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BeHealthy America, Inc.
2015 Formulary
(List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION
ABOUT THE DRUGS WE COVER IN THIS PLAN
HPMS Approved Formulary File Submission ID: 15583
Version Number: 6
This formulary was updated on 08/08/2014. For more recent information or other questions, please contact the BeHealthy America, Inc. Customer
Service Department at 855-522-2870. TTY users should call 855-522-2973. We are open:
 October 1 to February 14: Monday through Sunday, 8:00 am – 8:00 pm
 February 15 to September 30: Monday through Friday, 8:00 am – 8:00 pm
or visit www.behealthyus.com.
H2758_CompFormulary_2015 Accepted 10/06/2014
Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs
you take.
When this drug list (formulary) refers to “we,” “us”, or “our,” it means BeHealthy America. When it refers to “plan” or “our plan,” it means
BeHealthy America.
This document includes a list of the drugs (formulary) for our plan which is current as of 10/01/2014. For an updated formulary, please contact
us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.
You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or
copayments/coinsurance may change on January 1, 2016, and from time to time during the year.
What is the BeHealthy America, Inc. Formulary?
A formulary is a list of covered drugs selected by BeHealthy America in consultation with a team of health care providers, which represents the
prescription therapies believed to be a necessary part of a quality treatment program. BeHealthy America will generally cover the drugs listed in
our formulary as long as the drug is medically necessary, the prescription is filled at a BeHealthy America network pharmacy, and other plan rules
are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.
Can the Formulary (drug list) change?
Generally, if you are taking a drug on our 2014 formulary that was covered at the beginning of the year, we will not discontinue or reduce
coverage of the drug during the 2015 coverage year except when a new, less expensive generic drug becomes available or when new adverse
information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our
formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking
it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the
formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your
safety.
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H2758_CompFormulary_2015 Accepted 10/06/2014
If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug, or move a drug to a
higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the
member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration
deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug
from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of MM/DD/YYYY. To get updated
information about the drugs covered by BeHealthy America, please contact us. Our contact information appears on the front and back cover pages.
Every month, we update our printed formulary.
How do I use the Formulary?
There are two ways to find your drug within the formulary:
Medical Condition
The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they
are used to treat. For example, drugs used to treat a heart condition are listed under the category, “Cardiovascular Agents”. If you know what your
drug is used for, look for the category name in the list that begins on page number 1. Then look under the category name for your drug.
Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in the Index that begins on page 58. The Index provides an
alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index
and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the
Index and find the name of your drug in the first column of the list.
What are generic drugs?
BeHealthy America covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient
as the brand name drug. Generally, generic drugs cost less than brand name drugs.
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H2758_CompFormulary_2015 Accepted 10/06/2014
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:
Prior Authorization: BeHealthy America requires you or your physician to get prior authorization for certain drugs. This means that you will
need to get approval from BeHealthy America before you fill your prescriptions. If you don’t get approval, BeHealthy America may not cover the
drug.
Quantity Limits: For certain drugs, BeHealthy America limits the amount of the drug that BeHealthy America will cover. For example,
BeHealthy America provides 30 tablets per prescription for Cialis. This may be in addition to a standard one-month or three-month supply.
Step Therapy: In some cases, BeHealthy America requires you to first try certain drugs to treat your medical condition before we will cover
another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, BeHealthy America may not cover Drug B
unless you try Drug A first. If Drug A does not work for you, BeHealthy America will then cover Drug B.
You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more
information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our
prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last
updated the formulary, appears on the front and back cover pages.
You can ask BeHealthy America to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health
condition. See the section, “How do I request an exception to the BeHealthy America formulary?” on pages 4-5 for information about how to
request an exception.
What if my drug is not on the Formulary?
If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Services and ask if your drug is covered.
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H2758_CompFormulary_2015 Accepted 10/06/2014
If you learn that BeHealthy America does not cover your drug, you have two options:
You can ask Customer Services for a list of similar drugs that are covered by BeHealthy America. When you receive the list, show it to your
doctor and ask him or her to prescribe a similar drug that is covered by BeHealthy America.
You can ask BeHealthy America to make an exception and cover your drug. See below for information about how to request an exception.
How do I request an exception to the BeHealthy America, Inc. Formulary?
You can ask BeHealthy America to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.
You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and
you would not be able to ask us to provide the drug at a lower cost-sharing level.
You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the
amount you must pay for your drug.
You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, BeHealthy America limits the amount of the
drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.
Generally, BeHealthy America will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower
cost-sharing drug, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse
medical effects.
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H2758_CompFormulary_2015 Accepted 10/06/2014
You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a
formulary, tiering, or utilization restriction exception you should submit a statement from your prescriber or physician supporting your
request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited
(fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request
to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.
What do I do before I can talk to my doctor about changing my drugs or requesting an exception?
As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our
formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You
should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will
cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases
during the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 31-day supply (unless
you have a prescription written for fewer days) when you go to a network pharmacy. After your first 31-day supply, we will not pay for these
drugs, even if you have been a member of the plan less than 90 days.
If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with 91-98-day transition
supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these
drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is
limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a
prescription for fewer days) while you pursue a formulary exception.
For enrollees who are outside their transition period, and experience a level of care change in which an enrollee is changing from one treatment
setting to another (example: LTC to hospital to LTC, hospitals to home, home to LTC), upon admission or discharge from a treatment setting or
LTC, The Organization will allow the enrollee access to a 30/31 day refill (30 days in the retail setting and 31 days in the LTC setting) for
formulary medications and an emergency 30/31 day refill (30 days in the retail setting and 31 days in the LTC setting) transition fill for nonformulary medications (including Part D drugs that are on Plan Sponsor’s formulary but require prior authorization or step therapy).
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H2758_CompFormulary_2015 Accepted 10/06/2014
This policy does not apply for short-term leaves of absences (i.e. holidays or vacations) from LTC or hospital facilities.
For more information
For more detailed information about your BeHealthy America’s prescription drug coverage, please review your Evidence of Coverage and other
plan materials.
If you have questions about BeHealthy America, please contact us. Our contact information, along with the date we last updated the formulary,
appears on the front and back cover pages.
If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours
a day/7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov.
BeHealthy America’s Formulary
The formulary that begins on the next page provides coverage information about the drugs covered by BeHealthy America. If you have trouble
finding your drug in the list, turn to the Index that begins on page 80.
The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., CELEBREX CAP 100MG) and generic drugs are listed
in lower-case italics (e.g., ibuprofen sus 100mg/5ml).
The information in the Requirements/Limits column tells you if BeHealthy America has any special requirements for coverage of your drug.
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H2758_CompFormulary_2015 Accepted 10/06/2014
Drug Name
Tier
Notes
ANALGESICS
Opioid Analgesics, Long-acting
BUTRANS DIS 15MCG/HR
fentanyl dis 100mcg/h
fentanyl dis 12mcg/hr
fentanyl dis 25mcg/hr
fentanyl dis 50mcg/hr
fentanyl dis 75mcg/hr
METHADONE INJ 10MG/ML
methadone sol 10mg/5ml
methadone sol 5mg/5ml
methadone tab 10mg
methadone tab 5mg
morphine sul beads cap 120mg
morphine sul beads cap 30mg e
morphine sul beads cap 45mg e
morphine sul beads cap 60mg e
morphine sul beads cap 75mg e
morphine sul beads cap 90mg e
morphine sul cap 100mg er
morphine sul cap 10mg er
morphine sul cap 20mg er
morphine sul cap 30mg er
morphine sul cap 50mg er
morphine sul cap 60mg er
morphine sul cap 80mg er
morphine sul tab 100mg er
morphine sul tab 15mg er
3
2
2
2
2
2
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
MO
QL 10 ST MO
QL 10 ST MO
QL 10 ST MO
QL 10 ST MO
QL 10 ST MO
GC MO
GC MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Drug Name
morphine sul tab 30mg er
morphine sul tab 60mg er
NUCYNTA ER TAB 100MG
NUCYNTA ER TAB 150MG
NUCYNTA ER TAB 200MG
NUCYNTA ER TAB 250MG
NUCYNTA ER TAB 50MG
OPANA ER TAB 10MG
OPANA ER TAB 15MG
OPANA ER TAB 20MG
OPANA ER TAB 30MG
OPANA ER TAB 40MG
OPANA ER TAB 5MG
OPANA ER TAB 7.5MG
oxymorphone tab 10mg er
oxymorphone tab 15mg er
oxymorphone tab 20mg er
oxymorphone tab 30mg er
oxymorphone tab 40mg er
oxymorphone tab 5mg er
oxymorphone tab 7.5mg er
ZOHYDRO ER CAP 10MG
ZOHYDRO ER CAP 15MG
ZOHYDRO ER CAP 20MG
ZOHYDRO ER CAP 30MG
ZOHYDRO ER CAP 40MG
ZOHYDRO ER CAP 50MG
Opioid Analgesics, Short-acting
Tier
Notes
2
2
3
3
3
3
3
3
3
3
3
3
3
3
2
2
2
2
2
2
2
4
4
4
4
4
4
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA QL 180 MO
PA QL 180 MO
PA QL 180 MO
PA QL 180 MO
PA QL 180 MO
PA QL 180 MO
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
1
Drug Name
apap/cod sol120-12mg/5ml
apap/codeine tab 300-15mg
apap/codeine tab 300-30mg
apap/codeine tab 300-60mg
ascomp/cod cap 30mg
but/apap/caf cap codeine
duramorph inj 0.5mg/ml
duramorph inj 1mg/ml
endocet tab 10-325mg
endocet tab 5-325mg
endocet tab 7.5-325m
FENTORA TAB 200MCG
FENTORA TAB 400MCG
FENTORA TAB 600MCG
FENTORA TAB 800MCG
hydroco/apap sol 7.5-325mg
hydroco/apap tab 10-325mg
hydroco/apap tab 5-325mg
hydroco/apap tab 7.5-325mg
hydrocod/ibu tab 7.5-200mg
hydromorphon liq 1mg/ml
hydromorphon tab 12mg er
hydromorphon tab 16mg er
hydromorphon tab 8mg er
hydromorphone inj 500/50ml
hydromorphone tab 2mg
hydromorphone tab 4mg
hydromorphone tab 8mg
Tier
Notes
2
2
2
2
2
2
1
1
2
2
2
5
5
5
5
1
2
2
2
2
2
2
2
2
2
2
2
2
QL 5000 MO
QL 400 MO
QL 400 MO
QL 400 MO
PA MO
PA QL 370 MO
GC MO
GC MO
QL 370 MO
QL 370 MO
QL 370 MO
PA
PA
PA
PA
QL 5500 GC MO
QL 370 MO
QL 370 MO
QL 370 MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Drug Name
LAZANDA SPR 100MCG
LAZANDA SPR 400MCG
lorcet plus tab 7.5-325
morphine sul sol 10mg/5ml
morphine sul sol 20mg/5ml
morphine sul sol 20mg/ml
morphine sul tab 15mg
morphine sul tab 30mg
nalbuphine inj 10mg/ml
nalbuphine inj 20mg/ml
NUCYNTA TAB 100MG
NUCYNTA TAB 50MG
NUCYNTA TAB 75MG
oxycod/apap tab 10-325mg
oxycod/apap tab 2.5-325mg
oxycod/apap tab 5-325mg
oxycod/apap tab 7.5-325mg
oxycod/asa tab 4.8355-325mg
oxycod/ibu tab 5-400mg
oxycodone cap 5mg
oxycodone tab 10mg
oxycodone tab 15mg
oxycodone tab 20mg
oxycodone tab 30mg
oxycodone tab 5mg
oxymorphone tab hcl 10mg
oxymorphone tab hcl 5mg
pentaz/nalox tab 50-0.5mg
Tier
Notes
5
5
2
2
1
2
2
2
2
2
3
3
3
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
PA
PA
QL 370 MO
MO
GC MO
MO
MO
MO
MO
MO
MO
MO
MO
QL 370 MO
QL 370 MO
QL 370 MO
QL 370 MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA MO
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
2
Drug Name
tramad/apap tab 37.5-325mg
tramadol hcl tab 50mg
Tier
Notes
2
1
QL 370 MO
QL 240 GC MO
ANESTHETICS
Local Anesthetics
lido/prilocn cre 2.5-2.5%
lidocaine gel 2%
lidocaine inj 0.5%
lidocaine inj 1%
lidocaine inj 2%
CHANTIX TAB 0.5MG
CHANTIX TAB 1MG
NICOTROL INH
Tier
Notes
4
4
3
QL 11 MO
QL 180/90 MO
MO
3
3
3
3
2
2
2
2
1
2
2
2
2
2
2
2
2
1
2
1
1
1
1
MO
MO
MO
MO
MO
MO
MO
MO
GC MO
MO
MO
MO
MO
MO
MO
MO
MO
GC MO
MO
GC MO
GC MO
GC MO
GC MO
ANTI-INFLAMMATORY AGENTS
2
2
1
2
2
MO
MO
GC MO
MO
MO
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT
AGENTS
Alcohol Deterrents/Anti-craving
disulfiram tab 250mg
disulfiram tab 500mg
naltrexone tab 50mg
Opioid Antagonists
bupren/nalox sub 2-0.5mg
bupren/nalox sub 8-2mg
buprenorphine inj 0.3mg/ml
buprenorphine sub 2mg
buprenorphine sub 8mg
naloxone inj 1mg/ml
SUBOXONE MIS 12-3MG
SUBOXONE MIS 4-1MG
ZUBSOLV SUB 1.4-0.36
ZUBSOLV SUB 5.7-1.4
Smoking Cessation Agents
CHANTIX PAK 0.5MG & 1MG
Drug Name
2
2
2
MO
MO
MO
2
2
1
2
2
1
4
4
3
3
MO
MO
GC MO
MO
MO
GC MO
MO
MO
MO
MO
4
QL 53 MO
Nonsteroidal Anti-inflammatory Drugs
CELEBREX CAP 100MG
CELEBREX CAP 200MG
CELEBREX CAP 400MG
CELEBREX CAP 50MG
diclofen pot tab 50mg
diclofenac tab 100mg er
diclofenac tab 25mg dr
diclofenac tab 50mg dr
diclofenac tab 75mg dr
diflunisal tab 500mg
etodolac cap 200mg
etodolac cap 300mg
etodolac er tab 400mg
etodolac er tab 500mg
etodolac er tab 600mg
etodolac tab 400mg
etodolac tab 500mg
fenoprofen tab 600mg
flurbiprofen tab 100mg
flurbiprofen tab 50mg
ibuprofen sus 100mg/5ml
ibuprofen tab 400mg
ibuprofen tab 600mg
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
3
Drug Name
ibuprofen tab 800mg
indomethacin cap 25mg
indomethacin cap 50mg
indomethacin cap 75mg er
ketoprofen cap 200mg er
ketoprofen cap 50mg
ketoprofen cap 75mg
ketorolac inj 15mg/ml
ketorolac inj 30mg/ml
ketorolac tab 10mg
meclofen sod cap 100mg
meclofen sod cap 50mg
meloxicam sus 7.5/5ml
meloxicam tab 15mg
meloxicam tab 7.5mg
nabumetone tab 500mg
nabumetone tab 750mg
naproxen dr tab 375mg
naproxen dr tab 500mg
naproxen sod tab 275mg
naproxen sod tab 550mg
naproxen sus 125mg/5ml
naproxen tab 250mg
naproxen tab 375mg
naproxen tab 500mg
oxaprozin tab 600mg
piroxicam cap 10mg
piroxicam cap 20mg
Tier
Notes
1
1
2
2
2
1
2
1
1
2
1
1
1
2
2
2
2
1
2
2
2
1
2
1
1
2
2
1
GC MO
PA GC MO
PA MO
PA MO
MO
GC MO
MO
PA GC MO
PA GC MO
PA MO
GC MO
GC MO
GC MO
MO
MO
MO
MO
GC MO
MO
MO
MO
GC MO
MO
GC MO
GC MO
MO
MO
GC MO
Drug Name
sulindac tab 150mg
sulindac tab 200mg
tolmetin sod cap 400mg
tolmetin sod tab 600mg
Tier
Notes
2
2
2
1
MO
MO
MO
GC MO
1
2
1
1
1
1
1
2
2
2
2
2
2
GC MO
MO
GC MO
GC MO
GC MO
GC MO
GC MO
MO
MO
MO
MO
MO
PA MO
1
2
2
2
2
1
1
1
GC MO
MO
MO
MO
MO
GC MO
GC MO
GC MO
ANTIBACTERIALS
Aminoglycosides
gentamicin inj 10mg/ml
gentamicin inj 40mg/ml
gentamicin/nacl inj 0.9mg/ml
gentamicin/nacl inj 1.4mg/ml
gentamicin/nacl inj 1.6mg/ml
gentamicin/nacl inj 100mg
gentamicin/nacl inj 60mg
neomycin tab 500mg
paromomycin cap 250mg
streptomycin inj 1gm
tobramycin inj 10mg/ml
tobramycin inj 80mg/2ml
tobramycin neb 300/5ml
Antibacterials, Other
baciim inj 50000unit
chloramphenicol inj 1gm
clindamycin cap 150mg
clindamycin cap 300mg
clindamycin cap 75mg
clindamycin inj 150mg/ml
clindamycin inj 300mg
clindamycin inj 600mg
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
4
Drug Name
clindamycin inj 900mg
clindamycin sol 75mg/5ml
colistimethate inj 150mg
CUBICIN SOL 500MG
LINCOCIN INJ 300MG/ML
metronidazol cap 375mg
metronidazole tab 250mg
metronidazole tab 500mg
metronidazole/nacl inj 500mg
nitrofur mac cap 50mg
nitrofurantn cap 100mg
SYNERCID INJ 500MG
trimethoprim tab 100mg
TYGACIL INJ 50MG
vancomycin cap 125mg
vancomycin cap 250mg
vancomycin inj 1000mg
vancomycin inj 10gm
vancomycin inj 500mg
XIFAXAN TAB 550MG
ZYVOX SOL 2MG/ML
ZYVOX SUS 100MG/5ML
ZYVOX TAB 600MG
Beta-lactam, Cephalosporins
cefaclor cap 250mg
cefaclor cap 500mg
cefaclor er tab 500mg
cefazolin inj 10gm
Tier
Notes
1
2
2
4
4
1
1
1
2
2
2
4
2
4
2
2
2
2
4
4
5
4
5
GC MO
MO
MO
MO
MO
GC MO
GC MO
GC MO
PA MO
PA MO
PA MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
2
2
1
1
MO
MO
GC MO
GC MO
MO
Drug Name
cefazolin inj 1gm
cefazolin inj 1gm/50ml
cefazolin inj 500mg
cefdinir cap 300mg
cefdinir sus 125mg/5ml
cefdinir sus 250mg/5ml
cefepime inj 1gm
cefepime inj 2gm
cefoxitin inj 10gm
cefoxitin inj 180 mg/ml
cefoxitin inj 95 mg/ml
cefpodo prox sus 100mg/5ml
cefpodo prox sus 50mg/5ml
cefpodoxime tab 100mg
cefpodoxime tab 200mg
cefprozil sus 125/5ml
cefprozil sus 250/5ml
cefprozil tab 250mg
cefprozil tab 500mg
ceftriaxone inj 10gm
ceftriaxone inj 250mg
ceftriaxone inj 500mg
cefuroxime inj 1.5gm
cefuroxime inj 7.5gm
cefuroxime inj 750mg
cefuroxime tab 250mg
cephalexin cap 250mg
cephalexin cap 500mg
Tier
Notes
2
1
1
2
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
1
1
2
1
1
MO
GC MO
GC MO
MO
GC MO
GC MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
GC MO
GC MO
GC MO
MO
GC MO
GC MO
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
5
Drug Name
cephalexin sus 125mg/5ml
cephalexin sus 250mg/5ml
cephalexin tab 250mg
cephalexin tab 500mg
SUPRAX CAP 400MG
SUPRAX SUS 200MG/5ML
SUPRAX TAB 400MG
TEFLARO INJ 400MG
TEFLARO INJ 600MG
Beta-lactam, Other
AZACTAM/DEX INJ 1GM
AZACTAM/DEX INJ 2GM
aztreonam inj 1gm
CAYSTON INH 75MG
imipenem/cilas inj 250mg
imipenem/cilas inj 500mg
INVANZ INJ 1GM
meropenem inj 500mg
Beta-lactam, Penicillins
amox/k clav chw 200mg
amox/k clav chw 400mg
amox/k clav sus 200/5ml
amox/k clav sus 400/5ml
amox/k clav sus 600/5ml
amox/k clav tab 250mg
amox/k clav tab 500mg
amox/k clav tab 875mg
amoxicillin cap 250mg
Tier
Notes
2
1
1
1
4
4
4
4
4
MO
GC MO
GC MO
GC MO
MO
MO
MO
MO
MO
3
5
2
5
2
2
4
2
MO
1
1
1
2
2
2
2
2
1
GC MO
GC MO
GC MO
MO
MO
MO
MO
MO
GC MO
MO
MO
MO
MO
MO
Drug Name
amoxicillin cap 500mg
amoxicillin chw tab 125mg
amoxicillin chw tab 250mg
amoxicillin sus 125/5ml
amoxicillin sus 200/5ml
amoxicillin sus 250/5ml
amoxicillin sus 400/5ml
amoxicillin tab 500mg
amoxicillin tab 875mg
amp-sulbactam inj 15gm
ampicillin cap 250mg
ampicillin cap 500mg
ampicillin inj 10gm
ampicillin inj 125mg
ampicillin inj 1gm
ampicillin sus 125/5ml
ampicillin sus 250/5ml
BICILLIN L-A INJ 600000
dicloxacillin cap 250mg
dicloxacillin cap 500mg
nafcillin inj 10gm
nafcillin inj 1gm
pen g sod inj 5000000
penicillin gk inj 5mu
penicillin vk sol 125/5ml
penicillin vk sol 250/5ml
penicillin vk tab 250mg
penicillin vk tab 500mg
Tier
Notes
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
1
1
4
2
2
2
2
1
1
1
1
1
2
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
MO
MO
MO
MO
MO
MO
MO
GC MO
GC MO
MO
MO
MO
MO
MO
GC MO
GC MO
GC MO
GC MO
GC MO
MO
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
6
Drug Name
piper/tazoba inj 3-0.375g
piper/tazoba inj 4-0.5gm
Macrolides
azithromycin inj 500mg
azithromycin pow 1gm pak
azithromycin sus 100mg/5ml
azithromycin sus 200mg5ml
azithromycin tab 250mg
azithromycin tab 500mg
azithromycin tab 600mg
clarithromycin tab 250mg
clarithromycin tab 500mg
DIFICID TAB 200MG
erythrocin lac inj 500mg
erythrocin tab 250mg
erythromycin eth tab 400mg
KETEK TAB 300MG
KETEK TAB 400MG
Quinolones
ciprofloxacin inj 200mg
ciprofloxacin inj 400mg/40ml
ciprofloxacin tab 1000mg er
ciprofloxacin tab 100mg
ciprofloxacin tab 250mg
ciprofloxacin tab 500mg
ciprofloxacin tab 500mg er
ciprofloxacin tab 750mg
ciprofloxacn sus 250mg/5
Tier
Notes
2
2
MO
MO
2
2
1
2
2
2
2
2
2
5
2
2
1
4
4
MO
MO
GC MO
MO
MO
MO
MO
MO
MO
ST
MO
MO
GC MO
MO
MO
1
1
2
1
1
1
2
2
1
GC MO
GC MO
MO
GC MO
GC MO
GC MO
MO
MO
GC MO
Drug Name
ciprofloxacn sus 500mg/5
levoflox/d5w inj 500mg/100ml
levofloxacin inj 25mg/ml
levofloxacin sol 25mg/ml
levofloxacin tab 250mg
levofloxacin tab 500mg
levofloxacin tab 750mg
moxifloxacin tab 400mg
ofloxacin tab 200mg
ofloxacin tab 300mg
ofloxacin tab 400mg
Sulfonamides
smz-tmp inj 400-80mg/5ml
smz-tmp sus 200-40mg/5ml
smz-tmp tab 400-80mg
smz/tmp ds tab 800-160mg
sulfadiazine tab 500mg
Tetracyclines
doxycycl hyc inj 100mg
doxycycline hyc cap 100mg
doxycycline hyc cap 50mg
doxycycline hyc tab 100mg
doxycycline hyc tab 20mg
doxycycline mono tab 50mg
doxycycline mono tab 75mg
doxycycline sus 25mg/5ml
minocycline cap 100mg
minocycline cap 50mg
