1. No category

ValUcare Plus Formulary Guide
Includes generic and brand-name medications
October 2014
Locally based. Individually focused.
SM
UniveraHealthcare.com
UN-1531 / 8789-14FLRX
Dear Member,
The prescription drug benefit is one of the most important
and frequently utilized elements of health plan coverage.
To help you identify which medications are covered under
your plan, we are pleased to provide the 3-Tier Formulary
Guide. This booklet provides you with easy to understand
information about your prescription drug coverage including
descriptions of prescription drug safety and cost-saving
programs.
This booklet includes the Formulary Guide
and prescription drug benefit information.
Please refer to this booklet when you see
your healthcare practioner or are prescribed
a medication.
The drugs listed in the formulary and
program descriptions may not apply to
all plans. Please see your plan documents
for a complete description of your
pharmacy benefit.
If you have questions or need additional
information, please visit our website
or contact the Pharmacy Help Desk
at 1-800-724-5033.
The 3-Tier Formulary Guide lists commonly prescribed
medications and their tier classifications. The medications
listed have been approved by the Food and Drug
Administration as safe and effective and were selected in
consultation with a team of health care professionals
because they meet our criteria for safety, quality and value.
We continually review and update our formulary.
The drugs listed in the formulary and program
descriptions may not apply to all plans. Please
see your plan documents or contact the Pharmacy
Help Desk for a complete description of your
pharmacy benefit.
Your prescription drug benefit is managed through our
internal prescription drug management division named FLRx. The
FLRx logo on your insurance identification card means that you and
your covered family members will receive the maximum benefits
entitled to you under your plan.
What is a Formulary?
Alphabetical Listing
A formulary is a list of brand name and generic drugs
that are covered under your prescription drug benefit.
If you are not sure what category to look under, look for
your drug in the Index that follows the formulary. The
Index provides an alphabetical listing of all of the drugs
included in the formulary and the page where they can
be found in the formulary.
How is the Formulary Developed?
Drugs listed on the formulary were selected by our independent Pharmacy and Therapeutics (P&T) Committee
which is made up of practicing health care providers
and clinical pharmacists. The P&T Committee reviews
each drug based upon scientific evidence, findings by
federal government agencies, professional medical
associations and journals to help ensure that the
medications covered meet criteria for safety,
effectiveness and value.
How do I use the formulary?
3-Tier Drug Benefit
Your 3-tier prescription drug benefit allows you to make
informed choices and encourages value when choosing
your prescription medications. Your copayment will vary
depending on the tier in which your prescription drug
is placed.
•
Tier One drugs are typically generics and have the
lowest copayment amount.
•
Tier Two drugs are brand drugs that have unique,
significant clinical advantages and offer overall
greater value over the other products in the same
drug class.
•
Tier Three drugs are all other brand drugs,
including new brand drugs and drugs that have
generic equivalents. Tier Three drugs have the
highest copayment amount.
There are two ways to find your drug within
the formulary:
Medical Condition
Drugs are listed in alphabetical order according to
drug categories. For example, drugs used to treat
heart conditions are listed under the category
“Cardiovascular/Heart.” Drugs are listed in
alphabetical order by condition.
The 3-Tier Formulary Guide lists commonly used
medications and their tier designations. Because there
are thousands of medications included in your pharmacy
benefit, we list only the most commonly prescribed.
Your plan may not cover all medications listed in
this booklet. Please see your plan documents for a
complete description of your pharmacy benefit, or
call the Pharmacy Help Desk.
Can the Formulary Change?
Our P&T Committee regularly reviews the drugs on our
formulary to be sure they meet the criteria for safety,
effectiveness and value. The list is subject to change.
Drugs may be added, removed, or change tier
designation at any time.
Generics Are Real Medicine
Generic drugs: safe, effective, affordable!
To help keep your prescription drug costs down, choose
a generic drug over a brand. Generics are as safe and
effective as their brand name counterparts – they just
cost a lot less.
In fact, you’ll save money when you choose a generic
because generics have the lowest copay. That means
you’ll always pay the lowest out-of-pocket amount
for a generic.
Generic drugs treat your illness or condition with the
same effectiveness and safety as their brand name
equivalents because they have to meet the same
rigorous FDA requirements as brand name drugs.
Experience has shown that more than 90% of members
who start on a generic will stay on a generic. So the
next time you need your brand prescription filled, ask
your doctor or pharmacist if a generic is right for you.
Generic Trial Program - Everyone Saves
With Generics
The Generic Trial program gives you a free 30-day trial
of selected generic medications. The first time you fill a
prescription for one of the generic medications included
in the program your copayment will be waived. All
future prescriptions will be at the usual copayment
amount. For a complete list of generic medications
included in the Generic Trial program, please visit
our website.
Where Can I Purchase My
Prescription Medications?
You have access to more than 65,000 participating
pharmacies in our nationwide Pharmacy Network,
including national chains and most independents. Just
show your ID card at any participating pharmacy; it
identifies you as having prescription drug coverage. A
list of participating pharmacies in your area is available
on our website.
Mail Service Pharmacy
Get your prescriptions delivered right to your door!
When you use PrimeMail® or Wegmans® Home Delivery
Pharmacy, you get the convenience of home delivery
and the ease of ordering new prescriptions and refills
either by phone or via our website. Some benefits
offer copay savings for ordering prescriptions through
PrimeMail® or Wegmans® Home Delivery Pharmacy.
Using a home delivery pharmacy is ideal for those
who take prescription medication on a continuing basis.
For more information on how to use PrimeMail® or
Wegmans® Home Delivery Pharmacy, please visit our
website at ExcellusBCBS.com or contact the Pharmacy
Help Desk.
Specialty Pharmacy
Specialty pharmacies focus on you and your individual
health care needs. Because they work exclusively with
specialty medications, they are experts in handling and
administering these complex medications. Nationally
recognized specialty pharmacies Accredo Health (formerly
Curascript Pharmacy) and Walgreens Specialty Pharmacy
participates in our network. Accredo and Walgreens
Specialty Pharmacy offers outstanding customer service
and is dedicated to providing quality care to our members.
With a single, toll-free phone call they take care of all the
details – they will contact your doctor for your prescription
and arrange delivery to your home. There are several
local/regional specialty pharmacies also participating in
our specialty pharmacy network. A complete listing
of participating specialty pharmacies is available on
our website.
Are There Any Restrictions
On Coverage?
Some covered drugs may have additional requirements or
limits for coverage. If a drug has requirements or limits, it
will be noted in the formulary.
If your healthcare practitioner determines that you
need a medication that has a requirement or limit, we
have an exception process in place. Your healthcare
practitioner must submit a request to the Health Plan
supporting your need.
Coverage requirements or limits may include:
• Prior Authorization
Prior authorization helps assure that a prescribed
drug is safe and appropriate for your medical
condition. Certain medications require that your
doctor gets approval before the medication is
covered. Our clinical pharmacists and physicians
review medication requests to make sure that the
choice of drug or dose is appropriately prescribed
based on FDA and manufacturer guidelines, medical
literature, safety, use and benefit design.
• Step Therapy
In some cases you may be required to first try one
or more drugs to treat your medical condition
before another drug for that condition will be
covered. The medication treatment moves along a
series of “steps.” For example, if Drug A and Drug
B both treat your medical condition, we may not
cover Drug B unless you try Drug A first. If Drug A
does not work, we will then cover Drug B.
Pharmacy Network in order to receive coverage. If
a participating specialty pharmacy is not used you
may be responsible for the full cost of the prescription. However, the first time a prescription for a
specialty medication is filled, it may filled at any
participating network retail pharmacy of choice. A
complete listing of participating specialty pharmacies can be found on our website.
• Quantity Limits
For certain drugs, we limit the amount of the drug
that we will cover. The amount of drug we cover
is based on Food and Drug Administration (FDA)
approved dosing and usage guidelines.
• Generic Advantage Program
The Generic Advantage program promotes the use
of generic medications. If you fill your prescription
with a brand name medication when there is a
generic equivalent available, you will pay the
difference between the pharmacy’s charge for the
more costly brand name medication and our price
for the less expensive generic. Check your benefits
