1. No category

University Care Advantage (HMO SNP)
2013 Formulary
(List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION
ABOUT THE DRUGS WE COVER IN THIS PLAN
Note to existing members: This formulary has changed since last year. Please review this
document to make sure that it still contains the drugs you take.
Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits,
formulary, pharmacy network, premium and/or copayments/coinsurance may change on
January 1, 2014.
University Care Advantage is a Coordinated Care Plan with a Medicare contract and a contract
with the Arizona Medicaid program.
This information is available for free in other languages. Please contact our Customer Care
Center at (877) 874-3930 for additional information. TTY users should call 711. Hours are 8
am to 8 pm, 7 days a week. Our Customer Care Center has free language interpreter services
available for non-English speakers.
Esta información está disponible gratis en otros idiomas. Favor de llamar a nuestro Centro de
Atención al Cliente al (877) 874-3930 para más información. Usuarios TTY deben llamar al
711. Nuestro horario de servicio es de 8 am a 8 pm, 7 dias a la semana. Nuestro Centro de
Atención al Cliente tiene servicios gratuitos de intérpretes para personas que no hablan inglés.
H7352_Comprehensive Formulary CMS Accepted
Formulary ID: 13042.000, Version: 12
University Care Advantage
Effective Date: July 1, 2013
Last Updated: June 24, 2013
i
What is the University Care
Advantage Formulary?
A formulary is a list of covered drugs selected
by University Care Advantage in consultation
with a team of health care providers, which
represents the prescription therapies believed
to be a necessary part of a quality treatment
program. University Care Advantage will
generally cover the drugs listed in our
formulary as long as the drug is medically
necessary, the prescription is filled at a
University Care Advantage network
pharmacy, and other plan rules are followed.
For more information on how to fill your
prescriptions, please review your Evidence of
Coverage.
Can the Formulary change?
Generally, if you are taking a drug on our
2012 formulary that was covered at the
beginning of the year, we will not discontinue
or reduce coverage of the drug during the
2013 coverage year except when a new, less
expensive generic drug becomes available or
when new adverse information about the
safety or effectiveness of a drug is released.
Other types of formulary changes, such as
removing a drug from our formulary, will not
affect members who are currently taking the
drug. It will remain available at the same
cost-sharing for those members taking it for
the remainder of the coverage year. We feel
it is important that you have continued access
for the remainder of the coverage year to the
formulary drugs that were available when you
chose our plan, except for cases in which you
can save additional money or we can ensure
your safety.
If we remove drugs from our formulary, or
add prior authorization, quantity limits and/or
step therapy restrictions on a drug or move a
drug to a higher cost-sharing tier, we must
notify affected members of the change at
least 60 days before the change becomes
effective, or at the time the member requests
University Care Advantage
a refill of the drug, at which time the member
will receive a 60-day supply of the drug. If
the Food and Drug Administration deems a
drug on our formulary to be unsafe or the
drug’s manufacturer removes the drug from
the market, we will immediately remove the
drug from our formulary and provide notice to
members who take the drug. The enclosed
formulary is current as of July 1, 2013. To
get updated information about the drugs
covered by University Care Advantage,
please visit our Website at
www.universitycareadvantage.com or call our
Customer Care Center at 1-877-874-3930, 8
am to 8 pm, 7 days a week. TTY users
should call 711.
In the event of a mid-year non-maintenance
formulary change, an errata sheet with the
changes will be placed in front of the
formulary located on our website at
www.universitycareadvantage.com. Errata
sheets are placed in front of our printed
formularies as well.
How do I use the Formulary?
There are two ways to find your drug within
the formulary:
Medical Condition
The formulary begins on page 1. The drugs in
this formulary are grouped into categories
depending on the type of medical conditions
that they are used to treat. For example,
drugs used to treat a heart condition are
listed under the category, Cardiovascular
Medications. If you know what your drug is
used for, look for the category name in the list
that begins on page 1. Then look under the
category name for your drug.
Alphabetical Listing
If you are not sure what category to look
under, you should look for your drug in the
Index that begins on page I-1. The Index
provides an alphabetical list of all of the drugs
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drug for that condition. For example, if
Drug A and Drug B both treat your
medical condition, University Care
Advantage may not cover Drug B unless
you try Drug A first. If Drug A does not
work for you, University Care Advantage
will then cover Drug B.
included in this document. Both brand name
drugs and generic drugs are listed in the
Index. Look in the Index and find your drug.
Next to your drug, you will see the page
number where you can find coverage
information. Turn to the page listed in the
Index and find the name of your drug in the
first column of the list.
What are generic drugs?
University Care Advantage covers both brand
name drugs and generic drugs. A generic
drug is approved by the FDA as having the
same active ingredient as the brand name
drug. Generally, generic drugs cost less than
brand name drugs.
Are there any restrictions on
my coverage?
Some covered drugs may have additional
requirements or limits on coverage. These
requirements and limits may include:
•
•
•
Prior Authorization: University Care
Advantage requires your physician to get
prior authorization for certain drugs. This
means that you will need to get approval
from University Care Advantage before
you fill your prescriptions. If you don’t get
approval, University Care Advantage may
not cover the drug.
Quantity Limits: For certain drugs,
University Care Advantage limits the
amount of the drug that University Care
Advantage will cover.
For example,
University Care Advantage provides 136
capsules per 34 days per prescription for
itraconazole. This may be in addition to a
standard one month or three month
supply.
Step Therapy: In some cases, University
Care Advantage requires you to first try
certain drugs to treat your medical
condition before we will cover another
University Care Advantage
You can find out if your drug has any
additional requirements or limits by looking in
the formulary that begins on page 1. You can
also get more information about the
restrictions applied to specific covered drugs
by visiting our Website at
www.universitycareadvantage.com.
You can ask University Care Advantage to
make an exception to these restrictions or
limits. See the section, “How do I request an
exception to the University Care Advantage’s
formulary?” on the next page for information
about how to request an exception.
What are over-the counter
(OTC) drugs?
OTC drugs are non-prescription drugs that
are not normally covered by a Medicare
Prescription Drug Plan.
What if my drug is not on the
Formulary?
If your drug is not included in this formulary,
you should first contact our Customer Care
Center and confirm that your drug is not
covered. If you learn that University Care
Advantage does not cover your drug, you
have two options:
•
You can ask our Customer Care Center
for a list of similar drugs that are covered
by University Care Advantage. When you
receive the list, show it to your doctor and
ask him or her to prescribe a similar drug
that is covered by University Care
Advantage.
iii
•
You can ask University Care Advantage
to make an exception and cover your
drug. See below for information about
how to request an exception.
How do I request an exception
to the University Care
Advantage Formulary?
You can ask University Care Advantage to
make an exception to our coverage rules.
There are several types of exceptions that
you can ask us to make.
•
You can ask us to cover your drug even if
it is not on our formulary.
•
You can ask us to waive coverage
restrictions or limits on your drug. For
example, for certain drugs, University
Care Advantage limit the amount of the
drug that we will cover. If your drug has a
quantity limit, you can ask us to waive the
limit and cover more.
•
You can ask us to provide a higher level
of coverage for your drug. If your drug is
contained in our non-preferred/highest tier
subject to the tiering exceptions process
tier, you can ask us to cover it at the costsharing amount that applies to drugs in
the preferred/lowest tier subject to the
tiering exceptions process tier instead.
This would lower the amount you must
pay for your drug. Please note, if we
grant your request to cover a drug that is
not on our formulary, you may not ask us
to provide a higher level of coverage for
the drug.
Generally, University Care Advantage will
only approve your request for an exception if
the alternative drugs included on the plan’s
formulary, the lower-tiered drug or additional
utilization restrictions would not be as
effective in treating your condition and/or
University Care Advantage
would cause you to have adverse medical
effects.
You should contact us to ask us for an initial
coverage decision for a formulary, tiering or
utilization restriction exception. When you
are requesting a formulary, tiering or
utilization restriction exception you should
submit a statement from your physician
supporting your request. Generally, we must
make our decision within 72 hours of getting
your prescriber’s or prescribing physician’s
supporting statement. You can request an
expedited (fast) exception if you or your
doctor believe that your health could be
seriously harmed by waiting up to 72 hours
for a decision. If your request to expedite is
granted, we must give you a decision no later
than 24 hours after we get your prescriber’s
or prescribing physician’s supporting
statement.
What do I do before I can talk to
my doctor about changing my
drugs or requesting an
exception?
As a new or continuing member in our plan
you may be taking drugs that are not on our
formulary. Or, you may be taking a drug that
is on our formulary but your ability to get it is
limited. For example, you may need a prior
authorization from us before you can fill your
prescription. You should talk to your doctor
to decide if you should switch to an
appropriate drug that we cover or request a
formulary exception so that we will cover the
drug you take. While you talk to your doctor
to determine the right course of action for
you, we may cover your drug in certain cases
during the first 90 days you are a member of
our plan.
For each of your drugs that is not on our
formulary or if your ability to get your drugs is
limited, we will cover a temporary 30-day
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supply (unless you have a prescription written
for fewer days) when you go to a network
pharmacy. After your first 30-day supply, we
will not pay for these drugs, even if you have
been a member of the plan less than 90
days.
If you are a resident of a long-term care
facility, we will allow you to refill your
prescription until we have provided you with a
91-day transition supply, consistent with the
dispensing increment, (unless you have a
prescription written for fewer days). We will
cover more than one refill of these drugs for
the first 90 days you are a member of our
plan. If you need a drug that is not on our
formulary or if your ability to get your drugs is
limited, but you are past the first 90 days of
membership in our plan, we will cover a 31day emergency supply of that drug (unless
you have a prescription for fewer days) while
you pursue a formulary exception.
For more information
For more detailed information about your
University Care Advantage prescription drug
coverage, please review your Evidence of
Coverage and other plan materials.
If you have questions about University Care
Advantage, please call our Customer Care
Center at 1-877-874-3930, 8 am to 8 pm, 7
days a week. TTY users should call 711. Or
visit www.universitycareadvantage.com.
If you have general questions about Medicare
prescription drug coverage, please call
Medicare at 1-800-MEDICARE (1-800-6334227) 24 hours a day/7 days a week. TTY
users should call 1-877-486-2048. Or, visit
www.medicare.gov.
drugs covered by University Care Advantage.
If you have trouble finding your drug in the
list, turn to the Index that begins on page I-1.
The first column of the chart lists the drug
name. Brand name drugs are capitalized
(e.g., LIDODERM) and generic drugs are
listed in lower-case italics (e.g., lidocainprilocaine).
The information in the Requirements/Limits
column tells you if University Care Advantage
has any special requirements for coverage of
your drug.
This prescription may be available only at
certain pharmacies. For more information
consult your Pharmacy Directory or call our
Customer Care Center at 1-877-874-3930, 7
days a week. TTY users should call 711.
The symbol [LA] in the Requirements/Limits
column indicates that the drug has been
noted as being restricted to certain
pharmacies by the Food and Drug
Administration. These drugs can only be
obtained at specialty designated pharmacies
able to appropriately handle the drugs.
The symbol [PA] in the Requirements/Limits
column indicates that prior authorization may
apply.
The symbol [QL] in the Requirements/Limits
column indicates that quantities dispensed
may be limited.
The symbol [ST] in the Requirements/Limits
column indicates that step therapy may
apply.
University Care Advantage’s
Formulary
The formulary that begins on page 1 provides
coverage information about some of the
University Care Advantage
v
STRENGTH AND DOSAGE FORM ABBREVIATIONS
ABBREVIATION
DESCRIPTION
adh. patch
adhesive patch
aer br act
aerosol, breath activated
aer pow
aerosol, powder
aer pow ba
aerosol powder, breath activated
aer refill
aerosol refill
aer w/adap
aerosol with adapter
ampul
ampule
blkbaginj
bulk bag injection
cap dr mp
capsule, delayed release multiphasic
cap ds pk
capsule, dose pack
cap er 12h
capsule, 12 hour extended release
cap er 24h
capsule, 24 hour extended release
cap er deg
capsule, extended release degradable
cap er pel
capsule, extended release pellets
cap mphase
capsule, multiphasic
cap.sa 24h
capsule, 24 hour sustained action
cap.sr 12h
capsule, 12 hour sustained release
cap.sr 24h
capsule, 24 hour sustained release
cap24h pct
capsule, 24 hour controlled-onset pellets
cap24h pel
capsule, 24 hour sustained release pellets
cap sprink
capsule, sprinkle
cap sr pel
capsule sustained release pellets
cap w/dev
capsule with device
capsule dr
capsule, delayed release
capsule er
capsule, extended release
capsule sa
capsule, sustained action
cmb cappad
combination: capsule, pad
cmb ont fm
combination: ointment, foam
cmb ont lt
combination: ointment, lotion
cmb tabpad
combination: tablet, pad
combo. pkg
combination package
cpmp 12hr
capsule, 12 hour multiphasic
cpmp 24hr
capsule, 24 hour multiphasic
cpmp 30-70
capsule, multiphasic, 30%-70%
cpmp 50-50
capsule, multiphasic, 50%-50%
cream(g), cream(gm)
cream (grams)
cream(ml)
cream (milliliters)
cream/appl
cream with applicator
cream, er (g)
cream, extended release (grams)
cream pack
cream, package
dehp fr bg
di(2-ethylhexyl)phthalate free bag
dis needle
disposable needle
disk w/dev
disk with inhalation device
disp syrin
disposable syringe
drops susp
drops, suspension
University Care Advantage
vi
ABBREVIATION
drps hpvis
emul adhes
emul packt
emulsn(g)
foam/appl.
froz.piggy
g
gel/pf app
gel (gm)
gel (ml)
gel md pmp
gel w/appl
gel w/pump
gran pack
hfa aer ad
infus. btl
insuln pen
ip soln
irrig soln
iv soln.
jel
jelly/app
jel/pf app
kit cl&crm
kt crm le
kt lotn ce
kt oint le
lotion, er
lozenge hd
m.ht patch
ma buc tab
mcg
med. pad
med. swab
med. tape
mg
ml
muc er 12h
ndl fr inj
nl fm susp
oint. (g), oint.(gm)
oral conc
oral susp
paste (g)
patch td24
patch td72
University Care Advantage
DESCRIPTION
drops, hyperviscous
emulsion adhesive
emulsion packet
emulsion (grams)
foam with applicator
frozen piggyback
gram
gel with prefilled applicator
gel (grams)
gel (milliliters)
gel in metered dose pump
gel with applicator
gel with pump
granule pack
hfa aerosol adapter
infusion bottle
insulin pen
intraperitoneal solution
irrigating solution
intravenous solution
jelly
jelly with applicator
jelly with pre-filled applicator
kit: cleasner and cream
kit: cream, lotion emollient
kit: lotion, cream emollient
kit: ointment, lotion emollient
lotion, extended release
lozenge handle
medicated heated patch
mucoadhesive buccal tablet
microgram
medicated pad
medicated swab
medicated tape
milligram
milliliter
mucoadhesive system, 12 hour extended release
needle for injection
nail film suspension
ointment (grams)
oral concentrate
oral suspension
paste (grams)
patch, 24 hour transdermal
patch, 72 hour transdermal
vii
ABBREVIATION
patch tdsw
patch tdwk
pca syring
pca vial
pellet(ea)
pen ij kit
pen injctr
pggybk btl
plast. bag
powd pack
sol md pmp
sol w/appl
sol/pf app
sol-gel
soln recon
soln(gram)
spray susp
spray/pump
stick(ea)
supp.rect
supp.vag
suppos.
sus er 24h
sus er rec
sus mc rec
suspdr pkt
susp recon
syringekit
tab chew
tab er 12h
tab er 24h
tab er prt
tab er seq
tab disper
tab ds pk
tab er 24
tab mphase
tab part
tab rap dr
tab rapdis
tab subl
tab.sr 12h
tab.sr 24h
tabergr24hr
tablet dr
tablet, er
University Care Advantage
DESCRIPTION
patch, biweekly transdermal
patch, weekly transdermal
patient-controlled analgesic syringe
patient-controlled analgesic vial
pellet (each)
pen injector kit
pen injector
piggyback bottle
plastic bag
powder pack
solution with multi-dose pump
solution with applicator
solution with pre-filled applicator
solution, gel-forming
solution, reconstituted
solution (grams)
spray, suspension
spray with pump
stick (each)
suppository, rectal
suppository, vaginal
suppository
suspension, 24 hour extended release
suspension, extended release reconstituted
suspension, microcapsule reconstituted
suspension, delayed release packet
suspension, reconstituted
syringe kit
tablet, chewable
tablet, 12 hour extended release
tablet, 24 hour extended release
tablet, extended release particles
tablet, extended release sequels
tablet, dispersable
tablet, dose pack
tablet, 24 hour extended release
tablet, multiphasic
tablet, particles
tablet, rapid disintegrating delayed release
tablet, rapid disintegrating
tablet, sublingual
tablet, 12 hour sustained release
tablet, 24 hour sustained release
tablet, 24 hour gradual extended release
tablet, delayed release
tablet, extended release
viii
ABBREVIATION
tablet eff
tablet sa
tablet sol
tb er dspk
tb mp dspk
tb rd dspk
tbdspk 3mo
tbmp 12hr
tbmp 24hr
u
vag ring
University Care Advantage
DESCRIPTION
tablet, effervescent
tablet, sustained action
tablet, soluble
tablet, extended release dosepack
tablet, multiphasic dosepack
tablet, rapid disintegrating dosepack
tablet, 3-month dosepack
tablet, 12 hour multiphasic
tablet, 24 hour multiphasic
unit
vaginal ring
ix
University Care Advantage (HMO SNP)
Formulario 2013
(Lista de Medicamentos Bajo Cobertura)
FAVOR DE LEER: ESTE DOCUMENTO CONTIENE INFORMACIÓN
SOBRE LOS MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN
Aviso para miembros actuales: Este formulario ha cambiado desde el año pasado. Favor
de revisar este documento para asegurarse de que aún contiene los medicamentos que toma.
Los beneficiarios deben usar las farmacias de la red para tener acceso a los beneficios de
medicamentos recetados. Los beneficios, el formulario, la red de farmacia, la prima, y/o
copagos/coseguros pueden cambiar el 1 de enero de 2014.
University Care Advantage es un Plan de Atención Coordinada con un contrato de Medicare y
un contrato con el programa de Arizona Medicaid.
This information is available for free in other languages. Please contact our Customer Care
Center at (877) 874-3930 for additional information. TTY users should call 711. Hours are 8
am to 8 pm, 7 days a week. Our Customer Care Center has free language interpreter services
available for non-English speakers.
Esta información está disponible gratis en otros idiomas. Favor de llamar a nuestro Centro de
Atención al Cliente al (877) 874-3930 para más información. Usuarios TTY deben llamar al
711. Nuestro horario de servicio es de 8 am a 8 pm, 7 dias a la semana. Nuestro Centro de
Atención al Cliente tiene servicios gratuitos de intérpretes para personas que no hablan inglés.
H7352_Comprehensive Formulary CMS Accepted
University Care Advantage
x
¿Qué es el Formulario de
University Care Advantage?
Un formulario es una lista de medicamentos
bajo cobertura seleccionados por University
Care Advantage bajo consulta de un equipo
de proveedores de cuidados de la salud, lo
cual representa terapias bajo receta médica
las cuales se cree son una parte necesaria
de un programa de tratamientos de calidad.
University Care Advantage por lo general
cubre los medicamentos en lista en nuestro
formulario siempre y cuando el medicamento
sea médicamente necesario, la receta
médica sea surtida en una farmacia de la red
de University Care Advantage, y se sigan
otros reglamentos del plan. Para más
información de cómo surtir sus recetas
médicas, favor de revisar su Evidencia de
Cobertura.
¿Puede cambiar el Formulario?
Generalmente, si usted está tomando un
medicamento del formulario 2012 que estaba
bajo cobertura al principio del año, no vamos
a descontinuar o reducir la cobertura de ese
medicamento durante la cobertura del 2013
excepto cuando un medicamento nuevo y de
menos costo esté disponible o cuando nueva
información adversa sobre la seguridad o
efectividad de ese medicamento se informe.
Otros tipos de cambios al formulario, tal
como quitar un medicamento del formulario,
no van a afectar a miembros que están
actualmente tomando el medicamento.
Permanecerá disponible al mismo costo
compartido para esos miembros que lo están
tomando el resto del año de cobertura.
Sentimos que es importante que usted tenga
acceso continuo por el resto del año de
cobertura a los medicamentos del formulario
que estaban disponibles cuando usted
seleccionó nuestro plan, excepto en casos en
donde usted puede ahorrarse dinero o
nosotros podemos asegurarle su seguridad.
University Care Advantage
Sin nosotros quitamos medicamentos de
nuestro formulario, o agregamos un requisito
de autorización previa, límites en cantidad
y/o restricciones de terapia por etapas en un
medicamento o cambiamos un medicamento
a una etapa de costos compartidos más
altos, debemos notificar a los miembros que
serán afectados por el cambio por lo menos
60 días antes de que el cambio entre en
vigor, o al tiempo en que el miembro pida un
relleno del medicamento, por lo cual se le
dará un suministro de 60 días del
medicamento. Si la Administración del
Medicamento y Alimentos (FDA, por sus
siglas en inglés) determinan que un
medicamento en nuestro formulario no es
seguro o el manufacturador del medicamento
lo retira del mercado, nosotros vamos a
quitar el medicamento de inmediato del
formulario y a dar un aviso a miembros que
estén tomando el medicamento. El formulario
incluido está al corriente a partir del 1 de
mayo de 2013. Para obtener información
actualizada sobre los medicamentos bajo
cobertura por University Care Advantage,
favor de ir a la página Web en
www.universitycareadvantage.com o llame a
al Centro de Atención al Cliente al 1-877874-3930, 8 am a 8 pm, 7 días a la semana.
Usuarios TTY deben llamar al 711.
Si el formulario presenta un cambio durante
el año, una fe de errata con todos los
cambios será puesta al frente del formulario
en nuestra página Web en
www.universitycareadvantage.com. Una fe
de errata también será puesta al frente de los
formularios impresos.
¿Cómo uso el Formulario?
Hay dos métodos de cómo encontrar su
medicamento dentro del formulario:
Condición Médica
El formulario comienza en la página 1. Los
medicamentos en este formulario están
agrupados por categoría dependiendo en el
xi
tipo de condición médica en que se usan. Por
ejemplo, medicamentos usados para tratar
un condición del corazón están en lista bajo
la categoría, Medicamentos Cardiovascular.
Si usted sabe que uso tiene su medicamento,
búsquelo el nombre de la categoría en la lista
que comienza en la página 1. Después
busque bajo el nombre de la categoría por su
medicamento.
Lista por Alfabeto
Si usted no está seguro en que categoría
buscar, usted debe buscar su medicamento
en el Índice que comienza en la página I-1.
El Índice le ofrece una lista por alfabeto de
todos los medicamentos incluidos en este
documento. Ambos tipos de medicamentos,
los de marca y los genéricos, están en lista
en el Índice. Busque en el Índice para
encontrar su medicamento. En seguida de su
medicamento, usted verá el número de la
página en donde puede encontrar
información sobre cobertura. Vaya a la
página anotada en el Índice y encuentre el
nombre de su medicamento en la primera
columna de la lista.
¿Qué son los medicamentos
genéricos?
University Care Advantage cubre ambos
tipos de medicamentos, los de marca y los
genéricos. Un medicamento genérico está
aprobado por la Administración de
Medicamentos y Alimentos (FDA, por sus
siglas en inglés) de tener los mismos
ingredientes activos que un medicamento de
marca. Por lo general, los medicamentos
genéricos cuestan menos que los
medicamentos de marca.
•
Autorización Previa: University Care
Advantage requiere que o su médico
obtengan autorización previa para ciertos
medicamentos. Esto quiere decir que
usted va a necesitar obtener aprobación
de parte de University Care Advantage
antes de surtir sus medicamentos. Si
usted no obtiene aprobación, University
Care Advantage podría no cubrir el
medicamento.
•
Límites de Cantidades: Para ciertos
medicamentos,
University
Care
Advantage limita la cantidad del
medicamento
que
University
Care
Advantage va a cubrir. Por ejemplo,
University Care Advantage ofrece 136
cápsulas cada 34 días por receta de
itraconazole. Esto puede ser además de
un suministro estándar de un mes o tres
meses.
•
Terapia por Etapa: En algunos casos,
Universtiy Care Advantage requiere que
usted primero intente usar ciertos tipos de
medicamentos para tratar su condición
médica. Por ejemplo, si ambos, el
Medicamento A y el Medicamento B, se
usan para tratar su condición médica,
University Care Advantage puede no
cubrir el Medicamento B a menos que
usted pruebe el Medicamento A primero.
Si el Medicamento A no funciona para
usted,
University
Care
Advantage
entonces cubrirá el Medicamento B.
¿Hay alguna restricción en mi
cobertura?
Usted puede darse cuenta si su
medicamento tiene cualquier requisito o
límite adicional al ver el formulario que
empieza en la página 1. Usted también
puede obtener más información sobre las
restricciones que aplican a medicamentos
bajo cobertura específica al ir a la página
Web en www.universitycareadvantage.com.
Algunos medicamentos bajo cobertura
pueden tener requisitos adicionales o límites
en cobertura. Estos requisitos y límites
pueden incluir:
Usted puede pedirle a University Care
Advantage que haga una excepción a estas
restricciones o límites. Vea la sección
University Care Advantage
xii
“¿Cómo pido una excepción al formulario de
University Care Advantage?” en la página ix
para obtener información sobre como pedir
una excepción.
¿Qué son los medicamentos
sin receta médica?
Los medicamentos sin receta médica (OTC,
por sus siglas en inglés) son medicamentos
si receta médica que normalmento no están
bajo cobertura por un Plan de Medicamentos
Recetados de Medicare.
excepciones que nos puede pedir que
hagamos.
