2024 Abbreviated Formulary

2024 ABBREVIATED

FORMULARY

fepblue.org

REVIEW THIS ABBREVIATED FORMULARY TO LEARN HOW TO GET

THE MOST FROM YOUR PHARMACY BENEFIT SUCH AS:

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Understanding the Formulary

■

How to use the Abbreviated Formulary

■

Abbreviated Formulary

■

“Managed Not Covered” Drugs

■

Excluded Drug List

YOUR PHARMACY BENEFIT

The Blue Cross and Blue Shield Service Beneﬁt Plan works with CVS

Caremark to administer your pharmacy beneﬁt. CVS Caremark is an

independent company called a Pharmacy Beneﬁt Manager (PBM).

The PBM manages your:

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Retail Pharmacy Program

■

Mail Service Pharmacy Program

■

Specialty Pharmacy Program

GENERAL QUESTIONS

If you have any questions about your beneﬁts, please:

■

See the Blue Cross and Blue Shield Service Beneﬁt Plan brochures

(RI 71-005 or RI 71-017)

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Visit www.fepblue.org

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Call Customer Care any time toll-free at 1-800-624-5060

NEW FOR 2024

■

Expanded Standard Option excluded drug list. See p. 42

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Expanded Basic Option “Managed Not Covered” drug list. See p. 52

TABLE OF CONTENTS

UNDERSTANDING THE FORMULARY ...........................2

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Formulary ............................................2

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“Non-Covered” Drugs ..................................2

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Quantity Limits ........................................2

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Prior Approval .........................................3

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How Tiers Relate to Costs ...............................4

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How Prescription Drugs are Assigned to Tiers ...............5

COST SHARE TIERS

.........................................6

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Standard Option Cost Share Tiers .........................6

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Basic Option Cost Share Tiers ............................8

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FEP Blue Focus Cost Share Tiers ........................11

HOW TO USE THE ABBREVIATED FORMULARY

..................12

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Program Options .....................................12

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Legend .............................................13

ABBREVIATED FORMULARY

(NON-SPECIALTY BY CONDITION) .........14

ABBREVIATED FORMULARY

(ALPHABETIC INCLUDING SPECIALTY) ......24

EXCLUDED DRUG LIST STANDARD OPTION

.....................42

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Alphabetic Excluded Drug List Standard Option .............50

“MANAGED NOT COVERED” DRUG LIST BASIC OPTION

...........52

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Alphabetic “Managed Not Covered” Drug List Basic Option ...64

2024 PHARMACY BENEFIT CHANGE HIGHLIGHTS

................68

HOW TO CONTACT US

.....................................69

UNDERSTANDING THE FORMULARY

We continually review drugs in support of safe and appropriate

treatment. This helps to ensure that drugs in your beneﬁt plan work

well and are cost-effective.

FORMULARY

The formulary is a complete

list of your covered prescription

drugs. It includes generic, brand

name, and specialty drugs, as

well as Preferred drugs that will

lower your out-of-pocket costs.

The Standard Option and Basic

Option formularies have ﬁve tiers

of drugs. The FEP Blue Focus

formulary has two tiers of drugs.

See p. 4

NON-COVERED DRUGS

There are certain drugs approved

by the U.S. Food and Drug

Administration (FDA) that we

don’t cover. We call these drugs

“excluded” or “Managed Not

Covered.” These drugs all have

Preferred alternatives that you

can use.

Standard Option has a

comprehensive formulary.

This means we cover almost all

FDA-approved drugs. There is a

small list of excluded drugs that

are not covered. See p. 42–51

Basic Option has a managed

formulary. This means that we

cover most FDA-approved drugs.

There is a list of “Managed Not

Covered” drugs that provides

the Preferred alternatives that

you may use. See p. 52–66

FEP Blue Focus has a limited

or closed formulary. This means

that we only cover some

FDA-approved drugs. Any drug

not on the FEP Blue Focus

formulary is not covered.

If you buy a drug that is not

covered, you will pay full price.

QUANTITY LIMITS (QL)

Certain drugs on the formulary

have quantity limits (for example,

number of pills). This means your

pharmacy beneﬁt will only cover

up to a speciﬁc amount per

prescription or a limited amount

per year. Quantity limits help

ensure drugs are used safely and

appropriately. Drug quantities

are approved based on accepted

standards of healthcare practice

in the United States.

PRIOR APPROVAL (PA)

Some prescription drugs and

supplies need approval in

advance, or “prior approval”

before we provide coverage for

them. We need to conﬁrm:

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Your use of the drug is related

to a service or condition

covered under the Service

Beneﬁt Plan.

■

Your doctor prescribes it in a

way that matches generally

accepted medical practices.

FACTS TO KNOW ABOUT

PRIOR APPROVAL

■

You will need to renew your

prior approval periodically.

■

Drugs and supplies on the

Prior Approval list may change

throughout the year.

■

Mail Service and Specialty

Programs will not ﬁll

prescriptions that need prior

approval until you receive prior

approval.

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In-network (Preferred) retail

pharmacies will ﬁll your

prescriptions, but you will pay

the full cost of the drug until

you get prior approval. If you

receive prior approval, we’ll

reimburse you for our portion

of the drug cost once you ﬁle

a claim.

HELP WITH PRIOR APPROVAL

Visit fepblue.org/pharmacy/prescriptions

orcalltoll-free any time at 1-800-624-5060

(TTY: 711). You will be able to:

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See a list of drugs that need prior approval

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Get a prior approval request form

Your doctor can submit requests for prior approval by:

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Submitting an ePA (electronic prior approval)

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Calling toll-free 1-877-727-3784

■

Filling out the Prior Approval Form found at

fepblue.org/pharmacy/prescriptions

UNDERSTANDING THE FORMULARY

HOW TIERS RELATE TO COSTS

The costs of drugs vary. How much you pay is your cost share. Look

for your drug in the formulary for your plan option. The tier level where

your drug type is listed determines your cost.

Standard and Basic Options

TIER DRUG TYPE

Tier 1 Generic Drugs: typically the most affordable, and are equal to their

brand name counterparts in quality, effectiveness and intended use.

Tier 2 Preferred Brand Name Drugs: proven to be safe, effective, and

favorably priced compared to Non-preferred brands.

Tier 3

Non-preferred Brand Name Drugs: typically higher cost share

since there is a generic or Preferred brand available.

Tier 4 Preferred Specialty Drugs: proven to be safe, effective, and

favorably priced compared to Non-preferred specialty drugs.

Tier 5

Non-preferred Specialty Drugs: typically higher cost share since

there is a Preferred specialty drug available.

FEP Blue Focus

TIER DRUG TYPE

Tier 1 Preferred Generic Drugs: typically the most affordable, and are

equal to their brand name counterparts in quality, effectiveness and

intended use.

Tier 2 Preferred Brand Name Drugs and Preferred Specialty Drugs:

proven to be safe, effective, and favorably priced compared to

non-covered drug options.

HOW WE ASSIGN PRESCRIPTION DRUGS TO TIERS

The Pharmacy and Medical Policy Committee (PMPC) is an

independent group of doctors and pharmacists. This group

recommends drugs for each tier based on their:

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Effectiveness

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Safety

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How they compare to other drugs in the same class

The PMPC meets every quarter to review new drugs and other

changes to the formulary. Based on that review, we may change drug

tiers or add or remove them from the formulary. Check the formulary

often to be aware of any changes.

To see your 2024 cost share for a prescription drug:

■

Prior to January 1, 2024, visit fepblue.org/whatsnew

■

After January 1, 2024, visit fepblue.org/pharmacy/prescriptions

■

Call Customer Care: 1-800-624-5060 (T T Y: 711)

■

Use the FEP Prescription Drug Cost tool: fepblue.org/rx

COST SHARE TIERS

STANDARD OPTION COST SHARE TIERS

Standard Option members save by using the in-network (Preferred)

retail pharmacies or the Mail Service Pharmacy ﬁlling prescription drugs.

Members can also save by asking for generic and/or Preferred brand

name drugs when possible. Use the charts below to ﬁnd your cost share.

Standard Option: Generic and Brand Name Drugs

Cost Share Based on Where You Fill Your Prescription

TIER MAIL SERVICE

PHARMACY

PREFERRED

RETAIL

PHARMACY

NON-PREFERRED

RETAIL PHARMACY

Tier 1:

Generic

Drugs

$15* for up

to a 90-day

supply

$7.50* for up to

a 30-day supply

$22.50* for a 31

to 90-day supply

45% of the average

wholesale price

plus any difference

between our allowance

and the billed amount

If you use a

Non-preferred retail

pharmacy, you need

to ﬁle a paper claim

for reimbursement

Tier 2:

Preferred

Brand Name

Drugs

$90 for up

to a 90-day

supply

30% of our

allowance

Tier 3:

Non-

preferred

Brand Name

Drugs

$125 for up

to a 90-day

supply

50% of our

allowance

* Lower cost shares are available to Standard Option members with Medicare Part B primary.

Standard Option: Specialty Drugs

Cost Share Based on Where You Fill Your Prescription

TIER SPECIALT Y

PHARMACY

PREFERRED

RETAIL PHARMACY

NON-PREFERRED

RETAIL PHARMACY

Tier 4:

Preferred

Specialty

Drugs

$65 for up to a

30-day supply

$185 for a 31 to

90-day supply

You are limited to a

30-day supply for the

ﬁrst 3 ﬁlls of each

specialty drug. You

can get up to a 90-day

supply after the third ﬁll

30% of our

allowance

When you buy

specialty drugs at

a Preferred retail

pharmacy, you

are limited to one

30-day supply for

each prescription.

You must get all

reﬁlls through

the Specialty

Pharmacy

45% of the

average wholesale

price plus any

difference

between our

allowance and

the billed amount

When you buy

specialty drugs at

a Non-preferred

retail pharmacy,

you are limited

to one 30-day

supply for each

prescription.

You must get all

reﬁlls through

the Specialty

Pharmacy

Tier 5:

Non-

preferred

Specialty

Drugs

$85 for up to a

30-day supply

$240 for a 31 to

90-day supply

You are limited to a

30-day supply for the

ﬁrst 3 ﬁlls of each

specialty drug. You

can get up to a 90-day

supply after the third ﬁll

To see 2024 Standard Option with Medicare Part B

primary cost shares:

■

Prior to January 1, 2024, visit fepblue.org/whatsnew

■

After January 1, 2024, visit fepblue.org/pharmacy/prescriptions

■

Call Customer Care: 1-800-624-5060 (T T Y: 711)

■

Use the FEP Prescription Drug Cost tool: fepblue.org/rx

BASIC OPTION COST SHARE TIERS

Basic Option members must use an in-network (Preferred) retail

pharmacy and will save by choosing generic drugs and Preferred brand

name drugs when possible. Use the charts below to ﬁnd your cost share.

Basic Option: Generic and Brand Name Drugs

Cost Share Based on Where You Fill Your Prescription*

TIER PREFERRED

RETAIL PHARMACY

NON-PREFERRED

RETAIL PHARMACY

& MAIL SERVICE

PHARMACY

Tier 1:

Generic

Drugs

$15 for up to a 30-day supply

$40 for a 31 to 90-day supply

Not covered*

Tier 2:

Preferred

Brand Name

Drugs

$60 for up to a 30-day supply

$180 for a 31 to 90-day supply

Tier 3:

Non-preferred

Brand Name

Drugs

60% of our allowance with a $90

minimum for up to a 30-day supply

and $250 minimum for a 31 to

90-day supply

* Basic Option members with Medicare Part B primary coverage have Mail Service Pharmacy

beneﬁts and some lower cost shares.

COST SHARE TIERS

Basic Option: Specialty Drugs

Cost Share Based on Where You Fill Your Prescription*

TIER SPECIALT Y

PHARMACY

PREFERRED

RETAIL PHARMACY

Tier 4:

Preferred

Specialty

Drugs

$85 for up to a 30-day supply

$235 for a 31 to 90-day supply

You are limited to a 30-day

supply for the ﬁrst 3 ﬁlls of

each specialty drug. You can

get up to a 90-day supply

after the third ﬁll

$85 for up to a

30-day supply only

When you buy specialty

drugs at a Preferred retail

pharmacy, you are limited to

one 30-day supply for each

prescription. You must get

all reﬁlls through the

Specialty Pharmacy

Tier 5:

Non-preferred

Specialty

Drugs

$110 for up to a 30-day supply

$300 for a 31 to 90-day supply

You are limited to a 30-day

supply for the ﬁrst 3 ﬁlls of

each specialty drug. You can

get up to a 90-day supply

after the third ﬁll

$110 for up to a

30-day supply only

When you buy specialty

drugs at a Preferred retail

pharmacy, you are limited to

one 30-day supply for each

prescription. You must get

all reﬁlls through the

Specialty Pharmacy

* Basic Option members with Medicare Part B primary coverage have some lower cost shares.

To see 2024 Basic Option with Medicare Part B

primary cost shares:

■

Prior to January 1, 2024, visit fepblue.org/whatsnew

■

After January 1, 2024, visit fepblue.org/pharmacy/prescriptions

■

Call Customer Care: 1-800-624-5060 (T T Y: 711)

■

Use the FEP Prescription Drug Cost tool: fepblue.org/rx

COST SHARE TIERS

FEP BLUE FOCUS COST SHARE TIERS

Members who use generic medications will beneﬁt the most from

FEP Blue Focus. This plan has a limited or closed formulary of

covered drugs.

FEP Blue Focus

Cost Share Based on Where You Fill Your Prescription

TIER PREFERRED RETAIL PHARMACY AND

SPECIALT Y PHARMACY

Tier 1:

Preferred

Generic Drugs

$5 for up to a 30-day supply

$15 for a 31 to 90-day supply

Tier 2:

Preferred Brand

Name Drugs

and Preferred

Specialty Drugs

40% of our allowance up to $350 for up to a 30-day supply

40% of our allowance up to $1,050 for a 31 to 90-day supply

You are limited to a 30-day supply for each specialty

drug prescription

To see 2024 FEP Blue Focus cost shares:

■

Prior to January 1, 2024, visit fepblue.org/whatsnew

■

After January 1, 2024, visit fepblue.org/pharmacy/prescriptions

■

Call Customer Care: 1-800-624-5060 (T T Y: 711)

■

Use the FEP Prescription Drug Cost tool: fepblue.org/rx

HOW TO USE THE

ABBREVIATED FORMULARY

Use the abbreviated formulary to

ﬁnd the most cost-effective drugs

for your condition.

Find the tier related to your

drug. The charts are organized:

■

By drug category for

Non-specialty drugs by condition

See p. 14–23

■

Alphabetically, including

specialty for all drugs

See p. 24–40

See if there are any limitations

for your drug.

Review the cost share

charts to ﬁnd your copay or

coinsurance.

See p. 6 –11

If your drug is in Tiers 2, 3 or

5, ask your doctor if there is

a generic drug to treat your

condition. If there is not a

generic drug, ask your doctor

to prescribe a Preferred brand

name drug.

PROGRAM OPTIONS

The beneﬁt for Standard Option

(SO), Basic Option (BO) and

FEP Blue Focus (BF) varies. The

charts list the SO, BO and BF

tiers for each drug. In many cases

the tier is the same, but not in

every case.

To see the 2024 full formularies:

■

Prior to January 1, 2024, visit fepblue.org/whatsnew

■

After January 1, 2024, visit fepblue.org/pharmacy/prescriptions

■

Call Customer Care: 1-800-624-5060 (T T Y: 711)

PROGRAM LEGEND

Some drugs are noted with letters or symbols in the columns next

to them. The letters describe any limitations.

‡

Quantity Limit: beneﬁt will only cover up to a speciﬁed, limited amount

of the drug each time you ﬁll a prescription or a limited amount per year.

◊ Prior Approval: needs approval in advance before a drug is covered.

Step Therapy: before we provide coverage for a speciﬁc drug, we may

require you to try a different drug(s) ﬁrst.

◊$

Prior Approval with Step Therapy.

This list shows uses for why certain drugs are prescribed. Some

drugs can be prescribed for multiple conditions.

Generic oral contraceptives and select brand contraceptives are

available to eligible members at no copay.

NC Not Covered

SO Standard Option

Basic Option

BF FEP Blue Focus

BOLD Bold type means there is a generic for this drug.

ITALIC Italic type means this is a specialty drug.

This abbreviated formulary lists the most commonly used drugs.

Please note: Before ﬁlling your prescription, check the Preferred/

Non-preferred status of the drug. Other than changes resulting

from new drugs or safety issues, the Preferred drug list is updated

periodically during the year.

ABBREVIATED FORMULARY

(NON-SPECIALTY BY CONDITION)

Bold Type means there is a generic version for this drug. Drugs that

are listed in CAPITAL LETTERS are brand name drugs, while those in

lowercase are generic versions.

