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Providence Health Plan
Commercial Drug Formulary
List of Covered Prescription Drugs
www.providence.org/healthplans
Providence prescription drug coverage
Providence Health Plan wants to help you to make the most of your prescription drug coverage.
That’s why we strive to provide you with the information you need to make smart decisions about
medications.
Know more, save more
We encourage you to be knowledgeable about your prescription drug benefits. Information is
available on your benefit summary, in your member handbook and on the Providence Health Plan
website.
When you require a prescription, be sure to let your doctor know cost matters to you. Choosing a
generic when possible can help manage your costs.
Retail pharmacies
You have access to more than 25,000 participating pharmacies nationwide at discounted rates.
Search the provider directory to locate participating pharmacies near you.
Maintenance drugs
Maintenance medications are those typically prescribed to treat long-term or chronic conditions,
such as diabetes, high blood pressure and high cholesterol. A 90-day supply of maintenance
medication is available through participating mail-order pharmacies, as well as through preferred
retail pharmacies. Your 90-day supply copay or coinsurance applies. Not all covered prescription
drugs are available in a 90-day supply.
Learn more about mail-order pharmacies and preferred retail pharmacies.
Specialty drugs
Specialty drugs are prescriptions that require special delivery, handling, administration and
monitoring by your pharmacist. These drugs are listed in the Providence formulary with a status of
“Specialty,” and are available through Providence Specialty Pharmacy Services.
Learn more about specialty drugs.
Generic drugs
Making the switch from brand to generic medication can save you money. Generic drugs, which are
available only after the brand-name patent expires:
•
•
Have the same active ingredient formula as the brand-name drug and
Are tested by the Food and Drug Administration (FDA) to be as safe and effective as the
brand-name drug.
There are two types of generic drugs:
•
Generic equivalent - A generic equivalent is a generic drug that has the same active
ingredient, dosage form and strength as its brand-name counterpart. The FDA assures
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sameness between brand-name and generic equivalent products. Generic equivalents are an
important option to brand-name prescription drugs because they cost less.
Example: Zocor®, a brand-name drug commonly used to treat high cholesterol, is now
available in generic form under the name simvastatin. Zocor® and simvastatin are identical
drugs – the only difference is that one costs more than the other.
•
Generic alternative - A generic alternative is a generic drug used to treat the same
condition as a brand-name drug. It is not, however, the exact same medication as the brandname drug. According to clinical evidence, a generic alternative can be expected to treat the
same condition as well as the brand-name option.
Example: Simvastatin, the generic form of Zocor®, may be prescribed instead of Crestor® in
the treatment of high cholesterol. Generic alternatives are an important option for
prescription drugs for which there is no generic available.
Visit the Consumer Reports Best-Buy Drug website for more information regarding safe and effective
drug treatment options.
The Providence formulary
Your prescription drug plan provides coverage for medications listed on the Providence formulary.
Developed in collaboration with Providence Health Plans, physicians and pharmacists, the formulary
includes FDA-approved prescription generic, brand-name and specialty medications. The formulary
can help you and your physician choose effective, quality medications that minimize your out-ofpocket expense.
Search the formulary
There are two ways to search the formulary. They include:
1. By medical condition category (e.g., drugs used to treat heart conditions are listed under the
category, Cardiovascular Agents); and
2. By index (provides an alphabetical listing of drugs included in the formulary).
Formulary updates
The formulary is updated every two months. Providence’s Oregon Regional Pharmacy and
Therapeutics committee (comprised of doctors and pharmacists who practice in the communities we
serve) continuously reviews the latest evidence to identify opportunities to promote safe, effective
and affordable drug therapy. Generally, the formulary status of a drug covered by your Providence
Health Plan prescription drug coverage will not change during the year unless:
•
•
•
The medication becomes available in generic form;
There are safety or effectiveness concerns raised about the prescription drug; or
The Pharmacy and Therapeutics committee determines that changes to the formulary would
be in the best overall interest of Providence Health Plan members.
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If a change to the formulary results in a reduction of benefits or an increase in member copay,
affected individuals are notified in writing.
Formulary brand-name drugs
The Providence formulary includes prescription drugs that are proven safe, effective and that offer
value. Refer to your benefit summary for your brand-name drug copay or coinsurance amount.
Remember, even if a generic equivalent is not yet available, safe and effective generic alternatives may
be available to treat most common conditions. Using these options can provide cost savings.
Non-approved drugs
Your prescription drug benefit covers only FDA-approved prescription drugs. It is possible for
medications to be on the market without FDA approval. The FDA is taking action to ensure these
drugs become approved or are removed from the market. In the meantime, many remain on
pharmacy shelves. If the drug you are taking is not FDA approved, know that there are likely
approved prescription drugs available to treat your condition. We encourage you to discuss
alternative medications with your doctor. Should you and your doctor determine that there is no
covered alternative and you choose to continue to take a medication that is not FDA approved, your
health plan will not cover that expense.
More information regarding medications that are not FDA approved can be found on our website,
in the related article and in the FAQ document, which includes links to the FDA website. You may
also call the Providence Health Plan pharmacy team for more information and to discuss potential
alternatives.
Prior authorization
Prior authorization is a process to review a prescription drug for coverage before it is dispensed. The
prior authorization process is initiated by the prescribing medical provider.
Many factors – including the potential for serious health risks, FDA-approved indications and costeffectiveness – are considered before making the decision to require prior authorization of a
prescription medication. A limited number of medications require prior authorization review; any
medications requiring prior authorization are indicated as such in the Providence formulary.
Keep in mind, the formulary may contain other suitable options. You and your doctor may wish to
discuss the possibility of changing your prescription to an effective formulary alternative. Otherwise,
your doctor may submit a prior authorization request on your behalf.
Formulary exceptions
There may be times that you require a medication that is not on the Providence formulary. If you
currently take a prescription drug that is not on the formulary, contact customer service to confirm
that drug is not covered. If the prescription drug is not covered, your doctor may request a formulary
exception.
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Step therapy
Step therapy is a form of prior authorization. Its purpose is to confirm if drugs generally considered
"first-line" therapy based on clinical evidence already have been tried. If they have, the drug
requiring prior authorization will automatically be approved. In the event these drugs are not tried
first, cannot be tried first or the individual’s prescription medication history is not part of Providence
Health Plan claims history, prior authorization is required.
Quantity limit
For certain drugs, Providence Health Plan limits the amount of the drug covered for a specified
time frame [e.g., Providence Health Plan provides two inhalers per 30 days for Proair® or
Proventil® HFA (albuterol HFA)]. Quantity limits are in place to ensure safe and appropriate use of a
drug.
Answers to frequently asked questions
Learn more about your prescription drug coverage by reviewing answers to frequently asked
questions.
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Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
Analgesics
alagesic lq
Generic
butalbital/acetaminophen
Generic
butalbital/acetaminophen/caffeine (50325-40 capsule, 50-325-40 tablet, 50500-40 tablet)
Generic
butalbital/aspirin/caffeine
Generic
capacet
Generic
fioricet 50-325-40 mg tablet
Generic
tencon 50-325 mg tablet
Generic
tramadol hcl/acetaminophen
Generic
QL (240 PER 30 DAYS)
Nonsteroidal Anti-inflammatory Drugs
all day pain relief
Generic
all day relief
Generic
CELEBREX (50 MG, 100 MG, 200 MG)
BRAND
PA, QL (60 PER 30 DAYS)
CELEBREX 400 MG CAPSULE
BRAND
PA, QL (30 PER 30 DAYS)
diclofenac potassium
Generic
diclofenac sodium (25 mg tablet dr, 50
mg tablet dr, 75 mg tablet dr, 100 mg
tab er 24h)
Generic
diflunisal
Generic
etodolac (200 mg capsule, 300 mg
capsule, 400 mg tab er 24h, 400 mg
tablet, 500 mg tab er 24h, 500 mg
tablet, 600 mg tab er 24h)
Generic
fenoprofen calcium 600 mg tablet
Generic
flurbiprofen (50 mg, 100 mg)
Generic
ibuprofen (400 mg, 600 mg, 800 mg)
Generic
ibuprofen/oxycodone hcl
Generic
indomethacin (25 mg, 50 mg, 75 mg er)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
1
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
ketoprofen (50 mg capsule, 75 mg
capsule, 200 mg cap24h pel)
Generic
ketorolac tromethamine 10 mg tablet
Generic
meclofenamate sodium (50 mg, 100
mg)
Generic
meloxicam (7.5 mg tablet, 7.5 mg/5ml
oral susp, 15 mg tablet)
Generic
nabumetone (500 mg, 750 mg)
Generic
NAPRELAN CR 500 MG TABLET
BRAND
naproxen (125 mg/5ml oral susp, 250
mg tablet, 375 mg tablet, 375 mg tablet
dr, 500 mg tablet, 500 mg tablet dr)
Generic
naproxen sodium (220 mg, 275 mg, 550
mg)
Generic
oxaprozin
Generic
piroxicam (10 mg, 20 mg)
Generic
sulindac (150 mg, 200 mg)
Generic
tolmetin sodium
Generic
Requirements/Limits
Opioid Analgesics, Long-acting
fentanyl (12 mcg/hr, 25mcg/hr,
50mcg/hr, 75mcg/hr, 100 mcg/hr)
Generic
levorphanol tartrate 2 mg tablet
Generic
methadone hcl (5 mg tablet, 5 mg/5 ml
solution, 10 mg tablet, 10 mg/5 ml
solution, 10 mg/ml oral conc, 40 mg
tablet sol)
Generic
methadone intensol
Generic
methadose 40 mg tablet dispr
Generic
morphine sulfate (5 mg supp.rect, 10
mg supp.rect, 15 mg tablet er, 20 mg
supp.rect, 30 mg supp.rect, 30 mg
tablet er, 60 mg tablet er, 100 mg
tablet er, 200 mg tablet er)
Generic
oxycodone hcl (10 mg er, 20 mg er, 40
mg er, 80 mg er)
Generic
QL (15 PER 30 DAYS)
PA, QL (90 PER 30 DAYS)
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
2
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
OXYCONTIN (15 MG, 30 MG, 60 MG)
BRAND
PA, QL (90 PER 30 DAYS)
tramadol hcl (100 mg tab er 24h, 100
mg tbmp 24hr, 200 mg tab er 24h, 200
mg tbmp 24hr, 300 mg tab er 24h, 300
mg tbmp 24hr)
Generic
Opioid Analgesics, Short-acting
acetaminophen with codeine phosphate
(120-12mg/5 solution, 240-24/10
solution, 300mg-15mg tablet, 300mg30mg tablet, 300mg-60mg tablet,
300mg/12.5 solution, 360-36/15
solution)
Generic
ascomp with codeine
Generic
butalbit/acetamin/caff/codeine 50-32530 capsule
Generic
butorphanol tartrate 10 mg/ml spray
Generic
co-gesic
Generic
codeine
phosphate/butalbital/aspirin/caffeine
Generic
codeine phosphate/carisoprodol/aspirin
Generic
codeine sulfate (15 mg, 30 mg, 60 mg)
Generic
dihydrocodeine
bitartrate/acetaminophen/caffeine
Generic
endocet (5-325, 7.5-325 mg, 7.5-500
mg, 10-325 mg, 10-650 mg)
Generic
endodan
Generic
hydrocodone bit/acetaminophen
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
3
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
hydrocodone bitartrate/acetaminophen
(2.5-167/5 solution, 2.5-500 mg tablet,
5 mg-500mg tablet, 5-334mg/10
solution, 5mg-325mg tablet, 7.5-325/15
solution, 7.5-325mg tablet, 7.5-500/15
solution, 7.5-500mg tablet, 7.5-650 mg
tablet, 7.5-750mg tablet, 10-660mg
tablet, 10-750mg tablet, 10mg-325mg
tablet, 10mg-500mg tablet, 10mg650mg tablet)
Generic
hydrocodone/ibuprofen
Generic
hydromorphone hcl (1 mg/ml liquid, 2
mg tablet, 3 mg supp.rect, 4 mg tablet,
8 mg tablet)
Generic
ibudone 5-200 mg tablet
Generic
lorcet
Generic
lorcet hd
Generic
lorcet plus 7.5-325 mg tablet
Generic
lortab (5-325 mg, 5-500, 7.5-325 mg,
10-325 mg)
Generic
meperidine hcl (50 mg, 100 mg)
Generic
meperitab
Generic
morphine sulfate (10 mg/5 ml solution,
15 mg tablet, 20 mg/5 ml solution, 30
mg tablet, 100 mg/5ml solution)
Generic
oxycodone hcl (5 mg capsule, 5 mg
tablet, 5 mg/5 ml solution, 10 mg
tablet, 15 mg tablet, 20 mg tablet, 20
mg/ml oral conc, 30 mg tablet)
Generic
oxycodone hcl/acetaminophen (5 mg500mg capsule, 5mg-325mg tablet, 7.5325mg tablet, 7.5-500mg tablet, 10mg325mg tablet, 10mg-650mg tablet)
Generic
oxycodone hcl/aspirin
Generic
oxymorphone hcl (5 mg, 10 mg)
Generic
reprexain 10-200 mg tablet
Generic
Requirements/Limits
PA
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
4
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
ROXICET 5-325 ORAL SOLUTION
BRAND
roxicet 5-325 tablet
Generic
stagesic
Generic
tramadol hcl 50 mg tablet
Generic
xylon 10
Generic
Requirements/Limits
Anesthetics
Local Anesthetics
glydo
Generic
lidocaine 5 % oint. (g)
Generic
lidocaine 5%(700mg) adh. patch
Generic
lidocaine hcl (2 % jel (ml), 2 % jel/pf
app, 2 % solution, 4 % solution, 40
mg/ml solution)
Generic
lidocaine/prilocaine (2.5 %-2.5% cream
(g), 2.5 %-2.5% kit)
Generic
NAROPIN (0.2% 400 MG/200 ML, 2
MG/ML INFUSION, 5 MG/ML INFUSION,
200 MG/100 ML INF)
BRAND
PA, QL (90 PER 30 DAYS)
Anti-Addiction/Substance Abuse Treatment Agents
Alcohol Deterrents/Anti-craving
acamprosate calcium
Generic
disulfiram (250 mg, 500 mg)
Generic
buprenorphine hcl/naloxone hcl
Generic
SUBOXONE (2 MG-0.5 MG, 8 MG-2 MG)
BRAND
Opioid Antagonists
buprenorphine hcl (2 mg, 8 mg)
Generic
depade
Generic
naltrexone hcl 50 mg tablet
Generic
QL (90 PER 30 DAYS)
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
5
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
revia
Generic
Requirements/Limits
Smoking Cessation Agents
buproban
Generic
CHANTIX
BRAND
Anti-inflammatory Agents
Glucocorticoids
alclometasone dipropionate
Generic
amcinonide 0.1 % cream (g)
Generic
apexicon e
Generic
betamethasone dipropionate (0.05 %
cream (g), 0.05 % gel (gram), 0.05 %
lotion, 0.05 % oint. (g))
Generic
betamethasone dipropionate/propylene
glycol (0.05 % cream (g), 0.05 % lotion,
0.05 % oint. (g))
Generic
betamethasone valerate (0.1 % cream
(g), 0.1 % lotion, 0.1 % oint. (g))
Generic
clobetasol propionate (0.05 % cream
(g), 0.05 % foam, 0.05 % gel (gram),
0.05 % oint. (g), 0.05 % shampoo, 0.05
% solution)
Generic
clobetasol propionate/emoll 0.05 %
cream (g)
Generic
clobetasol propionate/emoll 0.05 %
foam
Generic
clodan 0.05% shampoo
Generic
cormax
Generic
cortisone acetate 25 mg tablet
Generic
desonide (0.05 % cream (g), 0.05 %
lotion, 0.05 % oint. (g))
Generic
desoximetasone
Generic
diflorasone diacetate
Generic
PA
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
6
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
fludrocortisone acetate 0.1 mg tablet
Generic
fluocinolone acetonide (0.01 % cream
(g), 0.01 % solution, 0.025 % cream (g),
0.025 % oint. (g))
Generic
fluocinonide (0.05 % cream (g), 0.05 %
gel (gram), 0.05 % oint. (g), 0.05 %
solution)
Generic
fluocinonide/emollient base
Generic
fluticasone propionate (0.005 % oint.
(g), 0.05 % cream (g), 0.05 % lotion)
Generic
halobetasol propionate
Generic
hydrocortisone (2.5 % cream (g), 2.5 %
lotion, 2.5 % oint. (g))
Generic
hydrocortisone butyrate 0.1 % cream
(g)
Generic
millipred 5 mg tablet
Generic
millipred dp
Generic
nystatin/triamcinolone acetonide
Generic
oralone
Generic
ORAPRED ODT
BRAND
prednisolone 15 mg/5 ml solution
Generic
prednisolone sod phosphate (5 ml, 15
ml)
Generic
prednisone (1 mg tablet, 2.5 mg tablet,
5 mg tab ds pk, 5 mg tablet, 5 mg/5 ml
solution, 10 mg tab ds pk, 10 mg tablet,
20 mg tablet, 50 mg tablet)
Generic
prednisone intensol
Generic
triamcinolone acetonide (0.025 %
cream (g), 0.025 % lotion, 0.025 % oint.
