presbyterian health plan presbyterian insurance...

Some medications may be excluded as determined by benefit.

Drug Name Dosage Form Tier Note

acetaminophen/codeine SOLN 1 (QL)

acetaminophen/codeine #2 TABS 1 (QL)



ADULT ASPIRIN LOW STRENGTH TBDP 1

ANAPROX TABS GP

ANAPROX DS TABS GP

ARTHROTEC 50 TBEC GP (GP)


aspirin TBEC 1

ASPIRIN LOW DOSE TABS 1

AVINZA CP24 GP (GP)

buprenorphine hcl/naloxone hcl SUBL 3 (PA) (QL)

butalbital/acetaminophen/caffeine TABS 1 (QL)

butalbital/acetaminophen/caffeine/codeine CAPS 1 (QL)

butalbital/aspirin/caffeine/codeine CAPS 1 (QL)

butorphanol tartrate SOLN 3

carisoprodol/aspirin TABS 1

carisoprodol/aspirin/codeine TABS 1

CELEBREX CAPS 3 (QL)

childrens ibuprofen SUSP 1

CLINORIL TABS GP

CODEINE SULFATE TABS 1 (QL)

DAYPRO TABS GP

DEMEROL TABS GP (QL)

diclofenac sodium dr TBEC 1

diclofenac sodium er TB24 1

diclofenac sodium/misoprostol TBEC 3

diflunisal TABS 1

DILAUDID TABS GP (QL)

DOLOPHINE TABS GP (QL)

DOLOPHINE HCL TABS GP (QL)

Analgesics

PHP Commercial-4/PIC Formulary - by Therapeutic Class

This list is in order by the therapeutic class. To find a specific drug or a therapeutic class, use the search feature

available in Adobe Acrobat Reader (keyboard shortcut: Ctrl+F).

Presbyterian Health Plan

Presbyterian Insurance Company, Inc.

[MPC021239] of 60 Effective September 1, 2014

DURAGESIC PT72 GP (QL)

endocet TABS 1

ESGIC * GP (QL)

ESGIC-PLUS * GP (QL)

ESGIC-PLUS CAPS GP (QL)

ESGIC-PLUS TABS GP (QL)

etodolac * 1

etodolac er TB24 1

FELDENE CAPS GP

FENOPROFEN CALCIUM TABS 1

fentanyl PT72 1 (QL)

FIORICET TABS GP (QL)

FIORICET/CODEINE CAPS GP (QL)

FIORINAL/CODEINE #3 CAPS GP (QL)

flurbiprofen TABS 1

hydrocodone bitartrate/acetaminophen SOLN 1 (QL)

HYDROCODONE BITARTRATE/ACETAMINOPHEN TABS 1 (QL)

hydrocodone/acetaminophen SOLN 1 (QL)

hydrocodone/acetaminophen (325mg; 10mg) TABS 1 (QL)


hydrocodone/acetaminophen (325mg; 7.5mg) TABS 1 (QL)



HYDROCODONE/ACETAMINOPHEN (500MG; 7.5MG) TABS 1 (QL)


HYDROCODONE/ACETAMINOPHEN (650MG; 7.5MG) TABS 1 (QL)


hydrocodone/acetaminophen (750mg; 7.5mg) TABS 1 (QL)

hydrogesic CAPS 1 (QL)

hydromorphone hcl TABS 1 (QL)

ibuprofen * 1

ibuprofen junior strength CHEW 1

indomethacin CAPS 1

indomethacin er CPCR 1

KADIAN CP24 GP (GP) (QL) (ST)

ketoprofen CAPS 1

KETOPROFEN ER CP24 1

ketorolac tromethamine TABS 1 (QL)

LEVORPHANOL TARTRATE TABS 3 (QL)

LORTAB * GP (QL)

MECLOFENAMATE SODIUM CAPS 1

MELOXICAM * 1

meloxicam * 1

MEPERIDINE HCL SOLN 1 (QL)

methadone hcl TABS 1 (QL)


methadone hcl SOLN 1

MOBIC TABS GP

MOBIC SUSP 2

MORPHINE SULFATE TABS 1 (QL)

morphine sulfate (10mg/5ml) SOLN 1 (QL)

morphine sulfate (20mg/5ml) SOLN 1 (QL)

morphine sulfate (20mg/ml) SOLN 1 (QL)

morphine sulfate er CP24 3 (ST) (QL)

morphine sulfate er TBCR 1 (QL)

morphine sulfate er CP24 3 (ST) (QL)

MS CONTIN TBCR GP (QL)

nabumetone TABS 1

nalbuphine hcl SOLN 1

NALFON CAPS GP

NAPROSYN * GP

naproxen * 1

naproxen dr TBEC 1

naproxen sodium TABS 1

NORCO TABS GP (QL)

oxaprozin TABS 1

OXYCODONE HCL CONC 1 (QL)

oxycodone hcl (10mg) TABS 2 (QL)





oxycodone/acetaminophen * 1 (QL)

oxycodone/acetaminophen (325mg; 10mg) TABS 1 (QL)

oxycodone/acetaminophen (325mg; 2.5mg) TABS 1 (QL)





oxycodone/aspirin TABS 1 (QL)

oxymorphone hydrochloride er TB12 3 (QL) (ST)

pentazocine/acetaminophen TABS 1 (QL)

PERCOCET TABS GP (GP) (QL)

PERCODAN TABS GP (QL)

piroxicam CAPS 1

ROXICET SOLN 2 (QL)

roxicet (325mg; 5mg) TABS 1 (QL)

ROXICET (500MG; 5MG) TABS 2 (QL)

ROXICODONE TABS GP (QL)

salsalate TABS 1

ST JOSEPH ADULT CHEW 1


st joseph aspirin CHEW 1

sulindac TABS 1

TOLMETIN SODIUM * 1

tolmetin sodium * 1

tramadol hcl TABS 1 (QL)

tramadol hcl er (100mg) TB24 3 (QL)



tramadol hydrochloride/acetaminophen TABS 1 (QL)

TYLENOL/CODEINE #3 TABS GP (QL)

TYLENOL/CODEINE #4 TABS GP (QL)

TYLOX CAPS GP (QL)

ULTRACET TABS GP (QL)

ULTRAM TABS GP (QL)

ULTRAM ER TB24 GP (QL)

VOLTAREN-XR TB24 GP

zebutal CAPS 1 (QL)


anecream CREA 1

antipyrine/benzocaine SOLN 1

lidocaine CREA 1

lidocaine OINT 1

lidocaine PTCH 3 (PA) (QL)

lidocaine hcl SOLN 1

lidocaine hcl jelly GEL 1

lidocaine viscous SOLN 1

lidocaine/prilocaine CREA 1

LIDODERM PTCH GP (GP) (PA) (QL)

XYLOCAINE SOLN GP


acamprosate calcium dr TBEC 3 (PA) (QL)

ANTABUSE TABS GP

buprenorphine hcl SUBL 3 (PA) (QL)

buprenorphine hcl/naloxone hcl SUBL 3 (PA) (QL)

buproban TB12 1

bupropion hcl sr TB12 1 (QL)

CAMPRAL TBEC GP (GP) (PA) (QL)

Anesthetics

Anti-Addiction/Substance Abuse Treatment Agents


CHANTIX TABS 3 (QL)

CHANTIX STARTING MONTH PAK TABS 3 (QL)

disulfiram TABS 1

naltrexone hcl TABS 1

REVIA TABS GP

SUBOXONE * 3 (PA) (QL)

SUBOXONE SUBL GP (GP) (PA) (QL)

VIVITROL SUSR 4 (MB) (PA) (QL) (SP)

ZYBAN TB12 GP (QL)


ADULT ASPIRIN LOW STRENGTH TBDP 1

ANAPROX TABS GP

ANAPROX DS TABS GP



aspirin TBEC 1

ASPIRIN LOW DOSE TABS 1

CELEBREX CAPS 3 (QL)

childrens ibuprofen SUSP 1

CLINORIL TABS GP

DAYPRO TABS GP

diclofenac sodium dr TBEC 1

diclofenac sodium er TB24 1


diflunisal TABS 1

etodolac * 1

etodolac er TB24 1

FELDENE CAPS GP

FENOPROFEN CALCIUM TABS 1

flurbiprofen TABS 1

hydrocortisone/acetic acid SOLN 1

ibuprofen * 1

ibuprofen junior strength CHEW 1

indomethacin CAPS 1

indomethacin er CPCR 1

ketoprofen CAPS 1

KETOPROFEN ER CP24 1

MECLOFENAMATE SODIUM CAPS 1

meloxicam * 1

MELOXICAM * 1

MOBIC TABS GP

Anti-inflammatory Agents


MOBIC SUSP 2

nabumetone TABS 1

NALFON CAPS GP

NAPROSYN * GP

naproxen * 1

naproxen dr TBEC 1

naproxen sodium TABS 1

NEOMYCIN/POLYMYXIN/HYDROCORTISONE SUSP 1

neomycin/polymyxin/hydrocortisone * 1

nystatin/triamcinolone * 1

oxaprozin TABS 1

piroxicam CAPS 1

ST JOSEPH ADULT CHEW 1

st joseph aspirin CHEW 1

sulindac TABS 1

tolmetin sodium * 1

TOLMETIN SODIUM * 1

VOLTAREN-XR TB24 GP


ak-poly-bac OINT 1

AKNE-MYCIN OINT 2

AMOXICILLIN * 1

amoxicillin * 1

amoxicillin/clavulanate potassium * 1

ampicillin CAPS 1

AMPICILLIN SUSR 3

AUGMENTIN * GP

AVELOX TABS GP

azithromycin * 1

bacitracin/polymyxin b OINT 1

BACTRIM TABS GP

BACTRIM DS TABS GP

BACTROBAN OINT GP

BACTROBAN NASAL OINT 2

BIAXIN TABS GP (QL)

BIAXIN SUSR GP

BIAXIN XL TB24 GP (QL)

BLEPH-10 SOLN GP

BLEPHAMIDE SUSP 2

BLEPHAMIDE S.O.P. OINT 2

cefaclor CAPS 1

Antibacterials


cefadroxil * 3

cefdinir * 1

cefpodoxime proxetil * 3

cefprozil * 1

CEFTIN * GP

cefuroxime axetil * 1

cephalexin * 1

CILOXAN OINT 2

CIPRO SUSR GP

CIPRODEX SUSP 2 (AG) (QL)

ciprofloxacin SUSR 1

ciprofloxacin hcl SOLN 1

ciprofloxacin hcl (100mg) TABS 1




clarithromycin TABS 1 (QL)

clarithromycin SUSR 1

CLEOCIN * GP

CLEOCIN CAPS GP

CLEOCIN PEDIATRIC GRANULES SOLR GP

clindamycin hcl CAPS 1

clindamycin palmitate hcl SOLR 1

clindamycin phosphate CREA 1

CORTISPORIN CREA 1

CORTISPORIN OINT GP

demeclocycline hcl TABS 3

dicloxacillin sodium CAPS 1

DIFICID TABS 4 (PA) (QL)

doxycycline hyclate * 1

doxycycline hyclate TABS 1 (QL)

