1. No category

2014
FORMULARY
better
care
better
health
better
together
DECEMBER 2014
better
care
better
health
better
together
Atempor
ectorempor
restium
inciet mil intof
At CareOregon,
we know
the importance
et
hilita anam
quo
officate
voluptat lab
intur?
having
great
team
of pharmacists.
“We
are
here to
make sure the
medications
you take
Quia
diorumquam
voluptat
repta quas
are
safe
and
effective,”
said
pharmacist
evendit labores ediaspitam fuga. Sam, Megan
ad
Viehmann
(upper
right,
with
member
Garrett
magnatatiis sitat et adit idundios essum ipis
Miles) at the OHSU et
Richmond
doluptatibusEstorro
quam el Pharmacy.
intur
“The OHSU Richmond Pharmacy is friendly
ab invenimus
and has helped me through my journey of
Am,
utetsmoking,”
faccae nihicieni
re, si cus eum quodis
quitting
said Garrett.
voloria cus, qui dolorat eris dis et aped mo eum
am vel id quibusamus.
INTRODUCTION
PHARMACY BENEFIT
CareOregon has a list of covered drugs called
a formulary. Pharmacists and doctors decide
which drugs should be in the formulary.
This formulary is effective on and after
January 1, 2014. To get up-to-date information
about drugs covered by CareOregon, visit our
web site at www.careoregon.org or call one
of the following numbers between 8 a.m. and
5 p.m. Monday through Friday:
•
Customer Service, 503-416-4100 in the
Portland, Oregon, calling area
•
Toll-free 1-800-224-4840 outside the
Portland, Oregon, calling area
•
TTY/TDD users should call
1-800-735-2900.
QUESTIONS TO ASK ABOUT YOUR
NEW PRESCRIPTIONS
For some drugs, your provider will need to
check with CareOregon before we will cover
the prescription.
3.If your provider does not prescribe
a different drug for you, ask your
provider’s office staff to mail or fax a
Prior Authorization or Formulary
Exception Request Form to CareOregon.
www.careoregon.org
If you check with your provider before leaving
the office, you will save time and start your
prescription as soon as possible. Be sure
to follow your provider’s and pharmacist’s
directions for taking your medication.
1. Before you leave your provider’s office, ask
if CareOregon covers the drug.
2.If CareOregon doesn’t cover it, ask if there
is a covered drug that would work for you.
Customer Service 503-416-4100
TOLL-FREE 1-800-224-4840
TTY/TDD number 1-800-735-2900
www.careoregon.org
i
CAREOREGON (OHP) 2014 FORMULARY
WHICH DRUGS ARE NOT
COVERED BY CAREOREGON?
To help members have the best possible health
outcomes, CareOregon may add or remove
drugs from the formulary or change coverage
rules on drugs. If we remove a drug from the
formulary or change the rules for a drug that
you take, we will tell you beforehand.
These items are not covered:
•
Drugs not listed in the formulary
•
Drugs removed from the formulary in
updates
•
Drugs used to treat conditions that are not
covered by the Oregon Health Plan, such
as fibromyalgia, allergic rhinitis, acne and
chronic back pain
HOW DO I FIND DRUG
INFORMATION IN THE
FORMULARY?
There are two ways to find a drug in the
formulary:
Medical Condition
The formulary begins on page 1. The drugs are
organized into categories that match the type
of medical conditions treated by each drug.
For example, drugs that treat a heart condition
are listed under the category “cardiovascular
medications.”
If you know what a drug is used for:
1. Look for the category name in the table
of contents.
•
Drugs used for cosmetic purposes
2.Look in the category name section for
your drug.
•
Drugs used for non-medically accepted
indications
Alphabetical Listing
•
Investigational drugs and drugs used in an
investigational manner
The index is an alphabetical list of all drugs
in the formulary. Both brand-name drugs and
generic drugs are in the index.
Mental health drugs, such as antidepressants,
anxiolytics and antipsychotics, are covered by
the Division of Medical Assistance Programs
(DMAP). These drugs are not listed in the
CareOregon Formulary. Your pharmacist sends
your prescription claim directly to DMAP.
CareOregon covers some over-the-counter
drugs that are listed in the formulary. These
drugs are covered if you have a prescription for
the drug from your provider.
ii
If you are not sure which category a drug is in,
look for the drug in the index that begins on
page 55. The page number next to the drug
shows which page has information on the
drug. Turn to that page and find the name of
your drug in the first column.
NOTE: If the formulary includes only generic
versions of a drug, the brand-name drug is not
covered by CareOregon.
WHAT ARE COVERAGE
RESTRICTIONS?
Some covered drugs have special rules for
using them.
Most drugs are limited to a 31-day supply
per prescription. The earliest date that you
can refill a prescription after getting a 31-day
supply is 23 days after the last refill.
EXCEPTIONS: You may get up to a 90-day
supply of the following drugs:
•
Generic oral contraceptives (birth control
pills)
•
Pediatric multivitamins with fluoride and
prenatal vitamins, folic acid, sodium fluoride
•
Digoxin, furosemide, hydrochlorothiazide,
atenolol, metoprolol, captopril, enalapril,
lisinopril
•Levothyroxine
•
Albuterol HFA inhalers and nebulizer
solutions
The earliest date that you can refill a
prescription after you get a 90-day supply
is 68 days after the last refill.
•
You need extra medication because your
dosage was increased.
•
You need a supply of a certain medication
for work or school.
For more information, call CareOregon
Customer Service at 503-416-4100 or toll free
at 1-800-224-4840, Monday through Friday,
8 a.m. to 5 p.m. TTY/TDD users may call
1-800-735-2900.
NOTE: CareOregon may approve an additional
refill in the following situations:
•
Your prescription is lost, stolen or spilled.
•
You need extra medication because you will
be out of town.
Customer Service 503-416-4100
TOLL-FREE 1-800-224-4840
TTY/TDD number 1-800-735-2900
www.careoregon.org
iii
CAREOREGON (OHP) 2014 FORMULARY
GENERIC DRUGS
A generic drug is a copy of a brandname drug. A generic has the same active
ingredients as the brand-name drug. Generic
drugs are approved by the U.S. Food and
Drug Administration and usually cost less than
brand-name drugs.
Generic drugs are listed in the formulary in
lower case (small letters), like this: morphine
sulf er. CareOregon does not cover the brandname versions of these drugs.
If your primary care provider (PCP) decides
that you have a medical need for a brandname drug, the provider must send a Prior
Authorization or Formulary Exception Request
Form to CareOregon.
PRIOR AUTHORIZATION (PA)
If a provider wants to prescribe a drug marked
PA in the formulary, he/ she must send a Prior
Authorization or Formulary Exception Request
Form to CareOregon. CareOregon cannot
pay for the prescription unless we approve
the request in advance.
iv
Usually, CareOregon only approves prior
authorization requests if the drug treats
conditions covered by the Oregon Health
Plan. Also, the prescription must meet drug
use rules set by the CareOregon Pharmacy &
Therapeutics Committee.
•
Each Prior Authorization or Formulary
Exception Request Form must have only one
medication request.
•
All fields on the form must be complete
and legible.
QUANTITY LIMIT (QL)
For drugs marked QL, CareOregon limits
the amount of the drug that we will pay for.
Your provider must send a Prior Authorization
or Formulary Exception Request Form to
CareOregon if he/she wants to prescribe an
amount of the drug over the quantity limits.
CareOregon’s decisions for prior authorization
and formulary exception requests are based
only on appropriate care and coverage.
CareOregon staff are not rewarded for denying
requests. CareOregon does not use financial
incentives to reward underutilization.
STEP THERAPY (ST)
CareOregon may ask you to first try other
drugs to treat your medical condition before
we will cover a drug marked ST. For example,
if Drug A and Drug B both treat the same
medical condition, CareOregon may not cover
Drug B before you try Drug A. If Drug A has
harmful side effects or does not work for you,
CareOregon will cover Drug B.
AGE RESTRICTIONS (AGE)
For some drugs, CareOregon requires you
to be younger than or older than a specific
age. For example, a drug may be restricted to
people under age 6 or over age 16.
OVER-THE-COUNTER (OTC)
DRUGS
Some over-the-counter (OTC) drugs are in the
formulary. CareOregon can cover an OTC drug
if you get a prescription from your provider and
give it to a network pharmacist.
Customer Service 503-416-4100
TOLL-FREE 1-800-224-4840
TTY/TDD number 1-800-735-2900
www.careoregon.org
v
CAREOREGON (OHP) 2014 FORMULARY
HOW TO FILL YOUR
PRESCRIPTIONS
Fill your prescriptions at a CareOregon
network pharmacy. A list of CareOregon
pharmacies is in your Provider Directory,
or you can find it on our web site at
www.careoregon.org.
Show your CareOregon ID card every time
you fill a prescription.
IMPORTANT: The drugs listed in the formulary
do not have copays. If a pharmacy asks you
to pay for a prescription, call CareOregon
Customer Service before you pay.
If your PCP’s clinic is closed and you think you
need a prescription filled immediately, call your
PCP’s after-hours telephone number.
WHAT IF A DRUG I AM TAKING
NOW IS NOT IN THE FORMULARY?
Drugs that are not in the formulary are
usually not covered. However, if your provider
believes that it is the best drug for you, the
provider must mail or fax a Prior Authorization
or Formulary Exception Request Form to
CareOregon.
Usually, CareOregon approves exception
requests only if other drugs or a smaller
amount of the drug would be less effective
in treating your condition or would cause side
effects that could hurt you.
vi
WHAT IF I URGENTLY NEED A
NON-FORMULARY OR
RESTRICTED DRUG?
You, your provider or a pharmacist may ask
for a five-day emergency supply of a nonformulary or restricted drug. This gives you,
your provider or the pharmacist time to send
a Prior Authorization or Formulary Exception
Request Form to CareOregon.
To ask for an emergency supply, call
CareOregon Customer Service at
503-416-4100 or toll free at 1-800-224-4840,
Monday through Friday, 8 a.m. to 5 p.m.
TTY/TDD users may call 1-800-735-2900.
WHAT IF I AM DOING WELL
ON A NON-FORMULARY OR
RESTRICTED DRUG FOR A
CHRONIC (CONSTANT)
MEDICAL CONDITION?
New members or members who move to a
different level of care may be using a nonformulary or restricted drug. If a provider asks
CareOregon to cover this drug, CareOregon
may provide a 60-day transition supply.
A transition supply gives you time to try a
different formulary drug to see if it meets your
needs. Meanwhile, your provider may send a
Prior Authorization or Formulary Exception
Request Form to CareOregon. You can find
the form at www.careoregon.org.
HOW DO I APPEAL IF MY PRIOR
AUTHORIZATION OR FORMULARY
EXCEPTION REQUEST WAS
DENIED?
Call CareOregon Customer Service as
soon as possible. Call 503-416-4100 or
toll free at 1-800-224-4840. TTY/TDD
users may call 1-800-735-2900.
CareOregon must receive requests for
reconsideration (appeals) no later than 45
days after the date on the original notice
of action (denial) letter. We may ask for
other information to support your appeal.
REFILL-TOO-SOON OVERRIDES
CareOregon may grant a refill-too-soon
override for lost, stolen or spilled medications,
vacation supplies and work or school
medications. Certain rules apply.
For more information, contact CareOregon
Customer Service at 503-416-4100 or
1-800-224-4840, Monday through
Friday 8 a.m. to 5 p.m. TTY/TDD users
can call 1-800-735-2900.
QUESTIONS ABOUT COVERED
PRODUCTS OR BENEFITS
Members and providers: Call CareOregon
Customer Service at 503-416-4100 or toll
free at 1-800-224-4840 or TTY/TDD users
can call 1-800-735-2900.
Customer Service 503-416-4100
TOLL-FREE 1-800-224-4840
TTY/TDD number 1-800-735-2900
www.careoregon.org
vii
CAREOREGON (OHP) 2014 FORMULARY
QUESTIONS ABOUT PHARMACY
CLAIMS PROCESSING
Providers and pharmacists:
For help on business days and to request
an appeal or reconsideration of a denial,
call CareOregon Customer Service at
503-416-4100 or toll free at 1-800-224-4840,
Monday-Friday, 8 a.m. to 5 p.m. TTY/TDD
users can call 1-800-735-2900.
For after-hours pharmacy benefits help,
call Catamaran at 1-866-843-5126. or
fax your questions to 503-416-8109.
viii
INDEX
ANESTHETICS.........................................................1
LOCAL ANESTHETICS......................................................1
TOPICAL ANESTHETICS.................................................1
ANTIDEPRESSANTS............................................1
SELECTIVE SEROTONIN REUPTAKE
INHIBITORS..................................................................................1
TRYCYCLICS................................................................................1
ANTIINFECTIVES....................................................1
AMEBICIDES................................................................................1
AMINOGLYCOSIDES............................................................1
ANTHELMINTICS....................................................................2
ANTIRETROVIRALS AND
PROTEASE INH........................................................................2
ANTITUBERCULOSIS DRUGS....................................3
CEPHALOSPORINS..............................................................3
CLINDAMYCINS........................................................................4
ERYTHROMYCINS.................................................................4
ORAL ANTIFUNGAL DRUGS......................................4
OTHER ANTIINFECTIVE DRUGS..............................4
HEPATITIS C.................................................................................5
OTHER MACROLIDES........................................................5
OTHER TOPICAL ANTIFUNGALS...........................6
PARENTERAL ANTIFUNGALS...................................6
PENICILLINS................................................................................6
PLASMODICIDES....................................................................7
QUINOLONES.............................................................................7
SULFONAMIDES.....................................................................7
SULFONES....................................................................................7
TETRACYCLINES....................................................................7
TOPICAL ANTIBACTERIAL DRUGS......................7
TOPICAL ANTIFUNGAL-CORTICOSTEROID
COMB.................................................................................................8
TRICHOMONOCIDES..........................................................8
URINARY ANTIINFECTIVES..........................................8
VAGINAL ANTIFUNGALS................................................8
ANTINEOPLASTIC/
IMMUNOSUPPRESSANT DRUGS.................8
ANTINEOPLASTIC/IMMUNOSUPPRESSANT
DRUGS..............................................................................................8
ANTIPSYCHOTICS...............................................10
ATYPICALS................................................................................10
AUTONOMIC AND CNS MEDICATIONS...11
ALCOHOL ANTAGONIST..............................................11
ANALGESICS...........................................................................11
ANTICONVULSANT BARBITURATES..............11
ANTICONVULSANT BENZODIAZEPINES....11
ANTIDEMENTIA DRUGS...............................................11
ANTIPARKINSON ANTICHOLINERGIC
DRUGS...........................................................................................12
ANTIVERTIGO AND ANTIEMETIC DRUGS..12
ANXIOLYTICS..........................................................................12
CARBAMAZEPINES..........................................................12
CLASS II NARCOTICS.....................................................13
CLASS III NARCOTICS....................................................14
CNS STIMULANT DRUGS...........................................14
DRUGS TO PREVENT AND TREAT
HEADACHES............................................................................15
DRUGS TO TREAT MULTIPLE
SCLEROSIS................................................................................15
HYDANTOINS..........................................................................15
Customer Service 503-416-4100
TOLL-FREE 1-800-224-4840
TTY/TDD number 1-800-735-2900
www.careoregon.org
ix
CAREOREGON (OHP) 2014 FORMULARY
OTHER ANTICONVULSANTS..................................15
OTHER ANTIPARKINSON DRUGS......................16
OTHER CNS/AUTONOMIC DRUGS...................16
SEDATIVE/HYPNOTIC DRUGS..............................16
SMOKING CESSATION PRODUCTS..................16
SUCCINIMIDES.......................................................................16
DERMATOLOGICAL MEDICATIONS.......... 22
ANTIPRURITIC DRUGS.................................................. 22
KERATOLYTIC DRUGS.................................................. 22
SCABICIDES............................................................................ 22
TOPICAL CORTICOSTEROID DRUGS............. 22
TOPICAL DERMATOLOGICAL DRUGS.......... 23
CARDIOVASCULAR MEDICATIONS...........17
ALPHA-ADRENERGIC ANTAGONISTS...........17
AMIODARONES.....................................................................17
ANGIOTENSIN CONVERTING ENZYME
INHIBITORS...............................................................................17
ANGIOTENSIN II RECEPTOR
ANTAGONISTS........................................................................17
BETA-ADRENERGIC ANTAGONIST
DRUGS...........................................................................................17
CALCIUM ANTAGONISTS............................................17
CARDIAC GLYCOSIDES.................................................18
CENTRALLY ACTING
ANTIHYPERTENSIVES...................................................18
CLASS 1A....................................................................................18
CLASS 1B....................................................................................18
CLASS 1C....................................................................................18
ENDOTHELIN RECPTR ANTAGONIST............19
HMG-COA COMBINATIONS......................................19
HMG-COA REDUCTASE INHIBITORS..............19
HYPOLIPOPROTEINEMICS........................................19
LOOP DIURETICS................................................................19
NITRATES................................................................................... 20
OTHER ANTIARRHYTHMICS.................................. 20
OTHER ANTIHYPERTENSIVES............................. 20
OTHER CARDIOVASCULAR DRUGS................21
OTHER VASODILATING DRUGS...........................21
POTASSIUM SPARING DIURETICS....................21
THIAZIDE AND RELATED DRUGS......................21
VASODILATOR ANTIHYPERTENSIVES..........21
DIAGNOSTIC AND MISCELLANEOUS
MEDICATIONS...................................................... 24
DIAGNOSTIC PRODUCTS............................................24
x
EAR-NOSE-THROAT MEDICATIONS........ 24
DRUGS AFFECTING THE EAR...............................24
DRUGS AFFECTING THE NOSE.......................... 25
DRUGS AFFECTING THE THROAT
AND MOUTH........................................................................... 25
ENDOCRINE MEDICATIONS......................... 25
ANTITHYROID DRUGS.................................................. 25
GLUCOCORTICOID DRUGS...................................... 25
GLUCOSE ELEVATING DRUGS............................ 25
INCRETIN MIMETICS....................................................... 26
INSULIN........................................................................................ 26
INSULIN SENSITIZERS & COMBOS.................. 27
MINERALOCORTICOID DRUGS............................ 27
ORAL HYPOGLYCEMICS AND COMBOS... 27
OTHER ENDOCRINE DRUGS.................................. 27
THYROID SUPPLEMENTS......................................... 28
GASTROINTESTINAL MEDICATIONS...... 28
ANTACIDS.................................................................................. 28
ANTIDIARRHEAL DRUGS.......................................... 28
ANTISPASMODICS/DRUGS AFFECT
GI MOTILITY.............................................................................29
