2016
Humana Drug List
This is a list of covered drugs
Please read: This document
contains information about the
drugs we cover in this plan.
2016 Rx4 Traditional Drug
List
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Humana.com
2016Rx4TC
PDL0041B
Welcome to Humana
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This Humana Drug List (formulary) is effective as of January 1, 2016 for employers plans, members, and healthcare
providers. This is an all-inclusive list and may change throughout the year.
What is the Drug List?
The Drug List is a list of covered drugs selected by Humana.* Humana will cover the drugs in our drug list as long
as the drug is medically necessary , the prescription is filled at a Humana network pharmacy and other plan rules
are followed.
If you have this insurance through your employer and live in Texas or Louisiana: You will continue to use the 2015
version of this formulary until your plan's renewal date in 2016. You can find that Drug List at Humana.com/DrugList.
How do I use the formulary?
Drugs are listed in the formulary alphabetically.
Prescription drugs are grouped into one of four levels – Level 1, Level 2, Level 3, or Level 4. Generic drugs have the
same active ingredients as brand drugs and are prescribed for the same reasons. The FDA requires generics to be safe
and work the same as brand name drugs. Generic drugs often cost much less.
•
Level One – Includes low-cost generic and brand-name drugs.
•
Level Two – Includes higher-cost generic and brand-name drugs.
•
Level Three – Includes high-cost, mostly brand-name drugs. These drugs may have generic or brand-name
alternatives in Levels 1 or 2.
•
Level Four – Includes highest-costs drugs.
•
*Specialty Drugs: High-cost/high-technology drugs that can often only be obtained at specialty pharmacies.
Please visit Humana.com and log into MyHumana to view specific prescription drug benefits, including
copayments or cost-share, limitations and exclusions; OR refer to your Certificate of Coverage/Insurance or
Summary Plan Description/Policy of Insurance.
Please note:
If your drug isn't included in this printed list of covered drugs, you should visit Humana.com following the instructions
below to see if your drug is covered.
• If Humana doesn't cover your drug, your doctor can ask Humana for approval. Generally, Humana will only
approve a request if a covered drug wouldn't work as well OR would have a negative effect on your health.
• Some covered drugs may have additional requirements or limits on coverage, such as requiring your doctor to get
advance approval from Humana in order to be covered under your pharmacy plan (also known as prior
authorization). Please follow the instructions on page 3 to get information on specific drug coverage.
Can the formulary change?
Yes. The Humana Pharmacy & Therapeutics (P&T) Committee reviews and updates the drug list regularly. New drugs
are added as needed, and drugs that are deemed unsafe by the Food and Drug Administration (FDA) or a drug's
manufacturer are immediately removed.
We communicate changes to the drug list to members based on the drug list notification requirements established by
each state. Members can view the most up-to-date drug list on Humana.com.
How much will I pay for covered drugs?
The amount of money you pay often depends on which drug level your medicine falls within the drug list and whether
you fill your prescription at a network pharmacy. Please refer to your Certificate of Coverage/ Summary Plan
Description/Policy of Insurance or call the number on the back of your Humana ID card to reach customer care to find
out more about your pharmacy coverage.
For specific coverage and cost information:
•
•
•
•
Visit Humana.com and log into MyHumana
Access the drug search tool through "Drug Pricing Tool" under "Tools & Resources" at the bottom of the page.
Search for your drug by name or by your condition.
Please note: MyHumana only shows benefits as of the date of log in. Depending on your plan, you should wait
until after your plan's 2016 renewal date to see your new benefit information.
2 - FORMULARY Updated 09/2015
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits
may include:
•
Prior authorization (PA): Some medicines need to be approved in advance to be covered under your pharmacy
plan. For these medicines to be covered, your doctor must get approval from Humana. Your plan benefits won't
cover this drug without prior authorization. You may pay the entire cost of the drug if you buy it without first
getting a prior authorization.
•
Quantity limits (QL): You may have a limit on how much you can get of some drugs at one time. These limits can
be placed on some drugs because of safety or health care concerns and help prevent misuse of these drugs. If
your prescription is over the limit there are two choices:
•
–
You can get the amount of drug that's covered by your plan, and then pay out-of-pocket for any drug that's
over the limit.
Or
–
If your doctor thinks you need more than the amount allowed, he or she can ask for prior authorization from
Humana for the amount of the drug that goes over the limit.
Step therapy (ST): Sometimes there's more than one drug that works to treat a health condition. Some drugs may
cost less but still work for you. Before a prescription is filled for a drug that costs more, you may be asked to try at
least one other drug first.
Talk to your doctor or health care provider if your drug has an additional requirement. Ask your doctor or health care
provider to contact Humana Clinical Pharmacy Review (HCPR) to ask for approval for a drug that requires prior
authorization, quantity limit, or step therapy. Your doctor can contact HCPR at 1-800-555-2546 between 8 a.m. – 6
p.m., Monday – Friday to request an approval. Please allow 24-48 hours for Humana to review and provide a response
back to your doctor.
You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on
page 5.
What if my drug is not on the formulary?
You can use the drug search tool by signing into MyHumana at Humana.com to view alternatives for your drug. You
can access the drug search tool through "Drug Pricing" under "Plan Tools" at the bottom of the page.
Your doctor can ask Humana to make an exception. Generally, Humana will only approve a request if a covered drug
wouldn’t work as well OR would have a negative effect on your health. To ask for an approval, your doctor can contact
HCPR at 1-800-555-2546 between 8 a.m. – 6 p.m., Monday – Friday.
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For More Information
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For more detailed information about your Humana prescription drug coverage, please review your Certificate of
Insurance/Summary Plan Description/Policy of Insurance and other plan materials.
If you have questions:
• If you're thinking about enrolling in a Humana plan, please call Customer Care number listed in your enrollment
materials
•
If you're already enrolled in a Humana plan, please call the number on the back of your Humana member ID card
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FORMULARY Updated 09/2015 - 3
2016 Rx4 Traditional Drug List
W
The formulary that begins on the next page provides coverage information about some of the drugs covered
by Humana.
How to read your formulary
The first column of the chart lists drug names in alphabetical order. Brand-name drugs are listed in UPPER CASE and
generic drugs are listed in lower case. Next to the drug name you may see the following indicators to tell you about
additional coverage information for that drug:
MM – Maintenance drugs are taken long-term such as drugs you take for high cholesterol, mental health, or high
blood pressure. Coverage may be different by plan and you may be required to fill your prescriptions using your plan's
mail-delivery pharmacy.
SP – Specialty medicines are typically high-cost/high-technology drugs that can often only be obtained at specialty
pharmacies. Specialty drug coverage may be different by plan.
The second column lists the drug level. See page 2 for more details on the drug levels in your plan.
The third column shows the utilization management requirements for the drug. Utilization management requirements
mean that Humana may have special rules for covering that drug. These can include prior authorization, quantity
limits, or step therapy requirements. The quantity limit for each drug is based on safety or health care concerns and
whether your doctor prescribes a supply for 30, 60, or 90 days. See page 3 for more details on these requirements for
your plan.
4 - FORMULARY Updated 09/2015
for PDL007
DRUG NAME
1ST TIER UNIFINE PENTIPS 29 GAUGE X 1/2" NEEDLE
1ST TIER UNIFINE PENTIPS 31 GAUGE X 1/4" NEEDLE
1ST TIER UNIFINE PENTIPS 31 X 3/16" NEEDLE
1ST TIER UNIFINE PENTIPS 31 X 5/16" NEEDLE
1ST TIER UNIFINE PENTIPS 32 X 5/32" NEEDLE
1ST TIER UNILET COMFORTOUCH LANCET 30 GAUGE
2TEK CONTROL (HIGH-NORMAL) SOLUTION
2TEK GLUCOSE/BLOOD PRESSURE KIT
8-MOP 10 MG CAPSULE
abacavir 300 mg tablet
abacavir-lamivudine-zidov tab
ABILIFY 1 MG/ML SOLUTION MM
ABILIFY 10 MG TABLET MM
ABILIFY 15 MG TABLET MM
ABILIFY 2 MG TABLET MM
ABILIFY 20 MG TABLET MM
ABILIFY 30 MG TABLET MM
ABILIFY 5 MG TABLET MM
ABILIFY DISCMELT 10 MG TABLET MM
ABILIFY DISCMELT 15 MG TABLET MM
ABSORICA 10 MG CAPSULE
ABSORICA 20 MG CAPSULE
ABSORICA 25 MG CAPSULE
ABSORICA 30 MG CAPSULE
ABSORICA 35 MG CAPSULE
ABSORICA 40 MG CAPSULE
ABSTRAL 100 MCG SUBLINGUAL TABLET
ABSTRAL 200 MCG SUBLINGUAL TABLET
ABSTRAL 300 MCG SUBLINGUAL TABLET
ABSTRAL 400 MCG SUBLINGUAL TABLET
ABSTRAL 600 MCG SUBLINGUAL TABLET
ABSTRAL 800 MCG SUBLINGUAL TABLET
acamprosate calc dr 333 mg tab MM
ACANYA 1.2 %-2.5 % TOPICAL GEL
acarbose 100 mg tablet MM
acarbose 25 mg tablet MM
acarbose 50 mg tablet MM
ACCOLATE 10 MG TABLET MM
ACCOLATE 20 MG TABLET MM
ACCU-CHEK ACTIVE GLUCOSE CONT COMBO PACK
ACCU-CHEK ACTIVE TEST STRIPS MM
ACCU-CHEK AVIVA CONNECT METER
ACCU-CHEK AVIVA CONTROL SOLN SOLUTION
ACCU-CHEK AVIVA PLUS METER
ACCU-CHEK AVIVA PLUS TEST STRIPS MM
DRUG LEVEL
1
1
1
1
1
1
3
3
3
2
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
3
2
2
2
2
3
3
1
1
1
3
1
1
UTILIZATION
MANAGEMENT
REQUIREMENTS
ST
QL
QL
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL
QL
QL
QL
QL
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 5
DRUG NAME
ACCU-CHEK AVIVA STRIPS MM
ACCU-CHEK CMFRT CURVE SOLN
ACCU-CHEK CMFRT CURVE SOLN
ACCU-CHEK CMFRT CURVE SOLN
ACCU-CHEK CMFRT CURVE STRIP MM
ACCU-CHEK COMPACT BLUE CONTROL, MID-HIGH SOLUTION
ACCU-CHEK COMPACT PLUS CARE KIT
ACCU-CHEK COMPACT PLUS CONTROL SOLUTION
ACCU-CHEK COMPACT PLUS TEST STRIPS MM
ACCU-CHEK COMPACT TEST STRIPS MM
ACCU-CHEK FASTCLIX
ACCU-CHEK FASTCLIX KIT
ACCU-CHEK MULTICLIX LANCET
ACCU-CHEK MULTICLIX LANCET KIT
ACCU-CHEK NANO
ACCU-CHEK SAFE-T-PRO 23 GAUGE
ACCU-CHEK SAFE-T-PRO PLUS 23 GAUGE
ACCU-CHEK SMARTVIEW CONTROL SOLUTION
ACCU-CHEK SMARTVIEW TEST STRIPS MM
ACCU-CHEK SOFTCLIX LANCET DEV
ACCU-CHEK SOFTCLIX LANCETS
ACCU-CHEK SOFTCLIX LANCING DEVICE+LANCETS KIT
ACCU-CHEK VOICEMATE KIT
ACCUNEB 0.63 MG/3 ML INH SOLN MM
ACCUNEB 1.25 MG/3 ML INH SOLN MM
ACCUPRIL 10 MG TABLET MM
ACCUPRIL 20 MG TABLET MM
ACCUPRIL 40 MG TABLET MM
ACCUPRIL 5 MG TABLET MM
ACCURETIC 10 MG-12.5 MG TABLET MM
ACCURETIC 20 MG-12.5 MG TABLET MM
ACCURETIC 20 MG-25 MG TABLET MM
ACCUTREND GLUCOSE CONTROL SOLUTION
ACCUTREND GLUCOSE STRIPS MM
ACD 2.45-2.2 GRAM-730 MG/100 ML SOLUTION
ACD-A SOLUTION
ACE AEROSOL CLOUD ENHANCER SPACER
acebutolol 200 mg capsule MM
acebutolol 400 mg capsule MM
ACEON 4 MG TABLET MM
ACEON 8 MG TABLET MM
acetamin-codein 300-30 mg/12.5
acetaminop-codeine 120-12 mg/5
acetaminop-codeine 120-12 mg/5
acetaminoph-caff-dihydrocodein
acetaminophen-cod #2 tablet
acetaminophen-cod #3 tablet
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
6 - FORMULARY Updated 09/2015
DRUG LEVEL
1
1
3
1
1
3
1
3
1
1
1
1
1
1
1
1
1
3
1
1
1
1
1
3
3
3
3
3
3
3
3
3
3
1
3
3
1
1
1
3
3
2
2
2
3
2
2
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
DRUG NAME
acetaminophen-cod #4 tablet
acetaminophn-butalbital 325-50
acetasol hc 1 %-2 % ear drops
acetazolamide 125 mg tablet MM
acetazolamide 250 mg tablet MM
acetazolamide er 500 mg cap MM
ACETEST TABLET,NON-ORAL MM
acetic acid 0.25% irrig soln
acetic acid 2% ear solution
acetic acid-aluminum drops
acetylcysteine 10% vial
acetylcysteine 20% vial
ACIPHEX 20 MG TABLET,DELAYED RELEASE MM
ACIPHEX SPRINKLE 10 MG CAPSULE,DELAYED RELEASE SPRINKLE MM
ACIPHEX SPRINKLE 5 MG CAPSULE,DELAYED RELEASE SPRINKLE MM
acitretin 10 mg capsule
acitretin 17.5 mg capsule
acitretin 25 mg capsule
ACTEMRA 162 MG/0.9 ML SUBCUTANEOUS SYRINGE SP
ACTHAR H.P. 80 UNIT/ML INJECTION GEL SP
ACTI-LANCE LANCETS 17 GAUGE
ACTI-LANCE LANCETS 23 GAUGE
ACTI-LANCE LANCETS 28 GAUGE
ACTICLATE 150 MG TABLET SP
ACTICLATE 75 MG TABLET SP
ACTIGALL 300 MG CAPSULE MM
ACTIMMUNE 100 MCG (2 MILLION UNIT)/0.5 ML SUBCUTANEOUS SOLUTION SP
ACTIQ 1,200 MCG LOZENGE ON A HANDLE
ACTIQ 1,600 MCG LOZENGE ON A HANDLE
ACTIQ 200 MCG LOZENGE ON A HANDLE
ACTIQ 400 MCG LOZENGE ON A HANDLE
ACTIQ 600 MCG LOZENGE ON A HANDLE
ACTIQ 800 MCG LOZENGE ON A HANDLE
ACTIVE FE 75 MG IRON-1,250 MCG TABLET
ACTIVE OB 20 MG IRON-1 MG-320 MG CAPSULE
ACTIVELLA 0.5 MG-0.1 MG TABLET MM
ACTIVELLA 1 MG-0.5 MG TABLET MM
ACTONEL 150 MG TABLET MM
ACTONEL 30 MG TABLET
ACTONEL 35 MG TABLET MM
ACTONEL 5 MG TABLET MM
ACTOPLUS MET 15 MG-500 MG TABLET MM
ACTOPLUS MET 15 MG-850 MG TABLET MM
ACTOPLUS MET XR 15 MG-1,000 MG TABLET,EXTENDED RELEASE MM
ACTOPLUS MET XR 30 MG-1,000 MG TABLET,EXTENDED RELEASE MM
ACTOS 15 MG TABLET MM
DRUG LEVEL
2
2
3
3
3
3
3
2
2
3
3
3
3
3
3
4
4
4
*
*
1
1
1
*
*
4
*
4
4
4
4
4
4
3
3
3
3
3
3
3
3
4
4
4
4
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL,ST
QL,ST
QL,ST
PA
PA
PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL
QL
QL
QL
QL
QL
QL,ST
QL,ST
QL
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 7
DRUG NAME
ACTOS 30 MG TABLET MM
ACTOS 45 MG TABLET MM
acuicyn 0.01 % topical spray
ACULAR 0.5 % EYE DROPS
ACULAR LS 0.4 % EYE DROPS
ACURA CONTROL SOLUTION HIGH
ACURA CONTROL SOLUTION LOW
ACURA CONTROL SOLUTION NORMAL
ACURA METER KIT
ACURA PLUS METER KIT
ACURA STARTER KIT
ACURA TEST STRIPS MM
ACUVAIL (PF) 0.45 % EYE DROPS IN A DROPPERETTE
acyclovir 200 mg capsule MM
acyclovir 200 mg/5 ml susp MM
acyclovir 400 mg tablet MM
acyclovir 5% ointment
acyclovir 800 mg tablet MM
ACZONE 5 % TOPICAL GEL
ADALAT CC 30 MG TABLET,EXTENDED RELEASE MM
ADALAT CC 60 MG TABLET,EXTENDED RELEASE MM
ADALAT CC 90 MG TABLET,EXTENDED RELEASE MM
adapalene 0.1% cream
adapalene 0.1% gel
adapalene 0.1% lotion
adapalene 0.3% gel
adapalene 0.3% gel pump
ADASUVE 10 MG BREATH ACTIVATED SP
ADCIRCA 20 MG TABLET SP
ADDERALL 10 MG TABLET
ADDERALL 12.5 MG TABLET
ADDERALL 15 MG TABLET
ADDERALL 20 MG TABLET
ADDERALL 30 MG TABLET
ADDERALL 5 MG TABLET
ADDERALL 7.5 MG TABLET
ADDERALL XR 10 MG CAPSULE,EXTENDED RELEASE
ADDERALL XR 15 MG CAPSULE,EXTENDED RELEASE
ADDERALL XR 20 MG CAPSULE,EXTENDED RELEASE
ADDERALL XR 25 MG CAPSULE,EXTENDED RELEASE
ADDERALL XR 30 MG CAPSULE,EXTENDED RELEASE
ADDERALL XR 5 MG CAPSULE,EXTENDED RELEASE
adefovir dipivoxil 10 mg tab SP
ADEMPAS 0.5 MG TABLET SP
ADEMPAS 1 MG TABLET SP
ADEMPAS 1.5 MG TABLET SP
ADEMPAS 2 MG TABLET SP
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
8 - FORMULARY Updated 09/2015
DRUG LEVEL
3
3
3
3
3
3
3
3
3
3
3
3
3
2
2
2
3
2
3
3
3
3
3
3
3
3
3
*
*
3
3
3
3
3
3
3
3
3
3
3
3
3
*
*
*
*
*
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
ST
ST
ST
ST
ST
QL,ST
ST
PA
QL
QL
QL
ST
QL,PA
QL,PA
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL,PA
QL,PA
QL,PA
QL,PA
DRUG NAME
ADEMPAS 2.5 MG TABLET SP
ADJUSTABLE LANCING DEVICE
ADOXA 150 MG CAPSULE
ADRENACLICK 0.15 MG/0.15 ML (1:1,000) INJECTION,AUTO-INJECTOR
ADRENACLICK 0.3 MG/0.3 ML (1:1,000) INJECTION,AUTO-INJECTOR
ADRENALIN 1:1,000 (0.1 %) NASAL SOLUTION
ADVAIR DISKUS 100 MCG-50 MCG/DOSE POWDER FOR INHALATION MM
ADVAIR DISKUS 250 MCG-50 MCG/DOSE POWDER FOR INHALATION MM
ADVAIR DISKUS 500 MCG-50 MCG/DOSE POWDER FOR INHALATION MM
ADVAIR HFA 115 MCG-21 MCG/ACTUATION AEROSOL INHALER MM
ADVAIR HFA 230 MCG-21 MCG/ACTUATION AEROSOL INHALER MM
ADVAIR HFA 45 MCG-21 MCG/ACTUATION AEROSOL INHALER MM
ADVANCED DNA MEDICATED COLLECTION 2 % MUCOSAL KIT
ADVANCED GLUCOSE METER
ADVANCED GLUCOSE METER TEST STRIPS MM
ADVANCED LANCING DEVICE KIT
ADVANCED TRAVEL LANCETS 28 GAUGE
ADVANCED TRAVEL LANCETS 30 GAUGE
ADVICOR 1,000 MG-20 MG TABLET,EXTENDED RELEASE MM
ADVICOR 1,000 MG-40 MG TABLET,EXTENDED RELEASE MM
ADVICOR 500 MG-20 MG TABLET,EXTENDED RELEASE MM
ADVICOR 750 MG-20 MG TABLET,EXTENDED RELEASE MM
ADVOCATE BLOOD GLUCOSE MONITOR
ADVOCATE CONTROL SOLUTION HIGH
ADVOCATE DUO DEVICE
ADVOCATE DUO METER KIT
ADVOCATE LANCET 26 GAUGE
ADVOCATE LANCET 30 GAUGE
ADVOCATE LANCING DEVICE
ADVOCATE LOW CONTROL SOLUTION
ADVOCATE PEN NEEDLES 29 GAUGE X 1/2"
ADVOCATE PEN NEEDLES 31 X 3/16"
ADVOCATE PEN NEEDLES 31 X 5/16"
ADVOCATE RAPID-SAFE LANCING DEVICE
ADVOCATE REDI-CODE
ADVOCATE REDI-CODE DUO METER
ADVOCATE REDI-CODE GLUCOSE MONITOR KIT
ADVOCATE REDI-CODE STRIPS MM
ADVOCATE REDI-CODE+
ADVOCATE REDI-CODE+ CTRL HIGH SOLUTION
ADVOCATE REDI-CODE+ CTRL LOW SOLUTION
ADVOCATE REDI-CODE+ STRIPS MM
ADVOCATE SYRINGES 0.3 ML 29 X 1/2" MM
ADVOCATE SYRINGES 0.3 ML 30 X 5/16" MM
ADVOCATE SYRINGES 0.3 ML 31 X 5/16" MM
ADVOCATE SYRINGES 1 ML 29 X 1/2" MM
ADVOCATE SYRINGES 1 ML 30 X 5/16" MM
DRUG LEVEL
*
3
4
3
3
2
2
2
2
2
2
2
3
3
3
1
1
1
3
3
3
3
3
3
3
3
1
1
1
3
1
1
1
3
3
3
3
3
3
3
3
3
1
1
1
1
1
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,PA
QL,PA
QL
QL
QL
QL
QL
QL
ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
ST
ST
ST
ST
ST
ST
QL,ST
ST
QL,ST
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 9
DRUG NAME
ADVOCATE SYRINGES 1 ML 31 X 5/16" MM
ADVOCATE SYRINGES 1/2 ML 29 X 1/2" MM
ADVOCATE SYRINGES 1/2 ML 30 X 5/16" MM
ADVOCATE SYRINGES 1/2 ML 31 X 5/16" MM
ADVOCATE TEST STRIPS MM
aero otic hc ear drops
AEROCHAMBER MINI
AEROCHAMBER MV SPACER
AEROCHAMBER PLUS FLOW-VU
AEROCHAMBER PLUS FLOW-VU,LARGE MASK
AEROCHAMBER PLUS FLOW-VU,MEDIUM MASK
AEROCHAMBER PLUS FLOW-VU,SMALL MASK
AEROCHAMBER PLUS Z STAT LARGE MASK
AEROCHAMBER PLUS Z STAT MEDIUM MASK
AEROCHAMBER PLUS Z STAT SMALL MASK
AEROCHAMBER PLUS Z STAT SPACER
AEROCHAMBER WITH FLOWSIGNAL
AEROCHAMBER Z-STAT PLUS-FLOW SIGNAL
AEROGEAR ACTION ASTHMA KIT
AEROSPAN 80 MCG/ACTUATION HFA AEROSOL INHALER MM
AEROTRACH PLUS SPACER
afeditab cr 30 mg tablet,extended release MM
afeditab cr 60 mg tablet,extended release MM
AFINITOR 10 MG TABLET SP
AFINITOR 2.5 MG TABLET SP
AFINITOR 5 MG TABLET SP
AFINITOR 7.5 MG TABLET SP
AFINITOR DISPERZ 2 MG TABLET FOR ORAL SUSPENSION SP
AFINITOR DISPERZ 3 MG TABLET FOR ORAL SUSPENSION SP
AFINITOR DISPERZ 5 MG TABLET FOR ORAL SUSPENSION SP
AFLURIA 2015-2016 (PF) 45 MCG (15 MCG X 3)/0.5 ML IM SYRINGE
AFLURIA 2015-2016 45 MCG (15 MCG X 3)/0.5 ML INTRAMUSCULAR SUSPENSION
AFREZZA 4 UNIT (30)/8 UNIT (60) CARTRIDGE WITH INHALATION DEVICE
AFREZZA 4 UNIT (60)/8 UNIT (30) CARTRIDGE WITH INHALATION DEVICE
AFREZZA 4 UNIT CARTRIDGE WITH INHALATION DEVICE
AFREZZA 8 UNIT (60)/12 UNIT (30) CARTRIDGE WITH INHALATION DEVICE
AGAMATRIX AMP GLUCOSE MONITORING SYSTEM
AGAMATRIX AMP TEST STRIPS MM
AGAMATRIX CONTROL HIGH SOLUTION
AGAMATRIX CONTROL NORM-HI SOLUTION
AGGRENOX 25 MG-200 MG CAPSULE, EXTENDED RELEASE MM
AGRYLIN 0.5 MG CAPSULE MM
ak-poly-bac 500 unit-10,000 unit/gram eye ointment
AKNE-MYCIN 2% OINTMENT
AKTEN (PF) 3.5 % EYE GEL
AKYNZEO 300 MG-0.5 MG CAPSULE
ALA-CORT 1 % TOPICAL CREAM
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
10 - FORMULARY Updated 09/2015
DRUG LEVEL
1
1
1
1
3
2
1
1
3
1
1
2
1
2
1
1
1
2
1
3
1
2
2
*
*
*
*
*
*
*
3
3
3
3
3
3
3
3
3
3
3
4
1
3
3
4
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,ST
QL,ST
QL
QL
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
ST
QL,ST
ST
QL,PA
DRUG NAME
ALA-QUIN 3 %-0.5 % TOPICAL CREAM
ALA-SCALP 2 % LOTION
alagesic lq oral solution
ALBENZA 200 MG TABLET
ALBUSTIX REAGENT STRIPS
albuterol 2.5 mg/0.5 ml sol MM
albuterol 5 mg/ml solution MM
albuterol sul 0.63 mg/3 ml sol MM
albuterol sul 1.25 mg/3 ml sol MM
albuterol sul 2.5 mg/3 ml soln MM
albuterol sulf 2 mg/5 ml syrup MM
albuterol sulfate 2 mg tab MM
albuterol sulfate 4 mg tab MM
albuterol sulfate er 4 mg tab MM
albuterol sulfate er 8 mg tab MM
ALCAINE 0.5 % EYE DROPS
alclometasone dipr 0.05% oint
alclometasone dipro 0.05% crm
ALCOHOL 70% SWABS
ALCOHOL PADS
ALCOHOL PREP PADS
ALCOHOL PREP SWABS
ALCOHOL WIPES
ALCORTIN A 2 %-1 %-1 % TOPICAL GEL
ALCORTIN A 2 %-1 %-1 % TOPICAL GEL PACKET
ALDACTAZIDE 25 MG-25 MG TABLET MM
ALDACTAZIDE 50 MG-50 MG TABLET MM
ALDACTONE 100 MG TABLET MM
ALDACTONE 25 MG TABLET MM
ALDACTONE 50 MG TABLET MM
ALDARA 5 % TOPICAL CREAM PACKET
alendronate sod 70 mg/75 ml MM
alendronate sodium 10 mg tab MM
alendronate sodium 35 mg tab MM
alendronate sodium 40 mg tab MM
alendronate sodium 5 mg tablet MM
alendronate sodium 70 mg tab MM
alfuzosin hcl er 10 mg tablet MM
ALINIA 100 MG/5 ML ORAL SUSPENSION
ALINIA 500 MG TABLET
ALKERAN 2 MG TABLET
ALLERGIST SYRINGE 1 ML 26 X 1/2"
ALLERGIST SYRINGE 1 ML 26 X 3/8"
ALLERGIST SYRINGE 1 ML 27 X 1/2"
ALLERGIST TRAY 1/2 ML 27GX3/8" 1/2 ML 27 X 3/8" SYRINGE
ALLERGIST TRAY INTRADERMAL BEVEL 1 ML 26 X 1/2" SYRINGE
ALLERGIST TRAY INTRADERMAL BEVEL 1 ML 26 X 3/8" SYRINGE
DRUG LEVEL
4
4
2
3
3
1
1
1
1
1
1
3
3
3
3
3
3
2
3
3
3
3
3
3
3
3
3
3
3
3
4
3
1
1
1
1
1
1
3
3
2
1
1
1
1
1
1
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 11
DRUG NAME
ALLERGIST TRAY INTRADERMAL BEVEL 1 ML 27 X 3/8" SYRINGE
ALLERGIST TRAY REGULAR BEVEL 1 ML 27 X 3/8" SYRINGE
allopurinol 100 mg tablet MM
allopurinol 300 mg tablet MM
almotriptan malate 12.5 mg tab
almotriptan malate 6.25 mg tab
ALOCRIL 2 % EYE DROPS
ALODOX CONVENIENCE KIT
ALOMIDE 0.1 % EYE DROPS
ALOQUIN 1.25 %-1 % TOPICAL GEL
ALORA 0.025 MG/24 HR TRANSDERMAL PATCH MM
ALORA 0.05 MG/24 HR TRANSDERMAL PATCH MM
ALORA 0.075 MG/24 HR TRANSDERMAL PATCH MM
ALORA 0.1 MG/24 HR TRANSDERMAL PATCH MM
alosetron hcl 0.5 mg tablet MM
alosetron hcl 1 mg tablet MM
ALPHAGAN P 0.1 % EYE DROPS MM
ALPHAGAN P 0.15 % EYE DROPS MM
alprazolam 0.25 mg tablet
alprazolam 0.5 mg tablet
alprazolam 1 mg tablet
alprazolam 2 mg tablet
alprazolam er 0.5 mg tablet
alprazolam er 1 mg tablet
alprazolam er 2 mg tablet
alprazolam er 3 mg tablet
alprazolam intensol 1 mg/ml oral concentrate
alprazolam odt 0.25 mg tab
alprazolam odt 0.5 mg tab
alprazolam odt 1 mg tab
alprazolam odt 2 mg tab
ALREX 0.2 % EYE DROPS,SUSPENSION
ALSUMA 6 MG/0.5 ML SUBCUTANEOUS PEN INJECTOR
ALTABAX 1 % TOPICAL OINTMENT
altacaine 0.5 % eye drops
ALTACE 1.25 MG CAPSULE MM
ALTACE 10 MG CAPSULE MM
ALTACE 2.5 MG CAPSULE MM
ALTACE 5 MG CAPSULE MM
altafluor 0.25 %-0.4 % eye drops
altavera (28) 0.15 mg-0.03 mg tablet MM
ALTERNATE SITE LANCET 26 GAUGE
ALTERNATE SITE LANCING DEVICE
ALTOPREV 20 MG TABLET,EXTENDED RELEASE MM
ALTOPREV 40 MG TABLET,EXTENDED RELEASE MM
ALTOPREV 60 MG TABLET,EXTENDED RELEASE MM
ALUVEA 39 % TOPICAL CREAM
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
12 - FORMULARY Updated 09/2015
DRUG LEVEL
1
1
1
1
3
3
3
4
3
3
3
3
3
3
4
4
3
3
1
1
1
1
2
2
2
2
1
3
3
3
3
3
3
3
1
3
3
3
3
3
1
1
1
4
4
4
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,ST
QL,ST
ST
QL
QL
QL
QL
QL,PA
QL,PA
ST
ST
QL
QL
QL
QL
QL
QL
QL
QL
ST
QL
QL,ST
QL,ST
QL,ST
DRUG NAME
ALVESCO 160 MCG/ACTUATION AEROSOL INHALER MM
ALVESCO 80 MCG/ACTUATION AEROSOL INHALER MM
alyacen 1/35 (28) 1 mg-35 mcg tablet MM
alyacen 7/7/7 (28) 0.5 mg/0.75 mg/1 mg-35 mcg tablet MM
amantadine 100 mg capsule MM
amantadine 100 mg tablet MM
amantadine 50 mg/5 ml solution MM
AMARYL 1 MG TABLET MM
AMARYL 2 MG TABLET MM
AMARYL 4 MG TABLET MM
AMBIEN 10 MG TABLET
AMBIEN 5 MG TABLET
AMBIEN CR 12.5 MG TABLET,EXTENDED RELEASE
AMBIEN CR 6.25 MG TABLET,EXTENDED RELEASE
amcinonide 0.1% cream
amcinonide 0.1% lotion
amcinonide 0.1% ointment
AMERGE 1 MG TABLET
AMERGE 2.5 MG TABLET
amethia 0.15 mg-30 mcg (84)/10 mcg(7) tablets,3 month dose pack
amethia lo 0.10 mg-20 mcg (84)/10 mcg(7) tablets,3 month dose pack MM
amethyst 90 mcg-20 mcg tablet MM
AMICAR 1,000 MG TABLET SP
AMICAR 250 MG/ML (25 %) ORAL SOLUTION SP
AMICAR 500 MG TABLET SP
amiloride hcl 5 mg tablet MM
amiloride hcl-hctz 5-50 mg tab MM
aminocaproic acid 1,000 mg tab SP
aminocaproic acid 25% solution SP
aminocaproic acid 500 mg tab SP
AMINOSYN 7 % WITH ELECTROLYTES INTRAVENOUS SOLUTION
AMINOSYN 8.5 % WITH ELECTROLYTES INTRAVENOUS SOLUTION
AMINOSYN II 8.5 % WITH ELECTROLYTES INTRAVENOUS SOLUTION
AMINOSYN M 3.5 % INTRAVENOUS SOLUTION
AMINOSYN-HBC 7% INTRAVENOUS SOLUTION
amiodarone hcl 100 mg tablet MM
amiodarone hcl 200 mg tablet MM
amiodarone hcl 400 mg tablet MM
AMITIZA 24 MCG CAPSULE MM
AMITIZA 8 MCG CAPSULE MM
amitriptyline hcl 10 mg tab MM
amitriptyline hcl 100 mg tab MM
amitriptyline hcl 150 mg tab MM
amitriptyline hcl 25 mg tab MM
amitriptyline hcl 50 mg tab MM
DRUG LEVEL
3
3
1
1
3
3
1
3
3
3
3
3
3
3
3
3
3
3
3
2
2
2
*
*
*
2
1
*
*
*
3
3
3
3
3
1
1
1
2
2
1
1
1
1
1
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL
QL
QL
QL
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 13
DRUG NAME
amitriptyline hcl 75 mg tab MM
amlod-valsa-hctz 10-160-12.5mg MM
amlod-valsa-hctz 10-160-25 mg MM
amlod-valsa-hctz 10-320-25 mg MM
amlod-valsa-hctz 5-160-12.5 mg MM
amlod-valsa-hctz 5-160-25 mg MM
amlodipine besylate 10 mg tab MM
amlodipine besylate 2.5 mg tab MM
amlodipine besylate 5 mg tab MM
amlodipine-atorvast 10-10 mg MM
amlodipine-atorvast 10-20 mg MM
amlodipine-atorvast 10-40 mg MM
amlodipine-atorvast 10-80 mg MM
amlodipine-atorvast 2.5-10 mg MM
amlodipine-atorvast 2.5-20 mg MM
amlodipine-atorvast 2.5-40 mg MM
amlodipine-atorvast 5-10 mg MM
amlodipine-atorvast 5-20 mg MM
amlodipine-atorvast 5-40 mg MM
amlodipine-atorvast 5-80 mg MM
amlodipine-benazepril 10-20 mg MM
amlodipine-benazepril 10-40 mg MM
amlodipine-benazepril 2.5-10 MM
amlodipine-benazepril 5-10 mg MM
amlodipine-benazepril 5-20 mg MM
amlodipine-benazepril 5-40 mg MM
amlodipine-valsartan 10-160 mg MM
amlodipine-valsartan 10-320 mg MM
amlodipine-valsartan 5-160 mg MM
amlodipine-valsartan 5-320 mg MM
ammonium lactate 12% cream
ammonium lactate 12% lotion
amnesteem 10 mg capsule
amnesteem 20 mg capsule
amnesteem 40 mg capsule
amox tr-k clv 200-28.5 tab chw
amox tr-k clv 200-28.5/5 susp
amox tr-k clv 250-125 mg tab
amox tr-k clv 250-62.5/5 susp
amox tr-k clv 400-57 tab chew
amox tr-k clv 400-57/5 susp
amox tr-k clv 500-125 mg tab
amox tr-k clv 600-42.9/5 susp
amox tr-k clv 875-125 mg tab
amoxapine 100 mg tablet MM
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
14 - FORMULARY Updated 09/2015
DRUG LEVEL
1
3
3
3
3
3
1
1
1
3
3
3
3
3
3
3
3
3
3
3
2
2
2
2
2
2
3
3
3
3
2
2
4
4
4
2
2
2
2
2
2
2
2
2
2
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL,ST
QL,ST
QL,ST
QL,ST
QL
QL
QL
DRUG NAME
amoxapine 150 mg tablet MM
amoxapine 25 mg tablet MM
amoxapine 50 mg tablet MM
amoxicillin 125 mg tab chew
amoxicillin 125 mg/5 ml susp
amoxicillin 200 mg/5 ml susp
amoxicillin 250 mg capsule
amoxicillin 250 mg tab chew
amoxicillin 250 mg/5 ml susp
amoxicillin 400 mg/5 ml susp
amoxicillin 500 mg capsule
amoxicillin 500 mg tablet
amoxicillin 875 mg tablet
amoxicillin er 775 mg tablet
amoxicillin-clav er 1,000-62.5
amphetamine salt combo 10 mg tablet
amphetamine salt combo 12.5 mg tablet
amphetamine salt combo 15 mg tablet
amphetamine salt combo 20 mg tablet
amphetamine salt combo 30 mg tablet
amphetamine salt combo 5 mg tablet
amphetamine salt combo 7.5 mg tablet
ampicillin 125 mg/5 ml susp
ampicillin 250 mg capsule
ampicillin 250 mg/5 ml susp
ampicillin 500 mg capsule
AMPYRA 10 MG TABLET,EXTENDED RELEASE SP
AMRIX 15 MG CAPSULE,EXTENDED RELEASE
AMRIX 30 MG CAPSULE,EXTENDED RELEASE
AMTURNIDE 150-5-12.5 MG TAB MM
AMTURNIDE 300-10-12.5 MG TAB MM
AMTURNIDE 300-10-25 MG TAB MM
AMTURNIDE 300-5-12.5 MG TAB MM
AMTURNIDE 300-5-25 MG TAB MM
amyl nitrite ampul
ANA-LEX 2 %-2 % RECTAL CREAM
ANA-LEX 2 %-2 % RECTAL KIT
ANACAINE 10 % TOPICAL OINTMENT
ANAFRANIL 25 MG CAPSULE MM
ANAFRANIL 50 MG CAPSULE MM
ANAFRANIL 75 MG CAPSULE MM
anagrelide hcl 0.5 mg capsule MM
anagrelide hcl 1 mg capsule MM
ANALPRAM ADVANCED 2.5 %-1 %/630 MG/1 %-1 % KIT
ANALPRAM E 2.5 %-1 % (4 GRAM)-1 % KIT,CREAM AND TOWELETTE
ANALPRAM E 2.5 %-1 %-1 % KIT,CREAM AND TOWELETTE
ANALPRAM HC 1% CREAM SINGLES
ANALPRAM-HC 1 %-1 % RECTAL CREAM
DRUG LEVEL
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
*
4
4
3
3
3
3
3
3
3
3
3
4
4
4
3
3
3
3
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
QL
QL
QL
QL,PA
QL,PA
QL,PA
QL
QL
QL
QL
QL
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 15
DRUG NAME
ANALPRAM-HC 2.5 %-1 % RECTAL CREAM
ANALPRAM-HC 2.5 %-1 % RECTAL LOTION
ANALPRAM-HC SINGLES 2.5 %-1 % (4G) RECTAL CREAM
ANAPROX 275 MG TABLET MM
ANAPROX DS 550 MG TABLET MM
ANASPAZ 0.125 MG DISINTEGRATING TABLET MM
anastrozole 1 mg tablet MM
ANCOBON 250 MG CAPSULE
ANCOBON 500 MG CAPSULE
ANDRODERM 2 MG/24 HOUR TRANSDERMAL 24 HOUR PATCH MM
ANDRODERM 4 MG/24 HR TRANSDERMAL 24 HOUR PATCH MM
ANDROGEL 1 % (25 MG/2.5 GRAM) TRANSDERMAL GEL PACKET MM
ANDROGEL 1 % (50 MG/5 GRAM) TRANSDERMAL GEL PACKET MM
ANDROGEL 1.25 GRAM/ACTUATION (1%) TRANSDERMAL GEL PUMP MM
ANDROGEL 1.62 % (20.25 MG/1.25 GRAM) TRANSDERMAL GEL PACKET MM
ANDROGEL 1.62 % (40.5 MG/2.5 GRAM) TRANSDERMAL GEL PACKET MM
ANDROGEL 20.25 MG/1.25 GRAM (1.62 %) TRANSDERMAL GEL PUMP MM
ANDROID 10 MG CAPSULE MM
ANGELIQ 0.25 MG-0.5 MG TABLET MM
ANGELIQ 0.5 MG-1 MG TABLET MM
ANORO ELLIPTA 62.5 MCG-25 MCG/ACTUATION POWDER FOR INHALATION MM
ANTABUSE 250 MG TABLET MM
ANTABUSE 500 MG TABLET MM
ANTARA 130 MG CAPSULE MM
ANTARA 30 MG CAPSULE MM
ANTARA 43 MG CAPSULE MM
ANTARA 90 MG CAPSULE MM
antipyrine-benzocaine ear drop
antipyrine-benzocaine otic sol
ANTIVERT 12.5 MG TABLET
ANTIVERT 25 MG TABLET
anucort-hc 25 mg suppository
ANUSOL-HC 2.5 % RECTAL CREAM
anusol-hc 25 mg suppository
ANZEMET 100 MG TABLET
ANZEMET 50 MG TABLET
apexicon e 0.05 % topical cream
APIDRA 100 UNIT/ML SUBCUTANEOUS SOLUTION MM
APIDRA SOLOSTAR 100 UNIT/ML SUBCUTANEOUS INSULIN PEN MM
APLENZIN 174 MG TABLET,EXTENDED RELEASE MM
APLENZIN 348 MG TABLET,EXTENDED RELEASE MM
APLENZIN 522 MG TABLET,EXTENDED RELEASE MM
APLIGRAF DISK
APOKYN 10 MG/ML SUBCUTANEOUS CARTRIDGE SP
APOP 10 %-0.5 % GEL
apraclonidine hcl 0.5% drops
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
16 - FORMULARY Updated 09/2015
DRUG LEVEL
3
3
3
3
3
3
1
3
3
3
3
3
3
3
2
2
2
4
3
3
2
3
3
3
3
3
3
2
3
3
3
3
3
3
4
4
4
3
3
4
4
4
3
*
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL
QL
QL
QL
QL,ST
QL,ST
QL,ST
QL,ST
QL
QL
ST
ST
QL,ST
QL,ST
QL,ST
QL
DRUG NAME
apri 0.15 mg-0.03 mg tablet MM
APRISO 0.375 GRAM CAPSULE,EXTENDED RELEASE MM
APTENSIO XR 10 MG CAPSULE,EXTENDED RELEASE SPRINKLE
APTENSIO XR 15 MG CAPSULE,EXTENDED RELEASE SPRINKLE
APTENSIO XR 20 MG CAPSULE,EXTENDED RELEASE SPRINKLE
APTENSIO XR 30 MG CAPSULE,EXTENDED RELEASE SPRINKLE
APTENSIO XR 40 MG CAPSULE,EXTENDED RELEASE SPRINKLE
APTENSIO XR 50 MG CAPSULE,EXTENDED RELEASE SPRINKLE
APTENSIO XR 60 MG CAPSULE,EXTENDED RELEASE SPRINKLE
APTIOM 200 MG TABLET MM
APTIOM 400 MG TABLET MM
APTIOM 600 MG TABLET MM
APTIOM 800 MG TABLET MM
APTIVUS 100 MG/ML ORAL SOLUTION SP
APTIVUS 250 MG CAPSULE SP
AQUA GLYCOLIC HC 2 % TOPICAL COMBO PACK
AQUA LANCE LANCING DEVICE
AQUORAL MUCOSAL SPRAY
aranelle (28) 0.5 mg/1 mg/0.5 mg-35 mcg tablet MM
ARANESP 10 MCG/0.4 ML (IN POLYSORBATE) INJECTION SYRINGE SP
ARANESP 100 MCG/0.5 ML (IN POLYSORBATE) INJECTION SYRINGE SP
ARANESP 100 MCG/ML (IN POLYSORBATE) INJECTION SP
ARANESP 150 MCG/0.3 ML (IN POLYSORBATE) INJECTION SYRINGE SP
ARANESP 150 MCG/0.75 ML (IN POLYSORBATE) INJECTION SP
ARANESP 200 MCG/0.4 ML (IN POLYSORBATE) INJECTION SYRINGE SP
ARANESP 200 MCG/ML (IN POLYSORBATE) INJECTION SP
ARANESP 25 MCG/0.42 ML (IN POLYSORBATE) INJECTION SYRINGE SP
ARANESP 25 MCG/ML (IN POLYSORBATE) INJECTION SP
ARANESP 300 MCG/0.6 ML (IN POLYSORBATE) INJECTION SYRINGE SP
ARANESP 300 MCG/ML (IN POLYSORBATE) INJECTION SP
ARANESP 40 MCG/0.4 ML (IN POLYSORBATE) INJECTION SYRINGE SP
ARANESP 40 MCG/ML (IN POLYSORBATE) INJECTION SP
ARANESP 500 MCG/ML (IN POLYSORBATE) INJECTION SYRINGE SP
ARANESP 60 MCG/0.3 ML (IN POLYSORBATE) INJECTION SYRINGE SP
ARANESP 60 MCG/ML (IN POLYSORBATE) INJECTION SP
ARAVA 10 MG TABLET MM
ARAVA 20 MG TABLET MM
arbinoxa 4 mg tablet
arbinoxa 4 mg/5 ml oral liquid
ARCALYST 220 MG SUBCUTANEOUS SOLUTION SP
ARCAPTA NEOHALER 75 MCG CAPSULE WITH INHALATION DEVICE MM
ARESTIN 1 MG DENTAL CARTRIDGE
ARICEPT 10 MG TABLET MM
ARICEPT 23 MG TABLET MM
ARICEPT 5 MG TABLET MM
DRUG LEVEL
1
2
3
3
3
3
3
3
3
3
3
3
3
*
*
3
1
3
1
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
4
4
3
3
*
3
4
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,PA
QL,PA
QL,PA
QL,PA
QL
QL
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL
QL
QL,PA
QL
QL,ST
QL,ST
QL,ST
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 17
DRUG NAME
ARICEPT ODT 10 MG TABLET MM
ARICEPT ODT 5 MG TABLET MM
ARIDOL BRONCHIAL CHALLENGE KIT
ARIMIDEX 1 MG TABLET MM
aripiprazole 10 mg tablet MM
aripiprazole 15 mg tablet MM
aripiprazole 2 mg tablet MM
aripiprazole 20 mg tablet MM
aripiprazole 30 mg tablet MM
aripiprazole 5 mg tablet MM
ARIXTRA 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE
ARIXTRA 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE
ARIXTRA 5 MG/0.4 ML SUBCUTANEOUS SOLUTION SYRINGE
ARIXTRA 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE
ARMOUR THYROID 120 MG TABLET MM
ARMOUR THYROID 15 MG TABLET MM
ARMOUR THYROID 180 MG TABLET MM
ARMOUR THYROID 240 MG TABLET MM
ARMOUR THYROID 30 MG TABLET MM
ARMOUR THYROID 300 MG TABLET MM
ARMOUR THYROID 60 MG TABLET MM
ARMOUR THYROID 90 MG TABLET MM
ARNUITY ELLIPTA 100 MCG/ACTUATION POWDER FOR INHALATION
ARNUITY ELLIPTA 200 MCG/ACTUATION POWDER FOR INHALATION
AROMASIN 25 MG TABLET MM
ARTHROTEC 50 MG-200 MCG TABLET,FILM-COATED MM
ARTHROTEC 75 75 MG-200 MCG TABLET,FILM-COATED MM
ARTISS 2.5-6.5 UNIT/ML (2ML) TOPICAL SYRINGE
ARTISS 2.5-6.5 UNIT/ML (4ML) TOPICAL SYRINGE
ARTISS 2.5-6.5 UNIT/ML(10ML) TOPICAL SYRINGE
ASACOL HD 800 MG TABLET,DELAYED RELEASE MM
ascomp with codeine 30 mg-50 mg-325 mg-40 mg capsule
ashlyna 0.15 mg-30 mcg (84)/10 mcg(7) tablets,3 month dose pack
ASMANEX HFA 100 MCG/ACTUATION AEROSOL INHALER
ASMANEX HFA 200 MCG/ACTUATION AEROSOL INHALER
ASMANEX TWISTHALER 110 MCG (30 DOSES) BREATH ACTIVATED MM
ASMANEX TWISTHALER 110 MCG (7 DOSES) BREATH ACTIVATED MM
ASMANEX TWISTHALER 220 MCG (120 DOSES) BREATH ACTIVATED MM
ASMANEX TWISTHALER 220 MCG (14 DOSES) BREATH ACTIVATED MM
ASMANEX TWISTHALER 220 MCG (30 DOSES) BREATH ACTIVATED MM
ASMANEX TWISTHALER 220 MCG (60 DOSES) BREATH ACTIVATED MM
aspirin ec 975 mg tablet
aspirin-caff-dihydrocodein cap
aspirin-dipyridam er 25-200 mg MM
ASSURE 4 BLOOD GLUCOSE METER
ASSURE 4 CONTROL SOLUTION COMBO PACK
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
18 - FORMULARY Updated 09/2015
DRUG LEVEL
3
3
3
3
4
4
4
4
4
4
4
4
4
4
2
2
2
2
2
2
2
2
3
3
4
3
3
3
3
3
4
3
2
2
2
2
2
2
2
2
2
1
3
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,ST
QL,ST
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
ST
ST
QL,ST
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
ST
ST
DRUG NAME
ASSURE 4 STRIPS MM
ASSURE DOSE NORMAL CONTROL SOLUTION
ASSURE DOSE NORMAL-HIGH CONTROL SOLUTION
ASSURE HAEMOLANCE PLUS 18 GAUGE
ASSURE HAEMOLANCE PLUS 21 GAUGE
ASSURE HAEMOLANCE PLUS 21 GAUGE
ASSURE HAEMOLANCE PLUS 25 GAUGE
ASSURE HAEMOLANCE PLUS 28 GAUGE
ASSURE ID INSULIN SAFETY 0.5 ML 29 X 1/2" SYRINGE MM
ASSURE ID INSULIN SAFETY 1 ML 29 X 1/2" SYRINGE MM
ASSURE LANCE 25 GAUGE
ASSURE LANCE 28 GAUGE
ASSURE LANCE PLUS 21 GAUGE
ASSURE LANCE PLUS 25 GAUGE
ASSURE LANCE PLUS 30 GAUGE
ASSURE PLATINUM
ASSURE PLATINUM STRIPS MM
ASSURE PRISM CONTROL 1-2 SOLUTION
ASSURE PRISM MULTI METER
ASSURE PRISM MULTI STRIP MM
ASSURE PRO TEST STRIPS MM
ASTAGRAF XL 0.5 MG CAPSULE,EXTENDED RELEASE
ASTAGRAF XL 1 MG CAPSULE,EXTENDED RELEASE
ASTAGRAF XL 5 MG CAPSULE,EXTENDED RELEASE
ASTELIN 137 MCG NASAL SPRAY MM
ASTEPRO 0.15 % (205.5 MCG) NASAL SPRAY MM
ASTHMAPACK CHILDREN'S KIT
ASTRINGYN 259 MG/G TOPICAL SOLUTION
ATABEX EC 29 MG-1 MG-50 MG TABLET,DELAYED RELEASE
ATACAND 16 MG TABLET MM
ATACAND 32 MG TABLET MM
ATACAND 4 MG TABLET MM
ATACAND 8 MG TABLET MM
ATACAND HCT 16 MG-12.5 MG TABLET MM
ATACAND HCT 32 MG-12.5 MG TABLET MM
ATACAND HCT 32 MG-25 MG TABLET MM
ATELVIA 35 MG TABLET,DELAYED RELEASE MM
atenolol 100 mg tablet MM
atenolol 25 mg tablet MM
atenolol 50 mg tablet MM
atenolol-chlorthalidone 100-25 MM
atenolol-chlorthalidone 50-25 MM
ATIVAN 0.5 MG TABLET
ATIVAN 1 MG TABLET
ATIVAN 2 MG TABLET
ATOPICLAIR TOPICAL CREAM
atorvastatin 10 mg tablet MM
DRUG LEVEL
3
3
3
3
3
3
3
3
1
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
1
3
1
3
3
3
3
3
3
3
3
1
1
1
1
1
4
4
4
3
1
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,ST
ST
QL,ST
ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL
QL
QL
QL
QL
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 19
DRUG NAME
atorvastatin 20 mg tablet MM
atorvastatin 40 mg tablet MM
atorvastatin 80 mg tablet MM
atovaquone 750 mg/5 ml susp
atovaquone-proguanil 250-100
atovaquone-proguanil 62.5-25
ATRALIN 0.05 % TOPICAL GEL
ATRAPRO CP TOPICAL PACK,CREAM AND GEL
ATRAPRO DERMAL SPRAY 0.004 %-0.003 % TOPICAL SPRAY
ATRAPRO HYDROGEL TOPICAL
ATRIPLA 600 MG-200 MG-300 MG TABLET SP
atropine 1% eye drops MM
atropine 1% eye ointment MM
atropine care 1% eye drops MM
ATROVENT 0.03 % NASAL SPRAY MM
ATROVENT 0.06 % NASAL SPRAY MM
ATROVENT HFA 17 MCG/ACTUATION AEROSOL INHALER MM
AUBAGIO 14 MG TABLET SP
AUBAGIO 7 MG TABLET SP
aubra 0.1 mg-20 mcg tablet MM
AUGMENTIN 125 MG-31.25 MG/5 ML ORAL SUSPENSION
AUGMENTIN 250 MG-62.5 MG/5 ML ORAL SUSPENSION
AUGMENTIN 500 MG-125 MG TABLET
AUGMENTIN 875 MG-125 MG TABLET
AUGMENTIN ES-600 600 MG-42.9 MG/5 ML ORAL SUSPENSION
AUGMENTIN XR 1,000 MG-62.5 MG TABLET,EXTENDED RELEASE
aurax otic solution
aurodex otic solution
auroguard 5.4 %-1.4 % ear drops
AURORA SUPER THIN 30G LANCETS
AURSTAT TOPICAL GEL
AURSTAT TOPICAL KIT,CREAM AND GEL
AURYXIA 210 MG IRON TABLET SP
AUTO-LANCET MINI
AUTOJECT 2 INJECTION DEVICE SUBCUTANEOUS INSULIN PEN
AUTOLET IMPRESSION LANCING DEVICE KIT
AUTOLET LANCING DEVICE
AUTOPEN 1 TO 16 UNITS SUBCUTANEOUS
AUTOPEN 1 TO 21 UNITS SUBCUTANEOUS
AUTOPEN 2 TO 32 UNITS SUBCUTANEOUS
AUTOPEN 2 TO 42 UNITS SUBCUTANEOUS
AUVI-Q 0.15 MG/0.15 ML (1:1,000) INJECTION,AUTO-INJECTOR
AUVI-Q 0.3 MG/0.3 ML (1:1,000) INJECTION,AUTO-INJECTOR
AVALIDE 150 MG-12.5 MG TABLET MM
AVALIDE 300 MG-12.5 MG TABLET MM
AVANDAMET 2 MG-1,000 MG TABLET MM
AVANDAMET 2 MG-500 MG TABLET MM
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
20 - FORMULARY Updated 09/2015
DRUG LEVEL
1
1
1
4
3
3
3
3
3
3
*
1
1
2
3
3
3
*
*
2
3
3
3
3
3
3
3
2
1
1
3
3
*
1
3
3
1
3
3
3
3
3
3
3
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
QL
QL
ST
QL
QL
QL
QL,ST
QL,PA
QL,PA
QL,PA
QL,ST
QL,ST
QL
QL
DRUG NAME
AVANDAMET 4 MG-1,000 MG TABLET MM
AVANDAMET 4 MG-500 MG TABLET MM
AVANDARYL 4 MG-1 MG TABLET MM
AVANDARYL 4 MG-2 MG TABLET MM
AVANDARYL 4 MG-4 MG TABLET MM
AVANDARYL 8 MG-2 MG TABLET MM
AVANDARYL 8 MG-4 MG TABLET MM
AVANDIA 2 MG TABLET MM
AVANDIA 4 MG TABLET MM
AVANDIA 8 MG TABLET MM
AVAPRO 150 MG TABLET MM
AVAPRO 300 MG TABLET MM
AVAPRO 75 MG TABLET MM
avar 10 %-5 % (w/w) topical cleanser
AVAR 9.5 %-5 % TOPICAL FOAM
AVAR 9.5 %-5 % TOPICAL PADS
AVAR LS 10 %-2 % TOPICAL CLEANSER
AVAR LS 10 %-2 % TOPICAL FOAM
AVAR LS 10 %-2 % TOPICAL PADS
avar-e 10 %-5 % (w/w) topical cream
avar-e green 10 %-5 % (w/w) topical cream
AVAR-E LS 10 %-2 % TOPICAL CREAM
AVC VAGINAL 15 % CREAM
AVELOX 400 MG TABLET
AVELOX ABC PACK 400 MG TABLET
AVENOVA 0.01 % TOPICAL SPRAY
aviane 0.1 mg-20 mcg tablet MM
avidoxy 100 mg tablet
AVIDOXY DK 100 MG-2 %-SPF 30 KIT
AVINZA 120 MG CAPSULE
AVINZA 30 MG CAPSULE
AVINZA 45 MG CAPSULE
AVINZA 60 MG CAPSULE
AVINZA 75 MG CAPSULE
AVINZA 90 MG CAPSULE
AVITA 0.025 % TOPICAL CREAM
AVITA 0.025 % TOPICAL GEL
AVITENE 35 MM X 35 MM TOPICAL SHEETS
AVITENE 70 MM X 35 MM TOPICAL SHEETS
AVITENE 70 MM X 70 MM TOPICAL SHEETS
AVITENE FLOUR TOPICAL POWDER
AVITENE TOPICAL POWDER IN PACKET
avo cream topical emulsion
AVODART 0.5 MG CAPSULE MM
AVONEX (WITH ALBUMIN) 30 MCG INTRAMUSCULAR KIT SP
AVONEX 30 MCG/0.5 ML INTRAMUSCULAR PEN INJECTOR SP
AVONEX 30 MCG/0.5 ML INTRAMUSCULAR PEN KIT SP
DRUG LEVEL
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
1
2
3
4
4
4
4
4
4
3
3
3
3
3
4
4
3
3
*
*
*
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,PA
QL,PA
QL,PA
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 21
DRUG NAME
AVONEX 30 MCG/0.5 ML INTRAMUSCULAR SYRINGE SP
AVONEX 30 MCG/0.5 ML INTRAMUSCULAR SYRINGE KIT SP
AXERT 12.5 MG TABLET
AXERT 6.25 MG TABLET
AXID 15 MG/ML ORAL SOLUTION MM
AXIRON 30 MG/ACTUATION (1.5 ML) TRANSDERM SOLUTION IN METERED PUMP MM
AXONA POWDER PACKET
AYGESTIN 5 MG TABLET MM
AZASAN 100 MG TABLET MM
AZASAN 75 MG TABLET MM
AZASITE 1 % EYE DROPS
azathioprine 50 mg tablet
azelastine 0.1% (137 mcg) spry MM
azelastine 0.15% nasal spray MM
azelastine hcl 0.05% drops
AZELEX 20 % TOPICAL CREAM
AZILECT 0.5 MG TABLET MM
AZILECT 1 MG TABLET MM
azithromycin 1 gm pwd packet
azithromycin 100 mg/5 ml susp
azithromycin 200 mg/5 ml susp
azithromycin 250 mg tablet
azithromycin 500 mg tablet
azithromycin 600 mg tablet
AZO TEST STRIPS
AZOPT 1 % EYE DROPS,SUSPENSION MM
AZOR 10 MG-20 MG TABLET MM
AZOR 10 MG-40 MG TABLET MM
AZOR 5 MG-20 MG TABLET MM
AZOR 5 MG-40 MG TABLET MM
AZULFIDINE 500 MG TABLET MM
AZULFIDINE EN-TABS 500 MG TABLET,DELAYED RELEASE MM
azurette (28) 0.15 mg-0.02 mg (21)/0.01 mg (5) tablet MM
B-NEXA TABLET
b-plex tablet
bacitracin 500 unit/gm ophth
bacitracin-polymyxin eye oint
baclofen 10 mg tablet MM
baclofen 20 mg tablet MM
BACTRIM 400 MG-80 MG TABLET
BACTRIM DS 800 MG-160 MG TABLET
BACTROBAN 2 % TOPICAL CREAM
BACTROBAN 2 % TOPICAL OINTMENT
BACTROBAN NASAL 2 % OINTMENT
bal-care dha 27 mg-1 mg-430 mg tablet&capsule,delayed release
BAL-CARE DHA ESSENTIAL 27 MG IRON-1 MG-374 MG TABLET&CAPSULE,DELAY
REL
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
22 - FORMULARY Updated 09/2015
DRUG LEVEL
*
*
3
3
3
3
3
3
3
3
2
2
2
3
2
3
3
3
2
2
2
2
2
2
3
3
3
3
3
3
3
3
2
2
1
2
2
1
1
3
3
3
3
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,PA
QL,PA
QL,ST
QL,ST
QL,ST
QL
QL
QL
PA
PA
QL
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL
QL
QL
QL
DRUG NAME
balsalazide disodium 750 mg cp
balziva (28) 0.4 mg-35 mcg tablet MM
BANZEL 200 MG TABLET MM
BANZEL 40 MG/ML ORAL SUSPENSION MM
BANZEL 400 MG TABLET MM
BARACLUDE 0.05 MG/ML ORAL SOLUTION SP
BARACLUDE 0.5 MG TABLET SP
BARACLUDE 1 MG TABLET SP
BD 1 ML SYRINGE-NEEDLE 25GX5/8
BD ALCOHOL SWABS
BD ALLERGIST TRAY REG BEVEL 1 ML 26 X 1/2" SYRINGE
BD ALLERGIST TRAY REG BEVEL 1 ML 27 X 1/2" SYRINGE
BD ALLERGIST TRAY REG BEVEL 1/2 ML 27 X 1/2"
BD AUTOSHIELD PEN NEEDLE 29 X 3/16"
BD AUTOSHIELD PEN NEEDLE 29 X 5/16"
BD BLUNT NEEDLE 18GX1-1/2"
BD ECLIPSE LUER-LOK 1 ML 30 X 1/2" SYRINGE MM
BD ECLIPSE NEEDLE 18GX1 1/2"
BD ECLIPSE SYRINGE 3 ML 22GX1"
BD FILTER NEEDLE-5 MICRON 19 X 1 1/2"
BD INSULIN PEN NEEDLE UF MINI 31 X 3/16"
BD INSULIN PEN NEEDLE UF ORIGINAL 29 GAUGE X 1/2"
BD INSULIN PEN NEEDLE UF SHORT 31 X 5/16"
BD INSULIN SYR 1 ML 25GX5/8" MM
BD INSULIN SYR 1 ML 28GX1/2" MM
BD INSULIN SYRINGE 1 ML 25 X 1" MM
BD INSULIN SYRINGE 1 ML 25 X 5/8" MM
BD INSULIN SYRINGE 1 ML 26 X 1/2" MM
BD INSULIN SYRINGE 1 ML 28 X 1/2" MM
BD INSULIN SYRINGE HALF UNIT 0.3 ML 31 X 15/64" MM
BD INSULIN SYRINGE HALF UNIT 0.3 ML 31 X 5/16" MM
BD INSULIN SYRINGE MICRO-FINE 0.3 ML 28 MM
BD INSULIN SYRINGE MICRO-FINE 1 ML 28 X 1/2" MM
BD INSULIN SYRINGE MICRO-FINE 1/2 ML 28 X 1/2" MM
BD INSULIN SYRINGE SAFETY-LOK 1 ML 29 X 1/2" MM
BD INSULIN SYRINGE SLIP TIP 1 ML MM
BD INSULIN SYRINGE ULT-FINE II 0.3 ML 31 X 5/16" MM
BD INSULIN SYRINGE ULT-FINE II 1 ML 31 X 5/16" MM
BD INSULIN SYRINGE ULT-FINE II 1/2 ML 31 X 5/16" MM
BD INSULIN SYRINGE ULTRA-FINE 0.3 ML 30 X 1/2" MM
BD INSULIN SYRINGE ULTRA-FINE 0.3 ML 31 X 15/64" MM
BD INSULIN SYRINGE ULTRA-FINE 0.3 ML 31 X 5/16" MM
BD INSULIN SYRINGE ULTRA-FINE 1 ML 29 X 1/2" MM
BD INSULIN SYRINGE ULTRA-FINE 1 ML 30 X 1/2" MM
BD INSULIN SYRINGE ULTRA-FINE 1 ML 31 X 15/64" MM
DRUG LEVEL
3
2
4
4
4
*
*
*
1
3
1
1
1
1
1
1
2
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL,PA
QL,PA
QL,PA
QL
QL,ST
QL,ST
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 23
DRUG NAME
BD INSULIN SYRINGE ULTRA-FINE 1 ML 31 X 5/16" MM
BD INSULIN SYRINGE ULTRA-FINE 1/2 ML 30 X 1/2" MM
BD INSULIN SYRINGE ULTRA-FINE 1/2 ML 31 X 15/64" MM
BD INSULIN SYRINGE ULTRA-FINE 1/2 ML 31 X 5/16" MM
BD INTEGRA INSULIN SYRINGE 1 ML 29 X 1/2" MM
BD INTEGRA SYRINGE 3 ML 25 X 1"
BD LANCET DEVICE
BD LO-DOSE MICRO-FINE IV 0.3 ML 28 X 1/2" SYRINGE MM
BD LO-DOSE MICRO-FINE IV 1/2 ML 28 X 1/2" SYRINGE MM
BD LO-DOSE ULTRA-FINE 0.3 ML 29 X 1/2" SYRINGE MM
BD LO-DOSE ULTRA-FINE 1/2 ML 29 X 1/2" SYRINGE MM
BD LUER-LOK 5 ML SYRINGE
BD LUER-LOK SYRINGE 1 ML MM
BD MICROTAINER LANCET 21 GAUGE
BD MICROTAINER LANCET 30 GAUGE
BD SAFETYGLIDE ALLERGIST TRAY 1 ML 27 X 1/2" SYRINGE
BD SAFETYGLIDE INSULIN SYRINGE 0.3 ML 29 X 1/2" MM
BD SAFETYGLIDE INSULIN SYRINGE 0.3 ML 31 X 5/16" MM
BD SAFETYGLIDE INSULIN SYRINGE 1 ML 29 X 1/2" MM
BD SAFETYGLIDE INSULIN SYRINGE 1/2 ML 29 X 1/2" MM
BD SAFETYGLIDE INSULIN SYRINGE 1/2 ML 30 X 5/16" MM
BD SAFETYGLIDE SYRINGE 1 ML 27 X 5/8" MM
BD SLIP TIP 60 ML SYRINGE
BD SYRINGE 30 ML
BD SYRINGE GLASS 3 ML
BD ULTRA FINE LANCETS 33 GAUGE
BD ULTRA-FINE II LANCETS 30 GAUGE
BD ULTRA-FINE NANO PEN NEEDLES 32 X 5/32"
BEAU RX TOPICAL GEL
BECONASE AQ 42 MCG (0.042 %) NASAL SPRAY MM
belladonna-opium 16.2 mg-30 mg rectal suppository
belladonna-opium 16.2-60 supp
BELSOMRA 10 MG TABLET
BELSOMRA 15 MG TABLET
BELSOMRA 20 MG TABLET
BELSOMRA 5 MG TABLET
benazepril hcl 10 mg tablet MM
benazepril hcl 20 mg tablet MM
benazepril hcl 40 mg tablet MM
benazepril hcl 5 mg tablet MM
benazepril-hctz 10-12.5 mg tab MM
benazepril-hctz 20-12.5 mg tab MM
benazepril-hctz 20-25 mg tab MM
benazepril-hctz 5-6.25 mg tab MM
BENICAR 20 MG TABLET MM
BENICAR 40 MG TABLET MM
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
24 - FORMULARY Updated 09/2015
DRUG LEVEL
2
2
2
2
2
1
1
2
2
2
2
1
1
1
1
1
2
2
2
2
2
2
1
1
1
1
1
1
3
3
3
2
3
3
3
3
1
1
1
1
2
2
2
2
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,ST
QL
QL
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
DRUG NAME
BENICAR 5 MG TABLET MM
BENICAR HCT 20 MG-12.5 MG TABLET MM
BENICAR HCT 40 MG-12.5 MG TABLET MM
BENICAR HCT 40 MG-25 MG TABLET MM
BENOXYLDOXY 30 100 MG-4.4 % KIT, CLEANSER ER AND TABLET
BENOXYLDOXY 60 100 MG-4.4 % KIT, CLEANSER ER AND TABLET
bensal hp 3 % topical ointment
BENTYL 10 MG CAPSULE
BENTYL 20 MG TABLET
BENZAC AC 5% GEL
benzac ac wash 10% liquid
benzac w wash 10% liquid
BENZACLIN 1 %-5 % TOPICAL GEL
BENZACLIN PUMP 1 %-5 % TOPICAL GEL
BENZAMYCIN 3 %-5 % TOPICAL GEL
BENZAMYCINPAK 3 %-5 % TOPICAL GEL
BENZEFOAM 5.3 % TOPICAL
BENZEFOAM ULTRA 9.8 % TOPICAL
benzepro (microspheres) 7 % topical cleanser
benzepro 6 % towelette
benzonatate 100 mg capsule
benzonatate 150 mg capsule
benzonatate 200 mg capsule
benzoyl peroxide 5.3% foam
benzoyl peroxide 9.8% foam
benztropine mes 0.5 mg tab MM
benztropine mes 1 mg tablet MM
benztropine mes 2 mg tablet MM
BEPREVE 1.5 % EYE DROPS
BESIVANCE 0.6 % EYE DROPS,SUSPENSION
BETADINE OPHTHALMIC PREP 5 % SOLUTION
BETAGAN 0.5 % EYE DROPS MM
betamethasone dp 0.05% crm
betamethasone dp 0.05% lot
betamethasone dp 0.05% oint
betamethasone dp aug 0.05% crm
betamethasone dp aug 0.05% gel
betamethasone dp aug 0.05% lot
betamethasone dp aug 0.05% oin
betamethasone va 0.1% cream
betamethasone va 0.1% lotion
betamethasone valer 0.1% ointm
betamethasone valer 0.12% foam
BETAPACE 120 MG TABLET MM
BETAPACE 160 MG TABLET MM
BETAPACE 240 MG TABLET MM
BETAPACE 80 MG TABLET MM
BETAPACE AF 120 MG TABLET MM
DRUG LEVEL
3
3
3
3
3
3
3
3
3
3
3
3
3
4
3
3
3
3
3
3
3
3
3
3
3
1
1
1
3
2
3
3
2
2
2
2
3
3
3
2
2
2
3
3
3
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 25
DRUG NAME
BETAPACE AF 160 MG TABLET MM
BETAPACE AF 80 MG TABLET MM
BETASERON 0.3 MG SUBCUTANEOUS KIT SP
BETASERON 0.3 MG SUBCUTANEOUS SOLUTION SP
betaxolol 10 mg tablet MM
betaxolol 20 mg tablet MM
betaxolol hcl 0.5% eye drop MM
bethanechol 10 mg tablet
bethanechol 25 mg tablet
bethanechol 5 mg tablet
bethanechol 50 mg tablet
