Formulario del Grupo del Empleador 2017 (Lista de Medicamentos Cubiertos) IMPORTANTE: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE LOS MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN Health Net CoCare Plan B (Employer HMO) y Health Net Seniority Plus (Employer HMO) N.º de Identificación de Presentación de Archivo del Formulario Aprobado de HPMS 17409, Número de versión 1. Este formulario se actualizó el 0/01/201. Para obtener información más reciente o si tiene alguna otra pregunta, comuníquese con Health Net a los siguientes teléfonos: Planes de Arizona: 1-800-977-7522 Planes HMO de California: 1-800-275-4737 o bien, para los usuarios de TTY, 711, de 8:00 a. m. a a 8:00 p. m., los siete días de la semana (en algunos fines de semana y días feriados se utiliza el servicio automático de teléfono), o visite www.healthnet.com/medicare. Y0020_2017_0009_SPN Aprobado por CMS 07012016 , 07042016 Nota para los afiliados existentes:Este formulario cambió con respecto al año pasado. Consulte este documento para asegurarse de que todavía incluye los medicamentos que usted toma. Cuando en esta lista de medicamentos (formulario) dice “nosotros”, “nos” o “nuestro”, se refiere a Health Net. Cuando dice “plan” o “nuestro plan”, se refiere a Health Net CoCare Plan B (Employer HMO) y a Health Net Seniority Plus (Employer HMO). Este documento incluye una lista de los medicamentos (formulario) para nuestro plan que tiene vigencia desde la fecha que figura en las páginas del frente y del reverso. Para obtener un formulario actualizado, comuníquese con nosotros. Nuestra información de contacto, junto con la fecha en que actualizamos por última vez el formulario, aparece en las páginas del frente y del reverso. Generalmente, debe usar farmacias de la red para usar su beneficio de medicamentos que requieren receta médica. Los beneficios, el formulario, la red de farmacias y/o los copagos/coseguro pueden modificarse el 1.º de enero de 2018 y ocasionalmente durante el año. ¿Qué es el formulario del Grupo del Empleador de Health Net CoCare Plan B (Employer HMO) y de Health Net Seniority Plus (Employer HMO)? Un formulario es una lista de medicamentos cubiertos seleccionados por nuestro plan en consulta con un equipo de proveedores de cuidado de la salud, que incluye las terapias que requieren receta médica consideradas como una parte necesaria de un programa de tratamiento de calidad. Por lo general, cubriremos los medicamentos que figuran en nuestro formulario siempre que el medicamento sea necesario a nivel médico, que surta la receta en una farmacia de la red del plan y que se cumplan otras reglas del plan. Para obtener más información sobre cómo surtir sus recetas, consulte su Evidencia de Cobertura. ¿Puede cambiar el formulario (lista de medicamentos)? Generalmente, si usted está tomando un medicamento del formulario 2017 que estaba cubierto al comienzo del año, no interrumpiremos ni reduciremos la cobertura de dicho medicamento durante el año de cobertura 2017, excepto cuando un nuevo medicamento genérico, menos costoso, se encuentre disponible o cuando se divulgue nueva información de efectos adversos sobre la seguridad o la eficacia de un medicamento. Otros tipos de cambios en el formulario, como la eliminación de un medicamento, no afectarán a los afiliados que estén actualmente tomando el medicamento. Continuará estando disponible con el mismo costo compartido para aquellos afiliados que lo estén tomando durante el resto del año de cobertura. Creemos que es importante que usted tenga un acceso continuo durante el resto del año de cobertura a los medicamentos del formulario que estaban disponibles cuando eligió nuestro plan, excepto en los casos en que usted pueda ahorrar dinero adicional o cuando podamos garantizar su seguridad. Si eliminamos medicamentos de nuestro formulario, agregamos restricciones de autorización previa, límites de cantidad y/o de terapia escalonada para un medicamento o trasladamos un medicamento a un nivel de costo compartido más alto, deberemos notificar sobre el cambio a los afiliados afectados al menos 60 días antes de que el cambio se haga efectivo, o en el momento en que el afiliado solicite una repetición de la receta del medicamento, en cuyo momento el afiliado recibirá un suministro de 60 días del medicamento. Si la Administración de Drogas y Alimentos considera que un medicamento de nuestro formulario no es seguro o i si el fabricante del medicamento lo retira del mercado, nosotros retiraremos de inmediato dicho medicamento de nuestro formulario y enviaremos un aviso a los afiliados que lo toman. El formulario que se adjunta tiene vigencia a partir de la fecha del formulario. Para obtener información actualizada sobre los medicamentos que cubre nuestro plan, comuníquese con nosotros. Nuestra información de contacto figura en las páginas del frente y del reverso. Si realizamos cualquier otro cambio negativo con respecto a un medicamento que esté tomando, se lo informaremos por correo. También publicaremos los cambios en nuestro sitio web. ¿Cómo uso el formulario? Hay dos maneras de buscar su medicamento en el formulario: Afección médica El formulario comienza en la página 1. Los medicamentos que figuran en este formulario se agrupan en categorías según el tipo de afecciones médicas que traten. Por ejemplo, los medicamentos utilizados para tratar una afección cardíaca se enumeran bajo la categoría “AGENTES CARDIOVASCULARES, VARIOS”. Si usted sabe para qué se usa su medicamento, busque el nombre de la categoría en la lista que comienza en la página 1. Luego busque su medicamento debajo del nombre de la categoría. Listado alfabético Si no está seguro en qué categoría buscar, deberá buscar su medicamento en el Índice que comienza en la página 1 del Índice. El Índice proporciona una lista alfabética de todos los medicamentos que se incluyen en este documento. Tanto los medicamentos de marca como los medicamentos genéricos están enumerados en el Índice. Busque en el Índice y encuentre su medicamento. Junto a su medicamento, verá el número de página en la que podrá encontrar información de la cobertura. Consulte la página que aparece en el Índice y busque el nombre de su medicamento en la primera columna de la lista. ¿Qué son los medicamentos genéricos? Nuestro plan cubre los medicamentos de marca y los medicamentos genéricos. Un medicamento genérico que, según la Administración de Medicamentos y Alimentos (por sus siglas en inglés, FDA), tiene los mismos principios activos que el medicamento de marca. Por lo general, los medicamentos genéricos son más económicos que los medicamentos de marca. ¿Hay alguna restricción en mi cobertura? Es posible que algunos medicamentos cubiertos tengan requisitos o límites adicionales en la cobertura. Estos requisitos y límites pueden incluir lo siguiente: x Autorización previa: Nuestro plan exige que usted o su médico obtenga una autorización previa para determinados medicamentos. Esto significa que tendrá que obtener nuestra aprobación antes de surtir sus recetas. Si no obtiene aprobación, es posible que no cubramos el medicamento. ii x x Límites de cantidad: Para determinados medicamentos, nuestro plan limita la cantidad del medicamento que cubriremos. Por ejemplo, nuestro plan proporciona dos tabletas por día por receta para simvastatin 40 mg. Esto puede proporcionarse además de un suministro estándar de un mes o tres meses. Terapia escalonada: En algunos casos, nuestro plan le exige que primero pruebe determinados medicamentos para tratar su afección médica antes de cubrir otro medicamento para esa afección. Por ejemplo, si tanto el medicamento A como el medicamento B tratan su afección médica, posiblemente no cubramos el medicamento B, a menos que usted pruebe primero el medicamento A. Si el medicamento A no es eficaz para usted, entonces cubriremos el medicamento B. Para averiguar si su medicamento tiene algún requisito o límite adicional, consulte el formulario que comienza en la página 1. También puede visitar nuestro sitio web para obtener más información sobre las restricciones que se aplican a medicamentos cubiertos específicos. Publicamos documentos en línea que explican nuestras restricciones de autorización previa y terapia escalonada. También puede solicitarnos una copia. Nuestra información de contacto, junto con la fecha en que actualizamos por última vez el formulario, aparece en las páginas del frente y del reverso. Puede pedirnos que hagamos una excepción a estas restricciones o límites o para una lista de otros medicamentos similares que podrían tratar su afección médica. Consulte la sección “¿Cómo solicito una excepción al formulario del Grupo del Empleador de Health Net CoCare Plan B (Employer HMO) y Health Net Seniority Plus (Employer HMO)”? en la página iii para obtener información sobre cómo solicitar una excepción. ¿Qué sucede si mi medicamento no está en el formulario? Si su medicamento no está incluido en este formulario (lista de medicamentos cubiertos), primero deberá comunicarse con Servicios al Afiliado y preguntar si su medicamento tiene cobertura. Si se entera de que nuestro plan no cubre su medicamento, tiene dos opciones: x Puede solicitar a Servicios al Afiliado una lista de medicamentos similares que cubra nuestro plan. Cuando reciba la lista, muéstresela a su médico y pídale que le recete un medicamento similar que esté cubierto por nuestro plan. x Puede pedirnos que hagamos una excepción y que cubramos su medicamento. Consulte a continuación para obtener información sobre cómo solicitar una excepción. ¿Cómo solicito una excepción al formulario del Grupo del Empleador de Health Net CoCare Plan B (Employer HMO) y de Health Net Seniority Plus (Employer HMO)? Puede pedirnos que hagamos una excepción a las reglas de nuestra cobertura. Existen varios tipos de excepciones que puede solicitar. iii x x x Nos puede pedir que cubramos un medicamento, aunque no esté en nuestro formulario. Si obtiene aprobación, este medicamento tendrá cobertura con un nivel de costo compartido predeterminado y usted no podrá pedirnos que proporcionemos el medicamento a un nivel de costo compartido más bajo. Puede pedirnos que cubramos un medicamento del formulario a un nivel de costo compartido más bajo si este medicamento no está en el nivel de especialidad. Si obtiene la aprobación, esto reduciría la cantidad que usted debe pagar por su medicamento. Puede pedirnos que anulemos las restricciones o los límites de la cobertura con respecto a su medicamento. Por ejemplo, para determinados medicamentos, nuestro plan limita la cantidad del medicamento que cubriremos. Si su medicamento tiene un límite de cantidad, puede pedirnos que anulemos dicho límite y que cubramos una cantidad mayor. Generalmente, solo aprobaremos su solicitud de excepción si los medicamentos alternativos incluidos en el formulario del plan, el medicamento con el costo compartido más bajo o las restricciones adicionales de utilización no fuesen tan eficaces en el tratamiento de su afección y/o le ocasionaran efectos médicos adversos. Deberá contactarse con nosotros para pedirnos que tomemos una decisión de cobertura inicial para una excepción del formulario, de nivel o de las restricciones de utilización. Cuando solicite una excepción del formulario, de nivel o de las restricciones de utilización, deberá enviar una declaración de la persona que receta o de su médico que respalde su solicitud. Generalmente, debemos tomar una decisión dentro de las 72 horas de haber recibido la declaración de respaldo de la persona que recetó el medicamento. Puede solicitar una excepción acelerada (rápida) si usted o su médico cree que su salud podría verse gravemente perjudicada al esperar las 72 horas para obtener una decisión. Si se otorga su solicitud de excepción acelerada, debemos informarle de la decisión en un lapso de 24 horas como máximo después de haber recibido la declaración de respaldo de su médico u otra persona que recete. ¿Qué debo hacer antes de hablar con mi médico sobre cambiar de medicamentos o solicitar una excepción? Como afiliado nuevo o existente en nuestro plan, es posible que esté tomando medicamentos que no estén en nuestro formulario. O bien, es posible que esté tomando un medicamento que está incluido en nuestro formulario, pero su capacidad para obtenerlo es limitada. Por ejemplo, es posible que necesite nuestra autorización previa antes de que pueda surtir su receta. Le recomendamos que hable con su médico para decidir si debe cambiar a un medicamento adecuado que cubramos o solicitar una excepción del formulario para que le cubramos el medicamento que toma. Mientras determina con su médico la forma de proceder correcta para usted, es posible que cubramos su medicamento en determinados casos durante los primeros 90 días en que sea afiliado de nuestro plan. Por cada uno de sus medicamentos que no esté en nuestro formulario o si su capacidad para obtener sus medicamentos es limitada, cubriremos un suministro temporal para 30 días (a menos que tenga una receta iv hecha para menos días) cuando vaya a una farmacia de la red. Después de su primer suministro para 30 días, no pagaremos estos medicamentos, aunque haya sido afiliado del plan menos de 90 días. Si es residente de un centro de atención a largo plazo, le permitiremos que repita su receta hasta que le hayamos proporcionando un suministro de transición para 98 días, que concuerde con el incremento de entrega (a menos que usted tenga una receta hecha por menos días). Cubriremos más de una repetición de estos medicamentos durante los primeros 90 días que sea afiliado de nuestro plan. Si necesita un medicamento que no está en nuestro formulario o si su capacidad para obtener sus medicamentos es limitada, pero ya transcurrieron los primeros 90 días de su membresía en nuestro plan, cubriremos un suministro de emergencia de ese medicamento para 31 días (a menos que tenga una receta hecha para menos días) mientras solicita una excepción del formulario. Cambios en el nivel de atención Si experimenta un cambio en su nivel de atención, cubriremos un suministro de transición de sus medicamentos. Un cambio en el nivel de atención ocurre cuando se le da de alta de un hospital o se le traslada desde o hacia un centro de atención a largo plazo. x x Si usted se traslada de un centro de atención a largo plazo o un hospital y necesita un suministro de transición, cubriremos un suministro para 30 días. Si en su receta se establecen menos días, permitiremos varias repeticiones de recetas hasta alcanzar el total de un suministro para un período de 30 días. Si se traslada de su hogar o de un hospital a un centro de atención a largo plazo y necesita un suministro de transición, cubriremos un suministro para 31 días. Si en su receta se establecen menos días, permitiremos varias repeticiones de recetas hasta alcanzar el total de un suministro para un período de 31 días. Comprendemos que existen otras circunstancias en las que se puede otorgar una anulación. Estas situaciones se tratan según cada caso mediante la comunicación entre la farmacia que provee el medicamento y Health Net. Para obtener más información Para obtener información más detallada sobre la cobertura de medicamentos que requieren receta médica de su plan, consulte la Evidencia de Cobertura y demás documentos del plan. Si tiene alguna pregunta sobre nuestro plan, comuníquese con nosotros. Nuestra información de contacto, junto con la fecha en que actualizamos por última vez el formulario, aparece en las páginas del frente y del reverso. v Si tiene preguntas generales sobre la cobertura de medicamentos que requieren receta médica de Medicare, llame a Medicare al 1-800-MEDICARE (1-800-633-4227), las 24 horas, los 7 días de la semana. Los usuarios de TTY deben llamar al 1-877-486-2048. O bien visite http://www.medicare.gov. Formulario del Grupo del Empleador de Health Net CoCare Plan B (Employer HMO) y de Health Net Seniority Plus (Employer HMO) El formulario que comienza en la página 1 proporciona información de cobertura sobre los medicamentos que cubre nuestro plan. Si tiene problemas para ubicar su medicamento en la lista, consulte el Índice que comienza en la página 1. La primera columna del cuadro detalla el nombre del medicamento. Los medicamentos de marca están escritos en letra mayúscula (por ejemplo, LIPITOR) y los medicamentos genéricos, en letra minúscula y cursiva (por ejemplo, atorvastatina cálcica). La información que se detalla en la columna Requisitos/Límites le indica si nuestro plan tiene algún requisito especial para la cobertura de su medicamento. Descripciones de los niveles del formulario Para averiguar cuánto paga por un medicamento, las abreviaciones a continuación aparecen en la columna Nivel de medicamentos en el formulario. El nivel de copago o de coseguro figura en la columna Copago/Coseguro. Para averiguar su copago o coseguro para cada nivel, consulte su Evidencia de Cobertura. Abreviatura 1 2 Copago/Coseguro Descripción Copago del nivel 1 Medicamentos genéricos preferidos (los de la Parte D y los que no están incluidos en la Parte D) Copago del nivel 2 Medicamentos de marca preferidos (los de la Parte D y los que no están incluidos en la Parte D) Estos medicamentos no son elegibles para excepciones de pago en un nivel inferior. 3 4 Copago del nivel 3 Medicamentos de marca no preferidos (los de la Parte D y los que no están incluidos en la Parte D) Copago del nivel 4 Los medicamentos inyectables que no cumplen con el límite de costo mínimo de los Centros de Servicios de Medicare y Medicaid (por sus siglas en inglés, CMS) que se requiere para que sean incluidos en el Nivel 5 (tanto los de la Parte D como los que no están incluidos en la Parte D) vi 5 (Especialidades) Copago o coseguro del Nivel 5 Medicamentos de alto costo. (los incluidos en la Parte D y los que no están incluidos en la Parte D) Estos medicamentos no son elegibles para excepciones de pago en un nivel inferior. NF Medicamentos fuera del formulario: Si se aprueba una solicitud de excepción para un medicamento fuera del formulario, se aplicará el copago del Nivel 3. No podrá pedirnos que proporcionemos el medicamento a un nivel de costo compartido más bajo. Medicamentos que no están cubiertos en el formulario de Medicare Parte D de Health Net. Usted puede solicitar una excepción por parte de Health Net para que cubra estos medicamentos. Consulte la sección “¿Cómo solicito una excepción del formulario del Grupo del Empleador de Health Net Medicare Parte D?” Abreviaturas Las siguientes abreviaturas pueden aparecer en la columna Requisitos/Límites en el formulario. Abreviatura Definición Descripción AL Límite de Edad B/D Medicare Parte B frente a Medicare Parte D Es posible que este medicamento requiera una autorización previa si su edad no está dentro de las recomendaciones clínicas, del fabricante o de la FDA. Este medicamento puede tener cobertura de Medicare Parte B o Parte D según las circunstancias. Es posible que se deba presentar información que describa el uso y las circunstancias de empleo del medicamento para tomar una decisión. GL Límite de Género Acceso limitado LA Este medicamento solo está cubierto para hombres o mujeres según las recomendaciones clínicas, del fabricante o de la FDA. Este medicamento podría estar sujeto a un acceso limitado o acceso restringido. Esto significa que el medicamento solo podría estar disponible en una farmacia o en una cantidad limitada de farmacias. El acceso limitado puede deberse a los siguientes motivos: La FDA ha restringido la distribución de un medicamento a determinados centros, farmacias o médicos. Determinados medicamentos requieren un manejo especial, una coordinación de la atención o una educación del paciente que no pueden proporcionarse en una farmacia de venta minorista. Puede hablar con su médico, otra persona que receta o el farmacéutico acerca de los detalles sobre conseguir medicamentos de acceso limitado. vii Abreviatura Definición Descripción MO Compra por Correo Fuera del Costo de Desembolso Real Este medicamento está disponible en la farmacia de compra por correo de Health Net además de otras farmacias de la red. Por lo general, este medicamento que requiere receta médica no tiene cobertura en el Medicare Prescription Drug Plan. El monto que usted paga cuando surte una receta por este medicamento no se aplica a los costos totales del medicamento (es decir, el monto que paga no ayuda a que califique para recibir cobertura catastrófica). Además, si recibe ayuda adicional para pagar sus recetas, no recibirá ninguna ayuda adicional para pagar este medicamento. Este medicamento requiere autorización previa. Esto significa que usted o la persona que receta deben obtener nuestra aprobación antes de surtir su receta. Si no obtiene aprobación, es posible que no cubramos el medicamento. Este medicamento tiene un límite en la cantidad que Health Net cubrirá. Por ejemplo, cubrimos dos tabletas por día por receta para simvastatin 40 mg. Esto puede ser además de un límite de suministro estándar para un mes o para tres meses. Este medicamento está disponible en una presentación que requiere receta médica y en presentación OTC. Además de algunas insulinas y suministros de insulina, solo los medicamentos que requieren receta médica están cubiertos por los planes de Health Net Medicare Parte D. Este medicamento tiene un límite de dosis diaria máxima por motivos de seguridad respaldado por la Administración de Medicamentos y Alimentos (por sus siglas en inglés, FDA). Esto significa que Health Net no cubrirá más que la dosis diaria máxima. Por ejemplo, la dosis diaria máxima de la FDA para simvastatin es de 80 mg. Por lo tanto, solo cubriremos hasta dos tabletas por día para simvastatin 40 mg. Este medicamento requiere una terapia escalonada. Esto significa que primero debe probar ciertos medicamentos para tratar su afección médica antes de que Health Net cubra otro medicamento para esa afección. NT PA Autorización Previa QL Límite de Cantidad RX/OTC Medicamentos que requieren receta médica y de venta libre (OTC) Límite de seguridad SL ST * Terapia Escalonada Cobertura adicional en la brecha Por ejemplo, si tanto el medicamento A como el medicamento B tratan su afección médica, posiblemente no cubramos el medicamento B, a menos que usted pruebe primero el medicamento A. Si el medicamento A no es eficaz para usted, entonces cubriremos el medicamento B. Proporcionamos cobertura adicional de este medicamento que requiere receta médica en la brecha de cobertura. Si desea más información sobre esta cobertura, consulte la Evidencia de Cobertura. viii Abreviatura Definición Descripción + Cobertura adicional en la brecha Solo para los planes Health Net CoCare Plan B (Employer HMO) y algunos planes Health Net Seniority Plus (Employer HMO): Proporcionamos cobertura adicional de este medicamento que requiere receta médica en la brecha de cobertura. Si desea más información sobre esta cobertura, consulte la Evidencia de Cobertura. ix Aviso sobre discriminación: Health Net cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. Health Net no excluye ni trata diferente a las personas por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. Health Net: • Ofrece ayuda y servicios gratuitos a personas con discapacidades para que puedan comunicarse de manera efectiva con nosotros, tales como intérpretes de lengua de señas calificados e información escrita en otros formatos (letras grandes, formatos electrónicos accesibles, otros formatos). • Ofrece servicios de idiomas gratuitos a personas cuyo idioma principal no es inglés, tales como intérpretes calificados e información escrita en otros idiomas. Si necesita estos servicios, comuníquese con el Centro de Comunicación con el Cliente de Health Net a los siguientes teléfonos: Arizona: 1-800-977-7522 (TTY: 711), de 8:00 a. m. a 8:00 p. m., hora de la montaña, los siete días de la semana. California: 1-800-275-4737 (TTY: 711), de 8:00 a. m. a 8:00 p. m., hora del Pacífico, los siete días de la semana. Oregón: 1-888-445-8913 (TTY: 711), de 8:00 a. m. a 8:00 p. m., hora del Pacífico, los siete días de la semana. Si usted considera que Health Net no proporcionó estos servicios o que le discriminó de otro modo por motivos de raza, color, nacionalidad, edad, discapacidad o sexo, podrá llamar al número que figura arriba para presentar una queja formal o para informarles que necesita ayuda para presentar una queja formal. El Centro de Comunicación con el Cliente de Health Net está disponible para ayudarle. También puede presentar una queja sobre derechos civiles ante el Departamento de Salud y Servicios Humanos de los EE. UU., en la Oficina de Derechos Civiles, por vía electrónica a través del Portal de Quejas de la Oficina de Derechos Civiles disponible en https://ocrportal.hhs.gov/ocr/portal/lobby.jsf o por correo postal o por teléfono a U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800–368–1019, (TDD: 1-800–537–7697). Los formularios de presentación de quejas están disponibles en http://www.hhs.gov/ocr/office/file/index.html x Multi-Language Insert Multi-language Interpreter Services English: ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-800-977-7522 (Arizona), 1-800-275-4737 (California), 1-888-445-8913 (Oregon) (TTY: 711). Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-977-7522 (Arizona), 1-800-275-4737 (California), 1-888-445-8913 (Oregon) (TTY: 711). Chinese Mandarin: 㲐シ烉⤪㝄ぐἧ䓐䷩橼ᷕ㔯炻ぐ⎗ẍ屣䌚⼿婆妨㎜≑㚵⊁ˤ婳农暣1-800-977-7522 (Arizona), 1-800-275-4737 (California), 1-888-445-8913 (Oregon) (TTY: 711)ˤġ Chinese Cantonese: ὀព㸸ዴᯝᝍ婒ⱥᩥ㸪ᝍྍ⋓ᚓච㈝ⓗㄒゝ༠ຓ᭹ົࠋㄳ⮴㟁 1-800-977-7522 (Arizona), 1-800-275-4737 (California), 1-888-445-8913 (Oregon)㸦⫎㞀ᑙ⥺㸸711㸧ࠋ Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-977-7522 (Arizona), 1-800-275-4737 (California), 1-888-445-8913 (Oregon) (TTY: 711). French: ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-800-977-7522 (Arizona), 1-800-275-4737 (California), 1-888-445-8913 (Oregon) (ATS :711). Vietnamese: CHÚ Ý: NӃu bҥn nói TiӃng ViӋt, có các dӏch vө hӛ trӧ ngôn ngӳ miӉn phí dành cho bҥn. Gӑi sӕ 1-800-977-7522 (Arizona), 1-800-275-4737 (California), 1-888-445-8913 (Oregon) (TTY: 711). German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-800-977-7522 (Arizona), 1-800-275-4737 (California), 1-888-445-8913 (Oregon) (TTY: 711). Korean: 㨰㢌aG䚐ạ㛨⪰G㇠㟝䚌㐐⏈Gᷱ㟤SG㛬㛨G㫴㠄G㉐⽸㏘⪰Gⱨ⨀⦐G㢨㟝䚌㐘G㍌G㢼㏩⏼␘UGGGGGGGGGGGGGGGGG 1-800-977-7522 (Arizona), 1-800-275-4737 (California), 1-888-445-8913 (Oregon) (TTY: 711)ⶼ㡰⦐G 㤸䞈䚨G㨰㐡㐐㝘U Russian: ȼɇɂɆȺɇɂȿ: ȿɫɥɢ ɜɵ ɝɨɜɨɪɢɬɟ ɧɚ ɪɭɫɫɤɨɦ ɹɡɵɤɟ, ɬɨ ɜɚɦ ɞɨɫɬɭɩɧɵ ɛɟɫɩɥɚɬɧɵɟ ɭɫɥɭɝɢ ɩɟɪɟɜɨɞɚ. Ɂɜɨɧɢɬɟ 1-800-977-7522 (Arizona), 1-800-275-4737 (California), 1-888-445-8913 (Oregon) (ɬɟɥɟɬɚɣɩ: 711). Arabic: ϢϗήΑ ϞμΗ .ϥΎΠϤϟΎΑ Ϛϟ ήϓϮΘΗ ΔϳϮϐϠϟ ΓΪϋΎδϤϟ ΕΎϣΪΧ ϥΈϓ ˬΔϐϠϟ ήϛΫ ΙΪΤΘΗ ΖϨϛ Ϋ· :ΔυϮΤϠϣ :ϢϜΒϟϭ Ϣμϟ ϒΗΎϫ Ϣϗέ) 1-800-977-7522 (Arizona), 1-800-275-4737 (California), 1-888-445-8913 (Oregon) .(711 Hindi: ᭟֑֞֊ֈᱶ: ֑ᳰֈը¡ȣ֎֫֔ֆ֧֛ᱹֆ֫ըշ֧ ֟֔ձ֡᭢ֆᱶ֏֛֑֚֞֙֞֞ֆ֧֚֞֗֞ձեի֔᭣։֛ᱹֿ 1-800-977-7522 (Arizona), 1-800-275-4737 (California), 1-888-445-8913 (Oregon) (TTY: 711)֒շ֩֔ շ֒ᱶ ֿ Italian: ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-800-977-7522 (Arizona), 1-800-275-4737 (California), 1-888-445-8913 (Oregon) (TTY: 711). Portugués: ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-800-977-7522 (Arizona), 1-800-275-4737 (California), 1-888-445-8913 (Oregon) (TTY: 711). French Creole: ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-800-977-7522 (Arizona), 1-800-275-4737 (California), 1-888-445-8913 (Oregon) (TTY: 711). Polish: UWAGA: JeĪeli mówisz po polsku, moĪesz skorzystaü z bezpáatnej pomocy jĊzykowej. ZadzwoĔ pod numer 1-800-977-7522 (Arizona), 1-800-275-4737 (California), 1-888-445-8913 (Oregon) (TTY: 711). Japanese: ὀព㡯㸸᪥ᮏㄒࢆヰࡉࢀࡿሙྜࠊ↓ᩱࡢゝㄒᨭࢆࡈ⏝࠸ࡓࡔࡅࡲࡍࠋ1-800-977-7522 (Arizona), 1-800-275-4737 (California), 1-888-445-8913 (Oregon) (TTY: 711)ࡲ࡛ࠊ࠾㟁ヰ࡚ࡈ㐃⤡ࡃ ࡔࡉ࠸ࠋ Navajo: Drug Name Drug Requirements/ Tier Limits ADHD/ANTI-NARCOLEPSY/ANTIOBESITY/ANOREXIANTS - Drugs to Treat ADHD, Sleep and Eating Disorders Amphetamines ADDERALL XR CP24 (AmphetamineDextroamphetamine) amphetaminedextroamphetamine cp24 amphetaminedextroamphetamine tabs 3.125mg-3.125mg3.125mg-3.125mg, 5mg5mg-5mg-5mg, 2.5mg2.5mg-2.5mg-2.5mg, 3.75mg-3.75mg-3.75mg3.75mg, 1.25mg-1.25mg1.25mg-1.25mg, 1.875mg1.875mg-1.875mg1.875mg, 7.5mg-7.5mg7.5mg-7.5mg DEXEDRINE CP24 (Dextroamphetamine Sulfate) dextroamphetamine sulfate cp24 dextroamphetamine sulfate tabs MO; + STRATTERA CAPS 10 MG STRATTERA CAPS 100 MG STRATTERA CAPS 18 MG 3 STRATTERA CAPS 25 MG 1 MO; * STRATTERA CAPS 40 MG MO; * STRATTERA CAPS 60 MG STRATTERA CAPS 80 MG 1 MO; + 3 1 MO; * 1 MO; * 3 VYVANSE CAPS 20 MG 3 VYVANSE CAPS 30 MG 3 VYVANSE CAPS 40 MG 3 VYVANSE CAPS 50 MG 3 VYVANSE CAPS 60 MG 3 VYVANSE CAPS 70 MG 3 Drug Requirements/ Tier Limits 2 SL(10 ea daily); MO; + 2 SL(1 ea daily); MO; + 2 SL(5.55 ea daily); MO; + 2 SL(4 ea daily); MO; + 2 SL(2.5 ea daily); MO; + 2 SL(1.66 ea daily); MO; + 2 SL(1.25 ea daily); MO; + Stimulants - Misc. armodafinil tabs VYVANSE CAPS 10 MG SL(7 ea daily); MO; + SL(3.5 ea daily); MO; + SL(2.33 ea daily); MO; + SL(1.75 ea daily); MO; + SL(1.4 ea daily); MO; + SL(1.16 ea daily); MO; + SL(1 ea daily); MO; + Attention-Deficit/Hyperactivity Disorder (ADHD) 1 AL; MO; * guanfacine hcl (adhd) tb24 INTUNIV TB24 (Guanfacine HCl (ADHD)) Drug Name CONCERTA TBCR (Methylphenidate HCl) DAYTRANA PTCH 30 MG/9HR dexmethylphenidate hcl cp24 15 mg, 20 mg, 10 mg dexmethylphenidate hcl tabs FOCALIN TABS (Dexmethylphenidate HCl) FOCALIN XR CP24 20 MG, 15 MG, 10 MG (Dexmethylphenidate HCl) METADATE CD CPCR (Methylphenidate HCl) METHYLIN CHEW (Methylphenidate HCl) 1 PA; MO; * 3 MO; + 3 MO; + 1 MO; * 1 MO; * 3 MO; + MO NF NF MO NF MO methylphenidate hcl cp24 1 MO; * methylphenidate hcl cpcr 1 MO; * methylphenidate hcl tabs 1 MO; * methylphenidate hcl tb24 1 methylphenidate hcl tbcr 27 mg, 18 mg, 54 mg, 20 mg, 36 mg 1 Non-Osmotic Release; * MO; * NF AL; MO You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 1 Drug Name modafinil tabs NUVIGIL TABS (Armodafinil) PROVIGIL TABS (Modafinil) RITALIN LA CP24 20 MG, 30 MG, 40 MG (Methylphenidate HCl) RITALIN LA CP24 60 MG, 10 MG RITALIN TABS (Methylphenidate HCl) Drug Requirements/ Tier Limits 1 PA; MO; * 3 PA; MO; + 5 PA; MO; + MO; + 3 3 MO; + 3 MO; + ALLERGENIC EXTRACTS/BIOLOGICALS MISC Allergenic Extracts Drug Name tobramycin nebu Drug Requirements/ Tier Limits 1 B/D; * tobramycin sulfate soln 1.2 gm/30ml, 80 mg/2ml, 40 mg/ml 4 tobramycin sulfate solr 4 MO; + + ANALGESICS - ANTI-INFLAMMATORY - Drugs to Treat Pain, Swelling, Muscle and Joint Conditions Anti-TNF-alpha - Monoclonal Antibodies HUMIRA PEDIATRIC PA; + 5 CROHNS DISEASE STARTER PACK PSKT 5 PA; + HUMIRA PEN PNKT 5 PA; + 5 PA; + HUMIRA PSKT 5 PA; + SIMPONI ARIA SOLN 5 PA; + SIMPONI SOAJ 5 PA; + AMINOGLYCOSIDES - Drugs to Treat Bacterial Infections SIMPONI SOSY 5 PA; + Aminoglycosides Antirheumatic - Enzyme Inhibitors GRASTEK SUBL 3 PA; MO; + ORALAIR SUBL 3 PA; + RAGWITEK SUBL 3 PA; MO; + Biologicals Misc ADAGEN SOLN 5 LA; + amikacin sulfate soln 4 MO; + BETHKIS NEBU 5 B/D; + 4 + 4 MO; + KITABIS PAK NEBU 5 neomycin sulfate tabs paromomycin sulfate caps gentamicin in saline soln 0.9%-1mg/ml gentamicin sulfate soln ij 40 mg/ml TOBI NEBU (Tobramycin) TOBI PODHALER CAPS HUMIRA PEN-CROHNS DISEASESTARTER PNKT HUMIRA PEN-PSORIASIS STARTER PNKT XELJANZ TABS 5 PA; + XELJANZ XR TB24 5 PA; + OTREXUP SOAJ 4 PA; + B/D; + RASUVO SOAJ 4 PA; + MO; * RHEUMATREX TABS 2 MO; + 1 1 MO; * Gold Compounds 5 MO; + 5 B/D; + 5 + 5 LA; + Antirheumatic Antimetabolites RIDAURA CAPS Interleukin-1 Blockers ARCALYST SOLR You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 2 Drug Name Drug Requirements/ Tier Limits Interleukin-1 Receptor Antagonist (IL-1Ra) 5 PA; + KINERET SOSY Drug Requirements/ Tier Limits 1 RX/OTC; MO; * ibuprofen susp 100 mg/5ml Drug Name ibuprofen tabs 400 mg 1 ibuprofen tabs 600 mg 1 ibuprofen tabs 800 mg 1 INDOCIN SUSP 3 SL(8 ea daily); MO; * SL(5.33 ea daily); MO; * SL(4 ea daily); MO; * AL; MO; + indomethacin caps 1 AL; MO; * indomethacin cpcr 1 AL; MO; * ketoprofen caps 1 MO; * ketoprofen cp24 1 MO; * 4 AL; MO; + Interleukin-1beta Blockers ILARIS SOLR 5 LA; + Interleukin-6 Receptor Inhibitors ACTEMRA SOLN 5 PA; + ACTEMRA SOSY 5 PA; + Nonsteroidal Anti-inflammatory Agents (NSAIDs) ANAPROX DS TABS 3 MO; + (Naproxen Sodium) ARTHROTEC 50 TBEC NF MO (Diclofenac w/ Misoprostol) ARTHROTEC 75 TBEC NF MO (Diclofenac w/ Misoprostol) CELEBREX CAPS NF MO (Celecoxib) 1 MO; * celecoxib caps DAYPRO TABS (Oxaprozin) 3 MO; + diclofenac potassium tabs 1 MO; * ketorolac tromethamine soln ij 30 mg/ml, 15 mg/ml ketorolac tromethamine soln im 60 mg/2ml, 30 mg/ml ketorolac tromethamine tabs meclofenamate sodium caps 100 mg diclofenac sodium tb24 1 MO; * diclofenac sodium tbec 1 diclofenac w/ misoprostol tbec AL; MO; + 4 1 AL; MO; * 1 MO; * mefenamic acid caps 1 MO; * MO; * meloxicam tabs 1 MO; * MO; * MOBIC TABS (Meloxicam) 3 MO; + 1 5 PA; MO; + nabumetone tabs 1 MO; * DUEXIS TABS EC-NAPROSYN TBEC (Naproxen) 3 MO; + NF etodolac caps 1 MO; * NAPRELAN TB24 500 MG, 375 MG (Naproxen Sodium) NAPRELAN TB24 750 MG 3 MO; + etodolac tabs 400 mg, 500 mg 1 MO; * 3 MO; + etodolac tb24 1 MO; * 1 MO; * FELDENE CAPS (Piroxicam) 3 MO; + naproxen sodium tb24 1 MO; * flurbiprofen tabs 1 MO; * naproxen tabs 250 mg, 375 mg, 500 mg 1 MO; * NAPROSYN TABS (Naproxen) naproxen sodium tabs 275 mg, 550 mg