CONDITION/DRUG

TIER

ALLERGY/COUGH & COLD

azelastine 1 1 1

BECONASE AQ 3 NC NC

benzonatate 1 1 1

CLARINEX 3 NC NC

CLARINEX-D 3 NC NC

desloratadine 1 NC NC

ﬂunisolide spray 1 1 1

ﬂuticasone spray 1 1 1

levocetirizine 1 NC NC

promethazine/codeine ‡ 1 1 1

VERAMYST 2 NC NC

ANTI-INFECTIVES/ANTIBIOTICS/

ANTIFUNGAL/ANTIVIRAL

amoxicillin 1 1 1

amoxicillin/ clavulanate

potassium

1 1 1

azithromycin 1 1 1

cephalexin 1 1 1

ciproﬂoxacin 1 1 1

clotrimazole/

betamethasone ‡

1 1 1

ERTACZO ◊ 3 NC NC

EXELDERM ◊ 3 3 NC

ﬂuconazole 1 1 1

CONDITION/DRUG

TIER

JUBLIA ◊ 3 NC NC

KERYDIN*◊ 3 NC NC

ketoconazole tabs ◊ 1 1 1

levoﬂoxacin 1 1 1

LOPROX ‡ 3 NC NC

LUZU ◊ 3 NC NC

MENTA X 3 NC NC

naftiﬁne ‡ 1 1 1

oseltamivir phosphate ‡ 1 1 1

OXISTAT ◊ 3 NC NC

sulfamethoxazole/

trimethoprim

1 1 1

TAMIFLU CAPS ‡ 3 3 NC

tavaborole sol 5% * ◊ 1 1 1

valacyclovir 1 1 1

VALTREX 3 3 NC

VUSION ‡ * 3 NC NC

XOFLUZA ‡ 3 3 2

ZOVIRAX 3 3 NC

ANTINEOPLASTICS AND

IMMUNOSUPPRESSANTS

anastrozole 1 1 1

ASTAGRAF XL 2 2 2

azathioprine 1 1 1

ABBREVIATED FORMULARY

(NON-SPECIALTY BY CONDITION)

CONDITION/DRUG

TIER

CELLCEPT 3 3 NC

cyclosporine 1 1 1

letrozole 1 1 1

megestrol acetate 1 1 1

mycophenolate mofetil 1 1 1

MYFORTIC 3 3 NC

NEORAL 3 3 NC

NILANDRON ◊ 3 3 NC

PROGRAF 3 3 NC

RAPAMUNE 3 3 NC

sirolimus 1 1 1

tacrolimus 1 1 1

tamoxifen citrate 1 1 1

ANTIVIRAL/HIV

abacavir 1 1 1

abacavir/ lamivudine/

zidovudine

1 1 1

APTIVUS 2 2 2

BIKTARV Y 2 2 2

COMBIVIR 3 3 NC

DESCOVY 2 2 2

DOVATO 2 2 2

EDURANT 2 2 2

efavirenz/emtricitabine/

tenofovir disoproxil

fumarate

1 1 1

emtricitabine/tenofovir

disoproxil fumarate

1 1 1

CONDITION/DRUG

TIER

EPIVIR 3 3 NC

EPZICOM 3 3 NC

etravirine 1 1 1

GENVOYA 2 2 2

ISENTRESS 2 2 2

lamivudine 1 1 1

lamivudine/zidovudine 1 1 1

nevirapine ext-rel 1 1 1

RETROVIR 3 3 NC

REYATAZ 3 3 NC

stavudine 1 1 1

STRIBILD 2 2 2

TRIUMEQ 2 2 2

TRIZIVIR 3 3 NC

TRUVADA 3 3 NC

VIRACEPT 2 2 2

ZIAGEN 3 3 NC

zidovudine 1 1 1

ASTHMA/COPD

ALVESCO 3 NC NC

ACCOLATE 3 3 NC

ADVAIR DISKUS 3 3 NC

ADVAIR HFA 3 3 NC

albuterol sulfate tablet/

solution

1 1 1

albuterol sulfate,

CFC-free aerosol

1 1 1

ABBREVIATED FORMULARY (NON-SPECIALTY BY CONDITION)

CONDITION/DRUG

TIER

ANORO ELLIPTA 2 2 2

arformeterol soln 1 1 1

ARNUITY ELLIPTA 2 2 2

ATROVENT HFA 2 3 NC

BREO ELLIPTA 3 3 NC

BROVANA 3 3 NC

budesonide/formoterol 1 1 1

COMBIVENT

RESPIMAT

3 3 NC

DULERA 2 2 2

FLOVENT HFA 3 3 NC

ﬂuticasone/salmeterol

CFC-free aerosol

1 1 1

ﬂuticasone/salmeterol

diskus

1 1 1

ﬂuticasone/vilanterol 1 1 1

FORADIL 3 3 NC

formeterol inhalation soln 1 1 1

INCRUSE ELLIPTA 3 NC NC

montelukast sodium 1 1 1

PERFOROMIST 3 3 NC

PROAIR HFA 3 3 NC

PROVENTIL HFA 3 NC NC

QVAR/REDIHALER 2 2 2

SINGULAIR 3 3 NC

SPIRIVA RESPIMAT 2 2 2

SPIRIVA 3 3 NC

STIOLTO RESPIMAT 2 2 2

STRIVERDI RESPIMAT 3 3 NC

CONDITION/DRUG

TIER

SYMBICORT 3 3 NC

tiotropium inhalation

powder caps

1 1 1

TRELEGY ELLIPTA 2 2 2

TUDORZA PRESSAIR 3 NC NC

VENTOLIN HFA 3 NC NC

XOPENEX HFA 3 NC NC

XOPENEX/

CONCENTRATE

3 3 NC

zaﬁrlukast 1 1 1

CARDIOVASCULAR DRUGS:

HIGH BLOOD PRESSURE

amlodipine besylate/

benazepril hydrochloride

1 1 1

ATACAND/HCT 3 NC NC

atenolol 1 1 1

AVALIDE 3 NC NC

AVAPRO 3 NC NC

AZOR 3 3 NC

BENICAR/HCT 3 3 NC

BREVIBLOC 3 3 NC

BYSTOLIC 3 NC NC

candesartan/hctz 1 1 1

carvedilol 1 1 1

clonidine 1 1 1

COZAAR 3 NC NC

diltiazem er 1 1 1

DIOVAN/HCT 3 NC NC

doxazosin mesylate 1 1 1

CONDITION/DRUG

TIER

EDARBI 3 NC NC

EDARBYCLOR 3 NC NC

enalapril maleate 1 1 1

EXFORGE/HCTZ 3 3 NC

furosemide 1 1 1

hydralazine 1 1 1

hydrochlorothiazide 1 1 1

HYZAAR 3 NC NC

irbesartan/hctz 1 1 1

lisinopril/hctz 1 1 1

losartan/hctz 1 1 1

metoprolol succinate/

tartrate

1 1 1

MICARDIS/HCT 3 NC NC

nebivolol 1 1 1

propranolol 1 1 1

ramipril 1 1 1

spironolactone 1 1 1

telmisartan/hctz 1 1 1

triamterene/hctz 1 1 1

valsartan/hctz 1 1 1

verapamil/er 1 1 1

CARDIOVASCULAR DRUGS:

HIGH CHOLESTEROL

amlodipine/atorvastatin 1 1 1

atorvastatin calcium 1 1 1

CADUET 3 NC NC

CRESTOR 3 NC NC

ezetimibe 1 1 1

CONDITION/DRUG

TIER

fenoﬁbrate 1 1 1

fenoﬁbric acid 1 1 1

gemﬁbrozil 1 1 1

icosapent ehtyl caps 1 1 1

LESCOL XL 3 NC NC

LIPITOR 3 NC NC

LIVALO 3 NC NC

lovastatin 1 1 1

LOVAZA 3 3 NC

niacin er 1 1 1

omega-3 acid

ethyl esters

1 1 1

pravastatin sodium 1 1 1

rosuvastatin 1 1 1

simvastatin (except susp) 1 1 1

VYTORIN 3 NC NC

WELCHOL 3 3 NC

ZETIA 3 3 NC

ZOCOR 3 NC NC

CARDIOVASCULAR DRUGS: OTHER

AGGRASTAT 3 3 NC

BRILINTA 3 3 NC

clopidogrel 1 1 1

dabigatran caps 1 1 1

digoxin 1 1 1

EFFIENT 3 3 NC

ELIQUIS 2 2 2

enoxaparin sodium 1 1 1

ABBREVIATED FORMULARY (NON-SPECIALTY BY CONDITION)

CONDITION/DRUG

TIER

ENTRESTO 3 3 2

isosorbide mononitrate er 1 1 1

NEXLETOL ◊ 3 3 NC

NEXLIZET ◊ 3 3 NC

NITROSTAT 3 3 NC

PLAVIX 3 3 NC

PRALUENT ◊ 3 NC NC

REPATHA ◊ 2 2 2

warfarin 1 1 1

X ARELTO 2 2 2

CENTRAL NERVOUS SYSTEM:

ANXIETY AND DEPRESSION

alprazolam 1 1 1

amitriptyline 1 1 1

bupropion/xl 1 1 1

citalopram tabs 1 1 1

CYMBALTA 3 3 NC

diazepam 1 1 1

duloxetine ER 1 1 1

EFFEXOR XR 3 3 NC

escitalopram oxalate 1 1 1

ﬂuoxetine 1 1 1

LEXAPRO 3 3 NC

lorazepam 1 1 1

paroxetine 1 1 1

PRISTIQ 3 3 NC

sertraline tabs 1 1 1

trazodone 1 1 1

CONDITION/DRUG

TIER

TRINTELLIX 3 3 NC

venlafaxine hcl/er 1 1 1

VIIBRYD 3 3 NC

vilazodone 1 1 1

WELLBUTRIN XL 3 NC NC

CENTRAL NERVOUS SYSTEM:

ATTENTION DEFICIT DISORDER

amphetamine salt

combo ◊

1 1 1

DAYTRANA ◊ 3 3 NC

dextro-amphetamine/

amphetamine salts ◊

1 1 1

FOCALIN XR ◊ 3 3 NC

INTUNIV 3 3 NC

JORNAY PM ◊ 3 3 NC

lisdexamfetamine ◊ 1 1 1

METHYLIN ◊ 3 3 NC

methylphenidate/er

(except methylphenidate

tab ER osmotic release

45mg, 63mg, 72mg) ◊

1 1 1

MYDAYIS ◊ 2 2 2

STRATTERA 3 3 NC

VYVANSE ◊ 3 3 NC

CENTRAL NERVOUS SYSTEM: MIGRAINE

AIMOVIG ◊ 2 2 2

EMGALITY ◊ 2 2 2

NURTEC ODT ◊ 2 2 2

RELPAX ‡ 3 3 NC

rizatriptan ‡ 1 1 1

CONDITION/DRUG

TIER

sumatriptan succinate ‡ 1 1 1

zolmitriptan ‡ 1 1 1

ZOMIG/ZMT ‡ 3 3 NC

CENTRAL NERVOUS SYSTEM: OTHER

ABILIFY 3 3 NC

ADLARITY 3 3 NC

AZILECT 3 3 NC

baclofen 1 1 1

carbidopa/levodopa & er 1 1 1

cyclobenzaprine 1 1 1

donepezil 1 1 1

EQUETRO 3 3 NC

EXELON 3 3 NC

LATUDA 3 3 NC

lurasidone 1 1 1

NAMENDA TABS 3 3 NC

NEUPRO 2 2 2

pramipexole

dihydrochloride

1 1 1

quetiapine fumarate 1 1 1

risperidone 1 1 1

ropinirole 1 1 1

SAVELLA ‡ 3 3 NC

SEROQUEL XR 3 3 NC

CENTRAL NERVOUS SYSTEM: PAIN

buprenorphine patch ‡ 1 1 1

buprenorphine/naloxone ‡ 1 1 1

butalbital/APAP ‡ 1 1 1

CONDITION/DRUG

TIER

BUTRANS ‡ 3 3 NC

EMBEDA ‡ 2 2 NC

fentanyl patch ‡ 1 1 1

hydrocodone/

acetaminophen ‡

1 1 1

hydromorphone ‡ 1 1 1

MORPHABOND ‡ 3 3 NC

OXYCONTIN ‡ 3 NC NC

SUBOXONE FILM ‡ 3 3 NC

tramadol

(except 100mg tab)/er ‡

1 1 1

ZUBSOLV ‡ 2 2 2

CENTRAL NERVOUS SYSTEM:

SEIZURE DISORDERS

clonazepam 1 1 1

gabapentin ‡ 1 1 1

lamotrigine 1 1 1

levetiracetam 1 1 1

LYRICA ‡ 3 NC NC

pregabalin ‡ 1 1 1

topiramate/er 1 1 1

CENTRAL NERVOUS SYSTEM:

SLEEP AGENTS

AMBIEN/CR ‡ 3 NC NC

EDLUAR ‡ 3 NC NC

eszopiclone ‡ 1 1 1

LUNESTA ‡ 3 NC NC

ramelteon ‡ 1 1 1

ROZEREM ‡ 3 NC NC

ABBREVIATED FORMULARY (NON-SPECIALTY BY CONDITION)

CONDITION/DRUG

TIER

temazepam ‡ 1 1 1

zaleplon ‡ 1 1 1

zolpidem/ER ‡ 1 1 1

CONTRACEPTIVES: OTHER

ANNOVERA 3 3 NC

etonogestrel/

EE vaginal ring**

1 1 1

NUVARING 3 3 NC

PARAGARD T 380A** 2 2 2

DERMATOLOGY

betamethasone ‡ 1 1 1

CARAC 3 NC NC

ciclopirox ‡ 1 1 1

clindamycin phosphate ‡ 1 1 1

clobetasol propionate ‡ 1 1 1

CLOBEX ‡ 3 3 NC

doxepin crm ‡ 1 1 1

EPIDUO/FORTE ◊ 3 3 NC

ERYGEL ‡ 3 3 NC

ﬂuorouracil cream 0.5% 1 NC NC

lidocaine topical ‡ 1 1 1

methylprednisolone 1 1 1

mupirocin ‡ 1 1 1

NORITATE ◊ 3 NC NC

ORACEA 3 3 NC

TAZORAC ◊ 3 3 NC

tretinoin ◊ 1 1 1

CONDITION/DRUG

TIER

DIABETES: BLOOD GLUCOSE MONITORING

ACCU CHEK

TEST STRIPS ‡

2 2 2

DEXCOM CGM

SYSTEM ◊

3 3 NC

FREESTYLE LIBRE/

FREESTYLE LIBRE

CGM SYSTEM ◊

2 2 2

ONETOUCH TEST

STRIPS ‡

2 2 2

DIABETES: DRUGS

AFREZZA ◊ 3 3 NC

BAQSIMI 2 2 2

FARXIGA $ 2 2 2

glimepiride 1 1 1

glipizide/er/xl 1 1 1

GLUCAGEN 2 2 2

glyburide 1 1 1

GVOKE 2 2 2

INVOKANA ◊ $ 3 NC NC

JANUMET 2 2 2

JANUMET XR 2 2 2

JANUVIA 2 2 2

JARDIANCE $ 2 2 2

MOUNJARO ◊ 2 2 2

OZEMPIC ◊ 2 2 2

pioglitazone 1 1 1

RYBELSUS ◊ 2 2 2

saxagliptin 1 1 1

CONDITION/DRUG

TIER

saxagliptin/metformin er 1 1 1

TRULICITY ◊ 2 2 2

VICTOZA ◊ 2 2 2

DIABETES: INSULIN

BASAGLAR 2 2 2

FIASP/FLEXTOUCH 2 2 2

HUMALOG/MIX/

KWIKPEN

2 NC NC

HUMULIN U-500

CONCENTRATE

2 2 2

HUMULIN/KWIKPEN

(EXCEPT HUMULIN

U-500 CONCENTRATE)

2 NC NC

INSULIN ASPART 2 2 2

INSULIN LISPRO 2 NC NC

LEVEMIR 2 2 2

LYUMJEV/KWIKPEN 3 NC NC

NOVOLIN 2 2 2

NOVOLOG/MIX/

FLEXPEN

2 2 2

TRESIBA 2 3 NC

DIABETES: MISCELLANEOUS

OMNIPOD DASH/5 G6

INSULIN INFUSION

DISPOSABLE PUMP ◊

3 3 NC

V-GO INSULIN

INFUSION

DISPOSABLE PUMP ◊

2 2 2

EYE/EAR

ALPHAGAN P 3 3 NC

ALREX 2 2 2

AZOPT 3 3 NC

CONDITION/DRUG

TIER

brimonidine tartrate 1 1 1

brimonidine/timolol 1 1 1

CEQUA ◊ 3 3 NC

CIPRODEX 3 3 NC

COMBIGAN 3 3 NC

diﬂuprednate 1 1 1

dorzolamide/timolol

maleate

1 1 1

DUREZOL 3 3 NC

latanoprost 1 1 1

LUMIGAN 2 NC NC

prednisolone acetate 1 1 1

RESTASIS ◊ 3 3 NC

RHOPRESSA 2 3 NC

ROCKL ATAN 2 3 NC

taﬂuprost 1 1 1

timolol maleate 1 1 1

TRAVATAN Z 3 3 NC

VIGAMOX 3 3 NC

XIIDRA ◊ 2 2 2

ZIOPTAN 3 3 NC

GASTROINTESTINAL DRUGS

ASACOL HD 3 NC NC

CREON 2 2 2

DELZICOL 3 NC NC

DEXILANT ‡ 3 NC NC

dexlansoprazole

delayed-rel ‡

1 1 1

dicyclomine 1 1 1

ABBREVIATED FORMULARY (NON-SPECIALTY BY CONDITION)

CONDITION/DRUG

TIER

EMEND ‡ 3 3 NC

esomeprazole

magnesium delayed-rel ‡

1 1 1

famotidine 40mg 1 1 1

lansoprazole ‡ 1 1 1

LIALDA 3 3 NC

LINZESS ◊ 2 2 2

lubiprostone ◊ 1 1 1

mesalamine er caps 1 1 1

MOVIPREP 3 3 NC

omeprazole 1 1 1

omeprazole/sodium

bicarbonate ‡

1 NC NC

ondansetron/odt ‡ 1 1 1

pantoprazole sodium ‡ 1 1 1

PENTASA 2 NC NC

polyethylene

glycol 3350

1 1 1

rabeprazole delayed-rel

(except rabeprazole

capsule sprinkle

delayed-rel) ‡

1 1 1

RELISTOR ◊ 3 3 2

sodium sulfate,

potassium sulfate and

magnesium sulfate

oral sol

1 1 1

sucralfate 1 1 1

SUPREP BOWEL

PREP KIT

3 3 NC

VARUBI ‡ 2 2 2

VIOKACE 2 2 2

CONDITION/DRUG

TIER

HORMONE REPLACEMENT

ANDRODERM ◊ 2 2 2

ANDROGEL ◊ 3 NC NC

ESTRACE 3 3 NC

estradiol 1 1 1

FORTESTA ◊ 3 3 NC

MINIVELLE 3 3 NC

PREFEST 3 3 NC

PREMARIN 2 2 2

PREMPRO 2 2 2

progesterone ◊ 1 1 1

STRIANT ◊ 3 3 NC

TESTIM ◊ 3 NC NC

testosterone

cypionate ◊

1 1 1

testosterone gel ◊ 1 1 1

VAGIFEM 3 3 NC

VIVELLE DOT 3 3 NC

VOGELXO ◊ 3 NC NC

INFLAMMATION: CORTICOSTEROIDS

CORTEF 3 NC NC

MEDROL 3 NC NC

ORAPRED ODT 3 NC NC

prednisone 1 1 1

RAYOS ◊ 3 NC NC

MISCELLANEOUS

allopurinol

(except 200mg tabs)

1 1 1

CONDITION/DRUG

TIER

calcitriol 1 1 1

COLCRYS 3 3 NC

epinephrine injection 1 1 1

EPIPEN/JR 3 3 NC

EVISTA 3 3 NC

febuxostat ◊ 1 1 1

naloxone 1 1 1

NARCAN 3 3 NC

ORAL CONTRACEPTIVES

MIRCETTE** 3 3 NC

LO LOESTRIN FE** 2 2 2

OSTEOPOROSIS/BONE DISEASES

ACTONEL 3 3 NC

alendronate 1 1 1

ibandronate 1 1 1

risedronate 1 1 1

PSORIASIS

acitretin 1 1 1

calcipotriene-

betamethasone ‡

1 1 1

RHEUMATOLOGY

ARTHROTEC 3 NC NC

CELEBREX ‡ 3 3 NC

celecoxib ‡ 1 1 1

diclofenac tablets 1 1 1

FELDENE 3 NC NC

ibuprofen 1 1 1

CONDITION/DRUG

TIER

meloxicam tabs 1 1 1

methotrexate inj 1 1 1

NAPROSYN 3 NC NC

OTREXUP ◊ 3 3 NC

RASUVO ◊ 3 3 NC

THYROID MEDICATIONS

ARMOUR THYROID 3 3 NC

levothyroxine 1 1 1

SYNTHROID 2 2 2

UROLOGIC DISORDERS

AVODART 3 3 NC

fesoterodine er 1 1 1

ﬁnasteride 1 1 1

GELNIQUE 3 NC NC

JALYN 3 NC NC

MYRBETRIQ 2 2 NC

oxybutynin/er 1 1 1

phenazopyridine 1 1 1

RAPAFLO 3 3 NC

silodosin 1 1 1

solifenacin 1 1 1

tamsulosin 1 1 1

tolterodine/ER 1 1 1

TOVIAZ 3 3 NC

trospium/er 1 1 1

ABBREVIATED FORMULARY

(ALPHABETIC INCLUDING SPECIALTY)

Bold Type means there is a generic version for this drug. Italic Type

means this is a specialty drug. Drugs that are listed in CAPITAL LETTERS

are brand name drugs, while those in lowercase are generic versions.