Tier
Notes
1
2
2
2
2
2
2
2
1
1
2
GC MO
MO
MO
MO
MO
MO
MO
MO
GC MO
GC MO
MO
2
1
1
1
2
MO
GC MO
GC MO
GC MO
MO
1
1
1
1
2
1
2
2
2
2
GC MO
GC MO
GC MO
GC MO
MO
GC MO
MO
MO
MO
MO
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
7
Drug Name
minocycline cap 75mg
minocycline tab 100mg
minocycline tab 50mg
minocycline tab 75mg
Tier
Notes
2
2
2
2
MO
MO
MO
MO
2
2
2
2
2
2
2
2
4
4
4
4
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
1
1
1
1
1
1
1
1
1
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
ANTICONVULSANTS
Anticonvulsants, Other
levetiraceta sol 100mg/ml
levetiraceta tab 1000mg
levetiraceta tab 250mg
levetiraceta tab 500mg
levetiraceta tab 500mg er
levetiraceta tab 750mg
levetiraceta tab 750mg er
levetiracetm inj 500mg/5ml
POTIGA TAB 200MG
POTIGA TAB 300MG
POTIGA TAB 400MG
POTIGA TAB 50MG
Barbiturates
phenobarb elx 20mg/5ml
phenobarb tab 100mg
phenobarb tab 15mg
phenobarb tab 16.2mg
phenobarb tab 30mg
phenobarb tab 32.4mg
phenobarb tab 60mg
phenobarb tab 64.8mg
phenobarb tab 97.2mg
Drug Name
Benzodiazepines
clonazep odt tab 0.125mg
clonazep odt tab 0.25mg
clonazep odt tab 0.5mg
clonazep odt tab 1mg
clonazep odt tab 2mg
clonazepam tab 0.5mg
clonazepam tab 1mg
clonazepam tab 2mg
diazepam gel 10mg
diazepam gel 2.5mg
diazepam gel 20mg
ONFI SUS 2.5MG/ML
ONFI TAB 10MG
ONFI TAB 20MG
Calcium Channel Modifying Agents
CELONTIN CAP 300MG
ethosuximide cap 250mg
ethosuximide sol 250/5ml
LYRICA CAP 200MG
LYRICA CAP 225MG
LYRICA CAP 25MG
LYRICA CAP 300MG
LYRICA CAP 50MG
LYRICA CAP 75MG
LYRICA SOL 20MG/ML
zonisamide cap 100mg
zonisamide cap 25mg
Tier
Notes
1
1
1
1
1
1
1
1
2
2
2
4
4
4
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
MO
MO
MO
MO
MO
MO
4
2
1
4
4
4
4
4
4
3
2
2
MO
MO
GC MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
8
Drug Name
Tier
Notes
zonisamide cap 50mg
2
MO
Gamma-aminobutyric Acid (GABA) Augmenting Agents
divalproex tab 250mg dr
2
MO
divalproex tab 250mg er
2
MO
divalproex tab 500mg dr
2
MO
divalproex tab 500mg er
2
MO
FYCOMPA TAB 10MG
4
MO
FYCOMPA TAB 12MG
4
MO
FYCOMPA TAB 2MG
4
MO
FYCOMPA TAB 4MG
4
MO
FYCOMPA TAB 6MG
4
MO
FYCOMPA TAB 8MG
4
MO
gabapentin cap 100mg
2
MO
gabapentin cap 300mg
2
MO
gabapentin cap 400mg
2
MO
gabapentin sol 250/5ml
2
MO
gabapentin tab 600mg
2
MO
gabapentin tab 800mg
2
MO
GABITRIL TAB 12MG
4
MO
GABITRIL TAB 16MG
4
MO
primidone tab 250mg
2
MO
primidone tab 50mg
2
MO
SABRIL POW 500MG
5
SABRIL TAB 500MG
5
tiagabine tab 2mg
2
MO
tiagabine tab 4mg
2
MO
valproate inj 100mg/ml
1
GC MO
valproic acd cap 250mg
2
MO
Drug Name
valproic acd syp 250mg/5ml
Glutamate Reducing Agents
felbamate sus 600mg/5ml
felbamate tab 400mg
felbamate tab 600mg
lamotrigine chw 25mg
lamotrigine chw 5mg
lamotrigine tab 100mg
lamotrigine tab 100mg er
lamotrigine tab 150mg
lamotrigine tab 200mg
lamotrigine tab 200mg er
lamotrigine tab 250mg er
lamotrigine tab 25mg
lamotrigine tab 25mg er
lamotrigine tab 300mg er
lamotrigine tab 50mg er
QUDEXY XR CAP 100/24HR
QUDEXY XR CAP 150/24HR
QUDEXY XR CAP 200/24HR
QUDEXY XR CAP 25/24HR
QUDEXY XR CAP 50/24HR
topiramate cap 15mg
topiramate cap 25mg
topiramate tab 200mg
topiramate tab 25mg
topiramate tab 50mg
TROKENDI XR CAP 100MG
Tier
Notes
2
MO
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
4
4
4
4
4
2
2
2
2
2
4
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
9
Drug Name
TROKENDI XR CAP 200MG
TROKENDI XR CAP 25MG
TROKENDI XR CAP 50MG
Sodium Channel Agents
APTIOM TAB 200MG
APTIOM TAB 400MG
APTIOM TAB 600MG
APTIOM TAB 800MG
BANZEL SUS 40MG/ML
BANZEL TAB 200MG
BANZEL TAB 400MG
carbamazepin cap 200mg er
carbamazepin cap 300mg er
carbamazepin sus 100mg/5ml
carbamazepin tab 200mg
carbamazepin tab 200mg er
carbamazepin tab 400mg er
epitol tab 200mg
fosphenytoin inj 100mg/2ml
oxcarbazepin sus 300mg/5m
oxcarbazepin tab 150mg
oxcarbazepin tab 300mg
oxcarbazepin tab 600mg
OXTELLAR XR TAB 150MG
OXTELLAR XR TAB 300MG
OXTELLAR XR TAB 600MG
PEGANONE TAB 250MG
phenytoin chw 50mg
Tier
Notes
4
4
4
MO
MO
MO
4
5
5
5
4
4
4
2
2
2
2
2
2
2
2
2
2
2
2
4
4
4
4
2
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Drug Name
phenytoin ex cap 100mg
phenytoin ex cap 200mg
phenytoin ex cap 300mg
phenytoin inj 50mg/ml
phenytoin sus 125mg/5ml
TEGRETOL XR TAB 100MG
VIMPAT INJ 200MG/20ML
VIMPAT SOL 10MG/ML
VIMPAT TAB 100MG
VIMPAT TAB 150MG
VIMPAT TAB 200MG
VIMPAT TAB 50MG
Tier
Notes
2
2
2
1
2
4
4
4
4
4
4
4
MO
MO
MO
GC MO
MO
MO
MO
MO
MO
MO
MO
MO
2
MO
2
2
2
2
2
3
3
3
2
2
2
2
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
ANTIDEMENTIA AGENTS
Antidementia Agents, Other
ergoloid mes tab 1mg oral
Cholinesterase Inhibitors
donepezil tab 10mg
donepezil tab 10mg odt
donepezil tab 5mg
donepezil tab 5mg odt
donepezil tab hcl 23mg
EXELON DIS 13.3/24
EXELON DIS 4.6MG/24HR
EXELON DIS 9.5MG/24HR
galantamine cap 16mg er
galantamine cap 24mg er
galantamine cap 8mg er
galantamine tab 12mg
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
10
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
Drug Name
Tier
galantamine tab 4mg
2
galantamine tab 8mg
2
rivastigmine cap 1.5mg
2
rivastigmine cap 3mg
2
rivastigmine cap 4.5mg
2
rivastigmine cap 6mg
2
N-METHYL-D-ASPARTATE (NMDA) RECEPTOR
ANTAGONIST
NAMENDA XR CAP 14MG
4
NAMENDA XR CAP 21MG
4
NAMENDA XR CAP 28MG
4
NAMENDA XR CAP 7MG
3
Notes
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
ANTIDEPRESSANTS
Antidepressants, Other
APLENZIN TAB 174MG
APLENZIN TAB 348MG
BRINTELLIX TAB 10MG
BRINTELLIX TAB 20MG
BRINTELLIX TAB 5MG
buproban tab 150mg
bupropion hcl tab 150mg xl
bupropion hcl tab 300mg xl
bupropion tab 100mg
bupropion tab 100mg sr
bupropion tab 150mg sr
bupropion tab 200mg sr
bupropion tab 75mg
FORFIVO XL TAB 450MG
4
4
4
4
4
2
2
2
2
2
2
2
2
3
MO
MO
ST MO
ST MO
ST MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Drug Name
maprotiline tab 25mg
maprotiline tab 50mg
maprotiline tab 75mg
mirtazapine tab 15mg
mirtazapine tab 15mg odt
mirtazapine tab 30mg
mirtazapine tab 30mg odt
mirtazapine tab 45mg
mirtazapine tab 45mg odt
mirtazapine tab 7.5mg
nefazodone tab 100mg
nefazodone tab 150mg
nefazodone tab 200mg
nefazodone tab 250mg
nefazodone tab 50mg
trazodone tab 100mg
trazodone tab 150mg
trazodone tab 300mg
trazodone tab 50mg
VIIBRYD KIT
VIIBRYD TAB 10MG
VIIBRYD TAB 20MG
VIIBRYD TAB 40MG
Monoamine Oxidase Inhibitors
EMSAM DIS 12MG/24H
EMSAM DIS 6MG/24HR
EMSAM DIS 9MG/24HR
MARPLAN TAB 10MG
Tier
Notes
1
2
1
2
2
2
2
2
2
2
2
2
2
2
1
1
1
2
1
3
3
3
3
GC MO
MO
GC MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
GC MO
GC MO
GC MO
MO
GC MO
MO
MO
MO
MO
5
5
5
4
MO
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
11
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
Drug Name
Tier
phenelzine tab 15mg
2
tranylcyprom tab 10mg
2
Serotonin/Norepinephrine Reuptake Inhibitors
BRISDELLE CAP 7.5MG
4
citalopram sol 10mg/5ml
2
citalopram tab 10mg
2
citalopram tab 20mg
1
citalopram tab 40mg
1
desvenlafaxine tab 100mg er
4
desvenlafaxine tab 50mg er
4
duloxetine cap 20mg
2
duloxetine cap 30mg
2
duloxetine cap 60mg
2
escitalopram sol 5mg/5ml
2
escitalopram tab 10mg
2
escitalopram tab 20mg
2
escitalopram tab 5mg
2
FETZIMA CAP 120MG
3
FETZIMA CAP 20MG
3
FETZIMA CAP 40MG
3
FETZIMA CAP 80MG
3
fluoxetine cap 10mg
1
fluoxetine cap 20mg
1
fluoxetine cap 40mg
1
fluoxetine cap 90mg dr
2
fluoxetine sol 20mg/5ml
2
fluoxetine tab 10mg
1
fluoxetine tab 20mg
2
Notes
MO
MO
MO
MO
MO
GC MO
GC MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
GC MO
GC MO
GC MO
MO
MO
GC MO
MO
Drug Name
FLUOXETINE TAB 60MG
fluvoxamine cap 100mg er
fluvoxamine cap 150mg er
fluvoxamine tab 100mg
fluvoxamine tab 25mg
fluvoxamine tab 50mg
KHEDEZLA TAB 100MG ER
KHEDEZLA TAB 50MG ER
olanza/fluox cap 12-25mg
olanza/fluox cap 12-50mg
olanza/fluox cap 3-25mg
olanza/fluox cap 6-25mg
olanza/fluox cap 6-50mg
paroxetin er tab 12.5mg
paroxetin er tab 37.5mg
paroxetine tab 10mg
paroxetine tab 20mg
paroxetine tab 25mg er
paroxetine tab 30mg
paroxetine tab 40mg
PAXIL SUS 10MG/5ML
PEXEVA TAB 10MG
PEXEVA TAB 20MG
PEXEVA TAB 30MG
PEXEVA TAB 40MG
PRISTIQ TAB 100MG
PRISTIQ TAB 50MG
sertraline con 20mg/ml
Tier
Notes
4
2
2
2
2
2
3
3
2
2
2
2
2
2
2
1
1
2
2
2
4
4
4
4
4
4
4
2
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
GC MO
GC MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
12
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
Drug Name
sertraline tab 100mg
sertraline tab 25mg
sertraline tab 50mg
venlafaxine cap 150mg er
venlafaxine cap 37.5mg
venlafaxine cap 75mg er
venlafaxine tab 100mg
venlafaxine tab 150mg er
venlafaxine tab 225mg er
venlafaxine tab 25mg
venlafaxine tab 37.5 er
venlafaxine tab 37.5mg
venlafaxine tab 50mg
venlafaxine tab 75mg
venlafaxine tab 75mg er
Tricyclics
amitriptyline tab 100mg
amitriptyline tab 10mg
amitriptyline tab 150mg
amitriptyline tab 25mg
amitriptyline tab 50mg
amitriptyline tab 75mg
amoxapine tab 100mg
amoxapine tab 150mg
amoxapine tab 25mg
amoxapine tab 50mg
cdp/amitrip tab 10-25mg
cdp/amitrip tab 5-12.5mg
Tier
Notes
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
1
1
2
1
1
1
2
1
1
1
1
1
PA GC MO
PA GC MO
PA MO
PA GC MO
PA GC MO
PA GC MO
MO
GC MO
GC MO
GC MO
PA GC MO
PA GC MO
Drug Name
clomipramine cap 25mg
clomipramine cap 50mg
clomipramine cap 75mg
desipramine tab 100mg
desipramine tab 10mg
desipramine tab 150mg
desipramine tab 25mg
desipramine tab 50mg
desipramine tab 75mg
doxepin hcl cap 100mg
doxepin hcl cap 10mg
doxepin hcl cap 150mg
doxepin hcl cap 25mg
doxepin hcl cap 50mg
doxepin hcl cap 75mg
doxepin hcl con 10mg/ml
imipramine hcl tab 10mg
imipramine hcl tab 25mg
imipramine hcl tab 50mg
imipramine pam cap 100mg
imipramine pam cap 125mg
imipramine pam cap 150mg
imipramine pam cap 75mg
NORTRIPTYLIN SOL 10MG/5ML
nortriptyline cap 10mg
nortriptyline cap 25mg
nortriptyline cap 50mg
nortriptyline cap 75mg
Tier
Notes
2
2
2
2
2
2
2
2
1
1
1
2
1
1
1
1
2
2
2
2
2
2
2
2
1
1
2
2
PA MO
PA MO
PA MO
MO
MO
MO
MO
MO
GC MO
PA GC MO
PA GC MO
PA MO
PA GC MO
PA GC MO
PA GC MO
PA GC MO
PA MO
PA MO
PA MO
PA MO
PA MO
PA MO
PA MO
MO
GC MO
GC MO
MO
MO
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
13
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
Drug Name
protriptyline tab 10mg
protriptyline tab 5mg
SURMONTIL CAP 100MG
SURMONTIL CAP 25MG
SURMONTIL CAP 50MG
Tier
Notes
2
2
4
4
4
MO
MO
MO
MO
MO
1
1
2
4
GC MO
GC MO
MO
MO
5
2
2
4
4
3
4
2
2
2
2
2
2
2
2
2
QL 60
QL 60 MO
QL 60 MO
PA QL 30 MO
PA QL 30 MO
PA QL 30 MO
PA QL 12 MO
PA QL 60 MO
PA QL 60 MO
PA QL 60 MO
PA QL 160 MO
PA MO
PA QL 30 MO
PA QL 60 MO
PA QL 60 MO
PA QL 60 MO
ANTIEMETICS
Antiemetics, Other
meclizine tab 12.5mg
meclizine tab 25mg
metoclopramide tab 5mg
TRANSDERM-SC DIS 1.5MG
Emetogenic Therapy Adjuncts
dronabinol cap 10mg
dronabinol cap 2.5mg
dronabinol cap 5mg
EMEND CAP 125MG
EMEND CAP 40MG
EMEND CAP 80MG
EMEND PAK 80 & 125MG
granisetron inj 0.1mg/ml
granisetron inj 1mg/ml
granisetron tab 1mg
ondansetron inj 4mg/2ml
ondansetron sol 4mg/5ml
ondansetron tab 24mg
ondansetron tab 4mg
ondansetron tab 4mg odt
ondansetron tab 8mg
Drug Name
ondansetron tab 8mg odt
SANCUSO DIS 3.1MG
Tier
Notes
2
3
PA QL 60 MO
QL 4 MO
4
4
2
4
4
2
4
2
2
2
2
2
2
2
5
5
1
2
2
5
4
4
4
2
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
ANTIFUNGALS
Antifungals
ABELCET INJ 5MG/ML
AMBISOME INJ 50MG
amphotericin b inj 50mg
CANCIDAS INJ 50MG
CANCIDAS INJ 70MG
clotrimazole troche 10mg
ERAXIS INJ 100MG
fluconazole sus 10mg/ml
fluconazole sus 40mg/ml
fluconazole tab 100mg
fluconazole tab 150mg
fluconazole tab 200mg
fluconazole tab 50mg
fluconazole/dex inj 400mg
flucytosine cap 250mg
flucytosine cap 500mg
griseofulvin sus 125mg/5ml
itraconazole cap 100mg
ketoconazole tab 200mg
MYCAMINE INJ 100MG
MYCAMINE INJ 50MG
NOXAFIL SUS 40MG/ML
NOXAFIL TAB 100MG
nystatin tab 500000 unit
GC MO
MO
MO
MO
MO
MO
MO
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
14
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
Drug Name
voriconazole inj 200mg
voriconazole sus 40mg/ml
voriconazole tab 200mg
Tier
Notes
2
5
5
MO
1
1
4
2
3
3
GC MO
GC MO
MO
MO
ST MO
ST MO
ANTIGOUT AGENTS
Antigout Agents
allopurinol tab 100mg
allopurinol tab 300mg
COLCRYS TAB 0.6MG
probenecid tab 500mg
ULORIC TAB 40MG
ULORIC TAB 80MG
ANTIMYASTHENIC AGENTS
Parasympathomimetics
GUANIDINE TAB 125MG
MESTINON SYP 60MG/5ML
pyridostigme tab 60mg
Tier
Notes
2
4
2
MO
MO
MO
2
2
2
2
MO
MO
MO
MO
4
2
2
1
1
1
1
4
4
1
2
1
3
5
4
MO
MO
MO
GC MO
GC MO
GC MO
GC MO
MO
MO
GC MO
MO
GC MO
MO
ANTIMYCOBACTERIALS
ANTIMIGRAINE AGENTS
Antimigraine Agents, Prophylactic
divalproex cap 125mg
divalproex tab 125mg dr
topiramate tab 100mg
Ergot Alkaloids
dihydroergot inj 1mg/ml
ERGOMAR SUB 2MG
Serotonin (5-HT) 1b/1d Receptor Agonists
RELPAX TAB 20MG
RELPAX TAB 40MG
sumatriptan inj 6mg/0.5ml
sumatriptan pfs 6mg/0.5ml
sumatriptan tab 100mg
sumatriptan tab 25mg
sumatriptan tab 50mg
Drug Name
2
2
2
MO
MO
MO
1
4
GC MO
MO
3
3
2
2
2
2
2
QL 9 MO
QL 9 MO
QL 10 MO
QL 4.5 MO
QL 9 MO
QL 9 MO
QL 9 MO
Antimycobacterials, Other
dapsone tab 100mg
dapsone tab 25mg
pyrazinamide tab 500mg
rifabutin cap 150mg
Antituberculars
CAPASTAT SUL INJ 1GM
ethambutol tab 100mg
ethambutol tab 400mg
isoniazid inj 100mg/ml
isoniazid syp 50mg/5ml
isoniazid tab 100mg
isoniazid tab 300mg
PASER GRANULES 4GM
PRIFTIN TAB 150MG
rifampin cap 150mg
rifampin cap 300mg
rifampin inj 600 mg
RIFATER TAB
SIRTURO TAB 100MG
TRECATOR TAB 250MG
MO
ANTINEOPLASTICS
Alkylating Agents
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
15
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
Drug Name
CYCLOPHOSPH CAP 25MG
CYCLOPHOSPH CAP 50MG
cyclophosph tab 25mg
cyclophosph tab 50mg
HEXALEN CAP 50MG
LEUKERAN TAB 2MG
lomustine cap 100mg
lomustine cap 10mg
lomustine cap 40mg
Antiangiogenic Agents
AVASTIN INJ 100MG/4ML
DEPEN TITRA TAB 250MG
REVLIMID CAP 10MG
REVLIMID CAP 15MG
REVLIMID CAP 2.5MG
REVLIMID CAP 20MG
REVLIMID CAP 25MG
REVLIMID CAP 5MG
SYPRINE CAP 250MG
THALOMID CAP 100MG
THALOMID CAP 150MG
THALOMID CAP 200MG
THALOMID CAP 50MG
Antimetabolites
ALIMTA INJ 500MG
azacitidine inj 100mg
DACOGEN INJ 50MG
decitabine inj 50mg
Tier
Notes
Drug Name
2
2
2
2
4
3
2
2
2
PA MO
PA MO
PA MO
PA MO
MO
MO
MO
MO
MO
fludarabine inj 50mg
gemcitabine inj 1gm
mercaptopurine tab 50mg
methotrexate inj 1gm
methotrexate inj 25mg/ml
methotrexate tab 2.5mg
PRIMAQUINE TAB 26.3MG
TABLOID TAB 40MG
Antineoplastics
ABRAXANE INJ 100MG
ACTIMMUNE INJ 2MU/0.5ML
AFINITOR DIS TAB 2MG
AFINITOR DIS TAB 3MG
AFINITOR DIS TAB 5MG
AFINITOR TAB 10MG
AFINITOR TAB 2.5MG
AFINITOR TAB 5MG
AFINITOR TAB 7.5MG
amifostine inj 500mg
ARRANON INJ 5MG/ML
ARZERRA CON 100/5ML
AZASAN TAB 100MG
AZASAN TAB 75 MG
bicalutamide tab 50mg
BICNU INJ 100MG
bleomycin inj 30unit
BOSULIF TAB 100MG
BOSULIF TAB 500MG
5
4
5
5
5
5
5
5
4
5
5
5
5
5
5
5
2
MO
LA
LA
LA
LA
MO
MO
Tier
Notes
2
5
2
1
2
2
4
4
MO
MO
PA GC MO
PA MO
PA MO
MO
MO
4
5
5
5
5
5
5
5
5
5
4
5
4
4
2
4
2
5
5
PA MO
LA
PA MO
PA
PA MO
PA MO
MO
PA MO
MO
PA
PA
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
16
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
Drug Name
BUSULFEX INJ 6MG/ML
CAPRELSA TAB 100MG
CAPRELSA TAB 300MG
carboplatin inj 150/15ml
cisplatin inj 100mg
cladribine inj 1mg/ml
CLOLAR INJ 1MG/ML
COMETRIQ KIT 100MG
COMETRIQ KIT 140MG
COMETRIQ KIT 60MG
COSMEGEN INJ 0.5MG
cytarabine inj 100mg/ml
cytarabine inj 20mg/ml
dacarbazine inj 200mg
daunorubicin inj 5mg/ml
DEPO-PROVERA INJ 400/ML
dexrazoxane inj 500mg
DOCEFREZ INJ 20MG
DOCEFREZ INJ 80MG
DOCETAXEL INJ 80MG/4ML
DOCETAXEL INJ 80MG/8ML
doxorubicin inj 50mg
ELIGARD INJ 22.5MG
ELIGARD INJ 30MG
ELIGARD INJ 45MG
ELIGARD INJ 7.5MG
ELITEK INJ 1.5MG
EMCYT CAP 140MG
Tier
Notes
Drug Name
4
5
5
2
2
2
4
5
5
5
4
2
2
2
2
4
5
5
5
5
5
2
4
4
4
4
5
4
PA MO
epirubicin inj 50/25ml
ERBITUX INJ 100MG
ERIVEDGE CAP 150MG
ERWINAZE INJ 10000UNT
ETOPOPHOS INJ 100MG
etoposide inj 20mg/ml
FARESTON TAB 60MG
FASLODEX INJ 250MG/5ML
FIRMAGON INJ 120MG
FIRMAGON INJ 80MG
fluorouracil inj 2.5g/50ml
fluorouracil sol 2%
fluorouracil sol 5%
flutamide cap 125mg
FOLOTYN INJ 40MG/2ML
FUSILEV INJ 50MG
GILOTRIF TAB 20MG
GILOTRIF TAB 30MG
GILOTRIF TAB 40MG
GLEEVEC TAB 100MG
GLEEVEC TAB 400MG
HALAVEN INJ 1MG/2ML
HERCEPTIN INJ 440MG
hydroxyurea cap 500mg
idarubicin inj 10/10ml
IFEX INJ 3GM
ifosfamide inj 1gm
IMBRUVICA CAP 140MG
PA MO
PA MO
PA MO
PA MO
PA MO
PA MO
PA MO
PA MO
PA MO
PA MO
PA
PA
PA MO
PA MO
PA MO
PA MO
PA MO
MO
Tier
Notes
2
5
5
4
4
2
4
5
5
4
2
2
2
2
4
5
5
5
5
5
5
5
5
2
2
4
2
5
PA MO
PA
PA MO
PA MO
PA MO
MO
MO
PA MO
MO
MO
MO
PA MO
PA
PA
PA
PA
MO
PA MO
PA MO
PA MO
PA
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
17
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
Drug Name
INLYTA TAB 1MG
INLYTA TAB 5MG
INTRON-A INJ 10MU
INTRON-A INJ 18MU
irinotecan inj 100/5ml
ISTODAX INJ 10MG
IXEMPRA KIT INJ 45MG
JAKAFI TAB 10MG
JAKAFI TAB 15MG
JAKAFI TAB 20MG
JAKAFI TAB 25MG
JAKAFI TAB 5MG
JEVTANA INJ 60/1.5ML
KADCYLA INJ 100MG
KEPIVANCE INJ 6.25MG
leucovorin ca inj 100mg
leucovorin ca inj 350mg
leucovorin ca tab 10mg
leucovorin ca tab 15mg
leucovorin ca tab 25mg
leucovorin ca tab 5mg
leuprolide inj 1mg/0.2ml
LUPRON DEPOT INJ 22.5MG
LUPRON DEPOT INJ 3.75MG
LUPRON DEPOT INJ 30MG
LUPRON DEPOT INJ 45MG
LUPRON DEPOT INJ 7.5MG
LYSODREN TAB 500MG
Tier
5
5
5
4
5
5
4
5
5
5
5
5
5
5
4
2
2
2
2
2
2
2
4
3
3
5
4
3
Notes
MO
PA
PA MO
PA
PA MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Drug Name
MATULANE CAP 50MG
MEGACE ES SUS 625/5ML
megestrol ace sus 40mg/ml
megestrol acetate tab 20mg
megestrol acetate tab 40mg
MEKINIST TAB 0.5MG
MEKINIST TAB 2MG
melphalan inj 50mg
mesna inj 1gm
MESNEX TAB 400MG
mitomycin inj 20mg
mitoxantrone inj 2mg/ml
MUSTARGEN INJ 10MG
NEXAVAR TAB 200MG
NILANDRON TAB 150MG
ONCASPAR INJ 750/ML
oxaliplatin inj 100mg
paclitaxel inj 300mg/50ml
PERJETA INJ 420/14ML
POMALYST CAP 1MG
POMALYST CAP 2MG
POMALYST CAP 3MG
POMALYST CAP 4MG
PROLEUKIN INJ 22MU
RHEUMATREX TAB 2.5MG
RITUXAN INJ 500MG
SPRYCEL TAB 100MG
SPRYCEL TAB 140MG
Tier
Notes
4
3
2
2
2
5
5
2
2
4
2
1
4
5
4
5
2
2
5
5
5
5
5
5
4
3
5
5
MO
PA MO
PA MO
PA MO
PA MO
LA
LA
PA MO
PA MO
MO
PA MO
GC MO
PA MO
LA
MO
PA
PA MO
PA MO
LA
LA
LA
LA
PA MO
MO
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
18
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
Drug Name
SPRYCEL TAB 20MG
SPRYCEL TAB 50MG
SPRYCEL TAB 70MG
SPRYCEL TAB 80MG
STIVARGA TAB 40MG
SUTENT CAP 12.5MG
SUTENT CAP 25MG
SUTENT CAP 50MG
SYLATRON KIT 296MCG
SYLATRON KIT 444MCG
SYLATRON KIT 888MCG
SYNRIBO INJ 3.5MG
TAFINLAR CAP 50MG
TAFINLAR CAP 75MG
tamoxifen tab 10mg
tamoxifen tab 20mg
TARCEVA TAB 100MG
TARCEVA TAB 150MG
TARCEVA TAB 25MG
TARGRETIN CAP 75MG
TASIGNA CAP 150MG
TASIGNA CAP 200MG
TAXOTERE INJ 80MG/4ML
toposar inj 1gm/50ml
topotecan inj 4mg
TORISEL SOL 25MG/ML
TREANDA INJ 100MG
TRELSTAR DEP INJ 3.75MG
Tier
5
5
5
5
5
5
5
5
5
5
5
5
5
5
1
1
5
5
5
5
5
5
4
2
2
4
5
5
Notes
PA
LA
LA
GC MO
GC MO
PA MO
PA MO
PA MO
PA MO
PA
Drug Name
Tier
TRELSTAR LA INJ 11.25MG
TRELSTAR MIX INJ 22.5MG
tretinoin cap 10mg
TRISENOX SOL 10MG/10ML
TYKERB TAB 250MG
UVADEX INJ 20MCG/ML
VECTIBIX INJ 100MG
VELCADE INJ 3.5MG
vinblastine inj 10mg
vincasar pfs inj 1mg/ml
vincristine inj 1mg/ml
vinorelbine inj 10mg/ml
VOTRIENT TAB 200MG
XALKORI CAP 200MG
XALKORI CAP 250MG
XTANDI CAP 40MG
YERVOY INJ 50MG/10ML
ZALTRAP INJ 100/4ML
ZELBORAF TAB 240MG
ZOLINZA CAP 100MG
ZYKADIA CAP 150MG
ZYTIGA TAB 250MG
Aromatase Inhibitors, 3rd Generation
anastrozole tab 1mg
exemestane tab 25mg
letrozole tab 2.5mg
5
5
1
4
5
4
4
5
2
2
2
2
5
5
5
5
5
5
5
5
5
5
Notes
GC MO
MO
2
2
2
PA MO
PA MO
PA MO
PA MO
PA MO
PA MO
PA
PA
PA
MO
MO
MO
ANTIPARASITICS
Anthelmintics
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
19
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
Drug Name
ALBENZA TAB 200MG
STROMECTOL TAB 3MG
Antiprotozoals
ALINIA SUS 100MG/5ML
ALINIA TAB 500MG
atovaq/progu tab 250-100mg
atovaquone sus 750/5ml
chloroquine tab 250mg
chloroquine tab 500mg
COARTEM TAB 20-120MG
DARAPRIM TAB 25MG
hydroxychlor tab 200mg
mefloquine tab 250mg
NEBUPENT INH 300MG
PENTAM 300 INJ 300MG
quinine sulf cap 324mg
Tier
Notes
4
3
MO
MO
4
4
2
5
1
1
4
4
2
2
3
4
2
MO
MO
MO
GC MO
GC MO
MO
MO
MO
MO
PA MO
MO
MO
2
2
2
1
1
1
2
MO
PA MO
PA MO
PA GC MO
PA GC MO
PA GC MO
PA MO
2
2
MO
MO
ANTIPARKINSON AGENTS
Anticholinergics
benztropine inj 1mg/ml
benztropine tab 0.5mg
benztropine tab 1mg
benztropine tab 2mg
trihexyphen elx 0.4mg/ml
trihexyphen tab 2mg
trihexyphen tab 5mg
Antiparkinson Agents, Other
amantadine cap 100mg
amantadine syp 50mg/5ml
Drug Name
Tier
Notes
amantadine tab 100mg
2
MO
entacapone tab 200mg
2
MO
Dopamine Agonists
APOKYN INJ
5
LA
bromocriptine cap 5mg
2
MO
bromocriptine tab 2.5mg
2
MO
NEUPRO DIS 1MG/24HR
4
MO
NEUPRO DIS 2MG/24HR
4
MO
NEUPRO DIS 3MG/24HR
4
MO
NEUPRO DIS 4MG/24HR
4
MO
NEUPRO DIS 6MG/24HR
4
MO
NEUPRO DIS 8MG/24HR
4
MO
pramipexole tab 0.125mg
2
MO
pramipexole tab 0.25mg
2
MO
pramipexole tab 0.5mg
2
MO
pramipexole tab 0.75mg
2
MO
pramipexole tab 1.5mg
2
MO
pramipexole tab 1mg
2
MO
ropinirole tab 0.25mg
2
MO
ropinirole tab 0.5mg
2
MO
ropinirole tab 1mg
2
MO
ropinirole tab 2mg
2
MO
ropinirole tab 3mg
2
MO
ropinirole tab 4mg
2
MO
ropinirole tab 5mg
2
MO
Dopamine Precursors/ L-Amino Acid Decarboxylase Inhibitors
carb/levo er tab 25-100mg
2
MO
carb/levo er tab 50-200mg
2
MO
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
20
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
Drug Name
Tier
carb/levo odt tab 10-100mg
carb/levo odt tab 25-100mg
carb/levo odt tab 25-250mg
carb/levo tab 10-100mg
carb/levo tab 25-100mg
carb/levo tab 25-250mg
carbidopa tab 25mg
Monoamine Oxidase B (MAO-B) Inhibitors
AZILECT TAB 0.5MG
AZILECT TAB 1MG
selegiline cap 5mg
selegiline tab 5mg
Notes
2
2
2
2
2
2
2
MO
MO
MO
MO
MO
MO
MO
4
4
2
2
MO
MO
MO
MO
1
2
2
2
2
2
2
2
2
1
1
2
1
2
PA GC MO
MO
PA MO
MO
MO
MO
MO
MO
MO
GC MO
GC MO
MO
GC MO
MO
ANTIPSYCHOTICS
1st Generation/Typical
chlorpromazine inj 25mg/ml
chlorpromazine tab 100mg
chlorpromazine tab 10mg
chlorpromazine tab 200mg
chlorpromazine tab 25mg
chlorpromazine tab 50mg
compro sup 25mg
fluphenaz de inj 25mg/ml
fluphenazine con 5mg/ml
fluphenazine elx 2.5mg/5ml
fluphenazine inj 2.5mg/ml
fluphenazine tab 10mg
fluphenazine tab 1mg
fluphenazine tab 2.5mg
Drug Name
fluphenazine tab 5mg
haloper dec inj 100mg/ml
haloper dec inj 50mg/ml
haloper lac inj 5mg/ml
haloperidol con 2mg/ml
haloperidol tab 0.5mg
haloperidol tab 10mg
haloperidol tab 1mg
haloperidol tab 20mg
haloperidol tab 2mg
haloperidol tab 5mg
loxapine cap 10mg
loxapine cap 25mg
loxapine cap 50mg
