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STANDARD PLAN FOUR TIER DRUG LISTPreferred 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 Medications 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, consider one of the preferred brand medications (Tier 2)identified on this list for a more cost-effective choice.
• Some Preventive Medications (Tier 0) including some over-the-counter drugs, devices and otherproducts approved by the Federal Food and Drug Administration are fully covered at no cost toyou, the member, when purchased through a participating pharmacy with a written prescription.To learn more about Preventive Medication coverage visit our website atwww.prescryptive.com.
© 2020 PRESCRYPTIVE. ALL RIGHTS RESERVED. 2020.03
pg. 1 www.prescryptive.com
Tier Level Description
Tier 1 Lowest Co-pay or Co-insurance Generic drugs.All generics in the Drug List are listed in bolded italics.
Preferred brand drugs.Preferred brand drugs are listed in ALL-CAPS.
Tier 4 Highest Co-pay or Co-insurance
Tier 3 Higher Co-pay or Co-insurance
Tier 2 Lower Co-pay or Co-insurance
Non-preferred brand drugs.Non-preferred brand drugs are not listed in this document.
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.
Note: Tier 0 medications are covered at no cost to members ($0 co-pay) as mandated by the federalAffordable Care Act (ACA).
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.
Four Tiers
© 2020 PRESCRYPTIVE. ALL RIGHTS RESERVED. 2020.03
pg. 2 www.prescryptive.com
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 Member Services 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 network 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.
© 2020 PRESCRYPTIVE. ALL RIGHTS RESERVED. 2020.03
pg. 3 www.prescryptive.com
Notes: "PAR" - Prior Authorization Required
© 2020 PRESCRYPTIVE. ALL RIGHTS RESERVED. 2020.03
pg. 4 www.prescryptive.com
PAR
PAR
PAR
PAR
PAR
PAR
Notes
1
1
1
1
1
1
0
4
0
1
4
2
2
0
0
1
1
1
1
1
1
1
1
1
1
1
1
1
1
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
Tier Drug Name
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
abacavir 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 hfa
albuterol, er
alclometasone
Alecensa
alendronate
Alferon N
Tier Drug Name Notes
PAR
PAR
pg. 5 www.prescryptive.com© 2020 PRESCRYPTIVE. ALL RIGHTS RESERVED. 2020.03
Notes: "PAR" - Prior Authorization Required
PAR
PAR
PAR
PAR
PAR
Notes
0
0
1
2
2
1
1
1
1
1
1
1
2
1
4
0
0
0
0
4
4
0
1
1
4
0
4
2
2
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
Tier Drug Name
2
1
1
1
1
1
1
4
1
1
1
0
2
1
4
1
1
0
2
2
2
0
4
4
4
1
1
2
2
Amoxapine
amoxicillin
amoxicillin-clarithromycin-lansoprazole
amoxicillin-clavulanate, er
amphetamine-dextroamphetamine, er
amphetamine, er
ampicillin
Anadrol-50
anagrelide
anaspaz
anastrozole
annovera
Anoro Ellipta
anucort-hc
Apokyn
apraclonidine
aprepitant
apri
Aptiom
Aptivus
Arakoda
aranelle
Aranesp
Arcalyst
Arikayce
aripiprazole
armodafinil
Armour Thyroid
Arnuity Ellipta
