Vivid Clear Rx Performance Formulary

The Vivid Clear Rx Performance Formulary is a list of drugs covered under your pharmacy benefit and developed to serve as a guide for physicians, pharmacists, healthcare professionals and members. This formulary is continually reviewed. Should you have any questions, please call us at (877) 848-4379.

Search for drug coverage below or view more details in our Vivid Clear Rx Performance Formulary

Drug NameSpecialtyTierPA RequiredQuantity Limit
12-Panel POC Toxicology System KIT In VitroNo3NoNo
1st Base Cream ExternalNo3NoNo
1st Medx-Patch/ Lidocaine Patch 4-0.0375-5-20 % ExternalNo3NoNo
1st Tier Unilet ComforTouchNo2NoNo
1st Tier Unilet ComforTouchNo2NoNo
2-Deoxy-D-Glucose POWDERNo3NoNo
2-Methoxyestradiol POWDERNo3NoNo
2-Way Foley Stabilization DevNo3NoNo
24HR Allergy Relief Tablet 180 MG OralNo1NoNo
4-Aminobutyric Acid CRYSTALSNo3NoNo