(g), 0.1 % cream (g), 0.1 % lotion, 0.1 %
oint. (g), 0.1 % paste (g), 0.5 % cream
(g), 0.5 % oint. (g))
Generic
triderm
Generic
Requirements/Limits
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
7
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
Antibacterials
Aminoglycosides
garamycin 0.3% eye drops
Generic
gentak (0.3 % ointment, 3 mg/ml drops)
Generic
gentamicin sulfate (0.1 % cream (g), 0.1
% oint. (g), 0.3 % drops, 0.3 % oint. (g))
Generic
neomycin sulfate 500 mg tablet
Generic
TOBI PODHALER
Specialty
tobramycin 0.3 % drops
Generic
tobramycin in 0.225 % sodium chloride
Generic
TOBREX 0.3% EYE OINTMENT
BRAND
LA
Antibacterials, Other
acetasol hc
Generic
acetic acid/aluminum acetate
Generic
acetic acid/hydrocortisone
Generic
bacitracin 500 unit/g oint. (g)
Generic
bacitracin zinc (500 oint. (g), 500
oint.(ea))
Generic
chlorhexidine gluconate 0.12 %
mouthwash
Generic
clinda-derm
Generic
clindacin etz 1% pledget
Generic
clindacin p
Generic
clindamycin hcl (75 mg, 150 mg, 300
mg)
Generic
clindamycin palmitate hcl
Generic
clindamycin phosphate (1 % foam, 1 %
gel (gram), 1 % lotion, 1 % med. swab, 1
% solution, 2 % cream/appl)
Generic
cycloserine 250 mg capsule
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
8
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
methenamine hippurate
Generic
metronidazole (0.75 % cream (g), 0.75
% gel (gram))
Generic
metronidazole (0.75 % gel w/appl, 0.75
% lotion, 250 mg tablet, 375 mg
capsule, 500 mg tablet)
Generic
MONUROL
BRAND
mupirocin 2 % oint. (g)
Generic
nitrofurantoin (25 mg/5 ml oral susp, 50
mg capsule)
Generic
nitrofurantoin macrocrystal (50 mg, 100
mg)
Generic
nitrofurantoin
monohydrate/macrocrystals
Generic
paroex
Generic
periogard
Generic
rosadan (0.75% cream, 0.75% gel)
Generic
trimethoprim 100 mg tablet
Generic
vancomycin hcl (125 mg, 250 mg)
Generic
vandazole
Generic
vitazol
Generic
PA
XIFAXAN
BRAND
PA, QL (60 PER 30 DAYS)
ZYVOX (100 MG/5 ML SUSPENSION,
600 MG TABLET)
BRAND
PA
PA
PA
Beta-lactam, Cephalosporins
cefaclor (125 mg/5ml susp recon, 250
mg capsule, 250 mg/5ml susp recon,
375 mg/5ml susp recon, 500 mg
capsule)
Generic
cefadroxil (1 g tablet, 250 mg/5ml susp
recon, 500 mg capsule, 500 mg/5ml
susp recon)
Generic
cefdinir (125 mg/5ml susp recon, 250
mg/5ml susp recon, 300 mg capsule)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
9
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
cefpodoxime proxetil (50 mg/5 ml susp
recon, 100 mg tablet, 100 mg/5ml susp
recon, 200 mg tablet)
Generic
cefprozil (125 mg/5ml susp recon, 250
mg tablet, 250 mg/5ml susp recon, 500
mg tablet)
Generic
ceftibuten dihydrate (180 mg/5ml susp
recon, 400 mg capsule)
Generic
CEFTIN (125 ML, 250 ML)
BRAND
cefuroxime axetil
Generic
cephalexin (125 mg/5ml susp recon,
250 mg capsule, 250 mg tablet, 250
mg/5ml susp recon, 500 mg capsule,
500 mg tablet)
Generic
Requirements/Limits
Beta-lactam, Penicillins
amoxicillin (125 mg tab chew, 125
mg/5ml susp recon, 200 mg/5ml susp
recon, 250 mg capsule, 250 mg tab
chew, 250 mg/5ml susp recon, 400 mg
tab chew, 400 mg/5ml susp recon, 500
mg capsule, 500 mg tablet, 875 mg
tablet)
Generic
amoxicillin/potassium clavulanate (20028.5/5 susp recon, 200-28.5mg tab
chew, 250-125 mg tablet, 250-62.5/5
susp recon, 400-57mg tab chew, 40057mg/5 susp recon, 500-125 mg tablet,
600-42.9/5 susp recon, 875-125 mg
tablet, 1000-62.5 tab er 12h)
Generic
ampicillin trihydrate (250 mg, 500 mg)
Generic
dicloxacillin sodium
Generic
penicillin v potassium (125 mg/5ml soln
recon, 250 mg tablet, 250 mg/5ml soln
recon, 500 mg tablet)
Generic
Macrolides
AZASITE
BRAND
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
10
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
azithromycin (1 g packet, 100 mg/5ml
susp recon, 200 mg/5ml susp recon, 250
mg tablet, 500 mg tablet, 600 mg
tablet)
Generic
clarithromycin (125 mg/5ml susp recon,
250 mg tablet, 250 mg/5ml susp recon,
500 mg tab er 24h, 500 mg tablet)
Generic
E.E.S. 200
BRAND
ERY-TAB
BRAND
erygel
Generic
ERYPED 200
BRAND
erythromycin base (5 mg/g oint. (g),
5mg/g oint. (g), 250 mg capsule dr, 250
mg tablet, 500 mg tablet)
Generic
erythromycin base/ethyl alcohol (2 %
gel (gram), 2 % solution)
Generic
erythromycin ethylsuccinate 400 mg
tablet
Generic
erythromycin
ethylsuccinate/sulfisoxazole acetyl
Generic
Requirements/Limits
Quinolones
ciprofloxacin hcl (0.3 % drops, 100 mg
tablet, 250 mg tablet, 500 mg tablet,
750 mg tablet)
Generic
ciprofloxacin/ciprofloxa hcl 500 mg
tbmp 24hr
Generic
levofloxacin (0.5 % drops, 250 mg
tablet, 250mg/10ml solution, 500 mg
tablet, 750 mg tablet)
Generic
MOXEZA
BRAND
moxifloxacin hcl
Generic
ofloxacin (0.3 % drops, 200 mg tablet,
300 mg tablet, 400 mg tablet)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
11
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
Sulfonamides
bleph-10
Generic
silver sulfadiazine 1 % cream (g)
Generic
sulfacetamide sodium (10 % drops, 10 %
suspension)
Generic
sulfadiazine 500 mg tablet
Generic
sulfamethoxazole/trimethoprim (20040mg/5 oral susp, 400mg-80mg tablet,
800-160 mg tablet, 800-160/20 oral
susp)
Generic
sulfamide
Generic
Tetracyclines
avidoxy
Generic
demeclocycline hcl (150 mg, 300 mg)
Generic
doxycycline hyclate (20 mg tablet, 50
mg capsule, 100 mg capsule, 100 mg
tablet)
Generic
doxycycline monohydrate (50 mg
capsule, 50 mg tablet, 75 mg tablet,
100 mg capsule, 100 mg tablet, 150 mg
tablet)
Generic
dynacin 100 mg tablet
Generic
minocycline hcl (50 mg capsule, 75 mg
capsule, 100 mg capsule, 100 mg
tablet)
Generic
morgidox 100 mg capsule
Generic
OCUDOX
BRAND
tetracycline hcl (250 mg, 500 mg)
Generic
Anticonvulsants
Anticonvulsants, Other
acetazolamide (125 mg, 250 mg)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
12
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
levetiracetam (100 mg/ml solution, 250
mg tablet, 500 mg tablet, 500 mg/5ml
solution, 750 mg tablet, 1000 mg
tablet)
Generic
primidone (50 mg, 250 mg)
Generic
Requirements/Limits
Calcium Channel Modifying Agents
CELONTIN
BRAND
ethosuximide (250 mg capsule, 250
mg/5ml solution)
Generic
LYRICA (20 MG/ML ORAL SOLUTION, 25
MG CAPSULE, 50 MG CAPSULE, 75 MG
CAPSULE, 100 MG CAPSULE, 150 MG
CAPSULE, 200 MG CAPSULE, 225 MG
CAPSULE, 300 MG CAPSULE)
BRAND
zonisamide
Generic
PA
Gamma-aminobutyric Acid (GABA) Augmenting Agents
clonazepam (0.125 mg tab rapdis, 0.25
mg tab rapdis, 0.5 mg tab rapdis, 0.5
mg tablet, 1 mg tab rapdis, 1 mg tablet,
2 mg tab rapdis, 2 mg tablet)
Generic
clorazepate dipotassium
Generic
DIASTAT
BRAND
diazepam (2 mg tablet, 5 mg tablet, 5
mg/5 ml solution, 5-7.5-10mg kit, 10
mg tablet, 12.5-15-20 kit)
Generic
diazepam 2.5 mg kit
BRAND
divalproex sodium
Generic
gabapentin (100 mg capsule, 250
mg/5ml solution, 300 mg capsule, 400
mg capsule, 600 mg tablet, 800 mg
tablet)
Generic
GABITRIL (12 MG, 16 MG)
BRAND
lorazepam (0.5 mg tablet, 1 mg tablet,
2 mg tablet, 2 mg/ml oral conc)
Generic
lorazepam intensol
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
13
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
ONFI (5 MG, 10 MG, 20 MG)
BRAND
PA, QL (60 PER 30 DAYS)
ONFI 2.5 MG/ML SUSPENSION
BRAND
PA
phenobarbital (15 mg tablet, 16.2 mg
tablet, 20 mg/5 ml elixir, 30 mg tablet,
32.4 mg tablet, 60 mg tablet, 64.8 mg
tablet, 97.2mg tablet, 100 mg tablet)
Generic
SABRIL
BRAND
tiagabine hcl
Generic
valproic acid (as sodium salt) (valproate
sodium) (250 mg/5ml solution, 500
mg/5ml vial, 500mg/10ml solution)
Generic
valproic acid 250 mg capsule
Generic
LA
Glutamate Reducing Agents
felbamate (400 mg tablet, 600 mg
tablet, 600 mg/5ml oral susp)
Generic
lamotrigine (5 mg tb chw dsp, 25 mg
tablet, 25 mg tb chw dsp, 25mg (35) tab
ds pk, 100 mg tablet, 150 mg tablet,
200 mg tablet)
Generic
QUDEXY XR 200 MG CAPSULE
BRAND
topiragen
Generic
topiramate (15 mg cap sprink, 25 mg
cap sprink, 25 mg tablet, 50 mg tablet,
100 mg tablet, 200 mg tablet)
Generic
topiramate (25 mg 24, 50 mg 24, 100
mg 24, 150 mg 24)
Generic
PA
topiramate 200 mg cap spr 24
BRAND
PA
APTIOM
BRAND
PA
BANZEL (40 MG/ML SUSPENSION, 200
MG TABLET, 400 MG TABLET)
BRAND
PA
PA
Sodium Channel Agents
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
14
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
carbamazepine (100 mg cpmp 12hr,
100 mg tab chew, 100 mg/5ml oral
susp, 200 mg cpmp 12hr, 200 mg tab er
12h, 200 mg tablet, 300 mg cpmp 12hr,
400 mg tab er 12h)
Generic
DILANTIN 30 MG CAPSULE
BRAND
epitol
Generic
EQUETRO
BRAND
oxcarbazepine (150 mg tablet, 300 mg
tablet, 300 mg/5ml oral susp, 600 mg
tablet)
Generic
phenytoin (50 mg tab chew, 100
mg/4ml oral susp, 125 mg/5ml oral
susp)
Generic
phenytoin sodium extended (100 mg,
200 mg)
Generic
VIMPAT (10 MG/ML SOLUTION, 50 MG
TABLET, 100 MG TABLET, 150 MG
TABLET, 200 MG TABLET)
BRAND
ziprasidone hcl 20 mg capsule
Generic
Requirements/Limits
PA
PA
Antidementia Agents
Cholinesterase Inhibitors
donepezil hcl (5 mg tab rapdis, 5 mg
tablet, 10 mg tab rapdis, 10 mg tablet)
Generic
EXELON (2 MG/ML ORAL SOLUTION, 4.6
MG/24HR PATCH, 9.5 MG/24HR PATCH,
13.3 MG/24HR PATCH)
BRAND
rivastigmine tartrate
Generic
N-methyl-D-aspartate (NMDA) Receptor Antagonist
NAMENDA (5 MG TABLET, 5-10 MG
TITRATION PK, 10 MG TABLET)
BRAND
PA, QL (60 PER 30 DAYS)
NAMENDA 10 MG/5 ML SOLUTION
BRAND
PA, QL (360 ML PER 30 DAYS)
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
15
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
Antidepressants
Antidepressants, Other
ABILIFY (1 MG/ML SOLUTION, 2 MG
TABLET, 5 MG TABLET, 10 MG TABLET,
15 MG TABLET, 20 MG TABLET, 30 MG
TABLET)
BRAND
ABILIFY DISCMELT
BRAND
budeprion sr
Generic
budeprion xl
Generic
bupropion hcl (75 mg tablet, 100 mg
tablet, 100 mg tablet er, 150 mg tab er
24h, 150 mg tablet er, 200 mg tablet er,
300 mg tab er 24h)
Generic
maprotiline hcl 75 mg tablet
Generic
mirtazapine (7.5 mg tablet, 15 mg tab
rapdis, 15 mg tablet, 30 mg tab rapdis,
30 mg tablet, 45 mg tab rapdis, 45 mg
tablet)
Generic
nefazodone hcl
Generic
trazodone hcl (50 mg, 100 mg, 150 mg,
300 mg)
Generic
Monoamine Oxidase Inhibitors
MARPLAN
BRAND
phenelzine sulfate 15 mg tablet
Generic
tranylcypromine sulfate
Generic
Serotonin/Norepinephrine Reuptake Inhibitors
citalopram hydrobromide (10 mg tablet,
10 mg/5 ml solution, 20 mg tablet, 40
mg tablet)
Generic
duloxetine hcl (20 mg, 30 mg)
Generic
QL (60 PER 30 DAYS)
duloxetine hcl 60 mg capsule dr
Generic
QL (30 PER 30 DAYS)
escitalopram oxalate (5 mg tablet, 5
mg/5 ml solution, 10 mg tablet, 20 mg
tablet)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
16
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
fluoxetine hcl (10 mg capsule, 10 mg
tablet, 20 mg capsule, 20 mg tablet, 20
mg/5 ml solution, 40 mg capsule, 60 mg
tablet, 90 mg capsule dr)
Generic
fluvoxamine maleate (25 mg, 50 mg,
100 mg)
Generic
olanzapine/fluoxetine hcl
Generic
paroxetine hcl (10 mg, 20 mg, 30 mg,
40 mg)
Generic
PAXIL 10 MG/5 ML SUSPENSION
BRAND
sertraline hcl (20 mg/ml oral conc, 25
mg tablet, 50 mg tablet, 100 mg tablet)
Generic
venlafaxine hcl (25 mg tablet, 37.5 mg
cap er 24h, 37.5 mg tab er 24, 37.5 mg
tablet, 50 mg tablet, 75 mg cap er 24h,
75 mg tab er 24, 75 mg tablet, 100 mg
tablet, 150 mg cap er 24h, 150 mg tab
er 24)
Generic
venlafaxine hcl 225 mg tab er 24
BRAND
Requirements/Limits
Tricyclics
amitriptyline hcl (10 mg, 25 mg, 50 mg,
75 mg, 100 mg, 150 mg)
Generic
amoxapine
Generic
clomipramine hcl (25 mg, 50 mg, 75
mg)
Generic
desipramine hcl (10 mg, 25 mg, 50 mg,
75 mg, 100 mg, 150 mg)
Generic
doxepin hcl (10 mg capsule, 10 mg/ml
oral conc, 25 mg capsule, 50 mg
capsule, 75 mg capsule, 100 mg
capsule, 150 mg capsule)
Generic
imipramine hcl (10 mg, 25 mg, 50 mg)
Generic
imipramine pamoate
Generic
nortriptyline hcl (10 mg capsule, 10
mg/5 ml solution, 25 mg capsule, 50 mg
capsule, 75 mg capsule)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
17
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
protriptyline hcl
Generic
trimipramine maleate (25 mg, 50 mg)
Generic
Requirements/Limits
Antiemetics
Antiemetics, Other
chlorpromazine hcl (10 mg, 25 mg, 50
mg, 100 mg, 200 mg)
Generic
compro
Generic
DICLEGIS
BRAND
hydroxyzine hcl (10 mg tablet, 10 mg/5
ml syrup, 25 mg tablet, 50 mg tablet)
Generic
hydroxyzine pamoate (25 mg, 50 mg,
100 mg)
Generic
meclizine hcl 12.5 mg tablet
Generic
metoclopramide hcl (5 mg tablet, 5
mg/5 ml solution, 10 mg tablet, 10
mg/10ml solution)
Generic
motion-time
Generic
perphenazine (2 mg, 4 mg, 8 mg, 16
mg)
Generic
phenadoz
Generic
prochlorperazine maleate (5 mg tablet,
10 mg tablet, 25 mg supp.rect)
Generic
promethazine hcl (6.25mg/5ml syrup,
12.5 mg supp.rect, 12.5 mg tablet, 25
mg supp.rect, 25 mg tablet, 50 mg
supp.rect, 50 mg tablet)
Generic
promethegan
Generic
TRANSDERM-SCOP
BRAND
trimethobenzamide hcl 300 mg capsule
Generic
QL (60 PER 30 DAYS)
Emetogenic Therapy Adjuncts
EMEND (80 MG CAPSULE, TRIFOLD
PACK)
BRAND
QL (4 PER 30 DAYS)
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
18
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
granisetron hcl 1 mg tablet
Generic
PA, QL (8 PER 30 DAYS)
ondansetron
Generic
ondansetron hcl (4 mg tablet, 4 mg/5
ml solution, 8 mg tablet)
Generic
Antifungals
ciclodan 0.77% cream
Generic
ciclodan 8% solution
Generic
ciclopirox (0.77 % gel (gram), 1 %
shampoo)
Generic
ciclopirox 8 % solution
Generic
ciclopirox olamine (0.77 % cream (g),
0.77 % suspension)
Generic
clotrimazole 10 mg troche
Generic
econazole nitrate 1 % cream (g)
Generic
fluconazole (10 mg/ml susp recon, 40
mg/ml susp recon, 50 mg tablet, 100
mg tablet, 150 mg tablet, 200 mg
tablet)
Generic
griseofulvin ultramicrosize 250 mg
tablet
Generic
griseofulvin, microsize (125 mg/5ml oral
susp, 500 mg tablet)
Generic
itraconazole 100 mg capsule
Generic
ketoconazole (2 % cream (g), 2 %
shampoo)
Generic
LAMISIL 187.5 MG GRANULES PACK
BRAND
NATACYN
BRAND
NOXAFIL 40 MG/ML SUSPENSION
BRAND
nyamyc
Generic
PA
PA
PA
PA
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
19
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
nystatin (50mm unit powder(ea), 100k
unit tablet, 150mm unit powder(ea),
500k unit tablet, 500mm unit
powder(ea), 100000/g cream (g),
100000/g oint. (g), 100000/g powder,
100000/ml oral susp)
Generic
nystop
Generic
pedi-dri
Generic
SPORANOX 10 MG/ML SOLUTION
BRAND
terbinafine hcl 250 mg tablet
Generic