loxapine cap 5mg
ORAP TAB 1MG
ORAP TAB 2MG
perphen/amit tab 2-10mg
perphen/amit tab 2-25mg
perphen/amit tab 4-10mg
perphen/amit tab 4-25mg
perphen/amit tab 4-50mg
perphenazine tab 16mg
perphenazine tab 2mg
perphenazine tab 4mg
perphenazine tab 8mg
PROCHLORPERAZINE INJ 5MG/ML
prochlorperazine sup 25mg
Tier
Notes
2
2
2
2
2
1
2
1
2
1
1
2
2
2
2
4
4
2
2
1
1
1
2
2
2
2
2
2
MO
MO
MO
MO
MO
GC MO
MO
GC MO
MO
GC MO
GC MO
MO
MO
MO
MO
MO
MO
PA MO
PA MO
PA GC MO
PA GC MO
PA GC MO
MO
MO
MO
MO
MO
MO
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
21
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
Drug Name
prochlorperazine tab 10mg
prochlorperazine tab 5mg
thioridazine tab 100mg
thioridazine tab 10mg
thioridazine tab 25mg
thioridazine tab 50mg
thiothixene cap 10mg
thiothixene cap 1mg
thiothixene cap 2mg
thiothixene cap 5mg
trifluoperazine tab 10mg
trifluoperazine tab 1mg
trifluoperazine tab 2mg
trifluoperazine tab 5mg
2nd Generation/Atypical
ABILIFY DISC TAB 10MG
ABILIFY DISC TAB 15MG
ABILIFY INJ 9.75MG
ABILIFY MAIN INJ 300MG
ABILIFY SOL 1MG/ML
ABILIFY TAB 10MG
ABILIFY TAB 15MG
ABILIFY TAB 20MG
ABILIFY TAB 2MG
ABILIFY TAB 30MG
ABILIFY TAB 5MG
FANAPT PAK
FANAPT TAB 10MG
Tier
Notes
1
2
2
2
1
1
2
2
1
2
2
2
2
2
GC MO
MO
PA MO
PA MO
PA GC MO
PA GC MO
MO
MO
GC MO
MO
MO
MO
MO
MO
4
4
4
4
4
4
4
4
4
4
4
4
4
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Drug Name
FANAPT TAB 12MG
FANAPT TAB 1MG
FANAPT TAB 2MG
FANAPT TAB 4MG
FANAPT TAB 6MG
FANAPT TAB 8MG
GEODON INJ 20MG
INVEGA SUSTENNA INJ 117MG
INVEGA SUSTENNA INJ 156MG
INVEGA SUSTENNA INJ 234MG
INVEGA SUSTENNA INJ 39MG
INVEGA SUSTENNA INJ 78MG
INVEGA TAB 1.5MG
INVEGA TAB 3MG
INVEGA TAB 6MG
INVEGA TAB 9MG
LATUDA TAB 120MG
LATUDA TAB 20MG
LATUDA TAB 40MG
LATUDA TAB 60MG
LATUDA TAB 80MG
olanzapine inj 10mg
olanzapine tab 10mg
olanzapine tab 10mg odt
olanzapine tab 15mg
olanzapine tab 15mg odt
olanzapine tab 2.5mg
olanzapine tab 20mg
Tier
Notes
4
4
4
4
4
4
4
5
5
5
4
4
4
4
4
5
5
4
4
4
4
2
2
2
2
2
2
2
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
22
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
Drug Name
olanzapine tab 20mg odt
olanzapine tab 5mg
olanzapine tab 5mg odt
olanzapine tab 7.5mg
quetiapine tab 100mg
quetiapine tab 200mg
quetiapine tab 25mg
quetiapine tab 300mg
quetiapine tab 400mg
quetiapine tab 50mg
RISPERDAL INJ 12.5MG
RISPERDAL INJ 25MG
RISPERDAL INJ 37.5MG
RISPERDAL INJ 50MG
risperidone sol 1mg/ml
risperidone tab 0.25 odt
risperidone tab 0.25mg
risperidone tab 0.5mg
risperidone tab 0.5mg od
risperidone tab 1mg
risperidone tab 1mg odt
risperidone tab 2mg
risperidone tab 2mg odt
risperidone tab 3mg
risperidone tab 3mg odt
risperidone tab 4mg
risperidone tab 4mg odt
SAPHRIS SUB 10MG
Tier
Notes
2
2
2
2
2
2
2
2
2
2
4
4
5
5
2
2
2
2
2
2
2
2
2
2
2
2
2
4
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Drug Name
SAPHRIS SUB 5MG
SEROQUEL XR TAB 150MG
SEROQUEL XR TAB 200MG
SEROQUEL XR TAB 300MG
SEROQUEL XR TAB 400MG
SEROQUEL XR TAB 50MG
ziprasidone cap 20mg
ziprasidone cap 40mg
ziprasidone cap 60mg
ziprasidone cap 80mg
Treatment-Resistant
clozapine tab 100mg
clozapine tab 200mg
clozapine tab 25mg
clozapine tab 50mg
FAZACLO TAB 100MG
FAZACLO TAB 12.5MG
FAZACLO TAB 150MG
FAZACLO TAB 200MG
FAZACLO TAB 25MG
VERSACLOZ SUS 50MG/ML
Tier
Notes
4
3
3
3
3
3
2
2
2
2
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
2
2
2
2
4
4
4
4
4
4
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
2
2
5
5
MO
PA MO
ANTIVIRALS
Anti-cytomegalovirus (CMV) Agents
foscarnet inj 24mg/ml
ganciclovir inj 500mg
VALCYTE SOL 50MG/ML
VALCYTE TAB 450MG
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
23
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
Drug Name
Tier
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase
Inhibitors
ATRIPLA TAB
5
COMPLERA TAB
5
EDURANT TAB 25MG
5
INTELENCE TAB 100MG
5
INTELENCE TAB 200MG
5
INTELENCE TAB 25MG
4
NEVIRAPINE SUS 50MG/5ML
2
nevirapine tab 200mg
2
nevirapine tab 400mg er
4
RESCRIPTOR TAB 100 MG
3
RESCRIPTOR TAB 200MG
3
SUSTIVA CAP 200MG
3
SUSTIVA CAP 50MG
3
SUSTIVA TAB 600MG
3
VIRAMUNE XR TAB 100MG
4
Anti-HIV Agents, Nucleoside and Nucleotide Reverse
Transcriptase Inhibitors
abacav/lamiv tab /zidovud
5
abacavir tab 300mg
2
desloratadin tab 5mg odt
2
didanosine cap 125mg
2
didanosine cap 200mg
2
didanosine cap 250mg
2
didanosine cap 400mg
2
EMTRIVA CAP 200MG
4
EMTRIVA SOL 10MG/ML
3
Notes
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Drug Name
EPIVIR HBV SOL 5MG/ML
EPIVIR SOL 10MG/ML
EPZICOM TAB 600-300MG
lamivud/zido tab 150-300mg
lamivudine tab 100mg
lamivudine tab 150mg
lamivudine tab 300mg
RETROVIR INJ 10MG/ML
stavudine cap 15mg
stavudine cap 20mg
stavudine cap 30mg
stavudine cap 40mg
TRUVADA TAB 200-300MG
VIDEX SOL 2GM
VIREAD POW 40MG/GM
VIREAD TAB 150MG
VIREAD TAB 200MG
VIREAD TAB 250MG
VIREAD TAB 300MG
ZIAGEN SOL 20MG/ML
zidovudine cap 100mg
zidovudine syp 50mg/5ml
zidovudine tab 300mg
Anti-HIV Agents, Other
FUZEON KIT
ISENTRESS CHW 100MG
ISENTRESS CHW 25MG
ISENTRESS POW 100MG
Tier
Notes
3
4
5
2
2
2
2
4
2
2
2
2
5
3
5
5
5
5
5
4
2
2
2
MO
MO
5
5
3
4
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
24
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
Drug Name
ISENTRESS TAB 400MG
SELZENTRY TAB 150MG
SELZENTRY TAB 300MG
STRIBILD TAB
TIVICAY TAB 50MG
Anti-HIV Agents, Protease Inhibitors
APTIVUS CAP 250MG
APTIVUS SOL 100MG/ML
CRIXIVAN CAP 200MG
CRIXIVAN CAP 400MG
INVIRASE CAP 200MG
INVIRASE TAB 500MG
KALETRA SOL 400-100MG/5ML
KALETRA TAB 100-25MG
KALETRA TAB 200-50MG
LEXIVA SUS 50MG/ML
LEXIVA TAB 700MG
NORVIR CAP 100MG
NORVIR SOL 80MG/ML
NORVIR TAB 100MG
PREZISTA SUS 100MG/ML
PREZISTA TAB 150MG
PREZISTA TAB 600MG
PREZISTA TAB 75MG
PREZISTA TAB 800MG
REYATAZ CAP 150MG
REYATAZ CAP 200MG
REYATAZ CAP 300MG
Tier
Notes
5
5
5
5
5
5
5
3
3
4
5
5
4
5
4
5
4
3
4
4
3
5
4
5
5
5
5
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Drug Name
Tier
VIRACEPT TAB 250MG
VIRACEPT TAB 625MG
Anti-influenza Agents
RELENZA MIS DISKHALE
rimantadine tab 100mg
TAMIFLU CAP 30MG
TAMIFLU CAP 45MG
TAMIFLU CAP 75MG
TAMIFLU SUS 6MG/ML
VIRAZOLE INH 6GM
Antihepatitis Agents
adefov dipiv tab 10mg
BARACLUDE SOL 0.05MG/ML
BARACLUDE TAB 0.5MG
BARACLUDE TAB 1MG
INCIVEK TAB 375MG
OLYSIO CAP 150MG
PEG-INTRON KIT 120MCG
PEG-INTRON KIT 150MCG
PEG-INTRON KIT 80MCG
PEGASYS INJ 180MCG/ML
PEGASYS INJ PROCLICK
PEGASYS KIT 180MCG/0.5ML
ribapak pak 1000mg/day
ribapak pak 800mg/day
ribasphere cap 200mg
ribasphere tab 200mg
RIBASPHERE TAB 400MG
Notes
5
5
4
1
4
4
4
4
4
MO
GC MO
MO
MO
MO
MO
MO
5
4
5
5
5
5
4
4
4
5
5
5
5
5
2
2
2
MO
PA
PA
MO
MO
MO
MO
MO
MO
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
25
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
Drug Name
ribavirin cap 200mg
ribavirin tab 200mg
SOVALDI TAB 400MG
TYZEKA TAB 600MG
VICTRELIS CAP 200MG
Antiherpetic Agents
acyclovir cap 200mg
acyclovir sus 200mg/5ml
acyclovir tab 400mg
acyclovir tab 800mg
acyclovir/na inj 500mg
famciclovir tab 125mg
famciclovir tab 250mg
famciclovir tab 500mg
valacyclovir tab 1gm
valacyclovir tab 500mg
Tier
Notes
2
2
5
4
5
MO
MO
PA
MO
PA
1
2
2
2
1
2
2
2
2
2
GC MO
MO
MO
MO
GC MO
MO
MO
MO
MO
MO
1
2
2
1
2
1
1
1
2
2
GC MO
MO
MO
GC MO
MO
PA GC MO
PA GC MO
PA GC MO
PA MO
PA MO
ANXIOLYTICS
Anxiolytics, Other
buspirone tab 10mg
buspirone tab 15mg
buspirone tab 30mg
buspirone tab 5mg
buspirone tab 7.5mg
hydroxyz hcl inj 25mg/ml
hydroxyz hcl inj 50mg/ml
hydroxyz hcl syp 10mg/5ml
hydroxyz hcl tab 10mg
hydroxyz hcl tab 25mg
Drug Name
hydroxyz hcl tab 50mg
hydroxyz pam cap 100mg
hydroxyz pam cap 25mg
hydroxyz pam cap 50mg
meprobamate tab 200mg
meprobamate tab 400mg
Benzodiazepines
ALPRAZOLAM CON 1 MG/ML
alprazolam tab 0.25mg
alprazolam tab 0.25mg odt
alprazolam tab 0.5mg
alprazolam tab 0.5mg er
alprazolam tab 0.5mg od
alprazolam tab 1mg
alprazolam tab 1mg odt
alprazolam tab 2mg
alprazolam tab 2mg odt
alprazolam tab xr 1mg
alprazolam tab xr 2mg
alprazolam tab xr 3mg
chlordiazepoxide cap 10mg
chlordiazepoxide cap 25mg
chlordiazepoxide cap 5mg
cloraz dipot tab 15mg
cloraz dipot tab 3.75mg
cloraz dipot tab 7.5mg
DIAZEPAM CON 5MG/ML
DIAZEPAM SOL 1MG/ML
Tier
Notes
2
2
2
2
2
2
PA MO
PA MO
PA MO
PA MO
PA MO
PA MO
2
1
1
1
1
1
1
1
1
2
1
2
1
1
1
1
1
1
1
2
2
MO
GC MO
QL 720 GC MO
GC MO
QL 120 GC MO
QL 180 GC MO
GC MO
QL 360 GC MO
GC MO
MO
QL 120 GC MO
MO
QL 120 GC MO
QL 120 GC MO
QL 120 GC MO
QL 120 GC MO
QL 120 GC MO
QL 90 GC MO
QL 90 GC MO
QL 240 MO
QL 1200 MO
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
26
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
Drug Name
diazepam tab 10mg
diazepam tab 2mg
diazepam tab 5mg
lorazepam con 2mg/ml
lorazepam tab 0.5mg
lorazepam tab 1mg
lorazepam tab 2mg
oxazepam cap 10mg
oxazepam cap 15mg
oxazepam cap 30mg
Tier
Notes
1
1
1
1
1
1
1
1
1
1
QL 120 GC MO
QL 600 GC MO
QL 240 GC MO
GC MO
QL 120 GC MO
QL 90 GC MO
QL 60 GC MO
QL 120 GC MO
QL 120 GC MO
QL 120 GC MO
2
2
2
1
2
2
2
2
1
MO
MO
MO
GC MO
MO
MO
MO
MO
GC MO
2
2
2
3
3
MO
MO
MO
MO
MO
BIPOLAR AGENTS
Mood Stabilizers
carbamazepin cap 100mg er
carbamazepin chw 100mg
lithium carb cap 150mg
lithium carb cap 300mg
lithium carb cap 600mg
lithium carb tab 300mg
lithium carb tab 300mg er
lithium carb tab 450mg er
lithium citr sol 8meq/5ml
BLOOD GLUCOSE REGULATORS
Antidiabetic Agents
acarbose tab 100mg
acarbose tab 25mg
acarbose tab 50mg
ACTOPLUS MET TAB XR 15-1000
ACTOPLUS MET TAB XR 30-1000
Drug Name
ALCOHOL PREP PAD
AVANDAMET TAB 2-1000MG
AVANDAMET TAB 2-500MG
AVANDAMET TAB 4-1000MG
AVANDAMET TAB 4-500MG
AVANDARYL TAB 4-1MG
AVANDARYL TAB 4-2MG
AVANDARYL TAB 4-4MG
AVANDARYL TAB 8-2MG
AVANDARYL TAB 8-4MG
AVANDIA TAB 2MG
AVANDIA TAB 4MG
AVANDIA TAB 8MG
BYETTA INJ 10MCG
BYETTA INJ 5MCG
chlorpropam tab 100mg
chlorpropam tab 250mg
CYCLOSET TAB 0.8MG
GAUZE PADS & DRESSINGS 2 X 2
glimepiride tab 1mg
glimepiride tab 2mg
glimepiride tab 4mg
glip/met tab 2.5-250mg
glip/met tab 2.5-500mg
glip/met tab 5-500mg
glipizide er tab 10mg
glipizide er tab 2.5mg
glipizide er tab 5mg
Tier
Notes
1
4
4
4
4
4
4
4
3
3
4
4
4
4
4
2
2
4
1
1
1
1
2
2
2
2
2
2
GC MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA MO
PA MO
MO
GC MO
GC MO
GC MO
GC MO
MO
MO
MO
MO
MO
MO
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
27
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
Drug Name
glipizide tab 10mg
glipizide tab 5mg
GLUMETZA TAB 1000MG
GLUMETZA TAB 500MG
glyb/met tab 1.25-250mg
glyb/met tab 2.5-500mg
glyb/metform tab 5-500mg
glyburide mcr tab 1.5mg
glyburide mcr tab 3mg
glyburide mcr tab 6mg
glyburide tab 1.25mg
glyburide tab 2.5mg
glyburide tab 5mg
INSULIN PEN NEEDLE
INSULIN SAFETY NEEDLES
INSULIN SYRINGE U-100 0.3 ML
INSULIN SYRINGE U-100 1 ML
INSULIN SYRINGE U-100 1/2 ML
INVOKANA TAB 100MG
INVOKANA TAB 300MG
JANUMET TAB 50-1000MG
JANUMET TAB 50-500MG
JANUMET XR TAB 100-1000MG
JANUMET XR TAB 50-1000MG
JANUMET XR TAB 50-500MG
JANUVIA TAB 100MG
JANUVIA TAB 25MG
JANUVIA TAB 50MG
Tier
Notes
1
1
4
4
2
2
2
1
1
1
2
1
1
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
GC MO
GC MO
MO
MO
PA MO
PA MO
PA MO
PA GC MO
PA GC MO
PA GC MO
PA MO
PA GC MO
PA GC MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Drug Name
KAZANO TAB 12.5-1000MG
KAZANO TAB 12.5-500MG
KOMBIGLYZE TAB 2.5-1000MG
KOMBIGLYZE TAB 5-1000MG
KOMBIGLYZE TAB 5-500MG
metformin er tab 1000mg
metformin tab 1000mg
metformin tab 500mg
metformin tab 500mg er
metformin tab 750mg er
metformin tab 850mg
nateglinide tab 120mg
nateglinide tab 60mg
NESINA TAB 12.5MG
NESINA TAB 25MG
NESINA TAB 6.25MG
ONGLYZA TAB 2.5MG
ONGLYZA TAB 5MG
OSENI TAB 12.5-15
OSENI TAB 12.5-30
OSENI TAB 12.5-45
OSENI TAB 25-15MG
OSENI TAB 25-30MG
OSENI TAB 25-45MG
pioglit/glim tab 30-4mg
pioglita/met tab 15-500mg
pioglita/met tab 15-850mg
pioglitazone tab 15mg
Tier
Notes
4
4
3
3
3
2
1
1
1
2
1
2
2
4
4
4
4
4
4
4
4
4
4
4
2
2
2
2
MO
MO
MO
MO
MO
MO
GC MO
GC MO
GC MO
MO
GC MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
28
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
Drug Name
pioglitazone tab 30mg
pioglitazone tab 45mg
PRANDIMET TAB 1-500MG
PRANDIMET TAB 2-500MG
PRANDIN TAB 0.5MG
PRANDIN TAB 1MG
PRANDIN TAB 2MG
repaglinide tab 0.5mg
repaglinide tab 1mg
repaglinide tab 2mg
RIOMET SOL 500MG/5ML
SYMLINPEN 120 INJ 1000MCG
SYMLINPEN 60 INJ 1000MCG
tolazamide tab 250mg
tolazamide tab 500mg
tolbutamide tab 500mg
valsart/hctz tab 160-12.5
Glycemic Agents
GLUCAGEN INJ HYPOKIT
GLUCAGON KIT 1MG
PROGLYCEM SUS 50MG/ML
Insulins
APIDRA INJ SOLOSTAR
APIDRA INJ U-100
LANTUS INJ 100/ML
LANTUS INJ SOLOSTAR
LEVEMIR INJ
LEVEMIR INJ FLEXPEN
Tier
Notes
2
2
4
4
4
4
4
2
2
2
4
4
4
2
2
2
2
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
4
3
3
MO
MO
MO
3
3
3
3
3
3
MO
MO
MO
MO
MO
MO
Drug Name
NOVOLIN INJ 70/30
NOVOLIN N INJ U-100
NOVOLIN R INJ U-100
NOVOLOG INJ 100UNIT/ML
NOVOLOG INJ FLEXPEN
NOVOLOG MIX INJ 70/30
NOVOLOG MIX INJ FLEXPEN
Tier
Notes
3
3
3
3
3
3
3
MO
MO
MO
MO
MO
MO
MO
BLOOD PRODUCTS/MODIFIERS/ VOLUME
EXPANDERS
Anticoagulants
enoxaparin inj 100mg/ml
enoxaparin inj 120/0.8ml
enoxaparin inj 150mg/ml
enoxaparin inj 300/3ml
enoxaparin inj 30mg/0.3ml
enoxaparin inj 40mg/0.4ml
enoxaparin inj 60mg/0.6ml
enoxaparin inj 80mg/0.8ml
fondapar sol 10mg/0.8ml
fondapar sol 2.5mg/0.5ml
fondapar sol 5mg/0.4ml
fondapar sol 7.5mg/0.6ml
hep sod/d5w inj 20000unit
hep sod/nacl inj 100unt/ml
hep sod/nacl inj 2unit/ml
hep sod/nacl inj 50unt/ml
heparin sod inj 10000u/ml
heparin sod inj 1000u/ml
2
2
2
2
2
2
2
2
5
2
5
5
1
1
1
1
1
1
MO
MO
MO
MO
MO
MO
MO
MO
MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
29
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
Drug Name
heparin sod inj 20000u/ml
heparin sod inj 5000u/ml
jantoven tab 10mg
jantoven tab 1mg
jantoven tab 2.5mg
jantoven tab 2mg
jantoven tab 3mg
jantoven tab 4mg
jantoven tab 5mg
jantoven tab 6mg
jantoven tab 7.5mg
PRADAXA CAP 150MG
PRADAXA CAP 75MG
warfarin tab 10mg
warfarin tab 1mg
warfarin tab 2.5mg
warfarin tab 2mg
warfarin tab 3mg
warfarin tab 4mg
warfarin tab 5mg
warfarin tab 6mg
warfarin tab 7.5mg
XARELTO TAB 10MG
XARELTO TAB 15MG
XARELTO TAB 20MG
Blood Formation Modifiers
LEUKINE INJ 250MCG
MOZOBIL INJ 24MG/1.2ML
Tier
Notes
1
2
1
1
1
1
1
1
1
1
1
4
4
1
1
1
1
1
1
1
1
1
3
3
3
GC MO
MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
MO
MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
MO
MO
MO
5
5
Drug Name
Tier
NEUMEGA INJ 5MG
NEUPOGEN INJ 300MCG/0.5ML
NEUPOGEN INJ 480MCG/0.8ML
NEUPOGEN INJ 480MCG/1.6ML
PROCRIT INJ 10000/ML
PROCRIT INJ 2000/ML
PROCRIT INJ 20000/ML
PROCRIT INJ 3000/ML
PROCRIT INJ 4000/ML
PROCRIT INJ 40000/ML
PROMACTA TAB 12.5MG
PROMACTA TAB 25MG
PROMACTA TAB 50MG
PROMACTA TAB 75MG
tranex acid tab 650mg
tranexamic inj acid 100mg/ml
Platelet Modifying Agents
AGGRENOX CAP 25-200MG
anagrelide cap 0.5mg
BRILINTA TAB 90MG
cilostazol tab 100mg
cilostazol tab 50mg
clopidogrel tab 300mg
clopidogrel tab 75mg
dipyridamole tab 25mg
dipyridamole tab 50mg
dipyridamole tab 75mg
EFFIENT TAB 10MG
5
5
5
5
4
3
5
3
4
5
5
5
5
5
2
2
Notes
PA QL 12/28 MO
PA QL 23 MO
PA QL 12/28
PA QL 16 MO
PA QL 12/28 MO
PA QL 12
4
2
4
2
2
2
2
2
2
2
4
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA MO
PA MO
PA MO
MO
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
30
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
Drug Name
EFFIENT TAB 5MG
ticlopidine tab 250mg
Tier
Notes
Drug Name
4
2
MO
PA MO
1
1
2
1
1
1
2
2
2
GC MO
GC MO
MO
PA GC MO
PA GC MO
PA GC MO
MO
MO
MO
1
1
1
1
1
1
1
1
1
1
1
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
2
2
MO
MO
BENICAR TAB 20MG
3
BENICAR TAB 40MG
3
BENICAR TAB 5MG
3
candesartan tab 16mg
2
candesartan tab 32mg
2
candesartan tab 4mg
2
candesartan tab 8mg
2
EDARBI TAB 40MG
4
EDARBI TAB 80MG
4
eprosart mes tab 600mg
2
irbesartan tab 150mg
2
irbesartan tab 300mg
2
irbesartan tab 75mg
2
losartan pot tab 100mg
2
losartan pot tab 25mg
2
losartan pot tab 50mg
2
telmisartan tab 20mg
2
telmisartan tab 40mg
2
telmisartan tab 80mg
2
Angiotensin-converting Enzyme (ACE) Inhibitors
benazepril tab 10mg
1
benazepril tab 20mg
1
benazepril tab 40mg
1
benazepril tab 5mg
1
captopril tab 100mg
1
captopril tab 12.5mg
1
captopril tab 25mg
1
captopril tab 50mg
1
CARDIOVASCULAR AGENTS
Alpha-adrenergic Agonists
clonidine tab 0.1mg
clonidine tab 0.2mg
clonidine tab 0.3mg
methyldopa tab 250mg
methyldopa tab 500mg
methyldopate inj 250mg/5ml
midodrine tab 10mg
midodrine tab 2.5mg
midodrine tab 5mg
Alpha-adrenergic Blocking Agents
doxazosin tab 1mg
doxazosin tab 2mg
doxazosin tab 4mg
doxazosin tab 8mg
prazosin hcl cap 1mg
prazosin hcl cap 2mg
prazosin hcl cap 5mg
terazosin cap 10mg
terazosin cap 1mg
terazosin cap 2mg
terazosin cap 5mg
Angiotensin II Receptor Antagonists
ATACAND TAB 16MG
ATACAND TAB 32MG
Tier
Notes
MO
MO
MO
MO
MO
MO
MO
ST MO
ST MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
31
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
Drug Name
enalapril tab 10mg
enalapril tab 2.5mg
enalapril tab 20mg
enalapril tab 5mg
fosinopril tab 10mg
fosinopril tab 20mg
fosinopril tab 40mg
lisinopril tab 10mg
lisinopril tab 2.5mg
lisinopril tab 20mg
lisinopril tab 30mg
lisinopril tab 40mg
lisinopril tab 5mg
moexipril tab 15mg
moexipril tab 7.5mg
perindopril tab 2mg
perindopril tab 4mg
perindopril tab 8mg
quinapril tab 10mg
quinapril tab 20mg
quinapril tab 40mg
quinapril tab 5mg
ramipril cap 1.25mg
ramipril cap 10mg
ramipril cap 2.5mg
ramipril cap 5mg
trandolapril tab 1mg
trandolapril tab 2mg
Tier
Notes
1
1
1
1
2
2
2
1
1
1
2
2
1
2
2
2
2
2
2
2
2
2
2
2
2
2
1
2
GC MO
GC MO
GC MO
GC MO
MO
MO
MO
GC MO
GC MO
GC MO
MO
MO
GC MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
GC MO
MO
Drug Name
trandolapril tab 4mg
Antiarrhythmics
amiodarone inj 50mg/ml
amiodarone tab 200mg
amiodarone tab 400mg
disopyramide cap 100mg
disopyramide cap 150mg
flecainide tab 100mg
flecainide tab 150mg
flecainide tab 50mg
mexiletine cap 150mg
mexiletine cap 200mg
mexiletine cap 250mg
MULTAQ TAB 400MG
pacerone tab 100mg
pacerone tab 200mg
procainamide inj 100mg/ml
propafenone tab 150mg
propafenone tab 225mg
propafenone tab 300mg
quinidine gl tab 324mg er
quinidine su tab 200mg
quinidine su tab 300mg
quinidine su tab 300mg er
TIKOSYN CAP 125MCG
TIKOSYN CAP 250MCG
TIKOSYN CAP 500MCG
Antihypertensive Combinations
Tier
Notes
2
MO
1
2
2
2
2
2
2
2
2
2
2
4
2
2
1
2
2
2
2
1
1
2
4
4
4
GC MO
MO
MO
PA MO
PA MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
GC MO
MO
MO
MO
MO
GC MO
GC MO
MO
MO
MO
MO
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
32
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
Drug Name
amiloride/hctz tab 5-50mg
amlod/benazp cap 10-20mg
amlod/benazp cap 10-40mg
amlod/benazp cap 2.5-10mg
amlod/benazp cap 5-10mg
amlod/benazp cap 5-20mg
amlod/benazp cap 5-40mg
AMTURNIDE TAB 150-5-12.5MG
AMTURNIDE TAB 300-10-12.5MG
AMTURNIDE TAB 300-10-25MG
AMTURNIDE TAB 300-5-12.5MG
AMTURNIDE TAB 300-5-25MG
atenol/chlor tab 100-25mg
atenol/chlor tab 50-25mg
AZOR TAB 10-20MG
AZOR TAB 10-40MG
AZOR TAB 5-20MG
AZOR TAB 5-40MG
benazep/hctz tab 10-12.5mg
benazep/hctz tab 20-12.5mg
benazep/hctz tab 20-25mg
benazep/hctz tab 5-6.25mg
BENICAR HCT TAB 20-12.5MG
BENICAR HCT TAB 40-12.5MG
BENICAR HCT TAB 40-25MG
bisoprl/hctz tab 10/6.25mg
bisoprl/hctz tab 2.5/6.25mg
bisoprl/hctz tab 5-6.25mg
Tier
Notes
1
2
2
2
2
2
2
4
4
4
4
4
1
1
4
4
4
4
2
2
2
1
3
3
3
1
1
1
GC MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
GC MO
GC MO
MO
MO
MO
MO
MO
MO
MO
GC MO
MO
MO
MO
GC MO
GC MO
GC MO
Drug Name
candesa/hctz tab 16-12.5
candesa/hctz tab 32-12.5
candesa/hctz tab 32-25mg
captopr/hctz tab 25-15mg
captopr/hctz tab 25-25mg
captopr/hctz tab 50-15mg
captopr/hctz tab 50-25mg
EDARBYCLOR TAB 40-12.5MG
EDARBYCLOR TAB 40-25MG
enalapr/hctz tab 10-25mg
enalapr/hctz tab 5-12.5mg
EXFOR/HCT TAB 10-160-12.5MG
EXFOR/HCT TAB 10-160-25MG
EXFOR/HCT TAB 10-320-25MG
EXFOR/HCT TAB 5-160-12.5MG
EXFOR/HCT TAB 5-160-25MG
EXFORGE TAB 10-160MG
EXFORGE TAB 10-320MG
EXFORGE TAB 5-160MG
EXFORGE TAB 5-320MG
fosinop/hctz tab 10/12.5mg
fosinop/hctz tab 20/12.5mg
lisinop/hctz tab 10-12.5mg
lisinop/hctz tab 20-12.5mg
lisinop/hctz tab 20-25mg
losartan/hct tab 100-12.5mg
losartan/hct tab 100-25mg
losartan/hct tab 50-12.5mg
Tier
Notes
2
2
2
1
1
1
1
4
4
2
1
4
4
4
4
4
4
4
4
4
1
2
1
1
1
2
2
2
MO
MO
MO
GC MO
GC MO
GC MO
GC MO
ST MO
ST MO
MO
GC MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
GC MO
MO
GC MO
GC MO
GC MO
MO
MO
MO
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
33
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
Drug Name
methyld/hctz tab 250/15mg
methyld/hctz tab 250/25mg
metoprl/hctz tab 100-25mg
metoprl/hctz tab 100-50mg
metoprl/hctz tab 50-25mg
moexipr/hctz tab 15-12.5mg
moexipr/hctz tab 15-25mg
moexipr/hctz tab 7.5-12.5mg
nadolol/bend tab 40-5mg
nadolol/bend tab 80-5mg
pioglit/glim tab 30-2mg
propran/hctz tab 40/25mg
propran/hctz tab 80/25mg
qnapril/hctz tab 10-12.5mg
qnapril/hctz tab 20-12.5mg
qnapril/hctz tab 20-25mg
spirono/hctz tab 25/25mg
TARKA TAB 1-240MG CR
TARKA TAB 2-180MG CR
TARKA TAB 2-240MG CR
TARKA TAB 4-240MG CR
TEKAMLO TAB 150-10MG
TEKAMLO TAB 150-5MG
TEKAMLO TAB 300-10MG
TEKAMLO TAB 300-5MG
TEKTURNA HCT TAB 150-12.5MG
TEKTURNA HCT TAB 150-25MG
TEKTURNA HCT TAB 300-12.5MG
Tier
Notes
1
1
2
1
2
2
2
1
2
2
2
1
2
2
2
2
2
4
4
4
4
4
4
4
4
3
3
3
PA GC MO
PA GC MO
MO
GC MO
MO
MO
MO
GC MO
MO
MO
MO
GC MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Drug Name
TEKTURNA HCT TAB 300-25MG
telmis/amlod tab 40-10mg
telmis/amlod tab 40-5mg
telmis/amlod tab 80-10mg
telmis/amlod tab 80-5mg
telmisa/hctz tab 40-12.5
telmisa/hctz tab 80-12.5
telmisa/hctz tab 80-25mg
TEVETEN HCT TAB 600-12.5MG
TEVETEN HCT TAB 600-25MG
triamt/hctz cap 50-25mg
triamt/hctz tab 37.5-25mg
triamt/hctz tab 75-50mg
TRIBENZOR TAB 20-5-12.5MG
TRIBENZOR TAB 40-10-12.5MG
TRIBENZOR TAB 40-10-25MG
TRIBENZOR TAB 40-5-12.5MG
TRIBENZOR TAB 40-5-25MG
valsart/hctz tab 160-25mg
valsart/hctz tab 320-12.5
valsart/hctz tab 320-25mg
valsart/hctz tab 80-12.5
Beta-adrenergic Blocking Agents
acebutolol cap 200mg
acebutolol cap 400mg
atenolol tab 100mg
atenolol tab 25mg
atenolol tab 50mg
Tier
Notes
3
2
2
2
2
2
2
2
4
4
1
1
1
4
4
4
4
4
2
2
2
2
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
GC MO
GC MO
GC MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
2
2
1
1
1
MO
MO
GC MO
GC MO
GC MO
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
34
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
Drug Name
betaxolol tab 10mg
betaxolol tab 20mg
bisoprolol fum tab 10mg
