1. No category

Citrus Valley Health Partners Formulary Alphabetical Listing 2015
The formulary represents a listing of frequently prescribed medications and may not include all drugs covered under your pharmacy drug benefit. Coverage for some drugs may be limited to specific dosage forms and/or strengths. Any drug on this listing that is available in a generic form (indicated by "O" or "Y" under Generic Indicator) will be provided at Tier 1 when dispensed as a generic; unless otherwise noted below. Brand names are listed for reference only.
This listing does not include Generic Drugs, nor is it inclusive of all Non‐Preferred Brand drugs available on the market. This list of out‐patient prescription drugs has been developed by a committee of physicians and pharmacists to ensure the provision of safe, efficacious, and cost‐effective drug therapy. The committee meets on a quarterly basis to discuss new drugs and new prescribing information as it becomes available.
TIERING
Tier 1 = Generic
Tier 2 = Preferred Brand Tier 3 = Non‐Preferred Brand Tier 4 = Preferred Specialty/Injectable
BENEFIT NOTES
A = Age Edit
G = Gender Edit
OTC = Over‐The‐Counter Drug
QL = Quantity Limit
ST = Step Therapy
Check your plan benefit materials for more information about your pharmacy benefit including copayment amounts for each tier. This listing is subject to change as new drugs and new prescribing information becomes available.
Generic Indicator
Premium Plus Tier
Benefit Notes
fluticasone and salmeterol
N
2
QL
Advair Hfa fluticasone and salmeterol
N
2
QL
Advicor
niacin and lovastatin
N
3
QL
Aerospan Aer flunisolide hfa inhal aerosol 80 mcg/act
N
2
Aggrenox Cap aspirin and dipyridamole
N
3
Akne‐Mycin Oint 2%
erythromycin ointment
N
3
Alamast Drop 0.1%
pemirolast
N
3
Allegra Susp 30Mg/5Ml
fexofenadine
N
3
Alocril Opth Sol 2%
nedocromil
N
3
Alomide Opth Sol 0.1% lodoxamide
N
3
Alphagan P Sol 0.1%
brimonidine
N
2
Ambifed‐G guaifenesin and pseudoephedrine
N
3
Amethyst levonorgestrel‐ethinyl estradiol (continuous) tab 90‐20 mcg
N
0
ST
Amitiza lubiprostone
N
3
QL
Analpram‐Hc Lotn 2.5‐1%
pramoxine and hydrocortisone
N
3
Androderm Dis testosterone
N
3
QL
Androderm Dis 5Mg/24Hr
testosterone
N
3
QL
Androgel Gel testosterone
N
2
QL
Androgel Gel Pump testosterone
N
2
QL
Androgel Pump Transdermal Gel
testosterone
N
2
QL
Antivert meclizine
N
3
Anzemet dolasetron
N
3
Apidra Inj
insulin glulisine
N
2
Apidra Solostar Pen
insulin glulisine
N
2
Apri ethinyl estradiol and desogestrel
Y
0
Aptivus tipranavir N
2
Aranelle Tab
ethinyl estradiol and norethindrone
Y
0
Armour Thyroid thyroid
N
2
Asacol Hd
mesalamine
N
2
Astepro Spray azelastine
O
2
Atripla efavirenz‐emtricitabine‐tenofovir df N
2
Atrovent Hfa
ipratropium
N
2
Augmentin Susp amoxicillin and clavulanate potassium
N
3
Auvi‐Q Injection Device epinephrine
N
2
3
3
Drug Name
Generic Name
Advair Disku
Avandamet rosiglitazone and metformin
N
Avar Gel sulfur and sulfacetamide
N
Aviane
levonorgestrel & ethinyl estradiol
Y
0
Avinza morphine sulfate
O
3
1
QL
QL
QL
QL
Citrus Valley Health Partners Formulary Alphabetical Listing 2015
Generic Indicator
Premium Plus Tier
interferon beta‐1a
N
4
Axert almotriptan
N
3
Azasan azathioprine
N
3
Azelex Cream azelaic acid
N
3
Azilect rasagiline
N
2
Azopt Sus 1% Op
brinzolamide
N
2
B & O Sup Supprett
belladonna and opium
N
3
Bactroban Oin Nasal 2%
mupirocin
N
3
Baraclude entecavir
N
2
QL
Beconase Aq Sus 0.042%
beclomethasone
N
3
QL
Benicar olmesartan
N
3
QL
Benicar Hct olmesartan and hydrochlorothiazide
N
3
QL
Benzamycin Gel Pak
erythromycin and benzoyl peroxide
N
3
Betadine Sol 5% Op
povidone‐iodine
N
3
Betoptic S Sus 0.2%
betaxolol
N
3
Beyaz
drospirenone‐ethinyl estradiol‐levomefolate calcium
N
0
3
Drug Name
Generic Name
Avonex Benefit Notes
QL
ST
Bio‐Statin Cap 500000
nystatin
N
Blephamide Oin S.O.P.
