Search Tip:
This is a large document, but you can search quickly and easily by clicking on the binocular icon on your toolbar. It will then display a search box for you to
type in the name of drug you want to locate. If you do not know the correct spelling, you can start your search by entering just the first few letters of the
name.
Navi-Gate Rx Formulary
Alphabetical Index
Last Updated 1/1/2017
Drug Name
Special Code
Level
Category
8-MOP CAP
abacavir tab (ZIAGEN equiv)
abacavir/ lamivudine/ zidovudine tab (TRIZIVIR equiv)
abacavir/lamivudine tab (EPZICOM equiv)
ABILIFY DISCMELT (QL= 2 tabs/day)
ABSORICA CAP
acamprosate calcium tab (CAMPRAL equiv)
QL
-
F
F
F
F
F
NC
F
DERMATOLOGICALS
ANTIVIRALS
ANTIVIRALS
ANTIVIRALS
ANTIPSYCHOTICS/ANTIMANIC AGENTS
DERMATOLOGICALS
ACANYA/ONEXTON GEL
acarbose tab (PRECOSE equiv)
ACCU-CHEK ACTIVE TEST STRIP
ACCU-CHEK AVIVA PLUS TEST STRIP
ACCU-CHEK COMFORT CURVE TEST STRIP
ACCU-CHEK COMPACT TEST STRIP
ACCU-CHEK MULTICLIX LANCETS
ACCU-CHEK NANO SMARTVIEW METER
ACCU-CHEK SMARTVIEW TEST STRIP
acebutolol cap (SECTRAL equiv)
acetaminophen/caffeine/dihydrocodeine cap (TREZIX equiv)
ACETAMINOPHEN/CAFFEINE/DIHYDROCODEINE TAB
acetaminophen/codeine tab (TYLENOL/CODEINE equiv)
acetaminophen/isometheptene/dichloral cap (MIDRIN equiv)
acetazolamide ER cap (DIAMOX equiv)
acetazolamide tab
ACETAZOLAMIDE TAB 125MG
acetic acid otic soln (VOSOL equiv)
ACETIC ACID/ALUMINUM ACETATE OTIC SOLN
acetic acid/hydrocoritisone otic soln (VOSOL HC equiv)
acetylcysteine soln (MUCOMYST equiv)
ACIDIC VAGINAL JELLY
ACIPHEX SPRINKLE CAP
acitretin cap (SORIATANE equiv)
ACTEMRA SC INJ (QL= 2 inj/28 days)
ACTICLATE TAB
ACTIMMUNE INJ (Only available through Walgreens 888-347-3416)
OTC
OTC
OTC
OTC
OTC
OTC
OTC
QL
LD
NC
F
F
F
F
F
F
F
F
F
NC
F
F
F
F
F
F
F
F
F
F
F
NC
F
F
NC
F
acyclovir cap (ZOVIRAX equiv)
acyclovir susp (ZOVIRAX equiv)
acyclovir tab (ZOVIRAX equiv)
ACZONE GEL
adapalene cream (DIFFERIN equiv)
adapalene gel 0.1% (DIFFERIN equiv)
adapalene gel 0.3% (DIFFERIN equiv)
ADAPALENE LOTION (DIFFERIN equiv)
ADASUVE INHALER
ADAZIN CREAM
ADCIRCA TAB
-
F
F
F
NC
F
F
NC
F
NC
NC
F
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
PSYCHOTHERAPEUTIC AND
NEUROLOGICAL AGENTS - MISC.
DERMATOLOGICALS
ANTIDIABETICS
DIAGNOSTIC PRODUCTS
DIAGNOSTIC PRODUCTS
DIAGNOSTIC PRODUCTS
DIAGNOSTIC PRODUCTS
MEDICAL DEVICES AND SUPPLIES
MEDICAL DEVICES AND SUPPLIES
DIAGNOSTIC PRODUCTS
BETA BLOCKERS
ANALGESICS - OPIOID
ANALGESICS - OPIOID
ANALGESICS - OPIOID
MIGRAINE PRODUCTS
DIURETICS
DIURETICS
DIURETICS
OTIC AGENTS
OTIC AGENTS
OTIC AGENTS
COUGH/COLD/ALLERGY
VAGINAL PRODUCTS
ULCER DRUGS
DERMATOLOGICALS
ANALGESICS - ANTI-INFLAMMATORY
TETRACYCLINES
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
ANTIVIRALS
ANTIVIRALS
ANTIVIRALS
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
ANTIPSYCHOTICS/ANTIMANIC AGENTS
DERMATOLOGICALS
CARDIOVASCULAR AGENTS - MISC.
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 1 of 101
Navi-Gate Rx Formulary Cont.
Alphabetical Index
Last Updated 1/1/2017
Drug Name
Special Code
Level
Category
ADDERALL XR CAP
-
F
ADDYI TAB
-
NC
adefovir dipivoxil tab (HEPSERA equiv)
LD-QL
F
F
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A
NOREXIANTS
PSYCHOTHERAPEUTIC AND
NEUROLOGICAL AGENTS - MISC.
ANTIVIRALS
CARDIOVASCULAR AGENTS - MISC.
-
NC
NC
F
ADVAIR HFA INHALER
-
F
ADVICOR TAB
ADZENYS XR TAB
-
NC
NC
AEROSPAN HFA INHALER
-
NC
AFINITOR TAB
-
NC
AFREZZA INH POWDER
AFSTYLA KIT
AGGRENOX/ASPIRIN-DIPYRIDAMOLE CAP
AKYNZEO CAP (QL= 1 cap/fill)
ALAMAST OPHTH SOLN
ALBENZA TAB
albuterol neb soln
QL
-
NC
NC
F
F
F
NC
F
albuterol sulfate ER tab (VOSPIRE ER equiv)
-
F
albuterol sulfate syrup
-
F
albuterol sulfate tab
-
F
alclometasone cream (ACLOVATE equiv)
alclometasone oint (ACLOVATE equiv)
ALCOHOL SWABS
ALECENSA CAP
OTC
-
F
F
NC
NC
alendronate tab (FOSAMAX equiv)
-
F
ALENDRONATE TAB 40MG
-
F
ALFERON-N INJ
-
F
alfuzosin SR tab (UROXATRAL equiv)
-
F
ALINIA SUSP
ALKERAN TAB
-
F
F
ALLEGRA-D TAB
allopurinol tab
almotriptan tab (AXERT equiv)
OTC
-
F
F
NC
ADEMPAS TAB (QL= 3 tabs/day; Only available through Accredo
888-773-7376)
ADLYXIN INJ
ADRENACLICK/EPINEPHRINE INJ
ADVAIR DISKUS INHALER
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
ANTIDIABETICS
VASOPRESSORS
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
ANTIHYPERLIPIDEMICS
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A
NOREXIANTS
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
ANTIDIABETICS
HEMATOLOGICAL AGENTS - MISC.
HEMATOLOGICAL AGENTS - MISC.
ANTIEMETICS
OPHTHALMIC AGENTS
ANTHELMINTICS
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
DERMATOLOGICALS
DERMATOLOGICALS
MEDICAL DEVICES AND SUPPLIES
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
ENDOCRINE AND METABOLIC AGENTS MISC.
ENDOCRINE AND METABOLIC AGENTS MISC.
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
GENITOURINARY AGENTS MISCELLANEOUS
ANTI-INFECTIVE AGENTS - MISC.
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
COUGH/COLD/ALLERGY
GOUT AGENTS
MIGRAINE PRODUCTS
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 2 of 101
Navi-Gate Rx Formulary Cont.
Alphabetical Index
Last Updated 1/1/2017
Drug Name
Special Code
Level
Category
ALOCRIL OPHTH SOLN
ALOMIDE OPHTH SOLN
ALOQUIN GEL
ALPHAGAN P OPHTH SOLN 0.1%
alprazolam tab (XANAX equiv)
ALREX OPHTH SUSP/ LOTEMAX OPHTH SUSP
ALSUMA INJ (QL= 4 inj/fill, 2 fills/30 days)
aluminum chloride soln (DRYSOL equiv)
ALVESCO INHALER
QL
-
F
F
NC
F
F
F
F
F
NC
OPHTHALMIC AGENTS
OPHTHALMIC AGENTS
DERMATOLOGICALS
OPHTHALMIC AGENTS
ANTIANXIETY AGENTS
OPHTHALMIC AGENTS
MIGRAINE PRODUCTS
DERMATOLOGICALS
amantadine caps (SYMMETREL equiv)
amantadine tab
AMCINONIDE CREAM 0.1%
amethyst tab (LYBREL equiv)
AMICAR ORAL SOLN
AMICAR SYRUP
AMICAR TAB
amiloride tab (MIDAMOR equiv)
amiloride/hydrochlorothiazide tab (MODURETIC equiv)
AMINOCAPROIC ACID TAB
aminocaproic acid tab (AMICAR equiv)
aminophylline tab
-
F
NC
NC
NC
NC
F
F
F
F
F
F
F
amiodarone tab (CORDARONE equiv)
AMITIZA CAP
amitriptyline tab (ELAVIL equiv)
amlodipine tab (NORVASC equiv)
amlodipine/atorvastatin tab (CADUET equiv)
amlodipine/benazepril cap (LOTREL equiv)
amlodipine/olmesartan tab (AZOR TAB equiv)
amlodipine/valsartan tab (EXFORGE equiv)
amlodipine/valsartan/hydrochlorothiazide tab (EXFORGE HCT equiv)
ammonium lactate cream (LAC-HYDRIN equiv)
ammonium lactate lotion (LAC-HYDRIN equiv)
AMOXAPINE TAB
amoxicillin cap
amoxicillin chew
amoxicillin susp
amoxicillin tab
amoxicillin/clavulanate chew tab (AUGMENTIN equiv)
amoxicillin/clavulanate ER tab (AUGMENTIN XR equiv)
amoxicillin/clavulanate susp (AUGMENTIN equiv)
amoxicillin/clavulanate tab (AUGMENTIN equiv)
amphetamine/dextroamphetamine tab (ADDERALL equiv)
-
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
ampicillin cap
ampicillin susp (PRINCIPEN equiv)
AMPYRA TAB (QL= 2 tabs/day)
QL
F
F
F
anagrelide cap (AGRYLIN equiv)
ANALPRAM-E KIT
ANASTIA LOTION
-
F
F
NC
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
ANTIPARKINSON AGENTS
ANTIPARKINSON AGENTS
DERMATOLOGICALS
CONTRACEPTIVES
HEMOSTATICS
HEMOSTATICS
HEMOSTATICS
DIURETICS
DIURETICS
HEMOSTATICS
HEMOSTATICS
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
ANTIARRHYTHMICS
GASTROINTESTINAL AGENTS - MISC.
ANTIDEPRESSANTS
CALCIUM CHANNEL BLOCKERS
CARDIOVASCULAR AGENTS - MISC.
ANTIHYPERTENSIVES
ANTIHYPERTENSIVES
ANTIHYPERTENSIVES
ANTIHYPERTENSIVES
DERMATOLOGICALS
DERMATOLOGICALS
ANTIDEPRESSANTS
PENICILLINS
PENICILLINS
PENICILLINS
PENICILLINS
PENICILLINS
PENICILLINS
PENICILLINS
PENICILLINS
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A
NOREXIANTS
PENICILLINS
PENICILLINS
PSYCHOTHERAPEUTIC AND
NEUROLOGICAL AGENTS - MISC.
HEMATOLOGICAL AGENTS - MISC.
ANORECTAL AGENTS
DERMATOLOGICALS
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 3 of 101
Navi-Gate Rx Formulary Cont.
Alphabetical Index
Last Updated 1/1/2017
Drug Name
Special Code
Level
Category
anastrozole tab (ARIMIDEX equiv)
-
F
ANDRODERM (QL= 1 patch/day)
ANDROGEL 1.62% 1.25GM (QL= 1 packet/day)
ANDROGEL 1.62% 2.5GM (QL= 2 packets/day)
ANDROGEL PUMP 1.62% (QL= 2 bottles/30 days)
ANORO ELLIPTA INHALER
QL
QL
QL
QL
-
F
F
F
F
NC
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
ANDROGENS-ANABOLIC
ANDROGENS-ANABOLIC
ANDROGENS-ANABOLIC
ANDROGENS-ANABOLIC
ANTARA CAP
antipyrine/benzocaine otic soln (AURALGAN equiv)
ANZEMET TAB
APHTHASOL PASTE
APLENZIN TAB
apraclonidine ophth soln (ISOPTO equiv)
apri tab (DESOGEN equiv)
APTIVUS CAP
APTIVUS SOLN
aranelle tab (TRI-NORINYL equiv)
ARANESP INJ
aripiprazole ODT (ABILIFY equiv) (QL= 2 tabs/day)
aripiprazole tab (ABILIFY equiv) (QL= 2 tabs/day)
armodafinil tab (NUVIGIL equiv)
QL
QL-¢
-
F
NC
F
F
NC
F
F
F
F
F
F
F
F
NC
ARNUITY ELLIPTA INHALER
-
F
ASACOL HD/MESALAMINE TAB
ASMANEX HFA INHALER (QL= 1 inhaler/fill)
QL
F
F
ASMANEX INHALER (QL= 1 inhaler/fill)
QL
F
aspirin/codeine tab
ASTAMED MYO CAP
-
F
NC
ASTELIN/ASTEPRO NASAL SPRAY
atenolol tab (TENORMIN equiv)
atenolol/chlorthalidone tab (TENORETIC equiv)
atorvastatin tab (LIPITOR equiv)
atovaquone susp (MEPRON equiv)
atovaquone/proguanil tab (MALARONE equiv)
ATRIPLA TAB
atropine ophth oint
atropine ophth soln (ISOPTO ATROPINE equiv)
ATROVENT HFA INHALER
-
F
F
F
F
F
F
F
F
F
F
AUBAGIO TAB (QL= 1 tab/day)
QL
F
AURYXIA TAB
AUVI-Q/EPIPEN (JR) INJ
AVANDAMET TAB
AVANDIA TAB
AVANDRYL TAB
AVAR PAD
-
F
NC
F
F
F
NC
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
ANTIHYPERLIPIDEMICS
OTIC AGENTS
ANTIEMETICS
MOUTH/THROAT/DENTAL AGENTS
ANTIDEPRESSANTS
OPHTHALMIC AGENTS
CONTRACEPTIVES
ANTIVIRALS
ANTIVIRALS
CONTRACEPTIVES
HEMATOPOIETIC AGENTS
ANTIPSYCHOTICS/ANTIMANIC AGENTS
ANTIPSYCHOTICS/ANTIMANIC AGENTS
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A
NOREXIANTS
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
GASTROINTESTINAL AGENTS - MISC.
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
ANALGESICS - OPIOID
DIETARY PRODUCTS/DIETARY
MANAGEMENT PRODUCTS
NASAL AGENTS - SYSTEMIC AND TOPICAL
BETA BLOCKERS
ANTIHYPERTENSIVES
ANTIHYPERLIPIDEMICS
ANTI-INFECTIVE AGENTS - MISC.
ANTIMALARIALS
ANTIVIRALS
OPHTHALMIC AGENTS
OPHTHALMIC AGENTS
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
PSYCHOTHERAPEUTIC AND
NEUROLOGICAL AGENTS - MISC.
GASTROINTESTINAL AGENTS - MISC.
VASOPRESSORS
ANTIDIABETICS
ANTIDIABETICS
ANTIDIABETICS
DERMATOLOGICALS
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 4 of 101
Navi-Gate Rx Formulary Cont.
Alphabetical Index
Last Updated 1/1/2017
Drug Name
Special Code
Level
Category
AVC VAGINAL CREAM
aviane tab (ALESSE equiv)
AVONEX INJ
-
F
F
F
VAGINAL PRODUCTS
CONTRACEPTIVES
AXIRON SOLN
AZASITE SOLN
azathioprine tab (IMURAN equiv)
azelastine nasal spray (ASTELIN/ASTEPRO equiv)
azelastine ophth drop (OPTIVAR equiv)
AZENASE PAK
AZILECT TAB
azithromycin susp (ZITHROMAX equiv)
azithromycin tab (ZITHROMAX equiv) (500mg tab is Not Covered)
AZOPT OPHTH SUSP
AZOR TAB
BACITRACIN OPHTH OINT
bacitracin/polymixin B ophth oint (POLYSPORIN equiv)
¢
-
NC
F
F
F
F
NC
F
F
F
F
F
F
F
F
OTC
OTC
OTC
OTC
-
NC
F
F
F
F
NC
F
F
F
F
NC
NC
NC
NC
BELVIQ XR TAB
-
NC
benazepril tab (LOTENSIN equiv)
benazepril/hydrochlorothiazide tab (LOTENSIN HCT equiv)
BENZONATATE CAP
benzonatate cap (TESSALON equiv)
benztropine tab
BEPREVE OPHTH SOLN
betamethasone augmented cream (DIPROLENE equiv)
betamethasone augmented gel (DIPROLENE equiv)
betamethasone augmented lotion (DIPROLENE equiv)
betamethasone augmented oint (DIPROLENE equiv)
betamethasone diproprionate cream (DIPROSONE equiv)
betamethasone diproprionate lotion (DIPROSONE equiv)
betamethasone diproprionate oint (DIPROSONE equiv)
betamethasone valerate cream
betamethasone valerate foam (LUXIQ equiv)
betamethasone valerate lotion
-
F
F
F
F
F
NC
F
F
F
F
F
F
F
F
NC
F
bacitracin/polymyxin/neomycin/hydrocortisone ophth oint (CORTISPORIN
equiv)
BACLOFEN CREAM COMPOUND KIT
baclofen tab
balsalazide cap (COLAZAL equiv)
BANZEL SUSP
BANZEL TAB
BASAGLAR INJ
B-D INSULIN SYRINGE
BD INSULIN SYRINGES
B-D PEN NEEDLE
BD PEN NEEDLES
b-donna tab (DONNATAL equiv)
BELBUCA FILM
BELSOMRA TAB
BELVIQ TAB
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
PSYCHOTHERAPEUTIC AND
NEUROLOGICAL AGENTS - MISC.
ANDROGENS-ANABOLIC
OPHTHALMIC AGENTS
ASSORTED CLASSES
NASAL AGENTS - SYSTEMIC AND TOPICAL
OPHTHALMIC AGENTS
NASAL AGENTS - SYSTEMIC AND TOPICAL
ANTIPARKINSON AGENTS
MACROLIDES
MACROLIDES
OPHTHALMIC AGENTS
ANTIHYPERTENSIVES
OPHTHALMIC AGENTS
OPHTHALMIC AGENTS
OPHTHALMIC AGENTS
DERMATOLOGICALS
MUSCULOSKELETAL THERAPY AGENTS
GASTROINTESTINAL AGENTS - MISC.
ANTICONVULSANTS
ANTICONVULSANTS
ANTIDIABETICS
MEDICAL DEVICES AND SUPPLIES
MEDICAL DEVICES AND SUPPLIES
MEDICAL DEVICES AND SUPPLIES
MEDICAL DEVICES AND SUPPLIES
ULCER DRUGS
ANALGESICS - OPIOID
HYPNOTICS
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A
NOREXIANTS
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A
NOREXIANTS
ANTIHYPERTENSIVES
ANTIHYPERTENSIVES
COUGH/COLD/ALLERGY
COUGH/COLD/ALLERGY
ANTIPARKINSON AGENTS
OPHTHALMIC AGENTS
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 5 of 101
Navi-Gate Rx Formulary Cont.
Alphabetical Index
Last Updated 1/1/2017
Drug Name
Special Code
Level
Category
betamethasone valerate oint
BETASERON INJ
-
F
NC
DERMATOLOGICALS
betaxolol ophth soln (BETOPTIC-S equiv)
betaxolol tab (KERLONE equiv)
bethanechol tab (URECHOLINE equiv)
BETHKIS NEB
BETIMOL OPHTH SOLN
BETOPIC-S OPTHTH SOLN
BEVESPI AEROSPHERE INHALER
-
F
F
F
NC
F
F
NC
bexarotene cap (TARGRETIN equiv)
-
F
bicalutamide tab (CASODEX equiv)
-
F
BILTRICIDE TAB
bisoprolol tab (ZEBETA equiv)
bisoprolol/hydrochlorothiazide tab (ZIAC equiv)
BLEPHAMIDE OPHTH SOLN
BLEPHAMIDE S.O.P. OPHTH OINT
BOSULIF TAB
F
F
F
F
F
F
F
BREO ELLIPTA INHALER
-
F
brimonidine ophth soln (ALPHAGAN P equiv)
BRISDELLE CAP
-
F
NC
BRIVIACT INJ 50MG/5ML
BRIVIACT SOLN 10MG/ML
BRIVIACT TAB
BROMFED DM SYRUP
bromfenac ophth soln (BROMDAY equiv)
bromocriptine cap (PARLODEL equiv)
bromocriptine tab (PARLODEL equiv)
BROMSITE OPHTH SOLN
B-SERENE PAD
budesonide inh susp (PULMICORT equiv)
-
NC
NC
NC
NC
F
F
F
NC
NC
F
budesonide nasal spray (RHINOCORT AQUA equiv) (QL= 2 bottles/fill)
budesonide SR cap (ENTOCORT EC equiv)
bumetanide tab (BUMEX equiv)
BUNAVAIL FILM
BUPHENYL TAB
QL
-
F
F
F
NC
F
buprenorphine/naloxone SL tab (SUBOXONE equiv)
bupropion ER tab (WELLBUTRIN equiv)
bupropion tab (WELLBUTRIN equiv)
bupropion XL tab (WELLBUTRIN XL equiv)
buspirone tab (BUSPAR equiv) (30mg tab is Not Covered)
BUTALBITAL/ASPIRIN/CAFFEINE TAB
butorphanol nasal spray (STADOL equiv) (QL= 1 bottle/fill, 2 fills/30 days)
BUTRANS PATCH
QL
-
F
F
F
F
F
NC
F
NC
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
PSYCHOTHERAPEUTIC AND
NEUROLOGICAL AGENTS - MISC.
OPHTHALMIC AGENTS
BETA BLOCKERS
URINARY ANTISPASMODICS
AMINOGLYCOSIDES
OPHTHALMIC AGENTS
OPHTHALMIC AGENTS
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
ANTHELMINTICS
BETA BLOCKERS
ANTIHYPERTENSIVES
OPHTHALMIC AGENTS
OPHTHALMIC AGENTS
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
OPHTHALMIC AGENTS
PSYCHOTHERAPEUTIC AND
NEUROLOGICAL AGENTS - MISC.
ANTICONVULSANTS
ANTICONVULSANTS
ANTICONVULSANTS
COUGH/COLD/ALLERGY
OPHTHALMIC AGENTS
ANTIPARKINSON AGENTS
ANTIPARKINSON AGENTS
OPHTHALMIC AGENTS
HEMATOPOIETIC AGENTS
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
NASAL AGENTS - SYSTEMIC AND TOPICAL
CORTICOSTEROIDS
DIURETICS
ANALGESICS - OPIOID
ENDOCRINE AND METABOLIC AGENTS MISC.
ANALGESICS - OPIOID
ANTIDEPRESSANTS
ANTIDEPRESSANTS
ANTIDEPRESSANTS
ANTIANXIETY AGENTS
ANALGESICS - NONNARCOTIC
ANALGESICS - OPIOID
ANALGESICS - OPIOID
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 6 of 101
Navi-Gate Rx Formulary Cont.
Alphabetical Index
Last Updated 1/1/2017
Drug Name
Special Code
Level
Category
BYDUREON INJ (QL= 4 inj/28 days)
BYDUREON PEN INJ (QL= 4 inj/28 days)
BYETTA INJ
BYSTOLIC TAB
BYVALSON TAB
cabergoline tab
QL
QL
¢
-
F
F
NC
F
NC
F
ANTIDIABETICS
ANTIDIABETICS
ANTIDIABETICS
BETA BLOCKERS
ANTIHYPERTENSIVES
CABOMETYX TAB (QL= 1 tab/day)
QL
F
caffeine citrate soln (CAFCIT equiv) (Only covered for those less than 1 year
old)
calcipotriene cream (DOVONEX equiv)
calcipotriene oint
calcipotriene soln (DOVONEX equiv)
calcitonin nasal spray (MIACALCIN equiv)
-
F
-
F
F
F
F
calcitriol cap (ROLCALTROL equiv)
-
F
calcitriol inj (CALCIJEX equiv)
-
F
calcitriol soln (ROCALTROL equiv)
-
F
calcium acetate cap (PHOSLO equiv)
CALIBRATION LIQUID
CAMBIA POWDER
CANASA SUPP
candesartan tab (ATACAND equiv)
candesartan/hydrochlorothiazide tab (ATACAND HCT equiv)
capecitabine tab (XELODA equiv)
OTC
NC
-
F
F
NC
F
NC
F
F
CAPRELSA TAB (Only available through Biologics 800-850-4306)
LD
F
capsaicin-menthol topical patch (SINELEE equiv)
captopril tab
captopril/hydrochlorothiazide tab (CAPOZIDE equiv)
CARAC CREAM
carbamazepine cap (CARBATROL equiv)
carbamazepine ER tab (TEGRETOL XR equiv)
carbamazepine tab (TEGRETOL equiv)
carbidopa tab (LODOSYN equiv)
carbidopa/levodopa ER tab (SINEMET CR equiv)
carbidopa/levodopa ODT (PARCOPA equiv)
carbidopa/levodopa tab (SINEMET equiv)
CARBIDOPA/LEVODOPA/ENTACAPONE TAB (STALEVO equiv)
carbinoxamine soln (PALGIC equiv)
CARDURA XL TAB
-
NC
F
F
F
F
F
F
F
F
F
F
F
F
F
carisoprodol (SOMA equiv) (250mg tab is Not Covered)
carisoprodol tab 250mg (SOMA equiv)
carisoprodol/aspirin tab (SOMA COMPOUND equiv)
carisoprodol/aspirin/codeine tab (SOMA COMPOUND/CODEINE equiv)
carteolol ophth soln (OCUPRESS equiv)
-
F
NC
F
F
F
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
ENDOCRINE AND METABOLIC AGENTS MISC.
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A
NOREXIANTS
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
ENDOCRINE AND METABOLIC AGENTS MISC.
ENDOCRINE AND METABOLIC AGENTS MISC.
ENDOCRINE AND METABOLIC AGENTS MISC.
ENDOCRINE AND METABOLIC AGENTS MISC.
GASTROINTESTINAL AGENTS - MISC.
MEDICAL DEVICES AND SUPPLIES
MIGRAINE PRODUCTS
GASTROINTESTINAL AGENTS - MISC.
ANTIHYPERTENSIVES
ANTIHYPERTENSIVES
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
DERMATOLOGICALS
ANTIHYPERTENSIVES
ANTIHYPERTENSIVES
DERMATOLOGICALS
ANTICONVULSANTS
ANTICONVULSANTS
ANTICONVULSANTS
ANTIPARKINSON AGENTS
ANTIPARKINSON AGENTS
ANTIPARKINSON AGENTS
ANTIPARKINSON AGENTS
ANTIPARKINSON AGENTS
ANTIHISTAMINES
GENITOURINARY AGENTS MISCELLANEOUS
MUSCULOSKELETAL THERAPY AGENTS
MUSCULOSKELETAL THERAPY AGENTS
MUSCULOSKELETAL THERAPY AGENTS
MUSCULOSKELETAL THERAPY AGENTS
OPHTHALMIC AGENTS
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 7 of 101
Navi-Gate Rx Formulary Cont.
Alphabetical Index
Last Updated 1/1/2017
Drug Name
Special Code
Level
Category
carvedilol tab (COREG equiv)
CAYSTON INH SOLN (Only available through Walgreens 888-347-3416)
CEDAX CAP
CEDAX SUSP
cefadroxil cap (DURICEF equiv)
cefadroxil susp
cefadroxil tab (DURICEF equiv)
cefdinir cap (OMNICEF equiv)
cefdinir susp (OMNICEF equiv)
CEFDITOREN TAB
cefpodoxime susp (VANTIN equiv)
cefpodoxime tab (VANTIN equiv)
cefprozil susp
cefprozil tab (CEFZIL equiv)
cefuroxime susp (CEFTIN equiv)
cefuroxime tab (CEFTIN equiv)
celecoxib cap (CELEBREX equiv) (QL= 2 caps/day)
CENTANY OINT
cephalexin susp (KEFLEX equiv)
CEPHALEXIN TAB (KEFLEX equiv)
CERDELGA CAP
CESAMET CAP
cesia tab (CYCLESSA equiv)
cetirizine chew tab (ZYRTEC equiv)
cetirizine syrup (ZYRTEC equiv)
cetirizine tab (ZYRTEC equiv)
cetirizine/pseudoephedrine 12-hour tab (ZYRTEC-D equiv)
CETYLEV TAB
cevimeline cap (EVOXAC equiv)
LD
*-QL
OTC
OTC
OTC
OTC
*
F
F
NC
NC
F
F
F
F
F
F
F
F
F
F
F
F
F
NC
F
F
NC
F
F
F
F
F
F
NC
F
F
BETA BLOCKERS
ANTI-INFECTIVE AGENTS - MISC.
CEPHALOSPORINS
CEPHALOSPORINS
CEPHALOSPORINS
CEPHALOSPORINS
CEPHALOSPORINS
CEPHALOSPORINS
CEPHALOSPORINS
CEPHALOSPORINS
CEPHALOSPORINS
CEPHALOSPORINS
CEPHALOSPORINS
CEPHALOSPORINS
CEPHALOSPORINS
CEPHALOSPORINS
ANALGESICS - ANTI-INFLAMMATORY
DERMATOLOGICALS
CEPHALOSPORINS
CEPHALOSPORINS
HEMATOPOIETIC AGENTS
ANTIEMETICS
CONTRACEPTIVES
ANTIHISTAMINES
ANTIHISTAMINES
ANTIHISTAMINES
COUGH/COLD/ALLERGY
ANTIDOTES AND SPECIFIC ANTAGONISTS
MOUTH/THROAT/DENTAL AGENTS
*
F
-
F
F
-
F
F
F
F
F
F
F
F
F
F
F
F
F
F
NC
F
CHANTIX PAK (Coverage does not apply to those individuals who exceed
300% FPL.)
CHANTIX TAB (Coverage does not apply to those individuals who exceed
300% FPL.)
chlordiazepoxide cap (LIBRIUM equiv)
chlordiazepoxide/amitriptyline tab (LIMBITROL equiv)
chlordiazepoxide/clidinium cap (LIBRIUM equiv)
chlorhexidine gluconate soln (PERIDEX equiv)
chloroquine tab (ARALEN equiv)
chlorothiazide tab
chlorpromazine tab (THORAZINE equiv)
CHLORPROPAMIDE TAB
chlorpropamide tab (DIABINESE equiv)
CHLORTHALIDONE TAB
chlorzoxazone tab (PARAFON FORTE equiv)
cholestyramine light powder (QUESTRAN LIGHT equiv)
cholestyramine light powder pack (QUESTRAN LIGHT equiv)
cholestyramine powder (QUESTRAN equiv)
CHOLINE MAGNESIUM TRISALICYLATE TAB
choline magnesium trisalicylate tab (TRILISATE equiv)
CIALIS TAB
ciclopirox cream (LOPROX equiv)
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
PSYCHOTHERAPEUTIC AND
NEUROLOGICAL AGENTS - MISC.
PSYCHOTHERAPEUTIC AND
NEUROLOGICAL AGENTS - MISC.
ANTIANXIETY AGENTS
PSYCHOTHERAPEUTIC AND
NEUROLOGICAL AGENTS - MISC.
ULCER DRUGS
MOUTH/THROAT/DENTAL AGENTS
ANTIMALARIALS
DIURETICS
ANTIPSYCHOTICS/ANTIMANIC AGENTS
ANTIDIABETICS
ANTIDIABETICS
DIURETICS
MUSCULOSKELETAL THERAPY AGENTS
ANTIHYPERLIPIDEMICS
ANTIHYPERLIPIDEMICS
ANTIHYPERLIPIDEMICS
ANALGESICS - NONNARCOTIC
ANALGESICS - NONNARCOTIC
CARDIOVASCULAR AGENTS - MISC.
DERMATOLOGICALS
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 8 of 101
Navi-Gate Rx Formulary Cont.
Alphabetical Index
Last Updated 1/1/2017
Drug Name
Special Code
Level
Category
ciclopirox gel (LOPROX equiv)
ciclopirox nail soln (PENLAC equiv)
ciclopirox shampoo (LOPROX equiv)
ciclopirox soln (LOPROX equiv)
cilostazol tab (PLETAL equiv)
cimetidine tab (TAGAMET equiv)
CIMZIA INJ
CIPRODEX OTIC SUSP
ciprofloxacin ER tab (CIPRO XR equiv)
ciprofloxacin ophth soln (CILOXAN equiv)
ciprofloxacin oral susp (CIPRO equiv)
CIPROFLOXACIN OTIC SOLN
ciprofloxacin tab (CIPRO equiv)
CIPROFLOXACIN TAB 100MG
citalopram tab (CELEXA equiv)
clarithromycin ER tab (BIAXIN XL equiv)
clarithromycin susp (BIAXIN equiv)
clarithromycin tab (BIAXIN equiv)
clindamycin cap (CLEOCIN equiv)
clindamycin gel (CLEOCIN GEL equiv)
clindamycin soln (CLEOCIN equiv)
clindamycin topical lotion
clindamycin topical soln (CLEOCIN-T equiv)
clindamycin vaginal cream (CLEOCIN equiv)
clindamycin/benzoyl peroxide gel (BENZACLIN equiv)
CLINISTIX
CLINISTIX TEST STRIP
clobetasol E foam (OLUX E equiv)
clobetasol foam (OLUX equiv)
clobetasol lotion (CLOBEX equiv)
clobetasol propionate cream (TEMOVATE equiv)
clobetasol propionate emollient cream (TEMOVATE equiv)
clobetasol propionate gel (TEMOVATE equiv)
clobetasol propionate oint (TEMOVATE equiv)
clobetasol propionate soln (TEMOVATE equiv)
clobetasol shampoo (CLOBEX SHAMPOO equiv)
clobetasol spray (CLOBEX equiv)
clomipramine cap (ANAFRANIL equiv)
clonazepam ODT (KLONOPIN equiv)
clonazepam tab (KLONOPIN equiv)
clonidine ER tab (KAPVAY equiv)
-
F
F
F
F
F
F
NC
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
NC
F
F
NC
F
NC
F
F
F
F
F
NC
NC
F
F
F
NC
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
HEMATOLOGICAL AGENTS - MISC.
ULCER DRUGS
GASTROINTESTINAL AGENTS - MISC.
OTIC AGENTS
FLUOROQUINOLONES
OPHTHALMIC AGENTS
FLUOROQUINOLONES
OTIC AGENTS
FLUOROQUINOLONES
FLUOROQUINOLONES
ANTIDEPRESSANTS
MACROLIDES
MACROLIDES
MACROLIDES
ANTI-INFECTIVE AGENTS - MISC.
DERMATOLOGICALS
ANTI-INFECTIVE AGENTS - MISC.
DERMATOLOGICALS
DERMATOLOGICALS
VAGINAL PRODUCTS
DERMATOLOGICALS
DIAGNOSTIC PRODUCTS
DIAGNOSTIC PRODUCTS
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
ANTIDEPRESSANTS
ANTICONVULSANTS
ANTICONVULSANTS
clonidine patch (CATAPRES equiv)
clonidine tab (CATAPRES equiv)
clopidogrel tab 300mg (PLAVIX equiv)
clopidogrel tab 75mg (PLAVIX equiv)
clorazepate tab (TRANXENE-T equiv)
clotrimazole troches (MYCELEX equiv)
clotrimazole/betamethasone cream (LOTRISONE equiv)
clotrimazole/betamethasone lotion (LOTRISONE equiv)
clozapine ODT 25mg, 100mg (CLOZAPINE/FAZACLO equiv)
-
F
F
NC
F
F
F
F
F
F
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A
NOREXIANTS
ANTIHYPERTENSIVES
ANTIHYPERTENSIVES
HEMATOLOGICAL AGENTS - MISC.
HEMATOLOGICAL AGENTS - MISC.
ANTIANXIETY AGENTS
MOUTH/THROAT/DENTAL AGENTS
DERMATOLOGICALS
DERMATOLOGICALS
ANTIPSYCHOTICS/ANTIMANIC AGENTS
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 9 of 101
Navi-Gate Rx Formulary Cont.
Alphabetical Index
Last Updated 1/1/2017
Drug Name
Special Code
Level
Category
CLOZAPINE ODT/FAZACLO ODT
clozapine tab (CLOZARIL equiv)
codeine tab
COLCHICINE CAP
COLCRYS/COLCHICINE TAB
colestipol granule (COLESTID equiv)
colestipol powder packet (COLESTID equiv)
colestipol tab (COLESTID equiv)
COLY-MYCIN S OTIC SUSP
COMBIGAN OPHTH SOLN
COMBIPATCH
COMBIVENT INHALER
*
-
F
F
F
NC
NC
F
F
F
F
F
F
F
ANTIPSYCHOTICS/ANTIMANIC AGENTS
ANTIPSYCHOTICS/ANTIMANIC AGENTS
ANALGESICS - OPIOID
GOUT AGENTS
GOUT AGENTS
ANTIHYPERLIPIDEMICS
ANTIHYPERLIPIDEMICS
ANTIHYPERLIPIDEMICS
OTIC AGENTS
OPHTHALMIC AGENTS
ESTROGENS
COMBIVENT RESPIMAT INHALER
-
F
COMETRIQ KIT
LD
F
COMPLERA TAB
CONCERTA TAB
-
F
F
CONTRAVE TAB (QL= 4 tabs/day)
QL
F
COPAXONE INJ 20MG/ML
-
F
COPAXONE INJ 40MG/ML
-
F
CORTANE-B AQUEOUS OTIC SOLN
CORTISONE ACETATE TAB
COTELLIC TAB
-
NC
F
NC
COVERA-HS TAB
CREON CAP
CRESEMBA CAP
CRESTOR TAB
CRINONE GEL
CRIXIVAN CAP
CROMOLYN NEB SOLN
-
F
F
NC
F
F
F
F
cromolyn nebulizer solution
-
F
cromolyn ophth soln (CROLOM equiv)
cromolyn soln (GASTROCROM equiv)
cryselle tab (LO/OVRAL equiv)
CUPRIMINE CAP
cyanocobalamin inj
CYCLOBENZAPRINE COMPOUND KIT
cyclobenzaprine tab (FLEXERIL equiv)
cyclopentolate ophth soln (CYCLOGYL equiv)
CYCLOPHOSPHAMIDE CAP
-
F
F
F
NC
F
NC
F
F
F
cyclophosphamide tab
-
F
CYCLOSERINE CAP
-
NC
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
ANTIVIRALS
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A
NOREXIANTS
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A
NOREXIANTS
PSYCHOTHERAPEUTIC AND
NEUROLOGICAL AGENTS - MISC.
PSYCHOTHERAPEUTIC AND
NEUROLOGICAL AGENTS - MISC.
OTIC AGENTS
CORTICOSTEROIDS
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
CALCIUM CHANNEL BLOCKERS
DIGESTIVE AIDS
ANTIFUNGALS
ANTIHYPERLIPIDEMICS
VAGINAL PRODUCTS
ANTIVIRALS
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
OPHTHALMIC AGENTS
GASTROINTESTINAL AGENTS - MISC.
