1. health and fitness
2. drugs

Geisinger Gold Standard Rx
2015 Comprehensive Formulary
(List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION
ABOUT SOME OF THE DRUGS WE COVER IN THIS PLAN
This formulary was updated on 02/25/2015. For more recent information or other questions, please contact
Geisinger Gold Member Services at (800) 988-4861 or, for TTY/TDD users, 711 or (800) 654-5984, 8 a.m. to 8
p.m. (7 days a week, Oct. – Feb.) or 8 a.m. to 8 p.m. (Mon. – Fri., March – Sept), or visit
www.thehealthplan.com/Gold/Landing_Pages/Formulary/
Formulary ID: 15222, Version: 9
H3954_14210_2 File and Use 8/3/14
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Note to existing members: This formulary has changed since last year. Please review this document to make
sure that it still contains the drugs you take.
When this drug list (formulary) refers to “we,” “us”, or “our,” it means Geisinger Gold. When it refers to “plan”
or “our plan,” it means Geisinger Gold Standard Rx.
This document includes a list of the drugs (formulary) for our plan which is current as of March 1, 2015. For an
updated formulary, please contact us. Our contact information, along with the date we last updated the
formulary, appears on the front and back cover pages.
You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary,
pharmacy network, and/or copayments/coinsurance may change on January 1, 2015, and from time to time
during the year.
What is the Geisinger Gold Standard Rx Formulary?
A formulary is a list of covered drugs selected by Geisinger Gold Standard Rx in consultation with a team of
health care providers, which represents the prescription therapies believed to be a necessary part of a quality
treatment program. Geisinger Gold Standard Rx will generally cover the drugs listed in our formulary as long
as the drug is medically necessary, the prescription is filled at a Geisinger Gold Standard Rx network pharmacy,
and other plan rules are followed. For more information on how to fill your prescriptions, please review your
Evidence of Coverage.
Can the Formulary (drug list) change?
Generally, if you are taking a drug on our 2015 formulary that was covered at the beginning of the year, we will
not discontinue or reduce coverage of the drug during the 2015 coverage year except when a new, less
expensive generic drug becomes available or when new adverse information about the safety or effectiveness of
a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not
affect members who are currently taking the drug. It will remain available at the same cost-sharing for those
members taking it for the remainder of the coverage year. We feel it is important that you have continued
access for the remainder of the coverage year to the formulary drugs that were available when you chose our
plan, except for cases in which you can save additional money or we can ensure your safety.
If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy
restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the
change at least 60 days before the change becomes effective, or at the time the member requests a refill of the
drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration
deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we
will immediately remove the drug from our formulary and provide notice to members who take the drug. The
enclosed formulary is current as of March 1, 2015. To get updated information about the drugs covered by
Geisinger Gold Standard Rx, please contact us. Our contact information appears on the front and back cover
pages. If non-maintenance changes are made to the formulary during the plan year, Geisinger Gold Standard
Rx communicates changes to the formulary in the member newsletter and on the monthly explanation of
benefits (EOB).
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How do I use the Formulary?
There are two ways to find your drug within the formulary:
Medical Condition
The formulary begins on page 14. The drugs in this formulary are grouped into categories depending on the
type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are
listed under the category, “Cardiovascular Agents”. If you know what your drug is used for, look for the
category name in the list that begins on page 14. Then look under the category name for your drug.
Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in the Index that begins on
page I-1. The Index provides an alphabetical list of all of the drugs included in this document. Both brand
name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your
drug, you will see the page number where you can find coverage information. Turn to the page listed in the
Index and find the name of your drug in the first column of the list.
What are generic drugs?
Geisinger Gold Standard Rx covers both brand name drugs and generic drugs. A generic drug is approved
by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less
than brand name drugs.
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits
may include:
•
Prior Authorization: Geisinger Gold Standard Rx requires you or your physician to get prior
authorization for certain drugs. This means that you will need to get approval from Geisinger Gold
Standard Rx before you fill your prescriptions. If you don’t get approval, Geisinger Gold Standard Rx
may not cover the drug.
•
Quantity Limits: For certain drugs, Geisinger Gold Standard Rx limits the amount of the drug that
Geisinger Gold Standard Rx will cover. For example, Geisinger Gold Standard Rx provides 16 tablets
per prescription for sumatriptan. This may be in addition to a standard one-month or three-month
supply.
•
Step Therapy: In some cases, Geisinger Gold Standard Rx requires you to first try certain drugs to treat
your medical condition before we will cover another drug for that condition. For example, if Drug A
and Drug B both treat your medical condition, Geisinger Gold Standard Rx may not cover Drug B
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unless you try Drug A first. If Drug A does not work for you, Geisinger Gold Standard Rx will then
cover Drug B.
You can find out if your drug has any additional requirements or limits by looking in the formulary that begins
on page 14. You can also get more information about the restrictions applied to specific covered drugs by
visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy
restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last
updated the formulary, appears on the front and back cover pages.
You can ask Geisinger Gold Standard Rx to make an exception to these restrictions or limits or for a list of
other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the
Geisinger Gold Standard Rx formulary?” on page 5 for information about how to request an exception.
What if my drug is not on the Formulary?
If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services
and ask if your drug is covered.
If you learn that Geisinger Gold Standard Rx does not cover your drug, you have two options:
•
You can ask Member Services for a list of similar drugs that are covered by Geisinger Gold Standard
Rx. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that
is covered by Geisinger Gold Standard Rx.
•
You can ask Geisinger Gold Standard Rx to make an exception and cover your drug. See below for
information about how to request an exception.
How do I request an exception to the Geisinger Gold Standard Rx Formulary?
You can ask Geisinger Gold Standard Rx to make an exception to our coverage rules. There are several types
of exceptions that you can ask us to make.
•
You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered
at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a
lower cost-sharing level.
•
You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs,
Geisinger Gold Standard Rx limits the amount of the drug that we will cover. If your drug has a
quantity limit, you can ask us to waive the limit and cover a greater amount.
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Generally, Geisinger Gold Standard Rx will only approve your request for an exception if the alternative drugs
included on the plan’s formulary, or additional utilization restrictions would not be as effective in treating your
condition and/or would cause you to have adverse medical effects.
You should contact us to ask us for an initial coverage decision for a formulary, or utilization restriction
exception. When you request a formulary, or utilization restriction exception you should submit a
statement from your prescriber or physician supporting your request. Generally, we must make our
decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast)
exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for
a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we
get a supporting statement from your doctor or other prescriber.
What do I do before I can talk to my doctor about changing my drugs or requesting an
exception?
As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may
be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior
authorization from us before you can fill your prescription. You should talk to your doctor to decide if you
should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the
drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your
drug in certain cases during the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a
temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network
pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of
the plan less than 90 days.
If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have
provided you with a 93-day transition supply, consistent with dispensing increment, (unless you have a
prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you
are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is
limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply
of that drug (unless you have a prescription for fewer days), while you pursue a formulary exception.
For members who experience a level of care change such as changing from one treatment setting to another
(e.g. hospital to long-term care facility), being admitted to or discharged from a long-term care facility, or
reverting from hospice status back to standard Medicare Part A and B benefits, an exception for a one-time
temporary fill will be granted even if the member is past the first 90 days of membership in our plan. Early
refill edits will not be applied when a level of care change exists.
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For more information
For more detailed information about your Geisinger Gold Standard Rx prescription drug coverage, please
review your Evidence of Coverage and other plan materials.
If you have questions about Geisinger Gold Standard Rx, please contact us. Our contact information, along with
the date we last updated the formulary, appears on the front and back cover pages.
If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or,
visit http://www.medicare.gov.
Geisinger Gold Standard Rx Formulary
The formulary that begins on page 14 provides coverage information about the drugs covered by Geisinger
Gold Standard Rx. If you have trouble finding your drug in the list, turn to the Index that begins on page I-1.
The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., ADVAIR DISKUS)
and generic drugs are listed in lower-case italics (e.g., simvastatin).
The information in the Requirements/Limits column tells you if Geisinger Gold Standard Rx has any special
requirements for coverage of your drug.
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The following Utilization Management abbreviations may be found within the body of this document
COVERAGE NOTES ABBREVIATIONS
ABBREVIATION
DESCRIPTION
EXPLANATION
General
generic (BRAND)
The reference brand name in parenthesis is provided for
information only to assist in identifying the generic
medication and does NOT indicate formulary status or
coverage.
Utilization Management Restrictions
PA
Prior Authorization
Restriction
You (or your physician) are required to get prior
authorization from Geisinger Gold Standard Rx before you
fill your prescription for this drug. Without prior approval,
Geisinger Gold Standard Rx may not cover this drug.
PA BvD
Prior Authorization
Restriction
for
Part B vs Part D
Determination
This drug may be eligible for payment under Medicare Part
B or Part D. You (or your physician) are required to get
prior authorization from Geisinger Gold Standard Rx to
determine that this drug is covered under Medicare Part D
before you fill your prescription for this drug. Without
prior approval, Geisinger Gold Standard Rx may not cover
this drug.
Prior Authorization
Restriction for
High Risk Medications
This drug has been deemed by CMS to be potentially
harmful and therefore, a High Risk Medication for
Medicare beneficiaries 65 years or older. Members age 65
yrs or older are required to get prior authorization from
Geisinger Gold Standard Rx before you fill your
prescription for this drug. Without prior approval,
Geisinger Gold Standard Rx may not cover this drug.
PA NSO
Prior Authorization
Restriction for
New Starts Only
If you are a new member or if you have not taken this drug
previously, you (or your physician) are required to get
prior authorization from Geisinger Gold Standard Rx
before you fill your prescription for this drug. Without
prior approval, Geisinger Gold Standard Rx may not cover
this drug.
QL
Quantity Limit
Restriction
Geisinger Gold Standard Rx limits the amount of this drug
that is covered per prescription, or within a specific time
frame.
Step Therapy Restriction
Before Geisinger Gold Standard Rx will provide coverage
for this drug, you must first try another drug(s) to treat
your medical condition. This drug may only be covered if
the other drug(s) does not work for you.
PA-HRM
ST
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The following additional coverage note abbreviations may be found within the body of this document
OTHER SPECIAL REQUIREMENTS FOR COVERAGE
ABBREVIATION
LA
NM
DESCRIPTION
EXPLANATION
Limited Access Drug
This prescription may be available only at certain
pharmacies. For more information consult your
Pharmacy Directory or call Member Services at at
(800) 988-4861, 8 a.m. to 8 p.m. (7 days a week,
Oct. – Feb.) or 8 a.m. to 8 p.m. (Mon. – Fri., March
– Sept). TTY/TDD users should call 711 or (800)
654-5984.
Non-Mail Order Drug
You may be able to receive greater than a 1-month
supply of most of the drugs on your formulary via
mail order at a reduced cost share. Drugs not
available via your mail order benefit are noted with
“NM” in the Requirements/Limits column of your
formulary.
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STRENGTH AND DOSAGE FORM ABBREVIATIONS
ABBREVIATION
adh. patch
aer br act
aer pow
aer pow ba
aer refill
aer w/adap
ampul
blkbaginj
cap dr mp
cap ds pk
cap er 12h
cap er 24h
cap er deg
cap er pel
cap mphase
cap.sa 24h
cap.sr 12h
cap.sr 24h
cap24h pct
cap24h pel
cap sprink
cap sr pel
cap w/dev
capsule dr
capsule er
capsule sa
cmb cappad
cmb ont fm
cmb ont lt
cmb tabpad
combo. pkg
cpmp 12hr
cpmp 24hr
cpmp 30-70
cpmp 50-50
cream(g), cream(gm)
cream(ml)
cream/appl
cream, er (g)
cream pack
dehp fr bg
DESCRIPTION
adhesive patch
aerosol, breath activated
aerosol, powder
aerosol powder, breath activated
aerosol refill
aerosol with adapter
ampule
bulk bag injection
capsule, delayed release multiphasic
capsule, dose pack
capsule, 12 hour extended release
capsule, 24 hour extended release
capsule, extended release degradable
capsule, extended release pellets
capsule, multiphasic
capsule, 24 hour sustained action
capsule, 12 hour sustained release
capsule, 24 hour sustained release
capsule, 24 hour controlled-onset pellets
capsule, 24 hour sustained release pellets
capsule, sprinkle
capsule sustained release pellets
capsule with device
capsule, delayed release
capsule, extended release
capsule, sustained action
combination: capsule, pad
combination: ointment, foam
combination: ointment, lotion
combination: tablet, pad
combination package
capsule, 12 hour multiphasic
capsule, 24 hour multiphasic
capsule, multiphasic, 30%-70%
capsule, multiphasic, 50%-50%
cream (grams)
cream (milliliters)
cream with applicator
cream, extended release (grams)
cream, package
di(2-ethylhexyl)phthalate free bag
9
ABBREVIATION
dis needle
disk w/dev
disp syrin
drops susp
drps hpvis
emul adhes
emul packt
emulsn(g)
foam/appl.
froz.piggy
g
gel/pf app
gel (gm)
gel (ml)
gel md pmp
gel w/appl
gel w/pump
gran pack
hfa aer ad
infus. btl
insuln pen
ip soln
irrig soln
iv soln.
jel
jelly/app
jel/pf app
kit cl&crm
kt crm le
kt lotn ce
kt oint le
lotion, er
lozenge hd
m.ht patch
ma buc tab
mcg
med. pad
med. swab
med. tape
mg
ml
muc er 12h
ndl fr inj
DESCRIPTION
disposable needle
disk with inhalation device
disposable syringe
drops, suspension
drops, hyperviscous
emulsion adhesive
emulsion packet
emulsion (grams)
foam with applicator
frozen piggyback
gram
gel with prefilled applicator
gel (grams)
gel (milliliters)
gel in metered dose pump
gel with applicator
gel with pump
granule pack
hfa aerosol adapter
infusion bottle
insulin pen
intraperitoneal solution
irrigating solution
intravenous solution
jelly
jelly with applicator
jelly with pre-filled applicator
kit: cleanser and cream
kit: cream, lotion emollient
kit: lotion, cream emollient
kit: ointment, lotion emollient
lotion, extended release
lozenge handle
medicated heated patch
mucoadhesive buccal tablet
microgram
medicated pad
medicated swab
medicated tape
milligram
milliliter
mucoadhesive system, 12 hour extended release
needle for injection
10
ABBREVIATION
nl fm susp
oint. (g), oint.(gm)
oral conc
oral susp
paste (g)
patch td24
patch td72
patch tdsw
patch tdwk
pca syring
pca vial
pellet(ea)
pen ij kit
pen injctr
pggybk btl
plast. bag
powd pack
sol md pmp
sol w/appl
sol/pf app
sol-gel
soln recon
soln(gram)
spray susp
spray/pump
stick(ea)
supp.rect
supp.vag
suppos.
sus er 24h
sus er rec
sus mc rec
suspdr pkt
susp recon
syringekit
tab chew
tab er 12h
tab er 24h
tab er prt
tab er seq
tab disper
tab ds pk
tab er 24
DESCRIPTION
nail film suspension
ointment (grams)
oral concentrate
oral suspension
paste (grams)
patch, 24 hour transdermal
patch, 72 hour transdermal
patch, biweekly transdermal
patch, weekly transdermal
patient-controlled analgesic syringe
patient-controlled analgesic vial
pellet (each)
pen injector kit
pen injector
piggyback bottle
plastic bag
powder pack
solution with multi-dose pump
solution with applicator
solution with pre-filled applicator
solution, gel-forming
solution, reconstituted
solution (grams)
spray, suspension
spray with pump
stick (each)
suppository, rectal
suppository, vaginal
suppository
suspension, 24 hour extended release
suspension, extended release reconstituted
suspension, microcapsule reconstituted
suspension, delayed release packet
suspension, reconstituted
syringe kit
tablet, chewable
tablet, 12 hour extended release
tablet, 24 hour extended release
tablet, extended release particles
tablet, extended release sequels
tablet, dispersible
tablet, dose pack
tablet, 24 hour extended release
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ABBREVIATION
tab mphase
tab part
tab rap dr
tab rapdis
tab subl
tab.sr 12h
tab.sr 24h
tabergr24hr
tablet dr
tablet, er
tablet eff
tablet sa
tablet sol
tb er dspk
tb mp dspk
tb rd dspk
tbdspk 3mo
tbmp 12hr
tbmp 24hr
u
vag ring
DESCRIPTION
tablet, multiphasic
tablet, particles
tablet, rapid disintegrating delayed release
tablet, rapid disintegrating
tablet, sublingual
tablet, 12 hour sustained release
tablet, 24 hour sustained release
tablet, 24 hour gradual extended release
tablet, delayed release
tablet, extended release
tablet, effervescent
tablet, sustained action
tablet, soluble
tablet, extended release dose pack
tablet, multiphasic dose pack
tablet, rapid disintegrating dose pack
tablet, 3-month dose pack
tablet, 12 hour multiphasic
tablet, 24 hour multiphasic
unit
vaginal ring
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Every medication on the Geisinger Gold Standard RX formulary is in a single cost-sharing tier, which is
associated with a 25 % coinsurance. Please note: what you pay for your medication depends on which “drug
payment stage” you are in when you get the medication, where you get the medication filled, and if you qualify
for any additional payment assistance.
If you are a member of an employer group, these prices may not apply to you. Please
refer to your benefit documents for appropriate cost sharing amounts.