summary to find out if the Generic Advantage
program applies to your plan.
Key:
UPPERCASE – Brand name medication
lowercase – generic medication
PA = Prior Authorization required
QL = Quantity Limit applies
• Mandatory Specialty Drug Benefit
Specialty medications are designed for conditions like
multiple sclerosis, rheumatoid arthritis, hepatitis C,
and others that are difficult to treat with traditional
medications. These medications are self-administered;
either taken orally or by injection.
Your prescription drug benefit may require that
you purchase certain specialty medications at a
specialty pharmacy that participates in the Specialty
ST = Step Therapy required
MS = Drug must be purchased at a
participating network specialty
pharmacy for coverage
GT = Qualifies for the Generic Trial
Program
DRUG
TIER
COMMENTS
DRUG
Addiction
Alcohol
ANTABUSE
disulfiram
3
1
Narcotics
buprenorphine hcl
buprenorphine hcl/naloxone hcl
EVZIO
naltrexone
SUBOXONE
ZUBSOLV
1
1
3
1
2
2
1
3
3
QL
montelukast sodium
zafirlukast
ZYFLO
ZYFLO CR
3
3
1
1
1
1
1
1
albuterol sulfate er
terbutaline
theophylline er
ADDERALL XR
amphetamine/dextroamphetamine
CONCERTA
DAYTRANA
DESOXYN
dexmethylphenidate
dextroamphetamine sulfate er
FOCALIN
FOCALIN XR
INTUNIV
KAPVAY
METADATE CD
metadate er
methylphenidate
methylphenidate hcl cd
methylphenidate hcl er
QUILLIVANT XR
RITALIN LA
STRATTERA
VYVANSE
3
1
1
2
3
1
QL, ST
3
2
2
QL
QL
QL
3
3
3
3
MS, PA, QL
MS, PA, QL
MS, PA, QL
MS, PA
Anaphylaxis Therapy Agents
Angioedema
BERINERT
CINRYZE
FIRAZYR
RUCONEST
3
2
1
2
3
3
2
QL
QL
QL, ST
QL
QL
QL, ST
QL
1
1
3
3
QL
QL
QL
3
1
3
3
3
1
1
3
3
2
3
3
1
1
1
1
3
3
3
2
QL, ST
QL
QL, ST
QL, ST
QL, ST
QL
QL, ST
QL, ST
QL
QL
PA, QL
QL, ST
ST
QL
Anticoagulants
1
1
ARIXTRA
COUMADIN
ELIQUIS
enoxaparin sodium
fondaparinux sodium
FRAGMIN
heparin
jantoven
PRADAXA
ticlopidine
warfarin
XARELTO
Asthma
Inhaled Beta Agonists / Inhaled Respiratory Drugs
acetylcysteine
1
ADVAIR
2
Note: Tier 2 after trial and failure of an inhaled steroid
albuterol sulfate
1
ANORO ELLIPTA
2
ARCAPTA NEOHALER
2
ATROVENT HFA
2
BREO ELLIPTA
2
BROVANA
3
COMBIVENT RESPIMAT
2
cromolyn
1
DALIRESP
3
DULERA
3
FORADIL
2
ipratropium
1
ipratropium/albuterol
1
MAXAIR
3
metaproterenol
1
1
1
1
Blood
Antispasmodic Drugs
dicyclomine
glycopyrrolate
QL
QL
Attention Deficit Disorder
QL
Alzheimer's
AUVI-Q
EPIPEN 2-PAK
EPIPEN-JR 2-PAK
QL
Respiratory Drugs (oral)
Antihistamines
ARICEPT 23MG
donepezil hcl
galantamine
NAMENDA
NAMENDA XR
rivastigmine tartrate
QL
QL
QL
Leukotriene Inhibitors
Antihistamine / Decongestant Combination
CLARINEX
cyproheptadine
desloratadine
desloratadine odt
diphenhydramine
levocetirizine dihydrochloride
promethazine
PERFOROMIST
3
PROAIR HFA
2
PROVENTIL HFA
3
SPIRIVA
2
SYMBICORT
2
Note: Tier 2 after trial and failure of an inhaled steroid
TUDORZA PRESSAIR
3
VENTOLIN HFA
2
XOPENEX
3
ALVESCO
ASMANEX TWISTHALER 120 METERED DOSES
budesonide nebulizer
FLOVENT
PULMICORT
PULMICORT NEBULIZER
QVAR
Allergy
CLARINEX-D
COMMENTS
Inhaled Steroids
QL
Smoking Deterrents
buproban
CHANTIX
NICOTROL INHALER
TIER
QL
QL
QL
QL
3
2
2
1
1
3
1
1
2
1
1
2
QL
QL
Antiplatelet
QL
AGGRENOX
BRILINTA
cilostazol
clopidogrel
dipyridamole
EFFIENT
pentoxifylline er
PLAVIX
ZONTIVITY
QL, ST
QL
QL
QL
1
3
2
1
1
1
2
1
3
3
QL
QL
QL
QL
PA, QL
(Rev. 10/01/14)
DRUG
TIER
COMMENTS
DRUG
captopril
enalapril
EPANED
fosinopril
lisinopril
quinapril
ramipril
trandolapril
Blood (continued)
Blood Cell Stimulation
ARANESP
EPOGEN
GRANIX
LEUKINE
MOZOBIL
NEULASTA
NEUPOGEN
PROCRIT
2
2
2
3
3
3
2
2
MS
MS
MS, QL
MS, QL
MS, PA, QL
MS, QL
MS, QL
MS
3
2
2
1
1
2
1
2
2
1
3
2
2
1
2
1
2
2
2
1
3
3
2
2
2
1
2
1
2
1
2
1
2
2
2
3
2
2
2
2
2
1
2
2
2
2
2
2
2
3
3
2
2
2
3
3
2
MS, PA
MS, PA, QL
benazepril hcl/hydrochlorothiazide
enalapril maleate/hydrochlorothiazide
fosinopril sodium/hydrochlorothiazide
lisinopril/hydrochlorothiazide
moexipril/hydrochlorothiazide
quinapril/hydrochlorothiazide
Antineoplastic
1
1
3
1
1
1
1
1
PA
GT
GT
1
1
1
1
1
1
Angiotensin II Receptor Blockers
ATACAND
BENICAR
DIOVAN
EDARBI
eprosartan mesylate
irbesartan
losartan potassium
MICARDIS
telmisartan
MS, PA, QL
MS
MS, PA, QL
MS, PA, QL
3
3
2
3
1
1
1
3
1
QL, ST
QL, ST
QL
QL, ST
QL
QL
GT
QL, ST
QL
1
1
3
1
1
3
2
3
PA, QL
QL
QL
Anti-anginal Agents
MS, PA, QL
isosorbide dinitrate
isosorbide mononitrate er
NITRO-BID
nitroglycerin
nitroglycerin er
NITROMIST
NITROSTAT
RANEXA
MS, PA, QL
MS, QL
MS, PA, QL
MS, PA, QL
PA
MS, PA, QL
MS, QL
MS, PA, QL
Antiarrhythmics
amiodarone
digoxin
disopyramide
flecainide
LANOXIN
mexiletine
MULTAQ
NORPACE CR
pacerone
propafenone
propafenone hcl er
quinidine
RYTHMOL SR
TIKOSYN
MS, PA, QL
MS, PA, QL
MS, PA, QL
PA, QL
MS, PA, QL
MS, PA, QL
MS, PA, QL
MS, PA, QL
MS, PA, QL
1
1
1
1
2
1
2
3
1
1
1
1
3
3
QL
Antihyperlipidemics
ADVICOR
ALTOPREV
ANTARA
atorvastatin calcium
cholestyramine
colestipol hcl
CRESTOR
fenofibrate
fenofibrate
FENOGLIDE
fluvastatin
gemfibrozil
JUXTAPID
KYNAMRO
LESCOL
LESCOL XL
LIPITOR
LIPTRUZET
LIVALO
LOFIBRA
lovastatin
LOVAZA
MEVACOR
MS, PA, QL
MS, PA, QL
MS, PA, QL
MS
MS, QL
MS, PA, QL
MS, PA, QL
MS, PA, QL
MS
MS, PA, QL, ST
MS, PA, QL
MS, PA, QL
PA, QL
MS, PA, QL
MS, PA, QL
Cardiovascular / Heart
ACE Inhibitors (high blood pressure)
benazepril
COMMENTS
ACE Inhibitors / Diuretic Combinations
Cancer
ACTIMMUNE
AFINITOR
ALKERAN
anastrozole
bicalutamide
BOSULIF
capecitabine
CAPRELSA
COMETRIQ
cyclophosphamide
DROXIA
EMCYT
ERIVEDGE
exemestane
FARESTON
flutamide
GILOTRIF
GLEEVEC
HYCAMTIN
hydroxyurea
ICLUSIG
IMBRUVICA
INLYTA
IRESSA
JAKAFI
letrozole
LEUKERAN
lomustine
LYSODREN
megestrol
MEKINIST
mercaptopurine
NEXAVAR
NILANDRON
POMALYST
PURIXAN
REVLIMID
SPRYCEL
STIVARGA
SUTENT
TAFINLAR
tamoxifen
TARCEVA
TARGRETIN
TASIGNA
TEMODAR
THALOMID
TYKERB
VOTRIENT
XALKORI
XELODA
XTANDI
ZELBORAF
ZOLINZA
ZYDELIG
ZYKADIA
ZYTIGA
TIER
1
2
3
3
3
1
1
1
2
1
1
3
1
1
3
3
3
3
3
3
3
3
1
3
3
QL, ST
QL, ST
QL, ST
QL
QL
QL
MS, PA, QL
MS, PA
QL, ST
QL, ST
ST
QL, ST
QL, ST
GT, QL
QL
ST
(Rev. 10/01/14)
DRUG
TIER
COMMENTS
DRUG
diltzac
felodipine er
isradipine
nicardipine
nifedipine
nifedipine er
nimodipine
nisoldipine
SULAR
verapamil
verapamil er
Cardiovascular / Heart (continued)
Antihyperlipidemics (continued)
omega-3-acid ethyl esters
PRAVACHOL
pravastatin
SIMCOR
simvastatin
TRICOR
TRILIPIX
VASCEPA
VYTORIN
WELCHOL
ZETIA
1
3
1
3
1
3
3
3
3
3
2
QL
ST
GT, QL
QL, ST
GT
QL
QL
QL
ST
1
1
3
3
3
3
3
1
3
1
1
1
1
3
3
3
3
3
1
1
1
1
1
1
3
1
1
1
3
3
3
3
1
1
3
3
3
1
acetazolamide
amiloride
amiloride/hydrochlorothiazide
chlorthalidone
DIURIL
DYRENIUM
eplerenone
furosemide
hydrochlorothiazide
metolazone
spironolactone
torsemide
triamterene/hydrochlorothiazide
PA, QL
QL, ST
QL, ST
PA, QL
QL, ST
QL
PA, QL
QL
1
1
1
3
1
3
1
1
1
1
1
1
1
1
1
QL
QL
1
1
1
1
3
3
1
1
1
1
1
1
1
GT
NORTHERA
3
MS, PA, QL
3
1
3
3
3
PA, QL
PA, QL
PA, QL
PA, QL
PA, QL
1
1
3
QL
QL
Central Nervous System
QL
QL
QL, ST
PA, QL
PA, QL
ST
QL
GT
CUVPOSA
modafinil
NUVIGIL
PROVIGIL
XYREM
Cough / Cold
Antitussives & Expectorants
benzonatate
hydrocodone polistirex/chlorpheniramine polistirex
TUSSIONEX
QL, ST
Cryopyrin Associated Periodic Syndromes
ARCALYST
QL
QL, ST
QL, ST
QL, ST
QL
QL
QL, ST
PA, QL
PA, QL
QL
3
PA
3
MS, PA, QL
3
3
3
2
3
3
MS, QL
Cushing's Syndrome
KORLYM
Cystic Fibrosis
BETHKIS
CAYSTON
KALYDECO
PULMOZYME
TOBI
TOBI PODHALER
MS, PA, QL
MS
MS
MS, QL
Dermatology
GT
Cancer / Topical Peeling Agents
QL
GT
QL, ST
CARAC
FLUOROPLEX
PANRETIN
PICATO
SOLARAZE
VALCHLOR
QL
GT
3
3
3
2
3
3
QL
MS, PA, QL
Immunomodulators
ALDARA
ELIDEL
imiquimod
PROTOPIC
ZYCLARA
Calcium Channel Blockers
afeditab cr
amlodipine
diltiazem cd
diltiazem
1
1
1
1
1
1
1
1
3
1
1
Hypotension
Beta Blockers (high blood pressure)
acebutolol
atenolol
betaxolol
BYSTOLIC
carvedilol
COREG CR
labetalol
metoprolol succinate er
metoprolol tartrate
nadolol
pindolol
propranolol
propranolol er
sotalol
timolol
COMMENTS
Diuretics
Antihypertensive Combinations / Miscellaneous
amlodipine besylate/atorvastatin calcium
amlodipine/benazepril
AMTURNIDE
ATACAND HCT
AZOR
BENICAR HCT
BIDIL
bisoprolol/hydrochlorothiazide
CADUET
candesartan cilexetil/hydrochlorothiazide
captopril/hydrochlorothiazide
chlorothiazide
clonidine
DUTOPROL
EDARBYCLOR
EXFORGE
EXFORGE HCT
HYZAAR
irbesartan/hydrochlorothiazide
losartan potassium/hydrochlorothiazide
methazolamide
methyldopa
methyldopa/hydrochlorothiazide
metoprolol/hydrochlorothiazide
MICARDIS HCT
minoxidil
propranolol/hydrochlorothiazide
spironolactone/hydrochlorothiazide
TARKA
TEKAMLO
TEKTURNA
TEKTURNA HCT
telmisartan/amlodipine
telmisartan/hydrochlorothiazide
TEVETEN HCT
TRIBENZOR
TWYNSTA
valsartan/hydrochlorothiazide
TIER
1
1
1
1
3
3
1
3
3
QL
QL
1
2
MS, PA, QL
QL
Psoriasis Products
calcipotriene
ENBREL
3
(Rev. 10/01/14)
DRUG
TIER
COMMENTS
DRUG
methylprednisolone
mometasone furoate
OLUX
prednisolone
prednisone
RAYOS
triamcinolone acetonide
TRIANEX
ULTRAVATE PAC
VANOS
VERDESO
Dermatology (continued)
Psoriasis Products (continued)
HUMIRA
OTEZLA
selenium sulfide
SORIATANE
SORILUX
STELARA
TACLONEX OINTMENT
TACLONEX SUSPENSION
TAZORAC
2
3
1
3
3
2
3
3
3
MS, PA, QL
MS, PA, QL
3
3
1
1
1
3
3
1
3
3
1
1
3
3
3
3
1
3
3
3
3
1
3
3
1
3
1
3
3
3
3
QL
QL, ST
QL
PA, QL
MS, PA, ST
ST
PA, QL
ALTABAX
BACTROBAN CREAM
gentamicin
METROGEL
mupirocin
NORITATE
silver sulfadiazine
3
1
1
1
1
2
1
1
3
1
3
1
3
3
1
3
1
1
1
1
1
1
1
1
3
1
1
3
3
3
1
1
3
1
1
3
1
3
3
3
3
ST
PA
ST
PA, QL
ST
ST
3
3
1
3
1
3
1
ST
ST
1
1
3
1
3
2
3
3
1
3
3
3
3
3
1
1
3
QL
ST
ST
Topical Antifungals
ciclopirox nail lacquer
ciclopirox olamine
CNL8 NAIL KIT
econazole nitrate
ERTACZO
EXELDERM
JUBLIA
KERYDIN
ketoconazole
LOPROX
LUZU
MENTAX
NAFTIN
NIZORAL SHAMPOO
nystatin/triamcinolone
nystop
XOLEGEL
ST
ST
ST
ST
QL
ST
PA, QL
PA, QL
QL, ST
ST
ST
PA, QL
PA, QL
ST
QL, ST
ST
ST
ST
ST
Diabetes
PA, QL
DIABETIC BENEFIT and/or DME BENEFIT APPLIES. Please refer to member contract
for copayment amount. If Diabetic Benefit DOES NOT apply please refer to the
following tier classifications:
PA, QL
PA
ST
PA
Blood Glucose Supplies
Lifescan and Abbott are preferred test meters/strips and Step Therapy applies prior
to all other meters and strips.