Tier Drug Name Notes
PAR
PAR
PAR
PAR
PAR
pg. 6 www.prescryptive.com
Notes: "PAR" - Prior Authorization Required
© 2020 PRESCRYPTIVE. ALL RIGHTS RESERVED. 2020.03
PAR
PAR
Notes
1
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
betamethasone dipropionate aug
betamethasone 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
Tier Drug Name
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
azathioprine
azelaic acid
azelastine
azelastine-fluticasone
azithromycin
azurette
bacitracin
bacitracin-neomycin-polymyxinb-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
Tier Drug Name Notes
PAR
PAR
PAR
PAR
pg. 7 www.prescryptive.com
Notes: "PAR" - Prior Authorization Required
© 2020 PRESCRYPTIVE. ALL RIGHTS RESERVED. 2020.03
PAR
PAR
Notes
4
1
2
4
1
1
1
1
1
1
1
2
1
1
1
0
4
0
1
2
1
1
2
1
1
1
1
1
2
Caprelsa
captopril
Captopril-hydrochlorothiazide
Carbaglu
carbamazepine, er
carbidopa
carbidopa-levodopa-entacapone
carbidopa-levodopa, er
carbinoxamine
carisoprodol
carisoprodol-aspirin
carisoprodol-aspirin-codeine
carteolol
carvedilol, er
cavarest
caya
Cayston
caziant
cefaclor
Cefaclor ER
cefadroxil
cefdinir
Cefditoren
cefixime
cefpodoxime
cefprozil
cefuroxime
celecoxib
Celontin
Tier Drug Name
1
1
1
1
1
0
1
1
1
1
1
1
1
1
1
4
1
1
1
1
1
1
1
4
0
0
1
1
1
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
Tier Drug Name Notes
PAR
PAR
PAR
pg. 8 www.prescryptive.com
Notes: "PAR" - Prior Authorization Required
© 2020 PRESCRYPTIVE. ALL RIGHTS RESERVED. 2020.03
PAR
PAR
PAR
PAR
Notes
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
citalopram hydrobromide
claravis
clarithromycin, er
clemastine
clenpiq
clindamycin
clindamycin-benzoyl peroxide
clindamycin-tretinoin
clinpro 5000
clobazam
clobetasol emulsion
clobetasol, emollient
clomipramine
clonazepam
clonidine, er
clopidogrel
clorazepate
clotrimazole
clotrimazole-betamethasone
clovique
clozapine
Coartem
codeine
colchicine
colchicine-probenecid
colesevelam
colestipol
coly-mycin s
Cometriq
Tier Drug Name
1
4
1
1
0
0
4
4
1
2
1
1
1
1
1
1
1
4
1
1
2
1
1
1
2
1
1
1
1
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
ciclopirox
cilostazol
Cimduo
cimetidine
cinacalcet
ciprofloxacin
ciprofloxacin-fluocinolone
Tier Drug Name Notes
PAR
PAR
pg. 9 www.prescryptive.com
Notes: "PAR" - Prior Authorization Required
© 2020 PRESCRYPTIVE. ALL RIGHTS RESERVED. 2020.03
PAR
PAR
PAR
PAR
Notes
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
citalopram hydrobromide
claravis
clarithromycin, er
clemastine
clenpiq
clindamycin
clindamycin-benzoyl peroxide
clindamycin-tretinoin
clinpro 5000
clobazam
clobetasol emulsion
clobetasol, emollient
clomipramine
clonazepam
clonidine, er
clopidogrel
clorazepate
clotrimazole
clotrimazole-betamethasone
clovique
clozapine
Coartem
codeine
colchicine
colchicine-probenecid
colesevelam
colestipol
coly-mycin s
Cometriq
Tier Drug Name
1
4
1
1
0
0
4
4
1
2
1
1
1
1
1
1
1
4
1
1
2
1
1
1
2
1
1
1
1
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
ciclopirox
cilostazol
Cimduo
