1. No category

April 2014
Blue Cross and Blue Shield of Minnesota FlexRx Drug Formulary
Contents
Introduction .................................................................... I
Pharmacy and Therapeutics (P&T) Committee
and Coverage Committee ............................................ I
Formulary guidelines ...................................................... II
Formulary addition request ............................................ III
Generic drugs ................................................................ III
Frequently asked questions about generics .................. III
How to use the drug list ................................................. IV
Benefit programs ............................................................ V
Managing drug usage ................................................... VII
Quantity Limits List ...................................................... 1
Therapeutic Class Drug List ........................................ 9
Anti-Infective Drugs ........................................................ 9
Immunizing Agents ....................................................... 11
Cancer Drugs ................................................................ 11
Hormones, Diabetes and Related Drugs ...................... 12
Heart and Circulatory Drugs ......................................... 15
Respiratory Drugs ......................................................... 17
Gastrointestinal Drugs .................................................. 18
Genitourinary Drugs...................................................... 20
Central Nervous System Drugs .................................... 20
Pain Relief Drugs .......................................................... 23
Neuromuscular Drugs ................................................... 24
Supplements ................................................................. 26
Blood Modifying Drugs.................................................. 26
Topical Drugs ................................................................ 27
Miscellaneous Categories ............................................ 30
Index ............................................................................ 32
Key
caps .................................................................... capsules
chew tabs.............................................. chewable tablets
conc............................................................... concentrate
crm ......................................................................... cream
ext-release ........................................... extended-release
inhal................................................................... inhalation
inj ......................................................................... injection
liq .............................................................................. liquid
lotn ........................................................................... lotion
NP ............................................................... non-preferred
ODT ....................................... orally disintegrating tablets
oint ..................................................................... ointment
OSM ......................................................... osmotic-release
OTC ........................................................ over-the-counter
SL ..................................................................... sublingual
soln ....................................................................... solution
supp ............................................................ suppositories
susp................................................................ suspension
tabs.........................................................................tablets
Please consider talking to your doctor about prescribing formulary medications, which may help reduce your
out-of-pocket costs. This list may help guide you and your doctor in selecting an appropriate medication for you.
The drug formulary is regularly updated. Please visit www.bluecrossmn.com for the most up-to-date formulary.
To search for a drug name within this PDF document, use the Control and F keys on your keyboard, or go to
Edit in the drop-down menu and select Find/Search. Type in the word or phrase you are looking for and click
on Search.
2746-A MN © Prime Therapeutics LLC 04/14
Introduction
Blue Cross and Blue Shield of Minnesota and Blue Plus are pleased to present the FlexRx drug formulary (drug list).
Our goal is to give members access to safe and effective prescription drugs at a reasonable cost.
Brand name drugs are not included in this formulary unless they are listed. Blue Cross may choose to not add a drug
to the formulary because of effectiveness or safety concerns, or because a similar, more cost-effective drug is
already on the formulary. New drugs are non-preferred (NP) until reviewed and approved for inclusion by the
Pharmacy and Therapeutics (P&T) Committee and Coverage Committee.
Blue Cross encourages providers to prescribe preferred drugs.
Your drug benefit is presented in the Drug Formulary, and includes most prescription drugs, although some
restrictions and exclusions do apply. For example, investigational drugs and drugs indicated for cosmetic purposes,
e.g., Propecia, may not be eligible for coverage under your prescription drug benefit. Some drugs may only be
available through your medical benefit. Coverage and copayment levels vary depending on the plan. This
prescription drug benefit is multi-tiered, placing prescription drugs into one of four Copay/Coinsurance levels: 

Preferred Generic drugs (Tier 1)

Preferred Brand drugs (Tier 2)

Non-preferred Brand and Generic drugs (Tier 3)

Specialty drugs (Tier 4)
There are various types of pharmacy benefit programs. To understand which program you have, please refer to your
Benefit Booklet, Certificate of Coverage, Contract, Member Handbook or prescription drug endorsement or call the
number on your member ID card for more information.
Pharmacy and Therapeutics (P&T) Committee and Coverage Committee
The Blue Cross Coverage Committee selects drugs for this formulary based on recommendations of an independent
Pharmacy and Therapeutics (P&T) Committee that includes practicing physicians and pharmacists. Decisions to add
or remove drugs from the FlexRx formulary are based on the drug’s safety, effectiveness, uniqueness and cost. The
P&T Committee and Coverage Committee meet at least quarterly. All drugs are reviewed each year as required by
the National Committee on Quality Assurance (NCQA) standards.
You can find recent changes and the current version of the formulary at bluecrossmn.com.
I
FlexRx Drug Formulary, April 2014
Formulary guidelines
The requirement of P&T and Coverage Committee review is a precondition of Blue Cross coverage and:

Applies in addition to all other conditions and terms stated in Blue Cross contracts and stated herein; and

Applies to medications and medical devices when administered in any manner that is approved by the
U. S. Food and Drug Administration (FDA); and

Applies to approved medications legally prescribed and medical devices legally used when administered in any
manner that is not mentioned in the labeling approved by the FDA (referred to as an “off-label” use). Use of a
medication or medical device for an indication, dosage form, dose regimen, population, or other use parameter
not mentioned in the approved labeling is considered to be an “off-label” use.
These guidelines in no way imply that members should not receive specific services based on the recommendation
of the provider. These guidelines govern coverage and not clinical practices. Providers are responsible for giving
medical advice and treating members. Members with specific health care needs should consult an appropriate
health care provider.
Members and providers have the right to appeal coverage decisions. These rights are explained in member and
provider plan documents. Members with questions about appeal rights should call customer service at the number on
the back of their member ID card. Providers can call provider services at 651.662.5200 or toll free at 1.800.262.0820.
This information is not an offer of coverage, solicitation of coverage, summary of coverage or guarantee of coverage.
All products and coverage guidelines are subject to applicable laws and regulations. Member or provider coverage is
contingent on all the applicable terms, conditions, limitations and exclusions of member or provider plan documents.
FlexRx Drug Formulary, April 2014
II
Formulary addition request
Any health care provider may request in writing that the Blue Cross Coverage Committee consider adding or deleting
a drug from the formulary. All formulary requests are brought before the Coverage Committee.
Generic drugs
Blue Cross encourages use of generic drugs as a way to provide high-quality, cost-effective care. Generic drugs are
safe, effective and they may cost less than brand name drugs. Members will likely pay a lower copayment or
coinsurance for a generic drug.
Frequently asked questions about generics
Are generics as good as brand name drugs?
Both brand name and generic drugs must be approved by the FDA. Generic drugs meet the same high standards as
brand name drugs.
Why should I take generics rather than brand name drugs?
We must all do our part to make health care affordable. One way is to be wise buyers of drugs. Generics provide the
same effectiveness and safety as their brand name counterparts, but are often lower in cost. This typically occurs
when competition among several manufacturers who produce the generic drug, results in lower prices for it. Lower
costs generally mean lower copayments for members. Generics also save money for your health plan, so it can help
keep insurance premiums as low as possible.
How can I take advantage of lower-cost generics?
Ask your pharmacist for a generic whenever available. Also, talk with your doctor or other provider about prescribing
generic drugs. Most drug classes include some generic drugs.
III
FlexRx Drug Formulary, April 2014
How to use this list
The drug list is organized into broad categories (e.g., HORMONES, DIABETES AND RELATED DRUGS).
The first column of the chart lists the drug name.
Generic drugs are listed in lowercase boldface (e.g., budesonide ext-release)
Preferred brand name drugs are capitalized (e.g., CORTISONE).
Non-preferred brand name drugs are not included in this Drug List
Separate drug entries are required for some dosage forms or routes of administration.
The second column indicates the formulary tier level.

Preferred Generic drugs (Tier 1)

Preferred Brand drugs (Tier 2)
The third column indicates if the drug is a specialty drug.
Note: Additional information about specialty drugs can be found in this document under the topic
Benefit Programs.
The remaining columns indicate the Utilization Management (UM) program(s) that apply to the prescription drug
(e.g., Prior Authorization, Quantity Limits, and Step Therapy). If an indicator is present in the column(s), then the
UM program applies.
Compounded prescriptions
Compounded prescriptions contain two or more drugs mixed together. The end product cannot be available in
an equivalent commercial form (except for hydroxyprogesterone). Plus, at least one ingredient must be an
FDA-approved prescription drug. Compounded prescriptions are processed according to member benefits.
Injectable drugs
Self-administered injectable drugs are generally part of the pharmacy benefit and may be included on the formulary.
Injectable drugs are processed according to member benefits.
Some injectable drugs that need to be administered by a health care professional are covered only under the plan’s
medical benefit.
FlexRx Drug Formulary, April 2014
IV
Benefit programs
90dayRx
Blue Cross has an optional 90dayRx program. Members with this benefit may receive up to a 90-day supply of drugs
at a reduced cost. In addition to being able to obtain up to a 90-day supply of drugs through our mail order pharmacy
you may be able to receive up to a 90-day supply of drugs through a participating retail pharmacy. Please refer to
your plan documents for complete coverage details.
Retail Pharmacy Vaccine Program
Blue Cross has an optional vaccine pharmacy program for flu, pneumonia, shingles, diphtheria tetanus combinations,
human papillomavirus (HPV) and meningitis vaccines. Members with this benefit can simply present their health plan
member ID card when visiting a participating pharmacy. The cost share will be based on their pharmacy coverage for
this benefit. Members can go to MyPrime.com to locate network pharmacies that administer approved vaccines for
Blue Cross Blue Shield of Minnesota members.
Please note that age limitations, advance registration or other requirements may apply. The availability of each
vaccine may vary by individual pharmacy or location. For your convenience, you may contact the pharmacy in
advance if you have questions or to make sure these services are available at a particular location.
Specialty drugs
Blue Cross has an optional specialty pharmacy network. Members with this benefit must obtain their specialty drugs
from an in-network specialty provider or they will pay 100 percent of the drug cost.
The specialty drug vendors and drugs covered by this specialty drug benefit are listed at bluecrossmn.com.
Over-the-counter (OTC) drugs
Blue Cross has an OTC drug benefit. Members with this coverage may receive an eligible OTC product at their
lowest cost. Covered OTC drugs require a prescription. Members can get a one-month supply with this benefit: The
program limits coverage to formulary and OTC drugs in these classes. Drugs not on the formulary or included in the
OTC benefit will not be covered.
Drugs covered by this OTC drug benefit are listed at bluecrossmn.com.
V
FlexRx Drug Formulary, April 2014
Affordable Care Act Contraceptives
Select contraceptives will be covered without cost share for women in accordance with each member’s specific
benefit plan. This new contraceptive benefit will take effect on the first day of a member’s plan year, on or after
January 1, 2014. The following select contraceptive medications will be available at $0 cost to eligible members:

Barrier Method Types
Cervical Caps
Diaphragms
Female Condom
Spermicide
Sponge


Emergency Contraceptives: ELLA, levonorgestrel, My Way, Next Choice/One Dose, PLAN B
Injectables
DEPO-PROVERA CONTRACEPTIVE
DEPO-SUBQ-PROVERA 104
medroxyprogesterone acetate

Hormonal Methods
NUVARING
Oral combination triphasic contraceptives include generic norgestimate-ethinyl estradiol, Trinessa,
Tri-Estarylla, Tri-Linyah, Tri-Previfem, and Tri-Sprintec.
Oral extended cycle/continuous use contraceptives include generic Introvale, Jolessa,
levonorgestrel/ethinyl estradiol (91-day) tab 0.15-0.03 mg, and Quasense.
Oral progestin contraceptives include generic Camila, Errin, Heather, Jencycla, Jolivette, Lyza,
Nora-BE, and norethindrone.
ORTHO EVRA
Affordable Care Act OTC Supplements
Select OTC supplements will be covered without cost share in accordance with each member’s specific benefit plan.
This new OTC supplemental benefit will take effect upon renewal the first day of a member’s plan year, beginning
on or after January 1, 2014. The following select OTC supplement will be available at $0 cost to eligible members
with a prescription.

Aspirin- men ages 45-79 and women ages 55-79

Folic acid- containing 0.4-0.8 mg for women ages 12-64

Fluoride- for preschool children ages 6 months-6 years

Iron- children ages 6-12 months and women ages 12-64

Vitamin D- adults ages 65 and older
Affordable Care Act Smoking Cessation
Select smoking cessation will be covered without cost share in accordance with each member’s specific benefit
plan. This new smoking cessation benefit will take effect upon renewal the first day of a member’s plan year,
beginning on or after January 1, 2014. The following select smoking cessation will be available at $0 cost to eligible
members with a prescription.





bupropion ext-release (Zyban)
CHANTIX
nicotine gum, lozenge, kit, patch
NICOTROL NS
NICOTROL Inhaler
FlexRx Drug Formulary, April 2014
VI
Managing drug usage
Formulary Exceptions

To request coverage of a non-preferred drug for a member with a closed formulary benefit plan

To request a brand name drug exception for a member with a mandatory generic plan
Steps on how a prescriber may request a Formulary Exception:

A prescriber may obtain a Minnesota Uniform Form for Prescription Drug Prior Authorization Request &
Formulary Exceptions online at providers.bluecrossmn.com in the Forms section. The prescriber can also
obtain the form by calling provider services at 651.662.5200 or 1.800.262.0820.

Submit the completed request form to the following address or fax:
Prime Therapeutics
Clinical Review Department
1305 Corporate Center Drive
Eagan, MN 55121
Fax number: 1.877.480.8130
Prior Authorization
Some drugs require prior authorization because of their high potential for misuse or overuse. Coverage may
be approved after certain criteria are met. Approval is required for claims to process at network pharmacies.
Policies regarding the covered uses of drugs and drug classes requiring prior authorization can be found at
bluecrossmn.com. For more information, call the number on the back of your member ID card. Providers can
call provider services at 651.662.5200 or toll free at 1.800.262.0820.
Steps on how a prescriber may request a Prior Authorization:

A prescriber may obtain a Minnesota Uniform Form for Prescription Drug Prior Authorization Request &
Formulary Exceptions online at providers.bluecrossmn.com in the Forms section. The prescriber can also
obtain the form by calling provider services at 651.662.5200 or 1.800.262.0820.

Submit the completed request form along with relevant medical records to the following address or fax:
Blue Cross and Blue Shield of Minnesota
Integrated Health Management, Route 472
P.O. Box 64265
St. Paul, MN 55164-0265
Fax number: 651.662.2810
VII
FlexRx Drug Formulary, April 2014
Step Therapy
Step therapy programs help manage the cost of expensive drugs by redirecting members to safe, effective and less
expensive alternatives. Preferred and non-preferred drugs may be subject to step therapy. If a member does not
meet the criteria in the automated review of the member’s claims, their doctor can submit a request for review.

Steps on how a prescriber may request a Step Therapy authorization:

A prescriber may obtain a Step Therapy Authorization request form online at providers.bluecrossmn.com
in the Forms section. The prescriber can also obtain the form by calling provider services at 651.662.5200
or 1.800.262.0820.

Submit the completed request form to the following address or fax:
Prime Therapeutics
Clinical Review Department
1305 Corporate Center Drive
Eagan, MN 55121
Fax number: 1.877.480.8130
Quantity Limits
Certain drugs have quantity limits to encourage appropriate drug usage, enhance drug therapy and reduce costs.
The quantity limit is the maximum quantity that can be dispensed over a given period of time. Preferred and
non-preferred drugs may have quantity limits.

Steps on how a prescriber may request a Quantity Limit exception:

A prescriber may obtain a Quantity Limits Override request form online at providers.bluecrossmn.com
in the Forms section. The prescriber can also obtain the form by calling provider services at 651.662.5200
or 1.800.262.0820.

