Blue Cross of Idaho s Standard Three-Tier Prescription Drug Formulary This document is a searchable PDF. On your keyboard press Ctrl+F (Command+F for Mac) and a search field will open. Type in the name of the drug you are looking for in the search field, press enter and it will locate the name of the drug in the document. 208 Blue Cross of Idaho is an Independent Licensee of the Blue Cross and Blue Shield Association
Things to know about Blue Cross of Idaho s Standard Three-Tier Prescription Drug Formulary The Blue Cross of Idaho formulary is a list of drugs approved by Blue Cross of Idaho s Pharmacy and Therapeutics Committee for coverage under your pharmacy benefit. The formulary includes brand name as well as generic drugs that have undergone rigorous testing and are approved by the Food and Drug Administration (FDA). Not all drugs approved by the FDA are covered under the Blue Cross of Idaho formulary. Please Note: Your specific prescription benefit plan may not cover certain products or categories, regardless of their appearance in this document. Your copayment amounts may vary based on the structure of your prescription benefits. Products recently approved by the U.S. Food and Drug Administration (FDA) may not be covered upon release to the market. The Multi-Tier Formulary In most cases you will be responsible for a portion of the cost of each prescription you have filled, and depending on the drug prescribed, your cost can vary. The Blue Cross of Idaho formulary has three tiers, with the first tier costing you the least and the third tier costing you the most. Asking your doctor to prescribe drugs listed in the first or second tier of the formulary can save you money. Tier Description Preferred Generic Drugs are equivalent to brand-name drugs in dosage, safety, strength, method of administration, performance characteristics and intended use and Blue Cross of Idaho has rated as preferred due to their quality and costeffectiveness. 2 Preferred Brand-Name Drugs are drugs that Blue Cross of Idaho has rated as preferred due to their quality and costeffectiveness. Non-Preferred Brand-Name Drugs are clinically effective medications, but come with an excessive cost compared to other alternatives within the same drug class. ACA Affordable Care Act Drugs are drugs prescribed for covered preventive services that may be available at no cost to members under the regulations of the Affordable Care Act. Some plans grandfathered under the Affordable Care Act may not be eligible for the ACA preventive drugs at no cost. This formulary is not an all-inclusive listing, and is subject to change as new products and information become available. If you cannot find a drug you are using on this formulary, call the CVS Caremark Customer Care number on the back of your member ID card or log onto bcidaho.com using your unique login and password. Once you are logged in, clicking on the Benefits & Coverage link under the Prescription Drugs menu, and click Access Your Pharmacy Benefits Now for access to additional drug information. If you have questions about any of your medications, please discuss them with your doctor or pharmacist. You can also refer to your group s contract provisions for more information about the terms and conditions of your prescription drug benefit.
Reading the Formulary On the following pages, you ll find a list of prescription drugs and columns that list the tier they each belong to and any specific requirements or limitations. Column Name Drug Reference Tier Notes What you will find in each column: Name of covered prescription drugs Brand name of the covered generic drug listed in the Drug column. *Please see information below regarding Mandatory Generic Substitution The tier assignment for the prescription drug listed in the Drug column Requirements and limitations, as well as indicating if drugs are part of the Preventive Drug List for HSA Plans. See Abbreviation Dictionary on the next page for definitions and more information about the abbreviations. Mandatory Generic Substitution Some Blue Cross of Idaho prescription drug plans include a mandatory generic substitution requirement. When a drug has both brand and generic forms available, the generic drug is listed under the Drug column as the covered option with the brand or trademark name listed under the Reference column. When you or your physician choose the brand name drug, in addition to any applicable cost share (deductible/coinsurance/copayments) for the brand name medication, you will pay the cost difference between the contracted cost of the generic drug and brand name drug. These cost difference amounts do not apply to your annual out of pocket maximum. Reference Specialty Drugs, designated by an SP in the Notes column, will apply a Tier 2 and cost share prior to the cost difference calculation Newly Approved Prescription Drugs Any newly FDA approved prescription drug, biological agent, or other agent is excluded from coverage by Blue Cross of Idaho until it has been reviewed and approved by Blue Cross of Idaho s Pharmacy and Therapeutics Committee. The Blue Cross of Idaho Pharmacy and Therapeutics Committee meets quarterly to review newly approved drugs and older medications for coverage recommendations. The committee is comprised of practicing board-certified physicians and licensed pharmacists from across the state of Idaho.
Abbreviation Dictionary PA - Prior authorization Medications that list PA need prior authorization from Blue Cross of Idaho before we will cover the drug. Your provider must provide documentation showing that the prescription is medically necessary. If prior authorization is not obtained, you may be held responsible for the entire cost of the drug. Please refer to your policy (also called a member contract) for more information about prior authorization. You can find a copy of your policy and detailed information on the prior authorization process online by logging into members.bcidaho.com. PREV - Preventive Drugs for HSA Plans Some preventive drugs may be available at no cost to members of High Deductible Health Plans, also known as HSA plans. Preventive medications are prescribed for the prevention of conditions or illnesses when individuals may be at high risk. QL - Quantity Limits Some formulary drugs can only be filled in limited quantities. These prescriptions have been found to be less effective or even dangerous when taken at higher than normal doses. The limits on OL drugs are in line with manufacturer s recommendations regarding safety and effectiveness. SP - Specialty Drug Program Specialty medications are generally prescribed for treatment of complex, on-going medical conditions. These medications are generally high cost, and have specific handling requirements. All specialty drugs are limited to a 0 day supply per fill. ST - Step Therapy You may need to use one or more alternative medications before Blue Cross of Idaho can authorize benefits for the use of another medication. Blue Cross of Idaho wants to ensure providers are trying equally or more effective, low-cost options before recommending effective, but higher cost treatments. AL - Age Limitation Some drugs may be only be safe or recommended for certain age groups. Blue Cross of Idaho places age limitations to ensure drugs are not prescribed to individuals who are not of the recommended age.