CONTRACEPTIVES
ASSORTED CLASSES
HEMATOPOIETIC AGENTS
MUSCULOSKELETAL THERAPY AGENTS
MUSCULOSKELETAL THERAPY AGENTS
OPHTHALMIC AGENTS
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
ANTIMYCOBACTERIAL AGENTS
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 10 of 101
Navi-Gate Rx Formulary Cont.
Alphabetical Index
Last Updated 1/1/2017
Drug Name
Special Code
Level
Category
CYCLOSET TAB
cyclosporine cap (SANDIMMUNE equiv)
cyclosporine modified cap (NEORAL equiv)
cyclosporine modified soln (NEORAL equiv)
cyproheptadine tab
CYSTAGON CAP (Only available through Pharmacare 800-238-7828)
LD
F
F
F
F
F
F
ANTIDIABETICS
ASSORTED CLASSES
ASSORTED CLASSES
ASSORTED CLASSES
ANTIHISTAMINES
CYSTARAN OPHTH SOLN (QL= 4 bottles/30 days; Only available through
Walgreens 888-347-3416)
DAKLINZA TAB
DALIRESP TAB
LD-QL
F
-
NC
NC
danazol cap
dantrolene cap (DANTRIUM equiv)
dapsone tab
DARAPRIM TAB (Only available through Walgreens 888-347-3416)
darifenacin SR tab (ENABLEX equiv)
DAYTRANA PATCH
LD
*
-
F
F
F
F
F
F
DELZICOL CAP
demeclocycline tab (DECLOMYCIN equiv)
DENAVIR CREAM
DEPEN TITRATAB
DEPLIN CAP
-
F
F
F
F
NC
DESCOVY TAB
desipramine tab (NORPRAMIN equiv)
DESLORATADINE ODT
desmopressin nasal spray (DDAVP equiv)
-
F
F
NC
F
desmopressin tab (DDAVP equiv)
-
F
desonide cream (DESOWEN equiv)
desonide lotion (DESOWEN equiv)
desonide oint (DESOWEN equiv)
desoximetasone cream 0.25% (TOPICORT equiv)
desoximetasone gel (TOPICORT equiv)
desoximetasone oint 0.25% (TOPICORT equiv)
DESVENLAFAXINE ER TAB
dexamethasone ophth soln (DEXAMETHASONE equiv)
dexamethasone soln
DEXAMETHASONE TAB
DEXILANT CAP
dexmethylphenidate ER cap (FOCALIN XR equiv)
-
NC
NC
NC
F
NC
NC
NC
F
F
F
F
F
dexmethylphenidate tab (FOCALIN equiv)
-
F
DEXPAK TAB
dextroamphetamine ER cap (DEXEDRINE equiv)
-
F
F
dextroamphetamine soln (PROCENTRA equiv)
-
F
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
GENITOURINARY AGENTS MISCELLANEOUS
OPHTHALMIC AGENTS
ANTIVIRALS
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
ANDROGENS-ANABOLIC
MUSCULOSKELETAL THERAPY AGENTS
ANTI-INFECTIVE AGENTS - MISC.
ANTIMALARIALS
URINARY ANTISPASMODICS
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A
NOREXIANTS
GASTROINTESTINAL AGENTS - MISC.
TETRACYCLINES
DERMATOLOGICALS
ASSORTED CLASSES
DIETARY PRODUCTS/DIETARY
MANAGEMENT PRODUCTS
ANTIVIRALS
ANTIDEPRESSANTS
ANTIHISTAMINES
ENDOCRINE AND METABOLIC AGENTS MISC.
ENDOCRINE AND METABOLIC AGENTS MISC.
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
ANTIDEPRESSANTS
OPHTHALMIC AGENTS
CORTICOSTEROIDS
CORTICOSTEROIDS
ULCER DRUGS
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A
NOREXIANTS
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A
NOREXIANTS
CORTICOSTEROIDS
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A
NOREXIANTS
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A
NOREXIANTS
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 11 of 101
Navi-Gate Rx Formulary Cont.
Alphabetical Index
Last Updated 1/1/2017
Drug Name
Special Code
Level
Category
dialyvite
dialyvite tab (NEPHRO-VITE equiv)
DIAPHRAGM
DIASTAT RECTAL GEL
diazepam conc (VALIUM equiv)
diazepam tab (VALIUM equiv)
diclofenac gel (SOLARAZE equiv)
diclofenac gel 1% (VOLTAREN equiv) (QL= 5 tubes/fill)
diclofenac potassium tab (CATAFLAM equiv)
diclofenac sodium ophth soln (VOLTAREN equiv)
diclofenac soln 1.5% (PENNSAID equiv)
diclofenac tab (VOLTAREN equiv)
dicloxacillin cap
dicyclomine cap (BENTYL equiv)
dicyclomine soln (BENTYL equiv)
dicyclomine tab (BENTYL equiv)
DIFFERIN GEL 0.3%
DIFICID TAB (QL= 20 tabs/fill)
DIFLORASONE CREAM
diflorasone oint
DIFLORASONE OINT (PSORCON equiv)
diflunisal tab (DOLOBID equiv)
digoxin soln (LANOXIN equiv)
digoxin tab (LANOXIN equiv)
dihydroergotamine mesylate inj (D.H.E equiv)
DILANTIN INFATABS
diltiazem CD cap (CARDIZEM CD equiv)
diltiazem ER cap
diltiazem ER tab (CARDIZEM LA equiv)
diltiazem tab (CARDIZEM equiv)
DIOVAN HCT TAB
diphenhydramine cap (Only 50mg covered)
diphenoxylate/atropine tab (LOMOTIL equiv)
dipyridamole tab (PERSANTINE equiv)
disopyramide cap (NORPACE equiv)
disulfiram tab (ANTABUSE equiv)
QL
QL
-
F
F
F
F
F
F
F
F
F
F
NC
F
F
F
F
F
F
F
NC
F
NC
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
MULTIVITAMINS
MULTIVITAMINS
MEDICAL DEVICES AND SUPPLIES
ANTICONVULSANTS
ANTIANXIETY AGENTS
ANTIANXIETY AGENTS
DERMATOLOGICALS
DERMATOLOGICALS
ANALGESICS - ANTI-INFLAMMATORY
OPHTHALMIC AGENTS
DERMATOLOGICALS
ANALGESICS - ANTI-INFLAMMATORY
PENICILLINS
ULCER DRUGS
ULCER DRUGS
ULCER DRUGS
DERMATOLOGICALS
MACROLIDES
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
ANALGESICS - NONNARCOTIC
CARDIOTONICS
CARDIOTONICS
MIGRAINE PRODUCTS
ANTICONVULSANTS
CALCIUM CHANNEL BLOCKERS
CALCIUM CHANNEL BLOCKERS
CALCIUM CHANNEL BLOCKERS
CALCIUM CHANNEL BLOCKERS
ANTIHYPERTENSIVES
ANTIHISTAMINES
ANTIDIARRHEALS
HEMATOLOGICAL AGENTS - MISC.
ANTIARRHYTHMICS
divalproex ER tab (DEPAKOTE ER equiv)
divalproex sodium DR tab (DEPAKOTE equiv)
divalproex sprinkle cap (DEPAKOTE equiv)
dofetilide cap (TIKOSYN equiv)
DOMETUSS-DMX LIQ
donepezil ODT (ARICEPT equiv) (QL= 1 tab/day)
QL
F
F
F
F
NC
F
donepezil tab (ARICEPT equiv) (QL= 2 tabs/day)
QL
F
donepezil tab 23mg (ARICEPT equiv) (QL= 1 tab/day)
QL
F
DONNATAL ELIXIR
DONNATAL EXTENTABS
DORYX MPC TAB
dorzolamide ophth soln (TRUSOPT equiv)
-
F
F
NC
F
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
PSYCHOTHERAPEUTIC AND
NEUROLOGICAL AGENTS - MISC.
ANTICONVULSANTS
ANTICONVULSANTS
ANTICONVULSANTS
ANTIARRHYTHMICS
COUGH/COLD/ALLERGY
PSYCHOTHERAPEUTIC AND
NEUROLOGICAL AGENTS - MISC.
PSYCHOTHERAPEUTIC AND
NEUROLOGICAL AGENTS - MISC.
PSYCHOTHERAPEUTIC AND
NEUROLOGICAL AGENTS - MISC.
ULCER DRUGS
ULCER DRUGS
TETRACYCLINES
OPHTHALMIC AGENTS
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 12 of 101
Navi-Gate Rx Formulary Cont.
Alphabetical Index
Last Updated 1/1/2017
Drug Name
Special Code
Level
Category
dorzolamide/timolol ophth soln (COSOPT equiv)
doxazosin tab (CARDURA equiv)
doxepin cap
DOXEPIN/PRUDOXIN/ZONALON CREAM
doxercalciferol cap (HECTOROL equiv)
-
F
F
F
F
F
OPHTHALMIC AGENTS
ANTIHYPERTENSIVES
ANTIDEPRESSANTS
DERMATOLOGICALS
doxycycline hyclate cap (VIBRAMYCIN equiv)
doxycycline hyclate DR tab (DORYX equiv)
doxycycline hyclate DR tab 200mg (DORYX equiv)
doxycycline hyclate tab (VIBRATAB equiv)
doxycycline monohydrate cap (MONODOX equiv)
doxycycline monohydrate tab (ADOXA equiv) (150mg tab is Not Covered)
doxycycline susp (VIBRAMYCIN equiv)
DOXYCYCLINE/ORACEA CAP
dronabinol cap (MARINOL equiv)
DRYSOL SOLN
DUAVEE TAB
DUETACT TAB
duloxetine cap (CYMBALTA equiv) (QL= 2 caps/day)
DUOPA ENTERAL SUSP
dutasteride cap (AVODART equiv)
QL
-
F
F
NC
F
F
F
F
NC
F
F
NC
F
F
NC
F
dutasteride/tamsulosin cap (JALYN equiv)
-
F
DUTOPROL TAB
DYANAVEL XR SUSP
-
NC
NC
DYRENIUM CAP
E.E.S SUSP
econazole cream (SPECTAZOLE equiv)
ECOZA FOAM
EDARBI TAB
EDARBYCLOR TAB
EDURANT TAB
EFFIENT TAB
EGRIFTA INJ
*
-
F
F
F
NC
F
F
F
F
NC
ELIDEL CREAM
ELIGEN B12 TAB
*
-
F
NC
ELIXOPHYLLIN ELIXIR
-
F
ELLA TAB
ELMIRON CAP
-
F
F
EMADINE OPHTH SOLN
EMBEDA CAP
EMCYT CAP
-
F
NC
F
EMEND CAP
EMEND SOLN
EMEND SUSP
-
F
F
NC
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
ENDOCRINE AND METABOLIC AGENTS MISC.
TETRACYCLINES
TETRACYCLINES
TETRACYCLINES
TETRACYCLINES
TETRACYCLINES
TETRACYCLINES
TETRACYCLINES
DERMATOLOGICALS
ANTIEMETICS
DERMATOLOGICALS
ESTROGENS
ANTIDIABETICS
ANTIDEPRESSANTS
ANTIPARKINSON AGENTS
GENITOURINARY AGENTS MISCELLANEOUS
GENITOURINARY AGENTS MISCELLANEOUS
ANTIHYPERTENSIVES
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A
NOREXIANTS
DIURETICS
MACROLIDES
DERMATOLOGICALS
DERMATOLOGICALS
ANTIHYPERTENSIVES
ANTIHYPERTENSIVES
ANTIVIRALS
HEMATOLOGICAL AGENTS - MISC.
ENDOCRINE AND METABOLIC AGENTS MISC.
DERMATOLOGICALS
DIETARY PRODUCTS/DIETARY
MANAGEMENT PRODUCTS
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
CONTRACEPTIVES
GENITOURINARY AGENTS MISCELLANEOUS
OPHTHALMIC AGENTS
ANALGESICS - OPIOID
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
ANTIEMETICS
ANTIEMETICS
ANTIEMETICS
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 13 of 101
Navi-Gate Rx Formulary Cont.
Alphabetical Index
Last Updated 1/1/2017
Drug Name
Special Code
Level
Category
EMSAM PATCH
EMTRIVA CAP
EMVERM TAB
enalapril tab (VASOTEC equiv)
enalapril/hydrochlorothiazide tab (VASERETIC equiv)
ENBREL INJ 25MG (QL= 8 inj/28 days)
ENBREL INJ 50MG (QL= 4 inj/28 days)
ENBREL SURECLICK INJ 50MG (QL= 4 inj/28 days)
ENDOMETRIN INSERT
enoxaparin inj (LOVENOX equiv)
enpresse tab (TRI-LEVLEN equiv)
ENSTILAR FOAM
entacapone tab (COMTAN equiv)
entecavir tab (BARACLUDE equiv) (QL= 1 tab/day)
ENTRESTO TAB
ENVARSUS XR TAB
EPANED PREMIXED SOLN
EPANED SOLN
EPCLUSA TAB
EPIDUO (FORTE) GEL
epinastine opthth soln (ELESTAT equiv)
EPINEPHRINE PEN INJ 0.15MG (MYLAN) (QL= 2 inj/fill)
EPINEPHRINE PEN INJ 0.3MG (MYLAN) (QL= 2 inj/fill)
EPIVIR HBV SOLN
eplerenone tab (INSPRA equiv)
EPOGEN INJ
ergocalciferol
ERGOLOID MESYLATES TAB
QL
QL
QL
QL-¢
QL
QL
-
F
F
NC
F
F
F
F
F
F
F
F
NC
F
F
NC
NC
NC
NC
NC
F
F
F
F
F
F
F
F
NC
ANTIDEPRESSANTS
ANTIVIRALS
ANTHELMINTICS
ANTIHYPERTENSIVES
ANTIHYPERTENSIVES
ANALGESICS - ANTI-INFLAMMATORY
ANALGESICS - ANTI-INFLAMMATORY
ANALGESICS - ANTI-INFLAMMATORY
VAGINAL PRODUCTS
ANTICOAGULANTS
CONTRACEPTIVES
DERMATOLOGICALS
ANTIPARKINSON AGENTS
ANTIVIRALS
CARDIOVASCULAR AGENTS - MISC.
ASSORTED CLASSES
ANTIHYPERTENSIVES
ANTIHYPERTENSIVES
ANTIVIRALS
DERMATOLOGICALS
OPHTHALMIC AGENTS
VASOPRESSORS
VASOPRESSORS
ANTIVIRALS
ANTIHYPERTENSIVES
HEMATOPOIETIC AGENTS
VITAMINS
ergotamine/caffeine tab (CAFERGOT equiv)
ERIVEDGE CAP
-
F
F
ERY-TAB
ERYTHROMYCIN CAP
erythromycin ethylsuccinate susp (ERYPED equiv)
erythromycin gel
erythromycin ophth oint
erythromycin pad
erythromycin soln
erythromycin tab
erythromycin/sulfisoxazole susp (PEDIAZOLE equiv)
ESBRIET CAP
escitalopram soln (LEXAPRO equiv)
escitalopram tab (LEXAPRO equiv)
esomeprazole cap (NEXIUM equiv)
ESOMEPRAZOLE STRONTIUM CAP
estazolam tab (PROSOM equiv)
-
F
F
F
F
F
F
F
F
F
NC
F
F
F
NC
F
ESTRACE VAGINAL CREAM
estradiol patch (CLIMARA equiv)
estradiol patch (VIVELLE-DOT equiv)
estradiol tab (ESTRACE equiv)
-
F
F
F
F
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
PSYCHOTHERAPEUTIC AND
NEUROLOGICAL AGENTS - MISC.
MIGRAINE PRODUCTS
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
MACROLIDES
MACROLIDES
MACROLIDES
DERMATOLOGICALS
OPHTHALMIC AGENTS
DERMATOLOGICALS
DERMATOLOGICALS
MACROLIDES
ANTI-INFECTIVE AGENTS - MISC.
RESPIRATORY AGENTS - MISC.
ANTIDEPRESSANTS
ANTIDEPRESSANTS
ULCER DRUGS
ULCER DRUGS
HYPNOTICS/SEDATIVES/SLEEP DISORDER
AGENTS
VAGINAL PRODUCTS
ESTROGENS
ESTROGENS
ESTROGENS
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 14 of 101
Navi-Gate Rx Formulary Cont.
Alphabetical Index
Last Updated 1/1/2017
Drug Name
Special Code
Level
Category
estradiol/norethindrone tab (ACTIVELLA equiv)
ESTRING
estropipate tab (OGEN equiv)
eszopiclone tab (LUNESTA equiv) (QL= 1 tab/day)
QL
F
F
F
F
ESTROGENS
VAGINAL PRODUCTS
ESTROGENS
ethacrynic tab (EDECRIN equiv)
ethambutol tab (MYAMBUTOL equiv)
ethosuximide cap (ZARONTIN equiv)
etidronate disodium tab 200mg (DIDRONEL equiv)
-
F
F
F
F
etodolac cap (LODINE equiv)
etodolac tab (LODINE equiv)
etoposide cap (VEPESID equiv)
-
F
F
F
EURAX CREAM
EURAX LOTION
EVOTAZ TAB
EVZIO INJ
exemestane tab (AROMASIN equiv)
-
F
F
F
NC
F
EXJADE TAB
EXTAVIA INJ
-
F
F
ezetimibe tab (ZETIA equiv)
FALESSA KIT
-
NC
NC
famotidine susp (PEPCID equiv)
famotidine tab (PEPCID equiv)
FANAPT TAB
FARESTON TAB
-
F
F
NC
F
FARXIGA TAB (QL= 1 tab/day)
felbamate susp (FELBATOL equiv)
felbamate tab (FELBATOL equiv)
FELBATOL TAB
fenofibrate cap (ANTARA equiv)
fenofibrate tab (TRICOR equiv)
fenoprofen calcium tab
FENOPROFEN CAP
fentanyl citrate lollipop (ACTIQ equiv) (QL= 120 lozenges/30 days)
fentanyl patch (DURAGESIC equiv)
ferrex 150 forte cap
QL
QL
LD
F
F
F
F
F
F
F
F
F
F
F
F
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
ANTIDIABETICS
ANTICONVULSANTS
ANTICONVULSANTS
ANTICONVULSANTS
ANTIHYPERLIPIDEMICS
ANTIHYPERLIPIDEMICS
ANALGESICS - ANTI-INFLAMMATORY
ANALGESICS - ANTI-INFLAMMATORY
ANALGESICS - OPIOID
ANALGESICS - OPIOID
HEMATOPOIETIC AGENTS
ANTIDOTES
LD
QL
QL
OTC
OTC
OTC
-
F
F
F
F
F
F
F
F
ANTIDOTES
ANTIDEPRESSANTS
ANTIDEPRESSANTS
ANTIHISTAMINES
COUGH/COLD/ALLERGY
COUGH/COLD/ALLERGY
DERMATOLOGICALS
DERMATOLOGICALS
FERRIPROX SOLN (Only available through Ferriprox Total Care
866-758-7071)
FERRIPROX TAB (Only available through Ferriprox Total Care 866-758-7071)
FETZIMA CAP (QL= 1 cap/day)
FETZIMA TITRATION PACK (QL= 1 cap/day)
fexofenadine tab (ALLEGRA equiv)
fexofenadine/pseudoephedrine 12-hour tab (ALLEGRA-D equiv)
fexofenadine/pseudoephedrine 24-hour tab (ALLEGRA-D equiv)
FINACEA FOAM
FINACEA GEL
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
HYPNOTICS/SEDATIVES/SLEEP DISORDER
AGENTS
DIURETICS
ANTIMYCOBACTERIAL AGENTS
ANTICONVULSANTS
ENDOCRINE AND METABOLIC AGENTS MISC.
ANALGESICS - ANTI-INFLAMMATORY
ANALGESICS - ANTI-INFLAMMATORY
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
DERMATOLOGICALS
DERMATOLOGICALS
ANTIVIRALS
ANTIDOTES
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
ANTIDOTES
PSYCHOTHERAPEUTIC AND
NEUROLOGICAL AGENTS - MISC.
ANTIHYPERLIPIDEMICS
DIETARY PRODUCTS/DIETARY
MANAGEMENT PRODUCTS
ULCER DRUGS
ULCER DRUGS
ANTIPSYCHOTICS/ANTIMANIC AGENTS
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 15 of 101
Navi-Gate Rx Formulary Cont.
Alphabetical Index
Last Updated 1/1/2017
Drug Name
Special Code
Level
Category
finasteride tab (PROSCAR equiv)
-
F
FIRST BACLOFEN SUSP KIT
FIRST METRONIDAZOLE SUSP
flavoxate tab
flecainide tab (TAMBOCOR equiv)
FLECTOR PATCH (QL= 30 patches/fill)
FLORIVA CHEW TAB
FLOVENT DISKUS INHALER
QL
-
NC
NC
NC
F
F
NC
F
GENITOURINARY AGENTS MISCELLANEOUS
MUSCULOSKELETAL THERAPY AGENTS
ANTI-INFECTIVE AGENTS - MISC.
URINARY ANTISPASMODICS
ANTIARRHYTHMICS
DERMATOLOGICALS
MULTIVITAMINS
FLOVENT HFA INHALER
-
F
fluconazole susp (DIFLUCAN equiv)
fluconazole tab (DIFLUCAN equiv)
fludrocortisone tab
flunisolide nasal spray (NASAREL equiv)
fluocinolone acetonide oil (DERMA SMOOTH/FS equiv)
fluocinolone cream (SYNALAR equiv)
fluocinolone oint (SYNALAR equiv)
fluocinolone otic oil (DERMOTIC equiv)
fluocinolone soln (SYNALAR equiv)
fluocinonide cream 0.05% (VANOS CREAM equiv)
fluocinonide cream 0.1% (VANOS CREAM equiv)
fluocinonide gel (LIDEX equiv)
fluocinonide oint (LIDEX equiv)
fluocinonide soln (LIDEX equiv)
fluocinonide-e cream (LIDEX-E equiv)
FLUORAC CREAM
fluorometholone ophth soln (FML LIQUIFILM equiv)
fluorouracil cream (EFUDEX equiv)
fluorouracil soln (EFUDEX equiv)
fluoxetine cap (PROZAC equiv)
FLUOXETINE CAP (PMDD)
-
F
F
F
NC
F
F
F
F
F
F
NC
F
F
F
F
NC
F
F
F
F
NC
fluoxetine soln (PROZAC equiv)
fluoxetine tab (PROZAC equiv)
FLUOXETINE TAB 60MG
fluphenazine tab (PROLIXIN equiv)
flurandrenolide cream (CORDRAN equiv)
FLURAZEPAM CAP
-
F
F
NC
F
F
F
flurbiprofen ophth soln (OCUFEN equiv)
flurbiprofen tab
flutamide cap
-
F
F
F
fluticasone nasal spray (FLONASE equiv) (QL= 2 bottles/fill)
fluticasone propionate cream (CUTIVATE equiv)
fluticasone propionate lotion (CUTIVATE equiv)
fluticasone propionate oint (CUTIVATE equiv)
fluvastatin cap (LESCOL equiv)
fluvastatin ER tab (LESCOL XL equiv)
fluvoxamine tab (LUVOX equiv)
QL
-
F
F
NC
F
NC
NC
F
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
ANTIFUNGALS
ANTIFUNGALS
CORTICOSTEROIDS
NASAL AGENTS - SYSTEMIC AND TOPICAL
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
OTIC AGENTS
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
OPHTHALMIC AGENTS
DERMATOLOGICALS
DERMATOLOGICALS
ANTIDEPRESSANTS
PSYCHOTHERAPEUTIC AND
NEUROLOGICAL AGENTS - MISC.
ANTIDEPRESSANTS
ANTIDEPRESSANTS
ANTIDEPRESSANTS
ANTIPSYCHOTICS/ANTIMANIC AGENTS
DERMATOLOGICALS
HYPNOTICS/SEDATIVES/SLEEP DISORDER
AGENTS
OPHTHALMIC AGENTS
ANALGESICS - ANTI-INFLAMMATORY
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
NASAL AGENTS - SYSTEMIC AND TOPICAL
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
ANTIHYPERLIPIDEMICS
ANTIHYPERLIPIDEMICS
ANTIDEPRESSANTS
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 16 of 101
Navi-Gate Rx Formulary Cont.
Alphabetical Index
Last Updated 1/1/2017
Drug Name
Special Code
Level
Category
FML S.O.P. OPHTH OINT
FOCALIN XR CAP
-
F
F
OPHTHALMIC AGENTS
FOLBEE PLUS CZ TAB
fondaparinux inj (ARIXTRA equiv)
FORADIL AEROLIZER
-
F
F
F
FORTEO INJ
*
F
FORTESTA GEL/ TESTOSTERONE GEL
fosinopril/hydrochlorothiazide tab (MONOPRIL HCT equiv)
FOSRENOL CHEW
FOSRENOL POWDER PACK
FRAGMIN INJ
FREESTYLE FREEDOM LITE METER
FREESTYLE FREEDOM METER
FREESTYLE INSULIN SYRINGE
FREESTYLE INSULINX TEST STRIP
FREESTYLE INSULINX TEST STRIPS
FREESTYLE KIT INSULINX
FREESTYLE LITE TEST STRIP
FREESTYLE METER
FREESTYLE PRECISION NEO METER
FREESTYLE PRECISION NEO TEST STRIP
FREESTYLE TEST STRIP
FULYZAQ TAB
furosemide soln
furosemide tab (LASIX equiv)
FUZEON INJ
FYCOMPA TAB
FYCOMPA SUSP
gabapentin cap (NEURONTIN equiv)
gabapentin tab (NEURONTIN equiv)
GABITRIL TAB 12MG, 16MG
galantamine ER cap (RAZADYNE ER equiv)
OTC
OTC
OTC
OTC
OTC
OTC
OTC
OTC
OTC
OTC
OTC
-
NC
F
F
F
F
F
F
F
F
F
F
F
F
NC
NC
F
NC
F
F
F
NC
NC
F
F
F
F
GALANTAMINE SOLN (RAZADYNE equiv)
-
F
galantamine tab (RAZADYNE equiv)
¢
F
GANCICLOVIR CAP
GANTRISIN SUSP
gatifloxacin ophth soln (ZYMAXID equiv)
gavilyte-h kit
GELNIQUE
gemfibrozil tab (LOPID equiv)
GENOTROPIN/HUMATROPE/OMNITROPE/ZOMACTON INJ
-
F
F
F
NC
NC
F
F
gentamicin ophth oint (GARAMYCIN equiv)
gentamicin ophth soln (GARAMYCIN equiv)
GENVOYA TAB
GIALAX KIT
-
F
F
F
NC
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A
NOREXIANTS
MULTIVITAMINS
ANTICOAGULANTS
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
ENDOCRINE AND METABOLIC AGENTS MISC.
ANDROGENS-ANABOLIC
ANTIHYPERTENSIVES
GASTROINTESTINAL AGENTS - MISC.
GASTROINTESTINAL AGENTS - MISC.
ANTICOAGULANTS
MEDICAL DEVICES AND SUPPLIES
MEDICAL DEVICES AND SUPPLIES
MEDICAL DEVICES AND SUPPLIES
DIAGNOSTIC PRODUCTS
DIAGNOSTIC PRODUCTS
MEDICAL DEVICES AND SUPPLIES
MEDICAL DEVICES AND SUPPLIES
MEDICAL DEVICES AND SUPPLIES
MEDICAL DEVICES AND SUPPLIES
DIAGNOSTIC PRODUCTS
DIAGNOSTIC PRODUCTS
ANTIDIARRHEALS
DIURETICS
DIURETICS
ANTIVIRALS
ANTICONVULSANTS
ANTICONVULSANTS
ANTICONVULSANTS
ANTICONVULSANTS
ANTICONVULSANTS
PSYCHOTHERAPEUTIC AND
NEUROLOGICAL AGENTS - MISC.
PSYCHOTHERAPEUTIC AND
NEUROLOGICAL AGENTS - MISC.
PSYCHOTHERAPEUTIC AND
NEUROLOGICAL AGENTS - MISC.
ANTIVIRALS
SULFONAMIDES
OPHTHALMIC AGENTS
LAXATIVES
URINARY ANTISPASMODICS
ANTIHYPERLIPIDEMICS
ENDOCRINE AND METABOLIC AGENTS MISC.
OPHTHALMIC AGENTS
OPHTHALMIC AGENTS
ANTIVIRALS
LAXATIVES
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 17 of 101
Navi-Gate Rx Formulary Cont.
Alphabetical Index
Last Updated 1/1/2017
Drug Name
Special Code
Level
Category
gianvi tab (YAZ equiv)
GILENYA CAP (QL= 1 cap/day)
QL
NC
F
CONTRACEPTIVES
GILOTRIF TAB (QL= 1 tab/day, Only available through Accredo
888-773-7376)
glatopa inj 20mg/ml (COPAXONE equiv)
LD-QL
F
-
NC
GLEEVEC TAB
-
NC
GLEOSTINE/LOMUSTINE CAP
-
F
glimepiride tab (AMARYL equiv)
glipizide ER tab (GLUCOTROL XL equiv)
glipizide tab (GLUCOTROL equiv)
glipizide/metformin tab (METAGLIP equiv)
GLUCAGEN HYPOKIT INJ
GLUCAGEN INJ
GLUCAGON DIAGNOSTIC INJ
GLUCAGON INJ KIT
glyburide micronized tab (GLYNASE equiv)
glyburide tab (MICRONASE equiv)
glyburide/metformin tab (GLUCOVANCE equiv)
GLYCATE TAB 1.5MG
glycopyrrolate tab (ROBINUL equiv)
GLYGEST PAK
-
F
F
F
F
F
F
NC
F
F
F
F
NC
F
NC
GLYXAMBI TAB (QL= 1 tab/day)
GONITRO POWDER
graniesetron tab (KYTRIL equiv)
GRANIX INJ
GRASTEK SL TAB
griseofulvin micro tab (GRIFULVIN-V equiv)
griseofulvin susp (GRIFULVIN equiv)
griseofulvin tab (GRIS-PEG equiv)
GRIS-PEG TAB
guaifenesin DM/pseudoephedrine tab
guaifenesin/codeine syrup (TUSSI-ORGANI equiv) (QL= 240ml/fill)
GUANABENZ TAB
guanfacine IR tab (TENEX equiv)
halobetasol propionate cream (ULTRAVATE equiv)
halobetasol propionate oint (ULTRAVATE equiv)
haloperidol tab (HALDOL equiv)
HARVONI TAB (QL= 1 tab/day)
hc pramoxine cream (ANALPRAM equiv)
HEMANGEOL SOLN
hemax tab
HEPARIN
heparin/ d5w inj (HEPARIN/ D5W equiv)
HETLIOZ CAP
QL
OTC
OTC-QL
QL
-
F
NC
F
F
NC
F
F
F
F
F
F
F
F
F
F
F
F
F
NC
F
F
F
NC
HEXALEN CAP
-
F
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
PSYCHOTHERAPEUTIC AND
NEUROLOGICAL AGENTS - MISC.
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
PSYCHOTHERAPEUTIC AND
NEUROLOGICAL AGENTS - MISC.
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
ANTIDIABETICS
ANTIDIABETICS
ANTIDIABETICS
ANTIDIABETICS
ANTIDIABETICS
DIAGNOSTIC PRODUCTS
DIAGNOSTIC PRODUCTS
ANTIDIABETICS
ANTIDIABETICS
ANTIDIABETICS
ANTIDIABETICS
ULCER DRUGS
ULCER DRUGS
DIETARY PRODUCTS/DIETARY
MANAGEMENT PRODUCTS
ANTIDIABETICS
ANTIANGINAL AGENTS
ANTIEMETICS
HEMATOPOIETIC AGENTS
BIOLOGICALS MISC
ANTIFUNGALS
ANTIFUNGALS
ANTIFUNGALS
ANTIFUNGALS
COUGH/COLD/ALLERGY
COUGH/COLD/ALLERGY
ANTIHYPERTENSIVES
ANTIHYPERTENSIVES
DERMATOLOGICALS
DERMATOLOGICALS
ANTIPSYCHOTICS/ANTIMANIC AGENTS
ANTIVIRALS
ANORECTAL AGENTS
BETA BLOCKERS
HEMATOPOIETIC AGENTS
ANTICOAGULANTS
ANTICOAGULANTS
HYPNOTICS/SEDATIVES/SLEEP DISORDER
AGENTS
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 18 of 101
Navi-Gate Rx Formulary Cont.
Alphabetical Index
Last Updated 1/1/2017
Drug Name
Special Code
Level
Category
homatropine ophth soln (ISOPTO HOMATROPINE equiv)
HUMALOG INJ
HUMALOG KWIKPEN INJ
HUMALOG MIX INJ
HUMALOG MIX KWIKPEN INJ
HUMALOG PEN INJ
HUMIRA INJ (QL= 2 inj/28 days)
HUMIRA PEN INJ (QL= 2 inj/28 days)
HUMULIN 70/30 INJ
HUMULIN N INJ
HUMULIN N PEN INJ
HUMULIN R INJ
HYCAMTIN CAP
QL
QL
OTC
OTC
-
F
NC
NC
NC
NC
NC
F
F
NC
NC
NC
NC
F
OPHTHALMIC AGENTS
ANTIDIABETICS
ANTIDIABETICS
ANTIDIABETICS
ANTIDIABETICS
ANTIDIABETICS
ANALGESICS - ANTI-INFLAMMATORY
ANALGESICS - ANTI-INFLAMMATORY
ANTIDIABETICS
ANTIDIABETICS
ANTIDIABETICS
ANTIDIABETICS
HYCOFENIX SOLN
hydralazine tab
hydrochlorothiazide cap
hydrochlorothiazide tab
hydrocodone/acetaminophen cap (LORCET equiv)
hydrocodone/acetaminophen soln (ZOLVIT equiv)
hydrocodone/acetaminophen tab (LORTAB equiv)
hydrocodone/acetaminophen tab 10mg/300mg (XODOL equiv)
hydrocodone/acetaminophen tab 2.5/325mg (NORCO equiv)
hydrocodone/acetaminophen tab 5mg/300mg (XODOL equiv)
hydrocodone/acetaminophen tab 7.5mg/300mg (XODOL equiv)
QL
NC
F
F
F
F
F
F
NC
F
NC
NC
F
-
NC
NC
NC
NC
F
F
F
F
F
F
F
NC
NC
NC
F
F
NC
hydroxyurea cap (HYDREA equiv)
-
F
hydroxyzine pamoate cap (VISTARIL equiv)
hydroxyzine tab (ATARAX equiv)
hyoscyamine sulfate SR cap (LEVSINEX equiv)
hyoscyamine tab (LEVSIN equiv)
HYSINGLA ER TAB (QL= 1 tab/day)
QL
F
F
F
F
F
hydrocodone/chlorpheniramine/pseudoephedrine liquid (ZUTRIPRO equiv)
(QL= 4 oz/Rx; 2 fills/month)
hydrocortisone butyrate cream (LOCOID equiv)
hydrocortisone butyrate lipocream (LOCOID equiv)
hydrocortisone butyrate oint (LOCOID equiv)
hydrocortisone butyrate soln (LOCOID equiv)
hydrocortisone cream (PROCTOCORT equiv)
hydrocortisone enema (CORTENEMA equiv)
hydrocortisone lotion (HYTONE equiv)
hydrocortisone oint
hydrocortisone pramoxine cream (PRAMOSONE equiv)
hydrocortisone supp (ANUSOL HC equiv)
hydrocortisone tab (CORTEF equiv)
hydrocortisone valerate cream (WESTCORT equiv)
hydrocortisone valerate oint (WESTCORT equiv)
hydromorphone ER tab (EXALGO equiv)
hydromorphone tab (DILAUDID equiv)
hydroxychloroquine tab (PLAQUENIL equiv)
HYDROXYPROGESTERONE CAPROATE INJ
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
COUGH/COLD/ALLERGY
ANTIHYPERTENSIVES
DIURETICS
DIURETICS
ANALGESICS - OPIOID
ANALGESICS - OPIOID
ANALGESICS - OPIOID
ANALGESICS - OPIOID
ANALGESICS - OPIOID
ANALGESICS - OPIOID
ANALGESICS - OPIOID
COUGH/COLD/ALLERGY
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
ANORECTAL AGENTS
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
ANORECTAL AGENTS
CORTICOSTEROIDS
DERMATOLOGICALS
DERMATOLOGICALS
ANALGESICS - OPIOID
ANALGESICS - OPIOID
ANTIMALARIALS
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
ANTIANXIETY AGENTS
ANTIANXIETY AGENTS
ULCER DRUGS
ULCER DRUGS
ANALGESICS - OPIOID
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 19 of 101
Navi-Gate Rx Formulary Cont.
Alphabetical Index
Last Updated 1/1/2017
Drug Name
Special Code
Level
Category
ibandronate tab 150mg (BONIVA equiv) (QL= 1 tab/month)
QL
F
ibuprofen susp (MOTRIN equiv)
ibuprofen tab (MOTRIN equiv)
ICLUSIG TAB (Only available through Biologics 800-850-4306)
LD
F
F
F
ENDOCRINE AND METABOLIC AGENTS MISC.
ANALGESICS - ANTI-INFLAMMATORY
ANALGESICS - ANTI-INFLAMMATORY
ILEVRO OPHTH SUSP
imatinib tab (GLEEVEC equiv)
-
F
F
IMBRUVICA CAP (QL= 4 caps/day; Only available through Diplomat Pharmacy
877-977-9118)
imipramine pamoate tab (TOFRANIL-PM equiv)
imipramine tab (TOFRANIL equiv)
imiquimod cream (ALDARA equiv)
IMPAVIDO CAP
INCIVEK TAB
INCRELEX INJ
LD-QL
F
-
F
F
F
NC
NC
F
INCRUSE ELLIPTA INHALER
-
F
indapamide tab (LOZOL equiv)
indomethacin cap (INDOCIN equiv)
indomethacin ER cap (INDOCIN SR equiv)
INFERGEN INJ
INLYTA TAB (QL= 8 tabs/day)
QL
F
F
F
F
F
INNOPRAN XL CAP
INTELENCE TAB
INTRON-A INJ
-
F
F
F
INVEGA SUSTENNA/TRINZ INJ
INVIRASE CAP
INVIRASE TAB
INVOKAMET TAB ( )
INVOKAMET XR TAB
INVOKANA TAB
iodoquinol/hydrocortisone cream 1.9-1% (VYTONE equiv)
ipratropium nasal spray (ATROVENT equiv)
-
NC
F
F
NC
NC
NC
NC
F
ipratropium nasal spray (ATROVENT equiv)
irbesartan tab (AVAPRO equiv)
irbesartan/hydrochlorothiazide tab (AVALIDE equiv)
IRESSA TAB (Only available through Diplomat Pharmacy 877-977-9118)
¢
LD
F
F
F
F
ISENTRESS CHEW TAB
ISENTRESS POWDER PACK
ISENTRESS TAB
isometheptene/caffeine/acetaminophen tab (PRODRIN equiv)
isoniazid tab
ISOPTO CARBACHOL OPHTH SOLN
isosorbide dinitrate ER tab
isosorbide dinitrate SL tab
-
F
F
F
F
F
F
F
F
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
OPHTHALMIC AGENTS
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
ANTIDEPRESSANTS
ANTIDEPRESSANTS
DERMATOLOGICALS
ANTI-INFECTIVE AGENTS - MISC.
