lista de medicamentos cubiertos para 2018 (listado) · ii si tiene alguna pregunta, llame a first...

ID del listado: 18395 Versión 13Actualizado 06/2018. Si tiene alguna pregunta, llame a First Choice VIP Care Plus al 1-888-978-0862 (TTY 711), los 7 días de la semana, de 8 a.m. a 8 p.m. La llamada es gratuita. Para obtener más información, visite www.firstchoicevipcareplus.com.

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Lista de medicamentos cubiertos para 2018 (Listado)

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http://www.firstchoicevipcareplus.com

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Si tiene alguna pregunta, llame a First Choice VIP Care Plus al 1-888-978-0862 (TTY 711), los siete días de la semana, de 8 a.m. a 8 p.m. La llamada es gratuita. Para obtener más información, visite www.firstchoicevipcareplus.com.

First Choice VIP Care Plus | Lista de medicamentos cubiertos para 2018 (Listado)

• Esta es una lista de los medicamentos que los miembros pueden obtener en First Choice VIP Care Plus.

• First Choice VIP Care Plus es un plan de salud que tiene contrato con Medicare y Medicaid de Healthy Connections de South Carolina para proporcionar los beneficios de ambos programas a los inscritos.

• La Lista de medicamentos cubiertos y/o las redes de farmacias y proveedores pueden cambiar en cualquier momento durante el año. Le enviaremos una notificación antes de realizar un cambio que lo afecte.

• Los beneficios se pueden modificar el 1 de enero de cada año. Usted siempre puede comprobar la Lista de medicamentos cubiertos actualizada de First Choice VIP Care Plus en Internet en www.firstchoicevipcareplus.com.

• Pueden aplicarse limitaciones y restricciones. Para obtener más información, llame a Servicios al Miembro de First Choice VIP Care Plus o lea el Manual del Miembro de First Choice VIP Care Plus.

• Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame a Servicios al Miembro de First Choice VIP Care Plus al 1-888-978-0862 (TTY 711), los siete días de la semana, de 8 a.m. a 8 p.m. La llamada es gratuita.

• Puede obtener esta información en otros formatos, como letra grande, braille, o audio de forma gratuita. Llame al 1-888-978-0862 (TTY 711), los siete días de la semana, de 8 a.m. a 8 p.m. La llamada es gratuita.

• Los miembros pueden solicitar materiales en un idioma que no sea el inglés o en un formato alternativo llamando a Servicios al Miembro al 1-888-978-0862 (TTY 711), los siete días de la semana, de 8 a.m. a 8 p.m. La llamada es gratuita.

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Preguntas frecuentes (FAQ)Encuentre aquí las respuestas a las preguntas que tiene sobre esta Lista de medicamentos cubiertos. Puede leer todas las FAQ para aprender más o buscar una pregunta y su respuesta.

1. ¿Qué medicamentos bajo receta están en la Lista de medicamentos cubiertos? (Llamamos “Lista de medicamentos” a la Lista de medicamentos cubiertos, para abreviar.)

Los medicamentos en la Lista de medicamentos cubiertos que comienza en la página 1 son los medicamentos cubiertos por First Choice VIP Care Plus. Estos medicamentos están disponibles en las farmacias dentro de nuestra red. Una farmacia está en nuestra red si tenemos un acuerdo con ella para que trabaje con nosotros y le preste servicios a usted. Nos referimos a estas farmacias como “farmacias de la red”.

➞ First Choice VIP Care Plus cubrirá todos los medicamentos médicamente necesarios en la Lista de medicamentos si:

• su médico u otro profesional que receta los medicamentos dice que usted los necesita para mejorar o mantenerse saludable, y

• usted surte la receta en una farmacia de la red de First Choice VIP Care Plus.

➞ Es posible que First Choice VIP Care Plus requiera medidas adicionales para poder acceder a ciertos medicamentos (ver pregunta 5 más abajo).

También puede encontrar una lista actualizada de los medicamentos que cubrimos en nuestro sitio de Internet indicado al final de la página o llame al número indicado al final de la página.

2. ¿Alguna vez cambia la Lista de medicamentos?Sí. First Choice VIP Care Plus puede agregar o retirar medicamentos de la Lista de medicamentos durante el año. En general, la Lista de medicamentos solo cambiará si:

• se desarrolla un medicamento más barato que funciona tan bien como uno de los medicamentos de la Lista de medicamentos actual, o

• nos enteramos de que un medicamento no es seguro.

También podemos cambiar nuestras normas sobre los medicamentos. Por ejemplo, podríamos:

• Decidir si un medicamento requiere o no requiere aprobación previa. (Aprobación previa es el permiso que otorga First Choice VIP Care Plus antes de que usted pueda obtener un medicamento).

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• Agregar o cambiar la cantidad de un medicamento que usted puede obtener (llamado “límites a la cantidad”).

• Agregar o cambiar las restricciones de la terapia escalonada sobre un medicamento. (Terapia escalonada significa que usted debe probar un medicamento antes de que cubramos otro medicamento.)

(Para obtener más información sobre estas normas sobre los medicamentos, consulte la página iv.)

Cuando retiremos un medicamento que usted está tomando, se lo haremos saber. También le diremos cuando cambiemos nuestras normas sobre la cobertura de un medicamento. Las preguntas 3, 4 y 7, a continuación, tienen más información sobre lo que sucede cuando la Lista de medicamentos cambia.

➞ Usted siempre puede revisar la Lista de medicamentos actualizada de First Choice VIP Care Plus en nuestro sitio web indicado al final de la página. También puede llamar a Servicios al Miembro al número que aparece al final de la página para revisar la Lista de medicamentos actual.

3. ¿Qué sucede cuando se desarrolla un medicamento más barato que funciona tan bien como uno de los medicamentos de la Lista de medicamentos actual?

Si usted está tomando un medicamento que se retira porque se desarrolla un medicamento más barato que funciona igualmente bien, se lo diremos. Se lo diremos como mínimo 60 días antes de que lo retiremos de la Lista de medicamentos o cuando usted pida que le renueven la receta. Entonces usted puede obtener un suministro del medicamento que dure 60 días antes de que se realice el cambio en la Lista de medicamentos.

• Cuando usted utiliza sus beneficios de farmacia de la Parte D, le enviaremos un informe resumido para ayudarlo a entender y a hacer un seguimiento de los pagos de los medicamentos bajo receta de la Parte D. Este informe resumido se llama Explicación de Beneficios (o “EOB”).

• La Explicación de Beneficios le dice la cantidad total que usted ha gastado en los medicamentos bajo receta de la Parte D y la cantidad total que nosotros hemos pagado por cada uno de los medicamentos bajo receta de la Parte D durante el mes. La Sección 4 (las actualizaciones a la Lista de medicamentos del plan que afectarán los medicamentos que usted toma) ofrece más información sobre las actualizaciones del listado de medicamentos que afectan los medicamentos que usted está tomando, que es cualquier medicamento cubierto por el plan para el que usted surtió una receta durante el año calendario actual como miembro del plan.

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4. ¿Qué sucede cuando descubrimos que un medicamento no es seguro?

Si la Administración de Alimentos y Medicamentos (FDA) dice que el medicamento que usted está tomando no es seguro, lo eliminaremos de la Lista de medicamentos inmediatamente. También le enviaremos una carta diciéndole eso. Si usted recibe una carta, puede optar por:

• Comunicarse con Servicios al Miembro a través de la información de contacto que aparece al final de la página para que lo ayudemos con sus dudas.

• Comunicarse con el Coordinador de Atención Médica.

• Comunicarse con el profesional que le recetó el medicamento para hablar de la situación.

5. ¿Existen restricciones o límites a la cobertura de medicamentos? ¿O se debe tomar alguna medida para conseguir ciertos medicamentos?

Sí, algunos medicamentos tienen normas sobre la cobertura o límites en la cantidad que usted puede obtener. En algunos casos, usted, su médico u otro profesional que recete medicamentos deben hacer algo antes de poder obtener el medicamento. Por ejemplo:

• Aprobación previa (o autorización previa): Para algunos medicamentos, usted o su médico u otro profesional que receta el medicamento deben obtener la aprobación de First Choice VIP Care Plus antes de surtir su receta. Si usted no recibe la aprobación, es posible que First Choice VIP Care Plus no cubra el medicamento.

• Límites a la cantidad: A veces, First Choice VIP Care Plus limita la cantidad de un medicamento que puede obtener.

• Terapia escalonada: A veces, First Choice VIP Care Plus requiere que usted realice una terapia escalonada. Esto significa que usted tendrá que probar medicamentos en un cierto orden para su condición médica. Es posible que usted tenga que probar un medicamento antes de que nosotros cubramos otro medicamento. Si su médico cree que el primer medicamento no funciona para usted, entonces cubriremos el segundo.

Usted puede averiguar si su medicamento tiene límites o requisitos adicionales buscándolo en las tablas en las páginas 1 – 160. Usted también puede obtener más información visitando nuestro sitio de Internet en www.firstchoicevipcareplus.com. Hemos publicado documentos en Internet que explican nuestras restricciones de autorización previa y terapia escalonada. Usted también puede pedirnos que le enviemos una copia.

Usted puede solicitar una “excepción” a estos límites. Por favor, consulte la pregunta 11 para obtener más información sobre las excepciones.

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➞ Si usted está en un hogar de ancianos o en otro centro médico de atención prolongada y necesita un medicamento que no está en la Lista de medicamentos, o si usted no puede conseguir fácilmente el medicamento que necesita, podemos ayudarlo. Cubriremos un suministro de emergencia de 31 días del medicamento que usted necesita (a menos que tenga una receta médica para menos días), sea o no un nuevo miembro de First Choice VIP Care Plus. Esto le dará tiempo para hablar con su médico u otro profesional que receta el medicamento. Pueden ayudarlo a decidir si existe un medicamento similar en la Lista de medicamentos con el que pueda reemplazarlo o si desea solicitar una excepción. Por favor, consulte la pregunta 11 para obtener más información sobre las excepciones.

6. ¿Cómo sabrá si el medicamento que usted quiere tiene limitaciones o si debe tomar alguna medida para conseguir el medicamento?

La Lista de medicamentos cubiertos en la página 1 tiene una columna denominada “Medidas necesarias, restricciones o límites de uso”.

7. ¿Qué sucede si cambiamos nuestras normas sobre cómo cubrimos algunos medicamentos? Por ejemplo, si agregamos autorización previa (aprobación), límites a la cantidad y/o restricciones a la terapia escalonada sobre un medicamento.

Le diremos si agregamos autorización previa, límites a la cantidad y/o restricciones a la terapia escalonada de un medicamento. Se lo diremos como mínimo 60 días antes de agregar la restricción o la próxima vez que usted pida que le renueven la receta. Entonces usted puede obtener un suministro del medicamento que dure 60 días antes de que se realice el cambio en la Lista de medicamentos. Esto le da tiempo para hablar con su médico u otro profesional que receta el medicamento sobre qué hacer a continuación.

8. ¿Cómo puede encontrar un medicamento en la Lista de medicamentos?

Existen dos formas de encontrar un medicamento:

• Puede buscarlo por orden alfabético (si sabe cómo se escribe el medicamento), o

• Puede buscarlo por condición médica.

Para buscar alfabéticamente, vaya a la sección de Listado alfabético. Lo puede encontrar en el Índice que comienza en la página 161. El Índice proporciona una lista alfabética de todos los medicamentos incluidos en este documento. Los medicamentos de marca, los medicamentos genéricos y los medicamentos de venta libre se indican en el Índice. Busque en el Índice y encuentre

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su medicamento. Al lado de cada medicamento, usted verá un número que le dice en qué página puede encontrar información sobre la cobertura.

Para buscar por condición médica, encuentre la sección denominada “Lista de medicamentos por condición médica” en la página xi. Los medicamentos de esta sección están agrupados en categorías según el tipo de condición médica que tratan. Por ejemplo, si usted tiene una enfermedad cardíaca, debe mirar en la categoría Medicamentos Cardiovasculares. Allí es donde encontrará los medicamentos que tratan las enfermedades cardíacas.

9. ¿Qué pasa si usted es miembro actualmente y el medicamento que quiere tomar no está en la Lista de medicamentos?

Si no ve su medicamento en la Lista de medicamentos, llame a Servicios al Miembro al número que aparece al final de la página y pregunte al respecto. Si usted se entera de que First Choice VIP Care Plus no cubrirá el medicamento, puede hacer una de estas cosas:

• Pida a Servicios al Miembro una lista de los medicamentos como el que usted quiere tomar. Luego muestre la lista a su médico o a otro profesional que receta el medicamento. Puede recetarle un medicamento de la Lista de medicamentos que sea como el que usted quiere tomar. O

• Usted puede pedir al plan de salud que haga una excepción para cubrir su medicamento. Por favor, consulte la pregunta 11 para obtener más información sobre las excepciones.

Los miembros que hayan sufrido un cambio en el nivel de atención (establecimiento) podrán recibir un único suministro de transición de 30 días por medicamento. Por ejemplo, los miembros que:

• Ingresan a establecimientos de atención médica prolongada (LTC) desde hospitales a veces tienen una lista de medicamentos de alta del listado de medicamentos del hospital, con una planificación a muy corto plazo (en general menos de 8 horas).

• Son dados de alta del hospital y trasladados a la casa.

• Finalizan su estadía en un establecimiento de enfermería especializada de la Parte A de Medicare (para la cual los pagos incluyen todos los gastos de farmacia) y que necesitan volver a su listado de medicamentos del plan de la Parte D.

• Finalizan una estadía en un establecimiento de atención médica prolongada y vuelven a la comunidad.

Si un miembro sufre más de un cambio en el nivel de atención en un mes, la farmacia deberá llamar a nuestro Plan para solicitar una extensión de la política de transición.

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10. ¿Qué sucede si usted es un miembro nuevo de First Choice VIP Care Plus y no puede encontrar su medicamento en la Lista de medicamentos o tiene problemas para obtener su medicamento?

Podemos ayudar. Cubriremos un suministro temporal de 30 días de su medicamento de la Parte D y un suministro de 90 días de su medicamento de Medicaid de Healthy Connections durante los primeros 180 días en que usted es miembro de First Choice VIP Care Plus. Esto le dará tiempo para hablar con su médico u otro profesional que receta el medicamento. Ellos determinarán si existe un medicamento similar en la Lista de medicamentos con el que pueda reemplazarlo o si desea solicitar una excepción.

Cubriremos un suministro temporal de su medicamento si:

• usted está tomando un medicamento que no está en nuestra Lista de medicamentos, o

• las normas del plan de salud no le permiten obtener la cantidad que pidió el profesional que recetó el medicamento, o

• el medicamento requiere la aprobación previa de First Choice VIP Care Plus, o

• usted está tomando un medicamento que es parte de una restricción de la terapia escalonada.

Si usted vive en un hogar de ancianos o en otro centro médico de atención prolongada, puede renovar su receta hasta un máximo de 98 días para los medicamentos de la Parte D y 98 días para medicamentos que no son de la Parte D. Usted puede renovar el medicamento varias veces durante este período de tiempo. Esto le da tiempo al profesional que receta el medicamento a cambiar sus medicamentos a aquellos que están en la Lista de medicamentos o solicitar una excepción.

11. ¿Usted puede pedir una excepción para cubrir su medicamento?Sí. Usted puede pedir a First Choice VIP Care Plus que haga una excepción para cubrir un medicamento que no está en la Lista de medicamentos.

También puede pedirnos que cambiemos las normas sobre su medicamento.

• Por ejemplo, First Choice VIP Care Plus puede limitar la cantidad de un medicamento que cubriremos. Si su medicamento tiene un límite, usted puede pedirnos que cambiemos el límite y cubramos más.

• Otros ejemplos: Puede solicitarnos que no apliquemos las restricciones de la terapia escalonada o los requisitos de la aprobación previa.

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12. ¿Cuánto tiempo lleva obtener una excepción?En primer lugar, debemos recibir una declaración del profesional que receta el medicamento que apoye su solicitud de excepción. Después de recibir la declaración, le haremos saber nuestra decisión sobre su solicitud de excepción dentro de las 72 horas.

Si usted o el profesional que receta el medicamento creen que su salud podría verse dañada si tiene que esperar una decisión durante 72 horas, usted puede pedir una excepción acelerada. Esta es una decisión más rápida. Si el profesional que receta el medicamento apoya su solicitud, le haremos conocer la decisión dentro de las 24 horas de recibir la declaración de apoyo del profesional que receta el medicamento.

13. ¿Cómo puede solicitar una excepción?Para solicitar una excepción, llame a Servicios al Miembro. Un representante de Servicios al Miembro trabajará con usted y su proveedor para ayudarlo a solicitar una excepción.

14. ¿Qué son los medicamentos genéricos?Los medicamentos genéricos se hacen con los mismos principios activos que los medicamentos de marca. Usualmente cuestan menos que los medicamentos de marca y generalmente no tienen nombres muy conocidos. Los medicamentos genéricos están aprobados por la Administración de Alimentos y Medicamentos (FDA).

First Choice VIP Care Plus cubre tanto medicamentos de marca como genéricos.

15. ¿Qué son los medicamentos OTC?OTC es la sigla en inglés para “de venta libre”. First Choice VIP Care Plus cubre algunos medicamentos OTC cuando su proveedor los receta.

Puede leer la Lista de medicamentos de First Choice VIP Care Plus para ver qué medicamentos OTC están cubiertos.

16. ¿First Choice VIP Care Plus cubre productos OTC que no son medicamentos?

First Choice VIP Care Plus cubre algunos productos OTC que no son medicamentos cuando su proveedor los receta.

Puede leer la Lista de medicamentos de First Choice VIP Care Plus para ver qué productos OTC que no son medicamentos están cubiertos.

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17. ¿Cuál es su copago?Como miembro de First Choice VIP Care Plus, usted no tiene copagos para medicamentos de venta bajo receta y medicamentos OTC siempre que siga las normas de First Choice VIP Care Plus.

18. ¿Qué son los niveles de medicamentos?Los niveles son grupos de medicamentos de nuestra Lista de medicamentos.

No hay copagos en ninguno de estos niveles, que son los siguientes:

• Los medicamentos del nivel 1 son los medicamentos genéricos cubiertos por Medicare.

• Los medicamentos del nivel 2 son los medicamentos de marca cubiertos por Medicare.

• Los medicamentos del nivel 3 son los medicamentos de venta bajo receta y de venta libre que no cubre Medicare. Estos medicamentos tienen la cobertura de Medicaid de Healthy Connections.

Lista de medicamentos cubiertosLa siguiente lista de medicamentos cubiertos le brinda información sobre los medicamentos que cubre First Choice VIP Care Plus. Si usted tiene problemas para encontrar su medicamento en la lista, consulte el Índice que comienza en la página 161.

La primera columna de la tabla menciona el nombre del medicamento. Los medicamentos de marca están escritos en mayúscula (por ejemplo, COUMADIN) y los medicamentos genéricos están escritos en letra cursiva minúscula (por ejemplo, warfarin).

La información en la columna “Medidas necesarias, restricciones o límites de uso” le indica si First Choice VIP Care Plus tiene normas para cubrir su medicamento.

A continuación, se enumeran los códigos usados en la columna “Medidas necesarias, restricciones o límites de uso”:

B/D: Este medicamento bajo receta puede estar cubierto por el beneficio médico o de farmacia, según cómo se use. La farmacia trabajará junto con el plan médico y su proveedor para determinar si el medicamento debe ser autorizado en virtud de su beneficio médico o de farmacia.

MO: Pedido por correo. Una farmacia de la red de First Choice VIP Care Plus que entrega pedidos por correo puede surtir esta receta. Consulte el Listado de Proveedores y Farmacias para obtener más información sobre qué farmacias ofrecen el servicio de pedidos por correo. Si desea más información, consulte su listado de Proveedores y Farmacias o llame al departamento de Servicios al Miembro al número que aparece al final de la página.

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QL: Límites a la cantidad. Para ciertos medicamentos, limitamos la cantidad del medicamento que usted puede recibir. Por ejemplo, el plan puede limitar la cantidad de reposiciones que usted puede obtener, o la cantidad de un medicamento que puede recibir cada vez que surte una receta. Por ejemplo, si en general no se considera seguro tomar más de una pastilla por día de cierto medicamento, podemos limitar la cobertura de su receta a no más de una pastilla por día.

ST: Terapia escalonada. En algunos casos, First Choice VIP Care Plus requiere que usted primero pruebe ciertos medicamentos para tratar su condición médica antes de que cubramos otro medicamento para esa condición. Por ejemplo, si el Medicamento A y el Medicamento B tratan su condición médica, es posible que First Choice VIP Care Plus no cubra el Medicamento B si usted primero no prueba el Medicamento A. Si el Medicamento A no funciona para usted, First Choice VIP Care Plus entonces cubrirá el Medicamento B.

PA: Autorización previa. First Choice VIP Care Plus requiere que usted o su médico obtengan autorización previa para ciertos medicamentos. Esto significa que usted necesitará obtener la aprobación de First Choice VIP Care Plus antes de surtir sus recetas. Si usted no recibe la aprobación, es posible que First Choice VIP Care Plus no cubra el medicamento.

LA: Disponibilidad limitada. Esta receta puede estar disponible solo en determinadas farmacias. Para obtener más información, consulte el Directorio de Farmacias o llame a Servicios al Miembro al número que aparece al final de la página.

Nota: Las letras “DP” al lado de un medicamento significan que el medicamento no es un “Medicamento de la Parte D”. La cantidad que usted paga cuando surte una receta para este medicamento no cuenta para sus costos totales en medicamentos (es decir, la cantidad que usted paga no lo ayuda para cumplir con los requisitos para la cobertura catastrófica). Además, si usted está recibiendo Ayuda adicional para pagar sus medicamentos bajo receta, no obtendrá ninguna Ayuda adicional para pagar estos medicamentos. Estos medicamentos también tienen diferentes normas para las apelaciones. Una apelación es una manera formal de pedirnos que revisemos una decisión de cobertura y que la cambiemos si usted cree que cometimos un error. Por ejemplo, podríamos decidir que un medicamento que usted quiere no está cubierto o ya no está cubierto por Medicare o Medicaid de Healthy Connections. Si usted o su médico no están de acuerdo con nuestra decisión, usted puede apelarla. Para pedir instrucciones sobre cómo apelar, llame a Servicios al Miembro al número que aparece al final de la página. También puede leer el Manual del Miembro para saber cómo apelar una decisión.

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Lista de medicamentos por condición médicaLos medicamentos de esta sección están agrupados en categorías según el tipo de condición médica que tratan. Por ejemplo, si usted tiene una enfermedad cardíaca, debe mirar en la categoría Medicamentos Cardiovasculares. Allí es donde encontrará los medicamentos que tratan las enfermedades cardíacas.

Clasificación de medicamentos bajo receta Condición médica

Analgésicos Tratamiento del dolor

Anestésicos Tratamiento local del dolor

Medicamentos contra las adicciones/ el abuso de sustancias tóxicas

Tratamiento de trastornos causados por abuso de sustancias tóxicas

Antibacterianos Tratamiento de infecciones bacterianas

Anticonvulsivos Tratamiento de convulsiones

Medicamentos contra la demencia Tratamiento de la demencia

Antidepresivos Tratamiento de la depresión

Antieméticos Tratamiento de vómitos o náuseas

Antimicóticos Tratamiento de micosis o candidiasis

Medicamentos contra la gota Tratamiento o prevención de la artritis gotosa

Medicamentos antiinflamatorios Tratamiento de la inflamación

Medicamentos contra la migraña Tratamiento de la migraña

Medicamentos contra la miastenia Tratamiento de la miastenia

Antimicobacterianos Tratamiento de infecciones por microorganismos del grupo M. tuberculosis

Antineoplásicos Tratamiento del cáncer

Antiparasitarios Antiparasitarios Tratamiento de infecciones parasitarias

Medicamentos antiparkinsoniano Tratamiento de la enfermedad de Parkinson

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Antipsicóticos Tratamiento de trastornos del comportamiento y emocionales

Medicamentos antiespasmódicos Tratamiento de espasmos musculares

Antivirales Tratamiento de infecciones víricas

Ansiolíticos Tratamiento de la ansiedad o el nerviosismo

Medicamentos para el trastorno bipolar Tratamiento del trastorno bipolar

Reguladores de glucosa en sangre Control de la diabetes

Hemoderivados/modificadores/ expansores de volumen

Prevención de coagulación y aumento de producción de células sanguíneas

Medicamentos cardiovasculares Tratamiento de enfermedades cardíacas y de los vasos sanguíneos

Medicamentos para el sistema nervioso central

Tratamiento de trastornos cerebrales y de la columna vertebral

Medicamentos odontológicos y bucales Tratamiento de trastornos bucales y de las encías

Medicamentos dermatológicos Tratamiento de enfermedades de la piel

Suministros para la diabetes Suministros usados para tratar la diabetes

Reemplazo/modificadores enzimáticos Medicamentos para reemplazar la carencia o deficiencia de enzimas

Medicamentos gastrointestinales Tratamiento de enfermedades estomacales e intestinales

Medicamentos del aparato genitourinario Tratamiento de enfermedades de las vías urinarias y de la próstata

Medicamentos hormonales, estimulantes/reemplazantes/modificadores (suprarrenales)

Tratamiento de enfermedades mediante esteroides

Medicamentos hormonales, estimulantes/reemplazantes/modificadores (hipófisis)

Tratamiento de enfermedades de la hipófisis

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Medicamentos hormonales, estimulantes/reemplazantes/modificadores (hormonas sexuales/modificadores)

Para el reemplazo o modificación de hormonas sexuales

Medicamentos hormonales, estimulantes/reemplazantes/modificadores (tiroides)

Tratamiento de enfermedades de la tiroides

Medicamentos hormonales, supresores (suprarrenales)

Tratamiento del cáncer de glándulas suprarrenales no operable

Medicamentos hormonales, supresores (paratiroides)

Tratamiento de enfermedades de la paratiroides

Medicamentos hormonales, supresores (hipófisis)

Tratamiento o modificación de la secreción de la hormona hipofisaria

Medicamentos hormonales, supresores (tiroides)

Tratamiento del hipertiroidismo

Medicamentos inmunológicos Medicamentos para alterar el sistema inmunológico, incluso vacunas

Medicamentos para las enfermedades inflamatorias intestinales

Tratamiento de la colitis ulcerativa o la enfermedad de Crohn

Medicamentos para la osteopatía metabólica

Tratamiento de osteopatías, incluso osteoporosis

Medicamentos oftalmológicos Tratamiento de enfermedades oculares

Medicamentos para enfermedades del oído Tratamiento de enfermedades del oído

Medicamento para el tracto respiratorio Tratamiento de enfermedades respiratorias

Medicamentos para los pulmones/ vías respiratorias

Tratamiento de enfermedades respiratorias

Relajantes musculares Tratamiento de la tensión muscular

Medicamentos para trastornos del sueño Tratamiento del insomnio

Nutrientes/minerales/electrolitos terapéuticos

Reemplazo o suplemento de minerales, nutrientes y vitaminas

2018 First Choice VIP Care Plus Formulary

Document: 2018 Formulary

Formulary ID: 18395

Last Updated: 06/2018

Effective Date: 07-01-2018

You can find information on what the symbols and abbreviations in this table mean by going to page ix.

1

Name of Drug What the drug will

cost you (Tier

Level)

Necessary actions, restrictions, or

limits on use

ANALGESICS - TREATMENT OF PAIN

ANALGESICS

8 HOUR ER 650 MG CAPLET MUSCLE

ACHES & PAIN 650 MG

$0 (Tier 3) DP

ACEPHEN 325 MG SUPPOSITORY 325 MG $0 (Tier 3) DP

ACEPHEN 650 MG SUPPOSITORY OUTER

650 MG

$0 (Tier 3) DP

acetaminophen 120 mg suppos inner 120 mg $0 (Tier 3) DP

acetaminophen 160 mg/5 ml elx 160 mg/5 ml $0 (Tier 3) DP

acetaminophen 325 mg tablet 325 mg $0 (Tier 3) DP

acetaminophen 500 mg caplet caplet,ex-strength

500 mg

$0 (Tier 3) DP

acetaminophen 500 mg tablet asa-free,ex-str 500

mg

$0 (Tier 3) DP

acetaminophen 650 mg suppos 650 mg $0 (Tier 3) DP

acetaminophen-codeine oral solution 120 mg-12

mg /5 ml (5 ml), 120-12 mg/5 ml, 300 mg-30 mg

/12.5 ml

$0 (Tier 1) MO

acetaminophen-codeine oral tablet 300-15 mg,

300-30 mg, 300-60 mg

$0 (Tier 1) MO

ARTHRITIS PAIN ER 650 MG CAPLT CAPLET

650 MG

$0 (Tier 3) DP

ARTHRITIS PAIN ER 650 MG CAPLT CAPLET

650 MG

$0 (Tier 3) DP

ARTHRITIS PAIN RELIEF ER 650 MG

CAPLET CAPLET 650 MG

$0 (Tier 3) DP

ascomp with codeine oral capsule 30-50-325-40

mg

$0 (Tier 1) PA; MO

butalbital compound w/codeine oral capsule 30-

50-325-40 mg

$0 (Tier 1) PA; MO


2


cost you (Tier

Level)


limits on use

butalbital-acetaminop-caf-cod oral capsule 50-

325-40-30 mg

$0 (Tier 1) PA; MO

butalbital-acetaminophen oral tablet 50-325 mg $0 (Tier 1) PA; MO

butalbital-acetaminophen-caff oral capsule 50-

325-40 mg

$0 (Tier 1) PA; MO

butalbital-acetaminophen-caff oral tablet 50-325-

40 mg

$0 (Tier 1) PA; MO

butalbital-aspirin-caffeine oral capsule 50-325-40

mg

$0 (Tier 1) PA; MO

capsaicin 0.025% cream 0.025 % $0 (Tier 3) DP

carisoprodol-asa-codeine oral tablet 200-325-16

mg

$0 (Tier 1) PA; MO

carisoprodol-aspirin oral tablet 200-325 mg $0 (Tier 1) PA; MO

codeine-butalbital-asa-caff oral capsule 30-50-

325-40 mg

$0 (Tier 1) PA; MO

GS PAIN RELIEF 500 MG CAPLET 500 MG $0 (Tier 3) DP

HM ARTHRITIS PAIN ER 650 MG CAPLET, 8

HOUR 650 MG

$0 (Tier 3) DP

HM PAIN RELIEF 500 MG CAPLET CAPLET,

EX-STRENGTH 500 MG

$0 (Tier 3) DP

HM PAIN RELIEF 500 MG TABLET EX-STR,

GLUTEN-FREE 500 MG

$0 (Tier 3) DP

HM PAIN RELIEVER 500 MG TABLET

EXTRA STRENGTH 500 MG

$0 (Tier 3) DP

hydrocodone-acetaminophen oral tablet 10-325

mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

$0 (Tier 1) MO

hydrocodone-ibuprofen oral tablet 10-200 mg, 5-

200 mg, 7.5-200 mg

$0 (Tier 1) MO

ibuprofen-oxycodone oral tablet 400-5 mg $0 (Tier 1)

MAPAP 325 MG TABLET U-D 325 MG $0 (Tier 3) DP

MAPAP 500 MG CAPLET CAPLET 500 MG $0 (Tier 3) DP

MAPAP 500 MG CAPLET CAPLET,BOXED

500 MG

$0 (Tier 3) DP

MAPAP ARTHRITIS ER 650 MG CPLT 650 MG $0 (Tier 3) DP

MAPAP PM CAPLET 25-500 MG $0 (Tier 3) DP



Formulary ID: 18395




3


cost you (Tier

Level)


limits on use

MUSCLE RUB CREAM 15-10 % $0 (Tier 3) DP

MUSCLE RUB CREAM ULTRA STRENGTH 4-

30-10 %

$0 (Tier 3) DP

oxycodone-acetaminophen oral tablet 10-325 mg,

2.5-325 mg, 5-325 mg, 7.5-325 mg

$0 (Tier 1) MO

oxycodone-aspirin oral tablet 4.8355-325 mg $0 (Tier 1) MO

PAIN & FEVER 500 MG CAPLET CAPLET 500

MG

$0 (Tier 3) DP

PAIN & FEVER 500 MG CAPLET CAPTABS

500 MG

$0 (Tier 3) DP

PAIN RELIEF 500 MG CAPLET CAPLET, EX-

STRENGTH 500 MG

$0 (Tier 3) DP

PAIN RELIEF 500 MG CAPLET EXTRA STR,

CAPLET 500 MG

$0 (Tier 3) DP

PAIN RELIEF ER 650 MG CAPLET CAPLET, 8

HOUR 650 MG

$0 (Tier 3) DP

PAIN RELIEF ER 650 MG CAPLET CAPLET,

ARTHRITIS 650 MG

$0 (Tier 3) DP

PAIN RELIEVER 325 MG TABLET 325 MG $0 (Tier 3) DP

PAIN RELIEVER 500 MG CAPLET CAPLET,X-

STRENGTH 500 MG

$0 (Tier 3) DP

PAIN RELIEVER 500 MG CAPLET EX-STR,

CAPLET 500 MG

$0 (Tier 3) DP

PAIN RELIEVER 500 MG TABLET EXTRA

STRENGTH 500 MG

$0 (Tier 3) DP

pentazocine-naloxone oral tablet 50-0.5 mg $0 (Tier 1) PA; MO

pramoxine hcl 1% foam 12's, non-steroid 1 % $0 (Tier 3) DP

QC ARTHRITIS PAIN ER 650 MG CAPLET 650

MG

$0 (Tier 3) DP

QC NON-ASPIRIN 500 MG CAPLET

CAPLET,EX-STRENGTH 500 MG

$0 (Tier 3) DP


4


cost you (Tier

Level)


limits on use

QC NON-ASPIRIN 500 MG CAPLET XTRA

STRENGTH,CAPLET 500 MG

$0 (Tier 3) DP

QC NON-ASPIRIN 500 MG TABLET EXTRA

STRENGTH 500 MG

$0 (Tier 3) DP

QC NON-ASPIRIN PAIN RELIEF TB EXTRA

STRENGTH 500 MG

$0 (Tier 3) DP

QC NON-ASPIRIN PM CAPLET CAPLET, EX-

STRENGTH 25-500 MG

$0 (Tier 3) DP

Q-PAP 325 MG TABLET 325 MG $0 (Tier 3) DP

Q-PAP EX-STR 500 MG TABLET 500 MG $0 (Tier 3) DP

Q-PAP EX-STR 500 MG TABLET ASPIRIN

FREE 500 MG

$0 (Tier 3) DP

SM 8 HOUR PAIN RELIEF 650 MG CAPLET

650 MG

$0 (Tier 3) DP

SM PAIN RELIEVER 325 MG TABLET 325 MG $0 (Tier 3) DP

SM PAIN RELIEVER 500 MG CAPLET

CAPLET, EXTRA STR 500 MG

$0 (Tier 3) DP

SM PAIN RELIEVER 500 MG CAPLET

CAPLET, EXTRA STR 500 MG

$0 (Tier 3) DP

SM PAIN RELIEVER 500 MG TABLET EXTRA

STRENGTH 500 MG

$0 (Tier 3) DP

tramadol-acetaminophen oral tablet 37.5-325 mg $0 (Tier 1) MO

NONSTEROIDAL ANTI-INFLAMMATORY DRUGS

ADVIL 200 MG LIQUI-GEL CAPSULE LIQUID

GEL 200 MG

$0 (Tier 3) DP

ALL DAY PAIN RELIEF 220 MG TAB 220 MG $0 (Tier 3) DP

ALL DAY PAIN RLF 220 MG CAPLET

CAPLET 220 MG

$0 (Tier 3) DP

aspirin 325 mg coated tablet coated 325 mg $0 (Tier 3) DP

aspirin 325 mg tablet 325 mg $0 (Tier 3) DP

aspirin 325 mg tablet 5 grain 325 mg $0 (Tier 3) DP

aspirin coated 325 mg tablet coated 325 mg $0 (Tier 3) DP

aspirin ec 325 mg tablet 325 mg $0 (Tier 3) DP

aspirin ec 325 mg tablet orange 325 mg $0 (Tier 3) DP



Formulary ID: 18395




5


cost you (Tier

Level)


limits on use

aspirin ec 325 mg tablet safety-coated 325 mg $0 (Tier 3) DP

celecoxib oral capsule 100 mg, 200 mg, 400 mg,

50 mg

$0 (Tier 1) MO

COMFORT PAC-IBUPROFEN KIT 800 MG $0 (Tier 1) MO

COMFORT PAC-MELOXICAM KIT 15 MG $0 (Tier 1) MO

COMFORT PAC-NAPROXEN KIT 500 MG $0 (Tier 1) MO

diclofenac potassium oral tablet 50 mg $0 (Tier 1) MO

diclofenac sodium oral tablet extended release 24

hr 100 mg

$0 (Tier 1) MO

diclofenac sodium oral tablet,delayed release

(dr/ec) 25 mg, 50 mg, 75 mg

$0 (Tier 1) MO

diclofenac sodium topical gel 1 %, 3 % $0 (Tier 1) MO

DICLOZOR TOPICAL KIT 1 % $0 (Tier 1) MO

diflunisal oral tablet 500 mg $0 (Tier 1) MO

etodolac oral capsule 200 mg, 300 mg $0 (Tier 1) MO

etodolac oral tablet 400 mg, 500 mg $0 (Tier 1) MO

etodolac oral tablet extended release 24 hr 400

mg, 500 mg, 600 mg

$0 (Tier 1) MO

flurbiprofen oral tablet 100 mg, 50 mg $0 (Tier 1) MO

gs aspirin 325 mg tablet 325 mg $0 (Tier 3) DP

gs ibuprofen 200 mg caplet 200 mg $0 (Tier 3) DP

hm aspirin ec 325 mg tablet reg strength 325 mg $0 (Tier 3) DP

IBU ORAL TABLET 600 MG, 800 MG $0 (Tier 1) MO

ibuprofen 200 mg caplet caplet 200 mg $0 (Tier 3) DP

ibuprofen 200 mg caplet coated caplet 200 mg $0 (Tier 3) DP

ibuprofen 200 mg tablet 200 mg $0 (Tier 3) DP

ibuprofen 200 mg tablet coated 200 mg $0 (Tier 3) DP

ibuprofen oral suspension 100 mg/5 ml $0 (Tier 1) MO


6


cost you (Tier

Level)


limits on use

ibuprofen oral tablet 400 mg, 600 mg, 800 mg $0 (Tier 1) MO

indomethacin oral capsule 25 mg, 50 mg $0 (Tier 1) PA; MO

indomethacin oral capsule, extended release 75

mg

$0 (Tier 1) PA; MO

ketoprofen oral capsule 50 mg, 75 mg $0 (Tier 1) MO

ketorolac oral tablet 10 mg $0 (Tier 1) PA; MO

meclofenamate oral capsule 100 mg, 50 mg $0 (Tier 1) MO

meloxicam oral tablet 15 mg, 7.5 mg $0 (Tier 1) MO

nabumetone oral tablet 500 mg, 750 mg $0 (Tier 1) MO

naproxen oral suspension 125 mg/5 ml $0 (Tier 1) MO

naproxen oral tablet 250 mg, 375 mg, 500 mg $0 (Tier 1) MO

naproxen oral tablet,delayed release (dr/ec) 375

mg, 500 mg

$0 (Tier 1) MO

naproxen sodium oral tablet 275 mg, 550 mg $0 (Tier 1) MO

piroxicam oral capsule 10 mg, 20 mg $0 (Tier 1) MO

qc aspirin ec 325 mg tablet regular strength 325

mg

$0 (Tier 3) DP

sm aspirin 325 mg tablet 325 mg $0 (Tier 3) DP

sm aspirin ec 325 mg tablet reg-str, gluten-free

325 mg

$0 (Tier 3) DP

sulindac oral tablet 150 mg, 200 mg $0 (Tier 1) MO

ZORVOLEX ORAL CAPSULE 18 MG, 35 MG $0 (Tier 2) ST; MO

OPIOID ANALGESICS, LONG-ACTING

buprenorphine transdermal patch weekly 10

mcg/hour, 15 mcg/hour, 20 mcg/hour, 5 mcg/hour,

7.5 mcg/hour

$0 (Tier 1) MO; QL (4 EA per 28 days)

fentanyl transdermal patch 72 hour 100 mcg/hr $0 (Tier 1) PA; MO; QL (10 EA per 30 days)

fentanyl transdermal patch 72 hour 12 mcg/hr, 25

mcg/hr, 50 mcg/hr, 75 mcg/hr


fentanyl transdermal patch 72 hour 37.5

mcg/hour, 62.5 mcg/hour, 87.5 mcg/hour

$0 (Tier 1) QL (10 EA per 30 days)

methadone oral solution 10 mg/5 ml $0 (Tier 1) MO; QL (1200 ML per 30 days)

methadone oral solution 5 mg/5 ml $0 (Tier 1) MO; QL (2400 ML per 30 days)



Formulary ID: 18395




7


cost you (Tier

Level)


limits on use

methadone oral tablet 10 mg $0 (Tier 1) PA; MO; QL (240 EA per 30 days)

methadone oral tablet 5 mg $0 (Tier 1) MO; QL (180 EA per 30 days)

morphine oral tablet extended release 100 mg, 200

mg

$0 (Tier 1) PA; MO; QL (60 EA per 30 days)

morphine oral tablet extended release 15 mg, 30

mg, 60 mg


oxycodone oral tablet,oral only,ext.rel.12 hr 10

mg, 15 mg, 20 mg, 30 mg, 40 mg, 60 mg, 80 mg

$0 (Tier 1) PA; QL (60 EA per 30 days)

OPIOID ANALGESICS, SHORT-ACTING

butorphanol tartrate injection solution 1 mg/ml, 2

mg/ml

$0 (Tier 1) MO

butorphanol tartrate nasal spray,non-aerosol 10

mg/ml

$0 (Tier 1) QL (5 ML per 30 days)

duramorph (pf) injection solution 0.5 mg/ml, 1

mg/ml

$0 (Tier 1) B/D; MO

fentanyl citrate buccal lozenge on a handle 1,200

mcg, 1,600 mcg, 200 mcg, 400 mcg, 600 mcg, 800

mcg


hydromorphone (pf) injection solution 10 (mg/ml)

(5 ml)

$0 (Tier 1)

hydromorphone (pf) injection solution 10 mg/ml $0 (Tier 1) MO

hydromorphone injection solution 1 mg/ml, 2

mg/ml, 4 mg/ml

$0 (Tier 1)

hydromorphone injection syringe 2 mg/ml $0 (Tier 1) MO

hydromorphone oral tablet 2 mg, 4 mg, 8 mg $0 (Tier 1) MO; QL (120 EA per 30 days)

LAZANDA NASAL SPRAY,NON-AEROSOL

100 MCG/SPRAY



300 MCG/SPRAY



400 MCG/SPRAY



8


cost you (Tier

Level)


limits on use

meperidine oral solution 50 mg/5 ml $0 (Tier 1) PA; MO; QL (900 ML per 30 days)

meperidine oral tablet 100 mg, 50 mg $0 (Tier 1) PA; MO; QL (180 EA per 30 days)

morphine oral tablet 15 mg, 30 mg $0 (Tier 1) MO; QL (120 EA per 30 days)

nalbuphine injection solution 10 mg/ml, 20 mg/ml $0 (Tier 1) B/D

oxycodone oral solution 5 mg/5 ml $0 (Tier 1) MO; QL (5400 ML per 30 days)

oxycodone oral tablet 10 mg, 15 mg, 20 mg, 30

mg, 5 mg


tramadol oral tablet 50 mg $0 (Tier 1) MO; QL (240 EA per 30 days)

ANESTHETICS - LOCAL TREATMENT OF PAIN

LOCAL ANESTHETICS

ACCUCAINE KIT KIT 10 MG/ML (1 %) $0 (Tier 1) MO

ANODYNE LPT TOPICAL KIT 2.5-2.5 % $0 (Tier 1) MO

dermacinrx empricaine topical kit 2.5-2.5 % $0 (Tier 1) MO

dibucaine 1% ointment 1 % $0 (Tier 3) DP

LEVA SET TOPICAL KIT 2.5-2.5 % $0 (Tier 1) MO

lidocaine (pf) injection solution 10 mg/ml (1 %), 5

mg/ml (0.5 %)

$0 (Tier 1) MO

lidocaine hcl injection solution 5 mg/ml (0.5 %) $0 (Tier 1) MO

lidocaine hcl laryngotracheal solution 4 % $0 (Tier 1) MO

lidocaine hcl mucous membrane jelly 2 % $0 (Tier 1) MO

lidocaine hcl mucous membrane jelly in applicator

2 %

$0 (Tier 1) MO

lidocaine hcl mucous membrane solution 4 % (40

mg/ml)

$0 (Tier 1) MO

lidocaine topical adhesive patch,medicated 5 % $0 (Tier 1) PA; MO; QL (90 EA per 30 days)

lidocaine topical ointment 5 % $0 (Tier 1) MO

lidocaine-prilocaine topical cream 2.5-2.5 % $0 (Tier 1) MO

lidocaine-prilocaine topical kit 2.5-2.5 % $0 (Tier 1) MO

LIDOPAC TOPICAL KIT 5 % $0 (Tier 1) MO

lidopril topical kit 2.5-2.5 % $0 (Tier 1) MO

lidopril xr topical kit 2.5-2.5 % $0 (Tier 1) MO



Formulary ID: 18395




9


cost you (Tier

Level)


limits on use

LIDO-PRILO CAINE PACK TOPICAL KIT 2.5-

2.5 %

$0 (Tier 1) MO

liprozonepak topical kit 2.5-2.5 % $0 (Tier 1) MO

livixil pak topical kit 2.5-2.5 % $0 (Tier 1) MO

MEDOLOR PAK TOPICAL KIT 2.5-2.5 % $0 (Tier 1) MO

prilolid topical kit 2.5-2.5 % $0 (Tier 1) MO

PUB HEMORRHOIDAL SUPPOSITORIES 0.25-

3 %

$0 (Tier 3) DP

SM HEMORRHOIDAL CREAM 0.25-1 % $0 (Tier 3) DP

ANTI-ADDICTION/ SUBSTANCE ABUSE TREATMENT AGENTS - TREATMENT OF

SUBSTANCE ABUSE DISORDERS

ALCOHOL DETERRENTS/ ANTI-CRAVING

acamprosate oral tablet,delayed release (dr/ec)

333 mg

$0 (Tier 1) MO

disulfiram oral tablet 250 mg, 500 mg $0 (Tier 1) MO

naltrexone oral tablet 50 mg $0 (Tier 1) MO

OPIOID DEPENDENCE TREATMENTS

buprenorphine hcl sublingual tablet 2 mg, 8 mg $0 (Tier 1) MO

buprenorphine-naloxone sublingual tablet 2-0.5

mg, 8-2 mg

$0 (Tier 1) MO

OPIOID REVERSAL AGENTS

naloxone injection solution 0.4 mg/ml $0 (Tier 1) MO

naloxone injection syringe 0.4 mg/ml, 1 mg/ml $0 (Tier 1) MO

SMOKING CESSATION AGENTS

buproban oral tablet extended release 12 hr 150

mg

$0 (Tier 1) MO

CHANTIX CONTINUING MONTH BOX ORAL

TABLET 1 MG


CHANTIX ORAL TABLET 0.5 MG, 1 MG $0 (Tier 2) MO; QL (336 EA per 365 days)


10


cost you (Tier

Level)


limits on use

CHANTIX STARTING MONTH BOX ORAL

TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (42)


NICODERM CQ 14 MG/24HR PATCH 14

MG/24 HR

$0 (Tier 3) DP

NICODERM CQ 21 MG/24HR PATCH 21

MG/24 HR

$0 (Tier 3) DP

NICODERM CQ 21 MG/24HR PATCH CLEAR

PATCH 21 MG/24 HR

$0 (Tier 3) DP

NICODERM CQ 7 MG/24HR PATCH 7 MG/24

HR

$0 (Tier 3) DP

nicotine 14 mg/24hr patch clear, step 2, outer (otc)

14 mg/24 hr

$0 (Tier 3) DP

nicotine 14 mg/24hr patch step 2 (otc) 14 mg/24 hr $0 (Tier 3) DP

nicotine 2 mg lozenge cinnamon,quittube 2 mg $0 (Tier 3) DP

nicotine 21 mg/24hr patch outer, clear, step 1 (otc)

21 mg/24 hr

$0 (Tier 3) DP

nicotine 4 mg chewing gum 4 mg $0 (Tier 3) DP

nicotine 4 mg lozenge mint 4 mg $0 (Tier 3) DP

nicotine 7 mg/24hr patch outer, clear, step 3 (otc)

7 mg/24 hr

$0 (Tier 3) DP

NICOTROL INHALATION CARTRIDGE 10

MG

$0 (Tier 2) MO

NICOTROL NS NASAL SPRAY,NON-

AEROSOL 10 MG/ML

$0 (Tier 2) MO

sm nicotine 2 mg chewing gum mint 2 mg $0 (Tier 3) DP

ANTIBACTERIALS - TREATMENT OF BACTERIAL INFECTIONS

AMINOGLYCOSIDES

amikacin injection solution 1,000 mg/4 ml, 500

mg/2 ml

$0 (Tier 1)

gentak ophthalmic (eye) ointment 0.3 % (3

mg/gram)

$0 (Tier 1) MO

gentamicin injection solution 20 mg/2 ml $0 (Tier 1)

gentamicin ophthalmic (eye) drops 0.3 % $0 (Tier 1) MO

gentamicin ophthalmic (eye) ointment 0.3 % (3

mg/gram)

$0 (Tier 1) MO



Formulary ID: 18395




11


cost you (Tier

Level)


limits on use

gentamicin sulfate (ped) (pf) injection solution 20

mg/2 ml

$0 (Tier 1)

gentamicin sulfate (pf) intravenous solution 60

mg/6 ml

$0 (Tier 1)

gentamicin sulfate (pf) intravenous solution 80

mg/8 ml

$0 (Tier 1) MO

gentamicin topical cream 0.1 % $0 (Tier 1) MO

gentamicin topical ointment 0.1 % $0 (Tier 1) MO

neomycin oral tablet 500 mg $0 (Tier 1) MO

paromomycin oral capsule 250 mg $0 (Tier 1) MO

streptomycin intramuscular recon soln 1 gram $0 (Tier 1)

TOBRADEX OPHTHALMIC (EYE)

OINTMENT 0.3-0.1 %

$0 (Tier 2) MO

tobramycin in 0.225 % nacl inhalation solution for

nebulization 300 mg/5 ml

$0 (Tier 1) B/D

tobramycin ophthalmic (eye) drops 0.3 % $0 (Tier 1) MO

tobramycin sulfate injection recon soln 1.2 gram $0 (Tier 1)

tobramycin sulfate injection solution 10 mg/ml, 40

mg/ml

$0 (Tier 1)

tobramycin with nebulizer inhalation solution for

nebulization 300 mg/5 ml

$0 (Tier 1) B/D

tobramycin-dexamethasone ophthalmic (eye)

drops,suspension 0.3-0.1 %

$0 (Tier 1) MO

ANTIBACTERIALS, OTHER

acetic acid otic (ear) solution 2 % $0 (Tier 1) MO

ak-poly-bac ophthalmic (eye) ointment 500-10,000

unit/gram

$0 (Tier 1) MO

ANTIBIOTIC OINTMENT 3.5MG-400 UNIT-

5,000 UNIT/GRAM

$0 (Tier 3) DP

bacitracin 500 unit/gm ointmnt 500 unit/gram $0 (Tier 3) DP


12


cost you (Tier

Level)


limits on use

bacitracin ophthalmic (eye) ointment 500

unit/gram

$0 (Tier 1) MO

bacitracin zn 500 unit/gm oint 5 panel carton 500

unit/gram

$0 (Tier 3) DP

bacitracin zn 500 unit/gm oint 500 unit/gram $0 (Tier 3) DP

bacitracin zn 500 unit/gm oint usp 500 unit/gram $0 (Tier 3) DP

bacitracin-polymyxin b ophthalmic (eye) ointment

500-10,000 unit/gram

$0 (Tier 1) MO

bacitracin-polymyxin ointment 500-10,000

unit/gram

$0 (Tier 3) DP

BACTROBAN NASAL NASAL OINTMENT 2

%

$0 (Tier 2) MO

BETADINE 10% SOLUTION ANTISEPTIC 10

%

$0 (Tier 3) DP

BETASEPT 4% SURGICAL SCRUB 4 % $0 (Tier 3) DP

CASTELLANI PAINT MODIFIED 1.5 % $0 (Tier 3) DP

chloramphenicol sod succinate intravenous recon

soln 1 gram

$0 (Tier 1) MO

clindamycin hcl oral capsule 150 mg, 300 mg, 75

mg

$0 (Tier 1) MO

clindamycin in 0.9 % sod chlor intravenous

piggyback 300 mg/50 ml, 600 mg/50 ml, 900

mg/50 ml

$0 (Tier 1) MO

clindamycin in 5 % dextrose intravenous


mg/50 ml

$0 (Tier 1)

clindamycin palmitate hcl oral recon soln 75 mg/5

ml

$0 (Tier 1) MO

clindamycin pediatric oral recon soln 75 mg/5 ml $0 (Tier 1) MO

clindamycin phosphate injection solution 150

(mg/ml) (6 ml), 150 mg/ml

$0 (Tier 1)

clindamycin phosphate intravenous solution 300

mg/2 ml, 600 mg/4 ml, 900 mg/6 ml

$0 (Tier 1)

clindamycin phosphate topical gel 1 % $0 (Tier 1) MO

clindamycin phosphate topical lotion 1 % $0 (Tier 1) MO

clindamycin phosphate topical solution 1 % $0 (Tier 1) MO



Formulary ID: 18395




13


cost you (Tier

Level)


limits on use

clindamycin phosphate topical swab 1 % $0 (Tier 1) MO

clindamycin phosphate vaginal cream 2 % $0 (Tier 1) MO

clindamycin-benzoyl peroxide topical gel 1.2 %(1

% base) -5 %

$0 (Tier 1) MO

colistin (colistimethate na) injection recon soln

150 mg

$0 (Tier 1)

daptomycin intravenous recon soln 500 mg $0 (Tier 1) PA

FIRST AID ABX PAIN RELIEF CRM 3.5-

10,000-10 MG-UNIT-MG/GRAM

$0 (Tier 3) DP

lincomycin injection solution 300 mg/ml $0 (Tier 1)

linezolid in dextrose 5% intravenous parenteral

solution 600 mg/300 ml

$0 (Tier 1) PA

linezolid oral suspension for reconstitution 100

mg/5 ml

$0 (Tier 1) PA; MO

linezolid oral tablet 600 mg $0 (Tier 1) PA; MO

linezolid-0.9% sodium chloride intravenous

parenteral solution 600 mg/300 ml

$0 (Tier 1) PA

methenamine hippurate oral tablet 1 gram $0 (Tier 1) MO

metro i.v. intravenous piggyback 500 mg/100 ml $0 (Tier 1)

metronidazole in nacl (iso-os) intravenous

piggyback 500 mg/100 ml

$0 (Tier 1)

metronidazole oral capsule 375 mg $0 (Tier 1) MO

metronidazole oral tablet 250 mg, 500 mg $0 (Tier 1) MO

metronidazole topical cream 0.75 % $0 (Tier 1) MO

metronidazole topical gel 0.75 %, 1 % $0 (Tier 1) MO

metronidazole topical gel with pump 1 % $0 (Tier 1) MO

metronidazole topical lotion 0.75 % $0 (Tier 1) MO

metronidazole vaginal gel 0.75 % $0 (Tier 1) MO

mupirocin topical ointment 2 % $0 (Tier 1) MO


14


cost you (Tier

Level)


limits on use

neomycin-bacitracin-poly-hc ophthalmic (eye)

ointment 3.5-400-10,000 mg-unit/g-1%

$0 (Tier 1) MO

neomycin-bacitracin-polymyxin ophthalmic (eye)

ointment 3.5-400-10,000 mg-unit-unit/g

$0 (Tier 1) MO

neomycin-polymyxin b gu irrigation solution 40

mg-200,000 unit/ml

$0 (Tier 1) MO

neomycin-polymyxin b-dexameth ophthalmic (eye)

drops,suspension 3.5mg/ml-10,000 unit/ml-0.1 %

$0 (Tier 1) MO

neomycin-polymyxin b-dexameth ophthalmic (eye)

ointment 3.5 mg/g-10,000 unit/g-0.1 %

$0 (Tier 1) MO

neomycin-polymyxin-gramicidin ophthalmic (eye)

drops 1.75 mg-10,000 unit-0.025mg/ml

$0 (Tier 1) MO

neomycin-polymyxin-hc ophthalmic (eye)

drops,suspension 3.5-10,000-10 mg-unit-mg/ml

$0 (Tier 1) MO

nitrofurantoin macrocrystal oral capsule 100 mg,

25 mg, 50 mg


nitrofurantoin monohyd/m-cryst oral capsule 100

mg


nitrofurantoin monohyd/m-cryst oral capsule 100

mg (75/25)


polymyxin b sulfate injection recon soln 500,000

unit

$0 (Tier 1)

polymyxin b sulf-trimethoprim ophthalmic (eye)

drops 10,000 unit- 1 mg/ml

$0 (Tier 1) MO

RA TRIPLE ANTIBIOTIC PLUS OINT 3.5-500-

10,000 MG-UNIT-UNIT/G

$0 (Tier 3) DP

SM ANTIBIOTIC 500 UNIT/GM OINT 500

UNIT/GRAM

$0 (Tier 3) DP

SYNERCID INTRAVENOUS RECON SOLN

500 MG

$0 (Tier 2) PA

trimethoprim oral tablet 100 mg $0 (Tier 1) MO

TRIPLE ANTIBIOTIC OINTMENT 3.5MG-400

UNIT- 5,000 UNIT/GRAM

$0 (Tier 3) DP

TRIPLE ANTIBIOTIC OINTMENT CARTON

3.5MG-400 UNIT- 5,000 UNIT/GRAM

$0 (Tier 3) DP



Formulary ID: 18395




15


cost you (Tier

Level)


limits on use

vancomycin in 0.9 % sodium chl intravenous

piggyback 1 gram/200 ml, 500 mg/100 ml, 750

mg/150 ml

$0 (Tier 1) B/D; MO

vancomycin in 0.9 % sodium chl intravenous

solution 1.25 gram/250 ml, 750 mg/150 ml

$0 (Tier 1) B/D; MO

vancomycin in dextrose 5 % intravenous

piggyback 1 gram/200 ml, 500 mg/100 ml, 750

mg/150 ml

$0 (Tier 1) B/D

vancomycin injection recon soln 100 gram $0 (Tier 1) B/D; MO

vancomycin intravenous recon soln 1,000 mg, 10

gram, 5 gram, 500 mg, 750 mg

$0 (Tier 1) B/D

vancomycin oral capsule 125 mg, 250 mg $0 (Tier 1) MO

XIFAXAN ORAL TABLET 200 MG, 550 MG $0 (Tier 2) PA; MO

BETA-LACTAM, CEPHALOSPORINS

cefaclor oral capsule 250 mg, 500 mg $0 (Tier 1) MO

cefaclor oral tablet extended release 12 hr 500 mg $0 (Tier 1) MO

cefadroxil oral capsule 500 mg $0 (Tier 1) MO

cefadroxil oral suspension for reconstitution 250

mg/5 ml, 500 mg/5 ml

$0 (Tier 1) MO

cefadroxil oral tablet 1 gram $0 (Tier 1) MO

cefazolin in dextrose (iso-os) intravenous

piggyback 1 gram/50 ml

$0 (Tier 1)

cefazolin injection recon soln 1 gram $0 (Tier 1)

cefazolin intravenous recon soln 1 gram $0 (Tier 1)

cefdinir oral capsule 300 mg $0 (Tier 1) MO

cefdinir oral suspension for reconstitution 125


$0 (Tier 1) MO

cefepime in dextrose 5 % intravenous piggyback 1

gram/50 ml, 2 gram/50 ml

$0 (Tier 1)

cefepime in dextrose,iso-osm intravenous

piggyback 1 gram/50 ml, 2 gram/100 ml

$0 (Tier 1)


