prescription drug program formulary · this is a listing of formulary drugs to be considered for...

PRESCRIPTION DRUG PROGRAM

FORMULARY

Effective April 1, 2016

myahatpa.com

1

Dear Plan Member:

In an effort to continue our commitment to provide you with comprehensive prescription drug coverage, a formulary feature is included in your prescription drug benefit. A formulary is a list of selected drugs that are approved by the U.S. Food and Drug Administration (FDA) and reviewed by our Pharmacy and Therapeutics Committee, a group of physicians and pharmacists from the area. These prescription drugs have been selected for their reported medical effectiveness, safety, and value while providing you with the highest level of coverage under your prescription drug benefits.

Our pharmacy benefits manager, FutureScripts®, an independent company, continuously monitors the effectiveness and safety of drugs and drug prescribing patterns. Several procedures support safe prescribing patterns for our prescription drug programs, such as:

• prior authorization; • age and gender limits; • quantity limits; • 96-Hour Temporary Supply Program; • coverage for medications not on the formulary.

These procedures are designed to optimize your prescription drug benefits by promoting appropriate utilization. They are based on FDA guidelines, and the criteria are endorsed by our Pharmacy and Therapeutics Committee.

A detailed description of the procedures that support safe prescribing is included at the end of the formulary list.

Please note: Because prescription drug benefits vary by group, the inclusion of a drug in this formulary does not imply coverage. This formulary was current at the time of printing and is subject to change. Please call Customer Service at the number listed on the back of your ID card if you have any questions about your prescription drug benefits. Please discuss any questions or concerns about your drug therapy with your physician or pharmacist.

Brand drugs listed in the formulary with a “3” in the immediate column to the right are available at the highest level of cost-sharing (i.e., the highest cost to you). It is displayed next to the equivalent formulary generic drug that is available at the lowest level of cost-sharing (i.e., the lowest cost to you). For example: amoxicillin is the formulary generic drug available at the lowest level of cost-sharing. Amoxil® is the non-formulary brand available at the highest level of cost-sharing. In most cases when brand drugs have a generic equivalent, the generic version is formulary and the brand version is non-formulary.

• Covered generic drugs not listed are formulary and are available at the lowest level of cost-sharing. • Covered brand drugs not listed are non-formulary and are available at the highest level of cost-sharing.

Certain preventive medications, as described in the Patient Protection and Affordable Care Act (PPACA), are covered without cost-sharing with a doctor’s prescription when provided by a participating retail or mail-order pharmacy. Coverage includes certain products within the following drug categories: (1) aspirin to prevent cardiovascular disease for men age 45-79 and women age 55-79 and low-dose aspirin (81 mg/d) as preventive medication after 12 weeks of gestation in women who are at high risk for preeclampsia, (2) breast cancer chemotherapy prevention for members 35 years of age and older, (3) fluoride supplementation for children 6 months to 60 months, (4) folic acid supplementation for women planning or capable of pregnancy, (5) iron supplementation for children ages 6 to 12 months who are at increased risk for iron deficiency anemia, (6) tobacco interventions for adults who use tobacco products, (7) vitamin D supplementation for ages 65 and over to prevent falls and (8) contraceptives, mandated by the Women’s Preventive Services provision.

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2

Dear Physician:

This is a listing of formulary drugs to be considered for your patient, a Prescription Drug Program participant. Please refer to this formulary guide in order to choose a drug. Because prescription drug benefits vary by group, the inclusion of a drug in this formulary does not imply coverage.

This formulary was current at the time of printing and is subject to change. Please understand that this formulary is not intended as a substitute for your independent, professional judgment. Rather, it is offered as a tool to help Plan members recognize formulary drugs. We hope that you will refer to the formulary as a guide to prescribing formulary drugs.

Sincerely,

AmeriHealth Administrators

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3

1. ANTIBIOTICS & OTHER DRUGS USED FOR INFECTION

BRAND Formulary Tier GENERIC Formulary

Tier Generic Available

Acticlate 3Adoxa 3 doxycycline monohydrate 1 Yes

Ancobon 3 flucytosine 1 YesAralen 3 chloroquine phosphate 1 YesAtripla 2

Augmentin 3 amoxicillin/clavulanate 1 Yes

Augmentin XR 3 amoxicillin/clavulanate extended- release 1 Yes

Avelox 3 moxifloxacin hcl 1 YesBactrim,

Bactrim DS 3 sulfamethoxazole/tmp 1 Yes

Baraclude 3 entecavir 1 YesBiaxin 3 clarithromycin 1 Yes

Biaxin XL 3 clarithromycin SR 1 YesCedax 3 ceftibuten 1 YesCeftin 3 cefuroxime axetil 1 YesCipro 3 ciprofloxacin tabs 1 Yes

Cipro oral suspension 3 ciprofloxacin susp. 1 Yes

Cipro XR 3 ciprofloxacin ER tabs 1 YesCleocin 3 clindamycin 1 Yes

Combivir 3 lamivudine/zidovudine 1 YesComplera 2Cresemba 3Crixivan 2Daklinza 3Diflucan 3 fluconazole 1 YesDoryx 3 doxycycline 1 Yes

EES, Eryped 3 erythromycin ethylsuccinate 1 YesEdurant 2Emtriva 2Epivir 3 lamivudine 1 Yes

Epzicom 2Ery-Tab 3 erythromycin delayed release 1 Yes

Erythrocin 3 erythromycin stearate 1 YesFactive 3Famvir 3 famciclovir 1 YesFlagyl 3 metronidazole 1 Yes

Flumadine 3 rimantadine 1 YesFuzeon 2

Grifulvin V 3 griseofulvin microsize 1 Yes

4




Gris-PEG 3 griseofulvin ultramicrosize 1 YesHarvoni 2Hepsera 3 adefovir dipivoxil 1 YesHiprex 3 methenamine hippurate 1 YesInvirase 2Isentress 2Kaletra 2

Kalydeco 3Keflex 3 cephalexin 1 Yes

Lamisil Tabs 3 terbinafine tabs 1 YesLevaquin 3 levofloxacin 1 YesLexiva 2

Macrodantin 3 nitrofurantoin macrocrystals 1 YesMalarone 3 atovaquone/proguanil 1 YesMepron 3 atovaquone 1 YesMinocin 3 minocycline caps 1 Yes

Monodox 3 doxycycline monohydrate 1 YesMoxatag 3 amoxicillin ER 1 Yes

Myambutol 3 ethambutol 1 YesMycobutin 3 rifabutin 1 Yes

Norvir 2Noxafil 3Olysio 3Onmel 3Oracea 3 doxycycline ir-dr 1 Yes

Orkambi 3Peg-Intron 2

Pegasys 2Plaquenil 3 hydroxychloroquine 1 YesPrezista 2

Qualaquin 3 quinine sulfate 1 YesRetrovir 3 zidovudine 1 YesReyataz 2Ribapak 3 moderiba 1 YesRifadin 3 rifampin 1 Yes

