Brand Drug Additions

Brand Name Strength Common Use Clinical Edits Prescription Drug List Tier
Standard Formulary Value Formulary Performance Formulary Advantage Formulary Legacy Formulary
ANNOVERA 0.15-0.013MG CONTRACEPTIVE   3 3 3 3 3
BAQSIMI 3 MG DIABETES QL 3 3 3 3 3
CORLANOR 5 MG/5 ML HEART FAILURE PA 2 2 2 2 2
DRIZALMA SPRINKLE 20, 30, 40, 60 MG DEPRESSION QL, ST NC NC NC NC 3
DUAKLIR PRESSAIR 400-12 MCG COPD   NC NC NC NC 3
EVEKEO ODT 5, 10, 15, 20 MG ADHD PA (age) 3 NC 3 NC 3
FASENRA PEN 30 MG/ML ASTHMA PA 3 3 3 3 3
FERRIPROX 1000 MG IRON OVERLOAD   3 3 3 3 3
FIASP PENFILL 100/ML (3) DIABETES QL NC NC NC NC 2
GVOKE HYPOPEN 0.5 MG/0.1, 1 MG/0.2ML LOW BLOOD SUGAR FROM DIABETES QL 3 3 3 3 3
GVOKE SYRINGE 0.5 MG/0.1, 1 MG/0.2ML LOW BLOOD SUGAR FROM DIABETES QL 3 3 3 3 3
HARVONI 45MG-200MG HEPATITIS C PA, QL 2 2 2 2 2
INREBIC 100 MG CANCER PA 3 3 3 3 3
KATERZIA 1 MG/ML HIGH BLOOD PRESSURE, CORONARY ARTERY DISEASE QL 3 3 3 3 3
NUBEQA 300 MG CANCER PA 3 3 3 3 3
OZOBAX 5 MG/5 ML MUSCLE RELAXANT   3 3 3 3 3
PROAIR DIGIHALER 90 MCG ASTHMA PA NC NC NC NC 3
RELAFEN DS 1000 MG ANTI-INFLAMMATORY PA NC NC NC NC 3
RINVOQ ER 15 MG RHEUMATOID ARTHRITIS PA 3 3 3 3 3
ROZLYTREK 100, 200 MG CANCER PA 3 3 3 3 3
SLYND 4 MG (28) CONTRACEPTIVE   3 3 3 3 3
SOVALDI 200 MG HEPATITIS C PA, QL 2 2 2 2 2
SYMJEPI 0.15MG/0.3 ML ALLERGIC REACTIONS PA, QL NC NC NC NC 3
TOSYMRA 10 MG MIGRAINE PA, QL NC NC NC NC 3
TRIKAFTA 100-50-75 CYSTIC FIBROSIS PA, QL 3 3 3 3 3
TURALIO 200 MG CANCER PA 3 3 3 3 3
VYLEESI* 1.75MG/0.3 HYPOACTIVE SEXUAL DESIRE DISORDER (HSDD)  PA, QL NC/3 NC/3 NC/3 NC/3 NC/3
VYNDAMAX 61 MG CARDIOMYOPATHY OF AMYLOIDOSIS PA, QL 3 3 3 3 3
XENLETA 600 MG ANTIBIOTIC PA, QL 3 3 3 3 3
XPOVIO 60, 80, 100, 160MG/WEEK CANCER PA 3 3 3 3 3

PA: Prior authorization
QL: Quantity limit
ST: Step therapy
T1/Tier 1: Generic
T2/Tier 2: Brand
T3/Tier 3: Non-preferred
NC: Not covered: This drug is not covered. However, if the covered alternative is not appropriate for the customer, there is a process where his/her provider can request approval of this drug.
*VYLEESI – Excluded under standard pharmacy benefits unless lifestyle benefit buy-up is elected

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