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Transcript of MedPerform High Formulary April 2017 MedPerform High Formulary MedPerform Formulary 2017.pdf ·...
MedPerform High Formulary April 2017
37014 MedPerform High Formulary – April 2017 i
MedPerform High Formulary April 2017
Foreword This document represents the efforts of Kroger Prescription Plan’s (KPP) Pharmacy and Therapeutics (P&T) and Formulary Committees, powered my MedImpact, to provide physicians and pharmacists with a method to evaluate the safety, efficacy and cost-effectiveness of commercially available drug products. A structured approach to the drug selection process is essential in ensuring continuing patient access to rational drug therapies. The ultimate goal of the formulary is to provide a process and framework to support the dynamic evolution of this document to guide prescribing decisions that reflect the most current clinical consensus associated with drug therapy decisions. This is accomplished through the auspices of the KPP P&T and Formulary Committees. These committees meet quarterly and more often as warranted to ensure clinical relevancy of the Formulary. To accommodate changes to this document, updates are made accessible as necessary. As you use this Formulary, you are encouraged to review the information and provide your input and comments to the KPP P&T and Formulary Committees. The KPP P&T and Formulary Committees use the following criteria in the evaluation of drug selection for the Portfolio Formulary:
Drug safety profile
Drug efficacy
Comparison of relevant therapeutic benefits to current formulary agents of similar use, and to minimize therapeutic duplication where possible
Cost-effectiveness relative to comparable therapies How to Use the Formulary The Formulary is a list of medications available to KPP members under their pharmacy benefit. All drugs are listed by their generic names and most common proprietary (branded) name. The Formulary may be accessed by using the index, either by generic or proprietary name (in capital letters) and by therapeutic drug category. In situations where an FDA approved generic equivalent is available, brand names are listed for reference purposes only, and do not denote coverage for the brand, unless specifically noted. Any drug not found in this Formulary listing, or any Formulary updates published by KPP shall be considered a Non-Formulary drug. All drugs are listed in each category in alphabetical order by generic name. Where an FDA approved generic is available for the listed generic name, the generic name is bolded. For certain agents within the Formulary, a recommended prescribing guideline may apply. These are denoted throughout the document using the following symbols:
AGE Age Edit Coverage may depend on patient age
CU Concurrent Use Edit
Coverage or lack thereof may depend upon concurrent use of another drug
MD Physician Specialty Edit
Coverage may depend on prescribing physician’s specialty or board certification
PA Prior Authorization
Requires specific physician request process
QL Quantity Limit
Coverage may be limited to specific quantities per prescription and/or time period
ST Step Therapy
Coverage may depend on previous use of another drug
Please refer to the prescribing guideline appendix within this document for details regarding specific agents. Benefit Coverage and Limitations This printed Formulary does not provide information regarding the specific coverage and limitations an individual member may be subject to. Many members have specific benefit inclusions, exclusions, copays, or a lack of coverage, which are not reflected in the Formulary. The Formulary applies only to outpatient drugs provided to members, and does not apply to medications used in inpatient settings. If a member has any specific questions regarding their coverage, they should contact their Plan Sponsor or KPP at (800) 482-1285. Excluded Agents As new drugs become available, they will be considered for coverage under the MedPerform Formulary. The plan administrator has the right to decide what drugs are covered and to what extent, as well as the right to modify coverage including the exclusion of any prescription drugs. Please note that prescribing guidelines such as Prior Authorization, Step Therapy, Quantity Limit, etc., may still apply to Formulary Therapeutic Alternatives.
EXCLUDED DRUGS
FORMULARY THERAPEUTIC ALTERNATIVES
THERAPEUTIC DRUG CLASS
VELTIN clindamycin/tretinoin,
ZIANA
ACNE AGENTS, TOPICAL
KADIAN
morphine sulfate ER tablets, oxycodone ER, NUCYNTA, NUCYNTA
ER
ANALGESICS, NARCOTICS
BELBUCA BUTRANS PATCH ANALGESICS, NARCOTICS
ABSTRAL, FENTORA, LAZANDA, ONSOLIS, SUBSYS
fentanyl citrate lozenge ANALGESICS, NARCOTICS
GRALISE immediate-release
gabapentin ANTICONVULSANTS
ACTIVE-PAC KIT,
SMARTRX GABA-V KIT, SMART RX GABA KIT
immediate-release
gabapentin & lidocaine/menthol
topical, or capsaicin/methyl
salicylate/menthol topical
ANTICONVULSANTS
HORIZANT
immediate-release gabapentin,
ropinirole, pramipexole
ANTICONVULSANTS (RESTLESS LEG
SYNDROME/POST HERPETIC NEURALGIA)
FORFIVO XL bupropion ER ANTIDEPRESSANTS
IRENKA duloxetine ANTIDEPRESSANTS
KHEDEZLA
desvenlafaxine succinate ER,
desvenlafaxine ER (Ranbaxy)
ANTIDEPRESSANTS
PEXEVA paroxetine ANTIDEPRESSANTS
ZUPLENZ ondansetron ODT ANTIEMETIC AGENTS
NYATA nystatin topical ANTI-INFECTIVE
ZIPSOR, ZORVOLEX
diclofenac ANTI-INFLAMMATORY
NON-STEROIDAL
NAPRELAN naproxen ANTI-INFLAMMATORY
NON-STEROIDAL
VIVLODEX meloxicam ANTI-INFLAMMATORY
NON-STEROIDAL
TIVORBEX indomethacin ANTI-INFLAMMATORY
NON-STEROIDAL
VIMOVO
naproxen & esomeprazole magnesium, lansoprazole,
omeprazole, or pantoprazole
ANTI-INFLAMMATORY NON-STEROIDAL
COMBINATION AGENTS
DUEXIS famotidine & ibuprofen
ANTI-INFLAMMATORY NON-STEROIDAL
COMBINATION AGENTS
RAYOS immediate-release
prednisone
ANTI-INFLAMMATORY STEROIDAL
CAPXIB
celecoxib & capsaicin/menthol
topical patch
ANTI-INFLAMMATORY NON-STEROIDAL
CYCLOOXYGENASE-2 (COX-2) SELECTIVE
INHIBITOR
HYCOFENIX codeine/pseudoephedrin
e/guaifenesin sol ANTITUSSIVES
MedPerform High Formulary
37014 MedPerform High Formulary – April 2017 ii
EXCLUDED DRUGS FORMULARY
THERAPEUTIC
ALTERNATIVES
THERAPEUTIC DRUG CLASS
APTENSIO XR, ADZENYS XR ODT
dextroamphetamine/ amphetamine,
methylphenidate
ATTENTION DEFICIT-HYPERACTIVITY
(ADHD)/NARCOLEPSY
CIMZIA, SIMPONI 50mg, TALTZ
HUMIRA, ENBREL, COSENTYX, STELARA,
XELJANZ/XR, *SIMPONI 100mg (*for diagnosis of ulcerative
colitis only)
AUTOIMMUNE DISEASE
BINOSTO alendronate 70mg,
ibandronate
BONE RESORPTION INHIBITORS
DURLAZA aspirin (OTC),
clopidogrel CARDIOLOGY
YOSPRALA aspirin (OTC) CARDIOLOGY
GONITRO nitroglycerin CARDIOLOGY
BEAU RX KELOCOTE, RECEDO DERMATOLOGY
DERMAPAK PLUS tretinoin topical DERMATOLOGY
ACCUCAINE lidocaine topical DERMATOLOGY
PEDIPAK ciclopirox DERMATOLOGY
SYNERDERM
OTC EMOLLIENTS (EUCERIN, CETAPHIL, VASELINE,
AQUAPHOR)
DERMATOLOGY
URE-K, KERALAC, UTOPIC, UREVAZ, DERMASORB XM
urea 40%, urea 50% DERMATOLOGY
PENNSAID diclofenac sodium 1%
topical DERMATOLOGY -
ANTIINFLAMMATORY
ADLYXIN, BYDUREON,
BYETTA, TANZEUM
TRULICITY, VICTOZA DIABETES
XULTOPHY, SOLIQUA
TRULICITY, VICTOZA, LANTUS, TOUJEO
DIABETES
FARXIGA, XIGDUO XR
INVOKANA, INVOKAMET, JARDIANCE, SYNJARDY
DIABETES
GLUMETZA metformin ER DIABETES
NESINA, KAZANO, OSENI,
ONGLYZA, KOMBIGLYZE XR
JENTADUETO, JENTADUETO XR,
TRADJENTA, JANUVIA, JANUMET,
JANUMET XR
DIABETES
ALL OTHER MANUFACTURER
S OF DIABETIC TEST STRIPS AND
METERS
KROGER & ABBOTT (PRECISION AND
FREESTYLE BRAND)
DIABETIC SUPPLIES (TEST STRIPS,
METERS)
LEVITRA, STENDRA, STAXYN
VIAGRA DRUGS TO TREAT
IMPOTENCY
AUVI-Q epinephrine 0.3mg or 0.15mg auto-injector
EMERGENCY TREATMENT OF
ALLERGIC REACTIONS (TYPE 1)
GENOTROPIN, HUMATROPE,
NUTROPIN, NUTROPIN AQ, NUTROPIN AQ
NUSPIN, SAIZEN, ZOMACTON
OMNITROPE, NORDITROPIN
GROWTH HORMONES
EXCLUDED DRUGS FORMULARY
THERAPEUTIC ALTERNATIVES
THERAPEUTIC DRUG CLASS
VIEKIRA PAK, DAKLINZA
HARVONI, EPCLUSA HEPATITIS C
ESTROGEL DIVIGEL HORMONAL DEFICIENCY
PRESTALIA amlodipine & benazepril hcl
HYPERTENSION
NATESTO, TESTIM,
VOGELXO, FORTESTA
ANDROGEL, AXIRON HORMONAL DEFICIENCY
H.P. ACTHAR N/A HORMONE MODIFIERS
DUTOPROL metoprolol succinate
ER-HCTZ HYPERTENSION
APIDRA, APIDRA SOLOSTAR
HUMALOG, NOVOLOG
INSULINS
BASAGLAR LANTUS, LEVEMIR, TOUJEO, TRESIBA
INSULINS
ALTOPREV, LESCOL XL
atorvastatin, lovastatin, pravastatin, simvastatin, rosuvastatin
LIPID IRREGULARITY
ANTARA fenofibrate/ micronized/
nanocrystallized LIPOTROPICS
ASACOL HD, DELZICOL, DIPENTUM
balsalazide disodium, APRISO, LIALDA,
PENTASA, sulfasalazine
LOWER GASTROINTESTINAL
DISORDERS
ONZETRA, ZEMBRACE SYMTOUCH, TREXIMET
sumatriptan MIGRAINE
EXTAVIA
REBIF, GILENYA, PLEGRIDY,
TECFIDERA, AVONEX, GLATOPA
MULTIPLE SCLEROSIS
METHAVER Individual vitamin
components MULTIVITAMIN
PREPARATIONS
armodafinil modafinil NARCOLEPSY AND SLEEP DISORDER THERAPY AGENTS
OMNARIS, ZETONNA,
BECONASE AQ, TICANASE
Nasal triamcinolone, flunisolide, fluticasone,
budesonide, mometasone, QNASL
NASAL ANTI-INFLAMMATORY
QSYMIA phentermine &
topiramate OBESITY AGENTS
ZIOPTAN
latanoprost, travoprost, LUMIGAN,
TRAVATAN Z
OPHTHALMIC GLAUCOMA
EVZIO NARCAN NASAL
SPRAY OPIOID REVERSAL
LASTACAFT, BEPREVE,
EMADINE, PAZEO
PATADAY, olopatadine OPHTHALMIC
ANTIHISTAMINES
ARESTIN N/A ORAL/PHARYNGEAL
DISORDERS
PANCREAZE, PERTZYE
lipase/protease/amylase, CREON, ZENPEP
PANCREATIC ENZYMES
ALVESCO, FLOVENT DISKUS,
FLOVENT HFA
ASMANEX HFA, ASMANEX
TWISTHALER, PULMICORT
FLEXHALER, QVAR
RESPIRATORY ASTHMA
MedPerform High Formulary
37014 MedPerform High Formulary – April 2017 iii
EXCLUDED DRUGS FORMULARY
THERAPEUTIC ALTERNATIVES
THERAPEUTIC DRUG CLASS
PROVENTIL HFA, levalbuterol HFA
PROAIR HFA, VENTOLIN HFA
RESPIRATORY ASTHMA AND COPD
TUDORZA PRESSAIR,
SEEBRI NEOHALER
SPIRIVA HANDIHALER,
SPIRIVIA RESPIMAT
RESPIRATORY COPD
UTIBRON, BEVESPI
STIOLTO RESPIRATORY COPD
NORITATE metronidazole 0.75% cream, gel or lotion
ROSACEA AGENTS, TOPICAL
EDLUAR, INTERMEZZO,
ROZEREM, ZOLPIMIST
eszopiclone, zaleplon, zolpidem
SEDATIVE-HYPNOTICS, NON-BARBITURATE
ALLZITAL butalbital/acetaminoph
en TENSION HEADACHE
AMRIX, FEXMID, FLEXEPAX
cyclobenzaprine 5mg or 10mg
SKELETAL MUSCLE RELAXANTS
TIROSINT levothyroxine THYROID HORMONES
DEXILANT
lansoprazole, omeprazole,
pantoprazole, esomeprazole
UPPER GASTROINTESTINAL
DISORDERS
Please note that prescribing guidelines such as Prior Authorization, Step Therapy, Quantity Limit, etc., may still apply to Formulary Therapeutic Alternatives. Depending upon a member’s specific benefit parameters, the following topics may apply:
1. Generic Substitution When available, FDA approved generic drugs are to be used in all situations, regardless of the brand name indicated. The generic names are bolded in the formulary listing wherever an FDA approved generic drug product is available. Greater economy is realized through the use of generic equivalents. This policy is not meant to preclude or supplant any state statutes that may exist. All drugs that are or become available generically are subject to review by KPP’s Pharmacy and Therapeutics Committee. KPP approves such multi-source drugs for addition to the MAC list based on the following criteria:
A multi-source drug product manufactured by at least one (1) nationally marketed company.
At least one (1) of the generic manufacturer’s products must have an “A” rating or the generic product has been determined to be unassociated with efficacy, safety or bioequivalency concerns by the KPP P & T Committee.
Drug product will be approved for generic substitution by the KPP P & T Committee.
This list is reviewed and updated periodically based on the clinical literature and pharmacokinetic characteristics of currently available versions of these drug products. If a member or physician requests a brand name product in lieu of an approved generic, the member, based upon their coverage, will typically be required to pay the difference in cost between the brand and the generic. If a physician determines that there is a documented medical need for the brand equivalent, a request for coverage may be made using the medication request process.
2. Three Tier Benefit The Formulary may be applied to a three tier benefit design, where the member shares the cost of prescription drug therapy at three levels of copayment. In most instances, generically available drugs will be covered under the first or lowest copay tier, branded drugs listed on the Formulary will be covered under the second copay tier, and branded drugs not on the Formulary will be covered under the third or highest copay tier.
3. Medication Request Process Depending upon plan benefit design, a medication request process may apply as follows:
A. Formulary Agents Drugs that are listed in the Formulary with associated Prior Authorization (PA) require evaluation, per KPP P & T Committee Prior Authorization guidelines prior to dispensing at a network pharmacy. Each request will be reviewed on an individual patient need basis. If the request does not meet the guidelines established by the P & T Committee, the request will not be approved and alternative therapy may be recommended.
B. Non-Formulary Agents
Any drug not found in the Formulary listing, or any Formulary updates published by KPP, shall be considered a Non-Formulary drug. Coverage for non-formulary agents may be applied for in advance. When a member gives a prescription order for a non-formulary drug to a pharmacist, the pharmacist will evaluate the patient’s drug history and contact the physician to determine if there is a reasonable medical need for a non-formulary drug. Each request will be reviewed on an individual patient need basis. Approval will be given if a documented medical need exists. The following basic guidelines are used:
The use of Formulary Drugs is contraindicated in the patient.
