Commercial
Brand Name Status Triple Tier Formulary
4th Tier Applicable
Traditional Formulary
Prior Authorization
Quantity
Limit Detailed Limits Formulary Alternatives
ARNUITY ELLIPTA Non Formulary
Non
Formulary No Non
Formulary Yes No −
Advair Diskus/HFA, Dulera, Flovent Diskus/HFA, Pulmicort Flexhaler, Qvar,
Asmanex HFA
BELSOMRA Non
Formulary
Non
Formulary No Non
Formulary Yes Yes 1 tablet per day
eszopiclone, zaleplon, zolpidem, amitriptyline, mirtazapine, trazodone, estazolam, flurazepam, quazepam, temazepam, triazolam, zolpidem ER
EVOTAZ Formulary 2 No 2 No No −
Aptivus, Crixivan, Invirase, Kaletra, Lexiva, Prezista,
Reyataz, Viracept
FARYDAK Formulary 3 Yes 2 Yes Yes 6 capsules per
21 day cycle
Thalomid, Pomalyst*, Revlimid*
HYSINGLA ER Non
Formulary
Non
Formulary No Non
Formulary Yes Yes 1 tablet per day
fentanyl, morphine sulfate ER, oxycodone ER*, tramadol ER, Avinza, Butrans*, Nucynta
ER*, Oxycontin*
LENVIMA Formulary 3 Yes 2 Yes Yes
3 capsules per day, 30 day supply per fill
Caprelsa*, Cometriq*, Nexavar*
MIRCERA Non
Formulary
Non
Formulary No Non
Formulary Yes No − Aranesp*, Epogen*, Procrit*
NALOXONE
PREFILLED SYRINGES Formulary 1 No 1 No No −
PREZCOBIX Formulary 2 No 2 No No −
Aptivus, Crixivan, Invirase, Kaletra, Lexiva, Prezista,
Reyataz, Viracept
SAVAYSA Non
Formulary
Non
Formulary No Non
Formulary Yes Yes 1 tablet per
day warfarin, Eliquis, Xarelto
ZOHYDRO ER Non
Formulary
Non
Formulary No Non
Formulary Yes Yes 2 tablets per day
fentanyl, morphine sulfate ER, oxycodone ER*, tramadol ER, Avinza, Butrans*, Nucynta
ER*, Oxycontin*
* Indicates prior authorization (PA) or step therapy (ST)
CHIP
Brand Name Status Tier Prior Authorization Quantity Limit
Detailed
Limits Formulary Alternatives
ARNUITY ELLIPTA Non
Formulary - Yes No
Advair Diskus/HFA, Dulera, Flovent Diskus/HFA, Pulmicort Flexhaler, Qvar, Asmanex HFA
BELSOMRA Non
Formulary - Yes Yes 1 tablet per
day
eszopiclone, zaleplon, zolpidem, amitriptyline, mirtazapine,
trazodone, estazolam, flurazepam, quazepam, temazepam, triazolam, zolpidem
ER
EVOTAZ Formulary 2 No No
Aptivus, Crixivan, Invirase, Kaletra, Lexiva, Prezista,
Reyataz, Viracept
FARYDAK Formulary 2 Yes Yes
6 capsules per 21 day
cycle
Thalomid, Pomalyst*, Revlimid*
HYSINGLA ER Non
Formulary - Yes Yes 1 tablet per
day
fentanyl, morphine sulfate ER, oxycodone ER*, tramadol ER, Avinza, Butrans*, Nucynta ER*,
Oxycontin*
LENVIMA Formulary 2 Yes Yes
3 capsules per day, 30 days supply
per fill
Caprelsa*, Cometriq*, Nexavar*
MIRCERA Non
Formulary - Yes No Aranesp*, Epogen*, Procrit*
NALOXONE
PREFILLED SYRINGES Formulary 2 No No
PREZCOBIX Formulary 2 No No
Aptivus, Crixivan, Invirase, Kaletra, Lexiva, Prezista,
