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PRESCRIPTION DRUG PROGRAM
FORMULARY
Effective April 1, 2016
myahatpa.com
1
Dear Plan Member:
In an effort to continue our commitment to provide you with comprehensive prescription drug coverage, a formulary feature is included in your prescription drug benefit. A formulary is a list of selected drugs that are approved by the U.S. Food and Drug Administration (FDA) and reviewed by our Pharmacy and Therapeutics Committee, a group of physicians and pharmacists from the area. These prescription drugs have been selected for their reported medical effectiveness, safety, and value while providing you with the highest level of coverage under your prescription drug benefits.
Our pharmacy benefits manager, FutureScripts®, an independent company, continuously monitors the effectiveness and safety of drugs and drug prescribing patterns. Several procedures support safe prescribing patterns for our prescription drug programs, such as:
• prior authorization; • age and gender limits; • quantity limits; • 96-Hour Temporary Supply Program; • coverage for medications not on the formulary.
These procedures are designed to optimize your prescription drug benefits by promoting appropriate utilization. They are based on FDA guidelines, and the criteria are endorsed by our Pharmacy and Therapeutics Committee.
A detailed description of the procedures that support safe prescribing is included at the end of the formulary list.
Please note: Because prescription drug benefits vary by group, the inclusion of a drug in this formulary does not imply coverage. This formulary was current at the time of printing and is subject to change. Please call Customer Service at the number listed on the back of your ID card if you have any questions about your prescription drug benefits. Please discuss any questions or concerns about your drug therapy with your physician or pharmacist.
Brand drugs listed in the formulary with a “3” in the immediate column to the right are available at the highest level of cost-sharing (i.e., the highest cost to you). It is displayed next to the equivalent formulary generic drug that is available at the lowest level of cost-sharing (i.e., the lowest cost to you). For example: amoxicillin is the formulary generic drug available at the lowest level of cost-sharing. Amoxil® is the non-formulary brand available at the highest level of cost-sharing. In most cases when brand drugs have a generic equivalent, the generic version is formulary and the brand version is non-formulary.
• Covered generic drugs not listed are formulary and are available at the lowest level of cost-sharing. • Covered brand drugs not listed are non-formulary and are available at the highest level of cost-sharing.
Certain preventive medications, as described in the Patient Protection and Affordable Care Act (PPACA), are covered without cost-sharing with a doctor’s prescription when provided by a participating retail or mail-order pharmacy. Coverage includes certain products within the following drug categories: (1) aspirin to prevent cardiovascular disease for men age 45-79 and women age 55-79 and low-dose aspirin (81 mg/d) as preventive medication after 12 weeks of gestation in women who are at high risk for preeclampsia, (2) breast cancer chemotherapy prevention for members 35 years of age and older, (3) fluoride supplementation for children 6 months to 60 months, (4) folic acid supplementation for women planning or capable of pregnancy, (5) iron supplementation for children ages 6 to 12 months who are at increased risk for iron deficiency anemia, (6) tobacco interventions for adults who use tobacco products, (7) vitamin D supplementation for ages 65 and over to prevent falls and (8) contraceptives, mandated by the Women’s Preventive Services provision.
1
2
Dear Physician:
This is a listing of formulary drugs to be considered for your patient, a Prescription Drug Program participant. Please refer to this formulary guide in order to choose a drug. Because prescription drug benefits vary by group, the inclusion of a drug in this formulary does not imply coverage.
This formulary was current at the time of printing and is subject to change. Please understand that this formulary is not intended as a substitute for your independent, professional judgment. Rather, it is offered as a tool to help Plan members recognize formulary drugs. We hope that you will refer to the formulary as a guide to prescribing formulary drugs.
Sincerely,
AmeriHealth Administrators
2
3
1. ANTIBIOTICS & OTHER DRUGS USED FOR INFECTION
BRAND Formulary Tier GENERIC Formulary
Tier Generic Available
Acticlate 3Adoxa 3 doxycycline monohydrate 1 Yes
Ancobon 3 flucytosine 1 YesAralen 3 chloroquine phosphate 1 YesAtripla 2
Augmentin 3 amoxicillin/clavulanate 1 Yes
Augmentin XR 3 amoxicillin/clavulanate extended- release 1 Yes
Avelox 3 moxifloxacin hcl 1 YesBactrim,
Bactrim DS 3 sulfamethoxazole/tmp 1 Yes
Baraclude 3 entecavir 1 YesBiaxin 3 clarithromycin 1 Yes
Biaxin XL 3 clarithromycin SR 1 YesCedax 3 ceftibuten 1 YesCeftin 3 cefuroxime axetil 1 YesCipro 3 ciprofloxacin tabs 1 Yes