bisoprolol fum tab 5mg
carvedilol tab 12.5mg
carvedilol tab 25mg
carvedilol tab 3.125mg
carvedilol tab 6.25mg
labetalol inj 5mg/ml
labetalol tab 100mg
labetalol tab 200mg
labetalol tab 300mg
metoprolol inj 1mg/ml
metoprolol tab 100mg er
metoprolol tab 200mg er
metoprolol tab 25mg er
metoprolol tab 50mg er
metoprolol tar tab 100mg
metoprolol tar tab 25mg
metoprolol tar tab 50mg
nadolol tab 20mg
nadolol tab 40mg
nadolol tab 80mg
pindolol tab 10mg
pindolol tab 5mg
propranolol cap 120mg er
propranolol cap 160mg er
propranolol cap 60mg er
Tier
Notes
1
1
2
2
1
1
1
1
1
2
2
2
1
2
2
2
2
1
1
1
1
1
2
1
1
2
2
2
GC MO
GC MO
MO
MO
GC MO
GC MO
GC MO
GC MO
GC MO
MO
MO
MO
GC MO
MO
MO
MO
MO
GC MO
GC MO
GC MO
GC MO
GC MO
MO
GC MO
GC MO
MO
MO
MO
Drug Name
propranolol cap 80mg er
propranolol inj 1mg/ml
propranolol sol 20mg/5ml
propranolol sol 40mg/5ml
propranolol tab 10mg
propranolol tab 20mg
propranolol tab 40mg
propranolol tab 60mg
propranolol tab 80mg
sorine tab 120mg
sorine tab 160mg
sorine tab 240mg
sorine tab 80mg
sotalol hcl tab 120mg
sotalol hcl tab 160mg
sotalol hcl tab 240mg
sotalol hcl tab 80mg
timolol mal tab 10mg
timolol mal tab 20mg
timolol mal tab 5mg
Calcium Channel Blocking Agents
afeditab tab 30mg cr
afeditab tab 60mg cr
amlodipine tab 10mg
amlodipine tab 2.5mg
amlodipine tab 5mg
cartia xt cap 120/24hr
cartia xt cap 180/24hr
Tier
Notes
2
1
1
1
1
1
1
2
1
2
2
2
1
2
2
2
1
2
1
1
MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
MO
GC MO
MO
MO
MO
GC MO
MO
MO
MO
GC MO
MO
GC MO
GC MO
2
2
2
2
2
2
2
MO
MO
MO
MO
MO
MO
MO
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
35
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
Drug Name
cartia xt cap 240/24hr
cartia xt cap 300/24hr
dilt-cd cap 120mg
dilt-xr cap 180mg
dilt-xr cap 240mg
diltiazem cap 120mg cd
diltiazem cap 120mg er
diltiazem cap 180mg/24hr
diltiazem cap 240mg cd
diltiazem cap 300mg cd
diltiazem cap 360mg/24hr
diltiazem cap 420mg/24
diltiazem cap 60mg er
diltiazem cap 90mg er
diltiazem inj 100mg
diltiazem inj 50mg/10ml
diltiazem tab 120mg
diltiazem tab 30mg
diltiazem tab 60mg
diltiazem tab 90mg
felodipine tab 10mg er
felodipine tab 2.5mg er
felodipine tab 5mg er
isradipine cap 2.5mg
isradipine cap 5mg
nicardipine cap 20mg
nicardipine cap 30mg
nifedical xl tab 30mg
Tier
Notes
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
1
1
1
1
1
2
2
2
1
1
2
1
2
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
MO
MO
MO
GC MO
GC MO
MO
GC MO
MO
Drug Name
nifedical xl tab 60mg
nifedipine cap 10mg
nifedipine cap 20mg
nifedipine tab 30mg er
nifedipine tab 60mg er
nifedipine tab 90mg er
nimodipine cap 30mg
nisoldipine tab 20mg
nisoldipine tab 30mg
nisoldipine tab 40mg
taztia xt cap 120mg/24hr
taztia xt cap 180mg/24hr
taztia xt cap 240mg/24hr
taztia xt cap 300mg/24hr
taztia xt cap 360mg/24hr
verapamil cap 100mg er
verapamil cap 120mg er
verapamil cap 180mg er
verapamil cap 200mg er
verapamil cap 240mg er
verapamil cap 300mg er
verapamil cap 360mg sr
verapamil inj 2.5mg/ml
verapamil tab 120mg
verapamil tab 120mg er
verapamil tab 180mg er
verapamil tab 240mg er
verapamil tab 40mg
Tier
Notes
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
1
2
2
2
2
MO
PA MO
PA MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
GC MO
GC MO
MO
MO
MO
MO
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
36
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
Drug Name
verapamil tab 80mg
Cardiovascular Agents, Other
digoxin inj 0.25mg/ml
digoxin sol 50mcg/ml
digoxin tab 0.125mg
digoxin tab 0.25mg
pentoxifylline tab 400mg er
RANEXA TAB 1000MG
RANEXA TAB 500MG
reserpine tab 0.1mg
TEKTURNA TAB 150MG
TEKTURNA TAB 300MG
Diuretics, Carbonic Anhydrase Inhibitors
acetazolamide cap 500mg er
acetazolamide tab 125mg
acetazolamide tab 250mg
methazolamide tab 25mg
methazolamide tab 50mg
Diuretics, Loop
bumetanide inj 0.25mg/ml
bumetanide tab 0.5mg
bumetanide tab 1mg
bumetanide tab 2mg
furosemide inj 10mg/ml
furosemide sol 10mg/ml
furosemide sol 8mg/ml
furosemide tab 20mg
furosemide tab 40mg
Tier
Notes
1
GC MO
1
1
1
1
2
3
3
1
3
3
PA GC MO
PA GC MO
GC MO
PA GC MO
MO
MO
MO
PA GC MO
MO
MO
2
2
2
2
2
MO
MO
MO
MO
MO
1
1
1
2
2
2
1
1
1
GC MO
GC MO
GC MO
MO
MO
MO
GC MO
GC MO
GC MO
Drug Name
furosemide tab 80mg
torsemide tab 100mg
torsemide tab 10mg
torsemide tab 20mg
torsemide tab 5mg
Diuretics, Potassium-sparing
amiloride tab 5mg
DEMSER CAP 250MG
DYRENIUM CAP 100MG
DYRENIUM CAP 50MG
eplerenone tab 25mg
eplerenone tab 50mg
spironolactone tab 100mg
spironolactone tab 25mg
spironolactone tab 50mg
Diuretics, Thiazide
chlorothiazide tab 250mg
chlorothiazide tab 500mg
chlorthalidone tab 25mg
CHLORTHALIDONE TAB 50MG
hydrochlorot cap 12.5mg
hydrochlorot tab 12.5mg
hydrochlorot tab 25mg
hydrochlorot tab 50mg
indapamide tab 1.25mg
indapamide tab 2.5mg
methyclothiazide tab 5mg
metolazone tab 10mg
Tier
Notes
1
2
2
2
2
GC MO
MO
MO
MO
MO
1
4
4
4
2
2
2
1
2
GC MO
MO
MO
MO
MO
MO
MO
GC MO
MO
2
2
1
1
1
1
1
1
1
1
1
2
MO
MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
MO
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
37
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
Drug Name
Tier
metolazone tab 2.5mg
2
metolazone tab 5mg
2
Dyslipidemics, Fibric Acid Derivatives
fenofibrate cap 134mg
2
fenofibrate cap 150mg
2
fenofibrate cap 200mg
2
fenofibrate cap 50mg
2
fenofibrate cap 67mg
2
fenofibrate tab 145mg
2
fenofibrate tab 160mg
2
fenofibrate tab 48mg
2
fenofibrate tab 54mg
2
gemfibrozil tab 600mg
2
Dyslipidemics, HMG CoA Reductase Inhibitors
ADVICOR TAB 1000-20MG
4
ADVICOR TAB 1000-40MG
4
ADVICOR TAB 500-20MG
4
ADVICOR TAB 750-20MG
4
ALTOPREV TAB 20MG ER
4
ALTOPREV TAB 40MG ER
4
ALTOPREV TAB 60MG ER
4
amlod/atorva tab 10-10mg
2
amlod/atorva tab 10-20mg
2
amlod/atorva tab 10-40mg
2
amlod/atorva tab 10-80mg
2
amlod/atorva tab 2.5-10mg
2
amlod/atorva tab 2.5-20mg
2
amlod/atorva tab 2.5-40mg
2
Notes
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Drug Name
amlod/atorva tab 5-10mg
amlod/atorva tab 5-20mg
amlod/atorva tab 5-40mg
amlod/atorva tab 5-80mg
atorvastatin tab 10mg
atorvastatin tab 20mg
atorvastatin tab 40mg
atorvastatin tab 80mg
CRESTOR TAB 10MG
CRESTOR TAB 20MG
CRESTOR TAB 40MG
CRESTOR TAB 5MG
fluvastatin cap 20mg
fluvastatin cap 40mg
LESCOL XL TAB 80MG
LIVALO TAB 1MG
LIVALO TAB 2MG
LIVALO TAB 4MG
lovastatin tab 10mg
lovastatin tab 20mg
lovastatin tab 40mg
pravastatin tab 10mg
pravastatin tab 20mg
pravastatin tab 40mg
pravastatin tab 80mg
simvastatin tab 10mg
simvastatin tab 20mg
simvastatin tab 40mg
Tier
Notes
2
2
2
2
2
2
2
2
3
3
3
3
2
2
4
4
4
4
2
2
2
1
1
1
2
2
2
2
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
GC MO
GC MO
GC MO
MO
MO
MO
MO
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
38
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
Drug Name
simvastatin tab 5mg
simvastatin tab 80mg
Dyslipidemics, Other
cholestyram pow 4gm lite
colestipol granules 5gm
colestipol tab 1gm
JUXTAPID CAP 10MG
JUXTAPID CAP 20MG
JUXTAPID CAP 5MG
KYNAMRO INJ 200MG/ML
niacin er tab 1000mg
niacin er tab 500mg
niacin er tab 750mg
NIACOR TAB 500MG
omega-3-acid cap 1gm
prevalite pow 4gm
VYTORIN TAB 10-10MG
VYTORIN TAB 10-20MG
VYTORIN TAB 10-40MG
VYTORIN TAB 10-80MG
WELCHOL PAK 3.75GM
WELCHOL TAB 625MG
ZETIA TAB 10MG
Vasodilators, Direct-acting Arterial
hydralazine inj 20mg/ml
hydralazine tab 100mg
hydralazine tab 10mg
hydralazine tab 25mg
Tier
Notes
2
2
MO
MO
2
1
2
5
5
5
5
2
2
2
1
2
2
4
4
4
4
3
3
4
MO
GC MO
MO
1
2
1
1
GC MO
MO
GC MO
GC MO
MO
MO
MO
GC MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Drug Name
Tier
hydralazine tab 50mg
minoxidil tab 10mg
minoxidil tab 2.5mg
Vasodilators, Direct-acting Arterial/Venous
isosorb din tab 40mg er
isosorb din tab 5mg
isosorb mono tab 10mg
isosorb mono tab 120mg er
isosorb mono tab 20mg
isosorb mono tab 30mg er
isosorb mono tab 60mg er
isosorbide din tab 10mg
isosorbide din tab 20mg
isosorbide din tab 30mg
minitran dis 0.1mg/hr
minitran dis 0.2mg/hr
minitran dis 0.4mg/hr
minitran dis 0.6mg/hr
nitroglyceri dis 0.6mg/hr
nitroglycerin dis 0.1mg/hr
nitroglycerin dis 0.2mg/hr
nitroglycerin dis 0.4mg/hr
nitroglycerin inj 5mg/ml
nitroglycrn spr 0.4mg
NITROSTAT SUBLINGUAL 0.3MG
NITROSTAT SUBLINGUAL 0.4MG
NITROSTAT SUBLINGUAL 0.6MG
Notes
2
2
2
MO
MO
MO
2
2
2
2
2
1
1
2
2
2
2
2
2
2
2
2
2
2
1
2
4
4
4
MO
MO
MO
MO
MO
GC MO
GC MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
GC MO
MO
MO
MO
MO
CENTRAL NERVOUS SYSTEM AGENTS
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
39
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
Drug Name
Tier
Notes
Attention Deficit Hyperactivity Disorder Agents, Amphetamines
amphetamine tab 10mg
2
MO
amphetamine tab 12.5mg
1
GC MO
amphetamine tab 15mg
2
MO
amphetamine tab 20mg
2
MO
amphetamine tab 30mg
2
MO
amphetamine tab 5mg
2
MO
amphetamine tab 7.5mg
2
MO
dextroamphet cap 10mg er
2
MO
dextroamphet cap 15mg er
2
MO
dextroamphet cap 5mg er
2
MO
dextroamphet tab 10mg
2
MO
dextroamphet tab 5mg
2
MO
Attention Deficit Hyperactivity Disorder Agents, Nonamphetamines
INTUNIV TAB 1MG
4
PA MO
INTUNIV TAB 2MG
4
PA MO
INTUNIV TAB 3MG
4
PA MO
INTUNIV TAB 4MG
4
PA MO
metadate tab 20mg er
2
MO
methylin chw 10mg
1
GC MO
methylin chw 2.5mg
1
GC MO
methylin chw 5mg
1
GC MO
methylphenidate cap 10mg
1
GC MO
methylphenidate sol 10mg/5ml
1
GC MO
methylphenidate sol 5mg/5ml
1
GC MO
methylphenidate tab 10mg
1
GC MO
methylphenidate tab 20mg
2
MO
Drug Name
methylphenidate tab 20mg er
methylphenidate tab 27mg er
methylphenidate tab 5mg
STRATTERA CAP 100MG
STRATTERA CAP 10MG
STRATTERA CAP 18MG
STRATTERA CAP 25MG
STRATTERA CAP 40MG
STRATTERA CAP 60MG
STRATTERA CAP 80MG
Central Nervous System, Other
acampro cal tab 333mg
NUEDEXTA CAP 20-10MG
riluzole tab 50mg
XENAZINE TAB 12.5MG
XENAZINE TAB 25MG
Fibromyalgia Agents
LYRICA CAP 100MG
LYRICA CAP 150MG
SAVELLA MIS TITR PAK
SAVELLA TAB 100MG
SAVELLA TAB 12.5MG
SAVELLA TAB 25MG
SAVELLA TAB 50MG
Multiple Sclerosis Agents
AMPYRA TAB 10MG
AUBAGIO TAB 14MG
AUBAGIO TAB 7MG
Tier
Notes
2
2
1
3
3
3
3
3
3
3
MO
PA MO
GC MO
MO
MO
MO
MO
MO
MO
MO
2
3
5
5
5
MO
MO
4
4
3
3
3
3
3
MO
MO
MO
MO
MO
MO
MO
5
5
5
ST
ST
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
40
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
Drug Name
BETASERON INJ 0.3MG
COPAXONE INJ 40MG/ML
COPAXONE KIT 20MG/ML
EXTAVIA INJ 0.3MG
GILENYA CAP 0.5MG
REBIF INJ 22MG/0.5ML
REBIF INJ 44MG/0.5ML
REBIF TITRTN SOL PACK
SOLTAMOX SOL 10MG/5ML
TYSABRI INJ 300MG/15ML
Tier
5
5
5
5
5
5
5
5
4
5
Notes
MO
DENTAL AND ORAL AGENTS
Dental and Oral Agents
chlorhex glu sol 0.12%
nystatin sus 100000u/ml
periogard sol 0.12%
pilocarpine tab 5mg
pilocarpine tab 7.5mg
triamcin/ora pst 0.1%
1
2
1
2
2
2
GC MO
MO
GC MO
MO
MO
MO
4
2
2
2
2
1
2
2
MO
MO
MO
MO
MO
GC MO
MO
MO
DERMATOLOGICAL AGENTS
Dermatological Agents
8-MOP CAP 10MG
acitretin cap 10mg
acitretin cap 17.5mg
acitretin cap 25mg
adapalene gel 0.3%
ala cort cre 1%
amcinonide cre 0.1%
amcinonide lot 0.1%
Drug Name
amcinonide oin 0.1%
ammonium lac lot 12%
amnesteem cap 10mg
amnesteem cap 20mg
amnesteem cap 40mg
aug betamet lot 0.05%
betameth dip cre 0.05%
betameth dip oin 0.05%
betameth val cre 0.1%
betameth val lot 0.1%
betameth val oin 0.1%
calcipotrien oin betameth
calcipotriene sol 0.005%
ciclopirox cre 0.77%
ciclopirox gel 0.77%
ciclopirox sol 8%
ciclopirox sus 0.77%
claravis cap 10mg
claravis cap 20mg
claravis cap 30mg
claravis cap 40mg
CLINDACIN KIT PAC 1%
clindamy/ben gel 1-5%
clindamycin gel 1%
clindamycin lot 1%
clindamycin pad 1%
clindamycin sol 1%
clobetasol e cre 0.05%
Tier
Notes
1
2
2
2
2
2
1
2
1
2
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
GC MO
MO
MO
MO
MO
MO
GC MO
MO
GC MO
MO
GC MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
41
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
Drug Name
clobetasol gel 0.05%
clobetasol oin 0.05%
clobetasol sol 0.05%
clotrim/beta cre diprop
clotrim/beta lot diprop
clotrimazole cre 1%
clotrimazole sol 1%
CONDYLOX GEL 0.5%
desonide cre 0.05%
desonide lot 0.05%
desonide oin 0.05%
desoximetasone cre 0.05%
desoximetasone cre 0.25%
desoximetasone gel 0.05%
desoximetasone oin 0.25%
diclofenac gel 3%
diflorasone cre 0.05%
diflorasone oin 0.05%
econazole cre 1%
ELIDEL CRE 1%
erythro gel/benzoyl 5-3%
erythromycin gel 2%
erythromycin sol 2%
EURAX CRE 10%
fluocinolone acet cre 0.01%
fluocinolone acet cre 0.025%
fluocinolone acet oil body
fluocinolone acet oin 0.025%
Tier
Notes
2
2
2
2
2
1
1
4
2
2
2
2
2
2
2
2
2
2
2
4
2
2
2
4
1
2
2
2
MO
MO
MO
MO
MO
GC MO
GC MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
GC MO
MO
MO
MO
Drug Name
fluocinolone acet sol 0.01%
fluocinonide cre -e 0.05%
fluocinonide gel 0.05%
fluocinonide oin 0.05%
fluocinonide sol 0.05%
fluorouracil cre 5%
fluticasone cre 0.05%
fluticasone oin 0.005%
gentamicin cre 0.1%
gentamicin oin 0.1%
halobetasol cre 0.05%
halobetasol oin 0.05%
hc valerate cre 0.2%
hc valerate oin 0.2%
hydrocortisone cre 1%
hydrocortisone cre 2.5%
hydrocortisone lot 2.5%
hydrocortisone oin 1%
hydrocortisone oin 2.5%
imiquimod cre 5%
ketoconazole cre 2%
ketoconazole sha 2%
lidocaine gel 2% jelly
lidocaine oin 5%
lidocaine sol 4%
LIDODERM DIS 5%
lindane lot 1%
lindane sha 1%
Tier
Notes
1
2
2
2
2
2
2
2
1
1
2
2
2
2
1
1
2
1
2
2
2
2
2
2
2
4
2
2
GC MO
MO
MO
MO
MO
MO
MO
MO
GC MO
GC MO
MO
MO
MO
MO
GC MO
GC MO
MO
GC MO
MO
MO
MO
MO
MO
MO
MO
PA QL 90 MO
MO
MO
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
42
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
Drug Name
lokara lot 0.05%
methoxsalen cap 10mg
metronidazol cre 0.75%
metronidazol gel 0.75%
metronidazol lot 0.75%
mometasone cre 0.1%
mometasone oin 0.1%
mupirocin oin 2%
NAFTIN CRE 2%
nyamyc pow 100000
nystat/triam cre
nystat/triam oin
nystatin cre 100000u/gm
nystatin oin 100000u/gm
nystatin pow 100000
nystop pow 100000
PANRETIN GEL 0.1%
pedi-dri pow 100000
permethrin cre 5%
PICATO GEL 0.015%
PICATO GEL 0.05%
podofilox sol 0.5%
prednicarbate cre 0.1%
prednicarbate oin 0.1%
procto-pak cre 1%
proctozone cre -hc 2.5%
REGRANEX GEL 0.01%
SANTYL OIN 250/GM
Tier
Notes
Drug Name
2
2
2
2
2
2
2
2
4
2
1
1
1
1
2
2
4
2
2
5
5
1
1
1
2
2
5
3
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
GC MO
GC MO
GC MO
GC MO
MO
MO
MO
MO
MO
selenium sul lot 2.5%
silver sulfa cre 1%
SOLARAZE GEL 3% W/W
ssd cre 1%
sulfacetamide sus 10%
TARGRETIN GEL 1%
TAZORAC CRE 0.05%
TAZORAC CRE 0.1%
TAZORAC GEL 0.05%
TAZORAC GEL 0.1%
triamcinolon cre 0.025%
triamcinolone cre 0.1%
triamcinolone cre 0.5%
triamcinolone lot 0.025%
triamcinolone lot 0.1%
triamcinolone oin 0.025%
triamcinolone oin 0.1%
triamcinolone oin 0.5%
triderm cre 0.1%
u-cort cre 1%
VOLTAREN GEL 1%
GC MO
GC MO
GC MO
MO
MO
PA
MO
ENZYME REPLACEMENT/ MODIFIERS
Enzyme Replacement/ Modifiers
ADAGEN INJ 250/ML
ALDURAZYME INJ 2.9MG/5ML
CEREZYME INJ 200UNIT
CREON CAP 36000UNT
CYSTADANE POW
Tier
Notes
1
1
3
1
2
4
4
4
4
4
1
1
1
2
2
2
1
2
1
1
4
GC MO
GC MO
QL 200 MO
GC MO
MO
MO
MO
MO
MO
MO
GC MO
GC MO
GC MO
MO
MO
MO
GC MO
MO
GC MO
GC MO
MO
5
5
5
3
5
LA
LA
LA
MO
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
43
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
Drug Name
ELAPRASE INJ 6MG/3ML
FABRAZYME INJ 35MG
KUVAN TAB 100MG
levocarnitine inj 200mg/ml
levocarnitine sol 1gm/10ml
levocarnitine tab 330mg
LUMIZYME INJ 50MG
NAGLAZYME INJ 1MG/ML
ORFADIN CAP 10MG
ORFADIN CAP 2MG
ORFADIN CAP 5MG
ZAVESCA CAP 100MG
ZENPEP CAP 10000UNT
ZENPEP CAP 15000UNT
ZENPEP CAP 20000UNT
ZENPEP CAP 25000UNT
ZENPEP CAP 3000UNIT
ZENPEP CAP 5000UNIT
Tier
5
5
5
1
1
2
5
5
5
5
5
5
3
3
3
3
3
3
Notes
LA
LA
GC MO
GC MO
MO
MO
MO
MO
MO
MO
MO
GASTROINTESTINAL AGENTS
Antispasmodics, Gastrointestinal
atropine sul inj 0.05mg/ml
atropine sul inj 0.1mg/ml
dicyclomine cap 10mg
dicyclomine sol 10mg/5ml
dicyclomine tab 20mg
methscopolamine tab 2.5mg
Gastrointestinal Agents, Other
diphen/atrop liq 2.5mg/5ml
1
1
2
2
1
2
1
GC MO
GC MO
MO
MO
GC MO
MO
GC MO
Drug Name
diphen/atrop tab 2.5mg
FULYZAQ TAB 125MG
loperamide cap 2mg
metoclopram tab 10mg
metoclopramide inj 5mg/ml
metoclopramide sol 5mg/5ml
RELISTOR KIT 12/0.6ML
ursodiol tab 250mg
ursodiol tab 500mg
Histamine2 (H2) Receptor Antagonists
famotidine inj 10mg/ml
FAMOTIDINE INJ 20MG/50M
famotidine tab 20mg
famotidine tab 40mg
ranitidine cap 150mg
ranitidine cap 300mg
ranitidine inj 150mg/6ml
ranitidine syp 15mg/ml
ranitidine tab 150mg
ranitidine tab 300mg
Irritable Bowel Syndrome Agents
AMITIZA CAP 24MCG
AMITIZA CAP 8MCG
LOTRONEX TAB 0.5MG
LOTRONEX TAB 1MG
Laxatives
constulose sol 10gm/15
enulose sol 10gm/15ml
Tier
Notes
2
4
2
1
1
1
4
2
2
MO
PA MO
MO
GC MO
GC MO
GC MO
MO
MO
MO
1
1
1
2
2
2
2
2
1
1
GC MO
GC MO
GC MO
MO
MO
MO
MO
MO
GC MO
GC MO
3
3
5
5
MO
MO
1
1
GC MO
GC MO
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
44
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
Drug Name
generlac sol 10gm/15
lactulose sol 10gm/15
polyeth glyc pow 3350 nf
PREPOPIK PAK
Protectants
CARAFATE SUS 1GM/10ML
misoprostol tab 100mcg
misoprostol tab 200mcg
sucralfate tab 1gm
Proton Pump Inhibitors
DEXILANT CAP 30MG DR
DEXILANT CAP 60MG DR
ESOMEPRAZOLE CAP 49.3MG
omeprazole cap 10mg
omeprazole cap 20mg
omeprazole cap 40mg
Tier
Notes
1
1
2
4
GC MO
GC MO
MO
MO
4
2
2
2
MO
MO
MO
MO
3
3
2
2
1
2
MO
MO
MO
MO
GC MO
MO
4
4
4
4
2
2
2
1
2
2
ST MO
ST MO
ST MO
ST MO
MO
MO
MO
GC MO
MO
MO
GENITOURINARY AGENTS
Antispasmodics, Urinary
ENABLEX TAB 15MG
ENABLEX TAB 7.5MG
MYRBETRIQ TAB 25MG
MYRBETRIQ TAB 50MG
oxybutynin syp 5mg/5ml
oxybutynin tab 10mg er
oxybutynin tab 15mg er
oxybutynin tab 5mg
oxybutynin tab 5mg er
tolterodine tab 1mg
Drug Name
tolterodine tab 2mg
VESICARE TAB 10MG
VESICARE TAB 5MG
Benign Prostatic Hypertrophy Agents
AVODART CAP 0.5MG
CIALIS TAB 2.5MG
CIALIS TAB 5MG
finasteride tab 5mg
JALYN CAP 0.5-0.4MG
RAPAFLO CAP 4MG
RAPAFLO CAP 8MG
tamsulosin cap 0.4mg
Genitourinary Agents, Other
CYSTAGON CAP 150MG
CYSTAGON CAP 50MG
ELMIRON CAP 100MG
neo/poly gu sol 40/ml ir
sodium chlor sol 0.9% irr
Phosphate Binders
calc acetate cap 667mg
FOSRENOL CHW 1000MG
FOSRENOL CHW 500MG
FOSRENOL CHW 750MG
RENVELA PAK 0.8GM
RENVELA PAK 2.4GM
RENVELA TAB 800MG
Vaginal Products
clindamycin cre 2% vag
Tier
Notes
2
3
3
MO
MO
MO
3
4
4
2
3
3
3
2
MO
PA QL 30 MO
PA QL 30 MO
MO
MO
MO
MO
MO
4
4
3
1
2
MO
MO
MO
GC MO
MO
2
4
4
4
4
4
4
MO
MO
MO
MO
MO
MO
MO
2
MO
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
45
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
Drug Name
metronidazole gel 0.75%vag
miconazole 3 sup 200mg
PREMARIN VAG CRE 0.625MG
terconazole cre 0.4%
terconazole sup 80mg
vandazole gel 0.75%
zazole cre 0.4%
zazole cre 0.8%
Tier
Notes
2
1
3
2
1
2
2
2
MO
GC MO
MO
MO
GC MO
MO
MO
MO
HORMONAL AGENTS, STIMULANT/ REPLACEMENT/
MODIFYING (ADRENAL)
Glucocorticoids/Mineralocorticoids
budesonide cap 3mg/24hr
dexameth pho inj 10mg/ml
dexameth pho inj 120mg/30
dexamethasone elx 0.5/5ml
dexamethasone tab 0.5mg
dexamethasone tab 0.75mg
dexamethasone tab 1.5mg
dexamethasone tab 1mg
dexamethasone tab 2mg
dexamethasone tab 4mg
dexamethasone tab 6mg
fludrocort tab 0.1mg
hydrocortisone tab 10mg
hydrocortisone tab 5mg
methylpr ace inj 40mg/ml
methylpr ace inj 80mg/ml
methylpr ss inj 125mg
2
2
2
2
1
1
2
2
2
1
1
2
2
2
2
2
2
MO
MO
MO
MO
GC MO
GC MO
MO
MO
MO
GC MO
GC MO
MO
MO
MO
MO
MO
MO
Drug Name
methylpr ss inj 40mg
methylprednisolone pak 4mg
methylprednisolone tab 16mg
methylprednisolone tab 32mg
methylprednisolone tab 4mg
methylprednisolone tab 8mg
pred sod pho sol 5mg/5ml
prednisolone sol 15mg/5ml
prednisolone sol 25mg/5ml
prednisone sol 5mg/5ml
prednisone tab 10mg
prednisone tab 1mg
prednisone tab 2.5mg
prednisone tab 20mg
prednisone tab 50mg
prednisone tab 5mg
triamcin ace inj 10mg/ml
triamcin ace inj 40mg/ml
UCERIS TAB 9MG
Tier
Notes
2
1
2
1
1
2
2
2
2
2
1
2
1
1
2
1
2
2
5
MO
GC MO
MO
GC MO
GC MO
MO
MO
MO
MO
MO
GC MO
MO
GC MO
GC MO
MO
GC MO
MO
MO
ST
HORMONAL AGENTS, STIMULANT/ REPLACEMENT/
MODIFYING (SEX HORMONES/ MODIFIERS)
Anabolic Steroids
oxandrolone tab 10mg
oxandrolone tab 2.5mg
Androgens
ANDRODERM DIS 2MG/24HR
ANDRODERM DIS 4MG/24HR
ANDROXY TAB 10MG
2
1
MO
GC MO
3
3
4
MO
MO
MO
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
46
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
Drug Name
danazol cap 100mg
danazol cap 200mg
danazol cap 50mg
testost cyp inj 100mg/ml
testost cyp inj 200mg/ml
testost enan inj 200mg/ml
Contraceptives
ELLA TAB 30MG
lyza tab 0.35mg
medroxypr ac inj 150mg/ml
norethindron tab 0.35mg
pirmella tab 1/35
tri-previfem tab
tri-sprintec tab
trinessa tab
vyfemla tab 0.4-35
xulane dis 150-35
Estrogens
estrad val inj 200mg/5
estradiol tab 0.5mg
estradiol tab 1mg
estradiol tab 2mg
MENEST TAB 0.3MG
MENEST TAB 0.625MG
MENEST TAB 1.25MG
MENEST TAB 2.5MG
PREMARIN INJ 25MG
PREMARIN TAB 0.3MG
Tier
Notes
2
2
2
2
2
2
MO
MO
MO
MO
MO
MO
3
2
2
2
2
2
2
2
1
2
MO
MO
MO
MO
MO
MO
MO
MO
GC MO
MO
2
1
1
1
2
2
2
2
3
3
MO
PA GC MO
PA GC MO
PA GC MO
PA MO
PA MO
PA MO
PA MO
MO
PA MO
Drug Name
Tier
PREMARIN TAB 0.45MG
3
PREMARIN TAB 0.625MG
3
PREMARIN TAB 0.9MG
3
PREMARIN TAB 1.25MG
3
PREMPHASE TAB
3
PREMPRO TAB .625-2.5
3
PREMPRO TAB 0.3-1.5
3
PREMPRO TAB 0.45-1.5
3
PREMPRO TAB 0.625-5
3
Progestins
medroxypr ac tab 10mg
1
medroxypr ac tab 2.5mg
1
medroxypr ac tab 5mg
1
norethin ace tab 5mg
1
Selective Estrogen Receptor Modifying Agents
raloxifene hcl tab 60mg
2
Notes
PA MO
PA MO
PA MO
PA MO
PA MO
PA MO
PA MO
PA MO
MO
GC MO
GC MO
GC MO
GC MO
MO
HORMONAL AGENTS, STIMULANT/REPLACEMENT/
MODIFYING (PITUITARY)
Hormonal Agents, Stimulant/Replacement/ Modifying (Pituitary)
cabergoline tab 0.5mg
2
MO
chor gonadot inj 10000unit
2
MO
desmopressin inj 4mcg/ml
2
MO
desmopressin spr 0.01%
2
MO
desmopressin tab 0.1mg
2
MO
desmopressin tab 0.2mg
2
MO
HUMATROPE INJ 12MG
5
PA
HUMATROPE INJ 24MG
5
PA
INCRELEX INJ 40MG/4ML
5
LA
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
47
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
Drug Name
NUTROPIN AQ INJ 20MG/2ML
NUTROPIN AQ INJ NUSPIN 5MG
SAIZEN INJ 5MG
SAIZEN INJ 8.8MG
Tier
Notes
5
5
5
5
PA
PA
PA
PA
HORMONAL AGENTS, STIMULANT/REPLACEMENT/
MODIFYING (THYROID)
Hormonal Agents, Stimulant/Replacement/ Modifying (Thyroid)
levothyroxine tab 100mcg
1
GC MO
levothyroxine tab 112mcg
1
GC MO
levothyroxine tab 125mcg
1
GC MO
levothyroxine tab 137mcg
1
GC MO
levothyroxine tab 150mcg
1
GC MO
levothyroxine tab 175mcg
1
GC MO
levothyroxine tab 200mcg
1
GC MO
levothyroxine tab 25mcg
1
GC MO
levothyroxine tab 300mcg
1
GC MO
levothyroxine tab 50mcg
1
GC MO
levothyroxine tab 75mcg
1