•
Usted puede pedirnos que cubramos su
medicamento aún si no está en nuestro
formulario.
•
Usted puede pedirnos que hagamos una
excepción al las restricciones o límites en
su medicamento. Por ejemplo, para
ciertos medicamentos, University Care
Advantage limita la cantidad del
medicamento que cubrimos. Si su
medicamento tiene límite en cantidad,
puede pedirnos una excepción sobre el
límite y que cubramos más.
•
Usted puede pedirnos que le demos un
nivel más alto de cobertura en su
medicamento. Si su medicamento está en
nuestra etapa más alta/sin preferencia
sujeta a la etapa de procesos de
excepciones, usted puede pedirnos que
en vez lo cubramos a la cantidad de
costos compartidos que aplica a los
medicamentos en la etapa más
baja/preferencial sujeta a la etapa de
procesos de excepciones. Esto bajaría la
cantidad que usted debe pagar por su
medicamento. Favor de tomar en cuenta
que si nosotros le concedemos su
petición de cubrir su medicamento que no
está en nuestro formulario, usted no
puede pedirnos un nivel de cobertura más
alta por su medicamento.
¿Qué si mi medicamento no
está en el Formulario?
Si su medicamento no está incluido en la lista
de medicamentos bajo cobertura, debe
primero contactar al Centro de Atención al
Cliente y preguntar si su medicamento está
bajo cobertura. Si se entera que University
Care Advantage no cubre su medicamento,
usted tiene dos opciones:
•
Le puede pedir al Centro de Atención al
Cliente una lista de medicamentos
similares que si están bajo cobertura por
University Care Advantage. Cuando
reciba la lista, enséñesela a su doctor y
pídale que le recete un medicamento
similar que esté bajo cobertura por
University Care Advantage.
•
Le puede pedir a University Care
Advantage que haga una excepción y
cubra su medicamento. Vea abajo para
obtener información de cómo pedir una
excepción.
¿Cómo pido una excepción
sobre el formulario de
University Care Advantage?
Usted le puede pedir a University Care
Advantage que haga una excepción a las
reglas de cobertura. Hay varios tipos de
University Care Advantage
En general, University Care Advantage solo
aprobará su petición por una excepción si el
medicamento alternativo incluido en el
formulario del plan, el medicamento en la
etapa más baja o las restricciones de
utilización adicional no sería efectivo en tratar
su condición y/o le causarían a tener efectos
médicos adversos.
Usted debe contactarnos para pedirnos una
decisión de cobertura inicial por una
excepción al formulario, las etapas de
xiii
medicamentos, o restricción de uso. Cuando
usted está solicitando una excepción en el
formulario, etapas de medicamentos, o
restricción de uso, usted debe presentar una
declaración de quien le receto o de su
médico en apoyo a su petición. En general,
nosotros debemos tomar una decisión dentro
de 72 horas de haber recibido la declaración
de apoyo de su médico quien le ha recetado.
Usted puede solicitar una excepción rápida si
usted o su doctor creen que su salud pudiera
ser dañada seriamente al tener que esperar
hasta 72 horas por una decisión. Si su
petición de ser acelerada es concedida,
nosotros debemos darle una decisión no más
de 24 horas después de recibir la declaración
de apoyo de su médico quien le ha recetado.
¿Qué debo hacer antes de
hablar con mi doctor sobre
cambiar mis medicamentos o
pedir una excepción?
Como miembro nuevo o continuo en nuestro
plan, usted puede estar tomando
medicamentos que no están en nuestro
formulario. O, usted puede estar tomando un
medicamento que si está en nuestro
formulario pero su capacidad de obtenerlo es
limitado. Por ejemplo, usted puede necesitar
de una autorización previa de nosotros antes
de surtir su receta médica. Usted deba hablar
con su doctor para decidir si usted debe
cambiar a un medicamento más apropiado
que nosotros cubrimos o pedir una excepción
al formulario para que nosotros podamos
cubrir el medicamento que toma. Mientras
habla con su doctor para determinar el mejor
curso a seguir para usted, nosotros
podríamos cubrir su medicamento en ciertos
casos durante los primeros 90 días que usted
es miembro de nuestro plan.
Por cada uno de sus medicamento que no
esté en nuestro formulario o si su capacidad
de obtener los medicamentos es limitado,
nosotros vamos a cubrir un suministro
University Care Advantage
temporal de 30 días (a menos que su receta
médica sea por menos días) cuando usted
vaya a una farmacia de la red. Después de
su primer suministro de 30 días, nosotros no
vamos a pagar por estos medicamentos, aún
si usted ha sido miembro del plan menos de
90 días.
Si usted es residente de un centro de
cuidados a largo plazo, nosotros vamos a
permitirle un relleno de receta médica hasta
que le hayamos proveído un suministro de
transición de 91 días, consistente con un
incremento dispensario, (a menos que usted
tenga una receta médica por menos días).
Vamos a cubrir más de un relleno de estos
medicamentos por los primeros 90 días que
usted sea miembro de nuestro plan. Si usted
necesita un medicamento que no está en
nuestro formulario o si su capacidad de
obtener su medicamentos es limitada, pero
usted ya se pasó los primeros 90 días de
membresía con nuestro plan, nosotros
vamos a cubrir un suministro de emergencia
de 31 días por ese medicamento (a menos
que su receta médica sea por menos días
mientras usted solicita la excepción al
formulario.
Para más información
Para información con más detalle sobre su
cobertura de medicamentos de University
Care Advantage, favor de repasar su
Evidencia de Cobertura y otros documentos
sobre el plan.
Si tiene preguntas sobre University Care
Advantage, usted puede llamar a nuestro
Centro de Atención al Cliente al 1-877-8743930, 8 am a 8 pm, 7 días a la semana.
Usuarios TTY deben llamar al 711. También
pueden ir a la página Web en
www.universitycareadvantage.com.
Si tiene preguntas generales sobre la
cobertura de medicamentos recetas de
Medicare, favor de llamar a Medicare al 1-
xiv
800-MEDICARE (1-800-633-4227) 24 horas
al día/7 días a la semana. Usuarios TTY
deben llamar al 1-877-486-2048. También
puede ir a la página Web www.medicare.gov.
Formulario de University Care
Advantage
El formulario corto a continuación le ofrece
información sobre la cobertura de algunos de
los medicamentos bajo cobertura por
University Care Advantage. Si usted tiene
problemas para encontrar un medicamento
en la lista, vaya al Índice que comienza en la
página I-1.
El símbolo [PA] en la columna de
Requisitos/Límites indica que puede se
puede requerir de una autorización previa.
El símbolo [QL] en la columna de
Requisitos/Límites indica que las cantidades
administradas pueden tener límites.
El símbolo [ST] en la columna de
Requisitos/Límites indica que terapia por
etapas puede aplicar.
La primera columna en esta gráfica pone en
lista el nombre de medicamento. Los
medicamentos de marca están con
mayúsculas (e.g., LIDODERM) y los
medicamentos genéricos están en lista en
minúsculas y letra itálica (e.g., lidocaineprilocaine).
La información en la columna de
Requisitos/Límites le dice si University Care
Advantage tiene algún requisito especial para
cubrir su medicamento.
Este medicamento recetado puede estar
disponible únicamente en ciertas farmacias.
Para más información consulte su Directiorio
de Farmacias o llame al Centro de Atención
al Cliente al 1-877-874-3930, 7 días a la
semana. Usuarios TTY deben llamar al 711.
El símbolo [LA] en la columna de
Requisitos/Límites indica que el
medicamento está anotado como restringido
de ciertas farmacias por la Administración de
Medicamentos y Alimentos (FDA, por sus
siglas en inglés). Estos medicamentos
únicamente pueden ser obtenidos
específicamente en farmacias designadas a
poder manejar estos medicamentos.
University Care Advantage
xv
FUERZA DE DOSIS FORMA DE ABREVIACIÓNES
ABREVIACIÓN
adh. patch
aer br act
aer pow
aer pow ba
aer refill
aer w/adap
ampul
blkbaginj
cap dr mp
cap ds pk
cap er 12h
cap er 24h
cap er deg
cap er pel
cap mphase
cap .sa 24h
cap.sr 12h
cap.sr 24h
cap24h pct
cap24h pel
cap sprink
cap sr pel
cap w/dev
capsule dr
capsule er
capsule sa
cmb cappad
cmb ont fm
cmb ont lt
cmb tabpad
combo. pkg
cpmp 12hr
cpmp 24hr
cpmp 30-70
cpmp 50-50
cream (g), cream(gm)
cream (ml)
cream/appl
cream, er (g)
cream pack
dehp fr bg
dis needle
University Care Advantage
DESCRIPCIÓN
remiendo adhesivo
aerosol, aliento activado
polvo de aerosol
polvo de aerosol, aliento activado
recambio de aerosol
aerosol con adaptador
contenedor de plástico (ampolla)
inyección en bulto de empaque
cápsula, liberación retrasada, multifásico
cápsula, paquete de dosis
cápsula, liberación extendida 12 horas
cápsula, liberación extendida 24 horas
cápsula, liberación extendida degradada
cápsula, bolitas de liberación extendida
cápsula, multifásico
cápsula, acción sostenida 24 horas
cápsula, liberación sostenida 12 horas
cápsula, liberación sostenida 24 horas
cápsula, bolitas de control-inicio 24 horas
cápsula, bolitas de sostuvo de liberación 24 horas
cápsula, rociador
cápsula de bolita liberación sostenida
cápsula con dispositivo
cápsula, liberación retrasada
cápsula, liberación extendida
cápsula, acción sostenida
combinación: cápsula, almohadilla
combinación: ungüento,espuma
combinación: ungüento, loción
combinación: tableta, almohadilla
paquete de combinación
cápsula, multifásico, 12 horas
cápsula, multifásico, 24 horas
cápsula, multifásico, 30%-70%
cápsula, multifásico , 50%-50%
crema (gramos)
crema (mililitros)
crema con aplicador
Crema, liberación extendida (gramos)
crema, paquete
di(2-ethylhexyl)phthalate bolsa gratis
aguja, desechable
xvi
ABREVIACIÓN
disk w/dev
disp syrin
drops susp
drps hpvis
emul adhes
emul packt
emulsn (g)
foam/appl.
froz.piggy
g
gel/pf app
gel (gm)
gel (ml)
gel md pmp
gel w/appl
gel w/pump
gran pack
hfa aer ad
infus. btl
insuln pen
ip soln
irrig soln
iv soln.
jel
jelly/app
jel/pf app
kit cl&crm
kt crm le
kt lotn ce
kt oint le
lotion, er
lozenge hd
m.ht patch
ma buc tab
mcg
med. pad
med. swab
med. tape
mg
ml
muc er 12h
ndl fr inj
nl fm susp
oint. (g), oint (gm)
University Care Advantage
DESCRIPCIÓN
disco con dispositivo de inhalación
jeringuilla desechable
gotas, suspensión
gotas, hiperviscoso
emulsión adhesivo
paquete de emulsión
emulsión (gramos)
espuma con el aplicador
piggyback congelado
gramo
gel con aplicador prelleno
gel (gramos)
gel (mililitros)
gel en bomba de dosis medida
gel con aplicador
gel con bomba
paquete de gránulo
hfa adaptador de aerosol
botella de infusión
pluma de insulina
solución, intraperitoneal
solución, irrigando
solución intravenosa
jalea
gel con aplicador
gel con aplicador prelleno
equipo: limpieza y crema
equipo: crema, loción emoliente
equipo: loción, crema emoliente
equipo: ungüento, loción emoliente
loción, liberación extendida
mango de tableta
remiendo de calor medicinal
mucoadhesivo tableta buccal
microgramo
almohadilla medicinal
esponja medicinal
cinta medicinal
miligramo
mililitro
sistema de mucoadhesivo, liberación extendida 12 horas
aguja para inyección
suspension de rollo de uña
pomada (gramos)
xvii
ABREVIACIÓN
oral conc.
oral susp
paste (g)
patch td24
patch td72
patch tdsw
patch tdwk
pca syring
pca vial
pellet(ea)
pen ij kit
pen injctr
pggybk btl
plast. bag
powd pack
sol md pmp
sol w/appl
sol/pf app
sol-gel
soln recon
soln (gram)
spray susp
spray/pump
stick (ea)
supp.rect
supp.vag
suppos.
sus er 24h
sus er rec
sus mc rec
suspdr pkt
susp recon
syringekit
tab chew
tab er 12h
tab er 24h
tab er prt
tab er seq
tab disper
tab ds pk
tab er 24
tab mphase
tab part
tab rap dr
University Care Advantage
DESCRIPCIÓN
concentrado, oral
suspensión oral
pasta (gramos)
remiendo, transdermal 24 horas
remiendo, transdermal 72 horas
remiendo, transdermal cada dos semanas
remiendo, transdermal semanario
jeringuilla analgésica control de paciente
frasco analgésico control de paciente
bolita (cada uno)
equipo de inyector de pluma
inyector de pluma
botella intravenosa piggyback
bolsa de plastico
paquete en polvo
solución con bomba multi-dosis
Solución con aplicador
solución con aplicador prelleno
solución que forma gel
solución, reconstituida, oral
solución (gramos)
spray, suspensión
spray con bomba
palo (cada uno)
supositorio, rectal
supositorio, vaginal
supositorio
suspension, liberación extendida 24horas
suspensión, liberación extendida reconstituida
suspensión, microcápsula reconstituida
suspensión, paquete de liberación retrasada
suspensión, reconstituida
equipo de jeringuilla
tableta, masticable
tableta, liberación extendida 12horas
tableta, liberación extendida 24horas
tableta, liberación extendida de particulas
tableta, secuelas de liberación extendida
tableta, dispersión
tableta, paquete de dosis
tableta, liberación extendida 24 horas
tableta, multifásico
partículas de tableta
tableta, desintegración rápida retrasó de liberación
xviii
ABREVIACIÓN
tab rapdis
tab subl
tab.sr 12h
tab.sr 24h
tabergr24hr
tablet dr
tablet, er
tablet eff
tablet sa
tablet sol
tb er dspk
tb mp dspk
tb rd dspk
tbdspk 3mo
tbmp 12hr
tbmp 24hr
u
vag ring
University Care Advantage
DESCRIPCIÓN
tableta, desintegración rápida
tableta, sublingual
tableta, liberación sostenida 12 horas
tableta, liberación sostenida 24 horas
tableta, liberación extendida gradual
tableta, retrasó de liberación
tableta, liberación extendida
tableta, efervescente
tableta, acción sostenida
tableta, soluble
tablet, paquete de dosis liberación extendida
tableta, paquete de dosis multifásico
tableta, paquete de dosis desintegración rápida
tableta, paquete de dosis de 3 meses
tableta, multifásico 12 horas
tableta, multifásico 24 horas
unidad
anillo vaginal
xix
Drug
Tier
Drug Name
Requirements/Limits
Anesthetics
Local Anesthetics
(Nesacaine-MPF)
chloroprocaine hcl/pf
1
(Xylocaine)
(Lidocaine HCl/PF)
1
1
(Tetracaine HCl/PF)
tetracaine hcl/pf
XYLOCAINE
Topical Anesthetics
(Xylocaine)
lidocaine hcl
1
1
lidocaine hcl
lidocaine hcl/pf
lidocaine hcl
lidocaine
lidocaine/prilocaine
LIDODERM
vial: 20mg/ml,
30mg/ml
ampul: 15mg/ml;
disp syrin
vial: 20mg/ml
1
(Xylocaine)
(Lidocaine)
(EMLA)
1
1
1
2
jel (ml), jel/pf app,
solution: 20mg/ml,
40mg/ml
solution: 4%
PA
Antiinfectives
Aminoglycosides
amikacin sulfate
gentamicin in nacl, isoosm
gentamicin in nacl, isoosm
gentamicin sulfate
gentamicin sulfate/pf
kanamycin sulfate
neomycin sulfate
TOBI PODHALER
(Amikacin Sulfate)
(Gentamicin In Nacl, Isoosm)
(Gentamicin In Nacl, Isoosm)
1
1
(Garamycin)
(Gentamicin Sulfate/PF)
(Kanamycin Sulfate)
(Neomycin Sulfate)
1
1
1
1
3
TOBI
tobramycin sulfate
tobramycin/sodium
chloride
1
3
(Nebcin)
(Tobramycin/sodium
Chloride)
piggyback: 100mg/
50ml
piggyback: 60mg/
50ml, 70mg/50ml,
80mg/100ml, 80mg/
50ml, 90mg/100ml,
100mg/0.1l
vial: 1g/3ml
QL: 224
in 28
days
PA, QL:
56 in 28
days
1
1
20
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
Anthelmintics
ALBENZA
STROMECTOL
Antiinfectives Specialized Indications
(Dapsone)
dapsone
(Flagyl)
metronidazole
(Metro IV)
metronidazole/sodium
chloride
(Paromomycin Sulfate)
paromomycin sulfate
Antiretrovirals And Protease Inh
(Ziagen)
abacavir sulfate
APTIVUS
APTIVUS
ATRIPLA
COMPLERA
CRIXIVAN
(Videx EC)
didanosine
EDURANT
EMTRIVA
EPIVIR
EPZICOM
FUZEON
INCIVEK
INTELENCE
INTELENCE
INVIRASE
INVIRASE
ISENTRESS
ISENTRESS
KALETRA
KALETRA
lamivudine
lamivudine/zidovudine
LEXIVA
LEXIVA
nevirapine
nevirapine
NORVIR
2
2
2
1
1
1
1
3
3
3
3
2
1
3
2
2
3
3
3
2
3
2
3
2
3
2
3
(Epivir)
(Combivir)
1
1
2
3
1
1
2
(Viramune)
(Viramune)
Requirements/Limits
capsule
solution
solution
PA
tablet: 25mg
tablet: 100mg,
200mg
capsule
tablet
tab chew
tablet
tablet: 100mg-25mg
solution, tablet:
200mg-50mg
oral susp
tablet
oral susp
tablet
21
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
PREZISTA
2
PREZISTA
3
RESCRIPTOR
RETROVIR
REYATAZ
REYATAZ
2
2
2
3
SELZENTRY
stavudine
STRIBILD
SUSTIVA
SUSTIVA
3
1
3
2
2
(Zerit)
TRIZIVIR
TRUVADA
VICTRELIS
VIDEX
VIRACEPT
VIRACEPT
VIRAMUNE XR
VIRAMUNE
VIREAD
ZIAGEN
(Zidovudine)
zidovudine
Antituberculosis Drugs
CAPASTAT SULFATE
(Myambutol)
ethambutol hcl
(Isoniazid)
isoniazid
MYCOBUTIN
PASER
PRIFTIN
(Pyrazinamide)
pyrazinamide
(Rifadin)
rifampin
(Rifampin/isoniazid)
rifampin/isoniazid
SEROMYCIN
SIRTURO
TRECATOR
Cephalosporins
(Cefaclor)
cefaclor
3
3
3
2
2
3
2
2
3
2
1
2
1
1
2
2
2
1
1
1
2
3
2
1
Requirements/Limits
oral susp, tablet:
75mg, 150mg
tablet: 400mg,
600mg, 800mg
vial
capsule: 100mg
capsule: 150mg,
200mg, 300mg
capsule: 100mg
capsule: 50mg,
200mg; tablet
PA
tablet: 250mg
tablet: 625mg
oral susp
solution
PA
capsule, tab er 12h
22
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
cefaclor
cefadroxil hydrate
cefazolin sodium
cefazolin sodium/
dextrose,iso
cefazolin sodium/
dextrose,iso
cefdinir
cefditoren pivoxil
cefepime hcl
cefotaxime sodium
cefotaxime sodium
cefotetan disod/
dextrose,iso
cefotetan disodium
cefoxitin sodium
cefoxitin sodium/
dextrose,iso
cefpodoxime proxetil
cefprozil
ceftazidime pentahydrate
ceftazidime pentahydrate
CEFTAZIDIME
ceftriaxone na/
dextrose,iso
ceftriaxone sodium
cefuroxime axetil
cefuroxime sodium
cefuroxime sodium/
dextrose,iso
cephalexin
(Cefaclor)
(Cefadroxil Hydrate)
(Ancef)
(Cefazolin Sodium/dextrose,
Iso)
(Cefazolin Sodium/dextrose,
Iso)
(Cefdinir)
(Spectracef)
(Maxipime)
(Claforan)
(Claforan)
(Cefotetan Disod/dextrose,
Iso)
(Cefotetan Disodium)
(Mefoxin)
(Cefoxitin Sodium/dextrose,
Iso)
(Cefpodoxime Proxetil)
(Cefprozil)
(Fortaz)
(Fortaz)
cephalexin
SUPRAX
(Keflex)
Erythromycins
E.E.S. 200
ery e-succ/sulfisoxazole
ERYPED 200
ERYPED 400
ERY-TAB
(Ceftriaxone Na/dextrose,
Iso)
(Rocephin)
(Ceftin)
(Zinacef)
(Cefuroxime Sodium/
dextrose, Iso)
(Keflex)
1
1
1
1
froz.piggy
1
piggyback
1
1
1
1
1
1
susp recon
vial: 1g, 2g, 10g
vial: 500mg
1
1
1
1
1
1
1
1
1
vial: 1g; vial port
vial: 2g, 6g, 500mg
1
1
1
1
1
1
2
(Ery E-succ/sulfisoxazole)
Requirements/Limits
capsule: 250mg,
500mg; susp recon,
tablet
capsule: 750mg
susp recon, tab
chew, tablet
2
1
2
2
2
23
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
ERYTHROCIN
LACTOBIONATE
ERYTHROCIN
LACTOBIONATE
(Erythromycin Base)
erythromycin base
(Erythromycin Base)
erythromycin base
(Erythromycin Base)
erythromycin base
(Erythromycin
erythromycin
Ethylsuccinate)
ethylsuccinate
(Erythromycin Stearate)
erythromycin stearate
Oral Antifungal Drugs
(Clindamycin Phosphate/
clindamycin phosphate/
D5W)
d5w
(Clotrimazole)
clotrimazole
(Diflucan)
fluconazole
(Diflucan)
fluconazole
Requirements/Limits
2
vial port: 1g
2
vial port: 500mg
1
1
2
1
capsule dr
tablet
tablet dr
1
1
1
1
1
fluconazole
(Diflucan)
1
flucytosine
griseofulvin ultramicrosize
griseofulvin,microsize
itraconazole
(Ancobon)
(Gris-peg)
(Griseofulvin,microsize)
(Sporanox)
3
1
1
1
(Ketoconazole)
ketoconazole
LAMISIL
NOXAFIL
(Nystatin)
nystatin
SPORANOX
(Lamisil)
terbinafine hcl
VFEND
(Vfend)
voriconazole
(Vfend)
voriconazole
Other Antiinfective Drugs
ALINIA
(Azactam)
aztreonam
(Bacitracin)
bacitracin
CAYSTON
1
2
3
1
2
1
3
1
3
chloramphenicol sod succ (Chloramphenicol Sod Succ)
1
2
1
1
3
PA
QL: 2 in
7 days
susp recon
tablet: 50mg,
100mg, 200mg
tablet: 150mg
PA, QL:
136 in 34
days
gran pack
solution
PA
PA
PA
PA
susp recon
tablet: 50mg
tablet: 200mg
LA, QL:
84 in 28
days
24
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
(Cleocin HCl)
clindamycin hcl
clindamycin palmitate hcl (Cleocin Palmitate)
(Cleocin Phosphate)
clindamycin phosphate
(Cleocin Phosphate In D5w)
clindamycin phosphate/
d5w
colistin (colistimethate na) (Coly-mycin M Parenteral)
CUBICIN
DORIBAX
(Primaxin)
imipenem/cilastatin
sodium
INVANZ
MEPRON
(Merrem)
meropenem
(Polymyxin B Sulfate)
polymyxin b sulfate
SYNERCID
TYGACIL
(Vancocin HCl)
vancomycin hcl
(Vancomycin HCl)
vancomycin hcl
(Vancomycin HCl)
vancomycin hcl
(Vancomycin HCl/D5W)
vancomycin hcl/d5w
VANCOMYCIN HCL
XIFAXAN
XIFAXAN
ZYVOX
ZYVOX
Other Antiviral Drugs
(Acyclovir Sodium)
acyclovir sodium
(Zovirax)
acyclovir
(Amantadine HCl)
amantadine hcl
BARACLUDE
BARACLUDE
(Vistide)
cidofovir
DENAVIR
EPIVIR HBV
(Famvir)
famciclovir
Requirements/Limits
1
1
1
1
1
3
2
1
2
3
1
1
3
2
3
1
1
1
2
2
3
3
3
1
1
1
2
3
1
2
2
1
famciclovir
(Famvir)
1
famciclovir
(Famvir)
1
foscarnet sodium
(Foscavir)
1
PA
vial
PA
PA
PA
PA
PA
capsule
vial: 1g, 10g
vial: 750mg
tablet: 200mg
tablet: 550mg
iv soln
susp recon, tablet
solution
tablet
QL: 21 in tablet: 125mg
10 days
QL: 21 in tablet: 500mg
7 days
QL: 68 in tablet: 250mg
34 days
25
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
ganciclovir sodium
ganciclovir
ganciclovir
HEPSERA
RELENZA
(Cytovene)
(Ganciclovir)
(Ganciclovir)
1
1
3
3
2
RIBATAB
capsule: 250mg
capsule: 500mg
QL: 60 in
180 days
3
ribavirin
(Copegus)
1
ribavirin
(Ribatab)
3
ribavirin
(Ribatab)
3
rimantadine hcl
TAMIFLU
(Flumadine)
1
2
TAMIFLU
2
TAMIFLU
2
TYZEKA
valacyclovir hcl
Requirements/Limits
3
1
(Valtrex)
VALCYTE
VIRAZOLE
XERESE
ZOVIRAX
Other Macrolides
(Azithromycin)
azithromycin
(Azithromycin)
azithromycin
tab ds pk: 600600mg
capsule, tablet:
200mg, 400mg
tab ds pk: 200400mg
tab ds pk: 400400mg, 600-400mg;
tablet: 600mg
QL: 42 in
180 days
QL: 600
in 180
days
QL: 84 in
180 days
capsule: 45mg,
75mg
susp recon
capsule: 30mg
QL: 34 in
34 days
3
2
2
2
cream (g), oint. (g)
1
1
packet
susp recon, tablet,
vial
(Biaxin)
clarithromycin
Other Topical Antifungals
CICLODAN
(Ciclodan)
ciclopirox olamine
(Loprox)
ciclopirox
1
1
1
PA
solution
(Penlac)
(Mycelex)
1
1
PA
gel (gram),
shampoo
solution
ciclopirox
clotrimazole
1
26
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
(Econazole Nitrate)
econazole nitrate
(Ketoconazole)
ketoconazole
(Nystatin)
nystatin
Parenteral Antifungals
ABELCET
AMBISOME
(Amphotericin B)
amphotericin b
CANCIDAS
(Fluconazole In Nacl,isofluconazole in nacl,isoosm)
osm
MYCAMINE
(Vfend IV)
voriconazole
Penicillins
(Trimox)
amoxicillin
amoxicillin/potassium clav (Augmentin)
(Totacillin-N)
ampicillin sodium
(Totacillin-N)
ampicillin sodium
(Unasyn)
ampicillin sodium/
sulbactam na
(Unasyn)
ampicillin sodium/
sulbactam na
(Ampicillin Trihydrate)
ampicillin trihydrate
AUGMENTIN
Requirements/Limits
1
1
1
3
3
1
3
1
3
1
1
1
1
1
1
vial
vial port
vial
1
vial port
1
2
dicloxacillin sodium
nafcillin in dextrose,isoosm
nafcillin sodium
nafcillin sodium
nafcillin sodium
oxacillin sodium
oxacillin sodium
oxacillin sodium/
dextrose,iso
oxacillin sodium/
dextrose,iso
pen g pot/dextrose-water
(Dicloxacillin Sodium)
(Nafcillin In Dextrose,isoosm)
(Unipen)
(Unipen)
(Unipen)
(Oxacillin Sodium)
(Oxacillin Sodium)
(Oxacillin Sodium/dextrose,
Iso)
(Oxacillin Sodium/dextrose,
Iso)
(Pen G Pot/dextrose-water)
pen g pot/dextrose-water
(Pen G Pot/dextrose-water)
1
penicillin g potassium
(Penicillin G Potassium)
1
susp recon: 12531.25/
1
3
1
1
3
1
3
1
vial port
vial: 2g
vial: 10g
vial port
vial
froz.piggy: 1g/50ml
3
froz.piggy: 2g/50ml
1
froz.piggy: 1mm/
50ml
froz.piggy: 2mm/
50ml, 3mm/50ml
27
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
penicillin g potassium/d5w (Penicillin G Potassium/
D5W)
(Penicillin G Procaine)
penicillin g procaine
penicillin g procaine
PENICILLIN G SODIUM
penicillin v potassium
piperacillin sodium/
tazobactam
Plasmodicides
atovaquone/proguanil hcl
atovaquone/proguanil hcl
chloroquine phosphate
COARTEM
DARAPRIM
hydroxychloroquine
sulfate
mefloquine hcl
PRIMAQUINE
QUALAQUIN
quinine sulfate
tinidazole
Quinolones
AVELOX IV
CIPRO
ciprofloxacin hcl
ciprofloxacin lactate
ciprofloxacin lactate/d5w
ciprofloxacin/ciprofloxa
hcl
levofloxacin
levofloxacin/d5w
ofloxacin
Sulfonamides
sulfadiazine
sulfamethoxazole/
trimethoprim
Tetracyclines
demeclocycline hcl
doxycycline hyclate
1
1
(Penicillin G Procaine)
1
(Veetids 500)
(Zosyn)
1
1
1
(Malarone)
(Malarone)
(Aralen Phosphate)
1
1
1
2
2
1
(Plaquenil)
(Mefloquine HCl)
Requirements/Limits
(Qualaquin)
(Tindamax)
1
2
2
1
1
(Cipro)
(Cipro I.V.)