doxycycline monohydrate CAPS 1

E.E.S. GRANULES SUSR 2

ERY-TAB TBEC 2

ERYPED 200 SUSR 2

ERYPED 400 SUSR 2

ERYTHROCIN STEARATE TABS 1

erythromycin OINT 1

erythromycin * 1

ERYTHROMYCIN BASE TABS 2

ERYTHROMYCIN ETHYLSUCCINATE TABS 2

erythromycin/sulfisoxazole SUSR 1

FACTIVE TABS 3

FLAGYL * GP

FURADANTIN SUSP 2


GARAMYCIN SOLN GP

gentak OINT 1

GENTAMICIN SULFATE * 1

gentamicin sulfate SOLN 1

HELIDAC MISC 3

HIPREX TABS GP

KEFLEX CAPS GP

LEVAQUIN * GP

levofloxacin * 1

MACROBID CAPS GP

MACRODANTIN (100MG) CAPS GP

MACRODANTIN (25MG) CAPS 2

MACRODANTIN (50MG) CAPS GP

MAXITROL * GP

methenamine hippurate TABS 1

methenamine mandelate TABS 1

METHENAMINE MANDELATE TABS 1

METROCREAM CREA GP

METROGEL-VAGINAL GEL GP

METROLOTION LOTN GP

metronidazole TABS 1

metronidazole * 1

metronidazole vaginal GEL 1

MINOCIN CAPS GP

minocycline hcl CAPS 1

MONODOX CAPS GP

moxifloxacin hcl TABS 3

mupirocin OINT 1

neo-polycin OINT 1

neomycin sulfate TABS 1

neomycin/bacitracin/polymyxin OINT 1

neomycin/polymyxin b sulfates SOLN 1

neomycin/polymyxin/bacitracin/hydrocortisone OINT 1

neomycin/polymyxin/dexamethasone * 1

neomycin/polymyxin/gramicidin SOLN 1



nitrofurantoin macrocrystals CAPS 1

nitrofurantoin monohydrate CAPS 1

NOROXIN TABS 3

OCUFLOX SOLN GP

ofloxacin SOLN 1

ofloxacin SOLN 1

paromomycin sulfate CAPS 1

penicillin v potassium * 1


polymyxin b sulfate/trimethoprim sulfate SOLN 1

PRIMSOL SOLN GP

SILVADENE CREA GP

silver sulfadiazine CREA 1

sulfacetamide sodium SOLN 1

sulfacetamide sodium/prednisolone sodium phosphate SOLN 1

SULFADIAZINE TABS 1

sulfamethoxazole/trimethoprim * 1

sulfamethoxazole/trimethoprim ds TABS 1

SUPRAX * 2

TETRACYCLINE HCL CAPS 1

TOBI NEBU GP

TOBI PODHALER CAPS 4 (QL)

TOBRADEX OINT 3

tobramycin NEBU 4

tobramycin sulfate SOLN 1

tobramycin/dexamethasone SUSP 1

TOBREX OINT 2

trimethoprim TABS 1

UREX TABS GP

VANCOCIN HCL CAPS GP (GP) (PA)

vancomycin hcl CAPS 4 (PA)

vancomycin hcl SOLR 1

VIBRAMYCIN SUSR 1

VIGAMOX SOLN 3

XIFAXAN TABS 4 (PA) (QL)

ZITHROMAX * GP

ZITHROMAX TRI-PAK TABS GP

ZYVOX * 4 (PA)


carbamazepine * 1

carbamazepine er * 1

CARBATROL CP12 GP

clonazepam TABS 1 (QL)

clonazepam odt TBDP 1 (QL)

clorazepate dipotassium (15mg) TABS 1 (QL)

clorazepate dipotassium (3.75mg) TABS 1 (QL)

clorazepate dipotassium (7.5mg) TABS 1 (QL)

DEPAKENE SYRP GP

DEPAKENE CAPS GP

DEPAKOTE TBEC GP

Anticonvulsants


DEPAKOTE ER TB24 GP

DEPAKOTE SPRINKLES CPSP GP

DIASTAT ACUDIAL GEL 2 (ST)

DIASTAT PEDIATRIC GEL 2 (ST)

diazepam TABS 1 (QL)

DIAZEPAM GEL 2 (ST)

DILANTIN CAPS 2

DILANTIN INFATABS CHEW 2

divalproex sodium CPSP 1

divalproex sodium dr TBEC 1

divalproex sodium er TB24 1

ethosuximide * 1

felbamate * 3

FELBATOL * GP

gabapentin * 1

GABITRIL TABS 3

KEPPRA * GP

KLONOPIN TABS GP (GP) (QL)

LAMICTAL TABS GP

LAMICTAL CHEWABLE DISPERSIBLE CHEW GP

lamotrigine TABS 1

levetiracetam * 1

LYRICA (100MG) CAPS 3 (PA) (QL)








MYSOLINE TABS GP

NEURONTIN * GP

oxcarbazepine SUSP 1

oxcarbazepine TABS 1

phenobarbital * 1

PHENOBARBITAL * 1

phenytoin SUSP 1

phenytoin sodium extended CAPS 1

POTIGA TABS 3 (PA) (QL)

primidone TABS 1

TEGRETOL * GP

TEGRETOL-XR TB12 2

tiagabine hydrochloride TABS 3

TOPAMAX TABS GP

TOPAMAX SPRINKLE CPSP GP


topiramate * 1

TRILEPTAL * GP

VALIUM TABS GP (GP) (QL)

valproic acid CAPS 1

valproic acid SYRP 1

ZARONTIN * GP

ZONEGRAN CAPS GP

zonisamide CAPS 1


ARICEPT TABS GP (QL)

ARICEPT ODT TBDP GP (QL)

donepezil hcl (10mg) TABS 1 (QL)

donepezil hcl (10mg) TBDP 1 (QL)

donepezil hcl (5mg) TBDP 1 (QL)

donepezil hcl (5mg) TABS 1 (QL)

ERGOLOID MESYLATES TABS 1

EXELON SOLN 3

galantamine hydrobromide * 1

NAMENDA TABS 2 (QL)

NAMENDA SOLN 2 (QL)

NAMENDA XR CP24 3 (ST) (QL)

RAZADYNE * GP

RAZADYNE ER CP24 GP (GP)

rivastigmine tartrate CAPS 3


ABILIFY TABS 4 (PA) (QL)

ABILIFY SOLN 4 (PA) (QL)

ABILIFY DISCMELT TBDP 4 (PA) (QL)

ABILIFY MAINTENA SUSR MED (MB) (PA) (SP)

amitriptyline hcl TABS 1

AMOXAPINE TABS 2

ANAFRANIL CAPS GP

bupropion hcl TABS 1 (QL)

bupropion hcl sr TB12 1 (QL)

bupropion hcl xl (150mg) TB24 1 (QL)

bupropion hcl xl (300mg) TB24 1 (QL)

CELEXA TABS GP (QL)

Antidementia Agents

Antidepressants


CHLORDIAZEPOXIDE/AMITRIPTYLINE TABS 1

citalopram hydrobromide SOLN 1 (QL)

citalopram hydrobromide (10mg) TABS 1 (QL)



clomipramine hcl CAPS 1

CYMBALTA (20MG) CPEP GP (GP) (PA) (QL)



desipramine hcl TABS 1

DOXEPIN HCL * 1

doxepin hcl * 1

duloxetine hcl (20mg) CPEP 3 (PA) (QL)



EFFEXOR XR CP24 GP (QL)

ELDEPRYL CAPS GP

EMSAM PT24 3 (PA) (QL)

escitalopram oxalate SOLN 1 (QL)

escitalopram oxalate (10mg) TABS 1 (QL)



fluoxetine hcl * 1

FLUOXETINE HCL TABS 1 (QL)

fluvoxamine maleate TABS 1

imipramine hcl TABS 1

LEXAPRO * GP (GP) (QL)

MAPROTILINE HCL TABS 1

mirtazapine * 1

mirtazapine odt TBDP 1

NARDIL TABS GP

NORPRAMIN TABS GP

nortriptyline hcl CAPS 1

PAMELOR CAPS GP

PARNATE TABS GP

paroxetine hcl (10mg) TABS 1 (QL)




paroxetine hcl er TB24 1 (ST)

PAXIL SUSP 2

PAXIL CR TB24 GP (GP) (ST)

PERPHENAZINE/AMITRIPTYLINE TABS 1

phenelzine sulfate TABS 1

PROZAC CAPS GP


quetiapine fumarate TABS 1 (QL)

quetiapine fumarate TABS 1 (AG) (QL)

REMERON TABS GP

selegiline hcl * 1

SEROQUEL TABS GP (GP) (QL)

SEROQUEL TABS GP (AG) (QL)

sertraline hcl * 1

TOFRANIL TABS GP

tranylcypromine sulfate TABS 1

trazodone hcl TABS 1

venlafaxine hcl TABS 1

venlafaxine hcl er (150mg) TB24 1 (QL)

venlafaxine hcl er (150mg) CP24 1 (QL)

venlafaxine hcl er (37.5mg) CP24 1 (QL)

venlafaxine hcl er (37.5mg) TB24 1 (QL)



VIIBRYD TABS 3 (PA) (QL)

WELLBUTRIN TABS GP

WELLBUTRIN SR TB12 GP (QL)

WELLBUTRIN XL TB24 GP (QL)

ZOLOFT * GP


ALOXI SOLN MED (MB) (PA) (QL)

ANZEMET TABS 3 (PA) (QL)

ANZEMET SOLN MED (MB) (PA)

chlorpromazine hcl TABS 1

compro SUPP 1

EMEND SOLR MED (MB) (PA) (QL)

EMEND (0) CAPS 3 (PA) (QL)

EMEND (125MG) CAPS 3 (PA) (QL)



granisetron hcl TABS 1 (QL) (ST)

hydroxyzine hcl * 1

HYDROXYZINE PAMOATE CAPS 1

hydroxyzine pamoate CAPS 1

metoclopramide hcl * 1

ondansetron hcl TABS 1 (QL)

ondansetron odt TBDP 1 (QL)

perphenazine TABS 1

Antiemetics


phenadoz SUPP 1

prochlorperazine SUPP 1

prochlorperazine edisylate SOLN 1

prochlorperazine maleate TABS 1

promethazine hcl * 1

promethazine hcl plain SYRP 1

promethegan SUPP 1

REGLAN TABS GP

TIGAN CAPS GP

TRANSDERM-SCOP PT72 3

trimethobenzamide hcl CAPS 1

VISTARIL CAPS GP

ZOFRAN TABS GP (QL)

ZOFRAN ODT TBDP GP (QL)


BIO-STATIN CAPS 1

ciclopirox GEL 1

ciclopirox SUSP 1

ciclopirox nail lacquer SOLN 1 (QL)

ciclopirox olamine CREA 1

clotrimazole LOZG 1

clotrimazole SOLN 1

clotrimazole anti-fungal CREA 1

clotrimazole/betamethasone dipropionate * 1

DIFLUCAN * GP

econazole nitrate CREA 1

fluconazole * 1

GRIS-PEG TABS 3

griseofulvin microsize SUSP 1

ketoconazole TABS 1

ketoconazole * 1

LAMISIL TABS GP (QL)

LOPROX GEL GP

LOPROX SHAMPOO SHAM GP

LOTRISONE CREA GP

NIZORAL SHAM GP

nystatin TABS 1

nystatin SUSP 1

nystatin * 1

NYSTATIN VAGINAL TABS 1

nystatin/triamcinolone * 1

Antifungals


pedi-dri POWD 1

PENLAC NAIL LACQUER SOLN GP (QL)

TERAZOL 3 * GP

TERAZOL 7 CREA GP

terbinafine hcl TABS 1 (QL)

terconazole * 1

VFEND SUSR 3 (PA) (QL)

voriconazole TABS 3 (PA) (QL)


allopurinol TABS 1

COLCRYS TABS 2

probenecid TABS 1

probenecid/colchicine TABS 1

ULORIC TABS 3 (PA) (QL)

ZYLOPRIM TABS GP


AMERGE TABS GP (QL)

AXERT TABS 3 (QL)

butalbital/acetaminophen/caffeine TABS 1 (QL)

CAFERGOT TABS GP

D.H.E. 45 SOLN GP

DEPAKENE CAPS GP

DEPAKOTE TBEC GP

DEPAKOTE ER TB24 GP


dihydroergotamine mesylate SOLN 3

DIHYDROERGOTAMINE MESYLATE SOLN 3 (QL)




ESGIC * GP (QL)

ESGIC-PLUS * GP (QL)

ESGIC-PLUS TABS GP (QL)

FIORICET TABS GP (QL)

FROVA TABS 3 (QL)

IMITREX TABS GP (QL)

IMITREX SOLN GP (QL)