MO You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 3 Drug Name naproxen tbec Drug Requirements/ Tier Limits 1 MO; * Drug Name Drug Requirements/ Tier Limits Salicylates MO; * oxaprozin tabs 1 MO; * diflunisal tabs piroxicam caps 1 MO; * ANALGESICS - OPIOID - Drugs to Treat Pain, Muscle and Joint Conditions PONSTEL CAPS (Mefenamic Acid) 3 MO; + Opioid Agonists sulindac tabs 1 MO; * ABSTRAL SUBL 100 MCG 3 tolmetin sodium caps 1 MO; * ABSTRAL SUBL 200 MCG 5 tolmetin sodium tabs 200 mg 1 * ABSTRAL SUBL 300 MCG 5 VIMOVO TBEC 5 PA; MO; + VOLTAREN-XR TB24 (Diclofenac Sodium) ZIPSOR CAPS NF MO; NT 3 MO; + Phosphodiesterase 4 (PDE4) Inhibitors 5 PA; + OTEZLA TABS OTEZLA TBPK 5 PA; + Pyrimidine Synthesis Inhibitors ARAVA TABS 3 (Leflunomide) MO; + leflunomide tabs MO; * 1 Selective Costimulation Modulators ORENCIA CLICKJECT 5 PA; + SOAJ 5 PA; + ORENCIA SOLR ORENCIA SOSY 5 PA; + Soluble Tumor Necrosis Factor Receptor Agents 5 PA; + ENBREL SOLR ENBREL SOSY 5 PA; + ENBREL SURECLICK SOAJ 5 PA; + ANALGESICS - NonNarcotic - Drugs to Treat Pain, Muscle and Joint Conditions ABSTRAL SUBL 600 MCG, 800 MCG, 400 MCG ACTIQ LPOP 200 MCG (Fentanyl Citrate) ACTIQ LPOP 800 MCG, 600 MCG, 1600 MCG, 1200 MCG, 400 MCG (Fentanyl Citrate) AVINZA CP24 30 MG (Morphine Sulfate Beads) AVINZA CP24 90 MG, 120 MG, 60 MG (Morphine Sulfate Beads) codeine sulfate tabs 15 mg codeine sulfate tabs 30 mg codeine sulfate tabs 60 mg DILAUDID LIQD (Hydromorphone HCl) DILAUDID SOLN 2 MG/ML DILAUDID TABS 2 MG (Hydromorphone HCl) DILAUDID TABS 4 MG (Hydromorphone HCl) DILAUDID TABS 8 MG (Hydromorphone HCl) DILAUDID-HP SOLN (Hydromorphone HCl) DOLOPHINE TABS 10 MG (Methadone HCl) 1 5 5 5 PA; QL(16 ea daily); + PA; QL(8 ea daily); + PA; QL(5.34 ea daily); + PA; QL(4 ea daily); + PA; QL(8 ea daily); MO; + PA; QL(4 ea daily); MO; + NF MO; NT MO NF SL(24 ea daily); MO; * 1 SL(12 ea daily); MO; * 1 SL(6 ea daily); MO; * NF QL(50 ml daily); MO 4 Preservative Free; + 3 QL(25 ea daily); MO; + 3 QL(12.5 ea daily); MO; + 3 QL(6.25 ea daily); MO; + NF NT 1 3 QL(6.67 ea daily); MO; + You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 4 Drug Name DOLOPHINE TABS 5 MG (Methadone HCl) DURAGESIC PT72 100 MCG/HR (Fentanyl) DURAGESIC PT72 12 MCG/HR (Fentanyl) DURAGESIC PT72 25 MCG/HR (Fentanyl) DURAGESIC PT72 50 MCG/HR (Fentanyl) DURAGESIC PT72 75 MCG/HR (Fentanyl) EXALGO T24A 12 MG (Hydromorphone HCl) EXALGO T24A 16 MG (Hydromorphone HCl) EXALGO T24A 32 MG (Hydromorphone HCl) EXALGO T24A 8 MG (Hydromorphone HCl) fentanyl citrate lpop 1200 mcg, 800 mcg, 1600 mcg, 600 mcg, 400 mcg fentanyl citrate lpop 200 mcg fentanyl pt72 100 mcg/hr fentanyl pt72 12 mcg/hr fentanyl pt72 25 mcg/hr Drug Requirements/ Tier Limits 3 QL(13.34 ea daily); MO; + 5 QL(0.5 ea daily); MO; + Limit 43 patches per 3 month;QL(1.44 ea daily); MO; + Limit 28 patches per 3 month;QL(0.94 ea daily); MO; + Limit 15 patches per 3 month;QL(0.5 ea daily); MO; + Limit 15 patches per 5 month;QL(0.5 ea daily); MO; + NF QL(4.17 ea daily); MO NF QL(3.14 ea daily); MO 3 QL(1.57 ea daily); MO; + NF QL(6.27 ea daily); MO PA; QL(4 ea 5 daily); MO; + 5 1 1 1 PA; QL(8 ea daily); MO; + QL(0.5 ea daily); MO; * Limit 43 patches per month;QL(1.44 ea daily); MO; * Limit 28 patches per month;QL(0.94 ea daily); MO; * Drug Name fentanyl pt72 75 mcg/hr, 50 mcg/hr FENTORA TABS 100 MCG FENTORA TABS 200 MCG FENTORA TABS 400 MCG, 600 MCG, 800 MCG hydromorphone hcl liqd hydromorphone hcl soln 10 mg/ml, 500 mg/50ml, 50 mg/5ml hydromorphone hcl soln 2 mg/ml hydromorphone hcl t24a 12 mg hydromorphone hcl t24a 16 mg hydromorphone hcl t24a 32 mg hydromorphone hcl t24a 8mg, 8 mg hydromorphone hcl tabs 2 mg hydromorphone hcl tabs 4 mg hydromorphone hcl tabs 8 mg HYSINGLA ER T24A 100 MG, 120 MG HYSINGLA ER T24A 20 MG, 60 MG HYSINGLA ER T24A 30 MG HYSINGLA ER T24A 40 MG HYSINGLA ER T24A 80 MG KADIAN CP24 10 MG (Morphine Sulfate) KADIAN CP24 100 MG (Morphine Sulfate) Drug Requirements/ Tier Limits Limit 15 1 patches per month;QL(0.5 ea daily); MO; * 5 PA; QL(16 ea daily); MO; + 5 PA; QL(8 ea daily); MO; + 5 PA; QL(4 ea daily); MO; + 1 QL(50 ml daily); MO; * + 4 4 1 1 1 1 1 1 1 3 3 3 3 3 3 5 MO; + QL(4.17 ea daily); MO; * QL(3.14 ea daily); MO; * QL(1.57 ea daily); MO; * QL(6.27 ea daily); MO; * QL(25 ea daily); MO; * QL(12.5 ea daily); MO; * QL(6.25 ea daily); MO; * PA; QL(1 ea daily); + PA; QL(2 ea daily); MO; + PA; QL(4 ea daily); MO; + PA; QL(2.67 ea daily); MO; + PA; QL(1.34 ea daily); MO; + QL(20 ea daily); MO; + QL(2 ea daily); MO; + You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 5 Drug Name KADIAN CP24 20 MG (Morphine Sulfate) KADIAN CP24 200 MG KADIAN CP24 30 MG (Morphine Sulfate) KADIAN CP24 40 MG KADIAN CP24 50 MG (Morphine Sulfate) KADIAN CP24 60 MG (Morphine Sulfate) KADIAN CP24 80 MG (Morphine Sulfate) LAZANDA SOLN 100 MCG/ACT LAZANDA SOLN 300 MCG/ACT LAZANDA SOLN 400 MCG/ACT methadone hcl conc methadone hcl soln or 10 mg/5ml methadone hcl soln or 5 mg/5ml methadone hcl tabs 10 mg methadone hcl tabs 5 mg METHADOSE CONC (Methadone HCl) METHADOSE SUGARFREE CONC (Methadone HCl) morphine sulfate beads cp24 120 mg morphine sulfate beads cp24 30 mg morphine sulfate beads cp24 45 mg morphine sulfate beads cp24 60 mg morphine sulfate beads cp24 75 mg Drug Requirements/ Tier Limits 3 QL(10 ea daily); MO; + 3 QL(1 ea daily); MO; + 3 QL(6.67 ea daily); MO; + 3 PA; QL(5 ea daily); MO; + 3 QL(4 ea daily); MO; + 3 QL(3.34 ea daily); MO; + 3 QL(2.5 ea daily); MO; + 5 PA; QL(1 ea daily); MO; + 5 PA; QL(0.5 ea daily); MO; + 5 PA; QL(0.25 ea daily); MO; + 1 QL(6.67 ml daily); MO; * 1 QL(33.34 ml daily); MO; * 1 QL(66.67 ml daily); MO; * 1 QL(6.67 ea daily); MO; * 1 QL(13.34 ea daily); MO; * 3 QL(6.67 ml daily); MO; + QL(6.67 ml 3 daily); MO; + 1 1 1 1 1 QL(1.67 ea daily); MO; * QL(6.67 ea daily); MO; * QL(4.44 ea daily); MO; * QL(3.34 ea daily); MO; * QL(2.67 ea daily); MO; * Drug Name morphine sulfate beads cp24 90 mg morphine sulfate cp24 10 mg morphine sulfate cp24 100 mg morphine sulfate cp24 20 mg morphine sulfate cp24 30 mg morphine sulfate cp24 50 mg morphine sulfate cp24 60 mg morphine sulfate cp24 80 mg morphine sulfate soln ij 0.5 mg/ml morphine sulfate soln ij 1 mg/ml morphine sulfate soln or 10 mg/5ml morphine sulfate soln or 100 mg/5ml, 20 mg/ml morphine sulfate soln or 20 mg/5ml MORPHINE SULFATE TABS 15 MG MORPHINE SULFATE TABS 30 MG morphine sulfate tbcr 100 mg, 200 mg morphine sulfate tbcr 15 mg morphine sulfate tbcr 30 mg morphine sulfate tbcr 60 mg MS CONTIN TBCR 100 MG, 200 MG (Morphine Sulfate) MS CONTIN TBCR 15 MG (Morphine Sulfate) MS CONTIN TBCR 30 MG (Morphine Sulfate) Drug Requirements/ Tier Limits 1 QL(2.24 ea daily); MO; * 1 QL(20 ea daily); MO; * 5 QL(2 ea daily); MO; + 1 QL(10 ea daily); MO; * 1 QL(6.67 ea daily); MO; * 1 QL(4 ea daily); MO; * 1 QL(3.34 ea daily); MO; * 1 QL(2.5 ea daily); MO; * 4 + 4 1 1 1 3 3 1 1 1 1 3 3 3 MO; + QL(100 ml daily); MO; * QL(10 ml daily); MO; * QL(50 ml daily); MO; * QL(13.34 ea daily); MO; + QL(6.67 ea daily); MO; + QL(2 ea daily); MO; * QL(13.34 ea daily); MO; * QL(6.67 ea daily); MO; * QL(3.34 ea daily); MO; * QL(2 ea daily); MO; + QL(13.34 ea daily); MO; + QL(6.67 ea daily); MO; + You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 6 Drug Requirements/ Tier Limits MS CONTIN TBCR 60 MG 3 QL(3.34 ea (Morphine Sulfate) daily); MO; + NUCYNTA ER TB12 100 2 QL(6.67 ea MG daily); MO; + NUCYNTA ER TB12 150 2 QL(4.44 ea MG daily); MO; + NUCYNTA ER TB12 200 2 QL(3.34 ea MG daily); MO; + NUCYNTA ER TB12 250 2 QL(2 ea daily); MG MO; + NUCYNTA ER TB12 50 2 QL(13.34 ea MG daily); MO; + 3 QL(6.67 ea NUCYNTA TABS 100 MG daily); MO; + 3 QL(13.34 ea NUCYNTA TABS 50 MG daily); MO; + 3 QL(8.88 ea NUCYNTA TABS 75 MG daily); MO; + OPANA ER (CRUSH 5 QL(2 ea daily); RESISTANT) T12A 40 MG MO; + OPANA TABS 10 MG 3 QL(6.67 ea (Oxymorphone HCl) daily); MO; + OPANA TABS 5 MG 3 QL(13.34 ea (Oxymorphone HCl) daily); MO; + 1 QL(26.67 ea oxycodone hcl caps daily); MO; * 1 QL(6.67 ml oxycodone hcl conc daily); MO; * OXYCODONE HCL ER 2 QL(13.34 ea T12A 10 MG daily); MO; + OXYCODONE HCL ER 2 QL(8.9 ea T12A 15 MG daily); MO; + OXYCODONE HCL ER 2 QL(6.67 ea T12A 20 MG daily); MO; + OXYCODONE HCL ER 2 QL(4.44 ea T12A 30 MG daily); MO; + OXYCODONE HCL ER QL(2 ea daily); 2 MO; + T12A 60 MG, 80 MG, 40 MG 1 QL(11.2 ea oxycodone hcl tabs 10 mg daily); MO; * 1 QL(8.9 ea oxycodone hcl tabs 15 mg daily); MO; * 1 QL(6.67 ea oxycodone hcl tabs 20 mg daily); MO; * Drug Name Drug Requirements/ Tier Limits 1 QL(4.44 ea oxycodone hcl tabs 30 mg daily); MO; * 1 QL(26.67 ea oxycodone hcl tabs 5 mg daily); MO; * 2 QL(13.34 ea OXYCONTIN T12A 10 MG daily); MO; + 2 QL(8.9 ea OXYCONTIN T12A 15 MG daily); MO; + 2 QL(6.67 ea OXYCONTIN T12A 20 MG daily); MO; + 2 QL(4.44 ea OXYCONTIN T12A 30 MG daily); MO; + OXYCONTIN T12A 40 MG, 2 QL(2 ea daily); 80 MG, 60 MG MO; + oxymorphone hcl tabs 10 1 QL(6.67 ea mg daily); MO; * ea oxymorphone hcl tabs 5 mg 1 QL(13.34 daily); MO; * oxymorphone hcl tb12 10 1 QL(5.6 ea mg daily); MO; * oxymorphone hcl tb12 15 1 QL(4.44 ea mg daily); MO; * oxymorphone hcl tb12 20 1 QL(3.34 ea mg daily); MO; * oxymorphone hcl tb12 30 1 QL(2.22 ea mg daily); MO; * oxymorphone hcl tb12 40 1 QL(2 ea daily); mg MO; * oxymorphone hcl tb12 5 1 QL(13.34 ea mg daily); MO; * oxymorphone hcl tb12 7.5 1 QL(8.89 ea mg daily); MO; * ROXICODONE TABS 15 3 QL(8.9 ea MG (Oxycodone HCl) daily); MO; + ROXICODONE TABS 30 3 QL(4.44 ea MG (Oxycodone HCl) daily); MO; + ROXICODONE TABS 5 NF QL(26.67 ea MG (Oxycodone HCl) daily); MO 5 PA; QL(16 ea SUBSYS LIQD 100 MCG daily); MO; + 5 PA; QL(2 ea SUBSYS LIQD 1200 MCG daily); + 5 PA; QL(8 ea SUBSYS LIQD 200 MCG daily); MO; + Drug Name You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 7 Drug Requirements/ Tier Limits SUBSYS LIQD 400 MCG, PA; QL(4 ea 5 daily); MO; + 600 MCG, 1600 MCG, 800 MCG 1 SL(8 ea daily); tramadol hcl tabs MO; * 1 SL(3 ea daily); tramadol hcl tb24 100 mg MO; * 1 SL(1.5 ea tramadol hcl tb24 200 mg daily); MO; * 1 SL(1 ea daily); tramadol hcl tb24 300 mg MO; * ULTRAM ER TB24 100 3 SL(3 ea daily); MG (Tramadol HCl) MO; + ULTRAM ER TB24 200 3 SL(1.5 ea MG (Tramadol HCl) daily); MO; + ULTRAM ER TB24 300 3 SL(1 ea daily); MG (Tramadol HCl) MO; + ULTRAM TABS (Tramadol 3 SL(8 ea daily); HCl) MO; + ZOHYDRO ER C12A 10 3 PA; QL(16.8 ea MG daily); MO; + ZOHYDRO ER C12A 15 3 PA; QL(11.2 ea MG daily); MO; + ZOHYDRO ER C12A 20 3 PA; QL(8.4 ea MG daily); MO; + ZOHYDRO ER C12A 30 3 PA; QL(5.6 ea MG daily); MO; + ZOHYDRO ER C12A 40 3 PA; QL(4.2 ea MG daily); MO; + ZOHYDRO ER C12A 50 3 PA; QL(3.37 ea MG daily); MO; + ZOHYDRO ER CP12 10 3 PA; QL(16.8 ea MG daily); + ZOHYDRO ER CP12 15 3 PA; QL(11.2 ea MG daily); + ZOHYDRO ER CP12 20 3 PA; QL(8.4 ea MG daily); + ZOHYDRO ER CP12 30 3 PA; QL(5.6 ea MG daily); + ZOHYDRO ER CP12 40 3 PA; QL(4.2 ea MG daily); + ZOHYDRO ER CP12 50 3 PA; QL(3.37 ea MG daily); + Drug Name Opioid Combinations Drug Name acetaminophen w/ codeine soln acetaminophen w/ codeine tabs 300mg-15mg acetaminophen w/ codeine tabs 300mg-30mg acetaminophen w/ codeine tabs 300mg-60mg butalbital-acetaminophencaffeine w/ codeine caps butalbital-aspirin-caffeine w/cod caps FIORINAL/CODEINE #3 CAPS (Butalbital-AspirinCaffeine w/Cod) hydrocodoneacetaminophen soln hydrocodoneacetaminophen tabs 10mg300mg, 5mg-300mg, 7.5mg-300mg hydrocodoneacetaminophen tabs 5mg325mg, 7.5mg-325mg, 10mg-325mg hydrocodone-ibuprofen tabs 200mg-5mg, 200mg7.5mg, 200mg-10mg Drug Requirements/ Tier Limits Limit 4500mls 1 per month;SL(150 ml daily); MO; * 1 SL(13.3 ea daily); MO; * 1 SL(12 ea daily); MO; * 1 SL(6 ea daily); MO; * 1 AL; SL(6 ea daily); MO; * 1 AL; SL(6 ea daily); MO; * AL; SL(6 ea 3 daily); MO; + 1 Limit 5535mls per month;SL(184. 5 ml daily); MO; * SL(13.3 ea daily); MO; * 1 SL(12.3 ea daily); MO; * 1 MO; * 1 oxycodone w/ acetaminophen soln 1 oxycodone w/ acetaminophen tabs 5mg325mg, 2.5mg-325mg, 7.5mg-325mg, 10mg325mg 1 oxycodone-aspirin tabs 1 tramadol-acetaminophen tabs ULTRACET TABS (Tramadol-Acetaminophen) 1 3 Limit 1845mls per month;SL(61.5 ml daily); * SL(12.3 ea daily); MO; * MO; * SL(8 ea daily); MO; * SL(8 ea daily); MO; + You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 8 Drug Name Opioid Partial Agonists BUNAVAIL FILM 4.2MG0.7MG, 2.1MG-0.3MG BUNAVAIL FILM 6.3MG1MG buprenorphine hcl subl 2 mg buprenorphine hcl subl 8 mg buprenorphine hclnaloxone hcl dihydrate subl 2mg-0.5mg buprenorphine hclnaloxone hcl dihydrate subl 8mg-2mg butorphanol tartrate soln ij 2 mg/ml Drug Requirements/ Tier Limits TALWIN SOLN 3 PA; + 3 PA; MO; + 1 PA; QL(16 ea daily); MO; * PA; QL(4 ea daily); MO; * PA; QL(16 ea daily); MO; * 1 PA; QL(4 ea daily); MO; * 4 MO; + 1 1 butorphanol tartrate soln na 10 mg/ml 1 BUTRANS PTWK 10 MCG/HR 2 BUTRANS PTWK 15 MCG/HR BUTRANS PTWK 20 MCG/HR BUTRANS PTWK 5 MCG/HR BUTRANS PTWK 7.5 MCG/HR SUBOXONE FILM Drug Name 2 2 2 2 3 Limit 126mls per month;QL(7 ml daily); MO; * Limit 8 patches per 28 days;SL(0.29 ea daily); MO; + Limit 5 patches per 28 days;SL(0.19 ea daily); MO; + Limit 4 patches per 28 days;SL(0.15 ea daily); MO; + Limit 16 patches per 28 days;SL(0.58 ea daily); MO; + Limit 10 patches per 28 days;SL(0.39 ea daily); MO; + PA; MO; + ZUBSOLV SUBL 0.7MG0.18MG ZUBSOLV SUBL 1.4MG0.36MG, 5.7MG-1.4MG, 2.9MG-0.71MG, 11.4MG2.9MG, 8.6MG-2.1MG Drug Requirements/ Tier Limits 4 AL; + 3 MO; + PA; MO; + 3 ANDROGENS-ANABOLIC - Drugs to Regulate Hormones Anabolic Steroids ANADROL-50 TABS OXANDRIN TABS 10 MG (Oxandrolone) OXANDRIN TABS 2.5 MG (Oxandrolone) 5 MO; + NF MO; NT NF MO oxandrolone tabs 10 mg 5 MO; + oxandrolone tabs 2.5 mg 1 MO; * 2 MO; + Androgens ANDRODERM PT24 ANDROGEL GEL 20.25 MG/1.25GM, 40.5 MG/2.5GM ANDROGEL GEL 25 MG/2.5GM, 50 MG/5GM (Testosterone) ANDROGEL PUMP GEL 1 % (Testosterone) ANDROGEL PUMP GEL 1.62 % MO; + 2 MO; + 2 NF MO; NT 2 MO; + AVEED SOLN 3 LA; + AXIRON SOLN 3 MO; + danazol caps 1 MO; * DEPO-TESTOSTERONE SOLN (Testosterone Cypionate) 4 fluoxymesterone tabs 1 MO; * FORTESTA GEL 3 MO; + MO; + You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 9 Drug Name methyltestosterone caps Drug Requirements/ Tier Limits 1 MO; * Drug Name BILTRICIDE TABS Drug Requirements/ Tier Limits 2 MO; + NATESTO GEL 3 MO; + ivermectin tabs 1 MO; * TESTIM GEL 3 MO; + STROMECTOL TABS (Ivermectin) 3 MO; + testosterone cypionate soln 4 MO; + 4 MO; + ANTI-INFECTIVE AGENTS - MISC. - Drugs to Treat Bacterial Infections testosterone enanthate soln TESTOSTERONE GEL 1 %, 10 MG/ACT, 50 MG/5GM, 25 MG/2.5GM testosterone gel 1 %, 25 mg/2.5gm, 50 mg/5gm TESTOSTERONE PUMP GEL MO; + 3 1 MO; * 3 MO; + VOGELXO GEL 3 MO; + VOGELXO PUMP GEL 3 MO; + ANORECTAL AGENTS - Rectal Drugs to Treat Pain, Swelling and Itching Intrarectal Steroids CORTENEMA ENEM (Hydrocortisone (Intrarectal)) MO NF CORTIFOAM FOAM 3 MO; + hydrocortisone (intrarectal) enem 1 MO; * UCERIS FOAM 3 MO; + 1 MO; * 3 MO; + Rectal Steroids hydrocortisone (rectal) crea 2.5 %, 1 % PROCTOCORT CREA (Hydrocortisone (Rectal)) Anti-infective Agents - Misc. AZACTAM SOLR (Aztreonam) 4 MO; + aztreonam solr 4 MO; + CAYSTON SOLR 5 LA; + colistimethate sodium solr 4 MO; + 4 MO; + COLY-MYCIN M SOLR (Colistimethate Sodium) FLAGYL CAPS (Metronidazole) FLAGYL TABS 250 MG (Metronidazole) FLAGYL TABS 500 MG (Metronidazole) 3 3 3 metronidazole caps 1 metronidazole in nacl soln 4 metronidazole tabs 250 mg 1 metronidazole tabs 500 mg 1 NEBUPENT SOLR 2 SL(16 ea daily); MO; * SL(8 ea daily); MO; * MO; B/D; + ORBACTIV SOLR 5 + PENTAM 300 SOLR 4 MO; + PRIMSOL SOLN 2 MO; + Vasodilating Agents RECTIV OINT 3 MO; + ANTHELMINTICS - Drugs to Treat Worm Infections Anthelmintics ALBENZA TABS 3 MO; + SL(10.6 ea daily); MO; + SL(16 ea daily); MO; + SL(8 ea daily); MO; + SL(10.6 ea daily); MO; * + TINDAMAX TABS (Tinidazole) NF MO tinidazole tabs 1 MO; * trimethoprim tabs 1 MO; * You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 10 Drug Name VANCOCIN HCL CAPS (Vancomycin HCl) vancomycin hcl caps VANCOMYCIN HCL IN DEXTROSE SOLN vancomycin hcl solr 1000 mg, 5000 mg, 10 gm vancomycin hcl solr 500 mg XIFAXAN TABS Drug Requirements/ Tier Limits 5 PA; MO; + 5 PA; MO; + 4 + 4 + 4 MO; + 5 MO; + Anti-infective Misc. - Combinations BACTRIM DS TABS MO; + 3 (SulfamethoxazoleTrimethoprim) BACTRIM TABS MO; + 3 (SulfamethoxazoleTrimethoprim) sulfamethoxazole1 MO; * trimethoprim susp sulfamethoxazole1 MO; * trimethoprim tabs SULFAMETHOXAZOLE/T 4 MO; + RIMETHOPRIM SOLN Antiprotozoal Agents ALINIA TABS atovaquone susp MEPRON SUSP (Atovaquone) 3 MO; + 5 MO; + 5 MO; + Carbapenems DORIBAX SOLR 500 MG 4 + DORIPENEM SOLR 500 MG 4 + imipenem-cilastatin solr 1 MO; * INVANZ SOLR IJ 4 MO; + meropenem solr 1 gm 4 MO; + meropenem solr 500 mg 1 MO; * Drug Name MERREM SOLR 1 GM (Meropenem) MERREM SOLR 500 MG (Meropenem) PRIMAXIN IV SOLR (Imipenem-Cilastatin) Chloramphenicols CHLORAMPHENICOL SODIUM SUCCINATE SOLR Cyclic Lipopeptides CUBICIN RF SOLR (Daptomycin) CUBICIN SOLR (Daptomycin) Drug Requirements/ Tier Limits 4 MO; + NF MO 3 MO; + + 4 5 + 5 + 5 + TIGECYCLINE SOLR 5 + TYGACIL SOLR 5 + 1 MO; * 3 MO; + daptomycin solr Glycylcyclines Leprostatics dapsone tabs Lincosamides CLEOCIN CAPS (Clindamycin HCl) CLEOCIN IN D5W SOLN (Clindamycin Phosphate in D5W) CLEOCIN PHOSPHATE SOLN IJ 9 GM/60ML (Clindamycin Phosphate) CLEOCIN PHOSPHATE SOLN IJ 900 MG/6ML, 600 MG/4ML (Clindamycin Phosphate) CLEOCIN PHOSPHATE SOLN IV 300 MG/2ML (Clindamycin Phosphate) CLEOCIN PHOSPHATE SOLN IV 600 MG/4ML + 4 + 4 MO; + 4 NF 4 + You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 11 Drug Name CLEOCIN PHOSPHATE SOLN IV 900MG/50ML5%, 300MG/50ML-5%, 600MG/50ML-5% (Clindamycin Phosphate in D5W) clindamycin hcl caps clindamycin palmitate hydrochloride solr clindamycin phosphate in d5w soln clindamycin phosphate soln ij 150 mg/ml, 9000 mg/60ml clindamycin phosphate soln ij 600 mg/4ml, 900 mg/6ml clindamycin phosphate soln iv 150 mg/ml LINCOCIN SOLN (Lincomycin HCl) lincomycin hcl soln Oxazolidinones linezolid soln 600 mg/300ml LINEZOLID SOLN 600MG/300ML-0.9% Drug Requirements/ Tier Limits + Drug Name polymyxin b sulfate solr Drug Requirements/ Tier Limits 4 + Streptogramins 4 SYNERCID SOLR 4 + 1 MO; * ANTIANGINAL AGENTS - Drugs to Treat Chest Pain 1 MO; * Antianginals-Other 4 + + 4 RANEXA TB12 3 PA; MO; + 3 MO; + 5 MO; + Nitrates DILATRATE SR CPCR 4 + ISORDIL TITRADOSE TABS 40 MG ISORDIL TITRADOSE TABS 5 MG (Isosorbide Dinitrate) isosorbide dinitrate tabs 1 MO; * 4 MO; + isosorbide dinitrate tbcr 1 MO; * 4 MO; + isosorbide mononitrate tabs 1 MO; * 1 MO; * MO; + 4 5 + 5 + linezolid susr 5 MO; + linezolid tabs 5 MO; + SIVEXTRO SOLR 5 + SIVEXTRO TABS 5 MO; + 5 isosorbide mononitrate tb24 120 mg, 60 mg, 30 mg NITRO-DUR PT24 0.1 MG/HR, 0.4 MG/HR, 0.2 MG/HR, 0.6 MG/HR (Nitroglycerin) NITRO-DUR PT24 0.3 MG/HR, 0.8 MG/HR NITROGLYCERIN LINGUAL AERS MO; + 3 MO; + 3 3 MO; + 3 MO; + nitroglycerin oint 1 MO; * + nitroglycerin pt24 1 MO; * 5 + nitroglycerin soln tl 0.4 mg/spray 1 MO; * ZYVOX SUSR (Linezolid) 5 MO; + nitroglycerin subl 1 MO; * ZYVOX TABS (Linezolid) 5 MO; + NITROLINGUAL PUMPSPRAY SOLN (Nitroglycerin) ZYVOX SOLN 200 MG/100ML ZYVOX SOLN 600 MG/300ML (Linezolid) Polymyxins NITROMIST AERS MO NF 3 MO; + You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 12 Drug Name NITROSTAT SUBL (Nitroglycerin) Drug Requirements/ Tier Limits 2 MO; + Drug Name lorazepam tabs Drug Requirements/ Tier Limits 1 MO; * ANTIANXIETY AGENTS - Drugs to Treat Anxiety TRANXENE T TABS (Clorazepate Dipotassium) NF MO Antianxiety Agents - Misc. VALIUM TABS (Diazepam) NF MO buspirone hcl tabs 1 MO; * hydroxyzine hcl soln 50 mg/ml 4 AL; MO; + hydroxyzine hcl syrp 1 AL; MO; * hydroxyzine hcl tabs 1 AL; MO; * hydroxyzine pamoate caps 25 mg, 50 mg 1 AL; MO; * meprobamate tabs 1 AL; MO; * VISTARIL CAPS (Hydroxyzine Pamoate) 3 AL; MO; + 1 MO; * Benzodiazepines alprazolam tabs XANAX TABS (Alprazolam) 3 MO; + XANAX XR TB24 (Alprazolam) 3 MO; + ANTIARRHYTHMICS - Drugs to treat abnormal heart rhythms Antiarrhythmics Type I-A disopyramide phosphate caps NORPACE CAPS (Disopyramide Phosphate) 1 AL; MO; * 3 AL; MO; + NORPACE CR CP12 3 AL; MO; + quinidine gluconate tbcr 1 MO; * quinidine sulfate tabs 1 MO; * 1 MO; * 1 MO; * 1 MO; * 3 MO; + 3 + 3 MO; + 1 MO; * diazepam conc 1 MO; * propafenone hcl cp12 1 SL(4 ea daily); MO; * SL(2.66 ea daily); MO; * SL(8 ea daily); MO; * MO; * diazepam soln 1 MO; * propafenone hcl tabs 1 MO; * diazepam tabs 1 MO; * 3 MO; + lorazepam conc 1 MO; * RYTHMOL SR CP12 (Propafenone HCl) RYTHMOL TABS (Propafenone HCl) 3 MO; + lorazepam soln 2 mg/ml, 20 mg/10ml 1 MO; * 1 * 1 MO; * lorazepam soln 4 mg/ml 1 * alprazolam tb24 alprazolam tbdp ATIVAN SOLN 2 MG/ML (Lorazepam) ATIVAN SOLN 4 MG/ML (Lorazepam) ATIVAN TABS (Lorazepam) clorazepate dipotassium tabs Antiarrhythmics Type I-B mexiletine hcl caps Antiarrhythmics Type I-C flecainide acetate tabs 100 mg flecainide acetate tabs 150 mg flecainide acetate tabs 50 mg Antiarrhythmics Type III amiodarone hcl tabs 200 mg, 100 mg, 400 mg dofetilide caps 1 1 1 You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 13 Drug Name MULTAQ TABS TIKOSYN CAPS (Dofetilide) Drug Requirements/ Tier Limits 2 MO; + 3 + ANTIASTHMATIC AND BRONCHODILATOR AGENTS - Drugs to Treat Lung Conditions Anti-Inflammatory Agents cromolyn sodium nebu 1 MO; B/D; * Drug Name montelukast sodium chew montelukast sodium tabs SINGULAIR CHEW (Montelukast Sodium) SINGULAIR TABS (Montelukast Sodium) zafirlukast tabs Antiasthmatic - Monoclonal Antibodies 5 PA; LA; + CINQAIR SOLN Drug Requirements/ Tier Limits 1 QL(1 ea daily); MO; * 1 QL(1 ea daily); MO; * 2 QL(1 ea daily); MO; + 2 QL(1 ea daily); MO; + 1 MO; * zileuton tb12 1 5 SL(4 ea daily); MO; * SL(4 ea daily); MO; + NUCALA SOLR 5 PA; LA; + ZYFLO CR TB12 (Zileuton) XOLAIR SOLR 5 PA; LA; + Selective Phosphodiesterase 4 (PDE4) Inhibitors 3 QL(1 ea daily); DALIRESP TABS MO; + Limit 2 inhalers per month;QL(0.86 gm daily); MO; + QL(1 ea daily); MO; + MO; B/D; * Steroid Inhalants Bronchodilators - Anticholinergics ATROVENT HFA AERS 3 INCRUSE ELLIPTA AEPB 2 ipratropium bromide soln 1 SPIRIVA HANDIHALER CAPS 2 SPIRIVA RESPIMAT AERS 2 TUDORZA PRESSAIR AEPB 2 TUDORZA PRESSAIR AEPB 2 Leukotriene Modulators ACCOLATE TABS (Zafirlukast) 3 QL(1 ea daily); MO; + Limit 1 inhaler per month (60 actuations);SL( 0.14 gm daily); MO; + Limit 2 inhalers per month (30 actuations);QL( 0.07 ea daily); MO; + Limit 1 inhaler per month (60 actuations);QL( 0.04 ea daily); MO; + MO; + AEROSPAN AERS 2 AEROSPAN AERS 2 ALVESCO AERS 160 MCG/ACT 3 ALVESCO AERS 80 MCG/ACT 3 ARNUITY ELLIPTA AEPB 2 ASMANEX HFA AERO 100 MCG/ACT 2 Limit 4 inhalers per month (institutional pack);SL(0.68 gm daily); MO; + Limit 2 inhalers per month (120 actuations);SL( 0.6 gm daily); MO; + Limit 2 inhalers per month;SL(0.41 gm daily); MO; + Limit 4 inhalers per month;SL(0.82 gm daily); MO; + SL(1 ea daily); MO; + Limit 2 inhalers per month;SL(0.87 gm daily); MO; + You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 14 Drug Requirements/ Tier Limits Limit 1 inhaler ASMANEX HFA AERO 200 2 per month;SL(0.44 MCG/ACT gm daily); MO; + Limit 1 inhaler ASMANEX TWISTHALER per 2 month;SL(0.04 120 METERED DOSES AEPB ea daily); MO; + Limit 8 inhalers ASMANEX TWISTHALER per 2 month;SL(0.29 14 METERED DOSES AEPB ea daily); MO; + Limit 1 inhaler ASMANEX TWISTHALER per 2 month;SL(0.04 30 METERED DOSES AEPB 110 MCG/INH ea daily); MO; + Limit 4 inhalers ASMANEX TWISTHALER per 2 month;SL(0.14 30 METERED DOSES AEPB 220 MCG/INH ea daily); MO; + Limit 2 inhalers ASMANEX TWISTHALER per 2 month;SL(0.07 60 METERED DOSES AEPB ea daily); MO; + Limit 4 inhalers ASMANEX TWISTHALER per 2 month;SL(0.15 7 METERED DOSES AEPB ea daily); MO; + budesonide (inhalation) 1 QL(8 ml daily); susp 0.25 mg/2ml MO; B/D; * budesonide (inhalation) 1 QL(4 ml daily); susp 0.5 mg/2ml MO; B/D; * budesonide (inhalation) 1 QL(2 ml daily); susp 1 mg/2ml MO; B/D; * FLOVENT DISKUS AEPB 2 SL(20 ea daily); 100 MCG/BLIST MO; + FLOVENT DISKUS AEPB 2 SL(8 ea daily); 250 MCG/BLIST MO; + FLOVENT DISKUS AEPB 2 SL(40 ea daily); 50 MCG/BLIST MO; + Drug Name Drug Requirements/ Tier Limits Limit 2 inhalers per FLOVENT HFA AERO 220 2 month;QL(0.8 MCG/ACT, 110 MCG/ACT gm daily); MO; + Limit 1 inhaler per FLOVENT HFA AERO 44 2 month;QL(0.36 MCG/ACT gm daily); MO; + Limit 2 inhalers per PULMICORT FLEXHALER 3 month;QL(0.07 AEPB 180 MCG/ACT ea daily); MO; + Limit 8 inhalers per PULMICORT FLEXHALER 3 month;QL(0.27 AEPB 90 MCG/ACT ea daily); MO; + PULMICORT SUSP 0.25 QL(8 ml daily); 3 MO; B/D; + MG/2ML (Budesonide (Inhalation)) PULMICORT SUSP 0.5 QL(4 ml daily); 3 MO; B/D; + MG/2ML (Budesonide (Inhalation)) PULMICORT SUSP 1 QL(2 ml daily); 3 MO; B/D; + MG/2ML (Budesonide (Inhalation)) Limit 3 inhalers per 2 month;QL(0.87 QVAR AERS gm daily); MO; + Drug Name Sympathomimetics ADVAIR DISKUS AEPB 2 ADVAIR HFA AERO 2 albuterol sulfate nebu 1 QL(2 ea daily); MO; + QL(4 gm daily); MO; + MO; B/D; * albuterol sulfate syrp 1 MO; * albuterol sulfate tabs 1 MO; * albuterol sulfate tb12 1 MO; * You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 15 Drug Requirements/ Tier Limits 2 QL(2 ea daily); ANORO ELLIPTA AEPB MO; + ARCAPTA NEOHALER 3 QL(1 ea daily); CAPS MO; + Limit 2 inhalers BREO ELLIPTA AEPB per month 2 (Institutional 25MCG/INH-100MCG/INH, 25MCG/INH-200MCG/INH Pack);SL(2 ea daily); MO; + Limit 1 inhaler BREO ELLIPTA AEPB 2 per month;SL(2 25MCG/INH-200MCG/INH, ea daily); MO; 25MCG/INH-100MCG/INH + 3 MO; B/D; + BROVANA NEBU Drug Name Drug Requirements/ Tier Limits Limit 1 inhaler per month (60 STRIVERDI RESPIMAT 2 actuations);SL( AERS 0.14 gm daily); MO; + Limit 2 inhalers per month SYMBICORT AERO 3 (Institutional 4.5MCG/ACTPack);QL(0.4 160MCG/ACT gm daily); MO; + Limit 2 inhalers per month SYMBICORT AERO 3 (Institutional 4.5MCG/ACT-80MCG/ACT Pack);QL(0.46 gm daily); MO; + SYMBICORT AERO Limit 1 inhaler 4.5MCG/ACTper 3 month;QL(0.34 80MCG/ACT, 4.5MCG/ACTgm daily); MO; 160MCG/ACT + 1 MO; * terbutaline sulfate tabs Drug Name COMBIVENT RESPIMAT AERS 3 DULERA AERO 2 ipratropium-albuterol soln 1 Limit 1 inhaler per month;SL(0.2 gm daily); MO; + QL(4 gm daily); MO; + MO; B/D; * levalbuterol hcl nebu 1 MO; B/D; * VENTOLIN HFA AERS 3 LEVALBUTEROL TARTRATE HFA AERO 3 MO; + 3 metaproterenol sulfate tabs 1 MO; * XOPENEX CONCENTRATE NEBU (Levalbuterol HCl) XOPENEX HFA AERO 3 PERFOROMIST NEBU 3 PROAIR HFA AERS MO; + MO; B/D; + MO; + XOPENEX NEBU (Levalbuterol HCl) 2 QL(4 ml daily); MO; B/D; + MO; + PROAIR RESPICLICK AEPB 2 MO; + aminophylline soln 4 + PROVENTIL HFA AERS 2 MO; + theophylline tb12 1 MO; * SEREVENT DISKUS AEPB 2 QL(2 ea daily); MO; + Limit 1 inhaler per month;QL(0.14 gm daily); MO; + theophylline tb24 1 MO; * STIOLTO RESPIMAT AERS 2 NF MO; B/D Xanthines ANTICOAGULANTS - Blood Thinners Coumarin Anticoagulants COUMADIN TABS (Warfarin Sodium) warfarin sodium tabs 3 MO; + 1 MO; * Direct Factor Xa Inhibitors You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 16 Drug Name ELIQUIS TABS Drug Requirements/ Tier Limits 3 MO; + 3 MO; + XARELTO STARTER PACK TBPK 2 MO; + XARELTO TABS 2 MO; + SAVAYSA TABS Heparins And Heparinoid-Like Agents ARIXTRA SOLN 10 MO; + 4 MG/0.8ML (Fondaparinux Sodium) ARIXTRA SOLN 2.5 MO NF MG/0.5ML (Fondaparinux Sodium) ARIXTRA SOLN 5 MO; + 5 MG/0.4ML, 7.5 MG/0.6ML (Fondaparinux Sodium) enoxaparin sodium soln ij 4 MO; + 300 mg/3ml enoxaparin sodium soln sc MO; * 120 mg/0.8ml, 150 mg/ml, 1 60 mg/0.6ml, 100 mg/ml, 80 mg/0.8ml enoxaparin sodium soln sc 4 MO; + 40 mg/0.4ml, 30 mg/0.3ml fondaparinux sodium soln 4 MO; + 10 mg/0.8ml fondaparinux sodium soln 1 MO; * 2.5 mg/0.5ml fondaparinux sodium soln 5 5 MO; + mg/0.4ml, 7.5 mg/0.6ml FRAGMIN SOLN 18000 MO; + UNT/0.72ML, 7500 4 UNIT/0.3ML, 12500 UNIT/0.5ML, 15000 UNIT/0.6ML FRAGMIN SOLN 2500 MO; + UNIT/0.2ML, 10000 3 UNIT/ML, 5000 UNIT/0.2ML FRAGMIN SOLN 95000 5 MO; + UNIT/3.8ML heparin sodium (porcine) 4 MO; + soln Drug Name LOVENOX SOLN IJ 300 MG/3ML (Enoxaparin Sodium) LOVENOX SOLN SC 30 MG/0.3ML, 40 MG/0.4ML (Enoxaparin Sodium) LOVENOX SOLN SC 60 MG/0.6ML, 100 MG/ML, 80 MG/0.8ML, 120 MG/0.8ML, 150 MG/ML (Enoxaparin Sodium) Thrombin Inhibitors argatroban soln 250 mg/2.5ml Drug Requirements/ Tier Limits MO; + 4 MO; + 4 MO NF 4 MO; + IPRIVASK SOLR 5 + PRADAXA CAPS 2 MO; + ANTICONVULSANTS - Drugs to Treat Seizures AMPA Glutamate Receptor Antagonists 3 MO; + FYCOMPA SUSP FYCOMPA TABS 3 MO; + Anticonvulsants - Benzodiazepines 1 SL(40 ea daily); clonazepam tabs 0.5 mg MO; * 1 SL(20 ea daily); clonazepam tabs 1 mg MO; * 1 SL(10 ea daily); clonazepam tabs 2 mg MO; * 1 MO; * clonazepam tbdp DIASTAT ACUDIAL GEL 3 MO; + DIASTAT PEDIATRIC GEL 3 MO; + DIAZEPAM GEL 3 MO; + KLONOPIN TABS 0.5 MG (Clonazepam) KLONOPIN TABS 1 MG (Clonazepam) KLONOPIN TABS 2 MG (Clonazepam) 3 3 3 SL(40 ea daily); MO; + SL(20 ea daily); MO; + SL(10 ea daily); MO; + You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 17 Drug Name ONFI SUSP Drug Requirements/ Tier Limits 3 MO; + ONFI TABS 10 MG 3 MO; + ONFI TABS 20 MG 5 MO; + 3 MO; + 5 MO; + BANZEL SUSP 3 MO; + BANZEL TABS 200 MG 3 MO; + BANZEL TABS 400 MG 5 MO; + Anticonvulsants - Misc. APTIOM TABS 200 MG APTIOM TABS 800 MG, 600 MG, 400 MG BRIVIACT SOLN IV 50 MG/5ML BRIVIACT SOLN OR 10 MG/ML BRIVIACT TABS 100 MG 5 BRIVIACT TABS 25 MG 5 BRIVIACT TABS 50 MG 5 BRIVIACT TABS 75 MG 5 carbamazepine chew 1 SL(20 ml daily); + PA; SL(20 ml daily); MO; + PA; SL(20 ea daily); MO; + PA; SL(2 ea daily); MO; + PA; SL(8 ea daily); MO; + PA; SL(4 ea daily); MO; + PA; SL(2.67 ea daily); MO; + MO; * carbamazepine cp12 1 carbamazepine susp BRIVIACT TABS 10 MG 5 5 5 Drug Name gabapentin tabs KEPPRA SOLN IV 500 MG/5ML (Levetiracetam) KEPPRA SOLN OR 100 MG/ML (Levetiracetam) KEPPRA TABS (Levetiracetam) KEPPRA XR TB24 (Levetiracetam) LAMICTAL CHEWABLE DISPERSIBLE CHEW (Lamotrigine) LAMICTAL ODT TBDP (Lamotrigine) LAMICTAL STARTER/NOT TAKING CARBAMAZEPINE KIT LAMICTAL STARTER/TAKING CARBAMAZEPINE/NOT TAKING VALPROATE KIT LAMICTAL STARTER/TAKING VALPROATE KIT LAMICTAL TABS (Lamotrigine) Drug Requirements/ Tier Limits 1 MO; * 4 MO; + 3 MO; + 3 MO; + 3 MO; + MO; + 3 3 MO; + MO; + 3 MO; + 3 MO; + 3 3 MO; + LAMICTAL XR KIT 3 MO; + LAMICTAL XR TB24 (Lamotrigine) 3 MO; + lamotrigine chew 1 MO; * MO; * lamotrigine tabs 1 MO; * 1 MO; * lamotrigine tb24 1 MO; * carbamazepine tabs 1 MO; * lamotrigine tbdp 1 MO; * carbamazepine tb12 1 MO; * levetiracetam in sodium chloride soln 4 + CARBATROL CP12 (Carbamazepine) 3 MO; + gabapentin caps 1 MO; * gabapentin soln 1 MO; * You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 18 Drug Name LEVETIRACETAM SOLN IV 1000MG/100ML750MG/100ML, 500MG/100ML820MG/100ML, 1500MG/100ML540MG/100ML (Levetiracetam in Sodium Chloride) levetiracetam soln iv 500 mg/5ml levetiracetam soln or 500 mg/5ml, 100 mg/ml Drug Requirements/ Tier Limits + Drug Name POTIGA TABS 200 MG POTIGA TABS 300 MG 4 POTIGA TABS 400 MG POTIGA TABS 50 MG Drug Requirements/ Tier Limits 5 SL(6 ea daily); MO; + 3 SL(4 ea daily); MO; + 3 SL(3 ea daily); MO; + 3 SL(24 ea daily); MO; + 1 MO; * 4 MO; + primidone tabs 1 MO; * SPRITAM TB3D 1000 MG 3 levetiracetam tabs 1 MO; * SPRITAM TB3D 250 MG 3 levetiracetam tb24 1 MO; * SPRITAM TB3D 500 MG 3 LYRICA CAPS 100 MG 2 SPRITAM TB3D 750 MG 3 LYRICA CAPS 150 MG 2 LYRICA CAPS 200 MG 2 LYRICA CAPS 225 MG 2 LYRICA CAPS 25 MG 2 LYRICA CAPS 300 MG 2 LYRICA CAPS 50 MG 2 LYRICA CAPS 75 MG 2 LYRICA SOLN 2 3 PA; SL(3 ea daily); MO; + PA; SL(12 ea daily); MO; + PA; SL(6 ea daily); MO; + PA; SL(4 ea daily); MO; + MO; + 3 MO; + 3 MO; + 3 MO; + 3 MO; + topiramate cpsp 1 MO; * topiramate tabs 1 MO; * 3 MO; + 3 MO; + 4 + 3 MO; + 3 SL(6 ea daily); MO; + SL(4 ea daily); MO; + SL(3 ea daily); MO; + SL(2.66 ea daily); MO; + SL(24 ea daily); MO; + SL(2 ea daily); MO; + SL(12 ea daily); MO; + SL(8 ea daily); MO; + SL(30 ml daily); MO; + MO; + 3 MO; + 3 MO; + 3 MO; + VIMPAT TABS 3 MO; + 1 MO; * ZONEGRAN CAPS (Zonisamide) 3 MO; + oxcarbazepine susp oxcarbazepine tabs 1 MO; * zonisamide caps 1 MO; * MYSOLINE TABS (Primidone) NEURONTIN CAPS (Gabapentin) NEURONTIN SOLN (Gabapentin) NEURONTIN TABS (Gabapentin) TEGRETOL SUSP (Carbamazepine) TEGRETOL TABS (Carbamazepine) TEGRETOL-XR TB12 (Carbamazepine) TOPAMAX SPRINKLE CPSP (Topiramate) TOPAMAX TABS (Topiramate) TRILEPTAL SUSP (Oxcarbazepine) TRILEPTAL TABS (Oxcarbazepine) VIMPAT SOLN IV 200 MG/20ML VIMPAT SOLN OR 10 MG/ML You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 19 Drug Name Drug Requirements/ Tier Limits Carbamates ethosuximide caps felbamate susp 1 MO; * felbamate tabs 1 MO; * 3 MO; + 3 MO; + FELBATOL SUSP (Felbamate) FELBATOL TABS (Felbamate) GABA Modulators GABITRIL TABS 12 MG, 16 MG GABITRIL TABS 4 MG, 2 MG (Tiagabine HCl) 3 MO; + 3 MO; + SABRIL PACK 5 LA; + SABRIL TABS 5 LA; + 1 MO; * tiagabine hcl tabs Hydantoins CEREBYX SOLN 100 MG PE/2ML (Fosphenytoin Sodium) CEREBYX SOLN 500 MG PE/10ML (Fosphenytoin Sodium) DILANTIN-125 SUSP (Phenytoin) fosphenytoin sodium soln 100 mg pe/2ml fosphenytoin sodium soln 500 mg pe/10ml Drug Name + Drug Requirements/ Tier Limits 1 MO; * ethosuximide soln 1 MO; * ZARONTIN CAPS (Ethosuximide) 3 MO; + 4 + 3 MO; + 3 MO; + 3 MO; + 3 MO; + 3 MO; + divalproex sodium csdr 1 MO; * divalproex sodium tb24 1 MO; * divalproex sodium tbec 1 MO; * 4 + 1 MO; * 1 MO; * Valproic Acid DEPACON SOLN (Valproate Sodium) DEPAKENE CAPS (Valproic Acid) DEPAKENE SOLN (Valproate Sodium) DEPAKOTE ER TB24 (Divalproex Sodium) DEPAKOTE SPRINKLES CSDR (Divalproex Sodium) DEPAKOTE TBEC (Divalproex Sodium) 4 MO; + 4 valproate sodium soln iv 100 mg/ml, 500 mg/5ml valproate sodium soln or 250 mg/5ml 3 MO; + 4 + valproic acid caps 4 MO; + ANTIDEPRESSANTS - Drugs to