FRESHKOTE 3 HYDROXYPROPYL CELLULOSE LACRISERT
Eent Nonsteroidal Anti-Inflam. Agents / OPHTHALMOLOGY Tier Generic Name Brand Name Notes
1 BROMFENAC SODIUM 2 BROMFENAC SODIUM BROMDAY 2 KETOROLAC TROMETHAMINE/PF ACUVAIL 2 NEPAFENAC NEVANAC 3 BROMFENAC SODIUM XIBROM 3 KETOROLAC TROMETHAMINE ACULAR LS 3 KETOROLAC TROMETHAMINE ACULAR
Emollients / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name Notes
1 EMOLLIENT COMBINATION NO.53 HPR PLUS 3 EMOLLIENT COMBINATION NO.10 BIAFINE 3 EMOLLIENT COMBINATION NO.32 EPICERAM 3 EMOLLIENT COMBINATION NO.35 MIMYX 3 EMOLLIENT COMBINATION NO.43 PROMISEB 3 EMOLLIENT COMBINATION NO.44 HYLATOPIC 3 EMOLLIENT COMBINATION NO.53 HYLATOPIC PLUS 3 EMOLLIENT COMBINATION NO.60 ATRAPRO HYDROGEL 3 VITE AC/GRAPE/HYALURONIC ACID ATOPICLAIR
Endothelin Receptor Antagonist / OFFICE ADMINISTERED Tier Generic Name Brand Name Notes
4 RAMUCIRUMAB CYRAMZA 4
Endothelin Receptor Antagonist / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes
3 MACITENTAN OPSUMIT 5
Enzyme Replacement / ENZYME REPLACEMENT Tier Generic Name Brand Name Notes
3 ELIGLUSTAT CERDELGA 5 4 AGALSIDASE BETA FABRAZYME 4
Enzyme Replacement / OFFICE ADMINISTERED Tier Generic Name Brand Name Notes
4 ELOSULFASE ALFA VIMIZIM 4
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3 DORNASE ALFA PULMOZYME 5
Ergot Alkaloids / ANTIMIGRAINE Tier Generic Name Brand Name Notes
1 DIHYDROERGOTAMINE MESYLATE 2 ERGOTAMINE TARTRATE ERGOMAR 2 ERGOTAMINE TARTRATE/CAFFEINE CAFERGOT
Estrogen Agonist-Antagonists / HORMONE: ER RECEPTOR MODIFIER Tier Generic Name Brand Name Notes
1 RALOXIFENE 3 ESTROGEN/BAZEDOXIFENE DUAVEE 3 OSPEMIFENE OSPHENA 3 RALOXIFENE EVISTA 4 CLOMIPHENE CITRATE 2
Estrogens / HORMONE: ESTROGENS Tier Generic Name Brand Name Notes
1 ESTRADIOL 1 ESTRADIOL/NORETHINDRONE ACET ESTRADIOL-NORETHINDRONE ACETAT 1 ESTROPIPATE 2 ESTRADIOL ALORA 2 ESTRADIOL ESTRACE 0.01% CREAM 2 ESTRADIOL MICRONIZED ESTRADIOL 3 ESTRADIOL DIVIGEL 3 ESTRADIOL EVAMIST 3 ESTRADIOL ESTROGEL 3 ESTRADIOL ELESTRIN 3 ESTRADIOL ESTRING 3 ESTRADIOL CLIMARA 3 ESTRADIOL ESTRACE TABLETS 3 ESTRADIOL ACETATE FEMRING 3 ESTRADIOL/NORETHINDRONE ACET ACTIVELLA 3 ESTROGENS,CONJ.,SYNTHETIC A CENESTIN 3 ESTROGENS,CONJ.,SYNTHETIC B ENJUVIA 3 NORETHIND AC/ETHINYL ESTRADIOL FEMHRT
Estrogens / OBSTETRICS & GYNECOLOGY Tier Generic Name Brand Name Notes
1 ESTRADIOL/NORETHINDRONE ACET MIMVEY 1 NORETHIND AC/ETHINYL ESTRADIOL JINTELI 1 NORETHIND AC/ETHINYL ESTRADIOL JEVANTIQUE 2 ESTRADIOL VAGIFEM 2 ESTRADIOL/LEVONORGESTREL CLIMARA PRO 2 ESTRADIOL/NORGESTIMATE PREFEST 2 ESTROGEN,CON/M-PROGEST ACET PREMPRO 2 ESTROGEN,CON/M-PROGEST ACET PREMPHASE 2 ESTROGENS, CONJUGATED PREMARIN
2 - Infertility 5 - Prior Authorization
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Estrogens / OBSTETRICS & GYNECOLOGY (cont.) Tier Generic Name Brand Name Notes
3 DROSPIRENONE/ESTRADIOL ANGELIQ 3 ESTRADIOL MENOSTAR 3 ESTRADIOL VIVELLE-DOT 3 ESTRADIOL/NORETHINDRONE ACET COMBIPATCH 3 ESTROGENS,ESTERIFIED MENEST 4 ESTRADIOL CYPIONATE DEPO-ESTRADIOL 5
Ethanolamine Derivatives / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes
1 DIPHENHYDRAMINE HCL
Farnesoid X Receptor Agonists / GI AGENTS Tier Generic Name Brand Name Notes
3 OBETICHOLIC ACID TABLETS OCALIVA 5
Fibric Acid Derivatives / CARDIOVASCULAR Tier Generic Name Brand Name Notes
1 FENOFIBRATE NANOCRYSTALLIZED FENOFIBRATE 1 FENOFIBRIC ACID (CHOLINE) FENOFIBRIC ACID 1 GEMFIBROZIL 3 FENOFIBRATE FENOGLIDE 3 FENOFIBRATE LIPOFEN 3 FENOFIBRATE NANOCRYSTALLIZED TRIGLIDE 3 FENOFIBRATE NANOCRYSTALLIZED TRICOR 3 FENOFIBRATE,MICRONIZED ANTARA 3 FENOFIBRIC ACID (CHOLINE) TRILIPIX
Fibromyalgia Agents / CNS AGENTS Tier Generic Name Brand Name Notes
1 GABAPENTIN 3 MILNACIPRAN HCL SAVELLA 3 PREGABALIN LYRICA