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Drug Name
Drug Tier
Requirements/Limits
Analgesics
Analgesics, Miscellaneous
acetaminophen with codeine solution
(Acetaminophen with
Codeine)
acetaminophen with codeine tablet: 300mg- (Vopac)
60mg
acetaminophen with codeine tablet: 300mg- (Vopac)
30mg
acetaminophen with codeine tablet: 300mg- (Vopac)
15mg
(Buprenorphine HCl)
buprenorphine hcl
(Butorphanol Tartrate)
butorphanol tartrate
BUTRANS
DURAMORPH
(Actiq)
fentanyl citrate
fentanyl patch td72: 12mcg/hr, 25mcg/hr,
50mcg/hr
fentanyl patch td72: 75mcg/hr, 100mcg/hr
hydrocodone/acetaminophen solution
hydrocodone/acetaminophen tablet: 5mg325mg, 7.5-325mg, 10mg-325mg
hydrocodone/acetaminophen tablet: 5mg300mg, 7.5-300mg, 10mg-300mg
hydrocodone/ibuprofen
hydromorphone hcl tablet
hydromorphone hcl/pf
ibuprofen/oxycodone hcl
levorphanol tartrate
methadone hcl solution
methadone hcl vial
methadone hcl tablet
morphine sulfate cap er pel: 20mg, 60mg,
80mg
morphine sulfate cap er pel: 30mg, 50mg,
100mg
morphine sulfate syringe
1
QL: 5000 in 30 days
1
QL: 180 in 30 days
1
QL: 360 in 30 days
1
QL: 390 in 30 days
1
1
1
1
1
NM (oral products only)
PA, QL: 4 in 28 days
(Duragesic)
1
NM, PA, QL: 120 in 30
days
NM, QL: 10 in 30 days
(Duragesic)
(Hycet)
(Norco)
1
1
1
NM, QL: 20 in 30 days
QL: 2700 in 30 days
QL: 360 in 30 days
(Norco)
1
QL: 390 in 30 days
(Ibudone)
(Dilaudid)
(Hydromorphone HCl/
PF)
(Combunox)
(Levo-dromoran)
(Methadone HCl)
1
1
1
QL: 150 in 30 days
NM, QL: 240 in 30 days
1
1
1
(Methadone HCl)
(Methadose)
(Kadian)
1
1
1
NM, QL: 28 in 30 days
NM, QL: 180 in 30 days
NM, QL: 1800 in 30
days
NM
NM, QL: 360 in 30 days
NM, QL: 120 in 30 days
(Kadian)
1
NM, QL: 90 in 30 days
(Morphine Sulfate)
1
QL: 300 in 30 days
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
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Geisinger Gold Standard Rx 2015 Part D Formulary
Formulary ID: 15222.000, Version: 9
Effective: March 01, 2015
Drug Name
morphine sulfate solution: 20mg/5ml
morphine sulfate solution: 10mg/5ml
nalbuphine hcl
oxycodone hcl/acetaminophen tablet
oxycodone hcl/acetaminophen solution
(MSIR)
(MSIR)
(Nalbuphine HCl)
(Alcet)
(Oxycodone HCl/
acetaminophen)
(Endodan)
oxycodone hcl/aspirin
oxymorphone hcl tablet
(Opana)
(Asp)
sal-amide/acetaminophn/p-tlox
tramadol hcl tab er 24h: 200mg
(Ultram ER)
tramadol hcl tab er 24h: 100mg
(Ultram ER)
tramadol hcl tablet
(Ultram)
(Ultracet)
tramadol hcl/acetaminophen
Nonsteroidal Anti-inflammatory Agents
CELEBREX
(Cataflam)
diclofenac potassium
diclofenac sodium tablet dr
(Voltaren)
diclofenac sodium tablet dr
(Voltaren)
(Diflunisal)
diflunisal
(Etodolac)
etodolac
(Fenoprofen Calcium)
fenoprofen calcium
(Ansaid)
flurbiprofen
(Motrin)
ibuprofen
(Ketoprofen)
ketoprofen
(Meclofenamate
meclofenamate sodium
Sodium)
(Ponstel)
mefenamic acid
(Mobic)
meloxicam
(Relafen)
nabumetone
(Anaprox)
naproxen sodium
(Naprosyn)
naproxen
(Phenylbutazone)
phenylbutazone
(Feldene)
piroxicam
SOLARAZE
(Clinoril)
sulindac
(Tolmetin Sodium)
tolmetin sodium
Drug Tier
Requirements/Limits
1
1
1
1
1
NM, QL: 300 in 30 days
NM, QL: 700 in 30 days
NM
NM, QL: 360 in 30 days
NM, QL: 1830 in 30
days
NM, QL: 360 in 30 days
NM, QL: 180 in 30 days
QL: 390 in 30 days
QL: 30 in 30 days
QL: 90 in 30 days
QL: 240 in 30 days
QL: 240 in 30 days
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
(oral products only)
(oral products only)
Anesthetics
Local Anesthetics
lidocaine hcl disp syrin
(Lidocaine HCl)
1
NM
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
15
Geisinger Gold Standard Rx 2015 Part D Formulary
Formulary ID: 15222.000, Version: 9
Effective: March 01, 2015
Drug Name
Drug Tier
lidocaine hcl jel (ml), jel/pf app, solution
lidocaine hcl/pf syringe
lidocaine hcl/pf vial: 5mg/ml
(Xylocaine)
(Lidocaine HCl/PF)
(Xylocaine-MPF)
1
1
1
lidocaine
(Lidocaine)
1
lidocaine/prilocaine cream (g)
(EMLA)
1
Requirements/Limits
NM
NM, PA BvD (PA for
ESRD Only)
PA BvD (PA for ESRD
Only)
PA BvD (PA for ESRD
Only)
Anti-addiction/substance Abuse Treatment Agents
Anti-addiction/substance Abuse Treatment Agents
buprenorphine hcl tab subl: 2mg
(Subutex)
1
buprenorphine hcl tab subl: 8mg
(Subutex)
1
(Antabuse)
(Naloxone HCl)
(Revia)
1
1
1
1
1
1
1
CHANTIX tab ds pk
CHANTIX tablet
disulfiram
naloxone hcl
naltrexone hcl
NICOTROL NS
SUBOXONE film: 2mg-0.5mg
SUBOXONE film: 8mg-2mg
1
NM, PA, QL: 20 in 30
days (oral products
only)
NM, PA, QL: 5 in 30
days (oral products
only)
QL: 60 in 30 days
NM
NM, PA, QL: 360 in 30
days
NM, PA, QL: 90 in 30
days
Antianxiety Agents
Benzodiazepines
ALPRAZOLAM INTENSOL
alprazolam
diazepam kit
diazepam oral conc, solution
lorazepam
ONFI
(Xanax XR)
(Diastat)
(Diazepam)
(Lorazepam)
1
1
1
1
1
1
PA NSO
1
NM
QL: 5 in 30 days
Antibacterials
Aminoglycosides
amikacin sulfate
(Amikacin Sulfate)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
16
Geisinger Gold Standard Rx 2015 Part D Formulary
Formulary ID: 15222.000, Version: 9
Effective: March 01, 2015
Drug Name
gentamicin in nacl, iso-osm piggyback:
80mg/100ml, 80mg/50ml, 100mg/0.1l,
120mg/0.1l
gentamicin in nacl, iso-osm piggyback:
70mg/50ml, 90mg/100ml
gentamicin sulfate
kanamycin sulfate
neomycin sulfate
streptomycin sulfate
tobramycin sulfate
tobramycin/sodium chloride
Antibacterials, Miscellaneous
bacitracin
chloramphenicol sod succ
clindamycin hcl
clindamycin phosphate vial port
colistin (colistimethate na)
Drug Tier
(Gentamicin In Nacl,
Iso-osm)
1
(Gentamicin In Nacl,
Iso-osm)
(Garamycin)
(Kanamycin Sulfate)
(Neomycin Sulfate)
(Streptomycin Sulfate)
(Nebcin)
(Tobramycin/sodium
Chloride)
1
NM
1
1
1
1
1
1
NM
NM
(Bacitracin)
(Chloramphenicol Sod
Succ)
(Cleocin HCl)
(Cleocin Phosphate)
(Coly-mycin M
Parenteral)
CUBICIN
LINCOCIN
nitrofurantoin macrocrystal
Requirements/Limits
NM
1
1
NM
NM
1
1
1
NM
NM
1
(Macrodantin)
NM
1
1
NM, PA BvD (PA for
ESRD only)
NM
PA, QL: 90 in 365 days
(PA Req for Ages 65 and
Older; High Risk Med)
NM
NM, PA
polymyxin b sulfate
SYNERCID
trimethoprim
vancomycin hcl vial: 10g
(Polymyxin B Sulfate)
(Trimethoprim)
(Vancomycin HCl)
1
1
1
1
vancomycin hcl vial: 5g
(Vancomycin HCl)
1
vancomycin hcl/d5w
(Vancomycin HCl/
D5W)
1
NM, PA BvD (PA for
ESRD only)
PA BvD (PA for ESRD
only)
NM
1
NM, PA
ZYVOX
Cephalosporins
cefaclor
cefadroxil
(Ceclor)
(Cefadroxil)
1
1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
17
Geisinger Gold Standard Rx 2015 Part D Formulary
Formulary ID: 15222.000, Version: 9
Effective: March 01, 2015
Drug Name
cefazolin sodium vial port
cefazolin sodium vial
cefepime hcl
cefotetan disodium
cefoxitin sodium
cefoxitin sodium/dextrose,iso
cefprozil
ceftazidime pentahydrate vial: 2g, 6g,
500mg
CEFTAZIDIME
ceftriaxone na/dextrose,iso froz.piggy: 1g/
50ml
ceftriaxone sodium vial
cefuroxime axetil
cefuroxime sodium
cephalexin
TEFLARO
Macrolides
azithromycin vial
azithromycin susp recon
clarithromycin
Drug Tier
(Ancef)
(Ancef)
(Maxipime)
(Cefotetan Disodium)
(Mefoxin)
(Cefoxitin Sodium/
dextrose, Iso)
(Cefzil)
(Fortaz)
(Ceftriaxone Na/
dextrose, Iso)
(Rocephin)
(Ceftin)
(Zinacef)
(Keflex)
1
1
1
1
1
1
NM
NM
NM
NM
NM
1
1
NM
1
1
NM
NM
1
1
1
1
1
NM
(Zithromax)
(Zithromax)
1
1
(Biaxin)
1
ERY-TAB
1
erythromycin base
(Erythromycin Base)
1
erythromycin ethylsuccinate tablet
(Erythromycin
Ethylsuccinate)
(Erythromycin
Stearate)
1
erythromycin stearate
Requirements/Limits
1
KETEK
PCE
1
1
Miscellaneous B-lactam Antibiotics
AZACTAM
(Azactam)
aztreonam
(Primaxin)
imipenem/cilastatin sodium
1
1
1
NM
PA (PA only w/
digoxin)
PA (PA only w/
digoxin)
PA (PA only w/
digoxin)
PA (PA only w/
digoxin)
PA (PA only w/
digoxin)
PA (PA only w/
digoxin)
PA
PA (PA only w/
digoxin)
NM
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
18
Geisinger Gold Standard Rx 2015 Part D Formulary
Formulary ID: 15222.000, Version: 9
Effective: March 01, 2015
Drug Name
INVANZ vial
meropenem
Penicillins
amoxicillin
amoxicillin/potassium clav
ampicillin sodium vial: 2g
ampicillin sodium vial: 10g, 125mg
ampicillin sodium/sulbactam na
ampicillin trihydrate
BICILLIN L-A
dicloxacillin sodium
nafcillin sodium
NALLPEN-ISO-OSMOTIC DEXTROSE
oxacillin sodium
oxacillin sodium/dextrose,iso
Drug Tier
(Merrem)
(Amoxil)
(Augmentin)
(Totacillin-N)
(Totacillin-N)
(Unasyn)
(Ampicillin Trihydrate)
(Dicloxacillin Sodium)
(Unipen)
(Oxacillin Sodium)
(Oxacillin Sodium/
dextrose, Iso)
(Pen G Pot/dextrosepen g pot/dextrose-water
water)
(Penicillin G
penicillin g potassium
Potassium)
(Penicillin G
penicillin g potassium/d5w
Potassium/D5W)
(Veetids 500)
penicillin v potassium
piperacillin sodium/tazobactam vial: 40.5g (Zosyn)
piperacillin sodium/tazobactam vial: 4.5g (Zosyn)
Quinolones
(Cipro)
ciprofloxacin hcl
(Cipro XR)
ciprofloxacin/ciprofloxa hcl
levofloxacin solution, tablet
(Levaquin)
levofloxacin vial
(Levaquin)
(Levaquin)
levofloxacin/d5w
(Nalidixic Acid)
nalidixic acid
(Floxin)
ofloxacin
Sulfonamides
(Sulfadiazine)
sulfadiazine
sulfamethoxazole/trimethoprim tablet
(Septra)
sulfamethoxazole/trimethoprim vial
(Sulfamethoxazole/
trimethoprim)
(Azulfidine)
sulfasalazine
1
1
Requirements/Limits
NM
1
1
1
1
1
1
1
1
1
1
1
1
NM
NM
NM
NM
1
NM
NM
NM
1
1
NM
1
1
1
NM
1
1
1
1
1
1
1
1
1
1
NM
NM
NM
1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
19
Geisinger Gold Standard Rx 2015 Part D Formulary
Formulary ID: 15222.000, Version: 9
Effective: March 01, 2015
Drug Name
Tetracyclines
demeclocycline hcl
doxycycline hyclate capsule, tablet: 20mg
doxycycline hyclate tablet: 100mg
doxycycline monohydrate capsule, tablet
minocycline hcl
Drug Tier
(Declomycin)
(Morgidox)
(Periostat)
(Adoxa)
(Dynacin)
Requirements/Limits
1
1
1
1
1
Anticancer Agents
Anticancer Agents
AFINITOR
ALIMTA
anastrozole
ARRANON
ARZERRA
AVASTIN
bicalutamide
BICNU
bleomycin sulfate
CAPRELSA
carboplatin
cisplatin
cladribine
CLOLAR
cytarabine
cytarabine/pf
dacarbazine
daunorubicin hcl
DOCEFREZ
docetaxel
DROXIA
ELIGARD
ELOXATIN
EMCYT
epirubicin hcl
ERBITUX
ETOPOPHOS
exemestane
FARESTON
FASLODEX
FIRMAGON
(Arimidex)
(Casodex)
(Bleomycin Sulfate)
(Carboplatin)
(Cisplatin)
(Leustatin)
(Tarabine Pfs)
(Cytarabine/PF)
(Dtic-Dome IV)
(Cerubidine)
(Taxotere)
(Ellence)
(Aromasin)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
NM, PA NSO
NM
NM, PA NSO
NM, PA NSO
NM, PA NSO
NM
NM, PA BvD
NM, PA NSO
NM
NM, PA BvD
NM, PA NSO
PA BvD
PA BvD
NM
NM
NM
NM
NM
NM, PA NSO
NM
NM
PA NSO
NM
NM
NM
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
20
Geisinger Gold Standard Rx 2015 Part D Formulary
Formulary ID: 15222.000, Version: 9
Effective: March 01, 2015
Drug Name
fludarabine phosphate
fluorouracil
FOLOTYN
gemcitabine hcl
GLEEVEC
HALAVEN
HERCEPTIN
hydroxyurea
idarubicin hcl
ifosfamide
irinotecan hcl
ISTODAX
IXEMPRA
JEVTANA
letrozole
LEUKERAN
leuprolide acetate
LUPRON DEPOT
LUPRON DEPOT-PED
LYSODREN
MATULANE
MEGACE ES
megestrol acetate
melphalan hcl
mercaptopurine
methotrexate sodium
methotrexate sodium/pf
MITHRACIN
mitomycin
mitoxantrone hcl
MUSTARGEN
NEXAVAR
NILANDRON
oxaliplatin
paclitaxel
PROLEUKIN
REVLIMID
Drug Tier
(Fludara)
(Fluorouracil)
(Gemzar)
(Hydrea)
(Idamycin Pfs)
(Ifex)
(Camptosar)
(Femara)
(Leuprolide Acetate)
(Megestrol Acetate)
(Alkeran)
(Purinethol)
(Methotrexate Sodium)
(Methotrexate Sodium/
PF)
(Mitomycin)
(Novantrone)
(Eloxatin)
(Taxol)
Requirements/Limits
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
NM
PA BvD
NM
