2015 Formulary

The Formulary List is a guide providing tier designation for common medicines withinselect therapeutic categories. The Formulary List may not include all drugs coveredby your prescription drug benefit. Generic medicines are available within many of thetherapeutic categories listed, in addition to categories not listed, and should beconsidered as the first line of prescribing.

For benefit coverage or restrictions please check your benefit plan document(s). Thislisting is revised periodically as new drugs and new prescribing information becomesavailable. It is recommended that you bring this list of medications when you or acovered family member sees a physician or other healthcare provider.

Page 1 | 2015 Formulary

ANALGESICS -

HEADACHE -

APAP/DICHLPHEN/ISOMETHEPTENECAPSULE

1

DIHYDROERGOTAMINE MESYLATEAEROSOL; SPRAY WITH PUMP (ML)

1

NARATRIPTAN HCLTABLET

1

RIZATRIPTANTABLET

1

SUMATRIPTAN SUCCINATEPEN INJECTOR (ML)

1

SUMATRIPTAN SUCCINATESPRAY; NON-AEROSOL (EA)

1

SUMATRIPTAN SUCCINATETABLET

1

ZOLMITRIPTANTABLET

1

ZOLMITRIPTAN ODTTABLET;DISINTEGRATING

1

RELPAXTABLET

2

SUMAVEL DOSEPRONEEDLE-FREE INJECTOR (ML)

2

TREXIMETTABLET

2

ZOMIGSPRAY; NON-AEROSOL (EA)

2

AXERTTABLET

3

CAFERGOTTABLET

3

ERGOMARTABLET; SUBLINGUAL

3

FROVATABLET

3

MISCELLANEOUS -

DIFLUNISALTABLET

1

SALSALATETABLET

1

TRAMADOL HCLTABLET

1

TRAMADOL HCL ERTABLET; EXTENDED RELEASE 24 HR

1

TRAMADOL HCL-ACETAMINOPHENTABLET

1

EUFLEXXASYRINGE (ML)

2

MONOVISCSYRINGE (ML)

2

NUCYNTATABLET

2

NUCYNTA ERTABLET; EXTENDED RELEASE 12 HR

2

ORTHOVISCSYRINGE (ML)

2

SYNVISCSYRINGE (ML)

2

SYNVISC-ONESYRINGE (ML)

2

CONZIPCAPSULE;EXT.RELEASE 24 HR BIPHASIC 25-75

3

GEL-ONESYRINGE (ML)

3

HYALGANSYRINGE (ML)

3

HYALGANVIAL (ML)

3

KADIANCAPSULE; EXTENDED RELEASE PELLETS

3

SUPARTZSYRINGE (ML)

3

ZOHYDRO ERCAPSULE; EXTENDED RELEASE 12 HR

3

NARCOTIC ANTAGONISTS -

BUPRENORPHINE-NALOXONETABLET; SUBLINGUAL

1

DEPADETABLET

1

NALTREXONE HYDROCHLORIDETABLET

1

SUBOXONEFILM; MEDICATED (EA)

2

VIVITROLSUSPENSION; EXTENDED RELEASE; RECONST.

2

ZUBSOLVTABLET; SUBLINGUAL

2

NARCOTICS -

ACETAMINOPHEN W/CODEINESOLUTION; ORAL

1

ACETAMINOPHEN W/CODEINETABLET

1

APAP-CAFFEINE-DIHYDROCODEINETABLET

1

BUPRENORPHINE HYDROCHLORIDETABLET; SUBLINGUAL

1

BUTALBITAL COMPOUNDCAPSULE

1

BUTALBITAL COMPOUND W/CODEINECAPSULE

1

BUTALBITAL/APAP/CAFFEINETABLET

1

BUTALBITAL/CAFF/APAP/CODEINECAPSULE

1

Page 2 | 2015 Formulary

CODEINE SULFATETABLET

1

DISKETSTABLET; SOLUBLE

1

FENTANYLPATCH; TRANSDERMAL 72 HOURS

1

FENTANYL CITRATELOZENGE ON A HANDLE

1

HYDROCODONE BIT-IBUPROFENTABLET

1

HYDROCODONE W/ACETAMINOPHENSOLUTION; ORAL

1

HYDROCODONE W/ACETAMINOPHENTABLET

1

HYDROMORPHONE HCLLIQUID (ML)

1

HYDROMORPHONE HCLSUPPOSITORY; RECTAL

1

HYDROMORPHONE HCLTABLET

1

MEPERIDINE HCLSOLUTION; ORAL

1

MEPERIDINE HCLTABLET

1

METHADONE HCLSOLUTION; ORAL

1

METHADONE HCLTABLET

1

MORPHINE SULFATESOLUTION; ORAL

1

MORPHINE SULFATESUPPOSITORY; RECTAL

1

MORPHINE SULFATETABLET

1

MORPHINE SULFATE ERTABLET; EXTENDED RELEASE

1

OXYCODONE HCLSOLUTION; ORAL

1

OXYCODONE HCLTABLET

1

OXYCODONE HCL-IBUPROFENTABLET

1

OXYCODONE W/ACETAMINOPHENTABLET

1

OXYCODONE W/ASPIRINTABLET

1

OXYMORPHONE HCLTABLET

1

OXYMORPHONE HCL ERTABLET; EXTENDED RELEASE 12 HR

1

VICODINTABLET

1

VICODIN ESTABLET

1

BUTRANSPATCH; TRANSDERMAL WEEKLY

2

FENTORATABLET; EFFERVESCENT

2

OPANA ERTABLET;ORAL ONLY;EXTENDED RELEASE 12 HR

2

OXYCONTINTABLET; EXTENDED RELEASE 12 HR

2

ABSTRALTABLET; SUBLINGUAL

3

CAPITAL W/CODEINESUSPENSION; ORAL (FINAL DOSE FORM)

3

CODEINE SULFATESOLUTION; ORAL

3

ONSOLISFILM; MEDICATED (EA)

3

OXECTATABLET; ORAL ONLY

3

PRIMLEVTABLET

3

SUBSYSSPRAY; NON-AEROSOL (EA)

3

NSAIDS -

DICLOFENAC POTASSIUMTABLET

1

DICLOFENAC SODIUMTABLET; EXTENDED RELEASE 24 HR

1

DICLOFENAC SODIUM-MISOPROSTOLTABLET;IMMEDIATE DELAY RELEASE;BIPHASE

1

ETODOLACTABLET

1

FENOPROFEN CALCIUMTABLET

1

FLURBIPROFENTABLET

1

INDOMETHACINCAPSULE

1

KETOPROFENCAPSULE

1

KETOROLAC TROMETHAMINETABLET

1

MECLOFENAMATE SODIUMCAPSULE

1

MEFENAMIC ACIDCAPSULE

1

MELOXICAMSUSPENSION; ORAL (FINAL DOSE FORM)

1

MELOXICAMTABLET

1

NABUMETONETABLET

1

Page 3 | 2015 Formulary

NAPROXENTABLET

1

NAPROXEN SODIUMTABLET

1

OXAPROZINTABLET

1

PIROXICAMCAPSULE

1

SULINDACTABLET

1

TOLMETIN SODIUMCAPSULE

1

CELEBREXCAPSULE

2

NAPROCREAM (GRAM)

2

VOLTARENGEL (GRAM)

2

ZORVOLEXCAPSULE

2

DUEXISTABLET

3

FLECTORPATCH; TRANSDERMAL 12 HOURS

3

INDOCINSUPPOSITORY; RECTAL

3

INDOCINSUSPENSION; ORAL (FINAL DOSE FORM)

3

NALFONCAPSULE

3

SPRIXSPRAY; NON-AEROSOL (EA)

3

VIMOVOTABLET;IMMEDIATE DELAY RELEASE;BIPHASE

3

ZIPSORCAPSULE

3

ANTI-INFECTIVES -

ANTIFUNGAL -

FLUCONAZOLESUSPENSION; RECONSTITUTED; ORAL (ML)

1

FLUCONAZOLETABLET

1

FLUCYTOSINECAPSULE

1

GRISEOFULVINSUSPENSION; ORAL (FINAL DOSE FORM)

1

GRISEOFULVINTABLET

1

GRISEOFULVIN ULTRAMICROSIZETABLET

1

ITRACONAZOLECAPSULE

1

KETOCONAZOLETABLET

1

NYSTATINPOWDER (EA)

1

NYSTATINSUSPENSION; ORAL (FINAL DOSE FORM)

1

NYSTATINTABLET

1

TERBINAFINETABLET

1

VORICONAZOLESUSPENSION; RECONSTITUTED; ORAL (ML)

1

VORICONAZOLETABLET

1

LAMISILGRANULES IN PACKET (EA)

2

NOXAFILSUSPENSION; ORAL (FINAL DOSE FORM)

2

SPORANOXSOLUTION; ORAL

2

ONMELTABLET

3

TERBINEXKIT

3

ANTIMALARIALS -

ATOVAQUONE-PROGUANIL HCLTABLET

1

CHLOROQUINE PHOSPHATETABLET

1

HYDROXYCHLOROQUINE SULFATETABLET

1

MEFLOQUINE HCLTABLET

1

QUININE SULFATECAPSULE

1

COARTEMTABLET

2

DARAPRIMTABLET

2

PRIMAQUINETABLET

2

ANTIMYCOBACTERIALS -

ETHAMBUTOL HCLTABLET

1

ISONIAZIDTABLET

1

PYRAZINAMIDETABLET

1

RIFAMPINCAPSULE

1

SIRTUROTABLET

2

Page 4 | 2015 Formulary

CYCLOSERINECAPSULE

3

PASERGRANULES DELAYED RELEASE FOR SUSP PACKET

3

RIFATERTABLET

3

TRECATORTABLET

3

ANTIPARASITICS -

METRONIDAZOLETABLET

1

PAROMOMYCIN SULFATECAPSULE

1

TINIDAZOLETABLET

1

ALBENZATABLET

2

ALINIASUSPENSION; RECONSTITUTED; ORAL (ML)

2

ALINIATABLET

2

MEPRONSUSPENSION; ORAL (FINAL DOSE FORM)

2

STROMECTOLTABLET

2

BILTRICIDETABLET

3

FLAGYL ERTABLET; EXTENDED RELEASE

3

YODOXINTABLET

3

CEPHALOSPORINS -

CEFACLORCAPSULE

1

CEFACLORSUSPENSION; RECONSTITUTED; ORAL (ML)

1

CEFADROXILCAPSULE

1

CEFADROXILSUSPENSION; RECONSTITUTED; ORAL (ML)

1

CEFDINIRCAPSULE

1

CEFDINIRSUSPENSION; RECONSTITUTED; ORAL (ML)

1

CEFPROZILSUSPENSION; RECONSTITUTED; ORAL (ML)

1

CEFPROZILTABLET

1

CEFTIBUTENCAPSULE

1

CEFTIBUTENSUSPENSION; RECONSTITUTED; ORAL (ML)

1

CEFUROXIME AXETILTABLET

1

CEPHALEXINSUSPENSION; RECONSTITUTED; ORAL (ML)

1

CEPHALEXINTABLET

1

CEDAXSUSPENSION; RECONSTITUTED; ORAL (ML)

3

CEFTINSUSPENSION; RECONSTITUTED; ORAL (ML)

3

SPECTRACEFTABLET

3

SUPRAXSUSPENSION; RECONSTITUTED; ORAL (ML)

3

ERYTHROMYCINS/MACROLIDS -

AZITHROMYCINSUSPENSION; RECONSTITUTED; ORAL (ML)

1

AZITHROMYCINTABLET

1

CLARITHROMYCINSUSPENSION; RECONSTITUTED; ORAL (ML)

1

CLARITHROMYCINTABLET

1

CLARITHROMYCIN ERTABLET; EXTENDED RELEASE 24 HR

1

ERY-TABTABLET; ENTERIC COATED

1

ERYTHROMYCINTABLET

1

ERYTHROMYCIN ETHYLSUCCINATETABLET

1

DIFICIDTABLET

3

PCETABLET; PARTICLES/CRYSTALS IN

3

HIV -

ABACAVIRTABLET

1

ABACAVIR-LAMIVUDINE-ZIDOVUDINETABLET

1

CLOTRIMAZOLETROCHE

1

DIDANOSINECAPSULE;DELAYED RELEASE (ENTERIC COATED)