Submit the completed request form to the following address or fax:
Prime Therapeutics
Clinical Review Department
1305 Corporate Center Drive
Eagan, MN 55121
Fax number: 1.877.480.8130
Key
caps .................................................................... capsules
chew tabs ............................................. chewable tablets
ODT ........................................ orally disintegrating tablets
oint ...................................................................... ointment
conc .............................................................. concentrate
crm ......................................................................... cream
OSM ........................................................ osmotic-release
OTC ........................................................ over-the-counter
ext-release ........................................... extended-release
inhal................................................................... inhalation
SL ..................................................................... sublingual
soln ...................................................................... solution
inj ......................................................................... injection
liq .............................................................................. liquid
supp ............................................................ suppositories
susp ............................................................... suspension
lotn ........................................................................... lotion
NP ............................................................... non-preferred
tabs ........................................................................ tablets
FlexRx Drug Formulary, April 2014
VIII
Quantity Limits (QL)
Brand Name (generic name - if available)
Abilify Discmelt
Abilify inj
Abilify Maintena
Abilify oral soln
Abilify tabs
Acetaminophen/Caffeine/Dihydrocodeine 712.8-60-32 mg
acetaminophen/codeine 120-12 mg/5 mL
Actonel 150 mg
Actonel 35 mg
Actonel 5 mg, 30 mg
Adderall 20 mg (amphetamine/dextroamphetamine)
Adderall 5 mg, 7.5 mg, 10 mg, 12.5 mg, 15 mg, 30 mg
(amphetamine/dextroamphetamine)
Adderall XR (amphetamine/dextroamphetamine extrelease)
Afinitor
Afinitor Disperz, 2 mg, 5 mg
Afinitor Disperz, 3 mg
Alagesic LQ
Alendronate soln
alendronate tabs, 35 mg, 70 mg
Alendronate tabs, 40 mg
alendronate tabs, 5 mg, 10 mg
Alsuma
Amerge (naratriptan)
Androderm 2 mg/day, 4 mg/day, 5 mg/day
Androderm 2.5 mg/day
Androgel 1% gel
Androgel 1% gel, pump
Androgel 1.62% gel, 20.25 mg/1.25 g packet
Androgel 1.62% gel, 40.5 mg/1.25 g packet
Androgel 1.62% gel, pump
Atelvia
Avinza (morphine sulfate ext-release)
Axert
Axiron
Binosto
Bio-T-Gel
Boniva tabs (ibandronate)
Bosulif 100 mg
Bosulif 500 mg
Bupap 50-300 mg
buprenorphine
butalbital/acetaminophen 50-325mg
FlexRx Drug Formulary, April 2014
Preferred Status
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes, generic; No, brand
Yes, generic; No, brand
Quantity Limit (per 30 days)
60 tabs
90 vials
1 vial/4 weeks
750 mL
30 tabs
150 tabs
2700 mL
1 tab
4 tabs
30 tabs
90 tabs
60 tabs
No, generic; Yes, brand 30 caps
Yes
Yes
Yes
No
No
Yes
Yes
Yes
No
Yes, generic; No, brand
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
Yes, generic; No, brand
Yes
Yes
No
Yes
Yes
30 tabs
60 tabs
90 tabs
2700 mL
300 mL/28 days
4 tabs
30 tabs
30 tabs
12 doses
18 tabs
30 patches
90 patches
60 packets
4 pumps
30 packets
60 packets
2 pumps
4 tabs/28 days
30 caps
12 tabs
2 pumps
4 tabs/28 days
60 packets
1 blister pack
120 tabs
30 tabs
180 tabs
15 tabs/90 days
180 tabs
1
Brand Name (generic name - if available)
butalbital/acetaminophen/caffeine/codeine
50-325-40-30 mg
butalbital/aspirin/caffeine caps, 50-325-40 mg
Butalbital/Aspirin/Caffeine tabs, 50-325-40 mg
butorphanol nasal spray
Butrans
Cafergot
Capacet
Capital w/Codeine
Caprelsa 100 mg
Caprelsa 300 mg
Cialis 10 mg, 20 mg
Cialis 2.5 mg, 5 mg
clozapine 200 mg
clozapine 50 mg
Clozapine ODT, 12.5 mg, 100 mg
Clozapine ODT, 25 mg
Clozaril 100 mg (clozapine)
Clozaril 25 mg (clozapine)
Co-Gesic
Cometriq
Commit (nicotine)
Concerta 18 mg, 27 mg, 54 mg (methylphenidate extrelease OSM)
Concerta 36 mg (methylphenidate ext-release OSM)
Conzip
D. H. E. 45 (dihydroergotamine)
Daytrana
Desoxyn (methamphetamine)
Detrol (tolterodine)
Detrol LA (tolterodine ext-release)
Dexedrine Spansules 10 mg, 15 mg (dextroamphetamine
ext-release)
Dexedrine Spansules 5 mg (dextroamphetamine extrelease)
dextroamphetamine 10 mg
dextroamphetamine 5 mg
Dihydroergotamine mesylate nasal spray, 4 mg/mL
Ditropan XL 10 mg, 15 mg (oxybutynin ext-release)
Ditropan XL 5 mg (oxybutynin ext-release)
Dolgic Plus
Eliquis
Enablex
Ergomar
Erivedge
2
Preferred Status
No
Quantity Limit (per 30 days)
180 caps
Yes
Yes
No
No
No
Yes, generic
No
Yes
Yes
No (covered for males
only > 18 years)
No (covered for males
only > 18 years)
Yes
Yes
No
No
Yes, generic; No, brand
Yes, generic; No, brand
Yes, generic
Yes
Yes
Yes, generic; No, brand
180 caps
180 tabs
3 x 2.5 mL
1 patch/7 days
40 tabs
180 caps
2700 mL
60 tabs
30 tabs
6 tabs
Yes, generic; No, brand
No
Yes, generic; No, brand
No
No
Yes, generic; No, brand
Yes
Yes, generic; No, brand
60 tabs
30 caps
20 ampules
30 patches
150 tabs
60 tabs
30 caps
120 caps
30 tabs
120 tabs
90 tabs
90 tabs
270 tabs
270 tabs
90 tabs
240 tabs
1 carton/28 days
680 lozenges
30 tabs
Yes, generic; No, brand 90 caps
Yes
Yes
No
Yes, generic; No, brand
Yes, generic; No, brand
No
No
No
No
Yes
180 tabs
60 tabs
16 ampules
60 tabs
30 tabs
150 tabs
60 tabs
30 tabs
40 tabs
30 caps
FlexRx Drug Formulary, April 2014
Brand Name (generic name - if available)
Esgic 50-325-40 mg (butalbital/acetaminophen/caffeine)
Esgic-Plus caps, 50-500-40 mg (butalbital/
acetaminophen/caffeine)
Esgic-Plus tabs, 50-500-40 mg (butalbital/acetaminophen/
caffeine)
Exalgo
Fanapt
FazaClo 12.5 mg, 100 mg
FazaClo 150 mg
FazaClo 200 mg
FazaClo 25 mg
Fioricet 50-300-40 mg (butalbital/acetaminophen/
caffeine)
Fioricet w/Codeine 50-300-40-30 mg (butalbital/
acetaminophen/caffeine/codeine)
Fiorinal caps, 50-325-40 mg (butalbital/aspirin/caffeine)
Fiorinal w/Codeine 50-325-40-30 mg (butalbital/aspirin/
caffeine/codeine)
First-Testosterone 2% ointment
First-Testosterone MC 2% cream
Focalin (dexmethylphenidate)
Focalin XR (dexmethylphenidate ext-release)
Fortesta
Fosamax tabs, 70 mg (alendronate)
Fosamax Plus D
Frova
Gelnique
Geodon caps (ziprasidone)
Geodon inj
Gilotrif
Gleevec 100 mg
Gleevec 400 mg
Hycet soln, 7.5-325 mg/15 mL (hydrocodone/
acetaminophen)
Hydrocodone/Acetaminophen soln, 10-325 mg/15 mL
hydrocodone/acetaminophen tabs, 10-660 mg
Hydrocodone/Acetaminophen tabs, 2.5-325 mg
hydrocodone/acetaminophen tabs, 2.5-500 mg
hydrocodone/acetaminophen tabs, 7.5-750 mg
hydrocodone/ibuprofen tabs, 5-200 mg
Hydrogesic caps, 5-500 mg
Ibudone 10-200 mg (hydrocodone/ibuprofen)
Ibudone 5-200 mg
Iclusig 15 mg
Iclusig 45 mg
Imbruvica
Imitrex nasal spray
FlexRx Drug Formulary, April 2014
Preferred Status
Quantity Limit (per 30 days)
Yes, generic; No, brand 180 tabs/caps
No
180 caps
Yes, generic; No, brand 180 tabs
No
No
No
No
No
No
No
30 tabs
60 tabs
90 tabs
180 tabs
120 tabs
270 tabs
180 caps
No
180 caps
Yes, generic; No, brand 180 caps
Yes, generic; No, brand 180 caps
No
No
Yes, generic; No, brand
No
No
Yes, generic; No, brand
No
No
No
Yes, generic; No, brand
No
Yes
Yes
Yes
No
60 g (one jar)
60 g (one jar)
60 tabs
30 caps
2 pumps
4 tabs
4 tabs
18 tabs
30 sachets
60 caps
60 vials
30 tabs
90 tabs
60 tabs
3600 mL
No
Yes
No
Yes
Yes
Yes
Yes, generic
Yes, generic; No, brand
Yes, generic
Yes
Yes
Yes
No
2700 mL
180 tabs
240 tabs
240 tabs
150 tabs
150 tabs
240 caps
150 tabs
150 tabs
60 tabs
30 tabs
120 caps
12 spray unit devices
3
Brand Name (generic name - if available)
Imitrex single dose vial, 6 mg/0.5 mL (sumatriptan)
Imitrex STATdose (sumatriptan)
Imitrex tabs (sumatriptan)
Inlyta 1 mg
Inlyta 5 mg
Intuniv
Invega 1.5 mg, 3 mg, 9 mg
Invega 6 mg
Invega Sustenna
Jakafi
Kadian 10 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg, 100 mg
(morphine sulfate ext-release)
Kadian 40 mg, 70 mg, 130 mg, 150 mg, 200 mg
Kapvay 0.1 mg (clonidine ext-release 12 hr)
Kapvay Dose Pack
Latuda 20 mg, 40 mg, 60 mg, 120 mg
Latuda 80 mg
Levitra
Liquicet
Lorcet Plus tabs, 7.5-650 mg (hydrocodone/
acetaminophen)
Lorcet tabs, 10-650 mg (hydrocodone/acetaminophen)
Lortab tabs, 5-500 mg (hydrocodone/acetaminophen)
Lortab soln, 10-300 mg/15 mL (hydrocodone/
acetaminophen)
Lortab tabs, 7.5-500 mg, 10-500 mg (hydrocodone/
acetaminophen)
Magnacet 10-400 mg
Magnacet 5-400 mg
Magnacet 7.5-400 mg
Makena
Margesic
Maxalt, Maxalt MLT (rizatriptan)
Maxidone 10-750 mg (hydrocodone/acetaminophen)
Mekinist 0.5 mg
Mekinist 1 mg, 2 mg
Metadate CD caps (methylphenidate ext-release)
Metadate ER tab, 20 mg
Methylin soln, 10 mg/5 mL (methylphenidate)
Methylin chew tabs, 10 mg
Methylin chew tabs, 2.5 mg, 5 mg
Methylin soln, 5 mg/5 mL (methylphenidate)
Methylphenidate ext-release tabs, 10 mg
Migergot
Migranal
4
Preferred Status
Yes, generic; No, brand
Yes, generic; No, brand
Yes, generic; No, brand
Yes
Yes
Yes
No
No
No
Yes
No
Quantity Limit (per 30 days)
10 vials
12 syringe cartridges
18 tabs
180 tabs
120 tabs
30 tabs
30 tabs
60 tabs
1 kit
60 tabs
60 caps
No
No
No
No
No
No (covered for males
only > 18 years)
No
Yes, generic; No, brand
60 caps
120 tabs
60 tabs
30 tabs
60 tabs
6 tabs
2700 mL
180 tabs
Yes, generic; No, brand 180 tabs
Yes, generic; No, brand 240 tabs
No
2700 mL
Yes, generic; No, brand 180 tabs
No
No
No
No
Yes, generic
Yes, generic; No, brand
Yes, generic; No, brand
Yes
Yes
Yes, generic; No, brand
Yes, generic
No
No
No
No
Yes
Yes
Yes
180 tabs
300 tabs
240 tabs
1 vial
180 caps
18 tabs
150 tabs
90 tabs
30 tabs
30 caps
90 tabs
900 mL
180 tabs
90 tabs
450 mL
90 tabs
40 supp
16 ampules
FlexRx Drug Formulary, April 2014
Brand Name (generic name - if available)
MS Contin (morphine sulfate ext-release)
Myrbetriq
Nexavar
Nicorette (nicotine)
Nicotrol nasal spray
Nicotrol oral inhaler
Norco 5-325 mg (hydrocodone/acetaminophen)
Norco 7.5-325 mg, 10-325 mg (hydrocodone/
acetaminophen)
Nucynta
Nucynta ER
Nuvigil
Opana ER (Crush Resistant)
oxybutynin syrup
oxybutynin tabs
oxycodone/acetaminophen caps, 5-500 mg
oxycodone/ibuprofen
Oxycontin 10 mg, 15 mg, 20 mg, 30 mg, 40 mg
Oxycontin 60 mg, 80 mg
Oxytrol
pentazocine/acetaminophen
Percocet 10-325 mg, 10-650 mg (oxycodone/
acetaminophen)
Percocet 2.5-325 mg (oxycodone/acetaminophen)
Percocet 5-325 mg (oxycodone/acetaminophen)
Percocet 7.5-325 mg, 7.5-500 mg (oxycodone/
acetaminophen)
Percodan (oxycodone/aspirin)
Phrenilin Forte
Pomalyst
Pradaxa
Primlev 10-300 mg
Primlev 5-300 mg
Primlev 7.5-300 mg
Procentra oral soln (dextroamphetamine)
Provigil (modafanil)
Quillivant XR oral suspension
Relpax
Repan
Reprexain 10-200 mg
Reprexain 2.5-200 mg (hydrocodone/ibuprofen)
Reprexain 5-200 mg (hydrocodone/ibuprofen)
Revlimid 15 mg, 20 mg, 25 mg
Revlimid 2.5 mg, 5 mg, 10 mg
Risperdal Consta
Risperdal M-Tab, 0.5 mg, 1 mg, 2 mg, 3 mg (risperidone)
FlexRx Drug Formulary, April 2014
Preferred Status
Yes, generic; No, brand
No
Yes
Yes
Yes
Yes
Yes, generic; No, brand
Yes, generic; No, brand
Quantity Limit (per 30 days)
90 tabs
30 tabs
120 tabs
816 pieces
12 bottles
3 inhalers
360 tabs
180 tabs
No
No
No
No
Yes
Yes
Yes
No
Yes
Yes
No
No
Yes, generic; No, brand
180 tabs
60 tabs
30 tabs
60 tabs
600 mL
120 tabs
240 caps
120 tabs
60 tabs
120 tabs
8 patches
180 tabs
180 tabs
No
360 tabs
Yes, generic; No, brand 360 tabs
Yes, generic; No, brand 240 tabs
Yes, generic; No, brand
No
Yes
Yes
No
No
No
No
Yes, generic; No, brand
No
No
Yes, generic
Yes, generic
No
Yes, generic; No, brand
Yes
Yes
No
Yes, generic; No, brand
360 tabs
180 caps
21 caps/28 days
60 caps
180 tabs
360 tabs
240 tabs
1800 mL
30 tabs
360 mL
12 tabs
180 tabs
150 tabs
150 tabs
150 tabs
21 caps/28 days
30 caps
2 vials/28 days
60 tabs
5
Brand Name (generic name - if available)
Risperdal M-Tab, 4 mg (risperidone)
Risperdal soln (risperidone)
Risperdal tabs, 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg
(risperidone)
Risperdal tabs, 4 mg (risperidone)
risperidone ODT 0.25 mg
Ritalin (methylphenidate)
Ritalin LA 10 mg
Ritalin LA 20 mg, 40 mg (methylphenidate ext-release)
Ritalin LA 30 mg (methylphenidate ext-release)
Ritalin SR tabs, 20 mg (methylphenidate ext-release)
Roxicet soln
Roxicet tabs, 5-325 mg
Sanctura (trospium)
Sanctura XR (trospium ext-release)
Saphris
Seroquel 25 mg, 50 mg, 100 mg, 200 mg (quetiapine)
Seroquel 300 mg, 400 mg (quetiapine)
Seroquel XR 150 mg, 200 mg
Seroquel XR 50 mg, 300 mg, 400 mg
Sprycel 20 mg
Sprycel 50 mg, 70 mg, 80 mg, 100 mg, 140 mg
Stagesic
Staxyn
Stendra
Stivarga
Strattera 10 mg, 18 mg, 25 mg, 40 mg
Strattera 60 mg, 80 mg, 100 mg
Striant
Suboxone (buprenorphine/naloxone)
Suboxone 2 mg/0.5 mg
Suboxone 4 mg/1 mg
Suboxone 8 mg/2 mg, 12 mg/3 mg
Sumatriptan nasal spray
sumatriptan single dose vial, 4 mg/0.5 mL
Sumavel DosePro
Sutent 12.5 mg
Sutent 25 mg, 50 mg
Synalgos DC
Tafinlar
Tarceva 100 mg, 150 mg
Tarceva 25 mg
Tasigna
Tencon
Testim
6
Preferred Status
Quantity Limit (per 30 days)
Yes, generic; No, brand 120 tabs
Yes, generic; No, brand 480 mL
Yes, generic; No, brand 60 tabs
Yes, generic; No, brand
Yes
Yes, generic; No, brand
No
Yes, generic; No, brand
Yes, generic; No, brand
Yes, generic; No, brand
Yes
Yes, generic
No
No
No
Yes, generic; No, brand
Yes, generic; No, brand
Yes
Yes
Yes
Yes
Yes, generic
No (Covered for males
only > 18 years)
No
Yes
Yes
Yes
No
Yes, generic; No, brand
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
No
Yes
Yes
Yes
Yes
No
No
120 tabs
60 tabs
90 tabs
30 caps
30 caps
60 caps
90 tabs
1800 mL
360 tabs
60 tabs
30 caps
60 tabs
90 tabs
60 tabs
30 tabs
60 tabs
60 tabs
30 tabs
240 caps
6 tabs
6 tabs
90 tabs
60 caps
30 caps
60 systems
90 tabs
90 films
30 films
60 films
12 spray unit devices
12 vials
12 injection devices
90 caps
30 caps
12 caps
120 caps
30 tabs
60 tabs
120 caps
180 tabs
60 tubes
FlexRx Drug Formulary, April 2014
Brand Name (generic name - if available)
Thalomid 150 mg, 200 mg
Thalomid 50 mg, 100 mg
Toviaz
Tramadol ER 150 mg
Treximet
Trezix
Tudorza
Tykerb
Tylenol w/Codeine 300-15 mg, 300-30 mg
(acetaminophen/codeine)
Tylenol w/Codeine 300-60 mg (acetaminophen/codeine)
Ultracet (tramadol/acetaminophen)
Ultram (tramadol)
Ultram ER (tramadol ext-release)
Versacloz
Vesicare
Viagra
Vicodin 5-300 mg
Vicodin ES 7.5-300 mg
Vicodin HP 10-300 mg
Vicoprofen 7.5-200 mg (hydrocodone/ibuprofen)
Votrient
Vyvanse
Xalkori
Xarelto 20 mg
Xarelto 10 mg
Xarelto 15 mg
Xenazine 12.5 mg
Xenazine 25 mg
Xodol 5-300 mg (hydrocodone/acetaminophen)
Xodol 7.5-300 mg, 10-300 mg (hydrocodone/
acetaminophen)
Xolox
Xtandi
Xyrem
Zamicet
Zavesca
Zebutal
Zelboraf
Zenzedi 10 mg
Zenzedi 2.5 mg
Zenzedi 5 mg
Zenzedi 7.5 mg
Zolinza
Zolvit
FlexRx Drug Formulary, April 2014
Preferred Status
Yes
Yes
No
No
No
No
No
Yes
Yes, generic; No, brand
Quantity Limit (per 30 days)
60 caps
30 caps
30 tabs
30 caps
18 tabs
300 caps
1 canister
180 tabs
360 tabs
Yes, generic; No, brand
Yes, generic; No, brand
Yes, generic; No, brand
Yes, generic; No, brand
No
Yes
Yes (covered only for
males > 18 years)
No
No
No
Yes, generic; No, brand
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
180 tabs
240 tabs
240 tabs
30 tabs
540 mL
30 tabs
6 tabs
No
Yes
No
No
No
No
Yes
Yes, generic
No
Yes, generic
No
Yes
No
240 tabs
120 caps
540 mL
2700 mL
90 caps
180 caps
240 tabs
180 tabs
90 tabs
60 tabs
60 tabs
120 caps
2025 mL
360 tabs
180 tabs
180 tabs
150 tabs
120 tabs
30 caps
60 caps
30 tabs
35 tabs/90 days
60 tabs
240 tabs
120 tabs
360 tabs
180 tabs
7
Brand Name (generic name - if available)
Zomig nasal spray
Zomig, Zomig ZMT (zolmitriptan)
Zubsolv
Zydone 5-400 mg
Zydone 7.5-400 mg, 10-400 mg
Zyprexa Relprevv 210 mg, 300 mg
Zyprexa Relprevv 405 mg
Zyprexa tabs (olanzapine)
Zyprexa Zydis (olanzapine)
Zytiga
8
Preferred Status
No
No
No
No
No
No
No
Yes, generic; No, brand
Yes, generic; No, brand
Yes
Quantity Limit (per 30 days)
12 spray units
12 tabs
90 tabs
240 tabs
180 tabs
2 vials/28 days
1 vial/28 days
30 tabs
30 tabs
120 tabs
FlexRx Drug Formulary, April 2014
erythromycin delayed-release
caps
1
ERYTHROMYCIN
ETHYLSUCCINATE
2
erythromycin/sulfisoxazole
1
ZITHROMAX packets
2
amoxicillin caps, susp, tabs
1
AMOXICILLIN chew tabs
2
amoxicillin/potassium
clavulanate (Augmentin – brand
is NP)
1
amoxicillin/potassium
clavulanate extrelease (Augmentin XR – brand
is NP)
1
ampicillin caps
1
AMPICILLIN susp
2
AUGMENTIN susp, 125 mg/5 mL
2
dicloxacillin
1
penicillin v potassium
TETRACYCLINES
demeclocycline
1
doxycycline hyclate
caps (Vibramycin – brand is NP)
1
doxycycline hyclate tabs
1
doxycycline
monohydrate (Adoxa, Monodox
– brands are NP)
1
1
minocycline (Dynacin, Minocin –
brands are NP)
1
cefadroxil
1
TETRACYCLINE
2
cefdinir
1
FLUOROQUINOLONES
cefpodoxime
1
CIPRO susp
cefprozil
1
ceftriaxone (Rocephin – brand is
NP)
1
ciprofloxacin (Cipro – brand is NP) 1
1
ciprofloxacin ext-release
cefuroxime (Ceftin – brand is NP)
1
levofloxacin (Levaquin – brand is
NP)
cephalexin caps, 250 mg,
500 mg; susp (Keflex – brand is
NP)
1
AMINOGLYCOSIDES
SUPRAX tabs, NP = chew tabs
2
CEPHALOSPORINS
MACROLIDES
azithromycin susp,
tabs (Zithromax – brand is NP)
1
clarithromycin (Biaxin – brand is
NP)
1
clarithromycin ext-release (Biaxin
XL – brand is NP)
1
DIFICID
2
ERY-TAB
2
ERYTHROCIN STEARATE
2
FlexRx Drug Formulary, April 2014
Step Therapy
PENICILLINS
Quantity Limits
2
Prior Authorization
ERYTHROMYCIN BASE
Specialty
Drug Tier
Step Therapy
Quantity Limits
Prior Authorization
ANTI-INFECTIVE DRUGS
Specialty
Drug Name
Drug Name
Drug Tier
2014
2
1
neomycin sulfate
1
paromomycin
1
TOBI, NP = Podhaler
2
tobramycin (Tobi)
1
•
•
SULFONAMIDES
sulfamethoxazole/trimethoprim
(Bactrim – brand is NP)
1
TUBERCULOSIS
ethambutol (Myambutol – brand is
NP)
1
ISONIAZID syrup
2
isoniazid tabs
1
9
1
pyrazinamide
1
1
rifampin (Rifadin – brand is NP)
1
abacavir/lamivudine/
zidovudine (Trizivir)
APTIVUS
2
ATRIPLA
2
COMPLERA
2
fluconazole (Diflucan – brand is
NP)
1
flucytosine (Ancobon – brand is
NP)
1
CRIXIVAN
2
griseofulvin microsize (Grifulvin V
– brand is NP)
didanosine delayedrelease (Videx EC – brand is NP)
1
1
EDURANT
2
itraconazole (Sporanox – brand is
NP)
1
EMTRIVA
2
2
EPIVIR oral soln
2
NOXAFIL
1
EPZICOM
2
nystatin oral
1
FUZEON
2
terbinafine (Lamisil – brand is NP)
2
INTELENCE
2
VFEND susp
1
INVIRASE
2
voriconazole (Vfend tabs – brand
is NP)
ISENTRESS
2
VIRAL INFECTIONS
KALETRA
2
Cytomegalovirus
lamivudine tabs (Epivir – brand is
NP)
1
lamivudine/zidovudine (Combivir
– brand is NP)
1
LEXIVA
2
VALCYTE
2
Hepatitis
adefovir (Hepsera – brand is NP)
1
BARACLUDE
2
EPIVIR-HBV
2
INCIVEK
2
lamivudine (Epivir HBV)
1
PEGASYS
2
ribavirin (Copegus, Rebetol –
brands are NP)
1
•
•
VICTRELIS
2
• •
Herpes
acyclovir (Zovirax – brand is NP)
1
famciclovir (Famvir – brand is NP)
1
valacyclovir (Valtrex – brand is
NP)
1
10
• •
•
nevirapine tabs (Viramune – brand 1
is NP)
2
NORVIR
PREZISTA
2
RESCRIPTOR
2
REYATAZ
2
SELZENTRY
2
stavudine (Zerit – brand is NP)
1
STRIBILD
2
SUSTIVA
2
TIVICAY
2
TRIZIVIR
2
FlexRx Drug Formulary, April 2014
Step Therapy
abacavir (Ziagen – brand is NP)
Quantity Limits
PRIFTIN
Prior Authorization
HIV/AIDS
2
Drug Name
Specialty
2
FUNGAL INFECTIONS
Drug Tier
Step Therapy
Quantity Limits
MYCOBUTIN
Specialty
Drug Name
Drug Tier
Prior Authorization
2014
Step Therapy
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Step Therapy
VIDEX
Quantity Limits
2
Prior Authorization
TRUVADA
Specialty
Drug Name
Drug Tier
2014
1
2
vancomycin (Vancocin – brand is
NP)
VIRACEPT
2
XIFAXAN 550 mg
2
VIRAMUNE susp
2
ZYVOX
2
VIRAMUNE XR
2
IMMUNIZING AGENTS
VIREAD
2
SYNAGIS
ZIAGEN soln
2
CANCER DRUGS
The list of drugs shown below includes selected oral
and injectable cancer drugs on the formulary. However,
all generic cancer drugs are on the formulary. All brand
drugs are on formulary until a generic version becomes
available and has been added to the formulary.
2 • • •
AFINITOR
zidovudine (Retrovir – brand is NP) 1
Influenza
amantadine, NP = tabs
1
TAMIFLU
2
MALARIA
AFINITOR DISPERZ
2
ALKERAN tabs
2
1
2
anastrozole (Arimidex – brand is
NP)
1
chloroquine phosphate (Aralen –
brand is NP)
1
bicalutamide (Casodex – brand is
NP)
BOSULIF
2
DARAPRIM
2
CAPRELSA
2
hydroxychloroquine (Plaquenil –
brand is NP)
1
COMETRIQ
2
CYCLOPHOSPHAMIDE
2
MALARONE 62.5-25 mg
2
EMCYT
2
mefloquine
1
ERIVEDGE
2
PRIMAQUINE
2
ETOPOSIDE caps
2
ALBENZA
exemestane (Aromasin – brand is
NP)
1
2