FREESTYLE FREEDOM LITE
2
FREESTYLE INSULINX BLOOD GLUCOSE MONITORING SYSTEM2
FREESTYLE INSULINX BLOOD GLUCOSE TEST
2
QL
FREESTYLE LITE BLOOD GLUCOSE MONITORING SYSTEM2
FREESTYLE LITE TEST STRIPS
2
QL
FREESTYLE TEST STRIPS
2
QL
ONETOUCH ULTRA 2
2
ONETOUCH ULTRA BLUE
2
QL
ONETOUCH ULTRA MINI
2
ONETOUCH ULTRA SYSTEM KIT
2
ONETOUCH ULTRASMART
2
ONETOUCH VERIO IQ BLOOD GLUCOSE MONITORING SYSTEM2
ONETOUCH VERIO TEST STRIPS
2
QL
PRECISION XTRA
2
PRECISION XTRA BLOOD GLUCOSE TEST STRIPS 2
QL
SURESTEP PRO LINEARITY KIT
2
Topical / Oral Steroids
ACLOVATE
alclometasone dipropionate
amcinonide
augmented betamethasone
betamethasone valerate
CAPEX
clobetasol propionate
clobetasol propionate emollient
CLOBEX
clocortolone pivalate
CLODERM
clotrimazole/betamethasone dipropionate
CORDRAN
DESONATE
desonide
DESOWEN LOTION/CETAPHIL CREAM
desoximetasone
dexamethasone
diflorasone diacetate
fludrocortisone acetate
fluocinolone acetonide
fluocinonide
fluticasone
halobetasol propionate
HALONATE
hydrocortisone butyrate
hydrocortisone valerate
KENALOG
LOCOID LIPOCREAM
LUXIQ
COMMENTS
Topical Antibiotics
Topical / Oral Acne Products
ACANYA
ACZONE
adapalene
amnesteem
avita
AZELEX
BENZAMYCIN
claravis
CLEOCIN-T
CLINDAGEL
clindamycin phosphate
clindamycin/benzoyl peroxide
DIFFERIN LOTION
DORYX
DUAC
EPIDUO
erythromycin
EVOCLIN
FABIOR
FINACEA
KLARON
minocycline hcl er
ORACEA
RETIN-A MICRO
sodium sulfacetamide
SOLODYN
tretinoin
TRETIN-X
VELTIN
ZACLIR CLEANSING
ZIANA
TIER
ST
ST
ST
PA, QL
Injectables
APIDRA
BYDUREON
BYETTA
GLUCAGEN
GLUCAGON EMERGENCY KIT
HUMALOG
HUMALOG MIX 50/50
HUMALOG MIX 75/25
HUMULIN N
HUMULIN R
LANTUS
LEVEMIR
PA, QL
ST
ST
ST
4
3
2
2
2
2
2
2
2
2
2
2
2
QL
QL
QL
(Rev. 10/01/14)
DRUG
TIER
COMMENTS
DRUG
Diabetes (continued)
Enzyme Replacements/ Modifiers
2
2
2
2
2
2
3
2
PROCYSBI
3
2
3
3
3
3
1
3
2
2
3
1
1
1
3
1
1
1
2
2
2
2
2
2
2
3
3
1
1
1
3
3
3
1
1
2
1
1
2
ALOCRIL
ALOMIDE
ALREX
azelastine hcl
BEPREVE
EMADINE
epinastine hcl
LASTACAFT
LOTEMAX GEL
LOTEMAX SUSPENSION
OPTIVAR
PATADAY
PATANOL
QL
QL
QL
QL
QL
QL
QL
AZASITE
BESIVANCE
CILOXAN OINTMENT
ciprofloxacin
gatifloxacin
neomycin/bacitracin/polymyxin
neomycin/polymyxin/gramicidin
polymyxin b sulfate/trimethoprim sulfate
tobramycin
trifluridine
VIGAMOX
ZYMAXID
QL
QL
QL
QL
QL
QL
QL, ST
QL, ST
ACULAR
ACULAR LS
ACUVAIL
diclofenac
DUREZOL
flurbiprofen
FML FORTE
ketorolac
neomycin/polymyxin/dexamethasone
NEVANAC
tobramycin/dexamethasone
VEXOL
QL, ST
QL, ST
QL, ST
QL
3
3
3
1
3
1
3
1
1
3
1
3
Cystinosis
CYSTARAN
QL
3
PA
3
3
3
1
1
1
1
3
1
1
2
1
1
3
3
3
3
QL
Glaucoma
AZOPT
BETIMOL
BETOPTIC-S
brimonidine
carteolol hcl
dorzolamide
dorzolamide/timolol
IOPIDINE
latanoprost
levobunolol
LUMIGAN
metipranolol
pilocarpine
PILOPINE HS
TRAVATAN Z
XALATAN
ZIOPTAN
1
1
2
2
1
1
1
3
3
1
3
1
2
MS, PA
MS
MS, PA
3
MS, PA
3
2
1
PA
PA
PA
ST
ST
QL, ST
QL, ST
Other
Enteral Formula
Enteral formulas
PKU products
various generics
3
3
2
1
1
1
1
1
1
1
2
3
Anti-inflammatory
PKU
KUVAN
3
3
3
1
3
3
1
3
3
2
3
3
3
Antiinfectives
Endocrine
calcitriol
HECTOROL
MYALEPT
octreotide
SIGNIFOR
vitamin d
ZEMPLAR
MS, PA, QL
Antiallergics
Ear
acetasol hc
antipyrine/benzocaine
CIPRO HC
CIPRODEX
neomycin/polymyxin/hydrocortisone
ofloxacin
3
Eye
Oral Hypoglycemics
ACTOPLUS MET
ACTOPLUS MET XR
ACTOS
AVANDAMET
AVANDARYL
AVANDIA
chlorpropamide
CYCLOSET
DUETACT
FARXIGA
FORTAMET
glimepiride
glipizide
glipizide/metformin
GLUMETZA
glyburide
glyburide micronized
glyburide/metformin
GLYSET
INVOKANA
JANUMET
JANUMET XR
JANUVIA
JENTADUETO
JUVISYNC
KAZANO
KOMBIGLYZE XR
metformin
metformin er
nateglinide
NESINA
ONGLYZA
OSENI
pioglitazone hcl/metformin hcl
pioglitazone hcl-glimepiride
PRANDIN
tolazamide
tolbutamide
TRADJENTA
COMMENTS
Enzyme Replacements/ Modifiers
Injectables (continued)
NOVOLIN 70/30
NOVOLIN N
NOVOLIN R
NOVOLOG
NOVOLOG MIX 70/30
SYMLINPEN 60
TANZEUM
VICTOZA
TIER
RESTASIS
3
Fibromyalgia
CYMBALTA
5
3
QL
(Rev. 10/01/14)
DRUG
TIER
COMMENTS
DRUG
STRIBILD
SUSTIVA
TIVICAY
TRIZIVIR
TRUVADA
VIRACEPT
VIRAMUNE
VIREAD
ZIAGEN
zidovudine
TRIUMEQ
Fibromyalgia (continued)
duloxetine hcl
LYRICA
SAVELLA
1
3
3
QL
QL
QL, ST
Gout
allopurinol
COLCRYS
probenecid
probenecid/colchicine
ULORIC
1
2
1
1
2
QL, ST
3
3
3
3
3
2
3
3
3
3
3
MS, PA, ST
MS, PA, ST
MS, PA
MS, PA, ST
MS, PA, ST
MS, PA
MS, PA, ST
MS, PA
PA
MS, PA, ST
MS, PA, QL
QL
XENAZINE
CARBAGLU
PA
MS, PA, QL
MS, PA
MS, PA
MS, PA
MS, PA, QL
PROMACTA
ASTAGRAF XL
AZASAN
azathioprine
CELLCEPT
cyclosporine
gengraf
leflunomide
mycophenolate mofetil
mycophenolic acid dr
MYFORTIC
NEORAL
RAPAMUNE
tacrolimus
ZORTRESS
3
3
3
3
2
3
1
1
3
3
3
MS, PA
MS, PA, ST
MS, PA
MS, PA, QL
MS, PA, QL
MS, PA, QL, ST
MS, PA
MS, PA
MS, PA, QL
MS, PA
MS, PA
CERDELGA
ORFADIN
ZAVESCA
MS, PA, QL
3
PA
3
MS, PA, QL
3
3
1
3
1
1
1
1
1
3
3
2
1
3
PA, QL
ST
3
3
3
MS, PA, QL
PA
PA, QL
3
MS, PA, QL
3
3
1
1
1
3
1
3
1
1
1
1
1
1
1
1
1
1
1
1
3
1
1
3
1
3
1
1
1
3
1
PA, QL
ST
Infantile Spasms
SABRIL
Infections
Antibiotics
ACTICLATE
ADOXA
amoxicillin
amoxicillin/clavulanate potassium
ampicillin
AVELOX
azithromycin
CEDAX
cefaclor
cefaclor er
cefadroxil
cefdinir
cefpodoxime
cefprozil
cefuroxime
cephalexin
ciprofloxacin
clarithromycin
clindamycin
dicloxacillin
DIFICID
doxycycline hyclate
erythrocin stearate
FURADANTIN
isoniazid
KETEK
levofloxacin
metronidazole
minocycline
MOXATAG
moxifloxacin hcl
HIV
abacavir
APTIVUS
ATRIPLA
COMBIVIR
COMPLERA
didanosine
EDURANT
EGRIFTA
EMTRIVA
EPIVIR
EPZICOM
FUZEON
INTELENCE
INVIRASE
ISENTRESS
KALETRA
lamivudine
lamivudine/zidovudine
LEXIVA
NORVIR
RESCRIPTOR
REYATAZ
SELZENTRY
stavudine
2
Inborn Errors of Metabolism
Hepatitis C
COPEGUS
INCIVEK
INFERGEN
OLYSIO
PEGASYS
PEG-INTRON
ribasphere
ribasphere ribapak
SOVALDI
SYLATRON
VICTRELIS
QL
QL
Immune System
1
1
1
1
1
1
2
2
2
1
2
QL
Idiopathic Thrombocytopenia
Hepatitis B
adefovir dipivoxil
BARACLUDE
EPIVIR HBV
HEPSERA
lamivudine
TYZEKA
2
2
3
3
2
2
3
2
3
1
3
Hyperammonemia
Hemorrhoids
ala cort
hemril-30
hydrocortisone
hydrocortisone acetate
proctozone-hc
COMMENTS
Huntington's Chorea
Growth Hormone / Factors
GENOTROPIN MINIQUICK
HUMATROPE
INCRELEX
NORDITROPIN FLEXPRO
NUTROPIN AQ PEN
OMNITROPE
SAIZEN
SEROSTIM
SOMAVERT
TEV-TROPIN
ZORBTIVE
TIER
1
2
2
3
2
1
3
3
2
3
2
3
2
2
2
2
1
1
2
2
2
2
2
1
QL
MS, PA
QL
QL
QL
6
ST
PA, QL
(Rev. 10/01/14)
DRUG
TIER
COMMENTS
DRUG
mesalamine
mesalamine kit
PENTASA
ROWASA KIT
sulfasalazine
UCERIS
Infections (continued)
Antibiotics (continued)
nitrofurantoin macrocrystals
ofloxacin
penicillin v potassium
rifampin
SIVEXTRO
SPECTRACEF
sulfamethoxazole/trimethoprim
SUPRAX
tetracycline
tinidazole
trimethoprim
vancomycin hcl
VIBRAMYCIN
XIFAXAN
ZMAX
ZYVOX
1
1
1
1
3
3
1
3
1
1
1
1
3
3
3
3
1
1
2
1
3
1
1
3
1
3
3
1
1
3
1
PA, QL
1
3
1
3
3
1
3
3
1
3
3
3
ASTEPRO
azelastine hcl
BECONASE AQ
budesonide
DYMISTA
FLONASE
flunisolide
fluticasone
NASACORT AQ
NASONEX
OMNARIS
PATANASE
QNASL
RHINOCORT AQUA
triamcinolone acetonide
VERAMYST
ZETONNA
PA
alfuzosin hcl er
AVODART
doxazosin
finasteride
FLOMAX
JALYN
prazosin
RAPAFLO
tamsulosin hcl
terazosin
UROXATRAL
PA, QL
PA
QL
QL
QL
ANDRODERM
ANDROGEL
ANDROID
androxy
AVEED
AXIRON
DELATESTRYL
DEPO-TESTOSTERONE
FIRST-TESTOSTERONE
FIRST-TESTOSTERONE MC COMPOUNDING KIT
FORTESTA
oxandrolone
STRIANT
TESTIM
testosterone enanthate
VOGELXO
VOGELXO PUMP
QL
QL
PA, QL
QL
1
1
3
3
1
3
PA
1
3
1
QL
QL
2
3
1
1
3
3
3
3
3
3
2
2
PA, QL
3
1
3
1
3
3
1
1
3
2
3
3
3
3
1
3
3
QL, ST
QL
QL, ST
PA, QL
ST
QL
ST
QL, ST
QL, ST
QL, ST
ST
QL, ST
QL, ST
1
3
1
1
3
3
1
3
1
1
3
QL
QL, ST
GT
QL, ST
PA, QL
QL, ST
GT, QL
QL, ST
Hormones
QL
2
2
3
1
3
3
3
3
3
3
3
1
3
3
1
3
3
PA
PA
PA
PA
3
3
3
3
3
3
2
QL
QL
QL
QL
QL
QL
QL
1
3
3
1
QL, ST
PA, QL
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
Sexual Dysfunction
CAVERJECT
CIALIS
EDEX
LEVITRA
MUSE
STAXYN
VIAGRA
Inflammatory Bowel
APRISO
ASACOL HD
balsalazide
budesonide
CANASA
CIMZIA
DELZICOL
DIPENTUM
ENTOCORT EC
GIAZO
HUMIRA PEN
LIALDA
PA, QL
BPH Agents (prostate)
PA, QL
Scabies
acticin
EURAX
lindane
PA, QL
Men's Health
Malaria
atovaquone/proguanil hcl
chloroquine
DARAPRIM
MALARONE
mefloquine
QUALAQUIN
1
1
2
3
1
3
Steroids / Antihistamines / Miscellaneous
Antiviral Drugs
acyclovir
DENAVIR
famciclovir
FAMVIR
RELENZA DISKHALER
rimantadine
SITAVIG
TAMIFLU
valacyclovir hcl
VALCYTE
XERESE
ZOVIRAX
COMMENTS
Intranasal
Antifungal Drugs (oral)
clotrimazole
fluconazole
GRIFULVIN V
griseofulvin
GRIS-PEG
itraconazole
ketoconazole
LAMISIL GRANULES
nystatin
ONMEL
ORAVIG
terbinafine
terconazole
VFEND
voriconazole
TIER
QL
Mental Health
MS, PA, QL, ST
QL
Antidepressants
amoxapine
APLENZIN
BRINTELLIX
budeprion sr
PA
MS, PA, QL
7
(Rev. 10/01/14)
DRUG
TIER
COMMENTS
DRUG
trifluoperazine
ziprasidone hcl
ZYPREXA
ZYPREXA ZYDIS
Mental Health (continued)
Antidepressants (continued)
bupropion
bupropion sr
bupropion hcl xl
CELEXA
chlordiazepoxide/amitriptyline
citalopram
clomipramine
desipramine
DESVENLAFAXINE ER
doxepin
duloxetine hcl
EFFEXOR XR
EMSAM
escitalopram oxalate
FETZIMA
fluoxetine dr
fluoxetine
fluvoxamine
FORFIVO XL
imipramine
LEXAPRO
LUVOX CR
maprotiline
mirtazapine
NARDIL
nefazodone
nortriptyline
olanzapine/fluoxetine
OLEPTRO
paroxetine
paroxetine hcl er
PAXIL
PAXIL CR
perphenazine/amitriptyline
PEXEVA
phenelzine sulfate
PRISTIQ
PROZAC
PROZAC WEEKLY
SARAFEM
sertraline
SURMONTIL
tranylcypromine
trazodone
venlafaxine
venlafaxine hcl er caps
venlafaxine hcl er tabs
VIIBRYD
WELLBUTRIN
WELLBUTRIN SR
WELLBUTRIN XL
ZOLOFT
1
1
1
3
1
1
1
1
3
1
1
3
3
1
3
1
1
1
3
1
3
3
1
1
3
1
1
1
3
1
1
3
3
1
3
1
3
3
3
3
1
3
1
1
1
1
1
3
3
3
3
3
COMMENTS
1
1
3
3
Sedatives / Hypnotics / Anxiety
alprazolam
alprazolam er
AMBIEN
AMBIEN CR
buspirone
clorazepate
diazepam
EDLUAR
estazolam
eszopiclone
flurazepam
hydroxyzine
INTERMEZZO
lorazepam
LUNESTA
meprobamate
oxazepam
ROZEREM
SILENOR
SONATA
temazepam
triazolam
zaleplon
zolpidem
zolpidem tartrate er
ZOLPIMIST
GT
ST
GT
QL, ST
QL
QL, ST
QL, ST
PA, QL
QL
QL, ST
ST
QL, ST
GT
QL
QL
QL, ST
1
1
3
3
1
1
1
3
1
1
1
1
3
1
3
1
1
3
3
3
1
1
1
1
1
3
QL, ST
QL, ST
QL, ST
QL
QL, ST
QL, ST
QL, ST
QL, ST
QL, ST
QL
QL
QL
QL, ST
Migraine
ALSUMA
AMERGE
AXERT
CAMBIA
divalproex sodium er
FROVA
IMITREX
migergot
MIGRANAL
naratriptan hcl
RELPAX
rizatriptan benzoate
rizatriptan benzoate odt
sumatriptan
SUMAVEL DOSEPRO
TREXIMET
zolmitriptan
zolmitriptan odt
ZOMIG
ZOMIG ZMT
QL
ST
QL, ST
QL, ST
PA, QL
ST
QL, ST
QL, ST
QL
QL
QL, ST
QL, ST
ST
ST
ST
ST
3
3
3
3
1
3
3
1
2
1
3
1
1
1
3
3
1
1
3
3
QL, ST
QL, ST
QL, ST
QL, ST
QL
QL
QL, ST
QL
QL
GT, QL
QL, ST
QL, ST
QL
QL
QL, ST
QL, ST
3
3
2
3
2
3
3
3
2
2
MS, PA, QL
MS, QL, ST
MS, QL
MS, ST
MS, QL
MS, PA
MS, QL, ST
PA, QL
MS, QL
MS, QL
2
1
2
3
3
2
3
3
QL, ST
GT, QL
QL, ST
QL, ST
QL, ST
QL, ST
QL, ST
Modified Solid Foods
All modified solid foods are covered as brand
Multiple Sclerosis
Antipsychosis
ABILIFY
ABILIFY DISCMELT
chlorpromazine
clozapine
FANAPT
FAZACLO
fluphenazine
haloperidol
INVEGA
LATUDA
loxapine
olanzapine
olanzapine odt
quetiapine fumarate
risperidone
risperidone odt
SAPHRIS
SEROQUEL XR
thioridazine
thiothixene
TIER
3
3
1
1
3
3
1
1
3
3
1
1
1
1
1
1
3
2
1
1
QL, ST
QL, ST
AMPYRA
AUBAGIO
AVONEX
BETASERON
COPAXONE
EXTAVIA
GILENYA
H.P. ACTHAR
REBIF
TECFIDERA
QL, ST
PA, QL
QL, ST
Osteoporosis
ACTONEL
alendronate
ATELVIA
BINOSTO
BONIVA
EVISTA
FORTEO
FORTICAL
GT
QL, ST
QL
8
MS, PA
(Rev. 10/01/14)
DRUG
TIER
COMMENTS
DRUG
3
3
1
3
1
1
3
QL, ST
QL, ST
QL
QL
1
3
3
3
1
3
3
1
1
3
3
3
1
1
3
1
1
2
QL, ST
ST
QL, ST
QL, ST
3
3
3
3
3
3
1
3
3
1
1
3
1
1
1
3
1
1
1
1
1
3
1
3
3
3
1
ST
QL, ST
1
3
3
2
QL, ST
ST
QL
Narcotic
ABSTRAL
acetaminophen/caffeine/dihydrocodeine bitartrate
acetaminophen/codeine
ACTIQ
AVINZA
BUTRANS
CONZIP
DURAGESIC
EXALGO
fentanyl
fentanyl lollipops
FENTORA
hydrocodone/acetaminophen
hydrocodone/ibuprofen
hydromorphone
KADIAN
LAZANDA
meperidine
methadone
methadose
morphine
morphine sulfate er
NUCYNTA
NUCYNTA ER
ONSOLIS
OPANA
OPANA ER (CRUSH RESISTANT)
OXECTA
oxycodone
oxycodone/acetaminophen
oxycodone/aspirin
oxycodone/ibuprofen
OXYCONTIN
oxymorphone hydrochloride
pentazocine/naloxone
roxicet
SUBSYS
tramadol
tramadol hcl er
tramadol hydrochloride/acetaminophen
ULTRAM ER
XARTEMIS XR
ZOHYDRO ER
QL, ST
QL, ST
QL, ST
QL, ST
QL
QL
QL, ST
QL
QL
QL
PA, QL
PA, QL
PA
PA, QL
PA, QL
QL
QL, ST
PA, QL
NSAIDs
ANAPROX
ANAPROX DS
ARTHROTEC 75
CATAFLAM
CELEBREX
DAYPRO
diclofenac dr
DUEXIS
EC-NAPROSYN
etodolac
etodolac er
FELDENE
fenoprofen
flurbiprofen
ibuprofen
INDOCIN
indomethacin
ketoprofen
ketorolac
meclofenamate
meloxicam
MOBIC
nabumetone
NALFON
NAPRELAN
NAPROSYN
naproxen
ST
QL, ST
Pain Relievers
Muscle Relaxants
3
1
1
1
1
3
1
3
3
1
1
1
3
3
1
QL
diclofenac
FLECTOR
PENNSAID
VOLTAREN
Pain / Inflammation
AMRIX
baclofen
carisoprodol
carisoprodol 250mg
chlorzoxazone
CYCLOBENZAPRINE COMFORT PAC
cyclobenzaprine
FEXMID
LORZONE
metaxalone
methocarbamol
orphenadrine er
SKELAXIN
SOMA 250mg
tizanidine
1
1
3
3
1
1
3
3
Topical NSAIDs
Overactive Bladder
bethanechol
DETROL
DITROPAN XL
ENABLEX
flavoxate
GELNIQUE
Note: Step edit bypassed if 65 years of age or older
MYRBETRIQ
oxybutynin
oxybutynin er
OXYTROL
SANCTURA
SANCTURA XR
tolterodine tartrate
tolterodine tartrate er
TOVIAZ
trospium chloride
trospium chloride er
VESICARE
COMMENTS
oxaprozin
piroxicam
PONSTEL
SPRIX
sulindac
tolmetin
VOLTAREN-XR
ZIPSOR
Osteoporosis (continued)
FOSAMAX
FOSAMAX PLUS D
ibandronate sodium
MIACALCIN
raloxifene hydrochloride
risedronate sodium
SKELID
TIER
ST
ST
QL, ST
ST
QL, ST
QL, ST
QL, ST
ST
3
1
1
3
3
3
3
3
3
1
1
3
1
1
1
3
3
1
1
1
1
1
3
2
3
3
3
3
1
1
1
1
3
1
1
1
3
1
1
1
3
3
3
PA, QL
PA, QL
QL
QL, ST
QL, ST
QL
QL, ST
QL
PA, QL
PA, QL
QL
PA, QL
QL
QL
QL
PA, QL
PA, QL
QL
PA, QL
PA, QL
QL
QL
PA, QL
PA, QL
Non-Narcotic
ST
butalbital/acetaminophen/caffeine
butalbital/asa/caffeine
diflunisal
dologesic
LIDODERM
RHINOFLEX-650
salsalate
SYNERA
ST
QL
GT
ST
QL
ST
ST
ST
GT
1
1
1
1
3
3
1
3
Opioid Analgesics
butalbital/acetaminophen/caffeine/codeine
1
Parkinson's Disease
amantadine
AZILECT
9
1
3
QL
(Rev. 10/01/14)
DRUG
TIER
COMMENTS
DRUG
EQUETRO
ethosuximide
felbamate
gabapentin
GABITRIL
KEPPRA
KEPPRA XR
LAMICTAL ODT
LAMICTAL XR
lamotrigine
lamotrigine er
levetiracetam
levetiracetam er
LYRICA
ONFI
oxcarbazepine
OXTELLAR XR
PEGANONE
phenobarbital
phenytoin
POTIGA
primidone
QUDEXY XR
STAVZOR
TOPAMAX
TOPAMAX SPRINKLE
topiramate
TROKENDI XR
valproic acid
VIMPAT
zonisamide
Parkinson's Disease (continued)
benztropine
bromocriptine
carbidopa/levodopa
carbidopa/levodopa odt
COMTAN
entacapone
LODOSYN
MIRAPEX ER
NEUPRO
pramipexole dihydrochloride
REQUIP XL
ropinirole er
ropinirole
selegiline
STALEVO
TASMAR
trihexyphenidyl
ZELAPAR
1
1
1
1
3
1
2
3
3
1
3
1
1
1
3
3
1
3
QL, ST
QL
QL, ST
QL
QL, ST
Phosphate Binders
calcium acetate
FOSRENOL
RENAGEL
RENVELA
1
3
2
2
QL
Post-Herpetic Neuralgia
GRALISE
3
PA, QL
Potassium Supplements
klor-con
potassium chloride
potassium citrate er
1
1
1
HETLIOZ
3
PA, QL
2
3
3
3
3
3
1
3
3
3
MS, PA, QL
MS, PA, QL
MS, PA, QL
MS, PA, QL
MS, PA
MS, PA, QL
MS, PA, QL
MS, PA
MS, PA, QL
MS, PA, QL
3
3
1
1
PA, QL
QL
3
3
2
2
1
3
1
3
3
2
3
3
MS, PA, QL, ST
MS, PA, QL, ST
MS, PA, QL
MS, PA, QL
ANZEMET
CESAMET
DICLEGIS
dronabinol
EMEND
granisetron
granisol
meclizine
ondansetron
SANCUSO
TRANSDERM-SCOP
trimethobenzamide
ZOFRAN
ZUPLENZ
FULYZAQ
QL
QL
QL
PA, QL
QL
PA, QL
PA, QL
3
MS, PA, QL
3
3
3
1
2
1
1
1
1
3
3
1
3
3
QL, ST
PA, QL
QL
QL
QL, ST
ST
QL, ST
3
PA, QL
Digestants
CREON
PANCREAZE
PERTZYE
ULTRESA
VIOKACE
ZENPEP
MS, PA, QL
2
3
3
3
3
2
Gallbladder
MS, PA, QL, ST
PA
MS, PA, QL
MS, PA, QL, ST
PA
URSO 250
URSO FORTE
ursodiol
3
3
1
Irritable Bowel
Seizure / Pain
APTIOM
BANZEL
carbamazepine er
CARBATROL
CELONTIN
clonazepam
DILANTIN
divalproex sodium dr
QL
Diarrhea
Rheumatoid Arthritis
ACTEMRA
CIMZIA
ENBREL
HUMIRA
hydroxychloroquine
KINERET
methotrexate
ORENCIA
OTREXUP
SIMPONI
XELJANZ
RASUVO
QL
QL, ST
QL, ST
Antiemetics (for nausea)
Restless Leg Syndrome
HORIZANT
NEUPRO
pramipexole dihydrochloride
ropinirole
3
1
1
1
2
3
3
3
3
1
1
1
1
3
3
1
3
2
1
1
3
1
3
3
3
3
1
3
1
2
1
Stomach / Intestinal
Pulmonary Arterial Hypertension
ADCIRCA
ADEMPAS
LETAIRIS
OPSUMIT
ORENITRAM
REVATIO
sildenafil citrate
TRACLEER
TYVASO STARTER
VENTAVIS
COMMENTS
Sleep-Wake Disorder
Pseudobulbar Affect
NUEDEXTA
TIER
3
3
1
3
2
1
2
1
AMITIZA
LINZESS
LOTRONEX
PA, QL
3
2
3
QL, ST
QL
QL
3
MS, PA, QL
Short Bowel Syndrome
GATTEX
10
(Rev. 10/01/14)
DRUG
TIER
COMMENTS
DRUG
errin
ESTROSTEP FE
gianvi
jolessa
jolivette
kariva
kelnor 1/35
levora 0.15/30-28
LOESTRIN 1.5/30-21
LOESTRIN FE 1.5/30
low-ogestrel
microgestin 1.5/30
microgestin fe 1.5/30
MINASTRIN 24 FE
MODICON
mononessa
NATAZIA
necon 0.5/35-28
necon 1/50-28
necon 10/11-28
nora-be
nortrel 0.5/35 (28)
NUVARING
ogestrel
ORTHO EVRA
ORTHO TRI-CYCLEN
ORTHO TRI-CYCLEN LO
ORTHO-CYCLEN
OVCON-35
portia-28
previfem
quasense
reclipsen
SEASONIQUE
solia
sprintec 28
trinessa
TRI-NORINYL 28
tri-previfem
tri-sprintec
trivora-28
wymzya fe
YASMIN 28
YAZ
zovia 1/35e
zovia 1/50e
Stomach / Intestinal (continued)
Ulcer / Heartburn
ACIPHEX
CARAFATE
cimetidine
DEXILANT
ESOMEPRAZOLE STRONTIUM
famotidine
lansoprazole
metoclopramide
METOZOLV ODT
misoprostol
NEXIUM
nizatidine
omeprazole
omeprazole/sodium bicarbonate
pantoprazole
PREVACID
PRILOSEC
prilosec otc
PROTONIX
rabeprazole sodium
ranitidine
sucralfate
ZEGERID
3
3
1
3
3
1
1
1
3
1
2
1
1
1
1
3
3
1
3
1
1
1
3
QL, ST
QL, ST
PA
QL
QL, ST
QL
GT, QL
QL
GT, QL
QL
QL, ST
QL
QL, ST
QL
QL, ST
Throat products - Miscellaneous
cevimeline hcl
1
Thyroid
ARMOUR THYROID
CYTOMEL
levothyroxine
liothyronine sodium
methimazole
propylthiouracil
SYNTHROID
THYROLAR
unithroid direct
3
3
1
1
1
1
3
3
1
Urea Cycle Disorders
RAVICTI
3
MS, PA, QL
Vitamins
multigen
multigen plus
1
1
BRAVELLE
CETROTIDE
chorionic gonadotropin
clomiphene
ENDOMETRIN
FOLLISTIM AQ
GANIRELIX
GONAL-F
leuprolide
MENOPUR
novarel
OVIDREL
pregnyl w/diluent benzyl alcohol/nacl
REPRONEX
SYNAREL
1
1
1
Weight Management
Anorexiants
BELVIQ
diethylpropion
phendimetrazine er
phentermine
QSYMIA
SUPRENZA
XENICAL
3
1
1
1
3
3
3
PA, QL
PA, QL
PA
PA
ALORA
CENESTIN
CLIMARA
CLIMARA PRO
COMBIPATCH
CRINONE
ENJUVIA
esterified estrogens/methyltestosterone hs
ESTRACE
estradiol
estradiol/norethindrone acetate
estropipate
EVAMIST
jinteli
Bleeding
1
QL
1
1
3
1
1
3
1
QL
QL
QL
QL
QL
QL
QL
Contraceptives
apri
aviane
BEYAZ
camila
cryselle-28
CYCLESSA
enpresse-28
1
3
1
1
1
1
1
1
3
3
1
1
1
3
3
1
3
1
1
1
1
1
2
1
3
3
3
3
3
1
1
1
1
3
1
1
1
3
1
1
1
1
3
3
1
1
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
2
3
1
1
3
3
3
2
1
2
1
3
1
3
2
MS, PA, QL
MS, PA
MS, PA, QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
PA
MS, PA, QL, ST
PA
MS, PA, QL
PA
MS, PA
MS, PA, QL
MS, PA
MS, PA, QL
MS, PA
MS
Hormones
Women's Health
tranexamic acid
COMMENTS
Fertility Drugs
Prenatal
mynatal plus
prenatabs fa
prenatal 19
TIER
11
3
3
2
2
3
3
3
1
3
1
1
1
3
1
QL
QL
QL
QL
(Rev. 10/01/14)
DRUG
TIER
COMMENTS
DRUG
TIER
COMMENTS
Women's Health (continued)
Hormones (continued)
medroxyprogesterone
MENEST
methyltestosterone/esterified estrogens hs
mimvey
norethindrone
OSPHENA
PREMARIN
PREMPHASE
PREMPRO
progesterone
PROMETRIUM
VAGIFEM
VIVELLE-DOT
1
3
1
1
1
3
2
2
2
1
3
2
3
QL
3
PA, QL
3
3
QL
ST
Menopause
BRISDELLE
Wound Healing
REGRANEX
SANTYL
12
(Rev. 10/01/14)
Formulary Index
A
abacavir ......................................................................6
ABILIFY ....................................................................8
ABILIFY DISCMELT ...............................................8
ABSTRAL ..................................................................9
ACANYA ...................................................................4
acebutolol hcl .............................................................3
acetaminophen/caffeine/dihydrocodeine
bitartrate .....................................................................9
acetaminophen/codeine ..............................................9
acetasol hc ..................................................................5
acetazolamide .............................................................3
acetylcysteine ..............................................................1
ACIPHEX .................................................................11
ACLOVATE ...............................................................4
ACTEMRA ...............................................................10
acticin .........................................................................7
ACTICLATE ..............................................................6
ACTIMMUNE ...........................................................2
ACTIQ ........................................................................9
ACTONEL .................................................................8
ACTOPLUS MET ......................................................5
ACTOPLUS MET XR ...............................................5
ACTOS .......................................................................5
ACULAR ....................................................................5
ACULAR LS ..............................................................5
ACUVAIL ..................................................................5
