UnitedHealthcare 3-tier Advantage Prescription Drug List

201 Pages·2015·1.89 MB·English

by  Theresa Woolhether

UnitedHealthcare 3-tier Advantage
Prescription Drug List
Effective: July 1, 2015

Please note: This Prescription Drug List (PDL) is accurate as of May 19, 2015 and is
subject to change after this date. Your estimated coverage and copay/co-insurance may
vary based on the benefit plan you choose and the effective date of the plan.

Health Care Reform Preventive Care
Some medications and supplements may be covered at $0 cost share when:
• Prescribed by a health care professional
• Age and/or gender appropriate
• Filled at a network pharmacy

Prior Authorization may be required to receive preventive care medications at $0 cost-share. Refer to the
Health Care Reform Preventive Care section at the end of this PDL for more information.

Updated May 19, 2015
Specialty
Label Name Generic Name Tier Value Notification Supply Limit Step Therapy
Medication
2-DEOXY-D POW -GLUCOSE 2-DEOXY-D-GLUCOSE POWDER Tier 3
8-MOP CAP 10MG METHOXSALEN CAP 10 MG Tier 2
ABACAV/LAMIV TAB /ZIDOVUD ABACAVIR SULFATE-LAMIVUDINE- Tier 1 X
ZIDOVUDINE TAB 300-150-300 MG
ABACAVIR TAB 300MG ABACAVIR SULFATE TAB 300 MG (BASE Tier 1 X
EQUIV)
ABILIFY SOL 1MG/ML ARIPIPRAZOLE ORAL SOLUTION 1 Tier 3
MG/ML
ACAMPRO CAL TAB 333MG ACAMPROSATE CALCIUM TAB DELAYED Tier 1
RELEASE 333 MG
ACARBOSE TAB 100MG ACARBOSE TAB 100 MG Tier 1
ACARBOSE TAB 25MG ACARBOSE TAB 25 MG Tier 1
ACARBOSE TAB 50MG ACARBOSE TAB 50 MG Tier 1
ACCOLATE TAB 10MG ZAFIRLUKAST TAB 10 MG Tier 3 X
ACCOLATE TAB 20MG ZAFIRLUKAST TAB 20 MG Tier 3 X
ACCU-CHEK KIT AVIVA PL *BLOOD GLUCOSE MONITORING KIT Tier 1
W/ DEVICE***
ACCU-CHEK KIT COMPACT *BLOOD GLUCOSE MONITORING Tier 1
KIT***
ACCU-CHEK KIT FASTCLIX *LANCETS KIT*** Tier 1
ACCU-CHEK KIT MLTICLIX *LANCETS KIT*** Tier 1
ACCU-CHEK KIT NANO *BLOOD GLUCOSE MONITORING KIT Tier 1
W/ DEVICE***
ACCU-CHEK KIT SOFTCLIX *LANCETS KIT*** Tier 1
ACCU-CHEK KIT VOICEMAT *BLOOD GLUCOSE MONITORING KIT Tier 1
W/ DEVICE***
ACCU-CHEK LIQ ACT/GLUC *BLOOD GLUCOSE CALIBRATION - Tier 1
LIQUID***
ACCU-CHEK LIQ COMPACT *BLOOD GLUCOSE CALIBRATION - Tier 1
LIQUID***
ACCU-CHEK LIQ SMART *BLOOD GLUCOSE CALIBRATION - Tier 1
LIQUID***
ACCU-CHEK MIS ADAPTER *INSULIN INFUSION PUMP - Tier 3
ACCESSORIES***
ACCU-CHEK MIS AVIVA *BLOOD GLUCOSE MONITORING Tier 3
DEVICES***
ACCU-CHEK MIS BATTERY *INSULIN INFUSION PUMP - Tier 3
ACCESSORIES***
ACCU-CHEK MIS MLTICLIX *LANCETS*** Tier 1 X
ACCU-CHEK SOL *BLOOD GLUCOSE CALIBRATION - Tier 1
LIQUID***
ACCU-CHEK SOL COMFORT *BLOOD GLUCOSE CALIBRATION - Tier 1
LIQUID***
ACCU-CHEK SOL COMPACT *BLOOD GLUCOSE CALIBRATION - Tier 1
LIQUID***
ACCU-CHEK TES ACTIVE GLUCOSE BLOOD TEST STRIP Tier 1 X
ACCU-CHEK TES AVIVA GLUCOSE BLOOD TEST STRIP Tier 1 X
ACCU-CHEK TES AVIVA PL GLUCOSE BLOOD TEST STRIP Tier 1 X
ACCU-CHEK TES COMFORT GLUCOSE BLOOD TEST STRIP Tier 1 X
ACCU-CHEK TES COMPACT GLUCOSE BLOOD TEST STRIP Tier 1 X
ACCU-CHEK TES DRUM GLUCOSE BLOOD TEST STRIP Tier 1 X
ACCU-CHEK TES SMART GLUCOSE BLOOD TEST STRIP Tier 1 X
ACCU-CHEK IN LIQ CONTROL *BLOOD GLUCOSE CALIBRATION - Tier 1
LIQUID***
ACCU-CK COMF TES CURVE GLUCOSE BLOOD TEST STRIP Tier 1 X