The patient has failed an appropriate trial of Formulary or related agents.
The choices available in the Formulary are not suited for the present patient care need, and the drug selected is required for patient safety.
The use of a Formulary drug may provoke an underlying condition, which would be detrimental to patient care.
If the request does not meet the guidelines established by the P & T Committee, the request will not be approved and alternative therapy may be recommended.
C. Obtaining Coverage Coverage, questions or information regarding the medication request or formulary process may be obtained by:
1. Faxing a completed Medication Request Form to KPP at (858) 790-7100.
2. Contacting KPP at (800) 482-1285 and providing all necessary information requested.
KPP will provide an authorization number, specific for the medical need, for all approved requests. Non-approved requests may be appealed. The prescriber must provide information to support the appeal on the basis of medical necessity. Prior Authorization is generally not available for drugs that are specifically excluded by benefit design.
4. General Exclusions A. Over the Counter (OTC) medications or their equivalents, unless otherwise
specified in the Formulary listing. B. Nicotine Smoking Cessation products (i.e., transdermal nicotine, nicotine
gum, nicotine inhaler). C. Drugs specifically listed as not covered. D. Any drug products used for cosmetic purposes. E. Experimental drug products or any drug product used in an experimental
manner. F. Replacement of lost or stolen medication. G. Non self-administered injectable drug products unless otherwise specified
in the Formulary listing. H. Foreign sourced drugs or drugs not approved by the United States Food &
Drug Administration.
The P & T and Formulary Committees recognize that not all medical needs can be met with this document and encourage inquiries about alternative therapies.
5. Pharmacist and Physician Communication The Formulary is a tool to promote cost-effective prescription drug use. The P&T and Formulary Committees have made every attempt to create a document that meets all therapeutic needs; however, the art of medicine makes this a formidable task.
MedPerform High Formulary
37014 MedPerform High Formulary – April 2017 iii
Foreword ............................................................................................................. i 1. Generic Substitution ........................................................................ iii 2. Three Tier Benefit ............................................................................ iii 3. Medication Request Process .......................................................... iii 4. General Exclusions ......................................................................... iii 5. Pharmacist and Physician Communication .................................... iii
ALLERGY ................................................................................................................. 6 Allergenic extracts .............................................................................................. 6 2nd Generation Antihistamine & Decongestant Combinations ......................... 6 Antihistamines - 1st Generation ......................................................................... 6 Antihistamines - 2nd Generation ....................................................................... 6 Nasal Anti-Inflammatory Steroids ...................................................................... 6 Nasal Antihistamine ........................................................................................... 6
ANTIEMESIS/ANTIVERTIGO .................................................................................. 6 Antiemetic/Antivertigo Agents ............................................................................ 6
ASTHMA ................................................................................................................... 6 Beta-Adrenergic Agents ..................................................................................... 6 Beta-Adrenergic & Anticholinergic Combinations .............................................. 6 Beta-Adrenergic & Glucocorticoid Combinations .............................................. 6 General Bronchodilator Agents .......................................................................... 6 Leukotriene Receptor Antagonists ..................................................................... 6 Mast Cell Stabilizers........................................................................................... 6 Oral Inhaled Corticosteroids .............................................................................. 6 Phosphodiesterase-4 (PDE4) Inhibitors ............................................................ 6 Xanthines ........................................................................................................... 6
AUTONOMIC NERVOUS SYSTEM DISORDERS .................................................. 6 Alzheimer's Therapy, NMDA Receptor Antagonists .......................................... 6 Alzheimer's Therapy, NMDA Receptor Antagonists & Cholines Inhibitors ....... 6 Cholinesterase Inhibitors ................................................................................... 6
BEHAVIORAL HEALTH - ANTIDEPRESSANTS .................................................... 6 Alpha-2 Receptor Antagonist Antidepressants .................................................. 6 MAOIs - Non-Selective & Irreversible ................................................................ 6 Norepinephrine & Dopamine Reuptake Inhibitors (NDRIs) ............................... 6 Selective Serotonin Reuptake Inhibitors (SSRIs) .............................................. 6 SSRI & Antipsycho, Atyp, Dopamine & Serotonin Antag Comb ....................... 6 SSRI & 5HT1A Partial Agonist Antidepressants................................................ 6 SSRI, Serotonin Receptor Modulator Antidepressants ..................................... 6 Serotonin-2 Antagonist/Reuptake Inhibitors (SARIs) ........................................ 6 Serotonin-Norepinephrine Reuptake-Inhib (SNRIs) .......................................... 6 Tricyclic Antidepressants & Rel. Non-Sel. Ru-Inhib .......................................... 7
BEHAVIORAL HEALTH - OTHER ........................................................................... 7 Adrenergics, Aromatic, Non-Catecholamine ..................................................... 7 Anti-Alcoholic Preparations ................................................................................ 7 Anti-Anxiety Drugs ............................................................................................. 7 Anti-Mania Drugs ............................................................................................... 7 Antipsychotics, Phenothiazines ......................................................................... 7 Antipsychotics, Atypical, D3/D2 Partial Agonist/5HT Mixed .............................. 7 Antipsychotics, Atypical, D2 Partial Agonist/5HT Mixed .................................... 7 Antipsychotics, Dopamine & Serotonin Antagonists ......................................... 7 Antipsychotics, Atypical, Dopamine, & Serotonin Antagonists .......................... 7 Antipsychotics, Dopamine Antagonists, Thioxanthenes .................................... 7 Antipsychotics, Dopamine Antagonists, Butyrophenones ................................. 7 Barbiturates ........................................................................................................ 7 Narcolepsy and Sleep Disorder Therapy Agents .............................................. 7 Narcotic Antagonists .......................................................................................... 7 Sedative-Hypnotics, Non-Barbiturate ................................................................ 7 Treatment for Attention Deficit-Hyperactivity (ADHD)/Narcolepsy .................... 7 Treatment for Attention Deficit-Hyperactivity (ADHD), Nri-Type ....................... 7
CARDIOVASCULAR DISEASE - ARRHYTHMIA .................................................... 7 Antiarrhythmics .................................................................................................. 7
CARDIOVASCULAR DISEASE - CARDIAC STIMULANTS ................................... 8 Digitalis Glycosides ............................................................................................ 8
CARDIOVASCULAR DISEASE - HYPERTENSION ............................................... 8 ACE Inhibitor/Calcium Channel Blocker Combinations ..................................... 8 ACE Inhibitor/Thiazide & Thiazide-Like Diuretics .............................................. 8 Alpha-Adrenergic Blocking Agents .................................................................... 8 Alpha/Beta-Adrenergic Blocking Agents ............................................................ 8 Angiotensin Receptor Antagonist/Calcium Channel Blocker/Thiazide Combinations ..................................................................................................... 8 Angiotensin Receptor Antagonist/Thiazide Diuretic Combinations ................... 8 Angiotensin II Receptor Blocker-Beta Blocker Comb. ....................................... 8 Angiotensin Receptor Antagonist & Calcium Channel Blockers ....................... 8 Antihypertensives, ACE Inhibitors ..................................................................... 8 Antihypertensives, Angiotensin Receptor Antagonist ........................................ 8 Antihypertensives, Sympatholytic ...................................................................... 8 Antihypertensives, Vasodilators ......................................................................... 8 Beta-Adrenergic Blocking Agents ...................................................................... 8 Beta-Adrenergic Blocking Agents/Thiazide & Related ...................................... 8 Calcium Channel Blocking Agents ..................................................................... 8 Loop Diuretics .................................................................................................... 8 Potassium Sparing Diuretics .............................................................................. 8 Potassium Sparing Diuretics in Combination .................................................... 8 Pulmonary Anti-HTN, Sel. C-GMP Phosphodiesterase T5 Inhibitors ............... 8 Pulmonary Anti-HTN, Endothelin Receptor Antagonists ................................... 8 Pulmonary Anti-HTN, Prostacyclin-Type ........................................................... 8 Pulmonary Anti-HTN, Soluble Guanylate Cyclase Stimulators ......................... 8 Thiazide & Related Diuretics.............................................................................. 8
CARDIOVASCULAR DISEASE - LIPID IRREGULARITY ....................................... 8 Antihyperlipidemic - APO B-100 Synthesis Inhibitor ................................................ 8
Antihyperlipidemic - HMG CoA Reductase Inhibitors ........................................ 9 Antihyperlipidemic - MTP Inhibitors ................................................................... 9 Antihyperlipidemic –PCSK9 Inhibitors ............................................................... 9 Bile Salt Sequestrants........................................................................................ 9 Lipotropics .......................................................................................................... 9 Niacin Preparations ............................................................................................ 9
CARDIOVASCULAR DISEASE - MISCELLANEOUS AGENTS ............................. 9 Adrenergic Vasopressor Agents ........................................................................ 9 Antianginal & Anti-Ischemic Agents, Non-Hemodynamic ................................. 9 Antihyperlipidemia - HMG-CoA & Calcium Channel Blocker Combinations ..... 9
Heart Rate Reducing, Selective I(F) Current Inhib. ................................................. 9 CARDIOVASCULAR DISEASE - VASODILATION ................................................. 9 Vasodilators, Combination ....................................................................................... 9
Vasodilators, Coronary ...................................................................................... 9 CONTRACEPTION/OXYTOCICS ............................................................................ 9
Contraceptives, Intravaginal, Systemic ............................................................. 9 Contraceptives, Oral .......................................................................................... 9 Contraceptives, Transdermal ............................................................................. 9 Oxytocics ............................................................................................................ 9
COUGH AND COLD ................................................................................................ 9 1st Generation Antihistamine & Decongestant Combinations .......................... 9 Narcotic Antitussive-1st Generation Antihistamine-Decongestants .................. 9 Narcotic Antitussive-1st Generation Antihistamines.......................................... 9 Narcotic Antitussive-Anticholinergic Comb. ....................................................... 9 Non-Narcotic Antitussive-1st Generation Antihistamine Combinations ............ 9
DERMATOLOGY - ACNE ........................................................................................ 9 Acne Agents, Systemic ...................................................................................... 9 Acne Agents, Topical ......................................................................................... 9 Keratolytic-Glucocorticoid Combinations ........................................................... 9 Keratolytics....................................................................................................... 10 Rosacea Agents, Topical ................................................................................. 10 Vitamin A Derivatives ....................................................................................... 10
DERMATOLOGY - ANTIINFECTIVE ..................................................................... 10 Topical Antibiotics ............................................................................................ 10 Topical Antifungals ........................................................................................... 10 Topical Antiparasitics ....................................................................................... 10 Topical Antivirals .............................................................................................. 10 Topical Sulfonamides....................................................................................... 10
DERMATOLOGY - ANTIINFLAMMATORY ........................................................... 10 Topical Anti-Inflammatory Steroidal ................................................................. 10 Topical Anti-Inflammatory, NSAIDs ................................................................. 10 Topical Antibiotics/Antiinflammatory, Steroidal ............................................... 10
DERMATOLOGY - MISCELLANEOUS ................................................................. 10 Antiperspirants ................................................................................................. 10 Antiseborrheic Agents ...................................................................................... 10 Topical Antineoplastic & Premalignant Lesion Agents .................................... 10 Topical Local Anesthetics ................................................................................ 10
DERMATOLOGY - PIGMENTATION DISORDERS .............................................. 10 Topical Hyperpigmentation Agents .................................................................. 10
DERMATOLOGY - PSORIASIS/ECZEMA ............................................................ 10 Antipsoriatic Agents, Systemic ........................................................................ 10 Antipsoriatics Agents ....................................................................................... 10 Topical Immunosuppressive Agents ................................................................ 10
DIABETES .............................................................................................................. 10 Antihyperglycemic, Alpha-Glucosidase Inhibitors (Non-Sulfonylurea) ............ 10 Antihyperglycemic, Amylin Analog-Type ......................................................... 10 Antihyperglycemic, DPP-4 Inhibitors ............................................................... 10 Antihyperglycemic, DPP-4 Inhibitor & Biguanide Combinations ..................... 10 Antihyperglycemic, Incretin Mimetic (GLP-1 Receptor Agonists) ................... 11 Antihyperglycemic, Insulin-Release Stimulant Type ....................................... 11 Antihyperglycemic, Insulin-Response Enhancer (Non-Sulfonylurea) ............. 11 Antihyperglycemic, Biguanide Type (Non-Sulfonylurea) ................................. 11 Antihyperglycemic, Insulin-Rel Stim.& Biguanide Combinations .................... 11 Antihyperglycemic, Insulin-Response & Release Combinations .................... 11 Antihyperglycemic Insul-Resp. Enhancer & Biguanide Combinations ............ 11 Antihyperglycemic-Glucocorticoid Receptor Blockers ..................................... 11 Antihyperglycemic-Sod/Gluc Cotransport2 (SGLT2) Inhibitors ....................... 11 Antihyperglycemic, Sodium/Glucose Cotransport-2 (SGLT2) Inhibitor and Biguanide Combination .................................................................................... 11 Antihyperglycemic, SGLT-2 & DPP-4 Inhibitor Combination .......................... 11 Diabetic Supplies ............................................................................................. 11 Diabetic Ulcer Preparations, Topical ............................................................... 11 Hyperglycemics ................................................................................................ 11 Insulins ............................................................................................................. 11 Syringes & Accessories ................................................................................... 11