First Gen. Antihist. Derivatives- Misc. / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes
1 CYPROHEPTADINE HCL
4 METHOTREXATE OTREXUP 5
GABA Augmenting Agents / AANTICONVULSANTS Tier Generic Name Brand Name Notes
3 GABAPENTIN ENACARBIL HORIZANT
GABA Augmenting Agents / ANTICONVULSANTS Tier Generic Name Brand Name Notes
1 DIVALPROEX SODIUM
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GABA Augmenting Agents / ANTICONVULSANTS (cont.) Tier Generic Name Brand Name Notes
1 DIVALPROEX SODIUM DIVALPROEX SODIUM ER 1 VALPROATE SODIUM VALPROIC ACID 3 DIVALPROEX SODIUM DEPAKOTE 3 DIVALPROEX SODIUM DEPAKOTE ER 3 DIVALPROEX SODIUM DEPAKOTE SPRINKLE 3 GABAPENTIN GRALISE 3 TIAGABINE GABITRIL 3 VIGABATRIN SABRIL 5
GLP-2 analog / GI AGENTS Tier Generic Name Brand Name Notes
4 TEDUGLUTIDE GATTEX 5
1 BACLOFEN
Genitourinary Smooth Muscle Relaxants / UROLOGICALS Tier Generic Name Brand Name Notes
1 FLAVOXATE HCL 1 OXYBUTYNIN CHLORIDE 1 OXYBUTYNIN CHLORIDE OXYBUTYNIN CHLORIDE ER 1 TOLTERODINE TARTRATE 3 DARIFENACIN HYDROBROMIDE ENABLEX 3 FESOTERODINE FUMARATE TOVIAZ 3 MIRABEGRON MYRBETRIQ 3 OXYBUTYNIN GELNIQUE 3 SOLIFENACIN SUCCINATE VESICARE 3 TOLTERODINE TARTRATE DETROL LA 3 TOLTERODINE TARTRATE DETROL 3 TROSPIUM CHLORIDE SANCTURA XR
Gi Drugs- Miscellaneous / GI AGENTS Tier Generic Name Brand Name Notes
3 CERTOLIZUMAB PEGOL CIMZIA 5 3 ELUXADOLINE TABLETS VIBERZI 3 LINACLOTIDE LINZESS 3 PLECANATIDE TABLETS TRULANCE 5
Glutamate Reducing Agents / ANTICONVULSANTS Tier Generic Name Brand Name Notes
1 GABAPENTIN 3 GABAPENTIN NEURONTIN
Glycogenolytic Agents / BLOOD GLUCOSE REGULATORS Tier Generic Name Brand Name Notes
3 GLUCAGON,HUMAN RECOMBINANT GLUCAGON EMERGENCY KIT 3 GLUCAGON,HUMAN RECOMBINANT GLUCAGEN
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4 CETRORELIX ACETATE CETROTIDE 2 4 GANIRELIX ACETATE 2
Gonadotropins / ENDOCRINE/DIABETES Tier Generic Name Brand Name Notes
4 CHORIONIC GONADOTROPIN, HUMAN CHORIONIC GONADOTROPIN 2 4 CHORIONIC GONADOTROPIN, HUMAN PREGNYL 2 4 FOLLITROPIN ALFA, RECOMB GONAL-F RFF 2 4 FOLLITROPIN ALFA, RECOMB GONAL-F 2 4 FOLLITROPIN BETA,RECOMB FOLLISTIM AQ 2 4 HCG ALPHA,RECOMBINANT OVIDREL 2 4 MENOTROPINS MENOPUR 2 4 UROFOLLITROPIN BRAVELLE 2
Gonadotropins / OBSTETRICS & GYNECOLOGY Tier Generic Name Brand Name Notes
4 CHORIONIC GONADOTROPIN NOVAREL 2
Growth Hormone Releasing Factor / DIAGNOSTICS & MISCELLANEOUS AGENTS Tier Generic Name Brand Name Notes
4 TESAMORELIN EGRIFTA 5
HER2 Targeted Antibody / ANTINEOPLASTICS Tier Generic Name Brand Name Notes
4 ADO-TRASTUZUMAB KADCYLA 5 4 TRASTUZUMAB HERCEPTIN 5
HYPOPHOSPHATASIA / ENDOCRINE Tier Generic Name Brand Name Notes
4 ASFOTASE ALFA INJECTION STRENSIQ 5
Hematopoietic Agents / ANTINEOPLASTICS Tier Generic Name Brand Name Notes
4 TBO-FILGRASTIM GRANIX 5
Hematopoietic Agents / IMMUNOLOGICAL AGENTS Tier Generic Name Brand Name Notes
4 EPOETIN ALFA PROCRIT 5 4 PEGFILGRASTIM NEULASTA 5
2 - Infertility 5 - Prior Authorization
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Hematopoietic Agents / IMMUNOLOGICAL AGENTS (cont.) Tier Generic Name Brand Name Notes
4 PLERIXAFOR MOZOBIL 5
Hematopoietic Agents / OFFICE ADMINISTERED Tier Generic Name Brand Name Notes
4 EPOETIN ALFA EPOGEN 4 4 FILGRASTIM NEUPOGEN 4
Hemorrheologic Agents / CARDIOVASCULAR Tier Generic Name Brand Name Notes
1 PENTOXIFYLLINE
Hemostatic / OFFICE ADMINISTERED Tier Generic Name Brand Name Notes
4 COAGULATION FACTOR IX ALPROLIX 4 4 COAGULATION FACTOR IX RIXUBIS 4 4 COAGULATION FACTOR XIII TRETTEN 4
Hemostatics / CARDIOVASCULAR Tier Generic Name Brand Name Notes
3 AMINOCAPROIC ACID 4 ANTIHEMOPH.FVIII PLAS/ALB FREE ADVATE 5
Hemostatics / OBSTETRICS & GYNECOLOGY Tier Generic Name Brand Name Notes
1 TRANEXAMIC ACID 3 TRANEXAMIC ACID LYSTEDA
