PPrreeffeerrrreedd DDrruugg LLiissttiinngg … Formulary Elite Plans.pdf · omnaris (st) ..... 36 . omnicef ..... 8 . onetouch ultra test strips (ql ) ..... 15 . onfi (pa

PPPrrreeefffeeerrrrrreeeddd DDDrrruuuggg LLLiiissstttiiinnnggg

IIInnndddeeexxxeeeddd bbbyyy BBBrrraaannnddd NNNaaammmeee

EEEffffffeeeccctttiiivvveee 2017

2017 Preferred Drug Listing Index

LEGEND PA = pre-approval is required before this medication can be covered (prior authorization) ST = a trial of a similar medication may be required before approval of this medication (step therapy) QL = quantity limits

ABILIFY ............................................ 27 ABILIFY MAINTENA (PA) ................ 27 ABSORICA (PA) ............................... 37 ACANYA ........................................... 37 ACCOLATE (PA) .............................. 21 ACCU-CHEK TEST STRIPS (QL) .... 15 ACCUNEB ........................................ 21 ACCUTANE (PA) ............................. 37 ACIPHEX (ST, QL) ........................... 22 ACTIQ (PA, QL) ............................... 29 ACTONEL (ST, QL) .......................... 15 ACTOPLUS MET (PA, QL) ............... 14 ACTOPLUS MET XR (PA, QL) ......... 14 ACTOS (PA, QL) .............................. 13 ACULAR ........................................... 34 ACULAR LS ..................................... 34 ACZONE (ST) .................................. 37 ADALAT-CC ..................................... 16 ADCIRCA (PA, QL) .......................... 20 ADDERALL (PA, QL) ....................... 28 ADDERALL XR (PA, QL) .................. 28 ADIPEX-P (PA) ................................ 41 ADVAIR DISKUS (QL)...................... 22 ADVAIR HFA (QL) ............................ 22 ADVICOR (QL) ................................. 20 AEROSPAN (QL) ............................. 21 AK-TRACIN ...................................... 34 ALBUTEROL .................................... 21 ALDACTAZIDE ................................. 19 ALDACTONE ................................... 19 ALDARA (QL) ................................... 39 ALDOMET ........................................ 18 ALESSE ........................................... 12 ALINIA .............................................. 22 ALKERAN ......................................... 40 ALLI (PA) .......................................... 41 ALORA ............................................. 11 ALPHAGAN-P .................................. 35 ALTABAX ......................................... 38 ALTACE ........................................... 17 ALVESCO (QL) ................................ 21 AMARYL ........................................... 13 AMBIEN (QL) ................................... 28 AMBIEN CR (QL) ............................. 28 AMERGE (ST, QL) ........................... 30 AMOXIL .............................................. 8 AMRIX (ST) ...................................... 33 ANAPROX ........................................ 30 ANAPROX DS .................................. 30 ANDRODERM (PA) .......................... 11 ANDROGEL (PA) ............................. 11 ANORO ELLIPTA (QL) ..................... 22 ANSAID ............................................ 30

ANTABUSE ...................................... 29 ANTARA ........................................... 19 ANTIVERT ....................................... 23 ANUSOL-HC SUPP ......................... 39 ANZEMET (PA, QL) ......................... 23 APIDRA ............................................ 14 APRESOLINE .................................. 18 APRISO ............................................ 24 ARALEN ........................................... 10 ARAVA ............................................. 40 ARICEPT (QL) ................................. 29 ARICEPT ODT (QL) ......................... 29 ARIMIDEX (PA) ................................ 40 ARIXTRA (PA, QL) ........................... 33 AROMASIN (PA) .............................. 40 ARTANE ........................................... 32 ARTHROTEC ................................... 30 ASACOL ........................................... 24 ASACOL HD (PA) ............................ 24 ASENDIN ......................................... 26 ASMANEX (QL) ............................... 21 ASTELIN .......................................... 37 ASTEPRO ........................................ 37 ATACAND (ST, QL) ......................... 17 ATACAND HCT (ST, QL) ................. 17 ATARAX ........................................... 20 ATIVAN ............................................ 26 ATRIPLA .......................................... 10 ATROVENT HFA (QL) ..................... 22 ATROVENT NASAL SPRAY ............ 37 AUGMENTIN ...................................... 8 AUGMENTIN XR ................................ 8 AURALGAN ..................................... 36 AUVI-Q (PA, QL) .............................. 22 AVALIDE (QL) .................................. 17 AVANDAMET (PA, QL) .................... 14 AVANDARYL (PA, QL) ..................... 14 AVANDIA (PA, QL) .......................... 13 AVAPRO (QL) .................................. 17 AVELOX ............................................. 8 AVINZA (PA, QL) ............................. 29 AVODART ........................................ 25 AXERT (ST, QL) .............................. 31 AXIRON (PA) ................................... 11 AZASITE .......................................... 35 AZELEX ........................................... 37 AZOPT ............................................. 35 AZOR (ST, QL) ................................ 18 AZULFIDINE .................................... 24 BACTRIM ........................................... 9 BACTRIM DS ..................................... 9 BACTROBAN ................................... 37 BD INSULIN SYRINGES .................. 15

BECONASE AQ (ST) ....................... 36 BELVIQ (PA) .................................... 41 BENADRYL ...................................... 20 BENICAR (ST, QL) .......................... 17 BENICAR HCT (ST, QL) .................. 18 BENTYL ........................................... 23 BENZAMYCIN ................................. 37 BETAGAN ........................................ 35 BETOPTIC S .................................... 35 BEYAZ ............................................. 12 BIAXIN ............................................... 8 BIAXIN XL .......................................... 8 BILTRICIDE ..................................... 11 BINOSTO (PA) ................................. 15 BLEPH-10 ........................................ 34 BLEPHAMIDE .................................. 35 B-NATAL .......................................... 23 BONIVA (QL) ................................... 15 BREO ELLIPTA (ST)........................ 22 BREVICON ...................................... 12 BRILINTA (PA) ................................. 33 BRINTELLIX (PA, QL) ...................... 27 BRISDELLE (PA, QL) ...................... 26 BROMDAY ....................................... 34 BUMEX ............................................ 18 BUSPAR .......................................... 25 BUTRANS (PA, QL) ......................... 30 BYDUREON (PA) ............................ 14 BYETTA (PA) ................................... 14 BYSTOLIC (ST, QL) ........................ 16 CADUET (QL) .................................. 20 CAFERGOT ..................................... 31 CALAN ............................................. 16 CALAN SR ....................................... 16 CAMPRAL ........................................ 29 CANASA .......................................... 24 CAPEX ............................................. 39 CAPOTEN ........................................ 17 CAPOZIDE ....................................... 17 CARAFATE ...................................... 23 CARBATROL (QL) ........................... 31 CARDENE ....................................... 16 CARDIZEM ...................................... 16 CARDIZEM CD ................................ 16 CARDURA ................................. 18, 25 CARDURA XL .................................. 25 CARNITOR ...................................... 33 CATAFLAM ...................................... 30 CATAPRES ...................................... 18 CATAPRES-TTS-1 .......................... 18 CATAPRES-TTS-2 .......................... 18 CATAPRES-TTS-3 .......................... 18

2

CECLOR ............................................ 8



CEDAX ............................................... 8 CEENU ............................................. 40 CEFTIN .............................................. 8 CELEBREX (PA, QL) ....................... 30 CELEXA (QL) ................................... 26 CENESTIN ....................................... 11 CEPHULAC ...................................... 23 CHANTIX (PA, QL) ........................... 29 CIALIS (QL) ...................................... 40 CIMZIA (PA) ..................................... 41 CIPRO ................................................ 8 CLARINEX (QL) ............................... 20 CLEOCIN ......................................... 37 CLEOCIN T ...................................... 37 CLEOCIN VAGINAL CREAM ........... 25 CLIMARA ......................................... 11 CLIMARA PRO ................................. 12 CLINORIL ......................................... 30 CLOBEX ........................................... 38 CLODERM ....................................... 38 CLOZARIL (ST) ................................ 27 COARTEM (PA) ............................... 11 CODEINE ......................................... 29 COGENTIN ...................................... 32 COLCRYS ........................................ 30 COLESTID ....................................... 20 COLYTE-FLAVOR PACKS .............. 24 COMBIPATCH ................................. 12 COMBIVENT INH AEROSOL (QL) .. 22 COMBIVENT RESPIMAT (QL) ......... 22 COMBIVIR .......................................... 9 COMPAZINE .................................... 23 COMPRO ......................................... 23 COMTAN .......................................... 32 CONCERTA (PA, QL) ...................... 28 CONDYLOX GEL ............................. 39 CONDYLOX SOLUTION .................. 39 CORDARONE .................................. 17 COREG ............................................ 16 COREG CR (ST) .............................. 16 CORGARD ....................................... 16 CORTENEMA .................................. 39 CORTIFOAM .................................... 39 CORTISPORIN (ophthalmic) ...... 34, 35 CORTISPORIN (otic)........................ 36 COSOPT .......................................... 35 COSOPT PF (ST) ............................. 35 COUMADIN ...................................... 33 COZAAR (QL) .................................. 17 CREON ............................................ 23 CRESTOR (QL) ................................ 19 CRIXIVAN ........................................ 10 CUPRIMINE ..................................... 40 CUVPOSA (PA) ................................ 24

CYCLOGYL ...................................... 36 CYCLOSET (PA, QL) ....................... 14 CYMBALTA (ST, QL) ................. 26, 31 CYTOMEL ........................................ 15 CYTOTEC ........................................ 23 DALIRESP (PA) ............................... 22 DALMANE ........................................ 28 DAPSONE ........................................ 11 DAYPRO .......................................... 30 DAYTRANA (PA, QL) ....................... 28 DDAVP ............................................. 15 DECADRON ..................................... 11 DELZICOL ........................................ 24 DEMEROL ....................................... 29 DEPAKENE ...................................... 31 DEPAKOTE ................................ 27, 31 DEPAKOTE ER (QL) ................. 27, 31 DEPAKOTE SPRINKLE ............. 27, 31 DERMA-SMOOTHE/FS ............. 38, 39 DERMOTIC ...................................... 36 DESOGEN ....................................... 12 DESOXYN (PA, QL) ......................... 28 DESQUAM-E ................................... 37 DESYREL ........................................ 26 DETROL ........................................... 25 DETROL LA (QL) ............................. 25 DEXEDRINE (PA, QL) ..................... 28 DEXPAK ........................................... 11 DEXTROSTAT (PA, QL) .................. 28 DIABETA .......................................... 13 DIAMOX ........................................... 20 DIBENZYLINE .................................. 18 DIFFERIN (PA) ................................ 37 DIFICID (PA) ...................................... 8 DIFLUCAN (QL) ........................... 9, 25 DILANTIN ......................................... 31 DILANTIN ER ................................... 31 DILANTIN INFATABS ...................... 31 DILAUDID ........................................ 29 DIMETANE-DX ................................ 20 DIOVAN (ST, QL) ............................. 17 DIOVAN HCT (ST, QL) .................... 18 DIPENTUM ...................................... 24 DIPROLENE .................................... 38 DITROPAN ....................................... 25 DITROPAN XL ................................. 25 DIURIL ............................................. 19 DOLOBID ......................................... 30 DOLOPHINE .................................... 29 DONNATAL ...................................... 24 DORYX (ST) ...................................... 8 DOVONEX ....................................... 39 DOXYTEX ........................................ 23 DRAMAMINE ................................... 23

DRYSOL .......................................... 39 DUAC ............................................... 37 DUETACT (PA, QL) ......................... 14 DULERA (QL) .................................. 22 DUONEB .......................................... 22 DURAGESIC PATCH (QL) .............. 29 DYAZIDE ......................................... 19 DYMISTA (PA) ................................. 37 DYRENIUM ...................................... 19 E.E.S. ................................................. 8 EDECRIN (PA) ................................. 19 EDLUAR (PA, QL) ........................... 28 EFFEXOR (ST, QL) ......................... 26 EFFEXOR XR (ST, QL) ................... 26 EFFIENT (PA) .................................. 33 EFUDEX .................................... 39, 40 ELAVIL ............................................. 26 ELDEPRYL ...................................... 32 ELESTAT ......................................... 34 ELIDEL ............................................. 39 ELIQUIS (PA) ................................... 33 ELLA ................................................ 13 ELMIRON ......................................... 25 ELOCON .......................................... 38 EMCYT ............................................ 40 EMEND (PA, QL) ............................. 23 EMSAM (PA, QL) ............................. 27 ENBREL (PA) .................................. 41 ENDURON ....................................... 19 ENTOCORT EC (PA, QL) ................ 24 EPANED (PA) .................................. 17 EPIDUO ........................................... 37 EPIFOAM ......................................... 39 EPIPEN (QL) .................................... 22 EPIPEN JR (QL) .............................. 22 EPIVIR ............................................... 9 EPIVIR HBV ....................................... 9 EPZICOM ......................................... 10 ERYCETTE ...................................... 37 ERY-TAB ........................................... 8 ERYTHROCIN ................................... 8 ESGIC-PLUS ............................. 30, 31 ESKALITH ........................................ 27 ESKALITH CR ................................. 27 ESTRACE (cream) ........................... 11 ESTRACE (tab) ................................ 11 ESTRADERM .................................. 11 ESTRATEST .................................... 12 ESTRATEST HS .............................. 12 ESTRING (QL) ................................. 12 EULEXIN .......................................... 40 EURAX ............................................. 39 EVISTA ............................................ 12