EAR - GENERAL DISORDERS ............................................................................. 11 Ear Preparations, Misc. Anti-Infectives ............................................................ 11 Ear Preparations, Antibiotics ........................................................................... 11 Otic Preparations, Anti-Inflammatory-Antibiotics ............................................. 11 Otic Preparations, Local anesthetics ............................................................... 11
ELECTROLYTE REGULATION ............................................................................. 11 Electrolyte Depleters ........................................................................................ 11 Potassium Replacement .................................................................................. 11
ENDOCRINE DISORDER - FERTILITY ................................................................ 11 Drugs to Treat Impotency ................................................................................ 11
MedPerform High Formulary
37014 MedPerform High Formulary – April 2017 iv
Fertility Stimulating Preparations, Non-FSH .................................................... 11 Follicle Stimulating / Luteinizing Hormones ..................................................... 11 Pregnancy Facilitating/Maintaining Agents, Hormonal .................................... 11
ENDOCRINE DISORDER - OTHER ...................................................................... 11 Antineoplastic LHRH (GNRH) Agonists, Pituitary Suppressants .................... 11 Antidiuretic & Vasopressor Hormones ............................................................. 11 Bone Formation Stim. Agents - Parathyroid Hormone .................................... 11 Bone Resorption Inhibitor & Vitamin D Combinations ..................................... 11 Bone Resorption Inhibitors ............................................................................... 12 Growth Hormone Receptor Antagonists .......................................................... 12 Growth Hormones ............................................................................................ 12 Hyperparathyroid Tx Agent, Vitamin D Analog-Type ...................................... 12 LHRH (GnRH) Antagonist, Pituitary Suppressant Agents ............................... 12 Luteinizing Hormone Releasing Hormone –LHRH (GnRH) ............................ 12 Pituitary Suppressive Agents ........................................................................... 12
ENDOCRINE DISORDER - THYROID .................................................................. 12 Antithyroid Preparations ................................................................................... 12 Iodine Containing Agents ................................................................................. 12 Thyroid Hormones............................................................................................ 12
EYE - GENERAL DISORDERS ............................................................................. 12 Eye Antibiotic-Corticoid Combinations............................................................. 12 Eye Antihistamines........................................................................................... 12 Eye Antiinflammatory Agents ........................................................................... 12 Eye Antivirals ................................................................................................... 12 Eye Sulfonamides ............................................................................................ 12
EYE - MISCELLANEOUS ...................................................................................... 12 Ophthalmic Cystine Depleting Agents ............................................................. 12 Ophthalmic Anti-Inflammatory Immunomodulator-Type .................................. 12 Ophthalmic Antibiotics ..................................................................................... 12 Ophthalmic Mast Cell Stabilizers ..................................................................... 12
EYE - GLAUCOMA ................................................................................................ 12 Carbonic Anhydrase Inhibitors ......................................................................... 12 Miotics/Other Intraocular Pressure Reducers .................................................. 12 Mydriatics ......................................................................................................... 13
GOUT AND RELATED DISEASES ....................................................................... 13 Colchicine ......................................................................................................... 13 Hyperuricemia Treatment - Purine Inhibitors ................................................... 13 Uricosuric Agents ............................................................................................. 13
HEMATOLOGICAL DISORDERS .......................................................................... 13 Anticoagulants, Coumarin Type ....................................................................... 13 Hematinics, Other ............................................................................................ 13 Hemorrheologic Agents ................................................................................... 13 Heparin & Related Preparations ...................................................................... 13 Leukocyte (WBC) Stimulants ........................................................................... 13 Platelet Aggregation Inhibitors ......................................................................... 13 Platelet Reducing Agents ................................................................................. 13 Thrombopoietin Receptor Agonists ................................................................. 13 Vitamin K Preparations .................................................................................... 13
HORMONAL DEFICIENCY .................................................................................... 13 Androgenic Agents ........................................................................................... 13 Estrogen/Androgen Combinations ................................................................... 13 Estrogenic Agents ............................................................................................ 13 Progestational Agents ...................................................................................... 13
IMMUNOSUPPRESSION/MODULATION ............................................................. 13 Immunomodulators .......................................................................................... 13 Immunosuppressives ....................................................................................... 13
INFECTIOUS DISEASE - BACTERIAL ................................................................. 13 Absorbable Sulfonamides ................................................................................ 13 Beta lactams .................................................................................................... 13 Cephalosporins - 1st Generation ..................................................................... 13 Cephalosporins - 2nd Generation .................................................................... 13 Cephalosporins - 3rd Generation ..................................................................... 13 Chemotherapeutics, Antibacterial, Miscellaneous ........................................... 13 Ketolides........................................................................................................... 13 Lincosamides ................................................................................................... 13 Macrolides ........................................................................................................ 13 Nitrofuran Derivatives ...................................................................................... 14 Oxazolidinones ................................................................................................. 14 Penicillins ......................................................................................................... 14 Quinolones ....................................................................................................... 14 Tetracyclines .................................................................................................... 14
INFECTIOUS DISEASE - FUNGAL ....................................................................... 14 Antifungal Agents ............................................................................................. 14 Antifungal Antibiotics ........................................................................................ 14
INFECTIOUS DISEASE - MISCELLANEOUS ....................................................... 14 Aminoglycosides .............................................................................................. 14 Anti-Mycobacterium Agents ............................................................................. 14 Antileprotics ...................................................................................................... 14 Antitubercular Antibiotics ................................................................................. 14 Rifamycins and Related Derivative Antibiotics ................................................ 14 Vancomycin & Derivatives ............................................................................... 14
INFECTIOUS DISEASE - PARASITIC .................................................................. 14 Amebacides ..................................................................................................... 14 Anaerobic Antiprotozoal-Antibacterial Agents ................................................. 14 Anthelmintics .................................................................................................... 14 Antimalarial Drugs ............................................................................................ 14 Antiprotozoal Drugs, Miscellaneous ................................................................ 14
INFECTIOUS DISEASE - VIRAL ........................................................................... 14
Antivirals, HIV-Spec, Non-Peptidic Protease Inhib .......................................... 14 Antivirals, HIV-Spec, Nucleoside-Nucleotide Analog ...................................... 14 Antivirals, HIV-Spec., Nucleoside Analog, RTI Comb ..................................... 14 Antivirals, HIV-Specific, CCR5 Co-Receptor Antag. ....................................... 14 Antivirals, HIV-Specific, Fusion Inhibitors ........................................................ 14 Antivirals, HIV-Specific, Non-Nucleoside, RTI ................................................. 15 Antivirals, HIV-Specific, Nucleoside Analog, RTI ............................................ 15 Antivirals, HIV-Specific, Nucleotide Analog, RTI ............................................. 15 Antivirals, HIV-Specific, Protease Inhibitor Comb ........................................... 15 Antivirals, HIV-Specific, Protease Inhibitors .................................................... 15 Antivirals, HIV-1 Integrase Strand Transfer Inhibtors ...................................... 15 Antiviral Combination Nucleoside, Nucleotide & Non-Nucleoside RTI ........... 15 Cytochrome P450 Inhibitors ............................................................................ 15 Hepatitis B Treatment Agents .......................................................................... 15 Hepatitis C Combination Agents ...................................................................... 15 Hepatitis C Treatment Agents .......................................................................... 15
INFLAMMATORY DISEASE .................................................................................. 15 Anti-Arthritic & Chelating Agents ..................................................................... 15 Anti-Arthritic, Folate Antagonist Agents ........................................................... 15 Anti-Inflammatory Tumor Necrosis Factor Inhibitor ......................................... 15 Anti-Inflammatory, Pyrimidine Synthesis Inhibitors ......................................... 15 Bradykinin B2 Receptor Antagonists ............................................................... 15 Glucocorticoids ................................................................................................ 15 Mineralocorticoids ............................................................................................ 15 Monoclonal antibody-human interleukin .......................................................... 15 NSAIDs, Cyclooxygenase Inhibitor-Type ........................................................ 15
LOCAL ANESTHESIA ............................................................................................ 15 Local Anesthetics ............................................................................................. 15
LOWER GASTROINTESTINAL DISORDERS - BOWEL INFLAMMAT ................ 15 Bowel Antiinflamatory Agents .......................................................................... 15 Chronic Inflam. Colon Dx, 5-A-Salicylat, Rectal Tx ......................................... 15 Drug Tx-Chronic Inflam. Colon Dx, 5-Aminosalicylat ...................................... 15 Hemorrhoidal Preparations .............................................................................. 15 Rectal Preparations ......................................................................................... 15 Rectal/Lower Bowel Prep., Glucocort. (Non-Hemorr) ..................................... 16
LOWER GASTROINTESTINAL DISORDERS - OTHER ...................................... 16 Ammonia Inhibitors .......................................................................................... 16 Antidiarrheals ................................................................................................... 16 Bile Salts .......................................................................................................... 16 Laxatives & Cathartics ..................................................................................... 16 Narcotic Antagonists, Peripherally-Acting ....................................................... 16
MISCELLANEOUS AGENTS ................................................................................. 16 Anaphylaxis Therapy Agents ........................................................................... 16 Parasympathetic Agents .................................................................................. 16 Pku Tx Agent-Cofactor Of Phenylalanine Hydroxylase ................................... 16
NEOPLASTIC DISEASE ........................................................................................ 16 Alkylating Agents ............................................................................................. 16 Antiandrogenic Agents ..................................................................................... 16 Antimetabolites ................................................................................................ 16 Antineoplastic - Aromatase Inhibitors .............................................................. 16 Antineoplastic -B Cell Lymphoma-2(bcl-2) Inhibitors ...................................... 16 Antineoplastic – Hedgehog Pathway Inhibitors ............................................... 16 Antineoplastic – Janus Kinase (JAK) Inhibitors ............................................... 16 Antineoplastic - MEK1 and MEK2 Kinase Inhibitors ....................................... 16 Antineoplastic - Topoisomerase I Inhibitors..................................................... 16 Antineoplastic - Immunomodulator Agents ...................................................... 16 Antineoplastic - Systemic Enzyme Inhibitors ................................................... 16 Antineoplastic, Histone Deacetylase Inhibitors, HDIS ..................................... 16 Antineoplastics, Miscellaneous ........................................................................ 16 Chemotherapy Rescue/Antidote Agents ......................................................... 17 Selective Estrogen Receptor Modulators (SERM) .......................................... 17 Selective Retinoid X Receptor Agonists (RXR) ............................................... 17 Steroid Antineoplastics .................................................................................... 17
NEUROLOGICAL DISEASE - MISCELLANEOUS ................................................ 17 Agents to Treat Multiple Sclerosis ................................................................... 17 Fibromyalgia Agents, Serotonin-Norepineph RU Inhibitor .............................. 17 Movement Disorders (Drug Therapy) .............................................................. 17
ORAL/PHARYNGEAL DISORDERS ..................................................................... 17 Dental Aids & Preparations .............................................................................. 17 Nose Preparations, Antibiotics ......................................................................... 17 Nose Preparations, Miscellaneous (Rx) .......................................................... 17
OTHER DRUGS ..................................................................................................... 17 Appetite Stimulators for Anorexia, Cachexia, Wasting Syndrome .................. 17 General Inhalation Agents ............................................................................... 17 Metabolic disease enzyme replace, hypophosphatasia .................................. 17 Needles/Needleless Devices ........................................................................... 17 Nucleic Acid/Nucleotide Supplements ............................................................. 17 Drugs to treat hereditary tyrosinemia .............................................................. 17
OTHER RESPIRATORY DISORDERS ................................................................. 17 Antifibrotic Therapy – Pyridone Analogs ................................................................ 17
