An Introduction to Independent Health’s Drug Formulary I The following information applies to plans offered through large group employers (and small group employers until their group renewal in 2014). Check your summary of benefits to ensure this formulary (Drug Formulary I) is associated with the plan offered to you by your employer prior to using your prescription drug benefit. Note: If you are reading a printed version of this drug formulary, content may have been updated since it was last printed. For the most up-to-date information, please visit independenthealth.com. Independent Health members benefit when their health care providers use the formulary because all medications included are selected due to their effectiveness and safety. Use of a formulary also ensures that premiums are kept to a minimum. The cost of each medication on the formulary is balanced with its effectiveness, which means that medications are not included on the formulary just because they are inexpensive; effectiveness is more important that the price of the medication. If a medication is not capable of achieving the desired effect, then the price of treating an illness or condition increases because other therapies must be used. Likewise, there are expensive medications that have not been proven to be any more effective than less costly alternatives. Since 1996, all prescriptions for Independent Health members have been written from the formulary in order to qualify for coverage. When health care providers write a prescription for Independent Health members, they consult the formulary and select the medication needed. Occasionally, members need a medication that is not on the formulary. In cases when it is medically necessary for a patient to have a medication that is not included on the formulary, health care providers are encouraged to request a medical exception from Independent Health’s Medical Director. The health care provider will need to complete a medical exception form and fax it to Independent Health’s Prior Authorization Department, who will review the details of the case. Independent Health’s three-tiered formulary lets you decide among preferred generic, preferred brand-name and non-preferred brand/generic medications with three different copayment/ coinsurance levels: • The lowest copayment is charged in Tier 1. This tier contains preferred generic medications, certain over-the-counter (OTC) medications and select brand-name medications. • A higher copayment/coinsurance is charged for those medications in Tier 2. This tier contains non-preferred generic medications and preferred brand-name medications. • The highest copayment/coinsurance is charged for those medications in Tier 3. This tier contains non-preferred brand-name medications and certain specified medications. • Brand-name medications with a generic equivalent are considered non-formulary (not covered). To obtain a medication that is non-formulary your health care provider is encouraged to submit a prior authorization request for coverage through the exceptions process. If the request is approved, that particular medication will be covered at your Tier 3 copayment/coinsurance level. All medications listed on the formulary will be available to you and you will be responsible for payment of the copayment/coinsurance as referenced in this document. You will note on the list that a medication’s copayment/coinsurance is assigned to a tier. How this affects your copayment/coinsurance depends upon what prescription plan you have. Independent Health reserves the right to modify the copay/tier of a particular medication as necessary. For example, when a generic equivalent becomes available for a covered brand-name medication, the brand-name medication becomes non-formulary (not covered) and will be covered only if approved though the medical exception process. The generic equivalent medication will be covered in Tier 1 or Tier 2.
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An Introduction to IndependentHealth’s Drug Formulary IThe following information applies to plans offered through large group employers (andsmall group employers until their group renewal in 2014). Check your summary ofbenefits to ensure this formulary (Drug Formulary I) is associated with the plan offeredto you by your employer prior to using yourprescription drug benefit.
Note: If you are reading a printed version ofthis drug formulary, content may have beenupdated since it was last printed. For the mostup-to-date information, please visit independenthealth.com.
Independent Health members benefit when theirhealth care providers use the formulary because all medications included are selected due to theireffectiveness and safety. Use of a formulary alsoensures that premiums are kept to a minimum. The cost of each medication on the formulary isbalanced with its effectiveness, which means thatmedications are not included on the formulary justbecause they are inexpensive; effectiveness is moreimportant that the price of the medication. If amedication is not capable of achieving the desiredeffect, then the price of treating an illness or condition increases because other therapies mustbe used. Likewise, there are expensive medicationsthat have not been proven to be any more effective than less costly alternatives.
Since 1996, all prescriptions for IndependentHealth members have been written from the formulary in order to qualify for coverage. Whenhealth care providers write a prescription for Independent Health members, they consult theformulary and select the medication needed. Occasionally, members need a medication that isnot on the formulary. In cases when it is medicallynecessary for a patient to have a medication that isnot included on the formulary, health care providersare encouraged to request a medical exception fromIndependent Health’s Medical Director. The healthcare provider will need to complete a medical exception form and fax it to Independent Health’s
Prior Authorization Department, who will reviewthe details of the case.
Independent Health’s three-tiered formulary letsyou decide among preferred generic, preferredbrand-name and non-preferred brand/genericmedications with three different copayment/coinsurance levels:
• The lowest copayment is charged in Tier 1. This tier contains preferred generic medications, certain over-the-counter (OTC) medications andselect brand-name medications.
• A higher copayment/coinsurance is charged forthose medications in Tier 2. This tier containsnon-preferred generic medications and preferredbrand-name medications.
• The highest copayment/coinsurance is chargedfor those medications in Tier 3. This tier contains non-preferred brand-name medications and certain specified medications.
• Brand-name medications with a generic equivalent are considered non-formulary (notcovered). To obtain a medication that is non-formulary your health care provider is encouraged to submit a prior authorization request for coverage through the exceptionsprocess. If the request is approved, that particularmedication will be covered at your Tier 3 copayment/coinsurance level.
All medications listed on the formulary will be available to you and you will be responsible for payment of the copayment/coinsurance as referenced in this document. You will note on thelist that a medication’s copayment/coinsurance isassigned to a tier. How this affects your copayment/coinsurance depends upon what prescription plan you have. Independent Health reserves the right to modify the copay/tier of aparticular medication as necessary. For example,when a generic equivalent becomes available for acovered brand-name medication, the brand-namemedication becomes non-formulary (not covered)and will be covered only if approved though themedical exception process. The generic equivalentmedication will be covered in Tier 1 or Tier 2.
Because of this, the actual copayment/coinsurancepaid may not match the copayment/coinsurancetier levels as published in this document. To determine which prescription plan you have, pleaserefer to your contract. If you have further questions, you may contact Independent Health’sMember Services Department.
Because there are thousands of medications in themarketplace, not all Tier 3 non-preferred medications can be listed here. Independent Healthmakes every attempt to provide you with as accurate a listing of medications as possible, however the list of medications and availability ofgenerics can change frequently. Since this list wascreated, some medications may have been added,while others may have been deleted. For an updated version of the formulary please visit ourwebsite at independenthealth.com.
Prior-AuthorizationIndependent Health requires you to get prior authorization for certain medications. To obtaincoverage for a medication requiring prior authorization, a prior authorization request formedical exception must be submitted by yourhealth care provider and approved by IndependentHealth’s Medical Director.
Step TherapyIn some cases, Independent Health requires you tofirst try certain medications to treat your medicalcondition before we cover another medication forthat condition. Step therapy is a way to help youget the best quality and value from your prescription medication benefit. This usually meansthat an equally effective generic medication is prescribed before a more expensive brand-namemedication. Step therapy may also ensure that twomedications are used together if they are more effective.
Quantity LimitationsQuantity limitations may apply to certain medications. Some medications are covered up to aspecific quantity per 30 or 90 days. Some examplesof medications with a quantity limitation are: sumatriptan (generic Imitrex®) and zolpidem tartrate (generic Ambien®).
Specialty MedicationsIn order to add value and accessibility in your pharmacy benefits, we offer a specialized prescription medication program for certain specialty medications through Reliance Rx Specialty Pharmacy. Specialty medications includethose that are either self-injectable, require specialdistribution, handling and/or are at limited supplyand certain oral oncology medications. These medications are restricted to designated pharmacies such as Reliance Rx. Reliance Rx specializes in providing high-quality service forcomplex chronic conditions such as hepatitis, multiple sclerosis, cancer and rheumatoid arthritis.
Along with providing these specialized medications,Reliance Rx also provides a convenient way for youto receive the medication, by arranging delivery atno charge directly to your home. They can alsoprovide you with education on the medicationyou’re taking, refill reminders and even thenecessary supplies, if applicable.
Age RestrictionSome prescription medications are restricted byage due to safety reasons or Food and MedicationAdministration (FDA) recommended labeling.
Maximum Daily Dose (MDD)Certain medications are dose limited by a maximum daily dose (MDD) as recommended bythe Food and Medication Administration (FDA) forsafety reasons. Limits may be set by the number oftablets/capsules per day or the total daily dose.
Maintenance MedicationsIndependent Health allows up to a 90-day supplyof certain medications to be filled. Medications eligible to be filled for a maintenance supply are indicated on the formulary.
Over-the-Counter (OTC) MedicationsCertain medications listed in the formulary areavailable over the counter. A prescription isrequired for coverage of the OTC products.
Sedative/Hypnotic MedicationsSedative/hypnotic medications are limited for allprescribers except sleep specialists to 14tablets/capsules per month with a maximum of 3fills per year (3 fills/365 days).
Tablet SplittingTablet splitting is the act of physically cutting ahigher strength tablet in half to achieve your prescribed dosage. This provides an identical dosewhile increasing the number of total doses available. For example, by splitting pills in two, 30tablets can be transformed into a 60-day supply forthe same copayment/coinsurance. Not all medications are good candidates for tablet splitting. We recommend that you speak with yourhealth care provider or pharmacist to see if yourmedication meets splitting requirements. Pleasenote this is a voluntary program. Tablet splitting isnot mandated by your plan.
Compounded Prescription MedicationsCompounded prescriptions (medications that arenot commercially manufactured) must be preparedby a participating pharmacy and contain at leastone prescription component. The dispensing pharmacy is required to submit for prior approvaland when covered the compounded prescriptionwill be available at a Tier 2 copayment/coinsurance. Coverage is provided in accordancewith our Compounding Medication Products Policy. Bulk products and powders are excludedfrom coverage because they are not prescriptionmedication products that are approved under sections 505, 505(j) or 507 of the Federal FoodMedication and Cosmetic Act.
Diabetic Supplies/MedicationsCoverage for medications and supplies used in thetreatment of diabetes is limited to products listedon the formulary. To obtain coverage for an unlisted diabetic medication or supply, a prior authorization request from the prescribing health care provider must be submitted to and approved by Independent Health’s Medical Director. Our preferred vendor will provide a glucose meter to you with no copayment/
coinsurance. Quantities are limited to one freemeter per member. Our preferred vendor contactinformation along with a list of meters that areavailable under this program can be found underthe “Blood Glucose Regulators” section of the formulary.
Antibiotic MedicationsAntibiotics are generally limited to a 10-day supplywith one refill within 15 days after the original fill.
Affordable Care Act (ACA) Preventive ServicesMedications listed on the formulary that are covered as preventive services under the Affordable Care Act may be covered. Certain restrictions may apply.
Lost/Stolen/Damaged MedicationsReplacement of any lost, stolen or damaged medications is the responsibility of the member.
Emergency Room PrescriptionsEmergency Room prescriptions are limited to a 10-day supply.
Benefit Exclusions:• Appetite suppressants/weight-loss medications
• Medications used for cosmetic purposes
• Medical devices (which may or may not require aprescription)
• Medical foods other than PKU supplements(which may or may not require a prescription)
• The following medications are excluded from theformulary (not covered): Antara®, fenofibrate48mg, 145mg (Generic Tricor®), fenofibric cap,Fenoglide®, Fibricor®, Karbinal® ER, Lipofen®,Liptruzet®, Lopid®, Onmel®, Tricor®, Triglide®
and Trilipix®.
IH18499 REV0114
Drug Formulary I (November 2014) 4
TABLE OF CONTENTS
CHAPTER 1 ‐ ALLERGY/COUGH & COLD ......................................................................................................................... 5
CHAPTER 2 – ASTHMA/RESPIRATORY ........................................................................................................................... 6
CHAPTER 3 – BLADDER/KIDNEY .................................................................................................................................... 7
CHAPTER 4 – BLOOD .................................................................................................................................................... 8
CHAPTER 5 – CANCER ................................................................................................................................................... 9
CHAPTER 6 – CARDIOVASCULAR – HYPERTENSION ..................................................................................................... 10
CHAPTER 7 – CARDIOVASCULAR – LIPID LOWERING ................................................................................................... 13
CHAPTER 8 – CARDIOVASCULAR/HEART ..................................................................................................................... 14
CHAPTER 9 – DERMATOLOGICAL MEDICATIONS ......................................................................................................... 15
CHAPTER 10 – DIABETES ............................................................................................................................................. 17
CHAPTER 11 – EAR/THROAT MEDICATIONS ................................................................................................................ 18
CHAPTER 12 – EYE ...................................................................................................................................................... 19
CHAPTER 13 – HORMONES/STEROIDS ........................................................................................................................ 21
CHAPTER 14 – INFECTION ........................................................................................................................................... 22
CHAPTER 15 – MEN’S HEALTH .................................................................................................................................... 24
CHAPTER 16 – MENTAL HEALTH ................................................................................................................................. 24
CHAPTER 17 – NERVOUS SYSTEM ............................................................................................................................... 26
CHAPTER 18 – PAIN .................................................................................................................................................... 28
CHAPTER 19 – SMOKING CESSATION .......................................................................................................................... 30
CHAPTER 20 – STOMACH/INTESTINAL ........................................................................................................................ 30
CHAPTER 21 – VITAMINS/MINERALS .......................................................................................................................... 32
CHAPTER 22 – WOMEN’S HEALTH .............................................................................................................................. 32
CHAPTER 23 – DENTAL FORMULARY ........................................................................................................................... 34
ADDITIONAL FORMULARY INFORMATION .................................................................................................................. 35
AFFORDABLE CARE ACT PREVENTATIVE SERVICES ...................................................................................................... 35
SPECIALTY PHARMACY INFORMATION ....................................................................................................................... 36
STEP THERAPY INFORMATION .................................................................................................................................... 37
KEY: PA – Prior Authorization QL – Quantity Limit ST – Step Therapy AL – Age Limit/Restriction RM – Restricted to MalesRF – Restricted to Females HT – Tablet Splitting ♦ ‐ Sedative/Hypnotic Drug ‡ ‐ Specialty Pharmacy + ‐ 90 day supplyLast Updated 11.13.2014
Please note: Medications listed on the drug formulary as covered without restriction may require prior authorization or may not be covered if it is determined that they are being used in conjunction with a procedure or treatment not covered under the members Health Contract.
Drug Formulary I (November 2014) 5
CHAPTER 1 ‐ ALLERGY/COUGH & COLD
1.A. Sedating Antihistamines
TIER 1 TIER 2 TIER 3
clemastine fumarate syrup cyproheptadine + diphenhydramine 50mg + hydroxyzine HCl + AL hydroxyzine pamoate + AL promethazine + PA
clemastine fumarate tabs Tavist® Vistaril®
1.B. Non‐Sedating Antihistamines
TIER 1 TIER 2 TIER 3
Clarinex® PA Clarinex® Reditab PA desloratadine PA desloratadine odt PA levocetirizine dihydrochloride PA Xyzal® PA
1.C. Sedating Antihistamine/Decongestant Combinations
TIER 1 TIER 2 TIER 3
promethazine AL
chlorphen/DM/PE AL Rynatan® susp
1.D. Nasal Steroids/Other Nasal Products
TIER 1 TIER 2 TIER 3
azelastine nasal spray azelastine nasal spray 0.15% ST flunisolide nasal fluticasone propionate nasal ipratropium
Nasonex®
Astelin® ST Astepro
® ST
Atrovent® 0.06% nasal spray Atrovent® 0.03% spray Atrovent
® nasal solution 0.06% Beconase® AQ ST AL Dymista® ST QL Flonase
® ST Nasarel
® Omnaris
® ST
Patanase® ST Qnasl® ST QL Rhinocort® Aqua ST Veramyst
® ST
ZetonnaTM ST
1.E. Narcotic‐containing Cough Products
TIER 1 TIER 2 TIER 3
codeine‐guaifenesin‐pseudoephedrine codeine‐guaifenesin hydrocodone‐homatropine hydrocodone‐guaifenesin‐phenylephrine hydrocodone polistirex‐chlorpheniramine polistirex
hydrocodone‐phenylephrine syruppromethazine with codeine promethazine/phenylephrine/codiene syrup
Allfen® CDX liquid Tussionex®
Drug Formulary I (November 2014) 6
1.F. Non‐Narcotic‐containing Cough Products
TIER 1 TIER 2 TIER 3
benzonatate promethazine/dextromethorphan PA SSKI
Tessalon®
1.G. Other Allergy
TIER 1 TIER 2 TIER 3
Auvi‐QTM Epipen® V‐Go®
CHAPTER 2 – ASTHMA/RESPIRATORY
2.A. Sympathomimetics
TIER 1 TIER 2 TIER 3
albuterol sulfate tabs +, syrup albuterol nebs metaproterenol tabs + syrup terbutaline tabs +
Arcapta® Neohaler + AL
Foradil® + ST
Maxair® Autohaler Proair
® HFA Proventil HFA
® Serevent® Diskus + ST Ventolin HFA®
Accuneb® Alupent
® Brethine® Isuprel
® Perforomist
® PA Proventil® Xopenex®