3

EVOXAC .......................................... 24



EXFORGE (ST, QL) ......................... 18 EXFORGE HCT (ST, QL) ................. 18 FACTIVE ............................................ 9 FAMVIR .............................................. 9 FANAPT (PA) ................................... 27 FARESTON ...................................... 40 FARXIGA (PA, QL) ........................... 14 FAZACLO (ST) ................................. 27 FELBATOL ....................................... 31 FELDENE ......................................... 30 FEMARA (PA) .................................. 40 FEMCON FE .................................... 12 FEMHRT .......................................... 12 FEMRING (QL) ................................. 12 FENOGLIDE ..................................... 19 FENTORA (PA, QL) ......................... 30 FINACEA .......................................... 38 FIORICET ......................................... 31 FIORINAL ......................................... 31 FIORINAL W/CODEINE ................... 29 FLAGYL ............................................ 11 FLAREX ........................................... 34 FLECTOR PATCH (PA) ................... 30 FLEXERIL ........................................ 32 FLOMAX ........................................... 25 FLONASE ......................................... 36 FLORINEF ........................................ 11 FLOVENT DISKUS (QL) .................. 21 FLOVENT HFA (QL) ........................ 21 FLOXIN OTIC ................................... 36 FLUOXETINE 60 MG ....................... 26 FML .................................................. 34 FML FORTE ..................................... 34 FML LIQUIFILM ................................ 34 FOCALIN (PA, QL) ........................... 28 FOCALIN XR (PA, QL) ..................... 28 FOLIC ACID ..................................... 33 FORADIL (PA, QL) ........................... 21 FORTAMET (ST) .............................. 13 FORTEO (PA, QL) ........................... 15 FORTESTA (PA) .............................. 11 FOSAMAX (QL) ................................ 15 FOSAMAX PLUS D (QL) .................. 15 FRAGMIN (PA, QL) .......................... 33 FREE STYLE TEST STRIPS (QL) ... 15 FROVA (ST, QL) .............................. 31 FULYZAQ (PA, QL) .......................... 22 FURADANTIN .................................. 11 FYCOMPA (PA, QL) ......................... 32 GABITRIL ......................................... 31 GARAMYCIN .................................... 34 GASTROCROM ............................... 22 GELNIQUE (PA) ............................... 25 GEODON ......................................... 27

GLUCAGEN (QL) ............................. 14 GLUCAGON (QL) ............................ 14 GLUCOPHAGE ................................ 13 GLUCOPHAGE XR .......................... 13 GLUCOTROL ................................... 13 GLUCOTROL XL ............................. 13 GLUCOVANCE ................................ 14 GLUMETZA (ST) .............................. 13 GLYNASE ........................................ 13 GOLYTELY ...................................... 24 GRANISOL (PA, QL) ........................ 23 GRANISOL solution (PA, QL) .......... 23 GRIFULVIN V ..................................... 9 GRIS-PEG .......................................... 9 HALCION ......................................... 28 HALDOL ........................................... 27 HALFLYTELY BOWEL

PREP/FLAVOR PACKS .............. 24 HALOG ............................................. 38 HECTOROL ..................................... 15 HEPSERA (PA, QL) ......................... 10 HORIZANT (PA) ............................... 33 HUMALOG ....................................... 14 HUMALOG MIX ................................ 14 HUMIRA (PA) ................................... 41 HUMULIN 70/30 ............................... 14 HUMULIN N ..................................... 14 HUMULIN R ..................................... 14 HYDERGINE .................................... 30 HYDREA .......................................... 40 HYDRODIURIL ................................ 19 HYGROTON .................................... 19 HYTONE .......................................... 39 HYTRIN ...................................... 18, 25 HYZAAR (QL) .................................. 18 IMDUR ............................................. 15 IMITREX (QL) .................................. 30 INCIVEK (PA) ................................... 10 INDERAL .......................................... 16 INDERAL LA .................................... 16 INDOCIN .......................................... 30 INSPRA ............................................ 19 INTELENCE (PA) ............................. 10 INTUNIV (QL) ................................... 29 INVEGA (PA) ................................... 27 INVEGA SUSTENNA (PA) ............... 27 INVIRASE ........................................ 10 INVOKANA (PA, QL) ........................ 14 IQUIX ............................................... 35 ISMO ................................................ 15 ISONIAZID ......................................... 9 ISOPTO ATROPINE ........................ 36 ISOPTO HOMATROPINE ................ 36 ISORDIL ........................................... 15

JALYN .............................................. 25 JANUMET (PA, QL) ......................... 14 JANUMET XR (PA) .......................... 14 JANUVIA (PA, QL) ........................... 13 JENTADUETO (PA) ......................... 14 JUVISYNC (PA) ............................... 14 KADIAN (PA, QL) ............................. 29 KALETRA ......................................... 10 KAPVAY (PA, QL) ............................ 28 KAZANO (PA, QL) ........................... 14 K-DUR 10 ......................................... 33 K-DUR 20 ......................................... 33 KEFLEX ............................................. 8 KENALOG ........................................ 38 KENALOG IN ORABASE ................. 36 KEPPRA (QL) .................................. 31 KEPPRA XR .................................... 31 KLONOPIN ................................ 26, 31 KOMBIGLYZE XR (PA, QL) ............. 14 K-TABS ............................................ 33 KYTRIL (PA, QL) ............................. 23 LAC-HYDRIN ................................... 39 LAMICTAL (QL) ......................... 27, 31 LAMICTAL ODT (QL) ....................... 32 LAMICTAL XR (QL) ......................... 31 LAMISIL (QL) ..................................... 9 LANOXIN ......................................... 17 LANTUS ........................................... 14 LANTUS SOLOSTAR ...................... 14 LASIX ............................................... 18 LASTACAFT (ST) ............................ 34 LATUDA (PA) ................................... 27 LESCOL (QL) ................................... 19 LESCOL XL (QL) ............................. 19 LEVAQUIN (QL) ................................. 9 LEVEMIR ......................................... 15 LEVITRA (QL) .................................. 40 LEVSIN ............................................ 24 LEVSINEX ....................................... 24 LEXAPRO (QL) ................................ 26 LIALDA ............................................. 24 LIBRAX ............................................ 24 LIBRIUM .......................................... 25 LIDEX............................................... 38 LIDODERM (PA, QL) ....................... 31 LINZESS (PA) .................................. 24 LIORESAL ....................................... 32 LIPITOR (QL) ................................... 19 LIPOFEN .......................................... 19 LIPTRUZET (ST, QL) ....................... 20 LIVALO (QL) .................................... 19 LO LOESTRIN/FE ............................ 12 LOCOID LIPOCREAM ..................... 38

4

LODOSYN ....................................... 32



LOESTRIN/FE .................................. 12 LOFIBRA .......................................... 19 LOMOTIL .......................................... 22 LOPID............................................... 19 LOPRESSOR ................................... 16 LOPRESSOR HCT ........................... 16 LOPROX .......................................... 38 LORCET (QL) ................................... 29 LORCET PLUS (QL) ........................ 29 LOTENSIN ....................................... 17 LOTENSIN HCT ............................... 17 LOTREL ........................................... 17 LOTRISONE ..................................... 38 LOVAZA (PA, QL) ............................ 20 LOVENOX (QL) ................................ 33 LOZOL.............................................. 19 LUMIGAN ......................................... 35 LUNESTA (ST, QL) .......................... 28 LUVOX (QL) ..................................... 26 LUVOX CR (PA, QL) ........................ 26 LYRICA (PA, QL) ............................. 31 LYSODREN ...................................... 40 LYSTEDA (QL) ................................. 15 MACROBID ...................................... 11 MACRODANTIN ............................... 11 MALARONE ..................................... 10 MANDELAMINE ............................... 25 MARINOL (PA, QL) .......................... 23 MAXAIR AUTOHALER (QL) ............. 21 MAXALT (QL) ................................... 31 MAXALT MLT (QL) ........................... 31 MAXITROL ....................................... 35 MAXZIDE ......................................... 19 MEDROL .......................................... 11 MENEST .......................................... 11 MEPRON .......................................... 11 MESTINON ...................................... 33 METADATE CD (PA, QL) ................. 28 METADATE ER (PA, QL) ................. 28 METAGLIP ....................................... 14 METHYLIN chew tab (PA, QL) .......... 28 METHYLIN solution (PA, QL) ............ 28 METROCREAM ............................... 38 METROGEL ..................................... 38 METROGEL-VAGINAL..................... 25 METROLOTION ............................... 38 MEVACOR (QL) ............................... 19 MEXITIL ........................................... 16 MICARDIS (ST, QL) ......................... 17 MICARDIS HCT (ST, QL) ................. 18 MICROZIDE ..................................... 19 MIDRIN ............................................. 30 MIGRANAL ....................................... 31 MINIPRESS ...................................... 18

MINOCIN ............................................ 8 MIRAPEX ......................................... 32 MIRAPEX ER (PA) ........................... 32 MIRCETTE ....................................... 12 MOBIC ............................................. 30 MONOKET ....................................... 15 MOTRIN ........................................... 30 MOVIPREP (PA) .............................. 24 MS CONTIN (PA, QL) ...................... 29 MULTAQ (PA) .................................. 17 MYAMBUTOL .................................... 9 MYCELEX .................................... 9, 36 MYCOBUTIN ...................................... 9 MYCOLOG II .................................... 39 MYCOSTATIN .................. 9, 25, 36, 38 MYDFRIN ......................................... 36 MYDRIACYL .................................... 36 MYRBETRIQ (PA, QL) ..................... 25 MYSOLINE ....................................... 31 NAMENDA (QL) ............................... 29 NAMENDA XR (PA, QL) .................. 29 NAPROSYN ..................................... 30 NASAREL ........................................ 36 NASONEX (ST) ................................ 36 NATROBA ........................................ 39 NAVANE .......................................... 27 NEEVO ............................................. 33 NEEVO DHA .................................... 33 NEOMYCIN ........................................ 9 NEOSPORIN .................................... 34 NESINA (PA, QL) ............................. 13 NEUPRO (PA) .................................. 32 NEURONTIN .................................... 31 NEVANAC ........................................ 34 NEXIUM (QL) ................................... 22 NIASPAN ......................................... 20 NIRAVAM (PA) ................................. 26 NITRO-BID ....................................... 16 NITROLINGUAL PUMPSPRAY ....... 15 NITROSTAT ..................................... 16 NIZORAL ...................................... 9, 38 NOLVADEX ...................................... 40 NORCO (QL) .................................... 29 NORDETTE ..................................... 12 NORPACE ....................................... 17 NORPRAMIN ................................... 26 NORVASC ....................................... 16 NORVIR ........................................... 10 NOVOLIN 70/30 ............................... 14 NOVOLIN N ..................................... 14 NOVOLIN R ..................................... 14 NOVOLOG ....................................... 15 NOVOLOG MIX ................................ 15 NUCYNTA (PA) ................................ 30

NUCYNTA ER (PA) ......................... 30 NUEDEXTA (PA) ............................. 29 NULYTELY/FLAVOR PACKS .......... 24 NUVIGIL (PA, QL) ............................ 28 OCUFEN .......................................... 34 OCUFLOX ........................................ 34 OLUX (ST, QL) ................................ 38 OLUX-E (ST, QL) ............................. 38 OLYSIO (PA) ................................... 10 OMNARIS (ST) ................................ 36 OMNICEF .......................................... 8 ONETOUCH ULTRA TEST STRIPS

(QL) ............................................. 15 ONFI (PA) ........................................ 32 ONGLYZA (PA, QL) ......................... 13 OPANA (PA) .................................... 29 OPANA ER (PA, QL)........................ 29 OPTIVAR ......................................... 34 ORACEA (ST) .................................... 8 ORAVIG (PA) ................................... 36 ORTHO EVRA ................................. 12 ORTHO MICRONOR ....................... 13 ORTHO TRI-CYCLEN ...................... 13 ORTHO TRI-CYCLEN LO ................ 13 ORTHO-NOVUM ............................. 12 ORTHO-NOVUM 7/7/7..................... 13 OSENI (PA, QL) ............................... 14 OVIDE .............................................. 39 OXTELLAR XR (PA, QL) ................. 32 OXYCODONE (PA) ......................... 29 OXYCONTIN (PA, QL) ..................... 29 PAMELOR ....................................... 26 PANCREAZE ................................... 23 PARLODEL ................................ 15, 32 PATANOL ........................................ 34 PAXIL (QL) ....................................... 26 PAXIL CR (QL) ................................ 26 PEDIAZOLE ....................................... 9 PENICILLIN ....................................... 8 PENTASA ........................................ 24 PERCOCET (QL) ............................. 29 PERCODAN ..................................... 29 PERIDEX ......................................... 36 PERSANTINE .................................. 33 PERTZYE ........................................ 23 PHENERGAN .................................. 23 PHENERGAN CODEINE ................. 20 PHENERGAN DM ............................ 21 PHENERGAN VC ............................ 20 PHENOBARBITAL ........................... 31 PICATO (PA) ................................... 40 PILOCAR ......................................... 36 PLAN B ONE-STEP ......................... 13

