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2018 National Formulary
Effective 01/01/2018
The Formulary List is a guide providing tier designation for common medicines within select therapeutic categories. The Formulary List may not include all drugs covered by your prescription drug benefit. Generic medicines are available within many of the therapeutic categories listed, in addition to categories not listed, and should be considered as the first line of prescribing.
For benefit coverage or restrictions please check your benefit plan document(s). This listing is revised periodically as new drugs and new prescribing information becomes available. It is recommended that you bring this list of medications when you or a covered family member sees a physician or other healthcare provider.
Tier Definitions 1 Generics 2 Preferred Brands 3 Non-Preferred Brands (ST) Step Therapy (PA) Prior Authorization (SP) Specialty Drugs
Major Drug Class Overview Non-Preferred and Excluded* Drugs With Preferred Options
2018
Preferred Non-Preferred / Excluded * Drug Class
ANALGESICS
EUFLEXXA, GEL-ONE, HYALGAN, MONOVISC, ORTHOVISC
GELSYN-3, SUPARTZ FX, SYNVISC, SYNVISC-ONE
ANTIARTHRITICS
ABSTRAL, EMBEDA, KADIAN, ZOHYDRO ER fentanyl, fentanyl citrate, morphine sulfate er, oxycodone hcl, FENTORA, HYSINGLA ER, NUCYNTA ER, OXYCONTIN
NARCOTICS
ANTI-INFECTIVES
REBETOL moderiba, ribapak, ribavirin, ribavirin ANTIVIRALS
DAKLINZA*, EPCLUSA*, HARVONI*, SOVALDI*, TECHNIVIE*, VIEKIRA PAK*
MAVYRET, ZEPATIER HEPATITIS C
DOXYCYCLINE IR-DR ORACEA TETRACYCLINES
CARDIAC
BENICAR HCT, EDARBI, EDARBYCLOR candesartan-hydrochlorothiazid, irbesartan-hydrochlorothiazide, losartan-hydrochlorothiazide, valsartan-hydrochlorothiazide
ANGIOTENSIN RECEPTOR BLOCKER
PRADAXA clopidogrel, ELIQUIS, XARELTO ANTICOAGULANTS
LIVALO, VYTORIN atorvastatin calcium, rosuvastatin calcium, simvastatin
STATINS
CNS
ADDERALL XR dextroamphetamine-amphet er, dextroamphetamine-amphetamine
ADHD
PEXEVA, SARAFEM citalopram hbr, escitalopram oxalate, escitalopram oxalate, fluoxetine hcl, fluvoxamine maleate, paroxetine er, paroxetine hcl, sertraline hcl, trazodone hcl, VIIBRYD
ANTIDEPRESSANTS
FANAPT, INVEGA, REXULTI aripiprazole, olanzapine, olanzapine odt, quetiapine fumarate, quetiapine fumarate er, LATUDA, SAPHRIS
ANTI-PSYCHOTIC
ZOLPIMIST eszopiclone, zaleplon, zolpidem tartrate er, BELSOMRA, ROZEREM
SLEEP
DIABETES
ALOGLIPTIN, KAZANO, KOMBIGLYZE XR, NESINA, ONGLYZA, OSENI
JANUMET XR, JANUVIA, JENTADUETO, TRADJENTA
DPP-4
BYDUREON PEN, BYETTA, TANZEUM TRULICITY, VICTOZA INCRETINS
AFREZZA, APIDRA HUMALOG, HUMALOG MIX 50-50, HUMALOG MIX 75-25, HUMULIN 70-30, HUMULIN N, HUMULIN R, NOVOLIN 70-30, NOVOLIN N, NOVOLIN R, NOVOLOG, NOVOLOG FLEXPEN, NOVOLOG MIX 70-30
INSULIN
BASAGLAR KWIKPEN U-100 LANTUS, LANTUS SOLOSTAR, LEVEMIR, TOUJEO SOLOSTAR, TRESIBA FLEXTOUCH U-200
INSULIN: LONG ACTING
GLUMETZA, RIOMET metformin hcl OTHER
INVOKAMET, INVOKANA FARXIGA, JARDIANCE, SYNJARDY, XIGDUO XR
SGLT-2
Preferred Non-Preferred / Excluded * Drug Class
DIABETES
ACCU-CHEK AVIVA CONNECT, ACCU-CHEK AVIVA PLUS, ADVOCATE BLOOD GLUCOSE MONITOR, ASCENSIA BREEZE 2, CONTOUR, EMBRACE, PRODIGY, TRUETEST TEST STRIPS, TRUETRACK SMART SYSTEM, UNISTRIP1
FREESTYLE TEST STRIPS, ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
TESTING
ENDOCRINE
ESTRING estradiol, DIVIGEL, PREMARIN ESTROGENS
GANIRELIX ACETATE, PREGNYL CETROTIDE, NOVAREL GONADOTROPIN
BRAVELLE clomiphene citrate, FOLLISTIM AQ, FOLLISTIM AQ, GONAL-F, MENOPUR
OVULATORY STIMULANTS
CRINONE, ENDOMETRIN PROGESTINS
FORTESTA, NATESTO, STRIANT, TESTIM, VOGELXO
ANDROGEL, AXIRON TESTOSTERONE
GASTROINTESTINAL
PANCREAZE, PERTZYE CREON, VIOKACE, ZENPEP DIGESTIVE ENZYMES
DIPENTUM, LIALDA balsalazide disodium, AMITIZA, APRISO, ASACOL HD, DELZICOL, LINZESS, PENTASA
OTHER
DEXILANT, ZEGERID RX lansoprazole, omeprazole, pantoprazole sodium
PROTON PUMP INHIBITORS
GROWTH HORMONES
GENOTROPIN, HUMATROPE, NUTROPIN AQ NUSPIN, OMNITROPE, SAIZEN, ZOMACTON, ZORBTIVE
NORDITROPIN FLEXPRO
HEMATOLOGY
ARANESP, EPOGEN, MIRCERA PROCRIT
MUSCULOSKELETAL
ACTEMRA, CIMZIA, OTEZLA, REMICADE, SIMPONI, STELARA, TALTZ AUTOINJECTOR, TALTZ SYRINGE, XELJANZ
COSENTYX 150MG, COSENTYX 300MG, ENBREL, ENTYVIO, HUMIRA, ORENCIA, SILIQ
ANTI-INFLAMMATORY **
** Trial of ONE First Line Product and ONE Second Line Product is Required before any Non-Preferred Products.
Required Second Line Required First Line Indication
HUMIRA or ORENCIA HUMIRA or ORENCIA Rheumatoid Arthritis
Juvenille Idiopathic Arthritis HUMIRA or ORENCIA HUMIRA or ORENCIA
COSENTYX or HUMIRA or ORENCIA HUMIRA or ORENCIA Ankylosing Spondylitis
Psoriatic Arthritis HUMIRA or ORENCIA HUMIRA or ORENCIA
COSENTYX or SILIQ COSENTYX or HUMIRA Plaque Psoriasis
ENBREL Pediatric Plaque Psoriasis
ENTYVIO HUMIRA Crohn's Disease
HUMIRA Pediatric Crohn's
ENTYVIO HUMIRA Ulcerative Colitis
HUMIRA Hidradentis Supperativa
HUMIRA Uvelitis
OPHTHALMIC
COSOPT PF, SIMBRINZA, ZIOPTAN dorzolamide hcl, latanoprost, AZOPT, COMBIGAN, TRAVATAN Z
GLAUCOMA
ACUVAIL bromfenac sodium, diclofenac sodium, ketorolac tromethamine, ILEVRO, NEVANAC, PROLENSA
NSAIDS
Preferred Non-Preferred / Excluded * Drug Class
OTIC
CETRAXAL ciprofloxacin hcl MISCELLANEOUS
RESPIRATORY
DULERA, INCRUSE ELLIPTA ADVAIR DISKUS, ANORO ELLIPTA, BREO ELLIPTA, SPIRIVA, STIOLTO RESPIMAT, SYMBICORT, TUDORZA PRESSAIR
ARCAPTA NEOHALER, FORADIL, PROVENTIL HFA, XOPENEX HFA
PERFOROMIST, PROAIR HFA, SEREVENT DISKUS, VENTOLIN HFA
BETA AGONISTS
ALVESCO, ASMANEX ARNUITY ELLIPTA, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER, QVAR
INHALED STEROIDS
BECONASE AQ, NASONEX, OMNARIS, QNASL, ZETONNA
flunisolide, DYMISTA NASAL STEROIDS
TOPICAL
ATRALIN, AVAGE, AZELEX, BENZACLIN, VELTIN
adapalene, clindamycin phos-tretinoin, clindamycin-benzoyl peroxide, erythromycin, metronidazole, tretinoin, ACANYA, EPIDUO, FINACEA, TAZORAC
ACNE
ALDARA, FLUOROURACIL, ZYCLARA fluorouracil, imiquimod, PICATO MISCELLANEOUS
UROLOGICAL
ENABLEX, GELNIQUE, TOVIAZ oxybutynin chloride, tolterodine tartrate, MYRBETRIQ, VESICARE
ANTISPASMODICS
LEVITRA, STAXYN, STENDRA, VIAGRA sildenafil citrate, CIALIS ERECTILE DYSFUNCTION
Please Note: Drugs Marked with * are Excluded
CARDIAC
ACE INHIBITORS
CAPSULE
amlodipine besylate-benazepril 1
TABLET
benazepril hcl 1
TABLET
benazepril hcl-hctz 1
TABLET
captopril 1
TABLET
captopril/hydrochlorothiazide 1
TABLET
enalapril maleate 1
TABLET
fosinopril sodium 1
TABLET
fosinopril-hydrochlorothiazide 1
TABLET
lisinopril 1
TABLET
lisinopril-hctz 1
TABLET
moexipril hcl 1
TABLET
moexipril-hydrochlorothiazide 1
TABLET
perindopril erbumine 1
TABLET
quinapril 1
TABLET
quinapril-hydrochlorothiazide 1
CAPSULE
ramipril 1
TABLET
trandolapril 1
TABLET
ACCUPRIL 3
CAPSULE
ALTACE 3
SOLUTION, ORAL
EPANED 3
TABLET
LOTENSIN 3
TABLET
MAVIK 3
TABLET
PRINIVIL 3
SOLUTION, ORAL
QBRELIS 3
TABLET,IMMED AND EXTEND REL BIPHASE 24HR
TARKA 3
TABLET
VASOTEC 3
TABLET
ZESTRIL 3
ANTICOAGULANTS
TABLET
cilostazol 1
TABLET
clopidogrel 1
TABLET
dipyridamole 1
SYRINGE (ML)
enoxaparin sodium SP 1
SYRINGE (ML)
fondaparinux sodium SP 1
VIAL (ML)
heparin sodium 1
TABLET
jantoven 1
TABLET, EXTENDED RELEASE
pentoxifylline 1
TABLET
ticlopidine hcl 1
TABLET
warfarin sodium 1
TABLET
BRILINTA 2
TABLET
COUMADIN 2
TABLET
EFFIENT 2
TABLET
ELIQUIS 2
SYRINGE (ML)
FRAGMIN SP 2
TABLET
MEPHYTON 2
TABLET
XARELTO SP 2
CAPSULE,EXTENDED RELEASE MULTIPHASE 12HR
AGGRENOX 3
CAPSULE
PRADAXA 3
ANTIARRHYTHMIC
TABLET
amiodarone hcl 1
SOLUTION, ORAL
digoxin 1
TABLET
digoxin 1
CAPSULE
disopyramide phosphate 1
TABLET
flecainide acetate 1
CAPSULE
mexiletine hcl 1
TABLET
pacerone 1
VIAL (ML)
procainamide hcl 1
TABLET
propafenone hcl 1
Printed Date:11/1/2017
Page 5 | 2018 National Formulary Data Last Updated:10/30/2017
B4G Participant: N
CARDIAC
ANTIARRHYTHMIC
VIAL (ML)
quinidine gluconate 1
TABLET, EXTENDED RELEASE
quinidine sulfate 1
TABLET
quinidine sulfate 1
TABLET
sorine 1
TABLET
sotalol 1
TABLET
sotalol af 1
TABLET
MULTAQ 2
CAPSULE, EXTENDED RELEASE
NORPACE CR 3
CAPSULE
TIKOSYN SP 3
OTHER
TABLET
ENTRESTO 2
TABLET, EXTENDED RELEASE 12 HR
RANEXA 2
TABLET
VECAMYL 3
ANGIOTENSIN RECEPTOR BLOCKER
TABLET
candesartan cilexetil 1
TABLET
candesartan-hydrochlorothiazid 1
TABLET
eprosartan mesylate 1
TABLET
irbesartan 1
TABLET
irbesartan-hydrochlorothiazide 1