ANTIULCER DRUGS.........................................................29
LAXATIVES AND CATHARTICS............................ 30
OTC H2 ANTAGONISTS.................................................31
OTHER ANTIULCER DRUGS....................................31
OTHER GI DRUGS...............................................................31
PROTON PUMP INHIBITORS................................... 32
IMMUNOLOGICALS AND VACCINES....... 32
ERYTHROID STIMULANTS....................................... 32
GROWTH HORMONES AND RELATED
DRUGS.......................................................................................... 32
IMMUNOGLOBULIN ANTIBODIES.....................33
IMMUNOLOGICALS AND VACCINES..............33
INSULIN LIKE GROWTH FACTORS-1............. 34
INTERFERONS....................................................................... 34
MYELOID STIMULANTS............................................... 34
MEDICAL (MISCELLANEOUS)
SUPPLIES................................................................ 35
DIABETIC SUPPLIES....................................................... 35
MEDICAL (MISCELLANEOUS)
SUPPLIES................................................................................... 35
MUSCULOSKELETAL MEDICATIONS...... 36
CNS MUSCLE RELAXANTS.................................... 36
DIRECT MUSCLE RELAXANTS............................ 36
DRUGS TO PREVENT AND TREAT
GOUT.............................................................................................. 36
NON-STEROIDAL ANTIINFLAMMATORY
AGENTS....................................................................................... 36
OTHER MUSCULOSKELETAL DRUGS.......... 37
SALICYLATES AND RELATED DRUGS......... 37
NUTRITION, BLOOD MODIFIERS,
ELECTROLYTES................................................... 38
ANTIPLATELET DRUGS............................................... 38
BLOOD DETOXICANTS................................................. 38
ELECTROLYTES, IRRIGATING
SOLUTIONS, ETC................................................................38
FLUORIDE PRODUCTS.................................................39
INJECTABLE ANTICOAGULANTS......................39
ORAL ANTICOAGULANTS, VITAMIN K..........40
OTHER MEDICATIONS AFFECTING
COAGULATION......................................................................40
POTASSIUM REMOVING RESINS.......................40
POTASSIUM SUPPLEMENTS...................................41
THERAPEUTIC VITAMINS
AND MINERALS....................................................................41
THROMBIN INHIBITORS.............................................. 42
VITAMINS AND MINERALS
AND RELATED PRODUCTS..................................... 42
OBSTETRICAL AND GYNECOLOGICAL
MEDICATIONS...................................................... 45
ANDROGEN DRUGS........................................................45
CONTRACEPTIVES...........................................................45
ESTROGEN DRUGS.........................................................48
ESTROGEN/PROGESTIN
COMBINATIONS...................................................................48
OB/GYN TOPICAL ANTIINFECTIVES..............48
OXYTOCICS..............................................................................48
PRENATAL VITAMINS.....................................................48
PROGESTIN DRUGS........................................................48
SELECTIVE ESTROGEN RECEPTOR
MODULATOR.......................................................................... 49
SPECIALIZED OB/GYN DRUGS........................... 49
Customer Service 503-416-4100
TOLL-FREE 1-800-224-4840
TTY/TDD number 1-800-735-2900
www.careoregon.org
xi
CAREOREGON (OHP) 2014 FORMULARY
OPHTHALMIC MEDICATIONS...................... 49
ANTIGLAUCOMA DRUGS.......................................... 49
OPHTHALMIC ANTIINFECTIVE/
CORTICOSTEROIDS......................................................... 50
OPHTHALMIC CORTICOSTEROID
DRUGS.......................................................................................... 50
OPHTHALMIC TOPICAL ANTIBACTERIAL
DRUGS.......................................................................................... 50
OPHTHALMIC TOPICAL ANTIVIRAL
DRUGS...........................................................................................51
OTHER OPHTHALMIC DRUGS..............................51
RESPIRATORY MEDICATIONS.................... 52
ANTIHISTAMINES............................................................... 52
ANTITUSSIVE AND EXPECTORANT
DRUGS.......................................................................................... 52
BETA-2 ADRENERGIC DRUGS............................. 52
LEUKOTRIENE MODIFIERS....................................... 52
RESPIRATORY MEDICATIONS.................... 53
METHYL XANTHINE DRUGS.................................53
OTHER DRUGS FOR ASTHMA..............................53
OTHER RESPIRATORY DRUGS............................53
UROLOGICAL MEDICATIONS...................... 54
ANTICHOLINERGIC ANTISPASMODICS...... 54
CHOLINERGIC STIMULANTS................................. 54
OTHER GENITOURINARY PRODUCTS.......... 54
UROLOGICAL MEDICATIONS...................... 54
OTHER MISCELLANEOUS
THERAPEUTIC AGENTS.............................................. 54
URINARY ANESTHETICS............................................ 54
xii
ANESTHETICS
LOCAL ANESTHETICS
lidocaine hcl 2% abboject, -2% luer-jet, -2% syringe
TOPICAL ANESTHETICS
lidocaine hcl jelly with prefilled applicator,
-solution non-oral
lidocaine hcl viscous
lidocaine-prilocaine
ANTIDEPRESSANTS
SELECTIVE SEROTONIN REUPTAKE INHIBITORS
CITALOPRAM
BILL TO DMAP
ESCITALOPRAM
BILL TO DMAP
FLUOXETINE
BILL TO DMAP
OLANZA/FLUOX
BILL TO DMAP
PAROXETINE
BILL TO DMAP
SERTRALINE
BILL TO DMAP
TRYCYCLICS
AMITRIPTYLINE
BILL TO DMAP
DESIPRAMINE
BILL TO DMAP
DOXEPIN
BILL TO DMAP
IMIPRAM HCL
BILL TO DMAP
NORTRIPTYLINE
BILL TO DMAP
ANTIINFECTIVES
AMEBICIDES
paromomycin sulfate
YODOXIN
AMINOGLYCOSIDES
NEO-FRADIN
neomycin sulfate tablet
diiodohydroxyquin
neomycin
Lower Case: indicates generic coverage only
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over-the-Counter
1
CAREOREGON (OHP) 2014 FORMULARY
ANTIINFECTIVES
AMINOGLYCOSIDES CONTINUED
tobramycin nebulized solution 300mg/5ml
tobramycin inhalation powder
tobramycin 40 mg/ml syringe, -40 mg/ml vial
ANTHELMINTICS
ALBENZA TABLET
BILTRICIDE
REESE PINWORM -CAPLET, -SUSPENSION
STROMECTOL
albendazole
praziquantel
pyrantel
ivermectin
ANTIRETROVIRALS AND PROTEASE INH
abacavir 300mg tablet
abacavir sulfate/lamivudine/zidovudine
APTIVUS
tipranavir
ATRIPLA
emtricitabine/tenofovir/efavir
COMPLERA
emtricitabine, rilpivirine, tenofovir
CRIXIVAN
indinavir
didanosine
EDURANT
rilpirvirine
EMTRIVA
emtricitabine
EPIVIR SOLUTION
lamivudine
EPZICOM
abacavir sulfate/lamivudine
FUZEON
enfuvirtide
INTELENCE
etravirine
INVIRASE
saquinavir mesylate
ISENTRESS
raltegravir potassium
KALETRA
ritonavir/lopinavir
lamivudine 150mg tablet
lamivudine 300mg tablet
lamivudine-zidovudine
LEXIVA
fosamprenavir calcium
nevirapine xr 400mg
NORVIR
ritonavir
PREZISTA
darunavir ethanolate
RESCRIPTOR
delavirdine mesylate
RETROVIR INJECTION
zidovudine
REYATAZ
atazanavir sulfate
2
QL
QL
QL
Lower Case: indicates generic coverage only
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over-the-Counter
ANTIRETROVIRALS AND PROTEASE INH CONTINUED
SELZENTRY
maraviroc
stavudine
STRIBILD
elvitegravir/cobicistat/cmtricitabine/
tenofovir disoproxil
SUSTIVA
efavirenz
TIVICAY
dolutegravir
TRIUMEQ
abacavir/dolutegravir/lamivudine QL
TRUVADA
emtricitabine/tenofovir
TYBOST
cobicistat
QL
VIDEX
didanosine
VIRACEPT
nelfinavir mesylate
VIRAMUNE XR 100mg
nevirapine
AR<19
VIREAD 150MG TABLET
tenofovir disproxil fumarate
QL
VIREAD 200MG, 250MG, 300MG TABLET
tenofovir disproxil fumarate
VIREAD 40MG POWDER tenofovir disproxil fumarate AR≤6
ZIAGEN 20 MG/ML SOLUTION
abacavir sulfate
zidovudine
ANTITUBERCULOSIS DRUGS
ethambutol hcl tablet
isonarif
isoniazid syrup, -tablet
pyrazinamide
rifabutin
rifampin 150 mg capsule, -300 mg capsule
CEPHALOSPORINS
cefaclor
cefadroxil
cefazolin 1 gm add-van vial, -10 gm vial,
-500 mg vial
cefdinir capsule
cefdinir suspension
cefprozil
ceftriaxone 1 gm piggyback, -1 gm vial,
-2 gm add vial, -2 gm piggyback,
-2 gm vial, -250 mg vial, -500 mg vial
cefuroxime tablet
Lower Case: indicates generic coverage only
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over-the-Counter
3
CAREOREGON (OHP) 2014 FORMULARY
ANTIINFECTIVES
CEPHALOSPORINS CONTINUED
cephalexin 250 mg capsule,
-500 mg capsule, -suspension
ROCEPHIN 1 GM VIAL
ceftriaxone
CLINDAMYCINS
clindamycin hcl capsule
clindamycin palmitate hcl solution
ERYTHROMYCINS
E.E.S. 200
ERY-TAB
erythrocin filmtab
erythromycin capsule enteric coated, -tablet
erythromycin ethylsuccinate tablet
PCE 500 MG DISPERTAB
AR≤6
erythromycin ethylsuccinate
erythromycin base
erythromycin base
ORAL ANTIFUNGAL DRUGS
bio-statin
ST
clotrimazole troche
fluconazole tablet, -suspension
fluconazole 150 mg tablet
fluocytosine 250mg, 500mg capsule
griseofulvin suspension oral
AR≤6
itraconazole capsule
ST
ketoconazole tablet
nystatin 150,000,000 units pwd, -50,000,000
units pwd, -500,000,000 units pwd
ST
nystatin 500,000 unit oral tab, -suspension oral
SPORANOX SOLUTION
itraconazole
ST
terbinafine hcl
voriconazolePA
OTHER ANTIINFECTIVE DRUGS
adefovir dipivoxil atovaquone
CAYSTON
aztreonam lysine
4
PA QL
PA QL
Lower Case: indicates generic coverage only
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over-the-Counter
ANTIINFECTIVES
OTHER ANTIINFECTIVE DRUGS CONTINUED
cidofovir
NEBUPENT
pentamidine
PENTAM 300
pentamidine
vancomycin 1 gm add-van vial, -1 gm vial, 500 mg a/v vial, -500 mg vial
vancomycin capsule
ZYVOX
linezolid
PA
acyclovir capsule, -suspension oral, -tablet
amantadine
BARACLUDE
entecavir
PA QL
famciclovir
PA
ganciclovir
lamivudine
RELENZA
zanamivir
QL
rimantadine hcl
TAMIFLU
oseltamivir phosphate
QL
TAMIFLU 6MG/ML SUSPENSION
QL AR≤8
TYZEKA
telbivudine
PA QL
valacyclovir
VALCYTE
valganciclovir
Solution: AR≤6
HEPATITIS C
HARVONI
ledipasvir/sofosbuvir
PEGASYS
peginterferon alfa-2a
PEGINTRON
peginterferon alfa-2b
PEGINTRONREDIPEN
peginterferon alfa-2b
ribasphere 200mg tablet
ribavirin tablet, capsule
SOVALDI
sofosubuvir
OTHER MACROLIDES
azithromycin 250 mg tablet
azithromycin 500 mg tablet, -600 mg tablet,
-packet, -suspension
clarithromycin
clarithromycin er
Lower Case: indicates generic coverage only
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over-the-Counter
PA QL
PA QL
PA
PA
PA
PA QL
PA QL
QL
5
CAREOREGON (OHP) 2014 FORMULARY
ANTIINFECTIVES
OTHER TOPICAL ANTIFUNGALS
antifungal 2% cream, -antifungal 2% cream [OTC] anti-fungal cream [OTC]
baza antifungal [OTC]
clotrimazole 1% cream
inzo antifungal [OTC]
miconazole nitrate cream [OTC]
micro-guard cream [OTC]
nuzole cream [OTC] nyamyc
NYSTATIN 1 BILLION UNIT POWDER,
-10 BILLION UNIT POWDER, -15 BILLION
UNIT POWDER, -2 BILLION UNIT POWDER,
-5 BILLION UNIT POWDER, -50 BILLION UNIT
POWDER,-50 MILLION UNITS PWDER,
-500 MILLION UNITS PWD
nystatin
nystatin 100,000 unit/gm powd nystatin 100,000 unit cream, ointment
nystop
pedi-dri
remedy antifungal cream [OTC]
secura antifungal [OTC]
PARENTERAL ANTIFUNGALS
amphotericin b injection
MICONAZOLE
PENICILLINS
amox tr-potassium clavulanate
amoxicillin 875 mg tablet, -capsule,
-suspension, -tablet chewable
ampicillin trihydrate
ampicillin-sulb 3 gm add vial, -3 gm vial
atovaquone/proguanil hcl
BICILLIN L-A
dicloxacillin sodium
penicillin g sodium
penicillin v potassium
6
miconazole
ST
ST
ST
ST
ST
ST
ST
ST
ST
ST
ST
ST
ST
PA
ST
penicillin g benzathine
Lower Case: indicates generic coverage only
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over-the-Counter
ANTIINFECTIVES
PLASMODICIDES
atovaquone-proguanil hcl
chloroquine phosphate tablet
COARTEM
DARAPRIM
hydroxychloroquine sulfate tablet
mefloquine hcl
PRIMAQUINE
QUINOLONES
CIPRO SUSPENSION
moxifloxacin 400mg tablet
ciprofloxacin hcl tablet
ciprofloxacin-d5w
levofloxacin solution, -tablet
artemether/lumefantrine
pyrimethamine
primaquine
ciprofloxacin
SULFONAMIDES
erythromycin-sulfisoxazole
sulfadiazine tablet
sulfamethoxazole-trimethoprim suspension oral, -tablet
SULFONES
DAPSONE
dapsone
TETRACYCLINES
doxycycline monohydrate 50mg cap, 100 mg cap
tetracycline hcl capsule
VIBRAMYCIN SYRUP
doxycycline calcium
QL
TOPICAL ANTIBACTERIAL DRUGS
bacitracin 500 unit/gm oin, -500 unit/gm oint,
-500 units/gm oin [OTC]
mupirocin ointment
silver sulfadiazine
ssd
ssd af
thermazene
tri-biozene [OTC]
triple antibiotic [OTC]
Lower Case: indicates generic coverage only
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over-the-Counter
7
CAREOREGON (OHP) 2014 FORMULARY
ANTIINFECTIVES
TOPICAL ANTIFUNGAL-CORTICOSTEROID COMB.
nystatin-triamcinolone
ST
TRICHOMONOCIDES
metronidazole capsule, -tablet
metryl
URINARY ANTIINFECTIVES
MACRODANTIN 25 MG CAPSULE
nitrofurantoin macrocrystal
nitrofurantoin capsule
nitrofurantoin mono-macro
nitrofurantoin suspension
trimethoprim tablet
AR<65
AR<65
AR<65
VAGINAL ANTIFUNGALS
3-day vaginal cream [OTC]
clotrimazole cream with applicator, -tablet [OTC]
clotrimazole-3 [OTC]
clotrimazole-7 [OTC]
miconazole 3 200 mg vag supp, -4% cream [OTC]
miconazole 7 [OTC]
miconazole nitrate cream, -cream with applicator,
-suppository vaginal, -vaginal products [OTC]
nystatin vaginal tablet
ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS
ACTEMRA SC
tocilizumbab
AFINITOR
everolimus
AFINITOR DISPERZ
everolimus
ALKERAN TABLETmelphalan
anagrelide hcl capsule
anastrozole tablet
azathioprine tablet
bicalutamide tablet
8
PA QL
PA QL
PA
Lower Case: indicates generic coverage only
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over-the-Counter
ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS CONTINUED
BOSULIF
bosutinib
PA
capecitabine
CELLCEPT SUSPENSION
RECONSTITUTED ORAL
mycophenolate mofetil
cyclophosphamide tablet
cyclosporine capsule, -softgel, -solution
cyclosporine modified
DEPO-PROVERA 400 MG/ML VIAL
medroxyprogesterone
DROXIA
hydroxyurea
EMCYT
estramustine phosphate sodium
ENBREL
etanercept
PA QL
etoposide 50mg capsule
exemestane
FARESTON
toremifene
flutamide
POMALYST
pomalidomide
PA
gengraf
GLEEVEC
imatinib mesylate
PA QL
hecoria
HEXALEN
altretamine
HUMIRA
adalimumab
PA QL
HYCAMTINtopotecan
hydroxyurea capsule
ICLUSIG
ponatinib
PA
IMBRUVICAibrutinib
PA
IRESSA
gefitinib
PA QL
leflunomide
letrozole
leucovorin calcium tablet
LEUKERAN
chlorambucil
lomustine
LYSODREN
mitotane
MATULANE
procarbazine
megestrol acetate suspension oral, -tablet
mercaptopurine tablet
Lower Case: indicates generic coverage only
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over-the-Counter
9
CAREOREGON (OHP) 2014 FORMULARY
ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS CONTINUED
methotrexate injection, -tablet
mycophenolate mofetil
MYLERANbusulfan
NEXAVAR
sorafenib tosylate
NILANDRON
nilutamide
octreotide 1,000 mcg/ml vial, -acet 100 mcg/ml
amp, -acet 100 mcg/ml syr, -acet 100 mcg/ml vl OTEZLA apremilast RAPAMUNE 1MG, 2MG
sirolimus
sirolimus 0.5mg
SPRYCEL
dasatinib
SUTENT
sunitinib malate
TABLOID
thioguanine
tacrolimus capsule
tamoxifen citrate tablet
TARCEVA
erlotinib hcl
TASIGNA 200 MG CAPSULE
nilotinib hydrochloride
TEMODAR CAPSULE
temozolomide
tretinoin capsule
TYKERB
lapatinib ditosylate
XALKORI crizotinib
ZOLINZA
vorinostat
ZORTRESS
everolimus
ZYKADIA ceritinib
PA QL
PA
PA QL
QL
QL
PA
PA QL
PA QL
PA
PA
PA QL
PA
PA
PA QL
ANTIPSYCHOTICS
ATYPICALS
ABILIFY
BILL TO DMAP
CLOZAPINE
BILL TO DMAP
INVEGA
BILL TO DMAP
OLANZAPINE
BILL TO DMAP
Lower Case: indicates generic coverage only
10 QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over-the-Counter
ANTIPSYCHOTICS
ATYPICALS CONTINUED
QUETIAPINE
BILL TO DMAP
RISPERDONE
BILL TO DMAP
SEROQUEL XR
BILL TO DMAP
AUTONOMIC AND CNS MEDICATIONS
ALCOHOL ANTAGONIST
disulfiram
ANALGESICS
acetaminophen -caplet, -chews, -drops, -elixir,
-gelcap, -geltab, -solution, -suppository rectal,
-suspension drops [OTC], -tablet
apap/pyrilamine/caffeine caplet, -gelcap [OTC]
aspirin buffered [OTC]
tramadol hcl tablet
tramadol-acetaminophen
ANTICONVULSANT BARBITURATES
phenobarbital elixir, -solution, -tablet
primidone
QL
QL
AR<65
ANTICONVULSANT BENZODIAZEPINES
clonazepam 0.5 mg tablet, -1 mg tablet, -2 mg tablet
DIASTAT
diazepam
DIASTAT ACUDIAL
diazepam
diazepam gel, -kit
ANTIDEMENTIA DRUGS
donepezil hcl
QL
galantamine
NAMENDA 10 MG TABLET,
-5 MG TABLET, -SOLUTION
memantine hcl
PA
NAMENDA XR
memantine hcl SR 24hr
PA
rivastigmine
Lower Case: indicates generic coverage only
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over-the-Counter
11
CAREOREGON (OHP) 2014 FORMULARY
AUTONOMIC AND CNS MEDICATIONS
ANTIPARKINSON ANTICHOLINERGIC DRUGS
benztropine mesylate injection, -tablet
trihexyphenidyl hcl
ANTIVERTIGO AND ANTIEMETIC DRUGS
compro
dimenhydrinate tablet [OTC]
driminate [OTC]
dronabinol 10 mg capsule, -2.5 mg capsule
dronabinol 5 mg capsule
EMEND 125 MG CAPSULE,
-80 MG CAPSULE, -TRIFOLD PACK
aprepitant
granisetron hcl 0.1 mg/ml vial
granisol
meclizine hcl tablet
meclizine hcl tablet chewable [OTC]
motion sickness [OTC]
ondansetron hcl 24 mg tablet,
-4 mg tablet, -8 mg tablet, -solution
ondansetron odt
phenadoz suppository rectal
prochlorperazine maleate suppository rectal, -tablet
promethazine hcl suppository rectal
promethegan suppository rectal
PA QL
PA
PA
PA
PA
QL
QL
AR>2
AR>2
ANXIOLYTICS
lorazepam injection
CARBAMAZEPINES
carbamazepine suspension oral, -tablet, -tablet chewable
carbamazepine er
carbamazepine xr
epitol
levetiracetam er
oxcarbazepine
TEGRETOL XR 100 MG TABLET
carbamazepine
TRILEPTAL SUSPENSION oxcarbazepine
AR≤6
Lower Case: indicates generic coverage only
12 QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over-the-Counter
AUTONOMIC AND CNS MEDICATIONS
CLASS II NARCOTICS
B+O SUPPOSITORY
codeine sulfate 30 mg tablet, -60 mg tablet
DILAUDID-HP 250 MG VIAL
hydromorphone
endocet 10-325 mg tablet, -10-650 mg
tablet,-5-325 tablet, -7.5-500 mg tablet
endocet 7.5-325 mg tablet
fentanyl
hydromorphone hcl injection
methadone 10 mg/ml oral conc,
-5 mg/5 ml solution
methadone hcl 10 mg tablet, -5 mg tablet
methadone intensol
methadose 10 mg tablet
methadose solution
morphine sulfate ir tab, - solution, - suppository
morphine sulf cr 100 mg tablet, -sulf cr
200 mg tablet, -sulf er 100 mg tab,
-sulf er 200 mg tab
morphine sulf cr 15 mg tablet, -sulf cr
30 mg tablet, -sulf cr 60 mg tablet,
-sulf er 15 mg tablet, -sulf er 30 mg
tablet, -sulf er 60 mg tablet
oxycodon-acetaminophen 5-325, -5-500 capsule oxycodon-acetaminophen 7.5-325
oxycodone hcl 10 mg tablet, -15 mg tablet,
-30 mg tablet, -5 mg tablet, - 5mg/5ml solution,
conc. 20mg/ml solution
oxycodone hcl-acetaminophen
oxycodone hct tablet sustained release 12hr
OXYCONTIN
oxycodone
roxicet 5-500 caplet
Lower Case: indicates generic coverage only
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over-the-Counter
QL
QL
PA QL
QL
QL
PA QL
QL
QL
QL
PA QL
PA QL
13
CAREOREGON (OHP) 2014 FORMULARY
AUTONOMIC AND CNS MEDICATIONS
CLASS II NARCOTICS CONTINUED
roxicet 5-325 tablet
ROXICET SOLUTION
oxycodone/acetaminophen
CLASS III NARCOTICS
acetaminophen-codeine elixir
acetaminophen-codeine tablet
buprenorphine hcl tablet sublingual
buprenorphine/naloxone sl tab
co-gesic
hydrocodon-acetaminophn 10-325,
-10-650, -10-660, -2.5-500, -5-325, -5-500,
-7.5-325, -7.5-500, -7.5-650, -7.5-750
hydrocodon-acetaminophn
7.5-325 mg/15ml, 10-500, -solution oral
hydrocodone bit-ibuprofen
hydrogesic
stagesic
QL
QL
PA QL
PA, QL
QL
QL
CNS STIMULANT DRUGS
amphetamine salts 10 mg tab, -salts 12.5 mg tb,
-salts 15 mg tab, -salts 20 mg tab, -salts 30 mg tab,
-salts 5 mg tab
QL AR<65
amphetamine salts 7.5 mg tab
AR<65
dexmethylphenidate hcl
AR<65
dextroamphetamine sulfate
AR<65
dextroamphetamine-amphetamine er
QL AR<19
metadate er tablet, 20mg
AR<65
methylin 10 mg tablet, -20 mg tablet, -5 mg tablet
AR<65
methylphenidate CD capsule, 10mg, 20mg,
30mg, 40mg, 50mg, 60mg
AR<19
methylphenidate er tablet, 10mg
AR<65
methylphenidate er tablet, 18mg, 27mg, 36mg, 54mg
QL AR<19
methylphenidate er capsule, 20mg, 30mg, 40mg
AR<19
methylphenidate hcl tablet
AR<65
methylphenidate soln
AR<6
methylphenidate sr tablet, 20mg
AR<65
Lower Case: indicates generic coverage only
14 QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over-the-Counter
AUTONOMIC AND CNS MEDICATIONS
DRUGS TO PREVENT AND TREAT HEADACHES