ANTIVIRALS
ENDOCRINE AND METABOLIC AGENTS MISC.
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
DIURETICS
ANALGESICS - ANTI-INFLAMMATORY
ANALGESICS - ANTI-INFLAMMATORY
ANTIVIRALS
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
BETA BLOCKERS
ANTIVIRALS
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
ANTIPSYCHOTICS/ANTIMANIC AGENTS
ANTIVIRALS
ANTIVIRALS
ANTIDIABETICS
ANTIDIABETICS
ANTIDIABETICS
DERMATOLOGICALS
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
NASAL AGENTS - SYSTEMIC AND TOPICAL
ANTIHYPERTENSIVES
ANTIHYPERTENSIVES
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
ANTIVIRALS
ANTIVIRALS
ANTIVIRALS
MIGRAINE PRODUCTS
ANTIMYCOBACTERIAL AGENTS
OPHTHALMIC AGENTS
ANTIANGINAL AGENTS
ANTIANGINAL AGENTS
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 20 of 101
Navi-Gate Rx Formulary Cont.
Alphabetical Index
Last Updated 1/1/2017
Drug Name
Special Code
Level
Category
isosorbide dinitrate tab (ISORDIL equiv)
ISOSORBIDE DINITRATE TAB 30MG, 40MG
isosorbide mononitrate ER tab (IMDUR equiv)
isosorbide mononitrate tab (MONOKET equiv)
isotretinoin cap (ACCUTANE equiv)
isradipine cap (DYNACIRC equiv)
ISTALOL OPHTH SOLN
itraconazole cap (SPORANOX equiv)
ivermectin tab (STROMECTOL equiv)
JADENU TAB
JAKAFI TAB (QL= 2 tabs/day)
QL
F
F
F
F
F
F
F
F
F
F
F
ANTIANGINAL AGENTS
ANTIANGINAL AGENTS
ANTIANGINAL AGENTS
ANTIANGINAL AGENTS
DERMATOLOGICALS
CALCIUM CHANNEL BLOCKERS
OPHTHALMIC AGENTS
ANTIFUNGALS
ANTHELMINTICS
ANTIDOTES
JANUMET TAB
JANUVIA TAB (QL= 1 tab/day)
JARDIANCE TAB (QL= 1 tab/day)
JENTADUETO TAB (QL= 2 tabs/day)
JENTADUETO XR TAB (QL= 2 tabs/day)
jinteli tab (FEMHRT equiv)
jolessa tab (SEASONALE equiv)
JUBLIA SOLN
junel FE tab (LO-ESTRIN equiv)
junel tab (MICROGESTIN equiv)
JUXTAPID CAP
KALETRA CAP
KALETRA TAB
KALYDECO PAK (QL= 2 packets/day)
KALYDECO TAB (QL= 2 tabs/day)
KARBINAL ER SUSP
kariva tab (MIRCETTE equiv)
KAZANO/ALOGLIPTIN-METFORMIN TAB
kelnor tab (DEMULEN equiv)
KERYDIN SOLN
ketoconazole cream (NIZORAL equiv)
ketoconazole shampoo (NIZORAL equiv)
ketoconazole tab (NIZORAL equiv)
KETO-DIASTIX TEST STRIP
ketoprofen cap
ketorolac ophth soln (ACULAR (LS) equiv)
ketorolac tab (TORADOL equiv) (QL= 20 tabs/5 days)
ketotifen ophth soln (ZADITOR equiv)
KEVEYIS TAB
KHEDEZLA ER TAB
QL-¢
QL
QL
QL
QL
QL
OTC
QL
OTC
LD-QL
F
F
F
F
F
F
NC
NC
F
F
NC
F
F
F
F
NC
F
NC
F
NC
F
F
F
F
F
F
F
F
NC
NC
F
LD
LD
NC
NC
F
F
KUVAN TAB (Only available through Walgreens 888-347-3416)
LD
F
KYBELLA INJ
-
NC
KINERET INJ (QL= 1 inj/day; Only available through Rx Crossroads:
1-866-547-0644)
KITABIS PAK NEB SOLN
KOMBIGLYZE XR TAB
KORLYM TAB (Only available through CuraScript 1-877-634-8553)
KUVAN POWDER PACK (Only available through Walgreens 888-347-3416)
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
ANTIDIABETICS
ANTIDIABETICS
ANTIDIABETICS
ANTIDIABETICS
ANTIDIABETICS
ESTROGENS
CONTRACEPTIVES
DERMATOLOGICALS
CONTRACEPTIVES
CONTRACEPTIVES
ANTIHYPERLIPIDEMICS
ANTIVIRALS
ANTIVIRALS
RESPIRATORY AGENTS - MISC.
RESPIRATORY AGENTS - MISC.
ANTIHISTAMINES
CONTRACEPTIVES
ANTIDIABETICS
CONTRACEPTIVES
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
ANTIFUNGALS
DIAGNOSTIC PRODUCTS
ANALGESICS - ANTI-INFLAMMATORY
OPHTHALMIC AGENTS
ANALGESICS - ANTI-INFLAMMATORY
OPHTHALMIC AGENTS
DIURETICS
ANTIDEPRESSANTS
ANALGESICS - ANTI-INFLAMMATORY
AMINOGLYCOSIDES
ANTIDIABETICS
ANTIDIABETICS
ENDOCRINE AND METABOLIC AGENTS MISC.
ENDOCRINE AND METABOLIC AGENTS MISC.
DERMATOLOGICALS
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 21 of 101
Navi-Gate Rx Formulary Cont.
Alphabetical Index
Last Updated 1/1/2017
Drug Name
Special Code
Level
Category
KYNAMRO INJ
labetaolol tab (TRANDATE equiv)
lactulose soln
lamivudine soln (EPIVIR SOLN equiv)
lamivudine tab (EPIVIR equiv)
lamivudine tab 100mg (EPIVIR HBV equiv)
lamivudine/zidovudine tab (COMBIVIR equiv)
lamotrigine chew (LAMICTAL equiv)
lamotrigine ODT (LAMICTAL equiv)
lamotrigine ODT kit (LAMICTAL equiv)
lamotrigine tab (LAMCITAL equiv)
LANCETS
LANOXIN TAB 0.0625MG, 0.1875MG
lansoprazole cap
lansoprazole/amoxicillin/clarithromycin kit (PREVPAC equiv)
LANTUS INJ
LANTUS SOLOSTAR INJ
LASTACAFT OPHTH SOLN (QL= 3ml/30 days)
latanoprost ophth soln (XALATAN equiv) (QL= 2.5ml/30 days)
LATUDA TAB
LAZANDA NASAL SPRAY (QL= 15 bottles/30 days)
leflunomide tab (ARAVA equiv)
LETAIRIS TAB (QL= 1 tab/day)
letrozole tab (FEMARA equiv)
OTC
OTC
QL
QL
QL
QL
-
NC
F
F
F
F
F
F
F
NC
F
F
F
NC
F
F
F
F
F
F
NC
F
F
F
F
ANTIHYPERLIPIDEMICS
BETA BLOCKERS
LAXATIVES
ANTIVIRALS
ANTIVIRALS
ANTIVIRALS
ANTIVIRALS
ANTICONVULSANTS
ANTICONVULSANTS
ANTICONVULSANTS
ANTICONVULSANTS
MEDICAL DEVICES AND SUPPLIES
CARDIOTONICS
ULCER DRUGS
ULCER DRUGS
ANTIDIABETICS
ANTIDIABETICS
OPHTHALMIC AGENTS
OPHTHALMIC AGENTS
ANTIPSYCHOTICS/ANTIMANIC AGENTS
ANALGESICS - OPIOID
ANALGESICS - ANTI-INFLAMMATORY
CARDIOVASCULAR AGENTS - MISC.
leucovorin tab
-
F
LEUKERAN TAB
-
F
LEUKINE INJ
levalbuterol neb soln (XOPENEX equiv)
-
F
F
LEVEMIR FLEXPEN/FLEXTOUCH INJ
LEVEMIR INJ
levetiracetam oral soln (KEPPRA equiv)
levetiracetam tab (KEPPRA equiv)
LEVITRA TAB
levobunolol ophth soln (BETAGAN equiv)
levocarnitine soln (CARNITOR equiv)
-
F
F
F
F
NC
F
F
levocarnitine tab (CARNITOR equiv)
-
F
levocetirizine soln (XYZAL equiv)
levocetrizine tab (XYZAL equiv)
levofloxacin ophth soln (QUIXIN equiv)
levofloxacin soln (LEVAQUIN equiv)
levofloxacin tab (LEVAQUIN equiv)
levonorgestrel tab (PLAN B equiv)
LEVONORGESTREL TAB 0.75MG
levothyroxine tab (SYNTHROID equiv)
LEXIVA SUSP
LEXIVA TAB
OTC
-
NC
NC
NC
F
F
F
F
F
F
F
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
HEMATOPOIETIC AGENTS
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
ANTIDIABETICS
ANTIDIABETICS
ANTICONVULSANTS
ANTICONVULSANTS
CARDIOVASCULAR AGENTS - MISC.
OPHTHALMIC AGENTS
ENDOCRINE AND METABOLIC AGENTS MISC.
ENDOCRINE AND METABOLIC AGENTS MISC.
ANTIHISTAMINES
ANTIHISTAMINES
OPHTHALMIC AGENTS
FLUOROQUINOLONES
FLUOROQUINOLONES
CONTRACEPTIVES
CONTRACEPTIVES
THYROID AGENTS
ANTIVIRALS
ANTIVIRALS
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 22 of 101
Navi-Gate Rx Formulary Cont.
Alphabetical Index
Last Updated 1/1/2017
Drug Name
Special Code
Level
Category
LIALDA TAB
LIDOCAINE CREAM
lidocaine gel (XYLOCAINE equiv)
LIDOCAINE ORAL SOLN 4%
lidocaine patch (LIDODERM equiv)
lidocaine soln (XYLOCAINE equiv)
lidocaine viscous soln
lidocaine/hydrocortisone cream (ANAMANTLE equiv)
lidocaine/prilocaine cream (EMLA equiv)
lidocaine/prilocaine kit (EMLA equiv)
LIDOCIN GEL
LIDOLOG KIT
lindane lotion
lindane shampoo
linezolid susp (ZYVOX equiv)
linezolid tab (ZYVOX equiv)
liothyronine tab (CYTOMEL equiv)
LIPTRUZET TAB
lisinopril tab (PRINIVIL equiv)
lisinopril/hydrochlorothiazide tab (PRINZIDE equiv)
lithium carbonate cap (LITHOBID equiv)
lithium carbonate ER tab (ESKALITH CR equiv)
lithium citrate soln
LO MINASTRIN 24 FE CHEW TAB
LOFIBRA/TRIGLIDE TAB
LONSURF TAB
-
F
NC
F
F
NC
F
F
F
F
F
NC
NC
F
F
F
F
F
NC
F
F
F
F
F
NC
NC
NC
GASTROINTESTINAL AGENTS - MISC.
DERMATOLOGICALS
DERMATOLOGICALS
MOUTH/THROAT/DENTAL AGENTS
DERMATOLOGICALS
DERMATOLOGICALS
MOUTH/THROAT/DENTAL AGENTS
ANORECTAL AGENTS
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
CORTICOSTEROIDS
DERMATOLOGICALS
DERMATOLOGICALS
ANTI-INFECTIVE AGENTS - MISC.
ANTI-INFECTIVE AGENTS - MISC.
THYROID AGENTS
ANTIHYPERLIPIDEMICS
ANTIHYPERTENSIVES
ANTIHYPERTENSIVES
ANTIPSYCHOTICS/ANTIMANIC AGENTS
ANTIPSYCHOTICS/ANTIMANIC AGENTS
ANTIPSYCHOTICS/ANTIMANIC AGENTS
CONTRACEPTIVES
ANTIHYPERLIPIDEMICS
loratadine ODT (CLARITIN equiv)
loratadine syrup (CLARITIN equiv)
loratadine tab (CLARITIN equiv)
loratadine/pseudoephedrine 12-hour tab (CLARITIN-D equiv)
loratadine/pseudoephedrine 24-hour tab (CLARITIN-D equiv)
lorazepam tab (ATIVAN equiv)
LORTAB ELIXIR
LORVATUS PHARMAPAK KIT
losartan tab (COZAAR equiv)
losartan/hydrochlorothiazide tab (HYZAAR equiv)
LOTEMAX OPHTH OINT
lovastatin tab (MEVACOR equiv)
loxapine cap (LOXITANE equiv)
lozi-flur
LUMIGAN OPHTH SOLN (QL= 2.5ml/30 days)
LUZU CREAM
LYRICA CAP
LYRICA SOLN
LYSODREN TAB
OTC
OTC
OTC
OTC
OTC
QL
*
-
F
F
F
F
F
F
F
NC
F
F
F
F
F
F
F
NC
F
F
F
mafenide acetate soln packet (SULFAMYLON equiv)
MALARONE TAB
malathion lotion (OVIDE equiv)
MARPLAN TAB
-
F
F
F
F
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
ANTIHISTAMINES
ANTIHISTAMINES
ANTIHISTAMINES
COUGH/COLD/ALLERGY
COUGH/COLD/ALLERGY
ANTIANXIETY AGENTS
ANALGESICS - OPIOID
MUSCULOSKELETAL THERAPY AGENTS
ANTIHYPERTENSIVES
ANTIHYPERTENSIVES
OPHTHALMIC AGENTS
ANTIHYPERLIPIDEMICS
ANTIPSYCHOTICS/ANTIMANIC AGENTS
MINERALS & ELECTROLYTES
OPHTHALMIC AGENTS
DERMATOLOGICALS
ANTICONVULSANTS
ANTICONVULSANTS
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
DERMATOLOGICALS
ANTIMALARIALS
DERMATOLOGICALS
ANTIDEPRESSANTS
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 23 of 101
Navi-Gate Rx Formulary Cont.
Alphabetical Index
Last Updated 1/1/2017
Drug Name
Special Code
Level
Category
MATULANE CAP
-
F
MAXALT TAB (QL= 12 tabs/fill, 3 fills/60 days)
MAXIDEX OPHTH SOLN
meclizine chew tab (BONINE equiv)
meclizine tab (DRAMAMINE equiv)
MEDROL DOSE PACK
medroxyprogesterone tab (PROVERA equiv)
mefenamic acid cap (PONSTEL equiv)
mefloquine tab (LARIAM equiv)
megestrol ES susp (MEGACE ES equiv)
megestrol susp (MEGACE equiv)
QL
OTC
OTC
-
F
F
F
F
F
F
NC
F
F
F
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
MIGRAINE PRODUCTS
OPHTHALMIC AGENTS
ANTIEMETICS
ANTIEMETICS
CORTICOSTEROIDS
PROGESTINS
ANALGESICS - ANTI-INFLAMMATORY
ANTIMALARIALS
PROGESTINS
megestrol tab (MEGACE equiv)
-
F
MEKINIST TAB
-
F
meloxicam tab (MOBIC equiv)
memantine sol (NAMENDA equiv)
-
F
F
memantine tab (NAMENDA equiv)
-
F
meperidine tab (DEMEROL equiv)
MEPHYTON TAB
meprobamate tab (MILTOWN equiv)
mercaptopurine tab (PURINETHOL equiv)
-
F
F
F
F
mesalamine enema (ROWASA equiv)
MESNEX TAB
-
F
F
METANX CAP
-
NC
metaproterenol syrup
-
F
metaxalone tab (SKELAXIN equiv)
METAXALONE TAB 400MG
metformin ER osmotic tab (FORTAMET equiv)
metformin ER osmotic tab (GLUMETZA equiv)
metformin ER tab (GLUCOPHAGE XL equiv)
metformin tab (GLUCOPHAGE equiv)
methadone oral soln
methadone tab
methadone tab (DOLOPHINE equiv)
methazolamide tab (NEPTAZANE equiv)
methenamine hippurate tab (HIPREX equiv)
methimazole tab (TAPAZOLE equiv)
methotrexate inj
-
F
F
NC
NC
F
F
F
F
F
F
F
F
F
methotrexate tab
-
F
methoxsalen cap (OXSORALEN ULTRA equiv)
methyldopa tab
methyldopa/hydrochlorothiazide tab
-
F
F
F
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
ANALGESICS - ANTI-INFLAMMATORY
PSYCHOTHERAPEUTIC AND
NEUROLOGICAL AGENTS - MISC.
PSYCHOTHERAPEUTIC AND
NEUROLOGICAL AGENTS - MISC.
ANALGESICS - OPIOID
VITAMINS
ANTIANXIETY AGENTS
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
GASTROINTESTINAL AGENTS - MISC.
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
DIETARY PRODUCTS/DIETARY
MANAGEMENT PRODUCTS
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
MUSCULOSKELETAL THERAPY AGENTS
MUSCULOSKELETAL THERAPY AGENTS
ANTIDIABETICS
ANTIDIABETICS
ANTIDIABETICS
ANTIDIABETICS
ANALGESICS - OPIOID
ANALGESICS - OPIOID
ANALGESICS - OPIOID
DIURETICS
URINARY ANTI-INFECTIVES
THYROID AGENTS
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
DERMATOLOGICALS
ANTIHYPERTENSIVES
ANTIHYPERTENSIVES
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 24 of 101
Navi-Gate Rx Formulary Cont.
Alphabetical Index
Last Updated 1/1/2017
Drug Name
Special Code
Level
Category
methylergonovine tab (METHERGINE equiv) (QL= 28 tabs/fill; 1 fill/365 days)
methylphenidate CD cap (METADATE CD equiv)
QL
-
F
NC
OXYTOCICS
methylphenidate chew tab (METHYLIN CHEW equiv)
-
F
methylphenidate ER cap (RITALIN LA equiv)
-
F
METHYLPHENIDATE ER TAB
-
F
methylphenidate ER tab 10mg, 20mg
-
F
methylphenidate soln (METHYLIN equiv)
-
F
methylphenidate tab (RITALIN equiv)
-
F
methylprednisolone dose pack (MEDROL equiv)
methylprednisolone tab (MEDROL equiv)
methyltestosterone cap (ANDROID/TESTRED equiv)
METIPRANOLOL OPHTH SOLN
metocarbamol tab (ROBAXIN equiv)
metoclopramide tab (REGLAN equiv)
metolazone tab (ZAROXOLYN equiv)
metoprolol ER tab (TOPROL XL equiv)
metoprolol tab (LOPRESSOR equiv)
METOPROLOL TARTRATE TAB 37.5MG, 75MG
metoprolol/hydrochlorothiazide tab (LOPRESSOR/HCT equiv)
METOZOLV ODT
metronidazole cap (FLAGYL equiv)
metronidazole cream (METROCREAM equiv)
metronidazole gel (METROGEL equiv)
metronidazole lotion (METROLOTION equiv)
metronidazole tab (FLAGYL equiv)
metronidazole vaginal gel (METROGEL equiv)
mexiletine cap
MICORT-HC CREAM
midodrine tab (PROAMATINE equiv)
MIGRANAL/ DIHYDROERGOTAMINE SPRAY
MILLIPRED DP PAK
MINASTRIN CHEW TAB
minocycline cap (MINOCIN equiv)
minocycline tab (DYNACIN equiv)
minoxidil tab
MIRCERA INJ
mirtazapine tab (REMERON equiv)
misoprostol tab (CYTOTEC equiv)
MITIGARE CAP
modafinil tab (PROVIGIL equiv) (QL= 2 tabs/day)
QL
F
F
NC
F
F
F
F
F
F
NC
F
NC
F
F
F
F
F
F
F
NC
F
NC
F
NC
F
F
F
NC
F
F
F
F
moexipril tab (UNIVASC equiv)
moexipril/hydrochlorothiazide tab (UNIRETIC equiv)
mometasone cream (ELOCON equiv)
mometasone nasal spray (NASONEX equiv) (QL= 2 bottles/fill)
QL
F
F
F
F
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A
NOREXIANTS
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A
NOREXIANTS
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A
NOREXIANTS
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A
NOREXIANTS
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A
NOREXIANTS
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A
NOREXIANTS
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A
NOREXIANTS
CORTICOSTEROIDS
CORTICOSTEROIDS
ANDROGENS-ANABOLIC
OPHTHALMIC AGENTS
MUSCULOSKELETAL THERAPY AGENTS
GASTROINTESTINAL AGENTS - MISC.
DIURETICS
BETA BLOCKERS
BETA BLOCKERS
BETA BLOCKERS
ANTIHYPERTENSIVES
GASTROINTESTINAL AGENTS - MISC.
ANTI-INFECTIVE AGENTS - MISC.
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
ANTI-INFECTIVE AGENTS - MISC.
VAGINAL PRODUCTS
ANTIARRHYTHMICS
DERMATOLOGICALS
VASOPRESSORS
MIGRAINE PRODUCTS
CORTICOSTEROIDS
CONTRACEPTIVES
TETRACYCLINES
TETRACYCLINES
ANTIHYPERTENSIVES
HEMATOPOIETIC AGENTS
ANTIDEPRESSANTS
ULCER DRUGS
GOUT AGENTS
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A
NOREXIANTS
ANTIHYPERTENSIVES
ANTIHYPERTENSIVES
DERMATOLOGICALS
NASAL AGENTS - SYSTEMIC AND TOPICAL
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 25 of 101
Navi-Gate Rx Formulary Cont.
Alphabetical Index
Last Updated 1/1/2017
Drug Name
Special Code
Level
Category
mometasone soln (ELOCON equiv)
montelukast chew tab (SINGULAIR equiv)
-
F
F
DERMATOLOGICALS
montelukast granules (SINGULAIR equiv)
-
F
montelukast tab (SINGULAIR equiv)
-
F
morphine oral soln
MORPHINE SULFATE ER BEAD CAP (QL= 2 caps/day)
morphine sulfate ER tab (MS CONTIN equiv)
morphine sulfate supp
morphine sulfate tab
MOVANTIK TAB
MOVIPREP SOLN
MOXATAG 775MG TAB
MOXATAG TAB
MOXEZA OPHTH SOLN/ VIGAMOX OPHTH SOLN
MUCINEX DM
MULTAQ TAB
MULTIVITAMIN/FLUORIDE CHEW TAB
mupirocin cream (BACTROBAN equiv)
mupirocin oint (BACTROBAN equiv)
MYALEPT INJ
QL
OTC
-
F
F
F
F
F
NC
F
NC
NC
F
F
F
NC
F
F
NC
mycophenolate DR tab (MYFORTIC equiv)
mycophenolate mofetil cap (CELLCEPT equiv)
mycophenolate mofetil susp (CELLCEPT equiv)
mycophenolate mofetil tab (CELLCEPT equiv)
MYLERAN TAB
-
F
F
F
F
F
nabumetone tab (RELAFEN equiv)
nadolol tab (CORGARD equiv)
naftifine cream (NAFTIN equiv)
NAFTIN GEL
NAFTIN GEL 2%
NAMENDA XR CAP ( )
-
F
F
F
F
NC
F
NAMZARIC CAP
-
F
NAMZARIC STARTER PACK
-
F
NAPRELAN CR TAB 375MG, 750MG
NAPROXEN CREAM COMPOUND KIT
naproxen sodium CR tab (NAPRELAN equiv)
NAPROXEN SUSP
naproxen tab (NAPROSYN equiv)
naratriptan tab (AMERGE equiv) (QL= 9 tabs/fill; 2 fills/30 days)
NARCAN NASAL SPRAY
NASACORT OTC NASAL SPRAY (QL= 2 bottles/fill)
nateglinide tab (STARLIX equiv)
NATROBA SUSP (QL= 1 bottle/fill)
necon tab (NORINYL equiv)
QL
OTC-QL
QL
-
NC
NC
NC
F
F
F
NC
F
F
F
F
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
ANALGESICS - OPIOID
ANALGESICS - OPIOID
ANALGESICS - OPIOID
ANALGESICS - OPIOID
ANALGESICS - OPIOID
GASTROINTESTINAL AGENTS - MISC.
LAXATIVES
PENICILLINS
PENICILLINS
OPHTHALMIC AGENTS
COUGH/COLD/ALLERGY
ANTIARRHYTHMICS
MULTIVITAMINS
DERMATOLOGICALS
DERMATOLOGICALS
ENDOCRINE AND METABOLIC AGENTS MISC.
ASSORTED CLASSES
ASSORTED CLASSES
ASSORTED CLASSES
ASSORTED CLASSES
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
ANALGESICS - ANTI-INFLAMMATORY
BETA BLOCKERS
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
PSYCHOTHERAPEUTIC AND
NEUROLOGICAL AGENTS - MISC.
PSYCHOTHERAPEUTIC AND
NEUROLOGICAL AGENTS - MISC.
PSYCHOTHERAPEUTIC AND
NEUROLOGICAL AGENTS - MISC.
ANALGESICS - ANTI-INFLAMMATORY
DERMATOLOGICALS
ANALGESICS - ANTI-INFLAMMATORY
ANALGESICS - ANTI-INFLAMMATORY
ANALGESICS - ANTI-INFLAMMATORY
MIGRAINE PRODUCTS
ANTIDOTES
NASAL AGENTS - SYSTEMIC AND TOPICAL
ANTIDIABETICS
DERMATOLOGICALS
CONTRACEPTIVES
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 26 of 101
Navi-Gate Rx Formulary Cont.
Alphabetical Index
Last Updated 1/1/2017
Drug Name
Special Code
Level
Category
neomycin tab
neomycin/ polymyxin/ dexamethasone ophth oint (MAXITROL equiv)
neomycin/ polymyxin/ dexamethasone ophth soln (MAXITROL equiv)
neomycin/ polymyxin/ hydrocortisone ophth soln (CORTISPORIN equiv)
neomycin/bacitracin/polymyxin ophth oint (NEOSPORIN equiv)
neomycin/polymixin/hydrocoritisone otic soln (CORTISPORIN equiv)
neomycin/polymixin/hydrocoritisone otic susp (CORTISPORIN equiv)
neomycin/polymyxin/gramicidin ophth soln (NEOSPORIN equiv)
NEOSALUS FOAM
NEO-SYNALAR CREAM
NESINA/ALOGLIPTIN TAB
NEULASTA INJ
NEUMEGA INJ
NEUPOGEN INJ
NEUPRO PATCH
NEVANAC OPHTH SOLN
nevirapine ER tab (VIRAMUNE XR equiv)
NEVIRAPINE SUSP (VIRAMUNE equiv)
nevirapine tab (VIRAMUNE equiv)
NEXAVAR TAB
-
F
F
F
F
F
F
F
F
NC
NC
NC
F
F
NC
F
F
F
F
F
F
AMINOGLYCOSIDES
OPHTHALMIC AGENTS
OPHTHALMIC AGENTS
OPHTHALMIC AGENTS
OPHTHALMIC AGENTS
OTIC AGENTS
OTIC AGENTS
OPHTHALMIC AGENTS
DERMATOLOGICALS
DERMATOLOGICALS
ANTIDIABETICS
HEMATOPOIETIC AGENTS
HEMATOPOIETIC AGENTS
HEMATOPOIETIC AGENTS
ANTIPARKINSON AGENTS
OPHTHALMIC AGENTS
ANTIVIRALS
ANTIVIRALS
ANTIVIRALS
NEXICLON XR SUSP
NEXICLON XR TAB
NEXIUM 24HR TAB
NEXIUM OTC CAP
niacin cap
niacin CR tab (SLO-NIACIN equiv)
niacin ER tab (NIASPAN equiv)
niacin tab
NIACIN TR TAB
niacinamide tab
NIASPAN ER TAB
nicardipine cap
nifedipine cap (PROCARDIA equiv)
nifedipine ER tab (ADALAT equiv)
nilutamide tab (NILANDRON equiv)
OTC
OTC
OTC
OTC
OTC
OTC
-
F
F
NC
NC
F
F
NC
F
F
F
F
F
F
F
F
NINLARO CAP
-
NC
NITRO-BID OINT
nitrofurantoin macrocrystals cap (MACRODANTIN equiv)
nitrofurantoin monohydrate cap (MACROBID equiv)
nitrofurantoin susp (FURADANTIN equiv)
nitroglycerin lingual spray (NITROLINGUAL equiv)
nitroglycerin patch (NITRO-DUR equiv)
nitroglycerin SL tab (NITROSTAT equiv)
nizatidine cap (AXID equiv)
nizatidine soln (AXID equiv)
NORDITROPIN INJ
-
F
F
F
F
NC
F
F
F
F
F
norethindrone acetate tab (AYGESTIN equiv)
norethindrone tab (ORTHO-MICRONOR equiv)
-
F
F
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
ANTIHYPERTENSIVES
ANTIHYPERTENSIVES
ULCER DRUGS
ULCER DRUGS
VITAMINS
VITAMINS
ANTIHYPERLIPIDEMICS
VITAMINS
VITAMINS
VITAMINS
ANTIHYPERLIPIDEMICS
CALCIUM CHANNEL BLOCKERS
CALCIUM CHANNEL BLOCKERS
CALCIUM CHANNEL BLOCKERS
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
ANTIANGINAL AGENTS
URINARY ANTI-INFECTIVES
URINARY ANTI-INFECTIVES
URINARY ANTI-INFECTIVES
ANTIANGINAL AGENTS
ANTIANGINAL AGENTS
ANTIANGINAL AGENTS
ULCER DRUGS
ULCER DRUGS
ENDOCRINE AND METABOLIC AGENTS MISC.
PROGESTINS
CONTRACEPTIVES
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 27 of 101
Navi-Gate Rx Formulary Cont.
Alphabetical Index
Last Updated 1/1/2017
Drug Name
Special Code
Level
Category
NORPACE CR CAP
NORTHERA CAP
nortrel tab (ORTHO-NOVUM equiv)
nortriptyline cap (PAMELOR equiv)
NORTRIPYLINE SOLN
NORVIR CAP
NORVIR SOLN
NORVIR TAB
NOVACORT GEL
NOVOFINE PEN NEEDLES
NOVOLIN 70/30 INJ
NOVOLIN N INJ
NOVOLIN R INJ
NOVOLOG FLEXPEN INJ
NOVOLOG INJ
NOVOLOG MIX 70/30 INJ
NOVOLOG MIX FLEXPEN INJ
NOVOLOG PENFILL INJ
NOVOPEN
NOVOPEN JR
NOVOTWIST PEN NEEDLES
NOXAFIL SUSP
NOXAFIL TAB
np thyroid tab (NATURE THROID/ARMOUR THYROID equiv)
NUCYNTA ER TAB (QL= 2 tabs/day)
NUEDEXTA CAP (QL= 2 caps/day)
OTC
OTC
OTC
*-OTC
OTC
OTC
OTC
QL
QL
F
NC
F
F
F
F
F
F
NC
F
F
F
F
F
F
F
F
F
F
F
F
F
NC
F
F
F
ANTIARRHYTHMICS
VASOPRESSORS
CONTRACEPTIVES
ANTIDEPRESSANTS
ANTIDEPRESSANTS
ANTIVIRALS
ANTIVIRALS
ANTIVIRALS
DERMATOLOGICALS
MEDICAL DEVICES AND SUPPLIES
ANTIDIABETICS
ANTIDIABETICS
ANTIDIABETICS
ANTIDIABETICS
ANTIDIABETICS
ANTIDIABETICS
ANTIDIABETICS
ANTIDIABETICS
MEDICAL DEVICES AND SUPPLIES
MEDICAL DEVICES AND SUPPLIES
MEDICAL DEVICES AND SUPPLIES
ANTIFUNGALS
ANTIFUNGALS
THYROID AGENTS
ANALGESICS - OPIOID
NUPLAZID TAB
NUVARING
nystatin cream
nystatin oint
nystatin powder
nystatin powder (BIO-STATIN equiv)
nystatin susp
nystatin tab
NYSTATIN VAGINAL TAB
nystatin/triamcinolone cream
nystatin/triamcinolone oint
OCALIVA TAB
ocella tab (YASMIN equiv)
octreotide inj (SANDOSTATIN equiv)
-
NC
F
F
F
F
F
F
F
F
NC
NC
NC
F
F
ODEFSEY TAB
ODOMZO CAP
-
F
NC
OFEV CAP
ofloxacin ophth soln (OCUFLOX equiv)
ofloxacin otic soln (FLOXIN equiv)
ofloxacin tab (FLOXIN equiv)
olanzapine ODT (ZYPREXA ZYDIS equiv)
olanzapine tab (ZYPREXA equiv)
-
NC
F
F
F
F
F
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
PSYCHOTHERAPEUTIC AND
NEUROLOGICAL AGENTS - MISC.
ANTIPSYCHOTICS/ANTIMANIC AGENTS
CONTRACEPTIVES
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
ANTIFUNGALS
MOUTH/THROAT/DENTAL AGENTS
ANTIFUNGALS
VAGINAL PRODUCTS
DERMATOLOGICALS
DERMATOLOGICALS
GASTROINTESTINAL AGENTS - MISC.
CONTRACEPTIVES
ENDOCRINE AND METABOLIC AGENTS MISC.
ANTIVIRALS
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
RESPIRATORY AGENTS - MISC.
OPHTHALMIC AGENTS
OTIC AGENTS
FLUOROQUINOLONES
ANTIPSYCHOTICS/ANTIMANIC AGENTS
ANTIPSYCHOTICS/ANTIMANIC AGENTS
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 28 of 101
Navi-Gate Rx Formulary Cont.
Alphabetical Index
Last Updated 1/1/2017
Drug Name
Special Code
Level
Category
olanzapine/fluoxetine cap (SYMBYAX equiv)
-
F
olmesartan/amlodipine/hydrochlorothiazide tab (TRIBENZOR TAB equiv)
olopatadine nasal spray (PATANASE equiv)
olopatadine ophth soln (PATANOL equiv)
OLYSIO CAP
omega-3-acid ethyl esters cap (LOVAZA equiv)
omeprazole DR cap (PRILOSEC equiv)
omeprazole/bicarbonate powder pack (ZEGERID equiv)
omeprazole/sodium bicarbonate cap (ZEGERID equiv)
OMNARIS NASAL SPRAY (QL= 2 bottles/fill)
OMNIPOD
ondansetron ODT (ZOFRAN equiv)
ondansetron oral soln (ZOFRAN equiv)
ondansetron tab (ZOFRAN equiv)
ONFI TAB
ONGLYZA TAB
ONZETRA XSAIL
OPANA ER TAB (CRUSH RESISTANT)
QL
*
LD-QL
F
F
F
NC
F
F
F
NC
F
NC
F
F
F
F
NC
NC
NC
F
PSYCHOTHERAPEUTIC AND
NEUROLOGICAL AGENTS - MISC.
ANTIHYPERTENSIVES
NASAL AGENTS - SYSTEMIC AND TOPICAL
OPHTHALMIC AGENTS
ANTIVIRALS
ANTIHYPERLIPIDEMICS
ULCER DRUGS
ULCER DRUGS
ULCER DRUGS
NASAL AGENTS - SYSTEMIC AND TOPICAL
MEDICAL DEVICES AND SUPPLIES
ANTIEMETICS
ANTIEMETICS
ANTIEMETICS
ANTICONVULSANTS
ANTIDIABETICS
MIGRAINE PRODUCTS
ANALGESICS - OPIOID
CARDIOVASCULAR AGENTS - MISC.
-
NC
NC
NC
NC
NC
ORFADIN SUSP
-
NC
orphenadrine citrate ER tab (NORFLEX equiv)
ORPHENADRINE/ASPIRIN/CAFFEINE TAB
orphenadrine/aspirin/caffeine tab (NORGESIC FORTE equiv)
oseltamivir cap (TAMIFLU equiv) (QL= 10 caps/fill)
oseltamivir cap 30mg (TAMIFLU CAP equiv) (QL= 20 caps/fill)
OSENI/ALOGLIPTIN-PIOGLITAZONE TAB
OSMOPREP TAB
OSPHENA TAB
QL
QL
-
F
F
F
F
F
NC
F
NC
OTEZLA STARTER PACK ( )
OTEZLA TAB ( )
otomax-HC otic soln (CORTANE-B equiv)
OTOVEL OTIC SOLN
OTOZIN OTIC DROPS
OTREXUP INJ/ RASUVO INJ
OVACE PLUS LOTION
OVACE PLUS FOAM
oxandrolone tab (OXANDRIN equiv)
oxaprozin tab (DAYPRO equiv)
OXAYDO TAB
oxazepam cap (SERAX equiv)
oxiconazole nitrate cream (OXISTAT equiv)
OXISTAT LOTION
-
NC
NC
NC
NC
NC
NC
NC
NC
F
F
F
F
F
F
OPSUMIT TAB (QL= 1 tab/day, Only available through Walgreens
888-347-3416)
ORALAIR SL TAB
ORENCIA CLICK INJ
ORENCIA SC INJ
ORENITRAM TAB
ORFADIN CAP
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
BIOLOGICALS MISC
ANALGESICS - ANTI-INFLAMMATORY
ANALGESICS - ANTI-INFLAMMATORY
CARDIOVASCULAR AGENTS - MISC.
ENDOCRINE AND METABOLIC AGENTS MISC.
ENDOCRINE AND METABOLIC AGENTS MISC.
MUSCULOSKELETAL THERAPY AGENTS
MUSCULOSKELETAL THERAPY AGENTS
MUSCULOSKELETAL THERAPY AGENTS
ANTIVIRALS
ANTIVIRALS
ANTIDIABETICS
LAXATIVES
ENDOCRINE AND METABOLIC AGENTS MISC.
ANALGESICS - ANTI-INFLAMMATORY
ANALGESICS - ANTI-INFLAMMATORY
OTIC AGENTS
OTIC AGENTS
OTIC AGENTS
ANALGESICS - ANTI-INFLAMMATORY
DERMATOLOGICALS
DERMATOLOGICALS
ANDROGENS-ANABOLIC
ANALGESICS - ANTI-INFLAMMATORY
ANALGESICS - OPIOID
ANTIANXIETY AGENTS
DERMATOLOGICALS
DERMATOLOGICALS
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 29 of 101
Navi-Gate Rx Formulary Cont.
Alphabetical Index
Last Updated 1/1/2017
Drug Name
Special Code
Level
Category
oxybutynin ER tab (DITROPAN XL equiv)
oxybutynin syrup
oxybutynin tab
oxycodone cap (OXYIR equiv)
oxycodone conc (ROXICODONE equiv)
oxycodone ER tab
oxycodone ER tab (OXYCONTIN equiv)
oxycodone soln
oxycodone tab (ROXICODONE equiv)
oxycodone/acetaminophen cap (TYLOX equiv)
OXYCODONE/ACETAMINOPHEN SOLN
oxycodone/acetaminophen tab
OXYCONTIN CR TAB (QL= 120 tabs/30 days)
OXYCONTIN CR TAB (QL= 4 tabs/day)
OXYTROL PATCH
paliperidone ER tab (INVEGA equiv)
pantoprazole EC tab (PROTONIX equiv)
PAPAVERINE/ALPROSTADIL INJ
PAPAVERINE/PHENTOLAMINE INJ
PAPAVERINE/PHENTOLAMINE/ALPROSTADIL INJ
PAREGORIC TINCTURE
paricalcitol cap (ZEMPLAR equiv)
QL
QL
-
F
F
F
F
F
NC
NC
F
F
F
F
F
F
F
F
F
NC
NC
NC
NC
NC
F
URINARY ANTISPASMODICS
URINARY ANTISPASMODICS
URINARY ANTISPASMODICS
ANALGESICS - OPIOID
ANALGESICS - OPIOID
ANALGESICS - OPIOID
ANALGESICS - OPIOID
ANALGESICS - OPIOID
ANALGESICS - OPIOID
ANALGESICS - OPIOID
ANALGESICS - OPIOID
ANALGESICS - OPIOID
ANALGESICS - OPIOID
ANALGESICS - OPIOID
URINARY ANTISPASMODICS
ANTIPSYCHOTICS/ANTIMANIC AGENTS
ULCER DRUGS
CARDIOVASCULAR AGENTS - MISC.
