Formulary 2017 Master Negative Changes from 2016 to … card for more information. ... Androgens North Carolina Value Formulary 2017 Master Negative Changes from 2016 to ... 2017 Master

Pg. 1 of 35

Affected Drug Description of Change Formulary Alternative, if Applicable Category Class

ACYCLOVIR CAP 200MG On formulary, tier change tier 1 to tier 2 Antivirals Antiherpetic AgentsACYCLOVIR SUS 200/5ML On formulary, tier change tier 2 to tier 3 Antivirals Antiherpetic AgentsALLOPURINOL TAB 100MG On formulary, tier change tier 1 to tier 2 Antigout Agents Antigout AgentsALLOPURINOL TAB 300MG On formulary, tier change tier 1 to tier 2 Antigout Agents Antigout AgentsAMNESTEEM CAP 40MG On formulary, tier change tier 2 to tier 4 Dermatological Agents Dermatological AgentsAMOX/K CLAV CHW 200MG On formulary, tier change tier 2 to tier 4 Antibacterials Beta-lactam, PenicillinsAMOX/K CLAV CHW 400MG On formulary, tier change tier 2 to tier 4 Antibacterials Beta-lactam, PenicillinsANASTROZOLE TAB 1MG On formulary, tier change tier 1 to tier 2 Antineoplastics

Aromatase Inhibitors, 3rd Generation

ANDROGEL GEL 1%(25MG) Not on 2017 formulary

testosterone 1% gel (generic Androgel 1% made by Actavis and Par brand only)* *This drug requires prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information.

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

North Carolina Value Formulary 2017 Master Negative Changes from 2016 to 2017

Pg. 2 of 35


ANDROGEL GEL 1%(50MG) Not on 2017 formulary

testosterone 1% gel (generic Androgel 1% made by Actavis and Par brand only)* *This drug requires prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information.


ANDROID CAP 10MG Not on 2017 formulary

methyltestosterone 10 mg capsules* *This drug requires prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information.


APAP/CODEINE SOL 120-12/5 On formulary, tier change tier 2 to tier 3 Analgesics

Opioid Analgesics, Short-acting

APAP/CODEINE TAB 300-15MG On formulary, tier change tier 2 to tier 3 Analgesics




Pg. 3 of 35




APTIOM TAB 200MG On formulary, tier change tier 4 to tier 5 Anticonvulsants Sodium Channel AgentsAPTIOM TAB 400MG On formulary, tier change tier 4 to tier 5 Anticonvulsants Sodium Channel AgentsAPTIOM TAB 600MG On formulary, tier change tier 4 to tier 5 Anticonvulsants Sodium Channel AgentsAPTIOM TAB 800MG On formulary, tier change tier 4 to tier 5 Anticonvulsants Sodium Channel AgentsARMODAFINIL TAB 50MG On formulary, tier change tier 2 to tier 3 Sleep Disorder Agents Sleep Disorders, OtherASCOMP/COD CAP 30MG Not on 2017 formulary

diclofenac, etodolac IR, ibuprofen, naproxen IR Antimigraine Agents Antimigraine Agents

BLEOMYCIN INJ 30UNIT On formulary, tier change tier 2 to tier 4 Antineoplastics Antineoplastics, Other

BLINCYTO INJ 35MCGOn formulary, requires prior authorization check with your doctor Antineoplastics Antineoplastics, Other

BUPREN/NALOX SUB 2-0.5MG On formulary, tier change tier 2 to tier 3

Anti-Addiction/ Substance Abuse Treatment Agents

Opioid Dependence Treatments

BUPROPION TAB 100MG ER On formulary, tier change tier 2 to tier 3 Antidepressants Antidepressants, OtherBUPROPION TAB 100MG SR On formulary, tier change tier 2 to tier 3 Antidepressants Antidepressants, OtherBUPROPION TAB 150MG ER On formulary, tier change tier 2 to tier 3 Antidepressants Antidepressants, OtherBUPROPION TAB 150MG SR On formulary, tier change tier 2 to tier 3 Antidepressants Antidepressants, OtherBUPROPION TAB 200MG ER On formulary, tier change tier 2 to tier 3 Antidepressants Antidepressants, OtherBUPROPION TAB 200MG SR On formulary, tier change tier 2 to tier 3 Antidepressants Antidepressants, OtherBUPROPN HCL TAB 150MG XL On formulary, tier change tier 2 to tier 3 Antidepressants Antidepressants, Other

Pg. 4 of 35


BUPROPN HCL TAB 300MG XL On formulary, tier change tier 2 to tier 3 Antidepressants Antidepressants, OtherBUT/APAP/CAF CAP CODEINE Not on 2017 formulary


