Medication Assessment Tool v3.0
The Medication Assessment Tool (MAT) will help to navigate ongoing changes to the ThedaCare Pharmacy Benefits by providing the information you need to know about your particular medications. This information will include whether your medication needs to be filled through a specific pharmacy, if a manufacturer coupon/copay card is available, or if you need to complete a visit with the ThedaCare Disease State Management (DSM) Ambulatory Care Pharmacist team.
Use the search bar to find your specific medication or scroll through the table to find out where you can fill at the lowest cost. If your medication is not on the table, you will be able to get your needed medication at the cheapest cost from the ThedaCare Retail Pharmacies. For any questions you may have, please visit our FAQ by selecting "Benefits Information" from the menu.
MAT v3 offers a lot of new updates!
- Drugs included on the MAT now show formulary information (simply hover over the circles to the right of the drug name);
- Clicking on the drug name will open a window with more information for filling your prescription, including DSM requirements, estimated costs, and any additional notes to be aware of;
- Clicking on circles containg "PA", "ST", or "WL" will open windows containing details for Prior Authorizations, Step Therapy Policy, or Weight Loss program requirements/FAQs, respectively;
**Disclaimer: While we do our best to continuously monitor and update all formulary and PA requirement information, this information is constantly changing, and details may vary. Please be sure to visit the HealthPartners formulary to be certain of any coverage requirements, especially if your medication does not appear below.**
| Drug Name Brand Name (Generic Name) |
Formulary Status | Disease State Management Requirements | Where to Fill | Copay Card Availability | Out-of-pocket Cost (with Copay Card, if Available) |
|---|---|---|---|---|---|
| Abiraterone acetate (Abiraterone acetate) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | No | 20% AWP, Max $150 (30-day fill) |
| Actemra (Tocilizumab) |
F
PA
QLQuantity Limit: 4 SYRINGES / 28 DAYS
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $5 |
| Acthar (Corticotropin Gel) |
F
PA
|
Yes | External Retail/Specialty Pharmacy | Yes | $0 |
| Actimmune (Interferon Gamma-1b) |
F
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Adalimumab-ADAZ (Adalimumab-ADAZ) |
NF
PA
QLQuantity Limit: 2 SYRINGES / 28 DAYS
STClick for Step Therapy details
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | 20% AWP, Max $150 (30-day fill) |
| Adalimumab-ADBM (Adalimumab-ADBM) |
NF
PA
QLQuantity Limit: 2 SYRINGES / 28 DAYS
STClick for Step Therapy details
|
Yes | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Adalimumab-FKJP (Adalimumab-FKJP) |
NF
PA
QLQuantity Limit: 2 SYNRINGES / 28 DAYS
STClick for Step Therapy details
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | 20% AWP, Max $150 (30-day fill) |
| Adbry (Tralokinumab-LDRM) |
NF
PA
QLQuantity Limit: 4 PENS / 28 DAYS
|
No | External Retail/Specialty Pharmacy | Yes | $0 |
| Adcirca (Tadalafil) |
NF
PA
QLQuantity Limit: 2 TABS / 1 DAY
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Adderall (Dextroamphetamine/Amphetamine) |
NF
QLQuantity Limit: 3 TABS / 1 DAY
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | 20% AWP, Max $100 (30-day fill) |
| Adderall XR (Dextroamphetamine/Amphetamine ER) |
F
QLQuantity Limit: 2 CAPS / 1 DAY
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | $5 |
| Adempas (Riociguat) |
F
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Adipex-P (Phentermine HCL) |
NC
WLClick for Weight Loss details
|
No | External Retail/Specialty Pharmacy | No | AWP |
| Admelog (Insulin lispro) |
NF
PA
STClick for Step Therapy details
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $35 |
| Advair Diskus (Fluticasone/Salmeterol) |
F
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | $5 |
| Advair HFA (Fluticasone/Salmeterol) |
F
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | 20% AWP, Max $100 (30-day fill) |
| Advate (Antihemophilic Factor VIII) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Adynovate (Antihemophilic Factor VIII Pegylated) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Adzenys XR-ODT (Amphetamine ER-ODT) |
F
PA
QLQuantity Limit: 2 CAPS / 1 DAY
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $75 |
| Afinitor (Everolimus) |
NF
PA
|
No | External Retail/Specialty Pharmacy | Yes | $1,275 |
| Afinitor Disperz (Everolimus) |
NF
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $25 |
| Afrezza (Insulin Regular, Human) |
F
PA
STClick for Step Therapy details
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $35 |
| Afstyla (Antihemophilic Factor, Human Recombinant) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Aimovig (Erenumab-AOOE) |
NF
PA
QLQuantity Limit: 1 ML / 28 DAYS
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $5 |
| AirDuo Digihaler (Fluticasone propionate/Salmeterol) |
NF
PA
STClick for Step Therapy details
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | 20% AWP, Max $100 (30-day fill) |
| Airduo RespiClick (Fluticasone propionate/Salmeterol) |
F
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | 20% AWP, Max $100 (30-day fill) |
| Ajovy (Fremanezumab-VFRM) |
F
PA
QLQuantity Limit: 4.5 ML / 84 DAYS (Ajovy 225mg/1.5mL Syringe)
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $15 |
| Albuterol sulfate (Albuterol sulfate inhalation solution) |
F
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | $5 |
| Albuterol sulfate HFA (Albuterol sulfate HFA) |
NF
PA
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | $5 |
| Alecensa (Alectinib) |
NF
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Alferon N (Interferon alfa-N3) |
F
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Alkeran (Melphalan) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $100 (30-day fill) |
| Alli (Orlistat) |
NC
WLClick for Weight Loss details
|
No | External Retail/Specialty Pharmacy | No | AWP |
| Alphanate (Antihemophilic Factor - von Willebrand Factor Complex, Human) |
F
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| AlphaNine SD (Coagulation Factor IX, Human) |
F
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Alprolix (Coagulation Factor IX - Recombinant, FC Fusion Protein) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Alunbrig (Brigatinib) |
NF
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Alvesco (Ciclesonide) |
NF
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | 20% AWP, Max $100 (30-day fill) |
| Alyq (Tadalafil) |
NF
PA
QLQuantity Limit: 2 TABS / 1 DAY
|
No | ThedaCare Retail Pharmacy - Any Site | No | 20% AWP, Max $150 (30-day fill) |
| Ambrisentan (Ambrisentan) |
F
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Amjevita CF (Adalimumab-ATTO) |
F
PA
QLQuantity Limit: 2 SYNRINGES / 28 DAYS
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | 20% AWP, Max $150 (30-day fill) |
| Amphetamine sulfate (Amphetamine sulfate) |
F
PA
QLQuantity Limit: 4 TABS / 1 DAY
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | $5 |
| Ampyra (Dalfampridine) |
NF
PA
QLQuantity Limit: 2 TABS / 1 DAY
|
Yes | External Retail/Specialty Pharmacy | Yes | $0 |
| Anoro Ellipta (Umeclidinium/Vilanterol) |
F
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | 20% AWP, Max $100 (30-day fill) |
| Apidra (Insulin glulisine) |
NF
PA
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $35 |
| Apokyn (Apomorphine HCL) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Aptensio XR (Methylphenidate) |
NF
QLQuantity Limit: 2 CAPS / 1 DAY
STClick for Step Therapy details
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | 20% AWP, Max $100 (30-day fill) |
| Aranesp (Darbepoetin Alfa/Polysorbate) |
F
|
No | ThedaCare Retail Pharmacy - Any Site | No | 20% AWP, Max $150 (30-day fill) |
| Arcalyst (Rilonacept) |
F
PA
|
Yes | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Arformoterol tartarate (Arformoterol tartarate) |
F
PA
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | $5 |
| Arikayce (Amikacin liposome inhalation solution) |
NF
PA
QLQuantity Limit: 8.4 ML / 1 DAY
|
No | External Retail/Specialty Pharmacy | Yes | $0 |
| ArmonAir Digihaler (Fluticasone propionate) |
NF
PA
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | 20% AWP, Max $100 (30-day fill) |
| Arnuity Ellipta (Fluticasone furoate) |
F
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | 20% AWP, Max $100 (30-day fill) |
| Asmanex (Mometasone furoate) |
F
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $15 |
| Asmanex HFA (Mometasone furoate HFA) |
F
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $15 |
| Atomoxetine HCL (Atomoxetine HCL) |
F
QLQuantity Limit: 2 CAPS / 1 DAY (10mg, 18mg, 25mg, 40mg) OR
1 CAP / 1 DAY (60mg, 80mg, 100mg) |
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | $5 |
| Atrovent HFA (Ipratropium bromide) |
F
QLQuantity Limit: 1 INHALER / 25 DAYS
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | 20% AWP, Max $100 (30-day fill) |
| Aubagio (Teriflunomide) |
NF
PA
QLQuantity Limit: 1 TAB / 1 DAY
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | 20% AWP, Max $150 (30-day fill) |