Cipro oral suspension 3 ciprofloxacin susp. 1 Yes
Cipro XR 3 ciprofloxacin ER tabs 1 YesCleocin 3 clindamycin 1 Yes
Combivir 3 lamivudine/zidovudine 1 YesComplera 2Cresemba 3Crixivan 2Daklinza 3Diflucan 3 fluconazole 1 YesDoryx 3 doxycycline 1 Yes
EES, Eryped 3 erythromycin ethylsuccinate 1 YesEdurant 2Emtriva 2Epivir 3 lamivudine 1 Yes
Epzicom 2Ery-Tab 3 erythromycin delayed release 1 Yes
Erythrocin 3 erythromycin stearate 1 YesFactive 3Famvir 3 famciclovir 1 YesFlagyl 3 metronidazole 1 Yes
Flumadine 3 rimantadine 1 YesFuzeon 2
Grifulvin V 3 griseofulvin microsize 1 Yes
4
1. ANTIBIOTICS & OTHER DRUGS USED FOR INFECTION
BRAND Formulary Tier GENERIC Formulary
Tier Generic Available
Gris-PEG 3 griseofulvin ultramicrosize 1 YesHarvoni 2Hepsera 3 adefovir dipivoxil 1 YesHiprex 3 methenamine hippurate 1 YesInvirase 2Isentress 2Kaletra 2
Kalydeco 3Keflex 3 cephalexin 1 Yes
Lamisil Tabs 3 terbinafine tabs 1 YesLevaquin 3 levofloxacin 1 YesLexiva 2
Macrodantin 3 nitrofurantoin macrocrystals 1 YesMalarone 3 atovaquone/proguanil 1 YesMepron 3 atovaquone 1 YesMinocin 3 minocycline caps 1 Yes
Monodox 3 doxycycline monohydrate 1 YesMoxatag 3 amoxicillin ER 1 Yes
Myambutol 3 ethambutol 1 YesMycobutin 3 rifabutin 1 Yes
Norvir 2Noxafil 3Olysio 3Onmel 3Oracea 3 doxycycline ir-dr 1 Yes
Orkambi 3Peg-Intron 2
Pegasys 2Plaquenil 3 hydroxychloroquine 1 YesPrezista 2
Qualaquin 3 quinine sulfate 1 YesRetrovir 3 zidovudine 1 YesReyataz 2Ribapak 3 moderiba 1 YesRifadin 3 rifampin 1 Yes
Selzentry 2Sivextro 3Sovaldi 2
Sporanox 3 itraconazole 1 YesStribild 2
5
1. ANTIBIOTICS & OTHER DRUGS USED FOR INFECTION
BRAND Formulary Tier GENERIC Formulary
Tier Generic Available
Stromectol 3 ivermectin 1 YesSuprax Susp 100 mg/5 ml, 200 mg/5 ml
3 cefixime susp 100 mg/5 ml, 200 mg/5 ml 1 Yes
Sustiva 2Tamiflu 2
Technivie 3Tindamax 3 tinidazole 1 Yes
Tobi 3 tobramycin 1 YesTrizivir 3 abacavir/lamivudine/zidovudine 1 YesTruvada 2
Valcyte tab 3 valganciclovir 1 YesValtrex 3 valacyclovir tab 1 Yes
Vancocin 3 vancomycin 1 YesVfend 3 voriconazole 1 Yes
Vibramycin 3 doxycycline hyclate 1 YesVidex EC 3 didanosine 1 Yes
Viekira Pak 3Viramune 3 nevirapine 1 Yes
Viramune XR 3 nevirapine XR 1 YesViread 2
Xifaxan 2Zerit 3 stavudine 1 Yes
Ziagen 3 abacavir sulfate 1 YesZithromax 3 azithromycin 1 Yes
Zmax 3Zovirax 3 acyclovir 1 YesZyvox 3 linezolid 1 Yes
amoxicillin 1 Yesampicillin 1 Yescefaclor 1 Yes
cefaclor ER 1 Yescefadroxil 1 Yescefdinir 1 Yes
clotrimazole troches 1 Yesdapsone 1 Yes
demeclocycline 1 Yesdicloxacillin 1 Yes
erythromycin susp w/sulfa 1 Yesisoniazid 1 Yes
6
1. ANTIBIOTICS & OTHER DRUGS USED FOR INFECTION
BRAND Formulary Tier GENERIC Formulary
Tier Generic Available
ketoconazole tabs 1 Yesmebendazole 1 Yesmefloquine 1 Yes
minocycline tabs 1 Yesmoderiba 1 Yesnystatin 1 Yesofloxacin 1 Yes
penicillin VK 1 Yesprimaquine phosphate 1 Yes
tetracycline 1 Yes
7
2. CANCER & ORGAN TRANSPLANT DRUGS
BRAND Formulary Tier GENERIC Formulary
Tier Generic Available
Arimidex 3 anastrazole 1 YesAromasin 3 exemestane 1 YesCasodex 3 bicalutamide 1 YesCellcept 3 mycophenolate 1 YesCytoxan 3 cyclophosphamide 1 Yes
Danocrine 3 danazol 1 YesDeltasone 3 prednisone 1 Yes
Emcyt 2Eulexin 3 flutamide 1 YesFarydak 3Femara 3 letrozole 1 YesGilotrif 3Gleevec 2Hydrea 3 hydroxyurea 1 YesIbrance 3
Imbruvica 3Imuran 3 azathioprine 1 Yes
Lenvima 3Leukeran 2Lonsurf 3
Lynparza 3Lysodren 2Matulane 2Megace 3 megestrol 1 YesMyfortic 3 mycophenolic acid 1 YesOdomzo 3Prograf 3 tacrolimus 1 YesProtopic 3 tacrolimus 1 Yes
Purinethol 3 mercaptopurine 1 YesRapamune 1mg/ml Sol 2
Rapamune tab 3 sirolimus 1 YesRheumatrex, Trexall tab 3 methotrexate 1 Yes
Sandimmune, Neoral 3 cyclosporine 1 Yes
Tabloid 3 thioguanine 1 YesTargretin cap 3 bexarotene 1 Yes
Temodar 3 temozolomide 1 YesValchlor 3VePesid 3 etoposide 1 Yes
8
2. CANCER & ORGAN TRANSPLANT DRUGS
BRAND Formulary Tier GENERIC Formulary
Tier Generic Available
Xeloda 3 capecitabine 1 YesZydelig 3Zykadia 3
leucovorin calcium 1 Yeslomustine 1 Yes
megestrol acetate 1 Yestamoxifen 1 Yes
temozolomide 1 Yes
9
3. PAIN, NERVOUS SYSTEM, & PSYCH
BRAND Formulary Tier GENERIC Formulary
Tier Generic Available
Abilify 3 aripiprazole 1 YesActiq 3 fentanyl citrate OTFC 1 Yes
Adasuve 3
Adderall 3amphetamine aspartate/
amphetamine sulfate/ dextroamphetamine
1 Yes
Adderall XR 3amphetamine aspartate/
amphetamine sulfate/ dextroamphetamine ER
1 Yes
Alsuma 3 sumatriptan succinate 1 YesAmbien 3 zolpidem tartrate 1 Yes
Ambien CR 3 zolpidem tartrate controlled release 1 Yes
Amerge 3 naratriptan 1 YesAnafranil 3 clomipramine HCl 1 YesAnsaid 3 flurbiprofen 1 Yes
Aptensio XR 3Aricept 3 donepezil hydrochloride 1 YesAtivan 3 lorazepam 1 Yes
Avinza 30mg, 45mg, 60mg, 75mg, 90mg
3 morphine sulfate ER 1 Yes
Avinza 120mg 3 morphine sulfate ER 1 YesAvonex 2Axert 3 almotriptan maleate 1 Yes
Azilect 2Belsomra 3
Belviq 3Betaseron 2Brintellix 3Bunavail 3Buspar 3 buspirone 1 YesButrans 3Cafergot 3 ergotamine tartrate/caffeine 1 YesCampral 3 acamprosate 1 YesCataflam 3 diclofenac potassium 1 YesCelexa 3 citalopram 1 Yes