lowercase bold = Generic drugs UPPERCASE = Brand name drugs Tier = Tier 2 = Tier 2 = Tier ACA = Affordable Care Act NC = Not Covered NF = Non-Formulary Notes AL = Age Limitations AL = Age Limitation PA = Prior Authorization PREV = Preventive Drugs for HSA Plans QL = Quantity Limits SP = Specialty Medication ST = Step Therapy Drug Reference Tier Notes *Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexiants* *Adhd Agent - Selective Alpha Adrenergic Agonists*** clonidine hcl er oral tablet extended release 2 hour guanfacine hcl er oral tablet extended release 24 hour Kapvay Intuniv *Adhd Agent - Selective Norepinephrine Reuptake Inhibitor*** atomoxetine hcl oral capsule Strattera *Amphetamine Mixtures*** amphetamine-dextroamphet er oral capsule extended release 24 hour amphetamine-dextroamphetamine oral tablet *Amphetamines*** ADZENYS XR-ODT ORAL TABLET EXTENDED RELEASE DISPERSIBLE Adderall XR Adderall DEXEDRINE ORAL TABLET Zenzedi dextroamphetamine sulfate er oral capsule extended release 24 hour Dexedrine Standard -Tier Formulary
dextroamphetamine sulfate oral solution ProCentra dextroamphetamine sulfate oral tablet Zenzedi DYANAVEL XR ORAL SUSPENSION EXTENDED RELEASE methamphetamine hcl oral tablet Desoxyn VYVANSE ORAL CAPSULE 2 VYVANSE ORAL TABLET CHEWABLE *Stimulants - Misc.*** QL armodafinil oral tablet Nuvigil QL DAYTRANA TRANSDERMAL PATCH dexmethylphenidate hcl er oral capsule extended release 24 hour Focalin XR dexmethylphenidate hcl oral tablet Focalin METADATE ER ORAL TABLET EXTENDED RELEASE 20 MG methylphenidate hcl er (cd) oral capsule extended release methylphenidate hcl er (la) oral capsule extended release 24 hour methylphenidate hcl er oral tablet extended release 0 mg methylphenidate hcl er oral tablet extended release 8 mg, 27 mg, 6 mg, 54 mg methylphenidate hcl er oral tablet extended release 20 mg methylphenidate hcl er oral tablet extended release 24 hour Metadate ER Ritalin LA Concerta Metadate ER methylphenidate hcl oral solution Methylin methylphenidate hcl oral tablet Ritalin methylphenidate hcl oral tablet chewable modafinil oral tablet Provigil QUILLICHEW ER ORAL TABLET CHEWABLE EXTENDED RELEASE 2 QL 2 Standard -Tier Formulary
QUILLIVANT XR ORAL SUSPENSION RECONSTITUTED *Alternative Medicines* *Alternative Medicine - Eu*** ISCAR MALI SUBCUTANEOUS INJECTABLE 5 MG/ML *Amebicides* *Amebicides*** SOLOSEC ORAL PACKET PA *Aminoglycosides* *Aminoglycosides*** neomycin sulfate oral tablet paromomycin sulfate oral capsule TOBI PODHALER INHALATION CAPSULE tobramycin inhalation nebulization solution *Analgesics - Anti-Inflammatory* *Antirheumatic - Janus Kinase (Jak) Inhibitors*** 2 2 SP; QL Kitabis Pak SP XELJANZ ORAL TABLET 2 PA; SP XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR *Antirheumatic Antimetabolites*** RHEUMATREX ORAL TABLET 2.5 MG *Anti-Tnf-Alpha - Monoclonal Antibodies*** HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML, 80 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML HUMIRA PEN SUBCUTANEOUS PEN- INJECTOR KIT HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 2 PA; SP 2 PA; SP 2 PA; SP 2 PA; SP Standard -Tier Formulary
HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN- INJECTOR KIT HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT *Anti-Tnf-Alpha - Monoclonoal Antibodies*** HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML, 80 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML HUMIRA PEN SUBCUTANEOUS PEN- INJECTOR KIT HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN- INJECTOR KIT HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT *Cyclooxygenase 2 (Cox-2) Inhibitors*** 2 PA; SP 2 PA; SP 2 PA; SP 2 PA; SP 2 PA; SP 2 PA; SP 2 PA; SP celecoxib oral capsule CeleBREX QL *Gold Compounds*** RIDAURA ORAL CAPSULE 2 *Interleukin- Blockers*** ARCALYST SUBCUTANEOUS SOLUTION RECONSTITUTED *Interleukin-Beta Blockers*** PA; SP ILARIS SUBCUTANEOUS SOLUTION PA; SP ILARIS SUBCUTANEOUS SOLUTION RECONSTITUTED *Interleukin-6 Receptor Inhibitors*** KEVZARA SUBCUTANEOUS SOLUTION AUTO-INJECTOR KEVZARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA; SP 2 PA; SP 2 PA; SP 4 Standard -Tier Formulary
*Nonsteroidal Anti-Inflammatory Agent Combinations*** diclofenac-misoprostol oral tablet delayed release Arthrotec *Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** diclofenac potassium oral tablet diclofenac sodium er oral tablet extended release 24 hour diclofenac sodium oral tablet delayed release etodolac er oral tablet extended release 24 hour etodolac oral capsule etodolac oral tablet Lodine fenoprofen calcium oral tablet Nalfon flurbiprofen oral tablet ibuprofen oral tablet 400 mg, 600 mg, 800 mg indomethacin er oral capsule extended release IBU indomethacin oral capsule ketoprofen er oral capsule extended release 24 hour ketoprofen oral capsule 50 mg, 75 mg ketorolac tromethamine oral tablet QL meclofenamate sodium oral capsule mefenamic acid oral capsule Ponstel meloxicam oral suspension meloxicam oral tablet Mobic nabumetone oral tablet naproxen dr oral tablet delayed release EC-Naprosyn naproxen oral tablet Naprosyn naproxen sodium oral tablet 275 mg naproxen sodium oral tablet 550 mg Anaprox DS oxaprozin oral tablet Daypro piroxicam oral capsule Feldene sulindac oral tablet Standard -Tier Formulary 5
tolmetin sodium oral capsule tolmetin sodium oral tablet *Pyrimidine Synthesis Inhibitors*** leflunomide oral tablet Arava QL *Soluble Tumor Necrosis Factor Receptor Agents*** ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO- INJECTOR *Analgesics - Nonnarcotic* *Analgesic Combinations*** duraxin oral capsule LEVACET ORAL TABLET *Analgesics-Sedatives*** BUPAP ORAL TABLET 50-00 MG butalbital-acetaminophen oral tablet 50-25 mg Tencon butalbital-apap-caffeine oral capsule Esgic butalbital-apap-caffeine oral tablet 50-25-40 mg Esgic butalbital-aspirin-caffeine oral capsule Fiorinal CAPACET ORAL CAPSULE Esgic ESGIC ORAL CAPSULE Esgic margesic oral capsule Esgic marten-tab oral tablet Tencon TENCON ORAL TABLET 50-25 MG Tencon ZEBUTAL ORAL CAPSULE 50-25-40 MG *Salicylate Combinations*** Esgic choline-mag trisalicylate oral liquid 2 PA; SP 2 PA; SP 2 PA; SP 2 PA; SP 6 Standard -Tier Formulary