terconazole (0.4 % cream/appl, 0.8 %
cream/appl, 80 mg supp.vag)
Generic
voriconazole 200 mg/5ml susp recon
Generic
Requirements/Limits
PA
Antigout Agents
allopurinol (100 mg, 300 mg)
Generic
colchicine/probenecid
Generic
COLCRYS
BRAND
probenecid
Generic
QL (60 PER 30 DAYS)
Antimigraine Agents
Ergot Alkaloids
cafergot
Generic
dihydroergotamine mesylate
0.5mg/spry spray/pump
BRAND
ergotamine tartrate/caffeine
Generic
migergot
Generic
MIGRANAL
BRAND
QL (3.5 ML PER 30 DAYS)
QL (3.5 ML PER 30 DAYS)
Prophylactic
timolol maleate (5 mg, 10 mg, 20 mg)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
20
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
Serotonin (5-HT) 1b/1d Receptor Agonists
rizatriptan benzoate
Generic
QL (24 PER 30 DAYS)
sumatriptan (5 mg, 20 mg)
Generic
QL (6 PER 30 DAYS)
sumatriptan succinate (25 mg, 50 mg,
100 mg)
Generic
QL (18 PER 30 DAYS)
sumatriptan succinate (4 cartridge, 4
pen injctr, 6 cartridge, 6 pen injctr, 6
syringe, 6 vial)
Generic
QL (2 ML PER 30 DAYS)
zolmitriptan (2.5 mg tab rapdis, 2.5 mg
tablet, 5 mg tab rapdis, 5 mg tablet)
Generic
QL (12 PER 30 DAYS)
ZOMIG (2.5 MG, 5 MG)
BRAND
QL (12 PER 30 DAYS)
Antimyasthenic Agents
Parasympathomimetics
guanidine hcl
Generic
MESTINON (60 MG/5 ML SYRUP, 180
MG TIMESPAN)
BRAND
pyridostigmine bromide 60 mg tablet
Generic
Antimycobacterials
Antimycobacterials, Other
dapsone (25 mg, 100 mg)
Generic
rifabutin
Generic
Antituberculars
ethambutol hcl
Generic
isonarif
Generic
isoniazid (50 mg/5 ml solution, 100 mg
tablet, 300 mg tablet)
Generic
PRIFTIN
BRAND
rifampin (150 mg, 300 mg)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
21
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
RIFATER
BRAND
SIRTURO
Specialty
TRECATOR
BRAND
Requirements/Limits
LA
Antineoplastics
Alkylating Agents
ALKERAN 2 MG TABLET
BRAND
CEENU
BRAND
cyclophosphamide capsules
Generic
cyclophosphamide tablets
Generic
LEUKERAN
BRAND
lomustine
BRAND
MATULANE
Specialty
Antiangiogenic Agents
REVLIMID
Specialty
THALOMID
Specialty
PA, LA
Antiestrogens/Modifiers
EMCYT
Specialty
FARESTON
BRAND
SOLTAMOX
BRAND
tamoxifen citrate (10 mg, 20 mg)
Generic
Antimetabolites
capecitabine
Generic
decitabine
Generic
DROXIA
BRAND
hydroxyurea 500 mg capsule
Generic
mercaptopurine 50 mg tablet
Generic
methotrexate sodium (2.5 mg tablet, 25
mg/ml vial)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
22
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
methotrexate sodium/pf (1 g, 25
mg/ml)
Generic
RHEUMATREX
BRAND
Requirements/Limits
Antineoplastics, Other
HEXALEN
Specialty
imiquimod 5 % cream pack
Generic
leucovorin calcium (5 mg, 10 mg, 15
mg, 25 mg)
Generic
MESNEX 400 MG TABLET
BRAND
temozolomide
Specialty
PA
VALCHLOR
Specialty
PA, LA
Aromatase Inhibitors, 3rd Generation
anastrozole 1 mg tablet
Generic
exemestane
Generic
letrozole 2.5 mg tablet
Generic
Enzyme Inhibitors
GILOTRIF
Specialty
PA, LA
HYCAMTIN 0.25 MG CAPSULE
BRAND
PA
HYCAMTIN 1 MG CAPSULE
Specialty
PA
JAKAFI
Specialty
PA, LA
MEKINIST
Specialty
PA
TAFINLAR
Specialty
PA
VOTRIENT
Specialty
PA
ZYTIGA
Specialty
PA
AFINITOR (2.5 MG, 5 MG, 10 MG)
Specialty
PA, QL (30 PER 30 DAYS)
AFINITOR 7.5 MG TABLET
BRAND
PA, QL (30 PER 30 DAYS)
AFINITOR DISPERZ
Specialty
PA, QL (30 PER 30 DAYS)
Molecular Target Inhibitors
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
23
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
BOSULIF
Specialty
PA
CAPRELSA 100 MG TABLET
Specialty
PA
CAPRELSA 300 MG TABLET
BRAND
PA
COMETRIQ
Specialty
PA, LA
ERIVEDGE
Specialty
PA, LA
GLEEVEC
Specialty
PA
ICLUSIG
Specialty
PA, LA
IMBRUVICA
Specialty
PA, LA
INLYTA
Specialty
PA, LA
NEXAVAR
Specialty
PA
SPRYCEL
Specialty
PA
STIVARGA
Specialty
PA
SUTENT
Specialty
PA
TARCEVA
Specialty
PA
TASIGNA
Specialty
PA
TYKERB
Specialty
PA
vandetanib
Specialty
PA
ZELBORAF
Specialty
PA
ZOLINZA
Specialty
PA
ZYKADIA
Specialty
PA
Retinoids
PANRETIN
BRAND
TARGRETIN (75 MG CAPSULE, 75 MG
SOFTGEL)
Specialty
TARGRETIN 1% GEL
Specialty
PA
tretinoin 10 mg capsule
Specialty
PA
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
24
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
Antiparasitics
Anthelmintics
ALBENZA
BRAND
STROMECTOL
BRAND
Antiprotozoals
ALINIA (100 MG/5 ML SUSPENSION,
500 MG TABLET)
BRAND
atovaquone
Generic
PA
chloroquine phosphate (250 mg, 500
mg)
Generic
PA
DARAPRIM
BRAND
PA
hydroxychloroquine sulfate 200 mg
tablet
Generic
mefloquine hcl
Generic
PA
tinidazole (250 mg, 500 mg)
Generic
PA
Pediculicides/Scabicides
elimite
Generic
lindane
Generic
permethrin 5 % cream (g)
Generic
ULESFIA
BRAND
Antiparkinson Agents
Anticholinergics
benztropine mesylate (0.5 mg, 1 mg, 2
mg)
Generic
trihexyphenidyl hcl (2 mg, 5 mg)
Generic
Antiparkinson Agents, Other
amantadine hcl (50 mg/5 ml syrup, 100
mg capsule, 100 mg tablet)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
25
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
carbidopa/levodopa/entacapone
Generic
entacapone
Generic
Requirements/Limits
Dopamine Agonists
bromocriptine mesylate (2.5 mg tablet,
5 mg capsule)
Generic
pramipexole di-hcl
Generic
ropinirole hcl (0.25 mg, 0.5 mg, 1 mg, 2
mg, 3 mg, 4 mg, 5 mg)
Generic
Dopamine Precursors/ L-Amino Acid Decarboxylase Inhibitors
carbidopa 25 mg tablet
Generic
carbidopa/levodopa (10mg-100mg,
25mg-100mg, 25mg-100mg er, 25mg250mg, 50mg-200mg er)
Generic
Monoamine Oxidase B (MAO-B) Inhibitors
AZILECT
BRAND
selegiline hcl (5 mg capsule, 5 mg
tablet)
Generic
Antipsychotics
1st Generation/Typical
fluphenazine hcl (1 mg, 2.5 mg, 5 mg,
10 mg)
Generic
haloperidol (0.5 mg, 1 mg, 2 mg, 5 mg,
10 mg, 20 mg)
Generic
haloperidol lactate 2 mg/ml oral conc
Generic
loxapine succinate (5 mg, 10 mg, 25
mg, 50 mg)
Generic
ORAP
BRAND
perphenazine/amitriptyline hcl
Generic
thioridazine hcl (10 mg, 25 mg, 50 mg,
100 mg)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
26
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
thiothixene
Generic
trifluoperazine hcl
Generic
Requirements/Limits
2nd Generation/Atypical
INVEGA
BRAND
LATUDA
BRAND
olanzapine (2.5 mg tablet, 5 mg tab
rapdis, 5 mg tablet, 7.5 mg tablet, 10
mg tab rapdis, 10 mg tablet, 15 mg tab
rapdis, 15 mg tablet, 20 mg tab rapdis,
20 mg tablet)
Generic
quetiapine fumarate
Generic
RISPERDAL CONSTA 12.5 MG SYR
BRAND
risperidone (0.25 mg tablet, 0.5 mg
tablet, 1 mg tablet, 1 mg/ml solution, 2
mg tablet, 3 mg tab rapdis, 3 mg tablet,
4 mg tablet)
Generic
SAPHRIS
BRAND
ziprasidone hcl (40 mg, 60 mg, 80 mg)
Generic
PA, QL (30 PER 30 DAYS)
PA
Treatment-Resistant
clozapine (12.5 mg tab rapdis, 25 mg
tab rapdis, 25 mg tablet, 100 mg tab
rapdis, 100 mg tablet, 200 mg tablet)
Generic
FAZACLO (150 MG, 200 MG)
BRAND
VERSACLOZ
BRAND
Antispasticity Agents
baclofen (10 mg, 20 mg)
Generic
dantrolene sodium (25 mg, 50 mg)
Generic
MYRBETRIQ
BRAND
tizanidine hcl (2 mg, 4 mg)
Generic
PA
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
27
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
Antivirals
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors
EDURANT
BRAND
INTELENCE
BRAND
nevirapine (200 mg tablet, 400 mg tab
er 24h)
Generic
SUSTIVA
BRAND
VIRAMUNE XR 100 MG TABLET
BRAND
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors
abacavir sulfate
Generic
abacavir sulfate/lamivudine/zidovudine
Generic
didanosine
Generic
EMTRIVA (10 MG/ML SOLUTION, 200
MG CAPSULE)
BRAND
EPZICOM
BRAND
lamivudine (150 mg, 300 mg)
Generic
lamivudine/zidovudine
Generic
stavudine (20 mg, 30 mg, 40 mg)
Generic
TRUVADA
BRAND
VIREAD (150 MG TABLET, 200 MG
TABLET, 250 MG TABLET, 300 MG
TABLET, POWDER)
BRAND
zidovudine (100 mg capsule, 300 mg
tablet)
Generic
Anti-HIV Agents, Other
ATRIPLA
BRAND
COMPLERA
BRAND
FUZEON
BRAND
ISENTRESS (100 MG POWDER PACKET,
400 MG TABLET)
BRAND
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
28
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
SELZENTRY
BRAND
STRIBILD
BRAND
TIVICAY
BRAND
Requirements/Limits
Anti-HIV Agents, Protease Inhibitors
APTIVUS (100 MG/ML SOLUTION, 250
MG CAPSULE)
BRAND
CRIXIVAN 400 MG CAPSULE
BRAND
INVIRASE
BRAND
KALETRA (100-25 MG, 200-50 MG)
BRAND
LEXIVA (50 MG/ML SUSPENSION, 700
MG TABLET)
BRAND
NORVIR (100 MG SOFTGEL CAP, 100
MG TABLET)
BRAND
PREZISTA (75 MG TABLET, 100 MG/ML
SUSPENSION, 150 MG TABLET, 400 MG
TABLET, 600 MG TABLET, 800 MG
TABLET)
BRAND
REYATAZ
BRAND
VIRACEPT
BRAND
Anti-cytomegalovirus (CMV) Agents
VALCYTE 450 MG TABLET
BRAND
VALCYTE 50 MG/ML SOLUTION
BRAND
ZIRGAN
BRAND
QL (60 PER 30 DAYS)
Anti-influenza Agents
rimantadine hcl
Generic
TAMIFLU (6 MG/ML SUSPENSION, 30
MG CAPSULE, 45 MG CAPSULE, 75 MG
CAPSULE)
BRAND
Antihepatitis Agents
adefovir dipivoxil
Specialty
BARACLUDE 0.05 MG/ML SOLUTION
Specialty
PA
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
29
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
entecavir
Specialty
PA
EPIVIR HBV 25 MG/5 ML SOLN
BRAND
INCIVEK
Specialty
INFERGEN
Specialty
INTRON A (6 UNIT/ML VL, 10 UNIT/ML,
10 UNITS VIL, 18 UNITS VIL, 50 UNITS
VIL)
Specialty
lamivudine 100 mg tablet
Generic
MODERIBA
Specialty
PA
OLYSIO
Specialty
PA
PEGASYS (180 MCG/0.5 ML SYRINGE,
180 MCG/ML VIAL)
Specialty
PA
PEGASYS PROCLICK
Specialty
PA
PEGINTRON
Specialty
PA
PEGINTRON REDIPEN
Specialty
PA
REBETOL 40 MG/ML SOLUTION
Specialty
PA
RIBAPAK
Specialty
PA
RIBASPHERE
Specialty
PA
RIBATAB
Specialty
PA
ribavirin (200 mg capsule, 200 mg
tablet, 400 mg tablet, 600 mg tablet)
Specialty
PA
SOVALDI
Specialty
PA
SYLATRON
Specialty
PA, QL (1 PER 28 DAYS)
SYLATRON 4-PACK
Specialty
PA, QL (1 PER 28 DAYS)
TYZEKA
BRAND
PA
VICTRELIS
Specialty
PA
PA
PA
Antiherpetic Agents
acyclovir (200 mg capsule, 200 mg/5ml
oral susp, 400 mg tablet, 800 mg tablet)
Generic
DENAVIR
BRAND
PA
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
30
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
famciclovir
Generic
trifluridine 1 % drops
Generic
valacyclovir hcl (500 mg, 1000 mg)
Generic
Requirements/Limits
Anxiolytics
Anxiolytics, Other
alprazolam (0.25 mg tablet, 0.5 mg tab
er 24h, 0.5 mg tablet, 1 mg tab er 24h,
1 mg tablet, 2 mg tab er 24h, 2 mg
tablet, 3 mg tab er 24h)
Generic
buspirone hcl (5 mg, 7.5 mg, 10 mg, 15
mg, 30 mg)
Generic
chlordiazepoxide hcl
Generic
meprobamate 400 mg tablet
Generic
oxazepam
Generic
Bipolar Agents
Mood Stabilizers
lithium carbonate (150 mg capsule, 300
mg capsule, 300 mg tablet, 300 mg
tablet er, 450 mg tablet er, 600 mg
capsule)
Generic
lithium citrate
Generic
Blood Glucose Regulators
Antidiabetic Agents
acarbose
Generic
ACTOPLUS MET XR
BRAND
BYDUREON
BRAND
PA
BYDUREON PEN
BRAND
PA
BYETTA
BRAND
PA
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
31
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
chlorpropamide
Generic
FARXIGA
BRAND
glimepiride
Generic
glipizide (2.5 mg tab er 24, 5 mg tab er
24, 5 mg tablet, 10 mg tab er 24, 10 mg
tablet)
Generic
glipizide/metformin hcl
Generic
glyburide
Generic
glyburide,micronized
Generic
glyburide/metformin hcl
Generic
INVOKANA
BRAND
PA
JANUMET
BRAND
PA
JANUMET XR
BRAND
PA
JANUVIA
BRAND
PA
JENTADUETO
BRAND
PA
JUVISYNC (50-10 MG, 50-20 MG, 50-40
MG)
BRAND
KAZANO
BRAND
PA
KOMBIGLYZE XR
BRAND
PA
metformin hcl (500 mg tab er 24h, 500
mg tablet, 750 mg tab er 24h, 850 mg
tablet, 1000 mg tablet)
Generic
nateglinide
Generic
NESINA
BRAND
PA
ONGLYZA
BRAND
PA
OSENI
BRAND
PA
pioglitazone hcl
Generic
pioglitazone hcl/glimepiride
Generic
pioglitazone hcl/metformin hcl
Generic
RIOMET
BRAND
PA
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
32
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
SYMLINPEN 120
BRAND
PA
SYMLINPEN 60
BRAND
PA
TRADJENTA
BRAND
PA
VICTOZA 2-PAK
BRAND
PA
VICTOZA 3-PAK
BRAND
PA
Glycemic Agents
GLUCAGEN
BRAND
GLUCAGON EMERGENCY KIT
BRAND
PROGLYCEM
BRAND
Insulins
APIDRA
BRAND
APIDRA SOLOSTAR
BRAND
HUMALOG
BRAND
HUMALOG MIX 50-50
BRAND
HUMALOG MIX 75-25
BRAND
HUMULIN 70-30
BRAND
HUMULIN N
BRAND
HUMULIN R
BRAND
LANTUS
BRAND
LANTUS SOLOSTAR
BRAND
LEVEMIR
BRAND
LEVEMIR FLEXPEN
BRAND
LEVEMIR FLEXTOUCH
BRAND
NOVOLIN 70-30
BRAND
NOVOLIN N
BRAND
NOVOLIN R
BRAND
NOVOLOG
BRAND
NOVOLOG FLEXPEN
BRAND
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
33
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
NOVOLOG MIX 70-30
BRAND
NOVOLOG MIX 70-30 FLEXPEN
BRAND
Requirements/Limits
Blood Products/Modifiers/ Volume Expanders
Anticoagulants
ELIQUIS
BRAND
enoxaparin sodium (30mg/0.3ml,
40mg/0.4ml, 60mg/0.6ml, 80mg/0.8ml,
100 mg/ml, 120mg/.8ml, 150 mg/ml)
Generic
fondaparinux sodium
Generic
FRAGMIN
Specialty
jantoven
Generic
PRADAXA
BRAND
warfarin sodium (1 mg, 2 mg, 2.5 mg, 3
mg, 4 mg, 5 mg, 6 mg, 7.5 mg, 10 mg)
Generic
XARELTO (10 MG, 15 MG, 20 MG)
BRAND
Blood Formation Modifiers
anagrelide hcl
Generic
ARANESP
Specialty
EPOGEN
Specialty
GRANIX
BRAND
LEUKINE (250 MCG, 500 MCG/ML)
Specialty
NEULASTA
Specialty
NEUMEGA
Specialty
NEUPOGEN
Specialty
PROCRIT
Specialty
PA
PROMACTA (12.5 MG, 25 MG, 50 MG)
Specialty
PA
PA
PA
PA
Coagulants
tranexamic acid 650 mg tablet
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
34
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
Platelet Modifying Agents
AGGRENOX
BRAND
BRILINTA
BRAND
cilostazol
Generic
clopidogrel bisulfate 75 mg tablet
Generic
dipyridamole (25 mg, 50 mg, 75 mg)
Generic
EFFIENT
BRAND
ticlopidine hcl
Generic
Cardiovascular Agents
Alpha-adrenergic Agonists
clonidine
Generic
clonidine hcl (0.1 mg, 0.2 mg, 0.3 mg)
Generic
guanfacine hcl
Generic
methyldopa
Generic
methyldopa/hydrochlorothiazide
Generic
midodrine hcl
Generic
Alpha-adrenergic Blocking Agents
doxazosin mesylate
Generic
prazosin hcl (1 mg, 2 mg, 5 mg)
Generic
terazosin hcl
Generic
Angiotensin II Receptor Antagonists
candesartan cilexetil
Generic
eprosartan mesylate
Generic
irbesartan
Generic
irbesartan/hydrochlorothiazide
Generic
losartan potassium
Generic
losartan potassium/hydrochlorothiazide
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
35
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
valsartan
Generic
valsartan/hydrochlorothiazide
Generic
Requirements/Limits
Angiotensin-converting Enzyme (ACE) Inhibitors
benazepril hcl (5 mg, 10 mg, 20 mg, 40
mg)
Generic
benazepril hcl/hydrochlorothiazide
Generic
captopril (12.5 mg, 25 mg, 50 mg, 100
mg)
Generic
captopril/hydrochlorothiazide
Generic
enalapril maleate (2.5 mg, 5 mg, 10 mg,
20 mg)
Generic
enalapril maleate/hydrochlorothiazide
Generic
EPANED
BRAND
fosinopril sodium