acyclovir .....................................................................7
ACZONE ....................................................................4
adapalene ...................................................................4
ADCIRCA ................................................................10
ADDERALL XR ........................................................1
adefovir dipivoxil ........................................................6
ADEMPAS ...............................................................10
ADOXA ......................................................................6
ADVAIR DISKUS .....................................................1
ADVICOR ..................................................................2
afeditab cr ...................................................................3
AFINITOR .................................................................2
AGGRENOX ..............................................................1
ala cort ........................................................................6
albuterol sulfate ..........................................................1
albuterol sulfate er .....................................................1
alclometasone dipropionate .......................................4
ALDARA ...................................................................3
alendronate sodium ....................................................8
alfuzosin hcl er ...........................................................7
ALKERAN .................................................................2
All modified solid foods are covered as
brand ...........................................................................8
allopurinol ..................................................................6
ALOCRIL ...................................................................5
ALOMIDE ..................................................................5
ALORA ....................................................................11
alprazolam ..................................................................8
alprazolam er ..............................................................8
ALREX .......................................................................5
ALSUMA ...................................................................8
ALTABAX .................................................................4
ALTOPREV ...............................................................2
ALVESCO ................................................................. 1
amantadine hcl ........................................................... 9
AMBIEN .................................................................... 8
AMBIEN CR ............................................................. 8
amcinonide ................................................................. 4
AMERGE ................................................................... 8
amiloride hcl .............................................................. 3
amiloride/hydrochlorothiazide .................................. 3
amiodarone hcl .......................................................... 2
AMITIZA ................................................................. 10
amlodipine besylate ................................................... 3
amlodipine besylate/atorvastatin
calcium ....................................................................... 3
amlodipine besylate/benazepril
hydrochloride ............................................................. 3
amnesteem .................................................................. 4
amoxapine .................................................................. 7
amoxicillin .................................................................. 6
amoxicillin/clavulanate potassium ............................. 6
amphetamine/dextroamphetamine ............................. 1
ampicillin ................................................................... 6
AMPYRA .................................................................. 8
AMRIX ...................................................................... 9
AMTURNIDE ............................................................ 3
ANAPROX ................................................................ 9
ANAPROX DS .......................................................... 9
anastrozole ................................................................. 2
ANDRODERM .......................................................... 7
ANDROGEL .............................................................. 7
ANDROID ................................................................. 7
androxy ...................................................................... 7
ANORO ELLIPTA .................................................... 1
ANTABUSE .............................................................. 1
ANTARA ................................................................... 2
antipyrine/benzocaine ................................................ 5
ANZEMET .............................................................. 10
APIDRA ..................................................................... 4
APLENZIN ................................................................ 7
apri ........................................................................... 11
APRISO ..................................................................... 7
APTIOM .................................................................. 10
APTIVUS ................................................................... 6
ARANESP ALBUMIN FREE ................................... 2
ARCALYST .............................................................. 3
ARCAPTA NEOHALER .......................................... 1
ARICEPT 23MG ....................................................... 1
ARIXTRA .................................................................. 1
ARMOUR THYROID ............................................. 11
ARTHROTEC 75 ....................................................... 9
ASACOL HD ............................................................. 7
ASMANEX TWISTHALER 120
METERED DOSES ................................................... 1
ASTAGRAF XL ........................................................ 6
ASTEPRO .................................................................. 7
ATACAND ................................................................ 2
ATACAND HCT ....................................................... 3
ATELVIA .................................................................. 8
atenolol ...................................................................... 3
atorvastatin calcium ................................................... 2
atovaquone/proguanil hcl .......................................... 7
ATRIPLA ................................................................... 6
13
ATROVENT HFA......................................................1
AUBAGIO ..................................................................8
augmented betamethasone dipropionate ....................4
AUVI-Q ......................................................................1
AVANDAMET ..........................................................5
AVANDARYL ...........................................................5
AVANDIA .................................................................5
AVEED.......................................................................7
AVELOX ....................................................................6
aviane .......................................................................11
AVINZA .....................................................................9
avita ............................................................................4
AVODART.................................................................7
AVONEX ...................................................................8
AXERT .......................................................................8
AXIRON.....................................................................7
AZASAN ....................................................................6
AZASITE ...................................................................5
azathioprine ................................................................6
azelastine hcl ..........................................................5, 7
AZELEX.....................................................................4
AZILECT ...................................................................9
azithromycin ...............................................................6
AZOPT .......................................................................5
AZOR .........................................................................3
B
baclofen ......................................................................9
BACTROBAN CREAM ............................................4
balsalazide disodium ..................................................7
BANZEL ..................................................................10
BARACLUDE ............................................................6
BECONASE AQ ........................................................7
BELVIQ ...................................................................11
benazepril hcl .............................................................2
benazepril hcl/hydrochlorothiazide ............................2
BENICAR...................................................................2
BENICAR HCT..........................................................3
BENZAMYCIN .........................................................4
benzonatate .................................................................3
benztropine mesylate ................................................10
BEPREVE ..................................................................5
BERINERT.................................................................1
BESIVANCE ..............................................................5
betamethasone valerate ..............................................4
BETASERON.............................................................8
betaxolol hcl ...............................................................3
bethanechol chloride ..................................................9
BETHKIS ...................................................................3
BETIMOL ..................................................................5
BETOPTIC-S .............................................................5
BEYAZ .....................................................................11
bicalutamide ...............................................................2
BIDIL .........................................................................3
BINOSTO ...................................................................8
bisoprolol fumarate/
hydrochlorothiazide ....................................................3
BONIVA.....................................................................8
BOSULIF ...................................................................2
BRAVELLE .............................................................11
Formulary Index
BREO ELLIPTA ........................................................1
BRILINTA .................................................................1
brimonidine tartrate ...................................................5
BRINTELLIX .............................................................7
BRISDELLE .............................................................12
bromocriptine mesylate ............................................10
BROVANA ................................................................1
budeprion sr ................................................................7
budesonide ..................................................................7
budesonide nebulizer ..................................................1
buprenorphine hcl ......................................................1
buprenorphine hcl/naloxone hcl .................................1
buproban .....................................................................1
bupropion hcl ..............................................................8
bupropion hcl sr .........................................................8
bupropion hcl xl ..........................................................8
buspirone hcl ..............................................................8
butalbital/acetaminophen/caffeine .............................9
butalbital/acetaminophen/caffeine/
codeine ........................................................................9
butalbital/asa/caffeine ................................................9
BUTRANS .................................................................9
BYDUREON ..............................................................4
BYETTA ....................................................................4
BYSTOLIC .................................................................3
C
CADUET ....................................................................3
calcipotriene ...............................................................3
calcitriol .....................................................................5
calcium acetate .........................................................10
CAMBIA ....................................................................8
camila .......................................................................11
CANASA ....................................................................7
candesartan cilexetil/
hydrochlorothiazide ....................................................3
capecitabine ................................................................2
CAPEX .......................................................................4
CAPRELSA ................................................................2
captopril .....................................................................2
captopril/hydrochlorothiazide ....................................3
CARAC ......................................................................3
CARAFATE .............................................................11
CARBAGLU ..............................................................6
carbamazepine er .....................................................10
CARBATROL ..........................................................10
carbidopa/levodopa ..................................................10
carbidopa/levodopa odt ............................................10
carisoprodol ...............................................................9
carisoprodol 250mg ....................................................9
carteolol hcl ................................................................5
carvedilol ....................................................................3
CATAFLAM ..............................................................9
CAVERJECT .............................................................7
CAYSTON .................................................................3
CEDAX ......................................................................6
cefaclor .......................................................................6
cefaclor er ...................................................................6
cefadroxil ....................................................................6
cefdinir ........................................................................6
cefpodoxime proxetil ..................................................6
cefprozil ...................................................................... 6
cefuroxime axetil ........................................................ 6
CELEBREX ............................................................... 9
CELEXA .................................................................... 8
CELLCEPT ................................................................ 6
CELONTIN .............................................................. 10
CENESTIN .............................................................. 11
cephalexin .................................................................. 6
CERDELGA .............................................................. 6
CESAMET ............................................................... 10
CETROTIDE ........................................................... 11
cevimeline hcl ........................................................... 11
CHANTIX .................................................................. 1
chlordiazepoxide/amitriptyline .................................. 8
chloroquine phosphate ............................................... 7
chlorothiazide ............................................................ 3
chlorpromazine hcl .................................................... 8
chlorpropamide .......................................................... 5
chlorthalidone ............................................................ 3
chlorzoxazone ............................................................ 9
cholestyramine ........................................................... 2
chorionic gonadotropin ........................................... 11
CIALIS ....................................................................... 7
ciclopirox nail lacquer ............................................... 4
ciclopirox olamine ..................................................... 4
cilostazol .................................................................... 1
CILOXAN .................................................................. 5
cimetidine ................................................................. 11
CIMZIA ............................................................... 7, 10
CINRYZE .................................................................. 1
CIPRO HC ................................................................. 5
CIPRODEX ................................................................ 5
ciprofloxacin hcl .................................................... 5, 6
citalopram hydrobromide .......................................... 8
claravis ....................................................................... 4
CLARINEX ............................................................... 1
CLARINEX-D 12 HOUR .......................................... 1
clarithromycin ............................................................ 6
CLEOCIN-T .............................................................. 4
CLIMARA ............................................................... 11
CLIMARA PRO ...................................................... 11
CLINDAGEL ............................................................. 4
clindamycin hcl .......................................................... 6
clindamycin phosphate ............................................... 4
clindamycin/benzoyl peroxide .................................... 4
clobetasol propionate ................................................. 4
clobetasol propionate emollient ................................. 4
CLOBEX .................................................................... 4
clocortolone pivalate ................................................. 4
CLODERM ................................................................ 4
clomiphene citrate .................................................... 11
clomipramine hcl ....................................................... 8
clonazepam .............................................................. 10
clonidine hcl ............................................................... 3
clopidogrel ................................................................. 1
clorazepate dipotassium ............................................. 8
clotrimazole ................................................................ 7
clotrimazole/betamethasone
dipropionate ............................................................... 4
clozapine .................................................................... 8
14
CNL8 NAIL KIT ........................................................4
COLCRYS ..................................................................6
colestipol hcl ...............................................................2
COMBIPATCH ........................................................11
COMBIVENT RESPIMAT........................................1
COMBIVIR ................................................................6
COMETRIQ ...............................................................2
COMPLERA ..............................................................6
COMTAN .................................................................10