Selzentry 2Sivextro 3Sovaldi 2

Sporanox 3 itraconazole 1 YesStribild 2

5




Stromectol 3 ivermectin 1 YesSuprax Susp 100 mg/5 ml, 200 mg/5 ml

3 cefixime susp 100 mg/5 ml, 200 mg/5 ml 1 Yes

Sustiva 2Tamiflu 2

Technivie 3Tindamax 3 tinidazole 1 Yes

Tobi 3 tobramycin 1 YesTrizivir 3 abacavir/lamivudine/zidovudine 1 YesTruvada 2

Valcyte tab 3 valganciclovir 1 YesValtrex 3 valacyclovir tab 1 Yes

Vancocin 3 vancomycin 1 YesVfend 3 voriconazole 1 Yes

Vibramycin 3 doxycycline hyclate 1 YesVidex EC 3 didanosine 1 Yes

Viekira Pak 3Viramune 3 nevirapine 1 Yes

Viramune XR 3 nevirapine XR 1 YesViread 2

Xifaxan 2Zerit 3 stavudine 1 Yes

Ziagen 3 abacavir sulfate 1 YesZithromax 3 azithromycin 1 Yes

Zmax 3Zovirax 3 acyclovir 1 YesZyvox 3 linezolid 1 Yes

amoxicillin 1 Yesampicillin 1 Yescefaclor 1 Yes

cefaclor ER 1 Yescefadroxil 1 Yescefdinir 1 Yes

clotrimazole troches 1 Yesdapsone 1 Yes

demeclocycline 1 Yesdicloxacillin 1 Yes

erythromycin susp w/sulfa 1 Yesisoniazid 1 Yes

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ketoconazole tabs 1 Yesmebendazole 1 Yesmefloquine 1 Yes

minocycline tabs 1 Yesmoderiba 1 Yesnystatin 1 Yesofloxacin 1 Yes

penicillin VK 1 Yesprimaquine phosphate 1 Yes

tetracycline 1 Yes

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2. CANCER & ORGAN TRANSPLANT DRUGS



Arimidex 3 anastrazole 1 YesAromasin 3 exemestane 1 YesCasodex 3 bicalutamide 1 YesCellcept 3 mycophenolate 1 YesCytoxan 3 cyclophosphamide 1 Yes

Danocrine 3 danazol 1 YesDeltasone 3 prednisone 1 Yes

Emcyt 2Eulexin 3 flutamide 1 YesFarydak 3Femara 3 letrozole 1 YesGilotrif 3Gleevec 2Hydrea 3 hydroxyurea 1 YesIbrance 3

Imbruvica 3Imuran 3 azathioprine 1 Yes

Lenvima 3Leukeran 2Lonsurf 3

Lynparza 3Lysodren 2Matulane 2Megace 3 megestrol 1 YesMyfortic 3 mycophenolic acid 1 YesOdomzo 3Prograf 3 tacrolimus 1 YesProtopic 3 tacrolimus 1 Yes

Purinethol 3 mercaptopurine 1 YesRapamune 1mg/ml Sol 2

Rapamune tab 3 sirolimus 1 YesRheumatrex, Trexall tab 3 methotrexate 1 Yes

Sandimmune, Neoral 3 cyclosporine 1 Yes

Tabloid 3 thioguanine 1 YesTargretin cap 3 bexarotene 1 Yes

Temodar 3 temozolomide 1 YesValchlor 3VePesid 3 etoposide 1 Yes

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2. CANCER & ORGAN TRANSPLANT DRUGS



Xeloda 3 capecitabine 1 YesZydelig 3Zykadia 3

leucovorin calcium 1 Yeslomustine 1 Yes

megestrol acetate 1 Yestamoxifen 1 Yes

temozolomide 1 Yes

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3. PAIN, NERVOUS SYSTEM, & PSYCH



Abilify 3 aripiprazole 1 YesActiq 3 fentanyl citrate OTFC 1 Yes

Adasuve 3

Adderall 3amphetamine aspartate/

amphetamine sulfate/ dextroamphetamine

1 Yes

Adderall XR 3amphetamine aspartate/

amphetamine sulfate/ dextroamphetamine ER

1 Yes

Alsuma 3 sumatriptan succinate 1 YesAmbien 3 zolpidem tartrate 1 Yes

Ambien CR 3 zolpidem tartrate controlled release 1 Yes

Amerge 3 naratriptan 1 YesAnafranil 3 clomipramine HCl 1 YesAnsaid 3 flurbiprofen 1 Yes

Aptensio XR 3Aricept 3 donepezil hydrochloride 1 YesAtivan 3 lorazepam 1 Yes

Avinza 30mg, 45mg, 60mg, 75mg, 90mg

3 morphine sulfate ER 1 Yes

Avinza 120mg 3 morphine sulfate ER 1 YesAvonex 2Axert 3 almotriptan maleate 1 Yes

Azilect 2Belsomra 3

Belviq 3Betaseron 2Brintellix 3Bunavail 3Buspar 3 buspirone 1 YesButrans 3Cafergot 3 ergotamine tartrate/caffeine 1 YesCampral 3 acamprosate 1 YesCataflam 3 diclofenac potassium 1 YesCelexa 3 citalopram 1 Yes

Celontin 2Chantix 3Clinoril 3 sulindac 1 YesClozaril 3 clozapine 1 Yes

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Comtan 3 entacapone 1 YesConcerta 3 methylphenidate 1 Yes

Contrave ER 3Conzip 3 tramadol hcl er 1 Yes

Copaxone 2 glatopa 1 YesCymbalta 3 duloxetine 1 YesDantrium 3 dantrolene 1 YesDaypro 3 oxaprozin 1 YesDemerol 3 meperidine HCl 1 YesDepakene 3 valproic acid 1 YesDepakote 3 divalproex sodium 1 Yes

Depakote ER 3 divalproex sodium ER 1 YesDepakote

Sprinkle Caps 3 divalproex sprinkle cap 1 Yes

Desoxyn 3 methamphetamine 1 YesDesyrel 3 trazodone 1 YesDiastat 3 diazepam rectal gel 1 Yes

Diastat AcuDial 3 diazepam rectal gel 1 YesDilantin

chewable tablets 2 phenytoin chewable tablets 1 Yes

Dilaudid 1 mg/ml liquid 3 hydromorphone 1 mg/ml liquid 1 Yes

Dilaudid 2mg 3 hydromorphone HCl 1 YesDilaudid 4mg,

8mg 3 hydromorphone HCl 1 Yes

Dolobid 3 diflunisal 1 YesDolophine 3 methadone 1 Yes

Doral 3 quazepam 1 YesDuragesic

12mcg 3 fentanyl transdermal 1 Yes

Duragesic 25mcg, 50mcg, 75mcg, 100mcg

3 fentanyl transdermal 1 Yes

Effexor 3 venlafaxine 1 YesEffexor XR 3 venlafaxine ER 1 Yes

Eldepryl 3 selegiline HCl 1 YesEmbeda 3

Esgic 3 butalbital/apap/caffeine 1 YesEsgic Plus 3 butalbital/apap/caffeine, zebutal 1 YesEskalith 3 lithium carbonate 1 Yes

Eskalith CR, Lithobid 3 lithium carbonate SR 1 Yes

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Evekeo 3Evzio 3

Exalgo 3 hydromorphone ER 1 YesExelon 3 rivastigmine 1 YesFazaclo 3 clozapine ODT 1 YesFelbatol 3 felbamate 1 YesFeldene 3 piroxicam 1 YesFetzima 3Fioricet 3 butalbital/apap/caffeine 1 Yes