Generic
fosinopril sodium/hydrochlorothiazide
Generic
lisinopril (2.5 mg, 5 mg, 10 mg, 20 mg,
30 mg, 40 mg)
Generic
lisinopril/hydrochlorothiazide
Generic
moexipril hcl
Generic
moexipril hcl/hydrochlorothiazide
Generic
perindopril erbumine
Generic
quinapril hcl
Generic
quinapril hcl/hydrochlorothiazide
Generic
ramipril
Generic
trandolapril
Generic
Antiarrhythmics
amiodarone hcl (100 mg, 200 mg, 400
mg)
Generic
disopyramide phosphate
Generic
flecainide acetate
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
36
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
mexiletine hcl (150 mg, 200 mg, 250
mg)
Generic
MULTAQ
BRAND
NORPACE CR
BRAND
pacerone 200 mg tablet
Generic
propafenone hcl
Generic
quinidine gluconate 324 mg tablet er
Generic
quinidine sulfate (200 mg, 300 mg, 300
mg er)
Generic
sorine
Generic
sotalol hcl (80 mg, 120 mg, 160 mg, 240
mg)
Generic
TIKOSYN
BRAND
verapamil hcl (40 mg, 80 mg, 120 mg)
Generic
Requirements/Limits
Beta-adrenergic Blocking Agents
acebutolol hcl (200 mg, 400 mg)
Generic
atenolol (25 mg, 50 mg, 100 mg)
Generic
atenolol/chlorthalidone
Generic
betaxolol hcl (10 mg, 20 mg)
Generic
bisoprolol fumarate
Generic
bisoprolol
fumarate/hydrochlorothiazide
Generic
carvedilol
Generic
COREG CR
BRAND
labetalol hcl (100 mg, 200 mg, 300 mg)
Generic
LEVATOL
BRAND
metoprolol succinate
Generic
metoprolol tartrate (25 mg, 50 mg, 100
mg)
Generic
metoprolol
tartrate/hydrochlorothiazide
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
37
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
nadolol (20 mg, 40 mg, 80 mg)
Generic
nadolol/bendroflumethiazide
Generic
pindolol
Generic
propranolol hcl (10 mg tablet, 20 mg
tablet, 40 mg tablet, 40mg/5ml
solution, 60 mg cap sa 24h, 60 mg
tablet, 80 mg cap sa 24h, 80 mg tablet,
120 mg cap sa 24h, 160 mg cap sa 24h)
Generic
propranolol hcl/hydrochlorothiazide
Generic
Requirements/Limits
Calcium Channel Blocking Agents
afeditab cr
Generic
amlodipine besylate (2.5 mg, 5 mg, 10
mg)
Generic
amlodipine besylate/benazepril hcl
Generic
cartia xt
Generic
dilt-cd
Generic
dilt-xr
Generic
diltia xt
Generic
diltiazem hcl (30 mg tablet, 60 mg cap
er 12h, 60 mg tablet, 90 mg cap er 12h,
90 mg tablet, 120 mg cap er 12h, 120
mg cap er 24h, 120 mg cap er deg, 120
mg capsule er, 120 mg tablet, 180 mg
cap er 24h, 180 mg cap er deg, 180 mg
capsule er, 180 mg tab er 24h, 240 mg
cap er 24h, 240 mg cap er deg, 240 mg
capsule er, 240 mg tab er 24h, 300 mg
cap er 24h, 300 mg capsule er, 300 mg
tab er 24h, 360 mg cap er 24h, 360 mg
capsule er, 360 mg tab er 24h, 420mg
capsule er, 420mg tab er 24h)
Generic
diltzac er
Generic
felodipine
Generic
isradipine
Generic
matzim la
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
38
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
nicardipine hcl (20 mg, 30 mg)
Generic
nifediac cc
Generic
nifedical xl
Generic
nifedipine (30 mg tab er 24, 30 mg
tablet er, 60 mg tab er 24, 60 mg tablet
er, 90 mg tab er 24, 90 mg tablet er)
Generic
nimodipine 30 mg capsule
Generic
nisoldipine
Generic
taztia xt
Generic
verapamil hcl (100 mg cap24h pct, 120
mg cap24h pel, 120 mg tablet er, 180
mg cap24h pel, 180 mg tablet er, 200
mg cap24h pct, 240 mg cap24h pel, 240
mg tablet er, 300 mg cap24h pct, 360
mg cap24h pel)
Generic
Requirements/Limits
Cardiovascular Agents, Other
amlodipine besylate/atorvastatin
calcium
Generic
digox
Generic
digoxin (50 mcg/ml solution, 125 mcg
tablet, 250 mcg tablet)
Generic
LANOXIN (62.5 MCG, 187.5 MCG)
BRAND
pentoxifylline 400 mg tablet er
Generic
RANEXA
BRAND
Diuretics, Carbonic Anhydrase Inhibitors
acetazolamide 500 mg capsule er
Generic
methazolamide (25 mg, 50 mg)
Generic
Diuretics, Loop
bumetanide (0.5 mg, 1 mg, 2 mg)
Generic
EDECRIN
BRAND
furosemide (10 mg/ml solution, 20 mg
tablet, 40 mg tablet, 80 mg tablet)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
39
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
torsemide (5 mg, 10 mg, 20 mg, 100
mg)
Generic
Requirements/Limits
Diuretics, Potassium-sparing
amiloride hcl 5 mg tablet
Generic
amiloride hcl/hydrochlorothiazide
Generic
DYRENIUM
BRAND
eplerenone
Generic
spironolactone (25 mg, 50 mg, 100 mg)
Generic
spironolactone/hydrochlorothiazide
Generic
triamterene/hydrochlorothiazide
Generic
Diuretics, Thiazide
chlorothiazide
Generic
chlorthalidone
Generic
hydrochlorothiazide (12.5 mg capsule,
12.5 mg tablet, 25 mg tablet, 50 mg
tablet)
Generic
indapamide
Generic
methyclothiazide
Generic
metolazone
Generic
Dyslipidemics, Fibric Acid Derivatives
fenofibrate (54 mg, 160 mg)
Generic
fenofibrate nanocrystallized
Generic
fenofibrate,micronized (67 mg, 134mg,
200 mg)
Generic
fenofibric acid
Generic
fenofibric acid (choline)
Generic
gemfibrozil 600 mg tablet
Generic
lofibra
Generic
TRIGLIDE 160 MG TABLET
BRAND
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
40
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
Dyslipidemics, HMG CoA Reductase Inhibitors
atorvastatin calcium
Generic
fluvastatin sodium
Generic
lovastatin
Generic
pravastatin sodium
Generic
simvastatin (5 mg, 10 mg, 20 mg, 40
mg)
Generic
Dyslipidemics, Other
cholestyramine (with sugar) (suar) 4
powd pack, suar) 4 powder)
Generic
cholestyramine/aspartame (4 powd
pack, 4 powder)
Generic
COLESTID FLAVORED GRANULES
BRAND
colestid granules
Generic
colestipol hcl (1 tablet, 5 packet, 5
ranules)
Generic
JUXTAPID
Specialty
PA, LA
KYNAMRO
Specialty
PA, LA
niacin (500 mg er, 750 mg er, 1000 mg
er)
Generic
PA
omega-3 acid ethyl esters
Generic
PA
prevalite (packet, powder)
Generic
ZETIA
BRAND
PA
Vasodilators, Direct-acting Arterial
hydralazine hcl (10 mg, 25 mg, 50 mg,
100 mg)
Generic
minoxidil (2.5 mg, 10 mg)
Generic
RECTIV
BRAND
Vasodilators, Direct-acting Arterial/Venous
DILATRATE-SR
BRAND
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
41
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
isochron
Generic
isosorbide dinitrate
Generic
isosorbide mononitrate
Generic
minitran
Generic
NITRO-BID
BRAND
NITRO-DUR (0.3, 0.8)
BRAND
nitro-time
Generic
nitroglycerin (0.1mg/hr patch td24,
0.2mg/hr patch td24, 0.4mg/hr patch
td24, 0.6mg/hr patch td24, 2.5 mg
capsule er, 6.5 mg capsule er, 9 mg
capsule er, 400mcg/spr spray)
Generic
NITROSTAT
BRAND
Requirements/Limits
Central Nervous System Agents
Attention Deficit Hyperactivity Disorder Agents, Amphetamines
dextroamphetamine sulfsaccharate/amphetamine sulfaspartate
Generic
dextroamphetamine sulfate (5 mg er,
10 mg er, 15 mg er)
Generic
dextroamphetamine sulfate (5 mg, 10
mg)
Generic
VYVANSE
BRAND
zenzedi (5 mg, 10 mg)
Generic
PA
PA
Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines
DAYTRANA
BRAND
PA, QL (30 PER 30 DAYS)
dexmethylphenidate hcl (15 mg, 30 mg,
40 mg)
Generic
PA
dexmethylphenidate hcl (2.5 mg, 5 mg,
10 mg)
Generic
FOCALIN XR (5 MG, 10 MG, 20 MG, 25
MG, 35 MG)
BRAND
PA
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
42
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
metadate er
Generic
methylphenidate hcl (5 mg tablet, 5
mg/5 ml solution, 10 mg cpbp 30-70, 10
mg tablet, 10 mg tablet er, 10 mg/5 ml
solution, 18 mg tab er 24, 20 mg cpbp
30-70, 20 mg cpbp 50-50, 20 mg tablet,
20 mg tablet er, 27 mg tab er 24, 30 mg
cpbp 30-70, 30 mg cpbp 50-50, 36 mg
tab er 24, 40 mg cpbp 30-70, 40 mg
cpbp 50-50, 50 mg cpbp 30-70, 54 mg
tab er 24, 60 mg cpbp 30-70)
Generic
RITALIN LA 10 MG CAPSULE
BRAND
STRATTERA
BRAND
PA, QL (30 PER 30 DAYS)
NUEDEXTA
BRAND
PA
riluzole
Generic
XENAZINE
Specialty
PA
SAVELLA (12.5 MG, 25 MG, 50 MG, 100
MG)
BRAND
PA, QL (60 PER 30 DAYS)
SAVELLA TITRATION PACK
BRAND
PA, QL (55 PER 30 DAYS)
AMPYRA
Specialty
PA, LA, QL (60 PER 30 DAYS)
AUBAGIO
Specialty
PA, LA, QL (30 PER 30 DAYS)
AVONEX (30 MCG, 30 MCG KT)
Specialty
AVONEX ADMINISTRATION PACK
Specialty
AVONEX PEN
Specialty
BETASERON 0.3 MG KIT
Specialty
PA, QL (14 PER 30 DAYS)
BETASERON 0.3 MG VIAL
Specialty
PA, QL (15 PER 30 DAYS)
COPAXONE 20 MG/ML SYRINGE
Specialty
QL (30 ML PER 30 DAYS)
COPAXONE 40 MG/ML SYRINGE
Specialty
QL (12 ML PER 28 DAYS)
EXTAVIA 0.3 MG KIT
Specialty
PA, QL (14 PER 30 DAYS)
Central Nervous System Agents, Other
Fibromyalgia Agents
Multiple Sclerosis Agents
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
43
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
EXTAVIA 0.3 MG VIAL
Specialty
PA, QL (15 PER 30 DAYS)
FIRAZYR
Specialty
PA, QL (9 ML PER 30 DAYS)
GILENYA
Specialty
PA, QL (30 PER 30 DAYS)
REBIF (22 ML, 44 ML)
Specialty
QL (6 ML PER 30 DAYS)
REBIF REBIDOSE (22 ML, 44 ML)
Specialty
QL (6 ML PER 30 DAYS)
REBIF REBIDOSE TITRATION PACK
Specialty
QL (4.2 ML PER 30 DAYS)
REBIF TITRATION PACK
Specialty
QL (4.2 ML PER 30 DAYS)
TECFIDERA
Specialty
QL (60 PER 30 DAYS)
Dental and Oral Agents
pilocarpine hcl (5 mg, 7.5 mg)
Generic
Dermatological Agents
acitretin
Generic
adapalene (0.1 % cream (g), 0.1 % gel
(gram))
Generic
adapalene (0.3 % gel (gram), 0.3 % gel
w/pump)
BRAND
ammonium lactate (12 % cream (g), 12
% lotion)
Generic
amnesteem
Generic
avita 0.025% cream
Generic
calcipotriene (0.005 % cream (g), 0.005
% solution)
Generic
CARAC
BRAND
claravis
Generic
clindamycin phos/benzoyl perox 1 %-5
% gel (gram)
Generic
clotrimazole/betamethasone
dipropionate (1 %-0.05 % cream (g), 1
%-0.05 % lotion)
Generic
DIFFERIN (0.3% GEL, 0.3% GEL PUMP)
BRAND
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
44
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
ELIDEL
BRAND
PA
EPIFOAM
BRAND
erythromycin base/benzoyl peroxide
Generic
FINACEA
BRAND
FLUOROPLEX
BRAND
fluorouracil (2 % solution, 5 % cream
(g), 5 % solution)
Generic
gengraf 100 mg capsule
Generic
hypercare
Generic
laclotion
Generic
methoxsalen, rapid
Specialty
mometasone furoate (0.1 % cream (g),
0.1 % oint. (g), 0.1 % solution)
Generic
myorisan
Generic
OXSORALEN
BRAND
PICATO
BRAND
podofilox 0.5 % solution
Generic
PROTOPIC
BRAND
refissa
Generic
REGRANEX
BRAND
PA
SANTYL
BRAND
QL (30 GM PER 30 DAYS)
TAZORAC
BRAND
tretinoin (0.01 % gel (gram), 0.025 %
cream (g), 0.025 % gel (gram), 0.05 %
cream (g), 0.1 % cream (g))
Generic
tretinoin/emollient base
Generic
trianex
Generic
VOLTAREN
BRAND
zenatane
Generic
PA
PA
PA
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
45
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
Enzyme Replacement/ Modifiers
ADAGEN
Specialty
BUPHENYL 500 MG TABLET
Specialty
CARBAGLU
BRAND
CEREZYME 400 UNITS VIAL
BRAND
CREON
BRAND
ELELYSO
Specialty
KUVAN
Specialty
ORFADIN
Specialty
pancrelipase 5,000
Generic
RAVICTI
Specialty
sodium phenylbutyrate 0.94 g/g powder
Specialty
SUCRAID
Specialty
ZAVESCA
Specialty
ZENPEP (3,000, 10,000, 15,000, 20,000,
25,000)
BRAND
PA, LA
LA
Gastrointestinal Agents
Antispasmodics, Gastrointestinal
CUVPOSA
BRAND
dicyclomine hcl (10 mg capsule, 10
mg/5 ml solution, 20 mg tablet)
Generic
glycopyrrolate (1 mg, 2 mg)
Generic
PA
Gastrointestinal Agents, Other
anti-diarrheal 1 mg/5 ml soln
Generic
APRISO
BRAND
ASACOL
BRAND
ASACOL HD
BRAND
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
46
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
CANASA
BRAND
DELZICOL
BRAND
diphenoxylate hcl/atropine sulfate (2.5.025/5 liquid, 2.5-.025mg tablet)
Generic
FULYZAQ
BRAND
PA
GATTEX
Specialty
PA, LA
gavilyte-c
Generic
gavilyte-g
Generic
gavilyte-n
Generic
GOLYTELY PACKET
BRAND
LIALDA
BRAND
mesalamine 4 g/60 ml enema
Generic
mesalamine with cleansing wipes
Generic
nulytely with flavor packs
Generic
peg 3350/sod sulf/sod bicarbonate/sod
chloride/potassium chl
Generic
PENTASA
BRAND
polyethylene glycol 3350 17g powd
pack
Generic
propantheline bromide 15 mg tablet
Generic
PYLERA
BRAND
sodium chloride/sodium
bicarbonate/potassium chloride/peg
Generic
sulfasalazine (500 mg, 500 mg dr)
Generic
sulfazine
Generic
sulfazine ec
Generic
trilyte with flavor packets
Generic
ursodiol (250 mg tablet, 300 mg
capsule, 500 mg tablet)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
47
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
Histamine2 (H2) Receptor Antagonists
cimetidine (300 mg, 400 mg, 800 mg)
Generic
cimetidine hcl
Generic
famotidine 40 mg tablet
Generic
nizatidine (150 mg, 300 mg)
Generic
PEPCID 20 MG TABLET
BRAND
ranitidine hcl (15 mg/ml syrup, 300 mg
tablet)
Generic
Irritable Bowel Syndrome Agents
LOTRONEX
BRAND
PA
Laxatives
constulose
Generic
enulose
Generic
generlac
Generic
lactulose
Generic
MOVIPREP
BRAND
SUPREP
BRAND
Protectants
misoprostol (100 mcg, 200 mcg)
Generic
sucralfate (1 g tablet, 1 g/10 ml oral
susp)
Generic
Proton Pump Inhibitors
FIRST-LANSOPRAZOLE
BRAND
FIRST-OMEPRAZOLE
BRAND
lansoprazole 30 mg capsule dr
Generic
lansoprazole/amoxicillin
trihydrate/clarithromycin
Generic
omeprazole (10 mg, 20 mg, 40 mg)
Generic
OMEPRAZOLE+SYRSPEND SF ALKA
BRAND
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
48
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
pantoprazole sodium (20 mg, 40 mg)
Generic
PROTONIX 40 MG SUSPENSION
BRAND
rabeprazole sodium
Generic
Requirements/Limits
Genitourinary Agents
Antispasmodics, Urinary
flavoxate hcl
Generic
oxybutynin chloride (5 mg tab er 24, 5
mg tablet, 5 mg/5 ml syrup, 10 mg tab
er 24, 15 mg tab er 24)
Generic
OXYTROL
BRAND
tolterodine tartrate
Generic
trospium chloride 20 mg tablet
Generic
Benign Prostatic Hypertrophy Agents
alfuzosin hcl
Generic
finasteride 5 mg tablet
Generic
tamsulosin hcl
Generic
Genitourinary Agents, Other
bethanechol chloride (5 mg, 10 mg, 25
mg, 50 mg)
Generic
CUPRIMINE
BRAND
CYSTAGON
Specialty
DEPEN
BRAND
ELMIRON
BRAND
phenazopyridine hcl (100 mg, 200 mg)
Generic
PROCYSBI
BRAND
THIOLA
BRAND
PA
PA, LA
Phosphate Binders
calcium acetate 667 mg capsule
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
49
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
RENAGEL
BRAND
PA
RENVELA
BRAND
PA
sevelamer carbonate
BRAND
PA
Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal)
Glucocorticoids/Mineralocorticoids
betamethasone
acetate/betamethasone sodium
phosphate
Generic
budesonide (3 mg & er, 3 mg - er)
Generic
CELESTONE 0.6 MG/5 ML SOLUTION
BRAND
dexamethasone (0.5 mg tablet, 0.5
mg/5ml elixir, 0.5 mg/5ml solution, 0.75
mg tablet, 1 mg tablet, 1.5 mg tablet, 2
mg tablet, 4 mg tablet, 6 mg tablet)
Generic
FLAREX
BRAND
FLOVENT DISKUS
BRAND
FLOVENT HFA
BRAND
fluocinolone acetonide oil
Generic
fluorometholone 0.1 % drops susp
Generic
fluticasone propionate 50 mcg spray
susp
Generic
FML FORTE
BRAND
FML S.O.P.