GC MO
levothyroxine tab 88mcg
1
GC MO
levoxyl tab 100mcg
1
GC MO
levoxyl tab 112mcg
1
GC MO
levoxyl tab 125mcg
1
GC MO
levoxyl tab 137mcg
1
GC MO
levoxyl tab 150mcg
1
GC MO
levoxyl tab 175mcg
1
GC MO
levoxyl tab 200mcg
1
GC MO
levoxyl tab 25mcg
1
GC MO
levoxyl tab 50mcg
1
GC MO
Drug Name
levoxyl tab 75mcg
levoxyl tab 88mcg
liothyronine tab 25mcg
liothyronine tab 50mcg
liothyronine tab 5mcg
SYNTHROID TAB 100MCG
SYNTHROID TAB 112MCG
SYNTHROID TAB 125MCG
SYNTHROID TAB 137MCG
SYNTHROID TAB 150MCG
SYNTHROID TAB 175MCG
SYNTHROID TAB 200MCG
SYNTHROID TAB 25MCG
SYNTHROID TAB 300MCG
SYNTHROID TAB 50MCG
SYNTHROID TAB 75MCG
SYNTHROID TAB 88MCG
unithroid tab 100mcg
unithroid tab 112mcg
unithroid tab 125mcg
unithroid tab 150mcg
unithroid tab 175mcg
unithroid tab 200mcg
unithroid tab 25mcg
unithroid tab 300mcg
unithroid tab 50mcg
unithroid tab 75mcg
unithroid tab 88mcg
Tier
Notes
1
1
2
2
2
4
4
4
4
4
4
4
4
4
4
4
4
1
1
1
1
1
1
1
1
1
1
1
GC MO
GC MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
48
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
Drug Name
Tier
Notes
SOMAVERT INJ 20MG
SYNAREL SOL 2MG/ML
HORMONAL AGENTS, SUPPRESSANT
(PARATHYROID)
Hormonal Agents, Suppressant (Parathyroid)
SENSIPAR TAB 30MG
3
SENSIPAR TAB 60MG
5
SENSIPAR TAB 90MG
5
Drug Name
Notes
5
5
LA
HORMONAL AGENTS, SUPPRESSANT (THYROID)
HORMONAL AGENTS, SUPPRESSANT (PITUITARY)
Antithyroid Agents
methimazole tab 10mg
methimazole tab 5mg
propylthiouracil tab 50mg
Hormonal Agents, Suppressant (Pituitary)
KORLYM TAB 300MG
LUPR DEP-PED INJ 11.25 MG/ML
LUPR DEP-PED INJ 15MG
LUPR DEP-PED INJ 7.5 MG/ML
octreotide inj 1000mcg
octreotide inj 100mcg
octreotide inj 200mcg
octreotide inj 500mcg
octreotide inj 50mcg/ml
SANDOSTATIN KIT LAR 10MG
SANDOSTATIN KIT LAR 20MG
SANDOSTATIN KIT LAR 30MG
SIGNIFOR INJ 0.3MG/ML
SIGNIFOR INJ 0.6MG/ML
SIGNIFOR INJ 0.9MG/ML
SOMATULINE INJ 120MG/0.5ML
SOMATULINE INJ 60MG/0.2ML
SOMATULINE INJ 90MG/0.3ML
SOMAVERT INJ 10MG
SOMAVERT INJ 15MG
Immune Suppressants
ASTAGRAF XL CAP 0.5MG
ASTAGRAF XL CAP 1MG
ASTAGRAF XL CAP 5MG
azathioprine tab 50mg
BENLYSTA INJ 120MG
CELLCEPT IV INJ 500MG
CELLCEPT SUS 200MG/ML
cyclosporine cap 100mg
cyclosporine cap 100mg md
cyclosporine cap 25mg
cyclosporine cap 25mg mod
cyclosporine cap 50mg mod
cyclosporine inj 50mg/ml
cyclosporine sol modified
ENBREL INJ 25/0.5ML
ENBREL INJ 25MG
ENBREL INJ 50MG/ML
gengraf cap 100mg
gengraf cap 25mg
5
3
3
4
5
2
2
5
2
5
5
5
4
4
4
5
5
5
5
5
Tier
MO
PA LA
MO
MO
MO
MO
MO
MO
MO
MO
MO
LA
LA
2
2
2
MO
MO
MO
4
4
5
2
5
3
3
2
2
2
2
2
2
2
5
5
5
2
2
PA MO
PA MO
PA
PA MO
IMMUNOLOGICAL AGENTS
PA MO
PA MO
PA MO
PA MO
PA MO
PA MO
PA MO
PA MO
PA MO
PA MO
PA MO
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
49
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
Drug Name
gengraf sol 100mg/ml
HUMIRA KIT 20MG/0.4ML
HUMIRA KIT 40MG/0.8ML
HUMIRA PEN KIT CROHNS
KINERET INJ 100MG
mycophenolate cap 250mg
mycophenolate tab 500mg
mycophenolic tab 180mg dr
mycophenolic tab 360mg dr
NULOJIX INJ 250MG
PROGRAF INJ 5MG/ML
RAPAMUNE SOL 1MG/ML
RAPAMUNE TAB 1MG
RAPAMUNE TAB 2MG
REMICADE INJ 100MG
SANDIMMUNE CAP 100MG
SANDIMMUNE CAP 25MG
SANDIMMUNE SOL 100MG/ML
sirolimus tab 0.5mg
tacrolimus cap 0.5mg
tacrolimus cap 1mg
tacrolimus cap 5mg
TREXALL TAB 10MG
TREXALL TAB 15MG
TREXALL TAB 5MG
TREXALL TAB 7.5MG
ZORTRESS TAB 0.25MG
ZORTRESS TAB 0.5MG
Tier
Notes
Drug Name
2
5
5
5
5
2
2
2
2
5
4
3
5
5
5
4
4
4
2
2
2
5
4
4
4
4
4
5
PA MO
ZORTRESS TAB 0.75MG
Immunizing Agents, Passive
ATGAM INJ 250MG
BIVIGAM INJ 10%
CARIMUNE NF INJ 3GM
GAMMAGARD INJ 2.5GM/25
GAMMAPLEX INJ 10GM
SYNAGIS INJ 50MG/0.5ML
THYMOGLOBULN INJ 25MG
Immunomodulators
ARCALYST INJ 220MG
ILARIS INJ 180MG
leflunomide tab 10mg
leflunomide tab 20mg
ORENCIA INJ 125MG/ML
ORENCIA INJ 250MG
Vaccines
ACTHIB INJ
ADACEL INJ
BCG VACCINE INJ
BOOSTRIX INJ
BOOSTRIX PFS
CERVARIX INJ
COMVAX INJ
DAPTACEL INJ
DIP/TET PED INJ 25-5LFU
ENGERIX-B INJ 10MCG/0.5ML
ENGERIX-B PFS 10MCG/0.5ML
PA MO
PA MO
PA MO
PA MO
PA
PA MO
PA MO
PA
PA
PA MO
PA MO
PA MO
PA MO
PA MO
PA MO
PA
PA MO
PA MO
PA MO
PA MO
PA MO
PA
Tier
Notes
5
PA
5
5
5
5
5
3
5
PA
PA
PA
PA
PA
MO
PA
5
4
2
2
5
5
4
4
4
3
3
4
4
4
2
4
4
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA MO
PA MO
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
50
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
Drug Name
ENGERIX-B PFS 20MCG/ML
GARDASIL INJ
HAVRIX INJ 1440UNIT
HAVRIX INJ 720UNIT
IMOVAX RABIE INJ 2.5/ML
INFANRIX INJ
IPOL INJ INACTIVE
IXIARO INJ
M-M-R II INJ LIVE
MENACTRA INJ
MENOMUNE INJ A/C/Y/W
MENVEO INJ
PEDVAX HIB INJ
PROQUAD INJ
RABAVERT INJ
RECOMBIVA HB INJ 10MCG/ML
RECOMBIVA-HB INJ 40MCG/ML
ROTARIX SUS
ROTATEQ SUS
TET/DIP TOX INJ 2-2 LF
TETANUS TOX INJ 5LF ADS
TWINRIX INJ
TYPHIM VI INJ
VAQTA INJ 25UNIT/0.5ML
VARIVAX INJ
YF-VAX INJ
ZOSTAVAX INJ
Tier
Notes
Drug Name
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
3
4
4
4
4
4
4
4
4
PA MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA MO
PA MO
PA MO
MO
MO
PA MO
MO
MO
MO
MO
MO
MO
MO
Aminosalicylates
APRISO CAP 0.375GM
ASACOL HD TAB 800MG
balsalazide cap 750mg
DIPENTUM CAP 250MG
mesalamine kit 4gm
Sulfonamides
sulfasalazin tab 500mg
sulfazine ec tab 500mg
INFLAMMATORY BOWEL DISEASE AGENTS
Tier
Notes
4
4
2
4
2
MO
MO
MO
MO
MO
2
2
MO
MO
METABOLIC BONE DISEASE AGENTS
Metabolic Bone Disease Agents
alendronate tab 10mg
alendronate tab 35mg
alendronate tab 40mg
alendronate tab 5mg
alendronate tab 70mg
ATELVIA TAB 35MG
calcitonin spr 200unit/act
calcitriol cap 0.25mcg
calcitriol cap 0.5mcg
calcitriol inj 1mcg/ml
calcitriol sol 1mcg/ml
FORTEO SOL 600/2.4
FOSAMAX + D TAB 70-2800
FOSAMAX + D TAB 70-5600
ibandronate inj 3mg/3ml
MIACALCIN INJ 200UNIT/ML
pamidronate inj 30mg/10ml
2
1
2
2
1
3
2
2
2
2
2
5
3
3
2
4
2
MO
GC MO
MO
MO
GC MO
MO
PA MO
MO
MO
MO
MO
QL 4 MO
MO
MO
MO
MO
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
51
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
Drug Name
pamidronate inj 6mg/ml
pamidronate inj 90mg/10ml
PROLIA SOL 60MG/ML
RECLAST INJ 5MG/100ML
XGEVA INJ 120MG
ZEMPLAR CAP 1MCG
ZEMPLAR CAP 2MCG
ZEMPLAR CAP 4MCG
ZEMPLAR INJ 2MCG/ML
ZEMPLAR INJ 5MCG/ML
zoledronic inj 4mg/5m
Tier
Notes
2
2
4
4
5
3
3
5
3
3
2
MO
MO
MO
MO
PA MO
PA MO
PA
PA MO
PA MO
MO
MISCELLANEOUS
Miscellaneous
EPIPEN 2-PAK INJ 0.3MG
EPIPEN-JR INJ 2-PAK 0.15MG
FETZIMA CAP TITRATIO
FIRAZYR INJ 30MG/3ML
lactated rin sol irrigation
physiolyte sol
physiosol sol irrigation
ringers irrigation sol
3
3
3
5
1
1
1
1
MO
MO
MO
GC MO
GC MO
GC MO
GC MO
OPHTHALMIC AGENTS
Ophthalmic Prostaglandin and Prostamide Analogs
latanoprost sol 0.005%
2
LUMIGAN SOL 0.01%
3
TRAVATAN Z DRO 0.004%
3
Ophthalmic Agents, Other
ak-con sol 0.1% op
1
MO
MO
MO
GC MO
Drug Name
RESTASIS EMU 0.05%
Ophthalmic Anti Infectives
bacit/polymy oin op
bacitracin oin op
ciprofloxacin sol 0.3% op
erythromycin oin op
gentak oin 0.3% op
gentamicin sol 0.3% op
MOXEZA SOL 0.5%
neo/bac/poly oin op
neo/poly/gra sol op
ofloxacin dro 0.3% op
sod sulfacet sol 10% op
tobramycin sol 0.3% op
trifluridine sol 1% op
trimetho sol polymyxn 0.1%
VIGAMOX DRO 0.5%
ZIRGAN GEL 0.15%
Ophthalmic Anti-allergy Agents
azelastine dro 0.05%
cromolyn sod sol 4% op
PATADAY SOL 0.2%
PATANOL SOL 0.1% OP
Ophthalmic Anti-inflammatories
dexameth pho sol 0.1% op
diclofenac sol 0.1% op
DUREZOL EMU 0.05%
flurbiprofen sol 0.03% op
Tier
Notes
3
MO
2
2
2
1
2
1
3
1
2
2
1
1
2
2
3
4
MO
MO
MO
GC MO
MO
GC MO
MO
GC MO
MO
MO
GC MO
GC MO
MO
MO
MO
MO
2
2
3
4
MO
MO
MO
MO
2
2
3
1
MO
MO
MO
GC MO
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
52
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
Drug Name
ketorolac sol 0.4%
ketorolac sol 0.5%
neo/poly/bac oin /hc 1%op
neo/poly/dex oin 0.1% op
neo/poly/dex sus 0.1% op
neo/poly/hc sus op
NEVANAC SUS 0.1%
pred sod pho sol 1% op
prednisolone sus 1% op
sulf/pred na sol op
tobramycin/ sus dexameth
Ophthalmic Antiglaucoma Agents
ALPHAGAN P SOL 0.1%
apraclonidine sol 0.5% op
AZOPT SUS 1% OP
betaxolol sol 0.5% op
brimonidine sol 0.15%
brimonidine sol 0.2% op
carteolol sol 1% op
COMBIGAN SOL 0.2/0.5%
dorzol/timol sol 2-0.5%op
dorzolamide sol 2% op
levobunolol sol 0.5% op
metipranolol sol 0.3% oph
PHOSPHOLINE SOL 0.125%OP
timolol gel sol 0.25% op
timolol gel sol 0.5% op
timolol mal sol 0.25% op
Tier
Notes
2
2
1
1
2
2
3
2
2
1
2
MO
MO
GC MO
GC MO
MO
MO
MO
MO
MO
GC MO
MO
3
2
3
1
2
2
1
3
2
2
1
1
3
2
2
2
MO
MO
MO
GC MO
MO
MO
GC MO
MO
MO
MO
GC MO
GC MO
MO
MO
MO
MO
Drug Name
timolol mal sol 0.5% op
Tier
Notes
2
MO
2
3
2
2
2
2
MO
MO
MO
MO
MO
MO
OTIC AGENTS
Otic Agents
acetic acid sol 2% otic
CIPRODEX SUS 0.3-0.1%
fluocin acet oil 0.01%
neo/poly/hc sol 1% otic
neo/poly/hc sus 1% otic
ofloxacin dro 0.3%otic
RESPIRATORY TRACT AGENTS
Anti-inflammatories, Inhaled Corticosteroids
FLOVENT DISK AER 100MCG
3
FLOVENT DISK AER 250MCG
3
FLOVENT DISK AER 50MCG
3
FLOVENT HFA AER 110MCG
3
FLOVENT HFA AER 220MCG
3
FLOVENT HFA AER 44MCG
3
QVAR AER 40MCG
3
QVAR AER 80MCG
3
Antihistamines
cetirizine syp 5mg/5ml
1
cyproheptad tab 4mg
2
desloratadin tab 2.5 odt
2
desloratadin tab 5mg
2
palgic liq 4mg/5ml
1
pantoprazole inj 40mg
2
promethazine inj 25mg/ml
2
promethazine inj 50mg/ml
2
MO
MO
MO
MO
MO
MO
MO
MO
GC MO
PA MO
MO
MO
PA GC MO
MO
MO
MO
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
53
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
Drug Name
Tier
Notes
stavudine sol 1mg/ml
2
MO
Antileukotrienes
montelukast chw 4mg
2
MO
montelukast chw 5mg
2
MO
montelukast gra 4mg
2
MO
montelukast tab 10mg
2
MO
zafirlukast tab 10mg
2
MO
zafirlukast tab 20mg
2
MO
ZYFLO CR TAB 600MG
4
MO
ZYFLO TAB 600MG
4
MO
Bronchodilators, Anticholinergic
ATROVENT HFA AER 17MCG
3
MO
ipratropium sol 0.02%inh
1
PA GC MO
SPIRIVA CAP HANDIHLR
3
MO
Bronchodilators, Phosphodiesterase Inhibitors (Xanthines)
aminophyllin inj 25mg/ml
1
GC MO
theophylline tab 100mg cr
2
MO
theophylline tab 200mg cr
2
MO
theophylline tab 300mg er
2
MO
theophylline tab 450mg er
2
MO
theophylline tab 600mg er
2
MO
Bronchodilators, Sympathomimetic
ADVAIR DISKU AER 100/50MCG
3
MO
ADVAIR DISKU AER 250/50MCG
3
MO
ADVAIR DISKU AER 500/50MCG
3
MO
ADVAIR HFA AER 115/21MCG
3
MO
ADVAIR HFA AER 230/21MCG
3
MO
ADVAIR HFA AER 45/21MCG
3
MO
Drug Name
albuterol neb 0.083%
albuterol neb 0.5%
albuterol neb 0.63mg/3ml
albuterol neb 1.25mg/3ml
albuterol syp 2mg/5ml
albuterol tab 2mg
albuterol tab 4mg
albuterol tab 4mg er
albuterol tab 8mg er
BREO ELLIPTA INH 100-25
COMBIVENT AER RESPIMAT
ipratropium/ sol albuter
PROAIR HFA AER
SEREVENT DIS AER 50MCG
SYMBICORT AER 160-4.5MCG
SYMBICORT AER 80-4.5MCG
terbutaline inj 1mg/ml
VENTOLIN HFA AER
Mast Cell Stabilizers
cromolyn sod neb 20mg/2ml
Nasal Agents
azelastine spr 0.1%
azelastine spr 0.15%
flunisolide spr 0.025%
fluticasone spr 50mcg
ipratropium spr 0.03%
ipratropium spr 0.06%
TYZINE PED NASAL DRO 0.05%
Tier
Notes
1
2
2
1
1
1
1
1
2
3
4
2
3
3
3
3
1
3
PA GC MO
PA MO
PA MO
PA GC MO
GC MO
GC MO
GC MO
GC MO
MO
MO
MO
PA MO
MO
MO
MO
MO
GC MO
MO
1
PA GC MO
2
2
2
2
2
2
4
MO
MO
MO
MO
MO
MO
MO
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
54
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
Drug Name
Pulmonary Antihypertensives
LETAIRIS TAB 10MG
LETAIRIS TAB 5MG
OPSUMIT TAB 10MG
ORENITRAM TAB 0.125MG
ORENITRAM TAB 0.25MG
ORENITRAM TAB 1MG
ORENITRAM TAB 2.5MG
REVATIO INJ 10MG
sildenafil tab 20mg
TRACLEER TAB 125MG
TRACLEER TAB 62.5MG
VENTAVIS SOL 10MCG/ML
VENTAVIS SOL 20MCG/ML
Respiratory Tract Agents, Other
DALIRESP TAB 500MCG
KALYDECO TAB 150MG
PROLASTIN-C INJ 1000MG
PULMOZYME SOL 1MG/ML
XOLAIR SOL 150MG
Tier
5
5
5
4
4
4
4
3
2
5
5
4
4
Notes
orphenadrine inj 30mg/ml
orphenadrine tab 100mg er
tizanidine tab 2mg
tizanidine tab 4mg
MO
MO
MO
MO
PA MO
PA MO
LA
LA
PA MO
PA MO
3
5
5
5
5
MO
PA
1
2
1
1
2
2
GC MO
MO
PA GC MO
PA GC MO
PA MO
PA MO
PA
LA
SKELETAL MUSCLE RELAXANTS
Skeletal Muscle Relaxants
baclofen tab 10mg
baclofen tab 20mg
cyclobenzaprine tab 10mg
cyclobenzaprine tab 5mg
methocarbamol tab 500mg
methocarbamol tab 750mg
Drug Name
Tier
Notes
2
2
2
2
PA MO
PA MO
MO
MO
4
4
4
4
PA MO
PA MO
PA MO
PA MO
1
1
1
1
1
1
1
1
1
1
QL 60 GC MO
QL 30 GC MO
QL 60 GC MO
QL 30 GC MO
QL 30 GC MO
QL 30 GC MO
QL 30 GC MO
QL 120 GC MO
QL 30 GC MO
QL 60 GC MO
2
2
4
2
2
2
MO
MO
MO
PA MO
MO
PA MO
SLEEP DISORDER AGENTS
Barbiturates
BUTISOL SOD ELX 30MG/5ML
BUTISOL SOD TAB 30MG
BUTISOL SOD TAB 50MG
SECONAL CAP 100MG
Benzodiazepines
estazolam tab 1mg
estazolam tab 2mg
flurazepam cap 15mg
flurazepam cap 30mg
temazepam cap 15mg
temazepam cap 22.5mg
temazepam cap 30mg
temazepam cap 7.5mg
triazolam tab 0.125mg
triazolam tab 0.25mg
GABA Receptor Modulators
eszopiclone tab 1mg
eszopiclone tab 3mg
ROZEREM TAB 8MG
zaleplon cap 10mg
zaleplon cap 5mg
zolpidem tab 10mg
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
55
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
Drug Name
zolpidem tab 5mg
Sleep Disorders, Other
modafinil tab 100mg
modafinil tab 200mg
XYREM SOL 500MG/ML
Tier
Notes
Drug Name
2
PA MO
2
2
5
PA MO
PA MO
LA
kcl/d5w inj 40meq/l
kcl/nacl inj 20meq/l
kcl10meq/l-d5w-0.45nacl inj
kcl20meq/l-d5w-0.225nacl inj
kcl20meq/l-d5w-0.2nacl inj
kcl20meq/l-d5w-0.33nacl inj
kcl20meq/l-d5w-0.45nacl inj
kcl20meq/l-d5w-lr inj
kcl30meq/l-d5w-0.45nacl inj
kcl40meq/l-d5w-0.45nacl inj
klor-con 10 tab 10meq er
klor-con 8 tab 8meq er
klor-con m20 tab 20meq er
lactated rin inj
magnesium sulf inj 50%
normosol -m inj /d5w
NORMOSOL -R INJ /D5W
NORMOSOL-R INJ PH 7.4
PLASMA-LYTE INJ -148
PLASMA-LYTE INJ 56/D5W
pot chlor inj 10meq/50ml
pot chlor inj 2meq/ml
pot chloride cap 10meq er
pot chloride cap 8meq er
pot citrate tab 1080mg
pot citrate tab 540mg
pot cl micro tab 10meq er
pot cl micro tab 20meq er
THERAPEUTIC NUTRIENTS/ MINERALS/
ELECTROLYTES
Electrolyte/Mineral Modifiers
EXJADE TAB 125MG
EXJADE TAB 250MG
EXJADE TAB 500MG
kionex pow usp
SAMSCA TAB 15MG
SAMSCA TAB 30MG
sod poly sul sus 15gm/60ml
Electrolyte/Mineral Replacement
CARBAGLU TAB 200MG
D10W/NACL INJ 0.2%
d2.5w/nacl inj 0.45%
d5w/lr inj
d5w/nacl inj 0.2%
d5w/nacl inj 0.33%
d5w/nacl inj 0.45%
d5w/nacl inj 0.9%
ISOLYTE-P INJ /D5W
ISOLYTE-S INJ
kcl in 1/2nacl inj 20meq
kcl/d5w inj 20meq/l
4
5
5
2
5
5
2
5
1
1
2
1
1
2
1
4
4
1
1
MO
MO
PA
PA
MO
GC MO
GC MO
MO
GC MO
GC MO
MO
GC MO
MO
MO
GC MO
GC MO
Tier
Notes
1
1
1
1
2
1
1
2
1
1
1
1
2
1
1
2
2
4
3
3
1
2
2
2
2
2
1
2
GC MO
GC MO
GC MO
GC MO
MO
GC MO
GC MO
MO
GC MO
GC MO
GC MO
GC MO
MO
GC MO
GC MO
MO
MO
MO
MO
MO
GC MO
MO
MO
MO
MO
MO
GC MO
MO
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
56
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
Drug Name
ringers inj
sod chloride inj 0.45%
sod chloride inj 0.9%
sod chloride inj 2.5meq/ml
sod chloride inj 3%
sod chloride inj 5%
SOD LACTATE INJ 5MEQ/ML
tpn electrol inj
Nutrients
AMINOSYN II INJ 10%
AMINOSYN II INJ 7%
AMINOSYN II INJ 8.5%
aminosyn ii inj 8.5%/lyte
aminosyn inj 8.5%/lyte
AMINOSYN M INJ 3.5%
AMINOSYN-HBC INJ 7%
AMINOSYN-PF INJ 10%
AMINOSYN-PF INJ 7%
CLINIMIX E INJ 2.75/D10W
CLINIMIX E INJ 2.75/D5W
CLINIMIX E INJ 4.25%/D25W
CLINIMIX E INJ 4.25%/D5W
CLINIMIX E INJ 5%/D15W
CLINIMIX E INJ 5%/D20W
CLINIMIX E INJ 5%/D25W
CLINIMIX INJ 2.75%/D5W
CLINIMIX INJ 4.25%/D10W
CLINIMIX INJ 4.25%/D20W
Tier
Notes
1
2
2
1
1
1
1
1
GC MO
MO
MO
GC MO
GC MO
GC MO
GC MO
GC MO
4
4
4
2
1
4
4
4
4
4
4
4
4
4
4
4
4
4
4
PA MO
PA MO
PA MO
PA MO
PA GC MO
PA MO
PA MO
PA MO
PA MO
PA MO
PA MO
PA MO
PA MO
PA MO
PA MO
PA MO
PA MO
PA MO
PA MO
Drug Name
CLINIMIX INJ 4.25%/D25W
CLINIMIX INJ 4.25%/D5W
CLINIMIX INJ 5%/D15W
CLINIMIX INJ 5%/D20W
CLINIMIX INJ 5%/D25W
dextrose inj 10%
dextrose inj 5%
hepatamine sol 8%
intralipid inj 20%
NEPHRAMINE INJ 5.4%
premasol sol 6%
PROCALAMINE INJ 3%
PROSOL INJ 20%
TRAVASOL INJ 10%
Vitamins
PRENATAL VITAMIN TABLET
SOD FLUORIDE 2.2MG(1 MG) TAB
Tier
Notes
4
4
4
4
4
1
2
1
1
4
1
3
3
3
PA MO
PA MO
PA MO
PA MO
PA MO
GC MO
MO
PA GC MO
PA GC MO
PA MO
PA GC MO
PA MO
PA MO
PA MO
3
1
MO
GC MO
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
57
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 8 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 08/08/2014
8
8-mop cap 10mg
A
abacav/lamiv tab /zidovud
abacavir tab 300mg
abelcet inj 5mg/ml
abilify disc tab 10mg
abilify disc tab 15mg
abilify inj 9.75mg
abilify main inj 300mg
abilify sol 1mg/ml
abilify tab 10mg
abilify tab 15mg
abilify tab 20mg
abilify tab 2mg
abilify tab 30mg
abilify tab 5mg
abraxane inj 100mg
acampro cal tab 333mg
acarbose tab 100mg
acarbose tab 25mg
acarbose tab 50mg
acebutolol cap 200mg
acebutolol cap 400mg
acetazolamide cap 500mg er
acetazolamide tab 125mg
acetazolamide tab 250mg
acetic acid sol 2% otic
acitretin cap 10mg
acitretin cap 17.5mg
acitretin cap 25mg
acthib inj
actimmune inj 2mu/0.5ml
actoplus met tab xr 15-1000
41
24
24
14
22
22
22
22
22
22
22
22
22
22
22
16
40
27
27
27
34
34
37
37
37
53
41
41
41
50
16
27
actoplus met tab xr 30-1000
acyclovir cap 200mg
acyclovir sus 200mg/5ml
acyclovir tab 400mg
acyclovir tab 800mg
acyclovir/na inj 500mg
adacel inj
adagen inj 250/ml
adapalene gel 0.3%
adefov dipiv tab 10mg
advair disku aer 100/50mcg
advair disku aer 250/50mcg
advair disku aer 500/50mcg
advair hfa aer 115/21mcg
advair hfa aer 230/21mcg
advair hfa aer 45/21mcg
advicor tab 1000-20mg
advicor tab 1000-40mg
advicor tab 500-20mg
advicor tab 750-20mg
afeditab tab 30mg cr
afeditab tab 60mg cr
afinitor dis tab 2mg
afinitor dis tab 3mg
afinitor dis tab 5mg
afinitor tab 10mg
afinitor tab 2.5mg
afinitor tab 5mg
afinitor tab 7.5mg
aggrenox cap 25-200mg
ak-con sol 0.1% op
ala cort cre 1%
albenza tab 200mg
albuterol neb 0.083%
27
26
26
26
26
26
50
43
41
25
54
54
54
54
54
54
38
38
38
38
35
35
16
16
16
16
16
16
16
30
52
41
20
54
albuterol neb 0.5%
albuterol neb 0.63mg/3ml
albuterol neb 1.25mg/3ml
albuterol syp 2mg/5ml
albuterol tab 2mg
albuterol tab 4mg
albuterol tab 4mg er
albuterol tab 8mg er
alcohol prep pad
aldurazyme inj 2.9mg/5ml
alendronate tab 10mg
alendronate tab 35mg
alendronate tab 40mg
alendronate tab 5mg
alendronate tab 70mg
alimta inj 500mg
alinia sus 100mg/5ml
alinia tab 500mg
allopurinol tab 100mg
allopurinol tab 300mg
alphagan p sol 0.1%
alprazolam con 1 mg/ml
alprazolam tab 0.25mg
alprazolam tab 0.25mg odt
alprazolam tab 0.5mg
alprazolam tab 0.5mg er
alprazolam tab 0.5mg od
alprazolam tab 1mg
alprazolam tab 1mg odt
alprazolam tab 2mg
alprazolam tab 2mg odt
alprazolam tab xr 1mg
alprazolam tab xr 2mg
alprazolam tab xr 3mg
54
54
54
54
54
54
54
54
27
43
51
51
51
51
51
16
20
20
15
15
53
26
26
26
26
26
26
26
26
26
26
26
26
26
altoprev tab 20mg er
altoprev tab 40mg er
altoprev tab 60mg er
amantadine cap 100mg
amantadine syp 50mg/5ml
amantadine tab 100mg
ambisome inj 50mg
amcinonide cre 0.1%
amcinonide lot 0.1%
amcinonide oin 0.1%
amifostine inj 500mg
amiloride tab 5mg
amiloride/hctz tab 5-50mg
aminophyllin inj 25mg/ml
aminosyn ii inj 10%
aminosyn ii inj 7%
aminosyn ii inj 8.5%
aminosyn ii inj 8.5%/lyte
aminosyn inj 8.5%/lyte
aminosyn m inj 3.5%
aminosyn-hbc inj 7%
aminosyn-pf inj 10%
aminosyn-pf inj 7%
amiodarone inj 50mg/ml
amiodarone tab 200mg
amiodarone tab 400mg
amitiza cap 24mcg
amitiza cap 8mcg
amitriptyline tab 100mg
amitriptyline tab 10mg
amitriptyline tab 150mg
amitriptyline tab 25mg
amitriptyline tab 50mg
amitriptyline tab 75mg
amlod/atorva tab 10-10mg
59
38
38
38
20
20
20
14
41
41
41
16
37
33
54
57
57
57
57
57
57
57
57
57
32
32
32
44
44
13
13
13
13
13
13
38
amlod/atorva tab 10-20mg
amlod/atorva tab 10-40mg
amlod/atorva tab 10-80mg
amlod/atorva tab 2.5-10mg
amlod/atorva tab 2.5-20mg
amlod/atorva tab 2.5-40mg
amlod/atorva tab 5-10mg
amlod/atorva tab 5-20mg
amlod/atorva tab 5-40mg
amlod/atorva tab 5-80mg
amlod/benazp cap 10-20mg
amlod/benazp cap 10-40mg
amlod/benazp cap 2.5-10mg
amlod/benazp cap 5-10mg
amlod/benazp cap 5-20mg
amlod/benazp cap 5-40mg
amlodipine tab 10mg
amlodipine tab 2.5mg
amlodipine tab 5mg
ammonium lac lot 12%
amnesteem cap 10mg
amnesteem cap 20mg
amnesteem cap 40mg
amox/k clav chw 200mg
amox/k clav chw 400mg
amox/k clav sus 200/5ml
amox/k clav sus 400/5ml
amox/k clav sus 600/5ml
amox/k clav tab 250mg
amox/k clav tab 500mg
amox/k clav tab 875mg
amoxapine tab 100mg
amoxapine tab 150mg
amoxapine tab 25mg
amoxapine tab 50mg
38
38
38
38
38
38
38
38
38
38
33
33
33
33
33
33
35
35
35
41
41
41
41
6
6
6
6
6
6
6
6
13
13
13
13
amoxicillin cap 250mg
amoxicillin cap 500mg
amoxicillin chw tab 125mg
amoxicillin chw tab 250mg
amoxicillin sus 125/5ml
amoxicillin sus 200/5ml
amoxicillin sus 250/5ml
amoxicillin sus 400/5ml
amoxicillin tab 500mg
amoxicillin tab 875mg
amphetamine tab 10mg
amphetamine tab 12.5mg
amphetamine tab 15mg
amphetamine tab 20mg
amphetamine tab 30mg
amphetamine tab 5mg
amphetamine tab 7.5mg
amphotericin b inj 50mg
ampicillin cap 250mg
ampicillin cap 500mg
ampicillin inj 10gm
ampicillin inj 125mg
ampicillin inj 1gm
ampicillin sus 125/5ml
ampicillin sus 250/5ml
amp-sulbactam inj 15gm
ampyra tab 10mg
amturnide tab 150-5-12.5mg
amturnide tab 300-10-12.5mg
amturnide tab 300-10-25mg
amturnide tab 300-5-12.5mg
amturnide tab 300-5-25mg
anagrelide cap 0.5mg
anastrozole tab 1mg
androderm dis 2mg/24hr
6
6
6
6
6
6
6
6
6
6
40
40
40
40
40
40
40
14
6
6
6
6
6
6
6
6
40
33
33
33
33
33
30
19
46
androderm dis 4mg/24hr
androxy tab 10mg
apap/cod sol120-12mg/5ml
apap/codeine tab 300-15mg
apap/codeine tab 300-30mg
apap/codeine tab 300-60mg
apidra inj solostar
apidra inj u-100
aplenzin tab 174mg
aplenzin tab 348mg
apokyn inj
apraclonidine sol 0.5% op
apriso cap 0.375gm
aptiom tab 200mg
aptiom tab 400mg
aptiom tab 600mg
aptiom tab 800mg
aptivus cap 250mg
aptivus sol 100mg/ml
arcalyst inj 220mg
arranon inj 5mg/ml
arzerra con 100/5ml
asacol hd tab 800mg
ascomp/cod cap 30mg
astagraf xl cap 0.5mg
astagraf xl cap 1mg
astagraf xl cap 5mg
atacand tab 16mg
atacand tab 32mg
atelvia tab 35mg
atenol/chlor tab 100-25mg
atenol/chlor tab 50-25mg
atenolol tab 100mg
atenolol tab 25mg
atenolol tab 50mg
60
46
46
2
2
2
2
29
29
11
11
20
53
51
10
10
10
10
25
25
50
16
16
51
2
49
49
49
31
31
51
33
33
34
34
34
atgam inj 250mg
atorvastatin tab 10mg
atorvastatin tab 20mg
atorvastatin tab 40mg
atorvastatin tab 80mg
atovaq/progu tab 250-100mg
atovaquone sus 750/5ml
atripla tab
atropine sul inj 0.05mg/ml
atropine sul inj 0.1mg/ml
atrovent hfa aer 17mcg
aubagio tab 14mg
aubagio tab 7mg
aug betamet lot 0.05%
avandamet tab 2-1000mg
avandamet tab 2-500mg
avandamet tab 4-1000mg
avandamet tab 4-500mg
avandaryl tab 4-1mg
avandaryl tab 4-2mg
avandaryl tab 4-4mg
avandaryl tab 8-2mg
avandaryl tab 8-4mg
avandia tab 2mg
