Standard Plan Four Tier Drug List
Preferred Generic and Branded Medications
This Preferred Drug List is regularly updated, but it may not reflect your specific plan coverage. Please log-in to your member portal on www.prescryptive.com for the most up to date list using your fully searchable formulary tool for your specific benefit information, or call Prescryptive Member Services at the number on your Member ID card for coverage information.
PRESCRIPTION COVERAGE
Your plan covers drugs on the Standard Plan Four Tier Drug List. This list of covered, preferred medications provides a guide for plan members and their healthcare providers to finding more cost effective, FDA approved medications.
HOW MUCH WILL MY MEDICATION COST?
Please refer to your benefit plan summary for more information about your specific benefit. With the Four Tier Drug List, the covered prescription medications fall into one of four cost levels or tiers, as outlined below. What you pay will depend on which tier your medication is in. Your benefit summary documents will provide the cost to you for each of the four tiers. To help you save money, ask your healthcare provider to consider the following when selecting a course of treatment:
• Consider prescribing a generic medication (Tier 1) as a first option.• If there is no generic available, there may be more than one brand name
medication to treat a condition. When clinically appropriate, considerone of the preferred brand medications (Tier 2) identified on this list fora more cost-effective choice.
• Some Preventive Medications (Tier 0) including some over-the-counterdrugs, devices and other products approved by the Federal Food andDrug Administration are fully covered at no cost to you, the member,when purchased through a participating pharmacy with a writtenprescription. To learn more about Preventive Medication coverage visitour website at www.prescryptive.com.
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FOUR TIERS
Tier Level Description
Tier 1 Lowest Co-pay or
Co-insurance
Generic drugs. All generics in the Drug List arelisted in bolded italics.
Tier 2 Lower Co-Pay or
Co-insurance
Preferred brand drugs. Preferred brand drugs are listed in ALL-CAPS.
Tier 3 Higher Co-Pay or
Co-Insurance
Non-preferred brand drugs. Non-preferred brand drugs are not listed in this document.
Tier 4 Highest Co-pay or
Co-insurance
Specialty Medications usually have a higher co-pay than other brand name drugs. Specialty medications are high cost, self-administered drugs that are used to treat rare or complex medical conditions. Specialty drugs typically require prior authorization before they are covered and must be filled through our designated specialty pharmacy.
For more information about Specialty Medications, visit our website at www.prescryptive.com or contact Prescryptive Member Services at the number listed on the back of your Member ID card.
FILLING YOUR PRESCRIPTION AT A NETWORK PHARMACY
You have access to Prescryptive’s nationwide network with thousands of participating pharmacies. To have your medication covered, you will need to use a participating pharmacy and show your Member ID card before purchasing your prescription. If you go to a pharmacy not in the network, the cost of your prescription may be higher and not fully covered, and you may need to pay for the prescription in full, and then manually submit for reimbursement using the Direct Member Reimbursement Form.
Log-in to your member portal at www.prescryptive.com to use the searchable pharmacy tool to find a pharmacy that is part of the Prescryptive nationwide network. Or, call Prescryptive Member Services at the number on the back of your Member ID for assistance.
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Note: Tier 0 medications are covered at no cost to members ($0 co-pay) as mandated by the federal Affordable Care Act (ACA).
HOME DELIVERY/MAIL ORDER
Most retail pharmacies can fill up to a 90-day supply of maintenance medications. It is your choice to use home delivery as a convenient way to ensure you maintain your
supply of any maintenance medications you are taking. For more information about our
home delivery or mail order service visit our website or call Prescryptive MemberServices at the number on the back of your Member ID for assistance.
SPECIALTY MEDICATIONS
Specialty medications are listed as Tier 4 drugs on this Drug List. All specialty
medications are managed and dispensed by Prescryptive’s Specialty Pharmacy partner
and require a Prior Authorization before these medications are covered under your
benefit plan. With written approval, your plan will cover a portion of the cost of these
medications as detailed in your benefit plan document, along with the support services provided by the Specialty Pharmacy care team to help with your treatment success. To
learn more about Specialty Medications, the Prior Authorization process, or your
benefit coverage visit our website at www.prescryptive.com or call Prescryptive Member Services at the number on the back of your Member ID for assistance.
PREFERRED DRUG LIST
The following list provides the tier coverage of each preferred drug, along with any prior authorization requirements. If the medication you are looking for is not on this list, it is a Tier 3 or Tier 4 non-preferred medication. Refer to your Benefit Plan Summary to understand how much your cost will be for each medication based upon its Tier classification.
Please note: Pharmacy products and services covered by your benefit plan may change from time to time. Some products and services may not be covered under a specific member’s plan design. The information provided here is for general information purposes only and does not guarantee coverage. Some pharmacy products and services require prior authorization before they are covered. Only a written prior authorization approval will guarantee coverage for such products and services. To confirm your coverage, reference your specific plan documents within your member portal account at www.prescryptive.com or contact Prescryptive Member Services at the phone number on your Member ID card.