NAME

TIER

abacavir 1 1 1

abacavir/lamivudine/

zidovudine

1 1 1

ABILIFY 3 3 NC

ABIRATERONE ◊ 4 4 2

ABRAXANE 5 5 NC

ACCOLATE 3 3 NC

ACCU CHEK TEST

STRIPS‡

2 2 2

acitretin 1 1 1

ACTEMRA ◊ 4 4 2

ACTHAR ◊ 5 5 NC

ACTONEL 3 3 NC

ADBRY ◊ 4 4 NC

ADCETRIS ◊ 4 4 NC

ADCIRCA ◊ 5 NC NC

ADEFOVIR DIPIVOXIL 4 4 2

ADEMPAS ◊ 5 5 2

ADLARITY 3 3 NC

ADRIAMYCIN 5 5 NC

ADVAIR DISKUS 3 3 NC

ADVAIR HFA 3 3 NC

ADVATE 4 4 NC

ADYNOVATE 5 5 NC

AFINITOR ◊ 5 NC NC

NAME

TIER

AFINITOR

DISPERZ TABS ◊

5 NC NC

AFREZZA ◊ 3 3 NC

AFSTYLA 4 4 NC

AGGRASTAT 3 3 NC

AIMOVIG ◊ 2 2 2

albuterol sulfate

tablet/solution

1 1 1

albuterol sulfate,

CFC-free aerosol

1 1 1

ALDURAZYME ◊ 4 4 NC

ALECENSA ◊ 4 4 2

alendronate 1 1 1

allopurinol

(except 200mg tabs)

1 1 1

ALPHAGAN P 3 3 NC

ALPHANATE 4 4 2

ALPHANINE SD 4 4 NC

alprazolam 1 1 1

ALPROLIX 4 4 2

ALREX 2 2 2

ALTUVIIIO 5 5 NC

ALUNBRIG ◊ 4 4 2

ALVESCO 3 NC NC

AMBIEN/CR ‡ 3 NC NC

AMBRISENTAN ◊ 4 4 2

ABBREVIATED FORMULARY

(ALPHABETIC INCLUDING SPECIALTY)

NAME

TIER

AMIFOSTINE 4 4 2

amitriptyline 1 1 1

amlodipine besylate/

benazepril hydrochloride

1 1 1

amlodipine/atorvastatin 1 1 1

AMONDYS-45 ◊ 5 5 NC

amoxicillin 1 1 1

amoxicillin/clavulanate

potassium

1 1 1

amphetamine

salt combo ◊

1 1 1

anastrozole 1 1 1

ANDRODERM ◊ 2 2 2

ANDROGEL ◊ 3 NC NC

ANNOVERA 3 3 NC

ANORO ELLIPTA 2 2 2

APOKYN ◊ 5 NC NC

APOMORPHINE ◊ 4 4 2

APTIVUS 2 2 2

ARALAST NP ◊ 5 5 NC

ARANESP ◊ 4 4 2

ARCALYST ◊ 4 4 2

arformeterol soln 1 1 1

ARMOUR THYROID 3 3 NC

ARNUITY ELLIPTA 2 2 2

ARRANON 5 5 NC

ARTHROTEC 3 NC NC

ASACOL HD 3 NC NC

NAME

TIER

ASTAGRAF XL 2 2 2

ATACAND/HCT 3 NC NC

atenolol 1 1 1

atorvastatin calcium 1 1 1

ATROVENT HFA 2 3 NC

AUBAGIO ◊ 5 5 NC

AVALIDE 3 NC NC

AVAPRO 3 NC NC

AVODART 3 3 NC

AVONEX ◊ 4 4 2

AZACITIDINE ◊ 4 4 NC

azathioprine 1 1 1

azelastine 1 1 1

AZILECT 3 3 NC

azithromycin 1 1 1

AZOPT 3 3 NC

AZOR 3 3 NC

baclofen 1 1 1

BAQSIMI 2 2 2

BARACLUDE SOLN 4 4 2

BASAGLAR 2 2 2

BECONASE AQ 3 NC NC

BELEODAQ ◊ 4 4 NC

BENDAMUSTINE ◊ 4 4 2

BENDEKA ◊ 4 4 NC

BENEFIX 4 4 2

BENICAR/HCT 3 3 NC

ABBREVIATED FORMULARY (ALPHABETIC INCLUDING SPECIALTY)

NAME

TIER

BENLYSTA ◊ 4 4 NC

benzonatate 1 1 1

BERINERT ◊ 4 4 2

BESREMI ◊ 5 5 NC

BETAINE ANHYDROUS 4 4 2

betamethasone ‡ 1 1 1

BETASERON ◊ 4 4 2

BETHKIS 5 5 NC

BEXAROTENE

CAPS/GEL ◊

4 4 2

BICNU 5 5 NC

BIKTARVY 2 2 2

BIVIGAM ◊ 4 4 NC

BLEOMYCIN 4 4 2

BLINCYTO ◊ 4 4 2

BOSENTAN ◊ 4 4 2

BOSULIF ◊ 4 4 2

BOTOX ◊ 4 4 2

BRAFTOVI ◊ 5 5 NC

BREO ELLIPTA 3 3 NC

BREVIBLOC 3 3 NC

BRILINTA 3 3 NC

brimonidine tartrate 1 1 1

brimonidine/timolol 1 1 1

BROVANA 3 3 NC

budesonide/formoterol 1 1 1

BUPHENYL ◊ 5 5 NC

buprenorphine patch ‡ 1 1 1

NAME

TIER

buprenorphine/naloxone ‡ 1 1 1

bupropion/xl 1 1 1

butalbital/APAP ‡ 1 1 1

BUTRANS ‡ 3 3 NC

BYSTOLIC 3 NC NC

CADUET 3 NC NC

calcipotriene-

betamethasone ‡

1 1 1

calcitriol 1 1 1

CALQUENCE ◊ 4 4 2

candesartan/hctz 1 1 1

CARAC 3 NC NC

carbidopa/

levodopa & er

1 1 1

carvedilol 1 1 1

CELEBREX ‡ 3 3 NC

celecoxib ‡ 1 1 1

CELLCEPT 3 3 NC

cephalexin 1 1 1

CEPROTIN ◊ 4 4 NC

CEQUA ◊ 3 3 NC

CERDELGA ◊ 4 4 2

CEREZYME ◊ 4 4 2

CETROTIDE ◊ 5 5 NC

CHORIONIC

GONADOTROPIN ◊

4 4 2

CIBINQO ◊ 5 5 NC

ciclopirox ‡ 1 1 1

CIMZIA ◊ 5 5 NC

NAME

TIER

CINACALCET ◊ 4 4 2

CINRYZE ◊ 4 4 2

CIPRODEX 3 3 NC

ciproﬂoxacin 1 1 1

CISPLATIN 4 4 2

citalopram tabs 1 1 1

CLADRIBINE 4 4 2

CLARINEX 3 NC NC

CLARINEX-D 3 NC NC

clindamycin phosphate ‡ 1 1 1

clobetasol propionate ‡ 1 1 1

CLOBEX ‡ 3 3 NC

CLOLAR 5 5 NC

clonazepam 1 1 1

clonidine 1 1 1

clopidogrel 1 1 1

clotrimazole/

betamethasone ‡

1 1 1

COAGADEX 4 4 NC

COLCRYS 3 3 NC

COMBIGAN 3 3 NC

COMBIVENT RESPIMAT 3 3 NC

COMBIVIR 3 3 NC

CORIFACT 4 4 NC

CORTEF 3 NC NC

CORTROPHIN GEL ◊ 4 4 NC

COSENTYX ◊ 5 5 NC

COSMEGEN 5 5 NC

NAME

TIER

COZAAR 3 NC NC

CREON 2 2 2

CRESTOR 3 NC NC

CUVITRU ◊ 5 5 2

cyclobenzaprine 1 1 1

CYCLOPHOSPHAMIDE 4 4 2

cyclosporine 1 1 1

CYMBALTA 3 3 NC

CYSTADANE 5 5 NC

CYSTAGON 4 4 2

CYTARABINE 4 4 2

CYTOGAM 4 4 2

dabigatran caps 1 1 1

DACARBAZINE 4 4 2

DACTINOMYCIN 4 4 2

DALFAMPRIDINE ER ◊ 4 4 2

DARZALEX ◊ 4 4 NC

DAUNORUBICIN HCL 4 4 2

DAYTRANA ◊ 3 3 NC

DECITABINE 4 4 2

DEFERASIROX ◊ 4 4 2

DEFEROXAMINE 4 4 2

DELZICOL 3 NC NC

DESCOVY 2 2 2

DESFERAL 5 5 NC

desloratadine 1 NC NC

DEXCOM CGM

SYSTEM ◊

3 3 NC

ABBREVIATED FORMULARY (ALPHABETIC INCLUDING SPECIALTY)

NAME

TIER

DEXILANT ‡ 3 NC NC

dexlansoprazole

delayed-rel ‡

1 1 1

dextro-amphetamine/

amphetamine salts ◊

1 1 1

diazepam 1 1 1

diclofenac tablets 1 1 1

dicyclomine 1 1 1

diﬂuprednate 1 1 1

digoxin 1 1 1

diltiazem er 1 1 1

DIMETHYL FUMARATE ◊ 4 4 2

DIOVAN/HCT 3 NC NC

DOCETAXEL 4 4 2

DOFETILIDE 4 4 2

donepezil 1 1 1

DOPTELET ◊ 5 5 NC

dorzolamide/

timolol maleate

1 1 1

DOVATO 2 2 2

doxazosin mesylate 1 1 1

doxepin crm ‡ 1 1 1

DOXIL 5 5 NC

DOXORUBICIN HCL 4 4 NC

DULERA 2 2 2

duloxetine ER 1 1 1

DUPIXENT ◊ 5 5 NC

DUREZOL 3 3 NC

DYSPORT ◊ 4 4 2

NAME

TIER

EDARBI 3 NC NC

EDARBYCLOR 3 NC NC

EDLUAR ‡ 3 NC NC

EDURANT 2 2 2

efavirenz/emtricitabine/

tenofovir disoproxil

fumarate

1 1 1

EFFEXOR XR 3 3 NC

EFFIENT 3 3 NC

EGRIFTA ◊ 4 4 2

ELAPRASE ◊ 4 4 NC

ELIGARD ◊ 4 4 2

ELIQUIS 2 2 2

ELITEK 4 4 2

ELLENCE 5 5 NC

ELOCTATE 4 4 2

EMBEDA ‡ 2 2 NC

EMEND ‡ 3 3 NC

EMGALITY ◊ 2 2 2

EMPLICITI ◊ 4 4 NC

emtricitabine/tenofovir

disoproxil fumarate

1 1 1

enalapril maleate 1 1 1

ENBREL ◊ 4 4 2

enoxaparin sodium 1 1 1

ENTECAVIR 4 4 2

ENTRESTO 3 3 2

ENTYVIO ◊ 5 5 NC

EPCLUSA ◊ 4 4 2

NAME

TIER

EPIDUO/FORTE ◊ 3 3 NC

epinephrine injection 1 1 1

EPIPEN/JR 3 3 NC

EPIVIR 3 3 NC

EPOGEN ◊ 5 5 NC

EPZICOM 3 3 NC

EQUETRO 3 3 NC

ERBITUX ◊ 4 4 NC

ERIVEDGE ◊ 4 4 2

ERLEADA ◊ 4 4 NC

ERLOTINIB ◊ 4 4 2

ERTACZO ◊ 3 NC NC

ERYGEL ‡ 3 3 NC

escitalopram oxalate 1 1 1

esomeprazole

magnesium delayed-rel ‡

1 1 1

ESTRACE 3 3 NC

estradiol 1 1 1

eszopiclone ‡ 1 1 1

ETHYOL 5 5 NC

etonogestrel/

EE vaginal ring**

1 1 1

ETOPOPHOS 4 4 NC

ETOPOSIDE 4 4 2

etravirine 1 1 1

EUFLEXXA ◊ 5 5 NC

EVISTA 3 3 NC

EXELDERM ◊ 3 3 NC

NAME

TIER

EXELON 3 3 NC

EXFORGE/HCTZ 3 3 NC

EXJADE ◊ 5 NC NC

EXONDYS 51 ◊ 5 5 NC

EXTAVIA ◊ 5 5 NC

ezetimibe 1 1 1

FABRAZYME ◊ 4 4 2

famotidine 40mg 1 1 1

FARXIGA $ 2 2 2

FASLODEX ◊ 5 NC NC

febuxostat ◊ 1 1 1

FEIBA 4 4 NC

FELDENE 3 NC NC

fenoﬁbrate 1 1 1

fenoﬁbric acid 1 1 1

fentanyl patch ‡ 1 1 1

fesoterodine er 1 1 1

FIASP/FLEXTOUCH 2 2 2

ﬁnasteride 1 1 1

FIRAZYR ◊ 5 NC NC

FIRMAGON ◊ 4 4 2

FLOVENT HFA 3 3 NC

ﬂuconazole 1 1 1

FLUDARABINE 4 4 2

ﬂunisolide spray 1 1 1

ﬂuorouracil cream 0.5% 1 NC NC

FLUOROURACIL INJ 4 4 2

ﬂuoxetine 1 1 1

ABBREVIATED FORMULARY (ALPHABETIC INCLUDING SPECIALTY)

NAME

TIER

ﬂuticasone spray 1 1 1

ﬂuticasone/salmeterol

CFC-free aerosol

1 1 1

ﬂuticasone/

salmeterol diskus

1 1 1

ﬂuticasone/vilanterol 1 1 1

FOCALIN XR ◊ 3 3 NC

FOLLISTIM AQ ◊ 4 4 2

FOLOTYN 5 5 NC

FORADIL 3 3 NC

formeterol

inhalation soln

1 1 1

FORTEO ◊ 4 4 2

FORTESTA ◊ 3 3 NC

FOTIVDA ◊ 5 5 NC

FREESTYLE LIBRE/

FREESTYLE LIBRE

CGM SYSTEM ◊

2 2 2

FULVESTRANT 4 4 2

furosemide 1 1 1

FUZEON 4 4 2

gabapentin ‡ 1 1 1

GAMMAGARD ◊ 4 4 2

GAMMAKED ◊ 4 4 2

GAMMAPLEX ◊ 4 4 2

GAMUNEX-C ◊ 4 4 2

GANCICLOVIR 4 4 2

GATTEX ◊ 4 4 2

GAZYVA ◊ 4 4 NC

NAME

TIER

GEFITINIB ◊ 4 4 2

GELNIQUE 3 NC NC

GEL-ONE ◊ 4 4 2

GELSYN-3 ◊ 4 4 2

GEMCITABINE 4 4 2

gemﬁbrozil 1 1 1

GENOTROPIN ◊ 5 NC NC

GENVOYA 2 2 2

GLASSIA ◊ 5 5 NC

GLATIRAMER ◊ 4 4 2

GLEEVEC ◊ 5 NC NC

glimepiride 1 1 1

glipizide/er/xl 1 1 1

GLUCAGEN 2 2 2

glyburide 1 1 1

GONAL-F ◊ 5 5 NC

GONAL-F RFF ◊ 5 5 NC

GVOKE 2 2 2

HALAVEN ◊ 4 4 2

HARVONI ◊ 4 4 2

HEMOFIL M 4 4 NC

HEPAGAM B 4 4 2

HIZENTRA ◊ 4 4 2

HUMALOG/ MIX/

KWIKPEN

2 NC NC

HUMATE-P 4 4 2

HUMATROPE ◊ 5 NC NC

HUMIRA ◊ 4 4 2

NAME

TIER

HUMULIN U-500

CONCENTRATE

2 2 2

HUMULIN/KWIKPEN

(EXCEPT HUMULIN

U-500 CONCENTRATE)