avandia tab 4mg
avandia tab 8mg
avastin inj 100mg/4ml
avodart cap 0.5mg
azacitidine inj 100mg
azactam/dex inj 1gm
azactam/dex inj 2gm
azasan tab 100mg
azasan tab 75 mg
azathioprine tab 50mg
azelastine dro 0.05%
50
38
38
38
38
20
20
24
44
44
54
40
40
41
27
27
27
27
27
27
27
27
27
27
27
27
16
45
16
6
6
16
16
49
52
azelastine spr 0.1%
azelastine spr 0.15%
azilect tab 0.5mg
azilect tab 1mg
azithromycin inj 500mg
azithromycin pow 1gm pak
azithromycin sus 100mg/5ml
azithromycin sus 200mg5ml
azithromycin tab 250mg
azithromycin tab 500mg
azithromycin tab 600mg
azopt sus 1% op
azor tab 10-20mg
azor tab 10-40mg
azor tab 5-20mg
azor tab 5-40mg
aztreonam inj 1gm
B
baciim inj 50000unit
bacit/polymy oin op
bacitracin oin op
baclofen tab 10mg
baclofen tab 20mg
balsalazide cap 750mg
banzel sus 40mg/ml
banzel tab 200mg
banzel tab 400mg
baraclude sol 0.05mg/ml
baraclude tab 0.5mg
baraclude tab 1mg
bcg vaccine inj
benazep/hctz tab 10-12.5mg
benazep/hctz tab 20-12.5mg
benazep/hctz tab 20-25mg
benazep/hctz tab 5-6.25mg
54
54
21
21
7
7
7
7
7
7
7
53
33
33
33
33
6
4
52
52
55
55
51
10
10
10
25
25
25
50
33
33
33
33
benazepril tab 10mg
benazepril tab 20mg
benazepril tab 40mg
benazepril tab 5mg
benicar hct tab 20-12.5mg
benicar hct tab 40-12.5mg
benicar hct tab 40-25mg
benicar tab 20mg
benicar tab 40mg
benicar tab 5mg
benlysta inj 120mg
benztropine inj 1mg/ml
benztropine tab 0.5mg
benztropine tab 1mg
benztropine tab 2mg
betameth dip cre 0.05%
betameth dip oin 0.05%
betameth val cre 0.1%
betameth val lot 0.1%
betameth val oin 0.1%
betaseron inj 0.3mg
betaxolol sol 0.5% op
betaxolol tab 10mg
betaxolol tab 20mg
bicalutamide tab 50mg
bicillin l-a inj 600000
bicnu inj 100mg
bisoprl/hctz tab 10/6.25mg
bisoprl/hctz tab 2.5/6.25mg
bisoprl/hctz tab 5-6.25mg
bisoprolol fum tab 10mg
bisoprolol fum tab 5mg
bivigam inj 10%
bleomycin inj 30unit
boostrix inj
61
31
31
31
31
33
33
33
31
31
31
49
20
20
20
20
41
41
41
41
41
41
53
35
35
16
6
16
33
33
33
35
35
50
16
50
boostrix pfs
bosulif tab 100mg
bosulif tab 500mg
breo ellipta inh 100-25
brilinta tab 90mg
brimonidine sol 0.15%
brimonidine sol 0.2% op
brintellix tab 10mg
brintellix tab 20mg
brintellix tab 5mg
brisdelle cap 7.5mg
bromocriptine cap 5mg
bromocriptine tab 2.5mg
budesonide cap 3mg/24hr
bumetanide inj 0.25mg/ml
bumetanide tab 0.5mg
bumetanide tab 1mg
bumetanide tab 2mg
bupren/nalox sub 2-0.5mg
bupren/nalox sub 8-2mg
buprenorphine inj 0.3mg/ml
buprenorphine sub 2mg
buprenorphine sub 8mg
buproban tab 150mg
bupropion hcl tab 150mg xl
bupropion hcl tab 300mg xl
bupropion tab 100mg
bupropion tab 100mg sr
bupropion tab 150mg sr
bupropion tab 200mg sr
bupropion tab 75mg
buspirone tab 10mg
buspirone tab 15mg
buspirone tab 30mg
buspirone tab 5mg
50
16
16
54
30
53
53
11
11
11
12
20
20
46
37
37
37
37
3
3
3
3
3
11
11
11
11
11
11
11
11
26
26
26
26
buspirone tab 7.5mg
busulfex inj 6mg/ml
but/apap/caf cap codeine
butisol sod elx 30mg/5ml
butisol sod tab 30mg
butisol sod tab 50mg
butrans dis 15mcg/hr
byetta inj 10mcg
byetta inj 5mcg
C
cabergoline tab 0.5mg
calc acetate cap 667mg
calcipotrien oin betameth
calcipotriene sol 0.005%
calcitonin spr 200unit/act
calcitriol cap 0.25mcg
calcitriol cap 0.5mcg
calcitriol inj 1mcg/ml
calcitriol sol 1mcg/ml
cancidas inj 50mg
cancidas inj 70mg
candesa/hctz tab 16-12.5
candesa/hctz tab 32-12.5
candesa/hctz tab 32-25mg
candesartan tab 16mg
candesartan tab 32mg
candesartan tab 4mg
candesartan tab 8mg
capastat sul inj 1gm
caprelsa tab 100mg
caprelsa tab 300mg
captopr/hctz tab 25-15mg
captopr/hctz tab 25-25mg
captopr/hctz tab 50-15mg
captopr/hctz tab 50-25mg
26
17
2
55
55
55
1
27
27
47
45
41
41
51
51
51
51
51
14
14
33
33
33
31
31
31
31
15
17
17
33
33
33
33
captopril tab 100mg
captopril tab 12.5mg
captopril tab 25mg
captopril tab 50mg
carafate sus 1gm/10ml
carb/levo er tab 25-100mg
carb/levo er tab 50-200mg
carb/levo odt tab 10-100mg
carb/levo odt tab 25-100mg
carb/levo odt tab 25-250mg
carb/levo tab 10-100mg
carb/levo tab 25-100mg
carb/levo tab 25-250mg
carbaglu tab 200mg
carbamazepin cap 100mg er
carbamazepin cap 200mg er
carbamazepin cap 300mg er
carbamazepin chw 100mg
carbamazepin sus 100mg/5ml
carbamazepin tab 200mg
carbamazepin tab 200mg er
carbamazepin tab 400mg er
carbidopa tab 25mg
carboplatin inj 150/15ml
carimune nf inj 3gm
carteolol sol 1% op
cartia xt cap 120/24hr
cartia xt cap 180/24hr
cartia xt cap 240/24hr
cartia xt cap 300/24hr
carvedilol tab 12.5mg
carvedilol tab 25mg
carvedilol tab 3.125mg
carvedilol tab 6.25mg
cayston inh 75mg
62
31
31
31
31
45
20
20
21
21
21
21
21
21
56
27
10
10
27
10
10
10
10
21
17
50
53
35
35
36
36
35
35
35
35
6
cdp/amitrip tab 10-25mg
cdp/amitrip tab 5-12.5mg
cefaclor cap 250mg
cefaclor cap 500mg
cefaclor er tab 500mg
cefazolin inj 10gm
cefazolin inj 1gm
cefazolin inj 1gm/50ml
cefazolin inj 500mg
cefdinir cap 300mg
cefdinir sus 125mg/5ml
cefdinir sus 250mg/5ml
cefepime inj 1gm
cefepime inj 2gm
cefoxitin inj 10gm
cefoxitin inj 180 mg/ml
cefoxitin inj 95 mg/ml
cefpodo prox sus 100mg/5ml
cefpodo prox sus 50mg/5ml
cefpodoxime tab 100mg
cefpodoxime tab 200mg
cefprozil sus 125/5ml
cefprozil sus 250/5ml
cefprozil tab 250mg
cefprozil tab 500mg
ceftriaxone inj 10gm
ceftriaxone inj 250mg
ceftriaxone inj 500mg
cefuroxime inj 1.5gm
cefuroxime inj 7.5gm
cefuroxime inj 750mg
cefuroxime tab 250mg
celebrex cap 100mg
celebrex cap 200mg
celebrex cap 400mg
13
13
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
3
3
3
celebrex cap 50mg
cellcept iv inj 500mg
cellcept sus 200mg/ml
celontin cap 300mg
cephalexin cap 250mg
cephalexin cap 500mg
cephalexin sus 125mg/5ml
cephalexin sus 250mg/5ml
cephalexin tab 250mg
cephalexin tab 500mg
cerezyme inj 200unit
cervarix inj
cetirizine syp 5mg/5ml
chantix pak 0.5mg & 1mg
chantix tab 0.5mg
chantix tab 1mg
chloramphenicol inj 1gm
chlordiazepoxide cap 10mg
chlordiazepoxide cap 25mg
chlordiazepoxide cap 5mg
chlorhex glu sol 0.12%
chloroquine tab 250mg
chloroquine tab 500mg
chlorothiazide tab 250mg
chlorothiazide tab 500mg
chlorpromazine inj 25mg/ml
chlorpromazine tab 100mg
chlorpromazine tab 10mg
chlorpromazine tab 200mg
chlorpromazine tab 25mg
chlorpromazine tab 50mg
chlorpropam tab 100mg
chlorpropam tab 250mg
chlorthalidone tab 25mg
chlorthalidone tab 50mg
3
49
49
8
5
5
6
6
6
6
43
50
53
3
3
3
4
26
26
26
41
20
20
37
37
21
21
21
21
21
21
27
27
37
37
cholestyram pow 4gm lite
chor gonadot inj 10000unit
cialis tab 2.5mg
cialis tab 5mg
ciclopirox cre 0.77%
ciclopirox gel 0.77%
ciclopirox sol 8%
ciclopirox sus 0.77%
cilostazol tab 100mg
cilostazol tab 50mg
ciprodex sus 0.3-0.1%
ciprofloxacin inj 200mg
ciprofloxacin inj 400mg/40ml
ciprofloxacin sol 0.3% op
ciprofloxacin tab 1000mg er
ciprofloxacin tab 100mg
ciprofloxacin tab 250mg
ciprofloxacin tab 500mg
ciprofloxacin tab 500mg er
ciprofloxacin tab 750mg
ciprofloxacn sus 250mg/5
ciprofloxacn sus 500mg/5
cisplatin inj 100mg
citalopram sol 10mg/5ml
citalopram tab 10mg
citalopram tab 20mg
citalopram tab 40mg
cladribine inj 1mg/ml
claravis cap 10mg
claravis cap 20mg
claravis cap 30mg
claravis cap 40mg
clarithromycin tab 250mg
clarithromycin tab 500mg
clindacin kit pac 1%
63
39
47
45
45
41
41
41
41
30
30
53
7
7
52
7
7
7
7
7
7
7
7
17
12
12
12
12
17
41
41
41
41
7
7
41
clindamy/ben gel 1-5%
clindamycin cap 150mg
clindamycin cap 300mg
clindamycin cap 75mg
clindamycin cre 2% vag
clindamycin gel 1%
clindamycin inj 150mg/ml
clindamycin inj 300mg
clindamycin inj 600mg
clindamycin inj 900mg
clindamycin lot 1%
clindamycin pad 1%
clindamycin sol 1%
clindamycin sol 75mg/5ml
clinimix e inj 2.75/d10w
clinimix e inj 2.75/d5w
clinimix e inj 4.25%/d25w
clinimix e inj 4.25%/d5w
clinimix e inj 5%/d15w
clinimix e inj 5%/d20w
clinimix e inj 5%/d25w
clinimix inj 2.75%/d5w
clinimix inj 4.25%/d10w
clinimix inj 4.25%/d20w
clinimix inj 4.25%/d25w
clinimix inj 4.25%/d5w
clinimix inj 5%/d15w
clinimix inj 5%/d20w
clinimix inj 5%/d25w
clobetasol e cre 0.05%
clobetasol gel 0.05%
clobetasol oin 0.05%
clobetasol sol 0.05%
clolar inj 1mg/ml
clomipramine cap 25mg
41
4
4
4
45
41
4
4
4
5
41
41
41
5
57
57
57
57
57
57
57
57
57
57
57
57
57
57
57
41
42
42
42
17
13
clomipramine cap 50mg
clomipramine cap 75mg
clonazep odt tab 0.125mg
clonazep odt tab 0.25mg
clonazep odt tab 0.5mg
clonazep odt tab 1mg
clonazep odt tab 2mg
clonazepam tab 0.5mg
clonazepam tab 1mg
clonazepam tab 2mg
clonidine tab 0.1mg
clonidine tab 0.2mg
clonidine tab 0.3mg
clopidogrel tab 300mg
clopidogrel tab 75mg
cloraz dipot tab 15mg
cloraz dipot tab 3.75mg
cloraz dipot tab 7.5mg
clotrim/beta cre diprop
clotrim/beta lot diprop
clotrimazole cre 1%
clotrimazole sol 1%
clotrimazole troche 10mg
clozapine tab 100mg
clozapine tab 200mg
clozapine tab 25mg
clozapine tab 50mg
coartem tab 20-120mg
colcrys tab 0.6mg
colestipol granules 5gm
colestipol tab 1gm
colistimethate inj 150mg
combigan sol 0.2/0.5%
combivent aer respimat
cometriq kit 100mg
13
13
8
8
8
8
8
8
8
8
31
31
31
30
30
26
26
26
42
42
42
42
14
23
23
23
23
20
15
39
39
5
53
54
17
cometriq kit 140mg
cometriq kit 60mg
complera tab
compro sup 25mg
comvax inj
condylox gel 0.5%
constulose sol 10gm/15
copaxone inj 40mg/ml
copaxone kit 20mg/ml
cosmegen inj 0.5mg
creon cap 36000unt
crestor tab 10mg
crestor tab 20mg
crestor tab 40mg
crestor tab 5mg
crixivan cap 200mg
crixivan cap 400mg
cromolyn sod neb 20mg/2ml
cromolyn sod sol 4% op
cubicin sol 500mg
cyclobenzaprine tab 10mg
cyclobenzaprine tab 5mg
cyclophosph cap 25mg
cyclophosph cap 50mg
cyclophosph tab 25mg
cyclophosph tab 50mg
cycloset tab 0.8mg
cyclosporine cap 100mg
cyclosporine cap 100mg md
cyclosporine cap 25mg
cyclosporine cap 25mg mod
cyclosporine cap 50mg mod
cyclosporine inj 50mg/ml
cyclosporine sol modified
cyproheptad tab 4mg
64
17
17
24
21
50
42
44
41
41
17
43
38
38
38
38
25
25
54
52
5
55
55
16
16
16
16
27
49
49
49
49
49
49
49
53
cystadane pow
cystagon cap 150mg
cystagon cap 50mg
cytarabine inj 100mg/ml
cytarabine inj 20mg/ml
D
d10w/nacl inj 0.2%
d2.5w/nacl inj 0.45%
d5w/lr inj
d5w/nacl inj 0.2%
d5w/nacl inj 0.33%
d5w/nacl inj 0.45%
d5w/nacl inj 0.9%
dacarbazine inj 200mg
dacogen inj 50mg
daliresp tab 500mcg
danazol cap 100mg
danazol cap 200mg
danazol cap 50mg
dapsone tab 100mg
dapsone tab 25mg
daptacel inj
daraprim tab 25mg
daunorubicin inj 5mg/ml
decitabine inj 50mg
demser cap 250mg
depen titra tab 250mg
depo-provera inj 400/ml
desipramine tab 100mg
desipramine tab 10mg
desipramine tab 150mg
desipramine tab 25mg
desipramine tab 50mg
desipramine tab 75mg
desloratadin tab 2.5 odt
43
45
45
17
17
56
56
56
56
56
56
56
17
16
55
47
47
47
15
15
50
20
17
16
37
16
17
13
13
13
13
13
13
53
desloratadin tab 5mg
desloratadin tab 5mg odt
desmopressin inj 4mcg/ml
desmopressin spr 0.01%
desmopressin tab 0.1mg
desmopressin tab 0.2mg
desonide cre 0.05%
desonide lot 0.05%
desonide oin 0.05%
desoximetasone cre 0.05%
desoximetasone cre 0.25%
desoximetasone gel 0.05%
desoximetasone oin 0.25%
desvenlafaxine tab 100mg er
desvenlafaxine tab 50mg er
dexameth pho inj 10mg/ml
dexameth pho inj 120mg/30
dexameth pho sol 0.1% op
dexamethasone elx 0.5/5ml
dexamethasone tab 0.5mg
dexamethasone tab 0.75mg
dexamethasone tab 1.5mg
dexamethasone tab 1mg
dexamethasone tab 2mg
dexamethasone tab 4mg
dexamethasone tab 6mg
dexilant cap 30mg dr
dexilant cap 60mg dr
dexrazoxane inj 500mg
dextroamphet cap 10mg er
dextroamphet cap 15mg er
dextroamphet cap 5mg er
dextroamphet tab 10mg
dextroamphet tab 5mg
dextrose inj 10%
53
24
47
47
47
47
42
42
42
42
42
42
42
12
12
46
46
52
46
46
46
46
46
46
46
46
45
45
17
40
40
40
40
40
57
dextrose inj 5%
diazepam con 5mg/ml
diazepam gel 10mg
diazepam gel 2.5mg
diazepam gel 20mg
diazepam sol 1mg/ml
diazepam tab 10mg
diazepam tab 2mg
diazepam tab 5mg
diclofen pot tab 50mg
diclofenac gel 3%
diclofenac sol 0.1% op
diclofenac tab 100mg er
diclofenac tab 25mg dr
diclofenac tab 50mg dr
diclofenac tab 75mg dr
dicloxacillin cap 250mg
dicloxacillin cap 500mg
dicyclomine cap 10mg
dicyclomine sol 10mg/5ml
dicyclomine tab 20mg
didanosine cap 125mg
didanosine cap 200mg
didanosine cap 250mg
didanosine cap 400mg
dificid tab 200mg
diflorasone cre 0.05%
diflorasone oin 0.05%
diflunisal tab 500mg
digoxin inj 0.25mg/ml
digoxin sol 50mcg/ml
digoxin tab 0.125mg
digoxin tab 0.25mg
dihydroergot inj 1mg/ml
dilt-cd cap 120mg
65
57
26
8
8
8
26
27
27
27
3
42
52
3
3
3
3
6
6
44
44
44
24
24
24
24
7
42
42
3
37
37
37
37
15
36
diltiazem cap 120mg cd
diltiazem cap 120mg er
diltiazem cap 180mg/24hr
diltiazem cap 240mg cd
diltiazem cap 300mg cd
diltiazem cap 360mg/24hr
diltiazem cap 420mg/24
diltiazem cap 60mg er
diltiazem cap 90mg er
diltiazem inj 100mg
diltiazem inj 50mg/10ml
diltiazem tab 120mg
diltiazem tab 30mg
diltiazem tab 60mg
diltiazem tab 90mg
dilt-xr cap 180mg
dilt-xr cap 240mg
dip/tet ped inj 25-5lfu
dipentum cap 250mg
diphen/atrop liq 2.5mg/5ml
diphen/atrop tab 2.5mg
dipyridamole tab 25mg
dipyridamole tab 50mg
dipyridamole tab 75mg
disopyramide cap 100mg
disopyramide cap 150mg
disulfiram tab 250mg
disulfiram tab 500mg
divalproex cap 125mg
divalproex tab 125mg dr
divalproex tab 250mg dr
divalproex tab 250mg er
divalproex tab 500mg dr
divalproex tab 500mg er
docefrez inj 20mg
36
36
36
36
36
36
36
36
36
36
36
36
36
36
36
36
36
50
51
44
44
30
30
30
32
32
3
3
15
15
9
9
9
9
17
docefrez inj 80mg
docetaxel inj 80mg/4ml
docetaxel inj 80mg/8ml
donepezil tab 10mg
donepezil tab 10mg odt
donepezil tab 5mg
donepezil tab 5mg odt
donepezil tab hcl 23mg
dorzol/timol sol 2-0.5%op
dorzolamide sol 2% op
doxazosin tab 1mg
doxazosin tab 2mg
doxazosin tab 4mg
doxazosin tab 8mg
doxepin hcl cap 100mg
doxepin hcl cap 10mg
doxepin hcl cap 150mg
doxepin hcl cap 25mg
doxepin hcl cap 50mg
doxepin hcl cap 75mg
doxepin hcl con 10mg/ml
doxorubicin inj 50mg
doxycycl hyc inj 100mg
doxycycline hyc cap 100mg
doxycycline hyc cap 50mg
doxycycline hyc tab 100mg
doxycycline hyc tab 20mg
doxycycline mono tab 50mg
doxycycline mono tab 75mg
doxycycline sus 25mg/5ml
dronabinol cap 10mg
dronabinol cap 2.5mg
dronabinol cap 5mg
duloxetine cap 20mg
duloxetine cap 30mg
17
17
17
10
10
10
10
10
53
53
31
31
31
31
13
13
13
13
13
13
13
17
7
7
7
7
7
7
7
7
14
14
14
12
12
duloxetine cap 60mg
duramorph inj 0.5mg/ml
duramorph inj 1mg/ml
durezol emu 0.05%
dyrenium cap 100mg
dyrenium cap 50mg
E
econazole cre 1%
edarbi tab 40mg
edarbi tab 80mg
edarbyclor tab 40-12.5mg
edarbyclor tab 40-25mg
edurant tab 25mg
effient tab 10mg
effient tab 5mg
elaprase inj 6mg/3ml
elidel cre 1%
eligard inj 22.5mg
eligard inj 30mg
eligard inj 45mg
eligard inj 7.5mg
elitek inj 1.5mg
ella tab 30mg
elmiron cap 100mg
emcyt cap 140mg
emend cap 125mg
emend cap 40mg
emend cap 80mg
emend pak 80 & 125mg
emsam dis 12mg/24h
emsam dis 6mg/24hr
emsam dis 9mg/24hr
emtriva cap 200mg
emtriva sol 10mg/ml
enablex tab 15mg
66
12
2
2
52
37
37
42
31
31
33
33
24
30
31
44
42
17
17
17
17
17
47
45
17
14
14
14
14
11
11
11
24
24
45
enablex tab 7.5mg
enalapr/hctz tab 10-25mg
enalapr/hctz tab 5-12.5mg
enalapril tab 10mg
enalapril tab 2.5mg
enalapril tab 20mg
enalapril tab 5mg
enbrel inj 25/0.5ml
enbrel inj 25mg
enbrel inj 50mg/ml
endocet tab 10-325mg
endocet tab 5-325mg
endocet tab 7.5-325m
engerix-b inj 10mcg/0.5ml
engerix-b pfs 10mcg/0.5ml
engerix-b pfs 20mcg/ml
enoxaparin inj 100mg/ml
enoxaparin inj 120/0.8ml
enoxaparin inj 150mg/ml
enoxaparin inj 300/3ml
enoxaparin inj 30mg/0.3ml
enoxaparin inj 40mg/0.4ml
enoxaparin inj 60mg/0.6ml
enoxaparin inj 80mg/0.8ml
entacapone tab 200mg
enulose sol 10gm/15ml
epipen 2-pak inj 0.3mg
epipen-jr inj 2-pak 0.15mg
epirubicin inj 50/25ml
epitol tab 200mg
epivir hbv sol 5mg/ml
epivir sol 10mg/ml
eplerenone tab 25mg
eplerenone tab 50mg
eprosart mes tab 600mg
45
33
33
32
32
32
32
49
49
49
2
2
2
50
50
51
29
29
29
29
29
29
29
29
20
44
52
52
17
10
24
24
37
37
31
epzicom tab 600-300mg
eraxis inj 100mg
erbitux inj 100mg
ergoloid mes tab 1mg oral
ergomar sub 2mg
erivedge cap 150mg
erwinaze inj 10000unt
erythro gel/benzoyl 5-3%
erythrocin lac inj 500mg
erythrocin tab 250mg
erythromycin eth tab 400mg
erythromycin gel 2%
erythromycin oin op
erythromycin sol 2%
escitalopram sol 5mg/5ml
escitalopram tab 10mg
escitalopram tab 20mg
escitalopram tab 5mg
esomeprazole cap 49.3mg
estazolam tab 1mg
estazolam tab 2mg
estrad val inj 200mg/5
estradiol tab 0.5mg
estradiol tab 1mg
estradiol tab 2mg
eszopiclone tab 1mg
eszopiclone tab 3mg
ethambutol tab 100mg
ethambutol tab 400mg
ethosuximide cap 250mg
ethosuximide sol 250/5ml
etodolac cap 200mg
etodolac cap 300mg
etodolac er tab 400mg
etodolac er tab 500mg
24
14
17
10
15
17
17
42
7
7
7
42
52
42
12
12
12
12
45
55
55
47
47
47
47
55
55
15
15
8
8
3
3
3
3
etodolac er tab 600mg
etodolac tab 400mg
etodolac tab 500mg
etopophos inj 100mg
etoposide inj 20mg/ml
eurax cre 10%
exelon dis 13.3/24
exelon dis 4.6mg/24hr
exelon dis 9.5mg/24hr
exemestane tab 25mg
exfor/hct tab 10-160-12.5mg
exfor/hct tab 10-160-25mg
exfor/hct tab 10-320-25mg
exfor/hct tab 5-160-12.5mg
exfor/hct tab 5-160-25mg
exforge tab 10-160mg
exforge tab 10-320mg
exforge tab 5-160mg
exforge tab 5-320mg
exjade tab 125mg
exjade tab 250mg
exjade tab 500mg
extavia inj 0.3mg
F
fabrazyme inj 35mg
famciclovir tab 125mg
famciclovir tab 250mg
famciclovir tab 500mg
famotidine inj 10mg/ml
famotidine inj 20mg/50m
famotidine tab 20mg
famotidine tab 40mg
fanapt pak
fanapt tab 10mg
fanapt tab 12mg
67
3
3
3
17
17
42
10
10
10
19
33
33
33
33
33
33
33
33
33
56
56
56
41
44
26
26
26
44
44
44
44
22
22
22
fanapt tab 1mg
fanapt tab 2mg
fanapt tab 4mg
fanapt tab 6mg
fanapt tab 8mg
fareston tab 60mg
faslodex inj 250mg/5ml
fazaclo tab 100mg
fazaclo tab 12.5mg
fazaclo tab 150mg
fazaclo tab 200mg
fazaclo tab 25mg
felbamate sus 600mg/5ml
felbamate tab 400mg
felbamate tab 600mg
felodipine tab 10mg er
felodipine tab 2.5mg er
felodipine tab 5mg er
fenofibrate cap 134mg
fenofibrate cap 150mg
fenofibrate cap 200mg
fenofibrate cap 50mg
fenofibrate cap 67mg
fenofibrate tab 145mg
fenofibrate tab 160mg
fenofibrate tab 48mg
fenofibrate tab 54mg
fenoprofen tab 600mg
fentanyl dis 100mcg/h
fentanyl dis 12mcg/hr
fentanyl dis 25mcg/hr
fentanyl dis 50mcg/hr
fentanyl dis 75mcg/hr
fentora tab 200mcg
fentora tab 400mcg
22
22
22
22
22
17
17
23
23
23
23
23
9
9
9
36
36
36
38
38
38
38
38
38
38
38
38
3
1
1
1
1
1
2
2
fentora tab 600mcg
fentora tab 800mcg
fetzima cap 120mg
fetzima cap 20mg
fetzima cap 40mg
fetzima cap 80mg
fetzima cap titratio
finasteride tab 5mg
firazyr inj 30mg/3ml
firmagon inj 120mg
firmagon inj 80mg
flecainide tab 100mg
flecainide tab 150mg
flecainide tab 50mg
flovent disk aer 100mcg
flovent disk aer 250mcg
flovent disk aer 50mcg
flovent hfa aer 110mcg
flovent hfa aer 220mcg
flovent hfa aer 44mcg
fluconazole sus 10mg/ml
fluconazole sus 40mg/ml
fluconazole tab 100mg
fluconazole tab 150mg
fluconazole tab 200mg
fluconazole tab 50mg
fluconazole/dex inj 400mg
flucytosine cap 250mg
flucytosine cap 500mg
fludarabine inj 50mg
fludrocort tab 0.1mg
flunisolide spr 0.025%
fluocin acet oil 0.01%
fluocinolone acet cre 0.01%
fluocinolone acet cre 0.025%
2
2
12
12
12
12
52
45
52
17
17
32
32
32
53
53
53
53
53
53
14
14
14
14
14
14
14
14
14
16
46
54
53
42
42
fluocinolone acet oil body
fluocinolone acet oin 0.025%
fluocinolone acet sol 0.01%
fluocinonide cre -e 0.05%
fluocinonide gel 0.05%
fluocinonide oin 0.05%
fluocinonide sol 0.05%
fluorouracil cre 5%
fluorouracil inj 2.5g/50ml
fluorouracil sol 2%
fluorouracil sol 5%
fluoxetine cap 10mg
fluoxetine cap 20mg
fluoxetine cap 40mg
fluoxetine cap 90mg dr
fluoxetine sol 20mg/5ml
fluoxetine tab 10mg
fluoxetine tab 20mg
fluoxetine tab 60mg
fluphenaz de inj 25mg/ml
fluphenazine con 5mg/ml
fluphenazine elx 2.5mg/5ml
fluphenazine inj 2.5mg/ml
fluphenazine tab 10mg
fluphenazine tab 1mg
fluphenazine tab 2.5mg
fluphenazine tab 5mg
flurazepam cap 15mg
flurazepam cap 30mg
flurbiprofen sol 0.03% op
flurbiprofen tab 100mg
flurbiprofen tab 50mg
flutamide cap 125mg
fluticasone cre 0.05%
fluticasone oin 0.005%
68
42
42
42
42
42
42
42
42
17
17
17
12
12
12
12
12
12
12
12
21
21
21
21
21
21
21
21
55
55
52
3
3
17
42
42
fluticasone spr 50mcg
fluvastatin cap 20mg
fluvastatin cap 40mg
fluvoxamine cap 100mg er
fluvoxamine cap 150mg er
fluvoxamine tab 100mg
fluvoxamine tab 25mg
fluvoxamine tab 50mg
folotyn inj 40mg/2ml
fondapar sol 10mg/0.8ml
fondapar sol 2.5mg/0.5ml
fondapar sol 5mg/0.4ml
fondapar sol 7.5mg/0.6ml
forfivo xl tab 450mg
forteo sol 600/2.4
fosamax + d tab 70-2800
fosamax + d tab 70-5600
foscarnet inj 24mg/ml
fosinop/hctz tab 10/12.5mg
fosinop/hctz tab 20/12.5mg
fosinopril tab 10mg
fosinopril tab 20mg
fosinopril tab 40mg
fosphenytoin inj 100mg/2ml
fosrenol chw 1000mg
fosrenol chw 500mg
fosrenol chw 750mg
fulyzaq tab 125mg
furosemide inj 10mg/ml
furosemide sol 10mg/ml
furosemide sol 8mg/ml
furosemide tab 20mg
furosemide tab 40mg
furosemide tab 80mg
fusilev inj 50mg
54
38
38
12
12
12
12
12
17
29
29
29
29
11
51
51
51
23
33
33
32
32
32
10
45
45
45
44
37
37
37
37
37
37
17
fuzeon kit
fycompa tab 10mg
fycompa tab 12mg
fycompa tab 2mg
fycompa tab 4mg
fycompa tab 6mg
fycompa tab 8mg
G
gabapentin cap 100mg
gabapentin cap 300mg
gabapentin cap 400mg
gabapentin sol 250/5ml
gabapentin tab 600mg
gabapentin tab 800mg
gabitril tab 12mg
gabitril tab 16mg
galantamine cap 16mg er
galantamine cap 24mg er
galantamine cap 8mg er
galantamine tab 12mg
galantamine tab 4mg
galantamine tab 8mg
gammagard inj 2.5gm/25
gammaplex inj 10gm
ganciclovir inj 500mg
gardasil inj
gauze pads & dressings 2 x 2
gemcitabine inj 1gm
gemfibrozil tab 600mg
generlac sol 10gm/15
gengraf cap 100mg
gengraf cap 25mg
gengraf sol 100mg/ml
gentak oin 0.3% op
gentamicin cre 0.1%
24
9
9
9
9
9
9
9
9
9
9
9
9
9
9
10
10
10
10
11
11
50
50
23
51
27
16
38
45
49
49
50
52
42
gentamicin inj 10mg/ml
gentamicin inj 40mg/ml
gentamicin oin 0.1%
gentamicin sol 0.3% op
gentamicin/nacl inj 0.9mg/ml
gentamicin/nacl inj 1.4mg/ml
gentamicin/nacl inj 1.6mg/ml
gentamicin/nacl inj 100mg
gentamicin/nacl inj 60mg
geodon inj 20mg
gilenya cap 0.5mg
gilotrif tab 20mg
gilotrif tab 30mg
gilotrif tab 40mg
gleevec tab 100mg
gleevec tab 400mg
glimepiride tab 1mg
glimepiride tab 2mg
glimepiride tab 4mg
glip/met tab 2.5-250mg
glip/met tab 2.5-500mg
glip/met tab 5-500mg
glipizide er tab 10mg
glipizide er tab 2.5mg
glipizide er tab 5mg
glipizide tab 10mg
glipizide tab 5mg
glucagen inj hypokit
glucagon kit 1mg
glumetza tab 1000mg
glumetza tab 500mg
glyb/met tab 1.25-250mg
glyb/met tab 2.5-500mg
glyb/metform tab 5-500mg
glyburide mcr tab 1.5mg
69
4
4
42
52
4
4
4
4
4
22
41
17
17
17
17
17
27
27
27
27
27
27
27
27
27
28
28
29
29
28
28
28