BETHKIS 300 MG/4 ML SOLUTION FOR NEBULIZATION SP
BETIMOL 0.25 % EYE DROPS MM
BETIMOL 0.5 % EYE DROPS MM
BETOPTIC S 0.25 % EYE DROPS,SUSPENSION MM
bexarotene 75 mg capsule SP
BEYAZ 3 MG-0.02 MG-0.451 MG (24) TABLET MM
BG-STAR STRIPS MM
BHT POWDER
BIAFINE EMULSION TOPICAL EMULSION
BIAXIN 250 MG TABLET
BIAXIN 250 MG/5 ML ORAL SUSPENSION
BIAXIN 500 MG TABLET
BIAXIN XL 500 MG TABLET
BIAXIN XL 500 MG TABLET
bicalutamide 50 mg tablet MM
BIDIL 20 MG-37.5 MG TABLET MM
BIFERA RX 22 MG-6 MG-1 MG-25 MCG TABLET
BILTRICIDE 600 MG TABLET
bimatoprost 0.03% eye drops MM
BINOSTO 70 MG EFFERVESCENT TABLET MM
bioglo 1 mg eye strips
BIONECT 0.2 % TOPICAL CREAM
BIONECT 0.2 % TOPICAL FOAM
BIONECT 0.2 % TOPICAL GEL
BIONECT 0.2% SPRAY
BIONIME RIGHTEST GM300 SYSTEM KIT
BIONIME RIGHTEST TEST STRIPS MM
bisoprolol fumarate 10 mg tab MM
bisoprolol fumarate 5 mg tab MM
bisoprolol-hctz 10-6.25 mg tab MM
bisoprolol-hctz 2.5-6.25 mg tb MM
bisoprolol-hctz 5-6.25 mg tab MM
BLEPH-10 10 % EYE DROPS
BLEPHAMIDE 10 %-0.2 % EYE DROPS,SUSPENSION
BLEPHAMIDE S.O.P. 10 %-0.2 % EYE OINTMENT
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
26 - FORMULARY Updated 09/2015
DRUG LEVEL
3
3
*
*
2
2
3
2
2
2
2
*
3
3
3
*
2
3
4
3
3
3
3
3
3
2
3
2
3
3
3
3
3
3
3
3
3
3
1
1
1
1
1
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,PA
QL,PA
QL,PA
ST
ST
QL,PA
QL,ST
QL
QL
QL
QL,ST
ST
QL,ST
DRUG NAME
BLOOD GLUCOSE CONTROL SOLUTION
BLOOD GLUCOSE MONITORING KIT
BLOOD GLUCOSE TEST STRIPS MM
BONIVA 150 MG TABLET MM
BOSULIF 100 MG TABLET SP
BOSULIF 500 MG TABLET SP
bp 10-1 10 %-1 % topical cleanser
bp-50% urea 50 % topical emulsion
bpo 3 % towelette
bpo 4 % topical gel
bpo 6 % towelette
bpo 8 % topical gel
bpo 9 % towelette
BREATHERITE MDI SPACER
BREATHERITE RIGID SPACER & MASK
BREATHERITE RIGID SPACER & MASK, ADULT
BREATHERITE RIGID SPACER & MASK, CHILD
BREATHERITE RIGID SPACER & MASK, INFANT
BREATHERITE RIGID SPACER & MASK, SMALL CHILD
BREATHERITE VALVED MDI CHAMBER SPACER
BREATHERITE VALVED MDI SPACER
BREATHERITE WITH MASK, LARGE
BREATHERITE WITH MASK, MEDIUM
BREATHERITE WITH MASK, SMALL
BREEZE 2 CONTROL SOLUTION, HIGH
BREEZE 2 CONTROL SOLUTION, LOW
BREEZE 2 CONTROL SOLUTION, NORMAL
BREEZE 2 KIT
BREEZE 2 TEST STRIPS MM
BREO ELLIPTA 100 MCG-25 MCG/DOSE POWDER FOR INHALATION MM
BREO ELLIPTA 200 MCG-25 MCG/DOSE POWDER FOR INHALATION
BREVICON (28) 0.5 MG-35 MCG TABLET MM
briellyn 0.4 mg-35 mcg tablet MM
BRILINTA 90 MG TABLET MM
brimonidine 0.2% eye drop MM
brimonidine tartrate 0.15% drp MM
BRINTELLIX 10 MG TABLET MM
BRINTELLIX 20 MG TABLET MM
BRINTELLIX 5 MG TABLET MM
BRISDELLE 7.5 MG CAPSULE
bromfed dm 2 mg-30 mg-10 mg/5 ml syrup
bromfenac sodium 0.09% eye drp
bromocriptine 2.5 mg tablet MM
bromocriptine 5 mg capsule MM
bromphenir-pseudoephed-dm syr
BROVANA 15 MCG/2 ML SOLUTION FOR NEBULIZATION MM
BUCALSEP MUCOSAL SOLUTION
BUCALSEP MUCOSAL SPRAY
DRUG LEVEL
3
3
3
3
*
*
3
3
3
3
3
3
3
1
1
1
1
1
1
1
1
1
1
1
3
3
3
3
3
2
2
3
2
2
1
3
3
3
3
4
3
3
3
3
3
4
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
ST
QL,ST
QL
QL,PA
QL,PA
ST
QL,ST
QL
QL
QL
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,PA
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 27
DRUG NAME
budeprion sr 100 mg tablet MM
budeprion sr 150 mg tablet MM
budesonide 0.25 mg/2 ml susp MM
budesonide 0.5 mg/2 ml susp MM
budesonide 1 mg/2 ml inh susp MM
budesonide 32 mcg nasal spray MM
budesonide ec 3 mg capsule
BULLSEYE MINI SAFETY LANCETS 21 GAUGE
BULLSEYE MINI SAFETY LANCETS 28 GAUGE
bumetanide 0.5 mg tablet MM
bumetanide 1 mg tablet MM
bumetanide 2 mg tablet MM
BUNAVAIL 2.1 MG-0.3 MG BUCCAL FILM
BUNAVAIL 4.2 MG-0.7 MG BUCCAL FILM
BUNAVAIL 6.3 MG-1 MG BUCCAL FILM
bupap 50 mg-300 mg tablet
BUPHENYL 0.94 GRAM/GRAM ORAL POWDER SP
BUPHENYL 500 MG TABLET SP
buprenorphin-naloxon 8-2 mg sl
buprenorphine 2 mg tablet sl
buprenorphine 8 mg tablet sl
buprenorphn-naloxn 2-0.5 mg sl
buproban 150 mg tablet,extended release
bupropion hcl 100 mg tablet MM
bupropion hcl 75 mg tablet MM
bupropion hcl sr 100 mg tablet MM
bupropion hcl sr 150 mg tablet MM
bupropion hcl sr 200 mg tab MM
bupropion hcl xl 150 mg tablet MM
bupropion hcl xl 300 mg tablet MM
buspirone hcl 10 mg tablet MM
buspirone hcl 15 mg tablet MM
buspirone hcl 30 mg tablet MM
buspirone hcl 5 mg tablet MM
buspirone hcl 7.5 mg tablet MM
butalb-acetamin-caff 50-300-40
butalb-acetamin-caff 50-325-40
butalb-acetamin-caff 50-500-40
butalb-acetaminoph-caff-codein
butalb-caff-acetaminoph-codein
butalbit-acetaminophen-caff cp
butalbital compound with codeine 30 mg-50 mg-325 mg-40 mg capsule
butalbital-asa-caffeine cap
butalbital-asa-caffeine tablet
BUTISOL 30 MG TABLET
BUTISOL SODIUM 30 MG/5 ML ELX
BUTISOL SODIUM 50 MG TABLET
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
28 - FORMULARY Updated 09/2015
DRUG LEVEL
2
2
3
3
4
3
4
1
1
2
2
2
3
3
3
3
*
*
3
3
3
3
2
2
2
2
2
2
2
2
1
1
1
1
1
3
2
2
3
3
2
3
2
2
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
QL,ST
QL,PA
QL,PA
QL,PA
QL
QL,PA
QL,PA
QL,PA
QL,PA
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
DRUG NAME
butorphanol 10 mg/ml spray
BUTRANS 10 MCG/HOUR TRANSDERMAL PATCH
BUTRANS 15 MCG/HOUR TRANSDERMAL PATCH
BUTRANS 20 MCG/HOUR TRANSDERMAL PATCH
BUTRANS 5 MCG/HOUR TRANSDERMAL PATCH
BUTRANS 7.5 MCG/HOUR TRANSDERMAL PATCH
BYDUREON 2 MG SUBCUTANEOUS EXTENDED RELEASE SUSPENSION MM
BYDUREON 2 MG/0.65 ML SUBCUTANEOUS PEN INJECTOR MM
BYETTA 10 MCG/DOSE(250 MCG/ML)2.4 ML SUBCUTANEOUS PEN INJECTOR MM
BYETTA 5 MCG/DOSE (250 MCG/ML)1.2 ML SUBCUTANEOUS PEN INJECTOR MM
BYSTOLIC 10 MG TABLET MM
BYSTOLIC 2.5 MG TABLET MM
BYSTOLIC 20 MG TABLET MM
BYSTOLIC 5 MG TABLET MM
c-nate dha 28 mg-1 mg-200 mg capsule
cabergoline 0.5 mg tablet MM
CADEAU DHA 29 MG IRON-1 MG-150 MG CAPSULE
CADUET 10 MG-10 MG TABLET MM
CADUET 10 MG-20 MG TABLET MM
CADUET 10 MG-40 MG TABLET MM
CADUET 10 MG-80 MG TABLET MM
CADUET 2.5 MG-10 MG TABLET MM
CADUET 2.5 MG-20 MG TABLET MM
CADUET 2.5 MG-40 MG TABLET MM
CADUET 5 MG-10 MG TABLET MM
CADUET 5 MG-20 MG TABLET MM
CADUET 5 MG-40 MG TABLET MM
CADUET 5 MG-80 MG TABLET MM
CAFCIT 20 MG/ML ORAL SOLN
CAFERGOT 1 MG-100 MG TABLET
caffeine cit 60 mg/3 ml oral
CALAN 120 MG TABLET MM
CALAN 80 MG TABLET MM
CALAN SR 120 MG TABLET,EXTENDED RELEASE MM
CALAN SR 180 MG TABLET,EXTENDED RELEASE MM
CALAN SR 240 MG TABLET,EXTENDED RELEASE MM
calcipotriene 0.005% cream
calcipotriene 0.005% ointment
calcipotriene 0.005% solution
calcipotriene-betameth dp oint
calcitonin-salmon 200 units sp MM
calcitrene 0.005 % topical ointment
calcitriol 0.25 mcg capsule MM
calcitriol 0.5 mcg capsule MM
calcitriol 1 mcg/ml solution MM
DRUG LEVEL
3
3
3
3
3
3
3
3
3
3
3
3
3
3
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
4
3
3
3
3
3
3
3
3
4
2
3
2
2
2
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 29
DRUG NAME
calcitriol 3 mcg/g ointment
calcium acetate 667 mg gelcap MM
calcium acetate 667 mg tablet MM
calcium pnv 28 mg-1 mg-250 mg capsule
calcium-folic acid-vitamin d 500 mg-50 mg-300 unit-1 mg oral wafer
CAMBIA 50 MG ORAL POWDER PACKET
camila 0.35 mg tablet MM
CAMPRAL DR 333 MG TABLET MM
camrese 0.15 mg-30 mcg (84)/10 mcg(7) tablets,3 month dose pack
camrese lo 0.10 mg-20 mcg (84)/10 mcg(7) tablets,3 month dose pack MM
CANASA 1,000 MG RECTAL SUPPOSITORY MM
candesartan cilexetil 16 mg tb MM
candesartan cilexetil 32 mg tb MM
candesartan cilexetil 4 mg tab MM
candesartan cilexetil 8 mg tab MM
candesartan-hctz 16-12.5 mg tb MM
candesartan-hctz 32-12.5 mg tb MM
candesartan-hctz 32-25 mg tab MM
CANTIL 25 MG TABLET
capacet 50 mg-325 mg-40 mg capsule
capecitabine 150 mg tablet SP
capecitabine 500 mg tablet SP
CAPEX 0.01 % SHAMPOO
CAPHOSOL MUCOSAL SOLUTION
CAPITAL WITH CODEINE 120 MG-12 MG/5 ML ORAL SUSPENSION
CAPRELSA 100 MG TABLET SP
CAPRELSA 300 MG TABLET SP
captopril 100 mg tablet MM
captopril 12.5 mg tablet MM
captopril 25 mg tablet MM
captopril 50 mg tablet MM
captopril-hctz 25-15 mg tablet MM
captopril-hctz 25-25 mg tablet MM
captopril-hctz 50-15 mg tablet MM
captopril-hctz 50-25 mg tablet MM
CARAC 0.5 % TOPICAL CREAM
CARAFATE 1 GRAM TABLET MM
CARAFATE 100 MG/ML ORAL SUSPENSION MM
carb-o-philic 40 % topical cream
CARB-O-PHILIC 40 % TOPICAL GEL
CARBAGLU 200 MG DISPERSIBLE TABLET SP
carbamazepine 100 mg tab chew MM
carbamazepine 100 mg/5 ml susp MM
carbamazepine 200 mg tablet MM
carbamazepine er 100 mg cap MM
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
30 - FORMULARY Updated 09/2015
DRUG LEVEL
3
3
3
3
3
4
1
3
2
2
2
2
2
2
2
2
2
2
3
1
*
*
2
4
4
*
*
3
3
3
3
3
3
3
3
4
3
3
2
3
*
2
2
2
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL,ST
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL,PA
QL,PA
QL
QL,PA
QL,PA
PA
DRUG NAME
carbamazepine er 200 mg cap MM
carbamazepine er 300 mg cap MM
carbamazepine xr 200 mg tablet MM
carbamazepine xr 400 mg tablet MM
CARBATROL 100 MG CAPSULE, EXTENDED RELEASE MM
CARBATROL 200 MG CAPSULE, EXTENDED RELEASE MM
CARBATROL 300 MG CAPSULE, EXTENDED RELEASE MM
carbidopa 25 mg tablet MM
carbidopa-levo 10-100 mg odt MM
carbidopa-levo 25-100 mg odt MM
carbidopa-levo 25-250 mg odt MM
carbidopa-levo er 25-100 tab MM
carbidopa-levo er 50-200 tab MM
carbidopa-levodopa 10-100 tab MM
carbidopa-levodopa 25-100 tab MM
carbidopa-levodopa 25-250 tab MM
carbidopa-levodopa-enta 100 mg MM
carbidopa-levodopa-enta 125 mg MM
carbidopa-levodopa-enta 150 mg MM
carbidopa-levodopa-enta 200 mg MM
carbidopa-levodopa-enta 50 mg MM
carbidopa-levodopa-enta 75 mg MM
carbinoxamine 4 mg/5 ml liquid
carbinoxamine maleate 4 mg tab
CARDENE SR 30 MG CAPSULE,EXTENDED RELEASE MM
CARDENE SR 45 MG CAPSULE,EXTENDED RELEASE MM
CARDENE SR 60 MG CAPSULE MM
CARDIOTEK-RX (BIOPERINE) 2 MG-500 MG-500 MCG-50 MG TABLET
CARDIOVID PLUS 600 MG-20 MG-500 MCG-800 MCG CAPSULE
CARDIZEM 120 MG TABLET MM
CARDIZEM 30 MG TABLET MM
CARDIZEM 60 MG TABLET MM
CARDIZEM 90 MG TABLET MM
CARDIZEM CD 120 MG CAPSULE,EXTENDED RELEASE MM
CARDIZEM CD 180 MG CAPSULE,EXTENDED RELEASE MM
CARDIZEM CD 240 MG CAPSULE,EXTENDED RELEASE MM
CARDIZEM CD 300 MG CAPSULE,EXTENDED RELEASE MM
CARDIZEM CD 360 MG CAPSULE,EXTENDED RELEASE MM
CARDIZEM LA 120 MG TABLET,EXTENDED RELEASE MM
CARDIZEM LA 180 MG TABLET,EXTENDED RELEASE MM
CARDIZEM LA 240 MG TABLET,EXTENDED RELEASE MM
CARDIZEM LA 300 MG TABLET,EXTENDED RELEASE MM
CARDIZEM LA 360 MG TABLET,EXTENDED RELEASE MM
DRUG LEVEL
3
3
3
3
3
3
3
3
3
3
3
2
2
1
1
1
3
3
3
3
3
3
3
3
3
3
3
2
3
3
3
3
3
4
4
4
4
4
3
3
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 31
DRUG NAME
CARDIZEM LA 420 MG TABLET,EXTENDED RELEASE MM
CARDURA 1 MG TABLET MM
CARDURA 2 MG TABLET MM
CARDURA 4 MG TABLET MM
CARDURA 8 MG TABLET MM
CARDURA XL 4 MG TABLET,EXTENDED RELEASE MM
CARDURA XL 8 MG TABLET,EXTENDED RELEASE MM
CAREFINE PEN NEEDLE 29 GAUGE X 1/2"
CAREFINE PEN NEEDLE 30 X 5/16"
CAREFINE PEN NEEDLE 31 GAUGE X 1/4"
CAREFINE PEN NEEDLE 31 X 5/16"
CAREFINE PEN NEEDLE 32 GAUGE X 3/16"
CAREFINE PEN NEEDLE 32 X 1/4"
CAREFINE PEN NEEDLE 32 X 5/32"
CARELANCE ULTIMATE COMFORT LANCING DEVICE
CAREONE LANCING DEVICE
CAREONE THIN LANCET
CAREONE ULTRA THIN LANCET
CARESENS CONTROL A & B SOLUTION
CARESENS CONTROL A NORMAL SOLUTION
CARESENS LANCETS 30 GAUGE
CARESENS N
CARESENS N KIT
CARESENS N TEST STRIPS MM
CARESENS N VOICE
CARESENS N VOICE KIT
CARESENS PREMIUM COMFORT LANCING DEVICE
carisoprodol 250 mg tablet
carisoprodol 350 mg tablet
carisoprodol compound tab
carisoprodol cpd-codeine tab
CARNITOR 100 MG/ML ORAL SOLUTION MM
CARNITOR 330 MG TABLET MM
CARNITOR SUGAR-FREE 100 MG/ML ORAL SOLUTION MM
carteolol hcl 1% eye drops MM
cartia xt 120 mg capsule,extended release MM
cartia xt 180 mg capsule,extended release MM
cartia xt 240 mg capsule,extended release MM
cartia xt 300 mg capsule,extended release MM
CARTICEL 12 MILLION CELL/0.4 ML SUSPENSION FOR IMPLANTATION
carvedilol 12.5 mg tablet MM
carvedilol 25 mg tablet MM
carvedilol 3.125 mg tablet MM
carvedilol 6.25 mg tablet MM
CASODEX 50 MG TABLET MM
CATAFLAM 50 MG TABLET
CATAPRES 0.1 MG TABLET MM
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
32 - FORMULARY Updated 09/2015
DRUG LEVEL
3
3
3
3
3
3
3
1
1
1
1
1
1
1
3
1
1
1
3
3
3
3
3
3
3
3
3
3
2
3
3
3
3
3
1
2
2
2
2
3
1
1
1
1
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
ST
ST
QL,ST
ST
ST
QL
QL
QL
QL
QL
QL
QL
DRUG NAME
CATAPRES 0.2 MG TABLET MM
CATAPRES 0.3 MG TABLET MM
CATAPRES-TTS-1 0.1 MG/24 HR TRANSDERMAL PATCH MM
CATAPRES-TTS-2 0.2 MG/24 HR TRANSDERMAL PATCH MM
CATAPRES-TTS-3 0.3 MG/24 HR TRANSDERMAL PATCH MM
cavan-alpha kit combo pack
cavan-ec sod dha vitamins
CAYA CONTOURED 60 MM-85 MM VAGINAL DIAPHRAGM
CAYSTON 75 MG/ML SOLUTION FOR NEBULIZATION SP
caziant (28) 0.1 mg/0.125 mg/0.15 mg-25 mcg tablet MM
CEDAX 180 MG/5 ML ORAL SUSPENSION
CEDAX 400 MG CAPSULE
cefaclor 125 mg/5 ml susp
cefaclor 250 mg capsule
cefaclor 250 mg/5 ml susp
cefaclor 375 mg/5 ml suspen
cefaclor 500 mg capsule
cefaclor er 500 mg tablet
cefadroxil 1 gm tablet
cefadroxil 250 mg/5 ml susp
cefadroxil 500 mg capsule
cefadroxil 500 mg/5 ml susp
cefdinir 125 mg/5 ml susp
cefdinir 250 mg/5 ml susp
cefdinir 300 mg capsule
cefditoren pivoxil 200 mg tab
cefditoren pivoxil 400 mg tab
cefixime 100 mg/5 ml susp
cefixime 200 mg/5 ml susp
cefpodoxime 100 mg tablet
cefpodoxime 100 mg/5 ml susp
cefpodoxime 200 mg tablet
cefpodoxime 50 mg/5 ml susp
cefprozil 125 mg/5 ml susp
cefprozil 250 mg tablet
cefprozil 250 mg/5 ml susp
cefprozil 500 mg tablet
ceftibuten 180 mg/5 ml susp
ceftibuten 400 mg capsule
CEFTIN 125 MG/5 ML ORAL SUSPENSION
CEFTIN 250 MG TABLET
CEFTIN 250 MG/5 ML ORAL SUSPENSION
CEFTIN 500 MG TABLET
cefuroxime axetil 250 mg tab
cefuroxime axetil 500 mg tab
CELACYN TOPICAL GEL WITH PUMP
CELEBREX 100 MG CAPSULE MM
CELEBREX 200 MG CAPSULE MM
CELEBREX 400 MG CAPSULE MM
DRUG LEVEL
3
3
3
3
3
2
3
4
*
1
3
3
3
2
3
3
2
2
3
3
2
3
2
2
2
3
3
3
3
3
3
3
3
2
2
2
2
3
3
3
3
3
3
2
2
3
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL,PA
QL,ST
QL,ST
QL,ST
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 33
DRUG NAME
CELEBREX 50 MG CAPSULE MM
celecoxib 100 mg capsule MM
celecoxib 200 mg capsule MM
celecoxib 400 mg capsule MM
celecoxib 50 mg capsule MM
CELESTONE 0.6 MG/5 ML SOLUTION
CELEXA 10 MG TABLET MM
CELEXA 20 MG TABLET MM
CELEXA 40 MG TABLET MM
CELLCEPT 200 MG/ML ORAL SUSPENSION
CELLCEPT 250 MG CAPSULE
CELLCEPT 500 MG TABLET
CELONTIN 300 MG CAPSULE MM
cem-urea 45 % topical gel
CENESTIN 0.3 MG TABLET MM
CENESTIN 0.45 MG TABLET MM
CENESTIN 0.625 MG TABLET MM
CENESTIN 0.9 MG TABLET MM
CENESTIN 1.25 MG TABLET MM
CENTANY 2 % TOPICAL OINTMENT
CENTANY AT 2 % OINTMENT TOPICAL KIT
centergy 1 mg-2 mg/ml oral drops
centergy dm 1 mg-2 mg-3 mg/ml oral drops
centratex 106 mg iron-1 mg capsule
cephalexin 125 mg/5 ml susp
cephalexin 250 mg capsule
cephalexin 250 mg tablet
cephalexin 250 mg/5 ml susp
cephalexin 500 mg capsule
cephalexin 500 mg tablet
cephalexin 750 mg capsule
CERDELGA 84 MG CAPSULE SP
CEREFOLIN 6 MG-5 MG-50 MG-1 MG TABLET
CEREFOLIN NAC (ALGAL OIL) 6 MG-600 MG-2 MG-90.314 MG TABLET
CERENX 500 MG CAPSULE
cerisa wash
CERVIDIL 10 MG VAGINAL INSERT,CONTROLLED RELEASE
CESAMET 1 MG CAPSULE
CESINEX SUSPENSION
CETACAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY
CETACAINE ANESTHETIC 2 %-2 %-14 % TOPICAL LIQUID
cetirizine hcl 1 mg/ml syrup MM
CETRAXAL 0.2 % EAR DROPS IN A DROPPERETTE
cevimeline hcl 30 mg capsule MM
chateal 0.15 mg-0.03 mg tablet MM
CHEK-STIX CONTROL STRIPS
CHEMET 100 MG CAPSULE
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
34 - FORMULARY Updated 09/2015
DRUG LEVEL
3
3
3
3
3
3
3
3
3
4
4
4
3
3
3
3
3
3
3
3
3
3
3
1
2
2
2
2
2
2
2
*
3
3
3
3
3
3
3
3
3
3
3
3
2
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL
QL
QL
QL
QL
QL,PA
QL,PA
QL
DRUG NAME
CHEMSTRIP 10 MD
CHEMSTRIP 10/SG
CHEMSTRIP 2
CHEMSTRIP 2 GP
CHEMSTRIP 50B
CHEMSTRIP 7
CHEMSTRIP 9
CHEMSTRIP K MM
CHEMSTRIP MICRAL
CHEMSTRIP UGK MM
CHENODAL 250 MG TABLET SP
chewables multivitamins-a,b,d,e,k,zn 1,000 unit-800 mcg tablet
chlordiazepo-amitriptyl 5-12.5 MM
chlordiazepox-amitriptyl 10-25 MM
chlordiazepoxide 10 mg capsule
chlordiazepoxide 25 mg capsule
chlordiazepoxide 5 mg capsule
chlordiazepoxide-clidinium cap
chlorhexidine 0.12% rinse
chloroquine ph 250 mg tablet MM
chloroquine ph 500 mg tablet MM
chlorothiazide 250 mg tablet MM
chlorothiazide 500 mg tablet MM
chlorpromazine 10 mg tablet MM
chlorpromazine 100 mg tablet MM
chlorpromazine 200 mg tablet MM
chlorpromazine 25 mg tablet MM
chlorpromazine 50 mg tablet MM
chlorpropamide 100 mg tablet MM
chlorpropamide 250 mg tablet MM
chlorthalidone 25 mg tablet MM
chlorthalidone 50 mg tablet MM
chlorzoxazone 500 mg tablet
CHOICE DM CLARUS NORMAL CONTROL SOLUTION
choice-ob + dha combo pack
CHOICEDM CLARUS
CHOICEDM CLARUS STRIPS MM
CHOICEDM G20 BLOOD GLUCOSE SYS
CHOICEDM G20 TEST STRIPS MM
CHOLBAM 250 MG CAPSULE SP
CHOLBAM 50 MG CAPSULE SP
cholestyramine light 4 gram oral powder MM
cholestyramine light 4 gram powder for susp in a packet MM
cholestyramine packet MM
cholestyramine powder MM
choline mag trisal liquid
DRUG LEVEL
3
3
3
3
3
3
3
3
3
3
*
1
3
3
2
2
2
2
2
2
2
1
1
3
3
3
3
3
3
3
1
1
1
3
2
3
3
3
3
*
*
3
3
3
3
1
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
ST
QL,ST
ST
QL,ST
QL,PA
QL,PA
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 35
DRUG NAME
CIALIS 2.5 MG TABLET MM
CIALIS 5 MG TABLET MM
ciclodan 0.77 % topical cream
CICLODAN KIT 0.77 % TOPICAL COMBO PACK
ciclopirox 0.77% cream
ciclopirox 0.77% gel
ciclopirox 0.77% topical susp
ciclopirox 1% shampoo
ciferex 3,775 unit-1 mg capsule
cilostazol 100 mg tablet MM
cilostazol 50 mg tablet MM
CILOXAN 0.3 % EYE DROPS
CILOXAN 0.3 % EYE OINTMENT
cimetidine 200 mg tablet MM
cimetidine 300 mg tablet MM
cimetidine 300 mg/5 ml soln MM
cimetidine 400 mg tablet MM
cimetidine 800 mg tablet MM
CIMZIA 400 MG/2 ML (200 MG/ML X 2) SUBCUTANEOUS SYRINGE KIT SP
CIMZIA STARTER KIT 400 MG/2 ML (200 MG/ML X2) SUBCUTANEOUS SYRINGE KIT
DRUG LEVEL
3
3
3
3
2
3
2
3
3
1
1
3
3
3
3
1
3
3
*
*
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,PA
QL,PA
QL,PA
QL,PA
SP
CIPRO 250 MG TABLET
CIPRO 250 MG/5 ML ORAL SUSPENSION
CIPRO 500 MG TABLET
CIPRO 500 MG/5 ML ORAL SUSPENSION
CIPRO HC 0.2 %-1 % EAR DROPS,SUSPENSION
CIPRO XR 1,000 MG TABLET,EXTENDED RELEASE
CIPRO XR 500 MG TABLET,EXTENDED RELEASE
CIPRODEX 0.3 %-0.1 % EAR DROPS,SUSPENSION
ciprofloxacin 0.2% otic soln
ciprofloxacin 0.3% eye drop
ciprofloxacin 250 mg/5 ml susp
ciprofloxacin 500 mg/5 ml susp
ciprofloxacin er 1,000 mg tab
ciprofloxacin er 500 mg tablet
ciprofloxacin hcl 100 mg tab
ciprofloxacin hcl 250 mg tab
ciprofloxacin hcl 500 mg tab
ciprofloxacin hcl 750 mg tab
citalopram hbr 10 mg tablet MM
citalopram hbr 10 mg/5 ml soln MM
citalopram hbr 20 mg tablet MM
citalopram hbr 40 mg tablet MM
CITRANATAL (DUAL-IRON) 27 MG IRON-1 MG-50 MG TABLET
CITRANATAL 90 DHA (ALGAL OIL) 90 MG IRON-1 MG-50 MG-300 MG ORAL PACK
CITRANATAL 90 DHA PACK
CITRANATAL ASSURE 35 MG IRON-1 MG-50 MG-300 MG ORAL PACK
CITRANATAL ASSURE COMBO PACK
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
36 - FORMULARY Updated 09/2015
3
3
3
3
3
3
3
2
3
2
3
3
3
3
2
2
2
2
1
2
1
1
3
3
2
3
2
ST
QL
QL
QL
DRUG NAME
CITRANATAL B-CALM (FE GLUC) 20 MG IRON-1 MG-25 MG/25 MG TABLETS
CITRANATAL DHA (ALGAL OIL) 27 MG IRON-1 MG-50 MG-250 MG ORAL PACK
CITRANATAL DHA PACK
CITRANATAL HARMONY CAPSULE
CITRANATAL HARMONY(IRON CARB-FUM) 27 MG IRON-1 MG-50 MG-260 MG
CAPSULE
CITRANATAL RX TABLET
citrate phos dextrose soln
CITRIC ACID POWDER
claravis 10 mg capsule
claravis 20 mg capsule
claravis 30 mg capsule
claravis 40 mg capsule
CLARIFOAM EF 10 %-5 % TOPICAL
CLARINEX 2.5 MG/5 ML (0.5 MG/ML) SYRUP MM
CLARINEX 5 MG TABLET MM
CLARINEX-D 12 HOUR 2.5 MG-120 MG TABLET,EXTENDED RELEASE
CLARINEX-D 24 HOUR TABLET
claris clarifying wash
clarithromycin 125 mg/5 ml sus
clarithromycin 250 mg tablet
clarithromycin 250 mg/5 ml sus
clarithromycin 500 mg tablet
clarithromycin er 500 mg tab
cleansing wash 10 %-4 %-10 % topical cleanser
clemastine 0.5 mg/5 ml syrup
clemastine fum 2.68 mg tab
CLEOCIN 100 MG VAGINAL SUPPOSITORY
CLEOCIN 150 MG CAPSULE
CLEOCIN 2 % VAGINAL CREAM
CLEOCIN 300 MG CAPSULE
CLEOCIN 75 MG CAPSULE
CLEOCIN 75 MG/5 ML ORAL SOLUTION
CLEOCIN T 1 % LOTION
CLEOCIN T 1 % SOLUTION
CLEOCIN T 1 % TOPICAL GEL
CLEOCIN T 1 % TOPICAL SWAB
CLEVER CHEK BLOOD GLUCOSE
CLEVER CHEK BLOOD GLUCOSE SYST KIT
CLEVER CHEK LANCETS 30 GAUGE
CLEVER CHOICE BLOOD GLUCOSE SYSTEM
CLEVER CHOICE LEVEL 1 CONTROL SOLUTION
CLEVER CHOICE LEVEL 2 CONTROL SOLUTION
CLEVER CHOICE LEVEL 3 CONTROL SOLUTION
CLEVER CHOICE MICRO
CLEVER CHOICE MICRO TEST STRIP MM
CLEVER CHOICE MINI BLOOD GLUCOSE MONITOR
CLEVER CHOICE PRO BLOOD GLUCOSE MONITOR
CLEVER CHOICE PRO BLOOD GLUCOSE MONITOR STRIPS MM
CLEVER CHOICE TALK BLOOD GLUCOSE SYSTEM
DRUG LEVEL
UTILIZATION
MANAGEMENT
REQUIREMENTS
2
3
3
2
3
3
3
4
4
4
4
4
3
3
3
3
3
2
3
2
3
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
1
3
3
3
3
3
3
3
3
3
3
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
ST
ST
ST
ST
QL,ST
ST
ST
QL,ST
ST
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 37
DRUG NAME
CLEVER CHOICE TALK TEST STRIPS MM
CLEVER CHOICE TEST STRIPS MM
CLEVER CHOICE VOICE+ TEST STRIPS MM
CLICKFINE 31 GAUGE X 1/4" NEEDLE
CLICKFINE 31 X 5/16" NEEDLE
CLICKFINE 32 X 5/32" NEEDLE
CLIMARA 0.025 MG/24 HR TRANSDERMAL PATCH MM
CLIMARA 0.0375 MG/24 HR TRANSDERMAL PATCH MM
CLIMARA 0.05 MG/24 HR TRANSDERMAL PATCH MM
CLIMARA 0.06 MG/24 HR TRANSDERMAL PATCH MM
CLIMARA 0.075 MG/24 HR TRANSDERMAL PATCH MM
CLIMARA 0.1 MG/24 HR TRANSDERMAL PATCH MM
CLIMARA PRO 0.045 MG-0.015 MG/24 HR TRANSDERMAL PATCH MM
clind ph-benzoyl perox 1.2-5%
CLINDACIN ETZ 1 % TOPICAL KIT
clindacin etz 1 % topical swab
clindacin p 1 % topical swab
CLINDACIN PAC 1 % TOPICAL KIT
CLINDAGEL 1 % TOPICAL
clindamycin 2% vaginal cream
clindamycin 75 mg/5 ml soln
clindamycin hcl 150 mg capsule
clindamycin hcl 300 mg capsule
clindamycin hcl 75 mg capsule
clindamycin pediatric 75 mg/5 ml oral solution
clindamycin ph 1% gel
clindamycin ph 1% solution
clindamycin phos 1% pledget
clindamycin phosp 1% lotion
clindamycin phosphate 1% foam
clindamycin-benzoyl perox gel
CLINDESSE 2 % VAGINAL CREAM,EXTENDED RELEASE
CLINIMIX 2.75 % IN 5 % DEXTROSE SULFITE FREE INTRAVENOUS SOLUTION
CLINIMIX 4.25 % IN 10 % DEXTROSE SULFITE FREE INTRAVENOUS SOLUTION
CLINIMIX 4.25 % IN 20 % DEXTROSE (SULFITE-FREE) INTRAVENOUS SOLUTION
CLINIMIX 4.25 % IN 25 % DEXTROSE (SULFITE-FREE) INTRAVENOUS SOLUTION
CLINIMIX 4.25 % IN 5 % DEXTROSE SULFITE FREE INTRAVENOUS SOLUTION
CLINIMIX 5 % IN 15 % DEXTROSE SULFITE FREE INTRAVENOUS SOLUTION
CLINIMIX 5 % IN 20 % DEXTROSE (SULFITE-FREE) INTRAVENOUS SOLUTION
CLINIMIX 5 % IN 25 % DEXTROSE SULFITE-FREE INTRAVENOUS SOLUTION
CLINIMIX E 2.75 % IN 10 % DEXTROSE SULFITE FREE INTRAVENOUS SOLUTION
CLINIMIX E 2.75 % IN 5 % DEXTROSE SULFITE FREE INTRAVENOUS SOLUTION
CLINIMIX E 4.25 % IN 10 % DEXTROSE SULFITE FREE INTRAVENOUS SOLUTION
CLINIMIX E 4.25 % IN 25 % DEXTROSE SULFITE FREE INTRAVENOUS SOLUTION
CLINIMIX E 4.25 % IN 5 % DEXTROSE SULFITE FREE INTRAVENOUS SOLUTION
CLINIMIX E 5 % IN 15 % DEXTROSE SULFITE FREE INTRAVENOUS SOLUTION
CLINIMIX E 5 % IN 20 % DEXTROSE SULFITE FREE INTRAVENOUS SOLUTION
CLINIMIX E 5 % IN 25 % DEXTROSE SULFITE FREE INTRAVENOUS SOLUTION
CLINITEST REAGENT TABLET,NON-ORAL MM
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
38 - FORMULARY Updated 09/2015
DRUG LEVEL
3
3
3
1
1
1
3
3
3
3
3
3
3
3
3
2
2
3
4
3
3
2
2
2
3
3
3
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,ST
QL,ST
QL,ST
QL
QL
QL
QL
QL
QL
QL
DRUG NAME
clobetasol 0.05% cream
clobetasol 0.05% gel
clobetasol 0.05% ointment
clobetasol 0.05% shampoo
clobetasol 0.05% solution
clobetasol 0.05% topical lotn
clobetasol emollient 0.05% crm
clobetasol emollnt 0.05% foam
clobetasol prop 0.05% foam
clobetasol prop 0.05% spray
CLOBEX 0.05 % LOTION
CLOBEX 0.05 % SHAMPOO
CLOBEX 0.05 % TOPICAL SPRAY
clocortolone pivalate 0.1% crm
clodan 0.05 % shampoo
CLODAN KIT 0.05 % TOPICAL KIT, SHAMPOO & CLEANSER
CLODERM 0.1 % TOPICAL CREAM
clomipramine 25 mg capsule MM
clomipramine 50 mg capsule MM
clomipramine 75 mg capsule MM
clonazepam 0.125 mg dis tab MM
clonazepam 0.25 mg odt MM
clonazepam 0.5 mg dis tablet MM
clonazepam 0.5 mg tablet MM
clonazepam 1 mg dis tablet MM
clonazepam 1 mg tablet MM
clonazepam 2 mg odt MM
clonazepam 2 mg tablet MM
clonidine 0.1 mg/day patch MM
clonidine 0.2 mg/day patch MM
clonidine 0.3 mg/day patch MM
clonidine hcl 0.1 mg tablet MM
clonidine hcl 0.2 mg tablet MM
clonidine hcl 0.3 mg tablet MM
clonidine hcl er 0.1 mg tablet MM
clopidogrel 300 mg tablet
clopidogrel 75 mg tablet MM
clorazepate 15 mg tablet
clorazepate 3.75 mg tablet
clorazepate 7.5 mg tablet
clorpres 0.1 mg-15 mg tablet MM
clorpres 0.2 mg-15 mg tablet MM
clorpres 0.3 mg-15 mg tablet MM
clotrimazole 1% cream
clotrimazole 1% solution
clotrimazole 10 mg troche
clotrimazole-betamethasone crm
DRUG LEVEL
3
3
3
3
3
3
3
3
3
3
4
4
4
3
3
3
3
4
4
4
2
2
2
1
2
1
2
1
3
3
3
1
1
1
3
3
1
2
2
2
3
3
3
2
2
2
2
UTILIZATION
MANAGEMENT
REQUIREMENTS
ST
ST
ST
ST
QL
QL
QL
QL,ST
QL
QL
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 39
DRUG NAME
clotrimazole-betamethasone lot
clozapine 100 mg tablet MM
clozapine 200 mg tablet MM
clozapine 25 mg tablet MM
clozapine 50 mg tablet MM
clozapine odt 100 mg tablet MM
clozapine odt 12.5 mg tablet MM
clozapine odt 150 mg tablet MM
clozapine odt 200 mg tablet MM
clozapine odt 25 mg tablet MM
CLOZARIL 100 MG TABLET MM
CLOZARIL 25 MG TABLET MM
co-gesic 5-500 tablet
COAGUCHEK LANCETS
coal tar topical solution
COARTEM 20 MG-120 MG TABLET
cocaine 4% solution
codeine sulfate 15 mg tablet
codeine sulfate 30 mg tablet
codeine sulfate 30 mg/5 ml sol
codeine sulfate 60 mg tablet
COLAZAL 750 MG CAPSULE
colchicine 0.6 mg capsule
colchicine 0.6 mg tablet MM
COLCRYS 0.6 MG TABLET MM
COLESTID 1 GRAM TABLET MM
COLESTID 5 GRAM ORAL GRANULES MM
COLESTID 5 GRAM ORAL PACKET MM
COLESTID FLAVORED 5 GRAM ORAL GRANULES MM
COLESTID FLAVORED 7.5 GRAM PACKET MM
colestipol hcl granules MM
colestipol hcl granules packet MM
colestipol micronized 1 gm tab MM
colocort 100 mg/60 ml enema
COLOR LANCETS 21 GAUGE
COLY-MYCIN S 3.3 MG-3 MG-10 MG-0.5 MG/ML EAR DROPS,SUSPENSION
COLYTE WITH FLAVOR PACKS 227.1 GRAM-21.5 GRAM-6.36 GRAM ORAL SOLUTION
COLYTE WITH FLAVOR PACKS 240 GRAM-22.72 G-6.72 G-5.84 G ORAL SOLUTION
COMBIGAN 0.2 %-0.5 % EYE DROPS MM
COMBIPATCH 0.05 MG-0.14 MG/24 HR TRANSDERMAL MM
COMBIPATCH 0.05 MG-0.25 MG/24 HR TRANSDERMAL MM
COMBISTIX REAGENT STRIPS
COMBIVENT INHALER MM
COMBIVENT RESPIMAT 20 MCG-100 MCG/ACTUATION SOLUTION FOR INHALATION
DRUG LEVEL
3
3
3
3
3
3
3
3
3
3
4
4
2
1
3
3
3
3
3
2
3
3
3
2
2
3
3
3
3
3
3
3
2
3
1
3
3
3
2
3
3
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
QL
QL
QL
QL,ST
QL
QL
ST
ST
QL
QL
QL
QL,ST
QL,ST
MM
COMBIVIR 150 MG-300 MG TABLET
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
40 - FORMULARY Updated 09/2015
4
QL
DRUG NAME
COMETRIQ 100 MG/DAY(80 MGÝ1¨-20 MGÝ1¨) CAPSULE SP
COMETRIQ 140 MG/DAY(80 MGÝ1¨-20 MGÝ3¨) CAPSULE SP
COMETRIQ 60 MG/DAY (20 MG Ý3¨/DAY) CAPSULE SP
COMFORT EZ LANCETS 21 GAUGE
COMFORT EZ LANCETS 23 GAUGE
COMFORT EZ LANCETS 28 GAUGE
COMFORT EZ PEN NEEDLES 31 GAUGE X 1/4"
COMFORT EZ PEN NEEDLES 31 X 3/16"
COMFORT EZ PEN NEEDLES 31 X 5/16"
COMFORT EZ PEN NEEDLES 32 GAUGE X 3/16"
COMFORT EZ PEN NEEDLES 32 X 1/4"
COMFORT EZ PEN NEEDLES 32 X 5/16"
COMFORT EZ PEN NEEDLES 32 X 5/32"
COMFORT EZ PEN NEEDLES 33 GAUGE X 1/4"
COMFORT EZ PEN NEEDLES 33 GAUGE X 3/16"
COMFORT EZ PEN NEEDLES 33 GAUGE X 5/16"
COMFORT EZ PEN NEEDLES 33 GAUGE X 5/32"
COMFORT EZ SYRINGE 0.3 ML 29 X 1/2" MM
COMFORT EZ SYRINGE 0.3 ML 30 X 1/2" MM
COMFORT EZ SYRINGE 0.3 ML 30 X 5/16" MM
COMFORT EZ SYRINGE 0.3 ML 31 X 5/16" MM
COMFORT EZ SYRINGE 1 ML 28 X 1/2" MM
COMFORT EZ SYRINGE 1 ML 29 X 1/2" MM
COMFORT EZ SYRINGE 1 ML 30 X 1/2" MM
COMFORT EZ SYRINGE 1 ML 30 X 5/16" MM
COMFORT EZ SYRINGE 1 ML 31 X 5/16" MM
COMFORT EZ SYRINGE 1/2 ML 28 X 1/2" MM
COMFORT EZ SYRINGE 1/2 ML 29 X 1/2" MM
COMFORT EZ SYRINGE 1/2 ML 30 X 1/2" MM
COMFORT EZ SYRINGE 1/2 ML 30 X 5/16" MM
COMFORT EZ SYRINGE 1/2 ML 31 X 5/16" MM
COMFORT LANCETS
COMFORT PAC-CYCLOBENZAPRINE 10 MG KIT
comfort pac-ibuprofen 800 mg kit
COMFORT PAC-MELOXICAM 15 MG KIT
COMFORT PAC-NAPROXEN 500 MG KIT
COMFORT PAC-TIZANIDINE 4 MG KIT
COMFORT POINT PEN NDL 31GX1/6"
COMPACT SPACE CHAMBER PLUS
COMPAZINE 10 MG TABLET
COMPAZINE 25 MG RECTAL SUPPOSITORY
COMPAZINE 5 MG TABLET
COMPLERA 200 MG-25 MG-300 MG TABLET SP
COMPLETE FORMULATION D3000 3,000 UNIT-800 MCG CAPSULE
COMPLETE FORMULATION PEDIATRIC 750 UNIT-500 MCG/0.5 ML ORAL DROPS
complete natal dha 29 mg-1 mg-250 mg oral pack
completenate 29 mg-1 mg chewable tablet
DRUG LEVEL
*
*
*
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
3
4
1
3
3
3
2
2
3
3
3
*
2
2
1
1
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,PA
QL,PA
QL,PA
QL
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 41
DRUG NAME
compound 347 gas for inhalation
compro 25 mg rectal suppository
COMTAN 200 MG TABLET MM
CONCEPT DHA 35 MG-1 MG-200 MG CAPSULE
CONCEPT OB 85 MG-1 MG CAPSULE
CONCERTA 18 MG TABLET,EXTENDED RELEASE
CONCERTA 27 MG TABLET,EXTENDED RELEASE
CONCERTA 36 MG TABLET,EXTENDED RELEASE
CONCERTA 54 MG TABLET,EXTENDED RELEASE
CONDYLOX 0.5 % TOPICAL GEL
CONDYLOX 0.5 % TOPICAL SOLUTION
constulose 10 gram/15 ml oral solution MM
CONTOUR CONTROL SOLUTION, HIGH
CONTOUR CONTROL SOLUTION, LOW
CONTOUR CONTROL SOLUTION, NORMAL
CONTOUR LINK KIT
CONTOUR METER
CONTOUR NEXT EZ METER
CONTOUR NEXT EZ METER KIT
CONTOUR NEXT LEVEL 1 CONTROL SOLUTION
CONTOUR NEXT LEVEL 2 CONTROL SOLUTION
CONTOUR NEXT LINK KIT MM
CONTOUR NEXT METER
CONTOUR NEXT STRIPS MM
CONTOUR NEXT USB METER
CONTOUR TEST STRIPS MM
CONTROL G3 STRIPS MM
CONTROL MONITORING SYSTEM KIT
CONTROL TEST STRIPS MM
CONZIP 100 MG CAPSULE,EXTENDED RELEASE (25-75)
CONZIP 200 MG CAPSULE,EXTENDED RELEASE (25-75)
CONZIP 300 MG CAPSULE, EXTENDED RELEASE
COPAXONE 20 MG/ML SUBCUTANEOUS SYRINGE SP
COPAXONE 40 MG/ML SUBCUTANEOUS SYRINGE SP
COPEGUS 200 MG TABLET
CORDARONE 200 MG TABLET MM
CORDRAN 0.05 % LOTION
CORDRAN 0.05 % TOPICAL CREAM
CORDRAN 0.05 % TOPICAL OINTMENT
CORDRAN TAPE LARGE ROLL 4 MCG/CM2
CORDRAN TAPE SMALL ROLL 4 MCG/CM2
COREG 12.5 MG TABLET MM
COREG 25 MG TABLET MM
COREG 3.125 MG TABLET MM
COREG 6.25 MG TABLET MM
COREG CR 10 MG CAPSULE, EXTENDED RELEASE MM
COREG CR 20 MG CAPSULE, EXTENDED RELEASE MM
COREG CR 40 MG CAPSULE, EXTENDED RELEASE MM
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
42 - FORMULARY Updated 09/2015
DRUG LEVEL
3
3
3
2
2
3
3
3
3
3
3
1
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
*
*
4
3
4
4
4
3
3
3
3
3
3
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL,ST
QL,ST
QL,ST
QL,ST
ST
ST
ST
ST
ST
ST
QL,ST
ST
QL,ST
QL,ST
ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,PA
QL,PA
QL
QL
QL
QL
DRUG NAME
COREG CR 80 MG CAPSULE, EXTENDED RELEASE MM
CORGARD 20 MG TABLET MM
CORGARD 40 MG TABLET MM
CORGARD 80 MG TABLET MM
CORLANOR 5 MG TABLET
CORLANOR 7.5 MG TABLET
cormax 0.05 % topical solution
CORTANE-B 1 %-1 %-0.1 % LOTION
CORTANE-B OTIC DROPS
cortane-b otic drops
CORTEF 10 MG TABLET MM
CORTEF 20 MG TABLET MM
CORTEF 5 MG TABLET MM
CORTENEMA 100 MG/60 ML
CORTIFOAM 10 % (80 MG) RECTAL
cortisone 25 mg tablet
CORTISPORIN 1 % TOPICAL OINTMENT
CORTISPORIN 3.5 MG/G-10,000 UNIT/G-0.5 % TOPICAL CREAM
CORTISPORIN EAR SOLUTION
CORTISPORIN-TC 3.3 MG-3 MG-10 MG-0.5 MG/ML EAR DROPS,SUSPENSION
corvita 150 150 mg-1.25 mg-120 mg-10 mg tablet
CORVITE 150 150 MG IRON-1 MG TABLET
CORVITE 150 TABLET
CORVITE FE 150 MG IRON-1 MG TABLET
CORVITE FE TABLET
CORZIDE 40 MG-5 MG TABLET MM
CORZIDE 80 MG-5 MG TABLET MM
COSENTYX (2 SYRINGES) 300 MG (150 MG/ML) SUBCUTANEOUS SP
COSENTYX 150 MG/ML SUBCUTANEOUS SYRINGE SP
COSENTYX PEN (2 PENS) 300 MG (150 MG/ML) SUBCUTANEOUS SP
COSENTYX PEN 150 MG/ML SUBCUTANEOUS SP
COSOPT (PF) 2 %-0.5 % EYE DROPS IN A DROPPERETTE MM
COSOPT 22.3 MG-6.8 MG/ML EYE DROPS MM
COTABFLU TABLET
COUMADIN 1 MG TABLET MM
COUMADIN 10 MG TABLET MM
COUMADIN 2 MG TABLET MM
COUMADIN 2.5 MG TABLET MM
COUMADIN 3 MG TABLET MM
COUMADIN 4 MG TABLET MM
COUMADIN 5 MG TABLET MM
COUMADIN 6 MG TABLET MM
COUMADIN 7.5 MG TABLET MM
covaryx 1.25 mg-2.5 mg tablet MM
covaryx h.s. 0.625 mg-1.25 mg tablet MM
COZAAR 100 MG TABLET MM
DRUG LEVEL
3
3
3
3
3
3
2
3
3
2
3
3
3
3
3
3
3
3
3
3
2
3
2
3
3
3
3
*
*
*
*
3
3
3
3
3
3
3
3
3
3
3
3
2
2
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,ST
QL,ST
QL,ST
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 43
DRUG NAME
COZAAR 25 MG TABLET MM
COZAAR 50 MG TABLET MM
CREON 12,000-38,000-60,000 UNIT CAPSULE,DELAYED RELEASE MM
CREON 24,000-76,000-120,000 UNIT CAPSULE,DELAYED RELEASE MM
CREON 3,000-9,500-15,000 UNIT CAPSULE,DELAYED RELEASE MM
CREON 36,000-114,000-180,000 UNIT CAPSULE,DELAYED RELEASE MM
CREON 6,000-19,000-30,000 UNIT CAPSULE,DELAYED RELEASE MM
CRESEMBA 186 MG CAPSULE
CRESTOR 10 MG TABLET MM
CRESTOR 20 MG TABLET MM
CRESTOR 40 MG TABLET MM
CRESTOR 5 MG TABLET MM
CRESYLATE EAR DROPS
CRINONE 4 % VAGINAL GEL
CRIXIVAN 200 MG CAPSULE
CRIXIVAN 400 MG CAPSULE
cromolyn 100 mg/5 ml oral conc
cromolyn 20 mg/2 ml neb soln MM
cromolyn 4% eye drops
CRYOSERV 99 % SOLUTION
cryselle (28) 0.3 mg-30 mcg tablet MM
CUPRIMINE 250 MG CAPSULE MM
CURITY ALCOHOL SWABS
CUROSURF 120 MG/1.5 ML INTRATRACHEAL SUSPENSION
CUROSURF 240 MG/3 ML INTRATRACHEAL SUSPENSION
CUTIVATE 0.05 % LOTION
CUTIVATE 0.05 % TOPICAL CREAM
CUVPOSA 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION MM
cvs glucose 40% gel
CVS LANCING DEVICE
CVS THIN 26G LANCETS
CVS ULTRA THIN LANCETS
cyanocobal-levomef-pyridoxn tb
cyanocobalamin 1,000 mcg/ml MM
cyclafem 1/35 (28) 1 mg-35 mcg tablet MM
cyclafem 7/7/7 (28) 0.5 mg/0.75 mg/1 mg-35 mcg tablet MM
CYCLESSA (28) 0.1 MG/0.125 MG/0.15 MG-25 MCG TABLET MM
cyclobenzaprine 10 mg tablet
cyclobenzaprine 5 mg tablet
cyclobenzaprine 7.5 mg tablet
CYCLOGYL 0.5 % EYE DROPS MM
CYCLOGYL 1 % EYE DROPS MM
CYCLOGYL 2 % EYE DROPS MM
CYCLOMYDRIL 0.2 %-1 % EYE DROPS MM
cyclopentolate 1% eye drops MM
cyclopentolate hcl 2% drops MM
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
44 - FORMULARY Updated 09/2015
DRUG LEVEL
3
3
2
2
2
2
2
3
2
2
2
2
3
3
3
3
4
3
1
3
1
4
3
3
3
4
3
3
3
1
1
1
3
2
1
1
3
1
1
3
3
3
3
2
1
1
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,ST
QL,ST
PA
QL
QL
QL
QL
QL
QL
QL
QL
QL,PA
DRUG NAME
cyclophosphamide 25 mg capsule
cyclophosphamide 25 mg tab
cyclophosphamide 50 mg capsule
cyclophosphamide 50 mg tablet
cycloserine 250 mg capsule
CYCLOSET 0.8 MG TABLET MM
cyclosporine 100 mg capsule
cyclosporine 100 mg/ml soln
cyclosporine 25 mg capsule
cyclosporine 50 mg/ml ampul
cyclosporine modified 100 mg
cyclosporine modified 25 mg
cyclosporine modified 50 mg
CYMBALTA 20 MG CAPSULE,DELAYED RELEASE MM
CYMBALTA 30 MG CAPSULE,DELAYED RELEASE MM
CYMBALTA 60 MG CAPSULE,DELAYED RELEASE MM
cyproheptadine 2 mg/5 ml syrup MM
cyproheptadine 4 mg tablet MM
CYSTADANE 1 GRAM/1.7 ML ORAL POWDER SP
CYSTAGON 150 MG CAPSULE MM
CYSTAGON 50 MG CAPSULE MM
CYSTARAN 0.44 % EYE DROPS SP
CYSTO-CONRAY II 17.2 % URETHRAL SOLUTION
CYSTOGRAFIN 30 % URETHRAL SOLUTION
CYSTOGRAFIN-DILUTE 18 % URETHRAL SOLUTION
CYTOMEL 25 MCG TABLET MM
CYTOMEL 5 MCG TABLET MM
CYTOMEL 50 MCG TABLET MM
CYTOTEC 100 MCG TABLET MM
CYTOTEC 200 MCG TABLET MM
cytra k crystals 3,300 mg-1,002 mg oral packet
cytra-2 500 mg-334 mg/5 ml oral solution
cytra-3 550 mg-500 mg-334 mg/5 ml oral solution
cytra-k 1,100 mg-334 mg/5 ml oral solution
d-amphetamine er 10 mg capsule
d-amphetamine er 15 mg capsule
d-amphetamine er 5 mg capsule
D.H.E.45 1 MG/ML INJECTION SOLUTION
DAKLINZA 30 MG TABLET SP
DAKLINZA 60 MG TABLET SP
DALIRESP 500 MCG TABLET MM
danazol 100 mg capsule
danazol 200 mg capsule
danazol 50 mg capsule
DANTRIUM 100 MG CAPSULE MM
DANTRIUM 25 MG CAPSULE MM
DANTRIUM 50 MG CAPSULE MM
DRUG LEVEL
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
2
2
*
3
3
*
3
3
3
3
3
3
3
3
2
1
2
2
3
3
3
4
*
*
3
3
3
3
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL,PA
QL
QL
QL
QL,PA
QL,PA
QL
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 45
DRUG NAME
dantrolene sodium 100 mg cap MM
dantrolene sodium 25 mg cap MM
dantrolene sodium 50 mg cap MM
dapsone 100 mg tablet MM
dapsone 25 mg tablet MM
DARAPRIM 25 MG TABLET
dasetta 1/35 (28) 1 mg-35 mcg tablet MM
dasetta 7/7/7 (28) 0.5 mg(7)/0.75 mg(7)/1 mg(7)-35 mcg tablet MM
DAYPRO 600 MG TABLET MM
daysee 0.15 mg-30 mcg (84)/10 mcg(7) tablets,3 month dose pack
DAYTRANA 10 MG/9 HR DAILY PATCH
DAYTRANA 15 MG/9 HR DAILY PATCH
DAYTRANA 20 MG/9 HR DAILY PATCH
DAYTRANA 30 MG/9 HR DAILY PATCH
DDAVP 0.1 MG TABLET MM
DDAVP 0.1 MG/ML (REFRIGERATE) NASAL SOLUTION MM
DDAVP 0.2 MG TABLET MM
DDAVP 10 MCG/SPRAY (0.1 ML) NASAL SPRAY AEROSOL MM
DDAVP 4 MCG/ML INJECTION SOLUTION
DEBACTEROL 30 %-50 % MUCOSAL SOLUTION
DEBACTEROL 30 %-50 % MUCOSAL SWAB
deblitane 0.35 mg tablet MM
DELTASONE 20 MG TABLET
delyla (28) 0.1 mg-20 mcg tablet MM
DELZICOL 400 MG CAPSULE,DELAYED RELEASE MM
DEMADEX 10 MG TABLET MM
DEMADEX 100 MG TABLET MM
DEMADEX 20 MG TABLET MM
DEMADEX 5 MG TABLET MM
demeclocycline 150 mg tablet
demeclocycline 300 mg tablet
DEMEROL 100 MG TABLET
DEMEROL 50 MG TABLET
DEMSER 250 MG CAPSULE
DENAVIR 1 % TOPICAL CREAM
depade 50 mg tablet
DEPAKENE 250 MG CAPSULE MM
DEPAKENE 250 MG/5 ML ORAL SOLUTION MM
DEPAKOTE 125 MG TABLET,DELAYED RELEASE MM
DEPAKOTE 250 MG TABLET,DELAYED RELEASE MM
DEPAKOTE 500 MG TABLET,DELAYED RELEASE MM
DEPAKOTE ER 250 MG TABLET,EXTENDED RELEASE MM
DEPAKOTE ER 500 MG TABLET,EXTENDED RELEASE MM
DEPAKOTE SPRINKLES 125 MG CAPSULE MM
DEPEN TITRATABS 250 MG TABLET MM
DEPLIN (ALGAL OIL) 15 MG-90.314 MG CAPSULE
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
46 - FORMULARY Updated 09/2015
DRUG LEVEL
3
3
3
2
2
3
1
1
3
2
3
3
3
3
4
4
4
4
4
3
3
2
3
2
4
3
3
3
3
4
4
3
3
4
4
2
4
4
3
3
3
3
3
3
4
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
QL
QL
QL
QL
QL,ST
QL
QL
PA
DRUG NAME
DEPLIN (ALGAL OIL) 7.5 MG-90.314 MG CAPSULE
DEPLIN 7.5 MG TABLET
DEPO-PROVERA 150 MG/ML INTRAMUSCULAR SUSPENSION
DEPO-PROVERA 150 MG/ML INTRAMUSCULAR SYRINGE
DEPO-SUBQ PROVERA 104 104 MG/0.65 ML SUBCUTANEOUS SYRINGE MM
DERMA-SMOOTHE/FS BODY OIL 0.01 %
DERMA-SMOOTHE/FS SCALP OIL 0.01 %
DERMAGRAFT 2" X 3" SHEETS
DERMANIC 760 MG-500 MCG-15 MCG TABLET,IMMEDIATE & DELAYED RELEASE
DERMASORB AF COMPLETE KIT 3 %-0.5 % TOPICAL CREAM
DERMASORB HC COMPLETE KIT 2 % TOPICAL,CLEANSER & LOTION
DERMASORB TA COMPLETE KIT 0.1 % TOPICAL CREAM
DERMASORB XM COMPLETE KIT 39 % TOPICAL CREAM
DERMATOP 0.1 % TOPICAL CREAM
DERMATOP 0.1 % TOPICAL OINTMENT
dermazene 1 %-1 % topical cream
DERMOTIC OIL 0.01 % EAR DROPS
desipramine 10 mg tablet MM
desipramine 100 mg tablet MM
desipramine 150 mg tablet MM
desipramine 25 mg tablet MM
desipramine 50 mg tablet MM
desipramine 75 mg tablet MM
desloratadine 2.5 mg odt MM
desloratadine 5 mg odt MM
desloratadine 5 mg tablet MM
desmopressin 0.01% solution MM
desmopressin 0.1 mg/ml sol MM
desmopressin 10 mcg/0.1 ml spr MM
desmopressin ac 4 mcg/ml ampul
desmopressin acetate 0.1 mg tb MM
desmopressin acetate 0.2 mg tb MM
DESOGEN 0.15 MG-0.03 MG TABLET MM
desogestr-eth estrad eth estra MM
desogestrel-ethinyl estrad tab MM
DESONATE 0.05 % TOPICAL GEL
desonide 0.05% cream
desonide 0.05% lotion
desonide 0.05% ointment
DESOWEN 0.05 % LOTION
DESOWEN 0.05 % TOPICAL CREAM
desoximetasone 0.05% cream
desoximetasone 0.05% gel
desoximetasone 0.05% ointment
desoximetasone 0.25% cream
desoximetasone 0.25% ointment
DESOXYN 5 MG TABLET
DRUG LEVEL
3
3
3
3
4
3
3
3
3
3
3
3
3
3
3
2
3
3
3
3
3
3
3
3
3
3
3
3
3
4
3
3
3
1
1
3
3
3
3
3
3
3
3
3
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
ST
QL,ST
QL,ST
QL
QL
QL
QL
QL
QL
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 47
DRUG NAME
desvenlafaxine er 100 mg tab MM
desvenlafaxine er 100 mg tab MM
desvenlafaxine er 50 mg tab MM
desvenlafaxine er 50 mg tablet MM
desvenlafaxine fum er 100 mg MM
desvenlafaxine fum er 50 mg MM
DETROL 1 MG TABLET MM
DETROL 2 MG TABLET MM
DETROL LA 2 MG CAPSULE,EXTENDED RELEASE MM
DETROL LA 4 MG CAPSULE,EXTENDED RELEASE MM
dex4 glucose 15 gram/33 gram oral gel packet
dex4 glucose 4 gram chewable tablet
dex4 glucose 40 % oral gel
dex4 glucose bits 1 gram chewable tablet
dex4 glucose pouch pack 4 gram chewable tablet
dex4 glucose quick dissolve 4 gram chewable tablet
dexamethasone 0.1% eye drop
dexamethasone 0.5 mg tablet
dexamethasone 0.5 mg/5 ml elx
dexamethasone 0.5 mg/5 ml liq
dexamethasone 0.75 mg tablet
dexamethasone 1 mg tablet
dexamethasone 1.5 mg tablet
dexamethasone 2 mg tablet
dexamethasone 4 mg tablet
dexamethasone 6 mg tablet
dexamethasone intensol 1 mg/ml drops (concentrate)
DEXCOM G4 RECEIVER MM
DEXCOM G4 RECEIVER PEDIATRIC MM
DEXCOM G4 RECEIVER WITH SHARE (PEDIATRIC) MM
DEXCOM G4 RECEIVER WITH SHARE KIT MM
DEXCOM G4 SENSOR DEVICE MM
DEXCOM G4 TRANSMITTER DEVICE MM
DEXEDRINE 10 MG TABLET
DEXEDRINE 5 MG TABLET
DEXEDRINE SPANSULE 10 MG CAPSULE,EXTENDED RELEASE
DEXEDRINE SPANSULE 15 MG CAPSULE,EXTENDED RELEASE
DEXEDRINE SPANSULE 5 MG CAPSULE,EXTENDED RELEASE
DEXILANT 30 MG CAPSULE, DELAYED RELEASE MM
DEXILANT 60 MG CAPSULE, DELAYED RELEASE MM
dexmethylphenidate 10 mg tab
dexmethylphenidate 2.5 mg tab
dexmethylphenidate 5 mg tab
dexmethylphenidate er 10 mg cp
dexmethylphenidate er 15 mg cp
dexmethylphenidate er 20 mg cp
dexmethylphenidate er 30 mg cp
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
48 - FORMULARY Updated 09/2015
DRUG LEVEL
3
3
3
3
2
2
3
3
3
3
3
3
3
3
3
3
2
1
2
2
1
1
1
1
1
1
2
4
4
4
4
4
4
2
2
4
4
3
3
3
2
2
2
3
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,ST
QL,ST
QL,ST
QL,ST
QL
QL
QL
QL
QL
QL
PA
PA
PA
PA
PA
PA
QL
QL
QL
QL
QL
QL,ST
QL,ST
QL
QL
QL
QL,ST
QL,ST
QL,ST
QL,ST
DRUG NAME
dexmethylphenidate er 40 mg cp
dexmethylphenidate er 5 mg cap
DEXPAK 10 DAY 1.5 MG (35 TABS) TABLETS IN A DOSE PACK
DEXPAK 13 DAY 1.5 MG (51 TABS) TABLETS IN A DOSE PACK
DEXPAK 6 DAY 1.5 MG (21 TABS) TABLETS IN A DOSE PACK
dextroamp-amphet er 10 mg cap
dextroamp-amphet er 15 mg cap
dextroamp-amphet er 20 mg cap
dextroamp-amphet er 25 mg cap
dextroamp-amphet er 30 mg cap
dextroamp-amphet er 5 mg cap
dextroamphetamine 10 mg tab
dextroamphetamine 5 mg tab
dextroamphetamine 5 mg/5 ml
DIABETA 1.25 MG TABLET MM
DIABETA 2.5 MG TABLET MM
DIABETA 5 MG TABLET MM
DIALYVITE 1 MG-100 MG-300 MCG-50 MG TABLET
DIALYVITE 100 MG-1 MG TABLET
DIALYVITE 3000 3 MG-70 MCG-15 MG TABLET
DIALYVITE 5000 5 MG TABLET
DIALYVITE SUPREME D 3 MG-2,000 UNIT TABLET
DIAMOX SEQUELS 500 MG CAPSULE,EXTENDED RELEASE MM
DIASCREEN 10 REAGENT STRIPS MM
DIASCREEN 1B REAGENT STRIPS
DIASCREEN 1G REAGENT STRIPS MM
DIASCREEN 1K REAGENT STRIPS MM
DIASCREEN 2GK REAGENT STRIPS MM
DIASCREEN 2GP STRIPS
DIASCREEN 3 REAGENT STRIPS MM
DIASCREEN 4NL REAGENT STRIPS
DIASCREEN 4OBL REAGENT STRIPS MM
DIASCREEN 4PH REAGENT STRIPS
DIASCREEN 5 REAGENT STRIPS MM
DIASCREEN 7 REAGENT STRIPS MM
DIASCREEN 8 REAGENT STRIPS MM
DIASCREEN 9 REAGENT STRIPS MM
DIASTAT 2.5 MG RECTAL KIT
DIASTAT ACUDIAL 12.5 MG-15 MG-17.5 MG-20 MG RECTAL KIT
DIASTAT ACUDIAL 5 MG-7.5 MG-10 MG RECTAL KIT
DIASTIX STRIPS MM
DIATRUE CONTROL SOLUTION HIGH
DIATRUE CONTROL SOLUTION LOW
DIATRUE CONTROL SOLUTION NORMAL
DIATRUE PLUS BLOOD GLUCOSE METER SYSTEM
DIATRUE PLUS TEST STRIP MM
diazepam 10 mg rectal gel syst
diazepam 10 mg tablet
DRUG LEVEL
3
3
2
3
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
2
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL
QL
QL
QL
ST
QL,ST
QL
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 49
DRUG NAME
diazepam 2 mg tablet
diazepam 2.5 mg rectal gel sys
diazepam 20 mg rectal gel syst
diazepam 5 mg tablet
diazepam 5 mg/5 ml oral soln
diazepam 5 mg/5 ml solution
diazepam 5 mg/ml oral conc
diazepam intensol 5 mg/ml oral concentrate
DIBENZYLINE 10 MG CAPSULE
DICLEGIS 10 MG-10 MG TABLET,DELAYED RELEASE
diclofenac 0.1% eye drops
diclofenac 1.5% topical soln MM
diclofenac pot 50 mg tablet
diclofenac sod ec 25 mg tab MM
diclofenac sod ec 50 mg tab MM
diclofenac sod ec 75 mg tab MM
diclofenac sod er 100 mg tab MM
diclofenac sodium 3% gel
diclofenac-misoprost 50-200 tb MM
diclofenac-misoprost 75-200 tb MM
dicloxacillin 250 mg capsule
dicloxacillin 500 mg capsule
dicyclomine 10 mg capsule
dicyclomine 10 mg/5 ml soln
dicyclomine 20 mg tablet
didanosine dr 125 mg capsule
didanosine dr 200 mg capsule
didanosine dr 250 mg capsule
didanosine dr 400 mg capsule
DIFFERIN 0.1 % LOTION
DIFFERIN 0.1 % TOPICAL CREAM
DIFFERIN 0.1 % TOPICAL GEL
DIFFERIN 0.3 % TOPICAL GEL
DIFFERIN 0.3 % TOPICAL GEL WITH PUMP
DIFICID 200 MG TABLET
difil-g 400 tablet MM
diflorasone 0.05% cream
diflorasone 0.05% ointment
DIFLUCAN 10 MG/ML ORAL SUSPENSION
DIFLUCAN 100 MG TABLET
DIFLUCAN 150 MG TABLET
DIFLUCAN 200 MG TABLET
DIFLUCAN 40 MG/ML ORAL SUSPENSION
DIFLUCAN 50 MG TABLET
diflunisal 500 mg tablet MM
DIGEX NF CAPSULE
DIGIBAR 190 SUSPENSION
digitek 125 mcg tablet MM
digitek 250 mcg tablet MM
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
50 - FORMULARY Updated 09/2015
DRUG LEVEL
2
3
3
2
2
2
2
2
4
3
2
3
1
2
2
2
2
4
3
3
2
2
1
2
1
3
3
3
3
3
3
3
3
3
4
3
3
3
3
3
3
3
3
3
2
3
3
2
2
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
QL
QL
QL
PA
ST
ST
QL
QL
QL
QL
ST
ST
ST
ST
ST
QL
QL
DRUG NAME
digox 125 mcg tablet MM
digox 250 mcg tablet MM
digoxin 125 mcg tablet MM
digoxin 250 mcg tablet MM
digoxin 50 mcg/ml solution MM
dihydrocodein-acetaminoph-caff
dihydroergotamine 1 mg/ml am
dihydroergotamine 4 mg/ml spry
DILACOR XR 240 MG CAPSULE MM
DILANTIN 30 MG CAPSULE MM
DILANTIN EXTENDED 100 MG CAPSULE MM
DILANTIN INFATABS 50 MG CHEWABLE TABLET MM
DILANTIN-125 125 MG/5 ML ORAL SUSPENSION MM
DILATRATE-SR 40 MG CAPSULE,EXTENDED RELEASE MM
DILAUDID 1 MG/ML ORAL LIQUID
DILAUDID 2 MG TABLET
DILAUDID 4 MG TABLET
DILAUDID 8 MG TABLET
dilt-cd 120 mg capsule MM
dilt-cd 180 mg capsule MM
dilt-cd 240 mg capsule MM
dilt-cd er 300 mg capsule MM
dilt-xr 120 mg capsule, extended release MM
dilt-xr 180 mg capsule, extended release MM
dilt-xr 240 mg capsule, extended release MM
diltiazem 120 mg tablet MM
diltiazem 12hr er 120 mg cap MM
diltiazem 12hr er 60 mg cap MM
diltiazem 12hr er 90 mg cap MM
diltiazem 24hr cd 120 mg cap MM
diltiazem 24hr er 180 mg cap MM
diltiazem 24hr er 240 mg cap MM
diltiazem 24hr er 300 mg cap MM
diltiazem 24hr er 360 mg cap MM
diltiazem 30 mg tablet MM
diltiazem 60 mg tablet MM
diltiazem 90 mg tablet MM
diltiazem er 120 mg capsule MM
diltiazem er 180 mg capsule MM
diltiazem er 180 mg capsule MM
diltiazem er 180 mg tablet MM
diltiazem er 240 mg capsule MM
diltiazem er 240 mg tablet MM
diltiazem er 300 mg tablet MM
DRUG LEVEL
2
2
2
2
2
3
4
4
3
3
3
3
3
2
3
3
3
3
2
2
2
2
2
2
2
1
2
2
2
2
2
2
2
3
1
1
1
2
2
2
3
2
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 51
DRUG NAME
diltiazem er 360 mg tablet MM
diltiazem er 420 mg tablet MM
diltiazem hcl er 120 mg cap MM
diltiazem hcl er 240 mg cap MM
diltiazem hcl er 300 mg cap MM
diltiazem hcl er 360 mg cap MM
diltiazem hcl er 420 mg cap MM
diltzac er 120 mg capsule MM
diltzac er 180 mg capsule MM
diltzac er 240 mg capsule MM
diltzac er 300 mg capsule MM
diltzac er 360 mg capsule MM
DIOVAN 160 MG TABLET MM
DIOVAN 320 MG TABLET MM
DIOVAN 40 MG TABLET MM
DIOVAN 80 MG TABLET MM
DIOVAN HCT 160 MG-12.5 MG TABLET MM
DIOVAN HCT 160 MG-25 MG TABLET MM
DIOVAN HCT 320 MG-12.5 MG TABLET MM
DIOVAN HCT 320 MG-25 MG TABLET MM
DIOVAN HCT 80 MG-12.5 MG TABLET MM
DIPENTUM 250 MG CAPSULE MM
diphenhydramine 12.5 mg/5 ml
diphenoxylat-atrop 2.5-0.025/5
diphenoxylate-atrop 2.5-0.025
DIPROLENE 0.05 % LOTION
DIPROLENE 0.05 % TOPICAL OINTMENT
DIPROLENE AF 0.05 % TOPICAL CREAM
dipyridamole 25 mg tablet MM
dipyridamole 50 mg tablet MM
dipyridamole 75 mg tablet MM
DISALCID 500 MG TABLET
DISALCID 750 MG TABLET
DISKETS 40 MG SOLUBLE TABLET
disopyramide 100 mg capsule MM
disopyramide 150 mg capsule MM
disulfiram 250 mg tablet MM
disulfiram 500 mg tablet MM
DITROPAN XL 10 MG TABLET,EXTENDED RELEASE MM
DITROPAN XL 15 MG TABLET,EXTENDED RELEASE MM
DITROPAN XL 5 MG TABLET,EXTENDED RELEASE MM
DIURIL 250 MG/5 ML ORAL SUSPENSION MM
divalproex sod dr 125 mg tab MM
divalproex sod dr 250 mg tab MM
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
52 - FORMULARY Updated 09/2015
DRUG LEVEL
3
3
2
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
4
3
2
1
3
3
3
1
1
1
3
3
2
2
2
3
3
3
3
3
3
1
1
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL
QL
QL
QL
QL
DRUG NAME
divalproex sod dr 500 mg tab MM
divalproex sod er 250 mg tab MM
divalproex sod er 500 mg tab MM
divalproex sodium 125 mg cap MM
DIVIGEL 0.25 MG (0.1 %) TRANSDERMAL GEL PACKET MM