BILTRICIDE
2
FARESTON
2
STROMECTOL
2
FIRMAGON
2
flutamide
1
GILOTRIF
2
GLEEVEC
2
HEXALEN
2
HYCAMTIN caps
2
hydroxyurea (Hydrea – brand is
NP)
1
atovaquone/proguanil
250-100 mg (Malarone – brand is
NP)
1
ATOVAQUONE/PROGUANIL
62.5-25 mg
WORM INFECTIONS
OTHER ANTI-INFECTIVES
clindamycin (Cleocin, Cleocin
Pediatric – brands are NP)
1
DAPSONE
2
metronidazole (Flagyl – brand is
NP)
1
NEBUPENT
2
trimethoprim
1
FlexRx Drug Formulary, April 2014
•
2
• • •
• • •
• • •
• • •
• • •
•
•
•
•
•
• •
• •
•
•
11
2
JAKAFI
2
letrozole (Femara – brand is NP)
TREXALL
2
TYKERB
2
VOTRIENT
2
XALKORI
2
1
XELODA
2
LEUCOVORIN CALCIUM tabs,
10 mg, 15 mg
2
XTANDI
2
ZELBORAF
2
leucovorin calcium tabs, 5 mg,
25 mg
1
ZOLINZA
2
2
ZYTIGA
2
LEUKERAN
LOMUSTINE
2
LYSODREN
2
MATULANE
2
megestrol (Megace – brand is NP)
1
MEKINIST
2
mercaptopurine (Purinethol –
brand is NP)
1
MESNEX tabs
2
methotrexate
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
HORMONES, DIABETES AND RELATED DRUGS
CORTICOSTEROIDS
• •
• •
budesonide ext-release (Entocort
EC – brand is NP)
1
CORTISONE
2
dexamethasone elixir; tabs,
0.5 mg, 0.75 mg, 1.5 mg, 4 mg,
6 mg
1
2
1
DEXAMETHASONE soln; tabs,
1 mg, 2 mg
MYLERAN
2
DEXAMETHASONE INTENSOL
2
NEXAVAR
2
fludrocortisone
1
NILANDRON
2
1
POMALYST
2
hydrocortisone (Cortef – brand is
NP)
2
methylprednisolone (Medrol –
brand is NP)
1
SPRYCEL
STIVARGA
2
SUTENT
prednisolone (Prelone – brand is
NP)
1
2
SYLATRON
2
1
TABLOID
2
TAFINLAR
2
prednisolone sodium phosphate
soln, 15 mg/5 mL (Orapred –
brand is NP)
1
prednisolone sodium phosphate
soln, 5 mg/5 mL
1
tamoxifen
TARCEVA
2
TARGRETIN caps
PREDNISONE dose packs; soln,
5 mg/5 mL; tabs, 50 mg
2
2
TASIGNA
2
1
temozolomide (Temodar caps –
brand is NP)
1
prednisone tabs, 1 mg, 2.5 mg,
5 mg, 10 mg, 20 mg
tretinoin caps
1
12
•
•
•
•
•
•
•
•
• • •
• • •
•
•
•
•
•
•
•
•
•
•
•
•
•
•
• • •
•
•
•
•
• •
•
• •
•
MALE HORMONES
• •
ANDRODERM
2
• •
FlexRx Drug Formulary, April 2014
Step Therapy
INLYTA
•
•
•
•
Quantity Limits
2
•
•
•
•
Prior Authorization
Quantity Limits
IMBRUVICA
•
•
•
•
Specialty
Prior Authorization
2
Drug Name
Drug Tier
Specialty
ICLUSIG
Step Therapy
Drug Name
Drug Tier
2014
ESTROGENS
1
ORTHO DIAPHRAGM ALL-FLEX
2
ORTHO EVRA
2
ORTHO TRI-CYCLEN LO
2
2
COMBIPATCH
2
ZOVIA 1/50E
DIVIGEL
2
INFERTILITY
estradiol (Climara, Estrace –
brands are NP)
1
CETROTIDE
2
chorionic gonadotropin
1
estradiol/norethindrone
acetate (Activella – brand is NP)
1
ESTROGEL
2
estropipate 0.75 mg, 1.5 mg
1
ESTROPIPATE 3 mg
2
PREMARIN tabs
2
PREMPHASE
2
PREMPRO
2
VIVELLE-DOT
2
PROGESTINS
medroxyprogesterone
acetate (Provera – brand is NP)
1
norethindrone acetate (Aygestin –
brand is NP)
1
progesterone
micronized (Prometrium – brand
is NP)
1
BIRTH CONTROL
clomiphene (Clomid – brand is NP) 1
2
FOLLISTIM AQ
MENOPUR
2
OVIDREL
2
• •
•
• •
• •
•
DIABETES
acarbose (Precose – brand is NP)
1
BYDUREON
2
BYETTA
2
glimepiride (Amaryl – brand is NP)
1
glipizide (Glucotrol – brand is NP)
1
glipizide ext-release (Glucotrol XL
– brand is NP)
1
glipizide/metformin
1
GLUCAGON EMERGENCY KIT
2
glyburide
1
glyburide micronized (Glynase –
brand is NP)
1
glyburide/metformin (Glucovance
– brand is NP)
1
GLYBURIDE, distributor of Diabeta
2
JANUMET
2
JANUMET XR
2
ELLA
2
levonorgestrel (Plan B, Plan B
One-Step – brands are NP)
1
medroxyprogesterone acetate
inj, 150 mg/mL (Depo-Provera –
brand is NP)
1
2
JANUVIA
2
NECON 1/50, 10/11
2
JUVISYNC
2
NUVARING
FlexRx Drug Formulary, April 2014
Step Therapy
1
oral contraceptive generics, NP
= generics of FEMCON FE,
LOSEASONIQUE, LYBREL,
SEASONIQUE
Quantity Limits
testosterone
enanthate (Delatestryl – brand is
NP)
2
Prior Authorization
1
OGESTREL
Specialty
testosterone cypionate (DepoTestosterone – brand is NP)
Drug Name
Drug Tier
1
• •
Step Therapy
danazol
Quantity Limits
2
Prior Authorization
ANDROGEL
Specialty
Drug Name
Drug Tier
2014
13
1
1
liothyronine (Cytomel – brand is
NP)
1
metformin extrelease (Glucophage XR – brand
is NP)
1
methimazole (Tapazole – brand is
NP)
propylthiouracil
1
nateglinide (Starlix – brand is NP)
1
ONGLYZA
2
pioglitazone (Actos – brand is NP)
1
pioglitazone/metformin (Actoplus
Met – brand is NP)
1
SYMLINPEN
2
VICTOZA
2
Rapid-Acting Insulins
HUMALOG
2
NOVOLOG
2
Short-Acting Insulins
HUMULIN R
2
NOVOLIN R
2
Intermediate-Acting Insulins
INCRELEX
2
OMNITROPE
2
OTHER HORMONES AND RELATED DRUGS
2
ACTONEL
alendronate tabs, 5 mg, 10 mg,
35 mg, 70 mg (Fosamax – brand
is NP)
1
•
ALENDRONATE 40 mg
2
ATELVIA
2
•
•
cabergoline
1
calcitonin-salmon (Miacalcin –
brand is NP)
1
calcitriol (Rocaltrol – brand is NP)
1
desmopressin (DDAVP – brand is
NP)
1
ETIDRONATE
2
EVISTA
2
FABRAZYME
2
ibandronate (Boniva – brand is
NP)
1
1
HUMULIN N
2
HUMULIN 70/30
2
NOVOLIN N
2
NOVOLIN 70/30
2
levocarnitine (Carnitor – brand is
NP)
NOVOLOG MIX 70/30
2
methylergonovine
1
NAGLAZYME
2
octreotide (Sandostatin – brand is
NP)
1
ORFADIN
2
paricalcitol (Zemplar)
1
SANDOSTATIN LAR DEPOT
2
SENSIPAR
2
2
LEVEMIR
2
THYROID REGULATION
levothyroxine (Synthroid – brand is 1
NP)
•
2
2
LANTUS
•
ALDURAZYME
HUMALOG MIX 50/50, 75/25
Basal Insulins
•
• •
•
•
•
•
FlexRx Drug Formulary, April 2014
Step Therapy
Quantity Limits
GROWTH HORMONE
Insulin
The formulary includes vials and insulin pens for the
insulin products listed. Humulin R 500 units/mL is only
available in vials.
14
Prior Authorization
Drug Name
Specialty
Drug Tier
Step Therapy
metformin (Glucophage – brand is
NP)
Quantity Limits
2
Prior Authorization
KOMBIGLYZE XR
Specialty
Drug Name
Drug Tier
2014
HEART AND CIRCULATORY DRUGS
ANGIOTENSIN CONVERTING ENZYME (ACE)
INHIBITORS AND COMBINATIONS
benazepril (Lotensin – brand is NP) 1
benazepril/
hydrochlorothiazide (Lotensin
HCT – brand is NP)
1
CAPTOPRIL/
HYDROCHLOROTHIAZIDE
2
enalapril (Vasotec – brand is NP)
1
enalapril/
hydrochlorothiazide (Vaseretic
– brand is NP)
1
fosinopril
DIOVAN, NP = Diovan HCT
2
irbesartan (Avapro – brand is NP)
1
losartan (Cozaar – brand is NP)
1
losartan/
hydrochlorothiazide (Hyzaar –
brand is NP)
1
valsartan/
hydrochlorothiazide (Diovan
HCT – brand is NP)
1
BETA BLOCKERS AND COMBINATIONS
acebutolol (Sectral – brand is NP) 1
atenolol (Tenormin – brand is NP)
1
atenolol/chlorthalidone (Tenoretic
– brand is NP)
1
1
bisoprolol (Zebeta – brand is NP)
1
fosinopril/hydrochlorothiazide
1
1
lisinopril (Prinivil, Zestril – brands
are NP)
1
bisoprolol/
hydrochlorothiazide (Ziac –
brand is NP)
1
carvedilol (Coreg – brand is NP)
1
lisinopril/
hydrochlorothiazide (Prinzide,
Zestoretic – brands are NP)
DUTOPROL
2
labetalol (Trandate – brand is NP)
1
moexipril (Univasc – brand is NP)
1
moexipril/
hydrochlorothiazide (Uniretic –
brand is NP)
1
perindopril (Aceon – brand is NP)
1
quinapril (Accupril – brand is NP)
1
1
quinapril/
hydrochlorothiazide (Accuretic –
brand is NP)
1
ramipril (Altace – brand is NP)
trandolapril (Mavik – brand is NP)
1
ANGIOTENSIN II RECEPTOR BLOCKERS (ARBs)
AND COMBINATIONS
FlexRx Drug Formulary, April 2014
Step Therapy
2
Quantity Limits
ZEMPLAR
1
Prior Authorization
2
candesartan/
hydrochlorothiazide (Atacand
HCT – brand is NP)
Specialty
SYNAREL
Drug Name
Drug Tier
2
Step Therapy
STIMATE
Quantity Limits
2
Prior Authorization
SOMAVERT
Specialty
Drug Name
Drug Tier
2014
1
metoprolol succinate extrelease (Toprol XL – brand is NP)
1
metoprolol tartrate (Lopressor –
brand is NP)
1
metoprolol/
hydrochlorothiazide (Lopressor
HCT – brand is NP)
1
nadolol (Corgard – brand is NP)
PINDOLOL
2
propranolol ext-release (Inderal
LA – brand is NP)
1
PROPRANOLOL soln
2
propranolol tabs
1
PROPRANOLOL/
HYDROCHLOROTHIAZIDE
2
15
CALCIUM CHANNEL BLOCKERS AND
COMBINATIONS
1
amlodipine (Norvasc – brand is
NP)
1
amlodipine/benazepril (Lotrel –
brand is NP)
diltiazem (Cardizem – brand is NP) 1
diltiazem ext-release (Cardizem
CD, Dilacor XR, Tiazac – brands
are NP)
1
felodipine ext-release
1
nifedipine ext-release (Adalat CC,
Procardia XL – brands are NP)
1
VERAPAMIL 40 mg
2
verapamil 80 mg, 120 mg (Calan – 1
brand is NP)
1
verapamil ext-release (Calan SR,
Isoptin SR, Verelan/PM – brands
are NP)
CHEST PAIN (ANGINA)
ISOSORBIDE DINITRATE tabs,
30 mg
2
isosorbide dinitrate, tabs, 5 mg,
10 mg, 20 mg (Isordil – brand is
NP)
1
isosorbide mononitrate (Monoket
– brand is NP)
1
isosorbide mononitrate extrelease (Imdur – brand is NP)
1
NITRO-BID
fenofibrate (Lofibra, Tricor –
brands are NP)
1
fenofibrate micronized (Lofibra –
brand is NP)
1
fenofibric acid delayedrelease (Trilipix – brand is NP)
1
gemfibrozil (Lopid – brand is NP)
1
lovastatin (Mevacor – brand is NP)
1
niacin ext-release (Niaspan)
1
NIASPAN
2
pravastatin (Pravachol – brand is
NP)
1
simvastatin (Zocor – brand is NP)
1
ZETIA
2
FLUID REDUCTION
ACETAZOLAMIDE 125 mg
2
acetazolamide 250 mg
1
1
acetazolamide extrelease (Diamox Sequels – brand
is NP)
1
amiloride
1
bumetanide
1
CHLOROTHIAZIDE 250 mg
2
chlorothiazide 500 mg
1
2
CHLORTHALIDONE 25 mg, 50 mg
2
nitroglycerin (Nitro-Dur – brand is
NP)
1
furosemide, NP = soln, 8 mg/
mL (Lasix – brand is NP)
1
NITROSTAT
2
hydrochlorothiazide
caps (Microzide – brand is NP)
1
1
hydrochlorothiazide tabs
1
atorvastatin (Lipitor – brand is NP)
1
indapamide
1
cholestyramine (Questran,
Questran Light – brands are NP)
methazolamide (Neptazane –
brand is NP)
1
16
FlexRx Drug Formulary, April 2014
Step Therapy
Quantity Limits
colestipol tabs (Colestid – brand is 1
NP)
2
CRESTOR
amiloride/hydrochlorothiazide
CHOLESTEROL LOWERING
Prior Authorization
Drug Name
Specialty
Drug Tier
Step Therapy
Quantity Limits
2
Prior Authorization
TIMOLOL tabs
Specialty
Drug Name
Drug Tier
2014
•
1
spironolactone (Aldactone – brand 1
is NP)
1
spironolactone/
hydrochlorothiazide (Aldactazide
– brand is NP)
1
torsemide (Demadex – brand is
NP)
1
triamterene/hydrochlorothiazide
caps, 37.5-25 mg;
tabs (Dyazide, Maxzide,
Maxzide-25 – brands are NP)
2
TRIAMTERENE/
HYDROCHLOROTHIAZIDE
caps, 50-25 mg
doxazosin (Cardura – brand is NP)
1
eplerenone (Inspra – brand is NP)
1
epoprostenol (Flolan – brand is
NP)
1
guanfacine (Tenex – brand is NP)
1
hydralazine
1
LETAIRIS
2
methyldopa
1
midodrine
1
minoxidil
1
prazosin (Minipress – brand is NP)
1
REMODULIN
2
HEART RHYTHM
sildenafil (Revatio – brand is NP)
1
terazosin
1
TRACLEER
2
VENTAVIS
2
amiodarone (Cordarone – brand is
NP)
1
disopyramide (Norpace – brand is
NP)
1
flecainide
1
ERECTILE DYSFUNCTION
mexiletine
1
VIAGRA (males only > 18 years)
propafenone (Rythmol – brand is
NP)
1
BEE STING KITS
propafenone ext-release (Rythmol
SR – brand is NP)
1
quinidine gluconate ext-release
1
ANTIHISTAMINES
quinidine sulfate
1
1
QUINIDINE SULFATE ext-release
2
carbinoxamine maleate (Palgic –
brand is NP)
sotalol (Betapace, Betapace AF –
brands are NP)
1
cetirizine syrup
1
cetirizine chew tabs, tabs – Nonpreferred (may have coverage
in an OTC program) (Zyrtec –
brand is NP)
1
cyproheptadine
1
diphenhydramine caps, 50 mg
1
levocetirizine (Xyzal – brand is
NP)
1
2
clonidine (Catapres, Catapres-TTS 1
– brands are NP)
2
DIBENZYLINE
DIGOXIN soln
FlexRx Drug Formulary, April 2014
EPIPEN
2
EPIPEN-JR
2
Step Therapy
Quantity Limits
Prior Authorization
•
•
•
• •
•
•
•
RESPIRATORY DRUGS
OTHER HEART RELATED DRUGS
ADCIRCA
2
Specialty
Drug Tier
Step Therapy
Drug Name
digoxin tabs (Lanoxin – brand is
NP)
metolazone (Zaroxolyn – brand is
NP)
1
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2014
2
• •
17
1
promethazine supp, 12.5 mg,
25 mg; syrup; tabs
1
PROMETHEGAN supp, 50 mg
2
NASAL PRODUCTS
ASTEPRO
2
azelastine (Astelin – brand is NP)
1
BACTROBAN NASAL
2
flunisolide 25 mcg/spray
1
fluticasone propionate (Flonase –
brand is NP)
1
ipratropium (Atrovent – brand is
NP)
1
NASONEX
2
triamcinolone (Nasacort AQ –
brand is NP)
1
COUGH/COLD/ALLERGY
acetylcysteine
1
benzonatate (Tessalon – brand is
NP)
1
cetirizine/pseudoephedrine
ext-release – Non-preferred
(may have coverage in an OTC
program) (Zyrtec-D – brand is
NP)
1
loratadine/pseudoephedrine
ext-release – Non-preferred
(may have coverage in an OTC
program) (Claritin-D – brand is
NP)
1
2
budesonide (Pulmicort Respules –
brand is NP)
1
COMBIVENT RESPIMAT
2
cromolyn sodium inhal soln
1
DULERA
2
FLOVENT DISKUS
2
FLOVENT HFA
2
FORADIL AEROLIZER
2
ipratropium inhal soln
1
ipratropium/albuterol (Duoneb –
brand is NP)
1
levalbuterol (Xopenex Concentrate 1
– brand is NP)
1
montelukast (Singulair – brand is
NP)
2
PROAIR HFA
PULMICORT RESPULES
1 mg/2 mL
2
QVAR
2
SEREVENT DISKUS
2
SPIRIVA HANDIHALER
2
SYMBICORT
2
terbutaline
1
theophylline ext-release
1
VENTOLIN HFA
2
zafirlukast (Accolate – brand is
NP)
1
OTHER RESPIRATORY DRUGS
ASTHMA/COPD
FIRAZYR
2
KALYDECO
2
PROLASTIN-C
2
PULMOZYME
2
ADVAIR DISKUS
2
ADVAIR HFA
2
albuterol ext-release (Vospire ER
– brand is NP)
1
albuterol inhal soln, syrup, tabs
1
GASTROINTESTINAL DRUGS
ASMANEX, NP = 7 metered doses
2
LAXATIVES
18
•
• •
•
•
FlexRx Drug Formulary, April 2014
Step Therapy
BREO ELLIPTA
Quantity Limits
2
Prior Authorization
ATROVENT HFA
Specialty
Step Therapy
Quantity Limits
Prior Authorization
Drug Name
Drug Tier
loratadine – Non-preferred (may
have coverage in an OTC
program) (Claritin – brand is NP)
Specialty
Drug Name
Drug Tier
2014
DIARRHEA
DIPHENOXYLATE/ATROPINE
soln
2
diphenoxylate/atropine
tabs (Lomotil – brand is NP)
1
OPIUM TINCTURE (PAREGORIC)
2 mg/5mL
2
pantoprazole delayedrelease (Protonix – brand is NP)
1
PRILOSEC OTC: Non-preferred
(may have coverage in an OTC
program)
2
PROPANTHELINE
2
ranitidine (Zantac – brand is NP)
1
sucralfate (Carafate – brand is NP)
1
Step Therapy
Quantity Limits
Prior Authorization
NAUSEA AND VOMITING
ULCER/GERD
dronabinol (Marinol – brand is NP)
1
EMEND
2
granisetron
1
meclizine
1
ondansetron (Zofran, Zofran ODT
– brands are NP)
1
ondansetron 24 mg
1
TRANSDERM-SCOP
2
CARAFATE susp
2
cimetidine
1
dicyclomine caps, tabs (Bentyl –
brand is NP)
1
DICYCLOMINE soln
2
famotidine tabs (Pepcid – brand is
NP)
1
glycopyrrolate (Robinul – brand is
NP)
1
hyoscyamine (Anaspaz, Levsin –
brands are NP)
1
CREON
hyoscyamine ext-release (Levbid
– brand is NP)
1
OTHER GASTROINTESTINAL DRUGS
2
ASACOL HD
lansoprazole delayed-release
caps (Prevacid – brand is NP)
1
methscopolamine (Pamine,
Pamine Forte – brands are NP)
1
misoprostol (Cytotec – brand is
NP)
1
NEXIUM
2
nizatidine (Axid – brand is NP)
trimethobenzamide (Tigan – brand 1
is NP)
DIGESTIVE ENZYMES
2
balsalazide (Colazal – brand is NP) 1
calcium acetate (Phoslo – brand is 1
NP)
2
CANASA
CHENODAL
2
DELZICOL
2
lactulose
1
1
LIALDA
2
omeprazole delayedrelease (Prilosec – brand is NP)
1
mesalamine
1
1
OMEPRAZOLE DELAYEDRELEASE OTC: Non-preferred
(may have coverage in an OTC
program)
2
metoclopramide (Reglan – brand
is NP)
PENTASA
2
RENVELA
2
FlexRx Drug Formulary, April 2014
Specialty
Drug Name
Drug Tier
1
Step Therapy
PEG – electrolytes for
soln (Colyte, Golytely, Nulytely –
brands are NP)
Quantity Limits
1
Prior Authorization
lactulose
Specialty
Drug Name
Drug Tier
2014
•
•
19
sulfasalazine (Azulfidine – brand is
NP)
1
terconazole (Terazol – brand is
NP)
1
sulfasalazine delayedrelease (Azulfidine EN-Tabs –
brand is NP)
1
VAGIFEM
2
ursodiol (Actigall, Urso 250, Urso
Forte – brands are NP)
1
URINARY TRACT INFECTIONS
alfuzosin ext-release (Uroxatral –
brand is NP)
1
AVODART
2
CYSTAGON
2
CYTRA-K soln
2
CYTRA-3
2
finasteride (Proscar – brand is NP)
1
MACRODANTIN 25 mg
2
methenamine hippurate (Hiprex,
Urex – brands are NP)
1
nitrofurantoin (Furadantin – brand
is NP)
1
K-PHOS NO. 2
2
2
nitrofurantoin
macrocrystalline (Macrodantin –
brand is NP)
1
POTASSIUM CITRATE ext-release
540 mg, 1080 mg
potassium citrate/citric acid
powder
1
nitrofurantoin monohydrate/
macrocrystalline (Macrobid –
brand is NP)
1
sodium citrate/citric acid (Shohl's
– brand is NP)
1
tamsulosin (Flomax – brand is NP)
1
phenazopyridine (Pyridium –
brand is NP)
1
TRICITRATES
2
•
CENTRAL NERVOUS SYSTEM DRUGS
URINARY TRACT SPASMS
bethanechol (Urecholine – brand is 1
NP)
2
DETROL LA
oxybutynin
1
oxybutynin ext-release (Ditropan
XL – brand is NP)
1
tolterodine (Detrol – brand is NP)
1
tolterodine ext-release (Detrol LA)
1
VESICARE
2
VAGINAL PRODUCTS
CLEOCIN supp
2
clindamycin (Cleocin – brand is
NP)
1
ESTRACE crm
2
metronidazole (MetroGel-Vaginal – 1
brand is NP)
ANXIETY
alprazolam (Xanax – brand is NP)
1
•
•
•
alprazolam ext-release (Xanax XR
– brand is NP)
1
buspirone, NP = 7.5 mg
1
DIAZEPAM oral soln, 1 mg/mL
2
•
•
•
diazepam tabs (Valium – brand is
NP)
1
hydroxyzine hcl
1
HYDROXYZINE PAMOATE
100 mg
2
hydroxyzine pamoate 25 mg,
50 mg (Vistaril – brand is NP)
1
lorazepam (Ativan – brand is NP)
1
lorazepam conc (Lorazepam
Intensol – brand is NP)
1
FlexRx Drug Formulary, April 2014
Step Therapy
Quantity Limits
OTHER GENITOURINARY DRUGS
GENITOURINARY DRUGS
20
Prior Authorization
Drug Name
Specialty
Drug Tier
Step Therapy
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2014
DEPRESSION
1
amitriptyline
1
tranylcypromine (Parnate – brand
is NP)
bupropion (Wellbutrin – brand is
NP)
1
trazodone
1
venlafaxine
1
bupropion ext-release (Wellbutrin
SR, Wellbutrin XL – brands are
NP)
1
venlafaxine ext-release
caps (Effexor XR – brand is NP)
1
1
venlafaxine ext-release tabs, NP
= 225 mg
1
citalopram (Celexa – brand is NP)
clomipramine (Anafranil – brand is
NP)
1
desipramine (Norpramin – brand is
NP)
1
doxepin 10 mg, 25 mg, 50 mg,
100 mg; conc
1
DOXEPIN 75 mg
PSYCHOTIC AND BIPOLAR DISORDERS
1
chlorpromazine
•
clozapine (Clozaril – brand is NP)
1
FLUPHENAZINE DECANOATE
2
FLUPHENAZINE HCL conc, elixir
2
2
fluphenazine hcl tabs
1
escitalopram (Lexapro – brand is
NP)
1
haloperidol decanoate (Haldol –
brand is NP)
1
fluoxetine delayedrelease (Prozac Weekly – brand
is NP)
1
haloperidol lactate oral soln
1
haloperidol tabs
1
lithium carbonate
1
fluoxetine, NP = 60 mg (Prozac –
brand is NP)
1
2
fluvoxamine
1
LITHIUM CARBONATE caps,
150 mg
1
lithium carbonate ext-release
300 mg (Lithobid – brand is NP)
1
imipramine hcl (Tofranil – brand is
NP)
1
lithium carbonate ext-release
450 mg
1
mirtazapine (Remeron, Remeron
Soltab – brands are NP)
LITHIUM CITRATE
2
nortriptyline caps (Pamelor –
brand is NP)
1
loxapine (Loxitane – brand is NP)
1
2
paroxetine hcl (Paxil – brand is
NP)
1
olanzapine (Zyprexa, Zyprexa
Zydis – brands are NP)
1
NORTRIPTYLINE soln
perphenazine
1
1
prochlorperazine
1
paroxetine hcl ext-release (Paxil
CR – brand is NP)
1
•
phenelzine (Nardil – brand is NP)
1
quetiapine (Seroquel – brand is
NP)
1
risperidone (Risperdal, Risperdal
M-Tab – brands are NP)
1
protriptyline (Vivactil – brand is
NP)
•
1
SEROQUEL XR
2
sertraline (Zoloft – brand is NP)
•
thiothixene
1
FlexRx Drug Formulary, April 2014
Step Therapy
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Step Therapy
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2014
•
21
•
SLEEP AIDS
estazolam
1
flurazepam
1
midazolam syrup
1
phenobarbital soln; tabs,
16.2 mg, 32.4 mg
1
PHENOBARBITAL tabs, 15 mg,
30 mg, 60 mg, 64.8 mg, 97.2 mg,
100 mg
2
temazepam (Restoril – brand is
NP)
1
zaleplon (Sonata – brand is NP)
1
zolpidem (Ambien – brand is NP)
1
zolpidem ext-release (Ambien CR
– brand is NP)
1
METHYLPHENIDATE ext-release
tabs, 10 mg
2
•
methylphenidate ext-release
tabs, 20 mg (Ritalin SR – brand
is NP)
1
•
modafinil (Provigil – brand is NP)
1
STRATTERA
2
VYVANSE
2
• •
•
•
Step Therapy
Quantity Limits
Prior Authorization
Specialty
Drug Name
MULTIPLE SCLEROSIS
BETASERON
2
COPAXONE
2
REBIF
2
TECFIDERA
2
•
•
•
•
TOBACCO CESSATION
The formulary includes all prescription (Rx) and over-thecounter (OTC) nicotine-containing products. Coverage of
Rx and/or OTCs may vary depending on the member's
benefit design.
1
bupropion ext-release (Zyban)
HYPERACTIVITY/NARCOLEPSY
•
•
ADDERALL XR
2
amphetamine/
dextroamphetamine (Adderall –
brand is NP)
1
caffeine citrate (Cafcit – brand is
NP)
1
dexmethylphenidate (Focalin –
brand is NP)
1
•
dextroamphetamine tabs
1
dextroamphetamine extrelease (Dexedrine Spansule –
brand is NP)
1
•
•
INTUNIV
2
methylphenidate tabs (Ritalin –
brand is NP)
1
•
•
methylphenidate extrelease (Metadate CD, Ritalin LA
– brands are NP)
1
•
methylphenidate ext-release
OSM (Concerta – brand is NP)
1
•
22
Drug Tier
1
Step Therapy
ziprasidone (Geodon – brand is
NP)
Quantity Limits
1
Prior Authorization
trifluoperazine
Specialty
Drug Name
Drug Tier
2014
CHANTIX
2
COMMIT – OTC
2
NICODERM CQ – OTC
2
NICORETTE – OTC
2
nicotine lozenges, gum –
OTC (Commit, Nicorette)
1
nicotine patches – OTC
(Nicoderm CQ)
1
NICOTROL INHALER
2
NICOTROL NS
2
ZYBAN
2
•
•
•
•
•
OTHER CENTRAL NERVOUS SYSTEM DRUGS
1
acamprosate delayedrelease (Campral – brand is NP)
1
disulfiram (Antabuse – brand is
NP)
1
donepezil, NP = 23 mg (Aricept,
Aricept ODT – brands are NP)
