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Formulary Abbreviations: F = Formulary, NF = Non-Formulary, PA = Prior Authorization, ST = Step Therapy, NC = Not Covered, SP = Specialty Drug, QL = Quantity Limit. MED = covered as a medical claim. A current formulary status is not shown for new medications. PRx = PreferredRx Drug Formulary, GA = GenericsAdvantageRx Drug Formulary.
Drug Formulary Update, January 2022
Commercial Programs
Updates to the HealthPartners Commercial Formularies (PreferredRx and GenericsAdvantageRx) are listed below. Please see www.healthpartners.com/formularies for details. Updates are effective by January 1, 2022. Updates include
Drug name Current
Status New Status Notes
Canagliflozin (Invokana)
F-QL NF-PA-QL Empagliflozin (Jardiance) remains on-formulary as the preferred alternative.
This update also applies to canagliflozin/ metformin (Invokamet and Invokamet XR).
Emtricitabine/ tenofovir (Descovy)
F F-PA Generic Truvada is preferred. Descovy is reserved for patients with: 1. decreased bone mineral density due to
osteopenia or osteoporosis, OR 2. decreased renal function (defined as creatinine
clearance <60 mL/ min, or documentation of a significant decline), OR
3. 65 years of age and older
Continuous glucose monitoring systems (Dexcom and Freestyle Libre)
COV-PA-QL COV-ST-QL Coverage criteria have been updated, including a step-therapy from insulin.
If you've used insulin within the previous 6 months, these will be covered.
These are also available for patients with type 2 diabetes and one of the following:
1. documented hypoglycemia, or 2. documentation of considerable variability in
glucose levels or inability to reach A1c goals despite frequent medication dose adjustments for 2 of more glucose lowering agents; or
3. documentation of barriers to glucose testing with glucose test strips (such as visual impairment, cognitive issues, and care giver assisting with care)
Formulary Update, page 2 of 22
Formulary Abbreviations: F = Formulary, NF = Non-Formulary, PA = Prior Authorization, ST = Step Therapy, NC = Not Covered, SP = Specialty Drug, QL = Quantity Limit. MED = covered as a medical claim. A current formulary status is not shown for new medications. PRx = PreferredRx Drug Formulary, GA = GenericsAdvantageRx Drug Formulary.
Drug name Current
Status New Status Notes
True Metrix glucose test strips
COV-QL NC-QL Accu-Chek remains as the preferred alternative.
Interferon beta (Rebif)
F-SP-QL F-SP-PA-QL Reserved for patients with an inadequate response or a medical contraindication to Avonex AND Plegridy
Weight loss medications, Saxenda and Wegovy
NF-PA NF-PA PA update. Phentermine/ topiramate (Qsymia) and naltrexone/ bupropion (Contrave) are preferred.
Mometasone/ formoterol (Dulera)
F-PA NF-PA Preferred alternatives include budesonide/ formoterol (Symbicort generic).
Salmeterol (Serevent)
F F-PA Olodaterol (Striverdi) remains on-formulary as the preferred alternative.
Ustekinumab (Stelara)
MED-PA F-PA-SP Ustekinumab (Stelara) is being added to HealthPartners’ self-administered drug list.
Medications on the self-administered drug list are processed through the pharmacy benefit.
All updates
GENERIC NAME Label Name PRx
Current GA Current New Status
ABIRATERONE ACETATE ABIRATERONE ACETATE 250 MG TAB
F PA F PA QL F PA QL
ACETAMINOPHEN/ CAFFEINE/ DIHYDROCODEINE BITARTRATE
ACETAMIN-CAF-DIHYDROCODEIN 325
NF PA NF PA F-PA
ACETAMINOPHEN/ CAFFEINE/ DIHYDROCODEINE BITARTRATE
ACETAMN-CAF-DIHYDRCODEIN 320.5
NF NF F-PA
ACYCLOVIR ACYCLOVIR 5% CREAM NF PA QL NF PA QL F-PA-QL
ACYCLOVIR ACYCLOVIR 5% OINTMENT NF QL NF QL F-PA-QL
ALCAFTADINE LASTACAFT 0.25% EYE DROPS NF NF F-PA
ALIROCUMAB PRALUENT 150 MG/ML PEN NF PA QL NF PA NF PA QL
ALIROCUMAB PRALUENT 75 MG/ML PEN NF PA QL NF PA NF PA QL
ALITRETINOIN PANRETIN 0.1% GEL NF NF NF PA
Formulary Update, page 3 of 22
Formulary Abbreviations: F = Formulary, NF = Non-Formulary, PA = Prior Authorization, ST = Step Therapy, NC = Not Covered, SP = Specialty Drug, QL = Quantity Limit. MED = covered as a medical claim. A current formulary status is not shown for new medications. PRx = PreferredRx Drug Formulary, GA = GenericsAdvantageRx Drug Formulary.
GENERIC NAME Label Name PRx
Current GA Current New Status
ALMOTRIPTAN MALATE ALMOTRIPTAN MALATE 12.5 MG TAB
NF QL NF QL F-PA-QL
ALMOTRIPTAN MALATE ALMOTRIPTAN MALATE 6.25 MG TAB
NF QL NF QL F-PA-QL
ALPROSTADIL CAVERJECT 20 MCG VIAL NF EXCL NF
ALPROSTADIL CAVERJECT 40 MCG VIAL NF EXCL NF
ALPROSTADIL CAVERJECT IMPULSE 10 MCG KIT NF EXCL NF
ALPROSTADIL CAVERJECT IMPULSE 10 MCG SYRNG
NF EXCL NF
ALPROSTADIL CAVERJECT IMPULSE 20 MCG KIT NF EXCL NF
ALPROSTADIL CAVERJECT IMPULSE 20 MCG SYRNG
NF EXCL NF
ALPROSTADIL EDEX 10 MCG CARTRIDGE 2-PK KIT NF EXCL NF
ALPROSTADIL EDEX 10 MCG CARTRIDGE 6-PK KIT NF EXCL NF
ALPROSTADIL EDEX 20 MCG CARTRIDGE 2-PK KIT NF EXCL NF
ALPROSTADIL EDEX 20 MCG CARTRIDGE 6-PK KIT NF EXCL NF
ALPROSTADIL EDEX 40 MCG CARTRIDGE 2-PK KIT NF EXCL NF
ALPROSTADIL EDEX 40 MCG CARTRIDGE 6-PK KIT NF EXCL NF
ALPROSTADIL MUSE 1,000 MCG URETHRAL SUPP NF EXCL NF
ALPROSTADIL MUSE 125 MCG URETHRAL SUPPOS NF EXCL NF
ALPROSTADIL MUSE 250 MCG URETHRAL SUPPOS NF EXCL NF
ALPROSTADIL MUSE 500 MCG URETHRAL SUPPOS NF EXCL NF
ALPROSTADIL IN BACTERIOSTATIC SODIUM CHLORIDE
IFE-PG20 100 MCG/5 ML VIAL NF EXCL NC
AMITRIPTYLINE HCL/ CHLORDIAZEPOXIDE
CHLORDIAZEPO-AMITRIPTYL 5-12.5 NF NF F-PA
AMITRIPTYLINE HCL/ CHLORDIAZEPOXIDE
CHLORDIAZEPOX-AMITRIPTYL 10-25
NF NF F-PA
AMOXAPINE AMOXAPINE 100 MG TABLET NF NF F-PA
AMOXAPINE AMOXAPINE 150 MG TABLET NF NF F-PA
AMOXAPINE AMOXAPINE 25 MG TABLET NF NF F-PA
AMOXAPINE AMOXAPINE 50 MG TABLET NF NF F-PA
AMPHETAMINE SULFATE AMPHETAMINE SULFATE 10 MG TAB
NF QL NF QL F-PA-QL
AMPHETAMINE SULFATE AMPHETAMINE SULFATE 5 MG TAB NF QL NF QL F-PA-QL
ANASTROZOLE ARIMIDEX 1 MG TABLET NF NF NF PA
ANTHRALIN DRITHOCREME HP 1% CREAM F NF NF
APOMORPHINE HCL KYNMOBI 10 MG SL FILM S NF PA S NF PA S F PA
APOMORPHINE HCL KYNMOBI 15 MG SL FILM S NF PA S NF PA S F PA
Formulary Update, page 4 of 22
Formulary Abbreviations: F = Formulary, NF = Non-Formulary, PA = Prior Authorization, ST = Step Therapy, NC = Not Covered, SP = Specialty Drug, QL = Quantity Limit. MED = covered as a medical claim. A current formulary status is not shown for new medications. PRx = PreferredRx Drug Formulary, GA = GenericsAdvantageRx Drug Formulary.