(Cipro I.V.)
(Cipro XR)
2
2
1
1
1
1
(Levaquin)
(Levaquin)
(Ofloxacin)
1
1
1
(Sulfadiazine)
(Bactrim DS)
1
1
(Demeclocycline HCl)
(Doxycycline Hyclate)
1
1
disp syrin: 1.2mm/
2ml
disp syrin: 600000/
ml
tablet: 250-100mg
tablet: 62.5-25mg
sus mc rec
capsule dr, tablet
28
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
doxycycline hyclate
(Vibramycin)
1
doxycycline monohydrate
(Adoxa)
1
doxycycline monohydrate (Monodox)
(Dynacin)
minocycline hcl
(Ala-tet)
tetracycline hcl
(Tetracycline HCl)
tetracycline hcl
Topical Antibacterial Drugs
(Gentamicin Sulfate)
gentamicin sulfate
(Sulfamylon)
mafenide acetate
(Mupirocin)
mupirocin
(Thermazene)
silver sulfadiazine
SULFAMYLON
THERMAZENE
TRIPLE ANTIBIOTIC
Topical Antifungal-corticosteroid Comb.
(Lotrisone)
clotrimazole/
betamethasone dip
(Nystatin/triamcin)
nystatin/triamcin
Urinary Antiinfectives
(Methenamine Mandelate)
methenamine mandelate
(Methenamine Mandelate)
methenamine mandelate
(Macrodantin)
nitrofurantoin
macrocrystal
(Furadantin)
nitrofurantoin
PRIMSOL
(Trimethoprim)
trimethoprim
Vaginal Antifungals
(Miconazole Nitrate)
miconazole nitrate
Requirements/Limits
capsule, tablet dr,
vial
capsule: 75mg;
tablet
capsule: 150mg
1
1
1
1
capsule
oral susp
1
1
1
1
2
1
1
cream (g)
1
1
1
1
1
tablet: 1g
tablet: 500mg
1
2
1
1
terconazole
(Terconazole)
1
terconazole
(Terconazole)
1
QL: 3 in
3 days
QL: 3 in supp.vag
3 days
QL: 45 in cream/appl
7 days
Antineoplastic/immunosuppressant Drugs
Antineoplastic/immunosuppressant Drugs
AFINITOR DISPERZ
AFINITOR
ALIMTA
AMEVIVE
3
3
3
3
LA, PA
29
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
amifostine crystalline
anagrelide hcl
anastrozole
AVASTIN
AZASAN
azathioprine sodium
azathioprine
BENLYSTA
bicalutamide
BOSULIF
(Amifostine Crystalline)
(Agrylin)
(Arimidex)
(Azathioprine Sodium)
(Imuran)
(Casodex)
3
1
1
2
2
1
1
2
1
3
BOSULIF
3
CAMPATH
CAPRELSA
CEENU
CELLCEPT
CELLCEPT
CIMZIA
3
3
2
2
3
3
COMETRIQ
3
cyclophosphamide
cyclosporine
cyclosporine, modified
DEPO-PROVERA
doxorubicin hcl pegliposomal
DROXIA
ELIGARD
ELITEK
EMCYT
ENBREL
ERIVEDGE
exemestane
FARESTON
(Cyclophosphamide)
(Sandimmune)
(Neoral)
1
1
1
2
3
(Doxil)
2
2
3
2
3
Requirements/Limits
PA
PA
PA
PA, QL: tablet: 100mg
120 in 30
days
PA, QL: tablet: 500mg
30 in 30
days
LA
PA
vial
PA
susp recon
PA, QL:
3 in 28
days
PA, QL:
112 in 28
days
PA
tablet
PA
PA
PA
PA, QL:
10 in 35
days
3
1
2
(Aromasin)
30
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
FASLODEX
flutamide
GLEEVEC
HALAVEN
HECORIA
3
1
3
3
1
(Flutamide)
HECORIA
HEXALEN
HUMIRA
3
3
3
HUMIRA
3
hydroxyurea
ICLUSIG
(Hydrea)
1
3
ICLUSIG
3
INLYTA
JAKAFI
KADCYLA
3
3
3
leflunomide
(Arava)
1
letrozole
leucovorin calcium
LEUKERAN
LUPRON DEPOT
LYSODREN
MATULANE
MEGACE ES
megestrol acetate
mercaptopurine
mesna
MESNEX
methotrexate sodium
methotrexate sodium/pf
mitoxantrone hcl
(Femara)
(Leucovorin Calcium)
1
1
2
3
2
3
2
1
1
1
3
1
1
1
(Megace)
(Purinethol)
(Mesnex)
(Methotrexate Sodium)
(Methotrexate Sodium/PF)
(Mitoxantrone HCl)
Requirements/Limits
PA
PA
capsule: 0.5mg,
1mg
capsule: 5mg
PA
PA, QL:
5 in 35
days
PA, QL:
6 in 180
days
PA, QL:
30 in 30
days
PA, QL:
60 in 30
days
kit, pen ij kit: 40mg/
0.8ml
pen ij kit: 40mg/
0.8ml
tablet: 45mg
tablet: 15mg
PA, QL:
2 in 21
days
QL: 34 in
34 days
PA
tablet
PA
PA
PA
31
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
mycophenolate mofetil
MYFORTIC
NEXAVAR
NILANDRON
NULOJIX
octreotide acetate
octreotide acetate
(Cellcept)
(Octreotide Acetate)
(Sandostatin)
1
2
3
2
3
1
1
octreotide acetate
(Sandostatin)
3
Requirements/Limits
PA
PA
LA
PA
disp syrin
vial: 50mcg/ml,
100mcg/ml
vial: 200mcg/ml,
500mcg/ml,
1000mcg/ml
disp syrin
vial
ORENCIA
ORENCIA
PERJETA
POMALYST
3
3
3
3
PA
PA
PROGRAF
RAPAMUNE
2
2
PA, QL:
21 in 28
days
PA
PA
RAPAMUNE
REMICADE
REVLIMID
REVLIMID
3
3
3
3
PA
PA
LA
LA
RITUXAN
SANDOSTATIN LAR
3
3
SANDOSTATIN LAR
3
SIGNIFOR
3
SIMULECT
SOLTAMOX
SPRYCEL
STELARA
STIVARGA
2
2
3
1
3
PA
QL: 1 in kit: 10mg, 30mg
28 days
QL: 2 in kit: 20mg
28 days
QL: 60 in
30 days
PA
SUTENT
3
ampul
solution, tablet:
0.5mg, 1mg
tablet: 2mg
capsule: 2.5mg
capsule: 5mg,
10mg, 15mg, 25mg
PA
vial
PA, QL:
84 in 28
days
32
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
SYNRIBO
3
TABLOID
tacrolimus
2
1
tacrolimus
tamoxifen citrate
TARCEVA
TARGRETIN
TASIGNA
TEMODAR
TRELSTAR
tretinoin
TYKERB
TYSABRI
VELCADE
VIDAZA
VOTRIENT
XALKORI
XTANDI
(Prograf)
(Prograf)
(Tamoxifen Citrate)
3
1
3
3
3
3
3
3
3
3
3
3
3
3
3
(Tretinoin)
ZELBORAF
ZOLADEX
ZOLINZA
ZORTRESS
ZORTRESS
3
2
3
2
3
ZYTIGA
3
Requirements/Limits
PA, QL:
28 in 28
days
PA
capsule: 0.5mg,
1mg
capsule: 5mg
PA
PA
PA
PA
LA, PA
PA
PA, QL:
120 in 30
days
PA
PA
PA
tablet: 0.25mg
tablet: 0.5mg,
0.75mg
Autonomic And Cns Medications
Analgesics
buprenorphine hcl
butorphanol tartrate
nalbuphine hcl
PRIALT
tramadol hcl
tramadol hcl
(Buprenorphine HCl)
(Butorphanol Tartrate)
(Nalbuphine HCl)
(Ultram ER)
1
1
1
2
1
(Ultram)
1
QL: 34 in tab er 24h
34 days
QL: 272 tablet
in 34
days
33
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
tramadol hcl/
acetaminophen
(Ultracet)
1
Antidementia Drugs
(Aricept)
donepezil hcl
EXELON
EXELON
(Razadyne)
galantamine hbr
NAMENDA XR
NAMENDA
(Exelon)
rivastigmine tartrate
Antineoplastic/immunosuppressant Drugs
(Medroxyprogesterone
medroxyprogesterone
Acetate)
acetate
Antiparkinson Anticholinergic Drugs
(Benztropine Mesylate)
benztropine mesylate
(Trihexyphenidyl HCl)
trihexyphenidyl hcl
Antipsychotic Drugs
ABILIFY DISCMELT
1
2
2
1
2
2
1
1
2
2
ABILIFY MAINTENA
3
ABILIFY
ABILIFY
2
2
ABILIFY
2
ABILIFY
2
ABILIFY
2
ABILIFY
3
ABILIFY
3
(Chlorpromazine HCl)
QL: 272
in 34
days
ST
ST
patch td24
solution
QL: 1 in
90 days
1
1
ABILIFY DISCMELT
chlorpromazine hcl
Requirements/Limits
1
QL: 102 tab rapdis: 10mg
in 34
days
QL: 68 in tab rapdis: 15mg
34 days
QL: 1 in
28 days
solution, vial
QL: 102 tablet: 10mg
in 34
days
QL: 204 tablet: 5mg
in 34
days
QL: 510 tablet: 2mg
in 34
days
QL: 68 in tablet: 15mg
34 days
QL: 34 in tablet: 30mg
34 days
QL: 68 in tablet: 20mg
34 days
ampul, tablet
34
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug Name
chlorpromazine hcl
clozapine
clozapine
FANAPT
(Chlorpromazine HCl)
(Clozaril)
(Fazaclo)
Drug
Tier
Requirements/Limits
1
1
1
2
oral conc.
tablet
tab rapdis
tab ds pk
FANAPT
2
FANAPT
2
FANAPT
2
FANAPT
2
FANAPT
2
FANAPT
2
FAZACLO
fluphenazine decanoate
fluphenazine hcl
GEODON
haloperidol decanoate
haloperidol lactate
haloperidol
INVEGA SUSTENNA
(Fluphenazine Decanoate)
(Fluphenazine HCl)
(Haloperidol Decanoate)
(Haloperidol Lactate)
(Haloperidol)
2
1
1
2
1
1
1
2
INVEGA SUSTENNA
3
INVEGA
2
INVEGA
2
INVEGA
2
QL: 1 in
34 days
QL: 102
in 34
days
QL: 136
in 34
days
QL: 204
in 34
days
QL: 408
in 34
days
QL: 68 in
34 days
QL: 816
in 34
days
tablet: 8mg, 10mg
tablet: 6mg
tablet: 4mg
tablet: 2mg
tablet: 12mg
tablet: 1mg
vial
disp syrin: 39mg/
0.25, 78mg/0.5ml
disp syrin: 117mg/
0.75, 156mg/ml,
234mg/1.5
tab er 24: 3mg
QL: 136
in 34
days
QL: 272 tab er 24: 1.5mg
in 34
days
QL: 46 in tab er 24: 9mg
34 days
35
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
INVEGA
2
LATUDA
2
LATUDA
2
loxapine succinate
olanzapine
(Loxitane)
(Zyprexa Zydis)
1
1
olanzapine
olanzapine
(Zyprexa)
(Zyprexa)
1
1
olanzapine
(Zyprexa)
1
olanzapine
(Zyprexa)
1
olanzapine
(Zyprexa)
1
olanzapine
(Zyprexa)
1
olanzapine
(Zyprexa)
3
olanzapine/fluoxetine hcl
ORAP
perphenazine
quetiapine fumarate
(Symbyax)
(Perphenazine)
(Seroquel)
1
2
1
1
quetiapine fumarate
(Seroquel)
1
quetiapine fumarate
(Seroquel)
1
quetiapine fumarate
(Seroquel)
1
quetiapine fumarate
(Seroquel)
1
Requirements/Limits
QL: 68 in
34 days
QL: 34 in
34 days
QL: 68 in
34 days
tab er 24: 6mg
tablet: 20mg, 80mg,
120mg
tablet: 40mg
QL: 34 in tab rapdis: 20mg
34 days
vial
QL: 136 tab rapdis: 5mg;
in 34
tablet: 5mg
days
QL: 272 tablet: 2.5mg
in 34
days
QL: 45 in tab rapdis: 15mg;
34 days tablet: 15mg
QL: 68 in tab rapdis: 10mg;
34 days tablet: 10mg
QL: 91 in tablet: 7.5mg
34 days
QL: 34 in tablet: 20mg
34 days
QL: 1022
in 34
days
QL: 136
in 34
days
QL: 272
in 34
days
QL: 544
in 34
days
QL: 68 in
34 days
tablet: 25mg
tablet: 200mg
tablet: 100mg
tablet: 50mg
tablet: 400mg
36
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
quetiapine fumarate
(Seroquel)
1
RISPERDAL CONSTA
2
RISPERDAL CONSTA
3
risperidone
(Risperdal)
1
risperidone
(Risperdal)
1
risperidone
(Risperdal)
1
risperidone
(Risperdal)
1
risperidone
(Risperdal)
1
risperidone
(Risperdal)
1
SAPHRIS
2
SAPHRIS
2
SEROQUEL XR
2
SEROQUEL XR
2
SEROQUEL XR
2
SEROQUEL XR
2
SEROQUEL XR
2
Requirements/Limits
QL: 91 in tablet: 300mg
34 days
disp syrin: 12.5mg/
2ml, 25mg/2ml
disp syrin: 37.5mg/
2ml, 50mg/2ml
QL: 1088 tab rapdis: 0.5mg;
in 34
tablet: 0.5mg
days
QL: 136 tab rapdis: 4mg;
in 34
tablet: 4mg
days
QL: 182 tab rapdis: 3mg;
in 34
tablet: 3mg
days
QL: 2176 tab rapdis: 0.25mg;
in 34
tablet: 0.25mg
days
QL: 272 tab rapdis: 2mg;
in 34
tablet: 2mg
days
QL: 544 solution, tab rapdis:
in 34
1mg; tablet: 1mg
days
QL: 136 tab subl: 5mg
in 34
days
QL: 68 in tab subl: 10mg
34 days
QL: 136 tab er 24h: 200mg
in 34
days
QL: 182 tab er 24h: 150mg
in 34
days
QL: 544 tab er 24h: 50mg
in 34
days
QL: 68 in tab er 24h: 400mg
34 days
QL: 91 in tab er 24h: 300mg
34 days
37
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
thioridazine hcl
thioridazine hcl
thiothixene
trifluoperazine hcl
ziprasidone hcl
(Thioridazine HCl)
(Thioridazine HCl)
(Thiothixene)
(Trifluoperazine HCl)
(Geodon)
1
1
1
1
1
ziprasidone hcl
(Geodon)
1
ziprasidone hcl
(Geodon)
1
ziprasidone hcl
(Geodon)
1
ZYPREXA RELPREVV
3
Antivertigo And Antiemetic Drugs
ALOXI
2
CESAMET
3
dronabinol
(Marinol)
1
dronabinol
EMEND
(Marinol)
3
2
EMEND
2
EMEND
2
granisetron hcl
(Granisetron HCl)
1
granisetron hcl
(Granisetron HCl)
1
granisetron hcl
granisetron hcl/pf
meclizine hcl
ondansetron hcl
(Kytril)
(Granisetron HCl/PF)
(Antivert)
(Zofran)
1
1
1
1
Requirements/Limits
oral conc.