FlexRx Drug Formulary, April 2014
1
galantamine extrelease (Razadyne ER – brand is
NP)
1
NAMENDA
2
NUEDEXTA
2
ORAP
2
rivastigmine (Exelon – brand is
NP)
1
2
fentanyl (Duragesic – brand is NP)
1
HYDROCODONE/
ACETAMINOPHEN tabs,
7.5-500 mg, 7.5-650 mg,
10-750 mg
2
•
hydrocodone/acetaminophen,
NP = soln, 7.5-325 mg/15 mL;
tabs, 2.5-325 mg, 5-300 mg,
5-300 mg, 7.5-300 mg,
10-300 mg
1
•
1
•
phentermine 15 mg, 30 mg
1
phentermine 37.5 mg (Adipex-P –
brand is NP)
1
•
•
hydrocodone/ibuprofen, NP
= tabs, 2.5-200 mg (Ibudone,
Reprexain, Vicoprofen – brands
are NP)
XENICAL
2
•
hydromorphone soln,
tabs (Dilaudid – brand is NP)
1
HYDROMORPHONE supp
2
methadone conc, soln
1
methadone tabs (Dolophine –
brand is NP)
1
morphine sulfate conc, soln
1
MORPHINE SULFATE supp, tabs
2
1
•
•
PAIN RELIEF DRUGS
NON-NARCOTIC DRUGS
•
•
butalbital/acetaminophen
1
butalbital/acetaminophen/
caffeine, NP = caps,
50-300-40 mg,
50-500-40 mg (Esgic – brand is
NP)
1
butalbital/aspirin/caffeine
caps (Fiorinal – brand is NP)
1
•
morphine sulfate ext-release (MS
Contin – brand is NP)
2
•
morphine sulfate extrelease (Avinza)
1
BUTALBITAL/ASPIRIN/CAFFEINE
tabs
naltrexone (ReVia – brand is NP)
1
ketorolac
1
oxycodone caps, conc, soln
1
salsalate
1
OXYCODONE conc
2
oxycodone tabs, 5 mg, 15 mg,
30 mg (Roxicodone – brand is
NP)
1
oxycodone/acetaminophen caps,
5-500 mg
1
•
oxycodone/acetaminophen, NP
= tabs, 2.5-325 mg (Percocet –
brand is NP)
1
•
oxycodone/aspirin (Percodan –
brand is NP)
1
•
NARCOTIC DRUGS
acetaminophen/codeine (Tylenol
w/Codeine – brand is NP)
1
•
AVINZA
2
buprenorphine
1
buprenorphine/naloxone
1
butalbital/aspirin/caffeine/
codeine (Fiorinal w/Codeine –
brand is NP)
1
•
• •
• •
•
FlexRx Drug Formulary, April 2014
Step Therapy
Quantity Limits
Prior Authorization
CODEINE SULFATE
Specialty
Step Therapy
Quantity Limits
Prior Authorization
WEIGHT LOSS
Drug Name
Drug Tier
galantamine (Razadyne – brand is
NP)
Specialty
Drug Name
Drug Tier
2014
23
tramadol ext-release (Ultram ER –
brand is NP)
1
•
tramadol/acetaminophen (Ultracet 1
– brand is NP)
oxaprozin (Daypro – brand is NP)
1
piroxicam (Feldene – brand is NP)
1
sulindac
1
tolmetin caps
1
MIGRAINE HEADACHES
RHEUMATOID AND OSTEOARTHRITIS
2
CELEBREX
acetaminophen/isometheptene/
dichloralphenazone
1
1
diclofenac potassium (Cataflam –
brand is NP)
1
dihydroergotamine mesylate
inj (D.H.E. 45 – brand is NP)
1
diclofenac sodium delayedrelease
1
divalproex ext-release (Depakote
ER – brand is NP)
MIGERGOT
2
diclofenac sodium extrelease (Voltaren-XR – brand is
NP)
1
MIGRANAL
2
ENBREL
2
ENBREL SURECLICK
2
etodolac
1
etodolac ext-release
1
naratriptan (Amerge – brand is NP) 1
1
rizatriptan (Maxalt, Maxalt-MLT –
brands are NP)
1
sumatriptan inj, tabs (Imitrex –
brand is NP)
2
SUMATRIPTAN nasal spray
flurbiprofen
1
GOUT
HUMIRA
2
ibuprofen
•
•
•
•
•
•
1
1
allopurinol (Zyloprim – brand is
NP)
indomethacin
1
COLCRYS
2
indomethacin ext-release
1
probenecid
1
ketoprofen
1
probenecid/colchicine
1
leflunomide (Arava – brand is NP)
1
NEUROMUSCULAR DRUGS
MECLOFENAMATE
2
SEIZURES
meloxicam tabs (Mobic – brand is
NP)
1
BANZEL tabs
2
1
methotrexate
1
carbamazepine (Tegretol – brand
is NP)
nabumetone
1
1
naproxen (Naprosyn – brand is
NP)
1
carbamazepine extrelease (Carbatrol, Tegretol-XR –
brands are NP)
1
CELONTIN
2
naproxen delayed-release (ECNaprosyn – brand is NP)
clonazepam (Klonopin – brand is
NP)
1
24
•
•
•
•
•
•
•
FlexRx Drug Formulary, April 2014
Step Therapy
1
1
Quantity Limits
tramadol (Ultram – brand is NP)
naproxen sodium (Anaprox –
brand is NP)
Prior Authorization
2
Drug Name
Specialty
SUBOXONE film
•
•
• •
•
•
Drug Tier
2
Step Therapy
ROXICET soln
Quantity Limits
2
Prior Authorization
OXYCONTIN
Specialty
Drug Name
Drug Tier
2014
DIASTAT
2
APOKYN
2
DILANTIN caps, susp
2
AZILECT
2
divalproex delayedrelease (Depakote, Depakote
Sprinkles – brands are NP)
1
benztropine
1
bromocriptine (Parlodel – brand is
NP)
1
divalproex ext-release (Depakote
ER – brand is NP)
1
carbidopa/levodopa (Parcopa,
Sinemet – brands are NP)
1
ethosuximide (Zarontin – brand is
NP)
1
1
felbamate (Felbatol – brand is NP)
1
carbidopa/levodopa extrelease (Sinemet CR – brand is
NP)
gabapentin (Neurontin – brand is
NP)
1
entacapone (Comtan – brand is
NP)
1
lamotrigine (Lamictal – brand is
NP)
1
pramipexole (Mirapex – brand is
NP)
1
levetiracetam (Keppra – brand is
NP)
1
ropinirole (Requip – brand is NP)
1
levetiracetam ext-release (Keppra
XR – brand is NP)
1
selegiline caps (Eldepryl – brand is 1
NP)
1
selegiline tabs
ONFI
2
oxcarbazepine (Trileptal – brand is
NP)
1
PEGANONE
2
phenytoin (Dilantin chew tabs –
brand is NP)
1
phenytoin sodium extrelease (Dilantin; Phenytek –
brand is NP)
1
primidone (Mysoline – brand is
NP)
STALEVO
2
trihexyphenidyl
1
•
MUSCLE RELAXANTS
baclofen
1
chlorzoxazone (Parafon Forte –
brand is NP)
1
cyclobenzaprine 5 mg, 10 mg
1
1
1
dantrolene (Dantrium – brand is
NP)
1
SABRIL
2
metaxalone (Skelaxin – brand is
NP)
TEGRETOL-XR 100 mg
2
1
topiramate (Topamax, Topamax
Sprinkle – brands are NP)
1
methocarbamol (Robaxin – brand
is NP)
orphenadrine ext-release
1
orphenadrine/aspirin/caffeine
25-385-30 mg
1
ORPHENADRINE/ASPIRIN/
CAFFEINE 50-770-60 mg
2
valproic acid (Depakene – brand is 1
NP)
1
zonisamide (Zonegran – brand is
NP)
Step Therapy
1
Quantity Limits
amantadine, NP = tabs
Prior Authorization
1
Specialty
Drug Tier
Step Therapy
Quantity Limits
clonazepam ODT
Prior Authorization
Drug Name
Specialty
Drug Name
Drug Tier
2014
PARKINSON'S DISEASE
FlexRx Drug Formulary, April 2014
25
tizanidine tabs (Zanaflex – brand
is NP)
1
OTHER NEUROMUSCULAR DRUGS
2
MESTINON syrup
MESTINON TIMESPAN
2
pyridostigmine (Mestinon – brand
is NP)
1
riluzole (Rilutek – brand is NP)
1
SUPPLEMENTS
VITAMINS
potassium chloride extrelease (Micro-K – brand is NP)
1
potassium phosphate/sodium
phosphates (K-Phos Neutral –
brand is NP)
1
sodium fluoride chew tabs;
soln, 0.275 mg/drop, 1.1 mg/
mL (Luride – brand is NP)
1
SODIUM FLUORIDE tabs
2
SSKI
2
1
MEPHYTON
2
phytonadione inj, 1 mg/0.5 mL
1
PHYTONADIONE inj, 10 mg/mL
2
MULTIVITAMINS
ESCAVITE LQ
2
MULTI-VITAMIN/IRON/FLUORIDE
2
pediatric multivitamins
1
pediatric vitamins ADC
1
PRENAFIRST
2
PRENATABS OBN, RX
2
PRENATAL AD, PLUS, U,
VITAMINS PLUS, 19
2
QUFLORA PEDIATRIC
2
TRI-VIT/FLUORIDE/IRON
2
TRINATE
2
MINERALS AND ELECTROLYTES
ADVATE
2
AGGRENOX
2
ALPHANATE/VWF
2
ALPHANINE SD
2
aminocaproic acid (Amicar –
brand is NP)
1
anagrelide (Agrylin – brand is NP)
1
ARANESP
2
BEBULIN
2
BEBULIN VH
2
BENEFIX
2
BRILINTA
2
CEREZYME
2
cilostazol (Pletal – brand is NP)
1
clopidogrel 75 mg (Plavix – brand
is NP)
1
cyanocobalamin inj
1
1
FLURA-DROPS 0.55 mg/drop
2
dipyridamole (Persantine – brand
is NP)
K-PHOS
2
EFFIENT
2
potassium bicarbonate/chloride
effervescent tabs, 25 mEq
1
enoxaparin (Lovenox – brand is
NP)
1
potassium chloride packets;
soln, 10%
1
FEIBA NF
2
FEIBA VH
2
POTASSIUM CHLORIDE soln,
20%
2
folic acid tabs, 1 mg
1
HELIXATE FS
2
•
•
•
•
•
•
•
•
•
•
•
FlexRx Drug Formulary, April 2014
Step Therapy
Quantity Limits
BLOOD MODIFYING DRUGS
ergocalciferol (Drisdol – brand is
NP)
26
Prior Authorization
Drug Name
Specialty
Drug Tier
Step Therapy
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2014
KOATE-DVI
2
KOGENATE FS
2
MONOCLATE-P
2
MONONINE
2
NEULASTA
2
NEUMEGA
2
NEUPOGEN
2
NOVOSEVEN RT
2
pentoxifylline ext-release (Trental
– brand is NP)
1
PRADAXA
2
PROCRIT
2
PROFILNINE SD
2
RECOMBINATE
2
RIXUBIS
2
SOLIRIS
2
warfarin (Coumadin – brand is NP)
1
WILATE
2
XARELTO
2
XYNTHA/SOLOFUSE
2
•
•
•
•
•
•
•
•
•
•
•
•
•
•
1
neomycin/polymyxin B/
gramicidin soln (Neosporin –
brand is NP)
1
ofloxacin soln (Ocuflox – brand is
NP)
1
polymyxin B/trimethoprim
soln (Polytrim – brand is NP)
1
sulfacetamide sodium
soln (Bleph-10 – brand is NP)
1
tobramycin soln (Tobrex – brand
is NP)
1
TOBREX oint
2
trifluridine soln (Viroptic – brand is 1
NP)
2
VIGAMOX
Steroids and Combination Products
2
ALREX
•
•
BLEPHAMIDE
2
BLEPHAMIDE S.O.P.
2
dexamethasone sodium
phosphate soln
1
TOPICAL DRUGS
fluorometholone susp, 0.1% (FML 1
Liquifilm – brand is NP)
2
FML oint
EYE
LOTEMAX
2
Anti-infectives
neomycin/polymyxin B/
bacitracin/hydrocortisone oint
1
neomycin/polymyxin B/
dexamethasone oint,
susp (Maxitrol – brand is NP)
1
prednisolone acetate susp (Pred
Forte – brand is NP)
1
•
AZASITE
2
BACITRACIN oint
2
bacitracin/polymyxin B oint
1
ciprofloxacin soln (Ciloxan –
brand is NP)
1
erythromycin oint
1
gentamicin oint, soln (Garamycin
– brand is NP)
sulfacetamide sodium/
prednisolone soln
1
1
1
MOXEZA
2
tobramycin/dexamethasone
susp (Tobradex – brand is NP)
FlexRx Drug Formulary, April 2014
Step Therapy
2
neomycin/polymyxin B/
bacitracin oint
Quantity Limits
HUMATE-P
2
Prior Authorization
1
NATACYN
Specialty
heparin sodium lock flush, NP =
2 units/mL
Drug Name
Drug Tier
•
Step Therapy
2
Quantity Limits
Specialty
HEMOFIL M
Prior Authorization
Drug Name
Drug Tier
2014
27
2
1
AZOPT
2
flurbiprofen soln (Ocufen – brand
is NP)
1
homatropine soln (Isopto
Homatropine – brand is NP)
1
brimonidine soln,
0.15% (Alphagan P – brand is
NP)
brimonidine soln, 0.2%
1
carteolol soln
1
dorzolamide soln (Trusopt – brand 1
is NP)
1
dorzolamide/timolol maleate
soln (Cosopt – brand is NP)
latanoprost soln (Xalatan – brand 1
is NP)
2
LEVOBUNOLOL soln, 0.25%
levobunolol soln, 0.5% (Betagan – 1
brand is NP)
1
metipranolol soln (Optipranolol –
brand is NP)
pilocarpine soln (Isopto Carpine – 1
brand is NP)
2
SIMBRINZA
timolol maleate soln (Timoptic,
Timoptic-XE – brands are NP)
1
TRAVATAN Z
2
Other Eye Products
ketorolac soln (Acular, Acular LS – 1
brands are NP)
2
PATADAY
RESTASIS
2
tropicamide soln (Mydriacyl –
brand is NP)
1
EAR
acetic acid soln
1
benzocaine/antipyrine soln
1
CIPRO HC susp
2
CIPRODEX
2
hydrocortisone/acetic acid
soln (Vosol HC – brand is NP)
1
neomycin/polymyxin B/
hydrocortisone soln,
susp (Cortisporin – brand is NP)
1
ofloxacin soln
1
MOUTH AND THROAT (LOCAL)
cevimeline (Evoxac – brand is NP)
1
chlorhexidine rinse (Peridex –
brand is NP)
1
ATROPINE SULFATE oint
2
clotrimazole troche
1
atropine sulfate soln (Isopto
Atropine – brand is NP)
1
lidocaine viscous
1
nystatin susp
1
azelastine soln (Optivar – brand is
NP)
1
pilocarpine (Salagen – brand is
NP)
1
BROMFENAC soln – twice daily
dosing
2
cromolyn sodium soln
1
cyclopentolate soln, 1% (Cyclogyl
– brand is NP)
1
28
sodium fluoride (Prevident – brand 1
is NP)
1
triamcinolone dental paste
ANORECTAL
CORTIFOAM
2
FlexRx Drug Formulary, April 2014
Step Therapy
ALPHAGAN P soln, 0.1%
Quantity Limits
1
Prior Authorization
diclofenac soln (Voltaren – brand
is NP)
Drug Name
Specialty
2
Glaucoma
Drug Tier
Step Therapy
Quantity Limits
ZYLET
Specialty
Drug Name
Drug Tier
Prior Authorization
2014
hydrocortisone
enema (Cortenema – brand is
NP)
1
hydrocortisone acetate crm,
supp (Anusol-HC – brand is NP)
1
SKIN CONDITIONS/PRODUCTS
Acne
adapalene (Differin – brand is NP)
1
AZELEX
2
CLARAVIS 30 mg
2
clindamycin (Cleocin-T – brand is
NP)
1
clindamycin/benzoyl
peroxide (Benzaclin, Duac –
brands are NP)
1
DIFFERIN gel, 0.3%; lotn
2
erythromycin (Erygel – brand is
NP)
1
erythromycin pads, soln
1
erythromycin/benzoyl
peroxide (Benzamycin – brand is
NP)
1
FINACEA
2
isotretinoin 10 mg, 20 mg,
40 mg (Amnesteem, Claravis,
Myorisan, Zenatane)
1
metronidazole (Metrocream,
Metrolotion – brands are NP)
1
metronidazole gel, 0.75%
Step Therapy
Quantity Limits
Prior Authorization
Anti-infectives
CENTANY, NP = kit
2
ciclopirox, NP = topical
kit (Loprox, Penlac – brands are
NP)
1
econazole
1
GENTAMICIN SULFATE topical
2
ketoconazole (Nizoral – brand is
NP)
1
mupirocin (Bactroban – brand is
NP)
1
nystatin topical
1
silver sulfadiazine (Silvadene –
brand is NP)
1
Corticosteroids
alclometasone (Aclovate – brand
is NP)
1
amcinonide crm
1
betamethasone dipropionate
1
betamethasone dipropionate,
augmented (Diprolene – brand is
NP)
1
betamethasone valerate crm,
lotn, oint
1
clobetasol (Olux, Temovate –
brands are NP)
1
1
1
clotrimazole/
betamethasone (Lotrisone –
brand is NP)
sulfacetamide sodium (Klaron –
brand is NP)
1
desonide (Desowen – brand is NP)
1
DESOXIMETASONE crm, 0.05%
2
SULFACETAMIDE SODIUM/
SULFUR susp, 10-5%
2
1
sulfacetamide sodium/sulfur
10-5% crm, emulsion, lotn
1
desoximetasone crm, 0.25%; gel;
oint, 0.25% (Topicort – brand is
NP)
DIFLORASONE crm
2
TAZORAC
2
diflorasone oint
1
tretinoin, NP = Avita gel,
microsphere gel (Retin-A –
brand is NP)
1
fluocinolone (Derma-Smoothe/FS,
Synalar – brands are NP)
1
fluocinonide, NP = crm, 0.1%
1
FlexRx Drug Formulary, April 2014
Specialty
Drug Name
Drug Tier
Step Therapy
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2014
29
fluticasone propionate (Cutivate –
brand is NP)
1
OXSORALEN-ULTRA
2
halobetasol (Ultravate – brand is
NP)
permethrin crm, 5% (Elimite –
brand is NP)
1
1
PICATO
2
hydrocortisone butyrate (Locoid – 1
brand is NP)
1
hydrocortisone topical, 2.5%
hydrocortisone valerate (Westcort 1
– brand is NP)
1
mometasone (Elocon – brand is
NP)
1
nystatin/triamcinolone
Step Therapy
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Step Therapy
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2014
podofilox (Condylox – brand is NP) 1
2
PROTOPIC
PRUDOXIN
2
selenium sulfide 2.5%
1
VALCHLOR
2
VOLTAREN
2
XERAC AC
2
•
triamcinolone crm; lotn; oint,
0.025%, 0.1%
1
MISCELLANEOUS CATEGORIES (includes supplies
and devices)
TRIAMCINOLONE oint, 0.5%
2
DIABETIC SUPPLIES
Other Skin Products
acitretin (Soriatane – brand is NP)
1
aluminum chloride (Drysol – brand 1
is NP)
calcipotriene crm, soln (Dovonex 1
– brand is NP)
2
CARAC
diclofenac sodium (Solaraze –
brand is NP)
1
DRITHO-CREME HP
2
ELIDEL
2
FLUOROPLEX
2
fluorouracil (Efudex – brand is NP) 1
1
imiquimod (Aldara – brand is NP)
lidocaine patches (Lidoderm)
1
lidocaine topical (Xylocaine –
brand is NP)
1
lidocaine/prilocaine crm
1
LIDOCAINE/PRILOCAINE kit
2
LIDODERM
2
lindane
1
malathion (Ovide – brand is NP)
1
30
BLOOD GLUCOSE METER –
BAYER BREEZE 2, CONTOUR,
CONTOUR LINK, CONTOUR
NEXT, CONTOUR USB,
DIDGET
2
BLOOD GLUCOSE METER
– ROCHE AVIVA PLUS,
COMPACT PLUS, NANO
SMARTVIEW, VOICEMATE
2
CALIBRATION LIQUID – BAYER
ASCENSIA AUTODISC,
BREEZE 2, CONTOUR,
CONTOUR NEXT
2
CALIBRATION LIQUID – ROCHE
ACCU-CHEK ACTIVE, AVIVA,
COMFORT CURVE, COMPACT,
INSTANT, SMARTVIEW;
ACCUTREND
2
INSULIN PEN NEEDLES –
NOVOFINE, NOVOTWIST,
OTHER VARIOUS
MANUFACTURERS
2
INSULIN SYRINGES – VARIOUS
MANUFACTURERS
2
LANCETS – VARIOUS
MANUFACTURERS
2
FlexRx Drug Formulary, April 2014
TEST STRIPS – BAYER
ASCENSIA AUTODISC,
BREEZE 2, CONTOUR,
CONTOUR NEXT
2
TEST STRIPS – ROCHE ACCUCHEK ACTIVE, AVIVA, AVIVA
PLUS, COMFORT CURVE,
COMPACT, SMARTVIEW;
ACCUTREND
2
Step Therapy
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2014
ORAL INHALER-ASSIST DEVICES - SPACERS
The formulary includes a number of products available
only as brand products. The most commonly prescribed
are AEROCHAMBER, EASIVENT, E-Z SPACER,
INSPIREASE and MICROCHAMBER.
MISCELLANEOUS DRUGS
azathioprine (Imuran – brand is
NP)
1
CELLCEPT oral susp
2
CHEMET
2
CUPRIMINE
2
cyclosporine (Sandimmune –
brand is NP)
1
cyclosporine modified caps,
25 mg, 100 mg; soln (Neoral –
brand is NP)
1
CYCLOSPORINE modified caps,
50 mg
2
•
mycophenolate mofetil (Cellcept – 1
brand is NP)
mycophenolate sodium delayed- 1
release (Myfortic – brand is NP)
2
MYFORTIC
RAPAMUNE
2
REVLIMID
2
sirolimus (Rapamune)
1
sodium polystyrene sulfonate
1
SYPRINE
2
tacrolimus (Prograf – brand is NP)
1
THALOMID
2
ZORTRESS
2
FlexRx Drug Formulary, April 2014
• • •
•
• • •
31
2014
INDEX
A
abacavir............................................................................ 10
abacavir/lamivudine/zidovudine.....................................10
acamprosate delayed-release........................................ 22
acarbose........................................................................... 13
acebutolol.........................................................................15
acetaminophen/codeine..................................................23
acetaminophen/isometheptene/
dichloralphenazone....................................................... 24
ACETAZOLAMIDE 125 mg............................................... 16
acetazolamide 250 mg.................................................... 16
acetazolamide ext-release.............................................. 16
acetic acid ear soln.........................................................28
acetylcysteine.................................................................. 18
acitretin.............................................................................30
ACTONEL..........................................................................14
acyclovir oral................................................................... 10
adapalene......................................................................... 29
ADCIRCA...........................................................................17
ADDERALL XR................................................................. 22
adefovir.............................................................................10
ADVAIR DISKUS...............................................................18
ADVAIR HFA.....................................................................18
ADVATE............................................................................ 26
AFINITOR.......................................................................... 11
AFINITOR DISPERZ......................................................... 11
AGGRENOX...................................................................... 26
ALBENZA.......................................................................... 11
albuterol ext-release....................................................... 18
albuterol inhal soln, syrup, tabs.................................... 18
alclometasone..................................................................29
ALDURAZYME.................................................................. 14
ALENDRONATE 40 mg.................................................... 14
alendronate 5 mg, 10 mg, 35 mg, 70 mg....................... 14
alfuzosin ext-release....................................................... 20
ALKERAN tabs..................................................................11
allopurinol........................................................................ 24
ALPHAGAN P eye soln, 0.1%.......................................... 28
ALPHANATE/VWF............................................................ 26
ALPHANINE SD................................................................ 26
alprazolam........................................................................ 20
alprazolam ext-release.................................................... 20
ALREX............................................................................... 27
aluminum chloride.......................................................... 30
amantadine, NP = tabs................................................... 11
amantadine, NP = tabs................................................... 25
amcinonide crm...............................................................29
amiloride...........................................................................16
amiloride/hydrochlorothiazide....................................... 16
aminocaproic acid........................................................... 26
amiodarone...................................................................... 17
amitriptyline..................................................................... 21
32
amlodipine........................................................................16
amlodipine/benazepril..................................................... 16
amoxicillin/potassium clavulanate.................................. 9
amoxicillin/potassium clavulanate ext-release...............9
amoxicillin caps, susp, tabs............................................ 9
AMOXICILLIN chew tabs.................................................... 9
amphetamine/dextroamphetamine................................ 22
ampicillin caps...................................................................9
AMPICILLIN susp................................................................9
anagrelide.........................................................................26
anastrozole.......................................................................11
ANDRODERM................................................................... 12
ANDROGEL.......................................................................13