16


cost you (Tier

Level)


limits on use

cefepime injection recon soln 1 gram, 2 gram $0 (Tier 1)

cefotaxime injection recon soln 1 gram, 2 gram,

500 mg

$0 (Tier 1)

cefoxitin in dextrose, iso-osm intravenous


$0 (Tier 1)

cefoxitin intravenous recon soln 1 gram, 10 gram,

2 gram

$0 (Tier 1)

cefpodoxime oral suspension for reconstitution

100 mg/5 ml, 50 mg/5 ml

$0 (Tier 1) MO

cefpodoxime oral tablet 100 mg, 200 mg $0 (Tier 1) MO

cefprozil oral suspension for reconstitution 125


$0 (Tier 1) MO

cefprozil oral tablet 250 mg, 500 mg $0 (Tier 1) MO

ceftazidime in d5w intravenous piggyback 1


$0 (Tier 1)

ceftazidime injection recon soln 1 gram, 2 gram, 6

gram

$0 (Tier 1)

ceftriaxone in dextrose,iso-os intravenous


$0 (Tier 1)

ceftriaxone injection recon soln 1 gram, 10 gram,

2 gram, 250 mg, 500 mg

$0 (Tier 1)

ceftriaxone injection recon soln 100 gram $0 (Tier 1) MO

ceftriaxone intravenous recon soln 1 gram, 2 gram $0 (Tier 1)

cefuroxime axetil oral tablet 250 mg, 500 mg $0 (Tier 1) MO

cefuroxime sodium intravenous recon soln 1.5

gram

$0 (Tier 1)

cephalexin oral capsule 250 mg, 500 mg $0 (Tier 1) MO

cephalexin oral suspension for reconstitution 125


$0 (Tier 1) MO

cephalexin oral tablet 250 mg, 500 mg $0 (Tier 1) MO

SUPRAX ORAL CAPSULE 400 MG $0 (Tier 2) MO

TAZICEF INJECTION RECON SOLN 1 GRAM,

2 GRAM, 6 GRAM

$0 (Tier 1)

TAZICEF INTRAVENOUS RECON SOLN 1

GRAM, 2 GRAM

$0 (Tier 1)



Formulary ID: 18395




17


cost you (Tier

Level)


limits on use

TEFLARO INTRAVENOUS RECON SOLN 400

MG, 600 MG

$0 (Tier 2) PA

BETA-LACTAM, OTHER

aztreonam injection recon soln 1 gram, 2 gram $0 (Tier 1)

doripenem intravenous recon soln 250 mg, 500 mg $0 (Tier 1) PA

imipenem-cilastatin intravenous recon soln 250

mg, 500 mg

$0 (Tier 1) PA

INVANZ INJECTION RECON SOLN 1 GRAM $0 (Tier 2) PA

INVANZ INTRAVENOUS RECON SOLN 1

GRAM

$0 (Tier 2) PA

meropenem intravenous recon soln 1 gram, 500

mg

$0 (Tier 1)

meropenem-0.9% sodium chloride intravenous

piggyback 1 gram/50 ml, 500 mg/50 ml

$0 (Tier 1) MO

VABOMERE INTRAVENOUS RECON SOLN 2

GRAM

$0 (Tier 2) PA; MO

BETA-LACTAM, PENICILLINS

amoxicillin oral capsule 250 mg, 500 mg $0 (Tier 1) MO

amoxicillin oral suspension for reconstitution 125

mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml

$0 (Tier 1) MO

amoxicillin oral tablet 500 mg, 875 mg $0 (Tier 1) MO

amoxicillin oral tablet,chewable 125 mg, 250 mg $0 (Tier 1) MO

amoxicillin-pot clavulanate oral suspension for

reconstitution 200-28.5 mg/5 ml, 250-62.5 mg/5

ml, 400-57 mg/5 ml, 600-42.9 mg/5 ml

$0 (Tier 1) MO

amoxicillin-pot clavulanate oral tablet 250-125

mg, 500-125 mg, 875-125 mg

$0 (Tier 1) MO

amoxicillin-pot clavulanate oral tablet extended

release 12 hr 1,000-62.5 mg

$0 (Tier 1) MO

amoxicillin-pot clavulanate oral tablet,chewable

200-28.5 mg, 400-57 mg

$0 (Tier 1) MO


18


cost you (Tier

Level)


limits on use

ampicillin oral capsule 250 mg, 500 mg $0 (Tier 1) MO

ampicillin oral suspension for reconstitution 125


$0 (Tier 1) MO

ampicillin sodium injection recon soln 1 gram, 10

gram, 125 mg, 2 gram, 250 mg, 500 mg

$0 (Tier 1)

ampicillin sodium intravenous recon soln 1 gram $0 (Tier 1)

ampicillin-sulbactam injection recon soln 1.5

gram, 15 gram, 3 gram

$0 (Tier 1)

ampicillin-sulbactam intravenous recon soln 1.5

gram, 3 gram

$0 (Tier 1)

BICILLIN L-A INTRAMUSCULAR SYRINGE

1,200,000 UNIT/2 ML, 2,400,000 UNIT/4 ML,

600,000 UNIT/ML

$0 (Tier 2) MO

dicloxacillin oral capsule 250 mg, 500 mg $0 (Tier 1) MO

nafcillin in dextrose iso-osm intravenous


$0 (Tier 1)

nafcillin injection recon soln 1 gram, 2 gram $0 (Tier 1)

nafcillin intravenous recon soln 1 gram, 2 gram $0 (Tier 1)

penicillin g procaine intramuscular syringe 1.2

million unit/2 ml

$0 (Tier 1)

penicillin g sodium injection recon soln 5 million

unit

$0 (Tier 1)

penicillin v potassium oral recon soln 125 mg/5

ml, 250 mg/5 ml

$0 (Tier 1) MO

penicillin v potassium oral tablet 250 mg, 500 mg $0 (Tier 1) MO

piperacillin-tazobactam intravenous recon soln

13.5 gram

$0 (Tier 1) MO

piperacillin-tazobactam intravenous recon soln

2.25 gram, 3.375 gram, 4.5 gram, 40.5 gram

$0 (Tier 1)

MACROLIDES

azithromycin intravenous recon soln 500 mg, 500

mg (2 mg/ml)

$0 (Tier 1) MO

azithromycin oral packet 1 gram $0 (Tier 1) MO

azithromycin oral suspension for reconstitution

100 mg/5 ml, 200 mg/5 ml

$0 (Tier 1) MO



Formulary ID: 18395




19


cost you (Tier

Level)


limits on use

azithromycin oral tablet 250 mg, 250 mg (6 pack),

500 mg, 500 mg (3 pack), 600 mg

$0 (Tier 1) MO

clarithromycin oral suspension for reconstitution

125 mg/5 ml, 250 mg/5 ml

$0 (Tier 1) MO

clarithromycin oral tablet 250 mg, 500 mg $0 (Tier 1) MO

clarithromycin oral tablet extended release 24 hr

500 mg

$0 (Tier 1) MO

DIFICID ORAL TABLET 200 MG $0 (Tier 2) PA; MO

ery pads topical swab 2 % $0 (Tier 1) MO

erythrocin (as stearate) oral tablet 250 mg $0 (Tier 1) MO

ERYTHROCIN INTRAVENOUS RECON SOLN

500 MG

$0 (Tier 2) MO

erythromycin ethylsuccinate oral suspension for

reconstitution 200 mg/5 ml

$0 (Tier 1) MO

erythromycin ethylsuccinate oral tablet 400 mg $0 (Tier 1) MO

erythromycin ophthalmic (eye) ointment 5

mg/gram (0.5 %)

$0 (Tier 1) MO

erythromycin oral tablet 250 mg, 500 mg $0 (Tier 1) MO

erythromycin with ethanol topical gel 2 % $0 (Tier 1) MO

erythromycin with ethanol topical solution 2 % $0 (Tier 1) MO

QUINOLONES

AVELOX IN NACL (ISO-OSMOTIC)

INTRAVENOUS PIGGYBACK 400 MG/250 ML

$0 (Tier 2)

ciprofloxacin (mixture) oral tablet, er multiphase

24 hr 1,000 mg, 500 mg

$0 (Tier 1) MO

ciprofloxacin hcl ophthalmic (eye) drops 0.3 % $0 (Tier 1) MO

ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500

mg, 750 mg

$0 (Tier 1) MO

ciprofloxacin lactate intravenous solution 200

mg/20 ml, 400 mg/40 ml

$0 (Tier 1)


20


cost you (Tier

Level)


limits on use

levofloxacin in d5w intravenous piggyback 500

mg/100 ml, 750 mg/150 ml

$0 (Tier 1)

levofloxacin intravenous solution 25 mg/ml $0 (Tier 1)

levofloxacin oral solution 250 mg/10 ml $0 (Tier 1) MO

levofloxacin oral tablet 250 mg, 500 mg, 750 mg $0 (Tier 1) MO

MOXEZA OPHTHALMIC (EYE) DROPS,

VISCOUS 0.5 %

$0 (Tier 2) MO

moxifloxacin in nacl (iso-osm) intravenous


$0 (Tier 1)

moxifloxacin ophthalmic (eye) drops 0.5 % $0 (Tier 1) MO

moxifloxacin oral tablet 400 mg $0 (Tier 1) MO

moxifloxacin-sod.ace,sul-water intravenous


$0 (Tier 1) MO

ofloxacin ophthalmic (eye) drops 0.3 % $0 (Tier 1) MO

ofloxacin oral tablet 300 mg, 400 mg $0 (Tier 1) MO

VIGAMOX OPHTHALMIC (EYE) DROPS 0.5

%

$0 (Tier 2) MO

SULFONAMIDES

silver sulfadiazine topical cream 1 % $0 (Tier 1) MO

ssd topical cream 1 % $0 (Tier 1) MO

sulfacetamide sodium (acne) topical suspension 10

%

$0 (Tier 1) MO

sulfacetamide sodium ophthalmic (eye) drops 10

%

$0 (Tier 1) MO

sulfacetamide sodium ophthalmic (eye) ointment

10 %

$0 (Tier 1) MO

sulfadiazine oral tablet 500 mg $0 (Tier 1) MO

sulfamethoxazole-trimethoprim intravenous

solution 400-80 mg/5 ml

$0 (Tier 1)

sulfamethoxazole-trimethoprim oral suspension

200-40 mg/5 ml

$0 (Tier 1) MO

sulfamethoxazole-trimethoprim oral tablet 400-80

mg, 800-160 mg

$0 (Tier 1) MO

TETRACYCLINES



Formulary ID: 18395




21


cost you (Tier

Level)


limits on use

demeclocycline oral tablet 150 mg, 300 mg $0 (Tier 1) MO

doxy-100 intravenous recon soln 100 mg $0 (Tier 1)

doxycycline hyclate intravenous recon soln 100 mg $0 (Tier 1)

doxycycline hyclate oral capsule 100 mg, 50 mg $0 (Tier 1) MO

doxycycline hyclate oral tablet 100 mg, 20 mg $0 (Tier 1) MO

doxycycline monohydrate oral capsule 100 mg, 50

mg

$0 (Tier 1) MO

doxycycline monohydrate oral tablet 100 mg, 150

mg, 50 mg, 75 mg

$0 (Tier 1) MO

minocycline oral capsule 100 mg, 50 mg, 75 mg $0 (Tier 1) MO

minocycline oral tablet 100 mg, 50 mg, 75 mg $0 (Tier 1) MO

MORGIDOX 1X 50 KIT 50 MG $0 (Tier 1) MO

morgidox oral capsule 50 mg $0 (Tier 1) MO

ANTICONVULSANTS - TREATMENT OF SEIZURES

ANTICONVULSANTS, OTHER

BRIVIACT INTRAVENOUS SOLUTION 50

MG/5 ML

$0 (Tier 2) PA; MO

BRIVIACT ORAL SOLUTION 10 MG/ML $0 (Tier 2) PA; MO

BRIVIACT ORAL TABLET 10 MG, 100 MG, 25

MG, 50 MG, 75 MG

$0 (Tier 2) PA; MO

levetiracetam in nacl (iso-os) intravenous

piggyback 1,000 mg/100 ml, 1,500 mg/100 ml, 500

mg/100 ml

$0 (Tier 1)

levetiracetam intravenous solution 500 mg/5 ml $0 (Tier 1)

levetiracetam oral solution 100 mg/ml, 500 mg/5

ml (5 ml)

$0 (Tier 1) MO

levetiracetam oral tablet 1,000 mg, 250 mg, 500

mg, 750 mg

$0 (Tier 1) MO

levetiracetam oral tablet extended release 24 hr

500 mg, 750 mg

$0 (Tier 1) MO


22


cost you (Tier

Level)


limits on use

ROWEEPRA ORAL TABLET 1,000 MG, 750

MG

$0 (Tier 1) MO

roweepra oral tablet 500 mg $0 (Tier 1) MO

ROWEEPRA XR ORAL TABLET EXTENDED

RELEASE 24 HR 500 MG, 750 MG

$0 (Tier 1) MO

SPRITAM ORAL TABLET FOR SUSPENSION

1,000 MG, 250 MG, 500 MG

$0 (Tier 2) ST; MO; QL (60 EA per 30 days)

SPRITAM ORAL TABLET FOR SUSPENSION

750 MG


CALCIUM CHANNEL MODIFYING AGENTS

CELONTIN ORAL CAPSULE 300 MG $0 (Tier 2) MO

ethosuximide oral capsule 250 mg $0 (Tier 1) MO

ethosuximide oral solution 250 mg/5 ml $0 (Tier 1) MO

LYRICA ORAL CAPSULE 100 MG, 150 MG,

200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75

MG

$0 (Tier 2) MO

LYRICA ORAL SOLUTION 20 MG/ML $0 (Tier 2) MO

zonisamide oral capsule 100 mg, 25 mg, 50 mg $0 (Tier 1) MO

GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS

DIASTAT ACUDIAL RECTAL KIT 12.5-15-

17.5-20 MG


DIASTAT ACUDIAL RECTAL KIT 5-7.5-10

MG


DIASTAT RECTAL KIT 2.5 MG $0 (Tier 2) MO; QL (5 EA per 30 days)

diazepam rectal kit 12.5-15-17.5-20 mg $0 (Tier 1) MO; QL (40 EA per 30 days)

diazepam rectal kit 2.5 mg $0 (Tier 1) MO; QL (5 EA per 30 days)

diazepam rectal kit 5-7.5-10 mg $0 (Tier 1) MO; QL (20 EA per 30 days)

divalproex oral capsule, delayed rel sprinkle 125

mg

$0 (Tier 1) MO

divalproex oral tablet extended release 24 hr 250

mg, 500 mg

$0 (Tier 1) MO

divalproex oral tablet,delayed release (dr/ec) 125

mg, 250 mg, 500 mg

$0 (Tier 1) MO

gabapentin oral capsule 100 mg, 300 mg, 400 mg $0 (Tier 1) MO



Formulary ID: 18395




23


cost you (Tier

Level)


limits on use

gabapentin oral solution 250 mg/5 ml, 250 mg/5

ml (5 ml), 300 mg/6 ml (6 ml)

$0 (Tier 1) MO

gabapentin oral tablet 600 mg, 800 mg $0 (Tier 1) MO

GABITRIL ORAL TABLET 12 MG, 16 MG $0 (Tier 2) MO

ONFI ORAL SUSPENSION 2.5 MG/ML $0 (Tier 2) PA; MO; QL (480 ML per 30 days)

ONFI ORAL TABLET 10 MG, 20 MG $0 (Tier 2) PA; MO; QL (60 EA per 30 days)

phenobarbital oral elixir 20 mg/5 ml (4 mg/ml) $0 (Tier 1) PA; MO

phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg,

30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg

$0 (Tier 1) PA; MO

primidone oral tablet 250 mg, 50 mg $0 (Tier 1) MO

SABRIL ORAL POWDER IN PACKET 500 MG $0 (Tier 2) PA

SABRIL ORAL TABLET 500 MG $0 (Tier 2) PA; QL (180 EA per 30 days)

tiagabine oral tablet 12 mg, 16 mg, 2 mg, 4 mg $0 (Tier 1) MO

valproate sodium intravenous solution 500 mg/5

ml (100 mg/ml)

$0 (Tier 1)

valproic acid (as sodium salt) oral solution 250

mg/5 ml, 250 mg/5 ml (5 ml), 500 mg/10 ml (10

ml)

$0 (Tier 1) MO

valproic acid oral capsule 250 mg $0 (Tier 1) MO

vigabatrin oral powder in packet 500 mg $0 (Tier 1) PA

GLUTAMATE REDUCING AGENTS

felbamate oral suspension 600 mg/5 ml $0 (Tier 1) MO

felbamate oral tablet 400 mg, 600 mg $0 (Tier 1) MO

FYCOMPA ORAL SUSPENSION 0.5 MG/ML $0 (Tier 2) ST; MO

FYCOMPA ORAL TABLET 10 MG, 12 MG, 2

MG, 4 MG, 6 MG, 8 MG


lamotrigine oral tablet 100 mg, 150 mg, 200 mg,

25 mg

$0 (Tier 1) MO

lamotrigine oral tablet extended release 24hr 100

mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg

$0 (Tier 1) MO


24


cost you (Tier

Level)


limits on use

lamotrigine oral tablet, chewable dispersible 25

mg, 5 mg

$0 (Tier 1) MO

lamotrigine oral tablets,dose pack 25 mg (35), 25

mg (42) -100 mg (7), 25 mg (84) -100 mg (14)

$0 (Tier 1) MO

topiramate oral capsule, sprinkle 15 mg, 25 mg $0 (Tier 1) MO

topiramate oral tablet 100 mg, 200 mg, 25 mg, 50

mg

$0 (Tier 1) MO

SODIUM CHANNEL AGENTS

APTIOM ORAL TABLET 200 MG, 400 MG, 800

MG


APTIOM ORAL TABLET 600 MG $0 (Tier 2) ST; MO; QL (60 EA per 30 days)

BANZEL ORAL SUSPENSION 40 MG/ML $0 (Tier 2) PA; MO; QL (2400 ML per 30 days)

BANZEL ORAL TABLET 200 MG, 400 MG $0 (Tier 2) PA; MO; QL (240 EA per 30 days)

carbamazepine oral capsule, er multiphase 12 hr

100 mg, 200 mg, 300 mg

$0 (Tier 1) MO

carbamazepine oral suspension 100 mg/5 ml $0 (Tier 1) MO

carbamazepine oral tablet 200 mg $0 (Tier 1) MO

carbamazepine oral tablet extended release 12 hr

100 mg, 200 mg, 400 mg

$0 (Tier 1) MO

carbamazepine oral tablet,chewable 100 mg $0 (Tier 1) MO

DILANTIN ORAL CAPSULE 30 MG $0 (Tier 2) MO

epitol oral tablet 200 mg $0 (Tier 1) MO

EQUETRO ORAL CAPSULE, ER

MULTIPHASE 12 HR 100 MG, 200 MG, 300

MG

$0 (Tier 2) MO

fosphenytoin injection solution 100 mg pe/2 ml,

500 mg pe/10 ml

$0 (Tier 1)

oxcarbazepine oral suspension 300 mg/5 ml (60

mg/ml)

$0 (Tier 1) MO

oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg $0 (Tier 1) MO

PEGANONE ORAL TABLET 250 MG $0 (Tier 2) MO

PHENYTEK ORAL CAPSULE 200 MG, 300 MG $0 (Tier 2) MO

phenytoin oral suspension 100 mg/4 ml, 125 mg/5

ml

$0 (Tier 1) MO



Formulary ID: 18395




25


cost you (Tier

Level)


limits on use

phenytoin oral tablet,chewable 50 mg $0 (Tier 1) MO

phenytoin sodium extended oral capsule 100 mg,

200 mg, 300 mg

$0 (Tier 1) MO

phenytoin sodium intravenous solution 50 mg/ml $0 (Tier 1)

VIMPAT INTRAVENOUS SOLUTION 200

MG/20 ML

$0 (Tier 2)

VIMPAT ORAL SOLUTION 10 MG/ML $0 (Tier 2) ST; MO; QL (1200 ML per 30 days)

VIMPAT ORAL TABLET 100 MG, 150 MG, 200

MG, 50 MG


ANTIDEMENTIA AGENTS - MANAGEMENT OF DEMENTIA

ANTIDEMENTIA AGENTS, OTHER

ergoloid oral tablet 1 mg $0 (Tier 1) PA; MO

CHOLINESTERASE INHIBITORS

donepezil oral tablet 10 mg, 23 mg, 5 mg $0 (Tier 1) MO

donepezil oral tablet,disintegrating 10 mg, 5 mg $0 (Tier 1) MO

rivastigmine tartrate oral capsule 1.5 mg, 3 mg,

4.5 mg, 6 mg

$0 (Tier 1) MO

rivastigmine transdermal patch 24 hour 13.3

mg/24 hour, 4.6 mg/24 hr, 9.5 mg/24 hr

$0 (Tier 1) MO

N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST

memantine oral capsule,sprinkle,er 24hr 14 mg,

21 mg, 28 mg, 7 mg


memantine oral tablet 10 mg, 5 mg $0 (Tier 1) MO

memantine oral tablets,dose pack 5-10 mg $0 (Tier 1) MO

NAMENDA XR ORAL CAP,SPRINKLE,ER

24HR DOSE PACK 7-14-21-28 MG

$0 (Tier 2) ST; MO

NAMENDA XR ORAL

CAPSULE,SPRINKLE,ER 24HR 14 MG, 21 MG,

28 MG, 7 MG



26


cost you (Tier

Level)


limits on use

ANTIDEPRESSANTS - TREATMENT OF DEPRESSION

ANTIDEPRESSANTS, OTHER

bupropion hcl (smoking deter) oral tablet extended

release 12 hr 150 mg

$0 (Tier 1) MO

bupropion hcl oral tablet 100 mg, 75 mg $0 (Tier 1) MO

bupropion hcl oral tablet extended release 12 hr

100 mg, 150 mg, 200 mg

$0 (Tier 1) MO

bupropion hcl oral tablet extended release 24 hr

150 mg, 300 mg

$0 (Tier 1) MO

FORFIVO XL ORAL TABLET EXTENDED

RELEASE 24 HR 450 MG

$0 (Tier 2) MO

mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5

mg

$0 (Tier 1) MO

mirtazapine oral tablet,disintegrating 15 mg, 30

mg, 45 mg

$0 (Tier 1) MO

nefazodone oral tablet 100 mg, 150 mg, 200 mg,

250 mg, 50 mg

$0 (Tier 1) MO

perphenazine-amitriptyline oral tablet 2-10 mg, 2-

25 mg, 4-10 mg, 4-25 mg, 4-50 mg

$0 (Tier 1) PA; MO

trazodone oral tablet 100 mg, 150 mg, 300 mg, 50

mg

$0 (Tier 1) MO

MONOAMINE OXIDASE INHIBITORS

EMSAM TRANSDERMAL PATCH 24 HOUR

12 MG/24 HR, 6 MG/24 HR, 9 MG/24 HR

$0 (Tier 2) MO

MARPLAN ORAL TABLET 10 MG $0 (Tier 2) MO

phenelzine oral tablet 15 mg $0 (Tier 1) MO

tranylcypromine oral tablet 10 mg $0 (Tier 1) MO

SSRIS/ SNRIS

citalopram oral solution 10 mg/5 ml $0 (Tier 1) MO

citalopram oral tablet 10 mg, 20 mg, 40 mg $0 (Tier 1) MO

desvenlafaxine succinate oral tablet extended

release 24 hr 100 mg, 25 mg, 50 mg

$0 (Tier 1) MO

duloxetine oral capsule,delayed release(dr/ec) 20

mg, 30 mg, 60 mg

$0 (Tier 1) MO



Formulary ID: 18395




27


cost you (Tier

Level)


limits on use

escitalopram oxalate oral solution 5 mg/5 ml $0 (Tier 1) MO

escitalopram oxalate oral tablet 10 mg, 20 mg, 5

mg

$0 (Tier 1) MO

FETZIMA ORAL CAPSULE,EXT REL 24HR

DOSE PACK 20 MG (2)- 40 MG (26)

$0 (Tier 2) ST; MO

FETZIMA ORAL CAPSULE,EXTENDED

RELEASE 24 HR 120 MG, 20 MG, 40 MG, 80

MG

$0 (Tier 2) ST; MO

fluoxetine oral capsule 10 mg, 20 mg, 40 mg $0 (Tier 1) MO

fluoxetine oral capsule,delayed release(dr/ec) 90

mg

$0 (Tier 1) MO

fluoxetine oral solution 20 mg/5 ml (4 mg/ml) $0 (Tier 1) MO

fluoxetine oral tablet 10 mg, 20 mg $0 (Tier 1) MO

fluvoxamine oral tablet 100 mg, 25 mg, 50 mg $0 (Tier 1) MO

maprotiline oral tablet 25 mg, 50 mg, 75 mg $0 (Tier 1) MO

paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40

mg

$0 (Tier 1) MO

paroxetine hcl oral tablet extended release 24 hr

12.5 mg, 25 mg, 37.5 mg

$0 (Tier 1) MO

PAXIL ORAL SUSPENSION 10 MG/5 ML $0 (Tier 2) MO

sertraline oral concentrate 20 mg/ml $0 (Tier 1) MO

sertraline oral tablet 100 mg, 25 mg, 50 mg $0 (Tier 1) MO

TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5

MG

$0 (Tier 2) ST; MO

venlafaxine oral capsule,extended release 24hr

150 mg, 37.5 mg, 75 mg

$0 (Tier 1) MO

venlafaxine oral tablet 100 mg, 25 mg, 37.5 mg, 50

mg, 75 mg

$0 (Tier 1) MO

venlafaxine oral tablet extended release 24hr 150

mg, 225 mg, 37.5 mg, 75 mg

$0 (Tier 1) MO


28


cost you (Tier

Level)


limits on use

VIIBRYD ORAL TABLET 10 MG, 20 MG, 40

MG

$0 (Tier 2) ST; MO

VIIBRYD ORAL TABLETS,DOSE PACK 10

MG (7)- 20 MG (23)

$0 (Tier 2) ST; MO

TRICYCLICS

amitriptyline oral tablet 10 mg, 100 mg, 150 mg,

25 mg, 50 mg, 75 mg

$0 (Tier 1) PA; MO

amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50

mg

$0 (Tier 1) MO

clomipramine oral capsule 25 mg, 50 mg, 75 mg $0 (Tier 1) PA; MO

desipramine oral tablet 10 mg, 100 mg, 150 mg,

25 mg, 50 mg, 75 mg

$0 (Tier 1) MO

doxepin oral capsule 10 mg, 100 mg, 150 mg, 25

mg, 50 mg, 75 mg

$0 (Tier 1) PA; MO

doxepin oral concentrate 10 mg/ml $0 (Tier 1) PA; MO

imipramine hcl oral tablet 10 mg, 25 mg, 50 mg $0 (Tier 1) PA; MO

imipramine pamoate oral capsule 100 mg, 125 mg,

150 mg, 75 mg

$0 (Tier 1) PA; MO

nortriptyline oral capsule 10 mg, 25 mg, 50 mg, 75

mg

$0 (Tier 1) MO

nortriptyline oral solution 10 mg/5 ml $0 (Tier 1) MO

protriptyline oral tablet 10 mg, 5 mg $0 (Tier 1) MO

trimipramine oral capsule 100 mg, 25 mg, 50 mg $0 (Tier 1) PA; MO

ANTIEMETICS - TREATMENT OF VOMITING OR NAUSEA

ANTIEMETICS, OTHER

chlorpromazine injection solution 25 mg/ml $0 (Tier 1) MO

chlorpromazine oral tablet 10 mg, 100 mg, 200

mg, 25 mg, 50 mg

$0 (Tier 1) MO

compro rectal suppository 25 mg $0 (Tier 1) MO

dimenhydrinate 50 mg tablet (otc) 50 mg $0 (Tier 3) DP

diphenhydramine hcl injection solution 50 mg/ml $0 (Tier 1) PA; MO

meclizine oral tablet 12.5 mg, 25 mg $0 (Tier 1) MO

metoclopramide hcl injection solution 5 mg/ml $0 (Tier 1) MO

metoclopramide hcl oral solution 5 mg/5 ml $0 (Tier 1) MO



Formulary ID: 18395




29


cost you (Tier

Level)


limits on use

metoclopramide hcl oral tablet 10 mg, 5 mg $0 (Tier 1) MO

MOTION SICKNESS RELIEF TB CHEW

CHEWABLE TABLET 25 MG

$0 (Tier 3) DP

perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg $0 (Tier 1) MO

phenadoz rectal suppository 12.5 mg $0 (Tier 1) PA; MO

prochlorperazine edisylate injection solution 10

mg/2 ml (5 mg/ml), 5 mg/ml

$0 (Tier 1) MO

prochlorperazine maleate oral tablet 10 mg, 5 mg $0 (Tier 1) MO

prochlorperazine rectal suppository 25 mg $0 (Tier 1) MO

promethazine oral syrup 6.25 mg/5 ml $0 (Tier 1) PA; MO

promethazine oral tablet 12.5 mg, 25 mg, 50 mg $0 (Tier 1) PA; MO

promethazine rectal suppository 12.5 mg, 25 mg $0 (Tier 1) PA; MO

promethegan rectal suppository 25 mg, 50 mg $0 (Tier 1) PA; MO

scopolamine base transdermal patch 3 day 1 mg

over 3 days

$0 (Tier 1) MO

TRANSDERM-SCOP TRANSDERMAL PATCH

3 DAY 1 MG OVER 3 DAYS

$0 (Tier 2) MO

trimethobenzamide oral capsule 300 mg $0 (Tier 1) PA; MO

EMETOGENIC THERAPY ADJUNCTS

aprepitant oral capsule 125 mg, 40 mg, 80 mg $0 (Tier 1) B/D; MO

aprepitant oral capsule,dose pack 125 mg (1)- 80

mg (2)

$0 (Tier 1) B/D; MO

dronabinol oral capsule 10 mg, 2.5 mg, 5 mg $0 (Tier 1) B/D; MO

EMEND ORAL SUSPENSION FOR

RECONSTITUTION 125 MG (25 MG/ ML

FINAL CONC.)

$0 (Tier 2) B/D; MO

granisetron (pf) intravenous solution 1 mg/ml (1

ml), 100 mcg/ml

$0 (Tier 1) B/D

granisetron hcl intravenous solution 1 mg/ml, 1

mg/ml (1 ml)

$0 (Tier 1) B/D


30


cost you (Tier

Level)


limits on use

granisetron hcl oral tablet 1 mg $0 (Tier 1) B/D; MO

ondansetron hcl (pf) injection solution 4 mg/2 ml $0 (Tier 1)

ondansetron hcl (pf) injection syringe 4 mg/2 ml $0 (Tier 1)

ondansetron hcl intravenous solution 2 mg/ml $0 (Tier 1)

ondansetron hcl oral solution 4 mg/5 ml $0 (Tier 1) B/D; MO

ondansetron hcl oral tablet 24 mg $0 (Tier 1) B/D; MO; QL (15 EA per 30 days)

ondansetron hcl oral tablet 4 mg, 8 mg $0 (Tier 1) B/D; MO

ondansetron oral tablet,disintegrating 4 mg, 8 mg $0 (Tier 1) B/D; MO

SYNDROS ORAL SOLUTION 5 MG/ML $0 (Tier 2) PA; MO

ANTIFUNGALS - TREATMENT OF FUNGAL OR YEAST INFECTIONS

ANTIFUNGALS

abelcet intravenous suspension 5 mg/ml $0 (Tier 1) B/D

AMBISOME INTRAVENOUS SUSPENSION

FOR RECONSTITUTION 50 MG

$0 (Tier 2) B/D

amphotericin b injection recon soln 50 mg $0 (Tier 1) B/D

ANTI-FUNGAL 1% POWDER 1 % $0 (Tier 3) DP

ANTIFUNGAL 2% CREAM 2 % $0 (Tier 3) DP

BAZA ANTIFUNGAL 2% CREAM 12'S 2 % $0 (Tier 3) DP

BREWER'S YEAST 680 MG TABLET 680 MG $0 (Tier 3) DP

CANCIDAS INTRAVENOUS RECON SOLN 50

MG, 70 MG

$0 (Tier 2) PA

caspofungin intravenous recon soln 50 mg, 70 mg $0 (Tier 1) PA

ciclopirox topical cream 0.77 % $0 (Tier 1) MO

ciclopirox topical solution 8 % $0 (Tier 1) MO

ciclopirox topical suspension 0.77 % $0 (Tier 1) MO

ciclopirox-ure-camph-menth-euc topical solution 8

%

$0 (Tier 1) MO

clotrim 1% vaginal cream 1 % $0 (Tier 3) DP

clotrimazole 1% cream w/7 applicators 1 % $0 (Tier 3) DP

clotrimazole 1% cream w/single applicator 1 % $0 (Tier 3) DP

CLOTRIMAZOLE 3 2% CREAM 2 % $0 (Tier 3) DP

clotrimazole mucous membrane troche 10 mg $0 (Tier 1) MO



Formulary ID: 18395




31


cost you (Tier

Level)


limits on use

clotrimazole topical cream 1 % $0 (Tier 1) MO

clotrimazole topical solution 1 % $0 (Tier 1) MO

DESENEX 2% POWDER 2 % $0 (Tier 3) DP

econazole topical cream 1 % $0 (Tier 1) MO

ERAXIS(WATER DILUENT) INTRAVENOUS

RECON SOLN 100 MG, 50 MG

$0 (Tier 2) PA

fluconazole in dextrose(iso-o) intravenous

piggyback 200 mg/100 ml, 400 mg/200 ml

$0 (Tier 1)

fluconazole in nacl (iso-osm) intravenous


mg/200 ml

$0 (Tier 1)

fluconazole oral suspension for reconstitution 10

mg/ml, 40 mg/ml

$0 (Tier 1) MO

fluconazole oral tablet 100 mg, 150 mg, 200 mg,

50 mg

$0 (Tier 1) MO

flucytosine oral capsule 250 mg $0 (Tier 1)

flucytosine oral capsule 500 mg $0 (Tier 1) MO

FUNGOID 2% TINCTURE 2 % $0 (Tier 3) DP

griseofulvin microsize oral suspension 125 mg/5

ml

$0 (Tier 1) MO

itraconazole oral capsule 100 mg $0 (Tier 1) MO

ketoconazole oral tablet 200 mg $0 (Tier 1) MO

ketoconazole topical cream 2 % $0 (Tier 1) MO

ketoconazole topical shampoo 2 % $0 (Tier 1) MO

LAMISIL AT 1% GEL 1 % $0 (Tier 3) DP

MENTAX TOPICAL CREAM 1 % $0 (Tier 2) MO

MICONAZOLE 7 100 MG VAG SUPP 100 MG $0 (Tier 3) DP

MICONAZOLE 7 CREAM 2 % $0 (Tier 3) DP

MICONAZOLE 7 CREAM W/7 DISP

APPLICATORS 2 %

$0 (Tier 3) DP


32


cost you (Tier

Level)


limits on use

miconazole nitrate 2% cream 2 % $0 (Tier 3) DP

miconazole nitrate 2% cream 2 % $0 (Tier 3) DP

miconazole nitrate 2% cream w/7 disp applicators

2 %

$0 (Tier 3) DP

miconazole nitrate 2% cream w/applicator 2 % $0 (Tier 3) DP

MICONAZORB AF 2% POWDER 2 % $0 (Tier 3) DP

MICRO-GUARD 2% POWDER

12'S,ANTIFUNGAL 2 %

$0 (Tier 3) DP

MYCAMINE INTRAVENOUS RECON SOLN

100 MG, 50 MG

$0 (Tier 2) PA

NOXAFIL ORAL SUSPENSION 200 MG/5 ML

(40 MG/ML)

$0 (Tier 2) PA; MO

NOXAFIL ORAL TABLET,DELAYED

RELEASE (DR/EC) 100 MG

$0 (Tier 2) PA; MO

nyamyc topical powder 100,000 unit/gram $0 (Tier 1) MO

nystatin oral suspension 100,000 unit/ml $0 (Tier 1) MO

nystatin oral tablet 500,000 unit $0 (Tier 1) MO

nystatin topical cream 100,000 unit/gram $0 (Tier 1) MO

nystatin topical ointment 100,000 unit/gram $0 (Tier 1) MO

nystatin topical powder 100,000 unit/gram $0 (Tier 1) MO

nystop topical powder 100,000 unit/gram $0 (Tier 1) MO

qc tolnaftate 1% cream 1 % $0 (Tier 3) DP

SM ATHLETE'S 1% FOOT CREAM 1 % $0 (Tier 3) DP

sm clotrimazole 1% cream 1 % $0 (Tier 3) DP

terbinafine 1% cream 1 % $0 (Tier 3) DP

terbinafine hcl oral tablet 250 mg $0 (Tier 1) MO

terconazole vaginal cream 0.4 %, 0.8 % $0 (Tier 1) MO

terconazole vaginal suppository 80 mg $0 (Tier 1) MO

TINACTIN 1% AEROSOL POWDER 1 % $0 (Tier 3) DP

tolnaftate 1% cream 1 % $0 (Tier 3) DP

voriconazole intravenous solution 200 mg $0 (Tier 1)

voriconazole oral suspension for reconstitution

200 mg/5 ml (40 mg/ml)

$0 (Tier 1) MO



Formulary ID: 18395




33


cost you (Tier

Level)


limits on use

voriconazole oral tablet 200 mg, 50 mg $0 (Tier 1) MO

ANTIGOUT AGENTS - TREATMENT OR PREVENTION OF GOUTY ARTHRITIS

ANTIGOUT AGENTS

allopurinol oral tablet 100 mg, 300 mg $0 (Tier 1) MO

colchicine oral capsule 0.6 mg $0 (Tier 1) MO

colchicine oral tablet 0.6 mg $0 (Tier 1) MO

probenecid oral tablet 500 mg $0 (Tier 1) MO

probenecid-colchicine oral tablet 500-0.5 mg $0 (Tier 1) MO

ULORIC ORAL TABLET 40 MG, 80 MG $0 (Tier 2) ST; MO

ANTI-INFLAMMATORY AGENTS - TREATMENT OF INFLAMMATION

GLUCOCORTICOIDS

ala-cort topical cream 1 %, 2.5 % $0 (Tier 1) MO

alclometasone topical cream 0.05 % $0 (Tier 1) MO

alclometasone topical ointment 0.05 % $0 (Tier 1) MO

betamethasone dipropionate topical cream 0.05 % $0 (Tier 1) MO

betamethasone dipropionate topical lotion 0.05 % $0 (Tier 1) MO

betamethasone dipropionate topical ointment 0.05

%

$0 (Tier 1) MO

betamethasone valerate topical cream 0.1 % $0 (Tier 1) MO

betamethasone valerate topical lotion 0.1 % $0 (Tier 1) MO

betamethasone valerate topical ointment 0.1 % $0 (Tier 1) MO

betamethasone, augmented topical cream 0.05 % $0 (Tier 1) MO

betamethasone, augmented topical gel 0.05 % $0 (Tier 1) MO

betamethasone, augmented topical lotion 0.05 % $0 (Tier 1) MO

betamethasone, augmented topical ointment 0.05

%

$0 (Tier 1) MO

clobetasol scalp solution 0.05 % $0 (Tier 1) MO


34


cost you (Tier

Level)


limits on use

clobetasol topical cream 0.05 % $0 (Tier 1) MO

clobetasol topical gel 0.05 % $0 (Tier 1) MO

clobetasol topical ointment 0.05 % $0 (Tier 1) MO

desonide topical cream 0.05 % $0 (Tier 1) MO

desonide topical lotion 0.05 % $0 (Tier 1) MO

desonide topical ointment 0.05 % $0 (Tier 1) MO

desoximetasone topical cream 0.05 %, 0.25 % $0 (Tier 1) MO

desoximetasone topical gel 0.05 % $0 (Tier 1) MO

desoximetasone topical ointment 0.05 %, 0.25 % $0 (Tier 1) MO

dexamethasone intensol oral drops 1 mg/ml $0 (Tier 1) MO

dexamethasone oral elixir 0.5 mg/5 ml $0 (Tier 1) MO

dexamethasone oral solution 0.5 mg/5 ml $0 (Tier 1) MO

dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg,

1.5 mg, 2 mg, 4 mg, 6 mg

$0 (Tier 1) MO

dexamethasone sodium phos (pf) injection solution

10 mg/ml

$0 (Tier 1)

dexamethasone sodium phosphate injection

solution 10 mg/ml, 4 mg/ml

$0 (Tier 1)

dexamethasone sodium phosphate injection

syringe 4 mg/ml

$0 (Tier 1) MO

fluocinolone topical cream 0.01 %, 0.025 % $0 (Tier 1) MO

fluocinolone topical ointment 0.025 % $0 (Tier 1) MO

fluocinolone topical solution 0.01 % $0 (Tier 1) MO

fluocinonide topical cream 0.05 % $0 (Tier 1) MO

fluocinonide topical gel 0.05 % $0 (Tier 1) MO

fluocinonide topical ointment 0.05 % $0 (Tier 1) MO

fluocinonide topical solution 0.05 % $0 (Tier 1) MO

fluocinonide-e topical cream 0.05 % $0 (Tier 1) MO

fluocinonide-emollient topical cream 0.05 % $0 (Tier 1) MO

fluticasone topical cream 0.05 % $0 (Tier 1) MO

fluticasone topical lotion 0.05 % $0 (Tier 1) MO

fluticasone topical ointment 0.005 % $0 (Tier 1) MO



Formulary ID: 18395




35


cost you (Tier

Level)


limits on use

halobetasol propionate topical cream 0.05 % $0 (Tier 1) MO

halobetasol propionate topical ointment 0.05 % $0 (Tier 1) MO

hydrocortisone butyrate topical cream 0.1 % $0 (Tier 1) MO

hydrocortisone butyrate topical ointment 0.1 % $0 (Tier 1) MO

hydrocortisone butyrate topical solution 0.1 % $0 (Tier 1) MO

hydrocortisone butyr-emollient topical cream 0.1

%

$0 (Tier 1) MO

hydrocortisone topical cream 1 %, 2.5 % $0 (Tier 1) MO

hydrocortisone topical cream with perineal

applicator 1 %

$0 (Tier 1) MO

hydrocortisone topical lotion 2.5 % $0 (Tier 1) MO

hydrocortisone topical ointment 1 %, 2.5 % $0 (Tier 1) MO

hydrocortisone valerate topical cream 0.2 % $0 (Tier 1) MO

hydrocortisone valerate topical ointment 0.2 % $0 (Tier 1) MO

hydrocortisone-aloe 1% cream 1 % $0 (Tier 3) DP

methylprednisolone acetate injection suspension

40 mg/ml, 80 mg/ml

$0 (Tier 1)

methylprednisolone oral tablet 16 mg, 32 mg, 4

mg, 8 mg

$0 (Tier 1) MO

methylprednisolone oral tablets,dose pack 4 mg $0 (Tier 1) MO

methylprednisolone sodium succ injection recon

soln 125 mg, 40 mg

$0 (Tier 1) MO

methylprednisolone sodium succ intravenous

recon soln 1,000 mg

$0 (Tier 1)

mometasone topical cream 0.1 % $0 (Tier 1) MO

mometasone topical ointment 0.1 % $0 (Tier 1) MO

mometasone topical solution 0.1 % $0 (Tier 1) MO

prednisolone oral solution 15 mg/5 ml $0 (Tier 1) MO


36


cost you (Tier

Level)


limits on use

prednisolone sodium phosphate oral solution 15

mg/5 ml (3 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg

base/5 ml (6.7 mg/5 ml)

$0 (Tier 1) MO

prednisone oral solution 5 mg/5 ml $0 (Tier 1) MO

prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20

mg, 5 mg, 50 mg

$0 (Tier 1) MO

prednisone oral tablets,dose pack 10 mg, 10 mg

(48 pack), 5 mg, 5 mg (48 pack)

$0 (Tier 1) MO

RAYOS ORAL TABLET,DELAYED RELEASE

(DR/EC) 1 MG, 2 MG, 5 MG

$0 (Tier 2) MO

triamcinolone acetonide topical cream 0.025 %,

0.1 %, 0.5 %

$0 (Tier 1) MO

triamcinolone acetonide topical lotion 0.025 %,

0.1 %

$0 (Tier 1) MO

triamcinolone acetonide topical ointment 0.025 %,

0.1 %, 0.5 %

$0 (Tier 1) MO

triderm topical cream 0.1 % $0 (Tier 1) MO

ANTIMIGRAINE AGENTS - TREATMENT OF MIGRAINE HEADACHES

ANTIMIGRAINE AGENTS

MIGRAINE RELIEF CAPLET CAPLET,

COATED 250-250-65 MG

$0 (Tier 3) DP

ERGOT ALKALOIDS

dihydroergotamine injection solution 1 mg/ml $0 (Tier 1) PA; MO

dihydroergotamine nasal spray,non-aerosol 0.5

mg/pump act. (4 mg/ml)

$0 (Tier 1) MO; QL (8 ML per 30 days)

ergotamine-caffeine oral tablet 1-100 mg $0 (Tier 1) MO

SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS

rizatriptan oral tablet 10 mg, 5 mg $0 (Tier 1) MO; QL (12 EA per 30 days)

rizatriptan oral tablet,disintegrating 10 mg, 5 mg $0 (Tier 1) MO; QL (12 EA per 30 days)

sumatriptan nasal spray,non-aerosol 20

mg/actuation, 5 mg/actuation


sumatriptan succinate oral tablet 100 mg, 25 mg,

50 mg


sumatriptan succinate subcutaneous cartridge 4

mg/0.5 ml, 6 mg/0.5 ml




Formulary ID: 18395




37


cost you (Tier

Level)


limits on use

sumatriptan succinate subcutaneous pen injector 4

mg/0.5 ml, 6 mg/0.5 ml, 6 mg/0.5 ml (auto-

injector)


sumatriptan succinate subcutaneous solution 6

mg/0.5 ml


sumatriptan succinate subcutaneous syringe 6

mg/0.5 ml


ANTIMYASTHENIC AGENTS - TREATMENT OF MYASTHENIA

PARASYMPATHOMIMETICS

guanidine oral tablet 125 mg $0 (Tier 1) MO

pyridostigmine bromide oral tablet 60 mg $0 (Tier 1) MO

ANTIMYCOBACTERIALS - TREATMENT FOR INFECTIONS BY TUBERCULOSIS-

TYPE ORGANISMS

ANTIMYCOBACTERIALS, OTHER

dapsone oral tablet 100 mg, 25 mg $0 (Tier 1)

rifabutin oral capsule 150 mg $0 (Tier 1) MO

ANTITUBERCULARS

CAPASTAT INJECTION RECON SOLN 1

GRAM

$0 (Tier 2)

ethambutol oral tablet 100 mg, 400 mg $0 (Tier 1) MO

isoniazid injection solution 100 mg/ml $0 (Tier 1) MO

isoniazid oral tablet 100 mg, 300 mg $0 (Tier 1) MO

PASER ORAL GRANULES DR FOR SUSP IN

PACKET 4 GRAM

$0 (Tier 2) MO

PRIFTIN ORAL TABLET 150 MG $0 (Tier 2) MO

pyrazinamide oral tablet 500 mg $0 (Tier 1) MO

rifampin intravenous recon soln 600 mg $0 (Tier 1)

rifampin oral capsule 150 mg, 300 mg $0 (Tier 1) MO

RIFATER ORAL TABLET 50-120-300 MG $0 (Tier 2) MO


38


cost you (Tier

Level)


limits on use

SIRTURO ORAL TABLET 100 MG $0 (Tier 2) PA; MO

TRECATOR ORAL TABLET 250 MG $0 (Tier 2) MO

ANTINEOPLASTICS - TREATMENT OF CANCER

ALKYLATING AGENTS

BICNU INTRAVENOUS RECON SOLN 100

MG

$0 (Tier 2) PA

busulfan intravenous solution 60 mg/10 ml $0 (Tier 1) PA

carboplatin intravenous recon soln 150 mg $0 (Tier 1) B/D

carboplatin intravenous solution 10 mg/ml $0 (Tier 1) B/D

cisplatin intravenous solution 1 mg/ml $0 (Tier 1) B/D

cyclophosphamide oral capsule 25 mg, 50 mg $0 (Tier 1) B/D; MO

dacarbazine intravenous recon soln 200 mg $0 (Tier 1) B/D

EMCYT ORAL CAPSULE 140 MG $0 (Tier 2) PA; MO

GLEOSTINE ORAL CAPSULE 10 MG, 100 MG,

40 MG, 5 MG

$0 (Tier 2) PA

HEXALEN ORAL CAPSULE 50 MG $0 (Tier 2) PA

ifosfamide intravenous recon soln 1 gram $0 (Tier 1) B/D

LEUKERAN ORAL TABLET 2 MG $0 (Tier 2)

MATULANE ORAL CAPSULE 50 MG $0 (Tier 2)

melphalan hcl intravenous recon soln 50 mg $0 (Tier 1) B/D

MUSTARGEN INJECTION RECON SOLN 10

MG

$0 (Tier 2) PA

oxaliplatin intravenous recon soln 100 mg $0 (Tier 1) B/D

oxaliplatin intravenous solution 100 mg/20 ml $0 (Tier 1) B/D

TEPADINA INJECTION RECON SOLN 100

MG, 15 MG

$0 (Tier 2) B/D

thiotepa injection recon soln 15 mg $0 (Tier 1) B/D

TREANDA INTRAVENOUS RECON SOLN 100

MG, 25 MG

$0 (Tier 2) PA

VALCHLOR TOPICAL GEL 0.016 % $0 (Tier 2) MO

ZANOSAR INTRAVENOUS RECON SOLN 1

GRAM

$0 (Tier 2) PA

ANTIANDROGENS



Formulary ID: 18395




39


cost you (Tier

Level)


limits on use

bicalutamide oral tablet 50 mg $0 (Tier 1) MO

ERLEADA ORAL TABLET 60 MG $0 (Tier 2) PA

flutamide oral capsule 125 mg $0 (Tier 1) MO

nilutamide oral tablet 150 mg $0 (Tier 1)

XTANDI ORAL CAPSULE 40 MG $0 (Tier 2) PA

ZYTIGA ORAL TABLET 250 MG, 500 MG $0 (Tier 2) PA

ANTIANGIOGENIC AGENTS

POMALYST ORAL CAPSULE 1 MG, 2 MG, 3

MG, 4 MG

$0 (Tier 2) PA

REVLIMID ORAL CAPSULE 10 MG, 15 MG,

2.5 MG, 20 MG, 25 MG, 5 MG

$0 (Tier 2) PA; LA

THALOMID ORAL CAPSULE 100 MG, 150

MG, 200 MG, 50 MG

$0 (Tier 2)

ANTIESTROGENS/MODIFIERS

DEPO-PROVERA INTRAMUSCULAR

SUSPENSION 400 MG/ML

$0 (Tier 2) PA; MO

FARESTON ORAL TABLET 60 MG $0 (Tier 2) PA; MO

FASLODEX INTRAMUSCULAR SYRINGE 250

MG/5 ML

$0 (Tier 2) PA; MO

SOLTAMOX ORAL SOLUTION 10 MG/5 ML $0 (Tier 2)

tamoxifen oral tablet 10 mg, 20 mg $0 (Tier 1) MO

ANTIMETABOLITES

ALIMTA INTRAVENOUS RECON SOLN 100

MG, 500 MG

$0 (Tier 2) PA

ARRANON INTRAVENOUS SOLUTION 250

MG/50 ML

$0 (Tier 2) PA

cladribine intravenous solution 10 mg/10 ml $0 (Tier 1) B/D

cytarabine (pf) injection solution 100 mg/5 ml (20

mg/ml), 2 gram/20 ml (100 mg/ml), 20 mg/ml

$0 (Tier 1) B/D


40


cost you (Tier

Level)


limits on use

cytarabine injection solution 20 mg/ml $0 (Tier 1) B/D

DROXIA ORAL CAPSULE 200 MG, 300 MG,

400 MG

$0 (Tier 2) MO

FLUDARABINE INTRAVENOUS RECON

SOLN 50 MG

$0 (Tier 2) PA

fluorouracil intravenous solution 1 gram/20 ml,

2.5 gram/50 ml, 5 gram/100 ml, 500 mg/10 ml

$0 (Tier 1) B/D

fluorouracil topical cream 0.5 %, 5 % $0 (Tier 1) MO

fluorouracil topical solution 2 %, 5 % $0 (Tier 1) MO

gemcitabine intravenous recon soln 1 gram, 2

gram

$0 (Tier 1) B/D

gemcitabine intravenous recon soln 200 mg $0 (Tier 1) B/D; MO

gemcitabine intravenous solution 1 gram/26.3 ml

(38 mg/ml), 100 mg/ml, 2 gram/52.6 ml (38

mg/ml), 200 mg/5.26 ml (38 mg/ml)

$0 (Tier 1) B/D

hydroxyurea oral capsule 500 mg $0 (Tier 1) MO

mercaptopurine oral tablet 50 mg $0 (Tier 1) MO

NIPENT INTRAVENOUS RECON SOLN 10

MG

$0 (Tier 2) PA

PURIXAN ORAL SUSPENSION 20 MG/ML $0 (Tier 2) MO

TABLOID ORAL TABLET 40 MG $0 (Tier 2) PA

ANTINEOPLASTICS

adriamycin intravenous solution 20 mg/10 ml $0 (Tier 1) B/D

docetaxel intravenous solution 20 mg/ml $0 (Tier 1) B/D

KADCYLA INTRAVENOUS RECON SOLN 160

MG

$0 (Tier 2) PA

PICATO TOPICAL GEL 0.015 %, 0.05 % $0 (Tier 2) PA; MO

ANTINEOPLASTICS, OTHER

azacitidine injection recon soln 100 mg $0 (Tier 1) PA

BELEODAQ INTRAVENOUS RECON SOLN

500 MG

$0 (Tier 2) PA

bleomycin injection recon soln 30 unit $0 (Tier 1) B/D

BORTEZOMIB INTRAVENOUS RECON SOLN

3.5 MG

$0 (Tier 1) PA



Formulary ID: 18395




41


cost you (Tier

Level)


limits on use

clofarabine intravenous solution 20 mg/20 ml $0 (Tier 2) PA

dactinomycin intravenous recon soln 0.5 mg $0 (Tier 2) PA; MO

daunorubicin intravenous solution 5 mg/ml $0 (Tier 1) B/D

decitabine intravenous recon soln 50 mg $0 (Tier 1) B/D

dexrazoxane hcl intravenous recon soln 250 mg $0 (Tier 1) B/D

doxorubicin intravenous solution 50 mg/25 ml $0 (Tier 1) B/D

doxorubicin, peg-liposomal intravenous

suspension 2 mg/ml

$0 (Tier 1) PA

epirubicin intravenous solution 200 mg/100 ml $0 (Tier 1) B/D

ERWINAZE INJECTION RECON SOLN 10,000

UNIT

$0 (Tier 2) PA

FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20

MG

$0 (Tier 2) PA

FLUDARABINE INTRAVENOUS SOLUTION

50 MG/2 ML

$0 (Tier 2) PA

FUSILEV INTRAVENOUS RECON SOLN 50

MG

$0 (Tier 2) B/D

HALAVEN INTRAVENOUS SOLUTION 1

MG/2 ML (0.5 MG/ML)

