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Medication Formulary

Grandfathered Commercial Plans

  • Select Plan to view: 2021 Prescription Drug Formulary (PDF) | Drug Search | Prior Authorization Criteria

B62 G01 G20 H01 H23 321 615 621 622
625 632 640 651 652 660 683 684

Non-Grandfathered Commercial Plans

Federal Exchange Plans

Prior Authorization Form