2 NC NC

HYALGAN ◊ 4 4 2

HYCAMTIN CAP 4 4 2

HYCAMTIN INJ 5 5 NC

hydralazine 1 1 1

hydrochlorothiazide 1 1 1

hydrocodone/

acetaminophen ‡

1 1 1

hydromorphone ‡ 1 1 1

HYPERHEP B S-D 4 4 2

HYPERRHO S-D 4 4 2

HYQVIA ◊ 4 4 2

HYZAAR 3 NC NC

ibandronate 1 1 1

IBRANCE ◊ 4 4 2

ibuprofen 1 1 1

ICATIBANT ◊ 4 4 2

ICLUSIG ◊ 4 4 2

icosapent ehtyl caps 1 1 1

IDAMYCIN PFS 5 5 NC

IDARUBICIN HCL 4 4 2

IDELVION 4 4 NC

IFEX 5 5 NC

IFOSFAMIDE 4 4 2

ILARIS ◊ 4 4 2

NAME

TIER

IMATINIB ◊ 4 4 2

IMBRUVICA ◊ 4 4 2

INCRELEX ◊ 4 4 2

INCRUSE ELLIPTA 3 NC NC

INLYTA ◊ 4 4 2

INSULIN ASPART 2 2 2

INSULIN LISPRO 2 NC NC

INTUNIV 3 3 NC

INVOKANA ◊ $ 3 NC NC

irbesartan/hctz 1 1 1

IRESSA ◊ 5 5 NC

IRINOTECAN 4 4 2

ISENTRESS 2 2 2

isosorbide mononitrate er 1 1 1

ISTODAX ◊ 5 5 NC

IXEMPRA 4 4 NC

IXINITY 4 4 NC

JADENU ◊ 5 NC NC

JAKAFI ◊ 4 4 2

JALYN 3 NC NC

JANUMET 2 2 2

JANUMET XR 2 2 2

JANUVIA 2 2 2

JARDIANCE $ 2 2 2

JEVTANA ◊ 4 4 2

JORNAY PM ◊ 3 3 NC

JUBLIA ◊ 3 NC NC

ABBREVIATED FORMULARY (ALPHABETIC INCLUDING SPECIALTY)

NAME

TIER

JYNARQUE ◊ 4 4 2

KADCYLA ◊ 4 4 NC

KALBITOR ◊ 4 4 2

KALYDECO ◊ 4 4 2

KEPIVANCE ◊ 4 4 2

KERYDIN* ◊ 3 NC NC

KESIMPTA ◊ 4 4 2

ketoconazole tabs ◊ 1 1 1

KEYTRUDA ◊ 4 4 2

KINERET ◊ 5 5 2

KOATE-DVI 4 4 NC

KOGENATE FS 4 4 2

KRYSTEXXA ◊ 5 5 NC

KUVAN ◊ 5 5 NC

KYPROLIS ◊ 5 5 2

lamivudine 1 1 1

lamivudine/zidovudine 1 1 1

lamotrigine 1 1 1

lansoprazole ‡ 1 1 1

latanoprost 1 1 1

LATUDA 3 3 NC

LEDIPASVIR/

SOFOSBUVIR ◊

4 4 2

LEMTRADA ◊ 5 5 2

LENALIDOMIDE ◊ 4 4 2

LESCOL XL 3 NC NC

LETAIRIS ◊ 5 NC NC

letrozole 1 1 1

NAME

TIER

LEUKINE ◊ 5 5 NC

LEUPROLIDE ◊ 4 4 2

LEVEMIR 2 2 2

levetiracetam 1 1 1

levocetirizine 1 NC NC

levoﬂoxacin 1 1 1

levothyroxine 1 1 1

LEXAPRO 3 3 NC

LIALDA 3 3 NC

lidocaine topical ‡ 1 1 1

LILETTA 5 5 NC

LINZESS ◊ 2 2 2

LIPITOR 3 NC NC

lisdexamfetamine ◊ 1 1 1

lisinopril/hctz 1 1 1

LIVALO 3 NC NC

LO LOESTRIN FE 2 2 2

LOPROX ‡ 3 NC NC

lorazepam 1 1 1

losartan/hctz 1 1 1

lovastatin 1 1 1

LOVAZA 3 3 NC

lubiprostone ◊ 1 1 1

LUMIGAN 2 NC NC

LUMIZYME ◊ 4 4 2

LUNESTA ‡ 3 NC NC

LUPRON DEPOT ◊ 4 4 2

NAME

TIER

lurasidone 1 1 1

LUZU ◊ 3 NC NC

LYNPARZA ◊ 4 4 2

LYRICA ‡ 3 NC NC

LYUMJEV/KWIKPEN 3 NC NC

MEDROL 3 NC NC

megestrol acetate 1 1 1

MEKINIST ◊ 4 4 2

MEKTOVI ◊ 5 5 NC

meloxicam tabs 1 1 1

MELPHALAN HCL 4 4 2

MENOPUR ◊ 4 4 2

MENTAX 3 NC NC

mesalamine er caps 1 1 1

MESNA 4 4 2

MESNEX INJ 5 5 NC

MESNEX TABS 4 4 2

methotrexate inj 1 1 1

METHYLIN ◊ 3 3 NC

methylphenidate/er

(except methylphenidate

tab ER osmotic release

45mg, 63mg, 72mg) ◊

1 1 1

methylprednisolone 1 1 1

metoprolol succinate/

tartrate

1 1 1

MICARDIS/HCT 3 NC NC

MICRHOGAM 4 4 2

MIGLUSTAT ◊ 4 4 2

NAME

TIER

MINIVELLE 3 3 NC

MIRCETTE 3 3 NC

MIRENA 4 4 2

MITOMYCIN 4 4 2

MITOXANTRONE 4 4 2

MONOVISC ◊ 5 5 NC

montelukast sodium 1 1 1

MORPHABOND ‡ 3 3 NC

MOUNJARO ◊ 2 2 2

MOVIPREP 3 3 NC

MOZOBIL ◊ 5 5 NC

mupirocin ‡ 1 1 1

mycophenolate mofetil 1 1 1

MYDAYIS ◊ 2 2 2

MYFORTIC 3 3 NC

MYOBLOC ◊ 4 4 2

MYRBETRIQ 2 2 NC

NABI-HB 4 4 NC

naftiﬁne ‡ 1 1 1

NAGLAZYME ◊ 4 4 NC

naloxone 1 1 1

NAMENDA TABS 3 3 NC

NAPROSYN 3 NC NC

NARCAN 3 3 NC

nebivolol 1 1 1

NELARABINE 4 4 2

NEORAL 3 3 NC

NEUPRO 2 2 2

ABBREVIATED FORMULARY (ALPHABETIC INCLUDING SPECIALTY)

NAME

TIER

nevirapine ext-rel 1 1 1

NEXAVAR ◊ 5 5 NC

NEXLETOL ◊ 3 3 NC

NEXLIZET ◊ 3 3 NC

niacin er 1 1 1

NILANDRON ◊ 3 3 NC

NIPENT 4 4 2

NITROSTAT 3 3 NC

NORDITROPIN ◊ 4 4 2

NORITATE ◊ 3 NC NC

NORTHERA ◊ 5 NC NC

NOVAREL ◊ 4 4 2

NOVOLIN 2 2 2

NOVOLOG/MIX/

FLEXPEN

2 2 2

NOVOSEVEN RT 4 4 2

NPLATE ◊ 4 4 2

NUBEQA◊ 4 4 NC

NUCALA ◊ 5 5 NC

NULOJIX 4 4 NC

NURTEC ODT ◊ 2 2 2

NUTROPIN AQ ◊ 5 NC NC

NUVARING 3 3 NC

NUWIQ 4 4 NC

OCALIVA ◊ 5 5 2

OCTAGAM ◊ 4 4 NC

OFEV ◊ 4 4 2

omega-3 acid ethyl esters 1 1 1

NAME

TIER

omeprazole 1 1 1

omeprazole/sodium

bicarbonate ‡

1 NC NC

OMNIPOD DASH/5 G6

INSULIN INFUSION

DISPOSABLE PUMP ◊

3 3 NC

OMNITROPE ◊ 5 NC NC

ondansetron/odt ‡ 1 1 1

ONETOUCH

TEST STRIPS ‡

2 2 2

ONIVYDE ◊ 5 5 NC

OPDIVO ◊ 4 4 2

OPSUMIT ◊ 4 4 2

ORACEA 3 3 NC

ORALAIR ◊ 5 5 2

ORAPRED ODT 3 NC NC

ORENCIA ◊ 5 5 NC

ORENITRAM ◊ 4 4 2

ORKAMBI ◊ 4 4 2

ORTHOVISC ◊ 5 5 NC

oseltamivir phosphate ‡ 1 1 1

OTEZLA ◊ 4 4 2

OTREXUP ◊ 3 3 NC

OVIDREL ◊ 4 4 2

OXALIPLATIN 4 4 2

OXISTAT ◊ 3 NC NC

oxybutynin/er 1 1 1

OXYCONTIN ‡ 3 NC NC

OZEMPIC ◊ 2 2 2

NAME

TIER

PACLITAXEL 4 4 2

PALYNZIQ ◊ 5 5 NC

PAMIDRONATE 4 4 2

pantoprazole sodium ‡ 1 1 1

PARAGARD T 380A 2 2 2

paroxetine 1 1 1

PEGASYS ◊ 4 4 2

PENTASA 2 NC NC

PERFOROMIST 3 3 NC

PERJETA ◊ 4 4 2

phenazopyridine 1 1 1

pioglitazone 1 1 1

PIRFENIDONE ◊ 4 4 2

PLAVIX 3 3 NC

PLEGRIDY/PEN ◊ 4 4 2

PLERIXAFOR ◊ 4 4 2

polyethylene glycol 3350 1 1 1

POMALYST ◊ 5 5 2

PRALATREXATE 4 4 2

PRALUENT ◊ 3 NC NC

pramipexole

dihydrochloride

1 1 1

pravastatin sodium 1 1 1

prednisolone acetate 1 1 1

prednisone 1 1 1

PREFEST 3 3 NC

pregabalin ‡ 1 1 1

PREGNYL ◊ 4 4 2

NAME

TIER

PREMARIN 2 2 2

PREMPRO 2 2 2

PRISTIQ 3 3 NC

PRIVIGEN ◊ 4 4 NC

PROAIR HFA 3 3 NC

PROCRIT ◊ 5 NC NC

PROFILNINE 4 4 NC

progesterone ◊ 1 1 1

PROGRAF 3 3 NC

PROLASTIN-C ◊ 4 4 2

PROLEUKIN 4 4 2

PROLIA ◊ 4 4 2

PROMACTA ◊ 4 4 2

promethazine/codeine ‡ 1 1 1

propranolol 1 1 1

PROVENTIL HFA 3 NC NC

PULMOZYME ◊ 4 4 2

quetiapine fumarate 1 1 1

QVAR/REDIHALER 2 2 2

rabeprazole delayed-rel

(except rabeprazole

capsule sprinkle

delayed-rel) ‡

1 1 1

ramelteon ‡ 1 1 1

ramipril 1 1 1

RAPAFLO 3 3 NC

RAPAMUNE 3 3 NC

RASUVO ◊ 3 3 NC

RAVICTI ◊ 4 4 2

ABBREVIATED FORMULARY (ALPHABETIC INCLUDING SPECIALTY)

NAME

TIER

RAYOS ◊ 3 NC NC

REBIF ◊ 4 4 2

REBINYN 4 4 NC

RECLAST ◊ 5 NC NC

RECOMBINATE 4 4 2

RELISTOR ◊ 3 3 2

RELPAX ‡ 3 3 NC

REMODULIN ◊ 5 5 NC

REPATHA ◊ 2 2 2

RESTASIS ◊ 3 3 NC

RETACRIT ◊ 4 4 2

RETROVIR 3 3 NC

REVATIO ◊ 5 NC NC

REVLIMID ◊ 4 4 2

REYATAZ 3 3 NC

RHOGAM PLUS 4 4 2

RHOPHYLAC 4 4 NC

RHOPRESSA 2 3 NC

RIASTAP 4 4 NC

RIBAVIRIN ◊ 4 4 2

RINVOQ ER ◊ 4 4 NC

risedronate 1 1 1

risperidone 1 1 1

RIXUBIS 4 4 2

rizatriptan ‡ 1 1 1

ROCKLATAN 2 3 NC

ROMIDEPSIN ◊ 4 4 NC

ropinirole 1 1 1

NAME

TIER

rosuvastatin 1 1 1

ROZEREM ‡ 3 NC NC

RYBELSUS 2 2 2

SABRIL ◊ 5 NC NC

SAIZEN ◊ 5 NC NC

SAMSCA ◊ 5 5 NC

SANDOSTATIN LAR ◊ 4 4 2

SAPROPTERIN ◊ 4 4 2

SAVELLA ‡ 3 3 NC

saxagliptin 1 1 1

saxagliptin/metformin er 1 1 1

SCEMBLIX◊ 5 5 NC

SENSIPAR ◊ 5 NC NC

SEROQUEL XR 3 3 NC

SEROSTIM ◊ 4 4 2

sertraline tab 1 1 1

SILDENAFIL (PAH) ◊ 4 4 2

silodosin 1 1 1

simvastatin (except susp) 1 1 1

SINGULAIR 3 3 NC

sirolimus 1 1 1

SKYLA 4 4 2

SKYRIZI ◊ 4 4 NC

SODIUM

PHENYLBUTYRATE ◊

4 4 2

sodium sulfate,

potassium sulfate and

magnesium sulfate

oral sol

1 1 1

NAME

TIER

SOFOSBUVIR/

VELPATASVIR ◊

4 4 2

SOLESTA 4 4 2

solifenacin 1 1 1

SOLIRIS ◊ 4 4 NC

SOMATULINE DEPOT ◊ 4 4 2

SOMAVERT 4 4 2

SORAFENIB ◊ 4 4 2

SOVALDI ◊ 4 4 2

SPIRIVA RESPIMAT 2 2 2

SPIRIVA 3 3 NC

spironolactone 1 1 1

SPRYCEL ◊ 4 4 2

stavudine 1 1 1

STELARA ◊ 4 4 NC

STIOLTO RESPIMAT 2 2 2

STIVARGA ◊ 4 4 2

STRATTERA 3 3 NC

STRIANT ◊ 3 3 NC

STRIBILD 2 2 2

STRIVERDI RESPIMAT 3 3 NC

SUBLOCADE ◊ 5 5 2

SUBOXONE FILM ‡ 3 3 NC

sucralfate 1 1 1

sulfamethoxazole/

trimethoprim

1 1 1

sumatriptan succinate ‡ 1 1 1

SUNITINIB ◊ 4 4 2

NAME

TIER

SUPARTZ FX ◊ 4 4 2

SUPPRELIN LA ◊ 4 4 2

SUPREP BOWEL

PREP KIT

3 3 NC

SUTENT ◊ 5 5 NC

SYMBICORT 3 3 NC

SYMDEKO ◊ 4 4 2

SYNAGIS ◊ 4 4 2

SYNTHROID 2 2 2

SYNVISC ◊ 5 5 NC

SYNVISC ONE ◊ 5 5 NC

TABRECTA ◊ 4 4 2

tacrolimus 1 1 1

TADALAFIL (PAH) ◊ 4 4 2

TAFINLAR ◊ 4 4 2

taﬂuprost 1 1 1

TAMIFLU CAPS ‡ 3 3 NC

tamoxifen citrate 1 1 1

tamsulosin 1 1 1

TARGRETIN

CAPS/GEL ◊

5 NC NC

TASIGNA ◊ 5 5 2

TASIMELTEON ◊ 4 4 2

tavaborole sol 5%* ◊ 1 1 1

TAVALISSE ◊ 5 5 NC

TAZORAC ◊ 3 3 NC

telmisartan/hctz 1 1 1

temazepam ‡ 1 1 1

ABBREVIATED FORMULARY (ALPHABETIC INCLUDING SPECIALTY)