BUT/ASA/CAF/ CAP COD 30MG Not on 2017 formulary


BUTORPHANOL INJ 1MG/ML On formulary, tier change tier 2 to tier 4 Analgesics


BUTORPHANOL INJ 2MG/ML On formulary, tier change tier 2 to tier 4 Analgesics


CALCIPOTRIEN SOL 0.005% On formulary, tier change tier 2 to tier 3 Dermatological Agents Dermatological AgentsCALCITRIOL SOL 1MCG/ML On formulary, tier change tier 2 to tier 3

Metabolic Bone Disease Agents


CARTIA XT CAP 120/24HR On formulary, tier change tier 2 to tier 3 Cardiovascular Agents

Calcium Channel Blocking Agents







CEFTRIAXONE INJ 10GM On formulary, tier change tier 2 to tier 4 Antibacterials

Beta-lactam, Cephalosporins

CEFUROXIME INJ 1.5GM On formulary, tier change tier 2 to tier 4 Antibacterials

Beta-lactam, Cephalosporins

CHLORPROMAZ TAB 100MG On formulary, tier change tier 2 to tier 4 Antiemetics Antiemetics, OtherCHLORPROMAZ TAB 200MG On formulary, tier change tier 2 to tier 4 Antiemetics Antiemetics, Other

Pg. 5 of 35


CHLORPROMAZ TAB 25MG On formulary, tier change tier 2 to tier 3 Antiemetics Antiemetics, OtherCHLORPROMAZ TAB 50MG On formulary, tier change tier 2 to tier 3 Antiemetics Antiemetics, Other

CHOR GONADOT INJ 10000UNT On formulary, tier change tier 2 to tier 4

Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary)


CHOR GONADOT INJ 10000UNT

On formulary, requires prior authorization check with your doctor



CIPROFLOXACN TAB 750MG On formulary, tier change tier 1 to tier 2 Antibacterials Quinolones

CLARAVIS CAP 40MG On formulary, tier change tier 2 to tier 4 Dermatological Agents Dermatological Agents

CLOBETASOL GEL 0.05% On formulary, tier change tier 2 to tier 3

Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal)

Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal)

CLONIDINE TAB 0.1MG On formulary, tier change tier 1 to tier 2 Cardiovascular Agents

Alpha-adrenergic Agonists

CLONIDINE TAB 0.1MG ER On formulary, tier change tier 2 to tier 3

Central Nervous System Agents

Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines





CLOZAPINE TAB 100/ODT On formulary, tier change tier 2 to tier 4 Antipsychotics Treatment-ResistantCOLISTIMETH INJ 150MG On formulary, tier change tier 2 to tier 4 Antibacterials Antibacterials, Other

Pg. 6 of 35


COMVAX INJ Not on 2017 formulary check with your doctor Immunological Agents Vaccines

CRESTOR TAB 10MG On formulary, tier change tier 3 to tier 4 Cardiovascular AgentsDyslipidemics, HMG CoA Reductase Inhibitors




CROMOLYN SOD SOL 4% OP On formulary, tier change tier 1 to tier 2 Ophthalmic Agents

Ophthalmic Anti-allergy Agents

CYCLOPHOSPH INJ 1GM On formulary, tier change tier 4 to tier 5 Antineoplastics Alkylating AgentsCYCLOPHOSPH INJ 2GM On formulary, tier change tier 4 to tier 5 Antineoplastics Alkylating AgentsCYCLOPHOSPH INJ 500MG On formulary, tier change tier 4 to tier 5 Antineoplastics Alkylating AgentsCYCLOSPORINE CAP 100MG On formulary, tier change tier 2 to tier 4 Immunological Agents Immune SuppressantsCYCLOSPORINE CAP 25MG On formulary, tier change tier 2 to tier 3 Immunological Agents Immune SuppressantsCYCLOSPORINE SOL MODIFIED On formulary, tier change tier 2 to tier 3 Immunological Agents Immune Suppressants

D5W/NACL INJ 0.45% On formulary, tier change tier 1 to tier 2Therapeutic Nutrients/ Minerals/ Electrolytes

Electrolyte/Mineral Replacement

D5W/NACL INJ 0.9% On formulary, tier change tier 1 to tier 2Therapeutic Nutrients/ Minerals/ Electrolytes