*Salicylates*** adult aspirin ec low strength oral tablet delayed release Aspir-Low ACA AL; QL aspir-8 oral tablet delayed release Aspir-Low ACA AL; QL aspirin adult low dose oral tablet delayed release aspirin adult low strength oral tablet chewable Aspir-Low ACA AL; QL Bayer Low Dose ACA AL; QL aspirin childrens oral tablet chewable Bayer Low Dose ACA AL; QL aspirin low dose oral tablet chewable Bayer Low Dose ACA AL; QL aspirin oral tablet delayed release 8 mg ASPIR-LOW ORAL TABLET DELAYED RELEASE BAYER ASPIRIN EC LOW DOSE ORAL TABLET DELAYED RELEASE BAYER LOW DOSE ORAL TABLET CHEWABLE BAYER LOW DOSE ORAL TABLET DELAYED RELEASE childrens aspirin low strength oral tablet chewable Aspir-Low ACA AL; QL Aspir-Low ACA AL; QL Aspir-Low ACA AL; QL Bayer Low Dose ACA AL; QL Aspir-Low ACA AL; QL Bayer Low Dose ACA AL; QL childrens aspirin oral tablet chewable Bayer Low Dose ACA AL; QL cvs aspirin child oral tablet chewable Bayer Low Dose ACA QL cvs childrens aspirin oral tablet chewable Bayer Low Dose ACA QL diflunisal oral tablet ECOTRIN LOW STRENGTH ORAL TABLET DELAYED RELEASE eq childrens aspirin oral tablet chewable gnp adult aspirin low strength oral tablet chewable gnp aspirin oral tablet delayed release 8 mg Aspir-Low ACA AL; QL Bayer Low Dose ACA AL; QL Bayer Low Dose ACA AL; QL Aspir-Low ACA AL; QL goodsense aspirin oral tablet chewable Bayer Low Dose ACA AL; QL kls aspirin low dose oral tablet delayed release Aspir-Low ACA AL; QL Standard -Tier Formulary 7
kp aspirin oral tablet delayed release Aspir-Low ACA AL; QL MINIPRIN LOW DOSE ORAL TABLET DELAYED RELEASE Aspir-Low ACA AL; QL px aspirin oral tablet chewable Bayer Low Dose ACA AL; QL px enteric aspirin oral tablet delayed release 8 mg qc childrens aspirin oral tablet chewable ra aspirin adult low strength oral tablet chewable ra aspirin ec adult low st oral tablet delayed release ra aspirin ec oral tablet delayed release 8 mg ra childrens aspirin oral tablet chewable Aspir-Low ACA AL; QL Bayer Low Dose ACA AL; QL Bayer Low Dose ACA AL; QL Aspir-Low ACA AL; QL Aspir-Low ACA AL; QL Bayer Low Dose ACA AL; QL salsalate oral tablet sb childrens aspirin oral tablet chewable ST JOSEPH LOW DOSE ORAL TABLET CHEWABLE tgt aspirin low dose oral tablet delayed release Bayer Low Dose ACA AL; QL Bayer Low Dose ACA AL; QL Aspir-Low ACA AL; QL tgt aspirin oral tablet chewable Bayer Low Dose ACA AL; QL tgt aspirin oral tablet delayed release Aspir-Low ACA AL; QL tgt childrens aspirin oral tablet chewable *Analgesics - Opioid* *Codeine Combinations*** Bayer Low Dose ACA AL; QL acetaminophen-codeine #2 oral tablet QL acetaminophen-codeine # oral tablet Tylenol with Codeine # QL acetaminophen-codeine #4 oral tablet Tylenol with Codeine #4 QL acetaminophen-codeine oral solution QL ASCOMP-CODEINE ORAL CAPSULE Ascomp-Codeine butalbital-apap-caff-cod oral capsule butalbital-asa-caff-codeine oral capsule Ascomp-Codeine 8 Standard -Tier Formulary
CAPITAL/CODEINE ORAL SUSPENSION *Dihydrocodeine Combinations*** aspirin-caff-dihydrocodeine oral capsule *Hydrocodone Combinations*** hydrocodone-acetaminophen oral solution 0-25 mg/5ml, 7.5-25 mg/5ml hydrocodone-acetaminophen oral tablet 0-00 mg hydrocodone-acetaminophen oral tablet 0-25 mg hydrocodone-acetaminophen oral tablet 2.5-25 mg hydrocodone-acetaminophen oral tablet 5-00 mg hydrocodone-acetaminophen oral tablet 5-25 mg hydrocodone-acetaminophen oral tablet 7.5-00 mg hydrocodone-acetaminophen oral tablet 7.5-25 mg QL QL QL Vicodin HP QL Lorcet HD QL Verdrocet QL Vicodin QL Lorcet QL Vicodin ES QL Lorcet Plus QL hydrocodone-ibuprofen oral tablet QL IBUDONE ORAL TABLET Ibudone QL LORCET HD ORAL TABLET Lorcet HD QL LORCET ORAL TABLET Lorcet QL LORCET PLUS ORAL TABLET 7.5-25 MG LORTAB ORAL ELIXIR 0-00 MG/5ML Lorcet Plus QL QL LORTAB ORAL TABLET 0-25 MG Lorcet HD QL LORTAB ORAL TABLET 5-25 MG Lorcet QL LORTAB ORAL TABLET 7.5-25 MG Lorcet Plus QL REPREXAIN ORAL TABLET 0-200 MG Ibudone QL VERDROCET ORAL TABLET Verdrocet QL Standard -Tier Formulary 9
VICODIN ES ORAL TABLET 7.5-00 MG VICODIN HP ORAL TABLET 0-00 MG Vicodin ES QL Vicodin HP QL VICODIN ORAL TABLET 5-00 MG Vicodin QL XYLON ORAL TABLET Ibudone QL ZAMICET ORAL SOLUTION QL *Opioid Agonists*** ABSTRAL SUBLINGUAL TABLET SUBLINGUAL ARYMO ER ORAL TABLET EXTENDED RELEASE ABUSE- DETERRENT PA QL codeine sulfate oral tablet QL EMBEDA ORAL CAPSULE EXTENDED RELEASE fentanyl citrate buccal lozenge on a handle fentanyl transdermal patch 72 hour 00 mcg/hr fentanyl transdermal patch 72 hour 2 mcg/hr fentanyl transdermal patch 72 hour 25 mcg/hr fentanyl transdermal patch 72 hour 50 mcg/hr fentanyl transdermal patch 72 hour 75 mcg/hr FENTORA BUCCAL TABLET 00 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG hydromorphone hcl er oral tablet er 24 hour abuse-deterrent hydromorphone hcl injection solution 4 mg/ml QL Actiq PA Duragesic-00 QL Duragesic-2 QL Duragesic-25 QL Duragesic-50 QL Duragesic-75 QL PA Exalgo QL hydromorphone hcl oral liquid Dilaudid QL hydromorphone hcl oral tablet Dilaudid QL hydromorphone hcl rectal suppository QL 0 Standard -Tier Formulary
KADIAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 200 MG QL levorphanol tartrate oral tablet QL meperidine hcl oral solution QL meperidine hcl oral tablet QL methadone hcl oral concentrate Methadone HCl Intensol QL methadone hcl oral solution QL methadone hcl oral tablet Dolophine QL methadone hcl oral tablet soluble Methadose METHADOSE ORAL TABLET SOLUBLE MORPHABOND ER ORAL TABLET ER 2 HOUR ABUSE-DETERRENT morphine sulfate (concentrate) oral solution 00 mg/5ml morphine sulfate er beads oral capsule extended release 24 hour morphine sulfate er oral capsule extended release 24 hour morphine sulfate er oral tablet extended release Methadose QL QL QL Kadian QL MS Contin QL morphine sulfate oral solution QL morphine sulfate oral tablet QL morphine sulfate rectal suppository 0 mg, 20 mg, 5 mg morphine sulfate rectal suppository 0 mg NUCYNTA ER ORAL TABLET EXTENDED RELEASE 2 HOUR QL QL QL NUCYNTA ORAL TABLET QL OPANA ER ORAL TABLET ER 2 HOUR ABUSE-DETERRENT OXAYDO ORAL TABLET ABUSE- DETERRENT oxycodone hcl er oral tablet er 2 hour abuse-deterrent QL QL OxyCONTIN QL oxycodone hcl oral capsule QL Standard -Tier Formulary