2.B. Xanthine Derivatives
TIER 1 TIER 2 TIER 3
aminophylline + theophylline SR + theophylline ER +
Dyphylline‐GG®
Lufyllin®
Quibron® Uniphyl
® 400mg, 600mg
2.C. Inhaled Corticosteroids and Combinations
TIER 1 TIER 2 TIER 3
Aerospan® + Alvesco® Asmanex
® + budesonide respules 0.25mg, 0.5mg AL + Flovent
® Diskus 50mcg, 100mcg, 250mg Flovent® HFA + Pulmicort
® Flexhaler Pulmicort® Respules 1mg AL + QVar® +
Advair® +
Advair® HFA + Dulera
® AL + Symbicort® +
Aerobid® Aerobid‐M® Daliresp
® PA
Pulmicort Respules® 0.25mg, 0.5mg AL Zetonna
® PA
Drug Formulary I (November 2014) 7
2.D. Mast Cell Stabilizers
TIER 1 TIER 2 TIER 3
cromolyn sodium 10mg/ml nebs + Intal® nebs
2.E. Leukotriene Modifiers
TIER 1 TIER 2 TIER 3
montelukast sodium chews (ages 1‐5 only) + montelukast sodium tabs +
Accolate® Singulair® chews AL Singulair® zafirlukast Zyflo
® CR PA
2.F. Other Respiratory Drugs
TIER 1 TIER 2 TIER 3
acetylcysteine ipratropium 200mcg/ml nebs + sodium chloride for inhalation
Anoro Ellipta®AL Atrovent
® HFA + Combivent® Kalydeco® PA ‡ Pulmozyme
® Spiriva® + AL
albuterol‐ipratropium neb soln Atrovent
® Neb Breo Ellipta® AL Duoneb®
Striverdi® Respimat AL TudorzaTM Pressair AL
CHAPTER 3 – BLADDER/KIDNEY
3.A. Antispasmodics
TIER 1 TIER 2 TIER 3
flavoxate hcl + hyoscyamine + AL oxybutynin + oxybutynin chloride SR + tolterodine er ST QL + tolterodine tartrate ST QL + trospium ST + trospium er ST +
Enablex® + ST
Anturol® ST Detrol
® ST QL Detrol LA® ST QL Ditropan® Ditropan
® XL Levsin®/SL MyrbetriqTM
ST
Sanctura® ST Sanctura XR
® ST Toviaz® ST Urispas® Vesicare® ST
Drug Formulary I (November 2014) 8
3.B. Cholinergic Stimulants
TIER 1 TIER 2 TIER 3
bethanechol chloride + Urecholine®
3.C. Urinary Anesthetics
TIER 1 TIER 2 TIER 3
phenazopyridine Pyridium®
3.D. Other Urinary Products
TIER 1 TIER 2 TIER 3
citric acid/sodium citrate potassium citrate + potassium citrate/citric acid +
Elmiron® PA QL Renacidin®
Bicitra® Polycitra® Urocit‐K
®
CHAPTER 4 – BLOOD
4.A. Anticoagulants
TIER 1 TIER 2 TIER 3
enoxaparin sodium PA fondaparinox PA heparin sodium jantoven + warfarin sodium +
Eliquis® Fragmin® PA Mephyton® + Pradaxa
TM +
Xarelto®+
Arixtra® PA Coumadin® Lovenox® PA Zontivity
® PA
4.B. Antiplatelets
TIER 1 TIER 2 TIER 3
aspirin/dipyridamole + clopidogrel bisulfate + dipyridamole + sulfinpyrazone +
Aggrenox® PA Brilinta
® +
Effient® + AL
Persantine® Plavix
® Ticlid® ticlopidine
4.C. Hematopoietic Agents
TIER 1 TIER 2 TIER 3 Aranesp® PA ‡
Epogen® PA ‡ Granix® PA ‡Neulasta® PA ‡ Neupogen® PA ‡ Procrit® PA ‡ Promacta® PA ‡
Leukine® PA Neumega® PA
4.D. Other Blood Modifiers
TIER 1 TIER 2 TIER 3
aminocaproic acid anagrelide + PA cilostazol + pentoxifylline +
Arcalyst® PA ‡
Exjade® PA ‡ Revlimid® PA ‡
Agrylin® PA Ferriprox® PA ‡ Firazyr® PA ‡ Pletal® Trental®
Drug Formulary I (November 2014) 9
CHAPTER 5 – CANCER
5.A. Cancer Drugs
TIER 1 TIER 2 TIER 3
anastrozole + ‡ PA RF bicalutamide ‡ RM capecitabine PA cyclophosphamide etoposide (caps only) ‡ exemestane ‡ + + ‡ PA RF flutamide ‡ RM hydroxyurea 500mg ‡ letrozole ‡ + PA RF (QL AL for Fertility) leucovorin calcium tabs megestrol acetate ‡ mercaptopurine methotrexate tabs + octreotide PA tamoxifen + temozolomide ‡ tretinoin ‡
Actimmune® PA ‡
Afinitor® PA ‡ Alkeran® ‡ Caprelsa® PA ‡
CeeNu® Emcyt® ‡ ErivedgeTM PA ‡ Fareston® + RF ‡ Gleevec® PA ‡ Hexalen® ‡ Hycamtin® cap PA ‡ Jakafi® PA ‡ Leukeran® ‡ Lysodren
® ‡ Matulane® ‡ Mesnex® PA ‡ Myleran
® ‡
Nilandron® PA
Oforta® PA ‡
Proleukin® PA Sprycel
® ST ‡ Sutent® PA ‡ Tabloid® Tarceva
® PA ‡ Tasigna® ST ‡ Teslac® Thalomid
® ‡ Tykerb
® PA ‡ Votrient® PA ‡ Zolinza® PA ‡ Zortress® PA Zytiga® PA ‡
Arimidex® + ‡ PA RF Aromasin® + ‡ PA RF Bosulif® PA ‡ Casodex® ‡ RM Cometriq
® PA ‡ Cytoxan® ‡ Droxia® ‡ Femara® ‡ + PA RF (QL AL for Fertility) Gilotrif
TM PA ‡ Hydrea® ‡ Iclusig® PA ‡ Imbruvica® PA ‡ Inlyta® PA ‡ Iressa
® ‡ Megace® ES ‡ Mekinist TM
PA ‡ Nexavar
® PA ‡
Pomalyst® PA ‡ Sandostatin® PA Signifor® PA Stivarga
® PA
SylatronTM PA ‡
Tafinlar TM PA ‡
Temodar® ‡ Vesanoid® ‡ Xalkori® PA ‡ Xeloda
® PA Xtandi
® PA ‡ ZelborafTM
PA ‡
5.B. Immunosuppressant Drugs
TIER 1 TIER 2 TIER 3
azathioprine + cyclosporine capsules cyclosporine modified + cyclosporine oral solution mycophenolate + mycophenolate sodium dr + PA prednisolone prednisone sirolimus 0.5mg PA tacrolimus
Azasan® + Rapamune
® 1mg, 2mg, soln PA
AstagrafTM XL PA CellCept
® Imuran® Myfortic® PA Neoral® Orapred
® Prograf® Rapamune
® 0.5mg PA Rayos® ST Sandimmune
®
Drug Formulary I (November 2014) 10
CHAPTER 6 – Cardiovascular – Hypertension
6.A. ACE Inhibitors
TIER 1 TIER 2 TIER 3
benazepril + captopril + enalapril + HT fosinopril + HT lisinopril + HT moexipril + HT quinapril + HT perindopril + HT ramipril + trandolapril + HT
Accupril® Aceon® Altace® caps Capoten® Epaned
® soln PA Lotensin® Mavik®
Prinivil® Univasc
® Vasotec® Zestril®
6.B. Angiotensin II Receptor Blockers
TIER 1 TIER 2 TIER 3
candesartan ST + eprosartan ST + irbesartan + HT losartan + telmisartan ST + valsartan + ST HT
Atacand® ST
Avapro® HT Benicar® ST Cozaar
® Diovan® ST HT Edarbi® ST Micardis
® ST Teveten® ST
6.C. Beta Blockers
TIER 1 TIER 2 TIER 3
acebutolol hcl + atenolol + bisoprolol fumerate + HT carvedilol + Dutoprol
® +
labetalol + metoprolol + metoprolol succinate SR + nadolol + pindolol+ propranolol + propranolol ER + timolol +
Betaxolol® Bystolic® Coreg® Corgard® Hemangeol® PA Inderal® LA Innopran XL® Kerlone
® Levatol® Lopressor® Sectral
® Tenormin® Toprol® XL Trandate® Zebeta
®
Drug Formulary I (November 2014) 11
6.D. Calcium Channel Blockers
TIER 1 TIER 2 TIER 3
amlodipine + amlodipine besylate‐benazepril hcl + diltiazem cd + Cartia XT + dilatiazem xr + diltiazem ER bead caps + diltiazem hcl + diltiazem SR + felodipine er + Nifediac CC Nifedical XL nifedipine ER + nimodipine PA verapamil + verapamil ER caps + verapamil SR tablets +
Adalat® CC
Calan® Calan® SR Cardene® SR Cardizem® Cardizem
® LA Cardizem
® CD Dilacor® XR DynaCirc® CR Isoptin® SR Kerlone® Lotrel® Nicardipine® Nimotop® PA nisoldipine Norvasc® Nymalize
® PA QL Plendil
® Procardia® XL Sular® Tiazac® Verelan® PM
6.E. Diuretics /Loop Diuretic
TIER 1 TIER 2 TIER 3
bumetanide + furosemide + torsemide +
Demadex® Edecrin
® Lasix®
6.E.ii. Thiazide and Related Drugs
TIER 1 TIER 2 TIER 3
chlorothiazide tabs + chlorthalidone + hydrochlorothiazide + indapamide + methyclothiazide + metolazone +
Diuril® susp Zaroxolyn®
6.E.iii. Potassium Sparing Diuretics
TIER 1 TIER 2 TIER 3
amiloride hcl + hctz/spironolactone + spironolactone + triamterene/hctz
Aldactazide® 50/50 + Aldactazide 25/25® Aldactone
®
Dyazide®
Dyrenium® Maxzide
®
Drug Formulary I (November 2014) 12
6.F. Vasodilators
TIER 1 TIER 2 TIER 3
doxazosin + hydralazine hcl + minoxidil tabs + prazosin hcl + terazosin +
Cardura® Cardura® XL Minipress®
6.G. Centrally Acting Hypertensives
TIER 1 TIER 2 TIER 3
clonidine hcl + clonidine hcl TD patch guanfacine hcl + methyldopa +
Catapres®
Catapres®‐TTS Tenex®
6.H. Hypertensive Combinations
TIER 1 TIER 2 TIER 3
amlodipine besylate/benazepril hcl + atenolol/chlorthalidone + benazepril/hctz + bisoprolol/hctz + candesartan/hctz + ST captopril/hctz + enalapril/hctz + HT irbesartan/hctz + HT lisinopril/hctz + HT losartan/hctz + metoprolol/hctz + moexipril/hctz + HT propranolol/hctz + quinapril/hctz + HT telmisartan/hctz + ST valsartan/hctz + HT
Accuretic® Atacand HCT® ST Avalide
® HT Azor® ST Benicar HCT® ST Corzide
® Diovan® HCT HT Edarbyclor® ST Exforge
® ST Exforge® HCT ST Hyzaar® Lopressor HCT
® Lotensin HCT® Lotrel® methyldopa/hctz Micardis
® HCT ST Prinzide
® Tarka® telmisartan/amlodipine ST trandolapril/verapamil hcl Tenoretic
® Tribenzor
TM ST
Twynsta® ST Uniretic® Vaseretic
® Zestoretic® Ziac®
6.I. Renin‐Angiotensin Inhibitor
TIER 1 TIER 2 TIER 3
AmturnideTM ST Tekamlo
® ST Tekturna® ST Tekturna
® HCT ST
Drug Formulary I (November 2014) 13
CHAPTER 7 – Cardiovascular – Lipid Lowering
7.A. Bile Acid Sequestrants
TIER 1 TIER 2 TIER 3 cholestyramine/cholestyramine light (bulk) + colestipol granules(bulk) + colestipol tab 1gm +
Welchol® + Colestid® (bulk) Colestid
® tab Questran
® Questran Light®
7.B. HMG‐CoA Reductase Inhibitors
TIER 1 TIER 2 TIER 3
atorvastatin calcium + HT lovastatin + HT pravastatin + HT simvastatin + HT
Crestor® + HT
fluvastatin Juxtapid® PA ‡ Kynamro® PA ‡ QL Lescol® Lipitor
® Livalo® Mevacor® Pravachol
® Zocor
®
7.C. Fibric Acid Derivatives
TIER 1 TIER 2 TIER 3
fenofibrate tabs 54mg, 160mg + fenofibrate caps 67mg, 134mg, 200mg + gemfibrozil + Lofibra +
7.D. Other Antihyperlipidemic
TIER 1 TIER 2 TIER 3
niacin er + omega‐3‐acid ethyl esters +
Zetia® +
Lovaza® ST Niaspan
® VascepaTM
Drug Formulary I (November 2014) 14
7.E. Antihyperlipidemic Combination Products
TIER 1 TIER 2 TIER 3
Simcor® +
Advicor® atorvastatin/amlodipine Caduet® Vytorin® ST
CHAPTER 8 – Cardiovascular/Heart
8.A. Antiarrhythmics
TIER 1 TIER 2 TIER 3
amiodarone + digoxin + disopyramide + flecainide acetate + mexiletine hcl + propafenone hcl + propafenone hcl sr + quinidine gluconate SR + quinidine sulfate + quinidine sulfate SR + sotalol +
Norpace CR® + Tikosyn®+
Lanoxin® Multaq® Norpace
® Rythmol® SR Tambocor®
8.B. Nitrates
TIER 1 TIER 2 TIER 3
isosorbide dinitrate + isosorbide mononitrate + isosorbide mononitrate SR + nitroglycerin long‐acting + nitroglycerin ointment nitroglycerin patch + nitroglycerin sublingual +
Nitrostat® QL Imdur®
Isordil®
Minitran® Nitro‐Bid
®
Nitro‐Dur® Nitrolingual aerosol spray
8.C. Other Cardiovascular Drugs
TIER 1 TIER 2 TIER 3
eplerenone + PA midodrine hcl phentolamine inj PA sildenafil AL PA
Adcirca® PA Dibenzyline
® Letairis® PA ‡ Tracleer® PA ‡
AdempasTM PA ‡
Inspra® PA
Opsumit® PA ‡ OrenitramTM
PA ‡ ProAmatine
® Ranexa® Revatio® AL PA VecamylTM PA ‡
Drug Formulary I (November 2014) 15
CHAPTER 9 – Dermatological Medications
9.A. Topical Corticosteroid Drugs
TIER 1 TIER 2 TIER 3
alclometasone diproprionate augmented betamethasone diproprionate (and AF)
augmented betamethasone betamethasone diproprionate bethamethasone valerate cream, lotion, oint clobetasol proprionate oint; cream desonide 0.05% cream; oint; lotion desoximetasone diflorasone diacetate fluticasone cr; oint fluocinonide fluocinolone acetonide fluticasone propionate lotion 0.05% halobetasol propionate hydrocortisone rectal cream 2.5% hydrocortisone 25mg rectal hydrocortisone 2.5% cream; oint; lotion hydrocortisone valerate mometasone furoate + prednicarbate cr, oint triamcinolone acetonide
Capex®
Cordran® Tape only Halog®
Aclovate® Apexicon E® betamethasone valerate foam Carmol‐HC® clobetasol propionate foam Clobex® Clobex® Spray Cordran® lotion Cutivate
® cream; oint Cutivate® 0.05% lotion DermAtop®
Desowen® lotion Diprolene® (and AF) Diprolene
® 0.05% lotion Elocon® Halonate® Lidex
®
Luxiq® foam
Novacort®
Olux® foam Pediderm
® HC Pramosone® E Temovate® Topicort
® Ultravate® Verdeso® Westcort
®
9.B. Antiacne Drugs
TIER 1 TIER 2 TIER 3
adapalene generic Avita
® benzoyl peroxide cr,gel,lot OTC clindamax clindamycin phosphate gel 1% clindamycin phosphate‐benzoyl peroxide gel clindamycintopical erythromycin gel erythromycin pads erythromycin/benzoyl peroxide gel isotretinoin PA metronidazole cream, lotion, gel Myorisan® PA generic Retin‐A® generic Sulfacet‐R
® rosadan sulfacetamide sodium lotion sulfacetamide sodium w/sulfur emulsion/cleanser
tretinoin microsphere gel Zenatane
® PA
Azelex® Derma‐Smoothe/FS
® Finacea® Finacea® Plus Kit Noritate
® Ziana®
Absorbica® PA Accutane
® PA Avar‐E® LS Avita® BenzaClin
® ST Benzefoam® Brevoxyl
® benzoyl peroxide (rx only), cloths, foam 5.3% Cleocin‐T
® Clindagel® Differin
® cream, gel Duac
® Klaron® Metrocream® Metrogel
® 0.75%, 1% Metrolotion® minocycline hcl er PA minocycline hcl tabs PA Plexion
® cleanser Retin‐A® Retin‐A
® Micro Rosadan® Kit Rosula
® Emulsion Cleanser Solodyn® PA sulfacetamide sodium w/sulfer cream, liquid Sumadan
TM Sumaxin® Wash Tretin® X QL Triaz
® Cloths 3% Veltin
TM
Drug Formulary I (November 2014) 16
9.C. Antipsoriasis and Antieczema Drugs
TIER 1 TIER 2 TIER 3
acitretin PA calcipotriene soln, oint, cream PA methotrexate tabs + selenium sulfide sulfacetamide sodium lotion
Elidel® AL PA FabiorTM
QL PA Protopic® AL PA Tazorac® PA
8‐Mop® Dovonex® PA Keralyt® scalp Salvax® Duo Kit PA Soriatane® PA SoriluxTM PA Taclonex
® PA Zithranol‐RR
® PA QL
9.D. Antifungal Drugs
TIER 1 TIER 2 TIER 3
ciclopirox 0.77% clotrimazole cream, lotion, soln OTC econazole nitrate cream 1% ketoconazole 2% shampoo ketoconazole cream Lamisil AT
® cream OTC miconazole cream, lotion, aerosol, soln OTC Nizoral A‐D® shampoo OTC nystatin 100,000u/1g cream; oint nystatin pwd nystatin‐triamcinolone Nystop
®
ciclopirox soln ciclopirox shampoo ciclopirox kit Extina®
Jublia® PA Kerydin® PA ketoconazole foam 2% Ketodan® Loprox
® Loprox® Shampoo Mentax® Micatin
® Naftin® Nizoral® shampoo Oxistat
® Penlac® Vusion®
9.E. Other Dermatological Products
TIER 1 TIER 2 TIER 3
aluminum chloride 20% ammonium lactate cr, lotion calcitriol ointment PA clotrimazole w/ betamethasone cream 1‐0.05%
diclofenac gel PA fluorouracil imiquimod cream PA lidocaine cr lidocaine hc cr lidocaine viscous soln lidocaine‐prilocaine cream lindane methoxsalen 10mg normal saline for irrigation permethrin cream podofilox solution
Carac®
Eurax® Oxsoralen‐Ultra® (oral only) Veregen
®
Aldara® PA Analpram® E Drysol® Efudex
® Epiduo
® PA Evoclin
® Foam lidocaine patch Lidoderm
® Medrox
‐RX® PA Mirvaso® Gel PA Momexin® Natroba® ST QL Oxsoralen‐Ultra
® 10mg (oral only) Panretin® Gel PA Picato® Gel PA Regranex
® PA Solaraze® PA spinosad suspension 0.9% ST QL Sklice
® ST QL
Targretin® Gel PA Ulesfia® Uramaxin® urea ValchlorTM
PA ‡ Vectical
® PA Vytone® Zyclara
® PA QL Zypram® 2.35‐1% cream and kit
Drug Formulary I (November 2014) 17
9.F. Antibiotics
TIER 1 TIER 2 TIER 3
acyclovir ointment gentamicin silver sulfadiazine mupirocin acyclovir oint
Aczone® PA Altabax® ST Bactroban® Sitavig® XereseTM Zovirax
®
CHAPTER 10 – Diabetes NOTE: Insulin, oral anti‐diabetic agents and diabetic suppplies that are not listed on the formulary require prior authorization and if authorized, will be covered in accordance with the member’s contract. Copayments vary by plan.
10.A. Insulin
TIER 1 TIER 2 TIER 3 Humulin® Insulins
Humalog®
Lantus®
Levemir® Novolin
® insulins Novolog
® insulins
Apidra® PA QL Apidra
® Solostar PA
10.B. Oral Hypoglycemic Drugs
TIER 1 TIER 2 TIER 3
acarbose + glimepiride + glimepiride/pioglitaone + glipizide + glipizide‐metformin glipizide CR tablets + glyburide + glyburide‐metformin + glyburide micronized + metformin hcl (500mg, 850mg, 1,000mg) + metformin tb24 + metformin SR + nateglinide + PA pioglitazone hcl + pioglitazone hcl/metformin hcl + repaglinide +
Actoplus Met® XR
Invokana® Invokamet® + Janumet
® + Janumet
® XR + Januvia® + HT Jentadueto
® +
Kombiglyze® XR Onglyza
® + HT Proglycem
® PA
Prandin® +
Prandimet® + Riomet®
Tradjenta® +
Actos®
Actoplus Met® Amaryl® Avandamet
® PA Avandaryl® PA Avandia® PA Cycloset
® Diabeta® PA Duetact
®
Farxiga® PA Fortamet
® PA
Glucophage/Glucophage XR® PA Glucotrol® PA Glucotrol XL
® PA Glucovance
® PA Glumetza® ST Glyset
® PA Glynase® PA Juvisync® Kazano® Metaglip
® Nesina® Oseni® Prandin
® Precose
® Starlix® PA
Drug Formulary I (November 2014) 18
10.B.i Other Drugs Affecting Glucose
TIER 1 TIER 2 TIER 3
glucagon
Bydureon® ST Byetta® ST Symlin® PA Victoza® ST Welchol® +
Tanzeum® ST
10.C. Diabetic Supplies
TIER 1 TIER 2 TIER 3
NovoFine® Needles
Blood Glucose Monitors The manufacturers listed below will provide a glucose meter to you with no copayment. Quantities are limited by each manufacturer to one meter per member. Please have your ID number available when you contact the manufacturer. Accu‐Chek glucose meters can be obtained by calling Roche Diagnostics at 1‐888‐744‐3671.
One Touch glucose meters can be obtained by calling Lifescan, Inc. at 1‐888‐377‐5227, please reference offer code 289IHA001.
Accu‐Chek® Glucose Meters OneTouch® Glucose Meters
Accu‐Chek® Active Accu‐Chek® Advantage Accu‐Chek® Aviva Plus Accu‐Chek
® Compact Accu‐Chek® Nano SmartView
OneTouch® Ultra® OneTouch® Ultra® 2 OneTouch® UltraMiniTM
OneTouch® UltraSmart® OneTouch® Verio® IQ OneTouc® Verio® Sync Meter
Diabetic Test Strips
Products listed in this section are a covered benefit based on your plan. Products not listed require prior authorization. Copayments vary by plan.
Accu‐Chek® Diabetic Test Strips OneTouch® Diabetic Test Strips
Accu‐Chek® Active Accu‐Chek
® Aviva Plus Accu‐Chek® Aviva Accu‐Chek® Comfort Curve Accu‐Chek
® Compact Accu‐Chek® SmartView
OneTouch® Basic® OneTouch
® Profile® OneTouch® SureStep® OneTouch® Ultra® OneTouch
® Verio®
CHAPTER 11 – Ear/Throat Medications
11.A. Drugs Affecting the Ear
TIER 1 TIER 2 TIER 3
acetic acid otic soln antyipyrine/benzocaine otic soln ciprofloxacin otic PA AL generic Cortisporin® Otic sol, susp generic Domeboro® Otic hydrocortisone w/acetic acid otic soln ofloxacin otic PA AL
Ciprodex® PA AL Chloromycetin® Otic
Auralgan® Otic Soln
Cipro HC® Otic PA AL colistimethate Cortane B
® Otic Cortisporin® otic sol, susp Cortisporin® Otic‐TC Cresylate
® Otic Domeboro® Otic Floxin® Otic PA AL Neotic
® Trioxin® Otic susp Zinotic®/Zinotic® ES
Drug Formulary I (November 2014) 19
11.B. Drugs Affecting the Throat and Mouth
TIER 1 TIER 2 TIER 3
cevimeline QL chlorhexidine oral rinse triamcinolone in Orabase lidocaine viscous pilocarpine tab +
Evoxac® QL Kenalog® in Orabase Peridex® Salagen®
CHAPTER 12 – Eye
12.A. Ophthalmic Antiinfective drugs
TIER 1 TIER 2 TIER 3
bacitracin ophthalmic chloramphenicol ciprofloxacin ophth soln erythromycin ophthalmic gentamicin ophthalmic generic Neosporin® ophthalmic levofloxacin opth soln ofloxacin ophth soln generic Polytrim
® generic Polysporin® ophthalmic sulfacetamide sodium 10% tobramycin trifluridine
Natacyn® PA
Zirgan®
Azasite® PA QL
Besivance® Ciloxan® gatifloxacin soln PA Moxeza
® PA Ocuflox® QL Quixin® Vigamox
® PA Viroptic® Zymaxid® PA
12.B. Ophthalmic Corticosteroid Drugs
TIER 1 TIER 2 TIER 3
dexamethasone ophthalmic hydrocortisone w/acetic acid otic soln fluorometholone ophthalmic prednisolone ophthalmic
Acuvail® PA
Alrex® 5ml only PA Flarex
® FML‐Forte
® ophthalmic Lotemax
® 5ml only Lotemax® ointment, gel Pred Mild® Vexol
® 5ml only
Acetasol® HC otic soln HMS® Pred Forte
®
12.C. Ophthalmic Antiinfective/Steroid Combination Drugs
TIER 1 TIER 2 TIER 3
dexamethasone/tobramycin generic Cortisporin® ophthalmic generic Maxitrol® ophthalmic generic Metimyd
® generic NeoDecadron
®
Blephamide® Liquifilm
Poly‐Pred® Tobradex® ointment
Pred‐G®
Pred‐G S.O.P. ® Tobradex® susp. Tobradex
® ST Zylet
®
Drug Formulary I (November 2014) 20
12.D. Glaucoma Drugs
TIER 1 TIER 2 TIER 3
acetazolamide tab + apraclonidine brimonidine tartrate 0.2% brimonidine solution carteolol dipivefrin dorzolamide hcl soln dorzolamide/timolol ophth soln + latanoprost ophth soln PA levobunolol HCl methazolamide + metipranolol pilocarpine soln timolol maleate timolol ophthalmic gel
Alphagan P® 0.1% Azopt® Betimol® 5ml only Betoptic® S Combigan® 5ml only Isopto Carbachol
® Lumigan
® PA Phospholine® iodide Pilopine® H.S. Simbrinza® Travatan® PA
Travatan® Z PA
Alphagan P® 0.15% Betagan® Cosopt® Cosopt® PF Diamox® Iopidine
® Optipranolol
® Rescula® PA Timoptic® Timolol® XE Trusopt® Xalatan® PA Zioptan® PA
12.E. Other Ophthalmic Drugs
TIER 1 TIER 2 TIER 3
Alaway® OTC atropine azelastine ST bromfenac cromolyn sodium + PA diclofenac sodium ophth soln + PA epinastine ST homatropine ketorolac tromethamine ophth soln 0.4% and 0.5% PA
naphazoline OTC QL phenylephrine ophthalmic 2.5% tropicamide Zaditor® OTC
Alomide® PA BromdayTM ® PA Max. 2 fills per year
Cystaran® PA Ilevro® PA Max. 2 fills per year Lacrisert® Nevanac
® PA Max. 2 fills per year Restasis® PA
Acular® PA Acular® LS PA Akten
® Alamast® Alocril® ST Bepreve
® opth ST Durezol® Elestat® ST
Emadine®
flurbiprofen ophth soln ketotifen fumerate ophth soln (rx only) LastacaftTM ST Mydfrin
® Ocufen® ophth soln Pataday
® ST
Patanol® ST Prolensa® ST PA Max 2 fills per year
Optivar® ST Voltaren
®ophth soln PA
Drug Formulary I (November 2014) 21
CHAPTER 13 – Hormones/Steroids
13.A. Oral Steroids
TIER 1 TIER 2 TIER 3
dexamethasone cortisone acetate + fludrocortisone acetate + hydrocortisone tab + methylprednisolone prednisolone oral syrup prednisone
Celestone® Cortef® Decadron® Medrol® Orapred
® Pediapred® Prelone®
13.B. Thyroid and Antithyroid Drugs
TIER 1 TIER 2 TIER 3
levothroid + levothyroxine + levoxyl + liothyronine + methimazole + propylthiouracil + thyroid + unithroid +
Armour Thyroid® + Synthroid
® + Cytomel® Tapazole
® TirosintTM
13.C. Growth Hormone Products
TIER 1 TIER 2 TIER 3
Norditropin® PA ‡ Somavert® PA ‡
Genotropin® PA ‡ Humatrope® PA ‡ Nutropin®/Nutropin® AQ PA ‡ Saizen
® PA ‡ Serostim® PA
13.D. Osteoporosis
TIER 1 TIER 2 TIER 3
alendronate tabs + calcitonin‐salmon Fortical
®
risedronate sodium 150mg +
Actonel® + Atelvia
TM Forteo
® PA ‡ (limited to 26 fills/lifetime) Fosamax® plus D + Miacalcin® inj. PA
Actonel® 150mg Binosto
® ST
Boniva® tabs QL
Fosamax® tabs ibandronate sodium tabs QL Miacalcin® nasal spray
13.E. Other Endocrine Drugs
TIER 1 TIER 2 TIER 3
cabergoline PA QL desmopressin + sodium phenylbutyrate PA
Buphenyl® PA CarbagluTM
PA
Chemet® Cystagon® PA Didronel
® Increlex
® PA ‡ Korlym® PA ‡ Menostar
® + RF AL Orfadin® PA ‡ Sensipar® + Stimate
® Syprine® + Zavesca® PA ‡
DDAVP® MyaleptTM PA ‡ Oxandrin
® Procysbi® PA ‡ Ravicti
® PA ‡ Samsca
® PA
Drug Formulary I (November 2014) 22
CHAPTER 14 – Infection
14.A. Antibiotics (Antibiotics are generally limited to a 10 day supply with one refill within 15 days of original fill.)