DANAZOL CAP 100MG On formulary, tier change tier 2 to tier 3


Pg. 7 of 35


DANAZOL CAP 200MG On formulary, tier change tier 2 to tier 3


DARAPRIM TAB 25MG On formulary, tier change tier 4 to tier 5 Antiparasitics AntiprotozoalsDAUNOXOME INJ 2MG/ML Not on 2017 formulary

daunorubicin injection 5 mg/ml Antineoplastics Antineoplastics, Other

DESMOPRESSIN INJ 4MCG/ML On formulary, tier change tier 2 to tier 4



DESMOPRESSIN SOL 0.01% On formulary, tier change tier 2 to tier 4



DESMOPRESSIN SPR 0.01% On formulary, tier change tier 2 to tier 3



DEXAMETH PHO SOL 0.1% OP On formulary, tier change tier 2 to tier 4 Ophthalmic Agents

Ophthalmic Anti-inflammatories

DICLOFEN POT TAB 50MG

On formulary, quantity limit may apply 120 tablets per 30 days Analgesics

Nonsteroidal Anti-inflammatory Drugs

DICLOFENAC TAB 100MG ER



DICLOFENAC TAB 25MG DR









Pg. 8 of 35


DIDANOSINE CAP 400MG On formulary, tier change tier 2 to tier 3 Antivirals

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)

DILTIAZEM CAP 120MG CD On formulary, tier change tier 2 to tier 3 Cardiovascular Agents


DILTIAZEM CAP 120MG ER On formulary, tier change tier 2 to tier 3 Cardiovascular Agents


DILTIAZEM CAP 120MG/24 On formulary, tier change tier 2 to tier 3 Cardiovascular Agents






















Pg. 9 of 35












DILTIAZEM TAB 30MG On formulary, tier change tier 1 to tier 2 Cardiovascular AgentsCalcium Channel Blocking Agents

DILT-XR CAP 120MG On formulary, tier change tier 2 to tier 3 Cardiovascular AgentsCalcium Channel Blocking Agents



DONEPEZIL TAB 10MG On formulary, tier change tier 1 to tier 2 Antidementia Agents Cholinesterase InhibitorsDONEPEZIL TAB 5MG On formulary, tier change tier 1 to tier 2 Antidementia Agents Cholinesterase InhibitorsDONEPEZIL TAB HCL 23MG On formulary, tier change tier 2 to tier 3 Antidementia Agents Cholinesterase InhibitorsDOXORUBICIN INJ 10MG On formulary, tier change tier 2 to tier 4 Antineoplastics Antineoplastics, OtherDOXORUBICIN INJ 2MG/ML On formulary, tier change tier 4 to tier 5 Antineoplastics Antineoplastics, OtherDOXORUBICIN INJ 50MG On formulary, tier change tier 2 to tier 4 Antineoplastics Antineoplastics, OtherDURAMORPH INJ 0.5MG/ML On formulary, tier change tier 2 to tier 4 Analgesics


Pg. 10 of 35


DURAMORPH INJ 1MG/ML On formulary, tier change tier 2 to tier 4 Analgesics


ELIDEL CRE 1%On formulary, requires prior authorization check with your doctor Dermatological Agents Dermatological Agents

ENTACAPONE TAB 200MG On formulary, tier change tier 2 to tier 3 Antiparkinson Agents

Antiparkinson Agents, Other

EQUETRO CAP 100MG Not on 2017 formulary

carbamazepine ER capsules (generic Carbatrol), carbamazepine ER tablets (generic Tegretol-XR) Bipolar Agents Mood Stabilizers





ETODOLAC CAP 200MG

On formulary, quantity limit may apply 150 capsules per 30 days Analgesics


ETODOLAC CAP 300MG

On formulary, quantity limit may apply 90 capsules per 30 days Analgesics


ETODOLAC TAB 400MG



Pg. 11 of 35


ETODOLAC TAB 500MG



EXELON DIS 13.3/24 Not on 2017 formularyrivastigmine 13.3 mg/24 patches Antidementia Agents Cholinesterase Inhibitors

EXELON DIS 4.6MG/24 Not on 2017 formulary

rivastigmine 4.6 mg/24 patches Antidementia Agents Cholinesterase Inhibitors

EXELON DIS 9.5MG/24 Not on 2017 formulary

rivastigmine 9.5 mg/24 patches Antidementia Agents Cholinesterase Inhibitors

FAMOTIDINE TAB 20MG On formulary, tier change tier 1 to tier 2 Gastrointestinal Agents

Histamine2 (H2) Receptor Antagonists

FAMOTIDINE TAB 40MG On formulary, tier change tier 1 to tier 2 Gastrointestinal Agents


FAZACLO TAB 100 ODT Not on 2017 formulary

clozapine 100 mg ODT* *This drug requires prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information. Antipsychotics Treatment-Resistant