NM
NM
NM, PA NSO
NM, PA BvD
1
1
1
1
1
NM
PA BvD
1
1
1
1
1
NM, PA BvD
NM
NM, PA NSO
NM, PA NSO
NM, PA NSO
NM
NM
NM
NM
NM
NM
NM
NM, PA BvD
NM
NM, PA NSO, QL: 120
in 30 days
NM
NM
NM
LA, NM, PA NSO
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
21
Geisinger Gold Standard Rx 2015 Part D Formulary
Formulary ID: 15222.000, Version: 9
Effective: March 01, 2015
Drug Name
RITUXAN
SPRYCEL
SUTENT
TABLOID
tamoxifen citrate
TARCEVA tablet: 100mg, 150mg
Drug Tier
(Nolvadex)
1
1
1
1
1
1
TARCEVA tablet: 25mg
1
TARGRETIN
TASIGNA
topotecan hcl
TORISEL
TREANDA
TRELSTAR
tretinoin
TRISENOX
TYKERB
VECTIBIX
vinblastine sulfate
vincristine sulfate
vinorelbine tartrate
VOTRIENT
1
1
1
1
1
1
1
1
1
1
1
1
1
1
(Hycamtin)
(Tretinoin)
(Vinblastine Sulfate)
(Vincristine Sulfate)
(Navelbine)
XALKORI
1
YERVOY
ZANOSAR
ZELBORAF
1
1
1
ZOLINZA
ZYTIGA
1
1
Requirements/Limits
NM, PA NSO
NM, PA NSO
NM, PA NSO
NM
NM, PA NSO, QL: 30 in
30 days
NM, PA NSO, QL: 90 in
30 days
NM
NM, PA NSO
NM
NM, PA NSO
PA NSO
NM
NM
NM
NM, PA NSO
NM, PA NSO
PA BvD
NM, PA BvD
NM, PA NSO, QL: 120
in 30 days
LA, NM, PA NSO, QL:
60 in 30 days
NM, PA NSO
NM
LA, NM, PA NSO, QL:
240 in 30 days
NM
LA, NM, PA NSO, QL:
120 in 30 days
Anticholinergic Agents
Antimuscarinics/Antispasmodics
atropine sulfate
propantheline bromide
(Atropine Sulfate)
(Propantheline
Bromide)
1
1
NM
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
22
Geisinger Gold Standard Rx 2015 Part D Formulary
Formulary ID: 15222.000, Version: 9
Effective: March 01, 2015
Drug Name
Drug Tier
Requirements/Limits
Anticonvulsants
Anticonvulsants
BANZEL
carbamazepine
CELONTIN
DILANTIN capsule
DILANTIN tab chew
divalproex sodium
ethosuximide
felbamate oral susp, tablet: 400mg
felbamate tablet: 600mg
fosphenytoin sodium
gabapentin
GABITRIL tablet: 12mg, 16mg
LAMICTAL (GREEN)
LAMICTAL (ORANGE)
LAMICTAL ODT
LAMICTAL XR (BLUE)
LAMICTAL XR (GREEN)
LAMICTAL XR (ORANGE)
lamotrigine
levetiracetam solution, tab er 24h, tablet
levetiracetam vial
LYRICA
oxcarbazepine
PEGANONE
PHENYTEK
phenytoin sodium extended
phenytoin
primidone
SABRIL
TEGRETOL XR tab er 12h: 100mg
topiramate
valproic acid (as sodium salt)
valproic acid
VIMPAT vial
VIMPAT solution
zonisamide
(Tegretol)
(Depakote ER)
(Zarontin)
(Felbatol)
(Felbatol)
(Cerebyx)
(Neurontin)
(Lamictal)
(Keppra)
(Keppra)
(Trileptal)
(Dilantin)
(Dilantin-125)
(Mysoline)
(Topamax)
(Depacon)
(Depakene)
(Zonegran)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
NM
NM
NM
NM, PA NSO
NM
NM, PA NSO
PA NSO
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
23
Geisinger Gold Standard Rx 2015 Part D Formulary
Formulary ID: 15222.000, Version: 9
Effective: March 01, 2015
Drug Name
Drug Tier
Requirements/Limits
Antidementia Agents
Antidementia Agents
donepezil hcl
galantamine hbr
NAMENDA
rivastigmine tartrate
(Aricept)
(Razadyne ER)
(Exelon)
1
1
1
1
Antidepressants
amitrip hcl/chlordiazepoxide
amitriptyline hcl
(Limbitrol)
(Amitriptyline HCl)
1
1
amoxapine
(Amoxapine)
1
APLENZIN
bupropion hcl
citalopram hydrobromide
clomipramine hcl
(Wellbutrin)
(Celexa)
(Anafranil)
1
1
1
1
desipramine hcl
doxepin hcl
fluoxetine hcl
fluvoxamine maleate
imipramine hcl
(Norpramin)
(Doxepin HCl)
(Prozac)
(Fluvoxamine Maleate)
(Tofranil)
1
1
1
1
1
imipramine pamoate
(Tofranil-PM)
1
maprotiline hcl
MARPLAN
mirtazapine
nefazodone hcl
nortriptyline hcl
paroxetine hcl
PAXIL oral susp
(Maprotiline HCl)
1
1
1
1
1
1
1
(oral products only)
Antidepressants
(Remeron)
(Nefazodone HCl)
(Pamelor)
(Paxil)
PA NSO (PA Req for
Ages 65 and Older; High
Risk Med)
PA NSO (PA Req for
Ages 65 and Older; High
Risk Med)
QL: 30 in 30 days
PA NSO (PA Req for
Ages 65 and Older; High
Risk Med)
PA NSO (PA Req for
Ages 65 and Older; High
Risk Med)
PA NSO (PA Req for
Ages 65 and Older; High
Risk Med)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
24
Geisinger Gold Standard Rx 2015 Part D Formulary
Formulary ID: 15222.000, Version: 9
Effective: March 01, 2015
Drug Name
perphenazine/amitriptyline hcl
PEXEVA
phenelzine sulfate
PRISTIQ ER
protriptyline hcl
sertraline hcl
SILENOR
SURMONTIL
tranylcypromine sulfate
trazodone hcl tablet: 50mg, 100mg, 150mg
VENLAFAXINE HCL ER
venlafaxine hcl
VIIBRYD
Drug Tier
(Perphenazine/
amitriptyline HCl)
(Nardil)
(Vivactil)
(Zoloft)
(Parnate)
(Trazodone HCl)
(Effexor XR)
Requirements/Limits
1
1
1
1
1
1
1
1
1
1
1
1
1
PA NSO
1
1
QL: 30 in 30 days
1
QL: 60 in 30 days
1
1
1
1
1
1
1
1
PA
ST
QL: 30 in 30 days
PA NSO
Antidiabetic Agents
Antidiabetic Agents, Miscellaneous
(Precose)
acarbose
ACTOPLUS MET XR tbmp 24hr: 301000mg
ACTOPLUS MET XR tbmp 24hr: 151000mg
CYCLOSET
GLYSET
JANUMET
JANUVIA
metformin hcl tab er 24h: 500mg
(Fortamet)
metformin hcl tab er 24h: 750mg
(Fortamet)
metformin hcl tablet
(Glucophage)
(Starlix)
nateglinide
Insulins
LANTUS
LEVEMIR
NOVOLIN 70-30
NOVOLIN N
NOVOLIN R
NOVOLOG MIX 70-30 FLEXPEN
NOVOLOG MIX 70-30
NOVOLOG
QL: 60 in 30 days
QL: 120 in 30 days
QL: 60 in 30 days
QL: 150 in 30 days
1
1
1
1
1
1
1
1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
25
Geisinger Gold Standard Rx 2015 Part D Formulary
Formulary ID: 15222.000, Version: 9
Effective: March 01, 2015
Drug Name
Drug Tier
Requirements/Limits
(Chlorpropamide)
1
glimepiride tablet: 2mg
glimepiride tablet: 1mg
glimepiride tablet: 4mg
glipizide tab er 24: 10mg
glipizide tab er 24: 5mg; tablet: 10mg
glipizide tab er 24: 2.5mg; tablet: 5mg
glipizide/metformin hcl tablet: 2.5-500mg,
5mg-500mg
glipizide/metformin hcl tablet: 2.5-250mg
glyburide tablet: 5mg
(Amaryl)
(Amaryl)
(Amaryl)
(Glucotrol XL)
(Glucotrol)
(Glucotrol)
(Metaglip)
1
1
1
1
1
1
1
PA, QL: 225 in 30 days
(PA Req for Ages 65 and
Older; High Risk Med)
QL: 120 in 30 days
QL: 240 in 30 days
QL: 60 in 30 days
QL: 60 in 30 days
QL: 120 in 30 days
QL: 240 in 30 days
QL: 120 in 30 days
(Metaglip)
(Micronase)
1
1
glyburide tablet: 2.5mg
(Micronase)
1
glyburide tablet: 1.25mg
(Micronase)
1
glyburide,micronized tablet: 3mg
(Glynase)
1
glyburide,micronized tablet: 1.5mg
(Glynase)
1
glyburide,micronized tablet: 6mg
(Glynase)
1
tolazamide tablet: 250mg
tolazamide tablet: 500mg
tolbutamide
(Tolazamide)
(Tolazamide)
(Tolbutamide)
1
1
1
QL: 240 in 30 days
PA, QL: 120 in 30 days
(PA Req for Ages 65 and
Older; High Risk Med)
PA, QL: 240 in 30 days
(PA Req for Ages 65 and
Older; High Risk Med)
PA, QL: 480 in 30 days
(PA Req for Ages 65 and
Older; High Risk Med)
PA, QL: 120 in 30 days
(PA Req for Ages 65 and
Older; High Risk Med)
PA, QL: 240 in 30 days
(PA Req for Ages 65 and
Older; High Risk Med)
PA, QL: 60 in 30 days
(PA Req for Ages 65 and
Older; High Risk Med)
QL: 120 in 30 days
QL: 60 in 30 days
QL: 180 in 30 days
(Amphotericin B)
1
1
1
NM, PA BvD
NM, PA BvD
NM, PA BvD
Sulfonylureas
chlorpropamide
Antifungals
Antifungals
ABELCET
AMBISOME
amphotericin b
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
26
Geisinger Gold Standard Rx 2015 Part D Formulary
Formulary ID: 15222.000, Version: 9
Effective: March 01, 2015
Drug Name
CANCIDAS
ciclopirox olamine
ciclopirox
clotrimazole solution, troche
clotrimazole/betamethasone dip
econazole nitrate
fluconazole in nacl,iso-osm
fluconazole
flucytosine
griseofulvin, microsize
itraconazole
ketoconazole
miconazole nitrate
NAFTIN
NOXAFIL
nystatin
nystatin/triamcin
voriconazole tablet: 50mg
voriconazole tablet: 200mg
Drug Tier
(Loprox)
(Penlac)
(Mycelex)
(Lotrisone)
(Spectazole)
(Diflucan in Saline)
(Diflucan)
(Ancobon)
(Griseofulvin,
Microsize)
(Sporanox)
(Kuric)
(Monistat 3)
1
1
1
1
1
1
1
1
1
1
Requirements/Limits
NM
NM
PA
(Nystatin)
(Mycogen II)
(Vfend)
(Vfend)
1
1
1
1
1
1
1
1
1
(Cetirizine HCl)
(Xyzal)
(P-epd Tan/chlor-tan)
(Promethazine HCl)
(Tripelennamine HCl)
1
1
1
1
1
(Rx product only)
NM, PA
NM
Antihistamines
Antihistamines
cetirizine hcl
levocetirizine dihydrochloride
p-epd tan/chlor-tan
promethazine hcl
tripelennamine hcl
PA
Anti-infectives (Skin and Mucous Membrane)
Anti-infectives (Skin and Mucous Membrane)
(Cleocin)
clindamycin phosphate
(Metrogel-vaginal)
metronidazole
(Terazol 3)
terconazole
1
1
1
Antimigraine Agents
Antimigraine Agents
AXERT
dihydroergotamine mesylate
MIGERGOT
naratriptan hcl
(D.H.E. 45)
(Amerge)
1
1
1
1
QL: 16 in 28 days
NM
QL: 16 in 28 days
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
27
Geisinger Gold Standard Rx 2015 Part D Formulary
Formulary ID: 15222.000, Version: 9
Effective: March 01, 2015
Drug Name
Drug Tier
Requirements/Limits
Antimycobacterials
Antimycobacterials
CAPASTAT SULFATE
dapsone
ethambutol hcl
isoniazid solution, tablet
isoniazid vial
PASER
rifampin capsule
rifampin vial
RIFATER
TRECATOR
1
1
1
1
1
1
1
1
1
1
NM
PA BvD
(Kytril)
(Zofran)
(Compazine)
(Phenergan)
1
1
1
1
1
1
1
promethazine hcl ampul, vial: 25mg/ml
(Promethazine HCl)
1
promethazine hcl vial: 50mg/ml
(Promethazine HCl)
1
(Dapsone)
(Myambutol)
(Isoniazid)
(Isoniazid)
(Rifadin)
(Rifadin)
NM
NM
Antinausea Agents
Antinausea Agents
ANZEMET tablet
dronabinol
EMEND cap ds pk, capsule
granisetron hcl
ondansetron hcl
prochlorperazine maleate
promethazine hcl supp.rect
(Marinol)
PA
PA BvD
PA BvD
PA (PA Req for Ages
65 and Older; High Risk
Med)
NM, PA (PA Req for
Ages 65 and Older; High
Risk Med)
NM, PA (PA Req for
Ages 65 and Older; High
Risk Med)
Antiparasite Agents
Antiparasite Agents
ALBENZA
ALINIA
atovaquone/proguanil hcl
BILTRICIDE
chloroquine phosphate
COARTEM
DARAPRIM
hydroxychloroquine sulfate
(Malarone)
(Aralen Phosphate)
(Plaquenil)
1
1
1
1
1
1
1
1
PA
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
28
Geisinger Gold Standard Rx 2015 Part D Formulary
Formulary ID: 15222.000, Version: 9
Effective: March 01, 2015
Drug Name
mefloquine hcl
MEPRON
metronidazole
metronidazole/sodium chloride
NEBUPENT
paromomycin sulfate
PENTAM 300
PRIMAQUINE
STROMECTOL
Drug Tier
(Lariam)
(Flagyl)
(Metro IV)
(Paromomycin Sulfate)
1
1
1
1
1
1
1
1
1
Requirements/Limits
NM
NM
PA BvD
NM
Antiparkinsonian Agents
Antiparkinsonian Agents
amantadine hcl
APOKYN
AZILECT
benztropine mesylate tablet
(Amantadine HCl)
(Benztropine Mesylate)
1
1
1
1
benztropine mesylate ampul
(Cogentin)
1
bromocriptine mesylate
cabergoline
carbidopa/levodopa
pramipexole di-hcl
ropinirole hcl
selegiline hcl
TASMAR
trihexyphenidyl hcl
(Parlodel)
(Cabergoline)
(Sinemet 10-100)
(Mirapex)
(Requip)
(Eldepryl)
1
1
1
1
1
1
1
1
(Trihexyphenidyl HCl)
NM
PA (PA Req for Ages
65 and Older; High Risk
Med)
NM, PA (PA Req for
Ages 65 and Older; High
Risk Med)
PA (PA Req for Ages
65 and Older; High Risk
Med)
Antipsychotic Agents
Antipsychotic Agents
ABILIFY DISCMELT
ABILIFY
chlorpromazine hcl oral conc.
chlorpromazine hcl tablet
chlorpromazine hcl ampul
clozapine
FANAPT
(Chlorpromazine HCl)
(Chlorpromazine HCl)
(Chlorpromazine HCl)
(Clozaril)
1
1
1
1
1
1
1
NM
NM
NM
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
29
Geisinger Gold Standard Rx 2015 Part D Formulary
Formulary ID: 15222.000, Version: 9
Effective: March 01, 2015
Drug Name
FAZACLO tab rapdis: 150mg, 200mg
fluphenazine decanoate
fluphenazine hcl elixir, oral conc, tablet
fluphenazine hcl vial
GEODON vial
haloperidol decanoate
haloperidol lactate oral conc
haloperidol lactate vial
haloperidol
INVEGA SUSTENNA syringe: 78mg/
0.5ml, 117mg/0.75, 156mg/ml, 234mg/1.5
INVEGA SUSTENNA syringe: 39mg/0.25
INVEGA
LATUDA
loxapine succinate
olanzapine
ORAP
perphenazine
RISPERDAL CONSTA
risperidone
SAPHRIS
SEROQUEL XR
thioridazine hcl oral conc.