NAME

TIER

TEMODAR ◊ 5 NC NC

TEMOZOLOMIDE 4 4 2

TEPMETKO ◊ 5 5 NC

TERIFLUNOMIDE ◊ 4 4 2

TESTIM ◊ 3 NC NC

testosterone cypionate ◊ 1 1 1

testosterone gel ◊ 1 1 1

TETRABENAZINE ◊ 4 4 2

THALOMID ◊ 4 4 2

THIOTEPA 4 4 2

THYROGEN 4 4 2

TICE BCG 4 4 2

TIKOSYN ◊ 5 NC NC

timolol maleate 1 1 1

tiotropium inhalation

powder caps

1 1 1

TOBI 5 5 NC

TOBI PODHALER 4 4 NC

TOBRAMYCIN

INH SOLN

4 4 2

tolterodine/er 1 1 1

TO LVA PTAN ◊ 4 4 2

topiramate/er 1 1 1

TOPOTECAN 4 4 2

TOVIAZ 3 3 NC

tramadol (except

100mg tab)/er ‡

1 1 1

TRAVATAN Z 3 3 NC

trazodone 1 1 1

NAME

TIER

TREANDA ◊ 5 5 NC

TRELEGY ELLIPTA 2 2 2

TRELSTAR ◊ 4 4 2

TRESIBA 2 3 NC

tretinoin ◊ 1 1 1

TRETTEN 4 4 NC

triamterene/hctz 1 1 1

TRIKAFTA ◊ 4 4 2

TRINTELLIX 3 3 NC

TRISENOX 5 5 NC

TRIUMEQ 2 2 2

TRIZIVIR 3 3 NC

TROGARZO ◊ 4 4 2

trospium/er 1 1 1

TRULICITY ◊ 2 2 2

TRUVADA 3 3 NC

TUDORZA PRESSAIR 3 NC NC

TYKERB ◊ 5 NC NC

TYMLOS ◊ 4 4 2

TYSABRI ◊ 4 4 2

TYVASO/DPI ◊ 5 5 NC

TYZEKA 4 4 2

UPTRAVI TABS ◊ 4 4 2

VAGIFEM 3 3 NC

valacyclovir 1 1 1

valsartan/hctz 1 1 1

VALTREX 3 3 NC

VARIZIG 4 4 2

NAME

TIER

VARUBI ‡ 2 2 2

VECTIBIX ◊ 4 4 NC

VELCADE ◊ 5 5 NC

VELETRI ◊ 5 5 NC

VEMLIDY 4 4 2

venlafaxine/er 1 1 1

VENTAVIS ◊ 4 4 2

VENTOLIN HFA 3 NC NC

VERAMYST 2 NC NC

verapamil/er 1 1 1

VERZENIO ◊ 4 5 2

V-GO INSULIN

INFUSION

DISPOSABLE PUMP ◊

2 2 2

VICTOZA ◊ 2 2 2

VIDAZA 5 5 NC

VIGABATRIN ◊ 4 4 2

VIGAMOX 3 3 NC

VIIBRYD 3 3 NC

vilazodone 1 1 1

VIMIZIM ◊ 4 4 NC

VINBLASTINE 4 4 2

VINCRISTINE 4 4 2

VINORELBINE 4 4 2

VIOKACE 2 2 2

VIRACEPT 2 2 2

VISUDYNE 4 4 2

VIVELLE DOT 3 3 NC

VIVITROL 4 4 2

NAME

TIER

VOGELXO ◊ 3 NC NC

VOTRIENT ◊ 4 4 2

VPRIV ◊ 5 5 NC

VUSION ‡ * 3 NC NC

VYEPTI ◊ 5 5 NC

VYTORIN 3 NC NC

VYVANSE ◊ 3 3 NC

warfarin 1 1 1

WELCHOL 3 3 NC

WELLBUTRIN XL 3 NC NC

WILATE 4 4 NC

WINRHO SDF 4 4 NC

XALKORI ◊ 4 4 2

XARELTO 2 2 2

XELJANZ/XR ◊ 4 4 NC

XELODA ◊ 5 NC NC

XENAZINE ◊ 5 NC NC

XEOMIN ◊ 4 4 2

XGEVA ◊ 4 4 2

XIAFLEX ◊ 4 4 2

XIIDRA ◊ 2 2 2

XOLAIR ◊ 4 4 2

XOFLUZA ‡ 3 3 2

XOPENEX HFA 3 NC NC

XOPENEX/

CONCENTRATE

3 3 NC

XTANDI ◊ 4 4 2

XYNTHA 4 4 NC

ABBREVIATED FORMULARY (ALPHABETIC INCLUDING SPECIALTY)

NAME

TIER

XYNTHA SOLOFUSE 4 4 NC

YERVOY ◊ 4 4 NC

YONSA ◊ 4 4 2

zaﬁrlukast 1 1 1

zaleplon ‡ 1 1 1

ZALTRAP ◊ 4 4 2

ZANOSAR 4 4 2

ZELBORAF ◊ 4 4 2

ZEMAIRA ◊ 5 5 NC

ZETIA 3 3 NC

ZIAGEN 3 3 NC

zidovudine 1 1 1

ZIOPTAN 3 3 NC

NAME

TIER

ZOCOR 3 NC NC

ZOLADEX ◊ 4 4 2

ZOLEDRONIC ACID 4 4 2

ZOLINZA ◊ 4 4 2

zolmitriptan ‡ 1 1 1

zolpidem/ER ‡ 1 1 1

ZOMACTON ◊ 5 NC NC

ZOMIG/ZMT ‡ 3 3 NC

ZORBTIVE ◊ 4 4 2

ZOVIRAX 3 3 NC

ZUBSOLV ‡ 2 2 2

ZYKADIA ◊ 4 4 2

ZYTIGA ◊ 5 NC NC

To see the 2024 full formularies:

■

Prior to January 1, 2024, visit fepblue.org/whatsnew

■

After January 1, 2024, visit fepblue.org/pharmacy/prescriptions

■

Call Customer Care: 1-800-624-5060 (T T Y: 711)

EXCLUDED DRUG LIST

STANDARD OPTION

These listed drugs are not covered under Standard Option. If you use any

of these Excluded Drugs, you will need to pay the full cost of the drug(s).

If you are using one of these non-covered drugs, ask your doctor for

one of the covered generic or brand name options.

CATEGORY*

DRUG CLASS*

DRUGS NOT COVERED IN

2024 FOR STANDARD OPTION

COVERED OPTIONS**

Acne

Oral Antibiotics

MINOLIRA azithromycin, doxycycline (except

20mg), minocycline, minocycline ext-

rel, sulfamethoxazole/trimethoprim,

MINOCIN, SOLODYN, VIBRAMYCIN,

ZITHROMAX

Acne

Miscellaneous

adapalene pad, adapalene

soln 0.1%

ABSORICA LD

adapalene crm, gel (Rx only),

DIFFERIN (Rx only)

isotretinoin, ABSORICA

Allergies

Antihistamines

carbinoxamine 6mg, RYVENT desloratadine, levocetirizine (Rx),

montelukast, zaﬁrlukast, ACCOLATE,

CLARINEX, CLARINEX-D, SINGULAIR

Anticoagulants PRADAXA, PRADAXA PAK,

SAVAYSA

dabigatran caps, warfarin, ELIQUIS,

XARELTO

Antidiarrheals opium tincture diphenoxylate/atropine, loperamide

Antifungals TOLSURA ﬂuconazole, itraconazole,

ketoconazole, posaconazole,

voriconazole, DIFLUCAN, NOXAFIL,

SPORANOX, VFEND

Anti-Inﬂammatories

Nonsteroidal Anti-

Inﬂammatories

(NSAIDs)

diclofenac potassium caps,

diclofenac sodium soln 2%,

fenoprofen cap 200mg,

indomethacin caps (20mg,

40mg), indomethacin

supp (50mg, 100mg),

meloxicam caps (5mg,

10mg), meloxicam susp

7.5mg/5mL, naproxen sodium

ext-rel tablets, CAMBIA,

FENORTHO, INDOCIN

susp/supp, NAPRELAN,

PENNSAID 2%, RELAFEN

DS, TIVORBEX, VIVLODEX,

ZIPSOR, ZORVOLEX

diclofenac DR/ER (except diclofenac

potassium caps), diclofenac gel/

soln (except soln 2%), etodolac/ER,

ﬂurbiprofen, ibuprofen, indomethacin/

ER (except indomethacin caps 20mg,

40mg and supp 50mg, 100mg),

ketoprofen/ER, meloxicam tabs,

nabumetone, naproxen, oxaprozin,

piroxicam, sulindac

EXCLUDED DRUG LIST

STANDARD OPTION

CATEGORY*

DRUG CLASS*

DRUGS NOT COVERED IN

2024 FOR STANDARD OPTION

COVERED OPTIONS**

Anti-Inﬂammatories

Nonsteroidal Anti-

Inﬂammatories

(NSAIDs)

Combinations

ibuprofen/famotidine tabs,

naproxen/esomeprazole

magnesium tabs DR,

DUEXIS, VIMOVO

CONSENSI

diclofenac/misoprostol, esomeprazole

magnesium delayed-rel, famotidine,

ibuprofen, naproxen

celecoxib, CELEBREX, AND

amlodipine tabs, NORVASC

Antiobesity ADIPEX-P, PLENITY benzphetamine tabs, diethylpropion

ext-rel tabs, diethylpropion tabs,

orlistat (RX), phendimetrazine tabs,

phentermine tabs/caps, CONTRAVE,

LOMAIRA, PHENDIMETRAZINE

TARTRATE EXT-REL CAP, QSYMIA,

SAXENDA, WEGOVY, XENICAL (RX)

Antirheumatics penicillamine caps,

CUPRIMINE

azathioprine, hydroxychloroquine,

leﬂunomide, methotrexate,

penicillamine tabs, DEPEN

Antispasmodics LIBRAX

DONNATAL

clidinium/chlordiazepoxide,

dicyclomine, hyoscyamine

atropine/hyoscyamine/scopolamine/

phenobarbital

Anxiety Disorders

Benzodiazepines

LOREEV XR alprazolam/ext-rel, chlordiazepoxide,

clonazepam, clorazepate, diazepam,

lorazepam, oxazepam, ATIVAN,

KLONOPIN, VALIUM, XANAX/XR

Asthma

Leukotriene

Modulators

zileuton ext-rel, ZYFLO CR montelukast, zaﬁrlukast, ACCOLATE,

SINGULAIR, ZYFLO

Benign Prostatic

Hyperplasia (BPH)

UROXATRAL alfuzosin ext-rel, dutasteride,

dutasteride/tamsulosin, ﬁnasteride,

silodosin, tadalaﬁl (2.5mg, 5mg),

tamsulosin, AVODART, CIALIS

(2.5mg, 5mg), JALYN, PROSCAR,

RAPAFLO, FLOMAX

Bladder Agents DETROL, DETROL LA,

ENABLEX, GEMTESA,

OXYTROL, VESICARE

darifenacin ext-rel, fesoterodine ext-

rel, oxybutynin, oxybutynin ext-rel,

solifenacin, tolterodine, tolterodine

ext-rel, trospium, trospium ext-

rel, DITROPAN XL, GELNIQUE,

MYRBETRIQ, TOVIAZ, VESICARE LS

Cardiovascular

Antiarrhythmics

BETAPACE, BETAPACE AF sotalol, sotalol AF

CATEGORY*

DRUG CLASS*

DRUGS NOT COVERED IN

2024 FOR STANDARD OPTION

COVERED OPTIONS**

Cardiovascular

Heart

aspirin/omeprazole delayed-

rel tabs, YOSPRALA

aspirin*** and esomeprazole

magnesium delayed-rel, lansoprazole,

omeprazole, pantoprazole,

rabeprazole (except rabeprazole

capsule sprinkle delayed-rel)

Central Nervous

System

Antidepressant

Combinations

SYMBYAX olanzapine/ﬂuoxetine

Central Nervous

System

Miscellaneous

methylphenidate tab ER

osmotic release 45mg,

63mg, 72mg, ADZENYS XR-

ODT, COTEMPLA XR-ODT,

DESOXYN, DYANAVEL XR,

EVEKEO ODT, RELEXXII

amphetamine/dextroamphetamine

mixed salts/ER, amphetamine

sulfate, dexmethylphenidate/

ER, dextroamphetamine/ER,

lisdexamfetamine, methylphenidate/

ER (except methylphenidate tab

ER osmotic release 45mg, 63mg,

72mg), ADDERALL, ADDERALL

XR, APTENSIO XR, AZSTARYS,

CONCERTA, DAYTRANA, DEXEDRINE,

EVEKEO, FOCALIN, FOCALIN XR,

JORNAY PM, METHYLIN, MYDAYIS,

PROCENTRA, QUILLICHEW ER,

QUILLIVANT XR, RITALIN, RITALIN LA,

VYVANSE, ZENZEDI

Corticosteroids

Oral

DEXABLISS, DXEVO 11-DAY,

MILLIPRED

dexamethasone, ﬂudrocortisone,

hydrocortisone, methylprednisolone,

prednisolone, prednisone, CORTEF,

MEDROL, ORAPRED ODT, RAYOS

Dermatology

Antifungal

ALCOTRIN-A, LOTRISONE*,

XOLEGEL

ciclopirox, clotrimazole, clotrimazole/

betamethasone, econazole,

hydrocortisone/iodoquinol,

hydrocortisone/iodoquinol/

aloe, ketoconazole, luliconazole,

miconazole nitrate/zinc oxide,

naftiﬁne, nystatin, oxiconazole crm,

sulconazole, tavaborole sol 5%,

ECOZA, ERTACZO, EXELDERM,

JUBLIA, KERYDIN, LOPROX, LUZU,

MENTAX, NAFTIN, OXISTAT, VUSION

Dermatology

Corticosteroids

halobetasol propionate

topical foam, triamcinolone

oint 0.05%, BRYHALI,

LEXETTE, NOVACORT,

OLUX/OLUX-E, PSORCON,

TRIANEX, VANOS

betamethasone dipropionate

(crm, lotion, oint), betamethasone

dipropionate augmented (crm, lotion,

gel, oint), clobetasol propionate,

diﬂorasone diacetate, ﬂuocinonide

(crm, gel, oint, soln), halobetasol

propionate crm, triamcinolone acetonide

(except triamcinolone oint 0.05%),

APEXICON E, CLOBEX, DIPROLENE,

HALOG, KENALOG SPRAY, SERNIVO,

TOPICORT, ULTRAVATE

EXCLUDED DRUG LIST STANDARD OPTION

CATEGORY*

DRUG CLASS*

DRUGS NOT COVERED IN

2024 FOR STANDARD OPTION

COVERED OPTIONS**

Dermatology

Miscellaneous

XERESE

VEREGEN

EXTINA

OVACE, OVACE PLUS

acyclovir, hydrocortisone

imiquimod, ZYCLARA

ketoconazole foam 2%

sulfacetamide sodium

Dermatology

Psoriasis

TACLONEX acitretin, betamethasone

dipropionate/calcipotriene (oint, susp),

calcipotriene, calcitriol, methoxsalen,

DUOBRII, ENSTILAR, SORILUX,

VECTICAL, WYNZORA

Dermatology

Rosacea

EPSOLAY azelaic acid gel, brimonidine topical

gel, doxycycline (except 20 mg),

ﬂurandrenolide, ivermectin crm

1%, metronidazole cream/gel/

lotion, FINACEA, METROCREAM,

METROGEL, METROLOTION,

MIRVASO, NORITATE, ORACEA,

RHOFADE, SOOLANTRA, ZILXI

Diabetes

Dipeptidyl

Peptidase-4

(DPP-4) Inhibitors/

Combinations

JENTADUETO, JENTADUETO

XR, KAZANO, KOMBIGLYZE

XR, NESINA, ONGLYZA,

OSENI, TRADJENTA

alogliptin, alogliptin/metformin,

alogliptin/pioglitazone, JANUMET,

JANUMET XR, JANUVIA

Diabetes

Incretin Mimetic

Agents

ADLYXIN, BYDUREON,

BYDUREON BCISE, BYETTA

MOUNJARO, OZEMPIC, RYBELSUS,

TRULICITY, VICTOZA

Diabetes

Incretin Mimetic

Agent Combinations

SOLIQUA XULTOPHY

Diabetes

Insulins

insulin glargine, LANTUS/

SOLOSTAR, SEMGLEE,

TOUJEO/SOLOSTAR/MAX

SOLOSTAR

BASAGLAR, BASAGLAR TEMPO,

INSULIN DEGLUDEC/FLEXTOUCH,

INSULIN GLARGINE - YFGN

(interchangeable biosimilar),

LEVEMIR, TRESIBA/FLEXTOUCH

Diabetes

Metformin

metformin 625mg tab,

GLUMETZA, RIOMET ER

metformin (does not include 625mg

tabs), metformin ext-rel, metformin

oral soln, RIOMET IR

Diabetes

Other

CYCLOSET alogliptin, alogliptin/metformin,

alogliptin/pioglitazone, bromocriptine

mesylate, glimepiride, glipizide,

glyburide, glyburide/metformin,

pioglitazone, repaglinide

Gout allopurinol 200mg tab allopurinol (does not include

200mg tab), colchicine, febuxostat,

probenecid, COLCRYS, KRYSTEXXA,

MITIGARE, ULORIC, ZYLOPRIM

CATEGORY*

DRUG CLASS*

DRUGS NOT COVERED IN

2024 FOR STANDARD OPTION

COVERED OPTIONS**

H2 Receptor

Antagonists

PEPCID cimetidine, famotidine 40mg,

nizatidine

High Blood Pressure

Angiotensin II

Receptor Blockers/

Combinations

(ARBs)

valsartan oral soln 4mg/ml candesartan, candesartan/HCT,

irbesartan, irbesartan/HCT, losartan,

losartan/HCT, olmesartan, olmesartan/

HCT, telmisartan, telmisartan/HCT,

valsartan, valsartan/HCT, ATACAND,

ATACAND HCT, AVAPRO, AVALIDE,

BENICAR, BENICAR HCT, COZAAR,

DIOVAN, DIOVAN HCT, EDARBI,

EDARBYCLOR, HYZAAR, MICARDIS,

MICARDIS HCT

High Blood Pressure

Calcium Channel

Blockers

levamlodipine maleate caps,

CONJUPRI, NORLIQVA

amlodipine tabs, felodipine ext-

rel, nicardipine, nifedipine ext-rel,

nisoldipine ext-rel, KATERZIA,

NORVASC, PROCARDIA XL, SULAR

High Cholesterol

Fibrates

FENOGLIDE fenoﬁbrate, fenoﬁbric acid del-rel,

gemﬁbrozil, ANTARA, LIPOFEN,

LOPID, TRICOR, TRIPLEX

High Cholesterol

Statins

simvastatin susp, ALTOPREV,

FLOLIPID, ZYPITAMAG

atorvastatin, ezetimibe/simvastatin,

ﬂuvastatin, ﬂuvastatin ext-rel, lovastatin,

pravastatin, rosuvastatin, simvastatin,

CRESTOR, EZALLOR SPRINKLE,

EZETIMIBE/ROSUVASTATIN tabs,

LESCOL XL, LIPITOR, LIVALO,

ROSZET, VYTORIN, ZOCOR

Inﬂuenza Agents FLUMADINE oseltamivir, rimantadine, RELENZA,

TAMIFLU, XOFLUZA

Interstitial Cystitis RIMSO-50 Members advised to discuss

suitable therapeutic alternatives with

prescriber

Irritable Bowel

Syndrome

Irritable Bowel

Syndrome with

Constipation

AMITIZA lubiprostone (generic), IBSRELA,

LINZESS, MOTEGRITY

Laxatives LACTULOSE PAK 10MG lactulose solution, PEG 3350/

electrolytes, sodium sulfate/

potassium sulfate/magnesium

sulfate, CLENPIQ, GOLYTELY,

KRISTALOSE, MOVIPREP,

OSMOPREP, PLENVU, PREPOPIK,

SUPREP, SUTAB

Migraine Agents

Calcitonin Gene-

Related Peptide

(CGRP) Inhibitors

AJOVY

UBRELVY

AIMOVIG, EMGALITY 120mg/mL,

QULIPTA, VYEPTI

NURTEC ODT

EXCLUDED DRUG LIST STANDARD OPTION

CATEGORY*

DRUG CLASS*

DRUGS NOT COVERED IN

2024 FOR STANDARD OPTION

COVERED OPTIONS**

Migraine Agents

Ergotamine

Derivatives

CAFERGOT, MIGRANAL,

TRUDHESA

dihydroergotamine nasal spray/inj,

ergotamine/caffeine tabs, D.H.E. 45

Migraine Agents

Selective Serotonin

Agonists

REYVOW almotriptan, eletriptan, frovatriptan,

naratriptan, rizatriptan, sumatriptan,

zolmitriptan, FROVA, IMITREX,

MAXALT, MAXALT-MLT, ONZETRA

XSAIL, RELPAX, TOSYMRA, ZOMIG

Movement

Disorders

TASMAR amantadine, apomorphine,

benztropine, bromocriptine,

carbidopa/levodopa, entacapone,

pramipexole, rasagiline, ropinirole/

ER, selegiline, tolcapone, APOKYN,

AZILECT, COMTAN, DUOPA,

GOCOVRI, KYNMOBI, MIRAPEX

XR, NEUPRO, OSMOLEX ER,

PARLODEL, RYTARY, SINEMET,

STALEVO, XADAGO, ZELAPAR

Multiple Sclerosis AMPYRA

COPAXONE

TECFIDERA

dalfampridine ER

glatiramer, glatopa

dimethyl fumarate delayed-rel

Musculoskeletal

Therapy Agents

cyclobenzaprine ext-rel,

AMRIX

chlorzoxazone tab (250mg,

375mg, 750mg), LORZONE

orphenadrine/aspirin/caffeine

tabs, ORPHENGESIC FORTE

baclofen, cyclobenzaprine

chlorzoxazone tab 500mg

aspirin***, caffeine†, baclofen,

cyclobenzaprine

Nausea and

Vomiting Therapy

(5HT-3 Blocker)