CONCERTA...............................................................1
CONZIP ......................................................................9
COPAXONE ..............................................................8
COPEGUS ..................................................................6
CORDRAN TAPE......................................................4
COREG CR ................................................................3
COUMADIN ..............................................................1
CREON.....................................................................10
CRESTOR ..................................................................2
CRINONE ................................................................11
cromolyn sodium ........................................................1
cryselle-28 ................................................................11
CUVPOSA .................................................................3
CYCLESSA ..............................................................11
CYCLOBENZAPRINE COMFORT
PAC ............................................................................9
cyclobenzaprine hcl ....................................................9
cyclophosphamide ......................................................2
CYCLOSET ...............................................................5
cyclosporine ................................................................6
CYMBALTA ..............................................................5
cyproheptadine hcl .....................................................1
CYSTARAN...............................................................5
CYTOMEL ...............................................................11
D
DALIRESP .................................................................1
DARAPRIM ...............................................................7
DAYPRO ....................................................................9
DAYTRANA ..............................................................1
DELATESTRYL ........................................................7
DELZICOL.................................................................7
DENAVIR ..................................................................7
DEPO-TESTOSTERONE ..........................................7
desipramine hcl ..........................................................8
desloratadine ..............................................................1
desloratadine odt ........................................................1
DESONATE ...............................................................4
desonide ......................................................................4
DESOWEN LOTION/CETAPHIL
CREAM ......................................................................4
desoximetasone ...........................................................4
DESOXYN .................................................................1
DESVENLAFAXINE ER ..........................................8
DETROL ....................................................................9
dexamethasone ...........................................................4
DEXILANT ..............................................................11
dexmethylphenidate hcl ..............................................1
dextroamphetamine sulfate er ....................................1
diazepam .....................................................................8
DICLEGIS ................................................................10
diclofenac sodium ...................................................5, 9
Formulary Index
diclofenac sodium dr ..................................................9
dicloxacillin sodium ....................................................6
dicyclomine hcl ...........................................................1
didanosine ...................................................................6
diethylpropion hcl .....................................................11
DIFFERIN LOTION ..................................................4
DIFICID .....................................................................6
diflorasone diacetate ..................................................4
diflunisal .....................................................................9
digoxin ........................................................................2
DILANTIN ...............................................................10
diltiazem cd .................................................................3
diltiazem hcl ................................................................3
diltzac .........................................................................3
DIOVAN ....................................................................2
DIPENTUM ...............................................................7
diphenhydramine hcl ..................................................1
dipyridamole ...............................................................1
disopyramide phosphate .............................................2
disulfiram ....................................................................1
DITROPAN XL ..........................................................9
DIURIL .......................................................................3
divalproex sodium dr ................................................10
divalproex sodium er ..................................................8
dologesic .....................................................................9
donepezil hcl ...............................................................1
DORYX ......................................................................4
dorzolamide hcl ..........................................................5
dorzolamide hcl/timolol maleate ................................5
doxazosin mesylate .....................................................7
doxepin hcl ..................................................................8
doxycycline hyclate .....................................................6
dronabinol ................................................................10
DROXIA .....................................................................2
DUAC .........................................................................4
DUETACT .................................................................5
DUEXIS .....................................................................9
DULERA ....................................................................1
duloxetine hcl ..........................................................6, 8
DURAGESIC .............................................................9
DUREZOL .................................................................5
DUTOPROL ...............................................................3
DYMISTA ..................................................................7
DYRENIUM ...............................................................3
E
EC-NAPROSYN ........................................................9
econazole nitrate ........................................................4
EDARBI .....................................................................2
EDARBYCLOR .........................................................3
EDEX .........................................................................7
EDLUAR ....................................................................8
EDURANT .................................................................6
EFFEXOR XR ............................................................8
EFFIENT ....................................................................1
EGRIFTA ...................................................................6
ELIDEL ......................................................................3
ELIQUIS .....................................................................1
EMADINE ..................................................................5
EMCYT ......................................................................2
EMEND ................................................................... 10
EMSAM ..................................................................... 8
EMTRIVA ................................................................. 6
ENABLEX ................................................................. 9
enalapril maleate ....................................................... 2
enalapril maleate/hydrochlorothiazide ...................... 2
ENBREL .............................................................. 3, 10
ENDOMETRIN ....................................................... 11
ENJUVIA ................................................................. 11
enoxaparin sodium ..................................................... 1
enpresse-28 .............................................................. 11
entacapone ............................................................... 10
Enteral formulas ......................................................... 5
ENTOCORT EC ........................................................ 7
EPANED .................................................................... 2
EPIDUO ..................................................................... 4
epinastine hcl ............................................................. 5
EPIPEN 2-PAK .......................................................... 1
EPIPEN-JR 2-PAK .................................................... 1
EPIVIR ....................................................................... 6
EPIVIR HBV ............................................................. 6
eplerenone .................................................................. 3
EPOGEN .................................................................... 2
eprosartan mesylate ................................................... 2
EPZICOM .................................................................. 6
EQUETRO ............................................................... 10
ERIVEDGE ................................................................ 2
errin .......................................................................... 11
ERTACZO ................................................................. 4
erythrocin stearate ..................................................... 6
erythromycin .............................................................. 4
escitalopram oxalate .................................................. 8
ESOMEPRAZOLE STRONTIUM .......................... 11
estazolam .................................................................... 8
esterified estrogens/methyltestosterone
hs .............................................................................. 11
ESTRACE ................................................................ 11
estradiol ................................................................... 11
estradiol/norethindrone acetate ............................... 11
estropipate ................................................................ 11
ESTROSTEP FE ...................................................... 11
eszopiclone ................................................................. 8
ethosuximide ............................................................ 10
etodolac ...................................................................... 9
etodolac er ................................................................. 9
EURAX ...................................................................... 7
EVAMIST ................................................................ 11
EVISTA ..................................................................... 8
EVOCLIN .................................................................. 4
EVZIO ........................................................................ 1
EXALGO ................................................................... 9
EXELDERM .............................................................. 4
exemestane ................................................................. 2
EXFORGE ................................................................. 3
EXFORGE HCT ........................................................ 3
EXTAVIA .................................................................. 8
F
FABIOR ..................................................................... 4
famciclovir ................................................................. 7
15
famotidine .................................................................11
FAMVIR.....................................................................7
FANAPT.....................................................................8
FARESTON ...............................................................2
FARXIGA ..................................................................5
FAZACLO ..................................................................8
felbamate ..................................................................10
FELDENE ..................................................................9
felodipine er ................................................................3
fenofibrate...................................................................2
fenofibrate micronized ................................................2
FENOGLIDE ..............................................................2
fenoprofen calcium .....................................................9
fentanyl .......................................................................9
fentanyl citrate oral transmucosal..............................9
FENTORA ..................................................................9
FETZIMA ...................................................................8
FEXMID .....................................................................9
FINACEA ...................................................................4
finasteride ...................................................................7
FIRAZYR ...................................................................1
FIRST-TESTOSTERONE .........................................7
FIRST-TESTOSTERONE MC
COMPOUNDING KIT ..............................................7
flavoxate hcl................................................................9
flecainide acetate ........................................................2
FLECTOR ..................................................................9
FLOMAX ...................................................................7
FLONASE ..................................................................7
FLOVENT HFA .........................................................1
fluconazole ..................................................................7
fludrocortisone acetate ...............................................4
flunisolide ...................................................................7
fluocinolone acetonide................................................4
fluocinonide ................................................................4
FLUOROPLEX ..........................................................3
fluoxetine dr ................................................................8
fluoxetine hcl ..............................................................8
fluphenazine hcl ..........................................................8
flurazepam hcl ............................................................8
flurbiprofen .................................................................9
flurbiprofen sodium ....................................................5
flutamide .....................................................................2
fluticasone propionate ............................................4, 7
fluvastatin ...................................................................2
fluvoxamine maleate ...................................................8
FML FORTE ..............................................................5
FOCALIN ...................................................................1
FOCALIN XR ............................................................1
FOLLISTIM AQ ......................................................11
fondaparinux sodium ..................................................1
FORADIL AEROLIZER............................................1
FORFIVO XL .............................................................8
FORTAMET...............................................................5
FORTEO.....................................................................8
FORTESTA ................................................................7
FORTICAL.................................................................8
FOSAMAX.................................................................9
FOSAMAX PLUS D ..................................................9
fosinopril sodium ........................................................2
Formulary Index
fosinopril sodium/hydrochlorothiazide ......................2
FOSRENOL .............................................................10
FRAGMIN ..................................................................1
FREESTYLE FREEDOM LITE ................................4
FREESTYLE INSULINX BLOOD
GLUCOSE MONITORING SYSTEM ......................4
FREESTYLE INSULINX BLOOD
GLUCOSE TEST .......................................................4
FREESTYLE LITE BLOOD
GLUCOSE MONITORING SYSTEM ......................4
FREESTYLE LITE TEST STRIPS ............................4
FREESTYLE TEST STRIPS .....................................4
FROVA .......................................................................8
FULYZAQ ...............................................................10
FURADANTIN ..........................................................6
furosemide ..................................................................3
FUZEON ....................................................................6
G
gabapentin ................................................................10
GABITRIL ...............................................................10
galantamine hydrobromide ........................................1
GANIRELIX ACETATE .........................................11
gatifloxacin .................................................................5
GATTEX ..................................................................10
GELNIQUE ................................................................9
gemfibrozil ..................................................................2
gengraf ........................................................................6
GENOTROPIN MINIQUICK ....................................6
gentamicin sulfate .......................................................4
gianvi ........................................................................11
GIAZO ........................................................................7
GILENYA ..................................................................8
GILOTRIF ..................................................................2
GLEEVEC ..................................................................2
glimepiride ..................................................................5
glipizide ......................................................................5
glipizide/metformin hcl ...............................................5
GLUCAGEN ..............................................................4
GLUCAGON EMERGENCY KIT ............................4
GLUMETZA ..............................................................5
glyburide .....................................................................5
glyburide micronized ..................................................5
glyburide/metformin hcl .............................................5
glycopyrrolate .............................................................1
GLYSET .....................................................................5
GONAL-F .................................................................11
GRALISE .................................................................10
granisetron hcl ..........................................................10
granisol .....................................................................10
GRANIX .....................................................................2
GRIFULVIN V ...........................................................7
griseofulvin microsize .................................................7
GRIS-PEG ..................................................................7
H
H.P. ACTHAR ............................................................8
halobetasol propionate ...............................................4
HALONATE ..............................................................4
haloperidol .................................................................8