Drug Tier
(Fluphenazine
Decanoate)
(Fluphenazine HCl)
(Fluphenazine HCl)
(Haloperidol
Decanoate)
(Haloperidol Lactate)
(Haloperidol Lactate)
(Haloperidol)
1
1
NM
1
1
1
1
NM
NM
NM
1
1
1
1
(Thioridazine HCl)
1
1
1
1
1
1
1
1
1
1
1
1
thioridazine hcl tablet
(Thioridazine HCl)
1
thioridazine hcl tablet
thiothixene
trifluoperazine hcl
(Thioridazine HCl)
(Navane)
(Trifluoperazine HCl)
1
1
1
(Loxitane)
(Zyprexa)
(Perphenazine)
(Risperdal)
Requirements/Limits
NM
NM, PA NSO
PA NSO
NM
PA NSO
NM, PA NSO
PA NSO
PA NSO (PA Req for
Ages 65 and Older; High
Risk Med)
PA NSO (PA Req for
Ages 65 and Older; High
Risk Med)
PA NSO
Antivirals (Systemic)
Antiretrovirals
APTIVUS capsule
APTIVUS solution
ATRIPLA
COMPLERA
1
1
1
1
NM
NM
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
30
Geisinger Gold Standard Rx 2015 Part D Formulary
Formulary ID: 15222.000, Version: 9
Effective: March 01, 2015
Drug Name
CRIXIVAN
didanosine
EDURANT
EMTRIVA
EPIVIR solution
EPZICOM
FUZEON
INTELENCE tablet: 200mg
INTELENCE tablet: 100mg
INVIRASE
ISENTRESS
KALETRA tablet: 100mg-25mg
KALETRA solution, tablet: 200mg-50mg
lamivudine
lamivudine/zidovudine
LEXIVA
NORVIR
PREZISTA
RESCRIPTOR
RETROVIR vial
REYATAZ
SELZENTRY
stavudine
SUSTIVA capsule: 100mg
SUSTIVA capsule: 50mg, 200mg; tablet
TRUVADA
VIDEX
VIRACEPT
VIRAMUNE XR
VIRAMUNE oral susp
VIREAD
ZIAGEN solution
zidovudine
Antivirals, Miscellaneous
foscarnet sodium
RELENZA
rimantadine hcl
SYNAGIS
TAMIFLU susp recon
Drug Tier
(Videx EC)
(Epivir)
(Combivir)
(Zerit)
(Retrovir)
(Foscavir)
(Flumadine)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Requirements/Limits
NM, QL: 30 in 30 days
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM, PA BvD
NM, PA
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
31
Geisinger Gold Standard Rx 2015 Part D Formulary
Formulary ID: 15222.000, Version: 9
Effective: March 01, 2015
Drug Name
Drug Tier
TAMIFLU capsule
Hcv Antivirals
VICTRELIS
Interferons
INTRON A vial: 10mm/ml
INTRON A vial: 6mmunit/ml
PEGASYS PROCLICK
PEGASYS
PEGINTRON REDIPEN
PEGINTRON kit: 50mcg/0.5
SYLATRON 4-PACK
Nucleosides and Nucleotides
acyclovir sodium
acyclovir
BARACLUDE
famciclovir
ganciclovir sodium
REBETOL solution
ribavirin capsule, tablet
TYZEKA
valacyclovir hcl
VALCYTE tablet
1
NM
1
NM, PA, QL: 360 in 30
days
1
1
1
1
1
1
1
(Acyclovir Sodium)
(Zovirax)
(Famvir)
(Cytovene)
(Rebetol)
(Valtrex)
Requirements/Limits
1
1
1
1
1
1
1
1
1
1
NM
NM
NM
NM
NM
NM, PA NSO
PA BvD
NM, PA BvD
NM
Blood Products/modifiers/volume Expanders
Anticoagulants
COUMADIN tablet
enoxaparin sodium syringe: 40mg/0.4ml
(Lovenox)
1
1
enoxaparin sodium syringe: 60mg/0.6ml
(Lovenox)
1
enoxaparin sodium syringe: 80mg/0.8ml,
120mg/.8ml
enoxaparin sodium syringe: 100mg/ml,
150mg/ml
enoxaparin sodium syringe: 30mg/0.3ml
(Lovenox)
1
(Lovenox)
1
(Lovenox)
1
fondaparinux sodium syringe: 10mg/0.8ml
fondaparinux sodium syringe: 5mg/0.4ml
fondaparinux sodium syringe: 2.5mg/0.5
(Arixtra)
(Arixtra)
(Arixtra)
1
1
1
NM, QL: 11.2 in 14 days
(30 syringes)
NM, QL: 16.8 in 14 days
(28 syringes)
NM, QL: 22.4 in 14 days
(28 syringes)
NM, QL: 28 in 14 days
(28 syringes)
NM, QL: 8.4 in 14 days
(30 syringes)
NM, QL: 11.2 in 14 days
NM, QL: 5.6 in 14 days
NM, QL: 7 in 14 days
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
32
Geisinger Gold Standard Rx 2015 Part D Formulary
Formulary ID: 15222.000, Version: 9
Effective: March 01, 2015
Drug Name
Drug Tier
fondaparinux sodium syringe: 7.5mg/0.6
(Arixtra)
heparin sod,pork in 0.45% nacl iv soln:
(Heparin Sod,pork In
25000/250
0.45% NaCl)
heparin sod,pork in 0.45% nacl iv soln:
(Heparin Sod,pork In
25000/500
0.45% NaCl)
heparin sodium,porcine vial: 1000/ml,
(Hep-lock)
5000/ml, 20000/ml
heparin sodium,porcine/d5w iv soln:
(Heparin Sodium,
12500/250, 25000/500
porcine/D5W)
heparin sodium,porcine/d5w iv soln: 20k/ (Heparin Sodium,
500ml
porcine/D5W)
PRADAXA
(Coumadin)
warfarin sodium
XARELTO tablet: 15mg, 20mg
XARELTO tablet: 10mg
Blood Formation Modifiers
ARANESP
CINRYZE
EPOGEN
MOZOBIL
NEULASTA
NEUPOGEN
PROCRIT
PROMACTA
Hematologic Agents, Miscellaneous
(Tranexamic Acid)
tranexamic acid
Platelet-aggregation Inhibitors
AGGRENOX
BRILINTA
cilostazol
dipyridamole
EFFIENT
pentoxifylline
(Pletal)
(Persantine)
(Trental)
Requirements/Limits
1
1
NM, QL: 8.4 in 14 days
1
NM
1
NM, PA BvD (PA for
ESRD only)
1
1
NM (PA for ESRD
only)
1
1
1
1
QL: 30 per fill
1
1
1
1
1
1
1
1
NM, PA
LA, NM, PA
NM, PA
NM
NM, PA
NM, PA
NM, PA
NM, PA
1
NM (Injectable form
only)
1
1
1
1
1
1
Caloric Agents
Caloric Agents
AMINOSYN II iv soln: 10%
AMINOSYN II iv soln: 15%
AMINOSYN II iv soln: 7%
1
1
1
NM, PA BvD
NM, PA BvD
NM, PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
33
Geisinger Gold Standard Rx 2015 Part D Formulary
Formulary ID: 15222.000, Version: 9
Effective: March 01, 2015
Drug Name
AMINOSYN M
AMINOSYN-HBC
AMINOSYN-PF iv soln: 10%
AMINOSYN-PF iv soln: 7%
CLINISOL
dextrose 10 % and 0.2 % nacl
dextrose 10 % and 0.45 % nacl
dextrose 10 % in water
dextrose 2.5 % and 0.45 % nacl
dextrose 2.5% in half ringers
dextrose 5 % and 0.3 % nacl
dextrose 5 % and 0.9 % nacl
dextrose 5 % in water
dextrose 5 %-0.2 % nacl
dextrose 5 %-0.45 % nacl
dextrose 5%-lactated ringers
fructose 10 %
potassium chloride in lr-d5
Drug Tier
(Dextrose 10 % and 0.2
% NaCl)
(Dextrose 10 % and
0.45 % NaCl)
(Dextrose 10 % in
Water)
(Dextrose 2.5 % and
0.45 % NaCl)
(Dextrose 2.5% In Half
Ringers)
(Dextrose 5 % and 0.3
% NaCl)
(Dextrose 5 % and 0.9
% NaCl)
(Dextrose 5 % in
Water)
(Dextrose 5 %-0.2 %
NaCl)
(Dextrose 5 %-0.45 %
NaCl)
(Dextrose 5%-Lactated
Ringers)
(Fructose 10 %)
(Potassium Chloride In
Lr-d5)
PREMASOL iv soln: 10%
PREMASOL iv soln: 6%
PROSOL
TRAVAMULSION
TRAVASOL W/ELECTROLYTES
TRAVASOL with ELECTROLYTES
TRAVASOL iv soln.
TRAVASOL iv soln: 5.5%
TRAVASOL iv soln: 8.5%
1
1
1
1
1
1
Requirements/Limits
NM, PA BvD
NM, PA BvD
NM, PA BvD
NM, PA BvD
NM, PA BvD
NM
1
1
PA BvD
1
1
NM
1
NM
1
NM
1
NM
1
1
NM
1
NM
1
1
NM, PA BvD
NM
1
1
1
1
1
1
1
1
1
NM, PA BvD
NM, PA BvD
NM, PA BvD
NM, PA BvD
NM, PA BvD
NM, PA BvD
NM, PA BvD
NM, PA BvD
NM, PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
34
Geisinger Gold Standard Rx 2015 Part D Formulary
Formulary ID: 15222.000, Version: 9
Effective: March 01, 2015
Drug Name
Drug Tier
TRAVASOL iv soln: 10%
TRAVERT IN NORMAL SALINE
TRAVERT iv soln: 10%
TRAVERT iv soln: 5%
TROPHAMINE iv soln: 10%
1
1
1
1
1
Requirements/Limits
PA BvD
NM, PA BvD
NM, PA BvD
NM, PA BvD
NM, PA BvD
Cardiovascular Agents
Alpha-adrenergic Agents
clonidine hcl
clonidine hcl/chlorthalidone
(Catapres)
(Clonidine HCl/
chlorthalidone)
(Catapres-tts 1)
clonidine
(Cardura)
doxazosin mesylate
(Proamatine)
midodrine hcl
(Minipress)
prazosin hcl
Angiotensin II Receptor Antagonists
BENICAR HCT
BENICAR
DIOVAN
EDARBI
EDARBYCLOR
(Teveten)
eprosartan mesylate
(Cozaar)
losartan potassium
(Hyzaar)
losartan/hydrochlorothiazide
TEVETEN HCT
Angiotensin-Converting Enzyme Inhibitors
(Lotensin)
benazepril hcl
(Lotensin HCT)
benazepril/hydrochlorothiazide
(Capoten)
captopril
(Capozide)
captopril/hydrochlorothiazide
(Vasotec)
enalapril maleate
(Vaseretic)
enalapril/hydrochlorothiazide
(Monopril)
fosinopril sodium
(Zestril)
lisinopril
(Prinzide)
lisinopril/hydrochlorothiazide
(Univasc)
moexipril hcl
(Uniretic)
moexipril/hydrochlorothiazide
(Aceon)
perindopril erbumine
(Accupril)
quinapril hcl
(Accuretic)
quinapril/hydrochlorothiazide
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
35
Geisinger Gold Standard Rx 2015 Part D Formulary
Formulary ID: 15222.000, Version: 9
Effective: March 01, 2015
Drug Name
ramipril
trandolapril
Antiarrhythmic Agents
amiodarone hcl
disopyramide phosphate
flecainide acetate
lidocaine hcl/pf
mexiletine hcl
MULTAQ
procainamide hcl capsule, tablet sa
procainamide hcl vial
propafenone hcl
quinidine gluconate tablet er
quinidine gluconate vial
quinidine sulfate
TIKOSYN
Beta-Adrenergic Blocking Agents
acebutolol hcl
atenolol
atenolol/chlorthalidone
bisoprolol fumarate
bisoprolol fumarate/hctz
carvedilol
labetalol hcl syringe
labetalol hcl tablet
metoprolol succinate
metoprolol tartrate
metoprolol/hydrochlorothiazide
nadolol
nadolol/bendroflumethiazide
pindolol
propranolol hcl cap sa 24h, solution, tablet
propranolol hcl vial
propranolol/hydrochlorothiazid
sotalol hcl
timolol maleate
Drug Tier
(Altace)
(Mavik)
1
1
(Cordarone)
(Norpace)
(Tambocor)
(Lidocaine HCl/PF)
(Mexitil)
1
1
1
1
1
1
1
1
1
1
1
1
1
(Procainamide HCl)
(Procainamide HCl)
(Rythmol)
(Quinidine Gluconate)
(Quinidine Gluconate)
(Quinidine Sulfate)
(Sectral)
(Tenormin)
(Tenoretic 50)
(Zebeta)
(Ziac)
(Coreg)
(Normodyne)
(Trandate)
(Toprol XL)
(Lopressor)
(Lopressor HCT)
(Corgard)
(Corzide)
(Pindolol)
(Propranolol HCl)
(Propranolol HCl)
(Propranolol/
hydrochlorothiazid)
(Betapace)
(Timolol Maleate)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Requirements/Limits
NM
NM
NM
NM
NM
1
1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
36
Geisinger Gold Standard Rx 2015 Part D Formulary
Formulary ID: 15222.000, Version: 9
Effective: March 01, 2015
Drug Name
Drug Tier
Requirements/Limits
Calcium-channel Blocking Agents
diltiazem hcl cap er 12h, cap er 24h, cap er (Dilacor XR)
deg, capsule er, tab er 24h, tablet, vial
diltiazem hcl vial port
(Diltiazem HCl)
(Calan)
verapamil hcl
Cardiovascular Agents, Miscellaneous
DEMSER
(Digoxin)
digoxin
(Dopamine HCl)
dopamine hcl
FIRAZYR
1
1
NM
1
1
1
1
NM, PA
NM
NM, PA BvD
NM, PA, QL: 9 in 30
days
hydralazine hcl tablet
hydralazine hcl vial
hydralazine/hydrochlorothiazid
(Apresoline)
(Hydralazine HCl)
(Hydralazine/
hydrochlorothiazid)
(Hydralazine/reserpin/
hctz)
(Papaverine HCl)
(Reserpine/
hydrochlorothiazide)
1
1
1
(Norvasc)
(Lotrel)
(Plendil)
(Dynacirc)
(Nicardipine HCl)
(Procardia XL)
(Nimotop)
(Sular)
1
1
1
1
1
1
1
1
(Midamor)
(Bumetanide)
(Bumex)
(Sodium Diuril)
(Chlorothiazide)
(Chlorthalidone)
(Lasix)
(Microzide)
(Lozol)
1
1
1
1
1
1
1
1
1
hydralazine/reserpin/hctz
papaverine hcl
reserpine/hydrochlorothiazide
Dihydropyridines
amlodipine besylate
amlodipine besylate/benazepril
felodipine
isradipine
nicardipine hcl
nifedipine tab er 24, tablet er
nimodipine
nisoldipine
Diuretics
amiloride hcl
bumetanide vial
bumetanide tablet
chlorothiazide sodium
chlorothiazide
chlorthalidone
furosemide
hydrochlorothiazide
indapamide
1
NM
1
1
1
NM
NM
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
37
Geisinger Gold Standard Rx 2015 Part D Formulary
Formulary ID: 15222.000, Version: 9
Effective: March 01, 2015
Drug Name
methyclothiazide
metolazone
torsemide tablet
torsemide vial
triamterene/hydrochlorothiazid
Dyslipidemics
atorvastatin calcium
cholestyramine (with sugar)
cholestyramine/aspartame
colestipol hcl
CRESTOR
fenofibrate
fenofibrate,micronized
gemfibrozil
lovastatin
LOVAZA
niacin
pravastatin sodium
simvastatin tablet: 5mg, 20mg
simvastatin tablet: 40mg, 80mg
Drug Tier
(Methyclothiazide)
(Zaroxolyn)
(Demadex)
(Torsemide)
(Maxzide)
1
1
1
1
1
(Lipitor)
(Questran)
(Questran Light)
(Colestid)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
(Lofibra)
(Antara)
(Lopid)
(Mevacor)
(Niacin)
(Pravachol)
(Zocor)
(Zocor)
WELCHOL
ZETIA
Renin-Angiotensin-Aldosterone System Inhibitors
ALDACTAZIDE tablet: 50mg-50mg
(Inspra)
eplerenone
(Aldactazide)
spironolact/hydrochlorothiazid
(Aldactone)
spironolactone
TEKTURNA HCT
TEKTURNA
Vasodilators
(Isordil)
isosorbide dinitrate
(Imdur)
isosorbide mononitrate
(Minoxidil)
minoxidil
nitroglycerin patch td24
(Nitro-dur)
nitroglycerin vial: 50mg/10ml
(Nitroglycerin)
nitroglycerin vial: 5mg/ml
(Nitroglycerin)
NITROSTAT
(Nylidrin HCl)
nylidrin hcl
Requirements/Limits
NM
PA (PA only w/
amiodarone)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
NM
NM
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
38
Geisinger Gold Standard Rx 2015 Part D Formulary
Formulary ID: 15222.000, Version: 9
Effective: March 01, 2015
Drug Name
Drug Tier
PROGLYCEM
Requirements/Limits
1
Central Nervous System Agents
Central Nervous System Agents
AMPYRA
dexmethylphenidate hcl
dextroamphetamine sulfate capsule er,
tablet: 5mg, 10mg
dextroamphetamine/amphetamine
INTUNIV
lithium carbonate
methamphetamine hcl
METHYLIN tab chew
methylphenidate hcl
NUEDEXTA
SAVELLA
STRATTERA
XENAZINE
1
(Focalin)
(Dexedrine)
1
1
(Adderall)
1
1
1
1
1
1
1
1
1
1
(Eskalith)
(Desoxyn)
(Ritalin)
NM, PA, QL: 60 in 30
days
PA
(oral products only)
(oral products only)
PA
PA
LA, NM
Contraceptives
Contraceptives
AMETHYST
desog-e.estradiol/e.estradiol
desogestrel-ethinyl estradiol
ELLA
ethinyl estradiol/drospirenone
ethynodiol d-ethinyl estradiol
levonorgestrel-ethin estradiol tablet: 0.10.02, 0.15-0.03, 6-5-10; tbdspk 3mo
l-norgest-eth estr/ethin estra
noreth-ethinyl estradiol/iron
norethindrone ac-eth estradiol
norethindrone
norethindrone-e.estradiol-iron
norethindrone-ethinyl estrad tablet: 0.40.035, 0.5-0.035, 1mg-35mcg, 7-9-5,
7daysx3, 10-11
norgestimate-ethinyl estradiol
norgestrel-ethinyl estradiol
NUVARING
(Yaz)
(Demulen 1/50-28)
(Nordette-28)
1
1
1
1
1
1
1
(Seasonique)
(Femcon Fe)
(Loestrin)
(Nor-Q-D)
(Loestrin Fe)
(Modicon)
1
1
1
1
1
1
(Ortho-cyclen)
(Ovral-21)
1
1
1
(Mircette)
(Desogen)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
39
Geisinger Gold Standard Rx 2015 Part D Formulary
Formulary ID: 15222.000, Version: 9
Effective: March 01, 2015
Drug Name
Drug Tier
Requirements/Limits
Dental And Oral Agents
Dental And Oral Agents
chlorhexidine gluconate
pilocarpine hcl
sodium fluoride
triamcinolone acetonide
(Peridex)
(Salagen)
(Cavarest)
(Kenalog In Orabase)
1
1
1
1
Dermatological Agents
Dermatological Agents, Other
8-MOP
alcohol antiseptic pads
calcipotriene
CARAC
CONDYLOX gel (gram)
fluorouracil
imiquimod
isotretinoin
OXSORALEN
OXSORALEN-ULTRA
PANRETIN
podofilox
silver nitrate applicator
UVADEX
ZONALON
ZOVIRAX cream (g)
ZYCLARA
Dermatological Antibacterials
clindamycin phos/benzoyl perox gel (gram):
1%-5%
clindamycin phosphate
erythromycin base/ethanol
erythromycin/benzoyl peroxide
gentamicin sulfate
metronidazole
mupirocin
neomy sulf/polymyxin b sulfate
selenium sulfide
(Alcohol Antiseptic
Pads)
(Calcipotriene)
(Carac)
(Aldara)
(Accutane)
(Condylox)
(Silver Nitrate
Applicator)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
(Duac)
1
(Cleocin T)
(A-T-S)
(Benzamycin)
(Gentamicin Sulfate)
(Nydamax)
(Centany)
(Neosporin G.U.