Hereditary Tyrosinemia / ENDOCRINE Tier Generic Name Brand Name Notes
3 NITISINONE ORFADIN 5
1 AMOXAPINE 1 MAPROTILINE HCL 1 MIRTAZAPINE
Histamine H2-Antagonists / GI AGENTS Tier Generic Name Brand Name Notes
1 CIMETIDINE 1 FAMOTIDINE 1 NIZATIDINE 1 RANITIDINE HCL 3 FAMOTIDINE PEPCID
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Histamine H2-Antagonists / GI AGENTS (cont.) Tier Generic Name Brand Name Notes
3 RANITIDINE HCL ZANTAC 25
Histone inhibitor / ANTINEOPLASTICS Tier Generic Name Brand Name Notes
3 PANOBINOSTAT FARYDAK 5 3 VORINOSTAT ZOLINZA 5
Histone inhibitor / OFFICE ADMINISTERED Tier Generic Name Brand Name Notes
4 BELINOSTAT BELEODAQ 4
Hmg-Coa Reductase Inhibitors / CARDIOVASCULAR Tier Generic Name Brand Name Notes
1 AMLODIPINE/ATORVASTATIN AMLODIPINE-ATORVASTATIN 1 ATORVASTATIN CALCIUM 1 FLUVASTATIN SODIUM 1 LOVASTATIN 1 PRAVASTATIN SODIUM 1 SIMVASTATIN 3 ATORVASTATIN CALCIUM LIPITOR 3 FLUVASTATIN SODIUM LESCOL XL 3 FLUVASTATIN SODIUM LESCOL 3 LOVASTATIN ALTOPREV 3 PITAVASTATIN CALCIUM LIVALO 3 PRAVASTATIN SODIUM PRAVACHOL 3 ROSUVASTATIN CALCIUM CRESTOR 3 SIMVASTATIN ZOCOR
Human Leptin / GENETIC DISORDERS Tier Generic Name Brand Name Notes
4 METRELEPTN MYALEPT 5
4 IXEKIZUMAB FOR SUBCUTANEOUS INJ TALTZ 5
Immunomodulator / IMMUNOLOGICAL AGENTS Tier Generic Name Brand Name Notes
3 APREMILAST OTEZLA 5 3 LENALIDOMIDE REVLIMID 5 3 POMALIDOMIDE POMALYST 5 3 THALIDOMIDE THALOMID 5 3 TOFACITINIB XELJANZ 5 4 INTERFERON ALFACON 1 INFERGEN 5
Immunosuppressive Agents / IMMUNOLOGICAL AGENTS Tier Generic Name Brand Name Notes
1 AZATHIOPRINE
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1 CYCLOSPORINE 1 CYCLOSPORINE, MODIFIED GENGRAF 1 CYCLOSPORINE, MODIFIED CYCLOSPORINE MODIFIED 1 MYCOPHENOLATE MOFETIL 1 TACROLIMUS 2 CYCLOSPORINE SANDIMMUNE 2 CYCLOSPORINE, MODIFIED NEORAL 2 MYCOPHENOLATE SODIUM MYFORTIC 2 SIROLIMUS RAPAMUNE 3 MYCOPHENOLATE MOFETIL CELLCEPT 3 TACROLIMUS PROGRAF 4 TOCILIZUMAB ACTEMRA SQ 5 4 TOCILIZUMAB ACTEMRA 5
Incretin Mimetics / BLOOD GLUCOSE REGULATORS Tier Generic Name Brand Name Notes
2 EXENATIDE BYETTA 5 2 EXENATIDE EXTENDED RELEASE BYDUREON BCISE 5 2 EXENATIDE MICROSPHERES BYDUREON 5 2 LIRAGLUTIDE VICTOZA 2-PAK 5 2 LIRAGLUTIDE VICTOZA 3-PAK 5 3 ALBIGLUTIDE TANZEUM 5 3 DULAGLUTIDE TRULICITY 5 3 LIXISENATIDE INJECTION ADLYXIN 5
Incretin Mimetics / OBESITY Tier Generic Name Brand Name Notes
4 LIRAGLUTIDE SAXENDA 5
Inhibit DNA polymerases / ANTINEOPLASTICS Tier Generic Name Brand Name Notes
1 TEMOZOLOMIDE
Inhibit DNA polymerases / ANTIVIRALS Tier Generic Name Brand Name Notes
3 GANCICLOVIR CYTOVENE 5
Inhibit Protein Synthesis / ANTIFUNGALS Tier Generic Name Brand Name Notes
3 TAVABOROLE KERYDIN 5
Inhibit Protein Synthesis / ANTINEOPLASTICS Tier Generic Name Brand Name Notes
4 OMACETAXINE SYNRIBO 5
Inhibit Protein Synthesis / GENETIC DISORDERS Tier Generic Name Brand Name Notes
3 MIGLUSTAT ZAVESCA 5
Insulins / BLOOD GLUCOSE REGULATORS Tier Generic Name Brand Name Notes
2 HUM INSULIN NPH/REG INSULIN HM HUMULIN 70-30 2 HUM INSULIN NPH/REG INSULIN HM NOVOLIN 70-30 2 INSULIN GLARGINE,HUM.REC.ANLOG LANTUS 2 INSULIN GLARGINE,HUM.REC.ANLOG LANTUS SOLOSTAR 2 INSULIN GLARGINE,HUM.REC.ANLOG TOUJEO 2 INSULIN LISPRO HUMALOG 2 INSULIN NPL/INSULIN LISPRO HUMALOG MIX 50-50 2 INSULIN NPL/INSULIN LISPRO HUMALOG MIX 75-25 2 INSULIN REGULAR, HUMAN HUMULIN R 2 INSULIN REGULAR, HUMAN NOVOLIN R 2 NPH, HUMAN INSULIN ISOPHANE HUMULIN N 2 NPH, HUMAN INSULIN ISOPHANE NOVOLIN N 3 INSULIN ASPART NOVOLOG 7 3 INSULIN ASPART NOVOLOG FLEXPEN 7 3 INSULIN DEGLUDEC INJECTION TRESIBA 7 3 INSULIN DETEMIR LEVEMIR FLEXTOUCH 7 3 INSULIN DETEMIR LEVEMIR 7 3 INSULIN GLARGINE,HUM.REC.ANLOG Basaglar KwikPen 7 3 INSULIN GLULISINE APIDRA SOLOSTAR 3 INSULIN GLULISINE APIDRA 3 INSULIN INHALED AFREZZA 3 INSULN ASP PRT/INSULIN ASPART NOVOLOG MIX 70-30 7 3 INSULN ASP PRT/INSULIN ASPART NOVOLOG MIX 70-30 FLEXPEN 7