28
28
28
glyburide mcr tab 3mg
glyburide mcr tab 6mg
glyburide tab 1.25mg
glyburide tab 2.5mg
glyburide tab 5mg
granisetron inj 0.1mg/ml
granisetron inj 1mg/ml
granisetron tab 1mg
griseofulvin sus 125mg/5ml
guanidine tab 125mg
H
halaven inj 1mg/2ml
halobetasol cre 0.05%
halobetasol oin 0.05%
haloper dec inj 100mg/ml
haloper dec inj 50mg/ml
haloper lac inj 5mg/ml
haloperidol con 2mg/ml
haloperidol tab 0.5mg
haloperidol tab 10mg
haloperidol tab 1mg
haloperidol tab 20mg
haloperidol tab 2mg
haloperidol tab 5mg
havrix inj 1440unit
havrix inj 720unit
hc valerate cre 0.2%
hc valerate oin 0.2%
hep sod/d5w inj 20000unit
hep sod/nacl inj 100unt/ml
hep sod/nacl inj 2unit/ml
hep sod/nacl inj 50unt/ml
heparin sod inj 10000u/ml
heparin sod inj 1000u/ml
heparin sod inj 20000u/ml
28
28
28
28
28
14
14
14
14
15
17
42
42
21
21
21
21
21
21
21
21
21
21
51
51
42
42
29
29
29
29
29
29
30
heparin sod inj 5000u/ml
hepatamine sol 8%
herceptin inj 440mg
hexalen cap 50mg
humatrope inj 12mg
humatrope inj 24mg
humira kit 20mg/0.4ml
humira kit 40mg/0.8ml
humira pen kit crohns
hydralazine inj 20mg/ml
hydralazine tab 100mg
hydralazine tab 10mg
hydralazine tab 25mg
hydralazine tab 50mg
hydrochlorot cap 12.5mg
hydrochlorot tab 12.5mg
hydrochlorot tab 25mg
hydrochlorot tab 50mg
hydroco/apap sol 7.5-325mg
hydroco/apap tab 10-325mg
hydroco/apap tab 5-325mg
hydroco/apap tab 7.5-325mg
hydrocod/ibu tab 7.5-200mg
hydrocortisone cre 1%
hydrocortisone cre 2.5%
hydrocortisone lot 2.5%
hydrocortisone oin 1%
hydrocortisone oin 2.5%
hydrocortisone tab 10mg
hydrocortisone tab 5mg
hydromorphon liq 1mg/ml
hydromorphon tab 12mg er
hydromorphon tab 16mg er
hydromorphon tab 8mg er
hydromorphone inj 500/50ml
30
57
17
16
47
47
50
50
50
39
39
39
39
39
37
37
37
37
2
2
2
2
2
42
42
42
42
42
46
46
2
2
2
2
2
hydromorphone tab 2mg
hydromorphone tab 4mg
hydromorphone tab 8mg
hydroxychlor tab 200mg
hydroxyurea cap 500mg
hydroxyz hcl inj 25mg/ml
hydroxyz hcl inj 50mg/ml
hydroxyz hcl syp 10mg/5ml
hydroxyz hcl tab 10mg
hydroxyz hcl tab 25mg
hydroxyz hcl tab 50mg
hydroxyz pam cap 100mg
hydroxyz pam cap 25mg
hydroxyz pam cap 50mg
I
ibandronate inj 3mg/3ml
ibuprofen sus 100mg/5ml
ibuprofen tab 400mg
ibuprofen tab 600mg
ibuprofen tab 800mg
idarubicin inj 10/10ml
ifex inj 3gm
ifosfamide inj 1gm
ilaris inj 180mg
imbruvica cap 140mg
imipenem/cilas inj 250mg
imipenem/cilas inj 500mg
imipramine hcl tab 10mg
imipramine hcl tab 25mg
imipramine hcl tab 50mg
imipramine pam cap 100mg
imipramine pam cap 125mg
imipramine pam cap 150mg
imipramine pam cap 75mg
imiquimod cre 5%
70
2
2
2
20
17
26
26
26
26
26
26
26
26
26
51
3
3
3
4
17
17
17
50
17
6
6
13
13
13
13
13
13
13
42
imovax rabie inj 2.5/ml
incivek tab 375mg
increlex inj 40mg/4ml
indapamide tab 1.25mg
indapamide tab 2.5mg
indomethacin cap 25mg
indomethacin cap 50mg
indomethacin cap 75mg er
infanrix inj
inlyta tab 1mg
inlyta tab 5mg
insulin pen needle
insulin safety needles
insulin syringe u-100 0.3 ml
insulin syringe u-100 1 ml
insulin syringe u-100 1/2 ml
intelence tab 100mg
intelence tab 200mg
intelence tab 25mg
intralipid inj 20%
intron-a inj 10mu
intron-a inj 18mu
intuniv tab 1mg
intuniv tab 2mg
intuniv tab 3mg
intuniv tab 4mg
invanz inj 1gm
invega sustenna inj 117mg
invega sustenna inj 156mg
invega sustenna inj 234mg
invega sustenna inj 39mg
invega sustenna inj 78mg
invega tab 1.5mg
invega tab 3mg
invega tab 6mg
51
25
47
37
37
4
4
4
51
18
18
28
28
28
28
28
24
24
24
57
18
18
40
40
40
40
6
22
22
22
22
22
22
22
22
invega tab 9mg
invirase cap 200mg
invirase tab 500mg
invokana tab 100mg
invokana tab 300mg
ipol inj inactive
ipratropium sol 0.02%inh
ipratropium spr 0.03%
ipratropium spr 0.06%
ipratropium/ sol albuter
irbesartan tab 150mg
irbesartan tab 300mg
irbesartan tab 75mg
irinotecan inj 100/5ml
isentress chw 100mg
isentress chw 25mg
isentress pow 100mg
isentress tab 400mg
isolyte-p inj /d5w
isolyte-s inj
isoniazid inj 100mg/ml
isoniazid syp 50mg/5ml
isoniazid tab 100mg
isoniazid tab 300mg
isosorb din tab 40mg er
isosorb din tab 5mg
isosorb mono tab 10mg
isosorb mono tab 120mg er
isosorb mono tab 20mg
isosorb mono tab 30mg er
isosorb mono tab 60mg er
isosorbide din tab 10mg
isosorbide din tab 20mg
isosorbide din tab 30mg
isradipine cap 2.5mg
22
25
25
28
28
51
54
54
54
54
31
31
31
18
24
24
24
25
56
56
15
15
15
15
39
39
39
39
39
39
39
39
39
39
36
isradipine cap 5mg
istodax inj 10mg
itraconazole cap 100mg
ixempra kit inj 45mg
ixiaro inj
J
jakafi tab 10mg
jakafi tab 15mg
jakafi tab 20mg
jakafi tab 25mg
jakafi tab 5mg
jalyn cap 0.5-0.4mg
jantoven tab 10mg
jantoven tab 1mg
jantoven tab 2.5mg
jantoven tab 2mg
jantoven tab 3mg
jantoven tab 4mg
jantoven tab 5mg
jantoven tab 6mg
jantoven tab 7.5mg
janumet tab 50-1000mg
janumet tab 50-500mg
janumet xr tab 100-1000mg
janumet xr tab 50-1000mg
janumet xr tab 50-500mg
januvia tab 100mg
januvia tab 25mg
januvia tab 50mg
jevtana inj 60/1.5ml
juxtapid cap 10mg
juxtapid cap 20mg
juxtapid cap 5mg
K
kadcyla inj 100mg
71
36
18
14
18
51
18
18
18
18
18
45
30
30
30
30
30
30
30
30
30
28
28
28
28
28
28
28
28
18
39
39
39
18
kaletra sol 400-100mg/5ml
kaletra tab 100-25mg
kaletra tab 200-50mg
kalydeco tab 150mg
kazano tab 12.5-1000mg
kazano tab 12.5-500mg
kcl in 1/2nacl inj 20meq
kcl/d5w inj 20meq/l
kcl/d5w inj 40meq/l
kcl/nacl inj 20meq/l
kcl10meq/l-d5w-0.45nacl inj
kcl20meq/l-d5w-0.225nacl inj
kcl20meq/l-d5w-0.2nacl inj
kcl20meq/l-d5w-0.33nacl inj
kcl20meq/l-d5w-0.45nacl inj
kcl20meq/l-d5w-lr inj
kcl30meq/l-d5w-0.45nacl inj
kcl40meq/l-d5w-0.45nacl inj
kepivance inj 6.25mg
ketek tab 300mg
ketek tab 400mg
ketoconazole cre 2%
ketoconazole sha 2%
ketoconazole tab 200mg
ketoprofen cap 200mg er
ketoprofen cap 50mg
ketoprofen cap 75mg
ketorolac inj 15mg/ml
ketorolac inj 30mg/ml
ketorolac sol 0.4%
ketorolac sol 0.5%
ketorolac tab 10mg
khedezla tab 100mg er
khedezla tab 50mg er
kineret inj 100mg
25
25
25
55
28
28
56
56
56
56
56
56
56
56
56
56
56
56
18
7
7
42
42
14
4
4
4
4
4
53
53
4
12
12
50
kionex pow usp
klor-con 10 tab 10meq er
klor-con 8 tab 8meq er
klor-con m20 tab 20meq er
kombiglyze tab 2.5-1000mg
kombiglyze tab 5-1000mg
kombiglyze tab 5-500mg
korlym tab 300mg
kuvan tab 100mg
kynamro inj 200mg/ml
L
labetalol inj 5mg/ml
labetalol tab 100mg
labetalol tab 200mg
labetalol tab 300mg
lactated rin inj
lactated rin sol irrigation
lactulose sol 10gm/15
lamivud/zido tab 150-300mg
lamivudine tab 100mg
lamivudine tab 150mg
lamivudine tab 300mg
lamotrigine chw 25mg
lamotrigine chw 5mg
lamotrigine tab 100mg
lamotrigine tab 100mg er
lamotrigine tab 150mg
lamotrigine tab 200mg
lamotrigine tab 200mg er
lamotrigine tab 250mg er
lamotrigine tab 25mg
lamotrigine tab 25mg er
lamotrigine tab 300mg er
lamotrigine tab 50mg er
lantus inj 100/ml
56
56
56
56
28
28
28
49
44
39
35
35
35
35
56
52
45
24
24
24
24
9
9
9
9
9
9
9
9
9
9
9
9
29
lantus inj solostar
latanoprost sol 0.005%
latuda tab 120mg
latuda tab 20mg
latuda tab 40mg
latuda tab 60mg
latuda tab 80mg
lazanda spr 100mcg
lazanda spr 400mcg
leflunomide tab 10mg
leflunomide tab 20mg
lescol xl tab 80mg
letairis tab 10mg
letairis tab 5mg
letrozole tab 2.5mg
leucovorin ca inj 100mg
leucovorin ca inj 350mg
leucovorin ca tab 10mg
leucovorin ca tab 15mg
leucovorin ca tab 25mg
leucovorin ca tab 5mg
leukeran tab 2mg
leukine inj 250mcg
leuprolide inj 1mg/0.2ml
levemir inj
levemir inj flexpen
levetiraceta sol 100mg/ml
levetiraceta tab 1000mg
levetiraceta tab 250mg
levetiraceta tab 500mg
levetiraceta tab 500mg er
levetiraceta tab 750mg
levetiraceta tab 750mg er
levetiracetm inj 500mg/5ml
levobunolol sol 0.5% op
72
29
52
22
22
22
22
22
2
2
50
50
38
55
55
19
18
18
18
18
18
18
16
30
18
29
29
8
8
8
8
8
8
8
8
53
levocarnitine inj 200mg/ml
levocarnitine sol 1gm/10ml
levocarnitine tab 330mg
levoflox/d5w inj 500mg/100ml
levofloxacin inj 25mg/ml
levofloxacin sol 25mg/ml
levofloxacin tab 250mg
levofloxacin tab 500mg
levofloxacin tab 750mg
levothyroxine tab 100mcg
levothyroxine tab 112mcg
levothyroxine tab 125mcg
levothyroxine tab 137mcg
levothyroxine tab 150mcg
levothyroxine tab 175mcg
levothyroxine tab 200mcg
levothyroxine tab 25mcg
levothyroxine tab 300mcg
levothyroxine tab 50mcg
levothyroxine tab 75mcg
levothyroxine tab 88mcg
levoxyl tab 100mcg
levoxyl tab 112mcg
levoxyl tab 125mcg
levoxyl tab 137mcg
levoxyl tab 150mcg
levoxyl tab 175mcg
levoxyl tab 200mcg
levoxyl tab 25mcg
levoxyl tab 50mcg
levoxyl tab 75mcg
levoxyl tab 88mcg
lexiva sus 50mg/ml
lexiva tab 700mg
lido/prilocn cre 2.5-2.5%
44
44
44
7
7
7
7
7
7
48
48
48
48
48
48
48
48
48
48
48
48
48
48
48
48
48
48
48
48
48
48
48
25
25
3
lidocaine gel 2%
lidocaine gel 2% jelly
lidocaine inj 0.5%
lidocaine inj 1%
lidocaine inj 2%
lidocaine oin 5%
lidocaine sol 4%
lidoderm dis 5%
lincocin inj 300mg/ml
lindane lot 1%
lindane sha 1%
liothyronine tab 25mcg
liothyronine tab 50mcg
liothyronine tab 5mcg
lisinop/hctz tab 10-12.5mg
lisinop/hctz tab 20-12.5mg
lisinop/hctz tab 20-25mg
lisinopril tab 10mg
lisinopril tab 2.5mg
lisinopril tab 20mg
lisinopril tab 30mg
lisinopril tab 40mg
lisinopril tab 5mg
lithium carb cap 150mg
lithium carb cap 300mg
lithium carb cap 600mg
lithium carb tab 300mg
lithium carb tab 300mg er
lithium carb tab 450mg er
lithium citr sol 8meq/5ml
livalo tab 1mg
livalo tab 2mg
livalo tab 4mg
lokara lot 0.05%
lomustine cap 100mg
3
42
3
3
3
42
42
42
5
42
42
48
48
48
33
33
33
32
32
32
32
32
32
27
27
27
27
27
27
27
38
38
38
43
16
lomustine cap 10mg
lomustine cap 40mg
loperamide cap 2mg
lorazepam con 2mg/ml
lorazepam tab 0.5mg
lorazepam tab 1mg
lorazepam tab 2mg
lorcet plus tab 7.5-325
losartan pot tab 100mg
losartan pot tab 25mg
losartan pot tab 50mg
losartan/hct tab 100-12.5mg
losartan/hct tab 100-25mg
losartan/hct tab 50-12.5mg
lotronex tab 0.5mg
lotronex tab 1mg
lovastatin tab 10mg
lovastatin tab 20mg
lovastatin tab 40mg
loxapine cap 10mg
loxapine cap 25mg
loxapine cap 50mg
loxapine cap 5mg
lumigan sol 0.01%
lumizyme inj 50mg
lupr dep-ped inj 11.25 mg/ml
lupr dep-ped inj 15mg
lupr dep-ped inj 7.5 mg/ml
lupron depot inj 22.5mg
lupron depot inj 3.75mg
lupron depot inj 30mg
lupron depot inj 45mg
lupron depot inj 7.5mg
lyrica cap 100mg
lyrica cap 150mg
73
16
16
44
27
27
27
27
2
31
31
31
33
33
33
44
44
38
38
38
21
21
21
21
52
44
49
49
49
18
18
18
18
18
40
40
lyrica cap 200mg
lyrica cap 225mg
lyrica cap 25mg
lyrica cap 300mg
lyrica cap 50mg
lyrica cap 75mg
lyrica sol 20mg/ml
lysodren tab 500mg
lyza tab 0.35mg
M
magnesium sulf inj 50%
maprotiline tab 25mg
maprotiline tab 50mg
maprotiline tab 75mg
marplan tab 10mg
matulane cap 50mg
meclizine tab 12.5mg
meclizine tab 25mg
meclofen sod cap 100mg
meclofen sod cap 50mg
medroxypr ac inj 150mg/ml
medroxypr ac tab 10mg
medroxypr ac tab 2.5mg
medroxypr ac tab 5mg
mefloquine tab 250mg
megace es sus 625/5ml
megestrol ace sus 40mg/ml
megestrol acetate tab 20mg
megestrol acetate tab 40mg
mekinist tab 0.5mg
mekinist tab 2mg
meloxicam sus 7.5/5ml
meloxicam tab 15mg
meloxicam tab 7.5mg
melphalan inj 50mg
8
8
8
8
8
8
8
18
47
56
11
11
11
11
18
14
14
4
4
47
47
47
47
20
18
18
18
18
18
18
4
4
4
18
menactra inj
menest tab 0.3mg
menest tab 0.625mg
menest tab 1.25mg
menest tab 2.5mg
menomune inj a/c/y/w
menveo inj
meprobamate tab 200mg
meprobamate tab 400mg
mercaptopurine tab 50mg
meropenem inj 500mg
mesalamine kit 4gm
mesna inj 1gm
mesnex tab 400mg
mestinon syp 60mg/5ml
metadate tab 20mg er
metformin er tab 1000mg
metformin tab 1000mg
metformin tab 500mg
metformin tab 500mg er
metformin tab 750mg er
metformin tab 850mg
methadone inj 10mg/ml
methadone sol 10mg/5ml
methadone sol 5mg/5ml
methadone tab 10mg
methadone tab 5mg
methazolamide tab 25mg
methazolamide tab 50mg
methimazole tab 10mg
methimazole tab 5mg
methocarbamol tab 500mg
methocarbamol tab 750mg
methotrexate inj 1gm
methotrexate inj 25mg/ml
51
47
47
47
47
51
51
26
26
16
6
51
18
18
15
40
28
28
28
28
28
28
1
1
1
1
1
37
37
49
49
55
55
16
16
methotrexate tab 2.5mg
methoxsalen cap 10mg
methscopolamine tab 2.5mg
methyclothiazide tab 5mg
methyld/hctz tab 250/15mg
methyld/hctz tab 250/25mg
methyldopa tab 250mg
methyldopa tab 500mg
methyldopate inj 250mg/5ml
methylin chw 10mg
methylin chw 2.5mg
methylin chw 5mg
methylphenidate cap 10mg
methylphenidate sol 10mg/5ml
methylphenidate sol 5mg/5ml
methylphenidate tab 10mg
methylphenidate tab 20mg
methylphenidate tab 20mg er
methylphenidate tab 27mg er
methylphenidate tab 5mg
methylpr ace inj 40mg/ml
methylpr ace inj 80mg/ml
methylpr ss inj 125mg
methylpr ss inj 40mg
methylprednisolone pak 4mg
methylprednisolone tab 16mg
methylprednisolone tab 32mg
methylprednisolone tab 4mg
methylprednisolone tab 8mg
metipranolol sol 0.3% oph
metoclopram tab 10mg
metoclopramide inj 5mg/ml
metoclopramide sol 5mg/5ml
metoclopramide tab 5mg
metolazone tab 10mg
74
16
43
44
37
34
34
31
31
31
40
40
40
40
40
40
40
40
40
40
40
46
46
46
46
46
46
46
46
46
53
44
44
44
14
37
metolazone tab 2.5mg
metolazone tab 5mg
metoprl/hctz tab 100-25mg
metoprl/hctz tab 100-50mg
metoprl/hctz tab 50-25mg
metoprolol inj 1mg/ml
metoprolol tab 100mg er
metoprolol tab 200mg er
metoprolol tab 25mg er
metoprolol tab 50mg er
metoprolol tar tab 100mg
metoprolol tar tab 25mg
metoprolol tar tab 50mg
metronidazol cap 375mg
metronidazol cre 0.75%
metronidazol gel 0.75%
metronidazol lot 0.75%
metronidazole gel 0.75%vag
metronidazole tab 250mg
metronidazole tab 500mg
metronidazole/nacl inj 500mg
mexiletine cap 150mg
mexiletine cap 200mg
mexiletine cap 250mg
miacalcin inj 200unit/ml
miconazole 3 sup 200mg
midodrine tab 10mg
midodrine tab 2.5mg
midodrine tab 5mg
minitran dis 0.1mg/hr
minitran dis 0.2mg/hr
minitran dis 0.4mg/hr
minitran dis 0.6mg/hr
minocycline cap 100mg
minocycline cap 50mg
38
38
34
34
34
35
35
35
35
35
35
35
35
5
43
43
43
46
5
5
5
32
32
32
51
46
31
31
31
39
39
39
39
7
7
minocycline cap 75mg
minocycline tab 100mg
minocycline tab 50mg
minocycline tab 75mg
minoxidil tab 10mg
minoxidil tab 2.5mg
mirtazapine tab 15mg
mirtazapine tab 15mg odt
mirtazapine tab 30mg
mirtazapine tab 30mg odt
mirtazapine tab 45mg
mirtazapine tab 45mg odt
mirtazapine tab 7.5mg
misoprostol tab 100mcg
misoprostol tab 200mcg
mitomycin inj 20mg
mitoxantrone inj 2mg/ml
m-m-r ii inj live
modafinil tab 100mg
modafinil tab 200mg
moexipr/hctz tab 15-12.5mg
moexipr/hctz tab 15-25mg
moexipr/hctz tab 7.5-12.5mg
moexipril tab 15mg
moexipril tab 7.5mg
mometasone cre 0.1%
mometasone oin 0.1%
montelukast chw 4mg
montelukast chw 5mg
montelukast gra 4mg
montelukast tab 10mg
morphine sul beads cap 120mg
morphine sul beads cap 30mg e
morphine sul beads cap 45mg e
morphine sul beads cap 60mg e
8
8
8
8
39
39
11
11
11
11
11
11
11
45
45
18
18
51
56
56
34
34
34
32
32
43
43
54
54
54
54
1
1
1
1
morphine sul beads cap 75mg e
morphine sul beads cap 90mg e
morphine sul cap 100mg er
morphine sul cap 10mg er
morphine sul cap 20mg er
morphine sul cap 30mg er
morphine sul cap 50mg er
morphine sul cap 60mg er
morphine sul cap 80mg er
morphine sul sol 10mg/5ml
morphine sul sol 20mg/5ml
morphine sul sol 20mg/ml
morphine sul tab 100mg er
morphine sul tab 15mg
morphine sul tab 15mg er
morphine sul tab 30mg
morphine sul tab 30mg er
morphine sul tab 60mg er
moxeza sol 0.5%
moxifloxacin tab 400mg
mozobil inj 24mg/1.2ml
multaq tab 400mg
mupirocin oin 2%
mustargen inj 10mg
mycamine inj 100mg
mycamine inj 50mg
mycophenolate cap 250mg
mycophenolate tab 500mg
mycophenolic tab 180mg dr
mycophenolic tab 360mg dr
myrbetriq tab 25mg
myrbetriq tab 50mg
N
nabumetone tab 500mg
nabumetone tab 750mg
75
1
1
1
1
1
1
1
1
1
2
2
2
1
2
1
2
1
1
52
7
30
32
43
18
14
14
50
50
50
50
45
45
4
4
nadolol tab 20mg
nadolol tab 40mg
nadolol tab 80mg
nadolol/bend tab 40-5mg
nadolol/bend tab 80-5mg
nafcillin inj 10gm
nafcillin inj 1gm
naftin cre 2%
naglazyme inj 1mg/ml
nalbuphine inj 10mg/ml
nalbuphine inj 20mg/ml
naloxone inj 1mg/ml
naltrexone tab 50mg
namenda xr cap 14mg
namenda xr cap 21mg
namenda xr cap 28mg
namenda xr cap 7mg
naproxen dr tab 375mg
naproxen dr tab 500mg
naproxen sod tab 275mg
naproxen sod tab 550mg
naproxen sus 125mg/5ml
naproxen tab 250mg
naproxen tab 375mg
naproxen tab 500mg
nateglinide tab 120mg
nateglinide tab 60mg
nebupent inh 300mg
nefazodone tab 100mg
nefazodone tab 150mg
nefazodone tab 200mg
nefazodone tab 250mg
nefazodone tab 50mg
neo/bac/poly oin op
neo/poly gu sol 40/ml ir
35
35
35
34
34
6
6
43
44
2
2
3
3
11
11
11
11
4
4
4
4
4
4
4
4
28
28
20
11
11
11
11
11
52
45
neo/poly/bac oin /hc 1%op
neo/poly/dex oin 0.1% op
neo/poly/dex sus 0.1% op
neo/poly/gra sol op
neo/poly/hc sol 1% otic
neo/poly/hc sus 1% otic
neo/poly/hc sus op
neomycin tab 500mg
nephramine inj 5.4%
nesina tab 12.5mg
nesina tab 25mg
nesina tab 6.25mg
neumega inj 5mg
neupogen inj 300mcg/0.5ml
neupogen inj 480mcg/0.8ml
neupogen inj 480mcg/1.6ml
neupro dis 1mg/24hr
neupro dis 2mg/24hr
neupro dis 3mg/24hr
neupro dis 4mg/24hr
neupro dis 6mg/24hr
neupro dis 8mg/24hr
nevanac sus 0.1%
nevirapine sus 50mg/5ml
nevirapine tab 200mg
nevirapine tab 400mg er
nexavar tab 200mg
niacin er tab 1000mg
niacin er tab 500mg
niacin er tab 750mg
niacor tab 500mg
nicardipine cap 20mg
nicardipine cap 30mg
nicotrol inh
nifedical xl tab 30mg
53
53
53
52
53
53
53
4
57
28
28
28
30
30
30
30
20
20
20
20
20
20
53
24
24
24
18
39
39
39
39
36
36
3
36
nifedical xl tab 60mg
nifedipine cap 10mg
nifedipine cap 20mg
nifedipine tab 30mg er
nifedipine tab 60mg er
nifedipine tab 90mg er
nilandron tab 150mg
nimodipine cap 30mg
nisoldipine tab 20mg
nisoldipine tab 30mg
nisoldipine tab 40mg
nitrofur mac cap 50mg
nitrofurantn cap 100mg
nitroglyceri dis 0.6mg/hr
nitroglycerin dis 0.1mg/hr
nitroglycerin dis 0.2mg/hr
nitroglycerin dis 0.4mg/hr
nitroglycerin inj 5mg/ml
nitroglycrn spr 0.4mg
nitrostat sublingual 0.3mg
nitrostat sublingual 0.4mg
nitrostat sublingual 0.6mg
norethin ace tab 5mg
norethindron tab 0.35mg
normosol -m inj /d5w
normosol -r inj /d5w
normosol-r inj ph 7.4
nortriptylin sol 10mg/5ml
nortriptyline cap 10mg
nortriptyline cap 25mg
nortriptyline cap 50mg
nortriptyline cap 75mg
norvir cap 100mg
norvir sol 80mg/ml
norvir tab 100mg
76
36
36
36
36
36
36
18
36
36
36
36
5
5
39
39
39
39
39
39
39
39
39
47
47
56
56
56
13
13
13
13
13
25
25
25
novolin inj 70/30
novolin n inj u-100
novolin r inj u-100
novolog inj 100unit/ml
novolog inj flexpen
novolog mix inj 70/30
novolog mix inj flexpen
noxafil sus 40mg/ml
noxafil tab 100mg
nucynta er tab 100mg
nucynta er tab 150mg
nucynta er tab 200mg
nucynta er tab 250mg
nucynta er tab 50mg
nucynta tab 100mg
nucynta tab 50mg
nucynta tab 75mg
nuedexta cap 20-10mg
nulojix inj 250mg
nutropin aq inj 20mg/2ml
nutropin aq inj nuspin 5mg
nyamyc pow 100000
nystat/triam cre
nystat/triam oin
nystatin cre 100000u/gm
nystatin oin 100000u/gm
nystatin pow 100000
nystatin sus 100000u/ml
nystatin tab 500000 unit
nystop pow 100000
O
octreotide inj 1000mcg
octreotide inj 100mcg
octreotide inj 200mcg
octreotide inj 500mcg
29
29
29
29
29
29
29
14
14
1
1
1
1
1
2
2
2
40
50
48
48
43
43
43
43
43
43
41
14
43
49
49
49
49
octreotide inj 50mcg/ml
ofloxacin dro 0.3% op
ofloxacin dro 0.3%otic
ofloxacin tab 200mg
ofloxacin tab 300mg
ofloxacin tab 400mg
olanza/fluox cap 12-25mg
olanza/fluox cap 12-50mg
olanza/fluox cap 3-25mg
olanza/fluox cap 6-25mg
olanza/fluox cap 6-50mg
olanzapine inj 10mg
olanzapine tab 10mg
olanzapine tab 10mg odt
olanzapine tab 15mg
olanzapine tab 15mg odt
olanzapine tab 2.5mg
olanzapine tab 20mg
olanzapine tab 20mg odt
olanzapine tab 5mg
olanzapine tab 5mg odt
olanzapine tab 7.5mg
olysio cap 150mg
omega-3-acid cap 1gm
omeprazole cap 10mg
omeprazole cap 20mg
omeprazole cap 40mg
oncaspar inj 750/ml
ondansetron inj 4mg/2ml
ondansetron sol 4mg/5ml
ondansetron tab 24mg
ondansetron tab 4mg
ondansetron tab 4mg odt
ondansetron tab 8mg
ondansetron tab 8mg odt
49
52
53
7
7
7
12
12
12
12
12
22
22
22
22
22
22
22
23
23
23
23
25
39
45
45
45
18
14
14
14
14
14
14
14
onfi sus 2.5mg/ml
onfi tab 10mg
onfi tab 20mg
onglyza tab 2.5mg
onglyza tab 5mg
opana er tab 10mg
opana er tab 15mg
opana er tab 20mg
opana er tab 30mg
opana er tab 40mg
opana er tab 5mg
opana er tab 7.5mg
opsumit tab 10mg
orap tab 1mg
orap tab 2mg
orencia inj 125mg/ml
orencia inj 250mg
orenitram tab 0.125mg
orenitram tab 0.25mg
orenitram tab 1mg
orenitram tab 2.5mg
orfadin cap 10mg
orfadin cap 2mg
orfadin cap 5mg
orphenadrine inj 30mg/ml
orphenadrine tab 100mg er
oseni tab 12.5-15
oseni tab 12.5-30
oseni tab 12.5-45
oseni tab 25-15mg
oseni tab 25-30mg
oseni tab 25-45mg
oxaliplatin inj 100mg
oxandrolone tab 10mg
oxandrolone tab 2.5mg
77
8
8
8
28
28
1
1
1
1
1
1
1
55
21
21
50
50
55
55
55
55
44
44
44
55
55
28
28
28
28
28
28
18
46
46
oxaprozin tab 600mg
oxazepam cap 10mg
oxazepam cap 15mg
oxazepam cap 30mg
oxcarbazepin sus 300mg/5m
oxcarbazepin tab 150mg
oxcarbazepin tab 300mg
oxcarbazepin tab 600mg
oxtellar xr tab 150mg
oxtellar xr tab 300mg
oxtellar xr tab 600mg
oxybutynin syp 5mg/5ml
oxybutynin tab 10mg er
oxybutynin tab 15mg er
oxybutynin tab 5mg
oxybutynin tab 5mg er
oxycod/apap tab 10-325mg
oxycod/apap tab 2.5-325mg
oxycod/apap tab 5-325mg
oxycod/apap tab 7.5-325mg
oxycod/asa tab 4.8355-325mg
oxycod/ibu tab 5-400mg
oxycodone cap 5mg
oxycodone tab 10mg
oxycodone tab 15mg
oxycodone tab 20mg
oxycodone tab 30mg
oxycodone tab 5mg
oxymorphone tab 10mg er
oxymorphone tab 15mg er
oxymorphone tab 20mg er
oxymorphone tab 30mg er
oxymorphone tab 40mg er
oxymorphone tab 5mg er
oxymorphone tab 7.5mg er
4
27
27
27
10
10
10
10
10
10
10
45
45
45
45
45
2
2
2
2
2
2
2
2
2
2
2
2
1
1
1
1
1
1
1
oxymorphone tab hcl 10mg
oxymorphone tab hcl 5mg
P
pacerone tab 100mg
pacerone tab 200mg
paclitaxel inj 300mg/50ml
palgic liq 4mg/5ml
pamidronate inj 30mg/10ml
pamidronate inj 6mg/ml
pamidronate inj 90mg/10ml
panretin gel 0.1%
pantoprazole inj 40mg
paromomycin cap 250mg
paroxetin er tab 12.5mg
paroxetin er tab 37.5mg
paroxetine tab 10mg
paroxetine tab 20mg
paroxetine tab 25mg er
paroxetine tab 30mg
paroxetine tab 40mg
paser granules 4gm
pataday sol 0.2%
patanol sol 0.1% op
paxil sus 10mg/5ml
pedi-dri pow 100000
pedvax hib inj
peganone tab 250mg
pegasys inj 180mcg/ml
pegasys inj proclick
pegasys kit 180mcg/0.5ml
peg-intron kit 120mcg
peg-intron kit 150mcg
peg-intron kit 80mcg
pen g sod inj 5000000
penicillin gk inj 5mu
2
2
32
32
18
53
51
52
52
43
53
4
12
12
12
12
12
12
12
15
52
52
12
43
51
10
25
25
25
25
25
25
6
6
penicillin vk sol 125/5ml
penicillin vk sol 250/5ml
penicillin vk tab 250mg
penicillin vk tab 500mg
pentam 300 inj 300mg
pentaz/nalox tab 50-0.5mg
pentoxifylline tab 400mg er
perindopril tab 2mg
perindopril tab 4mg