TIER 1 TIER 2 TIER 3
amoxicillin caps, susp amoxicillin clavulanate ampicillin caps, susp azithromycin QL, 600mg QL PA azithromycin
® susp QL cefaclor caps, susp cefadroxil cefdinir cefprozil cefuroxime 250mg & 500mg tabs cephalexin caps, susp cephradine capsules ciprofloxacin tabs clarithromycin clarithromycin SR QL clindamycin 75mg, 150mg, 300mg clindamycin granules dicloxacillin caps doxycycline hyclate caps, tabs erythromycin base enteric pellets erythromycin estolate caps, susp erythromycin ethylsuccinate tabs, susp erythromycin stearate erythromycin/sulfisoxazole susp levofloxacin minocycline caps (50mg & 100mg only) moxifloxacin hcl nitrofurantoin macrocrystals PA penicillin VK tabs, soln sulfamethoxazole/trimethoprim sulfisoxazole tabs tetracycline caps, susp trimethoprim tabs
Ery‐Tab® Suprax® tabs, susp Vibramycin® susp
amoxicillin/clavulanate er amoxicillin er QL Augmentin® XR Avelox® Biaxin
® Biaxin XL® tabs Ceftin® 125mg tabs, susp Cefzil® Cetraxal
® PA QL Max. 7 day supply Cipro® ciprofloxacin hcl SR 24 hr tabs Cleocin® pediatric granules Doryx® QL PA doxycycline DR QL doxycycline hyclate TBEC dr QL doxycycline monohydrate Furadantin
® susp PA
Keflex®
Ketek®
Noroxin® Levaquin
® Macrobid®
Minocin® Minocin Pac
® PA Monodox® 75mg Moxatag® Proquin
® XR Zithromax
® QL, 600mg QL PA Zithromax® susp QL ZMax
® Zyvox® PA
14.B. Antifungals
TIER 1 TIER 2 TIER 3
clotrimazole troche fluconazole 150mg tab (QL, females only) fluconazole tabs/oral suspension griseofulvin 125mg, 250mg griseofulvin suspension itraconazole caps PA ketoconazole tabs PA nystatin oral suspension nystatin tabs terbinafine hcl PA voriconazole PA
Lamisil® oral granules PA Noxafil
® PA Noxafil DR® PA
Ancobon® Diflucan
® 150mg (QL, females only) Diflucan
® tabs/oral suspension Ertaczo® QL flucytosine Grifulvin
® V Gris‐Peg® griseofulvin 500mg Lamisil® PA Mycelex® Troche Nizoral® PA Oravig® ST AL Sporanox
® PA Terbinex® PA QL Vfend® PA
Drug Formulary I (November 2014) 23
14.C. HIV Drugs
TIER 1 TIER 2 TIER 3
abacavir sulfate tabs + abacavir sulfate/lamivudine/zidovudine PA didanosine dr lamivudine + lamivudine/zidovudine nevirapine nevirapine sr stavudine zidovudine
Aptivus® Atripla® CompleraTM Crixivan® Emtriva® Epzicom
® Fuzeon
® PA ‡ Intelence® Invirase® Isentress® Kaletra® Lexiva® Norvir® Prezista® ST Rescriptor® Reyataz® Selzentry
® Stribild
TM Sustiva® Triumeq® PA Trivicay® Truvada® Videx
® Viramune® XR 100mgViread® Viracept® Ziagen
® soln
Combivir® EdurantTM Epivir® Retrovir® Trizivir® PA Videx
® EC Viramune
® Viramune® XR Zerit® Ziagen® tabs
14.D. Other Antiviral Drugs
TIER 1 TIER 2 TIER 3
acyclovir adefovir dipivoxil tabs PA amantadine + famciclovir QL ganciclovir PA lamivudine tab PA ribavirin ‡ PA valacyclovir QL
Alferon N® PA Baraclude
® PA Relenza® QL AL Tamiflu® QL Tyzeka
® PA Valcyte® PA
Copegus®‡ PA Epivir‐HBV
® PA Famvir® QL flumadine Hepsera
® PA Rebetol® ‡ PA Valtrex® QL Zovirax
®
14.E. Antituberculosis Drugs
TIER 1 TIER 2 TIER 3
ethambutol isoniazid + pyrazinamide rifabutin PA rifampin
Rifater®
Myambutol®
Mycobutin® PA
Rifadin®
Seromycin® Sirturo
® PA Trecator®
14.F. Other Specialized Antiinfective Drugs
TIER 1 TIER 2 TIER 3
chloroquine phosphate dapsone hydroxychloroquine sulfate + mebendazole QL metronidazole mefloquine hcl QL neomycin sulfate paromomycin primaquine phosphate quinine sulfate caps PA QL AL tinidazole tabs tobramycin neb QL ‡ vancomycin caps PA
Alinia® tabs PA, soln PA AL Cayston
® PA QL AL Must be obtained from Cystic Fibrosis Services
Coartem® QL Daraprim® Mepron
® PA Nebupent® PA Stromectol
® Yodoxin®
Aralen® phosphate
atovaquone/proguanil Bethkis
® PA QL ‡ Dificid® PA Flagyl
® Malarone® metronidazole 375mg caps Qualaquin
® PA QL AL Tindamax® Tobi
® PA QL ‡ Vancocin® capsules PA Xifaxan® 200mg QL, 550mg PA
Drug Formulary I (November 2014) 24
CHAPTER 15 – Men’s Health
15.A. Drugs for Benign Prostatic Dysplasia
TIER 1 TIER 2 TIER 3
alfuzosin + RM doxazosin + finasteride + RM tamsulosin hcl sr + terazosin (capsules only) +
Avodart® + RM Cardura® Cardura® XL Cialis® 2.5mg & 5mg RM Duplicate therapy with ED drugs is not allowed.
Flomax® Hytrin® Proscar
® RM
Rapaflo® RM Uroxatral® RM
15.B. Erectile Dysfunction
Drugs in this category are limited to male patients only. Duplicate therapy with other ED medications is not allowed.
TIER 1 TIER 2 TIER 3
yohimbine
Caverject® PA QL = 6 per fill/48 per year Edex
® PA QL = 6 per fill/48 per year
Muse® PA QL = 6 per fill/48 per year Viagra® QL = 6 per fill/72 per year
Cialis® 10mg & 20mg QL = 4 tabs mth/48 per year Levitra
® QL = 4 tabs mth/48 per year Staxyn® QL = 4 tabs mth/48 per year/12 fills year Stendra® QL = 4 tabs mth/48 per year/12 fills year
15.C. Male Hormones
TIER 1 TIER 2 TIER 3
testosterone cypionate PA Androderm® RM PA Androgel® RM PA Android
® + Androxy® + Methitest
® + Testim
® RM PA Testred® +
AxironTM RM PA
Aveed® RM PA
Bio‐T‐Gel® RM PA
Depo‐Testosterone® PA FortestaTM
RM PA
Striant® PA testosterone gel 1% PA RM Vogelxo® PA RM
CHAPTER 16 – Mental Health
16.A. Antianxiety Drugs
TIER 1 TIER 2 TIER 3
alprazolam buspirone clorazepate chlordiazepoxide diazepam AL lorazepam oxazepam
alprazolam xr Ativan® Tranxene
®
Valium® Xanax
®
Xanax® XR
16.B. Sedative/Hypnotic Drugs
TIER 1 TIER 2 TIER 3
diphenhydramine 50mg only + flurazepam ♦ AL hydroxyzine hcl + AL hydroxyzine AL pamoate + temazepam ♦ triazolam ♦ zaleplon ♦ zolpidem tartrate ♦
Rozerem® ♦
Ambien® ♦ Ambien
® CR ♦ ST Edular® SL ST QL ♦ eszopiclone PA Halcion
® ♦ HetliozTM
PA Intermezzo
® ST QL Lunesta® PA meprobamate AL Restoril
® ♦ Sonata
® ♦ Vistaril®
zolpidem er ♦ ST
Drug Formulary I (November 2014) 25
16.C. Depression/Mania
TIER 1 TIER 2 TIER 3
amitriptyline amitriptyline/perphenazine bupropion + bupropion hcl SR 12 hr + bupropion hcl SR 24hr + citalopram + HT clomipramine desipramine doxepin duloxetine escitalopram oxalate + HT fluoxetine hcl 10mg & 20mg tabs/capsules + fluoxetine liquid fluvoxamine imipramine HCl (PM non‐form) lithium carbonate + lithium carbonate CR tab maprotiline PA mirtazapine + mirtazapine ODT + nefazodone hcl + PA nortriptyline paroxetine tabs + HT paroxetine er + ST paroxetine hcl sr + ST phenelzine tab protriptyline sertraline + HT tranylcypromine trazodone + trimipramine venlafaxine + venlafaxine er +
Savella® +
Amoxapine® Anafranil® BrintellixTM
ST BrisdelleTM Celexa® Cymbalta
® desvenlafaxine ST Effexor® XR Emsam® PA Fetzima® ST fluoxetine 40mg capsules, 60mg tabs, PMDD, 90mg
fluvoxamine er Forfivo® XL Lexapro® + HT Nardil® Oleptro
® ST Pamelor
® Parnate® Paxil® Paxil® CR ST Prozac® Prozac
® Weekly Niravam® PA Norpramin® Pristiq
® ST Remeron® Remeron Sol‐Tab® Sarafem
® Silenor® QL Surmontil
® Tofranil® Tofranil® PM Viibryd
TM Vivactil® Wellbutrin
® Wellbutrin SR
® Wellbutrin XL® Zoloft®
16.D. Antipsychotic drugs
TIER 1 TIER 2 TIER 3
chlorpromazine + clozapine QL fluphenazine haloperidol + loxapine + olanzapine + olanzapine odt PA perphenazine + risperidone + risperidone odt PA risperidone solution AL thioridazine + AL thiothixene + trifluoperazine + quetiapine fumarate ziprasidone +
Abilify® 5mg & 15mg PA
Abilify® 10mg, 20mg & 30mg HT PA Abilify® oral solution PA Orap®
Abilify® Discmelt PA
Fanapt® PA Fazaclo® QL Geodon® Haldol
® LatudaTM Navane® olanzapine‐fluoxetine PA Risperdal® Risperdal® M PA Risperdal® solution AL Saphris® Seroquel
® Seroquel® XR ST Symbyax
® PA Thorazine
® Zyprexa® Zyprexa®/Zydis® PA
Drug Formulary I (November 2014) 26
16.E. CNS Stimulant Drugs
(Generally for Hyperkinesis or Narcolepsy only. Not covered as appetite suppressant.)
TIER 1 TIER 2 TIER 3
amphetamine mixture + AL amphetamine‐dextroamphetamine sr + AL dextroamphetamine tabs & SR + AL methamphetamine + AL methylphenidate + AL methylphenidate cd AL methylphenidate er AL methylphenidate SR tabs + AL
Nuvigil® + AL PAStrattera® + AL
Adderall® AL Adderall XR® AL clonidine hcl er Concerta
® AL Daytrana
® AL Dexedrine®/Spansules AL
dexmethylphenidate hcl cp24 AL Dextrostat® AL Focalin® XR AL KapvayTM Metadate CD
® AL Methylin
® AL modafinil PA AL Provigil
® PA AL Quillivant® XR ST AL Ritalin® AL /Ritalin LA® AL Vyvanse
® AL
Zenzedi® AL
CHAPTER 17 – Nervous System
17.A. Anticonvulsants
TIER 1 TIER 2 TIER 3
carbamazepine + carbamazepine er + clonazepam tabs clonazepam odt ST divalproex sodium tabs + divalproex sodium sr + divalproex sodium sprinkles + ethosuximide 250mg/5ml syrup ethosuximide capsules + felbamate gabapentin + lamotrigine tablets + lamotrigine chewable tablets + levetiracetam + oxcarbazepine tablets + oxcarbazepine suspension phenobarbital + phenytoin chew tab + phenytoin sodium + phenytoin sodium extended + phenytoin sodium susp + primidone + tiagabine + PA topiramate + topiramate sprinkle + PA AL valproic acid + zonisamide + PA
Banzel® PA AL Celontin® + Diastat® PA Lyrica
® Peganone
® + Phenytek® + Sabril
® PA Vimpat® PA AL
Aptiom® PA Carbatrol® Depakene® Depakote
® Depakote ER
® Depakote® Sprinkles Dilantin
® Dilantin® Infatab Dilantin® 125 suspension Felbatol
® FycompaTM PA AL Gabitril
® PA Gralise® ST Horizant
® PA Keppra® Keppra
® XR Klonopin
®/Klonopin® Wafers Lamictal® tabs Lamictal® chewable tablets Lamictal
® ODT PA, Titration Kit PA QL Lamictal® Starter Kit QL Lamictal® XR AL, Starter Kit PA QL AL lamotrigine er AL levetiracetam xr Mebaral
® Mysoline® Neurontin
® Oxtellar® XR Phenytek® Potiga® Qudexy® XR PA Tegretol®/Tegretol® XR Topamax
® Topamax
® Sprinkles PA AL topiramate er PA Trileptal® Trokendi
TM XR PA
Drug Formulary I (November 2014) 27
Zarontin® Zonegran® PA
17.B. Antiparkinson Drugs
TIER 1 TIER 2 TIER 3
amantadine hcl + benztropine + bromocriptine mesylate + carbidopa/levodopa + carbidopa/levodopa CR + carbidopa/levodopa/entacapone tabs + carbidopa/levodopa odt ST diphenhydramine 50mg + entacapone + ST pramipexole dihydrochloride + PA ropinirole hydrochloride tabs + PA selegiline + trihexyphenidyl +
Apokyn® PA ‡ Azilect® + PA Zelapar® + PA
carbidopa Cogentin® Comtan® ST Eldepryl® Kemadrin
® Lodosyn® Mirapex®/ Mirapex® ER PA Neupro® PA Parlodel
® Parcopa® ST Requip® PA Requip® XL PA ropinirole hcl tabs 24 hour PA Sinemet® Sinemet CR® Stalevo
® Tasmar® ST
17.C. Alzheimer’s Drugs
TIER 1 TIER 2 TIER 3
donepezil + donepezil 23mg + ST galantamine + galantamine SR + galantamine oral solution
Namenda® tabs, soln +
Namenda® XR
Aricept® Aricept
® ODT Aricept® 23mg ST Cognex® Exelon
® Razadyne®
Razadyne® ER
rivastigmine
17.D. Multiple Sclerosis Drugs
TIER 1 TIER 2 TIER 3
AmpyraTM ER PA ‡ Avonex
® PA ‡ Copaxone
® PA ‡ Gilenya
TM PA ‡ Tecfidera® PA ‡
Aubagio® PA ‡ Extavia
® PA ‡ Rebif® PA ‡
17.E. Other CNS/Autonomic Drugs
TIER 1 TIER 2 TIER 3
acamprosate calcium tab dr PA buprenorphine hcl PA buprenorphine hcl/naloxone hcl sublingual disulfiram naltrexone pyridostigmine bromide 60mg tab
Mestinon® 60mg syrup, 180mg CR tab NuedextaTM XR PA OnfiTM PA Prostigmin® Suboxone® Filmtab Xenazine
® PA QL Xyrem® PA Zubsolv®
Antabuse® PA ButransTM
PA
Campral® PA Evzio® PA Intuniv® AL NortheraTM PA ‡ Revia® Subutex® PA Suboxone® SL
Drug Formulary I (November 2014) 28
CHAPTER 18 – Pain
18.A. Narcotic Pain Relieving
TIER 1 TIER 2 TIER 3
acetaminophen w/codeine aspirin w/codeine belladonna/opium supp codeine sulfate fentanyl TD patch 12mcg, 25mcg fentanyl TD patch 50mcg, 75mg, 100mcg ST hydrocodone w/acetaminophen hydrocodone/APAP soln 7.5/500 mg per 15ml hydrocodone w/ibuprofen hydromorphone hcl PA methadone hcl 5mg,10mg morphine sulfate ir morphine sulfate cap sr 24hr 10mg, 20mg, 30mg, 50mg, 60mg, 80mg morphine sulfate cap sr 24hr 100mg, 200mgST morphine sulfate supp morphine sulfate tablets oral solution morphine sulfate ER oxycodone 5mg tablets/soln oxycodone w/acetaminophen tramadol tramadol er tablets ST
Nucynta®
Nucynta® ER Oxycontin® 10mg, 15mg, 20mg, 30mg, 40mg Oxycontin® 60mg, 80mg ST
AbstralTM PA AL
Limited distribution via REMS program. Actiq® PA Avinza® 30mg Avinza® 45mg, 60mg, 75mg, 90mg, 120mg ST B&O Supprettes® AL Combunox
® QL Conzip® ST Dilaudid® PA Duragesic® ST Exalgo® ST Fentora
® PA hydrocodone bitartrate/acetaminophen Kadian®
10mg, 20mg, 30mg, 50mg, 60mg, 80mg Kadian® 100mg, 200mg ST Lazanda
® PA
Lortab® Magnacet® morphine sulfate beads sr 24hr ST MS Contin® Norco
® Onsolis
® PA ‡ AL Opana® PA Opana ER
® Oramorph®
Oxecta® PA
oxycodone w/ibuprofen QL oxymorphone PA Percocet® Percodan
® Reprexain® PA
Roxicodone® Rybix
® ODT PA Ryzolt® ST Subsys® PA Talwin NX
® PA tramadol/apap PA Tylenol w/Codeine® Tylox® Ultracet
® PA Ultram® ER ST Vicodin® Vicoprofen
® 7.5mg/200mg Xodol®
Drug Formulary I (November 2014) 29
18.B. Antiinflammatory, i.e. NSAIDs
TIER 1 TIER 2 TIER 3 aspirin CR 800mg + diclofenac sodium enteric coated tablets + diclofenac sodium SR 24‐hr 100 mg + diflunisal + etodolac + flurbiprofen tabs + ibuprofen + (prescription strengths only, OTC not covered)
indomethacin + indomethacin SR + ketoprofen + ketorolac PA QL AL meclofenamate + meloxicam + nabumetone + naproxen + naproxen sodium + oxaprozin + piroxicam + salsalate + sulindac + tolmetin sodium +, 200mg PA
Celebrex® + ST fenoprofen +
Anaprox® Daypro® Duexis® PA EC Naprosyn
® Flector® patch Indocin
® ketoprofen extended release mefenamic acid Motrin® Mobic® Nalfon® Naprelan
® QL Naprelan
® SR Naprosyn®
Pennsaid® QL Ponstel® Meloxicam® Comfort PacKit QL Sprix
TM PA QL
Vimovo® PA Voltaren‐XR®
Voltaren® gel QL Zipsor
®
18.C. Migraine Drugs
TIER 1 TIER 2 TIER 3
butalbital/apap/caffeine/codeine butorphanol tartrate NS PA divalproex sodium sr ergotamine w/caffeine acetaminophen; butalbital; caffeineaspirin; butalbital; caffeine
aspirin; butalbital; caffeine; codeine isometheptene mucate/dichloralphenazone/acetaminophen acetaminophen; butalbital sumatriptan inj QL sumatriptan nasal spray QL sumatriptan tabs QL zolmitriptan QL
Cafergot®
Ergomar®
Migranal® PA QL Relpax
® tablets QL Zomig® Nasal Spray QL
Alsuma® QL Amerge
® QL Axert® QL Cambia
® PA QL AL Depakote ER® DHE® 45 QL PA Esgic
® Esgic Plus® Fiorinal® Fioricet
® Frova® QL Imitrex
® QL Maxalt
® QL Maxalt‐MLT® QL Midrin® naratriptan QL Phrenilin® Forte rizatriptan benzoate QL rizatriptan benzoate odt QL Stadol NS® PA Sumavel
® QL Treximet
® ST QL Zelrix® QL ZecuityTM
QL
Zomig® QL
18.D. Antirheumatics
TIER 1 TIER 2 TIER 3
diclofenac w/misoprostol QL hydroxychloroquine sulfate + leflunomide + PA methotrexate tabs + methotrexate inj PA
Cuprimine® Depen® Titratabs Enbrel
® ‡ PA Humira® ‡ PA Ridaura
® Thiola
TM Trexall®
Arava® 10mg, 20mg PA Arthrotec® QL Cimzia
® ‡ PA Kineret® ‡ PA Orencia® SQ ‡ PA Otezla® PA OtrexupTM
PA Rasuvo® PA Simponi
® ‡ PA
Drug Formulary I (November 2014) 30
Xeljanz® ‡ PA
18.E. Gout
TIER 1 TIER 2 TIER 3
allopurinol + colchicine w/probenicid + probenicid + sulfinpyrazone +
Colcrys® + Uloric
® ST Zyloprim®
18.F. Muscle Relaxants
TIER 1 TIER 2 TIER 3
baclofen + carisoprodol AL chlorzoxazone AL cyclobenzaprine 5mg, 10mg tabs AL dantrolene caps diazepam AL methocarbamol riluzole + tizanidine tablets +
Amrix® PA cyclobenzaprine er PA Dantrium® Equagesic® AL Flexeril® Lioresal® PA meprobamate/aspirin metaxalone AL Norflex
® Rilutek
® + Robaxin® Skelaxin® AL tizanidine caps Zanaflex
®
CHAPTER 19 – Smoking Cessation
19.A. Smoking Cessation
TIER 1 TIER 2 TIER 3
bupropion SR QL Chantix® QL Nicotrol® Inhaler QL Nicotrol
® NS QL Zyban® QL
CHAPTER 20 – Stomach/Intestinal
20.A. Antiulcer/Reflux Drugs
TIER 1 TIER 2 TIER 3
cimetidine + famotidine 10mg, 20mg, 40mg + QL lansoprazole misoprostol 100mcg, 200mcg + omeprazole 10mg, 20mg caps omeprazole 40mg caps + PA pantoprazole ranitidine tabs + ranitidine syrup rabeprazole sucralfate +
Aciphex® Dexilant® PA esomeprazole strontium PA Nexium® PA omeprazole sodium bicarbonate Prevacid
®
Prevacid Solutab PA Prilosec® Protonix
® ranitidine hcl capsules Zantac® tabs, syrup Zantac
® capsules Zegerid®
20.B. Drugs affecting GI Motility
TIER 1 TIER 2 TIER 3
bethanechol chloride + chlordiazepoxide/clidinium dicyclomine hyoscyamine sulfate + AL atropine sulfate; diphenoxylate hcl metoclopramide propantheline
Donnatal® Amitiza® ST Bentyl
® Fulyzaq
® PA
Levsin®
Librax® Linzess® ST Metozolv
® ODT PA ProBanthine® Reglan®
Drug Formulary I (November 2014) 31
20.C. Antiemetics
TIER 1 TIER 2 TIER 3
meclizine 12.5mg, 25mg + ondansetron 24mg QL ondansetron 4mg, 8mg QL ondansetron odt QL (no QL for hematology/oncology providers)
ondansetron susp QL promethazine hcl supp PA prochlorperazine tab + AL prochlorperazine supp trimethobenzamide PA
Diclegis® QL Emend® (Therapy pack only) ST QL Emend® 40mg capsules Emend® 80mg, 125mg capsules ST QL
Antivert® Anzemet® ST QL Compazine® granisetron ST QL Kytril® ST QL Marinol
® Phenergan
® suppositories Sancuso® Patch ST QL Tigan® PA Transderm‐Scop® QL Zofran® 4mg, 8mg QL Zofran® ODT QL Zofran® susp QL ZuplenzTM ST QL (no QL for hematology/oncology providers, ST applies to
all providers)
20.D. Other GI Drugs
TIER 1 TIER 2 TIER 3
balsalazide AL budesonide PA Colocort® cromolyn sodium oral generic Colyte
® generic Golytely® QL glycopyrrolate hydrocortisone cream, supp, enema lactulose syrup mesalamine enema Procto‐Pak
® 1% Proctocream‐HC® 2.5% Proctosol‐HC
® 2.5% Proctosone
® 2.5% sulfasalazine + sulfasalazine DR + ursodiol
AprisoTM
Asacol® HD + Canasa® suppositories Creon
® + Cystadane® ‡ PA Delzicol® Kuvan® ‡ PA QL Pancreaze
® + Pentasa® + Pertzye® + Relistor
® Sucraid® PA Ultresa
® Viokace
® Zenpep® +
Actigall®
Anusol HC® 2.5% Azulfidine® Azulfidine EN
® ChenodalTM PA Colazal® AL Colyte® Cortenema
® Cortifoam®
CuvposaTM ST Dipentum
® Entocort® EC PA Gastrocrom
® Gattex
® ‡ PA
Giazo® RM Golytely
® QL Glycate® ST Halflytely® Bowel Prep Kit Lialda
® Omeclamox‐Pak
® OsmoPrep
® Prepopik® Proctocort
® 1% Proctofoam HC
®
Robinul® Rowasa® Enema SuclearTM Uceris
® PA
Urso® Urso® Forte Zorbtive® ‡ PA
20.E. Hepatitis
TIER 1 TIER 2 TIER 3
adefovir dipivoxil tabs PA lamivudine tab PA ribavirin ‡ PA
Incivek® PA ‡ Infergen
® PA ‡ Intron A® PA ‡ Pegasys
® PA ‡ Peg‐Intron® PA ‡ Victrelis® PA ‡
Copegus® PA ‡ Epivir‐HBV® PA Hepsera® PA Moderiba
® PA ‡ OlysioTM
PA ‡ Rebetol® PA ‡ SovaldiTM
PA ‡
Drug Formulary I (November 2014) 32
CHAPTER 21 – Vitamins/Minerals
21.A. Vitamins/Minerals
Prenatal vitamins classified as medical foods are not covered. Multivitamins are NOT included in the Formulary as various OTC products are available.