Pg. 12 of 35


FAZACLO TAB 12.5 ODT Not on 2017 formulary

clozapine tablets (25 mg, 50 mg, 100 mg, 200 mg)*, clozapine ODT tablets (25 mg, 100 mg)* *These drugs require prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information. Antipsychotics Treatment-Resistant



Pg. 13 of 35




FAZACLO TAB 25MG ODT Not on 2017 formulary

clozapine 25 mg ODT* *This drug requires prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information. Antipsychotics Treatment-Resistant

FENTANYL DIS 100MCG/H On formulary, tier change tier 3 to tier 4 Analgesics

Opioid Analgesics, Long-acting

FENTANYL DIS 12MCG/HR On formulary, tier change tier 3 to tier 4 Analgesics






Pg. 14 of 35




FLUOROURACIL CRE 5% On formulary, tier change tier 2 to tier 3 Dermatological Agents Dermatological AgentsFLURBIPROFEN SOL 0.03% OP On formulary, tier change tier 1 to tier 2 Ophthalmic Agents

Ophthalmic Anti-inflammatories

FOSRENOL CHW 1000MG On formulary, tier change tier 4 to tier 5 Genitourinary Agents Phosphate BindersFOSRENOL CHW 500MG On formulary, tier change tier 4 to tier 5 Genitourinary Agents Phosphate BindersFOSRENOL CHW 750MG On formulary, tier change tier 4 to tier 5 Genitourinary Agents Phosphate BindersFOSRENOL POW 1000MG On formulary, tier change tier 4 to tier 5 Genitourinary Agents Phosphate BindersFOSRENOL POW 750MG On formulary, tier change tier 4 to tier 5 Genitourinary Agents Phosphate Binders

GABAPENTIN CAP 100MG

On formulary, quantity limit may apply

1080 capsules per 30 days Anticonvulsants

Gamma-aminobutyric Acid (GABA) Augmenting Agents


On formulary, quantity limit may apply 360 capsules per 30 days Anticonvulsants



On formulary, quantity limit may apply 270 capsules per 30 days Anticonvulsants


GABAPENTIN SOL 250/5ML

On formulary, quantity limit may apply 2160 mLs per 30 days Anticonvulsants


GABAPENTIN SOL 300/6ML

On formulary, quantity limit may apply 2160 mLs per 30 days Anticonvulsants


Pg. 15 of 35


GABAPENTIN TAB 600MG

On formulary, quantity limit may apply 180 tablets per 30 days Anticonvulsants


GABAPENTIN TAB 800MG

On formulary, quantity limit may apply 120 tablets per 30 days Anticonvulsants


GAMUNEX-C INJ 10GM/100 On formulary, tier change tier 3 to tier 5 Immunological Agents

Immunizing Agents, Passive

GAMUNEX-C INJ 1GM/10ML On formulary, tier change tier 3 to tier 5 Immunological Agents


GAMUNEX-C INJ 2.5GM/25 On formulary, tier change tier 3 to tier 5 Immunological Agents


GAMUNEX-C INJ 20GM/200 On formulary, tier change tier 3 to tier 5 Immunological Agents


GAMUNEX-C INJ 40/400ML On formulary, tier change tier 3 to tier 5 Immunological Agents


GAMUNEX-C INJ 5GM/50ML On formulary, tier change tier 3 to tier 5 Immunological Agents


GENGRAF SOL 100MG/ML On formulary, tier change tier 2 to tier 3 Immunological Agents Immune Suppressants

GLEEVEC TAB 100MG Not on 2017 formulary

imatinib 100 mg* *This drug requires prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information. Antineoplastics

Molecular Target Inhibitors

Pg. 16 of 35








HUMULIN R INJ U-500On formulary, requires prior authorization check with your doctor Blood Glucose Regulators Insulins

HYDROCO/APAP TAB 10-300MG Not on 2017 formulary

hydrocodone/acetaminophen (5/325mg, 7.5/325mg, 10/325mg) Analgesics


HYDROCO/APAP TAB 5-300MG Not on 2017 formulary



HYDROCO/APAP TAB 7.5-300 Not on 2017 formulary



Pg. 17 of 35


HYDROMORPHON LIQ 1MG/ML On formulary, tier change tier 2 to tier 4 Analgesics


HYDROMORPHON TAB 2MG On formulary, tier change tier 2 to tier 3 Analgesics






IBUPROFEN TAB 400MG



IBUPROFEN TAB 600MG



IBUPROFEN TAB 800MG



INVEGA TAB 1.5MG Not on 2017 formulary

paliperidone 1.5 mg* *This drug requires prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information. Antipsychotics 2nd Generation/Atypical