$0 (Tier 2) PA

idarubicin intravenous solution 1 mg/ml $0 (Tier 1) B/D

ISTODAX INTRAVENOUS RECON SOLN 10

MG/2 ML

$0 (Tier 2) PA

KADCYLA INTRAVENOUS RECON SOLN 100

MG

$0 (Tier 2) PA

KISQALI FEMARA CO-PACK ORAL TABLET

200 MG/DAY(200 MG X 1)-2.5 MG, 400

MG/DAY(200 MG X 2)-2.5 MG, 600

MG/DAY(200 MG X 3)-2.5 MG

$0 (Tier 2) PA

KISQALI ORAL TABLET 200 MG/DAY (200

MG X 1), 400 MG/DAY (200 MG X 2), 600

MG/DAY (200 MG X 3)

$0 (Tier 2) PA


42


cost you (Tier

Level)


limits on use

KYPROLIS INTRAVENOUS RECON SOLN 30

MG, 60 MG

$0 (Tier 2) PA

leucovorin calcium injection recon soln 100 mg,

200 mg, 350 mg, 50 mg, 500 mg

$0 (Tier 1) B/D

leucovorin calcium oral tablet 10 mg, 15 mg, 25

mg, 5 mg

$0 (Tier 1)

LEVOLEUCOVORIN INTRAVENOUS RECON

SOLN 50 MG

$0 (Tier 1) B/D

levoleucovorin intravenous solution 10 mg/ml $0 (Tier 1) B/D; MO

LONSURF ORAL TABLET 15-6.14 MG, 20-8.19

MG

$0 (Tier 2) PA

LYNPARZA ORAL CAPSULE 50 MG $0 (Tier 2) PA

LYNPARZA ORAL TABLET 100 MG, 150 MG $0 (Tier 2) PA

mesna intravenous solution 100 mg/ml $0 (Tier 1) B/D

MESNEX ORAL TABLET 400 MG $0 (Tier 2)

mitomycin intravenous recon soln 20 mg, 40 mg, 5

mg

$0 (Tier 1) B/D

NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4

MG

$0 (Tier 2) PA

ODOMZO ORAL CAPSULE 200 MG $0 (Tier 2) PA

PROLEUKIN INTRAVENOUS RECON SOLN

22 MILLION UNIT

$0 (Tier 2) PA

ROMIDEPSIN INTRAVENOUS RECON SOLN

10 MG/2 ML

$0 (Tier 1) PA

RUBRACA ORAL TABLET 200 MG, 250 MG,

300 MG

$0 (Tier 2) PA

SYLATRON SUBCUTANEOUS KIT 200 MCG,

300 MCG, 600 MCG

$0 (Tier 2) PA

SYLVANT INTRAVENOUS RECON SOLN 100

MG, 400 MG

$0 (Tier 2) PA

SYNRIBO SUBCUTANEOUS RECON SOLN

3.5 MG

$0 (Tier 2) PA

TOTECT INTRAVENOUS RECON SOLN 500

MG

$0 (Tier 2) PA

TRISENOX INTRAVENOUS SOLUTION 2

MG/ML

$0 (Tier 2) PA



Formulary ID: 18395




43


cost you (Tier

Level)


limits on use

VELCADE INJECTION RECON SOLN 3.5 MG $0 (Tier 2) PA

VENCLEXTA ORAL TABLET 10 MG, 100 MG,

50 MG

$0 (Tier 2) PA

VENCLEXTA STARTING PACK ORAL

TABLETS,DOSE PACK 10 MG-50 MG- 100 MG

$0 (Tier 2) PA

VERZENIO ORAL TABLET 100 MG, 150 MG,

200 MG, 50 MG

$0 (Tier 2) PA

vinblastine intravenous solution 1 mg/ml $0 (Tier 1) B/D

vincristine intravenous solution 1 mg/ml $0 (Tier 1) B/D

vinorelbine intravenous solution 50 mg/5 ml $0 (Tier 1) B/D

VYXEOS INTRAVENOUS RECON SOLN 44-

100 MG

$0 (Tier 2) PA

YONDELIS INTRAVENOUS RECON SOLN 1

MG

$0 (Tier 2) PA

ZALTRAP INTRAVENOUS SOLUTION 100

MG/4 ML (25 MG/ML), 200 MG/8 ML (25

MG/ML)

$0 (Tier 2) PA

ZOLINZA ORAL CAPSULE 100 MG $0 (Tier 2) PA

ZYDELIG ORAL TABLET 100 MG, 150 MG $0 (Tier 2) PA

AROMATASE INHIBITORS, 3RD GENERATION

anastrozole oral tablet 1 mg $0 (Tier 1) MO

exemestane oral tablet 25 mg $0 (Tier 1)

letrozole oral tablet 2.5 mg $0 (Tier 1) MO

ENZYME INHIBITORS

ABRAXANE INTRAVENOUS SUSPENSION


$0 (Tier 2) PA

docetaxel intravenous solution 10 mg/ml $0 (Tier 1) B/D; MO


44


cost you (Tier

Level)


limits on use

docetaxel intravenous solution 160 mg/16 ml (10

mg/ml), 160 mg/8 ml (20 mg/ml), 20 mg/2 ml (10

mg/ml), 20 mg/ml (1 ml), 80 mg/4 ml (20 mg/ml),

80 mg/8 ml (10 mg/ml)

$0 (Tier 1) B/D

ETOPOPHOS INTRAVENOUS RECON SOLN

100 MG

$0 (Tier 2) PA

etoposide intravenous solution 20 mg/ml $0 (Tier 1) B/D

IBRANCE ORAL CAPSULE 100 MG, 125 MG,

75 MG

$0 (Tier 2) PA

irinotecan intravenous solution 100 mg/5 ml $0 (Tier 1) B/D

JEVTANA INTRAVENOUS SOLUTION 10

MG/ML (FIRST DILUTION)

$0 (Tier 2) PA

mitoxantrone intravenous concentrate 2 mg/ml $0 (Tier 1)

paclitaxel intravenous concentrate 6 mg/ml $0 (Tier 1) B/D

topotecan intravenous recon soln 4 mg $0 (Tier 1) PA

topotecan intravenous solution 4 mg/4 ml (1

mg/ml)

$0 (Tier 1) PA

MOLECULAR TARGET INHIBITORS

AFINITOR DISPERZ ORAL TABLET FOR

SUSPENSION 2 MG, 3 MG, 5 MG

$0 (Tier 2) PA

AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5

MG, 7.5 MG

$0 (Tier 2) PA

ALECENSA ORAL CAPSULE 150 MG $0 (Tier 2) PA

ALIQOPA INTRAVENOUS RECON SOLN 60

MG

$0 (Tier 2) PA

ALUNBRIG ORAL TABLET 180 MG, 30 MG,

90 MG

$0 (Tier 2) PA

ALUNBRIG ORAL TABLETS,DOSE PACK 90

MG (7)- 180 MG (23)

$0 (Tier 2) PA

BOSULIF ORAL TABLET 100 MG, 400 MG,

500 MG

$0 (Tier 2) PA

CABOMETYX ORAL TABLET 20 MG, 40 MG,

60 MG

$0 (Tier 2) PA

CALQUENCE ORAL CAPSULE 100 MG $0 (Tier 2) PA

CAPRELSA ORAL TABLET 100 MG, 300 MG $0 (Tier 2) PA



Formulary ID: 18395




45


cost you (Tier

Level)


limits on use

COMETRIQ ORAL CAPSULE 100 MG/DAY(80

MG X1-20 MG X1), 140 MG/DAY(80 MG X1-20

MG X3), 60 MG/DAY (20 MG X 3/DAY)

$0 (Tier 2) PA

COTELLIC ORAL TABLET 20 MG $0 (Tier 2) PA

ERIVEDGE ORAL CAPSULE 150 MG $0 (Tier 2) PA

GILOTRIF ORAL TABLET 20 MG, 30 MG, 40

MG

$0 (Tier 2) PA

ICLUSIG ORAL TABLET 15 MG, 45 MG $0 (Tier 2) PA

IDHIFA ORAL TABLET 100 MG, 50 MG $0 (Tier 2) PA

imatinib oral tablet 100 mg, 400 mg $0 (Tier 1) PA

IMBRUVICA ORAL CAPSULE 140 MG, 70 MG $0 (Tier 2) PA

IMBRUVICA ORAL TABLET 140 MG, 280 MG,

420 MG, 560 MG

$0 (Tier 2) PA

INLYTA ORAL TABLET 1 MG, 5 MG $0 (Tier 2) PA

IRESSA ORAL TABLET 250 MG $0 (Tier 2) PA

JAKAFI ORAL TABLET 10 MG, 15 MG, 20

MG, 25 MG, 5 MG

$0 (Tier 2) PA

LENVIMA ORAL CAPSULE 10 MG/DAY (10

MG X 1/DAY), 14 MG/DAY(10 MG X 1-4 MG X

1), 18 MG/DAY (10 MG X 1-4 MG X2), 20

MG/DAY (10 MG X 2), 24 MG/DAY(10 MG X

2-4 MG X 1), 8 MG/DAY (4 MG X 2)

$0 (Tier 2) PA

MEKINIST ORAL TABLET 0.5 MG, 2 MG $0 (Tier 2) PA

NERLYNX ORAL TABLET 40 MG $0 (Tier 2) PA

NEXAVAR ORAL TABLET 200 MG $0 (Tier 2) PA

OFEV ORAL CAPSULE 100 MG, 150 MG $0 (Tier 2) PA

RYDAPT ORAL CAPSULE 25 MG $0 (Tier 2) PA

SPRYCEL ORAL TABLET 100 MG, 140 MG, 20

MG, 50 MG, 70 MG, 80 MG

$0 (Tier 2) PA

STIVARGA ORAL TABLET 40 MG $0 (Tier 2) PA


46


cost you (Tier

Level)


limits on use

SUTENT ORAL CAPSULE 12.5 MG, 25 MG,

37.5 MG, 50 MG

$0 (Tier 2) PA

TAFINLAR ORAL CAPSULE 50 MG, 75 MG $0 (Tier 2) PA

TAGRISSO ORAL TABLET 40 MG, 80 MG $0 (Tier 2) PA

TARCEVA ORAL TABLET 100 MG, 150 MG,

25 MG

$0 (Tier 2) PA

TASIGNA ORAL CAPSULE 150 MG, 200 MG,

50 MG

$0 (Tier 2) PA

TORISEL INTRAVENOUS RECON SOLN 30

MG/3 ML (10 MG/ML) (FIRST)

$0 (Tier 2) PA

TYKERB ORAL TABLET 250 MG $0 (Tier 2) PA

VOTRIENT ORAL TABLET 200 MG $0 (Tier 2) PA

XALKORI ORAL CAPSULE 200 MG, 250 MG $0 (Tier 2) PA

ZEJULA ORAL CAPSULE 100 MG $0 (Tier 2) PA

ZELBORAF ORAL TABLET 240 MG $0 (Tier 2) PA

ZYKADIA ORAL CAPSULE 150 MG $0 (Tier 2) PA

MONOCLONAL ANTIBODIES

AVASTIN INTRAVENOUS SOLUTION 25

MG/ML, 25 MG/ML (16 ML)

$0 (Tier 2) PA

BAVENCIO INTRAVENOUS SOLUTION 20

MG/ML

$0 (Tier 2) PA

BESPONSA INTRAVENOUS RECON SOLN 0.9

MG (0.25 MG/ML INITIAL)

$0 (Tier 2) PA

CYRAMZA INTRAVENOUS SOLUTION 10


$0 (Tier 2) PA

DARZALEX INTRAVENOUS SOLUTION 20

MG/ML

$0 (Tier 2) PA

EMPLICITI INTRAVENOUS RECON SOLN

300 MG, 400 MG

$0 (Tier 2) PA

ERBITUX INTRAVENOUS SOLUTION 100

MG/50 ML

$0 (Tier 2) PA

HERCEPTIN INTRAVENOUS RECON SOLN

150 MG, 440 MG

$0 (Tier 2) PA

IMFINZI INTRAVENOUS SOLUTION 50


$0 (Tier 2) PA



Formulary ID: 18395




47


cost you (Tier

Level)


limits on use

KEYTRUDA INTRAVENOUS SOLUTION 25

MG/ML

$0 (Tier 2) PA

LARTRUVO INTRAVENOUS SOLUTION 10

MG/ML

$0 (Tier 2) PA

MYLOTARG INTRAVENOUS RECON SOLN

4.5 MG (1 MG/ML INITIAL CONC)

$0 (Tier 2) PA

OPDIVO INTRAVENOUS SOLUTION 100

MG/10 ML, 240 MG/24 ML, 40 MG/4 ML

$0 (Tier 2) PA

PERJETA INTRAVENOUS SOLUTION 420

MG/14 ML (30 MG/ML)

$0 (Tier 2) PA

RITUXAN HYCELA SUBCUTANEOUS

SOLUTION 1400 MG/11.7 ML (120 MG/ML),

1600 MG/13.4 ML (120 MG/ML)

$0 (Tier 2) PA

RITUXAN INTRAVENOUS CONCENTRATE

10 MG/ML, 10 MG/ML (10 ML)

$0 (Tier 2) PA

TECENTRIQ INTRAVENOUS SOLUTION

1,200 MG/20 ML (60 MG/ML)

$0 (Tier 2) PA

VECTIBIX INTRAVENOUS SOLUTION 100

MG/5 ML (20 MG/ML)

$0 (Tier 2) PA

YERVOY INTRAVENOUS SOLUTION 50

MG/10 ML (5 MG/ML)

$0 (Tier 2) PA

RETINOIDS

bexarotene oral capsule 75 mg $0 (Tier 1)

PANRETIN TOPICAL GEL 0.1 % $0 (Tier 2) PA; MO

TARGRETIN TOPICAL GEL 1 % $0 (Tier 2) PA

tretinoin (chemotherapy) oral capsule 10 mg $0 (Tier 1)

ANTIPARASITICS - TREATMENT OF INFECTIONS FROM PARASITES

ANTHELMINTICS

ALBENZA ORAL TABLET 200 MG $0 (Tier 2) MO

benznidazole oral tablet 100 mg, 12.5 mg $0 (Tier 1) PA; MO


48


cost you (Tier

Level)


limits on use

BILTRICIDE ORAL TABLET 600 MG $0 (Tier 2) MO

ivermectin oral tablet 3 mg $0 (Tier 1) MO

praziquantel oral tablet 600 mg $0 (Tier 1) MO

ANTIPROTOZOALS

ALINIA ORAL SUSPENSION FOR

RECONSTITUTION 100 MG/5 ML

$0 (Tier 2) MO

ALINIA ORAL TABLET 500 MG $0 (Tier 2) MO

atovaquone oral suspension 750 mg/5 ml $0 (Tier 1) MO

atovaquone-proguanil oral tablet 250-100 mg,

62.5-25 mg

$0 (Tier 1) MO

chloroquine phosphate oral tablet 250 mg, 500 mg $0 (Tier 1) MO

COARTEM ORAL TABLET 20-120 MG $0 (Tier 2) MO

DARAPRIM ORAL TABLET 25 MG $0 (Tier 2)

hydroxychloroquine oral tablet 200 mg $0 (Tier 1) MO

mefloquine oral tablet 250 mg $0 (Tier 1) MO

NEBUPENT INHALATION RECON SOLN 300

MG

$0 (Tier 2) B/D

PENTAM INJECTION RECON SOLN 300 MG $0 (Tier 2) PA

PRIMAQUINE ORAL TABLET 26.3 MG $0 (Tier 2) MO

quinine sulfate oral capsule 324 mg $0 (Tier 1) MO

PEDICULICIDES/ SCABICIDES

cvs permethrin 1% lotion 1 % $0 (Tier 3) DP

lindane topical shampoo 1 % $0 (Tier 1) MO

malathion topical lotion 0.5 % $0 (Tier 1) MO

permethrin topical cream 5 % $0 (Tier 1) MO

spinosad topical suspension 0.9 % $0 (Tier 1) MO

ANTIPARKINSON AGENTS - TREATMENT OF PARKINSON'S DISEASE

ANTICHOLINERGICS

benztropine oral tablet 0.5 mg, 1 mg, 2 mg $0 (Tier 1) PA; MO

trihexyphenidyl oral elixir 0.4 mg/ml $0 (Tier 1) PA; MO

trihexyphenidyl oral tablet 2 mg, 5 mg $0 (Tier 1) PA; MO



Formulary ID: 18395




49


cost you (Tier

Level)


limits on use

ANTIPARKINSON AGENTS, OTHER

amantadine hcl oral capsule 100 mg $0 (Tier 1) MO

amantadine hcl oral solution 50 mg/5 ml $0 (Tier 1) MO

amantadine hcl oral tablet 100 mg $0 (Tier 1) MO

APOKYN SUBCUTANEOUS CARTRIDGE 10

MG/ML

$0 (Tier 2) PA

entacapone oral tablet 200 mg $0 (Tier 1) MO

GOCOVRI ORAL CAPSULE,EXTENDED

RELEASE 24HR 137 MG, 68.5 MG

$0 (Tier 2) PA; MO

tolcapone oral tablet 100 mg $0 (Tier 1) MO

DOPAMINE AGONISTS

bromocriptine oral capsule 5 mg $0 (Tier 1) MO

bromocriptine oral tablet 2.5 mg $0 (Tier 1) MO

NEUPRO TRANSDERMAL PATCH 24 HOUR 1

MG/24 HOUR, 2 MG/24 HOUR, 3 MG/24

HOUR, 4 MG/24 HOUR, 6 MG/24 HOUR, 8

MG/24 HOUR

$0 (Tier 2) PA; MO

pramipexole oral tablet 0.125 mg, 0.25 mg, 0.5

mg, 0.75 mg, 1 mg, 1.5 mg

$0 (Tier 1) MO

ropinirole oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg,

3 mg, 4 mg, 5 mg

$0 (Tier 1) MO

DOPAMINE PRECURSORS/ L-AMINO ACID DECARBOXYLASE INHIBITORS

carbidopa-levodopa oral tablet 10-100 mg, 25-100

mg, 25-250 mg

$0 (Tier 1) MO

carbidopa-levodopa oral tablet extended release

25-100 mg, 50-200 mg

$0 (Tier 1) MO

MONOAMINE OXIDASE B (MAO-B) INHIBITORS

rasagiline oral tablet 0.5 mg, 1 mg $0 (Tier 1) MO

selegiline hcl oral capsule 5 mg $0 (Tier 1) MO

selegiline hcl oral tablet 5 mg $0 (Tier 1) MO


50


cost you (Tier

Level)


limits on use

ANTIPSYCHOTICS - TREATMENT OF BEHAVIORAL AND EMOTIONAL

DISORDERS

1ST GENERATION/ TYPICAL

fluphenazine decanoate injection solution 25

mg/ml

$0 (Tier 1) MO

fluphenazine hcl injection solution 2.5 mg/ml $0 (Tier 1) MO

fluphenazine hcl oral concentrate 5 mg/ml $0 (Tier 1) MO

fluphenazine hcl oral elixir 2.5 mg/5 ml $0 (Tier 1) MO

fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5

mg

$0 (Tier 1) MO

haloperidol decanoate intramuscular solution 100

mg/ml, 50 mg/ml

$0 (Tier 1) MO

haloperidol lactate injection solution 5 mg/ml $0 (Tier 1) MO

haloperidol lactate intramuscular syringe 5 mg/ml $0 (Tier 1) MO

haloperidol lactate oral concentrate 2 mg/ml $0 (Tier 1) MO

haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg,

20 mg, 5 mg

$0 (Tier 1) MO

loxapine succinate oral capsule 10 mg $0 (Tier 1) MO; QL (120 EA per 30 days)

loxapine succinate oral capsule 25 mg, 50 mg $0 (Tier 1) MO

loxapine succinate oral capsule 5 mg $0 (Tier 1) MO; QL (90 EA per 30 days)

pimozide oral tablet 1 mg, 2 mg $0 (Tier 1) MO

thioridazine oral tablet 10 mg, 100 mg, 25 mg, 50

mg

$0 (Tier 1) PA; MO

thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg $0 (Tier 1) MO

trifluoperazine oral tablet 1 mg, 10 mg, 2 mg, 5

mg

$0 (Tier 1) MO

2ND GENERATION/ ATYPICAL

ABILIFY MAINTENA INTRAMUSCULAR

SUSPENSION,EXTENDED REL RECON 300

MG, 400 MG


ABILIFY MAINTENA INTRAMUSCULAR

SUSPENSION,EXTENDED REL SYRING 300

MG, 400 MG


aripiprazole oral solution 1 mg/ml $0 (Tier 1) MO; QL (900 ML per 30 days)



Formulary ID: 18395




51


cost you (Tier

Level)


limits on use

aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20

mg, 30 mg, 5 mg


aripiprazole oral tablet,disintegrating 10 mg, 15

mg


ARISTADA INTRAMUSCULAR

SUSPENSION,EXTENDED REL SYRING 1,064

MG/3.9 ML

$0 (Tier 2) PA; QL (3.9 ML per 56 days)



MG/1.6 ML




MG/2.4 ML




MG/3.2 ML


FANAPT ORAL TABLET 1 MG, 10 MG, 12

MG, 2 MG, 4 MG, 6 MG, 8 MG


FANAPT ORAL TABLETS,DOSE PACK

1MG(2)-2MG(2)- 4MG(2)-6MG(2)

$0 (Tier 2) ST; MO

GEODON INTRAMUSCULAR RECON SOLN

20 MG/ML (FINAL CONC.)


INVEGA SUSTENNA INTRAMUSCULAR

SYRINGE 117 MG/0.75 ML



SYRINGE 156 MG/ML

$0 (Tier 2) PA; QL (1 ML per 28 days)











52


cost you (Tier

Level)


limits on use

INVEGA TRINZA INTRAMUSCULAR












LATUDA ORAL TABLET 120 MG, 20 MG, 40

MG, 60 MG, 80 MG


NUPLAZID ORAL TABLET 17 MG $0 (Tier 2) PA; MO; QL (60 EA per 30 days)

olanzapine intramuscular recon soln 10 mg $0 (Tier 1) QL (90 EA per 30 days)

olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20

mg, 5 mg, 7.5 mg


olanzapine oral tablet,disintegrating 10 mg, 15

mg, 20 mg, 5 mg


paliperidone oral tablet extended release 24hr 1.5

mg, 3 mg, 9 mg


paliperidone oral tablet extended release 24hr 6

mg


quetiapine oral tablet 100 mg, 200 mg, 300 mg,

400 mg


quetiapine oral tablet 25 mg, 50 mg $0 (Tier 1) MO; QL (90 EA per 30 days)

quetiapine oral tablet extended release 24 hr 150

mg, 200 mg


quetiapine oral tablet extended release 24 hr 300

mg, 400 mg, 50 mg


REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1

MG, 2 MG, 3 MG, 4 MG


RISPERDAL CONSTA INTRAMUSCULAR

SYRINGE 12.5 MG/2 ML, 25 MG/2 ML, 37.5

MG/2 ML, 50 MG/2 ML


RISPERDAL M-TAB ORAL

TABLET,DISINTEGRATING 0.5 MG, 2 MG


risperidone oral solution 1 mg/ml $0 (Tier 1) MO; QL (240 ML per 30 days)



Formulary ID: 18395




53


cost you (Tier

Level)


limits on use

risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2

mg, 3 mg, 4 mg


risperidone oral tablet,disintegrating 0.25 mg, 0.5

mg, 1 mg, 2 mg, 3 mg, 4 mg


SAPHRIS (BLACK CHERRY) SUBLINGUAL

TABLET 10 MG, 2.5 MG, 5 MG


VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5

MG, 6 MG


VRAYLAR ORAL CAPSULE,DOSE PACK 1.5

MG (1)- 3 MG (6)


ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg,

80 mg


ZYPREXA RELPREVV INTRAMUSCULAR

SUSPENSION FOR RECONSTITUTION 210

MG, 300 MG


ZYPREXA RELPREVV INTRAMUSCULAR


MG


TREATMENT-RESISTANT

clozapine oral tablet 100 mg $0 (Tier 1) MO; QL (270 EA per 30 days)

clozapine oral tablet 200 mg $0 (Tier 1) MO; QL (120 EA per 30 days)

clozapine oral tablet 25 mg, 50 mg $0 (Tier 1) MO; QL (90 EA per 30 days)

clozapine oral tablet,disintegrating 100 mg $0 (Tier 1) MO; QL (270 EA per 30 days)

clozapine oral tablet,disintegrating 12.5 mg, 25

mg

$0 (Tier 1) MO



VERSACLOZ ORAL SUSPENSION 50 MG/ML $0 (Tier 2) MO; QL (540 ML per 30 days)

ANTISPASTICITY AGENTS - TREATMENT OF MUSCLE SPASMS

ANTISPASTICITY AGENTS


54


cost you (Tier

Level)


limits on use

baclofen oral tablet 10 mg, 20 mg $0 (Tier 1) MO

COMFORT PAC-TIZANIDINE KIT 4 MG $0 (Tier 1) MO

dantrolene oral capsule 100 mg, 25 mg, 50 mg $0 (Tier 1) MO

tizanidine oral tablet 2 mg, 4 mg $0 (Tier 1) MO

ANTIVIRALS - TREATMENT OF INFECTIONS BY VIRUSES

ANTI-CYTOMEGALOVIRUS (CMV) AGENTS

cidofovir intravenous solution 75 mg/ml $0 (Tier 1)

ganciclovir sodium intravenous recon soln 500 mg $0 (Tier 1) B/D

ganciclovir sodium intravenous solution 50 mg/ml $0 (Tier 1) B/D; MO

PREVYMIS INTRAVENOUS SOLUTION 240

MG/12 ML, 480 MG/24 ML

$0 (Tier 2) PA

PREVYMIS ORAL TABLET 240 MG, 480 MG $0 (Tier 2) PA

valganciclovir oral recon soln 50 mg/ml $0 (Tier 1)

valganciclovir oral tablet 450 mg $0 (Tier 1)

ZIRGAN OPHTHALMIC (EYE) GEL 0.15 % $0 (Tier 2) ST; MO

ANTI-HEPATITIS B (HBV) AGENTS

ADEFOVIR ORAL TABLET 10 MG $0 (Tier 2) PA

BARACLUDE ORAL SOLUTION 0.05 MG/ML $0 (Tier 2)

entecavir oral tablet 0.5 mg, 1 mg $0 (Tier 1)

EPIVIR HBV ORAL SOLUTION 25 MG/5 ML

(5 MG/ML)

$0 (Tier 2)

INTRON A INJECTION RECON SOLN 10

MILLION UNIT (1 ML), 18 MILLION UNIT (1

ML), 50 MILLION UNIT (1 ML)

$0 (Tier 2) PA

INTRON A INJECTION SOLUTION 10

MILLION UNIT/ML, 6 MILLION UNIT/ML

$0 (Tier 2) PA

lamivudine oral solution 10 mg/ml $0 (Tier 1) MO

lamivudine oral tablet 100 mg $0 (Tier 1) QL (30 EA per 30 days)

lamivudine oral tablet 150 mg $0 (Tier 1) MO; QL (60 EA per 30 days)

lamivudine oral tablet 300 mg $0 (Tier 1) MO; QL (30 EA per 30 days)

tenofovir disoproxil fumarate oral tablet 300 mg $0 (Tier 1) MO

VEMLIDY ORAL TABLET 25 MG $0 (Tier 2) MO



Formulary ID: 18395




55


cost you (Tier

Level)


limits on use

VIREAD ORAL POWDER 40 MG/SCOOP (40

MG/GRAM)

$0 (Tier 2) MO

VIREAD ORAL TABLET 150 MG, 200 MG, 250

MG, 300 MG

$0 (Tier 2) MO

ANTI-HEPATITIS C (HCV) AGENTS

EPCLUSA ORAL TABLET 400-100 MG $0 (Tier 2) PA

MAVYRET ORAL TABLET 100-40 MG $0 (Tier 2) PA

PEGASYS PROCLICK SUBCUTANEOUS PEN

INJECTOR 135 MCG/0.5 ML, 180 MCG/0.5 ML

$0 (Tier 2) PA

PEGASYS SUBCUTANEOUS SOLUTION 180

MCG/ML

$0 (Tier 2) PA

PEGASYS SUBCUTANEOUS SYRINGE 180

MCG/0.5 ML

$0 (Tier 2) PA

RIBAVIRIN ORAL CAPSULE 200 MG $0 (Tier 2) PA

RIBAVIRIN ORAL TABLET 200 MG $0 (Tier 2) PA

VOSEVI ORAL TABLET 400-100-100 MG $0 (Tier 2) PA

ZEPATIER ORAL TABLET 50-100 MG $0 (Tier 2) PA

ANTIHERPETIC AGENTS

acyclovir oral capsule 200 mg $0 (Tier 1) MO

acyclovir oral suspension 200 mg/5 ml $0 (Tier 1) MO

acyclovir oral tablet 400 mg, 800 mg $0 (Tier 1) MO

acyclovir sodium intravenous recon soln 1,000 mg,

500 mg

$0 (Tier 1) B/D

acyclovir sodium intravenous solution 50 mg/ml $0 (Tier 1) B/D

acyclovir topical ointment 5 % $0 (Tier 1) MO

DENAVIR TOPICAL CREAM 1 % $0 (Tier 2) MO

famciclovir oral tablet 125 mg, 250 mg, 500 mg $0 (Tier 1) MO

trifluridine ophthalmic (eye) drops 1 % $0 (Tier 1) MO

valacyclovir oral tablet 1 gram, 500 mg $0 (Tier 1) MO


56


cost you (Tier

Level)


limits on use

ZOVIRAX TOPICAL CREAM 5 % $0 (Tier 2) MO

ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI)

BIKTARVY ORAL TABLET 50-200-25 MG $0 (Tier 2) MO; QL (30 EA per 30 days)

ISENTRESS HD ORAL TABLET 600 MG $0 (Tier 2) MO; QL (60 EA per 30 days)

ISENTRESS ORAL POWDER IN PACKET 100

MG

$0 (Tier 2) MO

ISENTRESS ORAL TABLET 400 MG $0 (Tier 2) MO; QL (120 EA per 30 days)

ISENTRESS ORAL TABLET,CHEWABLE 100

MG, 25 MG


JULUCA ORAL TABLET 50-25 MG $0 (Tier 2) MO; QL (30 EA per 30 days)

STRIBILD ORAL TABLET 150-150-200-300

MG


TIVICAY ORAL TABLET 10 MG $0 (Tier 2) MO; QL (300 EA per 30 days)



ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS

(NNRTI)

COMPLERA ORAL TABLET 200-25-300 MG $0 (Tier 2) MO; QL (30 EA per 30 days)

EDURANT ORAL TABLET 25 MG $0 (Tier 2) MO; QL (30 EA per 30 days)

efavirenz oral capsule 200 mg $0 (Tier 1) MO; QL (120 EA per 30 days)

efavirenz oral capsule 50 mg $0 (Tier 1) MO; QL (360 EA per 30 days)

efavirenz oral tablet 600 mg $0 (Tier 1) MO; QL (30 EA per 30 days)

INTELENCE ORAL TABLET 100 MG, 25 MG $0 (Tier 2) MO; QL (120 EA per 30 days)

INTELENCE ORAL TABLET 200 MG $0 (Tier 2) MO; QL (60 EA per 30 days)

nevirapine oral suspension 50 mg/5 ml $0 (Tier 1) MO

nevirapine oral tablet 200 mg $0 (Tier 1) MO; QL (60 EA per 30 days)

nevirapine oral tablet extended release 24 hr 100

mg


nevirapine oral tablet extended release 24 hr 400

mg


RESCRIPTOR ORAL TABLET 200 MG $0 (Tier 2) MO; QL (180 EA per 30 days)

RESCRIPTOR ORAL TABLET, DISPERSIBLE

100 MG




Formulary ID: 18395




57


cost you (Tier

Level)


limits on use

SUSTIVA ORAL CAPSULE 200 MG $0 (Tier 2) MO; QL (120 EA per 30 days)

SUSTIVA ORAL CAPSULE 50 MG $0 (Tier 2) MO; QL (360 EA per 30 days)

SUSTIVA ORAL TABLET 600 MG $0 (Tier 2) MO; QL (30 EA per 30 days)

VIDEX EC ORAL CAPSULE,DELAYED

RELEASE(DR/EC) 125 MG


VIRAMUNE ORAL SUSPENSION 50 MG/5 ML $0 (Tier 2) MO

ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE

INHIBITORS (NRTI)

abacavir oral solution 20 mg/ml $0 (Tier 1) MO

abacavir oral tablet 300 mg $0 (Tier 1) MO; QL (60 EA per 30 days)

abacavir-lamivudine oral tablet 600-300 mg $0 (Tier 1) MO; QL (30 EA per 30 days)

abacavir-lamivudine-zidovudine oral tablet 300-

150-300 mg


DESCOVY ORAL TABLET 200-25 MG $0 (Tier 2) MO; QL (30 EA per 30 days)

didanosine oral capsule,delayed release(dr/ec)

200 mg


didanosine oral capsule,delayed release(dr/ec)

250 mg, 400 mg


EMTRIVA ORAL CAPSULE 200 MG $0 (Tier 2) MO; QL (30 EA per 30 days)

EMTRIVA ORAL SOLUTION 10 MG/ML $0 (Tier 2) MO

lamivudine-zidovudine oral tablet 150-300 mg $0 (Tier 1) MO; QL (60 EA per 30 days)

RETROVIR INTRAVENOUS SOLUTION 10

MG/ML

$0 (Tier 2) MO

stavudine oral capsule 15 mg, 20 mg $0 (Tier 1) MO; QL (120 EA per 30 days)

stavudine oral capsule 30 mg, 40 mg $0 (Tier 1) MO; QL (60 EA per 30 days)

TRUVADA ORAL TABLET 100-150 MG, 133-

200 MG, 167-250 MG, 200-300 MG


VIDEX 2 GRAM PEDIATRIC ORAL RECON

SOLN 10 MG/ML (FINAL)

$0 (Tier 2) MO


58


cost you (Tier

Level)


limits on use

VIDEX 4 GRAM PEDIATRIC ORAL RECON

SOLN 10 MG/ML (FINAL)

$0 (Tier 2) MO

ZERIT ORAL RECON SOLN 1 MG/ML $0 (Tier 2) MO

ZIAGEN ORAL SOLUTION 20 MG/ML $0 (Tier 2) MO

zidovudine oral capsule 100 mg $0 (Tier 1) MO; QL (180 EA per 30 days)

zidovudine oral syrup 10 mg/ml $0 (Tier 1) MO

zidovudine oral tablet 300 mg $0 (Tier 1) MO; QL (60 EA per 30 days)

ANTI-HIV AGENTS, OTHER

ATRIPLA ORAL TABLET 600-200-300 MG $0 (Tier 2) MO; QL (30 EA per 30 days)

FUZEON SUBCUTANEOUS RECON SOLN 90

MG

$0 (Tier 2)

GENVOYA ORAL TABLET 150-150-200-10

MG


ODEFSEY ORAL TABLET 200-25-25 MG $0 (Tier 2) MO; QL (30 EA per 30 days)

selzentry oral solution 20 mg/ml $0 (Tier 2) MO

SELZENTRY ORAL TABLET 150 MG, 75 MG $0 (Tier 2) MO; QL (60 EA per 30 days)

SELZENTRY ORAL TABLET 25 MG, 300 MG $0 (Tier 2) MO; QL (120 EA per 30 days)

SYMFI LO ORAL TABLET 400-300-300 MG $0 (Tier 2) MO; QL (30 EA per 30 days)

TRIUMEQ ORAL TABLET 600-50-300 MG $0 (Tier 2) MO; QL (30 EA per 30 days)

TROGARZO INTRAVENOUS SOLUTION 200

MG/1.33 ML (150 MG/ML)

$0 (Tier 2)

TYBOST ORAL TABLET 150 MG $0 (Tier 2) MO; QL (30 EA per 30 days)

ANTI-HIV AGENTS, PROTEASE INHIBITORS

APTIVUS ORAL CAPSULE 250 MG $0 (Tier 2) MO; QL (120 EA per 30 days)

APTIVUS ORAL SOLUTION 100 MG/ML $0 (Tier 2) MO

atazanavir oral capsule 150 mg, 300 mg $0 (Tier 1) MO; QL (30 EA per 30 days)

atazanavir oral capsule 200 mg $0 (Tier 1) MO; QL (60 EA per 30 days)

CRIXIVAN ORAL CAPSULE 200 MG $0 (Tier 2) MO; QL (360 EA per 30 days)

CRIXIVAN ORAL CAPSULE 400 MG $0 (Tier 2) MO; QL (180 EA per 30 days)

EVOTAZ ORAL TABLET 300-150 MG $0 (Tier 2) MO; QL (30 EA per 30 days)

fosamprenavir oral tablet 700 mg $0 (Tier 1) MO; QL (120 EA per 30 days)

INVIRASE ORAL CAPSULE 200 MG $0 (Tier 2) MO; QL (300 EA per 30 days)



Formulary ID: 18395




59


cost you (Tier

Level)


limits on use

INVIRASE ORAL TABLET 500 MG $0 (Tier 2) MO; QL (120 EA per 30 days)

KALETRA ORAL TABLET 100-25 MG $0 (Tier 2) MO; QL (240 EA per 30 days)

KALETRA ORAL TABLET 200-50 MG $0 (Tier 2) MO; QL (120 EA per 30 days)

LEXIVA ORAL SUSPENSION 50 MG/ML $0 (Tier 2) MO

LEXIVA ORAL TABLET 700 MG $0 (Tier 2) MO; QL (120 EA per 30 days)

lopinavir-ritonavir oral solution 400-100 mg/5 ml $0 (Tier 1) MO

NORVIR ORAL CAPSULE 100 MG $0 (Tier 2) MO; QL (360 EA per 30 days)

NORVIR ORAL SOLUTION 80 MG/ML $0 (Tier 2) MO

NORVIR ORAL TABLET 100 MG $0 (Tier 2) MO; QL (360 EA per 30 days)

PREZCOBIX ORAL TABLET 800-150 MG-MG $0 (Tier 2) MO; QL (30 EA per 30 days)

PREZISTA ORAL SUSPENSION 100 MG/ML $0 (Tier 2) MO

PREZISTA ORAL TABLET 150 MG $0 (Tier 2) MO; QL (180 EA per 30 days)




REYATAZ ORAL CAPSULE 150 MG, 300 MG $0 (Tier 2) MO; QL (30 EA per 30 days)

REYATAZ ORAL CAPSULE 200 MG $0 (Tier 2) MO; QL (60 EA per 30 days)

REYATAZ ORAL POWDER IN PACKET 50

MG

$0 (Tier 2) MO

ritonavir oral tablet 100 mg $0 (Tier 1) MO; QL (360 EA per 30 days)

VIRACEPT ORAL TABLET 250 MG $0 (Tier 2) MO; QL (300 EA per 30 days)

VIRACEPT ORAL TABLET 625 MG $0 (Tier 2) MO; QL (120 EA per 30 days)

ANTI-INFLUENZA AGENTS

oseltamivir oral capsule 30 mg $0 (Tier 1) MO; QL (84 EA per 180 days)



oseltamivir oral suspension for reconstitution 6

mg/ml



60


cost you (Tier

Level)


limits on use

RELENZA DISKHALER INHALATION

BLISTER WITH DEVICE 5 MG/ACTUATION


rimantadine oral tablet 100 mg $0 (Tier 1) MO

TAMIFLU ORAL SUSPENSION FOR

RECONSTITUTION 6 MG/ML


ANTIVIRALS

SYNAGIS INTRAMUSCULAR SOLUTION 100

MG/ML, 50 MG/0.5 ML

$0 (Tier 2) PA

ANXIOLYTICS - TREATMENT OF ANXIETY OR NERVOUSNESS

ANXIOLYTICS, OTHER

buspirone oral tablet 10 mg, 15 mg, 30 mg, 5 mg,

7.5 mg

$0 (Tier 1) MO

hydroxyzine hcl oral solution 10 mg/5 ml $0 (Tier 1) PA; MO

hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg $0 (Tier 1) PA; MO

hydroxyzine pamoate oral capsule 100 mg, 25 mg,

50 mg

$0 (Tier 1) PA; MO

meprobamate oral tablet 200 mg, 400 mg $0 (Tier 1) PA; MO

BENZODIAZEPINES

alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg $0 (Tier 1) MO; QL (120 EA per 30 days)

alprazolam oral tablet 2 mg $0 (Tier 1) MO; QL (150 EA per 30 days)

clonazepam oral tablet 0.5 mg, 1 mg $0 (Tier 1) PA; MO; QL (90 EA per 30 days)

clonazepam oral tablet 2 mg $0 (Tier 1) PA; MO; QL (300 EA per 30 days)

clonazepam oral tablet,disintegrating 0.125 mg,

0.25 mg, 0.5 mg, 1 mg


clonazepam oral tablet,disintegrating 2 mg $0 (Tier 1) PA; MO; QL (300 EA per 30 days)

clorazepate dipotassium oral tablet 15 mg $0 (Tier 1) PA; MO; QL (180 EA per 30 days)

clorazepate dipotassium oral tablet 3.75 mg, 7.5

mg


diazepam intensol oral concentrate 5 mg/ml $0 (Tier 1) PA; MO; QL (240 ML per 30 days)

diazepam oral concentrate 5 mg/ml $0 (Tier 1) PA; MO; QL (240 ML per 30 days)

diazepam oral solution 5 mg/5 ml (1 mg/ml), 5

mg/5 ml (1 mg/ml, 5 ml)

$0 (Tier 1) PA; MO; QL (1200 ML per 30 days)

diazepam oral tablet 10 mg, 2 mg, 5 mg $0 (Tier 1) PA; MO; QL (120 EA per 30 days)



Formulary ID: 18395




61


cost you (Tier

Level)


limits on use

lorazepam intensol oral concentrate 2 mg/ml $0 (Tier 1) MO; QL (150 ML per 30 days)

lorazepam oral concentrate 2 mg/ml $0 (Tier 1) MO; QL (150 ML per 30 days)

lorazepam oral tablet 0.5 mg, 1 mg $0 (Tier 1) MO; QL (90 EA per 30 days)

lorazepam oral tablet 2 mg $0 (Tier 1) MO; QL (150 EA per 30 days)

BIPOLAR AGENTS - TREATMENT FOR BIPOLAR ILLNESSES

MOOD STABILIZERS

lithium carbonate oral capsule 150 mg, 300 mg,

600 mg

$0 (Tier 1) MO

lithium carbonate oral tablet 300 mg $0 (Tier 1) MO

lithium carbonate oral tablet extended release 300

mg, 450 mg

$0 (Tier 1) MO

lithium citrate oral solution 8 meq/5 ml $0 (Tier 1) MO

BLOOD GLUCOSE REGULATORS - CONTROL OF DIABETES

ANTIDIABETIC AGENTS

acarbose oral tablet 100 mg, 25 mg, 50 mg $0 (Tier 1) ST; MO; QL (90 EA per 30 days)

AVANDIA ORAL TABLET 2 MG, 4 MG $0 (Tier 2) ST; MO; QL (60 EA per 30 days)

DM2 COMBO PACK, TABLET AND STRIP 500

MG


glimepiride oral tablet 1 mg $0 (Tier 1) MO; QL (240 EA per 30 days)



glipizide oral tablet 10 mg $0 (Tier 1) MO; QL (120 EA per 30 days)

glipizide oral tablet 5 mg $0 (Tier 1) MO; QL (240 EA per 30 days)

glipizide oral tablet extended release 24hr 10 mg $0 (Tier 1) MO; QL (60 EA per 30 days)

glipizide oral tablet extended release 24hr 2.5 mg $0 (Tier 1) MO; QL (240 EA per 30 days)

glipizide oral tablet extended release 24hr 5 mg $0 (Tier 1) MO; QL (90 EA per 30 days)

glipizide-metformin oral tablet 2.5-250 mg $0 (Tier 1) MO; QL (240 EA per 30 days)


62


cost you (Tier

Level)


limits on use

glipizide-metformin oral tablet 2.5-500 mg, 5-500

mg


glyburide micronized oral tablet 1.5 mg, 3 mg $0 (Tier 1) PA; MO; QL (90 EA per 30 days)

glyburide micronized oral tablet 6 mg $0 (Tier 1) PA; MO; QL (60 EA per 30 days)

glyburide oral tablet 1.25 mg, 2.5 mg $0 (Tier 1) PA; MO; QL (60 EA per 30 days)

glyburide oral tablet 5 mg $0 (Tier 1) PA; MO

glyburide-metformin oral tablet 1.25-250 mg $0 (Tier 1) PA; MO; QL (240 EA per 30 days)

glyburide-metformin oral tablet 2.5-500 mg, 5-500

mg


GLYXAMBI ORAL TABLET 10-5 MG, 25-5

MG


INVOKAMET ORAL TABLET 150-1,000 MG,

150-500 MG, 50-1,000 MG


INVOKAMET ORAL TABLET 50-500 MG $0 (Tier 2) ST; MO; QL (120 EA per 30 days)

INVOKAMET XR ORAL TABLET, IR - ER,

BIPHASIC 24HR 150-1,000 MG, 150-500 MG,

50-1,000 MG, 50-500 MG


INVOKANA ORAL TABLET 100 MG, 300 MG $0 (Tier 2) ST; MO; QL (30 EA per 30 days)

JANUMET ORAL TABLET 50-1,000 MG, 50-

500 MG


JANUMET XR ORAL TABLET, ER

MULTIPHASE 24 HR 100-1,000 MG


JANUMET XR ORAL TABLET, ER

MULTIPHASE 24 HR 50-1,000 MG, 50-500 MG


JANUVIA ORAL TABLET 100 MG, 25 MG, 50

MG


JARDIANCE ORAL TABLET 10 MG, 25 MG $0 (Tier 2) ST; MO; QL (30 EA per 30 days)

JENTADUETO ORAL TABLET 2.5-1,000 MG,

2.5-500 MG, 2.5-850 MG


JENTADUETO XR ORAL TABLET, IR - ER,

BIPHASIC 24HR 2.5-1,000 MG


JENTADUETO XR ORAL TABLET, IR - ER,

BIPHASIC 24HR 5-1,000 MG


metformin oral tablet 1,000 mg $0 (Tier 1) MO; QL (75 EA per 30 days)

metformin oral tablet 500 mg $0 (Tier 1) MO; QL (150 EA per 30 days)



Formulary ID: 18395




63


cost you (Tier

Level)


limits on use

metformin oral tablet 850 mg $0 (Tier 1) MO; QL (90 EA per 30 days)

metformin oral tablet extended release 24 hr 500

mg


metformin oral tablet extended release 24 hr 750

mg


nateglinide oral tablet 120 mg, 60 mg $0 (Tier 1) ST; MO; QL (90 EA per 30 days)

pioglitazone oral tablet 15 mg, 30 mg, 45 mg $0 (Tier 1) ST; MO; QL (30 EA per 30 days)

pioglitazone-metformin oral tablet 15-500 mg, 15-

850 mg


repaglinide oral tablet 0.5 mg, 1 mg $0 (Tier 1) ST; MO; QL (120 EA per 30 days)

repaglinide oral tablet 2 mg $0 (Tier 1) ST; MO

SYMLINPEN 120 SUBCUTANEOUS PEN

INJECTOR 2,700 MCG/2.7 ML

$0 (Tier 2) PA; MO

SYMLINPEN 60 SUBCUTANEOUS PEN

INJECTOR 1,500 MCG/1.5 ML

$0 (Tier 2) PA; MO

SYNJARDY ORAL TABLET 12.5-1,000 MG,

12.5-500 MG, 5-1,000 MG, 5-500 MG


TRADJENTA ORAL TABLET 5 MG $0 (Tier 2) ST; MO; QL (30 EA per 30 days)

TRULICITY SUBCUTANEOUS PEN

INJECTOR 0.75 MG/0.5 ML, 1.5 MG/0.5 ML


VICTOZA 2-PAK SUBCUTANEOUS PEN

INJECTOR 0.6 MG/0.1 ML (18 MG/3 ML)


VICTOZA 3-PAK SUBCUTANEOUS PEN

INJECTOR 0.6 MG/0.1 ML (18 MG/3 ML)


BLOOD GLUCOSE REGULATORS

KORLYM ORAL TABLET 300 MG $0 (Tier 2) PA; MO

GLYCEMIC AGENTS

GLUCAGEN DIAGNOSTIC KIT INJECTION

RECON SOLN 1 MG/ML



64


cost you (Tier

Level)


limits on use

GLUCAGEN HYPOKIT INJECTION RECON

SOLN 1 MG


GLUCAGON EMERGENCY KIT (HUMAN)

INJECTION KIT 1 MG


GLUCAGON HCL INJECTION RECON SOLN 1

MG


glucose 4 gram tablet chew na/f, caffeine free 4

gram

$0 (Tier 3) DP

INSTA-GLUCOSE GEL 24 GRAM/31 GRAM $0 (Tier 3) DP

PROGLYCEM ORAL SUSPENSION 50 MG/ML $0 (Tier 2) MO

INSULINS

BASAGLAR KWIKPEN U-100 INSULIN

SUBCUTANEOUS INSULIN PEN 100

UNIT/ML (3 ML)

$0 (Tier 2) MO

HUMALOG JUNIOR KWIKPEN U-100

SUBCUTANEOUS INSULIN PEN, HALF-UNIT

100 UNIT/ML

$0 (Tier 2) MO

HUMALOG KWIKPEN INSULIN


UNIT/ML, 200 UNIT/ML (3 ML)

$0 (Tier 2) MO

HUMALOG MIX 50-50 INSULN U-100

SUBCUTANEOUS SUSPENSION 100 UNIT/ML

(50-50)

$0 (Tier 2) MO

HUMALOG MIX 50-50 KWIKPEN


UNIT/ML (50-50)

$0 (Tier 2) MO

HUMALOG MIX 75-25 KWIKPEN


UNIT/ML (75-25)

$0 (Tier 2) MO

HUMALOG MIX 75-25(U-100)INSULN


(75-25)

$0 (Tier 2) MO

HUMALOG U-100 INSULIN SUBCUTANEOUS

CARTRIDGE 100 UNIT/ML

$0 (Tier 2) MO

HUMALOG U-100 INSULIN SUBCUTANEOUS

SOLUTION 100 UNIT/ML, 100 UNIT/ML

(PREFILLED SYRINGE)

$0 (Tier 2) MO



Formulary ID: 18395




65


cost you (Tier

Level)


limits on use

HUMULIN 70/30 U-100 INSULIN


(70-30)

$0 (Tier 2) MO

HUMULIN 70/30 U-100 KWIKPEN


UNIT/ML (70-30)

$0 (Tier 2) MO

HUMULIN N NPH INSULIN KWIKPEN


UNIT/ML (3 ML)

$0 (Tier 2) MO

HUMULIN N NPH U-100 INSULIN


$0 (Tier 2) MO

HUMULIN R REGULAR U-100 INSULN

INJECTION SOLUTION 100 UNIT/ML

$0 (Tier 2) MO

HUMULIN R U-500 (CONC) INSULIN

SUBCUTANEOUS SOLUTION 500 UNIT/ML

$0 (Tier 2) MO

HUMULIN R U-500 (CONC) KWIKPEN


UNIT/ML (3 ML)

$0 (Tier 2) MO

LANTUS SOLOSTAR U-100 INSULIN


UNIT/ML (3 ML)

$0 (Tier 2) MO

LANTUS U-100 INSULIN SUBCUTANEOUS

SOLUTION 100 UNIT/ML

$0 (Tier 2) MO

LEVEMIR FLEXTOUCH U-100 INSULN


UNIT/ML (3 ML)

$0 (Tier 2) MO

LEVEMIR U-100 INSULIN SUBCUTANEOUS


$0 (Tier 2) MO

NOVOLIN 70/30 U-100 INSULIN


(70-30)

$0 (Tier 2) MO

NOVOLIN N NPH U-100 INSULIN


$0 (Tier 2) MO


66


cost you (Tier

Level)


limits on use

NOVOLIN R REGULAR U-100 INSULN

INJECTION SOLUTION 100 UNIT/ML

$0 (Tier 2) MO

NOVOLOG FLEXPEN U-100 INSULIN


UNIT/ML

$0 (Tier 2) MO

NOVOLOG MIX 70-30 U-100 INSULN


(70-30)

$0 (Tier 2) MO

NOVOLOG MIX 70-30FLEXPEN U-100


UNIT/ML (70-30)

$0 (Tier 2) MO

NOVOLOG PENFILL U-100 INSULIN

SUBCUTANEOUS CARTRIDGE 100 UNIT/ML

$0 (Tier 2) MO

NOVOLOG U-100 INSULIN ASPART


$0 (Tier 2) MO

BLOOD PRODUCTS/ MODIFIERS/ VOLUME EXPANDERS - PREVENTION OF

CLOTTING AND INCREASING BLOOD CELL PRODUCTION

ANTICOAGULANTS

argatroban in 0.9 % sod chlor intravenous

parenteral solution 250 mg/250 ml (1 mg/ml)

$0 (Tier 1) B/D; MO

argatroban in 0.9 % sod chlor intravenous

solution 1 mg/ml

$0 (Tier 1) B/D; MO

argatroban in nacl (iso-os) intravenous solution

50 mg/50 ml (1 mg/ml)

$0 (Tier 1) B/D; MO

argatroban intravenous solution 100 mg/ml $0 (Tier 1) B/D; MO

COUMADIN ORAL TABLET 1 MG, 10 MG, 2

MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG

$0 (Tier 2) MO

ELIQUIS ORAL TABLET 2.5 MG, 5 MG $0 (Tier 2) MO

ELIQUIS ORAL TABLETS,DOSE PACK 5 MG

(74 TABS)

$0 (Tier 2) MO

enoxaparin subcutaneous solution 300 mg/3 ml $0 (Tier 1)

enoxaparin subcutaneous syringe 100 mg/ml, 120

mg/0.8 ml, 150 mg/ml, 30 mg/0.3 ml, 40 mg/0.4 ml,

60 mg/0.6 ml, 80 mg/0.8 ml

$0 (Tier 1)

fondaparinux subcutaneous syringe 10 mg/0.8 ml,

2.5 mg/0.5 ml, 5 mg/0.4 ml, 7.5 mg/0.6 ml

$0 (Tier 1)



Formulary ID: 18395




67


cost you (Tier

Level)


limits on use

FRAGMIN SUBCUTANEOUS SOLUTION

25,000 ANTI-XA UNIT/ML

$0 (Tier 2)

FRAGMIN SUBCUTANEOUS SYRINGE 10,000

ANTI-XA UNIT/ML, 12,500 ANTI-XA UNIT/0.5

ML, 15,000 ANTI-XA UNIT/0.6 ML, 18,000

ANTI-XA UNIT/0.72 ML, 2,500 ANTI-XA

UNIT/0.2 ML, 5,000 ANTI-XA UNIT/0.2 ML,

7,500 ANTI-XA UNIT/0.3 ML

$0 (Tier 2)

heparin (porcine) in 5 % dex intravenous

parenteral solution 20,000 unit/500 ml (40

unit/ml)

$0 (Tier 1)

heparin (porcine) injection cartridge 5,000 unit/ml

(1 ml)

$0 (Tier 1)

heparin (porcine) injection solution 1,000 unit/ml,

10,000 unit/ml, 5,000 unit/ml

$0 (Tier 1)

heparin, porcine (pf) injection solution 1,000

unit/ml, 5,000 unit/0.5 ml

$0 (Tier 1)

jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3

mg, 4 mg, 5 mg, 6 mg, 7.5 mg

$0 (Tier 1) MO

PRADAXA ORAL CAPSULE 110 MG, 150 MG,

75 MG

$0 (Tier 2) MO

warfarin oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3

mg, 4 mg, 5 mg, 6 mg, 7.5 mg

$0 (Tier 1) MO

XARELTO ORAL TABLET 10 MG, 15 MG, 20

MG

$0 (Tier 2) MO

XARELTO ORAL TABLETS,DOSE PACK 15

MG (42)- 20 MG (9)