Integrase Strand Inhibitor / ANTIVIRALS Tier Generic Name Brand Name Notes
2 ELVITEGRAVIR VITEKTA
4 INTERFERON ALFA-2B,RECOMB. INTRON A 5 4 INTERFERON ALFA-2B,RECOMB. PEG-INTRON 5 4 INTERFERON ALFA-2B,RECOMB. SYLATRON 5
Interleukin / CARDIOVASCULAR Tier Generic Name Brand Name Notes
4 OPRELVEKIN NEUMEGA 5
4 SECUKINUMAB COSENTYX 5
4 SILTUXIMAB SYLVANT 4
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4 OCRIPLASMIN JETREA 5
Keratolytic Agents / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name Notes
1 BENZOYL PEROXIDE LAVOCLEN-4 1 BENZOYL PEROXIDE BENZEPRO 1 BENZOYL PEROXIDE 1 BENZOYL PEROXIDE BP WASH 1 BENZOYL PEROXIDE BPO 1 BENZOYL PEROXIDE BP WASH ACNE TREATMENT 1 SALICYLIC ACID 1 SULFACET SOD/SULFUR/WITCH HAZ SE 10-5 SS 1 SULFACETAMIDE SODIUM/SULFUR ZENCIA 1 SULFACETAMIDE SODIUM/SULFUR SULFACETAMIDE SODIUM-SULFUR 1 SULFACETAMIDE SODIUM/SULFUR SODIUM SULFACETAMIDE-SULFUR 1 SULFACETAMIDE SODIUM/SULFUR PRASCION 1 SULFACETAMIDE SODIUM/SULFUR PRASCION FC 1 SULFACETAMIDE SODIUM/SULFUR BP 10-1 1 UREA 2 BENZOYL PEROXIDE BENZEFOAM ULTRA 2 BENZOYL PEROXIDE BENZAC AC 2 SULFACETAMIDE SODIUM/SULFUR CLARIFOAM EF 3 SALICYLIC ACID KERALYT 3 SALICYLIC ACID/CERAMIDE CMB #1 SALEX 3 SULFACETAMIDE SODIUM/SULFUR CLENIA
Keratoplastic Agents / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name Notes
1 ANTHRALIN DRITHOCREME HP 3 COAL TAR
Kinase Inhibitor / ANTINEOPLASTICS Tier Generic Name Brand Name Notes
3 CERITINIB ZYKADIA 5 3 IDELALISIB ZYDELIG 5 3 LENVATINIB LENVIMA 5 3 RIBOCICLIB TABLETS KISQALI 5 3 RUXOLITINIB JAKAFI 5 3 TRAMETINIB MEKINIST 5
LIPOSOMAL ACID LIPASE DEFICIENCY / ENDOCRINE Tier Generic Name Brand Name Notes
4 SEBELIPASE ALFA INJECTION KANUMA 4
Laxatives / GI AGENTS Tier Generic Name Brand Name Notes
1 PEG 3350/NA SULF,BICARB,CL/KCL PEG 3350-ELECTROLYTE
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Laxatives / GI AGENTS (cont.) Tier Generic Name Brand Name Notes
1 PEG 3350/NA SULF,BICARB,CL/KCL PEG-3350 AND ELECTROLYTES 1 PEG 3350/NA SULF,BICARB,CL/KCL GAVILYTE 1 POLYETHYLENE GLYCOL 3350 2 NAPHOS M-B M-H/NA PHOS,DI-BA OSMOPREP 2 PEG 3350/NA SULF,BICARB,CL/KCL GOLYTELY PACKETS 3 BISAC/NACL/NAHCO3/KCL/PEG 3350 HALFLYTELY-BISACODYL 3 LUBIPROSTONE AMITIZA 3 PEG 3350/NA SULF,BICARB,CL/KCL GOLYTELY 3 PEG 3350/NA SULF,BICARB,CL/KCL COLYTE WITH FLAVOR PACKETS 3 PEG3350/SOD SUL/NACL/ASB/C/KCL MOVIPREP 3 SOD PICOSULF/MAG OX/CITRIC AC PREPOPIK 3 SODIUM,POTASSIUM,&MAG SULFATES SUPREP
Leprosy / ANTIMYCOBACTERIALS - OTHER Tier Generic Name Brand Name Notes
2 DAPSONE 3 CLOFAZIMINE LAMPRENE
Leukotriene Modifiers / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes
1 MONTELUKAST SODIUM 1 ZAFIRLUKAST 3 MONTELUKAST SODIUM SINGULAIR 3 ZAFIRLUKAST ACCOLATE 3 ZILEUTON ZYFLO CR 5
Local Anesthetics / ANESTHETICS Tier Generic Name Brand Name Notes
1 HYDROCORTISONE AC/LIDOCAINE LIDOCAINE-HYDROCORTISONE 1 LIDOCAINE HCL 1 LIDOCAINE HCL LIDOCAINE HCL VISCOUS 1 LIDOCAINE/PRILOCAINE LIDOCAINE-PRILOCAINE 3 LIDOCAINE LIDODERM
Local Anesthetics (Eent) / OTIC AGENTS Tier Generic Name Brand Name Notes
1 ANTIPYRINE/BENZOCAINE/GLYCERIN AURODEX 1 ANTIPYRINE/BENZOCAINE/GLYCERIN ANTIPYRINE-BENZOCAINE 3 ANTIPY/BENZOCAINE/POLICOS NO.1 OTIC CARE 3 ANTIPYRINE/BENZOCAINE AURAX
Local Anti-Infectives- Miscellaneous / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name Notes
1 HYDROCORTISONE/IODOQUINOL HYDROCORTISONE-IODOQUINOL 1 SELENIUM SULFIDE 1 SILVER SULFADIAZINE SSD 1 SILVER SULFADIAZINE THERMAZENE 1 SILVER SULFADIAZINE 1 SULFACETAMIDE SOD/SULFUR/UREA CLEANSING WASH