Irrigant)
(Selenium Sulfide)
1
1
1
1
1
1
1
NM
NM
1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
40
Geisinger Gold Standard Rx 2015 Part D Formulary
Formulary ID: 15222.000, Version: 9
Effective: March 01, 2015
Drug Name
Drug Tier
(Silver Nitrate)
silver nitrate
(Silvadene)
silver sulfadiazine
(Klaron)
sulfacetamide sodium
Dermatological Anti-inflammatory Agents
(Aclovate)
alclometasone dipropionate
(Amcinonide)
amcinonide
(Betamethasone
betamethasone dipropionate
Dipropionate)
(Betamethasone
betamethasone valerate
Valerate)
(Diprolene AF)
betamethasone/propylene glyc
(Temovate)
clobetasol propionate
(Desowen)
desonide
(Topicort)
desoximetasone
(Psorcon)
diflorasone diacetate
ELIDEL
(Derma-smoothe-fs)
fluocinolone acetonide
(Vanos)
fluocinonide
(Cutivate)
fluticasone propionate
(Ultravate)
halobetasol propionate
hydrocortisone acetate/aloe v gel (gram)
(Nuzon)
(Carmol HC)
hydrocortisone acetate/urea
(Hydrocortisone
hydrocortisone valerate
Valerate)
(Hytone)
hydrocortisone
(Elocon)
mometasone furoate
(Dermatop)
prednicarbate
(Triamcinolone
triamcinolone acetonide
Acetonide)
Dermatological Retinoids
(Differin)
adapalene
TAZORAC
(Retin-A)
tretinoin
Scabicides and Pediculicides
(Ovide)
malathion
(Elimite)
permethrin
Requirements/Limits
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
PA
1
1
1
1
1
1
1
PA
1
1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
41
Geisinger Gold Standard Rx 2015 Part D Formulary
Formulary ID: 15222.000, Version: 9
Effective: March 01, 2015
Drug Name
Drug Tier
Requirements/Limits
Devices
Devices
needles, insulin disposable
syring w-ndl,disp,insul,0.3 ml
syringe & needle,insulin,1 ml
(Needles, Insulin
Disposable)
(Syring Wndl,disp,insul,0.3 Ml)
(Syringe &
Needle,insulin,1 Ml)
1
1
1
Enzyme Replacement/modifiers
Enzyme Replacement/modifiers
ADAGEN
ALDURAZYME
CEREZYME
CIMZIA
1
1
1
1
CIMZIA
1
CREON
CYSTAGON
ELAPRASE
ELITEK
FABRAZYME
KUVAN
LOTRONEX
MYOZYME
NAGLAZYME
ORFADIN
PULMOZYME
VPRIV
ZAVESCA
ZENPEP capsule dr: 3k-10k-16k, 10-3455k, 15-51-82k, 20-68-109k, 25-85-136k
1
1
1
1
1
1
1
1
1
1
1
1
1
1
NM
NM, PA
NM, PA
NM, PA, QL: 6 in 28
days (QL = 6ml : 3 vial
kits every 28 days)
NM, PA, QL: 6 in 28
days (QL = 6ml: 3
syringe kits every 28
days)
LA, NM
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM
NM, PA
NM, PA
NM, PA
Eye, Ear, Nose, Throat Agents
Eye, Ear, Nose, Throat Agents, Miscellaneous
ALOMIDE
(Iopidine)
apraclonidine hcl
1
1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
42
Geisinger Gold Standard Rx 2015 Part D Formulary
Formulary ID: 15222.000, Version: 9
Effective: March 01, 2015
Drug Name
azelastine hcl
carteolol hcl
cromolyn sodium
epinastine hcl
ipratropium bromide
naphazoline hcl/antazoline
Drug Tier
(Astelin)
(Carteolol HCl)
(Cromolyn Sodium)
(Elestat)
(Atrovent)
(Naphazoline HCl/
antazoline)
PATADAY
proparacaine hcl
proparacaine/fluorescein sod
(Ophthetic)
(Proparacaine/
fluorescein Sod)
Eye, Ear, Nose, Throat Anti-infectives Agents
(Vosol)
acetic acid
(Vosol HC)
acetic acid/hydrocortisone
AZASITE
(Polycin-b)
bacitracin/polymyxin b sulfate
BESIVANCE
BLEPHAMIDE S.O.P.
BLEPHAMIDE
CILOXAN oint. (g)
CIPRODEX
(Ciloxan)
ciprofloxacin hcl
(Garamycin)
gentamicin sulfate
(Quixin)
levofloxacin
(Maxitrol)
neo/polymyx b sulf/dexameth
(Neo-polycin)
neomy sulf/bacitra/polymyxin b
(Triple Antibiotic HC)
neomy sulf/bacitrac zn/poly/hc
(Neomycin Sulfate/dex
neomycin sulfate/dex na ph
Na Ph)
(Oticin HC)
neomycin/polymyxin b sulf/hc
(Neosporin)
neomycin/polymyxn b/gramicidin
(Floxin)
ofloxacin
(Polytrim)
polymyxin b sulf/trimethoprim
PRED-G drops susp
(Sulfac)
sulfacetamide sodium
(Sulfacetamide/
sulfacetamide/prednisolone sp
prednisolone Sp)
TOBRADEX ST
TOBRADEX oint. (g)
Requirements/Limits
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
43
Geisinger Gold Standard Rx 2015 Part D Formulary
Formulary ID: 15222.000, Version: 9
Effective: March 01, 2015
Drug Name
Drug Tier
(Tobradex)
tobramycin/dexamethasone
(Viroptic)
trifluridine
VIGAMOX
Eye, Ear, Nose, Throat Anti-inflammatory Agents
ALOCRIL
ALREX
(Bromfenac Sodium)
bromfenac sodium
dexamethasone sod phosphate drops
(Ak-dex)
(Voltaren)
diclofenac sodium
FLAREX
(Dermotic)
fluocinolone acetonide oil
(Ocufen)
flurbiprofen sodium
FML FORTE
FML S.O.P.
(Acular)
ketorolac tromethamine
LOTEMAX drops susp
MAXIDEX
NASONEX
(Omnipred)
prednisolone acetate
(Prednisol)
prednisolone sod phosphate
RESTASIS
RHINOCORT AQUA
Requirements/Limits
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
(oral products only)
Gastrointestinal Agents
Antiulcer Agents And Acid Suppressants
CARAFATE oral susp
(Cimetidine HCl)
cimetidine hcl
(Tagamet)
cimetidine
(Famotidine In
famotidine in nacl,iso-osm/pf
Nacl,iso-osm/PF)
(Pepcid)
famotidine
lansoprazole capsule dr: 30mg
(Prevacid)
(Cytotec)
misoprostol
NEXIUM capsule dr, suspdr pkt: 20mg,
40mg
(Axid)
nizatidine
(Protonix)
pantoprazole sodium
ranitidine hcl syrup, tablet
(Zantac)
(Carafate)
sucralfate
1
1
1
1
NM
1
1
1
1
ST
1
1
1
1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
44
Geisinger Gold Standard Rx 2015 Part D Formulary
Formulary ID: 15222.000, Version: 9
Effective: March 01, 2015
Drug Name
Gastrointestinal Agents, Other
AMITIZA
cromolyn sodium
dicyclomine hcl
diphenoxylate hcl/atropine
glycopyrrolate
isopropamide/prochlorperazine
lactulose solution: 10; syrup
lactulose solution: 10g/15ml
loperamide hcl
methscopolamine bromide
metoclopramide hcl tablet
RELISTOR
ursodiol
Laxatives
GOLYTELY powd pack
MOVIPREP
OSMOPREP
peg 3350/na sulf,bicarb,cl/kcl
sodium chloride/nahco3/kcl/peg
Phosphate Binders
calcium acetate
FOSRENOL
RENAGEL
RENVELA
sodium polystyrene sulfonate
Drug Tier
(Gastrocrom)
(Bentyl)
(Lomotil)
(Robinul)
(Isopropamide/
prochlorperazine)
(Lactulose)
(Lactulose)
(Loperamide HCl)
(Pamine)
(Reglan)
(Actigall)
(Golytely)
(Nulytely with Flavor
Packs)
(Phoslo)
(Sodium Polystyrene
Sulfonate)
1
1
1
1
1
1
1
1
1
1
1
1
Requirements/Limits
QL: 60 in 30 days
NM, PA, QL: 18 in 30
days
1
1
1
1
1
1
1
1
1
1
1
Genitourinary Agents
Antispasmodics, Urinary
(Urispas)
flavoxate hcl
(Ditropan)
oxybutynin chloride
(Sanctura)
trospium chloride
VESICARE
Genitourinary Agents, Miscellaneous
(Uroxatral)
alfuzosin hcl
(Flomax)
tamsulosin hcl
1
1
1
1
(oral products only)
1
1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
45
Geisinger Gold Standard Rx 2015 Part D Formulary
Formulary ID: 15222.000, Version: 9
Effective: March 01, 2015
Drug Name
terazosin hcl
Drug Tier
(Hytrin)
Requirements/Limits
1
Heavy Metal Antagonists
Heavy Metal Antagonists
DEPEN
edetate disodium
EXJADE
FERRIPROX
SYPRINE
(Edetate Disodium)
1
1
1
1
1
NM
NM, PA
LA, NM, PA
NM, PA
Hormonal Agents, Stimulant/replacement/modifying
Androgens
ANDROGEL
danazol
fluoxymesterone
oxandrolone
Estrogens and Antiestrogens
CENESTIN
(Danocrine)
(Fluoxymesterone)
(Oxandrin)
1
1
1
1
1
ESTRACE cream/appl
estradiol
(Estrace)
1
1
estradiol/norethindrone acet
(Activella)
1
ESTRING
estropipate
(Ogen)
1
1
FEMRING
MENEST
norethindrone ac-eth estradiol
1
1
(Femhrt)
PREMARIN cream/appl
PREMARIN vial
1
1
1
PA (PA Req for Ages
65 and Older; High Risk
Med)
PA (PA Req for Ages
65 and Older; High Risk
Med)
PA (PA Req for Ages
65 and Older; High Risk
Med)
PA (PA Req for Ages
65 and Older; High Risk
Med)
PA (PA Req for Ages
65 and Older; High Risk
Med)
PA (PA Req for Ages
65 and Older; High Risk
Med)
NM
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
46
Geisinger Gold Standard Rx 2015 Part D Formulary
Formulary ID: 15222.000, Version: 9
Effective: March 01, 2015
Drug Name
Drug Tier
Requirements/Limits
PREMARIN tablet
1
PA (PA Req for Ages
65 and Older; High Risk
Med)
VAGIFEM
VIVELLE-DOT
1
1
Glucocorticoids/mineralocorticoids
(Cortisone Acetate)
cortisone acetate
DEXAMETHASONE INTENSOL
(Dexamethasone)
dexamethasone
(Fludrocortisone
fludrocortisone acetate
Acetate)
(Hydrocortisone Sod
hydrocortisone sod succinate
Succinate)
(Cortef)
hydrocortisone
(Depo-medrol)
methylprednisolone acetate
(A-methapred)
methylprednisolone sod succ
(Medrol)
methylprednisolone
(Prednisolone Acetate)
prednisolone acetate
(Orapred)
prednisolone sod phosphate
(Prednisone)
prednisone
SOLU-MEDROL vial: 40mg/ml
VERIPRED 20
Pituitary
CHORIONIC GONADOTROPIN
desmopressin acetate tablet
(DDAVP)
desmopressin acetate vial
(DDAVP)
GENOTROPIN
INCRELEX
NORDITROPIN FLEXPRO
NUTROPIN AQ NUSPIN
(Sandostatin)
octreotide acetate
SOMATULINE DEPOT
SOMAVERT
SUPPRELIN
Progestins
CRINONE gel/pf app: 4%
DEPO-PROVERA vial: 400mg/ml
1
1
1
1
PA (PA Req for Ages
65 and Older; High Risk
Med)
PA BvD
PA BvD
1
NM, PA BvD
1
1
1
1
1
1
1
1
1
PA BvD
NM, PA BvD
NM, PA BvD
PA BvD
NM, PA BvD
PA BvD
PA BvD
NM, PA BvD
PA BvD
1
1
1
1
1
1
1
1
1
1
1
NM
NM
NM, PA
NM
NM, PA
NM, PA
NM
NM, PA
LA, NM
NM
1
1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
47
Geisinger Gold Standard Rx 2015 Part D Formulary
Formulary ID: 15222.000, Version: 9
Effective: March 01, 2015
Drug Name
medroxyprogesterone acetate vial
medroxyprogesterone acetate tablet
norethindrone acetate
Thyroid and Antithyroid Agents
levothyroxine sodium
LEVOXYL
liothyronine sodium tablet
liothyronine sodium vial
methimazole
propylthiouracil
SYNTHROID
UNITHROID
Drug Tier
(Depo-provera)
(Provera)
(Aygestin)
1
1
1
(Levoxyl)
1
1
1
1
1
1
1
1
(Cytomel)
(Triostat)
(Tapazole)
(Propylthiouracil)
Requirements/Limits
NM
NM
Immunological Agents
Immunological Agents
ANTIVENIN MICRURUS FULVIUS
ARCALYST
ATGAM
AZASAN
azathioprine
CARIMUNE NF NANOFILTERED
CELLCEPT vial
CELLCEPT susp recon
cyclosporine vial
cyclosporine capsule
cyclosporine, modified
ENBREL
(Imuran)
(Cyclosporine)
(Sandimmune)
(Neoral)
1
1
1
1
1
1
1
1
1
1
1
1
GAMMAGARD LIQUID
GAMUNEX-C
HUMIRA syringekit
1
1
1
HUMIRA pen ij kit: 40mg/0.8ml
1
HUMIRA pen ij kit: 40mg/0.8ml
1
ILARIS
NULOJIX
PRIVIGEN
PROGRAF ampul
1
1
1
1
NM
NM
NM
PA BvD
PA BvD
NM, PA
NM, PA BvD
PA BvD
NM, PA BvD
PA BvD
PA BvD
NM, PA, QL: 8 in 14
days (4 syringes)
NM, PA
NM, PA
NM, PA, QL: 2 in 28
days
NM, PA, QL: 4 in 28
days
NM, PA, QL: 6 in 28
days (Starter Kit)
NM, PA
NM, PA NSO
NM, PA
NM, PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
48
Geisinger Gold Standard Rx 2015 Part D Formulary
Formulary ID: 15222.000, Version: 9
Effective: March 01, 2015
Drug Name
RAPAMUNE solution, tablet: 1mg, 2mg
RIDAURA
tacrolimus
THYMOGLOBULIN
TYSABRI
ZORTRESS tablet: 0.5mg, 0.75mg
ZORTRESS tablet: 0.25mg
Vaccines
ACTHIB
ADACEL TDAP
BOOSTRIX TDAP
CERVARIX
COMVAX
DAPTACEL DTAP
ENGERIX-B ADULT syringe
ENGERIX-B ADULT vial
IPOL
IXIARO
MENHIBRIX
MENOMUNE-A-C-Y-W-135
MENVEO A-C-Y-W-135-DIP
M-M-R II VACCINE
PROQUAD
RABAVERT
RECOMBIVAX HB vial: 40mcg/ml
TE ANATOXAL BERNA
TETANUS DIPHTHERIA TOXOIDS
TYPHIM VI
VAQTA
VARIVAX VACCINE
YF-VAX
ZOSTAVAX
Drug Tier
(Hecoria)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Requirements/Limits
PA BvD
PA BvD
NM
LA, NM, PA
NM, PA NSO
PA NSO
NM
NM
NM
NM
NM
NM
NM, PA BvD
PA BvD
NM
NM
NM
NM
NM
NM
NM, PA BvD
NM, PA BvD
NM, PA BvD
NM
NM
NM
NM
NM
NM
Inflammatory Bowel Disease Agents
Inflammatory Bowel Disease Agents
ASACOL HD
(Colazal)
balsalazide disodium
CANASA
DIPENTUM
(Rowasa)
mesalamine w/cleansing wipes
1
1
1
1
1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
49
Geisinger Gold Standard Rx 2015 Part D Formulary
Formulary ID: 15222.000, Version: 9
Effective: March 01, 2015
Drug Name
Drug Tier
PENTASA
Requirements/Limits
1
Irrigating Solutions
Irrigating Solutions
LACTATED RINGERS
ringers solution
sodium chloride irrig solution
urologic solution-g
water for irrigation,sterile
(Tis-u-sol)
(Sodium Chloride Irrig
Solution)
(Urologic Solution-g)
(Water for Irrigation,
Sterile)
1
1
1
1
1
Metabolic Bone Disease Agents
Metabolic Bone Disease Agents
ACTONEL tablet: 30mg
alendronate sodium
BONIVA syringe
calcitonin,salmon,synthetic
calcitriol ampul
(Miacalcin)
(Calcijex)
1
1
1
1
1
calcitriol capsule, solution
(Rocaltrol)
1
etidronate disodium
FORTEO
FORTICAL
FOSAMAX PLUS D
HECTOROL vial
MIACALCIN vial
(Didronel)
1
1
1
1
1
1
pamidronate disodium vial: 60mg/10ml,
90mg/10ml
pamidronate disodium vial: 30mg/10ml
PROLIA
XGEVA
ZEMPLAR vial
(Aredia)
1
(Aredia)
1
1
1
1
PA BvD
PA
NM, PA NSO
NM, PA BvD (PA for
ESRD only)
Miscellaneous Therapeutic Agents
ACTEMRA
1
ACTIMMUNE
1
NM, PA, QL: 40 in 30
days
LA, NM
(Fosamax)
NM, PA
NM, PA BvD (PA for
ESRD only)
PA BvD (PA for ESRD
only)
NM, PA
PA BvD
NM, PA BvD (PA for
ESRD only)
NM, PA BvD
Miscellaneous Therapeutic Agents
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
50
Geisinger Gold Standard Rx 2015 Part D Formulary
Formulary ID: 15222.000, Version: 9
Effective: March 01, 2015
Drug Name
allopurinol
amifostine crystalline
ammonium chloride
AVODART
AVONEX ADMINISTRATION PACK
AVONEX
bethanechol chloride
buspirone hcl
citrate phosphate dextros soln
colchicine/probenecid
COLCRYS
COPAXONE
dexrazoxane hcl
ELMIRON
ergoloid mesylates tablet
finasteride
fomepizole
FUSILEV
gauze bandage
GILENYA
GLUCAGEN
GLUCAGON EMERGENCY KIT
glutethimide
hydroxyzine hcl vial
Drug Tier
(Zyloprim)
(Ethyol)
(Ammonium Chloride)
(Urecholine)
(Buspar)
(Citrate Phosphate
Dextros Soln)
(Colchicine/
probenecid)
1
1
1
1
1
1
1
1
1
(Glutethimide)
(Hydroxyzine HCl)
hydroxyzine hcl syrup, tablet
(Hydroxyzine HCl)
1
hydroxyzine hcl syrup, tablet
hydroxyzine pamoate
(Hydroxyzine HCl)
(Vistaril)
1
1
leucovorin calcium tablet, vial: 200mg
leucovorin calcium vial: 350mg
levocarnitine (with sugar)
(Leucovorin Calcium)
(Leucovorin Calcium)
(Carnitor)
1
1
1
(Ergoloid Mesylates)
(Proscar)
(Antizol)
(Dermacea)
NM
NM
NM, ST
NM, ST
NM
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
(Totect)
Requirements/Limits
QL: 60 in 30 days
NM
NM
NM
NM
NM
NM
NM
NM, PA (PA Req for
Ages 65 and Older; High
Risk Med)
PA (PA Req for Ages
65 and Older; High Risk
Med)
PA
PA (PA Req for Ages
65 and Older; High Risk
Med)
NM
PA BvD (PA for ESRD
only)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
51
Geisinger Gold Standard Rx 2015 Part D Formulary
Formulary ID: 15222.000, Version: 9
Effective: March 01, 2015
Drug Name
Drug Tier
Requirements/Limits
NM, PA BvD (PA for
ESRD only)
PA BvD (PA for ESRD
only)
PA (PA Req for Ages
65 and Older; High Risk
Med)
NM
levocarnitine vial
(Carnitor)
1
levocarnitine tablet
(Carnitor)
1
meprobamate
(Miltown)
1
mesna
MESNEX tablet
methylergonovine maleate
probenecid
pyridostigmine bromide
REMICADE
SENSIPAR tablet: 30mg
SENSIPAR tablet: 60mg, 90mg
SIMULECT
SYNAREL
THALOMID
ULORIC
(Mesnex)
1
1
1
1
1
1
1
1
1
1
1
1
(Methergine)
(Probenecid)
(Mestinon)
NM, PA
NM
NM, PA BvD
NM
NM
ST
Ophthalmic Agents
Antiglaucoma Agents
acetazolamide sodium
acetazolamide
ALPHAGAN P drops: 0.1%
AZOPT
betaxolol hcl
BETOPTIC S
brimonidine tartrate
dorzolamide hcl
dorzolamide hcl/timolol maleat
latanoprost
levobunolol hcl
LUMIGAN
methazolamide
metipranolol
PHOSPHOLINE IODIDE
timolol maleate
(Acetazolamide
Sodium)
(Acetazolamide)
(Betaxolol HCl)
(Alphagan P)
(Trusopt)
(Cosopt)
(Xalatan)
(Betagan)
(Neptazane)
(Optipranolol)
(Timoptic)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
NM
ST
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
52
Geisinger Gold Standard Rx 2015 Part D Formulary
Formulary ID: 15222.000, Version: 9
Effective: March 01, 2015
Drug Name
Drug Tier
Requirements/Limits
Replacement Preparations
Replacement Preparations
dex 2.5%-half str lact.ringers
electrolyte-48/fructose 10 %
electrolyte-48/fructose 5 %
electrolyte-75/fructose 5 %
KLOR-CON 10
KLOR-CON-EF
potassium chloride in 0.9%nacl
potassium chloride in d5w
potassium chloride tab er prt, tablet er
potassium chloride tablet sa
potassium chloride piggyback
potassium chloride/d5-0.2%nacl
potassium chloride/d5-0.45nacl iv soln:
20meq/l
potassium chloride/d5-0.45nacl iv soln:
10meq/l, 30meq/l, 40meq/l
potassium chloride/d5-0.9%nacl
potassium chloride/d5w
potassium chloride-0.45% nacl
potassium gluconate
ringers solution
sodium chloride 0.45 %
sodium chloride 3 %
sodium chloride 5 %
sodium chloride
sodium lactate vial
(Dex 2.5%-half Str
Lact.ringers)
(Electrolyte-48/fructose
10 %)
(Electrolyte-48/fructose
5 %)
(Electrolyte-75/fructose
5 %)
(Potassium Chloride In
0.9%NaCl)
(Potassium Chloride In
D5w)
(K-dur)
(Potassium Chloride)
(Potassium Chloride)
(Potassium Chloride/
d5-0.2%NaCl)
(Potassium Chloride/
d5-0.45NaCl)
(Potassium Chloride/
d5-0.45NaCl)
(Potassium Chloride/
d5-0.9%NaCl)
(Potassium Chloride/
D5W)
(Potassium Chloride0.45% NaCl)
(Potassium Gluconate)
(Ringers Solution)
(Sodium Chloride 0.45
%)
(Sodium Chloride 3 %)
(Sodium Chloride 5 %)
(Sodium Chloride)
(Sodium Lactate)
1
NM
1
NM
1
NM
1
NM
1
1
1
1
NM
1
1
1
1
NM
NM
1
1
NM
1
NM
1
NM
1
NM
1
1
1
NM
1
1
1
1
NM
NM
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
53
