MAGELLAN RX STANDARD FORMULARY 2015resource.carrollhospitalcenter.org › Documents › MRx Standard...

January 2015

© 2015 Magellan Rx Management. All rights expressly reserved. MRX0102_0115

MAGELLAN RX STANDARD FORMULARY 2015

We are pleased to provide you with our Formulary Drug List. This list is not intended to imply coverage, so please refer to your

plan document for detailed information about your drug benefit coverage.

Medications are listed as Tier 1 Generic, Tier 2 Brand, and Tier 3 Brand. Medications listed as “Specialty Drugs” are used to treat

complex medical conditions that require special handling, administration, and member care management. Depending on your

pharmacy benefit design, specialty drugs may be part of a specialty benefit with specific coverage and copay requirements that

differ from drugs in Tiers 1 – 3. If you do not have a defined specialty benefit, your copay may be based on whether the drug is

Generic or Brand, therefore Tier 1 or Tier 3 copays may apply.

Our Pharmacy and Therapeutics Committee (P&T) and Value Assessment Committee (VAC) dedicates many hours to the

clinical analysis and evaluation of peer reviewed literature and medical care guidelines to determine a drug’s safety and

efficacy. After this rigorous clinical evaluation, the committee weighs the financial implications of a drug compared to other

similar drugs and selects medications for Tier 1 and Tier 2 placement based on the drugs’ safety, efficacy and cost-effectiveness.

Please note all drugs on the Formulary Drug List are subjected to periodic review and amendment without notice.

For the most up-to-date Formulary Drug list visit our website at www.magellanrx.com. Or, you can call our toll-free Magellan Rx

Management Customer Service Help desk at: 1-800-424-3312.

Please keep in mind when a generic medication is chosen, patients pay the lowest copay available under their pharmacy benefit

plan. When clinically appropriate, please consider choosing a generic product.

Thank you for your support of the Drug Formulary.

TABLE OF CONTENTS PAGE

1.0 Analgesics……………………………………………………………………………………………………………………………………………………………………………….…. 2

2.0 Anesthetics………………………………………………………………………………………………………………………………………………………………………………… 4

3.0 Antibiotics…………………………………………………………………………………………………………………………………………………………………………………..4

4.0 Anti-Neoplastics/Immunosuppressants………………………………………………………………………………………................................................. 9

5.0 Cardiovascular Agents…………………………………………………………………………………………………………....................................................... 13

6.0 Central Nervous System Agents……………………………………………………………………………………………………………………………………………….. 17

7.0 Dermatologicals…………………………………………………………………………………………………………………………………………………………………………21

8.0 Eyes, Ears, Nose, Mouth and Throat…………………………………………………………………………………………………………………………………………. 24

9.0 Endocrine Agents……………………………………………………………………………………………………………………………………………………………………… 26

10.0 Gastrointestinal Agents………………………………………………………………………………………………………………………………………………………….. 29

11.0 Blood Modifiers, Nutritionals and Electrolytes……………………………………………………………………………………………………………………….. 30

12.0 Obstetrics/Gynecology…………………………………………………………………………………………………………………………………………………………….32

13.0 Respiratory Agents……………………………………………………………………………………………………………………………………………………………… ….34

14.0 Skeletal Muscle Relaxants………………………………………………………………………………………………………………………………………………………. 36

15.0 Urologicals……………………………………………………………………………………………………………………………………………………………………………….36

16.0 Immunologicals, Vaccines and Biotechnology Drugs………………………………………………………………………………………………………………. 37

17.0 Therapeutic Devices and Supplies…………………………………………………………………………………………………………………………………………… 39

KEY

Generic medications – lower case (example)

Brand medications – Leading Capital Letter (Example)

BRAND medications with generic equivalent products available- ALL CAPS (EXAMPLE)

PA – Prior Authorization needed under some benefits. Check your plan document for coverage details.

QL – Quantity Limits Apply under some benefits. Check your plan document for coverage details.

ST – Step Therapy Requirements under some benefits. Check your plan document for coverage details.

NTI – Narrow Therapeutic Index drugs

‡ - Preferred Specialty product

January 2015



BRAND medications with generic equivalent products available- ALL CAPS (EXAMPLE) © 2015 Magellan Rx Management. All rights expressly reserved. MRX0102_0115

2

Tier 1

Generic Products

Tier 2

Brand Products

Tier 3

Brand Products

Specialty Drugs

(See your plan documents)

1.0 ANALGESICS

AGENTS FOR MIGRAINE

apap/caffeine/butalbital QL Zomig spray, QL Alagesic LQ Sol, QL apap/caffeine/butalbital/codeine

QL ALSUMA INJ, QL

asa/caffeine/butalbital QL AMERGE, QL

butalbital / APAP QL Axert, QL

butalbital/APAP/cod, QL Bupap, QL

butalbital compound w/codeine DEPAKOTE ER

butorphanol NS, QL Dolgic Plus QL

cephadyn, QL Ergomar dihydroergotamine mesylate spr,

QL ESGIC, ESGIC PLUS QL

divalproex ER FIORICET, FIORICET/CODEINE, QL

isometh/dichlor/apap FIORINAL, FIORINAL/CODEINE, QL

naratriptan, QL Frova, QL

rizatriptan, QL IMITREX TABS, SPR, INJ, QL

sumatriptan tabs, spray,inj, QL MAXALT, MAXALT MLT, QL

zolmitriptan, QL MIGRANAL, QL

Phrenilin Forte, QL

Relpax, QL

Sumavel Dosepro, QL

Treximet, QL, ST

ZOMIG, ZOMIG ZMT, QL

DMARDS

azathioprine Depen ARAVA Actemra, PA

deltasone Ridaura AZULFIDINE ENTABS Cimzia, PA, QL hydroxychloroquine Cyclophosphamide, PA cyclosporine ‡