$0 (Tier 2) MO

BLOOD FORMATION MODIFIERS

anagrelide oral capsule 0.5 mg, 1 mg $0 (Tier 1) MO

ARANESP (IN POLYSORBATE) INJECTION

SOLUTION 100 MCG/ML, 150 MCG/0.75 ML,

200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40

MCG/ML, 60 MCG/ML

$0 (Tier 2) PA


68


cost you (Tier

Level)


limits on use

ARANESP (IN POLYSORBATE) INJECTION

SYRINGE 10 MCG/0.4 ML, 100 MCG/0.5 ML,

150 MCG/0.3 ML, 200 MCG/0.4 ML, 25

MCG/0.42 ML, 300 MCG/0.6 ML, 40 MCG/0.4

ML, 500 MCG/ML, 60 MCG/0.3 ML

$0 (Tier 2) PA

cilostazol oral tablet 100 mg, 50 mg $0 (Tier 1) MO

EPOGEN INJECTION SOLUTION 10,000

UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML,

20,000 UNIT/ML, 3,000 UNIT/ML, 4,000

UNIT/ML

$0 (Tier 2) PA

GRANIX SUBCUTANEOUS SYRINGE 300

MCG/0.5 ML, 480 MCG/0.8 ML

$0 (Tier 2) PA

LEUKINE INJECTION RECON SOLN 250 MCG $0 (Tier 2) PA

MOZOBIL SUBCUTANEOUS SOLUTION 24

MG/1.2 ML (20 MG/ML)

$0 (Tier 2) PA

NEULASTA SUBCUTANEOUS SYRINGE 6

MG/0.6ML

$0 (Tier 2) PA

NEULASTA SUBCUTANEOUS SYRINGE, W/

WEARABLE INJECTOR 6 MG/0.6 ML

$0 (Tier 2) PA

NEUPOGEN INJECTION SOLUTION 300

MCG/ML, 480 MCG/1.6 ML

$0 (Tier 2) PA

NEUPOGEN INJECTION SYRINGE 300

MCG/0.5 ML, 480 MCG/0.8 ML

$0 (Tier 2) PA

PROCRIT INJECTION SOLUTION 10,000

UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML,

20,000 UNIT/ML, 3,000 UNIT/ML, 4,000

UNIT/ML, 40,000 UNIT/ML

$0 (Tier 2) PA

PROMACTA ORAL TABLET 12.5 MG, 25 MG,

50 MG, 75 MG

$0 (Tier 2) QL (30 EA per 30 days)

ZARXIO INJECTION SYRINGE 300 MCG/0.5

ML, 480 MCG/0.8 ML

$0 (Tier 2) PA

COAGULANTS

MEPHYTON 5 MG TABLET 5 MG $0 (Tier 3) DP

phytonadione 1 mg/0.5 ml syr latex-free, p/f,sdv 1

mg/0.5 ml

$0 (Tier 3) DP

tranexamic acid intravenous solution 1,000 mg/10

ml (100 mg/ml)

$0 (Tier 1)



Formulary ID: 18395




69


cost you (Tier

Level)


limits on use

tranexamic acid oral tablet 650 mg $0 (Tier 1) MO

VITAMIN K-1 1 MG/0.5 ML AMPUL

SDV,LATEX-FREE 1 MG/0.5 ML

$0 (Tier 3) DP

VITAMIN K-1 10 MG/ML AMPUL LATEX-

FREE, SDV 10 MG/ML

$0 (Tier 3) DP

VITAMIN K-1 10 MG/ML AMPUL

SDV,LATEX-FREE 10 MG/ML

$0 (Tier 3) DP

PLATELET MODIFYING AGENTS

ASPIR EC 81 MG TABLET 81 MG $0 (Tier 3) DP

aspirin 81 mg chewable tablet 81 mg $0 (Tier 3) DP

aspirin 81 mg chewable tablet low dose, cherry 81

mg

$0 (Tier 3) DP

aspirin 81 mg chewable tablet low strength,

orange 81 mg

$0 (Tier 3) DP

aspirin 81 mg chewable tablet orange 81 mg $0 (Tier 3) DP

aspirin ec 81 mg tablet 81 mg $0 (Tier 3) DP

aspirin ec 81 mg tablet adult low dose 81 mg $0 (Tier 3) DP

aspirin ec 81 mg tablet adult low strength 81 mg $0 (Tier 3) DP

aspirin ec 81 mg tablet low dose 81 mg $0 (Tier 3) DP

aspirin-dipyridamole oral capsule, er multiphase

12 hr 25-200 mg

$0 (Tier 1) MO

ASPIR-LOW EC 81 MG TABLET 81 MG $0 (Tier 3) DP

BRILINTA ORAL TABLET 60 MG, 90 MG $0 (Tier 2) MO

CHILD ASPIRIN 81 MG CHEW TAB 81 MG $0 (Tier 3) DP

CHILD ASPIRIN 81 MG CHEW TAB

CHILDREN'S 81 MG

$0 (Tier 3) DP

clopidogrel oral tablet 300 mg, 75 mg $0 (Tier 1) MO

dipyridamole oral tablet 25 mg, 50 mg, 75 mg $0 (Tier 1) PA; MO

FYCOMPA ORAL TABLETS,DOSE PACK 2

MG (7)- 4 MG (7)

$0 (Tier 2) ST; MO


70


cost you (Tier

Level)


limits on use

gs aspirin 81 mg chewable tab 81 mg $0 (Tier 3) DP

hm aspirin 81 mg chewable tab adlt low

dose,orange 81 mg

$0 (Tier 3) DP

hm aspirin ec 81 mg tablet low dose 81 mg $0 (Tier 3) DP

HM LOW DOSE ASPIRIN EC 81 MG 81 MG $0 (Tier 3) DP

prasugrel oral tablet 10 mg, 5 mg $0 (Tier 1) MO

QC LO-DOSE ASPIRIN EC 81 MG TB 81 MG $0 (Tier 3) DP

sm aspirin ec 81 mg tablet 81 mg $0 (Tier 3) DP

SM CHILD ASPIRIN 81 MG CHW TAB

CHILDREN'S 81 MG

$0 (Tier 3) DP

BULK PRODUCTS

BULK PRODUCTS

CAPSULE #0 $0 (Tier 3) DP

CAPSULE #1 BLUE/BLUE $0 (Tier 3) DP

CAPSULE #1 VEGGIE CLEAR $0 (Tier 3) DP

glucosamine-chondroitin cap p/f 500-400 mg $0 (Tier 3) DP

glucosamine-chondroitin cap s/f, p/f 500-400 mg $0 (Tier 3) DP

LUBRISOFT LOTION $0 (Tier 3) DP

mineral oil heavy $0 (Tier 3) DP

sodium chlor 0.9% bacteriostat injection solution

0.9 %

$0 (Tier 1) MO

CARDIOVASCULAR AGENTS - TREATMENT OF CONDITIONS AFFECTING THE

HEART AND BLOOD VESSELS

ALPHA-ADRENERGIC AGONISTS

clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg $0 (Tier 1) MO

clonidine transdermal patch weekly 0.1 mg/24 hr,

0.2 mg/24 hr, 0.3 mg/24 hr

$0 (Tier 1) MO

guanfacine oral tablet 1 mg, 2 mg $0 (Tier 1) PA; MO

methyldopa oral tablet 250 mg, 500 mg $0 (Tier 1) PA; MO

methyldopate intravenous solution 250 mg/5 ml $0 (Tier 1) PA; MO

midodrine oral tablet 10 mg, 2.5 mg, 5 mg $0 (Tier 1) MO

ALPHA-ADRENERGIC BLOCKING AGENTS



Formulary ID: 18395




71


cost you (Tier

Level)


limits on use

doxazosin oral tablet 1 mg, 2 mg, 4 mg, 8 mg $0 (Tier 1) MO

prazosin oral capsule 1 mg, 2 mg, 5 mg $0 (Tier 1) MO

terazosin oral capsule 1 mg, 10 mg, 2 mg, 5 mg $0 (Tier 1) MO

ANGIOTENSIN II RECEPTOR ANTAGONISTS

irbesartan oral tablet 150 mg, 300 mg, 75 mg $0 (Tier 1) MO

losartan oral tablet 100 mg, 25 mg, 50 mg $0 (Tier 1) MO

olmesartan oral tablet 20 mg, 40 mg, 5 mg $0 (Tier 1) MO

valsartan oral tablet 160 mg, 320 mg, 40 mg, 80

mg

$0 (Tier 1) MO

ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS

benazepril oral tablet 10 mg, 20 mg, 40 mg, 5 mg $0 (Tier 1) MO

captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50

mg

$0 (Tier 1) MO

enalapril maleate oral tablet 10 mg, 2.5 mg, 20

mg, 5 mg

$0 (Tier 1) MO

fosinopril oral tablet 10 mg, 20 mg, 40 mg $0 (Tier 1) MO

lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg,

40 mg, 5 mg

$0 (Tier 1) MO

moexipril oral tablet 15 mg, 7.5 mg $0 (Tier 1) MO

quinapril oral tablet 10 mg, 20 mg, 40 mg, 5 mg $0 (Tier 1) MO

ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5

mg

$0 (Tier 1) MO

trandolapril oral tablet 1 mg, 2 mg, 4 mg $0 (Tier 1) MO

ANTIARRHYTHMICS

amiodarone oral tablet 100 mg, 200 mg, 400 mg $0 (Tier 1) MO

disopyramide phosphate oral capsule 100 mg, 150

mg

$0 (Tier 1) PA; MO

dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg $0 (Tier 1) MO

flecainide oral tablet 100 mg, 150 mg, 50 mg $0 (Tier 1) MO


72


cost you (Tier

Level)


limits on use

mexiletine oral capsule 150 mg, 200 mg, 250 mg $0 (Tier 1) MO

MULTAQ ORAL TABLET 400 MG $0 (Tier 2) MO

NORPACE CR ORAL CAPSULE, EXTENDED

RELEASE 100 MG, 150 MG

$0 (Tier 2) PA; MO

propafenone oral tablet 150 mg, 225 mg, 300 mg $0 (Tier 1) MO

quinidine gluconate oral tablet extended release

324 mg

$0 (Tier 1) MO

quinidine sulfate oral tablet 200 mg, 300 mg $0 (Tier 1) MO

sorine oral tablet 120 mg, 160 mg, 240 mg, 80 mg $0 (Tier 1) MO

sotalol af oral tablet 120 mg, 160 mg, 80 mg $0 (Tier 1) MO

sotalol oral tablet 120 mg, 160 mg, 240 mg, 80 mg $0 (Tier 1) MO

BETA-ADRENERGIC BLOCKING AGENTS

acebutolol oral capsule 200 mg, 400 mg $0 (Tier 1) MO

atenolol oral tablet 100 mg, 25 mg, 50 mg $0 (Tier 1) MO

bisoprolol fumarate oral tablet 10 mg, 5 mg $0 (Tier 1) MO

carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg,

6.25 mg

$0 (Tier 1) MO

labetalol oral tablet 100 mg, 200 mg, 300 mg $0 (Tier 1) MO

metoprolol succinate oral tablet extended release

24 hr 100 mg, 200 mg, 25 mg, 50 mg

$0 (Tier 1) MO

metoprolol tartrate oral tablet 100 mg, 25 mg,

37.5 mg, 50 mg, 75 mg

$0 (Tier 1) MO

nadolol oral tablet 20 mg, 40 mg, 80 mg $0 (Tier 1) MO

propranolol oral capsule,extended release 24 hr

120 mg, 160 mg, 60 mg, 80 mg

$0 (Tier 1) MO

propranolol oral solution 20 mg/5 ml (4 mg/ml),

40 mg/5 ml (8 mg/ml)

$0 (Tier 1) MO

propranolol oral tablet 10 mg, 20 mg, 40 mg, 60

mg, 80 mg

$0 (Tier 1) MO

CALCIUM CHANNEL BLOCKING AGENTS

amlodipine oral tablet 10 mg, 2.5 mg, 5 mg $0 (Tier 1) MO

cartia xt oral capsule,extended release 24hr 120

mg, 180 mg, 240 mg, 300 mg

$0 (Tier 1) MO

diltiazem hcl intravenous recon soln 100 mg $0 (Tier 1) MO



Formulary ID: 18395




73


cost you (Tier

Level)


limits on use

diltiazem hcl intravenous solution 5 mg/ml $0 (Tier 1) MO

diltiazem hcl oral capsule,ext.rel 24h degradable

120 mg, 180 mg, 240 mg

$0 (Tier 1) MO

diltiazem hcl oral capsule,extended release 12 hr

120 mg, 60 mg, 90 mg

$0 (Tier 1) MO

diltiazem hcl oral capsule,extended release 24 hr

120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg

$0 (Tier 1) MO

diltiazem hcl oral capsule,extended release 24hr

120 mg, 180 mg, 240 mg, 300 mg, 360 mg

$0 (Tier 1) MO

diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90

mg

$0 (Tier 1) MO

dilt-xr oral capsule,ext.rel 24h degradable 120

mg, 180 mg, 240 mg

$0 (Tier 1) MO

felodipine oral tablet extended release 24 hr 10

mg, 2.5 mg, 5 mg

$0 (Tier 1) MO

isradipine oral capsule 2.5 mg, 5 mg $0 (Tier 1) MO

nifedical xl oral tablet extended release 24hr 30

mg, 60 mg

$0 (Tier 1) MO

nifedipine oral capsule 10 mg, 20 mg $0 (Tier 1) PA; MO

nifedipine oral tablet extended release 24hr 30 mg,

60 mg, 90 mg

$0 (Tier 1) MO

nifedipine oral tablet extended release 30 mg, 60

mg, 90 mg

$0 (Tier 1) MO

nimodipine oral capsule 30 mg $0 (Tier 1) MO

taztia xt oral capsule,extended release 24 hr 120

mg, 180 mg, 240 mg, 300 mg, 360 mg

$0 (Tier 1) MO

verapamil oral capsule, 24 hr er pellet ct 100 mg,

200 mg, 300 mg

$0 (Tier 2) MO

verapamil oral capsule,ext rel. pellets 24 hr 120

mg, 180 mg, 240 mg, 360 mg

$0 (Tier 1) MO

verapamil oral tablet 120 mg, 40 mg, 80 mg $0 (Tier 1) MO


74


cost you (Tier

Level)


limits on use

verapamil oral tablet extended release 120 mg,

120 mg (24 hours), 180 mg, 240 mg

$0 (Tier 1) MO

CARDIOVASCULAR AGENTS

amiloride-hydrochlorothiazide oral tablet 5-50 mg $0 (Tier 1) MO

amlodipine-benazepril oral capsule 10-20 mg, 10-

40 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg

$0 (Tier 1) MO

amlodipine-olmesartan oral tablet 10-20 mg, 10-

40 mg, 5-20 mg, 5-40 mg

$0 (Tier 1) MO

amlodipine-valsartan oral tablet 10-160 mg, 10-

320 mg, 5-160 mg, 5-320 mg

$0 (Tier 1) MO

amlodipine-valsartan-hcthiazid oral tablet 10-160-

12.5 mg, 10-160-25 mg, 10-320-25 mg, 5-160-12.5

mg, 5-160-25 mg

$0 (Tier 1) MO

atenolol-chlorthalidone oral tablet 100-25 mg, 50-

25 mg

$0 (Tier 1) MO

benazepril-hydrochlorothiazide oral tablet 10-12.5

mg, 20-12.5 mg, 20-25 mg, 5-6.25 mg

$0 (Tier 1) MO

bisoprolol-hydrochlorothiazide oral tablet 10-6.25

mg, 2.5-6.25 mg, 5-6.25 mg

$0 (Tier 1) MO

captopril-hydrochlorothiazide oral tablet 25-15

mg, 25-25 mg, 50-15 mg, 50-25 mg

$0 (Tier 1) MO

DEMSER ORAL CAPSULE 250 MG $0 (Tier 2) PA

enalapril-hydrochlorothiazide oral tablet 10-25

mg, 5-12.5 mg

$0 (Tier 1) MO

ENTRESTO ORAL TABLET 24-26 MG, 49-51

MG, 97-103 MG

$0 (Tier 2) MO

fosinopril-hydrochlorothiazide oral tablet 10-12.5

mg, 20-12.5 mg

$0 (Tier 1) MO

irbesartan-hydrochlorothiazide oral tablet 150-

12.5 mg, 300-12.5 mg

$0 (Tier 1) MO

lisinopril-hydrochlorothiazide oral tablet 10-12.5

mg, 20-12.5 mg, 20-25 mg

$0 (Tier 1) MO

losartan-hydrochlorothiazide oral tablet 100-12.5

mg, 100-25 mg, 50-12.5 mg

$0 (Tier 1) MO

methyldopa-hydrochlorothiazide oral tablet 250-

15 mg, 250-25 mg

$0 (Tier 1) PA; MO



Formulary ID: 18395




75


cost you (Tier

Level)


limits on use

moexipril-hydrochlorothiazide oral tablet 15-12.5

mg, 15-25 mg, 7.5-12.5 mg

$0 (Tier 1) MO

NORTHERA ORAL CAPSULE 100 MG, 200

MG, 300 MG

$0 (Tier 2) MO

olmesartan-amlodipin-hcthiazid oral tablet 20-5-

12.5 mg, 40-10-12.5 mg, 40-10-25 mg, 40-5-12.5

mg, 40-5-25 mg

$0 (Tier 1) MO

olmesartan-hydrochlorothiazide oral tablet 20-

12.5 mg, 40-12.5 mg, 40-25 mg

$0 (Tier 1) MO

quinapril-hydrochlorothiazide oral tablet 10-12.5

mg, 20-12.5 mg, 20-25 mg

$0 (Tier 1) MO

spironolacton-hydrochlorothiaz oral tablet 25-25

mg

$0 (Tier 1) MO

TEKTURNA HCT ORAL TABLET 150-12.5

MG, 150-25 MG, 300-12.5 MG, 300-25 MG

$0 (Tier 2) MO

triamterene-hydrochlorothiazid oral capsule 37.5-

25 mg, 50-25 mg

$0 (Tier 1) MO

triamterene-hydrochlorothiazid oral tablet 37.5-25

mg, 75-50 mg

$0 (Tier 1) MO

valsartan-hydrochlorothiazide oral tablet 160-12.5

mg, 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5

mg

$0 (Tier 1) MO

CARDIOVASCULAR AGENTS, OTHER

CORLANOR ORAL TABLET 5 MG, 7.5 MG $0 (Tier 2) PA; MO

digitek oral tablet 125 mcg $0 (Tier 1) MO; QL (30 EA per 30 days)

digitek oral tablet 250 mcg $0 (Tier 1) PA; MO

digox oral tablet 125 mcg $0 (Tier 1) MO; QL (30 EA per 30 days)

digox oral tablet 250 mcg $0 (Tier 1) PA; MO

digoxin oral solution 50 mcg/ml $0 (Tier 1) PA; MO

digoxin oral tablet 125 mcg $0 (Tier 1) MO; QL (30 EA per 30 days)

digoxin oral tablet 250 mcg $0 (Tier 1) PA; MO


76


cost you (Tier

Level)


limits on use

pentoxifylline oral tablet extended release 400 mg $0 (Tier 1) MO

RANEXA ORAL TABLET EXTENDED

RELEASE 12 HR 1,000 MG, 500 MG

$0 (Tier 2) ST; MO

TEKTURNA ORAL TABLET 150 MG, 300 MG $0 (Tier 2) MO

DIURETICS, CARBONIC ANHYDRASE INHIBITORS

acetazolamide oral capsule, extended release 500

mg

$0 (Tier 1) MO

acetazolamide oral tablet 125 mg, 250 mg $0 (Tier 1) MO

KEVEYIS ORAL TABLET 50 MG $0 (Tier 2) PA; MO

methazolamide oral tablet 25 mg, 50 mg $0 (Tier 1) MO

DIURETICS, LOOP

bumetanide oral tablet 0.5 mg, 1 mg, 2 mg $0 (Tier 1) MO

furosemide injection solution 10 mg/ml $0 (Tier 1) MO

furosemide injection syringe 10 mg/ml $0 (Tier 1) MO

furosemide oral solution 10 mg/ml, 40 mg/5 ml (8

mg/ml)

$0 (Tier 1) MO

furosemide oral tablet 20 mg, 40 mg, 80 mg $0 (Tier 1) MO

torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg $0 (Tier 1) MO

DIURETICS, POTASSIUM-SPARING

amiloride oral tablet 5 mg $0 (Tier 1) MO

eplerenone oral tablet 25 mg, 50 mg $0 (Tier 1) MO

spironolactone oral tablet 100 mg, 25 mg, 50 mg $0 (Tier 1) MO

DIURETICS, THIAZIDE

chlorothiazide oral tablet 250 mg, 500 mg $0 (Tier 1) MO

chlorthalidone oral tablet 25 mg, 50 mg $0 (Tier 1) MO

hydrochlorothiazide oral capsule 12.5 mg $0 (Tier 1) MO

hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50

mg

$0 (Tier 1) MO

indapamide oral tablet 1.25 mg, 2.5 mg $0 (Tier 1) MO

methyclothiazide oral tablet 5 mg $0 (Tier 1) MO

metolazone oral tablet 10 mg, 2.5 mg, 5 mg $0 (Tier 1) MO

DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES



Formulary ID: 18395




77


cost you (Tier

Level)


limits on use

fenofibrate micronized oral capsule 134 mg, 200

mg, 67 mg

$0 (Tier 1) MO

fenofibrate nanocrystallized oral tablet 145 mg, 48

mg

$0 (Tier 1) MO

fenofibrate oral tablet 160 mg, 54 mg $0 (Tier 1) MO

fenofibric acid (choline) oral capsule,delayed

release(dr/ec) 135 mg, 45 mg

$0 (Tier 1) MO

gemfibrozil oral tablet 600 mg $0 (Tier 1) MO

DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS

atorvastatin oral tablet 10 mg, 20 mg, 40 mg, 80

mg

$0 (Tier 1) MO

LIVALO ORAL TABLET 1 MG, 2 MG, 4 MG $0 (Tier 2) MO

lovastatin oral tablet 10 mg, 20 mg, 40 mg $0 (Tier 1) MO

pravastatin oral tablet 10 mg, 20 mg, 40 mg, 80

mg

$0 (Tier 1) MO

rosuvastatin oral tablet 10 mg, 20 mg, 40 mg, 5

mg

$0 (Tier 1) MO

simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg,

80 mg

$0 (Tier 1) MO

DYSLIPIDEMICS, OTHER

cholestyramine (with sugar) oral powder 4 gram $0 (Tier 1) MO

cholestyramine (with sugar) oral powder in packet

4 gram

$0 (Tier 1) MO

cholestyramine light oral powder 4 gram $0 (Tier 1) MO

cholestyramine light oral powder in packet 4 gram $0 (Tier 1) MO

cod liver oil capsule $0 (Tier 3) DP

colestipol oral granules 5 gram $0 (Tier 1) MO

colestipol oral packet 5 gram $0 (Tier 1) MO

colestipol oral tablet 1 gram $0 (Tier 1) MO


78


cost you (Tier

Level)


limits on use

ezetimibe oral tablet 10 mg $0 (Tier 1) MO

ezetimibe-simvastatin oral tablet 10-10 mg, 10-20

mg, 10-40 mg, 10-80 mg

$0 (Tier 1) MO

JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 30

MG, 40 MG, 5 MG, 60 MG

$0 (Tier 2) PA

KYNAMRO SUBCUTANEOUS SYRINGE 200

MG/ML

$0 (Tier 2) PA

niacin 100 mg tablet 100 mg $0 (Tier 3) DP

niacin 500 mg capsule sa 500 mg $0 (Tier 3) DP

niacin 500 mg tablet 500 mg $0 (Tier 3) DP

niacin er 1,000 mg caplet 1,000 mg $0 (Tier 3) DP

niacin er 1,000 mg tablet 1,000 mg $0 (Tier 3) DP

niacin er 500 mg caplet caplet 500 mg $0 (Tier 3) DP

niacin er 500 mg tablet 500 mg $0 (Tier 3) DP

niacin inositol 500 mg capsule 400 mg niacin (500

mg)

$0 (Tier 3) DP

niacin oral tablet extended release 24 hr 1,000 mg,

500 mg, 750 mg

$0 (Tier 1) MO

niacin sa 250 mg capsule (otc) 250 mg $0 (Tier 3) DP

niacin tr 500 mg caplet caplet 500 mg $0 (Tier 3) DP

niacin tr 500 mg capsule 500 mg $0 (Tier 3) DP

niacinamide 500 mg tablet 500 mg $0 (Tier 3) DP

omega-3 acid ethyl esters oral capsule 1 gram $0 (Tier 1) MO

PRALUENT PEN SUBCUTANEOUS PEN

INJECTOR 150 MG/ML, 75 MG/ML

$0 (Tier 2) PA

PRALUENT SYRINGE SUBCUTANEOUS

SYRINGE 75 MG/ML

$0 (Tier 2) PA; MO

prevalite oral powder 4 gram $0 (Tier 1) MO

prevalite oral powder in packet 4 gram $0 (Tier 1) MO

qc cod liver oil usp $0 (Tier 3) DP

REPATHA PUSHTRONEX SUBCUTANEOUS

WEARABLE INJECTOR 420 MG/3.5 ML

$0 (Tier 2) PA

REPATHA SURECLICK SUBCUTANEOUS

PEN INJECTOR 140 MG/ML

$0 (Tier 2) PA



Formulary ID: 18395




79


cost you (Tier

Level)


limits on use

REPATHA SYRINGE SUBCUTANEOUS

SYRINGE 140 MG/ML

$0 (Tier 2) PA

TRIKLO ORAL CAPSULE 1 GRAM $0 (Tier 1) MO

v-r cod liver oil capsule $0 (Tier 3) DP

WELCHOL ORAL POWDER IN PACKET 3.75

GRAM

$0 (Tier 2) MO

WELCHOL ORAL TABLET 625 MG $0 (Tier 2) MO

VASODILATORS, DIRECT-ACTING ARTERIAL

hydralazine oral tablet 10 mg, 100 mg, 25 mg, 50

mg

$0 (Tier 1) MO

minoxidil oral tablet 10 mg, 2.5 mg $0 (Tier 1) MO

VASODILATORS, DIRECT-ACTING ARTERIAL/ VENOUS

isosorbide dinitrate oral tablet 10 mg, 20 mg, 30

mg, 5 mg

$0 (Tier 1) MO

isosorbide dinitrate oral tablet extended release 40

mg

$0 (Tier 1) MO

isosorbide mononitrate oral tablet 10 mg, 20 mg $0 (Tier 1) MO

isosorbide mononitrate oral tablet extended

release 24 hr 120 mg, 30 mg, 60 mg

$0 (Tier 1) MO

NITRO-BID TRANSDERMAL OINTMENT 2 % $0 (Tier 2) MO

NITRO-DUR TRANSDERMAL PATCH 24

HOUR 0.3 MG/HR, 0.8 MG/HR

$0 (Tier 2) MO

nitroglycerin sublingual tablet 0.3 mg, 0.4 mg, 0.6

mg

$0 (Tier 1) MO

nitroglycerin transdermal patch 24 hour 0.1

mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr

$0 (Tier 1) MO

nitroglycerin translingual aerosol,spray 400

mcg/spray

$0 (Tier 1) MO

nitroglycerin translingual spray,non-aerosol 400

mcg/spray

$0 (Tier 1) MO


80


cost you (Tier

Level)


limits on use

CENTRAL NERVOUS SYSTEM AGENTS - TREATMENT OF DISORDERS OF THE

BRAIN AND SPINAL COLUMN

ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES

dextroamphetamine oral capsule, extended release

10 mg



15 mg



5 mg


dextroamphetamine oral tablet 10 mg $0 (Tier 1) PA; MO; QL (180 EA per 30 days)

dextroamphetamine oral tablet 5 mg $0 (Tier 1) PA; MO; QL (60 EA per 30 days)

dextroamphetamine-amphetamine oral

capsule,extended release 24hr 10 mg, 15 mg, 20

mg, 25 mg, 30 mg, 5 mg


dextroamphetamine-amphetamine oral tablet 10

mg, 20 mg, 30 mg, 5 mg, 7.5 mg


dextroamphetamine-amphetamine oral tablet 12.5

mg


dextroamphetamine-amphetamine oral tablet 15

mg


ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-

AMPHETAMINES

atomoxetine oral capsule 10 mg, 100 mg, 18 mg,

25 mg, 40 mg, 60 mg, 80 mg

$0 (Tier 1) MO

clonidine hcl oral tablet extended release 12 hr 0.1

mg


dexmethylphenidate oral capsule,er biphasic 50-

50 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40

mg, 5 mg

$0 (Tier 1) PA; MO

dexmethylphenidate oral tablet 10 mg, 2.5 mg, 5

mg

$0 (Tier 1) PA; MO

guanfacine oral tablet extended release 24 hr 1

mg, 2 mg, 3 mg, 4 mg

$0 (Tier 1) MO

methylphenidate hcl oral tablet 10 mg, 20 mg, 5

mg

$0 (Tier 1) PA; MO



Formulary ID: 18395




81


cost you (Tier

Level)


limits on use

methylphenidate hcl oral tablet extended release

20 mg



24hr 18 mg



24hr 27 mg



24hr 36 mg



24hr 54 mg


CENTRAL NERVOUS SYSTEM, OTHER

EXONDYS 51 INTRAVENOUS SOLUTION 50


$0 (Tier 2) PA

HORIZANT ORAL TABLET EXTENDED


$0 (Tier 2) MO

INGREZZA ORAL CAPSULE 40 MG, 80 MG $0 (Tier 2) PA

NUEDEXTA ORAL CAPSULE 20-10 MG $0 (Tier 2) MO

RADICAVA INTRAVENOUS PIGGYBACK 30

MG/100 ML

$0 (Tier 2) PA

riluzole oral tablet 50 mg $0 (Tier 1)

tetrabenazine oral tablet 12.5 mg, 25 mg $0 (Tier 1)

FIBROMYALGIA AGENTS

SAVELLA ORAL TABLET 100 MG, 12.5 MG,

25 MG, 50 MG

$0 (Tier 2) MO

SAVELLA ORAL TABLETS,DOSE PACK 12.5

MG (5)-25 MG(8)-50 MG(42)

$0 (Tier 2) MO

MULTIPLE SCLEROSIS AGENTS

AMPYRA ORAL TABLET EXTENDED

RELEASE 12 HR 10 MG

$0 (Tier 2) PA

AUBAGIO ORAL TABLET 14 MG, 7 MG $0 (Tier 2) PA


82


cost you (Tier

Level)


limits on use

BETASERON SUBCUTANEOUS KIT 0.3 MG $0 (Tier 2) PA

BETASERON SUBCUTANEOUS RECON

SOLN 0.3 MG

$0 (Tier 2) PA

COPAXONE SUBCUTANEOUS SYRINGE 20

MG/ML, 40 MG/ML

$0 (Tier 2) PA

EXTAVIA SUBCUTANEOUS KIT 0.3 MG $0 (Tier 2) PA

EXTAVIA SUBCUTANEOUS RECON SOLN

0.3 MG

$0 (Tier 2) PA

GILENYA ORAL CAPSULE 0.5 MG $0 (Tier 2) PA

glatiramer subcutaneous syringe 20 mg/ml, 40

mg/ml

$0 (Tier 1) PA

REBIF (WITH ALBUMIN) SUBCUTANEOUS

SYRINGE 22 MCG/0.5 ML, 44 MCG/0.5 ML

$0 (Tier 2) PA

REBIF REBIDOSE SUBCUTANEOUS PEN

INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML,

8.8MCG/0.2ML-22 MCG/0.5ML (6)

$0 (Tier 2) PA

REBIF TITRATION PACK SUBCUTANEOUS

SYRINGE 8.8MCG/0.2ML-22 MCG/0.5ML (6)

$0 (Tier 2) PA

TECFIDERA ORAL CAPSULE,DELAYED

RELEASE(DR/EC) 120 MG, 120 MG (14)- 240

MG (46), 240 MG

$0 (Tier 2) PA

DENTAL AND ORAL AGENTS - TREATMENT OF MOUTH AND GUM DISORDERS

DENTAL AND ORAL AGENTS

cevimeline oral capsule 30 mg $0 (Tier 1) MO

chlorhexidine gluconate mucous membrane

mouthwash 0.12 %

$0 (Tier 1) MO

CUVPOSA ORAL SOLUTION 1 MG/5 ML (0.2

MG/ML)

$0 (Tier 2) MO

periogard mucous membrane mouthwash 0.12 % $0 (Tier 1) MO

pilocarpine hcl oral tablet 5 mg, 7.5 mg $0 (Tier 1) MO

triamcinolone acetonide dental paste 0.1 % $0 (Tier 1) MO

DERMATOLOGICAL AGENTS - TREATMENT OF SKIN CONDITIONS

DERMATOLOGICAL AGENTS

8-MOP ORAL CAPSULE 10 MG $0 (Tier 2) PA; MO



Formulary ID: 18395




83


cost you (Tier

Level)


limits on use

acitretin oral capsule 10 mg, 17.5 mg, 25 mg $0 (Tier 1) PA

ammonium lactate topical cream 12 % $0 (Tier 1) MO

ammonium lactate topical lotion 12 % $0 (Tier 1) MO

AMNESTEEM ORAL CAPSULE 10 MG, 20

MG, 40 MG

$0 (Tier 1) MO

ANTI-DANDRUFF 1% SHAMPOO 1 % $0 (Tier 3) DP

AQUA GLYCOLIC HAND-BODY LOT $0 (Tier 3) DP

calcipotriene scalp solution 0.005 % $0 (Tier 1) MO

calcipotriene topical cream 0.005 % $0 (Tier 1) MO

calcipotriene topical ointment 0.005 % $0 (Tier 1) MO

CERAVE MOISTURIZING CREAM $0 (Tier 3) DP

CETAPHIL GENTLE SKIN CLEANSER 16 OZ. $0 (Tier 3) DP

CETAPHIL MOISTURIZING CREAM $0 (Tier 3) DP

CETAPHIL MOISTURIZING LOTION $0 (Tier 3) DP

claravis oral capsule 10 mg, 20 mg, 30 mg, 40 mg $0 (Tier 1) MO

clotrimazole-betamethasone topical cream 1-0.05

%

$0 (Tier 1) MO

clotrimazole-betamethasone topical lotion 1-0.05

%

$0 (Tier 1) MO

COMPLEX 15 HAND-BODY LOTION HAND &

BODY

$0 (Tier 3) DP

COMPOUND W 17% GEL 17 % $0 (Tier 3) DP

CRITIC-AID SKIN PASTE 20-51 % $0 (Tier 3) DP

DERMACERIN CREAM $0 (Tier 3) DP

DERMACLOUD OINTMENT $0 (Tier 3) DP

DML FORTE CREAM W-PANTHENOL $0 (Tier 3) DP

DOXEPIN TOPICAL CREAM 5 % $0 (Tier 1) MO

ELIDEL TOPICAL CREAM 1 % $0 (Tier 2) ST; MO


84


cost you (Tier

Level)


limits on use

erythromycin-benzoyl peroxide topical gel 3-5 % $0 (Tier 1) MO

GS ITCH RELIEF CREAM 2-0.1 % $0 (Tier 3) DP

HEMORRHOIDAL OINTMENT $0 (Tier 3) DP

HYDRO SKIN 1% LOTION 1 % $0 (Tier 3) DP

hydrocortisone 0.5% cream (otc) 0.5 % $0 (Tier 3) DP

hydrocortisone 0.5% cream 0.5 % $0 (Tier 3) DP

hydrocortisone 0.5% ointment 0.5 % $0 (Tier 3) DP

hydrocortisone 1% cream 1 % $0 (Tier 3) DP

hydrocortisone-min oil-wht pet topical ointment 1

%

$0 (Tier 1) MO

imiquimod topical cream in packet 5 % $0 (Tier 1) MO

isotretinoin oral capsule 10 mg, 20 mg, 30 mg, 40

mg

$0 (Tier 1) MO

ITCH RELIEF CREAM 2-0.1 % $0 (Tier 3) DP

LACTINOL HX CREAM $0 (Tier 3) DP

LOTRIMIN AF 2% SPRAY POWDER 2 % $0 (Tier 3) DP

MEDERMA GEL $0 (Tier 3) DP

methoxsalen oral capsule,liqd-filled,rapid rel 10

mg

$0 (Tier 1) PA

MINERIN CREME $0 (Tier 3) DP

MINERIN LOTION $0 (Tier 3) DP

MOBISYL 10% CREAM 3.5OZ TUBE 10 % $0 (Tier 3) DP

myorisan oral capsule 10 mg, 20 mg, 30 mg, 40

mg

$0 (Tier 1) MO

nystatin-triamcinolone topical cream 100,000-0.1

unit/g-%

$0 (Tier 1) MO

nystatin-triamcinolone topical ointment 100,000-

0.1 unit/gram-%

$0 (Tier 1) MO

podofilox topical solution 0.5 % $0 (Tier 1) MO

prednicarbate topical cream 0.1 % $0 (Tier 1) MO

prednicarbate topical ointment 0.1 % $0 (Tier 1) MO

qc calamine lotion 8-8 % $0 (Tier 3) DP



Formulary ID: 18395




85


cost you (Tier

Level)


limits on use

RA DIAPER RASH OINTMENT BABY CARE

40 %

$0 (Tier 3) DP

REGRANEX TOPICAL GEL 0.01 % $0 (Tier 2) PA; MO; QL (15 GM per 30 days)

RISAMINE OINTMENT 0.44-20.6 % $0 (Tier 3) DP

SANTYL TOPICAL OINTMENT 250

UNIT/GRAM

$0 (Tier 2) MO

SARNA ANTI-ITCH LOTION 0.5-0.5 % $0 (Tier 3) DP

SCYTERA 2% FOAM NON-CALIFORNIA 2 % $0 (Tier 3) DP

SEBEX SHAMPOO 2-2 % $0 (Tier 3) DP

selenium sulfide topical lotion 2.5 % $0 (Tier 1) MO

SENSI-CARE PROTECTIVE OINTMENT 15-49

%

$0 (Tier 3) DP

SWEEN CREAM 12'S, W/PUMP $0 (Tier 3) DP

SWEEN CREAM WITH VIT A AND D 12'S $0 (Tier 3) DP

tacrolimus topical ointment 0.03 %, 0.1 % $0 (Tier 1) ST; MO

tazarotene topical cream 0.1 % $0 (Tier 1) MO

TAZORAC TOPICAL CREAM 0.05 % $0 (Tier 2) MO

TAZORAC TOPICAL GEL 0.05 %, 0.1 % $0 (Tier 2) MO

THERA-GEL 0.5% SHAMPOO 0.5 % $0 (Tier 3) DP

tretinoin (emollient) topical cream 0.05 % $0 (Tier 1) MO

tretinoin topical cream 0.025 %, 0.05 %, 0.1 % $0 (Tier 1) MO

tretinoin topical gel 0.01 %, 0.025 % $0 (Tier 1) MO

UREACIN-10 LOTION 10 % $0 (Tier 3) DP

VEREGEN TOPICAL OINTMENT 15 % $0 (Tier 2) MO

vitamin a and d ointment $0 (Tier 3) DP

WART REMOVER SOLUTION 17 % $0 (Tier 3) DP

ZENATANE ORAL CAPSULE 10 MG, 20 MG,

40 MG

$0 (Tier 1) MO


86


cost you (Tier

Level)


limits on use

zenatane oral capsule 30 mg $0 (Tier 1) MO

zinc oxide 20% ointment 20 % $0 (Tier 3) DP

ZYCLARA TOPICAL CREAM IN METERED-

DOSE PUMP 2.5 %, 3.75 %

$0 (Tier 2) PA; MO

ZYCLARA TOPICAL CREAM IN PACKET 3.75

%

$0 (Tier 2) PA; MO

DIABETIC SUPPLIES - SUPPLIES USED FOR DIABETES

DIABETIC SUPPLIES

alcohol pads topical pads, medicated $0 (Tier 1) MO

assure id insulin safety syringe 1 ml 29 gauge x

1/2"

$0 (Tier 1) MO

gauze pad topical bandage 2 x 2 " $0 (Tier 1) MO

insulin syringe-needle u-100 syringe 0.3 ml 29

gauge, 1 ml 29 gauge x 1/2", 1/2 ml 28 gauge

$0 (Tier 1) MO

pen needle, diabetic needle 29 gauge x 1/2" $0 (Tier 1) MO

ENZYME REPLACEMENT/ MODIFIERS - MEDICATIONS TO REPLACE MISSING OR

DEFICIENT ENZYME PRODUCTION

ENZYME REPLACEMENT/ MODIFIERS

ADAGEN INTRAMUSCULAR SOLUTION 250

UNIT/ML

$0 (Tier 2) PA

ALDURAZYME INTRAVENOUS SOLUTION

2.9 MG/5 ML

$0 (Tier 2) PA

allopurinol sodium intravenous recon soln 500 mg $0 (Tier 1) B/D; MO

CERDELGA ORAL CAPSULE 84 MG $0 (Tier 2) PA

CEREZYME INTRAVENOUS RECON SOLN

400 UNIT

$0 (Tier 2) PA

CHOLBAM ORAL CAPSULE 250 MG, 50 MG $0 (Tier 2) PA

CREON ORAL CAPSULE,DELAYED

RELEASE(DR/EC) 12,000-38,000 -60,000 UNIT,

24,000-76,000 -120,000 UNIT, 3,000-9,500-

15,000 UNIT, 36,000-114,000- 180,000 UNIT,

6,000-19,000 -30,000 UNIT

$0 (Tier 2) MO

CYSTADANE ORAL POWDER 1 GRAM/1.7

ML

$0 (Tier 2)

CYSTAGON ORAL CAPSULE 150 MG, 50 MG $0 (Tier 2) PA; MO



Formulary ID: 18395




87


cost you (Tier

Level)


limits on use

ELAPRASE INTRAVENOUS SOLUTION 6

MG/3 ML

$0 (Tier 2) PA

ELELYSO INTRAVENOUS RECON SOLN 200

UNIT

$0 (Tier 2) PA

ELITEK INTRAVENOUS RECON SOLN 1.5

MG, 7.5 MG

$0 (Tier 2) PA

FABRAZYME INTRAVENOUS RECON SOLN

35 MG, 5 MG

$0 (Tier 2) PA

KUVAN ORAL POWDER IN PACKET 100 MG,

500 MG

$0 (Tier 2) PA

KUVAN ORAL TABLET,SOLUBLE 100 MG $0 (Tier 2) PA

miglustat oral capsule 100 mg $0 (Tier 1) PA; MO

NAGLAZYME INTRAVENOUS SOLUTION 5

MG/5 ML

$0 (Tier 2) PA

NITYR ORAL TABLET 10 MG, 2 MG, 5 MG $0 (Tier 2) PA

ORFADIN ORAL CAPSULE 10 MG, 2 MG, 20

MG, 5 MG

$0 (Tier 2) PA

ORFADIN ORAL SUSPENSION 4 MG/ML $0 (Tier 2) PA

RAVICTI ORAL LIQUID 1.1 GRAM/ML $0 (Tier 2) PA; MO

STRENSIQ SUBCUTANEOUS SOLUTION 100

MG/ML, 40 MG/ML

$0 (Tier 2) PA

SUCRAID ORAL SOLUTION 8,500 UNIT/ML $0 (Tier 2) PA

SYPRINE ORAL CAPSULE 250 MG $0 (Tier 2) PA

trientine oral capsule 250 mg $0 (Tier 1) PA

VPRIV INTRAVENOUS RECON SOLN 400

UNIT

$0 (Tier 2) PA

XURIDEN ORAL GRANULES IN PACKET 2

GRAM

$0 (Tier 2) PA; MO

ZAVESCA ORAL CAPSULE 100 MG $0 (Tier 2) PA


88


cost you (Tier

Level)


limits on use

ZENPEP ORAL CAPSULE,DELAYED

RELEASE(DR/EC) 10,000-32,000 -42,000 UNIT,

10,000-34,000 -55,000 UNIT, 15,000-47,000 -

63,000 UNIT, 15,000-51,000 -82,000 UNIT,

20,000-63,000- 84,000 UNIT, 20,000-68,000 -

109,000 UNIT, 25,000-79,000- 105,000 UNIT,

25,000-85,000- 136,000 UNIT, 3,000-10,000 -

14,000-UNIT, 3,000-10,000- 16,000 UNIT,

40,000-126,000- 168,000 UNIT, 40,000-136,000-

218,000 UNIT, 5,000-17,000 -27,000 UNIT,

5,000-17,000- 24,000 UNIT

$0 (Tier 2) MO

GASTROINTESTINAL AGENTS - TREATMENT OF STOMACH AND INTESTINAL

CONDITIONS

ANTISPASMODICS, GASTROINTESTINAL

dicyclomine oral capsule 10 mg $0 (Tier 1) MO

dicyclomine oral solution 10 mg/5 ml $0 (Tier 1) MO

dicyclomine oral tablet 20 mg $0 (Tier 1) MO

glycopyrrolate oral tablet 1 mg, 2 mg $0 (Tier 1) MO

GASTROINTESTINAL AGENTS

gavilyte-c oral recon soln 240-22.72-6.72 -5.84

gram

$0 (Tier 1) MO

methscopolamine oral tablet 2.5 mg $0 (Tier 1) MO

GASTROINTESTINAL AGENTS, OTHER

acidophilus caplet caplet 25 million cell -100 mg $0 (Tier 3) DP

ACIDOPHILUS-PECTIN CAPSULE 75

MILLION CELL -100 MG

$0 (Tier 3) DP

ANTACID 500 MG CHEW TABLET ASST

FRUIT FLAVORED 200 MG CALCIUM (500

MG)

$0 (Tier 3) DP

ANTACID 500 MG CHEWABLE TABLET

NA/F 200 MG CALCIUM (500 MG)

$0 (Tier 3) DP

ANTACID ANTI-GAS LIQUID MAXIMUM

STRENGTH 400-400-40 MG/5 ML

$0 (Tier 3) DP

ANTACID MAXIMUM STRENGTH LIQ 400-

400-40 MG/5 ML

$0 (Tier 3) DP

ANTACID SUSPENSION 200-200-20 MG/5 ML $0 (Tier 3) DP



Formulary ID: 18395




89


cost you (Tier

Level)


limits on use

ANTACID XTRA STRENGTH CHEW TAB

EXTRA STRENGTH 300 MG (750 MG)

$0 (Tier 3) DP

ANTACID-ANTIGAS LIQUID 200-200-20 MG/5

ML

$0 (Tier 3) DP

ANTI-DIARRHEAL 2 MG CAPLET CAPLET 2

MG

$0 (Tier 3) DP

ANTI-DIARRHEAL 2 MG CAPLET CPLT

EASY TO SWALLOW 2 MG

$0 (Tier 3) DP

BISMATROL 525 MG/30 ML SUSP 262 MG/15

ML

$0 (Tier 3) DP

CALCIUM ANTACID EX-STR TABLET

EXTRA-STRENGTH 300 MG (750 MG)

$0 (Tier 3) DP

diphenoxylate-atropine oral liquid 2.5-0.025 mg/5

ml

$0 (Tier 1) MO

diphenoxylate-atropine oral tablet 2.5-0.025 mg $0 (Tier 1) MO

ENDARI ORAL POWDER IN PACKET 5

GRAM

$0 (Tier 2) PA

enulose oral solution 10 gram/15 ml $0 (Tier 1) MO

EPSOM SALT GRANULES 6'S 495 MG/5

GRAM

$0 (Tier 3) DP

FLORANEX TABLET 1 MILLION CELL $0 (Tier 3) DP

GAS RELIEF 180 MG SOFTGEL ULTRA STR,

SOFTGEL 180 MG

$0 (Tier 3) DP

GAS RELIEF 180 MG SOFTGEL ULTRA

STR,SFTGEL 180 MG

$0 (Tier 3) DP

GAS RELIEF 80 MG TABLET CHEW 80 MG $0 (Tier 3) DP

GATTEX 30-VIAL SUBCUTANEOUS KIT 5

MG

$0 (Tier 2) PA

GATTEX ONE-VIAL SUBCUTANEOUS KIT 5

MG

$0 (Tier 2) PA

GAVISCON EXTRA STRENGTH LIQUID

EXTRA STR,COOL MINT 254-237.5 MG/5 ML

$0 (Tier 3) DP


90


cost you (Tier

Level)


limits on use

generlac oral solution 10 gram/15 ml $0 (Tier 1) MO

GS ANTACID 500 MG CHEWABLE TAB 215

MG CALCIUM (500 MG)

$0 (Tier 3) DP

GS ANTACID PLUS ANTI-GAS LIQ 200-200-

20 MG/5 ML

$0 (Tier 3) DP

GS ANTI-DIARRHEAL 2 MG CAPLET 2 MG $0 (Tier 3) DP

GS CAL ANTACID 500 MG CHEW TAB 200

MG CALCIUM (500 MG)

$0 (Tier 3) DP

gs simethicone 20 mg/0.3 ml 40 mg/0.6 ml $0 (Tier 3) DP

lactase 3,000 unit caplet caplet 3,000 unit $0 (Tier 3) DP

loperamide oral capsule 2 mg $0 (Tier 1) MO

MAG DELAY DR 70 MG TABLET 70 MG $0 (Tier 3) DP

MI ACID SUSPENSION 200-200-20 MG/5 ML $0 (Tier 3) DP

MI-ACID GAS 80 MG TAB CHEW 80 MG $0 (Tier 3) DP

MINTOX SUSPENSION MINT CREME 200-

200-20 MG/5 ML

$0 (Tier 3) DP

MYTAB GAS 80 MG TABLET CHEW 80 MG $0 (Tier 3) DP

MYTAB GAS MAX STR 125 MG TAB 125 MG $0 (Tier 3) DP

OCALIVA ORAL TABLET 10 MG, 5 MG $0 (Tier 2) PA

PINK BISMUTH 262 MG/15 ML SUSP 262

MG/15 ML

$0 (Tier 3) DP

PINK BISMUTH TABLET CHEW 262 MG $0 (Tier 3) DP

QC ANTACID SUSPENSION REGULAR

STRENGTH 200-200-20 MG/5 ML

$0 (Tier 3) DP

QC GAS RELIEF 125 MG TAB CHEW EXTRA

STRENGTH 125 MG

$0 (Tier 3) DP

QC PINK BISMUTH TABLET CHEW 262 MG $0 (Tier 3) DP

RA PINK BISMUTH CAPLET CAPLET,S/F 262

MG

$0 (Tier 3) DP

RECTIV RECTAL OINTMENT 0.4 % (W/W) $0 (Tier 2) MO

RELISTOR ORAL TABLET 150 MG $0 (Tier 2) PA; MO

RELISTOR SUBCUTANEOUS SOLUTION 12

MG/0.6 ML

$0 (Tier 2) PA; MO



Formulary ID: 18395




91


cost you (Tier

Level)


limits on use

RELISTOR SUBCUTANEOUS SYRINGE 12

MG/0.6 ML, 8 MG/0.4 ML

$0 (Tier 2) PA; MO

RESTORA CAPSULE 120 MG-400 MG -4

BILLION CELL

$0 (Tier 3) DP

RISA-BID CAPLET 1 BILLION CELL- 250 MG $0 (Tier 3) DP

RISAQUAD CAPSULES 8 BILLION CELL $0 (Tier 3) DP

simethicone 80 mg tab chew anti gas 80 mg $0 (Tier 3) DP

SM ANTI-DIARRHEAL 2 MG CAPLET 2 MG $0 (Tier 3) DP

SM ANTI-DIARRHEAL 2 MG CAPLET

CAPLET 2 MG

$0 (Tier 3) DP

SM CAL ANTACID 500 MG CHEW TAB REG-

STR, FRUIT 200 MG CALCIUM (500 MG)

$0 (Tier 3) DP

SM EPSOM SALT GRANULES 495 MG/5

GRAM

$0 (Tier 3) DP

SM GAS RELIEF 125 MG SOFTGEL SOFTGEL,

EX-STRENGTH 125 MG

$0 (Tier 3) DP

sodium bicarb 325 mg tablet 325 mg $0 (Tier 3) DP

sodium bicarb 650 mg tablet 10 gr 650 mg $0 (Tier 3) DP

STOMACH RELIEF MAX STR LIQUID MAX.