Cystic Fibrosis-Cftr Potentiator & Corrector Comb. ......................................... 17 Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) Potentiators ......................................................................................................................... 17 Mucolytics ........................................................................................................ 17 Pulmonary Fibrosis – Systemic Enzyme Inhibitors ......................................... 17
PAIN MANAGEMENT - ANALGESICS ................................................................. 17 Analgesic, Non-Salicylate & Barbiturate Combinations .................................. 17 Analgesic, Salicylate, Barbiturate & Xanthine Combinations .......................... 17
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Analgesic, Non-Salicylate, Barbiturate & Xanthine Combinations .................. 17 Analgesic/Antipyretics, Salicylates .................................................................. 17 Analgesics, Narcotics ....................................................................................... 17 Antimigraine Preparations ................................................................................ 17 Narcotic & Non-Salicylate Analgesic, Barbiturate & Xanthine Combinations . 18 Narcotic & Salicylate Analgesics, Barbiturates & Xanthines ........................... 18 Narcotic Analgesic & Non-Salicylate Analgesic Combinations ....................... 18 Narcotic Withdrawal Therapy Agents .............................................................. 18
PARKINSON’S DISEASE ...................................................................................... 18 Antiparkinsonism Drugs, Anticholinergic ......................................................... 18 Antiparkinsonism Drugs, Other ........................................................................ 18 Decarboxylase Inhibitors .................................................................................. 18
SEIZURE DISORDER ............................................................................................ 18 Anticonvulsants ................................................................................................ 18
SKELETAL MUSCLE DISORDER ......................................................................... 18 Agents To Treat Periodic Paralysis ................................................................. 18 Skeletal Muscle Relaxants ............................................................................... 18
UPPER GASTROINTESTINAL DISORDERS - DIGESTIVE ................................ 18 Pancreatic Enzymes ........................................................................................ 18
UPPER GASTROINTESTINAL DISORDERS - SPASTIC DISEASE ................... 18 Anticholinergics/Antispasmodics ..................................................................... 18 Belladonna Alkaloids ........................................................................................ 18
UPPER GASTROINTESTINAL DISORDERS - ULCER DISEASE ....................... 18 Anti-Ulcer Preparations .................................................................................... 18 Anti-Ulcer-H.pylori Agents ................................................................................ 18 Anticholinergics, Quaternary Ammonium ........................................................ 18 Histamine H2-Receptor Inhibitors .................................................................... 18 Intestinal Motility Stimulants............................................................................. 18 Proton-Pump Inhibitors .................................................................................... 18
URINARY TRACT - FUNCTIONAL DISORDERS ................................................. 18 Benign Prostatic Hypertrophy/Micturition Agents ............................................ 18 Benign Prostatic Hypertrophy, 5-alpha red. Inhib & alpha-1 antag comb agents.......................................................................................................................... 19 Kidney Stone Agents ....................................................................................... 19 Overactive Bladder Agents, Beta-3 Adrenergic Recep ................................... 19 Urinary Tract Analgesic Agents ....................................................................... 19 Urinary Tract Anesthetic/Analgesic Agents (Azo-Dye) .................................... 19 Urinary Tract Antispasmodic, M(3) Selective Antagonists .............................. 19 Urinary Tract Antispasmodic/Antiincontinence Agents .................................... 19
VAGINAL DISORDERS ......................................................................................... 19 Vaginal Antibiotics ............................................................................................ 19 Vaginal Antifungals .......................................................................................... 19 Vaginal Estrogen Preparations ........................................................................ 19 Vaginal Sulfonamides ...................................................................................... 19
VITAMIN AND/OR MINERAL DEFICIENCY ......................................................... 19 Fluoride Preparations ....................................................................................... 19 Folic Acid Preparations .................................................................................... 19 Multivitamin Preparations ................................................................................. 19 Pediatric Vitamin Preparations ........................................................................ 19 Prenatal Vitamin Preparations ......................................................................... 19 Vitamin B Preparations .................................................................................... 19 Vitamin D Preparations .................................................................................... 19
SPECIALTY INJECTABLE CROSS REFERENCE LISTING ................................ 19
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37014 MedPerform High Formulary – April 2017 6
ALLERGY
Allergenic extracts
PA 5-grass pollen extract ORALAIR
PA short ragweed pollen extract RAGWITEK
PA timothy grass pollen extract GRASTEK
2nd Generation Antihistamine & Decongestant Combinations
p-ephed HCl/cetirizine HCl (OTC) ZYRTEC-D (OTC)
p-ephed sul/loratadine (OTC) CLARITIN-D 12 HOUR (OTC) CLARITIN-D 24 HOUR (OTC)
Antihistamines - 1st Generation
hydroxyzine HCl ATARAX
hydroxyzine pamoate VISTARIL
promethazine HCl PHENERGAN
Antihistamines - 2nd Generation
cetirizine HCl (OTC) ZYRTEC (OTC)
levocetirizine dihydrochloride XYZAL TABS
loratadine (OTC) CLARITIN (OTC)
Nasal Anti-Inflammatory Steroids
QL flunisolide NASAREL
QL fluticasone propionate FLONASE
QL triamcinolone acetonide NASACORT AQ
QL + ST QL + ST
betamethasone dipropionate QNASL QNASL CHILDREN
QL mometasone furoate NASONEX
Nasal Antihistamine
QL QL + ST
azelastine HCl ASTELIN ASTEPRO
ANTIEMESIS/ANTIVERTIGO
Antiemetic/Antivertigo Agents
QL + ST
dronabinol MARINOL
meclizine HCl ANTIVERT
ondansetron ZOFRAN ODT
QL ondansetron HCl (QL on solution)
ZOFRAN
prochlorperazine maleate COMPAZINE
promethazine HCl PHENERGAN
QL netupitant/palonosetron HCl AKYNZEO
QL aprepitant EMEND
prochlorperazine edisylate COMPAZINE SYRUP
ASTHMA
Beta-Adrenergic Agents
albuterol sulfate ALBUTEROL SULFATE
metaproterenol sulfate ALUPENT
terbutaline sulfate BRETHINE
albuterol sulfate PROAIR HFA PROAIR RESPICLICK VENTOLIN HFA
QL formoterol fumarate PERFOROMIST
QL olodaterol HCl STRIVERDI RESPIMAT
QL salmeterol xinafoate SEREVENT DISKUS
Beta-Adrenergic & Anticholinergic Combinations
ipratropium/albuterol sulfate DUONEB
ipratropium/albuterol sulfate COMBIVENT COMBIVENT RESPIMAT
QL tiotropium br/olodaterol HCl STIOLTO RESPIMAT
Beta-Adrenergic & Glucocorticoid Combinations
QL QL
fluticasone/salmeterol ADVAIR DISKUS ADVAIR HFA
QL fluticasone/vilanterol BREO ELLIPTA
QL QL
mometasone/formoterol budesonide/formoterol fumarate
DULERA SYMBICORT
General Bronchodilator Agents
ipratropium bromide ATROVENT
QL ipratropium bromide ATROVENT HFA
QL tiotropium bromide SPIRIVA
QL tiotropium bromide SPIRIVA RESPIMAT
Leukotriene Receptor Antagonists
montelukast sodium SINGULAIR
Mast Cell Stabilizers
cromolyn sodium INTAL
Oral Inhaled Corticosteroids
QL budesonide PULMICORT RESPULES
QL beclomethasone dipropionate QVAR
QL budesonide PULMICORT FLEXHALER
QL QL
mometasone furoate ASMANEX ASMANEX HFA
Phosphodiesterase-4 (PDE4) Inhibitors
QL + ST
roflumilast DALIRESP
Xanthines
aminophylline AMINOPHYLLIN
theophylline anhydrous UNIPHYL
theophylline anhydrous THEO-24
AUTONOMIC NERVOUS SYSTEM DISORDERS
Alzheimer's Therapy, NMDA Receptor Antagonists
QL memantine hcl NAMENDA
QL memantine hcl NAMENDA XR
Alzheimer's Therapy, NMDA Receptor Antagonists & Cholines Inhibitors
QL + ST QL + ST
memantine hcl/donepezil hcl NAMZARIC NAMZARIC TITRATION PACK
Cholinesterase Inhibitors
donepezil hcl ARICEPT ARICEPT ODT
QL QL
galantamine hydrobromide RAZADYNE RAZADYNE ER
pyridostigmine bromide MESTINON
QL rivastigmine EXELON PATCH
rivastigmine tartrate EXELON
neostigmine bromide PROSTIGMIN
BEHAVIORAL HEALTH - ANTIDEPRESSANTS
Alpha-2 Receptor Antagonist Antidepressants
mirtazapine REMERON
MAOIs - Non-Selective & Irreversible
tranylcypromine sulfate PARNATE
phenelzine sulfate NARDIL
Norepinephrine & Dopamine Reuptake Inhibitors (NDRIs)
bupropion HCl WELLBUTRIN WELLBUTRIN SR WELLBUTRIN XL
Selective Serotonin Reuptake Inhibitors (SSRIs)
citalopram hydrobromide CELEXA
escitalopram oxalate LEXAPRO
fluoxetine HCl PROZAC
fluoxetine er PROZAC WEEKLY
paroxetine HCl PAXIL
sertraline HCl ZOLOFT
SSRI & Antipsycho, Atyp, Dopamine & Serotonin Antag Comb
QL olanzapine/fluoxetine SYMBYAX
SSRI & 5HT1A Partial Agonist Antidepressants
QL + ST
vilazodone hcl VIIBRYD
SSRI, Serotonin Receptor Modulator Antidepressants
QL + ST
vortioxetine hydrobromide TRINTELLIX
Serotonin-2 Antagonist/Reuptake Inhibitors (SARIs)
trazodone HCl DESYREL 300MG
Serotonin-Norepinephrine Reuptake-Inhib (SNRIs)
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QL + ST
desvenlafaxine ER (Ranbaxy Brand)
DESVENLAFAXINE ER (RANBAXY BRAND)
QL + ST
desvenlafaxine succinate PRISTIQ
QL duloxetine hcl CYMBALTA
QL + ST
levomilnacipran hcl FETZIMA
venlafaxine hcl EFFEXOR, EFFEXOR XR
Tricyclic Antidepressants & Rel. Non-Sel. Ru-Inhib
amitriptyline HCl ELAVIL
amoxapine ASENDIN
clomipramine HCl ANAFRANIL
desipramine HCl NORPRAMIN
doxepin HCl SINEQUAN
imipramine HCl TOFRANIL
maprotiline HCl LUDIOMIL
nortriptyline HCl PAMELOR
BEHAVIORAL HEALTH - OTHER
Adrenergics, Aromatic, Non-Catecholamine
QL QL
amphet asp/amphet/d-amphet ADDERALL ADDERALL XR
QL QL QL
dextroamphetamine sulfate dextroamphetamine capsule dextroamphetamine tablet (5mg, 10mg)
DEXEDRINE DEXEDRINE SPANSULE ZENZEDI
QL + ST
dextroamphetamine tablet (2.5mg, 7.5mg)
ZENZEDI
QL dextroamphetamine tablet (15mg, 20mg, 30mg)
ZENZEDI
QL + ST
lisdexamfetamine dimesylate VYVANSE
Anti-Alcoholic Preparations
disulfiram ANTABUSE
Anti-Anxiety Drugs
alprazolam XANAX ALPRAZOLAM INTENSOL
buspirone HCl BUSPAR VANSPAR
chlordiazepoxide HCl LIBRIUM
clorazepate dipotassium TRANXENE T-TAB
diazepam VALIUM
lorazepam ATIVAN LORAZEPAM INTENSOL
meprobamate MILTOWN
oxazepam SERAX
Anti-Mania Drugs
lithium carbonate ESKALITH LITHOBID
lithium citrate CIBALITH-S
Antipsychotics, Phenothiazines
chlorpromazine HCl THORAZINE
fluphenazine HCl PROLIXIN
perphenazine TRILAFON
thioridazine HCl MELLARIL
trifluoperazine HCl STELAZINE
Antipsychotics, Atypical, D3/D2 Partial Agonist/5HT Mixed
QL + ST
cariprazine hcl VRAYLAR
Antipsychotics, Atypical, D2 Partial Agonist/5HT Mixed
ST + QL
aripiprazole
ABILIFY SOLUTION
QL aripiprazole ABILIFY TABLET
ST + QL
Aripiprazole
ABILIFY DISCMELT
ST + QL
brexpiprazole REXULTI
Antipsychotics, Dopamine & Serotonin Antagonists
loxapine succinate LOXITANE
Antipsychotics, Atypical, Dopamine, & Serotonin Antagonists
QL + ST QL QL + ST
asenapine maleate clozapine lurasidone hcl
SAPHRIS CLOZARIL LATUDA
QL olanzapine ZYPREXA
QL olanzapine ODT ZYPREXA ZYDIS
QL quetiapine fumarate SEROQUEL
QL quetiapine fumarate ER SEROQUEL XR
QL risperidone RISPERDAL
QL risperidone ODT RISPERDAL M-TAB
QL ziprasidone HCl GEODON
Antipsychotics, Dopamine Antagonists, Thioxanthenes
thiothixene NAVANE
Antipsychotics, Dopamine Antagonists, Butyrophenones
haloperidol HALDOL
haloperidol lactate HALDOL ORAL CONC.
Barbiturates
phenobarbital PHENOBARBITAL
Narcolepsy and Sleep Disorder Therapy Agents
PA modafinil PROVIGIL
Narcotic Antagonists
naltrexone HCl REVIA
QL naloxone HCl NARCAN NASAL
Sedative-Hypnotics, Non-Barbiturate
chloral hydrate NOCTEC
estazolam PROSOM
QL eszopiclone LUNESTA
flurazepam HCl DALMANE
temazepam RESTORIL
triazolam HALCION
QL zaleplon SONATA
QL QL + ST
zolpidem tartrate zolpidem tartrate ER
AMBIEN AMBIEN CR
Treatment for Attention Deficit-Hyperactivity (ADHD)/Narcolepsy
QL QL+ AGE
dexmethylphenidate HCl FOCALIN FOCALIN XR
QL+ AGE QL+ AGE QL+ AGE QL QL QL+ AGE QL+ AGE
methylphenidate HCl
CONCERTA METADATE CD METADATE ER METHYLIN CHEW TAB METHYLIN SOLN RITALIN RITALIN LA RITALIN SR
QL + ST
methylphenidate ER Susp QUILLIVANT XR
Treatment for Attention Deficit-Hyperactivity (ADHD), Nri-Type
QL atomoxetine HCl STRATTERA
CARDIOVASCULAR DISEASE - ARRHYTHMIA
Antiarrhythmics
amiodarone HCl CORDARONE
disopyramide phosphate NORPACE
flecainide acetate TAMBOCOR
mexiletine HCl MEXITIL
procainamide HCl PRONESTYL
propafenone HCl RYTHMOL
quinidine gluconate QUINAGLUTE
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quinidine sulfate QUINIDEX
disopyramide phosphate NORPACE CR
dofetilide TIKOSYN
dronedarone HCl MULTAQ
propafenone HCl RYTHMOL SR
CARDIOVASCULAR DISEASE - CARDIAC STIMULANTS
Digitalis Glycosides
digoxin LANOXIN
DIGOXIN ORAL SOLN.
CARDIOVASCULAR DISEASE - HYPERTENSION
ACE Inhibitor/Calcium Channel Blocker Combinations
amlodipine besylate/benazepril LOTREL
ACE Inhibitor/Thiazide & Thiazide-Like Diuretics
benazepril/hydrochlorothiazide LOTENSIN HCT
captopril/hydrochlorothiazide CAPOZIDE
enalapril/hydrochlorothiazide VASERETIC
fosinopril/hydrochlorothiazide MONOPRIL HCT
lisinopril/hydrochlorothiazide PRINZIDE ZESTORETIC
moexipril/hydrochlorothiazide UNIRETIC
quinapril/hydrochlorothiazide ACCURETIC
Alpha-Adrenergic Blocking Agents
doxazosin mesylate CARDURA
phenoxybenzamine HCl DIBENZYLINE
prazosin HCl MINIPRESS
terazosin HCl HYTRIN
Alpha/Beta-Adrenergic Blocking Agents
carvedilol COREG
labetalol HCl TRANDATE
carvedilol phosphate COREG CR
Angiotensin Receptor Antagonist/Calcium Channel Blocker/Thiazide Combinations
ST amlodipine/valsartan/hctz EXFORGE HCT
ST olmesartan/amlodipine/hctz TRIBENZOR
Angiotensin Receptor Antagonist/Thiazide Diuretic Combinations
irbesartan/hydrochlorothiazide AVALIDE
losartan/hydrochlorothiazide HYZAAR
valsartan/hydrochlorothiazide DIOVAN HCT
ST olmesartan/hydrochlorothiazide BENICAR HCT
Angiotensin II Receptor Blocker-Beta Blocker Comb.
nebivolol HCl/valsartan BYVALSON
Angiotensin Receptor Antagonist & Calcium Channel Blockers
ST amlodipine/valsartan EXFORGE
ST amlodipine bes/olmesartan med AZOR
Antihypertensives, ACE Inhibitors
benazepril HCl LOTENSIN
captopril CAPOTEN
enalapril maleate VASOTEC
fosinopril sodium MONOPRIL
lisinopril PRINIVIL ZESTRIL
moexipril HCl UNIVASC
quinapril HCl ACCUPRIL
ramipril ALTACE
trandolapril MAVIK
Antihypertensives, Angiotensin Receptor Antagonist
irbesartan AVAPRO
losartan potassium COZAAR
valsartan DIOVAN
ST olmesartan medoxomil BENICAR
Antihypertensives, Sympatholytic
clonidine HCl CATAPRES
guanfacine HCl TENEX
methyldopa ALDOMET
reserpine SERPASIL
Antihypertensives, Vasodilators
hydralazine HCl APRESOLINE
Beta-Adrenergic Blocking Agents
acebutolol HCl SECTRAL
atenolol TENORMIN
bisoprolol fumarate ZEBETA
metoprolol succinate TOPROL XL
metoprolol tartrate LOPRESSOR
nadolol CORGARD
pindolol VISKEN
propranolol HCl INDERAL LA
sotalol HCl BETAPACE BETAPACE AF
timolol maleate BLOCADREN
nebivolol HCl BYSTOLIC
Beta-Adrenergic Blocking Agents/Thiazide & Related
atenolol/chlorthalidone TENORETIC 100 TENORETIC 50
bisoprolol fumarate/hctz ZIAC
metoprolol/hctz LOPRESSOR HCT
propranolol/hydrochlorothiazide INDERIDE-40/25
Calcium Channel Blocking Agents
amlodipine besylate NORVASC
diltiazem HCl CARDIZEM CARDIZEM CD DILACOR XR TIAZAC
felodipine PLENDIL
isradipine IR capsules DYNACIRC
nicardipine HCl CARDENE
nifedipine ADALAT CC PROCARDIA PROCARDIA XL
nimodipine NIMOTOP
verapamil HCl CALAN VERELAN
verapamil HCl ER CALAN SR VERELAN PM
Loop Diuretics
bumetanide BUMEX
furosemide LASIX
torsemide DEMADEX
Potassium Sparing Diuretics
eplerenone INSPRA
spironolactone ALDACTONE
Potassium Sparing Diuretics in Combination
triamterene/hydrochlorothiazide DYAZIDE MAXZIDE MAXZIDE-25MG
Pulmonary Anti-HTN, Sel. C-GMP Phosphodiesterase T5 Inhibitors
PA sildenafil citrate REVATIO TABLET
PA tadalafil ADCIRCA
Pulmonary Anti-HTN, Endothelin Receptor Antagonists
PA ambrisentan LETAIRIS
PA bosentan TRACLEER
PA macitentan OPSUMIT
Pulmonary Anti-HTN, Prostacyclin-Type
PA selexipag UPTRAVI
Pulmonary Anti-HTN, Soluble Guanylate Cyclase Stimulators
PA riociguat ADEMPAS
Thiazide & Related Diuretics
chlorthalidone HYGROTON
hydrochlorothiazide MICROZIDE
indapamide LOZOL
metolazone ZAROXOLYN
chlorthalidone THALITONE
CARDIOVASCULAR DISEASE - LIPID IRREGULARITY
Antihyperlipidemic - APO B-100 Synthesis Inhibitor
PA mipomersen sodium KYNAMRO
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37014 MedPerform High Formulary – April 2017 9
Antihyperlipidemic - HMG CoA Reductase Inhibitors
atorvastatin calcium LIPITOR
QL
lovastatin pitavastatin
MEVACOR LIVALO
pravastatin sodium PRAVACHOL
simvastatin ZOCOR
ST simvastatin (80mg only)
QL rosuvastatin calcium CRESTOR
Antihyperlipidemic - MTP Inhibitors
PA + QL
lomitapide JUXTAPID
Antihyperlipidemic –PCSK9 Inhibitors
PA alirocumab PRALUENT
PA evolocumab REPATHA
Bile Salt Sequestrants
cholestyramine/aspartame QUESTRAN LIGHT
cholestyramine/sucrose QUESTRAN
colesevelam HCl WELCHOL WELCHOL POWDER PACKETS
colestipol COLESTID COLESTID GRANULES
Lipotropics
ST fenofibrate FENOGLIDE LOFIBRA TABS
fenofibrate, micronized LOFIBRA CAPS
fenofibrate nanocrystallized TRICOR
gemfibrozil LOPID
ST niacin NIASPAN
QL omega-3 acid ethyl esters LOVAZA
QL ezetimibe ZETIA
ST fenofibrate TRIGLIDE
QL icosapent ethyl VASCEPA
Niacin Preparations
niacin SLO-NIACIN
CARDIOVASCULAR DISEASE - MISCELLANEOUS AGENTS
Adrenergic Vasopressor Agents
midodrine HCl PROAMATINE
Antianginal & Anti-Ischemic Agents, Non-Hemodynamic
QL ranolazine RANEXA
Antihyperlipidemia - HMG-CoA & Calcium Channel Blocker Combinations
QL amlodipine/atorvastatin CADUET
Heart Rate Reducing, Selective I(F) Current Inhib.
