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.
1
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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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