HECTOROL ...............................................................5
hemril-30 .................................................................... 6
heparin sodium ........................................................... 1
HEPSERA .................................................................. 6
HETLIOZ ................................................................. 10
HORIZANT ............................................................. 10
HUMALOG ............................................................... 4
HUMALOG MIX 50/50 ............................................ 4
HUMALOG MIX 75/25 ............................................ 4
HUMATROPE ........................................................... 6
HUMIRA ............................................................. 4, 10
HUMIRA PEN ........................................................... 7
HUMULIN N ............................................................. 4
HUMULIN R ............................................................. 4
HYCAMTIN .............................................................. 2
hydrochlorothiazide ................................................... 3
hydrocodone polistirex/
chlorpheniramine polistirex ....................................... 3
hydrocodone/acetaminophen ..................................... 9
hydrocodone/ibuprofen .............................................. 9
hydrocortisone ........................................................... 6
hydrocortisone acetate ............................................... 6
hydrocortisone butyrate ............................................. 4
hydrocortisone valerate ............................................. 4
hydromorphone hcl .................................................... 9
hydroxychloroquine sulfate ...................................... 10
hydroxyurea ............................................................... 2
hydroxyzine hcl .......................................................... 8
HYZAAR ................................................................... 3
I
ibandronate sodium ................................................... 9
ibuprofen .................................................................... 9
ICLUSIG .................................................................... 2
IMBRUVICA ............................................................. 2
imipramine hcl ........................................................... 8
imiquimod .................................................................. 3
IMITREX ................................................................... 8
INCIVEK ................................................................... 6
INCRELEX ................................................................ 6
INDOCIN ................................................................... 9
indomethacin .............................................................. 9
INFERGEN ................................................................ 6
INLYTA ..................................................................... 2
INTELENCE .............................................................. 6
INTERMEZZO .......................................................... 8
INTUNIV ................................................................... 1
INVEGA .................................................................... 8
INVIRASE ................................................................. 6
INVOKANA .............................................................. 5
IOPIDINE .................................................................. 5
ipratropium bromide .................................................. 1
ipratropium bromide/albuterol sulfate ...................... 1
irbesartan ................................................................... 2
irbesartan/hydrochlorothiazide ................................. 3
IRESSA ...................................................................... 2
ISENTRESS ............................................................... 6
isoniazid ..................................................................... 6
isosorbide dinitrate .................................................... 2
isosorbide mononitrate er .......................................... 2
isradipine ................................................................... 3
16
itraconazole ................................................................7
J
JAKAFI ......................................................................2
JALYN .......................................................................7
jantoven ......................................................................1
JANUMET .................................................................5
JANUMET XR ...........................................................5
JANUVIA ...................................................................5
JENTADUETO ..........................................................5
jinteli .........................................................................11
jolessa .......................................................................11
jolivette .....................................................................11
JUBLIA ......................................................................4
JUVISYNC .................................................................5
JUXTAPID .................................................................2
K
KADIAN ....................................................................9
KALETRA .................................................................6
KALYDECO ..............................................................3
KAPVAY ...................................................................1
kariva ........................................................................11
KAZANO ...................................................................5
kelnor 1/35 ................................................................11
KENALOG .................................................................4
KEPPRA ...................................................................10
KEPPRA XR ............................................................10
KERYDIN ..................................................................4
KETEK .......................................................................6
ketoconazole ...........................................................4, 7
ketoprofen ...................................................................9
ketorolac tromethamine ..........................................5, 9
KINERET .................................................................10
KLARON ...................................................................4
klor-con.....................................................................10
KOMBIGLYZE XR ...................................................5
KORLYM ...................................................................3
KUVAN ......................................................................5
KYNAMRO ...............................................................2
L
labetalol hcl ................................................................3
LAMICTAL ODT ....................................................10
LAMICTAL XR .......................................................10
LAMISIL ....................................................................7
lamivudine ..................................................................6
lamivudine/zidovudine ................................................6
lamotrigine ...............................................................10
lamotrigine er ...........................................................10
LANOXIN ..................................................................2
lansoprazole .............................................................11
LANTUS ....................................................................4
LASTACAFT .............................................................5
latanoprost ..................................................................5
LATUDA ....................................................................8
LAZANDA .................................................................9
leflunomide .................................................................6
LESCOL .....................................................................2
LESCOL XL ...............................................................2
Formulary Index
LETAIRIS ................................................................10
letrozole ......................................................................2
LEUKERAN ...............................................................2
LEUKINE ...................................................................2
leuprolide acetate .....................................................11
LEVEMIR ..................................................................4
levetiracetam ............................................................10
levetiracetam er ........................................................10
LEVITRA ...................................................................7
levobunolol hcl ...........................................................5
levocetirizine dihydrochloride ....................................1
levofloxacin .................................................................6
levora 0.15/30-28 .....................................................11
levothyroxine sodium ................................................11
LEXAPRO ..................................................................8
LEXIVA .....................................................................6
LIALDA .....................................................................7
LIDODERM ...............................................................9
lindane ........................................................................7
LINZESS ..................................................................10
liothyronine sodium ..................................................11
LIPITOR .....................................................................2
LIPTRUZET ...............................................................2
lisinopril .....................................................................2
lisinopril/hydrochlorothiazide ....................................2
LIVALO .....................................................................2
LOCOID LIPOCREAM .............................................4
LODOSYN ...............................................................10
LOESTRIN 1.5/30-21 ..............................................11
LOESTRIN FE 1.5/30 ..............................................11
LOFIBRA ...................................................................2
lomustine .....................................................................2
LOPROX ....................................................................4
lorazepam ...................................................................8
LORZONE .................................................................9
losartan potassium ......................................................2
losartan potassium/hydrochlorothiazide ....................3
LOTEMAX GEL ........................................................5
LOTEMAX SUSPENSION .......................................5
LOTRONEX .............................................................10
lovastatin ....................................................................2
LOVAZA ....................................................................2
low-ogestrel ..............................................................11
loxapine succinate ......................................................8
LUMIGAN .................................................................5
LUNESTA ..................................................................8
LUVOX CR ................................................................8
LUXIQ ........................................................................4
LUZU .........................................................................4
LYRICA ...............................................................6, 10
LYSODREN ...............................................................2
M
MALARONE .............................................................7
maprotiline hcl ............................................................8
MAXAIR AUTOHALER ..........................................1
meclizine hcl .............................................................10
meclofenamate sodium ...............................................9
medroxyprogesterone acetate ...................................12
mefloquine hcl ............................................................7
megestrol acetate ....................................................... 2
MEKINIST ................................................................ 2
meloxicam .................................................................. 9
MENEST .................................................................. 12
MENOPUR .............................................................. 11
MENTAX .................................................................. 4
meperidine hcl ............................................................ 9
meprobamate .............................................................. 8
mercaptopurine .......................................................... 2
mesalamine ................................................................ 7
mesalamine kit ........................................................... 7
METADATE CD ....................................................... 1
metadate er ................................................................. 1
metaproterenol sulfate ............................................... 1
metaxalone ................................................................. 9
metformin hcl ............................................................. 5
metformin hcl er ......................................................... 5
methadone hcl ............................................................ 9
methadose .................................................................. 9
methazolamide ........................................................... 3
methimazole ............................................................. 11
methocarbamol .......................................................... 9
methotrexate ............................................................. 10
methyldopa ................................................................. 3
methyldopa/hydrochlorothiazide ............................... 3
methylphenidate hcl ................................................... 1
methylphenidate hcl cd............................................... 1
methylphenidate hcl er ............................................... 1
methylprednisolone .................................................... 4
methyltestosterone/esterified estrogens
hs .............................................................................. 12
metipranolol ............................................................... 5
metoclopramide hcl .................................................. 11
metolazone ................................................................. 3
metoprolol succinate er .............................................. 3
metoprolol tartrate ..................................................... 3
metoprolol/hydrochlorothiazide ................................ 3
METOZOLV ODT .................................................. 11
METROGEL .............................................................. 4
metronidazole ............................................................. 6
MEVACOR ................................................................ 2
mexiletine hcl ............................................................. 2
MIACALCIN ............................................................. 9
MICARDIS ................................................................ 2
MICARDIS HCT ....................................................... 3
microgestin 1.5/30 .................................................... 11
microgestin fe 1.5/30 ................................................ 11
migergot ..................................................................... 8
MIGRANAL .............................................................. 8
mimvey ..................................................................... 12
MINASTRIN 24 FE ................................................. 11
minocycline hcl .......................................................... 6
minocycline hcl er ...................................................... 4
minoxidil .................................................................... 3
MIRAPEX ER ......................................................... 10
mirtazapine ................................................................ 8
misoprostol ............................................................... 11
MOBIC ...................................................................... 9
modafinil .................................................................... 3
MODICON .............................................................. 11
17
moexipril/hydrochlorothiazide ...................................2
mometasone furoate....................................................4
mononessa ................................................................11
montelukast sodium ....................................................1
morphine sulfate .........................................................9
morphine sulfate er .....................................................9
MOXATAG ................................................................6
moxifloxacin hcl..........................................................6
MOZOBIL ..................................................................2
MULTAQ ...................................................................2
multigen ....................................................................11
multigen plus ............................................................11
mupirocin ....................................................................4
MUSE .........................................................................7
MYALEPT .................................................................5
mycophenolate mofetil ................................................6
mycophenolic acid dr .................................................6
MYFORTIC ...............................................................6
mynatal plus..............................................................11
MYRBETRIQ.............................................................9
N
nabumetone.................................................................9
nadolol ........................................................................3
NAFTIN .....................................................................4
NALFON ....................................................................9
naltrexone hcl .............................................................1
NAMENDA ................................................................1
NAMENDA XR .........................................................1
NAPRELAN ...............................................................9
NAPROSYN...............................................................9
naproxen .....................................................................9
naratriptan hcl ............................................................8
NARDIL .....................................................................8
NASACORT AQ ........................................................7
NASONEX .................................................................7
NATAZIA ................................................................11
nateglinide ..................................................................5
necon 0.5/35-28 ........................................................11
necon 1/50-28 ...........................................................11
necon 10/11-28 .........................................................11
nefazodone hcl ............................................................8
neomycin/bacitracin/polymyxin ..................................5
neomycin/polymyxin/dexamethasone .........................5
neomycin/polymyxin/gramicidin.................................5
neomycin/polymyxin/hydrocortisone ..........................5
NEORAL ....................................................................6
NESINA .....................................................................5