dihydroergotamine mesylate injection
dihydroergotamine nasal spray
QL
ERGOMAR
ergotamine
ergotamine-caffeine
PA QL
naratriptan
QL
rizatriptan tablets
QL
SUMATRIPTAN NASAL
sumatriptan
QL
sumatriptan succinate
QL
zolmatriptan tablets
QL
DRUGS TO TREAT MULTIPLE SCLEROSIS
AUBAGIO
COPAXONE
TECFIDERA
teriflunomide
glatiramer acetate
dimethyl fumarate
PA
QL
PA
HYDANTOINS
DILANTIN CAPSULE, -INFATAB, -SUSPENSION phenytoin sodium
fosphenytoin sodium
PEGANONE
ethotoin
phenytoin sodium extended cap
phenytoin sodium injection
phenytoin suspension oral
OTHER ANTICONVULSANTS
felbamate tablet, -suspension
gabapentin capsule, -solution, -tablet
levetiracetam er tablet
levetiracetam solution, -tablet
LYRICA
LYRICA 20 MG/ML SOLUTION
SABRIL
tiagabine
topiragen
topiramate capsule sprinkle, -tablet
VIMPAT SOLUTION, -TABLET
zonisamide
pregabalin
pregabalin
vigabatrin
PA QL
PA
PA
lacosamide
Lower Case: indicates generic coverage only
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over-the-Counter
15
CAREOREGON (OHP) 2014 FORMULARY
AUTONOMIC AND CNS MEDICATIONS
OTHER ANTIPARKINSON DRUGS
bromocriptine mesylate capsule, -tablet
carbidopa-levodopa
entacapone
pramipexole tablet ropinirole hcl
selegiline hcl capsule, -tablet
TASMAR
OTHER CNS/AUTONOMIC DRUGS
CAMPRAL
depade
MESTINON TABLET SUSTAINED ACTION
naltrexone hcl tablet
pyridostigmine bromide
REGONOL
tolcapone
acamprosate calcium
PA QL
pyridostigmine
pyridostigmine
SEDATIVE/HYPNOTIC DRUGS
zolpidem tartrate SMOKING CESSATION PRODUCTS
buproban
bupropion sr 150 mg tablet
CHANTIX
varenicline tartrate
nicorelief [OTC]
nicotine gum [OTC]
nicotine lozenge
nicotine patch [OTC]
thrive nicotine [OTC]
SUCCINIMIDES
CELONTIN
ethosuximide
QL
QL
QL
QL
QL
QL
QL
QL
QL
methsuximide
Lower Case: indicates generic coverage only
16 QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over-the-Counter
CARDIOVASCULAR MEDICATIONS
ALPHA-ADRENERGIC ANTAGONISTS
reserpine
AMIODARONES
amiodarone hcl 200 mg tablet, -injection
pacerone 200 mg tablet
ANGIOTENSIN CONVERTING ENZYME INHIBITORS
benazepril hcl
captopril tablet
enalapril maleate tablet
fosinopril sodium
lisinopril tablet
quinapril hcl
ramipril capsules
ANGIOTENSIN II RECEPTOR ANTAGONISTS
irbesartan
losartan potassium
BETA-ADRENERGIC ANTAGONIST DRUGS
acebutolol hcl capsule
atenolol tablet
carvedilol
labetalol hcl tablet
metoprolol succinate
metoprolol tartrate tablet
nadolol tablet
pindolol
propranolol hcl cap sa, -tablet
propranolol soln
CALCIUM ANTAGONISTS
afeditab cr
amlodipine besylate
cartia xt
dilt-cd
AR <7
Lower Case: indicates generic coverage only
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over-the-Counter
ST
17
CAREOREGON (OHP) 2014 FORMULARY
CARDIOVASCULAR MEDICATIONS
CALCIUM ANTAGONISTS CONTINUED
diltia xt
diltiazem 24hr er capsule, -24hr cd capsule
diltiazem er
diltiazem hcl tablet
dilt-xr
diltzac er
nifediac cc
nifedical xl
nifedipine er tablet
taztia xt
verapamil er -capsule, -capsule pellet, -tablet
verapamil er pm
verapamil hcl injection, -tablet
CARDIAC GLYCOSIDES
digoxin solution, -tablet
CENTRALLY ACTING ANTIHYPERTENSIVES
clonidine hcl tablet
guanfacine hcl
methyldopa
CLASS 1A
disopyramide phosphate
NORPACE CR
procainamide hcl injection
quinidine gluconate
quinidine sulfate tablet, -tablet sustained action
disopyramide
CLASS 1B
mexiletine hcl capsule
CLASS 1C
flecainide acetate
propafenone hcl tablet
Lower Case: indicates generic coverage only
18 QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over-the-Counter
ST
ST
CARDIOVASCULAR MEDICATIONS
ENDOTHELIN RECPTR ANTAGONIST
LETAIRIS
TRACLEER
ambrisentan
bosentan
HMG-COA COMBINATIONS
VYTORIN
ezetimibe/simvastatin
PA
PA
PA QL
HMG-COA REDUCTASE INHIBITORS
atorvastatin
lovastatin
pravastatin sodium
simvastatin
HYPOLIPOPROTEINEMICS
cholestyramine
cholestyramine light
choline fenofibrate capsule DR
colestipol hcl
fenofibrate 48 mg tablet, 145mg tablet,
-160mg tablet, -54mg tablet, 43mg capsule,
67 mg capsule, 130mg capsule,
-134mg capsule, -200mg capsule
gemfibrozil
NIACIN 1,000 MG TABLET SA [OTC]
niacin
niacin 250 mg tablet, -250 mg tablet sa, -250 mg
tr tablet, -500 mg caplet sa, -500 mg tablet,
-500 mg tablet sa, -750 mg tablet sa,
-capsule sustained action [OTC]
niacin ER 500mg tab, 750mg tab, 1000mg tab
prevalite
slo-niacin 500 mg tablet [OTC]
ZETIA
ezetimibe
PA
LOOP DIURETICS
bumetanide
furosemide injection, -solution, -tablet
torsemide tablet
Lower Case: indicates generic coverage only
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over-the-Counter
19
CAREOREGON (OHP) 2014 FORMULARY
CARDIOVASCULAR MEDICATIONS
NITRATES
DILATRATE-SR
isoditrate
ISORDIL
isosorbide dinitrate
isosorbide mononitrate
MINITRAN 0.1 MG/HR PATCH
nitro-bid ointment
NITRO-DUR 0.3 MG/HR PATCH,
-0.8 MG/HR PATCH
nitroglycerin 0.1 mg/hr patch, -0.2 mg/hr ptch,
-0.4 mg/hr ptch, -0.6 mg/hr patch
nitroglycerin spray
nitroglycerin injection, -tablet sublingual
NITROSTAT
OTHER ANTIARRHYTHMICS
adenosine 12 mg/4 ml vial, -6 mg/2 ml vial
sorine
sotalol
sotalol af
TIKOSYN
OTHER ANTIHYPERTENSIVES
atenolol-chlorthalidone
benazepril-hydrochlorothiazide
BENICAR HCT
bisoprolol-hydrochlorothiazide
captopril-hydrochlorothiazide
enalapril-hydrochlorothiazide
lisinopril-hydrochlorothiazide
losartan-hydrochlorothiazide
methyldopa-hydrochlorothiazide
metoprolol-hydrochlorothiazide
propranolol-hydrochlorothiazid
isosorbide dinitrate
isosorbide dinitrate
nitroglycerin
nitroglycerin
nitroglycerin
dofetilide
olmesartan medoxomil/hctz
Lower Case: indicates generic coverage only
20 QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over-the-Counter
ST
CARDIOVASCULAR MEDICATIONS
OTHER CARDIOVASCULAR DRUGS
midodrine hcl
pentoxifylline tablet sustained action
OTHER VASODILATING DRUGS
ADCIRCA
tadalafil
ADEMPAS
riociguat
epoprostenol sodium
REMODULIN
treprostinil sodium
sildenafil citrate
veletri
VENTAVIS 10 MCG/1 ML SOLUTION
iloprost
POTASSIUM SPARING DIURETICS
amiloride hcl tablet
amiloride-hydrochlorothiazide
DYRENIUM -100 MG CAPSULE, 50 MG
spironolactone tablet
spironolactone-hctz
triamterene-hctz
PA QL
PA
PA
PA
PA QL
PA
PA
triamterene
THIAZIDE AND RELATED DRUGS
chlorthalidone
hydrochlorothiazide 25 mg tab,
-50 mg tab, -capsule
indapamide
metolazone
VASODILATOR ANTIHYPERTENSIVES
doxazosin mesylate
hydralazine hcl tablet
minoxidil tablet
prazosin hcl
terazosin hcl
Lower Case: indicates generic coverage only
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over-the-Counter
21
CAREOREGON (OHP) 2014 FORMULARY
DERMATOLOGICAL MEDICATIONS
ANTIPRURITIC DRUGS
hydroxyzine hcl syrup, -tablet
hydroxyzine pamoate capsule
KERATOLYTIC DRUGS
CONDYLOX GEL
podofilox
SCABICIDES
acticin
EURAX
lice killing shampoo [OTC]
lice treatment 1% creme rinse, -killing
treatment, -permethrin, -shampoo [OTC]
LINDANE
permethrin 1% lotion [OTC]
permethrin cream
pyrethrin lice treatment [OTC]
AR<65
AR<65
podofilox
crotamiton
benzene hexachloride gamma
TOPICAL CORTICOSTEROID DRUGS
anti-itch 1% cream, -1% ointment [OTC]
beta hc [OTC]
betamethasone dp 0.05% crm,
-dp 0.05% lot, -ointment
betamethasone dp aug 0.05% ointment
betamethasone valerate cream,
-lotion, -ointment
betanate 0.05% cream
clobetasol emollient
clobetasol propionate cream, -ointment,
-solution non-oral
cormax
cortisone 1% cream [OTC]
del-beta
fluocinolone acetonide solution non-oral
Lower Case: indicates generic coverage only
22 QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over-the-Counter
DERMATOLOGICAL MEDICATIONS
TOPICAL CORTICOSTEROID DRUGS CONTINUED
fluocinonide cream, -solution non-oral
fluocinonide emollient
fluocinonide-e
hydro skin [OTC]
hydrocortisone 0.5% cream, -0.5% ointment,
-1% cream, -1% lotion, -1% oint, -aloe 1% cream,
-plus 1% cream [OTC]
hydrocortisone 1% cream, -1% ointment,
-2.5% cream, -2.5% ointment
hydrocortisone plus 12 [OTC]
hydrocortisone plus crm [OTC]
hydrocream [OTC]
itch-x hc [OTC]
medi-cortisone [OTC]
noble formula hc [OTC]
triamcinolone 0.025% cream, -0.025% oint,
-0.1% cream, -0.1% ointment, -0.5% ointment,
-0.5% cream
triderm
TOPICAL DERMATOLOGICAL DRUGS
arthritis pain relief cream [OTC]
capsaicin 0.025% cream, -0.075% cream,
-0.1% cream [OTC]
capsaicin apr [OTC]
capzasin-p [OTC]
fluorouracil 5% top solution, -cream
high potency capsaicin [OTC]
imiquimod cream
muscle relief [OTC]
REGRANEX
becaplermin
VEREGEN
sinecatechins
zostrix [OTC]
zostrix diabetic [OTC]
Lower Case: indicates generic coverage only
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over-the-Counter
PA
PA
PA QL
23
CAREOREGON (OHP) 2014 FORMULARY
DIAGNOSTIC AND MISCELLANEOUS MEDICATIONS
DIAGNOSTIC PRODUCTS
AIRZONE PEAK FLOW METER [OTC]
ASSESS [OTC]
ASSESS PEAK FLOW METER [OTC]
ASTHMA CHECK [OTC]
ASTHMAMENTOR [OTC]
ipecac
PEAK-AIR [OTC]
PEAK FLOW METER [OTC]
PERSONAL BEST [OTC]
PERSONAL BEST PEAK
FLOW METER [OTC]
POCKET PEAK [OTC]
TRUZONE PEAK FLOW METER
breathing
breathing
breathing
breathing
breathing
devices-peak
devices-peak
devices-peak
devices-peak
devices-peak
meters
meters
meters
meters
meters
breathing devices-peak meters
breathing devices-peak meters
breathing devices-peak meters
breathing devices-peak meters
breathing devices-peak meters
breathing devices-peak meters
EAR-NOSE-THROAT MEDICATIONS
DRUGS AFFECTING THE EAR
acetasol hc
acetic acid solution non-oral
acetic acid-hydrocortisone
antipyrine-benzocaine
aurodex
auroguard
CIPRODEX
cortomycin solution non-oral,
-suspension drops
neomycin-polymyxin-hc solution non-oral,
-suspension drops
ofloxacin drops
otocidin
otomycet-hc
ciprofloxacin/dexameth
PA
Lower Case: indicates generic coverage only
24 QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over-the-Counter
EAR-NOSE-THROAT MEDICATIONS
DRUGS AFFECTING THE NOSE
flunisolide 0.025% spray
flunisolide 29 mcg-0.025% spr
fluticasone propionate
nasal inhaled steroids
NASACORT ALLERGY 24HR [OTC]
QL ST
QL ST
QL ST
ST
DRUGS AFFECTING THE THROAT AND MOUTH
chlorhexidine gluconate mouthwash
periogard
pilocarpine hcl 5 mg tablet
ENDOCRINE MEDICATIONS
ANTITHYROID DRUGS
methimazole tablet
propylthiouracil
GLUCOCORTICOID DRUGS
baycadron
cortisone tablet
dexamethasone elixir, -solution oral, -tablet
DEXPAK
hydrocortisone tablet
methylprednisolone 32mg tab, -4mg dosepk,
-4mg tablet, -8mg tab, -16mg tab
prednisolone sodium phosphate solution
prednisolone solution oral
prednisone solution, -tablet, -tablet dose pack
GLUCOSE ELEVATING DRUGS
DEX4 GLUCOSE BITS, -4 GM TABLET CHEW,
-QUICK DISSOLVE TAB CHEW [OTC]
GLUCAGEN
GLUCAGON EMERGENCY KIT
gluco burst [OTC]
dexamethasone
dextrose
glucagon, human recombinant
glucagon, human recombinant
Lower Case: indicates generic coverage only
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over-the-Counter
25
CAREOREGON (OHP) 2014 FORMULARY
ENDOCRINE MEDICATIONS
GLUCOSE ELEVATING DRUGS CONTINUED
GLUCOSE 4 GM TAB CHEW, -DRUG
MART TABLET, -MEIJER 4 GRAM TAB CHEW,
-PREFERRED PLUS TAB CHEW,
-VALUE PLUS TABLET CHEW
dextrose
glucose 4 gram tab chew, 5 gram tab chew
-quick dissolve tab
GLUCOSE 40% GEL [OTC]
dextrose
GLUCOSE BITS [OTC]
dextrose
PROGLYCEM
diazoxide
ultilet tablet chewable [OTC]
INCRETIN MIMETICS
BYDUREON
BYETTA
TANZEUM
VICTOZA
exenatide exenatide
albiglutide
liraglutide
INSULIN
HUMALOG 100 UNITS/ML CARTRIDGE,
-KWIKPEN, -PEN
HUMALOG 100 UNITS/ML VIAL
HUMALOG MIX 75-25 KWIKPEN, -PEN
HUMALOG MIX 75-25 VIAL
HUMULIN 50-50 [OTC]
HUMULIN 70/30 KWIKPEN
HUMULIN 70-30 PEN [OTC] HUMULIN 70-30 VIAL, -RELION 70-30 [OTC]
HUMULIN N 100 UNITS/ML PEN [OTC] HUMULIN N 100 UNITS/ML VIAL,
-RELION 100 UNIT/ML [OTC]
HUMULIN R 100 UNITS/ML VIAL,
-RELION 100 UNIT/ML [OTC]
LANTUS 100 UNITS/ML CARTRIDGE
LANTUS 100 UNITS/ML VIAL
LANTUS SOLOSTAR
LEVEMIR 100 UNITS/ML VIAL
LEVEMIR 100 UNITS/ML PEN
PA
PA
PA
PA
QL
QL
QL
QL
PA
PA
PA
PA
PA
PA
PA
PA
Lower Case: indicates generic coverage only
26 QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over-the-Counter
ENDOCRINE MEDICATIONS
INSULIN CONTINUED
NOVOLIN 70-30 [OTC]
NOVOLIN N [OTC]
NOVOLIN R [OTC]
NOVOLOG 100 UNIT/ML CARTRIDGE,
-FLEXPEN SYRINGE
NOVOLOG 100 UNIT/ML VIAL
NOVOLOG MIX 70-30 FLEXPEN SYRN
NOVOLOG MIX 70-30 VIAL
PA
PA
INSULIN SENSITIZERS & COMBOS
pioglitazone hcl
pioglitazone hcl/metformin hc
QL ST
QL ST
MINERALOCORTICOID DRUGS
fludrocortisone acetate tablet
ORAL HYPOGLYCEMICS AND COMBOS
acarbose
glimepiride
glipizide er
glipizide tablet
glipizide xl
glipizide-meformin
glyburide
glyburide micronized
glyburide-metformin hcl
metformin hcl
metformin hcl er
tolazamide
tolbutamide
QL
QL
OTHER ENDOCRINE DRUGS
ACTONEL TABLET
risedronate
QL ST
alendronate sodium
QL
cabergoline
QL
calcitonin-salmon
QL
Lower Case: indicates generic coverage only
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over-the-Counter
27
CAREOREGON (OHP) 2014 FORMULARY
ENDOCRINE MEDICATIONS
OTHER ENDOCRINE DRUGS CONTINUED
cosyntropin 0.25 mg vial
desmopressin acetate aerosol spray
w/pump, -injection, -solution, -tablet
etidronate disodium
fortical
ibandronate tablet
KUVAN
sapropterin dihydrochloride
SENSIPAR
cinacalcet hcl
SIGNIFOR
pasireotide
SOMAVERT
pegvisomant
THYROID SUPPLEMENTS
ARMOUR THYROID -30 MG TABLET,
-60 MG TABLET, -90MG TABLET
-120 MG TABLET, -15 MG TABLET,
-180 MG TABLET, -240 MG TABLET,
-300 MG TABLET
levothroid
levothyroxine 500 mcg vial, -tablet
levoxyl
liothyronine sodium tablet
np thyroid -30 mg, -60 mg, -90mg
SYNTHROID
THYROLAR
unithroid
PA
QL
QL
PA
PA
PA
thyroid
AR<65
levothyroxine
liotrix
AR<65
GASTROINTESTINAL MEDICATIONS
ANTACIDS
antacid tablet, -gelcap, -tablet chew [OTC]
magnesium oxide 400mg tablet [OTC]
ANTIDIARRHEAL DRUGS
anti-diarrheal capsule [OTC]
bismuth chewable tablet [OTC]
diphenoxylate-atropine
Lower Case: indicates generic coverage only
28 QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over-the-Counter
GASTROINTESTINAL MEDICATIONS
ANTIDIARRHEAL DRUGS CONTINUED
lonox
AR<65
loperamide capsule
paregoric
pink bismuth caplet [OTC]
soothe caplet [OTC]
stomach relief caplet [OTC]
ANTISPASMODICS/DRUGS AFFECT GI MOTILITY
belladonna-phenobarbital
PA
colidrops
PA
dicyclomine hcl capsule, -syrup, -tablet
AR<65
ed-spaz
AR<65
hyomax
AR<65
hyomax-ft
AR<65
hyomax-sl
AR<65
hyomax-sr
AR<65
hyoscyamine sulfate drops, -elixir,
-sulf 0.125 mg tab, -tablet dispersible lingual,
-tablet sublingual, -tablet sustained release 12hr
AR<65
hyosyne
AR<65
metoclopramide hcl injection,
-solution oral, -tablet
oscimin ODT, -tablet, -sl tablet, -sr tablet
pb-hyos
PA
propantheline bromide tablet
AR<65
re-pb hyos
PA
symax
AR<65
symax-sl
AR<65
symax-sr
AR<65
ANTIULCER DRUGS
acid control 150 mg tablet, -20 mg tablet [OTC]
acid controller 20 mg tablet [OTC]
acid reducer 150 [OTC]
Lower Case: indicates generic coverage only
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over-the-Counter
29
CAREOREGON (OHP) 2014 FORMULARY
GASTROINTESTINAL MEDICATIONS
ANTIULCER DRUGS CONTINUED
acid reducer 150 mg tablet,
-20 mg tablet, -200 mg tablet [OTC]
acid relief [OTC]
cimetidine injection, -solution, -tablet
famotidine 20 mg tablet, -40 mg tablet
heartburn [OTC]
heartburn 200 [OTC]
heartburn preven 20 mg tab [OTC]
heartburn relief 150 [OTC]
heartburn relief 20 mg tablet, -200 mg tab,
-200 mg tablet, -relf 200 mg tb [OTC]
nizatidine solution
PEPCID AC
famotidine
ranitidine 150 mg tablet, -300 mg tablet, -capsule
ranitidine hcl syrup
AR≤6
LAXATIVES AND CATHARTICS
bisacodyl -10 mg suppository, -5 mg tablet, ec 5 mg tablet, -lax 10 mg supp [OTC]
cascara sagrada capsule
docusate sodium capsule, -softgel, -solution,
-syrup, -tablet [OTC]
enema [OTC]
glycerin 2 gram supp, -suppositories [OTC]
glycerin adult suppository, -child suppository [OTC]
konsyl capsule, -orange powder [OTC]
konsyl fiber [OTC]
magnesium citrate solution [OTC]
infant glycerin [OTC]
METAMUCIL PACKET, -WAFER [OTC]
psyllium/sucrose
milk of magnesia concentrated,
-susp, -suspension [OTC]
mineral oil heavy, -enema, -laxative [OTC]
oral saline laxative [OTC]
polyethylene glycol 3350 powd
polyethylene glycol 3350 packet
Lower Case: indicates generic coverage only
30 QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over-the-Counter
GASTROINTESTINAL MEDICATIONS
LAXATIVES AND CATHARTICS CONTINUED
PREP KIT #3 [OTC]
bisacodyl/sodium phosphate
psyllium fiber [OTC]
senna laxative [OTC]
senna-docusate sodium [OTC]
OTC H2 ANTAGONISTS
famotidine 10 mg tablet [OTC]
ranitidine 75 mg tablet [OTC]
OTHER ANTIULCER DRUGS
CARAFATE SUSPENSION ORAL
misoprostol
sucralfate tablet
OTHER GI DRUGS
anudil hc
APRISO
ASACOL
ASACOL HD 800MG
balsalazide
CANASA
CORTIFOAM
CREON
DELZICOL
DIPENTUM
gavilyte-c
gavilyte-g
gavilyte-n
GOLYTELY PKT
mesalamine enema
PANCREAZE
PANCRELIPASE 5,000
peg 3350-electrolyte
peg-3350 and electrolytes
peg-3350 with flavor packs
sucralfate
mesalamine
mesalamine
mesalamine delayed release
mesalamine
hydrocortisone acetate
amylase/lipase/protease
mesalamine
olsalazine
QL
QL
electrolyte solution/peg’s
amylase/lipase/protease
amylase/lipase/protease
Lower Case: indicates generic coverage only
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over-the-Counter
31
CAREOREGON (OHP) 2014 FORMULARY
GASTROINTESTINAL MEDICATIONS
OTHER GI DRUGS CONTINUED
PENTASA
procto-pak
proctosol-hc
proctozone-hc
SORBITOL SOLUTION [OTC]
sulfasalazine dr
sulfasalazine tablet
sulfazine
sulfazine ec
ursodiol capsule
ZENPEP
mesalamine
amylase/lipase/protease
PROTON PUMP INHIBITORS
FIRST-LANSOPRAZOLE
lansoprazole
FIRST-OMEPRAZOLE
omeprazole
lansoprazole capsule enteric coated, -tablet
omeprazole capsule enteric coated
pantoprazole sodium 20mg tab
pantoprazole sodium 40 mg tab
rabeprazole 20mg tab
PA
AR≤6
PA QL
QL
PA
IMMUNOLOGICALS AND VACCINES
ERYTHROID STIMULANTS
ARANESP 150 MCG/0.3 ML SYRINGE,
-200 MCG/0.4 ML SYRINGE, -300 MCG/0.6 ML
SYRINGE, -300 MCG/ML VIAL, -500 MCG/1 ML
SYRINGE, -60 MCG/0.3 ML SYRINGE
EPOGEN
PROCRIT
PROMACTA
darbepoetin alfa
epoetin alfa
epoetin alfa
eltrombopag olamine
GROWTH HORMONES AND RELATED DRUGS
GENOTROPIN
somatropin
HUMATROPE
somatropin
NORDITROPIN
somatropin
PA
PA
PA
PA
PA
PA
PA
Lower Case: indicates generic coverage only
32 QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over-the-Counter
IMMUNOLOGICALS AND VACCINES
GROWTH HORMONES AND RELATED DRUGS CONTINUED
NORDITROPIN FLEXPRO
somatropin
NUTROPIN
somatropin
NUTROPIN AQ 5 MG/ML VIAL,
-PEN CARTRIDGE
somatropin
NUTROPIN AQ NUSPIN 10 PEN CART,
-5 PEN CART
somatropin
OMNITROPE
somatropin
SAIZEN
somatropin
TEV-TROPIN
somatropin
ZORBTIVE
somatropin
PA
PA
PA
PA
PA
IMMUNOGLOBULIN ANTIBODIES
XOLAIR
omalizumab
PA
IMMUNOLOGICALS AND VACCINES
Age <19 covered by VFC
ADACEL
AFLURIA
BOOSTRIX
DAPTACEL
ENGERIX-B
FLUARIX
FLUARIX QUAD
FLULAVAL
FLULAVAL QUAD
FLUBLOK
FLUMIST
FLUMIST QUAD
FLUVIRIN
FLUZONE
FLUZONE QUAD
FLUZONE INTRADERMAL
FLUCELVAX
FLUZONE HIGH-DOSE SYR
GARDASIL
diphther,pertuss,tetanus vac
influenza virus trivalent
diphther,pertuss,tetanus vac
diphther,pertuss,tetanus vac
hepatitis b virus vaccine
influenza virus trivalent
influenza virus quadrivalent
influenza virus trivalent
influenza virus quadrivalent
influenza vaccine
AR 19-49
influenza virus trivalent
QL AR19-49
influenza virus quadrivalent AR19-49
influenza virus trivalent
influenza virus trivalent
influenza virus quadrivalent
influenza virus trivalent
influenza virus trivalent
influenza virus trivalent
AR≥65
human papillomavirus vacc
AR 19-26
Lower Case: indicates generic coverage only
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over-the-Counter
PA
PA
PA
33
CAREOREGON (OHP) 2014 FORMULARY
IMMUNOLOGICALS AND VACCINES
IMMUNOLOGICALS AND VACCINES CONTINUED
HAVRIX
hepatitis a virus vaccine
INFANRIX
diphther,pertuss,tetanus vac
MENACTRA
meningococcal vac a,c,y,w-135
MENOMUNE-A-C-Y-W-135
meningococcal vac a,c,y,w-135
MENVEO
meningococcal a,c,y,
w-135 diptheria conjugate vac AR 19-55
M-M-R II VACCINE
measles, mumps &
rubella vaccine
PREVNAR 13
pneumococcal vaccine
AR≥19
PNEUMOVAX 23
pneumococcal vaccine
QL
RECOMBIVAX HB
hepatitis b virus vaccine
SYNAGIS
palivizumab
PA
TRIPEDIA
diphther,pertuss,tetanus vac
VAQTA
hepatatis a virus vaccine
AR≥19
VARIVAX VACCINE
varicella virus vaccine live
ZOSTAVAX
varicella vacc/pf
AR≥60
INSULIN LIKE GROWTH FACTORS-1
INCRELEX
mecasermin
INTERFERONS
ACTIMMUNE
interferon
ALFERON N
interferon
AVONEX
interferon
AVONEX ADMINISTRATION PACK
interferon
BETASERON
interferon
INFERGEN
interferon
INTRON A
interferon
REBIF 22 MCG/0.5 ML SYRINGE,
-44 MCG/0.5 ML SYRINGE
interferon
rebif rebidose 22mcg/0.5ML, 44MCG/0.5ML
REBIF TITRATION PACK
interferon
MYELOID STIMULANTS
GRANIX
NEULASTA
NEUPOGEN 300 MCG/ML VIAL,
-480 MCG/1.6 ML VIAL
gamma-1b,recomb.
alfa-n3
beta-1a
beta-1a
beta-1b
alfacon-1
alfa-2b , recomb.