STRENGTH 525 MG/15 ML

$0 (Tier 3) DP

TUMS ULTRA TABLET CHEWABLE 400 MG

CALCIUM (1,000 MG)

$0 (Tier 3) DP

ursodiol oral capsule 300 mg $0 (Tier 1) MO

ursodiol oral tablet 250 mg, 500 mg $0 (Tier 1) MO

XERMELO ORAL TABLET 250 MG $0 (Tier 2) PA

HISTAMINE2 (H2) RECEPTOR ANTAGONISTS

ACID CONTROL 75 MG TABLET 75 MG $0 (Tier 3) DP

ACID REDUCER 10 MG TABLET 10 MG $0 (Tier 3) DP

ACID REDUCER 10 MG TABLET ORIGINAL

STRENGTH 10 MG

$0 (Tier 3) DP


92


cost you (Tier

Level)


limits on use

cimetidine hcl oral solution 300 mg/5 ml $0 (Tier 1) MO

cimetidine oral tablet 200 mg, 300 mg, 400 mg,

800 mg

$0 (Tier 1) MO

famotidine (pf) intravenous solution 20 mg/2 ml $0 (Tier 1)

famotidine intravenous solution 10 mg/ml $0 (Tier 1)

famotidine oral tablet 20 mg, 40 mg $0 (Tier 1) MO

hm famotidine 10 mg tablet original strength 10

mg

$0 (Tier 3) DP

nizatidine oral capsule 150 mg, 300 mg $0 (Tier 1) MO

ranitidine hcl oral syrup 15 mg/ml $0 (Tier 1) MO

ranitidine hcl oral tablet 150 mg, 300 mg $0 (Tier 1) MO

IRRITABLE BOWEL SYNDROME AGENTS

alosetron oral tablet 0.5 mg, 1 mg $0 (Tier 1) MO

AMITIZA ORAL CAPSULE 24 MCG, 8 MCG $0 (Tier 2) MO; QL (60 EA per 30 days)

LINZESS ORAL CAPSULE 145 MCG, 290

MCG, 72 MCG


LAXATIVES

BENEFIBER SUGAR FREE POWDER 38

SERVINGS, S/F 3 GRAM/3.5 GRAM

$0 (Tier 3) DP

BENEFIBER SUGAR FREE POWDER 62

SERVINGS, S/F 3 GRAM/3.5 GRAM

$0 (Tier 3) DP

bisacodyl 10 mg suppository 10 mg $0 (Tier 3) DP

bisacodyl ec 5 mg tablet 5 mg $0 (Tier 3) DP

BISA-LAX EC 5 MG TABLET 5 MG $0 (Tier 3) DP

BISCOLAX 10 MG SUPPOSITORY 10 MG $0 (Tier 3) DP

CITRUCEL 500 MG CAPLET 500 MG $0 (Tier 3) DP

CITRUCEL POWDER $0 (Tier 3) DP

CITRUCEL POWDER S-F S/F $0 (Tier 3) DP

COLACE CLEAR 50 MG SOFTGEL 50 MG $0 (Tier 3) DP

constulose oral solution 10 gram/15 ml $0 (Tier 1) MO

DOC-Q-LACE 100 MG SOFTGEL 100 MG $0 (Tier 3) DP

DOC-Q-LAX TABLET 8.6-50 MG $0 (Tier 3) DP



Formulary ID: 18395




93


cost you (Tier

Level)


limits on use

DOCU LIQUID 50 MG/5 ML 50 MG/5 ML $0 (Tier 3) DP

docusate cal 240 mg softgel softgel 240 mg $0 (Tier 3) DP

docusate sodium 100 mg softgel softgel 100 mg $0 (Tier 3) DP

docusate sodium 250 mg softgel softgel 250 mg $0 (Tier 3) DP

DOCUSATE SODIUM-SENNA TABLET 8.6-50

MG

$0 (Tier 3) DP

DOCUSIL 100 MG SOFTGEL 100 MG $0 (Tier 3) DP

ENEMA DISPOSABLE 19-7 GRAM/118 ML $0 (Tier 3) DP

ENEMEEZ MINI ENEMA 5CC TUBES, OUTER

283 MG/5 ML

$0 (Tier 3) DP

EX-LAX MAXIMUM STR 25 MG TAB 25 MG $0 (Tier 3) DP

FIBER LAXATIVE 625 MG CAPLET CAPLET

625 MG

$0 (Tier 3) DP

FIBER LAXATIVE 625 MG TABLET 625 MG $0 (Tier 3) DP

FIBER THERAPY POWDER 2 GRAM/19

GRAM

$0 (Tier 3) DP

FIBER-LAX CAPTABS 500MG

POLYCARBOPHIL 625 MG

$0 (Tier 3) DP

FLEET GLYCERIN ADULT SUPPOS $0 (Tier 3) DP

gavilyte-g oral recon soln 236-22.74-6.74 -5.86

gram

$0 (Tier 1) MO

gavilyte-n oral recon soln 420 gram $0 (Tier 1) MO

GS MILK OF MAGNESIA SUSPENSION 400

MG/5 ML

$0 (Tier 3) DP

HEALTHYLAX POWDER PACKET 14X17GM,

INNER 17 GRAM

$0 (Tier 3) DP

HM SENNA 8.6 MG TABLET 8.6 MG $0 (Tier 3) DP

HM STOOL SOFTENER 100 MG SFTGL

SOFTGEL 100 MG

$0 (Tier 3) DP


94


cost you (Tier

Level)


limits on use

KRISTALOSE ORAL PACKET 10 GRAM, 20

GRAM

$0 (Tier 2) ST; MO

lactulose oral solution 10 gram/15 ml, 10 gram/15

ml (15 ml), 20 gram/30 ml

$0 (Tier 1) MO

LAXATIVE 10 MG SUPPOSITORY 10 MG $0 (Tier 3) DP

LAXATIVE 15 MG PILLS 15 MG $0 (Tier 3) DP

LAXATIVE EC 5 MG TABLET 5 MG $0 (Tier 3) DP

magnesium citrate solution lemon $0 (Tier 3) DP

METAMUCIL FIBER SINGLES PACKET 3.4

GRAM

$0 (Tier 3) DP

METAMUCIL PACKET GLUTEN-FREE,

OUTER 3.4 GRAM

$0 (Tier 3) DP

METAMUCIL POWDER $0 (Tier 3) DP

METAMUCIL SUGAR-FREE POWDER S/F,

ORANGE FLAVOR 3.4 GRAM/5.8 GRAM

$0 (Tier 3) DP

MILK OF MAGNESIA SUSPENSION 400 MG/5

ML

$0 (Tier 3) DP

MILK OF MAGNESIA SUSPENSION NA/F 400

MG/5 ML

$0 (Tier 3) DP

MILK OF MAGNESIA SUSPENSION

STIMULANT FREE 400 MG/5 ML

$0 (Tier 3) DP

MINERAL OIL, HEAVY $0 (Tier 3) DP

NATURAL FIBER LAX POWDER $0 (Tier 3) DP

peg 3350-electrolytes oral recon soln 240-22.72-

6.72 -5.84 gram

$0 (Tier 1) MO

peg-3350 with flavor packs oral recon soln 420

gram

$0 (Tier 1) MO

peg-electrolyte soln oral recon soln 420 gram $0 (Tier 1) MO

polyethylene glycol 3350 oral powder 17

gram/dose

$0 (Tier 1) MO

polyethylene glycol 3350 oral powder in packet 17

gram

$0 (Tier 1) MO

qc docusate cal 240 mg capsule 240 mg $0 (Tier 3) DP

QC FIBERLAX 625 MG CAPLET CAPLET 625

MG

$0 (Tier 3) DP



Formulary ID: 18395




95


cost you (Tier

Level)


limits on use

QC GENTLE LAXATIVE 10 MG SUPP 10 MG $0 (Tier 3) DP

QC GENTLE LAXATIVE EC 5 MG TAB 5 MG $0 (Tier 3) DP

QC MILK OF MAGNESIA SUSPENSION MINT

FLAVOR 400 MG/5 ML

$0 (Tier 3) DP

QC NATURAL VEGETABLE POWDER $0 (Tier 3) DP

QC READY TO USE ENEMA TWIN PACK 19-7

GRAM/118 ML

$0 (Tier 3) DP

QC SENNA LAXATIVE 8.6 MG TAB 8.6 MG $0 (Tier 3) DP

QC SENNA-S TABLET 8.6-50 MG $0 (Tier 3) DP

QC STOOL SOFTENER 100 MG CAP LIQUID

CAPS 100 MG

$0 (Tier 3) DP

QC STOOL SOFTENER-LAXATIVE TAB 8.6-

50 MG

$0 (Tier 3) DP

REGULOID CAPSULE 0.52 GRAM $0 (Tier 3) DP

REGULOID LAXATIVE POWDER $0 (Tier 3) DP

REGULOID POWDER $0 (Tier 3) DP

REGULOID POWDER ORANGE $0 (Tier 3) DP

SENNA 8.6 MG TABLET 8.6 MG $0 (Tier 3) DP

SENNA 8.8 MG/5 ML SYRUP A/F,

CHOCOLATE 8.8 MG/5 ML

$0 (Tier 3) DP

SENNA PLUS TABLET 8.6-50 MG $0 (Tier 3) DP

SENNA SYRUP 176 MG/5 ML $0 (Tier 3) DP

SENNA-LAX 8.6 MG TABLET 8.6 MG $0 (Tier 3) DP

SENNALAX-S TABLET 8.6-50 MG $0 (Tier 3) DP

SENNA-S TABLET 8.6-50 MG $0 (Tier 3) DP

SILACE 50 MG/5 ML LIQUID 50 MG/5 ML $0 (Tier 3) DP

SILACE 60 MG/15 ML SYRUP 60 MG/15 ML $0 (Tier 3) DP

sm docusate cal 240 mg softgel softgel 240 mg $0 (Tier 3) DP


96


cost you (Tier

Level)


limits on use

SM FIBER LAXATIVE 625 MG TAB CAPLET

625 MG

$0 (Tier 3) DP

SM FIBER POWDER $0 (Tier 3) DP

SM FIBER POWDER 3.4 GRAM/11 GRAM $0 (Tier 3) DP

SM FIBER SMOOTH TEXTURE PWD $0 (Tier 3) DP

SM GENTLE LAXATIVE EC 5 MG TAB 5 MG $0 (Tier 3) DP

sm magnesium citrate solution $0 (Tier 3) DP

SM NAT LAX PLUS STOOL SOFTENER 8.6-50

MG

$0 (Tier 3) DP

SM SENNA LAXATIVE 8.6 MG TAB 8.6 MG $0 (Tier 3) DP

SM STOOL SOFTENER 100 MG SFTGL

SOFTGEL 100 MG

$0 (Tier 3) DP

SM STOOL SOFTENER-STIM LAX TAB 8.6-50

MG

$0 (Tier 3) DP

STOOL SOFTENER 100 MG CAPSULE 100 MG $0 (Tier 3) DP

STOOL SOFTENER 50 MG/5 ML LIQ 50 MG/5

ML

$0 (Tier 3) DP

STOOL SOFTENER-LAXATIVE TABLET 8.6-

50 MG

$0 (Tier 3) DP

STOOL SOFTENER-STIM LAX TABLET 8.6-50

MG

$0 (Tier 3) DP

trilyte with flavor packets oral recon soln 420

gram

$0 (Tier 1) MO

WOMANS LAXATIVE TABLET 5 MG $0 (Tier 3) DP

PROTECTANTS

misoprostol oral tablet 100 mcg, 200 mcg $0 (Tier 1) MO

sucralfate oral tablet 1 gram $0 (Tier 1) MO

PROTON PUMP INHIBITORS

lansoprazole oral capsule,delayed release(dr/ec)

15 mg, 30 mg

$0 (Tier 1) MO

omeprazole oral capsule,delayed release(dr/ec) 10

mg, 20 mg, 40 mg

$0 (Tier 1) MO

pantoprazole intravenous recon soln 40 mg $0 (Tier 1) MO



Formulary ID: 18395




97


cost you (Tier

Level)


limits on use

pantoprazole oral tablet,delayed release (dr/ec) 20

mg, 40 mg

$0 (Tier 1) MO

GENITOURINARY AGENTS - TREATMENT OF URINARY TRACT AND PROSTATE

CONDITIONS

ANTISPASMODICS, URINARY

darifenacin oral tablet extended release 24 hr 15

mg, 7.5 mg

$0 (Tier 1) ST; MO

flavoxate oral tablet 100 mg $0 (Tier 1) MO

MYRBETRIQ ORAL TABLET EXTENDED



oxybutynin chloride oral syrup 5 mg/5 ml $0 (Tier 1) MO

oxybutynin chloride oral tablet 5 mg $0 (Tier 1) MO

oxybutynin chloride oral tablet extended release

24hr 10 mg, 15 mg, 5 mg

$0 (Tier 1) MO

tolterodine oral capsule,extended release 24hr 2

mg, 4 mg

$0 (Tier 1) ST; MO

tolterodine oral tablet 1 mg, 2 mg $0 (Tier 1) ST; MO

TOVIAZ ORAL TABLET EXTENDED


$0 (Tier 2) MO

BENIGN PROSTATIC HYPERTROPHY AGENTS

alfuzosin oral tablet extended release 24 hr 10 mg $0 (Tier 1) MO

dutasteride oral capsule 0.5 mg $0 (Tier 1) MO

finasteride oral tablet 5 mg $0 (Tier 1) MO

tamsulosin oral capsule 0.4 mg $0 (Tier 1) MO

GENITOURINARY AGENTS, OTHER

bethanechol chloride oral tablet 10 mg, 25 mg, 5

mg, 50 mg

$0 (Tier 1) MO

DEPEN TITRATABS ORAL TABLET 250 MG $0 (Tier 2) PA; MO

ELMIRON ORAL CAPSULE 100 MG $0 (Tier 2) MO


98


cost you (Tier

Level)


limits on use

potassium citrate oral tablet extended release 10

meq (1,080 mg), 15 meq, 5 meq (540 mg)

$0 (Tier 1) MO

sodium phenylbutyrate oral powder 0.94

gram/gram

$0 (Tier 1) PA; MO

sodium phenylbutyrate oral tablet 500 mg $0 (Tier 1) PA

PHOSPHATE BINDERS

calcium acetate oral capsule 667 mg $0 (Tier 1) MO

FOSRENOL ORAL POWDER IN PACKET

1,000 MG, 750 MG

$0 (Tier 2) MO

FOSRENOL ORAL TABLET,CHEWABLE

1,000 MG, 500 MG, 750 MG

$0 (Tier 2) MO

lanthanum oral tablet,chewable 1,000 mg, 500 mg,

750 mg

$0 (Tier 1) MO

RENVELA ORAL TABLET 800 MG $0 (Tier 2) MO

sevelamer carbonate oral powder in packet 0.8

gram, 2.4 gram

$0 (Tier 1) MO

sevelamer carbonate oral tablet 800 mg $0 (Tier 1) MO

HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (ADRENAL) -

TREATMENT OF CONDITIONS REQUIRING STEROIDS

HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (ADRENAL)

ACTHAR H.P. INJECTION GEL 80 UNIT/ML $0 (Tier 2) PA; MO

clobetasol-emollient topical cream 0.05 % $0 (Tier 1) MO

cortisone oral tablet 25 mg $0 (Tier 1) MO

fludrocortisone oral tablet 0.1 mg $0 (Tier 1) MO

hydrocortisone oral tablet 10 mg, 20 mg, 5 mg $0 (Tier 1) MO

TRIDERM TOPICAL CREAM 0.5 % $0 (Tier 1) MO

HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (PITUITARY) -

TREATMENT OF PITUITARY GLAND CONDITIONS

HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (PITUITARY)

chorionic gonadotropin, human intramuscular

recon soln 10,000 unit

$0 (Tier 1) PA; MO

desmopressin injection solution 4 mcg/ml $0 (Tier 1) MO



Formulary ID: 18395




99


cost you (Tier

Level)


limits on use

desmopressin nasal solution 0.1 mg/ml

(refrigerate)

$0 (Tier 1) MO

desmopressin nasal spray with pump 10 mcg/spray

(0.1 ml)

$0 (Tier 1) MO

desmopressin nasal spray,non-aerosol 10

mcg/spray (0.1 ml)

$0 (Tier 1) MO

desmopressin oral tablet 0.1 mg, 0.2 mg $0 (Tier 1) MO

EGRIFTA SUBCUTANEOUS RECON SOLN 1

MG, 2 MG

$0 (Tier 2) PA

GENOTROPIN MINIQUICK SUBCUTANEOUS

SYRINGE 0.2 MG/0.25 ML, 0.4 MG/0.25 ML,

0.6 MG/0.25 ML, 0.8 MG/0.25 ML, 1 MG/0.25

ML, 1.2 MG/0.25 ML, 1.4 MG/0.25 ML, 1.6

MG/0.25 ML, 1.8 MG/0.25 ML, 2 MG/0.25 ML

$0 (Tier 2) PA

GENOTROPIN SUBCUTANEOUS

CARTRIDGE 12 MG/ML (36 UNIT/ML), 5

MG/ML (15 UNIT/ML)

$0 (Tier 2) PA

HUMATROPE INJECTION CARTRIDGE 12

MG (36 UNIT), 24 MG (72 UNIT), 6 MG (18

UNIT)

$0 (Tier 2) PA

HUMATROPE INJECTION RECON SOLN 5 (15

UNIT) MG

$0 (Tier 2) PA

INCRELEX SUBCUTANEOUS SOLUTION 10

MG/ML

$0 (Tier 2) PA

NOCTIVA NASAL SPRAY,NON-AEROSOL

0.83 MCG/SPRAY (0.1 ML), 1.66 MCG/SPRAY

(0.1 ML)

$0 (Tier 2) PA; MO

NORDITROPIN FLEXPRO SUBCUTANEOUS

PEN INJECTOR 10 MG/1.5 ML (6.7 MG/ML),

15 MG/1.5 ML (10 MG/ML), 30 MG/3 ML (10

MG/ML), 5 MG/1.5 ML (3.3 MG/ML)

$0 (Tier 2) PA


100


cost you (Tier

Level)


limits on use

NUTROPIN AQ NUSPIN SUBCUTANEOUS

PEN INJECTOR 10 MG/2 ML (5 MG/ML), 20

MG/2 ML (10 MG/ML), 5 MG/2 ML (2.5

MG/ML)

$0 (Tier 2) PA

NUTROPIN AQ SUBCUTANEOUS

CARTRIDGE 20 MG/2 ML (10 MG/ML)

$0 (Tier 2) PA; MO

OMNITROPE SUBCUTANEOUS CARTRIDGE

10 MG/1.5 ML (6.7 MG/ML), 5 MG/1.5 ML (3.3

MG/ML)

$0 (Tier 2) PA

OMNITROPE SUBCUTANEOUS RECON

SOLN 5.8 MG

$0 (Tier 2) PA

SEROSTIM SUBCUTANEOUS RECON SOLN 4

MG, 5 MG, 6 MG

$0 (Tier 2) PA

HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (SEX

HORMONES/ MODIFIERS) - FOR THE REPLACEMENT OR MODIFICATION OF SEX

HORMONES

ANABOLIC STEROIDS

ANADROL-50 ORAL TABLET 50 MG $0 (Tier 2) PA; MO

oxandrolone oral tablet 10 mg, 2.5 mg $0 (Tier 1) MO

ANDROGENS

ANDROGEL TRANSDERMAL GEL IN

PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62

% (40.5 MG/2.5 GRAM)

$0 (Tier 2) ST; MO

ANDROXY ORAL TABLET 10 MG $0 (Tier 2) MO

DANAZOL ORAL CAPSULE 100 MG, 200 MG,

50 MG

$0 (Tier 2) MO

methyltestosterone oral capsule 10 mg $0 (Tier 1) PA; MO

testosterone cypionate intramuscular oil 100

mg/ml, 200 mg/ml

$0 (Tier 1)

testosterone transdermal gel 50 mg/5 gram (1 %) $0 (Tier 1) MO

testosterone transdermal gel in metered-dose

pump 12.5 mg/ 1.25 gram (1 %)

$0 (Tier 1) MO

testosterone transdermal gel in packet 1 % (25

mg/2.5gram), 1 % (50 mg/5 gram)

$0 (Tier 1) MO

ESTROGENS



Formulary ID: 18395




101


cost you (Tier

Level)


limits on use

DUAVEE ORAL TABLET 0.45-20 MG $0 (Tier 2) MO

ESTRACE VAGINAL CREAM 0.01 % (0.1

MG/GRAM)

$0 (Tier 2) MO

estradiol oral tablet 0.5 mg, 1 mg, 2 mg $0 (Tier 1) MO

estradiol transdermal patch semiweekly 0.025

mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.075

mg/24 hr, 0.1 mg/24 hr

$0 (Tier 1) MO

estradiol transdermal patch weekly 0.025 mg/24

hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.06 mg/24

hr, 0.075 mg/24 hr, 0.1 mg/24 hr

$0 (Tier 1) MO

estradiol vaginal cream 0.01 % (0.1 mg/gram) $0 (Tier 1) MO

estradiol vaginal tablet 10 mcg $0 (Tier 1) MO

estradiol valerate intramuscular oil 20 mg/ml, 40

mg/ml

$0 (Tier 1)

ESTRING VAGINAL RING 2 MG (7.5 MCG /24

HOUR)

$0 (Tier 2) MO

estropipate oral tablet 0.75 mg, 1.5 mg, 3 mg $0 (Tier 1) PA; MO

MENEST ORAL TABLET 0.3 MG, 0.625 MG,

1.25 MG, 2.5 MG

$0 (Tier 2) PA; MO

PREMARIN INJECTION RECON SOLN 25 MG $0 (Tier 2) MO

PREMARIN ORAL TABLET 0.3 MG, 0.45 MG,

0.625 MG, 0.9 MG, 1.25 MG

$0 (Tier 2) MO

PREMARIN VAGINAL CREAM 0.625

MG/GRAM

$0 (Tier 2) MO

yuvafem vaginal tablet 10 mcg $0 (Tier 1) MO

HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (SEX

HORMONES/ MODIFIERS)

ALTAVERA (28) ORAL TABLET 0.15-0.03 MG $0 (Tier 1) MO

alyacen 1/35 (28) oral tablet 1-35 mg-mcg $0 (Tier 1) MO

amabelz oral tablet 0.5-0.1 mg, 1-0.5 mg $0 (Tier 1) MO


102


cost you (Tier

Level)


limits on use

apri oral tablet 0.15-0.03 mg $0 (Tier 1) MO

aranelle (28) oral tablet 0.5/1/0.5-35 mg-mcg $0 (Tier 1) MO

aubra oral tablet 0.1-20 mg-mcg $0 (Tier 1) MO

aviane oral tablet 0.1-20 mg-mcg $0 (Tier 1) MO

balziva (28) oral tablet 0.4-35 mg-mcg $0 (Tier 1) MO

bekyree (28) oral tablet 0.15-0.02 mgx21 /0.01 mg

x 5

$0 (Tier 1) MO

blisovi fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg

(21)/75 mg (7)

$0 (Tier 1) MO

blisovi fe 1/20 (28) oral tablet 1 mg-20 mcg

(21)/75 mg (7)

$0 (Tier 1) MO

briellyn oral tablet 0.4-35 mg-mcg $0 (Tier 1) MO

caziant (28) oral tablet 0.1/.125/.15-25 mg-mcg $0 (Tier 1) MO

CLIMARA PRO TRANSDERMAL PATCH

WEEKLY 0.045-0.015 MG/24 HR

$0 (Tier 2) MO

COMBIPATCH TRANSDERMAL PATCH

SEMIWEEKLY 0.05-0.14 MG/24 HR, 0.05-0.25

MG/24 HR

$0 (Tier 2) MO

cryselle (28) oral tablet 0.3-30 mg-mcg $0 (Tier 1) MO

cyclafem 1/35 (28) oral tablet 1-35 mg-mcg $0 (Tier 1) MO

cyclafem 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35

mcg

$0 (Tier 1) MO

delyla (28) oral tablet 0.1-20 mg-mcg $0 (Tier 1) MO

desog-e.estradiol/e.estradiol oral tablet 0.15-0.02

mgx21 /0.01 mg x 5

$0 (Tier 1) MO

desogestrel-ethinyl estradiol oral tablet 0.15-0.03

mg

$0 (Tier 1) MO

drospirenone-ethinyl estradiol oral tablet 3-0.03

mg

$0 (Tier 1) MO

emoquette oral tablet 0.15-0.03 mg $0 (Tier 1) MO

enpresse oral tablet 50-30 (6)/75-40 (5)/125-

30(10)

$0 (Tier 1) MO

ENSKYCE ORAL TABLET 0.15-0.03 MG $0 (Tier 1) MO

estradiol-norethindrone acet oral tablet 0.5-0.1

mg

$0 (Tier 2) MO



Formulary ID: 18395




103


cost you (Tier

Level)


limits on use

estradiol-norethindrone acet oral tablet 1-0.5 mg $0 (Tier 1) MO

ethynodiol diac-eth estradiol oral tablet 1-35 mg-

mcg, 1-50 mg-mcg

$0 (Tier 1) MO

falmina (28) oral tablet 0.1-20 mg-mcg $0 (Tier 1) MO

femynor oral tablet 0.25-35 mg-mcg $0 (Tier 1) MO

fyavolv oral tablet 1-5 mg-mcg $0 (Tier 1) MO

gildagia oral tablet 0.4-35 mg-mcg $0 (Tier 1) MO

gildess 1.5/30 (21) oral tablet 1.5-30 mg-mcg $0 (Tier 1) MO

introvale oral tablets,dose pack,3 month 0.15 mg-

30 mcg

$0 (Tier 1) MO

ISIBLOOM ORAL TABLET 0.15-0.03 MG $0 (Tier 1) MO

jinteli oral tablet 1-5 mg-mcg $0 (Tier 1) MO

juleber oral tablet 0.15-0.03 mg $0 (Tier 1) MO

junel 1.5/30 (21) oral tablet 1.5-30 mg-mcg $0 (Tier 1) MO

junel 1/20 (21) oral tablet 1-20 mg-mcg $0 (Tier 1) MO

junel fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg

(21)/75 mg (7)

$0 (Tier 1) MO

junel fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75

mg (7)

$0 (Tier 1) MO

kariva (28) oral tablet 0.15-0.02 mgx21 /0.01 mg x

5

$0 (Tier 1) MO

kelnor 1/35 (28) oral tablet 1-35 mg-mcg $0 (Tier 1) MO

KELNOR 1-50 ORAL TABLET 1-50 MG-MCG $0 (Tier 1) MO

kimidess (28) oral tablet 0.15-0.02 mgx21 /0.01

mg x 5

$0 (Tier 1) MO

KURVELO ORAL TABLET 0.15-0.03 MG $0 (Tier 1) MO

larin 1.5/30 (21) oral tablet 1.5-30 mg-mcg $0 (Tier 1) MO

larin 1/20 (21) oral tablet 1-20 mg-mcg $0 (Tier 1) MO


104


cost you (Tier

Level)


limits on use

larin fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg

(21)/75 mg (7)

$0 (Tier 1) MO

larin fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75

mg (7)

$0 (Tier 1) MO

larissia oral tablet 0.1-20 mg-mcg $0 (Tier 1) MO

leena 28 oral tablet 0.5/1/0.5-35 mg-mcg $0 (Tier 1) MO

lessina oral tablet 0.1-20 mg-mcg $0 (Tier 1) MO

levonest (28) oral tablet 50-30 (6)/75-40 (5)/125-

30(10)

$0 (Tier 1) MO

levonorgestrel-ethinyl estrad oral tablet 0.1-20

mg-mcg, 0.15-0.03 mg

$0 (Tier 1) MO

levonorgestrel-ethinyl estrad oral tablets,dose

pack,3 month 0.15 mg-30 mcg

$0 (Tier 1) MO

levonorg-eth estrad triphasic oral tablet 50-30

(6)/75-40 (5)/125-30(10)

$0 (Tier 1) MO

levora-28 oral tablet 0.15-0.03 mg $0 (Tier 1) MO

LILLOW ORAL TABLET 0.15-0.03 MG $0 (Tier 1) MO

lopreeza oral tablet 0.5-0.1 mg, 1-0.5 mg $0 (Tier 1) MO

low-ogestrel (28) oral tablet 0.3-30 mg-mcg $0 (Tier 1) MO

lutera (28) oral tablet 0.1-20 mg-mcg $0 (Tier 1) MO

marlissa oral tablet 0.15-0.03 mg $0 (Tier 1) MO

microgestin 1.5/30 (21) oral tablet 1.5-30 mg-mcg $0 (Tier 1) MO

microgestin 1/20 (21) oral tablet 1-20 mg-mcg $0 (Tier 1) MO

microgestin fe 1.5/30 (28) oral tablet 1.5 mg-30

mcg (21)/75 mg (7)

$0 (Tier 1) MO

microgestin fe 1/20 (28) oral tablet 1 mg-20 mcg

(21)/75 mg (7)

$0 (Tier 1) MO

mimvey lo oral tablet 0.5-0.1 mg $0 (Tier 1) MO

MIMVEY ORAL TABLET 1-0.5 MG $0 (Tier 2) MO

mononessa (28) oral tablet 0.25-35 mg-mcg $0 (Tier 1) MO

necon 0.5/35 (28) oral tablet 0.5-35 mg-mcg $0 (Tier 1) MO

necon 1/35 (28) oral tablet 1-35 mg-mcg $0 (Tier 1) MO

necon 10/11 (28) oral tablet 0.5-35/1-35 mg-

mcg/mg-mcg

$0 (Tier 1) MO



Formulary ID: 18395




105


cost you (Tier

Level)


limits on use

necon 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg $0 (Tier 1) MO

norethindrone ac-eth estradiol oral tablet 1-20

mg-mcg, 1-5 mg-mcg

$0 (Tier 1) MO

norgestimate-ethinyl estradiol oral tablet

0.18/0.215/0.25 mg-35 mcg (28), 0.25-35 mg-mcg

$0 (Tier 1) MO

NORLYDA ORAL TABLET 0.35 MG $0 (Tier 1) MO

nortrel 0.5/35 (28) oral tablet 0.5-35 mg-mcg $0 (Tier 1) MO

nortrel 1/35 (21) oral tablet 1-35 mg-mcg $0 (Tier 1) MO

nortrel 1/35 (28) oral tablet 1-35 mg-mcg $0 (Tier 1) MO

nortrel 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35

mcg

$0 (Tier 1) MO

ocella oral tablet 3-0.03 mg $0 (Tier 1) MO

orsythia oral tablet 0.1-20 mg-mcg $0 (Tier 1) MO

pimtrea (28) oral tablet 0.15-0.02 mgx21 /0.01 mg

x 5

$0 (Tier 1) MO

pirmella oral tablet 1-35 mg-mcg $0 (Tier 1) MO

portia oral tablet 0.15-0.03 mg $0 (Tier 1) MO

PREMPHASE ORAL TABLET 0.625 MG (14)/

0.625MG-5MG(14)

$0 (Tier 2) MO

PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-

1.5 MG, 0.625-2.5 MG, 0.625-5 MG

$0 (Tier 2) MO

previfem oral tablet 0.25-35 mg-mcg $0 (Tier 1) MO

quasense oral tablets,dose pack,3 month 0.15 mg-

30 mcg

$0 (Tier 1) MO

reclipsen (28) oral tablet 0.15-0.03 mg $0 (Tier 1) MO

setlakin oral tablets,dose pack,3 month 0.15 mg-30

mcg

$0 (Tier 1) MO

sprintec (28) oral tablet 0.25-35 mg-mcg $0 (Tier 1) MO

sronyx oral tablet 0.1-20 mg-mcg $0 (Tier 1) MO


106


cost you (Tier

Level)


limits on use

tarina fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75

mg (7)

$0 (Tier 1) MO

TRI FEMYNOR ORAL TABLET 0.18/0.215/0.25

MG-35 MCG (28)

$0 (Tier 1) MO

tri-legest fe oral tablet 1-20(5)/1-30(7) /1mg-

35mcg (9)

$0 (Tier 1) MO

TRI-MILI ORAL TABLET 0.18/0.215/0.25 MG-

35 MCG (28)

$0 (Tier 1) MO

trinessa (28) oral tablet 0.18/0.215/0.25 mg-35

mcg (28)

$0 (Tier 1) MO

tri-previfem (28) oral tablet 0.18/0.215/0.25 mg-35

mcg (28)

$0 (Tier 1) MO

tri-sprintec (28) oral tablet 0.18/0.215/0.25 mg-35

mcg (28)

$0 (Tier 1) MO

trivora (28) oral tablet 50-30 (6)/75-40 (5)/125-

30(10)

$0 (Tier 1) MO

TRI-VYLIBRA ORAL TABLET 0.18/0.215/0.25

MG-35 MCG (28)

$0 (Tier 1) MO

velivet triphasic regimen (28) oral tablet

0.1/.125/.15-25 mg-mcg

$0 (Tier 1) MO

vienva oral tablet 0.1-20 mg-mcg $0 (Tier 1) MO

vyfemla (28) oral tablet 0.4-35 mg-mcg $0 (Tier 1) MO

VYLIBRA ORAL TABLET 0.25-35 MG-MCG $0 (Tier 1) MO

xulane transdermal patch weekly 150-35 mcg/24

hr

$0 (Tier 1) MO

zarah oral tablet 3-0.03 mg $0 (Tier 1) MO

zenchent (28) oral tablet 0.4-35 mg-mcg $0 (Tier 1) MO

zovia 1/35e (28) oral tablet 1-35 mg-mcg $0 (Tier 1) MO

zovia 1/50e (28) oral tablet 1-50 mg-mcg $0 (Tier 1) MO

PROGESTINS

camila oral tablet 0.35 mg $0 (Tier 1) MO

deblitane oral tablet 0.35 mg $0 (Tier 1) MO

DEPO-SUBQ PROVERA 104

SUBCUTANEOUS SYRINGE 104 MG/0.65 ML

$0 (Tier 2) MO

errin oral tablet 0.35 mg $0 (Tier 1) MO



Formulary ID: 18395




107


cost you (Tier

Level)


limits on use

jolivette oral tablet 0.35 mg $0 (Tier 1) MO

lyza oral tablet 0.35 mg $0 (Tier 1) MO

medroxyprogesterone intramuscular suspension

150 mg/ml

$0 (Tier 1) MO

medroxyprogesterone intramuscular syringe 150

mg/ml

$0 (Tier 1) MO

medroxyprogesterone oral tablet 10 mg, 2.5 mg, 5

mg

$0 (Tier 1) MO

megestrol oral suspension 400 mg/10 ml (10 ml),

400 mg/10 ml (40 mg/ml), 625 mg/5 ml

$0 (Tier 1) PA; MO

megestrol oral tablet 20 mg, 40 mg $0 (Tier 1) PA; MO

nora-be oral tablet 0.35 mg $0 (Tier 1) MO

norethindrone (contraceptive) oral tablet 0.35 mg $0 (Tier 1) MO

norethindrone acetate oral tablet 5 mg $0 (Tier 1) MO

norlyroc oral tablet 0.35 mg $0 (Tier 1) MO

progesterone micronized oral capsule 100 mg, 200

mg

$0 (Tier 1) MO

sharobel oral tablet 0.35 mg $0 (Tier 1) MO

SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS

raloxifene oral tablet 60 mg $0 (Tier 1) MO

HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (THYROID) -

TREATMENT OF THYROID CONDITIONS

HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (THYROID)

levothyroxine intravenous recon soln 100 mcg $0 (Tier 1) MO

levothyroxine oral tablet 100 mcg, 112 mcg, 125

mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25

mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg

$0 (Tier 1) MO

levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg,

137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50

mcg, 75 mcg, 88 mcg

$0 (Tier 1) MO


108


cost you (Tier

Level)


limits on use

liothyronine intravenous solution 10 mcg/ml $0 (Tier 1) MO

liothyronine oral tablet 25 mcg, 5 mcg, 50 mcg $0 (Tier 1) MO

SYNTHROID ORAL TABLET 100 MCG, 112

MCG, 125 MCG, 137 MCG, 150 MCG, 175

MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG,

75 MCG, 88 MCG

$0 (Tier 2) MO

unithroid oral tablet 100 mcg, 112 mcg, 125 mcg,

150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50

mcg, 75 mcg, 88 mcg

$0 (Tier 1) MO

unithroid oral tablet 137 mcg $0 (Tier 1)

HORMONAL AGENTS, SUPPRESSANT (ADRENAL) - TREATMENT OF INOPERABLE

ADRENAL CANCER

HORMONAL AGENTS, SUPPRESSANT (ADRENAL)

LYSODREN ORAL TABLET 500 MG $0 (Tier 2)

HORMONAL AGENTS, SUPPRESSANT (PARATHYROID) - TREATMENT OF

PARATHYROID CONDITIONS

HORMONAL AGENTS, SUPPRESSANT (PARATHYROID)

SENSIPAR ORAL TABLET 30 MG, 60 MG $0 (Tier 2) MO; QL (60 EA per 30 days)

SENSIPAR ORAL TABLET 90 MG $0 (Tier 2) MO; QL (120 EA per 30 days)

HORMONAL AGENTS, SUPPRESSANT (PITUITARY) - TREATMENT OF OR

MODIFICATION OF PITUITARY HORMONE SECRETION

HORMONAL AGENTS, SUPPRESSANT (PITUITARY)

cabergoline oral tablet 0.5 mg $0 (Tier 1) MO

ELIGARD (3 MONTH) SUBCUTANEOUS

SYRINGE 22.5 MG

$0 (Tier 2) PA


SYRINGE 30 MG

$0 (Tier 2) PA


SYRINGE 45 MG

$0 (Tier 2) PA

ELIGARD SUBCUTANEOUS SYRINGE 7.5

MG (1 MONTH)

$0 (Tier 2) PA

FIRMAGON KIT W DILUENT SYRINGE

SUBCUTANEOUS RECON SOLN 120 MG, 80

MG

$0 (Tier 2) PA



Formulary ID: 18395




109


cost you (Tier

Level)


limits on use

FIRMAGON SUBCUTANEOUS RECON SOLN

120 MG

$0 (Tier 2) PA

leuprolide subcutaneous kit 1 mg/0.2 ml $0 (Tier 1)

leuprolide subcutaneous solution 1 mg/0.2 ml $0 (Tier 1) MO

LUPRON DEPOT (3 MONTH)

INTRAMUSCULAR SYRINGE KIT 11.25 MG,

22.5 MG

$0 (Tier 2) PA


INTRAMUSCULAR SYRINGE KIT 30 MG

$0 (Tier 2) PA


INTRAMUSCULAR SYRINGE KIT 45 MG

$0 (Tier 2) PA

LUPRON DEPOT INTRAMUSCULAR

SYRINGE KIT 3.75 MG, 7.5 MG

$0 (Tier 2) PA

LUPRON DEPOT-PED (3 MONTH)

INTRAMUSCULAR SYRINGE KIT 11.25 MG,

30 MG

$0 (Tier 2) PA

LUPRON DEPOT-PED INTRAMUSCULAR KIT

11.25 MG, 15 MG, 7.5 MG (PED)

$0 (Tier 2) PA

octreotide acetate injection solution 1,000 mcg/ml,

500 mcg/ml

$0 (Tier 1) PA

OCTREOTIDE ACETATE INJECTION

SOLUTION 100 MCG/ML, 200 MCG/ML, 50

MCG/ML

$0 (Tier 2) PA

SANDOSTATIN LAR DEPOT

INTRAMUSCULAR

SUSPENSION,EXTENDED REL RECON 10

MG, 20 MG, 30 MG

$0 (Tier 2) PA

SIGNIFOR SUBCUTANEOUS SOLUTION 0.3

MG/ML (1 ML), 0.6 MG/ML (1 ML), 0.9 MG/ML

(1 ML)

$0 (Tier 2) PA

SOMATULINE DEPOT SUBCUTANEOUS

SYRINGE 120 MG/0.5 ML, 60 MG/0.2 ML, 90

MG/0.3 ML

$0 (Tier 2) PA


110


cost you (Tier

Level)


limits on use

SOMAVERT SUBCUTANEOUS RECON SOLN

10 MG, 15 MG, 20 MG, 25 MG, 30 MG

$0 (Tier 2) PA

SYNAREL NASAL SPRAY,NON-AEROSOL 2

MG/ML

$0 (Tier 2) PA

TRELSTAR INTRAMUSCULAR SUSPENSION

FOR RECONSTITUTION 11.25 MG, 22.5 MG,

3.75 MG

$0 (Tier 2) PA

TRELSTAR INTRAMUSCULAR SYRINGE

11.25 MG/2 ML, 22.5 MG/2 ML, 3.75 MG/2 ML

$0 (Tier 2) PA

HORMONAL AGENTS, SUPPRESSANT (THYROID) - TREATMENT FOR

OVERACTIVE THYROID

ANTITHYROID AGENTS

IOSAT 130 MG TABLET INNER 130 MG $0 (Tier 3) DP

methimazole oral tablet 10 mg, 5 mg $0 (Tier 1) MO

propylthiouracil oral tablet 50 mg $0 (Tier 1) MO

THYROSAFE 65 MG TABLET 65 MG $0 (Tier 3) DP

IMMUNOLOGICAL AGENTS - MEDICATIONS THAT ALTER THE IMMUNE SYSTEM

INCLUDING VACCINATIONS

ANGIOEDEMA (HAE) AGENTS

CINRYZE INTRAVENOUS RECON SOLN 500

UNIT (5 ML)

$0 (Tier 2) PA

FIRAZYR SUBCUTANEOUS SYRINGE 30

MG/3 ML

$0 (Tier 2) PA

HAEGARDA SUBCUTANEOUS RECON SOLN

2,000 UNIT, 3,000 UNIT

$0 (Tier 2) PA

IMMUNE SUPPRESSANTS

ASTAGRAF XL ORAL CAPSULE,EXTENDED

RELEASE 24HR 0.5 MG, 1 MG, 5 MG

$0 (Tier 2) B/D

ATGAM INTRAVENOUS SOLUTION 50

MG/ML

$0 (Tier 2) B/D

AZASAN ORAL TABLET 100 MG, 75 MG $0 (Tier 2) PA; MO

azathioprine oral tablet 50 mg $0 (Tier 1) B/D; MO

azathioprine sodium injection recon soln 100 mg $0 (Tier 1) B/D; MO



Formulary ID: 18395




111


cost you (Tier

Level)


limits on use

CIMZIA POWDER FOR RECONST

SUBCUTANEOUS KIT 400 MG (200 MG X 2

VIALS)

$0 (Tier 2) PA

CIMZIA STARTER KIT SUBCUTANEOUS

SYRINGE KIT 400 MG/2 ML (200 MG/ML X 2)

$0 (Tier 2) PA

CIMZIA SUBCUTANEOUS SYRINGE KIT 400

MG/2 ML (200 MG/ML X 2)

$0 (Tier 2) PA

cyclosporine intravenous solution 250 mg/5 ml $0 (Tier 1) B/D

cyclosporine modified oral capsule 100 mg, 25

mg, 50 mg

$0 (Tier 1) B/D; MO

cyclosporine modified oral solution 100 mg/ml $0 (Tier 1) B/D; MO

cyclosporine oral capsule 100 mg, 25 mg $0 (Tier 1) B/D; MO

ENBREL MINI SUBCUTANEOUS

CARTRIDGE 50 MG/ML (0.98 ML)

$0 (Tier 2) PA

ENBREL SUBCUTANEOUS RECON SOLN 25

MG (1 ML)

$0 (Tier 2) PA

ENBREL SUBCUTANEOUS SYRINGE 25

MG/0.5ML (0.51), 50 MG/ML (0.98 ML)

$0 (Tier 2) PA

ENBREL SURECLICK SUBCUTANEOUS PEN

INJECTOR 50 MG/ML (0.98 ML)

$0 (Tier 2) PA

ENVARSUS XR ORAL TABLET EXTENDED

RELEASE 24 HR 0.75 MG, 1 MG, 4 MG

$0 (Tier 2) B/D; MO

gengraf oral capsule 100 mg, 25 mg $0 (Tier 1) B/D; MO

gengraf oral solution 100 mg/ml $0 (Tier 1) B/D; MO

HUMIRA PEDIATRIC CROHN'S START

SUBCUTANEOUS SYRINGE KIT 40 MG/0.8

ML, 40 MG/0.8 ML (6 PACK), 80 MG/0.8 ML,

80 MG/0.8 ML-40 MG/0.4 ML

$0 (Tier 2) PA

HUMIRA PEN CROHN'S-UC-HS START

SUBCUTANEOUS PEN INJECTOR KIT 40

MG/0.8 ML

$0 (Tier 2) PA


112


cost you (Tier

Level)


limits on use

HUMIRA PEN PSORIASIS-UVEITIS

SUBCUTANEOUS PEN INJECTOR KIT 40

MG/0.8 ML

$0 (Tier 2) PA

HUMIRA PEN SUBCUTANEOUS PEN

INJECTOR KIT 40 MG/0.4 ML, 40 MG/0.8 ML

$0 (Tier 2) PA

HUMIRA SUBCUTANEOUS SYRINGE KIT 10

MG/0.1 ML, 10 MG/0.2 ML, 20 MG/0.2 ML, 20

MG/0.4 ML, 40 MG/0.4 ML, 40 MG/0.8 ML

$0 (Tier 2) PA

INFLECTRA INTRAVENOUS RECON SOLN

100 MG

$0 (Tier 2) PA

KINERET SUBCUTANEOUS SYRINGE 100

MG/0.67 ML

$0 (Tier 2) PA

methotrexate sodium (pf) injection recon soln 1

gram

$0 (Tier 1)

methotrexate sodium (pf) injection solution 25

mg/ml

$0 (Tier 1)

methotrexate sodium injection solution 25 mg/ml $0 (Tier 1)

methotrexate sodium oral tablet 2.5 mg $0 (Tier 1) MO

mycophenolate mofetil hcl intravenous recon soln

500 mg

$0 (Tier 1) PA

mycophenolate mofetil oral capsule 250 mg $0 (Tier 1) B/D; MO

mycophenolate mofetil oral suspension for

reconstitution 200 mg/ml

$0 (Tier 1) B/D; MO

mycophenolate mofetil oral tablet 500 mg $0 (Tier 1) B/D; MO

mycophenolate sodium oral tablet,delayed release

(dr/ec) 180 mg, 360 mg

$0 (Tier 1) B/D; MO

NULOJIX INTRAVENOUS RECON SOLN 250

MG

$0 (Tier 2) B/D

ORENCIA (WITH MALTOSE) INTRAVENOUS

RECON SOLN 250 MG

$0 (Tier 2) PA

ORENCIA CLICKJECT SUBCUTANEOUS

AUTO-INJECTOR 125 MG/ML

$0 (Tier 2) PA

ORENCIA SUBCUTANEOUS SYRINGE 125

MG/ML, 50 MG/0.4 ML, 87.5 MG/0.7 ML

$0 (Tier 2) PA

OTEZLA ORAL TABLET 30 MG $0 (Tier 2) PA



Formulary ID: 18395




113


cost you (Tier

Level)


limits on use

OTEZLA STARTER ORAL TABLETS,DOSE

PACK 10 MG (4)-20 MG (4)-30 MG (47)

$0 (Tier 2) PA; MO

OTEZLA STARTER ORAL TABLETS,DOSE

PACK 10 MG (4)-20 MG (4)-30 MG(19)

$0 (Tier 2) PA

PROGRAF INTRAVENOUS SOLUTION 5

MG/ML

$0 (Tier 2) PA

RAPAMUNE ORAL SOLUTION 1 MG/ML $0 (Tier 2) B/D

REMICADE INTRAVENOUS RECON SOLN

100 MG

$0 (Tier 2) PA

RENFLEXIS INTRAVENOUS RECON SOLN

100 MG

$0 (Tier 2) PA

SANDIMMUNE ORAL SOLUTION 100 MG/ML $0 (Tier 2) B/D; MO

SIMPONI ARIA INTRAVENOUS SOLUTION

12.5 MG/ML

$0 (Tier 2) PA

SIMPONI SUBCUTANEOUS PEN INJECTOR

100 MG/ML, 50 MG/0.5 ML

$0 (Tier 2) PA

SIMPONI SUBCUTANEOUS SYRINGE 100

MG/ML, 50 MG/0.5 ML

$0 (Tier 2) PA

SIMULECT INTRAVENOUS RECON SOLN 10

MG, 20 MG

$0 (Tier 2) PA

sirolimus oral tablet 0.5 mg, 1 mg, 2 mg $0 (Tier 1) B/D

STELARA INTRAVENOUS SOLUTION 130

MG/26 ML

$0 (Tier 2) PA

STELARA SUBCUTANEOUS SOLUTION 45

MG/0.5 ML

$0 (Tier 2) PA; MO

STELARA SUBCUTANEOUS SYRINGE 45

MG/0.5 ML, 90 MG/ML

$0 (Tier 2) PA

tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg $0 (Tier 1) B/D

TREMFYA SUBCUTANEOUS SYRINGE 100

MG/ML

$0 (Tier 2) PA

TREXALL ORAL TABLET 10 MG, 15 MG, 5

MG, 7.5 MG

$0 (Tier 2) PA


114


cost you (Tier

Level)


limits on use

XATMEP ORAL SOLUTION 2.5 MG/ML $0 (Tier 2) PA; MO

ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG,

0.75 MG

$0 (Tier 2) B/D

IMMUNIZING AGENTS, PASSIVE

BIVIGAM INTRAVENOUS SOLUTION 10 % $0 (Tier 2) B/D

CARIMUNE NF NANOFILTERED

INTRAVENOUS RECON SOLN 12 GRAM, 6

GRAM

$0 (Tier 2) B/D

FLEBOGAMMA DIF INTRAVENOUS

SOLUTION 10 %

$0 (Tier 2) B/D

GAMASTAN S/D INTRAMUSCULAR

SOLUTION 15-18 % RANGE, 15-18 % RANGE

(10 ML), 15-18 % RANGE (2 ML)

$0 (Tier 2) B/D

GAMMAGARD LIQUID INJECTION

SOLUTION 10 %

$0 (Tier 2) B/D

GAMMAGARD S-D (IGA < 1 MCG/ML)

INTRAVENOUS RECON SOLN 10 GRAM, 5

GRAM

$0 (Tier 2) B/D

GAMMAKED INJECTION SOLUTION 1

GRAM/10 ML (10 %), 10 GRAM/100 ML (10

%), 2.5 GRAM/25 ML (10 %), 20 GRAM/200 ML

(10 %), 5 GRAM/50 ML (10 %)

$0 (Tier 2) B/D

GAMMAPLEX (WITH SORBITOL)

INTRAVENOUS SOLUTION 5 %

$0 (Tier 2) B/D

GAMMAPLEX INTRAVENOUS SOLUTION 10

%, 10 % (100 ML), 10 % (200 ML)

$0 (Tier 2) B/D

GAMUNEX-C INJECTION SOLUTION 1

GRAM/10 ML (10 %), 10 GRAM/100 ML (10

%), 2.5 GRAM/25 ML (10 %), 20 GRAM/200 ML

(10 %), 5 GRAM/50 ML (10 %)

$0 (Tier 2) B/D

GAMUNEX-C INJECTION SOLUTION 40

GRAM/400 ML (10 %)

$0 (Tier 2) B/D; MO

HYPERRAB (PF) INTRAMUSCULAR


$0 (Tier 2) MO

HYPERRAB S/D (PF) INTRAMUSCULAR

SOLUTION 150 UNIT/ML, 150 UNIT/ML (10

ML)

$0 (Tier 2)

PRIVIGEN INTRAVENOUS SOLUTION 10 % $0 (Tier 2) B/D



Formulary ID: 18395




115


cost you (Tier

Level)


limits on use

THYMOGLOBULIN INTRAVENOUS RECON

SOLN 25 MG

$0 (Tier 2) B/D

IMMUNOMODULATORS

ACTEMRA INTRAVENOUS SOLUTION 200

MG/10 ML (20 MG/ML), 400 MG/20 ML (20

MG/ML), 80 MG/4 ML (20 MG/ML)

$0 (Tier 2) PA

ACTEMRA SUBCUTANEOUS SYRINGE 162

MG/0.9 ML

$0 (Tier 2) PA; MO

ACTIMMUNE SUBCUTANEOUS SOLUTION

100 MCG/0.5 ML

$0 (Tier 2) PA

ARCALYST SUBCUTANEOUS RECON SOLN

220 MG

$0 (Tier 2) PA

BENLYSTA INTRAVENOUS RECON SOLN

120 MG, 400 MG

$0 (Tier 2) PA

BENLYSTA SUBCUTANEOUS AUTO-

INJECTOR 200 MG/ML

$0 (Tier 2) PA

BENLYSTA SUBCUTANEOUS SYRINGE 200

MG/ML

$0 (Tier 2) PA

ILARIS (PF) SUBCUTANEOUS RECON SOLN

180 MG/1.2 ML (150 MG/ML)

$0 (Tier 2) PA

ILARIS (PF) SUBCUTANEOUS SOLUTION

150 MG/ML

$0 (Tier 2) PA

leflunomide oral tablet 10 mg, 20 mg $0 (Tier 1) MO

TYSABRI INTRAVENOUS SOLUTION 300

MG/15 ML

$0 (Tier 2) PA; LA

VACCINES

ACTHIB (PF) INTRAMUSCULAR RECON

SOLN 10 MCG/0.5 ML

$0 (Tier 2) MO

ADACEL(TDAP ADOLESN/ADULT)(PF)

INTRAMUSCULAR SUSPENSION 2 LF-(2.5-5-

3-5 MCG)-5LF/0.5 ML

$0 (Tier 2) MO


116


cost you (Tier

Level)


limits on use

ADACEL(TDAP ADOLESN/ADULT)(PF)

INTRAMUSCULAR SYRINGE 2 LF-(2.5-5-3-5

MCG)-5LF/0.5 ML

$0 (Tier 2) MO

BCG VACCINE, LIVE (PF) PERCUTANEOUS

SUSPENSION FOR RECONSTITUTION 50 MG

$0 (Tier 2) MO

BEXSERO INTRAMUSCULAR SYRINGE 50-

50-50-25 MCG/0.5 ML

$0 (Tier 2) MO

BOOSTRIX TDAP INTRAMUSCULAR

SUSPENSION 2.5-8-5 LF-MCG-LF/0.5ML

$0 (Tier 2) MO

BOOSTRIX TDAP INTRAMUSCULAR

SYRINGE 2.5-8-5 LF-MCG-LF/0.5ML

$0 (Tier 2) MO

DAPTACEL (DTAP PEDIATRIC) (PF)

INTRAMUSCULAR SUSPENSION 15-10-5 LF-

MCG-LF/0.5ML

$0 (Tier 2) MO

ENGERIX-B (PF) INTRAMUSCULAR

SUSPENSION 20 MCG/ML

$0 (Tier 2) B/D; MO

ENGERIX-B (PF) INTRAMUSCULAR

SYRINGE 20 MCG/ML

$0 (Tier 2) B/D; MO

ENGERIX-B PEDIATRIC (PF)

INTRAMUSCULAR SUSPENSION 10 MCG/0.5

ML

$0 (Tier 2) B/D; MO

ENGERIX-B PEDIATRIC (PF)

INTRAMUSCULAR SYRINGE 10 MCG/0.5 ML

$0 (Tier 2) B/D; MO

GARDASIL (PF) INTRAMUSCULAR

SUSPENSION 20-40-40-20 MCG/0.5 ML

$0 (Tier 2) MO

GARDASIL (PF) INTRAMUSCULAR

SYRINGE 20-40-40-20 MCG/0.5 ML

$0 (Tier 2) MO

GARDASIL 9 (PF) INTRAMUSCULAR

SUSPENSION 0.5 ML

$0 (Tier 2) MO

GARDASIL 9 (PF) INTRAMUSCULAR

SYRINGE 0.5 ML

$0 (Tier 2) MO

HAVRIX (PF) INTRAMUSCULAR

SUSPENSION 1,440 ELISA UNIT/ML, 720

ELISA UNIT/0.5 ML

$0 (Tier 2) MO

HAVRIX (PF) INTRAMUSCULAR SYRINGE

1,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5

ML

$0 (Tier 2) MO



Formulary ID: 18395




117


cost you (Tier

Level)


limits on use

HEPLISAV-B INTRAMUSCULAR SOLUTION

20 MCG/0.5 ML

$0 (Tier 2) B/D; MO

HIBERIX (PF) INTRAMUSCULAR RECON

SOLN 10 MCG/0.5 ML

$0 (Tier 2) MO

IMOVAX RABIES VACCINE (PF)

INTRAMUSCULAR RECON SOLN 2.5 UNIT

$0 (Tier 2) MO

INFANRIX (DTAP) (PF) INTRAMUSCULAR

SUSPENSION 25-58-10 LF-MCG-LF/0.5ML

$0 (Tier 2) MO

INFANRIX (DTAP) (PF) INTRAMUSCULAR

SYRINGE 25-58-10 LF-MCG-LF/0.5ML

$0 (Tier 2) MO

IPOL INJECTION SUSPENSION 40-8-32

UNIT/0.5 ML

$0 (Tier 2) MO

IXIARO (PF) INTRAMUSCULAR SYRINGE 6

MCG/0.5 ML

$0 (Tier 2) MO

KINRIX (PF) INTRAMUSCULAR

SUSPENSION 25 LF-58 MCG-10 LF/0.5 ML

$0 (Tier 2) MO

KINRIX (PF) INTRAMUSCULAR SYRINGE 25

LF-58 MCG-10 LF/0.5 ML

$0 (Tier 2) MO

MENACTRA (PF) INTRAMUSCULAR

SOLUTION 4 MCG/0.5 ML

$0 (Tier 2) MO

MENOMUNE - A/C/Y/W-135 (PF)

SUBCUTANEOUS RECON SOLN 50 MCG

$0 (Tier 2) MO

MENOMUNE - A/C/Y/W-135

SUBCUTANEOUS RECON SOLN 50 MCG

$0 (Tier 2) MO

MENVEO A-C-Y-W-135-DIP (PF)

INTRAMUSCULAR KIT 10-5 MCG/0.5 ML

$0 (Tier 2) MO

M-M-R II (PF) SUBCUTANEOUS RECON

SOLN 1,000-12,500 TCID50/0.5 ML

$0 (Tier 2) MO

PEDIARIX (PF) INTRAMUSCULAR SYRINGE

10 MCG-25LF-25 MCG-10LF/0.5 ML

$0 (Tier 2) MO

PEDVAX HIB (PF) INTRAMUSCULAR

SOLUTION 7.5 MCG/0.5 ML

$0 (Tier 2) MO


118


cost you (Tier

Level)


limits on use

PENTACEL ACTHIB COMPONENT (PF)

INTRAMUSCULAR RECON SOLN 10 MCG/0.5

ML

$0 (Tier 2) MO

PROQUAD (PF) SUBCUTANEOUS

SUSPENSION FOR RECONSTITUTION

10EXP3-4.3-3- 3.99 TCID50/0.5

$0 (Tier 2) MO

QUADRACEL (PF) INTRAMUSCULAR

SUSPENSION 15 LF-48 MCG- 5 LF

UNIT/0.5ML

$0 (Tier 2) MO

RABAVERT (PF) INTRAMUSCULAR

SUSPENSION FOR RECONSTITUTION 2.5

UNIT

$0 (Tier 2) MO

RECOMBIVAX HB (PF) INTRAMUSCULAR

SUSPENSION 10 MCG/ML, 40 MCG/ML, 5

MCG/0.5 ML

$0 (Tier 2) B/D; MO

RECOMBIVAX HB (PF) INTRAMUSCULAR

SYRINGE 10 MCG/ML, 5 MCG/0.5 ML

$0 (Tier 2) B/D; MO

ROTARIX ORAL SUSPENSION FOR

RECONSTITUTION 10EXP6 CCID50/ML

$0 (Tier 2) MO

ROTATEQ VACCINE ORAL SOLUTION 2 ML $0 (Tier 2) MO

SHINGRIX (PF) INTRAMUSCULAR


MCG/0.5 ML

$0 (Tier 2) MO

SHINGRIX GE ANTIGEN COMPONENT

INTRAMUSCULAR SUSPENSION FOR

RECONSTITUTION 50 MCG

$0 (Tier 2) MO

TENIVAC (PF) INTRAMUSCULAR

SUSPENSION 5 LF UNIT- 2 LF UNIT/0.5ML

$0 (Tier 2) MO

TENIVAC (PF) INTRAMUSCULAR SYRINGE

5-2 LF UNIT/0.5 ML

$0 (Tier 2) MO

tetanus,diphtheria tox ped(pf) intramuscular

suspension 5-25 lf unit/0.5 ml

$0 (Tier 1) MO

tetanus-diphtheria toxoids-td intramuscular

suspension 2-2 lf unit/0.5 ml

$0 (Tier 1) MO

TICE BCG INTRAVESICAL SUSPENSION


$0 (Tier 2)

TRUMENBA INTRAMUSCULAR SYRINGE

120 MCG/0.5 ML

$0 (Tier 2) MO



Formulary ID: 18395




119


cost you (Tier

Level)


limits on use

TWINRIX (PF) INTRAMUSCULAR SYRINGE

720 ELISA UNIT- 20 MCG/ML

$0 (Tier 2) MO

TYPHIM VI INTRAMUSCULAR SOLUTION 25

MCG/0.5 ML

$0 (Tier 2) MO

TYPHIM VI INTRAMUSCULAR SYRINGE 25

MCG/0.5 ML

$0 (Tier 2) MO

VAQTA (PF) INTRAMUSCULAR

SUSPENSION 25 UNIT/0.5 ML, 50 UNIT/ML

$0 (Tier 2) MO

VAQTA (PF) INTRAMUSCULAR SYRINGE 25

UNIT/0.5 ML, 50 UNIT/ML

$0 (Tier 2) MO

VARIVAX (PF) SUBCUTANEOUS

SUSPENSION FOR RECONSTITUTION 1,350

UNIT/0.5 ML

$0 (Tier 2) MO

VARIZIG INTRAMUSCULAR RECON SOLN

125 UNIT

$0 (Tier 2)

