|
BRAND |
STRENGTH |
COMMON |
CLINICAL EDITS |
Copay TIER |
||||
|
Standard |
Value |
Performance |
Advantage |
Legacy |
||||
| ABILIFY MYCITE | 2,5,10,15,20,30 MG | Schizophrenia and bipolar disorder | NC | NC | NC | NC | 3 | |
| ACTEMRA ACTPEN | 162 MG/0.9 ML | Inflammatory conditions | PA | 2 | 2 | 2 | 2 | 2 |
| AEMCOLO | 194 MG | Traveler's diarrhea | QL | 3 | 3 | 3 | 3 | 3 |
| BRYHALI | 0.01% | Psoriasis | NC | NC | NC | NC | 3 | |
| CEQUA | 0.09% | Dry eye | NC | NC | NC | NC | 3 | |
| DAURISMO | 25,100 MG | Leukemia | PA | 3 | 3 | 3 | 3 | 3 |
| FIRDAPSE | 10 MG | Lambert-Eaton myasthenic syndrome | PA, QL | 3 | 3 | 3 | 3 | 3 |
| GRANIX | 300 MCG/ML | Neutropenia (low white blood cell count) | 2 | 2 | 2 | 2 | 2 | |
| INVELTYS | 1% | Ophthalmic inflammation following surgery | NC | NC | NC | NC | 3 | |
| LORBRENA | 25,100 MG | Lung cancer | PA | 3 | 3 | 3 | 3 | 3 |
| NUZYRA | 150 MG | Bacterial pneumonia and skin infections | PA | 3 | 3 | 3 | 3 | 3 |
| OXERVATE | 0.002% | Neurotrophic keratitis | PA | 3 | 3 | 3 | 3 | 3 |
| SEYSARA | 60,100,150 MG | Acne | NC | NC | NC | NC | 3 | |
| SIKLOS | 1000 MG | Sickle cell anemia | PA | 3 | 3 | 3 | 3 | 3 |
| SYMPAZAN | 5,10,20 MG | Lennox-Gastault syndrome | NC | NC | NC | NC | 3 | |
| TIROSINT | 175,200 MCG | Hypothyroidism | 3 | 3 | 3 | 3 | 3 | |
| TOLSURA | 65 MG | Systemic fungal infections | NC | NC | NC | NC | 3 | |
| TRESIBA | 100/ML | Diabetes | 2 | 2 | 2 | 2 | 2 | |
| UDENYCA | 6 MG/0.6ML | Neutropenia (low white blood cell count) | NC | NC | NC | NC | 3 | |
| VITRAKVI | 25 MG,100 MG,20 MG/ML | Solid tumors | PA | 3 | 3 | 3 | 3 | 3 |
| XELPROS | 0.005% | Glaucoma | 3 | 3 | 3 | 3 | 3 | |
| XOLAIR | 75MG/0.5ML,150MG/ML | Asthma | PA | 2 | 2 | 2 | 3 | 2 |
| XOSPATA | 40 MG | Leukemia | PA | 3 | 3 | 3 | 3 | 3 |
| XYOSTED | 50MG/0.5ML, 75 MG/0.5 ML, 100 MG/0.5 ML | Testosterone replacement | NC | NC | NC | NC | 3 | |
| YUPELRI | 175MCG/3ML | Chronic obstructive pulmonary disease (COPD) | NC | NC | NC | NC | 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.
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