1

LAMIVUDINETABLET

1

LAMIVUDINE-ZIDOVUDINETABLET

1

NEVIRAPINESUSPENSION; ORAL (FINAL DOSE FORM)

1

NEVIRAPINETABLET

1

Page 5 | 2015 Formulary

STAVUDINECAPSULE

1

STAVUDINESOLUTION; RECONSTITUTED; ORAL

1

ZIDOVUDINECAPSULE

1

ZIDOVUDINESYRUP

1

ZIDOVUDINETABLET

1

APTIVUSCAPSULE

2

APTIVUSSOLUTION; ORAL

2

ATRIPLATABLET

2

COMPLERATABLET

2

CRIXIVANCAPSULE

2

EDURANTTABLET

2

EMTRIVACAPSULE

2

EMTRIVASOLUTION; ORAL

2

EPIVIRSOLUTION; ORAL

2

EPZICOMTABLET

2

INTELENCETABLET

2

INVIRASETABLET

2

ISENTRESSTABLET

2

KALETRASOLUTION; ORAL

2

KALETRATABLET

2

LEXIVASUSPENSION; ORAL (FINAL DOSE FORM)

2

LEXIVATABLET

2

NORVIRSOLUTION; ORAL

2

NORVIRTABLET

2

PREZISTASUSPENSION; ORAL (FINAL DOSE FORM)

2

PREZISTATABLET

2

RESCRIPTORTABLET

2

REYATAZCAPSULE

2

SELZENTRYTABLET

2

STRIBILDTABLET

2

SUSTIVACAPSULE

2

TIVICAYTABLET

2

TRUVADATABLET

2

VIDEXSOLUTION; RECONSTITUTED; ORAL

2

VIRACEPTTABLET

2

VIREADTABLET

2

ZIAGENSOLUTION; ORAL

2

MISCELLANEOUS -

ACYCLOVIRCAPSULE

1

ACYCLOVIRSUSPENSION; ORAL (FINAL DOSE FORM)

1

ACYCLOVIRTABLET

1

AMANTADINE HCLCAPSULE

1

CLINDAMYCIN HCLCAPSULE

1

CLINDAMYCIN PALMITATE HCLSOLUTION; RECONSTITUTED; ORAL

1

FAMCICLOVIRTABLET

1

LAMIVUDINETABLET

1

METHENAMINE HIPPURATETABLET

1

METHENAMINE MANDELATETABLET

1

MODERIBATABLET

1

NITROFURANTOINCAPSULE

1

NITROFURANTOIN MACROCRYSTALCAPSULE

1

RIBAPAKTABLET; DOSE PACK

1

RIBASPHERECAPSULE

1

Page 6 | 2015 Formulary

RIMANTADINE HCLTABLET

1

SULFADIAZINETABLET

1

SULFAMETHOXAZOLE/TRIMETHOPRIMSUSPENSION; ORAL (FINAL DOSE FORM)

1

SULFAMETHOXAZOLE/TRIMETHOPRIMTABLET

1

TRIMETHOPRIMTABLET

1

VALACYCLOVIRTABLET

1

VANCOMYCIN HCLCAPSULE

1

BARACLUDETABLET

2

DAPSONETABLET

2

EPIVIR HBVSOLUTION; ORAL

2

OLYSIOCAPSULE

2

TAMIFLUCAPSULE

2

TAMIFLUSUSPENSION; RECONSTITUTED; ORAL (ML)

2

TYZEKATABLET

2

VALCYTESOLUTION; RECONSTITUTED; ORAL

2

VALCYTETABLET

2

VICTRELISCAPSULE

2

XIFAXANTABLET

2

ZYVOXTABLET

2

INCIVEKTABLET

3

MONUROLPACKET (EA)

3

PRIMSOLSOLUTION; ORAL

3

REBETOLSOLUTION; ORAL

3

TOBI PODHALERCAPSULE

3

PENICILLINS -

AMOX TR/POTASSIUM CLAVULANATESUSPENSION; RECONSTITUTED; ORAL (ML)

1

AMOX TR/POTASSIUM CLAVULANATETABLET

1

AMOXICILLINSUSPENSION; RECONSTITUTED; ORAL (ML)

1

AMOXICILLINTABLET

1

AMOXICILLIN-CLAVULANATE ERTABLET; EXTENDED RELEASE 12 HR

1

AMPICILLIN TRIHYDRATECAPSULE

1

AMPICILLIN TRIHYDRATESUSPENSION; RECONSTITUTED; ORAL (ML)

1

DICLOXACILLIN SODIUMCAPSULE

1

PENICILLIN V POTASSIUMSOLUTION; RECONSTITUTED; ORAL

1

PENICILLIN V POTASSIUMTABLET

1

QUINOLONES -

CIPROFLOXACIN ERTABLET;EXTENDED RELEASE MULTIPHASE 24 HR

1

CIPROFLOXACIN HCLTABLET

1

LEVOFLOXACIN HEMIHYDRATESOLUTION; ORAL

1

LEVOFLOXACIN HEMIHYDRATETABLET

1

FACTIVETABLET

3

NOROXINTABLET

3

TETRACYCLINES -

DEMECLOCYCLINE HCLTABLET

1

DOXYCYCLINE HYCLATETABLET

1

DOXYCYCLINE MONOHYDRATECAPSULE

1

MINOCYCLINE HCLCAPSULE

1

MORGIDOXCAPSULE

1

TETRACYCLINE HCLCAPSULE

1

ORACEACAPSULE;EXTENDED RELEASE MULTIPHASE 24HR

2

SOLODYNTABLET; EXTENDED RELEASE 24 HR

2

DORYXTABLET; ENTERIC COATED

3

VIBRAMYCINSYRUP

3

VAGINAL -

CLINDAMYCIN PHOSPHATECREAM WITH APPLICATOR

1

Page 7 | 2015 Formulary

METRONIDAZOLEGEL WITH APPLICATOR (GRAM)

1

MICONAZOLE 3SUPPOSITORY; VAGINAL

1

TERCONAZOLECREAM WITH APPLICATOR

1

TERCONAZOLESUPPOSITORY; VAGINAL

1

AVCCREAM WITH APPLICATOR

3

GYNAZOLE-1CREAM WITH PREFILLED APPLICATOR

3

CARDIAC -

ACE INHIBITORS -

AMLODIPINE BESYLATE-BENAZEPRILCAPSULE

1

BENAZEPRIL HCLTABLET

1

BENAZEPRIL HCL-HCTZTABLET

1

CAPTOPRILTABLET

1

CAPTOPRIL/HYDROCHLOROTHIAZIDETABLET

1

ENALAPRIL MALEATETABLET

1

FOSINOPRIL SODIUMTABLET

1

FOSINOPRIL-HYDROCHLOROTHIAZIDETABLET

1

LISINOPRILTABLET

1

LISINOPRIL-HCTZTABLET

1

MOEXIPRIL HCLTABLET

1

MOEXIPRIL-HYDROCHLOROTHIAZIDETABLET

1

PERINDOPRIL ERBUMINETABLET

1

QUINAPRIL-HYDROCHLOROTHIAZIDETABLET

1

RAMIPRILCAPSULE

1

TRANDOLAPRILTABLET

1

TARKATABLET;EXTENDED RELEASE MULTIPHASE 24 HR

2

ANTIARRHYTHMIC -

AMIODARONE HCLTABLET

1

DIGOXINSOLUTION; ORAL

1

DIGOXINTABLET

1

DISOPYRAMIDE PHOSPHATECAPSULE

1

FLECAINIDE ACETATETABLET

1

MEXILETINE HCLCAPSULE

1

PACERONETABLET

1

PROCAINAMIDE HCLVIAL (ML)

1

QUINIDINE GLUCONATEVIAL (ML)

1

QUINIDINE SULFATETABLET; EXTENDED RELEASE

1

SORINETABLET

1

SOTALOLTABLET

1

SOTALOL AFTABLET

1

TIKOSYNCAPSULE

2

MULTAQTABLET

3

NORPACE CRCAPSULE; EXTENDED RELEASE

3

ANTICOAGULANTS -

AMINOCAPROIC ACIDSOLUTION; ORAL

1

AMINOCAPROIC ACIDTABLET

1

CILOSTAZOLTABLET

1

CLOPIDOGRELTABLET

1

DIPYRIDAMOLETABLET

1

ENOXAPARIN SODIUMSYRINGE (ML)

1

FONDAPARINUX SODIUMSYRINGE (ML)

1

HEPARIN SODIUMVIAL (ML)

1

PENTOXIFYLLINETABLET; EXTENDED RELEASE

1

TICLOPIDINE HCLTABLET

1

WARFARIN SODIUMTABLET

1

AGGRENOXCAPSULE;EXTENDED RELEASE MULTIPHASE 12HR

2

Page 8 | 2015 Formulary

BRILINTATABLET

2

EFFIENTTABLET

2

ELIQUISTABLET

2

FRAGMINSYRINGE (ML)

2

MEPHYTONTABLET

2

PRADAXACAPSULE

2

XARELTOTABLET

2

ARB -

CANDESARTAN CILEXETILTABLET

1

CANDESARTAN-HYDROCHLOROTHIAZIDTABLET

1

EPROSARTAN MESYLATETABLET

1

IRBESARTANTABLET

1

IRBESARTAN-HYDROCHLOROTHIAZIDETABLET

1

LOSARTAN POTASSIUMTABLET

1

LOSARTAN-HYDROCHLOROTHIAZIDETABLET

1

TELMISARTANTABLET

1

TELMISARTAN-AMLODIPINETABLET

1

VALSARTAN-HYDROCHLOROTHIAZIDETABLET

1

AMTURNIDETABLET

2

AZORTABLET

2

BENICARTABLET

2

BENICAR HCTTABLET

2

EDARBITABLET

2

EDARBYCLORTABLET

2

EXFORGETABLET

2

EXFORGE HCTTABLET

2

TEKAMLOTABLET

2

TEKTURNATABLET

2

TEKTURNA HCTTABLET

2

TRIBENZORTABLET

2

TEVETENTABLET

3

TEVETEN HCTTABLET

3

BETA BLOCKERS -

ACEBUTOLOL HCLCAPSULE

1

ATENOLOLTABLET

1

ATENOLOL W/CHLORTHALIDONETABLET

1

BETAXOLOL HCLTABLET

1

BISOPROLOL FUMARATETABLET

1

BISOPROLOL FUMARATE/HCTZTABLET

1

CARVEDILOLTABLET

1

LABETALOL HCLTABLET

1

METOPROLOL SUCCINATETABLET; EXTENDED RELEASE 24 HR

1

METOPROLOL TARTRATETABLET

1

NADOLOLTABLET

1

NADOLOL-BENDROFLUMETHIAZIDETABLET

1

PINDOLOLTABLET

1

PROPRANOLOL HCLSOLUTION; ORAL

1

PROPRANOLOL HCLTABLET

1

PROPRANOLOL HCL-HCTZTABLET

1

TIMOLOL MALEATETABLET

1

BYSTOLICTABLET

2

COREG CRCAPSULE;EXTENDED RELEASE MULTIPHASE 24HR

2

LEVATOLTABLET

3

CALCIUM CHANNEL BLOCKERS -

Page 9 | 2015 Formulary

AFEDITAB CRTABLET; EXTENDED RELEASE

1

AMLODIPINE BESYLATETABLET

1

CARTIA XTCAPSULE; EXT RELEASE 24 HR

1

DILTIAZEM 24HR CDCAPSULE; EXT RELEASE 24 HR

1

DILTIAZEM ERCAPSULE; EXT RELEASE 24 HR

1

DILTIAZEM HCLTABLET

1

FELODIPINE ERTABLET; EXTENDED RELEASE 24 HR

1

ISRADIPINECAPSULE

1

NIFEDIPINECAPSULE

1

NIFEDIPINE ERTABLET; EXTENDED RELEASE

1

NIMODIPINECAPSULE

1

NISOLDIPINETABLET; EXTENDED RELEASE 24 HR

1

TAZTIA XTCAPSULE; EXTENDED RELEASE

1

VERAPAMIL ER PMCAPSULE;24HR EXTENDED RELEASE PELLET CT

1

VERAPAMIL HCLTABLET

1

DIURETICS -

ACETAZOLAMIDECAPSULE; EXTENDED RELEASE

1

ACETAZOLAMIDETABLET

1

AMILORIDE HCLTABLET

1

AMILORIDE HCL W/HCTZTABLET

1

BUMETANIDETABLET

1

CHLOROTHIAZIDETABLET

1

EPLERENONETABLET

1

FUROSEMIDESOLUTION; ORAL

1

FUROSEMIDETABLET

1

HYDROCHLOROTHIAZIDETABLET

1

INDAPAMIDETABLET

1

METHAZOLAMIDETABLET

1

METHYCLOTHIAZIDETABLET

1

METOLAZONETABLET

1

SPIRONOLACTONETABLET

1

SPIRONOLACTONE W/HCTZTABLET

1

TORSEMIDETABLET

1

TRIAMTERENE W/HCTZTABLET

1

DYRENIUMCAPSULE

3

NITRATES -

ISOSORBIDE DINITRATETABLET

1

ISOSORBIDE MONONITRATETABLET

1

NITRO-BIDOINTMENT (GRAM)