BRAND
hydrocortisone (5 mg, 10 mg, 20 mg)
Generic
hydrocortisone butyrate (0.1 % oint. (g),
0.1 % solution)
Generic
hydrocortisone valerate
Generic
methylprednisolone
Generic
triamcinolone acetonide 55 mcg spray
Generic
UCERIS
BRAND
PA
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
50
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
Hormonal Agents, Stimulant/Replacement/Modifying (Other)
MYALEPT
BRAND
PA, LA
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)
desmopressin (non-refrigerated)
Generic
desmopressin acetate (0.1 mg, 0.2 mg)
Generic
desmopressin acetate (0.1 mg/ml
solution, 4mcg/ml ampul, 4mcg/ml vial,
10/spray spray/pump)
Generic
EGRIFTA
Specialty
PA
GENOTROPIN
Specialty
PA
HUMATROPE
Specialty
PA
INCRELEX
Specialty
PA, LA
NORDITROPIN
Specialty
PA
NORDITROPIN FLEXPRO
Specialty
PA
NORDITROPIN NORDIFLEX (NORDIFLEX
5, NORDIFLX 10, NORDIFLX 15)
Specialty
PA
NUTROPIN
Specialty
PA
NUTROPIN AQ
Specialty
PA
NUTROPIN AQ NUSPIN
Specialty
PA
OMNITROPE 5 MG/1.5 ML CRTG
Specialty
PA
SAIZEN
Specialty
PA
SEROSTIM
Specialty
PA
STIMATE
BRAND
TEV-TROPIN
Specialty
PA
ZORBTIVE
Specialty
PA
PA
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
51
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)
Anabolic Steroids
ANADROL-50
Specialty
oxandrolone 10 mg tablet
Generic
Androgens
ANDROGEL
BRAND
danazol (50 mg, 100 mg, 200 mg)
Generic
testosterone (1.25g gel md pmp, 50 mg
gel packet)
BRAND
testosterone 50 mg (1%) gel (gram)
Generic
testosterone cypionate (100 mg/ml, 200
mg/ml)
Generic
testosterone enanthate 200 mg/ml vial
Generic
VOGELXO (12.5 MG/1.25 PUMP, 50
MG/5 GEL PACKT)
BRAND
Estrogens
ALORA
BRAND
altavera
Generic
alyacen
Generic
amethia
Generic
amethia lo
Generic
amethyst
Generic
apri
Generic
aranelle
Generic
aubra
Generic
aviane
Generic
azurette
Generic
balziva
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
52
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
briellyn
Generic
camrese
Generic
camrese lo
Generic
caziant
Generic
chateal
Generic
COMBIPATCH
BRAND
cryselle
Generic
cyclafem
Generic
dasetta
Generic
daysee
Generic
delyla
Generic
desogestrel-ethinyl estradiol
Generic
desogestrel-ethinyl estradiol/ethinyl
estradiol
Generic
DUAVEE
BRAND
elinest
Generic
emoquette
Generic
enpresse
Generic
enskyce
Generic
estarylla
Generic
ESTRACE 0.01% CREAM
BRAND
estradiol (.025mg/24h patch tdwk,
.0375mg/24 patch tdwk, 0.05mg/24h
patch tdwk, 0.06mg/24h patch tdwk,
.075mg/24h patch tdwk, 0.1mg/24hr
patch tdwk, 0.5 mg tablet, 1 mg tablet,
2 mg tablet)
Generic
estradiol/norethindrone acet 1 mg0.5mg tablet
Generic
ESTRING
BRAND
estropipate (0.75 mg, 1.5 mg, 3 mg)
Generic
Requirements/Limits
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
53
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
ethinyl estradiol/drospirenone
Generic
falmina
Generic
gianvi
Generic
gildagia
Generic
gildess
Generic
gildess fe
Generic
introvale
Generic
jolessa
Generic
junel
Generic
junel fe
Generic
kariva
Generic
kelnor 1-35
Generic
kurvelo
Generic
larin
Generic
larin fe
Generic
leena
Generic
lessina
Generic
levonest
Generic
levonorgestrel-eth estra/ethinyl
estradiol
Generic
levonorgestrel-ethinyl estradiol
Generic
levora-28
Generic
lomedia 24 fe
Generic
loryna
Generic
low-ogestrel
Generic
lutera
Generic
marlissa
Generic
microgestin
Generic
microgestin fe
Generic
Requirements/Limits
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
54
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
mimvey
Generic
MINIVELLE
BRAND
mono-linyah
Generic
mononessa
Generic
myzilra
Generic
necon
Generic
nikki
Generic
norethindrone acetate-ethinyl estradiol
Generic
norethindrone acetate-ethinyl
estradiol/ferrous fumarate
Generic
norgestimate-ethinyl estradiol
Generic
nortrel
Generic
NUVARING
BRAND
ocella
Generic
ogestrel
Generic
orsythia
Generic
ORTHO TRI-CYCLEN LO
BRAND
philith
Generic
pimtrea
Generic
pirmella
Generic
portia
Generic
PREMARIN (0.3 MG TABLET, 0.45 MG
TABLET, 0.625 MG TABLET, 0.9 MG
TABLET, 1.25 MG TABLET, VAGINAL
CREAM-APPL)
BRAND
PREMPHASE
BRAND
PREMPRO
BRAND
previfem
Generic
quasense
Generic
reclipsen
Generic
Requirements/Limits
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
55
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
sprintec
Generic
sronyx
Generic
syeda
Generic
tilia fe
Generic
tri-estarylla
Generic
tri-legest fe
Generic
tri-linyah
Generic
tri-previfem
Generic
tri-sprintec
Generic
trinessa
Generic
trivora-28
Generic
VAGIFEM
BRAND
velivet
Generic
vestura
Generic
viorele
Generic
VIVELLE-DOT
BRAND
vyfemla
Generic
wera
Generic
xulane
Generic
zarah
Generic
zenchent
Generic
zovia 1-35e
Generic
zovia 1-50e
Generic
Requirements/Limits
Progestins
camila
Generic
deblitane
Generic
DEPO-SUBQ PROVERA 104
BRAND
errin
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
56
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
heather
Generic
jencycla
Generic
jolivette
Generic
lyza
Generic
medroxyprogesterone acetate (2.5 mg
tablet, 5 mg tablet, 10 mg tablet, 150
mg/ml syringe, 150 mg/ml vial)
Generic
megestrol acetate (20 mg tablet, 40 mg
tablet, 400mg/10ml oral susp)
Generic
nora-be
Generic
norethindrone 0.35 mg tablet
Generic
norethindrone acetate 5 mg tablet
Generic
norlyroc
Generic
progesterone,micronized (100 mg, 200
mg)
Generic
sharobel
Generic
Requirements/Limits
Selective Estrogen Receptor Modifying Agents
raloxifene hcl
Generic
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)
levothroid
Generic
levothyroxine sodium (25 mcg, 50 mcg,
75 mcg, 88 mcg, 100 mcg, 112 mcg, 125
mcg, 137 mcg, 150 mcg, 175mcg, 200
mcg, 300 mcg)
Generic
levoxyl
Generic
liothyronine sodium (5 mcg, 25 mcg, 50
mcg)
Generic
unithroid (25 mcg, 50 mcg, 75 mcg, 88
mcg, 100 mcg, 112 mcg, 125 mcg, 150
mcg, 175 mcg, 200 mcg, 300 mcg)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
57
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
Hormonal Agents, Suppressant (Adrenal)
LYSODREN
BRAND
SIGNIFOR
Specialty
PA, LA
Hormonal Agents, Suppressant (Parathyroid)
calcitriol (0.25 mcg capsule, 0.5 mcg
capsule, 1 mcg/ml solution)
Generic
paricalcitol
Generic
ST
SENSIPAR (30 MG, 60 MG)
Specialty
QL (60 PER 30 DAYS)
SENSIPAR 90 MG TABLET
Specialty
ZEMPLAR (5 MCG/ML, 10 MCG/2 ML)
BRAND
ST
Hormonal Agents, Suppressant (Pituitary)
cabergoline
Generic
ELIGARD
BRAND
PA
leuprolide acetate 1 mg/0.2ml kit
Generic
PA
octreotide acetate (50 mcg/ml ampul,
50 mcg/ml vial, 100 mcg/ml ampul, 100
mcg/ml vial, 200 mcg/ml vial, 500
mcg/ml ampul, 500 mcg/ml vial,
1000mcg/ml vial)
Specialty
PA
SOMAVERT
Specialty
PA, LA
Hormonal Agents, Suppressant (Sex Hormones/Modifiers)
Antiandrogens
bicalutamide
Generic
NILANDRON
BRAND
XTANDI
Specialty
PA
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
58
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
Hormonal Agents, Suppressant (Thyroid)
Antithyroid Agents
methimazole (5 mg, 10 mg)
Generic
propylthiouracil 50 mg tablet
Generic
Immunological Agents
Angioedema (HAE) Agents
BERINERT 500 UNIT KIT
Specialty
PA, QL (3 PER 30 DAYS)
Immune Suppressants
ASTAGRAF XL
BRAND
azathioprine 50 mg tablet
Generic
CELLCEPT 200 MG/ML ORAL SUSP
BRAND
cyclosporine (25 mg, 100 mg)
Generic
cyclosporine, modified (25 mg capsule,
50 mg capsule, 100 mg capsule, 100
mg/ml solution)
Generic
ENBREL (25 MG/0.5 ML SYRINGE, 50
MG/ML SURECLICK SYR, 50 MG/ML
SYRINGE)
Specialty
QL (4 ML PER 28 DAYS)
ENBREL 25 MG KIT
Specialty
QL (8 PER 28 DAYS)
gengraf (25 mg capsule, 100 mg/ml
solution)
Generic
GRASTEK
BRAND
hecoria
Generic
HUMIRA
Specialty
mycophenolate mofetil
Generic
mycophenolate sodium
Generic
ORALAIR
Specialty
PROGRAF 5 MG/ML AMPULE
BRAND
PA
PA, LA
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
59
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
RAGWITEK
BRAND
PA
RAPAMUNE (1 MG TABLET, 1 MG/ML
ORAL SOLN, 2 MG TABLET)
BRAND
RESTASIS
BRAND
SANDIMMUNE 100 MG/ML SOLN
BRAND
tacrolimus (0.5 mg, 1 mg, 5 mg)
Generic
ZORTRESS
Specialty
PA, QL (60 PER 30 DAYS)
Immunizing Agents, Passive
GAMMAGARD S-D
BRAND
GAMMAKED
Specialty
GAMUNEX-C
Specialty
Immunomodulators
ACTIMMUNE
Specialty
ALFERON N
Specialty
leflunomide
Generic
PA
Inflammatory Bowel Disease Agents
Aminosalicylates
balsalazide disodium
Generic
DIPENTUM
BRAND
Glucocorticoids
anusol-hc 2.5% cream
Generic
procto-pak
Generic
proctocream-hc
Generic
PROCTOFOAM-HC
BRAND
proctosol-hc
Generic
proctozone-hc
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
60
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
ACTONEL (5 MG, 30 MG, 35 MG)
BRAND
PA
alendronate sodium (5 mg tablet, 10
mg tablet, 35 mg tablet, 40 mg tablet,
70 mg tablet, 70 mg/75ml solution)
Generic
calcitonin,salmon,synthetic
Generic
doxercalciferol (0.5 mcg, 1 mcg, 2.5
mcg)
Generic
doxercalciferol 4mcg/2ml vial
Generic
etidronate disodium
Generic
FORTEO
Specialty
ibandronate sodium 150 mg tablet
Generic
Metabolic Bone Disease Agents
ST
Miscellaneous
Glucose Testing
ACCU-CHECK (METERS & TEST STRIPS)
DME Benefit
QL
LIFESCAN (METERS & TEST STRIPS)
DME Benefit
QL
Ophthalmic Agents
Ophthalmic Prostaglandin and Prostamide Analogs
latanoprost
Generic
LUMIGAN 0.01% EYE DROPS
BRAND
ST
LUMIGAN 0.03% EYE DROPS
BRAND
Step Therapy
TRAVATAN Z
BRAND
travoprost (benzalkonium)
Generic
Ophthalmic Agents, Other
ak-poly-bac
Generic
bacitracin/polymyxin b sulfate
Generic
BLEPHAMIDE
BRAND
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
61
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
BLEPHAMIDE S.O.P.