TIER 1 TIER 2 TIER 3
calcitriol + calcium acetate caps + Dailyvite® + PA ergocalciferol + fe‐fumarate vit C/vit B12/folic acid + folic acid + iron poly complex/folic acid/vit b12 + Ferrex
® 150 Forte + ferrogels + generic prenatal vitamins + AL RF hematogen + iFerex® 150 Forte + Klor‐Con® levocarnitine 330mg PA Myferon® 150 Forte + Nephronex® + PA paricalcitrol + ST Pol‐iron
® 150 Forte polysaccharide iron forte + poly‐vitamin w/fluoride + potassium bicarbonate/chloride + potassium chloride tab, cap, liquid + potassium chloride er + Rena‐Vite Rx
®+ PA sevelamer carbonate + sodium fluoride + sodium fluoride gel, paste, cream sodium polystyrene sulfonate trigels + tri‐vitamin w/fluoride + vitamin B12 inj. Vol‐Care
® + PA
Brand Name Prenatal Vitamins + AL RF Fosrenol® + Galzin® + QL PhoslyraTM Renagel® + Renvela® +
doxercalciferol ST Hectorol® ST Nascobal® Velphoro® Zemplar® ST
CHAPTER 22 – Women’s Health
22.A. Estrogen Related Products
TIER 1 TIER 2 TIER 3
danazol estradiol + estradiol weekly patch + estropipate + raloxifene +
Alora® + Estrace® cream Estraderm® + Estring
® Minivelle® Premarin® + AL Premarin
® cream Vagifem® Vivelle‐Dot® +
Cenestin® Climara® Duavee® AL Estrace
® Estrogel® Evista® + Femring
® Menest® Osphena®
22.B. Estrogen Combinations
TIER 1 TIER 2 TIER 3
estradiol/norethindrone acetate + norethindrone acetate‐ethinyl estradiol + (Restricted to females)
Combipatch® + Femhrt Low Dose® + Premphase
® + Prempro
® + AL progesterone suppositories
Activella® Femhrt® + RF Angeliq® Prefest
®
Drug Formulary I (November 2014) 33
22.C. Progestins
TIER 1 TIER 2 TIER 3
medroxyprogesterone + norethindrone acetate + progesterone micronized caps +
Aygestin® Crinone® PA AL QL = 3 fills per year Endometrin® PA AL QL = 3 fills per year Prochieve® PA Prometrium® Provera
®
22.D. Contraceptives ‐ (For members with contraceptive coverage)
All tier 1 generic drugs are covered at a $0 copayment. Brand name drugs without a generic equivalent are covered at a $0 copayment. Brand name drugs with a generic equivalent are covered at the copayment based on your plan design. Cervical caps, diaphragms, female condoms, and spermicides are covered at a $0 copayment. Both prescription and over‐the‐counter (OTC) products are covered only when prescribed by a licensed healthcare provider and require a valid prescription.
TIER 1 TIER 2 TIER 3
Apri® + Altavera
® + Amethyst
® Aranelle® + Aviane® + Balziva
® + Camila® + Cesia® + Cryselle® + Daysee
® drospirenone/ estradiol
Enpresse® +
Errin® + estradiol/ norethindrone +
Gianvi® +
Jolessa® + Jolivette
® + Junel®/Junel FE® + Kariva
® + Kelnor
® + Leena® + Lessina® + levonorgestrel QL Levora® + Loryna
® + Low‐Ogestrel
® +
Lutera® + medoxyprogesterone PA
Microgestin® + Microgestin FE
® + Mononessa
® + Necon® + Next Choice® QL Nora‐Be
® + Nortrel® + Ocella
® + Ogestrel® + Portia® + Previfem
® + Quasense
® + Reclipsen® + Solia
® + Sprintec® + Sronyx® + Tilia FE
® + Tri‐Legest FE®+ Trinessa® + Tri‐Previfem
® + Tri‐Sprintec
® + Trivora® + Velivet
® + Xulane® + Zenchent
® + Zovia
® +
Cervical caps Diaphragms EllaTM QL NuvaRing® + QL Ortho Tri‐Cyclen® Lo +
BeyazTM Brevicon
® Camrese
® Lo Cyclessa® Depo‐Provera® PA Desogen
® estradiol/levonorgesterel Estrostep FE® Femcon FE® Generess
® FE Loestrin
® Loestrin FE® Loestrin
® 24 Fe Lo/Ovral® Loseasonique® QL Minastrin
® 24 FE Mircette® Modicon® Natazia
® PA Nordette® Nor‐QD
® Ortho‐Cept
® Norinyl® Ortho‐Cyclen® OrthoEvra
® Ortho Micronor® Ortho‐Novum
® Ortho Tri‐Cyclen
® Ovcon® Plan B
® QL = 6 fills per year Plan B® One Step QL Safyral
TM Seasonale® Seasonique® Tri‐Norinyl
® Yasmin® Yaz®
Zeosa®
22.E. Fertility
(Other coverage restrictions may apply)
TIER 1 TIER 2 TIER 3
chorionic gonadotropin ST clomiphene citrate QL RF
Bravelle® PA Menopur
® PA Repronex® PA
Follistim®/AQ PA
Ganirelix® PA
Gonal‐F® PA Gonal‐F RFF® PA Luveris
® PA Ovidrel® ST Pregnyl
® PA
Drug Formulary I (November 2014) 34
22.F. Vaginal Antiinfectives
TIER 1 TIER 2 TIER 3
clindamycin phosphate vaginal cream clotrimazole vaginal cream OTC metronidazole vaginal gel miconazole vaginal cream OTC
AVC® Cream Cleocin® vaginal suppositories
Cleocin® Vaginal Gyne‐Lotrimin® Metrogel® Vaginal Monistat® Terazol® QL
22.G. Other Women’s Health Drugs
TIER 1 TIER 2 TIER 3
nifedipine PA terbutaline
Alferon N® PA Lupron® Methergine
® Synarel® PA
Lysteda® PA AL tranexamic acid PA AL
CHAPTER 23 – Dental Formulary
Note: Drugs in this category are reserved for dental providers only. Unless otherwise specified, all products are limited to a 10 day supply with 1 refill. Drugs not on the list below will not be covered.
23.A. Antiinfectives
TIER 1 TIER 2 TIER 3
amoxicillin amoxicillin susp azithromycin 500mg QL cephalexin clarithromycin 500mg QL clindamycin 75mg, 150mg, 300mg clotrimazole troche doxycycline hyclate doxycycline hyclate 20mg QL erythromycin erythromycin susp nystatin oral suspension penicillin VK tetracycline capsules
23.B. Analgesics
TIER 1 TIER 2 TIER 3
acetaminophen w/codeine acetaminophen w/codeine susp apap/codeine tabs hydrocodone w/acetaminophen hydrocodone‐ibuprofen tab 7.5‐200mg ibuprofen (Rx strengths only) ibuprofen suspension (Rx strengths only) naproxen naproxen sodium
23.C. Fluoride Products
TIER 1 TIER 2 TIER 3
poly‐vitamin w/fluoride sodium fluoride QL tri‐vitamin w/fluoride
23.D. Glucocorticoid Drugs
TIER 1 TIER 2 TIER 3
dexamethasone triamcinolone in orabase methylprednisolone prednisone
Drug Formulary I (November 2014) 35
23.E. Other Drugs Affecting the Throat and Mouth
TIER 1 TIER 2 TIER 3
chlorhexidine QL lidocaine viscous
ADDITIONAL FORMULARY INFORMATION
AFFORDABLE CARE ACT PREVENTATIVE SERVICES Prescription and OTC versions (where applicable) will be covered only with a prescription written by a licensed healthcare provider.
Aspirin for Cardiovascular Disease Prevention Aspirin will be covered for men (ages 45 to 79) and women (ages 55 to 79) when the benefits outweigh the potential bleeding risks for cardiovascular disease prevention.
Contraceptive Coverage All formulary generic and preferred brand name drugs (without a generic equivalent) will have a zero dollar ($0) copayment. Cervical caps, diaphragms, female condoms and spermicides will have a zero ($0) copayment. Both prescription and over‐the‐counter (OTC) products will be covered only when prescribed by a licensed healthcare provider.
Fluoride Oral fluoride products (chewable tablets and solutions) will be covered for children 6 months of age and older who do not receive the recommended amount of fluoride in their water supply.
Folic Acid supplements Supplements containing 0.4mg to 0.8mg of folic acid will be covered for women who are planning or are capable of pregnancy.
Iron Supplementation for Children Iron supplements will be covered for children aged 6 months to 12 months who are at high risk for iron deficiency anemia.
Tobacco Cessation Products (FDA Approved) Prescription and OTC products will be covered for adults 18 years of age and older and for pregnant women with no age limit. The following products are covered: patches, gums, nasal sprays, inhalers, lozenges, Chantix and bupropion sr (generic version of Zyban).
Vaccines Flu, Pneumonia vaccinations will be covered when administered at a network pharmacy.
Vitamin D Prescription and OTC products will be covered for adults aged 65 years and older who are at an increased risk for falls.
Drug Formulary I (November 2014) 36
SPECIALTY PHARMACY INFORMATION
The specialty medications below are obtained at Reliance Rx: 1‐800‐809‐4763
AdempasTM Afinitor® Alkeran
® anastrozole Aranesp® Arimidex® Aromasin® Avonex® bicalutamide Bosulif® Casodex® Cimzia® Comtriq
® Copaxone
® Copegus® Cystadane® Cytoxan
® Droxia® Emcyt
® Enbrel® Epogen®
etoposide exemestane Extavia
® Fareston® Femara® Firazyr® flutamide Forteo® Fuzeon® Gattex® Genotropin® GilenyaTM Gleevec
® Hexalen
® Humatrope® Humira® Hydrea
® hydroxyurea Iclusig
® Imbruvica® Incivek®
Increlex®
Infergen® Intron‐A
® Juxtapid® Kalydeco® Kineret® Korlym® Leukeran® letrozole Lysodren® Megace® ES megestrol acetate Mekinist
TM Mesnex
® MyaleptTM Myleran® Neulasta
® Neupogen® Northera
TM Nutropin® Nutropin® AQ
Oforta®
OlysioTM Opsumit
® Orencia®SQ OrenitramTM Orfadin® Pegasys® Peg‐Intron® Pomalyst® Procrit® Procysbi® Ravicti® Rebetol
® Rebif
® ribavirin Saizen® Simponi
® SovaldiTM Sprycel
® Sutent® SylatronTM
TafinlarTM
Tarceva® Tasigna
® Tecfidera® Temodar® temozolomide tretinoin ValchlorTM VecamylTM Vesanoid® Victrelis® Xeljanz® Xtandi
® Zelboraf
TM Zolinza® Zorbtiv® Zytiga
®
The medications below are limited distribution and available Walgreens Specialty Pharmacy:
Actimmune® Ampyra
TM ER
Aubagio® Erivedge
®
Exjade® Hycamtin
® Jakafi® Kuvan
®
Kynamro®
Letairis® Inlyta® Nexavar
®
Promacta® Revlimid
® Stivarga®
Thalomid®
Tracleer® Tykerb
® Votrient® Xalkori
®
The medications below are limited distribution and available Accredo® Pharmacy: 1‐866‐489‐1875
Apokyn®
Arcalyst® GilotrifTM
Iressa® Matulane® Sabril
® Somavert® Sucraid
® Xenazine® Zavesca
®
The medications below are limited distribution and available at the specialty pharmacy listed: Caprelsa
® ‐ Biologics Inc. (1‐800‐850‐4306) Cayston
® ‐ Available through Cystic Fibrosis Services
Chenodal® ‐ Centric Specialty Pharmacy (1‐866‐849‐4481) Ferriprox® ‐ Centric Specialty Pharmacy (1‐866‐849‐4481) Onsolis® ‐ Express Scripts (1‐877‐536‐4340) Xyrem® ‐ Express Scripts (1‐877‐536‐4340)
Drug Formulary I (November 2014) 37
MEDICATIONS REQUIRING STEP THERAPY Medication Step Therapy Requirement(s)
Alocril® Prior use of Zaditor® or Alaway® OTC.
Altabax® Prior use of generic mupirocin.
Ambien® CR Prior use of Ambien® (zolpidem).
Amitiza® Prior use of lactulose.
Anturol® Prior use of oxybutynin, no step therapy required for patients over the age of 64.
Anzemet® Prior use of ondansetron.
Aricept® 23mg Prior use of donepezil 10mg once daily for three months.
Astelin® Prior use of generic azelastine.
Astepro® Prior use of generic azelastine.
Avinza® Prior use of narcotic medications.
Azor® Prior use of an Angiotensin Converting Enzyme, Angiotensin Receptor Blocker or a Calcium Channel Blocker.
Beconase® AQ Prior use of flunisolide, fluticasone propionate, triamcinolone acetonide or Nasonex.
Benicar® Prior use of generic Angiotensin Receptor Blockers.
Benzaclin®/Benzaclin® Pump Prior use of clindamycin phosphate‐benzoyl peroxide gel.
Bepreve® Prior use of Zaditor® or Alaway® OTC.
Binosto® Prior use of alendronate.
BrintellixTM Prior use of generic SSRI.
Bydureon® Concurrent use of metformin, a sulfonylurea or a thiazolodonedione (TZD).
Byetta® Concurrent use of metformin, a sulfonylurea or a thiazolodonedione (TZD).
candesartan/ candesartan/hctz Prior use of irbesartan and losartan.
carbidopa/levodopa odt Prior use of carbidopa/levodopa or carbidopa/levodopa sr.
Celebrex® Previous trial/failure of two non‐steroidal anti‐inflammatories (NSAIDs).
chorionic gonadotropin Prior use of clomiphene, menotropin, urofollitropin within previous 20 days.
clonazepam odt Prior use of immediate release clonazepam.
Comtan® Concurrent use of levodopa/carbidopa.
Conzip® Prior use of immediate release tramadol.
CuvposaTM/Glycate® Prior use of glycopyrrolate.
Detrol®/Detrol® LA Prior use of oxybutynin, no step therapy required for patients over the age of 64.
Duragesic® Prior use of narcotic medications.
Dymista® Prior use of azelastine or fluticasone propionate.
Edarbi® Prior use of generic Angiotensin Receptor Blockers.
Edular® Prior use of zolpidem.
Elestat® Prior use of Zaditor® or Alaway® OTC.
Emend®, Emend® Therapy Pack Concurrent use of dexamethasone.
Enablex® Prior use of oxybutynin, no step therapy required for patients over the age of 64.
entacapone Concurrent use of levodopa/carbidopa.
eprosartan Prior use of irbesartan and losartan.
Exalgo® Prior use of narcotic medications.
Exforge®/Exforge® HCT Prior use of an Angiotensin Converting Enzyme, Angiotensin Receptor Blocker or a Calcium Channel Blocker.
fentanyl Prior use of narcotic medications.
Fentora® Prior use of narcotic medications.
Fetzima® Prior use of venlafaxine er.
Flonase® Prior use of flunisolide, fluticasone propionate, triamcinolone acetonide or Nasonex.
Foradil® Concurrent use of an inhaled corticosteroid.
Gelnique® Prior use of oxybutynin, no step therapy required for patients over the age of 64.
Glumetza® Prior use of extended release metformin.
Gralise® Prior use of gabapentin.
granisetron Prior use of ondansetron.
Hectorol® Prior use of calcitriol.
Intermezzo® Prior use of zolpidem.
Kadian® Prior use of narcotic medications.
Kytril® Prior use of ondansetron.
LastacaftTM Prior use of Zaditor® or Alaway® OTC
Linzess® Prior use of lactulose.
Lovaza® Prior use of omega‐3‐acid ethyl esters.
metformin er Prior use of extended release metformin.
Micardis®/Micardis® HCT Prior use of a generic angiotensin II receptor blocker.
Myrbetriq® Prior use of oxybutynin, no step therapy required for patients over the age of 64.
Natroba® Prior use of generic permethrin or Lindane.
Oleptro® Prior use of generic trazodone.
Drug Formulary I (November 2014) 38
MEDICATIONS REQUIRING STEP THERAPY Medication Step Therapy Requirement(s)
Omnaris® Prior use of flunisolide, fluticasone propionate, triamcinolone acetonide or Nasonex.
Opana® ER (crush resistant) Prior use of narcotic medications.
Optivar® Prior use of Zaditor® or Alaway® OTC.
Oravig® Prior use of clotrimazole troche, fluconazole or nystatin.
Oxycontin® Prior use of narcotic medications.
Ovidrel® Prior use of clomiphene, menotropin, urofollitropin within previous 20 days.
paricalcitrol Prior use of calcitriol.
paroxetine hcl er Prior use of paroxetine.
Pataday® Prior use of Zaditor® or Alaway® OTC
Patanase® Prior use of flunisolide, fluticasone propionate, triamcinolone acetonide or Nasonex.
Patanol® Prior use of Zaditor® or Alaway® OTC
Paxil® CR Prior use of paroxetine.
Prezista® Concurrent use of Norvir®.
Prolensa® Prior use of generic bromfenac.
Pristiq® Prior use of venlafaxine er.
Qnasl® Prior use of flunisolide, fluticasone propionate, triamcinolone acetonide or Nasonex.
Quillivant® XR Prior use of generic methylphenidate sr.
Rayos® Prior use of immediate release prednisone.
Rhinocort® Aqua Prior use of flunisolide, fluticasone propionate, triamcinolone acetonide or Nasonex.
Sanctura®/Sanctura® XR Prior use of oxybutynin, no step therapy required for patients over the age of 64.
Sancuso® Prior use of ondansetron.
Serevent® Diskus Concurrent use of an inhaled corticosteroid.
Seroquel® XR Prior use of immediate release Seroquel®.
Sklice® Prior use of generic permethrin or Lindane.
Sprycel® Prior use of Gleevec® within a 90 day period.
Tanzeum® Concurrent use of metformin, a sulfonylurea or a thiazolodonedione (TZD).
Tasigna® Prior use of Gleevec® within a 90 day period.
Tasmar® Concurrent use of levodopa/carbidopa.
Tekamlo® Prior use of an Angiotensin Converting Enzyme, Angiotensin Receptor Blocker or a Calcium Channel Blocker.
Tekturna®/Tekturna® HCT Prior use of an Angiotensin Converting Enzyme Inhibitor and an Angiotensin Receptor Blocker.
telmisartan/telmisartan/hctz Prior use of irbesartan and losartan.
Teveten®/Teveten® HCT Prior use of an Angiotensin Converting Enzyme (ACE) Inhibitor.
tolterodine tartrate Prior use of oxybutynin, no step therapy required for patients over the age of 64.
Toviaz® Prior use of oxybutynin, no step therapy required for patients over the age of 64.
tramadol er Prior use of immediate release tramadol.
Treximet® Prior use of Imitrex® within previous 90 day period.
TribenzorTM Prior use of an Angiotensin Converting Enzyme, Angiotensin Receptor Blocker or a Calcium Channel Blocker.
trospium chloride er Prior use of oxybutynin, no step therapy required for patients over the age of 64.
Twynsta® Prior use of an Angiotensin Converting Enzyme, Angiotensin Receptor Blocker or a Calcium Channel Blocker.
Ulroic® Prior use of allopurinol.
Ultram® ER Prior use of immediate release tramadol.
Veramyst® Prior use of flunisolide, fluticasone propionate, triamcinolone acetonide or Nasonex.
Vesicare® Prior use of oxybutynin, no step therapy required for patients over the age of 64.
Victoza® Concurrent use of metformin, a sulfonylurea or a thiazolodonedione (TZD).
Vytorin® Prior use of simvastatin.
Zemplar® Prior use of calcitriol.
ZetonnaTM Prior use of flunisolide, fluticasone propionate, triamcinolone acetonide or Nasonex.
zolpidem er Prior use of zolpidem.
Zuplenz® Prior use of ondansetron.