sulfacetamide and prednisolone
N
3
Blephamide Sus Op
sulfacetamide and prednisolone
N
3
Breo Ellipta
fluticasone furoate‐vilanterol
N
2
QL
Brevicon ‐ 28
ethinyl estradiol and norethindrone
O
0
ST
Butisol Sod butabarbital
N
3
Bydureon exenatide
N
2
QL
Bydureon Pen‐Injector exenatide
N
2
QL
Byetta exenatide
N
2
QL
Camila norethindrone
Y
0
Canasa mesalamine
N
3
Capex Sha
fluocinolone
N
3
Capital/Cod Sus acetaminophen and codeine
N
3
Carac Cre
fluorouracil
N
3
Carafate Sus sucralfate
N
3
Cardene Sr nicardipine
N
3
Cardizem La diltiazem
N
3
Cardura Xl doxazosin
N
3
Cedax ceftibuten
M
3
Ceftin Sus cefuroxime
N
3
Celebrex celecoxib
N
2
Cellcept Sus mycophenolate
O
3
QL
Cesia
desogest‐ethin est
Y
0
Chantix varenicline tartrate N
3
QL
Cialis tadalafil
N
3
QL / G
Ciloxan Oin 0.3% Op
ciprofloxacin
N
3
Cipro Hc Sus Otic
ciprofloxacin and hydrocortisone
N
3
Ciprodex Sus 0.3‐0.1%
ciprofloxacin and dexamethasone
N
2
Clarinex Syp
desloratadine
N
3
Clarinex‐D desloratadine & pseudoephedrine
N
3
Clindagel Gel 1%
clindamycin
N
3
Clobex Spr 0.05%
clobetasol
N
3
Cloderm Cre 0.1%
clocortolone
N
3
Clorpres clonidine and chlorthalidone
N
3
Coly‐Mycin‐S Sus Otic
neomycin, colistin, hydrocortisone, and thonzonium
N
3
2
Citrus Valley Health Partners Formulary Alphabetical Listing 2015
Generic Indicator
Premium Plus Tier
brimonidine tartrate‐timolol maleate ophth soln
N
2
Combipatch Dis estradiol and norethindrone
N
3
Combivent Respimat Inh Aer
ipratropium and albuterol
N
2
QL
Concerta methylphenidate hcl sa osm
O
3
QL
Condylox Gel 0.5%
podofilox
N
3
Copaxone glatiramer acetate N
4
Cordran Lot 0.05%
flurandrenolide
N
3
Cordran Sp Cre 0.05%
flurandrenolide
N
3
Coreg Cr
carvedilol
N
3
Cortisporin Cre 0.5%
neomycin, polymyxin b, and hydrocortisone
N
3
Cortisporin Oin 1%
bacitracin, neomycin, polymyxin b, and hydrocortisone
N
3
Cortisporin Sus ‐Tc Otic
neomycin, colistin, hydrocortisone, and thonzonium
N
3
Covera‐Hs verapamil
N
3
Creon pancrelipase
N
2
Crestor rosuvastatin
N
2
Crixivan indinavir sulfate
N
2
Cryselle‐28 Tab ethinyl estradiol and norgestrel
Y
0
Cuprimine
penicillamine
N
3
Cyclessa ethinyl estradiol and desogestrel
O
0
Cyclogyl Sol 0.5% Op
cyclopentolate
N
3
Drug Name
Generic Name
Combigan Ophth Soln Benefit Notes
QL
ST
Delzicol
mesalamine
N
2
Depen Titra penicillamine
N
3
Desogen
ethinyl estradiol and desogestrel
O
0
Dexpak dexamethasone
N
3
Diabeta glyburide
M
3
Diastat Acdl diazepam
M
3
Dibenzyline phenoxybenzamine
N
3
Differin Gel 0.3%
adapalene
N
3
Dilantin Ext
phenytoin
N
3
Dilatrate Sr isosorbide dinitrate
N
3
Diovan valsartan
O
3
Dipentum Cap
olsalazine
N
3