BRAND
CYSTARAN
BRAND
gatifloxacin
Generic
LACRISERT
BRAND
naphazoline hcl 0.1 % drops
Generic
neo-polycin
Generic
neo-polycin hc
Generic
neomycin sulfate/bacitracin
zinc/polymyxin b/hydrocortisone
Generic
neomycin sulfate/bacitracin/polymyxin
b
Generic
neomycin sulfate/polymyxin b
sulfate/gramicidin d
Generic
neomycin/polymyxin b sulf/hc 3.5-10k10 drops susp
Generic
neomycin/polymyxin b
sulfate/dexamethasone (0.1 % drops
susp, 3.5-10k-.1 oint. (g))
Generic
neosporin eye drops
Generic
polycin
Generic
polymyxin b sulfate/trimethoprim
Generic
sulfacetamide sodium/prednisolone
sodium phosphate
Generic
TOBRADEX EYE OINTMENT
BRAND
TOBRADEX ST
BRAND
tobramycin/dexamethasone
Generic
tropicamide (0.5 %, 1 %)
Generic
VIGAMOX
BRAND
ZYLET
BRAND
Requirements/Limits
PA, LA, QL (60 ML PER 30 DAYS)
Ophthalmic Anti-allergy Agents
ALOMIDE
BRAND
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
62
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
azelastine hcl 0.05 % drops
Generic
cromolyn sodium 4 % drops
Generic
PATANOL
BRAND
Requirements/Limits
PA
Ophthalmic Anti-inflammatories
ALREX
BRAND
bromfenac sodium
Generic
dexamethasone sod phosphate 0.1 %
drops
Generic
diclofenac sodium 0.1 % drops
Generic
flurbiprofen sodium
Generic
ketorolac tromethamine (0.4 %, 0.5 %)
Generic
LOTEMAX (0.5% EYE DROPS, 0.5% EYE
OINTMENT, 0.5% OPHTHALMIC GEL)
BRAND
prednisolone acetate 1 % drops susp
Generic
prednisolone sod phosphate 1 % drops
Generic
VEXOL
BRAND
Ophthalmic Antiglaucoma Agents
ALPHAGAN P 0.1% DROPS
BRAND
AZOPT
BRAND
betaxolol hcl 0.5 % drops
Generic
BETIMOL
BRAND
BETOPTIC S
BRAND
brimonidine tartrate (0.15 %, 0.2 %)
Generic
carteolol hcl
Generic
dorzolamide hcl
Generic
dorzolamide hcl/timolol maleate
Generic
ISTALOL
BRAND
levobunolol hcl
Generic
metipranolol
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
63
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
pilocarpine hcl (1 %, 2 %, 4 %)
Generic
PILOPINE HS
BRAND
timolol maleate (0.25 % drops, 0.25 %
sol-gel, 0.5 % drops, 0.5 % sol-gel)
Generic
Requirements/Limits
Otic Agents
antipyrine/benzocaine 5.4 %-1.4% drops
Generic
aurodex
Generic
auroguard
Generic
CIPRO HC
BRAND
CIPRODEX
BRAND
ciprofloxacin hcl 0.2 % droperette
Generic
neomycin sulfate/polymyxin b
sulfate/hydrocortisone (drops susp,
solution)
Generic
otic care
Generic
Respiratory Tract Agents
Anti-inflammatories, Inhaled Corticosteroids
ADVAIR DISKUS
BRAND
ADVAIR HFA
BRAND
AEROSPAN
BRAND
ALVESCO
BRAND
ASMANEX
BRAND
BREO ELLIPTA
BRAND
budesonide (0.25mg/2ml ampul-neb,
0.5 mg/2ml ampul-neb, 32mcg
spray/pump)
Generic
flunisolide (25 mcg, 29mcg)
Generic
NASONEX
BRAND
PULMICORT 1 MG/2 ML RESPULE
BRAND
QL (17 GM PER 30 DAYS)
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
64
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
PULMICORT FLEXHALER
BRAND
QVAR
BRAND
Requirements/Limits
Antihistamines
azelastine hcl 137 mcg spray/pump
Generic
clemastine fumarate (0.67mg/5ml
syrup, 2.68 mg tablet)
Generic
cyproheptadine hcl (2 mg/5 ml syrup, 4
mg tablet)
Generic
levocetirizine dihydrochloride (2.5
mg/5ml solution, 5 mg tablet)
Generic
promethazine hcl/codeine
Generic
promethazine/phenylephrine
hcl/codeine
Generic
Antileukotrienes
montelukast sodium (4 mg gran pack, 4
mg tab chew, 5 mg tab chew, 10 mg
tablet)
Generic
zafirlukast
Generic
ZYFLO CR
BRAND
QL (60 PER 30 DAYS)
Bronchodilators, Anticholinergic
ATROVENT HFA
BRAND
COMBIVENT
BRAND
QL (14.7 GM PER 30 DAYS)
COMBIVENT RESPIMAT
BRAND
QL (4 GM PER 30 DAYS)
hydrocodone bit/homatrop me-br 5-1.5
mg/5 syrup
Generic
hydromet
Generic
ipratropium bromide (0.2 mg/ml
solution, 21 mcg spray, 42mcg spray)
Generic
ipratropium bromide/albuterol sulfate
Generic
SPIRIVA
BRAND
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
65
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
Bronchodilators, Phosphodiesterase Inhibitors (Xanthines)
theochron
Generic
theophylline anhydrous (100 mg tab er
12h, 200 mg tab er 12h, 300 mg tab er
12h, 400 mg tablet er, 450 mg tab er
12h, 600 mg tablet er)
Generic
Bronchodilators, Sympathomimetic
albuterol sulfate (0.63mg/3ml vial-neb,
1.25mg/3ml vial-neb, 2 mg tablet, 2
mg/5 ml syrup, 2.5 mg/0.5 vial-neb, 2.5
mg/3ml vial-neb, 4 mg tab er 12h, 4 mg
tablet, 5 mg/ml solution, 8 mg tab er
12h)
Generic
EPIPEN 2-PAK
BRAND
EPIPEN JR 2-PAK
BRAND
levalbuterol hcl (0.31mg/3ml,
0.63mg/3ml, 1.25mg/0.5, 1.25mg/3ml)
Generic
proair hfa
Generic
SEREVENT DISKUS
BRAND
terbutaline sulfate (2.5 mg, 5 mg)
Generic
ventolin hfa
Generic
XOPENEX HFA
BRAND
QL (17 GM PER 30 DAYS)
QL (36 GM PER 30 DAYS)
Mast Cell Stabilizers
cromolyn sodium (20 mg/2 ml ampulneb, 20 mg/ml solution)
Generic
Pulmonary Antihypertensives
ADCIRCA
Specialty
PA
ADEMPAS
Specialty
PA
LETAIRIS
Specialty
PA
OPSUMIT
Specialty
PA, LA
sildenafil citrate 20 mg tablet
Generic
PA, QL (90 PER 30 DAYS)
TRACLEER
Specialty
PA, LA
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
66
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
VELETRI 0.5 MG VIAL
Specialty
VENTAVIS
Specialty
Requirements/Limits
Respiratory Tract Agents, Other
ANORO ELLIPTA
BRAND
benzonatate
Generic
dextromethorphan hbr/promethazine
hcl
Generic
guaifenesin/codeine phosphate
Generic
HYPER-SAL 3.5% VIAL
BRAND
KALYDECO
Specialty
lortuss ex
Generic
mytussin dac
Generic
phenylephrine hcl/promethazine hcl
Generic
pulmosal
Generic
PULMOZYME
Specialty
sodium chloride for inhalation 7 % vialneb
Generic
sski
Generic
SYMBICORT
BRAND
TYZINE
BRAND
virtussin ac
Generic
PA, LA, QL (60 PER 30 DAYS)
Skeletal Muscle Relaxants
carisoprodol (250 mg, 350 mg)
Generic
carisoprodol/aspirin
Generic
chlorzoxazone
Generic
cyclobenzaprine hcl (5 mg, 7.5 mg, 10
mg)
Generic
metaxalone
Generic
methocarbamol (500 mg, 750 mg)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
67
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
orphenadrine citrate 100 mg tablet er
Generic
orphenadrine/aspirin/caffeine 50-77060 tablet
Generic
Requirements/Limits
Sleep Disorder Agents
GABA Receptor Modulators
estazolam
Generic
flurazepam hcl
Generic
temazepam
Generic
triazolam
Generic
zaleplon
Generic
QL (30 PER 30 DAYS)
zolpidem tartrate (5 mg, 10 mg)
Generic
QL (30 PER 30 DAYS)
modafinil
Generic
PA, QL (30 PER 30 DAYS)
ROZEREM
BRAND
PA, QL (30 PER 30 DAYS)
XYREM
Specialty
PA, LA, QL (540 ML PER 30 DAYS)
Sleep Disorders, Other
Therapeutic Nutrients/ Minerals/ Electrolytes
Electrolyte/Mineral Modifiers
EXJADE
Specialty
kionex 15 gm/60 ml suspension
Generic
sodium polystyrene sulfonate
(15g/60ml oral susp, 30g/120ml enema,
50g/200ml enema)
Generic
sps 15 gm/60 ml suspension
Generic
SYPRINE
BRAND
Electrolyte/Mineral Replacement
cyanocobalamin (vitamin b-12)
1000mcg/ml vial
Generic
ergocalciferol (vitamin d2) 50000 unit
capsule
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
68
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
FLUOR-A-DAY (0.25 MG TAB, 0.5 MG
TAB, 1 MG TABLET)
BRAND
fluoride/iron/vitamins a,c,and d
Generic
fluoritab 0.5 mg tablet chew
Generic
flura-drops
Generic
folic acid 1 mg tablet
Generic
klor-con 10
Generic
klor-con 8
Generic
klor-con m10
Generic
klor-con m20
Generic
levocarnitine 330 mg tablet
Generic
ludent fluoride
Generic
maternity
Generic
multivitamins with fluoride
Generic
pediatric multivitamin combination
no.2/sodium fluoride
Generic
pediatric multivitamins a,c,& d3 no.21
with sodium fluoride
Generic
pediatric multivitamins no.16 with
sodium fluoride
Generic
pediatric multivitamins no.17 with
sodium fluoride
Generic
pediatric multivitamins no.82 with
sodium fluoride
Generic
potassium chloride (8 meq capsule er, 8
meq tablet er, 10 meq capsule er, 10
meq tab er prt, 10 meq tablet er, 20
meq tab er prt, 20 meq tablet er,
20meq/15ml liquid, 40meq/15ml liquid)
Generic
potassium citrate (5 er, 10 er)
Generic
prenaplus
Generic
prenatal vitamins comb no.115/iron
fumarate/folic acid
Generic
Requirements/Limits
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
69
Providence Health Plan Commercial Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
prenatal vitamins comb no.115/iron
fumarate/folic acid/dss
Generic
prenatal vitamins combo no.60/ferrous
fumarate/folic acid
Generic
prenatal vitamins with calcium/ferrous
fumarate/folic acid
Generic
prenatal vitamins/ferrous
fumarate/folic acid
Generic
prenatal vitamins/ferrous sulfate/folic
acid
Generic
prenatal vits w-ca,fe,fa(<1mg)
Generic
prenatal vits with calcium #72/ferrous
fumarate/folic acid
Generic
prenatal vits with calcium
#72/iron,carbonyl/folic acid
Generic
preplus
Generic
QUFLORA (0.25 MG/ML, 0.5 MG/ML)
BRAND
se-natal 19
Generic
sodium fluoride (0.25(0.55) tab chew,
0.5 mg/ml drops, 0.5(1.1)mg tab chew,
1mg(2.2mg) tab chew, 1mg(2.2mg)
tablet)
Generic
tl-fluorivite
Generic
TRICARE
BRAND
trinatal rx 1
Generic
vinate one
Generic
vinate-m
Generic
vol-plus
Generic
Requirements/Limits
Uncategorized
Unclassified
IRESSA
Specialty
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
70
Non-Formulary Drugs That Require Prior Authorization
ABSTRAL
ACANYA
ACIPHEX SPRINKLE
ACTIQ
ACTONEL 150 MG TABLET
ACYCLOVIR 5% OINTMENT
ACZONE
ADOXA
ALTABAX
AMBIEN CR
AMITIZA
AMRIX
AMTURNIDE
ANZEMET 50 MG TABLET
ANZEMET 100 MG TABLET
APLENZIN
APOKYN
ARICEPT 23 MG TABLET
ARTHROTEC 50
ARTHROTEC 75
ASTEPRO
ATELVIA
ATOVAQUONE-PROGUANIL HCL
ATRALIN
AVINZA
AXID
AZACITIDINE
AZELASTINE 0.15% NASAL SPRAY
BENZACLIN GEL 35G PUMP
BENZACLIN GEL 50G PUMP
BEPREVE
BIDIL
BINOSTO
BIONECT 0.2% CREAM
BIONECT 0.2% GEL
BIONECT 0.2% SPRAY
BRINTELLIX
BRISDELLE
BUTALB-ACETAMIN-CAFF 50-300-40
BUTRANS 15 MCG/HR PATCH
BUTRANS 10 MCG/HR PATCH
BUTRANS 20 MCG/HR PATCH
BUTRANS 5 MCG/HR PATCH
BYSTOLIC
CALCIPOTRIENE-BETAMETHASONE DP
CALCITRIOL 3 MCG/G OINTMENT
CAMBIA
CARDIZEM LA 120 MG TABLET
CARDURA XL
CENTANY AT
CESAMET
CIALIS 5 MG TABLET
CIMZIA
CINRYZE
CLARIFOAM EF
CLARINEX
CLARINEX-D 12 HOUR
CLARINEX-D 24 HOUR
CLOBEX 0.05% SPRAY
CLONIDINE HCL ER
COARTEM
COMBIGAN
CONZIP
CRESTOR
CRINONE
CYCLOSET
DALIRESP
DERMASORB HC
DERMASORB TA
DESLORATADINE
DESONATE
DESVENLAFAXINE FUMARATE ER
DEXILANT
DICLOFENAC SODIUM 3% GEL
DICLOFENAC SODIUM 1.5% SOLN
DICLOFENAC SODIUM-MISOPROSTOL
DIFFERIN 0.1% LOTION
DIFICID
DONEPEZIL HCL 23 MG TABLET
DORYX
71
DOXYCYCLINE HYC DR 150 MG TAB
DOXYCYCLINE HYC DR 75 MG TAB
DOXYCYCLINE HYC DR 100 MG TAB
DOXYCYCLINE MONO 150 MG CAP
DOXYCYCLINE MONO 75 MG CAPSULE
DRONABINOL
DUEXIS
ECOZA
EDARBI
EDARBYCLOR
EDLUAR
ENABLEX
ENDOMETRIN
EPIDUO
ESOMEPRAZOLE STRONTIUM
ESZOPICLONE
EXALGO
EXFORGE HCT
FENOFIBRATE 50 MG CAPSULE
FENOFIBRATE 150 MG CAPSULE
FENTANYL CITRATE OTFC 600 MCG
FENTANYL CITRATE OTFC 200 MCG
FENTANYL CITRATE OTFC 400 MCG
FENTANYL CIT OTFC 1
600 MCG
FENTANYL CIT OTFC 1
200 MCG
FENTANYL CITRATE OTFC 800 MCG
FENTORA
FERRIPROX
FETZIMA
FIORICET 50-300-40 MG CAPSULE
FLECTOR
FLO-PRED
FLUOCINONIDE 0.1% CREAM
FLUVOXAMINE MALEATE ER
FORFIVO XL
FORTAMET
FOSAMAX PLUS D
FOSRENOL
FYCOMPA
GELNIQUE
GLUMETZA
GLYCATE
GRALISE
HETLIOZ
HORIZANT
HYDROMORPHONE ER
INTERMEZZO
INTUNIV
IPRIVASK
JALYN
KAPVAY
KETEK
KORLYM
LAMICTAL ODT
LAMICTAL ODT (BLUE)
LAMICTAL ODT (GREEN)
LAMICTAL ODT (ORANGE)
LASTACAFT
LAZANDA
LIPOFEN
LIPTRUZET
LIVALO
LUNESTA
LUPRON DEPOT
LUPRON DEPOT-PED
LUVOX CR
MALARONE
MARINOL
METFORMIN HCL ER 500 MG OSM-TB
METFORMIN ER 1
000 MG OSM-TAB
METOZOLV ODT
METROGEL
METRONIDAZOLE TOPICAL 1% GEL
MICARDIS
MICARDIS HCT
MIRAPEX ER
MONODOX 75 MG CAPSULE
MORGIDOX 1X100 MG KIT
MORGIDOX 2X100 MG KIT
72
MORPHINE SULFATE ER 45 MG CAP
MORPHINE SULFATE ER 30 MG CAP
MORPHINE SULFATE ER 75 MG CAP
MORPHINE SULFATE ER 120 MG CAP
MORPHINE SULFATE ER 60 MG CAP
MORPHINE SULFATE ER 90 MG CAP
MOZOBIL
NAMENDA XR
NATROBA
NEXIUM
NEXIUM 24HR
NIZATIDINE 15 MG/ML SOLUTION
NORDITROPIN NORDIFLEX 30 MG/3
NOXAFIL DR 100 MG TABLET
NUCYNTA
NUCYNTA ER
NUVIGIL
OCTREOTIDE ACET 50 MCG/ML SYR
OCTREOTIDE ACET 500 MCG/ML SYR
OCTREOTIDE ACET 100 MCG/ML SYR
OLEPTRO ER
OMNARIS
OMNITROPE 10 MG/1.5 ML CRTG
OMNITROPE 5.8 MG VIAL
ONSOLIS
OPANA ER
ORACEA
ORBIVAN
OXECTA
OXTELLAR XR
OXYMORPHONE HCL ER
PAROXETINE ER 37.5 MG TABLET
PAROXETINE CR 37.5 MG TABLET
PAROXETINE CR 12.5 MG TABLET
PAROXETINE CR 25 MG TABLET
PATADAY
PATANASE
PAXIL CR
PENNSAID
PEXEVA
POMALYST
POTIGA
PRIMAQUINE
PRISTIQ ER
PROMACTA 75 MG TABLET
QUALAQUIN
QUININE SULFATE 324 MG CAPSULE
QUTENZA
RAPAFLO
RELISTOR
RENOVA
RENOVA PUMP
REQUIP XL
RETIN-A MICRO
RETIN-A MICRO PUMP
RISEDRONATE SODIUM
ROPINIROLE HCL ER 2 MG TABLET
ROPINIROLE HCL ER 4 MG TABLET
ROPINIROLE HCL ER 12 MG TABLET
ROPINIROLE HCL ER 8 MG TABLET
ROPINIROLE HCL ER 6 MG TABLET
ROSADAN 0.75% CREAM KIT
ROSADAN 0.75% GEL KIT
SAMSCA
SANCTURA XR
SANCUSO
SEROQUEL XR
SILENOR
SIMPONI
SIMPONI ARIA
SIMVASTATIN 80 MG TABLET
SOD SULFACETAMIDE-SULFUR FOAM
SOLARAZE
SOLODYN ER 65 MG TABLET
SOLODYN ER 115 MG TABLET
SOLODYN ER 80 MG TABLET
SOLODYN ER 105 MG TABLET
SOLODYN ER 55 MG TABLET
SORILUX
SPINOSAD
SSS 10-5 FOAM
STAVZOR
73
STELARA
SUBSYS
SUMAVEL DOSEPRO 6 MG/0.5 ML
SYNALAR 0.025% OINTMENT KIT
SYNALAR 0.025% CREAM KIT
SYNALAR TS
TACLONEX
TEKTURNA
TEKTURNA HCT
TELMISARTAN
TELMISARTAN-AMLODIPINE
TELMISARTAN-HYDROCHLOROTHIAZID
TIZANIDINE HCL 4 MG CAPSULE
TIZANIDINE HCL 2 MG CAPSULE
TIZANIDINE HCL 6 MG CAPSULE
TOPICORT 0.25% SPRAY
TOVIAZ
TRAMADOL HCL ER 150 MG CAPSULE
TRETIN-X
TRETINOIN MICROSPHERE
TREXIMET
TRIBENZOR
TROSPIUM CHLORIDE ER
TWYNSTA
TYVASO
ULORIC
ULTRAVATE X CREAM COMBO PACK
VANOS
VECTICAL
VELPHORO
VELTIN
VERAMYST
VERDESO
VESICARE
VIDAZA
VIIBRYD
VIMOVO
VYTORIN
WELCHOL
XALKORI
XARTEMIS XR
XERESE
XOLEGEL
ZANAFLEX 4 MG CAPSULE
ZANAFLEX 2 MG CAPSULE
ZANAFLEX 6 MG CAPSULE
ZELAPAR
ZENZEDI 2.5 MG TABLET
ZENZEDI 15 MG TABLET
ZENZEDI 7.5 MG TABLET
ZENZEDI 20 MG TABLET
ZENZEDI 30 MG TABLET
ZETONNA
ZIANA
ZIPSOR
ZMAX
ZOCOR 80 MG TABLET
ZOHYDRO ER
ZOLPIDEM TARTRATE ER
ZOLPIMIST
ZORVOLEX
ZOVIRAX 5% CREAM
ZOVIRAX 5% OINTMENT
ZUPLENZ
ZYCLARA 3.75% CREAM
ZYCLARA 3.75% CREAM PUMP
74
Alphabetical Listing
A
all day pain relief
1
all day relief
1
abacavir sulfate
28
allopurinol
20
abacavir sulfate/lamivudine/zidovudine
28
ALOMIDE
62
ABILIFY
16
ALORA
52
ABILIFY DISCMELT
16
ALPHAGAN P
63
acamprosate calcium
5
alprazolam
31
acarbose
31
ALREX
63
acebutolol hcl
37
altavera
52
acetaminophen with codeine phosphate
3
ALVESCO
64
acetasol hc
8
alyacen
52
amantadine hcl
25
acetazolamide
12,39
acetic acid/aluminum acetate
8
amcinonide
6
acetic acid/hydrocortisone
8
amethia
52
acitretin
44
amethia lo
52
ACTIMMUNE
60
amethyst
52
ACTONEL
61
amiloride hcl
40
ACTOPLUS MET XR
31
amiloride hcl/hydrochlorothiazide
40
acyclovir
30
amiodarone hcl
36
ADAGEN
46
amitriptyline hcl
17
adapalene
44
amlodipine besylate
38
ADCIRCA
66
amlodipine besylate/atorvastatin calcium
39
adefovir dipivoxil
29
amlodipine besylate/benazepril hcl
38
ADEMPAS
66
ammonium lactate
44
ADVAIR DISKUS
64
amnesteem
44
ADVAIR HFA
64
amoxapine
17
AEROSPAN
64
amoxicillin
10
afeditab cr
38
amoxicillin/potassium clavulanate
10
AFINITOR
23
ampicillin trihydrate
10
AFINITOR DISPERZ
23
AMPYRA
43
AGGRENOX
35
ANADROL-50
52
ak-poly-bac
61
anagrelide hcl
34
alagesic lq
1
anastrozole
23
ALBENZA
25
ANDROGEL
52
albuterol sulfate
66
ANORO ELLIPTA
67
anti-diarrheal
46
alclometasone dipropionate
6
alendronate sodium
61
antipyrine/benzocaine
64
ALFERON N
60
anusol-hc
60
alfuzosin hcl
49
apexicon e
6
ALINIA
25
APIDRA
33
ALKERAN
22
APIDRA SOLOSTAR
33
75
apri
52
balziva
52
APRISO
46
BANZEL
14
APTIOM
14
BARACLUDE
29
APTIVUS
29
benazepril hcl
36
aranelle
52
benazepril hcl/hydrochlorothiazide
36
ARANESP
34
benzonatate
67
ASACOL
46
benztropine mesylate
25
ASACOL HD
46
BERINERT
59
ascomp with codeine
3
betamethasone acetate/betamethasone sodium
ASMANEX
64
phosphate
ASTAGRAF XL
59
betamethasone dipropionate
6
atenolol
37
betamethasone dipropionate/propylene glycol
6
atenolol/chlorthalidone
37
betamethasone valerate
6
atorvastatin calcium
41
BETASERON
atovaquone
25
betaxolol hcl
ATRIPLA
28
bethanechol chloride
49
ATROVENT HFA
65
BETIMOL
63
AUBAGIO
43
BETOPTIC S
63
aubra
52
bicalutamide
58
aurodex
64
bisoprolol fumarate
37
auroguard
64
bisoprolol fumarate/hydrochlorothiazide
37
aviane
52
bleph-10
12
avidoxy
12
BLEPHAMIDE
61
avita
44
BLEPHAMIDE S.O.P.