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Drug Tier Notes Drug Tier Notesabacavir sulfate
abacavir sulfate-lamivudine
abacavir-lamivudine-zidovudine
abaneu-sl
acamprosate calcium
acarbose
acebutolol
Acetaminophen-Caffeine-Dihydrocodeine
acetaminophen-codeine
acetazolamide, er
acetic acid
acetylcysteine
acitretin
acyclovir
adapalene
adapalene-benzoyl peroxide
adefovir dipivoxil
Adempas
Advair Diskus, HFA
Afinitor, Disperz
aftera
Aimovig
albendazole
albuterol, er
albuterol, hfa
alclometasone
Alecensa
alendronate
Alferon N
alfuzosin er
aliskiren
allopurinol
almotriptan
alosetron
alprazolam, er
altavera
Alunbrig
alyacen
amantadine
ambrisentan
Amcinonide
Ameluz
amethia, lo
amethyst
amiloride
amiloride-hydrochlorothiazide
aminoacetic acid
aminobenzoate potassium
aminocaproic acid
amiodarone
amitriptyline
amlodipine
amlodipine-benazepril
amlodipine -valsartan
amlodipine-atorvastatin
amlodipine-olmesartan
amlodipine-valsartan-hydrochlorothiazide
amnesteem
Amoxapine
amoxicillin
amoxicillin-clarithromycin-lansoprazole
amoxicillin-clavulanate, er
amphetamine, er
amphetamine-dextroamphetamine, er
ampicillin
anagrelide
anaspaz
anastrozole
annovera
Anoro Ellipta
anucort-hc
Apokyn
4
0
1
4
2
2
0
0
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
1
1
1
1
1
1
1
1
1
0
2
1
4
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
1
1
1
1
1
1
1
2
1
1
1
1
1
1
1
1
4
4
2
4
0
4
1
1
1
1
4
1
4
1
1
1
1
1
1
0
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
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Drug Tier Notes Drug Tier Notesapraclonidine
aprepitant
apri
Aptiom
Aptivus
Arakoda
aranelle
Aranesp
Arcalyst
Arikayce
aripiprazole
armodafinil
Armour Thyroid
Arnuity Ellipta
ashlyna
aspirin low strength
aspirin-dipyridamole er
Astagraf XL
Atabex
atazanavir sulfate
atenolol
atenolol-chlorthalidone
atomoxetine
atorvastatin
atovaquone
atovaquone-proguanil
Atripla
atropine sulfate
Aubagio
aubra, eq
aurovela
aurovela 24 fe
aurovela fe
Auryxia
Austedo
aviane
avidoxy
avita
Avonex
ayuna
Ayvakit
Azasan
AzaSite
azathioprine
azelaic acid
azelastine
azelastine-fluticasone
azithromycin
azurette
bacitracin
bacitracin-neomycin-polymyxin b-hydrocortisone
bacitracin-polymyxin b
baclofen
balcoltra
balsalazide
Balversa
balziva
Banzel
Baqsimi
Basaglar
bekyree
Belladonna Alkaloids-Opium
benazepril
benazepril-hydrochlorothiazide
Benlysta
benznidazole
benzonatate
benzoyl peroxide-erythromycin
benzoyl peroxide-hydrocortisone
benztropine
betamethasone dipropionate
betamethasone dipropionate aug
1
1
4
0
4
2
2
1
1
1
1
1
0
1
1
1
1
1
1
4
0
2
2
2
0
2
1
1
4
1
1
1
1
1
1
1
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
1
1
0
2
2
2
0
4
4
4
1
1
2
2
0
0
1
2
2
1
1
1
1
1
1
1
2
1
4
0
0
0
0
4
4
0
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
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Drug Tier Notes Drug Tier Notesbetamethasone valerate
betaxolol
bethanechol
bexarotene
bicalutamide
Biktarvy
bimatoprost
Bio-Statin
bisoprolol
bisoprolol-hydrochlorothiazide
blanche
blisovi 24 fe
blisovi fe
bosentan
Bosulif
Braftovi
Breo Ellipta
briellyn
Brilinta
brimonidine
Brimonidine-Dorzolamide
Briviact
bromfed dm
bromfenac
bromocriptine
Brompheniramine
Brukinsa
budesonide
budesonide er
budesonide-formoterol fumarate
bumetanide
buprenorphine
buprenorphine-naloxone
bupropion, er (smoking det)
bupropion, er, xl
buspirone
butalbital-acetaminophen
butalbital-acetaminophen-caffeine
butalbital-acetaminophen-caffeine-codeine
butalbital-aspirin-caffeine
butalbital-aspirin-caffeine-codeine
butorphanol tartrate
cabergoline
Cabometyx
caffeine citrate
calcipotriene
calcipotriene-betamethasone dipropionate
calcitonin
calcitrene
calcitriol
calcium acetate
Calquence
camila
camrese, lo
candesartan
candesartan-hydrochlorothiazide
capecitabine
Caprelsa
captopril
Captopril-hydrochlorothiazide
Carbaglu
carbamazepine, er
carbidopa
carbidopa-levodopa, er
carbidopa-levodopa-entacapone
carbinoxamine
carisoprodol
carisoprodol-aspirin
carisoprodol-aspirin-codeine
carteolol
carvedilol, er
cararest
1
1