Celontin 2Chantix 3Clinoril 3 sulindac 1 YesClozaril 3 clozapine 1 Yes
10
3. PAIN, NERVOUS SYSTEM, & PSYCH
BRAND Formulary Tier GENERIC Formulary
Tier Generic Available
Comtan 3 entacapone 1 YesConcerta 3 methylphenidate 1 Yes
Contrave ER 3Conzip 3 tramadol hcl er 1 Yes
Copaxone 2 glatopa 1 YesCymbalta 3 duloxetine 1 YesDantrium 3 dantrolene 1 YesDaypro 3 oxaprozin 1 YesDemerol 3 meperidine HCl 1 YesDepakene 3 valproic acid 1 YesDepakote 3 divalproex sodium 1 Yes
Depakote ER 3 divalproex sodium ER 1 YesDepakote
Sprinkle Caps 3 divalproex sprinkle cap 1 Yes
Desoxyn 3 methamphetamine 1 YesDesyrel 3 trazodone 1 YesDiastat 3 diazepam rectal gel 1 Yes
Diastat AcuDial 3 diazepam rectal gel 1 YesDilantin
chewable tablets 2 phenytoin chewable tablets 1 Yes
Dilaudid 1 mg/ml liquid 3 hydromorphone 1 mg/ml liquid 1 Yes
Dilaudid 2mg 3 hydromorphone HCl 1 YesDilaudid 4mg,
8mg 3 hydromorphone HCl 1 Yes
Dolobid 3 diflunisal 1 YesDolophine 3 methadone 1 Yes
Doral 3 quazepam 1 YesDuragesic
12mcg 3 fentanyl transdermal 1 Yes
Duragesic 25mcg, 50mcg, 75mcg, 100mcg
3 fentanyl transdermal 1 Yes
Effexor 3 venlafaxine 1 YesEffexor XR 3 venlafaxine ER 1 Yes
Eldepryl 3 selegiline HCl 1 YesEmbeda 3
Esgic 3 butalbital/apap/caffeine 1 YesEsgic Plus 3 butalbital/apap/caffeine, zebutal 1 YesEskalith 3 lithium carbonate 1 Yes
Eskalith CR, Lithobid 3 lithium carbonate SR 1 Yes
11
3. PAIN, NERVOUS SYSTEM, & PSYCH
BRAND Formulary Tier GENERIC Formulary
Tier Generic Available
Evekeo 3Evzio 3
Exalgo 3 hydromorphone ER 1 YesExelon 3 rivastigmine 1 YesFazaclo 3 clozapine ODT 1 YesFelbatol 3 felbamate 1 YesFeldene 3 piroxicam 1 YesFetzima 3Fioricet 3 butalbital/apap/caffeine 1 Yes
Fioricet with codeine 3 butalbital/apap/caffeine/codeine 1 Yes
Fiorinal 3 butalbital/aspirin/caffeine 1 YesFiorinal with
codeine 3 butalbital/aspirin/caffeine/codeine 1 Yes
Focalin XR 3 dexmethylphenidate hcl xr 1 YesGabitril 3 tiagabine hcl 1 YesGeodon 3 ziprasidone 1 YesHalcion 3 triazolam 1 YesHetlioz 3
Horizant 3Hycet 3 hydrocodone/apap 1 Yes
Hysingla 3Ibudone 3 ibuprofen/oxycodone HCl 1 YesImitrex 3 sumatriptan 1 YesIntuniv 3 guanfacine ER 1 YesInvega 3 paliperidone er 1 YesIrenka 3 duloxetine hcl 1 Yes
Kadian 10mg, 20mg, 30mg, 40mg, 50mg
3 morphine extended release 1 Yes
Kadian 60mg, 80mg, 100mg 3 morphine extended release 1 Yes
Kadian 200mg 3Kapvay 3 clonidine HCl ER 1 YesKeppra 3 levetiracetam 1 Yes
Keppra XR 3 levetiracetam ER 1 YesKhedezla 3 desvenlafaxine ER 1 YesKlonopin 3 clonazepam 1 YesLamictal 3 lamotrigine 1 Yes
Lamictal ODT 3 lamotrigine ODT 1 YesLamictal XR 3 lamotrigine 1 Yes
12
3. PAIN, NERVOUS SYSTEM, & PSYCH
BRAND Formulary Tier GENERIC Formulary
Tier Generic Available
Lexapro 3 escitalopram 1 YesLodine XL 3 etodolac 1 YesLodosyn 3 carbidopa 1 YesLortab 3 hydrocodone/acetaminophen elixir 1 Yes
Loxitane 3 loxapine 1 YesLunesta 3 eszopiclone 1 Yes
Luvox CR 3 fluvoxamine 1 YesMaxalt,
Maxalt-MLT 3 rizatriptan benzoate 1 Yes
Mestinon 3 pyridostigmine 1 YesMetadate CD 3 methylphenidate hcl 1 Yes
Methylin Chewable Tabs 3 methylphenidate hcl chewable
tabs 1 Yes
Midrin 3 isometheptene/ dichloralphenazone/apap 1 Yes
Migranal 3 dihydroergotamine 1 YesMirapex 3 pramipexole 1 Yes
MS Contin 15mg, 30mg 3 morphine sulfate, extended release 1 Yes
MS Contin 60mg, 100mg,
200mg3 morphine sulfate, extended release 1 Yes
MSIR 3 morphine sulfate 1 YesMysoline 3 primidone 1 Yes
Nalfon 3 fenoprofen calcium 1 YesNamenda 3 memantine hcl 1 YesNaprelan 3 naproxen sodium SA 1 Yes
Naprelan CR 3 naproxen sodium CR 1 YesNaprosyn 3 naproxen 1 Yes
Nardil 3 phenelzine 1 YesNeurontin 3 gabapentin 1 YesNeurontin solution 3 gabapentin solution 1 Yes
Norpramin 3 desipramine 1 YesNucynta 50mg,
75mgNucynta 100mg
Nucynta ER 50mg, 100mgNucynta ER
150mg, 200mg, 250mg
Opana 5mg 3 oxymorphone 1 Yes
13
3. PAIN, NERVOUS SYSTEM, & PSYCH
BRAND Formulary Tier GENERIC Formulary
Tier Generic Available
Opana 10mg 3 oxymorphone 1 YesOpana ER 5mg, 7.5mg, 10mg,
15mg3 oxymorphone 1 Yes
Opana ER 20mg, 30mg,
40mg3 oxymorphone 1 Yes
Orap 3 pimozide 1 YesOrudis 3 ketoprofen 1 YesOxaydo 3
Oxycontin 10mg, 15mg,
20mg3 oxycodone ER 1 Yes
Oxycontin 30mg, 40mg, 60mg, 80mg
3 oxycodone ER 1 Yes
OxyIR 3 oxycodone 1 YesPamelor 3 nortriptyline 1 YesParcopa 3 carbidopa/levodopa ODT 1 YesParlodel 3 bromocriptine mesylate 1 YesParnate 3 tranycypromine sulfate 1 YesPaxil 3 paroxetine 1 Yes
Paxil CR 3 paroxetine HCl ext-release 1 YesPercocet, Roxicet 3 oxycodone/acetaminophen,
endocet 1 Yes
Percodan 3 oxycodone/aspirin 1 YesPhenytek 3 phenytoin sodium 1 YesPlegridy 2Prodrin 3 isometheptene/APAP/caffeine 1 Yes
Prostigmin 2Provigil 3 modafinil 1 YesProzac 3 fluoxetine 1 Yes
Qudexy XR 3 topiramate ER 1 YesRazadyne 3 galantamine 1 Yes
Razadyne ER 3 galantamine ER 1 YesRegimex 3Relpax 3
Remeron 3 mirtazapine 1 YesRemeron SolTab 3 mirtazapine rapid dissolve tabs 1 Yes
Requip 3 ropinirole 1 YesRequip XL 3 ropinirole EL 1 Yes
Restoril 3 temazepam 1 Yes
14
3. PAIN, NERVOUS SYSTEM, & PSYCH
BRAND Formulary Tier GENERIC Formulary
Tier Generic Available
Rexulti 3Rilutek 3 riluzole 1 Yes
Risperdal, Risperdal M-Tab 3 risperidone 1 Yes