Pg. 18 of 35


INVEGA TAB 3MG Not on 2017 formulary

paliperidone 3 mg* *This drug requires prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information. Antipsychotics 2nd Generation/Atypical





Pg. 19 of 35


KCL/D5W/NACL INJ .15-.45% On formulary, tier change tier 1 to tier 2

Therapeutic Nutrients/ Minerals/ Electrolytes


KCL/D5W/NACL INJ .15/.45% On formulary, tier change tier 1 to tier 2



LACTATED RIN INJ On formulary, tier change tier 1 to tier 2Therapeutic Nutrients/ Minerals/ Electrolytes


LAMOTRIGINE TAB 100MG Not on 2017 formulary

lamotrigine tablets, lamotrigine chewable tablets (5 mg, 25 mg) Anticonvulsants

Glutamate Reducing Agents

LAMOTRIGINE TAB 200MG Not on 2017 formulary



LAMOTRIGINE TAB 25MG ODT Not on 2017 formulary



LAMOTRIGINE TAB 50MG ODT Not on 2017 formulary



LETROZOLE TAB 2.5MG On formulary, tier change tier 1 to tier 2 Antineoplastics

Aromatase Inhibitors, 3rd Generation

LEUCOVOR CA INJ 100MG On formulary, tier change tier 2 to tier 4 Antineoplastics Antineoplastics, OtherLEUCOVOR CA INJ 200MG On formulary, tier change tier 2 to tier 4 Antineoplastics Antineoplastics, OtherLIDOCAINE PAD 5% On formulary, tier change tier 2 to tier 3 Anesthetics Local AnestheticsLIDOCAINE SOL 4% On formulary, tier change tier 1 to tier 2 Anesthetics Local AnestheticsLIPODOX INJ 2MG/ML On formulary, tier change tier 4 to tier 5 Antineoplastics Antineoplastics, OtherLIPODOX 50 INJ 2MG/ML On formulary, tier change tier 4 to tier 5 Antineoplastics Antineoplastics, Other

Pg. 20 of 35


LITHIUM CARB CAP 150MG On formulary, tier change tier 1 to tier 2 Bipolar Agents Mood Stabilizers

MALATHION LOT 0.5% On formulary, tier change tier 2 to tier 3 Antiparasitics Pediculicides/Scabicides

MEDROXYPR AC TAB 10MG On formulary, tier change tier 1 to tier 2

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

MELOXICAM TAB 15MG



MELOXICAM TAB 7.5MG



METADATE TAB 20MG ER On formulary, tier change tier 2 to tier 3



METHADONE TAB 10MG On formulary, tier change tier 2 to tier 4 Analgesics


METHADONE TAB 5MG On formulary, tier change tier 2 to tier 4 Analgesics


METHAZOLAMID TAB 25MG On formulary, tier change tier 2 to tier 3 Cardiovascular Agents

Diuretics, Carbonic Anhydrase Inhibitors

METHAZOLAMID TAB 50MG On formulary, tier change tier 2 to tier 4 Cardiovascular Agents

Diuretics, Carbonic Anhydrase Inhibitors

METHERGINE TAB 0.2MG On formulary, tier change tier 4 to tier 5 Genitourinary Agents

Genitourinary Agents, Other

METHOCARBAM TAB 500MG


Skeletal Muscle Relaxants


METHOCARBAM TAB 750MG




Pg. 21 of 35


METHOTREXATE INJ 100/4ML On formulary, tier change tier 1 to tier 2 Immunological Agents Immune SuppressantsMETHOTREXATE INJ 1GM/40ML On formulary, tier change tier 1 to tier 2 Immunological Agents Immune SuppressantsMETHOTREXATE INJ 200/8ML On formulary, tier change tier 1 to tier 2 Immunological Agents Immune SuppressantsMETHOTREXATE INJ 250/10ML On formulary, tier change tier 1 to tier 2 Immunological Agents Immune SuppressantsMETHOTREXATE INJ 25MG/ML On formulary, tier change tier 1 to tier 2 Immunological Agents Immune SuppressantsMETHOTREXATE INJ 50MG/2ML On formulary, tier change tier 1 to tier 2 Immunological Agents Immune SuppressantsMETHOTREXATE TAB 2.5MG On formulary, tier change tier 2 to tier 3 Immunological Agents Immune SuppressantsMETHYLERGON TAB 0.2MG On formulary, tier change tier 4 to tier 5 Genitourinary Agents