leflunomide Cuprimine Enbrel, ‡ PA, QL methotrexate IMURAN Humira, ‡ PA, QL

sulfasalazine, EC Oracea, QL Kineret, PA, QL

Otrexup INJ, PA NEORAL

PLAQUENIL Orencia, PA, QL

Rheumatrex Provenge, PA

Trexall SANDIMMUNE ‡

Simponi, PA, QL

Simponi Aria Sol , PA Xeljanz, PA, QL

Zortress, PA

GOUT MEDICATIONS

allopurinol Colcrys QL ZYLOPRIM Krystexxa, PA, QL

colchicine, QL Uloric, QL, ST

probenecid

CHELATING AGENTS

Depen Syprine

January 2015




3

Tier 1

Generic Products

Tier 2

Brand Products

Tier 3

Brand Products

Specialty Drugs


MISCELLANEOUS ANALGESICS

tramadol, QL Gralise, QL, ST Prialt

tramadol ER, QL Gralise star, ST Qutenza

tramadol SR biphasic, QL, ST Ofirmev, QL

tramadol/APAP, QL ULTRAM , ER QL

NARCOTIC ANALGESICS

buprenorphine, PA, QL Suboxone film, PA, QL Abstral, PA, QL

bupren/nalox sub, PA, QL Suboxone, PA, QL ACTIQ, PA, QL

codeine AVINZA, QL

co-gesic, QL BUPRENEX

endocet, QL Butrans PA, QL

fentanyl patch, QL Conzip, PA, QL

fentanyl citrate loz, PA, QL DEMEROL

hydromorphone, QL DILAUDID, QL

levorphanol DOLOPHINE

meperidine DURAGESIC, QL

methadone EXALGO, QL

morphine supp Fentora, PA, QL

morphine sulfate, QL KADIAN, QL

morphine SR, QL Lazanda Spray PA, QL

oxycodone; ER, QL MS CONTIN, QL

oxycodone/ibuprofen QL Nucynta, ST, QL

oxymorphone, QL Nucynta ER, ST, QL

pentazocine NX OPANA, QL

Opana ER, QL

ORAMORPH SR, QL

Oxecta, QL

Oxycontin, QL, ST

ROXICODONE, QL

Subsys, PA, QL

SUBUTEX, PA, QL

Zohydro ER, PA, QL

Zubsolv, PA, QL

NARCOTIC ANALGESIC COMBINATIONS

butalbital/asa/caffeine/codeine, QL ANEXSIA, QL

codeine/apap QL Capital w/Codeine, QL

dihydrocodeine Cocet/Cocet Plus, QL

hydrocodone/apap, QL FIORICET/CODEINE, QL

hydrocodone-ibuprofen, QL HYCET QL

oxycodone/aspirin IBUDONE QL

Liquicet, QL

LORCET, LORCET PLUS, QL

LORTAB & NORCO, QL

PERCOCET, QL

PERCODAN

REPREXAIN QL

Roxicet 5/500 tab, sol, QL

SYNALGOS-DC

TYLENOL W/COD, QL

TYLOX, QL

VICODIN, QL

VICODIN E.S,/HP QL

January 2015




4

Tier 1

Generic Products

Tier 2

Brand Products

Tier 3

Brand Products

Specialty Drugs


VICOPROFEN, QL

VOPAC CREAM, GB CREAM

Xartemis XR, QL

Zydone, QL

NONSTEROIDAL ANTI-INFLAMMATORIES

diclofenac potassium, QL Voltaren Gel, QL ANAPROX, DS, QL Caldolor Inj, QL

diclofenac, ER ARTHROTEC

diclofenac sodium soln CATAFLAM, QL

etodolac, ER Celebrex, QL

fenoprofen CLINORIL

flurbiprofen, QL DAYPRO

ibuprofen E.C. – NAPROSYN

indomethacin IR & CR QL FELDENE

ketoprofen, SA Flector Patch, QL

ketorolac, QL Indocin supp & susp, QL

meclofenamate Lidoprofen, PA

mefenamic MOBIC, MOBIC Susp, QL

meloxicam, QL MOTRIN

nabumetone Nalfon

naproxen, E.C. Naprelan, QL

naproxen sodium, DS, QL NAPROSYN

oxaprozin Neoprofen Inj, QL

piroxicam PENNSAID

sulindac PONSTEL, QL

tolmetin SOLARAZE, QL

Sprix, QL

Vimovo, QL, ST

VOLTAREN, XR

Zipsor, QL

Zorvolex, QL

SALICYLATES

diflunisal

salsalate

2.0 ANESTHETICS

TOPICAL LOCAL ANESTHETICS

lidocaine patch, QL EMLA

lidocaine/hydrocortisone LIDODERM, QL

lidocaine/prilocaine XYLOCAINE

Vexa pad 2-4-30%

3.0 ANTIBIOTICS

AMEBICIDES

paromomycin Yodoxin

ANTIFUNGALS-ORAL

clotrimazole troche ANCOBAN

griseofulvin DIFLUCAN, QL

fluconazole tab, QL GRIFULVIN V TAB, SUSP

fluconazole soln GRIS-PEG

flucytosine oral LAMISIL TAB

itraconazole cap, PA LAMISIL GRANULES, PA

January 2015




5

Tier 1

Generic Products

Tier 2

Brand Products

Tier 3

Brand Products

Specialty Drugs


ketoconazole NIZORAL

nystatin Noxafil

terbinafine Oravig, QL

voriconazole QL SPORANOX; Sporanox soln

voriconazole IV, PA VFEND, QL

VFEND IV, PA

ANTIFUNGALS-TOPICAL

ciclodan sol, PA, QL CICLODAN KIT

ciclopirox, PA, QL CNL8 Nail Kit

clotrimazole/ betamethasone Ertaczo

econazole Exelderm cr, soln

ketoconazole EXTINA 2%

ketoconazole foam 2% Jublia, ST, QL

miconazole nitrate Ketodan 2% Kit

nystatin Lamisil Spray

nystatin/triamcinolone LOPROX GEL, SHAMPOO

LOTRIMIN

LOTRISONE

Luzu cream, QL

Mentax

Naftin

NIZORAL

Oxistat

PENLAC, PA, QL

ANTIHELMINTICS

mebendazole Biltricide

Stromectol

ANTIMALARIALS

atovaquone/proguanil, PA Daraprim ARALEN

chloroquine phosphate Coartem

hydroxychloroquine MALARONE, PA

mefloquine PLAQUENIL

primaquine QUALAQUIN, PA, QL

quinine sulfate cap 324mg, PA, QL

ANTIPROTAZOALS

atovaquone MEPRON

Nebupent

PENTAM

ANTITUBERCULOSIS

ethambutol MYAMBUTOL

isoniazid MYCOBUTIN

pyrazinamide Priftin, QL

rifabutin RIFADIN

rifampin Rifater

rimactane RIFAMATE

Sirturo, PA

Trecator

ANTIVIRALS

acyclovir FAMVIR adefovir dipivoxil amantadine FLUMADINE Baraclude, QL ‡ famciclovir Relenza, QL cidofovir

January 2015




6

Tier 1

Generic Products

Tier 2

Brand Products

Tier 3

Brand Products

Specialty Drugs


ganciclovir Tamiflu cap, susp, QL COPEGUS, PA

rimantadine Valcyte, QL Cytovene

valacyclovir VALTREX entecavir, QL

ZOVIRAX EPIVIR HBV, TAB ‡ Epivir HBV, soln Harvoni, PA, QL HEPSERA ‡ lamivudine Olysio, ‡ PA, QL Infergen, PA

REBETOL, PA

Rebetol sol, PA

ribavirin caps ‡ PA

ribatab‡, ribapak, ribasphere‡

PA Sovaldi, PA, QL

Tyzeka

Victrelis, PA, QL

Viread‡

VISTIDE

ANTIVIRALS-TOPICAL

acyclovir oint Zovirax cream Denavir

acyclovir buccal tab Sitavig

ZOVIRAX ointment

CEPHALOSPORINS

cefaclor, ER Ceftin 125/5 susp, QL Cedax susp 90mg/5ml

cefadroxil Ceftin 250/5 susp, QL CEDAX TAB, SUSP 180/5ml

cefdinir CEFTIN TABS 500mg, QL

cefditoren CEFTIN TABS 250mg

cefuroxime, QL KEFLEX

ceftibuten ROCEPHIN

ceftriaxone Spectracef 200mg

cephalexin SPECTRACEF 400mg

cefpodoxime, susp Suprax

cefprozil Suprax susp 100/5ml & 200/5ml, QL

Teflaro

FLUOROQUINOLONES

ciprofloxacin susp, ciprofloxacin, QL AVELOX, ABC, QL

levofloxacin, QL CIPRO TAB, XR, QL

ofloxacin, QL CIPRO SUSP

moxifloxacin Factive, QL

LEVAQUIN, QL

LEVAQUIN SOL

Noroxin, QL

LEPROSTATICS

Dapsone

MACROLIDES

clarithromycin, XL E.e.s gran sus BIAXIN

erythromycin Eryped sus 200/5ml BIAXIN XL

erythromycin base Zmax susp, QL Dificid

erythromycin ethylsuc. E.E.S.

January 2015




7

Tier 1

Generic Products

Tier 2

Brand Products

Tier 3

Brand Products

Specialty Drugs


erythromycin stearate Ery-tab

erythromycin/sulfisoxazole Eryped sus 400/5ml

azithromycin, QL PCE

ZITHROMAX TAB, SUSP, QL

ANTIRETROVIRALS - NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI)

Edurant ‡

Intelence ‡

nevirapine

Rescriptor

Sustiva ‡

VIRAMUNE

VIRAMUNE XR ‡

ANTIRETROVIRALS - NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITOR (NRTI) ANALOGUES

abacavir

didanosine ‡

Emtriva ‡

EPIVIR HBV, TAB ‡

Epivir HBV, soln

lamivudine

RETROVIR

Retrovir inj

stavudine ‡

Videc ‡, VIDEX EC

ZERIT

ZIAGEN ‡

Ziagen sol

zidovudine ‡

ANTIRETROVIRAL COMBINATIONS

abacavir sulfate/lamivudine/

zidovudine

Atripla ‡

COMBIVIR

Complera ‡

Epzicom ‡

Kaletra ‡

lamivudine/zidovudine ‡

Stribild

TRIZIVIR

Truvada‡

ANTIRETROVIRALS - PROTEASE INHIBITORS

ApPvus ‡

Crixivan ‡

Invirase ‡

Lexiva ‡

Norvir

Prezista ‡

Reyataz ‡

Viracept ‡

ANTIRETROVIRALS – MISCELLANEOUS

Isentress ‡

Tivicay

January 2015




8

Tier 1

Generic Products

Tier 2

Brand Products

Tier 3

Brand Products

Specialty Drugs


ANTIRETROVIRALS – CCR5 ANTAGONISTS

Selzentry‡, PA

PENICILLINS

amoxicillin Augmentin susp 125/5ml, QL AUGMENTIN, ES, QL

amoxicillin/ K clavulanate, QL AUGMENTIN SUSP 250/5, QL

ampicillin AUGMENTIN XR, QL

dicloxacillin Moxatag

penicillin VK

SULFONAMIDES

sulfadiazine BACTRIM, DS

sulfamethoxazole/trimeth, DS

TETRACYCLINES

doxycycline hyclate ADOXA CAP, QL, ST

doxycycline monohydrate cap, QL ADOXA, ST

doxycycline monohydrate DORYX 150mg

minocycline Doryx 200mg, QL

minocycline SR DYNACIN

tetracycline MINOCIN, Minocin cap

MONODOX

Oraxyl

PERIOSTAT

Solodyn

VIBRAMYCIN

Vibramycin syp

TOPICAL ANTIBIOTICS

gentamicin Bactroban, nasal Akne-Mycin

mafenide BACTROBAN, oint, crm

mupirocin ointment, crm Cortisporin

silver sulfadiazine GARAMYCIN

Neo-Synalar Kit

SILVADENE

SULFAMYLON PAK, Sulfamylon crm

URINARY ANTI-INFECTIVES

methenamine hippurate FURADANTIN

nitrofurantoin mono HIPREX

nitrofurantoin macro MACROBID

nitrofurantoin oral suspension MACRODANTIN, Macrodantin 25mg

trimethoprim Monurol

Primsol

UREX

MISCELLANEOUS ANTIINFECTIVES

atovaquone/proguanil, PA Cleocin sup Alinia Fuzeon inj , QL

clindamycin CLEOCIN

metronidazole Dalvance

neomycin Dificif, PA

tinidazole FLAGYL

vancomycin Flagyl ER

Ketek

MALARONE, PA

Sivextro inj; Sivextro Tab, PA, QL

January 2015




9

Tier 1

Generic Products

Tier 2

Brand Products

Tier 3

Brand Products

Specialty Drugs


Synercid

TINDAMAX

VANCOCIN

Vibativ

Xifaxan

Zyvox, QL

INTERSTITIAL CYSTITIS AGENTS

Elmiron

Rimso-50

4.0 ANTI-NEOPLASTICS/IMMUNOSUPPRESSANTS

ALKYLATING AGENTS

lomustine Alkeran tablet ALKERAN Inj

CEENU capsule Bicnu

Cyclophosphamide, PA Busulfex

Hexalen dacarbazine

Leukeran IFEX

ifosfamide

melphalan inj

Mustargen

Myleran

Treanda, PA

thiotepa

Zanosar

ANTINEOPLASTIC – HORMONAL AGENTS

TEMODAR oral ‡ PA Temodar IV, ‡

temozolomide PA

ANTINEOPLASTIC – HORMONAL AGENTS – ANTIANDROGEN

bicalutamide CASODEX

flutamide Nilandron

ANTINEOPLASTIC – HORMONAL AGENTS – ANTIESTROGEN

tamoxifen Fareston Faslodex

ANTINEOPLASTIC – HORMONAL AGENTS – AROMATASE INHIBITORS

anastrozole ARIMIDEX

exemestane AROMASIN

letrozole PA FEMARA, PA

ANTINEOPLASTIC – MONOCLONAL ANTIBODIES

Arzerra, PA

Avastin, PA

Campath, PA

Erbitux, PA

Gazyva, PA

Herceptin, PA

Perjeta, PA

Rituxan, PA

Vectibix, PA

Yervoy, PA

Zevalin

January 2015




10

Tier 1

Generic Products

Tier 2

Brand Products

Tier 3

Brand Products

Specialty Drugs


ANTINEOPLASTIC – HORMONAL AGENTS – PROGESTINS

megestrol MEGACE

Megace ES

GONADOTROPIN – RELEASING HORMONE AGONISTS/ANTAGONISTS (GRHA)