ANZEMET, ZUPLENZ granisetron, ondansetron,

palonosetron, promethazine,

SANCUSO

Omega-3 Fatty Acids VASCEPA icosapent ethyl caps, omega-3 acid

ethyl esters caps, LOVAZA

Ophthalmology

Anti-Infectives

BACIGUENT bacitracin ophthalmic

Ophthalmology

Miscellaneous

atropine sulfate eye ointment

PHOSPHOLINE IODIDE

VUITY

atropine ophthalmic

solution, cyclopentolate

ophthalmic solution

Members advised to discuss

suitable therapeutic alternatives with

prescriber

Members advised to discuss

suitable therapeutic alternatives with

prescriber

CATEGORY*

DRUG CLASS*

DRUGS NOT COVERED IN

2024 FOR STANDARD OPTION

COVERED OPTIONS**

Pain Medications

Neuropathic Pain

pregabalin ext-rel tabs,

GRALISE, HORIZANT,

LYRICA CR

gabapentin, pregabalin (does not

include ext-rel tabs), LYRICA,

NEURONTIN

Pain Medications

Opioids

benzhydrocodone/

acetaminophen, hydrocodone-

acetaminophen sol 10-325

mg/15 mL, oxycodone/

acetaminophen tab

(2.5mg–300mg, 5mg–300mg,

10mg–300mg), oxycodone-

acetaminophen soln

10–300mg/5ml, APADAZ,

NALOCET, PRIMLEV,

PROLATE

LAZANDA

levorphanol

tramadol 100mg tabs,

CONZIP

codeine/acetaminophen, hydrocodone/

acetaminophen, oxycodone/

acetaminophen (except 2.5mg–

300mg, 5mg–300mg, 10mg–300mg

tabs), tramadol/acetaminophen,

ENDOCET, PERCOCET

fentanyl buccal, fentanyl sublingual,

fentanyl transmucosal, FENTORA,

SUBSYS

hydromorphone, morphine,

oxycodone, tramadol (except 100mg

tab), DILAUDID, NUCYNTA, OPANA,

ROXICODONE

tramadol (except 100mg tabs), tramadol

ext-rel, tramadol/acetaminophen

Pain Medications

Topical

ZTLIDO lidocaine cream, lidocaine gel,

lidocaine lotion, lidocaine ointment,

lidocaine patch 5%, LIDODERM

PATCH, QUTENZA PATCH

Proton Pump

Inhibitors

esomeprazole strontium,

rabeprazole capsule sprinkle

delayed-rel, ACIPHEX, FIRST-

LANSOPRAZOLE, FIRST-

OMEPRAZOLE, NEXIUM,

PREVACID, PREVACID

SOLUTAB, PRILOSEC,

PROTONIX, ZEGERID

dexlansoprazole delayed-rel,

esomeprazole magnesium delayed-rel,

lansoprazole delayed-rel, omeprazole

delayed-rel, omeprazole/sodium

bicarbonate, pantoprazole delayed-rel,

rabeprazole (except rabeprazole capsule

sprinkle delayed-rel), DEXILANT

Sleep Agents zolpidem cap 7.5mg, DORAL,

QUVIVIQ, SECONAL

doxepin, estazolam, eszopiclone,

quazepam, ramelteon, temazepam,

triazolam, zaleplon, zolpidem tab/

ER tab, AMBIEN/CR, BELSOMRA,

DAYVIGO, EDLUAR, LUNESTA,

RESTORIL, ROZEREM, SILENOR

Testosterone Agents

Oral/Buccal

TLANDO JATENZO, KYZATREX, STRIANT

EXCLUDED DRUG LIST STANDARD OPTION

CATEGORY*

DRUG CLASS*

DRUGS NOT COVERED IN

2024 FOR STANDARD OPTION

COVERED OPTIONS**

Thyroid Disease ERMEZA levothyroxine, liothyronine,

CYTOMEL, SYNTHROID, TIROSINT,

THYQUIDITY

Ulcerative Colitis COLAZAL balsalazide, mesalamine delayed-

rel (caps, tabs), mesalamine ext-rel

caps, sulfasalazine, sulfasalazine

delayed, rel, ASACOL HD,

APRISO, AZULFIDINE, DELZICOL,

DIPENTIUM, LIALDA, PENTASA

Ulcer Therapy

Miscellaneous

CARAFATE sucralfate

*This list shows uses for which the drug is prescribed. Some drugs are prescribed for more than

one condition.

**For more covered options, review 2024 Standard Option formulary.

***Multiple strengths of aspirin are covered for men age 45 through 79 and women age 50

through 79. Low-dose aspirin (81mg per day) for female members at risk for preeclampsia.

†Denotes over-the-counter (OTC) availability only, and not covered through the prescription beneﬁt.

ALPHABETIC EXCLUDED DRUG LIST STANDARD OPTION

ABSORICA LD

ACIPHEX

adapalene pad

adapalene soln 0.1%

ADIPEX-P

ADLYXIN

ADZENYS XR-ODT

AJOVY

ALCOTRIN-A

allopurinol 200mg tab

ALTOPREV

AMITIZA

AMPYRA

AMRIX

ANZEMET

APADAZ

aspirin/omeprazole delayed-rel tabs

atropine sulfate eye ointment

BACIGUENT

benzhydrocodone/acetaminophen

BETAPACE

BETAPACE AF

BRYHALI

BYDUREON

BYDUREON BCISE

BYETTA

CAFERGOT

CAMBIA

CARAFATE

carbinoxamine 6 mg

chlorzoxazone tab (250mg,

375mg, 750mg)

COLAZAL

CONJUPRI

CONSENSI

CONZIP

COPAXONE

COTEMPLA XR-ODT

CUPRIMINE

cyclobenzaprine ext-rel

CYCLOSET

DESOXYN

DETROL

DETROL LA

DEXABLISS

diclofenac potassium caps

diclofenac sodium soln 2%

DONNATAL

DORAL

DUEXIS

DXEVO 11-DAY

DYANAVEL XR

ENABLEX

EPSOLAY

ERMEZA

esomeprazole strontium

EVEKEO ODT

EXTINA

FENOGLIDE

fenoprofen cap 200mg

FENORTHO

FIRST-LANSOPRAZOLE

FIRST-OMEPRAZOLE

FLOLIPID

FLUMADINE

GEMTESA

GLUMETZA

GRALISE

halobetasol propionate topical foam

HORIZANT

hydrocodone-acetaminophen sol

10–325mg/15mL

ibuprofen/famotidine tabs

INDOCIN SUSP/SUPP

indomethacin caps (20mg, 40mg)

indomethacin supp 50mg, 100mg

insulin glargine

JENTADUETO

JENTADUETO XR

KAZANO

KOMBIGLYZE XR

LACTULOSE PAK 10MG

LANTUS/SOLOSTAR

LAZANDA

levamlodipine maleate caps

levorphanol

LEXETTE

LIBRAX

LOREEV XR

LORZONE

LOTRISONE

LYRICA CR

meloxicam caps (5mg, 10mg)

meloxicam susp 7.5mg/5ml

metformin 625mg tab

methylphenidate tab ER osmotic

release 45mg, 63mg, 72mg

MIGRANAL

MILLIPRED

MINOLIRA

NALOCET

NAPRELAN

naproxen sodium ext-rel tablets

naproxen/esomeprazole

magnesium tabs DR

NESINA

NEXIUM

NORLIQVA

NOVACORT

OLUX

OLUX-E

ONGLYZA

opium tincture

orphenadrine/aspirin/caffeine tabs

ORPHENGESIC FORTE

OSENI

OVACE

OVACE PLUS

oxycodone/acetaminophen tab

(2.5mg–300mg, 5mg–300mg,

10mg–300mg)

EXCLUDED DRUG LIST STANDARD OPTION

oxycodone -acetaminophen soln

10–300mg/5ml

OXYTROL

penicillamine caps

PENNSAID 2%

PEPCID

PHOSPHOLINE IODIDE

PLENITY

PRADAXA

PRADAXA PAK

pregabalin ext-rel tabs

PREVACID

PREVACID SOLUTAB

PRILOSEC

PRIMLEV

PROLATE

PROTONIX

QUVIVIQ

rabeprazole capsule sprinkle

delayed-rel

RELAFEN DS

RELEXXII

REYVOW

RIMSO-50

RIOMET ER

RYVENT

SAVAYSA

SECONAL

SEMGLEE

simvastatin susp

SOLIQUA

SYMBYAX

TACLONEX

TASMAR

TECFIDERA

TIVORBEX

TLANDO

TOLSURA

TOUJEO/SOLOSTAR/MAX

SOLOSTAR

TRADJENTA

tramadol 100mg tabs

triamcinolone oint 0.05%

TRIANEX

TRUDHESA

UBRELVY

UROXATRAL

valsartan oral soln 4mg/ml

VANOS

VASCEPA

VEREGEN

VESICARE

VIMOVO

VIVLODEX

VUITY

XERESE

XOLEGEL

YOSPRALA

ZEGERID

zileuton ext-rel

ZIPSOR

zolpidem cap 7.5mg

ZORVOLEX

ZTLIDO

ZUPLENZ

ZYFLO CR

ZYPITAMAG

“MANAGED NOT COVERED” DRUG LIST

BASIC OPTION

These listed drugs are not covered under Basic Option. If you use any

of these “Managed Not Covered” Drugs, you will need to pay the full

cost of the drug(s).

If you are using one of these non-covered drugs, ask your doctor for

one of the covered generic or brand name options.

CATEGORY*

DRUG CLASS*

DRUGS NOT COVERED IN

2024 FOR BASIC OPTION

COVERED OPTIONS**

Acne

Oral Antibiotics

MINOLIRA, SEYSARA azithromycin, doxycycline (except

20mg), minocycline, minocycline ext-

rel, sulfamethoxazole/trimethoprim,

MINOCIN, SOLODYN, VIBRAMYCIN,

ZITHROMAX

Acne

Topical

ABSORICA LD

adapalene pad, adapalene

soln 0.1%, TWYNEO

isotretinoin, ABSORICA

adapalene crm, gel (Rx only),

adapalene/benzoyl peroxide, benzoyl

peroxide, clindamycin gel, lotion, soln,

swabs, clindamycin/benzoyl peroxide,

clindamycin/tretinoin, erythromycin

gel 2%, soln, erythromycin/benzoyl

peroxide, sulfacetamide sodium,

tazarotene crm 0.1%, gel 0.05%,

0.1%, tretinoin, ACANYA, AKLIEF,

AMZEEQ, ARAZLO, ATRALIN,

AZELEX, BENZAC AC, BENZAMYCIN,

CLEOCIN T, DIFFERIN (Rx only),

EPIDUO/FORTE, ERYGEL, FABIOR,

ONEXTON, RETIN A/MICRO,

TAZORAC, VELTIN, WINLEVI, ZIANA

Allergies

Antihistamines

carbinoxamine 6mg, cetirizine

solution, desloratadine,

levocetirizine, CLARINEX,

CLARINEX-D, RYVENT, XYZAL

montelukast, zaﬁrlukast, ACCOLATE,

SINGULAIR

Allergies

Nasal Steroids/

Antihistamines/

Combinations

BECONASE AQ, DYMISTA,

NASONEX, OMNARIS,

QNASL, RHINOCORT

AQUA, RYALTRIS,

VERAMYST, ZETONNA

azelastine spray, azelastine/

ﬂuticasone nasal spray, ﬂunisolide

spray, ﬂuticasone spray, mometasone

spray, olopatadine spray, PATANASE

Anticoagulants PRADAXA, PRADAXA PAK,

SAVAYSA

dabigatran caps, warfarin, ELIQUIS,

XARELTO

Antidiarrheals opium tincture diphenoxylate/atropine,loperamide

“MANAGED NOT COVERED” DRUG LIST

BASIC OPTION

CATEGORY*

DRUG CLASS*

DRUGS NOT COVERED IN

2024 FOR BASIC OPTION

COVERED OPTIONS**

Antifungals TOLSURA ﬂuconazole, itraconazole,

ketoconazole, posaconazole,

voriconazole, DIFLUCAN, NOXAFIL,

SPORANOX, VFEND

Anti-Inﬂammatories

Nonsteroidal Anti-

Inﬂammatories

(NSAIDs)

diclofenac potassium caps,

diclofenac sodium sol 2%,

fenoprofen caps 200mg,

indomethacin caps (20mg,

40mg), indomethacin supp

(50mg, 100mg), meloxicam

caps (5mg, 10mg),

meloxicam susp 7.5mg/5ml,

naproxen sodium ext-rel tabs,

ANAPROX DS, CAMBIA,

FELDENE, FENORTHO,

INDOCIN susp/supp,

NAPRELAN, NAPROSYN,

PENNSAID 2%, RELAFEN

DS, TIVORBEX, VIVLODEX,

ZIPSOR, ZORVOLEX

LICART

ELYXYB

diclofenac DR/ER (except diclofenac

potassium caps), diclofenac gel/

soln (except 2% soln), etodolac/ER,

ﬂurbiprofen, ibuprofen, indomethacin/

ER (except indomethacin caps 20mg,

40mg and supp 50mg, 100mg),

ketoprofen/ER, meloxicam tabs,

nabumetone, naproxen, oxaprozin,

piroxicam, sulindac

diclofenac epolamine patch 1.3%,

diclofenac sodium gel 1%, diclofenac

sodium solution (except 2% soln),

FLECTOR

celecoxib, CELEBREX

Anti-Inﬂammatories

Nonsteroidal Anti-

Inﬂammatories

(NSAIDs)

Combinations

ibuprofen/famotidine tabs,

naproxen/esomeprazole

magnesium tabs DR,

ARTHROTEC, DUEXIS,

VIMOVO

CONSENSI

diclofenac/misoprostol, esomeprazole

magnesium delayed-rel, famotidine,

ibuprofen, naproxen

celecoxib, CELEBREX, AND

amlodipine tabs, NORVASC

Antineoplastic

Agents

(Anti)Hormonal

ZYTIGA

FASLODEX

abiraterone

fulvestrant

Antineoplastic

Agents

Kinase Inhibitors

GLEEVEC

AFINITOR, AFINITOR

DISPERZ

TYKERB

imatinib mesylate

everolimus, everolimus tabs for oral

suspension

lapatinib

Antineoplastic

Agents

Miscellaneous

XELODA

TEMODAR

TARGRETIN CAPS/GEL

capecitabine

temozolomide

bexarotene caps/gel

CATEGORY*

DRUG CLASS*

DRUGS NOT COVERED IN

2024 FOR BASIC OPTION

COVERED OPTIONS**

Antiobesity ADIPEX-P, PLENITY benzphetamine tabs, diethylpropion

ext-rel tabs, diethylpropion tabs,

orlistat (RX), phendimetrazine tabs,

phentermine tabs/caps, CONTRAVE,

LOMAIRA, PHENDIMETRAZINE

TARTRATE EXT-REL CAP, QSYMIA,

SAXENDA, WEGOVY, XENICAL (RX)

Antirheumatics penicillamine caps,

CUPRIMINE

REDITREX

azathioprine, hydroxychloroquine,

leﬂunomide, methotrexate,

penicillamine tabs, DEPEN

methotrexate, OTREXUP, RASUVO

Antispasmotics LIBRAX

DONNATAL

chlordiazepoxide/clidinium,

dicyclomine, hyoscyamine

atropine/hyoscyamine/scopolamine/

phenobarbital

Anxiety Disorders

Benzodiazepines

LOREEV XR alprazolam/ext-rel, chlordiazepoxide,

clonazepam, clorazepate, diazepam,

lorazepam, oxazepam, ATIVAN,

KLONOPIN, VALIUM, XANAX/XR

Asthma

Beta Agonist

(Rescue Inhaler)