cimetidine
cinacalcet
ciprofloxacin
ciprofloxacin-fluocinolone
Tier Drug Name Notes
PAR
PAR
pg. 10 www.prescryptive.com
Notes: "PAR" - Prior Authorization Required
© 2020 PRESCRYPTIVE. ALL RIGHTS RESERVED. 2020.03
PAR
PAR
PAR
PAR
Notes
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
citalopram hydrobromide
claravis
clarithromycin, er
clemastine
clenpiq
clindamycin
clindamycin-benzoyl peroxide
clindamycin-tretinoin
clinpro 5000
clobazam
clobetasol emulsion
clobetasol, emollient
clomipramine
clonazepam
clonidine, er
clopidogrel
clorazepate
clotrimazole
clotrimazole-betamethasone
clovique
clozapine
Coartem
codeine
colchicine
colchicine-probenecid
colesevelam
colestipol
coly-mycin s
Cometriq
Tier Drug Name
1
4
1
1
0
0
4
4
1
2
1
1
1
1
1
1
1
4
1
1
2
1
1
1
2
1
1
1
1
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
ciclopirox
cilostazol
Cimduo
cimetidine
cinacalcet
ciprofloxacin
ciprofloxacin-fluocinolone
Tier Drug Name Notes
PAR
PAR
pg. 11 www.prescryptive.com
Notes: "PAR" - Prior Authorization Required
© 2020 PRESCRYPTIVE. ALL RIGHTS RESERVED. 2020.03
PAR
PAR
PAR
PAR
PAR
PAR
PAR
PAR
Notes
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
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
Tier Drug Name
1
4
4
1
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
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
Tier Drug Name Notes
PAR
PAR
PAR
PAR
PAR
pg. 12 www.prescryptive.com
Notes: "PAR" - Prior Authorization Required
© 2020 PRESCRYPTIVE. ALL RIGHTS RESERVED. 2020.03
PAR
Notes
1
1
1
1
2
1
1
1
1
1
1
2
1
4
1
1
1
1
4
1
2
2
1
4
1
1
4
1
1
fluorouracil
fluoxetine
fluphenazine
flurandrenolide
Flurazepam
flurbiprofen
flutamide
fluticasone
fluvastatin, er
fluvoxamine, er
folic acid
Folivane-OB
fondaparinux
Forteo
fosamprenavir
fosinopril
fosinopril-hydrochlorothiazide
frovatriptan succinate
Fulphila
furosemide
Fuzeon
Fycompa
gabapentin
Galafold
galantamine, er
gatifloxacin
Gattex
gemfibrozil
gengraf
Tier Drug Name
1
0
1
1
1
0
2
0
1
1
1
1
4
2
1
1
1
1
2
1
1
1
1
1
1
1
1
1
1
favipiravir
fayosim
febuxostat
felbamate
felodipine, er
femcap
Femring
femynor
fenofibrate, 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
Tier Drug Name Notes
PAR
PAR
PAR
PAR
pg. 13 www.prescryptive.com
Notes: "PAR" - Prior Authorization Required
© 2020 PRESCRYPTIVE. ALL RIGHTS RESERVED. 2020.03
PAR
PAR
PAR
PAR
PAR
PAR
Notes
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
homatropine hbr
Humira
HumuLIN R U-500
Hycamtin
hydralazine
hydrochlorothiazide
hydrocodone, er
hydrocodone-acetaminophen
hydrocodone-chlorpheniramine, er
hydrocodone-homatropine
hydrocodone-ibuprofen
hydrocortisone
hydrocortisone acetate
hydrocortisone acetate-pramoxine
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
Tier Drug Name
1
2
0
0
4
4
4
1
1
1
2
1
1
1
1
1
4
1
1
2
4
0
0
1
1
1
0
2
4
gentamicin
Genvoya
gialax
gianvi
Gilenya
Gilotrif
glatiramer
glimepiride
glipizide-metformin
glipizide, er
Glucagon Emergency
glyburide-metformin
glyburide, micronized