TABLET
losartan potassium 1
TABLET
losartan-hydrochlorothiazide 1
TABLET
olmesartan medoxomil 1
TABLET
olmesartan medoxomil 1
TABLET
telmisartan 1
TABLET
telmisartan-amlodipine 1
TABLET
telmisartan-hydrochlorothiazid 1
TABLET
valsartan 1
TABLET
valsartan-hydrochlorothiazide 1
TABLET
TEKAMLO 2
TABLET
TEKTURNA 2
TABLET
TEKTURNA HCT 2
TABLET
ATACAND HCT 3
TABLET
AZOR 3
TABLET
BENICAR 3
TABLET
BENICAR HCT 3
TABLET
DIOVAN HCT 3
TABLET
EDARBI 3
TABLET
EDARBYCLOR 3
TABLET
EXFORGE 3
TABLET
EXFORGE HCT 3
TABLET
TRIBENZOR 3
BETA BLOCKERS
CAPSULE
acebutolol hcl 1
TABLET
atenolol 1
TABLET
atenolol w/chlorthalidone 1
TABLET
betaxolol hcl 1
TABLET
bisoprolol fumarate 1
TABLET
bisoprolol fumarate/hctz 1
TABLET
carvedilol 1
TABLET
labetalol hcl 1
TABLET
metoprolol tartrate 1
TABLET
nadolol 1
TABLET
nadolol-bendroflumethiazide 1
TABLET
pindolol 1
TABLET
propranolol hcl 1
SOLUTION, ORAL
propranolol hcl 1
TABLET
propranolol hcl-hctz 1
Printed Date:11/1/2017
Page 6 | 2018 National Formulary Data Last Updated:10/30/2017
B4G Participant: N
CARDIAC
BETA BLOCKERS
TABLET
timolol maleate 1
TABLET
BYSTOLIC 2
CAPSULE,EXTENDED RELEASE MULTIPHASE 24HR
COREG CR 2
TABLET
LEVATOL 3
CALCIUM CHANNEL BLOCKERS
TABLET, EXTENDED RELEASE
afeditab cr 1
TABLET
amlodipine besylate 1
CAPSULE, EXT RELEASE 24 HR
cartia xt 1
CAPSULE, EXT RELEASE 24 HR
diltiazem 24hr cd 1
CAPSULE, EXT RELEASE 24 HR
diltiazem er 1
TABLET
diltiazem hcl 1
TABLET, EXTENDED RELEASE 24 HR
felodipine er 1
CAPSULE
isradipine 1
CAPSULE
nifedipine 1
TABLET, EXTENDED RELEASE
nifedipine er 1
CAPSULE
nimodipine 1
TABLET, EXTENDED RELEASE 24 HR
nisoldipine 1
CAPSULE, EXTENDED RELEASE 24HR
taztia xt 1
CAPSULE,24HR EXTENDED RELEASE PELLET CT
verapamil er pm 1
TABLET
verapamil hcl 1
DIURETICS
TABLET
acetazolamide 1
TABLET
amiloride hcl 1
TABLET
amiloride hcl w/hctz 1
TABLET
bumetanide 1
TABLET
chlorothiazide 1
TABLET
eplerenone 1
SOLUTION, ORAL
furosemide 1
TABLET
hydrochlorothiazide 1
TABLET
indapamide 1
TABLET
methazolamide 1
TABLET
methyclothiazide 1
TABLET
metolazone 1
TABLET
spironolactone 1
TABLET
spironolactone w/hctz 1
TABLET
torsemide 1
TABLET
triamterene w/hctz 1
CAPSULE
DYRENIUM 3
OTHER ANTI-HYPERTENSIVES
TABLET
clonidine hcl 1
TABLET
clorpres 1
TABLET
doxazosin mesylate 1
TABLET
guanfacine hcl 1
TABLET
hydralazine hcl 1
TABLET
methyldopa 1
TABLET
methyldopa/hydrochlorothiazide 1
TABLET
minoxidil 1
CAPSULE
prazosin hcl 1
TABLET
reserpine 1
CAPSULE
terazosin hcl 1
TABLET
BIDIL 3
TABLET, EXTENDED RELEASE 24 HR
CARDURA XL 3
STATINS
TABLET
amlodipine-atorvastatin 1
TABLET
atorvastatin calcium 1
POWDER IN PACKET (EA)
cholestyramine 1
TABLET
colestipol hcl 1
Printed Date:11/1/2017
Page 7 | 2018 National Formulary Data Last Updated:10/30/2017
B4G Participant: N
CARDIAC
STATINS
TABLET
fenofibrate 1
CAPSULE,DELAYED RELEASE (ENTERIC COATED)
fenofibric acid 1
CAPSULE
fluvastatin sodium 1
TABLET
gemfibrozil 1
TABLET
lovastatin 1
TABLET, EXTENDED RELEASE 24 HR
niacin er 1
TABLET
pravastatin sodium 1
POWDER IN PACKET (EA)
prevalite 1
TABLET
rosuvastatin calcium 1
TABLET
simvastatin 1
CAPSULE
JUXTAPID SP 2
CAPSULE
LIPOFEN 2
PEN INJECTOR (ML)
PRALUENT PEN SP 2
SYRINGE (ML)
PRALUENT SYRINGE SP 2
PEN INJECTOR (ML)
REPATHA SURECLICK SP 2
SYRINGE (ML)
REPATHA SYRINGE SP 2
CAPSULE
VASCEPA 2
TABLET
WELCHOL 2
POWDER IN PACKET (EA)
WELCHOL 2
TABLET, EXTENDED RELEASE 24 HR
ALTOPREV 3
CAPSULE
ANTARA 3
TABLET
CRESTOR 3
TABLET
FENOGLIDE 3
TABLET, EXTENDED RELEASE 24 HR
LESCOL XL 3
TABLET
LIVALO 3
CAPSULE
LOVAZA 3
TABLET
NIACOR 3
TABLET
TRIGLIDE 3
TABLET
VYTORIN 3
TABLET
ZETIA 3
NITRATES
TABLET
isosorbide dinitrate 1
TABLET
isosorbide mononitrate 1
OINTMENT (GRAM)
nitro-bid 1
PATCH, TRANSDERMAL 24 HOURS
nitroglycerin 1
AEROSOL, SPRAY (GRAM)
nitroglycerin 1
CAPSULE, EXTENDED RELEASE
DILATRATE-SR 2
PATCH, TRANSDERMAL 24 HOURS
MINITRAN 3
PATCH, TRANSDERMAL 24 HOURS
NITRO-DUR 3
TABLET, SUBLINGUAL
NITROSTAT 3
ANALGESICS
ANTIARTHRITICS
SYRINGE (ML)
GELSYN-3 SP 2
SYRINGE (ML)
SUPARTZ FX SP 2
SYRINGE (ML)
SYNVISC SP 2
SYRINGE (ML)
SYNVISC-ONE SP 2
SYRINGE (ML)
EUFLEXXA SP 3
SYRINGE (ML)
GEL-ONE SP 3
SYRINGE (ML)
GENVISC 850 SP 3
SYRINGE (ML)
HYALGAN SP 3
SYRINGE (ML)
HYMOVIS SP 3
SYRINGE (ML)
MONOVISC 3
SYRINGE (ML)
ORTHOVISC SP 3
HEADACHE
CAPSULE
apap/dichlphen/isometheptene 1
AEROSOL, SPRAY WITH PUMP (ML)
dihydroergotamine mesylate SP 1
TABLET
naratriptan hcl 1
Printed Date:11/1/2017
Page 8 | 2018 National Formulary Data Last Updated:10/30/2017
B4G Participant: N
ANALGESICS
HEADACHE
TABLET
rizatriptan 1
TABLET
sumatriptan succinate 1
PEN INJECTOR (ML)
sumatriptan succinate SP 1
SPRAY, NON-AEROSOL (EA)
sumatriptan succinate SP 1
TABLET
zolmitriptan 1
TABLET,DISINTEGRATING
zolmitriptan odt 1
NEEDLE-FREE INJECTOR (ML)
SUMAVEL DOSEPRO 2
TABLET
TREXIMET 2
SPRAY, NON-AEROSOL (EA)
ZOMIG 2
TABLET
AXERT 3
TABLET
CAFERGOT 3
TABLET, SUBLINGUAL
ERGOMAR 3
TABLET
FROVA 3
TABLET
RELPAX 3
NARCOTIC ANTAGONISTS
TABLET, SUBLINGUAL
buprenorphine-naloxone 1
TABLET
naltrexone hydrochloride 1
SPRAY, NON-AEROSOL (EA)
NARCAN 2
FILM, MEDICATED (EA)
SUBOXONE 2
SUSPENSION, EXTENDED RELEASE, RECONST.
VIVITROL SP 2
TABLET, SUBLINGUAL
ZUBSOLV 2
NARCOTICS
SOLUTION, ORAL
acetaminophen w/codeine 1
TABLET
acetaminophen w/codeine 1
TABLET, SUBLINGUAL
buprenorphine hydrochloride 1
CAPSULE
butalbital compound 1
CAPSULE
butalbital compound w/codeine 1
TABLET
butalbital/apap/caffeine 1
CAPSULE
butalbital/caff/apap/codeine 1
TABLET
codeine sulfate 1
TABLET, SOLUBLE
diskets 1
PATCH, TRANSDERMAL 72 HOURS
fentanyl 1
LOZENGE ON A HANDLE
fentanyl citrate 1
TABLET
hydrocodone bit-ibuprofen 1
TABLET
hydrocodone w/acetaminophen 1
SOLUTION, ORAL
hydrocodone w/acetaminophen 1
TABLET
hydromorphone hcl 1
SOLUTION, ORAL
meperidine hcl 1
SOLUTION, ORAL
methadone hcl 1
SUPPOSITORY, RECTAL
morphine sulfate 1
TABLET, EXTENDED RELEASE
morphine sulfate er 1
SOLUTION, ORAL
oxycodone hcl 1
TABLET
oxycodone hcl-ibuprofen 1
TABLET
oxycodone w/acetaminophen 1
TABLET
oxycodone w/aspirin 1
TABLET
oxymorphone hcl 1
PATCH, TRANSDERMAL WEEKLY
BUTRANS 2
TABLET, EFFERVESCENT
FENTORA 2
TABLET,ORAL ONLY,EXTENDED RELEASE 24 HR
HYSINGLA ER 2
TABLET
NUCYNTA 2
TABLET, EXTENDED RELEASE 12 HR
NUCYNTA ER 2
TABLET,ORAL ONLY,EXTENDED RELEASE 12 HR
OXYCONTIN 2
TABLET, SUBLINGUAL
ABSTRAL 3
SUSPENSION, ORAL (FINAL DOSE FORM)
CAPITAL W/CODEINE 3
CAPSULE,ORAL ONLY, EXT. RELEASE PELLETS
EMBEDA 3
CAPSULE, EXTENDED RELEASE PELLETS
KADIAN 3
Printed Date:11/1/2017
Page 9 | 2018 National Formulary Data Last Updated:10/30/2017
B4G Participant: N
ANALGESICS
NARCOTICS
TABLET
PRIMLEV 3
SPRAY, NON-AEROSOL (EA)
SUBSYS 3
CAPSULE,ORAL ONLY, EXTENDED RELEASE 12HR
ZOHYDRO ER 3
NSAIDS
CAPSULE
celecoxib 1
TABLET
diclofenac potassium 1
TABLET, EXTENDED RELEASE 24 HR
diclofenac sodium 1
TABLET,IMMEDIATE,DELAY RELEASE,BIPHASE
diclofenac sodium-misoprostol 1
TABLET
etodolac 1
TABLET
fenoprofen calcium 1
TABLET
flurbiprofen 1
CAPSULE
indomethacin 1
CAPSULE
ketoprofen 1
TABLET
ketorolac tromethamine 1
CAPSULE
meclofenamate sodium 1
CAPSULE
mefenamic acid 1
TABLET
meloxicam 1
SUSPENSION, ORAL (FINAL DOSE FORM)
meloxicam 1
TABLET
nabumetone 1
TABLET
naproxen 1
TABLET
naproxen sodium 1
TABLET
oxaprozin 1
CAPSULE
piroxicam 1
TABLET
sulindac 1
CAPSULE
tolmetin sodium 1
PATCH, TRANSDERMAL 12 HOURS
FLECTOR 2
CAPSULE
ZORVOLEX 2
CAPSULE
CELEBREX 3
TABLET
DUEXIS 3
SUPPOSITORY, RECTAL
INDOCIN 3
CAPSULE
NALFON 3
SPRAY, NON-AEROSOL (EA)
SPRIX SP 3
TABLET,IMMEDIATE,DELAY RELEASE,BIPHASE
VIMOVO 3
GEL (GRAM)
VOLTAREN 3
CAPSULE
ZIPSOR 3
MISCELLANEOUS
TABLET
diflunisal 1
TABLET
salsalate 1
TABLET
tramadol hcl 1
TABLET, EXTENDED RELEASE 24 HR
tramadol hcl er 1
TABLET
tramadol hcl-acetaminophen 1
CAPSULE,EXT.RELEASE 24 HR BIPHASIC 25-75
CONZIP 3
GROWTH HORMONES
PEN INJECTOR (ML)
NORDITROPIN FLEXPRO SP 2
VIAL (EA)
EGRIFTA SP 3
CARTRIDGE (EA)
GENOTROPIN SP 3
CARTRIDGE (EA)
HUMATROPE SP 3
PEN INJECTOR (ML)
NUTROPIN AQ NUSPIN SP 3
CARTRIDGE (ML)
OMNITROPE SP 3
CARTRIDGE (EA)
SAIZEN SP 3
VIAL (EA)
SEROSTIM SP 3
VIAL (EA)
ZOMACTON SP 3
VIAL (EA)
ZORBTIVE SP 3
HEMATOLOGY
SYRINGE (ML)
NEULASTA SP 2
VIAL (ML)
PROCRIT SP
2
SYRINGE (ML)
ZARXIO SP 2
Printed Date:11/1/2017
Page 10 | 2018 National Formulary Data Last Updated:10/30/2017
B4G Participant: N
HEMATOLOGY
VIAL (ML)
ARANESP SP 3
* ST: Must try and fail Procrit.