GENERIC NAME Label Name PRx
Current GA Current New Status
APOMORPHINE HCL KYNMOBI 20 MG SL FILM S NF PA S NF PA S F PA
APOMORPHINE HCL KYNMOBI 25 MG SL FILM S NF PA S NF PA S F PA
APOMORPHINE HCL KYNMOBI 30 MG SL FILM S NF PA S NF PA S F PA
APOMORPHINE HCL KYNMOBI TITRATION KIT S NF PA S NF PA S F PA
APRACLONIDINE HCL APRACLONIDINE HCL 0.5% DROPS NF NF F-PA
APREMILAST OTEZLA 30 MG TABLET S F PA QL S F PA S F PA QL
ARFORMOTEROL TARTRATE ARFORMOTEROL 15 MCG/2 ML SOLN
NF PA NF PA maintain
ARFORMOTEROL TARTRATE BROVANA 15 MCG/2 ML SOLUTION NF PA NF PA F-PA
ASPIRIN/ OMEPRAZOLE ASPIRIN-OMEPRAZOL DR 325-40 MG
NF NF F-PA
ASPIRIN/ OMEPRAZOLE ASPIRIN-OMEPRAZOLE DR 81-40 MG
NF NF F-PA
AVANAFIL STENDRA 100 MG TABLET NF EXCL NF
AVANAFIL STENDRA 200 MG TABLET NF EXCL NF
AVANAFIL STENDRA 50 MG TABLET NF EXCL NF
AZACITIDINE ONUREG 200 MG TABLET F PA F PA QL F PA QL
AZACITIDINE ONUREG 300 MG TABLET F PA F PA QL F PA QL
AZITHROMYCIN AZASITE 1% EYE DROPS NF NF F-PA
BENZHYDROCODONE HCL/ ACETAMINOPHEN
BENZHYDROCOD-ACETAMIN 4.08-325
NF NF F-PA
BENZHYDROCODONE HCL/ ACETAMINOPHEN
BENZHYDROCOD-ACETAMIN 8.16-325
NF NF F-PA
BENZYL ALCOHOL ULESFIA 5% LOTION NF NF F-PA
BEXAROTENE BEXAROTENE 75 MG CAPSULE NF PA QL NF PA QL F-PA-QL
BICALUTAMIDE CASODEX 50 MG TABLET NF NF NF PA
BRIMONIDINE TARTRATE ALPHAGAN P 0.1% DROPS F NF F
BRIMONIDINE TARTRATE/ TIMOLOL MALEATE
COMBIGAN 0.2%-0.5% EYE DROPS F NF F
BRINZOLAMIDE BRINZOLAMIDE 1% EYE DROPS F NF F
BRINZOLAMIDE/ BRIMONIDINE TARTRATE
SIMBRINZA 1%-0.2% EYE DROPS F NF F
BUPRENORPHINE HCL BUPRENORPHINE 2 MG TABLET SL NF QL NF QL F-PA-QL
BUPRENORPHINE HCL BUPRENORPHINE 8 MG TABLET SL NF QL NF QL F-PA-QL
BUTALBITAL/ ACETAMINOPHEN/ CAFFEINE/ CODEINE PHOSPHATE
BUTALB-ACETAMIN-CAF-COD 50-300
NF QL NF QL F-PA-QL
Formulary Update, page 5 of 22
Formulary Abbreviations: F = Formulary, NF = Non-Formulary, PA = Prior Authorization, ST = Step Therapy, NC = Not Covered, SP = Specialty Drug, QL = Quantity Limit. MED = covered as a medical claim. A current formulary status is not shown for new medications. PRx = PreferredRx Drug Formulary, GA = GenericsAdvantageRx Drug Formulary.
GENERIC NAME Label Name PRx
Current GA Current New Status
BUTALBITAL/ ACETAMINOPHEN/ CAFFEINE/ CODEINE PHOSPHATE
BUTALB-ACETAMIN-CAF-COD 50-325
NF NF F-PA
CALCITRIOL CALCITRIOL 3 MCG/G OINTMENT F PA NF PA F PA
CANNABIDIOL (CBD) EPIDIOLEX 100 MG/ML SOLUTION S F PA QL S F QL S F PA QL
CARBINOXAMINE MALEATE CARBINOXAMINE MALEATE 4 MG TAB
NF NF F-PA
CARISOPRODOL CARISOPRODOL 250 MG TABLET NF QL NF QL F-PA-QL
CARISOPRODOL CARISOPRODOL 350 MG TABLET NF QL NF QL F-PA-QL
CARISOPRODOL/ ASPIRIN/ CODEINE PHOSPHATE
CARISOPRODOL-ASPIRIN-CODEIN TB
NF QL NF QL F-PA-QL
CEFACLOR CEFACLOR 500 MG CAPSULE NF NF F-PA
CETIRIZINE HCL ZERVIATE 0.24% EYE DROP NF PA NF PA F-PA
CETRORELIX ACETATE CETROTIDE 0.25 MG KIT F EXCL F
CHLOROTHIAZIDE DIURIL 250 MG/5 ML ORAL SUSP F NF F
CHLORPROMAZINE HCL CHLORPROMAZINE 10 MG TABLET NF F PA F PA
CHLORPROMAZINE HCL CHLORPROMAZINE 100 MG TABLET NF F PA F PA
CHLORPROMAZINE HCL CHLORPROMAZINE 200 MG TABLET NF F PA F PA
CHLORPROMAZINE HCL CHLORPROMAZINE 25 MG TABLET NF F PA F PA
CHLORPROMAZINE HCL CHLORPROMAZINE 50 MG TABLET NF F PA F PA
CHORIOGONADOTROPIN ALFA
OVIDREL 250 MCG/0.5 ML SYRG F EXCL F
CHORIONIC GONADOTROPIN, HUMAN
CHORIONIC GONAD 1 MILLION UNIT
NF EXCL NF
CHORIONIC GONADOTROPIN, HUMAN
CHORIONIC GONAD 10,000 UNIT VL F EXCL F
CHORIONIC GONADOTROPIN, HUMAN
CHORIONIC GONAD 12,000 UNIT VL F EXCL F
CHORIONIC GONADOTROPIN, HUMAN
CHORIONIC GONAD 2 MILLION UNIT
NF EXCL NF
CHORIONIC GONADOTROPIN, HUMAN
CHORIONIC GONAD 5 MILLION UNIT
NF EXCL NF
CHORIONIC GONADOTROPIN, HUMAN
CHORIONIC GONAD 50,000 UNIT VL NF EXCL NF
CHORIONIC GONADOTROPIN, HUMAN
CHORIONIC GONAD 6,000 UNIT VL F EXCL F
CHORIONIC GONADOTROPIN, HUMAN
CHORIONIC GONADOTROPIN POWDER
NF EXCL NF
CHORIONIC GONADOTROPIN, HUMAN
NOVAREL 10,000 UNITS VIAL F EXCL F
Formulary Update, page 6 of 22
Formulary Abbreviations: F = Formulary, NF = Non-Formulary, PA = Prior Authorization, ST = Step Therapy, NC = Not Covered, SP = Specialty Drug, QL = Quantity Limit. MED = covered as a medical claim. A current formulary status is not shown for new medications. PRx = PreferredRx Drug Formulary, GA = GenericsAdvantageRx Drug Formulary.
GENERIC NAME Label Name PRx
Current GA Current New Status
CHORIONIC GONADOTROPIN, HUMAN
NOVAREL 5,000 UNIT VIAL F EXCL F
CHORIONIC GONADOTROPIN, HUMAN
PREGNYL 10,000 UNITS VIAL F EXCL F
CIPROFLOXACIN HCL CIPROFLOXACIN 0.2% OTIC SOLN NF NF F-PA
CIPROFLOXACIN HCL/ FLUOCINOLONE ACETONIDE
CIPROFLOX-FLUOCINLN 0.3-0.025% NF NF F-PA
CLINDAMYCIN PHOSPHATE CLEOCIN T 1% SOLUTION F QL NF QL NF QL
CLOMIPHENE CITRATE CLOMIPHENE CITRATE 50 MG TAB F EXCL F
CLOMIPHENE CITRATE SEROPHENE 50 MG TABLET F EXCL F
CLONIDINE HCL CLONIDINE HCL ER 0.1 MG TABLET F PA QL NF QL F PA QL
CLORAZEPATE DIPOTASSIUM CLORAZEPATE 15 MG TABLET NF QL NF QL F-PA-QL
CLORAZEPATE DIPOTASSIUM CLORAZEPATE 3.75 MG TABLET NF QL NF QL F-PA-QL
CLORAZEPATE DIPOTASSIUM CLORAZEPATE 7.5 MG TABLET NF QL NF QL F-PA-QL
CORTICOTROPIN ACTHAR GEL 400 UNIT/5 ML VIAL NF PA S F PA S F PA
CORTISONE ACETATE CORTISONE 25 MG TABLET NF NF F-PA
CROMOLYN SODIUM CROMOLYN 20 MG/2 ML NEB SOLN NF F PA F PA
CROTAMITON EURAX 10% CREAM F NF F-PA
CYCLOPENTOLATE HCL CYCLOPENTOLATE HCL 2% DROPS F NF NF
DAPSONE ACZONE 5% GEL NF PA NF NF PA
DAPSONE DAPSONE 5% GEL F PA NF F PA
DARIFENACIN HYDROBROMIDE
DARIFENACIN ER 15 MG TABLET NF NF F-PA
DARIFENACIN HYDROBROMIDE
DARIFENACIN ER 7.5 MG TABLET NF NF F-PA
DARIFENACIN HYDROBROMIDE
ENABLEX 15 MG TABLET NF NF F-PA
DARIFENACIN HYDROBROMIDE
ENABLEX 7.5 MG TABLET NF NF F-PA
DEFERASIROX DEFERASIROX 360 MG TABLET S F PA S NF PA S F PA
DELAFLOXACIN MEGLUMINE BAXDELA 450 MG TABLET NF PA NF PA F-PA
DESLORATADINE DESLORATADINE 5 MG TABLET NF NF F-PA
DICLOFENAC SODIUM/ MISOPROSTOL
DICLOFENAC-MISOPROST 50-0.2 MG
NF NF F-PA
DICLOFENAC SODIUM/ MISOPROSTOL
DICLOFENAC-MISOPROST 75-0.2 MG
NF NF F-PA
DIFLUNISAL DIFLUNISAL 500 MG TABLET NF NF F-PA
DIFLUPREDNATE DUREZOL 0.05% EYE DROPS NF NF F-PA
DIHYDROERGOTAMINE MESYLATE
DIHYDROERGOTAMINE 1 MG/ML AMP
NF PA QL NF PA QL F-PA-QL
Formulary Update, page 7 of 22
Formulary Abbreviations: F = Formulary, NF = Non-Formulary, PA = Prior Authorization, ST = Step Therapy, NC = Not Covered, SP = Specialty Drug, QL = Quantity Limit. MED = covered as a medical claim. A current formulary status is not shown for new medications. PRx = PreferredRx Drug Formulary, GA = GenericsAdvantageRx Drug Formulary.