1
1
1
1
1
4
1
1
1
1
1
1
1
4
0
0
1
1
1
4
1
2
4
1
1
1
1
1
1
1
2
1
1
1
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
1
1
1
1
1
2
1
2
1
1
0
0
0
4
4
4
2
0
2
1
2
2
1
1
1
2
4
1
1
1
1
1
1
0
1
1
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
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Drug Tier Notes Drug Tier Notesciclopirox
cilostazol
Cimduo
cimetidine
cinacalcet
ciprofloxacin
ciprofloxacin-fluocinolone
citalopram hydrobromide
claravis
clarithromycin, er
clemastine
clenpiq
clindamycin
clindamycin-benzoyl peroxide
clindamycin-tretinoin
clinpro 5000
clobazam
clobetasol,emollient
clobetasol,emulsion
clomipramine
clonazepam
clonidine, er
clopidogrel
clorazepate
clotrimazole
clotrimazole-betamethasone
clovique
clozapine
Coartem
codeine
colchicine
colchicine-probenecid
colesevelam
colestipol
coly-mycin s
Cometriq
1
1
2
1
1
1
1
1
1
1
1
0
1
1
1
1
1
1
1
1
1
1
1
1
1
1
4
1
2
1
1
1
1
1
1
4
Prior Authorization Required
Prior Authorization Required
caya
Cayston
caziant
cefaclor
Cefaclor ER
cefadroxil
cefdinir
Cefditoren
cefixime
cefpodoxime
cefprozil
cefuroxime
celecoxib
Celontin
cephalexin
Cerdelga
cerovel
cevimeline
chantix
chateal, eq
Chemet
Chenodal
chlordiazepoxide
Chlordiazepoxide-Amitriptyline
chlordiazepoxide-clidinium
chlorhexidine gluconate
chloroquine
chlorothiazide
chlorpromazine
chlorthalidone
chlorzoxazone
Cholbam
cholestyramine, light
choline-magnesium trisalicylate
Chondroitin Sulfate
ciclodan
0
4
0
1
2
1
1
2
1
1
1
1
1
2
1
4
1
1
0
0
4
4
1
2
1
1
1
1
1
1
1
4
1
1
2
1
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
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Drug Tier Notes Drug Tier Notesdeferasirox
Delstrigo
delyla
demeclocycline
Demser
Depo-Provera
Descovy
desipramine
desloratadine
desmopressin
desogestrel-ethinyl estradiol
desonide
desoximetasone
desvenlafaxine er
desvenlafaxine succinate er
dexamethasone
dexchlorpheniramine
dexmethylphenidate, er
dextroamphetamine, er
Diacomit
diazepam
diclofenac epolamine
diclofenac potassium
diclofenac sodium, er
diclofenac-misoprostol
dicloxacillin
dicyclomine
didanosine
Dificid
diflorasone
diflunisal
digoxin
dihydroergotamine
Dilatrate-SR
diltiazem, er
diphenoxylate-atropine
4
2
0
1
4
0
0
1
1
1
0
1
1
1
1
1
1
1
1
2
1
1
1
1
1
1
1
1
2
1
1
1
1
2
1
1
Prior Authorization Required
Prior Authorization Required
Complera
Copiktra
Cortisone Acetate
Corvita
Cosentyx
Cotellic
covaryx, hs
Creon
Crinone
Crixivan
cromolyn
cryselle-28
Crysvita
cyanocobalamin
cyclafem
cyclobenzaprine, er
cyclopentolate
cyclophosphamide
cycloserine
cyclosporine, modified
cyproheptadine
cyred, eq
Cystadane
Cystagon
Cystaran
dalfampridine er
Daliresp
danazol
dantrolene
dapsone
Daraprim
darifenacin er
dasetta
Daurismo
daysee
deblitane
2
4
2
2
4
4
1
2
2
2
1
0
4
1
0
1
1
1
1
1
1
0
4
4
4
1
2
1
1
1
4
1
0
4
0
0
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
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Drug Tier Notes Drug Tier Noteseluryng
Emcyt
Emflaza
Emgality
emoquette
Emtriva
enalapril
enalapril-hydrochlorothiazide
Enbrel
Endari
enoxaparin
enpresse-28
enskyce
entacapone
entecavir
Entresto
Envarsus XR
Epidiolex
epinastine
epinephrine
eplerenone
Epogen
Eprosartan
Epzicom
Ergocal
ergocalciferol
ergoloid mesylates
Ergotamine-Caffeine
Erivedge
Erleada
erlotinib
errin
Erythrocin Stearate
erythromycin, base, stearate
Esbriet
escitalopram oxalate
0
4
4
4
0
2
1
1
4
4
4
0
0
1
1
2
2
4
1
1
1
4
2
2
2
1
1
2
4
4
4
0
2
1
4
1
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
dipyridamole
disopyramide
disulfiram
divalproex, er
dofetilide
donepezil
Doptelet
dorzolamide
dorzolamide-timolol
dotti
Dovato
doxazosin
doxepin
doxercalciferol
doxycycline
doxylamine-pyridoxine
dronabinol
drospireninone-ethinyl estradiol-levomefol
drospirenone-ethinyl estradiol
Droxia
duloxetine
Dupixent
dutasteride
dutasteride-tamsulosin
dvorah
dxevo 11-day
E.E.S. 400
econazole
econtra ez, one step
Edurant
efavirenz
eletriptan
elinest
Eliquis
ella
Elmiron
1
1
0
1
1
1
4
1
1
1
2
1
1
1
1
1
1
0
0
2
1
4
1
1
1
1
2
1
0
2
1
1
0
2
0
4
