Votrient Tablet 200 MG Oral

---

Alternative Drugs

---

Drug	Tier*	Drug Restrictions	Therapy Class
PAZOPanib HCl Tablet 200 MG Oral	Tier 5	PA, QL	Molecular Target Inhibitors
* Please reference your Evidence of Coverage for applicable cost-sharing.

Vyvanse Capsule 10 MG Oral

---

Alternative Drugs

---

Drug	Tier*	Drug Restrictions	Therapy Class
Lisdexamfetamine Dimesylate Capsule 10 MG Oral	Tier 2	QL	Attention Deficit Hyperactivity Disorder Agents, Amphetamines
* Please reference your Evidence of Coverage for applicable cost-sharing.

Vyvanse Capsule 20 MG Oral

---

Alternative Drugs

---

Drug	Tier*	Drug Restrictions	Therapy Class
Lisdexamfetamine Dimesylate Capsule 20 MG Oral	Tier 2	QL	Attention Deficit Hyperactivity Disorder Agents, Amphetamines
* Please reference your Evidence of Coverage for applicable cost-sharing.

Vyvanse Capsule 30 MG Oral

---

Alternative Drugs

---

Drug	Tier*	Drug Restrictions	Therapy Class
Lisdexamfetamine Dimesylate Capsule 30 MG Oral	Tier 2	QL	Attention Deficit Hyperactivity Disorder Agents, Amphetamines
* Please reference your Evidence of Coverage for applicable cost-sharing.

Vyvanse Capsule 40 MG Oral

---

Alternative Drugs

---

Drug	Tier*	Drug Restrictions	Therapy Class
Lisdexamfetamine Dimesylate Capsule 40 MG Oral	Tier 2	QL	Attention Deficit Hyperactivity Disorder Agents, Amphetamines
* Please reference your Evidence of Coverage for applicable cost-sharing.

Vyvanse Capsule 50 MG Oral

---

Alternative Drugs

---

Drug	Tier*	Drug Restrictions	Therapy Class
Lisdexamfetamine Dimesylate Capsule 50 MG Oral	Tier 2	QL	Attention Deficit Hyperactivity Disorder Agents, Amphetamines
* Please reference your Evidence of Coverage for applicable cost-sharing.

Vyvanse Capsule 60 MG Oral

---

Alternative Drugs

---

Drug	Tier*	Drug Restrictions	Therapy Class
Lisdexamfetamine Dimesylate Capsule 60 MG Oral	Tier 2	QL	Attention Deficit Hyperactivity Disorder Agents, Amphetamines
* Please reference your Evidence of Coverage for applicable cost-sharing.

Vyvanse Capsule 70 MG Oral

---

Alternative Drugs

---

Drug	Tier*	Drug Restrictions	Therapy Class
Lisdexamfetamine Dimesylate Capsule 70 MG Oral	Tier 2	QL	Attention Deficit Hyperactivity Disorder Agents, Amphetamines
* Please reference your Evidence of Coverage for applicable cost-sharing.

Zulresso Solution 100 MG/20ML Intravenous

---

Alternative Drugs

---

Drug	Tier*	Drug Restrictions	Therapy Class
Citalopram Hydrobromide Tablet 10 MG Oral	Tier 1		SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors)
Citalopram Hydrobromide Tablet 20 MG Oral	Tier 1		SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors)
Citalopram Hydrobromide Tablet 40 MG Oral	Tier 1		SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors)
FLUoxetine HCl Capsule 10 MG Oral	Tier 1		SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors)
FLUoxetine HCl Capsule 20 MG Oral	Tier 1		SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors)
FLUoxetine HCl Capsule 40 MG Oral	Tier 1		SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors)
Sertraline HCl Tablet 100 MG Oral	Tier 1		SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors)
Sertraline HCl Tablet 25 MG Oral	Tier 1		SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors)
Sertraline HCl Tablet 50 MG Oral	Tier 1		SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors)
* Please reference your Evidence of Coverage for applicable cost-sharing.

Alphagan P Solution 0.1 % Ophthalmic

---

Alternative Drugs

---

Drug	Tier*	Drug Restrictions	Therapy Class
Brimonidine Tartrate Solution 0.1 % Ophthalmic	Tier 2		Ophthalmic Intraocular Pressure Lowering Agents, Other
* Please reference your Evidence of Coverage for applicable cost-sharing.