DIVIGEL 0.5 MG (0.1 %) TRANSDERMAL GEL PACKET MM
DIVIGEL 1 MG (0.1 %) TRANSDERMAL GEL PACKET MM
DOLGIC PLUS TABLET
DOLOPHINE 10 MG TABLET
DOLOPHINE 5 MG TABLET
DONATUSS DC SYRUP
donepezil hcl 10 mg tablet MM
donepezil hcl 23 mg tablet MM
donepezil hcl 5 mg tablet MM
donepezil hcl odt 10 mg tablet MM
donepezil hcl odt 5 mg tablet MM
DONNATAL 16.2 MG-0.1037 MG-0.0194 MG TABLET
DONNATAL 16.2 MG-0.1037MG-0.0194MG/5ML ORAL ELIXIR
DORAL 15 MG TABLET
DORYX 150 MG TABLET,DELAYED RELEASE
DORYX 200 MG TABLET,DELAYED RELEASE
DORYX 50 MG TABLET,DELAYED RELEASE
dorzolamide hcl 2% eye drops MM
dorzolamide-timolol eye drops MM
DOVONEX 0.005 % TOPICAL CREAM
doxazosin mesylate 1 mg tab MM
doxazosin mesylate 2 mg tab MM
doxazosin mesylate 4 mg tab MM
doxazosin mesylate 8 mg tab MM
doxepin 10 mg capsule MM
doxepin 10 mg/ml oral conc MM
doxepin 100 mg capsule MM
doxepin 150 mg capsule MM
doxepin 25 mg capsule MM
doxepin 50 mg capsule MM
doxepin 75 mg capsule MM
doxercalciferol 0.5 mcg cap MM
doxercalciferol 1 mcg capsule MM
doxercalciferol 2.5 mcg cap MM
doxycycline 25 mg/5 ml susp
doxycycline hyc dr 100 mg tab
doxycycline hyc dr 150 mg tab
doxycycline hyc dr 75 mg tab
doxycycline hyclate 100 mg cap
doxycycline hyclate 100 mg tab
doxycycline hyclate 20 mg tab
DRUG LEVEL
1
3
3
3
3
3
3
3
2
2
3
1
3
1
1
1
4
4
3
4
4
4
1
1
4
1
1
1
1
1
1
1
1
1
1
1
3
3
3
3
3
3
3
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
QL,ST
QL
QL
QL
QL
QL,PA
QL,PA
QL,PA
QL
QL
QL
QL
QL
QL
QL
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 53
DRUG NAME
doxycycline hyclate 50 mg cap
doxycycline ir-dr 40 mg cap
doxycycline mono 100 mg cap
doxycycline mono 100 mg tablet
doxycycline mono 150 mg cap
doxycycline mono 150 mg tablet
doxycycline mono 50 mg cap
doxycycline mono 50 mg tablet
doxycycline mono 75 mg capsule
doxycycline mono 75 mg tablet
doxytex 2.5 mg/2.5 ml liquid
DRISDOL 50,000 UNIT CAPSULE MM
DRITHOCREME HP 1 % TOPICAL
dronabinol 10 mg capsule
dronabinol 2.5 mg capsule
dronabinol 5 mg capsule
DROPLET LANCETS 30 GAUGE
DROPLET LANCING DEVICE
drospirenone-eth estradiol tab MM
DROXIA 200 MG CAPSULE MM
DROXIA 300 MG CAPSULE MM
DROXIA 400 MG CAPSULE MM
DRYSOL DAB-O-MATIC 20 % TOPICAL SOLUTION
DUAC 1.2 % (1 % BASE)-5 % TOPICAL GEL
DUAVEE 0.45 MG-20 MG TABLET MM
DUET DHA 400 EC COMBO PACK
DUET DHA 430 EC COMBO PACK
DUET DHA 430 MG COMBO PACK
DUET DHA BALANCED (26 MG IRON)
DUET DHA BALANCED 25 MG IRON-1 MG-267 MG-233 MG ORAL PACK
DUET DHA WITH OMEGA-3 25 MG IRON-1 MG-400 MG ORAL PACK
DUETACT 30 MG-2 MG TABLET MM
DUETACT 30 MG-4 MG TABLET MM
DUEXIS 800 MG-26.6 MG TABLET MM
DULERA 100 MCG-5 MCG/ACTUATION HFA AEROSOL INHALER MM
DULERA 200 MCG-5 MCG/ACTUATION HFA AEROSOL INHALER MM
duloxetine hcl dr 20 mg cap MM
duloxetine hcl dr 30 mg cap MM
duloxetine hcl dr 40 mg cap
duloxetine hcl dr 60 mg cap MM
DUONEB 0.5 MG-3 MG/3 ML SOLN MM
DURACHOL 3,775 UNIT-1 MG CAPSULE
DURAGESIC 100 MCG/HR TRANSDERMAL PATCH
DURAGESIC 12 MCG/HR TRANSDERMAL PATCH
DURAGESIC 25 MCG/HR TRANSDERMAL PATCH
DURAGESIC 50 MCG/HR TRANSDERMAL PATCH
DURAGESIC 75 MCG/HR TRANSDERMAL PATCH
DUREZOL 0.05 % EYE DROPS
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
54 - FORMULARY Updated 09/2015
DRUG LEVEL
3
3
2
2
4
2
2
2
4
2
3
3
3
3
3
3
1
3
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
4
2
2
2
2
3
2
4
3
4
4
4
4
4
2
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
QL
QL,PA
QL,PA
QL,PA
QL,PA
QL,ST
QL,ST
QL,ST
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
DRUG NAME
DUTOPROL 100 MG-12.5 MG TABLET,EXTENDED RELEASE MM
DUTOPROL 25 MG-12.5 MG TABLET,EXTENDED RELEASE MM
DUTOPROL 50 MG-12.5 MG TABLET,EXTENDED RELEASE MM
DYAZIDE 37.5 MG-25 MG CAPSULE MM
DYMISTA 137 MCG-50 MCG/SPRAY NASAL SPRAY MM
dynamic 2 % mucosal kit
DYRENIUM 100 MG CAPSULE MM
DYRENIUM 50 MG CAPSULE MM
E-Z DISK 700 MG TABLET
E-Z JECT LANCETS
E-Z JECT LANCETS 26 GAUGE
E-Z JECT LANCETS 30 GAUGE
E-Z JECT LANCETS 32 GAUGE
E-Z JECT LANCETS 33 GAUGE
E-Z JECT THIN LANCETS 28 GAUGE
E-Z SPACER
E-Z-CAT CONCENTRATE SUSP
E-Z-CAT DRY 2 % (W/W) ORAL POWDER PACKET
E-Z-DOSE-LIQ POLIBAR PLUS
E-Z-HD BARIUM 98 % ORAL SUSPENSION
E-Z-PAQUE 96 % (W/W) ORAL POWDER FOR SUSPENSION
E-Z-PASTE 60 % ORAL CREAM
E.E.S. 400 400 MG TABLET
E.E.S. GRANULES 200 MG/5 ML ORAL SUSPENSION
EASIVENT HOLDING CHAMBER
EASIVENT MASK LARGE
EASIVENT MASK MEDIUM
EASIVENT MASK SMALL
EASY CLICK LANCING DEVICE
EASY COMFORT INSULIN SYRINGE 0.3 ML 30 X 5/16" MM
EASY COMFORT INSULIN SYRINGE 1 ML 30 X 1/2" MM
EASY COMFORT INSULIN SYRINGE 1 ML 30 X 5/16" MM
EASY COMFORT INSULIN SYRINGE 1/2 ML 30 X 1/2" MM
EASY COMFORT INSULIN SYRINGE 1/2 ML 30 X 5/16" MM
EASY COMFORT LANCETS 30 GAUGE
EASY COMFORT PEN NEEDLES 31 GAUGE X 1/4"
EASY COMFORT PEN NEEDLES 31 X 3/16"
EASY COMFORT PEN NEEDLES 31 X 5/16"
EASY COMFORT PEN NEEDLES 32 X 5/32"
EASY GLUCO G2 STRIPS MM
EASY PLUS BLOOD GLUCOSE KIT
EASY PLUS GLUCOSE SYSTEM
EASY PLUS II BLOOD GLUCOSE METER
EASY PLUS II HIGH CONTROL SOLUTION
EASY PLUS II LOW CONTROL SOLUTION
EASY PLUS II TEST STRIPS MM
EASY PLUS STRIPS MM
EASY STEP BLOOD GLUCOSE METER
DRUG LEVEL
3
3
3
3
2
3
3
3
3
3
1
1
1
1
1
2
3
3
3
3
3
3
4
4
3
3
3
3
1
2
2
2
2
2
1
2
1
2
3
3
3
3
3
3
3
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
QL,ST
ST
ST
ST
QL,ST
QL,ST
ST
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 55
DRUG NAME
EASY STEP BLOOD GLUCOSE SYSTEM KIT
EASY STEP HIGH CONTROL SOLN SOLUTION
EASY STEP LOW CONTROL SOLUTION
EASY STEP NORMAL CONTROL SOLN SOLUTION
EASY STEP STRIPS MM
EASY TALK BLOOD GLUCOSE METER
EASY TALK GLUCOSE SYSTEM KIT
EASY TALK GLUCOSE TEST STRIPS MM
EASY TALK HIGH CONTROL SOLUTION
EASY TALK LOW CONTROL SOLUTION
EASY TOUCH 29 GAUGE X 1/2" NEEDLE
EASY TOUCH 31 GAUGE X 1/4" NEEDLE
EASY TOUCH 31 X 3/16" NEEDLE
EASY TOUCH 31 X 5/16" NEEDLE
EASY TOUCH 32 GAUGE X 3/16" NEEDLE
EASY TOUCH 32 X 1/4" NEEDLE
EASY TOUCH 32 X 5/32" NEEDLE
EASY TOUCH ALCOHOL PREP PADS
EASY TOUCH GLUCOSE MONITOR
EASY TOUCH HIGH-LOW CONTROL SOLUTION
EASY TOUCH INSULIN SAFETY SYRINGE 0.5 ML 29 X 1/2" MM
EASY TOUCH INSULIN SAFETY SYRINGE 0.5 ML 30 X 5/16" MM
EASY TOUCH INSULIN SAFETY SYRINGE 1 ML 29 X 1/2" MM
EASY TOUCH INSULIN SAFETY SYRINGE 1 ML 30 X 1/2" MM
EASY TOUCH INSULIN SYRINGE 0.3 ML 30 X 1/2" MM
EASY TOUCH INSULIN SYRINGE 0.3 ML 30 X 5/16" MM
EASY TOUCH INSULIN SYRINGE 0.3 ML 31 X 5/16" MM
EASY TOUCH INSULIN SYRINGE 1 ML 27 X 1/2" MM
EASY TOUCH INSULIN SYRINGE 1 ML 28 X 1/2" MM
EASY TOUCH INSULIN SYRINGE 1 ML 29 X 1/2" MM
EASY TOUCH INSULIN SYRINGE 1 ML 30 X 1/2" MM
EASY TOUCH INSULIN SYRINGE 1 ML 30 X 5/16" MM
EASY TOUCH INSULIN SYRINGE 1 ML 31 X 5/16" MM
EASY TOUCH INSULIN SYRINGE 1/2 ML 27 X 1/2" MM
EASY TOUCH INSULIN SYRINGE 1/2 ML 28 X 1/2" MM
EASY TOUCH INSULIN SYRINGE 1/2 ML 29 X 1/2" MM
EASY TOUCH INSULIN SYRINGE 1/2 ML 30 X 1/2" MM
EASY TOUCH INSULIN SYRINGE 1/2 ML 30 X 5/16" MM
EASY TOUCH INSULIN SYRINGE 1/2 ML 31 X 5/16" MM
EASY TOUCH LANCETS 26 GAUGE
EASY TOUCH LANCETS 30 GAUGE
EASY TOUCH LANCETS 32 GAUGE
EASY TOUCH LANCING DEVICE
EASY TOUCH SAFETY LANCETS 21 GAUGE
EASY TOUCH SAFETY LANCETS 23 GAUGE
EASY TOUCH SAFETY LANCETS 26 GAUGE
EASY TOUCH SAFETY LANCETS 28 GAUGE
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
56 - FORMULARY Updated 09/2015
DRUG LEVEL
3
3
3
3
3
3
3
3
3
3
1
1
1
1
1
1
3
3
3
3
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
3
3
3
3
1
1
1
1
UTILIZATION
MANAGEMENT
REQUIREMENTS
ST
QL,ST
ST
ST
QL,ST
ST
DRUG NAME
EASY TOUCH SAFETY LANCETS 30 GAUGE
EASY TOUCH SAFETY LANCETS 32 GAUGE
EASY TOUCH STRIPS MM
EASY TOUCH TWIST LANCETS 26 GAUGE
EASY TOUCH TWIST LANCETS 28 GAUGE
EASY TOUCH TWIST LANCETS 30 GAUGE
EASY TOUCH TWIST LANCETS 32 GAUGE
EASY TOUCH TWIST LANCETS 33 GAUGE
EASY TRAK BLOOD GLUCOSE METER
EASY TRAK GLUCOSE SYSTEM KIT
EASY TRAK GLUCOSE TEST STRIPS MM
EASY TRAK HIGH CONTROL SOLUTION
EASY TRAK LOW CONTROL SOLUTION
EASY TRAK NORMAL CONTROL SOLUTION
EASY TWIST & CAP LANCETS 28 GAUGE
EASYGLUCO METER KIT
EASYGLUCO MONITORING SYSTEM KIT
EASYGLUCO PLUS KIT
EASYGLUCO PLUS NORMAL CONTROL SOLUTION
EASYGLUCO PLUS STRIPS MM
EASYGLUCO TEST STRIPS MM
EASYMAX 15 LEVEL 1 SOLUTION
EASYMAX 15 LEVEL 2 SOLUTION
EASYMAX 15 STRIPS MM
EASYMAX L BLOOD GLUCOSE METER
EASYMAX LOW CONTROL SOLUTION
EASYMAX NG KIT
EASYMAX NG MISC
EASYMAX NORMAL CONTROL SOLUTION
EASYMAX STRIPS MM
EASYMAX V GLUCOSE SYSTEM KIT
EASYMAX V SPEAKING BLOOD GLUCOSE SYSTEM
EASYMAX V2 BLOOD GLUCOSE METER
EASYMAX V2 GLUCOSE SYSTEM KIT
EC-NAPROSYN 375 MG TABLET,DELAYED RELEASE MM
EC-NAPROSYN 500 MG TABLET,DELAYED RELEASE MM
ECLIPSE BLOOD GLUCOSE MONITOR
ECLIPSE CONTROL SOLN NORMAL
ECLIPSE CONTROL SOLUTION HIGH
ECLIPSE CONTROL SOLUTION LOW
ECLIPSE NEEDLE 23 X 1"
ECLIPSE NEEDLE 25 X 5/8"
ECLIPSE NEEDLE 27 X 1/2"
ECLIPSE SYRINGE 3 ML 21 X 1"
ECLIPSE SYRINGE 3 ML 25 X 1"
ECLIPSE TEST STRIPS MM
econazole nitrate 1% cream
ECOZA 1 % TOPICAL FOAM
ed-spaz 0.125 mg disintegrating tablet MM
DRUG LEVEL
1
1
3
1
1
1
1
1
3
3
3
3
3
3
1
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
1
1
1
1
1
3
2
3
2
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,ST
ST
ST
QL,ST
ST
ST
ST
QL,ST
QL,ST
QL,ST
ST
ST
ST
QL,ST
ST
ST
ST
ST
ST
QL,ST
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 57
DRUG NAME
EDARBI 40 MG TABLET MM
EDARBI 80 MG TABLET MM
EDARBYCLOR 40 MG-12.5 MG TABLET MM
EDARBYCLOR 40 MG-25 MG TABLET MM
EDECRIN 25 MG TABLET MM
EDLUAR 10 MG SUBLINGUAL TABLET
EDLUAR 5 MG SUBLINGUAL TABLET
EDURANT 25 MG TABLET SP
eemt 1.25 mg-2.5 mg tablet MM
eemt hs 0.625 mg-1.25 mg tablet MM
EFFER-K 10 MEQ EFFERVESCENT TABLET MM
EFFER-K 20 MEQ EFFERVESCENT TABLET MM
effer-k 25 meq effervescent tablet MM
EFFEXOR XR 150 MG CAPSULE,EXTENDED RELEASE MM
EFFEXOR XR 37.5 MG CAPSULE,EXTENDED RELEASE MM
EFFEXOR XR 75 MG CAPSULE,EXTENDED RELEASE MM
EFFIENT 10 MG TABLET MM
EFFIENT 5 MG TABLET MM
EFUDEX 5 % TOPICAL CREAM
EGRIFTA 1 MG SUBCUTANEOUS SOLUTION SP
EGRIFTA 2 MG SUBCUTANEOUS SOLUTION SP
ELDEPRYL 5 MG CAPSULE MM
ELEMENT BLOOD GLUCOSE METER KIT
ELEMENT COMPACT GLUCOSE METER
ELEMENT COMPACT HIGH CONTROL SOLUTION
ELEMENT COMPACT NORMAL CONTROL SOLUTION
ELEMENT COMPACT TEST STRIPS MM
ELEMENT COMPACT V GLUCOSE METER
ELEMENT HIGH CONTROL SOLUTION
ELEMENT LOW CONTROL SOLUTION
ELEMENT NORMAL CONTROL SOLUTION
ELEMENT PLUS BLOOD GLUCOSE KIT
ELEMENT PLUS CONTROL SOLUTION
ELEMENT PLUS CONTROL SOLUTION
ELEMENT PLUS CONTROL SOLUTION
ELEMENT PLUS TEST STRIPS MM
ELEMENT TEST STRIPS MM
ELESTAT 0.05 % EYE DROPS
ELESTRIN 0.87 GRAM/ACTUATION (0.06%) TRANSDERMAL GEL PUMP MM
ELETONE TOPICAL CREAM
ELIDEL 1 % TOPICAL CREAM
ELIGARD 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE SP
ELIGARD 30 MG (4 MONTH) SUBCUTANEOUS SYRINGE SP
ELIGARD 45 MG (6 MONTH) SUBCUTANEOUS SYRINGE SP
eligen b12 1,000 mcg tablet
elimite 5 % topical cream
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
58 - FORMULARY Updated 09/2015
DRUG LEVEL
3
3
3
3
4
3
3
*
2
2
3
3
3
3
3
3
2
2
3
*
*
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
*
*
*
2
2
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL
QL
QL
QL
QL
QL
QL,PA
QL,PA
ST
ST
QL,ST
ST
ST
QL,ST
QL,ST
QL,ST
QL
QL,PA
QL,PA
QL,PA
DRUG NAME
elinest 0.3 mg-30 mcg tablet MM
eliphos 667 mg tablet MM
ELIQUIS 2.5 MG TABLET MM
ELIQUIS 5 MG TABLET MM
elite-ob 28 mg-1.25 mg-200 mg capsule
elite-ob 400 35 mg-5 mg-1.2 mg-400 mg capsule
elite-ob 50 mg-1.25 mg tablet
ELIXOPHYLLIN 80 MG/15 ML ORAL ELIXIR MM
ELLA 30 MG TABLET
ELMIRON 100 MG CAPSULE
ELOCON 0.1 % TOPICAL CREAM
ELOCON 0.1 % TOPICAL LOTION (SOLUTION)
ELOCON 0.1 % TOPICAL OINTMENT
EMADINE 0.05 % EYE DROPS
EMBEDA 100 MG-4 MG CAPSULE, EXTEND RELEASE, ORAL ONLY
EMBEDA 20 MG-0.8 MG CAPSULE, EXTEND RELEASE, ORAL ONLY
EMBEDA 30 MG-1.2 MG CAPSULE, EXTEND RELEASE, ORAL ONLY
EMBEDA 50 MG-2 MG CAPSULE, EXTEND RELEASE, ORAL ONLY
EMBEDA 60 MG-2.4 MG CAPSULE, EXTEND RELEASE, ORAL ONLY
EMBEDA 80 MG-3.2 MG CAPSULE, EXTEND RELEASE, ORAL ONLY
EMBRACE BLOOD GLUCOSE KIT
EMBRACE BLOOD GLUCOSE SYSTEM
EMBRACE BLOOD GLUCOSE SYSTEM STRIPS MM
EMBRACE EVO BLOOD GLUCOSE KIT
EMBRACE EVO LEVEL 1 SOLUTION
EMBRACE EVO LEVEL 2 SOLUTION
EMBRACE EVO TEST STRIPS MM
EMBRACE GLUCOSE CONTROL HIGH SOLUTION
EMBRACE GLUCOSE CONTROL LOW SOLUTION
EMBRACE LANCETS 30 GAUGE
EMBRACE PRO BLOOD GLUCOSE METER
EMBRACE PRO SOLUTION
EMBRACE PRO TEST STRIPS MM
EMCYT 140 MG CAPSULE
EMEND 125 MG (1)-80 MG (2) CAPSULES IN A DOSE PACK
EMEND 125 MG CAPSULE
EMEND 40 MG CAPSULE
EMEND 80 MG CAPSULE
EMLA 2.5 %-2.5 % TOPICAL CREAM
emoquette 0.15 mg-0.03 mg tablet MM
EMSAM 12 MG/24 HR TRANSDERMAL 24 HOUR PATCH MM
EMSAM 6 MG/24 HR TRANSDERMAL 24 HOUR PATCH MM
EMSAM 9 MG/24 HR TRANSDERMAL 24 HOUR PATCH MM
EMTRIVA 10 MG/ML ORAL SOLUTION
EMTRIVA 200 MG CAPSULE
emulsion sb topical emulsion
ENABLEX 15 MG TABLET,EXTENDED RELEASE MM
ENABLEX 7.5 MG TABLET,EXTENDED RELEASE MM
DRUG LEVEL
1
3
2
2
2
2
2
4
3
4
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
1
4
4
4
3
3
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
ST
ST
QL,ST
ST
QL,ST
ST
QL,ST
QL
QL,PA
QL,PA
QL,PA
QL,PA
QL
QL
QL
QL
QL
QL,ST
QL,ST
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 59
DRUG NAME
enalapril maleate 10 mg tab MM
enalapril maleate 2.5 mg tab MM
enalapril maleate 20 mg tab MM
enalapril maleate 5 mg tablet MM
enalapril-hctz 10-25 mg tablet MM
enalapril-hctz 5-12.5 mg tab MM
ENBRACE HR 1.5 MG IRON-8.73 MG-6.4 MG CAPSULE,IMMED & DELAY RELEASE
ENBREL 25 MG (1 ML) SUBCUTANEOUS SOLUTION SP
ENBREL 25 MG/0.5 ML (0.51 ML) SUBCUTANEOUS SYRINGE SP
ENBREL 50 MG/ML (0.98 ML) SUBCUTANEOUS SYRINGE SP
ENBREL SURECLICK 50 MG/ML (0.98 ML) SUBCUTANEOUS PEN INJECTOR SP
endacof-c 2 mg-10 mg/5 ml oral liquid
ENDO AVITENE 10 MM TOPICAL SHEETS
ENDO AVITENE 5 MM TOPICAL SHEETS
endocet 10 mg-325 mg tablet
endocet 10-650 mg tablet
endocet 2.5 mg-325 mg tablet
endocet 5 mg-325 mg tablet
endocet 7.5 mg-325 mg tablet
endocet 7.5-500 mg tablet
endodan 4.8355 mg-325 mg tablet
endoform 16 x 16 cm template
endoform 16 x 16 cm template
endoform 2" x 2" topical sheets
endoform 4 x 4 cm template
endoform 4 x 4 cm template
endoform 4" x 5" topical sheets
endoform 8 x 8 cm template
endoform 8 x 8 cm template
endoform fenestrated 2" x 2" topical sheets
endoform fenestrated 4" x 5" topical sheets
ENJUVIA 0.3 MG TABLET MM
ENJUVIA 0.45 MG TABLET MM
ENJUVIA 0.625 MG TABLET MM
ENJUVIA 0.9 MG TABLET MM
ENJUVIA 1.25 MG TABLET MM
ENLITE GLUCOSE SENSOR DEVICE MM
ENLITE SYSTEM MM
ENLYTE (IRON GLYCINE) 1.5 MG IRON-8.73 MG CAPSULE,IMMED.,DELAY RELEASE
enoxaparin 100 mg/ml syringe
enoxaparin 120 mg/0.8 ml syr
enoxaparin 150 mg/ml syringe
enoxaparin 30 mg/0.3 ml syr
enoxaparin 300 mg/3 ml vial
enoxaparin 40 mg/0.4 ml syr
enoxaparin 60 mg/0.6 ml syr
enoxaparin 80 mg/0.8 ml syr
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
60 - FORMULARY Updated 09/2015
DRUG LEVEL
1
1
1
1
1
1
3
*
*
*
*
3
3
3
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,PA
QL,PA
QL,PA
QL,PA
QL
QL
QL
QL
QL
QL
QL
PA
PA
QL
QL
QL
QL
QL
QL
QL
QL
DRUG NAME
enpresse 50-30 (6)/75-40(5)/125-30(10) tablet MM
enskyce 0.15 mg-0.03 mg tablet MM
entacapone 200 mg tablet MM
entecavir 0.5 mg tablet SP
entecavir 1 mg tablet SP
ENTERAGAM 5 GRAM ORAL POWDER PACKET
ENTEREG 12 MG CAPSULE
ENTERO VU 13% LIQUID
ENTERO VU 13% PACKET
ENTERO VU 24 % ORAL LIQUID
ENTOCORT EC 3 MG CAPSULE,DELAYED,EXTENDED RELEASE
ENTRESTO 24 MG-26 MG TABLET
ENTRESTO 49 MG-51 MG TABLET
ENTRESTO 97 MG-103 MG TABLET
enulose 10 gram/15 ml oral solution MM
ENVISION CONTROL SOLN HIGH
ENVISION CONTROL SOLN LOW
ENVISION CONTROL SOLN NORMAL
ENVISION MONITORING SYSTEM
ENVISION TEST STRIPS MM
EPANED 1 MG/ML ORAL SOLUTION MM
EPICERAM TOPICAL EMULSION, EXTENDED RELEASE
EPIDUO 0.1 %-2.5 % TOPICAL GEL
EPIDUO 0.1 %-2.5 % TOPICAL GEL WITH PUMP
EPIDUO FORTE 0.3 %-2.5 % TOPICAL GEL WITH PUMP
EPIFOAM 1 %-1 % TOPICAL
epinastine hcl 0.05% eye drops
epinephrine 0.15 mg auto-injct
epinephrine 0.3 mg auto-inject
EPIPEN 2-PAK 0.3 MG/0.3 ML (1:1,000) INJECTION,AUTO-INJECTOR
EPIPEN JR 2-PAK 0.15 MG/0.3 ML (1:2,000) INJECTION,AUTO-INJECTOR
EPISIL GEL FORMING SOLUTION
epitol 200 mg tablet MM
EPIVIR 10 MG/ML ORAL SOLUTION
EPIVIR 150 MG TABLET
EPIVIR 300 MG TABLET
EPIVIR HBV 100 MG TABLET
EPIVIR HBV 25 MG/5 ML (5 MG/ML) ORAL SOLUTION
eplerenone 25 mg tablet MM
eplerenone 50 mg tablet MM
EPOGEN 10,000 UNIT/ML INJECTION SOLUTION SP
EPOGEN 2,000 UNIT/ML INJECTION SOLUTION SP
EPOGEN 20,000 UNIT/2 ML INJECTION SOLUTION SP
EPOGEN 20,000 UNIT/ML INJECTION SOLUTION SP
EPOGEN 3,000 UNIT/ML INJECTION SOLUTION SP
EPOGEN 4,000 UNIT/ML INJECTION SOLUTION SP
eprosartan mesylate 600 mg tab MM
DRUG LEVEL
1
1
3
*
*
3
4
3
3
3
4
3
3
3
1
3
3
3
3
3
3
3
3
3
3
3
2
3
3
2
2
4
1
3
3
3
3
3
3
3
*
*
*
*
*
*
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
QL,PA
QL,PA
QL,PA
ST
QL,ST
ST
ST
ST
QL
QL
QL
QL
QL
QL
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,ST
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 61
DRUG NAME
EPZICOM 600 MG-300 MG TABLET SP
EQL INSULIN 1 ML SYRINGE MM
EQUETRO 100 MG CAPSULE, EXTENDED RELEASE MM
EQUETRO 200 MG CAPSULE, EXTENDED RELEASE MM
EQUETRO 300 MG CAPSULE, EXTENDED RELEASE MM
ergoloid mesylates 1 mg tab MM
ERGOMAR 2 MG SUBLINGUAL TABLET
ergotamine-caffeine tablet
ERIVEDGE 150 MG CAPSULE SP
errin 0.35 mg tablet MM
ERTACZO 2 % TOPICAL CREAM
ery pads 2 % topical swab
ERY-TAB 250 MG TABLET,DELAYED RELEASE
ERY-TAB 333 MG TABLET,DELAYED RELEASE
ERY-TAB 500 MG TABLET,DELAYED RELEASE
erygel 2 % topical
ERYPED 200 200 MG/5 ML ORAL SUSPENSION
ERYPED 400 400 MG/5 ML ORAL SUSPENSION
ERYTHROCIN (AS STEARATE) 250 MG TABLET
erythromycin 0.5% eye ointment
erythromycin 2% gel
erythromycin 2% pledgets
erythromycin 2% solution
erythromycin 250 mg filmtab
erythromycin 500 mg filmtab
erythromycin ec 250 mg cap
erythromycin es 400 mg tab
erythromycin-benzoyl gel
erythromycin-sulfisox susp
ESBRIET 267 MG CAPSULE SP
ESCAVITE 7.5 MG IRON-0.25 MG FLUOR. CHEWABLE TABLET
ESCAVITE D 6 MG IRON-0.25 MG FLUORIDE CHEW TABLET,IMMEDIATE & DELAYED
ESCAVITE LQ 6 MG IRON-0.25 MG FLUORIDE/ML ORAL DROPS
escitalopram 10 mg tablet MM
escitalopram 20 mg tablet MM
escitalopram 5 mg tablet MM
escitalopram oxalate 5 mg/5 ml MM
ESGIC 50 MG-325 MG-40 MG CAPSULE
ESGIC 50 MG-325 MG-40 MG TABLET
ESGIC PLUS CAPSULE
ESGIC-PLUS 50-500-40 MG TABLET
ESOMEPRAZOLE DR 49.3 MG CAP MM
esomeprazole mag dr 20 mg cap MM
esomeprazole mag dr 40 mg cap MM
ESOPHO-CAT 3% CREAM
estarylla 0.25 mg-35 mcg tablet MM
estazolam 1 mg tablet
estazolam 2 mg tablet
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
62 - FORMULARY Updated 09/2015
DRUG LEVEL
*
2
3
3
3
4
3
2
*
1
3
3
3
3
3
3
4
4
3
2
2
3
2
3
3
3
3
3
2
*
3
3
3
1
1
1
3
3
3
3
3
3
3
3
3
1
2
2
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL,PA
QL,PA
QL
QL
QL
QL
QL
QL
QL
QL
QL,ST
QL
QL
QL
QL
DRUG NAME
ESTRACE 0.01% (0.1 MG/GRAM) VAGINAL CREAM MM
ESTRACE 0.5 MG TABLET MM
ESTRACE 1 MG TABLET MM
ESTRACE 2 MG TABLET MM
estradiol 0.025 mg patch MM
estradiol 0.025 mg/day patch MM
estradiol 0.0375 mg patch MM
estradiol 0.0375 mg/day patch MM
estradiol 0.05 mg patch MM
estradiol 0.05 mg/day patch MM
estradiol 0.06 mg/day patch MM
estradiol 0.075 mg patch MM
estradiol 0.075 mg/day patch MM
estradiol 0.1 mg patch MM
estradiol 0.1 mg/day patch MM
estradiol 0.5 mg tablet MM
estradiol 1 mg tablet MM
estradiol 2 mg tablet MM
estradiol-noreth 0.5-0.1 mg tb MM
estradiol-noreth 1-0.5 mg tab MM
ESTRASORB PACKET MM
ESTRING 2 MG VAGINAL
ESTROGEL 1.25 GRAM/ACTUATION (0.06%) TRANSDERMAL GEL PUMP
estrogen-methyltestos h.s. tab MM
estrogen-methyltestosterone tb MM
estropipate 0.625(0.75 mg) tab MM
estropipate 1.25(1.5 mg) tab MM
estropipate 2.5(3 mg) tab MM
ESTROSTEP FE-28 1-20 (5)/1-30(7)/1MG-35MCG(9) TABLET MM
eszopiclone 1 mg tablet
eszopiclone 2 mg tablet
eszopiclone 3 mg tablet
ethambutol hcl 100 mg tablet MM
ethambutol hcl 400 mg tablet MM
ethosuximide 250 mg capsule MM
ethosuximide 250 mg/5 ml soln MM
ETHYL ACETATE LIQUID
ethyl chloride spray
etidronate disodium 200 mg tab MM
etidronate disodium 400 mg tab MM
etodolac 200 mg capsule MM
etodolac 300 mg capsule MM
etodolac 400 mg tablet MM
etodolac 500 mg tablet MM
DRUG LEVEL
3
3
3
3
3
2
3
2
3
2
2
3
2
3
2
1
1
1
3
3
3
3
3
3
3
1
1
1
3
2
2
2
3
3
3
3
3
2
2
2
2
2
2
2
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 63
DRUG NAME
etodolac er 400 mg tablet MM
etodolac er 500 mg tablet MM
etodolac er 600 mg tablet MM
etoposide 50 mg capsule SP
EURAX 10 % LOTION
EURAX 10 % TOPICAL CREAM
EVAMIST 1.53 MG/SPRAY (1.7 %) TRANSDERMAL SPRAY
EVEKEO 10 MG TABLET
EVEKEO 5 MG TABLET
EVENCARE G2
EVENCARE G2 SOLUTION
EVENCARE G2 STRIPS MM
EVENCARE G3 CONTROL SOLUTION
EVENCARE G3 GLUCOSE METER KIT
EVENCARE G3 TEST STRIPS MM
EVENCARE KIT
EVENCARE SOLUTION
EVENCARE TEST STRIPS MM
EVISTA 60 MG TABLET MM
EVOCLIN 1 % TOPICAL FOAM
EVOLUTION BLOOD GLUCOSE METER KIT
EVOLUTION NORMAL CONTROL SOLUTION
EVOLUTION TEST STRIPS MM
EVOTAZ 300 MG-150 MG TABLET SP
EVOXAC 30 MG CAPSULE MM
EVZIO 0.4 MG/0.4 ML INJECTION,AUTO-INJECTOR SP
EXALGO ER 12 MG TABLET,EXTENDED RELEASE
EXALGO ER 16 MG TABLET,EXTENDED RELEASE
EXALGO ER 32 MG TABLET,EXTENDED RELEASE
EXALGO ER 8 MG TABLET,EXTENDED RELEASE
EXEL INSULIN 0.3 ML 29 X 1/2" SYRINGE MM
EXEL INSULIN 1 ML 27 X 1/2" SYRINGE MM
EXEL INSULIN 1 ML 30 X 5/16" SYRINGE MM
EXEL INSULIN 1/2 ML 28 X 1/2" SYRINGE MM
EXEL INSULIN 1/2 ML 30 X 5/16" SYRINGE MM
EXEL INSULIN SYRN 27G-1/2 ML MM
EXELDERM 1 % TOPICAL CREAM
EXELDERM 1 % TOPICAL SOLUTION
EXELON 1.5 MG CAPSULE MM
EXELON 2 MG/ML ORAL SOLUTION MM
EXELON 3 MG CAPSULE MM
EXELON 4.5 MG CAPSULE MM
EXELON 6 MG CAPSULE MM
EXELON PATCH 13.3 MG/24 HOUR TRANSDERMAL MM
EXELON PATCH 4.6 MG/24 HR TRANSDERMAL MM
EXELON PATCH 9.5 MG/24 HR TRANSDERMAL MM
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
64 - FORMULARY Updated 09/2015
DRUG LEVEL
3
3
3
*
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
*
3
*
4
4
4
4
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
ST
QL,ST
ST
QL,ST
ST
QL,ST
QL
ST
QL,ST
QL
QL,ST
QL,ST
QL,ST
QL,ST
QL
QL
QL
QL
QL
QL
QL
QL
DRUG NAME
exemestane 25 mg tablet MM
EXFORGE 10 MG-160 MG TABLET MM
EXFORGE 10 MG-320 MG TABLET MM
EXFORGE 5 MG-160 MG TABLET MM
EXFORGE 5 MG-320 MG TABLET MM
EXFORGE HCT 10 MG-160 MG-12.5 MG TABLET MM
EXFORGE HCT 10 MG-160 MG-25 MG TABLET MM
EXFORGE HCT 10 MG-320 MG-25 MG TABLET MM
EXFORGE HCT 5 MG-160 MG-12.5 MG TABLET MM
EXFORGE HCT 5 MG-160 MG-25 MG TABLET MM
EXJADE 125 MG DISPERSIBLE TABLET SP
EXJADE 250 MG DISPERSIBLE TABLET SP
EXJADE 500 MG DISPERSIBLE TABLET SP
exoderm 25 %-1 % lotion
exotic-hc ear drop
EXTAVIA 0.3 MG SUBCUTANEOUS KIT SP
EXTAVIA 0.3 MG SUBCUTANEOUS SOLUTION SP
EXTINA 2 % TOPICAL FOAM
extra-virt plus dha 29 mg iron-1.25 mg-55 mg capsule
EZ SMART CONTROL SOLUTION
EZ SMART LANCETS 28 GAUGE
EZ SMART PLUS SYSTEM KIT
EZ SMART PLUS TEST STRIPS MM
EZ SMART SYSTEM KIT
EZ SMART TEST STRIPS MM
fabb 2.2 mg-25 mg-1 mg tablet
FABIOR 0.1 % TOPICAL FOAM
FACTIVE 320 MG TABLET
falessa 1 mg tablet
falmina (28) 0.1 mg-20 mcg tablet MM
famciclovir 125 mg tablet
famciclovir 250 mg tablet
famciclovir 500 mg tablet
famotidine 20 mg tablet MM
famotidine 40 mg tablet MM
famotidine 40 mg/5 ml susp MM
FAMVIR 125 MG TABLET
FAMVIR 250 MG TABLET
FAMVIR 500 MG TABLET
FANAPT 1 MG TABLET MM
FANAPT 10 MG TABLET MM
FANAPT 12 MG TABLET MM
FANAPT 1MG(2)-2 MG(2)-4MG(2)-6 MG(2) TABLETS IN A DOSE PACK
FANAPT 2 MG TABLET MM
FANAPT 4 MG TABLET MM
FANAPT 6 MG TABLET MM
DRUG LEVEL
3
3
3
3
3
3
3
3
3
3
*
*
*
2
2
*
*
3
2
3
1
3
3
3
3
1
3
3
3
1
2
2
2
3
3
2
4
3
4
4
4
4
4
4
4
4
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
ST
QL,ST
ST
QL,ST
QL
QL
QL
QL
QL
QL
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 65
DRUG NAME
FANAPT 8 MG TABLET MM
FARESTON 60 MG TABLET SP
FARXIGA 10 MG TABLET MM
FARXIGA 5 MG TABLET MM
FARYDAK 10 MG CAPSULE SP
FARYDAK 15 MG CAPSULE SP
FARYDAK 20 MG CAPSULE SP
FAZACLO 100 MG DISINTEGRATING TABLET MM
FAZACLO 12.5 MG DISINTEGRATING TABLET MM
FAZACLO 150 MG DISINTEGRATING TABLET MM
FAZACLO 200 MG DISINTEGRATING TABLET MM
FAZACLO 25 MG DISINTEGRATING TABLET MM
fe 90 plus tablet
fe c plus 100 mg-250 mg-25 mcg-1 mg tablet
felbamate 400 mg tablet MM
felbamate 600 mg tablet MM
felbamate 600 mg/5 ml susp MM
FELBATOL 400 MG TABLET MM
FELBATOL 600 MG TABLET MM
FELBATOL 600 MG/5 ML ORAL SUSPENSION MM
FELDENE 10 MG CAPSULE MM
FELDENE 20 MG CAPSULE MM
felodipine er 10 mg tablet MM
felodipine er 2.5 mg tablet MM
felodipine er 5 mg tablet MM
FEM PH 0.9 %-0.025 % VAGINAL GEL
FEMARA 2.5 MG TABLET MM
FEMCAP 22 MM VAGINAL DEVICE
FEMCAP 26 MM VAGINAL DEVICE
FEMCAP 30 MM VAGINAL DEVICE
FEMCON FE 0.4 MG-35 MCG (21)/75 MG (7) CHEWABLE TABLET MM
FEMHRT LOW DOSE 0.5 MG-2.5 MCG TABLET MM
FEMRING 0.05 MG/24 HR VAGINAL
FEMRING 0.1 MG/24 HR VAGINAL
fenofibrate 120 mg tablet MM
fenofibrate 130 mg capsule MM
fenofibrate 134 mg capsule MM
fenofibrate 145 mg tablet MM
fenofibrate 150 mg capsule MM
fenofibrate 160 mg tablet MM
fenofibrate 200 mg capsule MM
fenofibrate 43 mg capsule MM
fenofibrate 48 mg tablet MM
fenofibrate 50 mg capsule MM
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
66 - FORMULARY Updated 09/2015
DRUG LEVEL
4
*
3
3
*
*
*
3
3
3
3
3
2
1
4
4
4
4
4
4
3
3
2
2
2
2
4
3
3
3
3
3
3
3
3
3
2
3
3
2
2
2
2
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,PA
QL
QL,ST
QL,ST
QL,PA
QL,PA
QL,PA
QL
QL
QL
QL
QL
QL
QL,ST
QL
QL
QL
QL
QL
QL
QL
QL
QL
DRUG NAME
fenofibrate 54 mg tablet MM
fenofibrate 67 mg capsule MM
fenofibric acid 105 mg tablet MM
fenofibric acid 35 mg tablet MM
fenofibric acid dr 135 mg cap MM
fenofibric acid dr 45 mg cap MM
FENOGLIDE 120 MG TABLET MM
FENOGLIDE 40 MG TABLET MM
fenoprofen 600 mg tablet MM
fenoprofen calcium 400 mg cap MM
fentanyl 100 mcg/hr patch
fentanyl 12 mcg/hr patch
fentanyl 25 mcg/hr patch
fentanyl 37.5 mcg/hr patch
fentanyl 50 mcg/hr patch
fentanyl 62.5 mcg/hr patch
fentanyl 75 mcg/hr patch
fentanyl 87.5 mcg/hr patch
fentanyl cit otfc 1,200 mcg
fentanyl cit otfc 1,600 mcg
fentanyl citrate otfc 200 mcg
fentanyl citrate otfc 400 mcg
fentanyl citrate otfc 600 mcg
fentanyl citrate otfc 800 mcg
FENTORA 100 MCG BUCCAL TABLET, EFFERVESCENT
FENTORA 200 MCG BUCCAL TABLET, EFFERVESCENT
FENTORA 400 MCG BUCCAL TABLET, EFFERVESCENT
FENTORA 600 MCG BUCCAL TABLET, EFFERVESCENT
FENTORA 800 MCG BUCCAL TABLET, EFFERVESCENT
FERIVA 21-7 TABLET 75 MG IRON-1 MG-175 MG TABLET
FERIVA 75 MG IRON-1 MG-175 MG CAPSULE,EXTENDED RELEASE
FERIVA FA (SUMALATE) 110 MG-1 MG-175 MG-12 MCG CAPSULE
FERIVA FA CAPSULE
ferocon 110 mg-0.5 mg capsule
FERRALET 90 DUAL-IRON DELIVERY 90 MG-1 MG-12 MCG-50 MG TABLET
ferraplus 90 90 mg-1 mg-12 mcg-120 mg-50mg tablet
ferrex 150 forte 150 mg-25 mcg-1 mg capsule
ferrex 150 forte plus 150 mg-60 mg-25 mcg-1 mg capsule
ferrex 28 151 mg-200 mg-1 mg-0.8 mg tablet
FERRIPROX 500 MG TABLET SP
ferrocite plus 106 mg iron-1 mg tablet
ferrogels forte 460 mg-60 mg-0.01 mg-1 mg capsule
FETZIMA 120 MG CAPSULE,EXTENDED RELEASE MM
FETZIMA 20 MG (2)-40 MG (26) CAPSULE,EXTENDED RELEASE,24 HR,DOSE PACK
FETZIMA 20 MG CAPSULE,EXTENDED RELEASE MM
FETZIMA 40 MG CAPSULE,EXTENDED RELEASE MM
FETZIMA 80 MG CAPSULE,EXTENDED RELEASE MM
FEXMID 7.5 MG TABLET
DRUG LEVEL
2
2
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
4
4
4
4
4
4
4
4
4
4
4
3
3
3
3
1
2
1
1
2
2
*
1
1
3
3
3
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
QL
QL
QL,ST
QL,ST
QL
QL
QL
QL
QL
QL
QL
QL
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 67
DRUG NAME
FIBRICOR 105 MG TABLET MM
FIBRICOR 35 MG TABLET MM
FIFTY50 GLUCOSE CONTROL SOLN
FIFTY50 RESERVOIR 1.8 ML MISC MM
FIFTY50 RESERVOIR 3 ML MISC MM
FIFTY50 SAFETY SEAL LANCETS 30 GAUGE
FIFTY50 SAFETY SEAL LANCETS 32 GAUGE
FIFTY50 TEST STRIP MM
FILTER NEEDLE 5 MICRON
FILTER NEEDLE 5 MICRON
FINACEA 15 % TOPICAL GEL
finasteride 5 mg tablet MM
FINE 30 UNIVERSAL LANCETS 30 GAUGE
FINGERSTIX LANCETS
fioricet 50 mg-300 mg-40 mg capsule
FIORICET WITH CODEINE 50 MG-300 MG-40 MG-30 MG CAPSULE
FIORINAL 50 MG-325 MG-40 MG CAPSULE
FIORINAL-CODEINE #3 30 MG-50 MG-325 MG-40 MG CAPSULE
FIRAZYR 30 MG/3 ML SUBCUTANEOUS SYRINGE SP
FIRMAGON 120 MG SUBCUTANEOUS SOLUTION
FIRMAGON 80 MG SUBCUTANEOUS SOLUTION
FIRMAGON KIT WITH DILUENT SYRINGE 120 MG SUBCUTANEOUS SOLUTION
FIRMAGON KIT WITH DILUENT SYRINGE 80 MG SUBCUTANEOUS SOLUTION
FIRST CHOICE LANCETS THIN
FLAGYL 250 MG TABLET
FLAGYL 375 MG CAPSULE
FLAGYL 500 MG TABLET
FLAGYL ER 750 MG TABLET,EXTENDED RELEASE
FLAREX 0.1 % EYE DROPS,SUSPENSION
flavoxate hcl 100 mg tablet MM
flecainide acetate 100 mg tab MM
flecainide acetate 150 mg tab MM
flecainide acetate 50 mg tab MM
FLECTOR 1.3 % TRANSDERMAL 12 HOUR PATCH
FLEXICHAMBER SPACER
FLO-PRED 15 MG/5 ML ORAL SUSPENSION
FLOMAX 0.4 MG CAPSULE MM
FLONASE 0.05% NASAL SPRAY MM
FLORIVA 0.5 MG FLUORIDE (1.1 MG) CHEWABLE TABLET
FLORIVA 1 MG FLUORIDE (2.2 MG) CHEWABLE TABLET
FLOVENT DISKUS 100 MCG/ACTUATION POWDER FOR INHALATION MM
FLOVENT DISKUS 250 MCG/ACTUATION POWDER FOR INHALATION MM
FLOVENT DISKUS 50 MCG/ACTUATION POWDER FOR INHALATION MM
FLOVENT HFA 110 MCG/ACTUATION AEROSOL INHALER MM
FLOVENT HFA 220 MCG/ACTUATION AEROSOL INHALER MM
FLOVENT HFA 44 MCG/ACTUATION AEROSOL INHALER MM
FLOWTUSS 2.5 MG-200 MG/5 ML ORAL SOLUTION
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
68 - FORMULARY Updated 09/2015
DRUG LEVEL
3
3
3
2
2
1
1
3
1
3
3
1
1
3
3
3
3
4
*
4
4
4
4
1
3
3
3
3
3
3
2
2
2
3
3
3
3
3
3
3
2
2
2
2
2
2
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL,ST
ST
QL
QL
QL
QL
QL
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
ST
QL,PA
QL
QL,ST
QL
QL
QL
QL
QL
QL
DRUG NAME
FLUARIX QUAD 2015-2016 (PF) 60 MCG (15 MCG X 4)/0.5 ML IM SYRINGE
FLUBLOK 2015-2016 (PF) 135 MCG (45 MCG X 3)/0.5 ML IM SOLUTION
FLUCAINE 0.25 %-0.5 % EYE DROPS
FLUCELVAX 2015-2016 (PF) 45 MCG (15 MCG X 3)/0.5 ML IM SYRINGE
fluconazole 10 mg/ml susp
fluconazole 100 mg tablet
fluconazole 150 mg tablet
fluconazole 200 mg tablet
fluconazole 40 mg/ml susp
fluconazole 50 mg tablet
flucytosine 250 mg capsule
flucytosine 500 mg capsule
fludrocortisone 0.1 mg tablet MM
FLULAVAL QUAD 2015-2016 60 MCG (15 MCG X 4)/0.5 ML IM SUSPENSION
FLUMADINE 100 MG TABLET
flunisolide 0.025% spray MM
fluocinolone 0.01% body oil
fluocinolone 0.01% cream
fluocinolone 0.01% scalp oil
fluocinolone 0.01% solution
fluocinolone 0.025% cream
fluocinolone 0.025% ointment
fluocinolone oil 0.01% ear drp
fluocinonide 0.05% cream
fluocinonide 0.05% gel
fluocinonide 0.05% ointment
fluocinonide 0.05% solution
fluocinonide 0.1% cream
fluocinonide-e 0.05 % topical cream
fluorescein-benoxinate eye drp
fluorescein-proparacaine drops
fluorets 1 mg opth strips
fluorometholone 0.1% drops
FLUOROPLEX 1 % TOPICAL CREAM
fluorouracil 0.5% cream
fluorouracil 2% topical soln
fluorouracil 5% cream
fluorouracil 5% top solution
fluoxetine 20 mg/5 ml solution MM
fluoxetine dr 90 mg capsule MM
fluoxetine hcl 10 mg capsule MM
fluoxetine hcl 10 mg tablet MM
fluoxetine hcl 20 mg capsule MM
fluoxetine hcl 20 mg tablet MM
fluoxetine hcl 40 mg capsule MM
fluoxetine hcl 60 mg tablet MM
fluphenazine 1 mg tablet MM
fluphenazine 10 mg tablet MM
DRUG LEVEL
3
3
3
3
2
2
2
2
2
2
2
2
1
3
3
2
3
3
3
3
3
3
3
2
3
2
3
4
3
3
3
3
3
3
3
3
3
3
1
3
1
2
1
2
1
2
1
1
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
ST
QL
QL
QL
QL
QL
QL
QL
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 69
DRUG NAME
fluphenazine 2.5 mg tablet MM
fluphenazine 2.5 mg/5 ml elix MM
fluphenazine 5 mg tablet MM
fluphenazine 5 mg/ml conc
flurazepam 15 mg capsule
flurazepam 30 mg capsule
flurbiprofen 0.03% eye drop
flurbiprofen 100 mg tablet MM
flurbiprofen 50 mg tablet MM
FLURESS EYE DROPS
flurox 0.25 %-0.4 % eye drops
flutamide 125 mg capsule MM
fluticasone prop 0.005% oint
fluticasone prop 0.05% cream
fluticasone prop 0.05% lotion
fluticasone prop 50 mcg spray MM
fluvastatin sodium 20 mg cap MM
fluvastatin sodium 40 mg cap MM
FLUVIRIN 2015-2016 (PF) 45 MCG (15 MCG X 3)/0.5 ML IM SYRINGE
FLUVIRIN 2015-2016 45 MCG (15 MCG X 3)/0.5 ML INTRAMUSCULAR SUSPENSION
fluvoxamine er 100 mg capsule MM
fluvoxamine er 150 mg capsule MM
fluvoxamine maleate 100 mg tab MM
fluvoxamine maleate 25 mg tab MM
fluvoxamine maleate 50 mg tab MM
FLUZONE 2015-2016 45 MCG (15 MCG X 3)/0.5 ML INTRAMUSCULAR SUSPENSION
FLUZONE HIGH-DOSE 2015-16 (PF) 180 MCG/0.5 ML INTRAMUSCULAR SYRINGE
FLUZONE INTRADERM QUAD 2015-16 (PF) 36 MCG/0.1 ML INTRADERMAL SYRINGE
FLUZONE QUAD 2015-2016 (PF) 60 MCG (15 MCG X 4)/0.5 ML IM SUSPENSION
FLUZONE QUAD 2015-2016 (PF) 60 MCG (15 MCG X 4)/0.5 ML IM SYRINGE
FLUZONE QUAD 2015-2016 60 MCG (15 MCG X 4)/0.5 ML IM SUSPENSION
FLUZONE QUAD PEDI 2015-16 (PF) 30 MCG (7.5 MCG X 4)/0.25 ML IM SYRINGE
FML FORTE 0.25 % EYE DROPS,SUSPENSION
FML LIQUIFILM 0.1 % EYE DROPS,SUSPENSION
FML S.O.P. 0.1 % EYE OINTMENT
focalgin 90 dha 90 mg iron-1 mg-50 mg-300 mg oral pack
focalgin ca 35 mg iron-1 mg-50 mg-300 mg oral pack
focalgin dss 90 mg-1 mg-12 mcg-50 mg tablet
focalgin-b tablet
FOCALIN 10 MG TABLET
FOCALIN 2.5 MG TABLET
FOCALIN 5 MG TABLET
FOCALIN XR 10 MG CAPSULE,EXTENDED RELEASE
FOCALIN XR 15 MG CAPSULE,EXTENDED RELEASE
FOCALIN XR 20 MG CAPSULE,EXTENDED RELEASE
FOCALIN XR 25 MG CAPSULE,EXTENDED RELEASE
FOCALIN XR 30 MG CAPSULE,EXTENDED RELEASE
FOCALIN XR 35 MG CAPSULE,EXTENDED RELEASE
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
70 - FORMULARY Updated 09/2015
DRUG LEVEL
1
1
1
1
2
2
1
1
1
3
1
3
2
2
3
1
3
3
3
3
3
3
1
1
1
3
3
3
3
3
3
3
3
3
3
3
3
3
2
3
3
3
3
3
3
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
ST
ST
ST
QL
QL
QL
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
DRUG NAME
FOCALIN XR 40 MG CAPSULE,EXTENDED RELEASE
FOCALIN XR 5 MG CAPSULE,EXTENDED RELEASE
folastin tablet
folbecal 1 mg-200 mg-75 mg-12 mcg tablet,extended release
folbee 2.5 mg-25 mg-1 mg tablet
folbee plus 5 mg tablet
folbee plus 5 mg-1.5 mg-25 mg tablet
folbic 2.5 mg-25 mg-2 mg tablet
folbic rf 2 mg-1.13 mg-25 mg tablet
folcal dha capsule
folcaps omega-3 capsule
folcaps tablet
FOLET DHA 38 MG-1 MG-50 MG-350 MG ORAL PACK
FOLET ONE 38 MG IRON-1 MG-25 MG-225 MG CAPSULE
FOLGARD OS 500 MG-1.1 MG TABLET
FOLGARD RX 2.2 MG-25 MG-1 MG TABLET
folic acid 1 mg tablet MM
folic acid-vit b6-vit b12 tab
folinatal plus b 1 mg-200 mg-75 mg-12 mcg tablet,extended release
folivane-f 125 mg-1 mg-40 mg-3 mg capsule
folivane-ob 85 mg-1 mg capsule
folivane-plus 125 mg-1 mg capsule
folivane-prx dha nf capsule
folplex 2.2 2.2 mg-25 mg-0.5 mg tablet
foltanx 3 mg-35 mg-2 mg tablet
foltanx rf 3 mg-35 mg-2 mg-90.314 mg capsule
FOLTRATE 0.5 MG-1 MG TABLET
FOLTX 2 MG-1.13 MG-25 MG TABLET
fondaparinux 10 mg/0.8 ml syr
fondaparinux 2.5 mg/0.5 ml syr
fondaparinux 5 mg/0.4 ml syr
fondaparinux 7.5 mg/0.6 ml syr
FORA D10 KIT
FORA D10 STRIPS MM
FORA D15 DEVICE
FORA D15C GLUCOSE TEST STRIPS MM
FORA D15G STRIPS MM
FORA D15Z GLUCOSE TEST STRIPS MM
FORA D20 KIT
FORA D20 STRIPS MM
FORA G20 KIT
FORA G20 STRIPS MM
FORA G30A
FORA G30A STRIPS MM
FORA G71A BLOOD GLUCOSE SYSTEM
FORA G71A GLUCOSE TEST STRIP MM
FORA G90 BLOOD GLUCOSE SYSTEM
FORA G90 GLUCOSE TEST STRIP MM
FORA GD50 BLOOD GLUCOSE SYSTEM
DRUG LEVEL
3
3
1
1
1
1
1
2
2
2
2
1
3
3
3
1
1
1
2
1
1
1
2
1
2
3
3
3
4
4
4
4
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,ST
QL,ST
QL
QL
QL
QL
ST
QL,ST
ST
QL,ST
QL,ST
QL,ST
ST
QL,ST
ST
QL,ST
ST
QL,ST
ST
QL,ST
ST
QL,ST
ST
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 71
DRUG NAME
FORA GD50 TEST STRIPS MM
FORA HIGH CONTROL SOLUTION
FORA LANCING DEVICE
FORA LOW CONTROL SOLUTION
FORA NORMAL CONTROL SOLUTION
FORA TEST N'GO TEST STRIPS MM
FORA TEST N'GO VOICE METER
FORA TEST STRIP MM
FORA V10 KIT
FORA V10 STRIPS MM
FORA V12 BLOOD GLUCOSE SYSTEM
FORA V12 BLOOD GLUCOSE SYSTEM KIT
FORA V12 GLUCOSE STRIPS MM
FORA V20 KIT
FORA V20 STRIPS MM
FORA V22 BLOOD GLUCOSE SYSTEM
FORA V22 GLUCOSE TEST STRIP MM
FORA V30A
FORA V30A KIT
FORA V30A STRIPS MM
FORACARE GD20 GLUCOSE METER
FORACARE GD20 STRIPS MM
FORACARE GD40 STRIPS MM
FORACARE GD40A GLUCOSE METER
FORACARE GD40B GLUCOSE METER
FORACARE GDH HIGH CONTROL SOLUTION
FORACARE GDH LOW CONTROL SOLUTION
FORACARE GDH NORMAL CONTROL SOLUTION
FORACARE LANCETS 30 GAUGE
FORADIL AEROLIZER 12 MCG CAPSULE WITH INHALATION DEVICE MM
FORANE 99.9 % INHALATION LIQUID
FORFIVO XL 450 MG TABLET,EXTENDED RELEASE MM
FORMA-RAY 20 % SOLUTION
FORMADON 10 % TOPICAL SOLUTION
formadon 10 % topical solution with applicator
formaldehyde 10% solution
FORTAMET 1,000 MG TABLET,EXTENDED RELEASE MM
FORTAMET 500 MG TABLET,EXTENDED RELEASE MM
FORTEO 20 MCG/DOSE (600 MCG/2.4 ML) SUBCUTANEOUS PEN INJECTOR SP
FORTESTA 10 MG/0.5 GRAM/ACTUATION TRANSDERMAL GEL PUMP MM
FORTICAL 200 UNIT/ACTUATION NASAL SPRAY MM
FORTISCARE BLOOD GLUCOSE SYSTEM KIT
FORTISCARE GLUCOSE TEST STRIPS MM
FORTISCARE HIGH SOLUTION
FORTISCARE LOW SOLUTION
FORTISCARE NORMAL SOLUTION
FOSAMAX 70 MG TABLET MM
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
72 - FORMULARY Updated 09/2015
DRUG LEVEL
3
3
1
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
1
2
3
3
3
3
2
2
4
4
*
3
3
3
3
3
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,ST
QL,ST
ST
QL,ST
ST
QL,ST
ST
ST
QL,ST
ST
QL,ST
ST
QL,ST
ST
ST
QL,ST
ST
QL,ST
QL,ST
ST
ST
QL
QL,ST
QL,ST
QL,ST
QL,PA
QL,ST
QL
ST
QL,ST
QL
DRUG NAME
FOSAMAX PLUS D 70 MG-2,800 UNIT TABLET MM
FOSAMAX PLUS D 70 MG-5,600 UNIT TABLET MM
fosinopril sodium 10 mg tab MM
fosinopril sodium 20 mg tab MM
fosinopril sodium 40 mg tab MM
fosinopril-hctz 10-12.5 mg tab MM
fosinopril-hctz 20-12.5 mg tab MM
FOSRENOL 1,000 MG CHEWABLE TABLET MM
FOSRENOL 1,000 MG ORAL POWDER PACKET
FOSRENOL 500 MG CHEWABLE TABLET MM
FOSRENOL 750 MG CHEWABLE TABLET MM
FOSRENOL 750 MG ORAL POWDER PACKET
FOSTEUM 27 MG-20 MG-200 UNIT CAPSULE
FOSTEUM PLUS 500 MG-70 MG-27 MG-400 UNIT CAPSULE
FOVEX CAPSULE
FRAGMIN 10,000 ANTI-XA UNIT/ML SUBCUTANEOUS SYRINGE
FRAGMIN 12,500 ANTI-XA UNIT/0.5 ML SUBCUTANEOUS SYRINGE
FRAGMIN 15,000 ANTI-XA UNIT/0.6 ML SUBCUTANEOUS SYRINGE
FRAGMIN 18,000 ANTI-XA UNIT/0.72 ML SUBCUTANEOUS SYRINGE
FRAGMIN 2,500 ANTI-XA UNIT/0.2 ML SUBCUTANEOUS SYRINGE
FRAGMIN 25,000 ANTI-XA UNIT/ML SUBCUTANEOUS SOLUTION
FRAGMIN 5,000 ANTI-XA UNIT/0.2 ML SUBCUTANEOUS SYRINGE
FRAGMIN 7,500 ANTI-XA UNIT/0.3 ML SUBCUTANEOUS SYRINGE
FREAMINE HBC 6.9 % INTRAVENOUS SOLUTION
FREESTYLE CONTROL SOLUTION
FREESTYLE FLASH SYSTEM KIT
FREESTYLE FREEDOM KIT
FREESTYLE FREEDOM LITE KIT
FREESTYLE INSULINX MISC
FREESTYLE INSULINX STRIPS MM
FREESTYLE INSULINX TEST STRIPS MM
FREESTYLE LANCETS 28 GAUGE
FREESTYLE LITE METER KIT
FREESTYLE LITE STRIPS MM
FREESTYLE NAVIGATOR GLUCOSE SENSOR DEVICE MM
FREESTYLE PRECISION 1 ML 30 X 5/16" SYRINGE MM
FREESTYLE PRECISION 1 ML 31 X 5/16" SYRINGE MM
FREESTYLE PRECISION 1/2 ML 30 X 5/16" SYRINGE MM
FREESTYLE PRECISION 1/2 ML 31 X 5/16" SYRINGE MM
FREESTYLE SIDEKICK II KIT
FREESTYLE SYSTEM KIT
FREESTYLE TEST STRIPS MM
FREESTYLE UNISTIK 2
FROVA 2.5 MG TABLET
FUL-GLO 0.6 MG EYE STRIPS
ful-glo 1 mg eye strips
FULYZAQ 125 MG TABLET,DELAYED RELEASE
DRUG LEVEL
3
3
1
1
1
2
2
4
4
4
4
4
3
3
3
4
4
4
4
4
4
4
4
3
3
3
3
3
3
3
3
3
3
3
3
2
2
2
2
3
3
3
3
3
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,ST
QL,ST
ST
ST
ST
ST
ST
QL
QL
QL
QL
QL
QL
QL
QL
ST
ST
ST
ST
QL,ST
QL,ST
ST
QL,ST
PA
ST
ST
QL,ST
QL,ST
QL,PA
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 73
DRUG NAME
FURADANTIN 25 MG/5 ML ORAL SUSPENSION
furosemide 10 mg/ml solution MM
furosemide 20 mg tablet MM
furosemide 40 mg tablet MM
furosemide 40 mg/5 ml soln MM
furosemide 80 mg tablet MM
FUSION PLUS 130 MG IRON-1,250 MCG CAPSULE
FUZEON 90 MG SUBCUTANEOUS SOLUTION SP
FYCOMPA 10 MG TABLET MM
FYCOMPA 12 MG TABLET MM
FYCOMPA 2 MG TABLET MM
FYCOMPA 4 MG TABLET MM
FYCOMPA 6 MG TABLET MM
FYCOMPA 8 MG TABLET MM
G-4 BLOOD GLUCOSE METER
G-4 TEST STRIPS MM
GABADONE 343 MG-20 MG-10 MG-56 MG CAPSULE
gabapentin 100 mg capsule MM
gabapentin 250 mg/5 ml soln MM
gabapentin 250 mg/5 ml soln MM
gabapentin 300 mg capsule MM
gabapentin 300 mg/6 ml soln MM
gabapentin 400 mg capsule MM
gabapentin 600 mg tablet MM
gabapentin 800 mg tablet MM
GABITRIL 12 MG TABLET MM
GABITRIL 16 MG TABLET MM
GABITRIL 2 MG TABLET MM
GABITRIL 4 MG TABLET MM
galantamine 4 mg/ml oral soln MM
galantamine er 16 mg capsule MM
galantamine er 24 mg capsule MM
galantamine er 8 mg capsule MM
galantamine hbr 12 mg tablet MM
galantamine hbr 4 mg tablet MM
galantamine hbr 8 mg tablet MM
GALZIN 25 MG (ZINC) CAPSULE
GALZIN 50 MG (ZINC) CAPSULE
garamycin 0.3 % eye drops
GARAMYCIN 3 MG/GM EYE OINTMENT
GASTROCROM 100 MG/5 ML ORAL CONCENTRATE
GASTROGRAFIN 66 %-10 % ORAL SOLUTION
GASTROMARK 175 MCG/ML IRON ORAL SUSPENSION
gatifloxacin 0.5% eye drops
GATTEX 30-VIAL 5 MG SUBCUTANEOUS KIT SP
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
74 - FORMULARY Updated 09/2015
DRUG LEVEL
3
1
1
1
1
1
2
*
3
3
3
3
3
3
3
3
3
2
3
3
2
3
2
2
2
4
4
4
4
2
3
3
3
3
3
3
3
3
2
2
4
3
3
3
*
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
ST
QL,ST
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL,PA
DRUG NAME
GATTEX ONE-VIAL 5 MG SUBCUTANEOUS KIT SP
gavilyte-c 240 gram-22.72 gram-6.72 gram-5.84 gram oral solution
gavilyte-g 236 gram-22.74 gram-6.74 gram-5.86 gram oral solution
gavilyte-h and bisacodyl 5 mg-210 gram oral kit
gavilyte-n 420 gram oral solution
GDRIVE KIT
GE100 BLOOD GLUCOSE SYSTEM KIT
GE100 BLOOD GLUCOSE TEST STRIP MM
GE100 CONTROL SOLUTION NORMAL
GELCLAIR MUCOSAL GEL PACKET
GELFILM FOR THE EYE
GELFILM IMPLANT
GELFOAM 4 SPONGE
GELFOAM COMPRESSED SIZE 100 100 CM SPONGE
GELFOAM MUCOSAL POWDER
GELFOAM SPONGE SIZE 100 100
GELFOAM SPONGE SIZE 12-7MM 12 MM-7 MM
GELFOAM SPONGE SIZE 200 200
GELFOAM SPONGE SIZE 50 50
GELNIQUE 10 % (100 MG/GRAM) TRANSDERMAL GEL PACKET MM
GELNIQUE 28 MG/0.92 GRAM (3 %) TRANSDERMAL GEL PUMP MM
GELX MUCOSAL GEL
gemfibrozil 600 mg tablet MM
GENADUR (WITH LEXINAL) 2,500 MCG KIT
GENADUR TOPICAL LIQUID
GENERESS FE 0.8 MG-25 MCG (24)/75 MG (4) CHEWABLE TABLET MM
generlac 10 gram/15 ml oral solution MM
gengraf 100 mg capsule
gengraf 100 mg/ml oral solution
gengraf 25 mg capsule
GENOTROPIN 12 MG/ML (36 UNIT/ML) SUBCUTANEOUS CARTRIDGE SP
GENOTROPIN 5 MG/ML (15 UNIT/ML) SUBCUTANEOUS CARTRIDGE SP
GENOTROPIN MINIQUICK 0.2 MG/0.25 ML SUBCUTANEOUS SYRINGE SP
GENOTROPIN MINIQUICK 0.4 MG/0.25 ML SUBCUTANEOUS SYRINGE SP
GENOTROPIN MINIQUICK 0.6 MG/0.25 ML SUBCUTANEOUS SYRINGE SP
GENOTROPIN MINIQUICK 0.8 MG/0.25 ML SUBCUTANEOUS SYRINGE SP
GENOTROPIN MINIQUICK 1 MG/0.25 ML SUBCUTANEOUS SYRINGE SP
GENOTROPIN MINIQUICK 1.2 MG/0.25 ML SUBCUTANEOUS SYRINGE SP
GENOTROPIN MINIQUICK 1.4 MG/0.25 ML SUBCUTANEOUS SYRINGE SP
GENOTROPIN MINIQUICK 1.6 MG/0.25 ML SUBCUTANEOUS SYRINGE SP
GENOTROPIN MINIQUICK 1.8 MG/0.25 ML SUBCUTANEOUS SYRINGE SP
GENOTROPIN MINIQUICK 2 MG/0.25 ML SUBCUTANEOUS SYRINGE SP
GENSTRIP TEST STRIP MM
gentak 0.3 % (3 mg/gram) eye ointment
gentamicin 0.1% cream
gentamicin 0.1% ointment
gentamicin 0.3% eye drops
DRUG LEVEL
*
2
2
3
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
4
1
3
3
3
1
3
3
3
*
*
*
*
*
*
*
*
*
*
*
*
3
2
2
2
2
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,PA
ST
ST
QL,ST
QL,ST
QL,ST
QL
QL
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,ST
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 75
DRUG NAME
gentamicin 0.3% eye ointment
GENULTIMATE TEST STRIPS MM
GEODON 20 MG CAPSULE MM
GEODON 40 MG CAPSULE MM
GEODON 60 MG CAPSULE MM
GEODON 80 MG CAPSULE MM
GESTICARE DHA COMBO PACK
gianvi (28) 3 mg-20 mcg tablet MM
GIAZO 1.1 GRAM TABLET
gildagia 0.4 mg-35 mcg tablet MM
gildess 1 mg-20 mcg tablet MM
gildess 1.5 mg-30 mcg tablet MM
gildess 24 fe 1 mg-20 mcg (24)/75 mg (4) tablet MM
gildess fe 1 mg-20 mcg (21)/75 mg (7) tablet MM
gildess fe 1.5 mg-30 mcg (21)/75 mg (7) tablet MM
GILENYA 0.5 MG CAPSULE SP
GILOTRIF 20 MG TABLET SP
GILOTRIF 30 MG TABLET SP
GILOTRIF 40 MG TABLET SP
glatopa 20 mg/ml subcutaneous syringe SP
GLEEVEC 100 MG TABLET SP
GLEEVEC 400 MG TABLET SP
GLEOSTINE 10 MG CAPSULE
GLEOSTINE 100 MG CAPSULE
GLEOSTINE 40 MG CAPSULE
GLIADEL WAFER 7.7 MG IMPLANT SP
glimepiride 1 mg tablet MM
glimepiride 2 mg tablet MM
glimepiride 4 mg tablet MM
glipizide 10 mg tablet MM
glipizide 5 mg tablet MM
glipizide er 2.5 mg tablet MM
glipizide xl 10 mg tablet MM
glipizide xl 5 mg tablet MM
glipizide-metformin 2.5-250 mg MM
glipizide-metformin 2.5-500 mg MM
glipizide-metformin 5-500 mg MM
GLUCAGEN DIAGNOSTIC KIT 1 MG/ML INJECTION
GLUCAGEN DIAGNOSTIC KIT 1 MG/ML INJECTION
GLUCAGEN HYPOKIT 1 MG INJECTION
glucagon 1 mg vial
GLUCAGON EMERGENCY KIT (HUMAN-RECOMB) 1 MG INJECTION
gluco burst 40 % oral gel
GLUCO NAVII GLUCOSE MONITOR KIT
GLUCO NAVII TEST STRIP MM
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
76 - FORMULARY Updated 09/2015
DRUG LEVEL
2
3
4
4
4
4
2
2
4
2
1
1
3
1
1
*
*
*
*
*
*
*
3
3
3
*
1
1
1
1
1
1
1
1
2
2
2
3
3
3
3
3
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,ST
QL
QL
QL
QL
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL
QL
QL
ST
QL,ST
DRUG NAME
GLUCOCARD 01 HIGH-NORMAL CONTROL SOLUTION
GLUCOCARD 01 METER KIT
GLUCOCARD 01 NORMAL CONTROL SOLUTION
GLUCOCARD 01 SENSOR PLUS STRIPS MM
GLUCOCARD 01-MINI METER KIT
GLUCOCARD EXPRESSION
GLUCOCARD EXPRESSION KIT
GLUCOCARD EXPRESSION SOLUTION
GLUCOCARD EXPRESSION STRIPS MM
GLUCOCARD SHINE METER
GLUCOCARD SHINE METER KIT
GLUCOCARD SHINE SOLUTION
GLUCOCARD SHINE TEST STRIPS MM
GLUCOCARD VITAL KIT
GLUCOCARD VITAL SENSOR STRIPS MM
GLUCOCOM BLOOD GLUCOSE KIT
GLUCOCOM CONTROL HIGH SOLUTION
GLUCOCOM CONTROL NORMAL SOLUTION
GLUCOCOM GLUCOSE STRIPS MM
GLUCOCOM LANCETS 30 GAUGE
GLUCOCOM LANCETS 33 GAUGE
GLUCOLAB CONTROL SOLN NORMAL
GLUCOLAB CONTROL SOLUTION HIGH
GLUCOLAB CONTROL SOLUTION LOW
GLUCOLAB METER KIT
GLUCOLAB TEST STRIPS MM
GLUCOLET 2 AUTOMATIC LANCING KIT
GLUCOLET 2 AUTOMATIC LANCING MISC
GLUCOPHAGE 1,000 MG TABLET MM
GLUCOPHAGE 500 MG TABLET MM
GLUCOPHAGE 850 MG TABLET MM
GLUCOPHAGE XR 500 MG TABLET,EXTENDED RELEASE MM
GLUCOPHAGE XR 750 MG TABLET,EXTENDED RELEASE MM
glucose 4 gram tablet chew
glucose bits 1 gram chewable tablet
GLUCOSE CONTROL SOLUTION
glucose gel 40 % oral gel
GLUCOSE KETONE CONTROL SOLN SOLUTION
glucose liquid
GLUCOSOURCE MISC
GLUCOTROL 10 MG TABLET MM
GLUCOTROL 5 MG TABLET MM
GLUCOTROL XL 10 MG TABLET,EXTENDED RELEASE MM
GLUCOTROL XL 2.5 MG TABLET,EXTENDED RELEASE MM
GLUCOTROL XL 5 MG TABLET,EXTENDED RELEASE MM
GLUCOVANCE 2.5 MG-500 MG TABLET MM
GLUCOVANCE 5 MG-500 MG TABLET MM
DRUG LEVEL
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
1
1
3
3
3
3
3
3
3
3
3
3
3
3
1
3
3
3
3
3
3
3
3
3
3
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
ST
QL,ST
ST
ST
ST
QL,ST
ST
ST
QL,ST
ST
QL,ST
ST
QL,ST
ST
QL,ST
ST
ST
ST
QL,ST
QL,ST
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 77
DRUG NAME
GLUMETZA 1,000 MG TABLET,EXTENDED RELEASE MM
GLUMETZA 500 MG TABLET,EXTENDED RELEASE MM
glutaraldehyde 25% aq solution
glutose 15 40 % oral gel
glutose 45 40 % oral gel
glyburid-metformin 1.25-250 mg MM
glyburide 1.25 mg tablet MM
glyburide 2.5 mg tablet MM
glyburide 5 mg tablet MM
glyburide micro 1.5 mg tab MM
glyburide micro 3 mg tablet MM
glyburide micro 6 mg tablet MM
glyburide-metformin 2.5-500 mg MM
glyburide-metformin 5-500 mg MM
GLYCATE 1.5 MG TABLET
glycine 1.5% irrigation
GLYCINE UROLOGIC 1.5 % IRRIGATION SOLUTION
glycopyrrolate 1 mg tablet
glycopyrrolate 2 mg tablet
glydo 2 % mucous membrane jelly in applicator
GLYNASE 1.5 MG TABLET MM
GLYNASE 3 MG TABLET MM
GLYNASE 6 MG TABLET MM
GLYSET 100 MG TABLET MM
GLYSET 25 MG TABLET MM
GLYSET 50 MG TABLET MM
GLYXAMBI 10 MG-5 MG TABLET
GLYXAMBI 25 MG-5 MG TABLET
GM100 KIT
GM100 STRIPS MM
GMATE CONTROL SOLUTION, HIGH
GMATE CONTROL SOLUTION, NORMAL
GMATE LANCETS 30 GAUGE
GMATE LANCING DEVICE
GMATE SMART METER MM
GMATE SMART STARTER KIT MM
GMATE TEST STRIPS MM
GMATE VOICE METER
GMATE VOICE STARTER KIT
GOLYTELY 227.1 G-21.5 G-6.36 G-5.53 G ORAL POWDER PACKET
GOLYTELY 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM ORAL SOLUTION
GORDONS UREA 22 % TOPICAL OINTMENT
GORDONS UREA 40 % TOPICAL OINTMENT
GRALISE 30-DAY STARTER PACK 300 MG (9)-600 MG (69) TABLET,EXT. RELEASE
GRALISE 300 MG TABLET,EXTENDED RELEASE
GRALISE 600 MG TABLET,EXTENDED RELEASE
granisetron hcl 1 mg tablet
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
78 - FORMULARY Updated 09/2015
DRUG LEVEL
4
4
3
3
3
1
1
1
1
1
1
1
1
1
3
1
3
2
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
2
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,ST
QL,ST
QL,PA
QL,PA
ST
QL,ST
ST
ST
QL,ST
ST
ST
QL,ST
QL,ST
QL,ST
QL
DRUG NAME
granisol 2 mg/10 ml solution
GRANIX 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE SP
GRANIX 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE SP
GRANULEX 0.12 MG-87 MG/GRAM TOPICAL SPRAY