PA + QL
ivabradine HCl CORLANOR
CARDIOVASCULAR DISEASE - VASODILATION
Vasodilators, Combination
isosorb dinit/hydralazine HCl BIDIL
Vasodilators, Coronary
isosorbide dinitrate ISOCHRON ISORDIL ISORDIL TITRADOSE
isosorbide mononitrate IMDUR ISMO MONOKET
nitroglycerin transdermal patch nitroglycerin sublingual solution
NITRO-DUR NITROLINGUAL
nitroglycerin transdermal ointment nitroglycerin sublingual tablet
NITRO-BID NITROSTAT
CONTRACEPTION/OXYTOCICS
Contraceptives, Intravaginal, Systemic
QL etonogestrel/ethinyl estradiol NUVARING
Contraceptives, Oral
desog-et estra/ethin estra MIRCETTE
desogestrel-ethinyl estradiol CYCLESSA DESOGEN ORTHO-CEPT
ST ethinyl estradiol/drospirenone GIANVI
ST ST ST ST ST ST ST
LORYNA OCELLA SYEDA VESTURA YASMIN 28 YAZ ZARAH
ethynodiol d-ethinyl estradiol DEMULEN 1-50-21
levonorgestrel AFTERA PLAN B ONE-STEP TAKE ACTION
QL
levonorgestrel-eth estra NORDETTE-28 SEASONALE AVIANE-28 LESSINA LUTERA ORSYTHIA SRONYX
ST
noreth a-et estra/fe fumarate LOESTRIN FE LOESTRIN FE24
norethindrone NOR-Q-D ORTHO MICRONOR
norethindrone a-e estradiol LOESTRIN
norethindrone-ethinyl estrad NORINYL 1+35 ORTHO-NOVUM TRI-NORINYL
norethindrone-mestranol NORINYL 1+50
norgestimate-ethinyl estradiol ORTHO TRI-CYCLEN ORTHO-CYCLEN
norgestrel-ethinyl estradiol LO-OVRAL-28
norgestimate-ethinyl estradiol ORTHO TRI-CYCLEN LO
ST noreth a-et estra/fe fumarate LO LOESTRIN FE
Contraceptives, Transdermal
QL norelgestromin/ethin.estradiol ORTHO EVRA
Oxytocics
methylergonovine maleate METHERGINE
COUGH AND COLD
1st Generation Antihistamine & Decongestant Combinations
phenylephrine HCl/prometh HCl PHENERGAN VC
Narcotic Antitussive-1st Generation Antihistamine-Decongestants
phenylephrine HCl/cod/prometh PHENERGAN VC W/CODEINE
Narcotic Antitussive-1st Generation Antihistamines
codeine/promethazine HCl PHENERGAN W/CODEINE
hydrocodone/chlorphen p-stirex TUSSIONEX
Narcotic Antitussive-Anticholinergic Comb.
hydrocodone/homatrop me-br HYCODAN
Non-Narcotic Antitussive-1st Generation Antihistamine Combinations
d-methorphan hb/prometh HCl PHENERGAN W/ DEXTROMETHORPHAN
DERMATOLOGY - ACNE
Acne Agents, Systemic
isotretinoin AMNESTEEM CLARAVIS MYORISAN SOTRET ZENATANE
Acne Agents, Topical
AGE + ST ST
adapalene/benzoyl peroxide clindamycin phos/benzoyl peroxide clindamycin phos/benzoyl peroxide
EPIDUO, EPIDUO FORTE ONEXTON BENZACLIN
clindamycin/tretinoin sulfacetamide sodium
ZIANA KLARON
Keratolytic-Glucocorticoid Combinations
benzoyl peroxide/hydrocortisone VANOXIDE-HC
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37014 MedPerform High Formulary – April 2017 10
Keratolytics
benzoyl peroxide BREVOXYL-4 BREVOXYL-8 TRIAZ
podofilox CONDYLOX
Rosacea Agents, Topical
metronidazole METROCREAM METROLOTION
Vitamin A Derivatives
AGE adapalene DIFFERIN
AGE tazorotene foam FABIOR
DERMATOLOGY - ANTIINFECTIVE
Topical Antibiotics
clindamycin phosphate CLEOCIN T
erythromycin base/benz per BENZAMYCIN
erythromycin base/ethanol EMGEL ERYGEL
gentamicin sulfate GARAMYCIN
mupirocin ointment BACTROBAN CENTANY
mupirocin calcium cream BACTROBAN
clindamycin phosphate EVOCLIN
erythromycin base/benz per BENZAMYCIN PAK
Topical Antifungals
ciclopirox olamine LOPROX
ciclopirox 8% solution CICLODAN
clotrimazole/betamet diprop LOTRISONE
ketoconazole KURIC NIZORAL
naftifine HCl 1% cream NAFTIN
naftifine HCl 1% gel, 2% cream/gel
NAFTIN
nystatin MYCOSTATIN
nystatin/triamcin MYCOLOG II
sulconazole nitrate EXELDERM
terbinafine HCl LAMISIL
Topical Antiparasitics
lindane KWELL
malathion OVIDE
permethrin ELIMITE
crotamiton EURAX
Topical Antivirals
acyclovir ZOVIRAX OINTMENT
acyclovir ZOVIRAX CREAM
Topical Sulfonamides
silver sulfadiazine SILVADENE THERMAZENE
DERMATOLOGY - ANTIINFLAMMATORY
Topical Anti-Inflammatory Steroidal
alclometasone dipropionate ACLOVATE
amcinonide CYCLOCORT
betamet diprop/prop gly DIPROLENE DIPROLENE AF
betamethasone dipropionate DEL-BETA DIPROSONE
betamethasone valerate VALISONE
clobetasol propionate CLOBEX
clobetasol propionate OLUX TEMOVATE
clobetasol propionate/emoll TEMOVATE EMOLLIENT
desonide DESOWEN TRIDESILON
desoximetasone TOPICORT TOPICORT LP
diflorasone diacetate APEXICON
fluocinolone acetonide SYNALAR
fluocinonide LIDEX VANOS
fluocinonide/emollient LIDEX-E
fluticasone propionate CUTIVATE
halobetasol propionate ULTRAVATE
hydrocortisone LACTICARE-HC REDERM SCALACORT
hydrocortisone acetate/urea CARMOL HC
hydrocortisone butyrate LOCOID
hydrocortisone valerate WESTCORT
mometasone furoate ELOCON
triamcinolone acetonide KENALOG TRIDERM
diflorasone diacetate/emoll APEXICON E
flurandrenolide CORDRAN CORDRAN SP
hydrocort/sal acid/sulf/shmp#1 SCALACORT DK
hydrocortisone TEXACORT
hydrocortisone butyrate/emoll LOCOID LIPOCREAM
hydrocortisone probutate PANDEL
Topical Anti-Inflammatory, NSAIDs
diclofenac sodium VOLTAREN GEL
Topical Antibiotics/Antiinflammatory, Steroidal
neomy sulf/polymyx b sulf/hc CORTISPORIN CREAM
neomycin/bacitra/polymyxin/hc CORTISPORIN OINT
DERMATOLOGY - MISCELLANEOUS
Antiperspirants
aluminum chloride DRYSOL
Antiseborrheic Agents
selenium sulfide SELSUN RX
sulfacetamide sodium OVACE PLUS SUSP
Topical Antineoplastic & Premalignant Lesion Agents
fluorouracil EFUDEX
PA bexarotene TARGRETIN
QL ingenol PICATO
PA mechlorethamine gel VALCHLOR
Topical Local Anesthetics
hc acetate/pramoxine HCl PRAMOSONE
DERMATOLOGY - PIGMENTATION DISORDERS
Topical Hyperpigmentation Agents
methoxsalen OXSORALEN
DERMATOLOGY - PSORIASIS/ECZEMA
Antipsoriatic Agents, Systemic
acitretin SORIATANE
methoxsalen, rapid OXSORALEN-ULTRA
methoxsalen 8-MOP
PA secukinumab COSENTYX
Antipsoriatics Agents
ST calcipotriene DOVONEX
anthralin DRITHO-SCALP
ST anthralin DRITHOCREME HP
tazarotene TAZORAC
Topical Immunosuppressive Agents
ST
tacrolimus pimecrolimus
PROTOPIC ELIDEL
DIABETES
Antihyperglycemic, Alpha-Glucosidase Inhibitors (Non-Sulfonylurea)
acarbose PRECOSE
Antihyperglycemic, Amylin Analog-Type
pramlintide acetate SYMLIN SYMLINPEN 120 SYMLINPEN 60
Antihyperglycemic, DPP-4 Inhibitors
QL linagliptin TRADJENTA
QL sitagliptin phosphate JANUVIA
Antihyperglycemic, DPP-4 Inhibitor & Biguanide Combinations
QL linagliptin/metformin HCl JENTADUETO
MedPerform High Formulary
37014 MedPerform High Formulary – April 2017 11
QL sitagliptin phos/metformin HCl JANUMET
QL sitagliptin phos/metformin HCl JANUMET XR
Antihyperglycemic, Incretin Mimetic (GLP-1 Receptor Agonists)
QL + ST
dulaglutide TRULICITY
QL + ST
liraglutide VICTOZA
Antihyperglycemic, Insulin-Release Stimulant Type
chlorpropamide DIABINESE
glimepiride AMARYL
glipizide GLUCOTROL GLUCOTROL XL
glipizide/metformin HCl METAGLIP
glyburide MICRONASE
nateglinide STARLIX
repaglinide PRANDIN
tolazamide TOLINASE
tolbutamide ORINASE
glyburide DIABETA
Antihyperglycemic, Insulin-Response Enhancer (Non-Sulfonylurea)
pioglitazone HCl ACTOS
Antihyperglycemic, Biguanide Type (Non-Sulfonylurea)
metformin HCl GLUCOPHAGE GLUCOPHAGE XR
metformin HCl RIOMET
Antihyperglycemic, Insulin-Rel Stim.& Biguanide Combinations
glyburide, micro/metformin HCl GLUCOVANCE
repaglinide/metformin HCl PRANDIMET
Antihyperglycemic, Insulin-Response & Release Combinations
ST pioglitazone/glimepiride DUETACT
Antihyperglycemic Insul-Resp. Enhancer & Biguanide Combinations
ST ST
pioglitazone HCl/metformin HCl pioglitazone HCl/metformin HCl
ACTOPLUS MET ACTOPLUS MET XR
Antihyperglycemic-Glucocorticoid Receptor Blockers
PA mifepristone KORLYM
Antihyperglycemic-Sod/Gluc Cotransport2 (SGLT2) Inhibitors
QL + ST
canagliflozin INVOKANA
QL + ST
empagliflozin JARDIANCE
Antihyperglycemic, Sodium/Glucose Cotransport-2 (SGLT2) Inhibitor and Biguanide Combination
QL + ST
canagliflozin/metformin HCl INVOKAMET
QL + ST
canagliflozin/metformin HCl INVOKAMET XR
QL + ST
empagliflozin/metformin HCl SYNJARDY
Antihyperglycemic, SGLT-2 & DPP-4 Inhibitor Combination
QL + ST
empagliflozin/linagliptin GLYXAMBI
Diabetic Supplies
blood-glucose calib. control ABBOTT CONTROL PRODUCTS (e.g., FREESTYLE, PRECISION)
blood-glucose meter ABBOTT METERS(e.g., FREESTYLE, PRECISION)
blood sugar diagnostics ABBOTT TEST STRIPS (e.g., FREESTYLE, PRECISION)
lancing device/lancets ABBOTT PRODUCTS
Diabetic Ulcer Preparations, Topical
becaplermin REGRANEX
Hyperglycemics
glucagon, human recombinant GLUCAGON EMERGENCY KIT
Insulins
QL QL
insulin glargine,hum.rec.anlog LANTUS TOUJEO
QL insulin lispro HUMALOG
QL insulin nph hum/reg insulin hm HUMULIN 70-30
QL insulin nph human isophane HUMULIN N
QL QL
insulin npl/insulin lispro HUMALOG MIX 50-50 HUMALOG MIX 75-25
QL insulin regular, human HUMULIN R
insulin regular, human HUMULIN R U-500
Syringes & Accessories
syringes & needles ALL COMMERCIALLY AVAILABLE SYRINGES AND NEEDLES
EAR - GENERAL DISORDERS
Ear Preparations, Misc. Anti-Infectives
acetic acid VOSOL
acetic acid/aluminum acetate DOMEBORO
acetic acid/hydrocortisone VOSOL HC
Ear Preparations, Antibiotics
neomy sulf/polymyx b sulf/hc CORTISPORIN OTIC OTICIN HC
ofloxacin FLOXIN
Otic Preparations, Anti-Inflammatory-Antibiotics
ciprofloxacin HCl/dexameth CIPRODEX
Otic Preparations, Local anesthetics
antipyrine/benzocaine otic BENZOTIC
ELECTROLYTE REGULATION
Electrolyte Depleters
calcium acetate PHOSLO
sodium polystyrene sulfonate KAYEXALATE
sevelamer carbonate RENVELA
sevelamer HCl RENAGEL
Potassium Replacement
potassium chloride K-DUR K-TAB MICRO-K
ENDOCRINE DISORDER - FERTILITY
Drugs to Treat Impotency
QL sildenafil citrate VIAGRA
Fertility Stimulating Preparations, Non-FSH
clomiphene citrate CLOMID SEROPHENE
Follicle Stimulating / Luteinizing Hormones
follitropin alpha, recomb GONAL-F GONAL-F RFF
gonadotropin, chorionic, human NOVAREL PREGNYL PROFASI
hcg alpha, recombinant OVIDREL
menotropins MENOPUR REPRONEX
Pregnancy Facilitating/Maintaining Agents, Hormonal
progesterone, micronized CRINONE ENDOMETRIN PROCHIEVE
ENDOCRINE DISORDER - OTHER
Antineoplastic LHRH (GNRH) Agonists, Pituitary Suppressants
PA leuprolide ELIGARD
Antidiuretic & Vasopressor Hormones
desmopressin (nonrefrigerated) DDAVP
Bone Formation Stim. Agents - Parathyroid Hormone
QL teriparatide FORTEO
Bone Resorption Inhibitor & Vitamin D Combinations
alendronate sodium/vitamin d3 FOSAMAX PLUS D
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Bone Resorption Inhibitors
alendronate sodium tablet FOSAMAX
QL alendronate sodium solution FOSAMAX SOLUTION
etidronate disodium DIDRONEL
ibandronate BONIVA
QL raloxifene HCl EVISTA
Growth Hormone Receptor Antagonists
pegvisomant SOMAVERT
Growth Hormones
PA somatropin NORDITROPIN
NORDITROPIN FLEXPRO
NORDITROPIN NORDIFLEX
PA somatropin OMNITROPE
Hyperparathyroid Tx Agent, Vitamin D Analog-Type
QL calcifediol paricalcitol
RAYALDEE ZEMPLAR
LHRH (GnRH) Antagonist, Pituitary Suppressant Agents
cetrorelix acetate CETROTIDE
ganirelix acetate GANIRELIX ACETATE
Luteinizing Hormone Releasing Hormone –LHRH (GnRH)
Pituitary Suppressive Agents
cabergoline DOSTINEX
danazol DANOCRINE
ENDOCRINE DISORDER - THYROID
Antithyroid Preparations
methimazole TAPAZOLE
propylthiouracil PROPYLTHIOURACIL
Iodine Containing Agents
potassium iodide POTASSIUM IODIDE
Thyroid Hormones
levothyroxine sodium LEVOTHROID LEVOXYL SYNTHROID
liothyronine sodium CYTOMEL
thyroid, pork ARMOUR THYROID NATURE-THROID WESTHROID
EYE - GENERAL DISORDERS
Eye Antibiotic-Corticoid Combinations
neo/polymyx b sulf/dexameth MAXITROL
neomy sulf/bacitrac zn/poly/hc NEO-POLYCIN HC OPHTH OINTMENT
neomy sulf/polymyx b sulf/hc CORTISPORIN OPHTH SUSPENSION
tobramycin sulfate/dexameth TOBRADEX
tobramycin/lotepred etab ZYLET
Eye Antihistamines
azelastine HCl OPTIVAR
ketotifen fumarate (OTC) ALAWAY (OTC)
olopatadine HCl PATADAY PATANOL
Eye Antiinflammatory Agents
diclofenac sodium VOLTAREN
fluorometholone FML
flurbiprofen sodium OCUFEN
ketorolac tromethamine ACULAR ACULAR LS
prednisolone acetate OMNIPRED PRED FORTE
prednisolone sod phosphate PREDNISOL
difluprednate DUREZOL
fluorometholone FML FORTE FML S.O.P.
fluorometholone acetate FLAREX
loteprednol etabonate ALREX
LOTEMAX
nepafenac ILEVRO NEVANAC
prednisolone acetate PRED MILD
Eye Antivirals
trifluridine VIROPTIC
ganciclovir ZIRGAN
Eye Sulfonamides
na sulfacetm/prednis sp VASOCIDIN
sulfacetamide sodium SULFAC
na sulfacetm/prednisol ac BLEPHAMIDE BLEPHAMIDE S.O.P.