SYRINGE (ML)
ARANESP SP 3
* ST: Must try and fail Procrit.
VIAL (ML)
EPOGEN SP 3
SYRINGE (ML)
MIRCERA SP 3
SYRINGE (ML)
NEUPOGEN SP 3
ONCOLOGY
TABLET
anastrozole SP 1
TABLET
bicalutamide SP 1
VIAL (ML)
cytarabine SP 1
TABLET
exemestane SP 1
CAPSULE
flutamide SP 1
CAPSULE
hydroxyurea 1
TABLET
imatinib mesylate 1
TABLET
letrozole SP 1
TABLET
leucovorin calcium 1
SUSPENSION, ORAL (FINAL DOSE FORM)
megestrol acetate 1
TABLET
megestrol acetate 1
TABLET
mercaptopurine 1
TABLET
methotrexate 1
TABLET
tamoxifen citrate 1
CAPSULE
temozolomide SP 1
TABLET
AFINITOR SP 2
TABLET FOR SUSPENSION
AFINITOR DISPERZ SP 2
CAPSULE
ALECENSA SP 2
TABLET
BOSULIF SP 2
TABLET
CAPRELSA SP 2
CAPSULE
DROXIA 2
SYRINGE (EA)
ELIGARD SP 2
CAPSULE
EMCYT SP 2
TABLET
FARESTON SP 2
TABLET
GILOTRIF SP 2
CAPSULE
HYCAMTIN SP 2
TABLET
ICLUSIG SP 2
CAPSULE
IMBRUVICA SP 2
TABLET
INLYTA SP 2
TABLET
JAKAFI SP 2
TABLET
LEUKERAN SP 2
TABLET
LYSODREN SP 2
CAPSULE
MATULANE SP 2
TABLET
MEKINIST SP 2
TABLET
MESNEX SP 2
TABLET
NEXAVAR SP 2
CAPSULE
POMALYST SP 2
CAPSULE
REVLIMID SP 2
TABLET
SPRYCEL SP 2
TABLET
STIVARGA SP 2
CAPSULE
SUTENT SP 2
TABLET
TABLOID 2
CAPSULE
TAFINLAR SP 2
TABLET
TARCEVA SP 2
CAPSULE
TASIGNA SP 2
CAPSULE
THALOMID SP 2
TABLET
TREXALL 2
TABLET
TYKERB SP 2
Printed Date:11/1/2017
Page 11 | 2018 National Formulary Data Last Updated:10/30/2017
B4G Participant: N
ONCOLOGY
TABLET
VOTRIENT SP 2
CAPSULE
XALKORI SP 2
TABLET
ZELBORAF SP 2
CAPSULE
ZOLINZA SP 2
TABLET
ZYTIGA SP 2
CAPSULE
COMETRIQ SP 3
TABLET
GLEEVEC SP 3
SUSPENSION, ORAL (FINAL DOSE FORM)
MEGACE ES 3
SOLUTION, ORAL
SOLTAMOX 3
CAPSULE
TEMODAR SP 3
VIAL (EA)
VIDAZA SP 3
CAPSULE
XTANDI SP 3
* ST: Must try and fail Zytiga.
IMMUNOSUPPRESSANTS
TABLET
azathioprine SP 1
CAPSULE
cyclosporine SP 1
SOLUTION, ORAL
cyclosporine SP 1
CAPSULE
gengraf SP 1
SOLUTION, ORAL
gengraf SP 1
CAPSULE
mycophenolate mofetil SP 1
TABLET
sirolimus SP 1
CAPSULE
tacrolimus SP 1
TABLET
AZASAN SP 2
CAPSULE
NEORAL SP 2
SOLUTION, ORAL
NEORAL SP 2
SOLUTION, ORAL
RAPAMUNE SP 2
SOLUTION, ORAL
SANDIMMUNE SP 2
CAPSULE
SANDIMMUNE SP 2
TABLET
ZORTRESS SP 2
CAPSULE, EXT RELEASE 24 HR
ASTAGRAF XL SP 3
SUSPENSION, RECONSTITUTED, ORAL (ML)
CELLCEPT SP 3
TABLET
RAPAMUNE SP 3
INTERFERONS
VIAL (ML)
ACTIMMUNE SP 2
VIAL (ML)
ALFERON N SP 2
KIT
AVONEX ADMINISTRATION PACK SP 2
KIT
BETASERON SP 2
VIAL (EA)
INTRON A SP 2
SYRINGE (ML)
PEGASYS SP 2
SYRINGE (ML)
REBIF SP 2
KIT
SYLATRON SP 2
KIT
EXTAVIA SP 3
KIT
PEG-INTRON SP 3
PEN INJECTOR KIT (EA)
PEG-INTRON REDIPEN SP 3
OPHTHALMIC
ANTIBIOTICS
OINTMENT (GRAM)
bacitracin 1
OINTMENT (GRAM)
bacitracin 1
OINTMENT (GRAM)
bacitracin/polymyxin 1
DROPS
ciprofloxacin hcl 1
OINTMENT (GRAM)
erythromycin 1
DROPS
gatifloxacin 1
OINTMENT (GRAM)
gentamicin sulfate 1
DROPS
gentamicin sulfate 1
DROPS
levofloxacin hemihydrate 1
OINTMENT (GRAM)
neo/polymyxin/dexamethasone 1
SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)
neo/polymyxin/dexamethasone 1
Printed Date:11/1/2017
Page 12 | 2018 National Formulary Data Last Updated:10/30/2017
B4G Participant: N
OPHTHALMIC
ANTIBIOTICS
OINTMENT (GRAM)
neomycin/bacitracin/poly/hc 1
OINTMENT (GRAM)
neomycin/bacitracin/polymyxin 1
DROPS
neomycin/polymyxin/gramicidin 1
SOLUTION, NON-ORAL
neomycin/polymyxin/hc 1
SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)
neomycin/polymyxin/hc 1
DROPS
ofloxacin 1
DROPS
polymyxin b sul-trimethoprim 1
DROPS
sulfacetamide sodium 1
DROPS
sulfacetamide w/prednisolone 1
DROPS
tobramycin sulfate 1
SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)
tobramycin-dexamethasone 1
DROPS
AZASITE 2
DROPS
AZASITE 2
SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)
BESIVANCE 2
SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)
CIPRODEX 2
DROPS, VISCOUS (ML)
MOXEZA 2
SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)
NATACYN 2
OINTMENT (GRAM)
TOBRADEX 2
SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)
TOBRADEX ST 2
SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)
ZYLET 2
DROPS
BLEPH-10 3
SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)
BLEPHAMIDE 3
OINTMENT (GRAM)
BLEPHAMIDE S.O.P. 3
OINTMENT (GRAM)
CILOXAN 3
SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)
CIPRO HC 3
SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)
COLY-MYCIN S 3
OINTMENT (GRAM)
PRED-G 3
OINTMENT (GRAM)
TOBREX 3
BETA BLOCKERS
DROPS
betaxolol hcl 1
DROPS
carteolol hcl 1
DROPS
levobunolol hcl 1
DROPS
metipranolol 1
DROPS
timolol maleate 1
DROPS
BETIMOL 3
SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)
BETOPTIC S 3
DROPS, ONCE DAILY
ISTALOL 3
DROPPERETTE, SINGLE-USE DROP DISPENSER
TIMOPTIC 3
GLAUCOMA
DROPS
dorzolamide hcl 1
DROPS
dorzolamide-timolol 1
DROPS
latanoprost 1
DROPS
pilocarpine hcl 1
SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)
AZOPT 2
DROPS
COMBIGAN 2
DROPS
LUMIGAN 2
DROPS
TRAVATAN Z 2
DROPPERETTE, SINGLE-USE DROP DISPENSER
COSOPT PF 3
KIT
MITOSOL 3
SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)
SIMBRINZA 3
DROPPERETTE, SINGLE-USE DROP DISPENSER
ZIOPTAN 3
NSAIDS
DROPS
bromfenac sodium 1
DROPS
diclofenac sodium 1
DROPS
flurbiprofen sodium 1
DROPS
ketorolac tromethamine 1
SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)
ILEVRO 2
Printed Date:11/1/2017
Page 13 | 2018 National Formulary Data Last Updated:10/30/2017
B4G Participant: N
OPHTHALMIC
NSAIDS
SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)
NEVANAC 2
DROPS
PROLENSA 2
DROPPERETTE, SINGLE-USE DROP DISPENSER
ACUVAIL 3
STEROIDS
DROPS
dexamethasone sodium phosphate 1
SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)
fluorometholone 1
SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)
prednisolone acetate 1
SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)
ALREX 2
SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)
LOTEMAX 2
SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)
PRED MILD 2
DROPS
DUREZOL 3
SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)
FLAREX 3
SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)
FML FORTE 3
SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)
MAXIDEX 3
MYDRIATICS
DROPS
atropine sulfate 1
DROPS
cyclopentolate hcl 1
DROPS
homatropine hydrobromide 1
DROPS
tropicamide 1
DROPS
CYCLOGYL 3
DROPS
PAREMYD 3
VASOCONSTRICTOR
DROPS
CYCLOMYDRIL 3
MISCELLANEOUS
DROPS
apraclonidine hcl 1
DROPS
azelastine hcl 1
DROPS
brimonidine tartrate 1
DROPS
cromolyn sodium 1
DROPS
epinastine hcl 1
DROPS
flucaine 1
DROPS
fluorescein-benoxinate 1
DROPS
proparacaine hcl 1
DROPS
tetracaine hcl 1
DROPS
trifluridine 1
DROPS
ALPHAGAN P 2
DROPS
BEPREVE 2
DROPS
CYSTARAN SP 2
DROPPERETTE, SINGLE-USE DROP DISPENSER
RESTASIS 2
DROPS
ALOCRIL 3
DROPS
EMADINE 3
DROPPERETTE, SINGLE-USE DROP DISPENSER
IOPIDINE 3
DROPS
LASTACAFT 3
DROPS
PATADAY 3
DROPS
PATANOL 3
DROPPERETTE, VISCOUS
TETRAVISC 3
GEL (GRAM)
ZIRGAN 3
OTIC
MISCELLANEOUS
DROPS
acetasol hc 1
SOLUTION, NON-ORAL
acetic acid 1
DROPS
acetic acid/hydrocortisone 1
DROPPERETTE, SINGLE-USE DROP DISPENSER
ciprofloxacin hcl 1
DROPPERETTE, SINGLE-USE DROP DISPENSER
CETRAXAL 3
TOPICAL
CORTICOSTEROIDS VERY HIGH POTENCY
CREAM (GRAM)
clobetasol e 1
SHAMPOO
clobetasol propionate 1
OINTMENT (GRAM)
clobetasol propionate 1
SOLUTION, NON-ORAL
clobetasol propionate 1
OINTMENT (GRAM)
halobetasol propionate 1
Printed Date:11/1/2017