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1 SULFACETAMIDE SOD/SULFUR/UREA SODIUM SULFACETAMIDE-SULFUR 1 SULFACETAMIDE SODIUM SEB-PREV 1 SULFACETAMIDE SODIUM SODIUM SULFACETAMIDE 1 SULFACETM NA/AVOBENZONE/SULFUR PRASCION RA 2 SELENIUM SULFIDE TERSI FOAM 3 HEXACHLOROPHENE PHISOHEX 3 SILVER SULFADIAZINE SILVADENE
Loop Diuretics / CARDIOVASCULAR Tier Generic Name Brand Name Notes
1 BUMETANIDE 1 FUROSEMIDE 1 TORSEMIDE 2 ETHACRYNIC ACID EDECRIN 3 FUROSEMIDE LASIX
MAO Inhibitor / ANTIDEPRESSANTS Tier Generic Name Brand Name Notes
1 PHENELZINE SULFATE 1 TRANYLCYPROMINE SULFATE
MEK Inhibitor / ANTINEOPLASTICS Tier Generic Name Brand Name Notes
4 COBIMETINIB TABLETS COTELLIC 5
MIXED 5HT1A AGONIST HT2A ANTAGONIST / CNS AGENTS Tier Generic Name Brand Name Notes
4 FLIBANSERIN ADDYI 5
MS / CNS AGENTS Tier Generic Name Brand Name Notes
2 GLATIRAMER ACETATE GLATOPA 5 3 DALFAMPRIDINE AMPYRA 5 3 DIMETHYL FUMARATE TECFIDERA 5 3 TERIFLUNOMIDE AUBAGIO 5 4 GLATIRAMER ACETATE COPAXONE 5 4 INTERFERON BETA-1A AVONEX 5 4 INTERFERON BETA-1A AVONEX PEN 5 4 INTERFERON BETA-1A/ALBUMIN REBIF 5 4 INTERFERON BETA-1A/ALBUMIN AVONEX ADMINISTRATION PACK 5 4 INTERFERON BETA-1B BETASERON 5
Macrolides / ANTIBACTERIALS Tier Generic Name Brand Name Notes
1 AZITHROMYCIN 1 CLARITHROMYCIN CLARITHROMYCIN ER 1 CLARITHROMYCIN 1 ERYTHROMYCIN BASE ERYTHROMYCIN
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1 ERYTHROMYCIN ETHYLSUCCINATE E.E.S. 400 1 ERYTHROMYCIN ETHYLSUCCINATE 1 ERYTHROMYCIN STEARATE ERYTHROCIN STEARATE 2 ERYTHROMYCIN BASE ERY-TAB 2 ERYTHROMYCIN ETHYLSUCCINATE E.E.S. 200 2 ERYTHROMYCIN ETHYLSUCCINATE ERYPED 400 2 ERYTHROMYCIN ETHYLSUCCINATE ERYPED 200 3 AZITHROMYCIN ZITHROMAX 3 AZITHROMYCIN ZMAX
Mast-Cell Stabilizers / OPHTHALMOLOGY Tier Generic Name Brand Name Notes
1 CROMOLYN SODIUM 3 NEDOCROMIL SODIUM ALOCRIL
Mast-Cell Stabilizers / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes
1 CROMOLYN SODIUM
Meglitinides / BLOOD GLUCOSE REGULATORS Tier Generic Name Brand Name Notes
1 NATEGLINIDE 3 NATEGLINIDE STARLIX
Meglitinides / ENDOCRINE/DIABETES Tier Generic Name Brand Name Notes
1 REPAGLINIDE 3 REPAGLINIDE PRANDIN
Melatonin Receptor Agonist / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes
3 TASIMELTEON HETLIOZ 5
1 PILOCARPINE HCL
1 ACETIC ACID/HYDROCORTISONE HYDROCORTISONE-ACETIC ACID
Miscellaneous Anti-Infectives (Eent) / OTIC AGENTS Tier Generic Name Brand Name Notes
1 ACETIC ACID 1 ACETIC ACID/HYDROCORTISONE ACETASOL HC
Miscellaneous Anti-Infectives (Systemic) / ANTI - INFECTIVES Tier Generic Name Brand Name Notes
1 SULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE-TRIMETHOPRIM
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3 METRONIDAZOLE FLAGYL ER 3 METRONIDAZOLE FLAGYL
Miscellaneous B-Lactam Antibiotics / ANTI - INFECTIVES Tier Generic Name Brand Name Notes
3 AZTREONAM LYSINE CAYSTON
Miscellaneous Gi Drugs / GI AGENTS Tier Generic Name Brand Name Notes
3 ALOSETRON HCL LOTRONEX 4 OCTREOTIDE ACETATE SANDOSTATIN 5
Monoamine Oxidase B Inhibitors / ANTIPARKINSON AGENTS Tier Generic Name Brand Name Notes
1 SELEGILINE HCL 3 SELEGILINE EMSAM
Monoamine Oxidase B Inhibitors / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes
3 RASAGILINE MESYLATE AZILECT
3 TETRABENAZINE XENAZINE 5
Monoclonal Antibody / ANTINEOPLASTICS Tier Generic Name Brand Name Notes
4 ATEZOLIZUMAB FOR INJECTION TECENTRIQ 4 4 AVELUMAB INJECTION BAVENCIO 4 4 BRENTUXIMAB ADCETRIS 4 4 CANAKINUMAB ILARIS 5 4 DARATUMUMAB INJECTION DARZALEX 4 4 DENOSUMAB XGEVA 5 4 ELOTUZUMAB INJECTION EMPLICITI 4 4 NECITUMUMAB FOR INJECTION PORTRAZZA 4 4 OLARATUMAB INJECTION LARTRUVO 4 4 PEMBROLIZUMAB KEYTRUDA 4
Monoclonal Antibody / DERMATOLOGICAL AGENTS Tier Generic Name Brand Name Notes
4 DUPILUMAB SUBCUTANEOUS INJECTION DUPIXENT 5