5

PLAQUENIL ..................................... 40



PLAVIX ............................................. 33 PLENDIL .......................................... 16 POLYSPORIN .................................. 34 POLYTRIM ....................................... 34 POLY-VI-FLOR ................................ 33 POTIGA (PA) .................................... 32 PRADAXA (PA) ................................ 33 PRANDIMET (QL) ............................ 14 PRANDIN (QL) ................................. 13 PRAVACHOL (QL) ........................... 19 PRECOSE ........................................ 13 PRED FORTE .................................. 34 PRED MILD ...................................... 34 PRED-G ........................................... 35 PREFERA OB .................................. 33 PREFERA OB DHA .......................... 33 PREFERAOB ONE .......................... 33 PRELONE ........................................ 11 PREMARIN ...................................... 11 PREMPHASE ................................... 12 PREMPRO ....................................... 12 PREPOPIK (PA) ............................... 24 PREVACID (ST, QL) ........................ 22 PREVPAC ........................................ 22 PRILOSEC (QL) ............................... 22 PRIMSOL ......................................... 11 PRINCIPEN ........................................ 8 PRINIVIL .......................................... 17 PRINZIDE ......................................... 17 PRISTIQ (ST, QL) ............................ 26 PROAIR HFA (QL) ........................... 21 PROCENTRA (PA, QL) .................... 28 PROCTOFOAM HC ......................... 39 PROLIA (PA, QL) ............................. 15 PROLIXIN ......................................... 27 PROLOPRIM .................................... 11 PROMETRIUM ................................. 12 PROSCAR ........................................ 25 PROSOM ......................................... 28 PROTONIX (ST, QL) ........................ 22 PROTOPIC ....................................... 40 PROVENTIL HFA (QL) ..................... 21 PROVIGIL (PA, QL) ......................... 28 PROZAC (QL) .................................. 26 PTU .................................................. 15 PULMICORT FLEXHALER (QL) ...... 21 PYRAZINAMIDE ................................ 9 PYRIDIUM ........................................ 25 QNASL (ST) ..................................... 36 QSYMIA (PA) ................................... 41 QUALAQUIN .................................... 11 QUESTRAN ..................................... 20 QUESTRAN LIGHT .......................... 20 QUILLIVANT XR (PA, QL) ................ 28

QUINAGLUTE .................................. 16 QUINORA ........................................ 16 QUIXIN ............................................. 34 QUTENZA (PA, QL) ......................... 31 QVAR (QL) ....................................... 21 RAPAFLO (PA) ................................ 25 REGLAN .................................... 23, 24 RELAFEN ......................................... 30 RELENZA (QL) ................................ 10 RELPAX (QL) ................................... 31 REMERON ....................................... 27 RENVELA ........................................ 24 REQUIP ........................................... 32 REQUIP XL ...................................... 32 RESCRIPTOR .................................. 10 RESTORIL ....................................... 28 RETIN A MICRO (PA, ST) ............... 37 RETIN-A (PA) ................................... 37 RETROVIR ......................................... 9 REVATIO (PA, QL) .......................... 20 RHEUMATREX ................................ 40 RHINOCORT AQUA (ST) ................ 36 RIDAURA ......................................... 40 RIFADIN ............................................. 9 RILUTEK .......................................... 29 RISPERDAL ..................................... 27 RISPERDAL CONSTA (PA) ............. 27 RISPERDAL M-TAB (PA) ................. 27 RITALIN (PA, QL) ............................ 28 RITALIN LA (PA, QL) ....................... 28 RITALIN SR (PA, QL)....................... 28 ROBAXIN ......................................... 32 ROBITUSSIN AC ............................. 21 RONDEC DM ................................... 21 ROWASA ......................................... 24 ROXICODONE (PA) ........................ 29 ROZEREM (QL) ............................... 28 RYTHMOL ........................................ 17 RYZOLT (QL) ................................... 29 SABRIL ............................................ 32 SANCTURA ..................................... 25 SANCTURA XR ............................... 25 SANCUSO (PA, QL)......................... 23 SAPHRIS ......................................... 27 SAVELLA (PA) ................................. 31 SELSUN ........................................... 39 SEPTRA ............................................. 9 SEPTRA DS ....................................... 9 SERAX ............................................. 26 SEREVENT (PA, QL) ....................... 21 SEROQUEL ..................................... 27 SILVADENE ..................................... 38 SIMCOR (QL) ................................... 20 SINEMET ......................................... 32

SINEMET CR ................................... 32 SINEQUAN ...................................... 26 SINGULAIR (PA, QL) ....................... 22 SKLICE (PA) .................................... 39 SOLARAZE (PA) .............................. 30 SOLODYN (ST) ................................. 8 SOMA .............................................. 33 SONATA (QL) .................................. 28 SORIATANE .................................... 39 SOVALDI (PA) ................................. 10 SPIRIVA (QL) ................................... 22 SPORANOX (PA) .............................. 9 STALEVO ........................................ 32 STARLIX .......................................... 13 STRATTERA (QL) ........................... 28 STRIBILD (PA) ................................. 10 SUBOXONE (PA, QL) ...................... 29 SUBSYS (PA, QL) ........................... 30 SUCLEAR ........................................ 24 SULAR ............................................. 16 SUMYCIN .......................................... 8 SUPRAX ............................................ 8 SUPREP BOWEL PREP KIT ........... 24 SUSTIVA .......................................... 10 SYMBICORT (QL) ........................... 22 SYMBYAX ........................................ 27 SYMLIN (PA) ................................... 14 SYMLINPEN (PA) ............................ 14 SYMMETREL ............................... 9, 32 SYNALAR ........................................ 38 SYNTHROID .................................... 15 TACLONEX (PA, QL) ....................... 39 TAMBOCOR .................................... 17 TAMIFLU (QL) ................................. 10 TAPAZOLE ...................................... 15 TARKA ............................................. 17 TASMAR .......................................... 32 TAVIST ............................................ 20 TAZORAC (PA, QL) ................... 37, 39 TEGRETOL ................................ 27, 32 TEGRETOL XR (QL).................. 27, 32 TEKAMLO (PA, QL) ......................... 18 TEKTURNA (PA, QL) ....................... 18 TEKTURNA HCT (PA, QL) .............. 18 TEMODAR (PA) ............................... 40 TEMOVATE ..................................... 38 TENEX ............................................. 18 TENORETIC .................................... 16 TENORMIN ...................................... 16 TENUATE (PA) ................................ 41 TESSALON ...................................... 21 TESTIM (PA) .................................... 11 TEVETEN (ST, QL) .......................... 17

6

TEVETEN HCT (ST, QL) ................. 18


7


THEO-DUR ...................................... 21 THORAZINE ..................................... 23 TIGAN .............................................. 23 TIMOPTIC ........................................ 35 TIMOPTIC-XE .................................. 35 TINDAMAX ....................................... 11 TIVICAY (PA) ................................... 10 TOBRADEX ...................................... 35 TOBREX ........................................... 34 TOFRANIL ........................................ 26 TOPAMAX (QL) ................................ 32 TOPICORT ....................................... 38 TOPICORT LP ................................. 38 TOPROL XL ..................................... 16 TOVIAZ (ST) .................................... 25 TRADJENTA (PA, QL) ..................... 13 TRANDATE ...................................... 16 TRANSDERM-SCOP ....................... 23 TRANXENE-T .................................. 26 TRAVATAN ...................................... 35 TRAVATAN Z ................................... 35 TREXALL ......................................... 40 TREXIMET (ST, QL) ........................ 31 TRIBENZOR (ST, QL) ...................... 18 TRICOR ............................................ 19 TRIDESILON .................................... 38 TRIGLIDE (QL) ................................. 19 TRILEPTAL ...................................... 32 TRILIPIX ........................................... 19 TRIPHASIL ....................................... 13 TRIZIVIR ............................................ 9 TRUSOPT ........................................ 35 TRUVADA ........................................ 10 TUSSICAPS ..................................... 21 TUSSIONEX ..................................... 21 TWYNSTA (ST, QL) ......................... 18 TYKERB (PA) ................................... 40 TYLENOL W/CODEINE ................... 29 UCERIS (PA, QL) ............................. 24 ULORIC (PA) .................................... 30 ULTRAM (QL) .................................. 29 ULTRAM ER (QL) ............................ 29 ULTRAVATE .................................... 38 ULTRESA ......................................... 23 UNIPHYL .......................................... 21 UNISOM ........................................... 23 URECHOLINE .................................. 25 UROCIT-K ........................................ 25

UROXATRAL (PA) ........................... 25 VALCYTE ......................................... 10 VALIUM ............................................ 26 VALTREX ........................................... 9 VANCOCIN ...................................... 11 VANOS (ST) ..................................... 38 VANTIN .............................................. 8 VASCEPA (PA) ................................ 20 VASERETIC ..................................... 17 VASOTEC ........................................ 17 V-CILLIN-K ......................................... 8 VECTICAL ........................................ 39 VENTOLIN HFA (QL) ....................... 21 VEPESID .......................................... 40 VERAMYST (ST) ............................. 36 VERMOX .......................................... 11 VESANOID ....................................... 40 VESICARE ....................................... 25 VFEND (PA) ....................................... 9 VIAGRA (QL) ................................... 40 VIBRAMYCIN ..................................... 8 VICTOZA (PA) ................................. 14 VICTRELIS (PA) .............................. 10 VIDEX .............................................. 10 VIDEX EC .......................................... 9 VIGAMOX ........................................ 35 VIMPAT (PA, QL) ............................. 32 VIOKACE ......................................... 23 VIRACEPT ....................................... 10 VIRAMUNE ...................................... 10 VIRAMUNE XR ................................ 10 VIREAD (PA) .................................... 10 VIROPTIC ........................................ 35 VISKEN ............................................ 16 VISTARIL ......................................... 20 VIVACTIL ......................................... 26 VIVELLE-DOT .................................. 11 VOLTAREN ................................ 30, 34 VOLTAREN GEL (PA)...................... 30 VOSOL ............................................. 36 VOSOL HC OTIC ............................. 36 VYTORIN (ST, QL) .......................... 20 VYVANSE (PA, QL) ......................... 28 WELCHOL ....................................... 20 WELLBUTRIN (ST, QL) ................... 27 WELLBUTRIN SR (ST, QL) ............. 27 WELLBUTRIN XL (ST, QL) .............. 27 WELLCOVORIN ............................... 40

WESTCORT .................................... 39 XALATAN ......................................... 35 XANAX ............................................. 26 XANAX XR ....................................... 26 XARELTO (QL) ................................ 33 XELJANZ (PA, QL) .......................... 41 XENICAL (PA) ................................. 41 XIBROM ........................................... 34 XOPENEX (QL) ............................... 21 XOPENEX HFA (QL) ....................... 21 XYLOCAINE VISCOUS ................... 36 YASMIN ........................................... 12 YAZ .................................................. 12 YODOXIN ........................................ 11 ZARONTIN ....................................... 32 ZAROXOLYN ................................... 19 ZEBETA ........................................... 16 ZELAPAR ......................................... 32 ZEMPLAR ........................................ 15 ZENPEP ........................................... 23 ZENZEDI (PA, QL) ........................... 28 ZERIT ............................................... 10 ZESTORETIC .................................. 17 ZESTRIL .......................................... 17 ZETIA (PA, QL) ................................ 20 ZETONNA (ST) ................................ 37 ZIAC ................................................. 16 ZIAGEN ............................................ 10 ZIANA .............................................. 37 ZIOPTAN (ST) ................................. 35 ZITHROMAX ...................................... 8 ZMAX ................................................. 8 ZOCOR (PA, QL) ............................. 19 ZOFRAN (PA, QL) ........................... 23 ZOFRAN ODT (PA, QL) ................... 23 ZOLOFT (QL) ................................... 26 ZOMIG (ST, QL) .............................. 31 ZOMIG ZMT (ST, QL) ...................... 31 ZOVIRAX (oral) ................................ 10 ZOVIRAX (topical cream) ................. 38 ZOVIRAX (topical ointment) ............. 38 ZYCLARA (PA) ................................ 40 ZYFLO (PA) ..................................... 22 ZYFLO CR (PA) ............................... 22 ZYLOPRIM ....................................... 30 ZYMAXID ......................................... 34 ZYPREXA ........................................ 27 ZYPREXA RELPREVV (PA) ............ 27

8

Preferred Drug Listing

Availability depends on formulation and the ordering protocols of a particular pharmacy. Generics may not be bioequivalent to their corresponding brands.

NOTE: Company plan designs may override formulary designations on certain medications; check benefit materials.