1

NITROGLYCERINAEROSOL; SPRAY (GRAM)

1

NITROGLYCERINCAPSULE; EXTENDED RELEASE

1

NITROGLYCERINPATCH; TRANSDERMAL 24 HOURS

1

DILATRATE-SRCAPSULE; EXTENDED RELEASE

2

NITROSTATTABLET; SUBLINGUAL

2

MINITRANPATCH; TRANSDERMAL 24 HOURS

3

NITRO-DURPATCH; TRANSDERMAL 24 HOURS

3

OTHER -

RANEXATABLET; EXTENDED RELEASE 12 HR

2

VECAMYLTABLET

3

OTHER ANTI-HYPERTENSIVES -

CLONIDINE HCLTABLET

1

CLORPRESTABLET

1

DOXAZOSIN MESYLATETABLET

1

GUANFACINE HCLTABLET

1

HYDRALAZINE HCLTABLET

1

Page 10 | 2015 Formulary

METHYLDOPATABLET

1

METHYLDOPA/HYDROCHLOROTHIAZIDETABLET

1

MINOXIDILTABLET

1

PRAZOSIN HCLCAPSULE

1

RESERPINETABLET

1

BIDILTABLET

3

CARDURA XLTABLET; EXTENDED RELEASE 24 HR

3

OTHER LIPID MEDS -

CHOLESTYRAMINEPOWDER IN PACKET (EA)

1

COLESTIPOL HCLTABLET

1

FENOFIBRATETABLET

1

FENOFIBRIC ACIDCAPSULE;DELAYED RELEASE (ENTERIC COATED)

1

GEMFIBROZILTABLET

1

NIACIN ERTABLET; EXTENDED RELEASE 24 HR

1

PREVALITEPOWDER IN PACKET (EA)

1

JUXTAPIDCAPSULE

2

LIPOFENCAPSULE

2

LOVAZACAPSULE

2

VASCEPACAPSULE

2

WELCHOLPOWDER IN PACKET (EA)

2

WELCHOLTABLET

2

ZETIATABLET

2

ANTARACAPSULE

3

COLESTIDGRANULES (GRAM)

3

FENOGLIDETABLET

3

NIACORTABLET

3

TRIGLIDETABLET

3

STATINS -

AMLODIPINE-ATORVASTATINTABLET

1

ATORVASTATIN CALCIUMTABLET

1

FLUVASTATIN SODIUMCAPSULE

1

LOVASTATINTABLET

1

PRAVASTATIN SODIUMTABLET

1

SIMVASTATINTABLET

1

CRESTORTABLET

2

LIPTRUZETTABLET

2

SIMCORTABLET;EXTENDED RELEASE MULTIPHASE 24 HR

2

VYTORINTABLET

2

ADVICORTABLET;EXTENDED RELEASE MULTIPHASE 24 HR

3

ALTOPREVTABLET; EXTENDED RELEASE 24 HR

3

LESCOL XLTABLET; EXTENDED RELEASE 24 HR

3

LIVALOTABLET

3

CNS -

ADHD -

AMPHETAMINE SALT COMBOTABLET

1

DEXMETHYLPHENIDATE HCLTABLET

1

DEXMETHYLPHENIDATE HCL XRCAPSULE;EXTENDED RELEASE BIPHASIC 50-50

1

DEXTROAMPHETAMINE SULFATESOLUTION; ORAL

1

DEXTROAMPHETAMINE SULFATETABLET

1

DEXTROAMPHETAMINE-AMPHETAMINECAPSULE; EXT RELEASE 24 HR

1

GUANIDINE HCLTABLET

1

METHYLPHENIDATE ERCAPSULE;EXTENDED RELEASE BIPHASIC 50-50

1

METHYLPHENIDATE HCLSOLUTION; ORAL

1

METHYLPHENIDATE HCLTABLET

1

METHYLPHENIDATE HCL CDCAPSULE;EXTENDED RELEASE BIPHASIC 30-70

1

Page 11 | 2015 Formulary

MODAFINILTABLET

1

DAYTRANAPATCH; TRANSDERMAL 24 HOURS

2

FOCALIN XRCAPSULE;EXTENDED RELEASE BIPHASIC 50-50

2

INTUNIVTABLET; EXTENDED RELEASE 24 HR

2

NUVIGILTABLET

2

QUILLIVANT XRSUSPENSION;EXTENDED RELEASE;RECONST.24HR

2

STRATTERACAPSULE

2

VYVANSECAPSULE

2

ALZHEIMER'S -

GALANTAMINECAPSULE; EXTENDED RELEASE PELLETS 24 HR

1

GALANTAMINESOLUTION; ORAL

1

RIVASTIGMINECAPSULE

1

EXELONPATCH; TRANSDERMAL 24 HOURS

2

NAMENDASOLUTION; ORAL

2

NAMENDA XRCAPSULE SPRINKLE; EXTENDED RELEASE 24 HR

2

ANTI-PSYCHOTIC -

CHLORPROMAZINE HCLTABLET

1

CLOZAPINETABLET

1

CLOZAPINE ODTTABLET;DISINTEGRATING

1

FLUPHENAZINE HCLCONCENTRATE; ORAL

1

FLUPHENAZINE HCLTABLET

1

HALOPERIDOLTABLET

1

HALOPERIDOL DECANOATEVIAL (ML)

1

HALOPERIDOL LACTATECONCENTRATE; ORAL

1

LOXAPINE SUCCINATECAPSULE

1

OLANZAPINETABLET

1

OLANZAPINE ODTTABLET;DISINTEGRATING

1

OLANZAPINE-FLUOXETINE HCLCAPSULE

1

PERPHENAZINETABLET

1

QUETIAPINE FUMARATETABLET

1

RISPERIDONESOLUTION; ORAL

1

RISPERIDONETABLET

1

RISPERIDONE ODTTABLET;DISINTEGRATING

1

THIORIDAZINE HCLTABLET

1

THIOTHIXENECAPSULE

1

TRIFLUOPERAZINE HCLTABLET

1

ZIPRASIDONE HCLCAPSULE

1

ABILIFYTABLET

2

ABILIFY DISCMELTTABLET;DISINTEGRATING

2

LATUDATABLET

2

RISPERDAL CONSTASYRINGE (EA)

2

SEROQUEL XRTABLET; EXTENDED RELEASE 24 HR

2

FANAPTTABLET

3

FAZACLOTABLET;DISINTEGRATING

3

INVEGATABLET; EXTENDED RELEASE 24 HR

3

ORAPTABLET

3

SAPHRISTABLET; SUBLINGUAL

3

VERSACLOZSUSPENSION; ORAL (FINAL DOSE FORM)

3

ANTICONVULSANTS -

CARBAMAZEPINESUSPENSION; ORAL (FINAL DOSE FORM)

1

CARBAMAZEPINETABLET

1

CARBAMAZEPINE ERTABLET; EXTENDED RELEASE 12 HR

1

CARBAMAZEPINE XRTABLET; EXTENDED RELEASE 12 HR

1

CLONAZEPAMTABLET

1

Page 12 | 2015 Formulary

CLONAZEPAMTABLET;DISINTEGRATING

1

DIAZEPAMKIT

1

DIVALPROEX SODIUMTABLET; ENTERIC COATED

1

DIVALPROEX SODIUM ERTABLET; EXTENDED RELEASE 24 HR

1

EPITOLTABLET

1

ETHOSUXIMIDECAPSULE

1

ETHOSUXIMIDESOLUTION; ORAL

1

FELBAMATESUSPENSION; ORAL (FINAL DOSE FORM)

1

FELBAMATETABLET

1

FOSPHENYTOIN SODIUMVIAL (ML)

1

GABAPENTINCAPSULE

1

GABAPENTINTABLET

1

LAMOTRIGINETABLET

1

LEVETIRACETAMSOLUTION; ORAL

1

LEVETIRACETAMTABLET

1

OXCARBAZEPINESUSPENSION; ORAL (FINAL DOSE FORM)

1

OXCARBAZEPINETABLET

1

PHENOBARBITALELIXIR

1

PHENOBARBITALTABLET

1

PHENYTOINSUSPENSION; ORAL (FINAL DOSE FORM)

1

PHENYTOIN SODIUMCAPSULE

1

PRIMIDONETABLET

1

TIAGABINE HCLTABLET

1

TOPIRAGENTABLET

1

TOPIRAMATETABLET

1

VALPROIC ACIDCAPSULE

1

VALPROIC ACIDSOLUTION; ORAL

1

ZONISAMIDECAPSULE

1

BANZELTABLET

2

FYCOMPATABLET

2

GABITRILTABLET

2

LAMICTAL XRTABLET; EXTENDED RELEASE; DOSE PACK

2

LYRICACAPSULE

2

ONFISUSPENSION; ORAL (FINAL DOSE FORM)

2

OXTELLAR XRTABLET; EXTENDED RELEASE 24 HR

2

PEGANONETABLET

2

POTIGATABLET

2

SABRILTABLET

2

VIMPATSOLUTION; ORAL

2

VIMPATTABLET

2

EQUETROCAPSULE;EXTENDED RELEASE MULTIPHASE 12HR

3

HORIZANTTABLET; EXTENDED RELEASE

3

LAMICTAL ODTTABLET;DISINTEGRATING

3

STAVZORCAPSULE;DELAYED RELEASE (ENTERIC COATED)

3

TROKENDI XRCAPSULE; EXT RELEASE 24 HR

3

ANTIDEPRESSANTS -

AMITRIPTYLINE HCLTABLET

1

AMITRIPTYLINE-PERPHENAZINETABLET

1

AMITRIPTYLINE/CHLORDIAZEPOXIDETABLET

1

AMOXAPINETABLET

1

BUPROPION HCLTABLET

1

BUPROPION HCL XLTABLET; EXTENDED RELEASE 24 HR

1

BUPROPION SRTABLET; EXTENDED RELEASE

1

Page 13 | 2015 Formulary

CITALOPRAM HBRSOLUTION; ORAL

1

CITALOPRAM HBRTABLET

1

CLOMIPRAMINE HCLCAPSULE

1

DESIPRAMINE HCLTABLET

1

DOXEPIN HCLCAPSULE

1

DOXEPIN HCLCONCENTRATE; ORAL

1

DULOXETINE HCLCAPSULE;DELAYED RELEASE (ENTERIC COATED)