PA
PA
QL
QL
QL
PA
PA
beta-1a/albumin
QL
QL
beta-1a/albumin
tbo-filgrastim pegfilgrastim
filgrastim
PA
PA
PA QL
PA
Lower Case: indicates generic coverage only
34 QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over-the-Counter
MEDICAL (MISCELLANEOUS) SUPPLIES
DIABETIC SUPPLIES
ALCOHOL PREP PADS [OTC]
ALCOHOL PREP SWABS [OTC]
ALCOHOL SWABS [OTC]
ALCOHOL WIPES [OTC]
MEDICAL (MISCELLANEOUS) SUPPLIES
AEROCHAMBER
AEROCHAMBER MAX INHALER
AEROCHAMBER MINI
AEROCHAMBER MV
AEROCHAMBER WITH FLOWSIGNAL
AEROCHAMBER Z-STAT PLUS
BREATHERITE
BREATHRITE
CUT N CRUSH [OTC]
EASIVENT
E-Z SPACER PEDSPAK
GLYCERIN LAXATIVE [OTC]
MICROCHAMBER
OPTICHAMBER ADVANTAGE INHALER,
-LARGE MASK, -MEDIUM MASK,
-SMALL MASK
OPTICHAMBER FACE MASK LARGE,
-MEDIUM, -SMALL
OPTICHAMBER DIAMOND VHC, -LARGE
MASK, -MEDIUM MASK, -SMALL MASK
OPTIHALER
PANDA MASK [OTC]
PEDIATRIC PANDA MASK [OTC]
PILL SPLITTER
POCKET CHAMBER
PRIMEAIRE
PROCHAMBER
RITEFLO
TABLET CUTTER [OTC]
nebulizer/supplies
nebulizer/supplies
nebulizer/supplies
nebulizer/supplies
nebulizer/supplies
nebulizer/supplies
nebulizer/supplies
nebulizer/supplies
misc supplies
nebulizer/supplies
nebulizer/supplies
misc supplies
nebulizer/supplies
QL
QL
QL
QL
QL
QL
QL
nebulizer/supplies
QL
nebulizer/supplies
QL
nebulizer/supplies
nebulizer/supplies
nebulizer/supplies
nebulizer/supplies
misc supplies
nebulizer/supplies
nebulizer/supplies
nebulizer/supplies
breathing supplies
misc supplies
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
Lower Case: indicates generic coverage only
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over-the-Counter
QL
QL
QL
QL
35
CAREOREGON (OHP) 2014 FORMULARY
MEDICAL (MISCELLANEOUS) SUPPLIES
MEDICAL (MISCELLANEOUS) SUPPLIES CONTINUED
ULTRA FINE CUT N CRUSH [OTC]
misc supplies
VORTEX
nebulizer/supplies
WATCHHALER
nebulizer/supplies
QL
QL
QL
MUSCULOSKELETAL MEDICATIONS
CNS MUSCLE RELAXANTS
chlorzoxazone
cyclobenzaprine hcl 10mg tablet, -5mg tablet
methocarbamol tablet
AR<65
AR<65
AR<65
DIRECT MUSCLE RELAXANTS
baclofen tablet
dantrolene sodium
tizanidine hcl tablet
DRUGS TO PREVENT AND TREAT GOUT
allopurinol tablet
COLCRYS
probenecid
probenecid-colchicine
colchicine
NON-STEROIDAL ANTIINFLAMMATORY AGENTS
all day pain relief [OTC]
CELEBREX 100 MG CAPSULE,
-200 MG CAPSULE
celecoxib
children’s ibuprofen [OTC]
diclofenac potassium
diclofenac sodium 25mg tab, -50mg tab,
-75mg tab 100mg er tab
etodolac capsule, -tablet
flurbiprofen tablet
ibu-drops [OTC]
PA QL
Lower Case: indicates generic coverage only
36 QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over-the-Counter
MUSCULOSKELETAL MEDICATIONS
NON-STEROIDAL ANTIINFLAMMATORY AGENTS CONTINUED
ibuprofen 100 mg caplet, -100mg tablet, -100 mg/5 ml sus,
-200 mg caplet, -200 mg capsule, -200 mg softgel,
-200 mg tablet, -ib 50 mg caplet, -tablet chewable [OTC]
ibuprofen 100 mg/5 ml susp, -400 mg tablet,
-600 mg tablet, -800 mg tablet
INDOCIN SUSPENSION ORAL
indomethacin
indomethacin capsule,
-capsule sustained action
infants ibu-drops [OTC]
infants ibuprofen [OTC]
ketoprofen 50 mg capsule, -75mg capsule
meloxicam 7.5mg tablet
meloxicam 15mg tablet
nabumetone tablet
naproxen sodium 220 mg caplet, -220 mg tablet, [OTC]
naproxen sodium 275 mg tab, -550 mg tab
naproxen suspension oral, -tablet
piroxicam capsule
sulindac tablet
QL
OTHER MUSCULOSKELETAL DRUGS
riluzole
SALICYLATES AND RELATED DRUGS
aspirin ec 162 mg tablet, -300 mg suppository,
-325 mg caplet, 325 mg tablet, -500 mg caplet,
-500 mg tablet, -600 mg suppository,
-81 mg chewable tablet, -81 mg tablet,
-children’s chewable tab [OTC]
choline mag trisalicylate
pamprin max [OTC]
salsalate tablet
aspirin/acetaminophen/caffeine
Lower Case: indicates generic coverage only
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over-the-Counter
37
CAREOREGON (OHP) 2014 FORMULARY
NUTRITION, BLOOD MODIFIERS, ELECTROLYTES
ANTIPLATELET DRUGS
AGGRENOX
cilostazol
clopidogrel 75 mg tablet
ticlopidine hcl
BLOOD DETOXICANTS
constulose
enulose
FOSRENOL
generlac
lactulose
RENAGEL
sevelamer carbonate
XIFAXAN 550MG
aspirin/dipyridamole
lanthanum carbonate
sevelamer
rifaximin
ELECTROLYTES, IRRIGATING SOLUTIONS, ETC.
dextrose 10%-water iv solution,
-40%-water iv soln, -50%-water abboject,
-50%-water iv soln, -50%-water syringe,
-50%-water vial, -70%-water iv soln
NEUT
sodium bicarbonate
normal saline flush
oralyte [OTC]
pedialyte [OTC]
pedialyte electrolyte singles [OTC]
pediatric electrolyte [OTC]
pediatric freezer pops [OTC]
prosource solution [OTC]
saline flush
sodium bicarbonate 4.2% abboject, -4.2% syringe,
-4.2% vial, -5% inj, -7.5% abboject, -7.5% vial,
-8.4% abboject, -8.4% vial
sodium chloride 0.9% irrig, -solution, -syringe, -vial
syrex
PA
PA QL
Lower Case: indicates generic coverage only
38 QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over-the-Counter
NUTRITION, BLOOD MODIFIERS, ELECTROLYTES
FLUORIDE PRODUCTS
denta 5000 plus
AR≤18
dentagel
AR≤18
FLUORABON DROPS
sodium fluoride
AR≤18
fluor-a-day tablet chewable
AR≤18
fluoridex daily defense
AR≤18
fluoritab chewable
AR≤18
FLURA-DROPS
sodium fluoride
AR≤18
ludent fluoride chew
AR≤18
neutragard advanced
AR≤18
sf
AR≤18
sf 5000 plus
AR≤18
sodium fluoride drops, -tablet chewable
AR≤18
INJECTABLE ANTICOAGULANTS
enoxaparin sodium
fondaparinux sodium
FRAGMIN
dalteparin (porcine)
heparin iv flush 10 unit/ml sy, -iv flush
100 units/ml, -lock flush 10 units/ml,
-lock flush 100 unit/ml
heparin lock
heparin sod 1,000 unit/ml vial, -10,000 unit/ml
vl, -20,000 unit/ml vl, -5,000 unit/0.5 ml,
-5,000 unit/ml syr, -5,000 unit/ml vial
LOVENOX 300 MG/3 ML VIAL
enoxaparin
monoject heparin 10 units/ml, -100 units/ml
NUTRITIONAL/SUPPLEMENT PRODUCTS
ACERFLEX POWDER
balanced nutritional
BCAD 1 POWDER
BCAD 2 POWDER
nutritional supplement
lactose free-food
nutritional supplement
nutritional supplement
Lower Case: indicates generic coverage only
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over-the-Counter
QL
QL
QL
QL
PA QL
PA QL
PA QL
PA QL
39
CAREOREGON (OHP) 2014 FORMULARY
NUTRITION, BLOOD MODIFIERS, ELECTROLYTES
NUTRITIONAL/SUPPLEMENT PRODUCTS CONTINUED
BOOST ENERGY DRINK, -DIABETIC LIQUID,
-HIGH PROTEIN, -KIDS ESSENTIALS, -PLUS
ENERGY DRINK, -SMOOTHIE, -VHC,
-WITH BENEFIBER
nutritional supplement
CALCILO XD POWDER
infant formula
CAMINO PRO 15 PKU SUSPENSION,
-RESTORE LIQUID
nutritional supplement
carnation instant breakfast [OTC]
choice dm liquid
nutritional drink [OTC]
nutritional drink plus [OTC]
nutritional supplement plus [OTC]
pediatric drink [OTC]
polycose liquid
polycose powder ORAL ANTICOAGULANTS, VITAMIN K
COUMADIN
jantoven
MEPHYTON
warfarin sodium
PA QL
PA QL
PA
PA
PA
PA
PA
PA
PA
QL
QL
QL
QL
QL
QL
QL
PA
PA
warfarin sodium
phytonadione
OTHER MEDICATIONS AFFECTING COAGULATION
XARELTO 10MG
rivaroxaban 10mgQL
XARELTO 15MG, 20MG
rivaroxaban 15mg, 20mg
PA
POTASSIUM REMOVING RESINS
kalexate
kionex suspension oral
marlexate
sodium polystyrene sulfonate
sps
Lower Case: indicates generic coverage only
40 QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over-the-Counter
NUTRITION, BLOOD MODIFIERS, ELECTROLYTES
POTASSIUM SUPPLEMENTS
cytra-2
effer-k 25 meq tablet eff
k effervescent
klor-con 10 meq tab, -8 meq tab
klor-con 20 meq packet
KLOR-CON 25 MEQ PACKET
potassium chloride
klor-con m10 tablet, -m20 tablet
klor-con-ef
phospha 250 neutral
potassium [OTC]
potassium & sodium phosphates powder pack 280-160-250mg
potassium acetate injection
potassium bicarbonate tablet effervescent
potassium chloride 10 meq cap er, -10 meq tab er,
-10 meq tab sa, -10% solution, -2 meq/ml IV sol,
-2 meq/ml vial, -20 meq/50ml solution,
-20 meq tab er, -20% solution, -8 meq cap er,
-8 meq tablet er, -8 meq tab sa.
potassium gluconate 2 meq tab, -2.5 meq tab,
-550 mg tab, -595 mg caplet, -595 mg tab,
-95 mg tab, -99 mg tab
sodium citrate & citric acid
THERAPEUTIC VITAMINS AND MINERALS
calcidol [OTC]
calcitriol capsule, -solution
calcium acetate
cyanocobalamin injection
delta d3 [OTC]
d-vi-sol [OTC]
eliphos
ergocalciferol drops [OTC]
folic acid 0.4 mg tablet, -0.8 mg tablet,
-1,000 mcg tablet, -400 mcg tab,
-400 mcg tablet, -800 mcg tablet [OTC]
folic acid 1 mg tablet, -injection
Lower Case: indicates generic coverage only
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over-the-Counter
41
CAREOREGON (OHP) 2014 FORMULARY
NUTRITION, BLOOD MODIFIERS, ELECTROLYTES
THERAPEUTIC VITAMINS AND MINERALS CONTINUED
JUST D [OTC]
cholecalciferol
levocarnitine solution, -tablet
MAXIMUM D3 [OTC]
cholecalciferol
nervidox
neurin-12
paricalcitol
PA QL
vitamin d 1,000 unit sftgl, -1,000 unit tab,
-1,000 unit tablet, -3 1,000 unit tab,
-3 1,000 unit tablet, -400 unit softgel,
-400 unit tablet, -capsule, -drops [OTC]
vitamin d2 capsule
vitamin d2 tablet [OTC]
VITAMIN D3 1,000 UNIT TAB CHEW [OTC]
cholecalciferol
vitamin d3 capsule, -d3 1,000 unit tab chew,
-tablet [OTC]
THROMBIN INHIBITORS
PRADAXA
ELIQUIS
dabigatran etexilate
apixaban
PA QL
PA QL
VITAMINS AND MINERALS AND RELATED PRODUCTS
calcium 500 w/vitamin d tab, -600 + vit d 400 tablet,
-600 mg with d tab, -d tablet, -shell calcium-vit d tab,
-shell calc-vit d caplet, -with vit d tablet [OTC]
calcium 500+d [OTC]
calcium 600 + vit d 200 tab,
-400 caplet, -400 tab [OTC]
calcium carbonate 1,250 mg tab,
-1.25 gm tab, -1.5 gm tab, -500 mg tablet,
-600 mg cplt, -suspension oral,
-tablet chewable [OTC]
calcium citrate - vitamin d [OTC]
calcium citrate 200 mg caplet,
-200 mg tablet, -250 mg caplet,
-250 mg tablet, -950 mg caplt [OTC]
calcium citrate plus [OTC]
calcium citrate+d [OTC]
Lower Case: indicates generic coverage only
42 QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over-the-Counter
NUTRITION, BLOOD MODIFIERS, ELECTROLYTES
VITAMINS AND MINERALS AND RELATED PRODUCTS CONTINUED
calcium cit-vit d 315-200 tab [OTC]
calcium gluconate 500 mg tab, -650 mg tab [OTC]
calcium lactate tablet [OTC]
cal-gest [OTC]
citrus calcium + d [OTC]
citrus calcium-vitamin d [OTC]
dialyvite 800 tablet [OTC]
dialyvite zinc
elemental calcium [OTC]
enlive [OTC]
PA QL
farbee w-c [OTC]
ferate [OTC]
fer-gen-sol [OTC]
fer-iron [OTC]
ferosul [OTC]
ferrex 150 [OTC]
ferro-time [OTC]
ferrous gluconate tablet [OTC]
ferrous sulfate 27 mg tablet, -325 mg tab,
-325 mg tablet, -drops, -oral drops,
-solution oral, -tablet enteric coated,
-tablet sustained action [OTC]
ferrousul [OTC]
ferus [OTC]
fish oil 1,000 mg capsule, -1,000 mg
softgel, -300 mg softgel, -conc 1,000
mg softgel, -concentrate softgel,
-extra strength softgl [OTC]
folic acid xtra [OTC]
full spectrum b [OTC]
iferex 150 [OTC]
iron 27 mg tablet, -325 mg tablet, -65 mg tablet,
-sulfate 5 gr tablet, -tablet sustained action [OTC]
iron supplement [OTC]
nephplex rx
NEPHRON FA
fe fumarate/doss/fa/b comp & c
Lower Case: indicates generic coverage only
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over-the-Counter
43
CAREOREGON (OHP) 2014 FORMULARY
NUTRITION, BLOOD MODIFIERS, ELECTROLYTES
VITAMINS AND MINERALS AND RELATED PRODUCTS CONTINUED
nephro-vite rx
niacin 100 mg caplet, -100 mg tablet,
-50 mg caplet, -50 mg tablet [OTC]
niacinamide tablet [OTC]
omega-3 1,000 mg softgel [OTC]
omega-3 1,000 mg softgel, -3 1,000 mg
softgel, -oil 1,000 mg softgel [OTC]
oyster shell 250 mg + vit d tb, -shell
calcium-vit d tab, -shell calc-vit d tab,
-shell-vit d tab, -shell-vit d tablet [OTC]
oyster shell calcium [OTC]
oyster shell calcium-vitamin d [OTC]
poly-iron [OTC]
polysaccharide iron [OTC]
poly-vitamin drops [OTC]
polyvitamin with iron drops [OTC]
polyvit-iron-fl 0.25 mg/ml
renal caps
renalpren
rena-vite [OTC]
rena-vite rx
reno caps
slow release iron [OTC]
superplex-t [OTC]
thiamine 100 mg tablet, -50 mg tablet [OTC]
TRI-VI-SOL WITH IRON [OTC]
vitamins a, c, d w/iron
tri-vitamin [OTC]
vitamin b-1 100 mg tab, -100 mg tablet,
-50 mg tablet [OTC]
vitamin b-12 1,000 mcg tab sl, -tablet,
-tablet sustained action [OTC]
vitamin b-complex & c caplet, -potency b-comp-c
caplet, -w-vitamin c caplet, -w-vitamin c tablet [OTC]
AR≤2
AR≤2
AR≤2
AR≤2
AR≤2
Lower Case: indicates generic coverage only
44 QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over-the-Counter
OBSTETRICAL AND GYNECOLOGICAL MEDICATIONS
ANDROGEN DRUGS
ANDRODERM
ANDROGEL
danazol capsule
DEPO-TESTOSTERONE
FIRST-TESTOSTERONE
METHITEST
oxandrolone 2.5 mg tablet
testosterone cypionate injection
testosterone enanthate
testosterone
testosterone
testosterone proprionate
testosterone propionate
methyltestosterone
PA
PA
PA
PA
PA
PA
PA
PA
CONTRACEPTIVES
altavera QL
alyacen
QL
amethia
QL
amethia lo
QL
amethyst 90-20 mcg tab
QL
apri
QL
aranelle
QL
aviane
QL
azurette
QL
balziva tab
QL
beyaz tab
QL
briellyn tab
QL
camrese
QL
caziant
QL
cesia
QL
cryselle
QL
cyclafem
QL
daysee
QL
deso/ethinyl tab estradiol
QL
elinest
QL
ELLA
QL
emoquette
QL
enpresse
QL
enskyce tab
QL
errin
QL
Lower Case: indicates generic coverage only
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over-the-Counter
45
CAREOREGON (OHP) 2014 FORMULARY
OBSTETRICAL AND GYNECOLOGICAL MEDICATIONS
CONTRACEPTIVES CONTINUED
ethinyl estradiol/norelgest
QL
generess fe chw
QL
gianvi tab
QL
gildagia 0.4-35 tab
QL
gildess QL
gildess fe
QL
introvale
QL
jolessa
QL
junel
QL
junel fe
QL
kariva
QL
kelnor 1-35
QL
larin
QL
leena
QL
lessina
QL
levonor/ethi tab QL
levonorgestrel QL
levora-28
QL
lo loestrin fe
lo minastrin pak fe
QL
loestrin 24 fe
QL
lomedia 24 fe
QL
loryna tab
QL
low-ogestrelQL
lutera
QL
marlissa QL
microgestin
QL
microgestin fe
QL
minastrin 24 fe QL
mononessa
QL
my way
QL
myzilra
QL
necon 0.5-35-28 tablet, -1/35-28 tablet,
-1/50-28 tablet, -7-7-7-28 tablet
QL
next choice
QL
next choice one dose
QL
Lower Case: indicates generic coverage only
46 QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over-the-Counter
OBSTETRICAL AND GYNECOLOGICAL MEDICATIONS
CONTRACEPTIVES CONTINUED
norethindronQL
norgestimate-ethinyl estradiol
QL
norgestrel-ethiny estra
QL
nortrel
QL
NUVARING
etonogestrel/ethin estradiol
QL
ocella 3-0.03mg tab
QL
orsythia QL
ortho tri-cyclen lo
QL
philith 0.4-35 tab
QL
pimtrea
QL
portia
QL
previfem
QL
quasense
QL
reclipsen
QL
solia
QL
sprintec
QL
sronyx
QL
syeda QL
tilia fe
QL
tri-legest fe
QL
tri-previfem
QL
tri-sprintec
QL
trinessa
QL
trivora-28
QL
velivet
QL
vestura tab
QL
viorele
QL
vyfemla 0.4-35 tab
QL
wymzya fe chw
QL
xulane (generic Ortho Evra)
QL
zarah QL
zenchent fe chw
QL
zenchent tab
QL
zeosa
QL
zovia
QL
Lower Case: indicates generic coverage only
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over-the-Counter
47
CAREOREGON (OHP) 2014 FORMULARY
OBSTETRICAL AND GYNECOLOGICAL MEDICATIONS
ESTROGEN DRUGS
ESTRACE CREAM WITH APPLICATOR
estradiol
estradiol patch transdermal weekly, -tablet
estropipate
AR<65
ESTRING
estradiol
MENEST
estrogens,esterified
AR<65
PREMARIN CREAM WITH APPLICATOR
estrogens,conjugated
QL
VAGIFEM
estradiol
ESTROGEN/PROGESTIN COMBINATIONS
COMBIPATCH
estradiol/noreth ac
OB/GYN TOPICAL ANTIINFECTIVES
AVC
CLEOCIN 100 MG VAGINAL OVULE
clindamycin phosphate cream with applicator
metronidazole gel with applicator
vandazole
sulfanilamide
clindamycin phosphate
OXYTOCICS
methylergonovine 0.2mg tablet
PRENATAL VITAMINS
generic prenatal vitamins (<1 mg folic acid)
generic prenatal vitamins (> or = 1 mg folic acid)
PROGESTIN DRUGS
camila
errin
heather
jolivette
medroxyprogesterone acetate tablet
nora-be
norethindrone
norethindrone acetate tablet
progesterone
AR≤50, Female Gender
AR≤50, Female Gender
QL
QL
QL
QL
QL
QL
Lower Case: indicates generic coverage only
48 QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over-the-Counter
OBSTETRICAL AND GYNECOLOGICAL MEDICATIONS
SELECTIVE ESTROGEN RECEPTOR MODULATOR
raloxifene
SPECIALIZED OB/GYN DRUGS
CONDOMS [OTC]
condoms, male
leuprolide acetate
PA
LUPANETA
leuprolide acetate/
norethindrone KIT PA
LUPRON DEPOT 11.25 MG 3MO KIT,
-22.5 MG 3MO KIT
leuprolide
PA QL
LUPRON DEPOT 3.75 MG KIT, -4 MONTH KIT,
-45 MG 6 MO KIT, -7.5 MG KIT leuprolide
PA
LUPRON DEPOT-PED 11.25 MG KIT,
-15MG KIT, -7.5 MG KIT
leuprolide
PA
LUPRON DEPOT-PED 30 MG 3MO KIT
leuprolide
PA QL
novarel
PA
ORTHO ALL-FLEX
diaphragm
QL
ORTHO-DIAPHRAGM
diaphragm
QL
vcf contraceptive foam [OTC]
WIDE SEAL DIAPHRAGM
diaphragm
QL
OPHTHALMIC MEDICATIONS
ANTIGLAUCOMA DRUGS
acetazolamide capsule sustained action, -tablet
apraclonidine hcl
AZOPT
BETOPTIC S
brimonidine tartrate
dorzolamide hcl
dorzolamide-timolol
ISOPTO CARBACHOL DROPS
latanoprost
levobunolol hcl
methazolamide
metipranolol
PHOSPHOLINE IODIDE
brinzolamide
betaxolol
carbachol
echothiophate iodide
Lower Case: indicates generic coverage only
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over-the-Counter
49
CAREOREGON (OHP) 2014 FORMULARY
OPHTHALMIC MEDICATIONS
ANTIGLAUCOMA DRUGS CONTINUED
pilocarpine hcl drops
PILOPINE HS
timolol maleate drops, -gel-forming solution
travoprost 0.004% drops
pilocarpine hcl
OPHTHALMIC ANTIINFECTIVE/CORTICOSTEROIDS
BLEPHAMIDE
sulfacetamide/prednisolone ac
BLEPHAMIDE S.O.P.
sulfacetamide/prednisolone ac
neomycin-bacitracin-poly-hc
neomycin-polymyxin-dexameth
neomycin-polymyxin-hc drops
poly-dex
sulfacetamide-prednisolone
TOBRADEX OINTMENT
tobramycin sulfate/dexameth
tobramycin-dexamethasone
OPHTHALMIC CORTICOSTEROID DRUGS
dexamethasone sodium phosphate drops
fluorometholone
FML FORTE
FML S.O.P.
