| Generic-First Step Program |
ABILIFY, ACZONE, ALPHAGAN P, ALTACE, ARIMIDEX, ARTHROTEC 50, ARTHROTEC 75, ATACAND, AVAPRO, AVODART, AZOPT, BROVANA, BYSTOLIC, CANASA, CARBATROL, CARDIZEM LA, CARNITOR, CARNITOR SF, CATAPRES-TTS-1, CATAPRES-TTS-2, CATAPRES-TTS-3, CELEXA, CIALIS, CLARINEX, CLIMARA, CLOBEX, COLESTID, COLESTID FLAVORED, COMBIGAN, COREG, COREG CR, CORTEF, COSOPT, COSOPT PF, COZAAR, DELESTROGEN, DEPAKOTE, DEPAKOTE ER, DEPAKOTE SPRINKLES, DILANTIN-125, EFFEXOR XR, EPIDUO, ESTRACE, EXFORGE, FIORICET, FIORICET/CODEINE, FLOMAX, GENERESS FE, GOLYTELY, HALOG, HYZAAR, IMITREX, IMITREX STATDOSE REFILL, IMITREX STATDOSE SYSTEM, INDERAL LA, K-TAB, KEPPRA, KEPPRA XR, KLONOPIN, LAMICTAL, LAMICTAL CHEWABLE DISPERSIBLE, LAMICTAL ODT, LAMICTAL STARTER/NOT TAKING CARBAMAZEPINE, LAMICTAL STARTER/TAKING CARBAMAZEPINE/NOT TAKING VALPROATE, LAMICTAL STARTER/TAKING VALPROATE, LAMICTAL XR, LASIX, LATISSE, LATUDA, LOESTRIN 1.5/30-21, LOESTRIN 1/20-21, LOESTRIN FE 1.5/30, LOESTRIN FE 1/20, LOTREL, LYRICA, MAXALT, MAXALT-MLT, MICARDIS, MICARDIS HCT, MOBIC, NALFON, NATROBA, NEURONTIN, NIASPAN, NITROSTAT, PAXIL, PAXIL CR, PLAQUENIL, PLAVIX, PRED FORTE, PREDNISOLONE ACETATE P-F, PROMETRIUM, PROPECIA, QUESTRAN, QUESTRAN LIGHT, RANEXA, RELPAX, RENAGEL, RESTORIL, RISPERDAL, RISPERDAL CONSTA, SAFYRAL, SEASONIQUE, SEROQUEL, SEROQUEL XR, SILVADENE, SKELAXIN, SOMA, SOVUNA, SUBOXONE, TEGRETOL, TEGRETOL-XR, TENORMIN, TIKOSYN, TIMOPTIC, TIMOPTIC OCUDOSE, TIMOPTIC-XE, TOPAMAX, TOPAMAX SPRINKLE, TOPICORT, TRAVATAN Z, TRICOR, TRILEPTAL, UCERIS, VALTREX, VANADOM, VECTICAL, VESICARE, VIGAMOX, VIMPAT, WELCHOL, XALATAN, YASMIN 28, ZANAFLEX, ZESTRIL, ZOLOFT, ZONEGRAN, ZOVIRAX, ZYPREXA |
| Gilenya (fingolimod) - PA, NF |
Gilenya (fingolimod) |
| Gilotrif (afatinib) |
Gilotrif (afatinib) |
| Givlaari (givosiran) |
Givlaari (givosiran) |
| Glumetza (metformin ER tablets) |
Glumetza (metformin ER tablets) |
| Glycopyrrolate Oral Solution |
Cuvposa (Glycopyrrolate oral solution) |
| Glycopyrrolate Tablets - PA, NF |
Dartisla ODT (glycopyrrolate), Robinul/Robinul Forte (glycopyrrolate tablet), Glycate (glycopyrrolate tablet) |
| Gomekli (mirdametinib) |
Gomekli (mirdametinib) |
| Gonadotropin-Releasing Hormone Agonists |
Camcevi (leuprolide), Leuprolide Acetate, Leuprolide Acetate Depot, Eligard (leuprolide acetate), Trelstar (triptorelin pamoate), Lupron Depot (leuprolide acetate) 1-Month 7.5 mg, Lupron Depot 3-Month 22.5 mg, Lupron Depot 4-Month 30 mg, Lupron Depot 6-Month 45 mg, Lupron Depot 1-Month 3.75 mg, Lupron Depot 3-Month 11.25 mg, Lupron Depot-PED (leuprolide acetate), Supprelin LA (histrelin acetate), Triptodur (triptorelin), Fensolvi (leuprolide acetate) |
| Growth Hormones - PA, NF |
Genotropin and Omnitrope, Genotropin, Humatrope, Norditropin Flexpro, Nutropin AQ NuSpin, Omnitrope, and Zomacton, Genotropin, Humatrope, Norditropin Flexpro, Nutropin AQ NuSpin, Omnitrope, Saizen, and Zomacton, Genotropin, Nutropin AQ NuSpin, and Omnitrope, Genotropin, Nutropin AQ NuSpin, Omnitrope, and Saizen, Humatrope and Zomacton, Ngenla (somatrogon-ghla), Norditropin Flexpro, Norditropin Flexpro and Humatrope, Norditropin Flexpro, Humatrope, and Zomacton, Norditropin Flexpro, Humatrope, and Zomacton, Nutropin AQ NuSpin, Serostim, Skytrofa (lonapegsomatropin-tcgd), Sogroya (somapacitan-beco), Zomacton, Zorbtive |