Generic Tier

Brand Tier

Drug Name Generic Name — Brand Name

Additional Information

Chapter 1 – ANTI-INFECTIVES 1.1 Penicillins

1 NA AMOXICILLIN — Amoxil

1 NA PENICILLIN — Penicillin, V-Cillin-K oral solution and tablet

1 NA AMPICILLIN — Principen

1 3 AMOXICILLIN/CLAVULANATE POTASSIUM

— Augmentin, Augmentin XR

1.2 Cephalosporins 1 NA CEFACLOR — Ceclor 1 NA CEFDINIR — Omnicef 1 NA CEFPODOXIME — Vantin 1 3 CEFTIBUTEN — Cedax 1 3 CEFUROXIME — Ceftin 1 3 CEPHALEXIN — Keflex

NA 2 CEFIXIME — Suprax 1.3 Macrolides

1 3 CLARITHROMYCIN — Biaxin, Biaxin XL 1 3 ERYTHROMYCIN ETHYLSUCCINATE — E.E.S. 1 3 AZITHROMYCIN — Zithromax

NA 2 ERYTHROMYCIN STEARATE — Erythrocin NA 3 FIDAXOMICIN — Dificid PA

NA 3 ERYTHROMYCIN BASE(ENTERIC-COATED) — Ery-Tab

NA 3 AZITHROMYCIN — Zmax 1.4 Tetracyclines

1 NA TETRACYCLINE — Sumycin 1 3 DOXYCYCLINE — Doryx ST 1 3 MINOCYCLINE — Minocin

1 3 MINOCYCLINE ER — Solodyn ST (generics

are 45, 90 and 135mg)

1 3 DOXYCYCLINE — Vibramycin NA 2 DOXYCYCLINE — Oracea ST

1.5 Fluoroquinolones 1 3 MOXIFLOXACIN — Avelox 1 3 CIPROFLOXACIN — Cipro

9




Generic Tier

Brand Tier



1 3 LEVOFLOXACIN — Levaquin QL NA 3 GEMIFLOXACIN — Factive

1.6 Aminoglycosides (Oral) 1 NA NEOMYCIN — Neomycin

1.7 Sulfonamides 1 NA SULFISOXAZOLE/ERYTHROMYCIN — Pediazole

1 3 TRIMETHOPRIM/SULFAMETHOXAZOLE

— Bactrim, Septra, Bactrim DS, Septra DS

1.8 Antituberculosis Drugs 1 NA ISONIAZID — Isoniazid 1 NA PYRAZINAMIDE — Pyrazinamide 1 3 ETHAMBUTOL — Myambutol 1 3 RIFABUTIN — Mycobutin 1 3 RIFAMPIN — Rifadin

1.9 Antifungals 1 NA NYSTATIN — Mycostatin 1 NA KETOCONAZOLE — Nizoral 1 3 FLUCONAZOLE — Diflucan QL

1 3 GRISEOFULVIN — Grifulvin V suspension is generic

1 3 GRISEOFULVIN — Gris-Peg 1 3 TERBINAFINE — Lamisil QL 1 3 CLOTRIMAZOLE — Mycelex 1 3 ITRACONAZOLE — Sporanox PA 1 3 VORICONAZOLE — VFEND PA

1.10 Antivirals 1 NA AMANTADINE — Symmetrel 1 3 ZIDOVUDINE/LAMIVUDINE — Combivir 1 3 LAMIVUDINE — Epivir 1 3 LAMIVUDINE — Epivir HBV 1 3 FAMCICLOVIR — Famvir 1 3 ZIDOVUDINE — Retrovir 1 3 ABACAVIR/LAMIVUDINE/ZIDOVUDINE — Trizivir 1 3 VALACYCLOVIR — Valtrex 1 3 DIDANOSINE Videx EC

10




Generic Tier

Brand Tier



1 3 NEVIRAPINE — Viramune 1 3 NEVIRAPINE — Viramune XR 1 3 STAVUDINE — Zerit 1 3 ABACAVIR — Ziagen 1 3 ACYCLOVIR — Zovirax (oral)

NA 2 EFAVIRENZ/EMTRICITABINE/TENOFOVIR

— Atripla

NA 2 INDINAVIR — Crixivan NA 2 ABACAVIR/LAMIVUDINE — Epzicom NA 2 SAQUINAVIR — Invirase NA 2 LOPINAVIR/RITONAVIR — Kaletra NA 2 RITONAVIR — Norvir NA 2 ZANAMIVIR — Relenza QL NA 2 DELAVIRDINE — Rescriptor

NA 2 ELVITEGRAVIR/COBICISTAT/EMTRICITABINE/TENOFOVIR

— Stribild PA

NA 2 EFAVIRENZ — Sustiva NA 2 OSELTAMIVIR — Tamiflu QL NA 2 DOLUTEGRAVIR — Tivicay PA NA 2 EMTRICITABINE/TENOFOVIR — Truvada NA 2 VALGANCICLOVIR — Valcyte

NA 2 DIDANOSINE — Videx pediatric formulation

NA 2 NELFINAVIR — Viracept

NA 2 TENOFOVIR — Viread Powder: PA (if >12 years

old) NA 3 ETRAVIRINE — Intelence PA

1 4 ADEFOVIR — Hepsera specialty—PA, QL

NA 4 TELAPREVIR — Incivek specialty—PANA 4 SIMEPREVIR — Olysio specialty—PANA 4 SOFOSBUVIR — Sovaldi specialty—PANA 4 BOCEPREVIR — Victrelis specialty—PA

1.11 Antimalarials 1 3 CHLOROQUINE — Aralen 1 3 ATOVAQUONE/PROGUANIL — Malarone

11




Generic Tier

Brand Tier



1 3 QUININE — Qualaquin NA 3 ARTEMETHER/LUMEFANTRINE — Coartem PA

1.12 Amebicides NA 2 IODOQUINOL — Yodoxin

1.13 Anthelmintics 1 NA MEBENDAZOLE — Vermox

NA 2 PRAZIQUANTEL — Biltricide 1.14 Miscellaneous Anti-Infectives

1 NA DAPSONE — Dapsone 1 NA TRIMETHOPRIM — Proloprim 1 3 METRONIDAZOLE — Flagyl

1 3 NITROFURANTOIN — Furadantin, Macrobid, Macrodantin

1 3 ATOVAQUONE — Mepron 1 3 TINIDAZOLE — Tindamax 1 3 VANCOMYCIN — Vancocin

NA 2 TRIMETHOPRIM — Primsol Chapter 2 – ENDOCRINE MEDICATIONS

2.1 Systemic Corticosteroids 2.1.1 Glucocorticosteroids

1 3 DEXAMETHASONE — Decadron, DexPak 1 3 METHYLPREDNISOLONE — Medrol 1 3 PREDNISOLONE SYRUP — Prelone

2.1.2 Mineralocorticoids1 NA FLUDROCORTISONE — Florinef

2.2 Androgens NA 2 TESTOSTERONE — Androgel, Testim PA NA 3 TESTOSTERONE — Androderm, Axiron, Fortesta PA

2.3 Estrogens 1 3 ESTRADIOL — Climara transdermal 1 3 ESTRADIOL — Estrace (tab)

NA 2 ESTROGENS — Cenestin, Menest, Premarin NA 2 ESTRADIOL — Estrace (cream) NA 2 ESTRADIOL — Estraderm, Vivelle-Dot transdermal NA 3 ESTRADIOL — Alora transdermal

12




Generic Tier

Brand Tier



NA 3 ESTRADIOL — Estring, Femring vaginal ring; QL for both

2.4 Estrogen & Progestin Combinations NA 2 ESTRADIOL/LEVONORGESTREL — Climara Pro transdermal NA 2 ESTRADIOL/NORETHINDRONE — Combipatch

NA 2 ETHINYL ESTRADIOL/NORETHINDRONE

— Femhrt

NA 2 ESTROGENS/MEDROXYPROGESTERONE

— Premphase, Prempro

2.5 Estrogen & Androgen Combinations

1 NA ESTROGENS, ESTERIFIED/ METHYLTESTOSTERONE

— Estratest, Estratest HS

2.6 Estrogen Modulators 1 3 RALOXIFENE — Evista

2.7 Progestins 1 3 PROGESTERONE — Prometrium

2.8 Non-Oral Contraceptives

1 3 NORELGESTROMIN/ETHINYL ESTRADIOL

— Ortho Evra

2.9 Oral Contraceptives 2.9.1 Mono-Phasic Oral Contraceptives

1 3 LEVONORGESTREL/ETHINYL ESTRADIOL

— Alesse, Nordette

1 3 ETHINYL ESTRADIOL/NORETHINDRONE

— Brevicon, Loestrin/Fe, Ortho-Novum

1 3 DESOGESTREL/ETHINYL ESTRADIOL — Desogen

1 3 ETHINYL ESTRADIOL/NORETHINDRONE

— Femcon Fe chew tab

1 3 DROSPIRENONE/ETHINYL ESTRADIOL

— Yasmin, Yaz

NA 2 ETHINYL ESTRADIOL/

DROSPIRENONE/LEVOMEFOLATE CALCIUM

— Beyaz

2.9.2 Bi-Phasic Oral Contraceptives

1 3 DESOGESTREL/ETHINYL ESTRADIOL — Mircette

NA 3 ETHINYL ESTRADIOL/NORETHINDRONE

— Lo Loestrin Fe

2.9.3 Tri-Phasic Oral Contraceptives

13




Generic Tier

Brand Tier



1 NA LEVONORGESTREL/ETHINYL ESTRADIOL

— Triphasil

1 3 NORETHINDRONE/ETHINYL ESTRADIOL

— Ortho-Novum 7/7/7

1 3 ETHINYL ESTRADIOL/NORGESTIMATE

— Ortho Tri-Cyclen

NA 2 ETHINYL ESTRADIOL/NORGESTIMATE

— Ortho Tri-Cyclen Lo

2.9.4 Progestin-Only Oral Contraceptives1 3 NORETHINDRONE — Ortho Micronor

2.9.5 Emergency Contraceptives1 3 LEVONORGESTREL — Plan B One-Step

NA 2 ULIPRISTAL — Ella 2.10 Oral Hypoglycemics

2.10.1 Biguanides1 3 METFORMIN — Glucophage, Glucophage XR 1 3 METFORMIN — Fortamet ST

NA 3 METFORMIN — Glumetza ST 2.10.2 Sulfonylureas

1 3 GLIMEPIRIDE — Amaryl 1 3 GLYBURIDE — Diabeta, Glynase 1 3 GLIPIZIDE — Glucotrol, Glucotrol XL

2.10.3 Meglitinide Derivatives1 3 REPAGLINIDE — Prandin QL 1 3 NATEGLINIDE — Starlix

2.10.4 Alpha-Glucosidase Inhibitors1 3 ACARBOSE — Precose

2.10.5 Dipeptidyl Peptidase IV InhibitorsNA 2 SITAGLIPTIN — Januvia PA, QL NA 2 SAXAGLIPTIN — Onglyza PA, QL NA 2 LINAGLIPTIN — Tradjenta PA, QL NA 3 ALOGLIPTIN — Nesina PA, QL

2.10.6 Thiazolidinediones1 3 PIOGLITAZONE — Actos PA, QL

NA 3 ROSIGLITAZONE — Avandia PA, QL 2.10.7 Sodium-Glucose Cotransporter 2 (SGLT2) Inhibitors

14




Generic Tier

Brand Tier



NA 3 DAPAGLIFLOZIN — Farxiga PA, QL NA 3 CANAGLIFLOZIN — Invokana PA, QL

2.10.8 Dopamine AgonistsNA 3 BROMOCRIPTINE — Cycloset PA, QL

2.10.9 Combination Oral Hypoglycemics1 3 PIOGLITAZONE/METFORMIN — Actoplus Met PA, QL 1 3 PIOGLITAZONE/GLIMEPIRIDE — Duetact PA, QL 1 3 GLYBURIDE/METFORMIN — Glucovance 1 3 GLIPIZIDE/METFORMIN — Metaglip

NA 2 SITAGLIPTIN/METFORMIN — Janumet PA, QL NA 2 SAXAGLIPTIN/METFORMIN XR — Kombiglyze XR PA, QL NA 2 REPAGLINIDE/METFORMIN — Prandimet QL NA 3 PIOGLITAZONE/METFORMIN XR — Actoplus Met XR PA, QL NA 3 ROSIGLITAZONE/METFORMIN — Avandamet PA, QL NA 3 ROSIGLITAZONE/GLIMEPIRIDE — Avandaryl PA, QL NA 3 SITAGLIPTIN/METFORMIN — Janumet XR PA NA 3 LINAGLIPTIN/METFORMIN — Jentadueto PA NA 3 SITAGLIPTIN/SIMVASTATIN — Juvisync PA NA 3 ALOGLIPTIN/METFORMIN — Kazano PA, QL NA 3 ALOGLIPTIN/PIOGLITAZONE — Oseni PA, QL

2.11 Non-Insulin Injectable Hypoglycemics NA 2 EXENATIDE — Byetta PA NA 2 GLUCAGON — Glucagen, Glucagon, QL NA 2 PRAMLINTIDE — Symlin, SymlinPen PA NA 3 EXENATIDE — Bydureon PA NA 3 LIRAGLUTIDE — Victoza PA

2.12 Insulins NA 2 GLULISINE — Apidra NA 2 LISPRO — Humalog NA 2 LISPRO & LISPRO PROTAMINE — Humalog Mix NA 2 INSULIN NPH — Humulin N, Novolin N NA 2 INSULIN REGULAR — Humulin R, Novolin R NA 2 INSULIN ISOPHANE & REGULAR — Humulin 70/30, Novolin 70/30 NA 2 GLARGINE — Lantus, Lantus SoloStar

15




Generic Tier

Brand Tier



NA 2 DETEMIR — Levemir NA 2 ASPART — Novolog NA 2 ASPART & ASPART PROTAMINE — Novolog Mix

2.13 Diabetic Supplies NA 2 BLOOD GLUCOSE TESTING STRIPS — Accu-Chek Test Strips QL NA 2 INSULIN SYRINGES — BD Insulin Syringes NA 2 BLOOD GLUCOSE TESTING STRIPS — Free Style Test Strips QL NA 2 BLOOD GLUCOSE TESTING STRIPS — OneTouch Ultra Test Strips QL