green glo 1.5 mg strips
GRIFULVIN V 500 MG TABLET
GRIS-PEG (ULTRAMICROSIZE) 125 MG TABLET
GRIS-PEG (ULTRAMICROSIZE) 250 MG TABLET
griseofulvin 125 mg/5 ml susp
griseofulvin micro 500 mg tab
griseofulvin ultra 125 mg tab
griseofulvin ultra 250 mg tab
grx hicort 25 25 mg rectal suppository
GUAIACOL LIQUID PURIFIED
guanfacine 1 mg tablet MM
guanfacine 2 mg tablet MM
guanfacine hcl er 1 mg tablet MM
guanfacine hcl er 2 mg tablet MM
guanfacine hcl er 3 mg tablet MM
guanfacine hcl er 4 mg tablet MM
guanidine hcl 125 mg tablet
GUARDIAN REAL-TIME GLUCOSE MONITOR MM
gynazole-1 2 % vaginal cream
HALCION 0.25 MG TABLET
halobetasol prop 0.05% cream
halobetasol prop 0.05% ointmnt
HALOG 0.1 % TOPICAL CREAM
HALOG 0.1 % TOPICAL OINTMENT
halonate combo pack
halonate pac combo pack
haloperidol 0.5 mg tablet MM
haloperidol 1 mg tablet MM
haloperidol 10 mg tablet MM
haloperidol 2 mg tablet MM
haloperidol 20 mg tablet MM
haloperidol 5 mg tablet MM
haloperidol lac 2 mg/ml conc MM
HARVONI 90 MG-400 MG TABLET SP
HEALTHPRO GLUCOSE MONITOR
HEALTHPRO HIGH-LOW CONTROL SOLUTION
HEALTHPRO TEST STRIPS MM
HEALTHY ACCENTS AUTOLET IMPRESSION LANCING DEVICE
HEALTHY ACCENTS UNIFINE PENTIP 29 X 1/2" NEEDLE
HEALTHY ACCENTS UNIFINE PENTIP 31 GAUGE X 1/4" NEEDLE
HEALTHY ACCENTS UNIFINE PENTIP 31 X 3/16" NEEDLE
HEALTHY ACCENTS UNIFINE PENTIP 31 X 5/16" NEEDLE
HEALTHY ACCENTS UNIFINE PENTIP 32 X 5/32" NEEDLE
DRUG LEVEL
4
*
*
3
4
3
3
3
3
3
3
3
3
3
1
1
3
3
3
3
3
3
3
3
3
3
3
3
3
3
2
2
2
2
2
2
2
*
3
3
3
3
1
1
1
1
1
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL,PA
QL,PA
QL,ST
QL,ST
QL,ST
QL,ST
PA
QL
QL,PA
ST
QL,ST
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 79
DRUG NAME
HEALTHY ACCENTS UNILET LANCET 30 GAUGE
heather 0.35 mg tablet MM
hecoria 0.5 mg capsule
hecoria 1 mg capsule
hecoria 5 mg capsule
HECTOROL 0.5 MCG CAPSULE MM
HECTOROL 1 MCG CAPSULE MM
HECTOROL 2.5 MCG CAPSULE MM
HELIDAC THERAPY
HEMA-COMBISTIX STRIPS
HEMANGEOL 4.28 MG/ML ORAL SOLUTION
hematinic plus vit/minerals 106 mg iron-1 mg tablet
hematinic/folic acid 324 mg (106 mg iron)-1 mg tablet
HEMATOGEN 200 MG (66 MG)-10 MCG-250 MG CAPSULE
hematogen fa 200 mg-250 mg-0.01 mg-1 mg capsule
hematogen forte 460 mg-60 mg-0.01 mg-1 mg capsule
HEMATRON 50 MG IRON-1 MG/5 ML ORAL LIQUID
HEMATRON-AF 150 MG-1 MG-50 MG TABLET,EXTENDED RELEASE
hemax 150 mg-1 mg-50 mg tablet,extended release
hemenatal ob + dha 28 mg iron-6 mg iron-1 mg oral pack
hemenatal ob 28 mg-6 mg-1 mg tablet
hemetab 22 mg-6 mg-1 mg-25 mcg tablet
HEMOCYTE-F 324 MG (106 MG IRON)-1 MG TABLET
HEMOCYTE-PLUS 106 MG IRON-1 MG CAPSULE
hemril-30 30 mg suppository
HEPATAMINE 8% INTRAVENOUS SOLUTION
HEPATASOL 8% IV SOLUTION
HEPSERA 10 MG TABLET SP
HETLIOZ 20 MG CAPSULE SP
HEXALEN 50 MG CAPSULE SP
HIPREX 1 GRAM TABLET
HIZENTRA 1 GRAM/5 ML (20 %) SUBCUTANEOUS SOLUTION SP
HIZENTRA 10 GRAM/50 ML (20 %) SUBCUTANEOUS SOLUTION SP
HIZENTRA 2 GRAM/10 ML (20 %) SUBCUTANEOUS SOLUTION SP
HIZENTRA 4 GRAM/20 ML (20 %) SUBCUTANEOUS SOLUTION SP
homatropaire 5 % eye drops MM
homatropine 5% eye drops MM
HORIZANT ER 300 MG TABLET,EXTENDED RELEASE MM
HORIZANT ER 600 MG TABLET,EXTENDED RELEASE MM
hpr plus hydrogel topical kit,cream and gel
hpr plus topical cream
hpr plus topical foam
hpr plus-mb hydrogel 96.53 %-3 %-0.4 %-0.066 % topical pack,gel & foam
hpr topical foam
HUMALOG 100 UNIT/ML SUBCUTANEOUS CARTRIDGE MM
HUMALOG 100 UNIT/ML SUBCUTANEOUS SOLUTION MM
HUMALOG KWIKPEN 100 UNIT/ML SUBCUTANEOUS MM
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
80 - FORMULARY Updated 09/2015
DRUG LEVEL
1
1
3
3
3
4
4
4
4
3
3
1
1
2
1
2
2
3
1
2
3
2
3
3
3
3
3
*
*
*
3
*
*
*
*
2
2
3
3
3
3
3
3
3
2
2
2
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL,PA
QL
PA
PA
PA
PA
QL,PA
QL,PA
QL
QL
DRUG NAME
HUMALOG KWIKPEN 200 UNIT/ML (3 ML) SUBCUTANEOUS
HUMALOG MIX 50-50 100 UNIT/ML SUBCUTANEOUS SUSPENSION MM
HUMALOG MIX 50-50 KWIKPEN 100 UNIT/ML SUBCUTANEOUS PEN MM
HUMALOG MIX 75-25 100 UNIT/ML SUBCUTANEOUS SUSPENSION MM
HUMALOG MIX 75-25 KWIKPEN 100 UNIT/ML SUBCUTANEOUS INSULIN PEN MM
HUMAPEN LUXURA HD SUBCUTANEOUS
HUMATROPE 12 MG (36 UNIT) INJECTION CARTRIDGE SP
HUMATROPE 24 MG (72 UNIT) INJECTION CARTRIDGE SP
HUMATROPE 5 MG (15 UNIT) SOLUTION FOR INJECTION SP
HUMATROPE 6 MG (18 UNIT) INJECTION CARTRIDGE SP
HUMIRA 10 MG/0.2 ML SUBCUTANEOUS SYRINGE KIT SP
HUMIRA 20 MG/0.4 ML SUBCUTANEOUS SYRINGE KIT SP
HUMIRA 40 MG/0.8 ML SUBCUTANEOUS SYRINGE KIT SP
HUMIRA CROHN'S DISEASE STARTER PACK 40 MG/0.8 ML SUBCUTANEOUS PEN KIT
DRUG LEVEL
UTILIZATION
MANAGEMENT
REQUIREMENTS
2
2
2
2
2
3
*
*
*
*
*
*
*
*
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
*
QL,PA
*
*
2
2
2
2
2
2
2
2
QL,PA
QL,PA
*
*
3
3
1
1
1
1
3
3
3
1
1
1
1
3
QL
QL
QL
SP
HUMIRA PEDIATRIC CROHN'S START PCK 40 MG/0.8 ML SUBCUTANEOUS SYRIN KIT
SP
HUMIRA PEN 40 MG/0.8 ML SUBCUTANEOUS SP
HUMIRA PSORIASIS STARTER PACK 40 MG/0.8 ML SUBCUTANEOUS PEN KIT SP
HUMULIN 70-30 PEN MM
HUMULIN 70/30 100 UNIT/ML SUBCUTANEOUS SUSPENSION MM
HUMULIN 70/30 KWIKPEN 100 UNIT/ML (70-30) SUBCUTANEOUS MM
HUMULIN N 100 UNIT/ML SUBCUTANEOUS SUSPENSION MM
HUMULIN N 100 UNITS/ML PEN MM
HUMULIN N KWIKPEN 100 UNIT/ML (3 ML) SUBCUTANEOUS MM
HUMULIN R 100 UNIT/ML INJECTION SOLUTION MM
HUMULIN R U-500 "CONCENTRATED" INSULIN 500 UNIT/ML SUBCUTANEOUS
SOLN MM
HYCAMTIN 0.25 MG CAPSULE SP
HYCAMTIN 1 MG CAPSULE SP
HYCET 7.5 MG-325 MG/15 ML ORAL SOLUTION
HYCOFENIX 2.5 MG-30 MG-200 MG/5 ML ORAL SOLUTION
hydralazine 10 mg tablet MM
hydralazine 100 mg tablet MM
hydralazine 25 mg tablet MM
hydralazine 50 mg tablet MM
HYDREA 500 MG CAPSULE MM
HYDRO 35 35 % TOPICAL FOAM
HYDRO 40 40 % TOPICAL FOAM
hydrochlorothiazide 12.5 mg cp MM
hydrochlorothiazide 12.5 mg tb MM
hydrochlorothiazide 25 mg tab MM
hydrochlorothiazide 50 mg tab MM
hydrocod-cpm-pseudoep 5-4-60/5
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 81
DRUG NAME
hydrocod-homatrop 5-1.5 mg tab
hydrocodon-acetamin 7.5-325/15
hydrocodon-acetamin 7.5-500/15
hydrocodon-acetamin 7.5-500/15
hydrocodon-acetaminoph 2.5-325
hydrocodon-acetaminoph 2.5-500
hydrocodon-acetaminoph 7.5-300
hydrocodon-acetaminoph 7.5-325
hydrocodon-acetaminoph 7.5-500
hydrocodon-acetaminoph 7.5-650
hydrocodon-acetaminoph 7.5-750
hydrocodon-acetaminophen 5-300
hydrocodon-acetaminophen 5-325
hydrocodon-acetaminophen 5-500
hydrocodon-acetaminophn 10-300
hydrocodon-acetaminophn 10-325
hydrocodon-acetaminophn 10-500
hydrocodon-acetaminophn 10-650
hydrocodon-acetaminophn 10-660
hydrocodon-acetaminophn 10-750
hydrocodone-acetamin 10-325/15
hydrocodone-acetamin 2.5-167/5
hydrocodone-acetamin 5-163/7.5
hydrocodone-acetamin 5-334/10
hydrocodone-chlorphen er susp
hydrocodone-homatropine syrup
hydrocodone-homatropine syrup
hydrocodone-ibuprofen 10-200
hydrocodone-ibuprofen 2.5-200
hydrocodone-ibuprofen 5-200 mg
hydrocodone-ibuprofen 7.5-200
hydrocort buty 0.1% lipo cream
hydrocort-iodoquinol-aloe sach
hydrocort-pram 2.5%-1% crm kit
hydrocort-pram 2.5%-1% crm kit
hydrocort-pramoxine 1%-1% crm
hydrocort-pramoxine 2.5%-1% cm
hydrocort-pramoxine 2.5-1% crm
hydrocortison-acetic acid soln
hydrocortisone 0.1% soln
hydrocortisone 1% absorbase
hydrocortisone 1% cream
hydrocortisone 1% ointment
hydrocortisone 10 mg tablet MM
hydrocortisone 100 mg/60 ml
hydrocortisone 2.5% cream
hydrocortisone 2.5% lotion
hydrocortisone 2.5% ointment
hydrocortisone 20 mg tablet MM
hydrocortisone 30 mg supp
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
82 - FORMULARY Updated 09/2015
DRUG LEVEL
3
3
3
3
2
2
3
2
2
2
2
3
2
2
3
2
2
2
2
2
2
3
2
3
3
3
3
2
2
2
2
3
3
3
3
3
3
3
3
3
1
1
1
2
3
1
2
1
2
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
DRUG NAME
hydrocortisone 5 mg tablet MM
hydrocortisone ac 25 mg supp
hydrocortisone acetate 2% gel
hydrocortisone buty 0.1% cream
hydrocortisone butyr 0.1% oint
hydrocortisone val 0.2% cream
hydrocortisone val 0.2% ointmt
hydrocortisone-iodoquinol crm
hydrocortisone-pramoxine cream
hydromet 5 mg-1.5 mg/5 ml syrup
hydromorphone 1 mg/ml solution
hydromorphone 2 mg tablet
hydromorphone 3 mg suppos
hydromorphone 4 mg tablet
hydromorphone 8 mg tablet
hydromorphone hcl er 12 mg tab
hydromorphone hcl er 16 mg tab
hydromorphone hcl er 32 mg tab
hydromorphone hcl er 8 mg tab
hydroxocobalamin 1,000 mcg/ml
hydroxychloroquine 200 mg tab MM
hydroxyurea 500 mg capsule MM
hydroxyzine 10 mg/5 ml soln
hydroxyzine hcl 10 mg tablet
hydroxyzine hcl 25 mg tablet
hydroxyzine hcl 50 mg tablet
hydroxyzine pam 100 mg cap
hydroxyzine pam 25 mg cap
hydroxyzine pam 50 mg cap
HYLATOPIC PLUS TOPICAL CREAM
HYLATOPIC PLUS TOPICAL FOAM
HYLATOPIC TOPICAL FOAM
hyolev mb 81 mg-10.8 mg-40.8 mg tablet
hyomax-sl 0.125 mg tablet sl MM
hyophen 81.6 mg-0.12 mg-10.8 mg tablet
hyoscyamine 0.125 mg odt MM
hyoscyamine 0.125 mg tab sl MM
hyoscyamine 0.125 mg/5 ml elix MM
hyoscyamine 0.125 mg/ml drop MM
hyoscyamine er 0.375 mg tab MM
hyoscyamine sulf 0.125 mg tab MM
hyosyne 0.125 mg/5 ml oral elixir MM
hyosyne 0.125 mg/ml oral drops MM
HYPER-SAL 3.5 % SOLUTION FOR NEBULIZATION
HYPER-SAL 7 % SOLUTION FOR NEBULIZATION
hypercare 20% solution
HYPERTENSA 14 MG-47 MG CAPSULE
HYPOLANCE AST LANCING KIT
DRUG LEVEL
2
3
3
3
3
3
3
3
3
3
3
2
2
2
2
4
4
4
4
2
1
2
1
1
1
1
1
1
1
3
3
3
3
2
3
2
2
2
2
3
2
2
2
3
3
1
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
QL
QL,ST
QL,ST
QL,ST
QL,ST
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 83
DRUG NAME
HYQVIA 10 GRAM/100 ML (10 %) SUBCUTANEOUS SOLUTION SP
HYQVIA 2.5 GRAM/25 ML (10 %) SUBCUTANEOUS SOLUTION SP
HYQVIA 20 GRAM/200 ML (10 %) SUBCUTANEOUS SOLUTION SP
HYQVIA 30 GRAM/300 ML (10 %) SUBCUTANEOUS SOLUTION SP
HYQVIA 5 GRAM/50 ML (10 %) SUBCUTANEOUS SOLUTION SP
HYSINGLA ER 100 MG TABLET, CRUSH RESISTANT, EXTENDED RELEASE
HYSINGLA ER 120 MG TABLET, CRUSH RESISTANT, EXTENDED RELEASE
HYSINGLA ER 20 MG TABLET, CRUSH RESISTANT, EXTENDED RELEASE
HYSINGLA ER 30 MG TABLET, CRUSH RESISTANT, EXTENDED RELEASE
HYSINGLA ER 40 MG TABLET, CRUSH RESISTANT, EXTENDED RELEASE
HYSINGLA ER 60 MG TABLET, CRUSH RESISTANT, EXTENDED RELEASE
HYSINGLA ER 80 MG TABLET, CRUSH RESISTANT, EXTENDED RELEASE
HYZAAR 100 MG-12.5 MG TABLET MM
HYZAAR 100 MG-25 MG TABLET MM
HYZAAR 50 MG-12.5 MG TABLET MM
ibandronate sodium 150 mg tab MM
IBG-STAR BLOOD GLUCOSE SYSTEM
IBRANCE 100 MG CAPSULE SP
IBRANCE 125 MG CAPSULE SP
IBRANCE 75 MG CAPSULE SP
IBUDONE 10 MG-200 MG TABLET
ibudone 5 mg-200 mg tablet
ibuprofen 100 mg/5 ml susp MM
ibuprofen 400 mg tablet MM
ibuprofen 600 mg tablet MM
ibuprofen 800 mg tablet MM
ICAR-C PLUS 100 MG-250 MG-25 MCG-1 MG TABLET
ICLUSIG 15 MG TABLET SP
ICLUSIG 45 MG TABLET SP
ICTOTEST TABLET,NON-ORAL
iferex 150 forte 150 mg-25 mcg-1 mg capsule
ILEVRO 0.3 % EYE DROPS,SUSPENSION
ILOTYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT
IMBRUVICA 140 MG CAPSULE SP
IMDUR ER 120 MG TABLET MM
IMDUR ER 30 MG TABLET MM
IMDUR ER 60 MG TABLET MM
imipramine hcl 10 mg tablet MM
imipramine hcl 25 mg tablet MM
imipramine hcl 50 mg tablet MM
imipramine pamoate 100 mg cap MM
imipramine pamoate 125 mg cap MM
imipramine pamoate 150 mg cap MM
imipramine pamoate 75 mg cap MM
imiquimod 5% cream packet
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
84 - FORMULARY Updated 09/2015
DRUG LEVEL
*
*
*
*
*
4
4
4
4
4
4
4
3
3
3
2
3
*
*
*
3
2
1
1
1
1
2
*
*
3
1
2
2
*
3
3
3
1
1
1
3
3
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
PA
PA
PA
PA
PA
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL
ST
QL,PA
QL,PA
QL,PA
QL
QL
QL,PA
QL,PA
QL,PA
QL
DRUG NAME
IMITREX 100 MG TABLET
IMITREX 20 MG/ACTUATION NASAL SPRAY
IMITREX 25 MG TABLET
IMITREX 5 MG/ACTUATION NASAL SPRAY
IMITREX 50 MG TABLET
IMITREX 6 MG/0.5 ML SUBCUTANEOUS SOLUTION
IMITREX STATDOSE KIT REFILL 4 MG/0.5 ML SUBCUTANEOUS CARTRIDGE
IMITREX STATDOSE KIT REFILL 6 MG/0.5 ML SUBCUTANEOUS CARTRIDGE
IMITREX STATDOSE PEN 4 MG/0.5 ML SUBCUTANEOUS PEN INJECTOR
IMITREX STATDOSE PEN 6 MG/0.5 ML SUBCUTANEOUS PEN INJECTOR
IMPLANON 68 MG IMPLANT SP
IMURAN 50 MG TABLET
IN CONTROL PEN NEEDLE 29 GAUGE X 1/2"
IN CONTROL PEN NEEDLE 31 GAUGE X 1/4"
IN CONTROL PEN NEEDLE 31 X 5/16"
inatal advance 90 mg-1 mg-50 mg tablet
inatal ultra 90 mg-1 mg-50 mg tablet
INCIVEK 375 MG TABLET SP
INCONTROL 32 X 5/32" NEEDLE
INCONTROL LANCING DEVICE
INCONTROL PEN NEEDLES 31 X 3/16"
INCONTROL SUPER THIN LANCETS 30 GAUGE
INCONTROL ULTRA THIN LANCETS 28 GAUGE
INCRELEX 10 MG/ML SUBCUTANEOUS SOLUTION SP
INCRUSE ELLIPTA 62.5 MCG/ACTUATION POWDER FOR INHALATION
indapamide 1.25 mg tablet MM
indapamide 2.5 mg tablet MM
INDERAL LA 120 MG CAPSULE,EXTENDED RELEASE MM
INDERAL LA 160 MG CAPSULE,EXTENDED RELEASE MM
INDERAL LA 60 MG CAPSULE,EXTENDED RELEASE MM
INDERAL LA 80 MG CAPSULE,EXTENDED RELEASE MM
INDERAL XL 120 MG CAPSULE,EXTENDED RELEASE MM
INDERAL XL 80 MG CAPSULE,EXTENDED RELEASE MM
INDICLOR 5 MCI/0.5 ML (185 MBQ) SOLUTION
INDOCIN 25 MG/5 ML ORAL SUSPENSION
INDOCIN 50 MG RECTAL SUPPOSITORY
indomethacin 25 mg capsule
indomethacin 50 mg capsule
indomethacin er 75 mg capsule
INFANATE BALANCE 29 MG IRON-1 MG-50 MG-265 MG CAPSULE
infanate plus softgel
INFASURF 35 MG/ML INTRATRACHEAL SUSPENSION
INFERGEN 15 MCG/0.5 ML VIAL SP
INFERGEN 9 MCG/0.3 ML VIAL SP
INFINITY CONTROL SOLUTION HIGH
INFINITY CONTROL SOLUTION LOW
INFINITY CONTROL SOLUTION NORMAL
INFINITY METER KIT
DRUG LEVEL
3
3
3
3
3
3
4
4
4
4
*
3
1
1
1
3
3
*
1
1
1
1
1
*
3
1
1
4
4
4
4
3
3
3
3
4
2
2
3
3
3
3
*
*
3
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL
QL
QL
QL
QL
QL
QL,PA
QL
QL
QL
ST
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 85
DRUG NAME
INFINITY STARTER KIT
INFINITY TEST STRIPS MM
INFLUDO LIQUID
INJECT EASE LANCETS 28 GAUGE
INJECT EASE LANCETS 30 GAUGE
INLYTA 1 MG TABLET SP
INLYTA 5 MG TABLET SP
INNOPRAN XL 120 MG CAPSULE,EXTENDED RELEASE MM
INNOPRAN XL 80 MG CAPSULE,EXTENDED RELEASE MM
INOVA 4 %-5 % TOPICAL COMBO PACK
INOVA 4-1 1 %-4 %-5 % TOPICAL COMBO PACK
INOVA 8 %-5 % TOPICAL COMBO PACK
INOVA 8-2 2 %-8 %-5 % TOPICAL COMBO PACK
INSPIRACHAMBER SPACER
INSPIRACHAMBER WITH MASK-MED
INSPIRACHAMBER WITH MASK-SMALL
INSPRA 25 MG TABLET MM
INSPRA 50 MG TABLET MM
INSTA-GLUCOSE 24 GRAM/31 GRAM ORAL GEL
INSULIN 1 ML SYRINGE MM
INSULIN 1/2 ML SYRINGE MM
INSULIN 3/10 ML SYRINGE MM
INSULIN PEN NEEDLE 29 GAUGE X 1/2"
INSULIN PEN NEEDLE 31
INSULIN PEN NEEDLE 31 GAUGE X 1/4"
INSULIN SYRIN 0.3 ML 30GX1/2" MM
INSULIN SYRIN 0.3 ML 31GX5/16" MM
INSULIN SYRIN 0.5 ML 30GX1/2" MM
INSULIN SYRIN 0.5 ML 31GX5/16" MM
INSULIN SYRINGE 1 ML 28 X 1/2" MM
INSULIN SYRINGE 1 ML 29 X 1/2" MM
INSULIN SYRINGE 1 ML 30 X 5/16" MM
INSULIN SYRINGE 1 ML 30GX1/2" MM
INSULIN SYRINGE 1 ML 31GX5/16" MM
INSULIN SYRINGE 1/2 ML 28 X 1/2" MM
INSULIN SYRINGE 1/2 ML 29 X 1/2" MM
INSULIN SYRINGE 1/2 ML 30 X 5/16" MM
INSULIN SYRINGE MICROFINE 0.3 ML 28 X 1/2" MM
INSULIN SYRINGE MICROFINE 1 ML 27 X 5/8" MM
INSULIN SYRINGE MICROFINE 1/2 ML 28 X 1/2" MM
INSULIN SYRINGE U100 1 ML MM
INSULIN SYRINGE ULTRAFINE 1/2 ML 29 X 1/2" MM
INSUPEN 29 GAUGE X 1/2" NEEDLE
INSUPEN 30 X 5/16" NEEDLE
INSUPEN 31 GAUGE X 1/4" NEEDLE
INSUPEN 31 X 5/16" NEEDLE
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
86 - FORMULARY Updated 09/2015
DRUG LEVEL
3
3
3
1
1
*
*
4
4
3
3
3
3
3
3
3
3
3
3
2
2
2
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
1
1
1
UTILIZATION
MANAGEMENT
REQUIREMENTS
ST
QL,ST
QL,PA
QL,PA
DRUG NAME
INSUPEN 32 X 1/4" NEEDLE
INSUPEN 32 X 5/16" NEEDLE
INSUPEN 32 X 5/32" NEEDLE
INSUPEN 33 GAUGE X 5/32" NEEDLE
INTEGRA F 125 MG-1 MG-40 MG-3 MG CAPSULE
INTEGRA PLUS 125 MG-1 MG CAPSULE
INTEGRA SYRINGE 3 ML 21 X 1"
INTELENCE 100 MG TABLET SP
INTELENCE 200 MG TABLET SP
INTELENCE 25 MG TABLET SP
INTERLINK SYRINGE AND CANNULA 15 X 10 ML
INTERMEZZO 1.75 MG SUBLINGUAL TABLET
INTERMEZZO 3.5 MG SUBLINGUAL TABLET
INTRON A 10 MILLION UNIT (1 ML) SOLUTION FOR INJECTION SP
INTRON A 10 MILLION UNIT/ML INJECTION SOLUTION SP
INTRON A 18 MILLION UNIT (1 ML) SOLUTION FOR INJECTION SP
INTRON A 50 MILLION UNIT (1 ML) SOLUTION FOR INJECTION SP
INTRON A 6 MILLION UNIT/ML INJECTION SOLUTION SP
introvale 0.15 mg-30 mcg tablets,3 month dose pack
INTUNIV ER 1 MG TABLET,EXTENDED RELEASE MM
INTUNIV ER 2 MG TABLET,EXTENDED RELEASE MM
INTUNIV ER 3 MG TABLET,EXTENDED RELEASE MM
INTUNIV ER 4 MG TABLET,EXTENDED RELEASE MM
INVACARE LANCETS 30 GAUGE
INVEGA 1.5 MG TABLET,EXTENDED RELEASE MM
INVEGA 3 MG TABLET,EXTENDED RELEASE MM
INVEGA 6 MG TABLET,EXTENDED RELEASE MM
INVEGA 9 MG TABLET,EXTENDED RELEASE MM
INVIRASE 200 MG CAPSULE SP
INVIRASE 500 MG TABLET SP
INVOKAMET 150 MG-1,000 MG TABLET
INVOKAMET 150 MG-500 MG TABLET
INVOKAMET 50 MG-1,000 MG TABLET
INVOKAMET 50 MG-500 MG TABLET
INVOKANA 100 MG TABLET MM
INVOKANA 300 MG TABLET MM
IODOFLEX 0.9 % TOPICAL PADS
IODOSORB 0.9 % TOPICAL GEL
IONSYS 40 MCG/ACTIVATION TRANSDERMAL PCA SYSTEM SP
IOPIDINE 0.5 % EYE DROPS
IOPIDINE 1 % EYE DROPS IN A DROPPERETTE
iprat-albut 0.5-3(2.5) mg/3 ml MM
ipratropium 0.03% spray MM
ipratropium 0.06% spray MM
ipratropium br 0.02% soln MM
irbesartan 150 mg tablet MM
DRUG LEVEL
1
1
1
1
2
2
1
*
*
*
1
3
3
*
*
*
*
*
2
3
3
3
3
1
4
4
4
4
*
*
2
2
2
2
2
2
3
3
*
3
3
2
1
1
1
1
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL,ST
QL,ST
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL
QL,ST
QL,ST
QL,ST
QL,ST
QL,PA
QL,PA
QL,PA
QL,PA
QL
QL
QL
QL
QL
QL
QL
QL
PA
QL
QL
QL
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 87
DRUG NAME
irbesartan 300 mg tablet MM
irbesartan 75 mg tablet MM
irbesartan-hctz 150-12.5 mg tb MM
irbesartan-hctz 300-12.5 mg tb MM
IRENKA 40 MG CAPSULE,DELAYED RELEASE
IRESSA 250 MG TABLET SP
iron ag-ps-asc-b12-fa-thre-suc
IROSPAN 24/6 65 MG-65 MG-1,000 MCG (24) TABLET
ISENTRESS 100 MG CHEWABLE TABLET SP
ISENTRESS 100 MG ORAL POWDER PACKET MM,SP
ISENTRESS 25 MG CHEWABLE TABLET SP
ISENTRESS 400 MG TABLET SP
isochron 40 mg tablet,extended release MM
isoflurane liquid
isomethept-caff-acetaminoph tb
isomethept-caff-acetaminophen
isomethept-dichloralp-acetamin
isoniazid 100 mg tablet MM
isoniazid 300 mg tablet MM
isoniazid 50 mg/5 ml solution MM
ISOPTO ATROPINE 1 % EYE DROPS MM
ISOPTO CARBACHOL 3% DROPS MM
ISOPTO CARPINE 1 % EYE DROPS MM
ISOPTO CARPINE 2 % EYE DROPS MM
ISOPTO CARPINE 4 % EYE DROPS MM
ISOPTO HOMATROPINE 2% DROPS MM
ISOPTO HOMATROPINE 5% DROPS MM
ISOPTO HYOSCINE 0.25% DROPS MM
ISORDIL 40 MG TABLET MM
ISORDIL TITRADOSE 5 MG TABLET MM
isosorbide dn 10 mg tablet MM
isosorbide dn 2.5 mg tab sl MM
isosorbide dn 20 mg tablet MM
isosorbide dn 30 mg tablet MM
isosorbide dn 5 mg tablet MM
isosorbide dn 5 mg tablet sl MM
isosorbide dn er 40 mg tablet MM
isosorbide mn 10 mg tablet MM
isosorbide mn 20 mg tablet MM
isosorbide mn er 120 mg tab MM
isosorbide mn er 30 mg tablet MM
isosorbide mn er 60 mg tablet MM
isoxsuprine 10 mg tablet MM
isoxsuprine 20 mg tablet MM
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
88 - FORMULARY Updated 09/2015
DRUG LEVEL
1
1
1
1
3
*
2
2
*
4
*
*
2
3
3
3
3
1
1
3
3
3
2
2
2
3
3
2
3
3
2
1
2
2
2
1
3
1
1
1
1
1
2
2
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
QL
QL,PA
QL
QL
QL
QL
QL
DRUG NAME
isradipine 2.5 mg capsule MM
isradipine 5 mg capsule MM
ISTALOL 0.5 % EYE DROPS MM
itraconazole 100 mg capsule
IV PREP WIPES MEDICATED
ivermectin 3 mg tablet
J-COF DHC LIQUID
J-MAX DHC LIQUID
JADENU 180 MG TABLET SP
JADENU 360 MG TABLET SP
JADENU 90 MG TABLET SP
JAKAFI 10 MG TABLET SP
JAKAFI 15 MG TABLET SP
JAKAFI 20 MG TABLET SP
JAKAFI 25 MG TABLET SP
JAKAFI 5 MG TABLET SP
JALYN 0.5 MG-0.4 MG CAPSULE, EXTENDED RELEASE MM
jantoven 1 mg tablet MM
jantoven 10 mg tablet MM
jantoven 2 mg tablet MM
jantoven 2.5 mg tablet MM
jantoven 3 mg tablet MM
jantoven 4 mg tablet MM
jantoven 5 mg tablet MM
jantoven 6 mg tablet MM
jantoven 7.5 mg tablet MM
JANUMET 50 MG-1,000 MG TABLET MM
JANUMET 50 MG-500 MG TABLET MM
JANUMET XR 100 MG-1,000 MG TABLET,EXTENDED RELEASE MM
JANUMET XR 50 MG-1,000 MG TABLET,EXTENDED RELEASE MM
JANUMET XR 50 MG-500 MG TABLET,EXTENDED RELEASE MM
JANUVIA 100 MG TABLET MM
JANUVIA 25 MG TABLET MM
JANUVIA 50 MG TABLET MM
JARDIANCE 10 MG TABLET
JARDIANCE 25 MG TABLET
jencycla 0.35 mg tablet MM
JENTADUETO 2.5 MG-1,000 MG TABLET MM
JENTADUETO 2.5 MG-500 MG TABLET MM
JENTADUETO 2.5 MG-850 MG TABLET MM
jinteli 1 mg-5 mcg tablet MM
jolessa 0.15 mg-30 mcg tablets,3 month dose pack
jolivette 0.35 mg tablet MM
junel 1.5/30 (21) 1.5 mg-30 mcg tablet MM
DRUG LEVEL
3
3
3
3
3
2
3
3
*
*
*
*
*
*
*
*
3
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
1
2
2
2
3
2
1
1
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,ST
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 89
DRUG NAME
junel 1/20 (21) 1 mg-20 mcg tablet MM
junel fe 1.5/30 (28) 1.5 mg-30 mcg (21)/75 mg (7) tablet MM
junel fe 1/20 (28) 1 mg-20 mcg (21)/75 mg (7) tablet MM
junel fe 24 1 mg-20 mcg (24)/75 mg (4) tablet MM
JUVISYNC 100-10 MG TABLET MM
JUVISYNC 100-20 MG TABLET MM
JUVISYNC 100-40 MG TABLET MM
JUVISYNC 50-10 MG TABLET MM
JUVISYNC 50-20 MG TABLET MM
JUVISYNC 50-40 MG TABLET MM
JUXTAPID 10 MG CAPSULE SP
JUXTAPID 20 MG CAPSULE SP
JUXTAPID 30 MG CAPSULE SP
JUXTAPID 40 MG CAPSULE SP
JUXTAPID 5 MG CAPSULE SP
JUXTAPID 60 MG CAPSULE SP
k-effervescent 25 meq tablet MM
K-PHOS NO 2 305 MG-700 MG TABLET
K-PHOS ORIGINAL 500 MG SOLUBLE TABLET
K-PHOS-NEUTRAL 250 MG TABLET
k-sol 20 meq/15 ml oral liquid MM
k-sol 40 meq/15 ml oral liquid MM
K-TAB 10 MEQ TABLET,EXTENDED RELEASE MM
K-TAB 20 MEQ TABLET,EXTENDED RELEASE MM
K-TAB 8 MEQ TABLET,EXTENDED RELEASE MM
KADIAN 10 MG CAPSULE,EXTENDED RELEASE
KADIAN 100 MG CAPSULE,EXTENDED RELEASE
KADIAN 20 MG CAPSULE,EXTENDED RELEASE
KADIAN 200 MG CAPSULE,EXTENDED RELEASE
KADIAN 30 MG CAPSULE,EXTENDED RELEASE
KADIAN 40 MG CAPSULE,EXTENDED RELEASE
KADIAN 50 MG CAPSULE,EXTENDED RELEASE
KADIAN 60 MG CAPSULE,EXTENDED RELEASE
KADIAN 80 MG CAPSULE,EXTENDED RELEASE
KADIAN ER 130 MG CAPSULE
KADIAN ER 150 MG CAPSULE
KADIAN ER 70 MG CAPSULE
KALETRA 100 MG-25 MG TABLET SP
KALETRA 200 MG-50 MG TABLET SP
KALETRA 400 MG-100 MG/5 ML ORAL SOLUTION SP
KALYDECO 150 MG TABLET SP
KALYDECO 50 MG ORAL GRANULES IN PACKET SP
KALYDECO 75 MG ORAL GRANULES IN PACKET SP
KAOCHLOR-EFF 20 MEQ TABLET MM
KAPVAY 0.1 MG TABLET,EXTENDED RELEASE MM
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
90 - FORMULARY Updated 09/2015
DRUG LEVEL
1
1
1
3
2
2
2
2
2
2
*
*
*
*
*
*
2
2
2
3
1
1
3
3
3
4
4
4
4
4
4
4
4
4
4
4
4
*
*
*
*
*
*
2
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
QL
QL
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL
QL
QL,PA
QL,PA
QL,PA
QL,ST
DRUG NAME
KAPVAY 0.1-0.2 MG DOSEPACK MM
KARBINAL ER 4 MG/5 ML ORAL SUSPENSION,EXTENDED RELEASE
kariva (28) 0.15 mg-0.02 mg (21)/0.01 mg (5) tablet MM
KAYEXALATE ORAL POWDER
KAZANO 12.5 MG-1,000 MG TABLET MM
KAZANO 12.5 MG-500 MG TABLET MM
KEFLEX 250 MG CAPSULE
KEFLEX 500 MG CAPSULE
KEFLEX 750 MG CAPSULE
kelnor 1/35 (28) 1 mg-35 mcg tablet MM
KENALOG 0.147 MG/GRAM TOPICAL AEROSOL
KEPPRA 1,000 MG TABLET MM
KEPPRA 100 MG/ML ORAL SOLUTION MM
KEPPRA 250 MG TABLET MM
KEPPRA 500 MG TABLET MM
KEPPRA 750 MG TABLET MM
KEPPRA XR 500 MG TABLET,EXTENDED RELEASE MM
KEPPRA XR 750 MG TABLET,EXTENDED RELEASE MM
KERAFOAM 30 % TOPICAL
KERAFOAM 42 % TOPICAL
KERALAC 47 % TOPICAL CREAM
KERALYT RX 6 % TOPICAL GEL
KERALYT SCALP COMPLETE 6 %-6 % KIT,SHAMPOO AND GEL
KETEK 300 MG TABLET
KETEK 400 MG TABLET
KETO-DIASTIX STRIPS MM
ketoconazole 2% cream
ketoconazole 2% foam
ketoconazole 2% shampoo
ketoconazole 200 mg tablet
ketodan 2% foam
KETODAN 2% FOAM KIT
KETONE CARE STRIPS MM
KETONE URINE TEST STRIPS MM
ketoprofen 50 mg capsule MM
ketoprofen 75 mg capsule MM
ketoprofen er 200 mg capsule MM
ketorolac 0.4% ophth solution
ketorolac 0.5% ophth solution
ketorolac 10 mg tablet
KETOSTIX STRIPS MM
KEYNOTE BLOOD GLUCOSE SYSTEM
KEYNOTE GLUCOSE TEST STRIPS MM
KEYNOTE PRO BLOOD GLUCOSE SYST
KHEDEZLA 100 MG TABLET,EXTENDED RELEASE MM
KHEDEZLA 50 MG TABLET,EXTENDED RELEASE MM
kimidess (28) 0.15 mg-0.02 mg (21)/0.01 mg (5) tablet MM
DRUG LEVEL
3
3
2
3
3
3
3
3
3
1
3
4
4
4
4
4
4
4
3
3
3
3
3
4
4
3
2
3
2
2
3
3
3
3
1
1
3
2
2
1
3
3
3
3
3
3
2
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,ST
QL
QL
ST
QL
QL
ST
QL,ST
ST
QL,ST
QL,ST
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 91
DRUG NAME
KINERET 100 MG/0.67 ML SUBCUTANEOUS SYRINGE SP
KINNEY BRAND LANCETS 23 GAUGE
kionex 15 gram/60 ml oral suspension
kionex oral powder
KITABIS PAK 300 MG/5 ML SOLUTION FOR NEBULIZATION SP
KLARON 10 % TOPICAL SUSPENSION
KLONOPIN 0.5 MG TABLET MM
KLONOPIN 1 MG TABLET MM
KLONOPIN 2 MG TABLET MM
KLOR-CON 10 MEQ TABLET,EXTENDED RELEASE MM
klor-con 20 meq oral packet MM
KLOR-CON 8 MEQ TABLET,EXTENDED RELEASE MM
klor-con m10 meq tablet,extended release MM
KLOR-CON M15 MEQ TABLET,EXTENDED RELEASE MM
klor-con m20 meq tablet,extended release MM
KLOR-CON/25 MEQ ORAL PACKET MM
klor-con/ef 25 meq effervescent tablet MM
KOMBIGLYZE XR 2.5 MG-1,000 MG TABLET,EXTENDED RELEASE MM
KOMBIGLYZE XR 5 MG-1,000 MG TABLET,EXTENDED RELEASE MM
KOMBIGLYZE XR 5 MG-500 MG TABLET,EXTENDED RELEASE MM
KORLYM 300 MG TABLET SP
KRISTALOSE 10 GRAM ORAL PACKET MM
KRISTALOSE 20 GRAM ORAL PACKET MM
kurvelo 0.15 mg-0.03 mg tablet MM
KUVAN 100 MG ORAL POWDER PACKET SP
KUVAN 100 MG SOLUBLE TABLET SP
KUVAN 500 MG ORAL POWDER PACKET SP
KYNAMRO 200 MG/ML SUBCUTANEOUS SYRINGE SP
l-cysteine 50 mg/ml vial
l-methyl-b6-b12 3 mg-35 mg-2 mg tablet
l-methyl-mc 6 mg-5 mg-50 mg-1 mg tablet
l-methyl-mc nac 600 mg-2 mg-6 mg tablet
l-methylfolate 15 mg tablet
l-methylfolate 7.5 mg tablet
l-methylfolate ca p-5-p me-cbl 3 mg-35 mg-2 mg-90.314 mg capsule
l-methylfolate calcium 15 mg
l-methylfolate calcium 7.5 mg
L-METHYLFOLATE FORMULA 15 MG-90.314 MG CAPSULE
L-METHYLFOLATE FORMULA 7.5 MG-90.314 MG CAPSULE
L-METHYLFOLATE FORTE 15 MG-90.314 MG CAPSULE
L-METHYLFOLATE FORTE 7.5 MG-90.314 MG CAPSULE
labetalol hcl 100 mg tablet MM
labetalol hcl 200 mg tablet MM
labetalol hcl 300 mg tablet MM
LABSTIX REAGENT STRIPS
LAC-HYDRIN 12% CREAM
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
92 - FORMULARY Updated 09/2015
DRUG LEVEL
*
1
2
3
*
3
3
3
3
2
2
2
1
1
1
2
2
3
3
3
*
3
3
1
*
*
*
*
2
2
3
3
3
3
3
3
3
3
3
3
3
2
2
2
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,PA
QL,PA
QL
QL
QL
QL,PA
PA
QL,PA
PA
QL,PA
DRUG NAME
LAC-HYDRIN 12% LOTION
LACRISERT 5 MG EYE INSERTS
lactated ringers irrigation
lactic acid 10% lotion
lactic acid e 10 % topical cream
lactulose 10 gm/15 ml solution MM
lactulose 10 gm/15 ml solution MM
lactulose 20 gm/30 ml solution MM
LAMICTAL 100 MG TABLET MM
LAMICTAL 150 MG TABLET MM
LAMICTAL 2 MG CHEWABLE DISPERSIBLE TABLET
LAMICTAL 200 MG TABLET MM
LAMICTAL 25 MG CHEWABLE DISPERSIBLE TABLET MM
LAMICTAL 25 MG TABLET MM
LAMICTAL 5 MG CHEWABLE DISPERSIBLE TABLET MM
LAMICTAL ODT 100 MG DISINTEGRATING TABLET MM
LAMICTAL ODT 200 MG DISINTEGRATING TABLET MM
LAMICTAL ODT 25 MG DISINTEGRATING TABLET MM
LAMICTAL ODT 50 MG DISINTEGRATING TABLET MM
LAMICTAL ODT STARTER (BLUE) 25 MG (21)-50 MG (7) TABLET,DISINTEGRATING
LAMICTAL ODT STARTER (GREEN) 50 MG (42)-100 MG (14) TABLET,DISINTEGRAT
LAMICTAL ODT STARTER(ORANGE) 25 MG(14)-50 MG(14)-100 MG(7) TAB,DISINT
LAMICTAL STARTER (BLUE) KIT 25 MG (35) TABLETS IN A DOSE PACK
LAMICTAL STARTER (GREEN) KIT 25 MG (84)-100 MG (14) TABLETS, DOSE PACK
LAMICTAL STARTER (ORANGE) KIT 25 MG (42)-100 MG (7) TABLETS, DOSE PACK
LAMICTAL XR 100 MG TABLET,EXTENDED RELEASE MM
LAMICTAL XR 200 MG TABLET,EXTENDED RELEASE MM
LAMICTAL XR 25 MG TABLET,EXTENDED RELEASE MM
LAMICTAL XR 250 MG TABLET,EXTENDED RELEASE MM
LAMICTAL XR 300 MG TABLET,EXTENDED RELEASE MM
LAMICTAL XR 50 MG TABLET,EXTENDED RELEASE MM
LAMICTAL XR STARTER (BLUE) 25 MG (21)-50 MG (7) TABLET,EXTEND RELEASE
LAMICTAL XR STARTER (GREEN) 50 MG(14)-100 MG(14)-200 MG(7) TAB,EXT.REL
LAMICTAL XR STARTER (ORANGE) 25 MG(14)-50 MG(14)-100 MG(7) TAB,EXT.REL
LAMISIL 125 MG ORAL GRANULES IN PACKET
LAMISIL 187.5 MG ORAL GRANULES IN PACKET
lamivudine 10 mg/ml oral soln
lamivudine 150 mg tablet
lamivudine 300 mg tablet
lamivudine hbv 100 mg tablet
lamivudine-zidovudine tablet
lamotrigine 100 mg tablet MM
lamotrigine 150 mg tablet MM
lamotrigine 200 mg tablet MM
lamotrigine 25 mg disper tab MM
lamotrigine 25 mg tablet MM
DRUG LEVEL
3
3
3
2
2
1
1
1
4
4
3
4
4
4
4
4
4
4
4
4
4
4
3
3
3
4
4
4
4
4
4
4
4
4
3
3
3
3
3
3
3
1
1
1
2
1
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
ST
ST
ST
ST
ST
ST
ST
QL
QL
QL
QL
QL
QL
QL
QL
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 93
DRUG NAME
lamotrigine 25 mg tb start kit
lamotrigine 5 mg disper tablet MM
lamotrigine er 100 mg tablet MM
lamotrigine er 200 mg tablet MM
lamotrigine er 25 mg tablet MM
lamotrigine er 250 mg tablet MM
lamotrigine er 300 mg tablet MM
lamotrigine er 50 mg tablet MM
lamotrigine odt 100 mg tablet MM
lamotrigine odt 200 mg tablet MM
lamotrigine odt 25 mg tablet MM
lamotrigine odt 50 mg tablet MM
LANCETS, SUPER THIN
LANCETS,THIN
LANCETS,THIN 23 GAUGE
LANCETS,THIN 28 GAUGE
LANCETS,ULTRA THIN 26 GAUGE
LANCING DEVICE WITH LANCETS
LANCING SYSTEM
LANOXIN 125 MCG TABLET MM
LANOXIN 187.5 MCG TABLET MM
LANOXIN 250 MCG TABLET MM
LANOXIN 62.5 MCG TABLET MM
lansoprazol-amoxicil-clarithro
lansoprazole dr 15 mg capsule MM
lansoprazole dr 30 mg capsule MM
LANTUS 100 UNIT/ML SUBCUTANEOUS SOLUTION MM
LANTUS SOLOSTAR 100 UNIT/ML (3 ML) SUBCUTANEOUS INSULIN PEN MM
LANZO LANCING DEVICE KIT
larin 1.5/30 (21) 1.5 mg-30 mcg tablet MM
larin 1/20 (21) 1 mg-20 mcg tablet MM
larin 24 fe 1 mg-20 mcg (24)/75 mg (4) tablet MM
larin fe 1 mg-20 mcg (21)/75 mg (7) tablet MM
larin fe 1.5 mg-30 mcg (21)/75 mg (7) tablet MM
LASIX 20 MG TABLET MM
LASIX 40 MG TABLET MM
LASIX 80 MG TABLET MM
LASTACAFT 0.25 % EYE DROPS
latanoprost 0.005% eye drops MM
latrix 50 % topical suspension
latrix xm 45% emulsion
LATUDA 120 MG TABLET MM
LATUDA 20 MG TABLET MM
LATUDA 40 MG TABLET MM
LATUDA 60 MG TABLET MM
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
94 - FORMULARY Updated 09/2015
DRUG LEVEL
3
2
3
3
3
3
3
3
4
4
4
4
1
1
1
1
1
1
1
2
3
2
3
3
2
2
2
2
1
2
1
3
1
1
3
3
3
3
1
2
3
4
4
4
4
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
ST
ST
ST
ST
QL
QL
QL
QL
QL
ST
QL
QL,PA
QL,PA
QL,PA
QL,PA
DRUG NAME
LATUDA 80 MG TABLET MM
LAYOLIS FE 0.8 MG-25 MCG (24)/75 MG (4) CHEWABLE TABLET MM
LAZANDA 100 MCG/SPRAY NASAL SPRAY
LAZANDA 400 MCG/SPRAY NASAL SPRAY
LEADER PEN NEEDLES 12MM 29G
LEADER PEN NEEDLES 31G
leena 28 0.5 mg/1 mg/0.5 mg-35 mcg tablet MM
leflunomide 10 mg tablet MM
leflunomide 20 mg tablet MM
LENVIMA 10 MG/DAY (10 MG Ý1¨/DAY) CAPSULE SP
LENVIMA 14 MG (10 MGÝ1¨-4 MGÝ1¨)/DAY CAPSULE SP
LENVIMA 20 MG/DAY (10 MG Ý2¨/DAY) CAPSULE SP
LENVIMA 24 MG (10 MGÝ2¨-4 MGÝ1¨)/DAY CAPSULE SP
LESCOL 20 MG CAPSULE MM
LESCOL 40 MG CAPSULE MM
LESCOL XL 80 MG TABLET,EXTENDED RELEASE MM
lessina 0.1 mg-20 mcg tablet MM
LETAIRIS 10 MG TABLET SP
LETAIRIS 5 MG TABLET SP
letrozole 2.5 mg tablet MM
leucovorin calcium 10 mg tab
leucovorin calcium 15 mg tab
leucovorin calcium 25 mg tab
leucovorin calcium 5 mg tab
LEUKERAN 2 MG TABLET
LEUKINE 250 MCG SOLUTION FOR INJECTION SP
LEUKINE 500 MCG/ML VIAL SP
leuprolide 2wk 1 mg/0.2 ml kit
LEVACET 500 MG-250 MG-150 MG-32.5 MG TABLET
levalbuterol 0.31 mg/3 ml sol MM
levalbuterol 0.63 mg/3 ml sol MM
levalbuterol 1.25 mg/3 ml sol MM
levalbuterol conc 1.25 mg/0.5 MM
LEVAQUIN 250 MG TABLET
LEVAQUIN 250 MG/10 ML ORAL SOLUTION
LEVAQUIN 500 MG TABLET
LEVAQUIN 750 MG TABLET
LEVATOL 20 MG TABLET MM
LEVBID 0.375 MG TABLET,EXTENDED RELEASE MM
LEVEMIR 100 UNIT/ML SUBCUTANEOUS SOLUTION MM
LEVEMIR FLEXPEN 100 UNITS/ML MM
LEVEMIR FLEXTOUCH 100 UNIT/ML (3 ML) SUBCUTANEOUS INSULIN PEN MM
levetiracetam 1,000 mg tablet MM
levetiracetam 100 mg/ml soln MM
levetiracetam 250 mg tablet MM
DRUG LEVEL
4
3
4
4
1
1
1
2
2
*
*
*
*
3
3
3
1
*
*
1
3
3
3
3
3
*
*
3
3
3
3
3
3
3
3
3
3
3
3
2
2
2
2
2
2
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,PA
QL,PA
QL,PA
QL
QL
QL,PA
QL,PA
QL,PA
QL,PA
QL,ST
QL,ST
QL,ST
QL,PA
QL,PA
QL
QL
QL,PA
QL,PA
QL,PA
QL
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 95
DRUG NAME
levetiracetam 500 mg tablet MM
levetiracetam 500 mg/5 ml soln MM
levetiracetam 750 mg tablet MM
levetiracetam er 500 mg tablet MM
levetiracetam er 750 mg tablet MM
levobunolol 0.25% eye drops MM
levobunolol 0.5% eye drops MM
levocarnitine 100 mg/ml soln MM
levocarnitine 330 mg tablet MM
levocetirizine 2.5 mg/5 ml sol MM
levocetirizine 5 mg tablet MM
levofloxacin 0.5% eye drops
levofloxacin 25 mg/ml solution
levofloxacin 250 mg tablet
levofloxacin 500 mg tablet
levofloxacin 750 mg tablet
levomefol-pyridoxal-mec-algal
levomefolate dha 27 mg-400 mcg-1.13 mg-250 mg capsule
levomefolate-algal 15 mg cap
levomefolate-algal 7.5 mg cap
levomefolate-nac-mecobal-algal
levonest (28) 50-30 (6)/75-40(5)/125-30(10) tablet MM
levono-e estrad 0.10-0.02-0.01 MM
levono-e estrad 0.15-0.03-0.01
levonor-eth estra 0.09-0.02 mg MM
levonor-eth estrad 0.1-0.02 mg MM
levonor-eth estrad 0.15-0.03 MM
levonor-eth estrad 0.15-0.03
levonorgestrel 0.75 mg tablet
levonorgestrel 1.5 mg tablet
levora-28 0.15 mg-0.03 mg tablet MM
levorphanol 2 mg tablet
levothyroxine 100 mcg tablet MM
levothyroxine 112 mcg tablet MM
levothyroxine 125 mcg tablet MM
levothyroxine 137 mcg tablet MM
levothyroxine 150 mcg tablet MM
levothyroxine 175 mcg tablet MM
levothyroxine 200 mcg tablet MM
levothyroxine 25 mcg tablet MM
levothyroxine 300 mcg tablet MM
levothyroxine 50 mcg tablet MM
levothyroxine 75 mcg tablet MM
levothyroxine 88 mcg tablet MM
LEVOXYL 100 MCG TABLET MM
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
96 - FORMULARY Updated 09/2015
DRUG LEVEL
2
2
2
2
2
1
1
3
3
3
3
3
3
2
2
2
3
3
3
3
3
1
2
3
2
1
1
1
2
2
1
3
1
1
1
1
1
1
1
1
1
1
1
1
1
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
QL
QL
DRUG NAME
LEVOXYL 112 MCG TABLET MM
LEVOXYL 125 MCG TABLET MM
LEVOXYL 137 MCG TABLET MM
LEVOXYL 150 MCG TABLET MM
LEVOXYL 175 MCG TABLET MM
LEVOXYL 200 MCG TABLET MM
LEVOXYL 25 MCG TABLET MM
LEVOXYL 50 MCG TABLET MM
LEVOXYL 75 MCG TABLET MM
LEVOXYL 88 MCG TABLET MM
LEVSIN 0.125 MG TABLET MM
LEVSIN/SL 0.125 MG SUBLINGUAL TABLET MM
LEVULAN 20 % TOPICAL SOLUTION
LEXAPRO 10 MG TABLET MM
LEXAPRO 20 MG TABLET MM
LEXAPRO 5 MG TABLET MM
LEXAPRO 5 MG/5 ML ORAL SOLUTION MM
LEXIVA 50 MG/ML ORAL SUSPENSION SP
LEXIVA 700 MG TABLET SP
LIALDA 1.2 GRAM TABLET,DELAYED RELEASE MM
LIBERTY BLOOD GLUCOSE MONITOR
LIBERTY LEVEL 1 GLUCOSE CONTROL LOW SOLUTION
LIBERTY LEVEL 2 GLUCOSE CONTROL NORMAL SOLUTION
LIBERTY TEST STRIPS MM
LIBRAX (WITH CLIDINIUM) 5 MG-2.5 MG CAPSULE
lidocaine 2% viscous soln
lidocaine 3% cream
lidocaine 5% ointment
lidocaine 5% patch
lidocaine hcl 2% jelly
lidocaine hcl 2% jelly
lidocaine hcl 3% lotion
lidocaine hcl 4% solution
lidocaine hcl 4% solution
lidocaine viscous 2 % mucosal solution
lidocaine-hc 2-2% cream kit
lidocaine-hc 2.8-0.55% gel
lidocaine-hc 3-0.5% cream
lidocaine-hc 3-0.5% cream kit
lidocaine-hc 3-0.5% cream kit
lidocaine-hc 3-1% cream
lidocaine-hc 3-1% cream kit
lidocaine-hc 3-2.5% gel kit
lidocaine-hydrocort 3-2.5% gel
lidocaine-prilocaine cream
lidocaine-prilocaine cream
lidocaine-tetracaine 7%-7% crm
DRUG LEVEL
1
1
1
1
1
1
1
1
1
1
3
3
4
3
3
3
3
*
*
2
1
3
3
1
4
1
3
3
3
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
2
2
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
QL
QL
QL
QL
QL,PA
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 97
DRUG NAME
LIDODERM 5 % (700 MG/PATCH) ADHESIVE PATCH
lidopin 3 % topical cream
LIDOPIN 3.25 % TOPICAL CREAM
LIDORX 3 % TOPICAL GEL WITH PUMP
LIDOVEX 3.75 % TOPICAL CREAM
LILETTA 18.6 MCG/24 HOUR (3 YEARS) INTRAUTERINE DEVICE SP
LIMBREL 250 MG CAPSULE
LIMBREL 500 MG CAPSULE
LIMBREL250 250 MG-50 MG CAPSULE
LIMBREL500 500 MG-50 MG CAPSULE
lindane 1% lotion
lindane 1% shampoo
linezolid 600 mg tablet
LINZESS 145 MCG CAPSULE MM
LINZESS 290 MCG CAPSULE MM
liothyronine sod 25 mcg tab MM
liothyronine sod 5 mcg tab MM
liothyronine sod 50 mcg tab MM
LIPICHOL 540 CAPSULE
LIPITOR 10 MG TABLET MM
LIPITOR 20 MG TABLET MM
LIPITOR 40 MG TABLET MM
LIPITOR 80 MG TABLET MM
LIPOCHOL PLUS 0.5 MG TABLET
LIPOFEN 150 MG CAPSULE MM
LIPOFEN 50 MG CAPSULE MM
LIPTRUZET 10 MG-10 MG TABLET MM
LIPTRUZET 10 MG-20 MG TABLET MM
LIPTRUZET 10 MG-40 MG TABLET MM
LIPTRUZET 10 MG-80 MG TABLET MM
liquid e-z paque 60 % (w/v) oral suspension
LIQUID POLIBAR PLUS 105 % (W/V), 58 % (W/W) ORAL SUSPENSION
LIQUID POLIBAR SUSPENSION
lisinopril 10 mg tablet MM
lisinopril 2.5 mg tablet MM
lisinopril 20 mg tablet MM
lisinopril 30 mg tablet MM
lisinopril 40 mg tablet MM
lisinopril 5 mg tablet MM
lisinopril-hctz 10-12.5 mg tab MM
lisinopril-hctz 20-12.5 mg tab MM
lisinopril-hctz 20-25 mg tab MM
LISTER-V 24 MG-21 MG CAPSULE
LITE TOUCH INSULIN PEN NEEDLES 29 GAUGE X 1/2"
LITE TOUCH INSULIN PEN NEEDLES 31 GAUGE X 1/4"
LITE TOUCH INSULIN PEN NEEDLES 31 X 3/16"
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
98 - FORMULARY Updated 09/2015
DRUG LEVEL
3
3
3
2
3
*
3
3
3
3
3
3
4
2
2
2
2
2
3
3
3
3
3
2
3
3
3
3
3
3
3
3
3
1
1
1
1
1
1
1
1
1
3
2
2
2
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,PA
QL
QL
QL
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
DRUG NAME
LITE TOUCH INSULIN PEN NEEDLES 31 X 5/16"
LITE TOUCH INSULIN SYRINGE 0.3 ML 29 X 1/2" MM
LITE TOUCH INSULIN SYRINGE 0.3 ML 30 X 5/16" MM
LITE TOUCH INSULIN SYRINGE 0.3 ML 31 X 5/16" MM
LITE TOUCH INSULIN SYRINGE 1 ML 28 MM
LITE TOUCH INSULIN SYRINGE 1 ML 29 MM
LITE TOUCH INSULIN SYRINGE 1 ML 30 GAUGE X 7/16" MM
LITE TOUCH INSULIN SYRINGE 1 ML 31 X 5/16" MM
LITE TOUCH INSULIN SYRINGE 1/2 ML 28 MM
LITE TOUCH INSULIN SYRINGE 1/2 ML 29 MM
LITE TOUCH INSULIN SYRINGE 1/2 ML 30 MM
LITE TOUCH INSULIN SYRINGE 1/2 ML 31 X 5/16" MM
LITE TOUCH LANCETS 30 GAUGE
LITE TOUCH LANCETS 33 GAUGE
LITE TOUCH LANCING DEVICE
LITE TOUCH-MEDIUM MASK
LITEAIRE MDI CHAMBER
LITETOUCH-LARGE MASK
LITETOUCH-SMALL MASK
lithium 8 meq/5 ml solution MM
lithium carbonate 150 mg cap MM
lithium carbonate 300 mg cap MM
lithium carbonate 300 mg tab MM
lithium carbonate 600 mg cap MM
lithium carbonate er 300 mg tb MM
lithium carbonate er 450 mg tb MM
LITHOBID 300 MG TABLET,EXTENDED RELEASE MM
LITHOSTAT 250 MG TABLET
LIVALO 1 MG TABLET MM
LIVALO 2 MG TABLET MM
LIVALO 4 MG TABLET MM
LIVIXIL PAK 2.5 %-2.5 % TOPICAL KIT
lmthf-pyridoxine-cyanocobalamin 2 mg-1.13 mg-25 mg tablet
LO LOESTRIN FE 1 MG-10 MCG (24)/10 MCG (2) TABLET MM
LO MINASTRIN FE TABLET CHEW MM
LOCOID 0.1 % LOTION
LOCOID 0.1 % TOPICAL CREAM
LOCOID 0.1 % TOPICAL OINTMENT
LOCOID 0.1 % TOPICAL SOLUTION
LOCOID LIPOCREAM 0.1 % TOPICAL
LODOSYN 25 MG TABLET MM
LOESTRIN 1.5/30 (21) 1.5 MG-30 MCG TABLET MM
LOESTRIN 1/20 (21) 1 MG-20 MCG TABLET MM
LOESTRIN 24 FE TABLET MM
LOESTRIN FE 1.5/30 (28-DAY) 1.5 MG-30 MCG (21)/75 MG (7) TABLET MM
DRUG LEVEL
2
2
2
2
2
2
2
2
2
2
2
2
1
1
3
1
1
1
1
1
1
1
1
1
1
1
3
2
3
3
3
4
3
2
3
4
4
4
4
3
4
3
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,ST
QL,ST
QL,ST
PA
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 99
DRUG NAME
LOESTRIN FE 1/20 (28-DAY) 1 MG-20 MCG (21)/75 MG (7) TABLET MM
lofibra 134 mg capsule MM
lofibra 160 mg tablet MM
lofibra 200 mg capsule MM
lofibra 54 mg tablet MM
lofibra 67 mg capsule MM
lomedia 24 fe 1 mg-20 mcg (24)/75 mg (4) tablet MM
LOMOTIL 2.5 MG-0.025 MG TABLET
LOMUSTINE 10 MG CAPSULE
LOMUSTINE 100 MG CAPSULE
LOMUSTINE 40 MG CAPSULE
loperamide 2 mg capsule MM
LOPID 600 MG TABLET MM
lopreeza 0.5 mg-0.1 mg tablet MM
lopreeza 1 mg-0.5 mg tablet MM
LOPRESSOR 100 MG TABLET MM
LOPRESSOR 50 MG TABLET MM
LOPRESSOR HCT 50 MG-25 MG TABLET MM
LOPROX 0.77% GEL
LOPROX 1 % SHAMPOO
lorazepam 0.5 mg tablet
lorazepam 1 mg tablet
lorazepam 2 mg tablet
lorazepam 2 mg/ml oral concent
lorazepam intensol 2 mg/ml oral concentrate
lorcet (hydrocodone) 5 mg-325 mg tablet
LORCET 10-650 TABLET
lorcet hd 10 mg-325 mg tablet
lorcet plus 7.5 mg-325 mg tablet
LORCET PLUS TABLET
lortab 10 mg-325 mg tablet
LORTAB 10-500 TABLET
lortab 5 mg-325 mg tablet
lortab 5-500 tablet
lortab 7.5 mg-325 mg tablet
LORTAB 7.5-500 MG/15 ML ELIXIR
LORTAB 7.5-500 TABLET
lortab elixir 10 mg-300 mg/15 ml oral solution
loryna (28) 3 mg-20 mcg tablet MM
LORZONE 375 MG TABLET
LORZONE 750 MG TABLET
losartan potassium 100 mg tab MM
losartan potassium 25 mg tab MM
losartan potassium 50 mg tab MM
losartan-hctz 100-12.5 mg tab MM
losartan-hctz 100-25 mg tab MM
losartan-hctz 50-12.5 mg tab MM
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
100 - FORMULARY Updated 09/2015
DRUG LEVEL
3
3
3
3
3
3
2
3
3
3
3
2
3
3
3
3
3
3
3
4
1
1
1
1
1
3
3
3
3
3
3
3
3
3
3
3
3
3
2
3
3
1
1
1
1
1
1
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL,ST
QL,ST
QL
QL
QL
QL
QL
QL
DRUG NAME
LOSEASONIQUE 0.10 MG-20 MCG (84)/10 MCG(7) TABLETS,3 MONTH DOSE PACK
DRUG LEVEL
UTILIZATION
MANAGEMENT
REQUIREMENTS
3
QL
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
4
4
3
1
1
1
3
4
4
4
4
4
4
4
4
1
2
2
2
2
3
3
3
3
3
3
2
3
3
ST
ST
ST
MM
LOTEMAX 0.5 % EYE DROPS,SUSPENSION
LOTEMAX 0.5 % EYE GEL DROPS
LOTEMAX 0.5 % EYE OINTMENT
LOTENSIN 20 MG TABLET MM
LOTENSIN 40 MG TABLET MM
LOTENSIN HCT 10 MG-12.5 MG TABLET MM
LOTENSIN HCT 20 MG-12.5 MG TABLET MM
LOTENSIN HCT 20 MG-25 MG TABLET MM
LOTREL 10 MG-20 MG CAPSULE MM
LOTREL 10 MG-40 MG CAPSULE MM
LOTREL 2.5 MG-10 MG CAPSULE MM
LOTREL 5 MG-10 MG CAPSULE MM
LOTREL 5 MG-20 MG CAPSULE MM
LOTREL 5 MG-40 MG CAPSULE MM
LOTRISONE 1 %-0.05 % TOPICAL CREAM
LOTRONEX 0.5 MG TABLET MM
LOTRONEX 1 MG TABLET MM
LOUTREX TOPICAL CREAM
lovastatin 10 mg tablet MM
lovastatin 20 mg tablet MM
lovastatin 40 mg tablet MM
LOVAZA 1 GRAM CAPSULE MM
LOVENOX 100 MG/ML SUBCUTANEOUS SYRINGE
LOVENOX 120 MG/0.8 ML SUBCUTANEOUS SYRINGE
LOVENOX 150 MG/ML SUBCUTANEOUS SYRINGE
LOVENOX 30 MG/0.3 ML SUBCUTANEOUS SYRINGE
LOVENOX 300 MG/3 ML SUBCUTANEOUS SOLUTION
LOVENOX 40 MG/0.4 ML SUBCUTANEOUS SYRINGE
LOVENOX 60 MG/0.6 ML SUBCUTANEOUS SYRINGE
LOVENOX 80 MG/0.8 ML SUBCUTANEOUS SYRINGE
low-ogestrel (28) 0.3 mg-30 mcg tablet MM
loxapine 10 mg capsule MM
loxapine 25 mg capsule MM
loxapine 5 mg capsule MM
loxapine 50 mg capsule MM
LOXITANE 5 MG CAPSULE MM
LTA PRE-ATTACHED 4 % LARYNGOTRACHEAL SOLUTION
LUFYLLIN 200 MG TABLET MM
LUFYLLIN-400 TABLET MM
lugols 5 % oral solution
lugols 5 %-10 % topical solution
LUMIGAN 0.01 % EYE DROPS MM
LUNESTA 1 MG TABLET
LUNESTA 2 MG TABLET
QL
QL
QL
QL
QL
QL
QL,PA
QL,PA
QL
QL
QL
QL,ST
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL,ST
QL,ST
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 101
DRUG NAME
LUNESTA 3 MG TABLET
LUNGLAID FOR ASTHMA EMULSION
LUPANETA PACK (1 MONTH) 3.75 MG-5 MG (30) KIT, IM SYRINGE, ORAL TABLET SP
LUPANETA PACK (3 MONTH) 11.25 MG-5 MG(90) KIT, IM SYRINGE, ORAL TABLET SP
lutera (28) 0.1 mg-20 mcg tablet MM
LUVOX CR 100 MG CAPSULE MM
LUVOX CR 150 MG CAPSULE MM
LUXIQ 0.12 % TOPICAL FOAM
LUZU 1 % TOPICAL CREAM
LYCELLE TOPICAL GEL
LYNPARZA 50 MG CAPSULE SP
LYRICA 100 MG CAPSULE MM
LYRICA 150 MG CAPSULE MM
LYRICA 20 MG/ML ORAL SOLUTION MM
LYRICA 200 MG CAPSULE MM
LYRICA 225 MG CAPSULE MM
LYRICA 25 MG CAPSULE MM
LYRICA 300 MG CAPSULE MM
LYRICA 50 MG CAPSULE MM
LYRICA 75 MG CAPSULE MM
LYSIPLEX PLUS TABLET
LYSODREN 500 MG TABLET SP
LYSTEDA 650 MG TABLET MM
lyza 0.35 mg tablet MM
M-VIT 27 MG-1 MG TABLET
macnatal cn dha 28 mg-1 mg-50 mg-250 mg capsule
MACROBID 100 MG CAPSULE
MACRODANTIN 100 MG CAPSULE
MACRODANTIN 25 MG CAPSULE
MACRODANTIN 50 MG CAPSULE
mafenide acetate 50 gm powd pk
MAGELLAN INSULIN SAFETY SYRINGE 0.3 ML 29 X 1/2" MM
MAGELLAN INSULIN SAFETY SYRINGE 0.5 ML 29 X 1/2" MM
MAGELLAN INSULIN SAFETY SYRINGE 1 ML 29 X 1/2" MM
MAGELLAN INSULIN SAFETY SYRINGE 1 ML 30 X 5/16" MM
MAGELLAN SYRINGE 0.3 ML 30 X 5/16" MM
MAGELLAN SYRINGE 0.5 ML 30 X 5/16" MM
MAGELLAN SYRINGE 1 ML 27 X 1/2"
MAGNACET 10 MG-400 MG TABLET
MAGNACET 5 MG-400 MG TABLET
MAGNACET 7.5 MG-400 MG TABLET
MAGNEBIND 400 400 MG-200 MG-1 MG TABLET
MALARONE 250 MG-100 MG TABLET
MALARONE PEDIATRIC 62.5 MG-25 MG TABLET
malathion 0.5% lotion
maprotiline 25 mg tablet MM
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
102 - FORMULARY Updated 09/2015
DRUG LEVEL
3
3
*
*
1
4
4
3
3
3
*
3
3
3
3
3
3
3
3
3
3
*
3
2
2
2
3
3
3
3
3
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,ST
QL,PA
QL,PA
QL
QL
QL,ST
QL,PA
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
DRUG NAME
maprotiline 50 mg tablet MM
maprotiline 75 mg tablet MM
MARGESIC 50 MG-325 MG-40 MG CAPSULE
MARINOL 10 MG CAPSULE
MARINOL 2.5 MG CAPSULE
MARINOL 5 MG CAPSULE
marlexate oral powder
marlissa 0.15 mg-0.03 mg tablet MM
MARNATAL-F 60 MG IRON-1 MG CAPSULE
MARPLAN 10 MG TABLET MM
MARTEN-TAB 50 MG-325 MG TABLET
MATRISTEM 10 CM X 15 CM TOPICAL SHEETS
MATRISTEM 3 CM X 3 1/2 CM TOPICAL SHEETS
MATRISTEM 3 CM X 7 CM TOPICAL SHEETS
MATRISTEM 7 CM X 10 CM TOPICAL SHEETS
MATRISTEM MICROMATRIX 100 MG TOPICAL POWDER
MATRISTEM MICROMATRIX 20 MG TOPICAL POWDER
MATRISTEM MICROMATRIX 200 MG TOPICAL POWDER
MATRISTEM MICROMATRIX 30 MG TOPICAL POWDER
MATRISTEM MICROMATRIX 60 MG TOPICAL POWDER
MATULANE 50 MG CAPSULE SP
matzim la 180 mg tablet,extended release MM
matzim la 240 mg tablet,extended release MM
matzim la 300 mg tablet,extended release MM
matzim la 360 mg tablet,extended release MM
matzim la 420 mg tablet,extended release MM
MAVIK 1 MG TABLET MM
MAVIK 2 MG TABLET MM
MAVIK 4 MG TABLET MM
MAXAIR AUTOHALER 0.2 MG AERO MM
MAXALT 10 MG TABLET
MAXALT 5 MG TABLET
MAXALT-MLT 10 MG DISINTEGRATING TABLET
MAXALT-MLT 5 MG DISINTEGRATING TABLET
MAXARON FORTE 150 MG IRON-200 MG-250 MCG TABLET
MAXFE 160 MG IRON-1 MG-60 MCG TABLET
MAXI-COMFORT INSULIN SYRINGE 1 ML 28 X 1/2" MM
MAXI-COMFORT INSULIN SYRINGE 1/2 ML 28 X 1/2" MM
maxibar 210% susp
MAXIDEX 0.1 % EYE DROPS,SUSPENSION
MAXIDONE 10-750 MG TABLET
MAXIFLU CD TABLET
MAXIFLU CDX TABLET
MAXIMA CONTROL SOLUTION
MAXIMA CONTROL SOLUTION
MAXIMA CONTROL SOLUTION
MAXIMA CONTROL SOLUTION
MAXIMA STRIPS MM
DRUG LEVEL
3
3
3
4
4
4
2
1
3
3
2
3
3
3
3
3
3
3
3
3
*
3
3
3
3
3
3
3
3
4
3
3
3
3
2
2
1
1
3
3
3
3
3
3
3
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL,PA
QL,PA
QL,PA
QL
QL
QL
QL
QL
QL
QL
QL,ST
QL,ST
QL,ST
QL,ST
ST
QL
QL,ST
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 103
DRUG NAME
MAXINATE 20 MG-0.8 MG TABLET
MAXITROL 3.5 MG/G-10,000 UNIT/G-0.1 % EYE OINTMENT
MAXITROL 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS,SUSPENSION
MAXZIDE 75 MG-50 MG TABLET MM
MAXZIDE-25MG 37.5 MG-25 MG TABLET MM
mb hydrogel (cyclomethicone) topical kit,cream and gel
mb hydrogel 96.53 %-3 %-0.4 %-0.066 % topical kit,cream and gel
md-gastroview 66 %-10 % oral solution
me-pb-hyos elixir
me-pb-hyos tablet
meclizine 12.5 mg tablet
meclizine 25 mg tablet
meclofenamate 100 mg capsule MM
meclofenamate 50 mg capsule MM
MEDI-10 2.5 MG-200 MG-1 MG CAPSULE
MEDI-JECTOR NEEDLE-FREE SYR A
MEDI-JECTOR NEEDLE-FREE SYR B
MEDI-JECTOR NEEDLE-FREE SYR C
MEDI-JECTOR VISION
MEDI-LANCE LANCETS
MEDISENSE COMBO PACK
MEDISENSE CONTROLS 1-HI 1-LO COMBO PACK
MEDISENSE GLUCOSE KETONE COMBO PACK
MEDISENSE MID CONTROL SOLUTION
MEDISENSE THIN LANCETS 28 GAUGE
MEDLANCE PLUS LANCETS 21 GAUGE
MEDLANCE PLUS LANCETS 25 GAUGE
MEDLANCE PLUS LANCETS 30 GAUGE
MEDPOINT NORMAL CONTROL SOLUTION
MEDROL (PAK) 4 MG TABLETS IN A DOSE PACK
MEDROL 16 MG TABLET
MEDROL 2 MG TABLET
MEDROL 32 MG TABLET
MEDROL 4 MG TABLET
MEDROL 8 MG TABLET
medroxyprogesterone 10 mg tab MM
medroxyprogesterone 150 mg/ml
medroxyprogesterone 150 mg/ml
medroxyprogesterone 2.5 mg tab MM
medroxyprogesterone 5 mg tab MM
mefenamic acid 250 mg capsule
mefloquine hcl 250 mg tablet MM
MEGACE 400 MG/10 ML (40 MG/ML) ORAL SUSPENSION MM
MEGACE ES 625 MG/5 ML ORAL SUSPENSION MM
megestrol 20 mg tablet
megestrol 40 mg tablet
megestrol 625 mg/5 ml susp MM
megestrol acet 40 mg/ml susp MM
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
104 - FORMULARY Updated 09/2015
DRUG LEVEL
3
3
3
3
3
3
3
3
3
3
2
2
3
3
3
3
3
3
3
1
3
3
3
3
1
1
1
1
3
3
3
3
3
3
3
1
2
2
1
1
3
2
3
4
1
1
4
2
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
ST
ST
DRUG NAME
megestrol acet 400 mg/10 ml MM
MEKINIST 0.5 MG TABLET SP
MEKINIST 2 MG TABLET SP
meloxicam 15 mg tablet MM
meloxicam 7.5 mg tablet MM
meloxicam 7.5 mg/5 ml susp MM
memantine 5-10 mg titration pk
memantine hcl 10 mg tablet MM
memantine hcl 5 mg tablet MM
MENEST 0.3 MG TABLET MM
MENEST 0.625 MG TABLET MM
MENEST 1.25 MG TABLET MM
MENEST 2.5 MG TABLET MM
MENOSTAR 14 MCG/24 HR TRANSDERMAL PATCH MM
MENTAX 1 % TOPICAL CREAM
meperidine 100 mg tablet
meperidine 50 mg tablet
meperidine 50 mg/5 ml solution
meperitab 100 mg tablet
MEPHYTON 5 MG TABLET
meprobamate 200 mg tablet
meprobamate 400 mg tablet
MEPRON 750 MG/5 ML ORAL SUSPENSION
mercaptopurine 50 mg tablet
mesalamine 4 gm/60 ml enema MM
mesalamine 4 gm/60 ml kit MM
MESNEX 400 MG TABLET SP
MESTINON 60 MG TABLET MM