EYE - MISCELLANEOUS
Ophthalmic Cystine Depleting Agents
PA cysteamine CYSTARAN
Ophthalmic Anti-Inflammatory Immunomodulator-Type
QL QL QL
cyclosporine lifitegrast
RESTASIS SINGLE DOSE VIAL RESTASIS MULTIDOSE VIAL XIIDRA
Ophthalmic Antibiotics
bacitracin AK-TRACIN
bacitracin/polymyxin b sulfate POLYCIN-B
ciprofloxacin HCl CILOXAN
erythromycin base ROMYCIN
gatifloxacin ZYMAXID
gentamicin sulfate GARAMYCIN
neomycin/bacitracin/polymyxin NEOSPORIN OPHTH OINTMENT
neomycin/polymyxn b/gramicidin
NEOSPORIN OPHTH DROPS
ofloxacin OCUFLOX
polymyxin b sulfate/tmp POLYTRIM
tobramycin sulfate TOBREX
besifloxacin HCl drops susp 0.6% BESIVANCE
moxifloxacin HCl VIGAMOX
Ophthalmic Mast Cell Stabilizers
cromolyn sodium OPTICROM
lodoxamide tromethamine ALOMIDE
nedocromil sodium ALOCRIL
pemirolast potassium ALAMAST
EYE - GLAUCOMA
Carbonic Anhydrase Inhibitors
acetazolamide DIAMOX SEQUELS
methazolamide NEPTAZANE
Miotics/Other Intraocular Pressure Reducers
betaxolol HCl BETOPTIC
QL bimatoprost 0.03% LUMIGAN
brimonidine tartrate ALPHAGAN P
carteolol HCl OCUPRESS
dorzolamide HCl TRUSOPT
dorzolamide HCl/timolol maleat COSOPT
latanoprost XALATAN
levobunolol HCl BETAGAN
metipranolol OPTIPRANOLOL
pilocarpine HCl ISOPTO CARPINE
timolol maleate TIMOPTIC (Except Ocudose) TIMOPTIC-XE
QL travoprost (benzalkonium) TRAVATAN
betaxolol HCl BETOPTIC S
QL bimatoprost 0.01% LUMIGAN
brimonidine/timolol COMBIGAN
brinzolamide AZOPT
brinzolamide/brimonidine SIMBRINZA
carbachol ISOPTO CARBACHOL
timolol BETIMOL
MedPerform High Formulary
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QL travoprost TRAVATAN Z
Mydriatics
atropine sulfate ISOPTO ATROPINE
cyclopentolate HCl CYCLOGYL
homatropine hbr ISOPTO HOMATROPINE
dipivefrin HCl PROPINE
GOUT AND RELATED DISEASES
Colchicine
QL colchicine COLCRYS
colchicine/probenecid COL-BENEMID
Hyperuricemia Treatment - Purine Inhibitors
allopurinol ZYLOPRIM
QL + ST
febuxostat ULORIC
Uricosuric Agents
QL + ST
lesinurad ZURAMPIC
probenecid BENEMID
HEMATOLOGICAL DISORDERS
Anticoagulants, Coumarin Type
warfarin sodium COUMADIN
Direct Factor XA Inhibitors
QL apixaban ELIQUIS
QL rivaroxaban XARELTO
Hematinics, Other
PA epoetin alfa PROCRIT
Hemorrheologic Agents
pentoxifylline TRENTAL
Heparin & Related Preparations
QL enoxaparin sodium LOVENOX
heparin sodium, porcine HEP-LOCK HEPARIN LOCK
heparin sodium, porcine/pf HEP-LOCK
QL dalteparin sodium, porcine FRAGMIN
QL fondaparinux sodium ARIXTRA
Leukocyte (WBC) Stimulants
PA filgrastim NEUPOGEN
PA pegfilgrastim NEULASTA
PA sargramostim LEUKINE
Platelet Aggregation Inhibitors
cilostazol PLETAL
clopidogrel bisulfate PLAVIX 75MG
QL clopidogrel bisulfate 300mg PLAVIX 300MG
dipyridamole PERSANTINE
QL prasugrel HCl EFFIENT
QL ticagrelor BRILINTA
Platelet Reducing Agents
anagrelide HCl AGRYLIN
Thrombopoietin Receptor Agonists
PA + QL
eltrombopag olamine PROMACTA
Vitamin K Preparations
phytonadione MEPHYTON
HORMONAL DEFICIENCY
Androgenic Agents
QL fluoxymesterone ANDROXY
methyltestosterone ANDROID
PA testosterone 1% ANDROGEL
PA + QL
testosterone cypionate DEPO-TESTOSTERONE
PA testosterone enanthate DELATESTRYL
methyltestosterone METHITEST
PA testosterone gel 1.62% ANDROGEL
PA testosterone solution AXIRON
Estrogen/Androgen Combinations
estrogen, ester/me-testosterone ESTRATEST H.S.
Estrogenic Agents
QL
estradiol CLIMARA ESTRACE VIVELLE-DOT
estropipate OGEN
norethindrone ac-eth estradiol FEMHRT
estradiol ALORA ESTRADERM
QL estradiol/noreth ac COMBIPATCH
estrogens, conj/bazedoxifene DUAVEE
estrogen, con/m-progest acet PREMPHASE PREMPRO
estrogens, conjugated PREMARIN
estrogens, esterified MENEST
Progestational Agents
medroxyprogesterone acet PROVERA
norethindrone acetate AYGESTIN
progesterone, micronized PROMETRIUM
IMMUNOSUPPRESSION/MODULATION
Immunomodulators
PA + QL
imiquimod ALDARA
PA interferon alfa-2b, recomb. INTRON A
Immunosuppressives
azathioprine IMURAN
cyclosporine SANDIMMUNE
cyclosporine, modified NEORAL
mycophenolate mofetil CELLCEPT
sirolimus RAPAMUNE
tacrolimus anhydrous PROGRAF
everolimus ZORTRESS
INFECTIOUS DISEASE - BACTERIAL
Absorbable Sulfonamides
sulfadiazine SULFADIAZINE
sulfamethoxazole/trimethoprim BACTRIM DS SEPTRA SEPTRA DS
sulfisoxazole acetyl GANTRISIN
Beta lactams
PA aztreonam lysine CAYSTON
Cephalosporins - 1st Generation
cefadroxil hydrate DURICEF
cephalexin monohydrate KEFLEX
Cephalosporins - 2nd Generation
cefaclor CECLOR
cefprozil CEFZIL
cefuroxime axetil CEFTIN
Cephalosporins - 3rd Generation
cefdinir OMNICEF
cefpodoxime proxetil VANTIN
cefixime SUPRAX
Chemotherapeutics, Antibacterial, Miscellaneous
trimethoprim PROLOPRIM
meth/meth blue/ba/salicy/hyos PROSED-DS
mth/me blue/salicy/na phos/hyo URETRON D-S URIN D.S.
trimethoprim PRIMSOL
Ketolides
telithromycin KETEK
Lincosamides
clindamycin HCl capsules CLEOCIN HCL
clindamycin palmitate CLEOCIN PALMITATE
Macrolides
azithromycin ZITHROMAX ZITHROMAX TRI-PAK
clarithromycin BIAXIN BIAXIN XL
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ery e-succ/sulfisoxazole PEDIAZOLE
erythromycin base ERYC
erythromycin ethylsuccinate ERYPED 200
erythromycin stearate ERYTHROCIN STEARATE
azithromycin ZMAX ZMAX PEDIATRIC
erythromycin base ERY-TAB PCE
erythromycin ethylsuccinate ERYPED 200 ERYPED 400
QL + ST
fidaxomicin DIFICID
Nitrofuran Derivatives
nitrofurantoin macrocrystal MACRODANTIN
nitrofurantoin/nitrofuran mac MACROBID
furazolidone FUROXONE
nitrofurantoin FURADANTIN
Oxazolidinones
PA linezolid ZYVOX
PA tedizolid phosphate tablet SIVEXTRO TABLET
Penicillins
amox tr/potassium clavulanate AUGMENTIN AUGMENTIN ES-600 AUGMENTIN XR
amoxicillin trihydrate AMOXIL
ampicillin trihydrate POLYCILLIN
dicloxacillin sodium PATHOCIL
penicillin v potassium V-CILLIN K
Quinolones
ciprofloxacin CIPRO ORAL SUSPENSION
ciprofloxacin HCl CIPRO
levofloxacin LEVAQUIN
moxifloxacin HCl AVELOX AVELOX ABC PACK
ofloxacin FLOXIN
Tetracyclines
QL QL QL
doxycycline hyclate
VIBRAMYCIN 100MG CAPSULE MORGIDOX 50MG CAPSULE MORGIDOX 100MG CAPSULE
QL doxycycline monohydrate DOXYCYCLINE MONOHYDRATE 150MG TABLET
minocycline HCl DYNACIN MINOCIN
tetracycline HCl ALA-TET
doxycycline calcium VIBRAMYCIN SYRUP
INFECTIOUS DISEASE - FUNGAL
Antifungal Agents
clotrimazole MYCELEX
fluconazole DIFLUCAN
itraconazole SPORANOX
ketoconazole NIZORAL
terbinafine HCl LAMISIL
voriconazole VFEND
terbinafine HCl LAMISIL GRANULES
Antifungal Antibiotics
griseofulvin ultramicrosize GRIS-PEG
nystatin MYCOSTATIN
griseofulvin suspension GRISEOFULVIN V
INFECTIOUS DISEASE - MISCELLANEOUS
Aminoglycosides
neomycin sulfate MYCIFRADIN
PA tobramycin in 0.225% nacl TOBI
PA tobramycin TOBI PODHALER
Anti-Mycobacterium Agents
ethambutol HCl MYAMBUTOL
isoniazid NYDRAZID
pyrazinamide PYRAZINAMIDE
Antileprotics
dapsone AVLOSULFON
PA thalidomide THALOMID
Antitubercular Antibiotics
rifampin RIFADIN
rifampin/isoniazid RIFAMATE
Rifamycins and Related Derivative Antibiotics
PA rifaximin XIFAXAN 550MG
Vancomycin & Derivatives
QL vancomycin HCl VANCOCIN HCL
INFECTIOUS DISEASE - PARASITIC
Amebacides
paromomycin sulfate HUMATIN
iodoquinol YODOXIN
Anaerobic Antiprotozoal-Antibacterial Agents
metronidazole FLAGYL
metronidazole FLAGYL ER
Anthelmintics
PA
praziquantel mebendazole
BILTRICIDE EMVERM
Antimalarial Drugs
chloroquine phosphate ARALEN PHOSPHATE
hydroxychloroquine sulfate PLAQUENIL
mefloquine HCl LARIAM
quinine sulfate QUALAQUIN
primaquine phosphate PRIMAQUINE
PA pyrimethamine DARAPRIM
Antiprotozoal Drugs, Miscellaneous
pentamidine isethionate NEBUPENT
PA miltefosine IMPAVIDO
INFECTIOUS DISEASE - VIRAL
All oral, non-experimental antiviral agents used for the treatment of AIDS or HIV-related diseases are considered a formulary benefit.
Antiretroviral Combination, Integrase Inhibitors
QL abacavir/dolutegravir/lamivudine TRIUMEQ
QL elvitegravir/cobicistat/emtricitabine/ tenofovir disoproxil fumarate
STRIBILD
QL elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide
GENVOYA
Antivirals, General
acyclovir ZOVIRAX
ganciclovir CYTOVENE
valacyclovir HCl VALTREX
QL oseltamivir phosphate TAMIFLU
ribavirin VIRAZOLE
Antivirals, HIV-Spec, Non-Peptidic Protease Inhib
QL darunavir ethanolate PREZISTA
QL darunavir/cobicistat PREZCOBIX
QL tipranavir APTIVUS CAPS
QL tipranavir/vitamin e tpgs APTIVUS SOLN
Antivirals, HIV-Spec, Nucleoside-Nucleotide Analog
QL emtricitabine/tenofovir TRUVADA
QL emtricitabine/tenofovir alafenamide DESCOVY
Antivirals, HIV-Spec., Nucleoside Analog, RTI Comb
QL abacavir/lamivudine/zidovudine TRIZIVIR
QL abacavir sulfate/lamivudine EPZICOM
QL lamivudine/zidovudine COMBIVIR
Antivirals, HIV-Specific, CCR5 Co-Receptor Antag.
QL maraviroc SELZENTRY
Antivirals, HIV-Specific, Fusion Inhibitors
MedPerform High Formulary
37014 MedPerform High Formulary – April 2017 15
QL enfuvirtide FUZEON
Antivirals, HIV-Specific, Non-Nucleoside, RTI
QL nevirapine VIRAMUNE
QL nevirapine ER VIRAMUNE XR
delavirdine mesylate RESCRIPTOR
efavirenz SUSTIVA
QL etravirine INTELENCE
QL rilpivirine EDURANT
Antivirals, HIV-Specific, Nucleoside Analog, RTI
QL abacavir sulfate ZIAGEN
QL didanosine VIDEX EC
QL lamivudine EPIVIR
QL stavudine ZERIT
QL zidovudine RETROVIR
QL didanosine VIDEX SOLUTION
QL emtricitabine EMTRIVA
Antivirals, HIV-Specific, Nucleotide Analog, RTI
QL tenofovir disoproxil fumarate VIREAD
Antivirals, HIV-Specific, Protease Inhibitor Comb
QL lopinavir/ritonavir KALETRA
Antivirals, HIV-Specific, Protease Inhibitors
QL atazanavir sulfate REYATAZ
QL atazanavir sulfate/cobicistat EVOTAZ
QL fosamprenavir calcium LEXIVA
indinavir sulfate CRIXIVAN
nelfinavir mesylate VIRACEPT
QL ritonavir NORVIR
QL saquinavir mesylate INVIRASE
Antivirals, HIV-1 Integrase Strand Transfer Inhibtors
QL dolutegravir TIVICAY
QL raltegravir potassium ISENTRESS
Antiviral Combination Nucleoside, Nucleotide & Non-Nucleoside RTI
QL efavirenz/emtricitabine/tenofovir ATRIPLA
QL rilpivirine/emtricitabine/tenofovir COMPLERA
QL rilpivirine/emtricitabine/ tenofovir alafenamide
ODEFSEY
Cytochrome P450 Inhibitors
QL cobicistat TYBOST
Hepatitis B Treatment Agents
QL adefovir dipivoxil HEPSERA
QL entecavir BARACLUDE
QL lamivudine EPIVIR HBV TABLET
QL lamivudine EPIVIR HBV SOLUTION
telbivudine TYZEKA
Hepatitis C Combination Agents
PA ledipasvir/sofosbuvir HARVONI
PA sofosbuvir/velpatasvir EPCLUSA
Hepatitis C Treatment Agents
ribavirin 200mg COPEGUS REBETOL CAPSULE
PA PA
peginterferon alfa-2a peginterferon alfa-2a
PEGASYS PEGASYS PROCLICK
ribavirin REBETOL SOLUTION
PA sofosbuvir SOVALDI
INFLAMMATORY DISEASE
Anti-Arthritic & Chelating Agents
PA penicillamine DEPEN
Anti-Arthritic, Folate Antagonist Agents
methotrexate sodium RHEUMATREX
QL ST
methotrexate OTREXUP
Anti-Inflammatory Tumor Necrosis Factor Inhibitor
PA adalimumab HUMIRA
PA etanercept ENBREL
Anti-Inflammatory, Pyrimidine Synthesis Inhibitors
leflunomide ARAVA
Bradykinin B2 Receptor Antagonists
PA icatibant acetate FIRAZYR
Glucocorticoids
budesonide BUDESONIDE
cortisone acetate CORTONE ACETATE
dexamethasone tablet, elixir DECADRON
hydrocortisone CORTEF
methylprednisolone MEDROL
prednisolone MILLIPRED MILLIPRED DP
prednisolone sod phosphate ORAPRED PEDIAPRED
prednisone DELTASONE PREDNISONE INTENSOL
budesonide ENTOCORT EC
Mineralocorticoids
fludrocortisone acetate FLORINEF ACETATE
Monoclonal antibody-human interleukin
PA ustekinumab STELARA SC
NSAIDs, Cyclooxygenase Inhibitor-Type
celecoxib CELEBREX
diclofenac sodium VOLTAREN VOLTAREN-XR
etodolac LODINE
fenoprofen calcium NALFON TABLET
flurbiprofen ANSAID
ibuprofen MOTRIN
indomethacin INDOCIN INDOCIN SR
ketoprofen ORUVAIL
QL ketorolac tromethamine TORADOL
meclofenamate sodium MECLOMEN
meloxicam MOBIC
nabumetone RELAFEN
naproxen EC-NAPROSYN NAPROSYN
naproxen sodium ANAPROX ANAPROX DS
oxaprozin DAYPRO
piroxicam FELDENE
sulindac CLINORIL
tolmetin sodium TOLECTIN 600
fenoprofen calcium NALFON CAPSULE
indomethacin INDOCIN SUPPOS. INDOCIN ORAL SUSP.