Treat Depression PEGANONE TABS 3 MO; + Alpha-2 Receptor Antagonists (Tetracyclics) 1 MO; * mirtazapine tabs phenytoin chew 1 MO; * phenytoin sodium extended caps 1 MO; * phenytoin sodium soln 4 + phenytoin susp 1 MO; * mirtazapine tbdp 3 MO; * NF MO NF MO Antidepressants - Misc. Succinimides CELONTIN CAPS REMERON SOLTAB TBDP (Mirtazapine) REMERON TABS (Mirtazapine) 1 MO; + APLENZIN TB24 174 MG 3 ST; SL(3 ea daily); MO; + You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 20 Drug Name APLENZIN TB24 348 MG APLENZIN TB24 522 MG bupropion hcl tabs 100 mg bupropion hcl tabs 75 mg bupropion hcl tb12 100 mg bupropion hcl tb12 150 mg bupropion hcl tb12 200 mg bupropion hcl tb24 150 mg bupropion hcl tb24 300 mg FORFIVO XL TB24 maprotiline hcl tabs WELLBUTRIN SR TB12 100 MG (Bupropion HCl) WELLBUTRIN SR TB12 150 MG (Bupropion HCl) WELLBUTRIN SR TB12 200 MG (Bupropion HCl) WELLBUTRIN TABS 100 MG (Bupropion HCl) WELLBUTRIN TABS 75 MG (Bupropion HCl) WELLBUTRIN XL TB24 150 MG (Bupropion HCl) WELLBUTRIN XL TB24 300 MG (Bupropion HCl) Drug Requirements/ Tier Limits 3 ST; SL(1.5 ea daily); MO; + 3 ST; SL(1 ea daily); MO; + 1 SL(4.5 ea daily); MO; * 1 SL(6 ea daily); MO; * 1 SL(4 ea daily); MO; * 1 SL(2.66 ea daily); MO; * 1 SL(2 ea daily); MO; * 1 SL(3 ea daily); MO; * 1 SL(1.5 ea daily); MO; * 3 ST; MO; + 1 NF NF NF NF NF NF NF MO; * SL(4 ea daily); MO SL(2.66 ea daily); MO SL(2 ea daily); MO SL(4.5 ea daily); MO SL(6 ea daily); MO SL(3 ea daily); MO SL(1.5 ea daily); MO Monoamine Oxidase Inhibitors (MAOIs) 5 MO; + EMSAM PT24 MARPLAN TABS NARDIL TABS (Phenelzine Sulfate) PARNATE TABS (Tranylcypromine Sulfate) 3 MO; + NF MO 5 MO; + Drug Name phenelzine sulfate tabs Drug Requirements/ Tier Limits 1 MO; * tranylcypromine sulfate 1 MO; * tabs Selective Serotonin Reuptake Inhibitors (SSRIs) CELEXA TABS 10 MG NF SL(4 ea daily); (Citalopram Hydrobromide) MO CELEXA TABS 20 MG NF SL(2 ea daily); (Citalopram Hydrobromide) MO CELEXA TABS 40 MG NF SL(1 ea daily); (Citalopram Hydrobromide) MO citalopram hydrobromide 1 SL(20 ml daily); soln MO; * citalopram hydrobromide 1 SL(4 ea daily); tabs 10 mg MO; * citalopram hydrobromide 1 SL(2 ea daily); tabs 20 mg MO; * citalopram hydrobromide 1 SL(1 ea daily); tabs 40 mg MO; * 1 MO; * escitalopram oxalate soln escitalopram oxalate tabs 1 MO; * fluoxetine hcl caps 1 MO; * fluoxetine hcl cpdr 1 MO; * fluoxetine hcl soln 1 MO; * 1 MO; * 3 MO; + fluvoxamine maleate cp24 1 MO; * fluvoxamine maleate tabs 1 MO; * fluoxetine hcl tabs 10 mg, 20 mg FLUOXETINE HCL TABS 60 MG LEXAPRO SOLN (Escitalopram Oxalate) LEXAPRO TABS (Escitalopram Oxalate) NF MO NF MO paroxetine hcl tabs 1 MO; * paroxetine hcl tb24 1 MO; * PAXIL CR TB24 (Paroxetine HCl) NF MO You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 21 Drug Name PAXIL SUSP PAXIL TABS (Paroxetine HCl) PEXEVA TABS PROZAC CAPS (Fluoxetine HCl) PROZAC WEEKLY CPDR (Fluoxetine HCl) Drug Requirements/ Tier Limits 3 MO; + NF MO 3 ST; MO; + NF MO NF MO sertraline hcl conc 1 MO; * sertraline hcl tabs 1 MO; * ZOLOFT CONC (Sertraline HCl) ZOLOFT TABS (Sertraline HCl) NF MO NF MO Serotonin Modulators BRINTELLIX TABS 20 MG 3 BRINTELLIX TABS 5 MG 3 nefazodone hcl tabs 1 ST; QL(2 ea daily); MO; + ST; QL(1 ea daily); MO; + ST; QL(4 ea daily); MO; + MO; * trazodone hcl tabs 1 MO; * TRINTELLIX TABS 10 MG 3 TRINTELLIX TABS 20 MG 3 TRINTELLIX TABS 5 MG 3 VIIBRYD KIT 3 ST; QL(2 ea daily); MO; + ST; QL(1 ea daily); MO; + ST; QL(4 ea daily); MO; + ST; + VIIBRYD STARTER PACK KIT 3 VIIBRYD TABS 3 BRINTELLIX TABS 10 MG 3 Drug Name desvenlafaxine succinate tb24 duloxetine hcl cpep 30 mg, 20 mg, 60 mg EFFEXOR XR CP24 150 MG (Venlafaxine HCl) EFFEXOR XR CP24 37.5 MG (Venlafaxine HCl) EFFEXOR XR CP24 75 MG (Venlafaxine HCl) FETZIMA CP24 20 MG FETZIMA CP24 80 MG, 40 MG, 120 MG FETZIMA TITRATION PACK C4PK KHEDEZLA TB24 PRISTIQ TB24 (Desvenlafaxine Succinate) venlafaxine hcl cp24 150 mg venlafaxine hcl cp24 37.5 mg venlafaxine hcl cp24 75 mg VENLAFAXINE HCL ER TB24 venlafaxine hcl tabs 100 mg Drug Requirements/ Tier Limits 1 ST; MO; * 1 NF SL(1.5 ea daily); MO NF SL(6 ea daily); MO NF SL(3 ea daily); MO 3 ST; QL(2 ea daily); MO; + 3 ST; QL(1 ea daily); MO; + 3 ST; MO; + 3 ST; MO; + 3 ST; MO; + 1 1 1 3 1 venlafaxine hcl tabs 25 mg 1 venlafaxine hcl tabs 37.5 mg 1 venlafaxine hcl tabs 50 mg 1 ST; MO; + venlafaxine hcl tabs 75 mg 1 ST; MO; + venlafaxine hcl tb24 150 mg venlafaxine hcl tb24 225 mg venlafaxine hcl tb24 37.5 mg Serotonin-Norepinephrine Reuptake Inhibitors CYMBALTA CPEP NF MO (Duloxetine HCl) DESVENLAFAXINE ER 3 ST; MO; + TB24 100 MG, 50 MG venlafaxine hcl tb24 75 mg MO; * 1 1 1 1 SL(1.5 ea daily); MO; * SL(6 ea daily); MO; * SL(3 ea daily); MO; * ST; SL(1 ea daily); MO; + SL(3.75 ea daily); MO; * SL(15 ea daily); MO; * SL(10 ea daily); MO; * SL(7.5 ea daily); MO; * SL(5 ea daily); MO; * SL(1.5 ea daily); MO; * ST; SL(1 ea daily); MO; * SL(6 ea daily); MO; * SL(3 ea daily); MO; * You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 22 Drug Name Drug Requirements/ Tier Limits Tricyclic Agents amitriptyline hcl tabs 1 AL; MO; * amoxapine tabs 1 MO; * ANAFRANIL CAPS (Clomipramine HCl) NF AL; MO 1 AL; MO; * desipramine hcl tabs 1 MO; * doxepin hcl caps 1 AL; MO; * doxepin hcl conc 1 AL; MO; * 3 AL; MO; + imipramine hcl tabs 1 AL; MO; * imipramine pamoate caps 1 AL; MO; * NORPRAMIN TABS (Desipramine HCl) NF MO nortriptyline hcl caps 1 MO; * nortriptyline hcl soln 1 MO; * PAMELOR CAPS (Nortriptyline HCl) protriptyline hcl tabs SURMONTIL CAPS (Trimipramine Maleate) TOFRANIL-PM CAPS (Imipramine Pamoate) trimipramine maleate caps NF MO 1 MO; * 3 AL; MO; + NF AL; MO 1 AL; MO; * ANTIDIABETICS - Drugs to Regulate Blood Sugar Alpha-Glucosidase Inhibitors acarbose tabs 1 GLYSET TABS (Miglitol) 3 miglitol tabs 1 PRECOSE TABS (Acarbose) Drug Requirements/ Tier Limits 3 QL(3 ea daily); MO; + Antidiabetic - Amylin Analogs clomipramine hcl caps ELAVIL TABS (Amitriptyline HCl) Drug Name QL(3 ea daily); MO; * QL(3 ea daily); MO; + QL(3 ea daily); MO; * SYMLINPEN 120 SOPN 4 SYMLINPEN 60 SOPN 4 Antidiabetic Combinations ACTOPLUS MET TABS (Pioglitazone HClMetformin HCl) ACTOPLUS MET XR TB24 15MG-1000MG ACTOPLUS MET XR TB24 30MG-1000MG ALOGLIPTIN/METFORMIN HCL TABS ALOGLIPTIN/PIOGLITAZO NE TABS 12.5MG-15MG ALOGLIPTIN/PIOGLITAZO NE TABS 12.5MG-30MG ALOGLIPTIN/PIOGLITAZO NE TABS 25MG-30MG, 12.5MG-45MG, 25MG15MG, 25MG-45MG DUETACT TABS (Pioglitazone HClGlimepiride) glipizide-metformin hcl tabs 2.5mg-250mg glipizide-metformin hcl tabs 5mg-500mg, 2.5mg-500mg GLUCOVANCE TABS (Glyburide-Metformin) glyburide-metformin tabs 1.25mg-250mg glyburide-metformin tabs 5mg-500mg, 2.5mg-500mg INVOKAMET TABS 50MG1000MG, 150MG-500MG, 150MG-1000MG INVOKAMET TABS 50MG500MG 2 Limit 12mls per month;QL(0.4 ml daily); MO; + Limit 12mls per month;QL(0.4 ml daily); MO; + SL(3 ea daily); MO; + 3 QL(2 ea daily); MO; + SL(1.5 ea daily); MO; + PA; SL(2 ea daily); MO; + PA; SL(2 ea daily); MO; + PA; SL(1.5 ea daily); MO; + PA; SL(1 ea daily); MO; + 2 SL(1.5 ea daily); MO; + 2 2 3 3 3 SL(8 ea daily); MO; * 1 SL(4 ea daily); MO; * NF AL; SL(4 ea daily); MO 1 AL; SL(8 ea daily); MO; * 1 AL; SL(4 ea daily); MO; * SL(2 ea daily); 2 MO; + 1 2 SL(4 ea daily); MO; + You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 23 Drug Name INVOKAMET XR TB24 50MG-1000MG, 150MG1000MG, 150MG-500MG INVOKAMET XR TB24 50MG-500MG JANUMET TABS JANUMET XR TB24 100MG-1000MG JANUMET XR TB24 50MG-1000MG, 50MG500MG JENTADUETO TABS JENTADUETO XR TB24 2.5MG-1000MG JENTADUETO XR TB24 5MG-1000MG KAZANO TABS KOMBIGLYZE XR TB24 2.5MG-1000MG KOMBIGLYZE XR TB24 5MG-500MG, 5MG1000MG OSENI TABS 12.5MG15MG OSENI TABS 12.5MG30MG OSENI TABS 25MG45MG, 12.5MG-45MG, 25MG-15MG, 25MG-30MG pioglitazone hcl-glimepiride tabs pioglitazone hcl-metformin hcl tabs PRANDIMET TABS (Repaglinide-Metformin HCl) repaglinide-metformin hcl tabs SYNJARDY TABS 12.5MG-1000MG, 5MG1000MG SYNJARDY TABS 12.5MG-500MG, 5MG500MG Drug Requirements/ Tier Limits SL(2 ea daily); 2 MO; + 2 2 2 2 2 2 2 3 3 3 3 3 3 1 1 2 SL(4 ea daily); MO; + SL(2 ea daily); MO; + SL(1 ea daily); MO; + SL(2 ea daily); MO; + SL(2 ea daily); MO; + SL(2 ea daily); MO; + SL(1 ea daily); MO; + PA; SL(2 ea daily); MO; + PA; SL(2 ea daily); MO; + PA; SL(1 ea daily); MO; + PA; SL(2 ea daily); MO; + PA; SL(1.5 ea daily); MO; + PA; SL(1 ea daily); MO; + SL(1.5 ea daily); MO; * SL(3 ea daily); MO; * SL(5 ea daily); MO; + 2 SL(5 ea daily); MO; * SL(2 ea daily); MO; + 2 SL(4 ea daily); MO; + 1 Drug Name XIGDUO XR TB24 10MG1000MG, 10MG-500MG XIGDUO XR TB24 5MG1000MG, 5MG-500MG Drug Requirements/ Tier Limits 3 SL(1 ea daily); MO; + 3 SL(2 ea daily); MO; + Biguanides FORTAMET TB24 1000 MG (Metformin HCl) 3 FORTAMET TB24 500 MG (Metformin HCl) 3 GLUCOPHAGE TABS 1000 MG (Metformin HCl) GLUCOPHAGE TABS 500 MG (Metformin HCl) GLUCOPHAGE TABS 850 MG (Metformin HCl) 3 3 3 GLUCOPHAGE XR TB24 500 MG (Metformin HCl) 3 GLUCOPHAGE XR TB24 750 MG (Metformin HCl) 3 metformin hcl tabs 1000 mg 1 metformin hcl tabs 500 mg 1 metformin hcl tabs 850 mg 1 metformin hcl tb24 1000 mg 1 metformin hcl tb24 500 mg 1 metformin hcl tb24 500 mg 1 metformin hcl tb24 750 mg 1 RIOMET SOLN 2 (FORTAMET); SL(2.5 ea daily); MO; + (FORTAMET); SL(5 ea daily); MO; + SL(2.55 ea daily); MO; + SL(5.1 ea daily); MO; + SL(3 ea daily); MO; + (GLUCOPHAG E XR);SL(4 ea daily); MO; + (GLUCOPHAG E XR);SL(2.66 ea daily); MO; + SL(2.55 ea daily); MO; * SL(5.1 ea daily); MO; * SL(3 ea daily); MO; * (FORTAMET); SL(2.5 ea daily); MO; * (FORTAMET); SL(5 ea daily); MO; * (GLUCOPHAG E XR);SL(4 ea daily); MO; * (GLUCOPHAG E XR);SL(2.66 ea daily); MO; * Limit 765mls per month;SL(25.5 ml daily); MO; + You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 24 Drug Name Diabetic Other GLUCAGEN HYPOKIT SOLR GLUCAGON EMERGENCY KIT KIT Drug Requirements/ Tier Limits Drug Name TANZEUM PEN 2 MO; + 2 MO; + KORLYM TABS 3 PROGLYCEM SUSP 3 SL(4 ea daily); LA; + MO; + Dipeptidyl Peptidase-4 (DPP-4) Inhibitors ALOGLIPTIN TABS 12.5 3 PA; QL(2 ea MG daily); MO; + 3 PA; QL(1 ea ALOGLIPTIN TABS 25 MG daily); MO; + ALOGLIPTIN TABS 6.25 3 PA; QL(4 ea MG daily); MO; + 2 QL(1 ea daily); JANUVIA TABS 100 MG MO; + 2 QL(4 ea daily); JANUVIA TABS 25 MG MO; + 2 QL(2 ea daily); JANUVIA TABS 50 MG MO; + 3 PA; QL(2 ea NESINA TABS 12.5 MG daily); MO; + 3 PA; QL(1 ea NESINA TABS 25 MG daily); MO; + 3 PA; QL(4 ea NESINA TABS 6.25 MG daily); MO; + 3 PA; QL(2 ea ONGLYZA TABS 2.5 MG daily); MO; + 3 PA; QL(1 ea ONGLYZA TABS 5 MG daily); MO; + 2 QL(1 ea daily); TRADJENTA TABS MO; + Drug Requirements/ Tier Limits 3 ST; MO; + TRULICITY SOPN 3 ST; MO; + VICTOZA SOPN 2 ST; MO; + Insulin Sensitizing Agents ACTOS TABS 15 MG (Pioglitazone HCl) ACTOS TABS 30 MG (Pioglitazone HCl) ACTOS TABS 45 MG (Pioglitazone HCl) 2 2 2 AVANDIA TABS 2 MG 2 AVANDIA TABS 4 MG 2 pioglitazone hcl tabs 15 mg 1 pioglitazone hcl tabs 30 mg 1 pioglitazone hcl tabs 45 mg 1 Insulin AFREZZA POWD 3 APIDRA SOLN 3 APIDRA SOLOSTAR SOPN 3 HUMALOG KWIKPEN SOPN 2 Dopamine Receptor Agonists - Antidiabetic 3 QL(6 ea daily); CYCLOSET TABS MO; + HUMALOG MIX 50/50 KWIKPEN SUPN 2 Incretin Mimetic Agents (GLP-1 Receptor 2 ST; MO; + BYDUREON PEN PEN HUMALOG MIX 50/50 SUSP 2 HUMALOG MIX 75/25 KWIKPEN SUPN 2 BYDUREON SRER 2 ST; MO; + BYETTA SOPN 2 ST; MO; + SL(3 ea daily); MO; + SL(1.5 ea daily); MO; + SL(1 ea daily); MO; + SL(4 ea daily); MO; + SL(2 ea daily); MO; + SL(3 ea daily); MO; * SL(1.5 ea daily); MO; * SL(1 ea daily); MO; * QL(18 ea daily); MO; + Limit 45mls per month;QL(1.5 ml daily); MO; + Limit 45mls per month;QL(1.5 ml daily); MO; + Limit 45mls per month;QL(1.5 ml daily); MO; + Limit 45mls per month;QL(1.5 ml daily); MO; + Limit 45mls per month;QL(1.5 ml daily); MO; + Limit 45mls per month;QL(1.5 ml daily); MO; + You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 25 Drug Requirements/ Tier Limits Limit 45mls per HUMALOG MIX 75/25 2 month;QL(1.5 SUSP ml daily); MO; + Limit 45mls per 2 month;QL(1.5 HUMALOG SOCT ml daily); MO; + Limit 45mls per 2 month;QL(1.5 HUMALOG SOLN ml daily); MO; + Limit 45mls per HUMULIN 70/30 KWIKPEN 2 month;QL(1.5 SUPN ml daily); MO; + Limit 45mls per 2 month;QL(1.5 HUMULIN 70/30 SUSP ml daily); MO; + Limit 45mls per HUMULIN N KWIKPEN 2 month;QL(1.5 SUPN ml daily); MO; + Limit 45mls per 2 month;QL(1.5 HUMULIN N SUSP ml daily); MO; + Limit 45mls per 2 month;QL(1.5 HUMULIN R SOLN ml daily); MO; + Limit 45mls per HUMULIN R U-500 2 month;QL(1.5 (CONCENTRATED) SOLN ml daily); MO; + Limit 45mls per HUMULIN R U-500 2 month;QL(1.5 KWIKPEN SOPN ml daily); MO; + Limit 45mls per 2 month;QL(1.5 LANTUS SOLN ml daily); MO; + Limit 45mls per LANTUS SOLOSTAR 2 month;QL(1.5 SOPN ml daily); MO; + Drug Name Drug Name LEVEMIR FLEXTOUCH SOPN LEVEMIR SOLN NOVOLIN 70/30 RELION SUSP NOVOLIN 70/30 SUSP NOVOLIN N RELION SUSP NOVOLIN N SUSP NOVOLIN R RELION SOLN NOVOLIN R SOLN NOVOLOG FLEXPEN SOPN NOVOLOG MIX 70/30 PREFILLED FLEXPEN SUPN NOVOLOG MIX 70/30 SUSP NOVOLOG PENFILL SOCT NOVOLOG SOLN TOUJEO SOLOSTAR SOPN TRESIBA FLEXTOUCH SOPN 100 UNIT/ML TRESIBA FLEXTOUCH SOPN 200 UNIT/ML Drug Requirements/ Tier Limits Limit 45mls per 2 month;QL(1.5 ml daily); MO; + Limit 45mls per 2 month;QL(1.5 ml daily); MO; + Limit 45mls per 3 month;QL(1.5 ml daily); MO; + Limit 45mls per 3 month;QL(1.5 ml daily); MO; + Limit 45mls per 3 month;QL(1.5 ml daily); MO; + Limit 45mls per 3 month;QL(1.5 ml daily); MO; + Limit 45mls per 3 month;QL(1.5 ml daily); MO; + Limit 45mls per 3 month;QL(1.5 ml daily); MO; + Limit 45mls per 3 month;QL(1.5 ml daily); MO; + Limit 45mls per 3 month;QL(1.5 ml daily); MO; + Limit 45mls per 3 month;QL(1.5 ml daily); MO; + Limit 45mls per 3 month;QL(1.5 ml daily); MO; + Limit 45mls per 3 month;QL(1.5 ml daily); MO; + Limit 15mls per 2 month;QL(0.5 ml daily); MO; + Limit 45mls per 2 month;QL(1.5 ml daily); MO; + Limit 27mls per 2 month;QL(0.9 ml daily); MO; + You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 26 Drug Name Drug Requirements/ Tier Limits Meglitinide Analogues nateglinide tabs PRANDIN TABS 0.5 MG (Repaglinide) PRANDIN TABS 1 MG (Repaglinide) PRANDIN TABS 2 MG (Repaglinide) repaglinide tabs 0.5 mg repaglinide tabs 1 mg repaglinide tabs 2 mg STARLIX TABS (Nateglinide) QL(3 ea daily); MO; * NF SL(32 ea daily); MO NF SL(16 ea daily); MO NF SL(8 ea daily); MO 1 SL(32 ea daily); MO; * 1 SL(16 ea daily); MO; * 1 SL(8 ea daily); MO; * 3 QL(3 ea daily); MO; + 1 Sodium-Glucose Co-Transporter 2 (SGLT2) 3 MO; + FARXIGA TABS INVOKANA TABS 2 MO; + JARDIANCE TABS 2 MO; + Sulfonylureas AMARYL TABS 1 MG (Glimepiride) AMARYL TABS 2 MG (Glimepiride) AMARYL TABS 4 MG (Glimepiride) chlorpropamide tabs 100 mg chlorpropamide tabs 250 mg DIABETA TABS 1.25 MG (Glyburide) DIABETA TABS 2.5 MG (Glyburide) DIABETA TABS 5 MG (Glyburide) 3 3 3 1 1 3 3 3 glimepiride tabs 1 mg 1 glimepiride tabs 2 mg 1 SL(8 ea daily); MO; + SL(4 ea daily); MO; + SL(2 ea daily); MO; + AL; SL(7.5 ea daily); MO; * AL; SL(3 ea daily); MO; * AL; SL(16 ea daily); MO; + AL; SL(8 ea daily); MO; + AL; SL(4 ea daily); MO; + SL(8 ea daily); MO; * SL(4 ea daily); MO; * Drug Requirements/ Tier Limits 1 SL(2 ea daily); glimepiride tabs 4 mg MO; * 1 SL(4 ea daily); glipizide tabs 10 mg MO; * 1 SL(8 ea daily); glipizide tabs 5 mg MO; * 1 SL(2 ea daily); glipizide tb24 10 mg MO; * 1 SL(8 ea daily); glipizide tb24 2.5 mg MO; * 1 SL(4 ea daily); glipizide tb24 5 mg MO; * GLUCOTROL TABS 10 3 SL(4 ea daily); MG (Glipizide) MO; + GLUCOTROL TABS 5 MG 3 SL(8 ea daily); (Glipizide) MO; + GLUCOTROL XL TB24 10 3 SL(2 ea daily); MG (Glipizide) MO; + GLUCOTROL XL TB24 2.5 3 SL(8 ea daily); MG (Glipizide) MO; + GLUCOTROL XL TB24 5 3 SL(4 ea daily); MG (Glipizide) MO; + glyburide micronized tabs 1 AL; SL(8 ea 1.5 mg daily); MO; * glyburide micronized tabs 3 1 AL; SL(4 ea mg daily); MO; * glyburide micronized tabs 6 1 AL; SL(2 ea mg daily); MO; * 1 AL; SL(16 ea glyburide tabs 1.25 mg daily); MO; * 1 AL; SL(8 ea glyburide tabs 2.5 mg daily); MO; * 1 AL; SL(4 ea glyburide tabs 5 mg daily); MO; * GLYNASE TABS 1.5 MG NF AL; SL(8 ea (Glyburide Micronized) daily); MO GLYNASE TABS 3 MG NF AL; SL(4 ea (Glyburide Micronized) daily); MO GLYNASE TABS 6 MG NF AL; SL(2 ea (Glyburide Micronized) daily); MO 1 SL(2 ea daily); tolazamide tabs 500 mg MO; * 1 SL(6 ea daily); tolbutamide tabs MO; * Drug Name ANTIDIARRHEALS - Drugs to Treat Diarrhea You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 27 Drug Name Drug Requirements/ Tier Limits Antidiarrheal - Chloride Channel Antagonists 3 PA; QL(2 ea FULYZAQ TBEC daily); MO; + 3 PA; QL(2 ea MYTESI TBEC daily); MO; + Antiperistaltic Agents diphenoxylate w/ atropine tabs LOMOTIL TABS (Diphenoxylate w/ Atropine) 1 MO; * MO; + 3 loperamide hcl caps 1 RX/OTC; MO; * MOTOFEN TABS 3 + opium tincture tinc 5 MO; + Drug Name ondansetron hcl soln ij 4 mg/2ml, 40 mg/20ml ondansetron hcl soln or 4 mg/5ml Drug Requirements/ Tier Limits 4 MO; + 1 MO; B/D; * ondansetron hcl tabs 1 MO; B/D; * ondansetron tbdp 1 MO; B/D; * SANCUSO PTCH 5 MO; + 3 MO; B/D; + 3 MO; B/D; + 3 MO; B/D; + ZOFRAN ODT TBDP (Ondansetron) ZOFRAN SOLN (Ondansetron HCl) ZOFRAN TABS (Ondansetron HCl) Antiemetics - Anticholinergic ANTIDOTES AND SPECIFIC ANTAGONISTS meclizine hcl tabs 1 RX/OTC; MO; * Antidotes - Chelating Agents TIGAN CAPS (Trimethobenzamide HCl) 3 AL; MO; + TIGAN SOLN 4 AL; MO; + TRANSDERM-SCOP PT72 3 MO; + 1 AL; MO; * AKYNZEO CAPS 3 MO; B/D; + CESAMET CAPS 3 MO; B/D; + dronabinol caps 10 mg 5 MO; B/D; + CHEMET CAPS 3 MO; + EXJADE TBSO 5 LA; + FERRIPROX TABS 5 PA; LA; + JADENU TABS 5 + Opioid Antagonists EVZIO SOAJ 3 PA; MO; + naloxone hcl sosy 1 MO; * naltrexone hcl tabs 1 MO; * NARCAN LIQD REVIA TABS (Naltrexone HCl) Limit 4 per 3 month;QL(0.13 4 ea daily); MO; + NF MO ANTIEMETICS - Drugs to Treat Nausea and Vomiting 5-HT3 Receptor Antagonists granisetron hcl tabs 1 MO; B/D; * trimethobenzamide hcl caps Antiemetics - Miscellaneous dronabinol caps 5 mg, 2.5 1 MO; B/D; * mg MARINOL CAPS 2.5 MG 3 MO; B/D; + (Dronabinol) MARINOL CAPS 5 MG, 10 5 MO; B/D; + MG (Dronabinol) Substance P/Neurokinin 1 (NK1) Receptor 1 PA; MO; * aprepitant caps 40 mg aprepitant caps 80 mg, , 125 mg 1 MO; B/D; * You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 28 Drug Name EMEND CAPS 40 MG (Aprepitant) EMEND CAPS 80 MG, , 125 MG (Aprepitant) Drug Requirements/ Tier Limits 3 PA; MO; + VARUBI TABS 3 MO; B/D; + 3 B/D; + ANTIFUNGALS - Drugs to Treat Fungal Infections Antifungal - Glucan Synthesis Inhibitors 4 + ERAXIS SOLR 100 MG MYCAMINE SOLR 100 MG 5 MO; + Antifungals ABELCET SUSP 4 PA; + AMBISOME SUSR 4 PA; + AMPHOTERICIN B SOLR 4 PA; MO; + ANCOBON CAPS 500 MG (Flucytosine) NF MO flucytosine caps 500 mg GRIFULVIN V TABS (Griseofulvin Microsize) GRIS-PEG TABS (Griseofulvin Ultramicrosize) 1 MO; * NF MO; NT MO NF Drug Name CRESEMBA SOLR DIFLUCAN SUSR (Fluconazole) DIFLUCAN TABS (Fluconazole) fluconazole in dextrose soln fluconazole in nacl soln 400mg/200ml-0.9%, 200mg/100ml-0.9% MO; + 4 + + 4 fluconazole tabs 1 MO; * itraconazole caps 1 MO; * ketoconazole tabs 1 MO; * NOXAFIL SOLN 5 + NOXAFIL SUSP 5 MO; + NOXAFIL TBEC 5 MO; + ONMEL TABS 3 MO; + 3 MO; + 3 MO; + 5 MO; + SPORANOX CAPS (Itraconazole) SPORANOX PULSEPAK CAPS (Itraconazole) SPORANOX SOLN griseofulvin microsize tabs 1 MO; * griseofulvin ultramicrosize tabs 1 MO; * LAMISIL PACK 125 MG 2 PA; MO; + LAMISIL TABS (Terbinafine HCl) 3 MO; + VFEND IV SOLR (Voriconazole) VFEND SUSR (Voriconazole) VFEND TABS (Voriconazole) nystatin tabs 1 MO; * terbinafine hcl tabs 1 MO; * MO; + 3 MO; * 1 5 MO; + 1 griseofulvin microsize susp CRESEMBA CAPS 3 fluconazole susr MO; * Imidazole-Related Antifungals Drug Requirements/ Tier Limits 5 + NF NF MO 5 MO; + voriconazole solr 1 * voriconazole susr 1 MO; * voriconazole tabs 5 MO; + ANTIHISTAMINES - Drugs to Treat Allergies Antihistamines - Ethanolamines You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 29 Drug Name carbinoxamine maleate soln carbinoxamine maleate tabs clemastine fumarate tabs 2.68 mg diphenhydramine hcl soln Drug Requirements/ Tier Limits 1 AL; MO; * cyproheptadine hcl tabs Drug Requirements/ Tier Limits 1 AL; MO; * 1 AL; MO; * ANTIHYPERLIPIDEMICS - Drugs to Treat High Cholesterol 1 AL; MO; * 4 AL; MO; + Antihyperlipidemics - Combinations ezetimibe-simvastatin tabs 1 QL(8 ea daily); 10mg-10mg MO; * ezetimibe-simvastatin tabs 1 QL(4 ea daily); 10mg-20mg MO; * ezetimibe-simvastatin tabs 1 QL(2 ea daily); 40mg-10mg MO; * ezetimibe-simvastatin tabs 1 PA; QL(1 ea 80mg-10mg daily); MO; * VYTORIN TABS 10MGQL(8 ea daily); 2 MO; + 10MG (EzetimibeSimvastatin) VYTORIN TABS 10MGQL(4 ea daily); 2 MO; + 20MG (EzetimibeSimvastatin) VYTORIN TABS 40MGQL(2 ea daily); 2 MO; + 10MG (EzetimibeSimvastatin) VYTORIN TABS 80MGPA; QL(1 ea 2 daily); MO; + 10MG (EzetimibeSimvastatin) Antihistamines - Non-Sedating cetirizine hcl soln 1 RX/OTC; MO; * cetirizine hcl syrp 1 RX/OTC; MO; * CLARINEX TABS (Desloratadine) 3 MO; + desloratadine tabs 1 MO; * desloratadine tbdp 1 MO; * levocetirizine 1 dihydrochloride soln levocetirizine 1 dihydrochloride tabs XYZAL SOLN 3 (Levocetirizine Dihydrochloride) XYZAL TABS 3 (Levocetirizine Dihydrochloride) Antihistamines - Phenothiazines PHENERGAN SOLN 4 (Promethazine HCl) promethazine hcl soln ij 50 4 mg/ml, 25 mg/ml promethazine hcl soln or 1 6.25 mg/5ml promethazine hcl supp 1 12.5 mg, 25 mg RX/OTC; MO; * AL; MO; * promethazine hcl syrp 1 promethazine hcl tabs 1 RX/OTC; MO; * RX/OTC; MO; + RX/OTC; MO; + AL; MO; + 1 Antihyperlipidemics - Misc. KYNAMRO SOSY LOVAZA CAPS (Omega-3acid Ethyl Esters) omega-3-acid ethyl esters caps 5 PA; LA; + NF MO 1 MO; * 3 ST; MO; + cholestyramine light pack 1 MO; * AL; MO; * cholestyramine light powd 1 MO; * AL; MO; * cholestyramine pack 1 MO; * cholestyramine powd or 1 COLESTID FLAVORED GRAN (Colestipol HCl) 3 AL; MO; + VASCEPA CAPS AL; MO; * Antihistamines - Piperidines cyproheptadine hcl syrp Drug Name AL; MO; * Bile Acid Sequestrants Powder Canister;MO; * MO; + You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 30 Drug Name COLESTID FLAVORED PACK (Colestipol HCl) COLESTID GRAN (Colestipol HCl) COLESTID PACK (Colestipol HCl) COLESTID TABS (Colestipol HCl) Drug Requirements/ Tier Limits 3 MO; + Drug Name LOPID TABS (Gemfibrozil) Drug Requirements/ Tier Limits 3 MO; + 3 MO; + TRICOR TABS (Fenofibrate) 3 MO; + 3 MO; + TRIGLIDE TABS 3 MO; + 3 MO; + TRILIPIX CPDR (Choline Fenofibrate) 1 MO; * HMG CoA Reductase Inhibitors 1 MO; * 1 MO; * WELCHOL PACK WELCHOL TABS colestipol hcl gran colestipol hcl pack colestipol hcl tabs ALTOPREV TB24 3 MO; + atorvastatin calcium tabs 1 MO; * 3 CRESTOR TABS (Rosuvastatin Calcium) 3 MO; + MO; + MO; + fluvastatin sodium caps 1 MO; * 3 fluvastatin sodium tb24 1 MO; * 3 MO; + Fibric Acid Derivatives 1 SL(4.33 ea daily); MO; + SL(1.44 ea daily); MO; + MO; * LESCOL CAPS (Fluvastatin Sodium) LESCOL XL TB24 (Fluvastatin Sodium) LIPITOR TABS (Atorvastatin Calcium) 3 MO; + LIVALO TABS SL(1 ea daily); MO; * MO; * lovastatin tabs 40 mg, 20 mg, 10 mg PRAVACHOL TABS (Pravastatin Sodium) SL(3.02 ea daily); MO; * MO; * ANTARA CAPS 30 MG 3 ANTARA CAPS 90 MG 3 choline fenofibrate cpdr FENOFIBRATE CAPS fenofibrate micronized caps 130 mg fenofibrate micronized caps 200 mg, 67 mg, 134 mg fenofibrate micronized caps 43 mg fenofibrate tabs 120 mg, 54 mg, 145 mg, 160 mg, 40 mg, 48 mg NF MO 1 1 1 1 NF MO 3 MO; + 3 MO; + 1 MO; * 3 MO; + pravastatin sodium tabs 1 MO; * rosuvastatin calcium tabs 1 MO; * simvastatin tabs 10 mg 1 simvastatin tabs 20 mg 1 simvastatin tabs 40 mg 1 3 MO; + FENOGLIDE TABS (Fenofibrate) 3 MO; + FIBRICOR TABS 3 MO; + gemfibrozil tabs 1 MO; * simvastatin tabs 5 mg 1 LIPOFEN CAPS 3 MO; + simvastatin tabs 80 mg 1 ZOCOR TABS 10 MG (Simvastatin) 3 FENOFIBRIC ACID TABS SL(8 ea daily); MO; * SL(4 ea daily); MO; * SL(2 ea daily); MO; * SL(16 ea daily); MO; * SL(1 ea daily); MO; * SL(8 ea daily); MO; + You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 31 Drug Name ZOCOR TABS 20 MG (Simvastatin) ZOCOR TABS 40 MG (Simvastatin) ZOCOR TABS 5 MG (Simvastatin) ZOCOR TABS 80 MG (Simvastatin) Drug Requirements/ Tier Limits 3 SL(4 ea daily); MO; + 3 SL(2 ea daily); MO; + 3 SL(16 ea daily); MO; + 3 SL(1 ea daily); MO; + Intestinal Cholesterol Absorption Inhibitors 1 MO; * ezetimibe tabs ZETIA TABS (Ezetimibe) 2 MO; + Microsomal Triglyceride Transfer Protein (MTP) 5 PA; SL(6 ea JUXTAPID CAPS 10 MG daily); LA; + 5 PA; SL(3 ea JUXTAPID CAPS 20 MG daily); LA; + 5 PA; SL(2 ea JUXTAPID CAPS 30 MG daily); LA; + 5 PA; SL(1.5 ea JUXTAPID CAPS 40 MG daily); LA; + 5 PA; SL(12 ea JUXTAPID CAPS 5 MG daily); LA; + 5 PA; SL(1 ea JUXTAPID CAPS 60 MG daily); LA; + Nicotinic Acid Derivatives niacin (antihyperlipidemic) tbcr NIASPAN TBCR (Niacin (Antihyperlipidemic)) 1 MO; * NF MO Proprotein Convertase Subtilisin/Kexin Type 9 PA; Limit 2mls PRALUENT SOPN 150 5 per 28 MG/ML days;SL(0.08 ml daily); + PA; Limit 4mls PRALUENT SOPN 75 5 per 28 MG/ML days;SL(0.15 ml daily); + PA; Limit 2mls PRALUENT SOSY 150 5 per 28 MG/ML days;SL(0.08 ml daily); + Drug Requirements/ Tier Limits PA; Limit 4mls PRALUENT SOSY 75 5 per 28 MG/ML days;SL(0.15 ml daily); + REPATHA PUSHTRONEX 5 PA; + SYSTEM SOCT 5 PA; + REPATHA SOSY Drug Name REPATHA SURECLICK SOAJ 5 PA; + ANTIHYPERTENSIVES - Drugs to Treat High Blood Pressure ACE Inhibitors ACCUPRIL TABS (Quinapril HCl) 3 MO; + ALTACE CAPS (Ramipril) 3 MO; + benazepril hcl tabs 40 mg, 5 mg, 20 mg, 10 mg 1 MO; * captopril tabs 1 MO; * enalapril maleate tabs 10 mg enalapril maleate tabs 2.5 mg enalapril maleate tabs 20 mg enalapril maleate tabs 5 mg 1 fosinopril sodium tabs 1 SL(4 ea daily); MO; * SL(16 ea daily); MO; * SL(2 ea daily); MO; * SL(8 ea daily); MO; * MO; * lisinopril tabs 1 MO; * 3 MO; + 3 MO; + 1 MO; * LOTENSIN TABS (Benazepril HCl) MAVIK TABS 2 MG, 1 MG (Trandolapril) moexipril hcl tabs perindopril erbumine tabs 2 mg perindopril erbumine tabs 4 mg perindopril erbumine tabs 8 mg PRINIVIL TABS (Lisinopril) 1 1 1 1 1 1 3 SL(8 ea daily); MO; * SL(4 ea daily); MO; * SL(2 ea daily); MO; * MO; + You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 32 Drug Name quinapril hcl tabs ramipril caps trandolapril tabs 1 mg, 2 mg, 4 mg VASOTEC TABS 10 MG (Enalapril Maleate) VASOTEC TABS 2.5 MG (Enalapril Maleate) VASOTEC TABS 20 MG (Enalapril Maleate) VASOTEC TABS 5 MG (Enalapril Maleate) ZESTRIL TABS (Lisinopril) Drug Requirements/ Tier Limits 1 MO; * Drug Requirements/ Tier Limits olmesartan medoxomil tabs 1 MO; * Drug Name 1 MO; * telmisartan tabs 1 MO; * 1 MO; * valsartan tabs 1 MO; * SL(4 ea daily); MO; + SL(16 ea daily); MO; + SL(2 ea daily); MO; + SL(8 ea daily); MO; + MO; + Antiadrenergic Antihypertensives CARDURA TABS 3 (Doxazosin Mesylate) CATAPRES TABS 3 (Clonidine HCl) CATAPRES-TTS-1 PTWK 3 (Clonidine HCl) CATAPRES-TTS-2 PTWK 3 (Clonidine HCl) CATAPRES-TTS-3 PTWK 3 (Clonidine HCl) 3 3 3 3 3 Agents for Pheochromocytoma MO; + MO; + MO; + MO; + MO; + 5 MO; + clonidine hcl ptwk 1 MO; * 3 MO; + clonidine hcl tabs 1 MO; * 1 MO; * doxazosin mesylate tabs 1 MO; * Angiotensin II Receptor Antagonists ATACAND TABS NF MO (Candesartan Cilexetil) AVAPRO TABS 3 MO; + (Irbesartan) BENICAR TABS 2 MO; + (Olmesartan Medoxomil) 1 MO; * candesartan cilexetil tabs guanfacine hcl tabs 1 AL; MO; * methyldopa tabs 1 AL; MO; * MINIPRESS CAPS (Prazosin HCl) 3 MO; + prazosin hcl caps 1 MO; * TENEX TABS (Guanfacine HCl) 3 AL; MO; + COZAAR TABS (Losartan Potassium) terazosin hcl caps 1 MO; * DEMSER CAPS DIBENZYLINE CAPS (Phenoxybenzamine HCl) phenoxybenzamine hcl caps DIOVAN TABS (Valsartan) 3 MO; + NF MO EDARBI TABS 3 MO; + eprosartan mesylate tabs 1 MO; * irbesartan tabs 1 MO; * losartan potassium tabs 1 MO; * MICARDIS TABS (Telmisartan) NF MO Antihypertensive Combinations ACCURETIC TABS 3 (QuinaprilHydrochlorothiazide) amlodipine besylate1 benazepril hcl caps amlodipine besylateolmesartan medoxomil tabs 1 amlodipine besylate1 valsartan tabs amlodipine-valsartan1 hydrochlorothiazide tabs MO; + MO; * MO; * MO; * MO; * You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 33 Drug Name ATACAND HCT TABS (Candesartan CilexetilHydrochlorothiazide) atenolol & chlorthalidone tabs AVALIDE TABS (IrbesartanHydrochlorothiazide) AZOR TABS (Amlodipine Besylate-Olmesartan Medoxomil) benazepril & hydrochlorothiazide tabs BENICAR HCT TABS (Olmesartan MedoxomilHydrochlorothiazide) bisoprolol & hydrochlorothiazide tabs BYVALSON TABS candesartan cilexetilhydrochlorothiazide tabs captopril & hydrochlorothiazide tabs CORZIDE TABS (Nadolol & Bendroflumethiazide) DIOVAN HCT TABS (ValsartanHydrochlorothiazide) EDARBYCLOR TABS enalapril maleate & hydrochlorothiazide tabs EXFORGE HCT TABS (Amlodipine-ValsartanHydrochlorothiazide) EXFORGE TABS (Amlodipine BesylateValsartan) fosinopril sodium & hydrochlorothiazide tabs HYZAAR TABS (Losartan Potassium & Hydrochlorothiazide) irbesartanhydrochlorothiazide tabs Drug Requirements/ Tier Limits MO; + 3 1 MO; * MO; + 3 MO; + 2 1 MO; * MO; + 2 1 MO; * 3 MO; + 1 MO; * 1 MO; * 3 MO; + MO; + 3 3 MO; + 1 MO; * MO NF MO NF 1 MO; * MO; + 3 1 MO; * Drug Name lisinopril & hydrochlorothiazide tabs LOPRESSOR HCT TABS (Metoprolol & Hydrochlorothiazide) losartan potassium & hydrochlorothiazide tabs LOTENSIN HCT TABS (Benazepril & Hydrochlorothiazide) LOTREL CAPS (Amlodipine BesylateBenazepril HCl) metoprolol & hydrochlorothiazide tabs MICARDIS HCT TABS (TelmisartanHydrochlorothiazide) moexiprilhydrochlorothiazide tabs nadolol & bendroflumethiazide tabs olmesartan medoxomilamlodipinehydrochlorothiazide tabs olmesartan medoxomilhydrochlorothiazide tabs propranolol & hydrochlorothiazide tabs quinaprilhydrochlorothiazide tabs TARKA TBCR 4MG240MG, 2MG-240MG (Trandolapril-Verapamil HCl) Drug Requirements/ Tier Limits 1 MO; * MO; + 3 1 MO; * MO; + 3 MO; + 3 1 MO; * MO NF 1 MO; * 1 MO; * MO; * 1 1 MO; * 1 MO; * 1 MO; * MO; + 3 TEKTURNA HCT TABS 2 MO; + telmisartan-amlodipine tabs 1 MO; * 1 MO; * 3 MO; + 3 MO; + telmisartanhydrochlorothiazide tabs TENORETIC 100 TABS (Atenolol & Chlorthalidone) TENORETIC 50 TABS (Atenolol & Chlorthalidone) You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 34 Drug Name trandolapril-verapamil hcl tbcr 2mg-240mg, 4mg240mg TRIBENZOR TABS (Olmesartan MedoxomilAmlodipineHydrochlorothiazide) TWYNSTA TABS (Telmisartan-Amlodipine) valsartanhydrochlorothiazide tabs VASERETIC TABS (Enalapril Maleate & Hydrochlorothiazide) ZESTORETIC TABS (Lisinopril & Hydrochlorothiazide) ZIAC TABS (Bisoprolol & Hydrochlorothiazide) Direct Renin Inhibitors TEKTURNA TABS Drug Requirements/ Tier Limits MO; * 1 1 MO; * mefloquine hcl tabs 1 MO; * PLAQUENIL TABS (Hydroxychloroquine Sulfate) 3 MO; * primaquine phosphate tabs 1 MO; * MO; + QUALAQUIN CAPS (Quinine Sulfate) 2 PA; MO; + quinine sulfate caps 1 PA; MO; * 2 NF MO 3 MO; + 3 3 MO; + 2 MO; + 3 MO; + hydralazine hcl tabs 1 MO; * minoxidil tabs 1 MO; * ANTIMALARIALS - Drugs to Treat Malaria (Parasitic Infections) COARTEM TABS MALARONE TABS (Atovaquone-Proguanil HCl) Antimalarials chloroquine phosphate tabs Antimyasthenic/Cholinergic Agents 2 + GUANIDINE HCL TABS MESTINON TABS (Pyridostigmine Bromide) MESTINON TIMESPAN TBCR (Pyridostigmine Bromide) pyridostigmine bromide tabs pyridostigmine bromide tbcr Vasodilators Antimalarial Combinations atovaquone-proguanil hcl tabs MO; + ANTIMYASTHENIC/CHOLINERGIC AGENTS Selective Aldosterone Receptor Antagonists 1 MO; * eplerenone tabs INSPRA TABS (Eplerenone) DARAPRIM TABS Drug Requirements/ Tier Limits 3 + hydroxychloroquine sulfate tabs MO; + 1 Drug Name 3 MO; + MO NF 1 MO; * 1 MO; * ANTIMYCOBACTERIAL AGENTS - Drugs to Treat Tuberculosis (Bacterial Infections) Anti TB Combinations isoniazid & rifampin caps 1 MO; * RIFATER TABS 3 MO; + 1 MO; * Antimycobacterial Agents aminosalicylic acid pack 1 MO; * 3 MO; + MO; + CAPASTAT SULFATE SOLR 4 + ethambutol hcl tabs 1 MO; * isoniazid tabs 1 MO; * 3 1 MO; * MYAMBUTOL TABS 100 MG (Ethambutol HCl) NF MO You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 35 Drug Name MYAMBUTOL TABS 400 MG (Ethambutol HCl) MYCOBUTIN CAPS (Rifabutin) Drug Requirements/ Tier Limits 3 MO; + NF MO Drug Name ELOXATIN SOLN 50 MG/10ML (Oxaliplatin) Drug Requirements/ Tier Limits 5 + EVOMELA SOLR 5 + PRIFTIN TABS 3 MO; + GLEOSTINE CAPS 3 + pyrazinamide tabs 1 MO; * HEXALEN CAPS 5 MO; + rifabutin caps 1 MO; * IFEX SOLR 1 GM (Ifosfamide) 4 + IFEX SOLR 3 GM 4 + RIFADIN CAPS (Rifampin) NF MO; NT RIFADIN SOLR (Rifampin) 4 MO; + ifosfamide soln 4 + rifampin caps 1 MO; * ifosfamide solr 1 gm 4 + rifampin solr 4 MO; + IFOSFAMIDE SOLR 3 GM 4 + SIRTURO TABS 5 + LEUKERAN TABS 3 MO; + TRECATOR TABS 3 MO; + melphalan hcl solr 4 + MUSTARGEN SOLR 4 + oxaliplatin soln 100 mg/20ml 1 * oxaliplatin soln 50 mg/10ml 5 + oxaliplatin solr 5 + TEMODAR SOLR 5 + ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES - Drugs to Treat Cancer Alkylating Agents ALKERAN SOLR (Melphalan HCl) 4 + ALKERAN TABS 3 MO; B/D; + BENDEKA SOLN 5 + BICNU SOLR 4 + busulfan soln 4 + BUSULFEX SOLN (Busulfan) 4 + carboplatin soln 1 * 4 + 4 2 CISPLATIN SOLN 200 MG/200ML cisplatin soln 50 mg/50ml, 100 mg/100ml CYCLOPHOSPHAMIDE CAPS ELOXATIN SOLN 100 MG/20ML (Oxaliplatin) TEPADINA SOLR 15 MG (Thiotepa) NF NT thiotepa solr 5 + TREANDA SOLN 5 + TREANDA SOLR 5 + YONDELIS SOLR 5 LA; + + ZANOSAR SOLR 4 MO; + MO; B/D; + Antimetabolites ALIMTA SOLR 100 MG 5 + ALIMTA SOLR 500 MG 5 MO; + NF You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 36 Drug Name ARRANON SOLN Drug Requirements/ Tier Limits 5 + Drug Name PURIXAN SUSP Drug Requirements/ Tier Limits 5 PA; + azacitidine susr 5 + TABLOID TABS 2 MO; + cladribine soln 4 PA; + VIDAZA SUSR (Azacitidine) 5 + clofarabine soln 4 + CLOLAR SOLN (Clofarabine) 4 + Antineoplastic - Angiogenesis Inhibitors 5 + AVASTIN SOLN 4 PA; + CYRAMZA SOLN 5 LA; + cytarabine soln ZALTRAP SOLN 5 + ARZERRA CONC 5 + BAVENCIO SOLN 5 + BLINCYTO SOLR 5 + CAMPATH SOLN 5 + DARZALEX SOLN 5 LA; + EMPLICITI SOLR 5 + ERBITUX SOLN 5 + GAZYVA SOLN 5 LA; + HERCEPTIN SOLR 5 + DACOGEN SOLR (Decitabine) NF decitabine solr 1 * fludarabine phosphate solr 1 * 4 + 4 PA; + FOLOTYN SOLN 5 + gemcitabine hcl soln 5 + 1 * 5 + fluorouracil soln 1 gm/20ml, 5 gm/100ml fluorouracil soln 500 mg/10ml, 2.5 gm/50ml gemcitabine hcl solr 2 gm, 1 gm gemcitabine hcl solr 200 mg GEMZAR SOLR 1 GM (Gemcitabine HCl) GEMZAR SOLR 200 MG (Gemcitabine HCl) mercaptopurine tabs methotrexate sodium soln 200 mg/8ml, 50 mg/2ml, 250 mg/10ml, 100 mg/4ml, 1 gm/40ml METHOTREXATE SODIUM SOLN 250 MG/10ML NF Antineoplastic - Antibodies 5 + IMFINZI SOLN 5 + 1 MO; * KADCYLA SOLR 5 + + KEYTRUDA SOLN 5 + KEYTRUDA SOLR 5 + LARTRUVO SOLN 5 LA; + OPDIVO SOLN 5 + PERJETA SOLN 5 + PORTRAZZA SOLN 5 + 4 + 4 methotrexate sodium solr 4 + methotrexate sodium tabs 1 MO; * You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 37 Drug Name RITUXAN SOLN Drug Requirements/ Tier Limits 5 + TECENTRIQ SOLN 5 + VECTIBIX SOLN 5 + YERVOY SOLN 5 + Antineoplastic - BCL-2 Inhibitors VENCLEXTA STARTING 3 PACK TBPK PA; LA; + VENCLEXTA TABS PA; LA; + 3 Antineoplastic - Hedgehog Pathway Inhibitors 5 LA; + ERIVEDGE CAPS ODOMZO CAPS 5 LA; + Antineoplastic - Hormonal and Related Agents 1 MO; * anastrozole tabs ARIMIDEX TABS (Anastrozole) AROMASIN TABS (Exemestane) bicalutamide tabs CASODEX TABS (Bicalutamide) NF MO NF MO 1 MO; * NF MO DEPO-PROVERA SUSP 4 MO; + ELIGARD KIT 4 + EMCYT CAPS 3 MO; + exemestane tabs 1 MO; * FARESTON TABS 5 MO; + FASLODEX SOLN 5 + FEMARA TABS (Letrozole) NF MO FIRMAGON SOLR 120 MG 5 + FIRMAGON SOLR 80 MG 4 + Drug Name flutamide caps Drug Requirements/ Tier Limits 1 MO; * HYDROXYPROGESTERO NE CAPROATE SOLN 5 + letrozole tabs 1 MO; * leuprolide acetate kit 4 + 4 + 5 + 5 + 5 + 5 + 2 MO; + LUPRON DEPOT (1MONTH) KIT 3.75 MG LUPRON DEPOT (1MONTH) KIT 7.5 MG LUPRON DEPOT (3MONTH) KIT LUPRON DEPOT (4MONTH) KIT LUPRON DEPOT (6MONTH) KIT LYSODREN TABS MEGACE ORAL SUSP (Megestrol Acetate) NF AL; MO megestrol acetate susp 1 AL; MO; * megestrol acetate tabs 1 AL; MO; * NILANDRON TABS (Nilutamide) 5 MO; + nilutamide tabs 1 MO; * SOLTAMOX SOLN 3 MO; + tamoxifen citrate tabs 1 MO; * 5 + 4 + TRELSTAR SUSR 4 + VANTAS KIT 5 + XTANDI CAPS 5 PA; LA; + ZOLADEX IMPL 3 + ZYTIGA TABS 5 + TRELSTAR MIXJECT SUSR 22.5 MG TRELSTAR MIXJECT SUSR 3.75 MG, 11.25 MG You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 38 Drug Name Drug Requirements/ Tier Limits Antineoplastic - Immunomodulators 5 LA; + POMALYST CAPS Antineoplastic Antibiotics bleomycin sulfate solr 15 unit bleomycin sulfate solr 30 unit 4 + 4 PA; + COSMEGEN SOLR 4 + daunorubicin hcl inj 4 + DOXIL INJ (Doxorubicin HCl Liposomal) doxorubicin hcl liposomal inj NF Drug Name BELEODAQ SOLR Drug Requirements/ Tier Limits 5 + BOSULIF TABS 5 PA; + CABOMETYX TABS 5 PA; + CAPRELSA TABS 5 LA; + COMETRIQ KIT 5 LA; + COTELLIC TABS 5 LA; + FARYDAK CAPS 5 PA; LA; + GILOTRIF TABS 5 LA; + GLEEVEC TABS 400 MG 2 + GLEEVEC TABS 400 MG, 100 MG (Imatinib Mesylate) 2 + IBRANCE CAPS 5 LA; + ICLUSIG TABS 5 LA; + imatinib mesylate tabs 1 * IMBRUVICA CAPS 5 PA; LA; + 1 * 4 + 4 + 4 + epirubicin hcl soln 4 + IDAMYCIN PFS SOLN (Idarubicin HCl) 4 + idarubicin hcl soln 4 + INLYTA TABS 5 PA; LA; + mitomycin solr 20 mg, 40 mg 4 MO; + IRESSA TABS 5 LA; MO; + MITOMYCIN SOLR 5 MG 4 MO; + ISTODAX (OVERFILL) SOLR 5 + mitoxantrone hcl conc 1 * ISTODAX SOLR 5 + VALSTAR SOLN 5 + JAKAFI TABS 5 LA; + KYPROLIS SOLR 5 + 5 PA; + 5 PA; + 5 PA; + 5 PA; + doxorubicin hcl soln DOXORUBICIN HCL SOLR ELLENCE SOLN (Epirubicin HCl) Antineoplastic Combinations LONSURF TABS 5 PA; + Antineoplastic Enzyme Inhibitors AFINITOR DISPERZ TBSO 5 + AFINITOR TABS 5 + ALECENSA CAPS 5 PA; LA; + LENVIMA 10 MG DAILY DOSE CPPK LENVIMA 14 MG DAILY DOSE CPPK LENVIMA 18 MG DAILY DOSE CPPK LENVIMA 20 MG DAILY DOSE CPPK You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 39 Drug Name LENVIMA 24 MG DAILY DOSE CPPK LENVIMA 8 MG DAILY DOSE CPPK Drug Requirements/ Tier Limits 5 PA; + 5 PA; + 5 PA; LA; + 5 + NEXAVAR TABS NINLARO CAPS Drug Name ONCASPAR SOLN Drug Requirements/ Tier Limits 5 + Antineoplastics Misc. ACTIMMUNE SOLN 5 LA; + bexarotene caps 5 + 5 DACARBAZINE SOLR 100 MG 4 + LA; + PA; + dacarbazine solr 200 mg 4 + 5 RUBRACA TABS 5 PA; LA; + HYDREA CAPS (Hydroxyurea) SPRYCEL TABS 5 + hydroxyurea caps STIVARGA TABS 5 PA; LA; + SUTENT CAPS 5 + TAFINLAR CAPS 5 + TAGRISSO TABS 5 TARCEVA TABS LYNPARZA CAPS MEKINIST TABS NF MO 1 MO; * 5 + 4 + INTRON A SOLR 5 + LA; + INTRON A W/DILUENT SOLR 5 + 2 + MATULANE CAPS 5 LA; + TASIGNA CAPS 5 + NIPENT SOLR 4 + TORISEL SOLN 5 + PROLEUKIN SOLR 5 + TYKERB TABS 5 + SYLATRON KIT 5 + VELCADE SOLR 5 + SYNRIBO SOLR 5 + VOTRIENT TABS 5 + TARGRETIN CAPS (Bexarotene) 5 + XALKORI CAPS 5 + THERACYS SUSR 5 + ZELBORAF TABS 5 LA; + TICE BCG SUSR 5 + ZOLINZA CAPS 5 + 5 MO; + ZYDELIG TABS 5 PA; LA; + tretinoin (chemotherapy) caps TRISENOX SOLN 4 + ZYKADIA CAPS 5 PA; LA; + UVADEX SOLN 4 + 5 + 5 + Antineoplastic Enzymes ERWINAZE SOLR INTRON A SOLN 10 MU/ML INTRON A SOLN 6000000 UNIT/ML Chemotherapy Adjuncts ELITEK SOLR You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 40 Drug Name KEPIVANCE SOLR Drug Requirements/ Tier Limits 5 + Chemotherapy Rescue/Antidote Agents 1 MO; * amifostine solr dexrazoxane solr 500 mg, 250 mg ETHYOL SOLR (Amifostine) FUSILEV SOLR (Levoleucovorin Calcium) leucovorin calcium solr 350 mg, 100 mg leucovorin calcium solr 50 mg, 200 mg LEUCOVORIN CALCIUM SOLR 500 MG 4 NF MO; NT + 4 MO; + 4 + 4 + leucovorin calcium tabs 1 MO; * levoleucovorin calcium soln 5 + levoleucovorin calcium solr 4 + LEVOLEUCOVORIN SOLN 5 + LEVOLEUCOVORIN SOLR 5 + mesna soln 4 MO; + MESNEX SOLN (Mesna) 4 MO; + MESNEX TABS 5 MO; + ZINECARD SOLR (Dexrazoxane) 4 + Mitotic Inhibitors DOCETAXEL CONC 80 MG/4ML, 140 MG/7ML, 20 MG/ML docetaxel conc 80 mg/4ml, 20 mg/ml DOCETAXEL SOLN 80 MG/8ML, 160 MG/16ML, 20 MG/2ML 5 etoposide soln 4 + HALAVEN SOLN 5 + IXEMPRA KIT SOLR 5 + JEVTANA SOLN 5 + MARQIBO SUSP 5 + 4 MO; + 4 + 4 + 4 MO; + NAVELBINE SOLN (Vinorelbine Tartrate) paclitaxel conc 100 mg/16.7ml PACLITAXEL CONC 150 MG/25ML paclitaxel conc 30 mg/5ml, 300 mg/50ml TAXOL CONC (Paclitaxel) TAXOTERE CONC (Docetaxel) VINBLASTINE SULFATE SOLN NF MO; NT 5 + 4 PA; MO; + vincristine sulfate soln 4 PA; MO; + vinorelbine tartrate soln 4 MO; + Topoisomerase I Inhibitors CAMPTOSAR SOLN 40 MG/2ML, 100 MG/5ML (Irinotecan HCl) HYCAMTIN SOLR (Topotecan HCl) NF 5 MO; + MO; + irinotecan hcl soln 1 * + ONIVYDE INJ 5 + topotecan hcl solr 5 MO; + 5 5 ETOPOPHOS SOLR Drug Requirements/ Tier Limits 4 + + 4 ABRAXANE SUSR Drug Name + + 5 ANTIPARKINSON AGENTS - Drugs to Treat Parkinson's Disease Antiparkinson Adjuvants carbidopa tabs 1 MO; * You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 41 Drug Name LODOSYN TABS (Carbidopa) Drug Requirements/ Tier Limits NF MO Drug Name benztropine mesylate soln 4 MO; + benztropine mesylate tabs 1 AL; MO; * COGENTIN SOLN (Benztropine Mesylate) 4 MO; + trihexyphenidyl hcl elix 1 AL; MO; * MIRAPEX ER TB24 3 MG, 0.375 MG, 2.25 MG, 1.5 MG, 4.5 MG, 0.75 MG (Pramipexole Dihydrochloride) MIRAPEX ER TB24 3.75 MG (Pramipexole Dihydrochloride) MIRAPEX TABS (Pramipexole Dihydrochloride) trihexyphenidyl hcl tabs 1 AL; MO; * NEUPRO PT24 Antiparkinson Anticholinergics Drug Requirements/ Tier Limits MO NF MO; + 3 MO NF 3 MO; + 1 MO; * amantadine hcl syrp 1 MO; * amantadine hcl tabs 1 MO; * PARLODEL CAPS (Bromocriptine Mesylate) PARLODEL TABS (Bromocriptine Mesylate) pramipexole dihydrochloride tabs pramipexole dihydrochloride tb24 REQUIP TABS (Ropinirole Hydrochloride) REQUIP XL TB24 (Ropinirole Hydrochloride) ropinirole hydrochloride tabs ropinirole hydrochloride tb24 APOKYN SOCT 5 LA; + RYTARY CPCR 1 MO; * 1 MO; * SINEMET CR TBCR (Carbidopa-Levodopa) SINEMET TABS (Carbidopa-Levodopa) carbidopa-levodopa tabs 1 MO; * STALEVO 100 TABS 3 MO; + carbidopa-levodopa tbcr 1 MO; * STALEVO 125 TABS 3 MO; + carbidopa-levodopa tbdp 1 MO; * STALEVO 150 TABS 3 MO; + CARBIDOPA/LEVODOPA/ ENTACAPONE TABS MO; + STALEVO 200 TABS 3 MO; + 3 3 B/D; + STALEVO 50 TABS 3 MO; + DUOPA SUSP STALEVO 75 TABS 3 MO; + Antiparkinson COMT Inhibitors COMTAN TABS NF SL(8 ea daily); (Entacapone) MO 1 SL(8 ea daily); entacapone tabs MO; * TASMAR TABS 2 MO; + (Tolcapone) 1 MO; * tolcapone tabs Antiparkinson Dopaminergics amantadine hcl caps bromocriptine mesylate caps bromocriptine mesylate tabs NF MO NF MO 1 MO; * 1 MO; * NF MO NF MO 1 MO; * 1 MO; * 3 MO; + NF MO NF MO You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 42 Drug Name Drug Requirements/ Tier Limits Antiparkinson Monoamine Oxidase Inhibitors AZILECT TABS (Rasagiline 2 MO; + Mesylate) ELDEPRYL CAPS NF MO (Selegiline HCl) 1 MO; * rasagiline mesylate tabs selegiline hcl caps selegiline hcl tabs ZELAPAR TBDP 1 MO; * 1 MO; * 3 MO; + ANTIPSYCHOTICS/ANTIMANIC AGENTS Drugs to Treat Mood Disorders Antimanic Agents lithium carbonate caps 300 mg, 150 mg, 600 mg LITHIUM CARBONATE CAPS 600 MG (Lithium Carbonate) 1 MO; * MO NF lithium carbonate tabs 1 MO; * lithium carbonate tbcr 1 MO; * LITHIUM SOLN 2 MO; + LITHOBID TBCR (Lithium Carbonate) NF MO Antipsychotics - Misc. EQUETRO CP12 GEODON CAPS (Ziprasidone HCl) 3 MO; + NF MO GEODON SOLR 4 LATUDA TABS 120 MG 5 LATUDA TABS 20 MG 5 LATUDA TABS 40 MG 5 LATUDA TABS 60 MG 5 LATUDA TABS 80 MG 5 MO; + SL(1.33 ea daily); MO; + SL(8 ea daily); MO; + SL(4 ea daily); MO; + SL(2.67 ea daily); MO; + SL(2 ea daily); MO; + Drug Name NUPLAZID TABS Drug Requirements/ Tier Limits 5 PA; LA; + VRAYLAR CAPS 1.5 MG 3 VRAYLAR CAPS 3 MG 3 VRAYLAR CAPS 4.5 MG 3 VRAYLAR CAPS 6 MG 3 VRAYLAR CPPK 3 PA; SL(4 ea daily); MO; + PA; SL(2 ea daily); MO; + PA; SL(1.4 ea daily); MO; + PA; SL(1 ea daily); MO; + PA; MO; + ziprasidone hcl caps 1 MO; * 3 MO; + 5 MO; + 3 + 4 MO; + Benzisoxazoles FANAPT TABS 2 MG, 1 MG, 4 MG, 10 MG FANAPT TABS 6 MG, 12 MG, 8 MG FANAPT TITRATION PACK TABS INVEGA SUSTENNA SUSP INVEGA TB24 1.5 MG (Paliperidone) INVEGA TB24 3 MG (Paliperidone) INVEGA TB24 6 MG (Paliperidone) INVEGA TB24 9 MG (Paliperidone) 5 5 5 5 INVEGA TRINZA SUSP 4 paliperidone tb24 1.5 mg 5 paliperidone tb24 3 mg 5 paliperidone tb24 6 mg 5 paliperidone tb24 9 mg 5 RISPERDAL CONSTA SUSR 12.5 MG 4 SL(8 ea daily); MO; + SL(4 ea daily); MO; + SL(2 ea daily); MO; + SL(1.33 ea daily); MO; + + SL(8 ea daily); MO; + SL(4 ea daily); MO; + SL(2 ea daily); MO; + SL(1.33 ea daily); MO; + Limit 8 vials per 28 days;SL(0.29 ea daily); MO; + You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 43 Drug Requirements/ Tier Limits Limit 4 vials per 28 RISPERDAL CONSTA 4 days;SL(0.15 SUSR 25 MG ea daily); MO; + Limit 4 vials per RISPERDAL CONSTA 5 42 days;SL(0.1 SUSR 37.5 MG ea daily); MO; + Limit 2 vials per 28 RISPERDAL CONSTA 5 days;SL(0.08 SUSR 50 MG ea daily); MO; + RISPERDAL M-TAB TBDP NF MO (Risperidone) RISPERDAL SOLN NF MO (Risperidone) RISPERDAL TABS NF MO (Risperidone) 1 MO; * risperidone soln Drug Name Drug Name CLOZAPINE ODT TBDP 200 MG Drug Requirements/ Tier Limits 5 + clozapine tabs 1 * clozapine tbdp 1 * CLOZARIL TABS (Clozapine) FAZACLO TBDP 100 MG, 25 MG (Clozapine) FAZACLO TBDP 150 MG, 12.5 MG NF NF 3 + FAZACLO TBDP 200 MG 5 + loxapine succinate caps 1 MO; * olanzapine solr 1 MO; * olanzapine tabs 1 MO; * olanzapine tbdp 1 MO; * risperidone tabs 1 MO; * quetiapine fumarate tabs 1 MO; * risperidone tbdp 1 MO; * quetiapine fumarate tb24 1 PA; MO; * SAPHRIS SUBL 10 MG 5 SAPHRIS SUBL 2.5 MG 3 SAPHRIS SUBL 5 MG 3 Butyrophenones HALDOL DECANOATE 100 SOLN (Haloperidol Decanoate) HALDOL DECANOATE 50 SOLN (Haloperidol Decanoate) HALDOL SOLN (Haloperidol Lactate) MO NF MO NF NF MO haloperidol decanoate soln 1 MO; * haloperidol lactate conc 1 MO; * haloperidol lactate soln haloperidol tabs Dibenzapines CLOZAPINE ODT TBDP 150 MG, 12.5 MG 1 MO; * 1 MO; * 3 + SEROQUEL TABS 100 MG, 200 MG, 50 MG, 25 MG (Quetiapine Fumarate) SEROQUEL TABS 400 MG, 300 MG (Quetiapine Fumarate) SEROQUEL XR TB24 400 MG (Quetiapine Fumarate) SEROQUEL XR TB24 50 MG, 150 MG, 300 MG, 200 MG (Quetiapine Fumarate) SL(2 ea daily); MO; + SL(8 ea daily); MO; + SL(4 ea daily); MO; + MO NF MO; + 3 5 PA; MO; + PA; MO; + 3 VERSACLOZ SUSP 5 ZYPREXA RELPREVV SUSR 210 MG 4 PA; SL(18 ml daily); + + You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 44 Drug Name ZYPREXA SOLR (Olanzapine) ZYPREXA TABS 15 MG, 20 MG (Olanzapine) ZYPREXA TABS 5 MG, 7.5 MG, 2.5 MG, 10 MG (Olanzapine) ZYPREXA ZYDIS TBDP (Olanzapine) Drug Requirements/ Tier Limits NF MO 5 MO; + MO NF NF MO Dihydroindolones Drug Name ABILIFY TABS 10 MG (Aripiprazole) ABILIFY TABS 15 MG (Aripiprazole) ABILIFY TABS 2 MG (Aripiprazole) ABILIFY TABS 20 MG (Aripiprazole) ABILIFY TABS 30 MG (Aripiprazole) ABILIFY TABS 5 MG (Aripiprazole) Drug Requirements/ Tier Limits 5 SL(3 ea daily); MO; + 5 SL(2 ea daily); MO; + 5 SL(15 ea daily); MO; + 5 SL(1.5 ea daily); MO; + 5 SL(1 ea daily); MO; + 5 SL(6 ea daily); MO; + 1 SL(30 ml daily); MO; * 1 SL(3 ea daily); MO; * 1 SL(2 ea daily); MO; * 1 SL(15 ea daily); MO; * 5 SL(1.5 ea daily); MO; + 5 SL(1 ea daily); MO; + 1 SL(6 ea daily); MO; * 5 SL(3 ea daily); MO; + 5 SL(2 ea daily); MO; + 5 + 1 MO; * 4 MO; + 4 + 1 MO; * 4 MO; + 1 MO; * FLUPHENAZINE HCL SOLN 4 MO; + fluphenazine hcl tabs 1 MO; * perphenazine tabs 1 MO; * aripiprazole tbdp 10 mg 4 MO; + aripiprazole tbdp 15 mg 1 MO; * ARISTADA PRSY prochlorperazine supp 1 MO; * REXULTI TABS 0.25 MG 5 thioridazine hcl tabs 1 AL; MO; * REXULTI TABS 0.5 MG 5 trifluoperazine hcl tabs 1 MO; * REXULTI TABS 1 MG 5 REXULTI TABS 2 MG 5 SL(3 ea daily); MO; + MO; + REXULTI TABS 3 MG 5 REXULTI TABS 4 MG 5 SL(4 ml daily); MO; + Thioxanthenes molindone hcl tabs Phenothiazines CHLORPROMAZINE HCL SOLN 25 MG/ML chlorpromazine hcl soln 50 mg/2ml chlorpromazine hcl tabs fluphenazine decanoate soln fluphenazine hcl conc prochlorperazine edisylate soln prochlorperazine maleate tabs aripiprazole soln aripiprazole tabs 10 mg aripiprazole tabs 15 mg Quinolinone Derivatives ABILIFY DISCMELT TBDP 5 ABILIFY MAINTENA SUSR 5 ABILIFY SOLN 4 aripiprazole tabs 2 mg aripiprazole tabs 20 mg aripiprazole tabs 30 mg aripiprazole tabs 5 mg PA; SL(16 ea daily); MO; + PA; SL(8 ea daily); MO; + PA; SL(4 ea daily); MO; + PA; SL(2 ea daily); MO; + PA; SL(1.33 ea daily); MO; + PA; SL(1 ea daily); MO; + You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 45 Drug Name thiothixene caps Drug Requirements/ Tier Limits 1 MO; * Drug Name INTELENCE TABS 200 MG Drug Requirements/ Tier Limits 5 MO; + ANTIVIRALS - Drugs to Treat Viral Infections INTELENCE TABS 25 MG 3 + Antiretrovirals INVIRASE CAPS 5 MO; + INVIRASE TABS 5 MO; + ISENTRESS CHEW 100 MG 2 ISENTRESS CHEW 25 MG 2 ISENTRESS PACK 3 ISENTRESS TABS 5 SL(6 ea daily); MO; + SL(24 ea daily); MO; + SL(2 ea daily); + MO; + 2 MO; + 3 MO; + 2 MO; + 1 MO; * 5 MO; + 5 MO; + 2 MO; + APTIVUS SOLN 2 + ATRIPLA TABS 2 MO; + 5 MO; + 5 MO; + 3 MO; + KALETRA SOLN (Lopinavir-Ritonavir) KALETRA TABS 100MG25MG KALETRA TABS 200MG50MG 5 lamivudine soln 1 MO; * DESCOVY TABS MO; + 1 MO; * lamivudine tabs 1 MO; * didanosine cpdr 5 MO; + lamivudine-zidovudine tabs 1 MO; * EDURANT TABS LEXIVA SUSP 2 MO; + 3 MO; + 3 LEXIVA TABS 5 MO; + EMTRIVA SOLN MO; + EPIVIR SOLN (Lamivudine) MO; + lopinavir-ritonavir soln 1 MO; * 2 NEVIRAPINE SUSP 2 MO; + nevirapine tabs 1 MO; * nevirapine tb24 1 MO; * NORVIR CAPS 2 + NORVIR SOLN 2 MO; + NORVIR TABS 2 MO; + ODEFSEY TABS 5 MO; + abacavir sulfate tabs abacavir sulfate-lamivudine tabs abacavir sulfatelamivudine-zidovudine tabs APTIVUS CAPS COMBIVIR TABS (Lamivudine-Zidovudine) COMPLERA TABS CRIXIVAN CAPS EMTRIVA CAPS EPIVIR TABS (Lamivudine) NF MO EPZICOM TABS (Abacavir Sulfate-Lamivudine) 5 EVOTAZ TABS 5 MO; + 5 + 5 MO; + FUZEON SOLR GENVOYA TABS INTELENCE TABS 100 MG 2 MO; + MO; + You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 46 Drug Name Drug Requirements/ Tier Limits 5 MO; + Drug Name Drug Requirements/ Tier Limits 3 MO; + PREZISTA SUSP 5 MO; + PREZISTA TABS 5 MO; + VIDEX EC CPDR 125 MG (Didanosine) VIDEX EC CPDR 400 MG, 250 MG, 200 MG (Didanosine) VIDEXPEDIATRIC SOLR 3 MO; + 2 MO; + VIRACEPT TABS 5 MO; + 3 MO; + VIRAMUNE SUSP 2 MO; + PREZCOBIX TABS RESCRIPTOR TABS 100 MG RESCRIPTOR TABS 200 MG RETROVIR CAPS (Zidovudine) RETROVIR IV INFUSION SOLN RETROVIR SYRP (Zidovudine) NF MO 4 + NF MO 5 MO; + 5 MO; + 2 MO; + 2 + stavudine caps 1 MO; * STRIBILD TABS 5 MO; + SUSTIVA CAPS 3 MO; + SUSTIVA TABS 5 MO; + TIVICAY TABS 10 MG 3 MO; + TIVICAY TABS 50 MG, 25 MG 5 MO; + TRIUMEQ TABS 5 MO; + MO; + REYATAZ CAPS REYATAZ PACK SELZENTRY TABS 300 MG, 150 MG SELZENTRY TABS 75 MG, 25 MG TRIZIVIR TABS (Abacavir Sulfate-LamivudineZidovudine) TRUVADA TABS 200MG133MG, 250MG-167MG, 150MG-100MG TRUVADA TABS 300MG200MG TYBOST TABS VIRAMUNE TABS (Nevirapine) VIRAMUNE XR TB24 100 MG (Nevirapine) VIRAMUNE XR TB24 400 MG (Nevirapine) MO NF NF MO 3 MO; + 5 MO; + VIREAD POWD 5 MO; + VIREAD TABS 5 MO; + ZERIT CAPS (Stavudine) NF MO ZERIT SOLR 3 MO; + ZIAGEN SOLN 2 MO; + ZIAGEN TABS (Abacavir Sulfate) NF MO zidovudine caps 1 MO; * zidovudine syrp 1 MO; * zidovudine tabs 1 MO; * cidofovir soln 5 + CYTOVENE SOLR (Ganciclovir Sodium) 4 PA; MO; + ganciclovir sodium solr 1 PA; MO; * 5 MO; + 5 MO; + 5 MO; + CMV Agents 5 MO; + 5 2 MO; + 3 MO; + VALCYTE SOLR (Valganciclovir HCl) VALCYTE TABS (Valganciclovir HCl) valganciclovir hcl solr You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 47 Drug Name valganciclovir hcl tabs VISTIDE SOLN (Cidofovir) Drug Requirements/ Tier Limits 5 MO; + 5 + Hepatitis Agents Drug Name ribavirin (hepatitis c) caps Drug Requirements/ Tier Limits 1 * ribavirin (hepatitis c) tabs 1 * SOVALDI TABS 5 PA; + TECHNIVIE TABS 5 PA; + TYZEKA TABS 5 + VEMLIDY TABS 5 ST; MO; + VICTRELIS CAPS 5 PA; + VIEKIRA PAK TBPK 5 PA; + ZEPATIER TABS 5 PA; + adefovir dipivoxil tabs 5 MO; + BARACLUDE SOLN 2 MO; + 2 MO; + 3 + DAKLINZA TABS 5 PA; + entecavir tabs 1 MO; * EPCLUSA TABS 5 PA; + Herpes Agents EPIVIR HBV SOLN 2 MO; + acyclovir caps 1 MO; * acyclovir sodium soln 4 PA; + BARACLUDE TABS (Entecavir) COPEGUS TABS (Ribavirin (Hepatitis C)) EPIVIR HBV TABS (Lamivudine (HBV)) NF MO 5 PA; + ACYCLOVIR SODIUM SOLR 4 MO; + HARVONI TABS HEPSERA TABS (Adefovir Dipivoxil) 5 MO; + acyclovir susp 1 MO; * 1 MO; * acyclovir tabs 1 MO; * lamivudine (hbv) tabs 5 PA; + famciclovir tabs 1 MO; * OLYSIO CAPS 5 + FAMVIR TABS (Famciclovir) 3 MO; + PEG-INTRON KIT 5 + valacyclovir hcl tabs 1 MO; * + 3 3 MO; + 5 + 5 + 3 MO; + PEGASYS SOLN VALTREX TABS (Valacyclovir HCl) ZOVIRAX CAPS (Acyclovir) ZOVIRAX SUSP (Acyclovir) MO; + 5 PEGINTRON KIT 5 + ZOVIRAX TABS (Acyclovir) 3 MO; + REBETOL CAPS (Ribavirin (Hepatitis C)) 3 + 2 + Influenza Agents FLUMADINE TABS (Rimantadine Hydrochloride) PEG-INTRON REDIPEN KIT PEG-INTRON REDIPEN PAK 4 KIT PEGASYS PROCLICK SOLN REBETOL SOLN MO; + 3 You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 48 Drug Requirements/ Tier Limits 1 MO; * oseltamivir phosphate caps Drug Name RELENZA DISKHALER AEPB rimantadine hydrochloride tabs TAMIFLU CAPS 45 MG, 30 MG (Oseltamivir Phosphate) TAMIFLU CAPS 75 MG (Oseltamivir Phosphate) TAMIFLU SUSR MO; + bisoprolol fumarate tabs 1 MO; * 1 MO; * BYSTOLIC TABS 3 MO; + MO; + LOPRESSOR TABS (Metoprolol Tartrate) 3 MO; + metoprolol succinate tb24 1 MO; * 1 MO; * 3 2 MO; + 3 MO; + 3 + BETA BLOCKERS - Drugs to Treat High Blood Pressure Alpha-Beta Blockers carvedilol tabs 12.5 mg 1 carvedilol tabs 25 mg 1 carvedilol tabs 3.125 mg 1 carvedilol tabs 6.25 mg 1 COREG CR CP24 3 COREG TABS 12.5 MG (Carvedilol) COREG TABS 25 MG (Carvedilol) COREG TABS 3.125 MG (Carvedilol) COREG TABS 6.25 MG (Carvedilol) labetalol hcl tabs betaxolol hcl tabs Drug Requirements/ Tier Limits 1 MO; * 3 Respiratory Syncytial Virus (RSV) Agents 1 * ribavirin solr VIRAZOLE SOLR (Ribavirin) Drug Name 3 3 3 3 1 SL(8 ea daily); MO; * SL(4 ea daily); MO; * SL(32 ea daily); MO; * SL(16 ea daily); MO; * MO; + SL(8 ea daily); MO; + SL(4 ea daily); MO; + SL(32 ea daily); MO; + SL(16 ea daily); MO; + MO; * Beta Blockers Cardio-Selective acebutolol hcl caps 1 MO; * atenolol tabs 1 MO; * metoprolol tartrate tabs 25 mg, 100 mg, 50 mg METOPROLOL TARTRATE TABS 75 MG, 37.5 MG SECTRAL CAPS (Acebutolol HCl) TENORMIN TABS (Atenolol) TOPROL XL TB24 (Metoprolol Succinate) ZEBETA TABS 10 MG (Bisoprolol Fumarate) ZEBETA TABS 5 MG (Bisoprolol Fumarate) Beta Blockers Non-Selective BETAPACE AF TABS (Sotalol HCl (AFIB/AFL)) BETAPACE TABS (Sotalol HCl) CORGARD TABS (Nadolol) MO; + 3 3 MO; + 3 MO; + 3 MO; + NF MO NF MO; NT 3 MO; + 3 tabs;MO; + 3 MO; + HEMANGEOL SOLN 3 AL; + INDERAL LA CP24 (Propranolol HCl) 3 MO; + nadolol tabs 1 MO; * pindolol tabs 1 MO; * propranolol hcl cp24 1 MO; * propranolol hcl soln or 40 mg/5ml, 20 mg/5ml 1 MO; * propranolol hcl tabs 1 MO; * You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 49 Drug Name sotalol hcl (afib/afl) tabs Sotalol Hcl IV Soln Drug Requirements/ Tier Limits 1 MO; * NF sotalol hcl tabs 1 tabs;MO; * SOTYLIZE SOLN 3 MO; + timolol maleate tabs 10 mg 1 timolol maleate tabs 20 mg 1 timolol maleate tabs 5 mg 1 SL(6 ea daily); MO; * SL(3 ea daily); MO; * SL(12 ea daily); MO; * CALCIUM CHANNEL BLOCKERS - Drugs to Treat High Blood Pressure Calcium Channel Blockers ADALAT CC TB24 (Nifedipine) amlodipine besylate tabs 10 mg amlodipine besylate tabs 2.5 mg amlodipine besylate tabs 5 mg CALAN SR TBCR (Verapamil HCl) CALAN TABS (Verapamil HCl) CARDIZEM CD CP24 (Diltiazem HCl Coated Beads) CARDIZEM LA TB24 120 MG CARDIZEM LA TB24 180 MG, 360 MG, 240 MG, 420 MG, 300 MG (Diltiazem HCl Coated Beads) CARDIZEM TABS (Diltiazem HCl) diltiazem hcl coated beads cp24 diltiazem hcl coated beads tb24 diltiazem hcl cp12 3 MO; + Drug Name diltiazem hcl cp24 Drug Requirements/ Tier Limits 1 MO; * diltiazem hcl extended release beads cp24 1 MO; * diltiazem hcl tabs 1 MO; * felodipine tb24 1 MO; * nicardipine hcl caps 1 MO; * nifedipine caps 20 mg 1 AL; MO; * nifedipine tb24 1 MO; * nimodipine caps 1 MO; * nisoldipine tb24 1 MO; * NORVASC TABS 10 MG (Amlodipine Besylate) NORVASC TABS 2.5 MG (Amlodipine Besylate) NORVASC TABS 5 MG (Amlodipine Besylate) NYMALIZE SOLN 5 SL(1 ea daily); MO; + SL(4 ea daily); MO; + SL(2 ea daily); MO; + + PROCARDIA XL TB24 (Nifedipine) 3 MO; + MO; + 3 3 SL(1 ea daily); MO; * SL(4 ea daily); MO; * SL(2 ea daily); MO; * MO; + 3 MO; + SULAR TB24 (Nisoldipine) 3 MO; + TIAZAC CP24 (Diltiazem HCl Extended Release Beads) 3 MO; + verapamil hcl cp24 1 MO; * MO; + verapamil hcl tabs 1 MO; * verapamil hcl tbcr 1 MO; * 1 1 1 3 2 3 3 3 MO; + 3 MO; + 1 MO; * VERELAN CP24 (Verapamil HCl) VERELAN PM CP24 (Verapamil HCl) NF MO 1 MO; * CARDIOTONICS - Drugs to Treat Heart Failure and Abnormal Heart Rhythm 1 MO; * Cardiac Glycosides NF MO You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 50 Drug Name DIGOXIN SOLN OR 0.05 MG/ML digoxin tabs LANOXIN PEDIATRIC SOLN LANOXIN TABS 187.5 MCG, 62.5 MCG LANOXIN TABS 250 MCG, 125 MCG (Digoxin) Drug Requirements/ Tier Limits 2 MO; + 1 MO; * 4 + 3 MO; + 3 MO; + Cardiovascular Agents Misc. - Combinations amlodipine besylate1 MO; * atorvastatin calcium tabs 3 MO; + BIDIL TABS ENTRESTO TABS EDEX KIT LEVITRA TABS CARDIOVASCULAR AGENTS - MISC. - Drugs to Treat Heart and Circulation Conditions CADUET TABS (Amlodipine BesylateAtorvastatin Calcium) Drug Name MUSE PLLT STAXYN TBDP MO NF 3 PA; MO; + STENDRA TABS Check plan for coverage; Limit 4 boxes per month ;QL(0.14 49 ea daily); MO; NT; + Check plan for coverage; Limit 4 vials per month ;QL(0.14 49 ea daily); MO; NT; + PA; Check plan for coverage;MO; + Check plan for coverage;QL(0. 1449 ea daily); MO; NT; + VIAGRA TABS 50 MG, 25 MG, 100 MG Impotence Agents CAVERJECT IMPULSE KIT CAVERJECT SOLR 40 MCG, 20 MCG CIALIS TABS 2.5 MG, 5 MG CIALIS TABS 20 MG, 10 MG 2 2 3 2 Prostaglandin Vasodilators ORENITRAM TBCR 0.125 MG ORENITRAM TBCR 2.5 MG, 1 MG, 0.25 MG Drug Requirements/ Tier Limits Check plan for coverage; Limit 2 4 boxes per month ;QL(0.14 49 ea daily); MO; NT; + Check plan for 3 coverage;QL(0. 1449 ea daily); MO; NT; + Check plan for coverage; Limit 2 4 boxes per month ;QL(0.14 49 ea daily); MO; NT; + Check plan for 3 coverage;QL(0. 1449 ea daily); MO; NT; + Check plan for 3 coverage;QL(0. 1449 ea daily); MO; NT; + Check plan for 2 coverage;QL(0. 1449 ea daily); MO; NT; + 3 PA; + 5 PA; + REMODULIN SOLN 5 LA; B/D; + TYVASO REFILL SOLN 5 LA; B/D; + TYVASO SOLN 5 LA; B/D; + TYVASO STARTER SOLN 5 LA; B/D; + 2 LA; B/D; + 5 LA; B/D; + VENTAVIS SOLN 10 MCG/ML VENTAVIS SOLN 20 MCG/ML Pulmonary Hypertension - Endothelin Receptor 5 LA; + LETAIRIS TABS You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 51 Drug Name OPSUMIT TABS TRACLEER TABS Drug Requirements/ Tier Limits 5 + 5 LA; + Pulmonary Hypertension - Phosphodiesterase 5 PA; + ADCIRCA TABS REVATIO SOLN (Sildenafil Citrate (Pulmonary Hypertension)) REVATIO TABS (Sildenafil Citrate (Pulmonary Hypertension)) sildenafil citrate (pulmonary hypertension) soln sildenafil citrate (pulmonary hypertension) tabs PA; + 5 PA; + 5 5 PA; + 1 PA; * 5 PA; LA; + Pulmonary Hypertension - Sol Guanylate Cyclase 5 PA; SL(15 ea ADEMPAS TABS 0.5 MG daily); + 5 PA; SL(7.5 ea ADEMPAS TABS 1 MG daily); + 5 PA; SL(5 ea ADEMPAS TABS 1.5 MG daily); + 5 PA; SL(3.75 ea ADEMPAS TABS 2 MG daily); + 5 PA; SL(3 ea ADEMPAS TABS 2.5 MG daily); + Sinus Node Inhibitors CORLANOR TABS 5 MG 3 CORLANOR TABS 7.5 MG 3 cefadroxil tabs Drug Requirements/ Tier Limits 1 MO; * cefazolin sodium solr ij 1 gm, 10 gm, 500 mg 4 MO; + cephalexin caps 1 MO; * cephalexin susr 1 MO; * cephalexin tabs 1 MO; * 3 MO; + KEFLEX CAPS 500 MG, 250 MG (Cephalexin) KEFLEX CAPS 750 MG (Cephalexin) NF MO Cephalosporins - 2nd Generation Pulmonary Hypertension - Prostacyclin Receptor 5 PA; LA; + UPTRAVI TABS UPTRAVI TBPK Drug Name SL(3 ea daily); MO; + SL(2 ea daily); MO; + CEPHALOSPORINS - Drugs to Treat Bacterial Infections Cephalosporins - 1st Generation cefadroxil caps 1 MO; * cefadroxil susr 500 mg/5ml 1 MO; * cefaclor caps 1 MO; * cefaclor monohydrate tb12 1 MO; * 4 + 4 MO; + 4 + cefprozil susr 250 mg/5ml 1 MO; * cefprozil tabs 1 MO; * CEFTIN TABS (Cefuroxime Axetil) 3 MO; + cefuroxime axetil tabs 1 MO; * cefoxitin sodium solr ij 10 gm cefoxitin sodium solr iv 1 gm cefoxitin sodium solr iv 2 gm cefuroxime sodium solr ij 4 + 1.5 gm ZINACEF SOLR IJ 1.5 GM 4 + (Cefuroxime Sodium) Cephalosporins - 3rd Generation 3 SL(1 ea daily); CEDAX CAPS MO; + 1 MO; * cefdinir caps cefdinir susr 1 MO; * cefixime susr 1 MO; * You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 52 Drug Name cefpodoxime proxetil susr 100 mg/5ml Drug Requirements/ Tier Limits 1 MO; * Drug Name TEFLARO SOLR 600 MG Drug Requirements/ Tier Limits 4 + cefpodoxime proxetil tabs 1 MO; * CONTRACEPTIVES - Drugs to Prevent Pregnancy ceftazidime solr ij 1 gm, 2 gm 4 MO; + ceftazidime solr ij 6 gm 4 + CEFTIBUTEN CAPS 3 Combination Contraceptives - Oral BEYAZ TABS MO; + (Drospirenone-Ethinyl 3 Estradiol-Levomefolate Calcium) BREVICON-28 TABS MO; + 3 (Norethindrone & Eth Estradiol) DESOGEN TABS MO; + 3 (Desogestrel & Ethinyl Estradiol) desogestrel & ethinyl 1 MO; * estradiol tabs desogestrel-ethinyl 1 MO; * estradiol (biphasic) tabs drospirenone-ethinyl 1 MO; * estradiol tabs drospirenone-ethinyl MO; * 1 estradiol-levomefolate calcium tabs ethynodiol diacet & eth 1 MO; * estrad tabs 1mg-35mcg FEMCON FE CHEW MO; + 3 (Norethindrone & Ethinyl Estradiol-Fe) GENERESS FE CHEW MO; + 3 (Norethindrone & Ethinyl Estradiol-Fe) levonorgestrel & eth 1 MO; * estradiol tabs levonorgestrel-eth estradiol 1 MO; * (triphasic) tabs levonorgestrel-ethinyl 1 MO; * estradiol (91-day) tabs levonorgestrel-ethinyl 1 MO; * estradiol (continuous) tabs 3 MO; + LO LOESTRIN FE TABS CEFTRIAXONE IN ISOOSMOTIC DEXTROSE SOLN 20MG/ML ceftriaxone sodium solr ij 1 gm ceftriaxone sodium solr ij 2 gm ceftriaxone sodium solr ij 250 mg ceftriaxone sodium solr ij 500 mg ceftriaxone sodium solr iv 1 gm ceftriaxone sodium solr iv 10 gm CLAFORAN SOLR IJ 1 GM, 10 GM (Cefotaxime Sodium) CLAFORAN SOLR IJ 500 MG, 2 GM (Cefotaxime Sodium) FORTAZ SOLR IJ 2 GM, 1 GM (Ceftazidime) FORTAZ SOLR IJ 6 GM (Ceftazidime) SUPRAX CAPS 4 4 4 4 4 4 4 SL(1 ea daily); MO; + SL(200 ml daily); + SL(4 ea daily); + SL(2 ea daily); MO; + SL(16 ea daily); MO; + SL(8 ea daily); MO; + SL(4 ea daily); + MO; + MO NF NF 4 MO; + 4 + 3 MO; + Cephalosporins - 4th Generation cefepime hcl solr CEFEPIME SOLN 2 GM/100ML MAXIPIME SOLR IJ 1 GM, 2 GM (Cefepime HCl) 4 MO; + 4 + 4 MO; + Cephalosporins - 5th Generation LOSEASONIQUE TABS (Levonorgestrel-Ethinyl Estradiol (91-Day)) MO; + 3 You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 53 Drug Name MINASTRIN 24 FE CHEW (Norethin Acet & EstradFe) MODICON TABS (Norethindrone & Eth Estradiol) norethin acet & estrad-fe chew norethin acet & estrad-fe tabs 75mg-30mcg-1.5mg, 75mg-20mcg-1mg norethindrone & eth estradiol tabs norethindrone & ethinyl estradiol-fe chew norethindrone acet & eth estra tabs norethindrone-eth estradiol (triphasic) tabs norgestimate-ethinyl estradiol (triphasic) tabs norgestimate-ethinyl estradiol tabs norgestrel & ethinyl estradiol tabs NORINYL 1+35 TABS (Norethindrone & Eth Estradiol) ORTHO TRI-CYCLEN LO TABS (NorgestimateEthinyl Estradiol (Triphasic)) ORTHO TRI-CYCLEN TABS (NorgestimateEthinyl Estradiol (Triphasic)) ORTHO-CEPT TABS (Desogestrel & Ethinyl Estradiol) ORTHO-CYCLEN TABS (Norgestimate-Ethinyl Estradiol) ORTHO-NOVUM 1/35 TABS (Norethindrone & Eth Estradiol) Drug Requirements/ Tier Limits MO; + 3 MO; NT NF Drug Name ORTHO-NOVUM 7/7/7 TABS (Norethindrone-Eth Estradiol (Triphasic)) QUARTETTE TABS (Levonorgestrel-Ethinyl Estradiol (91-Day)) Drug Requirements/ Tier Limits MO; + 3 MO; + 3 MO; * SAFYRAL TABS 3 MO; * SEASONIQUE TABS (Levonorgestrel-Ethinyl Estradiol (91-Day)) 3 1 MO; * TAYTULLA CAPS 3 1 MO; * 1 MO; * 1 MO; * YASMIN 28 TABS (Drospirenone-Ethinyl Estradiol) YAZ TABS (DrospirenoneEthinyl Estradiol) 1 MO; * 1 MO; * 1 MO; * Combination Contraceptives - Transdermal norelgestromin-ethinyl 1 MO; * estradiol ptwk ORTHO EVRA PTWK MO NF (Norelgestromin-Ethinyl Estradiol) MO; + Combination Contraceptives - Vaginal 2 MO; + NUVARING RING 1 1 3 MO; + 2 MO; + 3 MO; + 3 MO; + 3 MO; + 3 MO; + MO; + MO; + MO; + 3 3 MO; + Emergency Contraceptives ELLA TABS 2 + Progestin Contraceptives - Injectable DEPO-PROVERA MO; + CONTRACEPTIVE SUSP 4 (Medroxyprogesterone Acetate (Contraceptive)) DEPO-PROVERA MO; + CONTRACEPTIVE SUSY 4 (Medroxyprogesterone Acetate (Contraceptive)) DEPO-SUBQ PROVERA 4 MO; + 104 SUSY medroxyprogesterone MO; + 4 acetate (contraceptive) susp You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 54 Drug Name Drug Requirements/ Tier Limits MO; + 4 medroxyprogesterone acetate (contraceptive) susy Progestin Contraceptives - Oral NOR-QD TABS MO; + 3 (Norethindrone (Contraceptive)) norethindrone 1 MO; * (contraceptive) tabs ORTHO MICRONOR MO; + 3 TABS (Norethindrone (Contraceptive)) CORTICOSTEROIDS - Steroid Hormone Drugs to Treat Systemic Swelling Conditions Glucocorticosteroids betamethasone sod 4 MO; + phosphate & acetate susp 5 MO; + budesonide cpep CELESTONE-SOLUSPAN SUSP (Betamethasone Sod Phosphate & Acetate) CORTEF TABS (Hydrocortisone) cortisone acetate tabs DEPO-MEDROL SUSP 20 MG/ML DEPO-MEDROL SUSP 40 MG/ML, 80 MG/ML (Methylprednisolone Acetate) dexamethasone elix DEXAMETHASONE SODIUM PHOSPHATE SOLN 10 MG/ML DEXAMETHASONE SODIUM PHOSPHATE SOLN 10 MG/ML dexamethasone sodium phosphate soln 20 mg/5ml, 120 mg/30ml, 4 mg/ml, 100 mg/10ml dexamethasone soln MO; + 4 Drug Name dexamethasone tabs Drug Requirements/ Tier Limits 1 MO; * dexamethasone tbpk 1 MO; * ENTOCORT EC CPEP (Budesonide) 3 MO; + hydrocortisone tabs 1 MO; * KENALOG-10 SUSP 4 MO; + KENALOG-40 SUSP 4 MO; + LOCORT 11-DAY TBPK 5 + LOCORT 7-DAY TBPK 5 + MEDROL DOSEPAK TBPK (Methylprednisolone) MEDROL TABS 16 MG, 8 MG, 4 MG, 32 MG (Methylprednisolone) MEDROL TABS 2 MG NF MO MO NF 2 MO; + 1 MO; * 1 MO; * 1 MO; * methylprednisolone acetate susp methylprednisolone sod succ solr MO; + methylprednisolone tabs 1 MO; * 4 MO methylprednisolone tbpk 1 MO; * NF MO NF 1 MO; * + 4 4 Preservative Free;MO; + MO; + 4 1 MO; * ORAPRED ODT TBDP 10 MG (Prednisolone Sodium Phosphate) ORAPRED ODT TBDP 30 MG, 15 MG (Prednisolone Sodium Phosphate) prednisolone sodium phosphate soln or 5 mg/5ml, 6.7 mg/5ml, 15 mg/5ml, 25 mg/5ml prednisolone sodium phosphate tbdp MO; + 3 MO NF MO; * 1 1 MO; * prednisolone soln 1 MO; * prednisolone syrp 1 MO; * You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 55 Drug Name prednisolone tabs Drug Requirements/ Tier Limits 1 MO; * prednisone conc 1 MO; * prednisone soln 1 MO; * prednisone tabs 1 MO; * prednisone tbpk 1 MO; * RAYOS TBEC 5 MG, 2 MG 5 MO; + 4 MO; + SOLU-CORTEF SOLR 250 MG, 100 MG SOLU-MEDROL SOLR 1000 MG, 125 MG, 40 MG (Methylprednisolone Sod Succ) SOLU-MEDROL SOLR 2 GM MO NF 4 + UCERIS TB24 5 MO; + ZONACORT 11 DAY TBPK 5 + ZONACORT 7 DAY TBPK 5 + 1 MO; * Mineralocorticoids fludrocortisone acetate tabs Drug Name promethazinephenylephrine-codeine syrp pseudoephed-cpm w/ hydrocod soln Drug Requirements/ Tier Limits 1 AL; MO; NT; * 1 AL; MO; NT; * REZIRA SOLN 3 MO; NT; + SEMPREX-D CAPS 3 MO; + TUSSIONEX PENNKINETIC EXTENDED RELEASE SUER (Hydrocodone Polistirex-Chlorpheniramine Polistirex) ZUTRIPRO SOLN (Pseudoephed-CPM w/ Hydrocod) AL; MO; NT; + 3 AL; MO; NT; + 3 Mucolytics acetylcysteine soln 1 MO; B/D; * DERMATOLOGICALS - Drugs to Treat Skin Conditions Acne Products ABSORICA CAPS 30 MG (Isotretinoin) ABSORICA