| Austedo (Deutetrabenazine) |
F
PA
QLQuantity Limit: 2 TABS / 1 DAY (6mg) OR
4 TABS / 1 DAY (9mg, 12mg) |
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Austedo XR (Deutetrabenazine Extended Release) |
F
PA
QLQuantity Limit: 3 TABS / 1 DAY (6mg) OR
1 TAB / 1 DAY (12mg) OR 2 TABS / 1 DAY (24mg) |
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Avonex (Interferon beta-1a) |
F
QLQuantity Limit: 4 SYRINGES / 28 DAYS
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $0 |
| Ayvakit (Avapritinib) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Azstarys (Serdexmethylphenidate/Dexmethylphenidate) |
NF
PA
QLQuantity Limit: 1 CAP / 1 DAY
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $0 |
| Bafiertam (Monomethyl fumarate) |
F
PA
QLQuantity Limit: 4 CAPS / 1 DAY
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $0 |
| Balversa (Erdafitinib) |
F
PA
|
No | External Retail/Specialty Pharmacy | Yes | $5 |
| Baqsimi (Glucagon, nasal spray) |
F
QLQuantity Limit: 4 Vials/Rx
|
No | ThedaCare Retail Pharmacy - Any Site | No | $- |
| Basaglar Kwikpen (Insulin glargine) |
NF
PA
STClick for Step Therapy details
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $35 |
| Basaglar Tempo Pen (Insulin glargine) |
NF
PA
STClick for Step Therapy details
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $35 |
| Benefix (Coagulation Factor IX, Recombinany) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Benlysta (Belimumab) |
NF
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Benzphetamine HCL (Benzphetamine HCL) |
NC
WLClick for Weight Loss details
|
No | External Retail/Specialty Pharmacy | No | AWP |
| Berinert (Human C1-esterase Inhibitor) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Besremi (Ropeginterferon alfa-2B-NJFT) |
F
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Betaseron (Interferon beta-1b) |
F
QLQuantity Limit: 15 ML / 30 DAYS
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $0 |
| Bethkis (Tobramycin Inhalation Solution) |
NF
PA
|
No | ThedaCare Retail Pharmacy - Any Site | No | 20% AWP, Max $150 (30-day fill) |
| Bevespi Aerosphere (Glycopyrrolate/Formoterol furoate) |
NF
PA
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $0 |
| Bexarotene (Bexarotene) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | No | 20% AWP, Max $150 (30-day fill) |
| Bosentan (Bosentan) |
F
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Bosulif (Bosutinib monohydrate) |
NF
PA
|
No | External Retail/Specialty Pharmacy | Yes | $0 |
| Braftovi (Encorafenib) |
NF
PA
|
No | External Retail/Specialty Pharmacy | Yes | $0 |
| Breo Ellipta (Fluticasone furoate/Vilanterol) |
F
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | 20% AWP, Max $100 (30-day fill) |
| Breztri Aerosphere (Budesonide/Glycopyrrolate/Formoterol) |
F
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $0 |
| Bronchitol (Mannitol Inhalation Capsule) |
NF
PA
QLQuantity Limit: 560 CAPS / 28 DAYS
|
No | External Retail/Specialty Pharmacy | Yes | $0 |
| Brovana (Arformoterol tartarate) |
F
PA
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | 20% AWP, Max $100 (30-day fill) |
| Brukinsa (Zanubrutinib) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Budesonide Inhalation Suspension (Budesonide Inhalation Suspension) |
F
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | $5 |
| Budesonide/Formoterol (Budesonide/Formoterol fumarate (generic for Symbicort)) |
F
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | $5 |
| Buphenyl (Sodium phenylbutyrate) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Bydureon BCISE (Exenatide) |
F
PA
QLQuantity Limit: 4 AUTOINJECTORS (3.4 ML) / 28 DAYS
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $0 |
| Byetta (Exenatide) |
F
PA
QLQuantity Limit: 1 PEN (1.2 ML) / 30 DAYS
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | 20% AWP, Max $100 (30-day fill) |
| Bylvay (Odevixibat) |
NF
PA
|
No | External Retail/Specialty Pharmacy | Yes | $0 |
| Cablivi (Caplicizumab-YHDP) |
F
PA
|
No | External Retail/Specialty Pharmacy | Yes | $0 |
| Cabometyx (Cabozantinib) |
NF
PA
|
No | External Retail/Specialty Pharmacy | Yes | $0 |
| Calquence (Acalabrutunib) |
NF
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Camzyos (Mavacamten) |
NF
PA
QLQuantity Limit: 1 CAP / 1 DAY
|
No | External Retail/Specialty Pharmacy | Yes | $10 |
| Capecitabine (Capecitabine) |
F
|
No | ThedaCare Retail Pharmacy - Any Site | No | 20% AWP, Max $150 (30-day fill) |
| Caprelsa (Vandetanib) |
F
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Carbaglu (Carglumic acid) |
F
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Cayston (Aztreonam Inhalation Solution) |
F
PA
|
No | External Retail/Specialty Pharmacy | Yes | $10 |
| Cerdelga (Eliglustat tartarate) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Chenodal (Chenodiol) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Cholbam (Cholic acid) |
F
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Cibinqo (Abrocitinib) |
NF
PA
QLQuantity Limit: 1 TAB / 1 DAY
|
No | External Retail/Specialty Pharmacy | Yes | $0 |
| Cimzia (Certolizumab pegol) |
F
PA
QLQuantity Limit: 1 KIT = 2 SYRINGES / 28 DAYS
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $0 |
| Cinacalcet HCL (Cinacalcet HCL) |
F
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | $5 |
| Cinryze (Human C1-esterase Inhibitor) |
F
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Coagadex (Coagulation Factor X, Human) |
F
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Combivent Respimat (Albuterol/Ipratropium) |
F
QLQuantity Limit: 1 INHALER / 30 DAYS
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $10 |
| Cometriq (Cabozantinib s-malate) |
F
PA
|
No | External Retail/Specialty Pharmacy | Yes | $0 |
| Concerta (Methylphenidate HCL) |
F
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $4 |
| Contrave (Naltrexone HCL/Bupropion HCL) |
C
WLClick for Weight Loss details
|
No | ThedaCare Retail Pharmacy - Neenah (ONLY) | Yes | $199 |
| Copiktra (Duvelisib) |
NF
PA
|
No | External Retail/Specialty Pharmacy | Yes | $5 |
| Corifact (Factor XIII Concentrate, Human) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | No | 20% AWP, Max $150 (30-day fill) |
| Cortrophin (Repository corticotropin injection) |
F
PA
|
No | External Retail/Specialty Pharmacy | Yes | $0 |
| Cosentyx (Secukinumab) |
F
PA
QLQuantity Limit: 1 SYRINGE / 28 DAYS (75mg, 125mg, 150mg) OR
2 SYRINGES / 28 DAYS (300mg) |
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $0 |
| Cotellic (Cobimetinib) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Cotempla XR-ODT (Methylphenidate HCL) |
NF
QLQuantity Limit: 2 TABS / 1 DAY
STClick for Step Therapy details
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $75 |
| Crinone (Progesterone gel) |
NF
PA
|
No | External Retail/Specialty Pharmacy | Yes | $15 |
| Cuprimine (Penicillamine) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Cyclophosphamide (Cyclophosphamide) |
F
|
No | ThedaCare Retail Pharmacy - Any Site | No | $5 |
| Cyltezo (Adalimumab-ADBM) |
NF
PA
QLQuantity Limit: 2 SYRINGES / 28 DAYS
STClick for Step Therapy details
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $0 |
| Cystadrops (Cysteamine HCL) |
F
PA
QLQuantity Limit: 5 ML / RX
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Cystaran (Cysteamine HCL) |
F
PA
QLQuantity Limit: 15 ML / RX
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Dalfampridine ER (Dalfampridine extended-release) |
F
PA
QLQuantity Limit: 2 TABS / 1 DAY
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | 20% AWP, Max $150 (30-day fill) |
| Daurismo (Glasdegib) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Daytrana (Methylphenidate HCL) |
NF
QLQuantity Limit: 1 PATCH / 1 DAY
STClick for Step Therapy details
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $20 |
| Deferasirox (Deferasirox) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | No | 20% AWP, Max $150 (30-day fill) |
| Deferiprone (Deferiprone) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | No | 20% AWP, Max $150 (30-day fill) |
| Depen (Penicillamine) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Dexcom G7 CGM (Dexcom) |
F
STClick for Step Therapy details
|
No | ThedaCare Retail Pharmacy - Any Site | No | $0 |
| Dexmethylphenidate (Dexmethylphenidate HCL) |
F
QLQuantity Limit: 2 TABS / 1 DAY
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | $5 |
| Dexmethylphenidate ER (Dexmethylphenidate HCL extended-release) |
F
QLQuantity Limit: 2 CAPS / 1 DAY (5mg, 10mg, 15mg, 20mg) OR
1 CAP / 1 DAY (25mg, 30mg, 35mg, 40mg) |
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | $5 |
| Dextroamphetamine (Dextroamphetamine) |
F
QLQuantity Limit: 4 TABS / 1 DAY
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | $5 |
| Dextroamphetamine ER (Dextroamphetamine extended-release) |
F
QLQuantity Limit: 4 CAPS / 1 DAY
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | $5 |
| Dextroamphetamine-Amphetamine (Dextroamphetamine-Amphetamine) |
F
QLQuantity Limit: 3 TABS / 1 DAY (5mg, 7.5mg, 10mg, 12.5mg, 15mg, 20mg) OR
2 TABS / 1 DAY (30mg) |
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | $5 |
| Dextroamphetamine-Amphetamine ER (Dextroamphetamine-Amphetamine extended-release) |
NF