PRED MILD
prednisolone acetate suspension drops
prednisolone sodium phosphate drops
fluorometholone
fluorometholone
prednisolone acetate
OPHTHALMIC TOPICAL ANTIBACTERIAL DRUGS
ak-poly-bac
bacitracin 500 unit/gm ointmnt
bacitracin-polymyxin eye oint
CILOXAN OINTMENT
ciprofloxacin
ciprofloxacin hcl drops
erythromycin ointment
garamycin
gatifloxacin ophth soln 0.5%
gentak
Lower Case: indicates generic coverage only
50 QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over-the-Counter
OPHTHALMIC MEDICATIONS
OPHTHALMIC TOPICAL ANTIBACTERIAL DRUGS CONTINUED
gentamicin 3 mg/gm eye oint, -drops
neomycin-bacitracin-polymyxin
neomycin-polymyxin-gramicidin
neo-polycin
ofloxacin drops
polycin-b
polymyxin b sul-trimethoprim
romycin
sulfacetamide sodium drops, -ointment
sulfamide
tobramycin sulfate drops
OPHTHALMIC TOPICAL ANTIVIRAL DRUGS
trifluridine
ZIRGAN
ganciclovir
OTHER OPHTHALMIC DRUGS
atropine care
atropine sulfate drops, -ointment
CYCLOGYL 0.5% EYE DROPS
CYCLOMYDRIL
cyclopentolate hcl 2%
diclofenac sodium drops
flurbiprofen 0.3% ophth soln
homatropaire
homatropine
ketorolac
mydral
tropicamide
cyclopentolate
phenylephrine/cyclopentolate
Lower Case: indicates generic coverage only
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over-the-Counter
51
CAREOREGON (OHP) 2014 FORMULARY
RESPIRATORY MEDICATIONS
ANTIHISTAMINES
ala-hist IR 2 mg tablet [OTC]
chlorpheniramine maleate syrup, -tabs, -tabs SA [OTC]
cetirizine solution oral, syrup
cetirizine tablet
cyproheptadine hcl syrup, -tablet
diphenhydramine capsule, -solution, -syrup, -tablet [OTC]
loratadine solution oral, -syrup [OTC]
loratadine tablet, -tablet dispersible lingual [OTC]
promethazine 6.25 mg/5ml syrup, -tablet
promethazine inj ampule, syringe, vial
QL
AR≤64
AR≤64
QL
AR2-64
AR>2
ANTITUSSIVE AND EXPECTORANT DRUGS
benzonatate 100 mg capsule
SSKI
potassium iodide
BETA-2 ADRENERGIC DRUGS
albuterol sulfate 2mg tab, -2mg/5ml syrup,
-4mg tab, -4mg ER tab, -nebulizer solution
E-Z SPACER
INSPIREASE DRUG DLVRY SYSTEM
metaproterenol sulfate syrup
MICROSPACER
PROAIR HFA
PROVENTIL HFA
SEREVENT DISKUS
terbutaline sulfate tablet
VENTOLIN HFA
XOPENEX HFA
breathing supplies
breathing supplies
QL
QL
breathing supplies
albuterol
albuterol
salmeterol
QL
ST
albuterol
levalbuterol hydrochloride
LEUKOTRIENE MODIFIERS
montelukast sodium
zafirlukast
Lower Case: indicates generic coverage only
52 QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over-the-Counter
ST
RESPIRATORY MEDICATIONS
METHYL XANTHINE DRUGS
caffeine citrate solution
copd
ELIXOPHYLLIN
theophylline
THEO-24 ER 200 MG CAPSULE
theophylline
theochron
theophylline anhydrous tablet sustained release 12hr
theophylline tablet sustained action
OTHER DRUGS FOR ASTHMA
ADVAIR DISKUS
salmeterol/fluticasone
ADVAIR HFA
salmeterol/fluticasone
ANORO ELIPTA
umeclidinium
bromide/vilanterol) INH
ATROVENT HFA
ipratropium
budesonide ampul for nebulization
COMBIVENT
albuterol sulfate/ipratropium
COMBIVENT RESPIMAT
albuterol sulfate/ipratropium
cromolyn sodium ampul for nebulization
EPIPEN
epinephrine hcl
EPIPEN JR
epinephrine hcl
FLOVENT DISKUS
fluticasone propionate
FLOVENT HFA
fluticasone propionate
HYPER-SAL 7% VIAL
sodium chloride
ipratropium bromide nebulizer solution
ipratropium-albuterol
PULMICORT 1 MG/2 ML RESPULE
budesonide
QVAR
beclomethasone
sodium chloride 0.9% vial, -3% vial
SPIRIVA
tiotropium bromide
SYMBICORTbudesonide/formoterol
OTHER RESPIRATORY DRUGS
ARALAST NP
PROLASTIN 500 MG VIAL
PULMOZYME
alpha 1-proteinase inhibitor
alpha 1-proteinase inhibitor
deoxyribonuclease
Lower Case: indicates generic coverage only
QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over-the-Counter
AR≤1
QL
PA QL
AR≤6
AR≤6
PA QL
PA
PA
QL
53
CAREOREGON (OHP) 2014 FORMULARY
UROLOGICAL MEDICATIONS
ANTICHOLINERGIC ANTISPASMODICS
oxybutynin chloride syrup, -tablet
oxybutynin er tablet
OXYTROL FOR WOMEN TOPICAL PATCH OTC
tolterodine tartrate tablet
ST
PA
CHOLINERGIC STIMULANTS
bethanechol chloride tablet
OTHER GENITOURINARY PRODUCTS
cytra-3
cytra-k
K-PHOS ORIGINAL
potassium citrate tablet sustained action
tamsulosin
taron-crystals
potassium acid phosphate
UROLOGICAL MEDICATIONS
OTHER MISCELLANEOUS THERAPEUTIC AGENTS
ELMIRON
pentosan polysulfate sodium
PA
URINARY ANESTHETICS
phenazopyridine hcl tablet
Lower Case: indicates generic coverage only
54 QL: Quantity Limit | AR: Age Restriction | PA: Prior Authorization Required | ST: Step Therapy | OTC: Over-the-Counter
Symbols
3-day vaginal cream [OTC]................................ 8
A
abacavir 300mg tablet........................................ 2
abacavir/dolutegravir/lamivudine..................... 3
abacavir sulfate..................................................... 3
abacavir sulfate/lamivudine............................... 2
abacavir sulfate/lamivudine/zidovudine......... 2
ABILIFY................................................................ 10
acamprosate calcium........................................ 16
acarbose............................................................. 27
acebutolol hcl capsule...................................... 17
ACERFLEX POWDER...................................... 39
acetaminophen -caplet, -chews, -drops,
-elixir, -gelcap, -geltab, -solution,
-suppository rectal, -suspension drops
[OTC], -tablet.................................................... 11
acetaminophen-codeine elixir......................... 14
acetaminophen-codeine tablet....................... 14
acetasol hc.......................................................... 24
acetazolamide capsule sustained action,
-tablet................................................................ 49
acetic acid-hydrocortisone.............................. 24
acetic acid solution non-oral........................... 24
acid control 150 mg tablet, -20 mg tablet
[OTC]................................................................. 29
acid controller 20 mg tablet [OTC]................ 29
acid reducer 150 mg tablet,
-20 mg tablet, -200 mg tablet [OTC]......... 30
acid reducer 150 [OTC]................................... 29
acid relief [OTC]................................................. 30
ACTEMRA SC....................................................... 8
acticin.................................................................. 22
ACTIMMUNE...................................................... 34
ACTONEL TABLET........................................... 27
acyclovir capsule, -suspension oral, -tablet... 5
ADACEL.............................................................. 33
adalimumab........................................................... 9
ADCIRCA............................................................. 21
adefovir dipivoxil................................................... 4
ADEMPAS............................................................ 21
adenosine 12 mg/4 ml vial,
-6 mg/2 ml vial.............................................. 20
ADVAIR DISKUS................................................ 53
ADVAIR HFA...................................................... 53
AEROCHAMBER.............................................. 35
AEROCHAMBER MAX INHALER................. 35
AEROCHAMBER MINI..................................... 35
AEROCHAMBER MV....................................... 35
AEROCHAMBER WITH FLOWSIGNAL....... 35
AEROCHAMBER Z-STAT PLUS.................... 35
afeditab cr............................................................ 17
AFINITOR............................................................... 8
AFINITOR DISPERZ............................................ 8
AFLURIA............................................................. 33
AGGRENOX....................................................... 38
AIRZONE PEAK FLOW METER [OTC]......... 24
ak-poly-bac......................................................... 50
ala-hist IR 2 mg tablet [OTC].......................... 52
albendazole........................................................... 2
ALBENZA TABLET.............................................. 2
albiglutide........................................................... 26
albuterol.............................................................. 52
albuterol sulfate 2mg tab, -2mg/5ml
syrup, -4mg tab, -4mg ER tab,
-nebulizer solution......................................... 52
albuterol sulfate/ipratropium.......................... 53
ALCOHOL ANTAGONIST................................. 11
ALCOHOL PREP PADS [OTC]....................... 35
ALCOHOL PREP SWABS [OTC]................... 35
ALCOHOL SWABS [OTC]............................... 35
ALCOHOL WIPES [OTC]................................. 35
alendronate sodium.......................................... 27
ALFERON N....................................................... 34
ALKERAN TABLET............................................. 8
all day pain relief [OTC]................................... 36
allopurinol tablet................................................ 36
alpha 1-proteinase inhibitor............................ 53
ALPHA-ADRENERGIC ANTAGONISTS........ 17
altavera................................................................ 45
altretamine............................................................. 9
alyacen................................................................ 45
amantadine............................................................ 5
ambrisentan......................................................... 19
AMEBICIDES......................................................... 1
amethia................................................................ 45
amethia lo........................................................... 45
55
CAREOREGON (OHP) 2014 FORMULARY
amethyst 90-20 mcg tab................................. 45
amiloride hcl tablet............................................ 21
amiloride-hydrochlorothiazide......................... 21
AMINOGLYCOSIDES...................................... 1, 2
amiodarone hcl 200 mg tablet, -injection..... 17
AMIODARONES................................................. 17
AMITRIPTYLINE................................................... 1
amlodipine besylate........................................... 17
amoxicillin 875 mg tablet, -capsule,
-suspension, -tablet chewable....................... 6
amox tr-potassium clavulanate......................... 6
amphetamine salts 7.5 mg tab........................ 14
amphetamine salts 10 mg tab,
-salts 12.5 mg tb, -salts 15 mg tab,
-salts 20 mg tab, -salts 30 mg tab,
-salts 5 mg tab................................................ 14
amphotericin b injection..................................... 6
ampicillin-sulb 3 gm add vial, -3 gm vial........ 6
ampicillin trihydrate.............................................. 6
amylase/lipase/protease.......................... 31, 32
anagrelide hcl capsule........................................ 8
ANALGESICS...................................................... 11
anastrozole tablet................................................. 8
ANDRODERM.................................................... 45
ANDROGEL........................................................ 45
ANDROGEN DRUGS....................................... 45
ANESTHETICS..................................................... 1
ANGIOTENSIN CONVERTING ENZYME
INHIBITORS..................................................... 17
ANGIOTENSIN II RECEPTOR
ANTAGONISTS................................................ 17
ANORO ELIPTA................................................. 53
ANTACIDS.......................................................... 28
antacid tablet, -gelcap,
-tablet chew [OTC]......................................... 28
ANTHELMINTICS................................................. 2
ANTICHOLINERGIC ANTISPASMODICS.... 54
ANTICONVULSANT BENZODIAZEPINES... 11
ANTIDEMENTIA DRUGS.................................. 11
ANTIDEPRESSANTS.......................................... 1
anti-diarrheal capsule [OTC]........................... 28
ANTIDIARRHEAL DRUGS....................... 28, 29
antifungal 2% cream, -antifungal
2% cream [OTC]............................................... 6
56
anti-fungal cream [OTC]..................................... 6
ANTIGLAUCOMA DRUGS....................... 49, 50
ANTIHISTAMINES............................................. 52
ANTIINFECTIVES.................... 1, 2, 4, 5, 6, 7, 8
anti-itch 1% cream, -1% ointment [OTC]..... 22
ANTINEOPLASTIC/
IMMUNOSUPPRESSANT DRUGS... 8, 9, 10
ANTIPARKINSON ANTICHOLINERGIC
DRUGS.............................................................. 12
ANTIPLATELET DRUGS................................. 38
ANTIPRURITIC DRUGS................................... 22
antipyrine-benzocaine....................................... 24
ANTIRETROVIRALS AND
PROTEASE INH........................................... 2, 3
ANTISPASMODICS........................................... 29
ANTITHYROID DRUGS................................... 25
ANTITUBERCULOSIS DRUGS......................... 3
ANTITUSSIVE AND EXPECTORANT
DRUGS............................................................. 52
ANTIULCER DRUGS................................. 29, 30
ANTIVERTIGO AND ANTIEMETIC
DRUGS.............................................................. 12
anudil hc.............................................................. 31
ANXIOLYTICS..................................................... 12
apap/pyrilamine/caffeine caplet,
-gelcap [OTC]................................................... 11
apixaban.............................................................. 42
apraclonidine hcl............................................... 49
apremilast............................................................ 10
aprepitant............................................................. 12
apri........................................................................ 45
APRISO................................................................ 31
APTIVUS................................................................ 2
ARALAST NP.................................................... 53
aranelle................................................................ 45
ARANESP 150 MCG/0.3 ML SYRINGE,
-200 MCG/0.4 ML SYRINGE, -300
MCG/0.6 ML SYRINGE, -300 MCG/ML
VIAL, -500 MCG/1 ML SYRINGE,
-60 MCG/0.3 ML SYRINGE........................ 32
ARMOUR THYROID 120 MG TABLET,
-15 MG TABLET, -180 MG TABLET,
-240 MG TABLET, -300 MG TABLET....... 28
artemether/lumefantrine..................................... 7
arthritis pain relief cream [OTC]..................... 23
ASACOL............................................................... 31
ASACOL HD 800MG........................................ 31
aspirin/acetaminophen/caffeine................... 37
aspirin buffered [OTC]....................................... 11
aspirin/dipyridamole......................................... 38
aspirin ec 162 mg tablet, -300 mg
suppository, -325 mg caplet, 325 mg tablet,
-500 mg caplet, -500 mg tablet, -600 mg
suppository, -81 mg chewable tablet,
-81 mg tablet, -children’s chewable tab
[OTC]................................................................. 37
ASSESS [OTC].................................................... 24
ASSESS PEAK FLOW METER [OTC]........... 24
ASTHMA CHECK [OTC]................................... 24
ASTHMAMENTOR [OTC]................................. 24
atazanavir sulfate................................................. 2
atenolol-chlorthalidone.................................... 20
atenolol tablet..................................................... 17
atorvastatin.......................................................... 19
atovaquone............................................................ 4
atovaquone-proguanil hcl................................... 7
atovaquone/proguanil hcl.................................. 6
ATRIPLA................................................................. 2
atropine care....................................................... 51
atropine sulfate drops, -ointment.................... 51
ATROVENT HFA................................................ 53
ATYPICALS.................................................. 10, 11
AUBAGIO............................................................. 15
aurodex................................................................. 24
auroguard............................................................. 24
AUTONOMIC AND
CNS MEDICATIONS........... 11, 12, 13, 14, 15
AVC...................................................................... 48
aviane................................................................... 45
AVONEX.............................................................. 34
AVONEX ADMINISTRATION PACK.............. 34
azathioprine tablet............................................... 8
azithromycin 250 mg tablet............................... 5
azithromycin 500 mg tablet, -600 mg
tablet, -packet, -suspension............................ 5
AZOPT................................................................. 49
aztreonam lysine.................................................. 4
azurette................................................................ 45
B
bacitracin 500 unit/gm oin, -500 unit/gm
oint, -500 units/gm oin [OTC]........................ 7
bacitracin 500 unit/gm ointmnt..................... 50
bacitracin-polymyxin eye oint......................... 50
baclofen tablet................................................... 36
balanced nutritional.......................................... 39
balsalazide........................................................... 31
balziva tab........................................................... 45
BARACLUDE........................................................ 5
baycadron........................................................... 25
baza antifungal [OTC].......................................... 6
BCAD 1 POWDER............................................ 39
BCAD 2 POWDER............................................ 39
becaplermin........................................................ 23
beclomethasone................................................ 53
belladonna-phenobarbital............................... 29
benazepril hcl...................................................... 17
benazepril-hydrochlorothiazide..................... 20
BENICAR HCT................................................... 20
benzene hexachloride gamma....................... 22
benzonatate 100 mg capsule......................... 52
benztropine mesylate injection, -tablet.......... 12
BETA-2 ADRENERGIC DRUGS..................... 52
BETA-ADRENERGIC ANTAGONIST
DRUGS.............................................................. 17
beta hc [OTC]..................................................... 22
betamethasone dp 0.05% crm,
-dp 0.05% lot, -ointment.............................. 22
betamethasone dp aug 0.05% ointment..... 22
betamethasone valerate cream,
-lotion, -ointment............................................ 22
betanate 0.05% cream.................................... 22
BETASERON...................................................... 34
betaxolol.............................................................. 49
bethanechol chloride tablet............................ 54
BETOPTIC S....................................................... 49
beyaz tab............................................................. 45
bicalutamide tablet.............................................. 8
BICILLIN L-A.......................................................... 6
BILTRICIDE............................................................ 2
bio-statin................................................................ 4
57
CAREOREGON (OHP) 2014 FORMULARY
bisacodyl -10 mg suppository, -5 mg
tablet, -ec 5 mg tablet, -lax 10 mg
supp [OTC]...................................................... 30
bisacodyl/sodium phosphate.......................... 31
bismuth chewable tablet [OTC]..................... 28
bisoprolol-hydrochlorothiazide...................... 20
BLEPHAMIDE.................................................... 50
BLEPHAMIDE S.O.P......................................... 50
BLOOD DETOXICANTS.................................. 38
BOOST ENERGY DRINK, -DIABETIC LIQUID,
-HIGH PROTEIN, -KIDS ESSENTIALS,
-PLUS ENERGY DRINK, -SMOOTHIE,
-VHC, -WITH BENEFIBER........................... 40
BOOSTRIX.......................................................... 33
bosentan.............................................................. 19
BOSULIF................................................................ 9
B+O SUPPOSITORY........................................ 13
bosutinib................................................................ 9
BREATHERITE................................................... 35
breathing devices-peak meters...................... 24
breathing supplies..................................... 35, 52
BREATHRITE..................................................... 35
briellyn tab.......................................................... 45
brimonidine tartrate.......................................... 49
brinzolamide....................................................... 49
bromocriptine mesylate capsule, -tablet....... 16
budesonide......................................................... 53
budesonide ampul for nebulization.............. 53
bumetanide.......................................................... 19
buprenorphine hcl tablet sublingual.............. 14
buprenorphine/naloxone sl tab...................... 14
buproban.............................................................. 16
bupropion sr 150 mg tablet............................. 16
BYDUREON....................................................... 26
BYETTA............................................................... 26
C
cabergoline......................................................... 27
caffeine citrate solution................................... 53
calcidol [OTC]..................................................... 41
CALCILO XD POWDER................................... 40
calcitonin-salmon.............................................. 27
calcitriol capsule, -solution.............................. 41
58
calcium 500+d [OTC]...................................... 42
calcium 500 w/vitamin d tab, -600 + vit d
400 tablet, -600 mg with d tab, -d tablet,
-shell calcium-vit d tab, -shell calc-vit d
caplet, -with vit d tablet [OTC]..................... 42
calcium 600 + vit d 200 tab,
-400 caplet, -400 tab [OTC]........................ 42
calcium acetate.................................................. 41
CALCIUM ANTAGONISTS......................... 17, 18
calcium carbonate 1,250 mg tab,
-1.25 gm tab, -1.5 gm tab, -500 mg tablet,
-600 mg cplt, -suspension oral,
-tablet chewable [OTC]................................. 42
calcium citrate 200 mg caplet,
-200 mg tablet, -250 mg caplet,
-250 mg tablet, -950 mg caplt [OTC]........ 42
calcium citrate+d [OTC].................................. 42
calcium citrate plus [OTC]............................... 42
calcium citrate - vitamin d [OTC]................... 42
calcium cit-vit d 315-200 tab [OTC]............. 43
calcium gluconate 500 mg tab, -650 mg
tab [OTC].......................................................... 43
calcium lactate tablet [OTC]........................... 43
cal-gest [OTC].................................................... 43
camila.................................................................. 48
CAMINO PRO 15 PKU SUSPENSION,
-RESTORE LIQUID........................................ 40
CAMPRAL........................................................... 16
camrese............................................................... 45
CANASA.............................................................. 31
capecitabine.......................................................... 9
capsaicin 0.025% cream, -0.075% cream,
-0.1% cream [OTC]........................................ 23
capsaicin apr [OTC].......................................... 23
captopril-hydrochlorothiazide......................... 20
captopril tablet.................................................... 17
capzasin-p [OTC]............................................... 23
CARAFATE SUSPENSION ORAL.................. 31
carbachol............................................................ 49
carbamazepine................................................... 12
carbamazepine er.............................................. 12
CARBAMAZEPINES.......................................... 12
carbamazepine suspension oral, -tablet,
-tablet chewable............................................. 12
carbamazepine xr............................................... 12
carbidopa-levodopa........................................... 16
CARDIAC GLYCOSIDES................................... 18
CARDIOVASCULAR
MEDICATIONS.................... 17, 18, 19, 20, 21
carnation instant breakfast [OTC].................. 40
cartia xt................................................................. 17
carvedilol.............................................................. 17
cascara sagrada capsule................................ 30
CAYSTON............................................................... 4
caziant................................................................. 45
cefaclor................................................................... 3
cefadroxil................................................................ 3
cefazolin 1 gm add-van vial, -10 gm vial,
-500 mg vial....................................................... 3
cefdinir capule...................................................... 3
cefdinir suspension............................................. 3
cefprozil.................................................................. 3
ceftriaxone............................................................. 4
ceftriaxone 1 gm piggyback, -1 gm vial,
-2 gm add vial, -2 gm piggyback,
-2 gm vial, -250 mg vial, -500 mg vial......... 3
cefuroxime tablet.................................................. 3
CELEBREX 100 MG CAPSULE,
-200 MG CAPSULE...................................... 36
celecoxib............................................................. 36
CELLCEPT SUSPENSION
RECONSTITUTED ORAL................................ 9
CELONTIN........................................................... 16
CENTRALLY ACTING
ANTIHYPERTENSIVES................................. 18
cephalexin 250 mg capsule,
-500 mg capsule, -suspension...................... 4
CEPHALOSPORINS....................................... 3, 4
ceritinib................................................................. 10
cesia..................................................................... 45
cetirizine solution.............................................. 52
cetirizine tablet................................................... 52
CHANTIX............................................................. 16
children’s ibuprofen [OTC].............................. 36
chlorambucil.......................................................... 9
chlorhexidine gluconate mouthwash............ 25
chloroquine phosphate tablet............................ 7
chlorpheniramine maleate syrup, -tabs,
-tabs SA [OTC]............................................... 52
chlorthalidone..................................................... 21
chlorzoxazone.................................................... 36
choice dm liquid................................................ 40
cholecalciferol.................................................... 42
cholestyramine................................................... 19
cholestyramine light.......................................... 19
choline fenofibrate capsule DR....................... 19
choline mag trisalicylate.................................. 37
CHOLINERGIC STIMULANTS....................... 54
cidofovir.................................................................. 5
cilostazol............................................................. 38
CILOXAN OINTMENT...................................... 50
cimetidine injection, -solution, -tablet........... 30
cinacalcet hcl..................................................... 28
CIPRODEX.......................................................... 24
ciprofloxacin................................................... 7, 50
ciprofloxacin-d5w................................................ 7
ciprofloxacin/dexameth.................................... 24
ciprofloxacin hcl drops..................................... 50
ciprofloxacin hcl tablet........................................ 7
CIPRO SUSPENSION......................................... 7
CITALOPRAM....................................................... 1
citrus calcium + d [OTC]................................. 43
citrus calcium-vitamin d [OTC]....................... 43
clarithromycin........................................................ 5
clarithromycin er................................................... 5
CLASS 1A............................................................ 18
CLASS 1B............................................................ 18
CLASS 1C............................................................ 18
CLASS III NARCOTICS..................................... 14
class ii narcotics................................................. 14
CLASS II NARCOTICS...................................... 13
CLEOCIN 100 MG VAGINAL OVULE........... 48
clindamycin hcl capsule..................................... 4
clindamycin palmitate hcl solution................... 4
clindamycin phosphate.................................... 48
clindamycin phosphate cream
with applicator................................................ 48
CLINDAMYCINS................................................... 4
clobetasol emollient......................................... 22
clobetasol propionate cream, -ointment,
-solution non-oral.......................................... 22
59
CAREOREGON (OHP) 2014 FORMULARY
clonazepam 0.5 mg tablet, -1 mg tablet,
-2 mg tablet...................................................... 11
clonidine hcl tablet............................................ 18
clopidogrel 75 mg tablet................................. 38
clotrimazole 1% cream....................................... 6
clotrimazole-3 [OTC]........................................... 8
clotrimazole-7 [OTC]............................................ 8
clotrimazole cream with applicator, -tablet
[OTC].................................................................... 8
clotrimazole troche.............................................. 4
CLOZAPINE........................................................ 10
CNS MUSCLE RELAXANTS.......................... 36
CNS STIMULANT DRUGS............................... 14
COARTEM.............................................................. 7
cobicistat................................................................ 3
codeine sulfate 30 mg tablet,
-60 mg tablet................................................... 13
co-gesic............................................................... 14
colchicine............................................................ 36
COLCRYS........................................................... 36
colestipol hcl....................................................... 19
colidrops............................................................. 29
COMBIPATCH.................................................... 48
COMBIVENT...................................................... 53
COMBIVENT RESPIMAT................................. 53
COMPLERA........................................................... 2
compro................................................................. 12
condoms, male.................................................. 49
CONDOMS [OTC].............................................. 49
CONDYLOX GEL.............................................. 22
constulose.......................................................... 38
CONTRACEPTIVES............................ 45, 46, 47
COPAXONE......................................................... 15
copd..................................................................... 53
cormax................................................................. 22
CORTIFOAM........................................................ 31
cortisone 1% cream [OTC]............................. 22
cortisone tablet.................................................. 25
cortomycin solution non-oral,
-suspension drops.......................................... 24
cosyntropin 0.25 mg vial................................. 28
COUMADIN........................................................ 40
CREON................................................................. 31
60
CRIXIVAN............................................................... 2
crizotinib............................................................... 10
cromolyn sodium ampul for nebulization..... 53
crotamiton........................................................... 22
cryselle................................................................ 45
CUT N CRUSH [OTC]....................................... 35
cyanocobalamin injection................................ 41
cyclafem.............................................................. 45
cyclobenzaprine hcl 10mg tablet,
-5mg tablet...................................................... 36
CYCLOGYL 0.5% EYE DROPS,
-2% EYE DROPS............................................ 51
CYCLOMYDRIL.................................................. 51
cyclopentolate..................................................... 51
cyclopentolate hcl 2%...................................... 51
cyclophosphamide tablet................................... 9
cyclosporine capsule, -softgel, -solution......... 9