VARIZIG INTRAMUSCULAR SOLUTION 125

UNIT/1.2 ML

$0 (Tier 2) MO

VAXCHORA BUFFER COMPONENT ORAL

SUSPENSION FOR RECONSTITUTION

$0 (Tier 2) MO

VAXCHORA VACCINE ORAL SUSPENSION

FOR RECONSTITUTION 4X10EXP8 TO 2X

10EXP9 CF UNIT

$0 (Tier 2) MO

YF-VAX (PF) SUBCUTANEOUS SUSPENSION

FOR RECONSTITUTION 10 EXP4.74 UNIT/0.5

ML

$0 (Tier 2) MO

ZOSTAVAX (PF) SUBCUTANEOUS

SUSPENSION FOR RECONSTITUTION 19,400

UNIT/0.65 ML

$0 (Tier 2) MO

INFLAMMATORY BOWEL DISEASE AGENTS - TREATMENT OF ULCERATIVE

COLITIS OR CROHN?S DISEASE

AMINOSALICYLATES

balsalazide oral capsule 750 mg $0 (Tier 1) MO


120


cost you (Tier

Level)


limits on use

CANASA RECTAL SUPPOSITORY 1,000 MG $0 (Tier 2) MO

DELZICOL ORAL CAPSULE (WITH DEL REL

TABLETS) 400 MG

$0 (Tier 2) MO

DELZICOL ORAL CAPSULE,DELAYED

RELEASE(DR/EC) 400 MG

$0 (Tier 2) MO

DIPENTUM ORAL CAPSULE 250 MG $0 (Tier 2) MO

LIALDA ORAL TABLET,DELAYED RELEASE

(DR/EC) 1.2 GRAM

$0 (Tier 2) MO

mesalamine oral tablet,delayed release (dr/ec) 1.2

gram

$0 (Tier 1) MO

mesalamine rectal enema 4 gram/60 ml $0 (Tier 1) MO

mesalamine with cleansing wipe rectal enema kit 4

gram/60 ml

$0 (Tier 1) MO

PENTASA ORAL CAPSULE, EXTENDED


$0 (Tier 2) MO

GLUCOCORTICOIDS

BUDESONIDE ORAL

CAPSULE,DELAYED,EXTEND.RELEASE 3

MG

$0 (Tier 1) MO

colocort rectal enema 100 mg/60 ml $0 (Tier 1) MO

hydrocortisone rectal enema 100 mg/60 ml $0 (Tier 1) MO

hydrocortisone topical cream with perineal

applicator 2.5 %

$0 (Tier 1) MO

prednisone intensol oral concentrate 5 mg/ml $0 (Tier 1) MO

procto-med hc topical cream with perineal

applicator 2.5 %

$0 (Tier 1) MO

procto-pak topical cream with perineal applicator

1 %

$0 (Tier 1) MO

proctosol hc topical cream with perineal

applicator 2.5 %

$0 (Tier 1) MO

proctozone-hc topical cream with perineal

applicator 2.5 %

$0 (Tier 1) MO

SULFONAMIDES

sulfasalazine oral tablet 500 mg $0 (Tier 1) MO



Formulary ID: 18395




121


cost you (Tier

Level)


limits on use

sulfasalazine oral tablet,delayed release (dr/ec)

500 mg

$0 (Tier 1) MO

METABOLIC BONE DISEASE AGENTS - TREATMENT OF BONE DISEASES

INCLUDING OSTEOPOROSIS

METABOLIC BONE DISEASE AGENTS

alendronate oral tablet 10 mg, 35 mg, 40 mg, 5

mg, 70 mg

$0 (Tier 1) MO

calcitonin (salmon) nasal spray,non-aerosol 200

unit/actuation

$0 (Tier 1) MO

calcitriol oral capsule 0.25 mcg, 0.5 mcg $0 (Tier 1) MO

calcitriol oral solution 1 mcg/ml $0 (Tier 1) MO

doxercalciferol intravenous solution 4 mcg/2 ml $0 (Tier 1) MO

doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5

mcg

$0 (Tier 1) MO

etidronate disodium oral tablet 200 mg, 400 mg $0 (Tier 1) MO

FORTEO SUBCUTANEOUS PEN INJECTOR

20 MCG/DOSE - 600 MCG/2.4 ML

$0 (Tier 2) PA

ibandronate intravenous solution 3 mg/3 ml $0 (Tier 1) B/D

ibandronate intravenous syringe 3 mg/3 ml $0 (Tier 1) B/D

ibandronate oral tablet 150 mg $0 (Tier 1) MO

MIACALCIN INJECTION SOLUTION 200

UNIT/ML

$0 (Tier 2) B/D

NATPARA SUBCUTANEOUS CARTRIDGE

100 MCG/DOSE, 25 MCG/DOSE, 50

MCG/DOSE, 75 MCG/DOSE

$0 (Tier 2) PA; MO

pamidronate intravenous recon soln 30 mg, 90 mg $0 (Tier 1)

pamidronate intravenous solution 30 mg/10 ml (3

mg/ml), 60 mg/10 ml (6 mg/ml), 90 mg/10 ml (9

mg/ml)

$0 (Tier 1)

paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg $0 (Tier 1) MO


122


cost you (Tier

Level)


limits on use

PROLIA SUBCUTANEOUS SYRINGE 60

MG/ML

$0 (Tier 2) PA

risedronate oral tablet 150 mg, 30 mg, 35 mg, 35

mg (12 pack), 35 mg (4 pack), 5 mg

$0 (Tier 1) MO

TYMLOS SUBCUTANEOUS PEN INJECTOR

80 MCG (3,120 MCG/1.56 ML)

$0 (Tier 2) PA

XGEVA SUBCUTANEOUS SOLUTION 120

MG/1.7 ML (70 MG/ML)

$0 (Tier 2) PA

zoledronic acid intravenous recon soln 4 mg $0 (Tier 1) PA

zoledronic acid intravenous solution 4 mg/5 ml $0 (Tier 1) PA

zoledronic acid-mannitol-water intravenous


$0 (Tier 1) PA

ZOMETA INTRAVENOUS PIGGYBACK 4

MG/100 ML

$0 (Tier 2) PA

MISCELLANEOUS

MISCELLANEOUS

ISOLYTE S PH 7.4 INTRAVENOUS

PARENTERAL SOLUTION

$0 (Tier 2)

ISOLYTE-S INTRAVENOUS PARENTERAL

SOLUTION

$0 (Tier 2)

water for irrigation, sterile irrigation solution $0 (Tier 1) MO

OPHTHALMIC AGENTS - TREATMENT OF EYE CONDITIONS

OPHTHALMIC AGENTS, OTHER

ARTIFICIAL TEARS 1.4 % DROPS 1.4 % $0 (Tier 3) DP

ARTIFICIAL TEARS DROPS 0.5-0.6 % $0 (Tier 3) DP

atropine ophthalmic (eye) drops 1 % $0 (Tier 1) MO

CYSTARAN OPHTHALMIC (EYE) DROPS

0.44 %

$0 (Tier 2)

FRESHKOTE EYE DROPS 2-0.9-1.8 % $0 (Tier 3) DP

GENTEAL GEL DROPS 0.25-0.3 % $0 (Tier 3) DP

GENTEAL MILD-MODERATE EYE DROP P/F,

DRY EYE RELIEF 0.3 %

$0 (Tier 3) DP

GENTEAL PM OINTMENT 94-3 % $0 (Tier 3) DP



Formulary ID: 18395




123


cost you (Tier

Level)


limits on use

GENTEAL SEVERE 0.3% EYE GEL P/F, STRL,

INNER 0.3 %

$0 (Tier 3) DP

MURO-128 2% EYE DROPS 2 % $0 (Tier 3) DP

MURO-128 5% EYE DROPS 5 % $0 (Tier 3) DP

MURO-128 5% EYE OINTMENT 5 % $0 (Tier 3) DP

naphazoline ophthalmic (eye) drops 0.1 % $0 (Tier 1) MO

NATACYN OPHTHALMIC (EYE)

DROPS,SUSPENSION 5 %

$0 (Tier 2) MO

proparacaine ophthalmic (eye) drops 0.5 % $0 (Tier 1) MO

REFRESH CLASSIC EYE DROPS U-

D,P/F,30X.4ML 1.4-0.6 %

$0 (Tier 3) DP

REFRESH LACRI-LUBE OINTMENT 56.8-42.5

%

$0 (Tier 3) DP

REFRESH LIQUIGEL 1% EYE DROP 1 % $0 (Tier 3) DP

REFRESH LIQUIGEL 1% EYE DROPS 1 % $0 (Tier 3) DP

REFRESH OPTIVE EYE DROPS 0.5-0.9 % $0 (Tier 3) DP

REFRESH OPTIVE SENSITIVE DROPS

30X0.4ML, P/F 0.5-0.9 %

$0 (Tier 3) DP

REFRESH P.M. OINTMENT 57.3-42.5 % $0 (Tier 3) DP

REFRESH PLUS 0.5% EYE DROPS 30X0.4ML

0.5 %

$0 (Tier 3) DP

REFRESH PLUS 0.5% EYE DROPS U-

D,50X.4ML 0.5 %

$0 (Tier 3) DP

REFRESH TEARS 0.5% EYE DROP 0.5 % $0 (Tier 3) DP

RESTASIS MULTIDOSE OPHTHALMIC (EYE)

DROPS 0.05 %


RESTASIS OPHTHALMIC (EYE)

DROPPERETTE 0.05 %


sodium chloride 5% eye drop 5 % $0 (Tier 3) DP

sodium chloride 5% eye oint 5 % $0 (Tier 3) DP


124


cost you (Tier

Level)


limits on use

SYSTANE 0.3-0.4% EYE DROPS 0.4-0.3 % $0 (Tier 3) DP

SYSTANE 0.3-0.4% EYE DROPS U-

D,P/F,0.014X28 VL 0.4-0.3 %

$0 (Tier 3) DP

SYSTANE BALANCE 0.6% EYE DROP 0.6 % $0 (Tier 3) DP

SYSTANE ULTRA 0.4-0.3% EYE DRP 0.4-0.3

%

$0 (Tier 3) DP

TEARS NATURALE FORTE DROPS 0.1-0.3-0.2

%

$0 (Tier 3) DP

TEARS PURE DROPS $0 (Tier 3) DP

XIIDRA OPHTHALMIC (EYE) DROPPERETTE

5 %


OPHTHALMIC ANTI-ALLERGY AGENTS

azelastine ophthalmic (eye) drops 0.05 % $0 (Tier 1) MO

cromolyn ophthalmic (eye) drops 4 % $0 (Tier 1) MO

epinastine ophthalmic (eye) drops 0.05 % $0 (Tier 1) ST; MO

EYESCRUB CLEANSING PADS $0 (Tier 3) DP

NAPHCON-A EYE DROPS DROPTAINER

0.025-0.3 %

$0 (Tier 3) DP

NAPHCON-A EYE DROPS DROPTAINER,

2X5ML 0.025-0.3 %

$0 (Tier 3) DP

olopatadine ophthalmic (eye) drops 0.1 % $0 (Tier 1) ST; MO

OPHTHALMIC ANTIGLAUCOMA AGENTS

ALPHAGAN P OPHTHALMIC (EYE) DROPS

0.1 %

$0 (Tier 2) MO

AZOPT OPHTHALMIC (EYE)

DROPS,SUSPENSION 1 %

$0 (Tier 2) ST; MO

brimonidine ophthalmic (eye) drops 0.15 %, 0.2 % $0 (Tier 1) MO

carteolol ophthalmic (eye) drops 1 % $0 (Tier 1) MO

COMBIGAN OPHTHALMIC (EYE) DROPS 0.2-

0.5 %

$0 (Tier 2) MO

dorzolamide ophthalmic (eye) drops 2 % $0 (Tier 1) MO

dorzolamide-timolol ophthalmic (eye) drops 22.3-

6.8 mg/ml

$0 (Tier 1) MO

levobunolol ophthalmic (eye) drops 0.5 % $0 (Tier 1) MO



Formulary ID: 18395




125


cost you (Tier

Level)


limits on use

metipranolol ophthalmic (eye) drops 0.3 % $0 (Tier 1) MO

PHOSPHOLINE IODIDE OPHTHALMIC (EYE)

DROPS 0.125 %

$0 (Tier 2) MO

pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %,

4 %

$0 (Tier 1) MO

SIMBRINZA OPHTHALMIC (EYE)

DROPS,SUSPENSION 1-0.2 %

$0 (Tier 2) MO

timolol maleate ophthalmic (eye) drops 0.25 %,

0.5 %

$0 (Tier 1) MO

timolol maleate ophthalmic (eye) gel forming

solution 0.25 %, 0.5 %

$0 (Tier 1) MO

OPHTHALMIC ANTI-INFLAMMATORIES

dexamethasone sodium phosphate ophthalmic

(eye) drops 0.1 %

$0 (Tier 1) MO

diclofenac sodium ophthalmic (eye) drops 0.1 % $0 (Tier 1) MO

DUREZOL OPHTHALMIC (EYE) DROPS 0.05

%

$0 (Tier 2) MO

fluorometholone ophthalmic (eye)

drops,suspension 0.1 %

$0 (Tier 1) MO

flurbiprofen sodium ophthalmic (eye) drops 0.03

%

$0 (Tier 1) MO

FML FORTE OPHTHALMIC (EYE)

DROPS,SUSPENSION 0.25 %

$0 (Tier 2) MO

ketorolac ophthalmic (eye) drops 0.4 %, 0.5 % $0 (Tier 1) MO

prednisolone acetate ophthalmic (eye)

drops,suspension 1 %

$0 (Tier 1) MO

prednisolone sodium phosphate ophthalmic (eye)

drops 1 %

$0 (Tier 1) MO

sulfacetamide-prednisolone ophthalmic (eye)

drops 10 %-0.23 % (0.25 %)

$0 (Tier 1) MO

OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS


126


cost you (Tier

Level)


limits on use

latanoprost ophthalmic (eye) drops 0.005 % $0 (Tier 1) MO

LUMIGAN OPHTHALMIC (EYE) DROPS 0.01

%

$0 (Tier 2) MO

TRAVATAN Z OPHTHALMIC (EYE) DROPS

0.004 %

$0 (Tier 2) MO

OTIC AGENTS - TREATMENT OF EAR CONDITIONS

OTIC AGENTS

acetic acid-aluminum acetate otic (ear) drops 2 % $0 (Tier 1) MO

CIPRODEX OTIC (EAR) DROPS,SUSPENSION

0.3-0.1 %

$0 (Tier 2) MO

EAR DROPS 6.5% 6.5 % $0 (Tier 3) DP

EAR WAX REMOVAL 6.5% DROP 6.5 % $0 (Tier 3) DP

hydrocortisone-acetic acid otic (ear) drops 1-2 % $0 (Tier 1) MO

neomycin-polymyxin-hc otic (ear)

drops,suspension 3.5-10,000-1 mg/ml-unit/ml-%

$0 (Tier 1) MO

neomycin-polymyxin-hc otic (ear) solution 3.5-

10,000-1 mg/ml-unit/ml-%

$0 (Tier 1) MO

ofloxacin otic (ear) drops 0.3 % $0 (Tier 1) MO

QC EAR WAX REMOVAL 6.5% DROP 6.5 % $0 (Tier 3) DP

RESPIRATORY TRACT AGENTS - TREATMENT OF BREATHING CONDITIONS

RESPIRATORY TRACT AGENTS, OTHER

acetylcysteine solution 100 mg/ml (10 %), 200

mg/ml (20 %)

$0 (Tier 1) B/D

ALA-HIST PE TABLET 2-10 MG $0 (Tier 3) DP

ARALAST NP INTRAVENOUS RECON SOLN

1,000 MG, 500 MG

$0 (Tier 2) PA

AYR SALINE 0.65% NOSE DROPS 0.65 % $0 (Tier 3) DP

AYR SALINE NASAL GEL $0 (Tier 3) DP

DEEP SEA 0.65% NOSE SPRAY 0.65 % $0 (Tier 3) DP

GLASSIA INTRAVENOUS SOLUTION 1

GRAM/50 ML (2 %)

$0 (Tier 2) PA

GS CHILD COLD-ALLERGY SOLUTION 1-2.5

MG/5 ML

$0 (Tier 3) DP



Formulary ID: 18395




127


cost you (Tier

Level)


limits on use

GS NASAL SPRAY 0.05% 0.05 % $0 (Tier 3) DP

LUMIZYME INTRAVENOUS RECON SOLN 50

MG

$0 (Tier 2) PA

NASAL DECONGESTANT 0.05% SPRAY

12HR, MAXIMUM STR. 0.05 %

$0 (Tier 3) DP

ODACTRA SUBLINGUAL TABLET 12 SQ-

HDM

$0 (Tier 2) PA; MO

PROLASTIN-C INTRAVENOUS RECON SOLN

1,000 MG

$0 (Tier 2) PA

PROLASTIN-C INTRAVENOUS SOLUTION

1,000 MG (+/-)/20 ML

$0 (Tier 2) PA; MO

promethazine vc oral syrup 6.25-5 mg/5 ml $0 (Tier 1) PA; MO

promethazine-phenylephrine oral syrup 6.25-5

mg/5 ml

$0 (Tier 1) PA; MO

SALINE MIST 0.65% NOSE SPRY 0.65 % $0 (Tier 3) DP

ZEMAIRA INTRAVENOUS RECON SOLN

1,000 MG

$0 (Tier 2) PA

RESPIRATORY TRACT/ PULMONARY AGENTS - TREATMENT OF BREATHING

CONDITIONS

ANTIHISTAMINES

azelastine nasal aerosol,spray 137 mcg (0.1 %) $0 (Tier 1) MO

azelastine nasal spray,non-aerosol 0.15 % (205.5

mcg)

$0 (Tier 1) MO

BANOPHEN 12.5 MG/5 ML SOLUTION 12.5

MG/5 ML

$0 (Tier 3) DP

BANOPHEN 25 MG TABLET 25 MG $0 (Tier 3) DP

BANOPHEN ANTI-ITCH 2% CREAM 2-0.1 % $0 (Tier 3) DP

cetirizine hcl 10 mg tablet 10 mg $0 (Tier 3) DP

cetirizine hcl 5 mg tablet indoor/outdoor, 24hr 5

mg

$0 (Tier 3) DP


128


cost you (Tier

Level)


limits on use

CHILD ALL DAY ALLERGY 1 MG/ML

CHILDREN'S 1 MG/ML

$0 (Tier 3) DP

clemastine oral tablet 2.68 mg $0 (Tier 1) PA; MO

cyproheptadine oral syrup 2 mg/5 ml $0 (Tier 1) PA; MO

cyproheptadine oral tablet 4 mg $0 (Tier 1) PA; MO

DIPHEDRYL ALLERGY CAPSULE 25 MG $0 (Tier 3) DP

DIPHENHIST 12.5 MG/5 ML SOLN 12.5 MG/5

ML

$0 (Tier 3) DP

diphenhydramine 25 mg capsule (otc) 25 mg $0 (Tier 3) DP

diphenhydramine 25 mg capsule u-d, 10x10 (otc)

25 mg

$0 (Tier 3) DP

fexofenadine hcl 180 mg tablet 24 hour, non-

drowsy (otc) 180 mg

$0 (Tier 3) DP

fexofenadine hcl 60 mg tablet 12 hour, non-drowsy

(otc) 60 mg

$0 (Tier 3) DP

GS ALLERGY RELIEF 25 MG TABLET 25 MG $0 (Tier 3) DP

levocetirizine oral solution 2.5 mg/5 ml $0 (Tier 1) MO

levocetirizine oral tablet 5 mg $0 (Tier 1) MO

loratadine 10 mg tablet non-drowsy 10 mg $0 (Tier 3) DP

loratadine 5 mg/5 ml soln child's,a/f,s/f,d/f 5 mg/5

ml

$0 (Tier 3) DP

qc chlorpheniramine 4 mg tab 4 mg $0 (Tier 3) DP

QC COMPLETE ALLERGY 25 MG CPLT

CAPLET 25 MG

$0 (Tier 3) DP

Q-DRYL 25 MG CAPSULE 25 MG $0 (Tier 3) DP

SM ALLERGY RELIEF 25 MG TABLET 25 MG $0 (Tier 3) DP

ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS

ARNUITY ELLIPTA INHALATION BLISTER

WITH DEVICE 100 MCG/ACTUATION, 200

MCG/ACTUATION

$0 (Tier 2) MO

budesonide inhalation suspension for nebulization

0.25 mg/2 ml, 0.5 mg/2 ml, 1 mg/2 ml

$0 (Tier 1) B/D; MO

FLOVENT DISKUS INHALATION BLISTER

WITH DEVICE 100 MCG/ACTUATION, 250

MCG/ACTUATION, 50 MCG/ACTUATION

$0 (Tier 2) MO



Formulary ID: 18395




129


cost you (Tier

Level)


limits on use

FLOVENT HFA INHALATION HFA AEROSOL

INHALER 110 MCG/ACTUATION, 220


$0 (Tier 2) MO

flunisolide nasal spray,non-aerosol 25 mcg (0.025

%)

$0 (Tier 1) MO

fluticasone nasal spray,suspension 50

mcg/actuation

$0 (Tier 1) MO

fluticasone-salmeterol inhalation aerosol powdr

breath activated 113-14 mcg/actuation, 232-14

mcg/actuation, 55-14 mcg/actuation

$0 (Tier 1) MO

mometasone nasal spray,non-aerosol 50

mcg/actuation

$0 (Tier 1) MO

QVAR INHALATION AEROSOL 40


$0 (Tier 2) MO

QVAR REDIHALER INHALATION HFA

AEROSOL BREATH ACTIVATED 40


$0 (Tier 2) MO

ANTILEUKOTRIENES

montelukast oral granules in packet 4 mg $0 (Tier 1) MO

montelukast oral tablet 10 mg $0 (Tier 1) MO

montelukast oral tablet,chewable 4 mg, 5 mg $0 (Tier 1) MO

zafirlukast oral tablet 10 mg, 20 mg $0 (Tier 1) ST; MO

zileuton oral tablet, er multiphase 12 hr 600 mg $0 (Tier 1) PA; MO

ZYFLO ORAL TABLET 600 MG $0 (Tier 2) PA; MO

BRONCHODILATORS, ANTICHOLINERGIC

INCRUSE ELLIPTA INHALATION BLISTER

WITH DEVICE 62.5 MCG/ACTUATION

$0 (Tier 2) MO

ipratropium bromide inhalation solution 0.02 % $0 (Tier 1) B/D; MO

ipratropium bromide nasal spray,non-aerosol 0.03

%, 42 mcg (0.06 %)

$0 (Tier 1) MO


130


cost you (Tier

Level)


limits on use

SPIRIVA RESPIMAT INHALATION MIST 1.25

MCG/ACTUATION, 2.5 MCG/ACTUATION

$0 (Tier 2) MO

SPIRIVA WITH HANDIHALER INHALATION

CAPSULE, W/INHALATION DEVICE 18 MCG

$0 (Tier 2) MO

TUDORZA PRESSAIR INHALATION

AEROSOL POWDR BREATH ACTIVATED 400


(30 ACTUAT)

$0 (Tier 2) MO

BRONCHODILATORS, SYMPATHOMIMETICS

albuterol sulfate inhalation solution for

nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3

ml (0.083 %), 2.5 mg/0.5 ml, 5 mg/ml

$0 (Tier 1) B/D; MO

albuterol sulfate oral syrup 2 mg/5 ml $0 (Tier 1) MO

albuterol sulfate oral tablet 2 mg, 4 mg $0 (Tier 1) MO

albuterol sulfate oral tablet extended release 12 hr

4 mg, 8 mg

$0 (Tier 1) MO

BROVANA INHALATION SOLUTION FOR

NEBULIZATION 15 MCG/2 ML

$0 (Tier 2) PA; MO

epinephrine injection auto-injector 0.15 mg/0.15

ml, 0.15 mg/0.3 ml, 0.3 mg/0.3 ml


EPIPEN 2-PAK INJECTION AUTO-INJECTOR

0.3 MG/0.3 ML


EPIPEN INJECTION AUTO-INJECTOR 0.3

MG/0.3 ML


EPIPEN JR 2-PAK INJECTION AUTO-

INJECTOR 0.15 MG/0.3 ML


EPIPEN JR INJECTION AUTO-INJECTOR 0.15

MG/0.3 ML


levalbuterol hcl inhalation solution for

nebulization 0.31 mg/3 ml, 0.63 mg/3 ml

$0 (Tier 1) PA; MO

metaproterenol oral syrup 10 mg/5 ml $0 (Tier 1) MO

metaproterenol oral tablet 10 mg, 20 mg $0 (Tier 1) MO

SEREVENT DISKUS INHALATION BLISTER

WITH DEVICE 50 MCG/DOSE

$0 (Tier 2) MO

STRIVERDI RESPIMAT INHALATION MIST

2.5 MCG/ACTUATION

$0 (Tier 2) MO



Formulary ID: 18395




131


cost you (Tier

Level)


limits on use

terbutaline oral tablet 2.5 mg, 5 mg $0 (Tier 1) MO

terbutaline subcutaneous solution 1 mg/ml $0 (Tier 1) MO

VENTOLIN HFA INHALATION HFA

AEROSOL INHALER 90 MCG/ACTUATION

$0 (Tier 2) MO

CYSTIC FIBROSIS AGENTS

KALYDECO ORAL GRANULES IN PACKET

50 MG, 75 MG

$0 (Tier 2) PA

KALYDECO ORAL TABLET 150 MG $0 (Tier 2) PA

ORKAMBI ORAL TABLET 100-125 MG, 200-

125 MG

$0 (Tier 2) PA

PULMOZYME INHALATION SOLUTION 1

MG/ML

$0 (Tier 2) B/D

SYMDEKO ORAL TABLETS, SEQUENTIAL

100-150 MG (D)/ 150 MG (N)

$0 (Tier 2) PA

MAST CELL STABILIZERS

cromolyn inhalation solution for nebulization 20

mg/2 ml

$0 (Tier 1) B/D; MO

PHOSPHODIESTERASE INHIBITORS, AIRWAYS DISEASE

aminophylline intravenous solution 250 mg/10 ml,

500 mg/20 ml

$0 (Tier 1) MO

DALIRESP ORAL TABLET 250 MCG, 500

MCG

$0 (Tier 2) MO

ELIXOPHYLLIN ORAL ELIXIR 80 MG/15 ML $0 (Tier 2)

theophylline oral elixir 80 mg/15 ml $0 (Tier 1) MO

theophylline oral solution 80 mg/15 ml $0 (Tier 1) MO

theophylline oral tablet extended release 12 hr 100

mg, 200 mg, 300 mg, 450 mg

$0 (Tier 1) MO

theophylline oral tablet extended release 24 hr 400

mg, 600 mg

$0 (Tier 1) MO

theophylline oral tablet extended release 600 mg $0 (Tier 1) MO


132


cost you (Tier

Level)


limits on use

PULMONARY ANTIHYPERTENSIVES

ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5

MG, 2 MG, 2.5 MG

$0 (Tier 2) PA

LETAIRIS ORAL TABLET 10 MG, 5 MG $0 (Tier 2) PA

REMODULIN INJECTION SOLUTION 1

MG/ML, 10 MG/ML, 2.5 MG/ML, 5 MG/ML

$0 (Tier 2) PA

REVATIO ORAL SUSPENSION FOR

RECONSTITUTION 10 MG/ML

$0 (Tier 2) PA

sildenafil (antihypertensive) intravenous solution

10 mg/12.5 ml

$0 (Tier 1) PA

sildenafil (antihypertensive) oral tablet 20 mg $0 (Tier 1) PA

TRACLEER ORAL TABLET 125 MG, 62.5 MG $0 (Tier 2) PA; LA

TRACLEER ORAL TABLET FOR

SUSPENSION 32 MG

$0 (Tier 2) PA

VENTAVIS INHALATION SOLUTION FOR

NEBULIZATION 10 MCG/ML, 20 MCG/ML

$0 (Tier 2) PA

RESPIRATORY TRACT AGENTS, OTHER

ADVAIR DISKUS INHALATION BLISTER

WITH DEVICE 100-50 MCG/DOSE, 250-50

MCG/DOSE, 500-50 MCG/DOSE

$0 (Tier 2) MO

ADVAIR HFA INHALATION HFA AEROSOL

INHALER 115-21 MCG/ACTUATION, 230-21

MCG/ACTUATION, 45-21 MCG/ACTUATION

$0 (Tier 2) MO

ANORO ELLIPTA INHALATION BLISTER

WITH DEVICE 62.5-25 MCG/ACTUATION

$0 (Tier 2) MO

BREO ELLIPTA INHALATION BLISTER

WITH DEVICE 100-25 MCG/DOSE, 200-25

MCG/DOSE

$0 (Tier 2) MO

DULERA INHALATION HFA AEROSOL

INHALER 100-5 MCG/ACTUATION, 200-5

MCG/ACTUATION

$0 (Tier 2) MO

SYMBICORT INHALATION HFA AEROSOL

INHALER 160-4.5 MCG/ACTUATION, 80-4.5

MCG/ACTUATION

$0 (Tier 2) MO

RESPIRATORY TRACT/ PULMONARY AGENTS



Formulary ID: 18395




133


cost you (Tier

Level)


limits on use

COMBIVENT RESPIMAT INHALATION MIST

20-100 MCG/ACTUATION

$0 (Tier 2) ST; MO

ESBRIET ORAL CAPSULE 267 MG $0 (Tier 2) PA

ESBRIET ORAL TABLET 267 MG, 801 MG $0 (Tier 2) PA

ipratropium-albuterol inhalation solution for

nebulization 0.5 mg-3 mg(2.5 mg base)/3 ml

$0 (Tier 1) B/D; MO

XOLAIR SUBCUTANEOUS RECON SOLN 150

MG

$0 (Tier 2) PA

RESPIRATORY TRACT/ PULMONARY AGENTS, OTHER

cetirizine oral solution 1 mg/ml $0 (Tier 1) MO

STIOLTO RESPIMAT INHALATION MIST 2.5-

2.5 MCG/ACTUATION

$0 (Tier 2) MO

SKELETAL MUSCLE RELAXANTS - TREATMENT OF MUSCLE TIGHTNESS

SKELETAL MUSCLE RELAXANTS

carisoprodol oral tablet 250 mg, 350 mg $0 (Tier 1) PA; MO

chlorzoxazone oral tablet 500 mg $0 (Tier 1) PA; MO

COMFORT PAC-CYCLOBENZAPRINE KIT 10

MG

$0 (Tier 2) PA; MO

cyclobenzaprine oral tablet 10 mg, 5 mg $0 (Tier 1) PA; MO

CYCLOTENS REFILL COMBO PACK 10 MG $0 (Tier 1) PA; MO

CYCLOTENS STARTER COMBO PACK 10

MG

$0 (Tier 1) PA; MO

methocarbamol oral tablet 500 mg, 750 mg $0 (Tier 1) PA; MO

orphenadrine citrate oral tablet extended release

100 mg

$0 (Tier 1) PA; MO

SLEEP DISORDER AGENTS - TREATMENT OF INSOMNIA

GABA RECEPTOR MODULATORS

temazepam oral capsule 15 mg, 30 mg, 7.5 mg $0 (Tier 1) MO; QL (90 EA per 365 days)

zaleplon oral capsule 10 mg, 5 mg $0 (Tier 1) MO; QL (90 EA per 365 days)


134


cost you (Tier

Level)


limits on use

zolpidem oral tablet 10 mg, 5 mg $0 (Tier 1) MO; QL (90 EA per 365 days)

SLEEP DISORDERS, OTHER

armodafinil oral tablet 150 mg, 200 mg, 250 mg,

50 mg

$0 (Tier 1) PA; MO

HETLIOZ ORAL CAPSULE 20 MG $0 (Tier 2) PA

melatonin 3 mg tablet 3 mg $0 (Tier 3) DP

melatonin 5 mg tablet s/f, p/f, na/f 5 mg $0 (Tier 3) DP

MODAFINIL ORAL TABLET 100 MG, 200 MG $0 (Tier 1) PA; MO

ROZEREM ORAL TABLET 8 MG $0 (Tier 2) MO; QL (30 EA per 30 days)

XYREM ORAL SOLUTION 500 MG/ML $0 (Tier 2) LA

THERAPEUTIC NUTRIENTS/ MINERALS/ ELECTROLYTES - REPLACEMENT OR

SUPPLEMENTATION OF MINERALS, NUTRIENTS, AND VITAMINS

ELECTROLYTE/ MINERAL MODIFIERS

EXJADE ORAL TABLET, DISPERSIBLE 125

MG, 250 MG, 500 MG

$0 (Tier 2) PA

FERRIPROX ORAL TABLET 500 MG $0 (Tier 2) PA

ISOLYTE-P IN 5 % DEXTROSE

INTRAVENOUS PARENTERAL SOLUTION 5

%

$0 (Tier 2)

JADENU ORAL TABLET 180 MG, 360 MG, 90

MG

$0 (Tier 2) PA

JADENU SPRINKLE ORAL GRANULES IN

PACKET 180 MG, 360 MG, 90 MG

$0 (Tier 2) PA

kionex (with sorbitol) oral suspension 15-19.3

gram/60 ml

$0 (Tier 1) MO

kionex oral powder $0 (Tier 1) MO

SAMSCA ORAL TABLET 15 MG, 30 MG $0 (Tier 2)

sodium polystyrene (sorb free) oral suspension 15

gram/60 ml

$0 (Tier 1) MO

sodium polystyrene sulfonate oral powder $0 (Tier 1) MO

sodium polystyrene sulfonate oral suspension 15

gram/60 ml

$0 (Tier 1) MO

sodium polystyrene sulfonate rectal enema 30


$0 (Tier 1) MO



Formulary ID: 18395




135


cost you (Tier

Level)


limits on use

sps (with sorbitol) oral suspension 15-20 gram/60

ml

$0 (Tier 1) MO

sps (with sorbitol) rectal enema 30-40 gram/120

ml

$0 (Tier 1) MO

ELECTROLYTE/ MINERAL REPLACEMENT

ALIGN 4 MG CAPSULE 4 MG $0 (Tier 3) DP

AMINO ACIDS 15 % INTRAVENOUS

PARENTERAL SOLUTION 15 %

$0 (Tier 1) B/D

AMINOSYN 7 % WITH ELECTROLYTES


%

$0 (Tier 2) B/D

aminosyn 8.5 %-electrolytes intravenous

parenteral solution 8.5 %

$0 (Tier 1) B/D

AMINOSYN II 10 % INTRAVENOUS


$0 (Tier 2) B/D

AMINOSYN II 15 % INTRAVENOUS


$0 (Tier 2) B/D

AMINOSYN II 8.5 % INTRAVENOUS

PARENTERAL SOLUTION 8.5 %

$0 (Tier 2) B/D

aminosyn ii 8.5 %-electrolytes intravenous


$0 (Tier 1) B/D

AMINOSYN M 3.5 % INTRAVENOUS


$0 (Tier 2) B/D

AMINOSYN-HBC 7% INTRAVENOUS


$0 (Tier 2) B/D

AMINOSYN-PF 10 % INTRAVENOUS


$0 (Tier 2) B/D

AMINOSYN-PF 7 % (SULFITE-FREE)


%

$0 (Tier 2) B/D

AMINOSYN-RF 5.2 % INTRAVENOUS


$0 (Tier 2) B/D


136


cost you (Tier

Level)


limits on use

APATATE FORTE LIQUID $0 (Tier 3) DP

AQUADEKS PEDIATRIC LIQUID 400

MCG/ML

$0 (Tier 3) DP

BEELITH TABLET 362-20 MG $0 (Tier 3) DP

CALCIONATE 1.8 GM/5 ML SYRUP 115 MG/5

ML (1.8 GRAM/5 ML)

$0 (Tier 3) DP

CALCITRATE 200 MG (950 MG) TAB 200 MG

(950 MG)

$0 (Tier 3) DP

calcium 500 mg chewable tablet p/f,s/f,gluten-f

500-100 mg-unit

$0 (Tier 3) DP

CALCIUM 600-VIT D3 200 TABLET 600

MG(1,500MG) -200 UNIT

$0 (Tier 3) DP

calcium 600-vit d3 200 tablet p/f, s/f 600

mg(1,500mg) -200 unit

$0 (Tier 3) DP

calcium carb 1,250 mg/5 ml sus 500 mg/5 ml

(1,250 mg/5 ml)

$0 (Tier 3) DP

calcium carb 1,250 mg/5 ml sus s/f, a/f, na/f 500

mg/5 ml (1,250 mg/5 ml)

$0 (Tier 3) DP

CARBAGLU ORAL TABLET, DISPERSIBLE

200 MG

$0 (Tier 2) PA

CENTRUM SPECIALIST HEART TAB 3-200-

400 MG-MCG-MG

$0 (Tier 3) DP

clinisol sf 15 % intravenous parenteral solution 15

%

$0 (Tier 1) B/D

d10 %-0.45 % sodium chloride intravenous

parenteral solution

$0 (Tier 1)

d2.5 %-0.45 % sodium chloride intravenous

parenteral solution

$0 (Tier 1)

d5 % and 0.9 % sodium chloride intravenous

parenteral solution

$0 (Tier 1)

d5 %-0.45 % sodium chloride intravenous

parenteral solution

$0 (Tier 1)

dextrose 10 % and 0.2 % nacl intravenous

parenteral solution

$0 (Tier 1)

dextrose 10 % in water (d10w) intravenous

parenteral solution 10 %

$0 (Tier 1)



Formulary ID: 18395




137


cost you (Tier

Level)


limits on use


parenteral solution

$0 (Tier 1)


piggyback 5 %

$0 (Tier 1)

dextrose 5 %-lactated ringers intravenous

parenteral solution

$0 (Tier 1) MO

dextrose 5%-0.2 % sod chloride intravenous

parenteral solution

$0 (Tier 1)

dextrose 5%-0.3 % sod.chloride intravenous

parenteral solution

$0 (Tier 1)

DEXTROSE WITH SODIUM CHLORIDE

INTRAVENOUS PARENTERAL SOLUTION 5-

0.2 %

$0 (Tier 1)

DUOFER 28 MG TABLET 28 MG $0 (Tier 3) DP

EZFE 200 CAPSULE 200 MG IRON $0 (Tier 3) DP

FERAHEME 510 MG/17 ML VIAL SDV, P/F

510 MG/17 ML (30 MG/ML)

$0 (Tier 3) DP

FERAHEME 510 MG/17 ML VIAL SDV, P/F,

10'S 510 MG/17 ML (30 MG/ML)

$0 (Tier 3) DP

FERATE 27 MG TABLET 240 MG (27 MG

IRON)

$0 (Tier 3) DP

FERGON 27 MG TABLET 240 MG (27 MG

IRON)

$0 (Tier 3) DP

FEROSUL 325 MG TABLET F/C 325 MG (65

MG IRON)

$0 (Tier 3) DP

FEROSUL 325 MG TABLET F/C,BLISTER

PACK 325 MG (65 MG IRON)

$0 (Tier 3) DP

FERRETTS 325 MG TABLET 325 MG (106 MG

IRON)

$0 (Tier 3) DP

FERRETTS IPS LIQUID 40 MG/15 ML $0 (Tier 3) DP

FERREX 150 CAPSULE 150 MG IRON $0 (Tier 3) DP


138


cost you (Tier

Level)


limits on use

FERREX 150 CAPSULE INNER, U-D 150 MG

IRON

$0 (Tier 3) DP

FERREX 150 CAPSULE OUTER, U-D 150 MG

IRON

$0 (Tier 3) DP

FERREX 150 CAPSULE U-D,10X10 150 MG

IRON

$0 (Tier 3) DP

FERRIMIN 150 TAB 456 MG (150 MG IRON) $0 (Tier 3) DP

FERRLECIT 62.5 MG/5 ML VIAL 10'S,SUV,NO

LATEX 62.5 MG/5 ML

$0 (Tier 3) DP

FERRO-TIME 325 MG TABLET F/C, GREEN

325 MG (65 MG IRON)

$0 (Tier 3) DP

FERRO-TIME 325 MG TABLET F/C, RED 325

MG (65 MG IRON)

$0 (Tier 3) DP

ferrous fumarate 324 mg tab 324 mg (106 mg

iron)

$0 (Tier 3) DP

ferrous gluconate 324 mg tab 324 mg (38 mg iron) $0 (Tier 3) DP

ferrous sulf 300 mg/5 ml liq 300 mg (60 mg iron)/5

ml

$0 (Tier 3) DP

ferrous sulf ec 324 mg tablet 324 mg (65 mg iron) $0 (Tier 3) DP

ferrous sulf ec 325 mg tablet 325 mg (65 mg iron) $0 (Tier 3) DP

ferrous sulf ec 325 mg tablet u-d, inner 325 mg (65

mg iron)

$0 (Tier 3) DP

ferrous sulf ec 325 mg tablet u-d, outer 325 mg (65

mg iron)

$0 (Tier 3) DP

ferrous sulfate 325 mg tablet 325 mg (65 mg iron) $0 (Tier 3) DP

ferrous sulfate 325 mg tablet f/c 325 mg (65 mg

iron)

$0 (Tier 3) DP

ferrous sulfate 325 mg tablet f/c, 4x25,outer 325

mg (65 mg iron)

$0 (Tier 3) DP

ferrous sulfate 325 mg tablet f/c, green 325 mg (65

mg iron)

$0 (Tier 3) DP

ferrous sulfate 325 mg tablet f/c, red 325 mg (65

mg iron)

$0 (Tier 3) DP

ferrous sulfate 325 mg tablet inner,f/c 325 mg (65

mg iron)

$0 (Tier 3) DP



Formulary ID: 18395




139


cost you (Tier

Level)


limits on use

ferrous sulfate 325 mg tablet u-d,10x10, film coat

325 mg (65 mg iron)

$0 (Tier 3) DP

FERROUSUL 325 MG TABLET 325 MG (65

MG IRON)

$0 (Tier 3) DP

FISH OIL 1,000 MG CAPSULE 340-1,000 MG $0 (Tier 3) DP

fish oil 1,000 mg softgel softgel 300-1,000 mg $0 (Tier 3) DP

FLORANEX GRANULES PACKET

LACTOBACILLUS,OUTER 100 MILLION

CELL

$0 (Tier 3) DP

FLUORIDE (SODIUM) ORAL TABLET 1 MG

(2.2 MG SOD. FLUORIDE)

$0 (Tier 1) MO

fluoride (sodium) oral tablet,chewable 0.5 mg (1.1

mg sodium fluorid)

$0 (Tier 1) MO

FOLITAB 500 CAPLET (OTC) 105 MG IRON-

500 MG-800 MCG

$0 (Tier 3) DP

glucosamine 500 mg capsule capsule 500 mg $0 (Tier 3) DP

glucosamine-chondroit cplt caplet,dbl str,s/f 500-

400 mg

$0 (Tier 3) DP

glucosamine-chondroitin cplt caplet, dbl strength

500-400 mg

$0 (Tier 3) DP

HEMOCYTE TABLET 324 MG (106 MG IRON) $0 (Tier 3) DP

HM SLOW RELEASE IRON TABLET 143 MG

(45 MG IRON)

$0 (Tier 3) DP

ICAPS MV TABLET 100-1.66-0.83 MCG-MG-

MG

$0 (Tier 3) DP

ICAPS TABLET 3,300-5-200-75 UNIT-MG-MG-

UNIT

$0 (Tier 3) DP

IFEREX 150 CAPSULE 150 MG IRON $0 (Tier 3) DP

INFED 100 MG/2 ML VIAL

10S,OUTER,L/F,SDV 50 MG/ML

$0 (Tier 3) DP

INFUVITE ADULT BULK VIAL P/F,L/F, MUV

3,300 UNIT- 150 MCG/10 ML

$0 (Tier 3) DP


140


cost you (Tier

Level)


limits on use

INFUVITE ADULT VIAL 2X5ML, L/F, SUV

3,300 UNIT- 150 MCG/10 ML

$0 (Tier 3) DP

INJECTAFER 750 MG/15 ML VIAL 50 IRON

MG/ML

$0 (Tier 3) DP

iron 27 mg tablet 236 mg (27 mg iron) $0 (Tier 3) DP

IRON 325 MG TABLET 325 MG (65 MG IRON) $0 (Tier 3) DP


IRON TABLET COATED 325 MG (65 MG

IRON)

$0 (Tier 3) DP

klor-con 10 oral tablet extended release 10 meq $0 (Tier 1) MO

klor-con 8 oral tablet extended release 8 meq $0 (Tier 1) MO

klor-con m10 oral tablet,er particles/crystals 10

meq

$0 (Tier 1) MO

KLOR-CON M15 ORAL TABLET,ER

PARTICLES/CRYSTALS 15 MEQ

$0 (Tier 2) MO

klor-con m20 oral tablet,er particles/crystals 20

meq

$0 (Tier 1) MO

KLOR-CON SPRINKLE ORAL CAPSULE,

EXTENDED RELEASE 10 MEQ, 8 MEQ

$0 (Tier 2) MO

K-SOL ORAL LIQUID 20 MEQ/15 ML, 40

MEQ/15 ML

$0 (Tier 1) MO

M.V.I.-12 VIAL MDV,LATEX-FREE,OUTER

3,300 UNIT-200 UNIT/10 ML

$0 (Tier 3) DP

magnesium 250 mg tablet 250 mg $0 (Tier 3) DP

magnesium oxide 400 mg tablet 400 mg $0 (Tier 3) DP

magnesium oxide 400 mg tablet u-d 400 mg $0 (Tier 3) DP

magnesium oxide 500 mg tablet p/f,s/f,lactose-free

500 mg

$0 (Tier 3) DP

magnesium sulfate injection solution 4 meq/ml (50

%)

$0 (Tier 1)

MYKIDZ IRON SUSPENSION A/F, D/F 10-

1,500-400 MG -UNIT-UNIT/2 ML

$0 (Tier 3) DP

normosol-r intravenous parenteral solution $0 (Tier 1)

normosol-r ph 7.4 intravenous parenteral solution $0 (Tier 1)



Formulary ID: 18395




141


cost you (Tier

Level)


limits on use

NOVAFERRUM 125 LIQUID RASPBERRY

GRAPE, S/F 125 MG IRON- 100 UNIT/5 ML

$0 (Tier 3) DP

NOVAFERRUM 15 MG/ML DROPS

PEDIATRIC, S/F,A/F 15 MG IRON/ML

$0 (Tier 3) DP

NOVAFERRUM 50 MG CAPSULE 50 MG

IRON

$0 (Tier 3) DP

ONE DAILY TABLET 0.4-600 MG-MCG $0 (Tier 3) DP

PHOS-NAK PACKET OUTER 280-160-250 MG $0 (Tier 3) DP

PLENAMINE INTRAVENOUS PARENTERAL

SOLUTION 15 %

$0 (Tier 1) B/D

POLY-IRON 150 MG CAPSULE 150 MG IRON $0 (Tier 3) DP

potassium chloride in lr-d5 intravenous parenteral

solution 40 meq/l

$0 (Tier 1) MO

potassium chloride in water intravenous

piggyback 20 meq/50 ml, 40 meq/100 ml

$0 (Tier 1) MO

potassium chloride oral capsule, extended release

10 meq, 8 meq

$0 (Tier 1) MO

potassium chloride oral liquid 20 meq/15 ml, 40

meq/15 ml

$0 (Tier 1) MO

potassium chloride oral tablet extended release 10

meq, 20 meq, 8 meq

$0 (Tier 1) MO

potassium chloride oral tablet,er particles/crystals

10 meq, 20 meq

$0 (Tier 1) MO

PRESERVISION LUTEIN SOFTGEL SOFTGEL

226 MG-200 UNIT -5 MG-0.8 MG

$0 (Tier 3) DP

PRESERVISION LUTEIN SOFTGEL

W/LUTEIN, SOFTGEL 226 MG-200 UNIT -5

MG-0.8 MG

$0 (Tier 3) DP

PRO FE 180 MG CAPSULE 180 MG IRON $0 (Tier 3) DP

RA FISH OIL 120-180 SOFTGEL

SOFTGEL,NATURAL,P/F 120-180 MG

$0 (Tier 3) DP


142


cost you (Tier

Level)


limits on use

SEA-OMEGA 1,000 MG SOFTGEL 200 MG-300

MG- 100 MG-1,000 MG

$0 (Tier 3) DP

SEA-OMEGA 30 CAPSULE P/F,S/F,GLUTEN

FREE 360-1,200 MG

$0 (Tier 3) DP

SLOW FE 142 MG TABLET 142 MG (45 MG

IRON)

$0 (Tier 3) DP

sod fer gluc cplx 62.5 mg/5 ml 10's, sdv, outer 62.5

mg/5 ml

$0 (Tier 3) DP

sod fer gluc cplx 62.5 mg/5 ml 10's,sdv,outer 62.5

mg/5 ml

$0 (Tier 3) DP

sod fer gluc cplx 62.5 mg/5 ml sdv, inner 62.5

mg/5 ml

$0 (Tier 3) DP

sod fer gluc cplx 62.5 mg/5 ml sdv,inner 62.5 mg/5

ml

$0 (Tier 3) DP

sodium chloride 0.45 % intravenous parenteral

solution 0.45 %

$0 (Tier 1) MO

sodium chloride 0.9 % injection solution $0 (Tier 1) MO

sodium chloride 0.9 % intravenous parenteral

solution

$0 (Tier 1) MO

sodium chloride 0.9 % intravenous piggyback $0 (Tier 1) MO

sodium chloride 1,000 mg tab 1,000 mg $0 (Tier 3) DP

sodium chloride 3 % intravenous parenteral

solution 3 %

$0 (Tier 1) MO

sodium chloride intravenous parenteral solution

2.5 meq/ml

$0 (Tier 1) B/D; MO

sodium chloride irrigation solution 0.9 % $0 (Tier 1) MO

STRESS FORMULA TABLET $0 (Tier 3) DP

STRESS FORMULA WITH ZINC TAB $0 (Tier 3) DP

STRESS FORMULA-ZINC TABLET $0 (Tier 3) DP

TANDEM DUAL ACTION CAPSULE 162-115.2

(106) MG

$0 (Tier 3) DP

THERA-M CAPLET $0 (Tier 3) DP

VENOFER 200 MG/10 ML VIAL 200 MG

IRON/10 ML

$0 (Tier 3) DP



Formulary ID: 18395




143


cost you (Tier

Level)


limits on use

VENOFER 50 MG/2.5 ML VIAL 10'S,SDV,P/F

50 MG IRON/2.5 ML

$0 (Tier 3) DP

VENOFER 50 MG/2.5 ML VIAL 25'S,SUV,P/F

50 MG IRON/2.5 ML

$0 (Tier 3) DP

VITAMIN D3 2,000 UNIT SOFTGEL 2,000

UNIT

$0 (Tier 3) DP

VITAMIN D3 2,000 UNIT SOFTGEL SOFTGEL

2,000 UNIT

$0 (Tier 3) DP

VITAMIN D3 2,000 UNIT SOFTGEL SOFTGEL,

SUPER STR 2,000 UNIT

$0 (Tier 3) DP

V-R FATIGUE REL COMPLEX CPL 150-125-75

MG

$0 (Tier 3) DP

WEE CARE 15 MG/1.25 ML SUSP 15 MG/1.25

ML

$0 (Tier 3) DP

zinc 50 mg capsule (otc) 220 (50) mg $0 (Tier 3) DP

zinc gluconate 50 mg tablet 50 mg $0 (Tier 3) DP

zinc sulfate 220 mg tablet 220 mg $0 (Tier 3) DP

THERAPEUTIC NUTRIENTS/ MINERALS/ ELECTROLYTES

AQUASOL E 50 UNIT/ML DROPS 50 UNIT/ML $0 (Tier 3) DP

b-complex plus vitamin c cplt caplet $0 (Tier 3) DP

biotin 5 mg capsule p/f, gluten/f 5 mg $0 (Tier 3) DP

biotin 5,000 mcg capsule 5 mg $0 (Tier 3) DP

biotin 5,000 mcg capsule mx-str 5 mg $0 (Tier 3) DP

biotin 5,000 mcg capsule s/f 5 mg $0 (Tier 3) DP

biotin 5,000 mcg capsule s/f, p/f,gluten-free 5 mg $0 (Tier 3) DP

biotin 5,000 mcg softgel s/f, p/f,gluten-free 5 mg $0 (Tier 3) DP

biotin 5,000 mcg softgel softgel, s/f 5 mg $0 (Tier 3) DP

CALCI-CHEW TABLET 500 MG CALCIUM

(1,250 MG)

$0 (Tier 3) DP


144


cost you (Tier

Level)


limits on use

CALCITRATE + VIT D CAPLET 315-250 MG-

UNIT

$0 (Tier 3) DP

calcium 500+d tablet chew 500 mg(1,250mg) -400

unit

$0 (Tier 3) DP

calcium 500-vit d3 200 tablet 500 mg(1,250mg) -

200 unit

$0 (Tier 3) DP

calcium 600 mg tablet 600 mg calcium (1,500 mg) $0 (Tier 3) DP

CALCIUM 600 MG TABLET 600 MG

CALCIUM (1,500 MG)

$0 (Tier 3) DP

CALCIUM 600 MG TABLET 600MG

ELEMENTAL 600 MG CALCIUM (1,500 MG)

$0 (Tier 3) DP

CALCIUM 600 MG TABLET P/F 600 MG

CALCIUM (1,500 MG)

$0 (Tier 3) DP

calcium 600-vit d3 400 tablet 600 mg(1,500mg) -

400 unit

$0 (Tier 3) DP

CALCIUM 600-VIT D3 400 TABLET 600

MG(1,500MG) -400 UNIT

$0 (Tier 3) DP

CALCIUM 600-VIT D3 400 TABLET S/F 600

MG(1,500MG) -400 UNIT

$0 (Tier 3) DP

calcium carb 500 (1,250) mg tb 500 mg calcium

(1,250 mg)

$0 (Tier 3) DP

calcium carbonate 648 mg tab 260 mg calcium

(648 mg)

$0 (Tier 3) DP

calcium citrate - vit d caplet 315-250 mg-unit $0 (Tier 3) DP

calcium citrate - vit d caplet p/f, caplet 315-250

mg-unit

$0 (Tier 3) DP

CALTRATE 600 PLUS D3 TABLET 600

MG(1,500MG) -800 UNIT

$0 (Tier 3) DP

CENTRUM COMPLETE MULTIVIT TAB 18-

400 MG-MCG

$0 (Tier 3) DP

CENTRUM SILVER ULTRA WOMEN TAB $0 (Tier 3) DP

CENTRUM SPECIALIST ENERGY TAB 18 MG

IRON-400 MCG-25 MCG-75MG

$0 (Tier 3) DP

CENTRUM ULTRA WOMEN'S TABLET 18-

400 MG-MCG

$0 (Tier 3) DP

CENTURY ADVANCED FORMULA TABS $0 (Tier 3) DP



Formulary ID: 18395




145


cost you (Tier

Level)


limits on use

CENTURY ENERGY TABLET 18 MG IRON-

400 MCG-50 MG

$0 (Tier 3) DP

CENTURY ULTIMATE MEN'S TABLET 300-

600-300 MCG

$0 (Tier 3) DP

CERTAVITE-ANTIOXIDANT TABLET 18-400

MG-MCG

$0 (Tier 3) DP

CHILD CHEW + IRON TAB CHEW $0 (Tier 3) DP

CHILD VITAMIN-IRON TAB CHEW $0 (Tier 3) DP

CITRUS CALCIUM + D TABLET 315-250 MG-

UNIT

$0 (Tier 3) DP

CITRUS CALCIUM 200-VIT D3 250 200 MG

CALCIUM -250 UNIT

$0 (Tier 3) DP

clinimix 4.25%/d10w sulf free intravenous


$0 (Tier 1) B/D

clinimix 4.25%-d20w sulf-free intravenous


$0 (Tier 1) B/D

clinimix 4.25%-d25w sulf-free intravenous


$0 (Tier 1) B/D

clinimix n14g30e 4.25%-d15w sf intravenous

parenteral solution 4.25-15 %

$0 (Tier 1) B/D; MO

clinimix n9g15e 2.75%-d7.5w sf intravenous

parenteral solution 2.75-7.5 %

$0 (Tier 1) B/D; MO

cvs biotin 5,000 mcg capsule 5 mg $0 (Tier 3) DP

ELITE-OB ORAL TABLET 50 MG IRON- 1.25

MG

$0 (Tier 2) MO

folic acid 0.4 mg tablet 400 mcg $0 (Tier 3) DP

folic acid 0.8 mg tablet 800 mcg $0 (Tier 3) DP

folic acid 400 mcg tablet 400 mcg $0 (Tier 3) DP

folic acid 400 mcg tablet s/f,p/f,lactose-free 400

mcg

$0 (Tier 3) DP

gnp biotin 5,000 mcg capsule 5 mg $0 (Tier 3) DP


146


cost you (Tier

Level)


limits on use

hi potency b-comp-c caplet caplet $0 (Tier 3) DP

ICAPS PLUS TABLET LACTOSE FREE $0 (Tier 3) DP

INTEGRA CAPSULE 125-40-3 MG $0 (Tier 3) DP

intralipid intravenous emulsion 20 % $0 (Tier 1) B/D

IRON 100 PLUS TABLET 100-250-25-1 MG-

MG-MCG-MG

$0 (Tier 3) DP


lactated ringers intravenous parenteral solution $0 (Tier 1)

L-CARNITINE 250 MG CAPSULE 250 MG $0 (Tier 3) DP

levocarnitine (with sugar) oral solution 100 mg/ml $0 (Tier 1)

levocarnitine oral tablet 330 mg $0 (Tier 1)

