PREMIER Formulary Drug List
EFFECTIVE: JULY 1, 2025
About this drug list
This is a list of the medications included in your prescription plan. It is not, however, a complete list of products that are on the formulary, nor does it guarantee coverage. Please ask your prescriber to consider preferred medications from this list when medically appropriate.
How to read this drug list
Use the chart below to help you read this drug list. This chart is just an example. It may not show how these medications are actually covered on the 2025 Access Premier Formulary List. Medications are listed by the condition they treat, then listed alphabetically.
The formulary is the list of drugs included in your prescription plan. Ask your prescriber to consider PREFERRED medications from this list when medically appropriate. Inclusion on the list does not guarantee coverage. The following list is not a complete list of products that are on the formulary.
Newly FDA approved medications are subject to evaluation by the Plan for coverage status and formulary placement prior to inclusion in the Prescription Drug Benefit including the Specialty Drug Benefit.
Abbreviations next to medications
In this drug list, formulary status (i.e., generic, preferred, or non-preferred) and extra coverage requirements (i.e., prior authorization) are indicated to the right of the medication. Here’s what they mean:
(G)
(NP)
(EX)
Generic Medication
Generic medications are denoted by (G). The most affordable medications.
Non-Preferred Medication
Non-preferred medications are denoted by (NP). The more expensive medications.
Excluded Medication
Excluded medications are denoted by (EX). The medications your plan does not cover.
(SP)
(PA)
Specialty Medication
Some medications are considered specialty medications. These medications are denoted by (SP) and are available through our specialty pharmacy network.
Prior Authorization
Certain medications require VerusRx’s approval before they are covered by your plan. These medications are denoted by (PA). Unless your doctor requests and receives approval from VerusRx, your plan will not cover these medications.
Abbreviations next to medications
Medications are organized into groups in the table below. First, identify the appropriate group for your medication, then navigate to that section to view the covered medications. If you cannot find your medication within a group, please use the search feature or contact our customer service team for assistance.
This list contains injectable medical drugs covered under medical policies. For specific questions about your coverage, please call the phone number printed on your member ID card.
For the Health Care Provider: Please prescribe PREFERRED products and allow generic substitutions when medically appropriate.
ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS
| MEDI-SPAN DRUG GROUP | MEDI-SPAN PRODUCT NAME | FORMULARY STATUS | SPECIALTY (SP) | PRIOR AUTHORIZATION (PA) |
|---|---|---|---|---|
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | ADDERALL | EXCLUDED | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | ADDERALL XR | EXCLUDED | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | AMPHETAMINE/DEXTROAMPHETA | GENERIC | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | AMPHETAMINE SULFATE | GENERIC | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | APTENSIO XR | EXCLUDED | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | ARMODAFINIL | GENERIC | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | ATOMOXETINE | GENERIC | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | ATOMOXETINE HYDROCHLORIDE | GENERIC | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | AZSTARYS | PREFERRED | PA | |