Reyataz, Viracept
SAVAYSA Non
Formulary - Yes Yes 1 tablet per
day warfarin, Eliquis, Xarelto
ZOHYDRO ER Non
Formulary - Yes Yes 2 tablets per
day
fentanyl, morphine sulfate ER, oxycodone ER*, tramadol ER, Avinza, Butrans*, Nucynta ER*,
Oxycontin*
* Indicates prior authorization (PA) or step therapy (ST)
GHP Family
Brand Name Status
GHP Family Formulary
Tier
Prior Authorization
Quantity Limit
Detailed
Limits Formulary Alternative(s)
AMNESTEEM, CLARAVIS, MYORISAN, ZENATANE
Formulary Generic Yes No
tretinoin, adapalene 0.1%, benzoyl peroxide, clindamycin, erythromycin,
sulfacetamide, benzoyl peroide/clindamycin, benzoyl peroxide/erythromycin, teteracycline,
doxycycline, minocycline, erythromycin,
trimethoprim/sulfamethoxazole, azithromycin
ARNUITY ELLIPTA Non Formulary
Non
Formulary Yes No Advair Diskus/HFA*, Asmanex HFA,
Asmanex, Dulera, Flovent Diskus/HFA
BELSOMRA Non
Formulary
Non
Formulary Yes Yes 1 tablet per
day
zaleplon, zolpidem, flurazepam, temazepam, triazolam
EVOTAZ Formulary Brand No No
Aptivus (capsule/solution), Crixivan, Invirase, Kaletra, Lexiva, Prezista,
Reyataz, Viracept tablet
FARYDAK Formulary Brand Yes Yes 6 capsules
per 21 days Pomalyst*, Revlimid*
HYSINGLA ER Non
Formulary
Non
Formulary Yes Yes 1 tablet per
day
tramadol ER^, morphine sulfate ER^, fentanyl^
LENVIMA Formulary Brand Yes Yes
3 capsules per day, 30 day supply
per fill
Caprelsa*, Cometriq*, Nexavar*
MIRCERA Non
Formulary
Non
Formulary Yes No Aranesp*, Epogen*, Procrit*
NALOXONE
PREFILLED SYRINGE Formulary Generic No No
NATROBA Non
Formulary
Non
Formulary Yes No
Lindane Shampoo, Malathion, Permetherin 1%, Piperonyl butoxide/pyrethrin shampoo
PREZCOBIX Formulary Brand No No
Aptivus (capsule/solution), Crixivan, Invirase, Kaletra, Lexiva, Prezista,
Reyataz, Viracept tablet
SAVAYSA Non
Formulary
Non
Formulary Yes Yes 1 tablet per
day warfarin, Eliquis, Pradaxa*, Xarelto
ZOHYDRO ER Non
Formulary
Non
Formulary Yes Yes 2 tablets per
day
tramadol ER^, morphine sulfate ER^, fentanyl^, methadone^
* Indicates prior authorization (PA) or step therapy (ST)
Geisinger Gold
Brand Name Status $0 Deductible Formulary
Standard Formulary
Prior Authorization
Quantity Limit
Detailed
Limits Formulary Alternative(s)
ARNUITY ELLIPTA Non Formulary
Advair Diskus/HFA, Dulera, Flovent Diskus/HFA, Pulmicort Flexhaler, QVAR, Asmanex HFA,
Symbicort
BELSOMRA Non
Formulary Yes 1 tablet per
day
trazodone, mirtazapine, estazolam, temazepam, Rozerem, Silenor, zolpidem*, zolpidem ER*,
zaleplon* (*prior authorization/quantity limits
apply)
EVOTAZ Formulary Specialty 25%
coinsurance No No
Crixivan, Aptivus, Kaletra, Lexiva, Reyataz, Invirase, Prezista,