Ritalin LA 3 methylphenidate ER 1 YesRitalin SR 3 methylphenidate SR 1 YesRobaxin 3 methocarbamol 1 Yes
Roxicodone 15mg 3 oxycodone 1 Yes
Roxicodone 30mg 3 oxycodone 1 Yes
Rozerem 3Ryzolt 3 tramadol ER 1 YesSaphris 3Saxenda 3Seroquel 3 quetiapine fumarate 1 Yes
Seroquel XR 2Sinemet 3 carbidopa/levodopa 1 Yes
Sinemet CR 3 carbidopa/levodopa CR 1 YesSonata 3 zaleplon 1 YesStalevo 3 carbidopa/levodopa/entacapone 1 YesStrattera 2
Suboxone Sublingual Film 1
Sylatron 3Symbyax 3 olanzapine/fluoxetine hcl 1 Yes
Synalgos-DC 3 dihydrocodeine/aspirin/caffeine 1 YesTasmar 3 tolcapone 1 Yes
Tecfidera 3Tegretol 3 carbamazepine 1 Yes
Tegretol XR 3 carbamazepine XR 1 YesTofranil 3 imipramine 1 YesTopamax 3 topiramate 1 YesTopamax Sprinkle Capsules
3 topiramate sprinkle cap 1 Yes
Tranxene T 3 clorazepate dipotassium 1 YesTrezix 3 dihydrocodein-acetaminoph-caff 1 Yes
Trileptal 3 oxcarbazepine 1 YesUltracet 3 tramadol/acetaminophen 1 YesUltram 3 tramadol 1 Yes
15
3. PAIN, NERVOUS SYSTEM, & PSYCH
BRAND Formulary Tier GENERIC Formulary
Tier Generic Available
Ultram ER 3 tramadol ER 1 YesValium 3 diazepam 1 Yes
Vicodin ES 3 hydrocodone/acetaminophen ES 1 YesVicoprofen 3 hydrocodone/ibuprofen 1 Yes
Voltaren XR 3 diclofenac sodium 1 YesVyvanse 2
Wellbutrin 3 bupropion 1 YesWellbutrin SR 3 bupropion SR 1 YesWellbutrin XL 3 bupropion XR 1 Yes
Xanax 3 alprazolam 1 YesXanax XR 3 alprazolam ER 1 Yes
Xartemis XR 3Xenazine 3 tetrabenazine 1 Yes
Xodol, Norco, Maxidone,
Lortab, Lorcet, Lorcet Plus,
Zydone
3 hydrocodone/acetaminophen 1 Yes
Zarontin 3 ethosuximide 1 YesZecuity 3
Zenzedi 2mg, 7.5mg, 15mg, 20mg, 30mg
3
Zenzedi 5mg, 10mg 3 dextroamphetamine 1 Yes
Zohydro ER 3Zoloft 3 sertraline 1 Yes
Zomig, Zomig ZMT 3 zolmitriptan 1 Yes
Zomig Nasal Spray 3
Zonegran 3 zonsinamide 1 YesZubsolv 3Zyban 3 bupropion 1 Yes
Zyprexa 3 olanzapine 1 YesZyprexa Zydis 3 olanzapine ODT 1 Yes
acetaminophen/butalbital 1 Yesacetaminophen/codeine 1 Yes
acetazolamide 1 Yesamantadine 1 Yesamitriptyline 1 Yesamoxapine 1 Yes
16
3. PAIN, NERVOUS SYSTEM, & PSYCH
BRAND Formulary Tier GENERIC Formulary
Tier Generic Available
aspirin with codeine 1 Yesbenztropine 1 Yes
buprenorphine 1 Yesbuprenorphine hcl/naloxone hcl 1 Yes
butorphanol tartrate nasal 1 Yeschlordiazepoxide 1 Yes
chlorpromazine HCl 1 Yesclonidine HCL ER 1 Yes
codeine tabs, 30mg/5ml solution 1 Yesdesvenlafaxine ER 1 Yes
diflunisal 1 Yesdihydroergotamine mesylate 1 Yes
doxepin 1 Yesduraxin 1 Yes
estazolam 1 Yesfentanyl citrate OTFC 1 Yes
fluphenazine 1 Yesflurazepam 1 Yesfluvoxamine 1 Yeshaloperidol 1 Yes
hydromorphone ER 1 Yesketoprofen 1 Yesketorolac 1 Yes
maprotiline 1 Yesmeclofenamate 1 Yesmeprobamate 1 Yes
methadone 1 Yesmigergot 1 Yesmodafinil 1 Yes
nabumetone 1 Yesnefazodone 1 Yes
nicotine gum, inhalers, lozenges, patches 1 Yes
oxazepam 1 Yesoxycodone-ibuprofen 1 Yes
pentazocine-acetaminophen 1 Yespentazocine-naloxone 1 Yes
perphenazine 1 Yesphenytoin 1 Yessulindac 1 Yes
17
3. PAIN, NERVOUS SYSTEM, & PSYCH
BRAND Formulary Tier GENERIC Formulary
Tier Generic Available
thioridazine 1 Yesthiothixene 1 Yes
tolmetin sodium 1 Yestrifluoperazine 1 Yestrihexyphenidyl 1 Yestrimipramine 1 Yes
vicodin, vicodin es, vicodin hp 1 Yeszgesic 1 Yes
18
4. HEART, BLOOD PRESSURE, & CHOLESTEROL
BRAND Formulary Tier GENERIC Formulary
Tier Generic Available
Accupril 3 quinapril HCl 1 YesAccuretic 3 quinapril/HCTZ 1 Yes
Aceon 3 perindopril 1 YesAdalat CC 3 nifedipine ER 1 Yes
Adcirca 3Adempas 3Advate 2
Aggrenox 3 aspirin-dipyridamole er 1 YesAgrylin 3 anagrelide 1 Yes
Aldactazide 3 spironolactone/HCTZ 1 YesAldactone 3 spironolactone 1 Yes
Altace 3 ramipril 1 YesAlphanate 3
Alphanine SD 2Alprolix 3
Amturnide 3Antara 3 fenofibrate 1 YesArixtra 3 fondaparinux 1 YesAtacand 3 candesartan 1 Yes
Atacand HCT 3 candesartan/hydrochlorothiazide 1 YesAvalide 3 irbesartan/hydrochlorothiazide 1 YesAvapro 3 irbesartan 1 YesAzor 2
Bebulin 3BeneFIX 2Benicar 2
Benicar HCT 2Betapace AF 3 sotalol HCl 1 Yes
Bystolic 2Caduet 3 atorvastatin/amlodipine 1 YesCalan 3 verapamil HCl 1 Yes
Calan SR 3 verapamil HCl ER 1 YesCardizem 3 diltiazem HCl 1 Yes
Cardizem CD 3 diltiazem HCl CD 1 YesCardizem LA 3 diltiazem HCl LA 1 YesCardizem SR 3 diltiazem HCl SR 1 Yes
Cardura 3 doxazosin mesylate 1 YesCartia XT 1 diltiazem HCl ER 1 Yes
Catapres tablets 3 clonidine 1 YesCatapres-TTS 3 clonidine patch 1 Yes
19
4. HEART, BLOOD PRESSURE, & CHOLESTEROL
BRAND Formulary Tier GENERIC Formulary
Tier Generic Available
Colestid 3 colestipol HCl 1 YesCordarone 3 amiodarone HCl 1 Yes
Coreg 3 carvedilol 1 YesCorgard 3 nadolol 1 YesCorifact 3Corlanor 3Corzide 3 nadolol-bendroflume thiazide 1 Yes
Coumadin 2 warfarin 1 YesCozaar 3 losartan 1 YesCrestor 2
Demadex 3 torsemide 1 YesDiamox Sequels 3 acetazolamide ER 1 Yes
Dibenzyline 3 phenoxybenzamine hcl 1 YesDilacor XR 3 diltiazem HCl ER 1 Yes
Dilt-CD 1 diltiazem HCl CD 1 YesDiltzac ER 1 diltiazem HCl ER 1 Yes
Diovan 3 valsartan 1 YesDiovan HCT 3 valsartan/hydrochlorothiazide 1 Yes
Durlaza 3Dyazide 3 triamterene/HCTZ 1 YesEdarbi 3
Edarbyclor 3Edecrin 2Eliquis 2Eloctate 3Entresto 3Exforge 3 amlodipine/valsartan 1 Yes