tablet
QL: 136
in 34
days
QL: 272
in 34
days
QL: 68 in
34 days
QL: 91 in
34 days
QL: 2 in
28 days
capsule: 40mg
capsule: 20mg
capsule: 80mg
capsule: 60mg
QL: 10 in
30 days
PA, QL:
30 in 5
days
PA
capsule: 2.5mg,
5mg
PA
capsule: 10mg
PA, QL: capsule: 40mg,
1 per fill 125mg
PA, QL: capsule: 80mg
2 in 2
days
PA, QL: cap ds pk
3 in 3
days
PA, QL: tablet
2 per fill
PA, QL: solution
30 in 3
days
vial
vial
38
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
ondansetron hcl
(Zofran)
1
ondansetron hcl
(Zofran)
1
ondansetron hcl
(Zofran)
1
ondansetron
(Zofran Odt)
1
prochlorperazine edisylate (Compazine)
prochlorperazine maleate (Prochlorperazine Maleate)
(Promethazine HCl)
promethazine hcl
PA, QL:
1 per fill
PA, QL:
12 in 5
days
PA, QL:
150 in 5
days
PA, QL:
12 in 5
days
1
1
1
trimethobenzamide hcl
Anxiolytics
buspirone hcl
clorazepate dipotassium
diazepam
(Tigan)
1
(Buspirone HCl)
(Tranxene T-tab)
(Valium)
1
1
1
droperidol
hydroxyzine hcl
hydroxyzine hcl
hydroxyzine pamoate
lorazepam
lorazepam
(Droperidol)
(Hydroxyzine HCl)
(Hydroxyzine HCl)
(Vistaril)
(Ativan)
(Ativan)
1
1
1
1
1
1
oxazepam
Carbamazepines
carbamazepine
oxcarbazepine
TEGRETOL XR
Class Ii Narcotics
codeine sulfate
CODEINE SULFATE
DURAMORPH
fentanyl citrate
(Oxazepam)
1
(Tegretol)
(Trileptal)
1
1
2
(Actiq)
1
1
2
3
fentanyl
hydromorphone hcl
(Duragesic)
(Hydromorphone HCl)
1
1
(Codeine Sulfate)
Requirements/Limits
tablet: 24mg
tablet: 4mg, 8mg
solution
supp.rect: 12.5mg,
25mg, 50mg
capsule
oral conc, solution,
tablet
vial
syrup, tablet
PA
PA
QL: 2 in
30 days
oral conc, tablet
disp syrin, vial
tab er 12h: 100mg
PA, QL:
120 in 30
days
tablet
39
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
hydromorphone hcl/pf
ibuprofen/oxycodone hcl
levorphanol tartrate
meperidine hcl/pf
methadone hcl
(Hydromorphone HCl/PF)
(Ibuprofen/oxycodone HCl)
(Levorphanol Tartrate)
(Meperidine HCl/PF)
(Dolophine HCl)
1
1
1
1
1
methadone hcl
morphine sulfate
(Dolophine HCl)
(Kadian)
1
1
morphine sulfate
morphine sulfate
(Morphine Sulfate)
(Morphine Sulfate)
1
1
morphine sulfate
(MS Contin)
1
morphine sulfate/pf
OPANA ER
(Morphine Sulfate/PF)
1
2
OPANA ER
2
OPANA ER
3
oxycodone hcl
(Oxycodone HCl)
1
oxycodone hcl
(Roxicodone)
1
oxycodone hcl/
acetaminophen
oxycodone hcl/aspirin
OXYCONTIN
(Percocet)
1
(Percodan)
1
2
OXYCONTIN
oxymorphone hcl
3
(Opana)
1
Requirements/Limits
vial: 10mg/ml
vial
oral conc, solution,
tablet, vial
tablet sol
QL: 90 in cap er pel
30 days
solution, tablet
various dosage and/
or strengths are
available
QL: 120 tablet er
in 30
days
pca vial
ST, QL: tab er 12h: 5mg,
90 in 30 10mg, 20mg, 30mg
days
ST, QL: tab er 12h: 7.5mg,
90 in 30 15mg
days
ST, QL: tab er 12h: 40mg
90 in 30
days
QL: 1300 solution
in 30
days
capsule, oral conc,
tablet
capsule, tablet
QL: 90 in tab er 12h: 10mg,
30 days 15mg, 20mg, 30mg,
40mg, 60mg
QL: 120 tab er 12h: 80mg
in 30
days
tablet
40
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
oxymorphone hcl
(Oxymorphone HCl)
1
Class Iii Narcotics
(Tylenol-codeine No.3)
acetaminophen with
codeine
(Buprenorphine HCl)
buprenorphine hcl
(Suboxone)
buprenorphine hcl/
naloxone hcl
Requirements/Limits
QL: 90 in tab er 12h
30 days
1
1
1
PA, QL:
102 in 34
days
codeine phos/
acetaminophen
dhcodeine bt/
acetaminophn/caff
hydrocodone bit/
acetaminophen
hydrocodone bit/
acetaminophen
(Codeine Phos/
acetaminophen)
(Dhcodeine Bt/acetaminophn/
caff)
(Norco)
1
1
tablet: 2.5-325mg
(Norco)
1
various dosage and/
or strengths are
available
hydrocodone/ibuprofen
hydromorphone hcl
SUBOXONE
(Vicoprofen)
(Hydromorphone HCl)
1
1
2
1
SUBOXONE
2
ZAMICET
Cns Stimulant Drugs
(Cafcit)
caffeine citrated
(Focalin)
dexmethylphenidate hcl
(Dexedrine)
dextroamphetamine
sulfate
(Adderall)
dextroamphetamine/
amphetamine
METADATE ER
(Desoxyn)
methamphetamine hcl
(Ritalin)
methylphenidate hcl
1
modafinil
PROVIGIL
PA, QL: film: 2mg-0.5mg,
102 in 34 4mg-1mg, 8mg-2mg
days
PA, QL: film: 12mg-3mg
68 in 34
days
1
1
1
1
1
1
1
(Provigil)
1
2
cpmp 30-70, cpmp
50-50, solution,
tablet, tablet er:
20mg
PA
PA
41
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
Drugs To Prevent And Treat Headaches
(Fioricet with Codeine)
butalbit/acetamin/caff/
codeine
(Butorphanol Tartrate)
butorphanol tartrate
Requirements/Limits
1
1
QL: 5 in
3 days
codeine/butalbital/asa/
caffein
dhcodeine bt/
acetaminophn/caff
dihydroergotamine
mesylate
dihydroergotamine
mesylate
ERGOMAR
ergotamine tartrate/
caffeine
ergotamine tartrate/
caffeine
naratriptan hcl
(Fiorinal with Codeine #3)
1
(Dhcodeine Bt/acetaminophn/
caff)
(D.H.E. 45)
1
(Migranal)
1
(Cafergot)
2
1
tablet
(Ergotamine Tartrate/
caffeine)
(Amerge)
1
supp.rect
1
rizatriptan benzoate
(Maxalt Mlt)
1
sumatriptan succinate
(Imitrex)
1
sumatriptan succinate
(Imitrex)
1
sumatriptan succinate
(Imitrex)
1
sumatriptan
(Imitrex)
1
sumatriptan
(Imitrex)
1
zolmitriptan
ZOMIG
(Zomig Zmt)
1
2
Hydantoins
DILANTIN
fosphenytoin sodium
PEGANONE
phenytoin sodium
extended
phenytoin sodium
capsule: 30-50-325
1
ampul
QL: 8 in
28 days
QL: 18 in
28 days
QL: 18 in
28 days
QL: 16 in
28 days
QL: 18 in
28 days
QL: 4 in
28 days
QL: 12 in
28 days
QL: 18 in
28 days
spray/pump
cartridge: 6mg/
0.5ml; vial
tablet
cartridge: 4mg/
0.5ml
spray: 20mg
spray: 5mg
QL: 18 in spray
28 days
capsule: 30mg
(Dilantin)
2
1
2
1
(Phenytoin Sodium)
1
ampul
(Fosphenytoin Sodium)
42
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
(Phenytoin Sodium)
phenytoin sodium
(Dilantin-125)
phenytoin
Mao Inhibitors
EMSAM
MARPLAN
(Nardil)
phenelzine sulfate
(Parnate)
tranylcypromine sulfate
Other Anticonvulsants
BANZEL
BANZEL
clonazepam
diazepam
felbamate
gabapentin
GABITRIL
lamotrigine
lamotrigine
1
1
disp syrin
2
2
1
1
2
oral susp, tablet:
200mg
tablet: 400mg
3
1
1
1
1
2
1
1
(Klonopin)
(Diastat)
(Felbatol)
(Neurontin)
(Lamictal (green))
(Lamictal)
levetiracetam in nacl (iso- (Levetiracetam In Nacl (isoos))
os)
(Keppra)
levetiracetam
LYRICA
(Magnesium Chloride)
magnesium chloride
ONFI
(Phenobarbital Sodium)
phenobarbital sodium
(Phenobarbital)
phenobarbital
POTIGA
(Mysoline)
primidone
SABRIL
(Gabitril)
tiagabine hcl
(Topamax)
topiramate
VIMPAT
VIMPAT
(Zonegran)
zonisamide
Other Antidepressants
(Wellbutrin SR)
bupropion hcl
bupropion hcl
Requirements/Limits
(Wellbutrin SR)
tablet: 12mg, 16mg
tab ds pk
tab er 24, tablet, tb
chw dsp
1
1
2
1
2
1
1
2
1
3
1
1
2
2
1
1
1
PA
LA
PA
vial
solution, tablet
PA
PA
QL: 102
in 34
days
QL: 136
in 34
days
tablet er: 150mg
tablet er: 100mg
43
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
bupropion hcl
(Wellbutrin XL)
1
bupropion hcl
(Wellbutrin XL)
1
(Wellbutrin)
bupropion hcl
CYMBALTA
DESVENLAFAXINE ER
1
2
2
DESVENLAFAXINE ER
2
maprotiline hcl
mirtazapine
nefazodone hcl
perphenazine/
amitriptyline hcl
PRISTIQ ER
(Maprotiline HCl)
(Remeron)
(Nefazodone HCl)
(Perphenazine/amitriptyline
HCl)
2
2
SAVELLA
2
SAVELLA
2
SAVELLA
2
SAVELLA
2
SAVELLA
2
(Trazodone HCl)
(Effexor XR)
QL: 34 in tab er 24h: 150mg
34 days
QL: 68 in tab er 24h: 300mg;
34 days tablet er: 200mg
tablet
PA, QL: tab er 24h: 100mg
136 in 34
days
PA, QL: tab er 24h: 50mg
272 in 34
days
1
1
1
1
PRISTIQ ER
trazodone hcl
venlafaxine hcl
Requirements/Limits
1
1
PA, QL:
136 in 34
days
PA, QL:
272 in 34
days
QL: 1 in
34 days
QL: 136
in 34
days
QL: 272
in 34
days
QL: 544
in 34
days
QL: 68 in
34 days
tab er 24h: 100mg
QL: 102
in 34
days
cap er 24h: 75mg;
tablet: 75mg,
100mg
tab er 24h: 50mg
tab ds pk
tablet: 50mg
tablet: 25mg
tablet: 12.5mg
tablet: 100mg
44
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
venlafaxine hcl
(Effexor XR)
1
venlafaxine hcl
(Effexor XR)
1
venlafaxine hcl
(Venlafaxine HCl)
1
venlafaxine hcl
(Venlafaxine HCl)
1
Other Antiparkinson Drugs
APOKYN
AZILECT
(Parlodel)
bromocriptine mesylate
(Sinemet 25-100)
carbidopa/levodopa
(Stalevo 50)
carbidopa/levodopa/
entacapone
COMTAN
(Comtan)
entacapone
LODOSYN
NEUPRO
3
2
1
1
1
2
1
2
2
(Mirapex)
pramipexole di-hcl
(Requip)
ropinirole hcl
(Selegiline HCl)
selegiline hcl
TASMAR
Other Cns/autonomic Drugs
(Atropine Sulfate)
atropine sulfate
(Atropine Sulfate)
atropine sulfate
(Antabuse)
disulfiram
(Romazicon)
flumazenil
(Guanidine HCl)
guanidine hcl
INTUNIV
(Eskalith)
lithium carbonate
(Lithium Citrate)
lithium citrate
MESTINON
(Naloxone HCl)
naloxone hcl
naloxone hcl
naltrexone hcl
Requirements/Limits
QL: 204
in 34
days
QL: 68 in
34 days
QL: 170
in 34
days
QL: 306
in 34
days
cap er 24h: 37.5mg;
tablet: 37.5mg
cap er 24h: 150mg
tablet: 50mg
tablet: 25mg
LA
ST, QL:
30 in 30
days
1
1
1
3
1
1
1
1
1
2
1
1
2
1
(Naloxone HCl)
(Revia)
1
1
disp syrin
vial
PA
syrup, tablet er
ampul, disp syrin:
0.4mg/ml; vial
disp syrin: 1mg/ml
45
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
neostigmine methylsulfate (Neostigmine Methylsulfate)
NUEDEXTA
(Physostigmine Salicylate)
physostigmine salicylate
PROSTIGMIN
PROTOPAM CHLORIDE
(Mestinon)
pyridostigmine bromide
STRATTERA
XENAZINE
XYREM
Secondary Amines
(Amoxapine)
amoxapine
(Norpramin)
desipramine hcl
(Nortriptyline HCl)
nortriptyline hcl
(Pamelor)
nortriptyline hcl
(Vivactil)
protriptyline hcl
Sedative/hypnotic Drugs
ROZEREM
1
2
1
2
2
1
2
3
3
PA
PA
LA, PA
LA
1
1
1
1
1
2
temazepam
zaleplon
(Temazepam)
(Sonata)
1
1
zaleplon
(Sonata)
1
zolpidem tartrate
(Ambien)
1
Selective Serotonin Reuptake Inhibitors
citalopram hydrobromide (Celexa)
Requirements/Limits
1
citalopram hydrobromide
(Celexa)
1
citalopram hydrobromide
(Celexa)
1
citalopram hydrobromide
escitalopram oxalate
escitalopram oxalate
(Citalopram Hydrobromide)
(Lexapro)
(Lexapro)
1
1
1
escitalopram oxalate
(Lexapro)
1
solution
capsule
ST, QL:
34 in 34
days
QL: 34 in capsule: 5mg
34 days
QL: 68 in capsule: 10mg
34 days
QL: 34 in
34 days
QL: 136 tablet: 10mg
in 34
days
QL: 34 in tablet: 40mg
34 days
QL: 68 in tablet: 20mg
34 days
solution
solution
QL: 136 tablet: 5mg
in 34
days
QL: 34 in tablet: 20mg
34 days
46
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
escitalopram oxalate
(Lexapro)
1
fluoxetine hcl
(Prozac)
1
fluoxetine hcl
(Prozac)
1
fluoxetine hcl
(Prozac)
1
fluoxetine hcl
(Prozac)
1
fluvoxamine maleate
(Fluvoxamine Maleate)
1
fluvoxamine maleate
(Fluvoxamine Maleate)
1
fluvoxamine maleate
(Fluvoxamine Maleate)
1
fluvoxamine maleate
(Luvox CR)
1
paroxetine hcl
(Paxil)
1
paroxetine hcl
(Paxil)
1
paroxetine hcl
(Paxil)
1
paroxetine hcl
(Paxil)
1
PAXIL
sertraline hcl
sertraline hcl
(Zoloft)
(Zoloft)
2
1
1
sertraline hcl
(Zoloft)
1
Requirements/Limits
QL: 68 in tablet: 10mg
34 days
capsule: 20mg;
solution, tablet:
20mg, 60mg
QL: 272 capsule: 10mg;
in 34
tablet: 10mg
days
QL: 5 in capsule dr
34 days
QL: 68 in capsule: 40mg
34 days
QL: 102 tablet: 100mg
in 34
days
QL: 204 tablet: 50mg
in 34
days
QL: 408 tablet: 25mg
in 34
days
QL: 68 in cap er 24h
34 days
QL: 102 tab er 24h: 25mg;
in 34
tablet: 20mg
days
QL: 204 tab er 24h: 12.5mg;
in 34
tablet: 10mg
days
QL: 51 in tablet: 40mg
34 days
QL: 68 in tab er 24h: 37.5mg;
34 days tablet: 30mg
ST
oral susp
oral conc
QL: 136 tablet: 50mg
in 34
days
QL: 272 tablet: 25mg
in 34
days
47
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
sertraline hcl
(Zoloft)
1
VIIBRYD
2
VIIBRYD
2
VIIBRYD
2
VIIBRYD
2
Smoking Cessation Products
(Bupropion HCl)
bupropion hcl
CHANTIX
NICOTROL NS
NICOTROL
Succinimides
CELONTIN
(Zarontin)
ethosuximide
Tertiary Amines
(Amitriptyline HCl)
amitriptyline hcl
(Anafranil)
clomipramine hcl
(Doxepin HCl)
doxepin hcl
(Tofranil)
imipramine hcl
(Tofranil-PM)
imipramine pamoate
(Surmontil)
trimipramine maleate
Valproic Acid And Derivatives
(Depakote ER)
divalproex sodium
(Depacon)
valproate sodium
(Depakene)
valproic acid
Requirements/Limits
QL: 68 in
34 days
ST, QL:
136 in 34
days
ST, QL:
30 in 30
days
ST, QL:
34 in 34
days
ST, QL:
68 in 34
days
tablet: 100mg
tablet: 10mg
tab ds pk
tablet: 40mg
tablet: 20mg
1
2
2
2
2
1
1
1
1
1
1
1
1
1
1
Cardiovascular Medications
Angiotensin Converting Enzyme Inhibitors
(Lotensin)
benazepril hcl
(Captopril)
captopril
(Vasotec)
enalapril maleate
(Fosinopril Sodium)
fosinopril sodium
(Zestril)
lisinopril
(Univasc)
moexipril hcl
1
1
1
1
1
1
48
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
(Aceon)
perindopril erbumine
(Accupril)
quinapril hcl
(Altace)
ramipril
(Mavik)
trandolapril
Angiotensin II Receptor Antagonists
BENICAR
(Atacand)
candesartan cilexetil
DIOVAN
(Teveten)
eprosartan mesylate
(Avapro)
irbesartan
(Cozaar)
losartan potassium
MICARDIS
Antidysrhythmic Drugs
(Tambocor)
flecainide acetate
(Lidocaine HCl)
lidocaine hcl
(Mexiletine HCl)
mexiletine hcl
(Procainamide HCl)
procainamide hcl
(Procainamide HCl)
procainamide hcl
(Rythmol)
propafenone hcl
(Quinidine Gluconate)
quinidine gluconate
(Quinidine Sulfate)
quinidine sulfate
Beta-adrenergic Antagonist Drugs
(Sectral)
acebutolol hcl
(Tenormin)
atenolol
(Kerlone)
betaxolol hcl
(Zebeta)
bisoprolol fumarate
BYSTOLIC
(Coreg)
carvedilol
DUTOPROL
(Trandate)
labetalol hcl
(Toprol XL)
metoprolol succinate
(Lopressor)
metoprolol tartrate
(Corgard)
nadolol
(Pindolol)
pindolol
(Propranolol HCl)
propranolol hcl
(Timolol Maleate)
timolol maleate
Calcium Antagonists
(Norvasc)
amlodipine besylate
(Cardizem CD)
diltiazem hcl
(Felodipine)
felodipine
(Isradipine)
isradipine
Requirements/Limits
1
1
1
1
2
1
2
1
1
1
2
1
1
1
1
1
1
1
1
ST
ST
ST
capsule, tablet sa
vial
1
1
1
1
2
1
2
1
1
1
1
1
1
1
1
1
1
1
49
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
nicardipine hcl
nifedipine
nimodipine
nisoldipine
verapamil hcl
(Nicardipine HCl)
(Procardia XL)
(Nimotop)
(Sular)
(Calan SR)
1
1
1
1
1
verapamil hcl
(Verelan)
1
Centrally Acting Antihypertensives
(Catapres)
clonidine hcl
(Catapres-TTS 3)
clonidine
1
1
(Tenex)
guanfacine hcl
(Methyldopa)
methyldopa
(Methyldopate HCl)
methyldopate hcl
Drugs For Pheochromocytoma
DEMSER
DIBENZYLINE
HMG-CoA Reductase Inhibitors
ADVICOR
tab er 24, tablet er
ampul, cap24h pct,
cap24h pel: 120mg,
180mg, 240mg;
tablet, tablet er
cap24h pel: 360mg;
disp syrin
QL: 5 in
35 days
1
1
1
2
2
2
ADVICOR
atorvastatin calcium
Requirements/Limits
2
(Lipitor)
1
CRESTOR
2
CRESTOR
2
fluvastatin sodium
(Lescol)
1
fluvastatin sodium
(Lescol)
1
lovastatin
(Mevacor)
1
lovastatin
(Mevacor)
1
QL: 34 in
34 days
QL: 68 in
34 days
QL: 34 in
34 days
QL: 34 in
34 days
ST, QL:
34 in 34
days
QL: 34 in
34 days
QL: 68 in
34 days
QL: 34 in
34 days
QL: 68 in
34 days
tbmp 24hr: 500mg20mg
tbmp 24hr: 750mg20mg, 1000-20mg,
1000-40mg
tablet: 10mg, 20mg,
40mg
tablet: 5mg
capsule: 20mg
capsule: 40mg
tablet: 10mg
tablet: 20mg, 40mg
50
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
pravastatin sodium
(Pravachol)
1
SIMCOR
2
SIMCOR
2
simvastatin
(Zocor)
1
Hypolipoproteinemics
(Questran)
cholestyramine (with
sugar)
cholestyramine/aspartame (Questran Light)
(Colestid)
colestipol hcl
(Triglide)
fenofibrate
nanocrystallized
(Lofibra)
fenofibrate
(Antara)
fenofibrate,micronized
(Fibricor)
fenofibric acid
(Lopid)
gemfibrozil
KYNAMRO
LIPOFEN
LOVAZA
NIASPAN
WELCHOL
ZETIA
Loop Diuretics
bumetanide
furosemide
furosemide
torsemide
Nitrates
isosorbide dinitrate
isosorbide mononitrate
NITRO-BID
nitroglycerin
nitroglycerin
Requirements/Limits
QL: 34 in
34 days
QL: 34 in tbmp 24hr: 500mg34 days 20mg, 500mg40mg, 1000-40mg
QL: 68 in tbmp 24hr: 750mg34 days 20mg
QL: 34 in
34 days
1
1
1
1
1
1
1
1
3
2
2
2
2
2
(Bumetanide)
(Furosemide)
(Lasix)
(Demadex)
1
1
1
1
(Isordil Titradose)
(Imdur)
(Nitro-dur)
1
1
1
1
(Nitrolingual)
1
PA, QL:
4 in 28
days
ST
PA
disp syrin
solution, tablet, vial
patch td24: 0.1mg/
hr, 0.2mg/hr, 0.4mg/
hr, 0.6mg/hr; vial:
50mg/10ml
spray, vial: 5mg/ml
51
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
NITROSTAT
Other Antiarrhythmics
(Cordarone)
amiodarone hcl
(Milrinone Lactate)
milrinone lactate
(Milrinone Lactate/D5W)
milrinone lactate/d5w
(Betapace)
sotalol hcl
TIKOSYN
Other Antihypertensives
(Lotrel)
amlodipine besylate/
benazepril
AMTURNIDE
(Tenoretic 100)
atenolol/chlorthalidone
AZOR
(Lotensin HCT)
benazepril/
hydrochlorothiazide
BENICAR HCT
(Ziac)
bisoprolol fumarate/hctz
(Atacand HCT)
candesartan/
hydrochlorothiazid
(Captopril/
captopril/
hydrochlorothiazide)
hydrochlorothiazide
(Clonidine HCl/
clonidine hcl/
chlorthalidone)
chlorthalidone
(Vaseretic)
enalapril/
hydrochlorothiazide
EXFORGE HCT
EXFORGE
(Fosinopril/
fosinopril/
hydrochlorothiazide)
hydrochlorothiazide
(Avalide)
irbesartan/
hydrochlorothiazide
(Zestoretic)
lisinopril/
hydrochlorothiazide
(Hyzaar)
losartan/
hydrochlorothiazide
(Methyldopa/
methyldopa/
hydrochlorothiazide)
hydrochlorothiazide
(Lopressor HCT)
metoprolol/
hydrochlorothiazide
MICARDIS HCT
(Uniretic)
moexipril/
hydrochlorothiazide
Requirements/Limits
2
1
1
1
1
2
1
2
1
2
1
ST
2
1
1
ST
ST
1
1
1
2
2
1
ST
ST
1
1
1
1
1
2
1
ST
52
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
(Corzide)
nadolol/
bendroflumethiazide
(Phentolamine Mesylate)
phentolamine mesylate
(Propranolol/
propranolol/
hydrochlorothiazid)
hydrochlorothiazid
(Accuretic)
quinapril/
hydrochlorothiazide
(Reserpine)
reserpine
(Reserpine/
reserpine/
hydrochlorothiazide)
hydrochlorothiazide
TEKAMLO
TEKTURNA HCT
TEKTURNA
TRIBENZOR
TWYNSTA
(Diovan HCT)
valsartan/
hydrochlorothiazide
VECAMYL
Other Cardiovascular Drugs
(Caduet)
amlodipine/atorvastatin
(Lanoxin)
digoxin
DIGOXIN
(Dobutamine HCl)
dobutamine hcl
(Dobutamine HCl/D5W)
dobutamine hcl/d5w
(Dopamine HCl)
dopamine hcl
(Dopamine HCl/D5W)
dopamine hcl/d5w
(Dopamine HCl/dextrose 5%dopamine hcl/dextrose
water)
5%-water
(Midodrine HCl)
midodrine hcl
norepinephrine bitartrate (Levophed Bitartrate)
(Trental)
pentoxifylline
RANEXA
(Sodium Polystyrene
sodium polystyrene
Sulfonate)
sulfonate
Other Vasodilating Drugs
ADCIRCA
LETAIRIS
REMODULIN
REVATIO
TRACLEER
Requirements/Limits
1
1
1
1
1
1
2
2
2
2
2
1
ST
ST
ST
ST
ST
3
1
1
1
1
1
1
1
1
1
1
1
2
1
3
3
3
3
3
PA, QL:
68 in 34
days
LA, PA
LA, PA
LA, PA
53
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
Potassium Sparing Diuretics
(Amiloride HCl)
amiloride hcl
(Amiloride/
amiloride/
hydrochlorothiazide)
hydrochlorothiazide
(Inspra)
eplerenone
(Aldactazide)
spironolact/
hydrochlorothiazid
(Aldactone)
spironolactone
(Maxzide-25mg)
triamterene/
hydrochlorothiazid
Thiazide And Related Drugs
(Diuril Sodium)
chlorothiazide sodium
(Chlorothiazide)
chlorothiazide
(Chlorthalidone)
chlorthalidone
(Hydrochlorothiazide)
hydrochlorothiazide
(Indapamide)
indapamide
(Methyclothiazide)
methyclothiazide
(Zaroxolyn)
metolazone
Vasodilator Antihypertensives
(Cardura)
doxazosin mesylate
1
1
1
1
1
1
3
1
1
1
1
1
1
1
doxazosin mesylate
(Cardura)
1
epoprostenol sodium
(glycine)
hydralazine hcl
hydralazine/
hydrochlorothiazid
minoxidil
prazosin hcl
terazosin hcl
(Flolan)
1
(Hydralazine HCl)
(Hydralazine/
hydrochlorothiazid)
(Minoxidil)
(Minipress)
(Terazosin HCl)
1
1
1
1
1
terazosin hcl
(Terazosin HCl)
1
VELETRI
Requirements/Limits