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
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Drug Tier Notes Drug Tier Notesfenofibrate, micronized
fenofibric acid
fenoprofen
fentanyl
Ferriprox
Fiasp
finasteride
flac
flavoxate
flecainide acetate
Flovent Diskus, HFA
fluconazole
flucytosine
fludrocortisone
flunisolide
fluocinolone, body, scalp
fluocinonide, emulsified base
fluoride
fluoridex
fluoritab
fluorometholone
fluorouracil
fluoxetine
fluphenazine
flurandrenolide
Flurazepam
flurbiprofen
flutamide
fluticasone
fluvastatin, er
fluvoxamine, er
folic acid
Folivane-OB
fondaparinux
Forteo
fosamprenavir
1
1
1
1
4
2
1
1
1
1
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
1
1
1
1
1
1
2
4
4
1
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
esgic
esomeprazole magnesium
estarylla
estazolam
estirified estrogens-methyltestosterone, hs
estradiol
estradiol-norethindrone
estrostep fe
eszopiclone
ethacrynic acid
ethambutol
ethosuximide
ethynodiol-ethinyl estradiol
etodolac, er
etonogestrel-ethinyl estradiol
etoposide
euthyrox
Evenity
everolimus
Evotaz
exemestane
ezetimibe
ezetimibe-simvastatin
falessa
falmina
famciclovir
famotidine
Farydak
Fasenra
fayosim
febuxostat
felbamate
felodipine er
femcap
Femring
femynor
1
1
0
1
1
1
0
0
1
1
1
1
0
1
0
4
1
4
4
2
1
1
1
0
0
1
1
4
4
0
1
1
1
0
2
0
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
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Drug Tier Notes Drug Tier Noteshailey 24 fe
halcinonide
halobetasol propionate
haloperidol
heather
Hemlibra
homatropine hbr
Humira
HumuLIN R U-500
Hycamtin
hydralazine
hydrochlorothiazide
hydrocodone-chlorpheniramine er
hydrocodone er
hydrocodone-acetaminophen
hydrocodone-homatropine
hydrocodone-ibuprofen
hydrocortisone
hydrocortisone acetate-pramoxine
hydrocortisone acetate
hydrocortisone butyrate, lipo base
hydrocortisone valerate
hydrocortisone-acetic acid
hydrocortisone-iodoquinol
hydromorphone
hydroquinone
hydroxychloroquine
hydroxyprogesterone caproate
hydroxyurea
hydroxyzine HCl, pamoate
hyoscyamine sulfate, sl, er
ibandronate
Ibrance
ibuprofen
Iclusig
0
1
1
1
0
4
1
4
2
4
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
4
1
4
4
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
fosinopril
fosinopril-hydrochlorothiazide
frovatriptan succinate
Fulphila
furosemide
Fuzeon
Fycompa
gabapentin
Galafold
galantamine, er
gatifloxacin
Gattex
gemfibrozil
gengraf
gentamicin
Genvoya
gialax
gianvi
Gilenya
Gilotrif
glatiramer
glimepiride
glipizide, er
glipizide-metformin
Glucagon Emergency
glyburide, micronized
glyburide-metformin
glycine
glycopyrrolate
granisetron
Granix
griseofulvin microsize, ultramicrosize
guanfacine, er
Guanidine
Haegarda
hailey
1
1
1
4
1
2
2
1
4
1
1
4
1
1
1
2
0
0
4
4
4
1
1
1
2
1
1
1
1
1
4
1
1
2
4
0
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
IDHIFA
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Drug Tier Notes Drug Tier Notesisoxsuprine
isradipine
itraconazole
ivermectin
Jadenu Sprinkle
jaimiess
Jakafi
Jantoven
Janumet, XR
Januvia
Jardiance
jasmiel
jencycla
jolessa
juleber
Juluca
junel
junel fe
junel fe 24
Juxtapid
Jynarque
kaitlib fe
Kalbitor
Kaletra
kalliga
Kalydeco
kariva
kelnor
ketoconazole
ketoprofen
Ketoprofen ER
ketorolac
Ketostix
Keveyis
kinrix
1
1
1
1
4
0
4
1
2
2
2
0
0
0
0
2
0
0
0
4
4
0
4
2
0
4
0
0
1
1
2
1
2
4
0
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
IDHIFA
Ilaris
imatinib
Imbruvica
imipramine HCl, pamoate
imiquimod
Inbrija
incassia
Increlex
Incruse Ellipta
indapamide
indomethacin, er
Ingrezza
Inlyta
Inrebic
Intelence
Intron A
introvale
Invirase
Invokamet, XR
Invokana
Iodine Strong
iodoquimez-hydrocortisone
iodoquinol-hydrocortisone-aloe
ipratropium bromide
ipratropium-albuterol
irbesartan
irbesartan-hydrochlorothiazide
Iressa
Isentress
isibloom
isoniazid
isosorbide dinitrate
isosorbide mononitrate, er
isotretinoin
4
4
4
4
1
1
4
0
4
2
1
1
4
4
4
2
4
0
2
2
2
2
1
1
1
1
1
1
4
2
0
1
1
1
1
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Version 202002.2Copyright 2020 Prescryptive Health, Inc.