Genitourinary Agents, Other

METHYLPHENID TAB 20MG ER On formulary, tier change tier 2 to tier 3



METHYLPHENID TAB 20MG SR On formulary, tier change tier 2 to tier 3



METOCLOPRAM TAB 5MG On formulary, tier change tier 1 to tier 2 Antiemetics Antiemetics, OtherMORPHINE SUL INJ 0.5MG/ML On formulary, tier change tier 2 to tier 4 Analgesics


MORPHINE SUL INJ 1MG/ML On formulary, tier change tier 2 to tier 4 Analgesics


Pg. 22 of 35


MYORISAN CAP 40MG On formulary, tier change tier 2 to tier 4 Dermatological Agents Dermatological Agents

MYOZYME INJ 50MG Not on 2017 formulary check with your doctorEnzyme Replacement/ Modifiers

Enzyme Replacement/ Modifiers

MYRBETRIQ TAB 25MG Not on 2017 formulary

oxybutynin IR 5mg tablet, tolterodine ER capsule, Toviaz, Vesicare Genitourinary Agents Antispasmodics, Urinary

MYRBETRIQ TAB 50MG Not on 2017 formulary

oxybutynin IR 5mg tablet, tolterodine ER capsule, Toviaz, Vesicare Genitourinary Agents Antispasmodics, Urinary

NABUMETONE TAB 500MG



NABUMETONE TAB 750MG



NAFCILLIN INJ 10GM On formulary, tier change tier 4 to tier 5 Antibacterials Beta-lactam, Penicillins

NAMENDA SOL 10MG/5ML Not on 2017 formulary

memantine 2 mg/mL solution* *This drug requires prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information. Antidementia Agents

N-methyl-D-aspartate (NMDA) Receptor Antagonist

Pg. 23 of 35


NAMENDA TAB 10MG Not on 2017 formulary

memantine 10 mg tablet* *This drug requires prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information. Antidementia Agents


NAMENDA TAB 5-10MG Not on 2017 formulary

memantine 5-10 mg titration pack* *This drug requires prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information. Antidementia Agents


NAMENDA TAB 5MG Not on 2017 formulary

memantine 5 mg tablet* *This drug requires prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information. Antidementia Agents


Pg. 24 of 35


NAMENDA XR CAP 14MG Not on 2017 formulary

memantine IR tablets* *This drug requires prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information. Antidementia Agents








Pg. 25 of 35





NAMENDA XR CAP TITRATIO Not on 2017 formulary



NAPROXEN TAB 250MG



NAPROXEN TAB 375MG



NAPROXEN TAB 500MG



NASONEX SPR 50MCG/AC On formulary, tier change tier 3 to tier 4

Respiratory Tract/ Pulmonary Agents

Anti-inflammatories, Inhaled Corticosteroids

Pg. 26 of 35


NEVIRAPINE TAB 100MG

On formulary, quantity limit may apply 90 tablets per 30 days Antivirals

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)

NORMOSOL -M INJ /D5W On formulary, tier change tier 2 to tier 4



NORTRIPTYLIN CAP 25MG On formulary, tier change tier 1 to tier 2 Antidepressants TricyclicsNORTRIPTYLIN CAP 50MG On formulary, tier change tier 1 to tier 2 Antidepressants Tricyclics

NUVIGIL TAB 150MG Not on 2017 formulary

armodafinil 150 mg* *This drug requires prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information. Sleep Disorder Agents Sleep Disorders, Other



Pg. 27 of 35






ORAP TAB 1MG Not on 2017 formulary pimozide 1 mg Antipsychotics 1st Generation/TypicalORAP TAB 2MG Not on 2017 formulary pimozide 2 mg Antipsychotics 1st Generation/Typical

OXANDROLONE TAB 2.5MG On formulary, tier change tier 2 to tier 3

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

PAROXETIN ER TAB 12.5MG Not on 2017 formulary

citalopram, escitalopram, fluoxetine, fluvoxamine IR, sertraline Antidepressants

SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/ Serotonin and Norepinephrine Reuptake Inhibito

Pg. 28 of 35


PAROXETIN ER TAB 37.5MG Not on 2017 formulary



PAROXETINE TAB 25MG ER Not on 2017 formulary



PENICILLN VK SOL 250/5ML On formulary, tier change tier 1 to tier 2 Antibacterials Beta-lactam, PenicillinsPENICILLN VK TAB 500MG On formulary, tier change tier 1 to tier 2 Antibacterials Beta-lactam, PenicillinsPHENOXYBENZA CAP 10MG On formulary, tier change tier 4 to tier 5 Cardiovascular Agents