glycine
glycopyrrolate
granisetron
Granix
griseofulvin microsize, ultramicrosize
guanfacine, er
Guanidine
Haegarda
hailey
hailey 24 fe
halcinonide
halobetasol propionate
haloperidol
heather
Hemangeol
Hemlibra
Tier Drug Name Notes
PAR
PAR
PAR
PAR
pg. 14 www.prescryptive.com
Notes: "PAR" - Prior Authorization Required
© 2020 PRESCRYPTIVE. ALL RIGHTS RESERVED. 2020.03
PAR
PAR
PAR
PAR
PAR
PAR
PAR
PAR
PAR
PAR
Notes
1
1
4
2
0
1
1
1
1
1
1
1
1
4
0
4
1
2
2
2
0
0
0
0
2
0
0
0
4
irbesartan
irbesartan-hydrochlorothiazide
Iressa
Isentress
isibloom
isoniazid
isosorbide dinitrate
isosorbide mononitrate, er
isotretinoin
isoxsuprine
isradipine
itraconazole
ivermectin
Jadenu Sprinkle
jaimiess
Jakafi
Jantoven
Janumet, XR
Januvia
Jardiance
jasmiel
jencycla
jolessa
juleber
Juluca
junel
junel fe
junel fe 24
Juxtapid
Tier Drug Name
4
4
4
4
4
1
1
4
0
4
2
1
1
4
4
4
1
1
2
4
0
2
2
2
2
1
1
1
1
IDHIFA
iIcatibant
Ilaris
imatinib
Imbruvica
imipramine HCl, pamoate
imiquimod
Inbrija
incassia
Increlex
Incruse Ellipta
indapamide
indomethacin, er
Ingrezza
Inlyta
Inrebic
insulin aspart
insulin aspart & prot
Intelence
Intron A
introvale
Invirase
Invokamet, XR
Invokana
Iodine Strong
iodoquimez-hydrocortisone
iodoquinol-hydrocortisone-aloe
ipratropium bromide
ipratropium-albuterol
Tier Drug Name Notes
PAR
PAR
PAR
PAR
pg. 15 www.prescryptive.com
Notes: "PAR" - Prior Authorization Required
© 2020 PRESCRYPTIVE. ALL RIGHTS RESERVED. 2020.03
PAR
PAR
PAR
PAR
PAR
PAR
PAR
PAR
PAR
PAR
Notes
1
1
1
1
1
1
1
1
0
0
0
0
1
2
2
0
4
0
1
4
0
1
1
2
1
2
1
1
1
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
Leukeran
levalbuterol
Levemir FlexTouch
levetiracetam, er
levo-t
levobunolol
Tier Drug Name
4
2
1
0
4
2
0
4
0
0
1
1
2
1
2
4
0
1
4
4
4
2
1
4
2
0
4
0
4
Jynarque
K-Phos
k-tab
kaitlib fe
Kalbitor
Kaletra
kalliga
Kalydeco
kariva
kelnor
ketoconazole
ketoprofen
Ketoprofen ER
ketorolac
Ketostix
Keveyis
kinrix
kionex
Kisqali
Kisqali Femara
kitabis (tobramycin)
Klarity-A
klor-con
Korlym
Krintafel
kurvelo
Kuvan
kyleena
Kynmobi
Tier Drug Name Notes
PAR
PAR
pg. 16 www.prescryptive.com
Notes: "PAR" - Prior Authorization Required
© 2020 PRESCRYPTIVE. ALL RIGHTS RESERVED. 2020.03
PAR
PAR
Notes
1
4
0
1
1
1
1
0
1
4
1
2
0
4
4
0
1
4
2
0
2
4
4
4
2
4
2
2
0
lorazepam
Lorbrena
loryna
losartan
losartan-hydrochlorothiazide
loteprednol
lovastatin
low-ogestrel
loxapine
Lucemyra
ludent
Luliconazole
lutera
Lynparza
Lysodren
lyza
mafenide acetate
Makena
Maprotiline
marlissa
Marplan
Matulane
Mavenclad
Mavyret
Maxidex
Mayzent
Meclofenamate
Medrol
medroxyprogesterone
Tier Drug Name
1
1
0
0
0
0
1
1
2
1
1
1
1
0
0
1
1
2
1
1
1
2
1
0
0
0
4
4
1
levocarnitine
levofloxacin
levonest
levonorgestrel
levonorgestrel-ethinyl estradiol
levora
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
lo-zumandimine
lojaimiess
Lokelma
Lonsurf
lopinavir-ritonavir
Tier Drug Name Notes
PAR
PAR
PAR
PAR
PAR
PAR
PAR
PAR
PAR
pg. 17 www.prescryptive.com
Notes: "PAR" - Prior Authorization Required
© 2020 PRESCRYPTIVE. ALL RIGHTS RESERVED. 2020.03