Fioricet with codeine 3 butalbital/apap/caffeine/codeine 1 Yes

Fiorinal 3 butalbital/aspirin/caffeine 1 YesFiorinal with

codeine 3 butalbital/aspirin/caffeine/codeine 1 Yes

Focalin XR 3 dexmethylphenidate hcl xr 1 YesGabitril 3 tiagabine hcl 1 YesGeodon 3 ziprasidone 1 YesHalcion 3 triazolam 1 YesHetlioz 3

Horizant 3Hycet 3 hydrocodone/apap 1 Yes

Hysingla 3Ibudone 3 ibuprofen/oxycodone HCl 1 YesImitrex 3 sumatriptan 1 YesIntuniv 3 guanfacine ER 1 YesInvega 3 paliperidone er 1 YesIrenka 3 duloxetine hcl 1 Yes

Kadian 10mg, 20mg, 30mg, 40mg, 50mg

3 morphine extended release 1 Yes

Kadian 60mg, 80mg, 100mg 3 morphine extended release 1 Yes

Kadian 200mg 3Kapvay 3 clonidine HCl ER 1 YesKeppra 3 levetiracetam 1 Yes

Keppra XR 3 levetiracetam ER 1 YesKhedezla 3 desvenlafaxine ER 1 YesKlonopin 3 clonazepam 1 YesLamictal 3 lamotrigine 1 Yes

Lamictal ODT 3 lamotrigine ODT 1 YesLamictal XR 3 lamotrigine 1 Yes

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Lexapro 3 escitalopram 1 YesLodine XL 3 etodolac 1 YesLodosyn 3 carbidopa 1 YesLortab 3 hydrocodone/acetaminophen elixir 1 Yes

Loxitane 3 loxapine 1 YesLunesta 3 eszopiclone 1 Yes

Luvox CR 3 fluvoxamine 1 YesMaxalt,

Maxalt-MLT 3 rizatriptan benzoate 1 Yes

Mestinon 3 pyridostigmine 1 YesMetadate CD 3 methylphenidate hcl 1 Yes

Methylin Chewable Tabs 3 methylphenidate hcl chewable

tabs 1 Yes

Midrin 3 isometheptene/ dichloralphenazone/apap 1 Yes

Migranal 3 dihydroergotamine 1 YesMirapex 3 pramipexole 1 Yes

MS Contin 15mg, 30mg 3 morphine sulfate, extended release 1 Yes

MS Contin 60mg, 100mg,

200mg3 morphine sulfate, extended release 1 Yes

MSIR 3 morphine sulfate 1 YesMysoline 3 primidone 1 Yes

Nalfon 3 fenoprofen calcium 1 YesNamenda 3 memantine hcl 1 YesNaprelan 3 naproxen sodium SA 1 Yes

Naprelan CR 3 naproxen sodium CR 1 YesNaprosyn 3 naproxen 1 Yes

Nardil 3 phenelzine 1 YesNeurontin 3 gabapentin 1 YesNeurontin solution 3 gabapentin solution 1 Yes

Norpramin 3 desipramine 1 YesNucynta 50mg,

75mgNucynta 100mg

Nucynta ER 50mg, 100mgNucynta ER

150mg, 200mg, 250mg

Opana 5mg 3 oxymorphone 1 Yes

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Opana 10mg 3 oxymorphone 1 YesOpana ER 5mg, 7.5mg, 10mg,

15mg3 oxymorphone 1 Yes

Opana ER 20mg, 30mg,

40mg3 oxymorphone 1 Yes

Orap 3 pimozide 1 YesOrudis 3 ketoprofen 1 YesOxaydo 3

Oxycontin 10mg, 15mg,

20mg3 oxycodone ER 1 Yes

Oxycontin 30mg, 40mg, 60mg, 80mg

3 oxycodone ER 1 Yes

OxyIR 3 oxycodone 1 YesPamelor 3 nortriptyline 1 YesParcopa 3 carbidopa/levodopa ODT 1 YesParlodel 3 bromocriptine mesylate 1 YesParnate 3 tranycypromine sulfate 1 YesPaxil 3 paroxetine 1 Yes

Paxil CR 3 paroxetine HCl ext-release 1 YesPercocet, Roxicet 3 oxycodone/acetaminophen,

endocet 1 Yes

Percodan 3 oxycodone/aspirin 1 YesPhenytek 3 phenytoin sodium 1 YesPlegridy 2Prodrin 3 isometheptene/APAP/caffeine 1 Yes

Prostigmin 2Provigil 3 modafinil 1 YesProzac 3 fluoxetine 1 Yes

Qudexy XR 3 topiramate ER 1 YesRazadyne 3 galantamine 1 Yes

Razadyne ER 3 galantamine ER 1 YesRegimex 3Relpax 3

Remeron 3 mirtazapine 1 YesRemeron SolTab 3 mirtazapine rapid dissolve tabs 1 Yes

Requip 3 ropinirole 1 YesRequip XL 3 ropinirole EL 1 Yes

Restoril 3 temazepam 1 Yes

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Rexulti 3Rilutek 3 riluzole 1 Yes

Risperdal, Risperdal M-Tab 3 risperidone 1 Yes

Ritalin LA 3 methylphenidate ER 1 YesRitalin SR 3 methylphenidate SR 1 YesRobaxin 3 methocarbamol 1 Yes

Roxicodone 15mg 3 oxycodone 1 Yes

Roxicodone 30mg 3 oxycodone 1 Yes

Rozerem 3Ryzolt 3 tramadol ER 1 YesSaphris 3Saxenda 3Seroquel 3 quetiapine fumarate 1 Yes

Seroquel XR 2Sinemet 3 carbidopa/levodopa 1 Yes

Sinemet CR 3 carbidopa/levodopa CR 1 YesSonata 3 zaleplon 1 YesStalevo 3 carbidopa/levodopa/entacapone 1 YesStrattera 2

Suboxone Sublingual Film 1

Sylatron 3Symbyax 3 olanzapine/fluoxetine hcl 1 Yes

Synalgos-DC 3 dihydrocodeine/aspirin/caffeine 1 YesTasmar 3 tolcapone 1 Yes

Tecfidera 3Tegretol 3 carbamazepine 1 Yes

Tegretol XR 3 carbamazepine XR 1 YesTofranil 3 imipramine 1 YesTopamax 3 topiramate 1 YesTopamax Sprinkle Capsules

3 topiramate sprinkle cap 1 Yes

Tranxene T 3 clorazepate dipotassium 1 YesTrezix 3 dihydrocodein-acetaminoph-caff 1 Yes

Trileptal 3 oxcarbazepine 1 YesUltracet 3 tramadol/acetaminophen 1 YesUltram 3 tramadol 1 Yes

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Ultram ER 3 tramadol ER 1 YesValium 3 diazepam 1 Yes

Vicodin ES 3 hydrocodone/acetaminophen ES 1 YesVicoprofen 3 hydrocodone/ibuprofen 1 Yes

Voltaren XR 3 diclofenac sodium 1 YesVyvanse 2

Wellbutrin 3 bupropion 1 YesWellbutrin SR 3 bupropion SR 1 YesWellbutrin XL 3 bupropion XR 1 Yes