Alpha-adrenergic Blocking Agents

PIPER/TAZOBA INJ 3-0.375G On formulary, tier change tier 2 to tier 4 Antibacterials Beta-lactam, PenicillinsPIPER/TAZOBA INJ 4-0.5GM On formulary, tier change tier 2 to tier 4 Antibacterials Beta-lactam, PenicillinsPOLYMYXIN B/ SOL TRIMETHP On formulary, tier change tier 1 to tier 2 Antibacterials Antibacterials, OtherPRAMIPEXOLE TAB 1MG On formulary, tier change tier 1 to tier 2 Antiparkinson Agents Dopamine Agonists

PREGNYL INJ 10000UNT On formulary, tier change tier 2 to tier 4



PREGNYL INJ 10000UNT




Pg. 29 of 35


PROAIR HFA AER Not on 2017 formulary Ventolin HFARespiratory Tract/ Pulmonary Agents

Bronchodilators, Sympathomimetic

PROAIR RESPI AER Not on 2017 formulary Ventolin HFARespiratory Tract/ Pulmonary Agents

Bronchodilators, Sympathomimetic

PROCHLORPER INJ 10MG/2ML On formulary, tier change tier 2 to tier 4 Antiemetics Antiemetics, OtherPROCHLORPER INJ 5MG/ML On formulary, tier change tier 2 to tier 4 Antiemetics Antiemetics, OtherPROLASTIN-C INJ 1000MG



Respiratory Tract Agents, Other

PROPAFENONE CAP 225MG ER On formulary, tier change tier 3 to tier 4 Cardiovascular Agents AntiarrhythmicsPROPRANOLOL TAB 10MG On formulary, tier change tier 1 to tier 2 Cardiovascular Agents

Beta-adrenergic Blocking Agents

PROPRANOLOL TAB 20MG On formulary, tier change tier 1 to tier 2 Cardiovascular Agents






QUINIDINE SU TAB 300MG On formulary, tier change tier 2 to tier 4 Cardiovascular Agents Antiarrhythmics

QVAR AER 40MCG Not on 2017 formulary

Arnuity Ellipta, Flovent (Diskus, HFA), Asmanex (HFA, Twisthaler)



QVAR AER 80MCG Not on 2017 formulary

Arnuity Ellipta, Flovent (Diskus, HFA), Asmanex (HFA, Twisthaler)



RANEXA TAB 1000MG On formulary, tier change tier 3 to tier 4 Cardiovascular Agents

Cardiovascular Agents, Other

Pg. 30 of 35


RANEXA TAB 500MG On formulary, tier change tier 3 to tier 4 Cardiovascular AgentsCardiovascular Agents, Other

RANITIDINE TAB 300MG On formulary, tier change tier 1 to tier 2 Gastrointestinal Agents


RESTASIS EMU 0.05% On formulary, tier change tier 3 to tier 4 Ophthalmic Agents Ophthalmic Agents, OtherRESTASIS EMU 0.05%

On formulary, quantity limit may apply 60 vials per 30 days Ophthalmic Agents Ophthalmic Agents, Other

RIFABUTIN CAP 150MG On formulary, tier change tier 2 to tier 4 Antimycobacterials Antimycobacterials, OtherRISPERIDONE TAB 3MG ODT On formulary, tier change tier 2 to tier 3 Antipsychotics 2nd Generation/AtypicalRISPERIDONE TAB 4MG ODT On formulary, tier change tier 2 to tier 3 Antipsychotics 2nd Generation/AtypicalSEROQUEL XR TAB 150MG On formulary, tier change tier 3 to tier 4 Antipsychotics 2nd Generation/AtypicalSEROQUEL XR TAB 200MG On formulary, tier change tier 3 to tier 4 Antipsychotics 2nd Generation/AtypicalSEROQUEL XR TAB 300MG On formulary, tier change tier 3 to tier 4 Antipsychotics 2nd Generation/AtypicalSEROQUEL XR TAB 400MG On formulary, tier change tier 3 to tier 4 Antipsychotics 2nd Generation/AtypicalSEROQUEL XR TAB 50MG On formulary, tier change tier 3 to tier 4 Antipsychotics 2nd Generation/AtypicalSULINDAC TAB 150MG



SULINDAC TAB 200MG



Pg. 31 of 35


SURMONTIL CAP 100MG Not on 2017 formulary

citalopram, fluoxetine, escitalopram, sertraline, duloxetine capsules (20mg, 30mg, 60mg), venlafaxine IR tablets, ER tablets (37.5mg, 75mg, 150mg ), and ER capsules, mirtazapine, bupropion Antidepressants Tricyclics