LOCAL ANESTHESIA
Local Anesthetics
lidocaine HCl XYLOCAINE
LOWER GASTROINTESTINAL DISORDERS - BOWEL INFLAMMAT
Bowel Antiinflamatory Agents
sulfasalazine AZULFIDINE
Chronic Inflam. Colon Dx, 5-A-Salicylat, Rectal Tx
mesalamine SFROWASA
mesalamine w/cleansing wipes ROWASA
mesalamine CANASA
Drug Tx-Chronic Inflam. Colon Dx, 5-Aminosalicylat
balsalazide disodium COLAZAL
mesalamine APRISO LIALDA PENTASA
Hemorrhoidal Preparations
hc acetate/pramoxine HCl ANALPRAM HC
Irritable Bowel Agents, Guanylate Cylase-C Agonists
QL linaclotide LINZESS
Rectal Preparations
MedPerform High Formulary
37014 MedPerform High Formulary – April 2017 16
hydrocortisone PROCTO-KIT PROCTOCORT CREAM PROCTOCREAM-HC
hydrocortisone acetate ANUSOL-HC PROCTOCORT SUPPOS.
hc acetate/pramoxine HCl PROCTOFOAM-HC
Rectal/Lower Bowel Prep., Glucocort. (Non-Hemorr)
hydrocortisone CORTENEMA
LOWER GASTROINTESTINAL DISORDERS - OTHER
Ammonia Inhibitors
lactulose CHRONULAC
sodium phenylbutyrate BUPHENYL POWDER
sodium phenylbutyrate BUPHENYL TABLET
Antidiarrheals
diphenoxylate HCl/atrop sulf LOMOTIL
Bile Salts
ursodiol ACTIGALL URSO URSO FORTE
Laxatives & Cathartics
peg 3350/na sulf,bicarb,cl/kcl COLYTE WITH FLAVOR PACKETS
polyethylene glycol 3350 MIRALAX
sod chloride/nahco3/kcl/peg's NULYTELY WITH FLAVOR PACKS
lactulose KRISTALOSE
peg 3350/na sulf,bicarb,cl/kcl GOLYTELY OCL
Narcotic Antagonists, Peripherally-Acting
QL naloxegol oxalate MOVANTIK
Glucagon-Like Peptide (GLP-2) Analogs
PA teduglutide [rDNA origin] GATTEX
MISCELLANEOUS AGENTS
Anaphylaxis Therapy Agents
epinephrine EPIPEN
epinephrine EPIPEN JR
Parasympathetic Agents
bethanechol chloride URECHOLINE
cevimeline HCl EVOXAC
pilocarpine HCl SALAGEN
Pku Tx Agent-Cofactor Of Phenylalanine Hydroxylase
PA sapropterin dihydrochloride KUVAN
NEOPLASTIC DISEASE
Alkylating Agents
cyclophosphamide CYTOXAN
hydroxyurea HYDREA
lomustine CEENU
PA temozolomide TEMODAR
altretamine HEXALEN
busulfan MYLERAN
chlorambucil LEUKERAN
melphalan ALKERAN
Antiandrogenic Agents
bicalutamide CASODEX
flutamide EULEXIN
PA abiraterone acetate ZYTIGA
PA enzalutamide XTANDI
QL nilutamide NILANDRON
Antimetabolites
PA capecitabine XELODA
mercaptopurine PURINETHOL
methotrexate sodium METHOTREXATE TABLET
methotrexate sodium METHOTREXATE VIAL
thioguanine THIOGUANINE
fludarabine phosphate OFORTA
ST mercaptopurine PURIXAN
methotrexate sodium TREXALL
PA trifluridine/tipiracil HCl LONSURF
Antineoplastic - Aromatase Inhibitors
anastrozole ARIMIDEX
exemestane letrozole
AROMASIN FEMARA
Antineoplastic -B Cell Lymphoma-2(bcl-2) Inhibitors
PA venetoclax VENCLEXTA
Antineoplastic – Hedgehog Pathway Inhibitors
PA vismodegib ERIVEDGE
PA sonidegib phosphate ODOMZO
Antineoplastic – Janus Kinase (JAK) Inhibitors
PA ruxolitinib phosphate JAKAFI
PA tofacitinib citrate XELJANZ
PA tofacitinib citrate XR XELJANZ XR
Antineoplastic - MEK1 and MEK2 Kinase Inhibitors
PA + QL
cobimetinib fumarate COTELLIC
Antineoplastic - Topoisomerase I Inhibitors
topotecan HCl HYCAMTIN
Antineoplastic - Immunomodulator Agents
PA + QL
lenalidomide REVLIMID
PA pomalidomide POMALYST
Antineoplastic - Systemic Enzyme Inhibitors
PA imatinib mesylate GLEEVEC
PA afatinib GILOTRIF
PA+ QL
alectinib hydrochloride ALECENSA
PA+QL
axitinib INLYTA
PA bosutinib BOSULIF
PA cabozantinib s-malate CABOMETYX
PA cabozanitinib COMETRIQ
PA ceritinib ZYKADIA
PA QL
crizotinib XALKORI
PA dabrafanib TAFINLAR
PA dasatinib SPRYCEL
PA+QL
erlotinib HCl TARCEVA
PA gefitinib IRESSA
PA ibrutinib IMBRUVICA
PA idelalisib ZYDELIG
PA ixazomib citrate NINLARO
PA lapatinib ditosylate TYKERB
PA lenvatinib mesylate LENVIMA
PA nilotinib hydrochloride TASIGNA
PA olaparib LYNPARZA
PA + QL
osimertinib mesylate TAGRISSO
PA pazopanib hydrochloride VOTRIENT
PA palbociclib IBRANCE
PA ponatinib ICLUSIG
PA regorafenib STIVARGA
PA sorafenib tosylate NEXAVAR
PA sunitinib malate SUTENT
PA trametinib dimethyl sulfoxide MEKINIST
PA vemurafenib ZELBORAF
Antineoplastic, Histone Deacetylase Inhibitors, HDIS
PA panobinostat lactate FARYDAK
vorinostat ZOLINZA
Antineoplastics, Miscellaneous
etoposide VEPESID
mitotane LYSODREN
procarbazine HCl MATULANE
MedPerform High Formulary
37014 MedPerform High Formulary – April 2017 17
tretinoin VESANOID
PA QL PA
everolimus everolimus
AFINITOR AFINITOR DISPERZ
Chemotherapy Rescue/Antidote Agents
QL
leucovorin calcium uridine triacetate
LEUCOVORIN CALCIUM VISTOGARD
Selective Estrogen Receptor Modulators (SERM)
tamoxifen citrate NOLVADEX
PA toremifene citrate FARESTON
Selective Retinoid X Receptor Agonists (RXR)
PA bexarotene TARGRETIN
Steroid Antineoplastics
megestrol acetate MEGACE
estramustine phosphate sodium EMCYT
NEUROLOGICAL DISEASE - MISCELLANEOUS
Agents to Treat Multiple Sclerosis
PA glatiramer acetate COPAXONE
PA dimethyl fumarate TECFIDERA
PA fingolimod HCl GILENYA
PA interferon beta-1a AVONEX
PA PA PA
interferon beta-1a/albumin
AVONEX ADMINISTRATION PACK REBIF REBIF REBIDOSE
PA PA
peginterferon beta-1a PLEGRIDY PLEGRIDY PEN
Fibromyalgia Agents, Serotonin-Norepineph RU Inhibitor
milnacipran HCl SAVELLA
Movement Disorders (Drug Therapy)
PA tetrabenazine XENAZINE
ORAL/PHARYNGEAL DISORDERS
Dental Aids & Preparations
chlorhexidine gluconate PERIDEX
triamcinolone acetonide KENALOG IN ORABASE
Nose Preparations, Antibiotics
mupirocin calcium BACTROBAN NASAL
Nose Preparations, Miscellaneous (Rx)
ipratropium bromide ATROVENT
OTHER DRUGS
Appetite Stimulators for Anorexia, Cachexia, Wasting Syndrome
megestrol acetate MEGACE MEGACE ES
General Inhalation Agents
sodium chloride for inhalation HYPER-SAL 7%
Metabolic disease enzyme replace, hypophosphatasia
PA asfotase alfa STRENSIQ
Needles/Needleless Devices
needles, insulin disp., safety PEN NEEDLE
Nucleic Acid/Nucleotide Supplements
PA uridine triacetate XURIDEN
octreotide acetate SANDOSTATIN
Drugs to treat hereditary tyrosinemia
PA nitisinone ORFADIN
OTHER RESPIRATORY DISORDERS
Antifibrotic Therapy – Pyridone Analogs
PA pirfenidone ESBRIET
Cystic Fibrosis-Cftr Potentiator & Corrector Comb.
PA lumacaftor/ivacaftor ORKAMBI
Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) Potentiators
PA ivacaftor KALYDECO
Mucolytics
acetylcysteine MUCOMYST-10
PA dornase alfa PULMOZYME
Pulmonary Fibrosis – Systemic Enzyme Inhibitors
PA nintedanib esylate OFEV
PAIN MANAGEMENT - ANALGESICS
Analgesic, Non-Salicylate & Barbiturate Combinations
butalbital/acetaminophen PHRENILIN
butalbital/acetaminophen PHRENILIN FORTE
Analgesic, Salicylate, Barbiturate & Xanthine Combinations
butalbital/aspirin/caffeine FIORINAL
Analgesic, Non-Salicylate, Barbiturate & Xanthine Combinations
butalb/acetaminophen/caffeine ESGIC FIORICET
Analgesic/Antipyretics, Salicylates
diflunisal DOLOBID
salsalate DISALCID
Analgesics, Narcotics
codeine phos/carisoprodol/asa SOMA COMPOUND WITH CODEINE
PA fentanyl DURAGESIC
PA fentanyl citrate lozenge ACTIQ
QL hydrocodone bit/acetaminophen (300mg)
VICODIN VICODIN ES VICODIN HP
QL hydrocodone bit/acetaminophen (325mg)
LORCET LORCET PLUS LORTAB NORCO
QL hydrocodone bit/acetaminophen (300mg/15ml) oral solution
LORTAB ELIXIR
QL hydrocodone bit/acetaminophen oral elixir (325mg/15ml)
HYCET
QL hydrocodone bitartrate HYSINGLA ER
hydromorphone HCl DILAUDID
methadone HCl DOLOPHINE HCL
QL+ ST
methadone HCl injection solution
METHADONE HCL INJECTION SOLUTION
QL morphine sulfate AVINZA
QL morphine sulfate MS CONTIN
morphine sulfate MSIR ORAMORPH SR ROXANOL
oxycodone HCl PERCOLONE ROXICODONE ROXICODONE INTENSOL
QL oxycodone HCl/acetaminophen (325mg)
PERCOCET
QL oxycodone HCl/acetaminophen (325mg/5ml)
ROXICET
oxycodone HCl/aspirin PERCODAN
tramadol HCl ULTRAM
tramadol HCl/acetaminophen ULTRACET
QL buprenorphine BUTRANS
QL hydrocodone bit/acetaminophen (250mg)
STAGESIC-10
QL hydrocodone bit/acetaminophen (300mg)
XODOL 10-300
hydromorphone HCl DILAUDID-5
QL oxycodone HCl OXYCONTIN
QL tapentadol HCl NUCYNTA
QL tapentadol HCl ER NUCYNTA ER
Antimigraine Preparations
QL QL
ergotamine tartrate/caffeine CAFERGOT MIGERGOT
isomethept/acetaminop/dichlphn
MIDRIN
QL naratriptan AMERGE
QL rizatriptan benzoate MAXALT MAXALT MLT
QL sumatriptan IMITREX NASAL SPRAY
QL sumatriptan succinate IMITREX TABLET IMITREX INJECTION
QL + zolmitriptan ZOMIG
MedPerform High Formulary
37014 MedPerform High Formulary – April 2017 18
ST ZOMIG ZMT
Narcotic & Non-Salicylate Analgesic, Barbiturate & Xanthine Combinations
codeine/butalbit/acetamin/caff FIORICET WITH CODEINE
Narcotic & Salicylate Analgesics, Barbiturates & Xanthines
codeine/butalbital/asa/caffein FIORINAL WITH CODEINE #3
Narcotic Analgesic & Non-Salicylate Analgesic Combinations
acetaminophen with codeine TYLENOL-CODEINE NO.3 TYLENOL-CODEINE NO.4
acetaminophen and codeine CAPITAL AND CODEINE
Narcotic Withdrawal Therapy Agents
PA + CU PA + CU PA + QL + CU
buprenorphine hcl/naloxone hcl buprenorphine hcl buprenorphine hcl/naloxone hcl
SUBOXONE SUBUTEX ZUBSOLV
PARKINSON’S DISEASE
Antiparkinsonism Drugs, Anticholinergic
benztropine mesylate COGENTIN
trihexyphenidyl HCl ARTANE
Antiparkinsonism Drugs, Other
amantadine HCl SYMMETREL
bromocriptine mesylate PARLODEL
carbidopa/levodopa PARCOPA SINEMET 25-100 SINEMET CR
carbidopa/levodopa/entacapone STALEVO
entacapone COMTAN
pramipexole di-HCl MIRAPEX
QL + ST
ropinirole HCl REQUIP REQUIP XL
selegiline HCl ELDEPRYL
QL rasagiline mesylate AZILECT
QL + ST
rotigotine NEUPRO
Decarboxylase Inhibitors
carbidopa LODOSYN
SEIZURE DISORDER
Anticonvulsants
carbamazepine CARBATROL TEGRETOL TEGRETOL XR
clonazepam KLONOPIN
QL diazepam DIASTAT
divalproex sodium DEPAKOTE DEPAKOTE ER DEPAKOTE SPRINKLE
QL + ST
ethosuximide ezogabine
ZARONTIN POTIGA
QL + ST QL + ST
gabapentin lacosamide lacosamide
NEURONTIN VIMPAT ORAL SOLUTION VIMPAT TABLETS
lamotrigine LAMICTAL
levetiracetam KEPPRA
oxcarbazepine TRILEPTAL
phenytoin DILANTIN-125 DILANTIN CHEW TAB
phenytoin sodium extended DILANTIN PHENYTEK
primidone MYSOLINE
QL + ST
topiramate topiramate topiramate
TOPAMAX TOPAMAX SPRINKLE TROKENDI XR
valproate sodium DEPAKENE SYRUP
valproic acid DEPAKENE CAPSULES
zonisamide ZONEGRAN
pregabalin LYRICA
SKELETAL MUSCLE DISORDER
Agents To Treat Periodic Paralysis
PA dichlorphenamide KEVEYIS
Skeletal Muscle Relaxants
baclofen LIORESAL
carisoprodol SOMA
carisoprodol/aspirin SOMA COMPOUND
chlorzoxazone PARAFON FORTE DSC
cyclobenzaprine HCl FLEXERIL
dantrolene sodium DANTRIUM
metaxalone SKELAXIN
methocarbamol ROBAXIN ROBAXIN-750
orphenadrine citrate NORFLEX
orphenadrine/aspirin/caffeine NORGESIC FORTE
tizanidine HCl ZANAFLEX
UPPER GASTROINTESTINAL DISORDERS - DIGESTIVE
Pancreatic Enzymes