Xanax 3 alprazolam 1 YesXanax XR 3 alprazolam ER 1 Yes

Xartemis XR 3Xenazine 3 tetrabenazine 1 Yes

Xodol, Norco, Maxidone,

Lortab, Lorcet, Lorcet Plus,

Zydone

3 hydrocodone/acetaminophen 1 Yes

Zarontin 3 ethosuximide 1 YesZecuity 3

Zenzedi 2mg, 7.5mg, 15mg, 20mg, 30mg

3

Zenzedi 5mg, 10mg 3 dextroamphetamine 1 Yes

Zohydro ER 3Zoloft 3 sertraline 1 Yes

Zomig, Zomig ZMT 3 zolmitriptan 1 Yes

Zomig Nasal Spray 3

Zonegran 3 zonsinamide 1 YesZubsolv 3Zyban 3 bupropion 1 Yes

Zyprexa 3 olanzapine 1 YesZyprexa Zydis 3 olanzapine ODT 1 Yes

acetaminophen/butalbital 1 Yesacetaminophen/codeine 1 Yes

acetazolamide 1 Yesamantadine 1 Yesamitriptyline 1 Yesamoxapine 1 Yes

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aspirin with codeine 1 Yesbenztropine 1 Yes

buprenorphine 1 Yesbuprenorphine hcl/naloxone hcl 1 Yes

butorphanol tartrate nasal 1 Yeschlordiazepoxide 1 Yes

chlorpromazine HCl 1 Yesclonidine HCL ER 1 Yes

codeine tabs, 30mg/5ml solution 1 Yesdesvenlafaxine ER 1 Yes

diflunisal 1 Yesdihydroergotamine mesylate 1 Yes

doxepin 1 Yesduraxin 1 Yes

estazolam 1 Yesfentanyl citrate OTFC 1 Yes

fluphenazine 1 Yesflurazepam 1 Yesfluvoxamine 1 Yeshaloperidol 1 Yes

hydromorphone ER 1 Yesketoprofen 1 Yesketorolac 1 Yes

maprotiline 1 Yesmeclofenamate 1 Yesmeprobamate 1 Yes

methadone 1 Yesmigergot 1 Yesmodafinil 1 Yes

nabumetone 1 Yesnefazodone 1 Yes

nicotine gum, inhalers, lozenges, patches 1 Yes

oxazepam 1 Yesoxycodone-ibuprofen 1 Yes

pentazocine-acetaminophen 1 Yespentazocine-naloxone 1 Yes

perphenazine 1 Yesphenytoin 1 Yessulindac 1 Yes

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thioridazine 1 Yesthiothixene 1 Yes

tolmetin sodium 1 Yestrifluoperazine 1 Yestrihexyphenidyl 1 Yestrimipramine 1 Yes

vicodin, vicodin es, vicodin hp 1 Yeszgesic 1 Yes

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4. HEART, BLOOD PRESSURE, & CHOLESTEROL



Accupril 3 quinapril HCl 1 YesAccuretic 3 quinapril/HCTZ 1 Yes

Aceon 3 perindopril 1 YesAdalat CC 3 nifedipine ER 1 Yes

Adcirca 3Adempas 3Advate 2

Aggrenox 3 aspirin-dipyridamole er 1 YesAgrylin 3 anagrelide 1 Yes

Aldactazide 3 spironolactone/HCTZ 1 YesAldactone 3 spironolactone 1 Yes

Altace 3 ramipril 1 YesAlphanate 3

Alphanine SD 2Alprolix 3

Amturnide 3Antara 3 fenofibrate 1 YesArixtra 3 fondaparinux 1 YesAtacand 3 candesartan 1 Yes

Atacand HCT 3 candesartan/hydrochlorothiazide 1 YesAvalide 3 irbesartan/hydrochlorothiazide 1 YesAvapro 3 irbesartan 1 YesAzor 2

Bebulin 3BeneFIX 2Benicar 2

Benicar HCT 2Betapace AF 3 sotalol HCl 1 Yes

Bystolic 2Caduet 3 atorvastatin/amlodipine 1 YesCalan 3 verapamil HCl 1 Yes

Calan SR 3 verapamil HCl ER 1 YesCardizem 3 diltiazem HCl 1 Yes

Cardizem CD 3 diltiazem HCl CD 1 YesCardizem LA 3 diltiazem HCl LA 1 YesCardizem SR 3 diltiazem HCl SR 1 Yes

Cardura 3 doxazosin mesylate 1 YesCartia XT 1 diltiazem HCl ER 1 Yes

Catapres tablets 3 clonidine 1 YesCatapres-TTS 3 clonidine patch 1 Yes

19




Colestid 3 colestipol HCl 1 YesCordarone 3 amiodarone HCl 1 Yes

Coreg 3 carvedilol 1 YesCorgard 3 nadolol 1 YesCorifact 3Corlanor 3Corzide 3 nadolol-bendroflume thiazide 1 Yes

Coumadin 2 warfarin 1 YesCozaar 3 losartan 1 YesCrestor 2

Demadex 3 torsemide 1 YesDiamox Sequels 3 acetazolamide ER 1 Yes

Dibenzyline 3 phenoxybenzamine hcl 1 YesDilacor XR 3 diltiazem HCl ER 1 Yes

Dilt-CD 1 diltiazem HCl CD 1 YesDiltzac ER 1 diltiazem HCl ER 1 Yes

Diovan 3 valsartan 1 YesDiovan HCT 3 valsartan/hydrochlorothiazide 1 Yes

Durlaza 3Dyazide 3 triamterene/HCTZ 1 YesEdarbi 3

Edarbyclor 3Edecrin 2Eliquis 2Eloctate 3Entresto 3Exforge 3 amlodipine/valsartan 1 Yes

Exforge HCT 3 amlodipine/valsartan/HCTZ 1 YesFeiba 2

Fenoglide 3 fenofibrate 1 YesFibricor 3 fenofibric acid 1 Yes

Helixate FS 2Hemofil M 3Humate-P 2

Hyzaar 3 losartan-HCTZ 1 YesImdur 3 isosorbide mononitrate ER 1 Yes

Inderal LA 3 propranolol ER 1 YesInspra 3 eplerenone 1 YesIsordil

Titradose Tabs 3 isosorbide dinitrate 1 Yes

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Ixinity 3Jantoven 1 warfarin 1 YesJuxtapid 3

Koate-DVI 3Kogenate FS 2

Kynamro 3Lanoxin 3 digoxin 1 Yes

Lasix 3 furosemide 1 YesLescol 3 fluvastatin sodium 1 YesLetairis 3Lipitor 3 atorvastatin 1 YesLipofen 3 fenofibrate 1 YesLiptruzet 2

Livalo 3Lofibra 3 fenofibrate 1 YesLopid 3 gemfibrozil 1 Yes

Lopressor HCT 3 metoprolol tartrate/HCT 1 YesLotensin 3 benazepril 1 Yes

Lotrel 3 amlodipine/benazepril 1 YesLovaza 3 omega-3 acid ethyl esters 1 Yes

Lovenox 3 enoxaparin 1 YesMavik 3 trandolapril 1 Yes

Maxzide 3 triamterene/HCTZ 1 YesMevacor 3 lovastatin 1 YesMicardis 3 telmisartan 1 Yes

Micardis HCT 3 telmisartan/hydrochlorothiazide 1 YesMicrozide 3 hydrochlorothiazide 1 YesMinipress 3 prazosin 1 Yes

Monoclate-P 3Mononine 2

Multaq 2Niaspan 3 niacin ER 1 Yes

Nifedical XL 1 nifedipine ER 1 YesNitro-Bid 2Nitro-Dur 3 nitroglycerin patches 1 YesNitromist 3 nitroglycerin spray 1 Yes