Antigout Agents

Antimigraine Agents


IMITREX STATDOSE REFILL SOCT GP (QL)

IMITREX STATDOSE SYSTEM SOAJ GP (QL)

isometheptene/dichloralphenazone/acetaminophen CAPS 1 Not covered on Commercial Federal

Employees Formulary

MAXALT TABS GP (GP) (QL)

MAXALT-MLT TBDP GP (GP) (QL)

MIGERGOT SUPP 1

MIGRANAL SOLN 3 (QL)

naratriptan hcl TABS 3 (QL)

RELPAX TABS 3 (QL)

rizatriptan benzoate TABS 1 (QL)

rizatriptan benzoate odt TBDP 1 (QL)

SUMATRIPTAN SOLN 1 (QL)

sumatriptan succinate TABS 1 (QL)

sumatriptan succinate * 1 (QL)

sumatriptan succinate refill SOCT 1 (QL)

TOPAMAX TABS GP

TOPAMAX SPRINKLE CPSP GP

topiramate * 1


zolmitriptan TABS 3 (QL)

ZOMIG TABS GP (GP) (QL)


MESTINON SYRP 3

pyridostigmine bromide TABS 1


DAPSONE TABS 2

ethambutol hcl TABS 1

ISONIAZID * 1

isoniazid * 1

MYCOBUTIN CAPS GP (GP)

PASER PACK 1

PRIFTIN TABS 3

pyrazinamide TABS 1

rifabutin CAPS 3

RIFADIN CAPS GP

rifampin CAPS 1

Antimyasthenic Agents

Antimycobacterials


TRECATOR TABS 3


ABRAXANE SUSR MED (MB) (PA) (SP)

AFINITOR TABS 4 (PA) (SP)

AFINITOR DISPERZ TBSO 4 (PA) (SP)

ALIMTA SOLR MED (PA)

ALKERAN TABS 2

anastrozole TABS 1

ARIMIDEX TABS GP

AROMASIN TABS GP

AVASTIN SOLN MED (MB) (PA)

azacitidine SUSR MED

BOSULIF TABS 4 (PA) (QL) (SP)

CAMPATH SOLN MED (MB) (PA)

capecitabine TABS 4 (PA) (SP)

CAPRELSA TABS 4 (PA)

COMETRIQ KIT 4 (PA)

CYCLOPHOSPHAMIDE TABS 1

CYRAMZA SOLN MED (MB) (PA)

EMCYT CAPS 3 (PA) (SP)

ERIVEDGE CAPS 4 (PA) (QL) (SP)

ERWINAZE SOLR MED (MB) (PA)

ETHYOL SOLR MED (MB) (PA)

ETOPOSIDE CAPS 3 (SP)

exemestane TABS 3

FARESTON TABS 3 (PA) (SP)

FEMARA TABS GP

GAZYVA SOLN MED (MB) (PA)

GILOTRIF TABS 4 (PA)

GLEEVEC TABS 4 (PA) (SP)

HEXALEN CAPS 4 (PA) (SP)

HYCAMTIN CAPS 4 (PA) (SP)

HYDREA CAPS GP

hydroxyurea CAPS 1

IMBRUVICA CAPS 4 (PA)

INLYTA TABS 4 (PA) (SP)

IRESSA TABS 4 (PA)

JAKAFI TABS 4 (PA) (SP)

KADCYLA SOLR MED (MB) (PA) (SP)

KYPROLIS SOLR MED (MB) (PA) (SP)

letrozole TABS 1

Antineoplastics


leucovorin calcium TABS 1

LEUCOVORIN CALCIUM TABS 1

LEUKERAN TABS 2 (PA) (SP)

LOMUSTINE CAPS 3 (PA) (SP)

MARQIBO SUSP MED (MB) (PA)

MATULANE CAPS 2 (PA) (SP)

MEKINIST TABS 4 (PA) (QL) (SP)

MENEST TABS 2

mercaptopurine TABS 1

MESNEX TABS 2

MYLERAN TABS 2 (PA) (SP)

NEXAVAR TABS 4 (PA) (SP)

PERJETA SOLN MED (PA) (SP)

POMALYST CAPS 4 (PA) (QL) (SP)

PURINETHOL TABS GP

REVLIMID CAPS 4 (PA) (SP)

RITUXAN CONC MED (MB) (PA)

SPRYCEL TABS 4 (PA) (SP)

STIVARGA TABS 4 (PA) (QL) (SP)

SUTENT CAPS 4 (PA) (SP)

SYLATRON KIT 4 (PA) (SP)

TABLOID TABS 3 (PA) (SP)

TAFINLAR CAPS 4 (PA) (QL) (SP)

tamoxifen citrate TABS 1

TARCEVA TABS 4 (PA) (SP)

TARGRETIN CAPS 4 (PA) (SP)

TASIGNA CAPS 4 (PA) (SP)

TEMODAR CAPS GP (GP) (PA) (SP)

temozolomide CAPS 4 (PA) (SP)

THALOMID CAPS 4 (PA)

TYKERB TABS 4 (PA) (SP)

VOTRIENT TABS 4 (PA) (SP)

XALKORI CAPS 4 (PA) (SP)

XELODA TABS GP (PA) (SP)

YERVOY SOLN MED (MB) (PA)

ZALTRAP SOLN MED (MB) (PA) (SP)

ZELBORAF TABS 4 (PA) (SP)

ZOLINZA CAPS 4 (PA) (SP)

ZYKADIA CAPS 4 (PA) (QL) (SP)

ZYTIGA TABS 4 (PA) (SP)


Antiparasitics


ALBENZA TABS 3

ARALEN TABS GP

atovaquone SUSP 1

BILTRICIDE TABS 3

chloroquine phosphate TABS 1

EURAX * 2

hydroxychloroquine sulfate TABS 1

lindane * 1

MEPRON SUSP GP (GP)

NEBUPENT SOLR 1

PENTAM 300 SOLR 4

permethrin CREA 1

PLAQUENIL TABS GP

PRIMAQUINE PHOSPHATE TABS 2

SKLICE LOTN 3 (ST)

STROMECTOL TABS 3 (QL)


amantadine hcl * 1

AMANTADINE HCL * 1

APOKYN SOLN 3 (PA) (SP)

benztropine mesylate * 1

bromocriptine mesylate * 1

carbidopa/levodopa TABS 1

carbidopa/levodopa er TBCR 1

carbidopa/levodopa odt TBDP 1

CARBIDOPA/LEVODOPA/ENTACAPONE TABS 3

COMTAN TABS 2

ELDEPRYL CAPS GP

EMSAM PT24 3 (PA) (QL)

MIRAPEX TABS GP

PARCOPA TBDP GP

PARLODEL * GP

pramipexole dihydrochloride TABS 1

REQUIP TABS GP

ropinirole hcl TABS 1

selegiline hcl * 1

SINEMET TABS GP

SINEMET CR TBCR GP

STALEVO 100 TABS GP (GP)



Antiparkinson Agents





TASMAR TABS 3

trihexyphenidyl hcl * 1






chlorpromazine hcl TABS 1

clozapine TABS 1

CLOZARIL TABS GP

compro SUPP 1

fluphenazine decanoate SOLN 1

fluphenazine hcl * 1

FLUPHENAZINE HCL * 1

GEODON CAPS GP (QL)

HALDOL SOLN GP

HALDOL DECANOATE 100 SOLN GP

HALDOL DECANOATE 50 SOLN GP

haloperidol TABS 1

haloperidol CONC 1

haloperidol decanoate SOLN 1

haloperidol lactate SOLN 1

loxapine CAPS GP

loxapine succinate CAPS 1

LOXITANE CAPS GP

olanzapine TABS 1 (QL)

olanzapine odt (10mg) TBDP 3 (PA) (QL)




ORAP TABS 3

perphenazine TABS 1

PERPHENAZINE/AMITRIPTYLINE TABS 1

prochlorperazine SUPP 1

prochlorperazine edisylate SOLN 1

prochlorperazine maleate TABS 1



Antipsychotics


RISPERDAL * GP

RISPERDAL CONSTA SUSR MED (ME) (SP)

RISPERDAL M-TAB TBDP GP (PA)



thioridazine hcl TABS 1

thiothixene CAPS 1

trifluoperazine hcl TABS 1

ziprasidone hcl CAPS 1 (QL)

ZYPREXA TABS GP (QL)

ZYPREXA ZYDIS TBDP GP (PA) (QL)


baclofen TABS 1

DANTRIUM CAPS GP

dantrolene sodium CAPS 1

DANTROLENE SODIUM CAPS 1

tizanidine hcl TABS 1

ZANAFLEX TABS GP


abacavir TABS 1 (QL)

abacavir sulfate/lamivudine/zidovudine TABS 1 (QL)

acyclovir * 1

acyclovir OINT 1 (QL)

amantadine hcl * 1

AMANTADINE HCL * 1

APTIVUS SOLN 2 (QL)

APTIVUS CAPS 2 (QL)

ATRIPLA TABS 2 (QL)

COMBIVIR TABS GP (GP) (QL)

COMPLERA TABS 4 (SP)

COPEGUS TABS GP (GP) (SP)

CRIXIVAN CAPS 2 (QL)

DENAVIR CREA 2

didanosine CPDR 1 (QL)

EDURANT TABS 4 (SP)

EMTRIVA CAPS 2 (QL)

EMTRIVA SOLN 2

Antispasticity Agents

Antivirals


EPIVIR SOLN 2 (QL) (SP)

EPIVIR HBV SOLN 2

EPIVIR HBV TABS GP

EPZICOM TABS 2 (QL)

famciclovir TABS 1

FAMVIR TABS GP

FUZEON SOLR 2 (QL)

INCIVEK TABS 4 (PA) (QL) (SP)

INFERGEN INJ 4 (SP)

INTELENCE TABS 2 (QL) (SP)

INTRON-A SOLN 4 (SP)

INTRON-A W/DILUENT SOLR 4 (SP)

INVIRASE * 2 (QL) (SP)

ISENTRESS * 2 (QL)

ISENTRESS TABS 2 (QL)

ISENTRESS (100MG) CHEW 2 (QL)

ISENTRESS (25MG) CHEW 2 (QL)

KALETRA TABS 2 (QL)

KALETRA SOLN 2

lamivudine TABS 1

lamivudine TABS 1 (QL)

lamivudine/zidovudine TABS 1 (QL) (SP)

LEXIVA * 2 (QL)

nevirapine TABS 1 (QL)

NEVIRAPINE SUSP 1 (QL)

nevirapine er TB24 1 (QL)

NORVIR * 2 (QL)

NORVIR SOLN 2 (QL)

PEG-INTRON KIT 4 (SP)

PEG-INTRON REDIPEN PAK 4 KIT 4 (SP)

PEGASYS * 4 (PA) (SP)

PREZISTA SUSP 2 (QL)

PREZISTA (150MG) TABS 2 (QL)





REBETOL CAPS GP (GP) (SP)

RELENZA DISKHALER AEPB 3 (QL)

RESCRIPTOR TABS 2 (QL)

RETROVIR SYRP GP (GP)

RETROVIR CAPS GP (GP) (QL)

REYATAZ CAPS 2 (QL)

ribavirin * 4 (SP)

rimantadine hcl TABS 1


SELZENTRY TABS 2 (QL)

stavudine CAPS 1 (QL)

stavudine SOLR 1 (QL)

STRIBILD TABS 4 (QL) (SP)

SUSTIVA * 2 (QL)

TAMIFLU CAPS 3 (QL)

TAMIFLU SUSR 3 (QL)

TIVICAY TABS 4 (QL) (SP)

trifluridine SOLN 1

TRIZIVIR TABS GP (QL)

TRUVADA TABS 2 (QL)

valacyclovir hcl TABS 1

VALCYTE TABS 4 (PA) (QL)

VALCYTE SOLR 4 (PA)

VALTREX TABS GP

VICTRELIS CAPS 4 (PA) (QL) (SP)

VIDEX EC CPDR GP (QL)