PAR
PAR
PAR
Notes
1
1
1
1
1
2
1
1
1
1
1
0
1
0
0
1
1
1
1
4
0
1
1
1
4
0
1
1
1
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
midazolam
midodrine
mifepristone
miglitol
miglustat
mili
minitran
minocycline
minoxidil
Mircera
mirena
mirtazapine
misoprostol
modafinil
Tier Drug Name
1
1
1
4
4
0
1
1
1
1
1
1
1
4
2
1
1
1
1
1
1
1
1
1
1
1
1
2
1
mefenamic acid
mefloquine
megestrol
Mekinist
Mektovi
melodetta 24 fe
meloxicam
melphalan
memantine, 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
Tier Drug Name Notes
PAR
PAR
pg. 18 www.prescryptive.com
Notes: "PAR" - Prior Authorization Required
© 2020 PRESCRYPTIVE. ALL RIGHTS RESERVED. 2020.03
PAR
PAR
PAR
PAR
Notes
2
2
0
1
4
2
0
1
1
1
1
1
1
4
1
0
4
2
2
0
1
1
0
1
0
1
1
4
1
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
Nexlizet
nexplanon
niacin, er (antihyperlipidemic)
nicardipine
nicotine
nifedipine, er
nikki
nilutamide
nimodipine
Ninlaro
nisoldipine, er
Tier Drug Name
1
2
1
0
1
1
4
0
1
4
2
4
2
1
1
1
0
0
4
1
1
2
1
1
1
1
1
1
1
moexipril
Molindone
mometasone
mono-linyah
montelukast
morphine sulfate, er
Movantik
moviprep
moxifloxacin
Mozobil
Mucotrol
Mulpleta
Multaq
multivitamins/fluoride
multivitamins/fluoride/iron
mupirocin
my choice
my way
Myalept
mycophenolate
mycophenolate mofetil
Myleran
myorisan
nabumetone
nadolol
naftifine
naltrexone
naproxen, er, dr
naratriptan
Tier Drug Name Notes
PAR
PAR
PAR
PAR
pg. 19 www.prescryptive.com
Notes: "PAR" - Prior Authorization Required
© 2020 PRESCRYPTIVE. ALL RIGHTS RESERVED. 2020.03
PAR
PAR
PAR
PAR
PAR
PAR
PAR
PAR
Notes
4
4
4
1
1
4
0
1
1
4
0
4
2
4
4
1
0
1
1
1
1
1
1
1
1
1
0
1
2
Nubeqa
Nucala
Nuedexta
nufol
nulev
Nuplazid
nuvaring
nystatin
nystatin-triamcinolone
Ocaliva
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
Tier Drug Name
4
1
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
nitisinone
nitrofurantoin
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
Tier Drug Name Notes
PAR
PAR
PAR
PAR
PAR
PAR
PAR
PAR
pg. 20 www.prescryptive.com
Notes: "PAR" - Prior Authorization Required
© 2020 PRESCRYPTIVE. ALL RIGHTS RESERVED. 2020.03
PAR
PAR
PAR
PAR
PAR
PAR
PAR
Notes
1
1
2
1
4
1
4
4
1
0
2
1
1
1
1
1
2
0
2
4
4
4
4
1
1
1
2
1
1
oxycodone, er
oxymorphone, er
Ozempic
pacerone
Palforzia
paliperidone, er
Palynziq
Panretin
pantoprazole
paragard intrauterine copper
Paregoric
paricalcitol
paroex
paromomycin sulfate
paroxetine mesylate
paroxetine, er
Paser
peg-3350/electrolytes
Peganone
Pegasys
PegIntron
Pemazyre
penicillamine
penicillin v potassium
pentazocine-naloxone
pentoxifylline, er
Perforomist
perindopril
periogard
Tier Drug Name
2
2
2
0
1
4
0
2
4
4
4
4
1
1
0
1
1
2
4
2
1
1
1
4
1
1
1
1
1
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
oseltamivir phosphate
Osmolex ER
Otezla
Otrexup
oxandrolone
oxaprozin
oxazepam
Oxbryta
oxcarbazepine
oxiconazole
oxybutynin, er
oxycodone-acetaminophen
oxycodone-aspirin
Tier Drug Name Notes
PAR
PAR
PAR
PAR
PAR
PAR
PAR
pg. 21 www.prescryptive.com
Notes: "PAR" - Prior Authorization Required