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Drug Tier Notes Drug Tier NotesLeukeran
levalbuterol
Levemir FlexTouch
levetiracetam, er
levobunolol
levocarnitine
levofloxacin
levonest
levonorgestrel
levonorgestrel-ethinyl estradiol
levora
levo-t
levothyroxine
levoxyl
Lexiva
lidocaine
lidocaine viscous
lidocaine-hydrocortisone ace
lidocaine-prilocaine
liletta
lillow
lindane
linezolid
Linzess
liothyronine
lisinopril
lisinopril-hydrochlorothiazide
Lithium
lithium carbonate, er
Lo Loestrin Fe
lojaimiess
Lokelma
Lonsurf
lopinavir-ritonavir
llorazepam
Lorbrena
2
1
2
1
1
1
1
0
0
0
0
1
1
1
2
1
1
1
1
0
0
1
1
2
1
1
1
2
1
0
0
4
4
1
1
4
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
kionex
Kisqali
Kisqali Femara
kitabis (tobramycin)
Klarity-A
klor-con
Korlym
K-Phos
Krintafel
k-tab
kurvelo
Kuvan
kyleena
labetalol
lactic acid
lactulose
lamivudine
lamivudine-zidovudine
lamotrigine, er
lansoprazole
lanthanum carbonate
larin
larin 24 fe
larin fe
larissia
latanoprost
Latanoprost-Timolol Maleate
Latuda
layolis fe
Ledipasvir-Sofosbuvir
leena
leflunomide
Lenvima
lessina
letrozole
leucovorin calcium
1
4
4
4
2
1
4
2
2
1
0
4
0
1
1
1
1
1
1
1
1
0
0
0
0
1
2
2
0
4
0
1
4
0
1
1
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Version 202002.2Copyright 2020 Prescryptive Health, Inc.
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Drug Tier Notes Drug Tier Notesmemantine, er
meperidine
meprobamate
mercaptopurine
mesalamine, er
Mesnex
Metaproterenol
metaxalone
metformin, er (non-osm, non-mod)
methadone
methamphetamine
methazolamide
methenamine hippurate
methenamine mandelate
methimazole
methocarbamol
methotrexate
methscopolamine bromide
methyldopa
Methyldopa-hydrochlorothiazide
methylergonovine maleate
methylphenidate, er
methylprednisolone
methyltestosterone
metoclopramide
metolazone
Metopirone
metoprolol succinate er
metoprolol tartrate
metoprolol-hydrochlorothiazide
metronidazole
mexiletine
mibelas 24 fe
miconazole-zinc oxide-petrolatum
microgestin
microgestin fe
1
1
1
1
1
4
2
1
1
1
1
1
1
1
1
1
1
1
1
2
1
1
1
1
1
1
2
1
1
1
1
1
0
1
0
0
Prior Authorization Required
loryna
losartan
losartan-hydrochlorothiazide
loteprednol
lovastatin
low-ogestrel
loxapine
lo-zumandimine
Lucemyra
ludent
Luliconazole
lutera
Lynparza
Lysodren
lyza
mafenide acetate
Makena
Maprotiline
marlissa
Marplan
Matulane
Mavenclad
Mavyret
Maxidex
Mayzent
Meclofenamate
Medrol
medroxyprogesterone
mefenamic acid
mefloquine
megestrol
Mekinist
Mektovi
melodetta 24 fe
meloxicam
melphalan
0
1
1
1
1
0
1
0
4
1
2
0
4
4
0
1
4
2
0
2
4
4
4
2
4
2
2
0
1
1
1
4
4
0
1
1
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Version 202002.2Copyright 2020 Prescryptive Health, Inc.