1

ESCITALOPRAM OXALATESOLUTION; ORAL

1

ESCITALOPRAM OXALATETABLET

1

FLUOXETINE HCLCAPSULE

1

FLUOXETINE HCLSOLUTION; ORAL

1

FLUVOXAMINE MALEATETABLET

1

IMIPRAMINE HCLTABLET

1

IMIPRAMINE PAMOATECAPSULE

1

MAPROTILINE HCLTABLET

1

MIRTAZAPINETABLET

1

NEFAZODONE HCLTABLET

1

NORTRIPTYLINE HCLCAPSULE

1

NORTRIPTYLINE HCLSOLUTION; ORAL

1

PAROXETINE HCLTABLET

1

PHENELZINE SULFATETABLET

1

PROTRIPTYLINE HCLTABLET

1

SERTRALINE HCLCONCENTRATE; ORAL

1

SERTRALINE HCLTABLET

1

TRANYLCYPROMINE SULFATETABLET

1

TRAZODONE HCLTABLET

1

VENLAFAXINE HCLTABLET

1

VENLAFAXINE HCL ERCAPSULE; EXT RELEASE 24 HR

1

PRISTIQ ERTABLET; EXTENDED RELEASE 24 HR

2

VIIBRYDTABLET

2

APLENZINTABLET; EXTENDED RELEASE 24 HR

3

BRINTELLIXTABLET

3

BRISDELLECAPSULE

3

DESVENLAFAXINE ERTABLET; EXTENDED RELEASE 24 HR

3

EMSAMPATCH; TRANSDERMAL 24 HOURS

3

FETZIMACAPSULE;EXTENDED RELEASE 24 HR DOSE PACK

3

FORFIVO XLTABLET; EXTENDED RELEASE 24 HR

3

KHEDEZLATABLET; EXTENDED RELEASE 24 HR

3

MARPLANTABLET

3

OLEPTRO ERTABLET; EXTENDED RELEASE 24 HR

3

PEXEVATABLET

3

SARAFEMTABLET

3

ANTIPARKINSONISM -

BENZTROPINE MESYLATETABLET

1

BROMOCRIPTINE MESYLATETABLET

1

CARBIDOPA-LEVODOPA ERTABLET; EXTENDED RELEASE

1

CARBIDOPA-LEVODOPA-ENTACAPONETABLET

1

CARBIDOPA/LEVODOPATABLET

1

ENTACAPONETABLET

1

PRAMIPEXOLE DI-HCLTABLET

1

ROPINIROLE HCLTABLET

1

SELEGILINE HCLTABLET

1

TRIHEXYPHENIDYL HCLELIXIR

1

Page 14 | 2015 Formulary

TRIHEXYPHENIDYL HCLTABLET

1

AZILECTTABLET

2

MIRAPEX ERTABLET; EXTENDED RELEASE 24 HR

2

NEUPROPATCH; TRANSDERMAL 24 HOURS

3

TASMARTABLET

3

ZELAPARTABLET;DISINTEGRATING

3

ANXIOLYTICS -

ALPRAZOLAMTABLET

1

BUSPIRONE HCLTABLET

1

CHLORDIAZEPOXIDE HCLCAPSULE

1

CLORAZEPATE DIPOTASSIUMTABLET

1

DIAZEPAMCONCENTRATE; ORAL

1

DIAZEPAMTABLET

1

LORAZEPAMTABLET

1

LORAZEPAM INTENSOLCONCENTRATE; ORAL

1

MIDAZOLAM HCLSYRUP

1

OXAZEPAMCAPSULE

1

MISCELLANEOUS -

LITHIUM CARBONATECAPSULE

1

LITHIUM CARBONATETABLET; EXTENDED RELEASE

1

LITHIUM CITRATESOLUTION; ORAL

1

NUEDEXTACAPSULE

2

XENAZINETABLET

2

MS -

AMPYRATABLET; EXTENDED RELEASE 12 HR

2

AVONEX ADMINISTRATION PACKKIT

2

BETASERONKIT

2

COPAXONESYRINGE KIT (EA)

2

GILENYACAPSULE

2

REBIFSYRINGE (ML)

2

TECFIDERACAPSULE;DELAYED RELEASE (ENTERIC COATED)

2

AUBAGIOTABLET

3

EXTAVIAKIT

3

SLEEP -

ESTAZOLAMTABLET

1

FLURAZEPAM HCLCAPSULE

1

QUAZEPAMTABLET

1

TEMAZEPAMCAPSULE

1

ZALEPLONCAPSULE

1

ZOLPIDEM TARTRATETABLET

1

ZOLPIDEM TARTRATE ERTABLET; EXTENDED RELEASE MULTIPHASE

1

ROZEREMTABLET

2

BUTISOL SODIUMELIXIR

3

BUTISOL SODIUMTABLET

3

DORALTABLET

3

EDLUARTABLET; SUBLINGUAL

3

INTERMEZZOTABLET; SUBLINGUAL

3

SILENORTABLET

3

ZOLPIMISTAEROSOL; SPRAY WITH PUMP (ML)

3

DIABETES -

DPP-4 -

JANUMETTABLET

2

JANUMET XRTABLET;EXTENDED RELEASE MULTIPHASE 24 HR

2

JANUVIATABLET

2

JENTADUETOTABLET

2

KOMBIGLYZE XRTABLET;EXTENDED RELEASE MULTIPHASE 24 HR

2

Page 15 | 2015 Formulary

ONGLYZATABLET

2

TRADJENTATABLET

2

KAZANOTABLET

3

NESINATABLET

3

OSENITABLET

3

INCRETINS -

BYDUREONVIAL (EA)

2

BYETTAPEN INJECTOR (ML)

2

VICTOZAPEN INJECTOR (ML)

2

TANZEUMPEN INJECTOR (EA)

3

INSULIN -

HUMALOGVIAL (ML)

2

HUMALOG MIX 50-50VIAL (ML)

2

HUMALOG MIX 75-25VIAL (ML)

2

HUMULIN 70-30VIAL (ML)

2

HUMULIN NVIAL (ML)

2

HUMULIN RVIAL (ML)

2

LANTUSVIAL (ML)

2

LANTUS SOLOSTARINSULIN PEN (ML)

2

LEVEMIRVIAL (ML)

2

NOVOLOGCARTRIDGE (ML)

2

NOVOLOG FLEXPENINSULIN PEN (ML)

2

NOVOLOG MIX 70-30VIAL (ML)

2

APIDRAVIAL (ML)

3

APIDRA SOLOSTARINSULIN PEN (ML)

3

NOVOLIN 70-30VIAL (ML)

3

NOVOLIN NVIAL (ML)

3

NOVOLIN RVIAL (ML)

3

OTHER -

ACARBOSETABLET

1

METFORMIN HCLTABLET

1

METFORMIN HCL ERTABLET; EXTENDED RELEASE 24 HR

1

NATEGLINIDETABLET

1

REPAGLINIDETABLET

1

GLUCAGENVIAL (EA)

2

GLUCAGON EMERGENCY KITKIT

2

INSULIN- SYRINGESYRINGE; EMPTY DISPOSABLE

2

INVOKANATABLET

2

PRANDIMETTABLET

2

RIOMETSOLUTION; ORAL

2

SYMLINPEN 120PEN INJECTOR (ML)

2

CYCLOSETTABLET

3

FARXIGATABLET

3

GLUMETZATABLET; ER GASTRIC RETENTION 24 HR

3

GLYSETTABLET

3

SULFONYLUREAS -

GLIMEPIRIDETABLET

1

GLIPIZIDE ERTABLET; EXTENDED RELEASE 24 HR

1

GLIPIZIDE-METFORMINTABLET

1

GLYBURIDETABLET

1

GLYBURIDE MICRONIZEDTABLET

1

GLYBURIDE-METFORMIN HCLTABLET

1

TESTING -

FREESTYLE INSULINXSTRIP

2

FREESTYLE INSULINX TEST STRIPSSTRIP

2

Page 16 | 2015 Formulary

FREESTYLE LITE STRIPSSTRIP

2

FREESTYLE TEST STRIPSSTRIP

2

ONE TOUCH ULTRA TEST STRIPSSTRIP

2

ONE TOUCH VERIOSTRIP

2

OPTIUMSTRIP

2

OPTIUM EZSTRIP

2

PRECISION PCX PLUSSTRIP

2

PRECISION Q-I-DSTRIP

2

PRECISION XTRASTRIP

2

SURESTEP PROSTRIP

2

ACCU-CHEKEACH

3

ACCU-CHEK ACTIVESTRIP

3

ACCU-CHEK AVIVASTRIP

3

ACCU-CHEK AVIVA PLUSSTRIP

3

ACCU-CHEK COMFORT CURVESTRIP

3

ACCU-CHEK SMARTVIEWSTRIP

3

BREEZE 2KIT

3

CONTOURSTRIP

3

CONTOUR NEXT EZSTRIP

3

PRODIGY NO CODINGSTRIP

3

TRUETEST TEST STRIPSSTRIP

3

TRUETRACKSTRIP

3

TRUETRACK SMART SYSTEMSTRIP

3

TZD -

PIOGLITAZONE HCLTABLET

1

PIOGLITAZONE-GLIMEPIRIDETABLET

1

PIOGLITAZONE-METFORMINTABLET

1

ACTOPLUS MET XRTABLET;EXTENDED RELEASE MULTIPHASE 24 HR

2

AVANDAMETTABLET

3

AVANDARYLTABLET

3

ENDOCRINE -

ADRENAL HORMONES -

DEXAMETHASONETABLET

1

FLUDROCORTISONE ACETATETABLET

1

HYDROCORTISONETABLET

1

METHYLPREDNISOLONETABLET; DOSE PACK

1

METHYLPREDNISOLONE ACETATEVIAL (ML)

1

PREDNISOLONESOLUTION; ORAL

1

PREDNISONETABLET

1

ACTHAR H.P.VIAL (ML)

2

SOLU-CORTEFVIAL (EA)

2

ORAPRED ODTTABLET;DISINTEGRATING

3

RAYOSTABLET; ENTERIC COATED

3

CONTRACEPTIVES -

ALTAVERATABLET

1

ALYACENTABLET

1

AMETHIATABLET; DOSE PACK; 3 MONTHS

1

AMETHYSTTABLET

1

APRITABLET

1

ARANELLETABLET

1

AUBRATABLET

1

AVIANETABLET

1

AZURETTETABLET

1

BALZIVATABLET

1

BRIELLYNTABLET

1

Page 17 | 2015 Formulary

CAMRESETABLET; DOSE PACK; 3 MONTHS

1

CAZIANTTABLET

1

CHATEALTABLET

1

CRYSELLETABLET

1

CYCLAFEMTABLET

1

DASETTATABLET

1

DAYSEETABLET; DOSE PACK; 3 MONTHS

1

ELINESTTABLET

1

EMOQUETTETABLET

1

ENPRESSETABLET

1

ENSKYCETABLET

1

ESTARYLLATABLET

1

FALMINATABLET

1

GIANVITABLET

1

GILDAGIATABLET

1

GILDESSTABLET

1

INTROVALETABLET; DOSE PACK; 3 MONTHS

1

JOLESSATABLET; DOSE PACK; 3 MONTHS

1

JUNELTABLET

1

KARIVATABLET

1

KELNOR 1-35TABLET

1

KURVELOTABLET

1

LARIN FETABLET

1

LEENATABLET

1

LESSINATABLET

1

LEVONESTTABLET

1

LEVORATABLET

1

LOMEDIA 24 FETABLET

1

LORYNATABLET

1

LOW-OGESTRELTABLET

1

LUTERATABLET

1

MARLISSATABLET

1

MICROGESTINTABLET

1

MONO-LINYAHTABLET

1

MONONESSATABLET

1

MYZILRATABLET

1

NECONTABLET

1

NEXT CHOICE ONE DOSETABLET

1

NORTRELTABLET

1

OCELLATABLET

1

OGESTRELTABLET

1

ORSYTHIATABLET

1

PHILITHTABLET

1

PIMTREATABLET

1

PIRMELLATABLET

1

PORTIATABLET

1

PREVIFEMTABLET

1

QUASENSETABLET; DOSE PACK; 3 MONTHS

1

RECLIPSENTABLET

1

SPRINTECTABLET

1

SRONYXTABLET

1

SYEDATABLET

1

Page 18 | 2015 Formulary

TILIA FETABLET

1

TRI-ESTARYLLATABLET

1

TRI-LINYAHTABLET

1

TRI-PREVIFEMTABLET

1

TRI-SPRINTECTABLET

1

TRINESSATABLET

1

TRIVORATABLET

1

VELIVETTABLET

1

VESTURATABLET

1

VIORELETABLET

1

WERATABLET

1

WYMZYA FETABLET; CHEWABLE

1

ZARAHTABLET

1

ZENCHENTTABLET

1

ZEOSATABLET; CHEWABLE

1

ZOVIATABLET

1

BEYAZTABLET

2

LO LOESTRIN FETABLET

2

NATAZIATABLET

2

NUVARINGRING; VAGINAL

2

SAFYRALTABLET

2

GENERESS FETABLET; CHEWABLE

3

ORTHO TRI-CYCLEN LOTABLET

3

QUARTETTETABLET; DOSE PACK; 3 MONTHS

3

SKYLAINTRAUTERINE DEVICE

3

ESTROGENS -

COVARYXTABLET

1

ESTRADIOLPATCH; TRANSDERMAL WEEKLY

1

ESTRADIOLTABLET

1

ESTRADIOL-NORETHINDRONE ACETATTABLET

1

ESTROGEN METHYLTESTOSTERONETABLET

1

ESTROPIPATETABLET

1

JINTELITABLET

1

CENESTINTABLET

2

COMBIPATCHPATCH; TRANSDERMAL SEMIWEEKLY

2

DIVIGELGEL IN PACKET (EA)