Diuril Susp chlorothiazide
N
3
Donnatal Extentab T
hyoscyamine, atropine, scopolamine, and phenobarbital
N
3
Droxia
hydroxyurea
N
3
Dulera Aerosol mometasone furoate‐formoterol fumarate dihydrate
N
2
Durezol Emulsion 0.05 %
difluprednate
N
2
Dynacirc Cr isradipine
N
3
Dyrenium triamterene
N
3
E.E.S erythromycin
N
3
Effer‐K potassium bicarbonate and potassium citrate
N
3
Elidel Cream 1%
pimecrolimus
N
3
A
Eliquis apixaban
N
2
QL
Elixophylln Elixir theophylline
N
3
Elmiron Cap pentosan polysulfate sodium
N
3
Emend aprepitant
N
3
Emsam Dis selegiline
N
3
Emtriva emtricitabine
N
2
Enbrel etanercept
N
4
Epifoam Aer 1%
pramoxine and hydrocortisone
N
3
Epipen 2‐Pak epinephrine
N
2
3
ST
QL
QL
QL
Citrus Valley Health Partners Formulary Alphabetical Listing 2015
Generic Indicator
Premium Plus Tier
epinephrine
N
2
Epivir lamivudine
O
2
Epivir Hbv lamivudine
N
2
Epzicom abacavir sulfate‐lamivudine N
2
Equetro carbamazepine
N
3
Ergomar Sub ergotamine
N
3
Errin Tab 0.35 Mg
norethindrone
Y
0
Ery‐Tab erythromycin delayed release
N
2
Erythrocin erythromycin
N
2
Estrace Vag Cre estradiol
N
3
Estring estradiol
N
3
Estrostep‐Fe ethinyl estradiol and norethindrone
O
0
Exalgo Tablet Er hydromorphone hcl
N
3
Exelon rivastigmine
N
3
Exforge amlodipine besylate‐valsartan O
3
QL
Exforge Hct amlodipine besylate‐valsartan N
3
QL
Falessa *levonorgest‐eth estrad tab 0.1 mg‐20 mcg & fa tab 1 mg kit*
N
0
ST
Fareston toremifene
N
3
Fazaclo
clozapine
M
3
Femcon Fe
norethindrone & ethinyl estradiol‐fe
O
0
Femhrt ethinyl estradiol and norethindrone
N
3
Drug Name
Generic Name
Epipen Jr. 2‐Pak Benefit Notes
ST
ST
Femring estradiol
N
3
Fentora fentanyl
N
3
Finacea azelaic acid
N
3
Flagyl metronidazole sr
N
3
Flarex Ophth Susp 0.1%
fluorometholone
N
3
Flector Transdermal Patch 1.3 %
diclofenac epolamine
N
2
QL
Flovent Disk Aer fluticasone propionate N
2
QL
Flumist influenza virus vaccine
N
2
Flumist Quadrivalent influenza virus vaccine
N
2
Fluoroplex Cream 1%
fluorouracil
N
3
Fml Ophth Susp 0.25%
fluorometholone
N
3
Foradil Aer
formoterol
N
2
Fosamax + D alendronate and cholecalciferol
N
3
Fosrenol Chw lanthanum carbonate N
3
Freestyle Freedom Lite Meter N
2
O
Freestyle Insulinx System Kit
N
2
O
Freestyle Insulinx Test Strips ‐ 100Ct
N
2
O
Freestyle Insulinx Test Strips ‐ 50Ct
N
2
O
Freestyle Lite Meter N
2
O
Freestyle Lite Test Strips 100
N
2
O
Freestyle Lite Test Strips 50Ct
N
2
O
Freestyle Test Strips‐ 100Ct
N
2
O
Freestyle Test Strips‐ 50Ct
N
2
O
QL
QL
QL
Frova frovatriptan
N
3
Gabitril
tiagabine
N
3
Generess Fe Chw norethindrone & ethinyl estradiol‐fe chew tab 0.8 mg‐25 mcg
N
0
Glucagen glucagon
N
2