Ciprodex Suspension 0.3-0.1 % Otic

---

Alternative Drugs

---

Drug	Tier*	Drug Restrictions	Therapy Class
Ciprofloxacin-Dexamethasone Suspension 0.3-0.1 % Otic	Tier 2		Otic Agents
* Please reference your Evidence of Coverage for applicable cost-sharing.

Condylox Gel 0.5 % External

---

Alternative Drugs

---

Drug	Tier*	Drug Restrictions	Therapy Class
Podofilox Gel 0.5 % External	Tier 4		Dermatological Agents, Other
* Please reference your Evidence of Coverage for applicable cost-sharing.

Livalo Tablet 1 MG Oral

---

Alternative Drugs

---

Drug	Tier*	Drug Restrictions	Therapy Class
Pitavastatin Calcium Tablet 1 MG Oral	Tier 2	QL	Dyslipidemics, HMG CoA Reductase Inhibitors
* Please reference your Evidence of Coverage for applicable cost-sharing.

Livalo Tablet 2 MG Oral

---

Alternative Drugs

---

Drug	Tier*	Drug Restrictions	Therapy Class
Pitavastatin Calcium Tablet 2 MG Oral	Tier 2	QL	Dyslipidemics, HMG CoA Reductase Inhibitors
* Please reference your Evidence of Coverage for applicable cost-sharing.

Livalo Tablet 4 MG Oral

---

Alternative Drugs

---

Drug	Tier*	Drug Restrictions	Therapy Class
Pitavastatin Calcium Tablet 4 MG Oral	Tier 2	QL	Dyslipidemics, HMG CoA Reductase Inhibitors
* Please reference your Evidence of Coverage for applicable cost-sharing.

Korlym Tablet 300 MG Oral

---

Alternative Drugs

---

Drug	Tier*	Drug Restrictions	Therapy Class
miFEPRIStone Tablet 300 MG Oral	Tier 5	PA	Glycemic Agents
* Please reference your Evidence of Coverage for applicable cost-sharing.

Rectiv Ointment 0.4 % Rectal

---

Alternative Drugs

---

Drug	Tier*	Drug Restrictions	Therapy Class
Nitroglycerin Ointment 0.4 % Rectal	Tier 4		Vasodilators, Direct-acting Arterial/ Venous
* Please reference your Evidence of Coverage for applicable cost-sharing.

Relyvrio Packet 3-1 GM Oral

---

Alternative Drugs

---

Drug	Tier*	Drug Restrictions	Therapy Class
Riluzole Tablet 50 MG Oral	Tier 2		Central Nervous System, Other
* Please reference your Evidence of Coverage for applicable cost-sharing.

Sorine Tablet 80 MG Oral

---

Alternative Drugs

---

Drug	Tier*	Drug Restrictions	Therapy Class
Sotalol HCl (AF) Tablet 80 MG Oral	Tier 2		Antiarrhythmics
* Please reference your Evidence of Coverage for applicable cost-sharing.

Exkivity Capsule 40 MG Oral

---

Alternative Drugs

---

Drug	Tier*	Drug Restrictions	Therapy Class
Tagrisso Tablet 40 MG Oral	Tier 5	LA, PA, QL	Molecular Target Inhibitors
Tagrisso Tablet 80 MG Oral	Tier 5	LA, PA, QL	Molecular Target Inhibitors
* Please reference your Evidence of Coverage for applicable cost-sharing.

Zejula Capsule 100 MG Oral

---

Alternative Drugs

---

Drug	Tier*	Drug Restrictions	Therapy Class
Zejula Tablet 100 MG Oral	Tier 5	PA, QL	Molecular Target Inhibitors
* Please reference your Evidence of Coverage for applicable cost-sharing.

Amcinonide Cream 0.1 % External

---

Alternative Drugs

---

Drug	Tier*	Drug Restrictions	Therapy Class
Amcinonide Ointment 0.1 % External	Tier 4		Dermatitis and Pruitus Agents
* Please reference your Evidence of Coverage for applicable cost-sharing.

Endari Packet 5 GM Oral

---

Alternative Drugs

---

Drug	Tier*	Drug Restrictions	Therapy Class
L-Glutamine Packet 5 GM Oral	Tier 5	QL, ST	Genetic or Enzyme or Protein Disorder: Replacement, Modifiers, Treatment
* Please reference your Evidence of Coverage for applicable cost-sharing.

Isturisa Tablet 10 MG Oral

---

Alternative Drugs

---

Drug	Tier*	Drug Restrictions	Therapy Class
Isturisa Tablet 1 MG Oral	Tier 5	PA, QL	Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal)
Isturisa Tablet 5 MG Oral	Tier 5	PA, QL	Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal)
* Please reference your Evidence of Coverage for applicable cost-sharing.