GENERIC NAME Label Name PRx
Current GA Current New Status
DIHYDROERGOTAMINE MESYLATE
DIHYDROERGOTAMINE 4 MG/ML SPRY
NF PA QL NF PA QL F-PA-QL
DIMETHYL FUMARATE DIMETHYL FUMARATE 30D START PK
S F QL S F S F QL
DIMETHYL FUMARATE DIMETHYL FUMARATE DR 120 MG CP
S F QL S F S F QL
DIMETHYL FUMARATE DIMETHYL FUMARATE DR 240 MG CP
S F QL S F S F QL
DOXEPIN HCL DOXEPIN HCL 3 MG TABLET NF PA NF PA F-PA
DOXEPIN HCL DOXEPIN HCL 6 MG TABLET NF PA NF PA F-PA
DOXORUBICIN HCL ADRIAMYCIN 200 MG/100 ML VIAL MED NF MED
DOXYCYCLINE MONOHYDRATE
MONDOXYNE NL 100 MG CAPSULE NF PA F NF PA
DOXYCYCLINE MONOHYDRATE
MONDOXYNE NL 75 MG CAPSULE NF PA NF NF PA
DUPILUMAB DUPIXENT 300 MG/2 ML PEN S F PA QL S F PA S F PA QL
DUTASTERIDE/ TAMSULOSIN HCL
DUTASTERIDE-TAMSULOSIN 0.5-0.4 F NF F-PA
ECHOTHIOPHATE IODIDE PHOSPHOLINE IODIDE 0.125% F NF F
ELAGOLIX SODIUM ORILISSA 150 MG TABLET S-F PA QL S-F PA QL S-F PA QL
ELAGOLIX SODIUM ORILISSA 200 MG TABLET S-F PA QL S-F PA QL S-F PA QL
ELAGOLIX SODIUM/ ESTRADIOL/ NORETHINDRONE ACETATE
ORIAHNN 300-1-0.5MG/300MG CAPS
F PA QL S F PA QL S F PA QL
ELETRIPTAN HYDROBROMIDE ELETRIPTAN HBR 20 MG TABLET NF QL F PA QL F PA QL
ELETRIPTAN HYDROBROMIDE ELETRIPTAN HBR 40 MG TABLET NF QL F PA QL F PA QL
EMOL53/ E.WATER/ NAMGFS/ NAPHOS/ NACL/ HYPOCHLOROUS ACID/ NAHYPOCL
MB HYDROGEL KIT NF PA EXCL PA NF PA
ERGOLOID MESYLATES ERGOLOID MESYLATES 1 MG TAB NF F PA F PA
ERGOTAMINE TARTRATE ERGOMAR 2 MG TABLET SL F QL NF QL NF QL
ERGOTAMINE TARTRATE/ CAFFEINE
ERGOTAMINE-CAFFEINE 1-100MG TB
NF QL NF QL F-PA-QL
ERYTHROMYCIN BASE ERYTHROMYCIN 500 MG FILMTAB NF NF F-PA
ESTAZOLAM ESTAZOLAM 1 MG TABLET NF QL NF QL F-PA-QL
ESTAZOLAM ESTAZOLAM 2 MG TABLET NF QL NF QL F-PA-QL
ESTRADIOL ESTRING 2 MG VAGINAL RING F NF F
ESTRADIOL IMVEXXY 10 MCG MAINTENANCE PAK
NF QL EXCL NF QL
ESTRADIOL IMVEXXY 10 MCG STARTER PACK NF QL EXCL NF QL
Formulary Update, page 8 of 22
Formulary Abbreviations: F = Formulary, NF = Non-Formulary, PA = Prior Authorization, ST = Step Therapy, NC = Not Covered, SP = Specialty Drug, QL = Quantity Limit. MED = covered as a medical claim. A current formulary status is not shown for new medications. PRx = PreferredRx Drug Formulary, GA = GenericsAdvantageRx Drug Formulary.
GENERIC NAME Label Name PRx
Current GA Current New Status
ESTRADIOL IMVEXXY 4 MCG MAINTENANCE PACK
NF QL EXCL NF QL
ESTRADIOL IMVEXXY 4 MCG STARTER PACK NF QL EXCL NF QL
ESTRADIOL/ LEVONORGESTREL
CLIMARA PRO PATCH F NF F
ESTRADIOL/ NORETHINDRONE ACETATE
COMBIPATCH 0.05-0.14 MG PTCH F NF F
ESTRADIOL/ NORETHINDRONE ACETATE
COMBIPATCH 0.05-0.25 MG PTCH F NF F
ESTROGENS, CONJUGATED PREMARIN 0.3 MG TABLET F NF F
ESTROGENS, CONJUGATED PREMARIN 0.45 MG TABLET F NF F
ESTROGENS, CONJUGATED PREMARIN 0.625 MG TABLET F NF F
ESTROGENS, CONJUGATED PREMARIN 0.9 MG TABLET F NF F
ESTROGENS, CONJUGATED PREMARIN 1.25 MG TABLET F NF F
ESTROGENS, CONJUGATED/ MEDROXYPROGESTERONE ACETATE
PREMPHASE 0.625-5 MG TABLET F NF F
ETHACRYNIC ACID ETHACRYNIC ACID 25 MG TABLET NF PA NF PA F-PA
EVEROLIMUS EVEROLIMUS 0.25 MG TABLET NF NF F-PA
EVEROLIMUS EVEROLIMUS 0.5 MG TABLET NF NF F-PA
EVEROLIMUS EVEROLIMUS 0.75 MG TABLET NF NF F-PA
EVEROLIMUS EVEROLIMUS 2.5 MG TABLET F PA QL F PA F PA QL
EVEROLIMUS ZORTRESS 1 MG TABLET NF NF F-PA
EXEMESTANE AROMASIN 25 MG TABLET NF NF NF PA
EZETIMIBE/ SIMVASTATIN EZETIMIBE-SIMVASTATIN 10-10 MG NF NF F-PA
EZETIMIBE/ SIMVASTATIN EZETIMIBE-SIMVASTATIN 10-20 MG NF NF F-PA
EZETIMIBE/ SIMVASTATIN EZETIMIBE-SIMVASTATIN 10-40 MG NF NF F-PA
EZETIMIBE/ SIMVASTATIN EZETIMIBE-SIMVASTATIN 10-80 MG NF NF F-PA
FENOPROFEN CALCIUM FENOPROFEN 200 MG CAPSULE NF NF F-PA
FENOPROFEN CALCIUM FENOPROFEN 400 MG CAPSULE NF NF F-PA
FENOPROFEN CALCIUM FENOPROFEN 600 MG TABLET NF NF F-PA
FENTANYL CITRATE FENTANYL CIT 100 MCG BUCCAL TB NF PA NF NF PA
FENTANYL CITRATE FENTANYL CIT 200 MCG BUCCAL TB NF PA NF NF PA
FENTANYL CITRATE FENTANYL CIT 400 MCG BUCCAL TB NF PA NF NF PA
FENTANYL CITRATE FENTORA 100 MCG BUCCAL TABLET
NF PA NF NF PA
FENTANYL CITRATE FENTORA 200 MCG BUCCAL TABLET
NF PA NF NF PA
FENTANYL CITRATE FENTORA 400 MCG BUCCAL TABLET
NF PA NF NF PA
Formulary Update, page 9 of 22
Formulary Abbreviations: F = Formulary, NF = Non-Formulary, PA = Prior Authorization, ST = Step Therapy, NC = Not Covered, SP = Specialty Drug, QL = Quantity Limit. MED = covered as a medical claim. A current formulary status is not shown for new medications. PRx = PreferredRx Drug Formulary, GA = GenericsAdvantageRx Drug Formulary.