2.14 Antithyroid Drugs 1 NA PROPYLTHIOURACIL — PTU 1 2 METHIMAZOLE — Tapazole

2.15 Thyroid Hormones 1 2 LIOTHYRONINE — Cytomel 1 2 LEVOTHYROXINE — Synthroid

2.16 Osteoporosis Agents 1 3 RISEDRONATE — Actonel ST, QL 1 3 IBANDRONATE — Boniva QL

1 3 ALENDRONATE — Fosamax tablet & solution; QL

NA 2 ALENDRONATE/VITAMIN D — Fosamax Plus D QL NA 3 ALENDRONATE — Binosto PA NA 3 TERIPARATIDE — Forteo PA, QL NA 3 DENOSUMAB — Prolia PA, QL

2.17 Other Endocrine Drugs 1 3 DESMOPRESSIN — DDAVP tablet & spray 1 3 DOXERCALCIFEROL — Hectorol 1 3 TRANEXAMIC ACID — Lysteda QL 1 3 BROMOCRIPTINE — Parlodel 1 3 PARICALCITOL — Zemplar

Chapter 3 – CARDIOVASCULAR MEDICATIONS 3.1 Nitrates

1 3 ISOSORBIDE MONOHYDRATE — Imdur, Ismo, Monoket 1 3 ISOSORBIDE DINITRATE — Isordil 1 3 NITROGLYCERIN — Nitrolingual Pumpspray

16




Generic Tier

Brand Tier



NA 2 NITROGLYCERIN — Nitro-Bid, Nitrostat Nitrostat is sublingual

3.2 Beta-Blockers 3.2.1 Beta-1 Specifics

1 3 METOPROLOL TARTRATE — Lopressor 1 3 ATENOLOL — Tenormin 1 3 METOPROLOL SUCCINATE — Toprol XL 1 3 BISOPROLOL — Zebeta

NA 3 NEBIVOLOL — Bystolic ST, QL 3.2.2 Alpha- & Beta-Adrenergic Blockers

1 3 CARVEDILOL — Coreg 1 3 LABETALOL — Trandate

NA 2 CARVEDILOL — Coreg CR ST 3.2.3 Non-Selectives

1 NA PINDOLOL — Visken 1 3 NADOLOL — Corgard 1 3 PROPRANOLOL — Inderal, Inderal LA

3.2.4 Beta-Blocker Combinations

1 3 METOPROLOL/HYDROCHLOROTHIAZIDE

— Lopressor HCT

1 3 ATENOLOL/CHLORTHALIDONE — Tenoretic

1 3 BISOPROLOL/HYDROCHLOROTHIAZIDE

— Ziac

3.3 Calcium Channel Blocker (CCB) 3.3.1 Dihydropyridine Calcium Channel Blockers (DHPCCBs)

1 NA NICARDIPINE — Cardene 1 NA FELODIPINE — Plendil 1 3 NIFEDIPINE SR — Adalat-CC 1 3 AMLODIPINE — Norvasc 1 3 NISOLDIPINE — Sular

3.3.2 Nondihydropyridine Calcium Channel Blockers (Non-DHPCCBs)1 3 VERAPAMIL — Calan, Calan SR 1 3 DILTIAZEM — Cardizem, Cardizem CD

3.4 Antidysrhythmic Drugs 1 NA MEXILETINE — Mexitil 1 NA QUINIDINE — Quinaglute, Quinora

17




Generic Tier

Brand Tier



1 3 AMIODARONE — Cordarone 1 3 DIGOXIN — Lanoxin 1 3 DISOPYRAMIDE — Norpace 1 3 PROPAFENONE — Rythmol 1 3 FLECAINIDE — Tambocor

NA 2 DRONEDARONE — Multaq PA 3.5 Renin-Angiotensin-Aldosterone System (RAAS) Drugs

3.5.1 Angiotensin-Converting Enzyme Inhibitors (ACE-Is)1 NA CAPTOPRIL — Capoten 1 3 RAMIPRIL — Altace 1 3 BENAZEPRIL — Lotensin 1 3 LISINOPRIL — Prinivil, Zestril 1 3 ENALAPRIL — Vasotec

NA 3 ENALAPRIL — Epaned PA 3.5.2 Angiotensin-Converting Enzyme Inhibitor Combinations

1 NA CAPTOPRIL/HYDROCHLOROTHIAZIDE — Capozide

1 3 BENAZEPRIL/HYDROCHLOROTHIAZIDE

— Lotensin HCT

1 3 AMLODIPINE/BENAZEPRIL — Lotrel 1 3 LISINOPRIL/HYDROCHLOROTHIAZIDE — Prinzide, Zestoretic 1 3 ENALAPRIL/HYDROCHLOROTHIAZIDE — Vaseretic

NA 2 TRANDOLAPRIL/VERAPAMIL — Tarka 3.5.3 Angiotensin II Receptor Blockers (ARBs)

1 3 CANDESARTAN — Atacand ST, QL 1 3 IRBESARTAN — Avapro QL 1 3 LOSARTAN — Cozaar QL 1 3 TELMISARTAN — Micardis ST, QL 1 3 EPROSARTAN — Teveten ST, QL

NA 2 OLMESARTAN — Benicar ST, QL NA 2 VALSARTAN — Diovan ST, QL

3.5.4 Angiotensin II Receptor Blocker (ARB) Combinations

1 3 CANDESARTAN/HYDROCHLOROTHIAZIDE

— Atacand HCT ST, QL

1 3 IRBESARTAN/HYDROCHLOROTHIAZIDE

— Avalide QL

18




Generic Tier

Brand Tier



1 3 VALSARTAN/HYDROCHLOROTHIAZIDE

— Diovan HCT ST, QL

1 3 LOSARTAN/HYDROCHLOROTHIAZIDE — Hyzaar QL

1 3 TELMISARTAN/HYDROCHLOROTHIAZIDE

— Micardis HCT ST, QL

1 3 TELIMISARTAN/AMLODIPINE — Twynsta ST, QL NA 2 OLMESARTAN/AMLODIPINE — Azor ST, QL

NA 2 OLMESARTAN/HYDROCHLOROTHIAZIDE

— Benicar HCT ST, QL

NA 2 AMLODIPINE/VALSARTAN — Exforge ST, QL

NA 2 AMLODIPINE/VALSARTAN/HYDROCHLOROTHIAZIDE

— Exforge HCT ST, QL

NA 2 AMLODIPINE/OLMESARTAN/HYDROCHLOROTHIAZIDE

— Tribenzor ST, QL

NA 3 EPROSARTAN/ HYDROCHLOROTHIAZIDE

— Teveten HCT ST, QL

3.5.5 Renin Inhibitors & Renin Inhibitor CombinationsNA 3 ALISKIREN/AMLODIPINE — Tekamlo PA, QL NA 3 ALISKIREN — Tekturna PA, QL NA 3 ALISKIREN/ HYDROCHLOROTHIAZIDE — Tekturna HCT PA, QL

3.6 Antiadrenergic Agents (Centrally Acting) 1 NA METHYLDOPA — Aldomet

1 3 CLONIDINE — Catapres, Catapres-TTS-1, Catapres-TTS-2, Catapres-TTS-3

1 3 GUANFACINE — Tenex 3.7 Antiadrenergic Agents (Peripherally Acting)

1 NA TERAZOSIN — Hytrin 1 3 DOXAZOSIN — Cardura 1 3 PRAZOSIN — Minipress

3.8 Alpha-Blockers NA 2 PHENOXYBENZAMINE — Dibenzyline

3.9 Vasodilators 1 NA HYDRALAZINE — Apresoline

3.10 Diuretics 3.10.1 Loop Diuretics

1 NA BUMETANIDE — Bumex 1 3 FUROSEMIDE — Lasix

19




Generic Tier

Brand Tier



NA 3 ETHACRYNIC ACID — Edecrin PA 3.10.2 Thiazide & Related Diuretics

1 NA METHYCLOTHIAZIDE — Enduron 1 NA CHLORTHALIDONE — Hygroton 1 NA INDAPAMIDE — Lozol 1 3 HYDROCHLOROTHIAZIDE — Hydrodiuril, Microzide 1 3 CHLOROTHIAZIDE — Diuril 1 3 METOLAZONE — Zaroxolyn

3.10.3 Potassium-Sparing Diuretics1 3 SPIRONOLACTONE — Aldactone 1 3 EPLERENONE — Inspra

NA 3 TRIAMTERENE — Dyrenium 3.10.4 Potassium-Sparing & Thiazide Diuretic Combinations

1 3 SPIRONOLACTONE/HYDROCHLOROTHIAZIDE

— Aldactazide

1 3 TRIAMTERENE/HYDROCHLOROTHIAZIDE

— Dyazide, Maxzide

3.11 Cholesterol-Lowering Agents 3.11.1 HMG-CoA Reductase Inhibitors (Statins)

1 3 FLUVASTATIN — Lescol QL 1 3 ATORVASTATIN — Lipitor QL 1 3 LOVASTATIN — Mevacor QL 1 3 PRAVASTATIN — Pravachol QL 1 3 SIMVASTATIN — Zocor PA: 80mg; QL

NA 2 ROSUVASTATIN — Crestor QL NA 2 FLUVASTATIN — Lescol XL QL NA 3 PITAVASTATIN — Livalo QL

3.11.2 Fibric Acids1 3 FENOFIBRATE — Lipofen 1 3 FENOFIBRATE — Lofibra, Tricor 1 3 GEMFIBROZIL — Lopid 1 3 FENOFIBRATE — Triglide QL 1 3 FENOFIBRATE — Trilipix

NA 3 FENOFIBRATE — Antara, Fenoglide 3.11.3 Bile Acid Sequestrants

20




Generic Tier

Brand Tier



1 3 COLESTIPOL — Colestid tabs, can 1 3 CHOLESTYRAMINE SUCROSE — Questran 1 3 CHOLESTYRAMINE ASPARTAME — Questran Light

NA 2 COLESEVELAM — Welchol 3.11.4 Nicotinic Acids

1 3 NIACIN — Niaspan 3.11.5 Cholesterol Absorption Inhibitors

NA 3 EZETIMIBE — Zetia PA, QL 3.11.6 Omega-3 Fatty Acids

NA 3 OMEGA-3 –ACID ETHYL ESTERS — Lovaza PA, QL NA 3 ICOSAPENT ETHYL — Vascepa PA

3.11.6 Combination Cholesterol-Lowering Agents1 3 ATORVASTATIN/AMLODIPINE — Caduet QL

NA 2 LOVASTATIN/NIACIN — Advicor QL NA 2 SIMVASTATIN/NIACIN — Simcor QL NA 2 SIMVASTATIN/EZETIMIBE — Vytorin ST, QL NA 3 EZETIMIBE/ATORVASTATIN — Liptruzet ST, QL

3.12 Miscellaneous Cardiovascular Drugs 1 3 ACETAZOLAMIDE — Diamox 1 3 SILDENAFIL — Revatio PA, QL

NA 2 TADALAFIL — Adcirca PA, QL Chapter 4 – RESPIRATORY MEDICATIONS

4.1 Antihistamines 1 NA DIPHENHYDRAMINE — Benadryl 50mg 1 3 HYDROXYZINE — Atarax, Vistaril 1 3 DESLORATADINE — Clarinex QL 1 3 CLEMASTINE — Tavist

4.2 Antitussives & Expectorants

1 NA PSEUDOEPHEDRINE/BROMPHENIRAMINE/

DEXTROMETHORPHAN— Dimetane-DX

1 NA CODEINE/PROMETHAZINE — Phenergan Codeine

1 NA PHENYLEPHRINE/PROMETHAZINE — Phenergan VC

21




Generic Tier

Brand Tier



1 NA PHENYLEPHRINE/

CHLORPHENIRAMINE/DEXTROMETHORPHAN

— Rondec DM

1 3 DEXTROMETHORPHAN/PROMETHAZINE

— Phenergan DM

1 3 CODEINE/GUAIFENESIN — Robitussin AC

1 3 BENZONATATE — Tessalon

1 3 CHLORPHENIRAMINE/HYDROCODONE

— Tussionex

NA 2 CHLORPHENIRAMINE/HYDROCODONE

— Tussicaps

4.3 Antiasthmatics/COPD 4.3.1 Adrenergic Stimulants (Inhalers)

NA 2 FORMOTEROL — Foradil PA, QL NA 2 PIRBUTEROL — Maxair Autohaler QL NA 2 ALBUTEROL — ProAir HFA, Ventolin HFA QL NA 2 SALMETEROL — Serevent PA, QL NA 3 ALBUTEROL — Proventil HFA QL NA 3 LEVALBUTEROL — Xopenex HFA QL

4.3.2 Adrenergic Stimulants (Solutions)1 3 ALBUTEROL — AccuNeb 1 3 LEVALBUTEROL — Xopenex QL

4.3.3 Adrenergic Stimulants (Oral Tabs)1 NA ALBUTEROL — Albuterol

4.3.4 Methylxanthines1 NA THEOPHYLLINE — Theo-Dur, Uniphyl

4.3.5 Corticosteroids for InhalationNA 2 FLUNISOLIDE — Aerospan QL NA 2 CICLESONIDE — Alvesco QL NA 2 MOMETASONE — Asmanex QL NA 2 FLUTICASONE — Flovent Diskus, Flovent HFA QL NA 2 BUDESONIDE — Pulmicort Flexhaler QL NA 2 BECLOMETHASONE — QVAR QL

