Brand Drug Additions

Brand Name Strength Common Use Clinical Edits Prescription Drug List Tier
Standard Formulary Value Formulary Performance Formulary Advantage Formulary Legacy Formulary
EGRIFTA SV 2 MG GROWTH HORMONE RELEASING HORMONE(GHRH) AND ANALOGS PA 3 3 3 3 3
OLUMIANT 1 MG JANUS KINASE (JAK) INHIBITORS PA, QL 3 3 3 3 3
PRETOMANID 200 MG ANTITUBERCULAR ANTIBIOTICS PA, QL 3 3 3 3 3
ZIEXTENZO 6 MG/0.6ML LEUKOCYTE (WBC) STIMULANTS PA 2 2 2 2 2

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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