NEULASTA ...............................................................2
NEUPOGEN...............................................................2
NEUPRO ..................................................................10
NEVANAC.................................................................5
NEXAVAR.................................................................2
NEXIUM ..................................................................11
nicardipine hcl ............................................................3
NICOTROL INHALER .............................................1
nifedipine ....................................................................3
nifedipine er ................................................................3
NILANDRON ............................................................2
nimodipine ..................................................................3
Formulary Index
nisoldipine ..................................................................3
NITRO-BID ................................................................2
nitrofurantoin macrocrystals ......................................7
nitroglycerin ...............................................................2
nitroglycerin er ...........................................................2
NITROMIST ..............................................................2
NITROSTAT ..............................................................2
nizatidine ..................................................................11
NIZORAL ...................................................................4
nora-be .....................................................................11
NORDITROPIN FLEXPRO ......................................6
norethindrone acetate ...............................................12
NORITATE ................................................................4
NORPACE CR ...........................................................2
NORTHERA ..............................................................3
nortrel 0.5/35 (28) ....................................................11
nortriptyline hcl ..........................................................8
NORVIR .....................................................................6
novarel ......................................................................11
NOVOLIN 70/30 ........................................................5
NOVOLIN N ..............................................................5
NOVOLIN R ..............................................................5
NOVOLOG ................................................................5
NOVOLOG MIX 70/30 .............................................5
NUCYNTA .................................................................9
NUCYNTA ER ..........................................................9
NUEDEXTA ............................................................10
NUTROPIN AQ PEN .................................................6
NUVARING .............................................................11
NUVIGIL ...................................................................3
nystatin .......................................................................7
nystatin/triamcinolone ................................................4
nystop ..........................................................................4
O
octreotide acetate .......................................................5
ofloxacin .................................................................5, 7
ogestrel .....................................................................11
olanzapine ...................................................................8
olanzapine odt ............................................................8
olanzapine/fluoxetine ..................................................8
OLEPTRO ..................................................................8
OLUX .........................................................................4
OLYSIO .....................................................................6
omega-3-acid ethyl esters ...........................................3
omeprazole ...............................................................11
omeprazole/sodium bicarbonate ..............................11
OMNARIS ..................................................................7
OMNITROPE .............................................................6
ondansetron hcl ........................................................10
ONETOUCH ULTRA 2 .............................................4
ONETOUCH ULTRA BLUE ....................................4
ONETOUCH ULTRA MINI ......................................4
ONETOUCH ULTRA SYSTEM KIT .......................4
ONETOUCH ULTRASMART ..................................4
ONETOUCH VERIO IQ BLOOD
GLUCOSE MONITORING SYSTEM ......................4
ONETOUCH VERIO TEST STRIPS ........................4
ONFI .........................................................................10
ONGLYZA .................................................................5
ONMEL ..................................................................... 7
ONSOLIS ................................................................... 9
OPANA ...................................................................... 9
OPANA ER (CRUSH RESISTANT) ........................ 9
OPSUMIT ................................................................ 10
OPTIVAR .................................................................. 5
ORACEA ................................................................... 4
ORAVIG .................................................................... 7
ORENCIA ................................................................ 10
ORENITRAM .......................................................... 10
ORFADIN .................................................................. 6
orphenadrine citrate er .............................................. 9
ORTHO EVRA ........................................................ 11
ORTHO TRI-CYCLEN ........................................... 11
ORTHO TRI-CYCLEN LO ..................................... 11
ORTHO-CYCLEN .................................................. 11
OSENI ........................................................................ 5
OSPHENA ............................................................... 12
OTEZLA .................................................................... 4
OTREXUP ............................................................... 10
OVCON-35 .............................................................. 11
OVIDREL ................................................................ 11
oxandrolone ............................................................... 7
oxaprozin .................................................................... 9
oxazepam .................................................................... 8
oxcarbazepine .......................................................... 10
OXECTA ................................................................... 9
OXTELLAR XR ...................................................... 10
oxybutynin chloride .................................................... 9
oxybutynin chloride er ............................................... 9
oxycodone hcl ............................................................. 9
oxycodone/acetaminophen ......................................... 9
oxycodone/aspirin ...................................................... 9
oxycodone/ibuprofen .................................................. 9
OXYCONTIN ............................................................ 9
oxymorphone hydrochloride ...................................... 9
OXYTROL ................................................................ 9
P
pacerone ..................................................................... 2
PANCREAZE .......................................................... 10
PANRETIN ................................................................ 3
pantoprazole sodium ................................................ 11
paroxetine hcl ............................................................. 8
paroxetine hcl er ........................................................ 8
PATADAY ................................................................ 5
PATANASE ............................................................... 7
PATANOL ................................................................. 5
PAXIL ........................................................................ 8
PAXIL CR ................................................................. 8
PEGANONE ............................................................ 10
PEGASYS .................................................................. 6
PEG-INTRON ............................................................ 6
penicillin v potassium ................................................ 7
PENNSAID ................................................................ 9
PENTASA .................................................................. 7
pentazocine/naloxone hcl ........................................... 9
pentoxifylline er ......................................................... 1
PERFOROMIST ........................................................ 1
perphenazine/amitriptyline ........................................ 8
18
PERTZYE.................................................................10
PEXEVA ....................................................................8
phendimetrazine tartrate er ......................................11
phenelzine sulfate .......................................................8
phenobarbital ...........................................................10
phentermine hcl ........................................................11
phenytoin ..................................................................10
PICATO ......................................................................3
pilocarpine hcl ............................................................5
PILOPINE HS ............................................................5
pindolol .......................................................................3
pioglitazone hcl/metformin hcl ...................................5
pioglitazone hcl-glimepiride .......................................5
piroxicam ....................................................................9
PKU products .............................................................5
PLAVIX .....................................................................1
polymyxin b sulfate/trimethoprim sulfate ...................5
POMALYST...............................................................2
PONSTEL...................................................................9
portia-28 ...................................................................11
potassium chloride....................................................10
potassium citrate er ..................................................10
POTIGA ...................................................................10
PRADAXA .................................................................1
pramipexole dihydrochloride ...................................10
PRANDIN ..................................................................5
PRAVACHOL ............................................................3
pravastatin sodium .....................................................3
prazosin hcl ................................................................7
PRECISION XTRA....................................................4
PRECISION XTRA BLOOD
GLUCOSE TEST STRIPS .........................................4
prednisolone ...............................................................4
prednisone ..................................................................4
pregnyl w/diluent benzyl alcohol/nacl ......................11
PREMARIN .............................................................12
PREMPHASE ..........................................................12
PREMPRO ...............................................................12
prenatabs fa ..............................................................11
prenatal 19................................................................11
PREVACID ..............................................................11
previfem ....................................................................11
PRILOSEC ...............................................................11
prilosec otc ...............................................................11
primidone ..................................................................10
PRISTIQ .....................................................................8
PROAIR HFA ............................................................1
probenecid ..................................................................6
probenecid/colchicine.................................................6
PROCRIT ...................................................................2
proctozone-hc .............................................................6
PROCYSBI ................................................................5
progesterone .............................................................12
PROMACTA ..............................................................6
promethazine hcl plain ...............................................1
PROMETRIUM .......................................................12
propafenone hcl ..........................................................2
propafenone hcl er ......................................................2
propranolol hcl ...........................................................3
propranolol hcl er.......................................................3
Formulary Index
propranolol/hydrochlorothiazide ...............................3
propylthiouracil ........................................................11
PROTONIX ..............................................................11
PROTOPIC .................................................................3
PROVENTIL HFA .....................................................1
PROVIGIL .................................................................3
PROZAC ....................................................................8
PROZAC WEEKLY ..................................................8
PULMICORT FLEXHALER .....................................1
PULMICORT NEBULIZER ......................................1
PULMOZYME ...........................................................3
PURIXAN ..................................................................2
risperidone odt ........................................................... 8
RITALIN LA ............................................................. 1
rivastigmine tartrate .................................................. 1
rizatriptan benzoate ................................................... 8
rizatriptan benzoate odt ............................................. 8
ropinirole er ............................................................. 10
ropinirole hcl ........................................................... 10
ROWASA .................................................................. 7
roxicet ........................................................................ 9
ROZEREM ................................................................ 8
RUCONEST .............................................................. 1
RYTHMOL SR .......................................................... 2
Q
S
QNASL .......................................................................7
QSYMIA ..................................................................11
QUALAQUIN ............................................................7
quasense ...................................................................11
QUDEXY XR ...........................................................10
quetiapine fumarate ....................................................8
QUILLIVANT XR .....................................................1
quinapril hcl ...............................................................2
quinapril/hydrochlorothiazide ....................................2
quinidine gluconate cr ................................................2
QVAR .........................................................................1
SABRIL ..................................................................... 6
SAIZEN ..................................................................... 6
salsalate ..................................................................... 9
SANCTURA .............................................................. 9
SANCTURA XR ....................................................... 9
SANCUSO ............................................................... 10
SANTYL .................................................................. 12
SAPHRIS ................................................................... 8
SARAFEM ................................................................. 8
SAVELLA ................................................................. 6
SEASONIQUE ........................................................ 11
selegiline hcl ............................................................ 10
selenium sulfide .......................................................... 4
SELZENTRY ............................................................. 6
SEROQUEL XR ........................................................ 8
SEROSTIM ................................................................ 6
sertraline hcl .............................................................. 8
SIGNIFOR ................................................................. 5
sildenafil citrate ....................................................... 10
SILENOR ................................................................... 8
silver sulfadiazine ...................................................... 4
SIMCOR .................................................................... 3
SIMPONI ................................................................. 10
simvastatin ................................................................. 3
SITAVIG .................................................................... 7
SIVEXTRO ................................................................ 7
SKELAXIN ................................................................ 9
SKELID ..................................................................... 9
sodium sulfacetamide ................................................. 4
SOLARAZE ............................................................... 3
solia .......................................................................... 11
SOLODYN ................................................................ 4
SOMA ........................................................................ 9
SOMAVERT .............................................................. 6
SONATA ................................................................... 8
SORIATANE ............................................................. 4
SORILUX .................................................................. 4
sotalol hcl ................................................................... 3
SOVALDI .................................................................. 6
SPECTRACEF ........................................................... 7
SPIRIVA HANDIHALER ......................................... 1
spironolactone ............................................................ 3
spironolactone/hydrochlorothiazide .......................... 3
sprintec 28 ................................................................ 11
SPRIX ........................................................................ 9
SPRYCEL .................................................................. 2
R
rabeprazole sodium ..................................................11
raloxifene hydrochloride ............................................9
ramipril .......................................................................2
RANEXA ...................................................................2
ranitidine hcl ............................................................11
RAPAFLO ..................................................................7
RAPAMUNE ..............................................................6
RASUVO ..................................................................10
RAVICTI ..................................................................11
RAYOS .......................................................................4
REBIF .........................................................................8