CARDIOVASCULAR AGENTS - MISC.
CARDIOVASCULAR AGENTS - MISC.
ANTIDIARRHEALS
paroxetine ER tab (PAXIL CR equiv)
paroxetine tab (PAXIL equiv)
PATADAY OPHTH SOLN (QL= 2.5ml/30 days)
PAZEO OPHTH SOLN 0.7%
PEAK FLOW METER
pediatric multiple vitamins/fluoride chew tab
pediatric multiple vitamins/fluoride soln
peg 3350/electrolytes soln (COLYTE equiv)
PEGASYS INJ
PEGASYS INJ KIT
PEG-INTRON INJ
penicillin vk susp
penicillin vk tab
PENTASA CAP
pentazocine/naloxone tab (TALWIN NX equiv)
pentoxifylline tab (TRENTAL equiv)
PERFOROMIST NEB SOLN
QL
-
F
F
F
NC
F
F
F
F
F
F
F
F
F
F
NC
F
F
perindopril tab (ACEON equiv)
permethrin cream (ELIMITE equiv)
perphenazine tab (TRILAFON equiv)
PERPHENAZINE/AMITRIPTYLINE TAB
-
F
F
F
F
PEXEVA TAB
phenazopyridine tab (PYRIDIUM equiv)
-
F
F
phenelzine tab (NARDIL equiv)
phenobarbital tab
-
F
F
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
ENDOCRINE AND METABOLIC AGENTS MISC.
ANTIDEPRESSANTS
ANTIDEPRESSANTS
OPHTHALMIC AGENTS
OPHTHALMIC AGENTS
MEDICAL DEVICES AND SUPPLIES
MULTIVITAMINS
MULTIVITAMINS
LAXATIVES
ANTIVIRALS
ANTIVIRALS
ANTIVIRALS
PENICILLINS
PENICILLINS
GASTROINTESTINAL AGENTS - MISC.
ANALGESICS - OPIOID
HEMATOLOGICAL AGENTS - MISC.
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
ANTIHYPERTENSIVES
DERMATOLOGICALS
ANTIPSYCHOTICS/ANTIMANIC AGENTS
PSYCHOTHERAPEUTIC AND
NEUROLOGICAL AGENTS - MISC.
ANTIDEPRESSANTS
GENITOURINARY AGENTS MISCELLANEOUS
ANTIDEPRESSANTS
HYPNOTICS/SEDATIVES/SLEEP DISORDER
AGENTS
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 30 of 101
Navi-Gate Rx Formulary Cont.
Alphabetical Index
Last Updated 1/1/2017
Drug Name
Special Code
Level
Category
phenoxybenzamine cap (DIBENZYLINE equiv)
PHENTOLAMINE/ALPROSTADIL INJ
phenylephrine ophth soln (MYDFRIN equiv)
phenytoin cap (DILANTIN equiv)
phenytoin chew tab (DILANTIN equiv)
PHISOHEX LIQUID
PHOSLYRA SOLN
PHOSPHOLINE IODIDE
pilocarpine ophth soln (ISOPTO CARPINE equiv)
pilocarpine tab (SALAGEN equiv)
pimozide tab (ORAP equiv)
-
F
NC
F
F
F
F
F
F
F
F
F
ANTIHYPERTENSIVES
CARDIOVASCULAR AGENTS - MISC.
OPHTHALMIC AGENTS
ANTICONVULSANTS
ANTICONVULSANTS
ANTISEPTICS & DISINFECTANTS
GASTROINTESTINAL AGENTS - MISC.
OPHTHALMIC AGENTS
OPHTHALMIC AGENTS
MOUTH/THROAT/DENTAL AGENTS
pindolol tab
pioglitazone tab (ACTOS equiv)
pioglitazone/glimepiride tab (DUETACT equiv)
piroxicam cap (FELDENE equiv)
PLAN B TAB
PLEGRIDY INJ
OTC
-
F
F
F
F
F
F
PLEGRIDY PEN INJ
-
F
podofilox soln (CONDYLOX equiv)
polyethylene glycol 3350 powder (MIRALAX equiv)
POLYETHYLENE GLYCOL 8000 GRANULES
polymyxin b/trimethoprim ophth soln (POLYTRIM equiv)
POLY-TUSSIN DM SYRUP
POMALYST CAP 1MG
-
F
NC
F
F
NC
NC
POTABA TAB
potassium bicarbonate effer tab (K-LYTE equiv)
potassium chloride ER cap (MICRO-K equiv)
POTASSIUM CHLORIDE ER TAB
potassium chloride ER tab (KLOR-CON equiv)
potassium chloride micro tab (K-DUR equiv)
potassium chloride soln
potassium citrate CR tab (UROCIT-K equiv)
-
F
F
F
F
F
F
F
F
potassium citrate/citric acid
-
F
POTIGA TAB (QL= 3 tabs/day)
PRADAXA CAP
PRALUENT INJ
pramipexole ER tab (MIRAPEX equiv)
pramipexole tab (MIRAPEX equiv)
PRAMOSONE E CREAM
pramoxine rectal foam (PROCTOFOAM equiv)
pramoxine/hydrocortisone cream kit (ANALPRAM-HC equiv)
pramoxine-HC AQ otic soln (CORTANE-B AQUEOUS equiv)
PRASCION RA CREAM
pravastatin tab (PRAVACHOL equiv)
prazosin cap (MINIPRES equiv)
PRECISION SURE-DOSE INSULIN SYRINGES
QL
OTC
F
F
NC
F
F
F
F
F
NC
F
F
F
F
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
PSYCHOTHERAPEUTIC AND
NEUROLOGICAL AGENTS - MISC.
BETA BLOCKERS
ANTIDIABETICS
ANTIDIABETICS
ANALGESICS - ANTI-INFLAMMATORY
CONTRACEPTIVES
PSYCHOTHERAPEUTIC AND
NEUROLOGICAL AGENTS - MISC.
PSYCHOTHERAPEUTIC AND
NEUROLOGICAL AGENTS - MISC.
DERMATOLOGICALS
LAXATIVES
PHARMACEUTICAL ADJUVANTS
OPHTHALMIC AGENTS
COUGH/COLD/ALLERGY
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
VITAMINS
MINERALS & ELECTROLYTES
MINERALS & ELECTROLYTES
MINERALS & ELECTROLYTES
MINERALS & ELECTROLYTES
MINERALS & ELECTROLYTES
MINERALS & ELECTROLYTES
GENITOURINARY AGENTS MISCELLANEOUS
GENITOURINARY AGENTS MISCELLANEOUS
ANTICONVULSANTS
ANTICOAGULANTS
ANTIHYPERLIPIDEMICS
ANTIPARKINSON AGENTS
ANTIPARKINSON AGENTS
DERMATOLOGICALS
ANORECTAL AGENTS
ANORECTAL AGENTS
OTIC AGENTS
DERMATOLOGICALS
ANTIHYPERLIPIDEMICS
ANTIHYPERTENSIVES
MEDICAL DEVICES AND SUPPLIES
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 31 of 101
Navi-Gate Rx Formulary Cont.
Alphabetical Index
Last Updated 1/1/2017
Drug Name
Special Code
Level
Category
PRECISION XTRA TEST STRIP
prednicarbate cream (DERMATOP equiv)
prednicarbate oint (DERMATOP equiv)
prednisolone ODT (ORAPRED equiv)
prednisolone ophth soln (PRED FORTE equiv)
prednisolone soln (PEDIAPRED equiv)
prednisolone syrup (PRELONE equiv)
PREDNISOLONE/MOXIFLOXACIN OPHTH SOLN
PREDNISOLONE/MOXIFLOXACIN/BROMFENAC OPHTH SOLN
PREDNISOLONE/MOXIFLOXACIN/KETOROLAC OPHTH SOLN
PREDNISONE PAK
prednisone tab
PREMARIN TAB
PREMARIN VAGINAL CREAM
PREMPHASE/PREMPRO TAB
PRENATAL VITAMIN (RX ONLY)
PRENATAL VITAMINS (NON-PREFERRED)
PREPOPIK PAK
PRESTALIA TAB
PREVACID OTC CAP
PREZCOBIX TAB
PREZISTA SUSP
PREZISTA TAB
PRIFTIN TAB
PRIMAQUINE TAB
primidone tab (MYSOLINE equiv)
probenecid tab
probenecid/colchicine tab
PROCENTRA SOLN
OTC
OTC
-
F
F
F
F
F
F
F
NC
NC
NC
F
F
F
F
F
F
F
NC
NC
F
F
F
F
F
F
F
F
F
F
DIAGNOSTIC PRODUCTS
DERMATOLOGICALS
DERMATOLOGICALS
CORTICOSTEROIDS
OPHTHALMIC AGENTS
CORTICOSTEROIDS
CORTICOSTEROIDS
OPHTHALMIC AGENTS
OPHTHALMIC AGENTS
OPHTHALMIC AGENTS
CORTICOSTEROIDS
CORTICOSTEROIDS
ESTROGENS
VAGINAL PRODUCTS
ESTROGENS
MULTIVITAMINS
MULTIVITAMINS
LAXATIVES
ANTIHYPERTENSIVES
ULCER DRUGS
ANTIVIRALS
ANTIVIRALS
ANTIVIRALS
ANTIMYCOBACTERIAL AGENTS
ANTIMALARIALS
ANTICONVULSANTS
GOUT AGENTS
GOUT AGENTS
prochlorperazine supp (COMPAZINE equiv)
prochlorperazine tab (COMPAZINE equiv)
PROCRIT INJ
proctosol HC cream (ANUSOL equiv)
PROCYSBI CAP
-
F
F
F
F
NC
progesterone cap (PROMETRIUM equiv)
progesterone oil inj
PROGESTERONE SUPP
PROLENSA OPHTH SOLN
PROLEUKIN INJ
-
F
NC
F
F
F
PROMACTA TAB
promethazine DM syrup
promethazine supp (PHENERGAN equiv)
promethazine syrup (PHENERGAN equiv)
promethazine tab (PHENERGAN equiv)
promethazine VC syrup (PHENERGAN VC equiv)
promethazine VC w/codeine syrup (PHENERGAN VC/CODEINE equiv)
promethazine w/codeine syrup
propafenone tab (RYTHMOL equiv)
propranolol ER cap (INDERAL LA equiv)
-
F
F
F
F
F
F
F
F
F
F
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A
NOREXIANTS
ANTIPSYCHOTICS/ANTIMANIC AGENTS
ANTIPSYCHOTICS/ANTIMANIC AGENTS
HEMATOPOIETIC AGENTS
ANORECTAL AGENTS
GENITOURINARY AGENTS MISCELLANEOUS
PROGESTINS
PROGESTINS
VAGINAL PRODUCTS
OPHTHALMIC AGENTS
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
HEMATOPOIETIC AGENTS
COUGH/COLD/ALLERGY
ANTIHISTAMINES
ANTIHISTAMINES
ANTIHISTAMINES
COUGH/COLD/ALLERGY
COUGH/COLD/ALLERGY
COUGH/COLD/ALLERGY
ANTIARRHYTHMICS
BETA BLOCKERS
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 32 of 101
Navi-Gate Rx Formulary Cont.
Alphabetical Index
Last Updated 1/1/2017
Drug Name
Special Code
Level
Category
PROPRANOLOL SOLN
propranolol tab (INDERAL equiv)
propranolol/hydrochlorothiazide tab
propylthiouracil tab
PROTHELIAL PASTE
protriptyline tab (VIVACTIL equiv)
PULMICORT FLEXHALER
-
F
F
F
F
NC
F
NC
BETA BLOCKERS
BETA BLOCKERS
ANTIHYPERTENSIVES
THYROID AGENTS
MOUTH/THROAT/DENTAL AGENTS
ANTIDEPRESSANTS
PULMOZYME INH SOLN
PUREFOLIX TAB
PURIXAN SUSP
-
F
NC
NC
PYLERA CAP
pyrazinamide tab
pyridostigmine bromide tab (MESTINON equiv)
pyridostigmine CR tab (MESTINON equiv)
QBRELIS SOLN
QNASL NASAL SPRAY (QL= 2 bottles/fill)
QUARTETTE TAB
QUDEXY XR/TOPIRAMATE ER CAP
quetiapine tab (SEROQUEL equiv)
quetiapine XR tab (SEROQUEL XR equiv)
QUFLORA PEDIATRIC CHEW TAB
QUFLORA PEDIATRIC DROP
QUILLICHEW ER TAB
QL
-
F
F
F
F
NC
F
NC
NC
F
NC
F
F
NC
quinapril tab (ACCUPRIL equiv)
quinapril/hydrochlorothiazide tab (ACCURETIC equiv)
quinidine gluconate CR tab
QUINIDINE SULFATE ER TAB
quinidine sulfate tab
QVAR INHALER
-
F
F
F
F
F
NC
rabeprazole tab (ACIPHEX equiv)
RAGWITEK SL TAB
rajani tab (BEYAZ equiv)
raloxifene tab (EVISTA equiv)
-
F
NC
F
F
ramipril cap (ALTACE equiv)
RANEXA TAB
ranitidine cap (ZANTAC equiv)
ranitidine syrup (ZANTAC equiv)
ranitidine tab (Rx Only) (ZANTAC equiv)
RAPAMUNE SOLN
RAPTIVA
RAVICTI LIQUID
-
F
F
F
F
F
F
F
NC
RAYALDEE CAP
RAYOS TAB
REBIF INJ
-
NC
NC
F
REGRANEX GEL (QL= 30 grams/fill)
QL
F
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
RESPIRATORY AGENTS - MISC.
HEMATOPOIETIC AGENTS
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
ULCER DRUGS
ANTIMYCOBACTERIAL AGENTS
ANTIMYASTHENIC/CHOLINERGIC AGENTS
ANTIMYASTHENIC/CHOLINERGIC AGENTS
ANTIHYPERTENSIVES
NASAL AGENTS - SYSTEMIC AND TOPICAL
CONTRACEPTIVES
ANTICONVULSANTS
ANTIPSYCHOTICS/ANTIMANIC AGENTS
ANTIPSYCHOTICS/ANTIMANIC AGENTS
MULTIVITAMINS
MULTIVITAMINS
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A
NOREXIANTS
ANTIHYPERTENSIVES
ANTIHYPERTENSIVES
ANTIARRHYTHMICS
ANTIARRHYTHMICS
ANTIARRHYTHMICS
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
ULCER DRUGS
BIOLOGICALS MISC
CONTRACEPTIVES
ENDOCRINE AND METABOLIC AGENTS MISC.
ANTIHYPERTENSIVES
ANTIANGINAL AGENTS
ULCER DRUGS
ULCER DRUGS
ULCER DRUGS
ASSORTED CLASSES
DERMATOLOGICALS
ENDOCRINE AND METABOLIC AGENTS MISC.
VITAMINS
CORTICOSTEROIDS
PSYCHOTHERAPEUTIC AND
NEUROLOGICAL AGENTS - MISC.
DERMATOLOGICALS
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 33 of 101
Navi-Gate Rx Formulary Cont.
Alphabetical Index
Last Updated 1/1/2017
Drug Name
Special Code
Level
Category
RELENZA DISKHALER (QL= 1 inhaler/fill)
RELISTOR INJ
RELISTOR INJ KIT
RELISTOR TAB
RELPAX TAB
RENAGEL TAB
RENVELA TAB
REPATHA INJ
REPATHA PUSHTRONEX INJ
RESCRIPTOR TAB
RESTASIS OPHTH EMULSION
RETIN-A MICRO GEL 0.04%, 0.1%
RETIN-A MICRO GEL 0.08%
REVATIO SUSP
REVLIMID CAP (QL= 1 tab/day)
REXAPHENAC CREAM
REXULTI TAB
REYATAZ CAP
REYATAZ POWDER
ribavirin cap (REBETOL equiv)
ribavirin tab (COPEGUS equiv)
RIDAURA CAP
rifabutin cap (MYCOBUTIN equiv)
rifampin cap (RIFADIN equiv)
riluzole tab (RILUTEK equiv)
rimantadine tab (FLUMADINE equiv)
risedronate DR tab (ATELVIA equiv)
QL
QL
-
F
F
F
NC
NC
F
F
NC
NC
F
F
F
F
NC
F
NC
NC
F
F
F
F
F
F
F
F
F
NC
ANTIVIRALS
GASTROINTESTINAL AGENTS - MISC.
GASTROINTESTINAL AGENTS - MISC.
GASTROINTESTINAL AGENTS - MISC.
MIGRAINE PRODUCTS
GASTROINTESTINAL AGENTS - MISC.
GASTROINTESTINAL AGENTS - MISC.
ANTIHYPERLIPIDEMICS
ANTIHYPERLIPIDEMICS
ANTIVIRALS
OPHTHALMIC AGENTS
DERMATOLOGICALS
DERMATOLOGICALS
CARDIOVASCULAR AGENTS - MISC.
ASSORTED CLASSES
DERMATOLOGICALS
ANTIPSYCHOTICS/ANTIMANIC AGENTS
ANTIVIRALS
ANTIVIRALS
ANTIVIRALS
ANTIVIRALS
ANALGESICS - ANTI-INFLAMMATORY
ANTIMYCOBACTERIAL AGENTS
ANTIMYCOBACTERIAL AGENTS
NEUROMUSCULAR AGENTS
ANTIVIRALS
risedronate tab (ACTONEL equiv)
-
F
risperidone ODT (RISPERDAL equiv)
risperidone soln (RISPERDAL equiv)
risperidone tab (RISPERDAL equiv)
RITALIN LA CAP 10MG
-
F
F
F
F
RITALIN LA CAP 60MG
-
F
rivastigmine cap (EXELON equiv)
-
F
rivastigmine patch (EXELON equiv)
-
F
rizatriptan ODT (MAXALT equiv) (QL= 12 tabs/fill, 3 fills/60 days)
ropinirole ER tab (REQUIP XL equiv)
ROSULA WASH
rosuvastatin tab (CRESTOR equiv)
RUBRACA TAB
QL
¢
-
F
F
NC
F
NC
RYTARY CAP
RYZOLT
SABRIL POWDER PACK (Only available through Walgreens 888-347-3416)
SABRIL TAB (Only available through Walgreens 888-347-3416)
salsalate tab
LD
LD
-
F
F
F
F
F
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
ENDOCRINE AND METABOLIC AGENTS MISC.
ENDOCRINE AND METABOLIC AGENTS MISC.
ANTIPSYCHOTICS/ANTIMANIC AGENTS
ANTIPSYCHOTICS/ANTIMANIC AGENTS
ANTIPSYCHOTICS/ANTIMANIC AGENTS
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A
NOREXIANTS
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A
NOREXIANTS
PSYCHOTHERAPEUTIC AND
NEUROLOGICAL AGENTS - MISC.
PSYCHOTHERAPEUTIC AND
NEUROLOGICAL AGENTS - MISC.
MIGRAINE PRODUCTS
ANTIPARKINSON AGENTS
DERMATOLOGICALS
ANTIHYPERLIPIDEMICS
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
ANTIPARKINSON AGENTS
ANALGESICS - OPIOID
ANTICONVULSANTS
ANTICONVULSANTS
ANALGESICS - NONNARCOTIC
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 34 of 101
Navi-Gate Rx Formulary Cont.
Alphabetical Index
Last Updated 1/1/2017
Drug Name
Special Code
Level
Category
SANDIMMUNE SOLN 100MG/ML
SANTYL OINT
SAVELLA TAB (QL= 2 tabs/day)
QL
F
F
F
ASSORTED CLASSES
DERMATOLOGICALS
SEEBRI NEOHALER CAP
-
NC
selegiline cap (ELDEPRYL equiv)
selenium sulfide shampoo
SELZENTRY TAB
SENSIPAR TAB
*
-
F
F
F
F
SEREVENT DISKUS INHALER
-
F
SERNIVO SPRAY
SEROQUEL XR TAB
sertraline tab (ZOLOFT equiv)
SEVELAMER CARBONATE TAB
LD-QL
NC
F
F
F
F
-
F
F
NC
F
NC
NC
NC
F
F
sirolimus tab (RAPAMUNE equiv)
SIRTURO TAB
SITAVIG TAB
SIVEXTRO TAB (QL= 6 tabs/fill)
smz/tmp (DS) tab (BACTRIM equiv)
smz/tmp susp (BACTRIM/SEPTRA equiv)
sodium chloride nebs (NEBUSAL NEBS equiv)
sodium citrate/citric acid soln (ORACIT equiv)
QL
-
F
NC
NC
F
F
F
F
F
sodium fluoride chew tab (LURIDE equiv)
sodium fluoride cream (PREVIDENT equiv)
sodium fluoride gel (PREVIDENT equiv)
sodium fluoride paste (PREVIDENT equiv)
sodium fluoride rinse (PREVIDENT equiv)
sodium fluoride soln (LURIDE equiv)
SODIUM FLUORIDE TAB
sodium fluoride/potassium nitrate paste (PREVIDENT equiv)
sodium phenylbutyrate powder (BUPHENYL POWDER equiv)
-
F
F
F
F
F
F
F
F
F
sodium polystyrene powder (KAYEXALATE equiv)
sodium sulfacetamide gel (OVACE PLUS equiv)
sodium sulfacetamide lotion (KLARON equiv)
sodium sulfacetamide ophth soln (BLEPH-10 equiv)
-
F
NC
F
F
SIGNIFOR INJ (QL= 2 vials/day; Only available through Accredo
888-773-7376)
sildenafil tab (REVATIO equiv)
silver sulfadiazine cream (SILVADENE equiv)
SILVERA PAD
SIMBRINZA OPHTH SUSP
SIMCOR TAB
SIMPONI ARIA INJ
SIMPONI INJ
simvastatin tab (ZOCOR equiv) (80mg tab is Not Covered)
SINGULAIR GRANULES
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
PSYCHOTHERAPEUTIC AND
NEUROLOGICAL AGENTS - MISC.
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
ANTIPARKINSON AGENTS
DERMATOLOGICALS
ANTIVIRALS
ENDOCRINE AND METABOLIC AGENTS MISC.
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
DERMATOLOGICALS
ANTIPSYCHOTICS/ANTIMANIC AGENTS
ANTIDEPRESSANTS
GASTROINTESTINAL AGENTS - MISC.
ENDOCRINE AND METABOLIC AGENTS MISC.
CARDIOVASCULAR AGENTS - MISC.
DERMATOLOGICALS
DERMATOLOGICALS
OPHTHALMIC AGENTS
ANTIHYPERLIPIDEMICS
ANALGESICS - ANTI-INFLAMMATORY
ANALGESICS - ANTI-INFLAMMATORY
ANTIHYPERLIPIDEMICS
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
ASSORTED CLASSES
ANTIMYCOBACTERIAL AGENTS
ANTIVIRALS
ANTI-INFECTIVE AGENTS - MISC.
ANTI-INFECTIVE AGENTS - MISC.
ANTI-INFECTIVE AGENTS - MISC.
COUGH/COLD/ALLERGY
GENITOURINARY AGENTS MISCELLANEOUS
MINERALS & ELECTROLYTES
MOUTH/THROAT/DENTAL AGENTS
MOUTH/THROAT/DENTAL AGENTS
MOUTH/THROAT/DENTAL AGENTS
MOUTH/THROAT/DENTAL AGENTS
MINERALS & ELECTROLYTES
MINERALS & ELECTROLYTES
MOUTH/THROAT/DENTAL AGENTS
ENDOCRINE AND METABOLIC AGENTS MISC.
ASSORTED CLASSES
DERMATOLOGICALS
DERMATOLOGICALS
OPHTHALMIC AGENTS
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 35 of 101
Navi-Gate Rx Formulary Cont.
Alphabetical Index
Last Updated 1/1/2017
Drug Name
Special Code
Level
Category
sodium sulfacetamide wash (OVACE equiv)
sodium sulfacetamide/sulfur cream (PLEXION SCT equiv)
sodium sulfacetamide/sulfur emulsion (ROSAC equiv)
sodium sulfacetamide/sulfur emulsion (ROSULA equiv)
sodium sulfacetamide/sulfur foam (CLARIFOAM EF equiv)
sodium sulfacetamide/sulfur gel (ROSULA equiv)
sodium sulfacetamide/sulfur lotion (SULFACET R equiv)
sodium sulfacetamide/sulfur pad (PLEXION equiv)
sodium sulfacetamide/sunscreen kit (SUMADEN XLT equiv)
SOLAICE PATCH
SOLIQUA INJ
SOMAVERT INJ (Only available through Walgreens 888-347-3416)
LD
F
F
F
F
F
F
F
F
NC
NC
NC
F
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
ANTIDIABETICS
SORIATANE
sotalol AF tab (BETAPACE AF equiv)
sotalol tab (BETAPACE equiv)
SOTYLIZE SOLN
SOVALDI TAB (QL= 1 tab/day)
SPECTRACEF TAB
SPIRIVA HANDIHALER
QL
-
F
F
F
NC
F
F
F
SPIRIVA RESPIMAT INHALER
-
F
SPIRIVA RESPIMAT INHALER 1.25MCG/ACT
-
F
spironolactone tab (ALDACTONE equiv)
spironolactone/hydrochlorothiazide tab (ALDACTAZIDE equiv)
SPORANOX SOLN
sprintec tab (ORTHO-CYCLEN equiv)
SPRITAM TAB
SPRYCEL TAB
-
F
F
F
F
NC
F
stavudine cap (ZERIT equiv)
STELARA INJ ( )
STENDRA TAB
STIOLTO INHALER
-
F
NC
NC
F
STIVARGA TAB (QL= 4 tabs/day)
QL
F
STRATTERA CAP
*
F
STRENSIQ INJ
-
NC
STRIBILD TAB
STRIVERDI RESPIMAT INHALER (QL= 1 inhaler/30 days)
QL
F
F
SUBOXONE SL
SUCLEAR KIT
SUCRALFATE SUSP
sucralfate tab (CARAFATE equiv)
sulfacetamide sodium shampoo (OVACE equiv)
sulfacetamide sodium/prednisolone ophth soln (VASOCIDIN equiv)
-
F
NC
F
F
NC
F
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
ENDOCRINE AND METABOLIC AGENTS MISC.
DERMATOLOGICALS
BETA BLOCKERS
BETA BLOCKERS
BETA BLOCKERS
ANTIVIRALS
CEPHALOSPORINS
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
DIURETICS
DIURETICS
ANTIFUNGALS
CONTRACEPTIVES
ANTICONVULSANTS
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
ANTIVIRALS
DERMATOLOGICALS
CARDIOVASCULAR AGENTS - MISC.
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A
NOREXIANTS
ENDOCRINE AND METABOLIC AGENTS MISC.
ANTIVIRALS
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
ANALGESICS - OPIOID
LAXATIVES
ULCER DRUGS
ULCER DRUGS
DERMATOLOGICALS
OPHTHALMIC AGENTS
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 36 of 101
Navi-Gate Rx Formulary Cont.
Alphabetical Index
Last Updated 1/1/2017
Drug Name
Special Code
Level
Category
SULFAMYLON CREAM
SULFAMYLON PACK
sulfasalazine EC tab (AZULFIDINE equiv)
sulfasalazine tab (AZULFIDINE equiv)
sulindac tab (CLINORIL equiv)
sumatriptan inj (IMITREX equiv) (QL= 4 inj/fill, 2 fills/30 days)
SUMATRIPTAN INJ 6MG/0.5ML (QL= 4 inj/fill, 2 fills/30 days)
QL
QL
QL
F
F
F
F
F
F
F
F
DERMATOLOGICALS
DERMATOLOGICALS
GASTROINTESTINAL AGENTS - MISC.
GASTROINTESTINAL AGENTS - MISC.
ANALGESICS - ANTI-INFLAMMATORY
MIGRAINE PRODUCTS
MIGRAINE PRODUCTS
MIGRAINE PRODUCTS
QL
QL
-
F
F
NC
F
F
F
F
F
F
F
MIGRAINE PRODUCTS
MIGRAINE PRODUCTS
MIGRAINE PRODUCTS
CEPHALOSPORINS
CEPHALOSPORINS
CEPHALOSPORINS
ANTIDEPRESSANTS
ANTIVIRALS
ANTIVIRALS
SYLATRON INJ
-
NC
SYMAX DUOTAB
SYMBICORT INHALER
-
F
NC
SYNJARDY TAB (QL= 2 tabs/day)
SYNRIBO INJ
QL
-
F
NC
SYNVEXIA TC CREAM
TACLONEX SCALP
tacrolimus cap (PROGRAF equiv)
tacrolimus oint (PROTOPIC equiv)
TAFINLAR CAP (QL= 4 caps/day)
QL
NC
F
F
F
F
TAGRISSO TAB
-
NC
TALTZ INJ
TAMIFLU CAP (QL= 10 caps/fill)
TAMIFLU CAP 30MG (QL= 20 caps/fill)
TAMIFLU SUSP 6mg/ml (QL= 250 ml/fill)
tamoxifen tab (NOLVADEX equiv)
QL
QL
QL
-
NC
F
F
F
F
tamsulosin cap (FLOMAX equiv)
-
F
TANZEUM INJ
TARCEVA TAB
-
NC
F
TASIGNA CAP
-
F
TAYTULLA CAP
TAZORAC CREAM
TAZORAC GEL
-
NC
F
F
sumatriptan nasal spray (SUMATRIPTAN/IMITREX equiv) (QL= 6 sprays/fill, 2
fills/30 days)
sumatriptan tab (IMITREX equiv) (QL= 9 tabs/fill; 2 fills/30 days)
sumatriptan vial inj (IMITREX equiv) (QL= 5 inj/fill, 2 fills/30 days)
SUMAVEL DOSEPRO INJ
SUPRAX CAP
SUPRAX CHEW TAB
SUPRAX TAB
SURMONTIL CAP
SUSTIVA CAP
SUSTIVA TAB
SUTENT CAP
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
ULCER DRUGS
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
ANTIDIABETICS
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
DERMATOLOGICALS
DERMATOLOGICALS
ASSORTED CLASSES
DERMATOLOGICALS
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
DERMATOLOGICALS
ANTIVIRALS
ANTIVIRALS
ANTIVIRALS
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
GENITOURINARY AGENTS MISCELLANEOUS
ANTIDIABETICS
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
CONTRACEPTIVES
DERMATOLOGICALS
DERMATOLOGICALS
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 37 of 101
Navi-Gate Rx Formulary Cont.
Alphabetical Index
Last Updated 1/1/2017
Drug Name
Special Code
Level
Category
TECFIDERA CAP
-
F
TECFIDERA STARTER PACK
-
F
TECHNIVIE TAB
TEKTURNA HCT TAB
telmisartan tab (MICARDIS equiv)
telmisartan/amlodipine tab (TWYNSTA equiv)
telmisartan/hydrochlorothiazide tab (MICARDIS HCT equiv)
temazepam 15mg cap (RESTORIL equiv)
-
NC
F
F
NC
NC
F
PSYCHOTHERAPEUTIC AND
NEUROLOGICAL AGENTS - MISC.
PSYCHOTHERAPEUTIC AND
NEUROLOGICAL AGENTS - MISC.
ANTIVIRALS
ANTIHYPERTENSIVES
ANTIHYPERTENSIVES
ANTIHYPERTENSIVES
ANTIHYPERTENSIVES
temazepam 22.5mg cap (RESTORIL equiv)
-
F
temazepam 30mg cap (RESTORIL equiv)
-
F
temazepam 7.5mg cap (RESTORIL equiv)
-
F
temozolomide cap (TEMODAR equiv)
-
F
terazosin cap (HYTRIN equiv)
terbinafine tab (LAMISIL equiv)
terbutaline sulfate tab (BRETHINE equiv)
-
F
F
F
terconazole cream (TERAZOL equiv)
terconazole supp (TERAZOL equiv)
testosterone cypionate inj (DEPO-TESTOSTERONE equiv)
TESTOSTERONE GEL 1% 25MG (QL= 1 packet/day)
testosterone gel 1% 25mg (ANDROGEL equiv) (QL= 1 packet/day )
TESTOSTERONE GEL 1% 50MG (QL= 2 packets/day)
testosterone gel 1% 50mg (ANDROGEL equiv) (QL= 2 packets/day)
testosterone gel 1% pump (ANDROGEL equiv) (QL= 4 bottles/30 days)
TESTOSTERONE GEL PUMP (QL= 4 bottles/30 days)
TESTOSTERONE GEL/TESTIM GEL
tetrabenazine tab (XENAZINE equiv) ( )
QL
QL
QL
QL
QL
QL
-
F
F
F
F
F
F
F
F
F
NC
F
tetracaine ophth soln
tetracycline cap
THALOMID CAP
THEO-24 CAP
-
F
F
F
F
theophylline CR tab
-
F
theophylline ER tab (UNIPHYL equiv)
-
F
theophylline soln
-
F
THIOLA TAB
-
F
thioridazine tab (MELLARIL equiv)
thiothixene cap (NAVANE equiv)
THYROLAR TAB
tiagabine tab (GABITRIL equiv)
TICANASE PAK
-
F
F
F
F
NC
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
HYPNOTICS/SEDATIVES/SLEEP DISORDER
AGENTS
HYPNOTICS/SEDATIVES/SLEEP DISORDER
AGENTS
HYPNOTICS/SEDATIVES/SLEEP DISORDER
AGENTS
HYPNOTICS/SEDATIVES/SLEEP DISORDER
AGENTS
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
ANTIHYPERTENSIVES
ANTIFUNGALS
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
VAGINAL PRODUCTS
VAGINAL PRODUCTS
ANDROGENS-ANABOLIC
ANDROGENS-ANABOLIC
ANDROGENS-ANABOLIC
ANDROGENS-ANABOLIC
ANDROGENS-ANABOLIC
ANDROGENS-ANABOLIC
ANDROGENS-ANABOLIC
ANDROGENS-ANABOLIC
PSYCHOTHERAPEUTIC AND
NEUROLOGICAL AGENTS - MISC.
OPHTHALMIC AGENTS
TETRACYCLINES
ASSORTED CLASSES
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
GENITOURINARY AGENTS MISCELLANEOUS
ANTIPSYCHOTICS/ANTIMANIC AGENTS
ANTIPSYCHOTICS/ANTIMANIC AGENTS
THYROID AGENTS
ANTICONVULSANTS
NASAL AGENTS - SYSTEMIC AND TOPICAL
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 38 of 101
Navi-Gate Rx Formulary Cont.
Alphabetical Index
Last Updated 1/1/2017
Drug Name
Special Code
Level
Category
ticlodipine tab (TICLID equiv)
timolol maleate ophth gel (TIMOPTIC-XE equiv)
timolol maleate ophth soln (TIMOPTIC equiv)
timolol tab
TIVICAY TAB (QL= 2 tabs/day)
tizanidine tab (ZANAFLEX equiv)
TOBI PODHALER
TOBRADEX OPHTH OINT
tobramycin neb (TOBI equiv)
tobramycin ophth soln (TOBREX equiv)
tobramycin/dexamethasone ophth soln (TOBRADEX equiv)
TOBREX OPHTH OINT
tolazamide tab
TOLBUTAMIDE TAB
tolcapone tab (TASMAR equiv)
TOLMETIN CAP
tolmetin cap (TOLECTIN DS equiv)
TOLMETIN TAB
tolterodine SR cap (DETROL LA equiv)
tolterodine tab (DETROL equiv)
topiramate sprinkle cap (TOPAMAX equiv)
topiramate tab (TOPAMAX equiv)
torsemide tab (DEMADEX equiv)
TOUJEO SOLOSTAR INJ
TOVIAZ TAB
TRACLEER TAB (QL= 2 tabs/day)
TRADJENTA TAB (QL= 1 tab/day)
TRAMADOL CREAM COMPOUND KIT
tramadol ER tab (ULTRAM ER equiv)
tramadol tab (ULTRAM equiv)
trandolapril tab (MAVIK equiv)
trandolapril/verapamil ER tab (TARKA equiv)
tranexamic acid tab (LYSTEDA equiv)
tranylcypromine tab (PARNATE equiv)
TRAVATAN Z OPHTH SOLN (QL= 5 ml/30 days)
trazodone tab (300mg tab is Not Covered)
TRESIBA INJ
tretinoin cap (VESANOID equiv)
QL
¢
*
QL
QL
QL
-
F
F
F
F
F
F
F
F
F
F
F
F
F
F
NC
F
F
F
F
F
F
F
F
F
F
F
F
NC
F
F
F
F
F
F
F
F
NC
F
HEMATOLOGICAL AGENTS - MISC.
OPHTHALMIC AGENTS
OPHTHALMIC AGENTS
BETA BLOCKERS
ANTIVIRALS
MUSCULOSKELETAL THERAPY AGENTS
AMINOGLYCOSIDES
OPHTHALMIC AGENTS
AMINOGLYCOSIDES
OPHTHALMIC AGENTS
OPHTHALMIC AGENTS
OPHTHALMIC AGENTS
ANTIDIABETICS
ANTIDIABETICS
ANTIPARKINSON AGENTS
ANALGESICS - ANTI-INFLAMMATORY
ANALGESICS - ANTI-INFLAMMATORY
ANALGESICS - ANTI-INFLAMMATORY
URINARY ANTISPASMODICS
URINARY ANTISPASMODICS
ANTICONVULSANTS
ANTICONVULSANTS
DIURETICS
ANTIDIABETICS
URINARY ANTISPASMODICS
CARDIOVASCULAR AGENTS - MISC.
ANTIDIABETICS
DERMATOLOGICALS
ANALGESICS - OPIOID
ANALGESICS - OPIOID
ANTIHYPERTENSIVES
ANTIHYPERTENSIVES
HEMOSTATICS
ANTIDEPRESSANTS
OPHTHALMIC AGENTS
ANTIDEPRESSANTS
ANTIDIABETICS
tretinoin cream (RETIN-A CREAM equiv)
tretinoin gel (RETIN-A GEL equiv)
triamcinolone in orabase paste (KENALOG/ORABASE equiv)
triamcinolone nasal spray (NASACORT equiv) (QL= 2 bottles/fill)
triamcinolone OTC nasal spray (NASACORT equiv) (QL= 2 bottles/fill)
triamcinolone spray (KENALOG equiv)
triamcinolone topical
triamterene/hydrochlorothiazide cap (DYAZIDE equiv)
TRIAMTERENE/HYDROCHLOROTHIAZIDE CAP 50-25mg
triamterene/hydrochlorothiazide tab (MAXZIDE equiv)
TRIANEX OINT
triazolam tab (HALCION equiv)
QL
OTC-QL
-
F
F
F
F
F
NC
F
F
F
F
NC
F
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
DERMATOLOGICALS
DERMATOLOGICALS
MOUTH/THROAT/DENTAL AGENTS
NASAL AGENTS - SYSTEMIC AND TOPICAL
NASAL AGENTS - SYSTEMIC AND TOPICAL
DERMATOLOGICALS
DERMATOLOGICALS
DIURETICS
DIURETICS
DIURETICS
DERMATOLOGICALS
HYPNOTICS/SEDATIVES/SLEEP DISORDER
AGENTS
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 39 of 101
Navi-Gate Rx Formulary Cont.