VIDEX PEDIATRIC SOLR 2 (QL)

VIRACEPT TABS 2 (QL)

VIRAMUNE * GP (QL)

VIRAMUNE XR (100MG) TB24 3 (QL) (GP)

VIRAMUNE XR (400MG) TB24 3 (QL) (GP)

VIREAD TABS 4 (QL)

VIROPTIC SOLN GP

ZERIT * GP (GP) (QL)

ZIAGEN SOLN 2 (QL)

zidovudine * 1 (QL)

zidovudine SYRP 1 (QL) (SP)

ZOVIRAX OINT GP (GP) (QL)

ZOVIRAX CREA 2

ZOVIRAX * GP


alprazolam (0.25mg) TABS 1 (QL)

alprazolam (0.5mg) TABS 1 (QL)

alprazolam (1mg) TABS 1 (QL)

alprazolam (2mg) TABS 1 (QL)

ALPRAZOLAM INTENSOL CONC 3 (QL)

ATIVAN TABS GP (GP) (QL)

buspirone hcl TABS 1

chlordiazepoxide hcl CAPS 1 (QL)

Anxiolytics


chlordiazepoxide hcl/clidinium bromide CAPS 1 Not covered on Commercial Federal

Employees Formulary

CHLORDIAZEPOXIDE/AMITRIPTYLINE TABS 1

clonazepam TABS 1 (QL)

clonazepam odt TBDP 1 (QL)




diazepam TABS 1 (QL)

doxepin hcl * 1

DOXEPIN HCL * 1




EFFEXOR XR CP24 GP (QL)

escitalopram oxalate SOLN 1 (QL)




hydroxyzine hcl * 1



KLONOPIN TABS GP (GP) (QL)

LEXAPRO * GP (GP) (QL)

LIBRAX CAPS GP (GP) Not covered on Commercial Federal

Employees Formulary

lorazepam * 1

lorazepam TABS 1 (QL)

meprobamate TABS 1

midazolam hcl SYRP 1

oxazepam CAPS 1 (QL)





paroxetine hcl er TB24 1 (ST)

PAXIL SUSP 2

PAXIL CR TB24 GP (GP) (ST)

sertraline hcl * 1

VALIUM TABS GP (GP) (QL)

venlafaxine hcl TABS 1



venlafaxine hcl er (37.5mg) TB24 1 (QL)

venlafaxine hcl er (37.5mg) CP24 1 (QL)




VISTARIL CAPS GP

XANAX (0.25MG) TABS GP (GP) (QL)

XANAX (0.5MG) TABS GP (GP) (QL)

XANAX (1MG) TABS GP (GP) (QL)

XANAX (2MG) TABS GP (GP) (QL)

ZOLOFT * GP






carbamazepine * 1

carbamazepine er * 1

CARBATROL CP12 GP

DEPAKENE CAPS GP

DEPAKOTE TBEC GP

DEPAKOTE ER TB24 GP





GEODON CAPS GP (QL)

LAMICTAL TABS GP

LAMICTAL CHEWABLE DISPERSIBLE CHEW GP

lamotrigine TABS 1

LITHIUM CARBONATE * 1

lithium carbonate * 1

lithium carbonate er TBCR 1

LITHIUM CITRATE SOLN 1

LITHOBID TBCR GP

olanzapine TABS 1 (QL)







RISPERDAL * GP

RISPERDAL CONSTA SUSR MED (ME) (SP)

RISPERDAL M-TAB TBDP GP (PA)

Bipolar Agents


risperidone * 1

risperidone odt TBDP 3 (PA)



TEGRETOL * GP

TEGRETOL-XR TB12 2


ziprasidone hcl CAPS 1 (QL)

ZYPREXA TABS GP (QL)

ZYPREXA ZYDIS TBDP GP (PA) (QL)


acarbose TABS 1

ACTOPLUS MET TABS GP (GP) (ST)

ACTOS TABS GP (GP) (ST)

AMARYL TABS GP

AVANDAMET TABS 2 (ST)

AVANDIA TABS 3 (ST)

BYDUREON PEN 3 (QL)

BYDUREON SUSR 3 (QL)

BYETTA (10MCG/0.04ML) SOPN 2 (QL) (ST)

BYETTA (5MCG/0.02ML) SOPN 2 (QL) (ST)

CHLORPROPAMIDE TABS 1

DIABETA TABS GP

DUETACT TABS GP (GP) (ST)

glimepiride TABS 1

glipizide TABS 1

glipizide er TB24 1

glipizide/metformin hcl TABS 1

GLUCAGEN SOLR 2

GLUCAGON EMERGENCY KIT KIT 2

GLUCOPHAGE TABS GP

GLUCOPHAGE XR TB24 GP

GLUCOTROL TABS GP

GLUCOTROL XL TB24 GP

GLUCOVANCE TABS GP (GP) (ST)

glyburide TABS 1

glyburide micronized TABS 1

glyburide/metformin hcl TABS 1 (ST)

HUMALOG SOLN 3

HUMALOG KWIKPEN SOPN 3

HUMALOG MIX 50/50 SUSP 3

Blood Glucose Regulators


HUMALOG MIX 75/25 SUSP 3

HUMULIN 70/30 SUSP 3

HUMULIN 70/30 KWIKPEN SUPN 3

HUMULIN 70/30 PEN SUPN 3

HUMULIN N SUSP 3

HUMULIN N KWIKPEN SUPN 3

HUMULIN N U-100 PEN SUPN 3

HUMULIN R SOLN 3

HUMULIN R U-500 (CONCENTRATED) SOLN 3

JANUMET TABS 2 (QL) (ST)

JANUMET XR (1000MG; 100MG) TB24 2 (QL) (ST)



JANUVIA TABS 2 (QL) (ST)

KOMBIGLYZE XR TB24 3 (PA)

LANTUS SOLN 2 (QL)

LANTUS SOLOSTAR SOPN 2 (QL)

LEVEMIR SOLN 2 (QL)

LEVEMIR FLEXPEN SOPN 2 (QL)

METAGLIP TABS GP

metformin hcl TABS 1

metformin hcl er TB24 1

nateglinide TABS 1

NOVOLIN 70/30 SUSP 2 (QL)

NOVOLIN N SUSP 2 (QL)

NOVOLIN R SOLN 2 (QL)

NOVOLOG SOLN 2 (QL)

NOVOLOG FLEXPEN SOPN 2 (QL)

NOVOLOG MIX 70/30 SUSP 2 (QL)

NOVOLOG MIX 70/30 PREFILLED FLEXPEN SUPN 2 (QL)

NOVOLOG PENFILL SOCT 2 (QL)

ONGLYZA TABS 3 (PA) (QL)

pioglitazone hcl TABS 1 (ST)

pioglitazone hcl-glimepiride TABS 1 (ST)

pioglitazone hcl/metformin hcl TABS 1 (ST)

PRANDIMET TABS 3 (ST)

PRANDIN TABS GP (GP)

PRECOSE TABS GP

repaglinide TABS 3

STARLIX TABS GP

SYMLINPEN 120 SOPN 3 (PA)

SYMLINPEN 60 SOPN 3 (PA)

tolazamide TABS 1

TOLAZAMIDE TABS 1

TOLBUTAMIDE TABS 1


VICTOZA SOPN 2 (QL) (ST)

WELCHOL * 2


AGGRENOX CP12 3

AGRYLIN CAPS GP

AMICAR * GP (GP)

aminocaproic acid * 1

anagrelide hydrochloride CAPS 1

ARANESP ALBUMIN FREE SOLN MED (PA)

ARANESP ALBUMIN FREE SOLN MED (PA) (SP)

ARIXTRA SOLN GP (GP) (PA)

BERINERT KIT MED (PA) (SP)

BRILINTA TABS 2 (PA) (QL)

cilostazol TABS 1

CINRYZE SOLR 4 (PA)

clopidogrel TABS 1 75 MG STRENGTH ONLY (QL)

COUMADIN TABS GP

dipyridamole TABS 1

EFFIENT TABS 3 (PA)

enoxaparin sodium (100mg/ml) SOLN 1 (QL)

enoxaparin sodium (300mg/3ml) SOLN 1 (QL)

EPOGEN SOLN 4 (PA) (SP)

fondaparinux sodium SOLN 4 (PA)

GRANIX SOSY 4 (PA) (SP)

HEPARIN LOCK FLUSH SOLN 1

heparin lock flush SOLN 1

heparin sodium SOLN 1

HEPARIN SODIUM SOLN 1

heparin sodium lock flush SOLN 1

heparin sodium lock flush KIT 1

heparin sodium/d5w SOLN 1

HEPARIN SODIUM/D5W SOLN 1

HEPARIN SODIUM/NACL 0.45% SOLN 1

heparin sodium/sodium chloride 0.9% premix SOLN 1

INJECTAFER SOLN MED (MB) (PA)

LOVENOX SOLN GP (QL)

NEULASTA SOLN 4 (PA) (SP)

NEUMEGA SOLR 4 (PA) (SP)

NEUPOGEN SOLN 4 (PA) (SP)

PERSANTINE TABS GP

PLAVIX TABS GP 75 MG STRENGTH ONLY (QL)

Blood Products/Modifiers/Volume


PLETAL TABS GP

PROCRIT SOLN 4 (PA) (SP)

SOLIRIS SOLN MED (MB) (PA) (SP)

tranexamic acid TABS 1 (QL)

warfarin sodium TABS 1

XARELTO TABS 3 10 MG STRENGTH ONLY (QL)


ACCUPRIL TABS GP

ACCURETIC TABS GP

acebutolol hcl CAPS 1

ACEON TABS GP

acetazolamide TABS 1

ACETAZOLAMIDE TABS 1

ADALAT CC TB24 GP

ADVICOR TB24 3 (ST)

afeditab cr TB24 1

ALDACTAZIDE TABS 2

ALDACTONE TABS GP

ALTACE CAPS GP

amiloride hcl TABS 1

amiloride/hydrochlorothiazide TABS 1

amiodarone hcl * 1

amlodipine besylate TABS 1

amlodipine besylate/atorvastatin calcium TABS 3 (QL)

amlodipine besylate/benazepril hcl CAPS 1

amlodipine besylate/benazepril hydrochloride CAPS 1

ATACAND TABS GP (GP)

ATACAND HCT TABS GP (GP)

atenolol TABS 1

atorvastatin calcium TABS 1 (QL)

AVALIDE TABS GP

AVAPRO TABS GP

benazepril hcl TABS 1

benazepril hcl/hydrochlorothiazide TABS 1

BENICAR TABS 3

BENICAR HCT TABS 3

BETAPACE TABS GP

BETAPACE AF TABS GP

betaxolol hcl TABS 1

bisoprolol fumarate TABS 1

bisoprolol fumarate/hydrochlorothiazide TABS 1

Cardiovascular Agents


bumetanide TABS 1

BYSTOLIC TABS 3

CADUET TABS GP (GP) (QL)