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Drug Tier Notes Drug Tier Notesnabumetone
nadolol
naftifine
naltrexone
naproxen, er, dr
naratriptan
Narcan
Natacyn
natazia
nateglinide
Natpara
Nature-Throid
necon
nefazodone
neomycin sulfate
neomycin-bacitracin-polymyxin
neomycin-polymyxin-dexamethasone
neomycin-polymyxin-gramicidin
neomycin-polymyxin-hydrocortisone
Nerlynx
nevirapine, er
new day
NexAVAR
Nexletol
nexplanon
niacin, er (antihyperlipidemic)
nicardipine
nicotine
nifedipine, er
nikki
nilutamide
nimodipine
Ninlaro
nisoldipine er
nitisinone
nitrofurantoin
1
1
1
1
1
1
2
2
0
1
4
2
0
1
1
1
1
1
1
4
1
0
4
2
0
1
1
0
1
0
1
1
4
1
4
1
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
midazolam
midodrine
mifepristone
miglitol
miglustat
mili
minitran
minocycline
minoxidil
Mircera
mirena
mirtazapine
misoprostol
modafinil
moexipril
Molindone
mometasone
mono-linyah
montelukast
morphine sulfate, er
Movantik
moviprep
moxifloxacin
Mozobil
Mucotrol
Mulpleta
multivitamins/fluoride
multivitamins/fluoride/iron
mupirocin
my choice
my way
Myalept
mycophenolate mofetil
mycophenolate
Myleran
myorisan
1
1
1
1
4
0
1
1
1
4
0
1
1
1
1
2
1
0
1
1
4
0
1
4
2
4
1
1
1
0
0
4
1
1
2
1
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Version 202002.2Copyright 2020 Prescryptive Health, Inc.
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Drug Tier Notes Drug Tier NotesOcaliva
ocella
octreotide acetate
Odefsey
Odomzo
Ofev
ofloxacin
ogestrel
olanzapine
olanzapine-fluoxetine
olmesartan
olmesartan-amlodipine-hydrochlorothiazide
olmesartan-hydrochlorothiazide
olopatadine
omega-3-acid ethyl esters
omeprazole
omeprazole-bicarbonate
omniflex diaphragm
ondansetron
OneTouch Ultra 2
OneTouch Ultra Blue
OneTouch Ultra Mini
OneTouch Verio
opcicon one-step
opium
Opsumit
option 2
OraMagicRx
Orenitram
Orfadin
Orilissa
Orkambi
orphenadrine citrate er
orphenadrine-aspirin-caffeine
orsythia
oscimin, sr
4
0
4
2
4
4
1
0
1
1
1
1
1
1
1
1
1
0
1
2
2
2
2
0
1
4
0
2
4
4
4
4
1
1
0
1
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
nitroglycerin
Nityr
Niva-Plus
Nivestym
nizatidine
nolix
nora-be
Norditropin
norethindrone
norethindrone acetate
norethindrone-ethinyl estradiol
norethindrone-ethinyl estradiol-fe
norgestimate-ethinyl estradiol
norlyda
norlyroc
Northera
nortrel
nortriptyline
Nourianz
NovoLIN 70/30
NovoLIN N
NovoLIN R
NovoLOG
NovoLOG Mix 70/30
Noxafil
NP Thyroid
Nplate
Nubeqa
Nucala
Nuedexta
nufol
nulev
Nuplazid
nuvaring
nystatin
nystatin-triamcinolone
1
4
2
4
1
1
0
4
0
1
0
0
0
0
0
4
0
1
4
2
2
2
2
2
4
2
4
4
4
4
1
1
4
0
1
1
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Version 202002.2Copyright 2020 Prescryptive Health, Inc.
17 of 23
Drug Tier Notes Drug Tier Notespentazocine-naloxon
pentoxifylline er
Perforomist
perindopril
periogard
permethrin
perphenazine
Perphenazine-Amitriptyline
phenazopyridine
phenelzine
phenobarbital
phenobarbital-belladonna alk
phenoxybenzamine
phenylbutyrate
phenylephrine
phenytoin
philith
phosphorous
phytonadione
Picato
Pifeltro
pilocarpine
pimecrolimus
Pimozide
pimtrea
pindolol
pioglitazone
pioglitazone-glimepiride
pioglitazone-metformin
Piqray
pirmella
piroxicam
plan b one-step
Plegridy
podofilox
polycin
1
1
2
1
1
1
1
2
1
1
1
1
4
4
1
1
0
1
1
4
2
1
1
2
0
1
1
1
1
4
0
1
0
4
1
1
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
oseltamivir phosphate
Osmolex ER
Otezla
Otrexup
oxandrolone
oxaprozin
oxazepam
Oxbryta
oxcarbazepine
oxiconazole
oxybutynin, er
oxycodone, er
oxycodone-acetaminophen
oxycodone-aspirin
oxymorphone, er
Ozempic
pacerone
Palforzia
paliperidone er
Palynziq
Panretin
pantoprazole
paragard intrauterine copper
Paregoric
paricalcitol
paroex
paromomycin sulfate
paroxetine, er
paroxetine, mesylate
Paser
peg-3350/electrolytes
Peganone
Pegasys
PegIntron
penicillamine
penicillin v potassium
1
2
4
2
1
1
1
4
1
1
1
1
1
1
1
2
1
4
1
4
4
1
0
2
1
1
1
1
1
2
0
2
4
4
4
1
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Version 202002.2Copyright 2020 Prescryptive Health, Inc.