Alphabetical Index
Last Updated 1/1/2017
Drug Name
Special Code
Level
Category
TRIBENZOR TAB
tricitrates soln
-
F
F
ANTIHYPERTENSIVES
trifluoperazine tab (STELAZINE equiv)
trifluridine ophth soln (VIROPTIC equiv)
trihexyphenidyl tab (ARTANE equiv)
tri-legest FE tab (ESTROSTEP FE equiv)
TRILIPIX CAP
trilyte soln (GOLYTELY equiv)
trimethobenzamide cap (TIGAN equiv)
trimethoprim tab
trimipramine cap (SURMONTIL equiv)
TRINTELLIX TAB (QL= 1 tab/day)
TRIUMEQ TAB (QL= 1 tab/day)
tropicamide ophth soln (MYDRIACYL equiv)
trospium chloride SR cap (SANCTURA equiv)
TRULICITY INJ
TRUVADA TAB
TUDORZA PRESSAIR INHALER
QL
-
F
F
F
NC
F
F
F
F
F
F
F
F
F
F
F
NC
TYBOST TAB
TYKERB TAB
-
NC
F
TYVASO INH SOLN (Only available through Accredo 888-773-7376)
UCERIS RECTAL FOAM
UCERIS TAB (QL= 1 tab/day)
U-CORT CREAM
ULESFIA LOTION (QL= 4 bottles/fill)
ULORIC TAB
ULTRAVATE LOTION
UMECTA PD EMULSION
UPTRAVI TAB
UPTRAVI THERAPY PACK
URAMAXIN LOTION
urea cream (KERALAC equiv)
urea lotion
urea susp 40% (UMECTA equiv)
ursodiol tab (URSO FORTE equiv)
UTA cap
UTIBRON NEOHALER CAP
LD
QL
QL
¢
-
F
F
F
F
F
F
F
NC
NC
NC
NC
NC
NC
NC
F
NC
NC
valacyclovir tab (VALTREX equiv)
LD-QL
F
F
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
ANTIVIRALS
DERMATOLOGICALS
*
QL
F
F
F
F
F
F
F
F
ANTIVIRALS
ANTIVIRALS
ANTICONVULSANTS
ANTICONVULSANTS
ANTIHYPERTENSIVES
ANTIHYPERTENSIVES
ANTIHYPERTENSIVES
ANTI-INFECTIVE AGENTS - MISC.
VALCHLOR GEL (QL= 4 tubes/30 days; Only available through Accredo
888-773-7376)
valganciclovir soln (VALCYTE equiv)
valganciclovir tab (VALCYTE equiv)
valproic acid cap (DEPAKENE equiv)
valproic acid syrup (DEPAKENE equiv)
valsartan tab (DIOVAN equiv)
valsartan/hydrochlorothiazide tab (DIOVAN HCT equiv)
VALTURNA TAB
vancomycin cap (VANCOCIN CAP equiv) (QL= 56 caps/fill)
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
GENITOURINARY AGENTS MISCELLANEOUS
ANTIPSYCHOTICS/ANTIMANIC AGENTS
OPHTHALMIC AGENTS
ANTIPARKINSON AGENTS
CONTRACEPTIVES
ANTIHYPERLIPIDEMICS
LAXATIVES
ANTIEMETICS
ANTI-INFECTIVE AGENTS - MISC.
ANTIDEPRESSANTS
ANTIDEPRESSANTS
ANTIVIRALS
OPHTHALMIC AGENTS
URINARY ANTISPASMODICS
ANTIDIABETICS
ANTIVIRALS
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
ANTIVIRALS
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
CARDIOVASCULAR AGENTS - MISC.
ANORECTAL AGENTS
CORTICOSTEROIDS
DERMATOLOGICALS
DERMATOLOGICALS
GOUT AGENTS
DERMATOLOGICALS
DERMATOLOGICALS
CARDIOVASCULAR AGENTS - MISC.
CARDIOVASCULAR AGENTS - MISC.
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
GASTROINTESTINAL AGENTS - MISC.
URINARY ANTI-INFECTIVES
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 40 of 101
Navi-Gate Rx Formulary Cont.
Alphabetical Index
Last Updated 1/1/2017
Drug Name
Special Code
Level
Category
VANCOMYCIN ORAL SOLN KIT
VARUBI TAB
VAXCHORA SUSP
VECTICAL OINT
VELPHORO CHEW TAB
VELTASSA POWDER
VEMLIDY TAB
VENCLEXTA STARTER PACK
-
F
NC
NC
F
F
NC
NC
NC
ANTI-INFECTIVE AGENTS - MISC.
ANTIEMETICS
VACCINES
DERMATOLOGICALS
GASTROINTESTINAL AGENTS - MISC.
ASSORTED CLASSES
ANTIVIRALS
VENCLEXTA TAB
-
NC
venlafaxine ER cap (EFFEXOR XR equiv)
venlafaxine ER tab (EFFEXOR XR equiv)
VENLAFAXINE ER TAB 225MG
VENTAVIS INH SOLN (Only available through Accredo 888-773-7376)
VENTOLIN HFA INHALER (QL= 2 inhalers/fill, 2 fills/30 days)
LD
QL
F
F
F
F
F
VERAMYST NASAL SPRAY (QL= 2 bottles/fill)
verapamil ER cap (VERELAN equiv)
verapamil ER tab (CALAN SR equiv)
verapamil tab (CALAN equiv)
VERSACLOZ SUSP
VESICARE TAB
VEXOL OPHTH SUSP
V-GO 20 KIT (QL= 1 kit/day)
VIAGRA TAB
VIBERZI TAB
VICTOZA INJ (QL= 9 ml/30 days)
VICTRELIS CAP
VIDEX SOLN
VIEKIRA XR TAB
VIIBRYD STARTER KIT
VIMPAT ORAL SOLN
VIMPAT TAB (QL= 2 tabs/day)
VIRACEPT TAB
VIREAD TAB
VISICOL TAB
VISTOGARD PAK
vitamin D cap
VITEKTA TAB
VIVLODEX CAP
VIVOTIF BERNA CAP
VOGELXO PUMP
VOLTAREN GEL
VOPAC 5 CREAM
VOPAC CREAM
VOPAC GB CREAM
voriconazole susp (VFEND equiv)
voriconazole tab (VFEND equiv)
VOTRIENT TAB
QL
¢
QL
*
QL
QL
*
VAC
QL
-
F
F
F
F
NC
F
F
F
F
NC
F
NC
F
NC
NC
F
F
F
F
F
NC
F
F
NC
F
NC
F
NC
NC
NC
F
F
F
VRAYLAR CAP
-
NC
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
ANTIDEPRESSANTS
ANTIDEPRESSANTS
ANTIDEPRESSANTS
CARDIOVASCULAR AGENTS - MISC.
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
NASAL AGENTS - SYSTEMIC AND TOPICAL
CALCIUM CHANNEL BLOCKERS
CALCIUM CHANNEL BLOCKERS
CALCIUM CHANNEL BLOCKERS
ANTIPSYCHOTICS/ANTIMANIC AGENTS
URINARY ANTISPASMODICS
OPHTHALMIC AGENTS
MEDICAL DEVICES AND SUPPLIES
CARDIOVASCULAR AGENTS - MISC.
GASTROINTESTINAL AGENTS - MISC.
ANTIDIABETICS
ANTIVIRALS
ANTIVIRALS
ANTIVIRALS
ANTIDEPRESSANTS
ANTICONVULSANTS
ANTICONVULSANTS
ANTIVIRALS
ANTIVIRALS
LAXATIVES
ANTIDOTES
VITAMINS
ANTIVIRALS
ANALGESICS - ANTI-INFLAMMATORY
VACCINES
ANDROGENS-ANABOLIC
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
DERMATOLOGICALS
ANTIFUNGALS
ANTIFUNGALS
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
ANTIPSYCHOTICS/ANTIMANIC AGENTS
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 41 of 101
Navi-Gate Rx Formulary Cont.
Alphabetical Index
Last Updated 1/1/2017
Drug Name
Special Code
Level
Category
VRAYLAR PACK
VYTORIN TAB (QL= 1 tab/day; 10/80mg tab is Not Covered)
VYVANSE CAP
QL
-
NC
F
F
ANTIPSYCHOTICS/ANTIMANIC AGENTS
ANTIHYPERLIPIDEMICS
warfarin tab (COUMADIN equiv)
WELCHOL PAK
WELCHOL TAB
wymzya FE tab (FEMCON equiv)
XALKORI CAP
-
F
F
F
F
F
XAQUIL XR TAB
-
NC
XARELTO STARTER PACK
XARELTO TAB
XARTEMIS XR TAB
XELJANZ XR TAB
XENADERM OINT
XIGDUO XR TAB (QL= 1 tab/day)
XIGDUO XR TAB 5-1000MG (QL= 2 tabs/day)
XIIDRA OPHTH SOLN
XTAMPZA ER CAP
XTANDI CAP (QL= 4 caps/day)
QL
QL
QL
F
F
NC
NC
F
F
F
NC
NC
F
XULANE PATCH
XURIDEN POWDER
-
F
NC
XYREM SOLN (QL= 540ml/30 days; Only available through Xyrem Central
Pharmacy 866-997-3688)
XYZBAC TAB
LD-QL
F
-
NC
YAZ TAB
YOSPRALA TAB
yuvafem tab (VAGIFEM equiv) (QL= 8 tabs/28 days (18 tabs on first fill))
zafirlukast tab (ACCOLATE equiv)
QL
-
F
NC
F
NC
ZARXIO INJ
ZAVESCA CAP (Only available through Accredo 888-773-7376 )
ZECUITY PAD
ZEGERID CAP OTC
ZELAPAR ODT
ZELBORAF TAB
LD
OTC
-
F
F
NC
F
F
F
ZEMBRACE SYMTOUCH INJ
ZENPEP CAP
ZEPATIER TAB
ZETIA TAB (QL= 1 tab/day)
ZETONNA NASAL SPRAY (QL= 2 bottles/fill)
zidovudine cap (RETROVIR equiv)
zidovudine tab (RETROVIR equiv)
ZINBRYTA INJ
QL
QL
-
NC
NC
NC
F
F
F
F
NC
zinc sulfate cap
-
F
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A
NOREXIANTS
ANTICOAGULANTS
ANTIHYPERLIPIDEMICS
ANTIHYPERLIPIDEMICS
CONTRACEPTIVES
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
DIETARY PRODUCTS/DIETARY
MANAGEMENT PRODUCTS
ANTICOAGULANTS
ANTICOAGULANTS
ANALGESICS - OPIOID
ANALGESICS - ANTI-INFLAMMATORY
DERMATOLOGICALS
ANTIDIABETICS
ANTIDIABETICS
OPHTHALMIC AGENTS
ANALGESICS - OPIOID
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
CONTRACEPTIVES
ENDOCRINE AND METABOLIC AGENTS MISC.
PSYCHOTHERAPEUTIC AND
NEUROLOGICAL AGENTS - MISC.
DIETARY PRODUCTS/DIETARY
MANAGEMENT PRODUCTS
CONTRACEPTIVES
HEMATOLOGICAL AGENTS - MISC.
VAGINAL PRODUCTS
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
HEMATOPOIETIC AGENTS
HEMATOPOIETIC AGENTS
MIGRAINE PRODUCTS
ULCER DRUGS
ANTIPARKINSON AGENTS
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
MIGRAINE PRODUCTS
DIGESTIVE AIDS
ANTIVIRALS
ANTIHYPERLIPIDEMICS
NASAL AGENTS - SYSTEMIC AND TOPICAL
ANTIVIRALS
ANTIVIRALS
PSYCHOTHERAPEUTIC AND
NEUROLOGICAL AGENTS - MISC.
MINERALS & ELECTROLYTES
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 42 of 101
Navi-Gate Rx Formulary Cont.
Alphabetical Index
Last Updated 1/1/2017
Drug Name
Special Code
Level
Category
ziprasidone cap (GEODON equiv)
ZIRGAN GEL
ZOHYDRO ER CAP
ZOLINZA CAP
-
F
F
NC
F
ANTIPSYCHOTICS/ANTIMANIC AGENTS
OPHTHALMIC AGENTS
ANALGESICS - OPIOID
zolmitriptan ODT (ZOMIG ZMT equiv) (QL= 9 tabs/fill, 2 fills/30 days)
zolmitriptan tab (ZOMIG equiv) (QL= 9 tabs/fill; 2 fills/30 days)
zolpidem ER tab (AMBIEN CR equiv)
QL
QL
-
F
F
NC
zolpidem tab 10mg (AMBIEN equiv) (Male QL= 1 tab/day; Female QL= 0.5
tab/day)
zolpidem tab 5mg (AMBIEN equiv) (QL= 1 tab/day)
QL
F
QL
F
ZOMIG NASAL SPRAY (QL= 6 sprays/fill; 2 fills/30 days)
ZOMIG TAB (QL= 9 tabs/fill; 2 fills/30 days)
ZOMIG ZMT TAB (QL= 9 tabs/fill, 2 fills/30 days)
zonisamide cap (ZONEGRAN equiv)
ZONTIVITY TAB
ZOVIRAX CREAM
ZOVIRAX OINT
ZUBSOLV SL TAB
ZURAMPIC TAB
ZYDELIG TAB (Only available through Diplomat Pharmacy 877-977-9118)
QL
QL
QL
LD
F
F
F
F
NC
F
F
NC
NC
F
ZYFLO CR TAB
-
F
ZYFLO TAB
-
F
ZYKADIA CAP
-
NC
ZYLET OPHTH SOLN
ZYLET OPHTH SUSP 10ML
ZYTIGA TAB
-
F
F
F
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
MIGRAINE PRODUCTS
MIGRAINE PRODUCTS
HYPNOTICS/SEDATIVES/SLEEP DISORDER
AGENTS
HYPNOTICS/SEDATIVES/SLEEP DISORDER
AGENTS
HYPNOTICS/SEDATIVES/SLEEP DISORDER
AGENTS
MIGRAINE PRODUCTS
MIGRAINE PRODUCTS
MIGRAINE PRODUCTS
ANTICONVULSANTS
HEMATOLOGICAL AGENTS - MISC.
DERMATOLOGICALS
DERMATOLOGICALS
ANALGESICS - OPIOID
GOUT AGENTS
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
OPHTHALMIC AGENTS
OPHTHALMIC AGENTS
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 43 of 101
Navi-Gate Rx Formulary
Category/Class
Last Updated* 1/1/2017
DrugName
Special Code
Level
-
F
F
F
F
F
F
NC
NC
-
F
QL
-
F
NC
NC
*
-
F
NC
QL
-
F
F
F
F
F
F
F
F
F
F
F
F
F
F
NC
NC
NC
-
F
F
F
NC
NC
-
NC
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS
AMPHETAMINES
ADDERALL XR CAP
amphetamine/dextroamphetamine tab (ADDERALL equiv)
dextroamphetamine ER cap (DEXEDRINE equiv)
dextroamphetamine soln (PROCENTRA equiv)
PROCENTRA SOLN
VYVANSE CAP
ADZENYS XR TAB
DYANAVEL XR SUSP
ANALEPTICS
caffeine citrate soln (CAFCIT equiv) (Only covered for those less than 1 year old)
ANTI-OBESITY AGENTS
CONTRAVE TAB (QL= 4 tabs/day)
BELVIQ TAB
BELVIQ XR TAB
ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD) AGENTS
STRATTERA CAP
clonidine ER tab (KAPVAY equiv)
STIMULANTS - MISC.
CONCERTA TAB
DAYTRANA PATCH
dexmethylphenidate ER cap (FOCALIN XR equiv)
dexmethylphenidate tab (FOCALIN equiv)
FOCALIN XR CAP
methylphenidate chew tab (METHYLIN CHEW equiv)
methylphenidate ER cap (RITALIN LA equiv)
METHYLPHENIDATE ER TAB
methylphenidate ER tab 10mg, 20mg
methylphenidate soln (METHYLIN equiv)
methylphenidate tab (RITALIN equiv)
modafinil tab (PROVIGIL equiv) (QL= 2 tabs/day)
RITALIN LA CAP 10MG
RITALIN LA CAP 60MG
armodafinil tab (NUVIGIL equiv)
methylphenidate CD cap (METADATE CD equiv)
QUILLICHEW ER TAB
AMINOGLYCOSIDES
AMINOGLYCOSIDES
neomycin tab
TOBI PODHALER
tobramycin neb (TOBI equiv)
BETHKIS NEB
KITABIS PAK NEB SOLN
ANALGESICS - ANTI-INFLAMMATORY
ANTIRHEUMATIC - ENZYME INHIBITORS
XELJANZ XR TAB
Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 44 of 101
Navi-Gate Rx Formulary
Category/Class
Last Updated* 1/1/2017
DrugName
Special Code
Level
-
NC
QL
QL
-
F
F
NC
NC
-
F
LD-QL
F
QL
F
*-QL
QL
-
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
NC
NC
NC
NC
-
NC
NC
-
F
ANALGESICS - ANTI-INFLAMMATORY Cont.
ANTIRHEUMATIC ANTIMETABOLITES
OTREXUP INJ/ RASUVO INJ
ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES
HUMIRA INJ (QL= 2 inj/28 days)
HUMIRA PEN INJ (QL= 2 inj/28 days)
SIMPONI ARIA INJ
SIMPONI INJ
GOLD COMPOUNDS
RIDAURA CAP
INTERLEUKIN-1 RECEPTOR ANTAGONIST (IL-1RA)
KINERET INJ (QL= 1 inj/day; Only available through Rx Crossroads: 1-866-547-0644)
INTERLEUKIN-6 RECEPTOR INHIBITORS
ACTEMRA SC INJ (QL= 2 inj/28 days)
NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)
celecoxib cap (CELEBREX equiv) (QL= 2 caps/day)
diclofenac potassium tab (CATAFLAM equiv)
diclofenac tab (VOLTAREN equiv)
etodolac cap (LODINE equiv)
etodolac tab (LODINE equiv)
fenoprofen calcium tab
FENOPROFEN CAP
flurbiprofen tab
ibuprofen susp (MOTRIN equiv)
ibuprofen tab (MOTRIN equiv)
indomethacin cap (INDOCIN equiv)
indomethacin ER cap (INDOCIN SR equiv)
ketoprofen cap
ketorolac tab (TORADOL equiv) (QL= 20 tabs/5 days)
meloxicam tab (MOBIC equiv)
nabumetone tab (RELAFEN equiv)
NAPROXEN SUSP
naproxen tab (NAPROSYN equiv)
oxaprozin tab (DAYPRO equiv)
piroxicam cap (FELDENE equiv)
sulindac tab (CLINORIL equiv)
TOLMETIN CAP
tolmetin cap (TOLECTIN DS equiv)
TOLMETIN TAB
mefenamic acid cap (PONSTEL equiv)
NAPRELAN CR TAB 375MG, 750MG
naproxen sodium CR tab (NAPRELAN equiv)
VIVLODEX CAP
PHOSPHODIESTERASE 4 (PDE4) INHIBITORS
OTEZLA STARTER PACK ( )
OTEZLA TAB ( )
PYRIMIDINE SYNTHESIS INHIBITORS
leflunomide tab (ARAVA equiv)
Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 45 of 101
Navi-Gate Rx Formulary
Category/Class
Last Updated* 1/1/2017
DrugName
Special Code
Level
-
NC
NC
QL
QL
QL
F
F
F
-
NC
-
F
F
F
F
QL
QL
QL
QL
QL
QL
QL
*
-
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
NC
NC
NC
NC
ANALGESICS - ANTI-INFLAMMATORY Cont.
SELECTIVE COSTIMULATION MODULATORS
ORENCIA CLICK INJ
ORENCIA SC INJ
SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS
ENBREL INJ 25MG (QL= 8 inj/28 days)
ENBREL INJ 50MG (QL= 4 inj/28 days)
ENBREL SURECLICK INJ 50MG (QL= 4 inj/28 days)
ANALGESICS - NONNARCOTIC
ANALGESIC COMBINATIONS
BUTALBITAL/ASPIRIN/CAFFEINE TAB
SALICYLATES
CHOLINE MAGNESIUM TRISALICYLATE TAB
choline magnesium trisalicylate tab (TRILISATE equiv)
diflunisal tab (DOLOBID equiv)
salsalate tab
ANALGESICS - OPIOID
OPIOID AGONISTS
codeine tab
fentanyl citrate lollipop (ACTIQ equiv) (QL= 120 lozenges/30 days)
fentanyl patch (DURAGESIC equiv)
hydromorphone tab (DILAUDID equiv)
HYSINGLA ER TAB (QL= 1 tab/day)
LAZANDA NASAL SPRAY (QL= 15 bottles/30 days)
meperidine tab (DEMEROL equiv)
methadone oral soln
methadone tab
methadone tab (DOLOPHINE equiv)
morphine oral soln
MORPHINE SULFATE ER BEAD CAP (QL= 2 caps/day)
morphine sulfate ER tab (MS CONTIN equiv)
morphine sulfate supp
morphine sulfate tab
NUCYNTA ER TAB (QL= 2 tabs/day)
OXAYDO TAB
oxycodone cap (OXYIR equiv)
oxycodone conc (ROXICODONE equiv)
oxycodone soln
oxycodone tab (ROXICODONE equiv)
OXYCONTIN CR TAB (QL= 120 tabs/30 days)
OXYCONTIN CR TAB (QL= 4 tabs/day)
RYZOLT
tramadol ER tab (ULTRAM ER equiv)
tramadol tab (ULTRAM equiv)
EMBEDA CAP
hydromorphone ER tab (EXALGO equiv)
OPANA ER TAB (CRUSH RESISTANT)
oxycodone ER tab
Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 46 of 101
Navi-Gate Rx Formulary
Category/Class
Last Updated* 1/1/2017
DrugName
Special Code
Level
-
NC
NC
NC
-
F
F
F
F
F
F
F
F
F
F
F
NC
NC
NC
NC
NC
QL
-
F
F
F
NC
NC
NC
NC
NC
-
F
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
-
F
F
F
F
F
F
F
F
F
F
F
F
NC
NC
ANALGESICS - OPIOID Cont.
oxycodone ER tab (OXYCONTIN equiv)
XTAMPZA ER CAP
ZOHYDRO ER CAP
OPIOID COMBINATIONS
ACETAMINOPHEN/CAFFEINE/DIHYDROCODEINE TAB
acetaminophen/codeine tab (TYLENOL/CODEINE equiv)
aspirin/codeine tab
hydrocodone/acetaminophen cap (LORCET equiv)
hydrocodone/acetaminophen soln (ZOLVIT equiv)
hydrocodone/acetaminophen tab (LORTAB equiv)
hydrocodone/acetaminophen tab 2.5/325mg (NORCO equiv)
LORTAB ELIXIR
oxycodone/acetaminophen cap (TYLOX equiv)
OXYCODONE/ACETAMINOPHEN SOLN
oxycodone/acetaminophen tab
acetaminophen/caffeine/dihydrocodeine cap (TREZIX equiv)
hydrocodone/acetaminophen tab 10mg/300mg (XODOL equiv)
hydrocodone/acetaminophen tab 5mg/300mg (XODOL equiv)
hydrocodone/acetaminophen tab 7.5mg/300mg (XODOL equiv)
XARTEMIS XR TAB
OPIOID PARTIAL AGONISTS
buprenorphine/naloxone SL tab (SUBOXONE equiv)
butorphanol nasal spray (STADOL equiv) (QL= 1 bottle/fill, 2 fills/30 days)
SUBOXONE SL
BELBUCA FILM
BUNAVAIL FILM
BUTRANS PATCH
pentazocine/naloxone tab (TALWIN NX equiv)
ZUBSOLV SL TAB
ANDROGENS-ANABOLIC
ANABOLIC STEROIDS
oxandrolone tab (OXANDRIN equiv)
ANDROGENS
ANDRODERM (QL= 1 patch/day)
ANDROGEL 1.62% 1.25GM (QL= 1 packet/day)
ANDROGEL 1.62% 2.5GM (QL= 2 packets/day)
ANDROGEL PUMP 1.62% (QL= 2 bottles/30 days)
danazol cap
testosterone cypionate inj (DEPO-TESTOSTERONE equiv)
TESTOSTERONE GEL 1% 25MG (QL= 1 packet/day)
testosterone gel 1% 25mg (ANDROGEL equiv) (QL= 1 packet/day )
TESTOSTERONE GEL 1% 50MG (QL= 2 packets/day)
testosterone gel 1% 50mg (ANDROGEL equiv) (QL= 2 packets/day)
testosterone gel 1% pump (ANDROGEL equiv) (QL= 4 bottles/30 days)
TESTOSTERONE GEL PUMP (QL= 4 bottles/30 days)
AXIRON SOLN
FORTESTA GEL/ TESTOSTERONE GEL
Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 47 of 101
Navi-Gate Rx Formulary
Category/Class
Last Updated* 1/1/2017
DrugName
Special Code
Level
-
NC
NC
NC
-
F
F
-
F
F
F
F
-
F
-
F
F
-
F
F
NC
NC
-
F
-
F
F
F
F
F
F
F
F
F
NC
NC
-
F
F
F
F
-
F
ANDROGENS-ANABOLIC Cont.
methyltestosterone cap (ANDROID/TESTRED equiv)
TESTOSTERONE GEL/TESTIM GEL
VOGELXO PUMP
ANORECTAL AGENTS
INTRARECTAL STEROIDS
hydrocortisone enema (CORTENEMA equiv)
UCERIS RECTAL FOAM
RECTAL COMBINATIONS
ANALPRAM-E KIT
hc pramoxine cream (ANALPRAM equiv)
lidocaine/hydrocortisone cream (ANAMANTLE equiv)
pramoxine/hydrocortisone cream kit (ANALPRAM-HC equiv)
RECTAL LOCAL ANESTHETICS
pramoxine rectal foam (PROCTOFOAM equiv)
RECTAL STEROIDS
hydrocortisone supp (ANUSOL HC equiv)
proctosol HC cream (ANUSOL equiv)
ANTHELMINTICS
ANTHELMINTICS
BILTRICIDE TAB
ivermectin tab (STROMECTOL equiv)
ALBENZA TAB
EMVERM TAB
ANTIANGINAL AGENTS
ANTIANGINALS-OTHER
RANEXA TAB
NITRATES
isosorbide dinitrate ER tab
isosorbide dinitrate SL tab
isosorbide dinitrate tab (ISORDIL equiv)
ISOSORBIDE DINITRATE TAB 30MG, 40MG
isosorbide mononitrate ER tab (IMDUR equiv)
isosorbide mononitrate tab (MONOKET equiv)
NITRO-BID OINT
nitroglycerin patch (NITRO-DUR equiv)
nitroglycerin SL tab (NITROSTAT equiv)
GONITRO POWDER
nitroglycerin lingual spray (NITROLINGUAL equiv)
ANTIANXIETY AGENTS
ANTIANXIETY AGENTS - MISC.
buspirone tab (BUSPAR equiv) (30mg tab is Not Covered)
hydroxyzine pamoate cap (VISTARIL equiv)
hydroxyzine tab (ATARAX equiv)
meprobamate tab (MILTOWN equiv)
BENZODIAZEPINES
alprazolam tab (XANAX equiv)
Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 48 of 101
Navi-Gate Rx Formulary
Category/Class
Last Updated* 1/1/2017
DrugName
Special Code
Level
-
F
F
F
F
F
F
-
F
F
F
F
F
-
F
-
F
F
-
F
F
F
-
F
F
-
F
F
F
F
F
F
NC
NC
-
F
F
F
F
F
F
NC
-
NC
ANTIANXIETY AGENTS Cont.
chlordiazepoxide cap (LIBRIUM equiv)
clorazepate tab (TRANXENE-T equiv)
diazepam conc (VALIUM equiv)
diazepam tab (VALIUM equiv)
lorazepam tab (ATIVAN equiv)
oxazepam cap (SERAX equiv)
ANTIARRHYTHMICS
ANTIARRHYTHMICS TYPE I-A
disopyramide cap (NORPACE equiv)
NORPACE CR CAP
quinidine gluconate CR tab
QUINIDINE SULFATE ER TAB
quinidine sulfate tab
ANTIARRHYTHMICS TYPE I-B
mexiletine cap
ANTIARRHYTHMICS TYPE I-C
flecainide tab (TAMBOCOR equiv)
propafenone tab (RYTHMOL equiv)
ANTIARRHYTHMICS TYPE III
amiodarone tab (CORDARONE equiv)
dofetilide cap (TIKOSYN equiv)
MULTAQ TAB
ANTIASTHMATIC AND BRONCHODILATOR AGENTS
ANTI-INFLAMMATORY AGENTS
CROMOLYN NEB SOLN
cromolyn nebulizer solution
BRONCHODILATORS - ANTICHOLINERGICS
ATROVENT HFA INHALER
INCRUSE ELLIPTA INHALER
ipratropium nasal spray (ATROVENT equiv)
SPIRIVA HANDIHALER
SPIRIVA RESPIMAT INHALER
SPIRIVA RESPIMAT INHALER 1.25MCG/ACT
SEEBRI NEOHALER CAP
TUDORZA PRESSAIR INHALER
LEUKOTRIENE MODULATORS
montelukast chew tab (SINGULAIR equiv)
montelukast granules (SINGULAIR equiv)
montelukast tab (SINGULAIR equiv)
SINGULAIR GRANULES
ZYFLO CR TAB
ZYFLO TAB
zafirlukast tab (ACCOLATE equiv)
SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS
DALIRESP TAB
STEROID INHALANTS
Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 49 of 101
Navi-Gate Rx Formulary
Category/Class
Last Updated* 1/1/2017
DrugName
Special Code
Level
QL
QL
-
F
F
F
F
F
F
NC
NC
NC
NC
QL
QL
-
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
NC
NC
NC
NC
-
F
F
F
F
F
F
-
F
-
F
F
ANTIASTHMATIC AND BRONCHODILATOR AGENTS Cont.
ARNUITY ELLIPTA INHALER
ASMANEX HFA INHALER (QL= 1 inhaler/fill)
ASMANEX INHALER (QL= 1 inhaler/fill)
budesonide inh susp (PULMICORT equiv)
FLOVENT DISKUS INHALER
FLOVENT HFA INHALER
AEROSPAN HFA INHALER
ALVESCO INHALER
PULMICORT FLEXHALER
QVAR INHALER
SYMPATHOMIMETICS
ADVAIR DISKUS INHALER
ADVAIR HFA INHALER
albuterol neb soln
albuterol sulfate ER tab (VOSPIRE ER equiv)
albuterol sulfate syrup
albuterol sulfate tab
BREO ELLIPTA INHALER
COMBIVENT INHALER
COMBIVENT RESPIMAT INHALER
FORADIL AEROLIZER
levalbuterol neb soln (XOPENEX equiv)
metaproterenol syrup
PERFOROMIST NEB SOLN
SEREVENT DISKUS INHALER
STIOLTO INHALER
STRIVERDI RESPIMAT INHALER (QL= 1 inhaler/30 days)
terbutaline sulfate tab (BRETHINE equiv)
VENTOLIN HFA INHALER (QL= 2 inhalers/fill, 2 fills/30 days)
ANORO ELLIPTA INHALER
BEVESPI AEROSPHERE INHALER
SYMBICORT INHALER
UTIBRON NEOHALER CAP
XANTHINES
aminophylline tab
ELIXOPHYLLIN ELIXIR
THEO-24 CAP
theophylline CR tab
theophylline ER tab (UNIPHYL equiv)
theophylline soln
ANTICOAGULANTS
COUMARIN ANTICOAGULANTS
warfarin tab (COUMADIN equiv)
DIRECT FACTOR XA INHIBITORS
XARELTO STARTER PACK
XARELTO TAB
HEPARINS AND HEPARINOID-LIKE AGENTS
Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 50 of 101
Navi-Gate Rx Formulary
Category/Class
Last Updated* 1/1/2017
DrugName
Special Code
Level
-
F
F
F
F
F
-
F
-
NC
NC
-
F
F
F
F
*
QL
QL
-
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
NC
NC
NC
NC
NC
NC
-
F
F
ANTICOAGULANTS Cont.
enoxaparin inj (LOVENOX equiv)
fondaparinux inj (ARIXTRA equiv)
FRAGMIN INJ
HEPARIN
heparin/ d5w inj (HEPARIN/ D5W equiv)
THROMBIN INHIBITORS
PRADAXA CAP
ANTICONVULSANTS
AMPA GLUTAMATE RECEPTOR ANTAGONISTS
FYCOMPA TAB
FYCOMPA SUSP
ANTICONVULSANTS - BENZODIAZEPINES
clonazepam ODT (KLONOPIN equiv)
clonazepam tab (KLONOPIN equiv)
DIASTAT RECTAL GEL
ONFI TAB
ANTICONVULSANTS - MISC.
BANZEL SUSP
BANZEL TAB
carbamazepine cap (CARBATROL equiv)
carbamazepine ER tab (TEGRETOL XR equiv)
carbamazepine tab (TEGRETOL equiv)
gabapentin cap (NEURONTIN equiv)
gabapentin tab (NEURONTIN equiv)
lamotrigine chew (LAMICTAL equiv)
lamotrigine ODT kit (LAMICTAL equiv)
lamotrigine tab (LAMCITAL equiv)
levetiracetam oral soln (KEPPRA equiv)
levetiracetam tab (KEPPRA equiv)
LYRICA CAP
LYRICA SOLN
POTIGA TAB (QL= 3 tabs/day)
primidone tab (MYSOLINE equiv)
topiramate sprinkle cap (TOPAMAX equiv)
topiramate tab (TOPAMAX equiv)
VIMPAT ORAL SOLN
VIMPAT TAB (QL= 2 tabs/day)
zonisamide cap (ZONEGRAN equiv)
BRIVIACT INJ 50MG/5ML
BRIVIACT SOLN 10MG/ML
BRIVIACT TAB
lamotrigine ODT (LAMICTAL equiv)
QUDEXY XR/TOPIRAMATE ER CAP
SPRITAM TAB
CARBAMATES
felbamate susp (FELBATOL equiv)
felbamate tab (FELBATOL equiv)
Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 51 of 101
Navi-Gate Rx Formulary
Category/Class
Last Updated* 1/1/2017
DrugName
Special Code
Level
-
F
LD
LD
-
F
F
F
F
-
F
F
F
-
F
-
F
F
F
F
F
-
F
-
F
F
F
NC
-
F
F
F
F
-
F
F
F
F
F
F
F
F
F
F
F
NC
-
F
ANTICONVULSANTS Cont.
FELBATOL TAB
GABA MODULATORS
GABITRIL TAB 12MG, 16MG
SABRIL POWDER PACK (Only available through Walgreens 888-347-3416)
SABRIL TAB (Only available through Walgreens 888-347-3416)
tiagabine tab (GABITRIL equiv)
HYDANTOINS
DILANTIN INFATABS
phenytoin cap (DILANTIN equiv)
phenytoin chew tab (DILANTIN equiv)
SUCCINIMIDES
ethosuximide cap (ZARONTIN equiv)
VALPROIC ACID
divalproex ER tab (DEPAKOTE ER equiv)
divalproex sodium DR tab (DEPAKOTE equiv)
divalproex sprinkle cap (DEPAKOTE equiv)
valproic acid cap (DEPAKENE equiv)
valproic acid syrup (DEPAKENE equiv)
ANTIDEPRESSANTS
ALPHA-2 RECEPTOR ANTAGONISTS (TETRACYCLICS)
mirtazapine tab (REMERON equiv)
ANTIDEPRESSANTS - MISC.
bupropion ER tab (WELLBUTRIN equiv)
bupropion tab (WELLBUTRIN equiv)
bupropion XL tab (WELLBUTRIN XL equiv)
APLENZIN TAB
MONOAMINE OXIDASE INHIBITORS (MAOIS)
EMSAM PATCH
MARPLAN TAB
phenelzine tab (NARDIL equiv)
tranylcypromine tab (PARNATE equiv)
SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS)
citalopram tab (CELEXA equiv)
escitalopram soln (LEXAPRO equiv)
escitalopram tab (LEXAPRO equiv)
fluoxetine cap (PROZAC equiv)
fluoxetine soln (PROZAC equiv)
fluoxetine tab (PROZAC equiv)
fluvoxamine tab (LUVOX equiv)
paroxetine ER tab (PAXIL CR equiv)
paroxetine tab (PAXIL equiv)
PEXEVA TAB
sertraline tab (ZOLOFT equiv)
FLUOXETINE TAB 60MG
SEROTONIN MODULATORS
trazodone tab (300mg tab is Not Covered)
Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 52 of 101
Navi-Gate Rx Formulary
Category/Class
Last Updated* 1/1/2017
DrugName
Special Code
Level
QL
-
F
NC
QL
QL
QL
-
F
F
F
F
F
F
NC
NC
-
F
F
F
F
F
F
F
F
F
F
F
F
-
F
QL
QL
QL
QL
QL
QL
-
F
F
F
F
F
F
F
F
F
F
F
F
F
NC
NC
NC
NC
NC
NC
ANTIDEPRESSANTS Cont.
TRINTELLIX TAB (QL= 1 tab/day)
VIIBRYD STARTER KIT
SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS)
duloxetine cap (CYMBALTA equiv) (QL= 2 caps/day)
FETZIMA CAP (QL= 1 cap/day)
FETZIMA TITRATION PACK (QL= 1 cap/day)
venlafaxine ER cap (EFFEXOR XR equiv)
venlafaxine ER tab (EFFEXOR XR equiv)
VENLAFAXINE ER TAB 225MG
DESVENLAFAXINE ER TAB
KHEDEZLA ER TAB
TRICYCLIC AGENTS
amitriptyline tab (ELAVIL equiv)
AMOXAPINE TAB
clomipramine cap (ANAFRANIL equiv)
desipramine tab (NORPRAMIN equiv)
doxepin cap
imipramine pamoate tab (TOFRANIL-PM equiv)
imipramine tab (TOFRANIL equiv)
nortriptyline cap (PAMELOR equiv)
NORTRIPYLINE SOLN
protriptyline tab (VIVACTIL equiv)
SURMONTIL CAP
trimipramine cap (SURMONTIL equiv)
ANTIDIABETICS
ALPHA-GLUCOSIDASE INHIBITORS
acarbose tab (PRECOSE equiv)
ANTIDIABETIC COMBINATIONS
AVANDAMET TAB
AVANDRYL TAB
DUETACT TAB
glipizide/metformin tab (METAGLIP equiv)
glyburide/metformin tab (GLUCOVANCE equiv)
GLYXAMBI TAB (QL= 1 tab/day)
JANUMET TAB
JENTADUETO TAB (QL= 2 tabs/day)
JENTADUETO XR TAB (QL= 2 tabs/day)
pioglitazone/glimepiride tab (DUETACT equiv)
SYNJARDY TAB (QL= 2 tabs/day)
XIGDUO XR TAB (QL= 1 tab/day)
XIGDUO XR TAB 5-1000MG (QL= 2 tabs/day)
INVOKAMET TAB ( )
INVOKAMET XR TAB
KAZANO/ALOGLIPTIN-METFORMIN TAB
KOMBIGLYZE XR TAB
OSENI/ALOGLIPTIN-PIOGLITAZONE TAB
SOLIQUA INJ
Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 53 of 101
Navi-Gate Rx Formulary
Category/Class
Last Updated* 1/1/2017
DrugName
Special Code
Level
-
F
F
NC
NC
LD
F
F
F
QL-¢
QL
-
F
F
NC
NC
-
F
QL
QL
QL
-
F
F
F
F
NC
NC
NC
OTC
OTC
*-OTC
-
F
F
F
F
F
F
F
F
F
F
F
F
F
NC
NC
NC
NC
NC
NC
NC
NC
NC
ANTIDIABETICS Cont.