QLQuantity Limit: 2 CAPS / 1 DAY
STClick for Step Therapy details
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | $5 |
| Diacomit (Stiripentol) |
F
PA
QLQuantity Limit: 12 CAPS or PACKETS / 1 DAY (250mg) OR
6 CAPS or PACKETS / 1 DAY (500mg) |
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Dimethyl fumarate DR (Dimethyl fumarate delayed-release) |
F
QLQuantity Limit: 2 CAPS / 1 DAY
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | 20% AWP, Max $150 (30-day fill) |
| Diethylpropion HCL (Diethylpropion HCL) |
NC
WLClick for Weight Loss details
|
No | External Retail/Specialty Pharmacy | No | AWP |
| Dojolvi (Triheptanoin oral liquid) |
F
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Doptelet (Avatrombopaq maleate) |
NF
PA
|
No | External Retail/Specialty Pharmacy | Yes | $0 |
| Droxia (Hydroxyurea) |
NF
|
No | ThedaCare Retail Pharmacy - Any Site | No | 20% AWP, Max $150 (30-day fill) |
| Droxidopa (Droxidopa) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Duaklir Pressair (Aclidinium bromide/Formoterol fumarate) |
NF
PA
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | 20% AWP, Max $100 (30-day fill) |
| Dulera (Mometasone furoate/Formoterol fumarate) |
NF
PA
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $15 |
| Dupixent (Dupilumab) |
F
PA
QLQuantity Limit: 2 SYRINGES / 28 DAYS
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $0 |
| Dyanavel XR (Amphetamine base extended-release) |
NF
PA
QLQuantity Limit: 1 TAB / 1 DAY (5mg, 10mg, 15mg, 20mg) OR
8 ML / 1 DAY (2.5mg/mL suspension) |
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $25 |
| Egrifta SV (Tesamorelin acetate) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Eliquis (Apixaban) |
F
QLQuantity Limit: 2 TABS / 1 DAY (2.5mg) OR
74 TABS / 30 DAYS (5mg) |
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $10 |
| Eloctate (Antihemophilic Factor - Recombinant, FC Fusion Protein) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Emcyt (Estramustine phosphate calcium) |
F
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Emflaza (Deflazacort) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Emgality (Galcanezumab) |
F
PA
QLQuantity Limit: 3 ML / 28 DAYS (100mg/mL) OR
1 ML / 28 DAYS (120mg/mL) |
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Enbrel (Etanercept) |
F
PA
QLQuantity Limit: 8 VIALS (8 ML) / 28 DAYS (25mg kit) OR
4 ML (8 DOSES) / 28 DAYS (25mg/0.5mL syringe/vial, 50mg/mL syringe) |
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $0 |
| Enbrel SureClick (Etanercept) |
F
PA
QLQuantity Limit: 4 ML (8 DOSES) / 28 DAYS (50mg/1mL syringe)
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $0 |
| Endari (L-Glutamine) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $10 |
| Enspryng (Satralizumab-MWGE) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Epclusa (Velpatasvir/Sofosbuvir) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $5 |
| Epidiolex (Cannabidiol) |
F
PA
QLQuantity Limit: 20 ML / 1 DAY
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Epinephrine Auto-Injection (Epinephrine auto-injection) |
F
STClick for Step Therapy details
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | $5 |
| EpiPen (Epinephrine auto-injection) |
F
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $0 |
| Epogen (Epoetin alfa) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Epoprostenol sodium (Epoprostenol sodium) |
F
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Erivedge (Vismodegib) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Erleada (Apalutamide) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Erlotinib HCL (Erlotinib HCL) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | No | 20% AWP, Max $150 (30-day fill) |
| Esbriet (Pirfenidone) |
NF
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Esperoct (Antihemophilic Factor, Recombinant, Glycopegylated-EXEI) |
F
PA
|
No | External Retail/Specialty Pharmacy | Yes | $0 |
| Etoposide (Etoposide) |
F
|
No | ThedaCare Retail Pharmacy - Any Site | No | $5 |
| Eulexin (Flutamide) |
NF
|
No | External Retail/Specialty Pharmacy | Yes | $15 |
| Evekeo (Amphetamine base) |
F
PA
QLQuantity Limit: 4 TABS / 1 DAY
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $30 |
| Evekeo ODT (Amphetamine base, ODT) |
F
PA
QLQuantity Limit: 3 TABS / 1 DAY
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $30 |
| Everolimus (Everolimus) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | No | 20% AWP, Max $150 (30-day fill) |
| Evrysdi (Risdiplam) |
F
PA
|
No | External Retail/Specialty Pharmacy | Yes | $0 |
| Exjade (Deferasirox) |
NF
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $25 |
| Exkivity (Mobocertinib succinate) |
NF
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Extavia (Interferon beta-1b) |
NF
PA
QLQuantity Limit: 15 ML / 30 DAYS
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | 20% AWP, Max $150 (30-day fill) |
| Farxiga (Dapagliflozin) |
NF
PA
QLQuantity Limit: 1 TAB / 1 DAY
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $0 |
| Fasenra (Benralizumab) |
F
PA
QLQuantity Limit: 1 SYRINGE / 56 DAYS
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Feiba NF (Anti-inhibitor Coagulant Complex) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | No | 20% AWP, Max $150 (30-day fill) |
| Ferriprox Solution (Deferiprone) |
F
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Ferriprox Tablets (Deferiprone) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Fiasp (Insulin aspart injection) |
NF
PA
STClick for Step Therapy details
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $35 |
| Fibryga (Fibrinogen, Human) |
NF
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Fingolimod (Fingolimod) |
F
QLQuantity Limit: 1 CAP / 1 DAY
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | 20% AWP, Max $150 (30-day fill) |
| Fintepla (Fenfluramine) |
F
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Firazyr (Icatibant acetate) |
F
PA
QLQuantity Limit: 9 ML / 1 FILL
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Firdapse (Amifampridine phosphate) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Flolan (Epoprostenol sodium) |
F
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Flutamide (Flutamide) |
F
|
No | External Retail/Specialty Pharmacy | No | $5 |
| Fluticasone (Fluticasone propionate, inhalation) |
F
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | $5 |
| Fluticasone-Salmeterol (Fluticasone-Salmeterol - generic for Advair Diskus) |
F
STClick for Step Therapy details
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | $5 |
| Fluticasone-Salmeterol (Fluticasone-Salmeterol - generic for AirDuo RespiClick) |
NF
STClick for Step Therapy details
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | $5 |
| Fluticasone-Vilanterol (Fluticasone-Vilanterol) |
NF
PA
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | $5 |
| Focalin (Dexmethylphenidate) |
NF
QLQuantity Limit: 2 TABS / 1 DAY
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | 20% AWP, Max $100 (30-day fill) |
| Focalin XR (Dexmethylphenidate, extended-release) |
NF
QLQuantity Limit: 2 CAPS / 1 DAY (5mg, 10mg, 15mg, 20mg) OR
1 CAP / 1 DAY (25mg, 30mg, 35mg, 40mg) |
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $10 |
| Formoterol fumarate (Formoterol fumarate) |
F
PA
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | $5 |
| Forteo (Teriparatide acetate) |
NF
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $4 |
| Fotivda (Tivozanib HCL) |
NF
PA
|
No | External Retail/Specialty Pharmacy | Yes | $0 |
| FreeStyle Libre CGM (FreeStyle) |
F
|
No | ThedaCare Retail Pharmacy - Any Site | No | $0 |
| Fuzeon (Enfuvirtide) |
F
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Galafold (Migalastat HCL) |
F
PA
QLQuantity Limit: 14 CAPS / 28 DAYS
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Gattex (Teduglutide) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Gavreto (Pralsetinib) |
NF
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Genotropin (Somatropin) |
C
PA
|
No | External Retail/Specialty Pharmacy | Yes | $0 |
| Gilenya (Fingolimod) |
NF
PA
QLQuantity Limit: 1 CAP / 1 DAY
STClick for Step Therapy details
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $0 |
| Gilenya - 0.25mg (Fingolimod) |
NF
PA
QLQuantity Limit: 1 CAP / 1 DAY
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $0 |
| Gilotrif (Afatinib) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Glatiramer acetate (Glatiramer acetate) |
F
QLQuantity Limit: 30 ML / 30 DAYS (20mg/mL syringe) OR
12 ML / 28 DAYS (40mg/mL syringe) STClick for Step Therapy details
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | 20% AWP, Max $150 (30-day fill) |
| Glatopa (Glatiramer acetate) |
F
QLQuantity Limit: 30 ML / 30 DAYS (20mg/mL syringe) OR
12 ML / 28 DAYS (40mg/mL syringe) |
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $0 |
| Gleevec (Imatinib mesylate) |
NF
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $10 |
| Gleostine (Lomustine) |
F
|
No | ThedaCare Retail Pharmacy - Any Site | No | 20% AWP, Max $150 (30-day fill) |
| Granix (Tbo-Filgrastim) |
F
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Hadlima (Adalimumab-BWWD) |
F
PA
QLQuantity Limit: 2 SYRINGES / 28 DAYS
STClick for Step Therapy details