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Drug Tier Notes Drug Tier NotesProcrit
Procysbi
progesterone micronized
Proglycem
Prolia
Promacta
promethazine
promethazine-codeine
promethazine-dextromethorphan
Promethazine-Phenylephrine
promethazine-phenylephrine-codeine
propafenone, er
propranolol, er
Propranolol-hydrochlorothiazide
propylthiouracil
protriptyline
prudoxin
pseudoephdrine-brompheniramine-dextromethorphan
pulmosal
Pulmozyme
pyrazinamide
pyridostigmine bromide, er
Pyrimethamine-Leucovorin
Pyrogallic Acid
quartette
quetiapine, er
QuilliChew ER
Quillivant XR
quinapril
quinapril-hydrochlorothiazide
quinidine gluconate er
quinidine sulfate
quinine sulfate
rabeprazole
raloxifene
ramelteon
4
4
1
2
4
4
1
1
1
2
1
1
1
2
1
1
1
1
1
4
1
1
2
2
0
1
2
2
1
1
1
1
1
1
1
1
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
poly-iron 150 forte
polymyxin b-trimethoprim
polysaccharide iron forte
polystyrene sulfonate
Pomalyst
portia-28
posaconazole
potassium & sodium citrates-citric acid
potassium bicarbonate
potassium bicarbonate-potassium chloride
potassium chloride, er
potassium citrate, er
potassium citrate-citric acid
Praluent
pramipexole, er
prasugrel
pravastatin
praziquantel
prazosin
prednicarbate
prednisolone
prednisone
prednisone Intensol
pregabalin
premium lidocaine
Pretomanid
preventeza
previfem
Prevymis
Prezcobix
Prezista
Priftin
primaquine phosphate
primidone
probenecid
prochlorperazine
1
1
1
1
4
0
4
1
1
1
1
1
1
4
1
1
1
1
1
1
1
1
2
1
1
2
0
0
2
2
2
2
1
1
1
1
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Version 202002.2Copyright 2020 Prescryptive Health, Inc.
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Drug Tier Notes Drug Tier Notesramipril
ranitidine
ranolazine er
rasagiline mesylate
Rasuvo
Ravicti
Rayaldee
react
Rebif
Reblozyl
reclipsen
repaglinide
Repatha
Retacrit
Revlimid
Reyataz
ribavirin
rifabutin
Rifamate
rifampin
Rifater
riluzole
rimantadine
Rinvoq
risedronate
risperidone
ritonavir
rivastigmine
rivelsa
rizatriptan benzoate
ropinirole, er
rosadan
rosuvastatin
Rozlytrek
Rubraca
Ruzurgi
1
1
1
1
2
4
4
0
4
4
0
1
4
4
4
2
1
1
2
1
2
1
1
4
1
1
1
1
0
1
1
1
1
4
4
4
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Rybelsus
RyClora
Rydapt
SaliCept
salicylic acid
salsalate
Samsca
Sancuso
Savella
scopolamine
selegiline
selenium sulfide
Selzentry
Serevent Diskus
sertraline
setlakin
sevelamer
sevelamer carbonate
sharobel
Siklos
sildenafil
silodosin
Silver Nitrate
silver sulfadiazine
simliya
simpesse
simvastatin
sirolimus
Sirturo
skyla
Skyrizi
slynd
sodium citrate-citric acid
Sofosbuvir-Velpatasvir
solifenacin succinate
Somavert
2
2
4
2
1
1
4
4
2
1
1
1
2
2
1
0
4
1
0
4
1
1
2
1
0
0
1
1
4
0
4
0
1
4
1
4
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Version 202002.2Copyright 2020 Prescryptive Health, Inc.
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Drug Tier Notes Drug Tier NotesSoriatane
sorine
sotalol
spironolactone
spironolactone-hydrochlorothiazide
sprintec 28
Sprycel
sronyx
stavudine
Stivarga
Strensiq
Stribild
Strovite Forte
Sucraid
sucralfate
sulconazole nitrate
sulfacetamide
sulfacetamide-sulfur
sulfacetamide-prednisolone
sulfADIAZINE
sulfamethoxazole-trimethoprim
sulfasalazine
sulindac
sumatriptan
sumatriptan-naproxen
Sutent
syeda
Sylatron
Symdeko
Symfi, Lo
Symlin
Symproic
Symtuza
Synarel
Synjardy, XR
Synribo
4
1
1
1
1
0
4
0
1
4
4
2
2
4
1
1
1
1
1
2
1
1
1
1
1
4
0
4
4
2
2
2
2
4
2
4
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Tabloid
tacrolimus
tadalafil
Tafinlar
Tagrisso
take action
Takhzyro
Talzenna
tamoxifen citrate
tamsulosin
Targretin
tarina 24 fe
tarina fe, eq
Tasigna
Tavalisse
taytulla
tazarotene
Tazveril
Tecfidera
Tegsedi
telmisartan
telmisartan-amlodipine
telmisartan-hydrochlorothiazide
temazepam
Temixys
temozolomide
tenofovir disoproxil fumarate
terazosin
terbinafine
terbutaline
terconazole
testosterone (topical)
tetrabenazine
tetracycline
Thalomid
theophylline, er
2
1
1
4
4
0
4
4
1
1
4
0
0
4
4
0
1
4
4
4
1
1
1
1
2
1
1
1
1
1
1
1
4
1
4
1
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Version 202002.2Copyright 2020 Prescryptive Health, Inc.