reclipsen ...................................................................11
REGRANEX ............................................................12
RELENZA DISKHALER ..........................................7
RELPAX .....................................................................8
RENAGEL ...............................................................10
RENVELA ...............................................................10
REPRONEX .............................................................11
REQUIP XL .............................................................10
RESCRIPTOR ............................................................6
RESTASIS ..................................................................5
RETIN-A MICRO ......................................................4
REVATIO .................................................................10
REVLIMID .................................................................2
REYATAZ .................................................................6
RHINOCORT AQUA ................................................7
RHINOFLEX-650 ......................................................9
ribasphere ...................................................................6
ribasphere ribapak .....................................................6
rifampin ......................................................................7
rimantadine hcl ...........................................................7
risedronate sodium .....................................................9
risperidone ..................................................................8
19
STALEVO 50 ...........................................................10
stavudine .....................................................................6
STAVZOR ................................................................10
STAXYN ....................................................................7
STELARA ..................................................................4
STIVARGA ................................................................2
STRATTERA .............................................................1
STRIANT ...................................................................7
STRIBILD ..................................................................6
SUBOXONE ..............................................................1
SUBSYS .....................................................................9
sucralfate ..................................................................11
SULAR .......................................................................3
sulfamethoxazole/trimethoprim ..................................7
sulfasalazine ...............................................................7
sulindac.......................................................................9
sumatriptan succinate .................................................8
SUMAVEL DOSEPRO..............................................8
SUPRAX ....................................................................7
SUPRENZA .............................................................11
SURESTEP PRO LINEARITY KIT ..........................4
SURMONTIL .............................................................8
SUSTIVA ...................................................................6
SUTENT .....................................................................2
SYLATRON ...............................................................6
SYMBICORT .............................................................1
SYMLINPEN 60 ........................................................5
SYNAREL ................................................................11
SYNERA ....................................................................9
SYNTHROID ...........................................................11
T
TACLONEX OINTMENT .........................................4
TACLONEX SUSPENSION .....................................4
tacrolimus ...................................................................6
TAFINLAR ................................................................2
TAMIFLU ..................................................................7
tamoxifen citrate .........................................................2
tamsulosin hcl .............................................................7
TANZEUM.................................................................5
TARCEVA .................................................................2
TARGRETIN .............................................................2
TARKA ......................................................................3
TASIGNA...................................................................2
TASMAR .................................................................10
TAZORAC .................................................................4
TECFIDERA ..............................................................8
TEKAMLO.................................................................3
TEKTURNA...............................................................3
TEKTURNA HCT......................................................3
telmisartan ..................................................................2
telmisartan/amlodipine ...............................................3
telmisartan/hydrochlorothiazide ................................3
temazepam ..................................................................8
TEMODAR ................................................................2
terazosin hcl................................................................7
terbinafine hcl .............................................................7
terbutaline sulfate .......................................................1
terconazole .................................................................7
TESTIM ......................................................................7
Formulary Index
testosterone enanthate ................................................7
tetracycline hcl ...........................................................7
TEVETEN HCT .........................................................3
TEV-TROPIN .............................................................6
THALOMID ...............................................................2
theophylline er ............................................................1
thioridazine hcl ...........................................................8
thiothixene ..................................................................8
THYROLAR-1 .........................................................11
ticlopidine hcl .............................................................1
TIKOSYN ...................................................................2
timolol maleate ...........................................................3
tinidazole ....................................................................7
TIVICAY ....................................................................6
tizanidine hcl ..............................................................9
TOBI ...........................................................................3
TOBI PODHALER ....................................................3
tobramycin sulfate ......................................................5
tobramycin/dexamethasone ........................................5
tolazamide ...................................................................5
tolbutamide .................................................................5
tolmetin sodium ..........................................................9
tolterodine tartrate .....................................................9
tolterodine tartrate er .................................................9
TOPAMAX ..............................................................10
TOPAMAX SPRINKLE ..........................................10
topiramate .................................................................10
torsemide ....................................................................3
TOVIAZ .....................................................................9
TRACLEER .............................................................10
TRADJENTA .............................................................5
tramadol hcl ................................................................9
tramadol hcl er ...........................................................9
tramadol hydrochloride/acetaminophen ....................9
trandolapril .................................................................2
tranexamic acid ........................................................11
TRANSDERM-SCOP ..............................................10
tranylcypromine sulfate ..............................................8
TRAVATAN Z ...........................................................5
trazodone hcl ..............................................................8
tretinoin ......................................................................4
TRETIN-X ..................................................................4
TREXIMET ................................................................8
triamcinolone acetonide .........................................4, 7
triamterene/hydrochlorothiazide ................................3
TRIANEX ...................................................................4
triazolam .....................................................................8
TRIBENZOR ..............................................................3
TRICOR .....................................................................3
trifluoperazine hcl ......................................................8
trifluridine ...................................................................5
trihexyphenidyl hcl ...................................................10
TRILIPIX ...................................................................3
trimethobenzamide hcl ..............................................10
trimethoprim ...............................................................7
trinessa .....................................................................11
TRI-NORINYL 28 ...................................................11
tri-previfem ...............................................................11
tri-sprintec ................................................................11
TRIUMEQ ..................................................................6
trivora-28 ................................................................. 11
TRIZIVIR .................................................................. 6
TROKENDI XR ....................................................... 10
trospium chloride ....................................................... 9
trospium chloride er ................................................... 9
TRUVADA ................................................................ 6
TUDORZA PRESSAIR ............................................. 1
TUSSIONEX PENNKINETIC
EXTENDED RELEASE ............................................ 3
TWYNSTA ................................................................ 3
TYKERB .................................................................... 2
TYVASO STARTER ............................................... 10
TYZEKA .................................................................... 6
U
UCERIS ..................................................................... 7
ULORIC ..................................................................... 6
ULTRAM ER ............................................................. 9
ULTRAVATE PAC ................................................... 4
ULTRESA ................................................................ 10
unithroid direct ........................................................ 11
UROXATRAL ........................................................... 7
URSO 250 ................................................................ 10
URSO FORTE ......................................................... 10
ursodiol .................................................................... 10
V
VAGIFEM ............................................................... 12
valacyclovir hcl .......................................................... 7
VALCHLOR .............................................................. 3
VALCYTE ................................................................. 7
valproic acid ............................................................ 10
valsartan/hydrochlorothiazide ................................... 3
vancomycin hcl ........................................................... 7
VANOS ...................................................................... 4
Various generics ........................................................ 5
VASCEPA ................................................................. 3
VELTIN ..................................................................... 4
venlafaxine hcl ........................................................... 8
venlafaxine hcl er caps ............................................... 8
venlafaxine hcl er tabs ............................................... 8
VENTAVIS .............................................................. 10
VENTOLIN HFA ...................................................... 1
VERAMYST .............................................................. 7
verapamil hcl ............................................................. 3
verapamil hcl er ......................................................... 3
VERDESO ................................................................. 4
VESICARE ................................................................ 9
VEXOL ...................................................................... 5
VFEND ...................................................................... 7
VIAGRA .................................................................... 7
VIBRAMYCIN .......................................................... 7
VICTOZA .................................................................. 5
VICTRELIS ............................................................... 6
VIGAMOX ................................................................ 5
VIIBRYD ................................................................... 8
VIMPAT .................................................................. 10
VIOKACE ................................................................ 10
VIRACEPT ................................................................ 6
VIRAMUNE .............................................................. 6
20
VIREAD .....................................................................6
vitamin d .....................................................................5
VIVELLE-DOT ........................................................12
VOGELXO .................................................................7
VOGELXO PUMP .....................................................7
VOLTAREN...............................................................9
VOLTAREN-XR ........................................................9
voriconazole ...............................................................7
VOTRIENT ................................................................2
VYTORIN ..................................................................3
VYVANSE .................................................................1
W
warfarin sodium .........................................................1
WELCHOL.................................................................3
WELLBUTRIN ..........................................................8
WELLBUTRIN SR ....................................................8
WELLBUTRIN XL ....................................................8
wymzya fe..................................................................11
X
XALATAN .................................................................5
XALKORI ..................................................................2
XARELTO .................................................................1
XARTEMIS XR .........................................................9
XELJANZ.................................................................10
XELODA ....................................................................2
XENAZINE ................................................................6
XENICAL.................................................................11
XERESE .....................................................................7
XIFAXAN ..................................................................7
XOLEGEL ..................................................................4
XOPENEX .................................................................1
XTANDI .....................................................................2
XYREM ......................................................................3
Y
YASMIN 28 .............................................................11
YAZ ..........................................................................11
Z
ZACLIR CLEANSING ..............................................4
zafirlukast ...................................................................1
zaleplon.......................................................................8
ZAVESCA ..................................................................6
ZEGERID .................................................................11
ZELAPAR ................................................................10
ZELBORAF ...............................................................2
ZEMPLAR .................................................................5
ZENPEP ...................................................................10
ZETIA.........................................................................3
ZETONNA .................................................................7
ZIAGEN .....................................................................6
ZIANA ........................................................................4
zidovudine ...................................................................6
ZIOPTAN ...................................................................5
ziprasidone hcl............................................................8
ZIPSOR ......................................................................9
ZMAX ........................................................................7
ZOFRAN ..................................................................10
Formulary Index
ZOHYDRO ER ..........................................................9
ZOLINZA ...................................................................2
zolmitriptan .................................................................8
zolmitriptan odt ..........................................................8
ZOLOFT .....................................................................8
zolpidem tartrate ........................................................8
zolpidem tartrate er ....................................................8
ZOLPIMIST ...............................................................8
ZOMIG .......................................................................8
ZOMIG ZMT ..............................................................8
zonisamide ................................................................10
ZONTIVITY ...............................................................1
ZORBTIVE ................................................................6
ZORTRESS ................................................................6
zovia 1/35e ................................................................11
zovia 1/50e ................................................................11
ZOVIRAX ..................................................................7
ZUBSOLV ..................................................................1
ZUPLENZ ................................................................10
ZYCLARA .................................................................3
ZYDELIG ...................................................................2
ZYFLO .......................................................................1
ZYFLO CR .................................................................1
ZYKADIA ..................................................................2
ZYMAXID .................................................................5
ZYPREXA ..................................................................8
ZYPREXA ZYDIS .....................................................8
ZYTIGA .....................................................................2
ZYVOX ......................................................................7
21