Geisinger Gold Standard Rx 2015 Part D Formulary
Formulary ID: 15222.000, Version: 9
Effective: March 01, 2015
Drug Name
Drug Tier
TPN ELECTROLYTES II
Requirements/Limits
1
Respiratory Tract Agents
Anti-inflammatories, Inhaled Corticosteroids
(Pulmicort)
budesonide
DULERA
FLOVENT DISKUS
FLOVENT HFA
PULMICORT FLEXHALER
PULMICORT ampul-neb: 1mg/2ml
SYMBICORT
Antileukotrienes
(Accolate)
zafirlukast
ZYFLO CR
Bronchodilators
albuterol sulfate solution, vial-neb
(Accuneb)
albuterol sulfate syrup, tab er 12h, tablet
(Albuterol Sulfate)
(Aminophylline)
aminophylline
ATROVENT HFA
BROVANA
FORADIL
(Ipratropium Bromide)
ipratropium bromide
(Duoneb)
ipratropium/albuterol sulfate
(Isoetharine HCl)
isoetharine hcl
(Xopenex)
levalbuterol hcl
(Metaproterenol
metaproterenol sulfate
Sulfate)
PERFOROMIST
SPIRIVA
(Brethine)
terbutaline sulfate
(Theochron)
theophylline anhydrous
Respiratory Tract Agents, Other
(Acetadote)
acetylcysteine
ARALAST NP
(Intal)
cromolyn sodium
DALIRESP
XOLAIR
1
1
1
1
1
1
1
PA BvD
PA BvD
1
1
1
1
1
1
1
1
1
1
1
1
1
PA BvD
NM
PA
PA BvD
PA BvD
PA BvD
PA
1
1
1
1
PA
1
1
1
1
1
PA BvD
NM, PA
PA BvD
PA
NM, PA
Skeletal Muscle Relaxants
Skeletal Muscle Relaxants
baclofen
(Baclofen)
1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
54
Geisinger Gold Standard Rx 2015 Part D Formulary
Formulary ID: 15222.000, Version: 9
Effective: March 01, 2015
Drug Name
Drug Tier
Requirements/Limits
PA (PA Req for Ages
65 and Older; High Risk
Med)
PA (PA Req for Ages
65 and Older; High Risk
Med)
PA (PA Req for Ages
65 and Older; High Risk
Med)
PA (PA Req for Ages
65 and Older; High Risk
Med)
PA (PA Req for Ages
65 and Older; High Risk
Med)
carisoprodol
(Soma)
1
carisoprodol/aspirin
(Carisoprodol/aspirin)
1
chlorzoxazone
(Parafon Forte DSC)
1
codeine/carisoprodol/aspirin
(Codeine/carisoprodol/
aspirin)
1
cyclobenzaprine hcl tablet: 5mg
(Fexmid)
1
dantrolene sodium
methocarbamol
(Dantrium)
(Robaxin)
1
1
orphenadrine citrate
(Norflex)
1
tizanidine hcl
(Zanaflex)
1
Sleep Disorder Agents
NUVIGIL
ROZEREM
XYREM
zaleplon
(Sonata)
1
1
1
1
zolpidem tartrate
(Ambien)
1
PA (PA Req for Ages
65 and Older; High Risk
Med)
NM, PA (PA Req for
Ages 65 and Older; High
Risk Med)
Sleep Disorder Agents
PA
QL: 30 in 30 days
LA, NM
PA, QL: 90 in 365 days
(PA Req for Ages 65 and
Older; High Risk Med)
PA, QL: 90 in 365 days
(PA Req for Ages 65 and
Older; High Risk Med)
Vasodilating Agents
Vasodilating Agents
LETAIRIS
REVATIO vial
TRACLEER
1
1
1
LA, NM, PA
NM, PA
LA, NM, PA
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
55
Geisinger Gold Standard Rx 2015 Part D Formulary
Formulary ID: 15222.000, Version: 9
Effective: March 01, 2015
Drug Name
Drug Tier
VENTAVIS
1
Requirements/Limits
NM, PA
Vitamins and Minerals
Vitamins and Minerals
ped mv a,c,d3 #21 w-fluoride
pnv with ca,no.72/iron/fa
(Ped Mv A,c,d3 #21
W-fluoride)
(Pnv with Ca,no.72/
iron/fa)
1
1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
56
Geisinger Gold Standard Rx 2015 Part D Formulary
Formulary ID: 15222.000, Version: 9
Effective: March 01, 2015
INDEX
8-MOP................................... 40
ABELCET............................. 26
ABILIFY............................... 29
ABILIFY DISCMELT.......... 29
acarbose................................ 25
acebutolol hcl........................ 36
acetaminophen with codeine. 14
acetazolamide ....................... 52
acetazolamide sodium........... 52
acetic acid ............................. 43
acetic acid/hydrocortisone.... 43
acetylcysteine ........................ 54
ACTEMRA ........................... 50
ACTHIB................................ 49
ACTIMMUNE...................... 50
ACTONEL............................ 50
ACTOPLUS MET XR.......... 25
acyclovir................................ 32
acyclovir sodium ................... 32
ADACEL TDAP................... 49
ADAGEN.............................. 42
adapalene.............................. 41
AFINITOR............................ 20
AGGRENOX ........................ 33
ALBENZA............................ 28
albuterol sulfate .................... 54
alclometasone dipropionate.. 41
alcohol antiseptic pads ......... 40
ALDACTAZIDE .................. 38
ALDURAZYME................... 42
alendronate sodium............... 50
alfuzosin hcl .......................... 45
ALIMTA ............................... 20
ALINIA................................. 28
allopurinol............................. 51
ALOCRIL ............................. 44
ALOMIDE ............................ 42
ALPHAGAN P ..................... 52
alprazolam ............................ 16
ALPRAZOLAM INTENSOL16
ALREX ................................. 44
amantadine hcl...................... 29
AMBISOME ......................... 26
amcinonide............................ 41
AMETHYST......................... 39
amifostine crystalline ............ 51
amikacin sulfate .................... 16
amiloride hcl ......................... 37
aminophylline........................ 54
AMINOSYN II ..................... 33
AMINOSYN M .................... 34
AMINOSYN-HBC ............... 34
AMINOSYN-PF ................... 34
amiodarone hcl ..................... 36
AMITIZA.............................. 45
amitrip hcl/chlordiazepoxide 24
amitriptyline hcl .................... 24
amlodipine besylate .............. 37
amlodipine besylate/benazepril
........................................... 37
ammonium chloride .............. 51
amoxapine ............................. 24
amoxicillin............................. 19
amoxicillin/potassium clav.... 19
amphotericin b ...................... 26
ampicillin sodium.................. 19
ampicillin sodium/sulbactam na
........................................... 19
ampicillin trihydrate ............. 19
AMPYRA ............................. 39
anastrozole............................ 20
ANDROGEL......................... 46
ANTIVENIN MICRURUS
FULVIUS.......................... 48
ANZEMET ........................... 28
APLENZIN ........................... 24
APOKYN.............................. 29
apraclonidine hcl .................. 42
APTIVUS.............................. 30
ARALAST NP ...................... 54
ARANESP ............................ 33
ARCALYST ......................... 48
ARRANON........................... 20
ARZERRA............................ 20
ASACOL HD........................ 49
atenolol ................................. 36
atenolol/chlorthalidone......... 36
ATGAM................................ 48
atorvastatin calcium.............. 38
atovaquone/proguanil hcl ..... 28
ATRIPLA.............................. 30
atropine sulfate ..................... 22
ATROVENT HFA ................ 54
AVASTIN ............................. 20
AVODART ........................... 51
AVONEX.............................. 51
AVONEX
ADMINISTRATION PACK
........................................... 51
AXERT ................................. 27
AZACTAM........................... 18
AZASAN .............................. 48
AZASITE.............................. 43
azathioprine .......................... 48
azelastine hcl......................... 43
AZILECT.............................. 29
azithromycin.......................... 18
AZOPT.................................. 52
aztreonam.............................. 18
bacitracin .............................. 17
bacitracin/polymyxin b sulfate
........................................... 43
baclofen................................. 54
balsalazide disodium............. 49
BANZEL............................... 23
BARACLUDE ...................... 32
benazepril hcl........................ 35
I-1
Geisinger Gold Standard Rx 2015 Part D Formulary
Formulary ID: 15222.000, Version: 9
Effective: March 01, 2015
benazepril/hydrochlorothiazide
........................................... 35
BENICAR ............................. 35
BENICAR HCT .................... 35
benztropine mesylate............. 29
BESIVANCE ........................ 43
betamethasone dipropionate. 41
betamethasone valerate ........ 41
betamethasone/propylene glyc
........................................... 41
betaxolol hcl.......................... 52
bethanechol chloride............. 51
BETOPTIC S ........................ 52
bicalutamide.......................... 20
BICILLIN L-A...................... 19
BICNU .................................. 20
BILTRICIDE ........................ 28
bisoprolol fumarate............... 36
bisoprolol fumarate/hctz ....... 36
bleomycin sulfate .................. 20
BLEPHAMIDE..................... 43
BLEPHAMIDE S.O.P. ......... 43
BONIVA ............................... 50
BOOSTRIX TDAP ............... 49
BRILINTA............................ 33
brimonidine tartrate.............. 52
bromfenac sodium................. 44
bromocriptine mesylate......... 29
BROVANA........................... 54
budesonide ............................ 54
bumetanide............................ 37
buprenorphine hcl........... 14, 16
bupropion hcl ........................ 24
buspirone hcl......................... 51
butorphanol tartrate.............. 14
BUTRANS............................ 14
cabergoline ........................... 29
calcipotriene ......................... 40
calcitonin,salmon,synthetic... 50
calcitriol................................ 50
calcium acetate ..................... 45
CANASA .............................. 49
CANCIDAS .......................... 27
CAPASTAT SULFATE ....... 28
CAPRELSA .......................... 20
captopril................................ 35
captopril/hydrochlorothiazide
........................................... 35
CARAC................................. 40
CARAFATE ......................... 44
carbamazepine ...................... 23
carbidopa/levodopa .............. 29
carboplatin............................ 20
CARIMUNE NF
NANOFILTERED ............ 48
carisoprodol.......................... 55
carisoprodol/aspirin ............. 55
carteolol hcl .......................... 43
carvedilol .............................. 36
cefaclor ................................. 17
cefadroxil .............................. 17
cefazolin sodium.................... 18
cefepime hcl .......................... 18
cefotetan disodium ................ 18
cefoxitin sodium .................... 18
cefoxitin sodium/dextrose,iso 18
cefprozil................................. 18
CEFTAZIDIME.................... 18
ceftazidime pentahydrate ...... 18
ceftriaxone na/dextrose,iso ... 18
ceftriaxone sodium ................ 18
cefuroxime axetil................... 18
cefuroxime sodium ................ 18
CELEBREX.......................... 15
CELLCEPT........................... 48
CELONTIN........................... 23
CENESTIN ........................... 46
cephalexin ............................. 18
CEREZYME ......................... 42
CERVARIX .......................... 49
cetirizine hcl.......................... 27
CHANTIX............................. 16
chloramphenicol sod succ..... 17
chlorhexidine gluconate........ 40
chloroquine phosphate.......... 28
chlorothiazide ....................... 37
chlorothiazide sodium........... 37
chlorpromazine hcl ............... 29
chlorpropamide..................... 26
chlorthalidone ....................... 37
chlorzoxazone ....................... 55
cholestyramine (with sugar) . 38
cholestyramine/aspartame .... 38
CHORIONIC
GONADOTROPIN........... 47
ciclopirox .............................. 27
ciclopirox olamine ................ 27
cilostazol ............................... 33
CILOXAN............................. 43
cimetidine.............................. 44
cimetidine hcl ........................ 44
CIMZIA ................................ 42
CINRYZE ............................. 33
CIPRODEX........................... 43
ciprofloxacin hcl ............. 19, 43
ciprofloxacin/ciprofloxa hcl.. 19
cisplatin................................. 20
citalopram hydrobromide ..... 24
citrate phosphate dextros soln
........................................... 51
cladribine .............................. 20
clarithromycin....................... 18
clindamycin hcl ..................... 17
clindamycin phos/benzoyl perox
........................................... 40
clindamycin phosphate... 17, 27,
40
CLINISOL ............................ 34
clobetasol propionate............ 41
CLOLAR............................... 20
clomipramine hcl .................. 24
clonidine................................ 35
clonidine hcl.......................... 35
clonidine hcl/chlorthalidone . 35
clotrimazole........................... 27
I-2
Geisinger Gold Standard Rx 2015 Part D Formulary
Formulary ID: 15222.000, Version: 9
Effective: March 01, 2015
clotrimazole/betamethasone dip
........................................... 27
clozapine ............................... 29
COARTEM ........................... 28
codeine/carisoprodol/aspirin 55
colchicine/probenecid ........... 51
COLCRYS ............................ 51
colestipol hcl ......................... 38
colistin (colistimethate na).... 17
COMPLERA......................... 30
COMVAX............................. 49
CONDYLOX ........................ 40
COPAXONE......................... 51
cortisone acetate ................... 47
COUMADIN......................... 32
CREON ................................. 42
CRESTOR............................. 38
CRINONE............................. 47
CRIXIVAN ........................... 31
cromolyn sodium....... 43, 45, 54
CUBICIN .............................. 17
cyclobenzaprine hcl .............. 55
CYCLOSET.......................... 25
cyclosporine .......................... 48
cyclosporine, modified .......... 48
CYSTAGON......................... 42
cytarabine ............................. 20
cytarabine/pf ......................... 20
dacarbazine........................... 20
DALIRESP ........................... 54
danazol.................................. 46
dantrolene sodium................. 55
dapsone ................................. 28
DAPTACEL DTAP .............. 49
DARAPRIM ......................... 28
daunorubicin hcl ................... 20
demeclocycline hcl ................ 20
DEMSER .............................. 37
DEPEN.................................. 46
DEPO-PROVERA ................ 47
desipramine hcl..................... 24
desmopressin acetate ............ 47
desog-e.estradiol/e.estradiol. 39
desogestrel-ethinyl estradiol. 39
desonide ................................ 41
desoximetasone ..................... 41
dex 2.5%-half str lact.ringers 53
dexamethasone...................... 47
DEXAMETHASONE
INTENSOL ....................... 47
dexamethasone sod phosphate
........................................... 44
dexmethylphenidate hcl......... 39
dexrazoxane hcl .................... 51
dextroamphetamine sulfate ... 39
dextroamphetamine/
amphetamine ..................... 39
dextrose 10 % and 0.2 % nacl
........................................... 34
dextrose 10 % and 0.45 % nacl
........................................... 34
dextrose 10 % in water ......... 34
dextrose 2.5 % and 0.45 % nacl
........................................... 34
dextrose 2.5% in half ringers 34
dextrose 5 % and 0.3 % nacl 34
dextrose 5 % and 0.9 % nacl 34
dextrose 5 % in water ........... 34
dextrose 5 %-0.2 % nacl ....... 34
dextrose 5 %-0.45 % nacl ..... 34
dextrose 5%-lactated ringers 34
diazepam ............................... 16
diclofenac potassium............. 15
diclofenac sodium ........... 15, 44
dicloxacillin sodium .............. 19
dicyclomine hcl ..................... 45
didanosine ............................. 31
diflorasone diacetate............. 41
diflunisal ............................... 15
digoxin................................... 37
dihydroergotamine mesylate. 27
DILANTIN ........................... 23
diltiazem hcl .......................... 37
DIOVAN............................... 35
DIPENTUM.......................... 49
diphenoxylate hcl/atropine.... 45
dipyridamole ......................... 33
disopyramide phosphate ....... 36
disulfiram .............................. 16
divalproex sodium................. 23
DOCEFREZ.......................... 20
docetaxel ............................... 20
donepezil hcl ......................... 24
dopamine hcl......................... 37
dorzolamide hcl..................... 52
dorzolamide hcl/timolol maleat
........................................... 52
doxazosin mesylate................ 35
doxepin hcl ............................ 24
doxycycline hyclate ............... 20
doxycycline monohydrate...... 20
dronabinol............................. 28
