| Brand Name | Strength | Common Use | Clinical Edits | Prescription Drug List Tier | ||||
| Standard Formulary | Value Formulary | Performance Formulary | Advantage Formulary | Legacy Formulary | ||||
| ADHANSIA XR | 25, 35, 45, 55, 70, 85 MG | ADD, ADHD | NC | NC | NC | NC | NC | |
| DUOBRII | 0.01-0.045 | Psoriasis | NC | NC | NC | NC | 3 | |
| EGATEN | 250MG | Treatment of rare parasitic infection | ||||||
| EMGALITY SYRINGE | 100 MG/ML | Prevention of migraine | PA | 2 | 3 | 2 | 3 | 2 |
| EZALLOR SPRINKLE | 5, 10, 20, 40 MG | Cholesterol/lipid lowering | ST | NC | NC | NC | NC | 3 |
| FENOFIBRATE NANOCRYSTALLIZED | 160 MG | Cholesterol/lipid lowering | NC | NC | NC | NC | NC | |
| JORNAY PM | 20, 40, 80, 100 MG | ADD, ADHD | NC | NC | NC | NC | NC | |
| KALYDECO | 25 MG | Cystic fibrosis | PA | 3 | 3 | 3 | 3 | 3 |
| NUCALA | 100 MG/ML | Eosinophilic asthma | 3 | 3 | 3 | 3 | 3 | |
| PIQRAY | 200, 250, 300 MG/DAY | Breast cancer | PA | 3 | 3 | 3 | 3 | 3 |
| QTERN | 5 MG-5 MG | Diabetes, type II | QL | 2 | 3 | 2 | 3 | 2 |
| RUZURGI | 10 MG | Lambert-Eaton Myasthenic Syndrome (LEMS) | PA | 3 | 3 | 3 | 3 | 3 |
| SKYRIZI | 75 MG/0.83 | Psoriasis | PA | 3 | 3 | 3 | 3 | 3 |
| SYMDEKO | 50 MG-75MG | Cystic fibrosis | PA, QL | 3 | 3 | 3 | 3 | 3 |
| VYNDAQEL | 20 MG | Hereditary transthyretin-mediated amyloidosis | PA, QL | 3 | 3 | 3 | 3 | 3 |
| ZYKADIA | 150 MG | Lung cancer | 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.
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