oxycodone hcl oral concentrate 00 mg/5ml QL oxycodone hcl oral solution QL oxycodone hcl oral tablet QL OXYCONTIN ORAL TABLET ER 2 HOUR ABUSE-DETERRENT oxymorphone hcl er oral tablet extended release 2 hour OxyCONTIN 2 QL QL oxymorphone hcl oral tablet Opana QL tramadol hcl er oral tablet extended release 24 hour QL tramadol hcl oral tablet Ultram QL XTAMPZA ER ORAL CAPSULE ER 2 HOUR ABUSE-DETERRENT *Opioid Combinations*** ENDOCET ORAL TABLET 0-25 MG, 2.5-25 MG, 5-25 MG, 7.5-25 MG QL Endocet QL oxycodone-acetaminophen oral solution QL oxycodone-acetaminophen oral tablet 0-25 mg, 2.5-25 mg, 5-25 mg, 7.5-25 mg oxycodone-aspirin oral tablet 4.855-25 mg Endocet QL QL oxycodone-ibuprofen oral tablet QL *Opioid Partial Agonists*** BUNAVAIL BUCCAL FILM 2 buprenorphine hcl sublingual tablet sublingual buprenorphine hcl-naloxone hcl sublingual tablet sublingual buprenorphine transdermal patch weekly 0 mcg/hr, 5 mcg/hr, 20 mcg/hr, 5 mcg/hr Butrans QL butorphanol tartrate nasal solution BUTRANS TRANSDERMAL PATCH WEEKLY Butrans QL pentazocine-naloxone hcl oral tablet QL SUBOXONE SUBLINGUAL FILM 2 2 Standard -Tier Formulary
*Tramadol Combinations*** tramadol-acetaminophen oral tablet Ultracet QL *Androgens-Anabolic* *Anabolic Steroids*** ANADROL-50 ORAL TABLET oxandrolone oral tablet *Androgens*** ANDRODERM TRANSDERMAL PATCH 24 HOUR ANDROXY ORAL TABLET 2 danazol oral capsule methitest oral tablet methyltestosterone oral capsule STRIANT BUCCAL testosterone cypionate intramuscular solution 00 mg/ml, 200 mg/ml testosterone enanthate intramuscular solution testosterone transdermal gel 0 mg/act (2%) testosterone transdermal gel 2.5 mg/act (%) testosterone transdermal gel 25 mg/2.5gm (%), 50 mg/5gm (%) Depo-Testosterone Fortesta Vogelxo Pump AndroGel testosterone transdermal solution *Anorectal Agents* *Intrarectal Steroids*** COLOCORT RECTAL ENEMA Colocort CORTIFOAM RECTAL FOAM 2 hydrocortisone rectal enema Colocort *Nitrate Vasodilating Agents*** RECTIV RECTAL OINTMENT *Rectal Anesthetic/Steroids*** ANALPRAM-HC RECTAL LOTION - 2.5 % 2 Standard -Tier Formulary
hydrocortisone ace-pramoxine rectal cream - % Analpram-HC pramcort rectal cream Analpram-HC PROCTOFOAM HC RECTAL FOAM *Rectal Steroids*** hydrocortisone rectal cream Procto-Pak PROCTO-MED HC RECTAL CREAM Anusol-HC PROCTO-PAK RECTAL CREAM Procto-Pak PROCTOSOL HC RECTAL CREAM Anusol-HC PROCTOZONE-HC RECTAL CREAM Anusol-HC *Anthelmintics* *Anthelmintics*** albendazole oral tablet Albenza QL benznidazole oral tablet PA EMVERM ORAL TABLET CHEWABLE ivermectin oral tablet Stromectol QL praziquantel oral tablet Biltricide QL *Antianginal Agents* *Antianginals-Other*** RANEXA ORAL TABLET EXTENDED RELEASE 2 HOUR *Nitrates*** DILATRATE-SR ORAL CAPSULE EXTENDED RELEASE ISORDIL TITRADOSE ORAL TABLET 40 MG isosorbide dinitrate er oral tablet extended release isosorbide dinitrate oral tablet isosorbide mononitrate er oral tablet extended release 24 hour isosorbide mononitrate oral tablet MINITRAN TRANSDERMAL PATCH 24 HOUR Minitran 4 Standard -Tier Formulary
NITRO-BID TRANSDERMAL OINTMENT NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0. MG/HR, 0.8 MG/HR nitroglycerin er oral capsule extended release nitroglycerin sublingual tablet sublingual nitroglycerin transdermal patch 24 hour nitroglycerin translingual aerosol solution Nitro-Time Nitrostat Minitran NitroMist nitroglycerin translingual solution Nitrolingual NITRO-TIME ORAL CAPSULE EXTENDED RELEASE *Antianxiety Agents* *Antianxiety Agents - Misc.*** Nitro-Time buspirone hcl oral tablet hydroxyzine hcl oral syrup hydroxyzine hcl oral tablet hydroxyzine pamoate oral capsule meprobamate oral tablet *Benzodiazepines*** ALPRAZOLAM INTENSOL ORAL CONCENTRATE alprazolam oral tablet Xanax alprazolam oral tablet dispersible chlordiazepoxide hcl oral capsule clorazepate dipotassium oral tablet DIAZEPAM INTENSOL ORAL CONCENTRATE diazepam oral solution 5 mg/5ml diazepam oral tablet Valium LORAZEPAM INTENSOL ORAL CONCENTRATE lorazepam oral tablet Ativan 2 Standard -Tier Formulary 5
oxazepam oral capsule *Antiarrhythmics* *Antiarrhythmics Type I-A*** disopyramide phosphate oral capsule Norpace NORPACE CR ORAL CAPSULE EXTENDED RELEASE 2 HOUR quinidine gluconate er oral tablet extended release quinidine sulfate er oral tablet extended release quinidine sulfate oral tablet *Antiarrhythmics Type I-B*** mexiletine hcl oral capsule *Antiarrhythmics Type I-C*** flecainide acetate oral tablet propafenone hcl er oral capsule extended release 2 hour Rythmol SR propafenone hcl oral tablet *Antiarrhythmics Type Iii*** amiodarone hcl oral tablet Pacerone dofetilide oral capsule Tikosyn SP MULTAQ ORAL TABLET PACERONE ORAL TABLET 200 MG, 400 MG *Antiasthmatic And Bronchodilator Agents* *5-Lipoxygenase Inhibitors*** zileuton er oral tablet extended release 2 hour *Adrenergic Combinations*** ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED ADVAIR HFA INHALATION AEROSOL Pacerone Zyflo CR 2 PREV 2 PREV 6 Standard -Tier Formulary
ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED BREO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION DULERA INHALATION AEROSOL fluticasone-salmeterol inhalation aerosol powder breath activated ipratropium-albuterol inhalation solution STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION 2.5-2.5 MCG/ACT 2 2 2 PREV AirDuo RespiClick 55/4 PREV PREV SYMBICORT INHALATION AEROSOL 2 PREV TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED *Anti-Ige Monoclonal Antibodies*** XOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTED *Anti-Inflammatory Agents*** cromolyn sodium inhalation nebulization solution *Beta Adrenergics*** albuterol sulfate er oral tablet extended release 2 hour albuterol sulfate inhalation nebulization solution albuterol sulfate oral syrup albuterol sulfate oral tablet BROVANA INHALATION NEBULIZATION SOLUTION levalbuterol hcl inhalation nebulization solution 0. mg/ml, 0.6 mg/ml,.25 mg/ml ST 2 PA; SP PREV Xopenex PREV Standard -Tier Formulary 7