GENERIC NAME Label Name PRx
Current GA Current New Status
FLAVOXATE HCL FLAVOXATE HCL 100 MG TABLET NF NF F-PA
FLIBANSERIN ADDYI 100 MG TABLET NF PA EXCL NF PA
FLUCYTOSINE FLUCYTOSINE 250 MG CAPSULE NF PA NF PA F-PA
FLUCYTOSINE FLUCYTOSINE 500 MG CAPSULE NF PA NF PA F-PA
FLUOROURACIL FLUOROPLEX 1% CREAM F NF NF
FLURANDRENOLIDE CORDRAN 4 MCG/SQ CM TAPE LARGE
F PA NF PA F PA
FLURAZEPAM HCL FLURAZEPAM 15 MG CAPSULE NF QL NF QL F-PA-QL
FLURAZEPAM HCL FLURAZEPAM 30 MG CAPSULE NF QL NF QL F-PA-QL
FLUVASTATIN SODIUM FLUVASTATIN ER 80 MG TABLET NF NF F-PA
FLUVASTATIN SODIUM FLUVASTATIN SODIUM 20 MG CAP NF NF F-PA
FLUVASTATIN SODIUM FLUVASTATIN SODIUM 40 MG CAP NF NF F-PA
FOLLITROPIN ALFA, RECOMBINANT
GONAL-F 1,050 UNITS VIAL NF EXCL NF
FOLLITROPIN ALFA, RECOMBINANT
GONAL-F 450 UNITS VIAL NF EXCL NF
FOLLITROPIN ALFA, RECOMBINANT
GONAL-F RFF 75 UNITS VIAL NF EXCL NF
FOLLITROPIN ALFA, RECOMBINANT
GONAL-F RFF REDI-JECT 300 UNIT NF EXCL NF
FOLLITROPIN ALFA, RECOMBINANT
GONAL-F RFF REDI-JECT 450 UNIT NF EXCL NF
FOLLITROPIN ALFA, RECOMBINANT
GONAL-F RFF REDI-JECT 900 UNIT NF EXCL NF
FOLLITROPIN BETA,RECOMBINANT
FOLLISTIM AQ 300 UNIT CARTRIDG F EXCL F
FOLLITROPIN BETA,RECOMBINANT
FOLLISTIM AQ 600 UNIT CARTRIDG F EXCL F
FOLLITROPIN BETA,RECOMBINANT
FOLLISTIM AQ 900 UNIT CARTRIDG F EXCL F
FORMOTEROL FUMARATE FORMOTEROL 20 MCG/2 ML NEB VL
NF PA NF PA maintain
FORMOTEROL FUMARATE PERFOROMIST 20 MCG/2 ML SOLN NF PA NF PA F-PA
FROVATRIPTAN SUCCINATE FROVATRIPTAN SUCC 2.5 MG TAB NF QL NF QL F-PA-QL
GABAPENTIN/ LIDOCAINE/ PRILOCAINE/ TRANSPARENT DRESSING
LIPRITIN II KIT NF NF PA NC
GANIRELIX ACETATE GANIRELIX ACET 250 MCG/0.5 ML F EXCL F
GATIFLOXACIN GATIFLOXACIN 0.5% EYE DROPS F NF F
GEMIFLOXACIN MESYLATE FACTIVE 320 MG TABLET NF NF F-PA
GENTAMICIN SULFATE GENTAK 0.3 % EYE OINTMENT NF NF F-PA
Formulary Update, page 10 of 22
Formulary Abbreviations: F = Formulary, NF = Non-Formulary, PA = Prior Authorization, ST = Step Therapy, NC = Not Covered, SP = Specialty Drug, QL = Quantity Limit. MED = covered as a medical claim. A current formulary status is not shown for new medications. PRx = PreferredRx Drug Formulary, GA = GenericsAdvantageRx Drug Formulary.
GENERIC NAME Label Name PRx
Current GA Current New Status
GENTAMICIN SULFATE GENTAMICIN 0.3% EYE DROP NF NF F-PA
GENTAMICIN SULFATE/ PREDNISOLONE ACETATE
PRED-G 1% EYE DROPS NF NF F-PA
GENTAMICIN SULFATE/ PREDNISOLONE ACETATE
PRED-G S.O.P. EYE OINTMENT NF NF F-PA
GRANISETRON SANCUSO 3.1 MG/24 HR PATCH NF NF NF PA
GRANISETRON HCL GRANISETRON HCL 1 MG TABLET NF NF F PA
GUANIDINE HCL GUANIDINE HCL 125 MG TABLET NF NF F-PA
HALOBETASOL PROPIONATE HALOBETASOL PROP 0.05% FOAM NF NF F-PA
HYALURONATE SODIUM TRIVISC 25 MG/2.5 ML SYR MED PA MED PA MED
HYALURONATE SODIUM, MODIFIED, NON-CROSSLINKED
HYMOVIS 24 MG/3 ML SYRINGE MED PA MED PA MED
HYALURONATE SODIUM, STABILIZED
DUROLANE 60 MG/3 ML SYRINGE MED PA MED PA MED
HYDROCODONE BITARTRATE HYDROCODONE ER 10 MG CAPSULE
NF PA NF PA F-PA
HYDROCODONE BITARTRATE HYDROCODONE ER 15 MG CAPSULE
NF PA NF PA F-PA
HYDROCODONE BITARTRATE HYDROCODONE ER 20 MG CAPSULE
NF PA NF PA F-PA
HYDROCODONE BITARTRATE HYDROCODONE ER 30 MG CAPSULE
NF PA NF PA F-PA
HYDROCODONE BITARTRATE HYDROCODONE ER 40 MG CAPSULE
NF PA NF PA F-PA
HYDROCODONE BITARTRATE HYDROCODONE ER 50 MG CAPSULE
NF PA NF PA F-PA
HYDROCODONE POLISTIREX/ CHLORPHENIRAMINE POLISTIREX
HYDROCODONE-CHLORPHEN ER SUSP
NF NF F-PA
HYDROCORTISONE ACETATE/ PRAMOXINE HCL
PROCTOFOAM-HC 1%-1% FOAM F NF NF
HYDROCORTISONE SOD SUCCINATE
SOLU-CORTEF 100 MG VIAL MED MED F
HYDROCORTISONE SODIUM SUCCINATE/ PF
SOLU-CORTEF 250 MG ACT-O-VIAL MED MED F
HYDROCORTISONE SODIUM SUCCINATE/ PF
SOLU-CORTEF 500 MG ACT-O-VIAL MED MED F
HYDROCORTISONE/ ACETIC ACID
HYDROCORTISON-ACETIC ACID SOLN
NF NF F-PA
HYDROMORPHONE HCL HYDROMORPHONE HCL ER 12 MG TAB
NF PA NF PA F-PA
Formulary Update, page 11 of 22
Formulary Abbreviations: F = Formulary, NF = Non-Formulary, PA = Prior Authorization, ST = Step Therapy, NC = Not Covered, SP = Specialty Drug, QL = Quantity Limit. MED = covered as a medical claim. A current formulary status is not shown for new medications. PRx = PreferredRx Drug Formulary, GA = GenericsAdvantageRx Drug Formulary.
GENERIC NAME Label Name PRx
Current GA Current New Status
HYDROMORPHONE HCL HYDROMORPHONE HCL ER 16 MG TAB
NF PA NF PA F-PA
HYDROMORPHONE HCL HYDROMORPHONE HCL ER 32 MG TAB
NF PA NF PA F-PA
HYDROMORPHONE HCL HYDROMORPHONE HCL ER 8 MG TAB
NF PA NF PA F-PA
HYDROXYPROGESTERONE CAPROATE
HYDROXYPROGESTERONE CAPROATE MULTIDOSE 1.25 G/5ML VIAL
MED MED NC
HYDROXYPROGESTERONE CAPROATE
MAKENA 1,250 MG/5 ML VIAL MED MED NC
HYDROXYPROGESTERONE CAPROATE/ PF
MAKENA 250 MG/ML VIAL S-F QL S-F QL NC
HYDROXYPROGESTERONE CAPROATE/ PF
MAKENA 275 MG/1.1 ML AUTOINJCT
S-F QL S-F QL NC
HYDROXYPROPYL CELLULOSE LACRISERT 5 MG EYE INSERT F PA NF PA NF PA
HYDROXYUREA HYDREA 500 MG CAPSULE NF NF NF PA
IBUPROFEN/ FAMOTIDINE DUEXIS 800-26.6 MG TABLET NF PA NF PA F-PA
INDOMETHACIN, SUBMICRONIZED
INDOMETHACIN 20 MG CAPSULE EXCL EXCL PA EXCL/ NF-PA
INSULIN ASPART INSULIN ASPART 100 UNIT/ML CRT NF PA NF PA F-PA
INSULIN ASPART INSULIN ASPART 100 UNIT/ML PEN NF PA NF PA F-PA
INSULIN ASPART INSULIN ASPART 100 UNIT/ML VL NF PA NF PA F-PA
INTERFERON BETA-1A/ ALBUMIN HUMAN
REBIF 22 MCG/0.5 ML SYRINGE S-F QL S-F QL S-F PA QL
INTERFERON BETA-1A/ ALBUMIN HUMAN
REBIF 44 MCG/0.5 ML SYRINGE S-F QL S-F QL S-F PA QL
INTERFERON BETA-1A/ ALBUMIN HUMAN
REBIF REBIDOSE 22 MCG/0.5 ML S-F QL S-F QL S-F PA QL
INTERFERON BETA-1A/ ALBUMIN HUMAN
REBIF REBIDOSE 44 MCG/0.5 ML S-F QL S-F QL S-F PA QL
INTERFERON BETA-1A/ ALBUMIN HUMAN
REBIF REBIDOSE TITRATION PACK S-F QL S-F QL S-F PA QL
INTERFERON BETA-1A/ ALBUMIN HUMAN
REBIF TITRATION PACK S-F QL S-F QL S-F PA QL
IVERMECTIN IVERMECTIN 0.5% LOTION NF PA NF PA F-PA
KETAMINE HCL IN 0.9 % SODIUM CHLORIDE
KETAMINE 100 MG/100ML-0.9%NACL
MED PA MED MED PA
KETOPROFEN KETOPROFEN 25 MG CAPSULE NF NF F-PA
KETOPROFEN KETOPROFEN 50 MG CAPSULE NF NF F-PA
KETOPROFEN KETOPROFEN 75 MG CAPSULE NF NF F-PA
Formulary Update, page 12 of 22
Formulary Abbreviations: F = Formulary, NF = Non-Formulary, PA = Prior Authorization, ST = Step Therapy, NC = Not Covered, SP = Specialty Drug, QL = Quantity Limit. MED = covered as a medical claim. A current formulary status is not shown for new medications. PRx = PreferredRx Drug Formulary, GA = GenericsAdvantageRx Drug Formulary.