QL: 34 in tablet: 1mg, 2mg,
34 days 4mg
QL: 68 in tablet: 8mg
34 days
QL: 34 in capsule: 1mg, 2mg,
34 days 5mg
QL: 68 in capsule: 10mg
34 days
1
Dermatological Medications
Antiacne Drugs
adapalene
CLINDACIN P
clindamycin phos/benzoyl
perox
(Differin)
1
1
1
(Benzaclin)
PA
54
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
clindamycin phosphate
erythromycin base/ethanol
erythromycin/benzoyl
peroxide
metronidazole
tretinoin microspheres
tretinoin
Requirements/Limits
(Cleocin T)
(Erygel)
(Benzamycin)
1
1
1
(Vitazol)
(Retin-a Micro)
(Retin-A)
1
1
1
PA
PA
1
2
2
1
3
1
2
PA
Antipsoriasis And Antieczema Drugs
(Calcipotriene)
calcipotriene
DRITHOCREME HP
PRUDOXIN
(Selenium Sulfide)
selenium sulfide
SORIATANE
(Sulfacetamide Sodium)
sulfacetamide sodium
TAZORAC
Oral Dermatological Drugs
8-MOP
(Isotretinoin)
isotretinoin
OXSORALEN-ULTRA
Scabicides
EURAX
(Lindane)
lindane
(Ovide)
malathion
(Elimite)
permethrin
Topical Antibacterial Drugs
(Bactroban)
mupirocin calcium
Topical Corticosteroid Drugs
(Aclovate)
alclometasone
dipropionate
(Amcinonide)
amcinonide
(Del-beta)
betamethasone
dipropionate
(Betamethasone Valerate)
betamethasone valerate
betamethasone/propylene (Diprolene AF)
glyc
(Temovate)
clobetasol propionate
(Desowen)
desonide
(Topicort)
desoximetasone
(Apexicon)
diflorasone diacetate
cream (g): 0.025%,
0.05%, 0.1%; gel
(gram): 0.01%,
0.025%
2
1
3
2
2
1
1
1
1
1
1
1
1
1
1
1
1
55
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
fluocinolone acetonide
fluocinolone/shower cap
fluocinonide
fluticasone propionate
halobetasol propionate
HALONATE
hydrocortisone butyrate
hydrocortisone valerate
hydrocortisone
(Synalar)
(Derma-smoothe-fs)
(Fluocinonide)
(Cutivate)
(Ultravate)
(Hydrocortisone Butyrate)
(Hydrocortisone Valerate)
(Hydrocortisone)
1
1
1
1
1
1
1
1
1
hydrocortisone
mometasone furoate
prednicarbate
triamcinolone acetonide
triamcinolone acetonide
(Hydrocortisone)
(Elocon)
(Dermatop)
(Triamcinolone Acetonide)
(Triamcinolone Acetonide)
1
1
1
1
1
TRIDERM
Topical Dermatological Drugs
(Drysol)
aluminum chloride
(Lac-hydrin)
ammonium lactate
ELIDEL
FLUOROPLEX
(Efudex)
fluorouracil
(Aldara)
imiquimod
(Nystatin)
nystatin
OXSORALEN
PANRETIN
(Condylox)
podofilox
(Potassium Hydroxide)
potassium hydroxide
PROTOPIC
REGRANEX
SANTYL
selenium sulfide
SOLARAZE
URAMAXIN
urea
urea/lactic ac/zn
undecylenate
(Uramaxin)
(Kerol)
cream (g): 1%,
2.5%; lotion: 2.5%;
oint. (g)
cream(gm)
cream
cream (g), lotion,
oint. (g)
1
1
1
2
2
1
1
1
2
3
1
1
2
2
2
1
2
1
1
1
(Selenium Sulfide)
Requirements/Limits
PA
PA
PA, QL:
30 in 34
days
PA
cream (g)
56
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
urea/lactic acid/salicyl
acid
UVADEX
ZONALON
ZYCLARA
ZYCLARA
(Kerol)
Requirements/Limits
1
2
2
2
2
cream pack
crm md pmp
Diagnostic And Miscellaneous Medications
Diagnostic Products
CHEMET
EXJADE
EXJADE
2
2
3
FERRIPROX
Miscellaneous Drugs
ADAGEN
AMPYRA
AUBAGIO
3
3
3
BUPHENYL
CARBAGLU
CHENODAL
COPAXONE
3
3
3
3
ELELYSO
ergoloid mesylates
fomepizole
GILENYA
KRYSTEXXA
ORFADIN
PROSTIN E2 VAGINAL
SUPPOSITORY
RAVICTI
sodium phenylbutyrate
THALOMID
tranexamic acid
tranexamic acid
VORAXAZE
LA
LA
tab disper: 125mg
tab disper: 250mg,
500mg
3
3
1
1
3
3
3
2
(Ergoloid Mesylates)
(Fomepizole)
3
3
3
1
(Buphenyl)
(Lysteda)
(Tranexamic Acid)
1
3
LA
LA, PA
PA, QL:
28 in 28
days
PA, QL:
30 in 30
days
tablet
PA
LA
PA
QL: 34 in tablet
34 days
vial
57
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
XELJANZ
3
XIAFLEX
2
Requirements/Limits
PA, QL:
60 in 30
days
Ear-nose-throat Medications
Drugs Affecting The Ear
(Aa/antipyrn/bcaine/polico#1/
aa/antipyrn/bcaine/
al)
polico#1/al
(Acetic Acid)
acetic acid
acetic acid/hydrocortisone (Vosol HC)
(Otra Nr)
antipyrine/benzocaine/
glycerin
CIPRODEX
(Cetraxal)
ciprofloxacin hcl
fluocinolone acetonide oil (Dermotic)
(Oticin HC)
neomycin/polymyxin b
sulf/hc
(Floxin)
ofloxacin
Drugs Affecting The Nose
(Astelin)
azelastine hcl
1
1
1
1
2
1
1
1
1
1
flunisolide
(Flunisolide)
1
flunisolide
(Flunisolide)
1
fluticasone propionate
(Flonase)
1
ipratropium bromide
(Atrovent)
1
ipratropium bromide
(Atrovent)
1
triamcinolone acetonide
(Nasacort Aq)
1
TYZINE
Drugs Affecting The Throat And Mouth
(Evoxac)
cevimeline hcl
(Peridex)
chlorhexidine gluconate
(Doxycycline Hyclate)
doxycycline hyclate
(Salagen)
pilocarpine hcl
(Prevident 5000 Plus)
sodium fluoride
(Stannous Fluoride)
stannous fluoride
(Triamcinolone Acetonide)
triamcinolone acetonide
2
QL: 60 in
34 days
QL: 75 in
34 days
QL: 75 in
34 days
QL: 32 in
34 days
QL: 30 in
34 days
QL: 60 in
34 days
QL: 33 in
34 days
spray: 25mcg
spray: 29mcg
spray: 42mcg
spray: 21mcg
drops
1
1
1
1
1
1
1
58
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
Requirements/Limits
Endocrine Medications
Antithyroid Drugs
(Tapazole)
methimazole
(Tapazole)
methimazole
(Propylthiouracil)
propylthiouracil
Glucocorticoid Drugs
A-METHAPRED
(Cortisone Acetate)
cortisone acetate
(Dexamethasone Acetate)
dexamethasone acetate
DEXAMETHASONE
INTENSOL
(Dexamethasone Sod
dexamethasone sod
Phosphate)
phosphate
(Dexamethasone Sod
dexamethasone sod
Phosphate)
phosphate
(Dexamethasone)
dexamethasone
(Cortef)
hydrocortisone
(Depo-medrol)
methylprednisolone
acetate
(Solu-medrol)
methylprednisolone sod
succ
(Medrol)
methylprednisolone
(Prednisolone Acetate)
prednisolone acetate
(Orapred)
prednisolone sod
phosphate
(Prednisolone)
prednisolone
PREDNISONE
INTENSOL
(Prednisone)
prednisone
(Prednisone)
prednisone
VERIPRED 20
Glucose Elevating Drugs
GLUCAGEN
GLUCAGON
EMERGENCY KIT
PROGLYCEM
Hypoglycemic Drugs
BYDUREON
1
1
1
tablet: 20mg
tablet: 5mg, 10mg
1
1
1
1
1
vial: 10mg/ml
1
vial: 4mg/ml
1
1
1
1
1
1
1
1
1
1
1
1
solution, tablet
tab ds pk
2
2
2
2
ST, QL:
4 in 28
days
59
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
BYETTA
2
BYETTA
2
SYMLIN
2
SYMLINPEN 120
2
SYMLINPEN 60
2
Insulin
HUMALOG MIX 50-50
HUMALOG MIX 75-25
HUMALOG
HUMULIN 70-30
HUMULIN N
HUMULIN R
LANTUS SOLOSTAR
LANTUS
LEVEMIR FLEXPEN
LEVEMIR
NOVOLIN 70-30
NOVOLIN N
NOVOLIN R
NOVOLOG FLEXPEN
NOVOLOG MIX 70-30
FLEXPEN
NOVOLOG MIX 70-30
NOVOLOG
Oral Hypoglycemics And Combos
(Precose)
acarbose
acarbose
Requirements/Limits
PA, QL:
2 in 34
days
PA, QL:
5 in 34
days
PA, QL:
20 in 34
days
PA, QL:
22 in 34
days
PA, QL:
12 in 34
days
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
pen injctr: 5mcg/
0.02
pen injctr: 10mcg/
0.04
vial: 100/ml
vial
vial
vial
2
2
1
(Precose)
1
QL: 102
in 34
days
QL: 204
in 34
days
tablet: 100mg
tablet: 50mg
60
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
acarbose
(Precose)
1
ACTOPLUS MET XR
2
ACTOPLUS MET XR
2
DUETACT
2
glimepiride
(Amaryl)
1
glimepiride
(Amaryl)
1
glimepiride
(Amaryl)
1
glipizide
(Glucotrol XL)
1
glipizide
(Glucotrol)
1
glipizide
(Glucotrol)
1
glipizide/metformin hcl
(Glipizide/metformin HCl)
1
glipizide/metformin hcl
(Glipizide/metformin HCl)
1
glyburide
(Glyburide)
1
glyburide
(Glyburide)
1
glyburide
(Glyburide)
1
Requirements/Limits
QL: 408
in 34
days
QL: 34 in
34 days
QL: 68 in
34 days
QL: 34 in
34 days
QL: 136
in 34
days
QL: 272
in 34
days
QL: 68 in
34 days
QL: 68 in
34 days
QL: 136
in 34
days
QL: 272
in 34
days
QL: 136
in 34
days
QL: 272
in 34
days
QL: 136
in 34
days
QL: 272
in 34
days
QL: 544
in 34
days
tablet: 25mg
tbmp 24hr: 301000mg
tbmp 24hr: 151000mg
tablet: 2mg
tablet: 1mg
tablet: 4mg
tab er 24: 10mg
tab er 24: 5mg;
tablet: 10mg
tab er 24: 2.5mg;
tablet: 5mg
tablet: 2.5-500mg,
5mg-500mg
tablet: 2.5-250mg
tablet: 5mg
tablet: 2.5mg
tablet: 1.25mg
61
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
glyburide,micronized
(Glynase)
1
glyburide,micronized
(Glynase)
1
glyburide,micronized
(Glynase)
1
glyburide/metformin hcl
(Glucovance)
1
glyburide/metformin hcl
(Glucovance)
1
INVOKANA
2
INVOKANA
2
JANUMET XR
2
JANUMET XR
2
JANUMET
2
JANUVIA
2
JUVISYNC
2
KOMBIGLYZE XR
2
KOMBIGLYZE XR
2
metformin hcl
(Glucophage XR)
1
metformin hcl
(Glucophage)
1
Requirements/Limits
QL: 136
in 34
days
QL: 272
in 34
days
QL: 68 in
34 days
QL: 136
in 34
days
QL: 272
in 34
days
ST, QL:
30 in 30
days
ST, QL:
60 in 30
days
QL: 34 in
34 days
tablet: 3mg
tablet: 1.5mg
tablet: 6mg
tablet: 2.5-500mg,
5mg-500mg
tablet: 1.25-250mg
tablet: 300mg
tablet: 100mg
tbmp 24hr: 50mg500mg, 1001000mg
QL: 68 in tbmp 24hr: 5034 days 1000mg
QL: 68 in
34 days
QL: 34 in
34 days
QL: 34 in
34 days
QL: 34 in tbmp 24hr: 5mg34 days 1000mg, 5mg500mg
QL: 68 in tbmp 24hr: 2.534 days 1000mg
QL: 136 tab er 24h: 500mg
in 34
days
QL: 102 tablet: 850mg
in 34
days
62
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
metformin hcl
(Glucophage)
1
metformin hcl
(Glucophage)
1
nateglinide
(Starlix)
1
nateglinide
(Starlix)
1
ONGLYZA
pioglitazone hcl
2
(Actos)
1
(Duetact)
pioglitazone hcl/
glimepiride
pioglitazone hcl/metformin (Actoplus Met)
hcl
1
1
RIOMET
2
TECFIDERA
3
TECFIDERA
3
tolazamide
(Tolazamide)
1
tolazamide
(Tolazamide)
1
tolbutamide
(Tolbutamide)
1
Other Endocrine Drugs
ALDURAZYME
3
Requirements/Limits
QL: 170 tablet: 500mg
in 34
days
QL: 85 in tab er 24, tab er 24h:
34 days 750mg; tablet:
1000mg
QL: 102 tablet: 120mg
in 34
days
QL: 204 tablet: 60mg
in 34
days
QL: 34 in
34 days
QL: 34 in
34 days
QL: 34 in
34 days
QL: 102
in 34
days
QL: 867
in 34
days
PA, QL: capsule dr: 120mg
14 in 60
days
PA, QL: capsule dr: 12060 in 30 240mg, 240mg
days
QL: 136 tablet: 250mg
in 34
days
QL: 68 in tablet: 500mg
34 days
QL: 204
in 34
days
LA
63
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
alendronate sodium
(Alendronate Sodium)
1
alendronate sodium
(Fosamax)
1
alendronate sodium
(Fosamax)
1
ANADROL-50
BONIVA
cabergoline
3
2
(Cabergoline)
1
calcitonin,salmon,syntheti (Miacalcin)
c
CEREZYME
(DDAVP)
desmopressin acetate
desmopressin acetate
ELAPRASE
etidronate disodium
EVISTA
FABRAZYME
fludrocortisone acetate
FORTEO
FORTICAL
H.P. ACTHAR
ibandronate sodium
INCRELEX
KUVAN
LUMIZYME
MIACALCIN
MYOZYME
NAGLAZYME
pamidronate disodium
RECLAST
SAMSCA
Requirements/Limits
QL: 375
in 35
days
QL: 34 in
34 days
QL: 5 in
35 days
PA
ST, QL:
1 in 30
days
QL: 20 in
34 days
solution
tablet: 5mg, 10mg,
40mg
tablet: 35mg, 70mg
tablet
1
3
1
(Desmopressin Acetate)
(Didronel)
(Fludrocortisone Acetate)
1
3
1
2
3
1
3
1
3
1
(Boniva)
(Pamidronate Disodium)
3
3
3
2
3
3
1
2
3
LA
ampul, spray/pump,
tablet
solution
LA
LA
PA, QL:
3 in 28
days
QL: 1 in
30 days
LA
LA
LA
vial
LA
LA
PA
PA
PA, QL:
68 in 34
days
64
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
SENSIPAR
SENSIPAR
SOMAVERT
VPRIV
XGEVA
ZAVESCA
(Zometa)
zoledronic acid
(Reclast)
zoledronic acid/
mannitol&water
ZOMETA
Thyroid Supplements
ARMOUR THYROID
LEVOTHROID
(Levothyroxine Sodium)
levothyroxine sodium
(Synthroid)
levothyroxine sodium
LEVOXYL
(Cytomel)
liothyronine sodium
THYROLAR-1/2
THYROLAR-1/4
THYROLAR-1
THYROLAR-2
THYROLAR-3
UNITHROID
2
3
3
3
3
3
1
1
Requirements/Limits
tablet: 30mg
tablet: 60mg, 90mg
LA
LA
PA
3
infus. btl
2
1
1
1
1
1
2
2
2
2
2
1
vial
tablet
Gastrointestinal Medications
Antidiarrheal Drugs
diphenoxylate hcl/atropine (Lomotil)
FULYZAQ
1
2
(Loperamide HCl)
loperamide hcl
(Opium Tincture)
opium tincture
(Paregoric)
paregoric
Antispasmodics/drugs Affect Gi Motility
(Robinul)
glycopyrrolate
(Metoclopramide HCl)
metoclopramide hcl
(Reglan)
metoclopramide hcl
Antiulcer Drugs
(Cimetidine HCl)
cimetidine hcl
(Cimetidine In 0.9 % NaCl)
cimetidine in 0.9 % nacl
(Tagamet)
cimetidine
(Famotidine In Nacl,iso-osm/
famotidine in nacl,isoPF)
osm/pf
QL: 60 in
30 days
1
1
1
1
1
1
disp syrin
solution, tablet, vial
1
1
1
1
65
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
(Pepcid)
famotidine
(Axid)
nizatidine
(Zantac)
ranitidine hcl
Other Antiulcer Drugs
CARAFATE
(Cytotec)
misoprostol
(Carafate)
sucralfate
(Sucralfate)
sucralfate
Other Gi Drugs
AMITIZA
APRISO
(Colazal)
balsalazide disodium
(Entocort EC)
budesonide
CANASA
CORTIFOAM
CREON
(Dimenhydrinate)
dimenhydrinate
(Anusol-HC)
hydrocortisone
1
1
1
(Anusol-HC)
hydrocortisone
(Zenpep)
lipase/protease/amylase
LOTRONEX
(Rowasa)
mesalamine w/cleansing
wipes
peg 3350/na sulf,bicarb,cl/ (Colyte with Flavor Packets)
kcl
PENTASA
polyethylene glycol 3350 (Polyethylene Glycol 3350)
RECTIV
RELISTOR
sodium chloride/nahco3/ (Nulytely with Flavor Packs)
kcl/peg
SUCRAID
(Azulfidine)
sulfasalazine
(Actigall)
ursodiol
ZENPEP
Proton Pump Inhibitors
(Prevacid)
lansoprazole
(Prevacid)
lansoprazole
1
1
3
1
2
1
1
1
2
2
1
3
2
2
2
1
1
Requirements/Limits
oral susp
tablet
oral susp
cream (g): 1%,
2.5%; enema:
100mg/60ml
cream (g): 2.5%
1
2
1
2
2
1
vial
3
1
1
2
1
1
capsule dr: 30mg
QL: 34 in capsule dr: 15mg
34 days
66
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
lansoprazole
(Prevacid)
1
NEXIUM I.V.
NEXIUM
2
2
NEXIUM
2
omeprazole
omeprazole
(Prilosec)
(Prilosec)
1
1
omeprazole/sodium
bicarbonate
omeprazole/sodium
bicarbonate
pantoprazole sodium
pantoprazole sodium
(Zegerid)
1
(Zegerid)
1
(Protonix)
(Protonix)
1
1
Requirements/Limits
QL: 34 in tab rap dr
34 days
ST, QL:
34 in 34
days
ST
capsule dr: 20mg;
suspdr pkt: 10mg,
20mg
capsule dr: 40mg;
suspdr pkt: 40mg
capsule dr: 40mg
QL: 34 in capsule dr: 10mg,
34 days 20mg
capsule: 40mg-1.1g
QL: 34 in capsule: 20mg-1.1g
34 days
tablet dr: 40mg; vial
QL: 34 in tablet dr: 20mg
34 days
Immunologicals And Vaccines
Growth Hormones And Related Drugs
EGRIFTA
EGRIFTA
OMNITROPE
OMNITROPE
SAIZEN
SAIZEN
VANTAS
Immunologicals And Vaccines
ACTHIB
ADACEL
ADACEL
ATGAM
BCG VACCINE (TICE
STRAIN)
BOOSTRIX
CARIMUNE NF
NANOFILTERED
CERVARIX
CINRYZE
COMVAX
DAPTACEL
3
3
2
3
3
3
2
2
2
2
3
2
2
3
2
3
2
2
PA
PA
PA
PA
PA
PA
vial: 1mg
vial: 2mg
cartridge
vial
cartridge, vial: 5mg
vial: 8.8mg
disp syrin
vial
PA
PA
PA
67
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
DIPHTHERIATETANUS TOXOID
DIPHTHERIATETANUS TOXOIDSPED
ENGERIX-B
FIRAZYR
FLEBOGAMMA DIF
FLEBOGAMMA
GAMASTAN S-D
GAMMAGARD LIQUID
GAMMAPLEX
GAMUNEX-C
GARDASIL
GARDASIL
HAVRIX
HIZENTRA
HYPERHEP B S-D
HYPERRAB S-D
HYPERRHO S-D
IMOGAM RABIES-HT
IMOVAX RABIES
VACCINE
INFANRIX PF
INFANRIX
IPOL
IXIARO
JE-VAX
MENACTRA
MENOMUNE-A-C-Y-W135
MENVEO A-C-Y-W-135DIP
MICRHOGAM PLUS
M-M-R II VACCINE
MOZOBIL
OCTAGAM
PEDIARIX
PEDVAXHIB
PRIVIGEN
Requirements/Limits
2
2
2
3
3
3
2
3
3
3
2
2
2
2
2
2
2
2
2
PA
PA
PA
PA
PA
PA
PA
disp syrin
vial
PA
PA
2
2
2
2
2
2
2
2
2
2
3
3
2
2
3
PA
PA
68
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
Requirements/Limits
PROCRIT
2
PA
PROCRIT
3
PA
PROMACTA
PROQUAD
RABAVERT
RECOMBIVAX HB
3
2
2
2
LA, PA
RECOMBIVAX HB
2
RHOGAM PLUS
RHOPHYLAC
ROTATEQ
TE ANATOXAL BERNA
TENIVAC
TETANUS DIPHTHERIA
TOXOIDS
TETANUS TOXOID
ADSORBED
TETANUS-DIPHTERIADECAVAC
THERACYS
TRIPEDIA
TWINRIX
TWINRIX
TYPHIM VI
VAQTA
VAQTA
VARIVAX VACCINE
WINRHO SDF
YF-VAX
ZOSTAVAX
Interferons
ACTIMMUNE
ALFERON N
AVONEX
ADMINISTRATION
PACK
2
2
2
2
2
2
2
vial: 2000/ml, 3000/
ml, 4000/ml, 10000/
ml
vial: 20000/ml,
40000/ml
disp syrin: 10mcg/
ml; vial
disp syrin: 5mcg/
0.5ml
PA
PA
2
2
2
2
2
2
2
2
2
2
2
2
3
3
3
disp syrin
vial
disp syrin
vial
LA
PA, QL:
4 in 28
days
69
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
AVONEX
3
INFERGEN
INTRON A
3
2
INTRON A
3
INTRON A
3
PEGASYS PROCLICK
3
PEGASYS
3
PEGINTRON REDIPEN
3
PEGINTRON
3
PEGINTRON
3
REBIF REBIDOSE
3
REBIF REBIDOSE
3
REBIF
3
REBIF
3
SYLATRON
Interleukin Recptr Antagonist
ACTEMRA
3
3
Requirements/Limits
PA, QL:
4 in 28
days
pen ij kit: 3mm/
0.2ml, 10mm/0.2ml;
vial: 6mmunit/ml,
10mm/ml
pen ij kit: 5mm/
0.2ml
vial: 18mmunit,
50mmunit
PA, QL:
4 in 28
days
PA, QL:
4 in 28
days
PA, QL:
5 in 34
days
PA, QL:
5 in 34
days
PA, QL:
5 in 34
days
PA, QL:
12 in 28
days
PA, QL:
8 in 35
days
PA, QL:
12 in 28
days
PA, QL:
8 in 35
days
kit: 50mcg/0.5
kit: 80mcg/0.5,
120mcg/0.5,
150mcg/0.5
pen injctr: 8.8-22(6)
pen injctr: 22mcg/
.5ml, 44mcg/.5ml
disp syrin: 8.8-22(6)
disp syrin: 22mcg/
.5ml, 44mcg/.5ml
PA
70
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
Requirements/Limits
ARCALYST
ILARIS
Interleukins
NEUMEGA
3
3
LA, PA
LA, PA
3
QL: 21 in
21 days
PROLEUKIN
Myeloid Stimulants
LEUKINE
NEULASTA
3
NEUPOGEN
3
3
3
PA, QL:
2 in 30
days
PA
Medical (miscellaneous) Supplies
Diabetic Supplies
alcohol antiseptic pads
gauze bandage
needles, insulin disp.,
safety
needles, insulin disposable
syring wndl,disp,insul,0.3ml
syring wndl,disp,insul,0.5ml
syringe & needle,insulin,1
ml
(Alcohol Antiseptic Pads)
(Gauze Bandage)
(Needles, Insulin Disp.,
Safety)
(Needles, Insulin Disposable)
(Syring Wndl,disp,insul,0.3ml)
(Syring Wndl,disp,insul,0.5ml)
(Syringe & Needle,insulin,1
Ml)
2
2
2
2
2
2
2
Musculoskeletal Medications
Cns Muscle Relaxants
(Parafon Forte DSC)
chlorzoxazone
(Skelaxin)
metaxalone
(Robaxin)
methocarbamol
(Orphenadrine Citrate)
orphenadrine citrate
(Orphenadrine Citrate)
orphenadrine citrate
(Orphenadrine/aspirin/
orphenadrine/aspirin/
caffeine)
caffeine
RILUTEK
Direct Muscle Relaxants
(Baclofen)
baclofen
(Dantrium)
dantrolene sodium
(Dantrium)
dantrolene sodium
1
1
1
1
1
1
PA
PA
PA
PA
PA
ampul
tablet er
3
1
1
1
capsule
vial
71
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
GABLOFEN
2
LIORESAL
INTRATHECAL
(Zanaflex)
tizanidine hcl
Drugs To Prevent And Treat Gout
(Aloprim)
allopurinol sodium
(Zyloprim)
allopurinol
(Colchicine/probenecid)
colchicine/probenecid
COLCRYS
(Probenecid)
probenecid
ULORIC
Non-steroidal Antiinflammatory Agents
CELEBREX
choline sal/mag salicylate (Choline Sal/mag Salicylate)
(Cataflam)
diclofenac potassium
(Diclofenac Sodium)
diclofenac sodium
(Synalgos-dc)
dihydrocodeine/aspirin/
caffein
2
Requirements/Limits
disp syrin, vial:
10000/20ml, 40000/
20ml
1
1
1
1
2
1
2
2
1
1
1
1
etodolac
fenoprofen calcium
flurbiprofen
ibuprofen
indomethacin
ketoprofen
ketorolac tromethamine
ketorolac tromethamine
(Etodolac)
(Fenoprofen Calcium)
(Ansaid)
(Ibuprofen)
(Indomethacin)
(Ketoprofen)
(Ketorolac Tromethamine)
(Ketorolac Tromethamine)
1
1
1
1
1
1
1
1
ketorolac tromethamine
meclofenamate sodium
mefenamic acid
meloxicam
(Toradol)
(Meclofenamate Sodium)
(Ponstel)
(Mobic)
1
1
1
1
meloxicam
(Mobic)
1
nabumetone
naproxen sodium
naproxen
oxaprozin
piroxicam
(Nabumetone)
(Anaprox)
(Naprosyn)
(Oxaprozin)
(Feldene)
1
1
1
1
1
ST
ST
QL: 360
in 30
days
vial
QL: 20 in tablet
5 days
cartridge, disp syrin
oral susp, tablet:
15mg
QL: 34 in tablet: 7.5mg
34 days
72
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
(Salsalate)
salsalate
(Clinoril)
sulindac
(Tolmetin Sodium)
tolmetin sodium
VOLTAREN
Other Drugs For Arthritis
CUPRIMINE
(Arthrotec 50)
diclofenac sodium/
misoprostol
(Diflunisal)
diflunisal
RIDAURA
SYPRINE
1
1
1
2
Requirements/Limits
ST
2
1
1
2
3
Nutrition,blood Modifiers,electrolytes
Antiplatelet Drugs
AGGRENOX
(Aminocaproic Acid)
aminocaproic acid
BRILINTA
(Pletal)
cilostazol
(Plavix)
clopidogrel bisulfate
(Persantine)
dipyridamole
EFFIENT
Blood Detoxicants
(Lactulose)
lactulose
(Lactulose)
lactulose
RENVELA
Electrolytes, Irrigating Solutions, Etc.