ACCUPRIL TAB 10MG QUINAPRIL HCL TAB 10 MG Tier 3
ACCUPRIL TAB 20MG QUINAPRIL HCL TAB 20 MG Tier 3
ACCUPRIL TAB 40MG QUINAPRIL HCL TAB 40 MG Tier 3
ACCUPRIL TAB 5MG QUINAPRIL HCL TAB 5 MG Tier 3
ACCURETIC TAB 10-12.5 QUINAPRIL-HYDROCHLOROTHIAZIDE Tier 3
TAB 10-12.5 MG
1This drug is part of your HCR preventive care benefit and may be available at no cost to you
Specialty
Label Name Generic Name Tier Value Notification Supply Limit Step Therapy
Medication
ACCURETIC TAB 20-12.5 QUINAPRIL-HYDROCHLOROTHIAZIDE Tier 3
TAB 20-12.5 MG
ACCURETIC TAB 20-25MG QUINAPRIL-HYDROCHLOROTHIAZIDE Tier 3
TAB 20-25 MG
ACCUTREND SOL GLUCOSE *BLOOD GLUCOSE CALIBRATION - Tier 1
LIQUID***
ACCUTREND TES GLUCOSE GLUCOSE BLOOD TEST STRIP Tier 1 X
ACD/FLUORIDE DRO 0.25MG *PEDIATRIC VITAMINS ACD W/ Tier 1
FLUORIDE SOLN 0.25 MG/ML***
ACE ACD/ALUM SOL 2% OTIC ACETIC ACID 2% IN ALUMINUM Tier 1
ACETATE OTIC SOLN
ACEBUTOLOL CAP 200MG ACEBUTOLOL HCL CAP 200 MG Tier 1
ACEBUTOLOL CAP 400MG ACEBUTOLOL HCL CAP 400 MG Tier 1
ACEON TAB 4MG PERINDOPRIL ERBUMINE TAB 4 MG Tier 3
ACEON TAB 8MG PERINDOPRIL ERBUMINE TAB 8 MG Tier 3
ACETASOL HC SOL OTIC HYDROCORTISONE W/ ACETIC ACID Tier 2
OTIC SOLN 1-2%
ACETAZOLAMID CAP 500MG ER ACETAZOLAMIDE CAP SR 12HR 500 MG Tier 1
ACETAZOLAMID TAB 125MG ACETAZOLAMIDE TAB 125 MG Tier 1
ACETAZOLAMID TAB 250MG ACETAZOLAMIDE TAB 250 MG Tier 1
ACETIC ACID SOL 2% OTIC ACETIC ACID OTIC SOLN 2% Tier 1
ACETYLCYST SOL 10% ACETYLCYSTEINE INHAL SOLN 10% Tier 1
ACETYLCYST SOL 20% ACETYLCYSTEINE INHAL SOLN 20% Tier 1
ACITRETIN CAP 10MG ACITRETIN CAP 10 MG Tier 1
ACITRETIN CAP 17.5MG ACITRETIN CAP 17.5 MG Tier 1
ACITRETIN CAP 25MG ACITRETIN CAP 25 MG Tier 1
ACLOVATE CRE 0.05% ALCLOMETASONE DIPROPIONATE Tier 3
CREAM 0.05%
ACTEMRA INJ 162/0.9 TOCILIZUMAB SUBCUTANEOUS SOLN Tier 3 X X X X
PREFILLED SYRINGE 162 MG/0.9ML
ACTICIN CRE 5% PERMETHRIN CREAM 5% Tier 1
ACTIGALL CAP 300MG URSODIOL CAP 300 MG Tier 3
ACTIMMUNE INJ 2MU/0.5 INTERFERON GAMMA-1B INJ 100 Tier 2 X X X
MCG/0.5ML (2000000 UNIT/0.5ML)
ACTIVE MEDIC KIT SPECIMEN *URINE SPECIMEN COLLECTION KIT** Tier 1
ACTIVE OB CAP *PRENATAL W/O A W/FE CBN-FA-DHA Tier 3
CAP 20-1-320 MG***
ACTIVELLA TAB 0.5-0.1 ESTRADIOL & NORETHINDRONE Tier 3
ACETATE TAB 0.5-0.1 MG
ACTIVELLA TAB 1-0.5MG ESTRADIOL & NORETHINDRONE Tier 3
ACETATE TAB 1-0.5 MG
ACTONEL TAB 150MG RISEDRONATE SODIUM TAB 150 MG Tier 3 X
ACTONEL TAB 30MG RISEDRONATE SODIUM TAB 30 MG Tier 3
ACTONEL TAB 35MG RISEDRONATE SODIUM TAB 35 MG Tier 3 X
ACTONEL TAB 5MG RISEDRONATE SODIUM TAB 5 MG Tier 3
ACTOPLUS MET TAB 15-500MG PIOGLITAZONE HCL-METFORMIN HCL Tier 3 X
TAB 15-500 MG
ACTOPLUS MET TAB 15-850MG PIOGLITAZONE HCL-METFORMIN HCL Tier 3 X
TAB 15-850 MG
ACTOPLUS MET TAB XR PIOGLITAZONE HCL-METFORMIN HCL Tier 3 X
TAB SR 24HR 30-1000 MG
ACTOPLUS MET TAB XR PIOGLITAZONE HCL-METFORMIN HCL Tier 3 X
TAB SR 24HR 15-1000 MG
ACULAR SOL 0.5% OP KETOROLAC TROMETHAMINE OPHTH Tier 3
SOLN 0.5%
ACULAR LS SOL 0.4% KETOROLAC TROMETHAMINE OPHTH Tier 3
SOLN 0.4%
ACUNOL TAB 600MG *HOMEOPATHIC PRODUCTS - TAB** Tier 3
ACYCLOVIR CAP 200MG ACYCLOVIR CAP 200 MG Tier 1
1This drug is part of your HCR preventive care benefit and may be available at no cost to you
Specialty