CALAN TABS GP

CALAN SR TBCR GP

candesartan cilexetil TABS 3

candesartan cilexetil/hydrochlorothiazide TABS 3

captopril TABS 1

CAPTOPRIL/HYDROCHLOROTHIAZIDE TABS 1

CARDENE SR CP12 3

CARDIZEM TABS GP

CARDIZEM CD CP24 GP

CARDIZEM LA TB24 GP

CARDURA TABS GP

cartia xt CP24 1

carvedilol TABS 1

CATAPRES TABS GP

CATAPRES-TTS-1 PTWK GP



CHLORTHALIDONE TABS 1

cholestyramine * 1

cholestyramine light * 1

clonidine hcl * 1

CORDARONE TABS GP

COREG TABS GP

CORGARD TABS GP

COZAAR TABS GP

CRESTOR TABS 2

DEMADEX TABS GP

DIBENZYLINE CAPS 3

digoxin TABS 1

DILACOR XR CP24 GP

DILATRATE SR CPCR 2

dilt-cd CP24 1

diltiazem cd CP24 1

diltiazem hcl * 1

diltiazem hcl er * 1

diltiazem hcl er CP24 1

diltiazem hcl er CP24 1

diltzac CP24 1

DIOVAN TABS 3

DIOVAN HCT TABS GP (GP)

disopyramide phosphate CAPS 1

DIURIL SUSP GP


doxazosin mesylate TABS 1

DUTOPROL TB24 2

DYAZIDE CAPS GP

DYRENIUM CAPS 2

EDECRIN TABS 2

enalapril maleate TABS 1

enalapril maleate/hydrochlorothiazide TABS 1

EPANED SOLR 3 (AG) (QL)

felodipine er TB24 1

fenofibrate TABS 1

fenofibrate micronized CAPS 1

FIRAZYR SOLN 4 (PA) (SP)

flecainide acetate TABS 1

fluvastatin CAPS 3

fosinopril sodium TABS 1

fosinopril sodium/hydrochlorothiazide TABS 1

furosemide * 1

FUROSEMIDE * 1

gemfibrozil TABS 1

guanfacine hcl TABS 1

hydralazine hcl * 1

hydrochlorothiazide * 1

HYZAAR TABS GP

IMDUR TB24 GP

indapamide TABS 1

INDERAL LA CP24 GP

irbesartan TABS 1 (ST)

irbesartan/hydrochlorothiazide TABS 1 (ST)

isosorbide dinitrate * 1

ISOSORBIDE DINITRATE * 1

isosorbide dinitrate er TBCR 1

isosorbide mononitrate TABS 1

isosorbide mononitrate er TB24 1

ISRADIPINE CAPS 1

KERLONE TABS GP

labetalol hcl * 1

LANOXIN TABS GP

LASIX TABS GP

LESCOL CAPS GP

LESCOL XL TB24 3

LEVATOL TABS 3

LIPITOR TABS GP (QL)

lisinopril TABS 1

lisinopril/hydrochlorothiazide TABS 1

LOFIBRA TABS GP


LOFIBRA CAPS GP

LOPID TABS GP

LOPRESSOR TABS GP

LOPRESSOR HCT TABS GP

losartan potassium TABS 1

losartan potassium/hydrochlorothiazide TABS 1

LOTENSIN TABS GP

LOTENSIN HCT TABS GP

LOTREL CAPS GP

lovastatin TABS 1

LOVAZA CAPS GP (GP)

MAVIK TABS GP

MAXZIDE TABS GP

MAXZIDE-25 TABS GP

METHYCLOTHIAZIDE TABS 1

methyldopa TABS 1

METHYLDOPATE HCL SOLN 1

metolazone TABS 1

metoprolol succinate er TB24 1

metoprolol tartrate TABS 1

metoprolol/hydrochlorothiazide TABS 1

MEVACOR TABS GP

mexiletine hcl CAPS 1

MICROZIDE CAPS GP

midodrine hcl TABS 1

minitran PT24 1

minoxidil TABS 1

moexipril hcl TABS 1

moexipril/hydrochlorothiazide TABS 1

MULTAQ TABS 3 (PA) (QL)

nadolol TABS 1

niacin er TBCR 1

NIASPAN TBCR GP

nicardipine hcl CAPS 1

nifediac cc TB24 1

nifedical xl TB24 1

nifedipine CAPS 1

nifedipine er TB24 1

nimodipine CAPS 1

NITRO-BID OINT 2

NITRO-DUR PT24 GP

nitroglycerin er CPCR 1

nitroglycerin transdermal PT24 1

NITROSTAT SUBL 2

NORPACE CAPS GP


NORVASC TABS GP

omega-3-acid ethyl esters CAPS 3 (QL)

pacerone TABS GP

perindopril erbumine TABS 3

pindolol TABS 1

PRAVACHOL TABS GP

pravastatin sodium TABS 1

prazosin hcl CAPS 1

prevalite * 1

PRINIVIL TABS GP

PROCAINAMIDE HCL SOLN 1

PROCARDIA CAPS GP

PROCARDIA XL TB24 GP

propafenone hcl TABS 1

PROPRANOLOL HCL * 1

propranolol hcl * 1

propranolol hcl er CP24 1

PROPRANOLOL/HYDROCHLOROTHIAZIDE TABS 1

QUESTRAN * GP

quinapril hcl TABS 1

quinapril/hydrochlorothiazide TABS 1

QUINIDINE GLUCONATE SOLN 1

quinidine gluconate cr TBCR 1

quinidine sulfate TABS 1

QUINIDINE SULFATE ER TBCR 1

ramipril CAPS 1

RANEXA TB12 3 (ST)

RESERPINE TABS 1

RYTHMOL TABS GP

SIMCOR TB24 3 (ST)

simvastatin TABS 1

sotalol hcl TABS 1

sotalol hcl (af) TABS 1

spironolactone TABS 1

spironolactone/hydrochlorothiazide TABS 1

taztia xt CP24 1

TENEX TABS GP

TENORETIC 100 TABS GP

TENORETIC 50 TABS GP

TENORMIN TABS GP

terazosin hcl CAPS 1

TIAZAC CP24 GP

TIKOSYN CAPS 3

TIMOLOL MALEATE TABS 1

TOPROL XL TB24 GP


torsemide TABS 1

TRANDATE TABS GP

trandolapril TABS 1

triamterene/hydrochlorothiazide * 1

UNIRETIC TABS GP

UNIVASC TABS GP

valsartan/hydrochlorothiazide TABS 1

VASCEPA CAPS 3 (QL)

VASERETIC TABS GP

VASOTEC TABS GP

verapamil hcl TABS 1

VERAPAMIL HCL TABS 1

verapamil hcl er * 1

verapamil hcl sr CP24 1

VERELAN CP24 GP

VERELAN PM CP24 GP

VYTORIN TABS 3

WELCHOL * 2

ZAROXOLYN TABS GP

ZEBETA TABS GP

ZESTORETIC TABS GP

ZESTRIL TABS GP

ZETIA TABS 2

ZIAC TABS GP

ZOCOR TABS GP


ADDERALL TABS GP (QL)

ADDERALL XR (1.25MG; 1.25MG; 1.25MG; 1.25MG) CP24 GP (QL)



ADDERALL XR (5MG; 5MG; 5MG; 5MG) CP24 GP (QL)



ADIPEX-P CAPS GP

amphetamine/dextroamphetamine TABS 1 (QL)

amphetamine/dextroamphetamine (1.25mg; 1.25mg;

1.25mg; 1.25mg)

CP24 1 (QL)

amphetamine/dextroamphetamine (2.5mg; 2.5mg; 2.5mg;

2.5mg)

CP24 1 (QL)


3.75mg; 3.75mg)

CP24 1 (QL)

amphetamine/dextroamphetamine (5mg; 5mg; 5mg; 5mg) CP24 1 (QL)

Central Nervous System Agents



6.25mg; 6.25mg)

CP24 1 (QL)

amphetamine/dextroamphetamine (7.5mg; 7.5mg; 7.5mg;

7.5mg)

CP24 1 (QL)

AMPYRA TB12 4 (PA) (QL) (SP)

AUBAGIO TABS 4 (PA) (QL) (SP)

AVONEX KIT 4 (SP)

butalbital/acetaminophen/caffeine/codeine CAPS 1 (QL)

butalbital/asa/caffeine CAPS 1 (QL)

BUTALBITAL/ASPIRIN/CAFFEINE TABS 1 (QL)

butalbital/aspirin/caffeine/codeine CAPS 1 (QL)

CAFCIT SOLN GP

caffeine citrate SOLN 1

CONCERTA TBCR GP (QL)

COPAXONE KIT 4 (SP)




DEXEDRINE CP24 GP (QL)

dextroamphetamine sulfate TABS 1 (QL)

dextroamphetamine sulfate er CP24 1 (QL)




EXTAVIA KIT 4 (PA) (SP)

FIORICET/CODEINE CAPS GP (QL)

FIORINAL CAPS GP (QL)

FIORINAL/CODEINE #3 CAPS GP (QL)









METADATE CD CPCR GP (GP) (QL)

metadate er TBCR 1 (QL)

methylphenidate hcl TABS 1 (QL)

methylphenidate hcl cd CPCR 1 (QL)

methylphenidate hcl er TBCR 1 (QL)

METHYLPHENIDATE HCL ER TBCR 1 (QL)

phentermine hcl CAPS 3 (PA)

REBIF SOLN 4 (PA) (SP)

REBIF TITRATION PACK SOLN 4 (PA) (SP)

RILUTEK TABS GP (GP)


riluzole TABS 4

RITALIN TABS GP (QL)

RITALIN SR TBCR GP (QL)

STRATTERA CAPS 3 (ST)

TYSABRI CONC MED (MB) (PA)

VYVANSE CAPS 3 (QL)

zebutal CAPS 1 (QL)


chlorhexidine gluconate SOLN 1

oralone PSTE 1 (QL)

periogard SOLN 1

pilocarpine hcl TABS 1 (QL)

pilocarpine hydrochloride TABS 1 (QL)

SALAGEN TABS GP (QL)

triamcinolone in orabase PSTE 1 (QL)


ACLOVATE CREA GP

ACZONE GEL 3 (PA)

adapalene * 1 (AG)

AKNE-MYCIN OINT 2

alclometasone dipropionate * 1

ALDARA CREA GP (QL)

AMCINONIDE * 1

amcinonide * 1

amnesteem CAPS 1 (QL)

AZELEX CREA 2

BENZACLIN GEL GP (GP)

BENZAMYCIN GEL GP (GP)

betamethasone dipropionate * 1

betamethasone valerate * 1

calcipotriene * 1

calcipotriene OINT 2

calcitrene OINT 2

CHLORHEXIDINE GLUCONATE SOLN 1

CLARAVIS CAPS 1 (QL)

claravis CAPS 1 (QL)

CLEOCIN-T * GP

Dental and Oral Agents

Dermatological Agents


CLINDAGEL GEL GP

clindamax * 1

clindamycin phosphate * 1

clindamycin/benzoyl peroxide GEL 3 1.2%/5%

clindamycin/benzoyl peroxide GEL 3 1%/5%

clobetasol propionate * 1 CREA, GEL, OINT, SOLN

clobetasol propionate emollient CREA 1 CREA, GEL, OINT, SOLN


cormax scalp application SOLN 1

CORTIFOAM FOAM 3

CORTISPORIN CREA 1

CUTIVATE * GP

DERMA-SMOOTHE/FS SCALP OIL GP

desonide * 1

DESOWEN * GP

DIFFERIN * GP (GP) (AG)

DOVONEX CREA GP (GP)

DUAC GEL GP (GP)

EFUDEX CREA GP

ELIDEL CREA 3 (ST) (QL)

ELOCON * GP

erythromycin * 1

erythromycin/benzoyl peroxide GEL 1

FINACEA GEL 2

fluocinolone acetonide * 1

fluocinolone acetonide OIL 1

fluocinolone acetonide body OIL 1

fluocinolone acetonide scalp OIL 1

fluocinonide * 1

fluorouracil * 1

fluticasone propionate * 1

halobetasol propionate * 1

hydrocortisone * 1

hydrocortisone acetate/pramoxine CREA 1

hydrocortisone butyrate * 1

hydrocortisone valerate * 1

imiquimod CREA 3 (QL)

lanacort 10 CREA 1

lidocaine hcl/hydrocortisone acetate CREA 1

LOCOID * GP

LOTRISONE CREA GP

mometasone furoate * 1

myorisan CAPS 1 (QL)

podofilox SOLN 1

prascion fc PADS 1


proctocream hc CREA 1

proctosol hc CREA 1

PROTOPIC OINT 3 (ST) (QL)

REGRANEX GEL 3

RETIN-A * GP (QL)

SODIUM SULFACETAMIDE/SULFUR SUSP 2

sodium sulfacetamide/sulfur * 1

sss 10%-5% CREA 1

sulfacetamide sodium LOTN 3

sulfacetamide sodium/sulfur cleanser EMUL 1

TAZORAC CREA 3 (QL) (ST)