Drug Formulary I (November 2014) 39
INDEX
8
8‐Mop® .............................................................................................. 16
A
abacavir sulfate ................................................................................ 23 abacavir sulfate/lamivudine/zidovudine .......................................... 23 Abilify® .............................................................................................. 25 Abilify® Discmelt ................................................................................ 25 Abilify® oral solution ......................................................................... 25 Absorbica® ........................................................................................ 15 AbstralTM ........................................................................................... 28 acamprosate calcium tab dr ............................................................. 27 acarbose ........................................................................................... 17 Accolate
® ............................................................................................. 7 Accu‐Chek® Diabetic Test Strips ....................................................... 18 Accu‐Chek® Glucose Meters ............................................................. 18 Accuneb® ............................................................................................. 6 Accupril® ........................................................................................... 10 Accuretic
® ......................................................................................... 12 Accutane® ......................................................................................... 15 acebutolol HCl .................................................................................. 10 Aceon
® .............................................................................................. 10 acetaminophen w/codeine ......................................................... 28, 34 acetaminophen w/codeine susp ...................................................... 34 acetaminophen w/hydrocodone ...................................................... 34 acetaminophen; butalbital ............................................................... 29 acetaminophen; butalbital; caffeine ................................................ 29 Acetasol
® HC otic soln ....................................................................... 19 acetazolamide tab ............................................................................ 20 acetic acid otic soln........................................................................... 18 acetylcysteine ..................................................................................... 7 Aciphex
® ............................................................................................ 30 acitretin ............................................................................................ 16 Aclovate
® .......................................................................................... 15 Actigall® ............................................................................................. 31 Actimmune
® ................................................................................. 9, 36 Actiq
® ................................................................................................ 28 Actonel® ............................................................................................ 21 Actoplus Met
® ................................................................................... 17 Actoplus Met® XR .............................................................................. 17 Actos® ............................................................................................... 17 Acular
® .............................................................................................. 20 Acular® LS .......................................................................................... 20 Acuvail® ............................................................................................. 19 acyclovir ............................................................................................ 23 acyclovir oint .................................................................................... 17 acyclovir ointment ............................................................................ 17 Aczone® ............................................................................................. 17 Adalat
® CC ......................................................................................... 11 adapalene ......................................................................................... 15 Adcirca
®............................................................................................. 14 Adderall XR® ...................................................................................... 26 Adderall® ........................................................................................... 26 adefovir dipivoxil tabs ................................................................ 23, 31 Adempas
TM ................................................................................. 14, 36 Advair® ................................................................................................ 6 Advair
® HFA ......................................................................................... 6 Advicor® ............................................................................................ 14 Aerobid® .............................................................................................. 6
Aerobid‐M® ......................................................................................... 6 Aerospan® .......................................................................................... 6 Afinitor® ........................................................................................ 9, 36 Aggrenox® ........................................................................................... 8 Agrylin® ............................................................................................... 8 Akten® ............................................................................................... 20 Alamast® ........................................................................................... 20 Alaway
® ............................................................................................ 20 albuterol nebs .................................................................................... 6 albuterol sulfate tabs ......................................................................... 6 albuterol‐ipratropium neb soln .......................................................... 7 alclometasone .................................................................................. 15 Aldactazide 25/25
® ........................................................................... 11 Aldactazide® 50/50 ........................................................................... 11 Aldactone® ........................................................................................ 11 Aldara® .............................................................................................. 16 alendronate tabs .............................................................................. 21 Alferon N
® ................................................................................... 23, 34 alfuzosin ........................................................................................... 24 Alinia
® tabs, soln ............................................................................... 23 Alkeran
® ........................................................................................ 9, 36 Allfen® CDX ......................................................................................... 5 allopurinol ........................................................................................ 30 Alocril
® .............................................................................................. 37 Alomide® ........................................................................................... 20 Alora
® ................................................................................................ 32 Alphagan P® 0.1% ............................................................................. 20 Alphagan P® 0.15% ........................................................................... 20 alprazolam ........................................................................................ 24 alprazolam xr .................................................................................... 24 Alrex
® ................................................................................................ 19 Altabax
® ...................................................................................... 17, 37 Altace® caps ...................................................................................... 10 Altavera® ........................................................................................... 33 aluminum chloride 20%.................................................................... 16 Alupent
® ............................................................................................. 6 Alvesco® .............................................................................................. 6 alwin NX
® .......................................................................................... 28 amantadine ...................................................................................... 23 amantadine hcl ................................................................................. 27 Amaryl
® ............................................................................................. 17 Ambien
® ............................................................................................ 24 Ambien
® CR ................................................................................ 24, 37 Amerge® ........................................................................................... 29 Amethia
® .......................................................................................... 33 Amethyst® ......................................................................................... 33 amiloride hcl ..................................................................................... 11 aminocaproic acid .............................................................................. 8 aminophylline ..................................................................................... 6 amiodarone ...................................................................................... 14 Amitiza
® ...................................................................................... 30, 37 amitriptyline ..................................................................................... 25 amitriptyline/ perphenazine ............................................................ 25 amlodipine besylate‐ ........................................................................ 11 amlodipine besylate/benazepril hcl ................................................. 12 ammonium lactate cr ....................................................................... 16 Amoxapine
® ...................................................................................... 25 amoxicillin ........................................................................................ 34 amoxicillin caps, susp ....................................................................... 22 amoxicillin clavulanate ..................................................................... 22 amoxicillin er .................................................................................... 22 amoxicillin susp ................................................................................ 34 amoxicillin/ ....................................................................................... 22
Drug Formulary I (November 2014) 40
amphetamine mixture ...................................................................... 26 amphetamine‐dextroamphetamine sr ............................................. 26 ampicillin caps, susp ......................................................................... 22 AmpyraTM ER ..................................................................................... 27 Amrix® ............................................................................................... 30 Amturnide
TM ..................................................................................... 12 Anafranil® .......................................................................................... 25 anagrelide ........................................................................................... 8 Analpram® E ...................................................................................... 16 Anaprox® ........................................................................................... 29 anastrozole ................................................................................... 9, 36 Ancobon® .......................................................................................... 22 Androderm® ...................................................................................... 24 Androgel® .......................................................................................... 24 Android®............................................................................................ 24 Androxy
® ........................................................................................... 24 Anoro Ellipta® ...................................................................................... 7 Antabuse® ......................................................................................... 27 Antivert® ........................................................................................... 31 Anturol
® ........................................................................................ 7, 37 antyipyrine/benzocaine otic soln ..................................................... 18 Anusol HC® 2.5% ............................................................................... 31 Anzemet
® .................................................................................... 31, 37 apap/codeine tabs ............................................................................ 34 Apexicon E
® ....................................................................................... 15 Apidra
® .............................................................................................. 17 Apidra® Solostar ................................................................................ 17 Apokyn® ............................................................................................ 27 apraclonidine .................................................................................... 20 Apri
® .................................................................................................. 33 AprisoTM ............................................................................................ 31 Aptiom® ............................................................................................. 26 Aptivus
® ............................................................................................ 23 Aralen® phosphate ............................................................................ 23 Aranelle
® ........................................................................................... 33 Aranesp
® ....................................................................................... 8, 36 Arava® ............................................................................................... 29 Arcalyst
® ........................................................................................ 8, 36 Arcapta® Neohaler .............................................................................. 6 Aricept® ............................................................................................. 27 Aricept
® 23mg ................................................................................... 37 Aricept® ODT ..................................................................................... 27 Arimidex
® ...................................................................................... 9, 36 Arixtra
®................................................................................................ 8 Armour Thyroid
® ............................................................................... 21 Aromasin
® ..................................................................................... 9, 36
Arthrotec ® ........................................................................................ 29 Asacol® HD ........................................................................................ 31 Asmanex® ............................................................................................ 6 aspirin CR 800mg .............................................................................. 29 aspirin w/codeine ............................................................................. 28 aspirin/dipyridamole .......................................................................... 8 aspirin; butalbital; caffeine ............................................................... 29 aspirin; butalbital; caffeine; codeine ................................................ 29 Astagraf
TM XL ...................................................................................... 9 Astelin® ......................................................................................... 5, 37 Astepro
® ........................................................................................ 5, 37 Atacand HCT® .................................................................................... 12 Atacand
® ........................................................................................... 10 AtelviaTM ........................................................................................... 21 atenolol ............................................................................................ 10 atenolol/chlorthalidone .................................................................... 12 Ativan
® .............................................................................................. 24 atorvastatin calcium ......................................................................... 13 atorvastatin/amlodipine ................................................................... 14
atovaquone/proguanil ..................................................................... 23 Atripla® ............................................................................................. 23 atropine sulfate; diphenoxylate hcl .................................................. 30 Atrovent® 0.03% ................................................................................. 5 Atrovent® 0.06% ................................................................................. 5 Atrovent
® HFA .................................................................................... 7 Atrovent® nasal ................................................................................... 5 Atrovent® Neb .................................................................................... 7 Aubagio® ..................................................................................... 27, 36 augmented betamethasone ............................................................. 15 Augmentin
® XR ................................................................................. 22 Auralgan® Otic Soln ........................................................................... 18 Auvi‐QTM ............................................................................................. 6 Avalide® ............................................................................................ 12 Avandamet® ...................................................................................... 17 Avandaryl
® ........................................................................................ 17 Avandia® ........................................................................................... 17 Avapro® ............................................................................................. 10 Avar‐E® LS ......................................................................................... 15 AVC
® Cream ...................................................................................... 34 Aveed® ............................................................................................. 24 Avelox® ............................................................................................. 22 Aviane
® ............................................................................................. 33 Avinza® ........................................................................................ 28, 37 Avita
® ................................................................................................ 15 Avodart
® ........................................................................................... 24 Avonex® ...................................................................................... 27, 36 Axert® ............................................................................................... 29 AxironTM ........................................................................................... 24 Aygestin
® .......................................................................................... 33 Azasan® ............................................................................................... 9 Azasite® ............................................................................................. 19 azathioprine ....................................................................................... 9 azelastine ......................................................................................... 20 azelastine nasal spray ......................................................................... 5 Azelex
® .............................................................................................. 15 Azilect® ............................................................................................. 27 azithromycin ............................................................................... 22, 34 azithromycin® susp .......................................................................... 22 Azopt
® ............................................................................................... 20 Azor
® ........................................................................................... 12, 37 Azulfidine EN® ................................................................................... 31 Azulfidine
® ........................................................................................ 31
B
B&O Supprettes® .............................................................................. 28 bacitracin ophthalmic ....................................................................... 19 baclofen ............................................................................................ 30 Bactroban
® ........................................................................................ 17 balsalazide ........................................................................................ 31 Balziva
® ............................................................................................. 33 Banzel® .............................................................................................. 26 Baraclude® ........................................................................................ 23 Beconase
® AQ ............................................................................... 5, 37 belladonna/opium supp ................................................................... 28 benazepril ......................................................................................... 10 benazepril/hctz ................................................................................ 12 Benicar HCT® ..................................................................................... 12 Benicar
® ...................................................................................... 10, 37 Bentyl® .............................................................................................. 30 Benzaclin
® ......................................................................................... 37 BenzaClin
® ........................................................................................ 15 Benzaclin® Pump ............................................................................... 37 Benzefoam® ...................................................................................... 15
Drug Formulary I (November 2014) 41
benzoyl peroxide .............................................................................. 15 benzoyl peroxide cr,gel,lot ............................................................... 15 benztropine ...................................................................................... 27 Bepreve® ........................................................................................... 37 Bepreve® opth ................................................................................... 20 Besivance
® ........................................................................................ 19 Betagan® ........................................................................................... 20 betamethasone ................................................................................ 15 betamethasone valerate foam ......................................................... 15 Betaxolol® ......................................................................................... 10 bethamethasone valerate crem, lotion, oint .................................... 15 bethanechol chloride .................................................................... 8, 30 Bethkis® ............................................................................................. 23 Betimol® ............................................................................................ 20 Betoptic® S ........................................................................................ 20 Beyaz
TM ............................................................................................. 33 Biaxin XL® tabs .................................................................................. 22 Biaxin® ............................................................................................... 22 bicalutamide ................................................................................. 9, 36 Bicitra
® ................................................................................................ 8 Binosto® ...................................................................................... 21, 37 Bio‐T‐Gel® .......................................................................................... 24 bisoprolol fumerate .......................................................................... 10 Blephamide
® Liquifilm ....................................................................... 19 Boniva
® tabs ...................................................................................... 21 Bosulif
® .......................................................................................... 9, 36 brand and generic prenatal .............................................................. 32 Brand Name Prenatal Vitamins ........................................................ 32 Bravelle® ........................................................................................... 33 Breo Ellipta
® ........................................................................................ 7 Brethine® ............................................................................................. 6 Brevicon® .......................................................................................... 33 Brevoxyl
® ........................................................................................... 15 Brilinta® ............................................................................................... 8 brimonidine solution ........................................................................ 20 brimonidine tartrate 0.2% ................................................................ 20 Brintellix
TM .................................................................................. 25, 37 Brisdelle
TM ........................................................................................ 25 BromdayTM ........................................................................................ 20 bromfenac ........................................................................................ 20 bromocriptine mesylate ................................................................... 27 budesonide ....................................................................................... 31 budesonide respules 0.25mg, 0.5mg .................................................. 6 bumetanide ...................................................................................... 11 Buphenyl
® ......................................................................................... 21 buprenorphine hcl ............................................................................ 27 buprenorphine hcl/naloxone hcl sublingual ..................................... 27 bupropion ......................................................................................... 25 bupropion hcl SR 12 hr ..................................................................... 25 bupropion hcl SR 24hr ...................................................................... 25 bupropion SR .................................................................................... 30 buspirone .......................................................................................... 24 butalbital/apap/caffeine/codeine .................................................... 29 butorphanol tartrate NS ................................................................... 29 Butrans
TM .......................................................................................... 27 Bydureon® ................................................................................... 18, 37 Byetta
® ........................................................................................ 18, 37 Bystolic® ............................................................................................ 10
C
cabergoline ....................................................................................... 21 Caduet
® ............................................................................................. 14 Cafergot® ........................................................................................... 29 Calan®................................................................................................ 11
Calan® SR .......................................................................................... 11 calciprotiene soln, oint, cream ......................................................... 16 calcitonin‐salmon ............................................................................. 21 calcitriol ............................................................................................ 32 calcitriol ointment ............................................................................ 16 calcium acetate caps ........................................................................ 32 Cambia
® ............................................................................................ 29 Camila® ............................................................................................. 33 Campral® ........................................................................................... 27 Camrese® Lo ..................................................................................... 33 Canasa
® suppositories ...................................................................... 31 candesartan ................................................................................ 10, 37 candesartan/hctz ....................................................................... 12, 37 capecitabine ....................................................................................... 9 Capex® .............................................................................................. 15 Capoten
® ........................................................................................... 10 Caprelsa® ...................................................................................... 9, 36 captopril ........................................................................................... 10 captopril/hctz ................................................................................... 12 Carac
® ............................................................................................... 16 CarbagluTM ........................................................................................ 21 carbamazepine ................................................................................. 26 carbamazepine er ............................................................................. 26 Carbatrol® ......................................................................................... 26 carbidopa ......................................................................................... 27 carbidopa/levodopa ......................................................................... 27 carbidopa/levodopa CR .................................................................... 27 carbidopa/levodopa odt ............................................................. 27, 37 carbidopa/levodopa/entacapone tabs ............................................. 27 Cardene
® SR ...................................................................................... 11 Cardizem® ......................................................................................... 11 Cardizem® LA .................................................................................... 11 Cardizem
®CD..................................................................................... 11 Cardura® ..................................................................................... 12, 24 Cardura
® XL ................................................................................. 12, 24 carisoprodol ..................................................................................... 30 Carmol‐HC
® ....................................................................................... 15 carteolol ........................................................................................... 20 Cartia XT ........................................................................................... 11 carvedilol .......................................................................................... 10 Casodex
® ....................................................................................... 9, 36 Catapres® .......................................................................................... 12 Catapres
®‐TTS ................................................................................... 12 Caverject
® ......................................................................................... 24 Cayston
® ..................................................................................... 23, 36 CeeNu
® ............................................................................................... 9
cefaclor caps, susp ........................................................................... 22 cefadroxil .......................................................................................... 22 cefdinir ............................................................................................. 22 cefprozil ............................................................................................ 22 cefuroxime ....................................................................................... 22 Cefzil® ............................................................................................... 22 Celebrex® .................................................................................... 29, 37 Celestone
® ........................................................................................ 21 Celexa® .............................................................................................. 25 CellCept® ............................................................................................. 9 Celontin
® ........................................................................................... 26 Cenestin® .......................................................................................... 32 cephalexin ........................................................................................ 34 cephalexin caps, susp ....................................................................... 22 cephradine capsules ......................................................................... 22 Cervical caps ..................................................................................... 33 Cesia
® ................................................................................................ 33 Cetraxal® ........................................................................................... 22 cevimeline ........................................................................................ 19
Drug Formulary I (November 2014) 42
Chantix® ............................................................................................ 30 Chemet® ............................................................................................ 21 Chenodal® ........................................................................................ 36 ChenodalTM ....................................................................................... 31 chloramphenicol ............................................................................... 19 chlordiazepoxide .............................................................................. 24 chlordiazepoxide/clidinium .............................................................. 30 chlorhexidine .................................................................................... 35 chlorhexidine oral rinse .................................................................... 19 Chloromycetin
® Otic ......................................................................... 18 chloroquine phosphate .................................................................... 23 chlorothiazide tabs ........................................................................... 11 chlorphen/DM/PE ............................................................................... 5 chlorpromazine ................................................................................. 25 chlorthalidone .................................................................................. 11 chlorzoxazone ................................................................................... 30 cholestyramine/cholestyramine light (bulk) ..................................... 13 chorionic gonadotropin .............................................................. 33, 37 Cialis
® 10mg &20mg .......................................................................... 24 Cialis
® 2.5mg & 5mg .......................................................................... 24 ciclopirox kit ..................................................................................... 16 ciclopirox shampoo ........................................................................... 16 ciclopirox soln ................................................................................... 16 cilostazol ............................................................................................. 8 Ciloxan
® ............................................................................................. 19 cimetidine ......................................................................................... 30 Cimzia
® ........................................................................................ 29, 36 Cipro HC® Otic ................................................................................... 18 Cipro® ................................................................................................ 22 Cipro
® XR ........................................................................................... 22 Ciprodex® .......................................................................................... 18 ciprofloxacin hcl SR ........................................................................... 22 ciprofloxacin ophth soln ................................................................... 19 ciprofloxacin otic .............................................................................. 18 ciprofloxacin tabs ............................................................................. 22 citalopram ........................................................................................ 25 citric acid/sodium citrate .................................................................... 8 Clarinex
® ............................................................................................. 5 Clarinex® Reditab ................................................................................ 5 clarithromycin ................................................................................... 22 clarithromycin 500mg ....................................................................... 34 clarithromycin SR .............................................................................. 22 clemastine .......................................................................................... 5 clemastine fumarate tabs ................................................................... 5 Cleocin
® 75mg ................................................................................... 34 Cleocin
® pediatric granules ............................................................... 22
Cleocin® Vaginal ................................................................................ 34 Cleocin® vaginal suppositories .......................................................... 34 Cleocin‐T® .......................................................................................... 15 Climara
® ............................................................................................ 32 Clindagel® .......................................................................................... 15 clindamax ......................................................................................... 15 clindamycin ................................................................................. 22, 34 clindamycin granules ........................................................................ 22 clindamycin phosphate gel 1% ......................................................... 15 clindamycin phosphate vaginal cream ............................................. 34 clindamycin phosphate‐benzoyl peroxide gel .................................. 15 clindamycintopical ............................................................................ 15 clobetasol propionate foam ............................................................. 15 clobetasol proprionate ..................................................................... 15 Clobex
® .............................................................................................. 15 Clobex
® Spray .................................................................................... 15 clomipramine .................................................................................... 25 clonazepam odt .......................................................................... 26, 37 clonazepam tabs ............................................................................... 26
clonidine HCl .................................................................................... 12 clonidine HCl TD patch ..................................................................... 12 clopidogrel bisulfate ........................................................................... 8 clorazepate ....................................................................................... 24 clotrimazole cream, lotion, soln ....................................................... 16 clotrimazole troche .................................................................... 22, 34 clotrimazole vaginal cream .............................................................. 34 clotrimazole w/ betamethasone cream 1‐0.05% ............................. 16 clozapine .......................................................................................... 25 Coartem® .......................................................................................... 23 codeine sulfate ................................................................................. 28 codeine‐guaifenesin ........................................................................... 5 codeine‐guaifenesin‐pseudoephedrine.............................................. 5 Cogentin® .......................................................................................... 27 Cognex® ............................................................................................ 27 Colazal
® ............................................................................................. 31 colchicine w/probenicid ................................................................... 30 Colcrys® ............................................................................................. 30 Colestid® (bulk) ................................................................................. 13 Colestid
® tab ..................................................................................... 13 colestipol granules(bulk) .................................................................. 13 colestipol tab 1gm ............................................................................ 13 colistimethate .................................................................................. 18 Colocort® .......................................................................................... 31 Colyte
® .............................................................................................. 31 Combigan
® ........................................................................................ 20 Combipatch® ..................................................................................... 32 Combivent® ......................................................................................... 7 Combivir® .......................................................................................... 23 Combunox
® ....................................................................................... 28 Cometriq® ........................................................................................... 9 Compazine® ...................................................................................... 31 Complera
TM ...................................................................................... 23 Comtan® ..................................................................................... 27, 37 Comtriq
® ........................................................................................... 36 Concerta
® .......................................................................................... 26 Conzip® ....................................................................................... 28, 37 Copaxone
® .................................................................................. 27, 36 Copegus® .............................................................................. 23, 31, 36 Cordran® lotion ................................................................................. 15 Cordran
® Tape only ........................................................................... 15 Coreg® ............................................................................................... 10 Corgard
® ........................................................................................... 10 Cortane B
® Otic ................................................................................. 18 Cortef
® .............................................................................................. 21 Cortenema
® ...................................................................................... 31
Cortifoam® ........................................................................................ 31 cortisone acetate ............................................................................. 21 Cortisporin® otic sol, susp ................................................................ 18 Cortisporin® Otic‐TC .......................................................................... 18 Corzide® ............................................................................................ 12 Cosopt® ............................................................................................. 20 Coumadin® .......................................................................................... 8 Cozaar
® ............................................................................................. 10 Creon® .............................................................................................. 31 Crestor® ............................................................................................ 13 Cresylate
® Otic .................................................................................. 18 Crinone® ........................................................................................... 33 Crixivan
® ........................................................................................... 23 cromolyn sodium .............................................................................. 20 cromolyn sodium 10mg/ml nebs ....................................................... 7 cromolyn sodium oral ...................................................................... 31 Cryselle
®............................................................................................ 33 Cuprimine® ....................................................................................... 29 Cutivate
® 0.05% lotion ...................................................................... 15
Drug Formulary I (November 2014) 43
Cutivate® cream; oint ........................................................................ 15 CuvposaTM ......................................................................................... 37 Cyclessa® ........................................................................................... 33 cyclobenzaprine er ........................................................................... 30 cyclophosphamide .............................................................................. 9 Cycloset
® ........................................................................................... 17 cyclosporine capsules ......................................................................... 9 cyclosporine modified ........................................................................ 9 cyclosporine oral solution ................................................................... 9 Cymbalta® ......................................................................................... 25 cyproheptadine .................................................................................. 5 Cystadane® .................................................................................. 31, 36 Cystagon® .......................................................................................... 21 Cystaran® .......................................................................................... 20 Cytomel® ........................................................................................... 21 Cytoxan
® ....................................................................................... 9, 36
D
Dailyvite® .......................................................................................... 32 Daliresp® ............................................................................................. 6 danazol ............................................................................................. 32 Dantrium® ......................................................................................... 30 dantrolene caps ................................................................................ 30 Dapsone ............................................................................................ 23 Daraprim
® ......................................................................................... 23 Daypro® ............................................................................................. 29 Daytrana
