October 2021 2021 EMPIRE PLAN FLEXIBLE FORMULARY …

April 2024

2024 Empire Plan Flexible Formulary

Preferred Drug List Administered by CVS Caremark?

The Empire Plan Flexible Formulary Preferred Drug List is a guide within select therapeutic categories for

enrollees and health care providers. Generics should be considered the first line of prescribing. If there is

no generic available, there may be more than one brand-name drug to treat a condition. These preferred

brand-name drugs are listed to help identify products that are clinically appropriate and cost-effective. This is

not an all-inclusive list. This list includes commonly prescribed covered drugs by therapeutic class, a list of

commonly prescribed covered drugs in alphabetic order (Quick Reference Drug List), a list of commonly

prescribed non-preferred (Level 3) drugs along with covered preferred drug alternatives, and a list of

excluded drugs along with covered preferred drug alternatives. This list represents brand products in CAPS

and generic products in lowercase italics.

Generally generics are subject to a Level 1 copayment, or the lowest copayment; preferred brand drugs are

subject to a Level 2 copayment, and non-preferred brand drugs are subject to a Level 3 copayment, or the

highest copayment. Refer to your plan materials for specific information regarding copay amounts.

ENROLLEE

Your benefit plan provides you with prescription drug coverage administered by CVS Caremark. Ask your

doctor to consider prescribing, when medically appropriate, a preferred medicine from this list. Take this list

the next time you or a covered family member sees a doctor.

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You will be responsible for the full cost of medications and products that are excluded from coverage

unless a request for a medical exception is approved. Medications and products recently approved by the

U.S. Food and Drug Administration (FDA) may be subject to exclusion upon release to the market.

For specific information regarding your prescription benefit coverage and copay information, please visit

or call 1-877-7-NYSHIP (1-877-769-7447) and select option 4.

When a generic medication that is equivalent to a brand-name drug is released to the market, in most

instances, that brand-name drug will be designated as a non-preferred option. In this case, use of a nonpreferred product will result in you paying the applicable non-preferred copayment plus the difference in

cost between the brand-name drug and the generic, not to exceed the full retail cost of the drug (Ancillary

Charge).

HEALTH CARE PROVIDER

Your patient is covered under a prescription benefit plan administered by CVS Caremark. As a way to help

manage health care costs, authorize generic substitution whenever possible. If you believe a brand-name

product is necessary, consider prescribing a brand-name drug on this list.

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Generics should be considered the first line of prescribing.

This drug list represents a summary of prescription coverage. It is not all-inclusive and does not

guarantee coverage.

The enrollee's prescription benefit plan may have a different copay for specific products on the list.

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Unless specifically indicated, drug list products will include all dosage forms.

Log in to to check coverage and copay information for a specific

medicine.

LEGEND

B4G = Brand for Generic medication; Brand-name product is dispensed at the generic copayment

PA = Prior Authorization

PA/QL = Prior Authorization then Quantity Limit

QL = Quantity Limit

QL/PA = Quantity Limit with PA for possible additional quantity

SGM = Specialty Guideline Management

ANALGESICS

COX-2 INHIBITORS

celecoxib

GOUT

allopurinol

colchicine

febuxostat

probenecid

NON-OPIOID ANALGESICS

butalbital-acetaminophencaffeine

butalbital-aspirin-caffeine

NSAIDS

diclofenac sodium

etodolac

ibuprofen

meloxicam tablet

nabumetone

naproxen (except naproxen CR or

naproxen suspension)

naproxen sodium

oxaprozin

sulindac

NSAIDS, COMBINATIONS

diclofenac sodium-misoprostol

OPIOID ANALGESICS

codeine-acetaminophen QL

fentanyl buccal tablet PA/QL

fentanyl transdermal QL/PA

fentanyl transmucosal lozenge

PA/QL

hydrocodone ext-rel QL/PA

hydrocodone-acetaminophen

morphine suppository QL/PA

oxycodone QL/PA

oxycodone ext-rel QL/PA

oxycodone-acetaminophen

QL/PA

tramadol QL/PA

tramadol ext-rel QL/PA

NUCYNTA QL/PA

NUCYNTA ER QL/PA

SUBSYS PA/QL

XTAMPZA ER QL/PA

posaconazole (except posaconazole

OPIOID PARTIAL AGONISTS

ANTIRETROVIRAL AGENTS

buprenorphine transdermal

QL/PA

BELBUCA QL/PA

abacavir

atazanavir

darunavir

efavirenz

etravirine

lamivudine

maraviroc

ritonavir

ISENTRESS

ISENTRESS HD

TIVICAY

TIVICAY PD

SALICYLATES

diflunisal

VISCOSUPPLEMENTS

DUROLANE

GELSYN-3

HYALGAN

SUPARTZ FX

ANTI-INFECTIVES

ANTHELMINTICS

albendazole QL/PA

ivermectin tablet

praziquantel QL/PA

EMVERM

ANTI-BACTERIALS MISCELLANEOUS

sulfamethoxazoletrimethoprim

tinidazole

(except hydrocodone-acetaminophen

ANTIFUNGALS

tablet 7.5-300 mg, 10-300 mg)