Glucocard 01 Blood Glucose Kit
N
2
O
Glucocard 01 Control Solu Tion
N
2
O
Glucocard 01 Test Strips
N
2
O
4
ST
Citrus Valley Health Partners Formulary Alphabetical Listing 2015
Generic Indicator
Premium Plus Tier
Benefit Notes
Glucocard Vital Test Strips
N
2
O
Glucocard Vital Test Strips
N
2
O
N
3
Drug Name
Generic Name
Golytely polyethylene glycol‐electrolyte solution
Granix tbo‐filgrastim soln prefilled syringe
N
4
Gris‐Peg griseofulvin
O
3
Halog Oin 0.1%
halcinonide
N
3
Halog Cre 0.1%
halcinonide
N
3
Hectorol doxercalciferol
N
3
Helidac bismuth subsalicylate, metronidazole, and tetracycline
N
3
Homatropine Hbr Ophth Soln 2%
homatropine
N
3
Humira adalimumab
N
4
Ilevro Ophthalmic Suspension 0.3 %
nepafenac
N
2
Indocin Susp
indomethacin
N
3
Innopran Xl propranolol
N
3
Intelence etravirine
N
2
Invega paliperidone N
3
Invirase saquinavir mesylate N
2
Isentress raltegravir potassium
N
2
Isordil isosorbide dinitrate
N
3
Istalol Sol 0.5% Op
timolol
N
3
Janumet sitagliptin‐metformin hcl N
2
QL
Janumet Xr sitagliptin‐metformin hcl N
2
QL
Januvia sitagliptin phosphate N
2
QL
Jolivette Tab 0.35 Mg
norethindrone
Y
0
Junel 1.5/30
ethinyl estradiol and norethindrone
Y
0
Junel 1/20
ethinyl estradiol and norethindrone
Y
0
Junel Fe 1.5/30
ethinyl estradiol and norethindrone
Y
0
Junel Fe 1/20
ethinyl estradiol and norethindrone
Y
0
Kaletra lopinavir‐ritonavir N
2
Kariva ethinyl estradiol and desogestrel
Y
0
Kenalog Aerosol Soln
triamcinolone
N
3
Klor‐Con Powder Packet potassium chloride
N
3
Klor‐M Cr
potassium chloride
N
3
2
QL
Kombiglyze Xr
saxagliptin‐metformin hcl
N
K‐Phos potassium acid phosphate
N
3
Kristalose Pkt lactulose
N
3
Lamictal Odt lamotrigine
N
3
Lamictal Xr lamotrigine
O
3
Lamisil terbinafine
N
3
Lantus insulin glargine
N
2
Lantus Solostar
insulin glargine
N
2
Levemir insulin detemir
N
2
Levemir Flexpen
insulin detemir
N
2
Levemir Flextouch
insulin detemir
N
2
Levora 0.15/30‐28
levonorgestrel & ethinyl estradiol
Y
0
Lexiva fosamprenavir calcium
N
2
Lialda mesalamine
N
3
Lo Loestrin Fe
ethinyl estradiol and norethindrone ‐ fe fum
N
0
ST
Loestrin 1.5/30‐21
ethinyl estradiol and norethindrone
O
0
ST
Loestrin 1/20‐21
ethinyl estradiol and norethindrone
O
0
ST
Loestrin Fe 1.5/30
ethinyl estradiol and norethindrone
O
0
ST
5
QL
Citrus Valley Health Partners Formulary Alphabetical Listing 2015
Generic Indicator
Premium Plus Tier
Benefit Notes
ethinyl estradiol and norethindrone
O
0
ST
Lomedia 24 Tab Fe norethindrone ace‐ethinyl estradiol‐fe tab 1 mg‐20 mcg (24)
Y
0
Loseasonique
levonorg‐eth est
O
0
Lotemax loteprednol
N
3
Lotronex alosetron hcl
N
3
QL / G