® .......................................................................................... 26 DDAVP® ............................................................................................. 21 Decadron
® ......................................................................................... 21 Delzicol® ............................................................................................ 31 Demadex® ......................................................................................... 11 Depakene
® ........................................................................................ 26 Depakote ER® .............................................................................. 26, 29 Depakote® ......................................................................................... 26 Depakote
® Sprinkles.......................................................................... 26 Depen® Titratabs ............................................................................... 29 Depo‐Provera® .................................................................................. 33 Depo‐Testosterone
® ......................................................................... 24 Derma‐Smoothe/FS® ......................................................................... 15 desipramine ...................................................................................... 25 desloratadine odt ............................................................................... 5 desloratidine ....................................................................................... 5 desmopressin ................................................................................... 21 Desogen
® .......................................................................................... 33 desonide0.05% ................................................................................. 15 Desowen® lotion ............................................................................... 15 desoximetasone ............................................................................... 15 desvenlafaxine .................................................................................. 25 Detrol LA
® ........................................................................................... 7 Detrol® .......................................................................................... 7, 37 Detrol
® LA ......................................................................................... 37 dexamethasone .......................................................................... 21, 34 dexamethasone ophthalmic ............................................................. 19 dexamethasone/tobramycin ............................................................ 19 Dexedrine® ........................................................................................ 26 Dexilant® ........................................................................................... 30 dexmethylphenidate hcl cp24 .......................................................... 26 dextroamphetamine tabs & SR ......................................................... 26 Dextrostat® ....................................................................................... 26 DHE® 45 ............................................................................................ 29 Diabeta
® ............................................................................................ 17 Diamox
® ............................................................................................ 20 Diaphragms ....................................................................................... 33 Diastat® ............................................................................................. 26
diazepam .......................................................................................... 24 Dibenzyline® ..................................................................................... 14 Diclegis® ............................................................................................ 31 diclofenac gel ................................................................................... 16 diclofenac sodium enteric coated tablets ........................................ 29 diclofenac sodium ophth soln .......................................................... 20 diclofenac sodium SR 24‐hr 100 mg ................................................. 29 diclofenac w/misoprostol ................................................................. 29 dicloxacillin caps ............................................................................... 22 dicyclomine ...................................................................................... 30 didanosine DR .................................................................................. 23 Didronel
® .......................................................................................... 21 Differin® cream, gel .......................................................................... 15 Dificid® .............................................................................................. 23 diflorasone diacetate ....................................................................... 15 Diflucan tabs/oral suspension .......................................................... 22 Diflucan
® 150mg ............................................................................... 22 diflunisal ........................................................................................... 29 digoxin .............................................................................................. 14 Dilacor
® XR ........................................................................................ 11 Dilantin® ............................................................................................ 26 Dilantin® Infatab ............................................................................... 26 Dilantin
®125 suspension ................................................................... 26 dilatiazem xr ..................................................................................... 11 Dilaudid
® ........................................................................................... 28 diltiazem cd ...................................................................................... 11 diltiazem ER bead ............................................................................. 11 diltiazem HCl .................................................................................... 11 diltiazem SR ...................................................................................... 11 Diovan
® ............................................................................................. 10 Diovan® HCT ...................................................................................... 12 Dipentum® ........................................................................................ 31 diphenhydramine ............................................................................. 24 diphenhydramine 50mg .............................................................. 5, 27 dipivefrin .......................................................................................... 20 Diprolene
® ........................................................................................ 15 Diprolene® (and AF) .......................................................................... 15 dipyridamole ...................................................................................... 8 disopyramide .................................................................................... 14 disulfiram ......................................................................................... 27 Ditropan
® ............................................................................................ 7 Ditropan® XL ....................................................................................... 7 Diuril
® susp ....................................................................................... 11 divalproex sodium sprinkles ............................................................. 26 divalproex sodium sr .................................................................. 26, 29 divalproex sodium tabs .................................................................... 26 Domeboro
® Otic ............................................................................... 18 donepezil .......................................................................................... 27 donepezil 23mg ................................................................................ 27 Donnatal® ......................................................................................... 30 Doryx® ............................................................................................... 22 dorzolamide hcl soln ........................................................................ 20 dorzolamide/timolol ophth soln ...................................................... 20 Dovonex
® soln .................................................................................. 16 doxazosin ......................................................................................... 24 doxepin............................................................................................. 25 doxercalciferol .................................................................................. 32 doxycycline hyclate caps, tabs ......................................................... 22 doxycycline DR ................................................................................. 22 doxycycline hyclate .......................................................................... 34 doxycycline hyclate 20mg ................................................................ 34 doxycycline hyclate TBEC dr ............................................................. 22 doxycycline monohydrate ................................................................ 22 drospirenone/estradiol .................................................................... 33 Droxia
® .......................................................................................... 9, 36
Drug Formulary I (November 2014) 44
Drysol® .............................................................................................. 16 Duac® ................................................................................................ 15 Duavee® ............................................................................................ 32 Duetact® ............................................................................................ 17 Duexis® .............................................................................................. 29 Dulera
® ................................................................................................ 6 duloxetine ......................................................................................... 25 Duoneb® .............................................................................................. 7 Duragesic® ................................................................................... 28, 37 Durezol® ............................................................................................ 20 Dutoprol
® .......................................................................................... 10 Dyazide® ............................................................................................ 11 Dymista® ....................................................................................... 5, 37 DynaCirc® CR ..................................................................................... 11 Dyphylline‐GG® ................................................................................... 6 Dyrenium
® ......................................................................................... 11
E
EC Naprosyn® .................................................................................... 29 econazole nitrate cream 1% ............................................................. 16 Edarbi
® ........................................................................................ 10, 37 Edarbyclor® ....................................................................................... 12 Edecrin
® ............................................................................................ 11 Edex
® ................................................................................................. 24 Edular® .............................................................................................. 37 EdurantTM ......................................................................................... 23 Effexor
® XR ........................................................................................ 25 Effient® ................................................................................................ 8 Efudex
® ............................................................................................. 16 Eldepryl® ........................................................................................... 27 Elestat®........................................................................................ 20, 37 Elidel
® ................................................................................................ 16 Eliquis® ................................................................................................ 8 EllaTM ................................................................................................. 33 Elmiron
® .............................................................................................. 8 Elocon® .............................................................................................. 15 Emadine® .......................................................................................... 20 Emcyt
® ........................................................................................... 9, 36 Emend® ....................................................................................... 31, 37 Emsam® ............................................................................................. 25 Emtriva
® ............................................................................................ 23 Enablex
® ........................................................................................ 7, 37 enalapril ............................................................................................ 10 Enbrel® ........................................................................................ 29, 36 Endometrin
® ..................................................................................... 33 enoxaparin sodium ............................................................................. 8 Enpresse® .......................................................................................... 33 entacapone ....................................................................................... 37 Entocort
® EC ...................................................................................... 31 Epaned® soln ..................................................................................... 10 Epiduo
® ............................................................................................. 16 epinastine ......................................................................................... 20 Epipen® ............................................................................................... 6 Epivir
® ............................................................................................... 23 Epivir‐HBV® ................................................................................. 23, 31 eplerenone ....................................................................................... 14 Epogen® ........................................................................................ 8, 36 eprosartan .................................................................................. 10, 37 Epzicom
® ........................................................................................... 23 Equagesic® ........................................................................................ 30 ergocalciferol .................................................................................... 32 Ergomar
® ........................................................................................... 29 ergotamine w/caffeine ..................................................................... 29 Erivedge® .......................................................................................... 36
ErivedgeTM .......................................................................................... 9 Errin® ................................................................................................ 33 Ertaczo® ............................................................................................ 22 Ery‐Tab® ............................................................................................ 22 erythromycin .................................................................................... 34 erythromycin base enteric pellets .................................................... 22 erythromycin estolate caps, susp ..................................................... 22 erythromycin ethylsuccinate tabs, susp ........................................... 22 erythromycin gel .............................................................................. 15 erythromycin ophthalmic ................................................................. 19 erythromycin pads ........................................................................... 15 erythromycin stearate ...................................................................... 22 erythromycin susp ............................................................................ 34 erythromycin/benzoyl peroxide gel ................................................. 15 erythromycin/sulfisoxazole susp ...................................................... 22 escitalopram oxalate ........................................................................ 25 Esgic Plus
® ......................................................................................... 29 Esgic® ................................................................................................ 29 esomeprazole strontium .................................................................. 30 Estrace
® ............................................................................................ 32 Estrace® cream ................................................................................. 32 Estraderm® ....................................................................................... 32 estradiol ........................................................................................... 32 estradiol weekly patch ..................................................................... 32 estradiol/levonorgesterel ................................................................. 33 estradiol/norethindrone .................................................................. 33 Estring
® ............................................................................................. 32 Estrogel® ........................................................................................... 32 estropipate ....................................................................................... 32 Estrostep FE
® .................................................................................... 33 eszopiclone ....................................................................................... 24 ethambutol ....................................................................................... 23 ethosuximide 250mg/5ml syrup ...................................................... 26 ethosuximide capsules ..................................................................... 26 etodolac ........................................................................................... 29 etoposide ......................................................................................... 36 etoposide (caps only) ......................................................................... 9 Eurax
® ............................................................................................... 16 evetiracetam .................................................................................... 26 Evista® ............................................................................................... 32 Evoclin
® Foam ................................................................................... 16 Evoxac® ............................................................................................. 19 Evzio® ............................................................................................... 27 Exalgo
® ........................................................................................ 28, 37 Exelon
® ............................................................................................. 27 exemestane .................................................................................. 9, 36 Exforge® ...................................................................................... 12, 37 Exforge® HCT ............................................................................... 12, 37 Exjade® .......................................................................................... 8, 36 Extavia
® ....................................................................................... 27, 36 Extina® .............................................................................................. 16
F
FabiorTM ............................................................................................ 16 famciclovir ........................................................................................ 23 famotidine ........................................................................................ 30 Famvir® ............................................................................................. 23 Fanapt® ............................................................................................. 25 Fareston
® ...................................................................................... 9, 36 Farxiga® ............................................................................................. 17 Fazaclo
® ............................................................................................ 25 fe‐fumarate vitamin C/vitamin B12/folic acid .................................. 32 felbamate ......................................................................................... 26 Felbatol® ........................................................................................... 26
Drug Formulary I (November 2014) 45
felodipine er ..................................................................................... 11 Femara® ........................................................................................ 9, 36 Femcon FE® ....................................................................................... 33 Femhrt Low Dose® ............................................................................ 32 Femhrt® ............................................................................................. 32 Femring
® ........................................................................................... 32 fenofibrate tabs,caps ........................................................................ 13 fentanyl............................................................................................. 37 fentanyl TD patch ............................................................................. 28 Fentora® ...................................................................................... 28, 37 Ferrex® 150 Forte ............................................................................. 32 Ferriprox® ............................................................................................ 8 ferrogels ........................................................................................... 32 Fetzima® ...................................................................................... 25, 37 Finacea® ............................................................................................ 15 Finacea
® Plus Kit ................................................................................ 15 finasteride ........................................................................................ 24 Fioricet® ............................................................................................ 29 Fiorinal® ............................................................................................ 29 Firazyr
® .......................................................................................... 8, 36 Flagyl® ............................................................................................... 23 Flarex® ............................................................................................... 19 flavoxate hcl ....................................................................................... 7 flecainide acetate ............................................................................. 14 Flector
® patch ................................................................................... 29 Flexeril
® ............................................................................................. 30 Flomax® ............................................................................................. 24 Flonase® ........................................................................................ 5, 37 Flovent® Diskus 50mcg, 100mcg, 250mg ............................................ 6 Flovent
® HFA ....................................................................................... 6 Floxin® Otic ....................................................................................... 18 fluconazole 150mg tab ..................................................................... 22 fluconazole tabs/oral suspension ..................................................... 22 flucytosine ........................................................................................ 22 fludrocortisone acetate .................................................................... 21 flumadine ......................................................................................... 23 flunisolide nasal .................................................................................. 5 fluocinolone acetonide ..................................................................... 15 fluocinonide ...................................................................................... 15 fluorometholone ophthalmic ........................................................... 19 fluorouracil ....................................................................................... 16 fluoxetine.......................................................................................... 25 fluoxetine hcl .................................................................................... 25 fluoxetine liquid ................................................................................ 25 fluphenazine ..................................................................................... 25 flurazepam ........................................................................................ 24 flurbiprofen ophth soln .................................................................... 20 flurbiprofen tabs ............................................................................... 29 flutamide ...................................................................................... 9, 36 fluticasone cr; oint ............................................................................ 15 fluticasone propionate lotion 0.05% ................................................ 15 fluticasone propionate nasal .............................................................. 5 fluvastatin ......................................................................................... 13 fluvoxamine ...................................................................................... 25 fluvoxamine er .................................................................................. 25 FML‐Forte
® ophthalmic ..................................................................... 19 Focalin XR ......................................................................................... 26 folic acid............................................................................................ 32 Follistim
®/AQ .................................................................................... 33 fondaparinox ...................................................................................... 8 Foradil® ......................................................................................... 6, 37 Forfivo
® XL ......................................................................................... 25 Fortamet
® ......................................................................................... 17 Forteo® ........................................................................................ 21, 36 Fortesta
TM ......................................................................................... 24
Fortical ............................................................................................. 15 Fortical® ............................................................................................ 21 Fosamax® tabs ................................................................................. 21 Fosamax® plus D ............................................................................... 21 fosinopril .......................................................................................... 10 Fosrenol
® .......................................................................................... 32 Fragmin® ............................................................................................. 8 Frova® ............................................................................................... 29 Fulyzaq® ............................................................................................ 30 Furadantin® susp .............................................................................. 22 furosemide ....................................................................................... 11 Fuzeon® ............................................................................................ 36 FycompaTM ....................................................................................... 26
G
gabapentin ....................................................................................... 26 Gabitril® ............................................................................................ 26 galantamine ..................................................................................... 27 galantamine oral solution ................................................................ 27 galantamine SR ................................................................................. 27 Galzin
® .............................................................................................. 32 ganciclovir ........................................................................................ 23 Ganirelix
® .......................................................................................... 33 Gastrocrom
® ..................................................................................... 31 gatifloxacin soln ............................................................................... 19 Gattex® ....................................................................................... 31, 36 Gelnique
® .......................................................................................... 37 gemfibrozil ....................................................................................... 13 Generess
® FE ..................................................................................... 33 generic Avita® ................................................................................... 15 generic benzonatate .......................................................................... 6 generic Colyte
® ................................................................................. 31 generic Cortisporin® ophthalmic ...................................................... 19 generic Cortisporin® Otic sol, susp .................................................... 18 generic Domeboro
® Otic ................................................................... 18 generic Golytely® .............................................................................. 31 generic Maxitrol® ophthalmic ........................................................... 19 generic Metimyd
® ............................................................................. 19 generic NeoDecadron® ..................................................................... 19 generic Neosporin® ........................................................................... 19 generic Polysporin
®........................................................................... 19 generic Polytrim
® .............................................................................. 19 generic Retin‐A® ............................................................................... 15 generic Sulfacet‐R® ........................................................................... 15 generic Tylox
® ................................................................................... 28 Genotropin® ................................................................................ 21, 36 gentamicin ........................................................................................ 17 gentamicin ophthalmic ..................................................................... 19 Geodon
® ........................................................................................... 25 Gianvi® .............................................................................................. 33 Giazo
® ............................................................................................... 31 GilenyaTM .................................................................................... 27, 36 GilotrifTM ............................................................................................. 9 Gleevec
® ....................................................................................... 9, 36 glimepiride ....................................................................................... 17 glimepiride/pioglitaone .................................................................... 17 glipizide ............................................................................................ 17 glipizide CR tablets ........................................................................... 17 glipizide‐metformin .......................................................................... 17 glucagon ........................................................................................... 18 Glucophage ...................................................................................... 17 Glucophage XR
® ................................................................................ 17 Glucotrol XL® ..................................................................................... 17 Glucotrol® ......................................................................................... 17
Drug Formulary I (November 2014) 46
Glucovance® ...................................................................................... 17 Glumetza® ......................................................................................... 37 glyburide ........................................................................................... 17 glyburide micronized ........................................................................ 17 glyburide‐metformin ........................................................................ 17 Glycate
® ...................................................................................... 31, 37 glycopyrrolate ................................................................................... 31 Glynase® ............................................................................................ 17 Glyset® .............................................................................................. 17 Golytely® ........................................................................................... 31 Gonal‐F RFF
® ..................................................................................... 33 Gonal‐F® ............................................................................................ 33 Gralise® ....................................................................................... 26, 37 granisetron ................................................................................. 31, 37 Granix® ................................................................................................ 8 Grifulvin
® V ........................................................................................ 22 griseofulvin 125mg, 250mg .............................................................. 22 griseofulvin 500mg ........................................................................... 22 griseofulvin suspension .................................................................... 22 Gris‐Peg
® 125 mg .............................................................................. 22 guanfacine HCl .................................................................................. 12 Gyne‐Lotrimin® ................................................................................. 34
H
Halcion® ............................................................................................ 24 Haldol® .............................................................................................. 25 Halflytely
® Bowel Prep Kit ................................................................. 31 halobetasol propionate .................................................................... 15 Halog
® ............................................................................................... 15 Halonate® .......................................................................................... 15 haloperidol ....................................................................................... 25 hctz/spironolactone.......................................................................... 11 Hectorol
® ..................................................................................... 32, 37 hematogen ....................................................................................... 32 heparin sodium ................................................................................... 8 Hepsera
® ..................................................................................... 23, 31 Hexalen® ....................................................................................... 9, 36 HMS
® ................................................................................................. 19 homatropine ..................................................................................... 20 Horizant® ........................................................................................... 26 Humalog
® .......................................................................................... 17 Humatrope
® ................................................................................ 21, 36 Humira® ....................................................................................... 29, 36 Humulin® Insulins .............................................................................. 17 Hycamtin
® ......................................................................................... 36 Hycamtin® cap ..................................................................................... 9 hydralazine HCl ................................................................................. 12 Hydrea
® ......................................................................................... 9, 36 hydrochlorothiazide ......................................................................... 11 hydrocodone bitartrate/acetaminophen ......................................... 28 hydrocodone polistirex‐chlorpheniramine ......................................... 5 hydrocodone w/acetaminophen ................................................ 28, 34 hydrocodone w/ibuprofen ............................................................... 28 hydrocodone/APAP soln ................................................................... 28 hydrocodone‐guaifenesin‐phenylephrine .......................................... 5 hydrocodone‐homatropine ................................................................ 5 hydrocodone‐ibuprofen tab 7.5‐200mg ........................................... 34 hydrocodone‐phenylephrine syrup .................................................... 5 hydrocortisone 2.5% ......................................................................... 15 hydrocortisone 25mg rectal ............................................................. 15 hydrocortisone cream, supp ............................................................. 31 hydrocortisone rectal ....................................................................... 15 hydrocortisone tab ........................................................................... 21 hydrocortisone valerate ................................................................... 15
hydrocortisone w/acetic acid otic soln ....................................... 18, 19 hydromorphone hcl .......................................................................... 28 hydroxychloroquine sulfate ....................................................... 23, 29 hydroxyurea ..................................................................................... 36 hydroxyurea 500mg ........................................................................... 9 hydroxyzine hcl ................................................................................ 24 hydroxyzine HCl ................................................................................. 5 hydroxyzine pamoate ................................................................... 5, 24 hyoscyamine ...................................................................................... 7 hyoscyamine sulfate ......................................................................... 30 Hytrin® .............................................................................................. 24 Hyzaar® ............................................................................................. 12
I
ibandronate sodium tabs ................................................................. 21 ibuprofen .................................................................................... 29, 34 ibuprofen suspension ....................................................................... 34 Iclusig® .......................................................................................... 9, 36 iFerex® 150 Forte .............................................................................. 32 Ilevro® ............................................................................................... 20 Imbruvica
® .................................................................................... 9, 36 Imdur® .............................................................................................. 14 imipramine HCl ................................................................................. 25 imiquimod cream ............................................................................. 16 Imitrex
® ............................................................................................. 29 Imuran®............................................................................................... 9 Incivek
® ....................................................................................... 31, 36 Increlex® ........................................................................................... 36 indapamide ...................................................................................... 11 Inderal
® LA ........................................................................................ 10 Indocin® ............................................................................................ 29 indomethacin ................................................................................... 29 indomethacin SR .............................................................................. 29 Infergen
® ..................................................................................... 31, 36 Inlyta
® ........................................................................................... 9, 36 Innopran XL® ..................................................................................... 10 Inspra® .............................................................................................. 14 Inta
® nebs ........................................................................................... 7 Intelence® ......................................................................................... 23 Intermezzo® ................................................................................ 24, 37 Intron A
® ........................................................................................... 31 Intron‐A
® .......................................................................................... 36 Intuniv® ............................................................................................. 27 Invirase® ............................................................................................ 23 Invokamet
® ....................................................................................... 17 Invokana® ......................................................................................... 17 Iopidine® ........................................................................................... 20 ipratropium ........................................................................................ 5 ipratropium 200mcg/ml nebs ............................................................ 7 irbesartan ......................................................................................... 10 irbesartan/hctz ................................................................................. 12 Iressa
® ........................................................................................... 9, 36 iron poly complex/folic acid/vit b12 ................................................. 32 Isentress
® .......................................................................................... 23 Ismo® ................................................................................................ 14 isometheptene ................................................................................. 29 isoniazid ........................................................................................... 23 Isoptin®SR ......................................................................................... 11 Isopto Carbachol
® ............................................................................. 20 Isordil® .............................................................................................. 14 isosorbide dinitrate .......................................................................... 14 isosorbide mononitrate .................................................................... 14 isotretinoin ....................................................................................... 15 Isuprel
® ............................................................................................... 6
Drug Formulary I (November 2014) 47
itraconazole caps .............................................................................. 22
J
Jakafi® ........................................................................................... 9, 36 jantoven .............................................................................................. 8 Janumet® ........................................................................................... 17 Janumet® XR ...................................................................................... 17 Januvia®............................................................................................. 17 Jentadueto® ...................................................................................... 17 Jolessa® ............................................................................................. 33 Jublia® ............................................................................................... 16 Junel FE® ........................................................................................... 33 Junel
® ................................................................................................ 33 Juvisync
® ........................................................................................... 17 Juxtapid® ..................................................................................... 13, 36
K
Kadian®.............................................................................................. 37 Kadian® 100mg, 200mg ..................................................................... 28 Kadian
® 10mg, 20mg, 30mg, 50mg, 60mg, 80mg ............................. 28 Kaletra
® ............................................................................................. 23 Kalydeco® ...................................................................................... 7, 36 Kapvay
TM ........................................................................................... 26 Kariva® .............................................................................................. 33 Kazano® ............................................................................................. 17 Keflex
® ............................................................................................... 22 Kelnor® .............................................................................................. 33 Kemadrin® ......................................................................................... 27 Kenalog
® in Orabase ......................................................................... 19 Keppra® ............................................................................................. 26 Keppra® XR ........................................................................................ 26 Keralyt
® scalp .................................................................................... 16 Kerlone® ...................................................................................... 10, 11 Kerydin® ........................................................................................... 16 Ketek
® ............................................................................................... 22 ketoconazole 2% shampoo ............................................................... 16 ketoconazole cream ......................................................................... 16 ketoconazole foam 2% ..................................................................... 16 ketoconazole tabs ............................................................................. 22 Ketodan
® ........................................................................................... 16 ketoprofen ........................................................................................ 29 ketoprofen extended release ........................................................... 29 ketorolac ........................................................................................... 29 ketorolac tromethamine ophth soln 0.4% and 0.5% ........................ 20 ketotifen fumerate ophth soln ......................................................... 20 Kineret
® ....................................................................................... 29, 36 Klaron® .............................................................................................. 15 Klonopin
® .......................................................................................... 26 Klonopin® Wafers .............................................................................. 26 Klor‐Con® .......................................................................................... 32 Kombiglyze® XR ................................................................................. 17 Korlym
® ....................................................................................... 21, 36 Kuvan®......................................................................................... 31, 36 Kynamro® .......................................................................................... 13 Kytril® .......................................................................................... 31, 37
L