MESTINON 60 MG/5 ML SYRUP MM
MESTINON TIMESPAN 180 MG TABLET,EXTENDED RELEASE MM
METADATE CD 10 MG CAPSULE,EXTENDED RELEASE
METADATE CD 20 MG CAPSULE,EXTENDED RELEASE
METADATE CD 30 MG CAPSULE,EXTENDED RELEASE
METADATE CD 40 MG CAPSULE,EXTENDED RELEASE
METADATE CD 50 MG CAPSULE,EXTENDED RELEASE
METADATE CD 60 MG CAPSULE,EXTENDED RELEASE
metadate er 20 mg tablet,extended release
metafolbic 6 mg-5 mg-50 mg-1 mg tablet
metafolbic plus 600 mg-2 mg-6 mg tablet
metafolbic plus rf 6 mg-600 mg-2 mg-90.314 mg tablet
METANX (ALGAL OIL) 3 MG-35 MG-2 MG-90.314 MG CAPSULE
metaproterenol 10 mg tablet MM
metaproterenol 10 mg/5 ml syr MM
metaproterenol 20 mg tablet MM
metaxalone 400 mg tablet
metaxalone 800 mg tablet
METER-CHECK SOLUTION
DRUG LEVEL
2
*
*
1
1
2
3
3
3
3
3
3
3
3
3
2
2
2
2
4
3
3
4
2
3
3
*
4
3
4
3
3
3
3
3
3
2
2
3
3
3
1
1
1
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,PA
QL,PA
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL
QL
QL
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 105
DRUG NAME
metformin er 1,000 mg osm-tab MM
metformin hcl 1,000 mg tablet MM
metformin hcl 500 mg tablet MM
metformin hcl 850 mg tablet MM
metformin hcl er 500 mg osm-tb MM
metformin hcl er 500 mg tablet MM
metformin hcl er 750 mg tablet MM
methadone 10 mg/5 ml solution
methadone 10 mg/ml oral conc
methadone 40 mg tablet dispr
methadone 5 mg/5 ml solution
methadone hcl 10 mg tablet
methadone hcl 5 mg tablet
methadone intensol 10 mg/ml oral concentrate
METHADOSE 10 MG/ML ORAL CONCENTRATE
methadose 40 mg soluble tablet
methamphetamine 5 mg tablet
methazolamide 25 mg tablet MM
methazolamide 50 mg tablet MM
methenamine hipp 1 gm tablet
methenamine md 1 gm tablet
methenamine md 500 mg tablet
methimazole 10 mg tablet MM
methimazole 5 mg tablet MM
METHITEST 10 MG TABLET MM
methocarbamol 500 mg tablet
methocarbamol 750 mg tablet
methotrexate 2.5 mg tablet MM
methotrexate 50 mg/2 ml vial
methotrexate 50 mg/2 ml vial
methoxsalen 10 mg capsule
methscopolamine brom 2.5 mg tb
methscopolamine brom 5 mg tab
methyclothiazide 5 mg tablet MM
methyldopa 250 mg tablet MM
methyldopa 500 mg tablet MM
methyldopa-hctz 250-15 mg tab MM
methyldopa-hctz 250-25 mg tab MM
methylergonovine 0.2 mg tablet
METHYLIN 10 MG CHEWABLE TABLET
METHYLIN 10 MG/5 ML ORAL SOLUTION
METHYLIN 2.5 MG CHEWABLE TABLET
METHYLIN 5 MG CHEWABLE TABLET
METHYLIN 5 MG/5 ML ORAL SOLUTION
methylphenidate 10 mg chew tab
methylphenidate 10 mg tablet
methylphenidate 10 mg/5 ml sol
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
106 - FORMULARY Updated 09/2015
DRUG LEVEL
3
1
1
1
3
1
1
2
2
2
2
2
2
2
3
2
4
3
3
3
3
3
1
1
3
2
2
2
4
4
3
3
3
2
1
1
3
3
3
2
3
2
2
3
2
2
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,ST
QL,ST
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
DRUG NAME
methylphenidate 2.5 mg chew tb
methylphenidate 20 mg tablet
methylphenidate 5 mg chew tab
methylphenidate 5 mg tablet
methylphenidate 5 mg/5 ml soln
methylphenidate cd 10 mg cap
methylphenidate cd 20 mg cap
methylphenidate cd 30 mg cap
methylphenidate cd 40 mg cap
methylphenidate cd 50 mg cap
methylphenidate cd 60 mg cap
methylphenidate er 10 mg tab
methylphenidate er 18 mg tab
methylphenidate er 20 mg tab
methylphenidate er 27 mg tab
methylphenidate er 36 mg tab
methylphenidate er 54 mg tab
methylphenidate la 20 mg cap
methylphenidate la 30 mg cap
methylphenidate la 40 mg cap
methylprednisolone 16 mg tab
methylprednisolone 32 mg tab
methylprednisolone 4 mg dosepk
methylprednisolone 4 mg tablet
methylprednisolone 8 mg tab
metipranolol 0.3% eye drops MM
metoclopramide 10 mg tablet
metoclopramide 5 mg tablet
metoclopramide 5 mg/5 ml soln
metoclopramide hcl odt 5 mg tb
metolazone 10 mg tablet MM
metolazone 2.5 mg tablet MM
metolazone 5 mg tablet MM
METOPIRONE 250 MG CAPSULE
metoprolol succ er 100 mg tab MM
metoprolol succ er 200 mg tab MM
metoprolol succ er 25 mg tab MM
metoprolol succ er 50 mg tab MM
metoprolol tartrate 100 mg tab MM
metoprolol tartrate 25 mg tab MM
metoprolol tartrate 50 mg tab MM
metoprolol-hctz 100-25 mg tab MM
metoprolol-hctz 100-50 mg tab MM
metoprolol-hctz 50-25 mg tab MM
METOZOLV ODT 5 MG DISINTEGRATING TABLET
METROCREAM 0.75 % TOPICAL
METROGEL 1 % TOPICAL
METROGEL 1 % TOPICAL GEL WITH PUMP
DRUG LEVEL
2
2
2
2
3
3
3
3
3
3
3
2
3
2
3
3
3
3
3
3
2
2
2
2
2
1
1
1
1
3
2
2
2
3
2
2
2
2
1
1
1
2
2
2
3
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL,ST
QL
QL,ST
QL,ST
QL,ST
QL
QL
QL
QL
QL
QL
QL
QL
QL
ST
ST
ST
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 107
DRUG NAME
METROGEL VAGINAL 0.75 %
METROLOTION 0.75 % TOPICAL
metronidazole 0.75% cream
metronidazole 0.75% lotion
metronidazole 250 mg tablet
metronidazole 375 mg capsule
metronidazole 500 mg tablet
metronidazole topical 0.75% gl
metronidazole topical 1% gel
metronidazole topical 1% gel
metronidazole vaginal 0.75% gl
MEVACOR 20 MG TABLET MM
MEVACOR 40 MG TABLET MM
mexiletine 150 mg capsule MM
mexiletine 200 mg capsule MM
mexiletine 250 mg capsule MM
MIACALCIN 200 UNIT/ACTUATION NASAL SPRAY MM
MIACALCIN 200 UNIT/ML INJECTION SOLUTION
MICARDIS 20 MG TABLET MM
MICARDIS 40 MG TABLET MM
MICARDIS 80 MG TABLET MM
MICARDIS HCT 40 MG-12.5 MG TABLET MM
MICARDIS HCT 80 MG-12.5 MG TABLET MM
MICARDIS HCT 80 MG-25 MG TABLET MM
miconazole-3 200 mg vaginal suppository
MICRO BLOOD GLUCOSE STRIPS MM
MICRO THIN LANCETS 33 GAUGE
MICRO-BUMINTEST KIT
MICROCHAMBER SPACER
MICROCRYSTAL CELLULOSE POWDER
MICRODOT BLOOD GLUCOSE MONITORING SYSTEM
MICRODOT BLOOD GLUCOSE MONITORING SYSTEM KIT
MICRODOT BLOOD GLUCOSE MONITORING SYSTEM STRIPS MM
MICRODOT HIGH-LOW CONTROL SOLUTION
MICRODOT NORMAL CONTROL SOLUTION
MICRODOT XTRA BLOOD GLUCOSE STRIPS MM
microgestin 1.5/30 (21) 1.5 mg-30 mcg tablet MM
microgestin 1/20 (21) 1 mg-20 mcg tablet MM
microgestin fe 1.5/30 (28) 1.5 mg-30 mcg (21)/75 mg (7) tablet MM
microgestin fe 1/20 (28) 1 mg-20 mcg (21)/75 mg (7) tablet MM
MICROLET 2 LANCING DEVICE KIT
MICROLET LANCET
MICROSPACER
MICROZIDE 12.5 MG CAPSULE MM
midazolam hcl 2 mg/ml syrup
midodrine hcl 10 mg tablet
midodrine hcl 2.5 mg tablet
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
108 - FORMULARY Updated 09/2015
DRUG LEVEL
2
3
3
3
2
2
2
3
3
3
2
3
3
3
3
3
3
4
3
3
3
3
3
3
2
3
1
3
3
4
3
3
3
3
3
3
1
1
1
1
3
3
1
3
2
2
2
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
ST
ST
QL,ST
QL,ST
DRUG NAME
midodrine hcl 5 mg tablet
migergot 2 mg-100 mg rectal suppository
migragesic ida 65 mg-100 mg-325 mg capsule
MIGRANAL 0.5 MG/PUMP ACT. (4 MG/ML) NASAL SPRAY
MILLIPRED 10 MG/5 ML ORAL SOLUTION
millipred 5 mg tablet
millipred dp 5 mg (21 tabs) tablets in a dose pack
millipred dp 5 mg (48 tabs) tablets in a dose pack
mimvey 1 mg-0.5 mg tablet MM
mimvey lo 0.5 mg-0.1 mg tablet MM
MINASTRIN 24 FE 1 MG-20 MCG (24)/75 MG (4) CHEWABLE TABLET MM
MINI LANCING DEVICE
MINI ULTRA-THIN II 31 X 3/16" NEEDLE
MINI WRIGHT PEAK FLOW METER
MINI-WRIGHT PEAK FLOW METER
MINILINK REAL-TIME TRANSMITTER DEVICE MM
MINIMED SYRINGE RESERVOIR 3 ML MM
MINIPRESS 1 MG CAPSULE MM
MINIPRESS 2 MG CAPSULE MM
MINIPRESS 5 MG CAPSULE MM
minitran 0.1 mg/hr transdermal 24 hour patch MM
minitran 0.2 mg/hr transdermal 24 hour patch MM
minitran 0.4 mg/hr transdermal 24 hour patch MM
minitran 0.6 mg/hr transdermal 24 hour patch MM
MINIVELLE 0.025 MG/24 HR TRANSDERMAL PATCH MM
MINIVELLE 0.0375 MG/24 HR TRANSDERMAL PATCH MM
MINIVELLE 0.05 MG/24 HR TRANSDERMAL PATCH MM
MINIVELLE 0.075 MG/24 HR TRANSDERMAL PATCH MM
MINIVELLE 0.1 MG/24 HR TRANSDERMAL PATCH MM
MINOCIN 100 MG CAPSULE
MINOCIN 50 MG CAPSULE
MINOCIN 75 MG CAPSULE
MINOCIN KIT WITH WIPES 100 MG COMBO PACK
MINOCIN KIT WITH WIPES 50 MG COMBO PACK
minocycline 100 mg capsule
minocycline 50 mg capsule
minocycline 75 mg capsule
minocycline er 135 mg tablet
minocycline er 45 mg tablet
minocycline er 90 mg tablet
minocycline hcl 100 mg tablet
minocycline hcl 50 mg tablet
minocycline hcl 75 mg tablet
minoxidil 10 mg tablet MM
minoxidil 2.5 mg tablet MM
MIRAPEX 0.125 MG TABLET MM
MIRAPEX 0.25 MG TABLET MM
DRUG LEVEL
2
4
2
4
4
3
3
3
3
3
2
1
1
1
1
3
2
3
3
3
2
3
3
3
3
3
3
3
3
4
4
4
3
3
2
2
2
3
3
3
3
3
3
1
1
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL,ST
PA
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 109
DRUG NAME
MIRAPEX 0.5 MG TABLET MM
MIRAPEX 0.75 MG TABLET MM
MIRAPEX 1 MG TABLET MM
MIRAPEX 1.5 MG TABLET MM
MIRAPEX ER 0.375 MG TABLET,EXTENDED RELEASE MM
MIRAPEX ER 0.75 MG TABLET,EXTENDED RELEASE MM
MIRAPEX ER 1.5 MG TABLET,EXTENDED RELEASE MM
MIRAPEX ER 2.25 MG TABLET,EXTENDED RELEASE MM
MIRAPEX ER 3 MG TABLET,EXTENDED RELEASE MM
MIRAPEX ER 3.75 MG TABLET,EXTENDED RELEASE MM
MIRAPEX ER 4.5 MG TABLET,EXTENDED RELEASE MM
MIRCERA 100 MCG/0.3 ML INJECTION SYRINGE SP
MIRCERA 200 MCG/0.3 ML INJECTION SYRINGE SP
MIRCERA 50 MCG/0.3 ML INJECTION SYRINGE SP
MIRCERA 75 MCG/0.3 ML INJECTION SYRINGE SP
MIRCETTE (28) 0.15 MG-0.02 MG (21)/0.01 MG (5) TABLET MM
MIRENA 20 MCG/24 HR (5 YEARS) INTRAUTERINE DEVICE SP
mirtazapine 15 mg odt MM
mirtazapine 15 mg tablet MM
mirtazapine 30 mg odt MM
mirtazapine 30 mg tablet MM
mirtazapine 45 mg odt MM
mirtazapine 45 mg tablet MM
mirtazapine 7.5 mg tablet MM
MIRVASO 0.33 % TOPICAL GEL MM
misoprostol 100 mcg tablet MM
misoprostol 200 mcg tablet MM
MITIGARE 0.6 MG CAPSULE
MITOSOL 0.2 MG OPHTHALMIC KIT
MOBIC 15 MG TABLET MM
MOBIC 7.5 MG TABLET MM
MOBIC 7.5 MG/5 ML ORAL SUSPENSION MM
modafinil 100 mg tablet MM
modafinil 200 mg tablet MM
moderiba 200 mg tablet
moderiba dose pack 200 mg (7)-400 mg (7) tablets
moderiba dose pack 400 mg (7)-400 mg (7) tablets SP
moderiba dose pack 600 mg (7)-400 mg (7) tablets
moderiba dose pack 600 mg (7)-600 mg (7) tablets SP
MODICON (28) 0.5 MG-35 MCG TABLET MM
moexipril hcl 15 mg tablet MM
moexipril hcl 7.5 mg tablet MM
moexipril-hctz 15-12.5 mg tab MM
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
110 - FORMULARY Updated 09/2015
DRUG LEVEL
3
3
3
3
3
3
3
3
3
3
3
*
*
*
*
3
*
2
1
2
1
2
1
1
4
2
2
3
3
3
3
3
4
4
3
3
*
3
*
3
2
2
2
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL
QL
QL
QL
QL
QL
ST
QL,ST
QL
QL
QL
QL,PA
QL,PA
QL
QL
QL
QL
QL
DRUG NAME
moexipril-hctz 15-25 mg tablet MM
moexipril-hctz 7.5-12.5 mg tab MM
mometasone furoate 0.1% cream
mometasone furoate 0.1% oint
mometasone furoate 0.1% soln
MOMEXIN COMBO PACK
MONAGHAN Z STAT ANTI-STATIC VALVED HOLDING CHAMBER SPACER
MONAGHAN Z STAT CHAMBER-LARGE MASK
MONAGHAN Z STAT CHAMBER-MEDIUM MASK
MONAGHAN Z STAT CHAMBER-SMALL MASK
mono-linyah 0.25 mg-35 mcg tablet MM
MONODOX 100 MG CAPSULE
MONODOX 50 MG CAPSULE
MONODOX 75 MG CAPSULE
MONOJECT BLOOD COLLECTION 20 X 1 1/2" NEEDLE
MONOJECT BLOOD COLLECTION 20 X 1" NEEDLE
MONOJECT BLOOD COLLECTION 21 X 1" NEEDLE
MONOJECT BLOOD COLLECTION 22 X 1" NEEDLE
MONOJECT CONTROL SYRINGE LUER LOCK 12 ML
MONOJECT HYPODERMIC NEEDLES 22 X 1 1/2"
MONOJECT HYPODERMIC NEEDLES 22 X 1"
MONOJECT HYPODERMIC NEEDLES 23 X 1"
MONOJECT HYPODERMIC NEEDLES 23 X 1/2"
MONOJECT HYPODERMIC NEEDLES 25 X 1 1/2"
MONOJECT HYPODERMIC NEEDLES 25 X 1"
MONOJECT HYPODERMIC NEEDLES 25 X 5/8"
MONOJECT HYPODERMIC NEEDLES 26 X 1 1/2"
MONOJECT HYPODERMIC NEEDLES 27 X 1/2"
MONOJECT HYPODERMIC NEEDLES 30 X 3/4"
MONOJECT INSULIN SAFETY SYRINGE 0.3 ML 29 X 1/2" MM
MONOJECT INSULIN SAFETY SYRINGE 0.3 ML 30 X 5/16" MM
MONOJECT INSULIN SAFETY SYRINGE 1/2 ML 29 X 1/2" MM
MONOJECT INSULIN SAFETY SYRINGE 1/2 ML 30 X 5/16" MM
MONOJECT INSULIN SAFETY SYRINGE 29 X 1/2" MM
MONOJECT INSULIN SYRINGE 0.3 ML 29 X 1/2" MM
MONOJECT INSULIN SYRINGE 0.3 ML 30 X 5/16" MM
MONOJECT INSULIN SYRINGE 0.3 ML 31 X 5/16" MM
MONOJECT INSULIN SYRINGE 1 ML MM
MONOJECT INSULIN SYRINGE 1 ML 25 X 5/8" MM
MONOJECT INSULIN SYRINGE 1 ML 27 X 1/2" MM
MONOJECT INSULIN SYRINGE 1 ML 28 X 1/2" MM
MONOJECT INSULIN SYRINGE 1 ML 29 X 1/2" MM
MONOJECT INSULIN SYRINGE 1 ML 30 X 5/16" MM
MONOJECT INSULIN SYRINGE 1 ML 31 X 5/16" MM
MONOJECT INSULIN SYRINGE 1/2 ML 28 X 1/2" MM
MONOJECT INSULIN SYRINGE 1/2 ML 29 X 1/2" MM
MONOJECT INSULIN SYRINGE 1/2 ML 30 X 5/16" MM
DRUG LEVEL
2
2
2
2
2
3
1
1
1
1
1
4
4
4
1
1
1
1
3
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
1
2
2
2
2
2
2
2
2
2
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,PA
QL,PA
QL,PA
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 111
DRUG NAME
MONOJECT INSULIN SYRINGE 1/2 ML 31 X 5/16" MM
MONOJECT LUER-LOCK TIP 12 ML SYRINGE
MONOJECT MAGELLAN SYRINGE 1 ML 25 X 1"
MONOJECT MAGELLAN SYRINGE 1 ML 25 X 5/8"
MONOJECT MAGELLAN SYRINGE 3 ML 20 X 1"
MONOJECT PHARMACY TRAY REGULAR TIP 1 ML SYRINGE
MONOJECT REGULAR LUER 12 ML SYRINGE
MONOJECT SAFETY SYRINGES
MONOJECT SAFETY SYRINGES 12 ML 21 X 1 1/2"
MONOJECT SAFETY SYRINGES 3 ML 21 X 1"
MONOJECT SAFETY SYRINGES 3 ML 22 X 1 1/2"
MONOJECT SAFETY SYRINGES 6 ML
MONOJECT SMARTIP CANNULA 12 ML SYRINGE
MONOJECT SMARTIP CANNULA 3 ML SYRINGE
MONOJECT SMARTIP CANNULA 6 ML SYRINGE
MONOJECT SYRINGE 1/2 ML 28 MM
MONOJECT SYRINGE 12 ML
MONOJECT SYRINGE 3 ML
MONOJECT SYRINGE 6 ML
MONOJECT SYRINGE 6 ML 20 X 1 1/2"
MONOJECT SYRINGE 6 ML 21 X 1 1/2"
MONOJECT SYRINGE 6 ML 21 X 1"
MONOJECT SYRINGE 6 ML 22 X 1 1/2"
MONOJECT TB LUER LOK 1 ML SYRINGE
MONOJECT TUBERCULIN SYRINGE 1 ML
MONOJECT ULTRA COMFORT INSULIN 1/2 ML 28 SYRINGE MM
MONOLET LANCETS 21 GAUGE
MONOLET THIN LANCETS 28 GAUGE
mononessa (28) 0.25 mg-35 mcg tablet MM
MONSEL'S 0.2 GRAM TO 0.22 GRAM/ML IRON TOPICAL SOLUTION
MONSEL'S 0.2 GRAM TO 0.22 GRAM/ML TOPICAL SOLUTION WITH APPLICATOR
montelukast sod 10 mg tablet MM
montelukast sod 4 mg granules MM
montelukast sod 4 mg tab chew MM
montelukast sod 5 mg tab chew MM
MONUROL 3 GRAM ORAL PACKET
morgidox 100 mg capsule
MORGIDOX 1X100 100 MG KIT
MORGIDOX 2X100 100 MG KIT
morphine sulf 10 mg suppos
morphine sulf 10 mg/5 ml soln
morphine sulf 100 mg/5 ml soln
morphine sulf 20 mg suppos
morphine sulf 20 mg/5 ml soln
morphine sulf 30 mg suppos
morphine sulf 5 mg suppos
morphine sulf er 100 mg tablet
morphine sulf er 15 mg tablet
morphine sulf er 200 mg tablet
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
112 - FORMULARY Updated 09/2015
DRUG LEVEL
2
2
1
1
1
1
2
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
1
1
2
1
1
1
4
4
1
3
1
1
3
3
3
4
3
2
2
2
2
2
2
2
2
2
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
DRUG NAME
morphine sulf er 30 mg tablet
morphine sulf er 60 mg tablet
morphine sulfate er 10 mg cap
morphine sulfate er 100 mg cap
morphine sulfate er 120 mg cap
morphine sulfate er 20 mg cap
morphine sulfate er 30 mg cap
morphine sulfate er 30 mg cap
morphine sulfate er 45 mg cap
morphine sulfate er 50 mg cap
morphine sulfate er 60 mg cap
morphine sulfate er 60 mg cap
morphine sulfate er 75 mg cap
morphine sulfate er 80 mg cap
morphine sulfate er 90 mg cap
morphine sulfate ir 15 mg tab
morphine sulfate ir 30 mg tab
MOTOFEN 1 MG-0.025 MG TABLET
MOVANTIK 12.5 MG TABLET
MOVANTIK 25 MG TABLET
MOVIPREP 100 G-7.5 G-2.691 G-4.7 G ORAL POWDER PACKET
MOXATAG 775 MG TABLET,EXTENDED RELEASE
MOXEZA 0.5 % EYE DROPS
moxifloxacin hcl 400 mg tablet
MS CONTIN 100 MG TABLET,EXTENDED RELEASE
MS CONTIN 15 MG TABLET,EXTENDED RELEASE
MS CONTIN 200 MG TABLET,EXTENDED RELEASE
MS CONTIN 30 MG TABLET,EXTENDED RELEASE
MS CONTIN 60 MG TABLET,EXTENDED RELEASE
MUCOTROL ORAL WAFER
MUGARD MUCOSAL SOLUTION
MULTAQ 400 MG TABLET MM
MULTI-LANCET DEVICE
multi-vit with fluoride & iron 0.25 mg-10 mg/ml oral drops
multi-vitamin with fluoride 0.25 mg chewable tablet
multi-vitamin with fluoride 0.25 mg/ml oral drops
multi-vitamin with fluoride 0.5 mg chewable tablet
multi-vitamin with fluoride 0.5 mg/ml oral drops
multi-vitamin with fluoride 1 mg chewable tablet
multigen 70 mg-150 mg-10 mcg-2 mg-75mg tablet
multigen folic 70 mg-150 mg-10 mcg-1 mg-2 mg tablet
multigen plus 151 mg-60 mg-10 mcg-1 mg tablet
MULTISTIX 10 SG STRIPS
MULTISTIX 5 STRIPS
MULTISTIX 7 STRIPS
MULTISTIX 8 SG STRIPS
MULTISTIX 9 SG STRIPS
MULTISTIX 9 STRIPS
MULTISTIX STRIPS
multivitamin with fluoride 0.5 mg chewable tablet
multivitamins with fluoride 0.25 mg chewable tablet
DRUG LEVEL
2
2
4
4
4
4
4
4
4
4
4
4
4
4
4
2
2
3
3
3
3
3
3
3
4
4
4
4
4
3
4
2
3
1
1
1
1
1
1
2
2
2
3
3
3
3
3
3
3
1
1
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL
QL
QL,PA
QL,PA
ST
ST
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 113
DRUG NAME
multivitamins with fluoride 0.5 mg chewable tablet
multivitamins with fluoride 1 mg chewable tablet
mupirocin 2% cream
mupirocin 2% ointment
MURI-LUBE OIL
mv-iron fum-asp-asc-b12-fa-suc
mv-iron-asc-b12-thre-suc-stom
MVC-FLUORIDE 0.25 MG CHEWABLE TABLET
MVC-FLUORIDE 0.5 MG CHEWABLE TABLET
MVC-FLUORIDE 1 MG CHEWABLE TABLET
my way 1.5 mg tablet
MYALEPT 5 MG/ML (FINAL CONCENTRATION) SUBCUTANEOUS SOLUTION SP
MYAMBUTOL 400 MG TABLET MM
MYCOBUTIN 150 MG CAPSULE
mycophenolate 200 mg/ml susp
mycophenolate 250 mg capsule
mycophenolate 500 mg tablet
mycophenolic acid dr 180 mg tb
mycophenolic acid dr 360 mg tb
mydfrin 2.5% eye drops
MYDRIACYL 1 % EYE DROPS MM
myferon 150 forte 150 mg-25 mcg-1 mg capsule
MYFORTIC 180 MG TABLET,DELAYED RELEASE
MYFORTIC 360 MG TABLET,DELAYED RELEASE
MYGLUCOHEALTH CONTROL SOLUTION
MYGLUCOHEALTH KIT
MYGLUCOHEALTH LANCETS 30 GAUGE
MYGLUCOHEALTH STRIPS MM
MYKIDZ IRON FLUORIDE 10 MG-0.25 MG-1,500 UNIT/2 ML ORAL SUSPENSION
MYLERAN 2 MG TABLET
MYNATAL 65 MG-1 MG CAPSULE
mynatal 90 mg-1 mg-50 mg tablet
mynatal advance 90 mg-1 mg-50 mg tablet
mynatal plus 65 mg-1 mg tablet
mynatal-z 65 mg-1 mg tablet
mynate 90 plus 90 mg iron-1 mg tablet,extended release
mynephrocaps 1 mg capsule
myorisan 10 mg capsule
myorisan 20 mg capsule
myorisan 40 mg capsule
MYRBETRIQ 25 MG TABLET,EXTENDED RELEASE MM
MYRBETRIQ 50 MG TABLET,EXTENDED RELEASE MM
MYSOLINE 250 MG TABLET MM
MYSOLINE 50 MG TABLET MM
myzilra 50-30 (6)/75-40(5)/125-30(10) tablet MM
nabumetone 500 mg tablet MM
nabumetone 750 mg tablet MM
nadolol 20 mg tablet MM
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
114 - FORMULARY Updated 09/2015
DRUG LEVEL
1
1
3
2
3
2
2
2
2
2
2
*
3
4
3
2
2
3
3
3
3
1
4
4
3
3
1
3
3
2
1
1
1
1
1
1
1
4
4
4
3
3
4
4
1
1
1
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
QL
QL,PA
QL
QL
ST
QL,ST
QL
QL,ST
QL,ST
QL,ST
QL
QL
DRUG NAME
nadolol 40 mg tablet MM
nadolol 80 mg tablet MM
nadolol-bendroflu 40-5 mg tab MM
nadolol-bendroflu 80-5 mg tab MM
naftifine hcl 1% cream
NAFTIN 1 % TOPICAL CREAM
NAFTIN 1 % TOPICAL GEL
NAFTIN 2 % TOPICAL CREAM
NAFTIN 2 % TOPICAL GEL
NALFON 400 MG CAPSULE MM
naltrexone 50 mg tablet
NAMENDA 10 MG TABLET MM
NAMENDA 10 MG/5 ML ORAL SOLUTION MM
NAMENDA 5 MG TABLET MM
NAMENDA TITRATION PAK 5 MG-10 MG TABLETS IN A DOSE PACK
NAMENDA XR 14 MG CAPSULE SPRINKLE,EXTENDED RELEASE MM
NAMENDA XR 21 MG CAPSULE SPRINKLE,EXTENDED RELEASE MM
NAMENDA XR 28 MG CAPSULE SPRINKLE,EXTENDED RELEASE MM
NAMENDA XR 7 MG CAPSULE SPRINKLE,EXTENDED RELEASE MM
NAMENDA XR 7 MG-14 MG-21 MG-28 MG CAPSULE,SPRINKLE,ER 24HR,DOSE PACK
NAMZARIC 14 MG-10 MG CAPSULE SPRINKLE,EXTENDED RELEASE
NAMZARIC 28 MG-10 MG CAPSULE SPRINKLE,EXTENDED RELEASE
naphazoline 0.1% eye drops
NAPRELAN CR 375 MG TAB,EXTENDED RELEASE 24 HR MPHASE MM
NAPRELAN CR 500 MG TAB,EXTENDED RELEASE 24 HR MPHASE MM
NAPRELAN CR 750 MG TAB,EXTENDED RELEASE 24 HR MPHASE MM
NAPROSYN 125 MG/5 ML SUSPEN MM
NAPROSYN 250 MG TABLET MM
NAPROSYN 375 MG TABLET MM
NAPROSYN 500 MG TABLET MM
naproxen 125 mg/5 ml suspen MM
naproxen 250 mg tablet MM
naproxen 375 mg tablet MM
naproxen 500 mg tablet MM
naproxen dr 375 mg tablet MM
naproxen dr 500 mg tablet MM
naproxen sod cr 500 mg tablet MM
naproxen sodium 275 mg tab MM
naproxen sodium 550 mg tab MM
naratriptan hcl 1 mg tablet
naratriptan hcl 2.5 mg tablet
NARDIL 15 MG TABLET MM
NASACORT AQ NASAL SPRAY MM
NASCOBAL 500 MCG/SPRAY NASAL SPRAY MM
NASONEX 50 MCG/ACTUATION SPRAY MM
DRUG LEVEL
3
3
3
3
3
3
3
3
3
3
2
3
3
3
3
2
2
2
2
2
2
2
1
4
4
4
3
3
3
3
1
1
1
1
1
1
4
1
1
2
2
3
3
3
2
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,ST
QL
QL,ST
QL,ST
QL
QL
QL
QL
QL
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL
QL
QL,ST
QL
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 115
DRUG NAME
NATA KOMPLETE PRENATAL TABLET
NATACHEW (FE BIS-GLYCINATE) 28 MG IRON-1 MG TABLET
NATACYN 5 % EYE DROPS,SUSPENSION
NATAFORT TABLET
natal-v rx tablet
natalvirt 90 dha combo pack
natalvirt ca combo pack
natalvirt flt tablet
NATALVIT 75 MG-1 MG TABLET
NATAZIA 3 MG/2 MG-2 MG/2 MG-3 MG/1 MG TABLET MM
nateglinide 120 mg tablet MM
nateglinide 60 mg tablet MM
NATELLE ONE 28 MG-1 MG-250 MG CAPSULE
NATESTO 5.5 MG/0.122 GRAM PER ACTUATION NASAL GEL PUMP
NATPARA 100 MCG/DOSE SUBCUTANEOUS CARTRIDGE SP
NATPARA 25 MCG/DOSE SUBCUTANEOUS CARTRIDGE SP
NATPARA 50 MCG/DOSE SUBCUTANEOUS CARTRIDGE SP
NATPARA 75 MCG/DOSE SUBCUTANEOUS CARTRIDGE SP
NATROBA 0.9 % TOPICAL SUSPENSION
NATURE-THROID 113.75 MG TABLET MM
NATURE-THROID 130 MG TABLET MM
NATURE-THROID 146.25 MG TABLET MM
NATURE-THROID 16.25 MG TABLET MM
NATURE-THROID 162.5 MG TABLET MM
NATURE-THROID 195 MG TABLET MM
NATURE-THROID 260 MG TABLET MM
NATURE-THROID 32.5 MG TABLET MM
NATURE-THROID 325 MG TABLET MM
NATURE-THROID 48.75 MG TABLET MM
NATURE-THROID 65 MG TABLET MM
NATURE-THROID 81.25 MG TABLET MM
NATURE-THROID 97.5 MG TABLET MM
NEBUPENT 300 MG SOLUTION FOR INHALATION
NEBUSAL 6 % SOLUTION FOR NEBULIZATION
necon 0.5/35 (28) 0.5 mg-35 mcg tablet MM
necon 1/35 (28) 1 mg-35 mcg tablet MM
necon 1/50 (28) 1 mg-50 mcg tablet MM
necon 10/11 (28) 0.5 mg-35 mcg(10)/1 mg-35 mcg(11) tablet MM
necon 7/7/7 (28) 0.5 mg/0.75 mg/1 mg-35 mcg tablet MM
NEEDLE FREE SYRINGE KIT A
NEEDLE FREE SYRINGE KIT B
NEEDLE FREE SYRINGE KIT C
NEEVODHA (WITH ALGAL OIL) 27 MG IRON-1.13 MG-581.92 MG CAPSULE
nefazodone hcl 100 mg tablet MM
nefazodone hcl 150 mg tablet MM
nefazodone hcl 200 mg tablet MM
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
116 - FORMULARY Updated 09/2015
DRUG LEVEL
3
3
3
2
1
2
2
2
1
2
2
2
3
3
*
*
*
*
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
1
1
2
2
1
1
1
1
3
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,ST
QL,PA
QL,PA
QL,PA
QL,PA
QL
DRUG NAME
nefazodone hcl 250 mg tablet MM
nefazodone hcl 50 mg tablet MM
neo-bacit-poly-hc eye ointment
neo-polycin 3.5 mg-400 unit-10,000 unit/g eye ointment
neo-polycin hc 3.5 mg-400-10,000 unit/g-1 % eye ointment
NEO-SYNALAR 0.5 %-0.025 % TOPICAL CREAM
NEO-SYNALAR KIT 0.5 %-0.025 % TOPICAL CREAM
neofrin 10% eye drops
neofrin 2.5% eye drops
neomy-polymyxin b 40 mg/ml amp
neomyc-bacit-polymix eye oint
neomyc-polym-dexamet eye ointm
neomyc-polym-dexameth eye drop
neomyc-polym-gramicid eye drop
neomycin 500 mg tablet
neomycin-poly-hc eye drops
neomycin-polymyxin-hc ear soln
neomycin-polymyxin-hc ear susp
NEORAL 100 MG CAPSULE
NEORAL 100 MG/ML ORAL SOLUTION
NEORAL 25 MG CAPSULE
NEOSALUS LOTION
NEOSALUS TOPICAL CREAM
NEOSALUS TOPICAL FOAM
neosporin (neo-polym-gramicid) 1.75mg-10,000 unit-0.025mg/ml eye drops
NEOSPORIN GU IRRIGANT 40 MG-200,000 UNIT/ML
NEPHPLEX RX 1 MG-60 MG-300 MCG-12.5 MG TABLET
NEPHRAMINE 5.4 % INTRAVENOUS SOLUTION
NEPHRO-VITE RX 1 MG-60 MG-300 MCG TABLET
NEPHROCAPS 1 MG CAPSULE
NEPHROCAPS QT 1 MG-1,750 UNIT DISINTEGRATING TABLET
NEPHRON FA TABLET
NEPTAZANE 25 MG TABLET MM
NEPTAZANE 50 MG TABLET MM
NESINA 12.5 MG TABLET MM
NESINA 25 MG TABLET MM
NESINA 6.25 MG TABLET MM
NESTABS 32 MG-1,000 MCG TABLET
NESTABS ABC 32 MG IRON-1 MG-120 MG-180 MG ORAL PACK
NESTABS DHA 32 MG-1,000 MCG-230 MG ORAL PACK
neuac 1.2 % (1 % base)-5 % topical gel
NEUAC KIT 1.2 %-5 % TOPICAL PACK,CREAM AND GEL
NEULASTA 6 MG/0.6 ML SUBCUTANEOUS SYRINGE SP
NEULASTA 6 MG/0.6 ML WITH WEARABLE SUBCUTANEOUS INJECTOR SP
NEUMEGA 5 MG SUBCUTANEOUS SOLUTION SP
NEUPOGEN 300 MCG/0.5 ML INJECTION SYRINGE SP
NEUPOGEN 300 MCG/ML INJECTION SOLUTION SP
NEUPOGEN 480 MCG/0.8 ML INJECTION SYRINGE SP
DRUG LEVEL
3
3
2
2
2
3
3
2
2
4
2
2
2
2
2
3
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
2
2
2
3
3
3
2
3
2
3
3
*
*
*
*
*
*
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
QL,PA
QL,PA
QL
QL,PA
QL,PA
QL,PA
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 117
DRUG NAME
NEUPOGEN 480 MCG/1.6 ML INJECTION SOLUTION SP
NEUPRO 1 MG/24 HOUR TRANSDERMAL 24 HOUR PATCH MM
NEUPRO 2 MG/24 HOUR TRANSDERMAL 24 HOUR PATCH MM
NEUPRO 3 MG/24 HOUR TRANSDERMAL 24 HOUR PATCH MM
NEUPRO 4 MG/24 HOUR TRANSDERMAL 24 HOUR PATCH MM
NEUPRO 6 MG/24 HOUR TRANSDERMAL 24 HOUR PATCH MM
NEUPRO 8 MG/24 HOUR TRANSDERMAL 24 HOUR PATCH MM
NEURIN-SL 600 MCG-600 MCG SUBLINGUAL TABLET
NEURONTIN 100 MG CAPSULE MM
NEURONTIN 250 MG/5 ML ORAL SOLUTION MM
NEURONTIN 300 MG CAPSULE MM
NEURONTIN 400 MG CAPSULE MM
NEURONTIN 600 MG TABLET MM
NEURONTIN 800 MG TABLET MM
NEUTEK 2TEK TEST STRIPS MM
NEUTRASAL 538 MG MUCOSAL POWDER IN PACKET
NEVANAC 0.1 % EYE DROPS,SUSPENSION
nevirapine 200 mg tablet
nevirapine 50 mg/5 ml susp
nevirapine er 400 mg tablet
newgen 32 mg-1,000 mcg tablet
NEXA PLUS 29 MG IRON-1.25 MG-55 MG CAPSULE
NEXAVAR 200 MG TABLET SP
NEXIUM 20 MG CAPSULE,DELAYED RELEASE MM
NEXIUM 40 MG CAPSULE,DELAYED RELEASE MM
NEXIUM PACKET 10 MG GRANULES DELAYED RELEASE FOR SUSP MM
NEXIUM PACKET 2.5 MG GRANULES DELAYED RELEASE FOR SUSP MM
NEXIUM PACKET 20 MG GRANULES DELAYED RELEASE FOR SUSP MM
NEXIUM PACKET 40 MG GRANULES DELAYED RELEASE FOR SUSP MM
NEXIUM PACKET 5 MG GRANULES DELAYED RELEASE FOR SUSP MM
NEXPLANON 68 MG SUBDERMAL IMPLANT SP
next choice one dose 1.5 mg tablet
niacin er 1,000 mg tablet MM
niacin er 500 mg tablet MM
niacin er 750 mg tablet MM
niacin-azelaic ac-turmer-fa-b6-zn-cu 700 mg-500 mcg-8 mg-12 mg tablet
niacor 500 mg tablet MM
NIASPAN 1,000 MG TABLET,EXTENDED RELEASE MM
NIASPAN 500 MG TABLET,EXTENDED RELEASE MM
NIASPAN 750 MG TABLET,EXTENDED RELEASE MM
NICADAN 800 MG-10 MG-100 MG-500 MCG TABLET
nicardipine 20 mg capsule MM
nicardipine 30 mg capsule MM
NICAZEL 600 MG-5 MG-10 MG-5 MG-1.5 MG TABLET
NICAZEL FORTE 700 MG-500 MCG-8 MG-12 MG TABLET
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
118 - FORMULARY Updated 09/2015
DRUG LEVEL
*
3
3
3
3
3
3
1
3
3
3
3
3
3
3
4
3
1
2
3
3
3
*
3
3
3
3
3
3
3
*
2
3
3
3
2
2
3
3
3
3
3
2
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
ST
QL
QL
QL
QL,PA
QL,ST
QL,ST
QL
QL
QL
QL
QL
PA
PA
PA
PA
PA
PA
DRUG NAME
nifedical xl 30 mg tablet,extended release MM
nifedical xl 60 mg tablet,extended release MM
nifedipine 10 mg capsule MM
nifedipine 20 mg capsule MM
nifedipine er 30 mg tablet MM
nifedipine er 30 mg tablet MM
nifedipine er 60 mg tablet MM
nifedipine er 60 mg tablet MM
nifedipine er 90 mg tablet MM
nifedipine er 90 mg tablet MM
nikki (28) 3 mg-20 mcg tablet MM
NILANDRON 150 MG TABLET SP
nimodipine 30 mg capsule
NIRAVAM 0.25 MG ODT
NIRAVAM 0.5 MG ODT
NIRAVAM 1 MG ODT
NIRAVAM 2 MG ODT
NIRON KOMPLETE IRON TABLET
nisoldipine er 17 mg tablet MM
nisoldipine er 20 mg tablet MM
nisoldipine er 25.5 mg tablet MM
nisoldipine er 30 mg tablet MM
nisoldipine er 34 mg tablet MM
nisoldipine er 40 mg tablet MM
nisoldipine er 8.5 mg tablet MM
NITRATEST PAPER REFILLS
NITRATEST PAPER WITH DISPENSER 15 FEET MISC TEST
NITRO-BID 2 % TRANSDERMAL OINTMENT MM
NITRO-DUR 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH MM
NITRO-DUR 0.2 MG/HR TRANSDERMAL 24 HOUR PATCH MM
NITRO-DUR 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH MM
NITRO-DUR 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH MM
NITRO-DUR 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH MM
NITRO-DUR 0.8 MG/HR TRANSDERMAL 24 HOUR PATCH MM
nitro-time 2.5 mg capsule,extended release MM
nitro-time 6.5 mg capsule,extended release MM
nitro-time 9 mg capsule,extended release MM
nitrofurantoin 25 mg/5 ml susp
nitrofurantoin mcr 100 mg cap
nitrofurantoin mcr 50 mg cap
nitrofurantoin mono-mcr 100 mg
nitroglycerin 0.1 mg/hr patch MM
nitroglycerin 0.2 mg/hr patch MM
nitroglycerin 0.4 mg/hr patch MM
nitroglycerin 0.6 mg/hr patch MM
DRUG LEVEL
2
2
2
2
2
2
2
2
2
2
2
*
4
3
3
3
3
3
3
3
3
3
3
3
3
3
3
2
3
3
3
3
3
3
2
2
2
3
2
2
2
2
2
2
2
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 119
DRUG NAME
nitroglycerin 400 mcg spray MM
nitroglycerin er 2.5 mg cap MM
nitroglycerin er 6.5 mg cap MM
nitroglycerin er 9 mg capsule MM
nitroglycerin lingual 0.4 mg MM
NITROLINGUAL 400 MCG/SPRAY MM
NITROMIST 400 MCG/SPRAY TRANSLINGUAL AEROSOL MM
NITROSTAT 0.3 MG SUBLINGUAL TABLET MM
NITROSTAT 0.4 MG SUBLINGUAL TABLET MM
NITROSTAT 0.6 MG SUBLINGUAL TABLET MM
niva-fol 2.5 mg-25 mg-2 mg tablet
niva-plus 27 mg-1 mg tablet
nivatopic plus topical cream
nizatidine 15 mg/ml solution MM
nizatidine 150 mg capsule MM
nizatidine 300 mg capsule MM
NIZORAL 2 % SHAMPOO
NO-STICK GLUCOSE TEST STRIPS MM
nodolor 65 mg-100 mg-325 mg capsule
NOR-QD 0.35 MG TABLET MM
nora-be 0.35 mg tablet MM
NORCO 10 MG-325 MG TABLET
NORCO 5 MG-325 MG TABLET
NORCO 7.5 MG-325 MG TABLET
NORDITROPIN FLEXPRO 10 MG/1.5 ML (6.7 MG/ML) SUBCUTANEOUS PEN INJECTOR
DRUG LEVEL
UTILIZATION
MANAGEMENT
REQUIREMENTS
3
2
2
2
3
3
3
1
1
1
1
1
2
3
3
3
3
3
3
3
1
3
3
3
*
QL
QL
QL
QL,PA
*
QL,PA
*
*
QL,PA
QL,PA
*
3
1
2
3
3
1
1
2
1
1
3
3
4
QL,PA
QL
SP
NORDITROPIN FLEXPRO 15 MG/1.5 ML (10 MG/ML) SUBCUTANEOUS PEN INJECTOR
SP
NORDITROPIN FLEXPRO 30 MG/3 ML (10 MG/ML) SUBCUTANEOUS PEN INJECTOR SP
NORDITROPIN FLEXPRO 5 MG/1.5 ML (3.3 MG/ML) SUBCUTANEOUS PEN INJECTOR
SP
NORDITROPIN NORDIFLEX 30 MG/3 SP
norethin-estra-fe 0.8-0.025 mg MM
norethin-estrad-ferr 1-0.02 mg MM
norethin-estrad-ferr 1-0.02 mg MM
norethin-eth estrad 1 mg-5 mcg MM
norethind-eth estrad 0.5-2.5 MM
norethind-eth estrad 1-0.02 mg MM
norethindrone 0.35 mg tablet MM
norethindrone 5 mg tablet MM
norg-ee 0.18-0.215-0.25/0.035 MM
norg-ethin estra 0.25-0.035 mg MM
NORINYL 1+35 (28) 1 MG-35 MCG TABLET MM
NORINYL 1+50 (28) 1 MG-50 MCG TABLET MM
NORITATE 1 % TOPICAL CREAM
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
120 - FORMULARY Updated 09/2015
DRUG NAME
norlyroc 0.35 mg tablet MM
NORM-JECT SYRINGE
normlgel ag 0.11 % topical
NOROXIN 400 MG TABLET
NORPACE 100 MG CAPSULE MM
NORPACE 150 MG CAPSULE MM
NORPACE CR 100 MG CAPSULE,EXTENDED RELEASE MM
NORPACE CR 150 MG CAPSULE,EXTENDED RELEASE MM
NORPRAMIN 10 MG TABLET MM
NORPRAMIN 100 MG TABLET MM
NORPRAMIN 150 MG TABLET MM
NORPRAMIN 25 MG TABLET MM
NORPRAMIN 50 MG TABLET MM
NORPRAMIN 75 MG TABLET MM
NORTHERA 100 MG CAPSULE SP
NORTHERA 200 MG CAPSULE SP
NORTHERA 300 MG CAPSULE SP
nortrel 0.5/35 (28) 0.5 mg-35 mcg tablet MM
nortrel 1/35 (21) 1 mg-35 mcg tablet MM
nortrel 1/35 (28) 1 mg-35 mcg tablet MM
nortrel 7/7/7 (28) 0.5 mg/0.75 mg/1 mg-35 mcg tablet MM
nortriptyline 10 mg/5 ml sol MM
nortriptyline hcl 10 mg cap MM
nortriptyline hcl 25 mg cap MM
nortriptyline hcl 50 mg cap MM
nortriptyline hcl 75 mg cap MM
NORVASC 10 MG TABLET MM
NORVASC 2.5 MG TABLET MM
NORVASC 5 MG TABLET MM
NORVIR 100 MG CAPSULE
NORVIR 100 MG TABLET
NORVIR 80 MG/ML ORAL SOLUTION
NOVA MAX BLOOD GLUCOSE METER
NOVA MAX GLUCOSE CONTROL SOLUTION
NOVA MAX GLUCOSE TEST STRIPS MM
NOVA SAFETY LANCETS 23 GAUGE
NOVA SUREFLEX LANCETS
NOVACORT 2 %-1 %-1 % TOPICAL GEL
NOVAFERRUM SOLUTION
NOVAMAX PLUS GLU-KET SOLUTION
NOVOFINE 30 30 X 1/3" NEEDLE
NOVOFINE 32 32 X 1/4" NEEDLE
NOVOFINE AUTOCOVER 30 X 1/3" NEEDLE
NOVOFINE PLUS 32 GAUGE X 1/6" NEEDLE
NOVOLIN 70/30 100 UNIT/ML SUBCUTANEOUS SUSPENSION MM
DRUG LEVEL
2
1
3
3
3
3
3
3
3
3
3
3
3
3
*
*
*
1
2
1
1
2
1
1
1
1
3
3
3
3
3
3
3
3
3
1
1
3
2
3
1
1
1
1
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,PA
QL,PA
QL,PA
QL
QL
QL
QL
QL
QL
ST
QL,ST
ST
ST
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 121
DRUG NAME
NOVOLIN N 100 UNIT/ML SUBCUTANEOUS SUSPENSION MM
NOVOLIN R 100 UNIT/ML INJECTION SOLUTION MM
NOVOLOG 100 UNIT/ML SUBCUTANEOUS SOLUTION MM
NOVOLOG FLEXPEN 100 UNIT/ML SUBCUTANEOUS MM
NOVOLOG MIX 70-30 100 UNIT/ML SUBCUTANEOUS SOLUTION MM
NOVOLOG MIX 70-30 FLEXPEN 100 UNIT/ML SUBCUTANEOUS PEN MM
NOVOLOG PENFILL 100 UNIT/ML SUBCUTANEOUS CARTRIDGE MM
NOVOPEN 3 INSULIN DEVICE
NOVOPEN 3 PENMATE DEVICE
NOVOPEN ECHO SUBCUTANEOUS
NOVOPEN JR INSULIN DEVICE
NOVOTWIST 30 X 1/3" NEEDLE
NOVOTWIST 32 X 1/5" NEEDLE
NOXAFIL 100 MG TABLET,DELAYED RELEASE
NOXAFIL 200 MG/5 ML (40 MG/ML) ORAL SUSPENSION
np thyroid 30 mg tablet MM
np thyroid 60 mg tablet MM
np thyroid 90 mg tablet MM
NUCORT 2 % LOTION
NUCYNTA 100 MG TABLET
NUCYNTA 50 MG TABLET
NUCYNTA 75 MG TABLET
NUCYNTA ER 100 MG TABLET,EXTENDED RELEASE
NUCYNTA ER 150 MG TABLET,EXTENDED RELEASE
NUCYNTA ER 200 MG TABLET,EXTENDED RELEASE
NUCYNTA ER 250 MG TABLET,EXTENDED RELEASE
NUCYNTA ER 50 MG TABLET,EXTENDED RELEASE
NUEDEXTA 20 MG-10 MG CAPSULE
nulev 0.125 mg disintegrating tablet MM
NULYTELY WITH FLAVOR PACKS 420 GRAM ORAL SOLUTION
NUMOISYN 0.3 GRAM LOZENGES
NUMOISYN ORAL MUCOSAL LIQUID
NUOX 6 %-3 % TOPICAL GEL
NUTRESTORE 5 GRAM ORAL POWDER PACKET
NUTROPIN 10 MG VIAL SP
NUTROPIN AQ 10 MG/2 ML (5 MG/ML) SUBCUTANEOUS CARTRIDGE SP
NUTROPIN AQ 20 MG/2 ML (10 MG/ML) SUBCUTANEOUS CARTRIDGE SP
NUTROPIN AQ NUSPIN 10 MG/2 ML (5 MG/ML) SUBCUTANEOUS CARTRIDGE SP
NUTROPIN AQ NUSPIN 20 MG/2 ML (10 MG/ML) SUBCUTANEOUS CARTRIDGE SP
NUTROPIN AQ NUSPIN 5 MG/2 ML (2.5 MG/ML) SUBCUTANEOUS CARTRIDGE SP
NUVAIL 16 % NAIL FILM SOLUTION
NUVARING 0.12 MG -0.015 MG/24 HR VAGINAL MM
NUVESSA 1.3 % VAGINAL GEL
NUVIGIL 150 MG TABLET MM
NUVIGIL 200 MG TABLET MM
NUVIGIL 250 MG TABLET MM
NUVIGIL 50 MG TABLET MM
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
122 - FORMULARY Updated 09/2015
DRUG LEVEL
3
3
3
3
3
3
3
3
3
3
3
1
1
4
4
1
1
1
3
3
3
3
3
3
3
3
3
2
3
3
3
3
3
3
*
*
*
*
*
*
3
2
3
3
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
ST
ST
ST
ST
ST
ST
ST
QL,PA
QL,PA
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL
QL,PA
QL,PA
QL,PA
QL,PA
DRUG NAME
nyamyc 100,000 unit/gram topical powder
NYMALIZE 60 MG/20 ML ORAL SOLUTION
nystatin 100,000 unit/gm cream
nystatin 100,000 unit/gm powd
nystatin 100,000 units/gm oint
nystatin 100,000 units/ml susp
nystatin 150,000,000 units pwd
nystatin 50,000,000 units pwd
nystatin 500,000 unit oral tab
nystatin 500,000,000 units pwd
nystatin-triamcinolone cream
nystatin-triamcinolone ointm
nystop 100,000 unit/gram topical powder
O-CAL FA 66 MG-1 MG TABLET
O-CAL PRENATAL 15 MG-1 MG TABLET
OB COMPLETE 400 CAPSULE
OB COMPLETE 50 MG-1.25 MG TABLET
OB COMPLETE CHEWABLE TABLET
OB COMPLETE ONE 40 MG-10 MG-1 MG-300 MG CAPSULE
OB COMPLETE PETITE 35 MG IRON-5 MG IRON-1 MG CAPSULE
OB COMPLETE PREMIER 30 MG-20 MG-1 MG TABLET
OB COMPLETE WITH DHA 30 MG IRON-10 MG IRON-1 MG CAPSULE
OBREDON 2.5 MG-200 MG/5 ML ORAL SOLUTION
obstetrix dha 29 mg iron-1 mg-50 mg tablet&capsule,delayed release
OBSTETRIX EC 29 MG-1 MG-50 MG TABLET,DELAYED RELEASE
OBTREX DHA 29 MG IRON-1 MG-50 MG TABLET&CAPSULE,DELAYED RELEASE
OBTREX PRENATAL CAPLET
ocella 3 mg-0.03 mg tablet MM
octreotide 1,000 mcg/5 ml vial SP
octreotide 1,000 mcg/ml vial SP
octreotide acet 100 mcg/ml syr SP
octreotide acet 100 mcg/ml vl SP
octreotide acet 50 mcg/ml amp SP
octreotide acet 50 mcg/ml syr SP
octreotide acet 500 mcg/ml syr SP
octreotide acet 500 mcg/ml vl SP
OCUDOX CONVENIENCE KIT
OCUFEN 0.03 % EYE DROPS
OCUFLOX 0.3 % EYE DROPS
OFEV 100 MG CAPSULE SP
OFEV 150 MG CAPSULE SP
ofloxacin 0.3% ear drops
ofloxacin 0.3% eye drops
ofloxacin 200 mg tablet
ofloxacin 300 mg tablet
ofloxacin 400 mg tablet
ogestrel (28) 0.5 mg-50 mcg tablet MM
olanzapine 10 mg tablet MM
DRUG LEVEL
2
4
2
2
2
2
3
3
2
3
3
3
2
1
1
3
3
3
3
3
3
3
3
2
1
2
1
2
*
*
*
*
*
*
*
*
3
3
3
*
*
2
2
2
2
2
2
1
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
PA
PA
PA
PA
PA
PA
PA
PA
ST
QL,PA
QL,PA
QL
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 123
DRUG NAME
olanzapine 15 mg tablet MM
olanzapine 2.5 mg tablet MM
olanzapine 20 mg tablet MM
olanzapine 5 mg tablet MM
olanzapine 7.5 mg tablet MM
olanzapine odt 10 mg tablet MM
olanzapine odt 15 mg tablet MM
olanzapine odt 20 mg tablet MM
olanzapine odt 5 mg tablet MM
olanzapine-fluoxetine 12-25 mg MM
olanzapine-fluoxetine 12-50 mg MM
olanzapine-fluoxetine 3-25 mg MM
olanzapine-fluoxetine 6-25 mg MM
olanzapine-fluoxetine 6-50 mg MM
OLEPTRO ER 150 MG TABLET,EXTENDED RELEASE MM
OLEPTRO ER 300 MG TABLET,EXTENDED RELEASE MM
olopatadine 665 mcg nasal spry
OLUX 0.05 % TOPICAL FOAM
OLUX-E 0.05 % TOPICAL FOAM
OLYSIO 150 MG CAPSULE SP
OMECLAMOX-PAK 20 MG (20)-500 MG (20) ORAL PACK
omega-3 ethyl esters 1 gm cap MM
omeprazole dr 10 mg capsule MM
omeprazole dr 20 mg capsule MM
omeprazole dr 40 mg capsule MM
omeprazole-bicarb 20-1,100 cap MM
omeprazole-bicarb 40-1,100 cap MM
OMNARIS 50 MCG NASAL SPRAY MM
OMNIPRED 1 % EYE DROPS,SUSPENSION
OMNITROPE 10 MG/1.5 ML (6.7 MG/ML) SUBCUTANEOUS CARTRIDGE SP
OMNITROPE 5 MG/1.5 ML (3.3 MG/ML) SUBCUTANEOUS CARTRIDGE SP
OMNITROPE 5.8 MG SUBCUTANEOUS SOLUTION SP
ON CALL EXPRESS CONTROL SOLUTION
ON CALL EXPRESS METER
ON CALL EXPRESS METER KIT
ON CALL EXPRESS TEST STRIP MM
ON CALL LANCET 30 GAUGE
ON CALL LANCING DEVICE
ON CALL PLUS CONTROL SOLUTION
ON CALL PLUS LANCET 30 GAUGE
ON CALL PLUS LANCING DEVICE
ON CALL PLUS METER
ON CALL PLUS METER KIT
ON CALL PLUS TEST STRIP MM
ON CALL VIVID CONTROL SOLUTION
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
124 - FORMULARY Updated 09/2015
DRUG LEVEL
1
1
1
1
1
3
3
3
3
3
3
3
3
3
3
3
3
4
3
*
3
3
1
1
1
3
3
2
3
*
*
*
3
3
3
3
3
3
3
3
3
3
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL,PA
QL,PA
QL,ST
ST
ST
QL,PA
QL
QL
QL
QL
QL,ST
QL,ST
QL
ST
QL,PA
QL,PA
QL,PA
ST
ST
QL,ST
ST
ST
QL,ST
DRUG NAME
ON CALL VIVID METER
ON CALL VIVID METER KIT
ON CALL VIVID PAL BLOOD GLUCOSE METER
ON CALL VIVID PAL BLOOD GLUCOSE METER KIT
ON CALL VIVID TEST STRIP MM
ON-THE-GO LANCETS 30 GAUGE
ondansetron 4 mg/5 ml solution
ondansetron hcl 24 mg tablet
ondansetron hcl 4 mg tablet
ondansetron hcl 8 mg tablet
ondansetron odt 4 mg tablet
ondansetron odt 8 mg tablet
ONETOUCH DELICA LANCETS 30 GAUGE
ONETOUCH DELICA LANCETS 33 GAUGE
ONETOUCH DELICA LANCING DEVICE KIT
ONETOUCH FINEPOINT LANCETS 25 GAUGE
ONETOUCH SURESOFT LANCING DEVICES
ONETOUCH ULTRA CONTROL SOLUTION
ONETOUCH ULTRA SYSTEM KIT
ONETOUCH ULTRA TEST STRIPS MM
ONETOUCH ULTRA2 KIT
ONETOUCH ULTRALINK SYSTEM
ONETOUCH ULTRAMINI KIT
ONETOUCH ULTRASOFT LANCETS
ONETOUCH VERIO HIGH CONTROL SOLUTION
ONETOUCH VERIO IQ METER
ONETOUCH VERIO MID CONTROL SOLUTION
ONETOUCH VERIO STRIPS MM
ONETOUCH VERIO SYNC KIT
ONETOUCH VERIO SYSTEM
ONEXTON 1.2 % (1 % BASE)-3.75 % TOPICAL GEL
ONFI 10 MG TABLET MM
ONFI 2.5 MG/ML ORAL SUSPENSION MM
ONFI 20 MG TABLET MM
ONFI 5 MG TABLET MM
ONGLYZA 2.5 MG TABLET MM
ONGLYZA 5 MG TABLET MM
ONSOLIS 1,200 MCG SOLUBLE FILM
ONSOLIS 200 MCG SOLUBLE FILM
ONSOLIS 400 MCG SOLUBLE FILM
ONSOLIS 600 MCG SOLUBLE FILM
ONSOLIS 800 MCG SOLUBLE FILM
OPANA 10 MG TABLET
OPANA 5 MG TABLET
OPANA ER 10 MG TABLET, CRUSH RESISTANT, EXTENDED RELEASE
OPANA ER 15 MG TABLET, CRUSH RESISTANT, EXTENDED RELEASE
OPANA ER 20 MG TABLET, CRUSH RESISTANT, EXTENDED RELEASE
OPANA ER 30 MG TABLET, CRUSH RESISTANT, EXTENDED RELEASE
OPANA ER 40 MG TABLET, CRUSH RESISTANT, EXTENDED RELEASE
DRUG LEVEL
3
3
3
3
3
1
3
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
3
1
3
3
3
3
3
3
2
4
4
4
4
3
3
3
3
3
3
3
3
3
2
2
2
2
2
UTILIZATION
MANAGEMENT
REQUIREMENTS
ST
ST
ST
ST
QL,ST
QL
QL
QL
QL
QL
QL
ST
QL,ST
ST
ST
ST
ST
QL,ST
ST
ST
QL,PA
QL,PA
QL,PA
QL,PA
QL
QL
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL
QL
QL
QL
QL
QL
QL
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 125
DRUG NAME
OPANA ER 5 MG TABLET, CRUSH RESISTANT, EXTENDED RELEASE
OPANA ER 7.5 MG TABLET, CRUSH RESISTANT, EXTENDED RELEASE
opium tincture 10 mg/ml
OPSUMIT 10 MG TABLET SP
OPTICHAMBER ADULT MASK-LARGE
OPTICHAMBER DIAMOND DEVICE
OPTICHAMBER DIAMOND-LG MSK DEVICE
OPTICHAMBER DIAMOND-MED MSK DEVICE
OPTICHAMBER DIAMOND-SML MSK DEVICE
OPTIUM EZ STRIPS MM
OPTIUM TEST STRIPS MM
OPTIVAR 0.05% DROPS
OPTUMRX KIT
OPTUMRX MISC
OPTUMRX SOLUTION
OPTUMRX STRIPS MM
ORACEA 40 MG CAPSULE,IMMEDIATE & DELAY RELEASE
ORACIT 490 MG-640 MG/5 ML ORAL SOLUTION
ORAFATE 1 GRAM/10 ML MUCOSAL PASTE
ORALAIR 300 IR SUBLINGUAL TABLET
oralone 0.1 % dental paste
ORAMAGICRX MOUTHWASH
ORAP 1 MG TABLET MM
ORAP 2 MG TABLET MM
ORAPRED 15 MG/5 ML SOLUTION
ORAPRED ODT 10 MG DISINTEGRATING TABLET
ORAPRED ODT 15 MG DISINTEGRATING TABLET
ORAPRED ODT 30 MG DISINTEGRATING TABLET
ORAVIG 50 MG BUCCAL TABLET
ORENCIA 125 MG/ML SUBCUTANEOUS SYRINGE SP
ORENITRAM 0.125 MG TABLET,EXTENDED RELEASE SP
ORENITRAM 0.25 MG TABLET,EXTENDED RELEASE SP
ORENITRAM 1 MG TABLET,EXTENDED RELEASE SP
ORENITRAM 2.5 MG TABLET,EXTENDED RELEASE SP
ORFADIN 10 MG CAPSULE SP
ORFADIN 2 MG CAPSULE SP
ORFADIN 5 MG CAPSULE SP
ORKAMBI 200 MG-125 MG TABLET SP
orphenadrine comp forte tab
orphenadrine comp tablet
orphenadrine er 100 mg tablet
orsythia 0.1 mg-20 mcg tablet MM
ORTHO ALL-FLEX DIAPHRAGM 65MM
ORTHO ALL-FLEX DIAPHRAGM 70MM
ORTHO ALL-FLEX DIAPHRAGM 75MM
ORTHO ALL-FLEX DIAPHRAGM 80MM
ORTHO ALL-FLEX FITTING SET
ortho d 3,775 unit-1 mg capsule
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
126 - FORMULARY Updated 09/2015
DRUG LEVEL
2
2
4
*
1
3
2
2
2
3
3
3
3
3
3
3
3
1
3
3
2
4
3
3
3
3
3
3
3
*
*
*
*
*
*
*
*
*
3
2
2
1
3
3
3
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL,PA
QL,ST
QL,ST
ST
ST
ST
QL,ST
QL
QL,PA
QL
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
DRUG NAME
ORTHO EVRA 150 MCG-35 MCG/24 HR TRANSDERMAL PATCH MM
ORTHO MICRONOR 0.35 MG TABLET MM
ORTHO TRI-CYCLEN (28) 0.18 MG(7)/0.215 MG(7)/0.25 MG(7)-35 MCG TABLET MM
ORTHO TRI-CYCLEN LO (28) 0.18 MG/0.215 MG/0.25 MG-25 MCG TABLET MM
ORTHO-CEPT (28) 0.15 MG-0.03 MG TABLET MM
ORTHO-CYCLEN (28) 0.25 MG-35 MCG TABLET MM
ORTHO-NOVUM 1/35 (28) 1 MG-35 MCG TABLET MM
ORTHO-NOVUM 7/7/7 (28) 0.5 MG/0.75 MG/1 MG-35 MCG TABLET MM
oscimin 0.125 mg disintegrating tablet MM
oscimin 0.125 mg tablet MM
oscimin sl 0.125 mg sublingual tablet MM
oscimin sr 0.375 mg tablet,extended release MM
OSENI 12.5 MG-15 MG TABLET MM
OSENI 12.5 MG-30 MG TABLET MM
OSENI 12.5 MG-45 MG TABLET MM
OSENI 25 MG-15 MG TABLET MM
OSENI 25 MG-30 MG TABLET MM
OSENI 25 MG-45 MG TABLET MM
OSMOPREP 1.5 GRAM (1.102-0.398) TABLET
OSPHENA 60 MG TABLET MM
OTEZLA 30 MG TABLET SP
OTEZLA STARTER 10 MG (4)-20 MG (4)-30 MG(19) TABLETS IN A DOSE PACK SP
OTEZLA STARTER 10 MG (4)-20 MG (4)-30 MG(47) TABLETS IN A DOSE PACK SP
otic care otic solution
oticin 0.1 %-1 % ear drops
oticin hc (bak free) 10 mg-10 mg-1 mg/ml ear drops
oto-end 10 10 mg-10 mg-1 mg/ml ear drops
otomax-hc ear drops
otozin 5.4 %-1 %-2 %1 % ear drops
OTREXUP (PF) 10 MG/0.4 ML SUBCUTANEOUS AUTO-INJECTOR
OTREXUP (PF) 15 MG/0.4 ML SUBCUTANEOUS AUTO-INJECTOR
OTREXUP (PF) 20 MG/0.4 ML SUBCUTANEOUS AUTO-INJECTOR
OTREXUP (PF) 25 MG/0.4 ML SUBCUTANEOUS AUTO-INJECTOR
OVACE 10 % TOPICAL CLEANSER
OVACE PLUS 10 % TOPICAL CLEANSER,EXTENDED RELEASE
OVACE PLUS 10 % TOPICAL CREAM
OVACE PLUS 9.8 % LOTION
OVACE PLUS 9.8 % TOPICAL FOAM
OVACE PLUS SHAMPOO 10 %
OVACE PLUS WASH 10 % TOP CLEANSER,GEL EXTENDED RELEASE
OVCON-35 (28) 0.4 MG-35 MCG TABLET MM
OVIDE 0.5 % LOTION
OXALIS OINTMENT
oxaprozin 600 mg tablet MM
oxazepam 10 mg capsule
oxazepam 15 mg capsule
DRUG LEVEL
3
3
3
2
3
3
3
3
2
2
2
2
3
3
3
3
3
3
3
3
*
*
*
3
2
2
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
2
2
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
QL
QL
QL
ST
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 127
DRUG NAME
oxazepam 30 mg capsule
oxcarbazepine 150 mg tablet MM
oxcarbazepine 300 mg tablet MM
oxcarbazepine 300 mg/5 ml susp MM
oxcarbazepine 600 mg tablet MM
OXECTA 5 MG TABLET,ORAL ONLY(NOT FEEDING TUBES)
OXECTA 7.5 MG TABLET,ORAL ONLY(NOT FEEDING TUBES)
OXISTAT 1 % LOTION
OXISTAT 1 % TOPICAL CREAM
OXSORALEN 1 % LOTION
OXSORALEN ULTRA 10 MG CAPSULE
OXTELLAR XR 150 MG TABLET,EXTENDED RELEASE MM
OXTELLAR XR 300 MG TABLET,EXTENDED RELEASE MM
OXTELLAR XR 600 MG TABLET,EXTENDED RELEASE MM
oxybutynin 5 mg tablet MM
oxybutynin 5 mg/5 ml syrup MM
oxybutynin cl er 10 mg tablet MM
oxybutynin cl er 15 mg tablet MM
oxybutynin cl er 5 mg tablet MM
OXYCEL COTTON-TYPE PLEDGET 2" X 1" X 1" PADS
oxycodon-acetaminophen 2.5-325
oxycodon-acetaminophen 7.5-325
oxycodon-acetaminophen 7.5-500
oxycodone hcl 10 mg tablet
oxycodone hcl 100 mg/5 ml soln
oxycodone hcl 15 mg tablet
oxycodone hcl 20 mg tablet
oxycodone hcl 30 mg tablet
oxycodone hcl 5 mg capsule
oxycodone hcl 5 mg tablet
oxycodone hcl 5 mg/5 ml soln
oxycodone hcl er 10 mg tablet
oxycodone hcl er 20 mg tablet
oxycodone hcl er 40 mg tablet
oxycodone hcl er 80 mg tablet
oxycodone-acetaminophen 10-325
oxycodone-acetaminophen 10-650
oxycodone-acetaminophen 5-325
oxycodone-acetaminophen 5-500
oxycodone-aspirin 4.8355-325
oxycodone-ibuprofen 5-400 tab
OXYCONTIN 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE
OXYCONTIN 15 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE
OXYCONTIN 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE
OXYCONTIN 30 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE
OXYCONTIN 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE
OXYCONTIN 60 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE
OXYCONTIN 80 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE
oxymorphone hcl 10 mg tablet
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
128 - FORMULARY Updated 09/2015
DRUG LEVEL
2
2
2
3
2
3
3
3
3
3
4
3
3
3
1
1
2
2
2
3
2
2
2
2
3
2
2
2
2
2
2
3
3
3
4
2
2
2
2
2
2
4
4
4
4
4
4
4
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,PA
QL,PA
ST
ST
QL,ST
QL,ST
QL,ST
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL,PA
QL,PA
QL,PA
QL,PA
QL
QL
QL
QL
QL
QL
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL
DRUG NAME
oxymorphone hcl 5 mg tablet
oxymorphone hcl er 10 mg tab
oxymorphone hcl er 15 mg tab
oxymorphone hcl er 20 mg tab
oxymorphone hcl er 30 mg tab
oxymorphone hcl er 40 mg tab
oxymorphone hcl er 5 mg tablet
oxymorphone hcl er 7.5 mg tab
OXYTROL 3.9 MG/24 HR TRANSDERMAL PATCH MM
PACERONE 100 MG TABLET MM
pacerone 200 mg tablet MM
PACERONE 400 MG TABLET MM
PACNEX 7 % TOPICAL CLEANSER
PACNEX HP 7 % TOPICAL PADS
PACNEX LP 4.25 % TOPICAL PADS
PACNEX MX 4.25 % TOPICAL CLEANSER
PAIN EASE TOPICAL SPRAY
paire ob plus dha 22 mg-6 mg-1 mg-200 mg oral pack
palgic 4 mg tablet
palgic 4 mg/5 ml liquid
PAMELOR 10 MG CAPSULE MM
PAMELOR 25 MG CAPSULE MM
PAMELOR 50 MG CAPSULE MM
PAMELOR 75 MG CAPSULE MM
PAMINE 2.5 MG TABLET
PAMINE FORTE 5 MG TABLET
PAMINE FQ DOSE PACK KIT
PANCREAZE 10,500-25,000-43,750 UNIT CAPSULE,DELAYED RELEASE MM
PANCREAZE 16,800-40,000-70,000 UNIT CAPSULE,DELAYED RELEASE MM
PANCREAZE 21,000-37,000-61,000 UNIT CAPSULE,DELAYED RELEASE MM
PANCREAZE 4,200-10,000-17,500 UNIT CAPSULE,DELAYED RELEASE MM
pancrelipase 5000 5,000-17,000-27,000 unit capsule,delayed release MM
PANDEL 0.1 % TOPICAL CREAM
PANRETIN 0.1 % TOPICAL GEL SP
pantoprazole sod dr 20 mg tab MM
pantoprazole sod dr 40 mg tab MM
papaverine 150 mg capsule sa MM
PARADIGM REAL-TIME TRANSMITTER MISC MM
PARADIGM RESERVOIR 1.8 ML MM
PARADIGM RESERVOIR 3 ML MM
PARAFON FORTE DSC 500 MG TABLET
PARAGARD T 380A 380 SQUARE MM INTRAUTERINE DEVICE MM,SP
parcaine 0.5% eye drops
PARCOPA 10 MG-100 MG ODT MM
PARCOPA 25 MG-100 MG ODT MM
PARCOPA 25 MG-250 MG ODT MM
DRUG LEVEL
3
3
3
3
3
3
3
3
3
2
1
2
3
3
3
3
3
2
3
2
4
4
4
4
2
3
3
4
4
4
4
2
3
*
1
1
1
3
3
3
3
4
2
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
QL
QL
QL
QL
QL,ST
ST
ST
ST
ST
QL
QL
PA
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 129
DRUG NAME
paregoric liquid
PAREMYD 1 %-0.25 % EYE DROPS MM
paricalcitol 1 mcg capsule MM
paricalcitol 2 mcg capsule MM
paricalcitol 4 mcg capsule MM
PARLODEL 2.5 MG TABLET MM
PARLODEL 5 MG CAPSULE MM
PARNATE 10 MG TABLET MM
paroex oral rinse 0.12 % mouthwash
paromomycin 250 mg capsule
paroxetine cr 12.5 mg tablet MM
paroxetine cr 25 mg tablet MM
paroxetine er 37.5 mg tablet MM
paroxetine hcl 10 mg tablet MM
paroxetine hcl 20 mg tablet MM
paroxetine hcl 30 mg tablet MM
paroxetine hcl 40 mg tablet MM
PASER 4 GRAM GRANULES DELAYED-RELEASE PACKET MM
PATADAY 0.2 % EYE DROPS
PATANASE 0.6 % NASAL SPRAY
PATANOL 0.1 % EYE DROPS
PAXIL 10 MG TABLET MM
PAXIL 10 MG/5 ML ORAL SUSPENSION MM
PAXIL 20 MG TABLET MM
PAXIL 30 MG TABLET MM
PAXIL 40 MG TABLET MM
PAXIL CR 12.5 MG TABLET,EXTENDED RELEASE MM
PAXIL CR 25 MG TABLET,EXTENDED RELEASE MM
PAXIL CR 37.5 MG TABLET,EXTENDED RELEASE MM
PAZEO 0.7 % EYE DROPS
PCE 333 MG PARTICLES IN TABLET
PCE 500 MG PARTICLES IN TABLET
pedi-dri topical powder
PEDIADERM AF 100,000 UNIT/GRAM TOPICAL CREAM
PEDIADERM HC 2 % KIT,LOTION & CREAM,EMOLLIENT
PEDIADERM TA 0.1 % TOPICAL CREAM
PEDIAPRED 5 MG BASE/5 ML (6.7 MG/5 ML) ORAL SOLUTION
PEDIATRIC MULTIVITAMINS-A,B,D,E,K,ZN 500 UNIT-400 MCG/ML ORAL DROPS
PEDIPIROX-4 NAIL KIT
peg 3350 electrolyte soln
peg-3350 and electrolytes soln
peg-3350 solution
peg-3350 with flavor packs 420 gram oral solution
peg-prep 5 mg-210 gram oral kit
PEGANONE 250 MG TABLET MM
PEGASYS 180 MCG/0.5 ML SUBCUTANEOUS SYRINGE SP