Lovaza omega‐3‐acid ethyl esters
O
3
QL
Low‐Ogestrel
ethinyl estradiol and norgestrel
Y
0
Lufyllin dyphylline
N
3
2
Drug Name
Generic Name
Loestrin Fe 1/20
ST
Lumigan Solution 0.01 %
bimatoprost
N
Lunesta eszopiclone
N
3
Lyrica pregabalin
N
2
Macrodantin
nitrofurantoin
N
3
Mandelamine methenamine
N
3
Marplan isocarboxazid
N
3
Maxidex Sus 0.1% Op
dexamethasone
N
3
Maxiflor Cream 0.05%
diflorasone
N
3
Mebaral mephobarbital
N
3
Menest estrogens (esterified)
N
3
Methylin Chew methylphenidate
N
3
Metrogel Gel 1%
metronidazole
N
3
Micardis Hct telmisartan and hydrochlorothiazide
O
3
Microgestin Tab 1.5/30
ethinyl estradiol and norethindrone
Y
0
Microgestin Tab 1/20
ethinyl estradiol and norethindrone
Y
0
Microgestin Tab Fe1.5/30
ethinyl estradiol and norethindrone
Y
0
Minastrin 24 Fe norethin acet & estrad‐fe
N
0
ST
Mircette Tab 28 Day ethinyl estradiol and desogestrel
O
0
ST
Modicon Tab 0.5/35
ethinyl estradiol and norethindrone
O
0
ST
Mononessa Tab
ethinyl estradiol and norgestimate
Y
0
Moxeza Ophthalmic Solution 0.5 %
moxifloxacin
N
2
Multaq dronedarone hcl
N
2
Naftin naftifine
N
3
Namenda Sol memantine
N
2
Namenda Xr memantine
N
2
Naprelan naproxen
N
3
Nasonex mometasone furoate
N
2
Natazia
estradiol valerate‐dienogest
N
0
Nature‐Throid
thyroid
N
3
Necon Tab 0.5 Mg‐35 Mcg
ethinyl estradiol and norethindrone
Y
0
Necon Tab 0.5‐35/0.75‐35/1‐35 Mg‐Mcg
ethinyl estradiol and norethindrone
Y
0
Necon Tab 0.5‐35/1‐35 Mg‐Mcg (10/11)
ethinyl estradiol and norethindrone
N
0
Necon Tab 1 Mg‐35 Mcg
ethinyl estradiol and norethindrone
Y
0
Necon Tab 1 Mg‐50 Mcg
mestranol and norethindrone
N
0
Nevanac Sus 0.1%
nepafenac
N
2
Nexium esomeprazole
N
2
QL
Nicotrol nicotine
N
3
QL
Nitro‐Bid Oint 2%
nitroglycerin
N
3
Nitro‐Dur nitroglycerin
N
3
Nitrostat Sub
nitroglycerin
N
3
Nitrotab Sl nitroglycerin
N
3
Nora‐Be Tab 0.35Mg
norethindrone
Y
0
Norinyl Tab 1+35‐28
ethinyl estradiol and norethindrone
O
0
6
QL
QL
QL
ST
ST
ST
ST
Citrus Valley Health Partners Formulary Alphabetical Listing 2015
Generic Indicator
Premium Plus Tier
Benefit Notes
mestranol and norethindrone
N
0
ST
Noritate Cre 1%
metronidazole
N
3
Noroxin norfloxacin N
3
Norpace disopyramide
N
3
Nor‐Qd Tab 0.35Mg
norethindrone
O
0
Nortrel (28) Tab 1/35
ethinyl estradiol and norethindrone
Y
0
Nortrel 28 Tab 0.5/35
ethinyl estradiol and norethindrone
Y
0
Nortrel7/7/7 Tab 28 Days
ethinyl estradiol and norethindrone
Y
0
Norvir ritonavir N
2
Novofine 30Gx8Mm
insulin pen needle N
2
O
Novofine 31
insulin pen needle N
2
O
Novofine 32Gx6Mm
insulin pen needle N
2
O
Novofine Autocover 30Gx8M M
insulin pen needle N
2
O
Novolin 70/30 insulin isophane & regular