MAG-G 500 MG TABLET 27 MG (500 MG) $0 (Tier 3) DP

MEGA MULTI FOR MEN TABLET HIGH

POTENCY 200-175-250 MCG

$0 (Tier 3) DP

MEGA MULTIVIT FOR MEN CAPLET

CAPLET 200-175-250 MCG

$0 (Tier 3) DP

MULTI-DELYN LIQUID S/F,A/F $0 (Tier 3) DP

OCUVITE LUTEIN & ZEAXANTHIN CP 60

MG-30 UNIT- 15 MG-2 MG-6 MG

$0 (Tier 3) DP

ONE DAILY ESSENTIAL TABLET 400 MCG $0 (Tier 3) DP

ONE DAILY MAXIMUM TABLET 18-0.4 MG $0 (Tier 3) DP

ONE DAILY MEN'S 50+ TABLET 400-600-120

MCG-MCG-MG

$0 (Tier 3) DP

ONE DAILY PLUS IRON TABLET 18-400 MG-

MCG

$0 (Tier 3) DP

ONE DAILY WOMEN'S HEALTH TAB 18 MG

IRON-400 MCG-450 MG CA

$0 (Tier 3) DP

ONE DAILY WOMEN'S TABLET 27-0.4 MG $0 (Tier 3) DP

OS-CAL 500-VIT D3 200 CAPLET CAPLET 500

MG(1,250MG) -200 UNIT

$0 (Tier 3) DP

OYSCO 500-VIT D3 200 TABLET 500

MG(1,250MG) -200 UNIT

$0 (Tier 3) DP

OYSCO-500 TABLET 500 MG CALCIUM

(1,250 MG)

$0 (Tier 3) DP



Formulary ID: 18395




147


cost you (Tier

Level)


limits on use

OYSTER SHELL 500-VIT D3 200 TB 500

MG(1,250MG) -200 UNIT

$0 (Tier 3) DP

OYSTER SHELL CALCIUM 500 MG TB

500MG ELEMENTAL CA 500 MG CALCIUM

(1,250 MG)

$0 (Tier 3) DP

OYSTER SHELL CALCIUM 500 MG TB

500MG ELEMTL,NATURAL 500 MG

CALCIUM (1,250 MG)

$0 (Tier 3) DP

OYSTER SHELL CALCIUM-VIT D TAB 500

MG(1,250MG) -400 UNIT

$0 (Tier 3) DP

OYSTER SHELL CALCIUM-VIT D TAB

CAPLET 500 MG(1,250MG) -400 UNIT

$0 (Tier 3) DP

pantothenic acid 500 mg tabs 500 mg $0 (Tier 3) DP

potassium chlorid-d5-0.45%nacl intravenous

parenteral solution 20 meq/l

$0 (Tier 1) MO

PRENATAL VITAMIN PLUS LOW IRON

ORAL TABLET 27 MG IRON- 1 MG

$0 (Tier 2) MO

PRESERVISION AREDS SOFTGEL 14,320-226-

200 UNIT-MG-UNIT

$0 (Tier 3) DP

qc calcium 600-vit d3 400 tab high potency 600

mg(1,500mg) -400 unit

$0 (Tier 3) DP

RISACAL-D TABLET 105-120 MG-UNIT $0 (Tier 3) DP

RISANOID PLUS TABLET 200-100 MG $0 (Tier 3) DP

selenium dr 200 mcg tablet 200 mcg $0 (Tier 3) DP

SENTRY MULTIVIT & MINERAL CPLT 18-

500-300-250 MG-MCG-MCG-MCG

$0 (Tier 3) DP

SENTRY SENIOR MULTIVIT CAPLET

CAPLET 500-300-250 MCG

$0 (Tier 3) DP

SM CALCIUM 500-VIT D3 400 TAB 500

MG(1,250MG) -400 UNIT

$0 (Tier 3) DP

SM COMPLETE MULTI-VIT-MINERAL

ADVANCED FORMULA 18-400 MG-MCG

$0 (Tier 3) DP


148


cost you (Tier

Level)


limits on use

SM GLUCOSAMINE-CHONDR-MSM CPLT

CAPLET, TRIPLE STR 750-625-30 MG

$0 (Tier 3) DP

sv biotin 5,000 mcg softgel softgel, s/f 5 mg $0 (Tier 3) DP

THERA M PLUS TABLET 9 MG IRON-400

MCG

$0 (Tier 3) DP

THERA-M CAPLET CAPLET 27-0.4 MG $0 (Tier 3) DP

THERA-M CAPLET CAPLET,U-D,10X10 27-0.4

MG

$0 (Tier 3) DP

THERA-M TABLET W/BETA CAROTENE 9

MG IRON-400 MCG

$0 (Tier 3) DP

THERAPEUTIC-M CAPLET 27-0.4 MG $0 (Tier 3) DP

THERAPEUTIC-M CAPLET P/F, S/F, CAPLET

9 MG IRON-400 MCG

$0 (Tier 3) DP

THEREMS-M TABLET 27-0.4 MG $0 (Tier 3) DP

VENOFER 100 MG/5 ML VIAL 10'S,SDV,P/F

100 MG IRON/5 ML

$0 (Tier 3) DP

VENOFER 100 MG/5 ML VIAL 25'S,SDV,P/F

100 MG IRON/5 ML

$0 (Tier 3) DP

VITAMIN AND MINERALS TABLET $0 (Tier 3) DP

ZINC 15 MG LOZENGES NATURAL 15 MG $0 (Tier 3) DP

ZOO FRIENDS ORIGINAL TAB CHEW 300

MCG

$0 (Tier 3) DP

VITAMINS

ANIMAL CHEWS TABLET $0 (Tier 3) DP

ANIMAL SHAPES TABLET CHEW

CHILDREN'S

$0 (Tier 3) DP

ANTIOXIDANT VITAMIN TABLET $0 (Tier 3) DP

APATATE LIQUID $0 (Tier 3) DP

AQUADEKS CHEWABLE TABLET 100-350-5

MCG-MCG-MG

$0 (Tier 3) DP

AQUASOL A 50,000 UNITS/ML VIAL SDV,

LATEX-FREE 50,000 UNIT/ML

$0 (Tier 3) DP

ascorbic acid 500 mg tablet 500 mg $0 (Tier 3) DP

BALANCED B-100 TABLET 100 MG $0 (Tier 3) DP



Formulary ID: 18395




149


cost you (Tier

Level)


limits on use

BALANCED B-50 TABLET $0 (Tier 3) DP

B-COMPLEX WITH B12 TABLET $0 (Tier 3) DP

beta carotene 10,000 units cap 10,000 unit $0 (Tier 3) DP

biotin 300 mcg tablet 300 mcg $0 (Tier 3) DP

biotin 300 mcg tablet p/f,na/f,s/f 300 mcg $0 (Tier 3) DP

biotin 300 mcg tablet s/f,p/f,lactose-free 300 mcg $0 (Tier 3) DP

biotin 800 mcg tablet 800 mcg $0 (Tier 3) DP

CALCIFEROL 8,000 UNIT/ML DROPS 8,000

UNIT/ML

$0 (Tier 3) DP

CALCIUM 250+D TABLET OYSTER SHELL

250-125 MG-UNIT

$0 (Tier 3) DP

calcium 250-vit d3 125 tablet 250-125 mg-unit $0 (Tier 3) DP

calcium gluconate 500 mg tab 45 mg (500 mg) $0 (Tier 3) DP

CALTRATE 600 + D SOFT CHEW TAB

CHOCOLATE TRUFFLE 600 MG (1,500 MG)-

800 UNIT

$0 (Tier 3) DP

CALTRATE 600 + D SOFT CHEW TAB

VANILLA CREME 600 MG (1,500 MG)-800

UNIT

$0 (Tier 3) DP

CALTRATE 600+D PLUS TAB CHEW 600 MG

CALCIUM- 800 UNIT-40 MG

$0 (Tier 3) DP

CALTRATE 600+D PLUS TABLET 600 MG

CALCIUM- 800 UNIT-50 MG

$0 (Tier 3) DP

CARDIAMIN MULTIVITAMIN SOFTGEL 200

MCG-500 UNIT-200 MG

$0 (Tier 3) DP

CENTAMIN LIQUID 9 MG IRON/15 ML $0 (Tier 3) DP

CENTRAL-VITE TABLET VALU-SIZE $0 (Tier 3) DP

CENTRUM CHEWABLE TABLET 3,500-18-0.4

UNIT-MG-MG

$0 (Tier 3) DP

CENTRUM KIDS CHEW TAB TAB CHEW 18

MG IRON

$0 (Tier 3) DP


150


cost you (Tier

Level)


limits on use

CENTRUM MULTIVITAMIN TAB CHEW

3,500-18-0.4 UNIT-MG-MG

$0 (Tier 3) DP

CENTRUM MULTIVIT-MINERAL LIQ 9 MG

IRON/15 ML

$0 (Tier 3) DP

CENTRUM SILVER CHEWABLE TABLET

400-250 MCG

$0 (Tier 3) DP

CENTRUM SILVER TABLET ADULT 50+ 0.4-

300-250 MG-MCG-MCG

$0 (Tier 3) DP

CENTRUM SILVER TABLET ADULTS 50 +

0.4-300-250 MG-MCG-MCG

$0 (Tier 3) DP

CENTRUM SILVER TABLET FOR ADULT 50+

0.4-300-250 MG-MCG-MCG

$0 (Tier 3) DP

CENTRUM SILVER ULTRA MEN'S TAB FOR

MEN 50+ 300-600-300 MCG

$0 (Tier 3) DP

CENTRUM SPECIALIST VISION TAB 100-5-1

MCG-MG-MG

$0 (Tier 3) DP

CENTURY MATURE TABLET $0 (Tier 3) DP

CEROVITE LIQUID 9 MG IRON/15 ML $0 (Tier 3) DP

CERTA PLUS TABLET 18-0.4-250 MG-MG-

MCG

$0 (Tier 3) DP

CERTAVITE SR-ANTIOXIDANT TAB 0.4-300-

250 MG-MCG-MCG

$0 (Tier 3) DP

CERTAVITE-ANTIOXIDANT LIQUID 9 MG

IRON/15 ML

$0 (Tier 3) DP

CHILD CHEW VITAMIN TABLET $0 (Tier 3) DP

child ferrous sulfate 15 mg/ml 15 mg iron (75

mg)/ml

$0 (Tier 3) DP

CHILDRENS CHEW VITAMIN TAB $0 (Tier 3) DP

CHILDREN'S CHEWABLES 15 MG $0 (Tier 3) DP

CHILDREN'S CHEWABLES 300 MCG $0 (Tier 3) DP

CHILDREN'S CHEWABLES 300 MCG $0 (Tier 3) DP

CHILDREN'S CHEWABLES 9-200 MG IRON-

MCG

$0 (Tier 3) DP

coenzyme q-10 100 mg softgel s/f,p/f,na/f 100 mg $0 (Tier 3) DP



Formulary ID: 18395




151


cost you (Tier

Level)


limits on use

coenzyme q-10 100 mg softgel softgel,l/f,s/f,p/f 100

mg

$0 (Tier 3) DP

COMPETE TABLET $0 (Tier 3) DP

COMPLETE MULTIVITAMIN TAB $0 (Tier 3) DP

COMPLETE SENIOR TABLET $0 (Tier 3) DP

cyanocobalamin 1,000 mcg/ml 25's, latex-free,suv

1,000 mcg/ml

$0 (Tier 3) DP

cyanocobalamin 1,000 mcg/ml 25's, mdv 1,000

mcg/ml

$0 (Tier 3) DP

cyanocobalamin 1,000 mcg/ml mdv,5's 1,000

mcg/ml

$0 (Tier 3) DP

CYTO B-2 POWDER 343 MG/GRAM $0 (Tier 3) DP

DAILY VITAMIN + IRON TABLET $0 (Tier 3) DP

DAILY VITAMIN FORMULA TABLET $0 (Tier 3) DP

DAILY VITAMIN FORMULA TABLET $0 (Tier 3) DP

DAILY VITAMIN TABLET P/F,NA/F $0 (Tier 3) DP

DECARA 25,000 UNIT VEGICAP 25,000 UNIT $0 (Tier 3) DP

DECARA 50,000 UNIT SOFTGEL 50,000 UNIT $0 (Tier 3) DP

DIALYVITE 800 TABLET 0.8 MG $0 (Tier 3) DP

DIALYVITE 800-ULTRA D TABLET 0.8-2,000

MG-UNIT

$0 (Tier 3) DP

DIALYVITE 800-ZINC 15 MG TAB 0.8-15 MG $0 (Tier 3) DP

DIALYVITE 800-ZINC 50 MG TAB 0.8-50 MG $0 (Tier 3) DP

DIALYVITE VIT D3 50,000 UNIT 50,000 UNIT $0 (Tier 3) DP

DIALYVITE VITAMIN D 5,000 UNIT 5,000

UNIT

$0 (Tier 3) DP

D-VI-SOL 400 UNITS/ML DROP 400 UNIT/ML $0 (Tier 3) DP

D-VITA 400 UNIT/ML DROP 400 UNIT/ML $0 (Tier 3) DP


152


cost you (Tier

Level)


limits on use

ECEE PLUS TABLET 200-100-10-18 UNIT-MG-

MG-MG

$0 (Tier 3) DP

ELDERTONIC ELIXIR 0.5-0.6-7-0.7 MG $0 (Tier 3) DP

ergocalciferol 8,000 units/ml 8,000 unit/ml $0 (Tier 3) DP

FER-IN-SOL 15 MG/ML DROPS 15 MG IRON

(75 MG)/ML

$0 (Tier 3) DP

FEROSUL 220 MG/5 ML ELIXIR 220 MG (44

MG IRON)/5 ML

$0 (Tier 3) DP

ferrous gluconate 324 mg tab 324 mg (37.5 mg

iron)

$0 (Tier 3) DP

ferrous sulf 15 mg iron/ml drp 15 mg iron (75

mg)/ml

$0 (Tier 3) DP

ferrous sulf 15 mg iron/ml drp gluten-free 15 mg

iron (75 mg)/ml

$0 (Tier 3) DP

ferrous sulf 220 mg/5 ml elix 220 mg (44 mg

iron)/5 ml

$0 (Tier 3) DP

ferrous sulf 220 mg/5 ml liq 220 mg (44 mg iron)/5

ml

$0 (Tier 3) DP

ferrous sulfate er 140 mg tab

2x15,f/c,140mg(45mg) 140 mg (45 mg iron)

$0 (Tier 3) DP

ferrous sulfate er 140 mg tab

4x15,f/c,140mg(45mg) 140 mg (45 mg iron)

$0 (Tier 3) DP

FOLGARD TABLET 2,000-800-0.32 UNIT-

MCG-MG

$0 (Tier 3) DP

folic acid 1 mg tablet (rx) 1 mg $0 (Tier 3) DP

folic acid 1 mg tablet 10x10, u-d, inner (rx) 1 mg $0 (Tier 3) DP

folic acid 1 mg tablet 10x10, u-d, outer (rx) 1 mg $0 (Tier 3) DP

folic acid 1 mg tablet inner,u-d,robot-rdy (rx) 1 mg $0 (Tier 3) DP

folic acid 1 mg tablet outer,u-d,robot-rdy (rx) 1 mg $0 (Tier 3) DP

folic acid 1 mg tablet u-d,inner,10x10 (rx) 1 mg $0 (Tier 3) DP

folic acid 1 mg tablet u-d,outer,10x10 (rx) 1 mg $0 (Tier 3) DP

folic acid 5 mg/ml vial latex-free, mdv 5 mg/ml $0 (Tier 3) DP

GERIATON LIQUID $0 (Tier 3) DP

HEALTHY EYES CAPLET CAPLET 1,000

UNIT-200 MG-60 UNIT-2 MG

$0 (Tier 3) DP



Formulary ID: 18395




153


cost you (Tier

Level)


limits on use

HEALTHY EYES TABLET ADVANCED

ANTIOXIDANT 1,000 UNIT-200 MG-60 UNIT-

2 MG

$0 (Tier 3) DP

hydroxocobalamin 1,000 mcg/ml 1,000 mcg/ml $0 (Tier 3) DP

I.L.X. B-12 ELIXIR 102 MG IRON-10 MCG-98

MG/15 ML

$0 (Tier 3) DP

ICAPS AREDS FORMULA DR TABLET 7,160-

113-100 UNIT-MG-UNIT

$0 (Tier 3) DP

ICAPS AREDS SOFTGEL LACTOSE-FREE

14,320-226-200 UNIT-MG-UNIT

$0 (Tier 3) DP

ICAPS AREDS SOFTGEL SOFTGEL, L/F

14,320-226-200 UNIT-MG-UNIT

$0 (Tier 3) DP

I-CAPS WITH LUTEIN-OMEGA 3 SFG 280-10-

2 MG

$0 (Tier 3) DP

INFUVITE PEDIATRIC BULK VIAL SUV 80

MG-400 UNIT- 200 MCG/5 ML

$0 (Tier 3) DP

INFUVITE PEDIATRIC VIAL SUV 80 MG-400

UNIT- 200 MCG/5 ML

$0 (Tier 3) DP

iron 100-vitamin c tablet 100-250 mg $0 (Tier 3) DP

iron 28 mg tablet 256 mg (28 mg iron) $0 (Tier 3) DP

KENWOOD THERAPEUTIC LIQUID $0 (Tier 3) DP

LIPOFLAVOVIT CAPLET $0 (Tier 3) DP

M.V.I. ADULT VIAL MDV, LATEX-FREE

3,300 UNIT- 150 MCG/10 ML

$0 (Tier 3) DP

M.V.I. ADULT VIAL SDV, LATEX-FREE 3,300

UNIT- 150 MCG/10 ML

$0 (Tier 3) DP

M.V.I. PEDIATRIC VIAL 10'S,SDV,LATEX-

FREE 80-400-200 MG-UNIT-MCG

$0 (Tier 3) DP

MAXIMUM D3 10,000 UNIT CAPSULE 10,000

UNIT

$0 (Tier 3) DP

MEGA MULTI FOR WOMEN TAB 13.5-200-

250 MG-MCG-MCG

$0 (Tier 3) DP


154


cost you (Tier

Level)


limits on use

MEGA MULTIVIT FOR WOMEN CAPLET

13.5-200-250 MG-MCG-MCG

$0 (Tier 3) DP

MULTI-DELYN WITH IRON LIQUID 10 MG

IRON/5 ML

$0 (Tier 3) DP

MULTILEX TABLET $0 (Tier 3) DP

MULTILEX-T-M-MINERALS TAB $0 (Tier 3) DP

MULTIPLE VITAMIN TABLET $0 (Tier 3) DP

MULTIPLE VITAMIN-CA-IRON TB $0 (Tier 3) DP

multivitamins men tablet $0 (Tier 3) DP

multivitamins tablet $0 (Tier 3) DP

NAIL-EX ORAL TABLET 2,500 MCG $0 (Tier 3) DP

NASCOBAL 500 MCG NASAL SPRAY OUTER

500 MCG/SPRAY

$0 (Tier 3) DP

OCUVITE SOFTGEL 150-30-5-150 MG-UNIT-

MG-MG

$0 (Tier 3) DP

OCUVITE WITH LUTEIN TABLET 1,000

UNIT-200 MG-60 UNIT-2 MG

$0 (Tier 3) DP

omega-3 1,000 mg softgel softgel,l/f,s/f 300-1,000

mg

$0 (Tier 3) DP

ONCE DAILY TABLET $0 (Tier 3) DP

ONCE DAILY WITH IRON TABLET $0 (Tier 3) DP

ONCOVITE TABLET $0 (Tier 3) DP

ONE DAILY ESSENTIAL TABLET $0 (Tier 3) DP

ONE DAILY TABLET $0 (Tier 3) DP

ONE DAILY TABLET $0 (Tier 3) DP

ONE DAILY TABLET MEN'S FORMULA $0 (Tier 3) DP

OPTIMAL D3 50,000 UNITS CAP 50,000 UNIT $0 (Tier 3) DP

OYSCO 500+D TABLET CHEWABLE 500

MG(1,250MG) -600 UNIT

$0 (Tier 3) DP

POLY-VI-SOL DROPS 750-35-400 UNIT-MG-

UNIT/ML

$0 (Tier 3) DP

POLY-VI-SOL WITH IRON DROPS 750 UNIT-

400 UNIT-10 MG/ML

$0 (Tier 3) DP



Formulary ID: 18395




155


cost you (Tier

Level)


limits on use

POLY-VITA DROPS 1,500-35-400 UNIT-MG-

UNIT/ML

$0 (Tier 3) DP

POLY-VITA WITH IRON DROPS 1,500 UNIT-

400 UNIT-10 MG/ML

$0 (Tier 3) DP

PRESERVISION AREDS 2 SOFTGEL 250-2.5-

0.5 MG

$0 (Tier 3) DP

PRESERVISION AREDS TABLET 7,160-113-

100 UNIT-MG-UNIT

$0 (Tier 3) DP

PRORENAL MULTIVITAMIN TABLET 8 MG

IRON-800 MCG-1,000 UNIT

$0 (Tier 3) DP

PRORENAL QD SOFTGEL 400-500 MCG-UNIT $0 (Tier 3) DP

PROSIGHT TABLET 5,000-60-30 UNIT-MG-

UNIT

$0 (Tier 3) DP

pyridoxine 100 mg/ml vial 25's, mdv 100 mg/ml $0 (Tier 3) DP

pyridoxine 25 mg tablet 25 mg $0 (Tier 3) DP

pyridoxine 50 mg tablet (otc) 50 mg $0 (Tier 3) DP

RENA-VITE TABLET 0.8 MG $0 (Tier 3) DP

SB C-500 TABLET S/F, P/F,GLUTEEN-FRE 500

MG

$0 (Tier 3) DP

SLOW-MAG 71.5 MG TABLET 71.5 MG $0 (Tier 3) DP

SM COMPLETE 50+ TABLET 0.4-300-250 MG-

MCG-MCG

$0 (Tier 3) DP

SM COMPLETE SENIOR FORMULA TAB 0.4-

300-250 MG-MCG-MCG

$0 (Tier 3) DP

SM ULTIMATE WOMEN'S 50+ TABLET 8 MG

IRON-400 MCG-300 MCG

$0 (Tier 3) DP

SM VITAMIN B-1 100 MG TABLET 100 MG $0 (Tier 3) DP

sm vitamin c sr 500 mg tablet 500 mg $0 (Tier 3) DP

SM VITAMIN D3 1,000 UNIT TAB P/F 1,000

UNIT

$0 (Tier 3) DP


156


cost you (Tier

Level)


limits on use

sm vitamin e 1,000 unit sftgel softgel, gluten-free

1,000 unit

$0 (Tier 3) DP

sm vitamin e 400 unit softgel sftgel,natural blend

400 unit

$0 (Tier 3) DP

STRESS FORMULA WITH IRON TAB 500 MG-

400 MCG- 18 MG IRON

$0 (Tier 3) DP

SUPERPLEX-T TABLET $0 (Tier 3) DP

SV VITAMIN D3 400 UNIT SOFTGEL

SOFTGEL , P/F, S/F 400 UNIT

$0 (Tier 3) DP

TAB-A-VITE TABLET $0 (Tier 3) DP

TAB-A-VITE WITH IRON TABLET $0 (Tier 3) DP

TAB-A-VITE-MINERALS TABLET $0 (Tier 3) DP

THERA CAPLET $0 (Tier 3) DP

THERA TABLET 400 MCG $0 (Tier 3) DP

THERAPEUTIC-M TABLET 9-0.4 MG $0 (Tier 3) DP

thiamine 200 mg/2 ml vial 25's, mdv 100 mg/ml $0 (Tier 3) DP

thiamine 200 mg/2 ml vial 25's,mdv,outer 100

mg/ml

$0 (Tier 3) DP

thiamine 200 mg/2 ml vial mdv 100 mg/ml $0 (Tier 3) DP

thiamine 200 mg/2 ml vial mdv,inner 100 mg/ml $0 (Tier 3) DP

TOTAL B WITH VIT C CAPLET $0 (Tier 3) DP

TRI-VI-SOL DROPS 750 UNIT-35 MG -400

UNIT/ML

$0 (Tier 3) DP

TRI-VITA DROPS 1,500-35-400 UNIT-MG-

UNIT/ML

$0 (Tier 3) DP

UNICOMPLEX-M TABLET $0 (Tier 3) DP

vit d2 1.25 mg (50,000 unit) 50,000 unit $0 (Tier 3) DP

VIT D2 1.25 MG (50,000 UNIT) 50,000 UNIT $0 (Tier 3) DP

vit d2 1.25 mg (50,000 unit) softgel 50,000 unit $0 (Tier 3) DP

VIT D2 1.25 MG (50,000 UNIT) U-

D,10X10,OUTER 50,000 UNIT

$0 (Tier 3) DP

VIT E NAT'L BLND 1,000 UNIT CP 1,000 UNIT $0 (Tier 3) DP

vitamin a 10,000 unit capsule soluble 10,000 unit $0 (Tier 3) DP

vitamin a 25,000 units capsule softgel 25,000 unit $0 (Tier 3) DP



Formulary ID: 18395




157


cost you (Tier

Level)


limits on use

vitamin a 8,000 units softgel softgel, p/f 8,000 unit $0 (Tier 3) DP

VITAMIN B COMPLEX CAPSULE $0 (Tier 3) DP

vitamin b-1 100 mg tablet 100 mg $0 (Tier 3) DP

VITAMIN B-1 100 MG TABLET 100 MG $0 (Tier 3) DP


VITAMIN B-12 1,000 MCG TABLET 1,000

MCG

$0 (Tier 3) DP

VITAMIN B-12 1,000 MCG TABLET

NATURAL 1,000 MCG

$0 (Tier 3) DP

VITAMIN B-12 100 MCG TABLET 100 MCG $0 (Tier 3) DP

VITAMIN B-12 2,000 MCG TAB SA 2,000 MCG $0 (Tier 3) DP


VITAMIN B12 500 MCG TABLET 500 MCG $0 (Tier 3) DP


VITAMIN B-12 500 MCG TABLET NATURAL

500 MCG

$0 (Tier 3) DP

VITAMIN B-12 TR 1,000 MCG TAB TIMED

RELEASE 1,000 MCG

$0 (Tier 3) DP

VITAMIN B-2 100 MG TABLET GLUTEN-

FREE 100 MG

$0 (Tier 3) DP

VITAMIN B-2 100 MG TABLET

S/F,L/F,Y/F,GLUTEN/F 100 MG

$0 (Tier 3) DP

VITAMIN B-2 100 MG TABLET S/F,P/F 100

MG

$0 (Tier 3) DP



VITAMIN B-2 50 MG TABLET S/F 50 MG $0 (Tier 3) DP

VITAMIN B-2 50 MG TABLET S/F, P/F 50 MG $0 (Tier 3) DP



158


cost you (Tier

Level)


limits on use

VITAMIN B-6 100 MG TABLET SYNTHETIC

100 MG

$0 (Tier 3) DP



vitamin c 1,000 mg caplet caplet, w/ rose hips

1,000 mg

$0 (Tier 3) DP

VITAMIN C 1,000 MG TABLET 1,000 MG $0 (Tier 3) DP

VITAMIN C 250 MG TABLET 250 MG $0 (Tier 3) DP

VITAMIN C 250 MG TABLET CHEW 250 MG $0 (Tier 3) DP


VITAMIN C 500 MG CAPLET COATED

CAPLET 500 MG

$0 (Tier 3) DP

VITAMIN C 500 MG CHEW TABLET 500 MG $0 (Tier 3) DP

VITAMIN C 500 MG TABLET 10X10, U-D 500

MG

$0 (Tier 3) DP

vitamin c 500 mg tablet 500 mg $0 (Tier 3) DP

VITAMIN C 500 MG TABLET 500 MG $0 (Tier 3) DP


VITAMIN C 500 MG TABLET SYNTHETIC 500

MG

$0 (Tier 3) DP

VITAMIN C 500 MG TABLET U-D 500 MG $0 (Tier 3) DP

VITAMIN C 500 MG TABLET WITH ROSE

HIPS 500 MG

$0 (Tier 3) DP

VITAMIN C 500 MG/5 ML LIQUID 500 MG/5

ML

$0 (Tier 3) DP

VITAMIN C DROPS 60 MG $0 (Tier 3) DP

VITAMIN C-500 MG TR CAPSULE

NA/F,GLUTEN-FREE,P/F 500 MG

$0 (Tier 3) DP

vitamin d3 1,000 unit softgel softgel 1,000 unit $0 (Tier 3) DP

VITAMIN D3 1,000 UNIT SOFTGEL SOFTGEL

1,000 UNIT

$0 (Tier 3) DP

VITAMIN D3 1,000 UNIT TAB CHEW P/F,

PEACH VANILLA 1,000 UNIT

$0 (Tier 3) DP

vitamin d3 1,000 unit tablet 1,000 unit $0 (Tier 3) DP



Formulary ID: 18395




159


cost you (Tier

Level)


limits on use

vitamin d3 1,000 unit tablet gluten/f, d/f 1,000 unit $0 (Tier 3) DP

vitamin d3 1,000 unit tablet s/f, p/f 1,000 unit $0 (Tier 3) DP

VITAMIN D3 1,000 UNIT TABLET S/F,P/F

1,000 UNIT

$0 (Tier 3) DP

VITAMIN D3 1,000 UNIT TABLET U-D, 10X10

1,000 UNIT

$0 (Tier 3) DP

vitamin d3 10,000 unit softgel softgel 10,000 unit $0 (Tier 3) DP


vitamin d3 2,000 unit tablet s/f,p/f 2,000 unit $0 (Tier 3) DP

VITAMIN D3 400 UNIT SOFTGEL SOFTGEL

400 UNIT

$0 (Tier 3) DP

vitamin d3 400 unit tablet gluten free 400 unit $0 (Tier 3) DP

VITAMIN D3 400 UNIT TABLET S/F, P/F 400

UNIT

$0 (Tier 3) DP

VITAMIN D3 400 UNIT TABLET S/F,P/F 400

UNIT

$0 (Tier 3) DP

vitamin d3 400 unit/ml drop a/f, s/f, fruit 400

unit/ml

$0 (Tier 3) DP

vitamin d3 400 unit/ml drop s/f,w/dropper 400

unit/ml

$0 (Tier 3) DP

vitamin d3 400 unit/ml drop supplement drop 400

unit/ml

$0 (Tier 3) DP

vitamin d3 5,000 unit capsule s/f, p/f 5,000 unit $0 (Tier 3) DP


vitamin e 1,000 units capsule 1,000 unit $0 (Tier 3) DP

vitamin e 100 unit softgel softgel 100 unit $0 (Tier 3) DP

vitamin e 200 unit capsule 200 unit $0 (Tier 3) DP

vitamin e 400 unit capsule 400 unit $0 (Tier 3) DP

vitamin e 400 unit capsule p/f, sf, gluten-free 400

unit

$0 (Tier 3) DP


160


cost you (Tier

Level)


limits on use

vitamin e 400 unit capsule softgel, synthetic 400

unit

$0 (Tier 3) DP

vitamin e 400 unit softgel softgel 400 unit $0 (Tier 3) DP

vitamin e 400 unit softgel softgel,s/f,na/f,p/f 400

unit

$0 (Tier 3) DP

vitamin e 400 unit softgel softgel,s/f,p/f,na/f 400

unit

$0 (Tier 3) DP

vitamin e 400 unit softgel water dispersible 400

unit

$0 (Tier 3) DP

vitamin e 50 unit/ml drops 50 unit/ml $0 (Tier 3) DP

V-R VIT C 250 MG TABLET CHEW 250 MG $0 (Tier 3) DP

V-R VIT C 500 MG TABLET CHEW 500 MG $0 (Tier 3) DP

V-R VITAMIN C 1,000 MG TABLET 1,000 MG $0 (Tier 3) DP

V-R VITAMIN C 500 MG TABLET VALU-SIZE

500 MG

$0 (Tier 3) DP

ZOO FRIENDS COMPLETE TAB CHEW 9-200

MG-MCG

$0 (Tier 3) DP

ZOO FRIENDS GUMMIES $0 (Tier 3) DP

ZOO FRIENDS TABLET CHEWABLE 15 MG,

300 MCG

$0 (Tier 3) DP



Formulary ID: 18395



161

Index

8 8 HOUR PAIN RELIEVER .. 1,

4

8-MOP .................................. 82

A abacavir ................................ 57

abacavir-lamivudine ............. 57

abacavir-lamivudine-

zidovudine ........................ 57

abelcet................................... 30

ABILIFY MAINTENA ........ 50

ABRAXANE ........................ 43

acamprosate ............................ 9

acarbose ................................ 61

ACCUCAINE KIT ................. 8

acebutolol ............................. 72

ACEPHEN ............................. 1

acetaminophen ........................ 1

acetaminophen-codeine .......... 1

acetazolamide ....................... 76

acetic acid ............................. 11

acetic acid-aluminum acetate

........................................ 126

acetylcysteine ..................... 126

ACID CONTROL

(RANITIDINE) ................ 91

ACID REDUCER

(FAMOTIDINE) .............. 91

ACIDOPHILUS-PECTIN .... 88

acidophilus-pectin, citrus ..... 88

acitretin ................................. 83

ACTEMRA ........................ 115

ACTHAR H.P. ..................... 98

ACTHIB (PF) ..................... 115

ACTIMMUNE ................... 115

acyclovir ............................... 55

acyclovir sodium .................. 55

ADACEL(TDAP

ADOLESN/ADULT)(PF)

................................ 115, 116

ADAGEN ............................. 86

ADEFOVIR .......................... 54

ADEMPAS ......................... 132

adriamycin ............................ 40

ADVAIR DISKUS ............. 132

ADVAIR HFA ................... 132

ADVIL LIQUI-GEL............... 4

AFINITOR ........................... 44

AFINITOR DISPERZ .......... 44

ak-poly-bac ........................... 11

ala-cort .................................. 33

ALA-HIST PE .................... 126

ALBENZA ........................... 47

albuterol sulfate .................. 130

alclometasone ....................... 33

alcohol pads .......................... 86

ALDURAZYME .................. 86

ALECENSA ......................... 44

alendronate ......................... 121

alfuzosin ............................... 97

ALIGN................................ 135

ALIMTA .............................. 39

ALINIA ................................ 48

ALIQOPA ............................ 44

ALL DAY PAIN RELIEF ...... 4

ALLERGY

RELIEF(DIPHENHYDRA

MIN) ............................... 128

allopurinol ............................ 33

allopurinol sodium ................ 86

alosetron ............................... 92

ALPHAGAN P ................... 124

alprazolam ............................ 60

ALTAVERA (28) ............... 101

ALUNBRIG ......................... 44

alyacen 1/35 (28) ................ 101

amabelz ............................... 101

amantadine hcl ...................... 49

AMBISOME ........................ 30

amikacin ............................... 10

amiloride ............................... 76

amiloride-hydrochlorothiazide

.......................................... 74

AMINO ACIDS 15 % ........ 135

aminophylline ..................... 131

AMINOSYN 7 % WITH

ELECTROLYTES .......... 135

aminosyn 8.5 %-electrolytes

........................................ 135

AMINOSYN II 10 % .......... 135

AMINOSYN II 15 % .......... 135

AMINOSYN II 8.5 % ......... 135

aminosyn ii 8.5 %-electrolytes

........................................ 135

AMINOSYN M 3.5 % ........ 135

AMINOSYN-HBC 7% ....... 135

AMINOSYN-PF 10 % ....... 135

AMINOSYN-PF 7 %

(SULFITE-FREE) .......... 135

AMINOSYN-RF 5.2 % ...... 135

amiodarone ........................... 71

AMITIZA ............................. 92

amitriptyline ......................... 28

amlodipine ............................ 72

amlodipine-benazepril .......... 74

amlodipine-olmesartan ......... 74

amlodipine-valsartan ............ 74

amlodipine-valsartan-hcthiazid

.......................................... 74

ammonium lactate ................ 83

AMNESTEEM ..................... 83

amoxapine ............................. 28

amoxicillin ............................ 17

amoxicillin-pot clavulanate .. 17

amphotericin b ...................... 30

ampicillin .............................. 18

ampicillin sodium ................. 18

ampicillin-sulbactam ............ 18

AMPYRA ............................. 81

ANADROL-50 ................... 100

anagrelide ............................. 67

anastrozole ............................ 43

ANDROGEL ...................... 100

ANDROXY ........................ 100

ANIMAL CHEWS ............. 148

162

ANIMAL SHAPE VITAMINS

........................................ 148

ANODYNE LPT .................... 8

ANORO ELLIPTA ............ 132

ANTACID ............................ 90

ANTACID (CALCIUM

CARBONATE) .......... 88, 90

ANTACID ANTI-GAS .. 88, 89

ANTACID EXTRA-

STRENGTH ............... 88, 89

ANTACID MAXIMUM

STRENGTH ..................... 88

ANTACID PLUS ANTI-GAS

.......................................... 90

ANTIBIOTIC (BACITRACIN

ZINC) ............................... 14

ANTIBIOTIC (NEOMY-

BACIT-POLYM) ............. 11

ANTI-DANDRUFF ............. 83

ANTI-DIARRHEAL

(LOPERAMIDE) . 89, 90, 91

ANTIFUNGAL

(TOLNAFTATE) ............. 30

ANTIFUNGAL CREAM ..... 30

ANTIOXIDANT VITAMINS

........................................ 148

APATATE .......................... 148

APATATE FORTE ............ 136

APOKYN ............................. 49

aprepitant .............................. 29

apri ...................................... 102

APTIOM............................... 24

APTIVUS ............................. 58

AQUA GLYCOLIC ............. 83

AQUADEKS ...................... 148

AQUADEKS PEDIATRIC 136

AQUASOL A ..................... 148

AQUASOL E (D-ALPHA

TOCOPHEROL) ............ 143

ARALAST NP ................... 126

aranelle (28)........................ 102

ARANESP (IN

POLYSORBATE) ...... 67, 68

ARCALYST ....................... 115

argatroban ............................. 66

argatroban in 0.9 % sod chlor

.......................................... 66

argatroban in nacl (iso-os) .... 66

aripiprazole ..................... 50, 51

ARISTADA .......................... 51

armodafinil ......................... 134

ARNUITY ELLIPTA ......... 128

ARRANON .......................... 39

ARTHRITIS PAIN RELIEF

(ACETAM) ................ 1, 2, 3

ARTHRITIS PAIN

RELIEVER ......................... 1

ARTIFICIAL TEARS

(POLYVIN ALC) ........... 122

ARTIFICIAL

TEARS(PVALCH-POVID)

........................................ 122

ascomp with codeine .............. 1

ascorbic acid (vitamin c) ... 148,

155, 158

ASPIR-81 ............................. 69

aspirin ................. 4, 5, 6, 69, 70

ASPIRIN LOW DOSE ......... 70

aspirin-dipyridamole ............ 69

ASPIR-LOW ........................ 69

assure id insulin safety ......... 86

ASTAGRAF XL................. 110

atazanavir.............................. 58

atenolol ................................. 72

atenolol-chlorthalidone ......... 74

ATGAM ............................. 110

ATHLETE'S FOOT

(TERBINAFINE) ............. 32

atomoxetine .......................... 80

atorvastatin ........................... 77

atovaquone............................ 48

atovaquone-proguanil ........... 48

ATRIPLA ............................. 58

atropine ............................... 122

AUBAGIO............................ 81

aubra ................................... 102

AVANDIA ........................... 61

AVASTIN ............................ 46

AVELOX IN NACL (ISO-

OSMOTIC) ....................... 19

aviane.................................. 102

AYR SALINE .................... 126

azacitidine ............................. 40

AZASAN ............................ 110

azathioprine ........................ 110

azathioprine sodium ........... 110

azelastine .................... 124, 127

azithromycin ................... 18, 19

AZOPT ............................... 124

aztreonam ............................. 17

B B COMPLEX-VITAMIN B12

........................................ 149

bacitracin ........................ 11, 12

bacitracin zinc ....................... 12

bacitracin-polymyxin b ......... 12

baclofen ................................ 54

BACTROBAN NASAL ....... 12

BALANCED B-100 ........... 148

BALANCED B-50 ............. 149

balsalazide .......................... 119

balziva (28) ......................... 102

BANOPHEN ...................... 127

BANOPHEN ANTI-ITCH . 127

BANZEL .............................. 24

BARACLUDE ...................... 54

BASAGLAR KWIKPEN U-

100 INSULIN ................... 64

BAVENCIO ......................... 46

BAZA ANTIFUNGAL ........ 30

BCG VACCINE, LIVE (PF)

........................................ 116

b-complex with vitamin c .. 143,

146

BEELITH ........................... 136

bekyree (28) ........................ 102

BELEODAQ ......................... 40

benazepril ............................. 71

benazepril-hydrochlorothiazide

.......................................... 74

BENEFIBER SUGAR FREE

(DEXTRIN) ...................... 92

BENLYSTA ....................... 115

benznidazole ......................... 47

benztropine ........................... 48

BESPONSA .......................... 46

beta carotene ....................... 149

BETADINE .......................... 12

betamethasone dipropionate . 33

betamethasone valerate ......... 33

betamethasone, augmented ... 33

BETASEPT SURGICAL

SCRUB ............................. 12

BETASERON ....................... 82

bethanechol chloride ............. 97

bexarotene ............................. 47

BEXSERO .......................... 116

bicalutamide ......................... 39

BICILLIN L-A ..................... 18

BICNU .................................. 38



Formulary ID: 18395



163

BIKTARVY ......................... 56

BILTRICIDE ........................ 48

biotin........... 143, 145, 148, 149

bisacodyl............................... 92

BISA-LAX ........................... 92

BISCOLAX .......................... 92

BISMATROL ....................... 89

bisoprolol fumarate .............. 72

bisoprolol-hydrochlorothiazide

.......................................... 74

BIVIGAM .......................... 114

bleomycin ............................. 40

blisovi fe 1.5/30 (28) .......... 102

blisovi fe 1/20 (28) ............. 102

BOOSTRIX TDAP ............ 116

BORTEZOMIB .................... 40

BOSULIF ............................. 44

BREO ELLIPTA ................ 132

BREWER'S YEAST ............ 30

briellyn ............................... 102

BRILINTA ........................... 69

brimonidine ........................ 124

BRIVIACT ........................... 21

bromocriptine ....................... 49

BROVANA ........................ 130

budesonide .......................... 128

BUDESONIDE .................. 120

bumetanide ........................... 76

buprenorphine......................... 6

buprenorphine hcl ................... 9

buprenorphine-naloxone......... 9

buproban ................................. 9

bupropion hcl........................ 26

bupropion hcl (smoking deter)

.......................................... 26

buspirone .............................. 60

busulfan ................................ 38

butalbital compound w/codeine

............................................ 1

butalbital-acetaminop-caf-cod 2

butalbital-acetaminophen ....... 2

butalbital-acetaminophen-caff 2

butalbital-aspirin-caffeine ...... 2

butorphanol tartrate ................ 7

C C-500 .................................. 155

cabergoline ......................... 108

CABOMETYX ..................... 44

calamine-zinc oxide .............. 84

CALCI-CHEW ................... 143

CALCIFEROL ................... 149

CALCIONATE .................. 136

calcipotriene ......................... 83

calcitonin (salmon) ............. 121

CALCITRATE ................... 136

CALCITRATE-VITAMIN D

........................................ 144

calcitriol .............................. 121

CALCIUM 500 WITH D ... 147

CALCIUM 600................... 144

CALCIUM 600 + D(3) ...... 136,

144

calcium acetate ..................... 98

CALCIUM ANTACID.. 89, 90,

91

calcium carbonate ....... 136, 144

calcium carbonate-vitamin d3

................ 136, 144, 147, 149

calcium citrate-vitamin d3 .. 144

calcium gluconate ............... 149

CALQUENCE ...................... 44

CALTRATE 600 + D ......... 149

CALTRATE 600+D PLUS

MINERALS.................... 149

CALTRATE WITH VITAMIN

D3 ................................... 144

camila ................................. 106

CANASA............................ 120

CANCIDAS.......................... 30

CAPASTAT ......................... 37

CAPRELSA.......................... 44

capsaicin ................................. 2

CAPSULE #0 (CELLULOSE)

.......................................... 70

CAPSULE #1 ....................... 70

CAPSULE #1

(HYPROMELLOSE) ....... 70

captopril ................................ 71

captopril-hydrochlorothiazide

.......................................... 74

CARBAGLU ...................... 136

carbamazepine ...................... 24

carbidopa-levodopa .............. 49

carboplatin ............................ 38

CARDIAMIN ..................... 149

CARIMUNE NF

NANOFILTERED .......... 114

carisoprodol ........................ 133

carisoprodol-asa-codeine ........ 2

carisoprodol-aspirin ................ 2

carteolol .............................. 124

cartia xt ................................. 72

carvedilol .............................. 72

caspofungin ........................... 30

CASTELLANI PAINT

MODIFIED ....................... 12

caziant (28) ......................... 102

cefaclor ................................. 15

cefadroxil .............................. 15

cefazolin ............................... 15

cefazolin in dextrose (iso-os) 15

cefdinir .................................. 15

cefepime ............................... 16

cefepime in dextrose 5 % ..... 15

cefepime in dextrose,iso-osm

.......................................... 15

cefotaxime ............................ 16

cefoxitin ................................ 16

cefoxitin in dextrose, iso-osm

.......................................... 16

cefpodoxime ......................... 16

cefprozil ................................ 16

ceftazidime ........................... 16

ceftazidime in d5w ............... 16

ceftriaxone ............................ 16

ceftriaxone in dextrose,iso-os

.......................................... 16

cefuroxime axetil .................. 16

cefuroxime sodium ............... 16

celecoxib ................................. 5

CELONTIN .......................... 22

CENTAMIN ....................... 149

CENTRAL-VITE ............... 149

164

CENTRUM ................ 149, 150

CENTRUM COMPLETE .. 144

CENTRUM KIDS .............. 149

CENTRUM SILVER ......... 150

CENTRUM SILVER ULTRA

MEN'S ............................ 150

CENTRUM SILVER ULTRA

WOMEN'S ..................... 144

CENTRUM SPECIALIST

ENERGY ........................ 144

CENTRUM SPECIALIST

HEART........................... 136

CENTRUM SPECIALIST

VISION .......................... 150

CENTRUM ULTRA

WOMEN'S ..................... 144

CENTURY ADVANCED

FORMULA .................... 144

CENTURY ENERGY

METABOLISM ............. 145

CENTURY MATURE ....... 150

CENTURY ULTIMATE

MEN'S ............................ 145

cephalexin............................. 16

CERAVE .............................. 83

CERDELGA......................... 86

CEREZYME ........................ 86

CEROVITE ........................ 150

CERTA PLUS .................... 150

CERTAVITE SENIOR-

ANTIOXIDANT ............ 150

CERTAVITE-ANTIOXID

(IRON GLUC)................ 150

CERTAVITE-

ANTIOXIDANT ............ 145

CETAPHIL GENTLE

CLEANSER ..................... 83

CETAPHIL MOISTURIZING

.......................................... 83

cetirizine ..................... 127, 133

cevimeline ............................ 82

CHANTIX .............................. 9

CHANTIX CONTINUING

MONTH BOX .................... 9

CHANTIX STARTING

MONTH BOX .................. 10

CHEWABLE VITAMIN C 158

CHILDREN'S ASPIRIN 69, 70

CHILDREN'S CHEWABLE

COMPLETE ................... 150

CHILDREN'S CHEWABLE

VITAMIN ....................... 150

CHILDREN'S CHEWABLES

........................................ 150


EXTRA C ....................... 150


WITH IRON ................... 150

CHILDREN'S COLD-

ALLERGY (PE) ............. 126

CHILD'S ALL DAY

ALLERGY(CETIR) ....... 128

CHILDS CHEW VITE ....... 150

CHILD'S CHEWABLE

VITAMINS/IRON.......... 145

CHILDS/IRON ................... 145

chloramphenicol sod succinate

.......................................... 12

chlorhexidine gluconate ....... 82

chloroquine phosphate .......... 48

chlorothiazide ....................... 76

chlorpheniramine maleate .. 128

chlorpromazine ..................... 28

chlorthalidone ....................... 76

chlorzoxazone ..................... 133

CHOLBAM .......................... 86

cholecalciferol (vitamin d3)

................................ 158, 159

cholestyramine (with sugar) . 77

cholestyramine light ............. 77

chorionic gonadotropin, human

.......................................... 98

ciclopirox .............................. 30

ciclopirox-ure-camph-menth-

euc .................................... 30

cidofovir ............................... 54

cilostazol ............................... 68

cimetidine ............................. 92

cimetidine hcl ....................... 92

CIMZIA .............................. 111

CIMZIA POWDER FOR

RECONST ...................... 111

CIMZIA STARTER KIT ... 111

CINRYZE ........................... 110

CIPRODEX ........................ 126

ciprofloxacin (mixture)......... 19

ciprofloxacin hcl ................... 19

ciprofloxacin lactate ............. 19

cisplatin ................................ 38

citalopram ............................. 26

CITRUCEL ........................... 92

CITRUCEL (SUCROSE) ..... 92

CITRUCEL SUGAR FREE . 92

CITRUS CALCIUM .......... 145

cladribine .............................. 39

claravis .................................. 83

clarithromycin ....................... 19

clemastine ........................... 128

CLIMARA PRO ................. 102

clindamycin hcl .................... 12

clindamycin in 0.9 % sod chlor

.......................................... 12

clindamycin in 5 % dextrose 12

clindamycin palmitate hcl ..... 12

clindamycin pediatric ........... 12

clindamycin phosphate ... 12, 13

clindamycin-benzoyl peroxide

.......................................... 13

clinimix 4.25%/d10w sulf free

........................................ 145

clinimix 4.25%-d20w sulf-free

........................................ 145

clinimix 4.25%-d25w sulf-free

........................................ 145

clinimix n14g30e 4.25%-d15w

sf ..................................... 145

clinimix n9g15e 2.75%-d7.5w

sf ..................................... 145

clinisol sf 15 % ................... 136

clobetasol ........................ 33, 34

clobetasol-emollient ............. 98

clofarabine ............................ 41

clomipramine ........................ 28

clonazepam ........................... 60

clonidine ............................... 70

clonidine hcl ................... 70, 80

clopidogrel ............................ 69

clorazepate dipotassium ........ 60

clotrimazole .............. 30, 31, 32

CLOTRIMAZOLE 3 DAY .. 30

clotrimazole-betamethasone . 83

clozapine ............................... 53

COARTEM ........................... 48

cod liver oil ............... 77, 78, 79

codeine-butalbital-asa-caff ..... 2

coenzyme q10 ............. 150, 151

COLACE CLEAR ................ 92

colchicine .............................. 33

colestipol ............................... 77

colistin (colistimethate na) ... 13



Formulary ID: 18395



165

colocort ............................... 120

COMBIGAN ...................... 124

COMBIPATCH .................. 102

COMBIVENT RESPIMAT 133

COMETRIQ ......................... 45

COMFORT PAC-

CYCLOBENZAPRINE . 133

COMFORT PAC-

IBUPROFEN ...................... 5

COMFORT PAC-

MELOXICAM ................... 5

COMFORT PAC-

NAPROXEN ...................... 5

COMFORT PAC-

TIZANIDINE ................... 54

COMPETE ......................... 151

COMPLERA ........................ 56

COMPLETE 50+ ............... 155

COMPLETE ALLERGY ... 128

COMPLETE

MULTIVITAMIN .......... 151

COMPLETE

MULTIVITAMIN-

MINERAL ...................... 147

COMPLETE SENIOR 151, 155

COMPLEX 15 ...................... 83

COMPOUND W .................. 83

compro .................................. 28

constulose ............................. 92

COPAXONE ........................ 82

CORLANOR ........................ 75

cortisone ............................... 98

COTELLIC........................... 45

COUMADIN ........................ 66

CREON ................................ 86

CRITIC-AID ........................ 83

CRIXIVAN .......................... 58

cromolyn..................... 124, 131

cryselle (28) ........................ 102

CUVPOSA ........................... 82

cyanocobalamin (vitamin b-12)

........................................ 151

cyclafem 1/35 (28) ............. 102

cyclafem 7/7/7 (28) ............ 102

cyclobenzaprine .................. 133

cyclophosphamide ................ 38

cyclosporine........................ 111

cyclosporine modified ........ 111

CYCLOTENS REFILL ...... 133

CYCLOTENS STARTER .. 133

cyproheptadine ................... 128

CYRAMZA .......................... 46

CYSTADANE ...................... 86

CYSTAGON ........................ 86

CYSTARAN ...................... 122

cytarabine ............................. 40

cytarabine (pf) ...................... 39

CYTO B-2 .......................... 151

D d10 %-0.45 % sodium chloride

........................................ 136

d2.5 %-0.45 % sodium

chloride ........................... 136

d5 % and 0.9 % sodium

chloride ........................... 136

d5 %-0.45 % sodium chloride

........................................ 136

dacarbazine ........................... 38

dactinomycin ........................ 41

DAILY VITAMIN ............. 151

DAILY VITAMIN

FORMULA .................... 151

DAILY VITAMIN

FORMULA-MINERALS

........................................ 151

DAILY VITAMIN WITH

IRON .............................. 151

DAILY VITAMIN WITH

IRON AND CA .............. 154

DALIRESP ......................... 131

DANAZOL ......................... 100

dantrolene ............................. 54

dapsone ................................. 37

DAPTACEL (DTAP

PEDIATRIC) (PF) .......... 116

daptomycin ........................... 13

DARAPRIM ......................... 48

darifenacin ............................ 97

DARZALEX ........................ 46

daunorubicin ......................... 41

deblitane ............................. 106

DECARA ............................ 151

decitabine .............................. 41

DEEP SEA NASAL ........... 126

delyla (28) ........................... 102

DELZICOL ......................... 120

demeclocycline ..................... 21

DEMSER .............................. 74

DENAVIR ............................ 55

DEPEN TITRATABS .......... 97

DEPO-PROVERA ................ 39

DEPO-SUBQ PROVERA 104

........................................ 106

DERMACERIN .................... 83

dermacinrx empricaine ........... 8

DERMACLOUD .................. 83

DESCOVY ........................... 57

DESENEX ............................ 31

desipramine ........................... 28

desmopressin .................. 98, 99

desog-e.estradiol/e.estradiol

........................................ 102

desogestrel-ethinyl estradiol

........................................ 102

desonide ................................ 34

desoximetasone ..................... 34

desvenlafaxine succinate ...... 26

dexamethasone ..................... 34

dexamethasone intensol ........ 34

dexamethasone sodium phos

(pf) .................................... 34

dexamethasone sodium

phosphate .................. 34, 125

dexmethylphenidate .............. 80

dexrazoxane hcl .................... 41

dextroamphetamine .............. 80

dextroamphetamine-

amphetamine ..................... 80

dextrose 10 % and 0.2 % nacl

........................................ 136

dextrose 10 % in water (d10w)

........................................ 136

dextrose 5 % in water (d5w)

........................................ 137

166

dextrose 5 %-lactated ringers

........................................ 137

dextrose 5%-0.2 % sod

chloride ........................... 137

dextrose 5%-0.3 %

sod.chloride .................... 137

DEXTROSE WITH SODIUM

CHLORIDE .................... 137

DIALYVITE 800 ............... 151

DIALYVITE 800 WITH ZINC

15 .................................... 151

DIALYVITE 800 WITH ZINC

50 .................................... 151

DIALYVITE 800-ULTRA D

........................................ 151

DIALYVITE VITAMIN D 151

DIALYVITE VITAMIN D3

MAX............................... 151

DIAPER RASH .................... 85

DIASTAT ............................. 22

DIASTAT ACUDIAL .......... 22

diazepam......................... 22, 60

diazepam intensol ................. 60

dibucaine ................................ 8

diclofenac potassium .............. 5

diclofenac sodium .......... 5, 125

dicloxacillin .......................... 18

DICLOZOR ............................ 5

dicyclomine .......................... 88

didanosine............................. 57

DIFICID ............................... 19

diflunisal ................................. 5

digitek ................................... 75

digox ..................................... 75

digoxin .................................. 75

dihydroergotamine ............... 36

DILANTIN ........................... 24

diltiazem hcl ................... 72, 73

dilt-xr .................................... 73

dimenhydrinate ..................... 28

DIPENTUM ....................... 120

DIPHEDRYL ..................... 128

DIPHENHIST .................... 128

diphenhydramine hcl .... 28, 128

diphenoxylate-atropine ......... 89

dipyridamole......................... 69

disopyramide phosphate ....... 71

disulfiram ............................... 9

divalproex ............................. 22

DM2 ..................................... 61

DML FORTE ....................... 83

docetaxel ................... 40, 43, 44

DOC-Q-LACE...................... 92

DOC-Q-LAX ........................ 92

DOCU ................................... 93

docusate calcium ...... 93, 94, 95

docusate sodium ................... 93

DOCUSIL ............................. 93

dofetilide ............................... 71

donepezil .............................. 25

doripenem ............................. 17

dorzolamide ........................ 124

dorzolamide-timolol ........... 124

doxazosin .............................. 71

doxepin ................................. 28

DOXEPIN ............................ 83

doxercalciferol .................... 121

doxorubicin ........................... 41

doxorubicin, peg-liposomal .. 41

doxy-100 ............................... 21

doxycycline hyclate .............. 21

doxycycline monohydrate .... 21

dronabinol ............................. 29

drospirenone-ethinyl estradiol

........................................ 102

DROXIA .............................. 40

DUAVEE............................ 101

DULERA ............................ 132

duloxetine ............................. 26

DUOFER ............................ 137

duramorph (pf) ....................... 7

DUREZOL ......................... 125

dutasteride ............................ 97

D-VI-SOL ........................... 151

D-VITA .............................. 151

E EAR DROPS (CARBAMIDE

PEROXIDE) ................... 126

EAR WAX REMOVAL

DROPS ........................... 126

ECEE PLUS ....................... 152

econazole .............................. 31

EDURANT ........................... 56

efavirenz ............................... 56

EGRIFTA ............................. 99

ELAPRASE .......................... 87

ELDERTONIC ................... 152

ELELYSO ............................ 87

ELIDEL ................................ 83

ELIGARD .......................... 108

ELIGARD (3 MONTH) ..... 108



ELIQUIS ............................... 66

ELITEK ................................ 87

ELITE-OB .......................... 145

ELIXOPHYLLIN ............... 131

ELMIRON ............................ 97

EMCYT ................................ 38

EMEND ................................ 29

emoquette ........................... 102

EMPLICITI .......................... 46

EMSAM ............................... 26

EMTRIVA ............................ 57

enalapril maleate ................... 71

enalapril-hydrochlorothiazide

.......................................... 74

ENBREL ............................. 111

ENBREL MINI .................. 111

ENBREL SURECLICK ..... 111

ENDARI ............................... 89

ENEMA ................................ 95

ENEMA DISPOSABLE ....... 93

ENEMEEZ ........................... 93

ENGERIX-B (PF) .............. 116

ENGERIX-B PEDIATRIC

(PF) ................................. 116

enoxaparin ............................ 66

enpresse .............................. 102

ENSKYCE .......................... 102

entacapone ............................ 49

entecavir ............................... 54

ENTRESTO .......................... 74

enulose .................................. 89

ENVARSUS XR ................ 111

EPCLUSA ............................ 55

epinastine ............................ 124

epinephrine ......................... 130

EPIPEN ............................... 130

EPIPEN 2-PAK .................. 130

EPIPEN JR ......................... 130

EPIPEN JR 2-PAK ............. 130

epirubicin .............................. 41

epitol ..................................... 24

EPIVIR HBV ........................ 54

eplerenone ............................. 76

EPOGEN .............................. 68

EPSOM SALT ................ 89, 91

EQUETRO ........................... 24



Formulary ID: 18395



167

ERAXIS(WATER DILUENT)