Cetrotide

Eligard, PA

Firmagon, PA

Gonal F, RFF, ‡ PA Lupaneta KIT, PA

Lupr Dep Ped

Lupron DEPOT, ‡ PA leuprolide PA

Supprelin LA

Trelstar, Trelstar LA, & Trelstar

Depot

Vantas

Zoladex ‡

ANTIMETABOLITES

mercaptopurine PURINETHOL amifostine

methotrexate Rheumatrex capecitabine

Tabloid Caprelsa, PA, QL

Depocyt

Elitek

Folotyn, PA

Inlyta, PA, QL

Jakafi, PA, QL

Xalkori, PA, QL

XELODA ‡

IMMUNOSUPPRESSANTS/IMMUNOMODULATORS

azathioprine IMURAN Amevive, PA

dexamethasone Astagraf

prednisone Benlysta, PA

CELLCEPT‡

cyclosporine‡

Erwinaze

gengraf ‡

hecoria

Ilaris, PA,QL

MYFORTIC

mycophenolate‡

mycophenolic

NEORAL

PROGRAF CAP

Prograf inj

RAPAMUNE TAB 0.5 MG

Rapamune sol/tab

Revlimid, PA, QL

SANDIMMUNE‡

Sandimmune Sol ‡

sirolimus

tacrolimus

Thalomid, PA, QL

January 2015




11

Tier 1

Generic Products

Tier 2

Brand Products

Tier 3

Brand Products

Specialty Drugs


MISCELLANEOUS ANTINEOPLASTICS

etoposide cap Droxia Abraxane, PA

hydroxyurea HYDREA Adcetris, PA

leucovorin Kepivance adriamycin

lomustine Afinitor DIS, PA

Afinitor, PA

Alimta, PA

Arranon

azacitidine

Beleodaq, PA

Bexxar

bleomycin

Bosulif, PA, QL

Camptosar 300/15ml;

CAMPTOSAR

carboplatin

CERUBIDINE

cisplatin

cladribine

Clolar

Cometriq, PA, QL

Cosmegen

Cyramza, PA

cytarabine

DACOGEN

daunorubicin

Daunoxome

dexrazoxane, PA

decitabine

Docefrez

docetaxel

Doxil

doxorubicin

Eligard, PA

ELLENCE

Eloxatin 200MG; ELOXATION

Elspar

Emcyt

epirubicin

Erivedge, PA, QL

ETHYOL

Etopophos

etoposide

floxuridine

FLUDARA

fludarabine

Fusilev

gemcitabine

GEMZAR

Gilotrif, PA, QL

Gleevec ‡,PA,QL

Gliadel

Halaven, PA

Hycamtin cap, PA

January 2015




12

Tier 1

Generic Products

Tier 2

Brand Products

Tier 3

Brand Products

Specialty Drugs


HYCAMTIN inj

Iclusig, PA, QL

IDAMYCIN

idarubicin

Imbruvica, PA,QL

Iressa, PA,QL

irinotecan

Istodax, PA

Ixempra

Jevtana, PA

Kadcyla, PA

Kyprolis, PA

lipodox

Lysodren

Marqibo, PA

Matulane

Mekinist, PA, QL

mesna

Mesnex tab; MESNEX inj

mitomycin

mitoxantrone, PA

NAVELBINE

Nexavar, ‡ PA, QL

NIPENT

octreotide, PA

Oncaspar

Ontak, PA

oxaliplatin

paclitaxel

pentostatin

Photofrin

Pomalyst, PA, QL

Proleukin, PA

Purixan, PA

SANDOSTATIN, PA

Signifor, PA

Sprycel, PA, QL

Stivarga, PA, QL

Sutent, PA, QL

Sylatron, PA

Synribo, PA

Tafinlar, PA, QL

Tarceva, PA, QL

Targretin cap, PA

Targretin gel, PA

Tasigna ‡, PA, QL

TAXOTERE

teniposide

toposar

topotecan

Torisel, PA QL

TOTECT, PA

tretinoin oral ‡ PA, QL

Tykerb, ‡ PA, QL

January 2015




13

Tier 1

Generic Products

Tier 2

Brand Products

Tier 3

Brand Products

Specialty Drugs


Valchlor gel, PA, QL

Valstar

Vectibix, PA

Velcade, PA

VIDAZA

vinblastine

vincasar

vincristine

vinorelbine

Voraxaze

Votrient, PA, QL

VUMON

Xofigo, PA

Xtandi PA, QL

Zaltrap PA

Zelboraf, PA, QL

ZINECARD, PA

Zolinza, PA, QL

Zydelig, PA, QL

Zykadia, PA, QL

Zytiga ‡, PA

5.0 CARDIOVASCULAR AGENTS

ACE INHIBITORS/COMBINATIONS

benazepril/benazepril hctz, QL ACCUPRIL, QL

amlodipine /benazepril , QL ACEON, QL

captopril/captopril hctz ACCURETIC, QL

enalapril/enalapril hctz ALTACE, QL

fosinopril/fosinopril hctz, QL LOTENSIN/LOTENSIN HCT, QL

lisinopril/lisinopril hctz, QL LOTREL,QL

moexipril, QL MAVIK, QL

moexipril/hctz, QL PRINIVIL/PRINZIDE, QL

Perindoprilm QL Tarka

quinapril/quanipril hctz QL Tekamlo, QL

ramipril, QL Tekturna, QL, ST

trandolapril UNIVASC, QL

UNIRETIC, QL

VASOTEC/VASERETIC

ZESTRIL/ZESTORETIC, QL

ANGIOTENSIN RECEPTOR BLOCKERS/COMBINATIONS

candesartan/hctz, QL Azor Amturnide, QL, ST

eprosartan, QL Benicar/Benicar HCT, QL ATACAND/ ATACAND HCT, QL

irbesartan, QL Exforge/Exforge HCT, ST, QL AVAPRO/AVALIDE, QL

irbesartan-HCTZ, QL Tribenzor, QL, ST COZAAR/HYZAAR, QL

losartan, QL DIOVAN/DIOVAN/HCT, QL

losartan/HCTZ, QL Edarbi QL, ST

telmisartan, QL Edarbyclor, ST, QL

telmisartan-amlodipine, QL, ST MICARDIS, QL

telmisartan-hydrochlorothiazide MICARDIS HCT QL, ST

valsartan-hct/ valsartan, QL Teveten /Teveten HCT, QL

TEVETEN 600mg, QL

January 2015




14

Tier 1

Generic Products

Tier 2

Brand Products

Tier 3

Brand Products

Specialty Drugs


TWYNSTA, QL, ST

Valturna, QL, ST

Vecamyl, PA

ALPHA BETA BLOCKERS

carvedilol Coreg CR, QL ,ST COREG

labetalol TRANDATE

CENTRALLY ACTING & COMBINATIONS – ANTIADRENERGICS

clonidine, QL CATAPRES

guanabenz CATAPRES– TTS

guanfacine Nexiclon XR, QL

methyldopa/ hctz TENEX

ANTIADRENERGICS – PERIPHERALLY ACTING

doxazosin CARDURA

prazosin MINIPRESS

terazosin

HMG CO A REDUCTASE INHIBITORS (STATINS)/COMBINATIONS

atorvastatin, QL Crestor, QL Advicor, QL

atorvastatin/amlodipine, QL Vytorin, QL, ST Altoprev, QL, ST

amlodipine besylate-atorvastin, QL Vytorin 10-80MG, PA, QL, ST CADUET, QL

fluvastatin QL Juvisync, QL

lovastatin LESCOL, QL, ST

pravastatin, QL Lescol XL, ST

simvastatin, QL LIPITOR, QL, ST

simvastatin 80mg only, PA, QL LIPITOR 80mg, ST

Liptruzet, QL

Livalo, QL

MEVACOR, QL, ST

MEVACOR 40mg, ST

PRAVACHOL, QL, ST

PRAVACHOL 80mg, ST

Simcor, QL, ST

ZOCOR, QL, ST

ZOCOR 80mg only, PA,QL, ST

FIBRATES

fenofibric, QL ANTARA, QL

fenofibrate, QL Fenoglide, QL

fenofibrate micronized, QL FIBRICOR, QL

gemfibrozil, QL LIPOFEN QL

LOFIBRA, QL

LOPID, QL

TRICOR, QL

Triglide, QL

TRILIPIX, QL

Vascepa, QL

MISCELLANEOUS

omega-3-acid, QL Zetia, QL, ST LOVAZA, QL Juxtapid, PA, QL

Kynamro, PA

January 2015




15

Tier 1

Generic Products

Tier 2

Brand Products

Tier 3

Brand Products

Specialty Drugs


BILE ACID SEQUESTRANTS

cholestyramine Welchol, QL COLESTID

cholestyramine lite QUESTRAN, LITE

colestipol

prevalite

NICOTINIC ACID (NIACIN)