Viracept
FARYDAK Formulary Specialty 25%
coinsurance Yes Yes
6 capsules per 21 day
cycle
Pomalyst*, Revlimid*, Thalomid*
(*Prior authorization required)
HYSINGLA ER Non
Formulary Yes 1 tablet per
day
Tramadol ER, morphine sulfate ER, fentanyl, Butrans*, Oxycontin* (*PA required)
ILUVIEN Medical Yes
LENVIMA Formulary Specialty 25%
coinsurance Yes Yes
Limited to 3 capsules per
day
Caprelsa*, Cometriq*, Nexavar*
(*Prior authorization required)
MIRCERA Non
Formulary
Procrit*, Aranesp*, Epogen*
(*Prior authorization required)
PREZCOBIX Formulary Specialty 25%
coinsurance No No
Crixivan, Aptivus, Kaletra, Lexiva, Reyataz, Invirase, Prezista,
Viracept
RAPIVAB Non
Formulary
Relenza, Tamiflu, amantadine, rimantadine
SAVAYSA Non
Formulary Yes 1 tablet per
day warfarin, Eliquis, Xarelto, Pradaxa
ZERBAXA Formulary Specialty 25%
coinsurance No
Ampicillin/sulbactam, aztreonam, cefadroxil, cefazolin, cefepime,
cefotaxime, cefoxitin, ceftazidime, ceftriaxone, cefuroxime, ciprofloxacin,
imipenem/cilastatin, levofloxacin, meropenem,
piperacillin/tazobactam, Timentin, Invanz, Primaxin IM,
Tygacil
ZOHYDRO ER Non
Formulary Yes 2 tablets per
day
Tramadol ER, morphine sulfate ER, fentanyl, Butrans*, Oxycontin* (*PA required)
* Indicates prior authorization (PA) or step therapy (ST)
Marketplace
Brand Name Status Tier Prior
Authorization
Quantity Limit
Detailed
Limits Formulary Alternatives ARNUITY ELLIPTA Non
Formulary − Yes No −
Advair Diskus/HFA, Dulera, Flovent Diskus/HFA, Pulmicort
Flexhaler, Qvar, Asmanex HFA
BELSOMRA Non
Formulary − Yes Yes 1 tablet per
day
eszopiclone, zaleplon, zolpidem, amitriptyline, mirtazapine, trazodone, estazolam, flurazepam, quazepam, temazepam, triazolam, zolpidem ER
EVOTAZ Formulary 3 No No −
Aptivus, Crixivan, Invirase, Kaletra, Lexiva, Prezista,
Reyataz, Viracept
FARYDAK Formulary Specialty Yes Yes
6 capsules per 21 day
cycle
Thalomid, Pomalyst*, Revlimid*
HYSINGLA ER Non
Formulary − Yes Yes 1 tablet per
day
fentanyl, morphine sulfate ER, oxycodone ER*, tramadol ER, Avinza, Butrans*, Nucynta ER*,
Oxycontin*
LENVIMA Formulary Specialty Yes Yes
3 capsules per day, 30 day supply
per fill
Caprelsa*, Cometriq*, Nexavar*
MIRCERA Non
Formulary − Yes No − Aranesp*, Epogen*, Procrit*
NALOXONE PREFILLED SYRINGES
Formulary 2 No No −
PREZCOBIX Formulary 3 No No −
Aptivus, Crixivan, Invirase, Kaletra, Lexiva, Prezista,
Reyataz, Viracept
SAVAYSA Non
Formulary − Yes Yes 1 tablet per
day warfarin, Eliquis, Xarelto
ZOHYDRO ER Non
Formulary − Yes Yes 2 tablets per
day
fentanyl, morphine sulfate ER, oxycodone ER*, tramadol ER, Avinza, Butrans*, Nucynta ER*,
Oxycontin*
* Indicates prior authorization (PA) or step therapy (ST)