Pg. 32 of 35


TARGRETIN CAP 75MG Not on 2017 formulary

bexarotene 75mg capsule * *This drug requires prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information. Antineoplastics Retinoids

TAZTIA XT CAP 120MG/24 On formulary, tier change tier 2 to tier 3 Cardiovascular Agents










TEFLARO INJ 400MG On formulary, tier change tier 4 to tier 5 AntibacterialsBeta-lactam, Cephalosporins

TEFLARO INJ 600MG On formulary, tier change tier 4 to tier 5 AntibacterialsBeta-lactam, Cephalosporins

TEGRETOL-XR TAB 100MG Not on 2017 formulary

carbamazepine ER 100 mg tablets Anticonvulsants Sodium Channel Agents

TIKOSYN CAP 125MCG Not on 2017 formulary dofetilide 125 mcg Cardiovascular Agents AntiarrhythmicsTIKOSYN CAP 250MCG Not on 2017 formulary dofetilide 250 mcg Cardiovascular Agents Antiarrhythmics

Pg. 33 of 35


TIKOSYN CAP 500MCG Not on 2017 formulary dofetilide 500 mcg Cardiovascular Agents AntiarrhythmicsTOBRAMYCIN INJ 40MG/ML On formulary, tier change tier 2 to tier 4 Antibacterials AminoglycosidesTRAMADOL HCL TAB 50MG On formulary, tier change tier 2 to tier 3 Analgesics


TRANEX ACID TAB 650MG On formulary, tier change tier 2 to tier 3

Blood Products/Modifiers/ Volume Expanders Coagulants

TRANYLCYPROM TAB 10MG On formulary, tier change tier 2 to tier 3 Antidepressants

Monoamine Oxidase Inhibitors

TRIMETHOPRIM SOL POLYMYXN On formulary, tier change tier 1 to tier 2 Antibacterials Antibacterials, OtherTYGACIL INJ 50MG On formulary, tier change tier 4 to tier 5 Antibacterials Antibacterials, OtherURSODIOL CAP 300MG On formulary, tier change tier 3 to tier 4 Gastrointestinal Agents

Gastrointestinal Agents, Other

VERAPAMIL TAB 120MG On formulary, tier change tier 1 to tier 2 Cardiovascular Agents


VERAPAMIL TAB 80MG On formulary, tier change tier 1 to tier 2 Cardiovascular Agents


VESICARE TAB 10MG On formulary, tier change tier 3 to tier 4 Genitourinary Agents Antispasmodics, UrinaryVESICARE TAB 5MG On formulary, tier change tier 3 to tier 4 Genitourinary Agents Antispasmodics, Urinary

VICODIN TAB 5-300MG Not on 2017 formulary



VICODIN ES TAB 7.5-300 Not on 2017 formulary



VICODIN HP TAB 10-300MG Not on 2017 formulary



Pg. 34 of 35


VINCASAR PFS INJ 1MG/ML

On formulary, requires prior authorization check with your doctor Antineoplastics Antineoplastics, Other

VINCRISTINE INJ 1MG/ML

On formulary, requires prior authorization check with your doctor Antineoplastics Antineoplastics, Other

VINORELBINE INJ 10MG/ML On formulary, tier change tier 2 to tier 4 Antineoplastics Antineoplastics, OtherVINORELBINE INJ 50MG/5ML On formulary, tier change tier 2 to tier 4 Antineoplastics Antineoplastics, Other

VIRAMUNE XR TAB 100MG Not on 2017 formulary

nevirapine SR 100 mg tablet Antivirals

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)

VRAYLAR CAP 1.5-3MG Not on 2017 formulary

Vraylar capsules (1.5 mg, 3 mg, 4.5 mg, 6 mg)* *This drug requires prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information. Antipsychotics 2nd Generation/Atypical

ZEMPLAR INJ 2MCG/ML Not on 2017 formulary paricalcitol 2 mcg/ml inj



ZEMPLAR INJ 5MCG/ML Not on 2017 formulary paricalcitol 5 mcg/ml inj



ZENATANE CAP 40MG On formulary, tier change tier 2 to tier 4 Dermatological Agents Dermatological AgentsZETIA TAB 10MG On formulary, tier change tier 3 to tier 4 Cardiovascular Agents Dyslipidemics, Other

Pg. 35 of 35


ZYVOX SUS 100MG/5M Not on 2017 formulary

linezolid 100 mg/5 mL suspension* *This drug requires prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information. Antibacterials Antibacterials, Other

Documents

Formulary 2017 Master Negative Changes from 2016 to … card for more information. ... Androgens North Carolina Value Formulary 2017 Master Negative Changes from 2016 to ... 2017 Master