niacin, QL NIASPAN, QL

niacor

ANTIARRHYTHMICS

adenosine CORDARONE (NTI) BETAPACE, AF Nexterone

amiodarone Norpace CR Multaq, PA

disopyramide PACERONE (NTI) NORPACE

flecainide RYTHMOL, SR

mexiletine TAMBOCOR

procainamide, SR Tikosyn

propafenone, SR

quinidine gluconate,CR

quinidine sulfate,ER

sotalol, sotalol AF

BETA-ADRENERGIC ANTAGONISTS/COMBINATIONS

acebutolol Bystolic, QL CORGARD

atenolo/chlorthalidone Dutoprol, QL CORZIDE

betaxolol INDERAL,LA

bisoprolol; bisoprolol/hctz Innopran XL

metoprolol, XL KERLONE

metoprol/hctz Levatol

nadolol LOPRESSOR/ HCT

nadolol/bendroflumethiazide SECTRAL

pindolol TENORMIN, TENORETIC

propranolol, LA TOPROL XL

propranolol/hctz ZEBETA

timolol ZIAC

CALCIUM ANTAGONISTS

afeditab, QL ADALAT CC, only 30mg QL

amlodipine, QL CADUET, QL

amlodipine/atorvastatin, QL CALAN, SR

cartia XT, QL Cardene SR, QL

diltia XT, QL CARDIZEM/ SR / CD/LA, QL

diltiazem QL Cardizem LA 120mg, QL

diltiazem CR, QL Covera HS

diltiazem CD QL DILACOR XR

diltiazem SR, QL DYNACIRC; DYNACIRC CR, QL

felodipine, QL ISOPTIN, SR

nicardipine NORVASC 2.5MG & 5MG, QL

nifedipine; nifedipine ER, QL PROCARDIA/ 30 MG XL, QL

nisoldipine, QL SULAR

taztia XT TIAZAC, 120MG & 180MG,QL

verapamil; verapamil SR VERELAN; VERELAN PM, QL

CARDIAC GLYCOSIDES

digoxin LANOXIN (NTI) tab, elixir, inj

January 2015




16

Tier 1

Generic Products

Tier 2

Brand Products

Tier 3

Brand Products

Specialty Drugs


DIURETICS

amiloride ALDACTONE; ALDACTAZIDE

amiloride/hctz DEMADEX

bumetanide Diuril

chlorothiazide DYAZIDE

chlorthalidone Dyrenium

furosemide LASIX

hydrochlorothiazide MAXZIDE

indapamide MICROZIDE

methychlothiazide MIDAMOR

metolazone ZAROXOLYN

spironolactone/ hctz

torsemide

triamterene/hctz

NITRATES

isosorbide dinitrate Dilatrate SR BiDil, QL

isosorbide mononitrate Isordil 40mg IMDUR

minitran Nitro-Dur 0.8 mg/hr & 0.3mg/hr

Patch only

ISORDIL

nitroglycerin NITROLINGUAL Spray MONOKET

nitroglycerin patch Nitrostat SL NITRO-DUR

nitroglycerin SR NITROMIST

OTHER CARDIOVASCULARS

Cialis, QL Staxyn, GE, QL Adcirca, PA, QL

Ranexa epoprostenol

FLOLAN PA

Letairis‡, PA, QL

Opsumit, PA, QL

Orenitram, PA

Remodulin, PA

Revatio inj, PA

REVATIO tab PA, QL

Samsca, PA, QL

Sildenafil, PA, QL

Tracleer ‡, PA, QL

Tyvaso, PA, QL

Veletri, PA

Ventavis, PA, QL

PHEOCHROMOCYTOMA AGENTS

Dibenzyline

VASOPRESSORS

midodrine Northera, PA, QL

PERIPHERAL VASODILATORS & COMBINATIONS

hydralazine

minoxidil

PLATELET AGGREGATION INHIBITORS/ANTICOAGULANTS/PVD AGENTS

anagrelide Brilinta, QL Aggrenox Adempas, PA, QL

cilostazol COUMADIN (NTI) AGRYLIN ARIXTRA

clopidogrel, QL Effient, QL Eliquis enoxaparin

dipyridamole Pradaxa, PA, QL PERSANTINE fondaparinux

January 2015




17

Tier 1

Generic Products

Tier 2

Brand Products

Tier 3

Brand Products

Specialty Drugs


pentoxifylline Xarelto 10MG & 15MG, PA, QL PLAVIX,QL Fragmin

ticlopidine,QL Xarelto 20mg, QL PLETAL Iprivask

warfarin Zontivity, PA, QL LOVENOX

MISCELLANEOUS HEMATOLOGIC PRODUCTS

LYSTEDA, QL Activase

Alphanine

Berinert,PA

Cinryze, PA

Koate-DVI

Ruconest, PA

6.0 CENTRAL NERVOUS SYSTEM AGENTS

ANTIANXIETY

alprazolam & SR, QL ATIVAN, QL

alprazolam ODT, QL ATIVAN INJ

buspirone KLONOPIN QL

chlordiazepoxide, QL TRANXENE, QL

clonazepam, QL VALIUM

clorazepate, QL XANAX, XR , QL

diazepam

hydroxyzine HCl, pamoate

lorazepam, QL

meprobamate

oxazepam, QL

ANTICONVULSANTS-BARBITURATES

mephobarbital MYSOLINE

phenobarbital

primidone

ANTICONVULSANTS-HYDANTOINS

phenytoin; phenytoin extended Dilantin (NTI) cap; DILANTIN,

chew tab

Peganone

PHENYTEK (NTI)

