Drug name	Tier	Generic equivalent	Notes
ABELCET	4	n/a	Prior authorization required
ABILIFY	2	n/a
ABILIFY DISCMELT	3	n/a
ABRAXANE	4	n/a
ACANYA	3	n/a
acarbose	1	n/a
ACCOLATE	2	n/a
ACCUNEB	3	albuterol sulfate	Prior authorization required Generic substitution allowed
ACCUPRIL	3	quinapril hcl	Generic substitution allowed
ACCURETIC	3	hydrochlorothiazide; quinapril hcl	Generic substitution allowed
ACCUTANE	3	isotretinoin	Generic substitution allowed
acebutolol hcl	1	n/a
ACEON	3	n/a
acetaminophen/caffeine/dihydrocodeine bitartrate	1	n/a
acetaminophen/codeine	1	n/a
acetaminophen/codeine #3	1	n/a
acetaminophen/codeine #4	1	n/a
acetasol hc	1	n/a
acetazolamide	1	n/a
acetazolamide sodium inj	1	n/a
acetic acid otic	1	n/a
acetic acid/aluminum acetate	1	n/a
acetylcysteine	1	n/a	Prior authorization required
ACIPHEX	3	n/a	Step therapy applies
ACLOVATE	3	alclometasone dipropionate	Generic substitution allowed
ACTHIB	2	n/a
acticin	1	n/a
ACTIGALL	3	ursodiol	Generic substitution allowed
ACTIMMUNE	4	n/a
ACTIQ	4	fentanyl citrate	Prior authorization required Generic substitution allowed
ACTIVELLA	3	estradiol; norethindrone acetate	Generic substitution allowed
ACTONEL	3	n/a	Quantity limitations apply
ACTONEL 30 MG	3	n/a	Quantity limitations apply
ACTONEL WITH CALCIUM	3	n/a	Quantity limitations apply
ACTOPLUS MET	2	n/a
ACTOS	2	n/a
ACULAR	3	ketorolac tromethamine	Generic substitution allowed
ACULAR LS	3	ketorolac tromethamine	Generic substitution allowed
acyclovir	1	n/a
acyclovir sodium	1	n/a	Prior authorization required
ADACEL	2	n/a
ADAGEN	4	n/a
ADALAT CC	3	nifedipine	Generic substitution allowed
ADCIRCA	4	n/a	Prior authorization required
ADDERALL	3	amphetamine aspartate; amphetamine sulfate; dextroamphetamine saccharate; dextroamphetamine sulfate	Generic substitution allowed
ADDERALL XR	3	amphetamine aspartate; amphetamine sulfate; dextroamphetamine saccharate; dextroamphetamine sulfate	Generic substitution allowed
ADOXA	3	doxycycline monohydrate	Generic substitution allowed
ADOXA PAK	3	n/a
adriamycin	1	n/a	Prior authorization required
ADVAIR DISKUS	2	n/a
ADVAIR HFA	2	n/a
ADVICOR	3	n/a
AEROBID-M	3	n/a
afeditab cr	1	n/a
AFINITOR	4	n/a
AGGRENOX	3	n/a	Quantity limitations apply
AGRYLIN	3	anagrelide hydrochloride	Quantity limitations apply Generic substitution allowed
a-hydrocort	1	n/a
ak-con	1	n/a
AKNE-MYCIN	3	n/a
ak-poly-bac	1	n/a
ak-tob	1	n/a
ala-cort	1	n/a
ALAMAST	3	n/a
ALA-SCALP	3	hydrocortisone	Generic substitution allowed
ALBENZA	2	n/a
albuterol sulfate er tb12	1	n/a
albuterol sulfate neb	1	n/a	Prior authorization required
albuterol sulfate syrp	1	n/a
albuterol sulfate tab	1	n/a
ALCAINE	3	proparacaine hydrochloride	Generic substitution allowed
alclometasone dipropionate	1	n/a
alcohol 5%/dextrose 5%	1	n/a	Prior authorization required
ALCOHOL PREPS	2	n/a
ALDACTAZIDE	3	n/a
ALDACTONE	3	spironolactone	Generic substitution allowed
ALDARA	3	n/a
ALDURAZYME	4	n/a
alendronate sodium	1	n/a	Quantity limitations apply
alendronate sodium 40 mg	1	n/a	Quantity limitations apply
ALFERON N	4	n/a	Prior authorization required
ALIMTA	4	n/a
ALINIA	2	n/a
ALKERAN INJ	4	melphalan	Generic substitution allowed
ALLEGRA	3	fexofenadine hydrochloride	Generic substitution allowed
ALLEGRA-D 12 HOUR	3	fexofenadine hydrochloride; pseudoephedrine hydrochloride	Generic substitution allowed
ALLEGRA-D 24 HOUR	3	n/a
ALLOPURINOL SODIUM INJ	3	n/a
allopurinol tab	1	n/a
ALOCRIL	3	n/a
ALOMIDE	3	n/a
ALOPRIM	3	n/a
ALORA	3	n/a