levalbuterol hcl inhalation nebulization solution.25 mg/0.5ml Xopenex Concentrate PREV levalbuterol tartrate inhalation aerosol Xopenex HFA metaproterenol sulfate oral syrup PREV metaproterenol sulfate oral tablet PREV PERFOROMIST INHALATION NEBULIZATION SOLUTION PROAIR HFA INHALATION AEROSOL SOLUTION PROAIR RESPICLICK INHALATION AEROSOL POWDER BREATH ACTIVATED PROVENTIL HFA INHALATION AEROSOL SOLUTION SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 2 2 2 2 PREV terbutaline sulfate oral tablet PREV VENTOLIN HFA INHALATION AEROSOL SOLUTION *Bronchodilators - Anticholinergics*** ATROVENT HFA INHALATION AEROSOL SOLUTION ipratropium bromide inhalation solution LONHALA MAGNAIR STARTER KIT INHALATION SOLUTION SPIRIVA HANDIHALER INHALATION CAPSULE SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION.25 MCG/ACT, 2.5 MCG/ACT TUDORZA PRESSAIR INHALATION AEROSOL POWDER BREATH ACTIVATED *Leukotriene Receptor Antagonists*** 2 2 PREV 2 PREV 2 PREV montelukast sodium oral packet Singulair PREV montelukast sodium oral tablet Singulair PREV 8 Standard -Tier Formulary
montelukast sodium oral tablet chewable Singulair PREV zafirlukast oral tablet Accolate PREV *Selective Phosphodiesterase 4 (Pde4) Inhibitors*** DALIRESP ORAL TABLET *Steroid Inhalants*** ASMANEX 20 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED ASMANEX 4 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED ASMANEX 0 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 0 MCG/INH ASMANEX 0 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 220 MCG/INH ASMANEX 60 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED ASMANEX 7 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED ASMANEX HFA INHALATION AEROSOL 2 PREV 2 2 PREV 2 2 2 2 PREV budesonide inhalation suspension Pulmicort PREV FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED FLOVENT HFA INHALATION AEROSOL PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED QVAR INHALATION AEROSOL SOLUTION QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 2 PREV 2 PREV 2 PREV 2 PREV 2 PREV Standard -Tier Formulary 9
*Xanthine-Expectorants*** DIFIL-G FORTE ORAL LIQUID *Xanthines*** ELIXOPHYLLIN ORAL ELIXIR THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR THEOCHRON ORAL TABLET EXTENDED RELEASE 2 HOUR 00 MG, 200 MG, 00 MG theophylline er oral tablet extended release 2 hour theophylline er oral tablet extended release 24 hour Theochron PREV 2 PREV PREV theophylline oral solution PREV *Anticoagulants* *Coumarin Anticoagulants*** COUMADIN ORAL TABLET Coumadin 2 PREV JANTOVEN ORAL TABLET Coumadin PREV warfarin sodium oral tablet Coumadin PREV *Direct Factor Xa Inhibitors*** ELIQUIS ORAL TABLET 2 XARELTO ORAL TABLET 2 XARELTO STARTER PACK ORAL TABLET THERAPY PACK *Heparins And Heparinoid-Like Agents*** heparin (porcine) in nacl injection solution 00-0.45 unit/ml-%, 50-0.45 unit/ml-% heparin (porcine) in nacl injection solution 2-0.9 unit/ml-% *Low Molecular Weight Heparins*** enoxaparin sodium injection solution Lovenox enoxaparin sodium subcutaneous solution Lovenox 2 20 Standard -Tier Formulary
FRAGMIN SUBCUTANEOUS SOLUTION 0000 UNIT/ML, 2500 UNIT/0.5ML, 5000 UNIT/0.6ML, 8000 UNT/0.72ML, 2500 UNIT/0.2ML, 5000 UNIT/0.2ML, 7500 UNIT/0.ML, 95000 UNIT/.8ML *Synthetic Heparinoid-Like Agents*** fondaparinux sodium subcutaneous solution *Anticonvulsants* *Ampa Glutamate Receptor Antagonists*** Arixtra FYCOMPA ORAL SUSPENSION PA FYCOMPA ORAL TABLET PA *Anticonvulsants - Benzodiazepines*** clobazam oral suspension Onfi PA clobazam oral tablet Onfi PA clonazepam oral tablet KlonoPIN clonazepam oral tablet dispersible diazepam rectal gel Diastat Pediatric *Anticonvulsants - Misc.*** APTIOM ORAL TABLET PA BANZEL ORAL SUSPENSION 2 BANZEL ORAL TABLET 2 BRIVIACT ORAL SOLUTION PA BRIVIACT ORAL TABLET PA carbamazepine er oral capsule extended release 2 hour carbamazepine er oral tablet extended release 2 hour Carbatrol TEGretol-XR carbamazepine oral suspension TEGretol carbamazepine oral tablet Epitol carbamazepine oral tablet chewable CARBATROL ORAL CAPSULE EXTENDED RELEASE 2 HOUR Carbatrol 2 EPITOL ORAL TABLET Epitol gabapentin oral capsule Neurontin Standard -Tier Formulary 2
gabapentin oral solution Neurontin gabapentin oral tablet Neurontin LAMICTAL ODT ORAL KIT LaMICtal ODT 2 LAMICTAL ODT ORAL TABLET DISPERSIBLE LaMICtal ODT 2 LAMICTAL ORAL TABLET LaMICtal 2 LAMICTAL ORAL TABLET CHEWABLE 25 MG, 5 MG LaMICtal 2 LAMICTAL XR ORAL KIT 2 LAMICTAL XR ORAL TABLET EXTENDED RELEASE 24 HOUR lamotrigine er oral tablet extended release 24 hour lamotrigine oral kit 25 & 50 & 00 mg, 25 (2)-50 (7) mg, 50 (42)-00(4) mg LaMICtal XR 2 LaMICtal XR LaMICtal ODT lamotrigine oral tablet LaMICtal lamotrigine oral tablet chewable LaMICtal lamotrigine oral tablet dispersible LaMICtal ODT lamotrigine starter kit-blue oral kit LaMICtal Starter lamotrigine starter kit-green oral kit LaMICtal Starter lamotrigine starter kit-orange oral kit LaMICtal Starter levetiracetam er oral tablet extended release 24 hour Keppra XR levetiracetam oral solution Keppra levetiracetam oral tablet Keppra LYRICA ORAL CAPSULE 2 LYRICA ORAL SOLUTION 2 oxcarbazepine oral suspension Trileptal oxcarbazepine oral tablet Trileptal OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HOUR POTIGA ORAL TABLET primidone oral tablet Mysoline ROWEEPRA ORAL TABLET 500 MG Keppra SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 22 Standard -Tier Formulary
TEGRETOL ORAL SUSPENSION TEGretol 2 TEGRETOL ORAL TABLET Epitol 2 TEGRETOL-XR ORAL TABLET EXTENDED RELEASE 2 HOUR 200 MG, 400 MG TEGretol-XR 2 TOPAMAX ORAL TABLET Topamax 2 TOPAMAX SPRINKLE ORAL CAPSULE SPRINKLE Topamax Sprinkle 2 topiramate oral capsule sprinkle Topamax Sprinkle topiramate oral tablet Topamax TRILEPTAL ORAL SUSPENSION Trileptal 2 TRILEPTAL ORAL TABLET Trileptal 2 VIMPAT ORAL SOLUTION VIMPAT ORAL TABLET ZONEGRAN ORAL CAPSULE Zonegran 2 zonisamide oral capsule Zonegran *Carbamates*** felbamate oral suspension Felbatol felbamate oral tablet Felbatol *Gaba Modulators*** SABRIL ORAL TABLET 2 PA; SP tiagabine hcl oral tablet Gabitril vigabatrin oral packet Sabril PA; SP *Hydantoins*** DILANTIN INFATABS ORAL TABLET CHEWABLE Dilantin Infatabs 2 DILANTIN ORAL CAPSULE Dilantin 2 DILANTIN ORAL SUSPENSION Dilantin 2 PEGANONE ORAL TABLET PHENYTEK ORAL CAPSULE Phenytek 2 phenytoin oral suspension 25 mg/5ml Dilantin phenytoin oral tablet chewable Dilantin Infatabs phenytoin sodium extended oral capsule Dilantin *Succinimides*** CELONTIN ORAL CAPSULE Standard -Tier Formulary 2