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | 20% AWP, Max $150 (30-day fill) |
| Haegarda (C1-Esterase Inhibitor, Human) |
F
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Harvoni (Ledipasvir/Sofosbuvir) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Hemlibra (Emicizumab-KXWH) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Hemofil-M (Antihemophilic Factor, Human) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Hetlioz (Tasimelteon) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Hetlioz LQ (Tasimelteon suspension) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Hulio (Adalimumab-FKJP) |
NF
PA
QLQuantity Limit: 2 SYRINGES / 28 DAYS
STClick for Step Therapy details
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $0 |
| Humalog (Insulin lispro) |
F
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $35 |
| Humate-P (Antihemophilic Factor - von Willebrand Factor Complex, Human) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Humatrope (Somatropin, rDNA origin) |
NC
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Humira 40mg/0.8mL (Adalimumab, citrate containing) |
F
PA
QLQuantity Limit: 2 SYRINGES / 28 DAYS
STClick for Step Therapy details
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $0 |
| Humira CF (Adalimumab citrate-free 10mg, 20mg, and Starter Kits) |
NF
PA
QLQuantity Limit: 2 SYRINGES / 28 DAYS
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $0 |
| Humira CF 40mg/0.4mL (Adalimumab) |
NF
PA
QLQuantity Limit: 2 SYRINGES / 28 DAYS
STClick for Step Therapy details
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $0 |
| Humira CF 80mg/0.8mL (Adalimumab) |
NF
PA
QLQuantity Limit: 2 SYRINGES / 28 DAYS
STClick for Step Therapy details
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $0 |
| Humulin N (Insulin human isophane solution) |
F
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $35 |
| Humulin R (Insulin regular, human) |
F
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $35 |
| Humulin 70/30 (Insulin NPH/Regular, human) |
F
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $35 |
| Hycamtin (Topotecan HCL) |
F
|
No | ThedaCare Retail Pharmacy - Any Site | No | 20% AWP, Max $100 (30-day fill) |
| Hydrea (Hydroxyurea) |
NF
PA
|
No | ThedaCare Retail Pharmacy - Any Site | No | 20% AWP, Max $150 (30-day fill) |
| Hydroxyurea (Hydroxyurea) |
F
|
No | ThedaCare Retail Pharmacy - Any Site | No | $5 |
| Hyftor (Sirolimus) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Hyrimoz (Adalimumab-ADAZ) |
NF
PA
QLQuantity Limit: 2 SYRINGES / 28 DAYS
STClick for Step Therapy details
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | 20% AWP, Max $150 (30-day fill) |
| Ibrance (Palbociclib) |
F
PA
|
No | External Retail/Specialty Pharmacy | Yes | $0 |
| Icatibant acetate (Icatibant acetate) |
NF
PA
QLQuantity Limit: 9 ML / 1 FILL
|
No | ThedaCare Retail Pharmacy - Any Site | No | 20% AWP, Max $150 (30-day fill) |
| Iclusig (Ponatinib HCL) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Idacio (Adalimumab-AACF) |
NF
PA
QLQuantity Limit: 2 SYRINGES / 28 DAYS
STClick for Step Therapy details
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | 20% AWP, Max $150 (30-day fill) |
| Idelvion (Coagulation Factor IX Recombinant, Human) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Idhifa (Enasidenib mesylate) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Ilaris (Canakinumab) |
F
PA
QLQuantity Limit: 1 ML / 56 DAYS
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $30 |
| Imatinib mesylate (Imatinib mesylate) |
F
|
No | ThedaCare Retail Pharmacy - Any Site | No | 20% AWP, Max $150 (30-day fill) |
| Imbruvica (Ibrutinib) |
F
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Imcivree (Setmelanotide acetate) |
NC
WLClick for Weight Loss details
|
No | External Retail/Specialty Pharmacy | No | AWP |
| Inbrija (Levodopa) |
F
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Increlex (Mecasermin) |
NC
PA
|
No | External Retail/Specialty Pharmacy | Yes | $0 |
| Incruse Ellipta (Umeclidinium) |
F
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | 20% AWP, Max $100 (30-day fill) |
| Ingrezza (Valbenazine tosylate) |
F
PA
QLQuantity Limit: 1 CAP / 1 DAY
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Inlyta (Axitinib) |
F
PA
|
No | External Retail/Specialty Pharmacy | Yes | $0 |
| Inqovi (Decitabine/Cedazuridine) |
NF
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Inrebic (Fedratinib HCL) |
NF
PA
|
No | External Retail/Specialty Pharmacy | Yes | $0 |
| Insulin glargine (Insulin glargine) |
NF
STClick for Step Therapy details
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | $5 |
| Insulin glargine-YFGN (Insulin glargine-YFGN) |
NF
PA
STClick for Step Therapy details
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | $5 |
| Insulin lispro (Insulin lispro) |
NF
STClick for Step Therapy details
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | $5 |
| Insulin lispro mix 75/25 (Insulin lispro protamine and insulin lispro 75/25) |
NF
STClick for Step Therapy details
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | $5 |
| Intron A (Interferon alfa-2B) |
F
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Invokamet (Canagliflozin/Metformin HCL) |
NF
PA
QLQuantity Limit: 2 TABS / 1 DAY
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $0 |
| Invokamet XR (Canagliflozin/Metformin HCL, extended-release) |
NF
PA
QLQuantity Limit: 2 TABS / 1 DAY
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $0 |
| Invokana (Canagliflozin) |
NF
PA
QLQuantity Limit: 1 TAB / 1 DAY
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $0 |
| Ipratropium bromide (Ipratropium bromide) |
F
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | $5 |
| Ipratropium/Albuterol (Ipratropium/Albuterol) |
F
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | $5 |
| Iressa (Gefitinib) |
NF
PA
|
No | ThedaCare Retail Pharmacy - Any Site | No | 20% AWP, Max $150 (30-day fill) |
| Isturisa (Osilodrostat) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Ixinity (Coagulation Factor IX, Recombinant) |
F
PA
|
No | External Retail/Specialty Pharmacy | Yes | $0 |
| Jadenu (Deferasirox) |
F
PA
|
No | External Retail/Specialty Pharmacy | Yes | $25 |
| Jadenu Sprinkle (Deferasirox, granules) |
NF
PA
|
No | External Retail/Specialty Pharmacy | Yes | $25 |
| Jakafi (Ruxolitinib) |
F
PA
|
No | External Retail/Specialty Pharmacy | Yes | $0 |
| Janumet (Sitagliptin/Metformin HCL) |
NF
PA
QLQuantity Limit: 2 TABS / 1 DAY
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $5 |
| Janumet XR (Sitagliptin/Metformin HCL, extended-release) |
NF
PA
QLQuantity Limit: 2 TABS / 1 DAY
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $5 |
| Januvia (Sitagliptin phosphate) |
NF
PA
QLQuantity Limit: 1 TAB / 1 DAY
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $5 |
| Jardiance (Empagliflozin) |
F
QLQuantity Limit: 1 TAB / 1 DAY
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $10 |
| Javygtor (Sapropterin dihydrochloride) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Jentadueto (Linagliptin/Metformin HCL) |
F
QLQuantity Limit: 2 TABS / 1 DAY
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | $10 |
| Jentadueto XR (Linagliptin/Metformin HCL, extended release) |
F
QLQuantity Limit: 2 TABS / 1 DAY
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | $10 |
| Jivi (Antihemophilic Factor, Recombinant, Pegylated-AUCL) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Jornay PM (Methylphenidate HCL) |
NF
PA
STClick for Step Therapy details
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $25 |
| Juxtapid (Lomitapide mesylate) |
F
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Jynarque (Tolvaptan) |
NF
PA
QLQuantity Limit: 2 TABS / 1 DAY
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Kalbitor (Ecallantide) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Kalydeco (Ivacaftor) |
F
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Kazano (Alogliptin/Metformin HCL) |
NF
PA
QLQuantity Limit: 2 TABS / 1 DAY
|
Yes | External Retail/Specialty Pharmacy | No | 20% AWP, Max $100 (30-day fill) |
| Kesimpta (Natalizumab) |
F
PA
QLQuantity Limit: 1 PEN / 28 DAYS
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $0 |
| Keveyis (Dichlorphenamide) |
NF
PA
|
No | External Retail/Specialty Pharmacy | Yes | $0 |
| Kevzara (Sarilumab) |
NF
PA
QLQuantity Limit: 2 SYRINGES / 28 DAYS
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $0 |
| Kineret (Anakinra) |
F
PA
QLQuantity Limit: 28 SYRINGES / 28 DAYS
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $0 |
| Kisqali (Ribociclib) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $25 |
| Kisqali and Femara Co-Pack (Ribociclib) |
F
PA
|
No | External Retail/Specialty Pharmacy | Yes | $25 |
| Kitabis Pak (Tobramycin Inhalation Solution) |
NF
PA
|
No | External Retail/Specialty Pharmacy | Yes | $0 |
| Koate (Antihemophilic Factor, Human) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | No | 20% AWP, Max $150 (30-day fill) |
| Kogenate FS (Antihemophilic Factor, Recombinant) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Kombiglyze XR (Saxagliptin/Metformin HCL) |
NF
PA
QLQuantity Limit: 2 TABS / 1 DAY