CAPS 40 MG, 10 MG, 30 MG, 25 MG, 35 MG, 20 MG 3 + + 3 COUGH/COLD/ALLERGY - Drugs to Treat Cough, Cold and Allergy Symptoms ACANYA GEL 3 MO; + Antitussives adapalene crea 1 MO; * adapalene gel 0.1 % 1 RX/OTC; MO; * adapalene gel 0.3 % 1 MO; * ATRALIN GEL (Tretinoin) 3 MO; + AZELEX CREA 3 MO; + benzonatate caps TESSALON PERLES CAPS (Benzonatate) ZONATUSS CAPS (Benzonatate) 1 MO; NT; * 3 MO; NT; + NF MO; NT Cough/Cold/Allergy Combinations CLARINEX-D 12 HOUR 3 MO; + TB12 hydrocodone polistirexAL; MO; NT; * 1 chlorpheniramine polistirex suer promethazine & 1 MO; * phenylephrine syrp BENZACLIN GEL (Clindamycin PhosphateBenzoyl Peroxide) BENZACLIN WITH PUMP GEL (Clindamycin Phosphate-Benzoyl Peroxide) MO; + 3 MO; + 3 You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 56 Drug Name BENZAMYCIN GEL (Benzoyl PeroxideErythromycin) benzoyl peroxideerythromycin gel CLEOCIN-T GEL (Clindamycin Phosphate (Topical)) CLEOCIN-T LOTN (Clindamycin Phosphate (Topical)) CLEOCIN-T SOLN (Clindamycin Phosphate (Topical)) CLEOCIN-T SWAB (Clindamycin Phosphate (Topical)) CLINDAGEL GEL clindamycin phosphate (topical) foam clindamycin phosphate (topical) gel clindamycin phosphate (topical) lotn clindamycin phosphate (topical) soln clindamycin phosphate (topical) swab clindamycin phosphatebenzoyl peroxide (refrigerate) gel clindamycin phosphatebenzoyl peroxide gel clindamycin phosphatetretinoin gel DIFFERIN CREA (Adapalene) DIFFERIN GEL 0.1 % (Adapalene) DIFFERIN GEL 0.3 % (Adapalene) DUAC GEL (Clindamycin Phosphate-Benzoyl Peroxide (Refrigerate)) EPIDUO GEL Drug Requirements/ Tier Limits MO; + 3 1 MO; * MO; + 3 MO; + Drug Requirements/ Tier Limits 1 MO; * erythromycin (acne aid) gel Drug Name erythromycin (acne aid) soln EVOCLIN FOAM (Clindamycin Phosphate (Topical)) 1 MO; * MO; + 3 Limit 100gms per month;QL(3.34 gm daily); MO; + * FABIOR FOAM 3 isotretinoin caps 1 MO; + KLARON LOTN (Sulfacetamide Sodium (Acne)) 3 3 MO; + RETIN-A CREA (Tretinoin) 3 MO; + 1 MO; * RETIN-A GEL (Tretinoin) 3 MO; + 1 MO; * 1 MO; * 1 MO; * 1 MO; * 3 MO; + 3 3 MO; * 1 RETIN-A MICRO GEL (Tretinoin Microsphere) RETIN-A MICRO PUMP GEL 0.04 %, 0.1 % (Tretinoin Microsphere) RETIN-A MICRO PUMP GEL 0.08 % sulfacetamide sodium (acne) lotn sulfacetamide sodium (acne) susp MO; + NF MO MO NF 3 MO; + 1 MO; * 1 MO; * MO; * tretinoin crea 1 MO; * 1 tretinoin gel 1 MO; * 1 MO; * tretinoin microsphere gel 1 MO; * 3 MO; + ZIANA GEL (Clindamycin Phosphate-Tretinoin) 3 MO; + 3 RX/OTC; MO; + NF MO MO; + 3 3 MO; + Anti-inflammatory Agents - Topical diclofenac sodium (topical) 1 MO; * gel diclofenac sodium (topical) 1 MO; * soln 3 PA; MO; + FLECTOR PTCH You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 57 Drug Name PENNSAID SOLN 1.5 % (Diclofenac Sodium (Topical)) Drug Requirements/ Tier Limits MO NF PENNSAID SOLN 2 % 5 VOLTAREN GEL (Diclofenac Sodium (Topical)) 3 MO; + MO; + Drug Name JUBLIA SOLN Drug Requirements/ Tier Limits 3 PA; MO; + KERYDIN SOLN 3 PA; MO; + ketoconazole (topical) crea 1 MO; * ketoconazole (topical) foam 1 MO; * 1 MO; * CENTANY OINT 3 MO; + ketoconazole (topical) sham LOPROX CREA (Ciclopirox Olamine) LOPROX SHAMPOO SHAM (Ciclopirox) LOPROX SUSP (Ciclopirox Olamine) CORTISPORIN CREA 2 MO; + LUZU CREA 3 CORTISPORIN OINT 2 MO; + MENTAX CREA 2 1 MO; * naftifine hcl crea 1 RX/OTC; MO; + MO; * 1 MO; * NAFTIN CREA (Naftifine HCl) 3 MO; + 1 MO; * NAFTIN GEL 3 MO; + NIZORAL SHAM (Ketoconazole (Topical)) 3 MO; + nystatin (topical) crea 1 MO; * nystatin (topical) oint 1 MO; * nystatin (topical) powd 1 MO; * nystatin-triamcinolone crea 1 MO; * nystatin-triamcinolone oint 1 MO; * oxiconazole nitrate crea 1 MO; * OXISTAT CREA (Oxiconazole Nitrate) 3 MO; + OXISTAT LOTN 3 MO; + Antibiotics - Topical BACTROBAN CREA (Mupirocin Calcium (Topical)) BACTROBAN OINT (Mupirocin) gentamicin sulfate (topical) crea mupirocin calcium (topical) crea mupirocin oint MO NF NF MO; NT Antifungals - Topical ciclopirox gel 1 MO; * ciclopirox olamine crea 1 MO; * ciclopirox olamine susp 1 MO; * ciclopirox sham 1 MO; * clotrimazole (topical) crea 1 RX/OTC; MO; * clotrimazole (topical) soln 1 RX/OTC; MO; * econazole nitrate crea 1 MO; * ERTACZO CREA 3 MO; + EXELDERM SOLN 3 MO; + 3 MO; + EXTINA FOAM (Ketoconazole (Topical)) NF MO 3 MO; + 3 MO; + MO; + Antineoplastic or Premalignant Lesion Agents 5 MO; + CARAC CREA You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 58 Drug Name diclofenac sodium (actinic keratoses) gel EFUDEX CREA (Fluorouracil (Topical)) Drug Requirements/ Tier Limits 5 MO; + NF MO Drug Name OXSORALEN ULTRA CAPS (Methoxsalen Rapid) SORIATANE CAPS (Acitretin) Drug Requirements/ Tier Limits 5 MO; + 5 MO; + fluorouracil (topical) crea 1 MO; * SORILUX FOAM 3 MO; + fluorouracil (topical) soln 1 MO; * STELARA SOSY 5 PA; + FLUOROURACIL CREA 5 MO; + TALTZ SOAJ 5 PA; + PANRETIN GEL 2 MO; + TALTZ SOSY 5 PA; + PICATO GEL 5 MO; + tazarotene crea 1 MO; * SOLARAZE GEL (Diclofenac Sodium (Actinic Keratoses)) MO; + TAZORAC CREA 0.05 % 2 MO; + 5 2 5 TAZORAC CREA 0.1 % (Tazarotene) MO; + + TAZORAC GEL 2 MO; + 5 PA; + VECTICAL OINT 3 MO; + 1 MO; * acyclovir topical oint 1 MO; * DENAVIR CREA 5 MO; + XERESE CREA 3 MO; + ZOVIRAX CREA 5 MO; + TARGRETIN GEL VALCHLOR GEL Antipruritics - Topical DOXEPIN HYDROCHLORIDE CREA 3 MO; + 3 MO; + 3 MO; + acitretin caps 5 MO; + calcipotriene crea 1 MO; * calcipotriene oint 1 MO; * calcipotriene soln 1 MO; * CALCITRIOL OINT 3 MO; + COSENTYX SENSOREADY PEN SOAJ 5 PA; LA; + COSENTYX SOSY 5 PA; LA; + PRUDOXIN CREA ZONALON CREA methoxsalen rapid caps NF MO 5 selenium sulfide lotn 2.5 % Antivirals - Topical Antipsoriatics DOVONEX CREA (Calcipotriene) Antiseborrheic Products MO; + ZOVIRAX OINT (Acyclovir Topical) Burn Products SILVADENE CREA (Silver Sulfadiazine) NF MO 3 MO; + silver sulfadiazine crea 1 MO; * SULFAMYLON CREA 3 MO; + SULFAMYLON PACK (Mafenide Acetate) NF MO Corticosteroids - Topical You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 59 Drug Requirements/ Tier Limits alclometasone dipropionate 1 MO; * crea alclometasone dipropionate 1 MO; * oint 1 MO; * amcinonide crea Drug Name betamethasone dipropionate (topical) crea betamethasone dipropionate (topical) lotn betamethasone dipropionate (topical) oint betamethasone dipropionate augmented crea betamethasone dipropionate augmented gel betamethasone dipropionate augmented lotn betamethasone dipropionate augmented oint betamethasone valerate crea betamethasone valerate foam betamethasone valerate lotn betamethasone valerate oint calcipotrienebetamethasone dipropionate oint 1 MO; * 1 MO; * 1 MO; * MO; * 1 MO; * 1 MO; * 1 MO; * 1 Drug Name clobetasol propionate lotn Drug Requirements/ Tier Limits 1 MO; * clobetasol propionate oint 1 MO; * clobetasol propionate sham 1 MO; * clobetasol propionate soln 1 MO; * CLOBEX LIQD (Clobetasol Propionate) CLOBEX LOTN (Clobetasol Propionate) CLOBEX SHAM (Clobetasol Propionate) CLOCORTOLONE PIVALATE CREA CLOCORTOLONE PIVALATE PUMP CREA NF MO 3 MO; + 3 MO; + 3 MO; + 3 MO; + CLODERM CREA 3 MO; + CLODERM PUMP CREA 3 MO; + CORDRAN CREA (Flurandrenolide) CORDRAN LOTN (Flurandrenolide) NF MO; NT NF MO; NT 1 MO; * 1 MO; * CORDRAN TAPE 3 MO; + MO; * CORDRAN TAPE TAPE 3 MO; + 1 3 MO; + 1 MO; * 3 MO; + MO; * 1 CAPEX SHAM 3 MO; + clobetasol propionate crea 1 MO; * clobetasol propionate emollient base crea 1 MO; * clobetasol propionate foam 1 clobetasol propionate gel 1 Nonemulsion;MO; * MO; * clobetasol propionate liqd 1 MO; * CUTIVATE CREA (Fluticasone Propionate) CUTIVATE LOTN (Fluticasone Propionate) DERMA-SMOOTHE/FS BODY OIL (Fluocinolone Acetonide) DERMA-SMOOTHE/FS SCALP OIL (Fluocinolone Acetonide) DERMATOP CREA (Prednicarbate) MO; + 3 MO; + 3 3 MO; + DESONATE GEL 3 MO; + desonide crea 1 MO; * desonide lotn 1 MO; * You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 60 Drug Name desonide oint Drug Requirements/ Tier Limits 1 MO; * Drug Name flurandrenolide crea Drug Requirements/ Tier Limits 1 MO; * DESOWEN CREA (Desonide) 3 MO; + flurandrenolide lotn 1 MO; * desoximetasone crea 1 MO; * fluticasone propionate crea 1 MO; * desoximetasone gel 1 MO; * fluticasone propionate lotn 1 MO; * desoximetasone oint 1 MO; * fluticasone propionate oint 1 MO; * diflorasone diacetate crea 1 MO; * halobetasol propionate crea 1 MO; * diflorasone diacetate oint 1 MO; * halobetasol propionate oint 1 MO; * MO; + HALOG CREA 3 MO; + 1 RX/OTC; MO; * 1 MO; * 1 MO; * 1 RX/OTC; MO; * 1 MO; * 1 MO; * 1 MO; * 1 MO; * 1 MO; * 1 MO; * 1 MO; * DIPROLENE AF CREA (Betamethasone Dipropionate Augmented) DIPROLENE LOTN (Betamethasone Dipropionate Augmented) DIPROLENE OINT (Betamethasone Dipropionate Augmented) ELOCON CREA (Mometasone Furoate) ELOCON LOTN (Mometasone Furoate) ELOCON OINT (Mometasone Furoate) 3 MO; + 3 MO; + 3 hydrocortisone (topical) crea 1 % hydrocortisone (topical) crea 2.5 % hydrocortisone (topical) lotn 2.5 % hydrocortisone (topical) oint 1% hydrocortisone (topical) oint 2.5 % hydrocortisone butyrate crea hydrocortisone butyrate hydrophilic lipo base crea hydrocortisone butyrate oint hydrocortisone butyrate soln hydrocortisone valerate crea 3 MO; + 3 MO; + 3 MO; + ENSTILAR FOAM 5 MO; + fluocinolone acetonide crea 1 MO; * fluocinolone acetonide oil 1 MO; * fluocinolone acetonide oint 1 MO; * fluocinolone acetonide soln 1 MO; * hydrocortisone valerate oint fluocinonide crea 1 MO; * fluocinonide emulsified base crea 1 MO; * fluocinonide gel 1 MO; * fluocinonide oint 1 MO; * fluocinonide soln 1 MO; * KENALOG AERS (Triamcinolone Acetonide (Topical)) LOCOID CREA (Hydrocortisone Butyrate) LOCOID LIPOCREAM CREA (Hydrocortisone Butyrate Hydrophilic Lipo Base) MO NF 3 MO; + MO NF You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 61 Drug Name LOCOID LOTN LOCOID OINT (Hydrocortisone Butyrate) LOCOID SOLN (Hydrocortisone Butyrate) LUXIQ FOAM (Betamethasone Valerate) Drug Requirements/ Tier Limits 3 MO; + 3 MO; + 3 MO; + NF MO 1 MO; * mometasone furoate oint 1 MO; * mometasone furoate soln 1 MO; * mometasone furoate crea OLUX FOAM (Clobetasol Propionate) 3 prednicarbate crea 1 Nonemulsion;MO; + MO; * 3 MO; + 3 MO; + 3 MO; + SYNALAR CREA (Fluocinolone Acetonide) SYNALAR OINT (Fluocinolone Acetonide) SYNALAR SOLN (Fluocinolone Acetonide) TACLONEX OINT (CalcipotrieneBetamethasone Dipropionate) TACLONEX SUSP TEMOVATE CREA (Clobetasol Propionate) TEMOVATE E CREA (Clobetasol Propionate Emollient Base) TEMOVATE GEL (Clobetasol Propionate) TEMOVATE OINT (Clobetasol Propionate) TEMOVATE SOLN (Clobetasol Propionate) MO; + 5 5 MO; + 3 MO; + MO; NT NF Drug Name triamcinolone acetonide (topical) aers triamcinolone acetonide (topical) crea triamcinolone acetonide (topical) lotn triamcinolone acetonide (topical) oint 0.025 %, 0.1 % TRIDESILON CREA (Desonide) ULTRAVATE CREA (Halobetasol Propionate) ULTRAVATE LOTN ULTRAVATE OINT (Halobetasol Propionate) VANOS CREA (Fluocinonide) WESTCORT OINT (Hydrocortisone Valerate) Emollients LAC-HYDRIN CREA (Lactic Acid (Ammonium Lactate)) LAC-HYDRIN LOTN (Lactic Acid (Ammonium Lactate)) lactic acid (ammonium lactate) crea lactic acid (ammonium lactate) lotn 12 % MO; + 3 MO; + 3 MO; + TOPICORT LIQD 3 MO; + TOPICORT OINT (Desoximetasone) 3 MO; + 1 MO; * 1 MO; * MO; * 1 3 MO; + 3 MO; + 5 PA; MO; + 3 MO; + 5 MO; + NF MO; NT 3 RX/OTC; MO; + 1 RX/OTC; MO; + RX/OTC; MO; * 1 RX/OTC; MO; * 2 MO; + 3 Enzymes - Topical SANTYL OINT 3 Drug Requirements/ Tier Limits 1 MO; * Immunomodulating Agents - Topical ALDARA CREA NF MO (Imiquimod) 1 MO; * imiquimod crea ZYCLARA CREA 5 MO; + ZYCLARA PUMP CREA 5 MO; + Immunosuppressive Agents - Topical 3 MO; + ELIDEL CREA You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 62 Drug Name PROTOPIC OINT (Tacrolimus (Topical)) Drug Requirements/ Tier Limits NF MO tacrolimus (topical) oint 1 MO; * Keratolytic/Antimitotic Agents CONDYLOX GEL 3 MO; + CONDYLOX SOLN (Podofilox) 3 MO; + podofilox soln 1 MO; * Local Anesthetics - Topical lidocaine hcl gel 2 % 1 RX/OTC; MO; * lidocaine hcl soln ex 4 % 1 MO; * lidocaine oint 1 MO; * lidocaine ptch 1 PA; MO; * lidocaine-prilocaine crea 1 MO; * LIDODERM PTCH (Lidocaine) RELYYKS PTCH (Lidocaine-Menthol) XYLOCAINE SOLN EX 4 % (Lidocaine HCl) Drug Name MIRVASO GEL Drug Requirements/ Tier Limits 3 PA; MO; + NORITATE CREA 5 MO; + ORACEA CPDR 3 MO; + SOOLANTRA CREA 3 MO; + Scabicides & Pediculicides ELIMITE CREA (Permethrin) NF MO; NT EURAX CREA 3 MO; + EURAX LOTN 3 MO; + malathion lotn 1 MO; * permethrin crea 1 MO; * 5 MO; + Wound Care Products REGRANEX GEL NF PA; MO DIGESTIVE AIDS - Drugs to Treat Low Digestive Enzymes NF RX/OTC; NT Digestive Enzymes 3 MO; + Rosacea Agents CREON CPEP 2 MO; + PANCREAZE CPEP 2 MO; + 3 MO; + DOXYCYCLINE CPDR 3 MO; + PANCRELIPASE CPEP FINACEA FOAM 3 MO; + 3 3 MO; + PERTZYE CPEP 28750UNIT-8000UNIT30250UNIT, 57500UNIT16000UNIT-60500UNIT 3 MO; + SUCRAID SOLN 3 LA; + VIOKACE TABS 3 MO; + FINACEA GEL METROCREAM CREA (Metronidazole (Topical)) METROGEL GEL (Metronidazole (Topical)) METROLOTION LOTN (Metronidazole (Topical)) metronidazole (topical) crea NF MO 3 MO; + 1 MO; * metronidazole (topical) gel 1 MO; * metronidazole (topical) lotn 1 MO; * MO; + You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 63 Drug Name ZENPEP CPEP 10000UNIT-3000UNIT16000UNIT, 17000UNIT5000UNIT-27000UNIT, 68000UNIT-20000UNIT109000UNIT, 34000UNIT10000UNIT-55000UNIT, 51000UNIT-15000UNIT82000UNIT, 85000UNIT25000UNIT-136000UNIT ZENPEP CPEP 136000UNIT-40000UNIT218000UNIT Drug Requirements/ Tier Limits MO; + 3 Drug Name triamterene & hydrochlorothiazide caps triamterene & hydrochlorothiazide tabs Loop Diuretics bumetanide tabs MO; + 5 DIURETICS - Drugs to Treat Heart, Circulation Conditions and Blood Pressure BUMEX TABS (Bumetanide) DEMADEX TABS 5 MG, 10 MG, 20 MG (Torsemide) EDECRIN TABS (Ethacrynic Acid) Drug Requirements/ Tier Limits 1 MO; * 1 MO; * 1 MO; * NF MO 3 MO; + 5 MO; + ethacrynic acid tabs 5 MO; + Carbonic Anhydrase Inhibitors acetazolamide cp12 MO; * furosemide soln ij 10 mg/ml 4 MO; + 1 acetazolamide tabs 250 mg MO; * furosemide soln or 10 mg/ml 1 MO; * 1 DIAMOX CP12 (Acetazolamide) 3 MO; + furosemide tabs 1 MO; * 5 PA; SL(4 ea daily); + MO; * LASIX TABS (Furosemide) 3 MO; + KEVEYIS TABS torsemide tabs 20 mg, 10 1 mg, 100 mg, 5 mg Potassium Sparing Diuretics ALDACTONE TABS 3 (Spironolactone) MO; * amiloride hcl tabs 1 MO; * methazolamide tabs Diuretic Combinations ALDACTAZIDE TABS 25MG-25MG (Spironolactone & Hydrochlorothiazide) ALDACTAZIDE TABS 50MG-50MG amiloride & hydrochlorothiazide tabs DYAZIDE CAPS (Triamterene & Hydrochlorothiazide) MAXZIDE TABS (Triamterene & Hydrochlorothiazide) MAXZIDE-25 TABS (Triamterene & Hydrochlorothiazide) spironolactone & hydrochlorothiazide tabs 1 MO; + 3 MO; + MO; + DYRENIUM CAPS 3 MO; + 2 MO; * spironolactone tabs 1 MO; * 1 MO; + Thiazides and Thiazide-Like Diuretics 1 MO; * chlorothiazide tabs MO; + chlorthalidone tabs 1 MO; * hydrochlorothiazide caps 1 MO; * hydrochlorothiazide tabs 1 MO; * indapamide tabs 1 MO; * metolazone tabs 1 MO; * 3 3 MO; + 3 1 MO; * You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 64 Drug Name MICROZIDE CAPS (Hydrochlorothiazide) Drug Requirements/ Tier Limits 3 MO; + ibandronate sodium tabs ENDOCRINE AND METABOLIC AGENTS MISC. - Drugs to Treat Bone Disease and Regulate Hormones Bone Density Regulators ACTONEL TABS 150 MG (Risedronate Sodium) ACTONEL TABS 30 MG, 5 MG (Risedronate Sodium) ACTONEL TABS 35 MG (Risedronate Sodium) alendronate sodium tabs 10 mg, 5 mg alendronate sodium tabs 70 mg, 35 mg ATELVIA TBEC (Risedronate Sodium) BONIVA SOLN (Ibandronate Sodium) BONIVA TABS (Ibandronate Sodium) calcitonin (salmon) soln FORTEO SOLN NF QL(0.04 ea daily); MO NF QL(1 ea daily); MO NF QL(0.15 ea daily); MO 1 MO; * QL(0.15 ea daily); MO; * NF QL(0.15 ea daily); MO Limit 3mls per 3 4 months;QL(0.0 4 ml daily); MO; + Limit 1 tab per 28 days (3 per 3 84);QL(0.036 ea daily); MO; + 1 MO; * 1 5 FORTICAL SOLN 3 FOSAMAX PLUS D TABS 3 FOSAMAX TABS (Alendronate Sodium) 3 ibandronate sodium soln Drug Name 4 Limit 2.4mls per 28 days;QL(0.09 ml daily); + MO; + QL(0.15 ea daily); MO; + QL(0.15 ea daily); MO; + Limit 3mls per 3 months;QL(0.0 4 ml daily); MO; + MIACALCIN SOLN IJ 200 UNIT/ML MIACALCIN SOLN NA 200 UNIT/ACT (Calcitonin (Salmon)) NATPARA CART PROLIA SOLN RECLAST SOLN (Zoledronic Acid) risedronate sodium tabs 150 mg risedronate sodium tabs 30 mg, 5 mg risedronate sodium tabs 35 mg risedronate sodium tbec XGEVA SOLN zoledronic acid conc Drug Requirements/ Tier Limits Limit 1 tab per 1 28 days (3 per 84);QL(0.036 ea daily); MO; * 4 MO; + MO; + 3 5 PA; LA; + Limit 1 dose 2 every 6 months;QL(0.0 1 ml daily); + Limit 100mls NF per year;QL(0.28 ml daily) 1 QL(0.04 ea daily); MO; * 1 QL(1 ea daily); MO; * 1 QL(0.15 ea daily); MO; * 1 QL(0.15 ea daily); MO; * Limit 6.8mls 5 per 28 days;QL(0.243 ml daily); + 4 + zoledronic acid soln 5 mg/100ml 1 ZOMETA CONC (Zoledronic Acid) 5 Limit 100mls per year;QL(0.28 ml daily); * + 5 PA; LA; + 4 PA; + Corticotropin H.P. ACTHAR GEL Fertility Regulators chorionic gonadotropin solr Growth Hormone Receptor Antagonists You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 65 Drug Name SOMAVERT SOLR Drug Requirements/ Tier Limits 5 LA; + Drug Name Drug Requirements/ Tier Limits Metabolic Modifiers Growth Hormone Releasing Hormones (GHRH) 5 + EGRIFTA SOLR calcitriol caps 1 MO; * calcitriol soln or 1 MO; * Growth Hormones GENOTROPIN MINIQUICK SOLR 0.4 MG GENOTROPIN SOLR 5 MG HUMATROPE COMBO PACK SOLR HUMATROPE SOLR 12 MG, 24 MG CARBAGLU TABS 3 LA; + 3 RX/OTC; MO; + HUMATROPE SOLR 6 MG NORDITROPIN FLEXPRO SOLN 10 MG/1.5ML, 5 MG/1.5ML NUTROPIN AQ NUSPIN 20 SOLN OMNITROPE SOLN SEROSTIM SOLR 6 MG, 4 MG ZOMACTON SOLR 5 MG 4 PA; + 4 PA; + CARNITOR TABS (Levocarnitine (Metabolic Modifiers)) PA; + CYSTADANE POWD 3 LA; + 5 doxercalciferol caps 1 MO; * 5 PA; + 5 LA; + 5 PA; + FABRAZYME SOLR 35 MG HECTOROL CAPS 0.5 MCG, 2.5 MCG (Doxercalciferol) HECTOROL CAPS 1 MCG (Doxercalciferol) 5 PA; + 5 PA; + 4 PA; + 4 PA; + PA; + 5 Hormone Receptor Modulators EVISTA TABS (Raloxifene NF QL(1 ea daily); HCl) MO 1 QL(1 ea daily); raloxifene hcl tabs MO; * Insulin-Like Growth Factors (Somatomedins) 4 LA; + INCRELEX SOLN LHRH/GnRH Agonist Analog Pituitary LUPRON DEPOT-PED (1+ MONTH) KIT 11.25 MG, 15 4 MG LUPRON DEPOT-PED (15 + MONTH) KIT 7.5 MG LUPRON DEPOT-PED (35 3 Month Kit; + MONTH) KIT 5 MO; + SYNAREL SOLN MO NF 5 MO; + KANUMA SOLN 5 LA; + KUVAN PACK 5 LA; + KUVAN TBSO 5 LA; + levocarnitine (metabolic modifiers) tabs 1 RX/OTC; MO; * LUMIZYME SOLR 5 LA; + MYALEPT SOLR 5 LA; + NAGLAZYME SOLN 5 LA; + ORFADIN CAPS 2 LA; + paricalcitol caps 1 MO; * RAVICTI LIQD 3 LA; + RAYALDEE CPCR 3 PA; MO; + 3 MO; + 3 MO; + ROCALTROL CAPS (Calcitriol) ROCALTROL SOLN (Calcitriol) You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 66 SENSIPAR TABS Drug Requirements/ Tier Limits 2 + STRENSIQ SOLN 5 PA; LA; + VIMIZIM SOLN 5 LA; + Drug Name ZEMPLAR CAPS (Paricalcitol) Posterior Pituitary Hormones DDAVP SOLN IJ 4 MCG/ML (Desmopressin Acetate) DDAVP SOLN NA 0.01 % (Desmopressin Acetate Refrigerated) DDAVP SOLN NA 0.01 % (Desmopressin Acetate Spray) DDAVP TABS (Desmopressin Acetate) desmopressin acetate refrigerated soln desmopressin acetate soln desmopressin acetate spray refrigerated soln desmopressin acetate spray soln desmopressin acetate tabs STIMATE SOLN NF MO Somatostatic Agents octreotide acetate soln 200 mcg/ml, 100 mcg/ml, 50 mcg/ml SANDOSTATIN LAR DEPOT KIT 30 MG, 20 MG SANDOSTATIN SOLN 100 MCG/ML (Octreotide Acetate) SANDOSTATIN SOLN 50 MCG/ML, 200 MCG/ML (Octreotide Acetate) SIGNIFOR LAR SRER 20 MG SIGNIFOR LAR SRER 40 MG MO; + SIGNIFOR LAR SRER 60 MG MO; + SIGNIFOR SOLN 4 3 MO; + 3 3 MO; + 1 MO; * 4 MO; + SOMATULINE DEPOT SOLN Drug Requirements/ Tier Limits Limit 3 vials per 5 28 days;SL(0.11 ea daily); LA; + Limit 3 vials per 5 56 days;SL(0.054 ea daily); LA; + Limit 1 vial per 5 28 days;SL(0.036 ea daily); LA; + 5 LA; + 5 + Vasopressin Receptor Antagonists SAMSCA TABS 5 + ESTROGENS - Hormone Replacement/Modifying Drugs 1 MO; * Estrogen Combinations ACTIVELLA TABS (Estradiol & Norethindrone Acetate) MO; * CLIMARA PRO PTWK 3 AL; MO; + 1 COMBIPATCH PTTW 3 AL; MO; + 1 MO; * DUAVEE TABS 3 AL; MO; + 3 + 1 AL; MO; * Prolactin Inhibitors cabergoline tabs Drug Name 1 MO; * + 4 5 estradiol & norethindrone acetate tabs FEMHRT LOW DOSE TABS (Norethindrone Acetate-Ethinyl Estradiol) norethindrone acetateethinyl estradiol tabs 2.5mcg-0.5mg AL; MO; + 3 AL; MO; + 3 AL; MO; * 1 + PREMPHASE TABS 3 AL; MO; + + PREMPRO TABS 3 AL; MO; + + Estrogens CLIMARA PTWK (Estradiol) 3 AL; MO; + 5 4 You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 67 Drug Name DELESTROGEN OIL 10 MG/ML DELESTROGEN OIL 20 MG/ML, 40 MG/ML (Estradiol Valerate) Drug Requirements/ Tier Limits 4 MO; + MO; + 4 Drug Name ciprofloxacin hcl tabs ciprofloxacin in d5w soln 200mg/100ml-5% ciprofloxacin in d5w soln 400mg/200ml-5% 3 AL; MO; + 3 AL; MO; + 3 AL; + estradiol pttw 1 AL; MO; * estradiol ptwk 1 AL; MO; * estradiol tabs 1 AL; MO; * estradiol valerate oil 4 MO; + ciprofloxacin-ciprofloxacin hcl tb24 LEVAQUIN SOLN IV 500MG/100ML-5%, 750MG/150ML-5% (Levofloxacin in D5W) LEVAQUIN SOLN OR 25 MG/ML (Levofloxacin) LEVAQUIN TABS (Levofloxacin) estropipate tabs 1.5 mg, 0.75 mg 1 AL; MO; * EVAMIST SOLN DIVIGEL GEL ELESTRIN GEL ENJUVIA TABS 0.3 MG, 0.45 MG ciprofloxacin susr Drug Requirements/ Tier Limits 1 MO; * 4 + 4 MO; + 1 MO; * 1 MO; * + 4 3 MO; + 3 MO; + levofloxacin in d5w soln 4 + levofloxacin soln iv 4 + 3 AL; MO; + 3 AL; MO; + levofloxacin soln or 1 MO; * MENOSTAR PTWK 3 AL; MO; + levofloxacin tabs 1 MO; * PREMARIN TABS moxifloxacin hcl tabs 1 MO; * VIVELLE-DOT PTTW (Estradiol) NF AL; MO FLUOROQUINOLONES - Drugs to Treat Bacterial Infections Fluoroquinolones AVELOX ABC PACK TABS (Moxifloxacin HCl) AVELOX TABS (Moxifloxacin HCl) CIPRO I.V.-IN D5W SOLN (Ciprofloxacin in D5W) CIPRO SUSR 5 GM/100ML (Ciprofloxacin) CIPRO SUSR 500 MG/5ML (Ciprofloxacin) CIPRO TABS (Ciprofloxacin HCl) CIPRO XR TB24 (Ciprofloxacin-Ciprofloxacin HCl) NF MO NF MO 4 MO; + 3 MO; + NF MO 3 MO; + MO; + 3 GASTROINTESTINAL AGENTS - MISC. Miscellaneous Gastrointestinal Drugs Farnesoid X Receptor (FXR) Agonists 5 PA; SL(1 ea OCALIVA TABS 10 MG daily); + 5 PA; SL(2 ea OCALIVA TABS 5 MG daily); + Gallstone Solubilizing Agents ACTIGALL CAPS 3 (Ursodiol) MO; + CHENODAL TABS 5 LA; + 3 MO; + 3 MO; + 1 MO; * URSO 250 TABS (Ursodiol) URSO FORTE TABS (Ursodiol) ursodiol caps You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 68 Drug Name ursodiol tabs Drug Requirements/ Tier Limits 1 MO; * Gastrointestinal Antiallergy Agents cromolyn sodium 1 MO; * (mastocytosis) conc GASTROCROM CONC MO; + 3 (Cromolyn Sodium (Mastocytosis)) Gastrointestinal Chloride Channel Activators 2 MO; + AMITIZA CAPS Gastrointestinal Stimulants metoclopramide hcl soln ij 5 mg/ml metoclopramide hcl soln or 5 mg/5ml, 10 mg/10ml metoclopramide hcl tabs METOZOLV ODT TBDP (Metoclopramide HCl) REGLAN TABS (Metoclopramide HCl) 4 MO; + 1 MO; * 1 MO; * NF MO Drug Name INFLECTRA SOLR Drug Requirements/ Tier Limits 5 PA; + LIALDA TBEC 2 MO; + MESALAMINE DR TBEC 2 MO; + mesalamine enem 1 MO; * mesalamine w/ cleanser kit 1 MO; * PENTASA CPCR 250 MG 3 MO; + PENTASA CPCR 500 MG 5 MO; + REMICADE SOLR 5 PA; + 5 MO; + 5 PA; + sulfasalazine tabs 1 MO; * sulfasalazine tbec 1 MO; * ROWASA KIT (Mesalamine w/ Cleanser) STELARA SOLN IV 130 MG/26ML 3 MO; + APRISO CP24 2 MO; + ASACOL HD TBEC 2 MO; + 3 MO; + Intestinal Acidifiers lactulose (encephalopathy) 1 MO; * soln Irritable Bowel Syndrome (IBS) Agents 5 MO; + alosetron hcl tabs MO; + LINZESS CAPS 2 MO; + 3 1 LOTRONEX TABS (Alosetron HCl) 5 MO; + balsalazide disodium caps MO; * 5 MO; + VIBERZI TABS 5 PA; MO; + CANASA SUPP CIMZIA KIT 5 PA; + CIMZIA STARTER KIT KIT 5 PA; + Peripheral Opioid Receptor Antagonists 3 MO; + MOVANTIK TABS COLAZAL CAPS (Balsalazide Disodium) 3 MO; + DELZICOL CPDR 2 MO; + DIPENTUM CAPS 5 MO; + ENTYVIO SOLR 5 PA; + Inflammatory Bowel Agents AZULFIDINE EN-TABS TBEC (Sulfasalazine) AZULFIDINE TABS (Sulfasalazine) RELISTOR SOLN 5 MO; + RELISTOR TABS 5 PA; MO; + 5 MO; + Phosphate Binder Agents AURYXIA TABS You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 69 Drug Requirements/ Tier Limits calcium acetate (phosphate 1 MO; * binder) caps calcium acetate (phosphate 1 RX/OTC; MO; * binder) tabs 2 MO; + FOSRENOL CHEW Drug Name Drug Name sodium chloride (gu irrigant) soln Interstitial Cystitis Agents Drug Requirements/ Tier Limits 1 MO; * ELMIRON CAPS 3 MO; + 1 MO; * Prostatic Hypertrophy Agents PHOSLO CAPS (Calcium Acetate (Phosphate Binder)) 3 PHOSLYRA SOLN 3 MO; + AVODART CAPS (Dutasteride) RENAGEL TABS 800 MG 5 MO; + CARDURA XL TB24 3 MO; + RENVELA PACK 5 MO; + dutasteride caps 1 MO; * RENVELA TABS 5 MO; + dutasteride-tamsulosin hcl caps 1 MO; * VELPHORO CHEW 5 MO; + finasteride tabs 1 MO; * 3 MO; + MO; + alfuzosin hcl tb24 Short Bowel Syndrome (SBS) Agents 5 PA; LA; + GATTEX KIT GENITOURINARY AGENTS - MISCELLANEOUS - Miscellaneous Drugs to Treat Reproductive Organs and Urinary System Alkalinizers potassium citrate (alkalinizer) tbcr 540 mg, 1080 mg UROCIT-K 10 TBCR (Potassium Citrate (Alkalinizer)) UROCIT-K 5 TBCR (Potassium Citrate (Alkalinizer)) MO; * 1 MO NF FLOMAX CAPS (Tamsulosin HCl) JALYN CAPS (DutasterideTamsulosin HCl) PROSCAR TABS (Finasteride) NF MO NF MO 3 MO; + RAPAFLO CAPS 3 MO; + tamsulosin hcl caps 1 MO; * UROXATRAL TB24 (Alfuzosin HCl) 3 MO; + GOUT AGENTS - Drugs to Treat Gout MO NF Cystinosis Agents CYSTAGON CAPS 3 + PROCYSBI CPDR 3 LA; + acetic acid soln 1 neomycin/polymyxin b gu soln 1 Gout Agent Combinations colchicine w/ probenecid tabs 1 MO; * Gout Agents allopurinol tabs 100 mg 1 allopurinol tabs 300 mg 1 MO; * COLCHICINE CAPS 3 SL(8 ea daily); MO; * SL(2.66 ea daily); MO; * MO; + MO; * COLCHICINE TABS 2 MO; + COLCRYS TABS 2 MO; + Genitourinary Irrigants You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 70 Drug Name MITIGARE CAPS Drug Requirements/ Tier Limits 3 MO; + ULORIC TABS 2 ZURAMPIC TABS 3 ZYLOPRIM TABS 100 MG (Allopurinol) ZYLOPRIM TABS 300 MG (Allopurinol) 3 3 MO; + PA; SL(1 ea daily); MO; + SL(8 ea daily); MO; + SL(2.66 ea daily); MO; + Uricosurics probenecid tabs 1 MO; * HEMATOLOGICAL AGENTS - MISC. - Drugs to Treat Blood Disorders Bradykinin B2 Receptor Antagonists 5 + FIRAZYR SOLN Complement Inhibitors Drug Name clopidogrel bisulfate tabs 75 mg Drug Requirements/ Tier Limits 1 MO; * dipyridamole tabs 1 AL; MO; * EFFIENT TABS 2 MO; + 3 AL; MO; + 3 + 3 MO; + PERSANTINE TABS (Dipyridamole) PLAVIX TABS 300 MG (Clopidogrel Bisulfate) PLAVIX TABS 75 MG (Clopidogrel Bisulfate) PLETAL TABS 100 MG (Cilostazol) PLETAL TABS 50 MG (Cilostazol) NF MO; NT 3 MO; + ticlopidine hcl tabs 1 AL; * ZONTIVITY TABS 2 MO; + BERINERT KIT 5 LA; + HEMATOPOIETIC AGENTS - Drugs to Treat Blood Disorders CINRYZE SOLR 5 LA; + Agents for Gaucher Disease RUCONEST SOLR 5 + CERDELGA CAPS 5 PA; + CEREZYME SOLR 5 LA; + ELELYSO SOLR 5 + VPRIV SOLR 5 + ZAVESCA CAPS 5 LA; + 3 MO; + Hematorheologic Agents pentoxifylline tbcr 1 MO; * Plasma Kallikrein Inhibitors KALBITOR SOLN 5 Platelet Aggregation Inhibitors AGGRENOX CP12 2 (Aspirin-Dipyridamole) AGRYLIN CAPS 3 (Anagrelide HCl) + MO; + Agents for Sickle Cell Anemia DROXIA CAPS MO; + Cobalamins anagrelide hcl caps 1 MO; * cyanocobalamin soln 4 MO; NT; + aspirin-dipyridamole cp12 1 MO; * NASCOBAL SOLN 3 MO; NT; + BRILINTA TABS 2 MO; + Folic Acid/Folates cilostazol tabs 1 MO; * folic acid tabs 1 mg 1 RX/OTC; MO; NT; * clopidogrel bisulfate tabs 300 mg 1 * Hematopoietic Growth Factors You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 71 Drug Requirements/ Tier Limits ARANESP ALBUMIN PA; + FREE SOLN 100 MCG/ML, 4 60 MCG/ML, 25 MCG/ML, 40 MCG/ML ARANESP ALBUMIN PA; + FREE SOLN 200 MCG/ML, 5 300 MCG/ML ARANESP ALBUMIN PA; + FREE SOSY 10 MCG/0.4ML, 40 4 MCG/0.4ML, 60 MCG/0.3ML, 100 MCG/0.5ML, 25 MCG/0.42ML ARANESP ALBUMIN PA; + FREE SOSY 300 5 MCG/0.6ML, 200 MCG/0.4ML, 150 MCG/0.3ML, 500 MCG/ML EPOGEN SOLN 10000 3 PA; + UNIT/ML EPOGEN SOLN 2000 PA; + 4 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML EPOGEN SOLN 20000 5 PA; + UNIT/ML 5 PA; + GRANIX SOSY Drug Name LEUKINE SOLR MIRCERA SOSY 200 MCG/0.3ML MIRCERA SOSY 75 MCG/0.3ML, 100 MCG/0.3ML, 50 MCG/0.3ML NEULASTA ONPRO KIT PSKT Drug Name PROCRIT SOLN 4000 UNIT/ML, 2000 UNIT/ML, 10000 UNIT/ML, 3000 UNIT/ML PROCRIT SOLN 40000 UNIT/ML, 20000 UNIT/ML PROMACTA TABS 12.5 MG PA; + PROMACTA TABS 25 MG 5 PROMACTA TABS 50 MG 5 PROMACTA TABS 75 MG 5 ZARXIO SOSY 5 5 + 5 Stem Cell Mobilizers MOZOBIL SOLN HEMOSTATICS - Drugs to Stop Bleeding/Treat Blood Disorders Hemostatics - Systemic AMICAR SOLN 5 MO; + AMICAR TABS 1000 MG 5 + 3 MO; + 5 + 1 MO; * 3 + PA; + AMICAR TABS 500 MG 5 PA; B/D; + AMINOCAPROIC ACID TABS 1000 MG aminocaproic acid tabs 500 mg CYKLOKAPRON SOLN (Tranexamic Acid) LYSTEDA TABS (Tranexamic Acid) 3 5 SL(12 ea daily); LA; + SL(6 ea daily); LA; + SL(3 ea daily); LA; + SL(2 ea daily); LA; + PA; + 5 PA; B/D; + Drug Requirements/ Tier Limits PA; + 2 NF MO 5 PA; + NEULASTA SOSY 5 PA; + tranexamic acid soln 1 * NEUMEGA SOLR 5 PA; + tranexamic acid tabs 1 MO; * NEUPOGEN SOLN 5 PA; + HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS NEUPOGEN SOSY 5 PA; + Barbiturate Hypnotics BUTISOL SODIUM TABS 2 AL; MO; + You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 72 Drug Name phenobarbital elix Drug Requirements/ Tier Limits 1 AL; MO; * phenobarbital soln 1 AL; MO; * phenobarbital tabs 1 AL; MO; * Hypnotics - Tricyclic Agents SILENOR TABS 3 MG 3 SILENOR TABS 6 MG 3 Non-Barbiturate Hypnotics AMBIEN CR TBCR 12.5 MG (Zolpidem Tartrate) AMBIEN CR TBCR 6.25 MG (Zolpidem Tartrate) AMBIEN TABS 10 MG (Zolpidem Tartrate) AMBIEN TABS 5 MG (Zolpidem Tartrate) 3 3 3 3 EDLUAR SUBL 10 MG 3 EDLUAR SUBL 5 MG 3 eszopiclone tabs 1 INTERMEZZO SUBL 1.75 MG (Zolpidem Tartrate) INTERMEZZO SUBL 3.5 MG (Zolpidem Tartrate) LUNESTA TABS (Eszopiclone) RESTORIL CAPS (Temazepam) QL(2 ea daily); MO; + QL(1 ea daily); MO; + AL; SL(1 ea daily); MO; + AL; SL(2 ea daily); MO; + AL; SL(1 ea daily); MO; + AL; SL(2 ea daily); MO; + AL; SL(1 ea daily); MO; + AL; SL(2 ea daily); MO; + AL; MO; * AL; SL(2 ea daily); MO; + 3 AL; SL(1 ea daily); MO; + NF AL; MO 3 3 MO; + SONATA CAPS (Zaleplon) 3 AL; MO; + temazepam caps 1 MO; * 1 AL; MO; * zaleplon caps zolpidem tartrate subl 1.75 mg zolpidem tartrate subl 3.5 mg zolpidem tartrate tabs 10 mg 1 1 1 AL; SL(2 ea daily); MO; * AL; SL(1 ea daily); MO; * AL; SL(1 ea daily); MO; * Drug Requirements/ Tier Limits 1 AL; SL(2 ea zolpidem tartrate tabs 5 mg daily); MO; * zolpidem tartrate tbcr 12.5 1 AL; SL(1 ea mg daily); MO; * zolpidem tartrate tbcr 6.25 1 AL; SL(2 ea mg daily); MO; * 3 AL; SL(0.26 ml ZOLPIMIST SOLN daily); MO; + Drug Name Orexin Receptor Antagonists BELSOMRA TABS 10 MG 3 BELSOMRA TABS 15 MG 3 BELSOMRA TABS 20 MG 3 BELSOMRA TABS 5 MG 3 PA; SL(2 ea daily); MO; + PA; SL(1.33 ea daily); MO; + PA; SL(1 ea daily); MO; + PA; SL(4 ea daily); MO; + Selective Melatonin Receptor Agonists 5 PA; + HETLIOZ CAPS ROZEREM TABS 3 MO; + LAXATIVES - Bowel Treatment Drugs Laxative Combinations bisacodyl-peg 3350-pot chloride-sod bicarb-sod chloride kit COLYTE-FLAVOR PACKS SOLR 227.1GM-21.5GM5.53GM-2.82GM-6.36GM COLYTE-FLAVOR PACKS SOLR 240GM-22.72GM5.84GM-2.98GM-6.72GM (PEG 3350-KCl-Sod Bicarb-Sod Chloride-Sod Sulfate) GOLYTELY SOLR 227.1GM-21.5GM-5.53GM2.82GM-6.36GM GOLYTELY SOLR 236GM22.74GM-5.86GM-2.97GM6.74GM (PEG 3350-KClSod Bicarb-Sod ChlorideSod Sulfate) MOVIPREP SOLR * 1 + 3 MO NF MO; + 3 MO NF 3 MO; + You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 73 Drug Requirements/ Tier Limits NULYTELY/FLAVOR MO PACKS SOLR (PEG 3350- NF Potassium Chloride-Sod Bicarbonate-Sod Chloride) peg 3350-kcl-sod bicarbMO; * 1 sod chloride-sod sulfate solr peg 3350-potassium MO; * 1 chloride-sod bicarbonatesod chloride solr 3 MO; + PREPOPIK PACK Drug Name SUPREP BOWEL PREP KIT SOLN 3 MO; + Laxatives - Miscellaneous lactulose soln polyethylene glycol 3350 pack polyethylene glycol 3350 powd or Saline Laxatives OSMOPREP TABS 1 MO; * 1 RX/OTC; MO; * 1 RX/OTC; MO; * 3 MO; + LOCAL ANESTHETICS-Parenteral - Drugs for Numbing Local Anesthetics - Amides lidocaine hcl (local anesth.) 