M
2
O
Novolin N insulin isophane
M
2
O
Novolin R insulin regular
M
2
O
Novolog
insulin aspart
N
2
Novolog Flexpen
insulin aspart
N
2
Novolog Mix 70/30 insulin aspart protamine and insulin aspart
N
2
Novolog Mix 70/30 Flexpen
insulin aspart protamine and insulin aspart
N
2
Novotwist insulin pen needle
N
2
O
Nucynta tapentadol hcl
N
3
QL
Nuvaring Mis
ethinyl estradiol and etonogestrel
N
2
Nuvigil armodafinil
N
2
QL
Ogestrel Tab
ethinyl estradiol and norgestrel
N
0
ST
Onfi clobazapam
N
3
3
Onglyza saxagliptin
N
2
QL
Onsolis Film fentanyl citrate
N
3
Oracea doxycycline N
3
Oracit
sodium citrate and citric acid
N
3
Orap pimozide
N
3
Orapred Odt prednisolone
N
3
Orapred Sol prednisolone
N
3
Drug Name
Generic Name
Norinyl Tab 1+50‐28
ST
Ortho Evra
norelgestromin‐ethinyl estradiol
O
0
ST
Ortho Micronor Tab 0.35 Mg
norethindrone
O
0
ST
Ortho Tri‐Cyclen Tab
ethinyl estradiol and norgestimate
O
0
ST
Ortho Tri‐Cyclen Tab Lo
ethinyl estradiol and norgestimate
N
0
ST
Ortho‐Cept Tab 28
ethinyl estradiol and desogestrel
O
0
ST
Ortho‐Cyclen Tab 0.25/35
ethinyl estradiol and norgestimate
O
0
ST
Ortho‐Novum Tab 1/35‐28
ethinyl estradiol and norethindrone
O
0
ST
Ortho‐Novum Tab 7/7/7‐28
ethinyl estradiol and norethindrone
O
0
ST
Oticaine Sol 20% Otic
benzocaine
N
3
Ovcon Fe
ethinyl estradiol and norethindrone
Y
0
Ovcon‐35 Tab
ethinyl estradiol and norethindrone
O
0
Ovral Tab 0.5 Mg‐50 Mcg
ethinyl estradiol and norgestrel
Y
0
Oxistat Cre 1%
oxiconazole
N
3
Oxistat Lot 1%
oxiconazole
N
3
Oxycontin Cr
oxycodone
N
2
Para‐Time papaverine
N
3
Pataday olopatadine
N
2
olopatadine hcl O
3
Patanase
7
ST
QL
QL
Citrus Valley Health Partners Formulary Alphabetical Listing 2015
Generic Indicator
Premium Plus Tier
erythromycin
N
3
Peganone ethotoin
N
3
Peg‐Intron peginterferone alfa‐2b
N
4
Pexeva paroxetine
N
3
Phisohex Liq 3%
hexachlorophene
N
3
Pilocarpine Sol 0.5% Op
pilocarpine
N
3
Pilopine Hs Gel 4% Op
pilocarpine
N
3
Poly‐Pred Sus Op
neomycin, polymyxin b, and prednisolone
N
3
Pramosone Lot pramoxine and hydrocortisone
N
3
Pramosone Oin 2.5%
pramoxine and hydrocortisone
N
3
Precision Xtra Beta Ketone Test Strips
N
2
O
Precision Xtra Meter N
2
O
Precision Xtra Test Strips
N
2
O
Precision Xtra Test Strips
N
2
O
Drug Name
Generic Name
Pce Benefit Notes
Pred Mild Sus 0.12% Op
prednisolone
N
3
Pred‐G Sus Op
prednisolone and gentamicin
N
3
Prednisone Conc 5 Mg/Ml
prednisone
N
3
Prefest
estradiol and norgestimate
N
3
Premarin estrogens (conjugated/equine)
N
2
Premarin Vag Cre estrogens (conjugated/equine)
N
2
Premphase estrogens (conjugated/equine) and medroxyprogesterone
N
2