Label Name Generic Name Tier Value Notification Supply Limit Step Therapy
Medication
ACYCLOVIR OIN 5% ACYCLOVIR OINT 5% Tier 3 X X X
ACYCLOVIR SUS 200/5ML ACYCLOVIR SUSP 200 MG/5ML Tier 1
ACYCLOVIR TAB 400MG ACYCLOVIR TAB 400 MG Tier 1
ACYCLOVIR TAB 800MG ACYCLOVIR TAB 800 MG Tier 1
ACZONE GEL 5% DAPSONE GEL 5% Tier 3 X
ADALAT CC TAB 30MG ER NIFEDIPINE TAB SR 24HR 30 MG Tier 3
ADALAT CC TAB 60MG ER NIFEDIPINE TAB SR 24HR 60 MG Tier 3
ADALAT CC TAB 90MG ER NIFEDIPINE TAB SR 24HR 90 MG Tier 3
ADAPALENE CRE 0.1% ADAPALENE CREAM 0.1% Tier 3 X
ADAPALENE GEL 0.1% ADAPALENE GEL 0.1% Tier 3 X
ADAPALENE GEL 0.3% ADAPALENE GEL 0.3% Tier 3 X X
ADAPALENE LOT 0.1% ADAPALENE LOTION 0.1% Tier 3 X X
ADASUVE INH 10MG LOXAPINE AEROSOL POWDER BREATH Tier 3
ACTIVATED 10 MG
ADCIRCA TAB 20MG TADALAFIL TAB 20 MG (PAH) Tier 3 X X X
ADDERALL XR CAP 10MG AMPHETAMINE- Tier 2 X
DEXTROAMPHETAMINE CAP SR 24HR
10 MG
ADDERALL XR CAP 15MG AMPHETAMINE- Tier 2 X
DEXTROAMPHETAMINE CAP SR 24HR
15 MG
ADDERALL XR CAP 20MG AMPHETAMINE- Tier 2 X
DEXTROAMPHETAMINE CAP SR 24HR
20 MG
ADDERALL XR CAP 25MG AMPHETAMINE- Tier 2 X
DEXTROAMPHETAMINE CAP SR 24HR
25 MG
ADDERALL XR CAP 30MG AMPHETAMINE- Tier 2 X
DEXTROAMPHETAMINE CAP SR 24HR
30 MG
ADDERALL XR CAP 5MG AMPHETAMINE- Tier 2 X
DEXTROAMPHETAMINE CAP SR 24HR 5
MG
ADEFOV DIPIV TAB 10MG ADEFOVIR DIPIVOXIL TAB 10 MG Tier 1 X
ADEMPAS TAB 0.5MG RIOCIGUAT TAB 0.5 MG Tier 2 X X X
ADEMPAS TAB 1.5MG RIOCIGUAT TAB 1.5 MG Tier 2 X X X
ADEMPAS TAB 1MG RIOCIGUAT TAB 1 MG Tier 2 X X X
ADEMPAS TAB 2.5MG RIOCIGUAT TAB 2.5 MG Tier 2 X X X
ADEMPAS TAB 2MG RIOCIGUAT TAB 2 MG Tier 2 X X X
ADLT ASA LOW TAB 81MG EC ASPIRIN TAB DELAYED RELEASE 81 MG HCR Preventive Care1
ADRENALIN INJ 1MG/ML EPINEPHRINE INJ 1 MG/ML (1:1000) Tier 3
ADRENALIN SOL 1:1000 EPINEPHRINE HCL NASAL SOLN 0.1% Tier 2
ADV LANCING MIS DEVICE *LANCET DEVICES*** Tier 3
ADVAIR DISKU AER 100/50 FLUTICASONE-SALMETEROL AER Tier 3 X
POWDER BA 100-50 MCG/DOSE
ADVAIR DISKU AER 250/50 FLUTICASONE-SALMETEROL AER Tier 3 X
POWDER BA 250-50 MCG/DOSE
ADVAIR DISKU AER 500/50 FLUTICASONE-SALMETEROL AER Tier 3 X
POWDER BA 500-50 MCG/DOSE
ADVAIR HFA AER 115/21 FLUTICASONE-SALMETEROL INHAL Tier 3 X
AEROSOL 115-21 MCG/ACT
ADVAIR HFA AER 230/21 FLUTICASONE-SALMETEROL INHAL Tier 3 X
AEROSOL 230-21 MCG/ACT
ADVAIR HFA AER 45/21 FLUTICASONE-SALMETEROL INHAL Tier 3 X
AEROSOL 45-21 MCG/ACT
ADVANCED DNA KIT COLLECTI *DNA COLLECTION PRODUCT KIT** Tier 1
ADVATE INJ 1000UNIT ANTIHEMOPHILIC FACTOR RAHF-PFM Tier 2 X
FOR INJ 1000 UNIT
ADVATE INJ 1500UNIT ANTIHEMOPHILIC FACTOR RAHF-PFM Tier 2 X
FOR INJ 1500 UNIT
ADVATE INJ 2000UNIT ANTIHEMOPHILIC FACTOR RAHF-PFM Tier 2 X
FOR INJ 2000 UNIT
1This drug is part of your HCR preventive care benefit and may be available at no cost to you
Specialty
Label Name Generic Name Tier Value Notification Supply Limit Step Therapy
Medication
ADVATE INJ 250UNIT ANTIHEMOPHILIC FACTOR RAHF-PFM Tier 2 X
FOR INJ 250 UNIT
ADVATE INJ 3000UNIT ANTIHEMOPHILIC FACTOR RAHF-PFM Tier 2 X
FOR INJ 3000 UNIT
ADVATE INJ 4000UNIT ANTIHEMOPHILIC FACTOR RAHF-PFM Tier 2 X
FOR INJ 4000 UNIT
ADVATE INJ 500UNIT ANTIHEMOPHILIC FACTOR RAHF-PFM Tier 2 X
FOR INJ 500 UNIT