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | 20% AWP, Max $100 (30-day fill) |
| Korlym (Mifepristone) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Koselugo (Selumetinib) |
F
PA
QLQuantity Limit: 8 CAPS / 1 DAY (10mg) OR
4 CAPS / 1 DAY (25mg) |
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Kovaltry (Antihemophilic Factor, Recombinant) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Kuvan (Sapropterin dihydrochloride) |
NF
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Kynmobi (Apomorphine HCL) |
F
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Lanreotide acetate (Lanreotide acetate) |
NF
PA
|
No | ThedaCare Retail Pharmacy - Any Site | No | 20% AWP, Max $150 (30-day fill) |
| Lantus (Insulin glargine) |
F
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $35 |
| Lantus SoloStar (Insulin glargine) |
F
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $35 |
| Lapatinib ditosylate (Lapatinib ditosylate) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | No | 20% AWP, Max $150 (30-day fill) |
| Lenalidomide (Lenalidomide) |
F
|
No | ThedaCare Retail Pharmacy - Any Site | No | 20% AWP, Max $150 (30-day fill) |
| Lenvima (Lenvatinib) |
NF
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Letairis (Ambrisentan) |
NF
PA
|
No | External Retail/Specialty Pharmacy | Yes | $0 |
| Leukeran (Chlorambucil) |
F
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Leukine (Sargramostim) |
NF
PA
|
No | ThedaCare Retail Pharmacy - Any Site | No | 20% AWP, Max $150 (30-day fill) |
| Levalbuterol HCL (Levalbuterol HCL) |
NF
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | $5 |
| Levemir (Insulin detemir) |
F
PA
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $35 |
| Levemir Flextouch (Insulin detemir) |
F
PA
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $35 |
| Lisdexamfetamine (Lisdexamfetamine dimesylate) |
NF
QLQuantity Limit: 2 CAPS or TABS / 1 DAY (10mg, 20mg, 30mg) OR
1 CAP or TAB / 1 DAY (40mg, 50mg, 60mg, 70mg) STClick for Step Therapy details
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | $5 |
| Livmarli (Maralixibat chloride) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Livtencity (Maribavir) |
F
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Lomaira (Phentermine HCL) |
NC
WLClick for Weight Loss details
|
No | External Retail/Specialty Pharmacy | No | AWP |
| Lonsurf (Trifluridine/Tipiracil) |
F
PA
|
No | External Retail/Specialty Pharmacy | Yes | $0 |
| Lorbrena (Lorlatinib) |
NF
PA
|
No | External Retail/Specialty Pharmacy | Yes | $0 |
| Lumakras (Sotorasib) |
F
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Lupkynis (Voclosporin) |
NF
PA
QLQuantity Limit: 6 CAPS / 1 DAY
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Lynparza (Olaparib) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Lysodren (Mitotane) |
F
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Lyumjev (Insulin lispro-AABC) |
NF
PA
STClick for Step Therapy details
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $35 |
| Macrilen (Macimorelin acetate) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Matulane (Procarbazine HCL) |
F
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Mavenclad (Cladribine) |
F
PA
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $0 |
| Mavyret (Glecaprevir/Pibrentasvir) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $5 |
| Mayzent (Siponimod) |
F
QLQuantity Limit: 4 TABS / 1 DAY (0.25mg) OR
7 TABS / 4 DAYS (0.25mg start - 1mg maintenance) OR 12 TABS / 5 DAYS (0.25mg start - 2mg maintenance) OR 1 TAB / 1 DAY (1mg) OR 1 TAB / 1 DAY (2mg) |
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $0 |
| Mekinist (Trametinib dimethyl sulfoxide) |
F
PA
|
No | External Retail/Specialty Pharmacy | Yes | $25 |
| Mektovi (Binimetinib) |
NF
PA
|
No | External Retail/Specialty Pharmacy | Yes | $0 |
| Melphalan HCL (Melphalan HCL) |
F
|
No | ThedaCare Retail Pharmacy - Any Site | No | $5 |
| Menopur (Menotropins) |
F
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $100 (30-day fill) |
| Mercaptopurine (Mercaptopurine) |
F
|
No | ThedaCare Retail Pharmacy - Any Site | No | $5 |
| Metadate CD (Methylphenidate HCL, extended release) |
NF
PA
QLQuantity Limit: 2 CAPS / 1 DAY (10mg, 20mg, 30mg) OR
1 CAP / 1 DAY (40mg, 50mg, 60mg) STClick for Step Therapy details
|
Yes | External Retail/Specialty Pharmacy | No | 20% AWP, Max $100 (30-day fill) |
| Methylin (Methylphenidate HCL, oral solution) |
NF
QLQuantity Limit: 60 ML / 1 DAY (5mg/5mL) OR
30 ML / 1 DAY (10mg/5mL) |
Yes | External Retail/Specialty Pharmacy | No | 20% AWP, Max $100 (30-day fill) |
| Methylphenidate HCL (Methylphenidate HCL) |
F
QLQuantity Limit: 3 TABS / 1 DAY (5mg, 10mg, 20mg)
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | $5 |
| Methylphenidate HCL ER (Methylphenidate HCL, extended-release) |
NF
QLQuantity Limit: 2 CAPS / 1 DAY (10mg, 15mg, 20mg, 30mg) OR
1 CAP / 1 DAY (40mg, 50mg, 60mg) OR 4 TABS / 1 DAY (10mg) OR 2 TABS / 1 DAY (18mg, 27mg, 36mg) OR 1 TAB / 1 DAY (54mg) STClick for Step Therapy details
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | $5 |
| Miglustat (Miglustat) |
F
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Mircera (Methoxy polyethylene glycol-epoetin beta) |
NF
PA
|
No | ThedaCare Retail Pharmacy - Any Site | No | 20% AWP, Max $150 (30-day fill) |
| Mononine (Coagulation Factor IX, Human) |
F
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Mounjaro (Tirzepatide) |
F
PA
QLQuantity Limit: 4 PENS (2ML) / 28 DAYS
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $25 |
| Mulpleta (Lusutrombopag) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Myalept (Metreleptin) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Mycapssa (Octreotide) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Mydayis (Dextroamphetamine/Amphetamine, extended release) |
NF
QLQuantity Limit: 1 CAP / 1 DAY
STClick for Step Therapy details
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | 20% AWP, Max $100 (30-day fill) |
| Myfembree (Relugolix/Estradiol/Norethindrone) |
F
PA
QLQuantity Limit: 28 TABS / 28 DAYS
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $5 |
| Myleran (Busulfan) |
F
|
No | ThedaCare Retail Pharmacy - Any Site | No | 20% AWP, Max $100 (30-day fill) |
| Natpara (Parathyroid hormone) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Nerlynx (Neratinib maleate) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Nesina (Alogliptin benzoate) |
NF
PA
QLQuantity Limit: 1 TAB / 1 DAY
|
Yes | External Retail/Specialty Pharmacy | No | 20% AWP, Max $100 (30-day fill) |
| Neulasta (Pegfilgrastim) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Neupogen (Filgrastim) |
NF
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Nexavar (Sorafenib tosylate) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Nilandron (Nilutamide) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $100 (30-day fill) |
| Ninlaro (Ixazomid) |
F
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Nitisinone (Nitisinone) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Nityr (Nitisinone) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Nivestym (Filgrastim-AAFI) |
NF
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Norditropin FlexPro (Somatropin) |
C
PA
|
No | ThedaCare Retail Pharmacy - Any Site | No | 20% AWP, Max $100 (30-day fill) |
| Northera (Droxidopa) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Nourianz (Istradefylline) |
F
PA
|
No | External Retail/Specialty Pharmacy | Yes | $20 |
| Novoeight (Antihemophilic Factor VIII, Recombinant) |
F
PA
|
No | External Retail/Specialty Pharmacy | Yes | $0 |
| Novolin N (Insulin NPH, human recombinant) |
NF
PA
STClick for Step Therapy details
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $35 |
| Novolin R (Insulin Regular, human recombinant) |
NF
PA
STClick for Step Therapy details
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $35 |
| Novolin 70/30 (Insulin NPH/Insulin Regular, human recombinant) |
NF
PA
STClick for Step Therapy details
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $35 |
| Novolog (Insulin aspart) |
F
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $35 |
| Novolog 70/30 (Insulin aspart/Insulin aspart protamine) |
F
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $35 |
| Novoseven RT (Coagulation Factor VIIa, recombinant) |
F
PA
|
No | External Retail/Specialty Pharmacy | Yes | $0 |
| Nubeqa (Darolutamide) |
F
PA
|
No | External Retail/Specialty Pharmacy | Yes | $0 |
| Nucala (Mepolizumab) |
F
PA
QLQuantity Limit: 1 SYRINGE / 28 DAYS (40mg/0.4mL) OR
3 SYRINGES / 28 DAYS (100mg/mL) |
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Nuplazid (Pimavanserin tartarate) |
F
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Nutropin AQ Nuspin (Somatropin) |
NC
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $5 |
| Nuwiq (Antihemophilic Factor VII, recombinant) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Obizur (Antihemophilic Factor VIII, Porcine Sequence, Recombinant) |
F
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Ocaliva (Obeticholic acid) |
NF
PA
|
No | External Retail/Specialty Pharmacy | Yes | $0 |
| Odomzo (Sonidegib) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $10 |