4.3.6 Leukotriene Pathway Modulators1 3 ZAFIRLUKAST — Accolate PA

22




Generic Tier

Brand Tier



1 3 MONTELUKAST — Singulair PA, QL NA 3 ZILEUTON — Zyflo, Zyflo CR PA

4.3.7 AnticolinergicsNA 2 IPRATROPIUM — Atrovent HFA QL NA 2 TIOTROPIUM — Spiriva QL

4.3.8 Combinations and Other Drugs for Asthma & COPD1 3 ALBUTEROL/IPRATROPIUM — Duoneb

NA 2 FLUTICASONE/SALMETEROL — Advair Diskus, Advair HFA QL NA 2 UMECLIDINIUM/VILANTEROL — Anoro Ellipta QL NA 2 FLUTICASONE/VILANTEROL — Breo Ellipta ST

NA 2 ALBUTEROL/IPRATROPIUM — Combivent Inhalation Aerosol, Combivent Respimat

Inhalation Aerosol

phased out by 12/2013; QL

NA 2 MOMETASONE/FORMOTEROL — Dulera QL NA 2 BUDESONIDE/FORMOTEROL — Symbicort QL NA 3 ROFLUMILAST — Daliresp PA

4.4 Other Respiratory Agents 1 3 CROMOLYN — Gastrocrom oral solution

NA 2 EPINEPHRINE — Auvi-Q PA, QL NA 2 EPINEPHRINE — Epipen, Epipen JR QL

Chapter 5 – GASTROINTESTINAL MEDICATIONS 5.1 Antidiarrheal Preparations

1 3 DIPHENOXYLATE/ATROPINE — Lomotil NA 2 NITAZOXANIDE — Alinia NA 3 CROFELEMER — Fulyzaq PA, QL

5.2 Antiulcer Drugs 5.2.1 H. Pylori Treatments

1 3 LANSOPRAZOLE/AMOXICILLIN/CLARITHROMYCIN

— Prevpac

5.2.2 Proton Pump Inhibitors (PPI)1 3 RABEPRAZOLE — Aciphex ST, QL 1 3 LANSOPRAZOLE — Prevacid ST, QL 1 3 OMEPRAZOLE — Prilosec QL 1 3 PANTOPRAZOLE — Protonix ST, QL

NA 2 ESOMEPRAZOLE — Nexium QL

23




Generic Tier

Brand Tier



5.2.3 Other Antiulcer Products1 3 SUCRALFATE — Carafate (tab) 1 3 MISOPROSTOL — Cytotec

NA 2 SUCRALFATE — Carafate (suspension) 5.3 Antiemetics

1 NA MECLIZINE — Antivert

1 NA PYRIDOXINE — B-Natal low-dose

pyridoxine tablets

1 NA GRANISETRON — Granisol PA, QL 1 NA GRANISETRON — Kytril PA, QL 1 NA PROMETHAZINE — Phenergan oral/rectal 1 NA CHLORPROMAZINE — Thorazine 1 3 PROCHLORPERAZINE — Compazine, Compro

1 3 DOXYLAMINE — Doxytex, Unsiom chew tablet is plan exclusion

1 3 DIMENHYDRINATE — Dramamine 1 3 DRONABINOL — Marinol PA, QL 1 3 METOCLOPRAMIDE — Reglan 1 3 TRIMETHOBENZAMIDE — Tigan 1 3 ONDANSETRON — Zofran, Zofran ODT PA, QL

NA 2 GRANISETRON — Sancuso PA, QL NA 2 SCOPOLAMINE — Transderm-Scop NA 3 DOLASETRON — Anzemet PA, QL NA 3 APREPITANT — Emend PA, QL

NA 3 GRANISETRON — Granisol solution; PA, QL

5.4 Digestants NA 2 PANCRELIPASE — Creon, Zenpep NA 3 PANCRELIPASE — Pancreaze NA 3 PANCRELIPASE — Pertzye NA 3 PANCRELIPASE — Ultresa NA 3 PANCRELIPASE — Viokace

5.5 Antispasmodics & Drugs Affecting GI Motility 1 NA LACTULOSE — Cephulac 1 3 DICYCLOMINE — Bentyl

24




Generic Tier

Brand Tier



1 3 POLYETHYLENEGLYCOL-ELECTROLYTE SOLUTION

— Colyte-Flavor Packs, GoLytelyNuLytely/flavor Packs

1 3 BELLADONNA ALKALOIDS/PHENOBARBITAL

— Donnatal

1 3 HYOSCYAMINE — Levsin, Levsinex 1 3 CHLORDIAZEPOXIDE/CLIDINIUM — Librax 1 3 METOCLOPRAMIDE — Reglan

NA 2 POLYETHYLENEGLYCOL-ELECTROLYTE SOLUTION

— Suclear

NA 2 SODIUM, POTASSIUM, & MAGNESIUM SULFATES

— Suprep Bowel Prep Kit

NA 3 POLYETHYLENE

GLYCOL-ELECTROLYTE SOLUTION AND BISACODYL

— Halflytely Bowel Prep/Flavor Packs

NA 3 POLYETHYLENEGLYCOL-ELECTROLYTE SOLUTION

— MoviPrep PA

NA 3 SODIUM PICOSULFATE/MAGNESIUM OXIDE/CITRIC ACID

— Prepopik PA

5.6 Sulfonamide & Mesalamine Products 1 3 SULFASALAZINE — Azulfidine 1 3 MESALAMINE — Rowasa

NA 2 MESALAMINE — Asacol, Canasa, Pentasa

NA 3 MESALAMINE — Apriso, Lialda NA 3 MESALAMINE — Asacol HD PA NA 3 MESALAMINE — Delzicol NA 3 OLSALAZINE — Dipentum

5.7 Phosphate Binders 1 3 SEVELAMER — Renvela

5.8 Other GI Agents

1 3 BUDESONIDE — Entocort EC PA, QL (90/30)

1 3 CEVIMELINE — Evoxac NA 2 GLYCOPFYRROLATE — Cuvposa PA

NA 2 BUDESONIDE — Uceris PA, QL (30/30)

NA 3 LINACLOTIDE — Linzess PA Chapter 6 – GENITOURINARY AGENTS

6.1 Vaginal Anti-Infectives

25




Generic Tier

Brand Tier



1 NA METHENAMINE — Mandelamine 1 NA NYSTATIN — Mycostatin 1 3 CLINDAMYCIN — Cleocin Vaginal Cream 1 3 FLUCONAZOLE — Diflucan QL 1 3 METRONIDAZOLE — MetroGel-Vaginal

6.2 Anticholinergics & Antispasmodics 1 3 TOLTERODINE — Detrol 1 3 TOLTERODINE — Detrol LA QL 1 3 OXYBUTYNIN — Ditropan, Ditropan XL 1 3 TROSPIUM — Sanctura, Sanctura XR

NA 2 OXYBUTYNIN — Gelnique PA NA 2 SOLIFENACIN — Vesicare NA 3 MIRABEGRON — Myrbetriq PA, QL NA 3 FESOTERODINE ER — Toviaz ST

6.3 Cholinergic Drugs 1 3 BETHANECHOL — Urecholine

6.4 Urinary Analgesics 1 3 PHENAZOPYRIDINE — Pyridium

NA 2 PENTOSAN POLYSULFATE SODIUM — Elmiron 6.5 Other Genitourinary Products

1 NA TERAZOSIN — Hytrin 1 3 DOXAZOSIN — Cardura 1 3 TAMSULOSIN — Flomax 1 3 FINASTERIDE — Proscar 1 3 POTASSIUM CITRATE — Urocit-K 1 3 ALFUZOSIN — Uroxatral PA

NA 2 DUTASTERIDE — Avodart NA 2 DUTASTERIDE/TAMSULOSIN — Jalyn NA 3 DOXAZOSIN — Cardura XL NA 3 SILODOSIN — Rapaflo PA

Chapter 7 – CENTRAL NERVOUS SYSTEM (CNS) MEDICATIONS 7.1 Antianxiety Drugs

1 NA BUSPIRONE — Buspar 1 NA CHLORDIAZEPOXIDE — Librium

26




Generic Tier

Brand Tier



1 NA OXAZEPAM — Serax 1 3 LORAZEPAM — Ativan 1 3 CLONAZEPAM — Klonopin 1 3 ALPRAZOLAM ODT — Niravam PA 1 3 CLORAZEPATE — Tranxene-T 1 3 DIAZEPAM — Valium 1 3 ALPRAZOLAM — Xanax 1 3 ALPRAZOLAM — Xanax XR

7.2 Antidepressants 7.2.1 Selective Serotonin Reuptake Inhibitors (SSRIs)

1 NA FLUVOXAMINE — Luvox QL 1 3 CITALOPRAM — Celexa QL 1 3 ESCITALOPRAM — Lexapro QL 1 3 FLUVOXAMINE — Luvox CR PA, QL 1 3 PAROXETINE — Paxil, Paxil CR QL 1 3 FLUOXETINE — Prozac QL 1 3 SERTRALINE — Zoloft QL

NA 3 PAROXETINE — Brisdelle PA, QL

NA 3 FLUOXETINE 60 MG — Fluoxetine 60 mg tablet considered brand

7.2.2 Serotonin/Norepinephrine Reuptake Inhibitors (SNRIs)1 NA VENLAFAXINE — Effexor ST, QL 1 3 DULOXETINE — Cymbalta ST, QL 1 3 VENLAFAXINE — Effexor XR ST, QL

NA 3 DESVENLAFAXINE — Pristiq ST, QL 7.2.3 Tricyclic Antidepressants (TCAs)

1 NA AMOXAPINE — Asendin 1 NA AMITRIPTYLINE — Elavil 1 NA DOXEPIN — Sinequan 1 3 DESIPRAMINE — Norpramin 1 3 NORTRIPTYLINE — Pamelor 1 3 IMIPRAMINE — Tofranil 1 3 PROTRIPTYLINE — Vivactil

7.2.4 Miscellaneous Antidepressants1 NA TRAZODONE — Desyrel

27




Generic Tier

Brand Tier



1 3 MIRTAZAPINE — Remeron 1 3 OLANZAPINE/FLUOXETINE — Symbyax

1 3 BUPROPION — Wellbutrin, Wellbutrin SR, Wellbutrin XL ST, QL

NA 3 VORTIOXETINE — Brintellix PA, QL NA 3 SELEGILINE — Emsam PA, QL

7.3 Antimania Drugs 1 NA LITHIUM — Eskalith, Eskalith CR 1 2 DIVALPROEX — Depakote, Depakote Sprinkle 1 2 DIVALPROEX — Depakote ER QL 1 2 LAMOTRIGINE — Lamictal QL 1 2 CARBAMAZEPINE — Tegretol 1 2 CARBAMAZEPINE — Tegretol XR QL

NA 3 ASENAPINE — Saphris 7.4 Antipsychotics

1 NA FLUPHENAZINE — Prolixin 1 3 CLOZAPINE — Clozaril, Fazaclo ST 1 3 ZIPRASIDONE — Geodon 1 3 HALOPERIDOL — Haldol 1 3 THIOTHIXENE — Navane 1 3 RISPERIDONE — Risperdal tab, solution 1 3 RISPERIDONE — Risperdal M-tab PA 1 3 QUETIAPINE — Seroquel 1 3 OLANZAPINE — Zyprexa

NA 2 ARIPIPRAZOLE — Abilify NA 2 ARIPIPRAZOLE — Abilify Maintena PA NA 3 ILOPERIDONE — Fanapt PA NA 3 PALIPERIDONE — Invega PA NA 3 PALIPERIDONE — Invega Sustenna PA NA 3 LURASIDONE — Latuda PA NA 3 RISPERIDONE — Risperdal Consta PA NA 3 ASENAPINE — Saphris NA 3 OLANZAPINE — Zyprexa Relprevv PA

7.5 Sedatives & Hypnotics 7.5.1 Non-benzodiazepine Sedative-Hypnotics

28




Generic Tier

Brand Tier



1 3 ZOLPIDEM — Ambien, Ambien CR QL 1 3 ESZOPICLONE — Lunesta ST, QL 1 3 ZALEPLON — Sonata QL

NA 3 ZOLPIDEM — Edluar PA, QL NA 3 RAMELTEON — Rozerem QL

7.5.2 Benzodiazepines1 NA FLURAZEPAM — Dalmane 1 3 TRIAZOLAM — Halcion 1 3 ESTAZOLAM — Prosom 1 3 TEMAZEPAM — Restoril

7.6 CNS Stimulants

1 3 AMPHETAMINE/DEXTROAMPHETAMINE

— Adderall PA, QL

1 3 AMPHETAMINE/DEXTROAMPHETAMINE

— Adderall XR PA, QL

1 3 METHYLPHENIDATE — Concerta PA, QL 1 3 METHAMPHETAMINE — Desoxyn PA, QL 1 3 DEXTROAMPHETAMINE — Dexedrine PA, QL 1 3 DEXTROAMPHETAMINE — Dextrostat, Zenzedi PA, QL (90/30)1 3 DEXMETHYLPHENIDATE — Focalin PA, QL 1 3 DEXMETHYLPHENIDATE — Focalin XR PA, QL 1 3 CLONIDINE — Kapvay PA, QL

1 3 METHYLPHENIDATE — Metadate CD, Metadate ER, Ritalin, Ritalin LA, Ritalin SR PA, QL

1 3 METHYLPHENIDATE — Methylin solution; PA, QL

1 3 DEXTROAMPHETAMINE — Procentra PA, QL 1 3 MODAFINIL — Provigil PA, QL

NA 2 METHYLPHENIDATE — Daytrana transdermal; PA, QL

NA 2 ATOMOXETINE — Strattera QL NA 2 LISDEXAMFETAMINE — Vyvanse PA, QL

NA 3 METHYLPHENIDATE — Methylin chewable

tablet; PA, QL (90/30)