ALOXI	3	n/a
ALPHAGAN P	2	n/a
ALREX	3	n/a
ALTABAX	3	n/a
ALTACE	3	n/a
ALTOPREV	2	n/a	Quantity limitations apply
ALVESCO	3	n/a
amantadine hcl	1	n/a
AMARYL	3	glimepiride	Generic substitution allowed
AMBIEN	3	zolpidem tartrate	Generic substitution allowed
AMBIEN CR	3	n/a
AMBISOME	4	n/a	Prior authorization required
amcinonide	1	n/a
AMERGE	3	n/a	Quantity limitations apply
a-methapred	1	n/a
AMEVIVE	4	n/a
AMIFOSTINE	4	n/a
amikacin sulfate	1	n/a
amikin 250 mg/ml	1	n/a
AMIKIN 50 MG/ML	3	amikacin sulfate	Generic substitution allowed
amiloride /hydrochlorothiazide	1	n/a
amiloride hcl	1	n/a
aminophylline	1	n/a
AMINOSYN	2	n/a	Prior authorization required
AMINOSYN 7%/ELECTROLYTES	2	n/a	Prior authorization required
AMINOSYN 8.5%/ELECTROLYTES	3	acetate; alanine; arginine; chloride ion; glycine; histidine; isoleucine; leucine; lysine; magnesium (+2); methionine; phenylalanine; phosphorus; potassium (+1); proline (l-proline); serine; sodium (+1); threonine; tryptophan; tyrosine; valine	Prior authorization required Generic substitution allowed
AMINOSYN II	2	n/a	Prior authorization required
AMINOSYN II 3.5% M-DEXTROSE 5%	2	n/a	Prior authorization required
AMINOSYN II 3.5%/DEXTROSE25%	2	n/a	Prior authorization required
AMINOSYN II 3.5/DEXTROSE 25%	2	n/a	Prior authorization required
AMINOSYN II 4.25/DEXTROSE10%	2	n/a	Prior authorization required
AMINOSYN II 4.25/DEXTROSE20%	2	n/a	Prior authorization required
AMINOSYN II 4.25/DEXTROSE25%	2	n/a	Prior authorization required
AMINOSYN II 5/DEXTROSE 25	2	n/a	Prior authorization required
AMINOSYN II 8.5%/ELECTROLYTES	3	acetate; alanine; arginine; aspartic acid; chloride ion; glutamic acid hydrochloride; glycine; histidine; isoleucine; leucine; lysine; magnesium (+2); methionine; phenylalanine; phosphate; potassium (+1); proline (l-proline); serine; sodium (+1); threonin	Prior authorization required Generic substitution allowed
AMINOSYN II M 3.5%/DEXTROSE 5%	2	n/a	Prior authorization required
AMINOSYN M	2	n/a	Prior authorization required
AMINOSYN-HBC	2	n/a	Prior authorization required
AMINOSYN-HF	2	n/a	Prior authorization required
AMINOSYN-PF	2	n/a	Prior authorization required
AMINOSYN-PF 7%	2	n/a	Prior authorization required
amiodarone hcl	1	n/a
AMITIZA	3	n/a
amitriptyline hcl	1	n/a
amlodipine besylate	1	n/a
amlodipine besylate/benazepril hydrochloride	1	n/a
AMMONIUM CHLORIDE	2	n/a
ammonium lactate	1	n/a
amnesteem	1	n/a
amoclan	1	n/a
amoxapine	1	n/a
amoxicillin	1	n/a
amoxicillin/clavulanate potassium	1	n/a
amoxil cap	1	n/a
amoxil susp 250 mg/5 ml	1	n/a
AMOXIL SUSP 400 MG/5 ML	3	amoxicillin	Generic substitution allowed
amphetamine salt combo	1	n/a
AMPHOTEC	3	n/a	Prior authorization required
amphotericin b	1	n/a	Prior authorization required
ampicillin	1	n/a
ampicillin	1	n/a
ampicillin sodium inj 1 gm	1	n/a
ampicillin sodium inj 10 gm	1	n/a
AMPICILLIN SODIUM INJ 125 MG	2	n/a
ampicillin-sulbactam	1	n/a
AMRIX	3	n/a
ANADROL-50	4	n/a	Prior authorization required
ANAFRANIL	3	clomipramine hcl	Generic substitution allowed
anagrelide hydrochloride	1	n/a	Quantity limitations apply
ANAPROX	3	naproxen sodium	Generic substitution allowed
ANAPROX DS	3	naproxen sodium	Generic substitution allowed
ANCOBON	2	n/a
ANDRODERM	3	n/a	Prior authorization required
ANDROGEL	2	n/a	Prior authorization required
ANDROID	3	n/a	Prior authorization required
androxy	1	n/a	Prior authorization required
anestacon	1	n/a
ANGELIQ	3	n/a
ANTABUSE	2	n/a
ANTARA	3	n/a