APOKYN............................................................................25
APTIVUS........................................................................... 10
ARANESP..........................................................................26
ASACOL HD......................................................................19
ASMANEX, NP = 7 metered doses.................................. 18
ASTEPRO..........................................................................18
ATELVIA............................................................................ 14
atenolol............................................................................. 15
atenolol/chlorthalidone................................................... 15
atorvastatin...................................................................... 16
atovaquone/proguanil 250-100 mg................................ 11
ATOVAQUONE/PROGUANIL 62.5-25 mg........................11
ATRIPLA............................................................................10
ATROPINE SULFATE eye oint......................................... 28
atropine sulfate eye soln................................................28
ATROVENT HFA...............................................................18
AUGMENTIN susp, 125 mg/5 mL.......................................9
AVINZA..............................................................................23
AVODART......................................................................... 20
AZASITE............................................................................27
azathioprine......................................................................31
azelastine eye soln..........................................................28
azelastine nasal............................................................... 18
AZELEX............................................................................. 29
AZILECT............................................................................ 25
azithromycin susp, tabs................................................... 9
AZOPT...............................................................................28
B
bacitracin/polymyxin B eye oint.................................... 27
BACITRACIN eye oint.......................................................27
baclofen............................................................................ 25
BACTROBAN NASAL....................................................... 18
balsalazide........................................................................19
BANZEL tabs.....................................................................24
BARACLUDE.....................................................................10
BEBULIN........................................................................... 26
BEBULIN VH..................................................................... 26
benazepril......................................................................... 15
benazepril/hydrochlorothiazide......................................15
BENEFIX........................................................................... 26
benzocaine/antipyrine ear soln......................................28
benzonatate......................................................................18
FlexRx Drug Formulary, April 2014
2014
benztropine...................................................................... 25
betamethasone dipropionate......................................... 29
betamethasone dipropionate, augmented.................... 29
betamethasone valerate crm, lotn, oint.........................29
BETASERON.....................................................................22
bethanechol......................................................................20
bicalutamide.....................................................................11
BILTRICIDE....................................................................... 11
bisoprolol......................................................................... 15
bisoprolol/hydrochlorothiazide...................................... 15
BLEPHAMIDE....................................................................27
BLEPHAMIDE S.O.P.........................................................27
BLOOD GLUCOSE METER – BAYER BREEZE 2,
CONTOUR, CONTOUR LINK, CONTOUR NEXT,
CONTOUR USB, DIDGET.............................................. 30
BLOOD GLUCOSE METER – ROCHE AVIVA
PLUS, COMPACT PLUS, NANO SMARTVIEW,
VOICEMATE....................................................................30
BOSULIF........................................................................... 11
BREO ELLIPTA.................................................................18
BRILINTA...........................................................................26
brimonidine eye soln, 0.15%.......................................... 28
brimonidine eye soln, 0.2%............................................ 28
BROMFENAC soln – twice daily dosing........................... 28
bromocriptine...................................................................25
budesonide.......................................................................18
budesonide ext-release...................................................12
bumetanide.......................................................................16
buprenorphine................................................................. 23
buprenorphine/naloxone.................................................23
bupropion......................................................................... 21
bupropion ext-release..................................................... 21
bupropion ext-release..................................................... 22
buspirone, NP = 7.5 mg..................................................20
butalbital/acetaminophen............................................... 23
butalbital/acetaminophen/caffeine, NP = caps,
50-300-40 mg, 50-500-40 mg.........................................23
butalbital/aspirin/caffeine/codeine.................................23
butalbital/aspirin/caffeine caps...................................... 23
BUTALBITAL/ASPIRIN/CAFFEINE tabs........................... 23
BYDUREON...................................................................... 13
BYETTA.............................................................................13
C
cabergoline.......................................................................14
caffeine citrate................................................................. 22
calcipotriene crm, soln................................................... 30
calcitonin-salmon............................................................ 14
calcitriol............................................................................ 14
calcium acetate................................................................19
CALIBRATION LIQUID – BAYER ASCENSIA AUTODISC,
BREEZE 2, CONTOUR, CONTOUR NEXT.................... 30
CALIBRATION LIQUID – ROCHE ACCU-CHEK ACTIVE,
AVIVA, COMFORT CURVE, COMPACT, INSTANT,
SMARTVIEW; ACCUTREND.......................................... 30
CANASA............................................................................ 19
FlexRx Drug Formulary, April 2014
candesartan/hydrochlorothiazide.................................. 15
CAPRELSA........................................................................11
CAPTOPRIL/HYDROCHLOROTHIAZIDE.........................15
CARAC.............................................................................. 30
CARAFATE susp...............................................................19
carbamazepine.................................................................24
carbamazepine ext-release.............................................24
carbidopa/levodopa.........................................................25
carbidopa/levodopa ext-release.....................................25
carbinoxamine maleate...................................................17
carteolol eye soln............................................................28
carvedilol.......................................................................... 15
cefadroxil............................................................................9
cefdinir................................................................................9
cefpodoxime.......................................................................9
cefprozil.............................................................................. 9
ceftriaxone..........................................................................9
cefuroxime..........................................................................9
CELEBREX........................................................................24
CELLCEPT oral susp........................................................ 31
CELONTIN.........................................................................24
CENTANY, NP = kit.......................................................... 29
cephalexin caps, 250 mg, 500 mg; susp......................... 9
CEREZYME.......................................................................26
cetirizine/pseudoephedrine ext-release – Nonpreferred (may have coverage in an OTC
program)......................................................................... 18
cetirizine chew tabs, tabs – Non-preferred (may have
coverage in an OTC program)......................................17
cetirizine syrup................................................................ 17
CETROTIDE...................................................................... 13
cevimeline........................................................................ 28
CHANTIX........................................................................... 22
CHEMET............................................................................31
CHENODAL.......................................................................19
chlorhexidine oral rinse..................................................28
chloroquine phosphate...................................................11
CHLOROTHIAZIDE 250 mg..............................................16
chlorothiazide 500 mg.................................................... 16
chlorpromazine................................................................ 21
CHLORTHALIDONE 25 mg, 50 mg.................................. 16
chlorzoxazone..................................................................25
cholestyramine................................................................ 16
chorionic gonadotropin.................................................. 13
ciclopirox, NP = topical kit............................................. 29
cilostazol.......................................................................... 26
cimetidine......................................................................... 19
CIPRODEX........................................................................ 28
ciprofloxacin ext-release tabs..........................................9
ciprofloxacin eye soln.................................................... 27
ciprofloxacin tabs..............................................................9
CIPRO HC ear susp......................................................... 28
CIPRO susp........................................................................ 9
citalopram.........................................................................21
CLARAVIS 30 mg............................................................. 29
clarithromycin.................................................................... 9
33
2014
clarithromycin ext-release................................................ 9
CLEOCIN supp..................................................................20
clindamycin/benzoyl peroxide....................................... 29
clindamycin oral.............................................................. 11
clindamycin topical......................................................... 29
clindamycin vaginal crm................................................ 20
clobetasol......................................................................... 29
clomiphene.......................................................................13
clomipramine................................................................... 21
clonazepam...................................................................... 24
clonazepam ODT............................................................. 25
clonidine........................................................................... 17
clopidogrel 75 mg........................................................... 26
clotrimazole/betamethasone.......................................... 29
clotrimazole troche......................................................... 28
clozapine.......................................................................... 21
CODEINE SULFATE......................................................... 23
COLCRYS......................................................................... 24
colestipol tabs................................................................. 16
COMBIPATCH...................................................................13
COMBIVENT RESPIMAT..................................................18
COMETRIQ....................................................................... 11
COMMIT – OTC................................................................ 22
COMPLERA.......................................................................10
COPAXONE...................................................................... 22
CORTIFOAM..................................................................... 28
CORTISONE..................................................................... 12
CREON..............................................................................19
CRESTOR......................................................................... 16
CRIXIVAN..........................................................................10
cromolyn sodium eye soln.............................................28
cromolyn sodium inhal soln.......................................... 18
CUPRIMINE.......................................................................31
cyanocobalamin inj......................................................... 26
cyclobenzaprine 5 mg, 10 mg........................................ 25
cyclopentolate eye soln, 1%.......................................... 28
CYCLOPHOSPHAMIDE....................................................11
cyclosporine.....................................................................31
cyclosporine modified caps, 25 mg, 100 mg; soln....... 31
CYCLOSPORINE modified caps, 50 mg.......................... 31
cyproheptadine................................................................ 17
CYSTAGON.......................................................................20
CYTRA-3........................................................................... 20
CYTRA-K soln................................................................... 20
D
danazol............................................................................. 13
dantrolene........................................................................ 25
DAPSONE......................................................................... 11
DARAPRIM........................................................................11
DELZICOL......................................................................... 19
demeclocycline.................................................................. 9
desipramine......................................................................21
desmopressin.................................................................. 14
desonide........................................................................... 29
DESOXIMETASONE crm, 0.05%..................................... 29
34
desoximetasone crm, 0.25%; gel; oint, 0.25%.............. 29
DETROL LA...................................................................... 20
dexamethasone elixir; tabs, 0.5 mg, 0.75 mg, 1.5 mg, 4
mg, 6 mg........................................................................ 12
DEXAMETHASONE INTENSOL....................................... 12
dexamethasone sodium phosphate eye soln............... 27
DEXAMETHASONE soln; tabs, 1 mg, 2 mg..................... 12
dexmethylphenidate........................................................ 22
dextroamphetamine ext-release.....................................22
dextroamphetamine tabs................................................ 22
DIASTAT............................................................................25
DIAZEPAM oral soln, 1 mg/mL......................................... 20
diazepam tabs..................................................................20
DIBENZYLINE................................................................... 17
diclofenac eye soln......................................................... 28
diclofenac potassium......................................................24
diclofenac sodium delayed-release............................... 24
diclofenac sodium ext-release....................................... 24
diclofenac sodium gel.................................................... 30
dicloxacillin........................................................................ 9
dicyclomine caps, tabs...................................................19
DICYCLOMINE soln.......................................................... 19
didanosine delayed-release............................................10
DIFFERIN gel, 0.3%; lotn..................................................29
DIFICID................................................................................9
DIFLORASONE crm..........................................................29
diflorasone oint............................................................... 29
DIGOXIN soln....................................................................17
digoxin tabs..................................................................... 17
dihydroergotamine mesylate inj.................................... 24
DILANTIN caps, susp........................................................25
diltiazem........................................................................... 16
diltiazem ext-release....................................................... 16
DIOVAN, NP = Diovan HCT............................................. 15
diphenhydramine caps, 50 mg.......................................17
DIPHENOXYLATE/ATROPINE soln................................. 19
diphenoxylate/atropine tabs...........................................19
dipyridamole.................................................................... 26
disopyramide................................................................... 17
disulfiram..........................................................................22
divalproex delayed-release.............................................25
divalproex ext-release.....................................................24
divalproex ext-release.....................................................25
DIVIGEL.............................................................................13
donepezil, NP = 23 mg....................................................22
dorzolamide/timolol maleate eye soln...........................28
dorzolamide eye soln......................................................28
doxazosin......................................................................... 17
doxepin, 10 mg, 25 mg, 50 mg, 100 mg; conc.............. 21
DOXEPIN 75 mg............................................................... 21
doxycycline hyclate caps................................................. 9
doxycycline hyclate tabs..................................................9
doxycycline monohydrate................................................ 9
DRITHO-CREME HP.........................................................30
dronabinol........................................................................ 19
DULERA............................................................................ 18
FlexRx Drug Formulary, April 2014
2014
DUTOPROL.......................................................................15