GENERIC NAME Label Name PRx
Current GA Current New Status
KETOROLAC TROMETHAMINE/ PF
ACUVAIL 0.45% OPHTH SOLUTION F PA NF NF
LANSOPRAZOLE/ AMOXICILLIN TRIHYDRATE/ CLARITHROMYCIN
LANSOPRAZOL-AMOXICIL-CLARITHRO
NF NF F-PA
LANTHANUM CARBONATE LANTHANUM CARB 1,000 MG TB CHW
NF NF F-PA
LANTHANUM CARBONATE LANTHANUM CARB 500 MG TAB CHEW
NF NF F-PA
LANTHANUM CARBONATE LANTHANUM CARB 750 MG TAB CHEW
NF NF F-PA
LETROZOLE FEMARA 2.5 MG TABLET NF NF NF PA
LEUPROLIDE ACETATE LEUPROLIDE 2WK 1 MG/0.2 ML KIT F EXCL F
LEUPROLIDE ACETATE LEUPROLIDE 2WK 14 MG/2.8 ML KT F EXCL F
LEVOCETIRIZINE DIHYDROCHLORIDE
LEVOCETIRIZINE 5 MG TABLET NF NF F-PA
LEVOFLOXACIN LEVOFLOXACIN 0.5% EYE DROPS NF NF F-PA
LEVONORGESTREL/ ETHINYL ESTRADIOL AND ETHINYL ESTRADIOL
LEVONORG 0.15MG-EE 20-25-30MCG
F NF F
LEVORPHANOL TARTRATE LEVORPHANOL 2 MG TABLET NF PA NF PA F-PA
LEVORPHANOL TARTRATE LEVORPHANOL 3 MG TABLET NF PA NF PA F-PA
LIDOCAINE LIDOCAINE 5% PATCH F PA QL NF QL F PA QL
LIDOCAINE LIDODERM 5% PATCH NF PA QL NF QL NF PA QL
LIDOCAINE/ TETRACAINE LIDOCAINE-TETRACAINE 7%-7% CRM
NF NF F-PA
LINDANE LINDANE 1% SHAMPOO NF NF F-PA
LIOTRIX THYROLAR-1 STRENGTH TABLET NF NF F-PA
LIOTRIX THYROLAR-1/2 STRENGTH TAB NF NF F-PA
LIOTRIX THYROLAR-1/4 STRENGTH TAB NF NF F-PA
LIOTRIX THYROLAR-2 STRENGTH TABLET NF NF F-PA
LIOTRIX THYROLAR-3 STRENGTH TABLET NF NF F-PA
LIRAGLUTIDE SAXENDA 18 MG/3 ML PEN NF PA NF PA #REF!
LODOXAMIDE TROMETHAMINE
ALOMIDE 0.1% EYE DROPS NF NF F-PA
LOTEPREDNOL ETABONATE ALREX 0.2% EYE DROPS NF NF F-PA
LOTEPREDNOL ETABONATE LOTEMAX 0.5% EYE OINTMENT F NF F
LOTEPREDNOL ETABONATE LOTEMAX SM 0.38% OPHTH GEL F NF F
LOTEPREDNOL ETABONATE LOTEPREDNOL 0.5% OPHTHALMC GEL
F NF F
Formulary Update, page 13 of 22
Formulary Abbreviations: F = Formulary, NF = Non-Formulary, PA = Prior Authorization, ST = Step Therapy, NC = Not Covered, SP = Specialty Drug, QL = Quantity Limit. MED = covered as a medical claim. A current formulary status is not shown for new medications. PRx = PreferredRx Drug Formulary, GA = GenericsAdvantageRx Drug Formulary.
GENERIC NAME Label Name PRx
Current GA Current New Status
LOTEPREDNOL ETABONATE LOTEPREDNOL ETABONATE 0.5% DRP
F NF F
LULICONAZOLE LULICONAZOLE 1% CREAM NF PA NF PA F-PA
MAFENIDE ACETATE MAFENIDE ACETATE 50 GM POWD PK
NF NF F-PA
MAPROTILINE HCL MAPROTILINE 25 MG TABLET NF NF F-PA
MAPROTILINE HCL MAPROTILINE 50 MG TABLET NF NF F-PA
MAPROTILINE HCL MAPROTILINE 75 MG TABLET NF NF F-PA
MECLIZINE HCL MECLIZINE 25 MG TABLET NF NF F-PA
MECLOFENAMATE SODIUM MECLOFENAMATE 100 MG CAPSULE
NF NF F-PA
MECLOFENAMATE SODIUM MECLOFENAMATE 50 MG CAPSULE NF NF F-PA
MEFENAMIC ACID MEFENAMIC ACID 250 MG CAPSULE
NF NF F-PA
MELPHALAN ALKERAN 2 MG TABLET NF NF NF PA
MENOTROPINS MENOPUR 75 UNIT VIAL F EXCL F
MEPROBAMATE MEPROBAMATE 200 MG TABLET NF QL NF QL F-PA-QL
MEPROBAMATE MEPROBAMATE 400 MG TABLET NF QL NF QL F-PA-QL
METAXALONE METAXALONE 800 MG TABLET NF NF F-PA
METHENAMINE HIPPURATE METHENAMINE HIPP 1 GM TABLET NF NF F-PA
METHOTREXATE SODIUM TREXALL 10 MG TABLET NF NF NF PA
METHOTREXATE SODIUM TREXALL 15 MG TABLET NF NF NF PA
METHOTREXATE SODIUM TREXALL 5 MG TABLET NF NF NF PA
METHOTREXATE SODIUM TREXALL 7.5 MG TABLET NF NF NF PA
METHSCOPOLAMINE BROMIDE
METHSCOPOLAMINE BROM 2.5 MG TB
NF NF F-PA
METHSCOPOLAMINE BROMIDE
METHSCOPOLAMINE BROM 5 MG TAB
NF NF F-PA
METHSUXIMIDE CELONTIN 300 MG KAPSEAL NF NF F-PA
METHYLTESTOSTERONE METHYLTESTOSTERONE 10 MG CAP NF PA QL F PA QL F PA QL
METIPRANOLOL METIPRANOLOL 0.3% EYE DROPS NF NF F-PA
METRONIDAZOLE METRONIDAZOLE TOPICAL 1% GEL F NF F
METRONIDAZOLE NORITATE 1% CREAM NF PA NF PA maintain
MILNACIPRAN HCL SAVELLA 100 MG TABLET F PA QL NF PA QL F PA QL
MILNACIPRAN HCL SAVELLA 12.5 MG TABLET F PA QL NF PA QL F PA QL
MILNACIPRAN HCL SAVELLA 25 MG TABLET F PA QL NF PA QL F PA QL
MILNACIPRAN HCL SAVELLA 50 MG TABLET F PA QL NF PA QL F PA QL
MILNACIPRAN HCL SAVELLA TITRATION PACK F PA QL NF PA QL F PA QL
MITOTANE LYSODREN 500 MG TABLET NF PA F PA F-PA
Formulary Update, page 14 of 22
Formulary Abbreviations: F = Formulary, NF = Non-Formulary, PA = Prior Authorization, ST = Step Therapy, NC = Not Covered, SP = Specialty Drug, QL = Quantity Limit. MED = covered as a medical claim. A current formulary status is not shown for new medications. PRx = PreferredRx Drug Formulary, GA = GenericsAdvantageRx Drug Formulary.
GENERIC NAME Label Name PRx
Current GA Current New Status
MONOMETHYL FUMARATE BAFIERTAM DR 95 MG CAPSULE S-F PA QL S-F QL S-F PA QL
NABUMETONE RELAFEN DS 1,000 MG TABLET EXCL NF PA EXCL/ NF-PA
NAFTIFINE HCL NAFTIFINE HCL 1% CREAM NF NF F-PA
NAFTIFINE HCL NAFTIFINE HCL 1% GEL NF PA NF PA F-PA
NAFTIFINE HCL NAFTIFINE HCL 2% CREAM NF QL NF QL F-PA-QL
NALTREXONE HCL/ BUPROPION HCL
CONTRAVE ER 8-90 MG TABLET NF NF F-PA
NAPROXEN/ ESOMEPRAZOLE MAGNESIUM
NAPROXEN-ESOMEPRAZ DR 375-20MG
NF PA NF PA F-PA
NAPROXEN/ ESOMEPRAZOLE MAGNESIUM
NAPROXEN-ESOMEPRAZ DR 500-20MG
NF PA NF PA F-PA
NATAMYCIN NATACYN EYE DROPS NF NF F-PA
NEDOCROMIL SODIUM ALOCRIL 2% EYE DROPS NF NF F-PA
NEOMYCIN/ POLYMYXIN B SULFATE/ DEXAMETHASONE
NEOMYC-POLYM-DEXAMETH EYE DROP
F NF NF
NEPAFENAC ILEVRO 0.3% OPHTH DROPS NF NF F-PA
NILUTAMIDE NILANDRON 150 MG TABLET NF NF NF PA
NILUTAMIDE NILUTAMIDE 150 MG TABLET NF NF F PA
NINTEDANIB ESYLATE OFEV 100 MG CAPSULE S-F PA S-F PA S-NF PA
NINTEDANIB ESYLATE OFEV 150 MG CAPSULE S-F PA S-F PA S-NF PA
NIVOLUMAB OPDIVO 100 MG/10 ML VIAL MED PA MED PA MED PA
NIVOLUMAB OPDIVO 240 MG/24 ML VIAL MED PA MED PA MED PA
NIVOLUMAB OPDIVO 40 MG/4 ML VIAL MED PA MED PA MED PA
NIZATIDINE NIZATIDINE 15 MG/ML SOLUTION NF NF F-PA
NIZATIDINE NIZATIDINE 150 MG CAPSULE NF NF F-PA
NIZATIDINE NIZATIDINE 300 MG CAPSULE NF NF F-PA
NORETHINDRONE ACETATE-ETHINYL ESTRADIOL
NORETHIND-ETH ESTRAD 0.5-2.5 F NF F
NYSTATIN NYSTATIN 100,000 UNIT/ML SUSP F QL F F QL
NYSTATIN/ TRIAMCINOLONE ACETONIDE
NYSTATIN-TRIAMCINOLONE CREAM
NF NF F-PA
NYSTATIN/ TRIAMCINOLONE ACETONIDE
NYSTATIN-TRIAMCINOLONE OINTM NF NF F-PA
OLOPATADINE HCL OLOPATADINE 665 MCG NASAL SPRY
NF NF F-PA
OLSALAZINE SODIUM DIPENTUM 250 MG CAPSULE NF PA NF PA F-PA
ONDANSETRON HCL ZOFRAN 4 MG TABLET NF NF NF PA
ONDANSETRON HCL ZOFRAN 8 MG TABLET NF NF NF PA
Formulary Update, page 15 of 22
Formulary Abbreviations: F = Formulary, NF = Non-Formulary, PA = Prior Authorization, ST = Step Therapy, NC = Not Covered, SP = Specialty Drug, QL = Quantity Limit. MED = covered as a medical claim. A current formulary status is not shown for new medications. PRx = PreferredRx Drug Formulary, GA = GenericsAdvantageRx Drug Formulary.