TAZORAC GEL 3 (QL) (ST)

TEMOVATE * GP

TEMOVATE E CREA GP (GP)

TOPICORT * GP

tretinoin * 1 (AG)

TRIAMCINOLONE ACETONIDE * 1

triamcinolone acetonide * 1

ULTRAVATE * GP

VOLTAREN GEL 3 (QL) (ST)

WESTCORT OINT GP


CREON (120000UNIT; 24000UNIT; 76000UNIT) CPEP 2





PANCREAZE CPEP 2


ACIPHEX TBEC GP (QL)

ACTIGALL CAPS GP

AMITIZA CAPS 3 (QL) (ST)

ANASPAZ TBDP GP



AXID * GP

belladonna alkaloids/phenobarbital TABS 1

BENTYL * GP

CARAFATE SUSP 2

chlordiazepoxide hcl/clidinium bromide CAPS 1 Not covered on Commercial Federal

Employees Formulary

Enzyme Replacement/Modifiers

Gastrointestinal Agents


cimetidine TABS 1

cimetidine hcl SOLN 1

CYTOTEC TABS GP


DICYCLOMINE HCL * 1

dicyclomine hcl * 1

DIPHENOXYLATE/ATROPINE * 1

diphenoxylate/atropine * 1

DONNATAL ELIX GP Not covered on Commercial Federal

Employees Formulary

DONNATAL TABS GP

famotidine * 1

glycopyrrolate * 1

GOLYTELY SOLR GP

GOLYTELY SOLR GP

HALFLYTELY BOWEL PREP/FLAVOR PACKS KIT 3

HELIDAC MISC 3

hydrocortisone acetate SUPP 1

hyoscyamine sulfate * 1

hyoscyamine sulfate er TB12 1

ISOPTO HYOSCINE SOLN 2

lactulose SOLN 1

lactulose SOLN 1

lansoprazole CPDR 1 (QL)

LEVBID TB12 GP

LEVSIN TABS GP

LEVSIN/SL SUBL GP

LIBRAX CAPS GP (GP) Not covered on Commercial Federal

Employees Formulary

LINZESS CAPS 3 (PA) (QL)

LOMOTIL TABS GP

LOTRONEX TABS 4

metoclopramide hcl * 1

misoprostol TABS 1

nizatidine * 1

nulev TBDP 1

NULYTELY/FLAVOR PACKS SOLR GP

omeprazole CPDR 1 (QL)

pantoprazole sodium TBEC 1 (QL)

peg 3350/electrolytes SOLR 1 (QL)

peg-3350/electrolytes SOLR 1 (QL)

polyethylene glycol 3350 POWD 1

PREVACID CPDR GP (QL)

PREVACID SOLUTAB TBDP 3 (PA)

PRILOSEC CPDR GP (QL)

PROPANTHELINE BROMIDE TABS 1


PROTONIX TBEC GP

rabeprazole sodium TBEC 1 (ST) (QL)

ranitidine hcl * 1

REGLAN TABS GP

ROBINUL * GP (GP)

ROBINUL FORTE TABS GP (GP)

sucralfate TABS 1

URSO 250 TABS GP

URSO FORTE TABS GP

ursodiol * 1

XIFAXAN TABS 4 (PA) (QL)


alfuzosin hcl er TB24 3

AVODART CAPS 3 (ST)

bethanechol chloride TABS 1

CARDURA TABS GP

CUPRIMINE CAPS 2

DEPEN TITRATABS TABS 2

DETROL TABS GP (GP)

DETROL LA CP24 GP

DETROL LA CP24 GP (GP)

DITROPAN XL TB24 GP

doxazosin mesylate TABS 1

ENABLEX TB24 3 (ST)

finasteride TABS 1

flavoxate hcl TABS 1

FLOMAX CAPS GP

oxybutynin chloride * 1

oxybutynin chloride er TB24 1

phenazopyridine hcl TABS 1

prazosin hcl CAPS 1

PROSCAR TABS GP

RENAGEL TABS 2

RENVELA TABS GP

SANCTURA TABS GP (GP) (QL)

SEVELAMER CARBONATE TABS 1

tamsulosin hcl CAPS 1

terazosin hcl CAPS 1

tolterodine tartrate TABS 1

tolterodine tartrate er CP24 1

trospium chloride TABS 3 (ST)

Genitourinary Agents


URECHOLINE TABS GP

URELIEF PLUS TABS 1

UROXATRAL TB24 GP

VESICARE TABS 2


A-HYDROCORT SOLR 1

ACLOVATE CREA GP

alclometasone dipropionate * 1

AMCINONIDE * 1

amcinonide * 1

augmented betamethasone dipropionate * 1

betamethasone dipropionate * 1

betamethasone valerate * 1

budesonide CP24 3

clobetasol propionate * 1 CREA, GEL, OINT, SOLN

clobetasol propionate emollient CREA 1 CREA, GEL, OINT, SOLN


cormax scalp application SOLN 1

CORTEF TABS GP

CORTENEMA ENEM GP

CORTIFOAM FOAM 3

CORTISONE ACETATE TABS 1

CUTIVATE * GP

desonide * 1

DESOWEN * GP

DEXAMETHASONE * 1

dexamethasone * 1

DEXAMETHASONE INTENSOL CONC 1

DEXPAK 10 DAY TABS 1


DEXPAK 6 DAY TABS 1

DIPROLENE * GP

DIPROLENE AF CREA GP

ELOCON * GP

ENTOCORT EC CP24 GP

fludrocortisone acetate TABS 1

fluocinolone acetonide OIL 1

fluocinolone acetonide * 1

fluocinolone acetonide body OIL 1

fluocinolone acetonide scalp OIL 1

fluocinonide * 1

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)


fluticasone propionate * 1

halobetasol propionate * 1

hydrocortisone ENEM 1

hydrocortisone TABS 1

hydrocortisone * 1

hydrocortisone acetate SUPP 1

hydrocortisone acetate/pramoxine CREA 1

hydrocortisone butyrate * 1

hydrocortisone valerate * 1

KENALOG AERS 2

lanacort 10 CREA 1

lidocaine hcl/hydrocortisone acetate CREA 1

LOCOID * GP

LOTRISONE CREA GP

MEDROL TABS GP

methylprednisolone TABS 1

methylprednisolone dose pack TABS 1

mometasone furoate * 1

ORAPRED SOLN GP

prednisolone SOLN 1

prednisolone sodium phosphate SOLN 1

prednisone * 1

PREDNISONE * 1

PRELONE SYRP GP

proctocream hc CREA 1

proctosol hc CREA 1

SOLU-CORTEF SOLR GP (GP)

TEMOVATE * GP

TEMOVATE E CREA GP (GP)

TOPICORT * GP

triamcinolone acetonide * 1

TRIAMCINOLONE ACETONIDE * 1

ULTRAVATE * GP

WESTCORT OINT GP


DDAVP SOLN GP

DDAVP TABS GP

desmopressin acetate TABS 1

desmopressin acetate SOLN 1



Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)


INCRELEX SOLN 4 (PA) (SP)

minirin SOLN 1

OMNITROPE * 4 (PA) (SP)


CYTOTEC TABS GP

misoprostol TABS 1

PREPIDIL GEL 3


ACTIVELLA TABS 2

ALORA PTTW 2 (QL)

altavera TABS 1

ANDRODERM (2MG/24HR) PT24 3 (PA) (QL)

ANDRODERM (4MG/24HR) PT24 3 (PA) (QL)

ANDROGEL (20.25MG/1.25GM) GEL 2 (PA) (QL)

ANDROGEL (25MG/2.5GM) GEL 2 (PA) (QL)

ANDROGEL (40.5MG/2.5GM) GEL 2 (PA) (QL)

ANDROGEL (50MG/5GM) GEL 2 (PA) (QL)

ANDROGEL PUMP (1%) GEL 2 (PA) (QL)

ANDROGEL PUMP (1.62%) GEL 2 (PA) (QL)

ANDROXY TABS 3 (PA)

apri TABS 1

aranelle TABS 1

aviane TABS 1

AYGESTIN TABS GP

azurette TABS 1

balziva TABS 1

BEYAZ TABS 3

BREVICON-28 TABS GP

briellyn TABS 1

camila TABS Zero

Copayment

COVERED UNDER PPACA

caziant TABS 1

CENESTIN TABS 3

cesia TABS 1

CLIMARA PTWK GP

CLOMID TABS GP

clomiphene citrate TABS 1

Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)


COMBIPATCH PTTW 2 (ST)

cryselle-28 TABS 1

cyclafem 1/35 TABS Zero

Copayment

COVERED UNDER PPACA

cyclafem 7/7/7 TABS Zero

Copayment

COVERED UNDER PPACA

CYCLESSA TABS GP

danazol CAPS 1

DELATESTRYL OIL GP (GP) (PA)

DEPO-PROVERA CONTRACEPTIVE SUSP GP

DEPO-TESTOSTERONE OIL GP (GP) (PA)

DESOGEN TABS GP

DIVIGEL GEL 2

drospirenone/ethinyl estradiol TABS 1

emoquette TABS Zero

Copayment

COVERED UNDER PPACA

enpresse-28 TABS 1

errin TABS Zero

Copayment

COVERED UNDER PPACA

ESTRACE CREA 2

ESTRACE TABS GP

estradiol * 1

estradiol/norethindrone acetate TABS 1

ESTRASORB EMUL 3

ESTRING RING 3

ESTROGEL GEL 3

ESTROPIPATE TABS 1

estropipate TABS 1

ESTROSTEP FE TABS GP

EVAMIST SOLN 3

EVISTA TABS GP

FEMHRT LOW DOSE TABS 2

FEMRING RING 3

FORTESTA GEL 3 (PA) (QL)

gildagia TABS Zero

Copayment

COVERED UNDER PPACA

gildess 1.5/30 TABS 1

gildess 1/20 TABS 1

gildess fe 1.5/30 TABS Zero

Copayment

COVERED UNDER PPACA

gildess fe 1/20 TABS Zero

Copayment

COVERED UNDER PPACA

heather TABS Zero

Copayment

COVERED UNDER PPACA

JINTELI TABS 1

jolivette TABS Zero

Copayment

COVERED UNDER PPACA

junel 1.5/30 TABS 1

junel 1/20 TABS 1

junel fe 1.5/30 TABS 1


junel fe 1/20 TABS 1

kariva TABS 1

kelnor 1/35 TABS 1

leena TABS 1

lessina TABS 1

levonorgestrel TABS 1 $0.00 copay

levora 0.15/30-28 TABS 1

LOESTRIN 1.5/30-21 TABS GP

LOESTRIN 1/20-21 TABS GP

LOESTRIN FE 1.5/30 TABS GP

LOESTRIN FE 1/20 TABS GP

low-ogestrel TABS 1

lutera TABS 1

medroxyprogesterone acetate SUSP 1

medroxyprogesterone acetate TABS 1

MEGACE ES SUSP 2 (PA)

megestrol acetate * 1

MENEST TABS 2

MENOSTAR PTWK 2

methyltestosterone/esterified estrogens hs TABS 1

microgestin 1.5/30 TABS 1

microgestin 1/20 TABS 1

microgestin fe TABS 1

microgestin fe 1.5/30 TABS 1

mimvey TABS 1

MIRCETTE TABS GP

MIRENA IUD MED

MODICON TABS GP

mononessa TABS 1

myzilra TABS Zero

Copayment

COVERED UNDER PPACA

necon 0.5/35-28 TABS 1

necon 1/35 TABS 1

NECON 1/50-28 TABS 2

NECON 10/11-28 TABS 2

necon 7/7/7 TABS 1

NEXPLANON IMPL MED

next choice one dose TABS 1 (QL)