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | CAFFEINE CITRATE | EXCLUDED | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | CAFFEINE CITRATE | GENERIC | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | CAFFEINE CITRATE | NON PREFERRED | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | CAFFEINE ANHYDROUS | NON PREFERRED | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | CAFFEINE CITRATED | NON PREFERRED | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | CAFFEINE/SODIUM BENZOATE | GENERIC | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | CLONIDINE HCL ER | GENERIC | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | CLONIDINE HYDROCHLORIDE E | GENERIC | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | CONCERTA | EXCLUDED | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | DAYTRANA | EXCLUDED | PA | |
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | DEXMETHYLPHENIDATE HYDROC | GENERIC | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | DEXMETHYLPHENIDATE HCL ER | GENERIC | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | DEXMETHYLPHENIDATE HCL | GENERIC | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | DEXTROAMPHETAMINE SULFATE | GENERIC | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | DOPRAM | NON PREFERRED | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | DYANAVEL XR | EXCLUDED | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | EVEKEO | EXCLUDED | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | FOCALIN | NON PREFERRED | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | FOCALIN XR | EXCLUDED | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | GUANFACINE HYDROCHLORIDE | GENERIC | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | INTUNIV | EXCLUDED | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | JORNAY PM | EXCLUDED | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | LISDEXAMFETAMINE DIMESYLA | GENERIC | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | METADATE CD | EXCLUDED | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | METHAMPHETAMINE HYDROCHLO | GENERIC | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | METHYLIN | NON PREFERRED | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | METHYLPHENIDATE HYDROCHLO | GENERIC | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | METHYLPHENIDATE | GENERIC | PA | |
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | MODAFINIL | GENERIC | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | NUVIGIL | EXCLUDED | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | Onyda XR | EXCLUDED | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | PROCENTRA | GENERIC | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | PROVIGIL | EXCLUDED | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | QELBREE | PREFERRED | PA | |
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | QUILLICHEW ER | EXCLUDED | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | QUILLIVANT XR | EXCLUDED | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | RELEXXII | EXCLUDED | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | RITALIN LA | NON PREFERRED | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | RITALIN | NON PREFERRED | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | VYVANSE | EXCLUDED | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | WAKIX | PREFERRED | SP | PA |
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | XELSTRYM | EXCLUDED | PA | |
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | ZENZEDI | GENERIC |
AMEBICIDES
| MEDI-SPAN DRUG GROUP | MEDI-SPAN PRODUCT NAME | FORMULARY STATUS | SPECIALTY (SP) | PRIOR AUTHORIZATION (PA) |
|---|---|---|---|---|
| AMEBICIDES | IODOQUINOL | NON PREFERRED |
AMINOGLYCOSIDES
| MEDI-SPAN DRUG GROUP | MEDI-SPAN PRODUCT NAME | FORMULARY STATUS | SPECIALTY (SP) | PRIOR AUTHORIZATION (PA) |
|---|---|---|---|---|
| AMINOGLYCOSIDES | AMIKACIN SULFATE | GENERIC | ||
| AMINOGLYCOSIDES | AMIKACIN SULFATE | NON PREFERRED | ||
| AMINOGLYCOSIDES | ARIKAYCE | NON PREFERRED | SP | PA |
| AMINOGLYCOSIDES | BETHKIS | EXCLUDED | SP | PA |
| AMINOGLYCOSIDES | GENTAMICIN SULFATE/0.9% S | GENERIC | ||
| AMINOGLYCOSIDES | ISOTONIC GENTAMICIN | GENERIC | ||
| AMINOGLYCOSIDES | GENTAMICIN SULFATE PEDIAT | GENERIC | ||
