Premium Formulary
The Premium Formulary is a partially-closed formulary. The Premium Formulary is considered partially-closed because it excludes coverage of some brand-name drugs that do not offer a clear clinical advantage over other less costly brand or generic alternatives. Most other prescription drugs are on the formulary including specialty medications. Some medications may be subject to utilization management programs to ensure appropriate clinical use and cost efficiency. The formulary structure features medications generics (with the lowest copayments), preferred and non-preferred brand-name drugs.
To determine which commercial drugs require prior authorization, please refer to the
Premium Non-Specialty Prior Authorization List or the Premium Specialty Prior Authorization and Quantity Limit List, or download the applicable request form below, and fax it to 1-888-671-5285 (toll-free): *
If a drug specific form is not listed in the A-Z section, please select the "Other" section which has the general fax form and other administrative forms.
- Abiraterone acetate
- Absorica
- Acetaminophen-caffeine-dihydrocodeine
- Acetaminophen-codeine
- Acetaminophen-codeine #3
- Aciphex
- Aciphex Sprinkle
- Actemra
- Adapalene
- Adcirca
- Adderall
- Adderall XR
- Adempas
- Adipex-P
- Adlyxin
- Adzenys ER
- Adzenys XR-ODT
- Afinitor
- Afinitor Disperz
- Aimovig
- AirDuo RespiClick
- Ajovy
- Almotriptan
- Altoprev
- Altreno
- Alyq
- Ambrisentan (generic Letairis)
- Amerge
- Amitiza
- Amnesteem
- Amphetamine
- Amphetamine-dextroamphetamine
- Amphetamine-dextroamphetamine ER
- Ampyra
- Androderm
- Androgel
- Androgel Pump
- Android
- Apadaz
- Aptensio XR
- Aranesp
- Armodafinil
- Aspirin-caffeine-dihydrocodeine
- Atomoxetine
- Atorvastatin (10mg, 20mg)
- Atralin
- Aubagio
- Aveed
- Avita
- Axert
- Azelaic acid gel
- Cambia
- CapCof
- Capecitabine
- Cayston
- Cetrotide
- Cheratussin AC
- Chorionic gonadotropin (generic Novarel)
- Chorionic gonadotropin (generic Ovidrel)
- Chorionic gonadotropin (generic Pregnyl)
- Cialis
- Cimzia
- Claravis
- Codar AR
- Codeine-guaifenesin
- Codeine sulfate
- Coditussin AC
- Coditussin DAC
- Concerta
- Contrave
- ConZip
- Copaxone
- Corlanor
- Cosentyx
- Cotempla XR-ODT
- dalfampridine ER (generic Ampyra)
- Daytrana
- Demerol
- Depo-Testosterone
- Desoxyn
- Dexedrine Spansule
- Dexilant
- Dexmethylphenidate
- Dexmethylphenidate ER
- Dextroamphetamine
- Dextroamphetamine oral solution
- Dextroamphetamine SR
- Diabetic Test Strips
- Diclegis
- Diclofenac sodium 3% gel
- Diclofenac topical solution (generic Pennsaid)
- Diethylpropion
- Diethylpropion ER
- Differin
- Dilaudid
- Duexis
- Dulera
- Dupixent
- Duragesic
- Durolane
- Dyanavel XR
- Harvoni
- Hetlioz
- Histex-AC
- Hizentra
- Horizant
- H.P. Acthar Gel
- Humatrope
- Humira
- Hyalgan
- Hycet
- Hydrocodone-acetaminophen
- Hydrocodone-chlorpheniramine-pseudoephedrine
- Hydrocodone-homatropine
- Hydrocodone-ibuprofen
- Hydrocodone polistirex-chlorpheniramine polistirex
