
Generic Name | Strength | Corresponding Brand Name | Common Use | Clinical Edits | Prescription Drug List Tier | ||||
Standard Formulary | Value Formulary | Performance Formulary | Advantage Formulary | Legacy Formulary | |||||
dimethyl fumarate | 120mg & 240mg | Tecfidera | Multiple Sclerosis | PA | T1 | T1 | T1 | T1 | T1 |
emtricitabine | 200mg | Emtriva | HIV | PA | T1 | T1 | T1 | T1 | T1 |
PEG3350/sod/sul/nacl/kcl/asb/c | powder | Moviprep | Bowel Prep | T1 | T1 | T1 | T1 | T1 | |
sapropterin dihydrochloride | 100mg | Kuvan | Phenylketonuria | PA | T1 | T1 | T1 | T1 | T1 |
tobramycin | 300mg/4ml | Bethkis | Cystic Fibrosis | PA, QL | T1 | T1 | T1 | T1 | T1 |
diclofenac submicronized | 35mg | Zorvolex | Anti-inflammatory | NC | T3 | T3 | T3 | T3 | T3 |
efavirenz/lamivu/tenofov disop | 400/300/300mg | Symfi Lo | HIV | T1 | T1 | T1 | T1 | T1 | |
efavirenz/lamivu/tenofov disop | 600/300/300mg | Symfi | HIV | T1 | T1 | T1 | T1 | T1 | |
deferiprone | 500mg | Ferriprox | Iron chelator | PA | T1 | T1 | T1 | T1 | T1 |
lapatinib ditosylate | 250mg | Tykerb | Breast Cancer | PA | T1 | T1 | T1 | T1 | T1 |
emtricitabine/tenofovir | 200/300mg | Truvada | HIV | T1 | T1 | T1 | T1 | T1 | |
efavirenz/emtricit/tenofovr df | 600/200/300mg | Atripla | HIV | PA | T1 | T1 | T1 | T1 | T1 |
fosfomycin | 3gm | Monurol | Antibiotic | T1 | T1 | T1 | T1 | T1 | |
tavaborole | 5% | Kerydin | Antifungal | NC | T1 | T1 | T1 | T1 | T1 |
rufinamide | 40mg/ml | Banzel | Anticonvulsant | PA, QL | T1 | T1 | T1 | T1 | T1 |
icosapent ethyl | 1 gm | Vascepa | Hypertriglyceridemia | T1 | T1 | T1 | T1 | T1 | |
timolol maleate/PF | 0.50% | Timoptic Ocudose | Glaucoma | T1 | T1 | T1 | T1 | T1 | |
norethindrone-e.estradiol-iron | 1mg-20mcg/75mg | Taytulla | Contraception | T1 | T1 | T1 | T1 | T1 | |
levothyroxine sodium | all | Tirosint | Thyroid | PA(Val/Adv) | T3 | T3 | T3 | T3 | T3 |
ivermectin | 0.50% | Sklice | Head Lice | T1 | T1 | T1 | T1 | T1 |
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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