| AMINOGLYCOSIDES | GENTAMICIN SULFATE | GENERIC | ||
| AMINOGLYCOSIDES | HUMATIN | EXCLUDED | ||
| AMINOGLYCOSIDES | KITABIS PAK | EXCLUDED | SP | PA |
| AMINOGLYCOSIDES | NEOMYCIN SULFATE | EXCLUDED | ||
| AMINOGLYCOSIDES | NEOMYCIN SULFATE | GENERIC | ||
| AMINOGLYCOSIDES | STREPTOMYCIN SULFATE | GENERIC | ||
| AMINOGLYCOSIDES | STREPTOMYCIN SULFATE | NON PREFERRED | ||
| AMINOGLYCOSIDES | TOBI | EXCLUDED | SP | PA |
| AMINOGLYCOSIDES | TOBI PODHALER | EXCLUDED | SP | PA |
| AMINOGLYCOSIDES | TOBRAMYCIN SULFATE | GENERIC | ||
| AMINOGLYCOSIDES | TOBRAMYCIN | GENERIC | SP | PA |
| AMINOGLYCOSIDES | TOBRAMYCIN SULFATE | NON PREFERRED |
ANALGESICS - ANTI-INFLAMMATORY
| MEDI-SPAN DRUG GROUP | MEDI-SPAN PRODUCT NAME | FORMULARY STATUS | SPECIALTY (SP) | PRIOR AUTHORIZATION (PA) |
|---|---|---|---|---|
| ANALGESICS - ANTI-INFLAMMATORY | ABRILADA | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | ACTEMRA | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | ACTEMRA IV | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | ADALIMUMAB-AACF | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | ADALIMUMAB-AATY | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | ADALIMUMAB-ADAZ | PREFERRED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | ADALIMUMAB-ADBM | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | ADALIMUMAB-FKJP | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | ADALIMUMAB-RYVK | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | AMJEVITA | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | ANAPROX DS | NON PREFERRED | ||
| ANALGESICS - ANTI-INFLAMMATORY | ARAVA | NON PREFERRED | ||
| ANALGESICS - ANTI-INFLAMMATORY | ARCALYST | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | ARTHROTEC 50 | EXCLUDED | ||
| ANALGESICS - ANTI-INFLAMMATORY | ARTHROTEC 75 | EXCLUDED | ||
| ANALGESICS - ANTI-INFLAMMATORY | Avtozma | EXCLUDED | ||
| ANALGESICS - ANTI-INFLAMMATORY | CALDOLOR | NON PREFERRED | ||
| ANALGESICS - ANTI-INFLAMMATORY | CELEBREX | EXCLUDED | ||
| ANALGESICS - ANTI-INFLAMMATORY | CELECOXIB | GENERIC | ||
| ANALGESICS - ANTI-INFLAMMATORY | CELECOXIB | EXCLUDED | ||
| ANALGESICS - ANTI-INFLAMMATORY | COMBOGESIC | EXCLUDED | ||
| ANALGESICS - ANTI-INFLAMMATORY | COXANTO | EXCLUDED | ||
| ANALGESICS - ANTI-INFLAMMATORY | CYLTEZO | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | DICLOFENAC SODIUM/MISOPRO | GENERIC | ||
| ANALGESICS - ANTI-INFLAMMATORY | DICLOFENAC POTASSIUM | EXCLUDED | ||
| ANALGESICS - ANTI-INFLAMMATORY | DICLOFENAC POTASSIUM | GENERIC | ||
| ANALGESICS - ANTI-INFLAMMATORY | DICLOFENAC SODIUM ER | GENERIC | ||
| ANALGESICS - ANTI-INFLAMMATORY | DICLOFENAC SODIUM DR | GENERIC | ||
| ANALGESICS - ANTI-INFLAMMATORY | EC-NAPROSYN | NON PREFERRED | ||
| ANALGESICS - ANTI-INFLAMMATORY | ENBREL | PREFERRED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | ETODOLAC | GENERIC | ||
| ANALGESICS - ANTI-INFLAMMATORY | ETODOLAC ER | GENERIC | ||
| ANALGESICS - ANTI-INFLAMMATORY | ETODOLAC | EXCLUDED | ||
| ANALGESICS - ANTI-INFLAMMATORY | FENOPROFEN CALCIUM | EXCLUDED | ||
| ANALGESICS - ANTI-INFLAMMATORY | FENOPROFEN CALCIUM | NON PREFERRED | ||
| ANALGESICS - ANTI-INFLAMMATORY | FENOPRON | EXCLUDED | ||
| ANALGESICS - ANTI-INFLAMMATORY | FLURBIPROFEN | NON PREFERRED | ||
| ANALGESICS - ANTI-INFLAMMATORY | FLURBIPROFEN | EXCLUDED | ||
| ANALGESICS - ANTI-INFLAMMATORY | FLURBIPROFEN | GENERIC | ||
| ANALGESICS - ANTI-INFLAMMATORY | HADLIMA | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | HULIO | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | Humira (1 Pen) | PREFERRED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | Humira (2 Pen) | PREFERRED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | HUMIRA | PREFERRED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | HYRIMOZ | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | HYRIMOZ | PREFERRED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | IBU | GENERIC | ||