© 2020 PRESCRYPTIVE. ALL RIGHTS RESERVED. 2020.03
PAR
PAR
PAR
PAR
PAR
Notes
1
1
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
podofilox
poly-iron 150 forte
polycin
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
Tier Drug Name
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
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
Tier Drug Name Notes
PAR
PAR
PAR
pg. 22 www.prescryptive.com
Notes: "PAR" - Prior Authorization Required
© 2020 PRESCRYPTIVE. ALL RIGHTS RESERVED. 2020.03
PAR
PAR
PAR
PAR
Notes
4
1
1
2
2
0
1
2
2
1
1
1
1
1
1
1
1
1
1
1
1
2
4
4
0
4
4
0
1
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
ramipril
ranitidine
ranolazine, er
rasagiline mesylate
Rasuvo
Ravicti
Rayaldee
react
Rebif
Reblozyl
reclipsen
repaglinide
Tier Drug Name
0
2
2
2
2
1
1
1
1
4
4
1
2
4
4
1
1
1
2
1
1
2
1
1
1
1
1
1
previfem
Prevymis
Prezcobix
Prezista
Priftin
primaquine phosphate
primidone
probenecid
prochlorperazine
Procrit
Procysbi
progesterone micronized
Proglycem
Prolia
Promacta
promethazine
promethazine-codeine
promethazine-dextromethorphan
Promethazine-Phenylephrine
promethazine-phenylephrine-codeine
propafenone, er
Propranolol-hydrochlorothiazide
propranolol, er
propylthiouracil
protriptyline
prudoxin
pseudoephdrine-brompheniramine-dextromethorphan
pulmosal
Tier Drug Name Notes
PAR
PAR
PAR
PAR
PAR
pg. 23 www.prescryptive.com
Notes: "PAR" - Prior Authorization Required
© 2020 PRESCRYPTIVE. ALL RIGHTS RESERVED. 2020.03
PAR
PAR
PAR
PAR
PAR
PAR
PAR
PAR
Notes
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
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
Tier Drug Name
4
4
4
2
1
1
2
1
2
1
1
4
1
1
1
1
0
1
1
1
1
4
4
4
2
2
4
2
1
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
Rybelsus
RyClora
Rydapt
SaliCept
salicylic acid
Tier Drug Name Notes
PAR
PAR
PAR
PAR
PAR
PAR
PAR
pg. 24 www.prescryptive.com
Notes: "PAR" - Prior Authorization Required
© 2020 PRESCRYPTIVE. ALL RIGHTS RESERVED. 2020.03
PAR
PAR
PAR
PAR
PAR
PAR
PAR
Notes
0
4
4
2
2
2
2
4
2
4
2
4
1
1
4
4
0
4
4
1
1
4
0
0
4
4
0
1
4
syeda
Sylatron
Symdeko
Symfi, Lo
Symlin
Symproic
Symtuza
Synarel
Synjardy, XR
Synribo
Tabloid
Tabrecta
tacrolimus
tadalafil
Tafinlar
Tagrisso
take action
Takhzyro
Talzenna
tamoxifen citrate
tamsulosin
Targretin
tarina 24 fe
tarina fe, eq
Tasigna
Tavalisse
taytulla
tazarotene
Tazverik
Tier Drug Name
1
4
4
1
1
1
1
0
4
0
1
4
4
2
2
4
1
1
1
1
1
1
2
1
1
1
1
1
4
solifenacin succinate
Somavert
Soriatane
sorine
sotalol
spironolactone
spironolactone-hydrochlorothiazide
sprintec 28
Sprycel
sronyx
stavudine
Stivarga
Strensiq
Stribild
Strovite Forte
Sucraid
sucralfate
sulconazole nitrate
sulfacetamide
sulfacetamide
sulfacetamide-sulfur
sulfacetamide-prednisolone
sulfADIAZINE
sulfamethoxazole-trimethoprim
sulfasalazine
sulindac
sumatriptan
sumatriptan-naproxen
Sutent
Tier Drug Name Notes
PAR
PAR
PAR
PAR
PAR
PAR
PAR
PAR
PAR
PAR
PAR
PAR
PAR
pg. 25 www.prescryptive.com
Notes: "PAR" - Prior Authorization Required