NA 3 ARMODAFINIL — Nuvigil PA, QL NA 3 METHYLPHENIDATE — Quillivant XR PA, QL

29




Generic Tier

Brand Tier



7.7 Other CNS Drugs 1 3 DISULFIRAM — Antabuse 1 3 DONEPEZIL — Aricept, Aricept ODT QL 1 3 ACAMPROSATE — CAMPRAL 1 3 BUPRENORPHINE/NALOXONE — Suboxone PA, QL

NA 2 VARENICLINE — Chantix PA, QL NA 2 GUANFACINE — Intuniv QL NA 2 MEMANTINE — Namenda QL NA 3 MEMANTINE — Namenda XR PA, QL NA 3 DEXTROMETHORPHAN/QUINIDINE — Nuedexta PA 1 4 RILUZOLE — Rilutek

Chapter 8 – ANALGESICS 8.1 Narcotic Analgesics

1 NA CODEINE — Codeine 1 3 FENTANYL — Actiq PA, QL 1 3 MORPHINE — Avinza PA, QL 1 3 MEPERIDINE — Demerol 1 3 HYDROMORPHONE — Dilaudid 1 3 METHADONE — Dolophine 1 3 FENTANYL PATCH — Duragesic Patch QL

1 3 BUTALBITAL/ASPIRIN/CAFFEINE/CODEINE

— Fiorinal w/Codeine

1 3 MORPHINE — Kadian PA, QL

1 3 HYDROCODONE/ACETAMINOPHEN

— Lorcet, Lorcet Plus, Norco QL

1 3 MORPHINE — MS Contin PA, QL 1 3 OXYMORPHONE — Opana PA 1 3 OXYMORPHONE Opana ER PA, QL

1 3 OXYCODONE — Oxycodone oral solution; PA

1 3 OXYCODONE/ACETAMINOPHEN — Percocet QL 1 3 OXYCODONE/ASPIRIN — Percodan 1 3 OXYCODONE — Roxicodone PA 1 3 TRAMADOL — Ryzolt, Ultram, Ultram ER QL 1 3 ACETAMINOPHEN/CODEINE — Tylenol w/Codeine

NA 2 OXYCODONE — Oxycontin PA, QL

30




Generic Tier

Brand Tier



NA 3 BUPRENORPHINE — Butrans PA, QL NA 3 FENTANYL — Fentora PA, QL NA 3 TAPENTADOL — Nucynta PA NA 3 TAPENTADOL ER — Nucynta ER PA NA 3 FENTANYL (SUBLINGUAL) — Subsys PA, QL

8.2 Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) 1 NA FLURBIPROFEN — Ansaid 1 NA DIFLUNISAL — Dolobid 1 NA IBUPROFEN — Motrin 1 NA NABUMETONE — Relafen 1 3 NAPROXEN — Anaprox, Anaprox DS, Naprosyn 1 3 DICLOFENAC/MISOPROSTOL — Arthrotec 1 3 DICLOFENAC — Cataflam, Voltaren oral 1 3 SULINDAC — Clinoril 1 3 OXAPROZIN — Daypro 1 3 PIROXICAM — Feldene 1 3 INDOMETHACIN — Indocin 1 3 MELOXICAM — Mobic 1 3 DICLOFENAC — Solaraze topical, PA

NA 2 CELECOXIB — Celebrex PA, QL NA 3 DICLOFENAC — Flector Patch topical, PA NA 3 DICLOFENAC — Voltaren Gel topical, PA

8.3 Drugs to Prevent & Treat Gout 1 3 ALLOPURINOL — Zyloprim

NA 2 COLCHICINE — Colcrys NA 3 FEBUXOSTAT — Uloric PA

8.4 Migraine Drugs 1 NA ERGOLOID MESYLATES — Hydergine

1 NA ISOMETHEPTENE/

DICHLORALPHENAZONE/ACETAMINOPHEN

— Midrin

1 3 NARATRIPTAN — Amerge ST, QL

1 3 BUTALBITAL/ACETAMINOPHEN/CAFFEINE

— Esgic-Plus

1 3 SUMATRIPTAN — Imitrex QL

31




Generic Tier

Brand Tier



1 3 RIZATRIPTAN — Maxalt, Maxalt MLT QL 1 3 DIHYDROERGOTAMINE — Migranal 1 3 ZOLMITRIPTAN — Zomig, Zomig ZMT ST, QL

NA 2 ERGOTAMINE/CAFFEINE — Cafergot NA 2 ELETRIPTAN — Relpax QL NA 3 ALMOTRIPTAN — Axert ST, QL NA 3 FROVATRIPTAN — Frova ST, QL NA 3 SUMATRIPTAN/NAPROXEN — Treximet ST, QL

8.5 Miscellaneous Analgesics 1 3 DULOXETINE — Cymbalta ST, QL

1 3 BUTALBITAL/ACETAMINOPHEN/CAFFEINE

— Esgic-Plus, Fioricet

1 3 BUTALBITAL/ASPIRIN/CAFFEINE — Fiorinal 1 3 LIDOCAINE — Lidoderm patch; PA, QL1 3 GABAPENTIN — Neurontin

NA 2 PREGABALIN — Lyrica PA, QL NA 3 CAPSAICIN — Qutenza patch; PA, QLNA 3 MILNACIPRAN — Savella PA

Chapter 9 – NEUROMUSCULAR AGENTS 9.1 Anticonvulsants

1 NA PHENOBARBITAL — Phenobarbital 1 2 CARBAMAZEPINE — Carbatrol QL 1 2 VALPROIC ACID — Depakene 1 2 DIVALPROEX — Depakote, Depakote Sprinkle 1 2 DIVALPROEX — Depakote ER QL 1 2 PHENYTOIN — Dilantin, Dilantin ER 1 2 PHENYTOIN — Dilantin Infatabs 1 2 FELBAMATE — Felbatol 1 2 TIAGABINE — Gabitril 1 2 LEVETIRACETAM — Keppra QL 1 2 LEVETIRACETAM ER — Keppra XR 1 2 CLONAZEPAM — Klonopin 1 2 LAMOTRIGINE — Lamictal QL 1 2 LAMOTRIGINE — Lamictal XR QL 1 2 PRIMIDONE — Mysoline

32




Generic Tier

Brand Tier



1 2 CARBAMAZEPINE — Tegretol 1 2 CARBAMAZEPINE — Tegretol XR QL (90/30) 1 2 TOPIRAMATE — Topamax QL 1 2 OXCARBAZEPINE — Trileptal 1 2 ETHOSUXIMIDE — Zarontin

NA 2 LAMOTRIGINE — Lamictal ODT QL NA 2 CLOBAZAM — Onfi PA NA 2 EZOGABINE — Potiga PA NA 3 PERAMPANEL — Fycompa PA, QL NA 3 OXCARBAZEPINE — Oxtellar XR PA, QL NA 3 VIGABATRIN — Sabril

NA 3 LACOSAMIDE — Vimpat tab, solution; PA, QL

9.2 Anti-Parkinson’s Drugs 1 NA TRIHEXIPHENIDYL — Artane 1 NA AMANTADINE — Symmetrel 1 3 BENZTROPINE — Cogentin 1 3 ENTACAPONE — Comtan 1 3 SELEGILINE — Eldepryl 1 3 CARBIDOPA — Lodosyn 1 3 PRAMIPEXOLE — Mirapex 1 3 BROMOCRIPTINE — Parlodel 1 3 ROPINIROLE — Requip, Requip XL 1 3 CARBIDOPA/LEVODOPA — Sinemet, Sinemet CR

1 3 LEVODOPA/CARBIDOPA/ ENTACAPONE

— Stalevo

NA 2 TOLCAPONE — Tasmar NA 3 PRAMIPEXOLE — Mirapex ER PA

NA 3 ROTIGOTINE — Neupro transdermal; PA

NA 3 SELEGILINE — Zelapar 9.3 Skeletal Muscle Relaxants

1 3 CYCLOBENZAPRINE — Flexeril 1 3 BACLOFEN — Lioresal 1 3 METHOCARBAMOL — Robaxin

33




Generic Tier

Brand Tier



1 3 CARISOPRODOL — Soma NA 3 CYCLOBENZAPRINE — Amrix ST

9.4 Anticholinesterase Muscle Stimulants 1 3 PYRIDOSTIGMINE — Mestinon

9.5 Other Neuromuscular Agents NA 3 GABAPENTIN ENACARBIL — Horizant PA

Chapter 10 – NUTRITIONAL PRODUCTS 10.1 Prenatal Vitamins

NA 2 PRENATAL VITAMINS —Neevo, Neevo DHA, Prefera OB, Prefera OB DHA, PreferaOB ONE

10.2 Vitamins 1 3 MULTI-VITAMINS & FLUORIDE — Poly-Vi-Flor tabs, drops

10.3 Potassium Supplements 1 3 POTASSIUM CHLORIDE — K-Dur 10, K-Dur 20, K-Tabs

10.4 Miscellaneous Nutritional Products 1 3 LEVOCARNITINE — Carnitor

Chapter 11 – HEMATOLOGICAL AGENTS 11.1 Anemia Agents

1 NA FOLIC ACID — Folic Acid 11.2 Anticoagulants

1 3 FONDAPARINUX — Arixtra PA, QL (14-day supply)

1 3 WARFARIN — Coumadin

1 3 ENOXAPARIN — Lovenox QL (14-day supply)

NA 2 DABIGATRAN — Pradaxa PA NA 3 APIXABAN — Eliquis PA

NA 3 DALTEPARIN — Fragmin PA, QL (14-day supply)

NA 3 RIVAROXABAN — Xarelto QL (14-day supply)

11.3 Antiplatelet Drugs 1 3 DIPYRIDAMOLE — Persantine 1 3 CLOPIDOGREL — Plavix

NA 3 TICAGRELOR — Brilinta PA NA 3 PRASUGREL — Effient PA

34




Generic Tier

Brand Tier



Chapter 12 – OPHTHALMIC MEDICATIONS 12.1 Corticosteroids

1 3 FLUOROMETHOLONE — FML Liquifilm suspension 1 3 PREDNISOLONE ACETATE — Pred Forte

NA 2 FLUOROMETHOLONE — FML ointment NA 2 FLUOROMETHOLONE — FML Forte suspension NA 2 PREDNISOLONE ACETATE — Pred Mild NA 3 FLUOROMETHOLONE — Flarex suspension

12.2 Non-Steroidal Anti-Inflammatory Drugs 1 NA BROMFENAC — Xibrom 1 3 KETOROLAC — Acular, Acular LS 1 3 BROMFENAC — Bromday 1 3 FLURBIPROFEN — Ocufen 1 3 DICLOFENAC — Voltaren

NA 3 NEPAFENAC — Nevanac 12.3 Antiallergic Agents

1 3 EPINASTINE — Elestat 1 3 AZELASTINE — Optivar

NA 2 OLOPATADINE — Patanol NA 3 ALCAFTADINE — Lastacaft ST

12.4 Anti-infective Agents 12.4.1 Antibiotics & Antibiotic Combinations

1 NA BACITRACIN — AK-Tracin 500 un/g

1 NA NEOMYCIN/BACITRACIN/POLYMYXIN B — Cortisporin (ophthalmic),

Neosporin

1 3 SULFACETAMIDE — Bleph-10 1 3 GENTAMICIN — Garamycin

1 3 NEOMYCIN/POLYMYXIN B/ GRAMICIDIN

— Neosporin

1 3 OFLOXACIN — Ocuflox 1 3 BACITRACIN/POLYMYXIN B — Polysporin 1 3 TRIMETHOPRIM/POLYMYXIN B — Polytrim 1 3 LEVOFLOXACIN — Quixin 1 3 TOBRAMYCIN — Tobrex 1 3 GATIFLOXACIN — Zymaxid

35




Generic Tier

Brand Tier



NA 3 AZITHROMYCIN — Azasite NA 3 LEVOFLOXACIN — Iquix NA 3 MOXIFLOXACIN — Vigamox

12.4.2 Antibiotic & Corticosteroid Combinations

1 NA NEOMYCIN/BACITRACIN/POLYMYXIN B/HYDROCORTISONE

— Cortisporin (ophthalmic)

1 3 NEOMYCIN/POLYMYXIN B/DEXAMETHASONE

— Maxitrol

1 3 TOBRAMYCIN/DEXAMETHASONE — Tobradex NA 2 SULFACETAMIDE/PREDNISOLONE — Blephamide NA 2 PREDNISOLONE/GENTAMICIN — Pred-G

12.4.3 Antivirals1 3 TRIFLURIDINE — Viroptic

12.5 Glaucoma Agents 12.5.1 Prostaglandins

1 NA TRAVOPROST — Travatan 1 3 LATANOPROST — Xalatan

NA 3 BIMATOPROST — Lumigan NA 3 TRAVOPROST — Travatan Z NA 3 TAFLUPROST — Zioptan ST

12.5.2 Beta-Adrenoreceptor Antagonists1 3 LEVOBUNOLOL — Betagan 1 3 TIMOLOL MALEATE SOLUTION — Timoptic 1 3 TIMOLOL MALEATE GEL — Timoptic-XE