Monoclonal Antibody / MUSCULOSKELETAL & RHEUMATOLOGY Tier Generic Name Brand Name Notes
4 DENOSUMAB PROLIA 4
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Monoclonal Antibody / OFFICE ADMINISTERED Tier Generic Name Brand Name Notes
3 RESLIZUMAB INJECTION CINQAIR 4 4 MEPOLIZUMAB INJECTION NUCALA 4 4 OMALIZUMAB XOLAIR 4 4 RITUXIMAB RITUXAN 4 4 SYNAGIS PALIVIZUMAB 4
Mood Stabilizers / BIPOLAR AGENTS Tier Generic Name Brand Name Notes
1 CARBAMAZEPINE 1 LAMOTRIGINE 1 LITHIUM CARBONATE 1 LITHIUM CITRATE LITHIUM 1 VALPROATE SODIUM VALPROIC ACID 3 LITHIUM CARBONATE LITHOBID
Mucolytic Agents / RESPIRATORY AGENTS Tier Generic Name Brand Name Notes
1 ACETYLCYSTEINE
Multiple Sclerosis / CNS AGENTS Tier Generic Name Brand Name Notes
3 FINGOLIMOD HCL GILENYA 5 4 PEGINTERFERON ALFA-1A PLEGRIDY 5
Multiple Sclerosis / OFFICE ADMINISTERED Tier Generic Name Brand Name Notes
4 ALEMTUZUMAB LEMTRADA 4 4 NATALIZUMAB TYSABRI 4 4 OCRELIZUMAB INJECTION OCREVUS 4
Multivitamin Preparations / VITAMINS, HEMATINICS & ELECTROLYTES Tier Generic Name Brand Name Notes
1 FLUORIDE/IRON/VIT A,C TRI-VIT WITH FLUORIDE-IRON 1 FLUORIDE/VITAMINS A,C,AND D TRIPHLUORIVIT 1 MULTIVITAMINS WITH FLUORIDE MULTI-VITAMIN WITH FLUORIDE 1 MULTIVITAMINS WITH FLUORIDE PHLUORIVIT 1 MULTIVITS WITH IRON & FLUORIDE MULTI-VITAMIN W-FLUORIDE-IRON 1 PED MV A,C,D3 #21 W-FLUORIDE TRIPLE-VITAMIN W-FLUORIDE 1 PED MV A,C,D3 #21 W-FLUORIDE VITAMINS A,C,D & FLUORIDE 1 PED MV A,C,D3 #21 W-FLUORIDE TRI-VITAMIN WITH FLUORIDE 1 PEDI MVI NO.12/SODIUM FLUORIDE MVC-FLUORIDE 1 PNV COMBO #22/IRON/FA/OM3/DHA HEMENATAL OB + DHA 1 PNV NO.22/IRON CBN&GLUC/FA/DSS VINACAL 1 PNV W-O CA NO5/FE FUMARATE/FA PRENATAL-U 3 1 PNV WITH CA,NO.72/IRON,CARB/FA PRENATAL PLUS 3
3 - No copay 4 - Office/Clinic Administration 5 - Prior Authorization
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Multivitamin Preparations / VITAMINS, HEMATINICS & ELECTROLYTES (cont.) Tier Generic Name Brand Name Notes
1 PNV66/IRON FUMARATE/FA/DSS/DHA PNV-DHA + DOCUSATE 1 PNV66/IRON FUMARATE/FA/DSS/DHA FOLCAL DHA 1 PNV66/IRON FUMARATE/FA/DSS/DHA VEMAVITE-PRX 2 1 PNV77/SOD IRON EDTA& PS/FA/OM3 VENATAL COMPLETE DHA 1 PRENATAL NO.25/IRON/FA #6/DHA PRENA1 1 PRENATAL VIT 15/IRON CB/FA/DSS TRIADVANCE 3 1 PRENATAL VIT 15/IRON CB/FA/DSS PRENATAL AD 3 1 PRENATAL VIT 16/IRON CB/FA/DSS VINATE GT 1 PRENATAL VIT 18/IRON CB/FA/DSS VINATE ULTRA 3 1 PRENATAL VIT NO.78/IRON/FA PRENATABS FA 3 1 PRENATAL VIT/IRON FUMARATE/FA PRENATAL 19 1 PRENATAL VITAMINS#21, IRON, FA HEMENATAL OB 3 PED MV A,C,D3 #38 W-FLUORIDE TRI-VI-FLOR 3 PEDI MULTIVIT #37 W-FLUORIDE POLY-VI-FLOR 3 PN W-CA64/IRON CB&GL/FA/DSS/DH CITRANATAL 90 DHA 3 PNV #38/IRON FUM/FOLATE/DHA PRENATE DHA 3 PNV 18/FE,CARB/FA/DSS/UBI/DHA PREQUE 10 3 PNV COMBO #19/IRON/FOL AC/DHA PREFERA-OB ONE 3 PNV COMBO #22/IRON/FA/OM3/DHA PREFERA-OB PLUS DHA 3 PNV WITH CA,NO.71/IRON/FA VOL-PLUS 3 PNV WITH CA,NO63/IRON/FA/B6 CITRANATAL B-CALM 3 PNV#79/IRON/FA/LMFOLATE CA/DHA NEEVO DHA 3 PNV/FA/B6/CALCIUM PHOS/GINGER B-NEXA 3 PNV22/IRON CBN&GLUC/FA/DSS/DHA CITRANATAL DHA 3 PNV38/IRON CBN&GLUC/FA/DSS/DHA CITRANATAL ASSURE 3 PNV53/IRON FUM/FA/DOCUSATE/DHA NEXA PLUS 3 PNV66/IRON FUMARATE/FA/DSS/DHA PRENEXA 3 PNV69/IRON,CARBONYL/FA/DSS/DHA CITRANATAL HARMONY 3 PNV80/IRON FUMARATE/FA/DSS/DHA NEXA SELECT 3 PRENATAL NO.25/IRON/FA #6/DHA VITAMEDMD ONE RX 3 PRENATAL NO.39/IRON/FA #6/DHA VITAMEDMD PLUS RX 3 PRENATAL VIT #76/IRON,CARB/FA VOL-TAB RX 3 PRENATAL VIT NO.44/IRON/FA/DHA PRENATE MINI 3 PRENATAL VIT NO.78/IRON/FA VENATAL-FA 3 PRENATAL VIT#36/IRON/FA CMB#6 PRENATE ELITE 3 PRENATAL VIT#42/FA CMB#6 VITAMEDMD REDICHEW RX 3 PRENATAL VITAMINS#21, IRON, FA PREFERA OB
Mydriatics / OPHTHALMOLOGY Tier Generic Name Brand Name Notes