BIGUANIDES
metformin ER tab (GLUCOPHAGE XL equiv)
metformin tab (GLUCOPHAGE equiv)
metformin ER osmotic tab (FORTAMET equiv)
metformin ER osmotic tab (GLUMETZA equiv)
DIABETIC OTHER
GLUCAGEN HYPOKIT INJ
GLUCAGON INJ KIT
KORLYM TAB (Only available through CuraScript 1-877-634-8553)
DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS
JANUVIA TAB (QL= 1 tab/day)
TRADJENTA TAB (QL= 1 tab/day)
NESINA/ALOGLIPTIN TAB
ONGLYZA TAB
DOPAMINE RECEPTOR AGONISTS - ANTIDIABETIC
CYCLOSET TAB
INCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS)
BYDUREON INJ (QL= 4 inj/28 days)
BYDUREON PEN INJ (QL= 4 inj/28 days)
TRULICITY INJ
VICTOZA INJ (QL= 9 ml/30 days)
ADLYXIN INJ
BYETTA INJ
TANZEUM INJ
INSULIN
LANTUS INJ
LANTUS SOLOSTAR INJ
LEVEMIR FLEXPEN/FLEXTOUCH INJ
LEVEMIR INJ
NOVOLIN 70/30 INJ
NOVOLIN N INJ
NOVOLIN R INJ
NOVOLOG FLEXPEN INJ
NOVOLOG INJ
NOVOLOG MIX 70/30 INJ
NOVOLOG MIX FLEXPEN INJ
NOVOLOG PENFILL INJ
TOUJEO SOLOSTAR INJ
AFREZZA INH POWDER
BASAGLAR INJ
HUMALOG INJ
HUMALOG KWIKPEN INJ
HUMALOG MIX INJ
HUMALOG MIX KWIKPEN INJ
HUMALOG PEN INJ
HUMULIN 70/30 INJ
HUMULIN N INJ
Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 54 of 101
Navi-Gate Rx Formulary
Category/Class
Last Updated* 1/1/2017
DrugName
Special Code
Level
OTC
OTC
-
NC
NC
NC
-
F
F
-
F
QL
QL
-
F
F
NC
-
F
F
F
F
F
F
F
F
F
-
NC
-
F
NC
-
NC
LD
LD
-
F
F
F
F
-
NC
NC
-
NC
-
F
ANTIDIABETICS Cont.
HUMULIN N PEN INJ
HUMULIN R INJ
TRESIBA INJ
INSULIN SENSITIZING AGENTS
AVANDIA TAB
pioglitazone tab (ACTOS equiv)
MEGLITINIDE ANALOGUES
nateglinide tab (STARLIX equiv)
SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS
FARXIGA TAB (QL= 1 tab/day)
JARDIANCE TAB (QL= 1 tab/day)
INVOKANA TAB
SULFONYLUREAS
CHLORPROPAMIDE TAB
chlorpropamide tab (DIABINESE equiv)
glimepiride tab (AMARYL equiv)
glipizide ER tab (GLUCOTROL XL equiv)
glipizide tab (GLUCOTROL equiv)
glyburide micronized tab (GLYNASE equiv)
glyburide tab (MICRONASE equiv)
tolazamide tab
TOLBUTAMIDE TAB
ANTIDIARRHEALS
ANTIDIARRHEAL - CHLORIDE CHANNEL ANTAGONISTS
FULYZAQ TAB
ANTIPERISTALTIC AGENTS
diphenoxylate/atropine tab (LOMOTIL equiv)
PAREGORIC TINCTURE
ANTIDOTES
ANTIDOTES
VISTOGARD PAK
ANTIDOTES - CHELATING AGENTS
EXJADE TAB
FERRIPROX SOLN (Only available through Ferriprox Total Care 866-758-7071)
FERRIPROX TAB (Only available through Ferriprox Total Care 866-758-7071)
JADENU TAB
OPIOID ANTAGONISTS
EVZIO INJ
NARCAN NASAL SPRAY
ANTIDOTES AND SPECIFIC ANTAGONISTS
ANTIDOTES AND SPECIFIC ANTAGONISTS
CETYLEV TAB
ANTIEMETICS
5-HT3 RECEPTOR ANTAGONISTS
ANZEMET TAB
Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 55 of 101
Navi-Gate Rx Formulary
Category/Class
Last Updated* 1/1/2017
DrugName
Special Code
Level
-
F
F
F
F
OTC
OTC
-
F
F
F
QL
-
F
F
F
-
F
F
NC
NC
-
F
F
F
F
F
F
F
-
F
F
F
F
F
F
F
F
NC
NC
-
F
F
NC
OTC
OTC
OTC
OTC
F
F
F
F
ANTIEMETICS Cont.
graniesetron tab (KYTRIL equiv)
ondansetron ODT (ZOFRAN equiv)
ondansetron oral soln (ZOFRAN equiv)
ondansetron tab (ZOFRAN equiv)
ANTIEMETICS - ANTICHOLINERGIC
meclizine chew tab (BONINE equiv)
meclizine tab (DRAMAMINE equiv)
trimethobenzamide cap (TIGAN equiv)
ANTIEMETICS - MISCELLANEOUS
AKYNZEO CAP (QL= 1 cap/fill)
CESAMET CAP
dronabinol cap (MARINOL equiv)
SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS
EMEND CAP
EMEND SOLN
EMEND SUSP
VARUBI TAB
ANTIFUNGALS
ANTIFUNGALS
griseofulvin micro tab (GRIFULVIN-V equiv)
griseofulvin susp (GRIFULVIN equiv)
griseofulvin tab (GRIS-PEG equiv)
GRIS-PEG TAB
nystatin powder (BIO-STATIN equiv)
nystatin tab
terbinafine tab (LAMISIL equiv)
IMIDAZOLE-RELATED ANTIFUNGALS
fluconazole susp (DIFLUCAN equiv)
fluconazole tab (DIFLUCAN equiv)
itraconazole cap (SPORANOX equiv)
ketoconazole tab (NIZORAL equiv)
NOXAFIL SUSP
SPORANOX SOLN
voriconazole susp (VFEND equiv)
voriconazole tab (VFEND equiv)
CRESEMBA CAP
NOXAFIL TAB
ANTIHISTAMINES
ANTIHISTAMINES - ETHANOLAMINES
carbinoxamine soln (PALGIC equiv)
diphenhydramine cap (Only 50mg covered)
KARBINAL ER SUSP
ANTIHISTAMINES - NON-SEDATING
cetirizine chew tab (ZYRTEC equiv)
cetirizine syrup (ZYRTEC equiv)
cetirizine tab (ZYRTEC equiv)
fexofenadine tab (ALLEGRA equiv)
Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 56 of 101
Navi-Gate Rx Formulary
Category/Class
Last Updated* 1/1/2017
DrugName
Special Code
Level
OTC
OTC
OTC
-
F
F
F
NC
NC
NC
-
F
F
F
-
F
QL
-
F
NC
-
F
NC
-
F
F
F
F
F
F
F
F
-
F
F
F
F
F
NC
¢
-
F
F
F
F
F
F
NC
NC
NC
NC
ANTIHISTAMINES Cont.
loratadine ODT (CLARITIN equiv)
loratadine syrup (CLARITIN equiv)
loratadine tab (CLARITIN equiv)
DESLORATADINE ODT
levocetirizine soln (XYZAL equiv)
levocetrizine tab (XYZAL equiv)
ANTIHISTAMINES - PHENOTHIAZINES
promethazine supp (PHENERGAN equiv)
promethazine syrup (PHENERGAN equiv)
promethazine tab (PHENERGAN equiv)
ANTIHISTAMINES - PIPERIDINES
cyproheptadine tab
ANTIHYPERLIPIDEMICS
ANTIHYPERLIPIDEMICS - COMBINATIONS
VYTORIN TAB (QL= 1 tab/day; 10/80mg tab is Not Covered)
LIPTRUZET TAB
ANTIHYPERLIPIDEMICS - MISC.
omega-3-acid ethyl esters cap (LOVAZA equiv)
KYNAMRO INJ
BILE ACID SEQUESTRANTS
cholestyramine light powder (QUESTRAN LIGHT equiv)
cholestyramine light powder pack (QUESTRAN LIGHT equiv)
cholestyramine powder (QUESTRAN equiv)
colestipol granule (COLESTID equiv)
colestipol powder packet (COLESTID equiv)
colestipol tab (COLESTID equiv)
WELCHOL PAK
WELCHOL TAB
FIBRIC ACID DERIVATIVES
ANTARA CAP
fenofibrate cap (ANTARA equiv)
fenofibrate tab (TRICOR equiv)
gemfibrozil tab (LOPID equiv)
TRILIPIX CAP
LOFIBRA/TRIGLIDE TAB
HMG COA REDUCTASE INHIBITORS
atorvastatin tab (LIPITOR equiv)
CRESTOR TAB
lovastatin tab (MEVACOR equiv)
pravastatin tab (PRAVACHOL equiv)
rosuvastatin tab (CRESTOR equiv)
simvastatin tab (ZOCOR equiv) (80mg tab is Not Covered)
ADVICOR TAB
fluvastatin cap (LESCOL equiv)
fluvastatin ER tab (LESCOL XL equiv)
SIMCOR TAB
INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS
Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 57 of 101
Navi-Gate Rx Formulary
Category/Class
Last Updated* 1/1/2017
DrugName
Special Code
Level
QL
-
F
NC
-
NC
-
F
NC
-
NC
NC
NC
-
F
F
F
F
F
F
F
F
F
NC
NC
NC
-
F
¢
*
-
F
F
F
F
F
NC
-
F
F
F
F
F
F
F
F
F
F
-
F
ANTIHYPERLIPIDEMICS Cont.
ZETIA TAB (QL= 1 tab/day)
ezetimibe tab (ZETIA equiv)
MICROSOMAL TRIGLYCERIDE TRANSFER PROTEIN (MTP) INHIBITORS
JUXTAPID CAP
NICOTINIC ACID DERIVATIVES
NIASPAN ER TAB
niacin ER tab (NIASPAN equiv)
PROPROTEIN CONVERTASE SUBTILISIN/KEXIN TYPE 9 INHIBITORS
PRALUENT INJ
REPATHA INJ
REPATHA PUSHTRONEX INJ
ANTIHYPERTENSIVES
ACE INHIBITORS
benazepril tab (LOTENSIN equiv)
captopril tab
enalapril tab (VASOTEC equiv)
lisinopril tab (PRINIVIL equiv)
moexipril tab (UNIVASC equiv)
perindopril tab (ACEON equiv)
quinapril tab (ACCUPRIL equiv)
ramipril cap (ALTACE equiv)
trandolapril tab (MAVIK equiv)
EPANED PREMIXED SOLN
EPANED SOLN
QBRELIS SOLN
AGENTS FOR PHEOCHROMOCYTOMA
phenoxybenzamine cap (DIBENZYLINE equiv)
ANGIOTENSIN II RECEPTOR ANTAGONISTS
EDARBI TAB
irbesartan tab (AVAPRO equiv)
losartan tab (COZAAR equiv)
telmisartan tab (MICARDIS equiv)
valsartan tab (DIOVAN equiv)
candesartan tab (ATACAND equiv)
ANTIADRENERGIC ANTIHYPERTENSIVES
clonidine patch (CATAPRES equiv)
clonidine tab (CATAPRES equiv)
doxazosin tab (CARDURA equiv)
GUANABENZ TAB
guanfacine IR tab (TENEX equiv)
methyldopa tab
NEXICLON XR SUSP
NEXICLON XR TAB
prazosin cap (MINIPRES equiv)
terazosin cap (HYTRIN equiv)
ANTIHYPERTENSIVE COMBINATIONS
amlodipine/benazepril cap (LOTREL equiv)
Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 58 of 101
Navi-Gate Rx Formulary
Category/Class
Last Updated* 1/1/2017
DrugName
Special Code
Level
-
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
NC
NC
NC
NC
NC
-
F
-
F
F
LD
QL
-
F
F
F
F
F
F
NC
NC
ANTIHYPERTENSIVES Cont.
amlodipine/olmesartan tab (AZOR TAB equiv)
amlodipine/valsartan tab (EXFORGE equiv)
amlodipine/valsartan/hydrochlorothiazide tab (EXFORGE HCT equiv)
atenolol/chlorthalidone tab (TENORETIC equiv)
AZOR TAB
benazepril/hydrochlorothiazide tab (LOTENSIN HCT equiv)
bisoprolol/hydrochlorothiazide tab (ZIAC equiv)
candesartan/hydrochlorothiazide tab (ATACAND HCT equiv)
captopril/hydrochlorothiazide tab (CAPOZIDE equiv)
DIOVAN HCT TAB
EDARBYCLOR TAB
enalapril/hydrochlorothiazide tab (VASERETIC equiv)
fosinopril/hydrochlorothiazide tab (MONOPRIL HCT equiv)
irbesartan/hydrochlorothiazide tab (AVALIDE equiv)
lisinopril/hydrochlorothiazide tab (PRINZIDE equiv)
losartan/hydrochlorothiazide tab (HYZAAR equiv)
methyldopa/hydrochlorothiazide tab
metoprolol/hydrochlorothiazide tab (LOPRESSOR/HCT equiv)
moexipril/hydrochlorothiazide tab (UNIRETIC equiv)
olmesartan/amlodipine/hydrochlorothiazide tab (TRIBENZOR TAB equiv)
propranolol/hydrochlorothiazide tab
quinapril/hydrochlorothiazide tab (ACCURETIC equiv)
TEKTURNA HCT TAB
trandolapril/verapamil ER tab (TARKA equiv)
TRIBENZOR TAB
valsartan/hydrochlorothiazide tab (DIOVAN HCT equiv)
VALTURNA TAB
BYVALSON TAB
DUTOPROL TAB
PRESTALIA TAB
telmisartan/amlodipine tab (TWYNSTA equiv)
telmisartan/hydrochlorothiazide tab (MICARDIS HCT equiv)
SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS)
eplerenone tab (INSPRA equiv)
VASODILATORS
hydralazine tab
minoxidil tab
ANTI-INFECTIVE AGENTS - MISC.
ANTI-INFECTIVE AGENTS - MISC.
CAYSTON INH SOLN (Only available through Walgreens 888-347-3416)
metronidazole cap (FLAGYL equiv)
metronidazole tab (FLAGYL equiv)
trimethoprim tab
vancomycin cap (VANCOCIN CAP equiv) (QL= 56 caps/fill)
VANCOMYCIN ORAL SOLN KIT
FIRST METRONIDAZOLE SUSP
IMPAVIDO CAP
Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 59 of 101
Navi-Gate Rx Formulary
Category/Class
Last Updated* 1/1/2017
DrugName
Special Code
Level
-
F
F
F
-
F
F
-
F
-
F
F
QL
F
F
F
-
F
F
LD
-
F
F
F
F
F
-
F
F
-
F
F
F
F
F
F
NC
NC
-
F
F
F
F
ANTI-INFECTIVE AGENTS - MISC. Cont.
ANTI-INFECTIVE MISC. - COMBINATIONS
erythromycin/sulfisoxazole susp (PEDIAZOLE equiv)
smz/tmp (DS) tab (BACTRIM equiv)
smz/tmp susp (BACTRIM/SEPTRA equiv)
ANTIPROTOZOAL AGENTS
ALINIA SUSP
atovaquone susp (MEPRON equiv)
LEPROSTATICS
dapsone tab
LINCOSAMIDES
clindamycin cap (CLEOCIN equiv)
clindamycin soln (CLEOCIN equiv)
OXAZOLIDINONES
linezolid susp (ZYVOX equiv)
linezolid tab (ZYVOX equiv)
SIVEXTRO TAB (QL= 6 tabs/fill)
ANTIMALARIALS
ANTIMALARIAL COMBINATIONS
atovaquone/proguanil tab (MALARONE equiv)
MALARONE TAB
ANTIMALARIALS
chloroquine tab (ARALEN equiv)
DARAPRIM TAB (Only available through Walgreens 888-347-3416)
hydroxychloroquine tab (PLAQUENIL equiv)
mefloquine tab (LARIAM equiv)
PRIMAQUINE TAB
ANTIMYASTHENIC/CHOLINERGIC AGENTS
ANTIMYASTHENIC/CHOLINERGIC AGENTS
pyridostigmine bromide tab (MESTINON equiv)
pyridostigmine CR tab (MESTINON equiv)
ANTIMYCOBACTERIAL AGENTS
ANTIMYCOBACTERIAL AGENTS
ethambutol tab (MYAMBUTOL equiv)
isoniazid tab
PRIFTIN TAB
pyrazinamide tab
rifabutin cap (MYCOBUTIN equiv)
rifampin cap (RIFADIN equiv)
CYCLOSERINE CAP
SIRTURO TAB
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES
ALKYLATING AGENTS
ALKERAN TAB
CYCLOPHOSPHAMIDE CAP
cyclophosphamide tab
GLEOSTINE/LOMUSTINE CAP
Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 60 of 101
Navi-Gate Rx Formulary
Category/Class
Last Updated* 1/1/2017
DrugName
Special Code
Level
-
F
F
F
F
-
F
F
F
F
NC
-
NC
NC
-
F
NC
QL
-
F
F
F
F
F
F
F
F
F
F
F
F
F
F
NC
-
NC
-
NC
F
QL
LD
LD
LD-QL
LD
LD-QL
QL
LD
F
F
F
F
F
F
F
F
F
F
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Cont.
HEXALEN CAP
LEUKERAN TAB
MYLERAN TAB
temozolomide cap (TEMODAR equiv)
ANTIMETABOLITES
capecitabine tab (XELODA equiv)
mercaptopurine tab (PURINETHOL equiv)
methotrexate inj
methotrexate tab
PURIXAN SUSP
ANTINEOPLASTIC - BCL-2 INHIBITORS
VENCLEXTA STARTER PACK
VENCLEXTA TAB
ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITORS
ERIVEDGE CAP
ODOMZO CAP
ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS
anastrozole tab (ARIMIDEX equiv)
bicalutamide tab (CASODEX equiv)
EMCYT CAP
exemestane tab (AROMASIN equiv)
FARESTON TAB
flutamide cap
letrozole tab (FEMARA equiv)
LYSODREN TAB
megestrol susp (MEGACE equiv)
megestrol tab (MEGACE equiv)
nilutamide tab (NILANDRON equiv)
tamoxifen tab (NOLVADEX equiv)
XTANDI CAP (QL= 4 caps/day)
ZYTIGA TAB
HYDROXYPROGESTERONE CAPROATE INJ
ANTINEOPLASTIC - IMMUNOMODULATORS
POMALYST CAP 1MG
ANTINEOPLASTIC COMBINATIONS
LONSURF TAB
ANTINEOPLASTIC ENZYME INHIBITORS
BOSULIF TAB
CABOMETYX TAB (QL= 1 tab/day)
CAPRELSA TAB (Only available through Biologics 800-850-4306)
COMETRIQ KIT
GILOTRIF TAB (QL= 1 tab/day, Only available through Accredo 888-773-7376)
ICLUSIG TAB (Only available through Biologics 800-850-4306)
imatinib tab (GLEEVEC equiv)
IMBRUVICA CAP (QL= 4 caps/day; Only available through Diplomat Pharmacy 877-977-9118)
INLYTA TAB (QL= 8 tabs/day)
IRESSA TAB (Only available through Diplomat Pharmacy 877-977-9118)
Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 61 of 101
Navi-Gate Rx Formulary
Category/Class
Last Updated* 1/1/2017
DrugName
Special Code
Level
QL
QL
QL
LD
-
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
NC
NC
NC
NC
NC
NC
NC
NC
LD
-
F
F
F
F
F
F
F
F
NC
NC
-
F
F
-
F
-
F
-
F
-
F
F
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Cont.
JAKAFI TAB (QL= 2 tabs/day)
MEKINIST TAB
NEXAVAR TAB
SPRYCEL TAB
STIVARGA TAB (QL= 4 tabs/day)
SUTENT CAP
TAFINLAR CAP (QL= 4 caps/day)
TARCEVA TAB
TASIGNA CAP
TYKERB TAB
VOTRIENT TAB
XALKORI CAP
ZELBORAF TAB
ZOLINZA CAP
ZYDELIG TAB (Only available through Diplomat Pharmacy 877-977-9118)
AFINITOR TAB
ALECENSA CAP
COTELLIC TAB
GLEEVEC TAB
NINLARO CAP
RUBRACA TAB
TAGRISSO TAB
ZYKADIA CAP
ANTINEOPLASTICS MISC.
ACTIMMUNE INJ (Only available through Walgreens 888-347-3416)
ALFERON-N INJ
bexarotene cap (TARGRETIN equiv)
hydroxyurea cap (HYDREA equiv)
INTRON-A INJ
MATULANE CAP
PROLEUKIN INJ
tretinoin cap (VESANOID equiv)
SYLATRON INJ
SYNRIBO INJ
CHEMOTHERAPY RESCUE/ANTIDOTE AGENTS
LEUCOVORIN TAB
MESNEX TAB
MITOTIC INHIBITORS
etoposide cap (VEPESID equiv)
TOPOISOMERASE I INHIBITORS
HYCAMTIN CAP
ANTIPARKINSON AGENTS
ANTIPARKINSON ADJUVANTS
carbidopa tab (LODOSYN equiv)
ANTIPARKINSON ANTICHOLINERGICS
benztropine tab
trihexyphenidyl tab (ARTANE equiv)
Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 62 of 101
Navi-Gate Rx Formulary
Category/Class
Last Updated* 1/1/2017
DrugName
Special Code
Level
-
F
NC
-
F
F
F
F
F
F
F
F
F
F
F
F
NC
NC
¢
-
F
F
F
-
F
F
F
-
F
NC
NC
NC
NC
-
F
F
F
F
NC
NC
-
F
-
F
F
F
F
ANTIPARKINSON AGENTS Cont.
ANTIPARKINSON COMT INHIBITORS
entacapone tab (COMTAN equiv)
tolcapone tab (TASMAR equiv)
ANTIPARKINSON DOPAMINERGICS
amantadine caps (SYMMETREL equiv)
bromocriptine cap (PARLODEL equiv)
bromocriptine tab (PARLODEL equiv)
carbidopa/levodopa ER tab (SINEMET CR equiv)
carbidopa/levodopa ODT (PARCOPA equiv)
carbidopa/levodopa tab (SINEMET equiv)
CARBIDOPA/LEVODOPA/ENTACAPONE TAB (STALEVO equiv)
NEUPRO PATCH
pramipexole ER tab (MIRAPEX equiv)
pramipexole tab (MIRAPEX equiv)
ropinirole ER tab (REQUIP XL equiv)
RYTARY CAP
amantadine tab
DUOPA ENTERAL SUSP
ANTIPARKINSON MONOAMINE OXIDASE INHIBITORS
AZILECT TAB
selegiline cap (ELDEPRYL equiv)
ZELAPAR ODT
ANTIPSYCHOTICS/ANTIMANIC AGENTS
ANTIMANIC AGENTS
lithium carbonate cap (LITHOBID equiv)
lithium carbonate ER tab (ESKALITH CR equiv)
lithium citrate soln
ANTIPSYCHOTICS - MISC.
ziprasidone cap (GEODON equiv)
LATUDA TAB
NUPLAZID TAB
VRAYLAR CAP
VRAYLAR PACK
BENZISOXAZOLES
paliperidone ER tab (INVEGA equiv)
risperidone ODT (RISPERDAL equiv)
risperidone soln (RISPERDAL equiv)
risperidone tab (RISPERDAL equiv)
FANAPT TAB
INVEGA SUSTENNA/TRINZ INJ
BUTYROPHENONES
haloperidol tab (HALDOL equiv)
DIBENZAPINES
clozapine ODT 25mg, 100mg (CLOZAPINE/FAZACLO equiv)
CLOZAPINE ODT/FAZACLO ODT
clozapine tab (CLOZARIL equiv)
loxapine cap (LOXITANE equiv)
Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 63 of 101
Navi-Gate Rx Formulary
Category/Class
Last Updated* 1/1/2017
DrugName
Special Code
Level
-
F
F
F
F
NC
NC
NC
-
F
F
F
F
F
F
F
QL
QL
QL-¢
-
F
F
F
NC
-
F
-
F
-
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
ANTIPSYCHOTICS/ANTIMANIC AGENTS Cont.
olanzapine ODT (ZYPREXA ZYDIS equiv)
olanzapine tab (ZYPREXA equiv)
quetiapine tab (SEROQUEL equiv)
SEROQUEL XR TAB
ADASUVE INHALER
quetiapine XR tab (SEROQUEL XR equiv)
VERSACLOZ SUSP
PHENOTHIAZINES
chlorpromazine tab (THORAZINE equiv)
fluphenazine tab (PROLIXIN equiv)
perphenazine tab (TRILAFON equiv)
prochlorperazine supp (COMPAZINE equiv)
prochlorperazine tab (COMPAZINE equiv)
thioridazine tab (MELLARIL equiv)
trifluoperazine tab (STELAZINE equiv)
QUINOLINONE DERIVATIVES
ABILIFY DISCMELT (QL= 2 tabs/day)
aripiprazole ODT (ABILIFY equiv) (QL= 2 tabs/day)
aripiprazole tab (ABILIFY equiv) (QL= 2 tabs/day)
REXULTI TAB
THIOXANTHENES
thiothixene cap (NAVANE equiv)
ANTISEPTICS & DISINFECTANTS
CHLORINE ANTISEPTICS
PHISOHEX LIQUID
ANTIVIRALS
ANTIRETROVIRALS
abacavir tab (ZIAGEN equiv)
abacavir/ lamivudine/ zidovudine tab (TRIZIVIR equiv)
abacavir/lamivudine tab (EPZICOM equiv)
APTIVUS CAP
APTIVUS SOLN
ATRIPLA TAB
COMPLERA TAB
CRIXIVAN CAP
DESCOVY TAB
EDURANT TAB
EMTRIVA CAP
EVOTAZ TAB
FUZEON INJ
GENVOYA TAB
INTELENCE TAB
INVIRASE CAP
INVIRASE TAB
ISENTRESS CHEW TAB
ISENTRESS POWDER PACK
ISENTRESS TAB
Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 64 of 101
Navi-Gate Rx Formulary
Category/Class
Last Updated* 1/1/2017
DrugName
Special Code
Level
*
QL
*
-
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
NC
-
F
F
F
QL-¢
QL
-
F
F
F
F
F
F
F
F
ANTIVIRALS Cont.
KALETRA CAP
KALETRA TAB
lamivudine soln (EPIVIR SOLN equiv)
lamivudine tab (EPIVIR equiv)
lamivudine/zidovudine tab (COMBIVIR equiv)
LEXIVA SUSP
LEXIVA TAB
nevirapine ER tab (VIRAMUNE XR equiv)
NEVIRAPINE SUSP (VIRAMUNE equiv)
nevirapine tab (VIRAMUNE equiv)
NORVIR CAP
NORVIR SOLN
NORVIR TAB
ODEFSEY TAB
PREZCOBIX TAB
PREZISTA SUSP
PREZISTA TAB
RESCRIPTOR TAB
REYATAZ CAP
REYATAZ POWDER
SELZENTRY TAB
stavudine cap (ZERIT equiv)
STRIBILD TAB
SUSTIVA CAP
SUSTIVA TAB
TIVICAY TAB (QL= 2 tabs/day)
TRIUMEQ TAB (QL= 1 tab/day)
TRUVADA TAB
VIDEX SOLN
VIRACEPT TAB
VIREAD TAB
VITEKTA TAB
zidovudine cap (RETROVIR equiv)
zidovudine tab (RETROVIR equiv)
TYBOST TAB
CMV AGENTS
GANCICLOVIR CAP
valganciclovir soln (VALCYTE equiv)
valganciclovir tab (VALCYTE equiv)
HEPATITIS AGENTS
adefovir dipivoxil tab (HEPSERA equiv)
entecavir tab (BARACLUDE equiv) (QL= 1 tab/day)
EPIVIR HBV SOLN
HARVONI TAB (QL= 1 tab/day)
INFERGEN INJ
lamivudine tab 100mg (EPIVIR HBV equiv)
PEGASYS INJ
PEGASYS INJ KIT
Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 65 of 101
Navi-Gate Rx Formulary
Category/Class
Last Updated* 1/1/2017
DrugName
Special Code
Level
QL
-
F
F
F
F
NC
NC
NC
NC
NC
NC
NC
NC
NC
-
F
F
F
F
NC
QL
QL
QL
QL
QL
QL
F
F
F
F
F
F
F
-
F
NC
QL
-
F
F
-
F
F
F
F
F
F
F
F
F
F
F
F
ANTIVIRALS Cont.
PEG-INTRON INJ
ribavirin cap (REBETOL equiv)
ribavirin tab (COPEGUS equiv)
SOVALDI TAB (QL= 1 tab/day)
DAKLINZA TAB
EPCLUSA TAB
INCIVEK TAB
OLYSIO CAP
TECHNIVIE TAB
VEMLIDY TAB
VICTRELIS CAP
VIEKIRA XR TAB
ZEPATIER TAB
HERPES AGENTS
acyclovir cap (ZOVIRAX equiv)
acyclovir susp (ZOVIRAX equiv)
acyclovir tab (ZOVIRAX equiv)
valacyclovir tab (VALTREX equiv)
SITAVIG TAB
INFLUENZA AGENTS
oseltamivir cap (TAMIFLU equiv) (QL= 10 caps/fill)
oseltamivir cap 30mg (TAMIFLU CAP equiv) (QL= 20 caps/fill)
RELENZA DISKHALER (QL= 1 inhaler/fill)
rimantadine tab (FLUMADINE equiv)
TAMIFLU CAP (QL= 10 caps/fill)
TAMIFLU CAP 30MG (QL= 20 caps/fill)
TAMIFLU SUSP 6mg/ml (QL= 250 ml/fill)
ASSORTED CLASSES
CHELATING AGENTS
DEPEN TITRATAB
CUPRIMINE CAP
IMMUNOMODULATORS
REVLIMID CAP (QL= 1 tab/day)
THALOMID CAP
IMMUNOSUPPRESSIVE AGENTS
azathioprine tab (IMURAN equiv)
cyclosporine cap (SANDIMMUNE equiv)
cyclosporine modified cap (NEORAL equiv)
cyclosporine modified soln (NEORAL equiv)
mycophenolate DR tab (MYFORTIC equiv)
mycophenolate mofetil cap (CELLCEPT equiv)
mycophenolate mofetil susp (CELLCEPT equiv)
mycophenolate mofetil tab (CELLCEPT equiv)
RAPAMUNE SOLN
SANDIMMUNE SOLN 100MG/ML
sirolimus tab (RAPAMUNE equiv)
tacrolimus cap (PROGRAF equiv)
Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 66 of 101
Navi-Gate Rx Formulary
Category/Class
Last Updated* 1/1/2017
DrugName
Special Code
Level
-
NC
-
F
NC
-
F
F
¢
-
F
F
F
F
F
F
F
NC
-
F
F
F
F
F
F
F
F
F
NC
NC
-
NC
NC
NC
-
F
F
F
F
F
F
F
F
F
F
F
ASSORTED CLASSES Cont.
ENVARSUS XR TAB
POTASSIUM REMOVING RESINS
sodium polystyrene powder (KAYEXALATE equiv)
VELTASSA POWDER
BETA BLOCKERS
ALPHA-BETA BLOCKERS
carvedilol tab (COREG equiv)
labetaolol tab (TRANDATE equiv)
BETA BLOCKERS CARDIO-SELECTIVE
acebutolol cap (SECTRAL equiv)
atenolol tab (TENORMIN equiv)
betaxolol tab (KERLONE equiv)
bisoprolol tab (ZEBETA equiv)
BYSTOLIC TAB
metoprolol ER tab (TOPROL XL equiv)
metoprolol tab (LOPRESSOR equiv)
METOPROLOL TARTRATE TAB 37.5MG, 75MG
BETA BLOCKERS NON-SELECTIVE
INNOPRAN XL CAP
nadolol tab (CORGARD equiv)
pindolol tab
propranolol ER cap (INDERAL LA equiv)
PROPRANOLOL SOLN
propranolol tab (INDERAL equiv)
sotalol AF tab (BETAPACE AF equiv)
sotalol tab (BETAPACE equiv)
timolol tab
HEMANGEOL SOLN
SOTYLIZE SOLN
BIOLOGICALS MISC
ALLERGENIC EXTRACTS
GRASTEK SL TAB
ORALAIR SL TAB
RAGWITEK SL TAB
CALCIUM CHANNEL BLOCKERS
CALCIUM CHANNEL BLOCKERS
amlodipine tab (NORVASC equiv)
COVERA-HS TAB
diltiazem CD cap (CARDIZEM CD equiv)
diltiazem ER cap
diltiazem ER tab (CARDIZEM LA equiv)
diltiazem tab (CARDIZEM equiv)
isradipine cap (DYNACIRC equiv)
nicardipine cap
nifedipine cap (PROCARDIA equiv)
nifedipine ER tab (ADALAT equiv)
verapamil ER cap (VERELAN equiv)
Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 67 of 101
Navi-Gate Rx Formulary
Category/Class
Last Updated* 1/1/2017
DrugName
Special Code
Level
-
F
F
-
F
F
NC
-
F
NC
*
-
F
NC
NC
NC
NC
NC
NC
NC
LD
LD
-
F
F
NC
QL
LD-QL
QL
F
F
F
-
F
F
NC
-
NC
NC
LD-QL
F
-
F
F
F
F
F
-
F
CALCIUM CHANNEL BLOCKERS Cont.
verapamil ER tab (CALAN SR equiv)
verapamil tab (CALAN equiv)
CARDIOTONICS
CARDIAC GLYCOSIDES
digoxin soln (LANOXIN equiv)
digoxin tab (LANOXIN equiv)
LANOXIN TAB 0.0625MG, 0.1875MG
CARDIOVASCULAR AGENTS - MISC.
CARDIOVASCULAR AGENTS MISC. - COMBINATIONS
amlodipine/atorvastatin tab (CADUET equiv)
ENTRESTO TAB
IMPOTENCE AGENTS
VIAGRA TAB
CIALIS TAB
LEVITRA TAB
PAPAVERINE/ALPROSTADIL INJ
PAPAVERINE/PHENTOLAMINE INJ
PAPAVERINE/PHENTOLAMINE/ALPROSTADIL INJ
PHENTOLAMINE/ALPROSTADIL INJ
STENDRA TAB
PROSTAGLANDIN VASODILATORS
TYVASO INH SOLN (Only available through Accredo 888-773-7376)
VENTAVIS INH SOLN (Only available through Accredo 888-773-7376)
ORENITRAM TAB
PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS
LETAIRIS TAB (QL= 1 tab/day)
OPSUMIT TAB (QL= 1 tab/day, Only available through Walgreens 888-347-3416)
TRACLEER TAB (QL= 2 tabs/day)
PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS
ADCIRCA TAB
sildenafil tab (REVATIO equiv)
REVATIO SUSP
PULMONARY HYPERTENSION - PROSTACYCLIN RECEPTOR AGONIST
UPTRAVI TAB
UPTRAVI THERAPY PACK
PULMONARY HYPERTENSION - SOL GUANYLATE CYCLASE STIMULATOR
ADEMPAS TAB (QL= 3 tabs/day; Only available through Accredo 888-773-7376)
CEPHALOSPORINS
CEPHALOSPORINS - 1ST GENERATION
cefadroxil cap (DURICEF equiv)
cefadroxil susp
cefadroxil tab (DURICEF equiv)
cephalexin susp (KEFLEX equiv)
CEPHALEXIN TAB (KEFLEX equiv)
CEPHALOSPORINS - 2ND GENERATION
cefprozil susp
Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 68 of 101
Navi-Gate Rx Formulary
Category/Class
Last Updated* 1/1/2017
DrugName
Special Code
Level
-
F
F
F
-
F
F
F
F
F
F
F
F
F
NC
NC
-
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
NC
NC
NC
NC
NC
NC
NC
NC
NC
-
F
-
F
CEPHALOSPORINS Cont.
cefprozil tab (CEFZIL equiv)
cefuroxime susp (CEFTIN equiv)
cefuroxime tab (CEFTIN equiv)
CEPHALOSPORINS - 3RD GENERATION
cefdinir cap (OMNICEF equiv)
cefdinir susp (OMNICEF equiv)
CEFDITOREN TAB
cefpodoxime susp (VANTIN equiv)
cefpodoxime tab (VANTIN equiv)
SPECTRACEF TAB
SUPRAX CAP
SUPRAX CHEW TAB
SUPRAX TAB
CEDAX CAP
CEDAX SUSP
CONTRACEPTIVES
COMBINATION CONTRACEPTIVES - ORAL
apri tab (DESOGEN equiv)
aranelle tab (TRI-NORINYL equiv)
aviane tab (ALESSE equiv)
cesia tab (CYCLESSA equiv)
cryselle tab (LO/OVRAL equiv)
enpresse tab (TRI-LEVLEN equiv)
junel FE tab (LO-ESTRIN equiv)
junel tab (MICROGESTIN equiv)
kariva tab (MIRCETTE equiv)
kelnor tab (DEMULEN equiv)
necon tab (NORINYL equiv)
nortrel tab (ORTHO-NOVUM equiv)
ocella tab (YASMIN equiv)
rajani tab (BEYAZ equiv)
sprintec tab (ORTHO-CYCLEN equiv)
wymzya FE tab (FEMCON equiv)
YAZ TAB
amethyst tab (LYBREL equiv)
FALESSA KIT
gianvi tab (YAZ equiv)
jolessa tab (SEASONALE equiv)
LO MINASTRIN 24 FE CHEW TAB
MINASTRIN CHEW TAB
QUARTETTE TAB
TAYTULLA CAP
tri-legest FE tab (ESTROSTEP FE equiv)
COMBINATION CONTRACEPTIVES - TRANSDERMAL
XULANE PATCH
COMBINATION CONTRACEPTIVES - VAGINAL
NUVARING
Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 69 of 101
Navi-Gate Rx Formulary
Category/Class
Last Updated* 1/1/2017
DrugName
Special Code
Level
OTC
OTC
F
F
F
F
-
F
QL
-
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
NC
NC
-
F
-
F
F
OTC
OTC
OTC
OTC
OTC
OTC-QL
QL
OTC
OTC
OTC
-
F
F
F
F
F
F
F
F
F
F
F
F
F
CONTRACEPTIVES Cont.