Lexiva Suspension 50 MG/ML Oral

---

Alternative Drugs

---

Drug	Tier*	Drug Restrictions	Therapy Class
Fosamprenavir Calcium Tablet 700 MG Oral	Tier 5		Anti-HIV Agents, Protease Inhibitors (PI)
* Please reference your Evidence of Coverage for applicable cost-sharing.

Zorbtive Solution Reconstituted 8.8 MG Subcutaneous

---

Alternative Drugs

---

Drug	Tier*	Drug Restrictions	Therapy Class
Gattex KIT 5 MG Subcutaneous	Tier 5	LA, PA	Gastrointestinal Agents, Other
* Please reference your Evidence of Coverage for applicable cost-sharing.

Efavirenz Capsule 200 MG Oral

---

Alternative Drugs

---

Drug	Tier*	Drug Restrictions	Therapy Class
Efavirenz Tablet 600 MG Oral	Tier 4		Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)
Efavirenz-lamiVUDine-Tenofovir Tablet 400-300-300 MG Oral	Tier 2		Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)
* Please reference your Evidence of Coverage for applicable cost-sharing.

Efavirenz Capsule 50 MG Oral

---

Alternative Drugs

---

Drug	Tier*	Drug Restrictions	Therapy Class
Efavirenz Tablet 600 MG Oral	Tier 4		Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)
Efavirenz-lamiVUDine-Tenofovir Tablet 400-300-300 MG Oral	Tier 2		Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)
* Please reference your Evidence of Coverage for applicable cost-sharing.

Sancuso Patch 3.1 MG/24HR Transdermal

---

Alternative Drugs

---

Drug	Tier*	Drug Restrictions	Therapy Class
Granisetron HCl Tablet 1 MG Oral	Tier 2	PA	Emetogenic Therapy Adjuncts
* Please reference your Evidence of Coverage for applicable cost-sharing.

Oxbryta Tablet 500 MG Oral

---

Alternative Drugs

---

Drug	Tier*	Drug Restrictions	Therapy Class
L-Glutamine Packet 5 GM Oral	Tier 5	QL, ST	Genetic or Enzyme or Protein Disorder: Replacement, Modifiers, Treatment
* Please reference your Evidence of Coverage for applicable cost-sharing.

Sprycel Tablet 100 MG Oral

---

Alternative Drugs

---

Drug	Tier*	Drug Restrictions	Therapy Class
Dasatinib Tablet 100 MG Oral	Tier 5	PA, QL	Molecular Target Inhibitors
* Please reference your Evidence of Coverage for applicable cost-sharing.

Sprycel Tablet 140 MG Oral

---

Alternative Drugs

---

Drug	Tier*	Drug Restrictions	Therapy Class
Dasatinib Tablet 140 MG Oral	Tier 5	PA, QL	Molecular Target Inhibitors
* Please reference your Evidence of Coverage for applicable cost-sharing.

Sprycel Tablet 20 MG Oral

---

Alternative Drugs

---

Drug	Tier*	Drug Restrictions	Therapy Class
Dasatinib Tablet 20 MG Oral	Tier 5	PA, QL	Molecular Target Inhibitors
* Please reference your Evidence of Coverage for applicable cost-sharing.

Sprycel Tablet 50 MG Oral

---

Alternative Drugs

---

Drug	Tier*	Drug Restrictions	Therapy Class
Dasatinib Tablet 50 MG Oral	Tier 5	PA, QL	Molecular Target Inhibitors
* Please reference your Evidence of Coverage for applicable cost-sharing.

Sprycel Tablet 70 MG Oral

---

Alternative Drugs

---

Drug	Tier*	Drug Restrictions	Therapy Class
Dasatinib Tablet 70 MG Oral	Tier 5	PA, QL	Molecular Target Inhibitors
* Please reference your Evidence of Coverage for applicable cost-sharing.

Sprycel Tablet 80 MG Oral

---

Alternative Drugs

---

Drug	Tier*	Drug Restrictions	Therapy Class
Dasatinib Tablet 80 MG Oral	Tier 5	PA, QL	Molecular Target Inhibitors
* Please reference your Evidence of Coverage for applicable cost-sharing.

Tazorac Cream 0.05 % External

---

Alternative Drugs

---

Drug	Tier*	Drug Restrictions	Therapy Class
Tazarotene Cream 0.05 % External	Tier 4		Acne and Rosacea Agents
* Please reference your Evidence of Coverage for applicable cost-sharing.