GENERIC NAME Label Name PRx
Current GA Current New Status
OPIUM/ BELLADONNA ALKALOIDS
BELLADONNA-OPIUM 16.2-30 SUPP NF NF QL NF QL
ORLISTAT ALLI 60 MG CAPSULE F PA F PA #REF!
ORLISTAT XENICAL 120 MG CAPSULE F PA F PA #REF!
OSPEMIFENE OSPHENA 60 MG TABLET NF EXCL NF
OXANDROLONE OXANDRIN 10 MG TABLET NF QL NF PA QL NF PA QL
OXANDROLONE OXANDRIN 2.5 MG TABLET NF QL NF PA QL NF PA QL
OXANDROLONE OXANDROLONE 10 MG TABLET NF QL F PA QL F PA QL
OXANDROLONE OXANDROLONE 2.5 MG TABLET NF QL F PA QL F PA QL
OXAPROZIN OXAPROZIN 600 MG TABLET NF NF F-PA
OXAZEPAM OXAZEPAM 10 MG CAPSULE NF QL NF QL F-PA-QL
OXAZEPAM OXAZEPAM 15 MG CAPSULE NF QL NF QL F-PA-QL
OXAZEPAM OXAZEPAM 30 MG CAPSULE NF QL NF QL F-PA-QL
OXICONAZOLE NITRATE OXICONAZOLE NITRATE 1% CREAM NF QL NF QL F-PA-QL
OXICONAZOLE NITRATE OXISTAT 1% LOTION NF PA NF PA F-PA
OXYMETHOLONE ANADROL-50 TABLET NF PA NF PA F-PA
OXYMORPHONE HCL OXYMORPHONE HCL 10 MG TABLET
NF QL NF QL F-PA-QL
OXYMORPHONE HCL OXYMORPHONE HCL 5 MG TABLET NF QL NF QL F-PA-QL
OXYMORPHONE HCL OXYMORPHONE HCL ER 10 MG TAB NF PA NF PA F-PA
OXYMORPHONE HCL OXYMORPHONE HCL ER 15 MG TAB NF PA NF PA F-PA
OXYMORPHONE HCL OXYMORPHONE HCL ER 20 MG TAB NF PA NF PA F-PA
OXYMORPHONE HCL OXYMORPHONE HCL ER 30 MG TAB NF PA NF PA F-PA
OXYMORPHONE HCL OXYMORPHONE HCL ER 40 MG TAB NF PA NF PA F-PA
OXYMORPHONE HCL OXYMORPHONE HCL ER 5 MG TABLET
NF PA NF PA F-PA
OXYMORPHONE HCL OXYMORPHONE HCL ER 7.5 MG TAB
NF PA NF PA F-PA
OZANIMOD HYDROCHLORIDE ZEPOSIA 0.23-0.46 MG START PCK S-F QL S-F QL S-F PA QL
OZANIMOD HYDROCHLORIDE ZEPOSIA 0.23-0.46-0.92 MG KIT S-F QL S-F QL S-F PA QL
OZANIMOD HYDROCHLORIDE ZEPOSIA 0.92 MG CAPSULE S-F QL S-F QL S-F PA QL
PALM OIL/ BENZOYL PEROXIDE
KIVIK SKIN EMULSION EXCL NF NC
PAPAVERINE HCL/ PHENTOLAMINE MESYLATE IN WATER
IFE-BIMIX 30/1 150-5 MG/5 ML NF EXCL NC
PAPAVERINE HCL/ PHENTOLAMINE MESYLATE/ ALPROSTADIL IN WATER
PPVRN 12MG-PHNT 1MG-ALPR 10MCG
NF EXCL NC
Formulary Update, page 16 of 22
Formulary Abbreviations: F = Formulary, NF = Non-Formulary, PA = Prior Authorization, ST = Step Therapy, NC = Not Covered, SP = Specialty Drug, QL = Quantity Limit. MED = covered as a medical claim. A current formulary status is not shown for new medications. PRx = PreferredRx Drug Formulary, GA = GenericsAdvantageRx Drug Formulary.
GENERIC NAME Label Name PRx
Current GA Current New Status
PAPAVERINE HCL/ PHENTOLAMINE MESYLATE/ ALPROSTADIL IN WATER
PPVRN 30MG-PHNT 1MG-ALPR 20MCG
NF EXCL NC
PEG 3350/ SOD SULF/ SOD BICARB/ SOD CHLORIDE/ POTASSIUM CHLORIDE
COLYTE WITH FLAVOR PACKETS NF NF NF
PEG 3350/ SOD SULF/ SOD BICARB/ SOD CHLORIDE/ POTASSIUM CHLORIDE
GOLYTELY SOLUTION NF NF NF
PEG 3350/ SOD SULF/ SOD BICARB/ SOD CHLORIDE/ POTASSIUM CHLORIDE
PEG 3350 ELECTROLYTE SOLN NF NF F
PEG 3350/ SOD SULF/ SOD BICARB/ SOD CHLORIDE/ POTASSIUM CHLORIDE
PEG-3350 AND ELECTROLYTES SOLN
NF NF F
PEGFILGRASTIM NEULASTA 6 MG/0.6 ML SYRINGE S-NF PA S-NF PA NF-PA-SP
PEGFILGRASTIM NEULASTA ONPRO 6 MG/0.6 ML KIT
S-NF PA S-NF PA NF-PA-SP
PEGFILGRASTIM-APGF NYVEPRIA 6 MG/0.6 ML SYRINGE F F F-PA
PEGFILGRASTIM-BMEZ ZIEXTENZO 6 MG/0.6 ML SYRINGE F F F-PA
PEGFILGRASTIM-CBQV UDENYCA 6 MG/0.6 ML SYRINGE F F F-PA
PEGFILGRASTIM-JMDB FULPHILA 6 MG/0.6 ML SYRINGE F F F-PA
PEMBROLIZUMAB KEYTRUDA 100 MG/4 ML VIAL MED PA MED PA MED PA
PEMIGATINIB PEMAZYRE 4.5 MG TABLET F QL F PA QL F PA QL
PENCICLOVIR DENAVIR 1% CREAM NF NF F-PA
PENTAZOCINE HCL/ NALOXONE HCL
PENTAZOCINE-NALOXONE TABLET NF QL NF QL F-PA-QL
PERPHENAZINE/ AMITRIPTYLINE HCL
PERPHEN-AMITRIP 2 MG-10 MG TAB
NF AGE NF AGE F-PA-Age
PERPHENAZINE/ AMITRIPTYLINE HCL
PERPHEN-AMITRIP 2 MG-25 MG TAB
NF AGE NF AGE F-PA-Age
PERPHENAZINE/ AMITRIPTYLINE HCL
PERPHEN-AMITRIP 4 MG-10 MG TAB
NF AGE NF AGE F-PA-Age
PERPHENAZINE/ AMITRIPTYLINE HCL
PERPHEN-AMITRIP 4 MG-25 MG TAB
NF AGE NF AGE F-PA-Age
PERPHENAZINE/ AMITRIPTYLINE HCL
PERPHEN-AMITRIP 4 MG-50 MG TAB
NF AGE NF AGE F-PA-Age
PHENTERMINE HCL/ TOPIRAMATE
QSYMIA 11.25 MG-69 MG CAPSULE NF QL NF QL #REF!
PHENTERMINE HCL/ TOPIRAMATE
QSYMIA 15 MG-92 MG CAPSULE NF QL NF QL #REF!
Formulary Update, page 17 of 22
Formulary Abbreviations: F = Formulary, NF = Non-Formulary, PA = Prior Authorization, ST = Step Therapy, NC = Not Covered, SP = Specialty Drug, QL = Quantity Limit. MED = covered as a medical claim. A current formulary status is not shown for new medications. PRx = PreferredRx Drug Formulary, GA = GenericsAdvantageRx Drug Formulary.
GENERIC NAME Label Name PRx
Current GA Current New Status
PHENTERMINE HCL/ TOPIRAMATE
QSYMIA 3.75 MG-23 MG CAPSULE NF QL NF QL #REF!
PHENTERMINE HCL/ TOPIRAMATE
QSYMIA 7.5 MG-46 MG CAPSULE NF QL NF QL #REF!