ethosuximide oral capsule Zarontin ethosuximide oral solution Zarontin ZARONTIN ORAL CAPSULE Zarontin 2 ZARONTIN ORAL SOLUTION Zarontin 2 *Valproic Acid*** DEPAKENE ORAL CAPSULE Depakene 2 DEPAKENE ORAL SOLUTION Depakene 2 DEPAKOTE ER ORAL TABLET EXTENDED RELEASE 24 HOUR DEPAKOTE ORAL TABLET DELAYED RELEASE DEPAKOTE SPRINKLES ORAL CAPSULE DELAYED RELEASE SPRINKLE divalproex sodium er oral tablet extended release 24 hour divalproex sodium oral capsule delayed release sprinkle divalproex sodium oral tablet delayed release Depakote ER 2 Depakote 2 Depakote Sprinkles 2 Depakote ER Depakote Sprinkles Depakote valproate sodium oral solution Depakene valproic acid oral capsule Depakene valproic acid oral solution Depakene *Antidepressants* *Alpha-2 Receptor Antagonists (Tetracyclics)*** mirtazapine oral tablet Remeron mirtazapine oral tablet dispersible Remeron SolTab *Antidepressants - Misc.*** APLENZIN ORAL TABLET EXTENDED RELEASE 24 HOUR bupropion hcl er (sr) oral tablet extended release 2 hour bupropion hcl er (xl) oral tablet extended release 24 hour Wellbutrin SR Wellbutrin XL bupropion hcl oral tablet maprotiline hcl oral tablet 24 Standard -Tier Formulary
*Modified Cyclics*** nefazodone hcl oral tablet trazodone hcl oral tablet TRINTELLIX ORAL TABLET PA VIIBRYD ORAL KIT PA; ST; QL VIIBRYD ORAL TABLET PA; ST; QL *Monoamine Oxidase Inhibitors (Maois)*** EMSAM TRANSDERMAL PATCH 24 HOUR MARPLAN ORAL TABLET phenelzine sulfate oral tablet Nardil tranylcypromine sulfate oral tablet Parnate *Selective Serotonin Reuptake Inhibitors (Ssris)*** citalopram hydrobromide oral solution citalopram hydrobromide oral tablet CeleXA escitalopram oxalate oral solution escitalopram oxalate oral tablet Lexapro fluoxetine hcl oral capsule PROzac fluoxetine hcl oral capsule delayed release fluoxetine hcl oral solution fluoxetine hcl oral tablet fluvoxamine maleate er oral capsule extended release 24 hour fluvoxamine maleate oral tablet paroxetine hcl er oral tablet extended release 24 hour Paxil CR paroxetine hcl oral tablet Paxil PAXIL ORAL SUSPENSION PEXEVA ORAL TABLET sertraline hcl oral concentrate sertraline hcl oral tablet Zoloft *Serotonin-Norepinephrine Reuptake Inhibitors (Snris)*** desvenlafaxine er oral tablet extended release 24 hour Khedezla QL Standard -Tier Formulary 25
desvenlafaxine fumarate er oral tablet extended release 24 hour desvenlafaxine succinate er oral tablet extended release 24 hour duloxetine hcl oral capsule delayed release particles venlafaxine hcl er oral capsule extended release 24 hour venlafaxine hcl er oral tablet extended release 24 hour Pristiq Cymbalta Effexor XR venlafaxine hcl oral tablet *Tricyclic Agents*** amitriptyline hcl oral tablet amoxapine oral tablet clomipramine hcl oral capsule Anafranil desipramine hcl oral tablet Norpramin doxepin hcl oral capsule doxepin hcl oral concentrate imipramine hcl oral tablet Tofranil imipramine pamoate oral capsule nortriptyline hcl oral capsule Pamelor nortriptyline hcl oral solution protriptyline hcl oral tablet trimipramine maleate oral capsule Surmontil *Antidiabetics* *Alpha-Glucosidase Inhibitors*** acarbose oral tablet Precose PREV miglitol oral tablet Glyset *Antidiabetic - Amylin Analogs*** SYMLINPEN 20 SUBCUTANEOUS SOLUTION PEN-INJECTOR SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN-INJECTOR *Biguanides*** metformin hcl er oral tablet extended release 24 hour 26 PREV PREV Glucophage XR PREV Standard -Tier Formulary
metformin hcl oral tablet Glucophage PREV RIOMET ORAL SOLUTION *Diabetic Other*** GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED GLUCAGON EMERGENCY INJECTION KIT PROGLYCEM ORAL SUSPENSION 2 *Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors*** JANUVIA ORAL TABLET 2 ST *Dipeptidyl Peptidase-4 Inhibitor-Biguanide Combinations*** JANUMET ORAL TABLET 2 ST JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR *Dopamine Receptor Agonists - Ergot Derivatives*** CYCLOSET ORAL TABLET *Human Insulin*** FIASP FLEXTOUCH SUBCUTANEOUS SOLUTION PEN- INJECTOR 2 2 2 ST 2 PREV FIASP SUBCUTANEOUS SOLUTION 2 PREV HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION PEN- INJECTOR LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN- INJECTOR LANTUS SUBCUTANEOUS SOLUTION LEVEMIR FLEXTOUCH SUBCUTANEOUS SOLUTION PEN- INJECTOR LEVEMIR SUBCUTANEOUS SOLUTION 2 PREV 2 PREV 2 PREV 2 PREV 2 PREV 2 PREV Standard -Tier Formulary 27
NOVOLIN 70/0 SUBCUTANEOUS SUSPENSION NOVOLIN N SUBCUTANEOUS SUSPENSION 2 PREV 2 PREV NOVOLIN R INJECTION SOLUTION 2 PREV NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN- INJECTOR NOVOLOG MIX 70/0 FLEXPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR NOVOLOG MIX 70/0 SUBCUTANEOUS SUSPENSION NOVOLOG PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE NOVOLOG SUBCUTANEOUS SOLUTION TOUJEO MAX SOLOSTAR SUBCUTANEOUS SOLUTION PEN- INJECTOR TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTION PEN- INJECTOR TRESIBA FLEXTOUCH SUBCUTANEOUS SOLUTION PEN- INJECTOR *Incretin Mimetic Agents (Glp- Receptor Agonists)*** OZEMPIC SUBCUTANEOUS SOLUTION PEN-INJECTOR TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR VICTOZA SUBCUTANEOUS SOLUTION PEN-INJECTOR *Meglitinide Analogues*** 2 PREV 2 PREV 2 PREV 2 PREV 2 PREV 2 PREV 2 PREV 2 PREV 2 ST; PREV; QL 2 ST; PREV; QL 2 ST; PREV; QL nateglinide oral tablet Starlix PREV repaglinide oral tablet PREV *Meglitinide-Biguanide Combinations*** repaglinide-metformin hcl oral tablet 28 Standard -Tier Formulary
*Progesterone Receptor Antagonists*** KORLYM ORAL TABLET PA; SP *Sodium-Glucose Co-Transporter 2 (Sglt2) Inhibitors*** FARXIGA ORAL TABLET 2 ST JARDIANCE ORAL TABLET 2 ST *Sulfonylurea-Biguanide Combinations*** glipizide-metformin hcl oral tablet PREV glyburide-metformin oral tablet PREV *Sulfonylureas*** chlorpropamide oral tablet PREV glimepiride oral tablet Amaryl PREV glipizide er oral tablet extended release 24 hour Glucotrol XL PREV glipizide oral tablet Glucotrol PREV glipizide xl oral tablet extended release 24 hour Glucotrol XL PREV glyburide micronized oral tablet Glynase PREV glyburide oral tablet PREV tolazamide oral tablet PREV tolbutamide oral tablet *Sulfonylurea-Thiazolidinedione Combinations*** pioglitazone hcl-glimepiride oral tablet Duetact PREV *Thiazolidinedione-Biguanide Combinations*** ACTOPLUS MET XR ORAL TABLET EXTENDED RELEASE 24 HOUR pioglitazone hcl-metformin hcl oral tablet *Thiazolidinediones*** Actoplus Met PREV AVANDIA ORAL TABLET 2 pioglitazone hcl oral tablet Actos PREV *Antidiarrheal/Probiotic Agents* *Antidiarrheal/Probiotic Combinations*** RESTORA RX ORAL CAPSULE 2 Standard -Tier Formulary 29