(0.9 % Sodium Chloride)
0.9 % sodium chloride
(Acetic Acid)
acetic acid
ALBUKED-25
ALBUKED-5
ALBUMIN (HUMAN)
ALBUMINAR-25
ALBUMINAR-5
ALBURX
ALBUTEIN
AMINO ACIDS
AMINOSYN II
AMINOSYN II
AMINOSYN II
AMINOSYN II
AMINOSYN M
2
1
2
1
1
1
2
1
1
2
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
solution
syrup
iv soln: 10%
iv soln: 15%
iv soln: 7%
iv soln: 8.5%
73
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
AMINOSYN with
ELECTROLYTES
AMINOSYN
AMINOSYN
AMINOSYN
AMINOSYN
AMINOSYN-HBC
AMINOSYN-PF
AMINOSYN-PF
AMINOSYN-RF
ammonium chloride
BUMINATE
calcium chloride
calcium gluconate
citric acid/sodium citrate
CLINIMIX E
CLINIMIX E
CLINIMIX E
CLINIMIX
CLINIMIX
CLINIMIX
CLINISOL
CYSTAGON
dextrose 10 % and 0.2 %
nacl
dextrose 10 % and 0.2 %
nacl
dextrose 10 % and 0.9 %
nacl
dextrose 10%-0.5 normal
saline
dextrose 10%-water
dextrose 2.5 % in water
dextrose 2.5% in half
ringers
dextrose 2.5%-0.5normal
saline
dextrose 20%-water
dextrose 25 % in water
dextrose 40%-water
Requirements/Limits
2
(Ammonium Chloride)
(Calcium Chloride)
(Calcium Gluconate)
(Citric Acid/sodium Citrate)
(Dextrose 10 % and 0.2 %
NaCl)
(Dextrose 10 % and 0.2 %
NaCl)
(Dextrose 10 % and 0.9 %
NaCl)
(Dextrose 10%-0.5 Normal
Saline)
(Dextrose 10%-water)
(Dextrose 2.5 % in Water)
(Dextrose 2.5% In Half
Ringers)
(Dextrose 2.5%-0.5 Normal
Saline)
(Dextrose 20%-water)
(Dextrose 25 % in Water)
(Dextrose 40%-water)
2
2
2
2
2
2
2
2
2
1
1
1
1
2
2
2
2
2
2
2
2
1
1
iv soln: 10%
iv soln: 3.5%
iv soln: 7%
iv soln: 8.5%
iv soln: 10%
iv soln: 7%
solution: 334500mg
iv soln: 2.75%
iv soln: 4.25%
iv soln: 5%
iv soln: 2.75%
iv soln: 4.25%
iv soln: 5%
LA
dehp fr bg
iv soln
1
1
1
1
1
1
1
1
1
74
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
dextrose 5 % and 0.3 %
nacl
dextrose 5 % and 0.9 %
nacl
dextrose 5 % in water
dextrose 5 %-0.2 % nacl
dextrose 5 %-0.45 % nacl
dextrose 5% in ringers
dextrose 5%-lactated
ringers
dextrose 50 % in water
dextrose 60 % in water
dextrose 70%-water
DEXTROSE W/
ELECTROLYTE A
DEXTROSE W/
ELECTROLYTE B
electrolyte-48 solution/
d5w
electrolyte-48/fructose
10%
electrolyte-48/fructose 5%
electrolyte-75 solution/
d5w
electrolyte-75/fructose 5%
electrolyte-r solution/d5w
FLEXBUMIN
FREAMINE HBC
FREAMINE III with
ELECTROLYTES
FREAMINE III
FREAMINE III
glucose and potassium
chloride and sodium
chloride
GLYCINE
HEPATAMINE
HEPATASOL
IONOSOL B with
DEXTROSE 5%
IONOSOL MBDEXTROSE 5%
(Dextrose 5 % and 0.3 %
NaCl)
(Dextrose 5 % and 0.9 %
NaCl)
(Dextrose 5 % in Water)
(Dextrose 5 %-0.2 % NaCl)
(Dextrose 5 %-0.45 % NaCl)
(Dextrose 5% In Ringers)
(Dextrose 5%-Lactated
Ringers)
(Dextrose 50 % in Water)
(Dextrose 60 % in Water)
(Dextrose 70%-water)
Requirements/Limits
1
1
1
1
1
1
1
1
1
1
2
2
(Electrolyte-48 Solution/
D5W)
(Electrolyte-48/fructose 10%)
(Electrolyte-48/fructose 5%)
(Electrolyte-75 Solution/
D5W)
(Electrolyte-75/fructose 5%)
(Normosol-r and Dextrose)
(Glucose and Potassium
Chloride and Sodium
Chloride)
1
1
1
1
1
1
1
2
2
2
2
1
iv soln: 10%
iv soln: 8.5%
1
2
2
2
2
75
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
IONOSOL T-DEXTROSE
5%
ISOLYTE E
ISOLYTE H W/
DEXTROSE
ISOLYTE M W/
DEXTROSE
ISOLYTE P with
DEXTROSE
ISOLYTE S with
DEXTROSE
ISOLYTE S
KEDBUMIN
K-PHOS NO.2
LACTATED RINGERS
LIPOSYN III
Requirements/Limits
2
2
2
2
2
2
2
1
2
1
1
magnesium sulfate
magnesium sulfate
(Magnesium Sulfate)
(Magnesium Sulfate)
1
1
magnesium sulfate/d5w
NEPHRAMINE
NEUT
NORMOSOL-M and
DEXTROSE
NORMOSOL-R and
DEXTROSE
NORMOSOL-R PH 7.4
NOVAMINE
NUTRILYTE
phosphorus #1
PLASBUMIN-25
PLASBUMIN-5
PLASMA-LYTE 148
PLASMA-LYTE 56 IN
DEXTROSE
PLASMA-LYTE A PH
7.4
PLASMA-LYTE M IN
DEXTROSE
potassium acetate
(Magnesium Sulfate/D5W)
1
2
2
2
iv soln
emulsion: 10%,
20%
disp syrin
infus. btl,
piggyback, vial
2
2
2
1
1
1
1
2
2
(K-phos Neutral)
2
2
(Potassium Acetate)
1
76
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
potassium chlorid/d100.2%nacl
potassium chloride in
0.9%nacl
potassium chloride in d5w
potassium chloride/d50.2%nacl
potassium chloride/d50.2%nacl
potassium chloride/d50.25ns
potassium chloride/d50.3%nacl
potassium chloride/d50.45nacl
potassium chloride/d50.9%nacl
potassium chloride-0.45%
nacl
potassium phos,m-basic-dbasic
PREMASOL
PREMASOL
PROCALAMINE
PROCYSBI
QUICK MIX with LYTES
RENACIDIN
ringers solution
sod/pot/k cit/sod cit/cit
acid
sodium bicarbonate
sodium chloride 0.45 %
sodium chloride 3%
sodium chloride 5%
sodium chloride irrig
solution
sodium chloride
sodium chloride
sodium lactate
STERILE DILUENT
TPN ELECTROLYTES
(Potassium Chlorid/d100.2%NaCl)
(Potassium Chloride In
0.9%NaCl)
(Potassium Chloride In D5w)
(Potassium Chloride/d50.2%NaCl)
(Potassium Chloride/d50.2%NaCl)
(Potassium Chloride/D5-0.25
NS)
(Potassium Chloride/d50.3%NaCl)
(Potassium Chloride/d50.45NaCl)
(Potassium Chloride/d50.9%NaCl)
(Potassium Chloride-0.45%
NaCl)
(Potassium Phos,m-basic-dbasic)
(Ringers Solution)
(Sod/pot/k Cit/sod Cit/cit
Acid)
(Sodium Bicarbonate)
(Sodium Chloride 0.45 %)
(Sodium Chloride 3%)
(Sodium Chloride 5%)
(Sodium Chloride Irrig
Solution)
(Sodium Chloride)
(Sodium Chloride)
(Sodium Lactate)
Requirements/Limits
1
1
1
1
iv soln: 10meq/l,
30meq/l, 40meq/l
iv soln: 20meq/l
1
1
1
1
1
1
1
2
2
2
3
2
2
1
1
iv soln: 10%
iv soln: 6%
LA
iv soln
1
1
1
1
1
1
1
1
1
2
iv soln
vial
77
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
TRAVASOL W/
DEXTROSE
TRAVASOL W/
ELECTROLYTES
TRAVASOL W/
ELECTROLYTES
TRAVASOL with
DEXTROSE
TRAVASOL with
ELECTROLYTES
TRAVASOL
TRAVASOL
TRAVASOL
TRAVERTELECTROLYTE NO.2
TRAVERTELECTROLYTE NO.2
TRAVERTELECTROLYTE NO.3
TRAVERTELECTROLYTE NO.4
TROPHAMINE
TROPHAMINE
Fluoride Products
(Luride)
sodium fluoride
Injectable Anticoagulants
(Aminocaproic Acid)
aminocaproic acid
(Lovenox)
enoxaparin sodium
Requirements/Limits
2
2
iv soln.: 5.5%
2
iv soln.: 8.5%
2
iv soln: 8.5%
2
2
2
2
2
iv soln: 10%
iv soln: 5.5%
iv soln: 8.5%
iv soln: 10%
2
iv soln: 5%
2
2
2
2
iv soln: 10%
iv soln: 6%
1
1
1
enoxaparin sodium
(Lovenox)
3
fondaparinux sodium
(Arixtra)
1
fondaparinux sodium
(Arixtra)
3
heparin sodium,porcine
heparin sodium,porcine/
d5w
(Heparin Sodium, porcine)
(Heparin Sodium, porcine/
D5W)
1
1
disp syrin: 30mg/
0.3ml, 40mg/0.4ml,
60mg/0.6ml, 80mg/
0.8ml, 100mg/ml;
vial
disp syrin: 120mg/
.8ml, 150mg/ml
disp syrin: 2.5mg/
0.5
disp syrin: 5mg/
0.4ml, 7.5mg/0.6,
10mg/0.8ml
PA
PA
78
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
(Heparin Sodium, porcine/ns/
heparin sodium,porcine/
PF)
ns/pf
heparin sodium,porcine/pf (Heparin Sodium, porcine/
PF)
heparin sodium,porcine/pf (Heparin Sodium, porcine/
PF)
Oral Anticoagulants, Vitamin K
PRADAXA
(Coumadin)
warfarin sodium
XARELTO
XARELTO
Potassium Supplements
K-PHOS ORIGINAL
pot chloride/pot bicarb/cit (Pot Chloride/pot Bicarb/cit
Ac)
ac
potassium bicarbonate/cit (Potassium Bicarbonate/cit
Ac)
ac
potassium chloride in d5w (Potassium Chloride In D5w)
potassium chloride in d5w (Potassium Chloride In D5w)
1
PA
1
PA
disp syrin, vial port
1
PA
vial
2
1
2
2
PA
PA
tablet: 10mg
tablet: 15mg, 20mg
2
1
1
1
1
potassium chloride in lrd5
potassium chloride
(Potassium Chloride In Lrd5)
(Kaochlor)
1
potassium chloride
(Potassium Chloride)
1
(Urocit-K)
potassium citrate
(Potassium Citrate/citric
potassium citrate/citric
Acid)
acid
(Potassium Gluconate)
potassium gluconate
Therapeutic Vitamins And Minerals
(Calcijex)
calcitriol
(Rocaltrol)
calcitriol
(Phoslo)
calcium acetate
(Calcium Carbonate/mag
calcium carbonate/mag
Carb/fa)
carb/fa
levocarnitine (with sugar) (Carnitor)
(Carnitor)
levocarnitine
ZEMPLAR
Requirements/Limits
iv soln: 10meq/l
iv soln: 20meq/l,
40meq/l
1
iv soln, liquid,
packet, tablet sa
capsule er, disp
syrin, piggyback,
tab er prt, tablet er
1
1
1
1
1
1
1
PA
1
1
2
PA
PA
PA
ampul
capsule, solution
79
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
Requirements/Limits
Obstetrical And Gynecological Medications
Androgen Drugs
danazol
fluoxymesterone
FORTESTA
METHITEST
oxandrolone
TESTOPEL
testosterone cypionate
testosterone enanthate
Contraceptives
AMETHYST
desogestrel-ethinyl
estradiol
desog-et estra/ethin estra
ethinyl estradiol/
drospirenone
ethynodiol d-ethinyl
estradiol
levonorgestrel
levonorgestrel
levonorgestrel-eth
estradiol
l-norgest-eth estr/ethin
estra
l-norgest-eth estr/ethin
estra
noreth a-et estra/fe
fumarate
noreth-ethinyl estradiol/
iron
norethindrone a-e
estradiol
norethindrone-ethinyl
estrad
norethindrone-mestranol
norgestimate-ethinyl
estradiol
norgestimate-ethinyl
estradiol
(Danazol)
(Fluoxymesterone)
(Depo-testosterone)
(Delatestryl)
1
2
2
2
1
2
1
1
(Desogen)
1
1
(Mircette)
(Yaz)
1
1
(Demulen 1-50-21)
1
(Plan B One-step)
(Plan B One-step)
1
1
(Chateal)
1
(Seasonique)
1
(Seasonique)
1
(Loestrin Fe)
1
(Femcon Fe)
1
(Loestrin)
1
(Ortho-novum)
1
(Norinyl 1+50)
(Ortho Tri-cyclen)
1
1
(Ortho Tri-cyclen)
1
(Oxandrin)
PA
PA
tablet: 1.5mg
QL: 2 per tablet: 0.75mg
fill
tbdspk 3mo: 10020(84)
tbdspk 3mo: 15030(84)
tablet: 0.25-0.035,
7daysx328
tablet: 7daysx328
80
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
norgestrel-ethinyl
estradiol
Estrogen Drugs
ESTRACE
estradiol valerate
estradiol
(Norgestrel-ethinyl Estradiol)
1
(Delestrogen)
(Climara)
2
1
1
(Estrace)
estradiol
(Ogen)
estropipate
FEMRING
MENEST
PREMARIN
VAGIFEM
Estrogen/progestin Combinations
(Activella)
estradiol/norethindrone
acet
(Norethind Ac/ethinyl
norethind ac/ethinyl
Estradiol)
estradiol
PREMPHASE
PREMPRO
Ob/gyn Topical Antiinfectives
(Cleocin)
clindamycin phosphate
FEM PH
GYNAZOLE-1
(Vandazole)
metronidazole
VANDAZOLE
Prenatal Vitamins
pnv with ca,no.72/iron/fa (Pnv with Ca,no.72/iron/fa)
Progestin Drugs
MAKENA
medroxyprogesterone
acetate
medroxyprogesterone
acetate
norethindrone acetate
norethindrone
progesterone
progesterone,micronized
(Medroxyprogesterone
Acetate)
(Provera)
(Aygestin)
(Nor-Q-D)
(Progesterone)
(Prometrium)
Requirements/Limits
cream/appl
QL: 5 in
35 days
patch tdwk
1
1
2
2
2
2
tablet
1
tablet: 1mg-0.5mg
cream/appl
1
2
2
1
1
2
1
1
1
3
1
1
(All prenatal
vitamins are
covered)
QL: 1 in
90 days
vial
tablet
1
1
1
1
81
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
Specialized Ob/gyn Drugs
CHORIONIC
GONADOTROPIN
(Leuprolide Acetate)
leuprolide acetate
LUPRON DEPOT
LUPRON DEPOT-PED
methylergonovine maleate (Methylergonovine Maleate)
methylergonovine maleate (Methylergonovine Maleate)
NOVAREL
SYNAREL
Vaginal Antifungals
(Terazol 7)
terconazole
1
1
3
3
1
1
1
3
1
Requirements/Limits
PA
PA
PA
tablet
vial
PA
QL: 20 in cream/appl: 0.8%
3 days
Ophthalmic Medications
Antiglaucoma Drugs
(Acetazolamide Sodium)
acetazolamide sodium
(Acetazolamide)
acetazolamide
ALPHAGAN P
(Iopidine)
apraclonidine hcl
AZOPT
(Betaxolol HCl)
betaxolol hcl
(Alphagan P)
brimonidine tartrate
(Carteolol HCl)
carteolol hcl
COMBIGAN
(Trusopt)
dorzolamide hcl
(Cosopt)
dorzolamide hcl/timolol
maleat
(Xalatan)
latanoprost
(Betagan)
levobunolol hcl
(Betagan)
levobunolol hcl
LUMIGAN
methazolamide
metipranolol
PHOSPHOLINE IODIDE
pilocarpine hcl
timolol maleate
TRAVATAN Z
travoprost (benzalkonium)
(Neptazane)
(Metipranolol)
1
1
2
1
2
1
1
1
2
1
1
1
1
1
2
1
1
2
1
1
2
1
(Isopto Carpine)
(Timoptic)
(Travatan)
drops: 0.1%
drops: 0.25%
drops: 0.5%
QL: 2.5
in 25
days
ST
82
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
Ophthalmic Antiinfective/corticosteroids
(Ak-trol)
neo/polymyx b sulf/
dexameth
(Triple Antibiotic HC)
neomy sulf/bacitrac zn/
poly/hc
(Neomycin Sulfate/dex Na
neomycin sulfate/dex na
Ph)
ph
(Neomycin/polymyxin B
neomycin/polymyxin b
Sulf/HC)
sulf/hc
(Sulfacetamide/prednisolone
sulfacetamide/
Sp)
prednisolone sp
(Tobradex)
tobramycin/
dexamethasone
ZYLET
Ophthalmic Corticosteroid Drugs
(Ak-dex)
dexamethasone sod
phosphate
DUREZOL
(Fluorometholone)
fluorometholone
FML S.O.P.
PRED MILD
(Pred Forte)
prednisolone acetate
(Prednisolone Sod Phosphate)
prednisolone sod
phosphate
Ophthalmic Topical Antibacterial Drugs
AZASITE
(Bacitracin)
bacitracin
(Polysporin)
bacitracin/polymyxin b
sulfate
(Ciloxan)
ciprofloxacin hcl
(Ilotycin)
erythromycin base
GARAMYCIN
(Garamycin)
gentamicin sulfate
(Levofloxacin)
levofloxacin
MOXEZA
(Neo-polycin)
neomy sulf/bacitra/
polymyxin b
(Neosporin)
neomycin/polymyxn b/
gramicidin
NEO-POLYCIN
(Ocuflox)
ofloxacin
Requirements/Limits
1
1
1
1
1
1
2
1
2
1
2
2
1
1
2
1
1
1
1
1
1
1
2
1
drops
1
1
1
83
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
polymyxin b sulf/
trimethoprim
sulfacetamide sodium
(Polytrim)
1
(Sulfacetamide Sodium)
1
(Tobrex)
tobramycin
VIGAMOX
ZYMAXID
Other Ophthalmic Drugs
(Isopto Atropine)
atropine sulfate
(Optivar)
azelastine hcl
BOTOX
BOTOX
BROMDAY
(Bromfenac Sodium)
bromfenac sodium
(Cromolyn Sodium)
cromolyn sodium
(Cyclogyl)
cyclopentolate hcl
CYSTARAN
Requirements/Limits
drops: 10%; oint.
(g)
1
2
2
1
1
2
2
2
1
1
1
3
diclofenac sodium
epinastine hcl
flurbiprofen sodium
homatropine hbr
ketorolac tromethamine
naphazoline hcl
NATACYN
NEVANAC
PATADAY
PATANOL
phenylephrine hcl
PROLENSA
proparacaine hcl
proparacaine/fluorescein
sod
RESTASIS
(Diclofenac Sodium)
(Elestat)
(Flurbiprofen Sodium)
(Isopto Homatropine)
(Acular LS)
(Naphazoline HCl)
tetracaine hcl/pf
trifluridine
tropicamide
VISUDYNE
ZIRGAN
(Tetracaine HCl/PF)
(Viroptic)
(Mydriacyl)
(Mydfrin)
(Proparacaine HCl)
(Proparacaine/fluorescein
Sod)
PA
PA
vial: 100unit
vial: 200unit
PA, QL:
60 in 28
days
1
1
1
1
1
1
2
2
2
2
1
2
1
1
2
QL: 60 in
30 days
1
1
1
2
2
84
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
Requirements/Limits
Respiratory Medications
Antihistamine And Decongestant Drugs
(Palgic)
carbinoxamine maleate
(Cetirizine HCl)
cetirizine hcl
(Clemastine Fumarate)
clemastine fumarate
1
1
1
(Clemastine Fumarate)
(Cyproheptadine HCl)
(Clarinex)
(Clarinex)
1
1
1
1
clemastine fumarate
cyproheptadine hcl
desloratadine
desloratadine
(Dexchlorpheniramine
dexchlorpheniramine
Maleate)
maleate
(Diphenhydramine HCl)
diphenhydramine hcl
(Diphenhydramine HCl)
diphenhydramine hcl
(Diphenhydramine HCl)
diphenhydramine hcl
(Allegra)
fexofenadine hcl
(Fexofenadine/
fexofenadine/
pseudoephedrine)
pseudoephedrine
(Xyzal)
levocetirizine
dihydrochloride
(Xyzal)
levocetirizine
dihydrochloride
PALGIC
(Promethazine HCl)
promethazine hcl
(Promethazine HCl)
promethazine hcl
Beta-2 Adrenergic Drugs
(Accuneb)
albuterol sulfate
tab rapdis
QL: 34 in tablet
34 days
1
1
1
1
1
1
disp syrin
vial
capsule: 50mg
PA
1
1
solution
QL: 34 in tablet
34 days
1
1
1
PA
1
PA
albuterol sulfate
(Albuterol Sulfate)
1
albuterol
FORADIL
(Albuterol)
1
2
metaproterenol sulfate
PROAIR HFA
(Metaproterenol Sulfate)
PROVENTIL HFA
syrup, tablet:
2.68mg
tablet: 1.34mg
1
2
2
ampul, vial
syrup, tablet
solution, vial-neb:
0.63mg/3ml,
1.25mg/3ml, 2.5mg/
3ml
syrup, tab er 12h,
tablet
QL: 120
in 34
days
QL: 26 in
34 days
QL: 20 in
34 days
85
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
SEREVENT DISKUS
2
(Terbutaline Sulfate)
terbutaline sulfate
Methyl Xanthine Drugs
(Aminophylline)
aminophylline
(Theophylline Anhydrous)
theophylline anhydrous
1
(Theophylline Anhydrous)
1
theophylline anhydrous
Requirements/Limits
QL: 120
in 34
days
1
1
Other Drugs For Asthma
ADVAIR DISKUS
2
ADVAIR HFA
2
ASMANEX
2
ASMANEX
2
ASMANEX
2
ASMANEX
2
ATROVENT HFA
2
COMBIVENT
RESPIMAT
COMBIVENT
2
2
cromolyn sodium
cromolyn sodium
DULERA
(Cromolyn Sodium)
(Gastrocrom)
1
1
2
epinephrine
epinephrine
EPIPEN 2-PAK
(Epinephrine)
(Epinephrine)
1
1
2
vial
solution, tab er 12h:
200mg
tab er 12h: 100mg,
200mg, 300mg,
450mg; tablet er
QL: 120
in 30
days
QL: 24 in
34 days
QL: 120
in 30
days
QL: 14 in
14 days
QL: 240
in 30
days
QL: 60 in
30 days
aer pow ba:
220mcg(60)
aer pow ba:
220mcg(14)
aer pow ba:
220mcg120
aer pow ba:
110mcg(30),
220mcg(30)
QL: 26 in
34 days
QL: 8 in
34 days
QL: 44 in
34 days
PA
ampul-neb
solution
QL: 13 in
28 days
ampul
disp syrin
QL: 4 in
2 days
86
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
EPIPEN JR 2-PAK
2
FLOVENT DISKUS
2
FLOVENT DISKUS
2
FLOVENT HFA
2
FLOVENT HFA
2
FLOVENT HFA
2
ipratropium bromide
montelukast sodium
QVAR
(Ipratropium Bromide)
(Singulair)
1
1
2
SPIRIVA
2
SYMBICORT
2
XOLAIR
3
(Accolate)
zafirlukast
Other Respiratory Drugs
ARALAST
KALYDECO
PROLASTIN C
PROLASTIN
PULMOZYME
1
3
3
3
3
3
Requirements/Limits
QL: 4 in
2 days
QL: 120
in 30
days
QL: 60 in
30 days
QL: 12 in
28 days
QL: 21.2
in 28
days
QL: 24 in
28 days
PA
disk w/dev: 250mcg
disk w/dev: 50mcg,
100mcg
aer w/adap: 110mcg
aer w/adap: 44mcg
aer w/adap: 220mcg
QL: 22 in
34 days
QL: 60 in
30 days
PA, QL: hfa aer ad: 8020 in 34 4.5mcg, 160-4.5mcg
days
LA, PA,
QL: 6 in
28 days
LA, PA
LA, PA
PA
PA
Urological Medications
Anticholinergic Antispasmodics
DETROL LA
ENABLEX
(Flavoxate HCl)
flavoxate hcl
(Ditropan XL)
oxybutynin chloride
oxybutynin chloride
2
2
1
1
(Oxybutynin Chloride)
1
ST
QL: 34 in tab er 24: 5mg
34 days
syrup, tab er 24:
10mg, 15mg; tablet
87
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
Drug
Tier
Drug Name
(Detrol)
tolterodine tartrate
TOVIAZ
(Sanctura)
trospium chloride
VESICARE
Other Genitourinary Products
(Uroxatral)
alfuzosin hcl
(Alprostadil)
alprostadil
AVODART
(Urecholine)
bethanechol chloride
CYSTADANE
ELMIRON
(Proscar)
finasteride
JALYN
neomy sulf/polymyxin b
sulfate
tamsulosin hcl
Requirements/Limits
1
2
1
2
1
1
2
1
2
2
1
2
(Neomy Sulf/polymyxin B
Sulfate)
(Flomax)
QL: 30 in
30 days
1
1
88
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
INDEX
0.9 % sodium chloride .......... 73
8-MOP................................... 55
aa/antipyrn/bcaine/polico#1/al
........................................... 58
abacavir sulfate..................... 21
ABELCET............................. 27
ABILIFY............................... 34
ABILIFY DISCMELT.......... 34
ABILIFY MAINTENA ........ 34
acarbose.......................... 60, 61
acebutolol hcl........................ 49
acetaminophen with codeine. 41
acetazolamide ....................... 82
acetazolamide sodium........... 82
acetic acid ....................... 58, 73
acetic acid/hydrocortisone.... 58
ACTEMRA ........................... 70
ACTHIB................................ 67
ACTIMMUNE...................... 69
ACTOPLUS MET XR.......... 61
acyclovir................................ 25
acyclovir sodium ................... 25
ADACEL .............................. 67
ADAGEN.............................. 57
adapalene.............................. 54
ADCIRCA............................. 53
ADVAIR DISKUS................ 86
ADVAIR HFA ...................... 86
ADVICOR ............................ 50
AFINITOR............................ 29
AFINITOR DISPERZ........... 29
AGGRENOX ........................ 73
ALBENZA............................ 21
ALBUKED-25 ...................... 73
ALBUKED-5 ........................ 73
ALBUMIN HUMAN............ 73
ALBUMINAR-25 ................. 73
ALBUMINAR-5 ................... 73
ALBURX .............................. 73
ALBUTEIN........................... 73
albuterol................................ 85
albuterol sulfate .................... 85
alclometasone dipropionate.. 55
alcohol antiseptic pads ......... 71
ALDURAZYME................... 63
alendronate sodium............... 64
ALFERON N ........................ 69
alfuzosin hcl .......................... 88
ALIMTA ............................... 29
ALINIA................................. 24
allopurinol............................. 72
allopurinol sodium ................ 72
ALOXI .................................. 38
ALPHAGAN P ..................... 82
alprostadil ............................. 88
aluminum chloride ................ 56
amantadine hcl...................... 25
AMBISOME ......................... 27
amcinonide............................ 55
A-METHAPRED.................. 59
AMETHYST......................... 80
AMEVIVE ............................ 29
amifostine crystalline ............ 30
amikacin sulfate .................... 20
amiloride hcl ......................... 54
amiloride/hydrochlorothiazide
........................................... 54
AMINO ACIDS .................... 73
aminocaproic acid .......... 73, 78
aminophylline........................ 86
AMINOSYN ......................... 74
AMINOSYN II ..................... 73
AMINOSYN M .................... 73
AMINOSYN with
ELECTROLYTES ............ 74
AMINOSYN-HBC ............... 74
AMINOSYN-PF ................... 74
AMINOSYN-RF................... 74
amiodarone hcl ..................... 52
AMITIZA.............................. 66
amitriptyline hcl .................... 48
amlodipine besylate .............. 49
amlodipine besylate/benazepril
........................................... 52
amlodipine/atorvastatin ........ 53
ammonium chloride .............. 74
ammonium lactate................. 56
amoxapine ............................. 46
amoxicillin............................. 27
amoxicillin/potassium clav.... 27
amphotericin b ...................... 27
ampicillin sodium.................. 27
ampicillin sodium/sulbactam na
........................................... 27
ampicillin trihydrate ............. 27
AMPYRA ............................. 57
AMTURNIDE....................... 52
ANADROL-50...................... 64
anagrelide hcl ....................... 30
anastrozole............................ 30
antipyrine/benzocaine/glycerin
........................................... 58
APOKYN.............................. 45
apraclonidine hcl .................. 82
APRISO ................................ 66
APTIVUS.............................. 21
ARALAST ............................ 87
ARCALYST ......................... 71
ARMOUR THYROID .......... 65
ASMANEX........................... 86
atenolol ................................. 49
atenolol/chlorthalidone......... 52
ATGAM................................ 67
atorvastatin calcium.............. 50
atovaquone/proguanil hcl ..... 28
ATRIPLA.............................. 21
atropine sulfate ............... 45, 84
ATROVENT HFA ................ 86
AUBAGIO ............................ 57
AUGMENTIN ...................... 27
AVASTIN ............................. 30
AVELOX IV......................... 28
AVODART ........................... 88
I-1
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
AVONEX.............................. 70
AVONEX
ADMINISTRATION PACK
........................................... 69
AZASAN .............................. 30
AZASITE.............................. 83
azathioprine .......................... 30
azathioprine sodium.............. 30
azelastine hcl................... 58, 84
AZILECT.............................. 45
azithromycin.......................... 26
AZOPT.................................. 82
AZOR.................................... 52
aztreonam.............................. 24
bacitracin ........................ 24, 83
bacitracin/polymyxin b sulfate
........................................... 83
baclofen................................. 71
balsalazide disodium............. 66
BANZEL............................... 43
BARACLUDE ...................... 25
BCG VACCINE TICE
STRAIN ............................ 67
benazepril hcl........................ 48
benazepril/hydrochlorothiazide
........................................... 52
BENICAR ............................. 49
BENICAR HCT .................... 52
BENLYSTA.......................... 30
benztropine mesylate............. 34
betamethasone dipropionate. 55
betamethasone valerate ........ 55
betamethasone/propylene glyc
........................................... 55
betaxolol hcl.................... 49, 82
bethanechol chloride............. 88
bicalutamide.......................... 30
bisoprolol fumarate............... 49
bisoprolol fumarate/hctz ....... 52
BONIVA ............................... 64
BOOSTRIX........................... 67
BOSULIF.............................. 30
BOTOX................................. 84
BRILINTA............................ 73
brimonidine tartrate.............. 82
BROMDAY .......................... 84
bromfenac sodium................. 84
bromocriptine mesylate......... 45
budesonide ............................ 66
bumetanide............................ 51
BUMINATE ......................... 74
BUPHENYL ......................... 57
buprenorphine hcl........... 33, 41
buprenorphine hcl/naloxone hcl
........................................... 41
bupropion hcl ............ 43, 44, 48
buspirone hcl......................... 39
butalbit/acetamin/caff/codeine
........................................... 42
butorphanol tartrate........ 33, 42
BYDUREON ........................ 59
BYETTA............................... 60
BYSTOLIC ........................... 49
cabergoline ........................... 64
caffeine citrated .................... 41
calcipotriene ......................... 55
calcitonin,salmon,synthetic... 64
calcitriol................................ 79
calcium acetate ..................... 79
calcium carbonate/mag carb/fa
........................................... 79
calcium chloride.................... 74
calcium gluconate ................. 74
CAMPATH ........................... 30
CANASA .............................. 66
CANCIDAS .......................... 27
candesartan cilexetil ............. 49
candesartan/hydrochlorothiazid
........................................... 52
CAPASTAT SULFATE ....... 22
CAPRELSA .......................... 30
captopril................................ 48
captopril/hydrochlorothiazide
........................................... 52
CARAFATE ......................... 66
CARBAGLU......................... 57
carbamazepine ...................... 39
carbidopa/levodopa .............. 45
carbidopa/levodopa/entacapone
........................................... 45
carbinoxamine maleate......... 85
CARIMUNE NF
NANOFILTERED ............ 67
carteolol hcl .......................... 82
carvedilol .............................. 49
CAYSTON............................ 24
CEENU ................................. 30
cefaclor ........................... 22, 23
cefadroxil hydrate ................. 23
cefazolin sodium.................... 23
cefazolin sodium/dextrose,iso 23
cefdinir .................................. 23
cefditoren pivoxil .................. 23
cefepime hcl .......................... 23
cefotaxime sodium................. 23
cefotetan disod/dextrose,iso.. 23
cefotetan disodium ................ 23
cefoxitin sodium .................... 23