Page 14 | 2018 National Formulary Data Last Updated:10/30/2017
B4G Participant: N
TOPICAL
CORTICOSTEROIDS VERY HIGH POTENCY
SPRAY, NON-AEROSOL (ML)
CLOBEX 3
ANESTHETICS
OINTMENT (GRAM)
lidocaine 1
CREAM (GRAM)
lidocaine-hc 1
CREAM (GRAM)
lidocaine-prilocaine 1
GEL (GRAM)
NOVACORT 3
CREAM (GRAM)
PLIAGLIS 3
MISCELLANEOUS
CREAM (GRAM)
fluorouracil 1
CREAM IN PACKET (EA)
imiquimod 1
SHAMPOO
lindane 1
LOTION (ML)
malathion 1
CREAM (GRAM)
permethrin 1
SOLUTION, NON-ORAL
podofilox 1
CREAM (GRAM)
silver sulfadiazine 1
CREAM (GRAM)
thermazene 1
CREAM (GRAM)
CARAC 2
CREAM (GRAM)
ELIDEL 2
GEL (EA)
PICATO 2
GEL (GRAM)
REGRANEX 2
OINTMENT (GRAM)
SANTYL 2
CREAM IN PACKET (EA)
ALDARA 3
CREAM (GRAM)
BIONECT 3
GEL (GRAM)
BIONECT 3
CREAM (GRAM)
EURAX 3
CREAM (GRAM)
FLUOROURACIL 3
OINTMENT (GRAM)
PROTOPIC 3
CREAM IN PACKET (EA)
ZYCLARA 3
CREAM IN METERED-DOSE PUMP
ZYCLARA 3
CORTICOSTEROIDS HIGH POTENCY
CREAM (GRAM)
amcinonide 1
OINTMENT (GRAM)
amcinonide 1
LOTION (ML)
amcinonide 1
CREAM (GRAM)
apexicon e 1
CREAM (GRAM)
betamethasone dipropionate 1
OINTMENT (GRAM)
betamethasone dipropionate 1
LOTION (ML)
betamethasone dipropionate 1
OINTMENT (GRAM)
betamethasone valerate 1
GEL (GRAM)
desoximetasone 1
CREAM (GRAM)
desoximetasone 1
OINTMENT (GRAM)
desoximetasone 1
CREAM (GRAM)
diflorasone diacetate 1
CREAM (GRAM)
fluocinonide 1
CREAM (GRAM)
fluocinonide 1
OINTMENT (GRAM)
fluocinonide 1
CREAM (GRAM)
fluocinonide-e 1
CREAM (GRAM)
triamcinolone acetonide 1
CREAM (GRAM)
HALOG 3
OINTMENT (GRAM)
HALOG 3
SPRAY, NON-AEROSOL (ML)
TOPICORT 3
TOPICAL CORTICOSTEROIDS MEDIUM POTENCY
CREAM (GRAM)
betamethasone valerate 1
LOTION (ML)
betamethasone valerate 1
CREAM (GRAM)
fluticasone propionate 1
LOTION (ML)
fluticasone propionate 1
CREAM (GRAM)
hydrocortisone butyrate 1
SOLUTION, NON-ORAL
hydrocortisone butyrate 1
Printed Date:11/1/2017
Page 15 | 2018 National Formulary Data Last Updated:10/30/2017
B4G Participant: N
TOPICAL
TOPICAL CORTICOSTEROIDS MEDIUM POTENCY
OINTMENT (GRAM)
mometasone furoate 1
SOLUTION, NON-ORAL
mometasone furoate 1
OINTMENT (GRAM)
prednicarbate 1
OINTMENT (GRAM)
trianex 1
CREAM (GRAM)
triderm 1
CREAM (GRAM)
CLODERM 3
CREAM (GRAM)
CORDRAN 3
AEROSOL (GRAM)
KENALOG 3
LOTION (ML)
LOCOID 3
OINTMENT (GRAM)
TOPICORT 3
TOPICAL CORTICOSTEROIDS LOW POTENCY
CREAM (GRAM)
alclometasone dipropionate 1
OINTMENT (GRAM)
alclometasone dipropionate 1
OINTMENT (GRAM)
desonide 1
LOTION (ML)
desonide 1
CREAM (GRAM)
fluocinolone acetonide 1
SOLUTION, NON-ORAL
fluocinolone acetonide 1
CREAM (GRAM)
hydrocortisone 1
SHAMPOO
CAPEX SHAMPOO 3
GEL (GRAM)
DESONATE 3
CREAM (GRAM)
SYNALAR 3
SOLUTION, NON-ORAL
TEXACORT 3
FOAM (GRAM)
VERDESO 3
ACNE
GEL (GRAM)
adapalene 1
CLEANSER (ML)
benzoyl peroxide 1
FOAM (GRAM)
benzoyl peroxide 1
CAPSULE
claravis SP 1
SWAB, MEDICATED
clindamycin phosphate 1
FOAM (GRAM)
clindamycin phosphate 1
SOLUTION, NON-ORAL
clindamycin phosphate 1
GEL (GRAM)
clindamycin phosphate 1
LOTION (ML)
clindamycin phosphate 1
GEL (GRAM)
clindamycin phos-tretinoin 1
GEL (GRAM)
clindamycin-benzoyl peroxide 1
GEL (GRAM)
erygel 1
GEL (GRAM)
erythromycin 1
SOLUTION, NON-ORAL
erythromycin 1
GEL (GRAM)
erythromycin-benzoyl peroxide 1
GEL (GRAM)
metronidazole 1
CREAM (GRAM)
metronidazole 1
LOTION (ML)
metronidazole 1
CAPSULE
myorisan SP 1
CREAM (GRAM)
rosadan 1
GEL (GRAM)
rosadan 1
LOTION (GRAM)
sodium sulfacetamide/sulfur 1
CLEANSER (ML)
sodium sulfacetamide/sulfur 1
CREAM (GRAM)
tretinoin 1
GEL (GRAM)
tretinoin 1
GEL (GRAM)
tretinoin microsphere 1
CAPSULE
ABSORICA SP 2
GEL WITH PUMP (GRAM)
ACANYA 2
GEL WITH PUMP (GRAM)
EPIDUO 2
FOAM (GRAM)
FINACEA 2
GEL (GRAM)
MIRVASO 2
GEL (GRAM)
TAZORAC 2
Printed Date:11/1/2017
Page 16 | 2018 National Formulary Data Last Updated:10/30/2017
B4G Participant: N
TOPICAL
ACNE
CREAM (GRAM)
TAZORAC 2
KIT
ACCUCAINE 3
GEL (GRAM)
ACZONE 3
GEL (GRAM)
ATRALIN 3
CREAM (GRAM)
AVAGE 3
PADS, MEDICATED (EA)
AVAR 3
CREAM (GRAM)
AZELEX 3
GEL WITH PUMP (GRAM)
BENZACLIN 3
FOAM (GRAM)
BENZEFOAM 3
GEL (ML)
CLINDAGEL 3
LOTION (ML)
DIFFERIN 3
FOAM (GRAM)
FABIOR 3
COMBINATION PACKAGE (EA)
INOVA 3
CREAM (GRAM)
NORITATE 3
GEL (GRAM)
NUOX 3
PADS, MEDICATED (EA)
PACNEX HP 3
GEL (GRAM)
VELTIN 3
ANTIPSORIATIC
CAPSULE
acitretin 1
OINTMENT (GRAM)
calcipotriene 1
CREAM (GRAM)
calcipotriene 1
SOLUTION, NON-ORAL
calcipotriene 1
OINTMENT (GRAM)
calcitrene 1
CREAM (GRAM)
drithocreme hp 1
SHAMPOO
selenium sulfide 1
LOTION (ML)
selenium sulfide 1
CLEANSER (ML)
sodium sulfacetamide 1
SHAMPOO
sodium sulfacetamide 1
SUSPENSION, TOPICAL (GRAM)
TACLONEX 2
FOAM (GRAM)
EPIFOAM 3
SHAMPOO
OVACE PLUS 3
CREAM (GRAM)
PRAMOSONE 3
LOTION (ML)
PRAMOSONE 3
CREAM (GRAM)
PRAMOSONE E 3
FOAM (GRAM)
SORILUX 3
FOAM (GRAM)
TERSI FOAM 3
CREAM, RAPID RELEASE (GRAM)
ZITHRANOL-RR 3
ANTIFUNGALS
SUSPENSION, TOPICAL (ML)
ciclopirox 1
SHAMPOO
ciclopirox 1
GEL (GRAM)
ciclopirox 1
SOLUTION, NON-ORAL
clotrimazole 1
CREAM (GRAM)
clotrimazole 1
CREAM (GRAM)
clotrimazole/betamethasone 1
LOTION (ML)
clotrimazole/betamethasone 1
CREAM (GRAM)
econazole nitrate 1
SHAMPOO
ketoconazole 1
CREAM (GRAM)
ketoconazole 1
OINTMENT (GRAM)
nystatin 1
CREAM (GRAM)
nystatin w/triamcinolone 1
FOAM (GRAM)
ECOZA 3
CREAM (GRAM)
ERTACZO 3
SOLUTION, NON-ORAL
EXELDERM 3
LOTION (ML)
EXODERM 3
CREAM (GRAM)
MENTAX 3
CREAM (GRAM)
NAFTIN 3
GEL (GRAM)
NAFTIN 3
Printed Date:11/1/2017
Page 17 | 2018 National Formulary Data Last Updated:10/30/2017
B4G Participant: N
TOPICAL
ANTIFUNGALS
CREAM (GRAM)
OXISTAT 3
LOTION (ML)
OXISTAT 3
ANTIBACTERIALS
OINTMENT (GRAM)
mupirocin 1
CREAM (GRAM)
SULFAMYLON 2
GEL IN PACKET (GRAM)
ALCORTIN A 3
OINTMENT (GRAM)
ALTABAX 3
OINTMENT (GRAM)
CENTANY 3
ANTIVIRALS
OINTMENT (GRAM)
acyclovir 1
CREAM (GRAM)
DENAVIR 3
CREAM (GRAM)
XERESE 3
UROLOGICAL
BPH
TABLET
finasteride 1
CAPSULE
RAPAFLO 2
CAPSULE
AVODART 3
CAPSULE,EXTENDED RELEASE MULTIPHASE 24HR
JALYN 3
ANTISPASMODICS
TABLET
bethanechol chloride 1
TABLET
flavoxate hcl 1
TABLET
oxybutynin chloride 1
SYRUP
oxybutynin chloride 1
TABLET, EXTENDED RELEASE 24 HR
oxybutynin chloride er 1
TABLET
tolterodine tartrate 1
CAPSULE, EXT RELEASE 24 HR
tolterodine tartrate er 1
TABLET
trospium chloride 1
TABLET, EXTENDED RELEASE 24 HR
MYRBETRIQ 2
TABLET
VESICARE 2
TABLET, EXTENDED RELEASE 24 HR
ENABLEX 3
GEL IN PACKET (GRAM)
GELNIQUE 3
PATCH, TRANSDERMAL SEMIWEEKLY
OXYTROL 3
TABLET, EXTENDED RELEASE 24 HR
TOVIAZ 3
ERECTILE DYSFUNCTION
TABLET
sildenafil citrate 1
TABLET
CIALIS 2
SUPPOSITORY, URETHRAL
MUSE 2
TABLET
LEVITRA 3
TABLET,DISINTEGRATING
STAXYN 3
TABLET
STENDRA 3
TABLET
VIAGRA 3
DIABETES
INSULIN
VIAL (ML)
HUMALOG 2
VIAL (ML)
HUMALOG MIX 50-50 2
VIAL (ML)
HUMALOG MIX 75-25 2
VIAL (ML)
HUMULIN 70-30 2
VIAL (ML)
HUMULIN N 2
VIAL (ML)
HUMULIN R 2
VIAL (ML)
NOVOLIN 70-30 2
VIAL (ML)
NOVOLIN N 2
VIAL (ML)
NOVOLIN R 2
CARTRIDGE (ML)
NOVOLOG 2
INSULIN PEN (ML)
NOVOLOG FLEXPEN 2
VIAL (ML)
NOVOLOG MIX 70-30 2
CARTRIDGE WITH INHALER
AFREZZA 3
VIAL (ML)
APIDRA 3
INSULIN PEN (ML)
APIDRA SOLOSTAR 3
INSULIN: LONG ACTING
VIAL (ML)
LANTUS 2
Printed Date:11/1/2017
Page 18 | 2018 National Formulary Data Last Updated:10/30/2017
B4G Participant: N
DIABETES
INSULIN: LONG ACTING
INSULIN PEN (ML)
LANTUS SOLOSTAR 2
VIAL (ML)
LEVEMIR 2
INSULIN PEN (ML)
TOUJEO SOLOSTAR 2
INSULIN PEN (ML)
TRESIBA FLEXTOUCH U-200 2
INSULIN PEN (ML)
BASAGLAR KWIKPEN U-100 3
INCRETINS
PEN INJECTOR (ML)
TRULICITY 2