PROVENTIL HFA, VENTOLIN

HFA, XOPENEX HFA

albuterol solution, albuterol sulfate

CFC-free aerosol, levalbuterol

inhalation solution, levalbuterol

nebulizer solution concentrate,

levalbuterol tartrate CFC-free

aerosol, PROAIR HFA, XOPENEX

CONCENTRATE, XOPENEX

SOLUTION

Asthma

Inhaled

Corticosteroid

AEROSPAN, ALVESCO budesonide inhalation suspension,

ﬂuticasone, CFC-free aerosol,

ASMANEX, FLOVENT HFA,

PULMICORT, QVAR, QVAR

REDIHALER

Asthma

Leukotriene

Modulators

zileuton ext-rel, ZYFLO CR montelukast, zaﬁrlukast, SINGULAIR,

ACCOLATE, ZYFLO

Benign Prostatic

Hyperplasia (BPH)

ENTADFI, JALYN,

UROXATRAL

alfuzosin ext-rel, dutasteride,

dutasteride/tamsulosin, ﬁnasteride,

silodosin, tadalaﬁl (2.5mg, 5mg),

tamsulosin, AVODART, CIALIS (2.5mg,

5mg), PROSCAR, RAPAFLO, FLOMAX

Bladder Agents DETROL, DETROL LA,

ENABLEX, GELNIQUE,

GEMTESA, OXYTROL,

VESICARE, VESICARE LS

darifenacin ext-rel, fesoterodine ext-

rel, oxybutynin, oxybutynin ext-rel,

solifenacin, tolterodine, tolterodine

ext-rel, trospium, trospium ext-rel,

MYRBETRIQ, TOVIAZ

“MANAGED NOT COVERED” DRUG LIST BASIC OPTION

CATEGORY*

DRUG CLASS*

DRUGS NOT COVERED IN

2024 FOR BASIC OPTION

COVERED OPTIONS**

Cardiovascular

Heart

aspirin/omeprazole delayed-

rel tabs, YOSPRALA

aspirin*** and esomeprazole

magnesium delayed-rel, lansoprazole,

omeprazole, pantoprazole, rabeprazole

(except rabeprazole capsule sprinkle

delayed-rel)

Cardiovascular

Antiarrhythmics

TIKOSYN

BETAPACE, BETAPACE AF

dofetilide

sotalol, sotalol AF

Cardiovascular

Loop Diuretics

FUROSCIX, SOAANZ bumetanide, ethacrynic acid,

furosemide, torsemide, EDECRIN,

LASIX

Cardiovascular

Miscellaneous

NORTHERA droxidopa

Central Nervous

System

Anticonvulsants

SABRIL vigabatrin, vigadrone

Central Nervous

System

Antidepressant

Combinations

SYMBYAX olanzapine/ﬂuoxetine

Central Nervous

System

Antidepressants

Miscellaneous

WELLBUTRIN XL amitriptyline/perphenazine,

bupropion, bupropion ext-rel,

mirtazapine, nefazodone, trazodone,

APLENZIN, FORFIVO XL, REMERON,

SPRAVATO, WELLBUTRIN SR

Central Nervous

System

Miscellaneous

methylphenidate tab ER

osmotic release 45mg,

63mg, 72mg, ADHANSIA

XR, ADZENYS XR-ODT,

COTEMPLA XR-ODT,

DESOXYN, DYANAVEL XR,

EVEKEO ODT, RELEXXII,

XELSTRYM

amphetamine sulfate, amphetamine/

dextroamphetamine mixed

salts/ER, dexmethylphenidate/

ER, dextroamphetamine/ER,

lisdexamfetamine, methylphenidate/

ER (except methylphenidate tab

ER osmotic release 45mg, 63mg,

72mg), ADDERALL, ADDERALL

XR, APTENSIO XR, AZSTARYS,

CONCERTA, DAYTRANA, DEXEDRINE,

EVEKEO, FOCALIN, FOCALIN XR,

JORNAY PM, METHYLIN, MYDAYIS,

PROCENTRA, QUILLICHEW ER,

QUILLIVANT XR, RITALIN, RITALIN LA,

VYVANSE, ZENZEDI

COPD

Inhaled Long-Acting

Muscarinic Receptor

Antagonist (LAMA)

INCRUSE ELLIPTA,

TUDORZA PRESSAIR

ipratropium, tiotropium inhalation

powder caps, ATROVENT HFA,

SPIRIVA, SPIRIVA RESPIMAT

CATEGORY*

DRUG CLASS*

DRUGS NOT COVERED IN

2024 FOR BASIC OPTION

COVERED OPTIONS**

COPD

Inhaled Long-Acting

Muscarinic Receptor

Antagonist (LAMA)/

Long-Acting Beta

Agonist (LABA)

Combinations

DUAKLIR PRESSAIR ANORO ELLIPTA,

BEVESPI AEROSPHERE,

STIOLTO RESPIMAT

Corticosteroids ALKINDI SPRINKLE CAPS,

CORTEF, DELTASONE,

DEXABLISS, DXEVO 11-

DAY, MEDROL, MILLIPRED,

ORAPRED ODT, RAYOS,

TAPERDEX

dexamethasone, ﬂudrocortisone,

hydrocortisone, methylprednisolone,

prednisone

Dermatology

Actinic Keratosis

ﬂuorouracil cream 0.5%,

CARAC, KLISYRI

diclofenac sodium gel 3%,

ﬂuorouracil (except ﬂuorouracil cream

0.5%), EFUDEX

Dermatology

Antifungal

ALCORTIN-A, ERTACZO,

JUBLIA, KERYDIN*,

LOPROX, LOTRISONE*,

LUZU, MENTAX, NAFTIN*,

OXISTAT, VUSION*,

XOLEGEL*

ciclopirox, clotrimazole, clotrimazole/

betamethasone, econazole,

hydrocortisone/iodoquinol,

hydrocortisone/iodoquinol/aloe,

ketoconazole, luliconazole, miconazole

nitrate/zinc oxide, naftiﬁne, nystatin,

oxiconazole crm, sulconazole,

tavaborole sol 5%, terbinaﬁne tablets,

ECOZA, EXELDERM

Dermatology

Corticosteroids

halobetasol propionate

topical foam, triamcinolone

oint 0.05%, BRYHALI,

IMPEKLO, IMPOYZ,

LEXETTE, NOVACORT,

OLUX, OLUX-E, TRIANEX,

VANOS

betamethasone dipropionate

(crm, lotion, oint), betamethasone

dipropionate augmented (crm, lotion,

gel, oint), clobetasol propionate,

diﬂorasone diacetate, ﬂuocinonide (crm,

gel, oint, soln), halobetasol propionate

crm, hydrocortisone/pramoxine,

triamcinolone acetonide (except

triamcinolone oint 0.05%), APEXICON

E, CLOBEX, DIPROLENE, HALOG,

KENALOG SPRAY, PRAMOSONE,

SERNIVO, TOPICORT, ULTRAVATE

Dermatology

Impetigo

XEPI CREAM 1% mupirocin cream 2%, mupirocin

ointment 2%, ALTABAX OINTMENT 1%

Dermatology

Miscellaneous

XERESE

VEREGEN

EXTINA

OVACE, OVACE PLUS

acyclovir, hydrocortisone

imiquimod, ZYCLARA

ketoconazole foam 2%

sulfacetamide sodium

“MANAGED NOT COVERED” DRUG LIST BASIC OPTION

CATEGORY*

DRUG CLASS*

DRUGS NOT COVERED IN

2024 FOR BASIC OPTION

COVERED OPTIONS**

Dermatology

Psoriasis

TACLONEX, WYNZORA acitretin, betamethasone

dipropionate/calcipotriene (oint, susp),

calcipotriene, calcitriol, methoxsalen,

DUOBRII, ENSTILAR, SORILUX,

VECTICAL, VTAMA, ZORYVE

Dermatology

Rosacea

EPSOLAY, NORITATE azelaic acid gel, brimonidine topical

gel, doxycycline (except 20mg),

ﬂurandrenolide, ivermectin crm

1%, metronidazole cream/gel/

lotion, FINACEA, METROCREAM,

METROGEL, METROLOTION,

MIRVASO, ORACEA, SOOLANTRA,

ZILXI

Diabetes

Dipeptidyl

Peptidase-4

(DPP-4) Inhibitors/

Combinations

JENTADUETO, JENTADUETO

XR, KAZANO, KOMBIGLYZE

XR, NESINA, ONGLYZA,

OSENI, TRADJENTA

alogliptin, alogliptin/metformin,

alogliptin/pioglitazone, JANUMET,

JANUMET XR, JANUVIA

Diabetes

Incretin Mimetic

Agents

ADLYXIN, BYDUREON,

BYDUREON BCISE, BYETTA

MOUNJARO, OZEMPIC, RYBELSUS,

TRULICITY, VICTOZA

Diabetes

Incretin Mimetic

Agent Combinations

SOLIQUA XULTOPHY

Diabetes

Insulins

(NOTE: HUMULIN R

U-500 concentrate

will continue to be

covered)

insulin lispro, ADMELOG/

SOLOSTAR, APIDRA/

SOLOSTAR, HUMALOG,

HUMALOG TEMPO,

LYUMJEV, LYUMJEV

KWIKPEN, LYUMJEV TEMPO

HUMALOG MIX 50/50

insulin lispro protamine/

insulin lispro 75/25,

HUMALOG MIX 75/25

HUMULIN 70/30

HUMULIN N

HUMULIN R

insulin glargine, LANTUS/

SOLOSTAR, SEMGLEE,

TOUJEO/SOLOSTAR/MAX

SOLOSTAR

insulin aspart, FIASP/FLEXTOUCH,

NOVOLOG

insulin aspart protamine 70%/insulin

aspart 30%, NOVOLOG MIX 70/30

insulin aspart protamine 70%/insulin

aspart 30%, NOVOLOG MIX 70/30

NOVOLIN 70/30

NOVOLIN N

NOVOLIN R

BASAGLAR, BASAGLAR TEMPO,

INSULIN DEGLUDEC/FLEXTOUCH,

INSULIN GLARGINE - YFGN

(interchangeable biosimilar),

LEVEMIR, TRESIBA/FLEXTOUCH

CATEGORY*

DRUG CLASS*

DRUGS NOT COVERED IN

2024 FOR BASIC OPTION

COVERED OPTIONS**

Diabetes

Metformin

metformin 625mg tab,

FORTAMET, GLUMETZA,

RIOMET ER, RIOMET IR

metformin (does not include 625mg

tabs), metformin ext-rel, metformin

oral soln

Diabetes

Other

CYCLOSET alogliptin, alogliptin/metformin,

alogliptin/pioglitazone, bromocriptine

mesylate, glimepiride, glipizide,

glyburide, glyburide/metformin,

pioglitazone, repaglinide

Diabetes

SGLT2 Inhibitors

INVOKAMET, INVOKAMET XR,

INVOKANA, SEGLUROMET,

STEGLATRO, STEGLUJAN

FARXIGA, JARDIANCE, SYNJARDY,

SYNJARDY XR, XIGDUO XR

Endocrine And

Metabolic

Miscellaneous

RECLAST

SANDOSTATIN

SENSIPAR

zoledronic acid

octreotide

cinacalcet

Gastrointestinal

Diabetic

Gastroparesis

GIMOTI metoclopramide, REGLAN

Glaucoma

Prostaglandins

LUMIGAN latanoprost, taﬂuprost, travoprost,

TRAVATAN Z, VYZULTA, XALATAN,

XELPROS, ZIOPTAN

Gout allopurinol 200mg tab allopurinol (does not include 200mg

tab), colchicine, febuxostat, probenecid,

COLCRYS, KRYSTEXXA, MITIGARE,

ULORIC, ZYLOPRIM

Growth Hormone GENOTROPIN, HUMATROPE,

NUTROPIN, NUTROPIN

AQ, OMNITROPE, SAIZEN,

ZOMACTON

NORDITROPIN

H2 Receptor

Antagonists

PEPCID famotidine 40mg, cimetidine,

nizatidine

Hematopoietic

Growth Factors

NEUPOGEN

PROCRIT

GRANIX, NIVESTYM, RELEUKO,

ZARXIO

ARANESP, EPOGEN, RETACRIT

Hepatitis B BARACLUDE TABLETS

HEPSERA

entecavir tablets

adefovir dipivoxil

Hepatitis C ZEPATIER ledipasvir/sofosbuvir, sofosbuvir/

velpatasvir, EPCLUSA, HARVONI,

MAVYRET, SOVALDI, VOSEVI

Hereditary

Angioedema (HAE)

FIRAZYR icatibant

“MANAGED NOT COVERED” DRUG LIST BASIC OPTION

CATEGORY*

DRUG CLASS*

DRUGS NOT COVERED IN

2024 FOR BASIC OPTION

COVERED OPTIONS**

High Blood Pressure

Angiotensin II

Receptor Blockers/

Combinations

(ARBs)

valsartan oral soln 4mg/

mL, ATACAND, ATACAND

HCT, AVALIDE, AVAPRO,

COZAAR, DIOVAN,

DIOVAN HCT, EDARBI,

EDARBYCLOR, HYZAAR,

MICARDIS, MICARDIS HCT

candesartan, candesartan/HCTZ,

irbesartan, irbesartan/HCTZ, losartan,

losartan/HCTZ, olmesartan, olmesartan/

HCTZ, telmisartan, telmisartan/HCTZ,

valsartan (does not include valsartan

oral soln 4mg/mL), valsartan/HCTZ,

BENICAR, BENICAR HCT

High Blood Pressure

Beta-Blockers

BYSTOLIC acebutolol, atenolol, carvedilol/

ext-rel, metoprolol succinate ext-

rel, metoprolol tartrate, nebivolol,

pindolol, propranolol/ext-rel, COREG/

CR, INDERAL LA, INNOPRAN

XL, KAPSPARGO, LOPRESSOR,

TENORMIN, TOPROL-XL

High Blood Pressure

Calcium Channel

Blockers

levamlodipine maleate caps,

CONJUPRI, KATERZIA,

NORLIQVA

amlodipine tabs, felodipine ext-

rel, nicardipine, nifedipine ext-rel,

nisoldipine ext-rel, NORVASC,

PROCARDIA XL, SULAR

High Cholesterol

Fibrates

FENOGLIDE fenoﬁbrate, fenoﬁbric acid del-rel,

gemﬁbrozil, LIPOFEN, TRICOR,

TRIPLEX, LOPID, ANTARA

High Cholesterol

PCSK9 Inhibitors

PRALUENT REPATHA

High Cholesterol

Statins

simvastatin susp, ALTOPREV,

CADUET, CRESTOR,

EZALLOR SPRINKLE,

EZETIMIBE/ROSUVASTATIN

tabs, FLOLIPID, LESCOL/XL,

LIPITOR, LIPTRUZET, LIVALO,

MEVACOR, PRAVACHOL,

ROSZET, VYTORIN, ZOCOR,

ZYPITAMAG

amlodipine/atorvastatin, atorvastatin,

ezetimibe/simvastatin, ﬂuvastatin,

lovastatin, pravastatin, rosuvastatin,

simvastatin

Immunomodulators

Miscellaneous

ZORTRESS everolimus

Inﬂuenza Agents FLUMADINE oseltamivir, rimantadine, RELENZA,

TAMIFLU, XOFLUZA

Interstitial Cystitis RIMSO-50 Members advised to discuss

suitable therapeutic alternatives with

prescriber

Iron Deﬁciency ACCRUFER ferrous fumarate†, ferrous

gluconate†, ferrous sulfate†,

INJECTAFER, MONOFERRIC

Iron Overload EXJADE, JADENU deferasirox

CATEGORY*

DRUG CLASS*

DRUGS NOT COVERED IN

2024 FOR BASIC OPTION

COVERED OPTIONS**

Irritable Bowel

Syndrome

Irritable Bowel

Syndrome with

Constipation

AMITIZA lubiprostone (generic), IBSRELA,

LINZESS, MOTEGRITY

Laxatives LACTULOSE PAK 10MG,

SUTAB

lactulose solution, PEG 3350/

electrolytes, sodium sulfate/

potassium sulfate/magnesium

sulfate, CLENPIQ, GOLYTELY,

KRISTALOSE, MOVIPREP,

OSMOPREP, PLENVU, PREPOPIK,

SUPREP

Migraine Agents

Calcitonin Gene-

Related Peptide

(CGRP) Inhibitors

AJOVY

UBRELVY

AIMOVIG, EMGALITY 120 mg/mL,

QULIPTA, VYEPTI

NURTEC ODT

Migraine Agents

Ergotamine

Derivatives

CAFERGOT, MIGRANAL,

TRUDHESA

dihydroergotamine nasal spray/inj,

ergotamine/caffeine tabs, D.H.E. 45

Migraine Agents

Selective Serotonin

Agonists

REYVOW, TOSYMRA almotriptan, eletriptan, frovatriptan,

naratriptan, rizatriptan, sumatriptan,

zolmitriptan, FROVA, IMITREX,

MAXALT, MAXALT-MLT, ONZETRA

XSAIL, RELPAX, ZOMIG

Movement

Disorders

APOKYN, OSMOLEX ER,

TASMAR

XENAZINE

amantadine IR, apomorphine,

benztropine, bromocriptine,

carbidopa/levodopa, entacapone,

pramipexole, rasagiline, ropinirole/

ER, selegiline, tolcapone, AZILECT,

COMTAN, DUOPA, GOCOVRI,

KYNMOBI, MIRAPEX XR, NEUPRO,

PARLODEL, RYTARY, SINEMET,

STALEVO, XADAGO, ZELAPAR

tetrabenazine

Multiple Sclerosis AMPYRA

COPAXONE

TECFIDERA

dalfampridine ER

glatiramer, GLATOPA

dimethyl fumarate delayed-rel

“MANAGED NOT COVERED” DRUG LIST BASIC OPTION

CATEGORY*

DRUG CLASS*

DRUGS NOT COVERED IN

2024 FOR BASIC OPTION

COVERED OPTIONS**

Musculoskeletal

Therapy Agents

cyclobenzaprine ext-rel, AMRIX

FLEQSUVY, LYVISPAH

chlorzoxazone tab (250mg,

375mg, 750mg), LORZONE

orphenadrine/aspirin/caffeine

tabs, ORPHENGESIC FORTE

baclofen, cyclobenzaprine

baclofen, cyclobenzaprine,

dantrolene, DANTRIUM, LIORESAL

INTRATHECAL, OZOBAX

chlorzoxazone tab 500mg

aspirin***, caffeine†, baclofen,

cyclobenzaprine

Nausea And

Vomiting Therapy

(5HT-3 Blocker)