perindopril tab 8mg
periogard sol 0.12%
perjeta inj 420/14ml
permethrin cre 5%
perphen/amit tab 2-10mg
perphen/amit tab 2-25mg
perphen/amit tab 4-10mg
perphen/amit tab 4-25mg
perphen/amit tab 4-50mg
perphenazine tab 16mg
perphenazine tab 2mg
perphenazine tab 4mg
perphenazine tab 8mg
pexeva tab 10mg
pexeva tab 20mg
pexeva tab 30mg
pexeva tab 40mg
phenelzine tab 15mg
phenobarb elx 20mg/5ml
phenobarb tab 100mg
phenobarb tab 15mg
phenobarb tab 16.2mg
phenobarb tab 30mg
phenobarb tab 32.4mg
phenobarb tab 60mg
phenobarb tab 64.8mg
78
6
6
6
6
20
2
37
32
32
32
41
18
43
21
21
21
21
21
21
21
21
21
12
12
12
12
12
8
8
8
8
8
8
8
8
phenobarb tab 97.2mg
phenytoin chw 50mg
phenytoin ex cap 100mg
phenytoin ex cap 200mg
phenytoin ex cap 300mg
phenytoin inj 50mg/ml
phenytoin sus 125mg/5ml
phospholine sol 0.125%op
physiolyte sol
physiosol sol irrigation
picato gel 0.015%
picato gel 0.05%
pilocarpine tab 5mg
pilocarpine tab 7.5mg
pindolol tab 10mg
pindolol tab 5mg
pioglit/glim tab 30-2mg
pioglit/glim tab 30-4mg
pioglita/met tab 15-500mg
pioglita/met tab 15-850mg
pioglitazone tab 15mg
pioglitazone tab 30mg
pioglitazone tab 45mg
piper/tazoba inj 3-0.375g
piper/tazoba inj 4-0.5gm
pirmella tab 1/35
piroxicam cap 10mg
piroxicam cap 20mg
plasma-lyte inj -148
plasma-lyte inj 56/d5w
podofilox sol 0.5%
polyeth glyc pow 3350 nf
pomalyst cap 1mg
pomalyst cap 2mg
pomalyst cap 3mg
8
10
10
10
10
10
10
53
52
52
43
43
41
41
35
35
34
28
28
28
28
29
29
7
7
47
4
4
56
56
43
45
18
18
18
pomalyst cap 4mg
pot chlor inj 10meq/50ml
pot chlor inj 2meq/ml
pot chloride cap 10meq er
pot chloride cap 8meq er
pot citrate tab 1080mg
pot citrate tab 540mg
pot cl micro tab 10meq er
pot cl micro tab 20meq er
potiga tab 200mg
potiga tab 300mg
potiga tab 400mg
potiga tab 50mg
pradaxa cap 150mg
pradaxa cap 75mg
pramipexole tab 0.125mg
pramipexole tab 0.25mg
pramipexole tab 0.5mg
pramipexole tab 0.75mg
pramipexole tab 1.5mg
pramipexole tab 1mg
prandimet tab 1-500mg
prandimet tab 2-500mg
prandin tab 0.5mg
prandin tab 1mg
prandin tab 2mg
pravastatin tab 10mg
pravastatin tab 20mg
pravastatin tab 40mg
pravastatin tab 80mg
prazosin hcl cap 1mg
prazosin hcl cap 2mg
prazosin hcl cap 5mg
pred sod pho sol 1% op
pred sod pho sol 5mg/5ml
18
56
56
56
56
56
56
56
56
8
8
8
8
30
30
20
20
20
20
20
20
29
29
29
29
29
38
38
38
38
31
31
31
53
46
prednicarbate cre 0.1%
prednicarbate oin 0.1%
prednisolone sol 15mg/5ml
prednisolone sol 25mg/5ml
prednisolone sus 1% op
prednisone sol 5mg/5ml
prednisone tab 10mg
prednisone tab 1mg
prednisone tab 2.5mg
prednisone tab 20mg
prednisone tab 50mg
prednisone tab 5mg
premarin inj 25mg
premarin tab 0.3mg
premarin tab 0.45mg
premarin tab 0.625mg
premarin tab 0.9mg
premarin tab 1.25mg
premarin vag cre 0.625mg
premasol sol 6%
premphase tab
prempro tab .625-2.5
prempro tab 0.3-1.5
prempro tab 0.45-1.5
prempro tab 0.625-5
prenatal vitamin tablet
prepopik pak
prevalite pow 4gm
prezista sus 100mg/ml
prezista tab 150mg
prezista tab 600mg
prezista tab 75mg
prezista tab 800mg
priftin tab 150mg
primaquine tab 26.3mg
79
43
43
46
46
53
46
46
46
46
46
46
46
47
47
47
47
47
47
46
57
47
47
47
47
47
57
45
39
25
25
25
25
25
15
16
primidone tab 250mg
primidone tab 50mg
pristiq tab 100mg
pristiq tab 50mg
proair hfa aer
probenecid tab 500mg
procainamide inj 100mg/ml
procalamine inj 3%
prochlorperazine inj 5mg/ml
prochlorperazine sup 25mg
prochlorperazine tab 10mg
prochlorperazine tab 5mg
procrit inj 10000/ml
procrit inj 2000/ml
procrit inj 20000/ml
procrit inj 3000/ml
procrit inj 4000/ml
procrit inj 40000/ml
procto-pak cre 1%
proctozone cre -hc 2.5%
proglycem sus 50mg/ml
prograf inj 5mg/ml
prolastin-c inj 1000mg
proleukin inj 22mu
prolia sol 60mg/ml
promacta tab 12.5mg
promacta tab 25mg
promacta tab 50mg
promacta tab 75mg
promethazine inj 25mg/ml
promethazine inj 50mg/ml
propafenone tab 150mg
propafenone tab 225mg
propafenone tab 300mg
propran/hctz tab 40/25mg
9
9
12
12
54
15
32
57
21
21
22
22
30
30
30
30
30
30
43
43
29
50
55
18
52
30
30
30
30
53
53
32
32
32
34
propran/hctz tab 80/25mg
propranolol cap 120mg er
propranolol cap 160mg er
propranolol cap 60mg er
propranolol cap 80mg er
propranolol inj 1mg/ml
propranolol sol 20mg/5ml
propranolol sol 40mg/5ml
propranolol tab 10mg
propranolol tab 20mg
propranolol tab 40mg
propranolol tab 60mg
propranolol tab 80mg
propylthiouracil tab 50mg
proquad inj
prosol inj 20%
protriptyline tab 10mg
protriptyline tab 5mg
pulmozyme sol 1mg/ml
pyrazinamide tab 500mg
pyridostigme tab 60mg
Q
qnapril/hctz tab 10-12.5mg
qnapril/hctz tab 20-12.5mg
qnapril/hctz tab 20-25mg
qudexy xr cap 100/24hr
qudexy xr cap 150/24hr
qudexy xr cap 200/24hr
qudexy xr cap 25/24hr
qudexy xr cap 50/24hr
quetiapine tab 100mg
quetiapine tab 200mg
quetiapine tab 25mg
quetiapine tab 300mg
quetiapine tab 400mg
34
35
35
35
35
35
35
35
35
35
35
35
35
49
51
57
14
14
55
15
15
34
34
34
9
9
9
9
9
23
23
23
23
23
quetiapine tab 50mg
quinapril tab 10mg
quinapril tab 20mg
quinapril tab 40mg
quinapril tab 5mg
quinidine gl tab 324mg er
quinidine su tab 200mg
quinidine su tab 300mg
quinidine su tab 300mg er
quinine sulf cap 324mg
qvar aer 40mcg
qvar aer 80mcg
R
rabavert inj
raloxifene hcl tab 60mg
ramipril cap 1.25mg
ramipril cap 10mg
ramipril cap 2.5mg
ramipril cap 5mg
ranexa tab 1000mg
ranexa tab 500mg
ranitidine cap 150mg
ranitidine cap 300mg
ranitidine inj 150mg/6ml
ranitidine syp 15mg/ml
ranitidine tab 150mg
ranitidine tab 300mg
rapaflo cap 4mg
rapaflo cap 8mg
rapamune sol 1mg/ml
rapamune tab 1mg
rapamune tab 2mg
rebif inj 22mg/0.5ml
rebif inj 44mg/0.5ml
rebif titrtn sol pack
80
23
32
32
32
32
32
32
32
32
20
53
53
51
47
32
32
32
32
37
37
44
44
44
44
44
44
45
45
50
50
50
41
41
41
reclast inj 5mg/100ml
recombiva hb inj 10mcg/ml
recombiva-hb inj 40mcg/ml
regranex gel 0.01%
relenza mis diskhale
relistor kit 12/0.6ml
relpax tab 20mg
relpax tab 40mg
remicade inj 100mg
renvela pak 0.8gm
renvela pak 2.4gm
renvela tab 800mg
repaglinide tab 0.5mg
repaglinide tab 1mg
repaglinide tab 2mg
rescriptor tab 100 mg
rescriptor tab 200mg
reserpine tab 0.1mg
restasis emu 0.05%
retrovir inj 10mg/ml
revatio inj 10mg
revlimid cap 10mg
revlimid cap 15mg
revlimid cap 2.5mg
revlimid cap 20mg
revlimid cap 25mg
revlimid cap 5mg
reyataz cap 150mg
reyataz cap 200mg
reyataz cap 300mg
rheumatrex tab 2.5mg
ribapak pak 1000mg/day
ribapak pak 800mg/day
ribasphere cap 200mg
ribasphere tab 200mg
52
51
51
43
25
44
15
15
50
45
45
45
29
29
29
24
24
37
52
24
55
16
16
16
16
16
16
25
25
25
18
25
25
25
25
ribasphere tab 400mg
ribavirin cap 200mg
ribavirin tab 200mg
rifabutin cap 150mg
rifampin cap 150mg
rifampin cap 300mg
rifampin inj 600 mg
rifater tab
riluzole tab 50mg
rimantadine tab 100mg
ringers inj
ringers irrigation sol
riomet sol 500mg/5ml
risperdal inj 12.5mg
risperdal inj 25mg
risperdal inj 37.5mg
risperdal inj 50mg
risperidone sol 1mg/ml
risperidone tab 0.25 odt
risperidone tab 0.25mg
risperidone tab 0.5mg
risperidone tab 0.5mg od
risperidone tab 1mg
risperidone tab 1mg odt
risperidone tab 2mg
risperidone tab 2mg odt
risperidone tab 3mg
risperidone tab 3mg odt
risperidone tab 4mg
risperidone tab 4mg odt
rituxan inj 500mg
rivastigmine cap 1.5mg
rivastigmine cap 3mg
rivastigmine cap 4.5mg
rivastigmine cap 6mg
25
26
26
15
15
15
15
15
40
25
57
52
29
23
23
23
23
23
23
23
23
23
23
23
23
23
23
23
23
23
18
11
11
11
11
ropinirole tab 0.25mg
ropinirole tab 0.5mg
ropinirole tab 1mg
ropinirole tab 2mg
ropinirole tab 3mg
ropinirole tab 4mg
ropinirole tab 5mg
rotarix sus
rotateq sus
rozerem tab 8mg
S
sabril pow 500mg
sabril tab 500mg
saizen inj 5mg
saizen inj 8.8mg
samsca tab 15mg
samsca tab 30mg
sancuso dis 3.1mg
sandimmune cap 100mg
sandimmune cap 25mg
sandimmune sol 100mg/ml
sandostatin kit lar 10mg
sandostatin kit lar 20mg
sandostatin kit lar 30mg
santyl oin 250/gm
saphris sub 10mg
saphris sub 5mg
savella mis titr pak
savella tab 100mg
savella tab 12.5mg
savella tab 25mg
savella tab 50mg
seconal cap 100mg
selegiline cap 5mg
selegiline tab 5mg
81
20
20
20
20
20
20
20
51
51
55
9
9
48
48
56
56
14
50
50
50
49
49
49
43
23
23
40
40
40
40
40
55
21
21
selenium sul lot 2.5%
selzentry tab 150mg
selzentry tab 300mg
sensipar tab 30mg
sensipar tab 60mg
sensipar tab 90mg
serevent dis aer 50mcg
seroquel xr tab 150mg
seroquel xr tab 200mg
seroquel xr tab 300mg
seroquel xr tab 400mg
seroquel xr tab 50mg
sertraline con 20mg/ml
sertraline tab 100mg
sertraline tab 25mg
sertraline tab 50mg
signifor inj 0.3mg/ml
signifor inj 0.6mg/ml
signifor inj 0.9mg/ml
sildenafil tab 20mg
silver sulfa cre 1%
simvastatin tab 10mg
simvastatin tab 20mg
simvastatin tab 40mg
simvastatin tab 5mg
simvastatin tab 80mg
sirolimus tab 0.5mg
sirturo tab 100mg
smz/tmp ds tab 800-160mg
smz-tmp inj 400-80mg/5ml
smz-tmp sus 200-40mg/5ml
smz-tmp tab 400-80mg
sod chloride inj 0.45%
sod chloride inj 0.9%
sod chloride inj 2.5meq/ml
43
25
25
49
49
49
54
23
23
23
23
23
12
13
13
13
49
49
49
55
43
38
38
38
39
39
50
15
7
7
7
7
57
57
57
sod chloride inj 3%
sod chloride inj 5%
sod fluoride 2.2mg(1 mg) tab
sod lactate inj 5meq/ml
sod poly sul sus 15gm/60ml
sod sulfacet sol 10% op
sodium chlor sol 0.9% irr
solaraze gel 3% w/w
soltamox sol 10mg/5ml
somatuline inj 120mg/0.5ml
somatuline inj 60mg/0.2ml
somatuline inj 90mg/0.3ml
somavert inj 10mg
somavert inj 15mg
somavert inj 20mg
sorine tab 120mg
sorine tab 160mg
sorine tab 240mg
sorine tab 80mg
sotalol hcl tab 120mg
sotalol hcl tab 160mg
sotalol hcl tab 240mg
sotalol hcl tab 80mg
sovaldi tab 400mg
spiriva cap handihlr
spirono/hctz tab 25/25mg
spironolactone tab 100mg
spironolactone tab 25mg
spironolactone tab 50mg
sprycel tab 100mg
sprycel tab 140mg
sprycel tab 20mg
sprycel tab 50mg
sprycel tab 70mg
sprycel tab 80mg
57
57
57
57
56
52
45
43
41
49
49
49
49
49
49
35
35
35
35
35
35
35
35
26
54
34
37
37
37
18
18
19
19
19
19
ssd cre 1%
stavudine cap 15mg
stavudine cap 20mg
stavudine cap 30mg
stavudine cap 40mg
stavudine sol 1mg/ml
stivarga tab 40mg
strattera cap 100mg
strattera cap 10mg
strattera cap 18mg
strattera cap 25mg
strattera cap 40mg
strattera cap 60mg
strattera cap 80mg
streptomycin inj 1gm
stribild tab
stromectol tab 3mg
suboxone mis 12-3mg
suboxone mis 4-1mg
sucralfate tab 1gm
sulf/pred na sol op
sulfacetamide sus 10%
sulfadiazine tab 500mg
sulfasalazin tab 500mg
sulfazine ec tab 500mg
sulindac tab 150mg
sulindac tab 200mg
sumatriptan inj 6mg/0.5ml
sumatriptan pfs 6mg/0.5ml
sumatriptan tab 100mg
sumatriptan tab 25mg
sumatriptan tab 50mg
suprax cap 400mg
suprax sus 200mg/5ml
suprax tab 400mg
82
43
24
24
24
24
54
19
40
40
40
40
40
40
40
4
25
20
3
3
45
53
43
7
51
51
4
4
15
15
15
15
15
6
6
6
surmontil cap 100mg
surmontil cap 25mg
surmontil cap 50mg
sustiva cap 200mg
sustiva cap 50mg
sustiva tab 600mg
sutent cap 12.5mg
sutent cap 25mg
sutent cap 50mg
sylatron kit 296mcg
sylatron kit 444mcg
sylatron kit 888mcg
symbicort aer 160-4.5mcg
symbicort aer 80-4.5mcg
symlinpen 120 inj 1000mcg
symlinpen 60 inj 1000mcg
synagis inj 50mg/0.5ml
synarel sol 2mg/ml
synercid inj 500mg
synribo inj 3.5mg
synthroid tab 100mcg
synthroid tab 112mcg
synthroid tab 125mcg
synthroid tab 137mcg
synthroid tab 150mcg
synthroid tab 175mcg
synthroid tab 200mcg
synthroid tab 25mcg
synthroid tab 300mcg
synthroid tab 50mcg
synthroid tab 75mcg
synthroid tab 88mcg
syprine cap 250mg
T
tabloid tab 40mg
14
14
14
24
24
24
19
19
19
19
19
19
54
54
29
29
50
49
5
19
48
48
48
48
48
48
48
48
48
48
48
48
16
16
tacrolimus cap 0.5mg
tacrolimus cap 1mg
tacrolimus cap 5mg
tafinlar cap 50mg
tafinlar cap 75mg
tamiflu cap 30mg
tamiflu cap 45mg
tamiflu cap 75mg
tamiflu sus 6mg/ml
tamoxifen tab 10mg
tamoxifen tab 20mg
tamsulosin cap 0.4mg
tarceva tab 100mg
tarceva tab 150mg
tarceva tab 25mg
targretin cap 75mg
targretin gel 1%
tarka tab 1-240mg cr
tarka tab 2-180mg cr
tarka tab 2-240mg cr
tarka tab 4-240mg cr
tasigna cap 150mg
tasigna cap 200mg
taxotere inj 80mg/4ml
tazorac cre 0.05%
tazorac cre 0.1%
tazorac gel 0.05%
tazorac gel 0.1%
taztia xt cap 120mg/24hr
taztia xt cap 180mg/24hr
taztia xt cap 240mg/24hr
taztia xt cap 300mg/24hr
taztia xt cap 360mg/24hr
teflaro inj 400mg
teflaro inj 600mg
50
50
50
19
19
25
25
25
25
19
19
45
19
19
19
19
43
34
34
34
34
19
19
19
43
43
43
43
36
36
36
36
36
6
6
tegretol xr tab 100mg
tekamlo tab 150-10mg
tekamlo tab 150-5mg
tekamlo tab 300-10mg
tekamlo tab 300-5mg
tekturna hct tab 150-12.5mg
tekturna hct tab 150-25mg
tekturna hct tab 300-12.5mg
tekturna hct tab 300-25mg
tekturna tab 150mg
tekturna tab 300mg
telmis/amlod tab 40-10mg
telmis/amlod tab 40-5mg
telmis/amlod tab 80-10mg
telmis/amlod tab 80-5mg
telmisa/hctz tab 40-12.5
telmisa/hctz tab 80-12.5
telmisa/hctz tab 80-25mg
telmisartan tab 20mg
telmisartan tab 40mg
telmisartan tab 80mg
temazepam cap 15mg
temazepam cap 22.5mg
temazepam cap 30mg
temazepam cap 7.5mg
terazosin cap 10mg
terazosin cap 1mg
terazosin cap 2mg
terazosin cap 5mg
terbutaline inj 1mg/ml
terconazole cre 0.4%
terconazole sup 80mg
testost cyp inj 100mg/ml
testost cyp inj 200mg/ml
testost enan inj 200mg/ml
83
10
34
34
34
34
34
34
34
34
37
37
34
34
34
34
34
34
34
31
31
31
55
55
55
55
31
31
31
31
54
46
46
47
47
47
tet/dip tox inj 2-2 lf
tetanus tox inj 5lf ads
teveten hct tab 600-12.5mg
teveten hct tab 600-25mg
thalomid cap 100mg
thalomid cap 150mg
thalomid cap 200mg
thalomid cap 50mg
theophylline tab 100mg cr
theophylline tab 200mg cr
theophylline tab 300mg er
theophylline tab 450mg er
theophylline tab 600mg er
thioridazine tab 100mg
thioridazine tab 10mg
thioridazine tab 25mg
thioridazine tab 50mg
thiothixene cap 10mg
thiothixene cap 1mg
thiothixene cap 2mg
thiothixene cap 5mg
thymoglobuln inj 25mg
tiagabine tab 2mg
tiagabine tab 4mg
ticlopidine tab 250mg
tikosyn cap 125mcg
tikosyn cap 250mcg
tikosyn cap 500mcg
timolol gel sol 0.25% op
timolol gel sol 0.5% op
timolol mal sol 0.25% op
timolol mal sol 0.5% op
timolol mal tab 10mg
timolol mal tab 20mg
timolol mal tab 5mg
51
51
34
34
16
16
16
16
54
54
54
54
54
22
22
22
22
22
22
22
22
50
9
9
31
32
32
32
53
53
53
53
35
35
35
tivicay tab 50mg
tizanidine tab 2mg
tizanidine tab 4mg
tobramycin inj 10mg/ml
tobramycin inj 80mg/2ml
tobramycin neb 300/5ml
tobramycin sol 0.3% op
tobramycin/ sus dexameth
tolazamide tab 250mg
tolazamide tab 500mg
tolbutamide tab 500mg
tolmetin sod cap 400mg
tolmetin sod tab 600mg
tolterodine tab 1mg
tolterodine tab 2mg
topiramate cap 15mg
topiramate cap 25mg
topiramate tab 100mg
topiramate tab 200mg
topiramate tab 25mg
topiramate tab 50mg
toposar inj 1gm/50ml
topotecan inj 4mg
torisel sol 25mg/ml
torsemide tab 100mg
torsemide tab 10mg
torsemide tab 20mg
torsemide tab 5mg
tpn electrol inj
tracleer tab 125mg
tracleer tab 62.5mg
tramad/apap tab 37.5-325mg
tramadol hcl tab 50mg
trandolapril tab 1mg
trandolapril tab 2mg
25
55
55
4
4
4
52
53
29
29
29
4
4
45
45
9
9
15
9
9
9
19
19
19
37
37
37
37
57
55
55
3
3
32
32
trandolapril tab 4mg
tranex acid tab 650mg
tranexamic inj acid 100mg/ml
transderm-sc dis 1.5mg
tranylcyprom tab 10mg
travasol inj 10%
travatan z dro 0.004%
trazodone tab 100mg
trazodone tab 150mg
trazodone tab 300mg
trazodone tab 50mg
treanda inj 100mg
trecator tab 250mg
trelstar dep inj 3.75mg
trelstar la inj 11.25mg
trelstar mix inj 22.5mg
tretinoin cap 10mg
trexall tab 10mg
trexall tab 15mg
trexall tab 5mg
trexall tab 7.5mg
triamcin ace inj 10mg/ml
triamcin ace inj 40mg/ml
triamcin/ora pst 0.1%
triamcinolon cre 0.025%
triamcinolone cre 0.1%
triamcinolone cre 0.5%
triamcinolone lot 0.025%
triamcinolone lot 0.1%
triamcinolone oin 0.025%
triamcinolone oin 0.1%
triamcinolone oin 0.5%
triamt/hctz cap 50-25mg
triamt/hctz tab 37.5-25mg
triamt/hctz tab 75-50mg
84
32
30
30
14
12
57
52
11
11
11
11
19
15
19
19
19
19
50
50
50
50
46
46
41
43
43
43
43
43
43
43
43
34
34
34
triazolam tab 0.125mg
triazolam tab 0.25mg
tribenzor tab 20-5-12.5mg
tribenzor tab 40-10-12.5mg
tribenzor tab 40-10-25mg
tribenzor tab 40-5-12.5mg
tribenzor tab 40-5-25mg
triderm cre 0.1%
trifluoperazine tab 10mg
trifluoperazine tab 1mg
trifluoperazine tab 2mg
trifluoperazine tab 5mg
trifluridine sol 1% op
trihexyphen elx 0.4mg/ml
trihexyphen tab 2mg
trihexyphen tab 5mg
trimetho sol polymyxn 0.1%
trimethoprim tab 100mg
trinessa tab
tri-previfem tab
trisenox sol 10mg/10ml
tri-sprintec tab
trokendi xr cap 100mg
trokendi xr cap 200mg
trokendi xr cap 25mg
trokendi xr cap 50mg
truvada tab 200-300mg
twinrix inj
tygacil inj 50mg
tykerb tab 250mg
typhim vi inj
tysabri inj 300mg/15ml
tyzeka tab 600mg
tyzine ped nasal dro 0.05%
55
55
34
34
34
34
34
43
22
22
22
22
52
20
20
20
52
5
47
47
19
47
9
10
10
10
24
51
5
19
51
41
26
54
U
uceris tab 9mg
u-cort cre 1%
uloric tab 40mg
uloric tab 80mg
unithroid tab 100mcg
unithroid tab 112mcg
unithroid tab 125mcg
unithroid tab 150mcg
unithroid tab 175mcg
unithroid tab 200mcg
unithroid tab 25mcg
unithroid tab 300mcg
unithroid tab 50mcg
unithroid tab 75mcg
unithroid tab 88mcg
ursodiol tab 250mg
ursodiol tab 500mg
uvadex inj 20mcg/ml
V
valacyclovir tab 1gm
valacyclovir tab 500mg
valcyte sol 50mg/ml
valcyte tab 450mg
valproate inj 100mg/ml
valproic acd cap 250mg
valproic acd syp 250mg/5ml
valsart/hctz tab 160-12.5
valsart/hctz tab 160-25mg
valsart/hctz tab 320-12.5
valsart/hctz tab 320-25mg
valsart/hctz tab 80-12.5
vancomycin cap 125mg
vancomycin cap 250mg
vancomycin inj 1000mg
46
43
15
15
48
48
48
48
48
48
48
48
48
48
48
44
44
19
26
26
23
23
9
9
9
29
34
34
34
34
5
5
5
vancomycin inj 10gm
vancomycin inj 500mg
vandazole gel 0.75%
vaqta inj 25unit/0.5ml
varivax inj
vectibix inj 100mg
velcade inj 3.5mg
venlafaxine cap 150mg er
venlafaxine cap 37.5mg
venlafaxine cap 75mg er
venlafaxine tab 100mg
venlafaxine tab 150mg er
venlafaxine tab 225mg er
venlafaxine tab 25mg
venlafaxine tab 37.5 er
venlafaxine tab 37.5mg
venlafaxine tab 50mg
venlafaxine tab 75mg
venlafaxine tab 75mg er
ventavis sol 10mcg/ml
ventavis sol 20mcg/ml
ventolin hfa aer
verapamil cap 100mg er
verapamil cap 120mg er
verapamil cap 180mg er
verapamil cap 200mg er
verapamil cap 240mg er
verapamil cap 300mg er
verapamil cap 360mg sr
verapamil inj 2.5mg/ml
verapamil tab 120mg
verapamil tab 120mg er
verapamil tab 180mg er
verapamil tab 240mg er
verapamil tab 40mg
85
5
5
46
51
51
19
19
13
13
13
13
13
13
13
13
13
13
13
13
55
55
54
36
36
36
36
36
36
36
36
36
36
36
36
36
verapamil tab 80mg
versacloz sus 50mg/ml
vesicare tab 10mg
vesicare tab 5mg
victrelis cap 200mg
videx sol 2gm
vigamox dro 0.5%
viibryd kit
viibryd tab 10mg
viibryd tab 20mg
viibryd tab 40mg
vimpat inj 200mg/20ml
vimpat sol 10mg/ml
vimpat tab 100mg
vimpat tab 150mg
vimpat tab 200mg
vimpat tab 50mg
vinblastine inj 10mg
vincasar pfs inj 1mg/ml
vincristine inj 1mg/ml
vinorelbine inj 10mg/ml
viracept tab 250mg
viracept tab 625mg
viramune xr tab 100mg
virazole inh 6gm
viread pow 40mg/gm
viread tab 150mg
viread tab 200mg
viread tab 250mg
viread tab 300mg
voltaren gel 1%
voriconazole inj 200mg
voriconazole sus 40mg/ml
voriconazole tab 200mg
votrient tab 200mg
37
23
45
45
26
24
52
11
11
11
11
10
10
10
10
10
10
19
19
19
19
25
25
24
25
24
24
24
24
24
43
15
15
15
19
vyfemla tab 0.4-35
vytorin tab 10-10mg
vytorin tab 10-20mg
vytorin tab 10-40mg
vytorin tab 10-80mg
W
warfarin tab 10mg
warfarin tab 1mg
warfarin tab 2.5mg
warfarin tab 2mg
warfarin tab 3mg
warfarin tab 4mg
warfarin tab 5mg
warfarin tab 6mg
warfarin tab 7.5mg
welchol pak 3.75gm
welchol tab 625mg
X
xalkori cap 200mg
xalkori cap 250mg
xarelto tab 10mg
xarelto tab 15mg
xarelto tab 20mg
xenazine tab 12.5mg
xenazine tab 25mg
xgeva inj 120mg
xifaxan tab 550mg
xolair sol 150mg
xtandi cap 40mg
xulane dis 150-35
xyrem sol 500mg/ml
Y
yervoy inj 50mg/10ml
yf-vax inj
47
39
39
39
39
30
30
30
30
30
30
30
30
30
39
39
19
19
30
30
30
40
40
52
5
55
19
47
56
19
51
Z
zafirlukast tab 10mg
zafirlukast tab 20mg
zaleplon cap 10mg
zaleplon cap 5mg
zaltrap inj 100/4ml
zavesca cap 100mg
zazole cre 0.4%
zazole cre 0.8%
zelboraf tab 240mg
zemplar cap 1mcg
zemplar cap 2mcg
zemplar cap 4mcg
zemplar inj 2mcg/ml
zemplar inj 5mcg/ml
zenpep cap 10000unt
zenpep cap 15000unt
zenpep cap 20000unt
zenpep cap 25000unt
54
54
55
55
19
44
46
46
19
52
52
52
52
52
44
44
44
44
zenpep cap 3000unit
zenpep cap 5000unit
zetia tab 10mg
ziagen sol 20mg/ml
zidovudine cap 100mg
zidovudine syp 50mg/5ml
zidovudine tab 300mg
ziprasidone cap 20mg
ziprasidone cap 40mg
ziprasidone cap 60mg
ziprasidone cap 80mg
zirgan gel 0.15%
zohydro er cap 10mg
zohydro er cap 15mg
zohydro er cap 20mg
zohydro er cap 30mg
zohydro er cap 40mg
zohydro er cap 50mg
zoledronic inj 4mg/5m
zolinza cap 100mg
44
44
39
24
24
24
24
23
23
23
23
52
1
1
1
1
1
1
52
19
zolpidem tab 10mg
zolpidem tab 5mg
zonisamide cap 100mg
zonisamide cap 25mg
zonisamide cap 50mg
zortress tab 0.25mg
zortress tab 0.5mg
zortress tab 0.75mg
zostavax inj
zubsolv sub 1.4-0.36
zubsolv sub 5.7-1.4
zyflo cr tab 600mg
zyflo tab 600mg
zykadia cap 150mg
zytiga tab 250mg
zyvox sol 2mg/ml
zyvox sus 100mg/5ml
zyvox tab 600mg
55
56
8
8
9
50
50
50
51
3
3
54
54
19
19
5
5
5
BeHealthy America is an HMO plan with a Medicare contract. Enrollment in BeHealthy America depends on contract renewal.
This information is available for free in other languages. Please call our customer service number at 855-522-2870. We are open:
 October 1 to February 14: Monday through Sunday, 8:00 am – 8:00 pm
 February 15 to September 30: Monday through Friday, 8:00 am – 8:00 pm
TTY users should call 855-522-2973. You can also visit www.behealthyus.com for an up-to-date listing of participating providers.
Esta información está disponible gratis en otros idiomas. Para obtener información adicional por favor llame a nuestro Departamento de Servicio
al Cliente al 1-855-522-2870. Los usuarios de TTY/TTD deben llamar al 1-855-522-2973. El horario es de lunes a domingo, de 8:00 am a 8:00
pm a partir de 1 de Octubre al 14 de Febrero, y lunes a viernes, de 8:00 am a 5:00 pm de 15 Febrero -30 Septiembre.
86
This information may be available in different formats, such as Braille or larger print. Please call our Customer Service Department at 1-855-5222870 for additional information. TTY/TTD users should call 1-855-522-2973.
This formulary was updated on 08/08/2014. For more recent information or other questions, please contact BeHealthy America at 1-855-522-2870
or, for TTY users, 1-800-522-2973, 8am to 8pm, Monday through Sunday, from October 1, 2014 to February 14, 2015 and 8am to 8pm, Monday
through Friday from February 15, 2015 to September 30, 2015 or visit www.behealthyus.com.
H2758_CompFormulary_2015_Accepted 10/06/2014
87