cefoxitin sodium/dextrose,iso 23
cefpodoxime proxetil............. 23
cefprozil................................. 23
CEFTAZIDIME.................... 23
ceftazidime pentahydrate ...... 23
ceftriaxone na/dextrose,iso ... 23
ceftriaxone sodium ................ 23
cefuroxime axetil................... 23
cefuroxime sodium ................ 23
cefuroxime sodium/dextrose,iso
........................................... 23
CELEBREX.......................... 72
CELLCEPT........................... 30
CELONTIN........................... 48
cephalexin ............................. 23
CEREZYME ......................... 64
CERVARIX .......................... 67
CESAMET............................ 38
cetirizine hcl.......................... 85
cevimeline hcl........................ 58
CHANTIX............................. 48
CHEMET .............................. 57
CHENODAL......................... 57
chloramphenicol sod succ..... 24
I-2
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
chlorhexidine gluconate........ 58
chloroprocaine hcl/pf............ 20
chloroquine phosphate.......... 28
chlorothiazide ....................... 54
chlorothiazide sodium........... 54
chlorpromazine hcl ......... 34, 35
chlorthalidone ....................... 54
chlorzoxazone ....................... 71
cholestyramine (with sugar) . 51
cholestyramine/aspartame .... 51
choline sal/mag salicylate..... 72
CHORIONIC
GONADOTROPIN........... 82
CICLODAN.......................... 26
ciclopirox .............................. 26
ciclopirox olamine ................ 26
cidofovir ................................ 25
cilostazol ............................... 73
cimetidine.............................. 65
cimetidine hcl ........................ 65
cimetidine in 0.9 % nacl........ 65
CIMZIA ................................ 30
CINRYZE ............................. 67
CIPRO................................... 28
CIPRODEX........................... 58
ciprofloxacin hcl ....... 28, 58, 83
ciprofloxacin lactate ............. 28
ciprofloxacin lactate/d5w...... 28
ciprofloxacin/ciprofloxa hcl.. 28
citalopram hydrobromide ..... 46
citric acid/sodium citrate ...... 74
clarithromycin....................... 26
clemastine fumarate .............. 85
CLINDACIN P ..................... 54
clindamycin hcl ..................... 25
clindamycin palmitate hcl ..... 25
clindamycin phos/benzoyl perox
........................................... 54
clindamycin phosphate... 25, 55,
81
clindamycin phosphate/d5w. 24,
25
CLINIMIX ............................ 74
CLINIMIX E......................... 74
CLINISOL ............................ 74
clobetasol propionate............ 55
clomipramine hcl .................. 48
clonazepam ........................... 43
clonidine................................ 50
clonidine hcl.......................... 50
clonidine hcl/chlorthalidone . 52
clopidogrel bisulfate ............. 73
clorazepate dipotassium........ 39
clotrimazole..................... 24, 26
clotrimazole/betamethasone dip
........................................... 29
clozapine ............................... 35
COARTEM ........................... 28
codeine phos/acetaminophen 41
codeine sulfate ...................... 39
CODEINE SULFATE .......... 39
codeine/butalbital/asa/caffein42
colchicine/probenecid ........... 72
COLCRYS ............................ 72
colestipol hcl ......................... 51
colistin (colistimethate na).... 25
COMBIGAN......................... 82
COMBIVENT....................... 86
COMBIVENT RESPIMAT .. 86
COMETRIQ.......................... 30
COMPLERA......................... 21
COMTAN ............................. 45
COMVAX............................. 67
COPAXONE......................... 57
CORTIFOAM ....................... 66
cortisone acetate ................... 59
CREON ................................. 66
CRESTOR............................. 50
CRIXIVAN ........................... 21
cromolyn sodium............. 84, 86
CUBICIN .............................. 25
CUPRIMINE......................... 73
cyclopentolate hcl ................. 84
cyclophosphamide................. 30
cyclosporine .......................... 30
cyclosporine, modified .......... 30
CYMBALTA ........................ 44
cyproheptadine hcl................ 85
CYSTADANE ...................... 88
CYSTAGON......................... 74
CYSTARAN ......................... 84
danazol.................................. 80
dantrolene sodium................. 71
dapsone ................................. 21
DAPTACEL.......................... 67
DARAPRIM ......................... 28
demeclocycline hcl ................ 28
DEMSER .............................. 50
DENAVIR............................. 25
DEPO-PROVERA ................ 30
desipramine hcl..................... 46
desloratadine......................... 85
desmopressin acetate ............ 64
desogestrel-ethinyl estradiol. 80
desog-et estra/ethin estra...... 80
desonide ................................ 55
desoximetasone ..................... 55
DESVENLAFAXINE ER..... 44
DETROL LA ........................ 87
dexamethasone...................... 59
dexamethasone acetate ......... 59
DEXAMETHASONE
INTENSOL ....................... 59
dexamethasone sod phosphate
..................................... 59, 83
dexchlorpheniramine maleate85
dexmethylphenidate hcl......... 41
dextroamphetamine sulfate ... 41
dextroamphetamine/
amphetamine ..................... 41
dextrose 10 % and 0.2 % nacl
........................................... 74
dextrose 10 % and 0.9 % nacl
........................................... 74
dextrose 10%-0.5 normal saline
........................................... 74
dextrose 10%-water .............. 74
dextrose 2.5 % in water ........ 74
dextrose 2.5% in half ringers 74
dextrose 2.5%-0.5normal saline
........................................... 74
dextrose 20%-water .............. 74
I-3
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
dextrose 25 % in water ......... 74
dextrose 40%-water .............. 74
dextrose 5 % and 0.3 % nacl 75
dextrose 5 % and 0.9 % nacl 75
dextrose 5 % in water ........... 75
dextrose 5 %-0.2 % nacl ....... 75
dextrose 5 %-0.45 % nacl ..... 75
dextrose 5% in ringers .......... 75
dextrose 5%-lactated ringers 75
dextrose 50 % in water ......... 75
dextrose 60 % in water ......... 75
dextrose 70%-water .............. 75
DEXTROSE W/
ELECTROLYTE A .......... 75
DEXTROSE W/
ELECTROLYTE B........... 75
dhcodeine bt/acetaminophn/caff
..................................... 41, 42
diazepam ......................... 39, 43
DIBENZYLINE.................... 50
diclofenac potassium............. 72
diclofenac sodium ........... 72, 84
diclofenac sodium/misoprostol
........................................... 73
dicloxacillin sodium .............. 27
didanosine ............................. 21
diflorasone diacetate............. 55
diflunisal ............................... 73
digoxin................................... 53
DIGOXIN ............................. 53
dihydrocodeine/aspirin/caffein
........................................... 72
dihydroergotamine mesylate. 42
DILANTIN ........................... 42
diltiazem hcl .......................... 49
dimenhydrinate ..................... 66
DIOVAN............................... 49
diphenhydramine hcl............. 85
diphenoxylate hcl/atropine.... 65
DIPHTHERIA-TETANUS
TOXOID ........................... 68
DIPHTHERIA-TETANUS
TOXOIDS-PED ................ 68
dipyridamole ......................... 73
disulfiram .............................. 45
divalproex sodium................. 48
dobutamine hcl...................... 53
dobutamine hcl/d5w .............. 53
donepezil hcl ......................... 34
dopamine hcl......................... 53
dopamine hcl/d5w ................. 53
dopamine hcl/dextrose 5%water ................................. 53
DORIBAX ............................ 25
dorzolamide hcl..................... 82
dorzolamide hcl/timolol maleat
........................................... 82
doxazosin mesylate................ 54
doxepin hcl ............................ 48
doxorubicin hcl peg-liposomal
........................................... 30
doxycycline hyclate ... 28, 29, 58
doxycycline monohydrate...... 29
DRITHOCREME HP............ 55
dronabinol............................. 38
droperidol ............................. 39
DROXIA ............................... 30
DUETACT............................ 61
DULERA .............................. 86
DURAMORPH ..................... 39
DUREZOL............................ 83
DUTOPROL ......................... 49
E.E.S. 200 ............................. 23
econazole nitrate................... 27
EDURANT ........................... 21
EFFIENT............................... 73
EGRIFTA.............................. 67
ELAPRASE .......................... 64
electrolyte-48 solution/d5w... 75
electrolyte-48/fructose 10% .. 75
electrolyte-48/fructose 5% .... 75
electrolyte-75 solution/d5w... 75
electrolyte-75/fructose 5% .... 75
electrolyte-r solution/d5w ..... 75
ELELYSO............................. 57
ELIDEL................................. 56
ELIGARD ............................. 30
ELITEK................................. 30
ELMIRON ............................ 88
EMCYT................................. 30
EMEND ................................ 38
EMSAM................................ 43
EMTRIVA ............................ 21
ENABLEX............................ 87
enalapril maleate .................. 48
enalapril/hydrochlorothiazide
........................................... 52
ENBREL ............................... 30
ENGERIX-B ......................... 68
enoxaparin sodium................ 78
entacapone ............................ 45
epinastine hcl ........................ 84
epinephrine ........................... 86
EPIPEN 2-PAK..................... 86
EPIPEN JR 2-PAK ............... 87
EPIVIR.................................. 21
EPIVIR HBV ........................ 25
eplerenone............................. 54
epoprostenol sodium (glycine)
........................................... 54
eprosartan mesylate .............. 49
EPZICOM ............................. 21
ergoloid mesylates ................ 57
ERGOMAR........................... 42
ergotamine tartrate/caffeine . 42
ERIVEDGE........................... 30
ery e-succ/sulfisoxazole ........ 23
ERYPED 200 ........................ 23
ERYPED 400 ........................ 23
ERY-TAB ............................. 23
ERYTHROCIN
LACTOBIONATE............ 24
erythromycin base........... 24, 83
erythromycin base/ethanol.... 55
erythromycin ethylsuccinate . 24
erythromycin stearate ........... 24
erythromycin/benzoyl peroxide
........................................... 55
escitalopram oxalate....... 46, 47
ESTRACE............................. 81
estradiol ................................ 81
estradiol valerate .................. 81
I-4
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
estradiol/norethindrone acet. 81
estropipate............................. 81
ethambutol hcl....................... 22
ethinyl estradiol/drospirenone
........................................... 80
ethosuximide ......................... 48
ethynodiol d-ethinyl estradiol 80
etidronate disodium .............. 64
etodolac................................. 72
EURAX................................. 55
EVISTA ................................ 64
EXELON............................... 34
exemestane ............................ 30
EXFORGE ............................ 52
EXFORGE HCT ................... 52
EXJADE ............................... 57
FABRAZYME...................... 64
famciclovir ............................ 25
famotidine ............................. 66
famotidine in nacl,iso-osm/pf 65
FANAPT ............................... 35
FARESTON.......................... 30
FASLODEX.......................... 31
FAZACLO ............................ 35
felbamate............................... 43
felodipine............................... 49
FEM PH ................................ 81
FEMRING............................. 81
fenofibrate ............................. 51
fenofibrate nanocrystallized.. 51
fenofibrate,micronized .......... 51
fenofibric acid ....................... 51
fenoprofen calcium................ 72
fentanyl.................................. 39
fentanyl citrate ...................... 39
FERRIPROX......................... 57
fexofenadine hcl .................... 85
fexofenadine/pseudoephedrine
........................................... 85
finasteride ............................. 88
FIRAZYR ............................. 68
flavoxate hcl .......................... 87
FLEBOGAMMA .................. 68
FLEBOGAMMA DIF........... 68
flecainide acetate .................. 49
FLEXBUMIN ....................... 75
FLOVENT DISKUS............. 87
FLOVENT HFA ................... 87
fluconazole ............................ 24
fluconazole in nacl,iso-osm... 27
flucytosine ............................. 24
fludrocortisone acetate ......... 64
flumazenil.............................. 45
flunisolide.............................. 58
fluocinolone acetonide .......... 56
fluocinolone acetonide oil..... 58
fluocinolone/shower cap ....... 56
fluocinonide........................... 56
fluorometholone .................... 83
FLUOROPLEX..................... 56
fluorouracil ........................... 56
fluoxetine hcl......................... 47
fluoxymesterone .................... 80
fluphenazine decanoate......... 35
fluphenazine hcl .................... 35
flurbiprofen ........................... 72
flurbiprofen sodium............... 84
flutamide ............................... 31
fluticasone propionate .... 56, 58
fluvastatin sodium ................. 50
fluvoxamine maleate ............. 47
FML S.O.P. ........................... 83
fomepizole ............................. 57
fondaparinux sodium ............ 78
FORADIL ............................. 85
FORTEO ............................... 64
FORTESTA .......................... 80
FORTICAL ........................... 64
foscarnet sodium ................... 25
fosinopril sodium .................. 48
fosinopril/hydrochlorothiazide
........................................... 52
fosphenytoin sodium.............. 42
FREAMINE HBC................. 75
FREAMINE III ..................... 75
FREAMINE III with
ELECTROLYTES ............ 75
FULYZAQ............................ 65
furosemide............................. 51
FUZEON............................... 21
gabapentin............................. 43
GABITRIL............................ 43
GABLOFEN ......................... 72
galantamine hbr .................... 34
GAMASTAN S-D ................ 68
GAMMAGARD LIQUID..... 68
GAMMAPLEX..................... 68
GAMUNEX-C ...................... 68
ganciclovir ............................ 26
ganciclovir sodium................ 26
GARAMYCIN...................... 83
GARDASIL .......................... 68
gauze bandage ...................... 71
gemfibrozil ............................ 51
gentamicin in nacl, iso-osm .. 20
gentamicin sulfate ..... 20, 29, 83
gentamicin sulfate/pf............. 20
GEODON.............................. 35
GILENYA............................. 57
GLEEVEC ............................ 31
glimepiride ............................ 61
glipizide................................. 61
glipizide/metformin hcl ......... 61
GLUCAGEN......................... 59
GLUCAGON EMERGENCY
KIT.................................... 59
glucose and potassium chloride
and sodium chloride.......... 75
glyburide ............................... 61
glyburide,micronized ............ 62
glyburide/metformin hcl........ 62
GLYCINE ............................. 75
glycopyrrolate ....................... 65
granisetron hcl ...................... 38
granisetron hcl/pf.................. 38
griseofulvin ultramicrosize ... 24
griseofulvin,microsize ........... 24
guanfacine hcl....................... 50
guanidine hcl......................... 45
GYNAZOLE-1 ..................... 81
H.P. ACTHAR ...................... 64
HALAVEN ........................... 31
I-5
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
halobetasol propionate ......... 56
HALONATE......................... 56
haloperidol............................ 35
haloperidol decanoate .......... 35
haloperidol lactate ................ 35
HAVRIX ............................... 68
HECORIA............................. 31
heparin sodium,porcine ........ 78
heparin sodium,porcine/d5w. 78
heparin sodium,porcine/ns/pf 79
heparin sodium,porcine/pf .... 79
HEPATAMINE..................... 75
HEPATASOL ....................... 75
HEPSERA............................. 26
HEXALEN............................ 31
HIZENTRA........................... 68
homatropine hbr.................... 84
HUMALOG .......................... 60
HUMALOG MIX 50-50 ....... 60
HUMALOG MIX 75-25 ....... 60
HUMIRA .............................. 31
HUMULIN 70-30 ................. 60
HUMULIN N........................ 60
HUMULIN R ........................ 60
hydralazine hcl...................... 54
hydralazine/hydrochlorothiazid
........................................... 54
hydrochlorothiazide .............. 54
hydrocodone bit/acetaminophen
........................................... 41
hydrocodone/ibuprofen ......... 41
hydrocortisone .......... 56, 59, 66
hydrocortisone butyrate ........ 56
hydrocortisone valerate ........ 56
hydromorphone hcl ......... 39, 41
hydromorphone hcl/pf........... 40
hydroxychloroquine sulfate... 28
hydroxyurea .......................... 31
hydroxyzine hcl ..................... 39
hydroxyzine pamoate ............ 39
HYPERHEP B S-D............... 68
HYPERRAB S-D.................. 68
HYPERRHO S-D.................. 68
ibandronate sodium .............. 64
ibuprofen ............................... 72
ibuprofen/oxycodone hcl....... 40
ICLUSIG............................... 31
ILARIS.................................. 71
imipenem/cilastatin sodium .. 25
imipramine hcl ...................... 48
imipramine pamoate ............. 48
imiquimod ............................. 56
IMOGAM RABIES-HT........ 68
IMOVAX RABIES VACCINE
........................................... 68
INCIVEK .............................. 21
INCRELEX........................... 64
indapamide............................ 54
indomethacin......................... 72
INFANRIX ........................... 68
INFANRIX PF ...................... 68
INFERGEN........................... 70
INLYTA................................ 31
INTELENCE......................... 21
INTRON A............................ 70
INTUNIV.............................. 45
INVANZ ............................... 25
INVEGA ......................... 35, 36
INVEGA SUSTENNA ......... 35
INVIRASE............................ 21
INVOKANA ......................... 62
IONOSOL B with DEXTROSE
5% ..................................... 75
IONOSOL MB-DEXTROSE
5% ..................................... 75
IONOSOL T-DEXTROSE 5%
........................................... 76
IPOL...................................... 68
ipratropium bromide....... 58, 87
irbesartan.............................. 49
irbesartan/hydrochlorothiazide
........................................... 52
ISENTRESS.......................... 21
ISOLYTE E .......................... 76
ISOLYTE H W/DEXTROSE 76
ISOLYTE M W/DEXTROSE76
ISOLYTE P with DEXTROSE
........................................... 76
ISOLYTE S........................... 76
ISOLYTE S with DEXTROSE
........................................... 76
isoniazid ................................ 22
isosorbide dinitrate ............... 51
isosorbide mononitrate ......... 51
isotretinoin ............................ 55
isradipine .............................. 49
itraconazole........................... 24
IXIARO................................. 68
JAKAFI................................. 31
JALYN.................................. 88
JANUMET............................ 62
JANUMET XR ..................... 62
JANUVIA ............................. 62
JE-VAX................................. 68
JUVISYNC ........................... 62
KADCYLA ........................... 31
KALETRA............................ 21
KALYDECO......................... 87
kanamycin sulfate.................. 20
KEDBUMIN ......................... 76
ketoconazole.................... 24, 27
ketoprofen ............................. 72
ketorolac tromethamine .. 72, 84
KOMBIGLYZE XR.............. 62
K-PHOS NO.2 ...................... 76
K-PHOS ORIGINAL............ 79
KRYSTEXXA ...................... 57
KUVAN ................................ 64
KYNAMRO.......................... 51
labetalol hcl .......................... 49
LACTATED RINGERS ....... 76
lactulose ................................ 73
LAMISIL .............................. 24
lamivudine............................. 21
lamivudine/zidovudine .......... 21
lamotrigine............................ 43
lansoprazole.................... 66, 67
LANTUS............................... 60
LANTUS SOLOSTAR ......... 60
latanoprost ............................ 82
LATUDA .............................. 36
leflunomide............................ 31
I-6
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
LETAIRIS............................. 53
letrozole................................. 31
leucovorin calcium................ 31
LEUKERAN ......................... 31
LEUKINE ............................. 71
leuprolide acetate.................. 82
LEVEMIR............................. 60
LEVEMIR FLEXPEN .......... 60
levetiracetam......................... 43
levetiracetam in nacl (iso-os) 43
levobunolol hcl...................... 82
levocarnitine ......................... 79
levocarnitine (with sugar)..... 79
levocetirizine dihydrochloride
........................................... 85
levofloxacin ..................... 28, 83
levofloxacin/d5w ................... 28
levonorgestrel ....................... 80
levonorgestrel-eth estradiol .. 80
levorphanol tartrate .............. 40
LEVOTHROID..................... 65
levothyroxine sodium ............ 65
LEVOXYL............................ 65
LEXIVA................................ 21
lidocaine................................ 20
lidocaine hcl.................... 20, 49
lidocaine hcl/pf...................... 20
lidocaine/prilocaine .............. 20
LIDODERM ......................... 20
lindane................................... 55
LIORESAL INTRATHECAL
........................................... 72
liothyronine sodium .............. 65
lipase/protease/amylase........ 66
LIPOFEN .............................. 51
LIPOSYN III......................... 76
lisinopril................................ 48
lisinopril/hydrochlorothiazide
........................................... 52
lithium carbonate .................. 45
lithium citrate........................ 45
l-norgest-eth estr/ethin estra. 80
LODOSYN ........................... 45
loperamide hcl ...................... 65
lorazepam.............................. 39
losartan potassium ................ 49
losartan/hydrochlorothiazide 52
LOTRONEX ......................... 66
lovastatin............................... 50
LOVAZA .............................. 51
loxapine succinate................. 36
LUMIGAN............................ 82
LUMIZYME ......................... 64
LUPRON DEPOT........... 31, 82
LUPRON DEPOT-PED........ 82
LYRICA................................ 43
LYSODREN ......................... 31
mafenide acetate ................... 29
magnesium chloride .............. 43
magnesium sulfate................. 76
magnesium sulfate/d5w......... 76
MAKENA ............................. 81
malathion .............................. 55
maprotiline hcl ...................... 44
MARPLAN ........................... 43
MATULANE ........................ 31
meclizine hcl.......................... 38
meclofenamate sodium.......... 72
medroxyprogesterone acetate
..................................... 34, 81
mefenamic acid ..................... 72
mefloquine hcl....................... 28
MEGACE ES ........................ 31
megestrol acetate .................. 31
meloxicam ............................. 72
MENACTRA ........................ 68
MENEST............................... 81
MENOMUNE-A-C-Y-W-135
........................................... 68
MENVEO A-C-Y-W-135-DIP
........................................... 68
meperidine hcl/pf .................. 40
MEPRON.............................. 25
mercaptopurine ..................... 31
meropenem............................ 25
mesalamine w/cleansing wipes
........................................... 66
mesna .................................... 31
MESNEX .............................. 31
MESTINON.......................... 45
METADATE ER .................. 41
metaproterenol sulfate .......... 85
metaxalone ............................ 71
metformin hcl .................. 62, 63
methadone hcl ....................... 40
methamphetamine hcl ........... 41
methazolamide ...................... 82
methenamine mandelate........ 29
methimazole .......................... 59
METHITEST ........................ 80
methocarbamol ..................... 71
methotrexate sodium ............. 31
methotrexate sodium/pf......... 31
methyclothiazide ................... 54
methyldopa............................ 50
methyldopa/
hydrochlorothiazide .......... 52
methyldopate hcl ................... 50
methylergonovine maleate .... 82
methylphenidate hcl .............. 41
methylprednisolone ............... 59
methylprednisolone acetate .. 59
methylprednisolone sod succ 59
metipranolol.......................... 82
metoclopramide hcl............... 65
metolazone ............................ 54
metoprolol succinate............. 49
metoprolol tartrate................ 49
metoprolol/hydrochlorothiazide
........................................... 52
metronidazole............ 21, 55, 81
metronidazole/sodium chloride
........................................... 21
mexiletine hcl ........................ 49
MIACALCIN........................ 64
MICARDIS ........................... 49