1 ATROPINE SULFATE ATROPINE CARE 1 ATROPINE SULFATE/PF ATROPINE SULFATE 1 CYCLOPENTOLATE HCL 1 HOMATROPINE HBR HOMATROPAIRE 2 CYCLOPENTOLATE HCL CYCLOGYL 2 SCOPOLAMINE HYDROBROMIDE ISOPTO HYOSCINE 3 HOMATROPINE HBR ISOPTO HOMATROPINE
NMDA Receptor Blocker / ANTIDEMENTIA AGENTS Tier Generic Name Brand Name Notes
3 MEMANTINE HCL NAMENDA
3 CYSTEAMINE PROCYSBI 5
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4 ONABOTULINUMTOXINA BOTOX 4
Nitrates And Nitrites / CARDIOVASCULAR Tier Generic Name Brand Name Notes
1 ISOSORBIDE DINITRATE 1 ISOSORBIDE MONONITRATE ISOSORBIDE MONONITRATE ER 1 NITROGLYCERIN NITRO-BID 2 NITROGLYCERIN NITROMIST 2 NITROGLYCERIN NITROSTAT 2 NITROGLYCERIN NITRO-DUR 3 ISOSORBIDE MONONITRATE IMDUR
Nitrogen Binding Agent / UROLOGICALS Tier Generic Name Brand Name Notes
3 GLYCEROL PHENYLBUTYRATE RAVICTI 5
Non-Nucleoside Reverse Transcriptase Inhibitor / ANTIVIRALS Tier Generic Name Brand Name Notes
1 NEVIRAPINE 2 DELAVIRDINE RESCRIPTOR 2 EFAVIRENZ SUSTIVA 2 ETRAVIRINE INTELENCE 2 RILPIVIRINE EDURANT 3 NEVIRAPINE VIRAMUNE
Nonsteroidal Anti-Inflammatory Agents / ANALGESICS/ANTI-INFLAMMATORY Tier Generic Name Brand Name Notes
1 BUTALBITAL/ASPIRIN/CAFFEINE BUTALBITAL-ASPIRIN-CAFFEINE 1 CELECOXIB 7 1 DICLOFENAC SODIUM 1 DICLOFENAC SODIUM/MISOPROSTOL DICLOFENAC SODIUM-MISOPROSTOL 1 ETODOLAC 1 IBUPROFEN 1 INDOMETHACIN 1 KETOPROFEN 1 KETOROLAC TROMETHAMINE 1 MELOXICAM 1 NABUMETONE 1 NAPROXEN 1 OXAPROZIN 1 PIROXICAM 1 SALSALATE 1 SULINDAC 2 NAPROXEN SODIUM NAPRELAN 3 ASPIRIN EXTENDED-RELEASE CAPSULES DURLAZA 5 3 BUTALBITAL/ASPIRIN/CAFFEINE FIORINAL
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Nonsteroidal Anti-Inflammatory Agents / ANALGESICS/ANTI-INFLAMMATORY (cont.) Tier Generic Name Brand Name Notes
3 CELECOXIB CELEBREX 7 3 DICLOFENAC EPOLAMINE FLECTOR 5 3 DICLOFENAC POTASSIUM CAMBIA 3 DICLOFENAC POTASSIUM ZIPSOR 3 DICLOFENAC SODIUM PENNSAID 5 3 DICLOFENAC SODIUM VOLTAREN 3 DICLOFENAC SODIUM/MISOPROSTOL ARTHROTEC 75 3 DICLOFENAC SODIUM/MISOPROSTOL ARTHROTEC 50 3 INDOMETHACIN INDOCIN 3 KETOROLAC TROMETHAMINE SPRIX 3 MELOXICAM MOBIC 3 OXAPROZIN DAYPRO
Nucleoside/Nucleotide RT Inhibitors / ANTIVIRALS Tier Generic Name Brand Name Notes
1 ABACAVIR SULFATE ABACAVIR 1 LAMIVUDINE 1 ZIDOVUDINE 1 ZIDOVUDINE/LAMIVUDINE 2 ABACAVIR SULFATE/LAMIVUDINE EPZICOM 2 ABACAVIR/LAMIVUDINE/ZIDOVUDINE TRIZIVIR 2 EMTRICITABINE/RILPIVIRINE/TENOFOVIR ODFESEY 2 EMTRICITABINE/TENOFOVIR TRUVADA 2 LAMIVUDINE EPIVIR HBV 3 ABACAVIR SULFATE ZIAGEN 3 LAMIVUDINE/ZIDOVUDINE COMBIVIR 3 ZIDOVUDINE RETROVIR
Nucleosides And Nucleotides / ANTIVIRALS Tier Generic Name Brand Name Notes
1 ENTECAVIR 1 FAMCICLOVIR 2 ADEFOVIR DIPIVOXIL HEPSERA 2 TELBIVUDINE TYZEKA 3 ENTECAVIR BARACLUDE 3 FAMCICLOVIR FAMVIR 3 VALGANCICLOVIR HCL VALCYTE
ONCOLYTIC VIRUS / ANTINEOPLASTICS Tier Generic Name Brand Name Notes
4 TALIMOGENE LAHERPAREPVEC IMLYGIC 4
Ophthalmic Antiinflammatory / OPHTHALMOLOGY Tier Generic Name Brand Name Notes
4 DESAMETHASONE INTRAVITREAL OZURDEX 4
Opiate Agonists, Short Acting / ANALGESICS Tier Generic Name Brand Name Notes
1 ACETAMINOPHEN WITH CODEINE ACETAMINOPHEN-CODEINE
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Opiate Agonists, Short Acting / ANALGESICS (cont.) Tier Generic Name Brand Name Notes