fluconazole

griseofulvin ultramicrosize

itraconazole PA

nystatin

QL/PA

hydromorphone QL/PA

hydromorphone ext-rel QL/PA

methadone QL/PA

morphine QL/PA

morphine ext-rel QL/PA

delayed-rel tablet)

terbinafine tablet PA

voriconazole

NOXAFIL PAK

ANTIMALARIALS

atovaquone-proguanil

chloroquine

mefloquine

COARTEM

ANTIRETROVIRAL

COMBINATION AGENTS

abacavir-lamivudine

efavirenz-emtricitabinetenofovir disoproxil fumarate

efavirenz-lamivudine-tenofovir

disoproxil fumarate

emtricitabine-tenofovir

disoproxil fumarate

BIKTARVY

CIMDUO

DESCOVY

DOVATO

EVOTAZ

GENVOYA

ODEFSEY

STRIBILD

SYMTUZA

TRIUMEQ

ANTITUBERCULAR AGENTS

ethambutol

isoniazid

pyrazinamide

rifampin

PRIFTIN

TRECATOR

ANTIVIRALS

acyclovir

entecavir

famciclovir

lamivudine

oseltamivir QL/PA

valacyclovir

valganciclovir

BARACLUDE SOLUTION

EPIVIR HBV SOLUTION

RELENZA QL/PA

VEMLIDY

CEPHALOSPORINS

cefadroxil

cefdinir

cefixime

cefprozil

cefuroxime axetil

cephalexin

ERYTHROMYCINS /

MACROLIDES

azithromycin

clarithromycin

clarithromycin ext-rel

erythromycins

DIFICID

FLUOROQUINOLONES

ciprofloxacin

levofloxacin

moxifloxacin

HEPATITIS B AGENTS

tenofovir disoproxil fumarate

HEPATITIS C

ribavirin SGM

2

EPCLUSA SGM

HARVONI SGM

PEGASYS SGM

SOVALDI SGM

VOSEVI SGM

MISCELLANEOUS

atovaquone

clindamycin

dapsone

linezolid

metronidazole

nitazoxanide

nitrofurantoin

pentamidine

pyrimethamine

trimethoprim

vancomycin

ALINIA SUSPENSION

SIVEXTRO

XIFAXAN 550 MG

NUCLEOTIDE REVERSE

TRANSCRIPTASE

INHIBITORS

tenofovir disoproxil fumarate

PENICILLINS

amoxicillin

amoxicillin-clavulanate

ampicillin

dicloxacillin

penicillin vk

TETRACYCLINES

doxycycline hyclate

minocycline

tetracycline

ANTINEOPLASTIC

AGENTS

ANTIMETABOLITES

pemetrexed

KINASE INHIBITORS

gefitinib SGM

imatinib mesylate SGM

ALECENSA SGM

ALUNBRIG SGM

AVASTIN SGM

BOSULIF SGM

CABOMETYX SGM

IBRANCE SGM

ICLUSIG SGM

KISQALI SGM

KISQALI FEMARA CO-PACK

SGM

RYDAPT SGM

SPRYCEL SGM

TASIGNA SGM

VERZENIO SGM

VITRAKVI SGM

MISCELLANEOUS

LYNPARZA SGM

RUBRACA SGM

ZEJULA SGM

PROTEASOME INHIBITORS

bortezomib SGM

NINLARO SGM

CARDIOVASCULAR

ACE INHIBITOR

COMBINATIONS

amlodipine-benazepril

benazeprilhydrochlorothiazide

captopril-hydrochlorothiazide

enalapril-hydrochlorothiazide

fosinopril-hydrochlorothiazide

lisinopril-hydrochlorothiazide

quinapril-hydrochlorothiazide

trandolapril-verapamil ext-rel

ACE INHIBITORS

amlodipine-telmisartan

amlodipine-valsartan

amlodipine-valsartanhydrochlorothiazide

candesartanhydrochlorothiazide

irbesartan-hydrochlorothiazide

losartan-hydrochlorothiazide

olmesartan-amlodipinehydrochlorothiazide

olmesartanhydrochlorothiazide

telmisartanhydrochlorothiazide

valsartan-hydrochlorothiazide

lovastatin

pravastatin

rosuvastatin

simvastatin

ANGIOTENSIN II RECEPTOR

ANTAGONISTS

PRALUENT PA

REPATHA PA

candesartan

irbesartan

losartan

olmesartan

telmisartan

valsartan

BETA-BLOCKER/DIURETIC