ANTICONVULSANTS-SUCCINIMIDES

ethosuximide ZARONTIN (NTI) Celontin

ANTICONVULSANTS-MISCELLANEOUS

carbamazepine, XR CARBATROL (NTI) Aptiom Onfi, PA

clonazepam, QL DEPAKOTE SPRINKLES; ER (NTI) Banzel Sabril, PA, QL

clonazepam ODT, QL Gabitril 12mg & 16mg DEPAKENE

diazepam rectal, QL NEURONTIN soln DEPAKOTE

divalproex, ER, sprinkles TEGRETOL XR (NTI) DIASTAT, QL

felbamate ZONEGRAN (NTI) DIAZEPAM GEL, QL

gabapentin capsule, tablet FELBATOL, PA

lamotrigine, QL Fycompa, QL

levetiracetam, QL GABITRIL

levetiracetam XR QL Gralise, QL, ST

oxcarbazepine Gralise star, ST

tiagabine Horizant, QL

topiramate KEPPRA, XR QL

valproic acid KLONOPIN, QL

zonisamide LAMICTAL, QL

January 2015




18

Tier 1

Generic Products

Tier 2

Brand Products

Tier 3

Brand Products

Specialty Drugs


LAMICTAL; LAMICTAL XR, LAMICTAL

KIT, QL

Lyrica & soln, PA, QL

NEURONTIN CAPS, TABS

Potiga, QL, PA

Qudexy XR

Stavzor

TEGRETOL TAB, CHEW, SOLN

TOPAMAX & SPRINKLE

TRILEPTAL

Vimpat

ANTIDEPRESSANTS – MAO INHIBITORS

phenelzine sulfate NARDIL Marplan

tranylcypromine PARNATE

ANTIDEPRESSANTS – SSRIS

citalopram, QL Brintellix, QL, ST

escitalopram, QL Brisdelle, QL

fluoxetine, QL CELEXA, QL

fluvoxamine, QL Desvelafaxine, QL

paroxetine, QL LEXAPRO, QL

sertraline, QL LUVOX, CR, QL

PAXIL, CR , SUSP, QL

Pexeva, QL

PROZAC, QL

PROZAC WEEKLY, QL

SARAFEM

Viibryd, QL

ZOLOFT, QL

ANTIDEPRESSANTS-SEROTONIN/NOREPINEPHRINE REUPTAKE INHIBITORS

duloxetine Pristiq, QL CYMBALTA, QL

venlafaxine Desvenlafax, QL

venlafaxine XR, QL EFFEXOR XR, QL

Fetzima, QL, ST

Khedezla, QL

Savella, ST

ANTIDEPRESSANTS – TRICYCLICS

amitriptyline ANAFRANIL

amitriptyline/perphenazine Aplenzin, QL

amoxapine Forfivo XL, QL

bupropion, ER, XL, QL NORPRAMIN

clomipramine Oleptro, QL

desipramine PAMELOR

doxepin REMERON

imipramine Surmontil

maprotiline TOFRANIL

mirtazapine TOFRANIL – PM

nefazodone VIVACTIL

nortriptyline WELLBUTRIN, XL, 150MG XLONLY QL

protriptyline

trazodone

January 2015




19

Tier 1

Generic Products

Tier 2

Brand Products

Tier 3

Brand Products

Specialty Drugs


ANTIEMETIC AND ANTIVERTIGOS

dronabinol Transderm – Scop Antivert Aloxi

granisetron, QL Diclegis Anzemet, QL

granisol sol, QL Emend, PA, QL Cesamet, PA

meclizine MARINOL Emend inj, QL

metoclopramide, QL PHENERGAN granisetron inj

ondansetron, QL REGLAN, QL

prochlorperazine Sancuso, QL

promethazine TIGAN

trimethobenzamide ZOFRAN TAB,ODT,SOL, QL

ZOFRAN INJ

Zuplenz, QL

ANTIMANIA AGENTS

lithium LITHOBID

ANTIPARKINSON

amantadine Azilect Apokyn, PA

benztropine COGENTIN

bromocriptine tablet COMTAN

carbidopa ELDEPRYL

carbidopa/levodopa, CR LODOSYN

carbidopa/levodopa/entacapone MIRAPEX

diphenhydramine 50mg Mirapex XR, ST, QL

entacapone Neupro patch

pergolide PARLODEL

pramipexole REQUIP

selegiline REQUIP XL, ST, QL

ropinirole SINEMET; SINEMET CR

ropinirole XR, ST, QL STALEVO

trihexyphenidyl Tasmar

Zelapar

ANTIPSYCHOTICS

chlorpromazine Abilify, QL Abilify INJ

clozapine, QL Seroquel XR Abasuve

fluphenazine CLOZARIL

haloperidol Fanapt, ST, QL

haldolperidol deconate Fazaclo, QL

loxapine FAZACLO ODT, QL

olanzapine GEODON,QL,ST

olanzapine ODT Geodon INJ

olanzapine/ fluoxetine HALDOL

perphenazine Invega, ST

quetiapine Invega Sust, QL

risperidone, M-tab, solution Latuda, QL, ST

thioridazine LOXITANE

thiothixene Orap

trifluoperazine RISPERDAL, M-TAB, SOLN

ziprasidone, QL, ST Risperdal Consta,inj

Rybix ODT

SEROQUEL

Saphris, QL, ST

January 2015




20

Tier 1

Generic Products

Tier 2

Brand Products

Tier 3

Brand Products

Specialty Drugs


SYMBYAX

ZYPREXA, ZYPREXA ZYDIS

Zyprexa Relp, QL

CHOLINESTERASE INHIBITORS

donepezil Exelon SOL ARICEPT, ODT

donepezil ODT ARICEPT 23mg, ST

donepezil tab hcl 23 mg, ST EXELON capsule

galantamine, ER Exelon patch

rivastigmine capsulet RAZADYNE, ER

SEDATIVE & HYPNOTICS

chloral hydrate, PA AMBIEN, CR, QL ST Hetlioz, PA, QL

estazolam, QL Doral QL midazolam inj

eszopiclone, QL Edluar Sub, QL, ST

flurazepam, PA, QL HALCION QL

midazolam oral syrup Intermezzo sub, QL, ST

temazepam QL LUNESTA, QL, ST

triazolam QL RESTORIL QL

zaleplon, QL Rozerem, QL, ST

zolpidem, QL Silenor, QL

zolpidem CR, QL SOMNOTE, PA

SONATA, QL, ST

Zolpimist QL

STIMULANTS

amphetamine, QL Vyvanse, QL ADDERALL, QL

amphetamine, QL, ST ADDERALL XR, QL, ST

amphetamine/dextroam-phetamine

tab. QL

CONCERTA, QL, ST

amphetamine/dextroam-phetamine

cap SR, QL

Daytrana, ST, QL

dexmethylphenidate, QL DESOXYN QL, ST, AE

dextroamphetamine, SR, QL DEXEDRINE, QL

dextroamphetamine sulfate oral

solution, QL. ST

Focalin XR, QL, ST

methylphenidate solution, QL FOCALIN, QL

methylphenidate, S.R., QL METADATE CD & ER, QL, ST

methylphenidate CD, QL Methylin, CHEW, QL, ST

modafinil, PA, QL METHYLIN SOLN, ER QL

Nuvigil, PA

PROCENTRA, QL, ST, AE

PROVIGIL, PA, QL

RITALIN, S.R., QL

RITALIN, LA QL, ST

Quillivant XR, QL,ST

Zenzedi , QL, ST, AE

ZENZEDI 5mg & 10MG, QL, ST, AE

SUBSTANCE ABUSE

acamprosate ANTABUSE Vivitrol, PA

bupropion Bunavail, PA, QL

disulfiram CAMPRAL

naltrexone Evzio, PA, QL

Relistor, PA

REVIA

January 2015




21

Tier 1

Generic Products

Tier 2

Brand Products

Tier 3

Brand Products

Specialty Drugs


WEIGHT LOSS

benzphetamine Belviq, QL

diethylproprion Qsymia, PA, QL

phendimetrazine

phentermine

MISCELLANEOUS CNS

pyridostigmine Intuniv, QL KAPVAY, QL, ST Ampyra ‡, PA, QL

riluzole Mestinon timespan MESTINON Amyvid

ropivacaine Namenda, QL Namenda XR, QL, ST Botox, PA

Rilutek NAROPIN DACOGEN

Strattera, QL Nexiclon XR, QL decitabine

SUBOXONE SUB; Suboxone, QL,

PA Nuedexta, PA, QL

Dysport, PA

Perlane Myobloc, PA

Prostigmin Tecfidera ‡, PA, QL

Restylane-L Xenazine, PA

RILUTEK Xeomin, PA

SUBTEX, QL, PA Xyrem, PA, QL

Suprenza

7.0 DERMATOLOGICALS

ANTIACNE – ORAL

amnesteem, QL, PA Absorica, PA, QL

claravis, PA, QL Doryx 200mg, QL

doxycycline hyclate DORYX 150mg

isotretinoin, PA, QL Nicazeldoxy Kit

minocycline, SR MINOCIN CAPSULES

myorisan, PA Minocin kit

ANTIACNE – TOPICAL

adapalene, crm, gel, QL Finacea, QL Acanya Gel, QL

avita Finacea Kit, QL, ST Akne-Mycin

benzoyl peroxide foam Atralin

benzoyl peroxide Avar

bp cleansing, QL Azelex cream

claris wash, QL BENZAC

clindamycin/benzoyl peroxide, QL BENZACLIN, QL

clindamycin, QL BENZAMYCIN

erythromycin BENZEFOAM ULTRA

metronidazole BREVOXYL

sulfacetamide sodium/sulfur CLEOCIN-T LOT, PAD, SOL

CLEOCIN-T GEL, QL

CLENIA

CLINDAGEL

DIFFERIN CRM, QL

DIFFERIN GEL, QL

Differin Lotion, QL

DUAC gel, QL

Epiduo gel, QL

EVOCLIN, QL

Fabior, QL

KLARON LOTION

January 2015




22

Tier 1

Generic Products

Tier 2

Brand Products

Tier 3

Brand Products

Specialty Drugs


METROCREAM, METROGEL

METROLOTION

Neuac

Noritate

PANOXYL, AQ

Phisohex

Picato, ST

Plexion

RETIN-A CRM

RETIN-A MICROGEL, QL

SUMADAN WASH, KIT; Sumadan XLT

kit

Tretin-X

Veltin gel, QL

Ziana, QL

ORAL ANTIPRURITIC AGENTS

cetirizine syp, QL ALLEGRA & D

cyproheptadine VISTARIL

diphenhydramine ZYRTEC; Zyrtec 10 mg

fexofenadine & D, QL

hydroxyzine HCl, pamoate

ANTIPSORIASIS/ECZEMA/DERMATITIS

methotrexate Trexall Atopiclair Amevive, PA

acitretin, QL CLOBEX LOT, SHA; Clobex spr Cimzia, PA, QL calcipotriene DOVONEX CREAM & SOL Enbrel, ‡ PA, QL

calcipotriene-betanethasone Elidel, ST, QL Humira, ‡ PA, QL clobetasol LOCOID LIPO Otezla, PA, QL

selenium sulfide Mirvaso, QL, PA Rasuvo, PA, QL

Protopic, ST, QL Remicade, ‡ PA Rheumatrex Stelara, PA, QL

SELSUN

SORIATANE, QL

Taclonex scalp, sus QL

TACLONEX oint, QL

Tazorac, QL

ASTRINGENT

aluminum chloride sol DRYSOL

formaldehyde Spray 10% Formaldehyde Spray 37%

Xerac A.C.

BURN THERAPY

nitrofurazone SILVADENE

silver sulfadiazine Sulfamylon crm

SULDAMYLON PAK

CORTICOSTEROIDS-TOPICAL

amcinonide ACLOVATE

alclometasone Apexicone E

betamethasone dipropionate Clodan Kit

betamethasone valerate CLODERM

bupivilog kit Cordran; Lot: SP CRE; Tape, QL

clobetasol CUTIVATE

clocortolone cream DERMA-SMOOTH /F.S.