ANTIVERT	3	meclizine hydrochloride	Generic substitution allowed
ANTIZOL	4	fomepizole (4-methylpyrazole)	Generic substitution allowed
ANUSOL-HC	3	hydrocortisone	Generic substitution allowed
ANZEMET INJ	3	n/a
ANZEMET TAB	3	n/a	Prior authorization required
APHTHASOL	3	n/a
APIDRA	2	n/a
APIDRA SOLOSTAR	2	n/a
APLENZIN	3	n/a	Quantity limitations apply
APOKYN	3	n/a
apraclonidine hcl	1	n/a
apri	1	n/a
APRISO	3	n/a
APTIVUS	4	n/a
ARALAST	4	n/a
ARALEN	3	chloroquine phosphate	Generic substitution allowed
aranelle	1	n/a
ARANESP ALBUMIN FREE	4	n/a	Prior authorization required
ARANESP ALBUMIN FREE 100 MCG/ML	4	n/a	Prior authorization required
ARANESP ALBUMIN FREE 150 MCG/0.3 ML	4	n/a	Prior authorization required
ARANESP ALBUMIN FREE 200 MCG/0.4 ML	4	n/a	Prior authorization required
ARANESP ALBUMIN FREE 200MCG/ML	4	n/a	Prior authorization required
ARANESP ALBUMIN FREE 25MCG/0.42ML	3	n/a	Prior authorization required
ARANESP ALBUMIN FREE 25MCG/ML	3	n/a	Prior authorization required
ARANESP ALBUMIN FREE 300MCG/0.6ML	4	n/a	Prior authorization required
ARANESP ALBUMIN FREE 300MCG/ML	4	n/a	Prior authorization required
ARANESP ALBUMIN FREE 40MCG/0.4ML	3	n/a	Prior authorization required
ARANESP ALBUMIN FREE 40MCG/ML	3	n/a	Prior authorization required
ARANESP ALBUMIN FREE 500MCG/ML	4	n/a	Prior authorization required
ARANESP ALBUMIN FREE 60MCG/0.3ML	3	n/a	Prior authorization required
ARANESP ALBUMIN FREE 60MCG/ML	3	n/a	Prior authorization required
ARAVA	3	leflunomide	Generic substitution allowed
ARCALYST	4	n/a
AREDIA 30 MG	3	n/a	Prior authorization required
AREDIA 90 MG	4	n/a	Prior authorization required
ARICEPT	2	n/a	Quantity limitations apply
ARICEPT ODT	2	n/a	Quantity limitations apply
ARIMIDEX	2	n/a
ARIXTRA 10 MG/0.8 ML	4	n/a
ARIXTRA 2.5 MG/0.5 ML	3	n/a
ARIXTRA 5 MG/0.4 ML	4	n/a
ARIXTRA 7.5 MG/0.6 ML	4	n/a
AROMASIN	2	n/a
ARRANON	4	n/a
ARTHROTEC 50	3	n/a
ARTHROTEC 75	3	n/a
ARZERRA	4	n/a	Prior authorization required
ASACOL	2	n/a
ASACOL HD	2	n/a
ascomp/codeine	1	n/a
ASMANEX	2	n/a
ASTELIN	2	n/a
ASTEPRO	2	n/a
ASTRAMORPH	3	morphine sulfate	Prior authorization required Generic substitution allowed
ATACAND	3	n/a
ATACAND HCT	3	n/a
atenolol	1	n/a
atenolol/chlorthalidone	1	n/a
ATGAM	2	n/a	Prior authorization required
ATRALIN	3	n/a
ATRIPLA	4	n/a
ATROPINE SULFATE INJ 0.05 MG/ML	2	n/a
atropine sulfate inj 0.1 mg/ml	1	n/a
ATROVENT HFA	2	n/a
ATROVENT SPRAY	3	ipratropium bromide	Generic substitution allowed
ATTENUVAX	2	n/a
augmented betamethasone dipropionate	1	n/a
AUGMENTIN	3	n/a
AUGMENTIN ES-600	3	amoxicillin; potassium clavulanate	Generic substitution allowed
AUGMENTIN XR	3	n/a
AVALIDE	3	n/a
AVANDAMET	2	n/a
AVANDARYL	2	n/a
AVANDIA	2	n/a
AVAPRO	3	n/a
AVASTIN	4	n/a
AVELOX	2	n/a
AVELOX ABC PACK	2	n/a
aviane	1	n/a
AVINZA	3	n/a
avita cre	1	n/a
AVITA GEL	3	n/a
AVODART	2	n/a
AVONEX	4	n/a
AXERT	3	n/a	Quantity limitations apply
AXID CAP	3	nizatidine	Generic substitution allowed
AXID SOLN	2	nizatidine	Generic substitution allowed
AYGESTIN	3	norethindrone acetate	Generic substitution allowed
AZACTAM	2	n/a
AZACTAM IN DEXTROSE	2	n/a
AZASAN	3	n/a	Prior authorization required
AZASITE	3	n/a
azathioprine	1	n/a	Prior authorization required
azathioprine sodium	1	n/a	Prior authorization required
azelastine hcl	1	n/a
AZELEX	3	n/a
AZILECT	3	n/a
azithromycin	1	n/a
AZMACORT	2	n/a
AZOPT	2	n/a
AZOR	3	n/a
AZULFIDINE	3	sulfasalazine	Generic substitution allowed
AZULFIDINE EN-TABS	3	sulfasalazine	Generic substitution allowed