| ANALGESICS - ANTI-INFLAMMATORY | IBUPROFEN LYSINE | GENERIC | ||
| ANALGESICS - ANTI-INFLAMMATORY | IBUPROFEN | GENERIC | ||
| ANALGESICS - ANTI-INFLAMMATORY | IBUPROFEN | EXCLUDED | ||
| ANALGESICS - ANTI-INFLAMMATORY | ILARIS | NON PREFERRED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | INDOCIN | EXCLUDED | PA | |
| ANALGESICS - ANTI-INFLAMMATORY | INDOCIN | EXCLUDED | ||
| ANALGESICS - ANTI-INFLAMMATORY | INDOMETHACIN | GENERIC | ||
| ANALGESICS - ANTI-INFLAMMATORY | INDOMETHACIN ER | GENERIC | ||
| ANALGESICS - ANTI-INFLAMMATORY | INDOMETHACIN | EXCLUDED | ||
| ANALGESICS - ANTI-INFLAMMATORY | INDOMETHACIN | EXCLUDED | PA | |
| ANALGESICS - ANTI-INFLAMMATORY | INDOMETHACIN | GENERIC | PA | |
| ANALGESICS - ANTI-INFLAMMATORY | KETOROLAC TROMETHAMINE/BU | EXCLUDED | ||
| ANALGESICS - ANTI-INFLAMMATORY | KETOROCAINE-L | NON PREFERRED | ||
| ANALGESICS - ANTI-INFLAMMATORY | KETOROLAC TROMETHAMINE | GENERIC | ||
| ANALGESICS - ANTI-INFLAMMATORY | KETOROLAC TROMETHAMINE | EXCLUDED | ||
| ANALGESICS - ANTI-INFLAMMATORY | KETAMINE HYDROCHLORIDE/RO | EXCLUDED | ||
| ANALGESICS - ANTI-INFLAMMATORY | KEVZARA | PREFERRED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | KINERET | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | LEFLUNOMIDE | GENERIC | ||
| ANALGESICS - ANTI-INFLAMMATORY | LODINE | EXCLUDED | ||
| ANALGESICS - ANTI-INFLAMMATORY | LURBIRO | EXCLUDED | ||
| ANALGESICS - ANTI-INFLAMMATORY | MECLOFENAMATE SODIUM | GENERIC | ||
| ANALGESICS - ANTI-INFLAMMATORY | MEFENAMIC ACID | NON PREFERRED | ||
| ANALGESICS - ANTI-INFLAMMATORY | MELOXICAM | EXCLUDED | ||
| ANALGESICS - ANTI-INFLAMMATORY | MELOXICAM | GENERIC | ||
| ANALGESICS - ANTI-INFLAMMATORY | NABUMETONE | EXCLUDED | ||
| ANALGESICS - ANTI-INFLAMMATORY | NABUMETONE | GENERIC | ||
| ANALGESICS - ANTI-INFLAMMATORY | NAPROSYN | NON PREFERRED | ||
| ANALGESICS - ANTI-INFLAMMATORY | NAPROXEN DR | GENERIC | ||
| ANALGESICS - ANTI-INFLAMMATORY | NAPROXEN | GENERIC | ||
| ANALGESICS - ANTI-INFLAMMATORY | NAPROXEN | NON PREFERRED | ||
| ANALGESICS - ANTI-INFLAMMATORY | NAPROXEN SODIUM | NON PREFERRED | ||
| ANALGESICS - ANTI-INFLAMMATORY | NAPROXEN SODIUM | GENERIC | ||
| ANALGESICS - ANTI-INFLAMMATORY | NAPROXEN | EXCLUDED | ||
| ANALGESICS - ANTI-INFLAMMATORY | NEOPROFEN | NON PREFERRED | ||
| ANALGESICS - ANTI-INFLAMMATORY | OLUMIANT | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | ORENCIA | PREFERRED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | ORENCIA | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | OTEZLA | PREFERRED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | OXAPROZIN | GENERIC | ||
| ANALGESICS - ANTI-INFLAMMATORY | PHENYLBUTAZONE | NON PREFERRED | ||
| ANALGESICS - ANTI-INFLAMMATORY | PIROXICAM | GENERIC | ||
| ANALGESICS - ANTI-INFLAMMATORY | PIROXICAM | NON PREFERRED | ||
| ANALGESICS - ANTI-INFLAMMATORY | RIDAURA | NON PREFERRED | ||
| ANALGESICS - ANTI-INFLAMMATORY | RINVOQ | PREFERRED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | Simlandi (1 Syringe) | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | SIMLANDI | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | SIMPONI ARIA | PREFERRED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | SIMPONI | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | SULINDAC | NON PREFERRED | ||
| ANALGESICS - ANTI-INFLAMMATORY | SULINDAC | GENERIC | ||
| ANALGESICS - ANTI-INFLAMMATORY | TOFIDENCE | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | TOLECTIN 600 | EXCLUDED | ||
| ANALGESICS - ANTI-INFLAMMATORY | TOLMETIN SODIUM | EXCLUDED | ||
| ANALGESICS - ANTI-INFLAMMATORY | TOLMETIN SODIUM | GENERIC | ||
| ANALGESICS - ANTI-INFLAMMATORY | TRESNI | EXCLUDED | ||
| ANALGESICS - ANTI-INFLAMMATORY | TYENNE | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | XELJANZ | PREFERRED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | XIFYRM | EXCLUDED | ||
| ANALGESICS - ANTI-INFLAMMATORY | YUFLYMA | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | YUSIMRY | EXCLUDED | SP | PA |