62
AVONEX
43
blood sugar diagnostic
61
AVONEX ADMINISTRATION PACK
43
BOSULIF
24
AVONEX PEN
43
BREO ELLIPTA
64
AZASITE
10
briellyn
53
azathioprine
59
BRILINTA
35
brimonidine tartrate
63
azelastine hcl
63,65
50
43
37,63
AZILECT
26
bromfenac sodium
63
azithromycin
11
bromocriptine mesylate
26
AZOPT
63
budeprion sr
16
azurette
52
budeprion xl
16
budesonide
50,64
bumetanide
39
46
B
bacitracin
8
BUPHENYL
bacitracin zinc
8
buprenorphine hcl
5
bacitracin/polymyxin b sulfate
61
buprenorphine hcl/naloxone hcl
5
baclofen
27
buproban
6
balsalazide disodium
60
bupropion hcl
76
16
buspirone hcl
31
cefadroxil
9
9
butalbital/acetaminophen
1
cefdinir
butalbital/acetaminophen/caffeine
1
cefpodoxime proxetil
10
butalbital/acetaminophen/caffeine/codeine phosphate 3
cefprozil
10
butalbital/aspirin/caffeine
1
ceftibuten dihydrate
10
butorphanol tartrate
3
CEFTIN
10
10
BYDUREON
31
cefuroxime axetil
BYDUREON PEN
31
CELEBREX
BYETTA
31
CELESTONE
50
CELLCEPT
59
CELONTIN
13
C
1
cabergoline
58
cephalexin
10
cafergot
20
CEREZYME
46
calcipotriene
44
CHANTIX
calcitonin,salmon,synthetic
61
chateal
53
calcitriol
58
chlordiazepoxide hcl
31
calcium acetate
49
chlorhexidine gluconate
8
camila
56
chloroquine phosphate
25
camrese
53
chlorothiazide
40
camrese lo
53
chlorpromazine hcl
18
CANASA
47
chlorpropamide
32
candesartan cilexetil
35
chlorthalidone
40
1
chlorzoxazone
67
capacet
6
capecitabine
22
cholestyramine (with sugar)
41
CAPRELSA
24
cholestyramine/aspartame
41
captopril
36
ciclodan
19
captopril/hydrochlorothiazide
36
ciclopirox
19
CARAC
44
ciclopirox olamine
19
CARBAGLU
46
cilostazol
35
carbamazepine
15
cimetidine
48
carbidopa
26
cimetidine hcl
48
carbidopa/levodopa
26
CIPRO HC
64
carbidopa/levodopa/entacapone
26
CIPRODEX
64
carisoprodol
67
ciprofloxacin hcl
carisoprodol/aspirin
67
ciprofloxacin/ciprofloxacin hcl
11
carteolol hcl
63
citalopram hydrobromide
16
cartia xt
38
claravis
44
carvedilol
37
clarithromycin
11
caziant
53
clemastine fumarate
65
CEENU
22
clinda-derm
8
cefaclor
9
clindacin etz
8
77
11,64
clindacin p
8
CUPRIMINE
49
clindamycin hcl
8
CUVPOSA
46
clindamycin palmitate hcl
8
cyanocobalamin (vitamin b-12)
68
clindamycin phosphate
8
cyclafem
53
cyclobenzaprine hcl
67
clindamycin phosphate/benzoyl peroxide
44
clobetasol propionate
6
cyclophosphamide capsules
22
clobetasol propionate/emollient base
6
cyclophosphamide tablets
22
clodan
6
cycloserine
8
clomipramine hcl
17
cyclosporine
59
clonazepam
13
cyclosporine, modified
59
clonidine
35
cyproheptadine hcl
65
clonidine hcl
35
CYSTAGON
49
clopidogrel bisulfate
35
CYSTARAN
62
clorazepate dipotassium
13
clotrimazole
19
D
clotrimazole/betamethasone dipropionate
44
danazol
52
clozapine
27
dantrolene sodium
27
co-gesic
3
dapsone
21
codeine phosphate/butalbital/aspirin/caffeine
3
DARAPRIM
25
codeine phosphate/carisoprodol/aspirin
3
dasetta
53
codeine sulfate
3
daysee
53
colchicine/probenecid
20
DAYTRANA
42
COLCRYS
20
deblitane
56
COLESTID
41
decitabine
22
colestid
41
delyla
53
colestipol hcl
41
DELZICOL
47
COMBIPATCH
53
demeclocycline hcl
12
COMBIVENT
65
DENAVIR
30
COMBIVENT RESPIMAT
65
depade
5
COMETRIQ
24
DEPEN
49
COMPLERA
28
DEPO-SUBQ PROVERA 104
56
compro
18
desipramine hcl
17
constulose
48
desmopressin (non-refrigerated)
51
COPAXONE
43
desmopressin acetate
51
COREG CR
37
desogestrel-ethinyl estradiol
53
53
cormax
6
desogestrel-ethinyl estradiol/ethinyl estradiol
cortisone acetate
6
desonide
6
CREON
46
desoximetasone
6
CRIXIVAN
29
dexamethasone
50
dexamethasone sod phosphate
63
dexmethylphenidate hcl
42
cromolyn sodium
cryselle
63,66
53
78
dextroamphetamine sulf-saccharate/amphetamine sulf-
DUAVEE
53
aspartate
42
duloxetine hcl
16
dextroamphetamine sulfate
42
dynacin
12
dextromethorphan hbr/promethazine hcl
67
DYRENIUM
40
DIASTAT
13
diazepam
13
E
DICLEGIS
18
E.E.S. 200
11
econazole nitrate
19
EDECRIN
39
diclofenac potassium
diclofenac sodium
1
1,63
dicloxacillin sodium
10
EDURANT
28
dicyclomine hcl
46
EFFIENT
35
didanosine
28
EGRIFTA
51
DIFFERIN
44
ELELYSO
46
diflorasone diacetate
6
ELIDEL
45
diflunisal
1
ELIGARD
58
digox
39
elimite
25
digoxin
39
elinest
53
ELIQUIS
34
dihydrocodeine bitartrate/acetaminophen/caffeine
3
dihydroergotamine mesylate
20
ELMIRON
49
DILANTIN
15
EMCYT
22
DILATRATE-SR
41
EMEND
18
dilt-cd
38
emoquette
53
dilt-xr
38
EMTRIVA
28
diltia xt
38
enalapril maleate
36
diltiazem hcl
38
enalapril maleate/hydrochlorothiazide
36
diltzac er
38
ENBREL
59
DIPENTUM
60
endocet
3
diphenoxylate hcl/atropine sulfate
47
endodan
3
dipyridamole
35
enoxaparin sodium
34
disopyramide phosphate
36
enpresse
53
5
enskyce
53
disulfiram
divalproex sodium
13
entacapone
26
donepezil hcl
15
entecavir
30
dorzolamide hcl
63
enulose
48
dorzolamide hcl/timolol maleate
63
EPANED
36
doxazosin mesylate
35
EPIFOAM
45
doxepin hcl
17
EPIPEN 2-PAK
66
doxercalciferol
61
EPIPEN JR 2-PAK
66
doxycycline hyclate
12
epitol
15
doxycycline monohydrate
12
EPIVIR HBV
30
DROXIA
22
eplerenone
40
79
EPOGEN
34
felbamate
14
eprosartan mesylate
35
felodipine
38
EPZICOM
28
fenofibrate
40
EQUETRO
15
fenofibrate nanocrystallized
40
ergocalciferol (vitamin d2)
68
fenofibrate,micronized
40
ergotamine tartrate/caffeine
20
fenofibric acid
40
ERIVEDGE
24
fenofibric acid (choline)
40
errin
56
fenoprofen calcium
1
ERY-TAB
11
fentanyl
2
erygel
11
FINACEA
45
ERYPED 200
11
finasteride
49
erythromycin base
11
fioricet
erythromycin base/benzoyl peroxide
45
FIRAZYR
44
erythromycin base/ethyl alcohol
11
FIRST-LANSOPRAZOLE
48
erythromycin ethylsuccinate
11
FIRST-OMEPRAZOLE
48
erythromycin ethylsuccinate/sulfisoxazole acetyl
11
FLAREX
50
escitalopram oxalate
16
flavoxate hcl
49
estarylla
53
flecainide acetate
36
estazolam
68
FLOVENT DISKUS
50
ESTRACE
53
FLOVENT HFA
50
estradiol
53
fluconazole
19
estradiol/norethindrone acetate
53
fludrocortisone acetate
ESTRING
53
flunisolide
estropipate
53
fluocinolone acetonide
ethambutol hcl
21
fluocinolone acetonide oil
ethinyl estradiol/drospirenone
54
fluocinonide
7
ethosuximide
13
fluocinonide/emollient base
7
etidronate disodium
61
FLUOR-A-DAY
69
fluoride/iron/vitamins a,c,and d
69
1
7
64
7
50
etodolac
1
EXELON
15
fluoritab
69
exemestane
23
fluorometholone
50
EXJADE
68
FLUOROPLEX
45
fluorouracil
45
fluoxetine hcl
17
fluphenazine hcl
26
EXTAVIA
43,44
F
falmina
54
flura-drops
69
famciclovir
31
flurazepam hcl
68
famotidine
48
flurbiprofen
FARESTON
22
flurbiprofen sodium
FARXIGA
32
fluticasone propionate
FAZACLO
27
fluvastatin sodium
80
1
63
7,50
41
fluvoxamine maleate
17
glipizide/metformin hcl
32
FML FORTE
50
GLUCAGEN
33
FML S.O.P.