COMBINATIONS

ANTIARRHYTHMICS

BETA-BLOCKERS

amiodarone

disopyramide

dofetilide SGM

flecainide

propafenone

propafenone ext-rel

sotalol

MULTAQ

ANTILIPEMICS, BILE ACID

RESINS

cholestyramine

colesevelam

colestipol

ANTILIPEMICS,

CHOLESTEROL ABSORPTION

INHIBITOR

RITUXAN SGM

benazepril

captopril

enalapril

fosinopril

lisinopril

perindopril

quinapril

ramipril

trandolapril

HORMONAL

ANTINEOPLASTIC AGENTS

ALDOSTERONE RECEPTOR

ANTAGONISTS

ANTILIPEMICS, HMG-COA

REDUCTASE INHIBITORS /

COMBINATIONS

abiraterone SGM

ELIGARD SGM

ERLEADA SGM

LUPRON DEPOT SGM

XTANDI SGM

YONSA SGM

eplerenone

ezetimibe-simvastatin

ANGIOTENSIN II RECEPTOR

ANTAGONIST

COMBINATIONS

ANTILIPEMICS, HMG-COA

REDUCTASE INHIBITORS

BIOLOGIC RESPONSE

MODIFIERS

lenalidomide SGM

ERIVEDGE SGM

REVLIMID SGM

BIOSIMILARS

amlodipine-olmesartan

ezetimibe

ANTILIPEMICS, FIBRATES

fenofibrate (except fenofibrate capsule

50 mg, 130 mg; fenofibrate tablet 40 mg,

120 mg)

fenofibric acid delayed-rel

gemfibrozil

atorvastatin

fluvastatin

ANTILIPEMICS,

MISCELLANEOUS

niacin ext-rel

ANTILIPEMICS, OMEGA-3

FATTY ACIDS

omega-3-acid ethyl esters

VASCEPA B4G

ANTILIPEMICS, PCSK9

INHIBITORS

atenolol-chlorthalidone

bisoprolol-hydrochlorothiazide

metoprololhydrochlorothiazide

atenolol

bisoprolol

carvedilol

labetalol

metoprolol succinate ext-rel

metoprolol tartrate

nadolol

nebivolol

pindolol

propranolol

propranolol ext-rel

CALCIUM CHANNEL

BLOCKERS

amlodipine

diltiazem ext-rel

felodipine ext-rel

nifedipine ext-rel

verapamil ext-rel

DIGITALIS GLYCOSIDES

digoxin

DIRECT RENIN INHIBITORS /

COMBINATIONS

aliskiren

TEKTURNA HCT

DIURETICS

acetazolamide

acetazolamide ext-rel

amiloride

amiloride-hydrochlorothiazide

bumetanide

chlorthalidone

furosemide

3

hydrochlorothiazide

indapamide

methazolamide

metolazone

spironolactone

spironolactonehydrochlorothiazide

torsemide

triamterene

triamterenehydrochlorothiazide

lorazepam

oxazepam

HEART FAILURE

ANTIDEPRESSANTS

isosorbide dinitratehydralazine

CORLANOR

ENTRESTO

amitriptyline

bupropion

bupropion ext-rel (except bupropion

MISCELLANEOUS

clonidine

clonidine transdermal

guanfacine

hydralazine

methyldopa

midodrine

phenoxybenzamine

ranolazine ext-rel

NITRATES

isosorbide dinitrate (except

isosorbide dinitrate tablet 40 mg)

isosorbide mononitrate

isosorbide mononitrate ext-rel

nitroglycerin lingual spray

nitroglycerin sublingual tablet

nitroglycerin transdermal

PULMONARY ARTERIAL

HYPERTENSION

ambrisentan SGM

bosentan SGM

epoprostenol SGM

sildenafil 20 mg SGM

tadalafil SGM

treprostinil SGM

ADEMPAS SGM

OPSUMIT SGM

TYVASO SGM

UPTRAVI SGM

VENTAVIS SGM

CENTRAL NERVOUS

SYSTEM

ALCOHOL DETERRENTS

disulfiram

ANTIANXIETY

alprazolam

buspirone

clomipramine

fluvoxamine

ANTIDEMENTIA

donepezil

galantamine

galantamine ext-rel

memantine

rivastigmine

rivastigmine transdermal

NAMZARIC

ext-rel tablet 450 mg)