| Ofev (Nintedanib) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Olumiant (Baricitinib) |
F
PA
QLQuantity Limit: 1 TAB / 1 DAY
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $5 |
| Omnitrope (Somatropin, rDNA origin) |
NC
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Onglyza (Saxagliptin) |
NF
PA
QLQuantity Limit: 1 TAB / 1 DAY
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | 20% AWP, Max $100 (30-day fill) |
| Onureg (Azacitidine) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Opsumit (Macitentan) |
F
PA
|
No | External Retail/Specialty Pharmacy | Yes | $5 |
| Orencia (Abatacept) |
F
PA
QLQuantity Limit: 4 SYRINGES / 28 DAYS
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $5 |
| Orencia Clickject (Abatacept) |
F
PA
QLQuantity Limit: 4 ML / 28 DAYS
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $5 |
| Orenitram ER (Treprostinil diolamine, extended release) |
NF
PA
|
No | External Retail/Specialty Pharmacy | Yes | $0 |
| Orfadin (Nitisinone) |
NF
PA
|
No | External Retail/Specialty Pharmacy | Yes | $0 |
| Orgovyx (Relugolix) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $10 |
| Oriahnn (Elagolix/Estradiol/Norethindrone acetate) |
F
PA
QLQuantity Limit: 2 CAPS / 1 DAY
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $5 |
| Orilissa (Elagolix) |
F
PA
QLQuantity Limit: 1 TAB / 1 DAY (150mg) OR
56 TABS / 28 DAYS |
No | ThedaCare Retail Pharmacy - Any Site | Yes | $5 |
| Orkambi (Lumacaftor/Ivacaftor) |
F
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Orladeyo (Berotralstat HCL) |
F
PA
QLQuantity Limit: 1 CAP / 1 DAY
|
No | External Retail/Specialty Pharmacy | Yes | $0 |
| Orlistat (Orlistat) |
NC
WLClick for Weight Loss details
|
No | External Retail/Specialty Pharmacy | No | AWP |
| Oseni (Alogliptin benzoate/Pioglitazone) |
NF
PA
QLQuantity Limit: 1 TAB / 1 DAY
|
Yes | External Retail/Specialty Pharmacy | No | 20% AWP, Max $100 (30-day fill) |
| Otezla (Apremilast) |
F
PA
QLQuantity Limit: 2 TABS / 1 DAY (30mg) OR
55 TABS / 28 DAYS (28-day starter pack) OR 2 PACKS / 28 DAYS (starter pack) |
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $0 |
| Oxbryta (Voxelotor) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Oxervate (Cenegermin-BKBJ) |
F
PA
QLQuantity Limit: 1 ML / 1 DAY
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Ozempic (Semaglutide) |
F
PA
QLQuantity Limit: 1 PEN / 28 DAYS
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $25 |
| Palforzia (Peanut archis hypogaea allergen powder-DNFP) |
F
PA
|
No | External Retail/Specialty Pharmacy | Yes | $20 |
| Palynziq (Pegvaliase-PQPZ) |
NF
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Pegasys (Peginterferon alfa-2a) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | No | 20% AWP, Max $150 (30-day fill) |
| Pemazyre (Pemigatinib) |
NF
PA
|
No | External Retail/Specialty Pharmacy | Yes | $0 |
| Perforomist (Formoterol fumarate) |
F
PA
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | 20% AWP, Max $100 (30-day fill) |
| Phendimetrazine HCL (Phendimetrazine HCL) |
NC
WLClick for Weight Loss details
|
No | External Retail/Specialty Pharmacy | No | AWP |
| Phentermine HCL (Phentermine HCL) |
C
WLClick for Weight Loss details
|
No | ThedaCare Retail Pharmacy - Neenah (ONLY) | No | $27 (37.5mg) or $28 (30mg) |
| Pirfenidone (Pirfenidone) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Pheburane (Sodium phenylbutyrate) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Piqray (Alpelisib) |
NF
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $25 |
| Plegridy (Peginterferon beta-1a) |
F
QLQuantity Limit: 1 ML / 28 DAYS
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $0 |
| Pomalyst (Pomalidomide) |
F
PA
|
No | External Retail/Specialty Pharmacy | Yes | $0 |
| Ponvory (Ponesimod) |
NF
PA
QLQuantity Limit: 1 TAB / 1 DAY (20mg) OR
14 TABS / 14 DAYS (starter pack) |
No | External Retail/Specialty Pharmacy | Yes | $0 |
| Pradaxa (Dabigatran etexilate) |
NF
PA
QLQuantity Limit: 2 CAPS / 1 DAY
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $0 |
| Proair Digihaler (Albuterol sulfate) |
NF
PA
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | 20% AWP, Max $100 (30-day fill) |
| Proair RespiClick (Albuterol sulfate) |
NF
PA
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | 20% AWP, Max $100 (30-day fill) |
| Procrit (Epoetin alfa) |
NF
PA
|
No | ThedaCare Retail Pharmacy - Any Site | No | 20% AWP, Max $150 (30-day fill) |
| Procysbi (Cysteamine bitartarate) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Profilnine (Factor IX Complex, Human) |
F
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Promacta (Eltrombopag olamine) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $25 |
| Proventil HFA (Albuterol sulfate) |
NF
PA
|
Yes | External Retail/Specialty Pharmacy | No | 20% AWP, Max $100 (30-day fill) |
| Pulmicort (Budesonide, nebulizer suspension) |
NF
PA
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | 20% AWP, Max $100 (30-day fill) |
| Pulmicort Flexhaler (Budesonide, inhaler) |
F
PA
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | 20% AWP, Max $100 (30-day fill) |
| Pulmozyme (Dornase alfa) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $30 |
| Purixan (Mercaptopurine) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Pyrukynd (Mitapivat) |
F
PA
QLQuantity Limit: 56 TABS / 28 DAYS
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Qbrexza (Glycopyrronium) |
NF
PA
QLQuantity Limit: 1 TOWLETTE / 1 DAY
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Qelbree (Viloxazine) |
NF
PA
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $20 |
| Qinlock (Ripretinib) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Qsymia (Phentermine HCL/Topiramate HCL) |
C
WLClick for Weight Loss details
|
No | ThedaCare Retail Pharmacy - Neenah (ONLY) | Yes | $143 |
| Quillichew ER (Methylphenidate, extended release, chewable) |
F
QLQuantity Limit: 2 CHEW TABS / 1 DAY
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $25 |
| Quillivant XR (Methylphenidate, extended release, suspension) |
F
QLQuantity Limit: 12 ML / 1 DAY
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $25 |
| Qulipta (Atogepant) |
NF
PA
QLQuantity Limit: 1 TAB / 1 DAY
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Qvar Redihaler (Beclomethasone dipropionate) |
F
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | 20% AWP, Max $100 (30-day fill) |
| Radicava ORS (Edaravone oral suspension) |
F
PA
QLQuantity Limit: 70 ML / 28 DAYS
|
No | External Retail/Specialty Pharmacy | Yes | $0 |
| Ravicti (Glycerol phenylbutyrate) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Rebif (Interferon beta-1a/Albumin) |
F
PA
QLQuantity Limit: 6 ML / 28 DAYS OR (22mcg/0.5mL, 44mcg/0.5mL)
4.2 ML / 28 DAYS (titration pack) |
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $0 |
| Rebif Rebidose (Interferon beta-1a/Albumin) |
F
PA
QLQuantity Limit: 6 ML / 28 DAYS (22mcg/0.5mL, 44mcg/0.5mL) OR
4.2 ML / 28 DAYS (titration pack) |
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $0 |
| Rebinyn (Coagulation Factor IX, Recombinant, Pegylated) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | No | 20% AWP, Max $150 (30-day fill) |
| Recombinate (Antihemophilic Factor VIII, Recombinant) |
F
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Recorlev (Levoketoconazole) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Releuko (Filgrastim) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Relexxii (Methylphenidate) |
NF
PA
QLQuantity Limit: 2 TABS / 1 DAY (18mg, 27mg, 36mg) OR
1 TAB / 1 DAY (45mg, 54mg, 63mg, 72mg) STClick for Step Therapy details
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $15 |
| Remodulin (Treprostinil) |
NF
PA
|
No | External Retail/Specialty Pharmacy | Yes | $0 |
| Retacrit (Epoetin alfa-EPBX) |
F
|
No | ThedaCare Retail Pharmacy - Any Site | No | 20% AWP, Max $150 (30-day fill) |
| Retevmo (Selpercatinib) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Revatio (Sildenafil citrate) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Revcovi (Elapegademase-LVLR) |
F
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Revlimid (Lenalidomide) |
NF
PA
|
No | External Retail/Specialty Pharmacy | Yes | $0 |
| Rezurock (Belumosudil mesylate) |
F
PA
QLQuantity Limit: 1 TAB / 1 DAY
|
No | ThedaCare Retail Pharmacy - Any Site | No | 20% AWP, Max $150 (30-day fill) |
| Riastap (Fibrinogen Concentrate, Human) |
F
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Ribavirin (Ribavirin) |
F
|
No | External Retail/Specialty Pharmacy | No | $5 |
| Rinvoq ER (Upadacitinib) |
F
PA
QLQuantity Limit: 1 TAB / 1 DAY
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $0 |
| Ritalin (Methylphenidate HCL) |
NF
QLQuantity Limit: 3 TABS / 1 DAY
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | 20% AWP, Max $100 (30-day fill) |
| Ritalin LA (Methylphenidate HCL, extended release) |
NF
QLQuantity Limit: 2 CAPS / 1 DAY (10mg, 20mg, 30mg) OR
1 CAP / 1 DAY (40mg) STClick for Step Therapy details
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | 20% AWP, Max $100 (30-day fill) |
| Rixubis (Coagulation Factor IX, Recombinant) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Rozlytrek (Entrectinib) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Rubraca (Recaparib) |
NF