MICARDIS HCT .................. 52
miconazole nitrate................. 29
MICRHOGAM PLUS .......... 68
midodrine hcl ........................ 53
milrinone lactate ................... 52
milrinone lactate/d5w ........... 52
I-7
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
minocycline hcl ..................... 29
minoxidil ............................... 54
mirtazapine ........................... 44
misoprostol............................ 66
mitoxantrone hcl ................... 31
M-M-R II VACCINE............ 68
modafinil ............................... 41
moexipril hcl ......................... 48
moexipril/hydrochlorothiazide
........................................... 52
mometasone furoate .............. 56
montelukast sodium............... 87
morphine sulfate.................... 40
morphine sulfate/pf ............... 40
MOXEZA ............................. 83
MOZOBIL ............................ 68
mupirocin .............................. 29
mupirocin calcium ................ 55
MYCAMINE ........................ 27
MYCOBUTIN ...................... 22
mycophenolate mofetil .......... 32
MYFORTIC.......................... 32
MYOZYME.......................... 64
nabumetone ........................... 72
nadolol .................................. 49
nadolol/bendroflumethiazide 53
nafcillin in dextrose,iso-osm . 27
nafcillin sodium..................... 27
NAGLAZYME ..................... 64
nalbuphine hcl....................... 33
naloxone hcl .......................... 45
naltrexone hcl........................ 45
NAMENDA .......................... 34
NAMENDA XR.................... 34
naphazoline hcl ..................... 84
naproxen ............................... 72
naproxen sodium................... 72
naratriptan hcl ...................... 42
NATACYN ........................... 84
nateglinide............................. 63
needles, insulin disp., safety.. 71
needles, insulin disposable.... 71
nefazodone hcl ...................... 44
neo/polymyx b sulf/dexameth 83
neomy sulf/bacitra/polymyxin b
........................................... 83
neomy sulf/bacitrac zn/poly/hc
........................................... 83
neomy sulf/polymyxin b sulfate
........................................... 88
neomycin sulfate.................... 20
neomycin sulfate/dex na ph... 83
neomycin/polymyxin b sulf/hc
..................................... 58, 83
neomycin/polymyxn b/
gramicidin ......................... 83
NEO-POLYCIN.................... 83
neostigmine methylsulfate..... 46
NEPHRAMINE .................... 76
NEULASTA ......................... 71
NEUMEGA........................... 71
NEUPOGEN ......................... 71
NEUPRO............................... 45
NEUT.................................... 76
NEVANAC ........................... 84
nevirapine ............................. 21
NEXAVAR ........................... 32
NEXIUM............................... 67
NEXIUM I.V. ....................... 67
NIASPAN ............................. 51
nicardipine hcl ...................... 50
NICOTROL .......................... 48
NICOTROL NS .................... 48
nifedipine............................... 50
NILANDRON....................... 32
nimodipine............................. 50
nisoldipine............................. 50
NITRO-BID .......................... 51
nitrofurantoin........................ 29
nitrofurantoin macrocrystal.. 29
nitroglycerin.......................... 51
NITROSTAT ........................ 52
nizatidine............................... 66
norepinephrine bitartrate...... 53
noreth a-et estra/fe fumarate 80
noreth-ethinyl estradiol/iron. 80
norethind ac/ethinyl estradiol81
norethindrone........................ 81
norethindrone acetate ........... 81
norethindrone a-e estradiol .. 80
norethindrone-ethinyl estrad 80
norethindrone-mestranol ...... 80
norgestimate-ethinyl estradiol
........................................... 80
norgestrel-ethinyl estradiol... 81
NORMOSOL-M and
DEXTROSE...................... 76
NORMOSOL-R and
DEXTROSE...................... 76
NORMOSOL-R PH 7.4 ........ 76
nortriptyline hcl .................... 46
NORVIR ............................... 21
NOVAMINE......................... 76
NOVAREL ........................... 82
NOVOLIN 70-30 .................. 60
NOVOLIN N ........................ 60
NOVOLIN R......................... 60
NOVOLOG........................... 60
NOVOLOG FLEXPEN ........ 60
NOVOLOG MIX 70-30........ 60
NOVOLOG MIX 70-30
FLEXPEN ......................... 60
NOXAFIL ............................. 24
NUEDEXTA......................... 46
NULOJIX.............................. 32
NUTRILYTE ........................ 76
nystatin...................... 24, 27, 56
nystatin/triamcin ................... 29
OCTAGAM .......................... 68
octreotide acetate.................. 32
ofloxacin.................... 28, 58, 83
olanzapine ............................. 36
olanzapine/fluoxetine hcl ...... 36
omeprazole............................ 67
omeprazole/sodium bicarbonate
........................................... 67
OMNITROPE ....................... 67
ondansetron........................... 39
ondansetron hcl............... 38, 39
ONFI ..................................... 43
ONGLYZA ........................... 63
OPANA ER........................... 40
I-8
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
opium tincture ....................... 65
ORAP.................................... 36
ORENCIA............................. 32
ORFADIN............................. 57
orphenadrine citrate ............. 71
orphenadrine/aspirin/caffeine71
oxacillin sodium .................... 27
oxacillin sodium/dextrose,iso 27
oxandrolone .......................... 80
oxaprozin............................... 72
oxazepam............................... 39
oxcarbazepine ....................... 39
OXSORALEN ...................... 56
OXSORALEN-ULTRA........ 55
oxybutynin chloride............... 87
oxycodone hcl........................ 40
oxycodone hcl/acetaminophen
........................................... 40
oxycodone hcl/aspirin ........... 40
OXYCONTIN....................... 40
oxymorphone hcl............. 40, 41
PALGIC ................................ 85
pamidronate disodium .......... 64
PANRETIN........................... 56
pantoprazole sodium............. 67
paregoric............................... 65
paromomycin sulfate............. 21
paroxetine hcl........................ 47
PASER .................................. 22
PATADAY ........................... 84
PATANOL............................ 84
PAXIL................................... 47
PEDIARIX............................ 68
PEDVAXHIB ....................... 68
peg 3350/na sulf,bicarb,cl/kcl66
PEGANONE ......................... 42
PEGASYS............................. 70
PEGASYS PROCLICK ........ 70
PEGINTRON........................ 70
PEGINTRON REDIPEN ...... 70
pen g pot/dextrose-water....... 27
penicillin g potassium ........... 27
penicillin g potassium/d5w ... 28
penicillin g procaine ............. 28
PENICILLIN G SODIUM.... 28
penicillin v potassium ........... 28
PENTASA............................. 66
pentoxifylline......................... 53
perindopril erbumine ............ 49
PERJETA.............................. 32
permethrin............................. 55
perphenazine ......................... 36
perphenazine/amitriptyline hcl
........................................... 44
phenelzine sulfate.................. 43
phenobarbital........................ 43
phenobarbital sodium ........... 43
phentolamine mesylate.......... 53
phenylephrine hcl.................. 84
phenytoin............................... 43
phenytoin sodium ............ 42, 43
phenytoin sodium extended ... 42
PHOSPHOLINE IODIDE .... 82
phosphorus #1....................... 76
physostigmine salicylate ....... 46
pilocarpine hcl ................ 58, 82
pindolol ................................. 49
pioglitazone hcl..................... 63
pioglitazone hcl/glimepiride . 63
pioglitazone hcl/metformin hcl
........................................... 63
piperacillin sodium/tazobactam
........................................... 28
piroxicam .............................. 72
PLASBUMIN-25 .................. 76
PLASBUMIN-5 .................... 76
PLASMA-LYTE 148............ 76
PLASMA-LYTE 56 IN
DEXTROSE...................... 76
PLASMA-LYTE A PH 7.4... 76
PLASMA-LYTE M IN
DEXTROSE...................... 76
pnv with ca,no.72/iron/fa ...... 81
podofilox ............................... 56
polyethylene glycol 3350....... 66
polymyxin b sulf/trimethoprim
........................................... 84
polymyxin b sulfate ............... 25
POMALYST ......................... 32
pot chloride/pot bicarb/cit ac 79
potassium acetate.................. 76
potassium bicarbonate/cit ac 79
potassium chlorid/d100.2%nacl ........................... 77
potassium chloride ................ 79
potassium chloride in 0.9%nacl
........................................... 77
potassium chloride in d5w ... 77,
79
potassium chloride in lr-d5... 79
potassium chloride/d50.2%nacl ........................... 77
potassium chloride/d5-0.25ns77
potassium chloride/d50.3%nacl ........................... 77
potassium chloride/d5-0.45nacl
........................................... 77
potassium chloride/d50.9%nacl ........................... 77
potassium chloride-0.45% nacl
........................................... 77
potassium citrate................... 79
potassium citrate/citric acid . 79
potassium gluconate.............. 79
potassium hydroxide ............. 56
potassium phos,m-basic-d-basic
........................................... 77
POTIGA................................ 43
PRADAXA ........................... 79
pramipexole di-hcl ................ 45
pravastatin sodium................ 51
prazosin hcl........................... 54
PRED MILD ......................... 83
prednicarbate........................ 56
prednisolone.......................... 59
prednisolone acetate ....... 59, 83
prednisolone sod phosphate. 59,
83
prednisone............................. 59
PREDNISONE INTENSOL . 59
PREMARIN.......................... 81
PREMASOL ......................... 77
I-9
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
PREMPHASE ....................... 81
PREMPRO............................ 81
PREZISTA............................ 22
PRIALT................................. 33
PRIFTIN ............................... 22
PRIMAQUINE ..................... 28
primidone .............................. 43
PRIMSOL ............................. 29
PRISTIQ ER ......................... 44
PRIVIGEN............................ 68
PROAIR HFA....................... 85
probenecid............................. 72
procainamide hcl .................. 49
PROCALAMINE.................. 77
prochlorperazine edisylate.... 39
prochlorperazine maleate ..... 39
PROCRIT.............................. 69
PROCYSBI ........................... 77
progesterone ......................... 81
progesterone,micronized....... 81
PROGLYCEM...................... 59
PROGRAF ............................ 32
PROLASTIN......................... 87
PROLASTIN C..................... 87
PROLENSA.......................... 84
PROLEUKIN........................ 71
PROMACTA ........................ 69
promethazine hcl............. 39, 85
propafenone hcl .................... 49
proparacaine hcl................... 84
proparacaine/fluorescein sod 84
propranolol hcl ..................... 49
propranolol/hydrochlorothiazid
........................................... 53
propylthiouracil .................... 59
PROQUAD ........................... 69
PROSTIGMIN ...................... 46
PROSTIN E2 VAGINAL
SUPPOSITORY................ 57
PROTOPAM CHLORIDE.... 46
PROTOPIC ........................... 56
protriptyline hcl .................... 46
PROVENTIL HFA ............... 85
PROVIGIL............................ 41
PRUDOXIN.......................... 55
PULMOZYME ..................... 87
pyrazinamide......................... 22
pyridostigmine bromide ........ 46
QUALAQUIN....................... 28
quetiapine fumarate ........ 36, 37
QUICK MIX with LYTES.... 77
quinapril hcl.......................... 49
quinapril/hydrochlorothiazide
........................................... 53
quinidine gluconate............... 49
quinidine sulfate.................... 49
quinine sulfate....................... 28
QVAR ................................... 87
RABAVERT ......................... 69
ramipril ................................. 49
RANEXA.............................. 53
ranitidine hcl......................... 66
RAPAMUNE ........................ 32
RAVICTI .............................. 57
REBIF ................................... 70
REBIF REBIDOSE............... 70
RECLAST............................. 64
RECOMBIVAX HB ............. 69
RECTIV ................................ 66
REGRANEX......................... 56
RELENZA ............................ 26
RELISTOR ........................... 66
REMICADE.......................... 32
REMODULIN....................... 53
RENACIDIN......................... 77
RENVELA............................ 73
RESCRIPTOR ...................... 22
reserpine ............................... 53
reserpine/hydrochlorothiazide
........................................... 53
RESTASIS ............................ 84
RETROVIR........................... 22
REVATIO ............................. 53
REVLIMID ........................... 32
REYATAZ............................ 22
RHOGAM PLUS .................. 69
RHOPHYLAC ...................... 69
RIBATAB ............................. 26
ribavirin ................................ 26
RIDAURA ............................ 73
rifampin................................. 22
rifampin/isoniazid ................. 22
RILUTEK ............................. 71
rimantadine hcl ..................... 26
ringers solution ..................... 77
RIOMET ............................... 63
RISPERDAL CONSTA........ 37
risperidone ............................ 37
RITUXAN............................. 32
rivastigmine tartrate ............. 34
rizatriptan benzoate .............. 42
ropinirole hcl ........................ 45
ROTATEQ............................ 69
ROZEREM ........................... 46
SABRIL ................................ 43
SAIZEN ................................ 67
salsalate ................................ 73
SAMSCA .............................. 64
SANDOSTATIN LAR.......... 32
SANTYL............................... 56
SAPHRIS .............................. 37
SAVELLA ............................ 44
selegiline hcl ......................... 45
selenium sulfide............... 55, 56
SELZENTRY........................ 22
SENSIPAR............................ 65
SEREVENT DISKUS........... 86
SEROMYCIN ....................... 22
SEROQUEL XR ................... 37
sertraline hcl ................... 47, 48
SIGNIFOR ............................ 32
silver sulfadiazine ................. 29
SIMCOR ............................... 51
SIMULECT........................... 32
simvastatin ............................ 51
SIRTURO ............................. 22
sod/pot/k cit/sod cit/cit acid .. 77
sodium bicarbonate............... 77
sodium chloride..................... 77
sodium chloride 0.45 % ........ 77
sodium chloride 3% .............. 77
sodium chloride 5% .............. 77
I-10
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
sodium chloride irrig solution
........................................... 77
sodium chloride/nahco3/kcl/peg
........................................... 66
sodium fluoride ............... 58, 78
sodium lactate ....................... 77
sodium phenylbutyrate .......... 57
sodium polystyrene sulfonate 53
SOLARAZE.......................... 56
SOLTAMOX ........................ 32
SOMAVERT......................... 65
SORIATANE........................ 55
sotalol hcl.............................. 52
SPIRIVA ............................... 87
spironolact/hydrochlorothiazid
........................................... 54
spironolactone....................... 54
SPORANOX ......................... 24
SPRYCEL ............................. 32
stannous fluoride................... 58
stavudine ............................... 22
STELARA............................. 32
STERILE DILUENT ............ 77
STIVARGA .......................... 32
STRATTERA ....................... 46
STRIBILD............................. 22
STROMECTOL.................... 21
SUBOXONE......................... 41
SUCRAID ............................. 66
sucralfate............................... 66
sulfacetamide sodium...... 55, 84
sulfacetamide/prednisolone sp
........................................... 83
sulfadiazine ........................... 28
sulfamethoxazole/trimethoprim
........................................... 28
SULFAMYLON ................... 29
sulfasalazine.......................... 66
sulindac ................................. 73
sumatriptan ........................... 42
sumatriptan succinate ........... 42
SUPRAX............................... 23
SUSTIVA.............................. 22
SUTENT ............................... 32
SYLATRON ......................... 70
SYMBICORT ....................... 87
SYMLIN ............................... 60
SYMLINPEN 120................. 60
SYMLINPEN 60................... 60
SYNAREL ............................ 82
SYNERCID........................... 25
SYNRIBO ............................. 33
SYPRINE.............................. 73
syring w-ndl,disp,insul,0.3ml 71
syring w-ndl,disp,insul,0.5ml 71
syringe & needle,insulin,1 ml 71
TABLOID ............................. 33
tacrolimus ............................. 33
TAMIFLU............................. 26
tamoxifen citrate ................... 33
tamsulosin hcl ....................... 88
TARCEVA............................ 33
TARGRETIN........................ 33
TASIGNA ............................. 33
TASMAR.............................. 45
TAZORAC............................ 55
TE ANATOXAL BERNA.... 69
TECFIDERA......................... 63
TEGRETOL XR ................... 39
TEKAMLO ........................... 53
TEKTURNA ......................... 53
TEKTURNA HCT ................ 53
temazepam............................. 46
TEMODAR........................... 33
TENIVAC ............................. 69
terazosin hcl .......................... 54
terbinafine hcl ....................... 24
terbutaline sulfate ................. 86
terconazole...................... 29, 82
TESTOPEL ........................... 80
testosterone cypionate........... 80
testosterone enanthate .......... 80
TETANUS DIPHTHERIA
TOXOIDS ......................... 69
TETANUS TOXOID
ADSORBED ..................... 69
TETANUS-DIPHTERIADECAVAC ....................... 69
tetracaine hcl/pf .............. 20, 84
tetracycline hcl...................... 29
THALOMID ......................... 57
theophylline anhydrous......... 86
THERACYS ......................... 69
THERMAZENE ................... 29
thioridazine hcl ..................... 38
thiothixene............................. 38
THYROLAR-1 ..................... 65
THYROLAR-1/2 .................. 65
THYROLAR-1/4 .................. 65
THYROLAR-2 ..................... 65
THYROLAR-3 ..................... 65
tiagabine hcl.......................... 43
TIKOSYN ............................. 52
timolol maleate................ 49, 82
tinidazole............................... 28
tizanidine hcl......................... 72
TOBI ..................................... 20
TOBI PODHALER............... 20
tobramycin ............................ 84
tobramycin sulfate................. 20
tobramycin/dexamethasone... 83
tobramycin/sodium chloride . 20
tolazamide ............................. 63
tolbutamide ........................... 63
tolmetin sodium..................... 73
tolterodine tartrate................ 88
topiramate ............................. 43
torsemide............................... 51
TOVIAZ................................ 88
TPN ELECTROLYTES........ 77
TRACLEER.......................... 53
tramadol hcl .......................... 33
tramadol hcl/acetaminophen 34
trandolapril ........................... 49
tranexamic acid..................... 57
tranylcypromine sulfate ........ 43
TRAVASOL ......................... 78
TRAVASOL W/DEXTROSE
........................................... 78
TRAVASOL W/
ELECTROLYTES ............ 78
I-11
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
TRAVASOL with DEXTROSE
........................................... 78
TRAVASOL with
ELECTROLYTES ............ 78
TRAVATAN Z ..................... 82
TRAVERT-ELECTROLYTE
NO.2.................................. 78
TRAVERT-ELECTROLYTE
NO.3.................................. 78
TRAVERT-ELECTROLYTE
NO.4.................................. 78
travoprost (benzalkonium) .... 82
trazodone hcl......................... 44
TRECATOR ......................... 22
TRELSTAR .......................... 33
tretinoin........................... 33, 55
tretinoin microspheres .......... 55
triamcinolone acetonide.. 56, 58
triamterene/hydrochlorothiazid
........................................... 54
TRIBENZOR ........................ 53
TRIDERM............................. 56
trifluoperazine hcl................. 38
trifluridine ............................. 84
trihexyphenidyl hcl................ 34
trimethobenzamide hcl .......... 39
trimethoprim ......................... 29
trimipramine maleate............ 48
TRIPEDIA ............................ 69
TRIPLE ANTIBIOTIC ......... 29
TRIZIVIR ............................. 22
TROPHAMINE .................... 78
tropicamide ........................... 84
trospium chloride .................. 88
TRUVADA ........................... 22
TWINRIX ............................. 69
TWYNSTA ........................... 53
TYGACIL ............................. 25
TYKERB............................... 33
TYPHIM VI .......................... 69
TYSABRI ............................. 33
TYZEKA............................... 26
TYZINE ................................ 58
ULORIC................................ 72
UNITHROID ........................ 65
URAMAXIN......................... 56
urea ....................................... 56
urea/lactic ac/zn undecylenate
........................................... 56
urea/lactic acid/salicyl acid.. 57
ursodiol ................................. 66
UVADEX.............................. 57
VAGIFEM ............................ 81
valacyclovir hcl..................... 26
VALCYTE............................ 26
valproate sodium................... 48
valproic acid ......................... 48
valsartan/hydrochlorothiazide
........................................... 53
vancomycin hcl...................... 25
VANCOMYCIN HCL .......... 25
vancomycin hcl/d5w.............. 25
VANDAZOLE...................... 81
VANTAS .............................. 67
VAQTA................................. 69
VARIVAX VACCINE ......... 69
VECAMYL........................... 53
VELCADE............................ 33
VELETRI.............................. 54
venlafaxine hcl ................ 44, 45
verapamil hcl ........................ 50
VERIPRED 20 ...................... 59
VESICARE ........................... 88
VFEND ................................. 24
VICTRELIS .......................... 22
VIDAZA ............................... 33
VIDEX .................................. 22
VIGAMOX ........................... 84
VIIBRYD.............................. 48
VIMPAT ............................... 43
VIRACEPT ........................... 22
VIRAMUNE ......................... 22
VIRAMUNE XR .................. 22
VIRAZOLE........................... 26
VIREAD ............................... 22
VISUDYNE .......................... 84
VOLTAREN ......................... 73
VORAXAZE......................... 57
voriconazole.................... 24, 27
VOTRIENT........................... 33
VPRIV................................... 65
warfarin sodium .................... 79
WELCHOL ........................... 51
WINRHO SDF...................... 69
XALKORI............................. 33
XARELTO............................ 79
XELJANZ ............................. 58
XENAZINE .......................... 46
XERESE ............................... 26
XGEVA................................. 65
XIAFLEX ............................. 58
XIFAXAN............................. 25
XOLAIR ............................... 87
XTANDI ............................... 33
XYLOCAINE ....................... 20
XYREM ................................ 46
YF-VAX ............................... 69
zafirlukast.............................. 87
zaleplon ................................. 46
ZAMICET............................. 41
ZAVESCA ............................ 65
ZELBORAF.......................... 33
ZEMPLAR............................ 79
ZENPEP................................ 66
ZETIA ................................... 51
ZIAGEN................................ 22
zidovudine ............................. 22
ziprasidone hcl ...................... 38
ZIRGAN ............................... 84
ZOLADEX............................ 33
zoledronic acid...................... 65
zoledronic acid/
mannitol&water ................ 65
ZOLINZA ............................. 33
zolmitriptan ........................... 42
zolpidem tartrate................... 46
ZOMETA.............................. 65
ZOMIG ................................. 42
ZONALON ........................... 57
zonisamide............................. 43
ZORTRESS........................... 33
ZOSTAVAX ......................... 69
I-12
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013
ZOVIRAX............................. 26
ZYCLARA............................ 57
ZYLET.................................. 83
ZYMAXID............................ 84
ZYPREXA RELPREVV ...... 38
ZYTIGA................................ 33
ZYVOX................................. 25
I-13
University Care Advantage (HMO/SNP)
Formulary ID: 13042.000, Version: 12
Effective: July 01, 2013