Brand Drug Additions

Brand Name Strength Common Use Clinical Edits Prescription Drug List Tier
Standard Formulary Value Formulary Performance Formulary Advantage Formulary Legacy Formulary
Hemady 20mg Steroid NC T3 T3 T3 T3 T3
Epclusa 200/50mg Hepatitis C PA, QL T2 T2 T2 T2 T2
Teriparatide 620mcg Osteoporosis PA, QL T3 T3 T3 T3 T3
Trijardy XR Multiple Diabetes ST, QL T2 T2 T2 T2 T2
Koselugo 10mg & 20mg Oncology PA, QL T3 T3 T3 T3 T3
Licart 1.30% Pain PA, QL T3 T3 T3 T3 T3
Sovaldi Pellet 150mg & 200mg Hepatitis C PA, QL T2 T2 T2 T2 T2
Harvoni Pellet 45/200mg & 33.75/150mg Hepatitis C PA, QL T2 T2 T2 T2 T2
Nexlizet 180/10mg Hypercholesterolemia PA, QL T2 T2 T2 T2 T2
Arazlo 0.05% Acne NC (S/P/V/A) T3 T3 T3 T3 T2
Dayvigo 5mg & 10mg Insomnia ST, QL T2 T2 T2 T2 T2
Isturisa 1mg, 5mg & 10mg Cushing disease PA, QL T3 T3 T3 T3 T3
Tabrecta 150mg & 200mg Oncology PA, QL T3 T3 T3 T3 T3
Retevmo 40m & 80mg Oncology PA, QL T3 T3 T3 T3 T3
Lyumjev 100u/ml & 200u/ml Diabetes QL T2 T2 T2 T2 T2
Qinlock 50mg Oncology PA, QL T3 T3 T3 T3 T3
Bynfezia 2,500mcg/ml Acromegaly PA T3 T3 T3 T3 T3
Helidac   H. pylori NC T3 T3 T3 T3 T3
Fintepla 2.2mg/ml Dravet syndrome PA T3 T3 T3 T3 T3
Kynmobi Multiple Parkinson disease PA T2 T2 T2 T2 T2
Zilxi 1.50% Acne NC T3 T3 T3 T3 T3
Rukobia 600mg HIV PA, QL T3 T3 T3 T3 T3
Breztri 160-9-4.8mcg COPD   T2 T2 T2 T2 T2
Inqovi 35/100mg Oncology PA T3 T3 T3 T3 T3
Phexxi 1.8-1-0.4% Contraceptive NC T3 T3 T3 T3 T3
Oriahnn 300-1-0.5mg/300mg Uterine Leiomyomas PA, QL T2 T2 T2 T2 T2

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.

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