*Antidiarrheals* *Antidiarrheal Combinations*** RESTORA RX ORAL CAPSULE *Antiperistaltic Agents*** diphenoxylate-atropine oral liquid diphenoxylate-atropine oral tablet Lomotil opium oral tincture paregoric oral tincture *Antidotes And Specific Antagonists* *Antidotes And Specific Antagonists*** VISTOGARD ORAL PACKET 2 SP *Antidotes* *Antidotes - Chelating Agents*** CHEMET ORAL CAPSULE PA EXJADE ORAL TABLET SOLUBLE PA; SP FERRIPROX ORAL SOLUTION PA; SP FERRIPROX ORAL TABLET PA; SP JADENU ORAL TABLET PA; SP JADENU SPRINKLE ORAL PACKET PA; SP *Antidotes*** VISTOGARD ORAL PACKET 2 SP *Opioid Antagonists*** EVZIO INJECTION SOLUTION AUTO- INJECTOR naloxone hcl injection solution 0.4 mg/ml, 4 mg/0ml naloxone hcl injection solution cartridge naloxone hcl injection solution prefilled syringe naltrexone hcl oral tablet PA; ST; QL QL QL NARCAN NASAL LIQUID 2 QL VIVITROL INTRAMUSCULAR SUSPENSION RECONSTITUTED SP; QL 0 Standard -Tier Formulary
*Antiemetics* *5-Ht Receptor Antagonists*** ANZEMET ORAL TABLET QL granisetron hcl oral tablet QL ondansetron hcl oral solution Zofran ondansetron hcl oral tablet Zofran QL ondansetron oral tablet dispersible QL SANCUSO TRANSDERMAL PATCH QL ZUPLENZ ORAL FILM QL *Antiemetics - Anticholinergic*** meclizine hcl oral tablet scopolamine transdermal patch 72 hour Transderm-Scop (.5 MG) trimethobenzamide hcl oral capsule Tigan *Antiemetics - Miscellaneous*** CESAMET ORAL CAPSULE QL dronabinol oral capsule Marinol QL SYNDROS ORAL SOLUTION QL *Substance P/Neurokinin (Nk) Receptor Antagonists*** aprepitant oral capsule Emend QL EMEND ORAL SUSPENSION RECONSTITUTED QL VARUBI ORAL TABLET PA; QL *Antifungals* *Antifungals*** bio-statin oral capsule bio-statin oral powder griseofulvin microsize oral suspension griseofulvin microsize oral tablet griseofulvin ultramicrosize oral tablet LAMISIL ORAL PACKET nystatin oral tablet terbinafine hcl oral tablet LamISIL Standard -Tier Formulary
*Imidazoles*** ketoconazole oral tablet *Triazoles*** CRESEMBA ORAL CAPSULE PA fluconazole oral suspension reconstituted Diflucan fluconazole oral tablet Diflucan itraconazole oral capsule Sporanox itraconazole oral solution Sporanox NOXAFIL ORAL SUSPENSION PA NOXAFIL ORAL TABLET DELAYED RELEASE ONMEL ORAL TABLET voriconazole oral suspension reconstituted Vfend voriconazole oral tablet Vfend *Antihistamines* *Antihistamines - Alkylamines*** brompheniramine tannate oral tablet chewable RESPA-BR ORAL TABLET EXTENDED RELEASE 2 HOUR *Antihistamines - Ethanolamines*** ARBINOXA ORAL SOLUTION ARBINOXA ORAL TABLET carbinoxamine maleate oral solution carbinoxamine maleate oral tablet 4 mg clemastine fumarate oral syrup clemastine fumarate oral tablet 2.68 mg diphenhydramine hcl oral elixir pharbedryl oral capsule 50 mg Banophen *Antihistamines - Phenothiazines*** PHENADOZ RECTAL SUPPOSITORY Phenadoz PHENERGAN RECTAL SUPPOSITORY Phenadoz PA 2 Standard -Tier Formulary
promethazine hcl oral solution promethazine hcl oral syrup promethazine hcl oral tablet promethazine hcl rectal suppository Promethegan PROMETHEGAN RECTAL SUPPOSITORY *Antihistamines - Piperidines*** Promethegan cyproheptadine hcl oral syrup cyproheptadine hcl oral tablet *Antihyperlipidemics* *Bile Acid Sequestrants*** cholestyramine light oral packet Prevalite PREV cholestyramine light oral powder Prevalite PREV cholestyramine oral packet Questran PREV cholestyramine oral powder Questran PREV colesevelam hcl oral packet Welchol colesevelam hcl oral tablet Welchol colestipol hcl oral granules Colestid PREV colestipol hcl oral packet Colestid PREV colestipol hcl oral tablet Colestid PREV PREVALITE ORAL PACKET Prevalite PREV PREVALITE ORAL POWDER Prevalite PREV *Fibric Acid Derivatives*** ANTARA ORAL CAPSULE 0 MG, 90 MG fenofibrate micronized oral capsule PREV fenofibrate oral capsule 50 mg, 50 mg Lipofen PREV fenofibrate oral tablet Tricor PREV fenofibric acid oral capsule delayed release Trilipix PREV fenofibric acid oral tablet Fibricor PREV gemfibrozil oral tablet Lopid PREV *Hmg Coa Reductase Inhibitors*** ALTOPREV ORAL TABLET EXTENDED RELEASE 24 HOUR Standard -Tier Formulary
atorvastatin calcium oral tablet 0 mg, 20 mg atorvastatin calcium oral tablet 40 mg, 80 mg fluvastatin sodium er oral tablet extended release 24 hour Lipitor ACA PREV Lipitor PREV Lescol XL ACA fluvastatin sodium oral capsule Lescol ACA PREV lovastatin oral tablet ACA PREV pravastatin sodium oral tablet ACA PREV rosuvastatin calcium oral tablet 0 mg, 5 mg rosuvastatin calcium oral tablet 20 mg, 40 mg simvastatin oral tablet 0 mg, 20 mg, 40 mg, 5 mg Crestor ACA PREV Crestor PREV Zocor ACA PREV simvastatin oral tablet 80 mg Zocor PREV *Intest Cholest Absorp Inhib-Hmg Coa Reductase Inhib Comb*** ezetimibe-simvastatin oral tablet Vytorin PREV *Intestinal Cholesterol Absorption Inhibitors*** ezetimibe oral tablet Zetia PREV *Nicotinic Acid Derivatives*** NIACOR ORAL TABLET *Antihypertensives* *Ace Inhibitor & Calcium Channel Blocker Combinations*** amlodipine besy-benazepril hcl oral capsule trandolapril-verapamil hcl er oral tablet extended release *Ace Inhibitors & Thiazide/Thiazide-Like*** benazepril-hydrochlorothiazide oral tablet captopril-hydrochlorothiazide oral tablet enalapril-hydrochlorothiazide oral tablet PREV PREV PREV PREV Vaseretic PREV fosinopril sodium-hctz oral tablet PREV 4 Standard -Tier Formulary