Nitrostat SL 1Norpace 3 disopyramide 1 YesNorthera 3Norvasc 3 amlodipine 1 Yes

21




Novoeight 3Novoseven RT 3

Opsumit 3Orenitram 3Pacerone 1 amiodarone HCl 1 Yes

Persantine 3 dipyridamole 1 YesPlavix 3 clopidogrel 1 YesPletal 3 cilostazol 1 Yes

Praluent 3Pravachol 3 pravastatin 1 YesPrevalite 1 cholestyramine light 1 YesPrinivil 3 lisinopril 1 Yes

Procardia 3 nifedipine 1 YesProcardia XL 3 nifedipine ER 1 Yes

Procrit 2Profilnine 3Questran 3 cholestyramine 1 Yes

Questran Light 3 cholestyramine light 1 YesRecombinate 2

Repatha 3Revatio 3 sildenafil citrate 1 YesRixubis 3Rythmol 3 propafenone 1 Yes

Rythmol SR 3 propafenone SR 1 YesSamsca 3Sectral 3 acebutolol 1 YesSular 3 nisoldipine ER 1 YesTarka 3 trandolapril/verapamil ER 1 Yes

Taztia XT 1 diltiazem HCl ER 1 YesTekamlo 3Tekturna/

Tekturna HCT 3

Tenex 3 guanfacine 1 YesTenoretic 3 atenolol/chlorthalidone 1 YesTenormin 3 atenolol 1 YesTeveten 3 eprosartan 1 Yes

Teveten HCT 3Tiazac 3 diltiazem HCl ER 1 Yes

Toprol XL 3 metoprolol succinate 1 YesTracleer 2Trandate 3 labetalol HCl 1 Yes

22




Tretten 3Tribenzor 2

Tricor 3 fenofibrate nanocrystallized 1 YesTrilipix 3 fenofibric acid 1 YesTwynsta 3 telmisartan-amlodipine 1 YesTyvaso 3Uniretic 3 moexipril/HCTZ 1 YesUnivasc 3 moexipril 1 YesVascepa 2Vaseretic 3 enalapril/HCTZ 1 YesVasotec 3 enalapril 1 YesVecamyl 1Ventavis 3

Verelan ER, PM 3 verapamil HCl ER 1 Yes

Vytorin 2Wilate 3Xarelto 2Xyntha 2

Zaroxolyn 3 metolazone 1 YesZebeta 3 bisoprolol 1 Yes

Zestoretic 3 lisinopril/HCTZ 1 YesZestril 3 lisinopril 1 YesZetia 2Ziac 3 bisoprolol/HCTZ 1 Yes

Zocor 3 simvastatin 1 Yesacetazolamide 1 Yes

amiloride 1 Yesamiloride/HCTZ 1 Yes

aminocaproic acid 1 Yesbenazepril/HCTZ 1 Yes

betaxolol 1 Yesbumetanide 1 Yescaptopril 1 Yes

captopril/HCTZ 1 Yeschlorothiazide 1 Yeschlorthalidone 1 Yes

digoxin solution 1 Yesfelodipine ER 1 Yes

flecainide 1 Yesfosinopril 1 Yes

23




fosinopril/HCTZ 1 Yeshydralazine 1 Yesindapamide 1 Yes

isosorbide dinitrate ER 1 Yesisosorbide mononitrate 1 Yes

isradipine 1 Yeslisinopril/HCTZ 1 Yes

methyldopa 1 Yesmetoprolol tartrate 1 Yes

mexiletine HCl 1 Yesminoxidil 1 Yes

nicardipine 1 Yesnimodipine 1 Yes

nitroglycerin ER 1 Yesnitroglycerin SL 1 Yespentoxifylline ER 1 Yes

pindolol ER 1 Yespropranolol/HCTZ 1 Yes

propranolol solution 1 Yessildenafil citrate 1 Yesticlopidine HCl 1 Yes

timolol 1 Yes

24

5. SKIN MEDICATIONS



Absorica 3 isotretinoin 1 YesAcanya 2Aczone 3Aldara 3 imiquimod cream 1 YesAtralin 3 tretinoin 1 YesAurstat 3 MB hydrogel 1 YesAzelex 3

Bactroban cream 3 mupirocin cream 1 Yes

Bactroban ointment 3 mupirocin ointment 1 Yes

Benzaclin 3 clindamycin-benzoyl peroxide gel 1 YesBenzaclin

Pump 3

Benzamycin gel 3 benzoyl peroxide/erythromycin 1 YesBenzamycinpak 3

Carac 3 fluorouracil cream 1 YesCiclodan

0.77% cream 3 ciclopirox 0.77% cream 1 Yes

Ciclodan 8% solution 3 ciclopirox 8% solution 1 Yes

Cleocin T 3 clindamycin 1 YesClindagel 3Clobex 3 clobetasol propionate 1 Yes

Cloderm 3 clocortolone pivalate 1 YesCondylox 3 podofilox soln 1 YesCosentyx 3Cutivate 3 fluticasone propionate 1 Yes

Cyclocort 3 amcinonide 1 YesDermatop 3 prednicarbate ointment 1 Yes

Differin 0.1% cream, gel 3 adapalene cream, gel 1 Yes

Differin 0.3% gel 3 adapalene 0.3% gel 1 YesDifferin 0.1%

lotion 3 adapalene 0.1% lotion 1 Yes

Diprolene, Diprolene AF 3 betamethasone dipropionate 1 Yes

Dovonex cream 3 calcipotriene cream 1 YesDrithrocreme

HP 3 anthralin 1 Yes

Duac 3 clindamycin/benzoyl peroxide 1 YesEfudex cream 3 fluorouracil cream 1 Yes

25

5. SKIN MEDICATIONS



Elimite 3 permethrin 1 YesElocon 3 mometasone cream 1 Yes

Emla cream 3 prilocaine/lidocaine 1 YesEpiduo 2Erygel 3 erythromycin gel 1 YesEvoclin 3 clindamycin phosphate 1 YesJublia 3

Kenalog Spray 3 triamcinolone acetonide 1 YesKerydin 3Klaron 3 sodium sulfacetamide suspension 1 Yes

Lidoderm 3 lidocaine 1 YesLocoid 3 hydrocortisone butyrate 0.1% 1 YesLocoid

Lipocream 3 hydrocortisone butyrate/emoll 1 Yes

Loprox 3 ciclopirox cream, gel, shampoo, suspension 1 Yes

Lotrisone 3 betamethasone/clotrimazole 1 YesLuxiq 3 betamethasone valerate 1 Yes

MetroCream 3 metronidazole cream 1 YesMetrogel 3 metronidazole topical gel 1 Yes

Metrolotion 3 metronidazole lotion 1 YesNatroba 3 spinosad 1 YesNizoral

shampoo 3 ketoconazole shampoo 1 Yes

Onexton 3Ovide 3 malathion lotion 1 Yes

Oxsoralen lotion 1% 2

Oxsoralen Ultra 3 methoxsalen 1 YesPenlac 3 ciclopirox solution 1 Yes

Proctofoam HC 2Retin-A, Avita 3 tretinoin 1 YesRetin-A Micro 3 tretinoin gel 1 Yes