4 + soln 1 %, 2 % XYLOCAINE SOLN IJ 1 %, + 4 2 % (Lidocaine HCl (Local Anesth.)) XYLOCAINE-MPF SOLN 1 + 4 % (Lidocaine HCl (Local Anesth.)) MACROLIDES - Drugs to Treat Bacterial Infections Azithromycin 2 MO; + AZITHROMYCIN PACK azithromycin solr 4 MO; + azithromycin susr 1 MO; * azithromycin tabs 1 MO; * Drug Name ZITHROMAX PACK ZITHROMAX SOLR (Azithromycin) ZITHROMAX SUSR (Azithromycin) ZITHROMAX TABS (Azithromycin) ZITHROMAX TRI-PAK TABS (Azithromycin) ZITHROMAX Z-PAK TABS (Azithromycin) Clarithromycin BIAXIN SUSR (Clarithromycin) BIAXIN SUSR (Clarithromycin) BIAXIN TABS (Clarithromycin) clarithromycin susr 250 mg/5ml Drug Requirements/ Tier Limits 2 MO; + 4 MO; + 3 MO; + 3 MO; + 3 MO; + 3 MO; + NF NF NT 3 MO; + 1 MO; * clarithromycin tabs 1 MO; * clarithromycin tb24 1 MO; * 3 SL(100 ml daily); MO; + 3 SL(100 ml daily); MO; + Erythromycins E.E.S. GRANULES SUSR (Erythromycin Ethylsuccinate) ERYPED 200 SUSR (Erythromycin Ethylsuccinate) ERYPED 400 SUSR 3 ERYTHROCIN LACTOBIONATE SOLR 4 erythromycin base cpep 1 erythromycin base tabs 250 mg erythromycin base tabs 500 mg erythromycin ethylsuccinate susr erythromycin ethylsuccinate tabs 1 1 1 1 SL(50 ml daily); MO; + SL(8 ea daily); + SL(16 ea daily); MO; * SL(16 ea daily); MO; * SL(8 ea daily); MO; * SL(100 ml daily); MO; * SL(10 ea daily); MO; * You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 74 Drug Name PCE TBEC 333 MG Drug Requirements/ Tier Limits 3 SL(12 ea daily); MO; + Fidaxomicin DIFICID TABS 5 MO; + MEDICAL DEVICES AND SUPPLIES Bandages-Dressings-Tape gauze pads 2" x 2" 1 RX/OTC; MO; * 2 RX/OTC; MO; + Misc. Devices ALCOHOL PADS Parenteral Therapy Supplies INSULIN SYRINGES AND 2 PEN NEEDLES RX/OTC; MO; + MIGRAINE PRODUCTS - Drugs to Treat Migraine Headaches Migraine Combinations CAFERGOT TABS (Ergotamine w/ Caffeine) ergotamine w/ caffeine supp 3 MO; + 1 MO; * ergotamine w/ caffeine tabs 1 MO; * TREXIMET TABS 3 MO; + 3 MO; + Migraine Products - NSAIDs CAMBIA PACK Migraine Products D.H.E. 45 SOLN (Dihydroergotamine Mesylate) dihydroergotamine mesylate soln ij 1 mg/ml DIHYDROERGOTAMINE MESYLATE SOLN NA 4 MG/ML MO NF 1 MO; * MO; + 5 ergotamine tartrate subl 1 * MIGRANAL SOLN 5 MO; + Serotonin Agonists Drug Requirements/ Tier Limits 1 QL(0.4 ea almotriptan malate tabs daily); MO; * AMERGE TABS 3 QL(0.3 ea (Naratriptan HCl) daily); MO; + AXERT TABS (Almotriptan NF QL(0.4 ea Malate) daily); MO FROVA TABS (Frovatriptan 3 QL(0.6 ea Succinate) daily); MO; + 1 QL(0.6 ea frovatriptan succinate tabs daily); MO; * Limit 12 inhalers per IMITREX SOLN NA 20 3 month;QL(0.4 MG/ACT (Sumatriptan) ea daily); MO; + Limit 18 inhalers per IMITREX SOLN NA 5 3 month;QL(0.6 MG/ACT (Sumatriptan) ea daily); MO; + IMITREX SOLN SC 6 Limit 8mls per 4 month;QL(0.27 MG/0.5ML (Sumatriptan Succinate) ml daily); MO; + Solution IMITREX STATDOSE cartridge; Limit REFILL SOCT 4 MG/0.5ML 4 4mls per (Sumatriptan Succinate) month;QL(0.14 ml daily); MO; + Solution IMITREX STATDOSE cartridge; Limit REFILL SOCT 6 MG/0.5ML 4 8mls per (Sumatriptan Succinate) month;QL(0.27 ml daily); MO; + IMITREX STATDOSE Auto-injector; SYSTEM SOAJ 4 4 Limit 4mls per MG/0.5ML (Sumatriptan month;QL(0.14 Succinate) ml daily); MO; + IMITREX STATDOSE Auto-injector; SYSTEM SOAJ 6 NF Limit 8mls per MG/0.5ML (Sumatriptan month;QL(0.27 Succinate) ml daily); MO IMITREX TABS 100 MG 3 QL(0.3 ea (Sumatriptan Succinate) daily); MO; + IMITREX TABS 25 MG 3 QL(0.9 ea (Sumatriptan Succinate) daily); MO; + IMITREX TABS 50 MG 3 QL(0.6 ea (Sumatriptan Succinate) daily); MO; + Drug Name You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 75 Drug Requirements/ Tier Limits MAXALT TABS 10 MG 3 QL(0.4 ea (Rizatriptan Benzoate) daily); MO; + MAXALT TABS 5 MG 3 QL(0.8 ea (Rizatriptan Benzoate) daily); MO; + MAXALT-MLT TBDP 10 3 QL(0.4 ea MG (Rizatriptan Benzoate) daily); MO; + MAXALT-MLT TBDP 5 MG 3 QL(0.8 ea (Rizatriptan Benzoate) daily); MO; + 1 QL(0.3 ea naratriptan hcl tabs daily); MO; * 3 QL(0.2 ea RELPAX TABS daily); MO; + rizatriptan benzoate tabs 1 QL(0.4 ea 10 mg daily); MO; * rizatriptan benzoate tabs 5 1 QL(0.8 ea mg daily); MO; * rizatriptan benzoate tbdp 1 QL(0.4 ea 10 mg daily); MO; * rizatriptan benzoate tbdp 5 1 QL(0.8 ea mg daily); MO; * Limit 12 1 inhalers per sumatriptan soln 20 mg/act month;QL(0.4 ea daily); MO; * Limit 18 1 inhalers per sumatriptan soln 5 mg/act month;QL(0.6 ea daily); MO; * Auto-injector; Limit 4mls per sumatriptan succinate soaj 4 month;QL(0.14 4 mg/0.5ml ml daily); MO; + Auto-injector; sumatriptan succinate soaj 1 Limit 8mls per 6 mg/0.5ml month;QL(0.27 ml daily); MO; * Solution cartridge; Limit sumatriptan succinate soct 4 4mls per 4 mg/0.5ml month;QL(0.14 ml daily); MO; + Drug Name Drug Requirements/ Tier Limits Solution cartridge; Limit sumatriptan succinate soct 4 8mls per 6 mg/0.5ml month;QL(0.27 ml daily); MO; + Limit 8mls per 4 month;QL(0.27 sumatriptan succinate soln ml daily); MO; + Prefilled syringe; Limit SUMATRIPTAN 4 8mls per SUCCINATE SOSY month;QL(0.27 ml daily); + sumatriptan succinate tabs 1 QL(0.3 ea 100 mg daily); MO; * sumatriptan succinate tabs 1 QL(0.9 ea 25 mg daily); MO; * sumatriptan succinate tabs 1 QL(0.6 ea 50 mg daily); MO; * Limit 4mls per SUMAVEL DOSEPRO 4 month;QL(0.14 SOTJ ml daily); MO; + ZEMBRACE SYMTOUCH 4 SL(2 ml daily); SOAJ MO; + 1 SL(4 ea daily); zolmitriptan tabs 2.5 mg MO; * 1 SL(2 ea daily); zolmitriptan tabs 5 mg MO; * 1 SL(4 ea daily); zolmitriptan tbdp 2.5 mg MO; * 1 SL(2 ea daily); zolmitriptan tbdp 5 mg MO; * 3 SL(4 ea daily); ZOMIG SOLN 2.5 MG MO; + 3 SL(2 ea daily); ZOMIG SOLN 5 MG MO; + ZOMIG TABS 2.5 MG NF SL(4 ea daily); (Zolmitriptan) MO ZOMIG TABS 5 MG NF SL(2 ea daily); (Zolmitriptan) MO ZOMIG ZMT TBDP 2.5 MG NF SL(4 ea daily); (Zolmitriptan) MO ZOMIG ZMT TBDP 5 MG NF SL(2 ea daily); (Zolmitriptan) MO Drug Name MINERALS & ELECTROLYTES Electrolyte Mixtures You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 76 Drug Requirements/ Tier Limits dextrose in lactated ringers 4 + soln dextrose w/ sodium + 4 chloride soln 0.45%-2.5%, 0.45%-5% dextrose w/ sodium 4 MO; + chloride soln 0.9%-5% 4 + lactated ringer's soln Drug Name Drug Name GALZIN CAPS 25 MG MISCELLANEOUS THERAPEUTIC CLASSES Chelating Agents DEPEN TITRATABS TABS 3 MO; + SYPRINE CAPS 5 MO; + 5 + REVLIMID CAPS 5 LA; + THALOMID CAPS 2 + ASTAGRAF XL CP24 3 MO; B/D; + parenteral electrolytes conc 4 B/D; + Enzymes parenteral electrolytes soln 4 B/D; + XIAFLEX SOLR + Immunomodulators potassium chloride in dextrose & sodium chloride soln 0.45%-20meq/l-5% Magnesium magnesium sulfate soln ij 50 % Potassium K-TAB TBCR 10 MEQ (Potassium Chloride) K-TAB TBCR 8 MEQ, 20 MEQ MICRO-K CPCR (Potassium Chloride) potassium chloride cpcr POTASSIUM CHLORIDE ER TBCR potassium chloride microencapsulated crystals cr tbcr potassium chloride soln iv 2 meq/ml potassium chloride soln or 20 %, 10 % potassium chloride tbcr Sodium sodium chloride soln iv 0.45 % sodium chloride soln iv 0.9 % Zinc 4 4 MO; + Drug Requirements/ Tier Limits 3 MO; NT; + Immunosuppressive Agents 3 MO; + ATGAM INJ 4 B/D; + 3 MO; + AZATHIOPRINE SOLR 4 B/D; + 3 MO; + azathioprine tabs 1 MO; B/D; * 1 MO; * 5 MO; B/D; + 3 MO; + MO; * 1 4 MO; + 1 MO; * 1 MO; * 4 + 4 MO; + CELLCEPT CAPS (Mycophenolate Mofetil) CELLCEPT INTRAVENOUS SOLR (Mycophenolate Mofetil HCl) CELLCEPT SUSR (Mycophenolate Mofetil) CELLCEPT TABS (Mycophenolate Mofetil) B/D; + 4 5 MO; B/D; + 5 MO; B/D; + cyclosporine caps 1 MO; B/D; * cyclosporine modified (for microemulsion) caps 1 MO; B/D; * cyclosporine soln 4 B/D; + ENVARSUS XR TB24 3 MO; B/D; + IMURAN TABS (Azathioprine) 3 MO; B/D; + You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 77 Drug Name mycophenolate mofetil caps mycophenolate mofetil hcl solr Drug Requirements/ Tier Limits 1 MO; B/D; * 4 B/D; + mycophenolate mofetil susr 5 MO; B/D; + mycophenolate mofetil tabs 1 MO; B/D; * 1 MO; B/D; * 3 MO; B/D; + 5 MO; B/D; + mycophenolate sodium tbec MYFORTIC TBEC 180 MG (Mycophenolate Sodium) MYFORTIC TBEC 360 MG (Mycophenolate Sodium) NEORAL CAPS (Cyclosporine Modified (For Microemulsion)) MO; B/D; + 3 5 B/D; + 3 MO; B/D; + 5 MO; B/D; + PROGRAF SOLN 4 B/D; + RAPAMUNE SOLN 2 MO; B/D; + 2 MO; B/D; + 5 MO; B/D; + 3 MO; B/D; + 4 B/D; + 3 MO; B/D; + SIMULECT SOLR 5 B/D; + sirolimus tabs 1 MO; B/D; * tacrolimus caps 1 MO; B/D; * THYMOGLOBULIN SOLR 2 B/D; + ZORTRESS TABS 0.25 MG 2 MO; B/D; + NULOJIX SOLR PROGRAF CAPS 1 MG, 0.5 MG (Tacrolimus) PROGRAF CAPS 5 MG (Tacrolimus) RAPAMUNE TABS 0.5 MG, 2 MG (Sirolimus) RAPAMUNE TABS 1 MG (Sirolimus) SANDIMMUNE CAPS (Cyclosporine) SANDIMMUNE SOLN IV 50 MG/ML (Cyclosporine) SANDIMMUNE SOLN OR 100 MG/ML Drug Name ZORTRESS TABS 0.75 MG, 0.5 MG Irrigation Solutions irrigation solutions, physiological soln water for irrigation, sterile soln Drug Requirements/ Tier Limits 5 MO; B/D; + 1 * 1 MO; * Potassium Removing Agents KAYEXALATE POWD 3 (Sodium Polystyrene Sulfonate) sodium polystyrene 1 sulfonate powd sodium polystyrene 1 sulfonate susp or 15 gm/60ml VELTASSA PACK 16.8 GM 3 VELTASSA PACK 25.2 GM 3 VELTASSA PACK 8.4 GM 3 MO; + MO; * MO; * ST; SL(1.5 ea daily); LA; MO; + ST; SL(1 ea daily); LA; MO; + ST; SL(3 ea daily); LA; MO; + Systemic Lupus Erythematosus Agents 5 + BENLYSTA SOLR MOUTH/THROAT/DENTAL AGENTS Anesthetics Topical Oral lidocaine hcl (mouth-throat) soln 1 MO; * clotrimazole lozg 1 MO; * clotrimazole troc 1 MO; * 1 MO; * 1 MO; * Anti-infectives - Throat nystatin (mouth-throat) susp Antiseptics - Mouth/Throat chlorhexidine gluconate (mouth-throat) soln Dental Products You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 78 Drug Name GEL-KAM ORAL CARE RINSE CONC (Stannous Fluoride) Steroids - Mouth/Throat triamcinolone acetonide (mouth) pste Drug Requirements/ Tier Limits RX/OTC; MO; NF NT 1 MO; * 1 MO; * Throat Products - Misc. cevimeline hcl caps EVOXAC CAPS (Cevimeline HCl) NF MO pilocarpine hcl (oral) tabs 1 MO; * SALAGEN TABS (Pilocarpine HCl (Oral)) 3 MO; + MULTIVITAMINS Iron w/ Vitamins VITAFOL TABS (Iron w/ Vitamins) NF RX/OTC; MO; NT Multiple Vitamins w/ Minerals CENTRUM SILVER NF 50+MEN TABS (Multiple Vitamins w/ Minerals) CENTRUM SILVER 50+WOMEN TABS NF (Multiple Vitamins w/ Minerals) CENTRUM SILVER ADULT 50+ TABS (Multiple NF Vitamins w/ Minerals) CENTRUM SILVER TABS NF (Multiple Vitamins w/ Minerals) CENTRUM TABS (Multiple NF Vitamins w/ Minerals) CENTRUM ULTRA MENS TABS (Multiple Vitamins w/ NF Minerals) CENTRUM WOMEN TABS NF (Multiple Vitamins w/ Minerals) FOSFREE TABS (Multiple NF Vitamins w/ Minerals) RX/OTC; MO; NT RX/OTC; MO; NT RX/OTC; MO; NT RX/OTC; MO; NT Drug Requirements/ Tier Limits ONE-A-DAY WEIGHT RX/OTC; MO; SMART ADVANCED TABS NF NT (Multiple Vitamins w/ Minerals) ONE-A-DAY WOMENS RX/OTC; MO; 50+ ADVANTAGE TABS NF NT (Multiple Vitamins w/ Minerals) ONE-A-DAY WOMENS RX/OTC; MO; ACTIVE MIND & BODY NF NT TABS (Multiple Vitamins w/ Minerals) ONE-A-DAY WOMENS RX/OTC; MO; NF NT PETITES TABS (Multiple Vitamins w/ Minerals) ONE-A-DAY WOMENS RX/OTC; MO; PLUS HEALTHY SKIN NF NT SUPPORT TABS (Multiple Vitamins w/ Minerals) OPTIVITE P.M.T. TABS RX/OTC; MO; NF NT (Multiple Vitamins w/ Minerals) RAGUS TABS (Multiple NF RX/OTC; MO; Vitamins w/ Minerals) NT STROVITE FORTE TABS RX/OTC; MO; NF NT (Multiple Vitamins w/ Minerals) THERAMILL FORTE CAPS RX/OTC; MO; NF NT (Multiple Vitamins w/ Minerals) VITAROCA PLUS TABS RX/OTC; MO; NF NT (Multiple Vitamins w/ Minerals) Drug Name MUSCULOSKELETAL THERAPY AGENTS Drugs to Treat Spasms Central Muscle Relaxants RX/OTC; MO; NT RX/OTC; MO; NT AMRIX CP24 3 baclofen tabs 10 mg 1 RX/OTC; MO; NT baclofen tabs 20 mg 1 carisoprodol tabs 1 SL(8 ea daily); MO; * SL(4 ea daily); MO; * AL; MO; * chlorzoxazone tabs 1 AL; MO; * RX/OTC; MO; NT AL; MO; + You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 79 Drug Name cyclobenzaprine hcl tabs 7.5 mg, 10 mg, 5 mg Drug Requirements/ Tier Limits 1 AL; MO; * Drug Name NASAL AGENTS - SYSTEMIC AND TOPICAL Drugs to treat the Nose or Sinus metaxalone tabs 1 AL; MO; * Nasal Agent Combinations methocarbamol tabs 1 AL; MO; * DYMISTA SUSP orphenadrine citrate tb12 1 AL; MO; * 3 AL; MO; + Nasal Anti-infectives BACTROBAN NASAL OINT 3 AL; MO; + 3 AL; MO; + 3 AL; MO; + 3 AL; MO; + PATANASE SOLN (Olopatadine HCl (Nasal)) SL(18 ea daily); MO; * SL(9 ea daily); MO; * SL(6 ea daily); MO; * SL(18 ea daily); MO; * SL(9 ea daily); MO; * SL(18 ea daily); MO; + SL(9 ea daily); MO; + SL(6 ea daily); MO; + SL(9 ea daily); MO; + Nasal Anticholinergics ATROVENT SOLN (Ipratropium Bromide (Nasal)) ipratropium bromide (nasal) soln PARAFON FORTE DSC TABS (Chlorzoxazone) ROBAXIN TABS (Methocarbamol) ROBAXIN-750 TABS (Methocarbamol) SKELAXIN TABS (Metaxalone) SOMA TABS (Carisoprodol) tizanidine hcl caps 2 mg 1 tizanidine hcl caps 4 mg 1 tizanidine hcl caps 6 mg 1 tizanidine hcl tabs 2 mg 1 tizanidine hcl tabs 4 mg 1 ZANAFLEX CAPS 2 MG (Tizanidine HCl) ZANAFLEX CAPS 4 MG (Tizanidine HCl) ZANAFLEX CAPS 6 MG (Tizanidine HCl) ZANAFLEX TABS (Tizanidine HCl) Direct Muscle Relaxants DANTRIUM CAPS (Dantrolene Sodium) dantrolene sodium caps 3 3 3 3 3 MO; + 1 MO; * Muscle Relaxant Combinations carisoprodol w/ aspirin & 1 codeine tabs AL; MO; * carisoprodol w/ aspirin tabs AL; MO; * 1 Drug Requirements/ Tier Limits Nasal Antiallergy ASTEPRO SOLN (Azelastine HCl) 3 MO; + 3 MO; + NF MO azelastine hcl soln 1 MO; * olopatadine hcl (nasal) soln 1 MO; * NF MO MO; + 3 1 MO; * BECONASE AQ SUSP 3 MO; + budesonide (nasal) susp 1 RX/OTC; MO; * flunisolide (nasal) soln 1 MO; * 1 RX/OTC; MO; * 1 MO; * Nasal Steroids fluticasone propionate (nasal) susp mometasone furoate (nasal) susp NASONEX SUSP (Mometasone Furoate (Nasal)) MO; + 2 OMNARIS SUSP 3 MO; + QNASL AERS 3 MO; + 3 MO; + QNASL CHILDRENS AERS RHINOCORT AQUA SUSP (Budesonide (Nasal)) NF RX/OTC; MO You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 80 Drug Name triamcinolone acetonide (nasal) aero Drug Requirements/ Tier Limits 1 RX/OTC; MO; * VERAMYST SUSP 3 ZETONNA AERS 3 RX/OTC; MO; + MO; + NEUROMUSCULAR AGENTS - Drugs to Relax/Paralyze Muscles ALS Agents RILUTEK TABS (Riluzole) 5 MO; + riluzole tabs 1 MO; * 5 PA; LA; + Muscular Dystrophy Agents EXONDYS 51 SOLN Neuromuscular Blocking Agent - Neurotoxins 4 PA; + BOTOX SOLR 100 UNIT BOTOX SOLR 200 UNIT 3 PA; + XEOMIN SOLR 4 PA; + Drug Name TROPHAMINE SOLN 0.05GM/100ML0.41GM/100ML0.015GM/100ML0.73GM/100ML0.49GM/100ML0.12GM/100ML0.25GM/100ML0.47GM/100ML0.29GM/100ML0.29GM/100ML0.2GM/100ML0.84GM/100ML0.14GM/100ML0.49GM/100ML0.3GM/100ML0.19GM/100ML0.23GM/100ML0.32GM/100ML0.22GM/100ML0.014GM/100ML (Amino Acid Infusion) NUTRIENTS Carbohydrates 4 B/D; + dextrose soln 5 % 4 MO; B/D; + 4 B/D; + Lipids fat emulsion emul Proteins amino acid infusion 15% AMINOSYN II 15% (Use amino acid infusion) CLINIMIX 2.75%/DEXTROSE 5% SOLN PROSOL SOLN 3 MO; + betaxolol hcl (ophth) soln 1 MO; * BETIMOL SOLN 3 MO; + BETOPTIC-S SUSP 2 MO; + carteolol hcl (ophth) soln 1 MO; * COMBIGAN SOLN 3 MO; + 3 MO; + 4 B/D; + COSOPT PF SOLN 4 B/D; + COSOPT SOLN (Dorzolamide HCl-Timolol Maleate) dorzolamide hcl-timolol maleate soln B/D; + 4 4 B/D; + NF OPHTHALMIC AGENTS - Drugs to Treat the Eye Beta-blockers - Ophthalmic BETAGAN SOLN (Levobunolol HCl) dextrose soln 10 % Drug Requirements/ Tier Limits B/D MO; + 3 1 MO; * ISTALOL SOLN 2 MO; + levobunolol hcl soln 1 MO; * timolol maleate (ophth) solg 1 MO; * You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 81 Drug Name timolol maleate (ophth) soln TIMOPTIC OCUDOSE SOLN TIMOPTIC SOLN (Timolol Maleate (Ophth)) TIMOPTIC-XE SOLG (Timolol Maleate (Ophth)) Cycloplegic Mydriatics cyclopentolate hcl soln 1 %, 2 % Miotics ISOPTO CARPINE SOLN (Pilocarpine HCl) PHOSPHOLINE IODIDE SOLR pilocarpine hcl soln Drug Requirements/ Tier Limits 1 MO; * 3 MO; + 3 MO; + 3 MO; + 1 MO; * 3 MO; + 3 + 1 MO; * Ophthalmic - Angiogenesis Inhibitors 5 LA; + EYLEA SOLN Ophthalmic Adrenergic Agents ALPHAGAN P SOLN 0.1 % 2 MO; + ALPHAGAN P SOLN 0.15 % (Brimonidine Tartrate) 3 MO; + apraclonidine hcl soln 1 MO; * brimonidine tartrate soln 1 MO; * IOPIDINE SOLN 0.5 % (Apraclonidine HCl) SIMBRINZA SUSP NF MO 3 MO; + Ophthalmic Anti-infectives AZASITE SOLN 3 MO; + bacitracin (ophthalmic) oint 1 MO; * bacitracin-polymyxin b (ophth) oint 1 MO; * BESIVANCE SUSP 3 MO; + BLEPH-10 SOLN (Sulfacetamide Sodium (Ophth)) 3 MO; + Drug Name CILOXAN OINT CILOXAN SOLN (Ciprofloxacin HCl (Ophth)) ciprofloxacin hcl (ophth) soln Drug Requirements/ Tier Limits 3 MO; + 3 MO; + 1 MO; * erythromycin (ophth) oint 1 MO; * gatifloxacin (ophth) soln 1 MO; * 1 MO; * 1 MO; * levofloxacin (ophth) soln 1 MO; * MOXEZA SOLN 2 MO; + NATACYN SUSP 2 MO; + 1 MO; * 1 MO; * 3 MO; + 1 MO; * 1 MO; * gentamicin sulfate (ophth) oint gentamicin sulfate (ophth) soln neomycin-bacitracin znpolymyxin oint neomycin-polymyxingramicidin soln OCUFLOX SOLN (Ofloxacin (Ophth)) ofloxacin (ophth) soln polymyxin b-trimethoprim soln POLYTRIM SOLN (Polymyxin BTrimethoprim) sulfacetamide sodium (ophth) oint sulfacetamide sodium (ophth) soln MO; + 3 1 MO; * 1 MO; * tobramycin (ophth) soln 1 MO; * TOBREX OINT 3 MO; + TOBREX SOLN (Tobramycin (Ophth)) 3 MO; + trifluridine soln 1 MO; * VIGAMOX SOLN 2 MO; + You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 82 Drug Name VIROPTIC SOLN (Trifluridine) Drug Requirements/ Tier Limits 3 MO; + ZIRGAN GEL ZYMAXID SOLN (Gatifloxacin (Ophth)) 3 MO; + NF MO Ophthalmic Decongestants naphazoline hcl soln 1 * Ophthalmic Immunomodulators RESTASIS EMUL RESTASIS MULTIDOSE EMUL 2 MO; + 2 MO; + Ophthalmic Integrin Antagonists XIIDRA SOLN 3 PA; MO; + Ophthalmic Local Anesthetics Drug Name LOTEMAX SUSP MAXIDEX SUSP MAXITROL OINT (Neomycin-PolymyDexameth) MAXITROL SUSP (Neomycin-PolymyDexameth) neomycin-polymydexameth oint neomycin-polymydexameth susp OMNIPRED SUSP (Prednisolone Acetate (Ophth)) PRED FORTE SUSP (Prednisolone Acetate (Ophth)) 1 MO; * 3 MO; + bacitracin-poly-neomycinhc oint 1 MO; * prednisolone acetate (ophth) susp sulfacetamide sodprednisolone soln BLEPHAMIDE SUSP 3 MO; + dexamethasone sodium phosphate (ophth) soln 1 MO; * DUREZOL EMUL 2 MO; + FLAREX SUSP 2 MO; + fluorometholone (ophth) susp 1 MO; * FML FORTE SUSP 2 MO; + FML LIQUIFILM SUSP (Fluorometholone (Ophth)) 3 MO; + FML OINT 2 MO; + LOTEMAX GEL 3 MO; + LOTEMAX OINT 3 MO; + proparacaine hcl soln ALREX SUSP 3 MO; + MO; + 3 MO; + 3 1 MO; * 1 MO; * MO; + 3 MO; + 3 2 MO; + 1 MO; * 1 MO; * TOBRADEX OINT 3 MO; + TOBRADEX ST SUSP 3 MO; + PRED MILD SUSP Ophthalmic Steroids Drug Requirements/ Tier Limits 3 MO; + TOBRADEX SUSP (TobramycinDexamethasone) tobramycindexamethasone susp MO; + 3 1 MO; * VEXOL SUSP 3 + ZYLET SUSP 2 MO; + Ophthalmics - Misc. ACULAR LS SOLN (Ketorolac Tromethamine (Ophth)) ACULAR SOLN (Ketorolac Tromethamine (Ophth)) ACUVAIL SOLN MO; + 3 3 MO; + 3 MO; + You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 83 Drug Name ALOCRIL SOLN Drug Requirements/ Tier Limits 3 MO; + Drug Name Drug Requirements/ Tier Limits Prostaglandins - Ophthalmic 3 MO; + BIMATOPROST SOLN 2 MO; + ALOMIDE SOLN 1 MO; * latanoprost soln 1 MO; * azelastine hcl (ophth) soln 2 MO; + LUMIGAN SOLN 2 MO; + AZOPT SUSP 3 MO; + TRAVATAN Z SOLN 2 MO; + BEPREVE SOLN Once daily dosing;MO; * MO; * travoprost soln 1 * XALATAN SOLN (Latanoprost) 3 MO; + ZIOPTAN SOLN 3 MO; + bromfenac sodium (ophth) soln cromolyn sodium (ophth) soln 1 1 CYSTARAN SOLN 3 diclofenac sodium (ophth) soln 1 Limit 60mls per 28 days;QL(2.15 ml daily); LA; + MO; * dorzolamide hcl soln 1 MO; * ELESTAT SOLN (Epinastine HCl (Ophth)) 3 MO; + epinastine hcl (ophth) soln 1 MO; * flurbiprofen sodium soln 1 MO; * ofloxacin (otic) soln ILEVRO SUSP 2 MO; + Otic Combinations ketorolac tromethamine (ophth) soln 1 MO; * LASTACAFT SOLN 3 NEVANAC SUSP OTIC AGENTS - Drugs to Treat the Ear Otic Agents - Miscellaneous 1 MO; * 1 MO; * 3 MO; + 1 MO; * CIPRO HC SUSP 3 MO; + MO; + CIPRODEX SUSP 2 MO; + MO; + COLY-MYCIN S SUSP 3 MO; + 2 CORTISPORIN-TC SUSP 3 MO; + 3 MO; + 1 MO; * 1 MO; * 2 1 MO; * PATADAY SOLN MO; + PATANOL SOLN (Olopatadine HCl) 3 MO; + OCUFEN SOLN (Flurbiprofen Sodium) olopatadine hcl soln acetic acid (otic) soln PROLENSA SOLN 3 MO; + TRUSOPT SOLN (Dorzolamide HCl) 3 MO; + acetic acid-aluminum acetate soln Otic Anti-infectives FLOXIN OTIC SOLN (Ofloxacin (Otic)) neomycin-polymyxin-hc (otic) soln neomycin-polymyxin-hc (otic) susp Otic Steroids DERMOTIC OIL (Fluocinolone Acetonide (Otic)) fluocinolone acetonide (otic) oil MO; + 3 1 MO; * You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 84 Drug Name Drug Requirements/ Tier Limits 1 MO; * hydrocortisone w/acetic acid soln OXYTOCICS - Drugs to Prevent/Control Uterine Bleeding Oxytocics methylergonovine maleate 1 MO; * tabs PASSIVE IMMUNIZING AGENTS - Antibody Drugs to Treat Low Immune System Immune Serums 5 B/D; + BIVIGAM SOLN CUVITRU SOLN 1 GM/5ML CUVITRU SOLN 4 GM/20ML, 2 GM/10ML CUVITRU SOLN 8 GM/40ML FLEBOGAMMA DIF SOLN 10 % 3 B/D; + 4 B/D; + 5 B/D; + 5 B/D; + GAMASTAN S/D INJ 4 B/D; + GAMMAGARD LIQUID SOLN 5 B/D; + GAMMAKED SOLN 5 B/D; + GAMMAPLEX SOLN 5 GM/50ML, 20 GM/200ML, 10GM/100ML 5 GAMUNEX-C SOLN 5 HIZENTRA SOLN 1 GM/5ML HIZENTRA SOLN 10 GM/50ML HIZENTRA SOLN 2 GM/10ML, 4 GM/20ML OCTAGAM SOLN 5 GM/50ML, 10 GM/100ML, 2 GM/20ML, 20 GM/200ML B/D; + Drug Name SYNAGIS SOLN ZINPLAVA SOLN Drug Requirements/ Tier Limits 5 + 5 PA; + Passive Immunizing Agents - Combinations 5 B/D; + HYQVIA KIT PENICILLINS - Drugs to Treat Bacterial Infections Aminopenicillins amoxicillin caps 1 MO; * amoxicillin chew 1 MO; * amoxicillin susr 1 MO; * amoxicillin tabs 1 MO; * ampicillin caps 1 MO; * 4 MO; + 4 + ampicillin sodium solr ij 2 gm, 1 gm ampicillin sodium solr iv 10 gm Natural Penicillins BICILLIN L-A SUSP 2400000 UNIT/4ML, 1200000 UNIT/2ML MO; + 4 penicillin g potassium solr 4 MO; + B/D; + penicillin v potassium solr 250 mg/5ml 1 MO; * 3 B/D; + penicillin v potassium tabs 1 MO; * 5 B/D; + PFIZERPEN-G SOLR (Penicillin G Potassium) 4 MO; + 4 B/D; + Penicillin Combinations amoxicillin & pot clavulanate chew amoxicillin & pot clavulanate susr amoxicillin & pot clavulanate tabs amoxicillin & pot clavulanate tb12 1 MO; * 1 MO; * 1 MO; * 1 MO; * B/D; + 5 PRIVIGEN SOLN 5 B/D; + VARIZIG SOLN 5 + Monoclonal Antibodies You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 85 Drug Name Drug Requirements/ Tier Limits 4 MO; + ampicillin & sulbactam sodium solr ij 1gm-2gm ampicillin & sulbactam 4 sodium solr iv 5gm-10gm AUGMENTIN ES-600 3 SUSR (Amoxicillin & Pot Clavulanate) AUGMENTIN SUSR 250MG/5ML-62.5MG/5ML 3 (Amoxicillin & Pot Clavulanate) AUGMENTIN TABS 3 (Amoxicillin & Pot Clavulanate) AUGMENTIN XR TB12 3 (Amoxicillin & Pot Clavulanate) piperacillin sodium4 tazobactam sodium solr PIPERACILLIN/TAZOBAC 4 TAM SOLR UNASYN SOLR 1GM-2GM 4 (Ampicillin & Sulbactam Sodium) ZOSYN SOLN 4 0.375GM/50ML3GM/50ML-5% ZOSYN SOLR (Piperacillin 4 Sodium-Tazobactam Sodium) Penicillinase-Resistant Penicillins norethindrone acetate tabs MO; + progesterone micronized 1 MO; * caps PROMETRIUM CAPS 3 MO; + (Progesterone Micronized) PROVERA TABS MO; + 3 (Medroxyprogesterone Acetate) PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. - Drugs to Treat Mental and Emotional Conditions Agents for Chemical Dependency 1 MO; * acamprosate calcium tbec MO; + MO; + MO; + + + disulfiram tabs 500 mg, 250 mg Anti-Cataplectic Agents MO; + XYREM SOLN + + 1 nafcillin sodium solr ij 10 gm 5 + nafcillin sodium solr ij 2 gm 5 MO; + PROGESTINS - Hormone Replacement/Modifying Drugs Progestins medroxyprogesterone acetate tabs MEGACE ES SUSP (Megestrol Acetate (Appetite)) 1 megestrol acetate (appetite) susp Drug Requirements/ Tier Limits 1 AL; MO; * + MO; * dicloxacillin sodium caps Drug Name Antidementia Agents ARICEPT TABS (Donepezil Hydrochloride) donepezil hydrochloride tabs donepezil hydrochloride tbdp EXELON CAPS (Rivastigmine Tartrate) EXELON PT24 (Rivastigmine) galantamine hydrobromide cp24 galantamine hydrobromide soln galantamine hydrobromide tabs 1 MO; * 1 MO; * 5 LA; + NF MO 1 MO; * 1 MO; * NF MO 2 MO; + 1 MO; * 1 MO; * 1 MO; * MO; * memantine hcl soln 1 AL; MO; * AL; MO; + memantine hcl tabs 1 MO; * NAMENDA SOLN (Memantine HCl) 3 AL; MO; + 5 You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 86 Drug Name NAMENDA TABS (Memantine HCl) NAMENDA TITRATION PAK TABS (Memantine HCl) NAMENDA XR CP24 14 MG NAMENDA XR CP24 21 MG NAMENDA XR CP24 28 MG NAMENDA XR CP24 7 MG NAMENDA XR TITRATION PACK CP24 RAZADYNE ER CP24 (Galantamine Hydrobromide) RAZADYNE TABS (Galantamine Hydrobromide) Drug Requirements/ Tier Limits 3 MO; + MO; + 3 3 3 3 3 3 AL; SL(2 ea daily); MO; + AL; SL(1.33 ea daily); MO; + AL; SL(1 ea daily); MO; + AL; SL(4 ea daily); MO; + AL; MO; + MO NF MO NF Drug Name AUSTEDO TABS 12 MG AUSTEDO TABS 6 MG AUSTEDO TABS 9 MG tetrabenazine tabs XENAZINE TABS (Tetrabenazine) 5 LA; + AMPYRA TB12 5 + AUBAGIO TABS 5 PA; + AVONEX KIT 5 PA; + AVONEX PEN AJKT 5 PA; + AVONEX PSKT 5 PA; + 5 PA; + Multiple Sclerosis Agents rivastigmine pt24 1 MO; * BETASERON KIT rivastigmine tartrate caps 1 MO; * AL; MO; * COPAXONE SOSY 20 MG/ML (Glatiramer Acetate) COPAXONE SOSY 40 MG/ML MO; * AL; MO; * Combination Psychotherapeutics chlordiazepoxide1 amitriptyline tabs olanzapine-fluoxetine hcl 1 caps perphenazine-amitriptyline 1 tabs SYMBYAX CAPS NF (Olanzapine-Fluoxetine HCl) MO Fibromyalgia Agents SAVELLA TABS 3 PA; MO; + SAVELLA TITRATION PACK MISC 3 PA; MO; + Hypoactive Sexual Desire Disorder (HSDD) PA; Check plan 5 for ADDYI TABS coverage;NT; + Movement Disorder Drug Therapy Drug Requirements/ Tier Limits 5 SL(4 ea daily); + 5 SL(8 ea daily); + 5 SL(5.33 ea daily); + 5 + PA; + 5 5 PA; + EXTAVIA KIT 5 PA; + GILENYA CAPS 5 PA; + glatiramer acetate sosy 5 PA; + LEMTRADA SOLN 5 PA; LA; + PLEGRIDY SOPN 5 PA; + PLEGRIDY SOSY 5 PA; + 5 PA; + 5 PA; + REBIF REBIDOSE SOAJ 5 PA; + REBIF REBIDOSE TITRATIONPACK SOAJ 5 PA; + PLEGRIDY STARTER PACK SOPN PLEGRIDY STARTER PACK SOSY You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 87 Drug Name REBIF SOSY Drug Requirements/ Tier Limits 5 PA; + Drug Name Drug Requirements/ Tier Limits Vasomotor Symptom Agents MO; + REBIF TITRATION PACK SOSY 5 PA; + BRISDELLE CAPS TECFIDERA CPDR 5 PA; + RESPIRATORY AGENTS - MISC. - Drugs to Treat Lung Conditions TECFIDERA STARTER PACK MISC 5 PA; + TYSABRI CONC 5 PA; + Postherpetic Neuralgia (PHN) Agents 3 MO; + GRALISE STARTER MISC GRALISE TABS 3 MO; + 3 Alpha-Proteinase Inhibitor (Human) ARALAST NP SOLR 1000 5 LA; + MG 4 LA; + GLASSIA SOLN PROLASTIN-C SOLR 5 LA; + ZEMAIRA SOLR 5 LA; + Cystic Fibrosis Agents Premenstrual Dysphoric Disorder (PMDD) Agents fluoxetine hcl (pmdd) cap NF 10 mg, 20 mg KALYDECO PACK 5 PA; + Pseudobulbar Affect (PBA) Agents KALYDECO TABS 5 PA; + ORKAMBI TABS 5 PA; LA; + PULMOZYME SOLN 2 B/D; + ESBRIET CAPS 5 PA; LA; + OFEV CAPS 5 PA; LA; + NUEDEXTA CAPS 2 MO; + Psychotherapeutic and Neurological Agents 1 AL; MO; * ergoloid mesylates tabs ORAP TABS (Pimozide) pimozide tabs NF MO 1 MO; * Restless Leg Syndrome (RLS) Agents 3 MO; + HORIZANT TBCR Smoking Deterrents bupropion hcl (smoking deterrent) tb12 CHANTIX CONTINUING MONTHPAK TABS CHANTIX STARTING MONTH PAK TABS 3 SL(2 ea daily); MO; * MO; + 3 MO; + 1 CHANTIX TABS 3 NICOTROL INHALER INHA 3 NICOTROL NS SOLN 2 ZYBAN TB12 (Bupropion HCl (Smoking Deterrent)) 3 MO; + SL(16 ea daily); MO; + MO; + SL(2 ea daily); MO; + Pulmonary Fibrosis Agents SULFONAMIDES - Drugs to Treat Bacterial Infections Sulfonamides sulfadiazine tabs 1 MO; * TETRACYCLINES - Drugs to Treat Bacterial Infections Tetracyclines ADOXA PAK 1/100 TABS (Doxycycline (Monohydrate)) ADOXA PAK 1/150 TABS (Doxycycline (Monohydrate)) ADOXA PAK 2/100 TABS (Doxycycline (Monohydrate)) MO NF MO NF MO NF You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 88 Drug Name ADOXA TABS (Doxycycline (Monohydrate)) demeclocycline hcl tabs DORYX TBEC 200 MG (Doxycycline Hyclate) doxycycline (monohydrate) caps 50 mg, 75 mg, 100 mg doxycycline (monohydrate) susr doxycycline (monohydrate) tabs Drug Requirements/ Tier Limits MO NF 1 MO; * NF MO MO; * 1 Drug Name Antithyroid Agents methimazole tabs 10 mg, 5 mg Drug Requirements/ Tier Limits 1 MO; * 1 MO; * 3 MO; + levothyroxine sodium tabs 1 MO; * liothyronine sodium tabs 1 MO; * SYNTHROID TABS (Levothyroxine Sodium) 3 MO; + propylthiouracil tabs Thyroid Hormones CYTOMEL TABS (Liothyronine Sodium) 1 MO; * 1 MO; * 1 MO; * doxycycline hyclate solr 4 MO; + doxycycline hyclate tabs 1 MO; * ADACEL SUSP 4 + 1 MO; * BOOSTRIX SUSP 4 + 3 MO; + DAPTACEL SUSP 4 + DIPHTHERIA/TETANUS TOXOIDS ADSORBED PEDIATRIC SUSP 4 INFANRIX SUSP 4 + KINRIX SUSP 4 + QUADRACEL SUSP 4 + TENIVAC INJ 4 B/D; + doxycycline hyclate caps doxycycline hyclate tbec 150 mg, 200 mg, 100 mg MINOCIN CAPS 50 MG, 100 MG (Minocycline HCl) MINOCIN CAPS 75 MG (Minocycline HCl) minocycline hcl caps minocycline hcl tabs 50 mg, 100 mg MONODOX CAPS (Doxycycline (Monohydrate)) TETRACYCLINE HCL CAPS 250 MG, 500 MG (Tetracycline HCl) tetracycline hcl caps 500 mg, 250 mg VIBRAMYCIN CAPS (Doxycycline Hyclate) VIBRAMYCIN SUSR (Doxycycline (Monohydrate)) VIBRAMYCIN SYRP NF MO 1 MO; * 1 MO; * MO; NT NF MO; + 3 1 MO; * 3 MO; + Toxoid Combinations TETANUS/DIPHTHERIA TOXOIDS-ADSORBED ADULT SUSP TETANUS/DIPHTHERIA TOXOIDS-ADSORBED SUSP + + 4 + 4 MO; + ULCER DRUGS - Drugs to Treat Bowel, Intestine and Stomach Conditions MO; + Antispasmodics BENTYL CAPS (Dicyclomine HCl) 3 2 TOXOIDS THYROID AGENTS - Drugs to Regulate Thyroid Hormones 3 MO; + You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 89 Drug Name BENTYL TABS (Dicyclomine HCl) Drug Requirements/ Tier Limits 3 MO; + Drug Name ranitidine hcl syrp Drug Requirements/ Tier Limits 1 MO; * CANTIL TABS 3 + ranitidine hcl tabs 150 mg 1 RX/OTC; MO; * dicyclomine hcl caps 1 MO; * ranitidine hcl tabs 300 mg 1 MO; * dicyclomine hcl tabs 1 MO; * glycopyrrolate soln 0.2 mg/ml 4 MO; + glycopyrrolate tabs 1 mg 1 ZANTAC SOLN 25 MG/ML (Ranitidine HCl) ZANTAC TABS 150 MG (Ranitidine HCl) ZANTAC TABS 300 MG (Ranitidine HCl) glycopyrrolate tabs 2 mg 1 methscopolamine bromide tabs PAMINE FORTE TABS (Methscopolamine Bromide) PAMINE TABS (Methscopolamine Bromide) ROBINUL FORTE TABS (Glycopyrrolate) ROBINUL SOLN 0.2 MG/ML (Glycopyrrolate) ROBINUL TABS (Glycopyrrolate) H-2 Antagonists cimetidine tabs 200 mg cimetidine tabs 300 mg, 400 mg, 800 mg 1 SL(8 ea daily); MO; * SL(4 ea daily); MO; * MO; * MO; + 3 MO; + 3 3 RX/OTC; MO; + MO; + CARAFATE SUSP 3 MO; + CARAFATE TABS (Sucralfate) 3 MO; + sucralfate tabs 1 MO; * 2 ST; MO; + 4 SL(4 ea daily); MO; + MO; + 1 RX/OTC; MO; * 1 MO; * 3 SL(8 ea daily); MO; + 4 + 1 RX/OTC; MO; * lansoprazole cpdr 15 mg 1 RX/OTC; MO; * 1 MO; * lansoprazole cpdr 30 mg 1 MO; * 3 Misc. Anti-Ulcer Proton Pump Inhibitors DEXILANT CPDR 3 NF MO esomeprazole magnesium cpdr 20 mg esomeprazole magnesium cpdr 40 mg esomeprazole sodium solr 40 mg famotidine soln 4 + famotidine susr 1 MO; * famotidine tabs 20 mg 1 RX/OTC; MO; * famotidine tabs 40 mg 1 MO; * NEXIUM CPDR 20 MG (Esomeprazole Magnesium) NEXIUM CPDR 40 MG (Esomeprazole Magnesium) NEXIUM I.V. SOLR (Esomeprazole Sodium) nizatidine caps 1 MO; * PEPCID SUSR (Famotidine) ranitidine hcl caps RX/OTC; MO NF MO NF 4 + NEXIUM PACK 3 ST; MO; + omeprazole cpdr 10 mg, 20 mg, 40 mg 1 MO; * 3 MO; + MO; * pantoprazole sodium solr 1 * 1 You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 90 Drug Name pantoprazole sodium tbec Drug Requirements/ Tier Limits 1 MO; * PREVACID CPDR 15 MG (Lansoprazole) PREVACID CPDR 30 MG (Lansoprazole) PREVACID SOLUTAB TBDP PRILOSEC CPDR 40 MG (Omeprazole) PROTONIX PACK PROTONIX SOLR (Pantoprazole Sodium) PROTONIX TBEC (Pantoprazole Sodium) 3 RX/OTC; MO; + MO; + 3 MO; + 3 NF MO; NT 3 QL(1 ea daily); MO; + NF 3 MO; + Ulcer Drugs - Prostaglandins CYTOTEC TABS 3 (Misoprostol) MO; + misoprostol tabs MO; * Ulcer Therapy Combinations amoxicillin-clarithromycin w/ lansoprazole misc omeprazole-sodium bicarbonate caps 20mg1100mg omeprazole-sodium bicarbonate caps 40mg1100mg omeprazole-sodium bicarbonate pack 20mg1680mg omeprazole-sodium bicarbonate pack 40mg1680mg PREVPAC MISC (Amoxicillin-Clarithromycin w/ Lansoprazole) 1 1 MO; * RX/OTC; MO; * 1 MO; * 1 1 ST; 20MG1680 MG;MO; * Drug Name ZEGERID CAPS 40MG1100MG (OmeprazoleSodium Bicarbonate) ZEGERID PACK 20MG1680MG (OmeprazoleSodium Bicarbonate) ZEGERID PACK 40MG1680MG (OmeprazoleSodium Bicarbonate) Drug Requirements/ Tier Limits MO; + 3 3 ST; 20MG1680 MG;MO; + MO; + 3 URINARY ANTI-INFECTIVES - Drugs to Treat Bladder/Kidney Infections Urinary Anti-infective Combinations UROGESIC-BLUE TABS MO (MethenamineNF Hyoscamine-Methylene Blue-Sodium Phosphate) Urinary Anti-infectives FURADANTIN SUSP (Nitrofurantoin) HIPREX TABS (Methenamine Hippurate) MACROBID CAPS (Nitrofurantoin Monohyd Macro) MACRODANTIN CAPS (Nitrofurantoin Macrocrystal) methenamine hippurate tabs nitrofurantoin macrocrystal caps nitrofurantoin monohyd macro caps 5 AL; MO; + 3 MO; + MO; + 3 AL; MO; + 3 1 MO; * 1 AL; MO; * 1 MO; * 1 AL; MO; * MO; * nitrofurantoin susp MO URINARY ANTISPASMODICS - Drugs to Treat Miscellaneous Bladder Spasms 1 NF PYLERA CAPS 3 MO; + ZEGERID CAPS 20MG1100MG (OmeprazoleSodium Bicarbonate) 3 RX/OTC; MO; + Urinary Antispasmodic - Antimuscarinics darifenacin hydrobromide 1 MO; * tb24 DETROL LA CP24 NF MO (Tolterodine Tartrate) DETROL TABS NF MO (Tolterodine Tartrate) You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 91 Drug Name DITROPAN XL TB24 (Oxybutynin Chloride) ENABLEX TB24 (Darifenacin Hydrobromide) Drug Requirements/ Tier Limits 3 MO; + Drug Name MENACTRA INJ Drug Requirements/ Tier Limits 4 + MO; + MENHIBRIX SOLR 4 + MENOMUNE-A/C/Y/W-135 INJ 4 + MENVEO SOLR 4 + PEDVAX HIB SUSP 4 + TYPHIM VI SOLN 4 + ENGERIX-B SUSP 4 B/D; + GARDASIL 9 SUSP 4 + GARDASIL 9 SUSY 4 + GARDASIL SUSP 4 + HAVRIX SUSP 4 + 4 B/D; + 4 + IXIARO SUSP 4 + M-M-R II INJ 4 + PROQUAD INJ 4 + RABAVERT SUSR 4 B/D; + RECOMBIVAX HB SUSP 4 B/D; + ROTARIX SUSR 3 + ROTATEQ SOLN 2 + VACCINES STAMARIL SUSR 4 + Bacterial Vaccines TWINRIX SUSP 4 + VAQTA SUSP 4 + VARIVAX INJ 4 + 3 GELNIQUE GEL 10 % 3 MO; + GELNIQUE GEL 3 % 3 + GELNIQUE PUMP GEL 3 MO; + 1 MO; * oxybutynin chloride tabs 1 MO; * oxybutynin chloride tb24 1 MO; * OXYTROL PTTW 3 tolterodine tartrate cp24 1 RX/OTC; MO; + MO; * tolterodine tartrate tabs 1 MO; * TOVIAZ TB24 2 MO; + trospium chloride cp24 1 MO; * trospium chloride tabs 1 MO; * VESICARE TABS 2 MO; + oxybutynin chloride syrp Viral Vaccines Urinary Antispasmodics - Beta-3 Adrenergic 3 MO; + MYRBETRIQ TB24 Urinary Antispasmodics - Cholinergic Agonists bethanechol chloride tabs MO; * 10 mg, 50 mg, 5 mg, 25 mg 1 Urinary Antispasmodics - Direct Muscle Relaxants 1 MO; * flavoxate hcl tabs ACTHIB SOLR 4 + BEXSERO SUSY 4 + IMOVAX RABIES (H.D.C.V.) INJ IPOL INACTIVATED IPV INJ You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 92 Drug Name YF-VAX INJ Drug Requirements/ Tier Limits 4 + epinephrine soaj Drug Requirements/ Tier Limits 2 MO; + EPIPEN 2-PAK SOAJ 2 MO; + VAGINAL PRODUCTS - Drugs to Treat Vaginal Infections and Low Hormones EPIPEN-JR 2-PAK SOAJ 2 MO; + Vaginal Anti-infectives CLEOCIN CREA (Clindamycin Phosphate Vaginal) Neurogenic Orthostatic Hypotension (NOH) NORTHERA CAPS 100 5 PA; SL(18 ea MG daily); + NORTHERA CAPS 200 5 PA; SL(9 ea MG daily); + NORTHERA CAPS 300 5 PA; SL(6 ea MG daily); + ZOSTAVAX SUSR CLEOCIN SUPP clindamycin phosphate vaginal crea METROGEL-VAGINAL GEL (Metronidazole Vaginal) 4 + Drug Name MO; + 3 3 MO; + 1 MO; * Vasopressors MO; + 3 dobutamine hcl soln 4 + midodrine hcl tabs 1 MO; * 3 MO; NT; + ergocalciferol caps 1 MO; NT; * MEPHYTON TABS 3 MO; NT; + 1 MO; * 1 MO; * VITAMINS 3 MO; + 3 MO; + Oil Soluble Vitamins DRISDOL CAPS (Ergocalciferol) terconazole vaginal crea 1 MO; * terconazole vaginal supp 1 MO; * estradiol vaginal tabs 1 MO; * ESTRING RING 3 MO; + FEMRING RING 3 MO; + PREMARIN CREA 2 MO; + VAGIFEM TABS (Estradiol Vaginal) 3 MO; + 3 PA; MO; + metronidazole vaginal gel miconazole nitrate vaginal supp 200 mg TERAZOL 3 CREA (Terconazole Vaginal) TERAZOL 7 CREA (Terconazole Vaginal) Vaginal Estrogens Vaginal Progestins CRINONE GEL VASOPRESSORS - Drugs to Treat Heart and Circulation Conditions Anaphylaxis Therapy Agents You can find information on what the symbols and abbreviations on this table mean by going to page vii. 2017 Employer Group Formulary Updated 6/1/2017 93 Index abacavir sulfate 46 abacavir sulfate-lamivudine 46 abacavir sulfate-lamivudinezidovudine 46 ABELCET 29 ABILIFY 45 ABILIFY 10 MG 45 ABILIFY 15 MG 45 ABILIFY 2 MG 45 ABILIFY 20 MG 45 ABILIFY 30 MG 45 ABILIFY 5 MG 45 ABILIFY DISCMELT 45 ABILIFY MAINTENA 45 ABRAXANE 41 ABSORICA 30 MG 56 ABSORICA 40 MG, 10 MG, 30 MG, 25 MG, 35 MG, 20 MG 56 ABSTRAL 100 MCG 4 ABSTRAL 200 MCG 4 ABSTRAL 300 MCG 4 ABSTRAL 600 MCG, 800 MCG, 400 MCG 4 acamprosate calcium 86 ACANYA 56 acarbose 23 ACCOLATE 14 ACCUPRIL 32 ACCURETIC 33 acebutolol hcl 49 acetaminophen w/ codeine 8 acetaminophen w/ codeine 300mg-15mg 8 acetaminophen w/ codeine 300mg-30mg 8 acetaminophen w/ codeine 300mg-60mg 8 acetazolamide 64 acetazolamide 250 mg 64 acetic acid 70 acetic acid (otic) 84 acetic acid-aluminum acetate 84 acetylcysteine 56 acitretin 59 ACTEMRA 3 ACTHIB 92 ACTIGALL 68 ACTIMMUNE 40 Index 1 ACTIQ 200 MCG 4 ACTIQ 800 MCG, 600 MCG, 1600 MCG, 1200 MCG, 400 MCG 4 ACTIVELLA 67 ACTONEL 150 MG 65 ACTONEL 30 MG, 5 MG 65 ACTONEL 35 MG 65 ACTOPLUS MET 23 ACTOPLUS MET XR 15MG1000MG 23 ACTOPLUS MET XR 30MG1000MG 23 ACTOS 15 MG 25 ACTOS 30 MG 25 ACTOS 45 MG 25 ACULAR 83 ACULAR LS 83 ACUVAIL 83 acyclovir 48 acyclovir sodium 48 ACYCLOVIR SODIUM 48 acyclovir topical 59 ADACEL 89 ADAGEN 2 ADALAT CC 50 adapalene 56 adapalene 0.1 % 56 adapalene 0.3 % 56 ADCIRCA 52 ADDERALL XR 1 ADDYI 87 adefovir dipivoxil 48 ADEMPAS 0.5 MG 52 ADEMPAS 1 MG 52 ADEMPAS 1.5 MG 52 ADEMPAS 2 MG 52 ADEMPAS 2.5 MG 52 ADOXA 89 ADOXA PAK 1/100 88 ADOXA PAK 1/150 88 ADOXA PAK 2/100 88 ADVAIR DISKUS 15 ADVAIR HFA 15 AEROSPAN 14 AFINITOR 39 AFINITOR DISPERZ 39 AFREZZA 25 AGGRENOX 71 AGRYLIN 71 AKYNZEO 28 ALBENZA 10 albuterol sulfate 15 alclometasone dipropionate 60 ALCOHOL PADS 75 ALDACTAZIDE 25MG25MG 64 ALDACTAZIDE 50MG50MG 64 ALDACTONE 64 ALDARA 62 ALECENSA 39 alendronate sodium 10 mg, 5 mg 65 alendronate sodium 70 mg, 35 mg 65 alfuzosin hcl 70 ALIMTA 100 MG 36 ALIMTA 500 MG 36 ALINIA 11 ALKERAN 36 allopurinol 100 mg 70 allopurinol 300 mg 70 almotriptan malate 75 ALOCRIL 84 ALOGLIPTIN 12.5 MG 25 ALOGLIPTIN 25 MG 25 ALOGLIPTIN 6.25 MG 25 ALOGLIPTIN/METFORMIN HCL 23 ALOGLIPTIN/PIOGLITAZONE 12.5MG-15MG 23 ALOGLIPTIN/PIOGLITAZONE 12.5MG-30MG 23 ALOGLIPTIN/PIOGLITAZONE 25MG-30MG, 12.5MG-45MG, 25MG-15MG, 25MG-45MG 23 ALOMIDE 84 alosetron hcl 69 ALPHAGAN P 0.1 % 82 ALPHAGAN P 0.15 % 82 alprazolam 13 ALREX 83 ALTACE 32 ALTOPREV 31 ALVESCO 160 MCG/ACT 14 ALVESCO 80 MCG/ACT 14 amantadine hcl 42 AMARYL 1 MG 27 AMARYL 2 MG 27 AMARYL 4 MG 27 AMBIEN 10 MG 73 AMBIEN 5 MG 73 AMBIEN CR 12.5 MG 73 AMBIEN CR 6.25 MG 73 AMBISOME 29 amcinonide 60 AMERGE 75 AMICAR 72 AMICAR 1000 MG 72 AMICAR 500 MG 72 amifostine 41 amikacin sulfate 2 amiloride & hydrochlorothiazide 64 amiloride hcl 64 amino acid infusion 15% 81 AMINOCAPROIC ACID 1000 MG 72 aminocaproic acid 500 mg 72 aminophylline 16 aminosalicylic acid 35 AMINOSYN II 15% (Use amino acid infusion) 81 amiodarone hcl 200 mg, 100 mg, 400 mg 13 AMITIZA 69 amitriptyline hcl 23 amlodipine besylate 10 mg 50 amlodipine besylate 2.5 mg 50 amlodipine besylate 5 mg 50 amlodipine besylate-atorvastatin calcium 51 amlodipine besylate-benazepril hcl 33 amlodipine besylate-olmesartan medoxomil 33 amlodipine besylatevalsartan 33 amlodipine-valsartanhydrochlorothiazide 33 amoxapine 23 amoxicillin 85 amoxicillin & pot clavulanate 85 amoxicillin-clarithromycin w/ lansoprazole 91 amphetaminedextroamphetamine 1 amphetaminedextroamphetamine 3.125mg3.125mg-3.125mg-3.125mg, 5mg-5mg-5mg-5mg, 2.5mg2.5mg-2.5mg-2.5mg, 3.75mg3.75mg-3.75mg-3.75mg, 1.25mg-1.25mg-1.25mg1.25mg, 1.875mg-1.875mg1.875mg-1.875mg, 7.5mg7.5mg-7.5mg-7.5mg 1 AMPHOTERICIN B 29 ampicillin 85 ampicillin & sulbactam sodium 1gm-2gm 86 ampicillin & sulbactam sodium 5gm-10gm 86 ampicillin sodium 10 gm 85 ampicillin sodium 2 gm, 1 gm 85 AMPYRA 87 AMRIX 79 ANADROL-50 9 ANAFRANIL 23 anagrelide hcl 71 ANAPROX DS 3 anastrozole 38 ANCOBON 500 MG 29 ANDRODERM 9 ANDROGEL 20.25 MG/1.25GM, 40.5 MG/2.5GM 9 ANDROGEL 25 MG/2.5GM, 50 MG/5GM 9 ANDROGEL PUMP 1 % 9 ANDROGEL PUMP 1.62 % 9 ANORO ELLIPTA 16 ANTARA 30 MG 31 ANTARA 90 MG 31 APIDRA 25 APIDRA SOLOSTAR 25 APLENZIN 174 MG 20 APLENZIN 348 MG 21 APLENZIN 522 MG 21 APOKYN 42 apraclonidine hcl 82 aprepitant 40 mg 28 aprepitant 80 mg, , 125 mg 28 APRISO 69 APTIOM 200 MG 18 APTIOM 800 MG, 600 MG, 400 MG 18 APTIVUS 46 ARALAST NP 1000 MG 88 ARANESP ALBUMIN FREE 10 MCG/0.4ML, 40 MCG/0.4ML, 60 MCG/0.3ML, 100 MCG/0.5ML, 25 MCG/0.42ML 72 ARANESP ALBUMIN FREE 100 MCG/ML, 60 MCG/ML, 25 MCG/ML, 40 MCG/ML 72 ARANESP ALBUMIN FREE 200 MCG/ML, 300 MCG/ML 72 ARANESP ALBUMIN FREE 300 MCG/0.6ML, 200 MCG/0.4ML, 150 MCG/0.3ML, 500 MCG/ML 72 ARAVA 4 ARCALYST 2 ARCAPTA NEOHALER 16 argatroban 250 mg/2.5ml 17 ARICEPT 86 ARIMIDEX 38 aripiprazole 45 aripiprazole 10 mg 45 aripiprazole 15 mg 45 aripiprazole 2 mg 45 aripiprazole 20 mg 45 aripiprazole 30 mg 45 aripiprazole 5 mg 45 ARISTADA 45 ARIXTRA 10 MG/0.8ML 17 ARIXTRA 2.5 MG/0.5ML 17 ARIXTRA 5 MG/0.4ML, 7.5 MG/0.6ML 17 armodafinil 1 ARNUITY ELLIPTA 14 AROMASIN 38 ARRANON 37 ARTHROTEC 50 3 ARTHROTEC 75 3 ARZERRA 37 ASACOL HD 69 ASMANEX HFA 100 MCG/ACT 14 ASMANEX HFA 200 MCG/ACT 15 ASMANEX TWISTHALER 120 METERED DOSES 15 ASMANEX TWISTHALER 14 METERED DOSES 15 ASMANEX TWISTHALER 30 METERED DOSES 110 MCG/INH 15 Index 2 ASMANEX TWISTHALER 30 METERED DOSES 220 MCG/INH 15 ASMANEX TWISTHALER 60 METERED DOSES 15 ASMANEX TWISTHALER 7 METERED DOSES 15 aspirin-dipyridamole 71 ASTAGRAF XL 77 ASTEPRO 80 ATACAND 33 ATACAND HCT 34 ATELVIA 65 atenolol 49 atenolol & chlorthalidone 34 ATGAM 77 ATIVAN 13 ATIVAN 2 MG/ML 13 ATIVAN 4 MG/ML 13 atorvastatin calcium 31 atovaquone 11 atovaquone-proguanil hcl 35 ATRALIN 56 ATRIPLA 46 ATROVENT 80 ATROVENT HFA 14 AUBAGIO 87 AUGMENTIN 86 AUGMENTIN 250MG/5ML62.5MG/5ML 86 AUGMENTIN ES-600 86 AUGMENTIN XR 86 AURYXIA 69 AUSTEDO 12 MG 87 AUSTEDO 6 MG 87 AUSTEDO 9 MG 87 AVALIDE 34 AVANDIA 2 MG 25 AVANDIA 4 MG 25 AVAPRO 33 AVASTIN 37 AVEED 9 AVELOX 68 AVELOX ABC PACK 68 AVINZA 30 MG 4 AVINZA 90 MG, 120 MG, 60 MG 4 AVODART 70 Index 3 AVONEX 87 AVONEX PEN 87 AXERT 75 AXIRON 9 azacitidine 37 AZACTAM 10 AZASITE 82 AZATHIOPRINE 77 azathioprine 77 azelastine hcl 80 azelastine hcl (ophth) 84 AZELEX 56 AZILECT 43 AZITHROMYCIN 74 azithromycin 74 AZOPT 84 AZOR 34 aztreonam 10 AZULFIDINE 69 AZULFIDINE EN-TABS 69 bacitracin (ophthalmic) 82 bacitracin-poly-neomycin-hc 83 bacitracin-polymyxin b (ophth) 82 baclofen 10 mg 79 baclofen 20 mg 79 BACTRIM 11 BACTRIM DS 11 BACTROBAN 58 BACTROBAN NASAL 80 balsalazide disodium 69 BANZEL 18 BANZEL 200 MG 18 BANZEL 400 MG 18 BARACLUDE 48 BAVENCIO 37 BECONASE AQ 80 BELEODAQ 39 BELSOMRA 10 MG 73 BELSOMRA 15 MG 73 BELSOMRA 20 MG 73 BELSOMRA 5 MG 73 benazepril & hydrochlorothiazide 34 benazepril hcl 40 mg, 5 mg, 20 mg, 10 mg 32 BENDEKA 36 BENICAR 33 BENICAR HCT 34 BENLYSTA 78 BENTYL 89 BENZACLIN 56 BENZACLIN WITH PUMP 56 BENZAMYCIN 57 benzonatate 56 benzoyl peroxideerythromycin 57 benztropine mesylate 42 BEPREVE 84 BERINERT 71 BESIVANCE 82 BETAGAN 81 betamethasone dipropionate (topical) 60 betamethasone dipropionate augmented 60 betamethasone sod phosphate & acetate 55 betamethasone valerate 60 BETAPACE 49 BETAPACE AF 49 BETASERON 87 betaxolol hcl 49 betaxolol hcl (ophth) 81 bethanechol chloride 10 mg, 50 mg, 5 mg, 25 mg 92 BETHKIS 2 BETIMOL 81 BETOPTIC-S 81 bexarotene 40 BEXSERO 92 BEYAZ 53 BIAXIN 74 bicalutamide 38 BICILLIN L-A 2400000 UNIT/4ML, 1200000 UNIT/2ML 85 BICNU 36 BIDIL 51 BILTRICIDE 10 BIMATOPROST 84 bisacodyl-peg 3350-pot chloridesod bicarb-sod chloride 73 bisoprolol & hydrochlorothiazide 34 bisoprolol fumarate 49 BIVIGAM 85 bleomycin sulfate 15 unit 39 bleomycin sulfate 30 unit 39 BLEPH-10 82 BLEPHAMIDE 83 BLINCYTO 37 BONIVA 65 BOOSTRIX 89 BOSULIF 39 BOTOX 100 UNIT 81 BOTOX 200 UNIT 81 BREO ELLIPTA 25MCG/INH100MCG/INH, 25MCG/INH200MCG/INH 16 BREO ELLIPTA 25MCG/INH200MCG/INH, 25MCG/INH100MCG/INH 16 BREVICON-28 53 BRILINTA 71 brimonidine tartrate 82 BRINTELLIX 10 MG 22 BRINTELLIX 20 MG 22 BRINTELLIX 5 MG 22 BRISDELLE 88 BRIVIACT 10 MG 18 BRIVIACT 10 MG/ML 18 BRIVIACT 100 MG 18 BRIVIACT 25 MG 18 BRIVIACT 50 MG 18 BRIVIACT 50 MG/5ML 18 BRIVIACT 75 MG 18 bromfenac sodium (ophth) 84 bromocriptine mesylate 42 BROVANA 16 budesonide 55 budesonide (inhalation) 0.25 mg/2ml 15 budesonide (inhalation) 0.5 mg/2ml 15 budesonide (inhalation) 1 mg/2ml 15 budesonide (nasal) 80 bumetanide 64 BUMEX 64 BUNAVAIL 4.2MG-0.7MG, 2.1MG-0.3MG 9 BUNAVAIL 6.3MG-1MG 9 buprenorphine hcl 2 mg 9 buprenorphine hcl 8 mg 9 buprenorphine hcl-naloxone hcl dihydrate 2mg-0.5mg 9 buprenorphine hcl-naloxone hcl dihydrate 8mg-2mg 9 bupropion hcl (smoking deterrent) 88 bupropion hcl 100 mg 21 bupropion hcl 150 mg 21 bupropion hcl 200 mg 21 bupropion hcl 300 mg 21 bupropion hcl 75 mg 21 buspirone hcl 13 busulfan 36 BUSULFEX 36 butalbital-acetaminophencaffeine w/ codeine 8 butalbital-aspirin-caffeine w/cod 8 BUTISOL SODIUM 72 butorphanol tartrate 10 mg/ml 9 butorphanol tartrate 2 mg/ml9 BUTRANS 10 MCG/HR 9 BUTRANS 15 MCG/HR 9 BUTRANS 20 MCG/HR 9 BUTRANS 5 MCG/HR 9 BUTRANS 7.5 MCG/HR 9 BYDUREON 25 BYDUREON PEN 25 BYETTA 25 BYSTOLIC 49 BYVALSON 34 cabergoline 67 CABOMETYX 39 CADUET 51 CAFERGOT 75 CALAN 50 CALAN SR 50 calcipotriene 59 calcipotriene-betamethasone dipropionate 60 calcitonin (salmon) 65 CALCITRIOL 59 calcitriol 66 calcium acetate (phosphate binder) 70 CAMBIA 75 CAMPATH 37 CAMPTOSAR 40 MG/2ML, 100 MG/5ML 41 CANASA 69 candesartan cilexetil 33 candesartan cilexetilhydrochlorothiazide 34 CANTIL 90 CAPASTAT SULFATE 35 CAPEX 60 CAPRELSA 39 captopril 32 captopril & hydrochlorothiazide 34 CARAC 58 CARAFATE 90 CARBAGLU 66 carbamazepine 18 CARBATROL 18 carbidopa 41 carbidopa-levodopa 42 CARBIDOPA/LEVODOPA/ENTA CAPONE 42 carbinoxamine maleate 30 carboplatin 36 CARDIZEM 50 CARDIZEM CD 50 CARDIZEM LA 120 MG 50 CARDIZEM LA 180 MG, 360 MG, 240 MG, 420 MG, 300 MG 50 CARDURA 33 CARDURA XL 70 carisoprodol 79 carisoprodol w/ aspirin 80 carisoprodol w/ aspirin & codeine 80 CARNITOR 66 carteolol hcl (ophth) 81 carvedilol 12.5 mg 49 carvedilol 25 mg 49 carvedilol 3.125 mg 49 carvedilol 6.25 mg 49 CASODEX 38 CATAPRES 33 CATAPRES-TTS-1 33 CATAPRES-TTS-2 33 CATAPRES-TTS-3 33 CAVERJECT 40 MCG, 20 MCG 51 CAVERJECT IMPULSE 51 CAYSTON 10 CEDAX 52 cefaclor 52 cefaclor monohydrate 52 Index 4 cefadroxil 52 cefadroxil 500 mg/5ml 52 cefazolin sodium 1 gm, 10 gm, 500 mg 52 cefdinir 52 CEFEPIME 2 GM/100ML 53 cefepime hcl 53 cefixime 52 cefoxitin sodium 1 gm 52 cefoxitin sodium 10 gm 52 cefoxitin sodium 2 gm 52 cefpodoxime proxetil 53 cefpodoxime proxetil 100 mg/5ml 53 cefprozil 52 cefprozil 250 mg/5ml 52 ceftazidime 1 gm, 2 gm 53 ceftazidime 6 gm 53 CEFTIBUTEN 53 CEFTIN 52 CEFTRIAXONE IN ISOOSMOTIC DEXTROSE 20MG/ML 53 ceftriaxone sodium 1 gm 53 ceftriaxone sodium 10 gm 53 ceftriaxone sodium 2 gm 53 ceftriaxone sodium 250 mg 53 ceftriaxone sodium 500 mg 53 cefuroxime axetil 52 cefuroxime sodium 1.5 gm 52 CELEBREX 3 celecoxib 3 CELESTONE-SOLUSPAN 55 CELEXA 10 MG 21 CELEXA 20 MG 21 CELEXA 40 MG 21 CELLCEPT 77 CELLCEPT INTRAVENOUS 77 CELONTIN 20 CENTANY 58 CENTRUM 79 CENTRUM SILVER 79 CENTRUM SILVER 50+MEN 79 CENTRUM SILVER 50+WOMEN 79 CENTRUM SILVER ADULT 50+ 79 CENTRUM ULTRA MENS 79 Index 5 CENTRUM WOMEN 79 cephalexin 52 CERDELGA 71 CEREBYX 100 MG PE/2ML 20 CEREBYX 500 MG PE/10ML 20 CEREZYME 71 CESAMET 28 cetirizine hcl 30 cevimeline hcl 79 CHANTIX 88 CHANTIX CONTINUING MONTHPAK 88 CHANTIX STARTING MONTH PAK 88 CHEMET 28 CHENODAL 68 CHLORAMPHENICOL SODIUM SUCCINATE 11 chlordiazepoxide-amitriptyline 87 chlorhexidine gluconate (mouth-throat) 78 chloroquine phosphate 35 chlorothiazide 64 chlorpromazine hcl 45 CHLORPROMAZINE HCL 25 MG/ML 45 chlorpromazine hcl 50 mg/2ml 45 chlorpropamide 100 mg 27 chlorpropamide 250 mg 27 chlorthalidone 64 chlorzoxazone 79 cholestyramine 30 cholestyramine light 30 choline fenofibrate 31 chorionic gonadotropin 65 CIALIS 2.5 MG, 5 MG 51 CIALIS 20 MG, 10 MG 51 ciclopirox 58 ciclopirox olamine 58 cidofovir 47 cilostazol 71 CILOXAN 82 cimetidine 200 mg 90 cimetidine 300 mg, 400 mg, 800 mg 90 CIMZIA 69 CIMZIA STARTER KIT 69 CINQAIR 14 CINRYZE 71 CIPRO 68 CIPRO 5 GM/100ML 68 CIPRO 500 MG/5ML 68 CIPRO HC 84 CIPRO I.V.-IN D5W 68 CIPRO XR 68 CIPRODEX 84 ciprofloxacin 68 ciprofloxacin hcl 68 ciprofloxacin hcl (ophth) 82 ciprofloxacin in d5w 200mg/100ml-5% 68 ciprofloxacin in d5w 400mg/200ml-5% 68 ciprofloxacin-ciprofloxacin hcl 68 CISPLATIN 200 MG/200ML 36 cisplatin 50 mg/50ml, 100 mg/100ml 36 citalopram hydrobromide 21 citalopram hydrobromide 10 mg 21 citalopram hydrobromide 20 mg 21 citalopram hydrobromide 40 mg 21 cladribine 37 CLAFORAN 1 GM, 10 GM 53 CLAFORAN 500 MG, 2 GM 53 CLARINEX 30 CLARINEX-D 12 HOUR 56 clarithromycin 74 clarithromycin 250 mg/5ml 74 clemastine fumarate 2.68 mg30 CLEOCIN 11 CLEOCIN IN D5W 11 CLEOCIN PHOSPHATE 300 MG/2ML 11 CLEOCIN PHOSPHATE 600 MG/4ML 11 CLEOCIN PHOSPHATE 9 GM/60ML 11 CLEOCIN PHOSPHATE 900 MG/6ML, 600 MG/4ML 11 CLEOCIN PHOSPHATE 900MG/50ML-5%, 300MG/50ML5%, 600MG/50ML-5% 12 CLEOCIN-T 57 CLIMARA 67 CLIMARA PRO 67 CLINDAGEL 57 clindamycin hcl 12 clindamycin palmitate hydrochloride 12 clindamycin phosphate (topical) 57 clindamycin phosphate 150 mg/ml 12 clindamycin phosphate 150 mg/ml, 9000 mg/60ml 12 clindamycin phosphate 600 mg/4ml, 900 mg/6ml 12 clindamycin phosphate in d5w 12 clindamycin phosphate vaginal 93 clindamycin phosphate-benzoyl peroxide 57 clindamycin phosphate-benzoyl peroxide (refrigerate) 57 clindamycin phosphatetretinoin 57 CLINIMIX 2.75%/DEXTROSE 5% 81 clobetasol propionate 60 clobetasol propionate emollient base 60 CLOBEX 60 CLOCORTOLONE PIVALATE 60 CLOCORTOLONE PIVALATE PUMP 60 CLODERM 60 CLODERM PUMP 60 clofarabine 37 CLOLAR 37 clomipramine hcl 23 clonazepam 17 clonazepam 0.5 mg 17 clonazepam 1 mg 17 clonazepam 2 mg 17 clonidine hcl 33 clopidogrel bisulfate 300 mg 71 clopidogrel bisulfate 75 mg 71 clorazepate dipotassium 13 clotrimazole 78 clotrimazole (topical) 58 clozapine 44 CLOZAPINE ODT 150 MG, 12.5 MG 44 CLOZAPINE ODT 200 MG 44 CLOZARIL 44 COARTEM 35 codeine sulfate 15 mg 4 codeine sulfate 30 mg 4 codeine sulfate 60 mg 4 COGENTIN 42 COLAZAL 69 COLCHICINE 70 colchicine w/ probenecid 70 COLCRYS 70 COLESTID 31 COLESTID FLAVORED 30 colestipol hcl 31 colistimethate sodium 10 COLY-MYCIN M 10 COLY-MYCIN S 84 COLYTE-FLAVOR PACKS 227.1GM-21.5GM-5.53GM2.82GM-6.36GM 73 COLYTE-FLAVOR PACKS 240GM-22.72GM-5.84GM2.98GM-6.72GM 73 COMBIGAN 81 COMBIPATCH 67 COMBIVENT RESPIMAT 16 COMBIVIR 46 COMETRIQ 39 COMPLERA 46 COMTAN 42 CONCERTA 1 CONDYLOX 63 COPAXONE 20 MG/ML 87 COPAXONE 40 MG/ML 87 COPEGUS 48 CORDRAN 60 CORDRAN TAPE 60 COREG 12.5 MG 49 COREG 25 MG 49 COREG 3.125 MG 49 COREG 6.25 MG 49 COREG CR 49 CORGARD 49 CORLANOR 5 MG 52 CORLANOR 7.5 MG 52 CORTEF 55 CORTENEMA 10 CORTIFOAM 10 cortisone acetate 55 CORTISPORIN 58 CORTISPORIN-TC 84 CORZIDE 34 COSENTYX 59 COSENTYX SENSOREADY PEN 59 COSMEGEN 39 COSOPT 81 COSOPT PF 81 COTELLIC 39 COUMADIN 16 COZAAR 33 CREON 63 CRESEMBA 29 CRESTOR 31 CRINONE 93 CRIXIVAN 46 cromolyn sodium 14 cromolyn sodium (mastocytosis) 69 cromolyn sodium (ophth) 84 CUBICIN 11 CUBICIN RF 11 CUTIVATE 60 CUVITRU 1 GM/5ML 85 CUVITRU 4 GM/20ML, 2 GM/10ML 85 CUVITRU 8 GM/40ML 85 cyanocobalamin 71 cyclobenzaprine hcl 7.5 mg, 10 mg, 5 mg 80 cyclopentolate hcl 1 %, 2 % 82 CYCLOPHOSPHAMIDE 36 CYCLOSET 25 cyclosporine 77 cyclosporine modified (for microemulsion) 77 CYKLOKAPRON 72 CYMBALTA 22 cyproheptadine hcl 30 CYRAMZA 37 CYSTADANE 66 CYSTAGON 70 CYSTARAN 84 cytarabine 37 CYTOMEL 89 CYTOTEC 91 CYTOVENE 47 Index 6 D.H.E. 45 75 DACARBAZINE 100 MG 40 dacarbazine 200 mg 40 DACOGEN 37 DAKLINZA 48 DALIRESP 14 danazol 9 DANTRIUM 80 dantrolene sodium 80 dapsone 11 DAPTACEL 89 daptomycin 11 DARAPRIM 35 darifenacin hydrobromide 91 DARZALEX 37 daunorubicin hcl 39 DAYPRO 3 DAYTRANA 30 MG/9HR 1 DDAVP 67 DDAVP 0.01 % 67 DDAVP 4 MCG/ML 67 decitabine 37 DELESTROGEN 10 MG/ML 68 DELESTROGEN 20 MG/ML, 40 MG/ML 68 DELZICOL 69 DEMADEX 5 MG, 10 MG, 20 MG 64 demeclocycline hcl 89 DEMSER 33 DENAVIR 59 DEPACON 20 DEPAKENE 20 DEPAKOTE 20 DEPAKOTE ER 20 DEPAKOTE SPRINKLES 20 DEPEN TITRATABS 77 DEPO-MEDROL 20 MG/ML 55 DEPO-MEDROL 40 MG/ML, 80 MG/ML 55 DEPO-PROVERA 38 DEPO-PROVERA CONTRACEPTIVE 54 DEPO-SUBQ PROVERA 104 54 DEPO-TESTOSTERONE 9 DERMA-SMOOTHE/FS BODY 60 Index 7 DERMA-SMOOTHE/FS SCALP 60 DERMATOP 60 DERMOTIC 84 DESCOVY 46 desipramine hcl 23 desloratadine 30 desmopressin acetate 67 desmopressin acetate refrigerated 67 desmopressin acetate spray 67 desmopressin acetate spray refrigerated 67 DESOGEN 53 desogestrel & ethinyl estradiol 53 desogestrel-ethinyl estradiol (biphasic) 53 DESONATE 60 desonide 60 DESOWEN 61 desoximetasone 61 DESVENLAFAXINE ER 100 MG, 50 MG 22 desvenlafaxine succinate 22 DETROL 91 DETROL LA 91 dexamethasone 55 dexamethasone sodium phosphate (ophth) 83 DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML 55 dexamethasone sodium phosphate 20 mg/5ml, 120 mg/30ml, 4 mg/ml, 100 mg/10ml 55 DEXEDRINE 1 DEXILANT 90 dexmethylphenidate hcl 1 dexmethylphenidate hcl 15 mg, 20 mg, 10 mg 1 dexrazoxane 500 mg, 250 mg 41 dextroamphetamine sulfate 1 dextrose 10 % 81 dextrose 5 % 81 dextrose in lactated ringers77 dextrose w/ sodium chloride 0.45%-2.5%, 0.45%-5% 77 dextrose w/ sodium chloride 0.9%-5% 77 DIABETA 1.25 MG 27 DIABETA 2.5 MG 27 DIABETA 5 MG 27 DIAMOX 64 DIASTAT ACUDIAL 17 DIASTAT PEDIATRIC 17 diazepam 13 DIAZEPAM 17 DIBENZYLINE 33 diclofenac potassium 3 diclofenac sodium 3 diclofenac sodium (actinic keratoses) 59 diclofenac sodium (ophth) 84 diclofenac sodium (topical) 57 diclofenac w/ misoprostol 3 dicloxacillin sodium 86 dicyclomine hcl 90 didanosine 46 DIFFERIN 57 DIFFERIN 0.1 % 57 DIFFERIN 0.3 % 57 DIFICID 75 diflorasone diacetate 61 DIFLUCAN 29 diflunisal 4 digoxin 51 DIGOXIN 0.05 MG/ML 51 dihydroergotamine mesylate 1 mg/ml 75 DIHYDROERGOTAMINE MESYLATE 4 MG/ML 75 DILANTIN-125 20 DILATRATE SR 12 DILAUDID 4 DILAUDID 2 MG 4 DILAUDID 2 MG/ML 4 DILAUDID 4 MG 4 DILAUDID 8 MG 4 DILAUDID-HP 4 diltiazem hcl 50 diltiazem hcl coated beads 50 diltiazem hcl extended release beads 50 DIOVAN 33 DIOVAN HCT 34 DIPENTUM 69 diphenhydramine hcl 30 diphenoxylate w/ atropine 28 DIPHTHERIA/TETANUS TOXOIDS ADSORBED PEDIATRIC 89 DIPROLENE 61 DIPROLENE AF 61 dipyridamole 71 disopyramide phosphate 13 disulfiram 500 mg, 250 mg 86 DITROPAN XL 92 divalproex sodium 20 DIVIGEL 68 dobutamine hcl 93 DOCETAXEL 80 MG/4ML, 140 MG/7ML, 20 MG/ML 41 docetaxel 80 mg/4ml, 20 mg/ml 41 DOCETAXEL 80 MG/8ML, 160 MG/16ML, 20 MG/2ML 41 dofetilide 13 DOLOPHINE 10 MG 4 DOLOPHINE 5 MG 5 donepezil hydrochloride 86 DORIBAX 500 MG 11 DORIPENEM 500 MG 11 DORYX 200 MG 89 dorzolamide hcl 84 dorzolamide hcl-timolol maleate 81 DOVONEX 59 doxazosin mesylate 33 doxepin hcl 23 DOXEPIN HYDROCHLORIDE 59 doxercalciferol 66 DOXIL 39 doxorubicin hcl 39 DOXORUBICIN HCL 39 doxorubicin hcl liposomal 39 DOXYCYCLINE 63 doxycycline (monohydrate) 89 doxycycline (monohydrate) 50 mg, 75 mg, 100 mg 89 doxycycline hyclate 89 doxycycline hyclate 150 mg, 200 mg, 100 mg 89 DRISDOL 93 dronabinol 10 mg 28 dronabinol 5 mg, 2.5 mg 28 drospirenone-ethinyl estradiol 53 drospirenone-ethinyl estradiollevomefolate calcium 53 DROXIA 71 DUAC 57 DUAVEE 67 DUETACT 23 DUEXIS 3 DULERA 16 duloxetine hcl 30 mg, 20 mg, 60 mg 22 DUOPA 42 DURAGESIC 100 MCG/HR 5 DURAGESIC 12 MCG/HR 5 DURAGESIC 25 MCG/HR 5 DURAGESIC 50 MCG/HR 5 DURAGESIC 75 MCG/HR 5 DUREZOL 83 dutasteride 70 dutasteride-tamsulosin hcl 70 DYAZIDE 64 DYMISTA 80 DYRENIUM 64 E.E.S. GRANULES 74 EC-NAPROSYN 3 econazole nitrate 58 EDARBI 33 EDARBYCLOR 34 EDECRIN 64 EDEX 51 EDLUAR 10 MG 73 EDLUAR 5 MG 73 EDURANT 46 EFFEXOR XR 150 MG 22 EFFEXOR XR 37.5 MG 22 EFFEXOR XR 75 MG 22 EFFIENT 71 EFUDEX 59 EGRIFTA 66 ELAVIL 23 ELDEPRYL 43 ELELYSO 71 ELESTAT 84 ELESTRIN 68 ELIDEL 62 ELIGARD 38 ELIMITE 63 ELIQUIS 17 ELITEK 40 ELLA 54 ELLENCE 39 ELMIRON 70 ELOCON 61 ELOXATIN 100 MG/20ML 36 ELOXATIN 50 MG/10ML 36 EMCYT 38 EMEND 40 MG 29 EMEND 80 MG, , 125 MG 29 EMPLICITI 37 EMSAM 21 EMTRIVA 46 ENABLEX 92 enalapril maleate & hydrochlorothiazide 34 enalapril maleate 10 mg 32 enalapril maleate 2.5 mg 32 enalapril maleate 20 mg 32 enalapril maleate 5 mg 32 ENBREL 4 ENBREL SURECLICK 4 ENGERIX-B 92 ENJUVIA 0.3 MG, 0.45 MG 68 enoxaparin sodium 120 mg/0.8ml, 150 mg/ml, 60 mg/0.6ml, 100 mg/ml, 80 mg/0.8ml 17 enoxaparin sodium 300 mg/3ml 17 enoxaparin sodium 40 mg/0.4ml, 30 mg/0.3ml 17 ENSTILAR 61 entacapone 42 entecavir 48 ENTOCORT EC 55 ENTRESTO 51 ENTYVIO 69 ENVARSUS XR 77 EPCLUSA 48 EPIDUO 57 epinastine hcl (ophth) 84 epinephrine 93 EPIPEN 2-PAK 93 EPIPEN-JR 2-PAK 93 epirubicin hcl 39 EPIVIR 46 EPIVIR HBV 48 Index 8 eplerenone 35 EPOGEN 10000 UNIT/ML 72 EPOGEN 2000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML 72 EPOGEN 20000 UNIT/ML 72 eprosartan mesylate 33 EPZICOM 46 EQUETRO 43 ERAXIS 100 MG 29 ERBITUX 37 ergocalciferol 93 ergoloid mesylates 88 ergotamine tartrate 75 ergotamine w/ caffeine 75 ERIVEDGE 38 ERTACZO 58 ERWINAZE 40 ERYPED 200 74 ERYPED 400 74 ERYTHROCIN LACTOBIONATE 74 erythromycin (acne aid) 57 erythromycin (ophth) 82 erythromycin base 74 erythromycin base 250 mg 74 erythromycin base 500 mg 74 erythromycin ethylsuccinate 74 ESBRIET 88 escitalopram oxalate 21 esomeprazole magnesium 20 mg 90 esomeprazole magnesium 40 mg 90 esomeprazole sodium 40 mg90 estradiol 68 estradiol & norethindrone acetate 67 estradiol vaginal 93 estradiol valerate 68 ESTRING 93 estropipate 1.5 mg, 0.75 mg 68 eszopiclone 73 ethacrynic acid 64 ethambutol hcl 35 ethosuximide 20 ethynodiol diacet & eth estrad 1mg-35mcg 53 ETHYOL 41 etodolac 3 Index 9 etodolac 400 mg, 500 mg 3 ETOPOPHOS 41 etoposide 41 EURAX 63 EVAMIST 68 EVISTA 66 EVOCLIN 57 EVOMELA 36 EVOTAZ 46 EVOXAC 79 EVZIO 28 EXALGO 12 MG 5 EXALGO 16 MG 5 EXALGO 32 MG 5 EXALGO 8 MG 5 EXELDERM 58 EXELON 86 exemestane 38 EXFORGE 34 EXFORGE HCT 34 EXJADE 28 EXONDYS 51 81 EXTAVIA 87 EXTINA 58 EYLEA 82 ezetimibe 32 ezetimibe-simvastatin 10mg10mg 30 ezetimibe-simvastatin 10mg20mg 30 ezetimibe-simvastatin 40mg10mg 30 ezetimibe-simvastatin 80mg10mg 30 FABIOR 57 FABRAZYME 35 MG 66 famciclovir 48 famotidine 90 famotidine 20 mg 90 famotidine 40 mg 90 FAMVIR 48 FANAPT 2 MG, 1 MG, 4 MG, 10 MG 43 FANAPT 6 MG, 12 MG, 8 MG 43 FANAPT TITRATION PACK 43 FARESTON 38 FARXIGA 27 FARYDAK 39 FASLODEX 38 fat emulsion 81 FAZACLO 100 MG, 25 MG 44 FAZACLO 150 MG, 12.5 MG44 FAZACLO 200 MG 44 felbamate 20 FELBATOL 20 FELDENE 3 felodipine 50 FEMARA 38 FEMCON FE 53 FEMHRT LOW DOSE 67 FEMRING 93 FENOFIBRATE 31 fenofibrate 120 mg, 54 mg, 145 mg, 160 mg, 40 mg, 48 mg 31 fenofibrate micronized 130 mg 31 fenofibrate micronized 200 mg, 67 mg, 134 mg 31 fenofibrate micronized 43 mg 31 FENOFIBRIC ACID 31 FENOGLIDE 31 fentanyl 100 mcg/hr 5 fentanyl 12 mcg/hr 5 fentanyl 25 mcg/hr 5 fentanyl 75 mcg/hr, 50 mcg/hr 5 fentanyl citrate 1200 mcg, 800 mcg, 1600 mcg, 600 mcg, 400 mcg 5 fentanyl citrate 200 mcg 5 FENTORA 100 MCG 5 FENTORA 200 MCG 5 FENTORA 400 MCG, 600 MCG, 800 MCG 5 FERRIPROX 28 FETZIMA 20 MG 22 FETZIMA 80 MG, 40 MG, 120 MG 22 FETZIMA TITRATION PACK22 FIBRICOR 31 FINACEA 63 finasteride 70 FIORINAL/CODEINE #3 8 FIRAZYR 71 FIRMAGON 120 MG 38 FIRMAGON 80 MG 38 FLAGYL 10 FLAGYL 250 MG 10 FLAGYL 500 MG 10 FLAREX 83 flavoxate hcl 92 FLEBOGAMMA DIF 10 % 85 flecainide acetate 100 mg 13 flecainide acetate 150 mg 13 flecainide acetate 50 mg 13 FLECTOR 57 FLOMAX 70 FLOVENT DISKUS 100 MCG/BLIST 15 FLOVENT DISKUS 250 MCG/BLIST 15 FLOVENT DISKUS 50 MCG/BLIST 15 FLOVENT HFA 220 MCG/ACT, 110 MCG/ACT 15 FLOVENT HFA 44 MCG/ACT 15 FLOXIN OTIC 84 fluconazole 29 fluconazole in dextrose 29 fluconazole in nacl 400mg/200ml0.9%, 200mg/100ml-0.9% 29 flucytosine 500 mg 29 fludarabine phosphate 37 fludrocortisone acetate 56 FLUMADINE 48 flunisolide (nasal) 80 fluocinolone acetonide 61 fluocinolone acetonide (otic) 84 fluocinonide 61 fluocinonide emulsified base 61 fluorometholone (ophth) 83 FLUOROURACIL 59 fluorouracil (topical) 59 fluorouracil 1 gm/20ml, 5 gm/100ml 37 fluorouracil 500 mg/10ml, 2.5 gm/50ml 37 fluoxetine hcl 21 fluoxetine hcl (PMDD) cap 10 mg, 20 mg 88 fluoxetine hcl 10 mg, 20 mg 21 FLUOXETINE HCL 60 MG 21 fluoxymesterone 9 fluphenazine decanoate 45 fluphenazine hcl 45 FLUPHENAZINE HCL 45 flurandrenolide 61 flurbiprofen 3 flurbiprofen sodium 84 flutamide 38 fluticasone propionate 61 fluticasone propionate (nasal) 80 fluvastatin sodium 31 fluvoxamine maleate 21 FML 83 FML FORTE 83 FML LIQUIFILM 83 FOCALIN 1 FOCALIN XR 20 MG, 15 MG, 10 MG 1 folic acid 1 mg 71 FOLOTYN 37 fondaparinux sodium 10 mg/0.8ml 17 fondaparinux sodium 2.5 mg/0.5ml 17 fondaparinux sodium 5 mg/0.4ml, 7.5 mg/0.6ml 17 FORFIVO XL 21 FORTAMET 1000 MG 24 FORTAMET 500 MG 24 FORTAZ 2 GM, 1 GM 53 FORTAZ 6 GM 53 FORTEO 65 FORTESTA 9 FORTICAL 65 FOSAMAX 65 FOSAMAX PLUS D 65 FOSFREE 79 fosinopril sodium 32 fosinopril sodium & hydrochlorothiazide 34 fosphenytoin sodium 100 mg pe/2ml 20 fosphenytoin sodium 500 mg pe/10ml 20 FOSRENOL 70 FRAGMIN 18000 UNT/0.72ML, 7500 UNIT/0.3ML, 12500 UNIT/0.5ML, 15000 UNIT/0.6ML 17 FRAGMIN 2500 UNIT/0.2ML, 10000 UNIT/ML, 5000 UNIT/0.2ML 17 FRAGMIN 95000 UNIT/3.8ML 17 FROVA 75 frovatriptan succinate 75 FULYZAQ 28 FURADANTIN 91 furosemide 64 furosemide 10 mg/ml 64 FUSILEV 41 FUZEON 46 FYCOMPA 17 gabapentin 18 GABITRIL 12 MG, 16 MG 20 GABITRIL 4 MG, 2 MG 20 galantamine hydrobromide 86 GALZIN 25 MG 77 GAMASTAN S/D 85 GAMMAGARD LIQUID 85 GAMMAKED 85 GAMMAPLEX 5 GM/50ML, 20 GM/200ML, 10GM/100ML 85 GAMUNEX-C 85 ganciclovir sodium 47 GARDASIL 92 GARDASIL 9 92 GASTROCROM 69 gatifloxacin (ophth) 82 GATTEX 70 gauze pads 2" X 2" 75 GAZYVA 37 GEL-KAM ORAL CARE RINSE 79 GELNIQUE 10 % 92 GELNIQUE 3 % 92 GELNIQUE PUMP 92 gemcitabine hcl 37 gemcitabine hcl 2 gm, 1 gm 37 gemcitabine hcl 200 mg 37 gemfibrozil 31 GEMZAR 1 GM 37 GEMZAR 200 MG 37 GENERESS FE 53 GENOTROPIN 5 MG 66 GENOTROPIN MINIQUICK 0.4 MG 66 gentamicin in saline 0.9%1mg/ml 2 gentamicin sulfate (ophth) 82 gentamicin sulfate (topical) 58 gentamicin sulfate 40 mg/ml 2 Index 10 GENVOYA 46 GEODON 43 GILENYA 87 GILOTRIF 39 GLASSIA 88 glatiramer acetate 87 GLEEVEC 400 MG 39 GLEEVEC 400 MG, 100 MG 39 GLEOSTINE 36 glimepiride 1 mg 27 glimepiride 2 mg 27 glimepiride 4 mg 27 glipizide 10 mg 27 glipizide 2.5 mg 27 glipizide 5 mg 27 glipizide-metformin hcl 2.5mg250mg 23 glipizide-metformin hcl 5mg500mg, 2.5mg-500mg 23 GLUCAGEN HYPOKIT 25 GLUCAGON EMERGENCY KIT 25 GLUCOPHAGE 1000 MG 24 GLUCOPHAGE 500 MG 24 GLUCOPHAGE 850 MG 24 GLUCOPHAGE XR 500 MG 24 GLUCOPHAGE XR 750 MG 24 GLUCOTROL 10 MG 27 GLUCOTROL 5 MG 27 GLUCOTROL XL 10 MG 27 GLUCOTROL XL 2.5 MG 27 GLUCOTROL XL 5 MG 27 GLUCOVANCE 23 glyburide 1.25 mg 27 glyburide 2.5 mg 27 glyburide 5 mg 27 glyburide micronized 1.5 mg 27 glyburide micronized 3 mg 27 glyburide micronized 6 mg 27 glyburide-metformin 1.25mg250mg 23 glyburide-metformin 5mg-500mg, 2.5mg-500mg 23 glycopyrrolate 0.2 mg/ml 90 glycopyrrolate 1 mg 90 glycopyrrolate 2 mg 90 GLYNASE 1.5 MG 27 GLYNASE 3 MG 27 Index 11 GLYNASE 6 MG 27 GLYSET 23 GOLYTELY 227.1GM-21.5GM5.53GM-2.82GM-6.36GM 73 GOLYTELY 236GM-22.74GM5.86GM-2.97GM-6.74GM 73 GRALISE 88 GRALISE STARTER 88 granisetron hcl 28 GRANIX 72 GRASTEK 2 GRIFULVIN V 29 GRIS-PEG 29 griseofulvin microsize 29 griseofulvin ultramicrosize 29 guanfacine hcl 33 guanfacine hcl (adhd) 1 GUANIDINE HCL 35 H.P. ACTHAR 65 HALAVEN 41 HALDOL 44 HALDOL DECANOATE 100 44 HALDOL DECANOATE 50 44 halobetasol propionate 61 HALOG 61 haloperidol 44 haloperidol decanoate 44 haloperidol lactate 44 HARVONI 48 HAVRIX 92 HECTOROL 0.5 MCG, 2.5 MCG 66 HECTOROL 1 MCG 66 HEMANGEOL 49 heparin sodium (porcine) 17 HEPSERA 48 HERCEPTIN 37 HETLIOZ 73 HEXALEN 36 HIPREX 91 HIZENTRA 1 GM/5ML 85 HIZENTRA 10 GM/50ML 85 HIZENTRA 2 GM/10ML, 4 GM/20ML 85 HORIZANT 88 HUMALOG 26 HUMALOG KWIKPEN 25 HUMALOG MIX 50/50 25 HUMALOG MIX 50/50 KWIKPEN 25 HUMALOG MIX 75/25 26 HUMALOG MIX 75/25 KWIKPEN 25 HUMATROPE 12 MG, 24 MG 66 HUMATROPE 6 MG 66 HUMATROPE COMBO PACK 66 HUMIRA 2 HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK 2 HUMIRA PEN 2 HUMIRA PEN-CROHNS DISEASESTARTER 2 HUMIRA PEN-PSORIASIS STARTER 2 HUMULIN 70/30 26 HUMULIN 70/30 KWIKPEN 26 HUMULIN N 26 HUMULIN N KWIKPEN 26 HUMULIN R 26 HUMULIN R U-500 (CONCENTRATED) 26 HUMULIN R U-500 KWIKPEN 26 HYCAMTIN 41 hydralazine hcl 35 HYDREA 40 hydrochlorothiazide 64 hydrocodone polistirexchlorpheniramine polistirex 56 hydrocodone-acetaminophen 8 hydrocodone-acetaminophen 10mg-300mg, 5mg-300mg, 7.5mg-300mg 8 hydrocodone-acetaminophen 5mg-325mg, 7.5mg-325mg, 10mg-325mg 8 hydrocodone-ibuprofen 200mg5mg, 200mg-7.5mg, 200mg10mg 8 hydrocortisone 55 hydrocortisone (intrarectal) 10 hydrocortisone (rectal) 2.5 %, 1 % 10 hydrocortisone (topical) 1 % 61 hydrocortisone (topical) 2.5 % 61 hydrocortisone butyrate 61 hydrocortisone butyrate hydrophilic lipo base 61 hydrocortisone valerate 61 hydrocortisone w/acetic acid 85 hydromorphone hcl 5 hydromorphone hcl 10 mg/ml, 500 mg/50ml, 50 mg/5ml 5 hydromorphone hcl 12 mg 5 hydromorphone hcl 16 mg 5 hydromorphone hcl 2 mg 5 hydromorphone hcl 2 mg/ml 5 hydromorphone hcl 32 mg 5 hydromorphone hcl 4 mg 5 hydromorphone hcl 8 mg 5 hydromorphone hcl 8mg, 8 mg 5 hydroxychloroquine sulfate 35 HYDROXYPROGESTERONE CAPROATE 38 hydroxyurea 40 hydroxyzine hcl 13 hydroxyzine hcl 50 mg/ml 13 hydroxyzine pamoate 25 mg, 50 mg 13 HYQVIA 85 HYSINGLA ER 100 MG, 120 MG 5 HYSINGLA ER 20 MG, 60 MG 5 HYSINGLA ER 30 MG 5 HYSINGLA ER 40 MG 5 HYSINGLA ER 80 MG 5 HYZAAR 34 ibandronate sodium 65 IBRANCE 39 ibuprofen 100 mg/5ml 3 ibuprofen 400 mg 3 ibuprofen 600 mg 3 ibuprofen 800 mg 3 ICLUSIG 39 IDAMYCIN PFS 39 idarubicin hcl 39 IFEX 1 GM 36 IFEX 3 GM 36 ifosfamide 36 ifosfamide 1 gm 36 IFOSFAMIDE 3 GM 36 ILARIS 3 ILEVRO 84 imatinib mesylate 39 IMBRUVICA 39 IMFINZI 37 imipenem-cilastatin 11 imipramine hcl 23 imipramine pamoate 23 imiquimod 62 IMITREX 100 MG 75 IMITREX 20 MG/ACT 75 IMITREX 25 MG 75 IMITREX 5 MG/ACT 75 IMITREX 50 MG 75 IMITREX 6 MG/0.5ML 75 IMITREX STATDOSE REFILL 4 MG/0.5ML 75 IMITREX STATDOSE REFILL 6 MG/0.5ML 75 IMITREX STATDOSE SYSTEM 4 MG/0.5ML 75 IMITREX STATDOSE SYSTEM 6 MG/0.5ML 75 IMOVAX RABIES (H.D.C.V.) 92 IMURAN 77 INCRELEX 66 INCRUSE ELLIPTA 14 indapamide 64 INDERAL LA 49 INDOCIN 3 indomethacin 3 INFANRIX 89 INFLECTRA 69 INLYTA 39 INSPRA 35 INSULIN SYRINGES AND PEN NEEDLES 75 INTELENCE 100 MG 46 INTELENCE 200 MG 46 INTELENCE 25 MG 46 INTERMEZZO 1.75 MG 73 INTERMEZZO 3.5 MG 73 INTRON A 40 INTRON A 10 MU/ML 40 INTRON A 6000000 UNIT/ML 40 INTRON A W/DILUENT 40 INTUNIV 1 INVANZ 11 INVEGA 1.5 MG 43 INVEGA 3 MG 43 INVEGA 6 MG 43 INVEGA 9 MG 43 INVEGA SUSTENNA 43 INVEGA TRINZA 43 INVIRASE 46 INVOKAMET 50MG-1000MG, 150MG-500MG, 150MG1000MG 23 INVOKAMET 50MG-500MG 23 INVOKAMET XR 50MG-1000MG, 150MG-1000MG, 150MG500MG 24 INVOKAMET XR 50MG500MG 24 INVOKANA 27 IOPIDINE 0.5 % 82 IPOL INACTIVATED IPV 92 ipratropium bromide 14 ipratropium bromide (nasal) 80 ipratropium-albuterol 16 IPRIVASK 17 irbesartan 33 irbesartan-hydrochlorothiazide 34 IRESSA 39 irinotecan hcl 41 irrigation solutions, physiological 78 ISENTRESS 46 ISENTRESS 100 MG 46 ISENTRESS 25 MG 46 isoniazid 35 isoniazid & rifampin 35 ISOPTO CARPINE 82 ISORDIL TITRADOSE 40 MG 12 ISORDIL TITRADOSE 5 MG 12 isosorbide dinitrate 12 isosorbide mononitrate 12 isosorbide mononitrate 120 mg, 60 mg, 30 mg 12 isotretinoin 57 ISTALOL 81 ISTODAX 39 ISTODAX (OVERFILL) 39 itraconazole 29 ivermectin 10 IXEMPRA KIT 41 IXIARO 92 JADENU 28 JAKAFI 39 Index 12 JALYN 70 JANUMET 24 JANUMET XR 100MG1000MG 24 JANUMET XR 50MG-1000MG, 50MG-500MG 24 JANUVIA 100 MG 25 JANUVIA 25 MG 25 JANUVIA 50 MG 25 JARDIANCE 27 JENTADUETO 24 JENTADUETO XR 2.5MG1000MG 24 JENTADUETO XR 5MG1000MG 24 JEVTANA 41 JUBLIA 58 JUXTAPID 10 MG 32 JUXTAPID 20 MG 32 JUXTAPID 30 MG 32 JUXTAPID 40 MG 32 JUXTAPID 5 MG 32 JUXTAPID 60 MG 32 K-TAB 10 MEQ 77 K-TAB 8 MEQ, 20 MEQ 77 KADCYLA 37 KADIAN 10 MG 5 KADIAN 100 MG 5 KADIAN 20 MG 6 KADIAN 200 MG 6 KADIAN 30 MG 6 KADIAN 40 MG 6 KADIAN 50 MG 6 KADIAN 60 MG 6 KADIAN 80 MG 6 KALBITOR 71 KALETRA 46 KALETRA 100MG-25MG 46 KALETRA 200MG-50MG 46 KALYDECO 88 KANUMA 66 KAYEXALATE 78 KAZANO 24 KEFLEX 500 MG, 250 MG 52 KEFLEX 750 MG 52 KENALOG 61 KENALOG-10 55 KENALOG-40 55 Index 13 KEPIVANCE 41 KEPPRA 18 KEPPRA 100 MG/ML 18 KEPPRA 500 MG/5ML 18 KEPPRA XR 18 KERYDIN 58 ketoconazole 29 ketoconazole (topical) 58 ketoprofen 3 ketorolac tromethamine 3 ketorolac tromethamine (ophth) 84 ketorolac tromethamine 30 mg/ml, 15 mg/ml 3 ketorolac tromethamine 60 mg/2ml, 30 mg/ml 3 KEVEYIS 64 KEYTRUDA 37 KHEDEZLA 22 KINERET 3 KINRIX 89 KITABIS PAK 2 KLARON 57 KLONOPIN 0.5 MG 17 KLONOPIN 1 MG 17 KLONOPIN 2 MG 17 KOMBIGLYZE XR 2.5MG1000MG 24 KOMBIGLYZE XR 5MG500MG, 5MG-1000MG 24 KORLYM 25 KUVAN 66 KYNAMRO 30 KYPROLIS 39 labetalol hcl 49 LAC-HYDRIN 62 lactated ringer's 77 lactic acid (ammonium lactate) 62 lactic acid (ammonium lactate) 12 % 62 lactulose 74 lactulose (encephalopathy) 69 LAMICTAL 18 LAMICTAL CHEWABLE DISPERSIBLE 18 LAMICTAL ODT 18 LAMICTAL STARTER/NOT TAKING CARBAMAZEPINE 18 LAMICTAL STARTER/TAKING CARBAMAZEPINE/NOT TAKING VALPROATE 18 LAMICTAL STARTER/TAKING VALPROATE 18 LAMICTAL XR 18 LAMISIL 29 LAMISIL 125 MG 29 lamivudine 46 lamivudine (hbv) 48 lamivudine-zidovudine 46 lamotrigine 18 LANOXIN 187.5 MCG, 62.5 MCG 51 LANOXIN 250 MCG, 125 MCG 51 LANOXIN PEDIATRIC 51 lansoprazole 15 mg 90 lansoprazole 30 mg 90 LANTUS 26 LANTUS SOLOSTAR 26 LARTRUVO 37 LASIX 64 LASTACAFT 84 latanoprost 84 LATUDA 120 MG 43 LATUDA 20 MG 43 LATUDA 40 MG 43 LATUDA 60 MG 43 LATUDA 80 MG 43 LAZANDA 100 MCG/ACT 6 LAZANDA 300 MCG/ACT 6 LAZANDA 400 MCG/ACT 6 leflunomide 4 LEMTRADA 87 LENVIMA 10 MG DAILY DOSE 39 LENVIMA 14 MG DAILY DOSE 39 LENVIMA 18 MG DAILY DOSE 39 LENVIMA 20 MG DAILY DOSE 39 LENVIMA 24 MG DAILY DOSE 40 LENVIMA 8 MG DAILY DOSE 40 LESCOL 31 LESCOL XL 31 LETAIRIS 51 letrozole 38 leucovorin calcium 41 leucovorin calcium 350 mg, 100 mg 41 leucovorin calcium 50 mg, 200 mg 41 LEUCOVORIN CALCIUM 500 MG 41 LEUKERAN 36 LEUKINE 72 leuprolide acetate 38 levalbuterol hcl 16 LEVALBUTEROL TARTRATE HFA 16 LEVAQUIN 68 LEVAQUIN 25 MG/ML 68 LEVAQUIN 500MG/100ML-5%, 750MG/150ML-5% 68 LEVEMIR 26 LEVEMIR FLEXTOUCH 26 levetiracetam 19 LEVETIRACETAM 1000MG/100ML-750MG/100ML, 500MG/100ML-820MG/100ML, 1500MG/100ML-540MG/100ML 19 levetiracetam 500 mg/5ml 19 levetiracetam 500 mg/5ml, 100 mg/ml 19 levetiracetam in sodium chloride 18 LEVITRA 51 levobunolol hcl 81 levocarnitine (metabolic modifiers) 66 levocetirizine dihydrochloride30 levofloxacin 68 levofloxacin (ophth) 82 levofloxacin in d5w 68 LEVOLEUCOVORIN 41 levoleucovorin calcium 41 levonorgestrel & eth estradiol 53 levonorgestrel-eth estradiol (triphasic) 53 levonorgestrel-ethinyl estradiol (91-day) 53 levonorgestrel-ethinyl estradiol (continuous) 53 levothyroxine sodium 89 LEXAPRO 21 LEXIVA 46 LIALDA 69 lidocaine 63 lidocaine hcl (local anesth.) 