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
130 - FORMULARY Updated 09/2015
DRUG LEVEL
3
3
3
3
3
3
3
3
2
3
3
3
3
1
1
1
1
3
2
3
3
3
3
3
3
3
3
3
3
2
3
3
2
3
3
3
3
3
3
2
2
2
2
3
2
*
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL,ST
ST
QL
QL
QL
QL
QL
QL
QL
QL,PA
DRUG NAME
PEGASYS 180 MCG/0.5 ML SYRINGE SP
PEGASYS 180 MCG/ML SUBCUTANEOUS SOLUTION SP
PEGASYS PROCLICK 135 MCG/0.5 ML SUBCUTANEOUS PEN INJECTOR SP
PEGASYS PROCLICK 180 MCG/0.5 ML SUBCUTANEOUS PEN INJECTOR SP
PEGINTRON 120 MCG/0.5 ML SUBCUTANEOUS KIT SP
PEGINTRON 150 MCG/0.5 ML SUBCUTANEOUS KIT SP
PEGINTRON 50 MCG/0.5 ML SUBCUTANEOUS KIT SP
PEGINTRON 80 MCG/0.5 ML SUBCUTANEOUS KIT SP
PEGINTRON REDIPEN 120 MCG/0.5 ML SUBCUTANEOUS KIT SP
PEGINTRON REDIPEN 150 MCG/0.5 ML SUBCUTANEOUS KIT SP
PEGINTRON REDIPEN 50 MCG/0.5 ML SUBCUTANEOUS KIT SP
PEGINTRON REDIPEN 80 MCG/0.5 ML SUBCUTANEOUS KIT SP
PEN NEEDLE 29 GAUGE
PEN NEEDLE 29 GAUGE X 1/2"
PEN NEEDLE 30 X 5/16"
PEN NEEDLE 31 GAUGE X 1/4"
PEN NEEDLE 31 X 3/16"
PEN NEEDLE 31 X 5/16"
PEN NEEDLE 32 X 5/32"
PEN NEEDLES 6MM 31G
penicillin vk 125 mg/5 ml soln
penicillin vk 250 mg tablet
penicillin vk 250 mg/5 ml soln
penicillin vk 500 mg tablet
PENLET PLUS BLOOD SAMPLER KIT
PENNSAID 1.5% SOLUTION MM
PENNSAID 20 MG/GRAM/ACTUATION (2 %) TOPICAL SOLN IN METERED-DOSE
PUMP
PENTASA 250 MG CAPSULE,EXTENDED RELEASE MM
PENTASA 500 MG CAPSULE,EXTENDED RELEASE MM
pentazocin-acetaminophn 25-650
pentazocine-naloxone tablet
PENTIPS 31 X 3/16" NEEDLE
PENTIPS 31 X 5/16" NEEDLE
PENTIPS 32 X 5/32" NEEDLE
pentoxifylline er 400 mg tab MM
PEPCID 20 MG TABLET MM
PEPCID 40 MG TABLET MM
PEPCID 40 MG/5 ML ORAL SUSPENSION MM
PERCOCET 10 MG-325 MG TABLET
PERCOCET 10-650 MG TABLET
PERCOCET 2.5 MG-325 MG TABLET
PERCOCET 5 MG-325 MG TABLET
PERCOCET 7.5 MG-325 MG TABLET
PERCOCET 7.5-500 MG TABLET
PERCODAN 4.8355-325 MG TABLET
PERCURA 35.2 MG-10.2 MG-35.2 MG CAPSULE
DRUG LEVEL
UTILIZATION
MANAGEMENT
REQUIREMENTS
*
*
*
*
*
*
*
*
*
*
*
*
1
1
1
1
1
1
1
1
2
2
2
2
3
3
3
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
4
4
2
3
1
1
1
1
3
3
3
4
4
4
4
4
4
3
3
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 131
DRUG NAME
PERFOROMIST 20 MCG/2 ML SOLUTION FOR NEBULIZATION MM
PERIDEX 0.12 % MOUTHWASH
perindopril erbumine 2 mg tab MM
perindopril erbumine 4 mg tab MM
perindopril erbumine 8 mg tab MM
periogard 0.12 % mouthwash
permethrin 5% cream
perphen-amitrip 2 mg-10 mg tab MM
perphen-amitrip 2 mg-25 mg tab MM
perphen-amitrip 4 mg-10 mg tab MM
perphen-amitrip 4 mg-25 mg tab MM
perphen-amitrip 4 mg-50 mg tab MM
perphenazine 16 mg tablet MM
perphenazine 2 mg tablet MM
perphenazine 4 mg tablet MM
perphenazine 8 mg tablet MM
PERSANTINE 25 MG TABLET MM
PERSANTINE 50 MG TABLET MM
PERSANTINE 75 MG TABLET MM
PERTZYE 16,000-57,500-60,500 UNIT CAPSULE,DELAYED RELEASE MM
PERTZYE 8,000-28,750 UNIT-30,250 UNIT CAPSULE,DELAYED RELEASE MM
PEXEVA 10 MG TABLET MM
PEXEVA 20 MG TABLET MM
PEXEVA 30 MG TABLET MM
PEXEVA 40 MG TABLET MM
PFLEX INSPIRATORY TRAINER DEVICE
PHARMACIST CHOICE 30G LANCETS
PHARMACIST CHOICE 33G LANCETS
PHARMACIST CHOICE BLOOD GLUCOSE SYSTEM
PHARMACIST CHOICE GLUCOSE TEST STRIPS MM
PHASEAL PROTECTOR 13 MM DEVICE
PHASEAL PROTECTOR 20 MM DEVICE
PHASEAL PROTECTOR 28 MM DEVICE
phenadoz 12.5 mg rectal suppository
phenadoz 25 mg rectal suppository
phenazopyridine 100 mg tab
phenazopyridine 200 mg tab
phenazopyridine plus tablet
phenelzine sulfate 15 mg tab MM
PHENERGAN 12.5 MG RECTAL SUPPOSITORY
PHENERGAN 25 MG RECTAL SUPPOSITORY
PHENERGAN 50 MG RECTAL SUPPOSITORY
PHENFLU CD TABLET
PHENFLU CDX TABLET
phenobarbital 100 mg tablet MM
phenobarbital 15 mg tablet MM
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
132 - FORMULARY Updated 09/2015
DRUG LEVEL
4
3
1
1
1
2
3
3
3
2
3
3
3
3
3
3
3
3
3
4
4
3
3
3
3
1
1
1
3
3
1
1
1
3
3
2
2
3
3
3
3
3
3
3
2
2
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,PA
ST
ST
QL,ST
QL,ST
QL,ST
QL,ST
ST
QL,ST
QL
QL
DRUG NAME
phenobarbital 16.2 mg tablet MM
phenobarbital 20 mg/5 ml elix MM
phenobarbital 30 mg tablet MM
phenobarbital 32.4 mg tablet MM
phenobarbital 60 mg tablet MM
phenobarbital 64.8 mg tablet MM
phenobarbital 97.2 mg tablet MM
phenol liquified
phenoxybenzamine hcl 10 mg cap
phenylephrine 10% eye drops
phenylephrine 2.5% eye drop
PHENYTEK 200 MG CAPSULE MM
PHENYTEK 300 MG CAPSULE MM
phenytoin 100 mg/4 ml susp MM
phenytoin 125 mg/5 ml susp MM
phenytoin 50 mg tablet chew MM
phenytoin sod ext 100 mg cap MM
phenytoin sod ext 200 mg cap MM
phenytoin sod ext 300 mg cap MM
philith 0.4 mg-35 mcg tablet MM
PHISOHEX 3% CLEANSER
PHOSLO 667 MG CAPSULE MM
PHOSLYRA 667 MG (169 MG CALCIUM)/5 ML ORAL SOLUTION MM
phospha 250 neutral 250 mg tablet
phosphasal 81.6 mg-10.8 mg-40.8 mg tablet
PHOSPHOLINE IODIDE 0.125 % EYE DROPS MM
PHRENILIN FORTE CAPSULE
PHYSICIANS EZ USE B-12 1,000 MCG/ML INJECTION KIT
PHYSIOLYTE 140 MEQ-5 MEQ-3 MEQ-98 MEQ/L IRRIGATION SOLUTION
PHYSIOSOL IRRIGATION 140 MEQ-5 MEQ-3 MEQ-98 MEQ/L SOLUTION
phytonadione 1 mg/0.5 ml syr
PICATO 0.015 % TOPICAL GEL
PICATO 0.05 % TOPICAL GEL
pilocarpine 1% eye drops MM
pilocarpine 2% eye drops MM
pilocarpine 4% eye drops MM
pilocarpine hcl 5 mg tablet MM
pilocarpine hcl 7.5 mg tablet MM
pimtrea (28) 0.15 mg-0.02 mg (21)/0.01 mg (5) tablet MM
pindolol 10 mg tablet MM
pindolol 5 mg tablet MM
pinnacaine 20 % ear drops
pioglitaz-glimepir 30-2 mg tab MM
pioglitaz-glimepir 30-4 mg tab MM
pioglitazone hcl 15 mg tablet MM
DRUG LEVEL
2
2
2
2
2
2
2
3
4
2
2
3
3
1
1
2
2
2
1
2
3
3
3
2
2
3
4
3
3
3
4
3
3
2
2
2
2
2
2
2
2
3
3
3
1
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
QL
QL
QL
ST
QL
QL
QL
QL,ST
QL,ST
QL
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 133
DRUG NAME
pioglitazone hcl 30 mg tablet MM
pioglitazone hcl 45 mg tablet MM
pioglitazone-metformin 15-500 MM
pioglitazone-metformin 15-850 MM
pirmella 0.5/0.75/1 mg-35 mcg tablet MM
pirmella 1 mg-35 mcg tablet MM
piroxicam 10 mg capsule MM
piroxicam 20 mg capsule MM
PLAN B ONE-STEP 1.5 MG TABLET
PLAQUENIL 200 MG TABLET MM
PLAVIX 300 MG TABLET
PLAVIX 75 MG TABLET MM
PLEGRIDY 125 MCG/0.5 ML SUBCUTANEOUS PEN INJECTOR SP
PLEGRIDY 125 MCG/0.5 ML SUBCUTANEOUS SYRINGE SP
PLEGRIDY 63 MCG/0.5 ML-94 MCG/0.5 ML SUBCUTANEOUS PEN INJECTOR SP
PLEGRIDY 63 MCG/0.5 ML-94 MCG/0.5 ML SUBCUTANEOUS SYRINGE SP
PLETAL 100 MG TABLET MM
PLETAL 50 MG TABLET MM
PLEXION 9.8 %-4.8 % LOTION
PLEXION 9.8 %-4.8 % TOPICAL CLEANSER
PLEXION 9.8 %-4.8 % TOPICAL CREAM
PLEXION CLEANSING CLOTHS 9.8 %-4.8 %
PLIAGLIS 7 %-7 % TOPICAL CREAM
PNEUMOVAX 23 25 MCG/0.5 ML INJECTION SOLUTION
PNEUMOVAX 23 25 MCG/0.5 ML INJECTION SYRINGE
pnv 29-1 29 mg iron-1 mg tablet
pnv folic acid + iron tablet
pnv ob+dha 27 mg-1 mg-50 mg-250 mg oral pack
pnv-dha + docusate 27 mg-1.25 mg-55 mg-300 mg capsule
pnv-dha 27 mg-1 mg-300 mg capsule
pnv-ferrous fumarate 29 mg-docu 25 mg-fa 1 mg tablet
pnv-first softgel
pnv-ob with dha combo pack
pnv-omega 28 mg-1 mg-300 mg capsule
pnv-select 27 mg-1 mg tablet
pnv-total 35 mg-5 mg-1.2 mg-400 mg capsule
pnv-vp-u 106.5 mg-1 mg capsule
POCKET CHAMBER SPACER
PODIAPN 35 MG-5 MG-2 MG-300 MG CAPSULE
podocon 25 % topical liquid
podofilox 0.5% topical soln
POLIBAR ACB 96 % ENEMA
poly-iron 150 forte 150 mg-25 mcg-1 mg capsule
POLY-VI-FLOR 0.25 MG FLUORIDE CHEWABLE TABLET
POLY-VI-FLOR 0.25 MG/ML FLUORIDE BIPHASIC ORAL DROPS
POLY-VI-FLOR 0.5 MG FLUORIDE CHEWABLE TABLET
POLY-VI-FLOR 1 MG FLUORIDE CHEWABLE TABLET
POLY-VI-FLOR FS 0.25 MG FLUORIDE ORAL FILM
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
134 - FORMULARY Updated 09/2015
DRUG LEVEL
1
1
3
3
1
1
2
2
3
3
3
3
*
*
*
*
3
3
3
3
3
3
3
4
4
1
1
2
2
2
1
2
2
2
3
3
1
1
3
3
3
3
1
3
3
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
QL
QL
QL,PA
QL,PA
QL,PA
QL,PA
QL
DRUG NAME
POLY-VI-FLOR FS 0.5 MG FLUORIDE ORAL FILM
POLY-VI-FLOR FS 1 MG FLUORIDE ORAL FILM
POLY-VI-FLOR WITH IRON 0.25 MG FLUORIDE-7 MG IRON/ML BPHASE ORAL DROPS
POLY-VI-FLOR WITH IRON 0.5 MG FLUORIDE-10 MG IRON CHEWABLE TABLET
polycin 500 unit-10,000 unit/gram eye ointment
polyethylene glycol 3350 powd
polyethylene glycol 3350 powd
polymyxin b-tmp eye drops
POLYTRIM 10,000 UNIT-1 MG/ML EYE DROPS
POMALYST 1 MG CAPSULE SP
POMALYST 2 MG CAPSULE SP
POMALYST 3 MG CAPSULE SP
POMALYST 4 MG CAPSULE SP
PONSTEL 250 MG CAPSULE
PONTOCAINE 2 % TOPICAL SOLUTION
portia 0.15 mg-0.03 mg tablet MM
pot citrate-citric acid packet
POTABA 500 MG CAPSULE MM
potass cit-sod cit-citric soln
potassium 25 meq tablet eff MM
potassium cit-citric acid soln
potassium citrate er 10 meq tb MM
potassium citrate er 15 meq tb MM
potassium citrate er 5 meq tab MM
potassium cl 10% (40 meq/30 ml MM
potassium cl 20 meq packet MM
potassium cl 20% (40 meq/15 ml MM
potassium cl 25 meq tab eff MM
potassium cl er 10 meq capsule MM
potassium cl er 10 meq tablet MM
potassium cl er 10 meq tablet MM
potassium cl er 20 meq tablet MM
potassium cl er 20 meq tablet MM
potassium cl er 8 meq capsule MM
potassium cl er 8 meq tablet MM
potassium hydroxide 5% soln
POTIGA 200 MG TABLET MM
POTIGA 300 MG TABLET MM
POTIGA 400 MG TABLET MM
POTIGA 50 MG TABLET MM
pr benzoyl peroxide 7 % topical cleanser
pr benzoyl peroxide 7% wash
pr cream topical
pr natal 400 29 mg-1 mg-400 mg oral pack
pr natal 400 ec 29 mg-1 mg-400 mg tablet&capsule,delayed release
pr natal 430 29 mg-1 mg-430 mg oral pack
DRUG LEVEL
3
3
3
3
2
2
2
1
3
*
*
*
*
3
3
1
2
3
2
1
2
3
3
3
2
3
2
2
2
2
2
2
2
2
2
3
4
4
4
4
3
3
2
2
2
1
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL,PA
QL,PA
QL,PA
QL,PA
PA
PA
PA
PA
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 135
DRUG NAME
pr natal 430 ec 29 mg-1 mg-430 mg tablet&capsule,delayed release
PRADAXA 150 MG CAPSULE MM
PRADAXA 75 MG CAPSULE MM
PRALUENT PEN 150 MG/ML SUBCUTANEOUS PEN INJECTOR SP
PRALUENT PEN 75 MG/ML SUBCUTANEOUS PEN INJECTOR SP
PRALUENT SYRINGE 150 MG/ML SUBCUTANEOUS SP
PRALUENT SYRINGE 75 MG/ML SUBCUTANEOUS SP
pramcort 1 %-1 % rectal cream
pramipexole 0.125 mg tablet MM
pramipexole 0.25 mg tablet MM
pramipexole 0.5 mg tablet MM
pramipexole 0.75 mg tablet MM
pramipexole 1 mg tablet MM
pramipexole 1.5 mg tablet MM
pramipexole er 0.375 mg tablet MM
pramipexole er 0.75 mg tablet MM
pramipexole er 1.5 mg tablet MM
pramipexole er 3 mg tablet MM
pramipexole er 4.5 mg tablet MM
PRAMOSONE 1 %-1 % LOTION
PRAMOSONE 1 %-1 % TOPICAL CREAM
PRAMOSONE 1 %-1 % TOPICAL OINTMENT
PRAMOSONE 2.5 %- 1 % TOPICAL OINTMENT
PRAMOSONE 2.5 %-1 % TOPICAL CREAM
PRAMOSONE 2.5%-1 % LOTION
PRAMOSONE E 2.5 %-1 % TOPICAL CREAM
pramoxine-hc otic drops
PRANDIMET 1 MG-500 MG TABLET MM
PRANDIMET 2 MG-500 MG TABLET MM
PRANDIN 0.5 MG TABLET MM
PRANDIN 1 MG TABLET MM
PRANDIN 2 MG TABLET MM
PRAVACHOL 20 MG TABLET MM
PRAVACHOL 40 MG TABLET MM
PRAVACHOL 80 MG TABLET MM
pravastatin sodium 10 mg tab MM
pravastatin sodium 20 mg tab MM
pravastatin sodium 40 mg tab MM
pravastatin sodium 80 mg tab MM
prazosin 1 mg capsule MM
prazosin 2 mg capsule MM
prazosin 5 mg capsule MM
PRECISION GLUCOSE CONTROL SOLN COMBO PACK
PRECISION GLUCOSE/KETONE CONTR COMBO PACK
PRECISION MISC
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
136 - FORMULARY Updated 09/2015
DRUG LEVEL
2
3
3
*
*
*
*
2
1
1
1
1
1
1
3
3
3
3
3
3
3
3
3
3
3
3
2
3
3
3
3
3
3
3
3
2
2
2
2
1
1
1
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,ST
QL,ST
QL,ST
QL
QL
QL
QL
ST
DRUG NAME
PRECISION PCX PLUS TEST STRIPS MM
PRECISION PCX TEST STRIPS MM
PRECISION POINT OF CARE TEST STRIPS MM
PRECISION Q-I-D TEST STRIPS MM
PRECISION XTRA MONITOR
PRECISION XTRA TEST STRIPS MM
PRECOSE 100 MG TABLET MM
PRECOSE 25 MG TABLET MM
PRECOSE 50 MG TABLET MM
PRED FORTE 1 % EYE DROPS,SUSPENSION
PRED MILD 0.12 % EYE DROPS,SUSPENSION
PRED-G 0.3 %-1 % EYE DROPS,SUSPENSION
PRED-G S.O.P. 0.3 %-0.6 % EYE OINTMENT
prednicarbate 0.1% cream
prednicarbate 0.1% ointment
prednisolone 15 mg/5 ml soln
prednisolone 15 mg/5 ml syrup
prednisolone 5 mg/5 ml soln
prednisolone ac 1% eye drop
prednisolone odt 10 mg tablet
prednisolone odt 15 mg tablet
prednisolone odt 30 mg tablet
prednisolone sod 1% eye drop
prednisolone sod ph 25 mg/5 ml
prednisone 1 mg tablet
prednisone 10 mg tab dose pack
prednisone 10 mg tablet
prednisone 2.5 mg tablet
prednisone 20 mg tablet
prednisone 5 mg tablet
prednisone 5 mg tablet
prednisone 5 mg/5 ml solution
prednisone 50 mg tablet
prednisone intensol 5 mg/ml oral concentrate
PREFERA-OB 28 MG-6 MG-1 MG TABLET
PREFERA-OB ONE 22 MG-6 MG-1 MG-200 MG CAPSULE
PREFERA-OB PLUS DHA 28 MG IRON-6 MG IRON-1 MG ORAL PACK
PREFERRED PLUS SYRINGE 0.5 ML MM
PREFERRED PLUS SYRINGE 1 ML MM
PREFEST 1 MG (15)/1 MG-0.09 MG (15) TABLET MM
prefol-dha capsule
PRELONE 15 MG/5 ML SYRUP
PREMARIN 0.3 MG TABLET MM
PREMARIN 0.45 MG TABLET MM
PREMARIN 0.625 MG TABLET MM
PREMARIN 0.625 MG/GRAM VAGINAL CREAM MM
PREMARIN 0.9 MG TABLET MM
PREMARIN 1.25 MG TABLET MM
DRUG LEVEL
3
3
3
3
3
3
3
3
3
3
3
3
3
2
2
2
2
2
3
3
3
3
2
2
1
1
1
1
1
1
1
1
1
3
2
2
2
2
2
3
1
2
3
3
3
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,ST
QL,ST
QL,ST
QL,ST
ST
QL,ST
ST
ST
ST
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 137
DRUG NAME
PREMIUM BLOOD GLUCOSE MONITORING SYSTEM
PREMIUM V10
PREMIUM V10 STRIPS MM
PREMPHASE 0.625 MG(14)/0.625 MG-5MG(14) TABLET MM
PREMPRO 0.3 MG-1.5 MG TABLET MM
PREMPRO 0.45 MG-1.5 MG TABLET MM
PREMPRO 0.625 MG-2.5 MG TABLET MM
PREMPRO 0.625 MG-5 MG TABLET MM
PRENA1 CHEW 1.4 MG CHEW TABLET,IMMEDIATE & DELAYED REL
prena1 chew tablet
prena1 pearl 30 mg-1.4 mg-200 mg capsule,immediate & delay release
prena1 plus combo pack
prena1 softgel
prenaissance 29 mg-1.25 mg-55 mg-325 mg capsule
prenaissance 90 dha combo pack
prenaissance balance 30 mg iron-1 mg-50 mg-260 mg capsule
prenaissance dha combo pack
prenaissance dha harmony cmbpk
prenaissance harmony dha cmbpk
prenaissance next 1.2 mg-40 mg-124.1 mg-100 mg tablet
PRENAISSANCE NEXT-B 1.22 MG-42 MG-124.23 MG TABLET
prenaissance plus 28 mg-1 mg-50 mg-250 mg capsule
prenaissance promise combo pck
prenaplus tablet
PRENATA 29 MG IRON-1 MG CHEWABLE TABLET
PRENATABS FA 29 MG-1 MG TABLET
PRENATABS RX 29 MG IRON-1 MG TABLET
prenatal 19 (with docusate) 29 mg iron-1 mg-25 mg tablet
prenatal 19 29 mg iron-1 mg chewable tablet
prenatal ad tablet
prenatal low iron 27 mg-1 mg tablet
prenatal plus (calcium carbonate) 27 mg iron-1 mg tablet
prenatal plus 29 mg iron-1 mg tablet
prenatal plus iron tablet
prenatal vitamins with low iron 27 mg iron-1 mg tablet
prenatal-u 106.5 mg-1 mg capsule
PRENATE AM 1 MG-500 MG TABLET
PRENATE CHEWABLE 1 MG TABLET
PRENATE DHA (FERROUS ASPARTO GLYCINATE) 18 MG IRON-1 MG-300 MG
CAPSULE
PRENATE DHA 28 MG IRON-1 MG-300 MG CAPSULE
PRENATE ELITE (IRON ASPARTO GLYCINATE) 20 MG IRON-1 MG TABLET
PRENATE ELITE 26 MG IRON-1 MG TABLET
PRENATE ENHANCE 28 MG IRON-1 MG-400 MG CAPSULE
PRENATE ESSENTIAL (IRON ASPARTO GLYCINATE) 18 MG IRON-1 MG-300 MG CAP
PRENATE ESSENTIAL 29 MG IRON-1 MG-300 MG CAPSULE
PRENATE MINI (FERROUS ASPARTO GLYCINATE) 18 MG-1 MG-350 MG CAPSULE
PRENATE MINI 29 MG IRON-1 MG-350 MG CAPSULE
PRENATE PIXIE 10 MG IRON-1 MG-200 MG CAPSULE
PRENATE RESTORE 27 MG IRON-1 MG-400 MG CAPSULE
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
138 - FORMULARY Updated 09/2015
DRUG LEVEL
3
3
3
3
3
3
3
3
3
2
3
2
2
2
2
3
2
3
3
3
3
2
2
1
1
2
2
1
3
1
1
1
1
1
1
1
3
3
3
3
3
3
3
3
3
3
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
ST
ST
QL,ST
DRUG NAME
PRENATE STAR 20 MG IRON-1 MG TABLET
PRENEXA CAPSULE
PREPIDIL 0.5 MG/3 G VAGINAL GEL
preplus 27 mg iron-1 mg tablet
PREPOPIK 10 MG-3.5 GRAM-12 GRAM ORAL POWDER PACKET
PREQUE 10 15 MG IRON-0.5 MG-25 MG TABLET
PRESERA TOPICAL FOAM
PRESSURE ACTIVATED LANCETS 21 GAUGE
PRESSURE ACTIVATED LANCETS 28 GAUGE
PRESTALIA 14 MG-10 MG TABLET
PRESTALIA 3.5 MG-2.5 MG TABLET
PRESTALIA 7 MG-5 MG TABLET
PRESTO PRO BLOOD GLUCOSE METER
pretab 29 mg-1 mg tablet
PREVACID 15 MG CAPSULE,DELAYED RELEASE MM
PREVACID 30 MG CAPSULE,DELAYED RELEASE MM
PREVACID SOLUTAB 15 MG DELAYED RELEASE,DISINTEGRATING TABLET MM
PREVACID SOLUTAB 30 MG DELAYED RELEASE,DISINTEGRATING TABLET MM
prevalite 4 gram oral powder MM
prevalite 4 gram powder for susp in a packet MM
previfem 0.25 mg-35 mcg tablet MM
PREVNAR 13 (PF) 0.5 ML INTRAMUSCULAR SYRINGE
PREVPAC 500 MG-500 MG-30 MG ORAL PACK
PREZCOBIX 800 MG-150 MG TABLET SP
PREZISTA 100 MG/ML ORAL SUSPENSION SP
PREZISTA 150 MG TABLET SP
PREZISTA 400 MG TABLET SP
PREZISTA 600 MG TABLET SP
PREZISTA 75 MG TABLET SP
PREZISTA 800 MG TABLET SP
PRIFTIN 150 MG TABLET
PRILOSEC 10 MG CAPSULE,DELAYED RELEASE MM
PRILOSEC 10 MG ORAL SUSPENSION,DELAYED RELEASE MM
PRILOSEC 2.5 MG ORAL SUSPENSION,DELAYED RELEASE MM
PRILOSEC 20 MG CAPSULE,DELAYED RELEASE MM
PRILOSEC 40 MG CAPSULE,DELAYED RELEASE MM
primaquine 26.3 mg tablet MM
PRIMEAIRE SPACER
primidone 250 mg tablet MM
primidone 50 mg tablet MM
primlev 10 mg-300 mg tablet
primlev 5 mg-300 mg tablet
primlev 7.5 mg-300 mg tablet
PRIMSOL 50 MG/5 ML ORAL SOLUTION
PRINIVIL 10 MG TABLET MM
PRINIVIL 20 MG TABLET MM
DRUG LEVEL
3
3
3
1
3
2
3
1
1
3
3
3
3
3
3
3
3
3
3
3
1
4
3
*
*
*
*
*
*
*
3
3
3
3
3
3
2
1
1
1
4
4
4
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
ST
ST
ST
ST
ST
QL,ST
QL,ST
QL,ST
QL,ST
QL
QL
QL
QL
QL
QL
QL
QL,ST
QL
QL
QL,ST
QL,ST
QL
QL
QL
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 139
DRUG NAME
PRINIVIL 5 MG TABLET MM
PRISMASOL B22GK K (2 MEQ/L)-MG (1.5 MEQ/L) HEMODIALYSIS SOLUTION
PRISMASOL B22GK K (4 MEQ/L)-MG (1.5 MEQ/L) HEMODIALYSIS SOLUTION
PRISMASOL BGK CA (2.5 MEQ/L)-MG(1.5MEQ/L) HEMODIALYSIS SOLUTION
PRISMASOL BGK K (2 MEQ/L)-CA (3.5)-MG (1) HEMODIALYSIS SOLUTION
PRISMASOL BGK K (2 MEQ/L)-MG(1MEQ/L) HEMODIALYSIS SOLUTION
PRISMASOL BGK K (4 MEQ/L)-CA (2.5)-MG (1.5) HEMODIALYSIS SOLUTION
PRISMASOL BGK K (4 MEQ/L)-MG (1.2 MEQ/L) HEMODIALYSIS SOLUTION
PRISMASOL BK MG (1.2 MEQ/L) HEMODIALYSIS SOLUTION
PRISTIQ 100 MG TABLET,EXTENDED RELEASE MM
PRISTIQ 25 MG TABLET,EXTENDED RELEASE
PRISTIQ 50 MG TABLET,EXTENDED RELEASE MM
pro dna collection 2 % mucosal kit
PROAIR HFA 90 MCG/ACTUATION AEROSOL INHALER MM
PROAIR RESPICLICK 90 MCG/ACTUATION BREATH ACTIVATED
probenecid 500 mg tablet MM
probenecid-colchicine tabs
PROCALAMINE 3% INTRAVENOUS SOLUTION
PROCARDIA 10 MG CAPSULE MM
PROCARDIA XL 30 MG TABLET,EXTENDED RELEASE MM
PROCARDIA XL 60 MG TABLET,EXTENDED RELEASE MM
PROCARDIA XL 90 MG TABLET,EXTENDED RELEASE MM
procentra 5 mg/5 ml oral solution
PROCHAMBER
prochlorperazine 10 mg tab
prochlorperazine 25 mg supp
prochlorperazine 5 mg tablet
PROCORT 1.85 %-1.15 % RECTAL CREAM
PROCRIT 10,000 UNIT/ML INJECTION SOLUTION SP
PROCRIT 2,000 UNIT/ML INJECTION SOLUTION SP
PROCRIT 20,000 UNIT/2 ML INJECTION SOLUTION SP
PROCRIT 20,000 UNIT/ML INJECTION SOLUTION SP
PROCRIT 3,000 UNIT/ML INJECTION SOLUTION SP
PROCRIT 4,000 UNIT/ML INJECTION SOLUTION SP
PROCRIT 40,000 UNIT/ML INJECTION SOLUTION SP
procto-pak 1 % rectal cream
PROCTOCORT 1 % RECTAL CREAM
PROCTOCORT 30 MG RECTAL SUPPOSITORY
PROCTOFOAM HC 1 %-1 %
proctosol hc 2.5 % rectal cream
proctozone-hc 2.5 % rectal cream
PROCYSBI 25 MG CAPSULE,DELAYED RELEASE SPRINKLE SP
PROCYSBI 75 MG CAPSULE,DELAYED RELEASE SPRINKLE SP
PRODIGY AUTOCODE BLOOD GLUCOSE MONITORING SYSTEM
PRODIGY AUTOCODE METER KIT
PRODIGY CONTROL SOLUTION, LOW
PRODIGY CONTROL SOLUTION,HIGH
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
140 - FORMULARY Updated 09/2015
DRUG LEVEL
3
3
3
3
3
3
3
3
3
3
3
3
4
3
3
2
2
3
3
3
3
3
4
2
2
3
2
3
*
*
*
*
*
*
*
2
3
3
3
1
2
*
*
3
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL,ST
QL,ST
QL
QL
QL
QL
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
ST
ST
DRUG NAME
PRODIGY INSULIN SYRINGE 0.3 ML 31 X 5/16" MM
PRODIGY INSULIN SYRINGE 1 ML 28 X 1/2" MM
PRODIGY INSULIN SYRINGE 1/2 ML 31 X 5/16" MM
PRODIGY LANCETS 28 GAUGE
PRODIGY LANCING DEVICE
PRODIGY MINI PEN NDL 31GX3/16"
PRODIGY NO CODING STRIPS MM
PRODIGY PEN NEEDLE 29GX1/2"
PRODIGY PEN NEEDLE 31GX5/16"
PRODIGY POCKET METER KIT
PRODIGY TWIST TOP LANCET 28 GAUGE
PRODIGY VOICE GLUCOSE METER KIT
PRODRIN 65 MG-20 MG-325 MG TABLET
PRODRIN CAPLET
PROFERRIN-FORTE 12 MG-1 MG TABLET
progesterone 100 mg capsule MM
progesterone 200 mg capsule MM
PROGLYCEM 50 MG/ML ORAL SUSPENSION MM
PROGRAF 0.5 MG CAPSULE
PROGRAF 1 MG CAPSULE
PROGRAF 5 MG CAPSULE
PROLENSA 0.07 % EYE DROPS
promacet 50-650 mg tablet
PROMACTA 12.5 MG TABLET SP
PROMACTA 25 MG TABLET SP
PROMACTA 50 MG TABLET SP
PROMACTA 75 MG TABLET SP
promethazine 12.5 mg suppos
promethazine 12.5 mg tablet
promethazine 25 mg suppository
promethazine 25 mg tablet
promethazine 50 mg suppository
promethazine 50 mg tablet
promethazine 6.25 mg/5 ml syrp
promethazine vc 6.25 mg-5 mg/5 ml syrup
promethazine vc-codeine 6.25 mg-5 mg-10 mg/5 ml syrup
promethazine vc-codeine syrup
promethazine-codeine syrup
promethazine-dm syrup
promethazine-phenylephrine syr
promethegan 12.5 mg rectal suppository
promethegan 25 mg rectal suppository
promethegan 50 mg rectal suppository
PROMETRIUM 100 MG CAPSULE MM
PROMETRIUM 200 MG CAPSULE MM
PROMISEB COMPLETE TOP,CLEANSER AND CREAM KIT
PROMISEB TOPICAL CREAM
propafenone hcl 150 mg tablet MM
DRUG LEVEL
2
2
2
1
1
1
3
1
1
3
1
3
3
3
2
2
2
4
4
4
4
3
3
*
*
*
*
3
2
3
2
3
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
2
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,ST
ST
ST
QL
QL,ST
QL
QL,PA
QL,PA
QL,PA
QL,PA
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 141
DRUG NAME
propafenone hcl 225 mg tab MM
propafenone hcl 300 mg tab MM
propafenone hcl er 225 mg cap MM
propafenone hcl er 325 mg cap MM
propafenone hcl er 425 mg cap MM
propantheline 15 mg tablet
proparacaine 0.5% eye drops
propranolol 10 mg tablet MM
propranolol 20 mg tablet MM
propranolol 20 mg/5 ml soln MM
propranolol 40 mg tablet MM
propranolol 40 mg/5 ml soln MM
propranolol 60 mg tablet MM
propranolol 80 mg tablet MM
propranolol er 120 mg capsule MM
propranolol er 160 mg capsule MM
propranolol er 60 mg capsule MM
propranolol er 80 mg capsule MM
propranolol-hctz 40-25 mg tab MM
propranolol-hctz 80-25 mg tab MM
propylthiouracil 50 mg tablet MM
PROSCAR 5 MG TABLET MM
PROSTIGMIN 15 MG TABLET
PROSTIN E2 20 MG VAGINAL SUPPOSITORY
PROTECT NATAL TABLET
PROTHELIAL 1 GRAM/10 ML MUCOSAL PASTE
PROTONIX 20 MG TABLET,DELAYED RELEASE MM
PROTONIX 40 MG GRANULES DELAYED-RELEASE PACKET MM
PROTONIX 40 MG TABLET,DELAYED RELEASE MM
PROTOPIC 0.03 % TOPICAL OINTMENT
PROTOPIC 0.1 % TOPICAL OINTMENT
protriptyline hcl 10 mg tablet MM
protriptyline hcl 5 mg tablet MM
PROVENTIL HFA 90 MCG/ACTUATION AEROSOL INHALER MM
PROVERA 10 MG TABLET MM
PROVERA 2.5 MG TABLET MM
PROVERA 5 MG TABLET MM
PROVIDA DHA 32 MG-1.25 MG-110 MG CAPSULE
PROVIDA OB 40 MG IRON-1.25 MG CAPSULE
PROVIGIL 100 MG TABLET MM
PROVIGIL 200 MG TABLET MM
PROVOCHOLINE 100 MG SOLUTION FOR INHALATION
PROZAC 10 MG CAPSULE MM
PROZAC 20 MG CAPSULE MM
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
142 - FORMULARY Updated 09/2015
DRUG LEVEL
2
2
3
3
3
2
2
1
1
2
1
2
1
1
2
2
2
2
2
2
2
3
2
3
1
3
3
3
3
3
3
3
3
3
3
3
3
3
2
4
4
3
4
4
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,ST
QL,ST
QL
QL,ST
QL,ST
QL,PA
QL,PA
QL
QL
DRUG NAME
PROZAC 40 MG CAPSULE MM
PROZAC WEEKLY 90 MG CAPSULE,DELAYED RELEASE MM
pruclair topical cream
PRUDOXIN 5 % TOPICAL CREAM
prumyx topical cream
prutect topical emulsion
psorcon 0.05 % topical cream
PUB 28G LANCETS
PULMICORT 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION MM
PULMICORT 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION MM
PULMICORT 1 MG/2 ML SUSPENSION FOR NEBULIZATION MM
PULMICORT FLEXHALER 180 MCG/ACTUATION BREATH ACTIVATED MM
PULMICORT FLEXHALER 90 MCG/ACTUATION BREATH ACTIVATED MM
pulmosal 7 % solution for nebulization
PULMOZYME 1 MG/ML SOLUTION FOR INHALATION SP
PURALOR CI 3.6 MG-5 MG-2.5 MG CHEW TABLET,IMMEDIATE & DELAYED REL
PUREFE OB PLUS 106 MG IRON-1 MG CAPSULE
PUREFE PLUS 106 MG IRON-1 MG CAPSULE
purevit dualfe plus 162 mg-115.2 mg (106 mg)-1 mg capsule
PURINETHOL 50 MG TABLET
PURIXAN 20 MG/ML ORAL SUSPENSION SP
PUSH BUTTON SAFETY LANCETS 28 GAUGE
PYLERA 140 MG-125 MG-125 MG CAPSULE
pyrazinamide 500 mg tablet MM
PYRIDIUM 100 MG TABLET
PYRIDIUM 200 MG TABLET
pyridostigmine br 60 mg tablet MM
pyridostigmine er 180 mg tab MM
PYROGALLIC ACID 25 %-2 % TOPICAL OINTMENT
Q-TABS 1 MG TABLET
QNASL 40 MCG/ACTUATION NASAL AEROSOL SPRAY
QNASL 80 MCG/ACTUATION NASAL AEROSOL SPRAY MM
QUALAQUIN 324 MG CAPSULE
QUARTETTE 0.15 MG-20 MCG/0.15 MG-25 MCG TABLETS,3 MONTH DOSE PACK MM
quasense 0.15 mg-30 mcg tablets,3 month dose pack
quazepam 15 mg tablet
QUDEXY XR 100 MG CAPSULE SPRINKLE,EXTENDED RELEASE MM
QUDEXY XR 150 MG CAPSULE SPRINKLE,EXTENDED RELEASE MM
QUDEXY XR 200 MG CAPSULE SPRINKLE,EXTENDED RELEASE MM
QUDEXY XR 25 MG CAPSULE SPRINKLE,EXTENDED RELEASE MM
QUDEXY XR 50 MG CAPSULE SPRINKLE,EXTENDED RELEASE MM
QUESTRAN 4 GRAM ORAL POWDER MM
QUESTRAN 4 GRAM POWDER FOR SUSP IN A PACKET MM
QUESTRAN LIGHT 4 GRAM ORAL POWDER MM
QUESTRAN LIGHT PACKET MM
quetiapine fumarate 100 mg tab MM
DRUG LEVEL
4
3
3
3
3
2
3
1
4
4
4
3
3
3
*
3
3
3
1
3
*
1
4
3
3
3
2
4
3
3
3
3
3
3
2
3
3
3
3
3
3
3
3
3
3
1
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL,PA
QL
QL
QL
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 143
DRUG NAME
quetiapine fumarate 200 mg tab MM
quetiapine fumarate 25 mg tab MM
quetiapine fumarate 300 mg tab MM
quetiapine fumarate 400 mg tab MM
quetiapine fumarate 50 mg tab MM
QUFLORA PEDIATRIC 0.25MG FLUORIDE (0.55 MG) CHEWABLE TABLET
QUFLORA PEDIATRIC 0.5 MG FLUORIDE (1.1 MG) CHEWABLE TABLET
QUFLORA PEDIATRIC 1 MG FLUORIDE (2.2 MG) CHEWABLE TABLET
QUFLORA PEDIATRIC DROPS 0.25 MG FLUORIDE (0.55 MG)/ML ORAL
QUFLORA PEDIATRIC DROPS 0.5 MG FLUORIDE (1.1 MG)/ML ORAL
QUILLIVANT XR 5 MG/ML (25 MG/5 ML) ORAL SUSPENSION,EXTEND RELEASE 24HR
quinapril 10 mg tablet MM
quinapril 20 mg tablet MM
quinapril 40 mg tablet MM
quinapril 5 mg tablet MM
quinapril-hctz 10-12.5 mg tab MM
quinapril-hctz 20-12.5 mg tab MM
quinapril-hctz 20-25 mg tab MM
quinidine gluc er 324 mg tab MM
quinidine sulf er 300 mg tab MM
quinidine sulfate 200 mg tab MM
quinidine sulfate 300 mg tab MM
quinine sulfate 324 mg capsule
QUINTET AC MISC
QUINTET AC STRIPS MM
QUINTET BLOOD GLUCOSE METER
QUINTET GLUCOSE TEST STRIPS MM
QUTENZA 8 % TOPICAL KIT
QVAR 40 MCG/ACTUATION METERED AEROSOL ORAL INHALER MM
QVAR 80 MCG/ACTUATION METERED AEROSOL ORAL INHALER MM
r-natal ob 20 mg iron-1 mg-320 mg capsule
RA BLOOD GLUCOSE MONITOR
ra glucose tablet chew
rabeprazole sod dr 20 mg tab MM
RADIAGEL TOPICAL
RADIAPLEXRX TOPICAL GEL
RADIGEL ACEMANNAN HYDROGEL TOPICAL
RADIOGARDASE 0.5 GRAM CAPSULE SP
raloxifene hcl 60 mg tablet MM
ramipril 1.25 mg capsule MM
ramipril 10 mg capsule MM
ramipril 2.5 mg capsule MM
ramipril 5 mg capsule MM
RANEXA 1,000 MG TABLET,EXTENDED RELEASE MM
RANEXA 500 MG TABLET,EXTENDED RELEASE MM
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
144 - FORMULARY Updated 09/2015
DRUG LEVEL
1
1
1
1
1
3
3
3
3
3
3
1
1
1
1
2
2
2
4
1
2
2
3
3
3
3
3
3
2
2
3
3
3
2
3
3
3
*
3
1
1
1
1
2
2
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
QL
QL,ST
QL,PA
ST
QL,ST
ST
QL,ST
QL,PA
QL
QL
ST
QL
QL
QL,ST
QL,ST
DRUG NAME
ranitidine 15 mg/ml syrup MM
ranitidine 150 mg capsule MM
ranitidine 150 mg tablet MM
ranitidine 300 mg capsule MM
ranitidine 300 mg tablet MM
RAPAFLO 4 MG CAPSULE MM
RAPAFLO 8 MG CAPSULE MM
RAPAMUNE 0.5 MG TABLET
RAPAMUNE 1 MG TABLET
RAPAMUNE 1 MG/ML ORAL SOLUTION
RAPAMUNE 2 MG TABLET
RASUVO (PF) 10 MG/0.2 ML SUBCUTANEOUS AUTO-INJECTOR
RASUVO (PF) 12.5 MG/0.25 ML SUBCUTANEOUS AUTO-INJECTOR
RASUVO (PF) 15 MG/0.3 ML SUBCUTANEOUS AUTO-INJECTOR
RASUVO (PF) 17.5 MG/0.35 ML SUBCUTANEOUS AUTO-INJECTOR
RASUVO (PF) 20 MG/0.4 ML SUBCUTANEOUS AUTO-INJECTOR
RASUVO (PF) 22.5 MG/0.45 ML SUBCUTANEOUS AUTO-INJECTOR
RASUVO (PF) 25 MG/0.5 ML SUBCUTANEOUS AUTO-INJECTOR
RASUVO (PF) 27.5 MG/0.55 ML SUBCUTANEOUS AUTO-INJECTOR
RASUVO (PF) 30 MG/0.6 ML SUBCUTANEOUS AUTO-INJECTOR
RASUVO (PF) 7.5 MG/0.15 ML SUBCUTANEOUS AUTO-INJECTOR
RAVICTI 1.1 GRAM/ML ORAL LIQUID SP
RAYOS 1 MG TABLET,DELAYED RELEASE
RAYOS 2 MG TABLET,DELAYED RELEASE
RAYOS 5 MG TABLET,DELAYED RELEASE
RAZADYNE 12 MG TABLET MM
RAZADYNE 4 MG TABLET MM
RAZADYNE 4 MG/ML ORAL SOLUTION MM
RAZADYNE 8 MG TABLET MM
RAZADYNE ER 16 MG CAPSULE,EXTENDED RELEASE MM
RAZADYNE ER 24 MG CAPSULE,EXTENDED RELEASE MM
RAZADYNE ER 8 MG CAPSULE,EXTENDED RELEASE MM
rea lo 39 % topical cream
rea lo 40 % lotion
rea lo 40 topical cream
READI-CAT 1.2% SUSPENSION
READI-CAT 2 2.1 % (W/V), 2.0 % (W/W) ORAL SUSPENSION
REBETOL 200 MG CAPSULE
REBETOL 40 MG/ML ORAL SOLUTION
REBIF (WITH ALBUMIN) 22 MCG/0.5 ML SUBCUTANEOUS SYRINGE SP
REBIF (WITH ALBUMIN) 44 MCG/0.5 ML SUBCUTANEOUS SYRINGE SP
REBIF REBIDOSE 22 MCG/0.5 ML SUBCUTANEOUS PEN INJECTOR SP
REBIF REBIDOSE 44 MCG/0.5 ML SUBCUTANEOUS PEN INJECTOR SP
REBIF REBIDOSE 8.8 MCG/0.2 ML-22 MCG/0.5 ML (6) SUBCUTANEOUS PEN INJ. SP
REBIF TITRATION PACK 8.8 MCG/0.2 ML-22 MCG/0.5 ML SUBCUTANEOUS SYRINGE
DRUG LEVEL
1
2
1
2
1
3
3
4
4
4
4
3
3
3
3
3
3
3
3
3
3
*
4
4
4
3
3
3
3
3
3
3
3
1
2
3
3
3
3
*
*
*
*
*
*
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,ST
QL,ST
QL
QL
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
SP
recedo topical gel
3
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 145
DRUG NAME
reclipsen (28) 0.15 mg-0.03 mg tablet MM
RECOTHROM 20,000 UNIT TOPICAL SOLUTION
RECOTHROM 5,000 UNIT TOPICAL SOLUTION
RECOTHROM SPRAY KIT 20,000 UNIT TOPICAL SOLUTION
rectacort-hc 25 mg suppository
RECTIV 0.4 % (W/W) OINTMENT
REFUAH PLUS GLUCOSE CONTROL SOLUTION
REFUAH PLUS GLUCOSE MONITOR KIT
REFUAH PLUS STRIPS MM
REGENECARE 2 % TOPICAL GEL
REGENECARE WITH ALOE 2 % TOPICAL GEL
REGLAN 10 MG TABLET
REGLAN 5 MG TABLET
REGRANEX 0.01 % TOPICAL GEL
relador pak 2.5 %-2.5 % topical kit
relador pak plus 2.5 %-2.5 % topical kit
relagard 0.9 %-0.025 % vaginal gel
RELAGESIC 650-50 MG TABLET
RELAMINE TABLET
RELENZA DISKHALER 5 MG/ACTUATION POWDER FOR INHALATION
RELI-ON INSULIN 0.3 ML SYR MM
RELIAMED LANCET 23 GAUGE
RELIAMED LANCET 28 GAUGE
RELIAMED LANCET 30 GAUGE
RELIAMED MINI LANCING DEVICE
RELIAMED SAFETY SEAL LANCETS 28 GAUGE
RELIAMED SAFETY SEAL LANCETS 30 GAUGE
RELIAMED TWIST & CAP LANCET 28 GAUGE
RELION CONFIRM KIT
RELION CONFIRM-MICRO STRIPS MM
relion glucose 15 gram-400 unit/60 ml oral liquid
RELION INS SYR 0.3 ML 29GX1/2" MM
RELION INS SYR 0.3 ML 30GX5/16 MM
RELION INS SYR 1 ML 29GX1/2" MM
RELION INS SYR 1 ML 30GX5/16" MM
RELION INSULIN SYR 0.5 ML MM
RELION MICRO GLUCOSE MONITOR
RELION MICRO GLUCOSE MONITOR KIT
RELION NEEDLES 31 GAUGE X 1/4"
RELION PEN NEEDLES 32 X 5/32"
RELION PRIME METER
RELION PRIME TEST STRIPS MM
RELION SYR 0.5 ML 30GX5/16" MM
RELION THIN LANCETS 26 GAUGE
RELION ULTIMA STRIPS MM
RELION ULTRA THIN PLUS LANCETS
RELISTOR 12 MG/0.6 ML KIT SP
RELISTOR 12 MG/0.6 ML SUBCUTANEOUS SOLUTION SP
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
146 - FORMULARY Updated 09/2015
DRUG LEVEL
1
3
3
3
3
3
3
3
3
2
2
3
3
4
4
4
2
3
3
3
2
3
3
3
3
1
1
3
3
3
2
2
2
2
2
2
3
3
1
1
3
3
2
3
3
1
*
*
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
ST
QL,ST
QL
QL
ST
QL,ST
ST
ST
ST
QL,ST
QL,ST
QL,PA
QL,PA
DRUG NAME
RELISTOR 12 MG/0.6 ML SUBCUTANEOUS SYRINGE SP
RELISTOR 8 MG/0.4 ML SUBCUTANEOUS SYRINGE SP
relnate dha 28 mg-1 mg-200 mg capsule
RELPAX 20 MG TABLET
RELPAX 40 MG TABLET
REMERON 15 MG TABLET MM
REMERON 30 MG TABLET MM
REMERON 45 MG TABLET MM
REMERON SOLTAB 15 MG DISINTEGRATING TABLET MM
REMERON SOLTAB 30 MG DISINTEGRATING TABLET MM
REMERON SOLTAB 45 MG DISINTEGRATING TABLET MM
REMESENSE 3% DESENSITIZER STRP
remeven 50 % topical cream
rena-vite rx 1 mg-60 mg-300 mcg tablet
RENACIDIN 6.602 G-0.198 G/100 ML IRRIGATION SOLUTION
RENAGEL 400 MG TABLET MM
RENAGEL 800 MG TABLET MM
renal caps 1 mg capsule
RENEW ADVANCED LANCING SYSTEM
RENEW ADVANCED MICRO-LANCETS
reno caps 1 mg capsule
RENVELA 0.8 GRAM ORAL POWDER PACKET MM
RENVELA 2.4 GRAM ORAL POWDER PACKET MM
RENVELA 800 MG TABLET MM
repaglinide 0.5 mg tablet MM
repaglinide 1 mg tablet MM
repaglinide 2 mg tablet MM
reprexain 10 mg-200 mg tablet
REPREXAIN 2.5 MG-200 MG TABLET
REPREXAIN 5 MG-200 MG TABLET
REQUIP 0.25 MG TABLET MM
REQUIP 0.5 MG TABLET MM
REQUIP 1 MG TABLET MM
REQUIP 2 MG TABLET MM
REQUIP 3 MG TABLET MM
REQUIP 4 MG TABLET MM
REQUIP 5 MG TABLET MM
REQUIP XL 12 MG TABLET,EXTENDED RELEASE MM
REQUIP XL 2 MG TABLET,EXTENDED RELEASE MM
REQUIP XL 4 MG TABLET,EXTENDED RELEASE MM
REQUIP XL 6 MG TABLET,EXTENDED RELEASE MM
REQUIP XL 8 MG TABLET,EXTENDED RELEASE MM
RESCRIPTOR 100 MG DISPERSIBLE TABLET
RESCRIPTOR 200 MG TABLET
RESCULA 0.15 % EYE DROPS MM
DRUG LEVEL
*
*
3
3
3
3
3
3
3
3
3
3
2
1
3
4
4
1
1
1
1
4
4
4
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,PA
QL,PA
QL,ST
QL,ST
QL
QL
QL
QL
QL
QL
ST
ST
QL,ST
QL,ST
QL,ST
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL,ST
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 147
DRUG NAME
RESECTISOL 5 % URETHRAL SOLUTION
reserpine 0.1 mg tablet MM
reserpine 0.25 mg tablet MM
RESPA-AR 8 MG-90 MG-0.24 MG TABLET,EXTENDED RELEASE
RESTASIS 0.05 % EYE DROPS IN A DROPPERETTE MM
RESTORA RX 60 MG-1.25 MG CAPSULE
RESTORIL 15 MG CAPSULE
RESTORIL 22.5 MG CAPSULE
RESTORIL 30 MG CAPSULE
RESTORIL 7.5 MG CAPSULE
RETIN-A 0.01 % TOPICAL GEL
RETIN-A 0.025 % TOPICAL CREAM
RETIN-A 0.025 % TOPICAL GEL
RETIN-A 0.05 % TOPICAL CREAM
RETIN-A 0.1 % TOPICAL CREAM
RETIN-A MICRO 0.04 % TOPICAL GEL
RETIN-A MICRO 0.1 % TOPICAL GEL
RETIN-A MICRO PUMP 0.04 % TOPICAL GEL
RETIN-A MICRO PUMP 0.08 % TOPICAL GEL
RETIN-A MICRO PUMP 0.1 % TOPICAL GEL
RETROVIR 10 MG/ML INTRAVENOUS SOLUTION
RETROVIR 10 MG/ML SYRUP
RETROVIR 100 MG CAPSULE
REVATIO 10 MG/ML ORAL SUSPENSION SP
REVATIO 20 MG TABLET
REVEAL BLOOD GLUCOSE METER KIT
REVEAL TEST STRIP MM
REVESTA 5,750 UNIT-1 MG CAPSULE
revia 50 mg tablet
REVLIMID 10 MG CAPSULE SP
REVLIMID 15 MG CAPSULE SP
REVLIMID 2.5 MG CAPSULE SP
REVLIMID 20 MG CAPSULE SP
REVLIMID 25 MG CAPSULE SP
REVLIMID 5 MG CAPSULE SP
REXULTI 0.25 MG TABLET SP
REXULTI 0.5 MG TABLET SP
REXULTI 1 MG TABLET SP
REXULTI 2 MG TABLET SP
REXULTI 3 MG TABLET SP
REXULTI 4 MG TABLET SP
REYATAZ 150 MG CAPSULE SP
REYATAZ 200 MG CAPSULE SP
REYATAZ 300 MG CAPSULE SP
REYATAZ 50 MG ORAL POWDER PACKET SP
REZIRA 60 MG-5 MG/5 ML ORAL SOLUTION
REZYST 250 MG TABLET CHEW
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
148 - FORMULARY Updated 09/2015
DRUG LEVEL
3
1
1
3
2
3
3
3
3
3
3
3
3
3
3
4
4
4
4
4
4
4
4
*
4
3
3
3
3
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
QL
PA
PA
PA
PA
PA
QL
QL
QL,PA
QL,PA
ST
QL,ST
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL
QL
QL
DRUG NAME
RHEUMATE 1 MG-1 MG-500 MG CAPSULE
RHEUMATREX 2.5 MG TABLETS IN A DOSE PACK MM
RHINOCORT AQUA 32 MCG/ACTUATION NASAL SPRAY MM
rhinoflex-650 tablet
ribasphere 200 mg capsule
ribasphere 200 mg tablet
ribasphere 400 mg tablet
ribasphere 600 mg tablet
RIBASPHERE RIBAPAK 200 MG (28)-400 MG (28) TABLETS IN A DOSE PACK
RIBASPHERE RIBAPAK 200 MG (7)-400 MG (7) TABLETS IN A DOSE PACK
RIBASPHERE RIBAPAK 400 MG (28)-400 MG (28) TABLETS IN A DOSE PACK
RIBASPHERE RIBAPAK 400 MG (7)-400 MG (7) TABLETS IN A DOSE PACK SP
RIBASPHERE RIBAPAK 600 MG (28)-400 MG (28) TABLETS IN A DOSE PACK
RIBASPHERE RIBAPAK 600 MG (28)-600 MG (28) TABLETS IN A DOSE PACK
RIBASPHERE RIBAPAK 600 MG (7)-400 MG (7) TABLETS IN A DOSE PACK
RIBASPHERE RIBAPAK 600 MG (7)-600 MG (7) TABLETS IN A DOSE PACK SP
RIBATAB DOSE PACK 400 MG (28)-400 MG (28) TABLETS
RIBATAB DOSE PACK 600 MG (28)-400 MG (28) TABLETS
RIBATAB DOSE PACK 600 MG (28)-600 MG (28) TABLETS
ribavirin 200 mg capsule
ribavirin 200 mg tablet
RIDAURA 3 MG CAPSULE MM
rifabutin 150 mg capsule
RIFADIN 150 MG CAPSULE
RIFADIN 300 MG CAPSULE
RIFAMATE 300 MG-150 MG CAPSULE
rifampin 150 mg capsule
rifampin 300 mg capsule
RIFATER 50 MG-120 MG-300 MG TABLET
RIGHTEST CONTROL SOLUTION HIGH
RIGHTEST CONTROL SOLUTION NORMAL
RIGHTEST GC250S CONTROL SOLUTION NORMAL
RIGHTEST GD500 LANCING DEVICE
RIGHTEST GL300 LANCETS 30 GAUGE
RIGHTEST GM250S GLUCOSE METER
RIGHTEST GM260 GLUCOSE METER
RIGHTEST GM550 SYSTEM KIT
RIGHTEST GS250S TEST STRIPS MM
RIGHTEST GS260 TEST STRIPS MM
RIGHTEST GS550 TEST STRIPS MM
RILUTEK 50 MG TABLET SP
riluzole 50 mg tablet SP
rimantadine hcl 100 mg tablet
ringers irrigation solution
RIOMET 500 MG/5 ML ORAL SOLUTION MM
risedronate sod dr 35 mg tab MM
risedronate sodium 150 mg tab MM
risedronate sodium 30 mg tab
DRUG LEVEL
3
2
3
1
3
3
3
3
3
3
3
*
3
3
3
*
3
3
3
3
3
4
4
3
3
3
2
2
2
3
3
3
1
1
3
3
3
3
3
3
*
*
2
3
3
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,ST
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
ST
ST
ST
QL,ST
QL,ST
QL,ST
QL
QL
QL
QL
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 149
DRUG NAME
risedronate sodium 35 mg tab MM
risedronate sodium 5 mg tablet MM
RISPERDAL 0.25 MG TABLET MM
RISPERDAL 0.5 MG TABLET MM
RISPERDAL 1 MG TABLET MM
RISPERDAL 1 MG/ML ORAL SOLUTION MM
RISPERDAL 2 MG TABLET MM
RISPERDAL 3 MG TABLET MM
RISPERDAL 4 MG TABLET MM
RISPERDAL M-TAB 0.5 MG DISINTEGRATING TABLET MM
RISPERDAL M-TAB 1 MG DISINTEGRATING TABLET MM
RISPERDAL M-TAB 2 MG DISINTEGRATING TABLET MM
RISPERDAL M-TAB 3 MG DISINTEGRATING TABLET MM
RISPERDAL M-TAB 4 MG DISINTEGRATING TABLET MM
risperidone 0.25 mg odt MM
risperidone 0.25 mg tablet MM
risperidone 0.5 mg odt MM
risperidone 0.5 mg tablet MM
risperidone 1 mg odt MM
risperidone 1 mg tablet MM
risperidone 1 mg/ml solution MM
risperidone 2 mg odt MM
risperidone 2 mg tablet MM
risperidone 3 mg odt MM
risperidone 3 mg tablet MM
risperidone 4 mg odt MM
risperidone 4 mg tablet MM
RITALIN 10 MG TABLET
RITALIN 20 MG TABLET
RITALIN 5 MG TABLET
RITALIN LA 10 MG CAPSULE,EXTENDED RELEASE
RITALIN LA 20 MG CAPSULE,EXTENDED RELEASE
RITALIN LA 30 MG CAPSULE,EXTENDED RELEASE
RITALIN LA 40 MG CAPSULE,EXTENDED RELEASE
RITALIN LA 60 MG CAPSULE,EXTENDED RELEASE
RITALIN SR 20 MG TABLET
RITEFLO AEROCHAMBER
rivastigmine 1.5 mg capsule MM
rivastigmine 3 mg capsule MM
rivastigmine 4.5 mg capsule MM
rivastigmine 6 mg capsule MM
rizatriptan 10 mg odt
rizatriptan 10 mg tablet
rizatriptan 5 mg odt
rizatriptan 5 mg tablet
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
150 - FORMULARY Updated 09/2015
DRUG LEVEL
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
1
3
1
3
1
2
3
1
3
1
3
1
3
3
3
3
3
3
3
3
3
1
3
3
3
3
2
2
2
2
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL
QL
QL
QL
QL
QL
QL
QL
DRUG NAME
ROBAXIN 500 MG TABLET
ROBAXIN-750 750 MG TABLET
ROBINUL 1 MG TABLET
ROBINUL FORTE 2 MG TABLET
ROCALTROL 0.25 MCG CAPSULE MM
ROCALTROL 0.5 MCG CAPSULE MM
ROCALTROL 1 MCG/ML ORAL SOLUTION MM
ropinirole hcl 0.25 mg tablet MM
ropinirole hcl 0.5 mg tablet MM
ropinirole hcl 1 mg tablet MM
ropinirole hcl 2 mg tablet MM
ropinirole hcl 3 mg tablet MM
ropinirole hcl 4 mg tablet MM
ropinirole hcl 5 mg tablet MM
ropinirole hcl er 12 mg tablet MM
ropinirole hcl er 2 mg tablet MM
ropinirole hcl er 4 mg tablet MM
ropinirole hcl er 6 mg tablet MM
ropinirole hcl er 8 mg tablet MM
ROSADAN 0.75 % TOP,CLEANSER AND CREAM KIT
ROSADAN 0.75 % TOPICAL CLEANSER & GEL KIT
rosadan 0.75 % topical cream
rosadan 0.75 % topical gel
rosanil 10 %-5 % (w/w) topical cleanser
rose glo 1.3 mg strips
ROSULA 10 %-4.5 % TOPICAL CLEANSER
rosula cleansing cloths 10 %-5 %
ROWASA RECTAL SUSPENSION ENEMA 4 GRAM/60 ML MM
ROXICET 5-325 ORAL SOLUTION
roxicet 5-325 tablet
ROXICODONE 15 MG TABLET
ROXICODONE 30 MG TABLET
ROXICODONE 5 MG TABLET
ROZEREM 8 MG TABLET
RYTARY 23.75 MG-95 MG CAPSULE,EXTENDED RELEASE
RYTARY 36.25 MG-145 MG CAPSULE,EXTENDED RELEASE
RYTARY 48.75 MG-195 MG CAPSULE,EXTENDED RELEASE
RYTARY 61.25 MG-245 MG CAPSULE,EXTENDED RELEASE
RYTHMOL 150 MG TABLET MM
RYTHMOL 225 MG TABLET MM
RYTHMOL SR 225 MG CAPSULE,EXTENDED RELEASE MM
RYTHMOL SR 325 MG CAPSULE,EXTENDED RELEASE MM
RYTHMOL SR 425 MG CAPSULE,EXTENDED RELEASE MM
SABRIL 500 MG ORAL POWDER PACKET SP
SABRIL 500 MG TABLET SP
SACCHARIN POWDER
DRUG LEVEL
3
3
3
3
3
3
3
1
1
1
1
1
1
1
3
3
3
3
3
3
3
3
3
3
4
3
3
4
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
*
*
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,PA
QL,PA
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 151
DRUG NAME
SAFESNAP INSULIN SYRINGE 0.3 ML 30 X 5/16" MM
SAFESNAP INSULIN SYRINGE 0.5 ML 29 X 1/2" MM
SAFESNAP INSULIN SYRINGE 0.5 ML 30 X 5/16" MM
SAFESNAP INSULIN SYRINGE 1 ML 28 X 1/2" MM
SAFESNAP INSULIN SYRINGE 1 ML 29 X 1/2" MM
SAFETY LANCETS 21 GAUGE
SAFETY LANCETS 26 GAUGE
SAFETY LANCETS 28 GAUGE
SAFETY SEAL LANCETS 28 GAUGE
SAFETY SEAL LANCETS 30 GAUGE
SAFETY-LET LANCETS 30 GAUGE
SAFYRAL 3 MG-0.03 MG-0.451 MG (21/7) TABLET MM
SAIZEN 5 MG SUBCUTANEOUS SOLUTION SP
SAIZEN 8.8 MG SUBCUTANEOUS SOLUTION SP
SAIZEN CLICK.EASY 8.8 MG/1.5 ML (FINAL CONC.) SUBCUTANEOUS CARTRIDGE SP
salacyn 6 % lotion
salacyn 6 % topical cream
SALAGEN 5 MG TABLET MM
SALAGEN 7.5 MG TABLET MM
SALEX 6 % SHAMPOO
SALEX 6 % TOPICAL COMBO PACK
SALEX 6 % TOPICAL KIT,CLEANSER & CREAM EXTENDED RELEASE
salicylic acid 26% liquid
salicylic acid 27.5% liquid
salicylic acid 6% cream
salicylic acid 6% cream
salicylic acid 6% cream kit
salicylic acid 6% foam
salicylic acid 6% gel
salicylic acid 6% lotion
salicylic acid 6% lotion
salicylic acid 6% lotion kit
salicylic acid 6% shampoo
salicylic acid er 28.5% soln
SALKERA 6 % TOPICAL FOAM
salsalate 500 mg tablet
salsalate 750 mg tablet
SALVAX 6 % TOPICAL FOAM
SALVAX DUO PLUS 6 %-35 % TOPICAL FOAM
SAMSCA 15 MG TABLET SP
SAMSCA 30 MG TABLET SP
SANCTURA 20 MG TABLET MM
SANCTURA XR 60 MG CAPSULE MM
SANCUSO 3.1 MG/24 HOUR TRANSDERMAL PATCH
SANDIMMUNE 100 MG CAPSULE
SANDIMMUNE 100 MG/ML ORAL SOLUTION
SANDIMMUNE 25 MG CAPSULE
SANDIMMUNE 250 MG/5 ML INTRAVENOUS SOLUTION
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
152 - FORMULARY Updated 09/2015
DRUG LEVEL
2
2
2
2
2
1
3
1
1
1
1
3
*
*
*
2
2
3
3
3
3
3
3
3
2
2
3
3
2
3
3
3
2
3
3
3
3
3
3
*
*
3
3
4
3
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,PA
QL,PA
QL,PA
QL
QL
QL
QL,ST
QL
QL
DRUG NAME
SANDOSTATIN 1,000 MCG/ML INJECTION SOLUTION SP
SANDOSTATIN 100 MCG/ML INJECTION SOLUTION SP
SANDOSTATIN 200 MCG/ML INJECTION SOLUTION SP
SANDOSTATIN 50 MCG/ML INJECTION SOLUTION SP
SANDOSTATIN 500 MCG/ML INJECTION SOLUTION SP
SANTYL 250 UNIT/GRAM TOPICAL OINTMENT
SAPHRIS (BLACK CHERRY) 10 MG SUBLINGUAL TABLET MM
SAPHRIS (BLACK CHERRY) 2.5 MG SUBLINGUAL TABLET
SAPHRIS (BLACK CHERRY) 5 MG SUBLINGUAL TABLET MM
SARAFEM 10 MG TABLET MM
SARAFEM 20 MG TABLET MM
SAVAYSA 15 MG TABLET
SAVAYSA 30 MG TABLET
SAVAYSA 60 MG TABLET
SAVELLA 100 MG TABLET MM
SAVELLA 12.5 MG (5)-25 MG(8)-50MG(42) TABLETS IN A DOSE PACK
SAVELLA 12.5 MG TABLET MM
SAVELLA 25 MG TABLET MM
SAVELLA 50 MG TABLET MM
scalacort 2 % lotion
SCALACORT DK 2 %-2 %-2 % TOPICAL COMBO PACK
se 10-5 ss cream
se bpo 7% wash
se-natal 19 (with docusate) 29 mg iron-1 mg-25 mg tablet
se-natal 19 29 mg iron-1 mg chewable tablet
se-tan dha 30 mg-1 mg-310.1 mg capsule
se-tan plus 162 mg-115.2 mg (106 mg)-1 mg capsule
SEASONIQUE 0.15 MG-30 MCG (84)/10 MCG(7) TABLETS,3 MONTH DOSE PACK
seb-prev 10 % topical cleanser
SECONAL SODIUM 100 MG CAPSULE
SECTRAL 200 MG CAPSULE MM
SECTRAL 400 MG CAPSULE MM
SELECT-OB (FOLIC ACID) 29 MG-1 MG CHEWABLE TABLET
SELECT-OB + DHA 29 MG IRON-1 MG-250 MG ORAL PACK
SELECT-OB 29 MG IRON-1 MG CHEWABLE TABLET
selegiline hcl 5 mg capsule MM
selegiline hcl 5 mg tablet MM
selenium sulfide 2.25% shampoo
selenium sulfide 2.5% lotion
SELRX 2.3 % SHAMPOO
SELZENTRY 150 MG TABLET SP
SELZENTRY 300 MG TABLET SP
SEMPREX-D 8 MG-60 MG CAPSULE
SENSIPAR 30 MG TABLET MM
SENSIPAR 60 MG TABLET MM
SENSIPAR 90 MG TABLET MM
SENTRA AM 290 MG-40 MG-35 MG-70 MG CAPSULE
DRUG LEVEL
*
*
*
*
*
3
4
4
4
3
3
3
3
3
3
3
3
3
3
1
3
3
3
1
1
2
1
3
3
3
3
3
2
3
3
3
3
3
2
3
*
*
3
4
4
4
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
PA
PA
PA
PA
PA
QL,PA
QL,PA
QL,PA
QL
QL
QL,PA
QL,PA
QL,PA
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 153
DRUG NAME
SENTRA PM 290 MG-40 MG-15 MG-45.5 MG CAPSULE
SEREVENT DISKUS 50 MCG/DOSE POWDER FOR INHALATION MM
SEROMYCIN 250 MG CAPSULE
SEROQUEL 100 MG TABLET MM
SEROQUEL 200 MG TABLET MM
SEROQUEL 25 MG TABLET MM
SEROQUEL 300 MG TABLET MM
SEROQUEL 400 MG TABLET MM
SEROQUEL 50 MG TABLET MM
SEROQUEL XR 150 MG TABLET,EXTENDED RELEASE MM
SEROQUEL XR 200 MG TABLET,EXTENDED RELEASE MM
SEROQUEL XR 300 MG TABLET,EXTENDED RELEASE MM
SEROQUEL XR 400 MG TABLET,EXTENDED RELEASE MM
SEROQUEL XR 50 MG TABLET,EXTENDED RELEASE MM
SEROQUEL XR 50 MG(3)-200 MG(1)-300 MG(11) TABLET, ER 24 HR DOSE PACK
SEROSTIM 4 MG SUBCUTANEOUS SOLUTION SP
SEROSTIM 5 MG SUBCUTANEOUS SOLUTION SP
SEROSTIM 6 MG SUBCUTANEOUS SOLUTION SP
sertraline 20 mg/ml oral conc MM
sertraline hcl 100 mg tablet MM
sertraline hcl 25 mg tablet MM
sertraline hcl 50 mg tablet MM
setonet prenatal vitamin
SETONET-EC PRENATAL VITAMINS
sevelamer carbonate 800 mg tab MM
SEVEN SYSTEM SENSOR MM
sevoflurane inhalation liquid
SFROWASA 4 GRAM/60 ML ENEMA MM
sharobel 0.35 mg tablet MM
shohl's modified 500 mg-300 mg/5 ml oral solution
SIDEKICK BLOOD GLUCOSE SYSTEM KIT MM
SIDEROL LIQUID
SIGNIFOR 0.3 MG/ML (1 ML) SUBCUTANEOUS SOLUTION SP
SIGNIFOR 0.6 MG/ML (1 ML) SUBCUTANEOUS SOLUTION SP
SIGNIFOR 0.9 MG/ML (1 ML) SUBCUTANEOUS SOLUTION SP
sildenafil 20 mg tablet
SILENOR 3 MG TABLET
SILENOR 6 MG TABLET
SILICONE MASK - INFANT
SILVADENE 1 % TOPICAL CREAM
silver nitrate 0.5% soln
silver nitrate 10% ointment
silver nitrate 10% solution
silver nitrate 25% solution
silver nitrate 50% solution
silver nitrate applicator
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
154 - FORMULARY Updated 09/2015
DRUG LEVEL
3
2
2
4
4
4
4
4
4
2
2
2
2
2
2
*
*
*
2
1
1
1
2
2
4
3
3
4
2
1
1
3
*
*
*
3
3
3
1
3
3
3
3
3
3
1
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL,PA
QL,PA
QL,PA
QL
QL
QL
QL
QL
PA
QL
QL,PA
QL,PA
QL,PA
QL,PA
QL,ST
QL,ST
DRUG NAME
silver sulfadiazine 1% cream
SILVRSTAT 32 PPM TOPICAL GEL
SIMBRINZA 1 %-0.2 % EYE DROPS,SUSPENSION MM
SIMCOR 1,000 MG-20 MG TABLET,EXTENDED RELEASE MM
SIMCOR 1,000 MG-40 MG TABLET,EXTENDED RELEASE MM
SIMCOR 500 MG-20 MG TABLET,EXTENDED RELEASE MM
SIMCOR 500 MG-40 MG TABLET,EXTENDED RELEASE MM
SIMCOR 750 MG-20 MG TABLET,EXTENDED RELEASE MM
SIMPLE DIAGNSTIC LANCET DEVICE
SIMPONI 100 MG/ML SUBCUTANEOUS PEN INJECTOR SP
SIMPONI 100 MG/ML SUBCUTANEOUS SYRINGE SP
SIMPONI 50 MG/0.5 ML SUBCUTANEOUS PEN INJECTOR SP
SIMPONI 50 MG/0.5 ML SUBCUTANEOUS SYRINGE SP
simvastatin 10 mg tablet MM
simvastatin 20 mg tablet MM
simvastatin 40 mg tablet MM
simvastatin 5 mg tablet MM
simvastatin 80 mg tablet MM
SINEMET 10 MG-100 MG TABLET MM
SINEMET 25 MG-100 MG TABLET MM
SINEMET 25 MG-250 MG TABLET MM
SINEMET CR 25 MG-100 MG TABLET,EXTENDED RELEASE MM
SINEMET CR 50 MG-200 MG TABLET,EXTENDED RELEASE MM
SINGLE-LET MISC
SINGULAIR 10 MG TABLET MM
SINGULAIR 4 MG CHEWABLE TABLET MM
SINGULAIR 4 MG ORAL GRANULES IN PACKET MM
SINGULAIR 5 MG CHEWABLE TABLET MM
sirolimus 0.5 mg tablet
sirolimus 1 mg tablet
sirolimus 2 mg tablet
SIRTURO 100 MG TABLET
SITAVIG 50 MG BUCCAL TABLET
SITZMARKS 24 MARKERS CAPSULE
SIVEXTRO 200 MG TABLET
SKELAXIN 800 MG TABLET
SKLICE 0.5 % LOTION
SKYLA 14 MCG/24 HOUR (3 YEARS) INTRAUTERINE DEVICE SP
SM LANCETS 21G
SMART CARESENS N KIT
SMART CARESENS N TEST STRIPS MM
SMART SENSE LANCETS 21 GAUGE
SMART SENSE LANCETS 26 GAUGE
SMART SENSE LANCETS 33 GAUGE
SMART SENSE MONITORING SYSTEM
SMART SENSE TEST STRIPS MM
DRUG LEVEL
1
3
3
3
3
3
3
3
1
*
*
*
*
1
1
1
1
1
3
3
3
3
3
3
3
3
3
3
4
4
4
4
3
3
4
3
3
*
1
3
3
1
1
1
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,PA
QL,PA
QL,PA
QL,PA
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL,PA
QL,PA
QL
QL
ST
QL,ST
ST
QL,ST
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 155
DRUG NAME
SMARTDIABETES VANTAGE
SMARTDIABETES VANTAGE 30G
SMARTDIABETES XPRES GLUC SYST
SMARTDIABETES XPRES TEST STRIP MM
SMARTEST CONTROL SOLUTION
SMARTEST EJECT KIT
SMARTEST LANCET
SMARTEST PERSONA GLUCOSE METER
SMARTEST PERSONA STARTER KIT
SMARTEST PRONTO GLUCOSE METER
SMARTEST PRONTO STARTER KIT
SMARTEST PROTEGE KIT
SMARTEST SMART CODE METER KIT
SMARTEST TALKING METER KIT
SMARTEST TEST STRIPS MM
SMS GLUCOSE CONTROL SOL NORMAL
sod citrate-citric acid soln
sod sulfac-sulfur 9.8-4.8% crm
sod sulfac-sulfur 9.8-4.8% lot
sod sulface-sulf 9.8-4.8% clsr
sod sulface-sulfur 10-5% cloth
sod sulface-sulfur 9-4.5% kit
sod sulface-sulfur 9-4.5% wash
sod sulface-sulfur 9-4.5% wash
sod sulfacet-sulfur 10-2% clsr
sod sulfacet-sulfur 10-4% pad
sod sulfacet-sulfur 10-5% gel
sod sulfacetam 10% clnsng gel
sod sulfacetamide 10% shampoo
sod sulfacetamide-sulfur foam
sod sulfacetamide-sulfur lotn
sod sulfacetamide-sulfur lotn
sod sulfacetamide-sulfur susp
sodium chloride 0.9% inhal vl
sodium chloride 0.9% irrig.