Silvadene 3 silver sulfadiazine 1 YesSoritane 3 acitretin 1 Yes

Sulfamylon 3 mafenide acetate 1 Yes

Synalar 3 fluocinolone acetonide cream, soln 1 Yes

Taclonex 3 calcipotriene-betamethasone dp 1 YesTargretin gel 2

Tazorac 2

26

5. SKIN MEDICATIONS



Temovate 3 clobetasol cream, ointment, solution 1 Yes

Topicort 3 desoximetasone cream, gel, ointment 1 Yes

Vanos 3 fluocinonide 1 YesVectical 3 calcitriol ointment 1 YesVeltin 3

Westcort 3 hydrocortisone valerate 0.2% 1 YesXylocaine 3 lidocaine solution 1 Yes

Ziana 3Zovirax cream 2Zovirax oint 3 acyclovir 1 Yes

alclometasone cream, ointment 1 Yesbenzoyl peroxide/urea cream 1 Yes

diflorasone diacetate 1 Yeseconazole 1 Yes

erythromycin solution 1 Yeserythromycin swabs 1 Yes

fluocinonide cream, gel, ointment 1 Yesgentamicin topical cream,

ointment 1 Yes

hydrocortisone 2.5% 1 Yeshydrocortisone/lidocaine HCl 1 Yes

ketoconazole cream 1 Yesnaftifine hcl cream 1% 1 Yes

nystatin/triamcinolone cream, ointment 1 Yes

triamcinolone cream, ointment 1 Yes

27

6. EAR, NOSE, THROAT MEDICATIONS



Astelin 3 azelastine 1 YesAstepro 3 azelastine 1 Yes

Atrovent nasal spray 3 ipratropium 1 Yes

Bactroban nasal oint 2

Beconase AQ 3Cetraxal 3 ciprofloxacin 1 YesCiprodex 2

Cortisporin Otic 3 neomycin/polymyxin/

hydrocortisone 1 Yes

Dermotic 3 fluocinolone acetonide oil 1 YesEvoxac 3 cevimeline hcl 1 YesFlonase 3 fluticasone propionate nasal susp 1 Yes

Nasacort AQ 3 triamcinolone acetonide 1 YesNasonex 3Omnaris 3Patanase 3 olopatadine 1 Yes

Qnasl 3Rhinocort AQ 3 budesonide 1 Yes

Salagen 3 pilocarpine HCl 1 YesTrioxin 3 myoxin 1 Yes

Veramyst 3Vosol HC 3 acetasol HC, acetic acid HC otic 1 YesZetonna 3

aero otic HC 1 Yesaurodex otic 1 Yes

benzotic, benzocaine/antipyrine 1 Yescortane B otic drops 1 Yes

flunisolide 1 Yesofloxacin otic 1 Yes

oticin otic 1 Yes

28

7. DIABETES, THYROID, STEROIDS, & OTHER MISCELLANEOUS HORMONES



Actos 3 pioglitazone 1 YesAfrezza 3Amaryl 3 glimepiride 1 Yes

Androderm patch 3

Androgel 1% Packet, Pump 3 testosterone 1% packet 1 Yes

Androgel 1.62% Packet,

Pump2

Apidra Solostar 3Axiron 2

Bd Insulin Syringe Micro-

Fine2

Breeze 2 Test Strips 2

Bydureon 2Byetta 2

Contour Next Test Strips 2

Contour Test Strips 2

Cortef 3 hydrocortisone 1 YesCytomel 3 liothyronine 1 YesDDAVP 3 desmopressin acetate 1 Yes

Decadron 3 dexamethasone 1 YesDiabeta 3 glyburide 1 YesDuetact 3 pioglitazone/glimepiride 1 YesFarxiga 3

First Testosterone 3

Fortamet 3 metformin ER 1 YesFortesta 3 testosterone 1 YesFreestyle

InsuLinx Test Strips

2

Freestyle Lite Test Strips 2

Freestyle Test Strips 2

Genotropin 3Glucophage 3 metformin 1 Yes

29




Glucophage XR 3 metformin ER 1 Yes

Glucotrol 3 glipizide 1 YesGlucotrol XL 3 glipizide ER 1 YesGlucovance 3 metformin/glyburide 1 Yes

Glumetza ER tablet 3

Glynase 3 glyburide micronized 1 YesGlyxambi 3Hectorol 3 doxercalciferol 1 YesHumalog 3

Humatrope 3Humulin 3Increlex 3

Invokamet 2Invokana 2Janumet 2

Janumet XR 2Januvia 2

Jardiance 3Jentadueto

tablet 3

Kazano tablet 3Keynote Strips 3

Kombiglyze XR 2

Korlym tablet 3Lantus 3

Levemir 2Levoxyl,

Synthroid, Unithroid

3 levothyroxine 1 Yes

Medrol 3 methylprednisolone 1 YesMicronase 3 glyburide 1 YesMyalept 3Natesto 3Natpara 3

Nesina tablet 3Norditropin 2

Novolin 2Novolog 2

Novolog mix 2

30




Nutropin AQ 2Onglyza 2

Oseni 3Oxandrin 3 oxandrolone 1 YesPediapred, Orapred,

Orapred ODT3 prednisolone sodium phosphate 1 Yes

Prandin 3 repaglinide 1 YesPrecision

XTRA Test Strips

2

Precose 3 acarbose 1 YesPrelone 3 prednisolone syrup 1 Yes

Rocaltrol capsules 3 calcitriol capsules 1 Yes

Saizen 3Sensipar 2Serostim 3Signifor 3Starlix 3 nateglinide 1 Yes

Striant buccal system 3

Symlin 2Synjardy 3Tanzeum 3Tapazole 3 methimazole 1 Yes

Testim Gel 3 testosterone 1 YesTradjenta tablet 3

Trulicity 3Victoza 2Vogelxo 3 testosterone 1 Yes

Xigduo XR 3Zemplar 3 paricalcitol 1 Yes

Zomacton 3danazol 1 Yes

fludrocortisone acetate 1 Yespropylthiouracil 1 Yes

tolbutamide 1 Yes

31

8. STOMACH, ULCER, & BOWEL MEDS



Aciphex 3 rabeprazole 1 YesAciphex Sprinkle 3

Actigall 3 ursodiol 1 YesAnusol-HC

Cream 3 hydrocortisone cream 1 Yes

Azulfidine 3 sulfasalazine 1 YesBentyl 3 dicyclomine 1 Yes

Canasa supp 2Carafate susp 2Carafate tabs 3 sucralfate tabs 1 Yes

Cholbam 3Colazal 3 balsalazide 1 YesColocort 3 hydrocortisone retention enema 1 Yes

Compazine suppository 3 prochlorperazine suppository 1 Yes

Creon 2Cytotec 3 misoprostol 1 YesDelzicol 2Dexilant 3Duexis 3Emend 3

Entocort EC 3 budesonide 1 YesEsomeprazole

Strontium 3

Gastrocrom 3 cromolyn sodium solution 1 YesLialda 2

Lomotil 3 diphenoxylate HCl/atropine 1 YesMarinol 3 dronabinol 1 Yes

Metozolv ODT 3 metoclopramide HCl 1 YesNexium 3 esomeprazole 1 YesNulytely 3 PEG 3350 & electrolytes 1 YesPentasa 2