citalopram

desipramine

desvenlafaxine ext-rel

doxepin

duloxetine

escitalopram

fluoxetine (except fluoxetine tablet 60

ANTIPSYCHOTICS

aripiprazole

chlorpromazine

clozapine

fluphenazine

haloperidol

lurasidone

olanzapine

perphenazine

quetiapine

quetiapine ext-rel

risperidone

risperidone microsphere

injection

thiothixene

trifluoperazine

ziprasidone

ABILIFY MAINTENA

ARISTADA

ARISTADA INITIO

INVEGA SUSTENNA

INVEGA TRINZA

VRAYLAR

mg, fluoxetine tablet [generics for

ANTISEIZURE AGENTS

SARAFEM])

carbamazepine

carbamazepine ext-rel

clobazam

clonazepam

diazepam

diazepam rectal gel

divalproex sodium

divalproex sodium ext-rel

ethosuximide

gabapentin

lacosamide

lamotrigine

lamotrigine ext-rel

levetiracetam

levetiracetam ext-rel

oxcarbazepine

phenobarbital

phenytoin

phenytoin sodium extended

pregabalin

primidone

rufinamide

tiagabine

topiramate

topiramate ext-rel capsule

valproic acid

vigabatrin

zonisamide

DILANTIN 30 MG

FYCOMPA

OXTELLAR XR

imipramine hcl

mirtazapine

nortriptyline

paroxetine hcl

paroxetine hcl ext-rel

phenelzine

sertraline

tranylcypromine

trazodone

venlafaxine

venlafaxine ext-rel

vilazodone

MARPLAN

TRINTELLIX

ANTIPARKINSONIAN

AGENTS

amantadine

apomorphine SGM

benztropine

bromocriptine

carbidopa-levodopa

carbidopa-levodopa ext-rel

carbidopa-levodopaentacapone

entacapone

pramipexole

pramipexole ext-rel

rasagiline

ropinirole

selegiline

trihexyphenidyl

NEUPRO

RYTARY

ZELAPAR

ATTENTION DEFICIT

HYPERACTIVITY DISORDER

amphetaminedextroamphetamine mixed

salts

amphetaminedextroamphetamine mixed

salts ext-rel

atomoxetine

dexmethylphenidate

dexmethylphenidate ext-rel

dextroamphetamine

dextroamphetamine ext-rel

guanfacine ext-rel

lisdexamfetamine

methylphenidate

methylphenidate ext-rel

FIBROMYALGIA

SAVELLA

HYPNOTICS

doxepin

eszopiclone

temazepam

zolpidem

zolpidem ext-rel

BELSOMRA

MIGRAINE

dihydroergotamine injection

eletriptan QL/PA

naratriptan QL/PA

rizatriptan QL

sumatriptan QL/PA

zolmitriptan QL/PA

AJOVY

EMGALITY

NURTEC ODT

QULIPTA

UBRELVY

ZEMBRACE SYMTOUCH

MISCELLANEOUS

lithium carbonate

lithium carbonate ext-rel

pyridostigmine

pyridostigmine ext-rel

MOVEMENT DISORDERS

tetrabenazine

AUSTEDO SGM

INGREZZA SGM

MULTIPLE SCLEROSIS

AGENTS

dalfampridine ext-rel SGM

dimethyl fumarate SGM

fingolimod SGM

glatiramer SGM

teriflunomide SGM

AVONEX SGM

4

BETASERON SGM

COPAXONE SGM

MAYZENT SGM

PLEGRIDY SGM

REBIF SGM

TYSABRI SGM

VUMERITY SGM

ZEPOSIA SGM

MUSCULOSKELETAL

THERAPY AGENTS

baclofen

carisoprodol 350 mg

chlorzoxazone 375 mg

cyclobenzaprine (except

cyclobenzaprine tablet 7.5 mg)

dantrolene

metaxalone

methocarbamol (except

methocarbamol tablet 1000 mg)

orphenadrine 50 mg-aspirin

770 mg-caffeine 60 mg

tizanidine

NARCOLEPSY/CATAPLEXY

armodafinil PA

modafinil PA

LUMRYZ SGM

SUNOSI

WAKIX SGM

XYWAV SGM

OPIOID

AGONIST/ANTAGONIST

buprenorphine-naloxone

sublingual tablet

ZUBSOLV

OPIOID ANTAGONIST

naloxone injection

naloxone nasal spray

naltrexone

VIVITROL SGM

POSTHERPETIC NEURALGIA

(PHN)