ADVICOR TAB 1000-20 NIACIN-LOVASTATIN TAB SR 24HR 1000- Tier 3 X
20 MG
ADVICOR TAB 1000-40 NIACIN-LOVASTATIN TAB SR 24HR 1000- Tier 3 X
40 MG
ADVICOR TAB 500-20MG NIACIN-LOVASTATIN TAB SR 24HR 500- Tier 3 X
20 MG
ADVICOR TAB 750-20MG NIACIN-LOVASTATIN TAB SR 24HR 750- Tier 3 X
20 MG
AERCHMBR PLS MIS FLOW-VU *SPACER/AEROSOL-HOLDING Tier 3
CHAMBERS - DEVICE***
AERCHMBR PLS MIS LRG MASK *SPACER/AEROSOL-HOLDING Tier 3
CHAMBERS - DEVICE***
AERCHMBR PLS MIS SM MASK *SPACER/AEROSOL-HOLDING Tier 3
CHAMBERS - DEVICE***
AERO OTIC HC SOL PRAMOXINE-HC-CHLOROXYLENOL OTIC Tier 1
SOLN 10-10-1 MG/ML
AEROCHAMBER MIS PLUS *SPACER/AEROSOL-HOLDING Tier 3
CHAMBERS - DEVICE***
AEROSPAN AER 80MCG FLUNISOLIDE HFA INHAL AEROSOL 80 Tier 3 X
MCG/ACT
AFEDITAB TAB 30MG CR NIFEDIPINE TAB SR 24HR 30 MG Tier 1
AFEDITAB TAB 60MG CR NIFEDIPINE TAB SR 24HR 60 MG Tier 1
AFINITOR TAB 10MG EVEROLIMUS TAB 10 MG Tier 2 X X X
AFINITOR TAB 2.5MG EVEROLIMUS TAB 2.5 MG Tier 2 X X X
AFINITOR TAB 5MG EVEROLIMUS TAB 5 MG Tier 2 X X X
AFINITOR TAB 7.5MG EVEROLIMUS TAB 7.5 MG Tier 2 X X X
AFINITOR DIS TAB 2MG EVEROLIMUS TAB FOR ORAL SUSP 2 Tier 2 X X X
MG
AFINITOR DIS TAB 3MG EVEROLIMUS TAB FOR ORAL SUSP 3 Tier 2 X X X
MG
AFINITOR DIS TAB 5MG EVEROLIMUS TAB FOR ORAL SUSP 5 Tier 2 X X X
MG
AFTERA TAB 1.5MG LEVONORGESTREL TAB 1.5 MG HCR Preventive Care1
AGGRENOX CAP 25-200MG ASPIRIN-DIPYRIDAMOLE CAP SR 12HR Tier 3
25-200 MG
AGRYLIN CAP 0.5MG ANAGRELIDE HCL CAP 0.5 MG Tier 3
AKNE-MYCIN OIN 2% ERYTHROMYCIN OINT 2% Tier 2
AK-POLY-BAC OIN OP BACITRACIN-POLYMYXIN B OPHTH Tier 1
OINT
AKTEN GEL 3.5% LIDOCAINE HCL OPHTH GEL 3.5% Tier 3
AKYNZEO CAP NETUPITANT-PALONOSETRON CAP 300- Tier 3 X
0.5 MG
ALA QUIN CRE 3-0.5% CLIOQUINOL-HC CREAM 3-0.5% Tier 1
ALA SCALP LOT 2% HYDROCORTISONE LOTION 2% Tier 3
ALAGESIC LQ SOL BUTALBITAL-ACETAMINOPHEN- Tier 1 X
CAFFEINE SOLN 50-325-40 MG/15ML
ALBATUSSIN CAP PHENYLEPHRINE-CARBETAPENTANE- Tier 3
GG CAP 10-25-400 MG
ALBATUSSIN LIQ NN *PHENYLEPH-DM-PYRIL-POT GUAI-SOD Tier 2
CIT-CIT ACID LIQUID***
ALBENZA TAB 200MG ALBENDAZOLE TAB 200 MG Tier 2
ALBUTEROL NEB 0.083% ALBUTEROL SULFATE SOLN NEBU Tier 1
0.083% (2.5 MG/3ML)
ALBUTEROL NEB 0.5% ALBUTEROL SULFATE SOLN NEBU 0.5% Tier 1
(5 MG/ML)
1This drug is part of your HCR preventive care benefit and may be available at no cost to you
Specialty
Label Name Generic Name Tier Value Notification Supply Limit Step Therapy
Medication
ALBUTEROL NEB 0.63MG/3 ALBUTEROL SULFATE SOLN NEBU 0.63 Tier 1
MG/3ML (BASE EQUIV)
ALBUTEROL NEB 1.25MG/3 ALBUTEROL SULFATE SOLN NEBU 1.25 Tier 1
MG/3ML (BASE EQUIV)
ALBUTEROL SYP 2MG/5ML ALBUTEROL SULFATE SYRUP 2 MG/5ML Tier 1
ALBUTEROL TAB 2MG ALBUTEROL SULFATE TAB 2 MG Tier 1
ALBUTEROL TAB 4MG ALBUTEROL SULFATE TAB 4 MG Tier 1
ALBUTEROL TAB 4MG ER ALBUTEROL SULFATE TAB SR 12HR 4 Tier 1
MG
ALBUTEROL TAB 8MG ER ALBUTEROL SULFATE TAB SR 12HR 8 Tier 1
MG
ALCAINE SOL 0.5% OP PROPARACAINE HCL OPHTH SOLN 0.5% Tier 3
ALCLOMETASON CRE 0.05% ALCLOMETASONE DIPROPIONATE Tier 1
CREAM 0.05%
ALCLOMETASON OIN 0.05% ALCLOMETASONE DIPROPIONATE OINT Tier 1
0.05%
ALCOH-GLOVE PAD CONTOURE *ALCOHOL SWABS*** Tier 3
ALCOHOL PREP PAD *ALCOHOL SWABS*** Tier 3
ALCOHOL PREP PAD 70% *ALCOHOL SWABS*** Tier 1
