Brand/Generic Name

Dosage/Strength

Status

Restrictions

Notes

Relative Cost

Buphenyl sodium phenylbutyrate 500 mg tablet   Not Applicable Cuprimine penicillamine 250 mg capsule     $$$$$ Depen Titratabs penicillamine 250 mg tablet     $$$$$ Firazyr icatibant 30 mg/3 mL Syringe   Not Applicable Korlym mifepristone 300 mg tablet   $$$$$ Kuvan sapropterin 100 mg tablet,soluble   Not Applicable Nuedexta dextromethorphan-quinidine 20-10 mg capsule   Not Applicable Ravicti glycerol phenylbutyrate 25-mL glass bottles   Not Applicable Samsca tolvaptan 15 mg tablet; 30 mg tablet   Not Applicable Xalkori crizotinib 250 mg capsule   $$$$$

Key for Product(s) Listed Above

Formulary Prior Authorization (PA may not be required for some benefit plans) Non-Formulary (Third tier coverage applies for selected plans) Not Reimbursed Quantity Limit Not available through mail order as 90-day supply* Step Therapy Generic Available. Brand name medication may be covered at a higher member cost or may not be covered for certain plans. Notes $Relative cost compared to others in category Specialty distribution for selected plans (Fourth or fifth tier coverage applied for selected plans)

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