EMERGENCY CONTRACEPTIVES
ELLA TAB
levonorgestrel tab (PLAN B equiv)
LEVONORGESTREL TAB 0.75MG
PLAN B TAB
PROGESTIN CONTRACEPTIVES - ORAL
norethindrone tab (ORTHO-MICRONOR equiv)
CORTICOSTEROIDS
GLUCOCORTICOSTEROIDS
budesonide SR cap (ENTOCORT EC equiv)
CORTISONE ACETATE TAB
dexamethasone soln
DEXAMETHASONE TAB
DEXPAK TAB
hydrocortisone tab (CORTEF equiv)
MEDROL DOSE PACK
methylprednisolone dose pack (MEDROL equiv)
methylprednisolone tab (MEDROL equiv)
MILLIPRED DP PAK
prednisolone ODT (ORAPRED equiv)
prednisolone soln (PEDIAPRED equiv)
prednisolone syrup (PRELONE equiv)
PREDNISONE PAK
PREDNISONE TAB
UCERIS TAB (QL= 1 tab/day)
LIDOLOG KIT
RAYOS TAB
MINERALOCORTICOIDS
fludrocortisone tab
COUGH/COLD/ALLERGY
ANTITUSSIVES
BENZONATATE CAP
benzonatate cap (TESSALON equiv)
COUGH/COLD/ALLERGY COMBINATIONS
ALLEGRA-D TAB
cetirizine/pseudoephedrine 12-hour tab (ZYRTEC-D equiv)
fexofenadine/pseudoephedrine 12-hour tab (ALLEGRA-D equiv)
fexofenadine/pseudoephedrine 24-hour tab (ALLEGRA-D equiv)
guaifenesin DM/pseudoephedrine tab
guaifenesin/codeine syrup (TUSSI-ORGANI equiv) (QL= 240ml/fill)
hydrocodone/chlorpheniramine/pseudoephedrine liquid (ZUTRIPRO equiv) (QL= 4 oz/Rx; 2 fills/month)
loratadine/pseudoephedrine 12-hour tab (CLARITIN-D equiv)
loratadine/pseudoephedrine 24-hour tab (CLARITIN-D equiv)
MUCINEX DM
promethazine DM syrup
promethazine VC syrup (PHENERGAN VC equiv)
promethazine VC w/codeine syrup (PHENERGAN VC/CODEINE equiv)
Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 70 of 101
Navi-Gate Rx Formulary
Category/Class
Last Updated* 1/1/2017
DrugName
Special Code
Level
-
F
NC
NC
NC
NC
-
F
-
F
-
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
NC
NC
NC
NC
NC
NC
NC
NC
-
NC
COUGH/COLD/ALLERGY Cont.
promethazine w/codeine syrup
BROMFED DM SYRUP
DOMETUSS-DMX LIQ
HYCOFENIX SOLN
POLY-TUSSIN DM SYRUP
MISC. RESPIRATORY INHALANTS
sodium chloride nebs (NEBUSAL NEBS equiv)
MUCOLYTICS
acetylcysteine soln (MUCOMYST equiv)
DERMATOLOGICALS
ACNE PRODUCTS
adapalene cream (DIFFERIN equiv)
adapalene gel 0.1% (DIFFERIN equiv)
ADAPALENE LOTION (DIFFERIN equiv)
clindamycin gel (CLEOCIN GEL equiv)
clindamycin topical lotion
clindamycin topical soln (CLEOCIN-T equiv)
DIFFERIN GEL 0.3%
EPIDUO (FORTE) GEL
erythromycin gel
erythromycin pad
erythromycin soln
isotretinoin cap (ACCUTANE equiv)
PRASCION RA CREAM
RETIN-A MICRO GEL 0.04%, 0.1%
RETIN-A MICRO GEL 0.08%
sodium sulfacetamide lotion (KLARON equiv)
sodium sulfacetamide/sulfur cream (PLEXION SCT equiv)
sodium sulfacetamide/sulfur emulsion (ROSAC equiv)
sodium sulfacetamide/sulfur emulsion (ROSULA equiv)
sodium sulfacetamide/sulfur foam (CLARIFOAM EF equiv)
sodium sulfacetamide/sulfur gel (ROSULA equiv)
sodium sulfacetamide/sulfur lotion (SULFACET R equiv)
sodium sulfacetamide/sulfur pad (PLEXION equiv)
tretinoin cream (RETIN-A CREAM equiv)
tretinoin gel (RETIN-A GEL equiv)
ABSORICA CAP
ACANYA/ONEXTON GEL
ACZONE GEL
adapalene gel 0.3% (DIFFERIN equiv)
AVAR PAD
clindamycin/benzoyl peroxide gel (BENZACLIN equiv)
ROSULA WASH
sodium sulfacetamide/sunscreen kit (SUMADEN XLT equiv)
AGENTS FOR WRINKLES/LIPOATROPHY/OTHER AESTHETIC USES
KYBELLA INJ
ANALGESICS - TOPICAL
Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 71 of 101
Navi-Gate Rx Formulary
Category/Class
Last Updated* 1/1/2017
DrugName
Special Code
Level
-
NC
NC
-
F
F
NC
NC
-
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
NC
NC
NC
NC
NC
NC
NC
NC
NC
QL
QL
QL
-
F
F
F
NC
NC
NC
NC
NC
NC
-
F
F
F
DERMATOLOGICALS Cont.
BACLOFEN CREAM COMPOUND KIT
TRAMADOL CREAM COMPOUND KIT
ANTIBIOTICS - TOPICAL
mupirocin cream (BACTROBAN equiv)
mupirocin oint (BACTROBAN equiv)
CENTANY OINT
NEO-SYNALAR CREAM
ANTIFUNGALS - TOPICAL
ciclopirox cream (LOPROX equiv)
ciclopirox gel (LOPROX equiv)
ciclopirox nail soln (PENLAC equiv)
ciclopirox shampoo (LOPROX equiv)
ciclopirox soln (LOPROX equiv)
clotrimazole/betamethasone cream (LOTRISONE equiv)
clotrimazole/betamethasone lotion (LOTRISONE equiv)
econazole cream (SPECTAZOLE equiv)
ketoconazole cream (NIZORAL equiv)
ketoconazole shampoo (NIZORAL equiv)
naftifine cream (NAFTIN equiv)
NAFTIN GEL
nystatin cream
nystatin oint
nystatin powder
oxiconazole nitrate cream (OXISTAT equiv)
OXISTAT LOTION
ALOQUIN GEL
ECOZA FOAM
iodoquinol/hydrocortisone cream 1.9-1% (VYTONE equiv)
JUBLIA SOLN
KERYDIN SOLN
LUZU CREAM
NAFTIN GEL 2%
nystatin/triamcinolone cream
nystatin/triamcinolone oint
ANTI-INFLAMMATORY AGENTS - TOPICAL
diclofenac gel 1% (VOLTAREN equiv) (QL= 5 tubes/fill)
FLECTOR PATCH (QL= 30 patches/fill)
VOLTAREN GEL
diclofenac soln 1.5% (PENNSAID equiv)
NAPROXEN CREAM COMPOUND KIT
REXAPHENAC CREAM
VOPAC 5 CREAM
VOPAC CREAM
VOPAC GB CREAM
ANTINEOPLASTIC OR PREMALIGNANT LESION AGENTS - TOPICAL
CARAC CREAM
diclofenac gel (SOLARAZE equiv)
fluorouracil cream (EFUDEX equiv)
Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 72 of 101
Navi-Gate Rx Formulary
Category/Class
Last Updated* 1/1/2017
DrugName
Special Code
Level
LD-QL
-
F
F
NC
-
F
-
F
F
F
F
F
F
F
F
F
F
F
NC
NC
-
F
F
NC
NC
NC
NC
-
F
F
F
-
F
F
F
F
-
F
F
F
F
F
F
F
F
F
F
F
DERMATOLOGICALS Cont.
fluorouracil soln (EFUDEX equiv)
VALCHLOR GEL (QL= 4 tubes/30 days; Only available through Accredo 888-773-7376)
FLUORAC CREAM
ANTIPRURITICS - TOPICAL
DOXEPIN/PRUDOXIN/ZONALON CREAM
ANTIPSORIATICS
8-MOP CAP
acitretin cap (SORIATANE equiv)
calcipotriene cream (DOVONEX equiv)
calcipotriene oint
calcipotriene soln (DOVONEX equiv)
methoxsalen cap (OXSORALEN ULTRA equiv)
RAPTIVA
SORIATANE
TAZORAC CREAM
TAZORAC GEL
VECTICAL OINT
STELARA INJ ( )
TALTZ INJ
ANTISEBORRHEIC PRODUCTS
selenium sulfide shampoo
sodium sulfacetamide wash (OVACE equiv)
OVACE PLUS LOTION
OVACE PLUS FOAM
sodium sulfacetamide gel (OVACE PLUS equiv)
sulfacetamide sodium shampoo (OVACE equiv)
ANTIVIRALS - TOPICAL
DENAVIR CREAM
ZOVIRAX CREAM
ZOVIRAX OINT
BURN PRODUCTS
mafenide acetate soln packet (SULFAMYLON equiv)
silver sulfadiazine cream (SILVADENE equiv)
SULFAMYLON CREAM
SULFAMYLON PACK
CORTICOSTEROIDS - TOPICAL
alclometasone cream (ACLOVATE equiv)
alclometasone oint (ACLOVATE equiv)
betamethasone augmented cream (DIPROLENE equiv)
betamethasone augmented gel (DIPROLENE equiv)
betamethasone augmented lotion (DIPROLENE equiv)
betamethasone augmented oint (DIPROLENE equiv)
betamethasone diproprionate cream (DIPROSONE equiv)
betamethasone diproprionate lotion (DIPROSONE equiv)
betamethasone diproprionate oint (DIPROSONE equiv)
betamethasone valerate cream
betamethasone valerate lotion
Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 73 of 101
Navi-Gate Rx Formulary
Category/Class
Last Updated* 1/1/2017
DrugName
Special Code
Level
-
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
DERMATOLOGICALS Cont.
betamethasone valerate oint
clobetasol foam (OLUX equiv)
clobetasol propionate cream (TEMOVATE equiv)
clobetasol propionate emollient cream (TEMOVATE equiv)
clobetasol propionate gel (TEMOVATE equiv)
clobetasol propionate oint (TEMOVATE equiv)
clobetasol propionate soln (TEMOVATE equiv)
desoximetasone cream 0.25% (TOPICORT equiv)
diflorasone oint
fluocinolone acetonide oil (DERMA SMOOTH/FS equiv)
fluocinolone cream (SYNALAR equiv)
fluocinolone oint (SYNALAR equiv)
fluocinolone soln (SYNALAR equiv)
fluocinonide cream 0.05% (VANOS CREAM equiv)
fluocinonide gel (LIDEX equiv)
fluocinonide oint (LIDEX equiv)
fluocinonide soln (LIDEX equiv)
fluocinonide-e cream (LIDEX-E equiv)
flurandrenolide cream (CORDRAN equiv)
fluticasone propionate cream (CUTIVATE equiv)
fluticasone propionate oint (CUTIVATE equiv)
halobetasol propionate cream (ULTRAVATE equiv)
halobetasol propionate oint (ULTRAVATE equiv)
hydrocortisone cream (PROCTOCORT equiv)
hydrocortisone lotion (HYTONE equiv)
hydrocortisone oint
hydrocortisone pramoxine cream (PRAMOSONE equiv)
mometasone cream (ELOCON equiv)
mometasone soln (ELOCON equiv)
PRAMOSONE E CREAM
prednicarbate cream (DERMATOP equiv)
prednicarbate oint (DERMATOP equiv)
TACLONEX SCALP
triamcinolone topical
U-CORT CREAM
ULTRAVATE LOTION
AMCINONIDE CREAM 0.1%
betamethasone valerate foam (LUXIQ equiv)
clobetasol E foam (OLUX E equiv)
clobetasol lotion (CLOBEX equiv)
clobetasol shampoo (CLOBEX SHAMPOO equiv)
clobetasol spray (CLOBEX equiv)
desonide cream (DESOWEN equiv)
desonide lotion (DESOWEN equiv)
desonide oint (DESOWEN equiv)
desoximetasone gel (TOPICORT equiv)
desoximetasone oint 0.25% (TOPICORT equiv)
DIFLORASONE CREAM
Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 74 of 101
Navi-Gate Rx Formulary
Category/Class
Last Updated* 1/1/2017
DrugName
Special Code
Level
-
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
-
NC
NC
NC
NC
NC
-
F
F
-
F
F
-
F
*
-
F
F
-
F
-
F
F
F
F
NC
NC
NC
NC
NC
NC
NC
NC
DERMATOLOGICALS Cont.
DIFLORASONE OINT (PSORCON equiv)
ENSTILAR FOAM
fluocinonide cream 0.1% (VANOS CREAM equiv)
fluticasone propionate lotion (CUTIVATE equiv)
hydrocortisone butyrate cream (LOCOID equiv)
hydrocortisone butyrate lipocream (LOCOID equiv)
hydrocortisone butyrate oint (LOCOID equiv)
hydrocortisone butyrate soln (LOCOID equiv)
hydrocortisone valerate cream (WESTCORT equiv)
hydrocortisone valerate oint (WESTCORT equiv)
MICORT-HC CREAM
NOVACORT GEL
SERNIVO SPRAY
triamcinolone spray (KENALOG equiv)
TRIANEX OINT
EMOLLIENT/KERATOLYTIC AGENTS
UMECTA PD EMULSION
URAMAXIN LOTION
urea cream (KERALAC equiv)
urea lotion
urea susp 40% (UMECTA equiv)
EMOLLIENTS
ammonium lactate cream (LAC-HYDRIN equiv)
ammonium lactate lotion (LAC-HYDRIN equiv)
ENZYMES - TOPICAL
SANTYL OINT
XENADERM OINT
IMMUNOMODULATING AGENTS - TOPICAL
imiquimod cream (ALDARA equiv)
IMMUNOSUPPRESSIVE AGENTS - TOPICAL
ELIDEL CREAM
tacrolimus oint (PROTOPIC equiv)
KERATOLYTIC/ANTIMITOTIC AGENTS
podofilox soln (CONDYLOX equiv)
LOCAL ANESTHETICS - TOPICAL
lidocaine gel (XYLOCAINE equiv)
lidocaine soln (XYLOCAINE equiv)
lidocaine/prilocaine cream (EMLA equiv)
lidocaine/prilocaine kit (EMLA equiv)
ADAZIN CREAM
ANASTIA LOTION
capsaicin-menthol topical patch (SINELEE equiv)
LIDOCAINE CREAM
lidocaine patch (LIDODERM equiv)
LIDOCIN GEL
SILVERA PAD
SOLAICE PATCH
Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 75 of 101
Navi-Gate Rx Formulary
Category/Class
Last Updated* 1/1/2017
DrugName
Special Code
Level
-
NC
-
NC
-
F
F
-
F
F
F
F
F
NC
QL
QL
F
F
F
F
F
F
F
F
QL
F
-
F
NC
OTC
OTC
OTC
OTC
OTC
OTC
OTC
OTC
OTC
OTC
OTC
OTC
F
F
F
F
F
F
F
F
F
F
F
F
F
NC
-
NC
DERMATOLOGICALS Cont.
SYNVEXIA TC CREAM
MISC. DERMATOLOGICAL PRODUCTS
NEOSALUS FOAM
MISC. TOPICAL
aluminum chloride soln (DRYSOL equiv)
DRYSOL SOLN
ROSACEA AGENTS
FINACEA FOAM
FINACEA GEL
metronidazole cream (METROCREAM equiv)
metronidazole gel (METROGEL equiv)
metronidazole lotion (METROLOTION equiv)
DOXYCYCLINE/ORACEA CAP
SCABICIDES & PEDICULICIDES
EURAX CREAM
EURAX LOTION
LINDANE LOTION
lindane shampoo
malathion lotion (OVIDE equiv)
NATROBA SUSP (QL= 1 bottle/fill)
permethrin cream (ELIMITE equiv)
ULESFIA LOTION (QL= 4 bottles/fill)
WOUND CARE PRODUCTS
REGRANEX GEL (QL= 30 grams/fill)
DIAGNOSTIC PRODUCTS
DIAGNOSTIC DRUGS
GLUCAGEN INJ
GLUCAGON DIAGNOSTIC INJ
DIAGNOSTIC TESTS
ACCU-CHEK ACTIVE TEST STRIP
ACCU-CHEK AVIVA PLUS TEST STRIP
ACCU-CHEK COMFORT CURVE TEST STRIP
ACCU-CHEK COMPACT TEST STRIP
ACCU-CHEK SMARTVIEW TEST STRIP
CLINISTIX
CLINISTIX TEST STRIP
FREESTYLE INSULINX TEST STRIP
FREESTYLE INSULINX TEST STRIPS
FREESTYLE LITE TEST STRIP
FREESTYLE TEST STRIP
KETO-DIASTIX TEST STRIP
PRECISION XTRA TEST STRIP
FREESTYLE PRECISION NEO TEST STRIP
DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS
DIETARY MANAGEMENT PRODUCTS
ASTAMED MYO CAP
Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 76 of 101
Navi-Gate Rx Formulary
Category/Class
Last Updated* 1/1/2017
DrugName
Special Code
Level
DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS Cont.
DEPLIN CAP
ELIGEN B12 TAB
FALESSA KIT
GLYGEST PAK
METANX CAP
XAQUIL XR TAB
XYZBAC TAB
-
NC
NC
NC
NC
NC
NC
NC
-
F
NC
-
F
F
F
F
NC
-
F
F
F
F
F
-
F
F
F
F
F
-
F
F
F
-
F
F
F
F
F
F
-
F
F
F
DIGESTIVE AIDS
DIGESTIVE ENZYMES
CREON CAP
ZENPEP CAP
DIURETICS
CARBONIC ANHYDRASE INHIBITORS
acetazolamide ER cap (DIAMOX equiv)
acetazolamide tab
ACETAZOLAMIDE TAB 125MG
methazolamide tab (NEPTAZANE equiv)
KEVEYIS TAB
DIURETIC COMBINATIONS
amiloride/hydrochlorothiazide tab (MODURETIC equiv)
spironolactone/hydrochlorothiazide tab (ALDACTAZIDE equiv)
triamterene/hydrochlorothiazide cap (DYAZIDE equiv)
TRIAMTERENE/HYDROCHLOROTHIAZIDE CAP 50-25mg
triamterene/hydrochlorothiazide tab (MAXZIDE equiv)
LOOP DIURETICS
bumetanide tab (BUMEX equiv)
ethacrynic tab (EDECRIN equiv)
furosemide soln
furosemide tab (LASIX equiv)
torsemide tab (DEMADEX equiv)
POTASSIUM SPARING DIURETICS
amiloride tab (MIDAMOR equiv)
DYRENIUM CAP
spironolactone tab (ALDACTONE equiv)
THIAZIDES AND THIAZIDE-LIKE DIURETICS
chlorothiazide tab
CHLORTHALIDONE TAB
hydrochlorothiazide cap
hydrochlorothiazide tab
indapamide tab (LOZOL equiv)
metolazone tab (ZAROXOLYN equiv)
ENDOCRINE AND METABOLIC AGENTS - MISC.
BONE DENSITY REGULATORS
alendronate tab (FOSAMAX equiv)
ALENDRONATE TAB 40MG
calcitonin nasal spray (MIACALCIN equiv)
Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 77 of 101
Navi-Gate Rx Formulary
Category/Class
Last Updated* 1/1/2017
DrugName
Special Code
Level
*
QL
-
F
F
F
F
NC
LD
F
-
NC
-
F
F
-
F
NC
-
F
LD
LD
-
F
F
F
F
F
F
F
F
F
F
F
F
NC
NC
NC
NC
NC
NC
-
F
F
-
F
LD-QL
F
F
ENDOCRINE AND METABOLIC AGENTS - MISC. Cont.
etidronate disodium tab 200mg (DIDRONEL equiv)
FORTEO INJ
ibandronate tab 150mg (BONIVA equiv) (QL= 1 tab/month)
risedronate tab (ACTONEL equiv)
risedronate DR tab (ATELVIA equiv)
GROWTH HORMONE RECEPTOR ANTAGONISTS
SOMAVERT INJ (Only available through Walgreens 888-347-3416)
GROWTH HORMONE RELEASING HORMONES (GHRH)
EGRIFTA INJ
GROWTH HORMONES
GENOTROPIN/HUMATROPE/OMNITROPE/ZOMACTON INJ
NORDITROPIN INJ
HORMONE RECEPTOR MODULATORS
raloxifene tab (EVISTA equiv)
OSPHENA TAB
INSULIN-LIKE GROWTH FACTORS (SOMATOMEDINS)
INCRELEX INJ
METABOLIC MODIFIERS
BUPHENYL TAB
calcitriol cap (ROLCALTROL equiv)
calcitriol inj (CALCIJEX equiv)
calcitriol soln (ROCALTROL equiv)
doxercalciferol cap (HECTOROL equiv)
KUVAN POWDER PACK (Only available through Walgreens 888-347-3416)
KUVAN TAB (Only available through Walgreens 888-347-3416)
levocarnitine soln (CARNITOR equiv)
levocarnitine tab (CARNITOR equiv)
paricalcitol cap (ZEMPLAR equiv)
SENSIPAR TAB
sodium phenylbutyrate powder (BUPHENYL POWDER equiv)
MYALEPT INJ
ORFADIN CAP
ORFADIN SUSP
RAVICTI LIQUID
STRENSIQ INJ
XURIDEN POWDER
POSTERIOR PITUITARY HORMONES
desmopressin nasal spray (DDAVP equiv)
desmopressin tab (DDAVP equiv)
PROLACTIN INHIBITORS
cabergoline tab
SOMATOSTATIC AGENTS
octreotide inj (SANDOSTATIN equiv)
SIGNIFOR INJ (QL= 2 vials/day; Only available through Accredo 888-773-7376)
ESTROGENS
ESTROGEN COMBINATIONS
Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 78 of 101
Navi-Gate Rx Formulary
Category/Class
Last Updated* 1/1/2017
DrugName
Special Code
Level
*
-
F
F
F
F
NC
-
F
F
F
F
F
-
F
F
F
F
F
F
F
-
NC
-
F
-
F
-
F
-
F
NC
-
F
F
F
F
F
F
F
F
F
NC
-
F
ESTROGENS Cont.
COMBIPATCH
estradiol/norethindrone tab (ACTIVELLA equiv)
jinteli tab (FEMHRT equiv)
PREMPHASE/PREMPRO TAB
DUAVEE TAB
ESTROGENS
estradiol patch (CLIMARA equiv)
estradiol patch (VIVELLE-DOT equiv)
estradiol tab (ESTRACE equiv)
estropipate tab (OGEN equiv)
PREMARIN TAB
FLUOROQUINOLONES
FLUOROQUINOLONES
ciprofloxacin ER tab (CIPRO XR equiv)
ciprofloxacin oral susp (CIPRO equiv)
ciprofloxacin tab (CIPRO equiv)
CIPROFLOXACIN TAB 100MG
levofloxacin soln (LEVAQUIN equiv)
levofloxacin tab (LEVAQUIN equiv)
ofloxacin tab (FLOXIN equiv)
GASTROINTESTINAL AGENTS - MISC.
FARNESOID X RECEPTOR (FXR) AGONISTS
OCALIVA TAB
GALLSTONE SOLUBILIZING AGENTS
ursodiol tab (URSO FORTE equiv)
GASTROINTESTINAL ANTIALLERGY AGENTS
cromolyn soln (GASTROCROM equiv)
GASTROINTESTINAL CHLORIDE CHANNEL ACTIVATORS
AMITIZA CAP
GASTROINTESTINAL STIMULANTS
metoclopramide tab (REGLAN equiv)
METOZOLV ODT
INFLAMMATORY BOWEL AGENTS
ASACOL HD/MESALAMINE TAB
balsalazide cap (COLAZAL equiv)
CANASA SUPP
DELZICOL CAP
LIALDA TAB
mesalamine enema (ROWASA equiv)
PENTASA CAP
sulfasalazine EC tab (AZULFIDINE equiv)
sulfasalazine tab (AZULFIDINE equiv)
CIMZIA INJ
INTESTINAL ACIDIFIERS
lactulose soln
IRRITABLE BOWEL SYNDROME (IBS) AGENTS
Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 79 of 101
Navi-Gate Rx Formulary
Category/Class
Last Updated* 1/1/2017
DrugName
Special Code
Level
-
NC
-
F
F
NC
NC
-
F
F
F
F
F
F
F
F
F
-
F
F
F
F
LD
-
F
NC
-
F
-
F
F
F
F
F
F
-
F
-
F
-
F
¢
-
F
F
F
NC
GASTROINTESTINAL AGENTS - MISC. Cont.
VIBERZI TAB
PERIPHERAL OPIOID RECEPTOR ANTAGONISTS
RELISTOR INJ
RELISTOR INJ KIT
MOVANTIK TAB
RELISTOR TAB
PHOSPHATE BINDER AGENTS
AURYXIA TAB
calcium acetate cap (PHOSLO equiv)
FOSRENOL CHEW
FOSRENOL POWDER PACK
PHOSLYRA SOLN
RENAGEL TAB
RENVELA TAB
SEVELAMER CARBONATE TAB
VELPHORO CHEW TAB
GENITOURINARY AGENTS - MISCELLANEOUS
ALKALINIZERS
potassium citrate CR tab (UROCIT-K equiv)
potassium citrate/citric acid
sodium citrate/citric acid soln (ORACIT equiv)
tricitrates soln
CYSTINOSIS AGENTS
CYSTAGON CAP (Only available through Pharmacare 800-238-7828)
PROCYSBI CAP
INTERSTITIAL CYSTITIS AGENTS
ELMIRON CAP
PROSTATIC HYPERTROPHY AGENTS
alfuzosin SR tab (UROXATRAL equiv)
CARDURA XL TAB
dutasteride cap (AVODART equiv)
dutasteride/tamsulosin cap (JALYN equiv)
finasteride tab (PROSCAR equiv)
tamsulosin cap (FLOMAX equiv)
URINARY ANALGESICS
phenazopyridine tab (PYRIDIUM equiv)
URINARY STONE AGENTS
THIOLA TAB
GOUT AGENTS
GOUT AGENT COMBINATIONS
probenecid/colchicine tab
GOUT AGENTS
allopurinol tab
MITIGARE CAP
ULORIC TAB
COLCHICINE CAP
Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 80 of 101
Navi-Gate Rx Formulary
Category/Class
Last Updated* 1/1/2017
DrugName
Special Code
Level
-
NC
NC
-
F
-
NC
-
F
*
-
F
F
F
F
F
F
F
NC
NC
NC
LD
-
F
NC
-
F
-
F
F
F
F
F
F
F
F
F
NC
NC
-
F
F
NC
NC
-
F
GOUT AGENTS Cont.
COLCRYS/COLCHICINE TAB
ZURAMPIC TAB
URICOSURICS
probenecid tab
HEMATOLOGICAL AGENTS - MISC.
ANTIHEMOPHILIC PRODUCTS
AFSTYLA KIT
HEMATORHEOLOGIC AGENTS
pentoxifylline tab (TRENTAL equiv)
PLATELET AGGREGATION INHIBITORS
AGGRENOX/ASPIRIN-DIPYRIDAMOLE CAP
anagrelide cap (AGRYLIN equiv)
cilostazol tab (PLETAL equiv)
clopidogrel tab 75mg (PLAVIX equiv)
dipyridamole tab (PERSANTINE equiv)
EFFIENT TAB
ticlodipine tab (TICLID equiv)
clopidogrel tab 300mg (PLAVIX equiv)
YOSPRALA TAB
ZONTIVITY TAB
HEMATOPOIETIC AGENTS
AGENTS FOR GAUCHER DISEASE
ZAVESCA CAP (Only available through Accredo 888-773-7376 )
CERDELGA CAP
COBALAMINS
cyanocobalamin inj
HEMATOPOIETIC GROWTH FACTORS
ARANESP INJ
EPOGEN INJ
GRANIX INJ
LEUKINE INJ
NEULASTA INJ
NEUMEGA INJ
PROCRIT INJ
PROMACTA TAB
ZARXIO INJ
MIRCERA INJ
NEUPOGEN INJ
HEMATOPOIETIC MIXTURES
ferrex 150 forte cap
hemax tab
B-SERENE PAD
PUREFOLIX TAB
HEMOSTATICS
HEMOSTATICS - SYSTEMIC
AMICAR SYRUP
Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 81 of 101
Navi-Gate Rx Formulary
Category/Class
Last Updated* 1/1/2017
DrugName
Special Code
Level
-
F
F
F
F
NC
-
NC
-
F
QL
QL
QL
-
F
F
F
F
F
F
F
F
F
F
NC
-
NC
-
F
F
F
NC
NC
NC
-
F
NC
NC
-
F
F
-
F
F
-
F
HEMOSTATICS Cont.
AMICAR TAB
AMINOCAPROIC ACID TAB
aminocaproic acid tab (AMICAR equiv)
tranexamic acid tab (LYSTEDA equiv)
AMICAR ORAL SOLN
HYPNOTICS
OREXIN RECEPTOR ANTAGONISTS
BELSOMRA TAB
HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS
BARBITURATE HYPNOTICS
PHENOBARBITAL TAB
NON-BARBITURATE HYPNOTICS
estazolam tab (PROSOM equiv)
eszopiclone tab (LUNESTA equiv) (QL= 1 tab/day)
FLURAZEPAM CAP
temazepam 15mg cap (RESTORIL equiv)
temazepam 22.5mg cap (RESTORIL equiv)
temazepam 30mg cap (RESTORIL equiv)
temazepam 7.5mg cap (RESTORIL equiv)
triazolam tab (HALCION equiv)
zolpidem tab 10mg (AMBIEN equiv) (Male QL= 1 tab/day; Female QL= 0.5 tab/day)
zolpidem tab 5mg (AMBIEN equiv) (QL= 1 tab/day)
zolpidem ER tab (AMBIEN CR equiv)
SELECTIVE MELATONIN RECEPTOR AGONISTS
HETLIOZ CAP
LAXATIVES
LAXATIVE COMBINATIONS
MOVIPREP SOLN
peg 3350/electrolytes soln (COLYTE equiv)
trilyte soln (GOLYTELY equiv)
gavilyte-h kit
PREPOPIK PAK
SUCLEAR KIT
LAXATIVES - MISCELLANEOUS
lactulose soln
GIALAX KIT
polyethylene glycol 3350 powder (MIRALAX equiv)
SALINE LAXATIVES
OSMOPREP TAB
VISICOL TAB
MACROLIDES
AZITHROMYCIN
azithromycin susp (ZITHROMAX equiv)
azithromycin tab (ZITHROMAX equiv) (500mg tab is Not Covered)
CLARITHROMYCIN
clarithromycin ER tab (BIAXIN XL equiv)
Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 82 of 101
Navi-Gate Rx Formulary
Category/Class
Last Updated* 1/1/2017
DrugName
Special Code
Level
-
F
F
-
F
F
F
F
F
QL
F
-
F
OTC
OTC
OTC
OTC
OTC
OTC
OTC
OTC
OTC
QL
OTC
-
F
F
F
F
F
F
F
F
F
F
NC
NC
OTC
NC
OTC
OTC
OTC
OTC
OTC
OTC
OTC
OTC
OTC
OTC
F
F
F
F
F
F
F
F
F
F
-
F
-
F
F
F
MACROLIDES Cont.
clarithromycin susp (BIAXIN equiv)
clarithromycin tab (BIAXIN equiv)
ERYTHROMYCINS
E.E.S SUSP
ERY-TAB
ERYTHROMYCIN CAP
erythromycin ethylsuccinate susp (ERYPED equiv)
erythromycin tab
FIDAXOMICIN
DIFICID TAB (QL= 20 tabs/fill)
MEDICAL DEVICES AND SUPPLIES
CONTRACEPTIVES
DIAPHRAGM
DIABETIC SUPPLIES
ACCU-CHEK MULTICLIX LANCETS
ACCU-CHEK NANO SMARTVIEW METER
CALIBRATION LIQUID
FREESTYLE FREEDOM LITE METER
FREESTYLE FREEDOM METER
FREESTYLE KIT INSULINX
FREESTYLE LITE TEST STRIP
FREESTYLE METER
LANCETS
V-GO 20 KIT (QL= 1 kit/day)
FREESTYLE PRECISION NEO METER
OMNIPOD
MISC. DEVICES
ALCOHOL SWABS
PARENTERAL THERAPY SUPPLIES
B-D INSULIN SYRINGE
BD INSULIN SYRINGES
B-D PEN NEEDLE
BD PEN NEEDLES
FREESTYLE INSULIN SYRINGE
NOVOFINE PEN NEEDLES
NOVOPEN
NOVOPEN JR
NOVOTWIST PEN NEEDLES
PRECISION SURE-DOSE INSULIN SYRINGES
RESPIRATORY THERAPY SUPPLIES
PEAK FLOW METER
MIGRAINE PRODUCTS
MIGRAINE COMBINATIONS
acetaminophen/isometheptene/dichloral cap (MIDRIN equiv)
ergotamine/caffeine tab (CAFERGOT equiv)
isometheptene/caffeine/acetaminophen tab (PRODRIN equiv)
Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 83 of 101
Navi-Gate Rx Formulary
Category/Class
Last Updated* 1/1/2017
DrugName
Special Code
Level
-
F
NC
NC
NC
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
-
F
F
F
F
F
F
F
F
F
F
F
F
F
F
NC
NC
NC
NC
NC
NC
-
F
F
F
F
-
F
F
F
F
F
F
-
F
-
F
F
MIGRAINE PRODUCTS Cont.
MIGRAINE PRODUCTS
dihydroergotamine mesylate inj (D.H.E equiv)
MIGRANAL/ DIHYDROERGOTAMINE SPRAY
MIGRAINE PRODUCTS - NSAIDS
CAMBIA POWDER
SEROTONIN AGONISTS
ALSUMA INJ (QL= 4 inj/fill, 2 fills/30 days)
MAXALT TAB (QL= 12 tabs/fill, 3 fills/60 days)
naratriptan tab (AMERGE equiv) (QL= 9 tabs/fill; 2 fills/30 days)
rizatriptan ODT (MAXALT equiv) (QL= 12 tabs/fill, 3 fills/60 days)
sumatriptan inj (IMITREX equiv) (QL= 4 inj/fill, 2 fills/30 days)
SUMATRIPTAN INJ 6MG/0.5ML (QL= 4 inj/fill, 2 fills/30 days)
sumatriptan nasal spray (SUMATRIPTAN/IMITREX equiv) (QL= 6 sprays/fill, 2 fills/30 days)
sumatriptan tab (IMITREX equiv) (QL= 9 tabs/fill; 2 fills/30 days)
sumatriptan vial inj (IMITREX equiv) (QL= 5 inj/fill, 2 fills/30 days)
zolmitriptan ODT (ZOMIG ZMT equiv) (QL= 9 tabs/fill, 2 fills/30 days)
zolmitriptan tab (ZOMIG equiv) (QL= 9 tabs/fill; 2 fills/30 days)
ZOMIG NASAL SPRAY (QL= 6 sprays/fill; 2 fills/30 days)
ZOMIG TAB (QL= 9 tabs/fill; 2 fills/30 days)
ZOMIG ZMT TAB (QL= 9 tabs/fill, 2 fills/30 days)
almotriptan tab (AXERT equiv)
ONZETRA XSAIL
RELPAX TAB
SUMAVEL DOSEPRO INJ
ZECUITY PAD
ZEMBRACE SYMTOUCH INJ
MINERALS & ELECTROLYTES
FLUORIDE
lozi-flur
sodium fluoride chew tab (LURIDE equiv)
sodium fluoride soln (LURIDE equiv)
SODIUM FLUORIDE TAB
POTASSIUM
potassium bicarbonate effer tab (K-LYTE equiv)
potassium chloride ER cap (MICRO-K equiv)
POTASSIUM CHLORIDE ER TAB
potassium chloride ER tab (KLOR-CON equiv)
potassium chloride micro tab (K-DUR equiv)
potassium chloride soln
ZINC
zinc sulfate cap
MOUTH/THROAT/DENTAL AGENTS
ANESTHETICS TOPICAL ORAL
LIDOCAINE ORAL SOLN 4%
lidocaine viscous soln
ANTIALLERGY AGENTS - MOUTH/THROAT
Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 84 of 101
Navi-Gate Rx Formulary
Category/Class
Last Updated* 1/1/2017
DrugName
Special Code
Level
-
F
-
F
F
-
F
-
F
F
F
F
F
-
F
-
F
F
NC
-
F
F
F
-
NC
-
F
F
F
F
-
NC
-
F
F
-
F
F
F
F
F
F
F
F
F
MOUTH/THROAT/DENTAL AGENTS Cont.
APHTHASOL PASTE
ANTI-INFECTIVES - THROAT
clotrimazole troches (MYCELEX equiv)
nystatin susp
ANTISEPTICS - MOUTH/THROAT
chlorhexidine gluconate soln (PERIDEX equiv)
DENTAL PRODUCTS
sodium fluoride cream (PREVIDENT equiv)
sodium fluoride gel (PREVIDENT equiv)
sodium fluoride paste (PREVIDENT equiv)
sodium fluoride rinse (PREVIDENT equiv)
sodium fluoride/potassium nitrate paste (PREVIDENT equiv)
STEROIDS - MOUTH/THROAT
triamcinolone in orabase paste (KENALOG/ORABASE equiv)
THROAT PRODUCTS - MISC.
cevimeline cap (EVOXAC equiv)
pilocarpine tab (SALAGEN equiv)
PROTHELIAL PASTE
MULTIVITAMINS
B-COMPLEX W/ FOLIC ACID
dialyvite
dialyvite tab (NEPHRO-VITE equiv)
FOLBEE PLUS CZ TAB
MULTIPLE VITAMINS & FLUORIDE-FOLIC ACID
MULTIVITAMIN/FLUORIDE CHEW TAB
PED MV W/ FLUORIDE
pediatric multiple vitamins/fluoride chew tab
pediatric multiple vitamins/fluoride soln
QUFLORA PEDIATRIC CHEW TAB
QUFLORA PEDIATRIC DROP
PEDIATRIC MULTIPLE VITAMINS & MINERALS W/ FLUORIDE
FLORIVA CHEW TAB
PRENATAL VITAMINS
PRENATAL VITAMIN (RX ONLY)
PRENATAL VITAMINS (NON-PREFERRED)
MUSCULOSKELETAL THERAPY AGENTS
CENTRAL MUSCLE RELAXANTS
baclofen tab
carisoprodol (SOMA equiv) (250mg tab is Not Covered)
chlorzoxazone tab (PARAFON FORTE equiv)
cyclobenzaprine tab (FLEXERIL equiv)
metaxalone tab (SKELAXIN equiv)
METAXALONE TAB 400MG
metocarbamol tab (ROBAXIN equiv)
orphenadrine citrate ER tab (NORFLEX equiv)
tizanidine tab (ZANAFLEX equiv)
Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 85 of 101
Navi-Gate Rx Formulary
Category/Class
Last Updated* 1/1/2017
DrugName
Special Code
Level
-
NC
NC
NC
-
F
-
F
F
F
F
NC
-
NC
-
NC
-
F
F
F
-
F
QL
QL
QL
OTC-QL
QL
QL
QL
OTC-QL
QL
QL
-
F
F
F
F
F
F
F
F
F
F
NC
-
F
-
F
F
F
F
F
F
F
MUSCULOSKELETAL THERAPY AGENTS Cont.
carisoprodol tab 250mg (SOMA equiv)
CYCLOBENZAPRINE COMPOUND KIT
FIRST BACLOFEN SUSP KIT
DIRECT MUSCLE RELAXANTS
dantrolene cap (DANTRIUM equiv)
MUSCLE RELAXANT COMBINATIONS
carisoprodol/aspirin tab (SOMA COMPOUND equiv)
carisoprodol/aspirin/codeine tab (SOMA COMPOUND/CODEINE equiv)
ORPHENADRINE/ASPIRIN/CAFFEINE TAB
orphenadrine/aspirin/caffeine tab (NORGESIC FORTE equiv)
LORVATUS PHARMAPAK KIT
NASAL AGENTS - SYSTEMIC AND TOPICAL
NASAL AGENT COMBINATIONS
AZENASE PAK
NASAL AGENTS - MISC.