PEN INJECTOR (ML)
VICTOZA SP 2
VIAL (EA)
BYDUREON SP 3
PEN INJECTOR (EA)
BYDUREON PEN SP 3
PEN INJECTOR (ML)
BYETTA SP 3
PEN INJECTOR (EA)
TANZEUM 3
DPP-4
TABLET
GLYXAMBI 2
TABLET
JANUMET 2
TABLET,EXTENDED RELEASE MULTIPHASE 24 HR
JANUMET XR 2
TABLET
JANUVIA 2
TABLET
JENTADUETO 2
TABLET
TRADJENTA 2
TABLET
ALOGLIPTIN 3
TABLET
ALOGLIPTIN-METFORMIN 3
TABLET
KAZANO 3
TABLET,EXTENDED RELEASE MULTIPHASE 24 HR
KOMBIGLYZE XR 3
TABLET
NESINA 3
TABLET
ONGLYZA 3
TABLET
OSENI 3
SULFONYLUREAS
TABLET
glimepiride 1
TABLET, EXTENDED RELEASE 24 HR
glipizide er 1
TABLET
glipizide-metformin 1
TABLET
glyburide 1
TABLET
glyburide micronized 1
TABLET
glyburide-metformin hcl 1
TZD
TABLET
pioglitazone hcl 1
TABLET
pioglitazone-glimepiride 1
TABLET
pioglitazone-metformin 1
OTHER
TABLET
acarbose 1
TABLET
metformin hcl 1
TABLET, EXTENDED RELEASE 24 HR
metformin hcl er 1
TABLET
nateglinide 1
TABLET
repaglinide 1
VIAL (EA)
GLUCAGEN 2
KIT
GLUCAGON EMERGENCY KIT 2
PEN INJECTOR (ML)
SYMLINPEN 120 2
TABLET
CYCLOSET 3
TABLET, ER GASTRIC RETENTION 24 HR
GLUMETZA SP 3
TABLET
GLYSET 3
SOLUTION, ORAL
RIOMET 3
SGLT-2
TABLET
FARXIGA 2
TABLET
JARDIANCE 2
TABLET
SYNJARDY 2
TABLET,IMMED AND EXTEND REL BIPHASE 24HR
XIGDUO XR 2
TABLET
INVOKAMET 3
TABLET
INVOKANA 3
TESTING
EACH
ACCU-CHEK 2
Printed Date:11/1/2017
Page 19 | 2018 National Formulary Data Last Updated:10/30/2017
B4G Participant: N
DIABETES
TESTING
NEEDLE, DISPOSABLE
BD INSULIN PEN NEEDLE UF MINI 2
SYRINGE, EMPTY DISPOSABLE
B-D INSULIN SYRINGE 2
NEEDLE, DISPOSABLE
B-D NEEDLES 2
EACH
DEXCOM G4 2
EACH
DEXCOM G5 2
STRIP
FREESTYLE INSULINX 2
STRIP
FREESTYLE INSULINX TEST STRIPS 2
STRIP
FREESTYLE LITE STRIPS 2
STRIP
FREESTYLE TEST STRIPS 2
SYRINGE, EMPTY DISPOSABLE
INSULIN- SYRINGE 2
STRIP
ONE TOUCH ULTRA TEST STRIPS 2
STRIP
ONE TOUCH VERIO 2
STRIP
PRECISION XTRA 2
EACH
ACCU-CHEK AVIVA CONNECT 3
STRIP
ACCU-CHEK AVIVA PLUS 3
STRIP
ACCU-CHEK COMPACT 3
EACH
ACCU-CHEK NANO SMARTVIEW 3
STRIP
ACCU-CHEK SMARTVIEW 3
STRIP
ACCUTREND GLUCOSE 3
EACH
ADVOCATE BLOOD GLUCOSE MONITOR 3
STRIP
ASCENSIA BREEZE 2 3
STRIP
CONTOUR 3
STRIP
CONTOUR NEXT EZ 3
STRIP
EMBRACE 3
STRIP
OPTIUM 3
STRIP
OPTIUM EZ 3
STRIP
PRECISION PCX PLUS 3
STRIP
PRECISION Q-I-D 3
KIT
PRODIGY 3
STRIP
TRUETEST TEST STRIPS 3
KIT
TRUETRACK SMART SYSTEM 3
STRIP
UNISTRIP1 3
VACCINES
VIAL (ML)
BOOSTRIX 2
SYRINGE (ML)
CERVARIX 2
SYRINGE (ML)
ENGERIX-B 2
VIAL (ML)
GARDASIL 2
VIAL (ML)
HAVRIX 2
SYRINGE (ML)
INFANRIX 2
VIAL (ML)
PNEUMOVAX 23 2
SYRINGE (ML)
PREVNAR 13 2
VIAL (ML)
RECOMBIVAX HB 2
SOLUTION, ORAL
ROTATEQ 2
VIAL (ML)
TWINRIX 2
VIAL (EA)
ZOSTAVAX 2
VITAMINS/ELECTROLYTES
CAPSULE
calcium acetate 1
TABLET
dialyvite 1
TABLET
elite-ob 1
TABLET, CHEWABLE
fluoride 1
TABLET
folic acid 1
PACKET (EA)
klor-con 1
COMBINATION PACKAGE, TABLET AND DR CAP
obstetrix dha 1
LIQUID (ML)
potassium chloride 1
TABLET, EXTENDED RELEASE
potassium chloride 1
Printed Date:11/1/2017
Page 20 | 2018 National Formulary Data Last Updated:10/30/2017
B4G Participant: N
VITAMINS/ELECTROLYTES
TABLET
prenatabs rx 1
TABLET
prenatal plus 1
SPRAY, NON-AEROSOL (EA)
NASCOBAL 2
COMBINATION PACKAGE (EA)
DUET DHA 3
TABLET, EXTENDED RELEASE
K-TAB 3
TABLET
OB COMPLETE 3
SOLUTION, ORAL
PHOSLYRA 3
MISCELLANEOUS
TABLET, EXTENDED RELEASE 12 HR
bupropion sr 1
AEROSOL, SPRAY WITH PUMP (ML)
calcitonin-salmon 1
CAPSULE
cevimeline hcl 1
TABLET
disulfiram 1
TABLET
etidronate disodium 1
TABLET
midodrine hcl 1
TABLET
riluzole 1
TABLET, DISPERSIBLE
CARBAGLU SP 2
TABLET
CHANTIX 2
AUTO-INJECTOR (EA)
EPINEPHRINE 2
AUTO-INJECTOR (EA)
EPINEPHRINE 2
AUTO-INJECTOR (EA)
EPIPEN 2
AUTO-INJECTOR (EA)
EPIPEN JR. 2
TABLET, DISPERSIBLE
EXJADE SP 2
TABLET, CHEWABLE
FOSRENOL 2
AUTO-INJECTOR (EA)
ADRENACLICK 3
AUTO-INJECTOR (EA)
AUVI-Q 3
KIT
EPISNAP 3
GEL IN PACKET (ML)
GELCLAIR 3
TABLET
RENAGEL 3
POWDER IN PACKET (EA)
RENVELA 3
POWDER IN PACKET (EA)
SALIVAMAX 3
TABLET, CHEWABLE
VELPHORO 3
CNS
ANTIDEPRESSANTS
TABLET
amitriptyline hcl 1
TABLET
amitriptyline/chlordiazepoxide 1
TABLET
amitriptyline-perphenazine 1
TABLET
amoxapine 1
TABLET
bupropion hcl 1
TABLET, EXTENDED RELEASE 24 HR
bupropion hcl xl 1
SOLUTION, ORAL
citalopram hbr 1
TABLET
citalopram hbr 1
CAPSULE
clomipramine hcl 1
TABLET
desipramine hcl 1
CAPSULE
doxepin hcl 1
CONCENTRATE, ORAL
doxepin hcl 1
CAPSULE,DELAYED RELEASE (ENTERIC COATED)
duloxetine hcl 1
SOLUTION, ORAL
escitalopram oxalate 1
TABLET
escitalopram oxalate 1
SOLUTION, ORAL
fluoxetine hcl 1
CAPSULE
fluoxetine hcl 1
TABLET
fluvoxamine maleate 1
TABLET
imipramine hcl 1
CAPSULE
imipramine pamoate 1
TABLET
maprotiline hcl 1
TABLET
mirtazapine 1
TABLET
nefazodone hcl 1
Printed Date:11/1/2017
Page 21 | 2018 National Formulary Data Last Updated:10/30/2017
B4G Participant: N
CNS
ANTIDEPRESSANTS
CAPSULE
nortriptyline hcl 1
SOLUTION, ORAL
nortriptyline hcl 1
TABLET, EXTENDED RELEASE 24 HR
paroxetine er 1
TABLET
paroxetine hcl 1
TABLET
phenelzine sulfate 1
TABLET
protriptyline hcl 1
TABLET
sertraline hcl 1
TABLET
tranylcypromine sulfate 1
TABLET
trazodone hcl 1
TABLET
venlafaxine hcl 1
CAPSULE, EXT RELEASE 24 HR
venlafaxine hcl er 1
CAPSULE
BRISDELLE 2
CAPSULE,EXTENDED RELEASE 24 HR DOSE PACK
FETZIMA 2
TABLET
VIIBRYD 2
TABLET, EXTENDED RELEASE 24 HR
APLENZIN SP 3
TABLET, EXTENDED RELEASE 24 HR
DESVENLAFAXINE ER 3
PATCH, TRANSDERMAL 24 HOURS
EMSAM 3
TABLET, EXTENDED RELEASE 24 HR
FORFIVO XL 3
TABLET, EXTENDED RELEASE 24 HR
KHEDEZLA 3
TABLET
MARPLAN 3
TABLET
PEXEVA 3
TABLET, EXTENDED RELEASE 24 HR
PRISTIQ 3
TABLET
SARAFEM 3
MISCELLANEOUS
TABLET
armodafinil 1
TABLET, EXTENDED RELEASE
lithium carbonate 1
CAPSULE
lithium carbonate 1
SOLUTION, ORAL
lithium citrate 1
TABLET
modafinil 1
TABLET
BELVIQ 2
CAPSULE
NUEDEXTA 2
CAPSULE,EXTENDED RELEASE MULTIPHASE 24HR
QSYMIA 2
PEN INJECTOR (ML)
SAXENDA 2
TABLET
XENAZINE SP 3
ANTICONVULSANTS
SUSPENSION, ORAL (FINAL DOSE FORM)
carbamazepine 1
TABLET
carbamazepine 1
TABLET, EXTENDED RELEASE 12 HR
carbamazepine er 1
TABLET, EXTENDED RELEASE 12 HR
carbamazepine er 1
TABLET,DISINTEGRATING
clonazepam 1
TABLET
clonazepam 1
KIT
diazepam 1
TABLET, ENTERIC COATED
divalproex sodium 1
TABLET, EXTENDED RELEASE 24 HR
divalproex sodium er 1
TABLET
epitol 1
CAPSULE
ethosuximide 1
CAPSULE
ethosuximide 1
SOLUTION, ORAL
ethosuximide 1
TABLET
felbamate 1
SUSPENSION, ORAL (FINAL DOSE FORM)
felbamate 1
VIAL (ML)
fosphenytoin sodium 1
CAPSULE
gabapentin 1
TABLET
gabapentin 1
TABLET
lamotrigine 1
TABLET
levetiracetam 1
SOLUTION, ORAL
levetiracetam 1
TABLET
oxcarbazepine 1
Printed Date:11/1/2017
Page 22 | 2018 National Formulary Data Last Updated:10/30/2017
B4G Participant: N
CNS
ANTICONVULSANTS
SUSPENSION, ORAL (FINAL DOSE FORM)
oxcarbazepine 1
ELIXIR
phenobarbital 1
TABLET
phenobarbital 1
SUSPENSION, ORAL (FINAL DOSE FORM)
phenytoin 1
CAPSULE
phenytoin sodium 1
TABLET
primidone 1
TABLET
tiagabine hcl 1
TABLET
topiramate 1
CAPSULE
valproic acid 1
SOLUTION, ORAL
valproic acid 1
CAPSULE
zonisamide 1
TABLET
BANZEL SP 2
TABLET
FYCOMPA 2
TABLET
GABITRIL 2
TABLET, EXTENDED RELEASE, DOSE PACK
LAMICTAL XR 2
CAPSULE
LYRICA 2
SUSPENSION, ORAL (FINAL DOSE FORM)
ONFI SP 2
TABLET, EXTENDED RELEASE 24 HR
OXTELLAR XR 2
TABLET
PEGANONE 2
TABLET
POTIGA 2
TABLET
SABRIL SP 2
CAPSULE, EXT RELEASE 24 HR
TROKENDI XR 2
TABLET
VIMPAT 2
SOLUTION, ORAL
VIMPAT 2
TABLET, EXTENDED RELEASE 24 HR
DEPAKOTE ER 3
CAPSULE,EXTENDED RELEASE MULTIPHASE 12HR