ALCOHOL PREP PAD MED 70% *ALCOHOL SWABS*** Tier 3
ALCOHOL SWAB PAD *ALCOHOL SWABS*** Tier 3
ALCOH-WIPE PAD 12"X12" *ALCOHOL SWABS*** Tier 3
ALCORTIN A GEL *IODOQUINOL-HYDROCORTISONE- Tier 3
ALOE POLYSACCHARIDE GEL 1-2-1%***
ALDACTAZIDE TAB 25/25 SPIRONOLACTONE & Tier 3
HYDROCHLOROTHIAZIDE TAB 25-25
MG
ALDACTAZIDE TAB 50/50 SPIRONOLACTONE & Tier 2
HYDROCHLOROTHIAZIDE TAB 50-50
MG
ALDACTONE TAB 100MG SPIRONOLACTONE TAB 100 MG Tier 3
ALDACTONE TAB 25MG SPIRONOLACTONE TAB 25 MG Tier 3
ALDACTONE TAB 50MG SPIRONOLACTONE TAB 50 MG Tier 3
ALDARA CRE 5% IMIQUIMOD CREAM 5% Tier 3 X
ALENDRONATE SOL 70/75ML ALENDRONATE SODIUM ORAL SOLN 70 Tier 1
MG/75ML
ALENDRONATE TAB 10MG ALENDRONATE SODIUM TAB 10 MG Tier 1 X
ALENDRONATE TAB 35MG ALENDRONATE SODIUM TAB 35 MG Tier 1 X
ALENDRONATE TAB 40MG ALENDRONATE SODIUM TAB 40 MG Tier 1 X
ALENDRONATE TAB 5MG ALENDRONATE SODIUM TAB 5 MG Tier 1 X
ALENDRONATE TAB 70MG ALENDRONATE SODIUM TAB 70 MG Tier 1 X
ALEVICIN CRE *HOMEOPATHIC PRODUCTS - Tier 3
CREAM**
ALFERON N INJ 5MU/ML INTERFERON ALFA-N3 INJ 5000000 Tier 2 X
UNIT/ML
ALFUZOSIN TAB 10MG ALFUZOSIN HCL TAB SR 24HR 10 MG Tier 1
ALI-FLEX TAB 50-500MG PHENYLTOLOXAMINE- Tier 1
ACETAMINOPHEN TAB 50-500 MG
ALINIA SUS 100/5ML NITAZOXANIDE FOR SUSP 100 MG/5ML Tier 2 X
ALINIA TAB 500MG NITAZOXANIDE TAB 500 MG Tier 2 X
ALKERAN TAB 2MG MELPHALAN TAB 2 MG Tier 2 X
ALLOPURINOL TAB 100MG ALLOPURINOL TAB 100 MG Tier 1
ALLOPURINOL TAB 300MG ALLOPURINOL TAB 300 MG Tier 1
ALOCRIL SOL 2% NEDOCROMIL SODIUM OPHTH SOLN Tier 3
2%
ALODOX KIT 20MG *DOXYCYCLINE HYCLATE TAB 20 MG Tier 3
W/ EYELID CLEANSERS KIT*
ALOMIDE SOL 0.1% OP LODOXAMIDE TROMETHAMINE OPHTH Tier 3
SOLN 0.1%
1This drug is part of your HCR preventive care benefit and may be available at no cost to you
Specialty
Label Name Generic Name Tier Value Notification Supply Limit Step Therapy
Medication
ALOQUIN GEL 1.25-1% *IODOQUINOL-ALOE Tier 3
POLYSACCHARIDES GEL 1.25-1%***
ALORA DIS 0.025MG ESTRADIOL TD PATCH BIWEEKLY 0.025 Tier 3 X
MG/24HR
ALORA DIS 0.05MG ESTRADIOL TD PATCH TWICE WEEKLY Tier 3 X
0.05 MG/24HR
ALORA DIS 0.05MG ESTRADIOL TD PATCH BIWEEKLY 0.05 Tier 3 X
MG/24HR
ALORA DIS 0.075MG ESTRADIOL TD PATCH TWICE WEEKLY Tier 3 X
0.075 MG/24HR
ALORA DIS 0.075MG ESTRADIOL TD PATCH BIWEEKLY 0.075 Tier 3 X
MG/24HR
ALORA DIS 0.1MG ESTRADIOL TD PATCH TWICE WEEKLY Tier 3 X
0.1 MG/24HR
ALORA DIS 0.1MG ESTRADIOL TD PATCH BIWEEKLY 0.1 Tier 3 X
MG/24HR
ALPAIN TAB PHENYLTOLOXAMINE- Tier 1
ACETAMINOPHEN TAB 60-500 MG
ALPHAGAN P SOL 0.1% BRIMONIDINE TARTRATE OPHTH SOLN Tier 2 X
0.1%
ALPHAGAN P SOL 0.15% BRIMONIDINE TARTRATE OPHTH SOLN Tier 3 X
0.15%
ALPHANATE INJ VWF/HUM ANTIHEMOPHILIC FACTOR/VWF Tier 2 X
(HUMAN) FOR INJ 250 UNIT
ALPHANATE INJ VWF/HUM ANTIHEMOPHILIC FACTOR/VWF Tier 2 X
(HUMAN) FOR INJ 500 UNIT
ALPHANATE INJ VWF/HUM ANTIHEMOPHILIC FACTOR/VWF Tier 2 X
(HUMAN) FOR INJ 1000 UNIT
ALPHANATE INJ VWF/HUM ANTIHEMOPHILIC FACTOR/VWF Tier 2 X
(HUMAN) FOR INJ 1500 UNIT
ALPHANATE INJ VWF/HUM ANTIHEMOPHILIC FACTOR/VWF Tier 2 X
(HUMAN) FOR INJ 2000 UNIT
ALPHANINE SD INJ 1000UNIT COAGULATION FACTOR IX FOR INJ Tier 2 X
1000 UNIT
ALPHANINE SD INJ 1500UNIT COAGULATION FACTOR IX FOR INJ Tier 2 X
1500 UNIT