January 2015




23

Tier 1

Generic Products

Tier 2

Brand Products

Tier 3

Brand Products

Specialty Drugs


desonide DERMATOP

desoximetasone Desonate

diflorasone diacetate DESOWEN CR/LOTION

fluocinolone acetonide Desowen lot kit, crm kit, oint kit

fluocinonide DIPROLENE Gel/Lot/Oint/AF

fluticasone propionate ELOCON OINT, LOT, CRM

halobetasol Halog

hc butyrate cre Kenalog aerosol

hydrocortisone Locoid lot, LOCOID, SOL,CRM, SOL

lidolog kit LUXIQ

mometasone Momexin

triamcinolone acetonide OLUX

SYNALAR, SOL, CRM, OIN; Synalar

kit

TEMOVATE

Texacort

Topicort spr; TOPICORT CRM, GEL,

OIN

ULTRAVATE, Ultravate X Kit

Vanoxide H.C. Lotion

Verdeso

WESTCORT

Zyclara, QL

ZYPRAM

KERATOLYTICS

podofilox soln ALDARA, QL

salicylic acid film 27.5% Condylox gel

CONDYLOX SOL; Condylox gel

Keralyt kit, KERALYT GEL

Salvax Duo, SALVAX AER

VIRASAL

MISCELLANEOUS

actinic keratoses Carac Avage Uvadex

ammonium lactate Fluoroplex cream Dermasorb AF kit Xiaflex Inj

fluorouracil EFUDEX

sunscreen/hydroquinone GRANULEX

trypsin/balsam peru/castor oil Kerafoam

urea LAC-HYDRIN

Nivatopic cream

Oxsoralen

Panretin

Regranex

Renova

Santyl Ointment

SOLARAZE QL

VECTICAL OIN

Zithranol RR

ZONALON

ZYCLARA, QL

January 2015




24

Tier 1

Generic Products

Tier 2

Brand Products

Tier 3

Brand Products

Specialty Drugs


SCABICIDES/PEDICULICIDES

acticin ELIMITE

benzyl benzoate Eurax

lindane OVIDE

permethrin Ulesfia

8.0 EYES, EARS, NOSE, MOUTH AND THROAT

MOUTH AND THROAT/TEETH

chlorhexidine Aphthasol

doxycycline QL EVOXAC

lidocaine viscous GELKAM

pilocarpine PERIDEX

sodium fluoride PERIOSTAT

stannous fluoride PREVIDENT

triamcinolone acetonide SALAGEN

XYLOCAINE VISCOUS

NASAL STEROIDS

budesonide, QL Nasonex QL Beconase AQ, QL

flunisolide spray QL Dymista QL

fluticasone nasal spray, QL FLONASE NS, QL

triamcinolone nasal spray, QL NASACORT AQ, QL

Omnaris, QL

Qnasl QL

RHINOCORT AQUA, QL

Veramyst, QL

Zetonna QL

NASAL MISCELLANEOUS

azelastine NS ASTEPRO, QL Arcapta, QL, ST

butorphanol NS, QL ASTELIN, QL

ipratropium NS, QL ATROVENT NASAL SPR, QL

sumatriptan NS, QL IMITREX NASAL SPR, QL

Patanase, QL

OPHTHALMICS – ANTI-ALLERGY/DECONGESTANTS

azelastine, QL Alocril, QL

cromolyn sodium, QL Alomide, QL

epinastine, QL Bepreve, QL

ketotifen, QL ELESTAT, QL

Emadine, QL

OPTIVAR, QL

Pataday

Patanol, QL

ZADITOR

OPHTHALMICS – ANTIBIOTICS

bacitracin zinc/polymyxin B Tobradex oint Azasite

chloramphenicol oint Vigamox, QL Besivance, QL

ciprofloxacin, QL BLEPH-10

erythromycin CILOXAN SOLN; Ciloxan oint QL

gatifloxacin sol, QL GARAMYCIN

gentamicin NEOSPORIN SOL & OINT

neomycin/polymyxin/bacitracin OCUFLOX,QL

January 2015




25

Tier 1

Generic Products

Tier 2

Brand Products

Tier 3

Brand Products

Specialty Drugs


neomycin/polymyxin/gramicidin POLYTRIM

ofloxacin, QL Ocudox Kit , QL

polymyxin/ trimethoprim TOBREX SOL; Tobrex oint

sulfacetamide solution TOBRADEX SUS

tobramycin ZYMAXID, QL

tobramycin/dexamethasone

OPHTHALMICS – ANTIGLAUCOMA

acetazolamide Alphagan P (0.1%) ALPHAGAN P (0.15%), QL

apraclonidine Azopt QL BETAGAN

betaxolol Betoptic-S Betimol

brimonidine (0.15 & 0.2%), QL Combigan, QL COSOPT 2-0.5%; Cosopt PF sol

brinzolamide-brimonidine DIAMOX

carteolol hcl IOPIDINE 0.5%; Iopidine 1%

dorzolamide Isopto Carbachol

dorzolamide/timolol ISOPTO CARPINE

latanoprost, QL Istalol

levobunolol Lumigan, QL

methazolamide NEPTAZANE

metipranolol OPTIPRANOLOL

pilocarpine hcl Phospholine Iodide

timolol Pilopine H.S. gel

travoprost, QL Rescula, QL

SIMBRINZA, QL

TIMOPTIC/ XE

Travatan Z , QL

TRUSOPT

XALATAN, QL

Zioptan, QL

OPHTHALMICS – ANTIVIRALS

trifluridine VIROPTIC

Zirgan, QL

OPHTHALMICS – ANTI-INFLAMMATORIES

bacitracin/polymyxin/neomycin/

hydrocortisone

Acuvail, QL ACULAR LS, SOL, QL Ozurdex

bromfenac QL Blephamide oint Alrex

dexamethasone F.M.L. Forte BLEPHAMIDE SUSP

diclofenac, QL FML Oint. BROMDAY, QL

flurbiprofen sodium, QL Pred Mild Delzicol

fluorometholone Tobradex oint Durezol

ketorolac ophth, QL F.M.L. LIQUIFILM Oint.

neomycin/polymyxin/

dexamethasone

Flarex

neomycin/polymyxin/

hydrocortisone

Ilevro Dro, QL

prednisolone Lastacaft, QL, ST

sulfacetamide/prednisolone Lotemax

tobramycin/dexamethasone MAXITROL

Nevanac, QL

OCUFEN, QL

OMNIPRED

Pred-G oint, susp

PRED FORTE

PROLENSA, QL

January 2015




26

Tier 1

Generic Products

Tier 2

Brand Products

Tier 3

Brand Products

Specialty Drugs


TOBRADEX SUS

Vexol

VOLTAREN OPHTH, QL

Zylet

OPHTHALMICS – MISCELLANEOUS

atropine sulfate Isopto Homatropine CYCLOGYL Eylea

cyclopentolate Cystaran, PA Jetrea Inj, PA

homatropine ISOPTO ATROPINE Lucentis

naphazoline Isopto Hyoscine Macugen

naphazoline/antazoline Lacriserts Retisert

neosynephrine Membraneblue Trisenox, PA

phenylephrine MYDRIACYL Visudyne

tropicamide NEO-SYNEPHRINE

Restasis, PA

OTIC

acetic acid Ciprodex AURALGAN

acetic acid/aluminum acetate CETRAXA OTIC

acetic acid/hydrocortisone Cipro Otic Drops

antipyrine/benzocaine CORTANE-B

neomycin/polymyxin/

hydrocortisone

CORTISPORIN OTIC

ofloxacin, QL DOMEBORO

DERMOTIC

NEOTIC

Trioxin Otic

VOSOL HC

Zinotic ES

9.0 ENDOCRINE AGENTS

ANDROGENS, ANDROGEN INHIBITORS/ANABOLIC STEROIDS

androxy Androderm, PA, QL Anadrol Aveed, PA

danazol ANDROGEL, PA, QL Testopel, PA

testosterone cyp Android, PA

testosterone TD gel Axiron, PA, QL

oxandrolone DELATESTRYL

DEPO-TESTOSTERONE

Fortesta, PA, QL

Methitest, PA

OXANDRIN

Striant, PA, QL

TESTIM, PA, QL

Testred, PA

Vogelxo Gel/Gel Pump, PA, QL

ANTITHYROID

propylthiouracil TAPAZOLE Thyrogen

methimazole

BISPHOSPHONATES/OSTEOPOROSIS AGENTS/PAGETS DISEASE

alendronate, QL ACTONEL, QL BONIVA INJ

calcitonin (salmon, synth), QL Atelvia, QL, ST Forteo ‡, PA

etidronate disodium BONIVA, QL ibandronate

ibandronate, QL DIDRONEL Miacalcin inj

January 2015




27

Tier 1

Generic Products

Tier 2

Brand Products

Tier 3

Brand Products

Specialty Drugs


raloxifene hcl Duavee Prolia, PA, QL

risedronate sodium EVISTA RECLAST INJ

Fortical, QL zoledronic acid

FOSAMAX, QL zoledronic

Fosamax-D, QL ZOMETA INJ

MIACALCIN, QL

Skelid

ESTROGEN & ESTROGEN/ANDROGEN COMBINATIONS

azurette Cenestin, QL ACTIVELLA, QL

balziva Climara Pro, QL Alora, QL

briellyn Divigel Angeliq, QL

caziant Enjuvia, QL Binosto, QL

covaryx, HS Estrace vag CLIMARA, QL

cyclafem Estring, QL Combipatch, QL

eemt, HS Menest, QL DELESTROGEN

emoquette Natazia Depo-Estradiol

estradiol, QL Premarin (oral, cream) , QL Elestrin Gel

estradiol/norethindrone Premphase, QL ESTRACE, QL

estradiol cypionate IM Prempro, QL Estraderm patch, QL

estradiol valerate IM Vagifem Estrasorb, QL

estropipate, QL Vivelle-Dot, QL Estrogel, QL

jinteli, QL Evamist, QL

ortho-est Femhrt, QL

Femring, QL

Femtrace, QL

Minivelle, QL

Osphena

Prefest, QL

GLUCOCORTICOIDS

deltasone Medrol 2mg ONLY CORTEF

dexamethasone Millipred tab, 10mg/5ml sol Depo-Medrol 20mg/DEPO-MEDROL

40mg & 80MG

hydrocortisone Flo- Pred Sus

methylprednisolone MEDROL

prednisolone Millipred DP

prednisone Orapred; ORAPRED SOL

PEDIAPRED

PRELONE

HYPERGLYCEMICS

Glucagon Proglycem Korlym, PA

HYPOGLYCEMICS

acarbose, QL, ST ActoPlus Met XR, QL ACTOS, QL

chlorpropamide, QL Avandamet, QL, PA ACTOPLUS MET, QL

glimepiride Avandaryl, QL,PA AMARYL

glipizide; ER Avandia, QL,PA Bydureon, ST, QL

glipizide/metformin, QL Byetta, ST,QL DIABETA

glyburide; micronized Glyset, QL DIABINESE, QL

glyburide/metformin, QL Invokana, ST DUETACT, QL

metformin; ER QL Janumet, QL Farxiga, QL, ST

nateglinide, QL Janumet XR, ST, QL FORTAMET, QL

pioglit/glim, QL Januvia, QL GLUCOPHAGE, XR QL

pioglitazone, QL Jentadueto, ST, QL GLUCOTROL, XL

January 2015




28

Tier 1

Generic Products

Tier 2

Brand Products

Tier 3

Brand Products

Specialty Drugs


pioglitazone – metformin, QL Kombiglyze, QL, ST GLUCOVANCE, QL

repaglinide, QL Onglyza, QL Glumetza, QL

tolazamide, QL Symlin, Pen GLYNASE PRESTAB

tolbutamide, QL Tradjenta, QL, ST Jardiance

Juvisync, QL

Kazano, ST, QL

METAGLIP, QL

Nesina, ST, QL

Oseni, ST, QL

PRANDIN, QL

Prandimet, QL

PRECOSE, QL, ST

Riomet, QL

STARLIX, QL, ST

Tanzeum, QL, ST

Victoza, ST, QL

INSULIN

Apidra, ST

Humalog, Humalog Mix vials,

pens cartridges

Humulin vials, pens cartridges

Lantus, vials, pens

Levemir vials, pens

Novolin, vials, pens cartridges

Novolog, Novolog Mix vials, pens

cartridges

THYROID

levothyroxine LEVOTHROID (NTI) Armour Thyroid

levoxyl SYNTHROID (NTI) CYTOMEL

liothyronine Nature-thyroid

unithroid Thyrolar

MISCELLANEOUS

calcitriol Cycloset, PA, QL Acthar HP, PA

desmopressin acetate DDAVP Acthrel, PA

fludrocortisone Ravicti Aldurazyme, PA

ROCALTROL Cerdelga, PA, QL

VECTICAL Cerezyme, PA

Cystagon

Elaprase, PA

Elelyso, PA

Fabrazyme, PA

Increlex, PA

Kuvan, PA, QL

Lumizyme, PA

Myozyme, PA

Orfadin

Sensipar

Somatuline, PA

Stimate

Vpriv, PA

Zavesca, PA

January 2015




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Generic Products

Tier 2

Brand Products

Tier 3

Brand Products

Specialty Drugs


10.0 GASTROINTESTINAL AGENTS

ANTICHOLINERGICS/MOTILITY/ANTISPASMODICS

bethanechol ANASPAZ Entyvio, PA

chlordiazepoxide QL BENTYL

dicyclomine Cantil

clidinium Donnatal

glycopyrrolate LEVBID

hyoscyamine LEVSIN, SL

methscopolamine bromide LIBRAX

metoclopramide, QL METOZOLV ODT, QL, ST

propantheline NULEV

PAMINE TAB; Pamine FQ kit

Rectiv

REGLAN, QL

ROBINUL

URECHOLINE

ANTIDIARRHEAL

diphenoxylate/atropine LOMOTIL

loperamide

paregoric

ANTI-INFLAMMATORIES

balsalazide Asacol ANALPRAM-HC CR, E KIT; Analpram

Lot, kit

budesonide SR Apriso ANUSOL H.C. 2.5, SUPP

hydrocortisone Canasa AZULFIDINE, ENTABS

hydrocortisone enema Lialda COLAZAL

hydrocortisone/pramoxine Pentasa CORTENEMA

mesalamine Proctofoam – H.C. Cortifoam

sulfasalazine, EC Dipentum

ENTOCORT EC

Giazo, QL

Pramosone E cr, oint, lot;

PRAMOSONE 2.5% OINT, 1% & 1-

2.5% CR

PROCTOCORT; CRM-H.C.