DROXIA ............................... 20
DULERA .............................. 54
DURAMORPH ..................... 14
econazole nitrate................... 27
EDARBI................................ 35
EDARBYCLOR ................... 35
edetate disodium ................... 46
EDURANT ........................... 31
EFFIENT............................... 33
ELAPRASE .......................... 42
electrolyte-48/fructose 10 % . 53
electrolyte-48/fructose 5 % ... 53
electrolyte-75/fructose 5 % ... 53
ELIDEL................................. 41
ELIGARD ............................. 20
ELITEK................................. 42
ELLA .................................... 39
ELMIRON ............................ 51
ELOXATIN .......................... 20
EMCYT................................. 20
EMEND ................................ 28
EMTRIVA ............................ 31
enalapril maleate .................. 35
I-3
Geisinger Gold Standard Rx 2015 Part D Formulary
Formulary ID: 15222.000, Version: 9
Effective: March 01, 2015
enalapril/hydrochlorothiazide
........................................... 35
ENBREL ............................... 48
ENGERIX-B ADULT .......... 49
enoxaparin sodium................ 32
epinastine hcl ........................ 43
epirubicin hcl ........................ 20
EPIVIR.................................. 31
eplerenone............................. 38
EPOGEN............................... 33
eprosartan mesylate .............. 35
EPZICOM ............................. 31
ERBITUX ............................. 20
ergoloid mesylates ................ 51
ERY-TAB ............................. 18
erythromycin base................. 18
erythromycin base/ethanol.... 40
erythromycin ethylsuccinate . 18
erythromycin stearate ........... 18
erythromycin/benzoyl peroxide
........................................... 40
ESTRACE............................. 46
estradiol ................................ 46
estradiol/norethindrone acet. 46
ESTRING.............................. 46
estropipate............................. 46
ethambutol hcl....................... 28
ethinyl estradiol/drospirenone
........................................... 39
ethosuximide ......................... 23
ethynodiol d-ethinyl estradiol 39
etidronate disodium .............. 50
etodolac................................. 15
ETOPOPHOS ....................... 20
exemestane ............................ 20
EXJADE ............................... 46
FABRAZYME...................... 42
famciclovir ............................ 32
famotidine ............................. 44
famotidine in nacl,iso-osm/pf 44
FANAPT ............................... 29
FARESTON.......................... 20
FASLODEX.......................... 20
FAZACLO ............................ 30
felbamate............................... 23
felodipine............................... 37
FEMRING............................. 46
fenofibrate ............................. 38
fenofibrate,micronized .......... 38
fenoprofen calcium................ 15
fentanyl.................................. 14
fentanyl citrate ...................... 14
FERRIPROX......................... 46
finasteride ............................. 51
FIRAZYR ............................. 37
FIRMAGON ......................... 20
FLAREX ............................... 44
flavoxate hcl .......................... 45
flecainide acetate .................. 36
FLOVENT DISKUS............. 54
FLOVENT HFA ................... 54
fluconazole ............................ 27
fluconazole in nacl,iso-osm... 27
flucytosine ............................. 27
fludarabine phosphate .......... 21
fludrocortisone acetate ......... 47
fluocinolone acetonide .......... 41
fluocinolone acetonide oil..... 44
fluocinonide........................... 41
fluorouracil ..................... 21, 40
fluoxetine hcl......................... 24
fluoxymesterone .................... 46
fluphenazine decanoate......... 30
fluphenazine hcl .................... 30
flurbiprofen ........................... 15
flurbiprofen sodium............... 44
fluticasone propionate .......... 41
fluvoxamine maleate ............. 24
FML FORTE......................... 44
FML S.O.P. ........................... 44
FOLOTYN............................ 21
fomepizole ............................. 51
fondaparinux sodium ...... 32, 33
FORADIL ............................. 54
FORTEO ............................... 50
FORTICAL ........................... 50
FOSAMAX PLUS D ............ 50
foscarnet sodium ................... 31
fosinopril sodium .................. 35
fosphenytoin sodium.............. 23
FOSRENOL.......................... 45
fructose 10 % ........................ 34
furosemide............................. 37
FUSILEV .............................. 51
FUZEON............................... 31
gabapentin............................. 23
GABITRIL............................ 23
galantamine hbr .................... 24
GAMMAGARD LIQUID..... 48
GAMUNEX-C ...................... 48
ganciclovir sodium................ 32
gauze bandage ...................... 51
gemcitabine hcl ..................... 21
gemfibrozil ............................ 38
GENOTROPIN ..................... 47
gentamicin in nacl, iso-osm .. 17
gentamicin sulfate ..... 17, 40, 43
GEODON.............................. 30
GILENYA............................. 51
GLEEVEC ............................ 21
glimepiride ............................ 26
glipizide................................. 26
glipizide/metformin hcl ......... 26
GLUCAGEN......................... 51
GLUCAGON EMERGENCY
KIT.................................... 51
glutethimide........................... 51
glyburide ............................... 26
glyburide,micronized ............ 26
glycopyrrolate ....................... 45
GLYSET ............................... 25
GOLYTELY ......................... 45
granisetron hcl ...................... 28
griseofulvin, microsize .......... 27
HALAVEN ........................... 21
halobetasol propionate ......... 41
I-4
Geisinger Gold Standard Rx 2015 Part D Formulary
Formulary ID: 15222.000, Version: 9
Effective: March 01, 2015
haloperidol............................ 30
haloperidol decanoate .......... 30
haloperidol lactate ................ 30
HECTOROL ......................... 50
heparin sod,pork in 0.45% nacl
........................................... 33
heparin sodium,porcine ........ 33
heparin sodium,porcine/d5w. 33
HERCEPTIN......................... 21
HUMIRA .............................. 48
hydralazine hcl...................... 37
hydralazine/hydrochlorothiazid
........................................... 37
hydralazine/reserpin/hctz...... 37
hydrochlorothiazide .............. 37
hydrocodone/acetaminophen 14
hydrocodone/ibuprofen ......... 14
hydrocortisone ................ 41, 47
hydrocortisone acetate/aloe v41
hydrocortisone acetate/urea . 41
hydrocortisone sod succinate 47
hydrocortisone valerate ........ 41
hydromorphone hcl ............... 14
hydromorphone hcl/pf........... 14
hydroxychloroquine sulfate... 28
hydroxyurea .......................... 21
hydroxyzine hcl ..................... 51
hydroxyzine pamoate ............ 51
ibuprofen ............................... 15
ibuprofen/oxycodone hcl....... 14
idarubicin hcl ........................ 21
ifosfamide.............................. 21
ILARIS.................................. 48
imipenem/cilastatin sodium .. 18
imipramine hcl ...................... 24
imipramine pamoate ............. 24
imiquimod ............................. 40
INCRELEX........................... 47
indapamide............................ 37
INTELENCE......................... 31
INTRON A............................ 32
INTUNIV.............................. 39
INVANZ ............................... 19
INVEGA ............................... 30
INVEGA SUSTENNA ......... 30
INVIRASE............................ 31
IPOL...................................... 49
ipratropium bromide....... 43, 54
ipratropium/albuterol sulfate 54
irinotecan hcl ........................ 21
ISENTRESS.......................... 31
isoetharine hcl....................... 54
isoniazid ................................ 28
isopropamide/prochlorperazine
........................................... 45
isosorbide dinitrate ............... 38
isosorbide mononitrate ......... 38
isotretinoin ............................ 40
isradipine .............................. 37
ISTODAX ............................. 21
itraconazole........................... 27
IXEMPRA............................. 21
IXIARO................................. 49
JANUMET............................ 25
JANUVIA ............................. 25
JEVTANA............................. 21
KALETRA............................ 31
kanamycin sulfate.................. 17
KETEK ................................. 18
ketoconazole.......................... 27
ketoprofen ............................. 15
ketorolac tromethamine ........ 44
KLOR-CON 10..................... 53
KLOR-CON-EF.................... 53
KUVAN ................................ 42
labetalol hcl .......................... 36
LACTATED RINGERS ....... 50
lactulose ................................ 45
LAMICTAL GREEN............ 23
LAMICTAL ODT................. 23
LAMICTAL ORANGE ........ 23
LAMICTAL XR BLUE........ 23
LAMICTAL XR GREEN ..... 23
LAMICTAL XR ORANGE.. 23
lamivudine............................. 31
lamivudine/zidovudine .......... 31
lamotrigine............................ 23
lansoprazole.......................... 44
LANTUS............................... 25
latanoprost ............................ 52
LATUDA .............................. 30
LETAIRIS............................. 55
letrozole................................. 21
leucovorin calcium................ 51
LEUKERAN ......................... 21
leuprolide acetate.................. 21
levalbuterol hcl ..................... 54
LEVEMIR............................. 25
levetiracetam......................... 23
levobunolol hcl...................... 52
levocarnitine ......................... 52
levocarnitine (with sugar)..... 51
levocetirizine dihydrochloride
........................................... 27
levofloxacin ..................... 19, 43
levofloxacin/d5w ................... 19
levonorgestrel-ethin estradiol39
levorphanol tartrate .............. 14
levothyroxine sodium ............ 48
LEVOXYL............................ 48
LEXIVA................................ 31
lidocaine................................ 16
lidocaine hcl.................... 15, 16
lidocaine hcl/pf................ 16, 36
lidocaine/prilocaine .............. 16
LINCOCIN ........................... 17
liothyronine sodium .............. 48
lisinopril................................ 35
lisinopril/hydrochlorothiazide
........................................... 35
lithium carbonate .................. 39
l-norgest-eth estr/ethin estra. 39
loperamide hcl ...................... 45
lorazepam.............................. 16
losartan potassium ................ 35
losartan/hydrochlorothiazide 35
I-5
Geisinger Gold Standard Rx 2015 Part D Formulary
Formulary ID: 15222.000, Version: 9
Effective: March 01, 2015
LOTEMAX ........................... 44
LOTRONEX ......................... 42
lovastatin............................... 38
LOVAZA .............................. 38
loxapine succinate................. 30
LUMIGAN............................ 52
LUPRON DEPOT................. 21
LUPRON DEPOT-PED........ 21
LYRICA................................ 23
LYSODREN ......................... 21
malathion .............................. 41
maprotiline hcl ...................... 24
MARPLAN ........................... 24
MATULANE ........................ 21
MAXIDEX............................ 44
meclofenamate sodium.......... 15
medroxyprogesterone acetate48
mefenamic acid ..................... 15
mefloquine hcl....................... 29
MEGACE ES ........................ 21
megestrol acetate .................. 21
meloxicam ............................. 15
melphalan hcl........................ 21
MENEST............................... 46
MENHIBRIX........................ 49
MENOMUNE-A-C-Y-W-135
........................................... 49
MENVEO A-C-Y-W-135-DIP
........................................... 49
meprobamate......................... 52
MEPRON.............................. 29
mercaptopurine ..................... 21
meropenem............................ 19
mesalamine w/cleansing wipes
........................................... 49
mesna .................................... 52
MESNEX .............................. 52
metaproterenol sulfate .......... 54
metformin hcl ........................ 25
methadone hcl ....................... 14
methamphetamine hcl ........... 39
methazolamide ...................... 52
methimazole .......................... 48
methocarbamol ..................... 55
methotrexate sodium ............. 21
methotrexate sodium/pf......... 21
methscopolamine bromide .... 45
methyclothiazide ................... 38
methylergonovine maleate .... 52
METHYLIN.......................... 39
methylphenidate hcl .............. 39
methylprednisolone ............... 47
methylprednisolone acetate .. 47
methylprednisolone sod succ 47
metipranolol.......................... 52
metoclopramide hcl............... 45
metolazone ............................ 38
metoprolol succinate............. 36
metoprolol tartrate................ 36
metoprolol/hydrochlorothiazide
........................................... 36
metronidazole............ 27, 29, 40
metronidazole/sodium chloride
........................................... 29
mexiletine hcl ........................ 36
MIACALCIN........................ 50
miconazole nitrate................. 27
midodrine hcl ........................ 35
MIGERGOT ......................... 27
minocycline hcl ..................... 20
minoxidil ............................... 38
mirtazapine ........................... 24
misoprostol............................ 44
MITHRACIN........................ 21
mitomycin.............................. 21
mitoxantrone hcl ................... 21
M-M-R II VACCINE............ 49
moexipril hcl ......................... 35
moexipril/hydrochlorothiazide
........................................... 35
mometasone furoate .............. 41
morphine sulfate.............. 14, 15
MOVIPREP .......................... 45
MOZOBIL ............................ 33
MULTAQ ............................. 36
mupirocin .............................. 40
MUSTARGEN...................... 21
MYOZYME.......................... 42
nabumetone ........................... 15
nadolol .................................. 36
nadolol/bendroflumethiazide 36
nafcillin sodium..................... 19
NAFTIN................................ 27
NAGLAZYME ..................... 42
nalbuphine hcl....................... 15
nalidixic acid......................... 19
NALLPEN-ISO-OSMOTIC
DEXTROSE...................... 19
naloxone hcl .......................... 16
naltrexone hcl........................ 16
NAMENDA .......................... 24
naphazoline hcl/antazoline ... 43
naproxen ............................... 15
naproxen sodium................... 15
naratriptan hcl ...................... 27
NASONEX ........................... 44
nateglinide............................. 25
NEBUPENT.......................... 29
needles, insulin disposable.... 42
nefazodone hcl ...................... 24
neo/polymyx b sulf/dexameth 43
neomy sulf/bacitra/polymyxin b
........................................... 43
neomy sulf/bacitrac zn/poly/hc
........................................... 43
neomy sulf/polymyxin b sulfate
........................................... 40
neomycin sulfate.................... 17
neomycin sulfate/dex na ph... 43
neomycin/polymyxin b sulf/hc43
neomycin/polymyxn b/
gramicidin ......................... 43
NEULASTA ......................... 33
NEUPOGEN ......................... 33
NEXAVAR ........................... 21
NEXIUM............................... 44
I-6
Geisinger Gold Standard Rx 2015 Part D Formulary
Formulary ID: 15222.000, Version: 9
Effective: March 01, 2015
niacin..................................... 38
nicardipine hcl ...................... 37
NICOTROL NS .................... 16
nifedipine............................... 37
NILANDRON....................... 21
nimodipine............................. 37
nisoldipine............................. 37
nitrofurantoin macrocrystal.. 17
nitroglycerin.......................... 38
NITROSTAT ........................ 38