ALPHANINE SD INJ 500UNIT COAGULATION FACTOR IX FOR INJ 500 Tier 2 X
UNIT
ALPHATREX GEL 0.05% BETAMETHASONE DIPROPIONATE Tier 1
AUGMENTED GEL 0.05%
ALPRAZOLAM CON 1 MG/ML ALPRAZOLAM CONC 1 MG/ML Tier 1
ALPRAZOLAM TAB 0.25 ODT ALPRAZOLAM ORALLY Tier 1
DISINTEGRATING TAB 0.25 MG
ALPRAZOLAM TAB 0.25MG ALPRAZOLAM TAB 0.25 MG Tier 1
ALPRAZOLAM TAB 0.5MG ALPRAZOLAM TAB 0.5 MG Tier 1
ALPRAZOLAM TAB 0.5MG ER ALPRAZOLAM TAB SR 24HR 0.5 MG Tier 1
ALPRAZOLAM TAB 0.5MG OD ALPRAZOLAM ORALLY Tier 1
DISINTEGRATING TAB 0.5 MG
ALPRAZOLAM TAB 0.5MG XR ALPRAZOLAM TAB SR 24HR 0.5 MG Tier 1
ALPRAZOLAM TAB 1MG ALPRAZOLAM TAB 1 MG Tier 1
ALPRAZOLAM TAB 1MG ER ALPRAZOLAM TAB SR 24HR 1 MG Tier 1
ALPRAZOLAM TAB 1MG ODT ALPRAZOLAM ORALLY Tier 1
DISINTEGRATING TAB 1 MG
ALPRAZOLAM TAB 1MG XR ALPRAZOLAM TAB SR 24HR 1 MG Tier 1
ALPRAZOLAM TAB 2MG ALPRAZOLAM TAB 2 MG Tier 1
ALPRAZOLAM TAB 2MG ER ALPRAZOLAM TAB SR 24HR 2 MG Tier 1
ALPRAZOLAM TAB 2MG ODT ALPRAZOLAM ORALLY Tier 1
DISINTEGRATING TAB 2 MG
ALPRAZOLAM TAB 2MG XR ALPRAZOLAM TAB SR 24HR 2 MG Tier 1
ALPRAZOLAM TAB 3MG ER ALPRAZOLAM TAB SR 24HR 3 MG Tier 1
ALPRAZOLAM TAB 3MG XR ALPRAZOLAM TAB SR 24HR 3 MG Tier 1
ALPROLIX INJ 1000UNIT COAGULATION FACTOR IX (RECOMB) Tier 3 X
(RFIXFC) FOR INJ 1000 UNIT
1This drug is part of your HCR preventive care benefit and may be available at no cost to you
Specialty
Label Name Generic Name Tier Value Notification Supply Limit Step Therapy
Medication
ALPROLIX INJ 2000UNIT COAGULATION FACTOR IX (RECOMB) Tier 3 X
(RFIXFC) FOR INJ 2000 UNIT
ALPROLIX INJ 3000UNIT COAGULATION FACTOR IX (RECOMB) Tier 3 X
(RFIXFC) FOR INJ 3000 UNIT
ALPROLIX INJ 500UNIT COAGULATION FACTOR IX (RECOMB) Tier 3 X
(RFIXFC) FOR INJ 500 UNIT
ALREX SUS 0.2% LOTEPREDNOL ETABONATE OPHTH Tier 3 X
SUSP 0.2%
ALTABAX OIN 1% RETAPAMULIN OINT 1% Tier 3 X
ALTACAINE SOL 0.5% OP TETRACAINE HCL OPHTH SOLN 0.5% Tier 1
ALTACE CAP 1.25MG RAMIPRIL CAP 1.25 MG Tier 3
ALTACE CAP 10MG RAMIPRIL CAP 10 MG Tier 3
ALTACE CAP 2.5MG RAMIPRIL CAP 2.5 MG Tier 3
ALTACE CAP 5MG RAMIPRIL CAP 5 MG Tier 3
ALTAFLUOR SOL 0.25-0.4 FLUORESCEIN W/ BENOXINATE OPHTH Tier 1
SOLN 0.25-0.4%
ALTAFRIN SOL 10% OP PHENYLEPHRINE HCL OPHTH SOLN 10% Tier 1
ALTAFRIN SOL 2.5% OP PHENYLEPHRINE HCL OPHTH SOLN Tier 1
2.5%
ALTAVERA TAB LEVONORGESTREL & ETHINYL HCR Preventive Care1
ESTRADIOL TAB 0.15 MG-30 MCG
ALUVEA CRE 39% UREA CREAM 39% Tier 3
ALVESCO AER 160MCG CICLESONIDE INHAL AEROSOL 160 Tier 1 X
MCG/ACT
ALVESCO AER 80MCG CICLESONIDE INHAL AEROSOL 80 Tier 1 X
MCG/ACT
ALYACEN TAB 1/35 NORETHINDRONE & ETHINYL HCR Preventive Care1
ESTRADIOL TAB 1 MG-35 MCG
ALYACEN TAB 7/7/7 NORETHINDRONE-ETH ESTRADIOL TAB Tier 3
0.5-35/0.75-35/1-35 MG-MCG
AMANTADINE CAP 100MG AMANTADINE HCL CAP 100 MG Tier 1
AMANTADINE SYP 50MG/5ML AMANTADINE HCL SYRUP 50 MG/5ML Tier 1
AMANTADINE TAB 100MG AMANTADINE HCL TAB 100 MG Tier 1
AMARYL TAB 1MG GLIMEPIRIDE TAB 1 MG Tier 3
AMARYL TAB 2MG GLIMEPIRIDE TAB 2 MG Tier 3
AMARYL TAB 4MG GLIMEPIRIDE TAB 4 MG Tier 3
AMBITUSSIN SOL AC GUAIFENESIN-CODEINE SOLN 100-10 Tier 1
MG/5ML
AMCINONIDE CRE 0.1% AMCINONIDE CREAM 0.1% Tier 3
AMCINONIDE LOT 0.1% AMCINONIDE LOTION 0.1% Tier 3
AMCINONIDE OIN 0.1% AMCINONIDE OINT 0.1% Tier 1