2

ENJUVIATABLET

2

ESTRACECREAM WITH APPLICATOR

2

ESTRINGRING; VAGINAL

2

EVAMISTSPRAY; NON-AEROSOL (ML)

2

MINIVELLEPATCH; TRANSDERMAL SEMIWEEKLY

2

PREMARINTABLET

2

PREMPHASETABLET

2

PREMPROTABLET

2

VAGIFEMTABLET

2

VIVELLE- DOTPATCH; TRANSDERMAL SEMIWEEKLY

2

ALORAPATCH; TRANSDERMAL SEMIWEEKLY

3

ANGELIQTABLET

3

CLIMARA PROPATCH; TRANSDERMAL WEEKLY

3

ELESTRINGEL IN METERED-DOSE PUMP

3

ESTROGELGEL IN METERED-DOSE PUMP

3

FEMHRTTABLET

3

FEMRINGRING; VAGINAL

3

Page 19 | 2015 Formulary

MENESTTABLET

3

MENOSTARPATCH; TRANSDERMAL WEEKLY

3

PREFESTTABLET

3

PREMARINCREAM WITH APPLICATOR

3

GONADOTROPIN -

NOVARELVIAL (EA)

1

CHORIONIC GONADOTROPINPOWDER (EA)

2

GANIRELIX ACETATESYRINGE (ML)

2

CETROTIDEKIT

3

PREGNYLVIAL (EA)

3

MISCELLANEOUS -

CABERGOLINETABLET

1

CALCITONIN-SALMONAEROSOL; SPRAY WITH PUMP (ML)

1

CALCITRIOLCAPSULE

1

DESMOPRESSIN ACETATEAEROSOL; SPRAY WITH PUMP (ML)

1

DESMOPRESSIN ACETATETABLET

1

OVULATORY STIMULANTS -

CLOMIPHENE CITRATETABLET

1

BRAVELLEVIAL (EA)

2

FOLLISTIM AQCARTRIDGE (ML)

2

FOLLISTIM AQVIAL (ML)

2

MENOPURVIAL (EA)

2

GONAL-FVIAL (EA)

3

REPRONEXVIAL (EA)

3

PROGESTINS -

CAMILATABLET

1

ERRINTABLET

1

HEATHERTABLET

1

JENCYCLATABLET

1

JOLIVETTETABLET

1

LYZATABLET

1

NORA-BETABLET

1

NORETHINDRONE ACETATETABLET

1

PROGESTERONECAPSULE

1

TESTOSTERONE -

ANDROXYTABLET

1

DANAZOLCAPSULE

1

OXANDROLONETABLET

1

TESTOSTERONE CYPIONATEVIAL (ML)

1

ANDROGELGEL IN PACKET (GRAM)

2

AXIRONSOLUTION IN METERED-DOSE PUMP WITH APPL.

2

TESTOSTERONEPOWDER (GRAM)

2

ANDRODERMPATCH; TRANSDERMAL 24 HOURS

3

ANDROIDCAPSULE

3

DEPO-TESTOSTERONEVIAL (ML)

3

FORTESTAGEL IN METERED-DOSE PUMP

3

STRIANTMUCOADHESIVE SYSTEM;EXTEND.RELEASE 12 HR

3

TESTIMGEL (GRAM)

3

TESTOPELPELLET (EA)

3

TESTOSTERONE1% GEL (GRAM)

3

TESTOSTERONE1.25G (1%) GEL IN METERED-DOSE PUMP

3

TESTOSTERONE10 MG (2%) GEL IN METERED-DOSE PUMP

3

TESTOSTERONE50 MG (1%) GEL (GRAM)

3

TESTOSTERONE50 MG (1%) GEL IN PACKET (GRAM)

3

TESTREDCAPSULE

3

Page 20 | 2015 Formulary

VOGELXOGEL (GRAM)

3

VOGELXOGEL IN METERED-DOSE PUMP

3

VOGELXOGEL IN PACKET (GRAM)

3

THYROID -

LEVOTHYROXINE SODIUMTABLET

1

LEVOXYLTABLET

1

LIOTHYRONINE SODIUMTABLET

1

METHIMAZOLETABLET

1

NATURE-THROIDTABLET

1

UNITHROIDTABLET

1

ARMOUR THYROIDTABLET

2

SSKISOLUTION; ORAL

3

THYROLARTABLET

3

TIROSINTCAPSULE

3

GASTROINTESTINAL -

ANTIDIARRHEALS -

ANASPAZTABLET;DISINTEGRATING

1

DICYCLOMINE HCLCAPSULE

1

DIPHENOXYLATE W/ATROPINELIQUID (ML)

1

DIPHENOXYLATE W/ATROPINETABLET

1

GLYCOPYRROLATETABLET

1

HYOSCYAMINE SULFATEDROPS

1

LOPERAMIDE HCLCAPSULE

1

METHSCOPOLAMINE BROMIDETABLET

1

CANTILTABLET

3

CUVPOSASOLUTION; ORAL

3

FULYZAQTABLET; ENTERIC COATED

3

GLYCATETABLET

3

HOMAPIN 10TABLET

3

REZYSTTABLET; CHEWABLE

3

ANTIEMETIC -

DRONABINOLCAPSULE

1

GRANISETRON HCLTABLET

1

MECLIZINE HCLTABLET

1

ONDANSETRON HCLSOLUTION; ORAL

1

ONDANSETRON HCLTABLET

1

ONDANSETRON ODTTABLET;DISINTEGRATING

1

PROCHLORPERAZINE MALEATESUPPOSITORY; RECTAL

1

PROCHLORPERAZINE MALEATETABLET

1

TRIMETHOBENZAMIDE HCLCAPSULE

1

EMENDCAPSULE

2

SANCUSOPATCH; TRANSDERMAL WEEKLY

2

TRANSDERM-SCOPPATCH; TRANSDERMAL 72 HOURS

2

ANZEMETTABLET

3

ZUPLENZFILM; MEDICATED (EA)

3

BOWEL EVACUANTS -

PEG 3350-ELECTROLYTESOLUTION; RECONSTITUTED; ORAL

1

MOVIPREPPOWDER IN PACKET (EA)

2

SUPREPSOLUTION; RECONSTITUTED; ORAL

2

COLYTESOLUTION; RECONSTITUTED; ORAL

3

DIGESTIVE ENZYMES -

CREONCAPSULE;DELAYED RELEASE (ENTERIC COATED)

2

SUCRAIDSOLUTION; ORAL

2

VIOKACETABLET

2

ZENPEPCAPSULE;DELAYED RELEASE (ENTERIC COATED)

2

PANCREAZECAPSULE;DELAYED RELEASE (ENTERIC COATED)

3

Page 21 | 2015 Formulary

PERTZYECAPSULE;DELAYED RELEASE (ENTERIC COATED)

3

ULTRESACAPSULE;DELAYED RELEASE (ENTERIC COATED)

3

H2 ANTAGONISTS -

CIMETIDINESOLUTION; ORAL

1

CIMETIDINETABLET

1

FAMOTIDINESUSPENSION; ORAL (FINAL DOSE FORM)

1

FAMOTIDINETABLET

1

MISOPROSTOLTABLET

1

NIZATIDINECAPSULE

1

NIZATIDINESOLUTION; ORAL

1

RANITIDINE HCLSYRUP

1

RANITIDINE HCLTABLET

1

OTHER -

BALSALAZIDE DISODIUMCAPSULE

1

BUDESONIDE ECCAPSULE; DELAYED EXTENDED RELEASE

1

CLIDINIUM W/CHLORDIAZEPOXIDECAPSULE

1

CONSTULOSESOLUTION; ORAL

1

LACTULOSESOLUTION; ORAL

1

METOCLOPRAMIDE HCLSOLUTION; ORAL

1

METOCLOPRAMIDE HCLTABLET

1

SULFASALAZINETABLET

1

SULFAZINE ECTABLET; ENTERIC COATED

1

URSODIOLCAPSULE

1

ASACOL HDTABLET; ENTERIC COATED

2

BELLADONNALIQUID (ML)

2

CHENODALTABLET

2

DELZICOLCAPSULE;DELAYED RELEASE (ENTERIC COATED)

2

KINEVACVIAL (EA)

2

LIALDATABLET; ENTERIC COATED

2

LINZESSCAPSULE

2

LOTRONEXTABLET

2

PENTASACAPSULE; EXTENDED RELEASE

2

RELISTORSYRINGE (ML)

2

APRISOCAPSULE; EXT RELEASE 24 HR

3

CIMZIAKIT

3

CIMZIASYRINGE KIT (EA)

3

DIPENTUMCAPSULE

3

ENTEREGCAPSULE

3

GIAZOTABLET

3

KRISTALOSEPACKET (EA)

3

METOZOLV ODTTABLET;DISINTEGRATING

3

OSMOPREPTABLET

3

OTHER ULCER THERAPY -

CARAFATESUSPENSION; ORAL (FINAL DOSE FORM)

1

LANSOPRAZOL-AMOXICIL-CLARITHROCOMBINATION PACKAGE (EA)

1

SUCRALFATETABLET

1

PYLERACAPSULE

2

PROTON PUMP INHIBITORS -

LANSOPRAZOLECAPSULE;DELAYED RELEASE (ENTERIC COATED)

1

OMEPRAZOLECAPSULE;DELAYED RELEASE (ENTERIC COATED)

1

OMEPRAZOLE-SODIUM BICARBONATECAPSULE

1

PANTOPRAZOLE SODIUMTABLET; ENTERIC COATED

1

RABEPRAZOLE SODIUMTABLET; ENTERIC COATED

1

NEXIUM RXCAPSULE;DELAYED RELEASE (ENTERIC COATED)

2

Page 22 | 2015 Formulary

NEXIUM RXSUSP FOR RECON;DELAYED REL. IN A PACKET

2

DEXILANTCAPSULE; DELAYED RELEASE; BIPHASIC

3

ZEGERID RXPACKET (EA)

3

RECTAL -

ANUCORT-HCSUPPOSITORY; RECTAL

1

COLOCORTENEMA (ML)

1

LIDOCAINE-HCCREAM WITH APPLICATOR

1

MESALAMINEENEMA (ML)

1

PRAMOXINE-HCKIT; CREAM TOWELETTE

1

CANASASUPPOSITORY; RECTAL

2

CORTIFOAMAEROSOL; FOAM WITH APPLICATOR (GRAM)

2

GROWTH HORMONES -

GENOTROPINCARTRIDGE (EA)

2

HUMATROPECARTRIDGE (EA)

2

NORDITROPIN FLEXPROPEN INJECTOR (ML)

2

SEROSTIMVIAL (EA)

2

NUTROPIN AQCARTRIDGE (ML)