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Rybelsus (Semaglutide) |
F
PA
QLQuantity Limit: 1 TAB / 1 DAY
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $10 |
| Rydapt (Midostaurin) |
NF
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $25 |
| Sabril (Vigabatran) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Sajazir (Icatibant) |
NF
PA
QLQuantity Limit: 9 ML / 1 FILL
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Samsca (Tolvaptan) |
NF
PA
|
No | ThedaCare Retail Pharmacy - Any Site | No | 20% AWP, Max $150 (30-day fill) |
| Sandostatin LAR Depot (Octreotide acetate) |
NF
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $25 |
| Sapropterin (Sapropterin dihydrochloride) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | No | 20% AWP, Max $150 (30-day fill) |
| Saxenda (Liraglutide) |
C
WLClick for Weight Loss details
|
No | ThedaCare Retail Pharmacy - Neenah (ONLY) | No | $665 |
| Scemblix (Asciminib) |
NF
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $25 |
| Segluromet (Ertugliflozin/Metformin HCL) |
NF
PA
QLQuantity Limit: 2 TABS / 1 DAY
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | 20% AWP, Max $100 (30-day fill) |
| Semglee-YFGN (Insulin glargine-YFGN) |
NF
PA
STClick for Step Therapy details
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $0 |
| Sensipar (Cinacalcet HCL) |
NF
STClick for Step Therapy details
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | 20% AWP, Max $100 (30-day fill) |
| Serevent Diskus (Salmeterol xinafoate) |
F
PA
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | 20% AWP, Max $100 (30-day fill) |
| Serostim (Somatropin, rDNA origin) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Sevenfact (Coagulation Factor VIIa, Recombinant-JNCW) |
F
PA
|
No | External Retail/Specialty Pharmacy | Yes | $0 |
| Signifor LAR (Pasireotide) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Siklos (Hydroxyurea) |
NF
PA
QLQuantity Limit: 2 TABS / 1 DAY (applies to 100mg tabs only)
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Sildenafil (Sildenafil citrate) |
F
QLQuantity Limit: 1 TAB / 1 DAY (applies to 20mg tabs only)
|
No | ThedaCare Retail Pharmacy - Any Site | No | $5 |
| Siliq (Brodalumab) |
NF
PA
QLQuantity Limit: 2 SYRINGES / 28 DAYS
|
Yes | External Retail/Specialty Pharmacy | Yes | $0 |
| Simponi (Golimumab) |
NF
PA
QLQuantity Limit: 1 SYRINGE / 28 DAYS
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $5 |
| Singulair (Montelukast sodium) |
NF
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | 20% AWP, Max $100 (30-day fill) |
| Skyrizi (Risakizumab) |
F
PA
QLQuantity Limit: 1 SYRINGE / 84 DAYS (75mg/0.83mL, 150mg/mL,) OR
2 SYRINGES / 84 DAYS (150mg kit) |
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $0 |
| Skytrofa (Londapegsomatropin-TCGD) |
NC
PA
|
No | External Retail/Specialty Pharmacy | Yes | $5 |
| Sodium phenylbutyrate (Sodium phenylbutyrate, powder) |
F
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Sodium phenylbutyrate (Sodium phenylbutyrate, tablet) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Sofosbuvir/Velpatasvir (Sofosbuvir/Velpatasvir) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | No | 20% AWP, Max $150 (30-day fill) |
| Somatuline Depot (Lanreotide acetate) |
NF
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Somavert (Pegvisomant) |
NF
PA
|
No | External Retail/Specialty Pharmacy | Yes | $5 |
| Sorafenib (Sorafenib tosylate) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | No | 20% AWP, Max $150 (30-day fill) |
| Sotyktu (Deucravacitinib) |
NF
PA
QLQuantity Limit: 1 TAB / 1 DAY
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $0 |
| Sovaldi (Sofosbuvir) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | No | 20% AWP, Max $150 (30-day fill) |
| Spiriva Handihaler (Tiotropium bromide) |
NF
PA
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | 20% AWP, Max $100 (30-day fill) |
| Spiriva Respimat (Tiotropium bromide) |
NF
PA
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | 20% AWP, Max $100 (30-day fill) |
| Sprycel (Dasatinib) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Steglatro (Ertugliflozin) |
NF
PA
QLQuantity Limit: 1 TAB / 1 DAY
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | 20% AWP, Max $100 (30-day fill) |
| Steglujan (Ertugliflozin/Sitagliptin) |
NF
PA
QLQuantity Limit: 1 TAB / 1 DAY
|
Yes | External Retail/Specialty Pharmacy | No | 20% AWP, Max $100 (30-day fill) |
| Stelara (Ustekinumab) |
F
PA
QLQuantity Limit: 1 SYRINGE / 84 DAYS (45mg/0.5mL) OR
1 SYRINGE / 56 DAYS (90mg/mL) |
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $5 |
| Stiolto Respimat (Tiotropium bromide/Olodaterol HCL) |
NF
PA
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $0 |
| Stivarga (Regorafenib) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Strattera (Atomoxetine) |
NF
QLQuantity Limit: 2 CAPS / 1 DAY (10mg, 18mg, 25mg, 40mg) OR
1 CAP / 1 DAY (60mg, 80mg, 100mg) |
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | 20% AWP, Max $100 (30-day fill) |
| Strensiq (Asfotase alfa) |
F
PA
|
No | External Retail/Specialty Pharmacy | Yes | $0 |
| Striverdi Respimat (Olodaterol HCL) |
F
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | 20% AWP, Max $100 (30-day fill) |
| Sucraid (Sacrosidase) |
F
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Sunitinib (Sunitinib malate) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | No | 20% AWP, Max $150 (30-day fill) |
| Sutent (Sunitinib malate) |
NF
PA
|
No | External Retail/Specialty Pharmacy | Yes | $0 |
| Symdeko (Tezacaftor/Ivacaftor) |
F
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Symbicort (Budesonide/Formoterol fumarate) |
NF
PA
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $35 |
| Syndardy (Empagliflozin/Metformin HCL) |
F
QLQuantity Limit: 2 TABS / 1 DAY
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $10 |
| Syndardy XR (Empagliflozin/Metformin HCL, extended release) |
F
QLQuantity Limit: 2 TABS / 1 DAY (5-1,000mg, 12.5-1,000mg) OR
1 TAB / 1 DAY (10-1,000mg, 25-1,000mg) |
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $10 |
| Synribo (Omacetaxine mepesuccinate) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Syprine (Trientine HCL) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Tabloid (Thioguanine) |
F
|
No | ThedaCare Retail Pharmacy - Any Site | No | 20% AWP, Max $150 (30-day fill) |
| Tabrecta (Capmatinib) |
NF
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $25 |
| Tadliq (Tadalafil) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Tafinlar (Dabrafenib) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $25 |
| Tagrisso (Osimertinib) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Takhzyro (Lanadelumab-FLYO) |
F
PA
QLQuantity Limit: 2 ML / 28 DAYS
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Taltz (Ixekizumab) |
NF
PA
QLQuantity Limit: 1 ML / 28 DAYS
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $5 |
| Talzenna (Talazoparib) |
NF
PA
|
No | External Retail/Specialty Pharmacy | Yes | $0 |
| Tarceva (Erlotinib HCL) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Targretin (Bexarotene) |
NF
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Tasigna (Nilotinib) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $25 |
| Tavalisse (Fostamatinib) |
NF
PA
|
No | External Retail/Specialty Pharmacy | Yes | $15 |
| Tavneos (Avacopan) |
F
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Tazverik (Tazemetostat) |
F
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Tecfidera (Dimethyl fumarate) |
NF
PA
QLQuantity Limit: 2 CAPS / 1 DAY
|
Yes | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Tegsedi (Inotersen) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Temodar (Temozolomide) |
NF
PA
|
No | ThedaCare Retail Pharmacy - Any Site | No | 20% AWP, Max $150 (30-day fill) |
| Temozolomide (Temozolomide) |
F
|
No | ThedaCare Retail Pharmacy - Any Site | No | 20% AWP, Max $150 (30-day fill) |
| Tepmetko (Tepotinib HCL) |
NF
PA
|
No | External Retail/Specialty Pharmacy | Yes | $0 |
| Teriflunomide (Teriflunomide) |
F
QLQuantity Limit: 1 TAB / 1 DAY
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | 20% AWP, Max $150 (30-day fill) |
| Tetrabenazine (Tetrabenazine) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | No | 20% AWP, Max $150 (30-day fill) |
| Thalomid (Thalidomide) |
F
|
No | External Retail/Specialty Pharmacy | Yes | $0 |
| Thiola (Tiopronin) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Thiola EC (Tiopronin, delayed-release) |
F
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Tibsovo (Ivosidenib) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Tobi Podhaler (Tobramycin Inhalation Solution) |
NF
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Tobramycin (Tobramycin Inhalation Solution) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | No | 20% AWP, Max $150 (30-day fill) |
| Tolvaptan (Tolvaptan) |
NF
PA
|
No | ThedaCare Retail Pharmacy - Any Site | No | 20% AWP, Max $150 (30-day fill) |
| Toujeo Solostar (Insulin glargine) |
F
STClick for Step Therapy details
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $35 |
| Toujeo Max Solostar (Insulin glargine) |
F
STClick for Step Therapy details
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $35 |