Prempro estrogens (conjugated/equine) and medroxyprogesterone
N
2
Previfem ethinyl estradiol and norgestimate
Y
0
Prezista darunavir N
2
Prilosec Susp omeprazole
N
3
Primsol trimethoprim
N
3
Pristiq desvenlafaxine succinate N
2
Proair Hfa Aer
albuterol
N
2
Prochieve Gel 8% Vag
progesterone
M
3
Procrit epoetin alfa
M
4
Proctofoam Aer ‐Hc 1%
pramoxine and hydrocortisone
N
3
Protopic Oin tacrolimus
O
3
A
Provigil modafinil
O
3
QL
Prudoxin Cre 5%
doxepin
M
3
Pulmicort budesonide
O
3
Qnasl Nasal Aerosol Sol
beclomethasone dip
N
2
QL
QL
QL
Quartette Tab levonor‐eth est tab 0.15‐0.02/0.025/0.03 mg &eth est 0.01 mg
N
0
ST
Qvar Aer
beclomethasone
N
2
QL
Raniclor cefaclor
N
3
Rapaflo silodosin
N
3
Rapamune sirolimus
O
3
Rebetol Soln ribavirin soln
N
3
Relenza Aer Diskhale
zanamivir
N
2
QL
Relpax eletriptan
N
2
QL
Renagel sevelamer
N
3
Renvela sevelamer
N
2
Rescriptor delavirdine
N
2
Respa Dm
guaifenesin and dextromethorphan
N
3
Reyataz atazanavir
N
2
Rheumatrex methotrexate
N
3
Rifater rifampin, isoniazid, and pyrazinamide
N
3
8
Citrus Valley Health Partners Formulary Alphabetical Listing 2015
Generic Indicator
Premium Plus Tier
metformin
N
3
Ritalin La
methylphenidate
N
3
Rosanil Emul sulfur and sulfacetamide
N
3
Roxicet Soln oxycodone and acetaminophen
N
3
Rozerem ramelteon
N
3
QL
Safyral drospirenone‐ethinyl estrad‐levomefolate tab 3‐0.03‐0.451 mg
N
0
ST
Sal‐Tropine
atropine
N
3
Sandimmune Oral Soln cyclosporine
N
3
Saphris Sl asenapine maleate
N
3
QL
Seasonique
levonorg‐eth est
O
0
ST
Selzentry maraviroc
N
2
Serevent Dis Aer salmeterol
N
3
Seroquel Xr quetiapine fumarate
N
2
Simbrinza Ophthalmic
brinzolamide‐brimonidine tartrate
N
2
Solia Tab 0.15 Mg‐30 Mcg
ethinyl estradiol and desogestrel
Y
0
Soma carisoprodol
M
3
Somnote chloral hydrate
N
3
Spectracef cefditoren pivoxil M
3
Spiriva Cap Handihlr
tiotropium
N
2
QL
Spiriva Spray Respimat
tiotropium
N
2
QL
Sprintec 28 Tab 0.25 Mg‐35 Mcg
ethinyl estradiol and norgestimate
Y
0
Strattera
atomoxetine
N
3
QL
Striant testosterone
N
3
QL
Sulfamylon mafenide
N
3
Supartz
hyaluronate and derivatives
N
4
Suprax cefixime
N
3
Suprep Bowel Prep bowel evacuant
N
2
Sustiva efavirenz
N
2
Symbicort budesonide and formoterol
N
2
QL
Symlinpen pramlintide acetate N
2
QL
Synvisc hylan intra‐articular N
4
Synvisc One
hylan intra‐articular N
4
Tabloid thioguanine
N
3
Taclonex External Oint
calcipotriene‐betamethasone dipropionate
O
3
Talwin pentazocine
N
3
Tamiflu oseltamivir phosphate
N
3
Tarka trandolapril and verapamil
N
3
3
Drug Name
Generic Name
Riomet Oral Soln 500 Mg/5Ml
Benefit Notes
QL
QL
QL
Tasmar tolcapone N
Tazorac Cre tazarotene
N
3