EQUETRO 3
TABLET, EXTENDED RELEASE
HORIZANT 3
TABLET,DISINTEGRATING
LAMICTAL ODT 3
ADHD
TABLET
dexmethylphenidate hcl 1
CAPSULE,EXTENDED RELEASE BIPHASIC 50-50
dexmethylphenidate hcl er 1
SOLUTION, ORAL
dextroamphetamine sulfate 1
TABLET
dextroamphetamine sulfate 1
CAPSULE, EXT RELEASE 24 HR
dextroamphetamine-amphet er 1
TABLET
dextroamphetamine-amphetamine 1
TABLET
guanidine hcl 1
CAPSULE,EXTENDED RELEASE BIPHASIC 50-50
methylphenidate er 1
TABLET
methylphenidate hcl 1
SOLUTION, ORAL
methylphenidate hcl 1
CAPSULE,EXTENDED RELEASE BIPHASIC 30-70
methylphenidate hcl cd 1
PATCH, TRANSDERMAL 24 HOURS
DAYTRANA 2
TABLET,CHEW,IR AND ER BIPHASIC REL 24HR
QUILLICHEW ER 2
SUSPENSION,EXTENDED RELEASE,RECONST.24HR
QUILLIVANT XR 2
CAPSULE
VYVANSE 2
CAPSULE, EXT RELEASE 24 HR
ADDERALL XR 3
TABLET,DISINTEGRATING,ER BIPHASIC 24 HR
ADZENYS XR-ODT 3
CAPSULE,EXTENDED RELEASE BIPHASIC 50-50
FOCALIN XR 3
TABLET, EXTENDED RELEASE 24 HR
INTUNIV 3
CAPSULE
STRATTERA 3
ANTI-PSYCHOTIC
TABLET
aripiprazole 1
TABLET
chlorpromazine hcl 1
TABLET
clozapine 1
TABLET,DISINTEGRATING
clozapine odt 1
TABLET
fluphenazine hcl 1
CONCENTRATE, ORAL
fluphenazine hcl 1
Printed Date:11/1/2017
Page 23 | 2018 National Formulary Data Last Updated:10/30/2017
B4G Participant: N
CNS
ANTI-PSYCHOTIC
TABLET
haloperidol 1
VIAL (ML)
haloperidol decanoate 1
CONCENTRATE, ORAL
haloperidol lactate 1
CAPSULE
loxapine succinate 1
TABLET
olanzapine 1
TABLET,DISINTEGRATING
olanzapine odt 1
CAPSULE
olanzapine-fluoxetine hcl 1
TABLET
perphenazine 1
TABLET
quetiapine fumarate 1
TABLET, EXTENDED RELEASE 24 HR
quetiapine fumarate er 1
TABLET
risperidone 1
TABLET,DISINTEGRATING
risperidone odt 1
TABLET
thioridazine hcl 1
CAPSULE
thiothixene 1
TABLET
trifluoperazine hcl 1
CAPSULE
ziprasidone hcl 1
SUSPENSION,EXTENDED RELEASE SYRINGE (EA)
ABILIFY MAINTENA SP 2
TABLET
LATUDA 2
SYRINGE (EA)
RISPERDAL CONSTA SP 2
TABLET, SUBLINGUAL
SAPHRIS 2
TABLET
ABILIFY 3
TABLET
FANAPT 3
TABLET,DISINTEGRATING
FAZACLO 3
TABLET, EXTENDED RELEASE 24 HR
INVEGA SP 3
TABLET
ORAP 3
TABLET
REXULTI 3
TABLET, EXTENDED RELEASE 24 HR
SEROQUEL XR 3
SUSPENSION, ORAL (FINAL DOSE FORM)
VERSACLOZ 3
ANXIOLYTICS
TABLET
alprazolam 1
TABLET, EXTENDED RELEASE 24 HR
alprazolam er 1
CONCENTRATE, ORAL
alprazolam intensol 1
TABLET,DISINTEGRATING
alprazolam odt 1
TABLET, EXTENDED RELEASE 24 HR
alprazolam xr 1
TABLET
buspirone hcl 1
CAPSULE
chlordiazepoxide hcl 1
TABLET
clorazepate dipotassium 1
CONCENTRATE, ORAL
diazepam 1
TABLET
diazepam 1
TABLET
lorazepam 1
CONCENTRATE, ORAL
lorazepam intensol 1
SYRUP
midazolam hcl 1
CAPSULE
oxazepam 1
ALZHEIMER'S
CAPSULE, EXTENDED RELEASE PELLETS 24 HR
galantamine er 1
CAPSULE
rivastigmine 1
CAPSULE SPRINKLE, EXTENDED RELEASE 24 HR
NAMENDA XR 2
PATCH, TRANSDERMAL 24 HOURS
EXELON 3
SOLUTION, ORAL
NAMENDA 3
ANTIPARKINSONISM
TABLET
benztropine mesylate 1
TABLET
bromocriptine mesylate 1
TABLET
carbidopa/levodopa 1
TABLET, EXTENDED RELEASE
carbidopa-levodopa er 1
TABLET
carbidopa-levodopa-entacapone 1
TABLET
entacapone 1
TABLET
ropinirole hcl 1
Printed Date:11/1/2017
Page 24 | 2018 National Formulary Data Last Updated:10/30/2017
B4G Participant: N
CNS
ANTIPARKINSONISM
TABLET
selegiline hcl 1
ELIXIR
trihexyphenidyl hcl 1
TABLET
trihexyphenidyl hcl 1
PATCH, TRANSDERMAL 24 HOURS
NEUPRO 2
TABLET,DISINTEGRATING
ZELAPAR 2
TABLET
AZILECT 3
TABLET, EXTENDED RELEASE 24 HR
MIRAPEX ER 3
TABLET
STALEVO 3
TABLET
TASMAR 3
MS
TABLET, EXTENDED RELEASE 12 HR
AMPYRA SP 2
TABLET
AUBAGIO SP 2
CAPSULE
GILENYA SP 2
CAPSULE,DELAYED RELEASE (ENTERIC COATED)
TECFIDERA SP 2
SYRINGE (ML)
COPAXONE SP 3
SLEEP
TABLET
estazolam 1
TABLET
eszopiclone 1
CAPSULE
flurazepam hcl 1
TABLET
quazepam 1
CAPSULE
temazepam 1
CAPSULE
zaleplon 1
TABLET, EXTENDED RELEASE MULTIPHASE
zolpidem tartrate er 1
TABLET
BELSOMRA 2
TABLET
ROZEREM 2
TABLET
BUTISOL SODIUM 3
TABLET, SUBLINGUAL
INTERMEZZO 3
AEROSOL, SPRAY WITH PUMP (ML)
ZOLPIMIST 3
ENDOCRINE
CONTRACEPTIVES
TABLET
altavera 1
TABLET
alyacen 1
TABLET, DOSE PACK, 3 MONTHS
amethia 1
TABLET
amethyst 1
TABLET
apri 1
TABLET
aranelle 1
TABLET
aubra 1
TABLET
aviane 1
TABLET
azurette 1
TABLET
balziva 1
TABLET
briellyn 1
TABLET, DOSE PACK, 3 MONTHS
camrese 1
TABLET
caziant 1
TABLET
chateal 1
TABLET
cryselle 1
TABLET
cyclafem 1
TABLET
dasetta 1
TABLET, DOSE PACK, 3 MONTHS
daysee 1
TABLET
elinest 1
TABLET
emoquette 1
TABLET
enpresse 1
TABLET
enskyce 1
TABLET
estarylla 1
TABLET
falmina 1
TABLET
gianvi 1
TABLET
gildagia 1
TABLET, DOSE PACK, 3 MONTHS
introvale 1
TABLET, DOSE PACK, 3 MONTHS
jolessa 1
Printed Date:11/1/2017
Page 25 | 2018 National Formulary Data Last Updated:10/30/2017
B4G Participant: N
ENDOCRINE
CONTRACEPTIVES
TABLET
junel 1
TABLET
kariva 1
TABLET
kelnor 1-35 1
TABLET
kurvelo 1
TABLET
larin fe 1
TABLET
leena 1
TABLET
lessina 1
TABLET
levonest 1
TABLET
levora 1
TABLET
lomedia 24 fe 1
TABLET
loryna 1
TABLET
low-ogestrel 1
TABLET
lutera 1
TABLET
marlissa 1
TABLET
microgestin 1
TABLET
mono-linyah 1
TABLET
mononessa 1
TABLET
myzilra 1
TABLET
necon 1
TABLET
nortrel 1
TABLET
ocella 1
TABLET
ogestrel 1
TABLET
orsythia 1
TABLET
philith 1
TABLET
pimtrea 1
TABLET
pirmella 1
TABLET
portia 1
TABLET
previfem 1
TABLET, DOSE PACK, 3 MONTHS
quasense 1
TABLET
reclipsen 1
TABLET
sprintec 1
TABLET
sronyx 1
TABLET
syeda 1
TABLET
tilia fe 1
TABLET
tri-estarylla 1
TABLET
tri-linyah 1
TABLET
trinessa 1
TABLET
tri-previfem 1
TABLET
tri-sprintec 1
TABLET
trivora 1
TABLET
velivet 1
TABLET
vestura 1
TABLET
viorele 1
TABLET
wera 1
TABLET, CHEWABLE
wymzya fe 1
TABLET
zarah 1
TABLET
zenchent 1
TABLET
zovia 1
TABLET
LO LOESTRIN FE 2
TABLET
NATAZIA 2
RING, VAGINAL
NUVARING 2
TABLET
SAFYRAL 2
INTRAUTERINE DEVICE
SKYLA SP 2
TABLET
BEYAZ 3
TABLET, CHEWABLE
GENERESS FE 3
Printed Date:11/1/2017
Page 26 | 2018 National Formulary Data Last Updated:10/30/2017
B4G Participant: N
ENDOCRINE
CONTRACEPTIVES
TABLET
ORTHO TRI-CYCLEN LO 3
TABLET, DOSE PACK, 3 MONTHS
QUARTETTE 3
ESTROGENS
PATCH, TRANSDERMAL WEEKLY
estradiol 1
TABLET
estradiol-norethindrone acetat 1
TABLET
estrogen & methyltestosterone 1
TABLET
jinteli 1
PATCH, TRANSDERMAL SEMIWEEKLY
COMBIPATCH 2
GEL IN PACKET (EA)
DIVIGEL 2
TABLET
DUAVEE 2
CREAM WITH APPLICATOR
ESTRACE 2
PATCH, TRANSDERMAL SEMIWEEKLY
MINIVELLE 2
CREAM WITH APPLICATOR
PREMARIN 2
TABLET
PREMARIN 2
TABLET
PREMPHASE 2
TABLET
PREMPRO 2
PATCH, TRANSDERMAL SEMIWEEKLY
ALORA 3
TABLET
ANGELIQ 3
PATCH, TRANSDERMAL WEEKLY
CLIMARA PRO 3
RING, VAGINAL
ESTRING 3
GEL IN METERED-DOSE PUMP
ESTROGEL 3
TABLET
FEMHRT 3
TABLET
PREFEST 3
TABLET
VAGIFEM 3
PROGESTINS
TABLET
camila 1
TABLET
errin 1
TABLET
heather 1
TABLET
jencycla 1
TABLET
jolivette 1
TABLET
lyza 1
TABLET
nora-be 1
TABLET
norethindrone acetate 1
CAPSULE
progesterone 1
GEL WITH PREFILLED APPLICATOR (GRAM)
CRINONE SP 2
INSERT
ENDOMETRIN SP 2
OVULATORY STIMULANTS
TABLET
clomiphene citrate SP 1
VIAL (ML)
FOLLISTIM AQ SP 2
CARTRIDGE (ML)
FOLLISTIM AQ SP 2
VIAL (EA)
GONAL-F SP 2
VIAL (EA)
MENOPUR SP 2
VIAL (EA)
BRAVELLE SP 3
GONADOTROPIN
KIT
CETROTIDE SP 2
VIAL (EA)
NOVAREL SP 2
SYRINGE (ML)
GANIRELIX ACETATE SP 3
VIAL (EA)
PREGNYL SP 3
TESTOSTERONE
TABLET
androxy 1
CAPSULE
danazol 1
TABLET
oxandrolone 1
VIAL (ML)
testosterone cypionate 1
GEL IN PACKET (GRAM)
ANDROGEL 2
GEL IN METERED-DOSE PUMP
ANDROGEL 2
SOLUTION IN METERED-DOSE PUMP WITH APPL.