E
econazole......................................................................... 29
EDURANT......................................................................... 10
EFFIENT............................................................................26
ELIDEL.............................................................................. 30
ELLA.................................................................................. 13
EMCYT.............................................................................. 11
EMEND..............................................................................19
EMTRIVA...........................................................................10
enalapril............................................................................ 15
enalapril/hydrochlorothiazide.........................................15
ENBREL............................................................................ 24
ENBREL SURECLICK.......................................................24
enoxaparin........................................................................26
entacapone.......................................................................25
EPIPEN..............................................................................17
EPIPEN-JR........................................................................ 17
EPIVIR-HBV...................................................................... 10
EPIVIR oral soln................................................................10
eplerenone........................................................................17
epoprostenol.................................................................... 17
EPZICOM.......................................................................... 10
ergocalciferol................................................................... 26
ERIVEDGE........................................................................ 11
ERY-TAB............................................................................. 9
ERYTHROCIN STEARATE.................................................9
erythromycin/benzoyl peroxide..................................... 29
erythromycin/sulfisoxazole.............................................. 9
ERYTHROMYCIN BASE.....................................................9
erythromycin delayed-release caps................................ 9
ERYTHROMYCIN ETHYLSUCCINATE.............................. 9
erythromycin eye oint.....................................................27
erythromycin gel............................................................. 29
erythromycin topical pads, soln.................................... 29
ESCAVITE LQ...................................................................26
escitalopram.....................................................................21
estazolam......................................................................... 22
ESTRACE crm.................................................................. 20
estradiol............................................................................13
estradiol/norethindrone acetate.....................................13
ESTROGEL....................................................................... 13
estropipate 0.75 mg, 1.5 mg...........................................13
ESTROPIPATE 3 mg........................................................ 13
ethambutol......................................................................... 9
ethosuximide....................................................................25
ETIDRONATE....................................................................14
etodolac............................................................................ 24
etodolac ext-release........................................................ 24
ETOPOSIDE caps.............................................................11
EVISTA.............................................................................. 14
exemestane...................................................................... 11
F
FABRAZYME.....................................................................14
FlexRx Drug Formulary, April 2014
famciclovir........................................................................10
famotidine tabs................................................................19
FARESTON....................................................................... 11
FEIBA NF.......................................................................... 26
FEIBA VH.......................................................................... 26
felbamate.......................................................................... 25
felodipine ext-release......................................................16
fenofibrate........................................................................ 16
fenofibrate micronized.................................................... 16
fenofibric acid delayed-release......................................16
fentanyl............................................................................. 23
FINACEA........................................................................... 29
finasteride.........................................................................20
FIRAZYR........................................................................... 18
FIRMAGON....................................................................... 11
flecainide.......................................................................... 17
FLOVENT DISKUS........................................................... 18
FLOVENT HFA..................................................................18
fluconazole....................................................................... 10
flucytosine........................................................................10
fludrocortisone................................................................ 12
flunisolide 25 mcg/spray................................................ 18
fluocinolone..................................................................... 29
fluocinonide, NP = crm, 0.1%.........................................29
fluorometholone eye susp, 0.1%................................... 27
FLUOROPLEX...................................................................30
fluorouracil....................................................................... 30
fluoxetine, NP = 60 mg................................................... 21
fluoxetine delayed-release..............................................21
FLUPHENAZINE DECANOATE........................................21
FLUPHENAZINE HCL conc, elixir.....................................21
fluphenazine hcl tabs......................................................21
FLURA-DROPS 0.55 mg/drop.......................................... 26
flurazepam........................................................................22
flurbiprofen eye soln.......................................................28
flurbiprofen tabs..............................................................24
flutamide...........................................................................11
fluticasone propionate nasal..........................................18
fluticasone propionate topical....................................... 30
fluvoxamine......................................................................21
FML eye oint..................................................................... 27
folic acid tabs, 1 mg....................................................... 26
FOLLISTIM AQ..................................................................13
FORADIL AEROLIZER......................................................18
fosinopril.......................................................................... 15
fosinopril/hydrochlorothiazide....................................... 15
furosemide, NP = soln, 8 mg/mL................................... 16
FUZEON............................................................................ 10
G
gabapentin........................................................................25
galantamine......................................................................23
galantamine ext-release..................................................23
gemfibrozil........................................................................16
gentamicin eye oint, soln............................................... 27
GENTAMICIN SULFATE topical....................................... 29
35
2014
GILOTRIF.......................................................................... 11
GLEEVEC..........................................................................11
glimepiride........................................................................13
glipizide............................................................................ 13
glipizide/metformin..........................................................13
glipizide ext-release........................................................ 13
GLUCAGON EMERGENCY KIT....................................... 13
glyburide...........................................................................13
GLYBURIDE, distributor of Diabeta.................................. 13
glyburide/metformin........................................................ 13
glyburide micronized...................................................... 13
glycopyrrolate.................................................................. 19
granisetron....................................................................... 19
griseofulvin microsize.....................................................10
guanfacine........................................................................17
H
halobetasol.......................................................................30
haloperidol decanoate.................................................... 21
haloperidol lactate oral soln.......................................... 21
haloperidol tabs...............................................................21
HELIXATE FS................................................................... 26
HEMOFIL M...................................................................... 27
heparin sodium lock flush, NP = 2 units/mL.................27
HEXALEN.......................................................................... 11
homatropine eye soln..................................................... 28
HUMALOG.........................................................................14
HUMALOG MIX 50/50, 75/25............................................14
HUMATE-P........................................................................ 27
HUMIRA.............................................................................24
HUMULIN 70/30................................................................ 14
HUMULIN N...................................................................... 14
HUMULIN R...................................................................... 14
HYCAMTIN caps............................................................... 11
hydralazine....................................................................... 17
hydrochlorothiazide caps............................................... 16
hydrochlorothiazide tabs................................................16
hydrocodone/acetaminophen, NP = soln, 7.5-325
mg/15 mL; tabs, 2.5-325 mg, 5-300 mg, 5-300 mg,
7.5-300 mg, 10-300 mg.................................................. 23
HYDROCODONE/ACETAMINOPHEN tabs, 7.5-500 mg,
7.5-650 mg, 10-750 mg...................................................23
hydrocodone/ibuprofen, NP = tabs, 2.5-200 mg........... 23
hydrocortisone/acetic acid ear soln.............................. 28
hydrocortisone acetate rectal crm, supp...................... 29
hydrocortisone butyrate................................................. 30
hydrocortisone enema.................................................... 29
hydrocortisone oral.........................................................12
hydrocortisone topical, 2.5%......................................... 30
hydrocortisone valerate..................................................30
hydromorphone soln, tabs............................................. 23
HYDROMORPHONE supp................................................23
hydroxychloroquine........................................................ 11
hydroxyurea..................................................................... 11
hydroxyzine hcl............................................................... 20
HYDROXYZINE PAMOATE 100 mg.................................20
36
hydroxyzine pamoate 25 mg, 50 mg............................. 20
hyoscyamine.................................................................... 19
hyoscyamine ext-release................................................ 19
I
ibandronate...................................................................... 14
ibuprofen.......................................................................... 24
ICLUSIG............................................................................ 12
IMBRUVICA.......................................................................12
imipramine hcl................................................................. 21
imiquimod.........................................................................30
INCIVEK............................................................................ 10
INCRELEX.........................................................................14
indapamide.......................................................................16
indomethacin................................................................... 24
indomethacin ext-release............................................... 24
INLYTA.............................................................................. 12
INSULIN PEN NEEDLES – NOVOFINE, NOVOTWIST,
OTHER VARIOUS MANUFACTURERS......................... 30
INSULIN SYRINGES – VARIOUS
MANUFACTURERS........................................................ 30
INTELENCE.......................................................................10
INTUNIV............................................................................ 22
INVIRASE.......................................................................... 10
ipratropium/albuterol.......................................................18
ipratropium inhal soln.................................................... 18
ipratropium nasal............................................................ 18
irbesartan......................................................................... 15
ISENTRESS...................................................................... 10
ISONIAZID syrup.................................................................9
isoniazid tabs.....................................................................9
ISOSORBIDE DINITRATE tabs, 30 mg............................ 16
isosorbide dinitrate tabs, 5 mg, 10 mg, 20 mg............. 16
isosorbide mononitrate...................................................16
isosorbide mononitrate ext-release...............................16
isotretinoin 10 mg, 20 mg, 40 mg (Amnesteem,
Claravis, Myorisan, Zenatane)......................................29
itraconazole......................................................................10
J
JAKAFI...............................................................................12
JANUMET..........................................................................13
JANUMET XR................................................................... 13
JANUVIA............................................................................13
JUVISYNC......................................................................... 13
K
KALETRA.......................................................................... 10
KALYDECO....................................................................... 18
ketoconazole crm, shampoo.......................................... 29
ketoprofen........................................................................ 24
ketorolac eye soln...........................................................28
ketorolac tabs.................................................................. 23
KOATE-DVI....................................................................... 27
KOGENATE FS.................................................................27
KOMBIGLYZE XR............................................................. 14
FlexRx Drug Formulary, April 2014
2014
K-PHOS............................................................................. 26
K-PHOS NO. 2.................................................................. 20
L
labetalol............................................................................ 15
lactulose........................................................................... 19
lactulose........................................................................... 19
lamivudine........................................................................ 10
lamivudine/zidovudine.................................................... 10
lamivudine tabs............................................................... 10
lamotrigine....................................................................... 25
LANCETS – VARIOUS MANUFACTURERS.................... 30
lansoprazole delayed-release caps............................... 19
LANTUS.............................................................................14
latanoprost eye soln....................................................... 28
leflunomide.......................................................................24
LETAIRIS...........................................................................17
letrozole............................................................................ 12
LEUCOVORIN CALCIUM tabs, 10 mg, 15 mg..................12
leucovorin calcium tabs, 5 mg, 25 mg.......................... 12
LEUKERAN....................................................................... 12
levalbuterol inhal soln, 1.25 mg/0.5 mL........................ 18
LEVEMIR........................................................................... 14
levetiracetam....................................................................25
levetiracetam ext-release................................................25
LEVOBUNOLOL eye soln, 0.25%.....................................28
levobunolol eye soln, 0.5%............................................ 28
levocarnitine.....................................................................14
levocetirizine.................................................................... 17
levofloxacin oral................................................................ 9
levonorgestrel.................................................................. 13
levothyroxine................................................................... 14
LEXIVA.............................................................................. 10
LIALDA.............................................................................. 19
lidocaine/prilocaine crm................................................. 30
LIDOCAINE/PRILOCAINE kit............................................30
lidocaine patches............................................................ 30
lidocaine topical.............................................................. 30
lidocaine viscous............................................................ 28
LIDODERM........................................................................30
lindane.............................................................................. 30
liothyronine...................................................................... 14
lisinopril............................................................................15
lisinopril/hydrochlorothiazide........................................ 15
lithium carbonate............................................................ 21
LITHIUM CARBONATE caps, 150 mg..............................21
lithium carbonate ext-release 300 mg........................... 21
lithium carbonate ext-release 450 mg........................... 21
LITHIUM CITRATE............................................................21