Pepcid tabs, suspension 3 famotidine 40mg tab, suspension 1 Yes

Phenergan 3 promethazine 1 YesPrevacid, Prevacid SoluTab

3 lansoprazole tabs, ODT 1 Yes

Prilosec caps 3 omeprazole 1 YesPrilosec

suspension 3 omeprazole suspension 1 Yes

32

8. STOMACH, ULCER, & BOWEL MEDS



Protonix 3 pantoprazole 1 YesReglan 3 metoclopramide 1 YesRowasa 3 mesalamine rectal susp 1 YesTagamet 3 cimetidine 1 Yes

Tigan 3 trimethobenzamide 1 YesVimovo 3Zantac 3 ranitidine 300mg 1 YesZegerid 3 omeprazole-sodium bicarbonate 1 YesZenpep 2Zofran 3 ondansetron HCl 1 Yes

chlordiazepoxide/clidinium 1 Yesgranisetron 1 Yes

lactulose soln 1 Yesnizatidine solution 1 Yes

pancrelipase EC/SA 1 Yesprochlorperazine tabs 1 Yes

33

9. BONE, JOINT, & MUSCLE



Actemra SC 3Actonel 3 risedronate 1 YesAmrix 3

Anaprox 3 naproxen sodium 1 YesAnaprox DS 3 naproxen sodium 1 Yes

Ansaid 3 flurbiprofen 1 YesArava 3 leflunomide 1 Yes

Arthrotec 3 diclofenac/misoprostol 1 YesAtelvia 3 risedronate dr 1 YesBinosto 3Boniva 3 ibandronate 1 Yes

Cataflam 3 diclofenac potassium 1 YesCelebrex 3 celecoxib 1 YesColcrys 3 colchicine 1 Yes

Dantrium 3 dantrolene 1 YesDaypro 3 oxaprozin 1 YesEnbrel 2Evista 3 raloxifene hcl 1 Yes

Feldene 3 piroxicam 1 YesFexmid 3 cyclobenzaprine 1 Yes

Flector Patch 3Fosamax 3 alendronate 1 Yes

Fosamax Plus D 3Humira 2Kineret 3Lorzone 3Lotronex 3 alosetron hcl 1 Yes

Miacalcin 3 calcitonin-salmon (rDNA origin) nasal spray 1 Yes

Mitigare 3 colchicine 1 YesMobic 3 meloxicam 1 YesNalfon 3 fenoprofen calcium 1 Yes

Naprosyn 3 naproxen 1 YesOrencia 3Otezla 3

Otrexup 3Parafon Forte 3 chlorzoxazone 1 Yes

Pennsaid 3 diclofenac sodium 1 YesRasuvo 3Robaxin 3 methocarbamol 1 YesSimponi 3

34

9. BONE, JOINT, & MUSCLE



Skelaxin 3 metaxalone 1 YesSolaraze 3 diclofenac 1 Yes

Soma 3 carisoprodol 1 YesViibryd 3

Voltaren Gel 3Voltaren XR 3 diclofenac sodium ER 1 Yes

Xeljanz 3Zanaflex 3 tizanidine 1 YesZipsor 3

Zyloprim 3 allopurinol 1 Yesbaclofen 1 Yes

colchicine/probenecid 1 Yescyclobenzaprine 1 Yes

diflunisal 1 Yesetidronate disodium 1 Yes

etodolac 1 Yesibuprofen 1 Yes

indomethacin 1 Yesindomethacin SR 1 Yes

ketoprofen 1 Yesketoprofen SR 1 Yes

ketorolac 1 Yesmeclofenamate 1 Yes

nabumetone 1 Yesnaproxen sodium SA 1 Yes

orphenadrine ER 1 Yesprobenecid 1 Yes

sulindac 1 Yestolmetin 1 Yes

35

10. FEMALE, HORMONE REPLACEMENT, & BIRTH CONTROL

The Injectable Fertility Agents in this section are covered only under certain benefits programs. Please check your handbook to determine coverage.



Addyi 3Aygestin 3 norethindrone acetate 1 Yes

Beyaz 2Bravelle 2Cenestin 2

Cleocin vaginal 3 clindamycin cream 1 YesClimara patch 3 estradiol transdermal 1 YesDepo SubqQ

Provera 3

Depo-Provera 3 medroxyprogesteroneDesogen 3 apri 1 YesDiflucan 3 fluconazole 150mg 1 YesEstrace 3 estradiol 1 YesEstring 2

Estrostep FE 3 norethindrone acetate/ethinyl estradiol/ferrous fumarate 1 Yes

Evista 3 raloxifene 1 YesFemcon FE 3 ethinyl estradiol/norethindrone 1 YesFemHRT 3 norethindrone ethinyl estradiol 1 Yes

Follistim AQ 2Generess FE 3 noreth-ethinyl estradiol/iron 1 YesLoseasonique 3 amethia lo/camrese lo 1 Yes

Lo Loestrin FE 2Menopur 2Metrogel vaginal 3 metronidazole vaginal gel 1 Yes

Minastrin 24 FE 2

Natazia 2Nuvaring 2

Ogen 3 estropipate 1 YesOrtho All-flex

diaphragm 3

Ortho Evra 3 Xulane 1 YesOrtho Micronor/

Nor QD 3 camila 1 Yes

Ortho Novum 3 necon/cyclafem/alyacen 1 YesOrtho Tri- Cyclen Lo 2 tri-lo-sprintec 1 Yes

Plan B One-Step 3 levonorgestrel/my way/next dose 1 Yes

36

10. FEMALE, HORMONE REPLACEMENT, & BIRTH CONTROL

The Injectable Fertility Agents in this section are covered only under certain benefits programs. Please check your handbook to determine coverage.



Premarin 2Premarin

vaginal cream 2

Premphase 2Prempro 2

Prometrium 3 progesterone, micronized 1 YesProvera 3 medroxyprogesterone acetate 1 Yes

Seasonique 3 amethia 1 YesSerophene 3 clomiphene citrate 1 YesTerazol 3 3 terconazole cream 1 Yes

Tri-norinyl 3 aranelle 1 YesVandazole 3 metronidazole 1 YesVivelle Dot 3 estradiol 1 Yes

Yasmin 3 ethinyl estradiol/drospirenone 1 Yes

YAZ 3 Gianvi, ethinyl estradiol/ drospirenone 1 Yes

altavera/portia/levora 28/chateal/ marlissa/kurvelo 1 Yes

amethyst 1 Yesaviane 1 Yes

desogestrel/ethinyl estradiol 1 Yesesterified estrogens/ methyltestosterone 1 Yes