cyclosporine modified......................................... 9
cyproheptadine hcl syrup, -tablet.................. 52
cytra-2.................................................................. 41
cytra-3................................................................. 54
cytra-k.................................................................. 54
D
dabigatran etexilate.......................................... 42
dalteparin (porcine).......................................... 39
danazol capsule................................................ 45
dantrolene sodium............................................ 36
dapsone................................................................. 7
DAPSONE.............................................................. 7
DAPTACEL......................................................... 33
DARAPRIM............................................................ 7
darbepoetin alfa................................................. 32
darunavir ethanolate............................................ 2
dasatinib............................................................... 10
daysee................................................................. 45
delavirdine mesylate............................................ 2
del-beta............................................................... 22
delta d3 [OTC].................................................... 41
DELZICOL........................................................... 31
denta 5000 plus................................................ 39
dentagel.............................................................. 39
deoxyribonuclease............................................ 53
depade.................................................................. 16
DEPO-PROVERA 400 MG/ML VIAL.............. 9
DEPO-TESTOSTERONE.................................. 45
DERMATOLOGICAL MEDICATIONS..... 22, 23
DESIPRAMINE...................................................... 1
desmopressin acetate aerosol spray
w/pump, -injection, -solution, -tablet......... 28
deso/ethinyl tab estradiol............................... 45
DEX4 GLUCOSE BITS, -4 GM TABLET
CHEW, -QUICK DISSOLVE TAB CHEW
[OTC]................................................................. 25
dexamethasone................................................. 25
dexamethasone elixir, -solution oral,
-tablet................................................................ 25
dexamethasone sodium phosphate
drops................................................................. 50
dexmethylphenidate hcl.................................... 14
DEXPAK.............................................................. 25
dextroamphetamine-amphetamine er........... 14
dextroamphetamine sulfate............................. 14
dextrose........................................................ 25, 26
dextrose 10%-water iv soln, -10%-water iv
solution, -40%-water iv soln, -50%-water
abboject, -50%-water iv soln, -50%-water
syringe, -50%-water vial, -70%-water iv
soln................................................................... 38
DIABETIC SUPPLIES....................................... 35
DIAGNOSTIC AND MISCELLANEOUS
MEDICATIONS................................................. 24
DIAGNOSTIC PRODUCTS............................... 24
dialyvite 800 tablet [OTC]............................... 43
dialyvite zinc....................................................... 43
diaphragm........................................................... 49
DIASTAT............................................................... 11
DIASTAT ACUDIAL............................................ 11
diazepam.............................................................. 11
diazepam gel, -kit............................................... 11
diazoxide............................................................. 26
diclofenac potassium....................................... 36
diclofenac sodium 25mg tab, -50mg tab,
-75mg tab 100mg er tab.............................. 36
diclofenac sodium drops.................................. 51
dicloxacillin sodium............................................. 6
dicyclomine hcl capsule, -syrup, -tablet....... 29
didanosine........................................................ 2, 3
digoxin solution, -tablet..................................... 18
dihydroergotamine mesylate injection........... 15
dihydroergotamine nasal spray....................... 15
diiodohydroxyquin................................................ 1
DILANTIN CAPSULE, -INFATAB,
-SUSPENSION................................................ 15
DILATRATE-SR.................................................. 20
DILAUDID-HP 250 MG VIAL.......................... 13
dilt-cd.................................................................... 17
diltia xt.................................................................. 18
diltiazem 24hr er capsule, -24hr cd
capsule.............................................................. 18
diltiazem er.......................................................... 18
diltiazem hcl tablet............................................. 18
dilt-xr..................................................................... 18
diltzac er............................................................... 18
dimenhydrinate tablet [OTC]............................ 12
dimethyl fumarate............................................... 15
DIPENTUM.......................................................... 31
diphenhydramine capsule, -solution,
-syrup, -tablet [OTC]...................................... 52
diphenoxylate-atropine.................................... 28
diphther,pertuss,tetanus vac.................... 33, 34
DIRECT MUSCLE RELAXANTS.................... 36
disopyramide....................................................... 18
disopyramide phosphate.................................. 18
disulfiram.............................................................. 11
docusate sodium capsule, -softgel,
-solution, -syrup, -tablet [OTC].................... 30
dofetilide............................................................. 20
dolutegravir............................................................ 3
donepezil hcl....................................................... 11
dorzolamide hcl................................................. 49
dorzolamide-timolol.......................................... 49
doxazosin mesylate........................................... 21
DOXEPIN............................................................... 1
doxycycline calcium............................................ 7
doxycycline monohydrate................................... 7
driminate [OTC]................................................... 12
dronabinol 5 mg capsule................................. 12
dronabinol 10 mg capsule,
-2.5 mg capsule.............................................. 12
DROXIA.................................................................. 9
DRUGS AFFECTING THE EAR...................... 24
61
CAREOREGON (OHP) 2014 FORMULARY
DRUGS AFFECTING THE NOSE.................. 25
DRUGS AFFECTING THE THROAT
AND MOUTH.................................................. 25
DRUGS TO PREVENT AND TREAT
GOUT................................................................ 36
DRUGS TO PREVENT AND TREAT
HEADACHES................................................... 15
DRUGS TO TREAT MULTIPLE
SCLEROSIS...................................................... 15
d-vi-sol [OTC]...................................................... 41
DYRENIUM -100 MG CAPSULE, 50 MG...... 21
E
EAR-NOSE-THROAT MEDICATIONS.... 24, 25
EASIVENT........................................................... 35
echothiophate iodide....................................... 49
ed-spaz................................................................ 29
EDURANT.............................................................. 2
E.E.S. 200.............................................................. 4
efavirenz................................................................. 3
effer-k 25 meq tablet......................................... 41
ELECTROLYTES, IRRIGATING
SOLUTIONS, ETC.......................................... 38
electrolyte solution/peg’s................................. 31
elemental calcium [OTC]................................. 43
elinest.................................................................. 45
eliphos.................................................................. 41
ELIQUIS............................................................... 42
ELIXOPHYLLIN................................................. 53
ELLA.................................................................... 45
ELMIRON............................................................ 54
eltrombopag olamine....................................... 32
elvitegravir/cobicistat/cmtricitabine/
tenofovir disoproxil........................................... 3
EMCYT................................................................... 9
EMEND 125 MG CAPSULE,
-80 MG CAPSULE, -TRIFOLD PACK......... 12
emoquette........................................................... 45
emtricitabine.......................................................... 2
emtricitabine, rilpivirine, tenofovir..................... 2
emtricitabine/tenofovir........................................ 3
emtricitabine/tenofovir/efavir............................ 2
EMTRIVA................................................................ 2
enalapril-hydrochlorothiazide......................... 20
62
enalapril maleate tablet..................................... 17
ENBREL................................................................. 9
endocet 7.5-325 mg tablet.............................. 13
endocet 10-325 mg tablet, -10-650 mg
tablet,-5-325 tablet, -7.5-500 mg table...... 13
ENDOCRINE MEDICATIONS..... 25, 26, 27, 28
ENDOTHELIN RECPTR ANTAGONIST......... 19
enema [OTC]...................................................... 30
enfuvirtide.............................................................. 2
ENGERIX-B........................................................ 33
enlive [OTC]........................................................ 43
enoxaparin.......................................................... 39
enoxaparin sodium........................................... 39
enpresse............................................................. 45
enskyce tab........................................................ 45
entacapone.......................................................... 16
entecavir................................................................. 5
enulose................................................................ 38
epinephrine hcl.................................................. 53
EPIPEN................................................................ 53
EPIPEN JR.......................................................... 53
epitol..................................................................... 12
EPIVIR SOLUTION............................................... 2
epoetin alfa......................................................... 32
EPOGEN............................................................. 32
epoprostenol sodium........................................ 21
EPZICOM............................................................... 2
ergocalciferol drops [OTC]............................... 41
ERGOMAR........................................................... 15
ergotamine........................................................... 15
ergotamine-caffeine.......................................... 15
erlotinib hcl.......................................................... 10
errin............................................................... 45, 48
ERY-TAB................................................................. 4
erythrocin filmtab................................................. 4
ERYTHROID STIMULANTS............................ 32
erythromycin base............................................... 4
erythromycin capsule enteric coated,
-tablet................................................................... 4
erythromycin ethylsuccinate.............................. 4
erythromycin ethylsuccinate tablet................... 4
erythromycin ointment..................................... 50
ERYTHROMYCINS.............................................. 4
erythromycin-sulfisoxazole................................. 7
ESCITALOPRAM.................................................. 1
ESTRACE CREAM WITH APPLICATOR...... 48
estradiol............................................................... 48
estradiol/noreth ac........................................... 48
estradiol patch transdermal weekly, -tablet. 48
estramustine phosphate sodium...................... 9
ESTRING............................................................. 48
ESTROGEN DRUGS......................................... 48
ESTROGEN/PROGESTIN
COMBINATIONS............................................ 48
estrogens,conjugated....................................... 48
estrogens,esterified.......................................... 48
estropipate.......................................................... 48
etanercept.............................................................. 9
ethambutol hcl tablet........................................... 3
ethinyl estradiol/norelgest.............................. 46
ethosuximide....................................................... 16
ethotoin................................................................. 15
etidronate disodium.......................................... 28
etodolac capsule, -tablet................................. 36
etonogestrel/ethin estradiol............................ 47
etoposide 50mg capsule.................................... 9
etravirine................................................................. 2
EURAX................................................................ 22
everolimus....................................................... 8, 10
exemestane........................................................... 9
exenatide............................................................. 26
ezetimibe.............................................................. 19
ezetimibe/simvastatin....................................... 19
E-Z SPACER....................................................... 52
E-Z SPACER PEDSPAK.................................. 35
F
famciclovir.............................................................. 5
famotidine........................................................... 30
famotidine 10 mg tablet [OTC]........................ 31
famotidine 20 mg tablet, -40 mg tablet....... 30
farbee w-c [OTC]............................................... 43
FARESTON............................................................ 9
fe fumarate/doss/fa/b comp & c.................. 43
felbamate tablet, -suspension......................... 15
fenofibrate 48 mg tablet, 145mg tablet,
-160mg tablet, -54mg tablet, 43mg capsule,
67 mg capsule, 130mg capsule,
-134mg capsule, -200mg capsule.............. 19
fentanyl................................................................. 13
ferate [OTC]........................................................ 43
fer-gen-sol [OTC]............................................... 43
fer-iron [OTC]..................................................... 43
ferosul [OTC]...................................................... 43
ferrex 150 [OTC]................................................ 43
ferro-time [OTC]................................................. 43
ferrous gluconate tablet [OTC]....................... 43
ferrous sulfate 27 mg tablet, -325 mg tab,
-325 mg tablet, -drops, -oral drops,
-solution oral, -tablet enteric coated,
-tablet sustained action [OTC].................... 43
ferrousul [OTC]................................................... 43
ferus [OTC].......................................................... 43
filgrastim.............................................................. 34
FIRST-LANSOPRAZOLE................................. 32
FIRST-OMEPRAZOLE...................................... 32
FIRST-TESTOSTERONE.................................. 45
fish oil 1,000 mg capsule, -1,000 mg
softgel, -300 mg softgel, -conc 1,000
mg softgel, -concentrate softgel,
-extra strength softgl [OTC]......................... 43
flecainide acetate............................................... 18
FLOVENT DISKUS............................................ 53
FLOVENT HFA................................................... 53
FLUARIX............................................................. 33
FLUARIX QUAD................................................ 33
FLUBLOK........................................................... 33
FLUCELVAX....................................................... 33
fluconazole 150 mg tablet................................. 4
fluconazole tablet, -suspension........................ 4
fludrocortisone acetate tablet......................... 27
FLULAVAL.......................................................... 33
FLULAVAL QUAD............................................. 33
FLUMIST............................................................. 33
FLUMIST QUAD................................................ 33
flunisolide 0.025% spray................................. 25
flunisolide 29 mcg-0.025% spr..................... 25
fluocinolone acetonide solution non-oral.... 22
fluocinonide cream, -solution non-oral........ 23
63
CAREOREGON (OHP) 2014 FORMULARY
fluocinonide-e.................................................... 23
fluocinonide emollient...................................... 23
fluocytosine 250mg, 500mg capsule.............. 4
FLUORABON DROPS..................................... 39
fluor-a-day tablet chewable............................ 39
FLUORIDE PRODUCTS................................... 39
fluoridex daily defense..................................... 39
fluoritab chewable............................................ 39
fluorometholone................................................ 50
fluorouracil 5% top solution, -cream............. 23
FLUOXETINE........................................................ 1
FLURA-DROPS................................................. 39
flurbiprofen 0.3% ophth soln........................... 51
flurbiprofen tablet.............................................. 36
flutamide................................................................. 9
fluticasone propionate..................................... 53
fluticasone propionate
nasal inhaled steroids................................... 25
FLUVIRIN............................................................ 33
FLUZONE............................................................ 33
FLUZONE HIGH-DOSE 2010-11 SYR......... 33
FLUZONE INTRADERMAL............................. 33
FLUZONE QUAD............................................... 33
FML FORTE........................................................ 50
FML S.O.P............................................................ 50
folic acid 0.4 mg tablet, -0.8 mg tablet,
-1,000 mcg tablet, -400 mcg tab,
-400 mcg tablet, -800 mcg tablet [OTC]... 41
folic acid 1 mg tablet, -injection...................... 41
folic acid xtra [OTC].......................................... 43
fondaparinux sodium........................................ 39
fortical.................................................................. 28
fosamprenavir calcium........................................ 2
fosinopril sodium................................................ 17
fosphenytoin sodium......................................... 15
FOSRENOL........................................................ 38
FRAGMIN............................................................ 39
full spectrum b [OTC]....................................... 43
furosemide injection, -solution, -tablet.......... 19
FUZEON................................................................. 2
64
G
gabapentin capsule, -solution, -tablet............ 15
galantamine......................................................... 11
ganciclovir....................................................... 5, 51
garamycin............................................................ 50
GARDASIL.......................................................... 33
GASTROINTESTINAL
MEDICATIONS................... 28, 29, 30, 31, 32
gatifloxacin ophth soln 0.5%.......................... 50
gavilyte-c.............................................................. 31
gavilyte-g.............................................................. 31
gavilyte-n.............................................................. 31
gefitinib................................................................... 9
gemfibrozil........................................................... 19
generess fe chw................................................ 46
generic prenatal vitamins
(<1 mg folic acid).......................................... 48
generic prenatal vitamins
(> or = 1 mg folic acid)................................ 48
generlac............................................................... 38
gengraf................................................................... 9
GENOTROPIN.................................................... 32
gentak.................................................................. 50
gentamicin 3 mg/gm eye oint, -drops........... 51
gianvi tab............................................................. 46
gildagia 0.4-35 tab........................................... 46
gildess................................................................. 46
gildess fe............................................................. 46
glatiramer acetate............................................... 15
GLEEVEC............................................................... 9
glimepiride.......................................................... 27
glipizide er.......................................................... 27
glipizide-meformin............................................ 27
glipizide tablet.................................................... 27
glipizide xl........................................................... 27
GLUCAGEN........................................................ 25
GLUCAGON EMERGENCY KIT..................... 25
glucagon, human recombinant...................... 25
gluco burst [OTC].............................................. 25
GLUCOCORTICOID DRUGS.......................... 25
GLUCOSE 4 GM TAB CHEW, -DRUG
MART TABLET, -MEIJER 4 GRAM TAB
CHEW, -PREFERRED PLUS TAB CHEW,
-VALUE PLUS TABLET CHEW................... 26
glucose 4 gram tab chew, 5 gram tab chew
-quick dissolve tab........................................ 26
GLUCOSE 40% GEL [OTC]............................ 26
GLUCOSE BITS [OTC]..................................... 26
GLUCOSE ELEVATING DRUGS............. 25, 26
glyburide............................................................. 27
glyburide-metformin hcl................................... 27
glyburide micronized........................................ 27
glycerin 2 gram supp,
-suppositories [OTC]..................................... 30
glycerin adult suppository,
-child suppository [OTC].............................. 30
GLYCERIN LAXATIVE [OTC].......................... 35
GOLYTELY PKT................................................. 31
granisetron hcl 0.1 mg/ml vial......................... 12
granisol................................................................. 12
GRANIX............................................................... 34
griseofulvin suspension oral.............................. 4
GROWTH HORMONES AND
RELATED DRUGS.................................. 32, 33
guanfacine hcl.................................................... 18
H
HARVONI............................................................... 5
HAVRIX............................................................... 34
heartburn 200 [OTC]........................................ 30
heartburn [OTC]................................................. 30
heartburn preven 20 mg tab [OTC]............... 30
heartburn relief 20 mg tablet, -200 mg tab,
-200 mg tablet, -relf 200 mg tb [OTC]...... 30
heartburn relief 150 [OTC].............................. 30
heather................................................................. 48
hecoria.................................................................... 9
heparin iv flush 10 unit/ml sy, -iv flush
100 units/ml, -lock flush 10 units/ml,
-lock flush 100 unit/ml................................. 39
heparin lock........................................................ 39
heparin sod 1,000 unit/ml vial,
-10,000 unit/ml vl, -20,000 unit/ml vl,
-5,000 unit/0.5 ml, -5,000 unit/ml syr,
-5,000 unit/ml vial......................................... 39
hepatatis a virus vaccine................................. 34
hepatitis a virus vaccine.................................. 34
hepatitis b virus vaccine........................... 33, 34
hepatitis C.............................................................. 5
HEXALEN.............................................................. 9
high potency capsaicin [OTC]........................ 23
HMG-COA COMBINATIONS........................... 19
HMG-COA REDUCTASE INHIBITORS.......... 19
homatropaire....................................................... 51
homatropine........................................................ 51
HUMALOG 100 UNITS/ML CARTRIDGE,
-KWIKPEN, -PEN.......................................... 26
HUMALOG 100 UNITS/ML VIAL.................. 26
HUMALOG MIX 75-25 KWIKPEN, -PEN.... 26
HUMALOG MIX 75-25 VIAL.......................... 26
human papillomavirus vacc............................ 33
HUMATROPE..................................................... 32
HUMIRA................................................................. 9
HUMULIN 50-50 [OTC]................................... 26
HUMULIN 70/30 KWIKPEN.......................... 26
HUMULIN 70-30 PEN [OTC]......................... 26
HUMULIN 70-30 VIAL, -RELION 70-30
[OTC]................................................................. 26
HUMULIN N 100 UNITS/ML PEN [OTC].... 26
HUMULIN N 100 UNITS/ML VIAL,
-RELION 100 UNIT/ML [OTC].................... 26
HUMULIN R 100 UNITS/ML VIAL,
-RELION 100 UNIT/ML [OTC].................... 26
HYCAMTIN............................................................ 9
HYDANTOINS..................................................... 15
hydralazine hcl tablet........................................ 21
hydrochlorothiazide 25 mg tab,
-50 mg tab, -capsule...................................... 21
hydrocodon-acetaminophn 10-325, -10-650,
-10-660, -2.5-500, -5-325, -5-500,
-7.5-325, -7.5-500, -7.5-650, -7.5-750....... 14
hydrocodon-acetaminophn 10-500,
-solution oral.................................................... 14
hydrocodone bit-ibuprofen.............................. 14
hydrocortisone 0.5% cream, -0.5%
ointment, -1% cream, -1% lotion, -1% oint,
-aloe 1% cream, -plus 1% cream [OTC]... 23
hydrocortisone 1% cream, -1% ointment,
-2.5% cream, -2.5% ointment..................... 23
hydrocortisone acetate..................................... 31
hydrocortisone plus 12 [OTC]........................ 23
65
CAREOREGON (OHP) 2014 FORMULARY
hydrocortisone plus crm [OTC]...................... 23
hydrocortisone tablet....................................... 25
hydrocream [OTC]............................................. 23
hydrogesic........................................................... 14
hydromorphone.................................................. 13
hydromorphone hcl injection........................... 13
hydro skin [OTC]................................................ 23
hydroxychloroquine sulfate tablet..................... 7
hydroxyurea........................................................... 9
hydroxyurea capsule........................................... 9
hydroxyzine hcl syrup, -tablet......................... 22
hydroxyzine pamoate capsule........................ 22
hyomax................................................................ 29
hyomax-ft............................................................ 29
hyomax-sl............................................................ 29
hyomax-sr........................................................... 29
hyoscyamine sulfate drops, -elixir,
-sulf 0.125 mg tab,
-tablet dispersible lingual,
-tablet sublingual,
-tablet sustained release 12hr................... 29
hyosyne............................................................... 29
HYPER-SAL 7% VIAL..................................... 53
HYPOLIPOPROTEINEMICS............................ 19
I
ibandronate tablet............................................. 28
ibu-drops [OTC]................................................. 36
ibuprofen 100 mg/5 ml susp, -400 mg
tablet, -600 mg tablet, -800 mg tablet...... 37
ibuprofen 100 mg caplet, -100mg tablet,
-100 mg/5 ml sus, -200 mg caplet,
-200 mg capsule, -200 mg softgel,
-200 mg tablet, -ib 50 mg caplet,
-tablet chewable [OTC]................................. 37
ICLUSIG.................................................................. 9
iferex 150 [OTC]................................................ 43
iloprost.................................................................. 21
imatinib mesylate................................................. 9
IMBRUVICA........................................................... 9
IMIPRAM HCL...................................................... 1
imiquimod cream............................................... 23
IMMUNOGLOBULIN ANTIBODIES............... 33
66
IMMUNOLOGICALS AND
VACCINES......................................... 32, 33, 34
INCRELEX.......................................................... 34
INCRETIN MIMETICS....................................... 26
indapamide.......................................................... 21
indinavir.................................................................. 2
INDOCIN SUSPENSION ORAL..................... 37
indomethacin..................................................... 37
indomethacin capsule,
-capsule sustained action............................ 37
INFANRIX............................................................ 34
infant formula..................................................... 40
infant glycerin [OTC]......................................... 30
infants ibu-drops [OTC]................................... 37
infants ibuprofen [OTC].................................... 37
INFERGEN.......................................................... 34
influenza virus quadrivalent............................ 33
influenza virus trivalent.................................... 33
INJECTABLE ANTICOAGULANTS............... 39
INSPIREASE DRUG DLVRY SYSTEM.......... 52
INSULIN....................................................... 26, 27
INSULIN LIKE GROWTH FACTORS-1......... 34
INSULIN SENSITIZERS & COMBOS............ 27
INTELENCE........................................................... 2
interferon alfa-2b , recomb............................. 34
interferon alfacon-1........................................... 34
interferon alfa-n3............................................... 34
interferon beta-1a.............................................. 34
interferon beta-1a/albumin............................. 34
interferon beta-1b.............................................. 34
interferon gamma-1b,recomb......................... 34
INTERFERONS.................................................. 34
INTRON A........................................................... 34
introvale............................................................... 46
INVEGA................................................................ 10
INVIRASE............................................................... 2
inzo antifungal [OTC]........................................... 6
ipecac................................................................... 24
ipratropium.......................................................... 53
ipratropium-albuterol........................................ 53
ipratropium bromide nebulizer solution....... 53
irbesartan............................................................. 17
IRESSA................................................................... 9
iron 27 mg tablet, -325 mg tablet,
-65 mg tablet, -sulfate 5 gr tablet,
-tablet sustained action [OTC].................... 43
iron supplement [OTC]..................................... 43
ISENTRESS........................................................... 2
isoditrate............................................................. 20
isonarif.................................................................... 3
isoniazid syrup, -tablet........................................ 3
ISOPTO CARBACHOL DROPS..................... 49
ISORDIL............................................................... 20
isosorbide dinitrate........................................... 20
isosorbide mononitrate.................................... 20
itch-x hc [OTC]................................................... 23
itraconazole........................................................... 4
itraconazole capsule........................................... 4
ivermectin............................................................... 2
J
jantoven...............................................................
jolessa..................................................................
jolivette................................................................
junel......................................................................
junel fe.................................................................
