| Guideline | Drug Name |
|---|---|
| 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 |
| High-Cost Brand with Generics Program | |
| HIV PEP/PrEP - Copay Waiver | Combivir, Epivir, Kaletra, Descovy, Isentress, Retrovir, Tivicay, Truvada, Viread |
| Horizant (gabapentin enacarbil) | Horizant (gabapentin enacarbil) |
| Hyaluronic Acid Derivatives - PA, NF | Durolane/Euflexxa/Hyalgan/Sodium Hyaluronate/Supartz FX/Gelsyn-3/Genvisc 850/Triluron/TriVisc/Visco-3 (sodium hyaluronate), Gel-One (cross-linked hyaluronate), Monovisc/Orthovisc/Hymovis (hyaluronan), Synvisc/Synvisc-One (hylan), Synojoynt |
| Hyftor (sirolimus) topical gel | Hyftor (sirolimus) topical gel |
| Hympavzi (marstacimab-hncq) | Hympavzi (marstacimab-hncq) |
| Ibrance (palbociclib) | Ibrance (palbociclib) |
| IBS - Diarrhea | Lotronex (alosetron hydrochloride), Viberzi (eluxadoline) |
| Ibsrela (tenapanor) - PA, NF | Ibsrela (tenapanor) |
| Iclusig (ponatinib) | Iclusig (ponatinib) |
| Idhifa (enasidenib) | Idhifa (enasidenib) |
| iDose TR (travoprost intracameral implant) | iDose TR (travoprost intracameral implant) |
| Igalmi (dexmedetomidine) | Igalmi (dexmedetomidine) |
| Ilaris (canakinumab injection) | Ilaris (canakinumab injection) |
| Ilumya (tildrakizumab-asmn) - PA, NF | Ilumya (tildrakizumab-asmn) |
| Imatinib Products - PA, NF | Gleevec (imatinib mesylate), Imkeldi |
| Imbruvica (ibrutinib) - PA, NF | Imbruvica (ibrutinib) |
| Imcivree (setmelanotide) – PA, NF | Imcivree (setmelanotide) |
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