ANZEMET, ZUPLENZ granisetron, ondansetron,

palonosetron, promethazine,

SANCUSO

Nausea And

Vomiting

Pregnancy

BONJESTA doxylamine†, doxylamine/pyridoxine

delayed-rel, pyridoxine (vitamin B6)†,

DICLEGIS, UNISOM†

Omega-3 Fatty Acids VASCEPA icosapent ethyl caps, omega-3 acid

ethyl esters caps, LOVAZA

Ophthalmology

Anti-Infectives

BACIGUENT bacitracin ophthalmic

Ophthalmology

Dry Eye Disease

EYSUVIS, TYRVAYA cyclosporine emulsion, CEQUA,

RESTASIS, XIIDRA

Ophthalmology

Miscellaneous

atropine sulfate eye ointment

PHOSPHOLINE IODIDE

VUITY

atropine ophthalmic solution,

cyclopentolate ophthalmic solution

Members advised to discuss suitable

therapeutic alternatives with prescriber

Members advised to discuss suitable

therapeutic alternatives with prescriber

Pain Medications

Neuropathic Pain

pregabalin ext-rel tabs,

GRALISE, HORIZANT,

LYRICA, LYRICA CR

gabapentin, pregabalin (does not

include ext-rel tabs), NEURONTIN

CATEGORY*

DRUG CLASS*

DRUGS NOT COVERED IN

2024 FOR BASIC OPTION

COVERED OPTIONS**

Pain Medications

Opioids

ARYMO ER, HYSINGLA ER,

OXYCONTIN

benzhydrocodone/

acetaminophen,

hydrocodone/acetaminophen

soln 10–325mg/15mL,

oxycodone/acetaminophen

tab (2.5mg–300mg, 5mg–

300mg, 10mg–300mg),

oxycodone-acetaminophen

soln 10–300mg/5ml, APADAZ,

NALOCET, PRIMLEV,

PROLATE

LAZANDA

levorphanol

SEGLENTIS

tramadol 100mg tabs,

tramadol 5 mg/mL oral,

CONZIP, QDOLO

hydrocodone ext-rel, hydromorphone

ext-rel, morphine ext-rel, tramadol

ext-rel, EMBEDA, MORPHABOND,

MS CONTIN, NUCYNTA ER, OPANA

ER, XTAMPZA ER

codeine/acetaminophen,

hydrocodone/acetaminophen,

oxycodone/acetaminophen (except

2.5mg–300mg, 5mg–300mg,

10mg–300mg tabs), tramadol/

acetaminophen, ENDOCET,

PERCOCET

fentanyl buccal, fentanyl sublingual,

fentanyl transmucosal, FENTORA,

SUBSYS

hydromorphone, morphine, oxycodone,

tramadol (except 100mg tab, and 5mg/

mL oral soln), DILAUDID, NUCYNTA,

OPANA, ROXICODONE

celecoxib, tramadol (except 100mg

tabs, and 5mg/mL oral soln),

CELEBREX

tramadol (except 100mg tabs and

5mg/mL oral soln), tramadol ext-rel,

tramadol/acetaminophen

Pain Medications

Topical

ZTLIDO lidocaine cream, lidocaine gel,

lidocaine lotion, lidocaine ointment,

lidocaine patch 5%, LIDODERM

PATCH, QUTENZA PATCH

Pancreatic Enzymes PERTZYE, ZENPEP CREON, PANCREAZE, VIOKACE

Proton Pump

Inhibitors

esomeprazole strontium,

omeprazole/sodium

bicarbonate, rabeprazole

capsule sprinkle delayed-rel,

ACIPHEX, DEXILANT, FIRST-

LANSOPRAZOLE, FIRST-

OMEPRAZOLE, NEXIUM,

PREVACID, PREVACID

SOLUTAB, PRILOSEC,

PROTONIX, ZEGERID

dexlansoprazole delayed-rel,

esomeprazole magnesium delayed-rel,

lansoprazole delayed-rel, omeprazole

delayed-rel, pantoprazole delayed-

rel, rabeprazole (except rabeprazole

capsule sprinkle delayed-rel)

“MANAGED NOT COVERED” DRUG LIST BASIC OPTION

CATEGORY*

DRUG CLASS*

DRUGS NOT COVERED IN

2024 FOR BASIC OPTION

COVERED OPTIONS**

Pulmonary Arterial

Hypertension (PAH)

LETAIRIS

REVATIO

ADCIRCA

TRACLEER 62.5mg, 125mg tab

ambrisentan

sildenaﬁl (PAH)

tadalaﬁl (PAH), Alyq

bosentan

Sleep Agents zolpidem cap 7.5mg,

AMBIEN, AMBIEN

CR, DORAL, EDLUAR,

INTERMEZZO, LUNESTA,

QUVIVIQ, ROZEREM,

SECONAL, SONATA

doxepin, estazolam, eszopiclone,

quazepam, ramelteon, temazepam,

triazolam, zaleplon, zolpidem tab/

ER tab, BELSOMRA, DAYVIGO,

RESTORIL, SILENOR

TestosteroneAgents

Topical

ANDROGEL, NATESTO,

TESTIM, VOGELXO

testosterone gel, ANDRODERM,

FORTESTA

TestosteroneAgents

Oral/Buccal

TLANDO JATENZO, KYZATREX, STRIANT

Thyroid Disease ERMEZA, THYQUIDITY levothyroxine, liothyronine,

CYTOMEL, SYNTHROID, TIROSINT

Ulcer Therapy

Miscellaneous

CARAFATE

DARTISLA ODT

sucralfate

glycopyrrolate tabs (generic)

Ulcerative Colitis ASACOL HD, COLAZAL,

DELZICOL, PENTASA

balsalazide, mesalamine delayed-

rel (caps, tabs), mesalamine ext-rel

caps, sulfasalazine, sulfasalazine

delayed, rel, APRISO, AZULFIDINE,

DIPENTIUM, LIALDA

*This list shows uses for which the drug is prescribed. Some drugs are prescribed for more than

one condition.

**For more covered options, review 2024 Basic Option formulary.

***Multiple strengths of aspirin are covered for men age 45 through 79 and women age 50

through 79. Low-dose aspirin (81mg per day) for female members at risk for preeclampsia.

†Denotes over-the-counter (OTC) availability only, and not covered through the prescription beneﬁt.

ALPHABETIC “MANAGED NOT COVERED” DRUG LIST BASIC OPTION

ABSORICA LD

ACCRUFER

ACIPHEX

adapalene pad

adapalene soln 0.1%

ADCIRCA

ADHANSIA XR

ADIPEX-P

ADLYXIN

ADMELOG/SOLOSTAR

ADZENYS XR-ODT

AEROSPAN

AFINITOR

AFINITOR DISPERZ

AJOVY

ALCORTIN-A

ALKINDI SPRINKLE CAPS

allopurinol 200mg tab

ALTOPREV

ALVESCO

AMBIEN

AMBIEN CR

AMITIZA

AMPYRA

AMRIX

ANAPROX DS

ANDROGEL

ANZEMET

APADAZ

APIDRA/SOLOSTAR

APOKYN

ARTHROTEC

ARYMO ER

ASACOL HD

aspirin/omeprazole delayed-rel tabs

ATACAND

ATACAND HCT

atropine sulfate eye ointment

AVALIDE

AVAPRO

BACIGUENT

BARACLUDE TABLETS

BECONASE AQ

benzhydrocodone/acetaminophen

BETAPACE

BETAPACE AF

BONJESTA

BRYHALI

BYDUREON

BYDUREON BCISE

BYETTA

BYSTOLIC

CADUET

CAFERGOT

CAMBIA

CARAC

CARAFATE

carbinoxamine 6 mg

cetirizine solution

chlorzoxazone tab

(250mg, 375mg, 750mg)

CLARINEX

CLARINEX-D

COLAZAL

CONJUPRI

CONSENSI

CONZIP

COPAXONE

CORTEF

COTEMPLA XR-ODT

COZAAR

CRESTOR

CUPRIMINE

cyclobenzaprine ext-rel

CYCLOSET

DARTISLA ODT

DELTASONE

DELZICOL

desloratadine

DESOXYN

DETROL

DETROL LA

DEXABLISS

DEXILANT

diclofenac potassium caps

diclofenac sodium sol 2%

DIOVAN

DIOVAN HCT

DONNATAL

DORAL

DUAKLIR PRESSAIR

DUEXIS

DXEVO 11-DAY

DYANAVEL XR

DYMISTA

EDARBI

EDARBYCLOR

EDLUAR

ELYXYB

ENABLEX

ENTADFI

EPSOLAY

ERMEZA

ERTACZO

esomeprazole strontium

EVEKEO ODT

EXJADE

EXTINA

EYSUVIS

EZALLOR SPRINKLE

EZETIMIBE/ROSUVASTATIN tabs

FASLODEX

FELDENE

FENOGLIDE

fenoprofen caps 200mg

FENORTHO

FIRAZYR

FIRST-LANSOPRAZOLE

“MANAGED NOT COVERED” DRUG LIST BASIC OPTION

FIRST-OMEPRAZOLE

FLEQSUVY

FLOLIPID

FLUMADINE

ﬂuorouracil cream 0.5%

FORTAMET

FUROSCIX

GELNIQUE

GEMTESA

GENOTROPIN

GIMOTI

GLEEVEC

GLUMETZA

GRALISE

halobetasol propionate topical foam

HEPSERA

HORIZANT

HUMALOG

HUMALOG MIX 50/50

HUMALOG MIX 75/25

HUMALOG TEMPO

HUMATROPE

HUMULIN 70/30

HUMULIN N

HUMULIN R

hydrocodone/acetaminophen

soln 10–325mg/15mL

HYSINGLA ER

HYZAAR

ibuprofen/famotidine tabs

IMPEKLO

IMPOYZ

INCRUSE ELLIPTA

INDOCIN SUSP/SUPP

indomethacin caps (20mg, 40mg)

indomethacin supp (50mg, 100mg)

insulin glargine

insulin lispro

insulin lispro protamine/

insulin lispro 75/25

INTERMEZZO

INVOKAMET

INVOKAMET XR

INVOKANA

JADENU

JALYN

JENTADUETO

JENTADUETO XR

JUBLIA

KATERZIA

KAZANO

KERYDIN

KLISYRI

KOMBIGLYZE XR

LACTULOSE PAK 10MG

LANTUS/SOLOSTAR

LAZANDA

LESCOL/XL

LETAIRIS

levamlodipine maleate caps

levocetirizine

levorphanol

LEXETTE

LIBRAX

LICART

LIPITOR

LIPTRUZET

LIVALO

LOPROX

LOREEV XR

LORZONE

LOTRISONE

LUMIGAN

LUNESTA

LUZU

LYRICA

LYRICA CR

LYUMJEV

LYUMJEV KWIKPEN

LYUMJEV TEMPO

LYVISPAH

MEDROL

meloxicam caps (5mg, 10mg)

meloxicam susp 7.5mg/5ml

MENTAX

metformin 625mg tab

methylphenidate tab ER osmotic

release 45mg, 63mg, 72mg

MEVACOR

MICARDIS

MICARDIS HCT

MIGRANAL

MILLIPRED

MINOLIRA

NAFTIN

NALOCET

NAPRELAN

NAPROSYN

naproxen sodium ext-rel tabs

naproxen/esomeprazole

magnesium tabs DR

NASONEX

NATESTO

NESINA

NEUPOGEN

NEXIUM

NORITATE

NORLIQVA

NORTHERA

NOVACORT

NUTROPIN

NUTROPIN AQ

OLUX

OLUX-E

omeprazole/sodium bicarbonate

OMNARIS

OMNITROPE

ONGLYZA

opium tincture

ORAPRED ODT

orphenadrine/aspirin/caffeine tabs

ORPHENGESIC FORTE

OSENI

OSMOLEX ER

OVACE

OVACE PLUS

OXISTAT

oxycodone/acetaminophen tab

(2.5mg–300mg, 5mg–300mg,

10mg–300mg)

oxycodone-acetaminophen soln

10–300mg/5ml

OXYCONTIN

OXYTROL

penicillamine caps

PENNSAID 2%

PENTASA

PEPCID

PERTZYE

PHOSPHOLINE IODIDE

PLENITY

PRADAXA

PRADAXA PAK

PRALUENT

PRAVACHOL

pregabalin ext-rel tabs

PREVACID

PREVACID SOLUTAB

PRILOSEC

PRIMLEV

PROCRIT

PROLATE

PROTONIX

PROVENTIL HFA

QDOLO

QNASL

QUVIVIQ

rabeprazole capsule sprinkle

delayed-rel

RAYOS

RECLAST

REDITREX

RELAFEN DS

RELEXXII

REVATIO

REYVOW

RHINOCORT AQUA

RIMSO-50

RIOMET ER

RIOMET IR

ROSZET

ROZEREM

RYALTRIS

RYVENT

SABRIL

SAIZEN

SANDOSTATIN

SAVAYSA

SECONAL

SEGLENTIS

SEGLUROMET

SEMGLEE

SENSIPAR

SEYSARA

simvastatin susp

SOAANZ

SOLIQUA

SONATA

STEGLATRO

STEGLUJAN

SUTAB

SYMBYAX

TACLONEX

TAPERDEX

TARGRETIN CAPS/GEL

TASMAR

TECFIDERA

TEMODAR

TESTIM

THYQUIDITY

TIKOSYN

TIVORBEX

TLANDO

TOLSURA

TOSYMRA

TOUJEO/SOLOSTAR/

MAX SOLOSTAR

TRACLEER 62.5mg, 125mg tab

TRADJENTA

tramadol 100mg tabs

tramadol 5mg/mL oral

triamcinolone oint 0.05%

TRIANEX

TRUDHESA

TUDORZA PRESSAIR

TWYNEO

TYKERB

TYRVAYA

UBRELVY

UROXATRAL

valsartan oral soln 4 mg/mL

VANOS

VASCEPA

VENTOLIN HFA

VERAMYST

VEREGEN

VESICARE

VESICARE LS

VIMOVO

VIVLODEX

VOGELXO

VUITY

VUSION

VYTORIN

WELLBUTRIN XL

WYNZORA

XELODA

XELSTRYM

XENAZINE

XEPI CREAM 1%

XERESE

XOLEGEL

XOPENEX HFA

“MANAGED NOT COVERED” DRUG LIST BASIC OPTION

XYZAL

YOSPRALA

ZEGERID

ZENPEP

ZEPATIER

ZETONNA

zileuton ext-rel

ZIPSOR

ZOCOR

zolpidem cap 7.5mg

ZOMACTON

ZORTRESS

ZORVOLEX

ZTLIDO

ZUPLENZ

ZYFLO CR

ZYPITAMAG

ZYTIGA

2024 PHARMACY BENEFIT

CHANGE HIGHLIGHTS

DRUGS ASSOCIATED WITH ARTIFICIAL INSEMINATION (AI)

We now provide beneﬁts for drugs associated with covered artiﬁcial

insemination (AI) procedures.

DRUGS USED IN CONJUCTION WITH ASSISTED REPRODUCTIVE

TECHNOLOGIES (ART)

We now cover in vitro fertilization related drugs limited to three cycles

annually once prior approval has been obtained for individuals that

meet our deﬁnition of infertility.

MEDICARE PRESCRIPTION DRUG PROGRAM

For eligible members, prescription drug beneﬁts will now be provided

under a new FEP Medicare Prescription Drug Program. To learn more,

visit fepblue.org/medicarerx.

This is not a full list of beneﬁt changes. To see a full list, visit

fepblue.org/brochure to download the Standard and Basic

Option (RI 71-005) and/or FEP Blue Focus (RI 71-017) brochures.

To see the 2024 full formularies:

■

Prior to January 1, 2024, visit fepblue.org/whatsnew

■

After January 1, 2024, visit fepblue.org/pharmacy/prescriptions

■

Call Customer Care: 1-800-624-5060 (T T Y: 711)

2024 PHARMACY BENEFIT

CHANGE HIGHLIGHTS

HOW TO CONTACT US

Call these numbers for prescription drug information:

RETAIL PHARMACY PROGRAM

(Standard Option, Basic Option

and FEP Blue Focus)

Toll-free any time at

1-800-624-5060

( T T Y: 711)

MAIL SERVICE PHARMACY

PROGRAM

(Standard Option, Basic Option

with Medicare Part B)

Toll-free any time at

1-800-262-7890

(TTY: 1-800-216-5343)

SPECIALTY PHARMACY

PROGRAM

(Standard Option, Basic Option

and FEP Blue Focus)

Toll-free at 1-888-346-3731

(TTY: 1-877-853-9549)

Monday–Friday:

7 a.m. to 9 p.m. Eastern time

Saturday - Sunday:

8 a.m. to 6:30 p.m. Eastern time

OTHER BENEFIT OR CLAIMS

INFORMATION

Call the customer service number

on the back of your member

ID card. You can also see the

national list of customer service

numbers at fepblue.org/contact.

GENERAL QUESTIONS

Visit fepblue.org

This is a summary of the features of the Blue Cross and Blue Shield

Service Beneﬁt Plan. Before making a ﬁnal decision, please read the

Plan’s Federal brochures (Standard Option and Basic Option: RI 71-005;

FEP Blue Focus: RI 71-017). All beneﬁts are subject to the deﬁnitions,

limitations and exclusions set forth in the Federal brochures.

RXABRFRM2024