JUST D [OTC]....................................................
40
46
48
46
46
42
K
KALETRA.............................................................. 2
kalexate............................................................... 40
kariva.................................................................... 46
k effervescent...................................................... 41
kelnor 1-35......................................................... 46
KERATOLYTIC DRUGS................................... 22
ketoconazole tablet.............................................. 4
ketoprofen 50 mg capsule,
-75mg capsule................................................ 37
ketorolac............................................................... 51
kionex suspension oral.................................... 40
klor-con 10 meq tab, -8 meq tab.................... 41
klor-con 20 meq packet................................... 41
KLOR-CON 25 MEQ PACKET........................ 41
klor-con-ef........................................................... 41
klor-con m10 tablet, -m20 tablet.................... 41
konsyl capsule, -orange powder [OTC]........ 30
konsyl fiber [OTC].............................................. 30
K-PHOS ORIGINAL.......................................... 54
KUVAN................................................................ 28
L
labetalol hcl tablet.............................................. 17
lacosamide.......................................................... 15
lactose free-food............................................... 39
lactulose.............................................................. 38
lamivudine......................................................... 2, 5
lamivudine 150mg tablet.................................... 2
lamivudine 300mg tablet................................... 2
lamivudine-zidovudine........................................ 2
lansoprazole....................................................... 32
lansoprazole capsule enteric coated,
-tablet................................................................ 32
lanthanum carbonate....................................... 38
LANTUS 100 UNITS/ML CARTRIDGE........ 26
LANTUS 100 UNITS/ML VIAL...................... 26
LANTUS SOLOSTAR....................................... 26
lapatinib ditosylate............................................. 10
larin....................................................................... 46
latanoprost.......................................................... 49
LAXATIVES AND CATHARTICS............ 30, 31
ledipasvir/sofosbuvir........................................... 5
leena.................................................................... 46
leflunomide............................................................ 9
lessina.................................................................. 46
LETAIRIS.............................................................. 19
letrozole.................................................................. 9
leucovorin calcium tablet................................... 9
LEUKERAN........................................................... 9
LEUKOTRIENE MODIFIERS........................... 52
leuprolide............................................................ 49
leuprolide acetate.............................................. 49
leuprolide acetate/norethindrone KIT.......... 49
levalbuterol hydrochloride............................... 52
LEVEMIR 100 UNITS/ML PEN..................... 26
LEVEMIR 100 UNITS/ML VIAL..................... 26
levetiracetam er.................................................. 12
levetiracetam er tablet....................................... 15
levetiracetam solution, -tablet.......................... 15
levobunolol hcl.................................................. 49
67
CAREOREGON (OHP) 2014 FORMULARY
levocarnitine solution, -tablet.......................... 42
levofloxacin solution, -tablet............................... 7
levonor/ethi tab................................................. 46
levonorgestrel.................................................... 46
levora-28............................................................. 46
levothroid............................................................ 28
levothyroxine...................................................... 28
levothyroxine 500 mcg vial, -tablet............... 28
levoxyl.................................................................. 28
LEXIVA................................................................... 2
lice killing shampoo [OTC].............................. 22
lice treatment 1% creme rinse, -killing
treatment, -permethrin, -shampoo
[OTC]................................................................. 22
lidocaine hcl 2% abboject, -2% luer-jet,
-2% syringe........................................................ 1
lidocaine hcl jelly with prefilled applicator,
-solution non-oral............................................. 1
lidocaine hcl viscous........................................... 1
lidocaine-prilocaine............................................. 1
LINDANE............................................................. 22
linezolid.................................................................. 5
liothyronine sodium tablet............................... 28
liotrix..................................................................... 28
liraglutide............................................................ 26
lisinopril-hydrochlorothiazide......................... 20
lisinopril tablet..................................................... 17
LOCAL ANESTHETICS...................................... 1
loestrin 24 fe...................................................... 46
lo loestrin fe........................................................ 46
lomedia 24 fe..................................................... 46
lo minastrin pak fe............................................. 46
lomustine................................................................ 9
lonox..................................................................... 29
LOOP DIURETICS.............................................. 19
loperamide capsule.......................................... 29
loratadine solution oral, -syrup [OTC]........... 52
loratadine tablet, -tablet dispersible
lingual [OTC.................................................... 52
lorazepam injection........................................... 12
loryna tab............................................................ 46
losartan-hydrochlorothiazide.......................... 20
losartan potassium............................................ 17
68
lovastatin.............................................................. 19
LOVENOX 300 MG/3 ML VIAL..................... 39
low-ogestrel....................................................... 46
ludent fluoride chew......................................... 39
LUPANETA......................................................... 49
LUPRON DEPOT 3.75 MG KIT, -4 MONTH
KIT, -45 MG 6 MO KIT, -7.5 MG KIT.......... 49
LUPRON DEPOT 11.25 MG 3MO KIT,
-22.5 MG 3MO KIT........................................ 49
LUPRON DEPOT-PED 11.25 MG KIT,
-15MG KIT, -7.5 MG KIT................................ 49
LUPRON DEPOT-PED 30 MG 3MO KIT..... 49
lutera.................................................................... 46
LYRICA................................................................. 15
LYRICA 20 MG/ML SOLUTION..................... 15
LYSODREN............................................................ 9
M
MACRODANTIN 25 MG CAPSULE................. 8
magnesium citrate solution [OTC]................. 30
magnesium oxide 400mg tablet [OTC]........ 28
maraviroc................................................................ 3
marlexate............................................................. 40
marlissa............................................................... 46
MATULANE........................................................... 9
MAXIMUM D3 [OTC]........................................ 42
measles, mumps & rubella vaccine.............. 34
mecasermin........................................................ 34
meclizine hcl tablet............................................ 12
meclizine hcl tablet chewable [OTC]............. 12
MEDICAL (MISCELLANEOUS)
SUPPLIES................................................ 35, 36
medi-cortisone [OTC]....................................... 23
medroxyprogesterone......................................... 9
medroxyprogesterone acetate tablet............ 48
mefloquine hcl...................................................... 7
megestrol acetate suspension oral, -tablet.... 9
meloxicam 7.5mg tablet................................... 37
meloxicam 15mg tablet.................................... 37
memantine hcl.................................................... 11
memantine hcl SR 24hr.................................... 11
MENACTRA........................................................ 34
MENEST.............................................................. 48
meningococcal a,c,y, w-135 diptheria
conjugate vac.................................................. 34
meningococcal vac a,c,y,w-135..................... 34
MENOMUNE-A-C-Y-W-135............................. 34
MENVEO............................................................. 34
MEPHYTON....................................................... 40
mercaptopurine tablet......................................... 9
mesalamine.................................................. 31, 32
mesalamine delayed release........................... 31
mesalamine enema............................................ 31
MESTINON TABLET SUSTAINED
ACTION............................................................. 16
metadate er.......................................................... 14
METAMUCIL PACKET, -WAFER [OTC]........ 30
metaproterenol sulfate syrup.......................... 52
metformin hcl..................................................... 27
metformin hcl er................................................ 27
methadone 10 mg/ml oral conc,
-5 mg/5 ml solution....................................... 13
methadone hcl 10 mg tablet, -5 mg tablet... 13
methadone intensol........................................... 13
methadose 10 mg tablet................................... 13
methadose solution........................................... 13
methazolamide.................................................. 49
methimazole tablet............................................ 25
METHITEST........................................................ 45
methocarbamol tablet...................................... 36
methotrexate injection, -tablet......................... 10
methsuximide...................................................... 16
methyldopa.......................................................... 18
methyldopa-hydrochlorothiazide................... 20
methylergonovine 0.2mg tablet...................... 48
methylin 10 mg tablet, -20 mg tablet,
-5 mg tablet...................................................... 14
methylphenidate CD capsule.......................... 14
methylphenidate er capsule............................. 14
methylphenidate er tablet................................. 14
methylphenidate hcl tablet............................... 14
methylphenidate soln........................................ 14
methylphenidate sr tablet................................. 14
methylprednisolone 32mg tab, -4mg
dosepk, -4mg tablet, -8mg tab,
-16mg tab......................................................... 25
methyltestosterone............................................ 45
METHYL XANTHINE DRUGS........................ 53
metipranolol........................................................ 49
metoclopramide hcl injection,
-solution oral, -tablet...................................... 29
metolazone.......................................................... 21
metoprolol-hydrochlorothiazide..................... 20
metoprolol succinate......................................... 17
metoprolol tartrate tablet.................................. 17
metronidazole capsule, -tablet.......................... 8
metronidazole gel with applicator................. 48
metryl...................................................................... 8
mexiletine hcl capsule...................................... 18
miconazole............................................................ 6
MICONAZOLE...................................................... 6
miconazole 3 200 mg vag supp,
-4% cream [OTC].............................................. 8
miconazole 7 [OTC]............................................. 8
miconazole nitrate cream, -cream with
applicator, -suppository vaginal, -vaginal
products [OTC].................................................. 8
miconazole nitrate cream [OTC]....................... 6
MICROCHAMBER............................................. 35
microgestin......................................................... 46
microgestin fe.................................................... 46
micro-guard cream [OTC].................................. 6
MICROSPACER................................................. 52
midodrine hcl...................................................... 21
milk of magnesia concentrated,
-susp, -suspension [OTC]............................. 30
minastrin 24 fe................................................... 46
MINERALOCORTICOID DRUGS................... 27
mineral oil heavy, -enema, -laxative [OTC]... 30
MINITRAN 0.1 MG/HR PATCH...................... 20
minoxidil tablet.................................................... 21
misc supplies.............................................. 35, 36
misoprostol.......................................................... 31
mitotane.................................................................. 9
M-M-R II VACCINE............................................ 34
monoject heparin 10 units/ml,
-100 units/ml.................................................. 39
mononessa......................................................... 46
montelukast sodium......................................... 52
69
CAREOREGON (OHP) 2014 FORMULARY
morphine sulfate ir tab, - solution,
- suppository.................................................... 13
morphine sulf cr 15 mg tablet, -sulf cr
30 mg tablet, -sulf cr 60 mg tablet,
-sulf er 15 mg tablet, -sulf er 30 mg
tablet, -sulf er 60 mg tablet.......................... 13
morphine sulf cr 100 mg tablet, -sulf cr
200 mg tablet, -sulf er 100 mg tab,
-sulf er 200 mg tab........................................ 13
motion sickness [OTC]...................................... 12
moxifloxacin 400mg tablet................................. 7
mupirocin ointment.............................................. 7
muscle relief [OTC]........................................... 23
MUSCULOSKELETAL
MEDICATIONS......................................... 36, 37
mycophenolate mofetil................................. 9, 10
mydral................................................................... 51
MYELOID STIMULANTS................................. 34
MYLERAN........................................................... 10
my way................................................................. 46
myzilra.................................................................. 46
N
nabumetone tablet............................................ 37
nadolol tablet...................................................... 17
naltrexone hcl tablet.......................................... 16
NAMENDA 10 MG TABLET,
-5 MG TABLET, -SOLUTION........................ 11
NAMENDA XR.................................................... 11
naproxen sodium 220 mg caplet,
-220 mg tablet, [OTC]................................... 37
naproxen sodium 275 mg tab,
-550 mg tab.................................................... 37
naproxen suspension oral, -tablet................. 37
naratriptan............................................................ 15
NASACORT ALLERGY 24HR [OTC]............ 25
nebulizer/supplies..................................... 35, 36
NEBUPENT........................................................... 5
necon 0.5-35-28 tablet, -1/35-28 tablet,
-1/50-28 tablet, -7-7-7-28 tablet................ 46
nelfinavir mesylate............................................... 3
NEO-FRADIN........................................................ 1
neomycin................................................................ 1
70
neomycin-bacitracin-poly-hc.......................... 50
neomycin-bacitracin-polymyxin...................... 51
neomycin-polymyxin-dexameth..................... 50
neomycin-polymyxin-gramicidin..................... 51
neomycin-polymyxin-hc drops....................... 50
neomycin-polymyxin-hc solution non-oral,
-suspension drops.......................................... 24
neomycin sulfate tablet....................................... 1
neo-polycin.......................................................... 51
nephplex rx......................................................... 43
NEPHRON FA.................................................... 43
nephro-vite rx..................................................... 44
nervidox............................................................... 42
NEULASTA......................................................... 34
NEUPOGEN 300 MCG/ML VIAL,
-480 MCG/1.6 ML VIAL............................... 34
neurin-12............................................................. 42
NEUT................................................................... 38
neutragard advanced....................................... 39
nevirapine......................................................... 2, 3
NEXAVAR............................................................ 10
next choice......................................................... 46
next choice one dose....................................... 46
niacin.................................................................... 19
NIACIN 1,000 MG TABLET SA [OTC]........... 19
niacin 100 mg caplet, -100 mg tablet,
-50 mg caplet, -50 mg tablet [OTC]........... 44
niacin 250 mg tablet, -250 mg tablet sa,
-250 mg tr tablet, -500 mg caplet sa,
-500 mg tablet, -500 mg tablet sa,
-750 mg tablet sa, -capsule sustained
action [OTC]..................................................... 19
niacinamide tablet [OTC]................................. 44
niacin ER.............................................................. 19
nicorelief [OTC]................................................... 16
nicotine gum [OTC]............................................ 16
nicotine lozenge................................................. 16
nicotine patch [OTC].......................................... 16
nifediac cc........................................................... 18
nifedical xl............................................................ 18
nifedipine er tablet............................................. 18
NILANDRON....................................................... 10
nilotinib hydrochloride...................................... 10
nilutamide............................................................ 10
NITRATES........................................................... 20
nitro-bid ointment.............................................. 20
NITRO-DUR 0.3 MG/HR PATCH,
-0.8 MG/HR PATCH..................................... 20
nitrofurantoin capsule......................................... 8
nitrofurantoin macrocrystal................................ 8
nitrofurantoin mono-macro................................ 8
nitrofurantoin suspension................................... 8
nitroglycerin........................................................ 20
nitroglycerin 0.1 mg/hr patch,
-0.2 mg/hr ptch, -0.4 mg/hr ptch,
-0.6 mg/hr patch............................................ 20
nitroglycerin injection, -tablet sublingual..... 20
nitroglycerin spray............................................. 20
NITROSTAT......................................................... 20
nizatidine solution............................................. 30
noble formula hc [OTC].................................... 23
NON-STEROIDAL ANTIINFLAMMATORY
AGENTS.................................................... 36, 37
nora-be................................................................ 48
NORDITROPIN.................................................. 32
NORDITROPIN FLEXPRO.............................. 33
norethindron........................................................ 47
norethindrone..................................................... 48
norethindrone acetate tablet........................... 48
norgestimate-ethinyl estradiol......................... 47
norgestrel-ethiny estra...................................... 47
normal saline flush............................................ 38
NORPACE CR..................................................... 18
nortrel.................................................................... 47
NORTRIPTYLINE................................................. 1
NORVIR.................................................................. 2
novarel................................................................. 49
NOVOLIN 70-30 [OTC].................................... 27
NOVOLIN N [OTC]............................................ 27
NOVOLIN R [OTC]............................................ 27
NOVOLOG 100 UNIT/ML CARTRIDGE,
-FLEXPEN SYRINGE.................................... 27
NOVOLOG 100 UNIT/ML VIAL..................... 27
NOVOLOG MIX 70-30 FLEXPEN SYRN.... 27
NOVOLOG MIX 70-30 VIAL........................... 27
np thyroid -30 mg, -60 mg, -90mg............... 28
nutritional drink [OTC]...................................... 40
nutritional drink plus [OTC]............................. 40
nutritional supplement.............................. 39, 40
nutritional supplement plus [OTC]................. 40
NUTRITIONAL/SUPPLEMENT
PRODUCTS.............................................. 39, 40
NUTRITION, BLOOD MODIFIERS,
ELECTROLYTES. 38, 39, 40, 41, 42, 43, 44
NUTROPIN......................................................... 33
NUTROPIN AQ 5 MG/ML VIAL,
-PEN CARTRIDGE......................................... 33
NUTROPIN AQ NUSPIN 10 PEN CART,
-5 PEN CART................................................. 33
NUVARING.......................................................... 47
nuzole cream [OTC]............................................. 6
nyamyc.................................................................... 6
nystatin................................................................... 6
NYSTATIN 1 BILLION UNIT POWDER,
-10 BILLION UNIT POWDER, -15 BILLION
UNIT POWDER, -2 BILLION UNIT POWDER,
-5 BILLION UNIT POWDER, -50 BILLION
UNIT POWDER,-50 MILLION UNITS
PWDER, -500 MILLION UNITS PWD.......... 6
nystatin 100,000 unit cream, ointment............ 6
nystatin 100,000 unit/gm powd....................... 6
nystatin 150,000,000 units pwd,
-50,000,000 units pwd, -500,000,000
units pwd............................................................ 4
nystatin 500,000 unit oral tab, -suspension
oral....................................................................... 4
nystatin-triamcinolone......................................... 8
nystatin vaginal tablet.......................................... 8
nystop..................................................................... 6
O
OB/GYN TOPICAL ANTIINFECTIVES.......... 48
OBSTETRICAL AND GYNECOLOGICAL
MEDICATIONS................... 45, 46, 47, 48, 49
ocella 3-0.03mg tab.......................................... 47
octreotide 1,000 mcg/ml vial, -acet 100
mcg/ml amp, -acet 100 mcg/ml syr,
-acet 100 mcg/ml vl....................................... 10
ofloxacin drops........................................... 24, 51
OLANZA/FLUOX................................................. 1
71
CAREOREGON (OHP) 2014 FORMULARY
OLANZAPINE..................................................... 10
olmesartan medoxomil/hctz........................... 20
olsalazine............................................................. 31
omalizumab........................................................ 33
omega-3 1,000 mg softgel, -3 1,000 mg
softgel, -oil 1,000 mg softgel [OTC]........... 44
omega-3 1,000 mg softgel [OTC]................. 44
omeprazole......................................................... 32
omeprazole capsule enteric coated.............. 32
OMNITROPE...................................................... 33
ondansetron hcl 24 mg tablet,
-4 mg tablet, -8 mg tablet, -solution........... 12
ondansetron odt................................................. 12
OPHTHALMIC ANTIINFECTIVE/
CORTICOSTEROIDS..................................... 50
OPHTHALMIC CORTICOSTEROID
DRUGS............................................................. 50
OPHTHALMIC MEDICATIONS......... 49, 50, 51
OPHTHALMIC TOPICAL
ANTIBACTERIAL DRUGS..................... 50, 51
OPHTHALMIC TOPICAL
ANTIVIRAL DRUGS....................................... 51
OPTICHAMBER ADVANTAGE INHALER,
-LARGE MASK, -MEDIUM MASK,
-SMALL MASK............................................... 35
OPTICHAMBER DIAMOND VHC,
-LARGE MASK, -MEDIUM MASK,
-SMALL MASK............................................... 35
OPTICHAMBER FACE MASK LARGE,
-MEDIUM, -SMALL........................................ 35
OPTIHALER....................................................... 35
ORAL ANTICOAGULANTS, VITAMIN K...... 40
ORAL ANTIFUNGAL DRUGS........................... 4
ORAL HYPOGLYCEMICS AND
COMBOS......................................................... 27
oral saline laxative [OTC]................................. 30
oralyte [OTC]...................................................... 38
orsythia................................................................. 47
ORTHO ALL-FLEX............................................ 49
ORTHO-DIAPHRAGM..................................... 49
ortho tri-cyclen lo............................................... 47
oscimin ODT, -tablet, -sl tablet, -sr tablet..... 29
oseltamivir phosphate......................................... 5
OTC H2 ANTAGONISTS................................... 31
72
OTEZLA................................................................ 10
OTHER ANTIARRHYTHMICS........................ 20
OTHER ANTICONVULSANTS........................ 15
OTHER ANTIHYPERTENSIVES.................... 20
OTHER ANTIINFECTIVE DRUGS................ 4, 5
OTHER ANTIPARKINSON DRUGS................ 16
OTHER ANTIULCER DRUGS.......................... 31
OTHER CARDIOVASCULAR DRUGS........... 21
OTHER CNS/AUTONOMIC DRUGS.............. 16
OTHER DRUGS FOR ASTHMA..................... 53
OTHER ENDOCRINE DRUGS........................ 27
OTHER GENITOURINARY PRODUCTS...... 54
OTHER GI DRUGS...................................... 31, 32
OTHER MACROLIDES........................................ 5
OTHER MEDICATIONS AFFECTING
COAGULATION.............................................. 40
OTHER MISCELLANEOUS THERAPEUTIC
AGENTS........................................................... 54
OTHER MUSCULOSKELETAL DRUGS....... 37
OTHER OPHTHALMIC DRUGS...................... 51
OTHER RESPIRATORY DRUGS.................... 53
OTHER TOPICAL ANTIFUNGALS................... 6
OTHER VASODILATING DRUGS................... 21
otocidin................................................................. 24
otomycet-hc......................................................... 24
oxandrolone 2.5 mg tablet.............................. 45
oxcarbazepine..................................................... 12
oxybutynin chloride syrup, -tablet.................. 54
oxybutynin er tablet.......................................... 54
oxycodon-acetaminophen 5-325,
-5-500 capsule............................................... 13
oxycodon-acetaminophen 7.5-325................ 13
oxycodone........................................................... 13
oxycodone/acetaminophen............................. 14
oxycodone hcl 10 mg tablet, -15 mg tablet,
-30 mg tablet, -5 mg tablet, - 5mg/5ml
solution, conc. 20mg/ml solution................ 13
oxycodone hcl-acetaminophen....................... 13
oxycodone hct tablet sustained release
12hr.................................................................... 13
OXYCONTIN........................................................ 13
OXYTOCICS....................................................... 48
OXYTROL FOR WOMEN TOPICAL
PATCH OTC..................................................... 54
oyster shell 250 mg + vit d tb, -shell
calcium-vit d tab, -shell calc-vit d tab,
-shell-vit d tab, -shell-vit d tablet [OTC].... 44
oyster shell calcium [OTC].............................. 44
oyster shell calcium-vitamin d [OTC]............ 44
P
pacerone 200 mg tablet................................... 17
palivizumab......................................................... 34
pamprin max [OTC]........................................... 37
PANCREAZE....................................................... 31
PANCRELIPASE 5,000..................................... 31
PANDA MASK [OTC]........................................ 35
pantoprazole sodium 20mg tab..................... 32
pantoprazole sodium 40 mg tab................... 32
paregoric............................................................. 29
PARENTERAL ANTIFUNGALS........................ 6
paricalcitol.......................................................... 42
paromomycin sulfate........................................... 1
PAROXETINE........................................................ 1
pasireotide.......................................................... 28
pb-hyos................................................................ 29
PCE 500 MG DISPERTAB................................. 4
PEAK-AIR [OTC]................................................. 24
PEAK FLOW METER [OTC]............................. 24
pedialyte electrolyte singles [OTC]............... 38
pedialyte [OTC].................................................. 38
pediatric drink [OTC]........................................ 40
pediatric electrolyte [OTC].............................. 38
pediatric freezer pops [OTC]........................... 38
PEDIATRIC PANDA MASK [OTC]................. 35
pedi-dri................................................................... 6
peg-3350 and electrolytes.............................. 31
peg 3350-electrolyte........................................ 31
peg-3350 with flavor packs............................. 31
PEGANONE........................................................ 15
PEGASYS............................................................... 5
pegfilgrastim....................................................... 34
peginterferon alfa-2a........................................... 5
peginterferon alfa-2b........................................... 5
PEGINTRON.......................................................... 5
PEGINTRONREDIPEN........................................ 5
pegvisomant....................................................... 28
penicillin g benzathine........................................ 6
penicillin g sodium............................................... 6
PENICILLINS......................................................... 6
penicillin v potassium.......................................... 6
PENTAM 300........................................................ 5
pentamidine........................................................... 5
PENTASA............................................................ 32
pentosan polysulfate sodium......................... 54
pentoxifylline tablet sustained action............ 21
PEPCID AC......................................................... 30
periogard............................................................. 25
permethrin 1% lotion [OTC]............................ 22
permethrin cream.............................................. 22
PERSONAL BEST [OTC].................................. 24
PERSONAL BEST PEAK
FLOW METER [OTC]...................................... 24
PHARMACEUTICAL NECESSITIES.............. 36
phenadoz suppository rectal........................... 12
phenazopyridine hcl tablet.............................. 54
phenobarbital elixir, -solution, -tablet............. 11
phenylephrine/cyclopentolate......................... 51
phenytoin sodium.............................................. 15
phenytoin sodium extended cap.................... 15
phenytoin sodium injection.............................. 15
phenytoin suspension oral............................... 15
philith 0.4-35 tab................................................ 47
phospha 250 neutral......................................... 41
PHOSPHOLINE IODIDE.................................. 49
phytonadione..................................................... 40
PILL SPLITTER.................................................. 35
pilocarpine hcl................................................... 50
pilocarpine hcl 5 mg tablet............................. 25
pilocarpine hcl drops........................................ 50
PILOPINE HS..................................................... 50
pimtrea.................................................................. 47