AXIRON 2
PATCH, TRANSDERMAL 24 HOURS
ANDRODERM 3
CAPSULE
ANDROID 3
Printed Date:11/1/2017
Page 27 | 2018 National Formulary Data Last Updated:10/30/2017
B4G Participant: N
ENDOCRINE
TESTOSTERONE
VIAL (ML)
DEPO-TESTOSTERONE 3
GEL IN METERED-DOSE PUMP
FORTESTA 3
GEL IN METERED-DOSE PUMP
NATESTO 3
MUCOADHESIVE SYSTEM,EXTEND.RELEASE 12 HR
STRIANT 3
GEL (GRAM)
TESTIM 3
PELLET (EA)
TESTOPEL SP 3
GEL IN PACKET (GRAM)
TESTOSTERONE 3
GEL (GRAM)
TESTOSTERONE 3
GEL IN METERED-DOSE PUMP
TESTOSTERONE 3
CAPSULE
TESTRED 3
GEL (GRAM)
VOGELXO 3
GEL IN PACKET (GRAM)
VOGELXO 3
GEL IN METERED-DOSE PUMP
VOGELXO 3
ADRENAL HORMONES
TABLET
dexamethasone 1
TABLET
fludrocortisone acetate 1
TABLET
hydrocortisone 1
TABLET, DOSE PACK
methylprednisolone 1
VIAL (ML)
methylprednisolone acetate 1
SOLUTION, ORAL
prednisolone 1
TABLET
prednisone 1
VIAL (EA)
SOLU-CORTEF 2
VIAL (ML)
ACTHAR H.P. 3
TABLET,DISINTEGRATING
ORAPRED ODT 3
TABLET, ENTERIC COATED
RAYOS 3
THYROID
TABLET
levothyroxine sodium 1
TABLET
levoxyl 1
TABLET
liothyronine sodium 1
TABLET
methimazole 1
TABLET
nature-throid 1
TABLET
unithroid 1
TABLET
ARMOUR THYROID 2
SOLUTION, ORAL
SSKI 3
TABLET
THYROLAR 3
CAPSULE
TIROSINT 3
MISCELLANEOUS
TABLET
cabergoline 1
CAPSULE
calcitriol 1
AEROSOL, SPRAY WITH PUMP (ML)
desmopressin acetate 1
TABLET
desmopressin acetate 1
TABLET
ADDYI 3
GASTROINTESTINAL
H2 ANTAGONISTS
SOLUTION, ORAL
cimetidine 1
TABLET
cimetidine 1
SUSPENSION, ORAL (FINAL DOSE FORM)
famotidine 1
TABLET
famotidine 1
TABLET
misoprostol 1
CAPSULE
nizatidine 1
SYRUP
ranitidine hcl 1
TABLET
ranitidine hcl 1
PROTON PUMP INHIBITORS
CAPSULE,DELAYED RELEASE (ENTERIC COATED)
lansoprazole 1
CAPSULE,DELAYED RELEASE (ENTERIC COATED)
omeprazole 1
CAPSULE
omeprazole-sodium bicarbonate 1
TABLET, ENTERIC COATED
pantoprazole sodium 1
TABLET, ENTERIC COATED
rabeprazole sodium 1
Printed Date:11/1/2017
Page 28 | 2018 National Formulary Data Last Updated:10/30/2017
B4G Participant: N
GASTROINTESTINAL
PROTON PUMP INHIBITORS
CAPSULE, DELAYED RELEASE, BIPHASIC
DEXILANT 3
SUSP FOR RECON,DELAYED REL. IN A PACKET
NEXIUM RX 3
CAPSULE,DELAYED RELEASE (ENTERIC COATED)
NEXIUM RX 3
PACKET (EA)
ZEGERID RX 3
OTHER ULCER THERAPY
COMBINATION PACKAGE (EA)
lansoprazol-amoxicil-clarithro 1
TABLET
sucralfate 1
SUSPENSION, ORAL (FINAL DOSE FORM)
CARAFATE 2
CAPSULE
PYLERA 2
ANTIEMETIC
CAPSULE
dronabinol SP 1
TABLET
granisetron hcl SP 1
TABLET
meclizine hcl 1
SOLUTION, ORAL
ondansetron hcl 1
TABLET
ondansetron hcl 1
TABLET,DISINTEGRATING
ondansetron odt 1
SUPPOSITORY, RECTAL
prochlorperazine maleate 1
TABLET
prochlorperazine maleate 1
CAPSULE
trimethobenzamide hcl 1
PATCH, TRANSDERMAL WEEKLY
SANCUSO SP 2
TABLET
ANZEMET SP 3
CAPSULE
EMEND SP 3
PATCH,TRANSDERMAL 3 DAY
TRANSDERM-SCOP 3
FILM, MEDICATED (EA)
ZUPLENZ 3
ANTIDIARRHEALS
TABLET,DISINTEGRATING
anaspaz 1
CAPSULE
dicyclomine hcl 1
CAPSULE
dicyclomine hcl 1
TABLET
diphenoxylate w/atropine 1
LIQUID (ML)
diphenoxylate w/atropine 1
TABLET
glycopyrrolate 1
DROPS
hyoscyamine sulfate 1
CAPSULE
loperamide hcl 1
TABLET
methscopolamine bromide 1
SOLUTION, ORAL
CUVPOSA 3
TABLET
HOMAPIN 10 3
DIGESTIVE ENZYMES
CAPSULE,DELAYED RELEASE (ENTERIC COATED)
CREON SP 2
SOLUTION, ORAL
SUCRAID SP 2
TABLET
VIOKACE SP 2
CAPSULE,DELAYED RELEASE (ENTERIC COATED)
ZENPEP SP 2
CAPSULE,DELAYED RELEASE (ENTERIC COATED)
PANCREAZE SP 3
CAPSULE,DELAYED RELEASE (ENTERIC COATED)
PERTZYE SP 3
BOWEL EVACUANTS
SOLUTION, RECONSTITUTED, ORAL
SUPREP 2
SOLUTION, RECONSTITUTED, ORAL
COLYTE 3
POWDER IN PACKET (EA)
MOVIPREP 3
TABLET
OSMOPREP 3
RECTAL
SUPPOSITORY, RECTAL
anucort-hc 1
ENEMA (ML)
colocort 1
ENEMA (ML)
mesalamine 1
SUPPOSITORY, RECTAL
CANASA 2
AEROSOL, FOAM WITH APPLICATOR (GRAM)
CORTIFOAM 2
OTHER
CAPSULE
balsalazide disodium 1
CAPSULE, DELAYED, AND EXTENDED RELEASE
budesonide ec 1
CAPSULE
clidinium w/chlordiazepoxide 1
SOLUTION, ORAL
constulose 1
Printed Date:11/1/2017
Page 29 | 2018 National Formulary Data Last Updated:10/30/2017
B4G Participant: N
GASTROINTESTINAL
OTHER
SOLUTION, ORAL
lactulose 1
TABLET
metoclopramide hcl 1
SOLUTION, ORAL
metoclopramide hcl 1
TABLET
sulfasalazine 1
TABLET, ENTERIC COATED
sulfasalazine dr 1
CAPSULE
ursodiol 1
CAPSULE
AMITIZA 2
CAPSULE, EXT RELEASE 24 HR
APRISO 2
TABLET, ENTERIC COATED
ASACOL HD SP 2
LIQUID (ML)
BELLADONNA 2
TABLET
CHENODAL SP 2
CAPSULE (WITH DELAYED RELEASE TABLETS)
DELZICOL 2
VIAL (EA)
KINEVAC 2
CAPSULE
LINZESS 2
TABLET
MOVANTIK 2
CAPSULE, EXTENDED RELEASE
PENTASA 2
SYRINGE (ML)
RELISTOR SP 2
CAPSULE
DIPENTUM 3
CAPSULE
ENTEREG 3
TABLET
GIAZO 3
PACKET (EA)
KRISTALOSE 3
TABLET, ENTERIC COATED
LIALDA SP 3
TABLET
LOTRONEX 3
MUSCULOSKELETAL
OSTEOPOROSIS
SOLUTION, ORAL
alendronate sodium 1
TABLET
alendronate sodium 1
TABLET
ibandronate sodium 1
PEN INJECTOR (ML)
FORTEO SP 2
TABLET
ACTONEL 3
TABLET, ENTERIC COATED
ATELVIA 3
TABLET, EFFERVESCENT
BINOSTO 3
TABLET
FOSAMAX PLUS D 3
SYRINGE (ML)
PROLIA SP 3
MUSCLE RELAXANTS
TABLET
baclofen 1
TABLET
carisoprodol 1
TABLET
carisoprodol compound 1
TABLET
carisoprodol compound/codeine 1
TABLET
carisoprodol-aspirin 1
TABLET
chlorzoxazone 1
TABLET
cyclobenzaprine hcl 1
CAPSULE
dantrolene sodium 1
TABLET
meprobamate 1
TABLET
metaxalone 1
TABLET
methocarbamol 1
TABLET, EXTENDED RELEASE
orphenadrine citrate 1
TABLET
tizanidine hcl 1
CAPSULE, EXT RELEASE 24 HR
AMRIX 3
TABLET
LORZONE 3
GOUT THERAPY
TABLET
allopurinol 1
CAPSULE
COLCHICINE 1
TABLET
probenecid 1
TABLET
probenecid w/colchicine 1
TABLET
COLCRYS 2
Printed Date:11/1/2017
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B4G Participant: N
MUSCULOSKELETAL
GOUT THERAPY
CAPSULE
MITIGARE 2
TABLET
ULORIC 2
ANTI-INFLAMMATORY
PEN INJECTOR (ML)
COSENTYX 150MG SP 2
* PA: Coverage based on indication. See details in Major Drug Class Overview chart.
SYRINGE (ML)
COSENTYX 300MG SP 2
* PA: Coverage based on indication. See details in Major Drug Class Overview chart.
PEN INJECTOR (ML)
ENBREL SP 2
* PA: Coverage based on indication. See details in Major Drug Class Overview chart.
VIAL (EA)
ENTYVIO SP 2
* PA: Coverage based on indication. See details in Major Drug Class Overview chart.
PEN INJECTOR KIT (EA)
HUMIRA SP 2
* PA: Coverage based on indication. See details in Major Drug Class Overview chart.
SYRINGE (ML)
ORENCIA SP 2
* PA: Coverage based on indication. See details in Major Drug Class Overview chart.
AUTO-INJECTOR (ML)
ORENCIA CLICKJECT SP 2
* PA: Coverage based on indication. See details in Major Drug Class Overview chart.
AUTO-INJECTOR (ML)
OTREXUP SP 2
AUTO-INJECTOR (ML)
RASUVO SP 2
TABLET
SAVELLA 2
* PA: Coverage based on indication. See details in Major Drug Class Overview chart.
SYRINGE (ML)
SILIQ SP
2
* PA: Coverage based on indication. See details in Major Drug Class Overview chart.
SYRINGE (ML)
ACTEMRA SP 3
* PA: Coverage based on indication. See details in Major Drug Class Overview chart.
KIT
CIMZIA SP 3
* PA: Coverage based on indication. See details in Major Drug Class Overview chart.
SYRINGE KIT (EA)
CIMZIA SP 3
* PA: Coverage based on indication. See details in Major Drug Class Overview chart.
SYRINGE (ML)
KINERET SP 3
* PA: Coverage based on indication. See details in Major Drug Class Overview chart.
TABLET
OTEZLA SP 3
* PA: Coverage based on indication. See details in Major Drug Class Overview chart.
VIAL (EA)
REMICADE SP 3
* PA: Coverage based on indication. See details in Major Drug Class Overview chart.
TABLET
SAVELLA 3
* PA: Coverage based on indication. See details in Major Drug Class Overview chart.
PEN INJECTOR (ML)
SIMPONI SP 3
* PA: Coverage based on indication. See details in Major Drug Class Overview chart.
SYRINGE (ML)
STELARA SP 3
* PA: Coverage based on indication. See details in Major Drug Class Overview chart.
AUTO-INJECTOR (ML)
TALTZ AUTOINJECTOR SP 3
* PA: Coverage based on indication. See details in Major Drug Class Overview chart.
SYRINGE (ML)
TALTZ SYRINGE SP 3
* PA: Coverage based on indication. See details in Major Drug Class Overview chart.
TABLET
XELJANZ SP 3
* PA: Coverage based on indication. See details in Major Drug Class Overview chart.
TABLET, EXTENDED RELEASE 24 HR
XELJANZ XR SP 3
* PA: Coverage based on indication. See details in Major Drug Class Overview chart.
RESPIRATORY
AMPUL FOR NEBULIZATION (ML)
ipratropium-albuterol 1
GRANULES IN PACKET (EA)
montelukast sodium 1
TABLET
montelukast sodium 1
TABLET
sildenafil citrate SP 1
TABLET
zafirlukast 1
TABLET
ADCIRCA SP 2
TABLET
ADEMPAS 2
BLISTER, WITH INHALATION DEVICE
ADVAIR DISKUS 2
Printed Date:11/1/2017
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B4G Participant: N
RESPIRATORY
HFA AEROSOL WITH ADAPTER (GRAM)
ADVAIR HFA 2
BLISTER, WITH INHALATION DEVICE
ANORO ELLIPTA 2
HFA AEROSOL WITH ADAPTER (GRAM)
ATROVENT HFA 2
BLISTER, WITH INHALATION DEVICE
BREO ELLIPTA 2
MIST INHALER (GRAM)
COMBIVENT RESPIMAT 2
TABLET
DALIRESP 2
TABLET
KALYDECO SP 2
TABLET
LETAIRIS SP 2
SOLUTION, NON-ORAL
PULMOZYME SP 2
CAPSULE, WITH INHALATION DEVICE
SPIRIVA 2
MIST INHALER (GRAM)
SPIRIVA RESPIMAT 2
MIST INHALER (GRAM)
STIOLTO RESPIMAT 2
HFA AEROSOL WITH ADAPTER (GRAM)
SYMBICORT 2
TABLET
TRACLEER SP 2
AEROSOL POWDER, BREATH ACTIVATED (EA)
TUDORZA PRESSAIR 2
VIAL (EA)
XOLAIR SP 2
HFA AEROSOL WITH ADAPTER (GRAM)
DULERA 3
BLISTER, WITH INHALATION DEVICE
INCRUSE ELLIPTA 3
TABLET
ZYFLO SP 3
INHALED STEROIDS
AMPUL FOR NEBULIZATION (ML)