1 %, 2 % 74 lidocaine hcl (mouththroat) 78 lidocaine hcl 2 % 63 lidocaine hcl 4 % 63 lidocaine-prilocaine 63 LIDODERM 63 LINCOCIN 12 lincomycin hcl 12 linezolid 12 linezolid 600 mg/300ml 12 LINEZOLID 600MG/300ML0.9% 12 LINZESS 69 liothyronine sodium 89 LIPITOR 31 LIPOFEN 31 lisinopril 32 lisinopril & hydrochlorothiazide 34 LITHIUM 43 lithium carbonate 43 lithium carbonate 300 mg, 150 mg, 600 mg 43 LITHIUM CARBONATE 600 MG 43 LITHOBID 43 LIVALO 31 LO LOESTRIN FE 53 LOCOID 61 LOCOID LIPOCREAM 61 LOCORT 11-DAY 55 LOCORT 7-DAY 55 LODOSYN 42 LOMOTIL 28 LONSURF 39 loperamide hcl 28 LOPID 31 lopinavir-ritonavir 46 LOPRESSOR 49 LOPRESSOR HCT 34 LOPROX 58 LOPROX SHAMPOO 58 lorazepam 13 lorazepam 2 mg/ml, 20 mg/10ml 13 lorazepam 4 mg/ml 13 losartan potassium 33 losartan potassium & hydrochlorothiazide 34 LOSEASONIQUE 53 LOTEMAX 83 LOTENSIN 32 LOTENSIN HCT 34 LOTREL 34 LOTRONEX 69 lovastatin 40 mg, 20 mg, 10 mg 31 LOVAZA 30 LOVENOX 30 MG/0.3ML, 40 MG/0.4ML 17 LOVENOX 300 MG/3ML 17 LOVENOX 60 MG/0.6ML, 100 MG/ML, 80 MG/0.8ML, 120 MG/0.8ML, 150 MG/ML 17 loxapine succinate 44 LUMIGAN 84 LUMIZYME 66 LUNESTA 73 LUPRON DEPOT (1-MONTH) 3.75 MG 38 LUPRON DEPOT (1-MONTH) 7.5 MG 38 LUPRON DEPOT (3MONTH) 38 LUPRON DEPOT (4MONTH) 38 LUPRON DEPOT (6MONTH) 38 LUPRON DEPOT-PED (1MONTH) 11.25 MG, 15 MG 66 LUPRON DEPOT-PED (1MONTH) 7.5 MG 66 LUPRON DEPOT-PED (3MONTH) 66 LUXIQ 62 LUZU 58 LYNPARZA 40 LYRICA 19 LYRICA 100 MG 19 LYRICA 150 MG 19 LYRICA 200 MG 19 LYRICA 225 MG 19 LYRICA 25 MG 19 LYRICA 300 MG 19 LYRICA 50 MG 19 LYRICA 75 MG 19 LYSODREN 38 LYSTEDA 72 Index 14 M-M-R II 92 MACROBID 91 MACRODANTIN 91 magnesium sulfate 50 % 77 MALARONE 35 malathion 63 maprotiline hcl 21 MARINOL 2.5 MG 28 MARINOL 5 MG, 10 MG 28 MARPLAN 21 MARQIBO 41 MATULANE 40 MAVIK 2 MG, 1 MG 32 MAXALT 10 MG 76 MAXALT 5 MG 76 MAXALT-MLT 10 MG 76 MAXALT-MLT 5 MG 76 MAXIDEX 83 MAXIPIME 1 GM, 2 GM 53 MAXITROL 83 MAXZIDE 64 MAXZIDE-25 64 meclizine hcl 28 meclofenamate sodium 100 mg 3 MEDROL 16 MG, 8 MG, 4 MG, 32 MG 55 MEDROL 2 MG 55 MEDROL DOSEPAK 55 medroxyprogesterone acetate 86 medroxyprogesterone acetate (contraceptive) 54 mefenamic acid 3 mefloquine hcl 35 MEGACE ES 86 MEGACE ORAL 38 megestrol acetate 38 megestrol acetate (appetite) 86 MEKINIST 40 meloxicam 3 melphalan hcl 36 memantine hcl 86 MENACTRA 92 MENHIBRIX 92 MENOMUNE-A/C/Y/W-135 92 MENOSTAR 68 MENTAX 58 Index 15 MENVEO 92 MEPHYTON 93 meprobamate 13 MEPRON 11 mercaptopurine 37 meropenem 1 gm 11 meropenem 500 mg 11 MERREM 1 GM 11 MERREM 500 MG 11 mesalamine 69 MESALAMINE DR 69 mesalamine w/ cleanser 69 mesna 41 MESNEX 41 MESTINON 35 MESTINON TIMESPAN 35 METADATE CD 1 metaproterenol sulfate 16 metaxalone 80 metformin hcl 1000 mg 24 metformin hcl 500 mg 24 metformin hcl 750 mg 24 metformin hcl 850 mg 24 methadone hcl 6 methadone hcl 10 mg 6 methadone hcl 10 mg/5ml 6 methadone hcl 5 mg 6 methadone hcl 5 mg/5ml 6 METHADOSE 6 METHADOSE SUGARFREE 6 methazolamide 64 methenamine hippurate 91 methimazole 10 mg, 5 mg 89 methocarbamol 80 methotrexate sodium 37 methotrexate sodium 200 mg/8ml, 50 mg/2ml, 250 mg/10ml, 100 mg/4ml, 1 gm/40ml 37 METHOTREXATE SODIUM 250 MG/10ML 37 methoxsalen rapid 59 methscopolamine bromide 90 methyldopa 33 methylergonovine maleate 85 METHYLIN 1 methylphenidate hcl 1 methylphenidate hcl 27 mg, 18 mg, 54 mg, 20 mg, 36 mg 1 methylprednisolone 55 methylprednisolone acetate 55 methylprednisolone sod succ 55 methyltestosterone 10 metoclopramide hcl 69 metoclopramide hcl 5 mg/5ml, 10 mg/10ml 69 metoclopramide hcl 5 mg/ml 69 metolazone 64 metoprolol & hydrochlorothiazide 34 metoprolol succinate 49 metoprolol tartrate 25 mg, 100 mg, 50 mg 49 METOPROLOL TARTRATE 75 MG, 37.5 MG 49 METOZOLV ODT 69 METROCREAM 63 METROGEL 63 METROGEL-VAGINAL 93 METROLOTION 63 metronidazole 10 metronidazole (topical) 63 metronidazole 250 mg 10 metronidazole 500 mg 10 metronidazole in nacl 10 metronidazole vaginal 93 mexiletine hcl 13 MIACALCIN 200 UNIT/ACT 65 MIACALCIN 200 UNIT/ML 65 MICARDIS 33 MICARDIS HCT 34 miconazole nitrate vaginal 200 mg 93 MICRO-K 77 MICROZIDE 65 midodrine hcl 93 miglitol 23 MIGRANAL 75 MINASTRIN 24 FE 54 MINIPRESS 33 MINOCIN 50 MG, 100 MG 89 MINOCIN 75 MG 89 minocycline hcl 89 minocycline hcl 50 mg, 100 mg 89 minoxidil 35 MIRAPEX 42 MIRAPEX ER 3 MG, 0.375 MG, 2.25 MG, 1.5 MG, 4.5 MG, 0.75 MG 42 MIRAPEX ER 3.75 MG 42 MIRCERA 200 MCG/0.3ML 72 MIRCERA 75 MCG/0.3ML, 100 MCG/0.3ML, 50 MCG/0.3ML 72 mirtazapine 20 MIRVASO 63 misoprostol 91 MITIGARE 71 mitomycin 20 mg, 40 mg 39 MITOMYCIN 5 MG 39 mitoxantrone hcl 39 MOBIC 3 modafinil 2 MODICON 54 moexipril hcl 32 moexipril-hydrochlorothiazide 34 molindone hcl 45 mometasone furoate 62 mometasone furoate (nasal) 80 MONODOX 89 montelukast sodium 14 morphine sulfate 0.5 mg/ml 6 morphine sulfate 1 mg/ml 6 morphine sulfate 10 mg 6 morphine sulfate 10 mg/5ml 6 morphine sulfate 100 mg 6 morphine sulfate 100 mg, 200 mg 6 morphine sulfate 100 mg/5ml, 20 mg/ml 6 MORPHINE SULFATE 15 MG6 morphine sulfate 15 mg 6 morphine sulfate 20 mg 6 morphine sulfate 20 mg/5ml 6 morphine sulfate 30 mg 6 MORPHINE SULFATE 30 MG6 morphine sulfate 50 mg 6 morphine sulfate 60 mg 6 morphine sulfate 80 mg 6 morphine sulfate beads 120 mg 6 morphine sulfate beads 30 mg 6 morphine sulfate beads 45 mg 6 morphine sulfate beads 60 mg 6 morphine sulfate beads 75 mg 6 morphine sulfate beads 90 mg 6 MOTOFEN 28 MOVANTIK 69 MOVIPREP 73 MOXEZA 82 moxifloxacin hcl 68 MOZOBIL 72 MS CONTIN 100 MG, 200 MG 6 MS CONTIN 15 MG 6 MS CONTIN 30 MG 6 MS CONTIN 60 MG 7 MULTAQ 14 mupirocin 58 mupirocin calcium (topical) 58 MUSE 51 MUSTARGEN 36 MYALEPT 66 MYAMBUTOL 100 MG 35 MYAMBUTOL 400 MG 36 MYCAMINE 100 MG 29 MYCOBUTIN 36 mycophenolate mofetil 78 mycophenolate mofetil hcl 78 mycophenolate sodium 78 MYFORTIC 180 MG 78 MYFORTIC 360 MG 78 MYRBETRIQ 92 MYSOLINE 19 MYTESI 28 nabumetone 3 nadolol 49 nadolol & bendroflumethiazide 34 nafcillin sodium 10 gm 86 nafcillin sodium 2 gm 86 naftifine hcl 58 NAFTIN 58 NAGLAZYME 66 naloxone hcl 28 naltrexone hcl 28 NAMENDA 86 NAMENDA TITRATION PAK 87 NAMENDA XR 14 MG 87 NAMENDA XR 21 MG 87 NAMENDA XR 28 MG 87 NAMENDA XR 7 MG 87 NAMENDA XR TITRATION PACK 87 naphazoline hcl 83 NAPRELAN 500 MG, 375 MG 3 NAPRELAN 750 MG 3 NAPROSYN 3 naproxen 4 naproxen 250 mg, 375 mg, 500 mg 3 naproxen sodium 3 naproxen sodium 275 mg, 550 mg 3 naratriptan hcl 76 NARCAN 28 NARDIL 21 NASCOBAL 71 NASONEX 80 NATACYN 82 nateglinide 27 NATESTO 10 NATPARA 65 NAVELBINE 41 NEBUPENT 10 nefazodone hcl 22 neomycin sulfate 2 neomycin-bacitracin znpolymyxin 82 neomycin-polymy-dexameth 83 neomycin-polymyxin-gramicidin 82 neomycin-polymyxin-hc (otic) 84 neomycin/polymyxin b gu 70 NEORAL 78 NESINA 12.5 MG 25 NESINA 25 MG 25 NESINA 6.25 MG 25 NEULASTA 72 NEULASTA ONPRO KIT 72 NEUMEGA 72 NEUPOGEN 72 NEUPRO 42 NEURONTIN 19 NEVANAC 84 NEVIRAPINE 46 Index 16 nevirapine 46 NEXAVAR 40 NEXIUM 90 NEXIUM 20 MG 90 NEXIUM 40 MG 90 NEXIUM I.V. 90 niacin (antihyperlipidemic) 32 NIASPAN 32 nicardipine hcl 50 NICOTROL INHALER 88 NICOTROL NS 88 nifedipine 50 nifedipine 20 mg 50 NILANDRON 38 nilutamide 38 nimodipine 50 NINLARO 40 NIPENT 40 nisoldipine 50 NITRO-DUR 0.1 MG/HR, 0.4 MG/HR, 0.2 MG/HR, 0.6 MG/HR 12 NITRO-DUR 0.3 MG/HR, 0.8 MG/HR 12 nitrofurantoin 91 nitrofurantoin macrocrystal 91 nitrofurantoin monohyd macro 91 nitroglycerin 12 nitroglycerin 0.4 mg/spray 12 NITROGLYCERIN LINGUAL 12 NITROLINGUAL PUMPSPRAY 12 NITROMIST 12 NITROSTAT 13 nizatidine 90 NIZORAL 58 NOR-QD 55 NORDITROPIN FLEXPRO 10 MG/1.5ML, 5 MG/1.5ML 66 norelgestromin-ethinyl estradiol 54 norethin acet & estrad-fe 54 norethin acet & estrad-fe 75mg30mcg-1.5mg, 75mg-20mcg1mg 54 norethindrone & eth estradiol54 norethindrone & ethinyl estradiolfe 54 Index 17 norethindrone (contraceptive) 55 norethindrone acet & eth estra 54 norethindrone acetate 86 norethindrone acetate-ethinyl estradiol 2.5mcg-0.5mg 67 norethindrone-eth estradiol (triphasic) 54 norgestimate-ethinyl estradiol 54 norgestimate-ethinyl estradiol (triphasic) 54 norgestrel & ethinyl estradiol 54 NORINYL 1+35 54 NORITATE 63 NORPACE 13 NORPACE CR 13 NORPRAMIN 23 NORTHERA 100 MG 93 NORTHERA 200 MG 93 NORTHERA 300 MG 93 nortriptyline hcl 23 NORVASC 10 MG 50 NORVASC 2.5 MG 50 NORVASC 5 MG 50 NORVIR 46 NOVOLIN 70/30 26 NOVOLIN 70/30 RELION 26 NOVOLIN N 26 NOVOLIN N RELION 26 NOVOLIN R 26 NOVOLIN R RELION 26 NOVOLOG 26 NOVOLOG FLEXPEN 26 NOVOLOG MIX 70/30 26 NOVOLOG MIX 70/30 PREFILLED FLEXPEN 26 NOVOLOG PENFILL 26 NOXAFIL 29 NUCALA 14 NUCYNTA 100 MG 7 NUCYNTA 50 MG 7 NUCYNTA 75 MG 7 NUCYNTA ER 100 MG 7 NUCYNTA ER 150 MG 7 NUCYNTA ER 200 MG 7 NUCYNTA ER 250 MG 7 NUCYNTA ER 50 MG 7 NUEDEXTA 88 NULOJIX 78 NULYTELY/FLAVOR PACKS 74 NUPLAZID 43 NUTROPIN AQ NUSPIN 20 66 NUVARING 54 NUVIGIL 2 NYMALIZE 50 nystatin 29 nystatin (mouth-throat) 78 nystatin (topical) 58 nystatin-triamcinolone 58 OCALIVA 10 MG 68 OCALIVA 5 MG 68 OCTAGAM 5 GM/50ML, 10 GM/100ML, 2 GM/20ML, 20 GM/200ML 85 octreotide acetate 200 mcg/ml, 100 mcg/ml, 50 mcg/ml 67 OCUFEN 84 OCUFLOX 82 ODEFSEY 46 ODOMZO 38 OFEV 88 ofloxacin (ophth) 82 ofloxacin (otic) 84 olanzapine 44 olanzapine-fluoxetine hcl 87 olmesartan medoxomil 33 olmesartan medoxomilamlodipine-hydrochlorothiazide 34 olmesartan medoxomilhydrochlorothiazide 34 olopatadine hcl 84 olopatadine hcl (nasal) 80 OLUX 62 OLYSIO 48 omega-3-acid ethyl esters 30 omeprazole 10 mg, 20 mg, 40 mg 90 omeprazole-sodium bicarbonate 20mg-1100mg 91 omeprazole-sodium bicarbonate 20mg-1680mg 91 omeprazole-sodium bicarbonate 40mg-1100mg 91 omeprazole-sodium bicarbonate 40mg-1680mg 91 OMNARIS 80 OMNIPRED 83 OMNITROPE 66 ONCASPAR 40 ondansetron 28 ondansetron hcl 28 ondansetron hcl 4 mg/2ml, 40 mg/20ml 28 ondansetron hcl 4 mg/5ml 28 ONE-A-DAY WEIGHT SMART ADVANCED 79 ONE-A-DAY WOMENS 50+ ADVANTAGE 79 ONE-A-DAY WOMENS ACTIVE MIND & BODY 79 ONE-A-DAY WOMENS PETITES 79 ONE-A-DAY WOMENS PLUS HEALTHY SKIN SUPPORT 79 ONFI 18 ONFI 10 MG 18 ONFI 20 MG 18 ONGLYZA 2.5 MG 25 ONGLYZA 5 MG 25 ONIVYDE 41 ONMEL 29 OPANA 10 MG 7 OPANA 5 MG 7 OPANA ER (CRUSH RESISTANT) 40 MG 7 OPDIVO 37 opium tincture 28 OPSUMIT 52 OPTIVITE P.M.T. 79 ORACEA 63 ORALAIR 2 ORAP 88 ORAPRED ODT 10 MG 55 ORAPRED ODT 30 MG, 15 MG 55 ORBACTIV 10 ORENCIA 4 ORENCIA CLICKJECT 4 ORENITRAM 0.125 MG 51 ORENITRAM 2.5 MG, 1 MG, 0.25 MG 51 ORFADIN 66 ORKAMBI 88 orphenadrine citrate 80 ORTHO EVRA 54 ORTHO MICRONOR 55 ORTHO TRI-CYCLEN 54 ORTHO TRI-CYCLEN LO 54 ORTHO-CEPT 54 ORTHO-CYCLEN 54 ORTHO-NOVUM 1/35 54 ORTHO-NOVUM 7/7/7 54 oseltamivir phosphate 49 OSENI 12.5MG-15MG 24 OSENI 12.5MG-30MG 24 OSENI 25MG-45MG, 12.5MG45MG, 25MG-15MG, 25MG30MG 24 OSMOPREP 74 OTEZLA 4 OTREXUP 2 oxaliplatin 36 oxaliplatin 100 mg/20ml 36 oxaliplatin 50 mg/10ml 36 OXANDRIN 10 MG 9 OXANDRIN 2.5 MG 9 oxandrolone 10 mg 9 oxandrolone 2.5 mg 9 oxaprozin 4 oxcarbazepine 19 oxiconazole nitrate 58 OXISTAT 58 OXSORALEN ULTRA 59 oxybutynin chloride 92 oxycodone hcl 7 oxycodone hcl 10 mg 7 oxycodone hcl 15 mg 7 oxycodone hcl 20 mg 7 oxycodone hcl 30 mg 7 oxycodone hcl 5 mg 7 OXYCODONE HCL ER 10 MG 7 OXYCODONE HCL ER 15 MG 7 OXYCODONE HCL ER 20 MG 7 OXYCODONE HCL ER 30 MG 7 OXYCODONE HCL ER 60 MG, 80 MG, 40 MG 7 oxycodone w/ acetaminophen 8 oxycodone w/ acetaminophen 5mg-325mg, 2.5mg-325mg, 7.5mg-325mg, 10mg325mg 8 oxycodone-aspirin 8 OXYCONTIN 10 MG 7 OXYCONTIN 15 MG 7 OXYCONTIN 20 MG 7 OXYCONTIN 30 MG 7 OXYCONTIN 40 MG, 80 MG, 60 MG 7 oxymorphone hcl 10 mg 7 oxymorphone hcl 15 mg 7 oxymorphone hcl 20 mg 7 oxymorphone hcl 30 mg 7 oxymorphone hcl 40 mg 7 oxymorphone hcl 5 mg 7 oxymorphone hcl 7.5 mg 7 OXYTROL 92 paclitaxel 100 mg/16.7ml 41 PACLITAXEL 150 MG/25ML 41 paclitaxel 30 mg/5ml, 300 mg/50ml 41 paliperidone 1.5 mg 43 paliperidone 3 mg 43 paliperidone 6 mg 43 paliperidone 9 mg 43 PAMELOR 23 PAMINE 90 PAMINE FORTE 90 PANCREAZE 63 PANCRELIPASE 63 PANRETIN 59 pantoprazole sodium 90 PARAFON FORTE DSC 80 parenteral electrolytes 77 paricalcitol 66 PARLODEL 42 PARNATE 21 paromomycin sulfate 2 paroxetine hcl 21 PATADAY 84 PATANASE 80 PATANOL 84 PAXIL 22 PAXIL CR 21 PCE 333 MG 75 PEDVAX HIB 92 peg 3350-kcl-sod bicarb-sod chloride-sod sulfate 74 peg 3350-potassium chloride-sod bicarbonate-sod chloride 74 Index 18 PEG-INTRON 48 PEG-INTRON REDIPEN 48 PEG-INTRON REDIPEN PAK 4 48 PEGANONE 20 PEGASYS 48 PEGASYS PROCLICK 48 PEGINTRON 48 penicillin g potassium 85 penicillin v potassium 85 penicillin v potassium 250 mg/5ml 85 PENNSAID 1.5 % 58 PENNSAID 2 % 58 PENTAM 300 10 PENTASA 250 MG 69 PENTASA 500 MG 69 pentoxifylline 71 PEPCID 90 PERFOROMIST 16 perindopril erbumine 2 mg 32 perindopril erbumine 4 mg 32 perindopril erbumine 8 mg 32 PERJETA 37 permethrin 63 perphenazine 45 perphenazine-amitriptyline 87 PERSANTINE 71 PERTZYE 28750UNIT8000UNIT-30250UNIT, 57500UNIT-16000UNIT60500UNIT 63 PEXEVA 22 PFIZERPEN-G 85 phenelzine sulfate 21 PHENERGAN 30 phenobarbital 73 phenoxybenzamine hcl 33 phenytoin 20 phenytoin sodium 20 phenytoin sodium extended 20 PHOSLO 70 PHOSLYRA 70 PHOSPHOLINE IODIDE 82 PICATO 59 pilocarpine hcl 82 pilocarpine hcl (oral) 79 pimozide 88 Index 19 pindolol 49 pioglitazone hcl 15 mg 25 pioglitazone hcl 30 mg 25 pioglitazone hcl 45 mg 25 pioglitazone hclglimepiride 24 pioglitazone hcl-metformin hcl 24 piperacillin sodium-tazobactam sodium 86 PIPERACILLIN/TAZOBACTAM 86 piroxicam 4 PLAQUENIL 35 PLAVIX 300 MG 71 PLAVIX 75 MG 71 PLEGRIDY 87 PLEGRIDY STARTER PACK 87 PLETAL 100 MG 71 PLETAL 50 MG 71 podofilox 63 polyethylene glycol 3350 74 polymyxin b sulfate 12 polymyxin b-trimethoprim 82 POLYTRIM 82 POMALYST 39 PONSTEL 4 PORTRAZZA 37 potassium chloride 77 potassium chloride 2 meq/ml 77 potassium chloride 20 %, 10 % 77 POTASSIUM CHLORIDE ER 77 potassium chloride in dextrose & sodium chloride 0.45%20meq/l-5% 77 potassium chloride microencapsulated crystals cr 77 potassium citrate (alkalinizer) 540 mg, 1080 mg 70 POTIGA 200 MG 19 POTIGA 300 MG 19 POTIGA 400 MG 19 POTIGA 50 MG 19 PRADAXA 17 PRALUENT 150 MG/ML 32 PRALUENT 75 MG/ML 32 pramipexole dihydrochloride 42 PRANDIMET 24 PRANDIN 0.5 MG 27 PRANDIN 1 MG 27 PRANDIN 2 MG 27 PRAVACHOL 31 pravastatin sodium 31 prazosin hcl 33 PRECOSE 23 PRED FORTE 83 PRED MILD 83 prednicarbate 62 prednisolone 55 prednisolone acetate (ophth) 83 prednisolone sodium phosphate 55 prednisolone sodium phosphate 5 mg/5ml, 6.7 mg/5ml, 15 mg/5ml, 25 mg/5ml 55 prednisone 56 PREMARIN 68 PREMPHASE 67 PREMPRO 67 PREPOPIK 74 PREVACID 15 MG 91 PREVACID 30 MG 91 PREVACID SOLUTAB 91 PREVPAC 91 PREZCOBIX 47 PREZISTA 47 PRIFTIN 36 PRILOSEC 40 MG 91 primaquine phosphate 35 PRIMAXIN IV 11 primidone 19 PRIMSOL 10 PRINIVIL 32 PRISTIQ 22 PRIVIGEN 85 PROAIR HFA 16 PROAIR RESPICLICK 16 probenecid 71 PROCARDIA XL 50 prochlorperazine 45 prochlorperazine edisylate 45 prochlorperazine maleate 45 PROCRIT 4000 UNIT/ML, 2000 UNIT/ML, 10000 UNIT/ML, 3000 UNIT/ML 72 PROCRIT 40000 UNIT/ML, 20000 UNIT/ML 72 PROCTOCORT 10 PROCYSBI 70 progesterone micronized 86 PROGLYCEM 25 PROGRAF 78 PROGRAF 1 MG, 0.5 MG 78 PROGRAF 5 MG 78 PROLASTIN-C 88 PROLENSA 84 PROLEUKIN 40 PROLIA 65 PROMACTA 12.5 MG 72 PROMACTA 25 MG 72 PROMACTA 50 MG 72 PROMACTA 75 MG 72 promethazine & phenylephrine 56 promethazine hcl 30 promethazine hcl 12.5 mg, 25 mg 30 promethazine hcl 50 mg/ml, 25 mg/ml 30 promethazine hcl 6.25 mg/5ml 30 promethazine-phenylephrinecodeine 56 PROMETRIUM 86 propafenone hcl 13 proparacaine hcl 83 propranolol & hydrochlorothiazide 34 propranolol hcl 49 propranolol hcl 40 mg/5ml, 20 mg/5ml 49 propylthiouracil 89 PROQUAD 92 PROSCAR 70 PROSOL 81 PROTONIX 91 PROTOPIC 63 protriptyline hcl 23 PROVENTIL HFA 16 PROVERA 86 PROVIGIL 2 PROZAC 22 PROZAC WEEKLY 22 PRUDOXIN 59 pseudoephed-cpm w/ hydrocod 56 PULMICORT 0.25 MG/2ML 15 PULMICORT 0.5 MG/2ML 15 PULMICORT 1 MG/2ML 15 PULMICORT FLEXHALER 180 MCG/ACT 15 PULMICORT FLEXHALER 90 MCG/ACT 15 PULMOZYME 88 PURIXAN 37 PYLERA 91 pyrazinamide 36 pyridostigmine bromide 35 QNASL 80 QNASL CHILDRENS 80 QUADRACEL 89 QUALAQUIN 35 QUARTETTE 54 quetiapine fumarate 44 quinapril hcl 33 quinapril-hydrochlorothiazide 34 quinidine gluconate 13 quinidine sulfate 13 quinine sulfate 35 QVAR 15 RABAVERT 92 RAGUS 79 RAGWITEK 2 raloxifene hcl 66 ramipril 33 RANEXA 12 ranitidine hcl 90 ranitidine hcl 150 mg 90 ranitidine hcl 300 mg 90 RAPAFLO 70 RAPAMUNE 78 RAPAMUNE 0.5 MG, 2 MG 78 RAPAMUNE 1 MG 78 rasagiline mesylate 43 RASUVO 2 RAVICTI 66 RAYALDEE 66 RAYOS 5 MG, 2 MG 56 RAZADYNE 87 RAZADYNE ER 87 REBETOL 48 REBIF 88 REBIF REBIDOSE 87 REBIF REBIDOSE TITRATIONPACK 87 REBIF TITRATION PACK 88 RECLAST 65 RECOMBIVAX HB 92 RECTIV 10 REGLAN 69 REGRANEX 63 RELENZA DISKHALER 49 RELISTOR 69 RELPAX 76 RELYYKS 63 REMERON 20 REMERON SOLTAB 20 REMICADE 69 REMODULIN 51 RENAGEL 800 MG 70 RENVELA 70 repaglinide 0.5 mg 27 repaglinide 1 mg 27 repaglinide 2 mg 27 repaglinide-metformin hcl 24 REPATHA 32 REPATHA PUSHTRONEX SYSTEM 32 REPATHA SURECLICK 32 REQUIP 42 REQUIP XL 42 RESCRIPTOR 100 MG 47 RESCRIPTOR 200 MG 47 RESTASIS 83 RESTASIS MULTIDOSE 83 RESTORIL 73 RETIN-A 57 RETIN-A MICRO 57 RETIN-A MICRO PUMP 0.04 %, 0.1 % 57 RETIN-A MICRO PUMP 0.08 % 57 RETROVIR 47 RETROVIR IV INFUSION 47 REVATIO 52 REVIA 28 Index 20 REVLIMID 77 REXULTI 0.25 MG 45 REXULTI 0.5 MG 45 REXULTI 1 MG 45 REXULTI 2 MG 45 REXULTI 3 MG 45 REXULTI 4 MG 45 REYATAZ 47 REZIRA 56 RHEUMATREX 2 RHINOCORT AQUA 80 ribavirin 49 ribavirin (hepatitis c) 48 RIDAURA 2 rifabutin 36 RIFADIN 36 rifampin 36 RIFATER 35 RILUTEK 81 riluzole 81 rimantadine hydrochloride 49 RIOMET 24 risedronate sodium 65 risedronate sodium 150 mg 65 risedronate sodium 30 mg, 5 mg 65 risedronate sodium 35 mg 65 RISPERDAL 44 RISPERDAL CONSTA 12.5 MG 43 RISPERDAL CONSTA 25 MG 44 RISPERDAL CONSTA 37.5 MG 44 RISPERDAL CONSTA 50 MG 44 RISPERDAL M-TAB 44 risperidone 44 RITALIN 2 RITALIN LA 20 MG, 30 MG, 40 MG 2 RITALIN LA 60 MG, 10 MG 2 RITUXAN 38 rivastigmine 87 rivastigmine tartrate 87 rizatriptan benzoate 10 mg 76 rizatriptan benzoate 5 mg 76 ROBAXIN 80 ROBAXIN-750 80 Index 21 ROBINUL 90 ROBINUL 0.2 MG/ML 90 ROBINUL FORTE 90 ROCALTROL 66 ropinirole hydrochloride 42 rosuvastatin calcium 31 ROTARIX 92 ROTATEQ 92 ROWASA 69 ROXICODONE 15 MG 7 ROXICODONE 30 MG 7 ROXICODONE 5 MG 7 ROZEREM 73 RUBRACA 40 RUCONEST 71 RYTARY 42 RYTHMOL 13 RYTHMOL SR 13 SABRIL 20 SAFYRAL 54 SALAGEN 79 SAMSCA 67 SANCUSO 28 SANDIMMUNE 78 SANDIMMUNE 100 MG/ML 78 SANDIMMUNE 50 MG/ML 78 SANDOSTATIN 100 MCG/ML 67 SANDOSTATIN 50 MCG/ML, 200 MCG/ML 67 SANDOSTATIN LAR DEPOT 30 MG, 20 MG 67 SANTYL 62 SAPHRIS 10 MG 44 SAPHRIS 2.5 MG 44 SAPHRIS 5 MG 44 SAVAYSA 17 SAVELLA 87 SAVELLA TITRATION PACK 87 SEASONIQUE 54 SECTRAL 49 selegiline hcl 43 selenium sulfide 2.5 % 59 SELZENTRY 300 MG, 150 MG 47 SELZENTRY 75 MG, 25 MG 47 SEMPREX-D 56 SENSIPAR 67 SEREVENT DISKUS 16 SEROQUEL 100 MG, 200 MG, 50 MG, 25 MG 44 SEROQUEL 400 MG, 300 MG 44 SEROQUEL XR 400 MG 44 SEROQUEL XR 50 MG, 150 MG, 300 MG, 200 MG 44 SEROSTIM 6 MG, 4 MG 66 sertraline hcl 22 SIGNIFOR 67 SIGNIFOR LAR 20 MG 67 SIGNIFOR LAR 40 MG 67 SIGNIFOR LAR 60 MG 67 sildenafil citrate (pulmonary hypertension) 52 SILENOR 3 MG 73 SILENOR 6 MG 73 SILVADENE 59 silver sulfadiazine 59 SIMBRINZA 82 SIMPONI 2 SIMPONI ARIA 2 SIMULECT 78 simvastatin 10 mg 31 simvastatin 20 mg 31 simvastatin 40 mg 31 simvastatin 5 mg 31 simvastatin 80 mg 31 SINEMET 42 SINEMET CR 42 SINGULAIR 14 sirolimus 78 SIRTURO 36 SIVEXTRO 12 SKELAXIN 80 sodium chloride (gu irrigant) 70 sodium chloride 0.45 % 77 sodium chloride 0.9 % 77 sodium polystyrene sulfonate 78 sodium polystyrene sulfonate 15 gm/60ml 78 SOLARAZE 59 SOLTAMOX 38 SOLU-CORTEF 250 MG, 100 MG 56 SOLU-MEDROL 1000 MG, 125 MG, 40 MG 56 SOLU-MEDROL 2 GM 56 SOMA 80 SOMATULINE DEPOT 67 SOMAVERT 66 SONATA 73 SOOLANTRA 63 SORIATANE 59 SORILUX 59 sotalol hcl 50 sotalol hcl (afib/afl) 50 Sotalol Hcl IV Soln 50 SOTYLIZE 50 SOVALDI 48 SPIRIVA HANDIHALER 14 SPIRIVA RESPIMAT 14 spironolactone 64 spironolactone & hydrochlorothiazide 64 SPORANOX 29 SPORANOX PULSEPAK 29 SPRITAM 1000 MG 19 SPRITAM 250 MG 19 SPRITAM 500 MG 19 SPRITAM 750 MG 19 SPRYCEL 40 STALEVO 100 42 STALEVO 125 42 STALEVO 150 42 STALEVO 200 42 STALEVO 50 42 STALEVO 75 42 STAMARIL 92 STARLIX 27 stavudine 47 STAXYN 51 STELARA 59 STELARA 130 MG/26ML 69 STENDRA 51 STIMATE 67 STIOLTO RESPIMAT 16 STIVARGA 40 STRATTERA 10 MG 1 STRATTERA 100 MG 1 STRATTERA 18 MG 1 STRATTERA 25 MG 1 STRATTERA 40 MG 1 STRATTERA 60 MG 1 STRATTERA 80 MG 1 STRENSIQ 67 STRIBILD 47 STRIVERDI RESPIMAT 16 STROMECTOL 10 STROVITE FORTE 79 SUBOXONE 9 SUBSYS 100 MCG 7 SUBSYS 1200 MCG 7 SUBSYS 200 MCG 7 SUBSYS 400 MCG, 600 MCG, 1600 MCG, 800 MCG 8 SUCRAID 63 sucralfate 90 SULAR 50 sulfacetamide sodprednisolone 83 sulfacetamide sodium (acne) 57 sulfacetamide sodium (ophth) 82 sulfadiazine 88 sulfamethoxazole-trimethoprim 11 SULFAMETHOXAZOLE/TRIME THOPRIM 11 SULFAMYLON 59 sulfasalazine 69 sulindac 4 sumatriptan 20 mg/act 76 sumatriptan 5 mg/act 76 sumatriptan succinate 76 SUMATRIPTAN SUCCINATE 76 sumatriptan succinate 100 mg 76 sumatriptan succinate 25 mg 76 sumatriptan succinate 4 mg/0.5ml 76 sumatriptan succinate 50 mg 76 sumatriptan succinate 6 mg/0.5ml 76 SUMAVEL DOSEPRO 76 SUPRAX 53 SUPREP BOWEL PREP KIT 74 SURMONTIL 23 SUSTIVA 47 SUTENT 40 SYLATRON 40 SYMBICORT 4.5MCG/ACT160MCG/ACT 16 SYMBICORT 4.5MCG/ACT80MCG/ACT 16 SYMBICORT 4.5MCG/ACT80MCG/ACT, 4.5MCG/ACT160MCG/ACT 16 SYMBYAX 87 SYMLINPEN 120 23 SYMLINPEN 60 23 SYNAGIS 85 SYNALAR 62 SYNAREL 66 SYNERCID 12 SYNJARDY 12.5MG-1000MG, 5MG-1000MG 24 SYNJARDY 12.5MG-500MG, 5MG-500MG 24 SYNRIBO 40 SYNTHROID 89 SYPRINE 77 TABLOID 37 TACLONEX 62 tacrolimus 78 tacrolimus (topical) 63 TAFINLAR 40 TAGRISSO 40 TALTZ 59 TALWIN 9 TAMIFLU 49 TAMIFLU 45 MG, 30 MG 49 TAMIFLU 75 MG 49 tamoxifen citrate 38 tamsulosin hcl 70 TANZEUM 25 TARCEVA 40 TARGRETIN 40 TARKA 4MG-240MG, 2MG240MG 34 TASIGNA 40 TASMAR 42 TAXOL 41 TAXOTERE 41 TAYTULLA 54 tazarotene 59 TAZORAC 59 TAZORAC 0.05 % 59 Index 22 TAZORAC 0.1 % 59 TECENTRIQ 38 TECFIDERA 88 TECFIDERA STARTER PACK 88 TECHNIVIE 48 TEFLARO 600 MG 53 TEGRETOL 19 TEGRETOL-XR 19 TEKTURNA 35 TEKTURNA HCT 34 telmisartan 33 telmisartan-amlodipine 34 telmisartan-hydrochlorothiazide 34 temazepam 73 TEMODAR 36 TEMOVATE 62 TEMOVATE E 62 TENEX 33 TENIVAC 89 TENORETIC 100 34 TENORETIC 50 34 TENORMIN 49 TEPADINA 15 MG 36 TERAZOL 3 93 TERAZOL 7 93 terazosin hcl 33 terbinafine hcl 29 terbutaline sulfate 16 terconazole vaginal 93 TESSALON PERLES 56 TESTIM 10 TESTOSTERONE 1 %, 10 MG/ACT, 50 MG/5GM, 25 MG/2.5GM 10 testosterone 1 %, 25 mg/2.5gm, 50 mg/5gm 10 testosterone cypionate 10 testosterone enanthate 10 TESTOSTERONE PUMP 10 TETANUS/DIPHTHERIA TOXOIDS-ADSORBED 89 TETANUS/DIPHTHERIA TOXOIDS-ADSORBED ADULT 89 tetrabenazine 87 TETRACYCLINE HCL 250 MG, 500 MG 89 Index 23 tetracycline hcl 500 mg, 250 mg 89 THALOMID 77 theophylline 16 THERACYS 40 THERAMILL FORTE 79 thioridazine hcl 45 thiotepa 36 thiothixene 46 THYMOGLOBULIN 78 tiagabine hcl 20 TIAZAC 50 TICE BCG 40 ticlopidine hcl 71 TIGAN 28 TIGECYCLINE 11 TIKOSYN 14 timolol maleate (ophth) 81 timolol maleate 10 mg 50 timolol maleate 20 mg 50 timolol maleate 5 mg 50 TIMOPTIC 82 TIMOPTIC OCUDOSE 82 TIMOPTIC-XE 82 TINDAMAX 10 tinidazole 10 TIVICAY 10 MG 47 TIVICAY 50 MG, 25 MG 47 tizanidine hcl 2 mg 80 tizanidine hcl 4 mg 80 tizanidine hcl 6 mg 80 TOBI 2 TOBI PODHALER 2 TOBRADEX 83 TOBRADEX ST 83 tobramycin 2 tobramycin (ophth) 82 tobramycin sulfate 2 tobramycin sulfate 1.2 gm/30ml, 80 mg/2ml, 40 mg/ml 2 tobramycindexamethasone 83 TOBREX 82 TOFRANIL-PM 23 tolazamide 500 mg 27 tolbutamide 27 tolcapone 42 tolmetin sodium 4 tolmetin sodium 200 mg 4 tolterodine tartrate 92 TOPAMAX 19 TOPAMAX SPRINKLE 19 TOPICORT 62 topiramate 19 topotecan hcl 41 TOPROL XL 49 TORISEL 40 torsemide 20 mg, 10 mg, 100 mg, 5 mg 64 TOUJEO SOLOSTAR 26 TOVIAZ 92 TRACLEER 52 TRADJENTA 25 tramadol hcl 8 tramadol hcl 100 mg 8 tramadol hcl 200 mg 8 tramadol hcl 300 mg 8 tramadol-acetaminophen 8 trandolapril 1 mg, 2 mg, 4 mg 33 trandolapril-verapamil hcl 2mg240mg, 4mg-240mg 35 tranexamic acid 72 TRANSDERM-SCOP 28 TRANXENE T 13 tranylcypromine sulfate 21 TRAVATAN Z 84 travoprost 84 trazodone hcl 22 TREANDA 36 TRECATOR 36 TRELSTAR 38 TRELSTAR MIXJECT 22.5 MG 38 TRELSTAR MIXJECT 3.75 MG, 11.25 MG 38 TRESIBA FLEXTOUCH 100 UNIT/ML 26 TRESIBA FLEXTOUCH 200 UNIT/ML 26 tretinoin 57 tretinoin (chemotherapy) 40 tretinoin microsphere 57 TREXIMET 75 triamcinolone acetonide (mouth) 79 triamcinolone acetonide (nasal) 81 triamcinolone acetonide (topical) 62 triamcinolone acetonide (topical) 0.025 %, 0.1 % 62 triamterene & hydrochlorothiazide 64 TRIBENZOR 35 TRICOR 31 TRIDESILON 62 trifluoperazine hcl 45 trifluridine 82 TRIGLIDE 31 trihexyphenidyl hcl 42 TRILEPTAL 19 TRILIPIX 31 trimethobenzamide hcl 28 trimethoprim 10 trimipramine maleate 23 TRINTELLIX 10 MG 22 TRINTELLIX 20 MG 22 TRINTELLIX 5 MG 22 TRISENOX 40 TRIUMEQ 47 TRIZIVIR 47 TROPHAMINE 0.05GM/100ML0.41GM/100ML0.015GM/100ML0.73GM/100ML-0.49GM/100ML0.12GM/100ML-0.25GM/100ML0.47GM/100ML-0.29GM/100ML0.29GM/100ML-0.2GM/100ML0.84GM/100ML-0.14GM/100ML0.49GM/100ML-0.3GM/100ML0.19GM/100ML-0.23GM/100ML0.32GM/100ML-0.22GM/100ML0.014GM/100ML 81 trospium chloride 92 TRULICITY 25 TRUSOPT 84 TRUVADA 200MG-133MG, 250MG-167MG, 150MG100MG 47 TRUVADA 300MG-200MG 47 TUDORZA PRESSAIR 14 TUSSIONEX PENNKINETIC EXTENDED RELEASE 56 TWINRIX 92 TWYNSTA 35 TYBOST 47 TYGACIL 11 TYKERB 40 TYPHIM VI 92 TYSABRI 88 TYVASO 51 TYVASO REFILL 51 TYVASO STARTER 51 TYZEKA 48 UCERIS 10 ULORIC 71 ULTRACET 8 ULTRAM 8 ULTRAM ER 100 MG 8 ULTRAM ER 200 MG 8 ULTRAM ER 300 MG 8 ULTRAVATE 62 UNASYN 1GM-2GM 86 UPTRAVI 52 UROCIT-K 10 70 UROCIT-K 5 70 UROGESIC-BLUE 91 UROXATRAL 70 URSO 250 68 URSO FORTE 68 ursodiol 68 UVADEX 40 VAGIFEM 93 valacyclovir hcl 48 VALCHLOR 59 VALCYTE 47 valganciclovir hcl 47 VALIUM 13 valproate sodium 100 mg/ml, 500 mg/5ml 20 valproate sodium 250 mg/5ml 20 valproic acid 20 valsartan 33 valsartan-hydrochlorothiazide 35 VALSTAR 39 VALTREX 48 VANCOCIN HCL 11 vancomycin hcl 11 vancomycin hcl 1000 mg, 5000 mg, 10 gm 11 vancomycin hcl 500 mg 11 VANCOMYCIN HCL IN DEXTROSE 11 VANOS 62 VANTAS 38 VAQTA 92 VARIVAX 92 VARIZIG 85 VARUBI 29 VASCEPA 30 VASERETIC 35 VASOTEC 10 MG 33 VASOTEC 2.5 MG 33 VASOTEC 20 MG 33 VASOTEC 5 MG 33 VECTIBIX 38 VECTICAL 59 VELCADE 40 VELPHORO 70 VELTASSA 16.8 GM 78 VELTASSA 25.2 GM 78 VELTASSA 8.4 GM 78 VEMLIDY 48 VENCLEXTA 38 VENCLEXTA STARTING PACK 38 venlafaxine hcl 100 mg 22 venlafaxine hcl 150 mg 22 venlafaxine hcl 225 mg 22 venlafaxine hcl 25 mg 22 venlafaxine hcl 37.5 mg 22 venlafaxine hcl 50 mg 22 venlafaxine hcl 75 mg 22 VENLAFAXINE HCL ER 22 VENTAVIS 10 MCG/ML 51 VENTAVIS 20 MCG/ML 51 VENTOLIN HFA 16 VERAMYST 81 verapamil hcl 50 VERELAN 50 VERELAN PM 50 VERSACLOZ 44 VESICARE 92 VEXOL 83 VFEND 29 VFEND IV 29 VIAGRA 50 MG, 25 MG, 100 MG 51 Index 24 VIBERZI 69 VIBRAMYCIN 89 VICTOZA 25 VICTRELIS 48 VIDAZA 37 VIDEX EC 125 MG 47 VIDEX EC 400 MG, 250 MG, 200 MG 47 VIDEXPEDIATRIC 47 VIEKIRA PAK 48 VIGAMOX 82 VIIBRYD 22 VIIBRYD STARTER PACK 22 VIMIZIM 67 VIMOVO 4 VIMPAT 19 VIMPAT 10 MG/ML 19 VIMPAT 200 MG/20ML 19 VINBLASTINE SULFATE 41 vincristine sulfate 41 vinorelbine tartrate 41 VIOKACE 63 VIRACEPT 47 VIRAMUNE 47 VIRAMUNE XR 100 MG 47 VIRAMUNE XR 400 MG 47 VIRAZOLE 49 VIREAD 47 VIROPTIC 83 VISTARIL 13 VISTIDE 48 VITAFOL 79 VITAROCA PLUS 79 VIVELLE-DOT 68 VOGELXO 10 VOGELXO PUMP 10 VOLTAREN 58 VOLTAREN-XR 4 voriconazole 29 VOTRIENT 40 VPRIV 71 VRAYLAR 43 VRAYLAR 1.5 MG 43 VRAYLAR 3 MG 43 VRAYLAR 4.5 MG 43 VRAYLAR 6 MG 43 Index 25 VYTORIN 10MG-10MG 30 VYTORIN 10MG-20MG 30 VYTORIN 40MG-10MG 30 VYTORIN 80MG-10MG 30 VYVANSE 10 MG 1 VYVANSE 20 MG 1 VYVANSE 30 MG 1 VYVANSE 40 MG 1 VYVANSE 50 MG 1 VYVANSE 60 MG 1 VYVANSE 70 MG 1 warfarin sodium 16 water for irrigation, sterile 78 WELCHOL 31 WELLBUTRIN 100 MG 21 WELLBUTRIN 75 MG 21 WELLBUTRIN SR 100 MG 21 WELLBUTRIN SR 150 MG 21 WELLBUTRIN SR 200 MG 21 WELLBUTRIN XL 150 MG 21 WELLBUTRIN XL 300 MG 21 WESTCORT 62 XALATAN 84 XALKORI 40 XANAX 13 XANAX XR 13 XARELTO 17 XARELTO STARTER PACK 17 XELJANZ 2 XELJANZ XR 2 XENAZINE 87 XEOMIN 81 XERESE 59 XGEVA 65 XIAFLEX 77 XIFAXAN 11 XIGDUO XR 10MG-1000MG, 10MG-500MG 24 XIGDUO XR 5MG-1000MG, 5MG-500MG 24 XIIDRA 83 XOLAIR 14 XOPENEX 16 XOPENEX CONCENTRATE 16 XOPENEX HFA 16 XTANDI 38 XYLOCAINE 1 %, 2 % 74 XYLOCAINE 4 % 63 XYLOCAINE-MPF 1 % 74 XYREM 86 XYZAL 30 YASMIN 28 54 YAZ 54 YERVOY 38 YF-VAX 93 YONDELIS 36 zafirlukast 14 zaleplon 73 ZALTRAP 37 ZANAFLEX 80 ZANAFLEX 2 MG 80 ZANAFLEX 4 MG 80 ZANAFLEX 6 MG 80 ZANOSAR 36 ZANTAC 150 MG 90 ZANTAC 25 MG/ML 90 ZANTAC 300 MG 90 ZARONTIN 20 ZARXIO 72 ZAVESCA 71 ZEBETA 10 MG 49 ZEBETA 5 MG 49 ZEGERID 20MG-1100MG 91 ZEGERID 20MG-1680MG 91 ZEGERID 40MG-1100MG 91 ZEGERID 40MG-1680MG 91 ZELAPAR 43 ZELBORAF 40 ZEMAIRA 88 ZEMBRACE SYMTOUCH 76 ZEMPLAR 67 ZENPEP 10000UNIT-3000UNIT16000UNIT, 17000UNIT5000UNIT-27000UNIT, 68000UNIT-20000UNIT109000UNIT, 34000UNIT10000UNIT-55000UNIT, 51000UNIT-15000UNIT82000UNIT, 85000UNIT25000UNIT-136000UNIT 64 ZENPEP 136000UNIT40000UNIT-218000UNIT 64 ZEPATIER 48 ZERIT 47 ZESTORETIC ZESTRIL ZETIA ZETONNA ZIAC ZIAGEN ZIANA zidovudine zileuton ZINACEF 1.5 GM ZINECARD ZINPLAVA ZIOPTAN ziprasidone hcl ZIPSOR ZIRGAN ZITHROMAX ZITHROMAX TRI-PAK ZITHROMAX Z-PAK ZOCOR 10 MG ZOCOR 20 MG ZOCOR 40 MG ZOCOR 5 MG ZOCOR 80 MG ZOFRAN ZOFRAN ODT ZOHYDRO ER 10 MG ZOHYDRO ER 15 MG ZOHYDRO ER 20 MG ZOHYDRO ER 30 MG ZOHYDRO ER 40 MG ZOHYDRO ER 50 MG ZOLADEX zoledronic acid zoledronic acid 5 mg/100ml ZOLINZA zolmitriptan 2.5 mg zolmitriptan 5 mg ZOLOFT zolpidem tartrate 1.75 mg zolpidem tartrate 10 mg zolpidem tartrate 12.5 mg zolpidem tartrate 3.5 mg zolpidem tartrate 5 mg zolpidem tartrate 6.25 mg ZOLPIMIST 35 33 32 81 35 47 57 47 14 52 41 85 84 43 4 83 74 74 74 31 32 32 32 32 28 28 8 8 8 8 8 8 38 65 65 40 76 76 22 73 73 73 73 73 73 73 ZOMACTON 5 MG 66 ZOMETA 65 ZOMIG 2.5 MG 76 ZOMIG 5 MG 76 ZOMIG ZMT 2.5 MG 76 ZOMIG ZMT 5 MG 76 ZONACORT 11 DAY 56 ZONACORT 7 DAY 56 ZONALON 59 ZONATUSS 56 ZONEGRAN 19 zonisamide 19 ZONTIVITY 71 ZORTRESS 0.25 MG 78 ZORTRESS 0.75 MG, 0.5 MG 78 ZOSTAVAX 93 ZOSYN 86 ZOSYN 0.375GM/50ML3GM/50ML-5% 86 ZOVIRAX 48 ZUBSOLV 0.7MG-0.18MG 9 ZUBSOLV 1.4MG-0.36MG, 5.7MG-1.4MG, 2.9MG-0.71MG, 11.4MG-2.9MG, 8.6MG2.1MG 9 ZURAMPIC 71 ZUTRIPRO 56 ZYBAN 88 ZYCLARA 62 ZYCLARA PUMP 62 ZYDELIG 40 ZYFLO CR 14 ZYKADIA 40 ZYLET 83 ZYLOPRIM 100 MG 71 ZYLOPRIM 300 MG 71 ZYMAXID 83 ZYPREXA 45 ZYPREXA 15 MG, 20 MG 45 ZYPREXA 5 MG, 7.5 MG, 2.5 MG, 10 MG 45 ZYPREXA RELPREVV 210 MG 44 ZYPREXA ZYDIS 45 ZYTIGA 38 ZYVOX 12 ZYVOX 200 MG/100ML 12 ZYVOX 600 MG/300ML 12 Index 26 Este formulario se actualizó el 0/01/201. Para obtener información más reciente o si tiene alguna otra pregunta, comuníquese con Health Net a los siguientes teléfonos: Planes de Arizona: 1-800-977-7522 Planes de California: 1-800-275-4737 o bien, para los usuarios de TTY, 711, de 8:00 a. m. a 8:00 p. m., los siete días de la semana (en algunos fines de semana y días feriados se utiliza el servicio automático de teléfono), o visite www.healthnet.com/medicare. El Formulario puede cambiar en cualquier momento. Recibirá un aviso cuando sea necesario. Esta información está disponible en forma gratuita en otros idiomas. Llame al Departamento de Servicios al Afiliado al número de teléfono que figura arriba. Esta información está disponible en forma gratuita en otros idiomas. Por favor llame a nuestro número de servicio al cliente al número de teléfono que aparece arriba. Health Net tiene un contrato con Medicare para ofrecer planes HMO. La inscripción en un plan Health Net Medicare Advantage depende de la renovación del contrato. DIR04)00 (/1)
© Copyright 2026 Paperzz