Exforge HCT 3 amlodipine/valsartan/HCTZ 1 YesFeiba 2
Fenoglide 3 fenofibrate 1 YesFibricor 3 fenofibric acid 1 Yes
Helixate FS 2Hemofil M 3Humate-P 2
Hyzaar 3 losartan-HCTZ 1 YesImdur 3 isosorbide mononitrate ER 1 Yes
Inderal LA 3 propranolol ER 1 YesInspra 3 eplerenone 1 YesIsordil
Titradose Tabs 3 isosorbide dinitrate 1 Yes
20
4. HEART, BLOOD PRESSURE, & CHOLESTEROL
BRAND Formulary Tier GENERIC Formulary
Tier Generic Available
Ixinity 3Jantoven 1 warfarin 1 YesJuxtapid 3
Koate-DVI 3Kogenate FS 2
Kynamro 3Lanoxin 3 digoxin 1 Yes
Lasix 3 furosemide 1 YesLescol 3 fluvastatin sodium 1 YesLetairis 3Lipitor 3 atorvastatin 1 YesLipofen 3 fenofibrate 1 YesLiptruzet 2
Livalo 3Lofibra 3 fenofibrate 1 YesLopid 3 gemfibrozil 1 Yes
Lopressor HCT 3 metoprolol tartrate/HCT 1 YesLotensin 3 benazepril 1 Yes
Lotrel 3 amlodipine/benazepril 1 YesLovaza 3 omega-3 acid ethyl esters 1 Yes
Lovenox 3 enoxaparin 1 YesMavik 3 trandolapril 1 Yes
Maxzide 3 triamterene/HCTZ 1 YesMevacor 3 lovastatin 1 YesMicardis 3 telmisartan 1 Yes
Micardis HCT 3 telmisartan/hydrochlorothiazide 1 YesMicrozide 3 hydrochlorothiazide 1 YesMinipress 3 prazosin 1 Yes
Monoclate-P 3Mononine 2
Multaq 2Niaspan 3 niacin ER 1 Yes
Nifedical XL 1 nifedipine ER 1 YesNitro-Bid 2Nitro-Dur 3 nitroglycerin patches 1 YesNitromist 3 nitroglycerin spray 1 Yes
Nitrostat SL 1Norpace 3 disopyramide 1 YesNorthera 3Norvasc 3 amlodipine 1 Yes
21
4. HEART, BLOOD PRESSURE, & CHOLESTEROL
BRAND Formulary Tier GENERIC Formulary
Tier Generic Available
Novoeight 3Novoseven RT 3
Opsumit 3Orenitram 3Pacerone 1 amiodarone HCl 1 Yes
Persantine 3 dipyridamole 1 YesPlavix 3 clopidogrel 1 YesPletal 3 cilostazol 1 Yes
Praluent 3Pravachol 3 pravastatin 1 YesPrevalite 1 cholestyramine light 1 YesPrinivil 3 lisinopril 1 Yes
Procardia 3 nifedipine 1 YesProcardia XL 3 nifedipine ER 1 Yes
Procrit 2Profilnine 3Questran 3 cholestyramine 1 Yes
Questran Light 3 cholestyramine light 1 YesRecombinate 2
Repatha 3Revatio 3 sildenafil citrate 1 YesRixubis 3Rythmol 3 propafenone 1 Yes
Rythmol SR 3 propafenone SR 1 YesSamsca 3Sectral 3 acebutolol 1 YesSular 3 nisoldipine ER 1 YesTarka 3 trandolapril/verapamil ER 1 Yes
Taztia XT 1 diltiazem HCl ER 1 YesTekamlo 3Tekturna/
Tekturna HCT 3
Tenex 3 guanfacine 1 YesTenoretic 3 atenolol/chlorthalidone 1 YesTenormin 3 atenolol 1 YesTeveten 3 eprosartan 1 Yes
Teveten HCT 3Tiazac 3 diltiazem HCl ER 1 Yes
Toprol XL 3 metoprolol succinate 1 YesTracleer 2Trandate 3 labetalol HCl 1 Yes
22
4. HEART, BLOOD PRESSURE, & CHOLESTEROL
BRAND Formulary Tier GENERIC Formulary
Tier Generic Available
Tretten 3Tribenzor 2
Tricor 3 fenofibrate nanocrystallized 1 YesTrilipix 3 fenofibric acid 1 YesTwynsta 3 telmisartan-amlodipine 1 YesTyvaso 3Uniretic 3 moexipril/HCTZ 1 YesUnivasc 3 moexipril 1 YesVascepa 2Vaseretic 3 enalapril/HCTZ 1 YesVasotec 3 enalapril 1 YesVecamyl 1Ventavis 3
Verelan ER, PM 3 verapamil HCl ER 1 Yes
Vytorin 2Wilate 3Xarelto 2Xyntha 2
Zaroxolyn 3 metolazone 1 YesZebeta 3 bisoprolol 1 Yes
Zestoretic 3 lisinopril/HCTZ 1 YesZestril 3 lisinopril 1 YesZetia 2Ziac 3 bisoprolol/HCTZ 1 Yes
Zocor 3 simvastatin 1 Yesacetazolamide 1 Yes
amiloride 1 Yesamiloride/HCTZ 1 Yes
aminocaproic acid 1 Yesbenazepril/HCTZ 1 Yes
betaxolol 1 Yesbumetanide 1 Yescaptopril 1 Yes
captopril/HCTZ 1 Yeschlorothiazide 1 Yeschlorthalidone 1 Yes
digoxin solution 1 Yesfelodipine ER 1 Yes
flecainide 1 Yesfosinopril 1 Yes
23
4. HEART, BLOOD PRESSURE, & CHOLESTEROL
BRAND Formulary Tier GENERIC Formulary
Tier Generic Available
fosinopril/HCTZ 1 Yeshydralazine 1 Yesindapamide 1 Yes
isosorbide dinitrate ER 1 Yesisosorbide mononitrate 1 Yes
isradipine 1 Yeslisinopril/HCTZ 1 Yes
methyldopa 1 Yesmetoprolol tartrate 1 Yes
mexiletine HCl 1 Yesminoxidil 1 Yes
nicardipine 1 Yesnimodipine 1 Yes
nitroglycerin ER 1 Yesnitroglycerin SL 1 Yespentoxifylline ER 1 Yes
pindolol ER 1 Yespropranolol/HCTZ 1 Yes
propranolol solution 1 Yessildenafil citrate 1 Yesticlopidine HCl 1 Yes
timolol 1 Yes
24
5. SKIN MEDICATIONS
BRAND Formulary Tier GENERIC Formulary
Tier Generic Available
Absorica 3 isotretinoin 1 YesAcanya 2Aczone 3Aldara 3 imiquimod cream 1 YesAtralin 3 tretinoin 1 YesAurstat 3 MB hydrogel 1 YesAzelex 3
Bactroban cream 3 mupirocin cream 1 Yes
Bactroban ointment 3 mupirocin ointment 1 Yes
Benzaclin 3 clindamycin-benzoyl peroxide gel 1 YesBenzaclin
Pump 3
Benzamycin gel 3 benzoyl peroxide/erythromycin 1 YesBenzamycinpak 3
Carac 3 fluorouracil cream 1 YesCiclodan
0.77% cream 3 ciclopirox 0.77% cream 1 Yes
Ciclodan 8% solution 3 ciclopirox 8% solution 1 Yes
Cleocin T 3 clindamycin 1 YesClindagel 3Clobex 3 clobetasol propionate 1 Yes
Cloderm 3 clocortolone pivalate 1 YesCondylox 3 podofilox soln 1 YesCosentyx 3Cutivate 3 fluticasone propionate 1 Yes
Cyclocort 3 amcinonide 1 YesDermatop 3 prednicarbate ointment 1 Yes
Differin 0.1% cream, gel 3 adapalene cream, gel 1 Yes
Differin 0.3% gel 3 adapalene 0.3% gel 1 YesDifferin 0.1%
lotion 3 adapalene 0.1% lotion 1 Yes
Diprolene, Diprolene AF 3 betamethasone dipropionate 1 Yes
Dovonex cream 3 calcipotriene cream 1 YesDrithrocreme
HP 3 anthralin 1 Yes