Tegretol Xr carbamazepine
N
3
Testim Td Gel 1%
testosterone
N
3
Teveten eprosartan
N
3
QL
Teveten Hct eprosartan and hydrochlorothiazide
N
3
QL
Tev‐Tropin
somatropin N
4
Thalitone chlorthalidone
N
3
Theo‐24 Cap Sr theophylline
N
3
Thyrolar‐
liotrix
N
3
Tilia Fe
norethindrone ac‐ethinyl estrad‐fe
Y
0
Tobradex Oint Op
tobramycin and dexamethasone
N
3
Tobradex St Suspension 0.3‐0.05 %
tobramycin and dexamethasone
N
2
Tobrex Ophth Ointment 0.3%
tobramycin
N
2
9
QL
Citrus Valley Health Partners Formulary Alphabetical Listing 2015
Drug Name
Generic Name
Generic Indicator
Premium Plus Tier
Topicort Cream 0.05%
desoximetasone
N
3
Toviaz fesoterodine fumarate
N
2
Travatan Z travoprost
N
2
Trexall
methotrexate
N
3
Tri‐Legest Fe
norethindrone ac‐ethinyl estrad‐fe Y
0
Tri‐Levlen
levonorgestrel‐eth estra
Y
0
Tri‐Luma Cre
fluocinolone, hydroquinone, and tretinoin
N
3
Trinessa Tab 0.18‐35/0.215‐35/0.25‐35 Mg‐Mcg
ethinyl estradiol and norgestimate
Y
0
0
Trinorinyl Tab 0.5‐35/1‐35/0.5‐35 Mg‐Mcg
ethinyl estradiol and norethindrone
O
Triphasil 28
levonorgestrel‐eth estra
Y
0
Tri‐Previfem Tab 0.18‐35/0.215‐35/0.25‐35 Mg‐Mcg
ethinyl estradiol and norgestimate
Y
0
Tri‐Sprintec Tab 0.18‐35/0.215‐35/0.25‐35 Mg‐Mcg
ethinyl estradiol and norgestimate
Y
0
Trivora‐28
levonorgestrel‐eth estra
Y
0
Truvada emtricitabine‐tenofovir disoproxil fumarate
N
2
N
2
Tudorza Pressair Inhalation
Benefit Notes
ST
QL
Tyzeka telbivudine N
2
Tyzine tetrahydrozoline
N
3
Vagifem
estradiol
N
2
Velivet Tab 0.1‐0.025/0.125‐0.025/0.15‐0.025Mg‐Mg
ethinyl estradiol and desogestrel
Y
0
Ventolin Hfa
albuterol
N
2
QL
N
3
QL
Veramyst Spr Vexol Sus 1% Op
rimexolone
N
3
Viagra sildenafil
N
2
Vibramycin Syrup doxycycline
N
3
Victoza liraglutide
N
2
Videx Sol didanosine
N
2
Vigamox Dro 0.5%
moxifloxacin
N
2
Vimpat lacosamide
N
3
Viracept nelfinavir
N
2
Viread tenofovir
N
2
Vytorin ezetimibe and simvastatin
N
2
Welchol colesevelam
N
3
Westhroid thyroid
N
3
Xarelto rivaroxaban
N
3
QL
Yasmin 28 Tab 3‐0.03Mg
ethinyl estradiol and drospirenone
O
0
ST
Yaz Tab 3‐0.02Mg
drospirenone‐ethinyl estradiol
O
0
ST
Zantac ranitidine
N
3
Zelapar selegiline N
3
Zetia ezetimibe
N
2
Ziagen abacavir sulfate N
2
Zithromax azithromycin
M
3
3
Zmax azithromycin N
Zomig Spr zolmitriptan
N
3
Zonalon Cream 5%
doxepin
M
3
Zone‐A Forte Lotion 1‐2.5%
pramoxine and hydrocortisone
N
3
Zone‐A Lotion 1‐1%
pramoxine and hydrocortisone
N
3
Zorprin aspirin
N
3
Zovia 1/35
ethynodiol diacetate & ethinyl estradiol
Y
0
Zovia 1/50
ethynodiol diacetate & ethinyl estradiol
N
0
Zovirax Cream 5%
acyclovir
N
3
Zydone
hydrocodone and acetaminophen
N
3
10
QL / G
QL
QL
QL
QL
ST