© 2020 PRESCRYPTIVE. ALL RIGHTS RESERVED. 2020.03
PAR
PAR
PAR
PAR
PAR
PAR
PAR
Notes
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
2
4
2
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-acetaminophen
tramadol, er
trandolapril
trandolapril-verapamil, er
tranexamic acid
tranylcypromine sulfate
travoprost
trazodone
Trecator
Trelegy Ellipta
Tremfya
Tresiba
Tier Drug Name
4
4
1
1
1
1
2
1
1
1
1
1
1
1
4
1
4
1
4
1
1
1
1
1
4
4
0
1
2
Tecfidera
Tegsedi
telmisartan
telmisartan-amlodipine
telmisartan-hydrochlorothiazide
temazepam
Temixys
temozolomide
tenofovir disoproxil fumarate
terazosin
terbinafine
terbutaline
terconazole
testosterone
tetrabenazine
tetracycline
Thalomid
theophylline, er
Thiola, EC
thioridazine
thiothixene
thyroid
tiadylt, er
tiagabine
Tibsovo
Tiglutik
tilia fe
timolol maleate
Timolol-Brimonidine-Dorzolamide
Tier Drug Name Notes
PAR
PAR
pg. 26 www.prescryptive.com
Notes: "PAR" - Prior Authorization Required
© 2020 PRESCRYPTIVE. ALL RIGHTS RESERVED. 2020.03
PAR
PAR
Notes
2
0
2
1
1
2
0
0
4
0
4
2
0
4
4
4
4
1
1
4
1
1
1
4
1
1
1
1
1
Triumeq
trivora
Trizivir
tropicamide
trospium, er
Trulicity
trumenba
Truvada
Tukysa
tulana
Turalio
Tybost
tydemy
Tykerb
Tymlos
Tyvaso
Udenyca
umecta
unithroid
Uptravi
urea
ursodiol
valacyclovir
Valchlor
valganciclovir
valproic acid
valsartan
valsartan-hydrochlorothiazide
vancomycin
Tier Drug Name
1
1
0
2
0
0
0
0
0
0
0
0
0
0
1
0
1
1
1
1
4
1
1
1
4
0
1
1
1
tretinoin
tretinoin microsphere
tri femynor
Tri-Chlor
tri-estarylla
tri-legest fe
tri-linyah
tri-lo-estarylla
tri-lo-marzia
tri-lo-mili
tri-lo-sprintec
tri-mili
tri-previfem
tri-sprintec
tri-vitamin/fluoride
tri-vylibra, lo
triamcinolone acetonide
triamterene
triamterene-hydrochlorothiazide
triazolam
trientine
trifluoperazine
trifluridine
trihexyphenidyl
Trikafta
trilyte
trimethobenzamide
trimethoprim
trimipramine maleate
Tier Drug Name Notes
PAR
PAR
PAR
PAR
PAR
PAR
PAR
PAR
pg. 27 www.prescryptive.com
Notes: "PAR" - Prior Authorization Required
© 2020 PRESCRYPTIVE. ALL RIGHTS RESERVED. 2020.03
PAR
PAR
PAR
PAR
PAR
PAR
PAR
PAR
PAR
PAR
PAR
Notes
0
0
4
4
2
1
2
0
0
4
4
2
4
4
4
4
2
4
4
4
4
0
2
4
4
1
1
0
4
vyfemla
vylibra
Vyndamax
Vyndaqel
Vyvanse
warfarin
Westhroid
wide-seal diaphragm
wymzya fe
Xadago
Xalkori
Xarelto
Xeljanz, XR
Xenleta
Xermelo
Xgeva
Xiidra
Xolair
Xospata
Xpovio
Xtandi
xulane
Xultophy
Xuriden
Xyrem
zafirlukast
zaleplon
zarah
Zarxio
Tier Drug Name
1
2
4
0
4
4
2
4
1
4
1
4
2
2
0
1
2
0
2
2
1
4
4
0
1
4
4
2
4
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
Tier Drug Name Notes
PAR
PAR
PAR
PAR
PAR
PAR
PAR
PAR
PAR
PAR
PAR
PAR
PAR
PAR
PAR
pg. 28 www.prescryptive.com© 2020 PRESCRYPTIVE. ALL RIGHTS RESERVED. 2020.03
Notes: "PAR" - Prior Authorization Required
PAR
PAR
PAR
PAR
PAR
PAR
PAR
PAR
PAR
NotesTier Drug Name
4
4
4
2
2
1
4
4
1
4
1
1
1
2
2
0
0
4
4
4
Zejula
Zelapar
Zelboraf
Zenpep
Ziagen
zidovudine
Ziextenzo
zileuton ER
ziprasidone
Zolinza
zolmitriptan
zolpidem, er
zonisamide
Zontivity
Zortress
zovia
zumandimine
Zydelig
Zykadia
Zytiga