.......................................... 31

ERBITUX............................. 46

ergocalciferol (vitamin d2) 152,

156

ergoloid................................. 25

ergotamine-caffeine .............. 36

ERIVEDGE .......................... 45

ERLEADA ........................... 39

errin .................................... 106

ERWINAZE ......................... 41

ery pads ................................ 19

ERYTHROCIN .................... 19

erythrocin (as stearate) ......... 19

erythromycin ........................ 19

erythromycin ethylsuccinate 19

erythromycin with ethanol ... 19

erythromycin-benzoyl peroxide

.......................................... 84

ESBRIET ............................ 133

escitalopram oxalate ............. 27

ESTRACE .......................... 101

estradiol .............................. 101

estradiol valerate ................ 101

estradiol-norethindrone acet

................................ 102, 103

ESTRING ........................... 101

estropipate .......................... 101

ethambutol ............................ 37

ethosuximide ........................ 22

ethynodiol diac-eth estradiol

........................................ 103

etidronate disodium ............ 121

etodolac .................................. 5

ETOPOPHOS ....................... 44

etoposide............................... 44

EVOTAZ .............................. 58

exemestane ........................... 43

EXJADE ............................. 134

EX-LAX MAXIMUM

STRENGTH ..................... 93

EXONDYS 51 ...................... 81

EXTAVIA ............................ 82

EYESCRUB ....................... 124

ezetimibe .............................. 78

ezetimibe-simvastatin ........... 78

EZFE 200 ........................... 137

F FABRAZYME ..................... 87

falmina (28) ........................ 103

famciclovir............................ 55

famotidine ............................. 92

famotidine (pf) ...................... 92

FANAPT .............................. 51

FARESTON ......................... 39

FARYDAK ........................... 41

FASLODEX ......................... 39

FATIGUE RELIEF

COMPLEX ..................... 143

felbamate .............................. 23

felodipine .............................. 73

femynor .............................. 103

fenofibrate ............................ 77

fenofibrate micronized ......... 77

fenofibrate nanocrystallized . 77

fenofibric acid (choline) ....... 77

fentanyl ................................... 6

fentanyl citrate ........................ 7

FERAHEME ...................... 137

FERATE ............................. 137

FERGON ............................ 137

FER-IN-SOL ...................... 152

FEROSUL .................. 137, 152

FERRETTS ........................ 137

FERRETTS IPS .................. 137

FERREX 150 .............. 137, 138

FERRIMIN 150 .................. 138

FERRIPROX ...................... 134

FERRLECIT ....................... 138

FERRO-TIME .................... 138

ferrous fumarate ................. 138

ferrous gluconate ....... 138, 140,

152, 153

ferrous sulfate .... 138, 139, 150,

152

FERROUSUL ..................... 139

FETZIMA ............................. 27

fexofenadine ....................... 128

FIBER ................................... 96

FIBER (PSYLLIUM

HUSK/SUGAR) ............... 96

FIBER LAXATIVE (CA

POLYCARBO) ........... 93, 96

FIBER SMOOTH

(SUCROSE) ..................... 96

FIBER THERAPY (M-

CELL/SUGAR) ................ 93

FIBER-LAX ................... 93, 94

finasteride ............................. 97

FIRAZYR ........................... 110

FIRMAGON ....................... 109

FIRMAGON KIT W

DILUENT SYRINGE .... 108

FIRST AID ABX PAIN

RELIEF ............................. 13

FISH OIL .................... 139, 141

flavoxate ............................... 97

FLEBOGAMMA DIF ........ 114

flecainide .............................. 71

FLEET GLYCERIN (ADULT)

.......................................... 93

FLORANEX ................. 89, 139

FLOVENT DISKUS .......... 128

FLOVENT HFA ................. 129

fluconazole ........................... 31

fluconazole in dextrose(iso-o)

.......................................... 31

fluconazole in nacl (iso-osm)31

flucytosine ............................ 31

FLUDARABINE ............ 40, 41

fludrocortisone ...................... 98

flunisolide ........................... 129

fluocinolone .......................... 34

fluocinonide .......................... 34

fluocinonide-e ....................... 34

fluocinonide-emollient ......... 34

fluoride (sodium) ................ 139

FLUORIDE (SODIUM) ..... 139

fluorometholone ................. 125

fluorouracil ........................... 40

fluoxetine .............................. 27

fluphenazine decanoate ........ 50

fluphenazine hcl .................... 50

flurbiprofen ............................. 5

168

flurbiprofen sodium ............ 125

flutamide............................... 39

fluticasone .................... 34, 129

fluticasone-salmeterol ........ 129

fluvoxamine .......................... 27

FML FORTE ...................... 125

FOLGARD ......................... 152

folic acid ..................... 145, 152

FOLITAB ........................... 139

fondaparinux......................... 66

FORFIVO XL ...................... 26

FORTEO ............................ 121

fosamprenavir ....................... 58

fosinopril .............................. 71

fosinopril-hydrochlorothiazide

.......................................... 74

fosphenytoin ......................... 24

FOSRENOL ......................... 98

FRAGMIN ........................... 67

FRESHKOTE ..................... 122

FUNGOID TINCTURE ....... 31

furosemide ............................ 76

FUSILEV ............................. 41

FUZEON .............................. 58

fyavolv ................................ 103

FYCOMPA .................... 23, 69

G gabapentin ...................... 22, 23

GABITRIL ........................... 23

GAMASTAN S/D .............. 114

GAMMAGARD LIQUID .. 114

GAMMAGARD S-D (IGA < 1

MCG/ML) ...................... 114

GAMMAKED .................... 114

GAMMAPLEX .................. 114

GAMMAPLEX (WITH

SORBITOL) ................... 114

GAMUNEX-C ................... 114

ganciclovir sodium ............... 54

GARDASIL (PF)................ 116

GARDASIL 9 (PF)............. 116

GAS RELIEF ................. 89, 90

GAS RELIEF EXTRA

STRENGTH ..................... 91

GAS RELIEF ULTRA

STRENGTH ..................... 89

GATTEX 30-VIAL .............. 89

GATTEX ONE-VIAL .......... 89

gauze pad .............................. 86

gavilyte-c .............................. 88

gavilyte-g .............................. 93

gavilyte-n .............................. 93

GAVISCON EXTRA

STRENGTH ..................... 89

gemcitabine .......................... 40

gemfibrozil ........................... 77

generlac ................................ 90

gengraf ................................ 111

GENOTROPIN .................... 99

GENOTROPIN MINIQUICK

.......................................... 99

gentak ................................... 10

gentamicin ...................... 10, 11

gentamicin sulfate (ped) (pf) 11

gentamicin sulfate (pf).......... 11

GENTEAL MILD TO

MODERATE .................. 122

GENTEAL GEL ................. 122

GENTEAL PM ................... 122

GENTEAL SEVERE ......... 123

GENTLE LAXATIVE ... 95, 96

GENVOYA .......................... 58

GEODON ............................. 51

GERIATON........................ 152

gildagia ............................... 103

gildess 1.5/30 (21) .............. 103

GILENYA ............................ 82

GILOTRIF ............................ 45

GLASSIA ........................... 126

glatiramer.............................. 82

GLEOSTINE ........................ 38

glimepiride............................ 61

glipizide ................................ 61

glipizide-metformin ........ 61, 62

GLUCAGEN DIAGNOSTIC

KIT ................................... 63

GLUCAGEN HYPOKIT ..... 64

GLUCAGON EMERGENCY

KIT (HUMAN)................. 64

GLUCAGON HCL............... 64

glucosamine sulfate ............ 139

glucosamine-chondroitin ..... 70,

139

GLUCOSAMINE-

CHONDROITIN 3X ...... 148

glucose .................................. 64

glyburide ............................... 62

glyburide micronized ............ 62

glyburide-metformin ............ 62

glycopyrrolate ....................... 88

GLYXAMBI ......................... 62

GOCOVRI ............................ 49

granisetron (pf) ..................... 29

granisetron hcl ................ 29, 30

GRANIX ............................... 68

griseofulvin microsize .......... 31

guanfacine ....................... 70, 80

guanidine .............................. 37

H HAEGARDA ...................... 110

HALAVEN ........................... 41

halobetasol propionate .......... 35

haloperidol ............................ 50

haloperidol decanoate ........... 50

haloperidol lactate ................ 50

HAVRIX (PF) .................... 116

HEALTHY EYES ...... 152, 153

HEALTHYLAX ................... 93

HEMOCYTE ...................... 139

HEMORRHOID ................... 84

HEMORRHOIDAL ................ 9

HEMORRHOIDAL CREAM 9

heparin (porcine) .................. 67

heparin (porcine) in 5 % dex 67

heparin, porcine (pf) ............. 67

HEPLISAV-B ..................... 117

HERCEPTIN ........................ 46

HETLIOZ ........................... 134

HEXALEN ........................... 38

HIBERIX (PF) .................... 117

HORIZANT .......................... 81

HUMALOG JUNIOR

KWIKPEN U-100 ............ 64

HUMALOG KWIKPEN

INSULIN .......................... 64

HUMALOG MIX 50-50

INSULN U-100 ................ 64

HUMALOG MIX 50-50

KWIKPEN ........................ 64

HUMALOG MIX 75-25

KWIKPEN ........................ 64

HUMALOG MIX 75-25(U-

100)INSULN .................... 64

HUMALOG U-100 INSULIN

.......................................... 64

HUMATROPE ..................... 99

HUMIRA ............................ 112

HUMIRA PEDIATRIC

CROHN'S START.......... 111

HUMIRA PEN ................... 112



Formulary ID: 18395



169

HUMIRA PEN CROHN'S-

UC-HS START .............. 111

HUMIRA PEN PSORIASIS-

UVEITIS ........................ 112

HUMULIN 70/30 U-100

INSULIN .......................... 65

HUMULIN 70/30 U-100

KWIKPEN ....................... 65

HUMULIN N NPH INSULIN

KWIKPEN ....................... 65

HUMULIN N NPH U-100

INSULIN .......................... 65

HUMULIN R REGULAR U-

100 INSULN .................... 65

HUMULIN R U-500 (CONC)

INSULIN .......................... 65

HUMULIN R U-500 (CONC)

KWIKPEN ....................... 65

hydralazine ........................... 79

hydrochlorothiazide .............. 76

hydrocodone-acetaminophen . 2

hydrocodone-ibuprofen .......... 2

hydrocortisone .. 35, 84, 98, 120

hydrocortisone acetate .......... 84

hydrocortisone butyrate ........ 35

hydrocortisone butyr-emollient

.......................................... 35

hydrocortisone valerate ........ 35

hydrocortisone-acetic acid.. 126

hydrocortisone-aloe vera ...... 35

hydrocortisone-min oil-wht pet

.......................................... 84

hydromorphone ...................... 7

hydromorphone (pf) ............... 7

HYDROSKIN ...................... 84

hydroxocobalamin .............. 153

hydroxychloroquine ............. 48

hydroxyurea .......................... 40

hydroxyzine hcl .................... 60

hydroxyzine pamoate ........... 60

HYPERRAB (PF) .............. 114

HYPERRAB S/D (PF) ....... 114

I I.L.X. B-12 ......................... 153

ibandronate ......................... 121

IBRANCE ............................ 44

IBU ......................................... 5

ibuprofen ............................ 5, 6

ibuprofen-oxycodone.............. 2

ICAPS ................................. 139

I-CAPS ............................... 153

ICAPS AREDS................... 153

ICAPS MV ......................... 139

ICAPS PLUS ...................... 146

ICLUSIG .............................. 45

idarubicin .............................. 41

IDHIFA ................................ 45

IFEREX 150 ....................... 139

ifosfamide ............................. 38

ILARIS (PF) ....................... 115

imatinib ................................. 45

IMBRUVICA ....................... 45

IMFINZI ............................... 46

imipenem-cilastatin .............. 17

imipramine hcl ...................... 28

imipramine pamoate ............. 28

imiquimod ............................ 84

IMOVAX RABIES VACCINE

(PF) ................................. 117

INCRELEX .......................... 99

INCRUSE ELLIPTA .......... 129

indapamide ........................... 76

indomethacin .......................... 6

INFANRIX (DTAP) (PF) ... 117

INFED ................................ 139

INFLECTRA ...................... 112

INFUVITE ADULT ... 139, 140

INFUVITE PEDIATRIC .... 153

INGREZZA .......................... 81

INJECTAFER .................... 140

INLYTA ............................... 45

INSTA-GLUCOSE (WITH

DEXTRIN) ....................... 64

insulin syringe-needle u-100 86

INTEGRA .......................... 146

INTELENCE ........................ 56

intralipid ............................. 146

INTRON A ........................... 54

introvale .............................. 103

INVANZ ............................... 17

INVEGA SUSTENNA ......... 51

INVEGA TRINZA ............... 52

INVIRASE ..................... 58, 59

INVOKAMET ...................... 62

INVOKAMET XR ............... 62

INVOKANA ......................... 62

IOSAT ................................ 110

IPOL ................................... 117

ipratropium bromide ........... 129

ipratropium-albuterol .......... 133

irbesartan .............................. 71

irbesartan-hydrochlorothiazide

.......................................... 74

IRESSA ................................ 45

irinotecan .............................. 44

IRON .......................... 140, 146

IRON 100 PLUS ................. 146

iron,carbonyl-vitamin c ...... 153

ISENTRESS ......................... 56

ISENTRESS HD .................. 56

ISIBLOOM ......................... 103

ISOLYTE S PH 7.4 ............ 122

ISOLYTE-P IN 5 %

DEXTROSE ................... 134

ISOLYTE-S ........................ 122

isoniazid ................................ 37

isosorbide dinitrate ............... 79

isosorbide mononitrate ......... 79

isotretinoin ............................ 84

isradipine .............................. 73

ISTODAX ............................. 41

ITCH RELIEF ...................... 84

itraconazole ........................... 31

ivermectin ............................. 48

IXIARO (PF) ...................... 117

J JADENU ............................. 134

JADENU SPRINKLE ........ 134

JAKAFI ................................ 45

jantoven ................................ 67

JANUMET ........................... 62

JANUMET XR ..................... 62

JANUVIA ............................. 62

JARDIANCE ........................ 62

JENTADUETO .................... 62

170

JENTADUETO XR.............. 62

JEVTANA ............................ 44

jinteli................................... 103

jolivette ............................... 107

juleber ................................. 103

JULUCA............................... 56

junel 1.5/30 (21) ................. 103

junel 1/20 (21) .................... 103

junel fe 1.5/30 (28) ............. 103

junel fe 1/20 (28) ................ 103

JUXTAPID ........................... 78

K KADCYLA .................... 40, 41

KALETRA ........................... 59

KALYDECO ...................... 131

kariva (28) .......................... 103

kelnor 1/35 (28) .................. 103

KELNOR 1-50 ................... 103

ketoconazole ......................... 31

ketoprofen............................... 6

ketorolac ......................... 6, 125

KEVEYIS ............................. 76

KEYTRUDA ........................ 47

kimidess (28) ...................... 103

KINERET ........................... 112

KINRIX (PF) ...................... 117

kionex ................................. 134

kionex (with sorbitol) ......... 134

KISQALI .............................. 41

KISQALI FEMARA CO-

PACK ............................... 41

klor-con 10 ......................... 140

klor-con 8 ........................... 140

klor-con m10 ...................... 140

KLOR-CON M15 ............... 140

klor-con m20 ...................... 140

KLOR-CON SPRINKLE ... 140

KORLYM............................. 63

KRISTALOSE ..................... 94

K-SOL ................................ 140

KURVELO ......................... 103

KUVAN ............................... 87

KYNAMRO ......................... 78

KYPROLIS .......................... 42

L labetalol ................................ 72

lactase ................................... 90

lactated ringers ................... 146

LACTINOL HX ................... 84

lactulose ................................ 94

LAMISIL AT ....................... 31

lamivudine ............................ 54

lamivudine-zidovudine ......... 57

lamotrigine...................... 23, 24

lansoprazole .......................... 96

lanthanum ............................. 98

LANTUS SOLOSTAR U-100

INSULIN .......................... 65

LANTUS U-100 INSULIN .. 65

larin 1.5/30 (21) .................. 103

larin 1/20 (21) ..................... 103

larin fe 1.5/30 (28) .............. 104

larin fe 1/20 (28) ................. 104

larissia ................................. 104

LARTRUVO ........................ 47

latanoprost .......................... 126

LATUDA.............................. 52

LAXATIVE (BISACODYL)94

LAXATIVE PILLS

REGULAR ....................... 94

LAXATIVE PLUS STOOL

SOFTENER ...................... 96

LAZANDA ............................. 7

L-CARNITINE (TARTRATE)

........................................ 146

leena 28............................... 104

leflunomide ......................... 115

LENVIMA............................ 45

lessina ................................. 104

LETAIRIS .......................... 132

letrozole ................................ 43

leucovorin calcium ............... 42

LEUKERAN ........................ 38

LEUKINE ............................. 68

leuprolide ............................ 109

LEVA SET ............................. 8

levalbuterol hcl ................... 130

LEVEMIR FLEXTOUCH U-

100 INSULN .................... 65

LEVEMIR U-100 INSULIN 65

levetiracetam ........................ 21

levetiracetam in nacl (iso-os) 21

levobunolol ......................... 124

levocarnitine ....................... 146

levocarnitine (with sugar) ... 146

levocetirizine ...................... 128

levofloxacin .......................... 20

levofloxacin in d5w .............. 20

levoleucovorin ...................... 42

LEVOLEUCOVORIN ......... 42

levonest (28) ....................... 104

levonorgestrel-ethinyl estrad

........................................ 104

levonorg-eth estrad triphasic

........................................ 104

levora-28 ............................. 104

levothyroxine ...................... 107

levoxyl ................................ 107

LEXIVA ............................... 59

LIALDA ............................. 120

lidocaine ................................. 8

lidocaine (pf) .......................... 8

lidocaine hcl ............................ 8

lidocaine-prilocaine ................ 8

LIDOPAC ............................... 8

lidopril .................................... 8

lidopril xr ................................ 8

LIDO-PRILO CAINE PACK . 9

LILLOW ............................. 104

lincomycin ............................ 13

lindane .................................. 48

linezolid ................................ 13

linezolid in dextrose 5% ....... 13

linezolid-0.9% sodium chloride

.......................................... 13

LINZESS .............................. 92

liothyronine ......................... 108

LIPOFLAVOVIT ............... 153

liprozonepak ........................... 9

lisinopril ................................ 71

lisinopril-hydrochlorothiazide

.......................................... 74

lithium carbonate .................. 61

lithium citrate ........................ 61

LIVALO ............................... 77

livixil pak ................................ 9

LO-DOSE ASPIRIN ............ 70

LONSURF ............................ 42

loperamide ............................ 90

lopinavir-ritonavir ................. 59

lopreeza ............................... 104

loratadine ............................ 128

lorazepam ............................. 61

lorazepam intensol ................ 61

losartan ................................. 71

losartan-hydrochlorothiazide 74

LOTRIMIN AF POWDER ... 84

lovastatin ............................... 77

low-ogestrel (28) ................ 104

loxapine succinate ................ 50



Formulary ID: 18395



171

LUBRISOFT ........................ 70

LUMIGAN ......................... 126

LUMIZYME ...................... 127

LUPRON DEPOT .............. 109

LUPRON DEPOT (3

MONTH) ........................ 109

LUPRON DEPOT (4

MONTH) ........................ 109

LUPRON DEPOT (6

MONTH) ........................ 109

LUPRON DEPOT-PED ..... 109

LUPRON DEPOT-PED (3

MONTH) ........................ 109

lutera (28) ........................... 104

LYNPARZA......................... 42

LYRICA ............................... 22

LYSODREN....................... 108

lyza ..................................... 107

M M.V.I. ADULT................... 153

M.V.I. PEDIATRIC ........... 153

M.V.I.-12 (WITHOUT

VITAMIN K) ................. 140

MAG-DELAY ...................... 90

MAG-G .............................. 146

magnesium ......................... 140

magnesium citrate .......... 94, 96

magnesium oxide................ 140

magnesium sulfate .............. 140

malathion .............................. 48

MAPAP

(ACETAMINOPHEN) ....... 2

MAPAP ARTHRITIS PAIN .. 2

MAPAP EXTRA STRENGTH

............................................ 2

MAPAP PM ........................... 2

maprotiline ........................... 27

marlissa............................... 104

MARPLAN .......................... 26

MATULANE ....................... 38

MAVYRET .......................... 55

MAXIMUM D3 ................. 153

meclizine .............................. 28

meclofenamate ....................... 6

MEDERMA ......................... 84

MEDOLOR PAK ................... 9

medroxyprogesterone ......... 107

mefloquine ............................ 48

MEGA MULTI FOR WOMEN

........................................ 153

MEGA MULTIVITAMIN

FOR MEN ...................... 146

MEGA MULTIVITAMIN

WITH MINERAL .......... 154

megestrol ............................ 107

MEKINIST ........................... 45

melatonin ............................ 134

meloxicam .............................. 6

melphalan hcl ....................... 38

memantine ............................ 25

MENACTRA (PF) ............. 117

MENEST ............................ 101


........................................ 117


(PF) ................................. 117

MENTAX ............................. 31

MENVEO A-C-Y-W-135-DIP

(PF) ................................. 117

meperidine .............................. 8

MEPHYTON ........................ 68

meprobamate ........................ 60

mercaptopurine ..................... 40

meropenem ........................... 17

meropenem-0.9% sodium

chloride ............................. 17

mesalamine ......................... 120

mesalamine with cleansing

wipe ................................ 120

mesna .................................... 42

MESNEX.............................. 42

METAMUCIL (WITH

SUGAR) ........................... 94

METAMUCIL FIBER

SINGLES.......................... 94

METAMUCIL SUGAR-FREE

(ASPART) ........................ 94

METAMUCIL SUNRISE .... 94

metaproterenol .................... 130

metformin ....................... 62, 63

methadone ........................... 6, 7

methazolamide ...................... 76

methenamine hippurate ........ 13

methimazole ....................... 110

methocarbamol ................... 133

methotrexate sodium .......... 112

methotrexate sodium (pf) ... 112

methoxsalen .......................... 84

methscopolamine .................. 88

methyclothiazide ................... 76

methyldopa ........................... 70

methyldopa-

hydrochlorothiazide .......... 74

methyldopate ........................ 70

methylphenidate hcl ........ 80, 81

methylprednisolone .............. 35

methylprednisolone acetate .. 35

methylprednisolone sodium

succ ................................... 35

methyltestosterone .............. 100

metipranolol ........................ 125

metoclopramide hcl ........ 28, 29

metolazone ............................ 76

metoprolol succinate ............. 72

metoprolol tartrate ................ 72

metro i.v. ............................... 13

metronidazole ....................... 13

metronidazole in nacl (iso-os)

.......................................... 13

mexiletine ............................. 72

MIACALCIN ..................... 121

MI-ACID .............................. 90

MI-ACID GAS RELIEF ....... 90

MICONAZOLE 7 ................. 31

miconazole nitrate ................ 32

MICONAZORB AF ............. 32

microgestin 1.5/30 (21) ...... 104

microgestin 1/20 (21) ......... 104

microgestin fe 1.5/30 (28) .. 104

microgestin fe 1/20 (28) ..... 104

MICRO-GUARD ................. 32

midodrine .............................. 70

miglustat ............................... 87

MIGRAINE RELIEF ............ 36

172

MILK OF MAGNESIA 93, 94,

95

MIMVEY ........................... 104

mimvey lo ........................... 104

mineral oil ............................ 70

MINERAL OIL HEAVY ..... 94

MINERIN ............................. 84

MINERIN CREME .............. 84

minocycline .......................... 21

minoxidil .............................. 79

MINTOX .............................. 90

mirtazapine ........................... 26

misoprostol ........................... 96

mitomycin............................. 42

mitoxantrone......................... 44

M-M-R II (PF) .................... 117

MOBISYL ............................ 84

MODAFINIL ..................... 134

moexipril .............................. 71

moexipril-hydrochlorothiazide

.......................................... 75

mometasone .................. 35, 129

mononessa (28) .................. 104

montelukast ........................ 129

morgidox .............................. 21

MORGIDOX 1X 50 ............. 21

morphine............................. 7, 8

MOTION SICKNESS

RELIEF(MECLIZ) ........... 29

MOXEZA ............................. 20

moxifloxacin......................... 20

moxifloxacin in nacl (iso-osm)

.......................................... 20

moxifloxacin-sod.ace,sul-water

.......................................... 20

MOZOBIL ............................ 68

MULTAQ ............................. 72

MULTI-DELYN ................ 146

MULTI-DELYN WITH IRON

........................................ 154

MULTILEX ....................... 154

MULTILEX-T AND M ..... 154

MULTIPLE VITAMIN

ESSENTIAL................... 154

multivitamin ....................... 154

mupirocin ............................. 13

MURO 128 ......................... 123

MUSCLE RUB ...................... 3

MUSCLE RUB (WITH

CAMPHOR) ....................... 3

MUSTARGEN ..................... 38

MYCAMINE ........................ 32

mycophenolate mofetil ....... 112

mycophenolate mofetil hcl . 112

mycophenolate sodium ....... 112

MYKIDZ IRON ................. 140

MYLOTARG ....................... 47

myorisan ............................... 84

MYRBETRIQ ...................... 97

MYTAB GAS....................... 90

MYTAB GAS MAXIMUM

STRENGTH ..................... 90

N nabumetone ............................ 6

nadolol .................................. 72

nafcillin ................................. 18

nafcillin in dextrose iso-osm 18

NAGLAZYME ..................... 87

NAIL-EX ............................ 154

nalbuphine .............................. 8

naloxone ................................. 9

naltrexone ............................... 9

NAMENDA XR ................... 25

naphazoline ......................... 123

NAPHCON-A .................... 124

naproxen ................................. 6

naproxen sodium .................... 6

NASAL SPRAY

(OXYMETAZOLINE) ... 127

NASAL SPRAY 12 HOUR 127

NASCOBAL ...................... 154

NATACYN ........................ 123

nateglinide ............................ 63

NATPARA ......................... 121

NATURAL FIBER

LAXATIVE THERAPY .. 94

NATURAL VEGETABLE

(PSYLLIUM) ................... 95

NEBUPENT ......................... 48

necon 0.5/35 (28) ................ 104

necon 1/35 (28) ................... 104

necon 10/11 (28) ................. 104

necon 7/7/7 (28).................. 105

nefazodone............................ 26

neomycin .............................. 11

neomycin-bacitracin-poly-hc 14

neomycin-bacitracin-

polymyxin ......................... 14

neomycin-polymyxin b gu.... 14

neomycin-polymyxin b-

dexameth ........................... 14

neomycin-polymyxin-

gramicidin ......................... 14

neomycin-polymyxin-hc ...... 14,

126

NERLYNX ........................... 45

NEULASTA ......................... 68

NEUPOGEN ......................... 68

NEUPRO .............................. 49

nevirapine ............................. 56

NEXAVAR ........................... 45

niacin .................................... 78

niacin (inositol niacinate) ..... 78

niacinamide ........................... 78

NICODERM CQ .................. 10

nicotine ................................. 10

nicotine (polacrilex) .............. 10

NICOTROL .......................... 10

NICOTROL NS .................... 10

nifedical xl ............................ 73

nifedipine .............................. 73

nilutamide ............................. 39

nimodipine ............................ 73

NINLARO ............................ 42

NIPENT ................................ 40

NITRO-BID .......................... 79

NITRO-DUR ........................ 79

nitrofurantoin macrocrystal .. 14

nitrofurantoin monohyd/m-

cryst .................................. 14

nitroglycerin ......................... 79

NITYR .................................. 87

nizatidine .............................. 92

NOCTIVA ............................ 99

NON-ASPIRIN PAIN RELIEF

........................................ 3, 4

NON-ASPIRIN PM ................ 4

nora-be ................................ 107

NORDITROPIN FLEXPRO 99

norethindrone (contraceptive)

........................................ 107

norethindrone acetate .......... 107

norethindrone ac-eth estradiol

........................................ 105

norgestimate-ethinyl estradiol

........................................ 105

NORLYDA ......................... 105

norlyroc ............................... 107

normosol-r .......................... 140



Formulary ID: 18395



173

normosol-r ph 7.4 ............... 140

NORPACE CR ..................... 72

NORTHERA ........................ 75

nortrel 0.5/35 (28) .............. 105

nortrel 1/35 (21) ................. 105

nortrel 1/35 (28) ................. 105

nortrel 7/7/7 (28) ................ 105

nortriptyline .......................... 28

NORVIR............................... 59

NOVAFERRUM ................ 141

NOVAFERRUM 125 ......... 141

NOVAFERRUM 50 ........... 141

NOVOLIN 70/30 U-100

INSULIN .......................... 65

NOVOLIN N NPH U-100

INSULIN .......................... 65

NOVOLIN R REGULAR U-

100 INSULN .................... 66

NOVOLOG FLEXPEN U-100

INSULIN .......................... 66

NOVOLOG MIX 70-30 U-100

INSULN ........................... 66

NOVOLOG MIX 70-

30FLEXPEN U-100 ......... 66

NOVOLOG PENFILL U-100

INSULIN .......................... 66

NOVOLOG U-100 INSULIN

ASPART........................... 66

NOXAFIL ............................ 32

NUEDEXTA ........................ 81

NULOJIX ........................... 112

NUPLAZID .......................... 52

NUTROPIN AQ ................. 100

NUTROPIN AQ NUSPIN . 100

nyamyc ................................. 32

nystatin ................................. 32

nystatin-triamcinolone .......... 84

nystop ................................... 32

O OCALIVA ............................ 90

ocella .................................. 105

octreotide acetate ................ 109

OCTREOTIDE ACETATE 109

OCUVITE .......................... 154

OCUVITE LUTEIN AND

ZEAXANTHIN .............. 146

OCUVITE WITH LUTEIN 154

ODACTRA ......................... 127

ODEFSEY ............................ 58

ODOMZO ............................ 42

OFEV.................................... 45

ofloxacin ....................... 20, 126

olanzapine ............................. 52

olmesartan ............................ 71

olmesartan-amlodipin-

hcthiazid ........................... 75

olmesartan-

hydrochlorothiazide .......... 75

olopatadine ......................... 124

omega 3-dha-epa-fish oil .... 139

omega-3 acid ethyl esters ..... 78

omega-3 fatty acids-fish oil 154

omeprazole ........................... 96

OMNITROPE ..................... 100

ONCE DAILY .................... 154

ONCOVITE........................ 154

ondansetron .......................... 30

ondansetron hcl..................... 30

ondansetron hcl (pf).............. 30

ONE DAILY .............. 141, 154

ONE DAILY ESSENTIAL

................................ 146, 154

ONE DAILY MAXIMUM . 146

ONE DAILY MEN'S 50 PLUS

MEMORY ...................... 146

ONE DAILY PLUS IRON . 146

ONE DAILY WITH IRON 154

ONE DAILY WOMEN'S ... 146

ONE DAILY WOMEN'S

HEALTH ........................ 146

ONFI ..................................... 23

OPDIVO ............................... 47

OPTIMAL D3 .................... 154

ORENCIA .......................... 112

ORENCIA (WITH

MALTOSE) .................... 112

ORENCIA CLICKJECT .... 112

ORFADIN ............................ 87

ORKAMBI ......................... 131

orphenadrine citrate ............ 133

orsythia ............................... 105

OS-CAL 500 + D3.............. 146

oseltamivir ............................ 59

OTEZLA ............................. 112

OTEZLA STARTER .......... 113

oxaliplatin ............................. 38

oxandrolone ........................ 100

oxcarbazepine ....................... 24

oxybutynin chloride .............. 97

oxycodone ........................... 7, 8

oxycodone-acetaminophen ..... 3

oxycodone-aspirin .................. 3

OYSCO 500/D ............ 146, 154

OYSCO-500 ....................... 146

OYSTER SHELL + D3 ...... 149

OYSTER SHELL CALCIUM

500 .................................. 147

OYSTER SHELL CALCIUM-

VIT D3 ............................ 147

P paclitaxel ............................... 44

PAIN AND FEVER ............... 3

PAIN RELIEF .................... 2, 3

PAIN RELIEF EXTRA

STRENGTH ................... 2, 3

PAIN RELIEVER .............. 3, 4

PAIN RELIEVER EXTRA

STRENGTH ............... 2, 3, 4

paliperidone .......................... 52

pamidronate ........................ 121

PANRETIN .......................... 47

pantoprazole ................... 96, 97

pantothenic acid (vit b5) ..... 147

paricalcitol .......................... 121

paromomycin ........................ 11

paroxetine hcl ....................... 27

PASER .................................. 37

PAXIL .................................. 27

PEDIARIX (PF) ................. 117

PEDVAX HIB (PF) ............ 117

peg 3350-electrolytes ............ 94

peg-3350 with flavor packs .. 94

PEGANONE ......................... 24

PEGASYS ............................ 55

174

PEGASYS PROCLICK ....... 55

peg-electrolyte soln .............. 94

pen needle, diabetic .............. 86

penicillin g procaine ............. 18

penicillin g sodium ............... 18

penicillin v potassium........... 18

PENTACEL ACTHIB

COMPONENT (PF) ....... 118

PENTAM ............................. 48

PENTASA .......................... 120

pentazocine-naloxone ............. 3

pentoxifylline ....................... 76

periogard............................... 82

PERJETA ............................. 47

permethrin ............................ 48

perphenazine......................... 29

perphenazine-amitriptyline... 26

phenadoz............................... 29

phenelzine............................. 26

phenobarbital ........................ 23

PHENYTEK ......................... 24

phenytoin ........................ 24, 25

phenytoin sodium ................. 25

phenytoin sodium extended .. 25

PHOS-NAK ........................ 141

PHOSPHOLINE IODIDE .. 125

phytonadione (vitamin k1) ... 68

PICATO ............................... 40

pilocarpine hcl .............. 82, 125

pimozide ............................... 50

pimtrea (28) ........................ 105

PINK BISMUTH.................. 90

pioglitazone .......................... 63

pioglitazone-metformin ........ 63

piperacillin-tazobactam ........ 18

pirmella............................... 105

piroxicam ................................ 6

PLENAMINE ..................... 141

podofilox .............................. 84

polyethylene glycol 3350 ..... 94

POLY-IRON ...................... 141

polymyxin b sulfate .............. 14

polymyxin b sulf-trimethoprim

.......................................... 14

POLY-VI-SOL ................... 154

POLY-VI-SOL WITH IRON

........................................ 154

POLY-VITA....................... 155

POLY-VITA (IRON) ......... 155

POMALYST ........................ 39

portia ................................... 105

potassium chlorid-d5-

0.45%nacl ....................... 147

potassium chloride .............. 141

potassium chloride in lr-d5 . 141

potassium chloride in water 141

potassium citrate ................... 98

PRADAXA ........................... 67

PRALUENT PEN................. 78

PRALUENT SYRINGE ....... 78

pramipexole .......................... 49

pramoxine ............................... 3

prasugrel ............................... 70

pravastatin ............................ 77

praziquantel .......................... 48

prazosin ................................ 71

prednicarbate ........................ 84

prednisolone ......................... 35

prednisolone acetate ........... 125

prednisolone sodium phosphate

.................................. 36, 125

prednisone ............................ 36

prednisone intensol ............. 120

PREMARIN ....................... 101

PREMPHASE .................... 105

PREMPRO ......................... 105

PRENATAL VITAMIN PLUS

LOW IRON .................... 147

PRESERVISION AREDS . 147,

155

PRESERVISION AREDS 2

(OMEGA-3) ................... 155

PRESERVISION LUTEIN 141

prevalite ................................ 78

previfem.............................. 105

PREVYMIS .......................... 54

PREZCOBIX ........................ 59

PREZISTA ........................... 59

PRIFTIN ............................... 37

prilolid .................................... 9

PRIMAQUINE ..................... 48

primidone.............................. 23

PRIVIGEN ......................... 114

PRO FE............................... 141

probenecid ............................ 33

probenecid-colchicine .......... 33

prochlorperazine ................... 29

prochlorperazine edisylate .... 29

prochlorperazine maleate ..... 29

PROCRIT ............................. 68

procto-med hc ..................... 120

procto-pak ........................... 120

proctosol hc ........................ 120

proctozone-hc ..................... 120

progesterone micronized .... 107

PROGLYCEM ..................... 64

PROGRAF .......................... 113

PROLASTIN-C .................. 127

PROLEUKIN ....................... 42

PROLIA .............................. 122

PROMACTA ........................ 68

promethazine ........................ 29

promethazine vc .................. 127

promethazine-phenylephrine

........................................ 127

promethegan ......................... 29

propafenone .......................... 72

proparacaine ....................... 123

propranolol ........................... 72

propylthiouracil .................. 110

PROQUAD (PF) ................. 118

PRORENAL ....................... 155

PRORENAL QD ................ 155

PROSIGHT ......................... 155

protriptyline .......................... 28

PULMOZYME ................... 131

PURIXAN ............................ 40

pyrazinamide ........................ 37

pyridostigmine bromide ........ 37

pyridoxine (vitamin b6) ...... 155

Q Q-DRYL ............................. 128

Q-PAP ..................................... 4

Q-PAP EXTRA STRENGTH 4

QUADRACEL (PF) ........... 118

quasense .............................. 105

quetiapine ............................. 52

quinapril ................................ 71

quinapril-hydrochlorothiazide

.......................................... 75

quinidine gluconate .............. 72

quinidine sulfate ................... 72

quinine sulfate ...................... 48

QVAR ................................. 129

QVAR REDIHALER ......... 129

R RABAVERT (PF) .............. 118

RADICAVA ......................... 81

raloxifene ............................ 107

ramipril ................................. 71



Formulary ID: 18395



175

RANEXA ............................. 76

ranitidine hcl ......................... 92

RAPAMUNE ..................... 113

rasagiline .............................. 49

RAVICTI .............................. 87

RAYOS ................................ 36

REBIF (WITH ALBUMIN) . 82

REBIF REBIDOSE .............. 82

REBIF TITRATION PACK 82

reclipsen (28) ...................... 105

RECOMBIVAX HB (PF) .. 118

RECTIV ............................... 90

REFRESH CLASSIC (PF) . 123

REFRESH LACRI-LUBE.. 123

REFRESH LIQUIGEL ....... 123

REFRESH OPTIVE ........... 123

REFRESH OPTIVE

SENSITIVE (PF)............ 123

REFRESH P.M. ................. 123

REFRESH PLUS ............... 123

REFRESH TEARS ............. 123

REGRANEX ........................ 85

REGULOID ......................... 95

REGULOID (PSYLLIUM

HUSK) .............................. 95

REGULOID, SUGAR FREE95

RELENZA DISKHALER .... 60

RELISTOR ..................... 90, 91

REMICADE ....................... 113

REMODULIN .................... 132

RENA-VITE....................... 155

RENFLEXIS ...................... 113

RENVELA ........................... 98

repaglinide ............................ 63

REPATHA PUSHTRONEX 78

REPATHA SURECLICK .... 78

REPATHA SYRINGE ......... 79

RESCRIPTOR ...................... 56

RESTASIS ......................... 123

RESTASIS MULTIDOSE . 123

RESTORA ............................ 91

RETROVIR .......................... 57

REVATIO .......................... 132

REVLIMID .......................... 39

REXULTI ............................. 52

REYATAZ ........................... 59

RIBAVIRIN ......................... 55

rifabutin ................................ 37

rifampin ................................ 37

RIFATER ............................. 37

riluzole .................................. 81

rimantadine ........................... 60

RISA-BID ............................. 91

RISACAL-D ....................... 147

RISAMINE ........................... 85

RISANOID PLUS .............. 147

RISAQUAD ......................... 91

risedronate .......................... 122

RISPERDAL CONSTA ....... 52

RISPERDAL M-TAB .......... 52

risperidone ...................... 52, 53

ritonavir ................................ 59

RITUXAN ............................ 47

RITUXAN HYCELA ........... 47

rivastigmine .......................... 25

rivastigmine tartrate .............. 25

rizatriptan.............................. 36

ROMIDEPSIN...................... 42

ropinirole .............................. 49

rosuvastatin ........................... 77

ROTARIX .......................... 118

ROTATEQ VACCINE....... 118

roweepra ............................... 22

ROWEEPRA ........................ 22

ROWEEPRA XR ................. 22

ROZEREM ......................... 134

RUBRACA ........................... 42

RYDAPT .............................. 45

S SABRIL ................................ 23

SALINE MIST ................... 127

SAMSCA............................ 134

SANDIMMUNE ................ 113

SANDOSTATIN LAR

DEPOT ........................... 109

SANTYL .............................. 85

SAPHRIS (BLACK

CHERRY) ........................ 53

SARNA ANTI-ITCH ........... 85

SAVELLA ............................ 81

scopolamine base .................. 29

SCYTERA ............................ 85

SEA-OMEGA ..................... 142

SEA-OMEGA 30 ................ 142

SEBEX ................................. 85

selegiline hcl ......................... 49

selenium .............................. 147

selenium sulfide .................... 85

selzentry ................................ 58

SELZENTRY ....................... 58

SENNA ........................... 93, 95

SENNA LAX ........................ 95

SENNA LAXATIVE ............ 96

SENNA PLUS ...................... 95

SENNA WITH DOCUSATE

SODIUM .......................... 93

SENNALAX-S ..................... 95

SENNA-S ............................. 95

SENSI-CARE ....................... 85

SENSIPAR ......................... 108

SENTRY (WITH LUTEIN)

........................................ 147

SENTRY SENIOR ............. 147

SEREVENT DISKUS ........ 130

SEROSTIM ........................ 100

sertraline ............................... 27

setlakin ................................ 105

sevelamer carbonate ............. 98

sharobel ............................... 107

SHINGRIX (PF) ................. 118

SHINGRIX GE ANTIGEN

COMPONENT ............... 118

SIGNIFOR .......................... 109

SILACE ................................ 95

sildenafil (antihypertensive)

........................................ 132

silver sulfadiazine ................. 20

SIMBRINZA ...................... 125

simethicone ..................... 90, 91

SIMPONI ............................ 113

SIMPONI ARIA ................. 113

SIMULECT ........................ 113

simvastatin ............................ 77

sirolimus ............................. 113

SIRTURO ............................. 38

176

SLOW FE ........................... 142

SLOW RELEASE IRON ... 139

SLOW-MAG ...................... 155

sodium bicarbonate .............. 91

sodium chlor 0.9% bacteriostat

.......................................... 70

sodium chloride .......... 123, 142

sodium chloride 0.45 % ...... 142

sodium chloride 0.9 % ........ 142

sodium chloride 3 % ........... 142

sodium ferric gluconat-sucrose

........................................ 142

sodium phenylbutyrate ......... 98

sodium polystyrene (sorb free)

........................................ 134

sodium polystyrene sulfonate

........................................ 134

SOLTAMOX ........................ 39

SOMATULINE DEPOT .... 109

SOMAVERT ...................... 110

sorine .................................... 72

sotalol ................................... 72

sotalol af ............................... 72

spinosad ................................ 48

SPIRIVA RESPIMAT ....... 130

SPIRIVA WITH

HANDIHALER .............. 130

spironolactone ...................... 76

spironolacton-hydrochlorothiaz

.......................................... 75

sprintec (28)........................ 105

SPRITAM............................. 22

SPRYCEL ............................ 45

sps (with sorbitol) ............... 135

sronyx ................................. 105

ssd ......................................... 20

stavudine............................... 57

STELARA .......................... 113

STIOLTO RESPIMAT ...... 133

STIVARGA .......................... 45

STOMACH RELIEF MAX

STRENGTH ..................... 91

STOOL SOFTENER 93, 95, 96

STOOL SOFTENER-

LAXATIVE ................ 95, 96

STOOL SOFTENER-

STIMULANT LAXAT .... 96

STRENSIQ ........................... 87

streptomycin ......................... 11

STRESS FORMULA ......... 142

STRESS FORMULA WITH

IRON .............................. 156

STRESS FORMULA WITH

ZINC ............................... 142

STRIBILD ............................ 56

STRIVERDI RESPIMAT .. 130

SUCRAID ............................ 87

sucralfate .............................. 96

sulfacetamide sodium ........... 20

sulfacetamide sodium (acne) 20

sulfacetamide-prednisolone 125

sulfadiazine ........................... 20

sulfamethoxazole-trimethoprim

.......................................... 20

sulfasalazine ............... 120, 121

sulindac ................................... 6

sumatriptan ........................... 36

sumatriptan succinate ..... 36, 37

SUPERPLEX-T .................. 156

SUPRAX .............................. 16

SUSTIVA ............................. 57

SUTENT ............................... 46

SWEEN CREAM ................. 85

SYLATRON ......................... 42

SYLVANT ........................... 42

SYMBICORT ..................... 132

SYMDEKO ........................ 131

SYMFI LO ........................... 58

SYMLINPEN 120 ................ 63

SYMLINPEN 60 .................. 63

SYNAGIS ............................. 60

SYNAREL.......................... 110

SYNDROS ........................... 30

SYNERCID .......................... 14

SYNJARDY ......................... 63

SYNRIBO ............................ 42

SYNTHROID ..................... 108

SYPRINE ............................. 87

SYSTANE (PF) .................. 124

SYSTANE (PROPYLENE

GLYCOL) ...................... 124

SYSTANE BALANCE ...... 124

SYSTANE ULTRA (PF).... 124

T TAB-A-VITE ..................... 156

TAB-A-VITE/IRON .......... 156

TAB-A-VITE-MINERALS 156

TABLOID ............................ 40

tacrolimus ..................... 85, 113

TAFINLAR .......................... 46

TAGRISSO ........................... 46

TAMIFLU ............................ 60

tamoxifen .............................. 39

tamsulosin ............................. 97

TANDEM DUAL ACTION

........................................ 142

TARCEVA ........................... 46

TARGRETIN ....................... 47

tarina fe 1/20 (28) ............... 106

TASIGNA ............................. 46

tazarotene .............................. 85

TAZICEF .............................. 16

TAZORAC ........................... 85

taztia xt ................................. 73

TEARS NATURALE FORTE

........................................ 124

TEARS PURE .................... 124

TECENTRIQ ........................ 47

TECFIDERA ........................ 82

TEFLARO ............................ 17

TEKTURNA ......................... 76

TEKTURNA HCT ................ 75

temazepam .......................... 133

TENIVAC (PF) .................. 118

tenofovir disoproxil fumarate

.......................................... 54

TEPADINA .......................... 38

terazosin ................................ 71

terbinafine hcl ....................... 32

terbutaline ........................... 131

terconazole ............................ 32

testosterone ......................... 100

testosterone cypionate ........ 100

tetanus,diphtheria tox ped(pf)

........................................ 118

tetanus-diphtheria toxoids-td

........................................ 118

tetrabenazine ......................... 81

THALOMID ......................... 39

theophylline ........................ 131

THERA ............................... 156

THERA M PLUS (FERROUS

FUMARAT) ................... 148

THERA-GEL ........................ 85

THERA-M .................. 142, 148

THERAPEUTIC LIQUID .. 153

THERAPEUTIC-M .... 148, 156

THEREMS-M ..................... 148

thiamine hcl (vitamin b1) ... 156



Formulary ID: 18395



177

thiamine mononitrate (vit b1)

........................................ 157

thioridazine ........................... 50

thiotepa ................................. 38

thiothixene ............................ 50

THYMOGLOBULIN ......... 115

THYROSAFE .................... 110

tiagabine ............................... 23

TICE BCG .......................... 118

timolol maleate ................... 125

TINACTIN ........................... 32

TIVICAY ............................. 56

tizanidine .............................. 54

TOBRADEX ........................ 11

tobramycin ............................ 11

tobramycin in 0.225 % nacl . 11

tobramycin sulfate ................ 11

tobramycin with nebulizer .... 11

tobramycin-dexamethasone .. 11

tolcapone .............................. 49

tolnaftate ............................... 32

tolterodine............................. 97

topiramate ............................. 24

topotecan .............................. 44

TORISEL ............................. 46

torsemide .............................. 76

TOTAL B/C ....................... 156

TOTECT............................... 42

TOVIAZ ............................... 97

TRACLEER ....................... 132

TRADJENTA ....................... 63

tramadol .................................. 8

tramadol-acetaminophen ........ 4

trandolapril ........................... 71

tranexamic acid .............. 68, 69

TRANSDERM-SCOP .......... 29

tranylcypromine ................... 26

TRAVATAN Z .................. 126

trazodone .............................. 26

TREANDA ........................... 38

TRECATOR ......................... 38

TRELSTAR ........................ 110

TREMFYA ......................... 113

tretinoin ................................ 85

tretinoin (chemotherapy) ...... 47

tretinoin (emollient) .............. 85

TREXALL .......................... 113

TRI FEMYNOR ................. 106

triamcinolone acetonide . 36, 82

triamterene-hydrochlorothiazid

.......................................... 75

triderm .................................. 36

TRIDERM ............................ 98

trientine ................................. 87

trifluoperazine ...................... 50

trifluridine ............................. 55

trihexyphenidyl ..................... 48

TRIKLO ............................... 79

tri-legest fe .......................... 106

trilyte with flavor packets ..... 96

trimethobenzamide ............... 29

trimethoprim ......................... 14

TRI-MILI............................ 106

trimipramine ......................... 28

trinessa (28) ........................ 106

TRINTELLIX ....................... 27

TRIPLE ANTIBIOTIC......... 14

TRIPLE ANTIBIOTIC PLUS

.......................................... 14

tri-previfem (28) ................. 106

TRISENOX .......................... 42

tri-sprintec (28) ................... 106

TRIUMEQ ............................ 58

TRI-VI-SOL ....................... 156

TRI-VITA ........................... 156

trivora (28) .......................... 106

TRI-VYLIBRA .................. 106

TROGARZO ........................ 58

TRULICITY ......................... 63

TRUMENBA...................... 118

TRUVADA .......................... 57

TUDORZA PRESSAIR ..... 130

TUMS ULTRA..................... 91

TWINRIX (PF)................... 119

TYBOST .............................. 58

TYKERB .............................. 46

TYMLOS............................ 122

TYPHIM VI ....................... 119

TYSABRI ........................... 115

U ULORIC ............................... 33

ULTIMATE WOMEN'S

COMPLETE 50+ ............ 155

UNICOMPLEX-M ............. 156

unithroid ............................. 108

UREACIN-10 ....................... 85

ursodiol ................................. 91

V VABOMERE ........................ 17

valacyclovir .......................... 55

VALCHLOR ........................ 38

valganciclovir ....................... 54

valproate sodium .................. 23

valproic acid ......................... 23

valproic acid (as sodium salt)

.......................................... 23

valsartan ................................ 71

valsartan-hydrochlorothiazide

.......................................... 75

vancomycin ........................... 15

vancomycin in 0.9 % sodium

chl ..................................... 15

vancomycin in dextrose 5 % . 15

VAQTA (PF) ...................... 119

VARIVAX (PF) .................. 119

VARIZIG ............................ 119

VAXCHORA BUFFER

COMPONENT ............... 119

VAXCHORA VACCINE ... 119

VECTIBIX ........................... 47

VELCADE ........................... 43

velivet triphasic regimen (28)

........................................ 106

VEMLIDY ............................ 54

VENCLEXTA ...................... 43

VENCLEXTA STARTING

PACK ............................... 43

venlafaxine ........................... 27

VENOFER .......... 142, 143, 148

VENTAVIS ........................ 132

VENTOLIN HFA ............... 131

verapamil ........................ 73, 74

VEREGEN ........................... 85

VERSACLOZ ....................... 53

178

VERZENIO .......................... 43

VICTOZA 2-PAK ................ 63

VICTOZA 3-PAK ................ 63

VIDEX 2 GRAM PEDIATRIC

.......................................... 57

VIDEX 4 GRAM PEDIATRIC

.......................................... 58

VIDEX EC ........................... 57

vienva ................................. 106

vigabatrin .............................. 23

VIGAMOX........................... 20

VIIBRYD ............................. 28

VIMPAT............................... 25

vinblastine ............................ 43

vincristine ............................. 43

vinorelbine ............................ 43

VIRACEPT .......................... 59

VIRAMUNE ........................ 57

VIREAD ............................... 55

vitamin a ..................... 156, 157

VITAMIN B-1............ 155, 157

VITAMIN B-12.................. 157

VITAMIN B-2.................... 157

VITAMIN B-6............ 157, 158

VITAMIN C ............... 158, 160

VITAMIN C DROPS ......... 158

VITAMIN D2 ..................... 156

VITAMIN D3 .... 143, 155, 156,

158, 159

vitamin e ............. 156, 159, 160

vitamin e (dl, acetate) 156, 159,

160

VITAMIN E NATURAL

BLEND........................... 156

VITAMIN K ......................... 69

VITAMIN K1 ....................... 69

VITAMINS AND MINERALS

........................................ 148

VITAMINS B COMPLEX. 157

vits a and d-white pet-lanolin

.......................................... 85

voriconazole ................... 32, 33

VOSEVI ............................... 55

VOTRIENT .......................... 46

VPRIV .................................. 87

VRAYLAR ........................... 53

vyfemla (28) ....................... 106

VYLIBRA .......................... 106

VYXEOS .............................. 43

W warfarin ................................ 67

WART REMOVER .............. 85

water for irrigation, sterile .. 122

WEE CARE ........................ 143

WELCHOL .......................... 79

WOMAN'S LAXATIVE ...... 96

X XALKORI ............................ 46

XARELTO ........................... 67

XATMEP............................ 114

XERMELO ........................... 91

XGEVA .............................. 122

XIFAXAN ............................ 15

XIIDRA .............................. 124

XOLAIR ............................. 133

XTANDI ............................... 39

xulane ................................. 106

XURIDEN ............................ 87

XYREM.............................. 134

Y YERVOY ............................. 47

YF-VAX (PF) ..................... 119

YONDELIS .......................... 43

yuvafem .............................. 101

Z zafirlukast ........................... 129

zaleplon .............................. 133

ZALTRAP ............................ 43

ZANOSAR ........................... 38

zarah ................................... 106

ZARXIO ............................... 68

ZAVESCA............................ 87

ZEJULA ............................... 46

ZELBORAF ......................... 46

ZEMAIRA .......................... 127

zenatane ................................ 86

ZENATANE ......................... 85

zenchent (28) ...................... 106

ZENPEP ............................... 88

ZEPATIER ........................... 55

ZERIT ................................... 58

ZIAGEN ............................... 58

zidovudine ............................ 58

zileuton ............................... 129

zinc gluconate ..................... 143

zinc oxide .............................. 86

zinc sulfate .......................... 143

ZINC WITH VITAMINS A

AND C ............................ 148

ziprasidone hcl ...................... 53

ZIRGAN ............................... 54

zoledronic acid .................... 122

zoledronic acid-mannitol-water

........................................ 122

ZOLINZA ............................. 43

zolpidem ............................. 134

ZOMETA ........................... 122

zonisamide ............................ 22

ZOO FRIENDS .................. 160

ZOO FRIENDS COMPLETE

........................................ 160

ZOO FRIENDS ORIGINAL

........................................ 148

ZORTRESS ........................ 114

ZORVOLEX ........................... 6

ZOSTAVAX (PF) .............. 119

zovia 1/35e (28) .................. 106

zovia 1/50e (28) .................. 106

ZOVIRAX ............................ 56

ZYCLARA ........................... 86

ZYDELIG ............................. 43

ZYFLO ............................... 129

ZYKADIA ............................ 46

ZYPREXA RELPREVV ...... 53

ZYTIGA ............................... 39

xiv


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