3

OMNITROPECARTRIDGE (ML)

3

SAIZENCARTRIDGE (EA)

3

TEV-TROPINVIAL (EA)

3

ZORBTIVEVIAL (EA)

3

HEMATOLOGY -

ARANESPVIAL (ML)

2

NEULASTASYRINGE (ML)

2

NEUMEGAVIAL (EA)

2

NEUPOGENSYRINGE (ML)

2

PROCRITVIAL (ML)

2

EPOGENVIAL (ML)

3

IMMUNOSUPPRESSANTS -

AZATHIOPRINETABLET

1

CYCLOSPORINECAPSULE

1

CYCLOSPORINESOLUTION; ORAL

1

GENGRAFCAPSULE

1

GENGRAFSOLUTION; ORAL

1

HECORIACAPSULE

1

MYCOPHENOLATE MOFETILCAPSULE

1

SIROLIMUSTABLET

1

TACROLIMUSCAPSULE

1

AZASANTABLET

2

CELLCEPTSUSPENSION; RECONSTITUTED; ORAL (ML)

2

RAPAMUNESOLUTION; ORAL

2

RAPAMUNETABLET

2

ZORTRESSTABLET

2

ASTAGRAF XLCAPSULE; EXT RELEASE 24 HR

3

NEORALCAPSULE

3

NEORALSOLUTION; ORAL

3

SANDIMMUNECAPSULE

3

SANDIMMUNESOLUTION; ORAL

3

INTERFERONS -

ACTIMMUNEVIAL (ML)

2

ALFERON NVIAL (ML)

2

INTRON AVIAL (EA)

2

PEGASYSKIT

2

SYLATRONKIT

2

PEG-INTRONKIT

3

Page 23 | 2015 Formulary

PEG-INTRON REDIPENPEN INJECTOR KIT (EA)

3

MISCELLANEOUS -

BUPROPION SRTABLET; EXTENDED RELEASE

1

CEVIMELINE HCLCAPSULE

1

DISULFIRAMTABLET

1

ETIDRONATE DISODIUMTABLET

1

MIDODRINE HCLTABLET

1

RILUZOLETABLET

1

CARBAGLUTABLET; DISPERSIBLE

2

CHANTIXTABLET

2

EXJADETABLET; DISPERSIBLE

2

FOSRENOLTABLET; CHEWABLE

2

RENVELAPOWDER IN PACKET (EA)

2

RENAGELTABLET

3

MUSCULOSKELETAL -

ARTHRITIS -

LEFLUNOMIDETABLET

1

ENBRELPEN INJECTOR (ML)

2

HUMIRAPEN INJECTOR KIT (EA)

2

ORENCIASYRINGE (ML)

2

RIDAURACAPSULE

2

SAVELLATABLET

2

KINERETSYRINGE (ML)

3

OTREXUPAUTO-INJECTOR (ML)

3

SIMPONIPEN INJECTOR (ML)

3

SIMPONISYRINGE (ML)

3

XELJANZTABLET

3

GOUT THERAPY -

ALLOPURINOLTABLET

1

PROBENECIDTABLET

1

PROBENECID W/COLCHICINETABLET

1

COLCRYSTABLET

2

ULORICTABLET

2

MUSCLE RELAXANTS -

BACLOFENTABLET

1

CARISOPRODOLTABLET

1

CARISOPRODOL COMPOUNDTABLET

1

CARISOPRODOL COMPOUND/CODEINETABLET

1

CARISOPRODOL-ASPIRINTABLET

1

CHLORZOXAZONETABLET

1

CYCLOBENZAPRINE HCLTABLET

1

DANTROLENE SODIUMCAPSULE

1

MEPROBAMATETABLET

1

METAXALONETABLET

1

METHOCARBAMOLTABLET

1

ORPHENADRINE CITRATETABLET; EXTENDED RELEASE

1

ORPHENADRINE COMPOUND FORTETABLET

1

TIZANIDINE HCLTABLET

1

AMRIXCAPSULE; EXT RELEASE 24 HR

3

LORZONETABLET

3

OSTEOPOROSIS -

ALENDRONATE SODIUMSOLUTION; ORAL

1

ALENDRONATE SODIUMTABLET

1

IBANDRONATE SODIUMTABLET

1

ATELVIATABLET; ENTERIC COATED

2

Page 24 | 2015 Formulary

FORTEOPEN INJECTOR (ML)

2

ACTONELTABLET

3

BINOSTOTABLET; EFFERVESCENT

3

FOSAMAX PLUS DTABLET

3

PROLIASYRINGE (ML)

3

ONCOLOGY -

ANASTROZOLETABLET

1

BICALUTAMIDETABLET

1

CYCLOPHOSPHAMIDETABLET

1

EXEMESTANETABLET

1

FLUTAMIDECAPSULE

1

HYDROXYUREACAPSULE

1

LETROZOLETABLET

1

LEUCOVORIN CALCIUMTABLET

1

MEGESTROL ACETATESUSPENSION; ORAL (FINAL DOSE FORM)

1

MEGESTROL ACETATETABLET

1

MERCAPTOPURINETABLET

1

METHOTREXATETABLET

1

METHOTREXATE SODIUMVIAL (ML)

1

TAMOXIFEN CITRATETABLET

1

TEMOZOLOMIDECAPSULE

1

AFINITORTABLET

2

AFINITOR DISPERZTABLET FOR SUSPENSION

2

BOSULIFTABLET

2

CAPRELSATABLET

2

DROXIACAPSULE

2

ELIGARDSYRINGE (EA)

2

EMCYTCAPSULE

2

FARESTONTABLET

2

GILOTRIFTABLET

2

GLEEVECTABLET

2

HYCAMTINCAPSULE

2

ICLUSIGTABLET

2

IMBRUVICACAPSULE

2

INLYTATABLET

2

JAKAFITABLET

2

LEUKERANTABLET

2

LOMUSTINECAPSULE

2

LYSODRENTABLET

2

MATULANECAPSULE

2

MEKINISTTABLET

2

MESNEXTABLET

2

NEXAVARTABLET

2

POMALYSTCAPSULE

2

REVLIMIDCAPSULE

2

SPRYCELTABLET

2

STIVARGATABLET

2

SUTENTCAPSULE

2

TABLOIDTABLET

2

TAFINLARCAPSULE

2

TARCEVATABLET

2

TASIGNACAPSULE

2

THALOMIDCAPSULE

2

Page 25 | 2015 Formulary

TREXALLTABLET

2

TYKERBTABLET

2

VOTRIENTTABLET

2

XALKORICAPSULE

2

XTANDICAPSULE

2

ZELBORAFTABLET

2

ZOLINZACAPSULE

2

ZYTIGATABLET

2

COMETRIQCAPSULE

3

MEGACE ESSUSPENSION; ORAL (FINAL DOSE FORM)

3

RHEUMATREXTABLET; DOSE PACK

3

SOLTAMOXSOLUTION; ORAL

3

OPHTHALMIC -

ANTIBIOTICS -

BACITRACINOINTMENT (GRAM)

1

BACITRACIN/POLYMYXINOINTMENT (GRAM)

1

CIPROFLOXACIN HCLDROPS

1

ERYTHROMYCINOINTMENT (GRAM)

1

GATIFLOXACINDROPS

1

GENTAKDROPS

1

GENTAMICIN SULFATEOINTMENT (GRAM)

1

LEVOFLOXACIN HEMIHYDRATEDROPS

1

NEO/POLYMYXIN/DEXAMETHASONEOINTMENT (GRAM)

1

NEO/POLYMYXIN/DEXAMETHASONESUSPENSION; DROPS(FINAL DOSAGE FORM)(ML)

1

NEOMYCIN/BACITRACIN/POLY/HCOINTMENT (GRAM)

1

NEOMYCIN/BACITRACIN/POLYMYXINOINTMENT (GRAM)

1

NEOMYCIN/POLYMYXIN/GRAMICIDINDROPS

1

NEOMYCIN/POLYMYXIN/HCSUSPENSION; DROPS(FINAL DOSAGE FORM)(ML)

1

OFLOXACINDROPS

1

POLYMYXIN B SUL-TRIMETHOPRIMDROPS

1

SULFACETAMIDE SODIUMDROPS

1

SULFACETAMIDE W/PREDNISOLONEDROPS

1

TOBRAMYCIN SULFATEDROPS

1

TOBRAMYCIN-DEXAMETHASONESUSPENSION; DROPS(FINAL DOSAGE FORM)(ML)

1

BESIVANCESUSPENSION; DROPS(FINAL DOSAGE FORM)(ML)

2

MOXEZADROPS; VISCOUS (ML)

2

NATACYNSUSPENSION; DROPS(FINAL DOSAGE FORM)(ML)

2

TOBRADEXOINTMENT (GRAM)

2

TOBRADEX STSUSPENSION; DROPS(FINAL DOSAGE FORM)(ML)

2

ZYLETSUSPENSION; DROPS(FINAL DOSAGE FORM)(ML)

2

AZASITEDROPS

3

BLEPH-10DROPS

3

BLEPHAMIDESUSPENSION; DROPS(FINAL DOSAGE FORM)(ML)

3

BLEPHAMIDE S.O.P.OINTMENT (GRAM)

3

CILOXANOINTMENT (GRAM)

3

PRED-GOINTMENT (GRAM)

3

TOBREXOINTMENT (GRAM)

3

ZIRGANGEL (GRAM)

3

BETA-BLOCKERS -

BETAXOLOL HCLDROPS

1

CARTEOLOL HCLDROPS

1

LEVOBUNOLOL HCLDROPS

1

METIPRANOLOLDROPS

1

TIMOLOL MALEATEDROPS

1

Page 26 | 2015 Formulary

BETIMOLDROPS

3

BETOPTIC SSUSPENSION; DROPS(FINAL DOSAGE FORM)(ML)

3

ISTALOLDROPS; ONCE DAILY

3

TIMOPTICDROPPERETTE; SINGLE-USE DROP DISPENSER

3

GLAUCOMA -

DORZOLAMIDE HCLDROPS

1

DORZOLAMIDE-TIMOLOLDROPS

1

LATANOPROSTDROPS

1

PILOCARPINE HCLDROPS

1

COMBIGANDROPS

2

LUMIGANDROPS

2

TRAVATAN ZDROPS

2

AZOPTSUSPENSION; DROPS(FINAL DOSAGE FORM)(ML)

3

COSOPT PFDROPPERETTE; SINGLE-USE DROP DISPENSER

3

MITOSOLKIT

3

RESCULADROPS

3

SIMBRINZASUSPENSION; DROPS(FINAL DOSAGE FORM)(ML)

3

ZIOPTANDROPPERETTE; SINGLE-USE DROP DISPENSER

3

MISCELLANEOUS -

APRACLONIDINE HCLDROPS

1

AZELASTINE HCLDROPS

1

BRIMONIDINE TARTRATEDROPS

1

CROMOLYN SODIUMDROPS

1

EPINASTINE HCLDROPS

1

FLUCAINEDROPS

1

FLUORESCEIN-BENOXINATEDROPS

1

PROPARACAINE HCLDROPS

1

TETRACAINE HCLDROPS

1

TRIFLURIDINEDROPS

1

ALPHAGAN PDROPS

2

BEPREVEDROPS

2

CYSTARANDROPS

2

PATADAYDROPS

2

PATANOLDROPS

2

RESTASISDROPPERETTE; SINGLE-USE DROP DISPENSER

2

ALOCRILDROPS

3

EMADINEDROPS

3

IOPIDINEDROPPERETTE; SINGLE-USE DROP DISPENSER

3

LASTACAFTDROPS

3

TETRAVISCDROPPERETTE; VISCOUS

3

MYDRIATICS -

ATROPINE SULFATEDROPS

1

CYCLOPENTOLATE HCLDROPS

1

CYLATEDROPS

1

HOMATROPINE HYDROBROMIDEDROPS

1

MYDRALDROPS

1

TROPICAMIDEDROPS

1

CYCLOGYLDROPS

3

ISOPTO HYOSCINEDROPS

3

PAREMYDDROPS

3

NSAID -

BROMFENAC SODIUMDROPS

1

DICLOFENAC SODIUMDROPS

1

FLURBIPROFEN SODIUMDROPS

1

Page 27 | 2015 Formulary

KETOROLAC TROMETHAMINEDROPS

1

ILEVROSUSPENSION; DROPS(FINAL DOSAGE FORM)(ML)