NA 2 BETAXOLOL — Betoptic-S 12.5.3 Carbonic Anhydrase Inhibitors

1 3 DORZOLAMIDE — Trusopt NA 2 BRINZOLAMIDE — Azopt

12.5.4 Alpha-Adrenoreceptor Agonists1 3 BRIMONIDINE — Alphagan-P

12.5.5 Combinations and Miscellaneous Glaucoma Agents1 3 DORZOLAMIDE/TIMOLOL Cosopt

NA 3 DORZOLAMIDE/TIMOLOL — Cosopt PF ST 12.6 Dilating Agents

12.6.1 Anticholinergics

36




Generic Tier

Brand Tier



1 3 CYCLOPENTOLATE — Cyclogyl 1 3 ATROPINE — Isopto Atropine 1 3 HOMATROPINE — Isopto Homatropine 1 3 TROPICAMIDE — Mydriacyl

12.6.2 Sympathomimetics1 3 PHENYLEPHRINE — Mydfrin

12.7 Miotics 1 NA PILOCARPINE HYDROCHLORIDE — Pilocar

Chapter 13 – EAR, NOSE, THROAT MEDICATIONS 13.1 OTIC Anti-Infectives

1 NA OFLOXACIN — Floxin Otic 1 3 ACETIC ACID — Vosol

13.2 OTIC Steroid & Anti-Infective Combinations

1 3 HYDROCORTISONE/NEOMYCIN/POLYMYXIN B — Cortisporin (otic)

1 3 HYDROCORTISONE/ACETIC ACID — Vosol HC Otic 13.3 Miscellaneous OTIC Products

1 3 BENZOCAINE/ANTIPYRINE — Auralgan 1 3 FLUOCINOLONE — Dermotic

13.4 Throat Medications 1 NA TRIAMINCINOLONE PASTE — Kenalog In Orabase 1 NA NYSTATIN SUSPENSION — Mycostatin 1 NA LIDOCAINE VISCOUS — Xylocaine Viscous 1 3 CLOTRIMAZOLE — Mycelex 1 3 CHLORHEXIDINE GLUCONATE — Peridex

NA 3 MICONAZOLE — Oravig PA 13.5 Nasal Corticosteroids

1 NA FLUNISOLIDE — Nasarel 1 3 FLUTICASONE — Flonase 1 3 BUDESONIDE — Rhinocort Aqua ST

NA 2 MOMETASONE — Nasonex ST NA 2 BECLOMETHASONE — Qnasl ST NA 2 FLUTICASONE — Veramyst ST (>16years)NA 3 BECLOMETHASONE — Beconase AQ ST NA 3 CICLESONIDE — Omnaris ST

37




Generic Tier

Brand Tier



NA 3 CICLESONIDE — Zetonna ST 13.6 Nasal Antihistamines and Antihistamine Combinations

1 3 AZELASTINE — Astelin 1 3 AZELASTINE — Astepro

NA 3 AZELASTINE/FLUTICASONE — Dymista PA 13.7 Miscellaneous Nasal Products

1 3 IPRATROPIUM — Atrovent Nasal Spray Chapter 14 – DERMATOLOGICALS

14.1 Antiacne Medications 1 NA BENZOYL PEROXIDE GEL — Desquam-E 1 NA ERYTHROMYCIN TOPICAL SOLUTION — Erycette

1 3 BENZOYL PEROXIDE/ERYTHROMYCIN

— Benzamycin

1 3 CLINDAMYCIN — Cleocin, Cleocin T

1 3 ADAPALENE — Differin PA (>40years)

1 3 CLINDAMYCIN/BENZOYL PEROXIDE — Duac

1 3 TRETINOIN — Retin-A PA (>40years)

1 3 TRETINOIN — Retin A Micro PA

(>40years), ST

2 NA ISOTRETINOIN — Accutane

PA [Amnesteem,

Claravis, Myorisan, Zenatane]

NA 2 AZELAIC ACID — Azelex NA 2 TAZAROTENE — Tazorac PA, QL NA 3 ISOTRETINOIN — Absorica PA NA 3 CLINDAMYCIN/BENZOYL PEROXIDE — Acanya NA 3 DAPSONE — Aczone ST NA 3 ADAPALENE/BENZOYL PEROXIDE — Epiduo NA 3 CLINDAMYCIN/TRETINOIN — Ziana

14.2 Topical Anti-Infectives 1 3 MUPIROCIN — Bactroban cream 1 3 MUPIROCIN — Bactroban ointment only

38




Generic Tier

Brand Tier



1 3 METRONIDAZOLE — MetroCream, MetroGel, MetroLotion

1 3 SILVER SULFADIAZINE — Silvadene NA 2 RETAPAMULIN — Altabax NA 2 AZELAIC ACID — Finacea

14.3 Topical Antifungals 1 NA NYSTATIN — Mycostatin 1 3 CICLOPIROX — Loprox 1 3 BETAMETHASONE/CLOTRIMAZOLE — Lotrisone 1 3 KETOCONAZOLE — Nizoral

14.4 Topical Antivirals 1 3 ACYCLOVIR — Zovirax (topical) ointment

NA 2 ACYCLOVIR — Zovirax (topical) Cream 14.5 Topical Corticosteroids Group 1 (Very High Potency)

1 3 CLOBETASOL — Clobex, Temovate 1 3 BETAMETHASONE — Diprolene 1 3 CLOBETASOL — Olux ST, QL

1 3 CLOBETASOL — Olux-E topical foam; ST, QL

1 3 HALOBETASOL — Ultravate 1 3 FLUOCINONIDE — Vanos ST

Group 2 (High Potency) 1 NA FLUOCINONIDE — Lidex 1 NA DESOXIMETASONE — Topicort LP 1 3 DESOXIMETASONE — Topicort

NA 2 HALCINONIDE — Halog Group 3 (Medium Potency)

1 NA DESONIDE — Tridesilon 1 3 CLOCORTOLONE — Cloderm 1 3 FLUOCINOLONE — Derma-Smoothe/FS 1 3 MOMETASONE — Elocon 1 3 TRIAMCINOLONE ACETONIDE — Kenalog 1 3 HYDROCORTISONE — Locoid Lipocream 1 3 FLUOCINOLONE ACETONIDE — Synalar

39




Generic Tier

Brand Tier



1 3 HYDROCORTISONE VALERATE — Westcort NA 2 FLUOCINOLONE — Capex

Group 4 (Low Potency) 1 NA HYDROCORTISONE — Hytone

14.6 Topical Corticosteroids in Combination 1 NA TRIAMCINOLONE/NYSTATIN — Mycolog II

NA 2 PRAMOXINE/HYDROCORTISONE — Epifoam 14.7 Scabicides & Pediculocides TREATMENT OF CHOICE IS OTC NIX

1 2 SPINOSAD — Natroba 1 3 MALATHION — Ovide

NA 2 CROTAMITON — Eurax NA 3 IVERMECTIN — Sklice PA

14.8 Anorectals 1 3 HYDROCORTISONE ACETATE — Anusol-HC Supp suppository 1 3 HYDROCORTISONE — Cortenema suspension

NA 2 HYDROCORTISONE — Cortifoam NA 2 PRAMOXINE/HYDROCORTISONE — Proctofoam HC

14.9 Antipsoriatics 1 3 FLUOCINOLONE — Derma-Smoothe/FS 1 3 CALCIPOTRIENE — Dovonex cream 1 3 ACITRETIN — Soriatane 1 3 CALCIPOTRIENE/BETAMETHASONE — Taclonex PA, QL 1 3 CALCITRIOL — Vectical ST

NA 2 TAZAROTENE — Tazorac PA, QL 14.10 Miscellaneous Topicals

1 3 IMIQUIMOD — Aldara QL 1 3 PODOFILOX — Condylox Solution 1 3 ALUMINUM CHLORIDE — Drysol 1 3 FLUOROURACIL — Efudex 1 3 AMMONIUM LACTATE — Lac-Hydrin 1 3 SELENIUM SULFIDE — Selsun

NA 2 PODOFILOX — Condylox Gel NA 2 PIMECROLIMUS — Elidel

40




Generic Tier

Brand Tier



NA 2 INGENOL MEBUTATE — Picato PA NA 2 TACROLIMUS — Protopic NA 3 IMIQUIMOD — Zyclara PA

Chapter 15 – IMPOTENCE AGENTS NA 2 VARDENAFIL — Levitra QL NA 2 SILDENAFIL — Viagra QL NA 3 TADALAFIL — Cialis QL

Chapter 16 – ANTINEOPLASTIC AGENTS 1 NA FLUTAMIDE — Eulexin 1 NA TAMOXIFEN — Nolvadex 1 NA ETOPOSIDE — Vepesid 1 NA TRETINOIN — Vesanoid 1 NA LEUCOVORIN — Wellcovorin 1 3 ANASTROZOLE — Arimidex PA 1 3 EXEMESTANE — Aromasin PA 1 3 FLUOROURACIL — Efudex 1 3 LETROZOLE — Femara PA 1 3 HYDROXYUREA — Hydrea

NA 2 MELPHALAN — Alkeran NA 2 LOMUSTINE — Ceenu NA 2 ESTRAMUSTINE — Emcyt NA 2 TOREMIFENE — Fareston NA 2 MITOTANE — Lysodren NA 2 METHOTREXATE — Trexall 1 4 TEMOZOLOMIDE — Temodar specialty—PA

NA 4 LAPATINIB — Tykerb PA Chapter 17 – IMMUNOMODULATORS

17.1 Antirheumatics 1 3 LEFLUNOMIDE — Arava 1 3 HYDROXYCHLOROQUINE — Plaquenil 1 3 METHOTREXATE — Rheumatrex

NA 2 PENICILLAMINE — Cuprimine NA 2 AURANOFIN — Ridaura

17.2 Biologics

41




Generic Tier

Brand Tier



NA 2 ETANERCEPT — Enbrel specialty—PANA 2 ADALIMUMAB — Humira specialty—PANA 3 CERTOLIZUMAB — Cimzia specialty—PA

NA 4 TOFACITINIB — Xeljanz specialty—PA, QL

Chapter 18 – WEIGHT-LOSS AGENTS 1 NA DIETHYLPROPION — Tenuate PA 1 NA DIETHYLPROPION ER — Tenuate PA 1 3 PHENTERMINE — Adipex-P PA

NA 2 ORLISTAT — Alli PA NA 2 ORLISTAT — Xenical PA NA 3 LORCASERIN — Belviq PA NA 3 PHENTERMINE/TOPIRAMATE — Qsymia PA

42





PLAN EXCLUSIONS FENTANYL CITRATE — Abstral

DOXYLAMINE — Aldex AN

FEXOFENADINE OTC — Allegra OTC

TRIAMCINOLONE NASAL SPRAY — AllerNaze

SUMATRIPTAN INJECTION — Alsuma

LOVASTATIN ER — Altoprev

DALFAMPRIDINE, 4-AMINOPYRIDINE — Ampyra

BUPROPION HYDROBROMIDE — Aplenzin

RISEDRONATE — Atelvia

BESIFLOXACIN — Besivance

NABILONE — Cesamet

CIPROFLOXACIN OTIC SOLUTION 0.2% — Cetraxal

DEXLANSOPRAZOLE — Dexilant

DOXYLAMINE/PYRIDOXINE — Diclegis

IBUPROFEN/FAMOTIDINE — Duexis

AZILSARTAN — Edarbi

MORPHINE SULFATE/NALTREXONE — Embeda

HYDROMORPHONE ER — Exalgo

TAZAROTENE — Fabior

FLUOXETINE 40 MG (GENERIC ONLY) — Fluoxetine 40 mg

TEDUGLUTIDE — Gattex

BASALAZIDE — Giazo

NEPAFENAC — Ilevro

ZOLPIDEM — Intermezzo

PILOCARPINE — Isopto Carpine

LOMITAPIDE — Juxtapid

BIMATOPROST — Latisse

FENTANYL — Lazanda

LEVONORGESTREL/ETHINYL ESTRADIOL — LoSeasonique

43




GUAIFENESIN ER — Mucinex ER

ESTRADIOL VALERATE/DIENOGESTROL — Natazia

TRAZODONE ER — Oleptro Drug Name

Generic Name — Brand Name FENTANYL BUCCAL FILM — Onsolis

OSPEMIFENE — Osphena

DICLOFENAC TOPICAL SOLUTION — Pennsaid

LANSOPRAZOLE OTC — Prevacid OTC

CYSTEAMINE ER — Procysbi

CAPSAICIN — Quentza 8% Patch

PREDNISONE DELAYED-RELEASE — Rayos

UNOPROSTONE ISOPROPYL — Rescula

DOXEPIN — Silenor

GOLIMUMAB — Simponi

KETOROLAC NASAL SPRAY — Sprix

VARDENAFIL ODT — Staxyn

AVANAFIL — Stendra

SUMATRIPTAN INJECTION — Sumavel DosePro

PHENTERMINE — Suprenza

ACLIDINIUM — Tudorza

TREPROSTINIL — Tyvaso

CLINDAMYCIN/TRETINOIN — Veltin

VILAZODONE — Viibryd

NAPROXEN/OMEPRAZOLE — Vimovo

CHLORPHENIRAMINE/HYDROCODONE — Vituz

LEVOCETIRIZINE — Xyzal OMEPRAZOLE 20 MG/SODIUM BICARBONATE

1100 MG OTC— Zegerid OTC

HYDROCODONE — Zohydro ER

ZOLPIDEM — Zolpimist

ONDANSETRON — Zuplenz

Documents

PPrreeffeerrrreedd DDrruugg LLiissttiinngg … Formulary Elite Plans.pdf · omnaris (st) ..... 36 . omnicef ..... 8 . onetouch ultra test strips (ql ) ..... 15 . onfi (pa