gabapentin ext-rel

GRALISE 450 MG, 750 MG,

900 MG

PSYCHOTHERAPEUTICMISC

paroxetine mesylate

pimozide

NUEDEXTA

SMOKING DETERRENTS

bupropion ext-rel

varenicline

NICOTROL

NICOTROL NS

ENDOCRINE AND

METABOLIC

ACROMEGALY

SANDOSTATIN LAR SGM

SOMATULINE DEPOT SGM

SOMAVERT SGM

ANDROGENS

testosterone cypionate

testosterone enanthate

testosterone solution

ANDRODERM

LANTUS

LEVEMIR

NOVOLIN 70/30

NOVOLIN N

NOVOLIN R

NOVOLOG

NOVOLOG MIX 70/30

TOUJEO

TRESIBA

ANTIDIABETICS, INSULIN

SENSITIZER

pioglitazone

ANTIOBESITY

CONTRAVE PA

SAXENDA PA

WEGOVY PA

ZEPBOUND PA

BISPHOSPHONATES

alendronate

ibandronate

risedronate

CALCIUM RECEPTOR

AGONISTS

cinacalcet SGM

ANTIDIABETICS, ALPHAGLUCOSIDASE INHIBITORS

ANTIDIABETICS, INSULIN

SENSITIZER/BIGUANIDE

COMBINATION

acarbose

pioglitazone-metformin

levocarnitine

ANTIDIABETICS, AMYLIN

ANALOGS

ANTIDIABETICS, INSULIN

SENSITIZER /

SULFONYLUREA

COMBINATION

CHELATING AGENTS

SYMLINPEN

ANTIDIABETICS, BIGUANIDE

metformin

metformin ext-rel

ANTIDIABETICS,

BIGUANIDE/

SULFONYLUREA

COMBINATIONS

glipizide-metformin

ANTIDIABETICS,

DIPEPTIDYL PEPTIDASE-4

INHIBITORS

JANUVIA

TRADJENTA

ANTIDIABETICS, DPP-4

INHIBITOR COMBINATIONS

pioglitazone-glimepiride

ANTIDIABETICS,

MEGLITINIDE

nateglinide

repaglinide

ANTIDIABETICS, SODIUMGLUCOSE

COTRANSPORTER-2 (SGLT2)

INHIBITOR COMBINATIONS

INVOKAMET

INVOKAMET XR

SYNJARDY B4G

SYNJARDY XR B4G

XIGDUO XR B4G

JANUMET

JANUMET XR

JENTADUETO

JENTADUETO XR

ANTIDIABETICS, SODIUMGLUCOSE

COTRANSPORTER-2 (SGLT2)

INHIBITOR/DPP-4

INHIBITOR COMBINATIONS

ANTIDIABETICS, INCRETIN

MIMETIC AGENTS

GLYXAMBI

QTERN

MOUNJARO PA

OZEMPIC PA

RYBELSUS PA

TRULICITY PA

VICTOZA PA

ANTIDIABETICS, SODIUMGLUCOSE

COTRANSPORTER-2 (SGLT2)

INHIBITORS

ANTIDIABETICS, INCRETIN

MIMETIC COMBINATION

AGENTS

SOLIQUA

XULTOPHY

ANTIDIABETICS, INSULIN

FIASP

HUMULIN R U-500

FARXIGA B4G

INVOKANA

JARDIANCE B4G

ANTIDIABETICS,

SULFONYLUREA

glimepiride

glipizide

glipizide ext-rel

CARNITINE DEFICIENCY

AGENTS

deferasirox SGM

penicillamine

trientine

CHEMET

LOKELMA

VELTASSA

CONTRACEPTIVES

ethinyl estradiol-desogestrel

ethinyl estradiol-drospirenone

ethinyl estradiol-drospirenonelevomefolate

ethinyl estradiol-ethynodiol

diacetate

ethinyl estradiol-levonorgestrel

ethinyl estradiolnorelgestromin

ethinyl estradiol-norethindrone

acetate

ethinyl estradiol-norethindrone

acetate-iron

ethinyl estradiol-norgestimate

medroxyprogesterone acetate

150 mg/ml

norethindrone

DEPO-SUBQ PROVERA

KYLEENA

LO LOESTRIN FE

MIRENA

NATAZIA

NUVARING B4G

SKYLA

DIABETIC SUPPLIES

DEXCOM CONTINUOUS

GLUCOSE MONITORING

SYSTEM

OMNIPOD 5 INSULIN

INFUSION PUMP

ENDOMETRIOSIS

danazol

5

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