2

NEVANACSUSPENSION; DROPS(FINAL DOSAGE FORM)(ML)

2

PROLENSADROPS

2

ACUVAILDROPPERETTE; SINGLE-USE DROP DISPENSER

3

STEROIDS -

DEXAMETHASONE SODIUM PHOSPHATEDROPS

1

DEXASOLDROPS

1

FLUOROMETHOLONESUSPENSION; DROPS(FINAL DOSAGE FORM)(ML)

1

PREDNISOLONE ACETATESUSPENSION; DROPS(FINAL DOSAGE FORM)(ML)

1

ALREXSUSPENSION; DROPS(FINAL DOSAGE FORM)(ML)

2

LOTEMAXSUSPENSION; DROPS(FINAL DOSAGE FORM)(ML)

2

PRED MILDSUSPENSION; DROPS(FINAL DOSAGE FORM)(ML)

2

DUREZOLDROPS

3

FLAREXSUSPENSION; DROPS(FINAL DOSAGE FORM)(ML)

3

FML FORTESUSPENSION; DROPS(FINAL DOSAGE FORM)(ML)

3

MAXIDEXSUSPENSION; DROPS(FINAL DOSAGE FORM)(ML)

3

VEXOLSUSPENSION; DROPS(FINAL DOSAGE FORM)(ML)

3

VASOCONSTRICTOR -

CYCLOMYDRILDROPS

3

OTIC -

ANTIBIOTIC -

NEOMYCIN/POLYMYXIN/HCSOLUTION; NON-ORAL

1

CIPRODEXSUSPENSION; DROPS(FINAL DOSAGE FORM)(ML)

2

CETRAXALDROPPERETTE; SINGLE-USE DROP DISPENSER

3

CIPRO HCSUSPENSION; DROPS(FINAL DOSAGE FORM)(ML)

3

COLY-MYCIN SSUSPENSION; DROPS(FINAL DOSAGE FORM)(ML)

3

CORTISPORIN-TCSUSPENSION; DROPS(FINAL DOSAGE FORM)(ML)

3

MISCELLANEOUS -

ACETASOL HCDROPS

1

ACETIC ACIDSOLUTION; NON-ORAL

1

ACETIC ACID/HYDROCORTISONEDROPS

1

ANTIPYRINE W/BENZOCAINEDROPS

1

AURODEXDROPS

1

CIPROFLOXACIN HCLDROPPERETTE; SINGLE-USE DROP DISPENSER

1

OFLOXACINDROPS

1

TRIOXINSUSPENSION; DROPS(FINAL DOSAGE FORM)(ML)

3

RESPIRATORY -

ANTIHISTAMINES -

ARBINOXALIQUID (ML)

1

ARBINOXATABLET

1

CARBINOXAMINELIQUID (ML)

1

CARBINOXAMINETABLET

1

CLEMASTINE FUMARATESYRUP

1

CLEMASTINE FUMARATETABLET

1

CYPROHEPTADINE HCLTABLET

1

DESLORATADINETABLET

1

DIPHENHYDRAMINE HCLELIXIR

1

HYDROXYZINE HCLSYRUP

1

HYDROXYZINE HCLTABLET

1

HYDROXYZINE PAMOATECAPSULE

1

LEVOCETIRIZINE DIHYDROCHLORIDETABLET

1

PROMETHAZINE HCLSYRINGE (ML)

1

PROMETHAZINE HCLTABLET

1

PROMETHAZINE VCSYRUP

1

R-TANNATABLET

1

Page 28 | 2015 Formulary

CYPROHEPTADINE HCLSYRUP

3

SEMPREX-DCAPSULE

3

ANTITUSSIVE -

BENZONATATECAPSULE

1

GUAIFENESIN WITH CODEINELIQUID (ML)

1

HYDROCODONE-CHLORPHENIRAMINESUSPENSION; EXTENDED RELEASE 12 HR

1

HYDROCODONE/HOMATROPINETABLET

1

PROMETHAZINE VC W/CODEINESYRUP

1

PROMETHAZINE W/DMSYRUP

1

TUSSICAPSCAPSULE; EXTENDED RELEASE 12 HR

2

BROMFED-DMSYRUP

3

ZODRYL AC 35SUSPENSION; ORAL (FINAL DOSE FORM)

3

BETA AGONISTS -

ALBUTEROL SULFATESOLUTION; NON-ORAL

1

ALBUTEROL SULFATESYRUP

1

ALBUTEROL SULFATETABLET

1

ALBUTEROL SULFATEVIAL; NEBULIZER (ML)

1

LEVALBUTEROL HCLVIAL; NEBULIZER (ML)

1

METAPROTERENOL SULFATESYRUP

1

METAPROTERENOL SULFATETABLET

1

TERBUTALINE SULFATETABLET

1

ARCAPTA NEOHALERCAPSULE; WITH INHALATION DEVICE

2

FORADILCAPSULE; WITH INHALATION DEVICE

2

PERFOROMISTVIAL; NEBULIZER (ML)

2

PROAIR HFAHFA AEROSOL WITH ADAPTER (GRAM)

2

SEREVENT DISKUSBLISTER; WITH INHALATION DEVICE

2

VENTOLIN HFAHFA AEROSOL WITH ADAPTER (GRAM)

2

PROVENTIL HFAHFA AEROSOL WITH ADAPTER (GRAM)

3

XOPENEX HFAHFA AEROSOL WITH ADAPTER (GRAM)

3

INHALED STEROIDS -

BUDESONIDEAMPUL FOR NEBULIZATION (ML)

1

ADVAIR DISKUSBLISTER; WITH INHALATION DEVICE

2

ADVAIR HFAHFA AEROSOL WITH ADAPTER (GRAM)

2

ASMANEXAEROSOL POWDER; BREATH ACTIVATED (EA)

2

BREO ELLIPTABLISTER; WITH INHALATION DEVICE

2

DULERAHFA AEROSOL WITH ADAPTER (GRAM)

2

FLOVENT DISKUSBLISTER; WITH INHALATION DEVICE

2

FLOVENT HFAAEROSOL WITH ADAPTER (GRAM)

2

PULMICORT FLEXHALERAEROSOL POWDER; BREATH ACTIVATED (EA)

2

QVARAEROSOL WITH ADAPTER (GRAM)

2

SYMBICORTHFA AEROSOL WITH ADAPTER (GRAM)

2

ALVESCOHFA AEROSOL WITH ADAPTER (GRAM)

3

NASAL STEROIDS -

FLUNISOLIDEAEROSOL; SPRAY (ML)

1

FLUTICASONE PROPIONATESPRAY; SUSPENSION

1

TRIAMCINOLONE ACETONIDEAEROSOL; SPRAY (GRAM)

1

DYMISTAAEROSOL; SPRAY WITH PUMP (GRAM)

2

NASONEXAEROSOL; SPRAY WITH PUMP (GRAM)

2

VERAMYSTSPRAY; SUSPENSION

2

BECONASE AQAEROSOL; SPRAY (GRAM)

3

OMNARISAEROSOL; SPRAY WITH PUMP (GRAM)

3

QNASLHFA AEROSOL WITH ADAPTER (GRAM)

3

ZETONNAHFA AEROSOL WITH ADAPTER (GRAM)

3

OTHER -

AZELASTINE HCLAEROSOL; SPRAY WITH PUMP (ML)

1

Page 29 | 2015 Formulary

IPRATROPIUM BROMIDEAEROSOL; SPRAY (ML)

1

IPRATROPIUM BROMIDESOLUTION; NON-ORAL

1

IPRATROPIUM-ALBUTEROLAMPUL FOR NEBULIZATION (ML)

1

MONTELUKAST SODIUMGRANULES IN PACKET (EA)

1

MONTELUKAST SODIUMTABLET

1

SILDENAFIL CITRATETABLET

1

THEOPHYLLINE ANHYDROUSSOLUTION; ORAL

1

THEOPHYLLINE ANHYDROUSTABLET; EXTENDED RELEASE 12 HR

1

ZAFIRLUKASTTABLET

1

ADCIRCATABLET

2

ADEMPASTABLET

2

AEROCHAMBERSPACER (EA)

2

AEROCHAMBER PLUSSPACER (EA)

2

ASTEPROAEROSOL; SPRAY WITH PUMP (ML)

2

ATROVENT HFAHFA AEROSOL WITH ADAPTER (GRAM)

2

AUVI-QAUTO-INJECTOR (EA)

2

COMBIVENT RESPIMATAEROSOL WITH ADAPTER (GRAM)

2

DALIRESPTABLET

2

EPIPENAUTO-INJECTOR (EA)

2

EPIPEN JR.AUTO-INJECTOR (EA)

2

KALYDECOTABLET

2

LETAIRISTABLET

2

PULMOZYMESOLUTION; NON-ORAL

2

SPIRIVACAPSULE; WITH INHALATION DEVICE

2

TRACLEERTABLET

2

TUDORZA PRESSAIRAEROSOL POWDER; BREATH ACTIVATED (EA)

2

XOLAIRVIAL (EA)

2

PATANASEAEROSOL; SPRAY WITH PUMP (GRAM)

3

ZYFLOTABLET

3

TOPICAL -

ACNE -

ADAPALENEGEL (GRAM)

1

AMNESTEEMCAPSULE

1

BENZEPROFOAM (GRAM)

1

BENZOYL PEROXIDECLEANSER (ML)

1

BENZOYL PEROXIDEFOAM (GRAM)

1

BP FOAMFOAM (GRAM)

1

CLARAVISCAPSULE

1

CLARISCLEANSER (ML)

1

CLINDAMYCIN PHOSPHATEFOAM (GRAM)

1

CLINDAMYCIN PHOSPHATEGEL (GRAM)

1

CLINDAMYCIN PHOSPHATELOTION (ML)

1

CLINDAMYCIN PHOSPHATESOLUTION; NON-ORAL

1

CLINDAMYCIN PHOSPHATESWAB; MEDICATED

1

CLINDAMYCIN-BENZOYL PEROXIDEGEL (GRAM)

1

ERYGELGEL (GRAM)

1

ERYTHROMYCINGEL (GRAM)

1

ERYTHROMYCINSOLUTION; NON-ORAL

1

ERYTHROMYCIN-BENZOYL PEROXIDEGEL (GRAM)

1

METRONIDAZOLECREAM (GRAM)

1

METRONIDAZOLEGEL (GRAM)

1

METRONIDAZOLELOTION (ML)

1

MYORISANCAPSULE

1

Page 30 | 2015 Formulary

ROSADANCREAM (GRAM)

1

ROSADANGEL (GRAM)

1

SODIUM SULFACETAMIDE/SULFURCLEANSER (ML)

1

SODIUM SULFACETAMIDE/SULFURLOTION (GRAM)

1

TRETINOINCREAM (GRAM)

1

TRETINOINGEL (GRAM)

1

TRETINOIN MICROSPHEREGEL (GRAM)

1

ACANYAGEL WITH PUMP (GRAM)

2

ACZONEGEL (GRAM)

2

ATRALINGEL (GRAM)

2

DIFFERINLOTION (ML)

2

EPIDUOGEL WITH PUMP (GRAM)

2

FINACEAGEL (GRAM)

2

MIRVASOGEL (GRAM)

2

TAZORACCREAM (GRAM)

2

TAZORACGEL (GRAM)

2

ABSORICACAPSULE

3

AVAGECREAM (GRAM)

3

AVARPADS; MEDICATED (EA)

3

AZELEXCREAM (GRAM)

3

BENZAC ACCLEANSER (GRAM)

3

BENZACLINGEL WITH PUMP (GRAM)

3

BENZEFOAMFOAM (GRAM)

3

CLARIFOAM EFFOAM (GRAM)

3

CLINDAGELGEL (ML)

3

FABIORFOAM (GRAM)