labetalol ............................................................................................ 10 Lacrisert® ........................................................................................... 20 lactulose syrup .................................................................................. 31 Lamictal® chewable tablets ............................................................... 26 Lamictal® ODT ................................................................................... 26
Lamictal® ODT Titration Kit ............................................................... 26 Lamictal® Starter Kit .......................................................................... 26 Lamictal® tabs ................................................................................... 26 Lamictal® XR ...................................................................................... 26 Lamictal® XR Starter Kit .................................................................... 26 Lamisil AT
® cream ............................................................................. 16 Lamisil® ............................................................................................. 22 Lamisil® oral granules....................................................................... 22 lamivudine ........................................................................................ 23 lamivudine tab ........................................................................... 23, 31 lamivudine/zidovudine ..................................................................... 23 lamotrigine chewable tablets ........................................................... 26 lamotrigine er ................................................................................... 26 lamotrigine tablets ........................................................................... 26 Lanoxin® ............................................................................................ 14 lansoprazole ..................................................................................... 30 Lantus
®.............................................................................................. 17 Lasix® ................................................................................................ 11 LastacaftTM ................................................................................. 20, 37 latanoprost ophth soln ..................................................................... 20 LatudaTM ........................................................................................... 25 Lazanda® ........................................................................................... 28 Leena
®............................................................................................... 33 leflunomide ...................................................................................... 29 Lescol
® .............................................................................................. 13 Lessina
® ............................................................................................ 33 Letairis®....................................................................................... 14, 36 letrozole ....................................................................................... 9, 36 leucovorin calcium tabs ...................................................................... 9 Leukeran
® ..................................................................................... 9, 36 Leukine® .............................................................................................. 8 Levaquin® .......................................................................................... 22 Levatol
® ............................................................................................ 10 Levemir® ........................................................................................... 17 levetiracetam xr ............................................................................... 26 Levitra
® ............................................................................................. 24 levobunolol HCl ................................................................................ 20 levocarnitine 330mg ......................................................................... 32 levocetirizine dihydrochloride ............................................................ 5 levofloxacin ...................................................................................... 22 levofloxacin opth soln ...................................................................... 19 levonorgestrel .................................................................................. 33 Levora
® ............................................................................................. 33 levothroid ......................................................................................... 21 levothyroxine ................................................................................... 21 levoxyl .............................................................................................. 21 Levsin
® .............................................................................................. 30 Levsin®/SL ........................................................................................... 7 Lexapro® ........................................................................................... 25 Lexiva
® .............................................................................................. 23 Lialda® ............................................................................................... 31 Librax® .............................................................................................. 30 Lidex® ................................................................................................ 15 lidocaine cr ....................................................................................... 16 lidocaine HC cr .................................................................................. 16 lidocaine patch ................................................................................. 16 lidocaine viscous ........................................................................ 19, 35 lidocaine viscous soln ....................................................................... 16 lidocaine‐prilocaine cream ............................................................... 16 Lidoderm
® ......................................................................................... 16 lindane.............................................................................................. 16 Linzess® ....................................................................................... 30, 37 Lioresal
® ............................................................................................ 30 liothyronine ...................................................................................... 21 Lipitor® .............................................................................................. 13
Drug Formulary I (November 2014) 48
lisinopril ............................................................................................ 10 lisinopril/hctz .................................................................................... 12 lithium carbonate ............................................................................. 25 lithium carbonate CR tab .................................................................. 25 Livalo® ............................................................................................... 13 Lo/Ovral
® ........................................................................................... 33 Lodosyn® ........................................................................................... 27 Loestrin FE® ....................................................................................... 33 Loestrin® ........................................................................................... 33 Loestrin® 24 Fe .................................................................................. 33 Lofibra ............................................................................................... 13 Lopressor HCT® ................................................................................. 12 Lopressor® ......................................................................................... 10 Loprox® ............................................................................................. 16 Loprox® Shampoo ............................................................................. 16 lorazepam ......................................................................................... 24 Lortab
® .............................................................................................. 28 Loryna®.............................................................................................. 33 losartan ............................................................................................. 10 losartan/hctz .................................................................................... 12 Loseasonique® ................................................................................... 33 Lotemax® ........................................................................................... 19 Lotensin
® ........................................................................................... 10 LotensinHCT® .................................................................................... 12 Lotrel
® ......................................................................................... 11, 12 lovastatin .......................................................................................... 13 Lovaza
®........................................................................................ 13, 37 Lovenox® ............................................................................................. 8 Low‐Ogestrel® ................................................................................... 33 loxapine ............................................................................................ 25 Lufyllin
® ............................................................................................... 6 Lumigan® ........................................................................................... 20 Lunesta
® ............................................................................................ 24 Lupron® ............................................................................................. 34 Lutera
® .............................................................................................. 33 Luveris
® ............................................................................................. 33 Luxiq® foam ....................................................................................... 15 Lyrica
® ............................................................................................... 26 Lysodren® ...................................................................................... 9, 36 Lysteda® ............................................................................................ 34
M
Macrobid® ......................................................................................... 22 Magnacet® ........................................................................................ 28 Malarone
® ......................................................................................... 23 maprotiline ....................................................................................... 25 Marinol® ............................................................................................ 31 Matulane
® ..................................................................................... 9, 36 Mavik® ............................................................................................... 10 Maxair® Autohaler .............................................................................. 6 Maxalt
® ............................................................................................. 29 Maxalt‐MLT® ..................................................................................... 29 Maxzide® ........................................................................................... 11 Mebaral
® ........................................................................................... 26 mebendazole .................................................................................... 23 meclizine ........................................................................................... 31 meclofenamate ................................................................................ 29 medoxyprogesterone ....................................................................... 33 Medrol® ............................................................................................. 21 Medrox‐RX® ....................................................................................... 16 medroxyprogesterone ...................................................................... 33 mefenamic acid ................................................................................ 29 mefloquine hcl .................................................................................. 23 Megace
® ES ................................................................................... 9, 36
megestrol acetate ........................................................................ 9, 36 Mekinist TM ......................................................................................... 9 MekinistTM ....................................................................................... 36 meloxicam ........................................................................................ 29 Meloxicam® Comfort PacKit ............................................................. 29 Menest
® ............................................................................................ 32 Menopur® ......................................................................................... 33 Menostar® ........................................................................................ 21 Mentax® ............................................................................................ 16 Mephyton® ......................................................................................... 8 meprobamate .................................................................................. 24 meprobamate/aspirin ...................................................................... 30 Mepron® ........................................................................................... 23 mercaptopurine ................................................................................. 9 mesalamine enema .......................................................................... 31 Mesnex
® ....................................................................................... 9, 36 Mestinon® ......................................................................................... 27 Metadate CD® ................................................................................... 26 Metaglip® .......................................................................................... 17 metaproterenol tabs .......................................................................... 6 metaxalone ...................................................................................... 30 metformin er .................................................................................... 37 metformin hcl ................................................................................... 17 metformin SR ................................................................................... 17 metformin tb24 ................................................................................ 17 methadone hcl ................................................................................. 28 methamphetamine .......................................................................... 26 methazolamide ................................................................................ 20 Methergine
® ..................................................................................... 34 methimazole .................................................................................... 21 Methitest
® ........................................................................................ 24 methocarbamol ................................................................................ 30 methotrexate inj .............................................................................. 29 methotrexate tabs .................................................................. 9, 16, 29 methoxsalen 10mg ........................................................................... 16 methyclothiazide .............................................................................. 11 methyldopa ...................................................................................... 12 methyldopa/hctz .............................................................................. 12 Methylin
® .......................................................................................... 26 methylphenidate .............................................................................. 26 methylphenidate cd ......................................................................... 26 methylphenidate SR tabs ................................................................. 26 methylprednisolone ......................................................................... 34 metipranolol ..................................................................................... 20 metoclopramide ............................................................................... 30 metolazone ...................................................................................... 11 metoprolol ....................................................................................... 10 metoprolol succinate SR ................................................................... 10 metoprolol/hctz ............................................................................... 12 Metozolv
® ODT ................................................................................. 30 Metrocream® .................................................................................... 15 Metrogel® 0.75%, 1% ........................................................................ 15 Metrogel® Vaginal ............................................................................. 34 Metrolotion
® ..................................................................................... 15 metronidazole .................................................................................. 23 metronidazole 375mg caps .............................................................. 23 metronidazole cream, lotion, gel ..................................................... 15 metronidazole vaginal gel ................................................................ 34 Mevacor® .......................................................................................... 13 mexiletine HCl .................................................................................. 14 Miacalcin® inj. ................................................................................... 21 Miacalcin
® nasal spray ...................................................................... 21 Micardis
® .................................................................................... 10, 37 Micardis® HCT ............................................................................. 12, 37 Micatin
® ............................................................................................ 16
Drug Formulary I (November 2014) 49
miconazole cream, lotion, aerosol, soln ........................................... 16 miconazole vaginal cream ................................................................ 34 Microgestin FE® ................................................................................. 33 Microgestin® ..................................................................................... 33 Midamor® .......................................................................................... 11 midodrine hcl .................................................................................... 14 Midrin
® .............................................................................................. 29 Migranal® .......................................................................................... 29 Minastrin® ......................................................................................... 33 Minipress® ......................................................................................... 12 Minitran
® .......................................................................................... 14 Minivelle® .......................................................................................... 32 Minocin Pac® ..................................................................................... 22 Minocin® ........................................................................................... 22 minocycline caps (50mg & 100mg only) ........................................... 22 minocycline hcl er ............................................................................. 15 minocycline hcl tabs ......................................................................... 15 minoxidil tabs ................................................................................... 12 Mirapex
® ........................................................................................... 27 Mirapex
® ER ...................................................................................... 27 Mircette® .......................................................................................... 33 mirtazapine ODT ............................................................................... 25 Mirvaso
® Gel ..................................................................................... 16 misoprostol ....................................................................................... 30 Mobic
® .............................................................................................. 29 modafinil ........................................................................................... 26 Moderiba
® ......................................................................................... 31 Modicon® .......................................................................................... 33 moexipril/hctz .................................................................................. 12 mometasone furoate ........................................................................ 15 Momexin
® ......................................................................................... 16 Monistat® .......................................................................................... 34 Monodox
® ......................................................................................... 22 Mononessa® ...................................................................................... 33 montelukast sodium chews ................................................................ 7 montelukast sodium tabs ................................................................... 7 morphine sulfate beads sr ................................................................ 28 morphine sulfate cap sr 24hr 100mg, 200mg ................................... 28 morphine sulfate cap sr 24hr 10mg, 20mg, ...................................... 28 morphine sulfate ER ......................................................................... 28 morphine sulfate ir ........................................................................... 28 morphine sulfate supp ...................................................................... 28 morphine sulfate tablets, oral solution ............................................ 28 Motrin
® ............................................................................................. 29 Moxatag
® .......................................................................................... 22 Moxeza
® ............................................................................................ 19
moxifloxacin hcl ................................................................................ 22 MS Contin® ........................................................................................ 28 mucate/dichloralphenazone/acetaminophen .................................. 29 Multaq® ............................................................................................. 14 mupirocin ......................................................................................... 17 Muse® ............................................................................................... 24 MyaleptTM ........................................................................................ 36 Myambutol
® ...................................................................................... 23 Mycelex® Troche ............................................................................... 22 Mycobutin® ....................................................................................... 23 mycophenolate ................................................................................... 9 mycophenolate sodium dr .................................................................. 9 Mydfrin
® ............................................................................................ 20 Myferon® 150 Forte .......................................................................... 32 Myfortic® ............................................................................................. 9 Myleran
® ....................................................................................... 9, 36 Myorisan
® ......................................................................................... 15 Myrbetriq® ........................................................................................ 37 Myrbetriq
TM ........................................................................................ 7
Mysoline® ......................................................................................... 26
N
nabumetone ..................................................................................... 29 nadolol ............................................................................................. 10 Naftin® .............................................................................................. 16 Nalfon® ............................................................................................. 29 naltrexone ........................................................................................ 27 Namenda® soln ................................................................................. 27 Namenda® XR .................................................................................... 27 naphazoline ...................................................................................... 20 Naprelan® ......................................................................................... 29 Naprelan
® SR..................................................................................... 29 Naprosyn
® ......................................................................................... 29 naproxen .................................................................................... 29, 34 naproxen sodium ....................................................................... 29, 34 naratriptan ....................................................................................... 29 Nardil® .............................................................................................. 25 Nasarel® .............................................................................................. 5 Nascobal® ......................................................................................... 32 Nasonex
® ............................................................................................ 5 Natacyn® ........................................................................................... 19 Natazia
® ............................................................................................ 33 nateglinide ....................................................................................... 17 Natroba
® ..................................................................................... 16, 37 Navane® ............................................................................................ 25 Nebupent
® ........................................................................................ 23 Necon® .............................................................................................. 33 nefazodone hcl ................................................................................. 25 neomycin sulfate .............................................................................. 23 Neoral
® ............................................................................................... 9 Neotic
® .............................................................................................. 18 Nesina® ............................................................................................. 17 Neulasta® ...................................................................................... 8, 36 Neumega
® ........................................................................................... 8 Neupogen® ................................................................................... 8, 36 Neupro® ............................................................................................ 27 Neurontin
® ........................................................................................ 26 Nevanac® .......................................................................................... 20 nevirapine ........................................................................................ 23 nevirapine sr ..................................................................................... 23 Nexavar
® ............................................................................................. 9 Nexium® ............................................................................................ 30 Next Choice® ..................................................................................... 33 niacin er ............................................................................................ 13 Niaspan® ........................................................................................... 13 Nicardipine® ...................................................................................... 11 Nicotrol
® Inhaler ............................................................................... 30 Nicotrol® NS ...................................................................................... 30 Nifediac CC ....................................................................................... 11 Nifedical XL ....................................................................................... 11 nifedipine ......................................................................................... 34 nifedipine ER .................................................................................... 11 nimodipine ....................................................................................... 11 Nimotop
® .......................................................................................... 11 Niravam® ........................................................................................... 25 nisoldipine ........................................................................................ 11 Nitro‐Bid®.......................................................................................... 14 Nitro‐Dur
® ......................................................................................... 14 nitrofurantoin macrocrystals ............................................................ 22 nitroglycerin ointment ..................................................................... 14 nitroglycerin patch ........................................................................... 14 nitroglycerin sublingual .................................................................... 14 Nitrolingual aerosol spray ................................................................ 14
Drug Formulary I (November 2014) 50
Nitrostat® .......................................................................................... 14 Nizoral A‐D® shampoo....................................................................... 16 Nizoral® ............................................................................................. 22 Nizoral® shampoo ............................................................................. 16 Nora‐Be® ........................................................................................... 33 Norco
® ............................................................................................... 28 Nordette® .......................................................................................... 33 Norditropin® ...................................................................................... 21 norethindrone acetate ..................................................................... 33 norethindrone acetate‐ethinyl estradiol .......................................... 32 Norflex
® ............................................................................................. 30 Norinyl® ............................................................................................. 33 Noritate® ........................................................................................... 15 Noroxin® ............................................................................................ 22 Norpace CR® ...................................................................................... 14 Norpace
® ........................................................................................... 14 Norpramin® ....................................................................................... 25 Nor‐QD® ............................................................................................ 33 NortheraTM .................................................................................. 27, 36 Nortrel
® ............................................................................................. 33 nortriptyline ...................................................................................... 25 Norvasc® ........................................................................................... 11 Norvir
® .............................................................................................. 23 Novacort® .......................................................................................... 15 NovoFine
® Needles ........................................................................... 18 Novolin
® insulins ............................................................................... 17 Novolog® insulins .............................................................................. 17 Noxafil DR® ........................................................................................ 22 Noxafil® ............................................................................................. 22 Nucynta
® ........................................................................................... 28 Nucynta® ER ...................................................................................... 28 NuedextaTM XR .................................................................................. 27 Nutropin
® .................................................................................... 21, 36 Nutropin® AQ .............................................................................. 21, 36 NuvaRing
® ......................................................................................... 33 Nuvigil
® ............................................................................................. 26 Nymalize® .......................................................................................... 11 nystatin 100,000u/1g cream; oint .................................................... 16 nystatin oral suspension ............................................................. 22, 34 nystatin pwd ..................................................................................... 16 nystatin tabs ..................................................................................... 22 nystatin‐triamcinolone ..................................................................... 16 Nystop
® ............................................................................................. 16
O
Ocella® .............................................................................................. 33 octreotide ........................................................................................... 9 Ocufen
® ophth soln ........................................................................... 20 Ocuflox® ............................................................................................ 19 ofloxacin ophth soln ......................................................................... 19 ofloxacin otic .................................................................................... 18 Oforta
® .......................................................................................... 9, 36 Ogestrel® ........................................................................................... 33 olanzapine ........................................................................................ 25 olanzapine odt .................................................................................. 25 olanzapine‐fluoxetine ....................................................................... 25 Oleptro® ...................................................................................... 25, 37 Olux® foam ........................................................................................ 15 Olysio
TM ...................................................................................... 31, 36 Omeclamox‐Pak® .............................................................................. 31 omega‐3‐acid ethyl esters ................................................................ 13 omeprazole ....................................................................................... 30 omeprazole sodium bicarbonate ...................................................... 30 Omnaris
® ....................................................................................... 5, 38
ondansetron ..................................................................................... 31 ondansetron odt .............................................................................. 31 ondansetron susp ............................................................................. 31 OneTouch® Diabetic Test Strips ....................................................... 18 OneTouch® Glucose Meters ............................................................. 18 OnfiTM ............................................................................................... 27 Onglyza® ........................................................................................... 17 Onsolis® ...................................................................................... 28, 36 Opana ER® ......................................................................................... 28 Opana® .............................................................................................. 28 Opana
® ER (crush resistant) .............................................................. 38 Opsumit® .................................................................................... 14, 36 Optipranolol® .................................................................................... 20 Optivar® ...................................................................................... 20, 38 Oramorph® ....................................................................................... 28 Orap
® ................................................................................................ 25 Orapred® ....................................................................................... 9, 21 Oravig® ........................................................................................ 22, 38 Orencia® SQ ...................................................................................... 29 Orencia
®SQ ....................................................................................... 36 OrenitramTM ............................................................................... 14, 36 Orfadin® ...................................................................................... 21, 36 Ortho Micronor
® ............................................................................... 33 Ortho Tri‐Cyclen® .............................................................................. 33 Ortho Tri‐Cyclen
® Lo ......................................................................... 33 Ortho‐Cept
® ...................................................................................... 33 Ortho‐Cyclen® ................................................................................... 33 OrthoEvra® ........................................................................................ 33 Ortho‐Novum® .................................................................................. 33 Oseni
® ............................................................................................... 17 OsmoPrep® ....................................................................................... 31 Osphena® .......................................................................................... 32 Otezla® ............................................................................................. 29 Otrexup
TM ......................................................................................... 29 Ovcon
® .............................................................................................. 33 Ovidrel
® ...................................................................................... 33, 38 Oxandrin® ..................................................................................... 9, 21 oxaprozin .......................................................................................... 29 oxazepam ......................................................................................... 24 oxcarbazepine .................................................................................. 26 Oxecta
® ............................................................................................. 28 Oxistat® ............................................................................................. 16 Oxsoralen‐Ultra
® ............................................................................... 16 Oxtellar
® XR ...................................................................................... 26 oxybutynin.......................................................................................... 7 oxybutynin chloride SR ....................................................................... 7 oxycodone 5mg tablets/soln ............................................................ 28 oxycodone w/acetaminophen 5/325mg .......................................... 28 oxycodone w/ibuprofen ................................................................... 28 Oxycontin
® .................................................................................. 28, 38 oxymorphone ................................................................................... 28
P
Pamelor® ........................................................................................... 25 Pancreaze® ........................................................................................ 31 Panretin® Gel .................................................................................... 16 pantoprazole .................................................................................... 30 Parcopa® ........................................................................................... 27 paricalcitrol ...................................................................................... 32 Parlodel® ........................................................................................... 27 Parnate
®............................................................................................ 25 paromomycin ................................................................................... 23 paroxetine hcl er .............................................................................. 38 paroxetine hcl sr ............................................................................... 25
Drug Formulary I (November 2014) 51
paroxetine tabs ................................................................................. 25 Pataday® ........................................................................................... 38 Patanase® ...................................................................................... 5, 38 Patanol® ...................................................................................... 20, 38 Paxil CR® ............................................................................................ 25 Paxil
® ................................................................................................. 25 Paxil® CR ............................................................................................ 38 Pediapred® ........................................................................................ 21 Pediderm® HC ................................................................................... 15 Peganone® ........................................................................................ 26 Pegasys
® ...................................................................................... 31, 36 Peg‐Intron® ................................................................................. 31, 36 penicillin VK ...................................................................................... 34 penicillin VK tabs, soln ...................................................................... 22 Penlac® .............................................................................................. 16 Pennsaid
® .......................................................................................... 29 Pentasa® ............................................................................................ 31 pentoxifylline ...................................................................................... 8 Percocet® .......................................................................................... 28 Percodan
® ......................................................................................... 28 Perforomist® ....................................................................................... 6 Peridex® ............................................................................................ 19 perindopril ........................................................................................ 10 permethrin cream ............................................................................ 16 perphenazine .................................................................................... 25 Persantine
® ......................................................................................... 8 Pertzye® ............................................................................................ 31 phenazopyridine ................................................................................. 8 phenelzine tab .................................................................................. 25 Phenergan suppositories
® ................................................................. 31 phenobarbital ................................................................................... 26 phentolamine inj .............................................................................. 14 phenylephrine ophthalmic 2.5% ....................................................... 20 Phenytek
® ......................................................................................... 26 phenytoin ......................................................................................... 26 phenytoin chew tab .......................................................................... 26 phenytoin sodium ............................................................................. 26 phenytoin sodium susp..................................................................... 26 Phoslyra
TM ........................................................................................ 32 Phospholine® iodide .......................................................................... 20 Phrenilin
® Forte ................................................................................. 29 Picato® Gel ........................................................................................ 16 pilocarpine soln ................................................................................ 20 pilocarpine tab .................................................................................. 19 Pilopine
® H.S. .................................................................................... 20 pioglitazone hcl ................................................................................. 17 pioglitazone hcl/metformin hcl ........................................................ 17 piroxicam .......................................................................................... 29 Plan B® .............................................................................................. 33 Plan B
® One Step ............................................................................... 33 Plavix® ................................................................................................. 8 Plendil®.............................................................................................. 11 Pletal® ................................................................................................. 8 Plexion
® cleanser .............................................................................. 15 podofilox solution ............................................................................. 16 Pol‐iron® 150 Forte ........................................................................... 32 Polycitra
® ............................................................................................ 8 Poly‐Pred® ......................................................................................... 19 polysaccharide iron forte .................................................................. 32 poly‐vitamin w/fluoride .............................................................. 32, 34 Pomalyst® ...................................................................................... 9, 36 Ponstel
® ............................................................................................ 29 Portia
® ............................................................................................... 33 potassium bicarbonate/chloride ...................................................... 32 potassium chloride er ....................................................................... 32
potassium chloride tab, cap, liquid .................................................. 32 potassium citrate ............................................................................... 8 potassium citrate/citric acid ............................................................... 8 Potiga® .............................................................................................. 26 PradaxaTM ........................................................................................... 8 pramipexole dihydrochloride ........................................................... 27 Pramosone
® E ................................................................................... 15 Prandimet® ....................................................................................... 17 Prandin® ............................................................................................ 17 Pravachol® ........................................................................................ 13 pravastatin ....................................................................................... 13 prazosin HCl ...................................................................................... 12 Precose® ........................................................................................... 17 Pred Forte® ....................................................................................... 19 Pred Mild® ........................................................................................ 19 Pred‐G S.O.P.