LOMUSTINE......................................................................12
loratadine/pseudoephedrine ext-release – Nonpreferred (may have coverage in an OTC
program)......................................................................... 18
loratadine – Non-preferred (may have coverage in an
OTC program)................................................................ 18
lorazepam......................................................................... 20
FlexRx Drug Formulary, April 2014
lorazepam conc............................................................... 20
losartan.............................................................................15
losartan/hydrochlorothiazide......................................... 15
LOTEMAX..........................................................................27
lovastatin.......................................................................... 16
loxapine............................................................................ 21
LYSODREN....................................................................... 12
M
MACRODANTIN 25 mg.................................................... 20
MALARONE 62.5-25 mg...................................................11
malathion..........................................................................30
MATULANE....................................................................... 12
meclizine...........................................................................19
MECLOFENAMATE.......................................................... 24
medroxyprogesterone acetate....................................... 13
medroxyprogesterone acetate inj, 150 mg/mL............. 13
mefloquine........................................................................11
megestrol..........................................................................12
MEKINIST..........................................................................12
meloxicam tabs............................................................... 24
MENOPUR........................................................................ 13
MEPHYTON...................................................................... 26
mercaptopurine................................................................12
mesalamine...................................................................... 19
MESNEX tabs................................................................... 12
MESTINON syrup..............................................................26
MESTINON TIMESPAN.................................................... 26
metaxalone....................................................................... 25
metformin......................................................................... 14
metformin ext-release..................................................... 14
methadone conc, soln.................................................... 23
methadone tabs...............................................................23
methazolamide.................................................................16
methenamine hippurate.................................................. 20
methimazole..................................................................... 14
methocarbamol................................................................ 25
methotrexate.................................................................... 12
methotrexate.................................................................... 24
methscopolamine............................................................ 19
methyldopa.......................................................................17
methylergonovine............................................................14
methylphenidate ext-release.......................................... 22
methylphenidate ext-release OSM................................. 22
METHYLPHENIDATE ext-release tabs, 10 mg.................22
methylphenidate ext-release tabs, 20 mg..................... 22
methylphenidate tabs......................................................22
methylprednisolone.........................................................12
metipranolol eye soln..................................................... 28
metoclopramide............................................................... 19
metolazone....................................................................... 17
metoprolol/hydrochlorothiazide.....................................15
metoprolol succinate ext-release.................................. 15
metoprolol tartrate.......................................................... 15
metronidazole tabs..........................................................11
metronidazole topical......................................................29
37
2014
metronidazole topical gel, 0.75%................................... 29
metronidazole vaginal gel.............................................. 20
mexiletine......................................................................... 17
midazolam syrup............................................................. 22
midodrine......................................................................... 17
MIGERGOT....................................................................... 24
MIGRANAL........................................................................ 24
minocycline........................................................................ 9
minoxidil........................................................................... 17
mirtazapine.......................................................................21
misoprostol...................................................................... 19
modafinil...........................................................................22
moexipril...........................................................................15
moexipril/hydrochlorothiazide....................................... 15
mometasone.....................................................................30
MONOCLATE-P................................................................ 27
MONONINE....................................................................... 27
montelukast......................................................................18
morphine sulfate conc, soln.......................................... 23
morphine sulfate ext-release..........................................23
morphine sulfate ext-release..........................................23
MORPHINE SULFATE supp, tabs.................................... 23
MOXEZA............................................................................27
MULTI-VITAMIN/IRON/FLUORIDE................................... 26
mupirocin topical............................................................ 29
MYCOBUTIN..................................................................... 10
mycophenolate mofetil................................................... 31
mycophenolate sodium delayed-release...................... 31
MYFORTIC........................................................................ 31
MYLERAN......................................................................... 12
N
nabumetone..................................................................... 24
nadolol.............................................................................. 15
NAGLAZYME.....................................................................14
naltrexone.........................................................................23
NAMENDA.........................................................................23
naproxen...........................................................................24
naproxen delayed-release.............................................. 24
naproxen sodium............................................................ 24
naratriptan........................................................................ 24
NASONEX......................................................................... 18
NATACYN..........................................................................27
nateglinide........................................................................14
NEBUPENT....................................................................... 11
NECON 1/50, 10/11.......................................................... 13
neomycin/polymyxin B/bacitracin/hydrocortisone eye
oint.................................................................................. 27
neomycin/polymyxin B/bacitracin eye oint...................27
neomycin/polymyxin B/dexamethasone eye oint,
susp.................................................................................27
neomycin/polymyxin B/gramicidin eye soln.................27
neomycin/polymyxin B/hydrocortisone ear soln,
susp.................................................................................28
neomycin sulfate............................................................... 9
NEULASTA........................................................................27
38
NEUMEGA.........................................................................27
NEUPOGEN...................................................................... 27
nevirapine tabs................................................................ 10
NEXAVAR..........................................................................12
NEXIUM.............................................................................19
niacin ext-release............................................................ 16
NIASPAN........................................................................... 16
NICODERM CQ – OTC.................................................... 22
NICORETTE – OTC..........................................................22
nicotine lozenges, gum – OTC.......................................22
nicotine patches – OTC.................................................. 22
NICOTROL INHALER....................................................... 22
NICOTROL NS..................................................................22
nifedipine ext-release......................................................16
NILANDRON......................................................................12
NITRO-BID........................................................................ 16
nitrofurantoin................................................................... 20
nitrofurantoin macrocrystalline..................................... 20
nitrofurantoin monohydrate/macrocrystalline..............20
nitroglycerin..................................................................... 16
NITROSTAT...................................................................... 16
nizatidine.......................................................................... 19
norethindrone acetate.....................................................13
nortriptyline caps............................................................ 21
NORTRIPTYLINE soln...................................................... 21
NORVIR.............................................................................10
NOVOLIN 70/30................................................................ 14
NOVOLIN N.......................................................................14
NOVOLIN R.......................................................................14
NOVOLOG.........................................................................14
NOVOLOG MIX 70/30.......................................................14
NOVOSEVEN RT..............................................................27
NOXAFIL........................................................................... 10
NUEDEXTA....................................................................... 23
NUVARING........................................................................13
nystatin/triamcinolone.................................................... 30
nystatin oral..................................................................... 10
nystatin susp................................................................... 28
nystatin topical................................................................ 29
O
octreotide......................................................................... 14
ofloxacin ear soln............................................................28
ofloxacin eye soln........................................................... 27
OGESTREL....................................................................... 13
olanzapine........................................................................ 21
omeprazole delayed release...........................................19
OMEPRAZOLE DELAYED-RELEASE OTC: Nonpreferred (may have coverage in an OTC program)........19
OMNITROPE..................................................................... 14
ondansetron..................................................................... 19
ondansetron 24 mg......................................................... 19
ONFI.................................................................................. 25
ONGLYZA..........................................................................14
OPIUM TINCTURE (PAREGORIC) 2 mg/5mL..................19
FlexRx Drug Formulary, April 2014
2014
oral contraceptive generics, NP = generics
of FEMCON FE, LOSEASONIQUE, LYBREL,
SEASONIQUE................................................................. 13
ORAP.................................................................................23
ORFADIN...........................................................................14
orphenadrine/aspirin/caffeine 25-385-30 mg................ 25
ORPHENADRINE/ASPIRIN/CAFFEINE 50-770-60
mg.................................................................................... 25
orphenadrine ext-release................................................25
ORTHO DIAPHRAGM ALL-FLEX..................................... 13
ORTHO EVRA...................................................................13
ORTHO TRI-CYCLEN LO................................................. 13
OVIDREL........................................................................... 13
oxaprozin..........................................................................24
oxcarbazepine..................................................................25
OXSORALEN-ULTRA....................................................... 30
oxybutynin........................................................................20
oxybutynin ext-release....................................................20
oxycodone/acetaminophen, NP = tabs, 2.5-325 mg..... 23
oxycodone/acetaminophen caps, 5-500 mg................. 23
oxycodone/aspirin........................................................... 23
oxycodone caps, conc, soln.......................................... 23
OXYCODONE conc.......................................................... 23
oxycodone tabs, 5 mg, 15 mg, 30 mg........................... 23
OXYCONTIN..................................................................... 24
P
pantoprazole delayed-release........................................ 19
paricalcitol........................................................................14
paromomycin..................................................................... 9
paroxetine hcl.................................................................. 21
paroxetine hcl ext-release.............................................. 21
PATADAY.......................................................................... 28
pediatric multivitamins................................................... 26
pediatric vitamins ADC...................................................26
PEGANONE...................................................................... 25
PEGASYS..........................................................................10
PEG – electrolytes for soln............................................ 19
penicillin v potassium.......................................................9
PENTASA.......................................................................... 19
pentoxifylline ext-release................................................27
perindopril........................................................................ 15
permethrin crm, 5%.........................................................30
perphenazine....................................................................21
phenazopyridine.............................................................. 20
phenelzine........................................................................ 21
phenobarbital soln; tabs, 16.2 mg, 32.4 mg..................22
PHENOBARBITAL tabs, 15 mg, 30 mg, 60 mg, 64.8 mg,
97.2 mg, 100 mg............................................................. 22
phentermine 15 mg, 30 mg............................................ 23
phentermine 37.5 mg...................................................... 23
phenytoin..........................................................................25
phenytoin sodium ext-release........................................25
PHYTONADIONE inj, 10 mg/mL.......................................26
phytonadione inj, 1 mg/0.5 mL...................................... 26
PICATO............................................................................. 30
FlexRx Drug Formulary, April 2014
pilocarpine eye soln........................................................28
pilocarpine tabs...............................................................28
PINDOLOL.........................................................................15
pioglitazone......................................................................14
pioglitazone/metformin................................................... 14
piroxicam..........................................................................24
podofilox...........................................................................30
polymyxin B/trimethoprim eye soln.............................. 27
POMALYST....................................................................... 12
potassium bicarbonate/chloride effervescent tabs, 25
mEq................................................................................. 26
potassium chloride ext-release......................................26
potassium chloride packets; soln, 10%........................ 26
POTASSIUM CHLORIDE soln, 20%.................................26
potassium citrate/citric acid powder............................. 20
POTASSIUM CITRATE ext-release 540 mg, 1080 mg..... 20
potassium phosphate/sodium phosphates.................. 26
PRADAXA..........................................................................27
pramipexole......................................................................25
pravastatin........................................................................16
prazosin............................................................................ 17
prednisolone.................................................................... 12
prednisolone acetate eye susp......................................27
prednisolone sodium phosphate oral soln, 15 mg/5
mL....................................................................................12
prednisolone sodium phosphate oral soln, 5 mg/5
mL....................................................................................12
PREDNISONE dose packs; soln, 5 mg/5 mL; tabs, 50
mg.................................................................................... 12
prednisone tabs, 1 mg, 2.5 mg, 5 mg, 10 mg, 20
mg....................................................................................12
PREMARIN tabs................................................................13
PREMPHASE.................................................................... 13
PREMPRO.........................................................................13
PRENAFIRST.................................................................... 26
PRENATABS OBN, RX.....................................................26
PRENATAL AD, PLUS, U, VITAMINS PLUS, 19.............. 26
PREZISTA......................................................................... 10
PRIFTIN.............................................................................10
PRILOSEC OTC: Non-preferred (may have coverage in