| Harvoni (ledipasvir/sofosbuvir) - PA, NF |
Harvoni (ledipasvir/sofosbuvir) |
| Healthcare Reform Copay Waiver Review |
ANASTROZOLE, APO-VARENICLINE, APRETUDE, ARIMIDEX, AROMASIN, Aspirin, ATORVASTATIN CALCIUM, Bowel preparation agents for colorectal cancer screening, bupropion, DESCOVY, EMTRICITABINE/TENOFOVIR DISOPROXIL FUMARATE, ERYTHROMYCIN, EVISTA, EXEMESTANE, Fluoride supplementation products, FLUVASTATIN SODIUM, Folic acid supplementation products, Health Care Reform Exceptions, Healthcare, Healthcare Reform Exceptions, Heplisav, Immunizations, nicotine, NICOTROL INHALER, NICOTROL NS, PITAVASTATIN CALCIUM, PRAVASTATIN SODIUM, RALOXIFENE HYDROCHLORIDE, ROSUVASTATIN CALCIUM, Shingrix, SIMVASTATIN, SOLTAMOX, TAMOXIFEN CITRATE, TENOFOVIR DISOPROXIL FUMARATE, TRUVADA, VARENICLINE, VIREAD, Zostavax |
| Healthcare Reform Copay Waiver Review - Contraceptives |
Contraceptives, Health Care Reform Exceptions, Healthcare, Healthcare Reform Exceptions |
| Hemangeol (propranolol hydrochloride oral solution) |
Hemangeol (propranolol hydrochloride oral solution) |
| Hemophilia B Gene Therapies - PA, NF |
Beqvez (fidanacogene elaparvovec-dzkt), Hemgenix (etranacogene dezaparvovec-drlb) |
| Hereditary Angioedema Agents (HAE) Quantity Limit Override |
Berinert (C1 esterase inhibitor [Human]), Firazyr (icatibant), Kalbitor (ecallantide), Ruconest (C1 esterase inhibitor [Recombinant]), Sajazir (icatibant) |
| Hereditary Angioedema Agents - PA, NF |
Berinert (C1 esterase inhibitor [Human]), Cinryze (C1 esterase inhibitor [Human]), Firazyr (icatibant), Haegarda (C1 esterase inhibitor [Human]), Kalbitor (ecallantide), Orladeyo (berotralstat), Ruconest (C1 esterase inhibitor [Recombinant]), Sajazir (icatibant), Takhzyro (lanadelumab-flyo) |
| Hetlioz, Hetlioz LQ (tasimelteon) - PA, NF |
Hetlioz (tasimelteon) capsule, Hetlioz LQ (tasimelteon) suspension |
| High Cost, Low Value Non-Formulary Program |
ABSORICA, ABSORICA LD, ACZONE, ADAPALENE, ANUSOL-HC, ARAZLO, ATOPADERM, AZESCO, BENSAL HP, CABTREO, CHLORZOXAZONE, COXANTO, DICLOFENAC EPOLAMINE, DORYX, DORYX MPC, DOXEPIN HYDROCHLORIDE, DUEXIS, EPICERAM, FENOPROFEN CALCIUM, FLECTOR, FLUOVIX, FLUOVIX PLUS, FOLIC-K, GENICIN VITA-S, IBUPROFEN/FAMOTIDINE, INDERAL XL, INNOPRAN XL, KAMDOY, KELARX, LICART, LIDOCAINE AND TETRACAINE CREAM, LIDOCAINE/TETRACAINE, NAPROSYN, NAPROXEN/ESOMEPRAZOLE MAGNESIUM, non-preferred, ORACEA, ORTHO DF, OXAPROZIN, PENNSAID, PLIAGLIS, POKONZA, PREGENNA, PRODIGEN, PROMETHAZINE HYDROCHLORIDE, PROMETHAZINE HYDROCHLORIDE PLAIN, PROMETHAZINE VC, PRUDOXIN, RAYOS, RELAFEN DS, SAJAZIR, SITAVIG, SPRIX, TIVORBEX, TOLSURA, VIMOVO, WINLEVI, XERESE, XHANCE, YOSPRALA, ZIPSOR, ZONALON, ZORVOLEX, ZTLIDO, ZYCLARA, ZYCLARA PUMP, ZYFLO |
| High Dollar/Claim Dollar |
Claim, Dollar, High |
HEALTHY LIVING