PIMOZIDE PIMOZIDE 1 MG TABLET NF AGE NF AGE F PA Age
PIMOZIDE PIMOZIDE 2 MG TABLET NF AGE NF AGE F PA Age
PIRFENIDONE ESBRIET 267 MG CAPSULE S-F PA S-F PA S-NF PA
PIRFENIDONE ESBRIET 267 MG TABLET S-F PA S-F PA S-NF PA
PIRFENIDONE ESBRIET 801 MG TABLET S-F PA S-F PA S-NF PA
PRAMIPEXOLE DI-HCL MIRAPEX ER 0.375 MG TABLET NF PA NF NF PA
PRAMIPEXOLE DI-HCL MIRAPEX ER 0.75 MG TABLET NF PA NF NF PA
PRAMIPEXOLE DI-HCL MIRAPEX ER 1.5 MG TABLET NF PA NF NF PA
PRAMIPEXOLE DI-HCL MIRAPEX ER 2.25 MG TABLET NF PA NF NF PA
PRAMIPEXOLE DI-HCL MIRAPEX ER 3 MG TABLET NF PA NF NF PA
PRAMIPEXOLE DI-HCL MIRAPEX ER 3.75 MG TABLET NF PA NF NF PA
PRAMIPEXOLE DI-HCL MIRAPEX ER 4.5 MG TABLET NF PA NF NF PA
PRAMIPEXOLE DI-HCL PRAMIPEXOLE ER 0.375 MG TABLET F PA NF NF
PRAMIPEXOLE DI-HCL PRAMIPEXOLE ER 0.75 MG TABLET F PA NF NF
PRAMIPEXOLE DI-HCL PRAMIPEXOLE ER 1.5 MG TABLET F PA NF NF
PRAMIPEXOLE DI-HCL PRAMIPEXOLE ER 2.25 MG TABLET F PA NF NF
PRAMIPEXOLE DI-HCL PRAMIPEXOLE ER 3 MG TABLET F PA NF NF
PRAMIPEXOLE DI-HCL PRAMIPEXOLE ER 3.75 MG TABLET F PA NF NF
PRAMIPEXOLE DI-HCL PRAMIPEXOLE ER 4.5 MG TABLET F PA NF NF
PRASTERONE (DHEA) INTRAROSA 6.5 MG VAG INSERT NF EXCL NF
PRENATAL VITAMIN NO.59/ IRON CARB,FUM/ FOLIC ACID/ DOCUSATE/ DHA
CITRANATAL HARMONY CAPSULE NF PA NF NC
PRENATAL VITAMINS NO.147/ FERROUS GLUCONATE/ FOLIC ACID
AZESCO TABLET NF PA NF NC
PRENATAL VITS NO.114/ FERROUS ASPART GLYCINATE/ FOLATE NO.1
PRENATE ELITE TABLET F PA NF PA NC
PROGESTERONE, MICRONIZED
CRINONE 8% GEL NF EXCL NF
PROGESTERONE, MICRONIZED
ENDOMETRIN 100 MG VAG INSERT NF EXCL NF
PROTRIPTYLINE HCL PROTRIPTYLINE HCL 10 MG TABLET NF NF F-PA
PROTRIPTYLINE HCL PROTRIPTYLINE HCL 5 MG TABLET NF NF F-PA
QUAZEPAM QUAZEPAM 15 MG TABLET NF QL NF QL F-PA-QL
Formulary Update, page 18 of 22
Formulary Abbreviations: F = Formulary, NF = Non-Formulary, PA = Prior Authorization, ST = Step Therapy, NC = Not Covered, SP = Specialty Drug, QL = Quantity Limit. MED = covered as a medical claim. A current formulary status is not shown for new medications. PRx = PreferredRx Drug Formulary, GA = GenericsAdvantageRx Drug Formulary.
GENERIC NAME Label Name PRx
Current GA Current New Status
QUININE SULFATE QUININE SULFATE 324 MG CAPSULE
NF NF F-PA
RETAPAMULIN ALTABAX 1% OINTMENT F STEP NF F STEP
RIBOCICLIB SUCCINATE KISQALI 200 MG DAILY DOSE F PA QL F PA F PA QL
RIBOCICLIB SUCCINATE KISQALI 400 MG DAILY DOSE F PA QL F PA F PA QL
RIBOCICLIB SUCCINATE KISQALI 600 MG DAILY DOSE F PA QL F PA F PA QL
RISEDRONATE SODIUM RISEDRONATE SODIUM 150 MG TAB
F NF F
RISEDRONATE SODIUM RISEDRONATE SODIUM 30 MG TAB F NF F
RISEDRONATE SODIUM RISEDRONATE SODIUM 35 MG TAB F NF F
RISEDRONATE SODIUM RISEDRONATE SODIUM 5 MG TABLET
F NF F
RIVASTIGMINE RIVASTIGMINE 13.3 MG/24HR PTCH
F NF F
RIVASTIGMINE RIVASTIGMINE 4.6 MG/24HR PATCH
F NF F
RIVASTIGMINE RIVASTIGMINE 9.5 MG/24HR PATCH
F NF F
ROPINIROLE HCL REQUIP XL 12 MG TABLET NF PA NF NF PA
ROPINIROLE HCL REQUIP XL 4 MG TABLET NF PA NF NF PA
ROPINIROLE HCL REQUIP XL 6 MG TABLET NF PA NF NF PA
ROPINIROLE HCL REQUIP XL 8 MG TABLET NF PA NF NF PA
ROPINIROLE HCL ROPINIROLE HCL ER 12 MG TABLET F PA NF F PA
ROPINIROLE HCL ROPINIROLE HCL ER 2 MG TABLET F PA NF F PA
ROPINIROLE HCL ROPINIROLE HCL ER 4 MG TABLET F PA NF F PA
ROPINIROLE HCL ROPINIROLE HCL ER 6 MG TABLET F PA NF F PA
ROPINIROLE HCL ROPINIROLE HCL ER 8 MG TABLET F PA NF F PA
SELEGILINE EMSAM 12 MG/24 HOURS PATCH F PA NF PA F PA
SELEGILINE EMSAM 6 MG/24 HOURS PATCH F PA NF PA F PA
SELEGILINE EMSAM 9 MG/24 HOURS PATCH F PA NF PA F PA
SELUMETINIB SULFATE/ VITAMIN E TPGS
KOSELUGO 10 MG CAPSULE F PA QL F PA F PA QL
SELUMETINIB SULFATE/ VITAMIN E TPGS
KOSELUGO 25 MG CAPSULE F PA QL F PA F PA QL
SEMAGLUTIDE WEGOVY 0.25 MG/0.5 ML PEN NF PA NF PA #REF!
SEMAGLUTIDE WEGOVY 0.5 MG/0.5 ML PEN NF PA NF PA #REF!
SEMAGLUTIDE WEGOVY 1 MG/0.5 ML PEN NF PA NF PA #REF!
SEMAGLUTIDE WEGOVY 1.7 MG/0.75 ML PEN NF PA NF PA #REF!
SEMAGLUTIDE WEGOVY 2.4 MG/0.75 ML PEN NF PA NF PA #REF!
SILDENAFIL CITRATE REVATIO 10 MG/12.5 ML VIAL MED PA MED MED PA
Formulary Update, page 19 of 22
Formulary Abbreviations: F = Formulary, NF = Non-Formulary, PA = Prior Authorization, ST = Step Therapy, NC = Not Covered, SP = Specialty Drug, QL = Quantity Limit. MED = covered as a medical claim. A current formulary status is not shown for new medications. PRx = PreferredRx Drug Formulary, GA = GenericsAdvantageRx Drug Formulary.
GENERIC NAME Label Name PRx
Current GA Current New Status
SILDENAFIL CITRATE SILDENAFIL 100 MG TABLET F EXCL F
SILDENAFIL CITRATE SILDENAFIL 25 MG TABLET F EXCL F
SILDENAFIL CITRATE SILDENAFIL 50 MG TABLET F EXCL F
SILDENAFIL CITRATE VIAGRA 100 MG TABLET NF PA EXCL NF PA
SILDENAFIL CITRATE VIAGRA 25 MG TABLET NF PA EXCL NF PA
SILDENAFIL CITRATE VIAGRA 50 MG TABLET NF PA EXCL NF PA
SILODOSIN SILODOSIN 4 MG CAPSULE NF NF F-PA
SILODOSIN SILODOSIN 8 MG CAPSULE NF NF F-PA
SODIUM CHLORIDE/ SODIUM BICARBONATE/ POTASSIUM CHLORIDE/ PEG
TRILYTE WITH FLAVOR PACKETS F F NF
SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE
FERRLECIT 62.5 MG/5 ML VIAL NF MED MED
SODIUM ZIRCONIUM CYCLOSILICATE
LOKELMA 10 GRAM POWDER PACKET
NF NF F
SODIUM ZIRCONIUM CYCLOSILICATE
LOKELMA 5 GRAM POWDER PACKET
NF NF F
SPINOSAD SPINOSAD 0.9% TOPICAL SUSP NF NF F-PA
SPIRONOLACTONE/ HYDROCHLOROTHIAZIDE
ALDACTAZIDE 50-50 TABLET F NF NF
STIRIPENTOL DIACOMIT 500 MG CAPSULE S F PA S F PA QL S F PA QL
SUCRALFATE CARAFATE 1 GM/10 ML SUSP NF NF PA NF PA
SUCRALFATE SUCRALFATE 1 GM/10 ML SUSP NF F PA F PA
SULCONAZOLE NITRATE SULCONAZOLE NITRATE 1% CREAM NF PA NF PA F-PA
SULCONAZOLE NITRATE SULCONAZOLE NITRATE 1% SOLN NF PA NF PA F-PA
SULFACETAMIDE SODIUM/ SULFUR
PLEXION 9.8-4.8% CLEANSER NF NF NC
SULFACETAMIDE SODIUM/ SULFUR
PLEXION 9.8-4.8% CLNSING CLOTH NF NF NC
SULFACETAMIDE SODIUM/ SULFUR
PLEXION 9.8-4.8% CREAM NF NF NC
SULFACETAMIDE SODIUM/ SULFUR
PLEXION 9.8-4.8% LOTION NF NF NC
SULFADIAZINE SULFADIAZINE 500 MG TABLET NF NF F-PA
SUMATRIPTAN SUCCINATE ONZETRA XSAIL 11 MG/NOSEPIECE NF PA QL NF QL NF PA QL
SUMATRIPTAN SUCCINATE/ NAPROXEN SODIUM
SUMATRIPTAN-NAPROXEN 85-500 MG
NF PA QL NF PA QL F-PA-QL
TADALAFIL CIALIS 10 MG TABLET NF PA EXCL NF PA
TADALAFIL CIALIS 20 MG TABLET NF PA EXCL NF PA
TADALAFIL TADALAFIL 10 MG TABLET F EXCL F
Formulary Update, page 20 of 22
Formulary Abbreviations: F = Formulary, NF = Non-Formulary, PA = Prior Authorization, ST = Step Therapy, NC = Not Covered, SP = Specialty Drug, QL = Quantity Limit. MED = covered as a medical claim. A current formulary status is not shown for new medications. PRx = PreferredRx Drug Formulary, GA = GenericsAdvantageRx Drug Formulary.