sodium chloride 10% vial
sodium chloride 3% vial
sodium chloride 7% vial
sodium citrate 4% soln
sodium phenylbutyrate powder SP
sodium polystyrene sulfonate (sorbitol free) 15 gram/60 ml oral susp
SODIUM SUCCINATE POWDER
sodium sulf-sulfur cleanser
sodium sulf-sulfur cleanser
sodium sulfacet-sulfur wash
sodium sulfacetamide 10% clnsg
sodium sulfacetamide 10% wash
SOF-SENSOR DEVICE MM
SOFT TOUCH LANCETS
sojourn inhalation liquid
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
156 - FORMULARY Updated 09/2015
DRUG LEVEL
3
3
3
3
3
3
1
3
3
3
3
3
3
3
3
3
1
3
3
3
3
3
3
3
3
3
2
3
3
3
3
3
3
2
1
4
2
2
4
*
2
3
3
3
3
3
3
3
1
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
ST
QL,ST
ST
ST
ST
ST
ST
ST
ST
ST
QL,ST
PA
DRUG NAME
SOLARAZE 3 % TOPICAL GEL
SOLESTA 50 MG-15 MG/ML (4) SYRINGE
SOLODYN 105 MG TABLET,EXTENDED RELEASE
SOLODYN 115 MG TABLET,EXTENDED RELEASE
SOLODYN 55 MG TABLET,EXTENDED RELEASE
SOLODYN 65 MG TABLET,EXTENDED RELEASE
SOLODYN 80 MG TABLET,EXTENDED RELEASE
SOLODYN ER 45 MG TABLET
SOLTAMOX 10 MG/5 ML ORAL SOLUTION MM
SOLUS V2 AUDIBLE METER
SOLUS V2 AUDIBLE METER KIT
SOLUS V2 CONTROL SOLUTION, LOW
SOLUS V2 CONTROL SOLUTION,HIGH
SOLUS V2 LANCETS 28 GAUGE
SOLUS V2 LANCETS 30 GAUGE
SOLUS V2 LANCING DEVICE KIT
SOLUS V2 TEST STRIPS MM
SOMA 250 MG TABLET
SOMA 350 MG TABLET
SOMATULINE DEPOT 120 MG/0.5 ML SUBCUTANEOUS SYRINGE SP
SOMATULINE DEPOT 60 MG/0.2 ML SUBCUTANEOUS SYRINGE SP
SOMATULINE DEPOT 90 MG/0.3 ML SUBCUTANEOUS SYRINGE SP
SOMAVERT 10 MG SUBCUTANEOUS SOLUTION SP
SOMAVERT 15 MG SUBCUTANEOUS SOLUTION SP
SOMAVERT 20 MG SUBCUTANEOUS SOLUTION SP
SOMAVERT 25 MG SUBCUTANEOUS SOLUTION SP
SOMAVERT 30 MG SUBCUTANEOUS SOLUTION SP
sonafine topical emulsion
SONATA 10 MG CAPSULE
SONATA 5 MG CAPSULE
SOOLANTRA 1 % TOPICAL CREAM
sorbitol 3% urologic irrig
sorbitol 3.3% urologic soln
SORBITOL 70% SOLUTION
sorbitol-mannitol irrig
SORIATANE 10 MG CAPSULE
SORIATANE 17.5 MG CAPSULE
SORIATANE 25 MG CAPSULE
SORILUX 0.005 % TOPICAL FOAM
sorine 120 mg tablet MM
sorine 160 mg tablet MM
sorine 240 mg tablet MM
sorine 80 mg tablet MM
sotalol 120 mg tablet MM
sotalol 160 mg tablet MM
sotalol 240 mg tablet MM
sotalol 80 mg tablet MM
DRUG LEVEL
4
3
3
3
3
3
3
4
3
3
3
3
3
1
1
1
3
3
4
*
*
*
*
*
*
*
*
2
3
3
3
3
3
3
3
4
4
4
4
1
1
1
1
1
1
1
1
UTILIZATION
MANAGEMENT
REQUIREMENTS
PA
QL
QL
QL
QL
QL
QL
QL
ST
ST
QL,ST
QL
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL
QL
ST
PA
PA
PA
QL
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 157
DRUG NAME
sotalol af 120 mg tablet MM
sotalol af 160 mg tablet MM
sotalol af 80 mg tablet MM
SOTYLIZE 5 MG/ML ORAL SOLUTION
SOVALDI 400 MG TABLET SP
SPACE CHAMBER PLUS
SPECTRACEF 400 MG TABLET
spinosad 0.9% topical susp
SPIRIVA RESPIMAT 2.5 MCG/ACTUATION SOLUTION FOR INHALATION
SPIRIVA WITH HANDIHALER 18 MCG & INHALATION CAPSULES MM
spironolactone 100 mg tablet MM
spironolactone 25 mg tablet MM
spironolactone 50 mg tablet MM
spironolactone-hctz 25-25 tab MM
SPORANOX 10 MG/ML ORAL SOLUTION
SPORANOX 100 MG CAPSULE
SPORANOX PULSEPAK 100 MG CAPSULE
SPRAY AND STRETCH TOPICAL
sprintec (28) 0.25 mg-35 mcg tablet MM
SPRIX 15.75 MG/SPRAY NASAL SPRAY
SPRYCEL 100 MG TABLET SP
SPRYCEL 140 MG TABLET SP
SPRYCEL 20 MG TABLET SP
SPRYCEL 50 MG TABLET SP
SPRYCEL 70 MG TABLET SP
SPRYCEL 80 MG TABLET SP
sps 15 gm/60 ml suspension
SPS 15 GRAM/60 ML ORAL SUSPENSION
sps 30 gm/120 ml enema
SPS 30 GRAM/120 ML ENEMA
sps 50 gm/200 ml enema
sronyx 0.1 mg-20 mcg tablet MM
ss 10-2 10 %-2 % topical cleanser
SSD 1 % TOPICAL CREAM
sski 1 gram/ml oral solution MM
sss 10-5 10 %-5 % (w/w) topical cream
sss 10-5 10 %-5 % topical foam
STALEVO 100 25 MG-100 MG-200 MG TABLET MM
STALEVO 125 31.25 MG-125 MG-200 MG TABLET MM
STALEVO 150 37.5 MG-150 MG-200 MG TABLET MM
STALEVO 200 50 MG-200 MG-200 MG TABLET MM
STALEVO 50 12.5 MG-50 MG-200 MG TABLET MM
STALEVO 75 18.75 MG-75 MG-200 MG TABLET MM
STARLIX 120 MG TABLET MM
STARLIX 60 MG TABLET MM
stavudine 1 mg/ml solution
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
158 - FORMULARY Updated 09/2015
DRUG LEVEL
1
1
1
3
*
2
3
3
2
2
1
1
1
2
4
4
4
3
1
3
*
*
*
*
*
*
3
3
3
3
3
1
3
3
1
1
3
4
3
3
3
3
3
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,PA
QL
QL
QL
QL
QL
QL
QL,ST
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL
DRUG NAME
stavudine 15 mg capsule
stavudine 20 mg capsule
stavudine 30 mg capsule
stavudine 40 mg capsule
STAVZOR DR 125 MG CAPSULE MM
STAVZOR DR 250 MG CAPSULE MM
STAVZOR DR 500 MG CAPSULE MM
STELARA 45 MG/0.5 ML SUBCUTANEOUS SYRINGE SP
STELARA 90 MG/ML SUBCUTANEOUS SYRINGE SP
STERILANCE TL 30 GAUGE
STERILANCE TL 32 GAUGE
sterile water for irrigation
STIMATE 150 MCG/SPRAY (0.1 ML) NASAL SPRAY MM
STIOLTO RESPIMAT 2.5 MCG-2.5 MCG/ACTUATION SOLUTION FOR INHALATION
STIVARGA 40 MG TABLET SP
STRATTERA 10 MG CAPSULE MM
STRATTERA 100 MG CAPSULE MM
STRATTERA 18 MG CAPSULE MM
STRATTERA 25 MG CAPSULE MM
STRATTERA 40 MG CAPSULE MM
STRATTERA 60 MG CAPSULE MM
STRATTERA 80 MG CAPSULE MM
STRIANT 30 MG BUCCAL SYSTEM,SUSTAINED RELEASE MM
STRIBILD 150 MG-150 MG-200 MG-300 MG TABLET SP
STRIVERDI RESPIMAT 2.5 MCG/ACTUATION SOLUTION FOR INHALATION
STROMECTOL 3 MG TABLET
strong iodine 5 % oral solution
SUBOXONE 12 MG-3 MG SUBLINGUAL FILM
SUBOXONE 2 MG-0.5 MG SUBLINGUAL FILM
SUBOXONE 4 MG-1 MG SUBLINGUAL FILM
SUBOXONE 8 MG-2 MG SUBLINGUAL FILM
SUBSYS 1,200 MCG (600 MCG/SPRAY X2) SUBLINGUAL SPRAY
SUBSYS 1,600 MCG (800 MCG/SPRAY X2) SUBLINGUAL SPRAY
SUBSYS 100 MCG/SPRAY SUBLINGUAL SPRAY
SUBSYS 200 MCG/SPRAY SUBLINGUAL SPRAY
SUBSYS 400 MCG/SPRAY SUBLINGUAL SPRAY
SUBSYS 600 MCG/SPRAY SUBLINGUAL SPRAY
SUBSYS 800 MCG/SPRAY SUBLINGUAL SPRAY
SUCLEAR BOWEL PREP KIT
sucralfate 1 gm tablet MM
SULAR 17 MG TABLET,EXTENDED RELEASE MM
SULAR 34 MG TABLET,EXTENDED RELEASE MM
SULAR 8.5 MG TABLET,EXTENDED RELEASE MM
sulf-pred 10-0.23% eye drops
sulfacetamide 10% eye drops
sulfacetamide 10% eye ointment
sulfacetamide sod 10% top susp
DRUG LEVEL
3
3
3
3
3
3
3
*
*
1
1
1
4
3
*
3
3
3
3
3
3
3
3
*
3
2
1
3
3
3
3
4
4
4
4
4
4
4
3
2
3
3
3
1
2
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL
QL
QL
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 159
DRUG NAME
sulfacetamide-sulfur 10-2% crm
sulfacetamide-sulfur 10-5% crm
sulfacetamide-sulfur 8-4% susp
sulfacleanse 8-4 8 %-4 % topical suspension
sulfadiazine 500 mg tablet
sulfamethoxazole-tmp ds tablet
sulfamethoxazole-tmp ss tablet
sulfamethoxazole-tmp susp
SULFAMYLON 50 GRAM TOPICAL PACKET
SULFAMYLON 85 MG/G TOPICAL CREAM
sulfasalazine 500 mg tablet MM
sulfasalazine dr 500 mg tab MM
SULFATRIM 200 MG-40 MG/5 ML ORAL SUSPENSION
sulfazine 500 mg tablet MM
sulfazine ec 500 mg tablet,delayed release MM
sulindac 150 mg tablet MM
sulindac 200 mg tablet MM
SUMADAN 9 %-4.5 % TOPICAL CLEANSER
SUMADAN 9 %-4.5 % TOPICAL KIT
SUMADAN XLT 9 %-4.5 %-SPF 25 TOPICAL PACK,CLEANSER AND CREAM
sumatriptan 20 mg nasal spray
sumatriptan 4 mg/0.5 ml cart
sumatriptan 4 mg/0.5 ml inject
sumatriptan 5 mg nasal spray
sumatriptan 6 mg/0.5 ml inject
sumatriptan 6 mg/0.5 ml refill
sumatriptan 6 mg/0.5 ml syrng
sumatriptan 6 mg/0.5 ml vial
sumatriptan succ 100 mg tablet
sumatriptan succ 25 mg tablet
sumatriptan succ 50 mg tablet
SUMAVEL DOSEPRO 4 MG/0.5 ML SUBCUTANEOUS NEEDLE-FREE INJECTOR
SUMAVEL DOSEPRO 6 MG/0.5 ML SUBCUTANEOUS NEEDLE-FREE INJECTOR
SUMAXIN 10 %-4 % TOPICAL PADS
SUMAXIN 9 %-4 % TOPICAL CLEANSER
SUMAXIN CP 10 %-4 % TOPICAL KIT
SUMAXIN TS 8 %-4 % TOPICAL SUSPENSION
SUPER THIN LANCETS 28 GAUGE
SUPER THIN LANCETS 30 GAUGE
SUPER THIN LANCETS 33 GAUGE
SUPERVITE 1,000 MG-75 MG-1 MG/15 ML ORAL LIQUID
SUPRANE INHALATION LIQUID
SUPRAX 100 MG CHEWABLE TABLET
SUPRAX 100 MG/5 ML ORAL SUSPENSION
SUPRAX 200 MG CHEWABLE TABLET
SUPRAX 200 MG/5 ML ORAL SUSPENSION
SUPRAX 400 MG CAPSULE
SUPRAX 400 MG TABLET
SUPRAX 500 MG/5 ML ORAL SUSPENSION
SUPREP BOWEL PREP KIT 17.5 GRAM-3.13 GRAM-1.6 GRAM ORAL SOLUTION
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
160 - FORMULARY Updated 09/2015
DRUG LEVEL
3
3
3
3
3
2
2
2
3
3
1
1
3
1
2
1
1
3
3
3
3
3
3
3
3
3
3
3
2
2
2
4
4
3
3
3
3
1
1
1
3
3
3
3
3
3
3
3
3
2
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL,ST
QL,ST
DRUG NAME
SURE COMFORT ALCOHOL PREP PADS
SURE COMFORT INSULIN SYRINGE 0.3 ML 29 X 1/2" MM
SURE COMFORT INSULIN SYRINGE 0.3 ML 30 X 1/2" MM
SURE COMFORT INSULIN SYRINGE 0.3 ML 30 X 5/16" MM
SURE COMFORT INSULIN SYRINGE 0.3 ML 31 X 5/16" MM
SURE COMFORT INSULIN SYRINGE 1 ML 28 X 1/2" MM
SURE COMFORT INSULIN SYRINGE 1 ML 29 X 1/2" MM
SURE COMFORT INSULIN SYRINGE 1 ML 30 X 1/2" MM
SURE COMFORT INSULIN SYRINGE 1 ML 30 X 5/16" MM
SURE COMFORT INSULIN SYRINGE 1 ML 31 X 5/16" MM
SURE COMFORT INSULIN SYRINGE 1/2 ML 28 X 1/2" MM
SURE COMFORT INSULIN SYRINGE 1/2 ML 30 X 1/2" MM
SURE COMFORT INSULIN SYRINGE 1/2 ML 30 X 5/16" MM
SURE COMFORT INSULIN SYRINGE 1/2 ML 31 X 5/16" MM
SURE COMFORT INSULIN SYRINGE U-100 1/2 ML 29 X 1/2" MM
SURE COMFORT LANCETS 30 GAUGE
SURE COMFORT LANCING PEN
SURE COMFORT PEN NEEDLE 29 GAUGE X 1/2"
SURE COMFORT PEN NEEDLE 30 X 5/16"
SURE COMFORT PEN NEEDLE 31 X 3/16"
SURE COMFORT PEN NEEDLE 31 X 5/16"
SURE COMFORT PEN NEEDLE 32 X 1/4"
SURE COMFORT PEN NEEDLE 32 X 5/32"
SURE EDGE BLOOD GLUCOSE METER
SURE EDGE GLUCOSE CONTROL SOLN
SURE EDGE GLUCOSE CONTROL SOLN
SURE EDGE GLUCOSE CONTROL SOLN
SURE EDGE TEST STRIPS MM
SURE-FINE PEN NEEDLES 29 GAUGE X 1/2"
SURE-FINE PEN NEEDLES 31 X 3/16"
SURE-FINE PEN NEEDLES 31 X 5/16"
SURE-JECT INSULIN SYRINGE 0.3 ML 29 X 1/2" MM
SURE-JECT INSULIN SYRINGE 0.3 ML 30 X 5/16" MM
SURE-JECT INSULIN SYRINGE 0.3 ML 31 X 5/16" MM
SURE-JECT INSULIN SYRINGE 1 ML 28 X 1/2" MM
SURE-JECT INSULIN SYRINGE 1 ML 29 X 1/2" MM
SURE-JECT INSULIN SYRINGE 1 ML 30 X 5/16" MM
SURE-JECT INSULIN SYRINGE 1 ML 31 X 5/16" MM
SURE-JECT INSULIN SYRINGE 1/2 ML 28 X 1/2" MM
SURE-JECT INSULIN SYRINGE 1/2 ML 29 X 1/2" MM
SURE-JECT INSULIN SYRINGE 1/2 ML 30 X 5/16" MM
SURE-JECT INSULIN SYRINGE 1/2 ML 31 X 5/16" MM
SURE-LANCE 26 GAUGE
SURE-LANCE 28 GAUGE
SURE-LANCE ULTRA THIN 30 GAUGE
SURE-PEN LANCING DEVICE
DRUG LEVEL
3
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
1
1
1
1
1
1
1
3
3
3
3
3
1
1
1
2
2
2
2
2
2
2
2
2
2
2
1
1
1
1
UTILIZATION
MANAGEMENT
REQUIREMENTS
ST
QL,ST
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 161
DRUG NAME
SURE-PREP ALCOHOL PREP PADS
SURE-TEST EASYPLUS MINI METER
SURE-TEST EASYPLUS MINI SOLUTION
SURE-TEST EASYPLUS MINI STRIPS MM
SURE-TOUCH LANCET
SURECHEK BLOOD GLUCOSE MONITOR
SURECHEK GLUCOSE CONTROL SOLN
SURECHEK TEST STRIPS MM
SUREFLEX LANCING DEVICE
SUREFLEX LANCING DEVICE WITH LANCETS KIT
SURESTEP PRO CONTROL SOLN
SURESTEP PRO CONTROL SOLN
SURESTEP PRO CONTROL SOLN
SURESTEP PRO CONTROL SOLN
SURESTEP PRO LINEARITY KIT
SURESTEP PRO TEST STRIPS MM
SURFAXIN 34 MG/ML INTRATRACHEAL SUSPENSION
SURGUARD2 SAFETY 1 ML 25 X 5/8" SYRINGE
SURGUARD2 SAFETY 1 ML 26 X 3/8" SYRINGE
SURGUARD2 SAFETY 1 ML 27 X 1/2" SYRINGE
SURGUARD2 SAFETY 10 ML 20 X 1 1/2" SYRINGE
SURGUARD2 SAFETY 10 ML 20 X 1" SYRINGE
SURGUARD2 SAFETY 10 ML 21 X 1 1/2" SYRINGE
SURGUARD2 SAFETY 18 X 1 1/2" NEEDLE
SURGUARD2 SAFETY 18 X 1" NEEDLE
SURGUARD2 SAFETY 19 X 1 1/2" NEEDLE
SURGUARD2 SAFETY 19 X 1" NEEDLE
SURGUARD2 SAFETY 20 X 1 1/2" NEEDLE
SURGUARD2 SAFETY 20 X 1" NEEDLE
SURGUARD2 SAFETY 21 X 1 1/2" NEEDLE
SURGUARD2 SAFETY 21 X 1" NEEDLE
SURGUARD2 SAFETY 22 X 1 1/2" NEEDLE
SURGUARD2 SAFETY 22 X 1" NEEDLE
SURGUARD2 SAFETY 23 X 1 1/2" NEEDLE
SURGUARD2 SAFETY 23 X 1" NEEDLE
SURGUARD2 SAFETY 25 X 1 1/2" NEEDLE
SURGUARD2 SAFETY 25 X 1" NEEDLE
SURGUARD2 SAFETY 25 X 5/8" NEEDLE
SURGUARD2 SAFETY 26 X 1/2" NEEDLE
SURGUARD2 SAFETY 27 X 1/2" NEEDLE
SURGUARD2 SAFETY 3 ML 20 X 1 1/2" SYRINGE
SURGUARD2 SAFETY 3 ML 20 X 1" SYRINGE
SURGUARD2 SAFETY 3 ML 21 X 1 1/2" SYRINGE
SURGUARD2 SAFETY 3 ML 21 X 1" SYRINGE
SURGUARD2 SAFETY 3 ML 22 X 1 1/2" SYRINGE
SURGUARD2 SAFETY 3 ML 22 X 1" SYRINGE
SURGUARD2 SAFETY 3 ML 23 X 1" SYRINGE
SURGUARD2 SAFETY 3 ML 25 X 1" SYRINGE
SURGUARD2 SAFETY 3 ML 25 X 5/8" SYRINGE
SURGUARD2 SAFETY 30 X 1 1/2" NEEDLE
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
162 - FORMULARY Updated 09/2015
DRUG LEVEL
3
3
3
3
1
3
3
3
1
1
3
3
3
3
3
3
4
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
UTILIZATION
MANAGEMENT
REQUIREMENTS
ST
QL,ST
ST
QL,ST
ST
QL,ST
DRUG NAME
SURGUARD2 SAFETY 5 ML 20 X 1 1/2" SYRINGE
SURGUARD2 SAFETY 5 ML 20 X 1" SYRINGE
SURGUARD2 SAFETY 5 ML 21 X 1 1/2" SYRINGE
SURMONTIL 100 MG CAPSULE MM
SURMONTIL 25 MG CAPSULE MM
SURMONTIL 50 MG CAPSULE MM
SURVANTA 25 MG/ML INTRATRACHEAL SUSPENSION
SUSTIVA 200 MG CAPSULE SP
SUSTIVA 50 MG CAPSULE SP
SUSTIVA 600 MG TABLET SP
SUTENT 12.5 MG CAPSULE SP
SUTENT 25 MG CAPSULE SP
SUTENT 37.5 MG CAPSULE SP
SUTENT 50 MG CAPSULE SP
syeda 3 mg-0.03 mg tablet MM
SYLATRON 200 MCG 4-PACK SP
SYLATRON 200 MCG SUBCUTANEOUS KIT SP
SYLATRON 300 MCG 4-PACK SP
SYLATRON 300 MCG SUBCUTANEOUS KIT SP
SYLATRON 600 MCG SUBCUTANEOUS KIT SP
SYMAX DUOTAB 0.125 MG & 0.25 MG (0.375 MG) TABLET,EXTENDED RELEASE MM
symax fastabs 0.125 mg disintegrating tablet MM
symax-sl 0.125 mg sublingual tablet MM
symax-sr 0.375 mg tablet,extended release MM
SYMBICORT 160 MCG-4.5 MCG/ACTUATION HFA AEROSOL INHALER MM
SYMBICORT 80 MCG-4.5 MCG/ACTUATION HFA AEROSOL INHALER MM
SYMBYAX 12 MG-25 MG CAPSULE MM
SYMBYAX 12 MG-50 MG CAPSULE MM
SYMBYAX 3 MG-25 MG CAPSULE MM
SYMBYAX 6 MG-25 MG CAPSULE MM
SYMBYAX 6 MG-50 MG CAPSULE MM
SYMLINPEN 120 2,700 MCG/2.7 ML SUBCUTANEOUS PEN INJECTOR MM
SYMLINPEN 60 1,500 MCG/1.5 ML SUBCUTANEOUS PEN INJECTOR MM
SYNAGEX CAPSULE
SYNALAR 0.01 % TOPICAL SOLUTION
SYNALAR 0.025 % TOPICAL CREAM
SYNALAR 0.025 % TOPICAL OINTMENT
SYNALAR CREAM KIT 0.025 % TOPICAL
SYNALAR OINTMENT KIT 0.025 % TOPICAL PACK,OINTMENT AND CREAM
SYNALAR TS 0.01 % TOPICAL KIT
SYNALGOS-DC 16 MG-356.4 MG-30 MG CAPSULE
SYNAREL 2 MG/ML NASAL SPRAY SP
SYNERA 70 MG-70 MG PATCH
SYNTHROID 100 MCG TABLET MM
SYNTHROID 112 MCG TABLET MM
DRUG LEVEL
2
2
2
4
4
4
3
*
*
*
*
*
*
*
2
*
*
*
*
*
3
2
3
3
2
2
3
3
3
3
3
4
4
3
3
3
3
3
3
3
3
*
4
2
2
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL,PA
PA
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 163
DRUG NAME
SYNTHROID 125 MCG TABLET MM
SYNTHROID 137 MCG TABLET MM
SYNTHROID 150 MCG TABLET MM
SYNTHROID 175 MCG TABLET MM
SYNTHROID 200 MCG TABLET MM
SYNTHROID 25 MCG TABLET MM
SYNTHROID 300 MCG TABLET MM
SYNTHROID 50 MCG TABLET MM
SYNTHROID 75 MCG TABLET MM
SYNTHROID 88 MCG TABLET MM
SYPRINE 250 MG CAPSULE
SYRINGE AVITENE TOPICAL POWDER
TABLOID 40 MG TABLET
TACHOSIL 4.8 CM X 4.8 CM ADHESIVE PATCH
TACHOSIL 9.5 CM X 4.8 CM ADHESIVE PATCH
TACLONEX 0.005 %-0.064 % TOPICAL OINTMENT
TACLONEX 0.005 %-0.064 % TOPICAL SUSPENSION
tacrolimus 0.03% ointment
tacrolimus 0.1% ointment
tacrolimus 0.5 mg capsule
tacrolimus 1 mg capsule
tacrolimus 5 mg capsule
TAFINLAR 50 MG CAPSULE SP
TAFINLAR 75 MG CAPSULE SP
TAGITOL V 40 % (W/V), 30 % (W/W) ORAL SUSPENSION
TAMIFLU 30 MG CAPSULE
TAMIFLU 45 MG CAPSULE
TAMIFLU 6 MG/ML ORAL SUSPENSION
TAMIFLU 75 MG CAPSULE
tamoxifen 10 mg tablet MM
tamoxifen 20 mg tablet MM
tamsulosin hcl 0.4 mg capsule MM
TANDEM PLUS 162 MG-115.2 MG (106 MG)-1 MG CAPSULE
TANZEUM 30 MG/0.5 ML SUBCUTANEOUS PEN INJECTOR MM
TANZEUM 50 MG/0.5 ML SUBCUTANEOUS PEN INJECTOR MM
TAPAZOLE 10 MG TABLET MM
TAPAZOLE 5 MG TABLET MM
TARCEVA 100 MG TABLET SP
TARCEVA 150 MG TABLET SP
TARCEVA 25 MG TABLET SP
TARGRETIN 1 % TOPICAL GEL SP
TARGRETIN 75 MG CAPSULE SP
tarina fe 1 mg-20 mcg (21)/75 mg (7) tablet MM
TARKA 1 MG-240 MG TABLET, EXTENDED RELEASE MM
TARKA 2 MG-180 MG TABLET, EXTENDED RELEASE MM
TARKA 2 MG-240 MG TABLET, EXTENDED RELEASE MM
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
164 - FORMULARY Updated 09/2015
DRUG LEVEL
2
2
2
2
2
2
2
2
2
2
4
3
2
3
3
4
3
3
3
3
3
3
*
*
3
3
3
3
3
1
1
1
2
3
3
3
3
*
*
*
*
*
2
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL,ST
QL,ST
QL
QL,PA
QL,PA
QL
QL
QL
QL
QL
QL,ST
QL,ST
QL,PA
QL,PA
QL,PA
PA
QL,PA
DRUG NAME
TARKA 4 MG-240 MG TABLET, EXTENDED RELEASE MM
taron forte 150 mg-60 mg-25 mcg-1 mg capsule
taron-bc 20 mg iron-1 mg-25 mg/25 mg tablets
taron-c dha 35 mg-1 mg-200 mg capsule
taron-prex prenatal-dha 30 mg iron-1.2 mg-55 mg-265mg capsule
TASIGNA 150 MG CAPSULE SP
TASIGNA 200 MG CAPSULE SP
TASMAR 100 MG TABLET MM
TAZORAC 0.05 % TOPICAL CREAM
TAZORAC 0.05 % TOPICAL GEL
TAZORAC 0.1 % TOPICAL CREAM
TAZORAC 0.1 % TOPICAL GEL
taztia xt 120 mg capsule,extended release MM
taztia xt 180 mg capsule,extended release MM
taztia xt 240 mg capsule,extended release MM
taztia xt 300 mg capsule,extended release MM
taztia xt 360 mg capsule,extended release MM
tc99m sulfur colloid prep kit
TD GOLD BLOOD GLUCOSE MONITOR
TD GOLD LEVEL 1 CONTROL SOLUTION
TD GOLD LEVEL 2 CONTROL SOLUTION
TD GOLD LEVEL 3 CONTROL SOLUTION
TD GOLD TEST STRIP MM
TD GOLD VOICE GLUCOSE MONITOR
TEARS AGAIN HYDRATE 250 MG-125 MG-12.5 MG CAPSULE
TECFIDERA 120 MG (14)-240 MG (46) CAPSULE,DELAYED RELEASE SP
TECFIDERA 120 MG CAPSULE,DELAYED RELEASE SP
TECFIDERA 240 MG CAPSULE,DELAYED RELEASE SP
TECHLITE LANCETS 25 GAUGE
TECHLITE LANCETS 28 GAUGE
TECHLITE LANCETS 30 GAUGE
TECHNIVIE 12.5 MG-75 MG-50 MG TABLET SP
TEGRETOL 100 MG/5 ML ORAL SUSPENSION MM
TEGRETOL 200 MG TABLET MM
TEGRETOL XR 100 MG TABLET,EXTENDED RELEASE MM
TEGRETOL XR 200 MG TABLET,EXTENDED RELEASE MM
TEGRETOL XR 400 MG TABLET,EXTENDED RELEASE MM
TEKAMLO 150 MG-10 MG TABLET MM
TEKAMLO 150 MG-5 MG TABLET MM
TEKAMLO 300 MG-10 MG TABLET MM
TEKAMLO 300 MG-5 MG TABLET MM
TEKTURNA 150 MG TABLET MM
TEKTURNA 300 MG TABLET MM
TEKTURNA HCT 150 MG-12.5 MG TABLET MM
TEKTURNA HCT 150 MG-25 MG TABLET MM
TEKTURNA HCT 300 MG-12.5 MG TABLET MM
DRUG LEVEL
3
1
2
1
2
*
*
4
3
3
3
3
2
2
2
2
2
3
3
3
3
3
3
3
3
*
*
*
3
3
1
*
3
3
3
3
3
2
2
2
2
2
2
2
2
2
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,PA
QL,PA
QL,PA
QL
QL
QL
QL
QL
ST
QL,ST
ST
QL,PA
QL,PA
QL,PA
QL,PA
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 165
DRUG NAME
TEKTURNA HCT 300 MG-25 MG TABLET MM
TELCARE BGM KIT
TELCARE BLOOD GLUCOSE KIT
TELCARE CONTROL SOLUTION
TELCARE LANCETS 30 GAUGE
TELCARE TEST STRIPS MM
telmisartan 20 mg tablet MM
telmisartan 40 mg tablet MM
telmisartan 80 mg tablet MM
telmisartan-amlodipine 40-10 MM
telmisartan-amlodipine 40-5 mg MM
telmisartan-amlodipine 80-10 MM
telmisartan-amlodipine 80-5 mg MM
telmisartan-hctz 40-12.5 mg tb MM
telmisartan-hctz 80-12.5 mg tb MM
telmisartan-hctz 80-25 mg tab MM
temazepam 15 mg capsule
temazepam 22.5 mg capsule
temazepam 30 mg capsule
temazepam 7.5 mg capsule
TEMODAR 100 MG CAPSULE SP
TEMODAR 140 MG CAPSULE SP
TEMODAR 180 MG CAPSULE SP
TEMODAR 20 MG CAPSULE SP
TEMODAR 250 MG CAPSULE SP
TEMODAR 5 MG CAPSULE SP
TEMOVATE 0.05 % TOPICAL CREAM
TEMOVATE 0.05 % TOPICAL OINTMENT
TEMOVATE E 0.05 % TOPICAL CREAM
temozolomide 100 mg capsule SP
temozolomide 140 mg capsule SP
temozolomide 180 mg capsule SP
temozolomide 20 mg capsule SP
temozolomide 250 mg capsule SP
temozolomide 5 mg capsule SP
tencon 50 mg-325 mg tablet
tencon tablet
TENEX 1 MG TABLET MM
TENEX 2 MG TABLET MM
TENORETIC 100 100 MG-25 MG TABLET MM
TENORETIC 50 50 MG-25 MG TABLET MM
TENORMIN 100 MG TABLET MM
TENORMIN 25 MG TABLET MM
TENORMIN 50 MG TABLET MM
TERAZOL 3 0.8 % VAGINAL CREAM
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
166 - FORMULARY Updated 09/2015
DRUG LEVEL
2
3
3
3
1
3
3
3
3
3
3
3
3
3
3
3
2
2
2
2
*
*
*
*
*
*
3
3
3
*
*
*
*
*
*
2
3
3
3
3
3
3
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
ST
ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL
QL
QL
QL
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL
QL
DRUG NAME
TERAZOL 3 80 MG SUPPOSITORY
TERAZOL 7 0.4 % VAGINAL CREAM
terazosin 1 mg capsule MM
terazosin 10 mg capsule MM
terazosin 2 mg capsule MM
terazosin 5 mg capsule MM
terbutaline sulfate 2.5 mg tab MM
terbutaline sulfate 5 mg tab MM
terconazole 0.4% cream
terconazole 0.8% cream
terconazole 80 mg suppository
terrell 99.9 % inhalation liquid
TERSI FOAM 2.25 % TOPICAL
TERUMO INS SYRINGE U100-1 ML MM
TERUMO INSULIN SYRINGE 0.3 ML 30 X 3/8" MM
TERUMO INSULIN SYRINGE 0.5CC/27G 1/2 ML 27 X 1/2" MM
TERUMO INSULIN SYRINGE 1 ML 27 X 1/2" MM
TERUMO INSULIN SYRINGE 1 ML 28 X 1/2" MM
TERUMO INSULIN SYRINGE 1 ML 29 X 1/2" MM
TERUMO INSULIN SYRINGE 1/2 ML 28 X 1/2" MM
TERUMO INSULIN SYRINGE 1/2 ML 29 X 1/2" MM
TERUMO INSULIN SYRINGE 1/2 ML 30 X 3/8" MM
TESSALON PERLES 100 MG CAPSULE
TEST N'GO BLOOD GLUCOSE SYSTEM
TEST N'GO TEST STRIPS MM
TESTIM 50 MG/5 GRAM (1 %) TRANSDERMAL GEL MM
TESTOPEL 75 MG IMPLANT PELLET
testosteron cyp 1,000 mg/10 ml MM
testosteron enan 1,000 mg/5 ml
testosterone 10 mg gel pump MM
testosterone 12.5 mg/1.25 gram MM
testosterone 25 mg/2.5 gm pkt MM
testosterone 50 mg/5 gram gel MM
testosterone 50 mg/5 gram pkt MM
testosterone cyp 200 mg/ml MM
TESTRED 10 MG CAPSULE MM
tetcaine 0.5 % eye drops
tetracaine 0.5% eye drops
tetracaine 0.5% eye drops
tetracycline 250 mg capsule
tetracycline 500 mg capsule
TETRAVISC 0.5 % VISCOUS EYE DROPS
TETRAVISC 0.5 % VISCOUS EYE DROPS IN A DROPPERETTE
TETRAVISC FORTE 0.5 % HYPERVISCOUS DROPS
TETRAVISC FORTE 0.5 % HYPERVISCOUS EYE DROPS IN A DROPPERETTE
TETRIX TOPICAL CREAM
DRUG LEVEL
3
3
1
1
1
1
2
2
2
2
3
3
3
2
2
2
2
2
2
2
2
2
3
3
3
3
4
2
2
3
3
3
3
3
2
4
1
1
1
3
3
1
1
1
1
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
ST
QL,ST
QL,ST
QL,PA
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 167
DRUG NAME
TEV-TROPIN 5 MG VIAL SP
TEVETEN 600 MG TABLET MM
TEVETEN HCT 600 MG-25 MG TABLET MM
TEVETEN HCT 600-12.5 MG TAB MM
TEXACORT 2.5 % TOPICAL SOLUTION
TEXAVITE LQ 7 MG-0.25 MG/ML ORAL DROPS
THALOMID 100 MG CAPSULE SP
THALOMID 150 MG CAPSULE SP
THALOMID 200 MG CAPSULE SP
THALOMID 50 MG CAPSULE SP
THEO-24 100 MG CAPSULE,EXTENDED RELEASE MM
THEO-24 200 MG CAPSULE,EXTENDED RELEASE MM
THEO-24 300 MG CAPSULE,EXTENDED RELEASE MM
THEO-24 400 MG CAPSULE,EXTENDED RELEASE MM
theochron 100 mg tablet,extended release MM
theochron 200 mg tablet,extended release MM
theochron 300 mg tablet,extended release MM
theophylline 80 mg/15 ml soln MM
theophylline 80 mg/15 ml soln MM
theophylline er 100 mg tablet MM
theophylline er 200 mg tablet MM
theophylline er 300 mg tab MM
theophylline er 400 mg tablet MM
theophylline er 450 mg tab MM
theophylline er 600 mg tablet MM
THERAMINE 62.5 MG-100 MG CAPSULE
THERAMINE PLUS 62.5 MG-100 MG-9 GRAM ORAL POWDER PACKET
THERMAZENE 1 % TOPICAL CREAM
thiamine 200 mg/2 ml vial
THIN LANCETS 26 GAUGE
THINPRO INSULIN SYRINGE 0.3 ML 29 X 1/2" MM
THINPRO INSULIN SYRINGE 0.3 ML 30 X 3/8" MM
THINPRO INSULIN SYRINGE 0.3 ML 31 X 3/8" MM
THINPRO INSULIN SYRINGE 0.5 ML 31 X 3/8" MM
THINPRO INSULIN SYRINGE 1 ML 28 X 1/2" MM
THINPRO INSULIN SYRINGE 1 ML 29 X 1/2" MM
THINPRO INSULIN SYRINGE 1 ML 30 X 3/8" MM
THINPRO INSULIN SYRINGE 1 ML 31 X 3/8" MM
THINPRO INSULIN SYRINGE 1/2 ML 28 X 1/2" MM
THINPRO INSULIN SYRINGE 1/2 ML 29 X 1/2" MM
THINPRO INSULIN SYRINGE 1/2 ML 30 X 3/8" MM
THINSET RESERVOIR 1.8 ML MM
THINSET RESERVOIR 3 ML MM
THIOLA 100 MG TABLET
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
168 - FORMULARY Updated 09/2015
DRUG LEVEL
*
3
3
3
3
3
*
*
*
*
3
3
3
3
1
1
1
2
2
2
2
2
2
2
2
3
3
2
2
1
2
2
2
2
2
2
2
2
2
2
2
2
2
4
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,PA
QL,ST
QL,ST
QL,ST
QL,PA
QL,PA
QL,PA
QL,PA
DRUG NAME
thioridazine 10 mg tablet MM
thioridazine 100 mg tablet MM
thioridazine 25 mg tablet MM
thioridazine 50 mg tablet MM
thiothixene 1 mg capsule MM
thiothixene 10 mg capsule MM
thiothixene 2 mg capsule MM
thiothixene 5 mg capsule MM
THRESHOLD IMT TRAINER DEVICE
THRESHOLD PEP DEVICE
thrivite-19 29 mg iron-1 mg-25 mg tablet
THROMBI-GEL 10 CM2 TOPICAL PADS
THROMBI-GEL 100 CM2 TOPICAL PADS
THROMBI-GEL 40 CM2 TOPICAL PADS
THROMBI-PAD 3" X 3" TOPICAL PADS
THROMBIN-JMI 20,000 UNIT TOPICAL SOLUTION
THROMBIN-JMI 20,000 UNIT TOPICAL SPRAY
THROMBIN-JMI 20,000 UNIT TOPICAL SPRAY SYRINGE
THROMBIN-JMI 5,000 UNIT NASAL SPRAY SYRINGE
THROMBIN-JMI 5,000 UNIT TOPICAL SOLUTION
THROMBIN-JMI 5,000 UNIT TOPICAL SPRAY SYRINGE
THYROLAR-1 12.5 MCG-50 MCG TABLET MM
THYROLAR-1/2 6.25 MCG-25 MCG TABLET MM
THYROLAR-1/4 3.1 MCG-12.5 MCG TABLET MM
THYROLAR-2 25 MCG-100 MCG TABLET MM
THYROLAR-3 37.5 MCG-150 MCG TABLET MM
tiagabine hcl 2 mg tablet MM
tiagabine hcl 4 mg tablet MM
TIAZAC 120 MG CAPSULE,EXTENDED RELEASE MM
TIAZAC 180 MG CAPSULE,EXTENDED RELEASE MM
TIAZAC 240 MG CAPSULE,EXTENDED RELEASE MM
TIAZAC 300 MG CAPSULE,EXTENDED RELEASE MM
TIAZAC 360 MG CAPSULE,EXTENDED RELEASE MM
TIAZAC 420 MG CAPSULE,EXTENDED RELEASE MM
ticlopidine 250 mg tablet MM
TIGAN 300 MG CAPSULE
TIKOSYN 125 MCG CAPSULE
TIKOSYN 250 MCG CAPSULE
TIKOSYN 500 MCG CAPSULE
tilia fe 1-20 (5)/1-30(7)/1mg-35mcg(9) tablet MM
timolol 0.25% eye drops MM
timolol 0.25% gel-solution MM
timolol 0.5% eye drops MM
timolol 0.5% gel-solution MM
timolol maleate 10 mg tablet MM
DRUG LEVEL
1
2
2
2
2
2
2
2
1
1
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
2
3
3
3
3
2
1
3
1
3
2
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 169
DRUG NAME
timolol maleate 20 mg tablet MM
timolol maleate 5 mg tablet MM
TIMOPTIC 0.25 % EYE DROPS MM
TIMOPTIC 0.5 % EYE DROPS MM
TIMOPTIC OCUDOSE (PF) 0.25 % EYE DROPS IN A DROPPERETTE MM
TIMOPTIC OCUDOSE (PF) 0.5 % EYE DROPS IN A DROPPERETTE MM
TIMOPTIC-XE 0.25 % EYE GEL MM
TIMOPTIC-XE 0.5 % EYE GEL MM
TINDAMAX 250 MG TABLET
TINDAMAX 500 MG TABLET
tinidazole 250 mg tablet
tinidazole 500 mg tablet
TIROSINT 100 MCG CAPSULE MM
TIROSINT 112 MCG CAPSULE MM
TIROSINT 125 MCG CAPSULE MM
TIROSINT 13 MCG CAPSULE MM
TIROSINT 137 MCG CAPSULE MM
TIROSINT 150 MCG CAPSULE MM
TIROSINT 25 MCG CAPSULE MM
TIROSINT 50 MCG CAPSULE MM
TIROSINT 75 MCG CAPSULE MM
TIROSINT 88 MCG CAPSULE MM
TISSEEL VHSD 10 ML TOPICAL KIT
TISSEEL VHSD 10 ML TOPICAL SYRINGE
TISSEEL VHSD 2 ML TOPICAL KIT
TISSEEL VHSD 2 ML TOPICAL SYRINGE
TISSEEL VHSD 4 ML TOPICAL KIT
TISSEEL VHSD 4 ML TOPICAL SYRINGE
TIVICAY 50 MG TABLET SP
TIVORBEX 20 MG CAPSULE
TIVORBEX 40 MG CAPSULE
tizanidine hcl 2 mg capsule MM
tizanidine hcl 2 mg tablet MM
tizanidine hcl 4 mg capsule MM
tizanidine hcl 4 mg tablet MM
tizanidine hcl 6 mg capsule MM
TL FOLATE 27 MG IRON-1 MG TABLET
tl g-fol os 500 mg-1.1 mg tablet
tl gard rx 2.2 mg-25 mg-1 mg tablet
tl icon 110 mg-0.5 mg capsule
tl triseb cream
tl-care dha softgel
tl-cermide topical emulsion
tl-fluorivite chewable tablet
tl-fol 500 caplet
tl-hem 150 150 mg-1 mg-50 mg tablet,extended release
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
170 - FORMULARY Updated 09/2015
DRUG LEVEL
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
*
3
3
3
1
3
1
3
3
1
1
2
3
2
3
3
2
1
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL,ST
QL,ST
ST
ST
ST
DRUG NAME
TL-ICARE 3.33 MG-200 MG CAPSULE
tl-select 29 mg-1.25 mg-55 mg-325 mg capsule
TL-SELECT DHA SOFTGEL
TOBI 300 MG/5 ML SOLUTION FOR NEBULIZATION SP
TOBI PODHALER 28 MG CAPSULE WITH INHALATION DEVICE SP
TOBI PODHALER 28 MG CAPSULES FOR INHALATION SP
TOBRADEX 0.3 %-0.1 % EYE DROPS,SUSPENSION
TOBRADEX 0.3 %-0.1 % EYE OINTMENT
TOBRADEX ST 0.3 %-0.05 % EYE DROPS,SUSPENSION
tobramycin 0.3% eye drops
tobramycin 300 mg/5 ml ampule SP
tobramycin-dexameth ophth susp
TOBREX 0.3 % EYE DROPS
TOBREX 0.3 % EYE OINTMENT
TOFRANIL 10 MG TABLET MM
TOFRANIL 25 MG TABLET MM
TOFRANIL 50 MG TABLET MM
TOFRANIL-PM 100 MG CAPSULE MM
TOFRANIL-PM 125 MG CAPSULE MM
TOFRANIL-PM 150 MG CAPSULE MM
TOFRANIL-PM 75 MG CAPSULE MM
tolazamide 250 mg tablet MM
tolazamide 500 mg tablet MM
tolbutamide 500 mg tablet MM
tolcapone 100 mg tablet MM
tolmetin sodium 200 mg tab MM
tolmetin sodium 400 mg cap MM
tolmetin sodium 600 mg tab MM
tolterodine tart er 2 mg cap MM
tolterodine tart er 4 mg cap MM
tolterodine tartrate 1 mg tab MM
tolterodine tartrate 2 mg tab MM
TOOMEY SYRINGE 70 ML
TOPAMAX 100 MG TABLET MM
TOPAMAX 15 MG SPRINKLE CAPSULE MM
TOPAMAX 200 MG TABLET MM
TOPAMAX 25 MG SPRINKLE CAPSULE MM
TOPAMAX 25 MG TABLET MM
TOPAMAX 50 MG TABLET MM
TOPCARE CLICKFINE 31 GAUGE X 1/4" NEEDLE
TOPCARE CLICKFINE 31 X 5/16" NEEDLE
TOPCARE ULTRA COMFORT 0.3 ML 29 X 1/2" SYRINGE MM
TOPCARE ULTRA COMFORT 0.3 ML 30 X 5/16" SYRINGE MM
TOPCARE ULTRA COMFORT 0.3 ML 31 X 5/16" SYRINGE MM
TOPCARE ULTRA COMFORT 1 ML 29 X 1/2" SYRINGE MM
DRUG LEVEL
3
2
3
*
*
*
3
3
3
2
*
3
3
3
3
3
3
4
4
4
4
1
1
1
4
3
3
3
2
2
3
3
1
4
4
4
4
4
4
1
1
2
2
2
2
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 171
DRUG NAME
TOPCARE ULTRA COMFORT 1 ML 30 X 5/16" SYRINGE MM
TOPCARE ULTRA COMFORT 1 ML 31 X 5/16" SYRINGE MM
TOPCARE ULTRA COMFORT 1/2 ML 29 X 1/2" SYRINGE MM
TOPCARE ULTRA COMFORT 1/2 ML 30 X 5/16" SYRINGE MM
TOPCARE ULTRA COMFORT 1/2 ML 31 X 5/16" SYRINGE MM
TOPCARE UNIVERSAL1 THIN LANCET
TOPICORT 0.05 % TOPICAL CREAM
TOPICORT 0.05 % TOPICAL GEL
TOPICORT 0.05 % TOPICAL OINTMENT
TOPICORT 0.25 % TOPICAL CREAM
TOPICORT 0.25 % TOPICAL OINTMENT
TOPICORT 0.25 % TOPICAL SPRAY
topiragen 100 mg tablet MM
topiragen 200 mg tablet MM
topiragen 25 mg tablet MM
topiragen 50 mg tablet MM
topiramate 100 mg tablet MM
topiramate 15 mg sprinkle cap MM
topiramate 200 mg tablet MM
topiramate 25 mg sprinkle cap MM
topiramate 25 mg tablet MM
topiramate 50 mg tablet MM
topiramate er 100 mg capsule MM
topiramate er 150 mg capsule MM
topiramate er 200 mg capsule MM
topiramate er 25 mg capsule MM
topiramate er 50 mg capsule MM
TOPROL XL 100 MG TABLET,EXTENDED RELEASE MM
TOPROL XL 200 MG TABLET,EXTENDED RELEASE MM
TOPROL XL 25 MG TABLET,EXTENDED RELEASE MM
TOPROL XL 50 MG TABLET,EXTENDED RELEASE MM
torsemide 10 mg tablet MM
torsemide 100 mg tablet MM
torsemide 20 mg tablet MM
torsemide 5 mg tablet MM
TOUJEO SOLOSTAR 300 UNIT/ML (1.5 ML) SUBCUTANEOUS INSULIN PEN
TOVIAZ 4 MG TABLET,EXTENDED RELEASE MM
TOVIAZ 8 MG TABLET,EXTENDED RELEASE MM
toxicology saliva collection 600 mg oral kit
TOZAL 3.33 MG-200 MG CAPSULE
TRACLEER 125 MG TABLET SP
TRACLEER 62.5 MG TABLET SP
TRADJENTA 5 MG TABLET MM
tramadol er 100 mg tablet
tramadol er 200 mg tablet
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
172 - FORMULARY Updated 09/2015
DRUG LEVEL
2
2
2
2
2
1
3
3
3
3
3
3
1
1
1
1
1
2
1
2
1
1
3
3
3
3
3
3
3
3
3
1
1
1
1
2
2
2
4
3
*
*
2
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL
QL
QL
QL
QL
QL
QL,PA
QL,PA
QL
QL,ST
QL,ST
DRUG NAME
tramadol er 300 mg tablet
tramadol hcl 50 mg tablet
tramadol hcl er 100 mg capsule
tramadol hcl er 100 mg tablet
tramadol hcl er 150 mg capsule
tramadol hcl er 200 mg capsule
tramadol hcl er 200 mg tablet
tramadol hcl er 300 mg capsule
tramadol hcl er 300 mg tablet
tramadol-acetaminophn 37.5-325
TRANDATE 100 MG TABLET MM
TRANDATE 200 MG TABLET MM
TRANDATE 300 MG TABLET MM
trandolapr-verapam er 1-240 mg MM
trandolapr-verapam er 2-180 mg MM
trandolapr-verapam er 2-240 mg MM
trandolapr-verapam er 4-240 mg MM
trandolapril 1 mg tablet MM
trandolapril 2 mg tablet MM
trandolapril 4 mg tablet MM
tranexamic acid 650 mg tablet MM
TRANSCYTE 5"X7.5" SHEET
TRANSDERM-SCOP 1.5 MG TRANSDERMAL PATCH (1 MG OVER 3 DAYS)
TRANXENE T-TAB 15 MG
TRANXENE T-TAB 3.75 MG TABLET
TRANXENE T-TAB 7.5 MG TABLET
tranylcypromine sulf 10 mg tab MM
TRAVATAN Z 0.004 % EYE DROPS MM
travoprost 0.004% eye drop MM
trazodone 100 mg tablet MM
trazodone 150 mg tablet MM
trazodone 300 mg tablet MM
trazodone 50 mg tablet MM
TRECATOR 250 MG TABLET
TREPADONE (WITH BROMELAIN) 116 MG-100 MG CAPSULE
TRETIN-X 0.0375 % TOPICAL CREAM
TRETIN-X 0.075 % TOPICAL CREAM
TRETIN-X CREAM 0.025 % TOPICAL KIT
TRETIN-X CREAM 0.05 % TOPICAL KIT
TRETIN-X CREAM 0.1 % TOPICAL KIT
tretinoin 0.01% gel
tretinoin 0.025% cream
tretinoin 0.025% gel
tretinoin 0.05% cream
tretinoin 0.1% cream
tretinoin 10 mg capsule SP
tretinoin gel micro 0.04% pump
DRUG LEVEL
3
2
3
3
3
3
3
3
3
2
3
3
3
3
3
3
3
1
1
1
4
3
3
3
3
3
3
2
3
1
1
1
1
2
3
3
3
3
3
3
3
3
3
3
3
*
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,ST
QL
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL
QL
QL
QL
QL
QL
ST
ST
ST
ST
ST
QL,PA
PA
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 173
DRUG NAME
tretinoin gel micro 0.04% tube
tretinoin gel micro 0.1% pump
tretinoin gel micro 0.1% tube
TREXALL 10 MG TABLET MM
TREXALL 15 MG TABLET MM
TREXALL 5 MG TABLET MM
TREXALL 7.5 MG TABLET MM
TREXIMET 85 MG-500 MG TABLET
TREZIX 16 MG-320.5 MG-30 MG CAPSULE
trezix capsule
TRI-CHLOR 80 % TOPICAL SOLUTION
tri-estarylla 0.18/0.215/0.25 mg-35 mcg(28) tablet MM
tri-legest fe 1-20 (5)/1-30(7)/1mg-35mcg(9) tablet MM
tri-linyah (28) 0.18 mg(7)/0.215 mg(7)/0.25 mg(7)-35 mcg tablet MM
TRI-NORINYL (28) 0.5 MG/1 MG/0.5 MG-35 MCG TABLET MM
tri-previfem (28) 0.18 mg(7)/0.215 mg(7)/0.25 mg(7)-35 mcg tablet MM
tri-sprintec (28) 0.18 mg(7)/0.215 mg(7)/0.25 mg(7)-35 mcg tablet MM
tri-tabs dha 32 mg-1,000 mcg-230 mg oral pack
TRI-VI-FLOR 0.25 MG/ML FLUORIDE BIPHASIC ORAL DROPS
TRI-VI-FLOR 0.5 MG/ML FLUORIDE BIPHASIC ORAL DROPS
tri-vi-floro 0.25 mg/ml drop
tri-vi-floro 0.5 mg/ml drop
tri-vit with fluoride & iron 0.25 mg-10 mg/ml oral drops
tri-vitamin with fluoride 0.25 mg fluoride (0.55 mg)/ml oral drops
tri-vitamin with fluoride 0.5 mg fluoride (1.1 mg)/ml oral drops
tri-zel tablet
triacetin liquid
triadvance 90 mg-1 mg-50 mg tablet
triamcinolone 0.025% cream
triamcinolone 0.025% lotion
triamcinolone 0.025% oint
triamcinolone 0.1% cream
triamcinolone 0.1% lotion
triamcinolone 0.1% ointment
triamcinolone 0.1% paste
triamcinolone 0.147 mg/g spray
triamcinolone 0.5% cream
triamcinolone 0.5% ointment
triamcinolone 55 mcg nasal spr MM
triamterene-hctz 37.5-25 mg cp MM
triamterene-hctz 37.5-25 mg tb MM
triamterene-hctz 50-25 mg cap MM
triamterene-hctz 75-50 mg tab MM
trianex 0.05 % topical ointment
triazolam 0.125 mg tablet
triazolam 0.25 mg tablet
TRIBENZOR 20 MG-5 MG-12.5 MG TABLET MM
TRIBENZOR 40 MG-10 MG-12.5 MG TABLET MM
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
174 - FORMULARY Updated 09/2015
DRUG LEVEL
3
3
3
3
3
3
3
4
3
3
3
1
2
1
3
1
1
2
3
3
3
3
1
1
1
2
3
1
1
2
1
1
2
1
2
3
1
1
3
1
1
1
1
3
2
2
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
PA
PA
PA
QL
QL
QL
QL
QL,ST
QL
QL
QL
QL
QL
QL
QL
QL
QL
ST
QL,ST
ST
QL
QL
QL,ST
QL,ST
DRUG NAME
TRIBENZOR 40 MG-10 MG-25 MG TABLET MM
TRIBENZOR 40 MG-5 MG-12.5 MG TABLET MM
TRIBENZOR 40 MG-5 MG-25 MG TABLET MM
TRICARE 27 MG IRON-1 MG TABLET
TRICARE PRENATAL COMPLEAT PACK
TRICARE PRENATAL DHA ONE 27 MG-1 MG-25 MG-500 MG CAPSULE
trichloroacetic acid 25%
trichloroacetic acid 75%
tricitrates 550 mg-500 mg-334 mg/5 ml oral solution
tricon 110 mg-0.5 mg capsule
TRICOR 145 MG TABLET MM
TRICOR 48 MG TABLET MM
triderm 0.1 % topical cream
trifluoperazine 1 mg tablet MM
trifluoperazine 10 mg tablet MM
trifluoperazine 2 mg tablet MM
trifluoperazine 5 mg tablet MM
trifluridine 1% eye drops
trigels-f forte 460 mg-60 mg-0.01 mg-1 mg capsule
TRIGLIDE 160 MG TABLET MM
trihexyphenidyl 2 mg tablet MM
trihexyphenidyl 2 mg/5 ml elx MM
trihexyphenidyl 5 mg tablet MM
TRILEPTAL 150 MG TABLET MM
TRILEPTAL 300 MG TABLET MM
TRILEPTAL 300 MG/5 ML ORAL SUSPENSION MM
TRILEPTAL 600 MG TABLET MM
TRILIPIX 135 MG CAPSULE,DELAYED RELEASE MM
TRILIPIX 45 MG CAPSULE,DELAYED RELEASE MM
trilyte with flavor packets 420 gram oral solution
trimethobenzamide 300 mg cap
trimethoprim 100 mg tablet
trimipramine maleate 100 mg cp MM
trimipramine maleate 25 mg cap MM
trimipramine maleate 50 mg cap MM
trinatal gt 90 mg-1 mg-50 mg tablet
trinatal rx 1 60 mg iron-1 mg tablet
trinatal ultra tablet
TRINATE 28 MG-1 MG TABLET
trinessa (28) 0.18 mg(7)/0.215 mg(7)/0.25 mg(7)-35 mcg tablet MM
TRIOXIN 1 MG-15 MG-10 MG/ML EAR DROPS,SUSPENSION
triphrocaps 1 mg capsule
triple dye 2.29 mg-2.29 mg-1.14 mg/ml topical swab
triple vitamin with fluoride 0.25 mg fluoride (0.55 mg)/ml oral drops
TRISTART DHA 31 MG IRON-1 MG-200 MG CAPSULE
TRIUMEQ 600 MG-50 MG-300 MG TABLET SP
DRUG LEVEL
3
3
3
2
3
2
3
3
2
1
3
3
1
2
2
2
2
3
2
3
1
1
1
4
4
3
4
3
3
2
2
2
3
3
3
1
1
1
1
1
3
1
3
1
3
*
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,ST
QL,ST
QL,ST
QL
QL
QL
QL
QL
QL
QL
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 175
DRUG NAME
triveen-duo dha 29 mg-1 mg-400 mg oral pack
triveen-one 27 mg-1 mg-250 mg capsule
triveen-prx rnf 26 mg-1.2 mg-55 mg-300 mg capsule
triveen-ten tablets
triveen-u 106.5 mg-1 mg capsule
trivora (28) 50-30 (6)/75-40(5)/125-30(10) tablet MM
TRIZIVIR 300 MG-150 MG-300 MG TABLET
TROKENDI XR 100 MG CAPSULE, EXTENDED RELEASE MM
TROKENDI XR 200 MG CAPSULE, EXTENDED RELEASE MM
TROKENDI XR 25 MG CAPSULE,EXTENDED RELEASE MM
TROKENDI XR 50 MG CAPSULE, EXTENDED RELEASE MM
TROPAZONE CREAM
TROPAZONE LOTION TOPICAL
TROPHAMINE 10 % INTRAVENOUS SOLUTION
TROPHAMINE 6% INTRAVENOUS SOLUTION
tropicamide 0.5% eye drops MM
tropicamide 1% eye drops MM
trospium chloride 20 mg tablet MM
trospium chloride er 60 mg cap MM
TRUE METRIX AIR GLUCOSE METER
TRUE METRIX GLUCOSE METER
TRUE METRIX GLUCOSE TEST STRIP MM
TRUE METRIX LEVEL 1 SOLUTION
TRUE METRIX LEVEL 2 SOLUTION
TRUE METRIX LEVEL 3 SOLUTION
TRUE2GO BLOOD GLUCOSE SYSTEM KIT
TRUECONTROL LEVEL 0 SOLUTION
TRUECONTROL LEVEL 1 SOLUTION
TRUEDRAW LANCING DEVICE
trueplus glucose 15 gram-400 unit/42 ml oral gel
trueplus glucose 15 gram-400 unit/60 ml oral liquid
trueplus glucose 4 gram-400 unit chewable tablet
TRUEPLUS INSULIN 0.3 ML 29 X 1/2" SYRINGE MM
TRUEPLUS INSULIN 0.3 ML 30 X 5/16" SYRINGE MM
TRUEPLUS INSULIN 0.3 ML 31 X 5/16" SYRINGE MM
TRUEPLUS INSULIN 1 ML 28 X 1/2" SYRINGE MM
TRUEPLUS INSULIN 1 ML 29 X 1/2" SYRINGE MM
TRUEPLUS INSULIN 1 ML 30 X 5/16" SYRINGE MM
TRUEPLUS INSULIN 1 ML 31 X 5/16" SYRINGE MM
TRUEPLUS INSULIN 1/2 ML 28 X 1/2" SYRINGE MM
TRUEPLUS INSULIN 1/2 ML 29 X 1/2" SYRINGE MM
TRUEPLUS INSULIN 1/2 ML 30 X 5/16" SYRINGE MM
TRUEPLUS INSULIN 1/2 ML 31 X 5/16" SYRINGE MM
TRUEPLUS LANCETS 26 GAUGE
TRUEPLUS LANCETS 28 GAUGE
TRUEPLUS LANCETS 30 GAUGE
TRUEPLUS LANCETS 33 GAUGE
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
176 - FORMULARY Updated 09/2015
DRUG LEVEL
2
3
1
2
3
1
4
4
4
4
4
3
3
3
3
2
2
3
3
1
1
1
3
3
3
1
3
3
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
1
1
1
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL,ST
QL,ST
QL,ST
QL,ST
QL
QL
QL
DRUG NAME
TRUERESULT BLOOD GLUCOSE SYSTEM
TRUERESULT BLOOD GLUCOSE SYSTEM KIT
TRUETEST HIGH GLUCOSE CONTROL SOLUTION
TRUETEST LOW GLUCOSE CONTROL SOLUTION
TRUETEST NORMAL GLUCOSE CONTROL SOLUTION
TRUETEST TEST STRIPS MM
TRUETRACK BLOOD GLUCOSE SYSTEM KIT