pindolol................................................................. 17
pink bismuth caplet [OTC]............................... 29
pioglitazone hcl................................................. 27
pioglitazone hcl/metformin hc....................... 27
piroxicam capsule............................................. 37
PLASMODICIDES................................................ 7
73
CAREOREGON (OHP) 2014 FORMULARY
pneumococcal vaccine.................................... 34
PNEUMOVAX 23.............................................. 34
POCKET CHAMBER........................................ 35
POCKET PEAK [OTC]....................................... 24
podofilox.............................................................. 22
polycin-b.............................................................. 51
polycose liquid................................................... 40
polycose powder............................................... 40
poly-dex............................................................... 50
polyethylene glycol 3350 packet................... 30
polyethylene glycol 3350 powd..................... 30
poly-iron [OTC].................................................. 44
polymyxin b sul-trimethoprim.......................... 51
polysaccharide iron [OTC]............................... 44
poly-vitamin drops [OTC]................................. 44
polyvitamin with iron drops [OTC]................. 44
polyvit-iron-fl 0.25 mg/ml................................ 44
pomalidomide....................................................... 9
POMALYST............................................................ 9
ponatinib................................................................ 9
portia..................................................................... 47
potassium acetate injection............................. 41
potassium acid phosphate.............................. 54
potassium bicarbonate tablet effervescent.. 41
potassium chloride............................................ 41
potassium chloride 10 meq cap er, -10 meq
tab er, -10 meq tab sa, -10% solution,
-2 meq/ml IV sol, -2 meq/ml vial, -20
meq/50ml solution, -20 meq tab er,
-20% solution, -8 meq cap er,
-8 meq tablet er, -8 meq tab sa................... 41
potassium citrate tablet sustained action.... 54
potassium gluconate 2 meq tab, -2.5 meq
tab, -550 mg tab, -595 mg caplet,
-595 mg tab, -95 mg tab, -99 mg tab........ 41
potassium iodide............................................... 52
potassium [OTC]................................................. 41
POTASSIUM REMOVING RESINS................ 40
potassium & sodium phosphates powder.... 41
POTASSIUM SPARING DIURETICS.............. 21
POTASSIUM SUPPLEMENTS......................... 41
PRADAXA.......................................................... 42
pramipexole tablet.............................................. 16
74
pravastatin sodium............................................. 19
praziquantel........................................................... 2
prazosin hcl......................................................... 21
PRED MILD........................................................ 50
prednisolone acetate........................................ 50
prednisolone acetate suspension drops..... 50
prednisolone sodium phosphate drops....... 50
prednisolone sodium phosphate solution... 25
prednisolone solution oral.............................. 25
prednisone solution, -tablet,
-tablet dose pack........................................... 25
pregabalin............................................................ 15
PREMARIN CREAM WITH APPLICATOR... 48
PRENATAL VITAMINS...................................... 48
PREP KIT #3 [OTC]........................................... 31
prevalite................................................................ 19
previfem................................................................ 47
PREVNAR 13..................................................... 34
PREZISTA.............................................................. 2
primaquine............................................................. 7
PRIMAQUINE........................................................ 7
PRIMEAIRE........................................................ 35
primidone............................................................. 11
PROAIR HFA...................................................... 52
probenecid......................................................... 36
probenecid-colchicine..................................... 36
procainamide hcl injection............................... 18
procarbazine......................................................... 9
PROCHAMBER................................................. 35
prochlorperazine maleate suppository
rectal, -tablet.................................................... 12
PROCRIT............................................................. 32
procto-pak........................................................... 32
proctosol-hc....................................................... 32
proctozone-hc.................................................... 32
progesterone...................................................... 48
PROGESTIN DRUGS........................................ 48
PROGLYCEM..................................................... 26
PROLASTIN 500 MG VIAL............................. 53
PROMACTA........................................................ 32
promethazine 6.25 mg/5ml syrup, -tablet... 52
promethazine hcl suppository rectal.............. 12
promethazine inj ampule, syringe, vial.......... 52
promethegan suppository rectal..................... 12
propafenone hcl tablet...................................... 18
propantheline bromide tablet......................... 29
propranolol hcl cap sa, -tablet......................... 17
propranolol-hydrochlorothiazid...................... 20
propranolol soln.................................................. 17
propylthiouracil.................................................. 25
prosource solution [OTC]................................ 38
PROTON PUMP INHIBITORS........................ 32
PROVENTIL HFA.............................................. 52
psyllium fiber [OTC]........................................... 31
psyllium/sucrose............................................... 30
PULMICORT....................................................... 53
PULMOZYME.................................................... 53
pyrantel................................................................... 2
pyrazinamide......................................................... 3
pyrethrin lice treatment [OTC]........................ 22
pyridostigmine..................................................... 16
pyridostigmine bromide.................................... 16
pyrimethamine...................................................... 7
Q
quasense.............................................................. 47
QUETIAPINE....................................................... 11
quinapril hcl......................................................... 17
quinidine gluconate........................................... 18
quinidine sulfate tablet, -tablet sustained
action................................................................. 18
QUINOLONES....................................................... 7
QVAR................................................................... 53
R
rabeprazole 20mg tab...................................... 32
raloxifene............................................................. 49
raltegravir potassium........................................... 2
ramipril capsules................................................ 17
ranitidine 75 mg tablet [OTC].......................... 31
ranitidine 150 mg tablet, -300 mg tablet,
-capsule........................................................... 30
ranitidine hcl syrup........................................... 30
RAPAMUNE 1MG, 2MG................................... 10
REBIF 22 MCG/0.5 ML SYRINGE,
-44 MCG/0.5 ML SYRINGE........................ 34
rebif rebidose..................................................... 34
REBIF TITRATION PACK................................. 34
reclipsen............................................................... 47
RECOMBIVAX HB............................................ 34
REESE PINWORM -CAPLET,
-SUSPENSION.................................................. 2
REGONOL........................................................... 16
REGRANEX........................................................ 23
RELENZA............................................................... 5
remedy antifungal cream [OTC]........................ 6
REMODULIN....................................................... 21
RENAGEL........................................................... 38
renal caps........................................................... 44
renalpren............................................................. 44
rena-vite [OTC]................................................... 44
rena-vite rx.......................................................... 44
reno caps............................................................ 44
re-pb hyos........................................................... 29
RESCRIPTOR........................................................ 2
reserpine.............................................................. 17
RESPIRATORY MEDICATIONS............... 52, 53
RETROVIR INJECTION....................................... 2
REYATAZ................................................................ 2
ribasphere 200mg tablet.................................... 5
ribavirin tablet, capsule....................................... 5
rifabutin................................................................... 3
rifampin 150 mg capsule, -300 mg
capsule................................................................ 3
rifaximin............................................................... 38
rilpirvirine............................................................... 2
riluzole................................................................. 37
rimantadine hcl..................................................... 5
riociguat................................................................ 21
risedronate.......................................................... 27
RISPERDONE..................................................... 11
RITEFLO.............................................................. 35
ritonavir................................................................... 2
ritonavir/lopinavir................................................. 2
rivaroxaban 10mg.............................................. 40
rivaroxaban 15mg, 20mg................................. 40
75
CAREOREGON (OHP) 2014 FORMULARY
rivastigmine......................................................... 11
rizatriptan tablets................................................ 15
ROCEPHIN 1 GM VIAL....................................... 4
romycin................................................................. 51
ropinirole hcl....................................................... 16
roxicet 5-325 tablet........................................... 14
roxicet 5-500 caplet.......................................... 13
ROXICET SOLUTION........................................ 14
S
SABRIL................................................................. 15
SAIZEN................................................................ 33
SALICYLATES AND RELATED DRUGS...... 37
saline flush.......................................................... 38
salmeterol........................................................... 52
salmeterol/fluticasone..................................... 53
salsalate tablet................................................... 37
sapropterin dihydrochloride............................ 28
saquinavir mesylate............................................. 2
SCABICIDES...................................................... 22
secura antifungal [OTC]...................................... 6
sedative/hypnotic DRUGS............................... 16
SELECTIVE ESTROGEN RECEPTOR
MODULATOR................................................. 49
SELECTIVE SEROTONIN REUPTAKE
INHIBITORS....................................................... 1
selegiline hcl capsule, -tablet.......................... 16
SELZENTRY.......................................................... 3
senna-docusate sodium [OTC]....................... 31
senna laxative [OTC].......................................... 31
SENSIPAR.......................................................... 28
SEREVENT DISKUS......................................... 52
SEROQUEL XR.................................................. 11
SERTRALINE........................................................ 1
sevelamer............................................................ 38
sevelamer carbonate........................................ 38
sf 39
sf 5000 plus....................................................... 39
SIGNIFOR........................................................... 28
sildenafil citrate................................................... 21
silver sulfadiazine................................................. 7
simvastatin........................................................... 19
sinecatechins..................................................... 23
76
sirolimus............................................................... 10
sirolimus 0.5mg.................................................. 10
slo-niacin 500 mg tablet [OTC]...................... 19
slow release iron [OTC]................................... 44
SMOKING CESSATION PRODUCTS............. 16
sodium bicarbonate.......................................... 38
sodium bicarbonate 4.2% abboject, -4.2%
syringe, -4.2% vial, -5% inj, -7.5%
abboject, -7.5% vial, -8.4% abboject,
-8.4% vial......................................................... 38
sodium chloride................................................. 53
sodium chloride 0.9% irrig, -solution,
-syringe, -vial................................................... 38
sodium chloride 0.9% vial, -3% vial............. 53
sodium citrate & citric acid.............................. 41
sodium fluoride.................................................. 39
sodium fluoride drops, -tablet chewable..... 39
sodium polystyrene sulfonate........................ 40
sofosubuvir............................................................ 5
solia....................................................................... 47
somatropin................................................... 32, 33
SOMAVERT........................................................ 28
soothe caplet [OTC].......................................... 29
sorafenib tosylate............................................... 10
SORBITOL SOLUTION [OTC]......................... 32
sorine................................................................... 20
sotalol.................................................................. 20
sotalol af.............................................................. 20
SOVALDI................................................................ 5
SPECIALIZED OB/GYN DRUGS................... 49
SPIRIVA............................................................... 53
spironolactone-hctz........................................... 21
spironolactone tablet......................................... 21
SPORANOX SOLUTION.................................... 4
sprintec................................................................. 47
SPRYCEL............................................................. 10
sps........................................................................ 40
sronyx.................................................................... 47
ssd........................................................................... 7
ssd af...................................................................... 7
SSKI..................................................................... 52
stagesic................................................................ 14
stavudine................................................................ 3
stomach relief caplet [OTC]............................ 29
STRIBILD............................................................... 3
STROMECTOL...................................................... 2
SUCCINIMIDES.................................................. 16
sucralfate.............................................................. 31
sucralfate tablet.................................................. 31
sulfacetamide-prednisolone........................... 50
sulfacetamide/prednisolone ac..................... 50
sulfacetamide sodium drops, -ointment........ 51
sulfadiazine tablet................................................ 7
sulfamethoxazole-trimethoprim suspension
oral, -tablet.......................................................... 7
sulfamide.............................................................. 51
sulfanilamide...................................................... 48
sulfasalazine dr.................................................. 32
sulfasalazine tablet........................................... 32
sulfazine.............................................................. 32
sulfazine ec........................................................ 32
SULFONAMIDES................................................. 7
SULFONES............................................................ 7
sulindac tablet................................................... 37
sumatriptan.......................................................... 15
SUMATRIPTAN NASAL.................................... 15
sumatriptan succinate....................................... 15
sunitinib malate.................................................. 10
superplex-t [OTC].............................................. 44
SUSTIVA................................................................. 3
SUTENT............................................................... 10
syeda..................................................................... 47
symax................................................................... 29
symax-sl.............................................................. 29
symax-sr.............................................................. 29
SYNAGIS............................................................. 34
SYNTHROID....................................................... 28
syrex..................................................................... 38
T
TABLET CUTTER [OTC].................................. 35
TABLOID.............................................................. 10
tacrolimus capsule............................................. 10
tadalafil................................................................. 21
TAMIFLU................................................................ 5
TAMIFLU 6MG/ML SUSPENSION.................. 5
tamoxifen citrate tablet...................................... 10
tamsulosin.......................................................... 54
TANZEUM........................................................... 26
TARCEVA............................................................. 10
taron-crystals..................................................... 54
TASIGNA 200 MG CAPSULE......................... 10
TASMAR............................................................... 16
taztia xt................................................................. 18
tbo-filgrastim...................................................... 34
TECFIDERA......................................................... 15
TEGRETOL XR 100 MG TABLET................... 12
telbivudine............................................................. 5
TEMODAR CAPSULE....................................... 10
temozolomide...................................................... 10
tenofovir disproxil fumarate................................ 3
terazosin hcl........................................................ 21
terbinafine hcl....................................................... 4
terbutaline sulfate tablet.................................. 52
teriflunomide....................................................... 15
testosterone........................................................ 45
testosterone cypionate injection.................... 45
testosterone enanthate.................................... 45
testosterone propionate................................... 45
testosterone proprionate................................. 45
tetracycline hcl capsule...................................... 7
TETRACYCLINES................................................ 7
TEV-TROPIN....................................................... 33
THEO-24 ER 200 MG CAPSULE................. 53
theochron............................................................ 53
theophylline........................................................ 53
theophylline anhydrous tablet
sustained release 12hr................................. 53
theophylline tablet sustained action............. 53
THERAPEUTIC VITAMINS AND
MINERALS................................................ 41, 42
thermazene............................................................ 7
thiamine 100 mg tablet, -50 mg
tablet [OTC]..................................................... 44
THIAZIDE AND RELATED DRUGS............... 21
thioguanine.......................................................... 10
thrive nicotine [OTC].......................................... 16
THROMBIN INHIBITORS................................ 42
thyroid.................................................................. 28
77
CAREOREGON (OHP) 2014 FORMULARY
THYROID SUPPLEMENTS............................. 28
THYROLAR........................................................ 28
tiagabine............................................................... 15
ticlopidine hcl..................................................... 38
TIKOSYN............................................................. 20
tilia fe..................................................................... 47
timolol maleate drops, -gel-forming
solution............................................................. 50
tiotropium bromide............................................ 53
tipranavir................................................................. 2
TIVICAY.................................................................. 3
tizanidine hcl...................................................... 36
TOBRADEX OINTMENT.................................. 50
tobramycin 40 mg/ml syringe,
-40 mg/ml vial................................................... 2
tobramycin-dexamethasone........................... 50
tobramycin inhalation powder........................... 2
tobramycin nebulized solution
300mg/5ml........................................................ 2
tobramycin sulfate/dexameth......................... 50
tobramycin sulfate drops.................................. 51
tocilizumbab.......................................................... 8
tolazamide.......................................................... 27
tolbutamide......................................................... 27
tolcapone............................................................. 16
tolterodine tartrate tablet................................. 54
TOPICAL ANESTHETICS................................... 1
TOPICAL ANTIBACTERIAL DRUGS................ 7
TOPICAL ANTIFUNGAL-CORTICOSTEROID
COMB.................................................................. 8
TOPICAL CORTICOSTEROID
DRUGS...................................................... 22, 23
TOPICAL DERMATOLOGICAL DRUGS....... 23
topiragen.............................................................. 15
topiramate capsule sprinkle, -tablet............... 15
toremifene.............................................................. 9
torsemide tablet.................................................. 19
TRACLEER.......................................................... 19
tramadol-acetaminophen................................. 11
tramadol hcl tablet............................................. 11
travoprost 0.004% drops................................ 50
treprostinil sodium............................................. 21
tretinoin capsule................................................. 10
78
triamcinolone -0.025% cream,
-0.025% oint, -0.1% cream, -0.1% ointment,
-0.5% ointment, -0.5% cream..................... 23
triamcinolone 0.025% cream, -0.025%
oint, -0.1% cream, -0.1% ointment,
-0.5% ointment, -0.5% cream..................... 23
triamterene........................................................... 21
triamterene-hctz................................................. 21
tri-biozene [OTC].................................................. 7
TRICHOMONOCIDES......................................... 8
triderm.................................................................. 23
trifluridine............................................................. 51
trihexyphenidyl hcl............................................. 12
tri-legest fe........................................................... 47
TRILEPTAL SUSPENSION............................... 12
trimethoprim tablet............................................... 8
trinessa................................................................. 47
TRIPEDIA............................................................ 34
triple antibiotic [OTC]........................................... 7
tri-previfem........................................................... 47
tri-sprintec............................................................ 47
TRIUMEQ............................................................... 3
TRI-VI-SOL WITH IRON [OTC]....................... 44
tri-vitamin [OTC]................................................. 44
trivora-28.............................................................. 47
tropicamide.......................................................... 51
TRUVADA.............................................................. 3
TRUZONE PEAK FLOW METER.................... 24
TRYCYCLICS......................................................... 1
TYBOST................................................................. 3
TYKERB............................................................... 10
TYZEKA................................................................. 5
U
ultilet tablet chewable [OTC].......................... 26
ULTRA FINE CUT N CRUSH [OTC].............. 36
umeclidinium bromide/vilanterol) INH......... 53
unithroid.............................................................. 28
URINARY ANESTHETICS............................... 54
URINARY ANTIINFECTIVES.............................. 8
UROLOGICAL MEDICATIONS....................... 54
ursodiol capsule................................................ 32
V
VAGIFEM............................................................. 48
VAGINAL ANTIFUNGALS.................................. 8
valacyclovir............................................................ 5
VALCYTE............................................................... 5
valganciclovir........................................................ 5
vancomycin 1 gm add-van vial, -1 gm vial,
-500 mg a/v vial, -500 mg vial...................... 5
vancomycin capsule............................................ 5
vandazole............................................................ 48
VAQTA.................................................................. 34
varenicline tartrate............................................. 16
varicella vacc/pf................................................ 34
varicella virus vaccine live............................... 34
VARIVAX VACCINE........................................... 34
VASODILATOR ANTIHYPERTENSIVES....... 21
vcf contraceptive foam [OTC]......................... 49
veletri..................................................................... 21
velivet.................................................................... 47
VENTAVIS 10 MCG/1 ML SOLUTION.......... 21
VENTOLIN HFA................................................. 52
verapamil er -capsule, -capsule pellet,
-tablet................................................................. 18
verapamil er pm.................................................. 18
verapamil hcl injection, -tablet......................... 18
VEREGEN........................................................... 23
vestura tab........................................................... 47
VIBRAMYCIN SYRUP......................................... 7
VICTOZA............................................................. 26
VIDEX..................................................................... 3
vigabatrin............................................................. 15
VIMPAT SOLUTION, -TABLET......................... 15
viorele................................................................... 47
VIRACEPT.............................................................. 3
VIRAMUNE XR..................................................... 3
VIREAD 40MG POWDER.................................. 3
VIREAD 150MG TABLET................................... 3
VIREAD 200MG, 250MG, 300MG
TABLET............................................................... 3
vitamin b-1 100 mg tab, -100 mg tablet,
-50 mg tablet [OTC]...................................... 44
vitamin b-12 1,000 mcg tab sl, -tablet,
-tablet sustained action [OTC].................... 44
vitamin b-complex & c caplet, -potency
b-comp-c caplet, -w-vitamin c caplet,
-w-vitamin c tablet [OTC]............................. 44
vitamin d 1,000 unit sftgl, -1,000 unit tab,
-1,000 unit tablet, -3 1,000 unit tab,
-3 1,000 unit tablet, -400 unit softgel,
-400 unit tablet, -capsule, -drops [OTC]... 42
vitamin d2 capsule........................................... 42
vitamin d2 tablet [OTC].................................... 42
VITAMIN D3 1,000 UNIT TAB CHEW
[OTC]................................................................. 42
vitamin d3 capsule, -d3 1,000 unit tab
chew, -tablet [OTC]........................................ 42
vitamins a, c, d w/iron...................................... 44
VITAMINS AND MINERALS AND
RELATED PRODUCTS................... 42, 43, 44
voriconazole.......................................................... 4
vorinostat.............................................................. 10
VORTEX.............................................................. 36
vyfemla 0.4-35 tab............................................. 47
VYTORIN.............................................................. 19
W
warfarin sodium................................................. 40
WATCHHALER.................................................. 36
WIDE SEAL DIAPHRAGM.............................. 49
wymzya fe chw................................................... 47
X
XALKORI.............................................................. 10
XARELTO 10MG............................................... 40
XARELTO 15MG, 20MG.................................. 40
xifaxan.................................................................. 38
XOLAIR............................................................... 33
XOPENEX HFA................................................. 52
xulane (generic Ortho Evra)............................. 47
Y
YODOXIN............................................................... 1
79
CAREOREGON (OHP) 2014 FORMULARY
Z
zafirlukast............................................................ 52
zanamivir................................................................ 5
zarah..................................................................... 47
zenchent fe chw................................................. 47
zenchent tab........................................................ 47
ZENPEP.............................................................. 32
zeosa..................................................................... 47
ZETIA.................................................................... 19
ZIAGEN................................................................... 3
zidovudine........................................................ 2, 3
ZIRGAN................................................................ 51
ZOLINZA.............................................................. 10
zolmatriptan tablets........................................... 15
zolpidem tartrate................................................. 16
zonisamide.......................................................... 15
ZORBTIVE........................................................... 33
ZORTRESS.......................................................... 10
ZOSTAVAX.......................................................... 34
zostrix diabetic [OTC]....................................... 23
zostrix [OTC]....................................................... 23
zovia...................................................................... 47
ZYKADIA............................................................. 10
ZYVOX.................................................................... 5
80
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