3

INOVACOMBINATION PACKAGE (EA)

3

NORITATECREAM (GRAM)

3

NUOXGEL (GRAM)

3

PACNEX HPPADS; MEDICATED (EA)

3

RIAXFOAM (GRAM)

3

VELTINGEL (GRAM)

3

ANESTHETICS -

LIDOCAINEOINTMENT (GRAM)

1

LIDOCAINE-HCCREAM (GRAM)

1

LIDOCAINE-PRILOCAINECREAM (GRAM)

1

NOVACORTGEL (GRAM)

3

PLIAGLISCREAM (GRAM)

3

ANTIBACTERIALS -

MUPIROCINOINTMENT (GRAM)

1

SULFAMYLONCREAM (GRAM)

2

ALCORTIN AGEL IN PACKET (GRAM)

3

ALTABAXOINTMENT (GRAM)

3

CENTANYOINTMENT (GRAM)

3

ANTIFUNGALS -

CICLOPIROXGEL (GRAM)

1

CICLOPIROXSHAMPOO

1

CICLOPIROXSUSPENSION; TOPICAL (ML)

1

CLOTRIMAZOLECREAM (GRAM)

1

CLOTRIMAZOLESOLUTION; NON-ORAL

1

CLOTRIMAZOLE/BETAMETHASONECREAM (GRAM)

1

CLOTRIMAZOLE/BETAMETHASONELOTION (ML)

1

ECONAZOLE NITRATECREAM (GRAM)

1

KETOCONAZOLECREAM (GRAM)

1

Page 31 | 2015 Formulary

KETOCONAZOLESHAMPOO

1

NYSTATINOINTMENT (GRAM)

1

NYSTATIN W/TRIAMCINOLONECREAM (GRAM)

1

ECOZAFOAM (GRAM)

3

ERTACZOCREAM (GRAM)

3

EXELDERMCREAM (GRAM)

3

EXELDERMSOLUTION; NON-ORAL

3

EXODERMLOTION (ML)

3

MENTAXCREAM (GRAM)

3

NAFTINCREAM (GRAM)

3

NAFTINGEL (GRAM)

3

OXISTATCREAM (GRAM)

3

OXISTATLOTION (ML)

3

XOLEGELGEL (GRAM)

3

ANTIPSORIATIC -

ACITRETINCAPSULE

1

CALCIPOTRIENECREAM (GRAM)

1

CALCIPOTRIENEOINTMENT (GRAM)

1

CALCIPOTRIENESOLUTION; NON-ORAL

1

CALCITRENEOINTMENT (GRAM)

1

DRITHOCREME HPCREAM (GRAM)

1

SELENIUM SULFIDESHAMPOO

1

SELENIUM SULFIDESUSPENSION; TOPICAL (ML)

1

SODIUM SULFACETAMIDECLEANSER (ML)

1

SODIUM SULFACETAMIDESHAMPOO

1

PRAMOSONECREAM (GRAM)

2

PRAMOSONELOTION (ML)

2

PRAMOSONEOINTMENT (GRAM)

2

PRAMOSONE ECREAM (GRAM)

2

STELARASYRINGE (ML)

2

TACLONEXSUSPENSION; TOPICAL (GRAM)

2

EPIFOAMFOAM (GRAM)

3

OVACE PLUSSHAMPOO

3

SORILUXFOAM (GRAM)

3

TERSI FOAMFOAM (GRAM)

3

ZITHRANOL-RRCREAM; RAPID RELEASE (GRAM)

3

ANTIVIRALS -

ACYCLOVIROINTMENT (GRAM)

1

DENAVIRCREAM (GRAM)

2

LIDOVIROINTMENT (GRAM)

3

XERESECREAM (GRAM)

3

CORTICOSTEROIDS HIGH POTENCY -

AMCINONIDECREAM (GRAM)

1

AMCINONIDELOTION (ML)

1

AMCINONIDEOINTMENT (GRAM)

1

APEXICON ECREAM (GRAM)

1

BETAMETHASONE DIPROPIONATECREAM (GRAM)

1

BETAMETHASONE DIPROPIONATELOTION (ML)

1

BETAMETHASONE DIPROPIONATEOINTMENT (GRAM)

1

BETAMETHASONE VALERATEOINTMENT (GRAM)

1

DESOXIMETASONECREAM (GRAM)

1

DESOXIMETASONEGEL (GRAM)

1

DESOXIMETASONEOINTMENT (GRAM)

1

DIFLORASONE DIACETATECREAM (GRAM)

1

Page 32 | 2015 Formulary

FLUOCINONIDECREAM (GRAM)

1

FLUOCINONIDEGEL (GRAM)

1

FLUOCINONIDEOINTMENT (GRAM)

1

FLUOCINONIDE-ECREAM (GRAM)

1

TRIAMCINOLONE ACETONIDECREAM (GRAM)

1

HALOGCREAM (GRAM)

3

HALOGOINTMENT (GRAM)

3

TOPICORTSPRAY; NON-AEROSOL (ML)

3

CORTICOSTEROIDS VERY HIGH POTENCY -

BETAMETHASONE DIPROPIONATEOINTMENT (GRAM)

1

CLOBETASOL ECREAM (GRAM)

1

CLOBETASOL PROPIONATEOINTMENT (GRAM)

1

CLOBETASOL PROPIONATESHAMPOO

1

CLOBETASOL PROPIONATESOLUTION; NON-ORAL

1

HALOBETASOL PROPIONATEOINTMENT (GRAM)

1

HALONATECOMBINATION PACKAGE; OINTMENT FOAM

1

CLOBEXSPRAY; NON-AEROSOL (ML)

3

MISCELLANEOUS -

FLUOROURACILCREAM (GRAM)

1

FLUOROURACILSOLUTION; NON-ORAL

1

IMIQUIMODCREAM IN PACKET (EA)

1

LINDANESHAMPOO

1

MALATHIONLOTION (ML)

1

PERMETHRINCREAM (GRAM)

1

PODOFILOXSOLUTION; NON-ORAL

1

SILVER SULFADIAZINECREAM (GRAM)

1

THERMAZENECREAM (GRAM)

1

VASOLEXOINTMENT (GRAM)

1

CARACCREAM (GRAM)

2

ELIDELCREAM (GRAM)

2

PROTOPICOINTMENT (GRAM)

2

REGRANEXGEL (GRAM)

2

SANTYLOINTMENT (GRAM)

2

BIONECTCREAM (GRAM)

3

BIONECTGEL (GRAM)

3

EURAXCREAM (GRAM)

3

PICATOGEL (EA)

3

XERAC ACSOLUTION; NON-ORAL

3

TOPICAL CORTICOSTEROIDS LOW POTENCY -

ALCLOMETASONE DIPROPIONATECREAM (GRAM)

1

ALCLOMETASONE DIPROPIONATEOINTMENT (GRAM)

1

DESONIDELOTION (ML)

1

DESONIDEOINTMENT (GRAM)

1

FLUOCINOLONE ACETONIDECREAM (GRAM)

1

FLUOCINOLONE ACETONIDESOLUTION; NON-ORAL

1

HYDROCORTISONECREAM (GRAM)

1

HYDROCORTISONE ACETATEGEL (GRAM)

1

CAPEX SHAMPOOSHAMPOO

3

DESONATEGEL (GRAM)

3

PEDIADERM HCKIT; LOTION CREAM; EMOLLIENT

3

SYNALARCREAM (GRAM)

3

TEXACORTSOLUTION; NON-ORAL

3

VERDESOFOAM (GRAM)

3

TOPICAL CORTICOSTEROIDS MEDIUM POTENCY -

Page 33 | 2015 Formulary

BETAMETHASONE VALERATECREAM (GRAM)

1

BETAMETHASONE VALERATELOTION (ML)

1

DESOXIMETASONECREAM (GRAM)

1

DESOXIMETASONEOINTMENT (GRAM)

1

FLUOCINOLONE ACETONIDECREAM (GRAM)

1

FLUTICASONE PROPIONATECREAM (GRAM)

1

FLUTICASONE PROPIONATELOTION (ML)

1

HYDROCORTISONE BUTYRATECREAM (GRAM)

1

HYDROCORTISONE BUTYRATESOLUTION; NON-ORAL

1

MOMETASONE FUROATEOINTMENT (GRAM)

1

MOMETASONE FUROATESOLUTION; NON-ORAL

1

PREDNICARBATEOINTMENT (GRAM)

1

TRIAMCINOLONE ACETONIDECREAM (GRAM)

1

TRIAMCINOLONE ACETONIDELOTION (ML)

1

TRIANEXOINTMENT (GRAM)

1

TRIDERMCREAM (GRAM)

1

CLODERMCREAM (GRAM)

3

CORDRANCREAM (GRAM)

3

KENALOGAEROSOL (GRAM)

3

LOCOIDLOTION (ML)

3

MOMEXINCOMBINATION PACKAGE (GRAM)

3

PANDELCREAM (GRAM)

3

TOPICORTOINTMENT (GRAM)

3

UROLOGICAL -

ANTISPASMODICS -

BETHANECHOL CHLORIDETABLET

1

FLAVOXATE HCLTABLET

1

OXYBUTYNIN CHLORIDESYRUP

1

OXYBUTYNIN CHLORIDETABLET

1

OXYBUTYNIN CHLORIDE ERTABLET; EXTENDED RELEASE 24 HR

1

TOLTERODINE TARTRATETABLET

1

TOLTERODINE TARTRATE ERCAPSULE; EXT RELEASE 24 HR

1

TROSPIUM CHLORIDETABLET

1

GELNIQUEGEL IN METERED-DOSE PUMP

2

MYRBETRIQTABLET; EXTENDED RELEASE 24 HR

2

TOVIAZTABLET; EXTENDED RELEASE 24 HR

2

VESICARETABLET

2

ENABLEXTABLET; EXTENDED RELEASE 24 HR

3

OXYTROLPATCH; TRANSDERMAL SEMIWEEKLY

3

BPH -

ALFUZOSIN HCLTABLET; EXTENDED RELEASE 24 HR

1

FINASTERIDETABLET

1

RAPAFLOCAPSULE

2

AVODARTCAPSULE

3

JALYNCAPSULE;EXTENDED RELEASE MULTIPHASE 24HR

3

ERECTILE DYSFUNCTION -

CIALISTABLET

2

MUSESUPPOSITORY; URETHRAL

2

VIAGRATABLET

2

LEVITRATABLET

3

STAXYNTABLET;DISINTEGRATING

3

STENDRATABLET

3

VACCINES -

BOOSTRIXVIAL (ML)

2

CERVARIXSYRINGE (ML)

2

Page 34 | 2015 Formulary

ENGERIX-BSYRINGE (ML)

2

FLUZONEVIAL (ML)

2

GARDASILVIAL (ML)

2

HAVRIXVIAL (ML)

2

INFANRIXSYRINGE (ML)

2

PNEUMOVAX 23VIAL (ML)

2

PREVNAR 13SYRINGE (ML)

2

RECOMBIVAX HBVIAL (ML)

2

ROTATEQSUSPENSION; ORAL (FINAL DOSE FORM)

2

TWINRIXVIAL (ML)

2

ZOSTAVAXVIAL (EA)

2

VITAMINS/ELECTROLYTES -

CALCIUM ACETATECAPSULE

1

DIALYVITETABLET

1

ELITE-OBTABLET

1

FLUORIDETABLET; CHEWABLE

1

FOLIC ACIDTABLET

1

KLOR-CONPACKET (EA)

1

MATERNITYTABLET

1

OBSTETRIX DHACOMBINATION PACKAGE; TABLET DR CAP

1

POTASSIUM CHLORIDELIQUID (ML)

1

POTASSIUM CHLORIDETABLET; EXTENDED RELEASE

1

PRENA1CAPSULE

1

PRENATABS RXTABLET

1

PRENATAL PLUSTABLET

1

NASCOBALSPRAY; NON-AEROSOL (ML)

2

DUET DHACOMBINATION PACKAGE (EA)

3

K-TABTABLET; EXTENDED RELEASE

3

LIMBRELCAPSULE

3

OB COMPLETETABLET

3