Duac 3 clindamycin/benzoyl peroxide 1 YesEfudex cream 3 fluorouracil cream 1 Yes
25
5. SKIN MEDICATIONS
BRAND Formulary Tier GENERIC Formulary
Tier Generic Available
Elimite 3 permethrin 1 YesElocon 3 mometasone cream 1 Yes
Emla cream 3 prilocaine/lidocaine 1 YesEpiduo 2Erygel 3 erythromycin gel 1 YesEvoclin 3 clindamycin phosphate 1 YesJublia 3
Kenalog Spray 3 triamcinolone acetonide 1 YesKerydin 3Klaron 3 sodium sulfacetamide suspension 1 Yes
Lidoderm 3 lidocaine 1 YesLocoid 3 hydrocortisone butyrate 0.1% 1 YesLocoid
Lipocream 3 hydrocortisone butyrate/emoll 1 Yes
Loprox 3 ciclopirox cream, gel, shampoo, suspension 1 Yes
Lotrisone 3 betamethasone/clotrimazole 1 YesLuxiq 3 betamethasone valerate 1 Yes
MetroCream 3 metronidazole cream 1 YesMetrogel 3 metronidazole topical gel 1 Yes
Metrolotion 3 metronidazole lotion 1 YesNatroba 3 spinosad 1 YesNizoral
shampoo 3 ketoconazole shampoo 1 Yes
Onexton 3Ovide 3 malathion lotion 1 Yes
Oxsoralen lotion 1% 2
Oxsoralen Ultra 3 methoxsalen 1 YesPenlac 3 ciclopirox solution 1 Yes
Proctofoam HC 2Retin-A, Avita 3 tretinoin 1 YesRetin-A Micro 3 tretinoin gel 1 Yes
Silvadene 3 silver sulfadiazine 1 YesSoritane 3 acitretin 1 Yes
Sulfamylon 3 mafenide acetate 1 Yes
Synalar 3 fluocinolone acetonide cream, soln 1 Yes
Taclonex 3 calcipotriene-betamethasone dp 1 YesTargretin gel 2
Tazorac 2
26
5. SKIN MEDICATIONS
BRAND Formulary Tier GENERIC Formulary
Tier Generic Available
Temovate 3 clobetasol cream, ointment, solution 1 Yes
Topicort 3 desoximetasone cream, gel, ointment 1 Yes
Vanos 3 fluocinonide 1 YesVectical 3 calcitriol ointment 1 YesVeltin 3
Westcort 3 hydrocortisone valerate 0.2% 1 YesXylocaine 3 lidocaine solution 1 Yes
Ziana 3Zovirax cream 2Zovirax oint 3 acyclovir 1 Yes
alclometasone cream, ointment 1 Yesbenzoyl peroxide/urea cream 1 Yes
diflorasone diacetate 1 Yeseconazole 1 Yes
erythromycin solution 1 Yeserythromycin swabs 1 Yes
fluocinonide cream, gel, ointment 1 Yesgentamicin topical cream,
ointment 1 Yes
hydrocortisone 2.5% 1 Yeshydrocortisone/lidocaine HCl 1 Yes
ketoconazole cream 1 Yesnaftifine hcl cream 1% 1 Yes
nystatin/triamcinolone cream, ointment 1 Yes
triamcinolone cream, ointment 1 Yes
27
6. EAR, NOSE, THROAT MEDICATIONS
BRAND Formulary Tier GENERIC Formulary
Tier Generic Available
Astelin 3 azelastine 1 YesAstepro 3 azelastine 1 Yes
Atrovent nasal spray 3 ipratropium 1 Yes
Bactroban nasal oint 2
Beconase AQ 3Cetraxal 3 ciprofloxacin 1 YesCiprodex 2
Cortisporin Otic 3 neomycin/polymyxin/
hydrocortisone 1 Yes
Dermotic 3 fluocinolone acetonide oil 1 YesEvoxac 3 cevimeline hcl 1 YesFlonase 3 fluticasone propionate nasal susp 1 Yes
Nasacort AQ 3 triamcinolone acetonide 1 YesNasonex 3Omnaris 3Patanase 3 olopatadine 1 Yes
Qnasl 3Rhinocort AQ 3 budesonide 1 Yes
Salagen 3 pilocarpine HCl 1 YesTrioxin 3 myoxin 1 Yes
Veramyst 3Vosol HC 3 acetasol HC, acetic acid HC otic 1 YesZetonna 3
aero otic HC 1 Yesaurodex otic 1 Yes
benzotic, benzocaine/antipyrine 1 Yescortane B otic drops 1 Yes
flunisolide 1 Yesofloxacin otic 1 Yes
oticin otic 1 Yes
28
7. DIABETES, THYROID, STEROIDS, & OTHER MISCELLANEOUS HORMONES
BRAND Formulary Tier GENERIC Formulary
Tier Generic Available
Actos 3 pioglitazone 1 YesAfrezza 3Amaryl 3 glimepiride 1 Yes
Androderm patch 3
Androgel 1% Packet, Pump 3 testosterone 1% packet 1 Yes
Androgel 1.62% Packet,
Pump2
Apidra Solostar 3Axiron 2
Bd Insulin Syringe Micro-
Fine2
Breeze 2 Test Strips 2
Bydureon 2Byetta 2
Contour Next Test Strips 2
Contour Test Strips 2
Cortef 3 hydrocortisone 1 YesCytomel 3 liothyronine 1 YesDDAVP 3 desmopressin acetate 1 Yes
Decadron 3 dexamethasone 1 YesDiabeta 3 glyburide 1 YesDuetact 3 pioglitazone/glimepiride 1 YesFarxiga 3
First Testosterone 3
Fortamet 3 metformin ER 1 YesFortesta 3 testosterone 1 YesFreestyle
InsuLinx Test Strips
2
Freestyle Lite Test Strips 2
Freestyle Test Strips 2
Genotropin 3Glucophage 3 metformin 1 Yes
29
7. DIABETES, THYROID, STEROIDS, & OTHER MISCELLANEOUS HORMONES
BRAND Formulary Tier GENERIC Formulary
Tier Generic Available
Glucophage XR 3 metformin ER 1 Yes
Glucotrol 3 glipizide 1 YesGlucotrol XL 3 glipizide ER 1 YesGlucovance 3 metformin/glyburide 1 Yes
Glumetza ER tablet 3
Glynase 3 glyburide micronized 1 YesGlyxambi 3Hectorol 3 doxercalciferol 1 YesHumalog 3
Humatrope 3Humulin 3Increlex 3
Invokamet 2Invokana 2Janumet 2
Janumet XR 2Januvia 2
Jardiance 3Jentadueto
tablet 3
Kazano tablet 3Keynote Strips 3
Kombiglyze XR 2
Korlym tablet 3Lantus 3
Levemir 2Levoxyl,
Synthroid, Unithroid
3 levothyroxine 1 Yes
Medrol 3 methylprednisolone 1 YesMicronase 3 glyburide 1 YesMyalept 3Natesto 3Natpara 3
Nesina tablet 3Norditropin 2
Novolin 2Novolog 2
Novolog mix 2
30
7. DIABETES, THYROID, STEROIDS, & OTHER MISCELLANEOUS HORMONES
BRAND Formulary Tier GENERIC Formulary
Tier Generic Available
Nutropin AQ 2Onglyza 2
Oseni 3Oxandrin 3 oxandrolone 1 YesPediapred, Orapred,
Orapred ODT3 prednisolone sodium phosphate 1 Yes
Prandin 3 repaglinide 1 YesPrecision
XTRA Test Strips
2
Precose 3 acarbose 1 YesPrelone 3 prednisolone syrup 1 Yes
Rocaltrol capsules 3 calcitriol capsules 1 Yes