lisinopril-hydrochlorothiazide oral tablet moexipril-hydrochlorothiazide oral tablet quinapril-hydrochlorothiazide oral tablet *Ace Inhibitors*** Zestoretic PREV PREV Accuretic PREV benazepril hcl oral tablet Lotensin PREV captopril oral tablet PREV enalapril maleate oral tablet Vasotec PREV EPANED ORAL SOLUTION EPANED ORAL SOLUTION RECONSTITUTED fosinopril sodium oral tablet PREV lisinopril oral tablet Prinivil PREV moexipril hcl oral tablet PREV perindopril erbumine oral tablet PREV quinapril hcl oral tablet Accupril PREV ramipril oral capsule Altace PREV trandolapril oral tablet PREV *Adrenolytics-Central & Thiazide/Thiazide-Like Comb*** CLORPRES ORAL TABLET PREV methyldopa-hydrochlorothiazide oral tablet *Agents For Pheochromocytoma*** DEMSER ORAL CAPSULE *Angiotensin Ii Receptor Antag & Ca Channel Blocker Comb*** amlodipine besylate-valsartan oral tablet PREV Exforge PREV amlodipine-olmesartan oral tablet Azor telmisartan-amlodipine oral tablet Twynsta PREV *Angiotensin Ii Receptor Antag & Thiazide/Thiazide-Like*** candesartan cilexetil-hctz oral tablet Atacand HCT PREV EDARBYCLOR ORAL TABLET Standard -Tier Formulary 5
irbesartan-hydrochlorothiazide oral tablet Avalide PREV losartan potassium-hctz oral tablet Hyzaar PREV olmesartan medoxomil-hctz oral tablet Benicar HCT PREV telmisartan-hctz oral tablet Micardis HCT PREV valsartan-hydrochlorothiazide oral tablet *Angiotensin Ii Receptor Antagonists*** Diovan HCT PREV candesartan cilexetil oral tablet Atacand PREV EDARBI ORAL TABLET eprosartan mesylate oral tablet PREV irbesartan oral tablet Avapro PREV losartan potassium oral tablet Cozaar PREV olmesartan medoxomil oral tablet Benicar PREV telmisartan oral tablet Micardis PREV valsartan oral tablet Diovan PREV *Angiotensin Ii Receptor Ant-Ca Channel Blocker-Thiazides*** amlodipine-valsartan-hctz oral tablet Exforge HCT PREV olmesartan-amlodipine-hctz oral tablet Tribenzor *Antiadrenergics - Centrally Acting*** clonidine hcl oral tablet Catapres PREV clonidine transdermal patch weekly Catapres-TTS- PREV guanfacine hcl oral tablet PREV methyldopa oral tablet PREV *Antiadrenergics - Peripherally Acting*** doxazosin mesylate oral tablet Cardura prazosin hcl oral capsule Minipress terazosin hcl oral capsule *Antihypertensives - Misc.*** VECAMYL ORAL TABLET *Beta Blocker & Diuretic Combinations*** atenolol-chlorthalidone oral tablet Tenoretic 00 PREV bisoprolol-hydrochlorothiazide oral tablet Ziac PREV 6 Standard -Tier Formulary
metoprolol-hydrochlorothiazide oral tablet PREV nadolol-bendroflumethiazide oral tablet Corzide PREV propranolol-hctz oral tablet PREV *Direct Renin Inhibitors & Thiazide/Thiazide-Like Comb*** TEKTURNA HCT ORAL TABLET *Direct Renin Inhibitors*** TEKTURNA ORAL TABLET *Selective Aldosterone Receptor Antagonists (Saras)*** eplerenone oral tablet Inspra PREV *Vasodilators*** hydralazine hcl oral tablet PREV minoxidil oral tablet PREV *Anti-Infective Agents - Misc.* *Anti-Infective Agents - Misc.*** metronidazole oral capsule Flagyl metronidazole oral tablet Flagyl NEBUPENT INHALATION SOLUTION RECONSTITUTED PRIMSOL ORAL SOLUTION tinidazole oral tablet Tindamax trimethoprim oral tablet XIFAXAN ORAL TABLET 2 *Anti-Infective Misc. - Combinations*** sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5ml sulfamethoxazole-trimethoprim oral tablet SULFATRIM PEDIATRIC ORAL SUSPENSION *Antiprotozoal Agents*** ALINIA ORAL SUSPENSION RECONSTITUTED Sulfatrim Pediatric Bactrim Sulfatrim Pediatric ALINIA ORAL TABLET atovaquone oral suspension Mepron 2 Standard -Tier Formulary 7
*Ketolides*** KETEK ORAL TABLET 2 *Leprostatics*** dapsone oral tablet *Lincosamides*** clindamycin hcl oral capsule Cleocin clindamycin palmitate hcl oral solution reconstituted *Oxazolidinones*** Cleocin linezolid oral suspension reconstituted Zyvox linezolid oral tablet Zyvox *Antimalarials* *Antimalarial Combinations*** atovaquone-proguanil hcl oral tablet Malarone COARTEM ORAL TABLET *Antimalarials*** chloroquine phosphate oral tablet DARAPRIM ORAL TABLET 2 hydroxychloroquine sulfate oral tablet Plaquenil mefloquine hcl oral tablet QL primaquine phosphate oral tablet 2 quinine sulfate oral capsule Qualaquin *Antimyasthenic Agents* *Antimyasthenic Agents*** guanidine hcl oral tablet MESTINON ORAL SYRUP 2 pyridostigmine bromide er oral tablet extended release Mestinon pyridostigmine bromide oral tablet Mestinon *Antimyasthenic/Cholinergic Agents*** guanidine hcl oral tablet MESTINON ORAL SYRUP 2 pyridostigmine bromide er oral tablet extended release Mestinon 8 Standard -Tier Formulary
pyridostigmine bromide oral tablet Mestinon *Antimyasthenic/Cholinergic Agents* guanidine hcl oral tablet MESTINON ORAL SYRUP 2 pyridostigmine bromide er oral tablet extended release Mestinon pyridostigmine bromide oral tablet Mestinon *Antimycobacterial Agents* *Anti Tb Combinations*** RIFAMATE ORAL CAPSULE RIFATER ORAL TABLET 2 *Antimycobacterial Agents*** cycloserine oral capsule Seromycin ethambutol hcl oral tablet Myambutol isoniazid oral syrup isoniazid oral tablet PASER ORAL PACKET PRIFTIN ORAL TABLET pyrazinamide oral tablet rifabutin oral capsule Mycobutin rifampin oral capsule Rifadin TRECATOR ORAL TABLET *Antineoplastic - Bcl-2 Inhibitors*** *Antineoplastic - Bcl-2 Inhibitors*** VENCLEXTA ORAL TABLET PA; SP VENCLEXTA STARTING PACK ORAL TABLET THERAPY PACK *Antineoplastics And Adjunctive Therapies* *Alkylating Agents*** HEXALEN ORAL CAPSULE 2 MYLERAN ORAL TABLET 2 *Androgen Biosynthesis Inhibitors*** PA; SP YONSA ORAL TABLET PA; SP ZYTIGA ORAL TABLET PA; SP Standard -Tier Formulary 9
*Antiadrenals*** LYSODREN ORAL TABLET 2 *Antiandrogens*** bicalutamide oral tablet Casodex ERLEADA ORAL TABLET PA; SP flutamide oral capsule nilutamide oral tablet Nilandron XTANDI ORAL CAPSULE PA; SP *Antiestrogens*** FARESTON ORAL TABLET 2 SOLTAMOX ORAL SOLUTION tamoxifen citrate oral tablet ACA AL; PREV *Antimetabolites*** capecitabine oral tablet Xeloda PA; SP mercaptopurine oral tablet methotrexate oral tablet methotrexate sodium (pf) injection solution 50 mg/2ml methotrexate sodium injection solution 50 mg/2ml PURIXAN ORAL SUSPENSION SP TABLOID ORAL TABLET 2 *Antineoplastic - Braf Kinase Inhibitors*** BRAFTOVI ORAL CAPSULE PA; SP TAFINLAR ORAL CAPSULE PA; SP ZELBORAF ORAL TABLET PA; SP *Antineoplastic - Hedgehog Pathway Inhibitors*** ERIVEDGE ORAL CAPSULE PA; SP ODOMZO ORAL CAPSULE PA; SP *Antineoplastic - Histone Deacetylase Inhibitors*** FARYDAK ORAL CAPSULE PA; SP ZOLINZA ORAL CAPSULE 2 PA; SP *Antineoplastic - Immunomodulators*** POMALYST ORAL CAPSULE PA; SP 40 Standard -Tier Formulary