AMERGE TAB 1MG NARATRIPTAN HCL TAB 1 MG (BASE Tier 3 X
EQUIV)
AMERGE TAB 2.5MG NARATRIPTAN HCL TAB 2.5 MG (BASE Tier 3 X
EQUIV)
AMETHIA TAB LEVONORG-ETH EST TAB 0.15- Tier 3 X
0.03MG(84) & ETH EST TAB 0.01MG(7)
AMETHIA LO TAB LEVONORG-ETH EST TAB 0.1- Tier 3 X
0.02MG(84) & ETH EST TAB 0.01MG(7)
AMETHYST TAB 90-20MCG LEVONORGESTREL-ETHINYL ESTRADIOL Tier 3
(CONTINUOUS) TAB 90-20 MCG
AMICAR SYP 25% AMINOCAPROIC ACID SYRUP 25% Tier 3
AMICAR TAB 1000MG AMINOCAPROIC ACID TAB 1000 MG Tier 3
AMICAR TAB 500MG AMINOCAPROIC ACID TAB 500 MG Tier 3
1This drug is part of your HCR preventive care benefit and may be available at no cost to you
Specialty
Label Name Generic Name Tier Value Notification Supply Limit Step Therapy
Medication
AMILOR/HCTZ TAB 5-50 AMILORIDE & HYDROCHLOROTHIAZIDE Tier 1
TAB 5-50 MG
AMILORIDE TAB 5MG AMILORIDE HCL TAB 5 MG Tier 1
AMINOBEZ POT POW POTASSIUM AMINOBENZOATE PACKET Tier 1
2 GM
AMINOCAPR AC SYP 25% AMINOCAPROIC ACID SYRUP 25% Tier 1
AMINOCAPR AC TAB 1000MG AMINOCAPROIC ACID TAB 1000 MG Tier 1
AMINOCAPR AC TAB 500MG AMINOCAPROIC ACID TAB 500 MG Tier 1
AMIODARONE TAB 100MG AMIODARONE HCL TAB 100 MG Tier 1
AMIODARONE TAB 200MG AMIODARONE HCL TAB 200 MG Tier 1
AMIODARONE TAB 400MG AMIODARONE HCL TAB 400 MG Tier 1
AMITIZA CAP 24MCG LUBIPROSTONE CAP 24 MCG Tier 3 X X X
AMITIZA CAP 8MCG LUBIPROSTONE CAP 8 MCG Tier 3 X X X
AMITRIPTYLIN TAB 100MG AMITRIPTYLINE HCL TAB 100 MG Tier 1
AMITRIPTYLIN TAB 10MG AMITRIPTYLINE HCL TAB 10 MG Tier 1
AMITRIPTYLIN TAB 150MG AMITRIPTYLINE HCL TAB 150 MG Tier 1
AMITRIPTYLIN TAB 25MG AMITRIPTYLINE HCL TAB 25 MG Tier 1
AMITRIPTYLIN TAB 50MG AMITRIPTYLINE HCL TAB 50 MG Tier 1
AMITRIPTYLIN TAB 75MG AMITRIPTYLINE HCL TAB 75 MG Tier 1
AMLOD/BENAZP CAP 10-20MG AMLODIPINE BESYLATE-BENAZEPRIL Tier 2 X
HCL CAP 10-20 MG
AMLOD/BENAZP CAP 10-40MG AMLODIPINE BESYLATE-BENAZEPRIL Tier 2 X
HCL CAP 10-40 MG
AMLOD/BENAZP CAP 2.5-10MG AMLODIPINE BESYLATE-BENAZEPRIL Tier 2 X
HCL CAP 2.5-10 MG
AMLOD/BENAZP CAP 5-10MG AMLODIPINE BESYLATE-BENAZEPRIL Tier 2 X
HCL CAP 5-10 MG
AMLOD/BENAZP CAP 5-20MG AMLODIPINE BESYLATE-BENAZEPRIL Tier 2 X
HCL CAP 5-20 MG
AMLOD/BENAZP CAP 5-40MG AMLODIPINE BESYLATE-BENAZEPRIL Tier 2 X
HCL CAP 5-40 MG
AMLODIPINE TAB 10MG AMLODIPINE BESYLATE TAB 10 MG Tier 1
AMLODIPINE TAB 2.5MG AMLODIPINE BESYLATE TAB 2.5 MG Tier 1
AMLODIPINE TAB 5MG AMLODIPINE BESYLATE TAB 5 MG Tier 1
AMNESTEEM CAP 10MG ISOTRETINOIN CAP 10 MG Tier 2 X
AMNESTEEM CAP 20MG ISOTRETINOIN CAP 20 MG Tier 2 X
AMNESTEEM CAP 40MG ISOTRETINOIN CAP 40 MG Tier 2 X
AMOX/K CLAV CHW 200MG AMOXICILLIN & K CLAVULANATE CHEW Tier 1
TAB 200-28.5 MG
AMOX/K CLAV CHW 400MG AMOXICILLIN & K CLAVULANATE CHEW Tier 1
TAB 400-57 MG
AMOX/K CLAV SUS 200/5ML AMOXICILLIN & K CLAVULANATE FOR Tier 1
SUSP 200-28.5 MG/5ML
AMOX/K CLAV SUS 250/5ML AMOXICILLIN & K CLAVULANATE FOR Tier 1
SUSP 250-62.5 MG/5ML
AMOX/K CLAV SUS 400/5ML AMOXICILLIN & K CLAVULANATE FOR Tier 1
SUSP 400-57 MG/5ML
AMOX/K CLAV SUS 600/5ML AMOXICILLIN & K CLAVULANATE FOR Tier 1
SUSP 600-42.9 MG/5ML
AMOX/K CLAV TAB 250MG AMOXICILLIN & K CLAVULANATE TAB Tier 1
250-125 MG
AMOX/K CLAV TAB 500MG AMOXICILLIN & K CLAVULANATE TAB Tier 1
500-125 MG
AMOX/K CLAV TAB 875MG AMOXICILLIN & K CLAVULANATE TAB Tier 1