NOR-QD TABS GP

nora-be TABS Zero

Copayment

COVERED UNDER PPACA

NORDETTE-28 TABS GP

norethindrone TABS Zero

Copayment

COVERED UNDER PPACA

norethindrone acetate TABS 1

NORINYL 1+35 TABS GP

nortrel 0.5/35 (28) TABS 1


nortrel 1/35 TABS 1

nortrel 7/7/7 TABS 1

NUVARING RING 2

ocella TABS 1

OGESTREL TABS 2

orsythia TABS Zero

Copayment

COVERED UNDER PPACA

ORTHO EVRA PTWK GP (GP)

ORTHO MICRONOR TABS GP

ORTHO TRI-CYCLEN TABS GP

ORTHO-CEPT TABS GP

ORTHO-CYCLEN TABS GP

ORTHO-NOVUM 1/35 TABS GP

ORTHO-NOVUM 7/7/7 TABS GP

OVCON-35 TABS GP

pirmella 1/35 TABS 1

pirmella 7/7/7 TABS 1

portia-28 TABS 1

PREFEST TABS 2

PREMARIN TABS 2

PREMARIN CREA 2

PREMPHASE TABS 2

PREMPRO TABS 2

previfem TABS Zero

Copayment

COVERED UNDER PPACA

progesterone CAPS 1

PROMETRIUM CAPS GP

PROVERA TABS GP

raloxifene hydrochloride TABS 1

reclipsen TABS 1

solia TABS 1

sprintec 28 TABS 1

sronyx TABS 1

syeda TABS 1

TESTIM GEL 3 (PA) (QL)

TESTOPEL PLLT MED (PA) (QL)

TESTOSTERONE GEL 3 (PA) (QL)

testosterone cypionate OIL 1 (PA)

testosterone enanthate OIL 1 (PA)

tilia fe TABS 1

tri-legest fe TABS 1

tri-linyah TABS 1

TRI-NORINYL 28 TABS GP

tri-previfem TABS Zero

Copayment

COVERED UNDER PPACA

tri-sprintec TABS 1


trinessa TABS 1

trivora-28 TABS 1

VAGIFEM (10MCG) TABS 2 (QL)

VAGIFEM (10MCG) TABS 2 (QL)

velivet TABS 1

VIVELLE-DOT PTTW 2 (QL)

xulane PTWK 3 (QL)

YASMIN 28 TABS GP

zarah TABS 1

zenchent TABS 1

zovia 1/35e TABS 1

ZOVIA 1/50E TABS 1


CYTOMEL TABS GP

levothyroxine sodium TABS 1

levoxyl TABS 1

liothyronine sodium TABS 1

np thyroid 30 TABS 1



WESTHROID TABS 2


LYSODREN TABS 4


SENSIPAR TABS 3 (PA)


bromocriptine mesylate * 1

cabergoline TABS 1

ELIGARD KIT MED (SP)

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)

Hormonal Agents, Suppressant (Adrenal)

Hormonal Agents, Suppressant (Parathyroid)

Hormonal Agents, Suppressant (Pituitary)





leuprolide acetate KIT 4

LUPRON DEPOT KIT 4

LUPRON DEPOT KIT 4

LUPRON DEPOT KIT 4

LUPRON DEPOT KIT 4

LUPRON DEPOT-PED KIT 4

PARLODEL * GP

SANDOSTATIN SOLN 4 (SP)

SANDOSTATIN LAR DEPOT KIT 4 (SP)

ZOLADEX IMPL MED


AVODART CAPS 3 (ST)

bicalutamide TABS 1

CASODEX TABS GP

finasteride TABS 1

flutamide CAPS 1

PROSCAR TABS GP

XTANDI CAPS 4 (PA) (QL) (SP)


methimazole TABS 1

propylthiouracil TABS 1

TAPAZOLE TABS GP


ACTEMRA * 4 (PA) (SP)

ACTIMMUNE SOLN MED (SP)

ARAVA TABS GP

AVONEX KIT 4 (SP)

azathioprine TABS 1

BENLYSTA SOLR MED (MB) (PA)

BIVIGAM SOLN MED (PA)

Hormonal Agents, Suppressant (Thyroid)

Hormonal Agents, Suppressant (Sex Hormones/Modifiers)

Immunological Agents


CARIMUNE NANOFILTERED SOLR 4

CELLCEPT * GP

CUPRIMINE CAPS 2

cyclosporine CAPS 1

cyclosporine modified * 1

CYCLOSPORINE MODIFIED * 1

CYTOGAM INJ MED (MB) (PA)


ELIDEL CREA 3 (ST) (QL)

ENBREL * 4 (PA) (SP)

EXTAVIA KIT 4 (PA) (SP)

FLEBOGAMMA DIF SOLN 4

GAMASTAN S/D INJ 4

GAMMAGARD LIQUID SOLN 4

GAMMAGARD S/D SOLR 4

GAMMAGARD S/D IGA LESS THAN 1MCG/ML SOLR 4

GAMMAPLEX SOLN 4

GAMUNEX SOLN 4 (PA)

GAMUNEX-C SOLN 4 (PA)

gengraf * 2

hecoria CAPS 1

HEPAGAM B SOLN MED (MB) (PA)

HIZENTRA SOLN 4 (PA) (SP)

HUMIRA KIT 4 (PA) (SP)

IMURAN TABS GP

leflunomide TABS 1

mercaptopurine TABS 1

methotrexate TABS 1

methotrexate sodium * 1

mycophenolate mofetil * 1

NEORAL * GP

OCTAGAM SOLN MED (PA)

ORENCIA * 4 (PA) (SP)

PRIVIGEN SOLN 4 (PA)

PROGRAF CAPS GP

PROTOPIC OINT 3 (ST) (QL)

PROVENGE SUSP MED (MB) (PA)

PURINETHOL TABS GP

RAPAMUNE * 3

REBIF SOLN 4 (PA) (SP)

REBIF TITRATION PACK SOLN 4 (PA) (SP)

REMICADE SOLR MED (MB) (PA) (SP)

RIDAURA CAPS 2

SANDIMMUNE SOLN 2

sirolimus TABS 3


tacrolimus CAPS 1

TREXALL TABS 2

TYSABRI CONC MED (MB) (PA)

XELJANZ TABS 4 (PA) (QL) (SP)

ZOSTAVAX SOLR 2 (AG)


A-HYDROCORT SOLR 1

APRISO CP24 2 (QL) (ST)

AZULFIDINE TABS GP

AZULFIDINE EN-TABS TBEC GP

balsalazide disodium CAPS 1

budesonide CP24 3

CANASA SUPP 2

COLAZAL CAPS GP

CORTEF TABS GP

CORTENEMA ENEM GP

CORTISONE ACETATE TABS 1

DELZICOL CPDR 3 (ST)

dexamethasone * 1

DEXAMETHASONE * 1

DEXAMETHASONE INTENSOL CONC 1



DEXPAK 6 DAY TABS 1

ENTOCORT EC CP24 GP

hydrocortisone ENEM 1

hydrocortisone TABS 1

MEDROL TABS GP

mesalamine ENEM 1

methylprednisolone TABS 1

ORAPRED SOLN GP

PENTASA CPCR 3 (ST)

prednisolone SOLN 1

prednisolone sodium phosphate SOLN 1

PREDNISONE * 1

prednisone * 1

PRELONE SYRP GP

ROWASA KIT GP

SOLU-CORTEF SOLR GP (GP)

sulfasalazine * 1

Inflammatory Bowel Disease Agents



ACTONEL (150MG) TABS 3 (QL)




alendronate sodium TABS 1

ALENDRONATE SODIUM TABS 1

ATELVIA TBEC 3 (QL)

BONIVA TABS GP (GP) (QL) (ST)

calcitonin-salmon SOLN 1

calcitriol CAPS 1

DIDRONEL TABS GP

doxercalciferol CAPS 3

ETIDRONATE DISODIUM TABS 1

FORTEO SOLN 4 (PA) (SP)

FOSAMAX TABS GP

FOSAMAX PLUS D TABS 3

HECTOROL CAPS GP (GP)

ibandronate sodium TABS 3 (QL) (ST)

MIACALCIN (200UNIT/ACT) SOLN GP

MIACALCIN (200UNIT/ML) SOLN 2

PROLIA SOLN MED (PA) (SP)

risedronate sodium TABS 3 (QL)

ROCALTROL CAPS GP

XGEVA SOLN MED (MB) (PA) (SP)

zoledronic acid * MED (MB) (PA) (SP)


ACCU-CHEK ACTIVE STRIPS STRP 1 (QL)

ACCU-CHEK AVIVA PLUS STRP 1 (QL)

ACCU-CHEK COMFORT CURVE TEST STRIPS STRP 1 (QL)

ACCU-CHEK COMPACT PLUS STRP 1 (QL)

ACCU-CHEK SMARTVIEW STRIPS STRP 1 (QL)

ASSESS PEAK FLOW METER LOW RANGE DEVI 2

BD INSULIN SYRINGES MISC 1

BD PEN NEEDLES MISC 1

BOTOX SOLR MED (MB) (PA)

EUFLEXXA SOLN MED (QL)

KALBITOR SOLN MED (MB) (PA)

Metabolic Bone Disease Agents

Miscellaneous Therapeutic Agents


methylergonovine maleate * 2

NOVOFINE PEN NEEDLES MISC 1

NOVOTWIST PEN NEEDLES MISC 1

SYNVISC SOSY MED (QL)

SYNVISC ONE SOSY MED (QL)


ACETAZOLAMIDE TABS 1

acetazolamide TABS 1

acetazolamide er CP12 1

ACULAR SOLN GP

ACULAR LS SOLN GP

ALCAINE SOLN GP

ALOCRIL SOLN 3

ALOMIDE SOLN 2

ALPHAGAN P (0.1%) SOLN 2

ALPHAGAN P (0.15%) SOLN GP

ALREX SUSP 3 (ST)

apraclonidine SOLN 1

atropine sulfate * 1

ATROPINE SULFATE * 1

azelastine hcl SOLN 1

AZOPT SUSP 2

bacitracin/polymyxin b OINT 1

BETAGAN SOLN GP

betaxolol hcl SOLN 1

BETOPTIC-S SUSP 2

BLEPHAMIDE SUSP 2

BLEPHAMIDE S.O.P. OINT 2

brimonidine tartrate SOLN 1

carteolol hcl SOLN 1

CIPRODEX SUSP 2 (AG) (QL)

COMBIGAN SOLN 3

COSOPT SOLN GP

cromolyn sodium SOLN 1

CYCLOGYL SOLN 2

cyclopentolate hcl SOLN 1

dexamethasone sodium phosphate SOLN 1

DIAMOX CP12 GP

diclofenac sodium SOLN 1

dorzolamide hcl SOLN 1

dorzolamide hcl/timolol maleate SOLN 3

Ophthalmic Agents


ELESTAT SOLN GP

epinastine hcl SOLN 1

EYLEA SOLN MED

fluorometholone SUSP 1

flurbiprofen sodium SOLN 1

FML OINT 2

FML FORTE SUSP 2

FML LIQUIFILM SUSP GP

homatropaire SOLN 1

IOPIDINE SOLN GP

ISOPTO ATROPINE SOLN GP

ISOPTO CARBACHOL SOLN 2

ISOPTO CARPINE SOLN GP

ISOPTO HOMATROPINE SOLN 2

ISTALOL SOLN 2

ketorolac tromethamine SOLN 1

latanoprost SOLN 1

levobunolol hcl SOLN 1

LEVOBUNOLOL HCL SOLN 1

LOTEMAX * 2 (ST)

LUMIGAN SOLN 2

MAXIDEX SUSP 2

MAXITROL * GP

methazolamide TABS 1

METIPRANOLOL SOLN 1

MYDRIACYL SOLN GP

NAPHAZOLINE HCL SOLN 3

neo-polycin OINT 1

neomycin/polymyxin/bacitracin/hydrocortisone OINT 1

neomycin/polymyxin/dexamethasone * 1

NEPTAZANE TABS GP

OMNIPRED SUSP GP

OPTIVAR SOLN GP

PATADAY SOLN 2

PATANOL SOLN 2

phenylephrine hcl SOLN 1

PHOSPHOLINE IODIDE SOLR 2

pilocarpine hcl SOLN 1

PRED FORTE SUSP GP

PRED MILD SUSP 2

prednisolone acetate SUSP 1

PREDNISOLONE SODIUM PHOSPHATE SOLN 1

proparacaine hcl SOLN 1

RESTASIS EMUL 3 (QL)