1 BUTALBIT/ACETAMIN/CAFF/CODEINE BUTALB-CAFF-ACETAMINOPH-CODEIN 1 CODEINE/BUTALBITAL/ASA/CAFFEIN BUTALBITAL COMPOUND-CODEINE 1 CODEINE/BUTALBITAL/ASA/CAFFEIN ASCOMP WITH CODEINE 1 HYDROCODONE BIT/ACETAMINOPHEN HYDROCODONE-ACETAMINOPHEN 1 HYDROCODONE/IBUPROFEN HYDROCODONE BIT-IBUPROFEN 1 HYDROCODONE/IBUPROFEN HYDROCODONE-IBUPROFEN 1 HYDROMORPHONE HCL 1 MEPERIDINE HCL 1 MORPHINE SULFATE 1 OXYCODONE HCL OXYCODONE CONCENTRATE 1 OXYCODONE HCL 1 OXYCODONE HCL/ACETAMINOPHEN OXYCODONE-ACETAMINOPHEN 1 OXYCODONE HCL/ACETAMINOPHEN ENDOCET 1 OXYCODONE HCL/ASPIRIN ENDODAN 1 OXYCODONE HCL/OXYCODON TER/ASA OXYCODONE-ASPIRIN 1 OXYMORPHONE HCL 1 TRAMADOL HCL 1 TRAMADOL HCL/ACETAMINOPHEN TRAMADOL HCL-ACETAMINOPHEN 2 HYDROMORPHONE HCL DILAUDID 2 METHADONE HCL 2 MORPHINE SULFATE AVINZA 2 MORPHINE SULFATE KADIAN 2 OXYCODONE HCL/ACETAMINOPHEN ROXICET 3 ACETAMINOPHEN WITH CODEINE TYLENOL-CODEINE NO.3 3 FENTANYL DURAGESIC 3 FENTANYL CITRATE FENTORA 3 FENTANYL CITRATE ABSTRAL 3 HYDROCODONE BIT/ACETAMINOPHEN VICODIN HP 3 HYDROCODONE BIT/ACETAMINOPHEN LORTAB 3 HYDROCODONE BIT/ACETAMINOPHEN NORCO 3 HYDROCODONE BIT/ACETAMINOPHEN VICODIN 3 HYDROCODONE BITARTRATE ZOHYDRO 3 HYDROCODONE BITARTRATE 3 HYDROCODONE/IBUPROFEN IBUDONE 3 HYDROCODONE/IBUPROFEN REPREXAIN 3 HYDROCODONE/IBUPROFEN VICOPROFEN 3 HYDROMORPHONE HCL EXALGO 3 OXYCODONE HCL/ACETAMINOPHEN PERCOCET 3 TAPENTADOL HCL NUCYNTA 3 TRAMADOL HCL RYBIX ODT 3 TRAMADOL HCL ULTRAM
Opiate Agonists,Long Acting / ANALGESICS Tier Generic Name Brand Name Notes
1 FENTANYL TRANSDERMAL FENTANYL 1 HYDROMORPHONE ER 1 MORPHINE SULFATE MORPHINE SULFATE ER 2 OXYCODONE HCL OXYCONTIN 3 HYDROCODONE BITARTRATE HYSINGLA ER 3 MORPHINE SULFATE MS CONTIN 3 OXYCODONE HCL XARTEMIS XR 3 OXYMORPHONE HCL OPANA ER 3 TAPENTADOL HCL NUCYNTA ER 3 TRAMADOL HCL ULTRAM ER
Opiate Antagonists / ANTI-ADDICTION/SUBSTANCE ABUSE Tier Generic Name Brand Name Notes
1 NALOXONE
4 NALOXONE EVZIO 5
Opiate Antagonists / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes
3 NALTREXONE HCL
Opiate Antagonists / GASTROINTESTINAL OTHER Tier Generic Name Brand Name Notes
3 METHYLNALTREXONE BROMIDE TABLETS RELISTOR 5
Opiate Antagonists / GI AGENTS Tier Generic Name Brand Name Notes
3 NALOXEGOL MOVANTIK 5
3 NALOXONE/BUPROPION CONTRAVE 5
Opiate Partial Agonists / ANALGESICS Tier Generic Name Brand Name Notes
3 BUPRENORPHINE BUTRANS 3 BUPRENORPHINE BUCCAL FILM BELBUCA
Opiate Partial Agonists / ANTI-ADDICTION/SUBSTANCE ABUSE Tier Generic Name Brand Name Notes
1 BUPRENORPHINE HCL/NALOXONE HCL BUPRENORPHINE/NALOXONE SL TABS 5 3 BUPRENORPHINE HCL/NALOXONE HCL SUBOXONE SL TABS 5 4 BUPRENORPHINE IMPLANT PROBUPHINE 4
Other Miscellaneous Therapeutic Agents / ANTINEOPLASTICS Tier Generic Name Brand Name Notes
4 OCTREOTIDE ACETATE 5
1 LEVOCARNITINE (WITH SUGAR) LEVOCARNITINE 3 LEVOCARNITINE CARNITOR SF 3 LEVOCARNITINE CARNITOR
Other Miscellaneous Therapeutic Agents / ENDOCRINE/DIABETES Tier Generic Name Brand Name Notes
3 CINACALCET HCL SENSIPAR 5 3 SAPROPTERIN DIHYDROCHLORIDE KUVAN
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Other Miscellaneous Therapeutic Agents / UROLOGICALS Tier Generic Name Brand Name Notes
3 PENTOSAN POLYSULFATE SODIUM ELMIRON
Other Miscellaneous Therapeutic Agents / VITAMINS, HEMATINICS & ELECTROLYTES Tier Generic Name Brand Name Notes
3 BAICALIN/CATECHIN/CITRATED ZNC LIMBREL250
3 TEDIZOLID SIVEXTRO
1 METHYLERGONOVINE MALEATE 3 METHYLERGONOVINE MALEATE METHERGINE
PCSK9 INHIBITOR / CARDIOVASCULAR Tier Generic Name Brand Name Notes
4 ALIROCUMAB PRALUENT 5 4 EVOLOCUMAB REPATHA 5
PO4 scavengers / GENETIC DISORDERS Tier Generic Name Brand Name Notes
3 CARGLUMIC ACID CARBAGLU 5
Parasympathomimetic (Cholinergic Agents) / AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH Tier Generic Name Brand Name Notes
1 PYRIDOSTIGMINE BROMIDE 2 PYRIDOSTIGMINE BROMIDE MESTINON
Parasympathomimetic (Cholinergic Agents) / DIAGNOSTICS & MISCELLANEOUS AGENTS Tier Generic Name Brand Name Notes
1 CEVIMELINE HCL 2 CEVIMELINE HCL EVOXAC
Parasympathomimetic (Cholinergic Agents) / UROLOGICALS Tier Generic Name Brand Name Notes
1 BETHANECHOL CHLORIDE
1 NEOSTIGMINE 1 PYRIDOSTIGMINE
4 PARATHYROID HORMONE FOR INJEC

Prescription Drug List - Marin County

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