ROWASA

Z-PRAM KIT

H2 RECEPTOR ANTAGONISTS

cimetidine AXID

famotidine PEPCID

nizatidine TAGAMET

ranitidine ZANTAC

H.PYLORI

amoxicillin/clarithro/lansopraz, QL Pylera, QL Helidac, QL

lansoprazole/amoxicillin/clarithrom

ycin, QL

Omeclamox MIS, QL

PREVPAC, QL

Tritec

January 2015




30

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Generic Products

Tier 2

Brand Products

Tier 3

Brand Products

Specialty Drugs


PROTECTANTS

misoprostol Carafate suspension CARAFATE

sucralfate CYTOTEC

Orafate

Prothelial

PROTON PUMP INHIBITORS

lansoprazole, QL ACIPHEX, ST, QL

lansoprazole solutab, QL Aciphex SPR, QL

esomeprazole IV, QL Esomeprzaole strontium, QL, ST

omeprazole, QL Dexilant ST, QL

omeprazole/bicarbonate Nexium cap, gra, ST, QL

pantoprazole, QL NEXIUM IV, ST, QL

rabeprazole, QL PREVACID CAP; Prevacid STB, ST, QL

PRILOSEC, ST, QL

PROTONIX, ST, QL

Protonix pak, ST, QL

ZEGERID, ST

LAXATIVES

gavilyte G; gavilyte N, QL COLYTE

glycolax GOLYTELY SOLUTION, QL

lactulose Halflytely, QL

polyethylene glycol-electrolyte MIRALAX

trilyte Moviprep, QL

NULYTELY QL

Prepopik, QL

Suprep Bowel, QL

Suclear, QL

MISCELLANEOUS

pancrelipase Creon ACTIGALL Carbaglu

ursodiol, forte Linzess, QL, ST Amitiza, QL, ST, AE Gattex, PA

Zenpep GASTROCROM Myalept., PA

Lotronex PA Remicade, ‡ PA

PANCREAZE, ST

Pertzye, ST

Ultresa, ST

Viokace, ST

11.0 BLOOD MODIFIERS, NUTRITIONALS AND ELECTROLYTES

ANTIHEMOPHILIC AND OTHER COAGULOPATHY AGENTS

Advate

Alphanate

Alprolix, PA

Bebulin

Benefix

Corifact

Eloctate, PA

Feiba NF

Helixate

Hemofil-M

Novoseven RT

Profilnine SD

January 2015




31

Tier 1

Generic Products

Tier 2

Brand Products

Tier 3

Brand Products

Specialty Drugs


Koate-DVI

Kogenate FS

Monoclate-P

Mononine

Recombinate

Riastap

Rixubis

Thrombate III

Tretten inj, PA

PLATELET AGGREGATION INHIBITORS/ANTICOAGULANT/PVD AGENTS

anagrelide Brilinta, QL Aggrenox ARIXTRA

cilostazol COUMADIN (NTI) AGRYLIN enoxaparin

clopidogrel, QL Effient, QL Eliquis, PA fondaparinux

dipyridamole Pradaxa. PA, QL PERSANTINE Fragmin

pentoxifylline Xarelto 10MG & 15MG, PA, QL PLAVIX,QL Iprivask

ticlopidine,QL Xarelto 20MG, QL PLETAL LOVENOX

warfarin Zontivity, PA, QL

PHOSPHATE BINDERS

calcium acetate Renagel Phoslyra

eliphos RENVELA

sevelamer carbonate

POTASSIUM SUPPLEMENTS

klorcon powder, tab K-LOR

potassium chloride K-TAB; K-Tab 20MEQ

MICRO-K

POTASSIUM REMOVING RESIN

sodium polystyrene sulfonate KAYEXALATE

PRENATAL VITAMINS

active FE Active OB

ob complete with DHA (generic) Be Well Pak Rounded

Calcium PNV Cap

Citranatal cap harmony

Duet, Duet DHA

Folet DHA

Folet One Cap 38-1-225

Nata Komplet

Natafort

Neevo DHA

Nestabs & DHA Pak

OB Complete

PNV tabs

Prefol-DHA

Prenatal MIS Compleat

Prenate

Prenate Tab Elite

Prenate DHA Cap

Prenate Star Tab 20-1mg

Pretab tab 29-1mg

Select-OB+ DHA Pak

Vitafol PN

Virt-bal DHA MIS

January 2015




32

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Generic Products

Tier 2

Brand Products

Tier 3

Brand Products

Specialty Drugs


VITAMINS/MINERALS/SUPPLEMENTS

aminobenzoate Calciferol drops, inj Addamel N dexferrum

b-complex w/c & folic acid Aquasol A soln, inj doxercalciferol

calcitriol B-Nexa Feraheme

fe 90 plus B12/lmthf/B6 tab FERRLECIT

folic acid FE succ/ac-c Cap THRE/B12 HECTOROL

iron/B12/folic acid Ferivafa sodium ferric gluconate

iron/intrinsic factor/B12 Focalgin-B Venofer

multivitamins w/fluoride Folgard

potassium citrate Foltx

sodium fluoride Galzin

Glycophos

Levomefolate cap/algal

LURIDE

Maxfe

Methylfol/ME Cap CBL/P5P

MV FE/C/B12/tab CA/Succ

Nascobal

NEPHROCAPS

Newgen

Pedictrace

Poly-vi-flor

POTABA CAP; Potaba tab

ROCALTROL

Tri-vi-flor

Velphoro chw

Vitapearl

MISCELLANEOUS

aminocaproic acid Fosrenol AMICAR Carbaglu

cytra-2, cytra-3, cytra-K Mephyton CARNITOR

levocarnitine Renagel Chemet CYKLOKAPRON

phospha 250 DESFERAL Exjade

pot. citrate – citric acid K-PHOS NEUTRAL; K-Phos tab Ferriprox, PA

pot & sod cit w/citric acid LYSTEDA, QL Firazyr, PA

sodium citrate & citric acid Oracit Humate-P

sevelamer carbonate PHOSLO Kalbitor, PA

tranexamic acid tab, QL RENVELA Pamidronate

UROCIT-K paricalcitol

Sucraid

tranexamic acid inj

Wilate

Xyntha

ZEMPLAR

12.0 OBSTETRICS/GYNECOLOGY

ANTIFUNGALS-VAGINAL

fluconazole 150mg tab., QL DIFLUCAN 150MG TAB, QL

nystatin Gynazole-1

terconazole TERAZOL 3 SUPP, QL

TERAZOL 7 CR, SUPP

January 2015




33

Tier 1

Generic Products

Tier 2

Brand Products

Tier 3

Brand Products

Specialty Drugs


ANTI-INFECTIVES - VAGINAL

clindamycin CLEOCIN VAGINAL

metronidazole METROGEL VAGINAL

DIAPHRAGMS

All brands are formulary

MONOPHASICS – ORAL CONTRACEPTIVES

apri Beyaz BREVICON

altavera Natazia DESOGEN

amethyst Safyral Falessa

aviane FEMCON FE

cryselle LOESTRIN, FE

dasetta LO/OVRAL

daysee, QL Lo Minastrin FE

drospirenone/ethinyl estradiol LYBREL

elinest MODICON

Jolessa QL NORDETTE

kelnor NORINYL

lessina ORTHO-CEPT

levora ORTHO-CYCLEN

low ogestrel ORTHO-NOVUM

microgestin, fe OVCON

necon SEASONALE

nortrel YASMIN

ocella YAZ

ogestrel

portia

reclipsen

sprintec

zeosa

zovia

BIPHASICS – ORAL CONTRACEPTIVES

alyacen ACTIVELLA, QL

amethia Generess Fe

amethia LO LO SEASONIQUE, QL

amethyst MIRCETTE

estradiol- levonorgestrel, QL ORTHO-NOVUM

estradiol-norethindrone SEASONIQUE, QL

kariva

necon 10/11

TRIPHASICS – ORAL CONTRACEPTIVES

enpresse Ortho Tri-Cyclen Lo CYCLESSA

necon 7/7/7 ESTROSTEP FE

tilia fe ORTHO-NOVUM

tri-legest fe ORTHO TRI-CYCLEN

tri-nessa TRI-NORINYL

tri-sprintec

trivora

velivet

January 2015




34

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Generic Products

Tier 2

Brand Products

Tier 3

Brand Products

Specialty Drugs


PROGESTIN ONLY – ORAL CONTRACEPTIVES

camila NOR-Q.D.