TRUETRACK SMART SYSTEM KIT
TRUETRACK SMART SYSTEM STRIPS MM
TRUETRACK TEST STRIPS MM
TRULICITY 0.75 MG/0.5 ML SUBCUTANEOUS PEN INJECTOR
TRULICITY 1.5 MG/0.5 ML SUBCUTANEOUS PEN INJECTOR
TRUSOPT 2 % EYE DROPS MM
trust natal dha 29 mg-1 mg-250 mg oral pack
TRUVADA 200 MG-300 MG TABLET SP
TRUZONE PEAK FLOW METER
TUBERCULIN SYRINGE 1 ML 25 X 1"
TUDORZA PRESSAIR 400 MCG/ACTUATION BREATH ACTIVATED MM
TUSNEL PEDIATRIC 15 MG-5 MG-50 MG/5 ML ORAL LIQUID
TUSSICAPS 10 MG-8 MG CAPSULE,EXTENDED RELEASE
TUSSICAPS 5 MG-4 MG CAPSULE,EXTENDED RELEASE
tussigon 5 mg-1.5 mg tablet
TUSSIONEX PENNKINETIC ER 10 MG-8 MG/5 ML SUSPENSION,EXTENDED RELEASE
TUZISTRA XR 14.7 MG-2.8 MG/5 ML ORAL SUSPENSION,EXTENDED RELEASE
TWYNSTA 40 MG-10 MG TABLET MM
TWYNSTA 40 MG-5 MG TABLET MM
TWYNSTA 80 MG-10 MG TABLET MM
TWYNSTA 80 MG-5 MG TABLET MM
TYBOST 150 MG TABLET
TYKERB 250 MG TABLET SP
TYLENOL-CODEINE #3 300 MG-30 MG TABLET
TYLENOL-CODEINE #4 300 MG-60 MG TABLET
TYVASO 1.74 MG/2.9 ML (0.6 MG/ML) SOLUTION FOR NEBULIZATION SP
TYVASO INSTITUTIONAL STARTER KIT 1.74 MG/2.9 ML SOLN FOR NEBULIZATION SP
TYVASO REFILL KIT 1.74 MG/2.9 ML (0.6 MG/ML) SOLUTION FOR NEBULIZATION SP
TYVASO STARTER KIT 1.74 MG/2.9 ML SOLUTION FOR NEBULIZATION SP
TYZEKA 600 MG TABLET SP
TYZINE 0.05 % NASAL DROPS
TYZINE 0.1 % NASAL DROPS
TYZINE 0.1 % NASAL SPRAY
u-cort 1 %-10 % topical cream
UCERIS 2 MG/ACTUATION RECTAL FOAM
UCERIS 9 MG TABLET, EXTENDED RELEASE
ULESFIA 5 % LOTION
ULORIC 40 MG TABLET MM
ULORIC 80 MG TABLET MM
ULTANE INHALATION LIQUID
DRUG LEVEL
1
1
3
3
3
1
1
1
1
1
2
2
3
2
*
1
1
3
3
3
3
3
3
3
3
3
3
3
3
*
3
3
*
*
*
*
*
2
2
2
2
3
4
3
2
2
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL,ST
QL,ST
QL,ST
QL,ST
QL
QL,PA
QL
QL
QL,PA
QL,PA
QL,PA
QL,PA
QL
PA
QL,PA
QL,ST
QL,ST
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 177
DRUG NAME
ULTI-LANCE KIT
ULTI-LANCE MISC
ULTICARE 0.3 ML 29 X 1/2" SYRINGE MM
ULTICARE 0.3 ML 30 X 1/2" SYRINGE MM
ULTICARE 0.3 ML 30 X 5/16" SYRINGE MM
ULTICARE 0.3 ML 31 X 5/16" SYRINGE MM
ULTICARE 1 ML 25 X 5/8" SYRINGE
ULTICARE 1 ML 29 X 1/2" SYRINGE MM
ULTICARE 1 ML 30 X 1/2" SYRINGE MM
ULTICARE 1 ML 30 X 5/16" SYRINGE MM
ULTICARE 1 ML 31 X 5/16" SYRINGE MM
ULTICARE 1.5 ML 22 X 1 1/2" SYRINGE
ULTICARE 1/2 ML 29 X 1/2" SYRINGE MM
ULTICARE 1/2 ML 30 X 1/2" SYRINGE MM
ULTICARE 1/2 ML 30 X 5/16" SYRINGE MM
ULTICARE 1/2 ML 31 X 5/16" SYRINGE MM
ULTICARE 29 GAUGE X 1/2" NEEDLE
ULTICARE 31 GAUGE X 1/4" NEEDLE
ULTICARE 31 X 5/16" NEEDLE
ULTICARE 32 X 5/32" NEEDLE
ULTICARE SYR 0.5 ML 29GX1/2" MM
ULTICARE SYRIN 0.5 ML 28GX1/2" MM
ULTILET ALCOHOL SWAB
ULTILET BASIC LANCETS 30 GAUGE
ULTILET CLASSIC LANCETS 28 GAUGE
ULTILET CLASSIC LANCETS 30 GAUGE
ULTILET CLASSIC LANCETS 33 GAUGE
ULTILET INSULIN SYRINGE 0.3 ML 29 MM
ULTILET INSULIN SYRINGE 0.3 ML 29 X 1/2" MM
ULTILET INSULIN SYRINGE 0.3 ML 30 X 5/16" MM
ULTILET INSULIN SYRINGE 0.3 ML 31 X 5/16" MM
ULTILET INSULIN SYRINGE 1 ML 29 MM
ULTILET INSULIN SYRINGE 1 ML 29 X 1/2" MM
ULTILET INSULIN SYRINGE 1 ML 30 X 5/16" MM
ULTILET INSULIN SYRINGE 1 ML 31 X 5/16" MM
ULTILET INSULIN SYRINGE 1/2 ML 29 MM
ULTILET INSULIN SYRINGE 1/2 ML 29 X 1/2" MM
ULTILET INSULIN SYRINGE 1/2 ML 30 X 5/16" MM
ULTILET INSULIN SYRINGE 1/2 ML 31 X 5/16" MM
ULTILET LANCETS 28 GAUGE
ULTILET LANCETS 30 GAUGE
ULTILET LANCETS 33 GAUGE
ULTILET PEN NEEDLE 29 GAUGE
ULTILET PEN NEEDLE 32 X 5/32"
ULTILET SAFETY LANCETS 23 GAUGE
ULTIMA MONITOR
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
178 - FORMULARY Updated 09/2015
DRUG LEVEL
UTILIZATION
MANAGEMENT
REQUIREMENTS
3
3
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
3
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
1
1
1
1
1
1
3
ST
DRUG NAME
ULTIMA TEST STRIPS MM
ultimate ob dha combo pack
ultimatecare one 27 mg-1 mg-330 mg capsule
ultimatecare one nf 27 mg-1 mg-50 mg-500 mg capsule
ULTRA COMFORT INSULIN SYRINGE MM
ULTRA COMFORT INSULIN SYRINGE 0.3 ML 29 X 1/2" MM
ULTRA COMFORT INSULIN SYRINGE 0.3 ML 30 MM
ULTRA COMFORT INSULIN SYRINGE 0.3 ML 30 X 5/16" MM
ULTRA COMFORT INSULIN SYRINGE 0.3 ML 31 X 5/16" MM
ULTRA COMFORT INSULIN SYRINGE 1 ML 28 MM
ULTRA COMFORT INSULIN SYRINGE 1 ML 28 X 1/2" MM
ULTRA COMFORT INSULIN SYRINGE 1 ML 29 MM
ULTRA COMFORT INSULIN SYRINGE 1 ML 29 X 1/2" MM
ULTRA COMFORT INSULIN SYRINGE 1 ML 30 GAUGE X 7/16" MM
ULTRA COMFORT INSULIN SYRINGE 1 ML 30 X 5/16" MM
ULTRA COMFORT INSULIN SYRINGE 1 ML 31 X 5/16" MM
ULTRA COMFORT INSULIN SYRINGE 1/2 ML 28 MM
ULTRA COMFORT INSULIN SYRINGE 1/2 ML 28 X 1/2" MM
ULTRA COMFORT INSULIN SYRINGE 1/2 ML 29 MM
ULTRA COMFORT INSULIN SYRINGE 1/2 ML 29 X 1/2" MM
ULTRA COMFORT INSULIN SYRINGE 1/2 ML 30 MM
ULTRA COMFORT INSULIN SYRINGE 1/2 ML 30 X 5/16" MM
ULTRA COMFORT INSULIN SYRINGE 1/2 ML 31 X 5/16" MM
ULTRA COMFORT INSULIN SYRINGE HALF UNIT 0.3 ML 29 X 1/2" MM
ULTRA COMFORT INSULIN SYRINGE HALF UNIT 0.3 ML 30 X 5/16" MM
ULTRA COMFORT INSULIN SYRINGE HALF UNIT 0.3 ML 31 X 5/16" MM
ULTRA THIN II LANCETS 30 GAUGE
ULTRA THIN LANCETS 28 GAUGE
ULTRA THIN LANCETS 28 GAUGE
ULTRA THIN LANCETS 30 GAUGE
ULTRA THIN LANCETS 31 GAUGE
ULTRA THIN LANCETS 33 GAUGE
ULTRA THIN PLUS LANCETS 33 GAUGE
ULTRA TLC LANCETS
ULTRA-THIN II (SHORT) INSULIN SYRINGE 0.3 ML 30 X 5/16" MM
ULTRA-THIN II (SHORT) INSULIN SYRINGE 0.3 ML 31 X 5/16" MM
ULTRA-THIN II (SHORT) INSULIN SYRINGE 1 ML 30 X 5/16" MM
ULTRA-THIN II (SHORT) INSULIN SYRINGE 1 ML 31 X 5/16" MM
ULTRA-THIN II (SHORT) INSULIN SYRINGE 1/2 ML 30 X 5/16" MM
ULTRA-THIN II (SHORT) INSULIN SYRINGE 1/2 ML 31 X 5/16" MM
ULTRA-THIN II (SHORT) PEN NDL 31 X 5/16" NEEDLE
ULTRA-THIN II INS PEN NEEDLES 29 GAUGE X 1/2"
ULTRA-THIN II INSULIN SYRINGE 0.3 ML 29 X 1/2" MM
ULTRA-THIN II INSULIN SYRINGE 1 ML 29 X 1/2" MM
ULTRA-THIN II INSULIN SYRINGE 1/2 ML 29 X 1/2" MM
DRUG LEVEL
3
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
1
1
1
1
1
1
3
1
1
1
1
1
1
1
1
1
1
1
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,ST
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 179
DRUG NAME
ULTRA-THIN II LANCETS 26 GAUGE
ULTRACET 37.5 MG-325 MG TABLET
ULTRAFOAM 2 CM X 6.25 CM X 7 MM SPONGE
ULTRAFOAM 8 CM X 12.5 CM X 1 CM SPONGE
ULTRAFOAM 8 CM X 12.5 CM X 3 MM SPONGE
ULTRAFOAM 8 CM X 6.25 CM X 1 CM SPONGE
ULTRALANCE LANCETS 26 GAUGE
ULTRALANCE LANCETS 28 GAUGE
ULTRAM 50 MG TABLET
ULTRAM ER 100 MG TABLET,EXTENDED RELEASE
ULTRAM ER 200 MG TABLET,EXTENDED RELEASE
ULTRAM ER 300 MG TABLET,EXTENDED RELEASE
ULTRASAL-ER 28.5 % TOPICAL FILM-FORMING SOLUTION WITH APPLICATOR
ULTRATRAK GLUCOSE METER
ULTRATRAK GLUCOSE METER KIT
ULTRATRAK HIGH-LOW CONTROL SOLUTION
ULTRATRAK NORMAL CONTROL SOLUTION
ULTRATRAK STRIPS MM
ULTRATRAK ULTIMATE
ULTRATRAK ULTIMATE SOLUTION
ULTRATRAK ULTIMATE STRIPS MM
ULTRAVATE 0.05 % TOPICAL CREAM
ULTRAVATE 0.05 % TOPICAL OINTMENT
ULTRAVATE PAC OINTMENT KIT
ULTRAVATE X 0.05 %-10 % TOPICAL COMBO PACK
ULTRAVATE X 0.05 %-10 % TOPICAL PACK,OINTMENT AND CREAM
ULTRESA 13,800 UNIT-27,600 UNIT CAPSULE,DELAYED RELEASE MM
ULTRESA 20,700 UNIT-41,400 UNIT CAPSULE,DELAYED RELEASE MM
ULTRESA 23,000 UNIT-46,000 UNIT CAPSULE,DELAYED RELEASE MM
UMECTA 40 % NAIL FILM SUSPENSION
UMECTA 40 % TOPICAL EMULSION
umecta 40 % topical foam
UMECTA 40% SUSPENSION
UMECTA NAIL FILM PEN 40 %
UMECTA PD 40 % TOPICAL EMULSION
UMECTA PD 40 % TOPICAL SUSPENSION
UNIFINE PENTIPS 29 GAUGE NEEDLE
UNIFINE PENTIPS 29 GAUGE X 1/2" NEEDLE
UNIFINE PENTIPS 29 X 5/16" NEEDLE
UNIFINE PENTIPS 30 X 5/16" NEEDLE
UNIFINE PENTIPS 31 GAUGE X 1/4" NEEDLE
UNIFINE PENTIPS 31 NEEDLE
UNIFINE PENTIPS 31 X 3/16" NEEDLE
UNIFINE PENTIPS 31 X 5/16" NEEDLE
UNIFINE PENTIPS 32 X 5/32" NEEDLE
UNIFINE PENTIPS PLUS 31 GAUGE X 1/4" NEEDLE MM
UNIFINE PENTIPS PLUS 31 X 3/16" NEEDLE MM
UNIFINE PENTIPS PLUS 31 X 5/16" NEEDLE MM
UNILET COMFORTOUCH LANCET
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
180 - FORMULARY Updated 09/2015
DRUG LEVEL
1
3
3
3
3
3
1
1
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
1
1
1
1
1
1
1
1
1
1
1
1
1
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL,ST
QL,ST
QL,ST
ST
ST
QL,ST
ST
QL,ST
ST
ST
ST
DRUG NAME
UNILET COMFORTOUCH LANCET 26 GAUGE
UNILET EXCELITE II LANCET
UNILET EXCELITE LANCET
UNILET GP LANCET
UNILET LANCET
UNILET LANCET 28 GAUGE
UNILET LANCET 33 GAUGE
UNILET LANCETS 30 GAUGE
UNILET SUPER THIN LANCETS 30 GAUGE
UNIRETIC 15-12.5 TABLET MM
UNIRETIC 15-25 MG TABLET MM
UNIRETIC 7.5-12.5 MG TABLET MM
UNISTIK 2 DEVICE KIT
UNISTIK 2 EXTRA KIT
UNISTIK 2 NORMAL LANCET&DEVICE KIT
UNISTIK 3 COMFORT DEVICE KIT
UNISTIK 3 COMFORT LANCET
UNISTIK 3 EXTRA LANCET 21 GAUGE
UNISTIK 3 GENTLE 30 GAUGE
UNISTIK 3 KIT
UNISTIK 3 LANCETS 21 GAUGE
UNISTIK 3 NEONATAL DEVICE KIT
UNISTIK 3 NEONATAL KIT
UNISTIK CZT LANCET 23 GAUGE
UNISTIK CZT LANCET 28 GAUGE
UNISTIK SAFETY 28 GAUGE
UNISTIK SAFETY 30 GAUGE
UNISTRIP HIGH CONTROL SOLUTION
UNISTRIP LOW CONTROL SOLUTION
UNISTRIP1 TEST STRIP MM
UNITHROID 100 MCG TABLET MM
UNITHROID 112 MCG TABLET MM
UNITHROID 125 MCG TABLET MM
UNITHROID 137 MCG TABLET MM
UNITHROID 150 MCG TABLET MM
UNITHROID 175 MCG TABLET MM
UNITHROID 200 MCG TABLET MM
UNITHROID 25 MCG TABLET MM
UNITHROID 300 MCG TABLET MM
UNITHROID 50 MCG TABLET MM
UNITHROID 75 MCG TABLET MM
UNITHROID 88 MCG TABLET MM
UNIVASC 15 MG TABLET MM
UNIVASC 7.5 MG TABLET MM
UNIVERSAL 1 LANCETS 21 GAUGE
UNIVERSAL 1 LANCETS 26 GAUGE
UNIVERSAL 1 LANCETS 30 GAUGE
DRUG LEVEL
1
3
3
1
3
1
1
3
1
3
3
3
3
1
1
3
1
1
3
3
1
3
3
1
1
1
1
3
3
3
1
1
1
1
1
1
1
1
1
1
1
1
3
3
1
1
1
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,ST
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 181
DRUG NAME
UNIVERSAL 1 LANCETS 33 GAUGE
ur n-c 81.6 mg-10.8 mg-40.8 mg tablet
URAMAXIN 20 % TOPICAL FOAM
URAMAXIN 45 % LOTION
URAMAXIN 45 % TOPICAL CREAM
URAMAXIN 45 % TOPICAL GEL
URAMAXIN GT 45 % TOPICAL GEL
URAMAXIN GT 45 % TOPICAL KIT,CREAM AND GEL
uramit mb 118 mg-10 mg-40.8 mg-36 mg capsule
urea 35% foam
urea 39% cream
urea 40% cream
urea 40% gel
urea 40% lotion
urea 40% nail film susp
urea 40% nail kit
urea 45% cream
urea 45% lotion
urea 45% nail gel
urea 47% cream
urea 50% cream
urea 50% emulsion
urea 50% topical suspension
urea nail stick 50 % topical solution
URECHOLINE 10 MG TABLET
URECHOLINE 25 MG TABLET
URECHOLINE 5 MG TABLET
URECHOLINE 50 MG TABLET
URELLE 81 MG-10.8 MG-40.8 MG TABLET
URETRON D-S 81.6 MG-10.8 MG-40.8 MG TABLET
URETRON D-S TABLET
UREVAZ 44 % TOPICAL CREAM
URIBEL 118 MG-10 MG-40.8 MG-36 MG CAPSULE
urimar-t 120 mg-0.12 mg-10.8 mg tablet
urin ds 81.6 mg-10.8 mg-40.8 mg tablet
URINARY TRACT INFECTION TEST FOR LEUKOCYTES STRIPS
URISTIX 4 STRIPS
URISTIX REAGENT STRIPS
uro-blue 81.6 mg-40.8 mg-0.12 mg tablet
uro-l 81 mg-10.8 mg-40.8 mg tablet
uro-mp 118 mg-10 mg-40.8 mg-36 mg capsule
UROCIT-K 10 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE MM
UROCIT-K 15 15 MEQ (1,620 MG) TABLET,EXTENDED RELEASE MM
UROCIT-K 5 5 MEQ (540 MG) TABLET,EXTENDED RELEASE MM
UROGESIC-BLUE 81.6 MG-40.8 MG-0.12 MG TABLET
urolet mb 81.6 mg-40.8 mg-0.12 mg tablet
UROQID-ACID NO.2 500 MG-500 MG TABLET
UROXATRAL 10 MG TABLET,EXTENDED RELEASE MM
URSO 250 250 MG TABLET MM
URSO FORTE 500 MG TABLET MM
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
182 - FORMULARY Updated 09/2015
DRUG LEVEL
1
2
3
3
3
3
3
3
3
3
2
2
3
2
3
2
2
2
3
3
2
3
3
3
3
3
3
3
3
3
3
4
3
2
1
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
DRUG NAME
ursodiol 250 mg tablet MM
ursodiol 300 mg capsule MM
ursodiol 500 mg tablet MM
uryl 81.6 mg-40.8 mg-0.12 mg tablet
ustell 120 mg-0.12 mg capsule
UTA (WITH PHENYL SALICYLATE) 120 MG-0.12 MG CAPSULE
UTA 120 MG-40.8 MG-10 MG CAPSULE
utira-c 81.6 mg-10.8 mg-40.8 mg tablet
UTOPIC 41 % TOPICAL CREAM
VAGIFEM 10 MCG VAGINAL TABLET MM
valacyclovir hcl 1 gram tablet MM
valacyclovir hcl 500 mg tablet MM
VALCHLOR 0.016 % TOPICAL GEL SP
VALCYTE 450 MG TABLET MM
VALCYTE 50 MG/ML ORAL SOLUTION MM
valganciclovir 450 mg tablet MM
VALIUM 10 MG TABLET
VALIUM 2 MG TABLET
VALIUM 5 MG TABLET
valproic acid 250 mg capsule MM
valproic acid 250 mg/5 ml soln MM
valproic acid 250 mg/5 ml soln MM
valproic acid 500 mg/10 ml sol MM
valsartan 160 mg tablet MM
valsartan 320 mg tablet MM
valsartan 40 mg tablet MM
valsartan 80 mg tablet MM
valsartan-hctz 160-12.5 mg tab MM
valsartan-hctz 160-25 mg tab MM
valsartan-hctz 320-12.5 mg tab MM
valsartan-hctz 320-25 mg tab MM
valsartan-hctz 80-12.5 mg tab MM
VALTREX 1 GRAM TABLET MM
VALTREX 500 MG TABLET MM
VANACOF CD LIQUID
vanatol lq 50 mg-325 mg-40 mg/15 ml oral solution
VANCOCIN 125 MG CAPSULE
VANCOCIN 250 MG CAPSULE
vancomycin hcl 125 mg capsule
vancomycin hcl 250 mg capsule
VANDAZOLE 0.75 % VAGINAL GEL
VANISHPOINT SYRINGE 1 ML 29 X 1/2" MM
VANISHPOINT SYRINGE 1/2 ML 30 X 1/2" MM
VANOS 0.1 % TOPICAL CREAM
VANOXIDE-HC 5 %-0.5 % TOPICAL SUSPENSION
VANTAS 50 MG (50 MCG/DAY) IMPLANT KIT
DRUG LEVEL
3
3
3
3
3
3
3
2
3
3
2
2
*
4
4
4
3
3
3
1
1
1
1
2
2
2
2
1
1
1
1
1
3
3
3
2
4
4
4
4
2
2
2
4
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL,PA
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
ST
QL
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 183
DRUG NAME
VARIBAR HONEY 40 % (W/V), 29% (W/W) ORAL SUSPENSION
VARIBAR NECTAR 40 % (W/V), 30 % (W/W) ORAL SUSPENSION
VARIBAR PUDDING 40 % (W/V), 30% (W/W) ORAL PASTE
VARIBAR THIN HONEY 40 % (W/V), 29% (W/W) ORAL SUSPENSION
VARIBAR THIN LIQUID 40 % (W/V) ORAL POWDER
VASCAZEN 900 MG-110 MG-680 MG CAPSULE
VASCEPA 1 GRAM CAPSULE MM
vaseline white petroleum topical ointment in packet
VASERETIC 10 MG-25 MG TABLET MM
vashe wound therapy 0.033 % irrigation solution
vasolex ointment
VASOTEC 10 MG TABLET MM
VASOTEC 2.5 MG TABLET MM
VASOTEC 20 MG TABLET MM
VASOTEC 5 MG TABLET MM
VAYACOG 100 MG-19.5 MG-6.5 MG CAPSULE
VAYARIN 75 MG-8.5 MG-21.5 MG CAPSULE
VAYAROL 0.63 GRAM-232.5 MG-92.5 MG CAPSULE
vecamyl 2.5 mg tablet
VECTICAL 3 MCG/GRAM TOPICAL OINTMENT
VEHICLE-N MILD SOLUTION
VEHICLE-N SOLUTION
velivet triphasic regimen (28) 0.1 mg/0.125 mg/0.15 mg-25 mcg tablet MM
VELPHORO 500 MG CHEWABLE TABLET MM
VELTIN 1.2 %-0.025 % TOPICAL GEL
vemavite-prx-2 27 mg-1.25 mg-55 mg-300 mg capsule
vena-bal dha 27 mg-1 mg-430 mg tablet&capsule,delayed release
venatal complete dha 27 mg-1 mg-430 mg tablet &capsule,delayed release
venatal-fa tablet
VENELEX 87 MG-788 MG/GRAM TOPICAL OINTMENT
venelex 87 mg-788 mg/gram topical ointment in packet
venlafaxine hcl 100 mg tablet MM
venlafaxine hcl 25 mg tablet MM
venlafaxine hcl 37.5 mg tablet MM
venlafaxine hcl 50 mg tablet MM
venlafaxine hcl 75 mg tablet MM
venlafaxine hcl er 150 mg cap MM
VENLAFAXINE HCL ER 150 MG TAB MM
VENLAFAXINE HCL ER 225 MG TAB MM
venlafaxine hcl er 37.5 mg cap MM
VENLAFAXINE HCL ER 37.5 MG TAB MM
venlafaxine hcl er 75 mg cap MM
VENLAFAXINE HCL ER 75 MG TAB MM
VENTAVIS 10 MCG/ML SOLUTION FOR NEBULIZATION SP
VENTAVIS 20 MCG/ML SOLUTION FOR NEBULIZATION SP
VENTOLIN HFA 90 MCG/ACTUATION AEROSOL INHALER MM
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
184 - FORMULARY Updated 09/2015
DRUG LEVEL
3
3
3
3
3
3
3
3
3
3
2
3
3
3
3
3
3
3
4
4
3
3
1
4
3
2
2
2
3
3
3
1
1
1
1
1
1
3
3
1
3
1
3
*
*
2
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
ST
ST
QL
QL
QL
QL
QL
QL
QL
QL,PA
QL,PA
QL
DRUG NAME
VERAMYST 27.5 MCG/ACTUATION NASAL SPRAY,SUSPENSION MM
verapamil 120 mg tablet MM
verapamil 360 mg cap pellet MM
verapamil 40 mg tablet MM
verapamil 80 mg tablet MM
verapamil er 120 mg capsule MM
verapamil er 120 mg tablet MM
verapamil er 180 mg capsule MM
verapamil er 180 mg tablet MM
verapamil er 240 mg capsule MM
verapamil er 240 mg tablet MM
verapamil er pm 100 mg capsule MM
verapamil er pm 200 mg capsule MM
verapamil er pm 300 mg capsule MM
VERDESO 0.05 % TOPICAL FOAM
verdrocet 2.5 mg-325 mg tablet
VEREGEN 15 % TOPICAL OINTMENT
VERELAN 120 MG CAPSULE,EXTENDED RELEASE MM
VERELAN 180 MG CAPSULE,EXTENDED RELEASE MM
VERELAN 240 MG CAPSULE,EXTENDED RELEASE MM
VERELAN 360 MG CAPSULE,EXTENDED RELEASE MM
VERELAN PM 100 MG CAPSULE, EXTENDED RELEASE MM
VERELAN PM 200 MG CAPSULE, EXTENDED RELEASE MM
VERELAN PM 300 MG CAPSULE, EXTENDED RELEASE MM
VERIPRED 20 20 MG/5 ML ORAL SOLUTION
VERSACLOZ 50 MG/ML ORAL SUSPENSION MM
VESICARE 10 MG TABLET MM
VESICARE 5 MG TABLET MM
vestura (28) 3 mg-20 mcg tablet MM
VEXOL 1 % EYE DROPS,SUSPENSION
VFEND 200 MG TABLET
VFEND 200 MG/5 ML (40 MG/ML) ORAL SUSPENSION
VFEND 50 MG TABLET
VIBRAMYCIN 100 MG CAPSULE
VIBRAMYCIN 25 MG/5 ML ORAL SUSPENSION
VIBRAMYCIN 50 MG/5 ML SYRUP
vicodin 5 mg-300 mg tablet
vicodin es 7.5 mg-300 mg tablet
vicodin hp 10 mg-300 mg tablet
VICOPROFEN 7.5 MG-200 MG TABLET
VICTORY BLOOD GLUCOSE MONITOR
VICTORY GLUCOSE TEST STRIPS MM
VICTORY HIGH-LOW CONTROL SOLN
VICTOZA 2-PAK 0.6 MG/0.1 ML (18 MG/3 ML) SUBCUTANEOUS PEN INJECTOR MM
VICTOZA 3-PAK 0.6 MG/0.1 ML (18 MG/3 ML) SUBCUTANEOUS PEN INJECTOR MM
DRUG LEVEL
3
1
2
1
1
2
1
2
1
2
1
3
3
3
4
3
4
3
3
3
3
3
3
3
3
3
3
3
2
3
4
4
4
3
3
3
3
3
3
3
3
3
3
2
2
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL,ST
QL
QL
ST
QL,PA
QL,PA
QL,PA
QL
QL
QL
QL
QL
ST
QL,ST
QL
QL
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 185
DRUG NAME
VICTRELIS 200 MG CAPSULE SP
VIDEX 2 GRAM PEDIATRIC 10 MG/ML (FINAL CONC.) ORAL SOLUTION
VIDEX 4 GRAM PEDIATRIC 10 MG/ML (FINAL CONC.) ORAL SOLUTION
VIDEX EC 125 MG CAPSULE,DELAYED RELEASE
VIDEX EC 200 MG CAPSULE,DELAYED RELEASE
VIDEX EC 250 MG CAPSULE,DELAYED RELEASE
VIDEX EC 400 MG CAPSULE,DELAYED RELEASE
VIEKIRA PAK 12.5 MG-75 MG-50 MG/250 MG TABLETS IN A DOSE PACK SP
VIGAMOX 0.5 % EYE DROPS
VIIBRYD 10 MG (7)-20 MG (23) TABLETS IN A DOSE PACK
VIIBRYD 10 MG (7)-20 MG (7)-40 MG(16) TABLETS IN A DOSE PACK
VIIBRYD 10 MG TABLET MM
VIIBRYD 20 MG TABLET MM
VIIBRYD 40 MG TABLET MM
VIMOVO 375 MG-20 MG TABLET,IMMEDIATE & DELAYED RELEASE MM
VIMOVO 500 MG-20 MG TABLET,IMMEDIATE & DELAYED RELEASE MM
VIMPAT 10 MG/ML ORAL SOLUTION MM
VIMPAT 100 MG TABLET MM
VIMPAT 150 MG TABLET MM
VIMPAT 200 MG TABLET MM
VIMPAT 50 MG (14)-100 MG (14) TABLETS IN A DOSE PACK
VIMPAT 50 MG TABLET MM
vinacal 27 mg-1 mg-50 mg tablet
VINATE CARE 40 MG IRON-1 MG CHEWABLE TABLET
vinate dha 27 mg-400 mcg-1.13 mg-250 mg capsule
VINATE DHA RF 27 MG IRON-1.13 MG-581.28 MG CAPSULE
vinate gt 90 mg-1 mg-50 mg tablet
vinate ii 29 mg-1 mg tablet
vinate m 27 mg-1 mg tablet
vinate one 60 mg iron-1 mg tablet
vinate pn care 30 mg-1 mg-50 mg tablet
vinate ultra 90 mg-1 mg-50 mg tablet
VIOKACE 10,440-39,150-39,150 UNIT TABLET MM
VIOKACE 20,880-78,300-78,300 UNIT TABLET MM
viorele (28) 0.15 mg-0.02 mg (21)/0.01 mg (5) tablet MM
VIRACEPT 250 MG TABLET SP
VIRACEPT 625 MG TABLET SP
VIRAMUNE 200 MG TABLET
VIRAMUNE 50 MG/5 ML ORAL SUSPENSION
VIRAMUNE XR 100 MG TABLET,EXTENDED RELEASE
VIRAMUNE XR 400 MG TABLET,EXTENDED RELEASE
VIRASAL 27.5 % TOPICAL FILM-FORMING LIQUID
VIRAZOLE 6 GRAM SOLUTION FOR INHALATION
VIREAD 150 MG TABLET SP
VIREAD 200 MG TABLET SP
VIREAD 250 MG TABLET SP
VIREAD 300 MG TABLET SP
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
186 - FORMULARY Updated 09/2015
DRUG LEVEL
*
3
3
3
3
3
3
*
3
3
3
3
3
3
4
4
4
4
4
4
4
4
1
2
2
3
1
1
1
1
2
1
3
3
2
*
*
3
3
4
3
3
3
*
*
*
*
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
QL
QL
QL
QL,PA
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,PA
PA
PA
PA
PA
PA
ST
ST
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
DRUG NAME
VIREAD 40 MG/SCOOP (40 MG/GRAM) ORAL POWDER SP
VIROPTIC 1 % EYE DROPS
virt nate 28 mg-1 mg tablet
virt-advance 90 mg-1 mg-50 mg tablet
VIRT-BAL DHA COMBO PACK
VIRT-BAL DHA PLUS COMBO PACK
virt-c dha 35 mg-1 mg-200 mg capsule
virt-caps 1 mg capsule
virt-care one 27 mg-1 mg-330 mg capsule
virt-phos 250 neutral 250 mg tablet
virt-pn 27 mg-1 mg tablet
virt-pn dha 27 mg-1 mg-300 mg capsule
virt-pn plus 28 mg-1 mg-300 mg capsule
virt-select 29 mg-1.25 mg-55 mg-325 mg capsule
virt-vite 2.5 mg-25 mg-1 mg tablet
virt-vite forte 2.5 mg-25 mg-2 mg tablet
virt-vite gt 90 mg-1 mg-50 mg tablet
VIRT-VITE PLUS 5 MG TABLET
virti-sulf emollient cream
virtprex 26 mg-1.2 mg-55 mg-300 mg capsule
virtrate-2 500 mg-334 mg/5 ml oral solution
virtrate-3 550 mg-500 mg-334 mg/5 ml oral solution
virtrate-k 1,100 mg-334 mg/5 ml oral solution
VISTARIL 25 MG CAPSULE
VISTARIL 50 MG CAPSULE
vit d2 1.25 mg (50,000 unit) MM
VITA-RESPA 2.2 MG-25 MG-1.3 MG TABLET
VITAFOL 65 MG-1 MG TABLET
VITAFOL NANO 18 MG IRON-1 MG TABLET
VITAFOL ULTRA 29 MG IRON-1 MG-200 MG CAPSULE
VITAFOL-OB 65 MG-1 MG TABLET
VITAFOL-OB+DHA 65 MG-1 MG-250 MG ORAL PACK
VITAFOL-ONE 29 MG IRON-1 MG-200 MG CAPSULE
VITAFOL-PN CAPLET
VITAL-D RX 1,750 UNIT-60 MG-1 MG-12.5 MG TABLET
VITAMED MD ONE RX 30 MG IRON-1 MG-200 MG CAPSULE
VITAMED MD PLUS RX 30 MG IRON-1 MG-300 MG ORAL PACK
VITAMEDMD REDICHEW RX 1.4 MG CHEW TABLET,IMMEDIATE & DELAYED REL
VITAMEDMD REDICHEW RX TAB CHEW
vitamin d2 50,000 unit capsule MM
vitamin k 1 mg/0.5 ml injection solution
vitamin k1 10 mg/ml injection solution
vitamins a,c,d & fluoride 0.25 mg fluoride (0.55 mg)/ml oral drops
VITAPEARL 30 MG-1.4 MG-200 MG CAPSULE,IMMEDIATE & DELAY RELEASE
vitaspire 29 mg-1 mg tablet
VITEKTA 150 MG TABLET SP
VITEKTA 85 MG TABLET SP
VITUZ 5 MG-4 MG/5 ML ORAL SOLUTION
VIVA CT PRENATAL CHEWABLE TAB
VIVA DHA 28 MG-1 MG-200 MG CAPSULE
DRUG LEVEL
*
3
1
1
3
3
2
1
2
2
2
2
2
2
1
1
1
1
3
1
1
2
2
3
3
1
3
3
3
3
3
3
2
3
3
2
2
3
2
1
4
4
1
3
3
*
*
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 187
DRUG NAME
VIVACTIL 10 MG TABLET MM
VIVACTIL 5 MG TABLET MM
VIVELLE-DOT 0.025 MG/24 HR TRANSDERMAL PATCH MM
VIVELLE-DOT 0.0375 MG/24 HR TRANSDERMAL PATCH MM
VIVELLE-DOT 0.05 MG/24 HR TRANSDERMAL PATCH MM
VIVELLE-DOT 0.075 MG/24 HR TRANSDERMAL PATCH MM
VIVELLE-DOT 0.1 MG/24 HR TRANSDERMAL PATCH MM
VOCAL POINT GLUCOSE CONTROL SOLUTION
VOCAL POINT TEST STRIP MM
VOCALPOINT GLUCOSE CONTROL SOLUTION
VOGELXO 1 % (50 MG/5 GRAM) TRANSDERMAL GEL PACKET MM
VOGELXO 1.25 GRAM/ACTUATION (1%) TRANSDERMAL GEL PUMP MM
VOGELXO 50 MG/5 GRAM (1 %) TRANSDERMAL GEL MM
vol-care rx 1 mg-60 mg-300 mcg tablet
vol-nate 28 mg-1 mg tablet
vol-plus 27 mg-1 mg tablet
vol-plus tablet
vol-tab rx 29 mg iron-1 mg tablet
VOLTAREN 1 % TOPICAL GEL MM
VOLTAREN-XR 100 MG TABLET,EXTENDED RELEASE MM
VOLUMEN 0.1 % (W/V), 0.1 % (W/W) ORAL SUSPENSION
voriconazole 200 mg tablet
voriconazole 40 mg/ml susp
voriconazole 50 mg tablet
VORTEX HOLDING CHAMBER
VORTEX HOLDING CHAMBER WITH CHILD MASK
VORTEX HOLDING CHAMBER WITH TODDLER MASK
VORTEX VHC FROG MASK-CHILD
VORTEX VHC LADYBUG MASK-TODDLER
VOSOL HC EAR DROPS
VOSPIRE ER 4 MG TABLET,EXTENDED RELEASE MM
VOSPIRE ER 8 MG TABLET,EXTENDED RELEASE MM
VOTRIENT 200 MG TABLET SP
VP CH ULTRA SOFTGEL
vp-ch plus 29 mg iron-1 mg-50 mg-265 mg capsule
vp-ch-pnv 30 mg iron-1 mg-50 mg-260 mg capsule
vp-era ob plus tablet
vp-ggr-b6 1.2 mg-40 mg-124.1 mg-100 mg tablet
vp-gstn 27 mg-20 mg-200 unit capsule
vp-heme ob + dha 28 mg iron-6 mg iron-1 mg oral pack
vp-heme ob 28 mg-6 mg-1 mg tablet
vp-heme one 22 mg-6 mg-1 mg-200 mg capsule
VP-PNV-DHA 28 MG IRON-1 MG-200 MG CAPSULE
VP-PRECIP 250 MG-125 MG-10 MG CAPSULE
vp-zel 600 mg-5 mg-10 mg-5 mg-1.5 mg tablet
VSL#3 DS 900 BILLION CELL ORAL POWDER PACKET
VUSION 0.25 %-15 %-81.35 % TOPICAL OINTMENT
vyfemla (28) 0.4 mg-35 mcg tablet MM
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
188 - FORMULARY Updated 09/2015
DRUG LEVEL
3
3
3
3
3
3
3
3
3
3
3
3
3
1
1
1
3
1
3
4
3
4
4
4
2
1
1
1
1
3
3
3
*
3
2
2
3
2
2
2
2
2
3
3
2
3
3
2
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
QL
QL,ST
QL,ST
QL,ST
QL,ST
PA
QL,PA
QL,PA
QL,PA
QL,PA
DRUG NAME
VYTONE 1.9 %-1 % TOPICAL CREAM PACKET
VYTORIN 10 MG-10 MG TABLET MM
VYTORIN 10 MG-20 MG TABLET MM
VYTORIN 10 MG-40 MG TABLET MM
VYTORIN 10 MG-80 MG TABLET MM
VYVANSE 10 MG CAPSULE
VYVANSE 20 MG CAPSULE
VYVANSE 30 MG CAPSULE
VYVANSE 40 MG CAPSULE
VYVANSE 50 MG CAPSULE
VYVANSE 60 MG CAPSULE
VYVANSE 70 MG CAPSULE
warfarin sodium 1 mg tablet MM
warfarin sodium 10 mg tablet MM
warfarin sodium 2 mg tablet MM
warfarin sodium 2.5 mg tablet MM
warfarin sodium 3 mg tablet MM
warfarin sodium 4 mg tablet MM
warfarin sodium 5 mg tablet MM
warfarin sodium 6 mg tablet MM
warfarin sodium 7.5 mg tablet MM
WATCHHALER SPACER
WAVESENSE AMP KIT
WAVESENSE CONTROL SOLUTION
WAVESENSE JAZZ KIT
WAVESENSE JAZZ STRIPS MM
WAVESENSE PRESTO
WAVESENSE PRESTO KIT
WAVESENSE PRESTO STRIPS MM
WEBCOL TOPICAL PADS
WELCHOL 3.75 GRAM ORAL POWDER PACKET MM
WELCHOL 625 MG TABLET MM
WELLBUTRIN 100 MG TABLET MM
WELLBUTRIN 75 MG TABLET MM
WELLBUTRIN SR 100 MG TABLET,SUSTAINED-RELEASE MM
WELLBUTRIN SR 150 MG TABLET,SUSTAINED-RELEASE MM
WELLBUTRIN SR 200 MG TABLET,SUSTAINED-RELEASE MM
WELLBUTRIN XL 150 MG 24 HR TABLET, EXTENDED RELEASE MM
WELLBUTRIN XL 300 MG 24 HR TABLET, EXTENDED RELEASE MM
wera (28) 0.5 mg-35 mcg tablet MM
WESTCORT 0.2% OINTMENT
WESTHROID 130 MG TABLET MM
WESTHROID 16.25 MG TABLET MM
WESTHROID 195 MG TABLET MM
WESTHROID 32.5 MG TABLET MM
DRUG LEVEL
3
3
3
3
3
2
2
2
2
2
2
2
1
1
1
1
1
1
1
1
1
1
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
4
4
1
3
3
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
ST
ST
QL,ST
ST
ST
QL,ST
ST
ST
QL
QL
QL
QL
QL
QL
QL
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 189
DRUG NAME
WESTHROID 48.75 MG TABLET MM
WESTHROID 65 MG TABLET MM
WESTHROID 97.5 MG TABLET MM
WIDE-SEAL DIAPHRAGM 60 MM VAGINAL
WIDE-SEAL DIAPHRAGM 65 MM VAGINAL
WIDE-SEAL DIAPHRAGM 70 MM VAGINAL
WIDE-SEAL DIAPHRAGM 75 MM VAGINAL
WIDE-SEAL DIAPHRAGM 80 MM VAGINAL
WIDE-SEAL DIAPHRAGM 85 MM VAGINAL
WIDE-SEAL DIAPHRAGM 90 MM VAGINAL
WIDE-SEAL DIAPHRAGM 95 MM VAGINAL
WP THYROID 113.75 MG TABLET MM
WP THYROID 130 MG TABLET MM
WP THYROID 16.25 MG TABLET MM
WP THYROID 32.5 MG TABLET MM
WP THYROID 48.75 MG TABLET MM
WP THYROID 65 MG TABLET MM
WP THYROID 81.25 MG TABLET MM
WP THYROID 97.5 MG TABLET MM
wymzya fe 0.4 mg-35 mcg (21)/75 mg (7) chewable tablet MM
x-viate 40% cream
x-viate 40% gel
x-viate 40% lotion
XALATAN 0.005 % EYE DROPS MM
XALKORI 200 MG CAPSULE SP
XALKORI 250 MG CAPSULE SP
XANAX 0.25 MG TABLET
XANAX 0.5 MG TABLET
XANAX 1 MG TABLET
XANAX 2 MG TABLET
XANAX XR 0.5 MG TABLET,EXTENDED RELEASE
XANAX XR 1 MG TABLET,EXTENDED RELEASE
XANAX XR 2 MG TABLET,EXTENDED RELEASE
XANAX XR 3 MG TABLET,EXTENDED RELEASE
XARELTO 10 MG TABLET
XARELTO 15 MG (42)-20 MG (9) TABLETS IN A DOSE PACK
XARELTO 15 MG TABLET MM
XARELTO 20 MG TABLET MM
XARTEMIS XR 7.5 MG-325 MG TABLET EXTENDED RELEASE, ORAL ONLY
XCLAIR TOPICAL CREAM
XELJANZ 5 MG TABLET SP
XELODA 150 MG TABLET SP
XELODA 500 MG TABLET SP
XENADERM OINTMENT
XENAZINE 12.5 MG TABLET SP
XENAZINE 25 MG TABLET SP
XERESE 5 %-1 % TOPICAL CREAM
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
190 - FORMULARY Updated 09/2015
DRUG LEVEL
3
3
3
4
4
4
4
4
4
4
4
3
3
3
3
3
3
3
3
2
2
2
2
3
*
*
3
3
3
3
3
3
3
3
2
2
2
2
3
3
*
*
*
3
*
*
4
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL,PA
QL,PA
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
PA
DRUG NAME
XIFAXAN 200 MG TABLET
XIFAXAN 550 MG TABLET MM
XIGDUO XR 10 MG-1,000 MG TABLET,EXTENDED RELEASE
XIGDUO XR 10 MG-500 MG TABLET,EXTENDED RELEASE
XIGDUO XR 5 MG-1,000 MG TABLET,EXTENDED RELEASE
XIGDUO XR 5 MG-500 MG TABLET,EXTENDED RELEASE
XODOL 10/300 10 MG-300 MG TABLET
XODOL 5/300 5 MG-300 MG TABLET
XODOL 7.5/300 7.5 MG-300 MG TABLET
XOLEGEL 2 % TOPICAL
xolox 10-500 mg tablet
XOPENEX 0.31 MG/3 ML SOLUTION FOR NEBULIZATION MM
XOPENEX 0.63 MG/3 ML SOLUTION FOR NEBULIZATION MM
XOPENEX 1.25 MG/3 ML SOLUTION FOR NEBULIZATION MM
XOPENEX CONCENTRATE 1.25 MG/0.5 ML SOLUTION FOR NEBULIZATION MM
XOPENEX HFA 45 MCG/ACTUATION AEROSOL INHALER MM
XPRES CONTROL SOLUTION NORMAL
XTANDI 40 MG CAPSULE SP
xulane 150 mcg-35 mcg/24 hr transdermal patch MM
XYLOCAINE 4 % (40 MG/ML) MUCOSAL SOLUTION
xylon 10 10 mg-200 mg tablet
XYREM 500 MG/ML ORAL SOLUTION SP
XYZAL 2.5 MG/5 ML ORAL SOLUTION MM
XYZAL 5 MG TABLET MM
YASMIN (28) 3 MG-0.03 MG TABLET MM
YAZ (28) 3 MG-20 MCG TABLET MM
YODOXIN 210 MG TABLET
YODOXIN 650 MG TABLET
zafirlukast 10 mg tablet MM
zafirlukast 20 mg tablet MM
zaleplon 10 mg capsule
zaleplon 5 mg capsule
ZAMICET 10 MG-325 MG/15 ML ORAL SOLUTION
ZANAFLEX 2 MG CAPSULE MM
ZANAFLEX 4 MG CAPSULE MM
ZANAFLEX 4 MG TABLET MM
ZANAFLEX 6 MG CAPSULE MM
ZANTAC 15 MG/ML SYRUP MM
ZANTAC 150 MG TABLET MM
ZANTAC 300 MG TABLET MM
zarah 3 mg-0.03 mg tablet MM
ZARONTIN 250 MG CAPSULE MM
ZARONTIN 250 MG/5 ML ORAL SOLUTION MM
ZAROXOLYN 2.5 MG TABLET MM
ZAROXOLYN 5 MG TABLET MM
zatean-ch 27 mg-1 mg-50 mg-250 mg capsule
DRUG LEVEL
4
4
3
3
3
3
2
2
2
3
3
3
4
4
3
3
3
*
3
3
3
*
3
3
3
3
3
3
3
3
1
1
3
3
3
3
3
3
3
3
2
3
3
3
3
2
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,PA
QL,PA
QL,ST
QL,ST
QL,ST
QL,ST
QL
QL
QL
QL
QL
QL,PA
QL
QL
QL,PA
QL
QL
QL
QL
QL
QL
QL
ST
ST
ST
ST
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 191
DRUG NAME
zatean-pn dha 27 mg-1 mg-300 mg capsule
zatean-pn plus 28 mg-1 mg-300 mg capsule
zatean-pn tablet
ZAVESCA 100 MG CAPSULE SP
ZEBETA 10 MG TABLET MM
ZEBETA 5 MG TABLET MM
ZEBUTAL 50 MG-325 MG-40 MG CAPSULE
zebutal capsule
ZEGERID 20 MG-1,680 MG ORAL PACKET
ZEGERID 20 MG-1.1 GRAM CAPSULE MM
ZEGERID 40 MG-1,680 MG ORAL PACKET
ZEGERID 40 MG-1.1 GRAM CAPSULE MM
ZELAPAR 1.25 MG DISINTEGRATING TABLET MM
ZELBORAF 240 MG TABLET SP
ZEMPLAR 1 MCG CAPSULE MM
ZEMPLAR 2 MCG CAPSULE MM
ZEMPLAR 4 MCG CAPSULE MM
zenatane 10 mg capsule
zenatane 20 mg capsule
zenatane 30 mg capsule
zenatane 40 mg capsule
zenchent (28) 0.4 mg-35 mcg tablet MM
zenchent fe 0.4 mg-35 mcg (21)/75 mg (7) chewable tablet MM
zencia 9 %-4 % topical cleanser
ZENPEP 10,000-34,000-55,000 UNIT CAPSULE,DELAYED RELEASE MM
ZENPEP 15,000-51,000-82,000 UNIT CAPSULE,DELAYED RELEASE MM
ZENPEP 20,000-68,000-109,000 UNIT CAPSULE,DELAYED RELEASE MM
ZENPEP 25,000-85,000-136,000 UNIT CAPSULE,DELAYED RELEASE MM
ZENPEP 3,000-10,000-16,000 UNIT CAPSULE,DELAYED RELEASE MM
ZENPEP 40,000-136,000-218,000 UNIT CAPSULE,DELAYED RELEASE
ZENPEP 5,000-17,000-27,000 UNIT CAPSULE,DELAYED RELEASE MM
zenzedi 10 mg tablet
ZENZEDI 15 MG TABLET
ZENZEDI 2.5 MG TABLET
ZENZEDI 20 MG TABLET
ZENZEDI 30 MG TABLET
zenzedi 5 mg tablet
ZENZEDI 7.5 MG TABLET
zeosa 0.4 mg-35 mcg (21)/75 mg (7) chewable tablet MM
ZERIT 1 MG/ML ORAL SOLUTION
ZERIT 15 MG CAPSULE
ZERIT 20 MG CAPSULE
ZERIT 30 MG CAPSULE
ZERIT 40 MG CAPSULE
ZESTORETIC 10 MG-12.5 MG TABLET MM
ZESTORETIC 20 MG-12.5 MG TABLET MM
ZESTORETIC 20 MG-25 MG TABLET MM
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
192 - FORMULARY Updated 09/2015
DRUG LEVEL
2
3
2
*
3
3
2
3
3
3
3
3
4
*
3
3
3
4
4
4
4
2
2
3
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,PA
QL
QL
QL,ST
QL,ST
QL,ST
QL,ST
QL,PA
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
DRUG NAME
ZESTRIL 10 MG TABLET MM
ZESTRIL 2.5 MG TABLET MM
ZESTRIL 20 MG TABLET MM
ZESTRIL 30 MG TABLET MM
ZESTRIL 40 MG TABLET MM
ZESTRIL 5 MG TABLET MM
ZETIA 10 MG TABLET MM
ZETONNA 37 MCG/ACTUATION NASAL HFA INHALER MM
zflex tablet
zgesic tablet
ZIAC 10 MG-6.25 MG TABLET MM
ZIAC 2.5 MG-6.25 MG TABLET MM
ZIAC 5 MG-6.25 MG TABLET MM
ZIAGEN 20 MG/ML ORAL SOLUTION
ZIAGEN 300 MG TABLET
ZIANA 1.2 %-0.025 % TOPICAL GEL
zidovudine 100 mg capsule
zidovudine 300 mg tablet
zidovudine 50 mg/5 ml syrup
zinc sulfate 220 mg capsule
zingiber 1.2 mg-40 mg-124.1 mg-100 mg tablet
ZIOPTAN (PF) 0.0015 % EYE DROPS IN A DROPPERETTE MM
ziprasidone hcl 20 mg capsule MM
ziprasidone hcl 40 mg capsule MM
ziprasidone hcl 60 mg capsule MM
ziprasidone hcl 80 mg capsule MM
ZIPSOR 25 MG CAPSULE
ZIRGAN 0.15 % EYE GEL
ZITHRANOL 1 % SHAMPOO
ZITHRANOL-RR 1.2 % TOPICAL CREAM RAPID RELEASE
ZITHROMAX 1 GRAM ORAL PACKET
ZITHROMAX 100 MG/5 ML ORAL SUSPENSION
ZITHROMAX 200 MG/5 ML ORAL SUSPENSION
ZITHROMAX 250 MG TABLET
ZITHROMAX 500 MG TABLET
ZITHROMAX 600 MG TABLET
ZITHROMAX TRI-PAK 500 MG TABLET
ZITHROMAX Z-PAK 250 MG TABLET
ZMAX 2 GRAM/60 ML ORAL SUSPENSION,EXTENDED RELEASE
ZOCOR 10 MG TABLET MM
ZOCOR 20 MG TABLET MM
ZOCOR 40 MG TABLET MM
ZOCOR 5 MG TABLET MM
ZOCOR 80 MG TABLET MM
ZOFRAN 4 MG TABLET
ZOFRAN 4 MG/5 ML ORAL SOLUTION
ZOFRAN 8 MG TABLET
DRUG LEVEL
3
3
3
3
3
3
2
2
3
2
3
3
3
4
4
3
2
2
3
2
3
3
3
3
3
3
4
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL
QL
QL
QL
QL
QL
QL,ST
QL
QL
QL
QL
QL,ST
QL
QL
QL
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL
QL
QL
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 193
DRUG NAME
ZOFRAN ODT 4 MG DISINTEGRATING TABLET
ZOFRAN ODT 8 MG DISINTEGRATING TABLET
ZOHYDRO ER 10 MG CAPSULE
ZOHYDRO ER 10 MG CAPSULE, ORAL ONLY,EXTENDED RELEASE
ZOHYDRO ER 15 MG CAPSULE
ZOHYDRO ER 15 MG CAPSULE, ORAL ONLY,EXTENDED RELEASE
ZOHYDRO ER 20 MG CAPSULE
ZOHYDRO ER 20 MG CAPSULE, ORAL ONLY,EXTENDED RELEASE
ZOHYDRO ER 30 MG CAPSULE
ZOHYDRO ER 30 MG CAPSULE, ORAL ONLY,EXTENDED RELEASE
ZOHYDRO ER 40 MG CAPSULE
ZOHYDRO ER 40 MG CAPSULE, ORAL ONLY,EXTENDED RELEASE
ZOHYDRO ER 50 MG CAPSULE
ZOHYDRO ER 50 MG CAPSULE, ORAL ONLY,EXTENDED RELEASE
ZOLINZA 100 MG CAPSULE SP
zolmitriptan 2.5 mg odt
zolmitriptan 2.5 mg tablet
zolmitriptan 5 mg odt
zolmitriptan 5 mg tablet
ZOLOFT 100 MG TABLET MM
ZOLOFT 20 MG/ML ORAL CONCENTRATE MM
ZOLOFT 25 MG TABLET MM
ZOLOFT 50 MG TABLET MM
zolpidem tart er 12.5 mg tab
zolpidem tart er 6.25 mg tab
zolpidem tartrate 10 mg tablet
zolpidem tartrate 5 mg tablet
ZOLPIMIST 5 MG/SPRAY (0.1 ML) ORAL SPRAY
ZOLVIT 10 MG-300 MG/15 ML SOLN
ZOMACTON 10 MG SUBCUTANEOUS SOLUTION SP
ZOMACTON 5 MG SUBCUTANEOUS SOLUTION SP
ZOMIG 2.5 MG NASAL SPRAY
ZOMIG 2.5 MG TABLET
ZOMIG 5 MG NASAL SPRAY
ZOMIG 5 MG TABLET
ZOMIG ZMT 2.5 MG DISINTEGRATING TABLET
ZOMIG ZMT 5 MG DISINTEGRATING TABLET
ZONALON 5 % TOPICAL CREAM
ZONATUSS 150 MG CAPSULE
ZONEGRAN 100 MG CAPSULE MM
ZONEGRAN 25 MG CAPSULE MM
zonisamide 100 mg capsule MM
zonisamide 25 mg capsule MM
zonisamide 50 mg capsule MM
ZONTIVITY 2.08 MG TABLET MM
ZORBTIVE 8.8 MG SUBCUTANEOUS SOLUTION SP
ZORTRESS 0.25 MG TABLET
ZORTRESS 0.5 MG TABLET
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
194 - FORMULARY Updated 09/2015
DRUG LEVEL
3
3
3
3
3
3
3
3
3
3
3
3
3
3
*
3
3
3
3
3
3
3
3
3
3
1
1
3
3
*
*
4
4
3
4
4
4
3
3
4
4
1
1
1
3
*
4
4
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL
QL
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,ST
QL,ST
QL,ST
QL,ST
QL
QL
QL
QL
QL,ST
QL,ST
QL
QL
QL,ST
QL
QL,PA
QL,PA
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,ST
QL,PA
QL,PA
QL,PA
QL,PA
DRUG NAME
ZORTRESS 0.75 MG TABLET
ZORVOLEX 18 MG CAPSULE
ZORVOLEX 35 MG CAPSULE
zovia 1/35e (28) 1 mg-35 mcg tablet MM
zovia 1/50e (28) 1 mg-50 mcg tablet MM
ZOVIRAX 200 MG CAPSULE MM
ZOVIRAX 200 MG/5 ML ORAL SUSPENSION MM
ZOVIRAX 400 MG TABLET MM
ZOVIRAX 5 % TOPICAL CREAM
ZOVIRAX 5 % TOPICAL OINTMENT
ZOVIRAX 800 MG TABLET MM
ZUBSOLV 1.4 MG-0.36 MG SUBLINGUAL TABLET
ZUBSOLV 5.7 MG-1.4 MG SUBLINGUAL TABLET
ZUBSOLV 8.6 MG-2.1 MG SUBLINGUAL TABLET
ZUPLENZ 4 MG ORAL SOLUBLE FILM
ZUPLENZ 8 MG ORAL SOLUBLE FILM
ZUTRIPRO 4 MG-60 MG-5 MG/5 ML ORAL SOLUTION
ZYCLARA 2.5 % TOPICAL CREAM PUMP
ZYCLARA 3.75 % TOPICAL CREAM PACKET
ZYCLARA 3.75 % TOPICAL CREAM PUMP
ZYDELIG 100 MG TABLET SP
ZYDELIG 150 MG TABLET SP
ZYDONE 10-400 MG TABLET
ZYDONE 5-400 MG TABLET
ZYDONE 7.5-400 MG TABLET
ZYFLO 600 MG TABLET MM
ZYFLO CR 600 MG TABLET,EXTENDED RELEASE MM
ZYKADIA 150 MG CAPSULE SP
ZYLET 0.3 %-0.5 % EYE DROPS,SUSPENSION
ZYLOPRIM 100 MG TABLET MM
ZYLOPRIM 300 MG TABLET MM
ZYMAXID 0.5 % EYE DROPS
ZYPRAM 2.35 %-1 % KIT,CREAM AND TOWELETTE
ZYPREXA 10 MG TABLET MM
ZYPREXA 15 MG TABLET MM
ZYPREXA 2.5 MG TABLET MM
ZYPREXA 20 MG TABLET MM
ZYPREXA 5 MG TABLET MM
ZYPREXA 7.5 MG TABLET MM
ZYPREXA ZYDIS 10 MG DISINTEGRATING TABLET MM
ZYPREXA ZYDIS 15 MG DISINTEGRATING TABLET MM
ZYPREXA ZYDIS 20 MG DISINTEGRATING TABLET MM
ZYPREXA ZYDIS 5 MG DISINTEGRATING TABLET MM
ZYTIGA 250 MG TABLET SP
ZYVOX 100 MG/5 ML ORAL SUSPENSION
ZYVOX 600 MG TABLET
DRUG LEVEL
4
3
3
2
2
3
3
4
4
4
3
3
3
3
3
3
3
4
4
4
*
*
3
3
3
4
4
*
3
3
3
3
3
4
4
4
4
4
4
4
4
4
4
*
4
4
UTILIZATION
MANAGEMENT
REQUIREMENTS
QL,PA
QL,ST
QL,ST
PA
PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,PA
QL,ST
ST
QL,ST
QL,PA
QL,PA
QL
QL
QL
QL,ST
QL,ST
QL,PA
ST
QL,ST
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL,PA
QL
QL
ST - Step Therapy • QL - Quantity Limit • PA - Prior Authorization
FORMULARY Updated 09/2015 - 195
* Not all the drugs listed on this formulary are covered by all prescription drug benefit plans. For more information about the drugs
covered by your prescription drug benefit plan, copayment or coinsurance amounts, you can call the number on the back of your
Humana member ID card or log into MyHumana, click on "Coverage, Claims & Spending" then "Pharmacy."
** For Commercial Fully-Insured and Individual policies issued in Texas, Louisiana, and Puerto Rico:
formulary changes are effective on a plan's renewal date.
Humana Plans are offered by Humana Medical Plan, Inc., Humana Employers Health Plan of Georgia, Inc., Humana Health Plan, Inc.,
Humana Health Benefit Plan of Louisiana, Inc., Humana Health Plan of Ohio, Inc., Humana Health Plans of Puerto Rico, Inc. License #
00235-0008, Humana Wisconsin Health Organization Insurance Corporation, or Humana Health Plan of Texas, Inc. - A Health
Maintenance Organization, or insured by Humana Health Insurance Company of Florida, Inc., Humana Health Plan, Inc., Humana
Health Benefit Plan of Louisiana, Inc., Humana Insurance Company, Humana Insurance Company of Kentucky, Humana Insurance of
Puerto Rico, Inc. License # 00187-0009, or administered by Humana Insurance Company or Humana Health Plan, Inc.
Statements in languages other than English contained in the advertisement do not necessarily reflect the exact contents of the policy
written in English, because of possible linguistic differences. In the event of a dispute, the policy as written in English is considered the
controlling authority.
For Arizona Residents: Offered by Humana Health Plan, Inc. or insured by Humana Insurance Company.
Please refer to your Benefit Plan Document (Certificate of Coverage/Insurance or Summary Plan Description) for more information on
the company providing your benefits.
Our health benefit plans have details left out, limits, and terms under which the coverage by be continues or ended. For costs and
complete details of the coverage, call or write your Humana insurance agent or broker.
ASO products are administered by Humana Insurance Company or Humana Health Plan, Inc.
Humana.com
2016Rx4TC