levonorgestrel/ethinyl estradiol 1 Yeslomedia 24 Fe 1 Yesnorethindrone 1 Yes

norethindrone/ethinyl estradiol 1 Yesnorethindrone/ethinyl estradiol,

Fe 1 Yes

norethindrone/mestranol 1 Yesnorgestimate/ethinyl estradiol 1 Yes

norgestrel/ethinyl estradiol 1 Yes

37

11. EYE MEDICATIONS



Acular/Acular LS 3 ketorolac opth soln 1 YesAlcaine 3 proparacaine 1 Yes

Alphagan P 3 brimonidine tartrate 1 YesAlrex 2Azopt 2

Besivance 2Betagan 3 levobunolol 1 YesBetimol 2

Betoptic S 2Bleph 10 3 sulfacetamide 1 Yes

Blephamide S.O.P. ointment 2

Ciloxan Sol. 3 ciprofloxacin 1 YesCosopt 3 dorzolamide-timolol 1 Yes

Cyclogyl 3 cyclopentolate HCl 1 YesDiamox Sequels 3 acetazolamide ER 1 Yes

Elestat 3 epinastine HCl 1 YesFml 3 fluorometholone 1 Yes

Gentak 3 gentamicin ophth 1 YesIopidine 3 apraclonidine 1 Yes

Isopto Atropine 3 atropine sulfate 1 YesIsopto

Carbachol 3% 3 carbachol 3% 1 Yes

Isopto Carpine 3 pilocarpine 1 YesIstalol Drops 2

Lotemax 2Lumigan 2

Maxitrol 3 neomycin/polymyxin B/ dexamethasone 1 Yes

Mydriacyl 3 tropicamide 1 YesNeosporin soln 3 polymyxin B/neo/gramicidin 1 Yes

Ocufen 3 flurbiprofen 1 YesOcuflox 3 ofloxacin 1 Yes

Omnipred 3 prednisolone 1 YesOptivar 3 azelastine HCL drops 1 YesPatanol 2

Phospholine Iodide 2

Pilopine HS gel 2Polysporin 3 bacitracin/polymyxin B ophth oint 1 YesPolytrim 3 trimethoprim sulfate/polymyxin B 1 Yes

38

11. EYE MEDICATIONS



Pred-Forte 3 prednisolone acetate 1 YesRescula 3Restasis 2Timoptic 3 timolol ophth 1 Yes

Timoptic XE 3 timolol XE 1 YesTobradex 3 tobramycin-dexamethasone 1 YesTobrex 3 tobramycin 1 Yes

Travatan Z 2Trusopt 3 dorzolamide HCl 2% 1 Yes

Vasocidin oint 3 prednisolone/sodium sulfacetamide 1 Yes

Vexol 2Vigamox 2Viroptic 3 trifluridine 1 YesVoltaren 3 diclofenac sodium 1 YesXalatan 3 latanoprost 1 YesZioptan 3Zymaxid 3 gatifloxacin 1 Yes

acetazolamide 1 Yesbacitracin ophth 1 Yes

betaxolol 1 Yesbimatoprost 1 Yes

carteolol 1 Yescromolyn ophth 1 Yes

dexamethasone ophth 1 Yeserythromycin 1 Yes

methazolamide 1 Yespolymyxin B/neo/bacitracin 1 Yes

prednisolone sodium phosphate 1 Yes

39

12. ALLERGY, COUGH & COLD, LUNG MEDS



Accolate 3 zafirlukast 1 YesAdcirca 3

AdrenaClick 3Advair Diskus 3Advair HFA 3

Aerospan 3Alvesco 3

Anoro Ellipta 3Arnuity Ellipta 3

Asmanex 2Astelin Nasal

Spray 3 azelastine nasal spray 1 Yes

Atrovent HFA 2Breo Ellipta 3

Bromfed DM 1Cheratussin AC 1Cheratussin DAC 1

Clarinex 3 desloratadine 1 YesCombivent Respimat 2

Dulera 2Duoneb 3 ipratropium-albuterol 1 Yes

Elixophyllin Elixir 3 theophylline elixir 1 Yes

EpiPen 2EpiPen Jr. 2

Esbriet 3Flovent Diskus 3Flovent HFA 3

Grastek 3Guiatuss AC 3 guaifenesin/codeine 1 YesHycofenix 3Hydromet 1

Iophen C-NR 1Obredon 3

Ofev 3Oralair 3

Proair HFA 2Proair

RespiClick 2

Proventil HFA 3

40




Pulmicort Flexhaler 3

Pulmicort Respules 3 budesonide 1 Yes

Pulmozyme 2Qvar 2

Ragwitek 3Serevent Diskus 2

Singulair 3 montelukast sodium 1 YesSpiriva 2Stiolto

Respimat 3

Symbicort 2Tessalon Perles 3 benzonatate 1 Yes

Theo-24 2Theochron 1 theophylline extended release 1 Yes

Tracleer 2Tussionex 3 hydrocodone-chlorpheniramine susp 1 Yes

Tuzistra XR 3Ventolin HFA 3

Vistaril 3 hydroxyzine pamoate 1 YesVituz 3

VoSpire ER 3 albuterol sulfate er 1 YesXopenex 3 levalbuterol 1 Yes

Xopenex HFA 3Xyzal 3 levocetirizine dihydrochloride 1 Yes

Zutripro 3 hydrocod-cpm-pseudoephedrine 1 Yesacetylcysteine 1 Yes

albuterol sulfate soln, syrup, tab 1 Yesaminophylline tabs 1 Yes

carbinoxamine 1 Yesclemastine 1 Yes

cromolyn inhalation soln 1 Yescyproheptadine 1 Yes

flunisolide 1 Yesguaifenesin/hydrocodone 1 Yes

guaifenesin/pseudoephedrine/ codeine 1 Yes

hydrocodone/homatropine syrup 1 Yeshydroxyzine HCl 1 Yes

ipratropium inhalation soln 1 Yes

41




metaproterenol tabs, syrup, inh soln 1 Yes

phenylephrine/cpm/hydrocodone 1 Yespromethazine 1 Yes

promethazine/codeine 1 Yespromethazine/dextromethorphan 1 Yes

promethazine/phenylephrine 1 Yespromethazine/phenylephrine/

codeine 1 Yes

pseudoephedrine/ chlorpheniramine/codeine 1 Yes

terbutaline sulfate tabs 1 Yes

42

13. URINARY & PROSTATE MEDS



Avodart 3 dutasteride 1 YesCardura 3 doxazosin mesylate 1 Yes

Caverject 2Cialis 2Detrol 3 tolterodine tartrate 1 Yes

Detrol LA 3 tolterodine tartrate LA 1 YesDitropan 3 oxybutynin 1 Yes

Ditropan XL 3 oxybutynin ER 1 YesEdex 3

Enablex 2Flomax 3 tamsulosin 1 YesLevitra 3Muse 2

Myrbetriq 2Proscar 3 finasteride 1 YesRapaflo 2

Sanctura XR 3 trospium chloride 1 YesStaxyn 3Stendra 3

Urecholine 3 bethanechol 1 YesUrocit-K 3 potassium citrate 1 YesUroxatral 3 alfuzosin 1 YesVESIcare 2

Viagra 3flavoxate 1 Yesterazosin 1 Yes

43

14. VITAMINS & ELECTROLYTES



Calciferol 3 ergocalciferol 1 YesIcar 3 iron, carbonyl 15mg 1 Yes

K-Tab 3 potassium chloride 1 YesKlor-Con 1 potassium chloride 1 YesMephyton 2

Tri-Vi-Flor, Poly-Vi-Flor

with and without iron

3 multivitamin with fluoride drops, tabs 1 Yes

fluoride 1 YesMultigen 1 Yes

Multigen plus 1 Yespotassium bicarbonate/potassium

citrate effervescent 1 Yes

sodium fluoride drops 1 Yes

44

15. DIAGNOSTICS & MISCELLANEOUS AGENTS



Cerdelga 3Chemet 2Jadenu 3Keveyis 3Novarel 3 chorionic gonadotropin 1 YesPhosLo 3 calcium acetate 1 YesPregnyl 3 chorionic gonadotropin 1 Yes

Proamatine 3 midodrine HCl 1 YesRenvela 3 sevelamer carbonate 1 Yes

Repronex 3Zavesca 2

prescription drug program formulary · this is a listing of formulary drugs to be considered for...

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