GENERIC NAME Label Name PRx
Current GA Current New Status
TADALAFIL TADALAFIL 2.5 MG TABLET F QL F PA QL F QL
TADALAFIL TADALAFIL 20 MG TABLET F EXCL F
TADALAFIL TADALAFIL 5 MG TABLET F QL F PA QL F QL
TAPENTADOL HCL NUCYNTA 100 MG TABLET NF QL NF QL F-PA-QL
TAPENTADOL HCL NUCYNTA 50 MG TABLET NF QL NF QL F-PA-QL
TAPENTADOL HCL NUCYNTA 75 MG TABLET NF QL NF QL F-PA-QL
TAZAROTENE TAZORAC 0.05% CREAM F PA QL NF PA QL F PA QL
TAZAROTENE TAZORAC 0.05% GEL F PA QL NF PA QL F PA QL
TAZAROTENE TAZORAC 0.1% GEL F PA QL NF PA QL F PA QL
TERBUTALINE SULFATE TERBUTALINE SULFATE 2.5 MG TAB NF NF F-PA
TERBUTALINE SULFATE TERBUTALINE SULFATE 5 MG TAB NF NF F-PA
TETRACYCLINE HCL TETRACYCLINE 250 MG CAPSULE NF NF F-PA
TETRACYCLINE HCL TETRACYCLINE 500 MG CAPSULE NF NF F-PA
TINIDAZOLE TINIDAZOLE 250 MG TABLET NF NF F-PA
TINIDAZOLE TINIDAZOLE 500 MG TABLET NF NF F-PA
TOBRAMYCIN TOBRAMYCIN 300 MG/4 ML AMPULE
S NF PA NF PA S NF PA
TOBRAMYCIN/ LOTEPREDNOL ETABONATE
ZYLET EYE DROPS NF NF F-PA
TOCILIZUMAB ACTEMRA 162 MG/0.9 ML SYRINGE S F PA QL S F PA S F PA QL
TOLMETIN SODIUM TOLMETIN SODIUM 200 MG TAB NF F PA F PA
TOLMETIN SODIUM TOLMETIN SODIUM 400 MG CAP NF F PA F PA
TOLMETIN SODIUM TOLMETIN SODIUM 600 MG TAB NF F PA F PA
TOLVAPTAN JYNARQUE 15 MG TABLET S-NF PA S-NF PA S-NF PA
TOLVAPTAN JYNARQUE 15 MG-15 MG TABLET S-NF PA S-NF PA S-NF PA
TOLVAPTAN JYNARQUE 30 MG TABLET S-NF PA S-NF PA S-NF PA
TOLVAPTAN JYNARQUE 30 MG-15 MG TABLET S-NF PA S-NF PA S-NF PA
TOLVAPTAN JYNARQUE 45 MG-15 MG TABLET S-NF PA S-NF PA S-NF PA
TOLVAPTAN JYNARQUE 60 MG-30 MG TABLET S-NF PA S-NF PA S-NF PA
TOLVAPTAN JYNARQUE 90 MG-30 MG TABLET S-NF PA S-NF PA S-NF PA
TOLVAPTAN TOLVAPTAN 15 MG TABLET S NF PA S NF S NF PA
TOREMIFENE CITRATE FARESTON 60 MG TABLET NF NF NF PA
TOREMIFENE CITRATE TOREMIFENE CITRATE 60 MG TAB NF NF F PA
TRAMADOL HCL TRAMADOL ER 100 MG TABLET NF PA QL AGE
NF PA QL AGE
F-PA-QL-Age
TRAMADOL HCL TRAMADOL ER 200 MG TABLET NF PA QL AGE
NF PA QL AGE
F-PA-QL-Age
TRAMADOL HCL TRAMADOL ER 300 MG TABLET NF PA QL AGE
NF PA QL AGE
F-PA-QL-Age
Formulary Update, page 21 of 22
Formulary Abbreviations: F = Formulary, NF = Non-Formulary, PA = Prior Authorization, ST = Step Therapy, NC = Not Covered, SP = Specialty Drug, QL = Quantity Limit. MED = covered as a medical claim. A current formulary status is not shown for new medications. PRx = PreferredRx Drug Formulary, GA = GenericsAdvantageRx Drug Formulary.
GENERIC NAME Label Name PRx
Current GA Current New Status
TRAMADOL HCL TRAMADOL HCL ER 100 MG CAPSULE
NF PA NF PA F-PA
TRAMADOL HCL TRAMADOL HCL ER 100 MG TABLET NF PA NF PA F-PA
TRAMADOL HCL TRAMADOL HCL ER 150 MG CAPSULE
NF PA NF PA F-PA
TRAMADOL HCL TRAMADOL HCL ER 200 MG CAPSULE
NF PA NF PA F-PA
TRAMADOL HCL TRAMADOL HCL ER 200 MG TABLET NF PA NF PA F-PA
TRAMADOL HCL TRAMADOL HCL ER 300 MG CAPSULE
NF PA NF PA F-PA
TRAMADOL HCL TRAMADOL HCL ER 300 MG TABLET NF PA NF PA F-PA
TRASTUZUMAB HERCEPTIN 150 MG VIAL MED PA MED PA MED PA
TRASTUZUMAB-ANNS KANJINTI 150 MG VIAL MED PA MED PA MED PA
TRASTUZUMAB-ANNS KANJINTI 420 MG VIAL MED PA MED PA MED PA
TRASTUZUMAB-DKST OGIVRI 150 MG VIAL MED PA MED PA MED PA
TRASTUZUMAB-DKST OGIVRI 420 MG VIAL MED PA MED PA MED PA
TRASTUZUMAB-DTTB ONTRUZANT 150 MG VIAL MED PA MED PA MED PA
TRASTUZUMAB-DTTB ONTRUZANT 420 MG VIAL MED PA MED PA MED PA
TRASTUZUMAB-HYALURONIDASE-OYSK
HERCEPTIN HYLECTA 600MG-10,000
MED PA MED PA MED PA
TRASTUZUMAB-PKRB HERZUMA 150 MG VIAL MED PA MED PA MED PA
TRASTUZUMAB-PKRB HERZUMA 420 MG VIAL MED PA MED PA MED PA
TRASTUZUMAB-QYYP TRAZIMERA 150 MG VIAL MED PA MED PA MED PA
TRASTUZUMAB-QYYP TRAZIMERA 420 MG VIAL MED PA MED PA MED PA
TRIAZOLAM TRIAZOLAM 0.125 MG TABLET NF QL NF QL F-PA-QL
TRIAZOLAM TRIAZOLAM 0.25 MG TABLET NF QL NF QL F-PA-QL
TRIMIPRAMINE MALEATE TRIMIPRAMINE MALEATE 100 MG CP
NF NF F-PA
TRIMIPRAMINE MALEATE TRIMIPRAMINE MALEATE 25 MG CAP
NF NF F-PA
TRIMIPRAMINE MALEATE TRIMIPRAMINE MALEATE 50 MG CAP
NF NF F-PA
VARDENAFIL HCL LEVITRA 10 MG TABLET NF PA EXCL NF PA
VARDENAFIL HCL LEVITRA 20 MG TABLET NF PA EXCL NF PA
VARDENAFIL HCL STAXYN 10 MG ODT NF EXCL NF
VARDENAFIL HCL VARDENAFIL HCL 10 MG ODT NF EXCL NF
VARDENAFIL HCL VARDENAFIL HCL 10 MG TABLET NF PA EXCL NF PA
VARDENAFIL HCL VARDENAFIL HCL 2.5 MG TABLET NF PA EXCL NF PA
VARDENAFIL HCL VARDENAFIL HCL 20 MG TABLET NF PA EXCL NF PA
VARDENAFIL HCL VARDENAFIL HCL 5 MG TABLET NF PA EXCL NF PA
Formulary Update, page 22 of 22
Formulary Abbreviations: F = Formulary, NF = Non-Formulary, PA = Prior Authorization, ST = Step Therapy, NC = Not Covered, SP = Specialty Drug, QL = Quantity Limit. MED = covered as a medical claim. A current formulary status is not shown for new medications. PRx = PreferredRx Drug Formulary, GA = GenericsAdvantageRx Drug Formulary.
GENERIC NAME Label Name PRx
Current GA Current New Status
VIGABATRIN SABRIL 500 MG TABLET S NF S NF PA S NF PA
ZAFIRLUKAST ZAFIRLUKAST 10 MG TABLET NF NF F-PA
ZAFIRLUKAST ZAFIRLUKAST 20 MG TABLET NF NF F-PA
ZILEUTON ZILEUTON ER 600 MG TABLET NF PA QL NF PA QL F-PA-QL
ZOLPIDEM TARTRATE ZOLPIDEM TART ER 12.5 MG TAB F STEP NF F STEP
ZOLPIDEM TARTRATE ZOLPIDEM TART ER 6.25 MG TAB F STEP NF F STEP
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