nizatidine............................... 44
NORDITROPIN FLEXPRO. 47
noreth-ethinyl estradiol/iron. 39
norethindrone........................ 39
norethindrone acetate ........... 48
norethindrone ac-eth estradiol
..................................... 39, 46
norethindrone-e.estradiol-iron
........................................... 39
norethindrone-ethinyl estrad 39
norgestimate-ethinyl estradiol
........................................... 39
norgestrel-ethinyl estradiol... 39
nortriptyline hcl .................... 24
NORVIR ............................... 31
NOVOLIN 70-30 .................. 25
NOVOLIN N ........................ 25
NOVOLIN R......................... 25
NOVOLOG........................... 25
NOVOLOG MIX 70-30........ 25
NOVOLOG MIX 70-30
FLEXPEN ......................... 25
NOXAFIL ............................. 27
NUEDEXTA......................... 39
NULOJIX.............................. 48
NUTROPIN AQ NUSPIN .... 47
NUVARING ......................... 39
NUVIGIL.............................. 55
nylidrin hcl ............................ 38
nystatin.................................. 27
nystatin/triamcin ................... 27
octreotide acetate.................. 47
ofloxacin.......................... 19, 43
olanzapine ............................. 30
ondansetron hcl..................... 28
ONFI ..................................... 16
ORAP.................................... 30
ORFADIN............................. 42
orphenadrine citrate ............. 55
OSMOPREP ......................... 45
oxacillin sodium .................... 19
oxacillin sodium/dextrose,iso 19
oxaliplatin ............................. 21
oxandrolone .......................... 46
oxcarbazepine ....................... 23
OXSORALEN ...................... 40
OXSORALEN-ULTRA........ 40
oxybutynin chloride............... 45
oxycodone hcl/acetaminophen
........................................... 15
oxycodone hcl/aspirin ........... 15
oxymorphone hcl................... 15
paclitaxel............................... 21
pamidronate disodium .......... 50
PANRETIN........................... 40
pantoprazole sodium............. 44
papaverine hcl....................... 37
paromomycin sulfate............. 29
paroxetine hcl........................ 24
PASER .................................. 28
PATADAY ........................... 43
PAXIL................................... 24
PCE ....................................... 18
ped mv a,c,d3 #21 w-fluoride 56
peg 3350/na sulf,bicarb,cl/kcl45
PEGANONE ......................... 23
PEGASYS............................. 32
PEGASYS PROCLICK ........ 32
PEGINTRON........................ 32
PEGINTRON REDIPEN ...... 32
pen g pot/dextrose-water....... 19
penicillin g potassium ........... 19
penicillin g potassium/d5w ... 19
penicillin v potassium ........... 19
PENTAM 300 ....................... 29
PENTASA............................. 50
pentoxifylline......................... 33
p-epd tan/chlor-tan ............... 27
PERFOROMIST ................... 54
perindopril erbumine ............ 35
permethrin............................. 41
perphenazine ......................... 30
perphenazine/amitriptyline hcl
........................................... 25
PEXEVA............................... 25
phenelzine sulfate.................. 25
phenylbutazone ..................... 15
PHENYTEK ......................... 23
phenytoin............................... 23
phenytoin sodium extended ... 23
PHOSPHOLINE IODIDE .... 52
pilocarpine hcl ...................... 40
pindolol ................................. 36
piperacillin sodium/tazobactam
........................................... 19
piroxicam .............................. 15
pnv with ca,no.72/iron/fa ...... 56
podofilox ............................... 40
polymyxin b sulf/trimethoprim
........................................... 43
polymyxin b sulfate ............... 17
potassium chloride ................ 53
potassium chloride in 0.9%nacl
........................................... 53
potassium chloride in d5w .... 53
potassium chloride in lr-d5... 34
potassium chloride/d50.2%nacl ........................... 53
potassium chloride/d5-0.45nacl
........................................... 53
potassium chloride/d50.9%nacl ........................... 53
potassium chloride/d5w ........ 53
potassium chloride-0.45% nacl
........................................... 53
potassium gluconate.............. 53
I-7
Geisinger Gold Standard Rx 2015 Part D Formulary
Formulary ID: 15222.000, Version: 9
Effective: March 01, 2015
PRADAXA ........................... 33
pramipexole di-hcl ................ 29
pravastatin sodium................ 38
prazosin hcl........................... 35
PRED-G ................................ 43
prednicarbate........................ 41
prednisolone acetate ....... 44, 47
prednisolone sod phosphate. 44,
47
prednisone............................. 47
PREMARIN.................... 46, 47
PREMASOL ......................... 34
PREZISTA............................ 31
PRIMAQUINE ..................... 29
primidone .............................. 23
PRISTIQ ER ......................... 25
PRIVIGEN............................ 48
probenecid............................. 52
procainamide hcl .................. 36
prochlorperazine maleate ..... 28
PROCRIT.............................. 33
PROGLYCEM...................... 39
PROGRAF ............................ 48
PROLEUKIN........................ 21
PROLIA ................................ 50
PROMACTA ........................ 33
promethazine hcl............. 27, 28
propafenone hcl .................... 36
propantheline bromide.......... 22
proparacaine hcl................... 43
proparacaine/fluorescein sod 43
propranolol hcl ..................... 36
propranolol/hydrochlorothiazid
........................................... 36
propylthiouracil .................... 48
PROQUAD ........................... 49
PROSOL ............................... 34
protriptyline hcl .................... 25
PULMICORT ....................... 54
PULMICORT FLEXHALER 54
PULMOZYME ..................... 42
pyridostigmine bromide ........ 52
quinapril hcl.......................... 35
quinapril/hydrochlorothiazide
........................................... 35
quinidine gluconate............... 36
quinidine sulfate.................... 36
RABAVERT ......................... 49
ramipril ................................. 36
ranitidine hcl......................... 44
RAPAMUNE ........................ 49
REBETOL............................. 32
RECOMBIVAX HB ............. 49
RELENZA ............................ 31
RELISTOR ........................... 45
REMICADE.......................... 52
RENAGEL............................ 45
RENVELA............................ 45
RESCRIPTOR ...................... 31
reserpine/hydrochlorothiazide
........................................... 37
RESTASIS ............................ 44
RETROVIR........................... 31
REVATIO ............................. 55
REVLIMID ........................... 21
REYATAZ............................ 31
RHINOCORT AQUA........... 44
ribavirin ................................ 32
RIDAURA ............................ 49
rifampin................................. 28
RIFATER.............................. 28
rimantadine hcl ..................... 31
ringers solution ............... 50, 53
RISPERDAL CONSTA........ 30
risperidone ............................ 30
RITUXAN............................. 22
rivastigmine tartrate ............. 24
ropinirole hcl ........................ 29
ROZEREM ........................... 55
SABRIL ................................ 23
sal-amide/acetaminophn/p-tlox
........................................... 15
SAPHRIS .............................. 30
SAVELLA ............................ 39
selegiline hcl ......................... 29
selenium sulfide..................... 40
SELZENTRY........................ 31
SENSIPAR............................ 52
SEROQUEL XR ................... 30
sertraline hcl ......................... 25
SILENOR.............................. 25
silver nitrate .......................... 41
silver nitrate applicator ........ 40
silver sulfadiazine ................. 41
SIMULECT........................... 52
simvastatin ............................ 38
sodium chloride..................... 53
sodium chloride 0.45 % ........ 53
sodium chloride 3 % ............. 53
sodium chloride 5 % ............. 53
sodium chloride irrig solution
........................................... 50
sodium chloride/nahco3/kcl/peg
........................................... 45
sodium fluoride ..................... 40
sodium lactate ....................... 53
sodium polystyrene sulfonate 45
SOLARAZE.......................... 15
SOLU-MEDROL.................. 47
SOMATULINE DEPOT....... 47
SOMAVERT......................... 47
sotalol hcl.............................. 36
SPIRIVA ............................... 54
spironolact/hydrochlorothiazid
........................................... 38
spironolactone....................... 38
SPRYCEL ............................. 22
stavudine ............................... 31
STRATTERA ....................... 39
streptomycin sulfate .............. 17
STROMECTOL.................... 29
SUBOXONE......................... 16
sucralfate............................... 44
sulfacetamide sodium...... 41, 43
sulfacetamide/prednisolone sp
........................................... 43
I-8
Geisinger Gold Standard Rx 2015 Part D Formulary
Formulary ID: 15222.000, Version: 9
Effective: March 01, 2015
sulfadiazine ........................... 19
sulfamethoxazole/trimethoprim
........................................... 19
sulfasalazine.......................... 19
sulindac ................................. 15
SUPPRELIN ......................... 47
SURMONTIL ....................... 25
SUSTIVA.............................. 31
SUTENT ............................... 22
SYLATRON 4-PACK .......... 32
SYMBICORT ....................... 54
SYNAGIS ............................. 31
SYNAREL ............................ 52
SYNERCID........................... 17
SYNTHROID ....................... 48
SYPRINE.............................. 46
syring w-ndl,disp,insul,0.3 ml42
syringe & needle,insulin,1 ml 42
TABLOID ............................. 22
tacrolimus ............................. 49
TAMIFLU....................... 31, 32
tamoxifen citrate ................... 22
tamsulosin hcl ....................... 45
TARCEVA............................ 22
TARGRETIN........................ 22
TASIGNA ............................. 22
TASMAR.............................. 29
TAZORAC............................ 41
TE ANATOXAL BERNA.... 49
TEFLARO............................. 18
TEGRETOL XR ................... 23
TEKTURNA ......................... 38
TEKTURNA HCT ................ 38
terazosin hcl .......................... 46
terbutaline sulfate ................. 54
terconazole............................ 27
TETANUS DIPHTHERIA
TOXOIDS ......................... 49
TEVETEN HCT.................... 35
THALOMID ......................... 52
theophylline anhydrous......... 54
thioridazine hcl ..................... 30
thiothixene............................. 30
THYMOGLOBULIN ........... 49
TIKOSYN ............................. 36
timolol maleate................ 36, 52
tizanidine hcl......................... 55
TOBRADEX......................... 43
TOBRADEX ST ................... 43
tobramycin sulfate................. 17
tobramycin/dexamethasone... 44
tobramycin/sodium chloride . 17
tolazamide ............................. 26
tolbutamide ........................... 26
tolmetin sodium..................... 15
topiramate ............................. 23
topotecan hcl......................... 22
TORISEL .............................. 22
torsemide............................... 38
TPN ELECTROLYTES II.... 54
TRACLEER.......................... 55
tramadol hcl .......................... 15
tramadol hcl/acetaminophen 15
trandolapril ........................... 36
tranexamic acid..................... 33
tranylcypromine sulfate ........ 25
TRAVAMULSION............... 34
TRAVASOL ................... 34, 35
TRAVASOL W/
ELECTROLYTES ............ 34
TRAVASOL with
ELECTROLYTES ............ 34
TRAVERT ............................ 35
TRAVERT IN NORMAL
SALINE ............................ 35
trazodone hcl......................... 25
TREANDA ........................... 22
TRECATOR ......................... 28
TRELSTAR .......................... 22
tretinoin........................... 22, 41
triamcinolone acetonide.. 40, 41
triamterene/hydrochlorothiazid
........................................... 38
trifluoperazine hcl................. 30
trifluridine ............................. 44
trihexyphenidyl hcl................ 29
trimethoprim ......................... 17
tripelennamine hcl ................ 27
TRISENOX........................... 22
TROPHAMINE .................... 35
trospium chloride .................. 45
TRUVADA ........................... 31
TYKERB............................... 22
TYPHIM VI .......................... 49
TYSABRI ............................. 49
TYZEKA............................... 32
ULORIC................................ 52
UNITHROID ........................ 48
urologic solution-g................ 50
ursodiol ................................. 45
UVADEX.............................. 40
VAGIFEM ............................ 47
valacyclovir hcl..................... 32
VALCYTE............................ 32
valproic acid ......................... 23
valproic acid (as sodium salt)23
vancomycin hcl...................... 17
vancomycin hcl/d5w.............. 17
VAQTA................................. 49
VARIVAX VACCINE ......... 49
VECTIBIX............................ 22
venlafaxine hcl ...................... 25
VENLAFAXINE HCL ER ... 25
VENTAVIS........................... 56
verapamil hcl ........................ 37
VERIPRED 20 ...................... 47
VESICARE ........................... 45
VICTRELIS .......................... 32
VIDEX .................................. 31
VIGAMOX ........................... 44
VIIBRYD.............................. 25
VIMPAT ............................... 23
vinblastine sulfate ................. 22
vincristine sulfate .................. 22
vinorelbine tartrate ............... 22
VIRACEPT ........................... 31
I-9
Geisinger Gold Standard Rx 2015 Part D Formulary
Formulary ID: 15222.000, Version: 9
Effective: March 01, 2015
VIRAMUNE ......................... 31
VIRAMUNE XR .................. 31
VIREAD ............................... 31
VIVELLE-DOT .................... 47
voriconazole.......................... 27
VOTRIENT........................... 22
VPRIV................................... 42
warfarin sodium .................... 33
water for irrigation,sterile .... 50
WELCHOL ........................... 38
XALKORI............................. 22
XARELTO............................ 33
XENAZINE .......................... 39
XGEVA................................. 50
XOLAIR ............................... 54
XYREM ................................ 55
YERVOY.............................. 22
YF-VAX ............................... 49
zafirlukast.............................. 54
zaleplon ................................. 55
ZANOSAR............................ 22
ZAVESCA ............................ 42
ZELBORAF.......................... 22
ZEMPLAR............................ 50
ZENPEP................................ 42
ZETIA ................................... 38
ZIAGEN................................ 31
zidovudine ............................. 31
ZOLINZA ............................. 22
zolpidem tartrate................... 55
ZONALON ........................... 40
zonisamide............................. 23
ZORTRESS........................... 49
ZOSTAVAX ......................... 49
ZOVIRAX............................. 40
ZYCLARA............................ 40
ZYFLO CR ........................... 54
ZYTIGA................................ 22
ZYVOX................................. 17
I-10
Geisinger Gold Standard Rx 2015 Part D Formulary
Formulary ID: 15222.000, Version: 9
Effective: March 01, 2015
This formulary was updated on 02/25/2015. For more recent information or other questions, please contact
Geisinger Gold Member Services at (800) 988-4861 or, for TTY/TDD users, 711 or (800) 654-5984, 8 a.m. to
8 p.m. (7 days a week, Oct. – Feb.) or 8 a.m. to 8 p.m. (Mon. – Fri., March – Sept), or visit
www.thehealthplan.com/Gold/Landing_Pages/Formulary/