- Hydromet
- Hydromorphone
- Hydromorphone ER
- Hydroxyprogesterone caproate injection
- Hymovis
- Hysingla ER
- M-Clear WC
- M-End PE
- Makena
- Mar-Cof BP
- Mar-Cof CG
- Mavyret
- Maxalt
- Maxalt-MLT
- Mekinist
- Menopur
- Meperidine
- Meperidine-promethazine
- Metadate CD
- Metadate ER
- Methamphetamine
- Methitest
- Methylin oral solution
- Methylphenidate chewable tablet
- Methylphenidate ER
- Methylphenidate IR
- Methylphenidate oral solution
- Methyltestosterone
- Modafinil
- Monovisc
- Morphine ER capsule (generic Avinza)
- Morphine sulfate
- Morphine sulfate ER tablet
- MS Contin
- Mydayis
- Myorisan
- Obredon
- Ocaliva
- Ocrevus
- Olumiant
- Omeprazole
- Omeprazole-sodium bicarbonate capsule
- Omeprazole-sodium bicarbonate suspension
- Omnitrope
- Onzetra
- Opana
- Opana ER (Crush Resistant)
- Opsumit
- Orencia
- Orilissa
- Orthovisc
- Otezla
- Otrexup
- Ovidrel
- Oxaydo
- Oxtellar XR
- Oxycodone
- Oxycodone-acetaminophen
- Oxycodone-aspirin
- Oxycodone ER
- Oxycodone-ibuprofen
- OxyContin
- Oxymorphone
- Oxymorphone ER
- Ozempic
- Pantoprazole
- Pennsaid
- Pentazocine-naloxone
- Percocet
- Phendimetrazine
- Phendimetrazine ER
- Phentermine
- Picato
- Plixda
- Poly-Tussin AC
- Pomalyst
- Praluent
- Pregnyl
- Prevacid capsule
- Prevacid Solutab
- Prilosec
- Prilosec suspension
- Primlev
- Pro-Clear AC
- Prolastin-C
- Prolia
- Promacta
- Promethazine-codeine
- Promethazine-phenylephrine-codeine
- Promethazine VC with codeine
- ProCentra
- Pro-Red AC
- Protonix
- Protonix suspension
- Provigil
- Pulmozyme
- Saxenda
- Segluromet
- Sildenafil (generic Revatio)
- Siliq
- Simponi
- Simponi Aria
- Simvastatin (5mg, 10mg, 20mg, 40mg)
- sofosbuvir/velpatasvir (generic Epclusa)
- Soliqua
- Sprycel
- Steglatro
- Steglujan
- Stelara
- Stivarga
- Strattera
- Striant
- Sumatriptan-naproxen
- Sumatriptan injection
- Sumatriptan nasal spray
- Sumatriptan tablet
- Sumavel DosePro
- Supartz
- Supartz FX
- Supprelin LA
- Symdeko
- Synagis
- Synalgos-DC
- Synjardy
- Synjardy XR
- Synvisc
- Synvisc-One
- Tadalafil (for BPH, impotence)
- Tadalafil (for pulmonary arterial hypertension)
- Tafinlar
- Tagrisso
- Taltz
- Tasigna
- Tecfidera
- Temodar
- Temozolomide
- Testim
- Testone CIK
- Testopel
- Testosterone 10mg/actuation (2%) gel
- Testosterone cypionate
- Testosterone enanthate
- Testosterone implant pellet
- Testosterone propionate
- Testosterone solution (generic Axiron)
- Testosterone Topical Gel (Generic Androgel, Testim, And Vogelxo)
- Testosterone Topical Gel Pump (Generic Androgel Pump And Vogelxo Pump)
- Testred
- Thyrogen
- Tolsura
- Tradjenta
- Tramadol
- Tramadol-acetaminophen
- Tramadol ER capsule
- Tremfya
- Tretinoin
- Tretinoin Microsphere
- Tretinoin Microsphere Pump
- Tretin-X
- Treximet
- Trezix
- Trintellix
- Trokendi XR
- Trulance
- Trulicity
- Trymine CG
- TussiCaps
- Tussigon
- Tussionex
- Tuxarin ER
- Tuzistra XR
- Tylenol-codeine #3
- Tylenol-codeine #4
- Tymlos
- Tysabri
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