SIMBRINZA SUSP 3 (QL)


sulfacetamide sodium/prednisolone sodium phosphate SOLN 1

timolol maleate SOLN 1

timolol maleate ophthalmic gel forming SOLG 1

TIMOPTIC SOLN GP

TIMOPTIC-XE SOLG GP

TOBRADEX OINT 3

tobramycin/dexamethasone SUSP 1

TRAVATAN Z SOLN 2

tropicamide SOLN 1

TRUSOPT SOLN GP

VEXOL SUSP 3

VOLTAREN SOLN GP

XALATAN SOLN GP


acetic acid SOLN 1

ACETIC ACID/ALUMINUM ACETATE SOLN 1

antipyrine/benzocaine SOLN 1

hydrocortisone/acetic acid SOLN 1




ACCOLATE TABS GP

ACCUNEB NEBU GP

acetylcysteine SOLN 1

ADVAIR DISKUS AEPB 3 (QL) (ST)

ADVAIR HFA AERO 3 (QL) (ST)

albuterol sulfate * 1

albuterol sulfate er TB12 1

ANORO ELLIPTA AEPB 3 (ST)

ASMANEX TWISTHALER 30 METERED DOSES AEPB 2

ASMANEX TWISTHALER 60 METERED DOSES AEPB 2

ASTELIN SOLN GP

ATROVENT SOLN GP

ATROVENT HFA AERS 2

AUVI-Q SOAJ 2

azelastine hcl SOLN 1

BECONASE AQ SUSP 3 (ST)

Otic Agents

Respiratory Tract Agents


benzonatate CAPS 1

budesonide SUSP 1 (AG)

budesonide SUSP 3 (ST)

COMBIVENT RESPIMAT AERS 3 (QL)

cromolyn sodium NEBU 1

cyproheptadine hcl * 1

DALIRESP TABS 2 (PA) (QL)

DULERA AERO 2 (QL) (ST)

DUONEB SOLN GP

ELIXOPHYLLIN ELIX 2

EPIPEN 2-PAK SOAJ 3

EPIPEN-JR 2-PAK SOAJ 3

FLONASE SUSP GP

FLOVENT DISKUS AEPB 2

FLOVENT HFA AERO 2

FLUNISOLIDE SOLN 1

fluticasone propionate SUSP 1

FORADIL AEROLIZER CAPS 2

hydroxyzine hcl * 1



ipratropium bromide SOLN 1

ipratropium bromide/albuterol sulfate SOLN 1

LETAIRIS TABS 4 (PA) (QL) (SP)

MAXAIR AUTOHALER AERB 3

METAPROTERENOL SULFATE * 1

montelukast sodium * 1 (QL) (ST)

NASACORT AQ AERS GP

NASONEX SUSP 3 (ST)

phenadoz SUPP 1

promethazine hcl * 1

promethazine hcl plain SYRP 1

promethazine/codeine SYRP 1

promethegan SUPP 1

PULMICORT SUSP 2 (AG)

PULMICORT FLEXHALER AEPB 3

PULMOZYME SOLN 4

QVAR AERS 3

REVATIO TABS GP (GP) (PA) (QL)

RHINOCORT AQUA SUSP GP (GP)

SEREVENT DISKUS AEPB 2

sildenafil citrate TABS 3 (PA) (QL)

simply saline baby AERS 1

SINGULAIR * GP (GP) (QL)

sodium chloride NEBU 1


SPIRIVA HANDIHALER CAPS 2

SYMBICORT AERO 2 (QL) (ST)

terbutaline sulfate * 1

theophylline cr TB12 1

theophylline er * 1

TUDORZA PRESSAIR AEPB 2

VENTOLIN HFA AERS 2

VISTARIL CAPS GP

XOLAIR SOLR 4 (MB) (PA) (SP)

zafirlukast TABS 1


carisoprodol TABS 1

carisoprodol/aspirin TABS 1

carisoprodol/aspirin/codeine TABS 1

chlorzoxazone TABS 1

cyclobenzaprine hcl TABS 1

FLEXERIL TABS GP

methocarbamol TABS 1

orphenadrine citrate er TB12 1

PARAFON FORTE DSC TABS GP

ROBAXIN-750 TABS GP

SOMA TABS GP


AMBIEN TABS GP (QL)

AMBIEN CR TBCR GP (QL)

eszopiclone TABS 3 (QL) (ST)

flurazepam hcl CAPS 1 (QL)

HALCION TABS GP (GP) (QL)

LUNESTA TABS GP (GP) (ST) (QL)

modafinil TABS 4 (PA) (QL)

NUVIGIL TABS 2 (PA) (QL)

PHENOBARBITAL * 1

phenobarbital * 1

PROVIGIL TABS GP (GP) (PA) (QL)

PROVIGIL TABS GP (PA) (QL)

RESTORIL CAPS GP (GP) (QL)

ROZEREM TABS 3 (PA) (QL)

SOMNOTE CAPS 1

SONATA CAPS GP

Skeletal Muscle Relaxants

Sleep Disorder Agents


temazepam CAPS 1 (QL)

triazolam TABS 1 (QL)

XYREM SOLN 4

zaleplon CAPS 1

zolpidem tartrate TABS 1 (QL)

zolpidem tartrate er TBCR 3 (PA) (QL)


calciferol SOLN 1

calcium acetate CAPS 1

CUPRIMINE CAPS 2


dexferrum SOLN MED (MB) (PA)

DRISDOL * GP

ELIPHOS TABS GP

ESTROSTEP FE TABS GP

ferosul ELIX 1

FERRLECIT SOLN MED (MB) (PA)

FERROUS SULFATE SYRP 1

FLUORABON SOLN 1

flura-drops SOLN 1

FLURA-DROPS SOLN 1

folic acid TABS 1

FOSAMAX PLUS D TABS 3

gildess fe 1.5/30 TABS Zero

Copayment

COVERED UNDER PPACA

gildess fe 1/20 TABS Zero

Copayment

COVERED UNDER PPACA

infed SOLN MED (MB) (PA)

junel fe 1.5/30 TABS 1

junel fe 1/20 TABS 1

K-PHOS NEUTRAL TABS GP

KAYEXALATE POWD GP

kionex * 1

klor-con PACK 1

klor-con 10 TBCR 1

KLOR-CON 25 PACK 1

klor-con 8 TBCR 1

klor-con m10 TBCR 1

KLOR-CON M15 TBCR 2

klor-con m20 TBCR 1

klor-con/ef TBEF 1

LOESTRIN FE 1.5/30 TABS GP

LOESTRIN FE 1/20 TABS GP

LOZI-FLUR LOZG 1

Therapeutic Nutrients/Minerals/Electrolytes


MEPHYTON TABS 2

MICRO-K CPCR GP

microgestin fe TABS 1

microgestin fe 1.5/30 TABS 1

niacin er TBCR 1

PHOSLO CAPS GP

PHOSLYRA SOLN 2

potassium chloride LIQD 1

potassium chloride er * 1

potassium chloride er TBCR 1

potassium citrate er TBCR 1

sodium ferric gluconate complex/sucrose SOLN MED (PA)

sodium fluoride * 1

sodium polystyrene sulfonate POWD 1

tilia fe TABS 1

tri-legest fe TABS 1

UROCIT-K 15 TBCR 2

VENOFER SOLN MED (MB) (PA)

vitamin d CAPS 1

vitamin d-400 TABS 1 (AG) (QL) $0.00 copay


ADCETRIS SOLR MED (PA)

BYDUREON PEN 3 (QL)

CHEMSTRIP UGK STRP 2

DEX-TUSS LIQD 1

FERAHEME SOLN MED (MB) (PA)

SANDOSTATIN SOLN 4 (SP)

XENICAL CAPS 3 (PA)

Please see following page for disclaimer and explanation of terms.

UnClassified


DISCLAIMER Please be sure a prescription drug benefit is part of your specific coverage before consulting this list. If you do not know which list is correct, please contact the Presbyterian Customer Service Center at (505) 923-5678 or 1-800-356-2219, Monday through Friday from 7:00 a.m. to 6:00 p.m. TTY users may call 1-877-298-7407. Coverage for some drugs may be limited to specific dosage forms and/or strengths. Your benefit design determines what is covered for you and what your copayment will be. Please refer to your benefit materials for your specific coverage information. The medications listed on this Formulary/Preferred Drug Listing (PDL) are subject to change pursuant to the Formulary/PDL management activities of Presbyterian Health Plan. This list is not all-inclusive nor does it imply a guarantee of coverage. In addition, coverage for some drugs listed may be limited to specific dosage forms and/or strengths. Substitution of a generic product for a brand-name drug is mandatory when a generic equivalent is available. If a member requests the brand-name drug in this situation, a Prior Authorization may be required and the member must pay the difference in cost between the generic and branded versions. Non-formulary medications are not considered for coverage unless trial and failure of formulary alternatives are documented. Explanation of Terms in your Formulary 1. Age Limitation (AG) -- a coverage limit based on minimum or maximum age of the member imposed as a result of safety, efficacy or dosage form considerations. 2. Generics preferred/Generic equivalent available (GP) -- Generics preferred/Generic equivalent available (GP) - if there is a generic available and the patient receives a brand name product the patient pays the copay plus the difference in cost between the brand and generic copay plus the plan designated copay (brand or generic). 3. Medical Drugs (MED) -- Medications obtained through the medical benefit. Medical drugs are defined as medications administered in the office or facility that require a health care professional to administer. These medications include, but are not limited to, injectable, infused, oral or inhaled drugs. They may involve unique distribution and may be provided by a specialty pharmacy vendor. Some Medical Drugs may require Benefit Certification before they can be obtained. Office administered applies to all outpatient settings including, but are not limited to, physician's offices, emergency rooms, urgent care facilities and outpatient surgery facilities. For a complete list of Medical Drugs and to determine which require Benefit Certification please see the Presbyterian Pharmacy web site at: https://www.phs.org/Pages/default.aspx 4. Prior Authorization (PA) -- a drug that requires prior approval before the Plan will cover it, and when the patient meets the established criteria. The doctor must submit a Pharmacy Prior Authorization Form. The doctor can submit the request by fax, phone, or regular mail.


https://www.phs.org/Pages/default.aspx

5. Quantity Limit (QL) -- a coverage limit on the medication quantity covered for a defined days' supply (usually 30 or 90 days) based on safety, efficacy and/or dose optimization issues. 6. Specialty (SP) -- Tier 4 medications obtained through the pharmacy benefit. Tier 4 medications are defined as high cost (greater than $600 per 30 day supply) injectable, infused, oral or inhaled drugs that generally require complex care and supervision. These medications involve unique distribution and are usually provided by a specialty pharmacy vendor. Specialty pharmaceuticals are self-administered, meaning they are administered by the patient or to the patient by a family member or caregiver. Non-formulary medications, when approved by prior authorization, may be subject to specialty pharmacy requirements. 7. Step Edit (ST) -- a drug that requires a prescription history of specific drugs in the pharmacy claims or data system, and these specific drugs must be taken during a given time frame. After the specific drugs have been taken within the given time frame, online coverage of the newly-prescribed drug occurs at the pharmacy. Step Edits make it easier to access drugs that would normally require a Prior Authorization. 8. Medical Exception -- a drug that is not on the Plan’s formulary. Non-formulary drugs require an Exception to the formulary due to allergy, adverse reactions, or no response to all formulary drugs. 9. Patient Protection and Affordable Care Act (PPACA) – Under the PPACA, certain women’s preventive health care is covered with no copayment or co-insurance and is not subject to any deductible or out-of-pocket maximum.


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