an OTC program)............................................................ 19
PRIMAQUINE.................................................................... 11
primidone......................................................................... 25
PROAIR HFA.................................................................... 18
probenecid....................................................................... 24
probenecid/colchicine.....................................................24
prochlorperazine..............................................................21
PROCRIT...........................................................................27
PROFILNINE SD...............................................................27
progesterone micronized................................................13
PROLASTIN-C...................................................................18
promethazine supp, 12.5 mg, 25 mg; syrup; tabs........ 18
PROMETHEGAN supp, 50 mg......................................... 18
propafenone..................................................................... 17
propafenone ext-release................................................. 17
PROPANTHELINE............................................................ 19
39
2014
PROPRANOLOL/HYDROCHLOROTHIAZIDE..................15
propranolol ext-release...................................................15
PROPRANOLOL soln....................................................... 15
propranolol tabs.............................................................. 15
propylthiouracil................................................................14
PROTOPIC........................................................................ 30
protriptyline......................................................................21
PRUDOXIN........................................................................30
PULMICORT RESPULES 1 mg/2 mL...............................18
PULMOZYME.................................................................... 18
pyrazinamide....................................................................10
pyridostigmine................................................................. 26
Q
quetiapine.........................................................................21
QUFLORA PEDIATRIC..................................................... 26
quinapril............................................................................15
quinapril/hydrochlorothiazide........................................ 15
quinidine gluconate ext-release.....................................17
quinidine sulfate..............................................................17
QUINIDINE SULFATE ext-release....................................17
QVAR.................................................................................18
R
ramipril..............................................................................15
ranitidine...........................................................................19
RAPAMUNE...................................................................... 31
REBIF................................................................................ 22
RECOMBINATE................................................................ 27
REMODULIN..................................................................... 17
RENVELA.......................................................................... 19
RESCRIPTOR................................................................... 10
RESTASIS......................................................................... 28
REVLIMID..........................................................................31
REYATAZ.......................................................................... 10
ribavirin.............................................................................10
rifampin.............................................................................10
riluzole.............................................................................. 26
risperidone....................................................................... 21
rivastigmine......................................................................23
RIXUBIS............................................................................ 27
rizatriptan......................................................................... 24
ropinirole.......................................................................... 25
ROXICET soln...................................................................24
S
SABRIL.............................................................................. 25
salsalate............................................................................23
SANDOSTATIN LAR DEPOT........................................... 14
selegiline caps.................................................................25
selegiline tabs..................................................................25
selenium sulfide 2.5%.....................................................30
SELZENTRY......................................................................10
SENSIPAR.........................................................................14
SEREVENT DISKUS.........................................................18
SEROQUEL XR................................................................ 21
40
sertraline...........................................................................21
sildenafil........................................................................... 17
silver sulfadiazine........................................................... 29
SIMBRINZA....................................................................... 28
simvastatin....................................................................... 16
sirolimus...........................................................................31
sodium citrate/citric acid................................................ 20
sodium fluoride chew tabs; soln, 0.275 mg/drop, 1.1
mg/mL............................................................................. 26
sodium fluoride dental crm, gel, paste, rinse............... 28
SODIUM FLUORIDE tabs................................................. 26
sodium polystyrene sulfonate....................................... 31
SOLIRIS.............................................................................27
SOMAVERT.......................................................................15
sotalol............................................................................... 17
SPIRIVA HANDIHALER.................................................... 18
spironolactone................................................................. 17
spironolactone/hydrochlorothiazide..............................17
SPRYCEL.......................................................................... 12
SSKI...................................................................................26
STALEVO.......................................................................... 25
stavudine.......................................................................... 10
STIMATE........................................................................... 15
STIVARGA.........................................................................12
STRATTERA..................................................................... 22
STRIBILD...........................................................................10
STROMECTOL..................................................................11
SUBOXONE film............................................................... 24
sucralfate..........................................................................19
sulfacetamide sodium/prednisolone eye soln..............27
sulfacetamide sodium/sulfur 10-5% crm, emulsion,
lotn.................................................................................. 29
SULFACETAMIDE SODIUM/SULFUR susp, 10-5%.........29
sulfacetamide sodium eye soln..................................... 27
sulfacetamide sodium lotn............................................. 29
sulfamethoxazole/trimethoprim....................................... 9
sulfasalazine.................................................................... 20
sulfasalazine delayed-release........................................ 20
sulindac............................................................................ 24
sumatriptan inj, tabs....................................................... 24
SUMATRIPTAN nasal spray............................................. 24
SUPRAX tabs, NP = chew tabs..........................................9
SUSTIVA........................................................................... 10
SUTENT............................................................................ 12
SYLATRON....................................................................... 12
SYMBICORT..................................................................... 18
SYMLINPEN...................................................................... 14
SYNAGIS...........................................................................11
SYNAREL.......................................................................... 15
SYPRINE........................................................................... 31
T
TABLOID........................................................................... 12
tacrolimus.........................................................................31
TAFINLAR......................................................................... 12
TAMIFLU........................................................................... 11
FlexRx Drug Formulary, April 2014
2014
tamoxifen..........................................................................12
tamsulosin........................................................................20
TARCEVA..........................................................................12
TARGRETIN caps............................................................. 12
TASIGNA........................................................................... 12
TAZORAC..........................................................................29
TECFIDERA...................................................................... 22
TEGRETOL-XR 100 mg....................................................25
temazepam....................................................................... 22
temozolomide...................................................................12
terazosin........................................................................... 17
terbinafine........................................................................ 10
terbutaline........................................................................ 18
terconazole.......................................................................20
testosterone cypionate................................................... 13
testosterone enanthate................................................... 13
TEST STRIPS – BAYER ASCENSIA AUTODISC,
BREEZE 2, CONTOUR, CONTOUR NEXT.................... 31
TEST STRIPS – ROCHE ACCU-CHEK ACTIVE,
AVIVA, AVIVA PLUS, COMFORT CURVE, COMPACT,
SMARTVIEW; ACCUTREND.......................................... 31
TETRACYCLINE................................................................. 9
THALOMID........................................................................ 31
theophylline ext-release..................................................18
thiothixene........................................................................21
timolol maleate eye soln................................................ 28
TIMOLOL tabs...................................................................16
TIVICAY.............................................................................10
tizanidine tabs................................................................. 26
TOBI, NP = Podhaler.......................................................... 9
tobramycin/dexamethasone eye susp...........................27
tobramycin eye soln....................................................... 27
tobramycin inhal soln....................................................... 9
TOBREX eye oint..............................................................27
tolmetin caps................................................................... 24
tolterodine........................................................................ 20
tolterodine ext-release.................................................... 20
topiramate........................................................................ 25
torsemide..........................................................................17
TRACLEER........................................................................17
tramadol............................................................................24
tramadol/acetaminophen................................................ 24
tramadol ext-release....................................................... 24
trandolapril....................................................................... 15
TRANSDERM-SCOP.........................................................19
tranylcypromine...............................................................21
TRAVATAN Z.................................................................... 28
trazodone..........................................................................21
tretinoin, NP = Avita gel, microsphere gel.................... 29
tretinoin caps...................................................................12
TREXALL...........................................................................12
triamcinolone crm; lotn; oint, 0.025%, 0.1%................. 30
triamcinolone dental paste.............................................28
triamcinolone nasal.........................................................18
TRIAMCINOLONE oint, 0.5%........................................... 30
FlexRx Drug Formulary, April 2014
triamterene/hydrochlorothiazide caps, 37.5-25 mg;
tabs..................................................................................17
TRIAMTERENE/HYDROCHLOROTHIAZIDE caps, 50-25
mg.................................................................................... 17
TRICITRATES................................................................... 20
trifluoperazine.................................................................. 22
trifluridine eye soln......................................................... 27
trihexyphenidyl................................................................ 25
trimethobenzamide..........................................................19
trimethoprim.....................................................................11
TRINATE........................................................................... 26
TRI-VIT/FLUORIDE/IRON................................................. 26
TRIZIVIR............................................................................10
tropicamide eye soln...................................................... 28
TRUVADA..........................................................................11
TYKERB............................................................................ 12
U
ursodiol.............................................................................20
V
VAGIFEM...........................................................................20
valacyclovir...................................................................... 10
VALCHLOR....................................................................... 30
VALCYTE.......................................................................... 10
valproic acid.................................................................... 25
valsartan/hydrochlorothiazide........................................15
vancomycin...................................................................... 11
venlafaxine....................................................................... 21
venlafaxine ext-release caps..........................................21
venlafaxine ext-release tabs, NP = 225 mg................... 21
VENTAVIS......................................................................... 17
VENTOLIN HFA................................................................ 18
VERAPAMIL 40 mg...........................................................16
verapamil 80 mg, 120 mg............................................... 16
verapamil ext-release...................................................... 16
VESICARE.........................................................................20
VFEND susp......................................................................10
VIAGRA (males only > 18 years)......................................17
VICTOZA........................................................................... 14
VICTRELIS........................................................................ 10
VIDEX................................................................................ 11
VIGAMOX.......................................................................... 27
VIRACEPT.........................................................................11
VIRAMUNE susp...............................................................11
VIRAMUNE XR................................................................. 11
VIREAD............................................................................. 11
VIVELLE-DOT................................................................... 13
VOLTAREN gel................................................................. 30
voriconazole.....................................................................10
VOTRIENT.........................................................................12
VYVANSE..........................................................................22
W
warfarin.............................................................................27
WILATE............................................................................. 27
41
2014
X
XALKORI........................................................................... 12
XARELTO.......................................................................... 27
XELODA............................................................................ 12
XENICAL........................................................................... 23
XERAC AC........................................................................ 30
XIFAXAN 550 mg..............................................................11
XTANDI..............................................................................12
XYNTHA/SOLOFUSE........................................................27
Y
Z
zafirlukast......................................................................... 18
zaleplon............................................................................ 22
ZELBORAF........................................................................12
ZEMPLAR..........................................................................15
ZETIA.................................................................................16
ZIAGEN soln..................................................................... 11
zidovudine........................................................................ 11
ziprasidone.......................................................................22
ZITHROMAX packets.......................................................... 9
ZOLINZA............................................................................12
zolpidem........................................................................... 22
zolpidem ext-release....................................................... 22
zonisamide....................................................................... 25
ZORTRESS....................................................................... 31
ZOVIA 1/50E..................................................................... 13
ZYBAN...............................................................................22
ZYLET................................................................................28
ZYTIGA..............................................................................12
ZYVOX...............................................................................11
42
FlexRx Drug Formulary, April 2014