| Tracleer (Bosentan) |
NF
PA
|
No | External Retail/Specialty Pharmacy | Yes | $5 |
| Tradjenta (Linagliptin) |
F
QLQuantity Limit: 1 TAB / 1 DAY
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $10 |
| Trelegy Ellipta (Fluticasone furoate/Umeclidinium/Vilanterol) |
F
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $0 |
| Tremfya (Guselkumab) |
NF
PA
QLQuantity Limit: 1 ML / 56 DAYS
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $5 |
| Tresiba (Insulin degludec) |
NF
PA
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $35 |
| Tretinoin (Tretinoin) |
F
|
No | ThedaCare Retail Pharmacy - Any Site | No | $5 |
| Tretten (Coagulation Factor XIII A-subunit, Recombinant) |
F
PA
|
No | External Retail/Specialty Pharmacy | Yes | $0 |
| Trexall (Methotrexate) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Trijardy XR (Empagliflozin/Linagliptin/Metformin HCL) |
F
QLQuantity Limit: 2 TABS / 1 DAY (5-2.5-1,000mg, 12.5-2.5-1,000mg) OR
1 TAB / 1 DAY (10-5-1,000mg, 25-5-1,000mg) |
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $10 |
| Trikafta (Elexacaftor/Tezacaftor/Ivacaftor) |
F
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Trulicity (Dulaglutide) |
F
PA
QLQuantity Limit: 4 PENS (2 ML) / 28 DAYS
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $25 |
| Tudorza Pressair (Aclidinium bromide) |
NF
PA
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | 20% AWP, Max $100 (30-day fill) |
| Tukysa (Tucatinib) |
NF
PA
|
No | ThedaCare Retail Pharmacy - Any Site | No | 20% AWP, Max $150 (30-day fill) |
| Turalio (Pexidartinib) |
F
PA
|
No | External Retail/Specialty Pharmacy | Yes | $0 |
| Tykerb (Lapatinib ditosylate) |
NF
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $25 |
| Tymlos (Abaloparatide) |
F
PA
|
Yes | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Tyvaso (Treprostinil inhalation powder) |
F
PA
|
No | External Retail/Specialty Pharmacy | Yes | $0 |
| Tyvaso DPI (Treprostinil inhalation powder) |
F
PA
|
No | External Retail/Specialty Pharmacy | Yes | $0 |
| Uptravi (Selexipag) |
F
PA
|
No | External Retail/Specialty Pharmacy | Yes | $5 |
| Valchlor (Mechlorethamine gel) |
F
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Veletri (Epoprostenol sodium) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Venclexta (Venetoclax) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Ventavis (Iloprost) |
F
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Ventolin HFA (Albuterol sulfate) |
F
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | 20% AWP, Max $100 (30-day fill) |
| Verzenio (Abemaciclib) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Victoza (Liraglutide) |
F
PA
QLQuantity Limit: 3 PENS (9 ML) / 30 DAYS
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | 20% AWP, Max $100 (30-day fill) |
| Vigadrone (Vigabatrin) |
F
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Vijoice (Alpelisib) |
NF
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Virazole (Ribavirin) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Vistogard (Uridine triacetate) |
F
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Vitrakvi (Larotrectinib) |
NF
PA
|
No | External Retail/Specialty Pharmacy | Yes | $0 |
| Vonjo (Pacritinib) |
F
PA
|
No | External Retail/Specialty Pharmacy | Yes | $25 |
| Vonvendi (Von Willebrand Factor Complex, Recombinant, Human) |
F
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Vosevi (Sofosbuvir/Velpatasvir/Voxilaprevir) |
F
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Votrient (Pazopanib HCL) |
NF
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $25 |
| Voxzogo (Vosoritide) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Vumerity (Diroximel fumarate) |
F
QLQuantity Limit: 4 CAPS / 1 DAY
|
Yes | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Vyndamax (Tafamidis meglumine) |
F
PA
|
No | External Retail/Specialty Pharmacy | Yes | $0 |
| Vyndaqel (Tafamidis meglumine) |
F
PA
|
No | External Retail/Specialty Pharmacy | Yes | $0 |
| Vyvanse (Lisdexamfetamine dimesylate) |
F
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | $5 |
| Wakix (Pitolisant) |
NF
PA
QLQuantity Limit: 2 TABS / 1 DAY
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Wegovy (Semaglutide) |
C
WLClick for Weight Loss details
|
No | ThedaCare Retail Pharmacy - Neenah (ONLY) | Yes | $650 |
| Welireg (Belzutifan) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Wilate (von Willebrand Factor - Coagulation Factor VIII Complex, Human) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Wixela Inhub (Fluticasone propionate/Salmeterol) |
NF
STClick for Step Therapy details
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $10 |
| Xalkori (Crizotinib) |
NF
PA
|
No | External Retail/Specialty Pharmacy | Yes | $0 |
| Xarelto (Rivaroxiban) |
F
QLQuantity Limit: 2 TABS / 1 DAY (2.5mg, 10mg, 15mg) OR
1 TAB / 1 DAY (20mg) OR 51 TABS / 30 DAYS (DVT-PE TREAT START PACK) |
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $10 |
| Xatmep (Methotrexate sodium oral solution) |
NF
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $5 |
| Xeljanz (Tofacitinib) |
NF
PA
QLQuantity Limit: 2 TABS / 1 DAY
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $0 |
| Xeljanz XR (Tofacitinib, extended-release) |
NF
PA
QLQuantity Limit: 1 TAB / 1 DAY
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $0 |
| Xeloda (Capecitabine) |
NF
PA
|
No | ThedaCare Retail Pharmacy - Any Site | No | 20% AWP, Max $150 (30-day fill) |
| Xelstrym (Dextroamphetamine) |
NF
PA
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $50 |
| Xenazine (Tetrabenazine) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Xenical (Orlistat) |
NC
WLClick for Weight Loss details
|
No | External Retail/Specialty Pharmacy | No | AWP |
| Xermelo (Telotristat ethyl) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Xigduo XR (Dapagliflozin/Metformin HCL, extended release) |
NF
PA
QLQuantity Limit: 1 TAB / 1 DAY (5-500mg, 10-500mg, 2.5-1,000mg, 10-1,000mg) OR
2 TABS / 1 DAY (5-500mg) |
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $0 |
| Xolair (Omalizumab) |
NF
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Xopenex HFA (Levalbuterol tartarate) |
NF
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | 20% AWP, Max $100 (30-day fill) |
| Xospata (Gilteritinib) |
NF
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Xpovio (Selinexor) |
F
PA
|
No | External Retail/Specialty Pharmacy | Yes | $5 |
| Xtandi (Enzalutamide) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Xuriden (Uridine triacetate) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Xyntha (Antihemophilic Factor VIII, Recombinant) |
F
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Xyntha Solofuse (Antihemophilic Factor VIII, Recombinant) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Xyrem (Sodium oxybate) |
NF
PA
QLQuantity Limit: 18 ML / 1 DAY
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Xywav (Calcium/Magnesium/Potassium/Sodium oxybates) |
F
PA
QLQuantity Limit: 18 ML / 1 DAY
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Yonsa (Abiraterone acetate) |
NF
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Yuflyma (Adalimumab-AATY) |
NF
PA
QLQuantity Limit: 2 SYRINGES / 28 DAYS
STClick for Step Therapy details
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | 20% AWP, Max $150 (30-day fill) |
| Yupelri (Revefenacin) |
NF
PA
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | 20% AWP, Max $100 (30-day fill) |
| Yusimry (Adalimumab-AQVH) |
NF
PA
QLQuantity Limit: 2 PENS / 28 DAYS
STClick for Step Therapy details
|
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | No | 20% AWP, Max $150 (30-day fill) |
| Zarxio (Filgrastim-SNDZ) |
NF
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Zavesca (Miglustat) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Zejula (Niraparib) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Zelboraf (Vemurafenib) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $0 |
| Zepatier (Elbasvir/Grazoprevir) |
NF
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Zepbound (Tirzepatide) |
C
WLClick for Weight Loss details
|
No | ThedaCare Retail Pharmacy - Neenah (ONLY) | Yes | $550 |
| Zeposia (Ozanimod) |
F
PA
QLQuantity Limit: 1 CAP / 1 DAY (0.92mg) OR
7 CAPS / 180 DAYS (7-day Starter Kit) OR 28 CAPS / 180 DAYS (28-day Starter Kit) OR 37 CAPS / 180 DAYS (37-day Starter Kit) |
Yes | ThedaCare Retail Pharmacy - Shawano (ONLY) | Yes | $0 |
| Zokinvy (Lonafarnib) |
F
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $150 (30-day fill) |
| Zolinza (Vorinostat) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | No | 20% AWP, Max $150 (30-day fill) |
| Zomacton (Somatropin) |
NC
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $100 (30-day fill) |
| Zorbtive (Somatropin) |
NC
PA
|
No | External Retail/Specialty Pharmacy | No | 20% AWP, Max $100 (30-day fill) |
| Ztalmy (Ganaxolone) |
NF
PA
|
No | External Retail/Specialty Pharmacy | Yes | $0 |
| Zydelig (Idelalisib) |
NF
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $5 |
| Zykadia (Ceritinib) |
F
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $25 |
| Zytiga (Abiraterone acetate) |
NF
PA
|
No | ThedaCare Retail Pharmacy - Any Site | Yes | $10 |