budesonide 1
BLISTER, WITH INHALATION DEVICE
ARNUITY ELLIPTA 2
BLISTER, WITH INHALATION DEVICE
FLOVENT DISKUS 2
AEROSOL WITH ADAPTER (GRAM)
FLOVENT HFA 2
AEROSOL POWDER, BREATH ACTIVATED (EA)
PULMICORT FLEXHALER 2
AEROSOL WITH ADAPTER (GRAM)
QVAR 2
HFA AEROSOL WITH ADAPTER (GRAM)
ALVESCO 3
AEROSOL POWDER, BREATH ACTIVATED (EA)
ASMANEX 3
NASAL STEROIDS
AEROSOL, SPRAY (ML)
flunisolide 1
SPRAY, SUSPENSION
fluticasone propionate 1
AEROSOL, SPRAY WITH PUMP (GRAM)
DYMISTA 2
AEROSOL, SPRAY (GRAM)
BECONASE AQ 3
AEROSOL, SPRAY WITH PUMP (GRAM)
NASONEX 3
AEROSOL, SPRAY WITH PUMP (GRAM)
OMNARIS 3
HFA AEROSOL WITH ADAPTER (GRAM)
QNASL 3
HFA AEROSOL WITH ADAPTER (GRAM)
ZETONNA 3
BETA AGONISTS
SOLUTION, NON-ORAL
albuterol sulfate 1
TABLET
albuterol sulfate 1
SYRUP
albuterol sulfate 1
VIAL, NEBULIZER (ML)
levalbuterol hcl 1
SYRUP
metaproterenol sulfate 1
TABLET
metaproterenol sulfate 1
TABLET
terbutaline sulfate 1
VIAL, NEBULIZER (ML)
PERFOROMIST 2
HFA AEROSOL WITH ADAPTER (GRAM)
PROAIR HFA 2
BLISTER, WITH INHALATION DEVICE
SEREVENT DISKUS 2
MIST INHALER (GRAM)
STRIVERDI RESPIMAT 2
HFA AEROSOL WITH ADAPTER (GRAM)
VENTOLIN HFA 2
CAPSULE, WITH INHALATION DEVICE
ARCAPTA NEOHALER 3
CAPSULE, WITH INHALATION DEVICE
FORADIL 3
HFA AEROSOL WITH ADAPTER (GRAM)
PROVENTIL HFA 3
HFA AEROSOL WITH ADAPTER (GRAM)
XOPENEX HFA 3
ANTIHISTAMINES
TABLET
arbinoxa 1
TABLET
carbinoxamine 1
LIQUID (ML)
carbinoxamine 1
Printed Date:11/1/2017
Page 32 | 2018 National Formulary Data Last Updated:10/30/2017
B4G Participant: N
RESPIRATORY
ANTIHISTAMINES
TABLET
clemastine fumarate 1
TABLET
cyproheptadine hcl 1
TABLET
desloratadine 1
ELIXIR
diphenhydramine hcl 1
SOLUTION, ORAL
hydroxyzine hcl 1
TABLET
hydroxyzine hcl 1
CAPSULE
hydroxyzine pamoate 1
CAPSULE
hydroxyzine pamoate 1
TABLET
levocetirizine dihydrochloride 1
TABLET
promethazine hcl 1
TABLET
r-tanna 1
SYRUP
CYPROHEPTADINE HCL 3
CAPSULE
SEMPREX-D 3
ANTITUSSIVE
CAPSULE
benzonatate 1
LIQUID (ML)
guaifenesin with codeine 1
TABLET
hydrocodone/homatropine 1
SUSPENSION, EXTENDED RELEASE 12 HR
hydrocodone-chlorpheniramine 1
SYRUP
promethazine vc w/codeine 1
SYRUP
promethazine w/dm 1
CAPSULE, EXTENDED RELEASE 12 HR
TUSSICAPS 2
SYRUP
BROMFED-DM 3
SUSPENSION, ORAL (FINAL DOSE FORM)
ZODRYL AC 35 3
OTHER
AEROSOL, SPRAY WITH PUMP (ML)
azelastine hcl 1
AEROSOL, SPRAY (ML)
ipratropium bromide 1
TABLET, EXTENDED RELEASE 12 HR
theophylline anhydrous 1
SOLUTION, ORAL
theophylline anhydrous 1
SPACER (EA)
AEROCHAMBER 2
SPACER (EA)
AEROCHAMBER PLUS 2
AEROSOL, SPRAY WITH PUMP (GRAM)
PATANASE 3
ANTI-INFECTIVES
PENICILLINS
TABLET
amoxicillin 1
SUSPENSION, RECONSTITUTED, ORAL (ML)
amoxicillin 1
TABLET, EXTENDED RELEASE 12 HR
amoxicillin-clavulanate pot er 1
TABLET
amoxicillin-clavulanate potass 1
SUSPENSION, RECONSTITUTED, ORAL (ML)
amoxicillin-clavulanate potass 1
CAPSULE
ampicillin trihydrate 1
SUSPENSION, RECONSTITUTED, ORAL (ML)
ampicillin trihydrate 1
CAPSULE
dicloxacillin sodium 1
TABLET
penicillin v potassium 1
SOLUTION, RECONSTITUTED, ORAL
penicillin v potassium 1
HIV
TABLET
abacavir SP 1
TABLET
abacavir-lamivudine-zidovudine SP 1
CAPSULE,DELAYED RELEASE (ENTERIC COATED)
didanosine SP 1
TABLET
lamivudine-zidovudine SP 1
SUSPENSION, ORAL (FINAL DOSE FORM)
nevirapine SP 1
TABLET
nevirapine SP 1
CAPSULE
stavudine SP 1
SOLUTION, RECONSTITUTED, ORAL
stavudine SP 1
TABLET
zidovudine 1
CAPSULE
zidovudine 1
SYRUP
zidovudine 1
SOLUTION, ORAL
APTIVUS SP 2
CAPSULE
APTIVUS SP 2
TABLET
ATRIPLA SP 2
Printed Date:11/1/2017
Page 33 | 2018 National Formulary Data Last Updated:10/30/2017
B4G Participant: N
ANTI-INFECTIVES
HIV
TABLET
COMPLERA SP 2
CAPSULE
CRIXIVAN SP 2
TABLET
DESCOVY SP 2
TABLET
EDURANT SP 2
CAPSULE
EMTRIVA SP 2
SOLUTION, ORAL
EMTRIVA SP 2
TABLET
GENVOYA SP 2
TABLET
INTELENCE SP 2
TABLET
INVIRASE SP 2
TABLET
ISENTRESS SP 2
TABLET
KALETRA SP 2
TABLET
LEXIVA SP 2
SUSPENSION, ORAL (FINAL DOSE FORM)
LEXIVA SP 2
SOLUTION, ORAL
NORVIR SP 2
TABLET
NORVIR SP 2
TABLET
ODEFSEY 2
TABLET
PREZISTA SP 2
SUSPENSION, ORAL (FINAL DOSE FORM)
PREZISTA SP 2
TABLET
RESCRIPTOR SP 2
CAPSULE
REYATAZ SP 2
TABLET
SELZENTRY SP 2
TABLET
STRIBILD SP 2
CAPSULE
SUSTIVA SP 2
TABLET
TIVICAY SP 2
TABLET
TRUVADA SP 2
SOLUTION, RECONSTITUTED, ORAL
VIDEX SP 2
TABLET
VIRACEPT SP 2
TABLET
VIREAD SP 2
SOLUTION, ORAL
ZIAGEN 2
SOLUTION, ORAL
EPIVIR SP 3
TABLET
EPZICOM SP 3
SOLUTION, ORAL
KALETRA 3
ANTIVIRALS
SUSPENSION, ORAL (FINAL DOSE FORM)
acyclovir 1
CAPSULE
acyclovir 1
TABLET
acyclovir 1
CAPSULE
amantadine hcl 1
SOLUTION, ORAL
amantadine hcl 1
TABLET
famciclovir 1
TABLET
lamivudine SP 1
TABLET
moderiba SP 1
TABLET, DOSE PACK
ribapak SP 1
CAPSULE
ribasphere SP 1
TABLET
ribavirin SP 1
CAPSULE
ribavirin SP 1
TABLET
rimantadine hcl 1
TABLET
valacyclovir 1
SOLUTION, ORAL
EPIVIR HBV SP 2
SUSPENSION, RECONSTITUTED, ORAL (ML)
TAMIFLU 2
TABLET
BARACLUDE SP 3
SOLUTION, ORAL
REBETOL SP 3
MUCO-ADHESIVE BUCCAL TABLET
SITAVIG SP 3
CAPSULE
TAMIFLU 3
TABLET
VALCYTE SP 3
SOLUTION, RECONSTITUTED, ORAL
VALCYTE SP 3
VAGINAL
Printed Date:11/1/2017
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B4G Participant: N
ANTI-INFECTIVES
VAGINAL
CREAM WITH APPLICATOR
clindamycin phosphate 1
GEL WITH APPLICATOR (GRAM)
metronidazole 1
SUPPOSITORY, VAGINAL
miconazole 3 1
CREAM WITH APPLICATOR
terconazole 1
SUPPOSITORY, VAGINAL
terconazole 1
CREAM WITH APPLICATOR
AVC 3
CREAM WITH PREFILLED APPLICATOR
GYNAZOLE-1 3
MISCELLANEOUS
CAPSULE
clindamycin hcl 1
SOLUTION, RECONSTITUTED, ORAL
clindamycin palmitate hcl 1
TABLET
dapsone 1
TABLET
linezolid SP 1
TABLET
methenamine hippurate 1
TABLET
methenamine mandelate 1
CAPSULE
nitrofurantoin 1
CAPSULE
nitrofurantoin macrocrystal 1
TABLET
sulfadiazine 1
TABLET
sulfamethoxazole/trimethoprim 1
SUSPENSION, ORAL (FINAL DOSE FORM)
sulfamethoxazole/trimethoprim 1
TABLET
trimethoprim 1
CAPSULE
vancomycin hcl 1
CAPSULE
TOBI PODHALER SP 2
TABLET
XIFAXAN SP 2
PACKET (EA)
MONUROL 3
SOLUTION, ORAL
PRIMSOL 3
TABLET
SIVEXTRO SP 3
TABLET
ZYVOX SP 3
HEPATITIS C
TABLET
MAVYRET 2
TABLET
ZEPATIER SP 2
TABLET
DAKLINZA SP 4
TABLET
EPCLUSA SP 4
TABLET
HARVONI SP 4
CAPSULE
OLYSIO SP 4
TABLET
SOVALDI SP 4
TABLET
TECHNIVIE SP 4
TABLET, DOSE PACK
VIEKIRA PAK SP 4
CEPHALOSPORINS
SUSPENSION, RECONSTITUTED, ORAL (ML)
cefaclor 1
CAPSULE
cefaclor 1
CAPSULE
cefadroxil 1
SUSPENSION, RECONSTITUTED, ORAL (ML)
cefadroxil 1
CAPSULE
cefdinir 1
SUSPENSION, RECONSTITUTED, ORAL (ML)
cefdinir 1
SUSPENSION, RECONSTITUTED, ORAL (ML)
cefprozil 1
TABLET
cefprozil 1
SUSPENSION, RECONSTITUTED, ORAL (ML)
ceftibuten 1
CAPSULE
ceftibuten 1
TABLET
cephalexin 1
SUSPENSION, RECONSTITUTED, ORAL (ML)
cephalexin 1
SUSPENSION, RECONSTITUTED, ORAL (ML)
CEFTIN 3
SUSPENSION, RECONSTITUTED, ORAL (ML)
SUPRAX 3
ERYTHROMYCINS/MACROLIDS
SUSPENSION, RECONSTITUTED, ORAL (ML)
azithromycin 1
SUSPENSION, RECONSTITUTED, ORAL (ML)
clarithromycin 1
TABLET
clarithromycin 1
TABLET, EXTENDED RELEASE 24 HR
clarithromycin er 1
Printed Date:11/1/2017
Page 35 | 2018 National Formulary Data Last Updated:10/30/2017
B4G Participant: N
ANTI-INFECTIVES
ERYTHROMYCINS/MACROLIDS
TABLET, ENTERIC COATED
ery-tab 1
TABLET
erythromycin 1
TABLET
erythromycin ethylsuccinate 1
TABLET
DIFICID SP 3
TABLET, PARTICLES/CRYSTALS IN
PCE 3
TETRACYCLINES
TABLET
demeclocycline hcl 1
TABLET
doxycycline hyclate 1
CAPSULE
doxycycline monohydrate 1
CAPSULE
minocycline hcl 1
CAPSULE
morgidox 1
CAPSULE
tetracycline hcl 1
CAPSULE,IMMEDIATE, DELAY RELEASE,BIPHASE
ORACEA 2
TABLET, EXTENDED RELEASE 24 HR
SOLODYN 2
TABLET, ENTERIC COATED
DORYX 3
CAPSULE,IMMEDIATE, DELAY RELEASE,BIPHASE
DOXYCYCLINE IR-DR 3
SYRUP
VIBRAMYCIN 3
QUINOLONES
TABLET,EXTENDED RELEASE MULTIPHASE 24 HR
ciprofloxacin er 1
TABLET
ciprofloxacin hcl 1
SOLUTION, ORAL
levofloxacin hemihydrate 1
TABLET
levofloxacin hemihydrate 1
ANTIFUNGAL
TROCHE
clotrimazole 1
SUSPENSION, RECONSTITUTED, ORAL (ML)
fluconazole 1
TABLET
fluconazole 1
CAPSULE
flucytosine 1
TABLET
griseofulvin 1
SUSPENSION, ORAL (FINAL DOSE FORM)
griseofulvin 1
TABLET
griseofulvin ultramicrosize 1
CAPSULE
itraconazole 1
TABLET
ketoconazole 1
TABLET
nystatin 1
SUSPENSION, ORAL (FINAL DOSE FORM)
nystatin 1
TABLET
terbinafine 1
SUSPENSION, RECONSTITUTED, ORAL (ML)
voriconazole 1
TABLET
voriconazole 1
SUSPENSION, ORAL (FINAL DOSE FORM)
NOXAFIL SP 2
SOLUTION, ORAL
SPORANOX 2
TABLET
ONMEL SP 3
ANTIMALARIALS
TABLET
atovaquone-proguanil hcl 1
TABLET
chloroquine phosphate 1
TABLET
hydroxychloroquine sulfate 1
TABLET
mefloquine hcl 1
CAPSULE
quinine sulfate 1
TABLET
COARTEM 2
TABLET
DARAPRIM 2
TABLET
PRIMAQUINE 2
ANTIMYCOBACTERIALS
TABLET
ethambutol hcl 1
TABLET
isoniazid 1
TABLET
pyrazinamide 1
CAPSULE
rifampin 1
TABLET
SIRTURO 2
CAPSULE
CYCLOSERINE 3
GRANULES DELAYED RELEASE FOR SUSP PACKET
PASER 3
TABLET
RIFATER 3
Printed Date:11/1/2017
Page 36 | 2018 National Formulary Data Last Updated:10/30/2017
B4G Participant: N
ANTI-INFECTIVES
ANTIMYCOBACTERIALS
TABLET
TRECATOR 3
ANTIPARASITICS
TABLET
metronidazole 1
CAPSULE
paromomycin sulfate 1
TABLET
tinidazole 1
TABLET
ALBENZA SP 2
TABLET
ALINIA 2
SUSPENSION, RECONSTITUTED, ORAL (ML)
ALINIA 2
TABLET
BILTRICIDE 2
TABLET, EXTENDED RELEASE
FLAGYL ER 3
SUSPENSION, ORAL (FINAL DOSE FORM)
MEPRON 3
TABLET
STROMECTOL 3
Quick Reference Preferred Drug List
Printed Date:11/1/2017
Page 37 | 2018 National Formulary Data Last Updated:10/30/2017
B4G Participant: N