Saizen 3Sensipar 2Serostim 3Signifor 3Starlix 3 nateglinide 1 Yes
Striant buccal system 3
Symlin 2Synjardy 3Tanzeum 3Tapazole 3 methimazole 1 Yes
Testim Gel 3 testosterone 1 YesTradjenta tablet 3
Trulicity 3Victoza 2Vogelxo 3 testosterone 1 Yes
Xigduo XR 3Zemplar 3 paricalcitol 1 Yes
Zomacton 3danazol 1 Yes
fludrocortisone acetate 1 Yespropylthiouracil 1 Yes
tolbutamide 1 Yes
31
8. STOMACH, ULCER, & BOWEL MEDS
BRAND Formulary Tier GENERIC Formulary
Tier Generic Available
Aciphex 3 rabeprazole 1 YesAciphex Sprinkle 3
Actigall 3 ursodiol 1 YesAnusol-HC
Cream 3 hydrocortisone cream 1 Yes
Azulfidine 3 sulfasalazine 1 YesBentyl 3 dicyclomine 1 Yes
Canasa supp 2Carafate susp 2Carafate tabs 3 sucralfate tabs 1 Yes
Cholbam 3Colazal 3 balsalazide 1 YesColocort 3 hydrocortisone retention enema 1 Yes
Compazine suppository 3 prochlorperazine suppository 1 Yes
Creon 2Cytotec 3 misoprostol 1 YesDelzicol 2Dexilant 3Duexis 3Emend 3
Entocort EC 3 budesonide 1 YesEsomeprazole
Strontium 3
Gastrocrom 3 cromolyn sodium solution 1 YesLialda 2
Lomotil 3 diphenoxylate HCl/atropine 1 YesMarinol 3 dronabinol 1 Yes
Metozolv ODT 3 metoclopramide HCl 1 YesNexium 3 esomeprazole 1 YesNulytely 3 PEG 3350 & electrolytes 1 YesPentasa 2
Pepcid tabs, suspension 3 famotidine 40mg tab, suspension 1 Yes
Phenergan 3 promethazine 1 YesPrevacid, Prevacid SoluTab
3 lansoprazole tabs, ODT 1 Yes
Prilosec caps 3 omeprazole 1 YesPrilosec
suspension 3 omeprazole suspension 1 Yes
32
8. STOMACH, ULCER, & BOWEL MEDS
BRAND Formulary Tier GENERIC Formulary
Tier Generic Available
Protonix 3 pantoprazole 1 YesReglan 3 metoclopramide 1 YesRowasa 3 mesalamine rectal susp 1 YesTagamet 3 cimetidine 1 Yes
Tigan 3 trimethobenzamide 1 YesVimovo 3Zantac 3 ranitidine 300mg 1 YesZegerid 3 omeprazole-sodium bicarbonate 1 YesZenpep 2Zofran 3 ondansetron HCl 1 Yes
chlordiazepoxide/clidinium 1 Yesgranisetron 1 Yes
lactulose soln 1 Yesnizatidine solution 1 Yes
pancrelipase EC/SA 1 Yesprochlorperazine tabs 1 Yes
33
9. BONE, JOINT, & MUSCLE
BRAND Formulary Tier GENERIC Formulary
Tier Generic Available
Actemra SC 3Actonel 3 risedronate 1 YesAmrix 3
Anaprox 3 naproxen sodium 1 YesAnaprox DS 3 naproxen sodium 1 Yes
Ansaid 3 flurbiprofen 1 YesArava 3 leflunomide 1 Yes
Arthrotec 3 diclofenac/misoprostol 1 YesAtelvia 3 risedronate dr 1 YesBinosto 3Boniva 3 ibandronate 1 Yes
Cataflam 3 diclofenac potassium 1 YesCelebrex 3 celecoxib 1 YesColcrys 3 colchicine 1 Yes
Dantrium 3 dantrolene 1 YesDaypro 3 oxaprozin 1 YesEnbrel 2Evista 3 raloxifene hcl 1 Yes
Feldene 3 piroxicam 1 YesFexmid 3 cyclobenzaprine 1 Yes
Flector Patch 3Fosamax 3 alendronate 1 Yes
Fosamax Plus D 3Humira 2Kineret 3Lorzone 3Lotronex 3 alosetron hcl 1 Yes
Miacalcin 3 calcitonin-salmon (rDNA origin) nasal spray 1 Yes
Mitigare 3 colchicine 1 YesMobic 3 meloxicam 1 YesNalfon 3 fenoprofen calcium 1 Yes
Naprosyn 3 naproxen 1 YesOrencia 3Otezla 3
Otrexup 3Parafon Forte 3 chlorzoxazone 1 Yes
Pennsaid 3 diclofenac sodium 1 YesRasuvo 3Robaxin 3 methocarbamol 1 YesSimponi 3
34
9. BONE, JOINT, & MUSCLE
BRAND Formulary Tier GENERIC Formulary
Tier Generic Available
Skelaxin 3 metaxalone 1 YesSolaraze 3 diclofenac 1 Yes
Soma 3 carisoprodol 1 YesViibryd 3
Voltaren Gel 3Voltaren XR 3 diclofenac sodium ER 1 Yes
Xeljanz 3Zanaflex 3 tizanidine 1 YesZipsor 3
Zyloprim 3 allopurinol 1 Yesbaclofen 1 Yes
colchicine/probenecid 1 Yescyclobenzaprine 1 Yes
diflunisal 1 Yesetidronate disodium 1 Yes
etodolac 1 Yesibuprofen 1 Yes
indomethacin 1 Yesindomethacin SR 1 Yes
ketoprofen 1 Yesketoprofen SR 1 Yes
ketorolac 1 Yesmeclofenamate 1 Yes
nabumetone 1 Yesnaproxen sodium SA 1 Yes
orphenadrine ER 1 Yesprobenecid 1 Yes
sulindac 1 Yestolmetin 1 Yes
35
10. FEMALE, HORMONE REPLACEMENT, & BIRTH CONTROL
The Injectable Fertility Agents in this section are covered only under certain benefits programs. Please check your handbook to determine coverage.
BRAND Formulary Tier GENERIC Formulary
Tier Generic Available
Addyi 3Aygestin 3 norethindrone acetate 1 Yes
Beyaz 2Bravelle 2Cenestin 2
Cleocin vaginal 3 clindamycin cream 1 YesClimara patch 3 estradiol transdermal 1 YesDepo SubqQ
Provera 3
Depo-Provera 3 medroxyprogesteroneDesogen 3 apri 1 YesDiflucan 3 fluconazole 150mg 1 YesEstrace 3 estradiol 1 YesEstring 2
Estrostep FE 3 norethindrone acetate/ethinyl estradiol/ferrous fumarate 1 Yes
Evista 3 raloxifene 1 YesFemcon FE 3 ethinyl estradiol/norethindrone 1 YesFemHRT 3 norethindrone ethinyl estradiol 1 Yes
Follistim AQ 2Generess FE 3 noreth-ethinyl estradiol/iron 1 YesLoseasonique 3 amethia lo/camrese lo 1 Yes
Lo Loestrin FE 2Menopur 2Metrogel vaginal 3 metronidazole vaginal gel 1 Yes
Minastrin 24 FE 2
Natazia 2Nuvaring 2
Ogen 3 estropipate 1 YesOrtho All-flex
diaphragm 3
Ortho Evra 3 Xulane 1 YesOrtho Micronor/
Nor QD 3 camila 1 Yes
Ortho Novum 3 necon/cyclafem/alyacen 1 YesOrtho Tri- Cyclen Lo 2 tri-lo-sprintec 1 Yes
Plan B One-Step 3 levonorgestrel/my way/next dose 1 Yes
36
10. FEMALE, HORMONE REPLACEMENT, & BIRTH CONTROL
The Injectable Fertility Agents in this section are covered only under certain benefits programs. Please check your handbook to determine coverage.