875-125 MG
AMOXAPINE TAB 100MG AMOXAPINE TAB 100 MG Tier 1
AMOXAPINE TAB 150MG AMOXAPINE TAB 150 MG Tier 1
AMOXAPINE TAB 25MG AMOXAPINE TAB 25 MG Tier 1
AMOXAPINE TAB 50MG AMOXAPINE TAB 50 MG Tier 1
AMOXICILLIN CAP 250MG AMOXICILLIN (TRIHYDRATE) CAP 250 Tier 1
MG
1This drug is part of your HCR preventive care benefit and may be available at no cost to you
Specialty
Label Name Generic Name Tier Value Notification Supply Limit Step Therapy
Medication
AMOXICILLIN CAP 500MG AMOXICILLIN (TRIHYDRATE) CAP 500 Tier 1
MG
AMOXICILLIN CHW 125MG AMOXICILLIN (TRIHYDRATE) CHEW TAB Tier 1
125 MG
AMOXICILLIN CHW 250MG AMOXICILLIN (TRIHYDRATE) CHEW TAB Tier 1
250 MG
AMOXICILLIN SUS 125/5ML AMOXICILLIN (TRIHYDRATE) FOR SUSP Tier 1
125 MG/5ML
AMOXICILLIN SUS 200/5ML AMOXICILLIN (TRIHYDRATE) FOR SUSP Tier 1
200 MG/5ML
AMOXICILLIN SUS 250/5ML AMOXICILLIN (TRIHYDRATE) FOR SUSP Tier 1
250 MG/5ML
AMOXICILLIN SUS 400/5ML AMOXICILLIN (TRIHYDRATE) FOR SUSP Tier 1
400 MG/5ML
AMOXICILLIN TAB 500MG AMOXICILLIN (TRIHYDRATE) TAB 500 Tier 1
MG
AMOXICILLIN TAB 775MG AMOXICILLIN (TRIHYDRATE) TAB SR Tier 1
24HR 775 MG
AMOXICILLIN TAB 875MG AMOXICILLIN (TRIHYDRATE) TAB 875 Tier 1
MG
AMPHETAMINE TAB 10MG AMPHETAMINE- Tier 1 X
DEXTROAMPHETAMINE TAB 10 MG
AMPHETAMINE TAB 12.5MG AMPHETAMINE- Tier 1 X
DEXTROAMPHETAMINE TAB 12.5 MG
AMPHETAMINE TAB 15MG AMPHETAMINE- Tier 1 X
DEXTROAMPHETAMINE TAB 15 MG
AMPHETAMINE TAB 20MG AMPHETAMINE- Tier 1 X
DEXTROAMPHETAMINE TAB 20 MG
AMPHETAMINE TAB 30MG AMPHETAMINE- Tier 1 X
DEXTROAMPHETAMINE TAB 30 MG
AMPHETAMINE TAB 5MG AMPHETAMINE- Tier 1 X
DEXTROAMPHETAMINE TAB 5 MG
AMPHETAMINE TAB 7.5MG AMPHETAMINE- Tier 1 X
DEXTROAMPHETAMINE TAB 7.5 MG
AMPICILLIN CAP 250MG AMPICILLIN CAP 250 MG Tier 1
AMPICILLIN CAP 500MG AMPICILLIN CAP 500 MG Tier 1
AMPICILLIN SUS 125/5ML AMPICILLIN FOR SUSP 125 MG/5ML Tier 1
AMPICILLIN SUS 250/5ML AMPICILLIN FOR SUSP 250 MG/5ML Tier 1
AMPYRA TAB 10MG DALFAMPRIDINE TAB SR 12HR 10 MG Tier 2 X X X
ANACAINE OIN BENZOCAINE OINT 10% Tier 2
ANADROL-50 TAB 50MG OXYMETHOLONE TAB 50 MG Tier 3
ANAFRANIL CAP 25MG CLOMIPRAMINE HCL CAP 25 MG Tier 3
ANAFRANIL CAP 50MG CLOMIPRAMINE HCL CAP 50 MG Tier 3
ANAFRANIL CAP 75MG CLOMIPRAMINE HCL CAP 75 MG Tier 3
ANAGRELIDE CAP 0.5MG ANAGRELIDE HCL CAP 0.5 MG Tier 1
ANAGRELIDE CAP 1MG ANAGRELIDE HCL CAP 1 MG Tier 1
ANA-LEX KIT LIDOCAINE-HYDROCORTISONE Tier 1
ACETATE RECTAL CREAM KIT 2-2%
ANALPRAM E KIT *HC-PRAMOXINE EMOL CREAM 2.5-1% Tier 3 X
& PRAMOXINE WIPE 1% KIT***
ANALPRAM-HC CRE 1-1% HYDROCORTISONE ACETATE W/ Tier 3
PRAMOXINE RECTAL CREAM 1-1%
ANALPRAM-HC CRE 1-2.5% HYDROCORTISONE ACETATE W/ Tier 3
PRAMOXINE RECTAL CREAM 2.5-1%
ANALPRAM-HC CRE SINGLES HYDROCORTISONE ACETATE W/ Tier 3
PRAMOXINE RECTAL CREAM 1-1%
ANALPRAM-HC CRE SINGLES HYDROCORTISONE ACETATE W/ Tier 3
PRAMOXINE RECTAL CREAM 2.5-1%
ANALPRAM-HC LOT 2.5% HYDROCORTISONE ACETATE W/ Tier 3
PRAMOXINE RECTAL LOTN 2.5-1%
ANAPROX TAB 275MG NAPROXEN SODIUM TAB 275 MG Tier 3
ANAPROX DS TAB 550MG NAPROXEN SODIUM TAB 550 MG Tier 3
ANASPAZ TAB 0.125MG HYOSCYAMINE SULFATE TAB DISP Tier 2
0.125 MG
1This drug is part of your HCR preventive care benefit and may be available at no cost to you