® .................................................................................. 19 Pred‐G® ............................................................................................. 19 prednicarbate cr,oint ....................................................................... 15 prednisolone ...................................................................................... 9 prednisolone ophthalmic ................................................................. 19 prednisolone oral syrup ................................................................... 21 prednisone ............................................................................. 9, 21, 34 Prefest
® ............................................................................................. 32 Pregnyl® ............................................................................................ 33 Prelone
® ............................................................................................ 21 Premarin
® ......................................................................................... 32 Premarin® cream .............................................................................. 32 Premphase® ...................................................................................... 32 Prempro® .......................................................................................... 32 Prepopik
® .......................................................................................... 31 Prevacid Solutab ............................................................................... 30 Prevacid® .......................................................................................... 30 Previfem
® .......................................................................................... 33 Prezista® ..................................................................................... 23, 38 Prilosec
® ............................................................................................ 30 primaquine phosphate ..................................................................... 23 primidone ......................................................................................... 26 Prinivil
® ............................................................................................. 10 Prinzide® ........................................................................................... 12 Pristiq® ........................................................................................ 25, 38 Proair
® HFA ......................................................................................... 6 ProAmatine® ..................................................................................... 14 ProBanthine
® .................................................................................... 30 probenicid ........................................................................................ 30 Procardia
® XL .................................................................................... 11 Prochieve
® ........................................................................................ 33
prochlorperazine tab, supp .............................................................. 31 Procrit® ......................................................................................... 8, 36 Proctocort® 1% ................................................................................. 31 Proctocream‐HC
®2.5% ...................................................................... 31 Proctofoam HC® ................................................................................ 31 Procto‐Pak® 1% ................................................................................. 31 Proctosol‐HC® 2.5% .......................................................................... 31 Proctosone
® 2.5% ............................................................................. 31 Procysbi® ..................................................................................... 21, 36 progesterone suppositories ............................................................. 32 Proglycem
® ....................................................................................... 17 Prograf® .............................................................................................. 9 Prolensa
® .................................................................................... 20, 38 Proleukin® ........................................................................................... 9 Promacta® ..................................................................................... 8, 36 promethazine ..................................................................................... 5 promethazine hcl supp ..................................................................... 31 promethazine/ ................................................................................... 5 promethazine/dextromethorphan ..................................................... 6
Drug Formulary I (November 2014) 52
Prometrium® ..................................................................................... 33 propafenone hcl ............................................................................... 14 propafenone hcl sr............................................................................ 14 propantheline ................................................................................... 30 propranolol ....................................................................................... 10 propranolol ER .................................................................................. 10 propranolol/hctz ............................................................................... 12 propylthiouracil ................................................................................ 21 Proquin
® XR ....................................................................................... 22 Proscar® ............................................................................................ 24 Prostigmin
® ....................................................................................... 27 Protonix® ........................................................................................... 30 Protopic® ........................................................................................... 16 protriptyline ...................................................................................... 25 Proventil HFA® .................................................................................... 6 Proventil
® ............................................................................................ 6 Provera® ............................................................................................ 33 Provigil® ............................................................................................. 26 Prozac® .............................................................................................. 25 Prozac
® Weekly ................................................................................. 25 Pulmicort Respules® 0.25mg, 0.5mg ................................................... 6 Pulmicort® Flexhaler ........................................................................... 6 Pulmicort
® Respules 1mg .................................................................... 6 Pulmozyme® ........................................................................................ 7 pyrazinamide .................................................................................... 23 Pyridium
® ............................................................................................ 8 pyridostigmine bromide 60mg tab ................................................... 27
Q
Qnasl® ........................................................................................... 5, 38 Qualaquin® ........................................................................................ 23 Quasense
® ......................................................................................... 33 Qudexy® XR ...................................................................................... 26 Questran Light® ................................................................................. 13 Questran
® ......................................................................................... 13 quetiapine fumarate ......................................................................... 25 Quibron® ............................................................................................. 6 Quillivant
® XR .............................................................................. 26, 38 quinapril ........................................................................................... 10 quinapril/hctz ................................................................................... 12 quinidine gluconate SR ..................................................................... 14 quinidine sulfate ............................................................................... 14 quinidine sulfate SR .......................................................................... 14 quinine sulfate caps .......................................................................... 23 Quixin
® .............................................................................................. 19 QVar® .................................................................................................. 6
R
rabeprazole ....................................................................................... 30 raloxifene .......................................................................................... 32 ramipril ............................................................................................. 10 Ranexa® ............................................................................................. 14 ranitidine hcl capsules ...................................................................... 30 ranitidine syrup ................................................................................ 30 ranitidine tabs................................................................................... 30 Rapaflo® ...................................................................................... 12, 24 Rapamune® ......................................................................................... 9 Rasuvo® ............................................................................................ 29 Ravicti
® ........................................................................................ 21, 36 Rayos® ............................................................................................... 38 Razadyne® ......................................................................................... 27 Razadyne
® ER .................................................................................... 27 Rebetol® ................................................................................ 23, 31, 36
Rebif® .......................................................................................... 27, 36 Reclipsen® ......................................................................................... 33 Reglan® ............................................................................................. 30 Regranex® ......................................................................................... 16 Relenza® ............................................................................................ 23 Relistor
® ............................................................................................ 31 Relpax® tablets ................................................................................. 29 Remeron Sol‐Tab® ............................................................................. 25 Remeron® ......................................................................................... 25 Renacidin® .......................................................................................... 8 Renagel
® ........................................................................................... 32 Renvela® ........................................................................................... 32 Repronex® ......................................................................................... 33 Requip® ............................................................................................. 27 Requip® XL ........................................................................................ 27 Rescriptor
® ........................................................................................ 23 Rescula® ............................................................................................ 20 Restasis® ........................................................................................... 20 Restoril® ............................................................................................ 24 Retin‐A
® ............................................................................................ 15 Retin‐A® Micro .................................................................................. 15 Retrovir® ........................................................................................... 23 Revatio
® ............................................................................................ 14 Revia® ............................................................................................... 27 Revlimid
® ...................................................................................... 8, 36 Reyataz
®............................................................................................ 23 Rhinocort® Aqua ........................................................................... 5, 38 ribavirin ................................................................................ 23, 31, 36 Ridaura® ............................................................................................ 29 rifabutin ............................................................................................ 23 Rifadin
® ............................................................................................. 23 rifampin ............................................................................................ 23 Rifater
® ............................................................................................. 23 Rilutek® ............................................................................................. 30 Riomet
®............................................................................................. 17 risedronate sodium 150mg .............................................................. 21 Risperdal
® ......................................................................................... 25 Risperdal
® M ..................................................................................... 25 Risperdal® solution ........................................................................... 25 risperidone ....................................................................................... 25 risperidone odt ................................................................................ 25 Ritalin LA
® ......................................................................................... 26 Ritalin
® .............................................................................................. 26 rivastigmine ...................................................................................... 27 rizatriptan benzoate ......................................................................... 29 rizatriptan benzoate odt................................................................... 29 Robaxin
® ........................................................................................... 30 Robinul® ............................................................................................ 31 ropinirole hcl tabs 24 hour ............................................................... 27 ropinirole hydrochloride .................................................................. 27 rosadan ............................................................................................ 15 Rosadan® Kit...................................................................................... 15 Rosula® Emulsion Cleanser ............................................................... 15 Rowasa
® Enema ................................................................................ 31 Roxicodone® ..................................................................................... 28 Rozerem® .......................................................................................... 24 Rybix
® ODT ........................................................................................ 28 Rynatan® susp ..................................................................................... 5 Rythmol
® SR ...................................................................................... 14 Ryzolt® .............................................................................................. 28
S
Sabril® ......................................................................................... 26, 36 Saizen® ........................................................................................ 21, 36
Drug Formulary I (November 2014) 53
Salagen® ............................................................................................ 19 salsalate ............................................................................................ 29 Salvax® Duo Kit .................................................................................. 16 Samsca® ............................................................................................ 21 Sanctura XR® ....................................................................................... 7 Sanctura
® .......................................................................................... 38 Sanctura® XR ..................................................................................... 38 Sancuso® ........................................................................................... 38 Sancuso® Patch ................................................................................. 31 Sandimmune® ..................................................................................... 9 Sandostatin
® ....................................................................................... 9 Saphris® ............................................................................................. 25 Sarafem® ........................................................................................... 25 Savella® ............................................................................................. 25 Seasonale® ........................................................................................ 33 Seasonique
® ...................................................................................... 33 Sectral® ............................................................................................. 10 selegiline ........................................................................................... 27 selenium sulfide ................................................................................ 16 Selzentry
® .......................................................................................... 23 Sensipar® ........................................................................................... 21 Serevent® Diskus ........................................................................... 6, 38 Seromycin
® ........................................................................................ 23 Seroquel® .......................................................................................... 25 Seroquel
® XR ............................................................................... 25, 38 Serostim
® .......................................................................................... 21 sertraline .......................................................................................... 25 sevelamer carbonate ........................................................................ 32 Signifor® .............................................................................................. 9 sildenafil ........................................................................................... 14 Silenor
® ............................................................................................. 25 silver sulfadiazine ............................................................................. 17 Simcor
® ............................................................................................. 14 Simponi® ..................................................................................... 29, 36 simvastatin ....................................................................................... 13 Sinemet CR
® ...................................................................................... 27 Sinemet® ........................................................................................... 27 Singulair
® ............................................................................................. 7 Singulair® chews .................................................................................. 7 sirolimus 0.5mg .................................................................................. 9 Sirturo
® ............................................................................................. 23 Sitavig® .............................................................................................. 17 Skelaxin
® ........................................................................................... 30 Sklice
® ............................................................................................... 38 sodium chloride for inhalation ........................................................... 7 sodium fluoride .......................................................................... 32, 34 sodium fluoride gel, paste, cream .................................................... 32 sodium phenylbutyrate .................................................................... 21 sodium polystyrene sulfonate .......................................................... 32 Solaraze
® ........................................................................................... 16 Solia® ................................................................................................. 33 Solodyn® ............................................................................................ 15 Somavert® ................................................................................... 21, 36 Sonata
® ............................................................................................. 24 Soriatane® ......................................................................................... 16 SoriluxTM ........................................................................................... 16 sotalol ............................................................................................... 14 SovaldiTM ..................................................................................... 31, 36 spinosad suspension 0.9% ................................................................ 16 Spiriva
® ................................................................................................ 7 spironolactone .................................................................................. 11 Sporanox® ......................................................................................... 22 Sprintec
® ........................................................................................... 33 SprixTM .............................................................................................. 29 Sprycel
® ................................................................................... 9, 36, 38
Sronyx® ............................................................................................. 33 SSKI ..................................................................................................... 6 Stadol NS® ......................................................................................... 29 Stalevo® ............................................................................................ 27 Starlix® .............................................................................................. 17 stavudine .......................................................................................... 23 Staxyn
® ............................................................................................. 24 Stendra® ............................................................................................ 24 Stimate® ............................................................................................ 21 Stivarga® ............................................................................................. 9 Strattera
® .......................................................................................... 26 Striant® ............................................................................................. 24 StribildTM .......................................................................................... 23 Striverdi® Respimat ............................................................................ 7 Stromectol® ...................................................................................... 23 Suboxone
® Filmtab ........................................................................... 27 Suboxone® SL ................................................................................... 27 Subsys® ............................................................................................. 28 Subutex® ........................................................................................... 27 Sucraid
® ...................................................................................... 31, 36 sucralfate .......................................................................................... 30 Sular® ................................................................................................ 11 sulfacetamide sodium 10% .............................................................. 19 sulfacetamide sodium lotion ...................................................... 15, 16 sulfacetamide sodium w/sulfer cream, liquid .................................. 15 sulfacetamide sodium w/sulfur emulsion/cleanser ......................... 15 sulfamethoxazole/ ............................................................................ 22 sulfamethoxazole/trimethoprim ...................................................... 22 sulfasalazine ..................................................................................... 31 sulfasalazine DR ................................................................................ 31 sulfinpyrazone .............................................................................. 8, 30 sulfisoxazole tabs ............................................................................. 22 sulindac ............................................................................................ 29 SumadanTM ....................................................................................... 15 sumatriptan inj ................................................................................. 29 sumatriptan nasal spray ................................................................... 29 sumatriptan tabs .............................................................................. 29 Sumavel
® .......................................................................................... 29 Sumaxin® .......................................................................................... 15 Suprax® tabs, susp ............................................................................ 22 Surmontil
® ........................................................................................ 25 Sustiva® ............................................................................................. 23 Sutent
®.......................................................................................... 9, 36 Sylatron
TM ..................................................................................... 9, 36 Symbicort
® .......................................................................................... 6 Symbyax
® .......................................................................................... 25
Symlin® ............................................................................................. 18 Synarel® ............................................................................................ 34 Synthroid® ......................................................................................... 21 Syprine
® ............................................................................................ 21
T
Tabloid® .............................................................................................. 9 Taclonex
® .......................................................................................... 16 tacrolimus .......................................................................................... 9 Tafinlar TM ........................................................................................... 9 TafinlarTM ......................................................................................... 36 Tambocor® ........................................................................................ 14 Tamiflu
® ............................................................................................ 23 tamoxifen ........................................................................................... 9 tamsulosin hcl sr ............................................................................... 24 Tanzeum® ................................................................................... 18, 38 Tapazole
® .......................................................................................... 21 Tarceva® ........................................................................................ 9, 36
Drug Formulary I (November 2014) 54
Targretin® Gel ................................................................................... 16 Tarka®................................................................................................ 12 Tasigna® .................................................................................. 9, 36, 38 Tasmar® ....................................................................................... 27, 38 Tavist® ................................................................................................. 5 Tazorac
® ............................................................................................ 16 Tecfidera® ................................................................................... 27, 36 Tegretol® ........................................................................................... 26 Tegretol® XR ...................................................................................... 26 Tekamlo® ..................................................................................... 12, 38 Tekturna
® .................................................................................... 12, 38 Tekturna® HCT ............................................................................. 12, 38 telmisartan ................................................................................. 10, 38 telmisartan/amlodipine .................................................................... 12 telmisartan/hctz ......................................................................... 12, 38 temazepam ....................................................................................... 24 Temodar
® ...................................................................................... 9, 36 Temovate® ........................................................................................ 15 temozolomide .............................................................................. 9, 36 Tenex
® ............................................................................................... 12 Tenoretic® ......................................................................................... 12 Tenormin® ......................................................................................... 10 Terazol
® ............................................................................................. 34 terazosin ........................................................................................... 24 terbinafine hcl .................................................................................. 22 Terbinex
® .......................................................................................... 22 terbutaline ........................................................................................ 34 terbutaline tabs .................................................................................. 6 Teslac® ................................................................................................ 9 Tessalon
® ............................................................................................ 6 Testim® .............................................................................................. 24 testosterone cypionate..................................................................... 24 testosterone gel 1% .......................................................................... 24 Testred
® ............................................................................................ 24 tetracycline caps, susp ...................................................................... 22 tetracycline capsules ........................................................................ 34 Teveten
® ..................................................................................... 10, 38 Teveten
® HCT .................................................................................... 38 Thalomid® ..................................................................................... 9, 36 theophylline ER ................................................................................... 6 theophylline SR ................................................................................... 6 thioguanine......................................................................................... 9 Thiola
TM ............................................................................................ 29 thioridazine ....................................................................................... 25 thiothixene ....................................................................................... 25 Thorazine
® ......................................................................................... 25
thyroid .............................................................................................. 21 tiagabine ........................................................................................... 26 Tiazac® ............................................................................................... 11 Ticlid
® .................................................................................................. 8 ticlopidine ........................................................................................... 8 Tigan® ................................................................................................ 31 Tikosyn® ............................................................................................ 14 Tilia FE
® ............................................................................................. 33 timolol .............................................................................................. 10 timolol maleate ................................................................................ 20 timolol ophthalmic gel ...................................................................... 20 Timolol® XE ........................................................................................ 20 Timoptic
® .......................................................................................... 20 Tindamax® ......................................................................................... 23 tinidazole tabs .................................................................................. 23 TirosintTM .......................................................................................... 21 tizanidine caps .................................................................................. 30 tizanidine tablets .............................................................................. 30 Tobi
® ................................................................................................. 23
Tobradex® ointment ......................................................................... 19 Tobradex® ST .................................................................................... 19 Tobradex® susp ................................................................................. 19 tobramycin ....................................................................................... 19 tobramycin neb ................................................................................ 23 Tofranil
® ............................................................................................ 25 Tofranil® PM ..................................................................................... 25 tolmetin sodium ............................................................................... 29 tolterodine er ..................................................................................... 7 tolterodine tartrate ...................................................................... 7, 38 Topamax
® ......................................................................................... 26 Topamax® Sprinkles .......................................................................... 26 Topicort® ........................................................................................... 15 topiramate ....................................................................................... 26 topiramate er ................................................................................... 26 topiramate sprinkle .......................................................................... 26 Toprol
® XL ......................................................................................... 10 torsemide ......................................................................................... 11 Toviaz® .......................................................................................... 7, 38 Tracleer
® ..................................................................................... 14, 36 Tradjenta® ......................................................................................... 17 tramadol ........................................................................................... 28 tramadol er ................................................................................ 28, 38 Trandate® .......................................................................................... 10 trandolapril ....................................................................................... 10 trandolapril/ ..................................................................................... 12 tranexamic acid ................................................................................ 34 Transderm‐Scop
® .............................................................................. 31 Tranxene® ......................................................................................... 24 tranylcypromine ............................................................................... 25 trazodone ......................................................................................... 25 Trecator
® .......................................................................................... 23 Trental
® ............................................................................................... 8 Tretin® X ............................................................................................ 15 tretinoin ....................................................................................... 9, 36 tretinoin microsphere gel ................................................................. 15 Trexall
® ............................................................................................. 29 Treximet
® .................................................................................... 29, 38 triamcinolone in orabase................................................................. 19 triamcinolone acetonide .............................................................. 5, 15 triamcinolone in orabase ................................................................. 34 triamterene/hctz .............................................................................. 11 Triaz
® Cloths 3% ................................................................................ 15 triazolam .......................................................................................... 24 Tribenzor
TM ................................................................................. 12, 38 trifluoperazine .................................................................................. 25 trifluridine ........................................................................................ 19 trigels ................................................................................................ 32 trihexyphenidyl ................................................................................ 27 Tri‐Legest FE® .................................................................................... 33 Trileptal® ........................................................................................... 26 trimethobenzamide .......................................................................... 31 trimethoprim tabs ............................................................................ 22 trimipramine .................................................................................... 25 Trinessa
® ........................................................................................... 33 Tri‐Norinyl® ....................................................................................... 33 Trioxin
® Otic susp .............................................................................. 18 Tri‐Previfem® .................................................................................... 33 Tri‐Sprintec
® ..................................................................................... 33 Trivicay® ............................................................................................ 23 tri‐vitamin w/fluoride ................................................................. 32, 34 Trivora® ............................................................................................. 33 Trizivir
® ............................................................................................. 23 TrokendiTM XR ................................................................................... 26 tropicamide ...................................................................................... 20
Drug Formulary I (November 2014) 55
trospium ............................................................................................. 7 trospium chloride er ......................................................................... 38 trospium er ......................................................................................... 7 Trusopt® ............................................................................................ 20 Truvada® ........................................................................................... 23 Tudorza
TM Pressair .............................................................................. 7 Tussionex® ........................................................................................... 5 Twinject® ............................................................................................. 6 Twynsta® ..................................................................................... 12, 38 Tykerb® ......................................................................................... 9, 36 Tylenol w/Codeine
® .......................................................................... 28 Tylox® ................................................................................................ 28 Tyzeka® ............................................................................................. 23
U
Uceris® .............................................................................................. 31 Ulesfia® ............................................................................................. 16 Uloric® ............................................................................................... 30 Ulroic® ............................................................................................... 38 Ultracet® ........................................................................................... 28 Ultram
® ER .................................................................................. 28, 38 Ultravate® ......................................................................................... 15 Ultresa
® ............................................................................................. 31 Uniphyl
® .............................................................................................. 6 Uniretic® ............................................................................................ 12 unithroid ........................................................................................... 21 Univasc
® ............................................................................................ 10 Uramaxin® ......................................................................................... 16 urea .................................................................................................. 16 Urecholine
® ......................................................................................... 8 Urispas®............................................................................................... 7 Urocit‐K
® ............................................................................................. 8 Uroxatral® ......................................................................................... 24 Urso® ................................................................................................. 31 Urso
® Forte ....................................................................................... 31 ursodiol ............................................................................................. 31
V
Vagifem® ........................................................................................... 32 valacyclovir ....................................................................................... 23 Valchlor
TM ................................................................................... 16, 36 Valcyte
® ............................................................................................. 23 Valium® ............................................................................................. 24 valproic acid ...................................................................................... 26 valsartan ........................................................................................... 10 valsartan/hctz ................................................................................... 12 Valtrex® ............................................................................................. 23 Vancocin
® capsules ........................................................................... 23 vancomycin caps ............................................................................... 23 VascepaTM ......................................................................................... 13 Vaseretic®.......................................................................................... 12 Vasotec
® ............................................................................................ 10 VecamylTM ................................................................................... 14, 36 Vectical® ............................................................................................ 16 Velivet® ............................................................................................. 33 Velphoro
® .......................................................................................... 32 VeltinTM ............................................................................................. 15 venlafaxine ....................................................................................... 25 venlafaxine er ................................................................................... 25 Ventolin HFA
® ..................................................................................... 6 Veramyst® ..................................................................................... 5, 38 verapamil .......................................................................................... 11 verapamil ER caps ............................................................................. 11
Verdeso® ........................................................................................... 15 Veregen® ........................................................................................... 16 Verelan® PM ..................................................................................... 11 Vesanoid® ..................................................................................... 9, 36 Vesicare®....................................................................................... 7, 38 Vexol
® ............................................................................................... 19 Vfend®............................................................................................... 22 V‐Go® .................................................................................................. 6 Viagra® .............................................................................................. 24 Vibramycin® susp .............................................................................. 22 Vicodin
® ............................................................................................ 28 Vicoprofen® ...................................................................................... 28 Victoza® ...................................................................................... 18, 38 Victrelis® ..................................................................................... 31, 36 Videx® ............................................................................................... 23 Videx
® EC .......................................................................................... 23 Vigamox® .......................................................................................... 19 ViibrydTM........................................................................................... 25 Vimovo® ............................................................................................ 29 Vimpat
® ............................................................................................ 26 Viokace® ............................................................................................ 31 Viracept® ........................................................................................... 23 Viramune
® ........................................................................................ 23 Viramune® XR ................................................................................... 23 Viread
® .............................................................................................. 23 Viroptic
®............................................................................................ 19 Vistaril® ......................................................................................... 5, 24 vitamin B12 inj.................................................................................. 32 Vivactil® ............................................................................................ 25 Vivelle‐Dot
® ...................................................................................... 32 Vogelxo® ........................................................................................... 24 Vol‐Care® .......................................................................................... 32 Voltaren
® gel ..................................................................................... 29 Voltaren® ophth soln ........................................................................ 20 Voltaren‐XR
® ..................................................................................... 29 voriconazole ..................................................................................... 22 Votrient
® ....................................................................................... 9, 36 Vusion
® ............................................................................................. 16 Vytone® ............................................................................................. 16 Vytorin® ...................................................................................... 14, 38 Vyvanse
® ........................................................................................... 26
W
warfarin sodium ................................................................................. 8 Welchol
® ..................................................................................... 13, 18 Wellbutrin SR® .................................................................................. 25 Wellbutrin XL® .................................................................................. 25 Wellbutrin
® ....................................................................................... 25 Westcort® ......................................................................................... 15
X
Xalatan® ............................................................................................ 20 Xalkori® ......................................................................................... 9, 36 Xanax® .............................................................................................. 24 Xanax® XR .......................................................................................... 24 Xarelto
® .............................................................................................. 8 Xeljanz® ....................................................................................... 29, 36 Xeloda
® ............................................................................................... 9 Xenazine
® .................................................................................... 27, 36 XereseTM ........................................................................................... 17 Xifaxan® ............................................................................................ 23 Xodol
® ............................................................................................... 28 Xopenex® ............................................................................................ 6
Drug Formulary I (November 2014) 56
Xtandi® .......................................................................................... 9, 36 Xulane® ............................................................................................. 33 Xylocaine Viscous® ............................................................................ 19 Xyrem® ........................................................................................ 27, 36 Xyzal® .................................................................................................. 5
Y
Yasmin® ............................................................................................. 33 Yaz® ................................................................................................... 33 Yodoxin® ............................................................................................ 23 yohimbine ......................................................................................... 24
Z
Zaditor® ............................................................................................. 20 zafirlukast ........................................................................................... 7 zaleplon ............................................................................................ 24 Zanaflex® ........................................................................................... 30 Zantac® capsules ............................................................................... 30 Zantac® tabs/syrup ............................................................................ 30 Zarontin
® ........................................................................................... 26 Zaroxolyn
® ......................................................................................... 11 Zavesca® ...................................................................................... 21, 36 Zebeta
® ............................................................................................. 10 ZecuityTM ........................................................................................... 29 Zegerid® ............................................................................................ 30 Zelapar
® ............................................................................................ 27 ZelborafTM ..................................................................................... 9, 36 Zelrix® ................................................................................................ 29 Zemplar
® ..................................................................................... 32, 38 Zenatane® ......................................................................................... 15 Zenchent® ......................................................................................... 33 Zenpep
® ............................................................................................ 31 Zenzedi® ............................................................................................ 26 Zeosa® ............................................................................................... 33 Zerit
® ................................................................................................. 23 Zestoretic® ........................................................................................ 12 Zestril
®............................................................................................... 10 Zetia® ................................................................................................ 13 Zetonna
® ............................................................................................. 6 Zetonna
TM ..................................................................................... 5, 38 Ziac
® .................................................................................................. 12 Ziagen
® soln ....................................................................................... 23
Ziagen® tabs ...................................................................................... 23
Ziana® ............................................................................................... 15 zidovudine ........................................................................................ 23 Zinotic® ............................................................................................. 18 Zinotic® ES ......................................................................................... 18 Zioptan
® ............................................................................................ 20 ziprasidone ....................................................................................... 25 Zipsor® .............................................................................................. 29 Zirgan® .............................................................................................. 19 Zithromax® ........................................................................................ 22 ZMax
® ............................................................................................... 22 Zocor® ............................................................................................... 13 Zofran® .............................................................................................. 31 Zofran® ODT ...................................................................................... 31 Zofran® susp ..................................................................................... 31 Zolinza
® ......................................................................................... 9, 36 zolmitriptan ..................................................................................... 29 Zoloft® ............................................................................................... 25 zolpidem er ................................................................................ 24, 38 zolpidem tartrate ............................................................................. 24 Zomig® .............................................................................................. 29 Zomig® Nasal Spray ........................................................................... 29 Zonegran
® ......................................................................................... 26 zonisamide ....................................................................................... 26 Zontivity
® ............................................................................................ 8 Zorbtiv
® ............................................................................................ 36 Zorbtive® ........................................................................................... 31 Zortress® ............................................................................................. 9 Zovia® ................................................................................................ 33 Zovirax
® ...................................................................................... 17, 23 Zovirax® ointment ............................................................................. 17 Zuplenz® ............................................................................................ 38 Zuplenz
TM ......................................................................................... 31 Zyban® .............................................................................................. 30 Zyclara
® ............................................................................................. 16 Zyflo
® CR ............................................................................................. 7 Zylet® ................................................................................................ 19 Zyloprim
® .......................................................................................... 30 Zymaxid® ........................................................................................... 19 Zypram® 2.35‐1% cream and kit ....................................................... 16 Zyprexa
® ........................................................................................... 25 Zytiga® ................................................................................................ 9 Zyvox
® ............................................................................................... 22
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