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Drug Tier Notes Drug Tier NotesThiola, EC
thioridazine
thiothixene
thyroid
tiadylt er
tiagabine
Tibsovo
Tiglutik
tilia fe
timolol maleate
Timolol-Brimonidine-Dorzolamide
Timolol-Brimonidine-Dorzolamide-Latanoprost
Timolol-Dorzolamide-Latanoprost
tinidazole
Tivicay
tizanidine
Tobi Podhaler
tobramycin
tobramycin-dexamethasone
TOLBUTamide
tolcapone
Tolmetin
tolterodine, er
topiramate
Topiramate ER
toremifene citrate
torsemide
tramadol, er
tramadol-acetaminophen
trandolapril
trandolapril-verapamil er
tranexamic acid
tranylcypromine sulfate
travoprost
trazodone
Trecator
Trelegy Ellipta
Tremfya
Tresiba
tretinoin
tretinoin microsphere
tri femynor
triamcinolone acetonide
triamterene
triamterene-hydrochlorothiazide
triazolam
Tri-Chlor
trientine
tri-estarylla
trifluoperazine
trifluridine
trihexyphenidyl
Trikafta
tri-legest fe
tri-linyah
tri-lo-estarylla
tri-lo-marzia
tri-lo-mili
tri-lo-sprintec
trilyte
trimethobenzamide
trimethoprim
tri-mili
trimipramine maleate
tri-previfem
tri-sprintec
Triumeq
tri-vitamin/fluoride
trivora
tri-vylibra, lo
Trizivir
tropicamide
4
4
2
1
1
0
1
1
1
1
2
4
0
1
1
1
4
0
0
0
0
0
0
0
1
1
0
1
0
0
2
1
0
0
2
1
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
4
1
1
1
1
1
4
4
0
1
2
2
2
1
2
1
4
1
1
2
1
2
1
1
2
1
1
1
1
1
1
1
1
1
1
2
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Version 202002.2Copyright 2020 Prescryptive Health, Inc.
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Drug Tier Notes Drug Tier Notestrospium, er
Trulicity
trumenba
Truvada
tulana
Turalio
Tybost
tydemy
Tykerb
Tymlos
Tyvaso
Udenyca
umecta
unithroid
Uptravi
urea
ursodiol
valacyclovir
Valchlor
valganciclovir
valproic acid
valsartan
valsartan-hydrochlorothiazide
vancomycin
vanoxide-hc
Vascepa
Vecamyl
velivet
Velphoro
Veltassa
Vemlidy
Venclexta
venlafaxine, er
Ventavis
verapamil, er
Viberzi
Victoza
Videx
vienva
vigabatrin
Vimpat
viorele
Viracept
Viread
vitamin d (ergocalciferol)
Vitrakvi
Vizimpro
volnea
voriconazole
Vosevi
Votrient
Vraylar
Vumerity
vyfemla
vylibra
Vyndamax
Vyndaqel
Vyvanse
warfarin
Westhroid
wide-seal diaphragm
wymzya fe
Xadago
Xalkori
Xarelto
Xeljanz, XR
Xenleta
Xermelo
Xgeva
Xiidra
Xolair
Xospata
2
2
0
1
2
0
2
2
1
4
4
0
1
4
4
2
4
0
0
4
4
2
1
2
0
0
4
4
2
4
4
4
4
2
4
4
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
1
2
0
0
0
4
2
0
4
4
4
4
1
1
4
1
1
1
4
1
1
1
1
1
1
2
4
0
4
4
2
4
1
4
1
4
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
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Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Version 202002.2Copyright 2020 Prescryptive Health, Inc.
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Drug Tier NotesXpovio
Xtandi
xulane
Xultophy
Xuriden
Xyrem
zafirlukast
zaleplon
zarah
Zarxio
Zejula
Zelapar
Zelboraf
Zenpep
Ziagen
zidovudine
Ziextenzo
zileuton ER
ziprasidone
Zolinza
zolmitriptan
zolpidem, er
zonisamide
Zontivity
Zortress
zovia
zumandimine
Zydelig
Zykadia
Zytiga
4
4
0
2
4
4
1
1
0
4
4
4
4
2
2
1
4
4
1
4
1
1
1
2
2
0
0
4
4
4
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Required
Prior Authorization Requiredd
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