BRAND Formulary Tier GENERIC Formulary
Tier Generic Available
Premarin 2Premarin
vaginal cream 2
Premphase 2Prempro 2
Prometrium 3 progesterone, micronized 1 YesProvera 3 medroxyprogesterone acetate 1 Yes
Seasonique 3 amethia 1 YesSerophene 3 clomiphene citrate 1 YesTerazol 3 3 terconazole cream 1 Yes
Tri-norinyl 3 aranelle 1 YesVandazole 3 metronidazole 1 YesVivelle Dot 3 estradiol 1 Yes
Yasmin 3 ethinyl estradiol/drospirenone 1 Yes
YAZ 3 Gianvi, ethinyl estradiol/ drospirenone 1 Yes
altavera/portia/levora 28/chateal/ marlissa/kurvelo 1 Yes
amethyst 1 Yesaviane 1 Yes
desogestrel/ethinyl estradiol 1 Yesesterified estrogens/ methyltestosterone 1 Yes
levonorgestrel/ethinyl estradiol 1 Yeslomedia 24 Fe 1 Yesnorethindrone 1 Yes
norethindrone/ethinyl estradiol 1 Yesnorethindrone/ethinyl estradiol,
Fe 1 Yes
norethindrone/mestranol 1 Yesnorgestimate/ethinyl estradiol 1 Yes
norgestrel/ethinyl estradiol 1 Yes
37
11. EYE MEDICATIONS
BRAND Formulary Tier GENERIC Formulary
Tier Generic Available
Acular/Acular LS 3 ketorolac opth soln 1 YesAlcaine 3 proparacaine 1 Yes
Alphagan P 3 brimonidine tartrate 1 YesAlrex 2Azopt 2
Besivance 2Betagan 3 levobunolol 1 YesBetimol 2
Betoptic S 2Bleph 10 3 sulfacetamide 1 Yes
Blephamide S.O.P. ointment 2
Ciloxan Sol. 3 ciprofloxacin 1 YesCosopt 3 dorzolamide-timolol 1 Yes
Cyclogyl 3 cyclopentolate HCl 1 YesDiamox Sequels 3 acetazolamide ER 1 Yes
Elestat 3 epinastine HCl 1 YesFml 3 fluorometholone 1 Yes
Gentak 3 gentamicin ophth 1 YesIopidine 3 apraclonidine 1 Yes
Isopto Atropine 3 atropine sulfate 1 YesIsopto
Carbachol 3% 3 carbachol 3% 1 Yes
Isopto Carpine 3 pilocarpine 1 YesIstalol Drops 2
Lotemax 2Lumigan 2
Maxitrol 3 neomycin/polymyxin B/ dexamethasone 1 Yes
Mydriacyl 3 tropicamide 1 YesNeosporin soln 3 polymyxin B/neo/gramicidin 1 Yes
Ocufen 3 flurbiprofen 1 YesOcuflox 3 ofloxacin 1 Yes
Omnipred 3 prednisolone 1 YesOptivar 3 azelastine HCL drops 1 YesPatanol 2
Phospholine Iodide 2
Pilopine HS gel 2Polysporin 3 bacitracin/polymyxin B ophth oint 1 YesPolytrim 3 trimethoprim sulfate/polymyxin B 1 Yes
38
11. EYE MEDICATIONS
BRAND Formulary Tier GENERIC Formulary
Tier Generic Available
Pred-Forte 3 prednisolone acetate 1 YesRescula 3Restasis 2Timoptic 3 timolol ophth 1 Yes
Timoptic XE 3 timolol XE 1 YesTobradex 3 tobramycin-dexamethasone 1 YesTobrex 3 tobramycin 1 Yes
Travatan Z 2Trusopt 3 dorzolamide HCl 2% 1 Yes
Vasocidin oint 3 prednisolone/sodium sulfacetamide 1 Yes
Vexol 2Vigamox 2Viroptic 3 trifluridine 1 YesVoltaren 3 diclofenac sodium 1 YesXalatan 3 latanoprost 1 YesZioptan 3Zymaxid 3 gatifloxacin 1 Yes
acetazolamide 1 Yesbacitracin ophth 1 Yes
betaxolol 1 Yesbimatoprost 1 Yes
carteolol 1 Yescromolyn ophth 1 Yes
dexamethasone ophth 1 Yeserythromycin 1 Yes
methazolamide 1 Yespolymyxin B/neo/bacitracin 1 Yes
prednisolone sodium phosphate 1 Yes
39
12. ALLERGY, COUGH & COLD, LUNG MEDS
BRAND Formulary Tier GENERIC Formulary
Tier Generic Available
Accolate 3 zafirlukast 1 YesAdcirca 3
AdrenaClick 3Advair Diskus 3Advair HFA 3
Aerospan 3Alvesco 3
Anoro Ellipta 3Arnuity Ellipta 3
Asmanex 2Astelin Nasal
Spray 3 azelastine nasal spray 1 Yes
Atrovent HFA 2Breo Ellipta 3
Bromfed DM 1Cheratussin AC 1Cheratussin DAC 1
Clarinex 3 desloratadine 1 YesCombivent Respimat 2
Dulera 2Duoneb 3 ipratropium-albuterol 1 Yes
Elixophyllin Elixir 3 theophylline elixir 1 Yes
EpiPen 2EpiPen Jr. 2
Esbriet 3Flovent Diskus 3Flovent HFA 3
Grastek 3Guiatuss AC 3 guaifenesin/codeine 1 YesHycofenix 3Hydromet 1
Iophen C-NR 1Obredon 3
Ofev 3Oralair 3
Proair HFA 2Proair
RespiClick 2
Proventil HFA 3
40
12. ALLERGY, COUGH & COLD, LUNG MEDS
BRAND Formulary Tier GENERIC Formulary
Tier Generic Available
Pulmicort Flexhaler 3
Pulmicort Respules 3 budesonide 1 Yes
Pulmozyme 2Qvar 2
Ragwitek 3Serevent Diskus 2
Singulair 3 montelukast sodium 1 YesSpiriva 2Stiolto
Respimat 3
Symbicort 2Tessalon Perles 3 benzonatate 1 Yes
Theo-24 2Theochron 1 theophylline extended release 1 Yes
Tracleer 2Tussionex 3 hydrocodone-chlorpheniramine susp 1 Yes
Tuzistra XR 3Ventolin HFA 3
Vistaril 3 hydroxyzine pamoate 1 YesVituz 3
VoSpire ER 3 albuterol sulfate er 1 YesXopenex 3 levalbuterol 1 Yes
Xopenex HFA 3Xyzal 3 levocetirizine dihydrochloride 1 Yes
Zutripro 3 hydrocod-cpm-pseudoephedrine 1 Yesacetylcysteine 1 Yes
albuterol sulfate soln, syrup, tab 1 Yesaminophylline tabs 1 Yes
carbinoxamine 1 Yesclemastine 1 Yes
cromolyn inhalation soln 1 Yescyproheptadine 1 Yes
flunisolide 1 Yesguaifenesin/hydrocodone 1 Yes
guaifenesin/pseudoephedrine/ codeine 1 Yes
hydrocodone/homatropine syrup 1 Yeshydroxyzine HCl 1 Yes
ipratropium inhalation soln 1 Yes
41
12. ALLERGY, COUGH & COLD, LUNG MEDS
BRAND Formulary Tier GENERIC Formulary
Tier Generic Available
metaproterenol tabs, syrup, inh soln 1 Yes
phenylephrine/cpm/hydrocodone 1 Yespromethazine 1 Yes
promethazine/codeine 1 Yespromethazine/dextromethorphan 1 Yes
promethazine/phenylephrine 1 Yespromethazine/phenylephrine/
codeine 1 Yes
pseudoephedrine/ chlorpheniramine/codeine 1 Yes
terbutaline sulfate tabs 1 Yes
42
13. URINARY & PROSTATE MEDS
BRAND Formulary Tier GENERIC Formulary
Tier Generic Available
Avodart 3 dutasteride 1 YesCardura 3 doxazosin mesylate 1 Yes
Caverject 2Cialis 2Detrol 3 tolterodine tartrate 1 Yes
Detrol LA 3 tolterodine tartrate LA 1 YesDitropan 3 oxybutynin 1 Yes
Ditropan XL 3 oxybutynin ER 1 YesEdex 3
Enablex 2Flomax 3 tamsulosin 1 YesLevitra 3Muse 2
Myrbetriq 2Proscar 3 finasteride 1 YesRapaflo 2
Sanctura XR 3 trospium chloride 1 YesStaxyn 3Stendra 3
Urecholine 3 bethanechol 1 YesUrocit-K 3 potassium citrate 1 YesUroxatral 3 alfuzosin 1 YesVESIcare 2
Viagra 3flavoxate 1 Yesterazosin 1 Yes
43
14. VITAMINS & ELECTROLYTES
BRAND Formulary Tier GENERIC Formulary
Tier Generic Available
Calciferol 3 ergocalciferol 1 YesIcar 3 iron, carbonyl 15mg 1 Yes
K-Tab 3 potassium chloride 1 YesKlor-Con 1 potassium chloride 1 YesMephyton 2
Tri-Vi-Flor, Poly-Vi-Flor
with and without iron
3 multivitamin with fluoride drops, tabs 1 Yes
fluoride 1 YesMultigen 1 Yes
Multigen plus 1 Yespotassium bicarbonate/potassium
citrate effervescent 1 Yes
sodium fluoride drops 1 Yes
44
15. DIAGNOSTICS & MISCELLANEOUS AGENTS
BRAND Formulary Tier GENERIC Formulary
Tier Generic Available
Cerdelga 3Chemet 2Jadenu 3Keveyis 3Novarel 3 chorionic gonadotropin 1 YesPhosLo 3 calcium acetate 1 YesPregnyl 3 chorionic gonadotropin 1 Yes
Proamatine 3 midodrine HCl 1 YesRenvela 3 sevelamer carbonate 1 Yes
Repronex 3Zavesca 2
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