TICANASE PAK
NASAL ANTIALLERGY
ASTELIN/ASTEPRO NASAL SPRAY
azelastine nasal spray (ASTELIN/ASTEPRO equiv)
olopatadine nasal spray (PATANASE equiv)
NASAL ANTICHOLINERGICS
ipratropium nasal spray (ATROVENT equiv)
NASAL STEROIDS
budesonide nasal spray (RHINOCORT AQUA equiv) (QL= 2 bottles/fill)
fluticasone nasal spray (FLONASE equiv) (QL= 2 bottles/fill)
mometasone nasal spray (NASONEX equiv) (QL= 2 bottles/fill)
NASACORT OTC NASAL SPRAY (QL= 2 bottles/fill)
OMNARIS NASAL SPRAY (QL= 2 bottles/fill)
QNASL NASAL SPRAY (QL= 2 bottles/fill)
triamcinolone nasal spray (NASACORT equiv) (QL= 2 bottles/fill)
triamcinolone OTC nasal spray (NASACORT equiv) (QL= 2 bottles/fill)
VERAMYST NASAL SPRAY (QL= 2 bottles/fill)
ZETONNA NASAL SPRAY (QL= 2 bottles/fill)
flunisolide nasal spray (NASAREL equiv)
NEUROMUSCULAR AGENTS
ALS AGENTS
riluzole tab (RILUTEK equiv)
OPHTHALMIC AGENTS
BETA-BLOCKERS - OPHTHALMIC
betaxolol ophth soln (BETOPTIC-S equiv)
BETIMOL OPHTH SOLN
BETOPIC-S OPTHTH SOLN
carteolol ophth soln (OCUPRESS equiv)
COMBIGAN OPHTH SOLN
dorzolamide/timolol ophth soln (COSOPT equiv)
ISTALOL OPHTH SOLN
Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 86 of 101
Navi-Gate Rx Formulary
Category/Class
Last Updated* 1/1/2017
DrugName
Special Code
Level
-
F
F
F
F
-
F
F
F
F
F
-
F
F
F
-
F
F
F
F
-
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
NC
-
F
-
F
-
NC
-
F
OPHTHALMIC AGENTS Cont.
levobunolol ophth soln (BETAGAN equiv)
METIPRANOLOL OPHTH SOLN
timolol maleate ophth gel (TIMOPTIC-XE equiv)
timolol maleate ophth soln (TIMOPTIC equiv)
CYCLOPLEGIC MYDRIATICS
atropine ophth oint
atropine ophth soln (ISOPTO ATROPINE equiv)
cyclopentolate ophth soln (CYCLOGYL equiv)
homatropine ophth soln (ISOPTO HOMATROPINE equiv)
tropicamide ophth soln (MYDRIACYL equiv)
MIOTICS
ISOPTO CARBACHOL OPHTH SOLN
PHOSPHOLINE IODIDE
pilocarpine ophth soln (ISOPTO CARPINE equiv)
OPHTHALMIC ADRENERGIC AGENTS
ALPHAGAN P OPHTH SOLN 0.1%
apraclonidine ophth soln (ISOPTO equiv)
brimonidine ophth soln (ALPHAGAN P equiv)
SIMBRINZA OPHTH SUSP
OPHTHALMIC ANTI-INFECTIVES
AZASITE SOLN
BACITRACIN OPHTH OINT
bacitracin/polymixin B ophth oint (POLYSPORIN equiv)
ciprofloxacin ophth soln (CILOXAN equiv)
erythromycin ophth oint
gatifloxacin ophth soln (ZYMAXID equiv)
gentamicin ophth oint (GARAMYCIN equiv)
gentamicin ophth soln (GARAMYCIN equiv)
MOXEZA OPHTH SOLN/ VIGAMOX OPHTH SOLN
neomycin/bacitracin/polymyxin ophth oint (NEOSPORIN equiv)
neomycin/polymyxin/gramicidin ophth soln (NEOSPORIN equiv)
ofloxacin ophth soln (OCUFLOX equiv)
polymyxin b/trimethoprim ophth soln (POLYTRIM equiv)
sodium sulfacetamide ophth soln (BLEPH-10 equiv)
tobramycin ophth soln (TOBREX equiv)
TOBREX OPHTH OINT
trifluridine ophth soln (VIROPTIC equiv)
ZIRGAN GEL
levofloxacin ophth soln (QUIXIN equiv)
OPHTHALMIC DECONGESTANTS
phenylephrine ophth soln (MYDFRIN equiv)
OPHTHALMIC IMMUNOMODULATORS
RESTASIS OPHTH EMULSION
OPHTHALMIC INTEGRIN ANTAGONISTS
XIIDRA OPHTH SOLN
OPHTHALMIC LOCAL ANESTHETICS
tetracaine ophth soln
Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 87 of 101
Navi-Gate Rx Formulary
Category/Class
Last Updated* 1/1/2017
DrugName
Special Code
Level
-
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
NC
NC
NC
LD-QL
OTC
QL
QL
-
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
NC
NC
NC
OPHTHALMIC AGENTS Cont.
OPHTHALMIC STEROIDS
ALREX OPHTH SUSP/ LOTEMAX OPHTH SUSP
bacitracin/polymyxin/neomycin/hydrocortisone ophth oint (CORTISPORIN equiv)
BLEPHAMIDE OPHTH SOLN
BLEPHAMIDE S.O.P. OPHTH OINT
dexamethasone ophth soln (DEXAMETHASONE equiv)
fluorometholone ophth soln (FML LIQUIFILM equiv)
FML S.O.P. OPHTH OINT
LOTEMAX OPHTH OINT
MAXIDEX OPHTH SOLN
neomycin/ polymyxin/ dexamethasone ophth oint (MAXITROL equiv)
neomycin/ polymyxin/ dexamethasone ophth soln (MAXITROL equiv)
neomycin/ polymyxin/ hydrocortisone ophth soln (CORTISPORIN equiv)
prednisolone ophth soln (PRED FORTE equiv)
sulfacetamide sodium/prednisolone ophth soln (VASOCIDIN equiv)
TOBRADEX OPHTH OINT
tobramycin/dexamethasone ophth soln (TOBRADEX equiv)
VEXOL OPHTH SUSP
ZYLET OPHTH SOLN
ZYLET OPHTH SUSP 10ML
PREDNISOLONE/MOXIFLOXACIN OPHTH SOLN
PREDNISOLONE/MOXIFLOXACIN/BROMFENAC OPHTH SOLN
PREDNISOLONE/MOXIFLOXACIN/KETOROLAC OPHTH SOLN
OPHTHALMICS - MISC.
ALAMAST OPHTH SOLN
ALOCRIL OPHTH SOLN
ALOMIDE OPHTH SOLN
azelastine ophth drop (OPTIVAR equiv)
AZOPT OPHTH SUSP
bromfenac ophth soln (BROMDAY equiv)
cromolyn ophth soln (CROLOM equiv)
CYSTARAN OPHTH SOLN (QL= 4 bottles/30 days; Only available through Walgreens 888-347-3416)
diclofenac sodium ophth soln (VOLTAREN equiv)
dorzolamide ophth soln (TRUSOPT equiv)
EMADINE OPHTH SOLN
epinastine opthth soln (ELESTAT equiv)
flurbiprofen ophth soln (OCUFEN equiv)
ILEVRO OPHTH SUSP
ketorolac ophth soln (ACULAR (LS) equiv)
ketotifen ophth soln (ZADITOR equiv)
LASTACAFT OPHTH SOLN (QL= 3ml/30 days)
NEVANAC OPHTH SOLN
olopatadine ophth soln (PATANOL equiv)
PATADAY OPHTH SOLN (QL= 2.5ml/30 days)
PROLENSA OPHTH SOLN
BEPREVE OPHTH SOLN
BROMSITE OPHTH SOLN
PAZEO OPHTH SOLN 0.7%
Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 88 of 101
Navi-Gate Rx Formulary
Category/Class
Last Updated* 1/1/2017
DrugName
Special Code
Level
QL
QL
QL
F
F
F
-
F
F
-
F
F
-
F
F
F
F
NC
NC
NC
NC
NC
NC
-
F
F
QL
F
-
F
F
F
F
F
F
NC
NC
-
F
F
-
F
F
F
F
OPHTHALMIC AGENTS Cont.
PROSTAGLANDINS - OPHTHALMIC
latanoprost ophth soln (XALATAN equiv) (QL= 2.5ml/30 days)
LUMIGAN OPHTH SOLN (QL= 2.5ml/30 days)
TRAVATAN Z OPHTH SOLN (QL= 5 ml/30 days)
OTIC AGENTS
OTIC AGENTS - MISCELLANEOUS
acetic acid otic soln (VOSOL equiv)
ACETIC ACID/ALUMINUM ACETATE OTIC SOLN
OTIC ANTI-INFECTIVES
CIPROFLOXACIN OTIC SOLN
ofloxacin otic soln (FLOXIN equiv)
OTIC COMBINATIONS
CIPRODEX OTIC SUSP
COLY-MYCIN S OTIC SUSP
neomycin/polymixin/hydrocoritisone otic soln (CORTISPORIN equiv)
neomycin/polymixin/hydrocoritisone otic susp (CORTISPORIN equiv)
antipyrine/benzocaine otic soln (AURALGAN equiv)
CORTANE-B AQUEOUS OTIC SOLN
otomax-HC otic soln (CORTANE-B equiv)
OTOVEL OTIC SOLN
OTOZIN OTIC DROPS
pramoxine-HC AQ otic soln (CORTANE-B AQUEOUS equiv)
OTIC STEROIDS
acetic acid/hydrocoritisone otic soln (VOSOL HC equiv)
fluocinolone otic oil (DERMOTIC equiv)
OXYTOCICS
OXYTOCICS
methylergonovine tab (METHERGINE equiv) (QL= 28 tabs/fill; 1 fill/365 days)
PENICILLINS
AMINOPENICILLINS
amoxicillin cap
amoxicillin chew
amoxicillin susp
amoxicillin tab
ampicillin cap
ampicillin susp (PRINCIPEN equiv)
MOXATAG 775MG TAB
MOXATAG TAB
NATURAL PENICILLINS
penicillin vk susp
penicillin vk tab
PENICILLIN COMBINATIONS
amoxicillin/clavulanate chew tab (AUGMENTIN equiv)
amoxicillin/clavulanate ER tab (AUGMENTIN XR equiv)
amoxicillin/clavulanate susp (AUGMENTIN equiv)
amoxicillin/clavulanate tab (AUGMENTIN equiv)
Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 89 of 101
Navi-Gate Rx Formulary
Category/Class
Last Updated* 1/1/2017
DrugName
Special Code
Level
-
F
-
F
-
F
F
F
F
NC
PENICILLINS Cont.
PENICILLINASE-RESISTANT PENICILLINS
dicloxacillin cap
PHARMACEUTICAL ADJUVANTS
SEMI SOLID VEHICLES
POLYETHYLENE GLYCOL 8000 GRANULES
PROGESTINS
PROGESTINS
medroxyprogesterone tab (PROVERA equiv)
megestrol ES susp (MEGACE ES equiv)
norethindrone acetate tab (AYGESTIN equiv)
progesterone cap (PROMETRIUM equiv)
progesterone oil inj
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.
AGENTS FOR CHEMICAL DEPENDENCY
acamprosate calcium tab (CAMPRAL equiv)
disulfiram tab (ANTABUSE equiv)
-
F
F
LD-QL
F
QL
QL
QL
¢
-
F
F
F
F
F
F
F
F
F
F
F
F
F
-
F
F
F
QL
F
-
NC
-
F
QL
QL
-
F
F
F
ANTI-CATAPLECTIC AGENTS
XYREM SOLN (QL= 540ml/30 days; Only available through Xyrem Central Pharmacy 866-997-3688)
ANTIDEMENTIA AGENTS
donepezil ODT (ARICEPT equiv) (QL= 1 tab/day)
donepezil tab (ARICEPT equiv) (QL= 2 tabs/day)
donepezil tab 23mg (ARICEPT equiv) (QL= 1 tab/day)
galantamine ER cap (RAZADYNE ER equiv)
GALANTAMINE SOLN (RAZADYNE equiv)
galantamine tab (RAZADYNE equiv)
memantine sol (NAMENDA equiv)
memantine tab (NAMENDA equiv)
NAMENDA XR CAP ( )
NAMZARIC CAP
NAMZARIC STARTER PACK
rivastigmine cap (EXELON equiv)
rivastigmine patch (EXELON equiv)
COMBINATION PSYCHOTHERAPEUTICS
chlordiazepoxide/amitriptyline tab (LIMBITROL equiv)
olanzapine/fluoxetine cap (SYMBYAX equiv)
PERPHENAZINE/AMITRIPTYLINE TAB
FIBROMYALGIA AGENTS
SAVELLA TAB (QL= 2 tabs/day)
HYPOACTIVE SEXUAL DESIRE DISORDER (HSDD) AGENTS
ADDYI TAB
MOVEMENT DISORDER DRUG THERAPY
tetrabenazine tab (XENAZINE equiv) ( )
MULTIPLE SCLEROSIS AGENTS
AMPYRA TAB (QL= 2 tabs/day)
AUBAGIO TAB (QL= 1 tab/day)
AVONEX INJ
Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 90 of 101
Navi-Gate Rx Formulary
Category/Class
Last Updated* 1/1/2017
DrugName
Special Code
Level
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. Cont.
COPAXONE INJ 20MG/ML
COPAXONE INJ 40MG/ML
EXTAVIA INJ
GILENYA CAP (QL= 1 cap/day)
PLEGRIDY INJ
PLEGRIDY PEN INJ
REBIF INJ
TECFIDERA CAP
TECFIDERA STARTER PACK
BETASERON INJ
glatopa inj 20mg/ml (COPAXONE equiv)
ZINBRYTA INJ
QL
-
F
F
F
F
F
F
F
F
F
NC
NC
NC
-
NC
QL
F
-
F
NC
*
*
F
F
-
NC
QL
QL
-
F
F
F
-
NC
NC
-
F
-
F
F
F
F
F
F
F
F
F
PREMENSTRUAL DYSPHORIC DISORDER (PMDD) AGENTS
FLUOXETINE CAP (PMDD)
PSEUDOBULBAR AFFECT (PBA) AGENTS
NUEDEXTA CAP (QL= 2 caps/day)
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.
pimozide tab (ORAP equiv)
ERGOLOID MESYLATES TAB
SMOKING DETERRENTS
CHANTIX PAK (Coverage does not apply to those individuals who exceed 300% FPL.)
CHANTIX TAB (Coverage does not apply to those individuals who exceed 300% FPL.)
VASOMOTOR SYMPTOM AGENTS
BRISDELLE CAP
RESPIRATORY AGENTS - MISC.
CYSTIC FIBROSIS AGENTS
KALYDECO PAK (QL= 2 packets/day)
KALYDECO TAB (QL= 2 tabs/day)
PULMOZYME INH SOLN
PULMONARY FIBROSIS AGENTS
ESBRIET CAP
OFEV CAP
SULFONAMIDES
SULFONAMIDES
GANTRISIN SUSP
TETRACYCLINES
TETRACYCLINES
demeclocycline tab (DECLOMYCIN equiv)
doxycycline hyclate cap (VIBRAMYCIN equiv)
doxycycline hyclate DR tab (DORYX equiv)
doxycycline hyclate tab (VIBRATAB equiv)
doxycycline monohydrate cap (MONODOX equiv)
doxycycline monohydrate tab (ADOXA equiv) (150mg tab is Not Covered)
doxycycline susp (VIBRAMYCIN equiv)
minocycline cap (MINOCIN equiv)
minocycline tab (DYNACIN equiv)
Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 91 of 101
Navi-Gate Rx Formulary
Category/Class
Last Updated* 1/1/2017
DrugName
Special Code
Level
-
F
NC
NC
NC
-
F
F
-
F
F
F
F
-
F
F
F
F
F
F
F
F
F
F
NC
NC
-
F
F
F
F
F
F
F
F
-
F
F
OTC
OTC
-
F
F
F
F
F
F
NC
TETRACYCLINES Cont.
tetracycline cap
ACTICLATE TAB
DORYX MPC TAB
doxycycline hyclate DR tab 200mg (DORYX equiv)
THYROID AGENTS
ANTITHYROID AGENTS
methimazole tab (TAPAZOLE equiv)
propylthiouracil tab
THYROID HORMONES
levothyroxine tab (SYNTHROID equiv)
liothyronine tab (CYTOMEL equiv)
np thyroid tab (NATURE THROID/ARMOUR THYROID equiv)
THYROLAR TAB
ULCER DRUGS
ANTISPASMODICS
chlordiazepoxide/clidinium cap (LIBRIUM equiv)
dicyclomine cap (BENTYL equiv)
dicyclomine soln (BENTYL equiv)
dicyclomine tab (BENTYL equiv)
DONNATAL ELIXIR
DONNATAL EXTENTABS
glycopyrrolate tab (ROBINUL equiv)
hyoscyamine sulfate SR cap (LEVSINEX equiv)
hyoscyamine tab (LEVSIN equiv)
SYMAX DUOTAB
b-donna tab (DONNATAL equiv)
GLYCATE TAB 1.5MG
H-2 ANTAGONISTS
cimetidine tab (TAGAMET equiv)
famotidine susp (PEPCID equiv)
famotidine tab (PEPCID equiv)
nizatidine cap (AXID equiv)
nizatidine soln (AXID equiv)
ranitidine cap (ZANTAC equiv)
ranitidine syrup (ZANTAC equiv)
ranitidine tab (Rx Only) (ZANTAC equiv)
MISC. ANTI-ULCER
SUCRALFATE SUSP
sucralfate tab (CARAFATE equiv)
PROTON PUMP INHIBITORS
DEXILANT CAP
esomeprazole cap (NEXIUM equiv)
lansoprazole cap
omeprazole DR cap (PRILOSEC equiv)
PREVACID OTC CAP
rabeprazole tab (ACIPHEX equiv)
ACIPHEX SPRINKLE CAP
Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 92 of 101
Navi-Gate Rx Formulary
Category/Class
Last Updated* 1/1/2017
DrugName
Special Code
Level
OTC
-
NC
NC
NC
NC
-
F
OTC
-
F
F
F
F
NC
-
NC
-
F
F
F
F
¢
*
¢
-
F
F
F
F
F
F
F
F
NC
*
-
F
F
-
F
-
NC
VAC
-
F
NC
-
F
ULCER DRUGS Cont.
ESOMEPRAZOLE STRONTIUM CAP
NEXIUM 24HR TAB
NEXIUM OTC CAP
pantoprazole EC tab (PROTONIX equiv)
ULCER DRUGS - PROSTAGLANDINS
misoprostol tab (CYTOTEC equiv)
ULCER THERAPY COMBINATIONS
lansoprazole/amoxicillin/clarithromycin kit (PREVPAC equiv)
omeprazole/bicarbonate powder pack (ZEGERID equiv)
PYLERA CAP
ZEGERID CAP OTC
omeprazole/sodium bicarbonate cap (ZEGERID equiv)
URINARY ANTI-INFECTIVES
URINARY ANTI-INFECTIVE COMBINATIONS
UTA cap
URINARY ANTI-INFECTIVES
methenamine hippurate tab (HIPREX equiv)
nitrofurantoin macrocrystals cap (MACRODANTIN equiv)
nitrofurantoin monohydrate cap (MACROBID equiv)
nitrofurantoin susp (FURADANTIN equiv)
URINARY ANTISPASMODICS
URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLIN) (NEW)
oxybutynin ER tab (DITROPAN XL equiv)
oxybutynin syrup
oxybutynin tab
OXYTROL PATCH
tolterodine tab (DETROL equiv)
TOVIAZ TAB
trospium chloride SR cap (SANCTURA equiv)
VESICARE TAB
GELNIQUE
URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)
darifenacin SR tab (ENABLEX equiv)
tolterodine SR cap (DETROL LA equiv)
URINARY ANTISPASMODICS - CHOLINERGIC AGONISTS
bethanechol tab (URECHOLINE equiv)
URINARY ANTISPASMODICS - DIRECT MUSCLE RELAXANTS (NEW)
flavoxate tab
VACCINES
BACTERIAL VACCINES
VIVOTIF BERNA CAP
VAXCHORA SUSP
VAGINAL PRODUCTS
MISCELLANEOUS VAGINAL PRODUCTS
ACIDIC VAGINAL JELLY
Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 93 of 101
Navi-Gate Rx Formulary
Category/Class
Last Updated* 1/1/2017
DrugName
Special Code
Level
-
F
F
F
F
F
F
QL
F
F
F
F
-
F
F
F
QL
QL
-
F
F
NC
NC
-
NC
-
F
-
F
F
F
NC
OTC
OTC
OTC
OTC
OTC
-
F
F
F
F
F
F
VAGINAL PRODUCTS Cont.
VAGINAL ANTI-INFECTIVES
AVC VAGINAL CREAM
clindamycin vaginal cream (CLEOCIN equiv)
metronidazole vaginal gel (METROGEL equiv)
NYSTATIN VAGINAL TAB
terconazole cream (TERAZOL equiv)
terconazole supp (TERAZOL equiv)
VAGINAL ESTROGENS
ESTRACE VAGINAL CREAM
ESTRING
PREMARIN VAGINAL CREAM
yuvafem tab (VAGIFEM equiv) (QL= 8 tabs/28 days (18 tabs on first fill))
VAGINAL PROGESTINS
CRINONE GEL
ENDOMETRIN INSERT
PROGESTERONE SUPP
VASOPRESSORS
ANAPHYLAXIS THERAPY AGENTS
EPINEPHRINE PEN INJ 0.15MG (MYLAN) (QL= 2 inj/fill)
EPINEPHRINE PEN INJ 0.3MG (MYLAN) (QL= 2 inj/fill)
ADRENACLICK/EPINEPHRINE INJ
AUVI-Q/EPIPEN (JR) INJ
NEUROGENIC ORTHOSTATIC HYPOTENSION (NOH) - AGENTS
NORTHERA CAP
VASOPRESSORS
midodrine tab (PROAMATINE equiv)
VITAMINS
OIL SOLUBLE VITAMINS
ergocalciferol
MEPHYTON TAB
vitamin D cap
RAYALDEE CAP
WATER SOLUBLE VITAMINS
niacin cap
niacin CR tab (SLO-NIACIN equiv)
niacin tab
NIACIN TR TAB
niacinamide tab
POTABA TAB
Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.
*
NC
VAC
NC =Not Covered
Discounts may not apply who exceed 300% FPL
Not Covered
Vaccine Program
F
OTC
¢
generic =small letters
Formulary
Over-the-Counter
RxCENTS
LD
QL
BRANDS =CAPITAL LETTERS
Limited Distribution
Quantity Limit
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 94 of 101
Navi-Gate Rx Formulary
Last Updated* 1/1/2017
RxCents (Cost Savings Enabled by Tablet Splitting)
Tablet splitting helps control prescription drug benefit costs and can provide significant savings for members. Participation in the
program is voluntary. Through this program, members pay up to one-half of their usual copayment on a select group of prescription
drugs. Drugs included in this program are based on the following criteria:
• The drug product is on the formulary.
• The drug product is recognized as an appropriate product to split by the Pharmacy & Therapeutics Committee.
• The drug is flat priced (i.e. various strengths of the medication must be comparably priced).
• The medication must have once-daily dosing.
An example of the savings that can be realized through this program is illustrated below:
Product & Strength
Quantity
Member Copay
Without Tablet Splitting
Drug A 40 mg tab
30
$15.00
With Tablet Splitting
Drug A 80 mg tab
15
$7.50
Member Annual Savings
$90
As the example illustrates, tablet splitting allows members to receive the same dose in a fewer number of tablets; thus, the overall
RxCents Program Medications
aripiprazole tab
galantamine tab
tolterodine tab
AZILECT TAB
irbesartan tab
ULORIC TAB
BYSTOLIC TAB
JANUVIA TAB
VESICARE TAB
entecavir tab
rosuvastatin tab
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 95 of 101
Navi-Gate Rx Formulary
Last Updated* 1/1/2017
Over-the-Counter (OTC)
• The following OTC drugs are a covered benefit with a prescription
Over-the-Counter (OTC) Medications
ACCU-CHEK ACTIVE TEST
STRIP
ACCU-CHEK MULTICLIX
LANCETS
B-D INSULIN SYRINGE
CALIBRATION LIQUID
cetirizine/pseudoephedrine
12-hour tab
FREESTYLE FREEDOM
LITE METER
FREESTYLE INSULINX
TEST STRIPS
FREESTYLE TEST STRIP
ketotifen ophth soln
loratadine ODT
loratadine/pseudoephedrine
24-hour tab
NASACORT OTC NASAL
SPRAY
NIACIN TR TAB
NOVOLIN N INJ
NOVOTWIST PEN
NEEDLES
PREVACID OTC CAP
ACCU-CHEK AVIVA PLUS
TEST STRIP
ACCU-CHEK NANO
SMARTVIEW METER
BD INSULIN SYRINGES
cetirizine chew tab
fexofenadine tab
FREESTYLE FREEDOM
METER
FREESTYLE KIT INSULINX
guaifenesin
DM/pseudoephedrine tab
LANCETS
loratadine syrup
ACCU-CHEK COMFORT
CURVE TEST STRIP
ACCU-CHEK SMARTVIEW
TEST STRIP
B-D PEN NEEDLE
cetirizine syrup
fexofenadine/pseudoephedrin
e 12-hour tab
FREESTYLE INSULIN
SYRINGE
FREESTYLE LITE TEST
STRIP
guaifenesin/codeine syrup
ACCU-CHEK COMPACT
TEST STRIP
ALLEGRA-D TAB
lansoprazole cap
loratadine tab
BD PEN NEEDLES
cetirizine tab
fexofenadine/pseudoephedrin
e 24-hour tab
FREESTYLE INSULINX
TEST STRIP
FREESTYLE METER
KETO-DIASTIX TEST STRIP
meclizine chew tab
meclizine tab
levonorgestrel tab
loratadine/pseudoephedrine
12-hour tab
MUCINEX DM
niacin cap
niacin CR tab
niacin tab
niacinamide tab
NOVOLIN R INJ
PLAN B TAB
NOVOFINE PEN NEEDLES
NOVOPEN
PRECISION SURE-DOSE
INSULIN SYRINGES
ZEGERID CAP OTC
NOVOLIN 70/30 INJ
NOVOPEN JR
PRECISION XTRA TEST
STRIP
triamcinolone OTC nasal
spray
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 96 of 101
Navi-Gate Rx Formulary
Last Updated* 1/1/2017
Mandatory Specialty Pharmacy (MSP)
• Navitus utilizes a specialty pharmacy, experienced in handling specialty drugs, to coordinate personalized support for members
impacted by chronic illnesses and complex diseases.
• Specialty drugs are only available for a one month supply due to their high cost and use.
• The following drugs are required to be filled through a Specialty Pharmacy provider.
Mandatory Specialty Pharmacy (MSP) Medications
ACTIMMUNE INJ
COMETRIQ KIT
FERRIPROX SOLN
IMBRUVICA CAP
KUVAN POWDER PACK
SABRIL TAB
VALCHLOR GEL
ZYDELIG TAB
ADEMPAS TAB
CYSTAGON CAP
FERRIPROX TAB
IRESSA TAB
KUVAN TAB
SIGNIFOR INJ
VENTAVIS INH SOLN
CAPRELSA TAB
CYSTARAN OPHTH SOLN
GILOTRIF TAB
KINERET INJ
OPSUMIT TAB
SOMAVERT INJ
XYREM SOLN
CAYSTON INH SOLN
DARAPRIM TAB
ICLUSIG TAB
KORLYM TAB
SABRIL POWDER PACK
TYVASO INH SOLN
ZAVESCA CAP
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 97 of 101
Navi-Gate Rx Formulary
Last Updated* 1/1/2017
Quantity Limit (QL)
• The following drugs are covered on the formulary with a Quantity Limit.
Quantity Limit (QL) Medications
Drug Name
Quantity Limit
ABILIFY DISCMELT
ACTEMRA SC INJ
ADEMPAS TAB
AKYNZEO CAP
ALSUMA INJ
AMPYRA TAB
ANDRODERM
ANDROGEL 1.62% 1.25GM
ANDROGEL 1.62% 2.5GM
ANDROGEL PUMP 1.62%
aripiprazole ODT
aripiprazole tab
ASMANEX HFA INHALER
ASMANEX INHALER
AUBAGIO TAB
budesonide nasal spray
butorphanol nasal spray
BYDUREON INJ
BYDUREON PEN INJ
CABOMETYX TAB
celecoxib cap
CONTRAVE TAB
CYSTARAN OPHTH SOLN
diclofenac gel 1%
DIFICID TAB
donepezil ODT
donepezil tab
donepezil tab 23mg
duloxetine cap
ENBREL INJ 25MG
ENBREL INJ 50MG
ENBREL SURECLICK INJ 50MG
entecavir tab
EPINEPHRINE PEN INJ 0.15MG (MYLAN)
EPINEPHRINE PEN INJ 0.3MG (MYLAN)
eszopiclone tab
FARXIGA TAB
fentanyl citrate lollipop
FETZIMA CAP
FETZIMA TITRATION PACK
FLECTOR PATCH
fluticasone nasal spray
GILENYA CAP
GILOTRIF TAB
GLYXAMBI TAB
QL= 2 tabs/day
QL= 2 inj/28 days
QL= 3 tabs/day; Only available through Accredo 888-773-7376
QL= 1 cap/fill
QL= 4 inj/fill, 2 fills/30 days
QL= 2 tabs/day
QL= 1 patch/day
QL= 1 packet/day
QL= 2 packets/day
QL= 2 bottles/30 days
QL= 2 tabs/day
QL= 2 tabs/day
QL= 1 inhaler/fill
QL= 1 inhaler/fill
QL= 1 tab/day
QL= 2 bottles/fill
QL= 1 bottle/fill, 2 fills/30 days
QL= 4 inj/28 days
QL= 4 inj/28 days
QL= 1 tab/day
QL= 2 caps/day
QL= 4 tabs/day
QL= 4 bottles/30 days; Only available through Walgreens 888-347-3416
QL= 5 tubes/fill
QL= 20 tabs/fill
QL= 1 tab/day
QL= 2 tabs/day
QL= 1 tab/day
QL= 2 caps/day
QL= 8 inj/28 days
QL= 4 inj/28 days
QL= 4 inj/28 days
QL= 1 tab/day
QL= 2 inj/fill
QL= 2 inj/fill
QL= 1 tab/day
QL= 1 tab/day
QL= 120 lozenges/30 days
QL= 1 cap/day
QL= 1 cap/day
QL= 30 patches/fill
QL= 2 bottles/fill
QL= 1 cap/day
QL= 1 tab/day, Only available through Accredo 888-773-7376
QL= 1 tab/day
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 98 of 101
Navi-Gate Rx Formulary Cont.
Last Updated* 1/1/2017
Quantity Limit (QL)
• The following drugs are covered on the formulary with a Quantity Limit.
Quantity Limit (QL) Medications
Drug Name
Quantity Limit
guaifenesin/codeine syrup
QL= 240ml/fill
HARVONI TAB
QL= 1 tab/day
HUMIRA INJ
QL= 2 inj/28 days
HUMIRA PEN INJ
QL= 2 inj/28 days
hydrocodone/chlorpheniramine/pseudoephe QL= 4 oz/Rx; 2 fills/month
drine liquid
HYSINGLA ER TAB
QL= 1 tab/day
ibandronate tab 150mg
QL= 1 tab/month
IMBRUVICA CAP
QL= 4 caps/day; Only available through Diplomat Pharmacy 877-977-9118
INLYTA TAB
QL= 8 tabs/day
JAKAFI TAB
QL= 2 tabs/day
JANUVIA TAB
QL= 1 tab/day
JARDIANCE TAB
QL= 1 tab/day
JENTADUETO TAB
QL= 2 tabs/day
JENTADUETO XR TAB
QL= 2 tabs/day
KALYDECO PAK
QL= 2 packets/day
KALYDECO TAB
QL= 2 tabs/day
ketorolac tab
QL= 20 tabs/5 days
KINERET INJ
QL= 1 inj/day; Only available through Rx Crossroads: 1-866-547-0644
LASTACAFT OPHTH SOLN
QL= 3ml/30 days
latanoprost ophth soln
QL= 2.5ml/30 days
LAZANDA NASAL SPRAY
QL= 15 bottles/30 days
LETAIRIS TAB
QL= 1 tab/day
LUMIGAN OPHTH SOLN
QL= 2.5ml/30 days
MAXALT TAB
QL= 12 tabs/fill, 3 fills/60 days
methylergonovine tab
QL= 28 tabs/fill; 1 fill/365 days
modafinil tab
QL= 2 tabs/day
mometasone nasal spray
QL= 2 bottles/fill
MORPHINE SULFATE ER BEAD CAP
QL= 2 caps/day
naratriptan tab
QL= 9 tabs/fill; 2 fills/30 days
NASACORT OTC NASAL SPRAY
QL= 2 bottles/fill
NATROBA SUSP
QL= 1 bottle/fill
NUCYNTA ER TAB
QL= 2 tabs/day
NUEDEXTA CAP
QL= 2 caps/day
OMNARIS NASAL SPRAY
QL= 2 bottles/fill
OPSUMIT TAB
QL= 1 tab/day, Only available through Walgreens 888-347-3416
oseltamivir cap
QL= 10 caps/fill
oseltamivir cap 30mg
QL= 20 caps/fill
OXYCONTIN CR TAB
QL= 120 tabs/30 days
PATADAY OPHTH SOLN
QL= 2.5ml/30 days
POTIGA TAB
QL= 3 tabs/day
QNASL NASAL SPRAY
QL= 2 bottles/fill
REGRANEX GEL
QL= 30 grams/fill
RELENZA DISKHALER
QL= 1 inhaler/fill
REVLIMID CAP
QL= 1 tab/day
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 99 of 101
Navi-Gate Rx Formulary Cont.
Last Updated* 1/1/2017
Quantity Limit (QL)
• The following drugs are covered on the formulary with a Quantity Limit.
Quantity Limit (QL) Medications
Drug Name
Quantity Limit
rizatriptan ODT
SAVELLA TAB
SIGNIFOR INJ
SIVEXTRO TAB
SOVALDI TAB
STIVARGA TAB
STRIVERDI RESPIMAT INHALER
sumatriptan inj
SUMATRIPTAN INJ 6MG/0.5ML
sumatriptan nasal spray
sumatriptan tab
sumatriptan vial inj
SYNJARDY TAB
TAFINLAR CAP
TAMIFLU CAP
TAMIFLU CAP 30MG
TAMIFLU SUSP 6mg/ml
testosterone gel 1% 25mg
TESTOSTERONE GEL 1% 50MG
testosterone gel 1% pump
TESTOSTERONE GEL PUMP
TIVICAY TAB
TRACLEER TAB
TRADJENTA TAB
TRAVATAN Z OPHTH SOLN
triamcinolone nasal spray
triamcinolone OTC nasal spray
TRINTELLIX TAB
UCERIS TAB
ULESFIA LOTION
VALCHLOR GEL
vancomycin cap
VENTOLIN HFA INHALER
VERAMYST NASAL SPRAY
V-GO 20 KIT
VICTOZA INJ
VIMPAT TAB
VOLTAREN GEL
VYTORIN TAB
XIGDUO XR TAB
XIGDUO XR TAB 5-1000MG
XTANDI CAP
XYREM SOLN
yuvafem tab
ZETIA TAB
QL= 12 tabs/fill, 3 fills/60 days
QL= 2 tabs/day
QL= 2 vials/day; Only available through Accredo 888-773-7376
QL= 6 tabs/fill
QL= 1 tab/day
QL= 4 tabs/day
QL= 1 inhaler/30 days
QL= 4 inj/fill, 2 fills/30 days
QL= 4 inj/fill, 2 fills/30 days
QL= 6 sprays/fill, 2 fills/30 days
QL= 9 tabs/fill; 2 fills/30 days
QL= 5 inj/fill, 2 fills/30 days
QL= 2 tabs/day
QL= 4 caps/day
QL= 10 caps/fill
QL= 20 caps/fill
QL= 250 ml/fill
QL= 1 packet/day
QL= 2 packets/day
QL= 4 bottles/30 days
QL= 4 bottles/30 days
QL= 2 tabs/day
QL= 2 tabs/day
QL= 1 tab/day
QL= 5 ml/30 days
QL= 2 bottles/fill
QL= 2 bottles/fill
QL= 1 tab/day
QL= 1 tab/day
QL= 4 bottles/fill
QL= 4 tubes/30 days; Only available through Accredo 888-773-7376
QL= 56 caps/fill
QL= 2 inhalers/fill, 2 fills/30 days
QL= 2 bottles/fill
QL= 1 kit/day
QL= 9 ml/30 days
QL= 2 tabs/day
QL= 1 tab/day; 10/80mg tab is Not Covered
QL= 1 tab/day
QL= 2 tabs/day
QL= 4 caps/day
QL= 540ml/30 days; Only available through Xyrem Central Pharmacy 866-997-3688
QL= 8 tabs/28 days (18 tabs on first fill)
QL= 1 tab/day
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 100 of 101
Navi-Gate Rx Formulary Cont.
Last Updated* 1/1/2017
Quantity Limit (QL)
• The following drugs are covered on the formulary with a Quantity Limit.
Quantity Limit (QL) Medications
Drug Name
Quantity Limit
ZETONNA NASAL SPRAY
zolmitriptan ODT
zolmitriptan tab
zolpidem tab 10mg
zolpidem tab 5mg
ZOMIG NASAL SPRAY
ZOMIG TAB
ZOMIG ZMT TAB
QL= 2 bottles/fill
QL= 9 tabs/fill, 2 fills/30 days
QL= 9 tabs/fill; 2 fills/30 days
Male QL= 1 tab/day; Female QL= 0.5 tab/day
QL= 1 tab/day
QL= 6 sprays/fill; 2 fills/30 days
QL= 9 tabs/fill; 2 fills/30 days
QL= 9 tabs/fill, 2 fills/30 days
Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims
transaction processing.** Products listed may not be all inclusive and are subject to change.
Page 101 of 101

Download this short guide

Saudi Arabia over the Counter (OTC) Drugs Market (1)

Middle-East And Africa Over The Counter (OTC) Drugs Market

Global Over The Counter (OTC) Drugs Market

Germany over the Counter (OTC) Drugs Market

North America Over The Counter (OTC) Drugs Market

South Korea over the Counter (OTC) Drugs Market

Promo- Latin America Over The Counter (OTC) Drugs Market

Over-the-counter Drugs Market Set for Rapid Growth and Trend, by 2026