errin ORTHO MICRONOR

jolivette

nora-be

INJECTABLE CONTRACEPTIVES

medroxyprogesterone, QL DEPO-PROVERA 150MG, QL

MISCELLANEOUS CONTRACEPTIVES

levonorestrel , QL Nuvaring Ella, QL Implanon

norelgestromin-ethinyl estradiol td ORTHO EVRA PATCH Mirena

PLAN B ONE STEP, QL Nexplanon

Preven, QL Paragard T 380-A

Skyla

OVULATORY STIMULANTS

clomiphene CLOMID Bravelle, PA

serophene chorionic gonadotropin

Follistim AQ, ‡ PA Gonal-F/Gonal-RFF,‡ PA Menopur, PA

novarel, PA

Ovidrel, PA

pregnyl, ‡ PA Repronex, PA

Synarel

OXYTOCICS

methylergonovine tab, inj Cervidil

oxytocin METHERGINE TAB, INJ

Prepidil

PROGESTINS

medroxyprogesterone AYGESTIN Makena, PA

norethindrone Crinone gel

progesterone micro PROMETRIUM

PROVERA

PROSTAGLANDINS

Prostin E2

MISCELLANEOUS

acetic acid vaginal Cetrotide

terbutaline Ganirelix

13.0 RESPIRATORY AGENTS

ANTIHISTAMINES – NON-SEDATING

fexofenadine ALLEGRA

clemastine fumarate CLARINEX, RDT, SYR QL

desloratadine, QL Clarinex D, QL

January 2015




35

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Generic Products

Tier 2

Brand Products

Tier 3

Brand Products

Specialty Drugs


ANTIHISTAMINES – OTHER

brompheniramine SR Respa-Br

levocetirizine, QL TAVIST

XYZAL, QL

ANTIHISTAMINE & DECONGESTANTS

cetirizine/peusoephedrine Atrohist

fexofenadine- D (PSE), QL PHENERGAN V.C. SYRUP

phenyleph/chlorphen/ carbeta Semprex-D

pse/carbinoxamine Zyrtec-D, QL

pse/hydrocod/carbinx

DECONGESTANT/EXPECTORANT/ANTITUSSIVE COMBINATIONS

benzonatate Humibid sprinkle

deconsal HUMIBID L.A.

dextromethorphan/guaifen Phenagil CH

guaifenesin PHENERGAN D.M.

guaifenesin/pseudoephed. TESSALON PERLES

guaifenesin S.R. Vituz

phenyleph-ephed-cpd w/

carbetapentane

potassium iodide

promethazine/ dextromethorphan

pseudoephedrine-gg & gg

pseudoephed/ dexchlorphen/dm

NARCOTIC ANTITUSSIVE/EXPECTORANT/DECONGESTANTS

guaifenesin/codeine HYCODAN SYRUP

guaifenesin/hydrocodone PHENERGAN/CODEINE

hydrocodone w/homatropine PHENERGAN V.C./CODEINE

phenyleph/chlorphen /w

hydrocodone

TUSSIONEX

phenyleph hcl/hydrocod bit/cp

phenyleph-pyrilamine w/

hydrocodone

phenylephrine/promethazine/

codeine

promethazine/codeine

BRONCHODILATORS AND RELATED MEDICATIONS

albuterol, QL Advair, HFA, QL ACCUNEB

albuterol/ipratropium Breo Ellipta Anoro Ellipt

ipratropium bromide, QL Combivent Respimat, QL Arcapta, QL, ST

levalbuterol, QL Foradil, QL, ST Atrovent Inhaler, HFA QL

metaproterenol, QL ProAir HFA, QL ATROVENT SOLN, QL

terbutaline Serevent Diskus, QL Brovana, QL

Spiriva, QL Daliresp, PA, QL

Symbicort Inhaler, QL Dulera, ST, QL

Tudorza, QL DUONEB

Ventolin HFA, QL Maxair, QL

Perforomist, QL

Proventil HFA, QL

Striverdi Respimat, QL, ST

VOSPIRE ER

Xopenex HFA, QL

January 2015




36

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Generic Products

Tier 2

Brand Products

Tier 3

Brand Products

Specialty Drugs


XOPENEX NEB SOLN

LEUKOTRIENE RECEPTOR ANTAGONISTS/MODIFIERS

montelukast, QL ACCOLATE

montelukast chew, QL SINGULAIR TAB, CHEW, QL

montelukast granules, QL SINGULAIR GRANULES, QL

zafirlukast Zyflo, QL

Zyflo, CR, QL

METHYLXANTHINES

aminophylline Theo-24 400mg ELIXOPHYLLIN

dyphylline Lufyllin

theochron Theo-24

theophylline syrup, elixir

theophylline, CR, ER, SR

INHALED ANTIINFLAMMATORY

cromolyn QL Asmanex, QL Aerobid, Aerobid-M, QL

budesonide neb, QL Flovent, HFA, QL Azmacort

Pulmicort Flexhaler; Pulmicort

1mg/2ml QL QL

PULMICORT SUS, QL

Qvar, QL

MISCELLANEOUS

acetylcysteine Epipen, QL Adrenaclick, QL, ST Aralast, NP, PA

Auvi-Q, QL, ST Bethkis ‡

Epinephrine, QL, ST Cayston

Grastek, PA, QL Glassia, PA

Oralair, PA Kalydeco, PA, QL

Ragwitek, PA Prolastin C, PA

Surfaxin Pulmozyme

Twinject, QL TOBI , PA

Tobi Podhalr

tobramycin, PA

Xolair, PA

Zemaira, PA

14.0 SKELETAL MUSCLE RELAXANTS

SKELETAL MUSCLE RELAXANTS

baclofen DANTRIUM Gablofen

carisoprodol cpd FEXMID Lioresal INT

chlorzoxazone FLEXERIL

cyclobenzaprine NORFLEX

dantrolene sodium NORGESIC, FORTE

diazepam PARAFON, FORTE

methocarbamol ROBAXIN

metaxalone SKELAXIN

orphenadrine, cpd, forte SOMA

tizanidine VALIUM

ZANAFLEX

15.0 UROLOGICALS

UROLOGICALS

alfuzosin, QL Vesicare, QL Avodart, QL Procysbi

dimethyl sulfoxide CARDURA

January 2015




37

Tier 1

Generic Products

Tier 2

Brand Products

Tier 3

Brand Products

Specialty Drugs


doxazosin Cardura XL, QL, ST

fesoterodine DETROL: DETROL LA QL

flavoxate DITROPAN XL, QL

finasteride Elmiron

oxybutynin, XL Enablex, QL

phenazopyridine FLOMAX, QL

tamsulosin, QL Gelnique, ST,QL

terazosin Jalyn, QL

tolterodine Myrbetriq, QL

trospium Oxytrol, QL

PROSCAR

PYRIDIUM

Rapaflo, ST, QL

SANCTURA, QL

SANCTURA XR QL, ST

TOVIAZ, QL

Uribel, QL

Urogesic Blue

UROXATRAL, QL

16.0 IMMUNOLOGICALS, VACCINES AND BIOTECHNOLOGY DRUGS

GROWTH HORMONES AND ANTAGONISTS

Atgam

Bivigam, PA

Carimune, PA

Cytogam

Egrifta, PA, QL

Flebogamma, PA

Gamastan SD, PA

Gammagard, PA

Gammaked, PA

Gammaplex, PA

Gamunex, PA

Genotropin, PA

Hizentra, PA

Humatrope, PA

Hyperrab

Hyperrho

Hypertet

Imogam

Micrhogam PL

Norditropin, PA

Nutropin, ‡ PA

Nutropin, AQ, ‡ PA

Octagam, PA

Omnitrope, PA

Privigen, PA

Rhogam plus

Rhophylac

Saizen, ‡ PA

Serostim, PA,QL

January 2015




38

Tier 1

Generic Products

Tier 2

Brand Products

Tier 3

Brand Products

Specialty Drugs


Somavert, PA

Tev-Tropin, ‡ PA

Winrho SDF

Zorbtive, PA,QL

INTERFERONS/IMMUNOMODULATORS

Actemra, PA

Actimmune

Alferon-N

Arcalyst, PA

Aubagio PA, QL

Avonex, ‡ PA, QL

Betaseron ‡, PA, QL

Copaxone, ‡ PA, QL

Extavia, PA, QL

Gilenya, QL, PA

Infergen, PA

Intron-A, PA

Moderiba, PA

Nulojix, PA

Pegasys, ‡ PA

Peg-Intron, PA

Plegridy, ‡ PA, QL

Rebif, PA, QL

Soliris

Sylatron, PA

Synagis, PA

Thalomid, PA, QL

Tysabri, PA

Vandetanib, PA, QL

Xgeva, PA, QL

INTERLEUKIN

Proleukin, PA

HEMATOPOIETIC GROWTH FACTORS

Aranesp, ‡ PA

Epogen, PA

Granix Inj, PA

Leukine, PA

Mozobil, PA

Neulasta, ‡ PA

Neumega, PA

Neupogen, ‡ PA

Nplate, PA

Omontys, PA

Procrit, ‡ PA

Promacta, PA

MISCELLANEOUS

Adagen

Ceredase, PA

Euflexxa, ‡ PA

Gel-One, PA

January 2015




39

Tier 1

Generic Products

Tier 2

Brand Products

Tier 3

Brand Products

Specialty Drugs


Hepagam B

Hyperhep B S-D

Hyalgan, PA

HyQvia, PA

Monovisc, PA

Nabi-HB

Naglazyme, PA

Orthovisc, PA Prolastin, PA

Supartz, PA

Sylvant, PA

Synvisc, ‡ PA Vimizim Inj

VACCINES

Adacel Flumist Theracys

Afluria Tice BCG

Cervarix

Flublok

Flulaval

Gardasil

Havrix

Hiberix

Infanrix

Ixiaro

JE-Vax

Menactra

Menveo

Prevnar

Rotarix

Twinrix

Varzig

Zostavax

17.0 THERAPEUTIC DEVICES AND SUPPLIES

METERS AND TEST STRIPS

Accu-Chek (Meters, Strips) QL Ascensia (Strips), QL, ST

One Touch (Meters, Strips) QL Bayer (Meters, Strips), QL, ST

Fast Take (Meters, Strips), QL, ST

Freestyle (Meter &Strips) QL, ST

Glucocard (Meters, Strips) QL, ST

Precision (Meter&Strips) QL, ST

Prestige (Meter&Strips), QL, ST

Prodigy (Meter, Strips), QL, ST

TrueResult (Meter, Strips), QL, ST

TrueTrack (Meter&Strips) QL, ST

LANCETS AND INSULIN SYRINGES

Accu-Chek Kit FastClix SoftClix

NovoFine Needles

Insulin Pen Needles

Lancets

MAGELLAN RX STANDARD FORMULARY 2015resource.carrollhospitalcenter.org › Documents › MRx Standard...

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Transcript of MAGELLAN RX STANDARD FORMULARY 2015resource.carrollhospitalcenter.org › Documents › MRx Standard...