50
GLUCAGON EMERGENCY KIT
33
FOCALIN XR
42
glyburide
32
folic acid
69
glyburide,micronized
32
fondaparinux sodium
34
glyburide/metformin hcl
32
FORTEO
61
glycopyrrolate
46
fosinopril sodium
36
glydo
fosinopril sodium/hydrochlorothiazide
36
GOLYTELY
47
FRAGMIN
34
granisetron hcl
19
FULYZAQ
47
GRANIX
34
furosemide
39
GRASTEK
59
FUZEON
28
griseofulvin ultramicrosize
19
griseofulvin, microsize
19
guaifenesin/codeine phosphate
67
G
5
gabapentin
13
guanfacine hcl
35
GABITRIL
13
guanidine hcl
21
GAMMAGARD S-D
60
GAMMAKED
60
H
GAMUNEX-C
60
halobetasol propionate
garamycin
8
gatifloxacin
7
haloperidol
26
62
haloperidol lactate
26
GATTEX
47
heather
57
gavilyte-c
47
hecoria
59
gavilyte-g
47
HEXALEN
23
gavilyte-n
47
HUMALOG
33
gemfibrozil
40
HUMALOG MIX 50-50
33
generlac
48
HUMALOG MIX 75-25
33
HUMATROPE
51
HUMIRA
59
gengraf
GENOTROPIN
45,59
51
gentak
8
HUMULIN 70-30
33
gentamicin sulfate
8
HUMULIN N
33
gianvi
54
HUMULIN R
33
gildagia
54
HYCAMTIN
23
gildess
54
hydralazine hcl
41
gildess fe
54
hydrochlorothiazide
40
GILENYA
44
hydrocodone bit/acetaminophen
3
GILOTRIF
23
hydrocodone bitartrate/acetaminophen
4
GLEEVEC
24
hydrocodone bitartrate/homatropine methylbromide 65
glimepiride
32
hydrocodone/ibuprofen
glipizide
32
hydrocortisone
81
4
7,50
hydrocortisone butyrate
7,50
isoniazid
21
hydrocortisone valerate
50
isosorbide dinitrate
42
hydromet
65
isosorbide mononitrate
42
4
isradipine
38
hydroxychloroquine sulfate
25
ISTALOL
63
hydroxyurea
22
itraconazole
19
hydroxyzine hcl
18
hydroxyzine pamoate
18
J
HYPER-SAL
67
JAKAFI
23
hypercare
45
jantoven
34
JANUMET
32
JANUMET XR
32
JANUVIA
32
hydromorphone hcl
I
ibandronate sodium
61
ibudone
4
jencycla
57
ibuprofen
1
JENTADUETO
32
ibuprofen/oxycodone hcl
1
jolessa
54
ICLUSIG
24
jolivette
57
IMBRUVICA
24
junel
54
imipramine hcl
17
junel fe
54
imipramine pamoate
17
JUVISYNC
32
imiquimod
23
JUXTAPID
41
INCIVEK
30
INCRELEX
51
K
indapamide
40
KALETRA
29
KALYDECO
67
indomethacin
1
INFERGEN
30
kariva
54
INLYTA
24
KAZANO
32
INTELENCE
28
kelnor 1-35
54
INTRON A
30
ketoconazole
19
introvale
54
ketoprofen
INVEGA
27
ketorolac tromethamine
INVIRASE
29
kionex
68
INVOKANA
32
klor-con 10
69
ipratropium bromide
65
klor-con 8
69
ipratropium bromide/albuterol sulfate
65
klor-con m10
69
irbesartan
35
klor-con m20
69
irbesartan/hydrochlorothiazide
35
KOMBIGLYZE XR
32
IRESSA
70
kurvelo
54
ISENTRESS
28
KUVAN
46
isochron
42
KYNAMRO
41
isonarif
21
82
2
2,63
levora-28
L
levorphanol tartrate
54
2
labetalol hcl
37
levothroid
57
laclotion
45
levothyroxine sodium
57
LACRISERT
62
levoxyl
57
lactulose
48
LEXIVA
29
LAMISIL
19
LIALDA
47
lidocaine
5
lamivudine
28,30
lamivudine/zidovudine
28
lidocaine hcl
5
lamotrigine
14
lidocaine/prilocaine
5
LANOXIN
39
lindane
25
lansoprazole
48
liothyronine sodium
57
lansoprazole/amoxicillin trihydrate/clarithromycin
48
lisinopril
36
LANTUS
33
lisinopril/hydrochlorothiazide
36
LANTUS SOLOSTAR
33
lithium carbonate
31
larin
54
lithium citrate
31
larin fe
54
lofibra
40
latanoprost
61
lomedia 24 fe
54
LATUDA
27
lomustine
22
leena
54
lorazepam
13
leflunomide
60
lorazepam intensol
13
lessina
54
lorcet
4
LETAIRIS
66
lorcet hd
4
letrozole
23
lorcet plus
4
leucovorin calcium
23
lortab
4
LEUKERAN
22
lortuss ex
67
LEUKINE
34
loryna
54
leuprolide acetate
58
losartan potassium
35
levalbuterol hcl
66
losartan potassium/hydrochlorothiazide
35
LEVATOL
37
LOTEMAX
63
LEVEMIR
33
LOTRONEX
48
LEVEMIR FLEXPEN
33
lovastatin
41
LEVEMIR FLEXTOUCH
33
low-ogestrel
54
levetiracetam
13
loxapine succinate
26
levobunolol hcl
63
ludent fluoride
69
levocarnitine
69
LUMIGAN
61
levocetirizine dihydrochloride
65
lutera
54
levofloxacin
11
LYRICA
13
levonest
54
LYSODREN
58
levonorgestrel-eth estra/ethinyl estradiol
54
lyza
57
levonorgestrel-ethinyl estradiol
54
83
M
metipranolol
63
metoclopramide hcl
18
maprotiline hcl
16
metolazone
40
marlissa
54
metoprolol succinate
37
MARPLAN
16
metoprolol tartrate
37
maternity
69
metoprolol tartrate/hydrochlorothiazide
37
MATULANE
22
metronidazole
9
matzim la
38
mexiletine hcl
37
meclizine hcl
18
microgestin
54
2
microgestin fe
54
medroxyprogesterone acetate
57
midodrine hcl
35
mefloquine hcl
25
migergot
20
megestrol acetate
57
MIGRANAL
20
MEKINIST
23
millipred
7
meloxicam
2
millipred dp
7
meperidine hcl
4
mimvey
55
meperitab
4
minitran
42
meclofenamate sodium
meprobamate
31
MINIVELLE
55
mercaptopurine
22
minocycline hcl
12
mesalamine
47
minoxidil
41
mesalamine with cleansing wipes
47
mirtazapine
16
MESNEX
23
misoprostol
48
MESTINON
21
modafinil
68
metadate er
43
MODERIBA
30
metaxalone
67
moexipril hcl
36
metformin hcl
32
moexipril hcl/hydrochlorothiazide
36
methadone hcl
2
mometasone furoate
45
methadone intensol
2
mono-linyah
55
methadose
2
mononessa
55
montelukast sodium
65
methazolamide
methenamine hippurate
39
9
MONUROL
9
methimazole
59
morgidox
12
methocarbamol
67
morphine sulfate
2,4
methotrexate sodium
22
motion-time
18
methotrexate sodium/pf
23
MOVIPREP
48
methoxsalen, rapid
45
MOXEZA
11
methyclothiazide
40
moxifloxacin hcl
11
methyldopa
35
MULTAQ
37
methyldopa/hydrochlorothiazide
35
multivitamins with fluoride
69
methylphenidate hcl
43
mupirocin
9
methylprednisolone
50
MYALEPT
51
84
mycophenolate mofetil
59
nicardipine hcl
39
mycophenolate sodium
59
nifediac cc
39
myorisan
45
nifedical xl
39
MYRBETRIQ
27
nifedipine
39
mytussin dac
67
nikki
55
myzilra
55
NILANDRON
58
nimodipine
39
nisoldipine
39
2
NITRO-BID
42
nadolol
38
NITRO-DUR
42
nadolol/bendroflumethiazide
38
nitro-time
42
N
nabumetone
naltrexone hcl
5
nitrofurantoin
9
NAMENDA
15
nitrofurantoin macrocrystal
9
naphazoline hcl
62
nitrofurantoin monohydrate/macrocrystals
9
NAPRELAN
2
nitroglycerin
42
naproxen
2
NITROSTAT
42
naproxen sodium
2
nizatidine
48
NAROPIN
5
nora-be
57
NASONEX
64
NORDITROPIN
51
NATACYN
19
NORDITROPIN FLEXPRO
51
nateglinide
32
NORDITROPIN NORDIFLEX
51
necon
55
norethindrone
57
nefazodone hcl
16
norethindrone acetate
57
neo-polycin
62
norethindrone acetate-ethinyl estradiol
55
neo-polycin hc
62
norethindrone acetate-ethinyl estradiol/ferrous
neomycin sulfate
8
neomycin sulfate/bacitracin zinc/polymyxin
fumarate
55
norgestimate-ethinyl estradiol
55
b/hydrocortisone
62
norlyroc
57
neomycin sulfate/bacitracin/polymyxin b
62
NORPACE CR
37
neomycin sulfate/polymyxin b sulfate/gramicidin d
62
nortrel
55
nortriptyline hcl
17
NORVIR
29
neomycin sulfate/polymyxin b
sulfate/hydrocortisone
62,64
neomycin/polymyxin b sulfate/dexamethasone
62
NOVOLIN 70-30
33
neosporin
62
NOVOLIN N
33
NESINA
32
NOVOLIN R
33
NEULASTA
34
NOVOLOG
33
NEUMEGA
34
NOVOLOG FLEXPEN
33
NEUPOGEN
34
NOVOLOG MIX 70-30
34
nevirapine
28
NOVOLOG MIX 70-30 FLEXPEN
34
NEXAVAR
24
NOXAFIL
19
niacin
41
NUEDEXTA
43
85
nulytely with flavor packs
47
oxazepam
31
NUTROPIN
51
oxcarbazepine
15
NUTROPIN AQ
51
OXSORALEN
45
NUTROPIN AQ NUSPIN
51
oxybutynin chloride
49
NUVARING
55
oxycodone hcl
2,4
nyamyc
19
oxycodone hcl/acetaminophen
4
nystatin
20
oxycodone hcl/aspirin
4
OXYCONTIN
3
oxymorphone hcl
4
nystatin/triamcinolone acetonide
nystop
7
20
OXYTROL
O
49
ocella
55
P
octreotide acetate
58
pacerone
37
OCUDOX
12
pancrelipase 5,000
46
ofloxacin
11
PANRETIN
24
ogestrel
55
pantoprazole sodium
49
olanzapine
27
paricalcitol
58
olanzapine/fluoxetine hcl
17
paroex
OLYSIO
30
paroxetine hcl
17
omega-3 acid ethyl esters
41
PATANOL
63
omeprazole
48
PAXIL
17
OMEPRAZOLE+SYRSPEND SF ALKA
48
pedi-dri
20
OMNITROPE
51
pediatric multivitamin combination no.2/sodium
ondansetron
19
fluoride
ondansetron hcl
19
pediatric multivitamins a,c,& d3 no.21 with sodium
ONFI
14
fluoride
69
ONGLYZA
32
pediatric multivitamins no.16 with sodium fluoride
69
OPSUMIT
66
pediatric multivitamins no.17 with sodium fluoride
69
ORALAIR
59
pediatric multivitamins no.82 with sodium fluoride
69
oralone
7
ORAP
26
ORAPRED ODT
7
9
69
peg 3350/sod sulf/sod bicarbonate/sod
chloride/potassium chl
47
PEGASYS
30
ORFADIN
46
PEGASYS PROCLICK
30
orphenadrine citrate
68
PEGINTRON
30
orphenadrine citrate/aspirin/caffeine
68
PEGINTRON REDIPEN
30
orsythia
55
penicillin v potassium
10
ORTHO TRI-CYCLEN LO
55
PENTASA
47
OSENI
32
pentoxifylline
39
otic care
64
PEPCID
48
oxandrolone
52
perindopril erbumine
36
oxaprozin
2
86
periogard
9
permethrin
25
prenatal vitamins comb no.115/iron fumarate/folic
perphenazine
18
acid
perphenazine/amitriptyline hcl
26
prenatal vitamins comb no.115/iron fumarate/folic
phenadoz
18
acid/dss
phenazopyridine hcl
49
prenatal vitamins combo no.60/ferrous fumarate/folic
phenelzine sulfate
16
acid
phenobarbital
14
prenatal vitamins with calcium/ferrous fumarate/folic
phenylephrine hcl/promethazine hcl
67
acid
70
phenytoin
15
prenatal vitamins/ferrous fumarate/folic acid
70
phenytoin sodium extended
15
prenatal vitamins/ferrous sulfate/folic acid
70
philith
55
prenatal vits w-ca,fe,fa(<1mg)
70
PICATO
45
prenatal vits with calcium #72/ferrous fumarate/folic
70
70
pilocarpine hcl
44,64
PILOPINE HS
64
prenatal vits with calcium #72/iron,carbonyl/folic acid 70
pimtrea
55
preplus
70
pindolol
38
prevalite
41
pioglitazone hcl
32
previfem
55
pioglitazone hcl/glimepiride
32
PREZISTA
29
pioglitazone hcl/metformin hcl
32
PRIFTIN
21
pirmella
55
primidone
13
piroxicam
2
proair hfa
66
podofilox
45
probenecid
20
polycin
62
prochlorperazine maleate
18
polyethylene glycol 3350
47
PROCRIT
34
polymyxin b sulfate/trimethoprim
62
procto-pak
60
portia
55
proctocream-hc
60
potassium chloride
69
PROCTOFOAM-HC
60
potassium citrate
69
proctosol-hc
60
PRADAXA
34
proctozone-hc
60
pramipexole di-hcl
26
PROCYSBI
49
pravastatin sodium
41
progesterone,micronized
57
prazosin hcl
35
PROGLYCEM
33
prednisolone
7
PROGRAF
59
PROMACTA
34
promethazine hcl
18
prednisolone acetate
prednisolone sod phosphate
63
7,63
acid
69
70
prednisone
7
promethazine hcl/codeine
65
prednisone intensol
7
promethazine/phenylephrine hcl/codeine
65
PREMARIN
55
promethegan
18
PREMPHASE
55
propafenone hcl
37
PREMPRO
55
propantheline bromide
47
prenaplus
69
propranolol hcl
38
87
propranolol hcl/hydrochlorothiazide
38
reprexain
propylthiouracil
59
RESTASIS
PROTONIX
49
revia
PROTOPIC
45
REVLIMID
22
protriptyline hcl
18
REYATAZ
29
PULMICORT
64
RHEUMATREX
23
PULMICORT FLEXHALER
65
RIBAPAK
30
pulmosal
67
RIBASPHERE
30
PULMOZYME
67
RIBATAB
30
PYLERA
47
ribavirin
30
pyridostigmine bromide
21
rifabutin
21
rifampin
21
RIFATER
22
Q
4
60
6
quasense
55
riluzole
43
QUDEXY XR
14
rimantadine hcl
29
quetiapine fumarate
27
RIOMET
32
QUFLORA
70
RISPERDAL CONSTA
27
quinapril hcl
36
risperidone
27
quinapril hcl/hydrochlorothiazide
36
RITALIN LA
43
quinidine gluconate
37
rivastigmine tartrate
15
quinidine sulfate
37
rizatriptan benzoate
21
QVAR
65
ropinirole hcl
26
R
rosadan
9
ROXICET
5
5
rabeprazole sodium
49
roxicet
RAGWITEK
60
ROZEREM
raloxifene hcl
57
ramipril
36
S
RANEXA
39
SABRIL
14
ranitidine hcl
48
SAIZEN
51
RAPAMUNE
60
SANDIMMUNE
60
RAVICTI
46
SANTYL
45
REBETOL
30
SAPHRIS
27
REBIF
44
SAVELLA
43
REBIF REBIDOSE
44
se-natal 19
70
reclipsen
55
selegiline hcl
26
RECTIV
41
SELZENTRY
29
refissa
45
SENSIPAR
58
REGRANEX
45
SEREVENT DISKUS
66
RENAGEL
50
SEROSTIM
51
RENVELA
50
sertraline hcl
17
88
68
sevelamer carbonate
50
sulfamethoxazole/trimethoprim
12
sharobel
57
sulfamide
12
SIGNIFOR
58
sulfasalazine
47
sildenafil citrate
66
sulfazine
47
silver sulfadiazine
12
sulfazine ec
47
simvastatin
41
sulindac
SIRTURO
22
sumatriptan
21
sodium chloride for inhalation
67
sumatriptan succinate
21
SUPREP
48
sodium chloride/sodium bicarbonate/potassium
2
chloride/peg
47
SUSTIVA
28
sodium fluoride
70
SUTENT
24
sodium phenylbutyrate
46
syeda
56
sodium polystyrene sulfonate
68
SYLATRON
30
SOLTAMOX
22
SYLATRON 4-PACK
30
SOMAVERT
58
SYMBICORT
67
sorine
37
SYMLINPEN 120
33
sotalol hcl
37
SYMLINPEN 60
33
SOVALDI
30
SYPRINE
68
SPIRIVA
65
spironolactone
40
T
spironolactone/hydrochlorothiazide
40
tacrolimus
60
SPORANOX
20
TAFINLAR
23
sprintec
56
TAMIFLU
29
SPRYCEL
24
tamoxifen citrate
22
sps
68
tamsulosin hcl
49
sronyx
56
TARCEVA
24
sski
67
TARGRETIN
24
5
TASIGNA
24
stavudine
28
TAZORAC
45
STIMATE
51
taztia xt
39
STIVARGA
24
TECFIDERA
44
STRATTERA
43
temazepam
68
STRIBILD
29
temozolomide
23
STROMECTOL
25
tencon
stagesic
SUBOXONE
5
1
terazosin hcl
35
SUCRAID
46
terbinafine hcl
20
sucralfate
48
terbutaline sulfate
66
sulfacetamide sodium
12
terconazole
20
testosterone
52
sulfacetamide sodium/prednisolone sodium
phosphate
62
testosterone cypionate
52
sulfadiazine
12
testosterone enanthate
52
89
tetracycline hcl
12
tretinoin
TEV-TROPIN
51
tretinoin/emollient base
45
THALOMID
22
tri-estarylla
56
theochron
66
tri-legest fe
56
theophylline anhydrous
66
tri-linyah
56
THIOLA
49
tri-previfem
56
thioridazine hcl
26
tri-sprintec
56
thiothixene
27
triamcinolone acetonide
tiagabine hcl
14
triamterene/hydrochlorothiazide
40
ticlopidine hcl
35
trianex
45
TIKOSYN
37
triazolam
68
tilia fe
56
TRICARE
70
timolol maleate
20,64
triderm
24,45
7,50
7
tinidazole
25
trifluoperazine hcl
27
TIVICAY
29
trifluridine
31
tizanidine hcl
27
TRIGLIDE
40
tl-fluorivite
70
trihexyphenidyl hcl
25
trilyte with flavor packets
47
18
TOBI PODHALER
8
TOBRADEX
62
trimethobenzamide hcl
TOBRADEX ST
62
trimethoprim
9
tobramycin
8
trimipramine maleate
18
tobramycin in 0.225 % sodium chloride
8
trinatal rx 1
70
trinessa
56
tobramycin/dexamethasone
62
TOBREX
8
trivora-28
56
tolmetin sodium
2
tropicamide
62
tolterodine tartrate
49
trospium chloride
49
topiragen
14
TRUVADA
28
topiramate
14
TYKERB
24
torsemide
40
TYZEKA
30
TRACLEER
66
TYZINE
67
TRADJENTA
33
tramadol hcl
3,5
tramadol hcl/acetaminophen
U
1
UCERIS
50
trandolapril
36
ULESFIA
25
tranexamic acid
34
unithroid
57
TRANSDERM-SCOP
18
ursodiol
47
tranylcypromine sulfate
16
TRAVATAN Z
61
V
travoprost (benzalkonium)
61
VAGIFEM
56
trazodone hcl
16
valacyclovir hcl
31
TRECATOR
22
VALCHLOR
23
90
VALCYTE
29
wera
56
valproic acid
14
valproic acid (as sodium salt) (valproate sodium)
14
X
valsartan
36
XARELTO
34
valsartan/hydrochlorothiazide
36
XENAZINE
43
vancomycin hcl
9
XIFAXAN
vandazole
9
XOPENEX HFA
66
vandetanib
24
XTANDI
58
VELETRI
67
xulane
56
velivet
56
xylon 10
5
venlafaxine hcl
17
XYREM
68
VENTAVIS
67
ventolin hfa
66
verapamil hcl
37,39
VERSACLOZ
9
Z
zafirlukast
65
27
zaleplon
68
vestura
56
zarah
56
VEXOL
63
ZAVESCA
46
VICTOZA 2-PAK
33
ZELBORAF
24
VICTOZA 3-PAK
33
ZEMPLAR
58
VICTRELIS
30
zenatane
45
VIGAMOX
62
zenchent
56
VIMPAT
15
ZENPEP
46
vinate one
70
zenzedi
42
vinate-m
70
ZETIA
41
viorele
56
zidovudine
28
VIRACEPT
29
ziprasidone hcl
VIRAMUNE XR
28
ZIRGAN
29
VIREAD
28
ZOLINZA
24
virtussin ac
67
zolmitriptan
21
zolpidem tartrate
68
vitazol
9
15,27
VIVELLE-DOT
56
ZOMIG
21
VOGELXO
52
zonisamide
13
vol-plus
70
ZORBTIVE
51
VOLTAREN
45
ZORTRESS
60
voriconazole
20
zovia 1-35e
56
VOTRIENT
23
zovia 1-50e
56
vyfemla
56
ZYFLO CR
65
VYVANSE
42
ZYKADIA
24
ZYLET
62
ZYTIGA
23
ZYVOX
9
W
warfarin sodium
34
91
Category Listing
Analgesics
Anesthetics
Anti-Addiction/Substance Abuse Treatment Agents
Anti-inflammatory Agents
Antibacterials
Anticonvulsants
Antidementia Agents
Antidepressants
Antiemetics
Antifungals
Antigout Agents
Antimigraine Agents
Antimyasthenic Agents
Antimycobacterials
Antineoplastics
Antiparasitics
Antiparkinson Agents
Antipsychotics
Antispasticity Agents
Antivirals
Anxiolytics
Bipolar Agents
Blood Glucose Regulators
Blood Products/Modifiers/ Volume Expanders
Cardiovascular Agents
Central Nervous System Agents
Dental and Oral Agents
Dermatological Agents
Enzyme Replacement/ Modifiers
Gastrointestinal Agents
Genitourinary Agents
Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal)
Hormonal Agents, Stimulant/Replacement/Modifying (Other)
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)
Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)
Hormonal Agents, Suppressant (Adrenal)
Hormonal Agents, Suppressant (Parathyroid)
Hormonal Agents, Suppressant (Pituitary)
Hormonal Agents, Suppressant (Sex Hormones/Modifiers)
Hormonal Agents, Suppressant (Thyroid)
Immunological Agents
92
1
5
5
6
8
12
15
16
18
19
20
20
21
21
22
25
25
26
27
28
31
31
31
34
35
42
44
44
46
46
49
50
51
51
52
57
58
58
58
58
59
59
Inflammatory Bowel Disease Agents
Metabolic Bone Disease Agents
Miscellaneous
Ophthalmic Agents
Otic Agents
Respiratory Tract Agents
Skeletal Muscle Relaxants
Sleep Disorder Agents
Therapeutic Nutrients/ Minerals/ Electrolytes
Uncategorized
60
61
61
61
64
64
67
68
68
70
93