amylase/lipase/protease PANCRELIPASE 5,000
amylase/lipase/protease CREON ULTRASE ULTRASE MT ZENPEP
UPPER GASTROINTESTINAL DISORDERS - SPASTIC DISEASE
Anticholinergics/Antispasmodics
dicyclomine HCl BENTYL
Belladonna Alkaloids
belladonna alkaloids/phenobarb DONNATAL
hyoscyamine sulfate ANASPAZ LEVBID LEVSIN-SL
UPPER GASTROINTESTINAL DISORDERS - ULCER DISEASE
Anti-Ulcer Preparations
misoprostol CYTOTEC
sucralfate CARAFATE
Anti-Ulcer-H.pylori Agents
lansoprazole/amox tr/clarith PREVPAC
Anticholinergics, Quaternary Ammonium
chlordiazepoxide/clidinium br LIBRAX
Histamine H2-Receptor Inhibitors
cimetidine HCl TAGAMET
famotidine PEPCID
nizatidine AXID
ranitidine HCl ZANTAC
Intestinal Motility Stimulants
metoclopramide HCl REGLAN
Proton-Pump Inhibitors
QL + ST
esomeprazole magnesium NEXIUM
lansoprazole PREVACID RX
omeprazole capsules (RX) PRILOSEC CAPSULES (RX)
omeprazole magnesium tablets (OTC)
PRILOSEC OTC TABLETS (OTC)
pantoprazole sodium PROTONIX
ST lansoprazole PREVACID SOLUTABS
ST pantoprazole sodium suspension PROTONIX SUSP
URINARY TRACT - FUNCTIONAL DISORDERS
Benign Prostatic Hypertrophy/Micturition Agents
MedPerform High Formulary
37014 MedPerform High Formulary – April 2017 19
alfuzosin UROXATRAL
ST dutasteride AVODART
finasteride PROSCAR
tamsulosin HCl FLOMAX
Benign Prostatic Hypertrophy, 5-alpha red. Inhib & alpha-1 antag comb agents
ST dutasteride/tamsulosin HCl JALYN
Kidney Stone Agents
PA cysteamine bitartrate PROCYSBI
Overactive Bladder Agents, Beta-3 Adrenergic Recep
ST mirabegron MYRBETRIQ
Urinary Tract Analgesic Agents
pentosan polysulfate sodium ELMIRON
Urinary Tract Anesthetic/Analgesic Agents (Azo-Dye)
phenazopyridine HCl PYRIDIUM
Urinary Tract Antispasmodic, M(3) Selective Antagonists
ST solifenacin succinate VESICARE
Urinary Tract Antispasmodic/Antiincontinence Agents
oxybutynin chloride DITROPAN XL
ST trospium chloride SANCTURA
ST ST
tolterodine tartrate DETROL DETROL LA
ST fesoterodine fumarate TOVIAZ
VAGINAL DISORDERS
Vaginal Antibiotics
metronidazole METROGEL-VAGINAL VANDAZOLE
Vaginal Antifungals
miconazole nitrate MONISTAT 3
butoconazole nitrate GYNAZOLE-1
Vaginal Estrogen Preparations
estradiol cream estradiol tablet
ESTRACE VAGIFEM
estrogens, conjugated PREMARIN
Vaginal Sulfonamides
sulfanilamide AVC
VITAMIN AND/OR MINERAL DEFICIENCY
Fluoride Preparations
sodium fluoride FLUORITAB FLURA-DROPS FLURA-TABS LURIDE
Folic Acid Preparations
folic acid FOLIC ACID
Multivitamin Preparations
folic acid/mu-vits-min th VICON FORTE
Pediatric Vitamin Preparations
fluoride ion/iron/vit a,c&d TRI-VI-FLOR W/IRON
fluoride ion/multivitamins POLY-VI-FLOR
fluoride ion/multivits w-fe POLY-VI-FLOR W/IRON
fluoride ion/vit a,c&d FLUORABON BASIC
Prenatal Vitamin Preparations
prenatal vit 15/iron cb/fa/dss TRIADVANCE
prenatal vit 16/iron cb/fa/dss VINATE GT
prenatal vit 18/iron cb/fa/dss VINATE ULTRA
prenatal vit 95/fe fum/fa PRENAVITE
Vitamin B Preparations
cyanocobalamin/fa/pyridoxine FOLGARD RX
Vitamin D Preparations
ST
calcitriol calcitriol
ROCALTROL VECTICAL
ergocalciferol DRISDOL
SPECIALTY INJECTABLE CROSS REFERENCE LISTING
The following cross reference is being provided as a guide to formulary choices within prominent “specialty” injectable drug categories. General specialty categories are cross referenced to
their corresponding formulary classification status and page number. This cross reference is not meant to be all-inclusive. Please refer to the Table of Contents or Index to determine formulary status of injectable medications not listed in this cross reference (e.g., Antineoplastics, Leukocyte Stimulants, etc.). EPO Hematinics, Other Page 7 HEPATITIS C Hepatitis C Treatment Agents Page 9 HUMAN GROWTH FACTORS Growth Hormones Page 6 LOW MOLECULAR WEIGHT HEPARINS Heparin and Related Preparations Page 7 MULTIPLE SCLEROSIS Agents to Treat Multiple Sclerosis Page 10 RHEUMATOID ARTHRITIS Anti-Inflammatory, Pyrimidine Synthesis Inhibitors
MEDICATION PRESCRIBING LIMITATIONS 1. AGE RESTRICTIONS (FORMULARY)- Covered for ages: Concerta ≤ 18 years old
Differin
Epiduo
Epiduo Forte
≤ 25 years old ≤ 25 years old ≤ 25 years old
Fabior
Focalin XR
Metadate CD
≥ 12 years old ≤ 18 years old ≤ 18 years old
Metadate ER ≤ 18 years old
Ritalin LA 60mg ≤ 18 years old
Ritalin SR ≤ 18 years old
2. AGE RESTRICTIONS (NON FORMULARY)- Covered for ages: All carbinoxamine containing products (i.e.,
Palgic, Tussafed, etc.)
≥ 2 years old
Atralin ≤ 25 years old
Avita ≤ 25 years old
Epaned (Step Therapy applies) ≥ 12 years old
Oracea ≥ 18 years old
Refissa ≤ 25 years old
Renova ≤ 25 years old
Retin-A ≤ 25 years old
Retin-A Micro ≤ 25 years old
Retin-A Micro Pump ≤ 25 years old
Solodyn ≥ 12 years old
Tretin-X ≤ 25 years old
3. QUANTITY RESTRICTIONS (FORMULARY) Abilify
tablets solution
30 tablets per 30 days 900mL per 30 days
Abilify Discmelt 10mg
15mg
90 tablets per 30 days 60 tablets per 30 days
Adderall 60 tablets per 30 days
Adderall XR 5mg, 10mg, 15mg 20mg, 25mg, 30mg
30 capsules per 30 days 60 capsules per 30 days
Advair Diskus 60 units per 30 days
Advair HFA
Afinitor
12g (1 inhaler) per 30 days 30 tablets per 30 days
Akynzeo 1 capsule per 28 days
Aldara 24 packets per 30 days
Alecensa 240 capsules per 30 days
Alendronate solution 300mL per 28 days
Ambien / Ambien CR 30 tablets per 30 days
Amerge 18 tablets per 30 days
Androxy 120 tablets per 30 days
Anoro Ellipta 60 blister packs per 30 days
MedPerform High Formulary
37014 MedPerform High Formulary – April 2017 20
Aptivus capsule solution
120 capsules per 30 days 380mL (4 bottles) per 30 days
Arixtra 2.5mg/0.5mL 5mg/0.4mL 7.5mg/0.6mL 10mg/0.8mL
5mL (10 syringes) per 30 days 4mL (10 syringes) per 30 days 6mL (10 syringes) per 30 days 8mL (10 syringes) per 30 days
Asmanex 1 inhaler per 30 days
Asmanex HFA 13 grams per 30 days
Astelin 60mL (2 bottles) per 30 days
Astepro 60mL (2 bottles) per 30 days
Atripla 30 tablets per 30 days
Atrovent HFA 2 inhalers per 28 days
Avinza 30mg, 45mg, 60mg, 75mg, 90mg 120mg
1 capsule per day 2 capsules per day
Azilect
Baraclude 0.5mg, 1mg oral solution
30 tablets per 30 days 30 tablets per 30 days 630ml (3 bottles) per 30 days
Breo Ellipta 60 units per 30 days
Brilinta 60 tablets per 30 days
Butrans 4 patches per 28 days
Caduet 30 tablets per 30 days
Cafergot 40 tablets 28 days
Climara 4 patches per 28 days
Clozaril 90 tablets per 30 day
Colcrys 120 tablets per 30 days
Combipatch 8 patches per 30 days
Combivir
Complera
60 tablets per 30 days 30 tablets per 30 days
Concerta 18mg, 27mg, 54mg 36mg
30 tablets per 30 days 60 tablets per 30 days
Corlanor 60 tablets per 30 days
Cotellic 63 tablets per 28 days
Crestor 30 tablets per 30 days
Cymbalta 60 capsules per 30 days
Daliresp 30 tablets per 30 days
Depo-Testosterone 10mL per 30 days
Descovy 30 tablets per 30 days
Desvenlavaxine ER (Ranbaxy Brand)
30 tablets per 30 days
Dexedrine Spansule 5mg, 10mg 15mg
60 capsules per 30 days 120 capsules per 30 days
Diastat 1 kit per copay
Dificid 20 tablets per 30 days
Doxycycline monohydrate 150mg tablet
60 tablets per 30 days
Dulera
13g (1 inhaler) per 30 days
Duragesic 10 patches per 30 days
Edurant 30 tablets per 30 days
Effient 30 tablets per 30 days
Eliquis 60 tablets per 30 days
Emend 40mg 80mg 125mg
1 capsules per 21 days 2 capsules per 21 days 1 capsule per 21 days
Emend Trifold Pack 1 packet per 21 days
Emtriva 10mg/mL oral solution 200mg capsules
850mL (5 bottles) per 30 days 30 capsules per 30 days
Epivir 150mg tablets 300mg tablets 10mg/mL oral solution
60 tablets per 30 days 30 tablets per 30 days 960mL (4 bottles)per 30 days
Epivir HBV 100mg oral solution
Epzicom
30 tablets per 30 days 720ml (3 bottles) per 30 days 30 tablets per 30 days
Evista 30 tablets per 30 days
Evotaz 30 tablets per 30 days
Exelon patch
Fetzima
30 patches per 30 days 30 capsules per 30 days
Flonase 16gm (1 bottle) per 30 days
Flunisolide 25mL (1 bottle) per 30 days
Focalin 60 tablets per 30 days
Focalin XR 30 capsules per 30 days
Forteo 2.4mL (1 pen) per 28 days with a max duration of 2 years per lifetime
Fragmin 2500 units/0.2mL 5000 units/0.2mL 7500 units/0.3mL 10,000 units/1mL 12,500 units/0.5mL
15,000 units/0.6mL 18,000 units/0.72mL
25,000 units/ml
2mL(10 syringes) per 30 days 2mL(10 syringes) per 30 days 3mL(10 syringes) per 30 days 10mL(10 syringes)per 30 days 5mL (10 syringes) per 30 days 6mL (10 syringes) per 30 days 7.2mL (10 syringes) per 30 days 7.6mL (2 vials) per 30 days
Fuzeon 60 vials per 30 days
Genvoya 30 tablets per 30 days
Geodon (oral) 60 capsules per 30 days
Glyxambi
Hepsera
30 tablets per 30 days 30 tablets per 30 days
Humulin N vial Kwikpen
40mL (4 vials) per 28 days 30mL (10 pens) per 28 days
Humulin R 100u/mL 500u/mL
40mL (4 vials) per 28 days 40mL (2 vials) per 28 days
Humulin R U-500 Kwikpen
8 pens (4 boxes of 2 pens) per 28 days
Humulin 70/30 vial Kwikpen
40mL (4 vials) per 28 days 30mL (10 pens) per 28 days
Humalog vial pen/cartridge
40mL (4 vials) per 28 days 30mL (10 pens/cartridges) per 28 days
Humalog Mix 50/50 / 75/25 vial Kwikpen
40mL (4 vials) per 28 days 30mL (10 pens) per 28 days
Hydrocodone bit/acetaminophen (maximum of 4gm of acetaminophen per day):
250mg 300mg 325mg 300mg/15ml soln 325mg/15ml elixir
16 tablets per 1 day supply 13 tablets per 1 day supply 12 tablets per 1 day supply 200ml per 1 day supply 184ml per 1 day supply
Hysingla ER 30 tablets per 30 days
Imitrex tablets (all strengths) nasal spray injection (kits and vials)
6mg/0.5ml vial 6mg/0.5ml kit/refill kit 4mg/0.5ml kit/refill kit
18 tablets per 30 days 12 units per 30 days 4 vials per 30 days 2 kits per 30 days 2 kits per 30 days
Inlyta 1mg 5mg
180 tablets per 30 days 120 tablets per 30 days
Intelence 25mg, 100mg 200mg
120 tablets per 30 days 60 tablets per 30 days
Invirase 200mg capsules 500mg tablets
300 capsules per 30 days 120 tablets per 30 days
Invokamet 60 tablets per 30 days
Invokamet XR 60 tablets per 30 days
Invokana 30 tablets per 30 days
Isentress 400 mg tablets 25mg, 100mg tablets
100mg powder
60 tablets per 30 days 180 chew tablets per 30 days 60 packets per 30 days
MedPerform High Formulary
37014 MedPerform High Formulary – April 2017 21
Janumet 60 tablets per 30 days
Janumet XR 100-1000mg
50-1000mg 50-500mg
30 tablets per 30 days 60 tablets per 30 days 60 tablets per 30 days
Januvia 30 tablets per 30 days
Jentadueto 60 tablets per 30 days
Jardiance 30 tablets per 30 days
Juxtapid 30 capsules per 30 days
Kaletra 100-25mg tablets
200-50mg tablets oral solution
60 tablets per 30 days 120 tablets per 30 days 480mL (3 bottles) per 30 days
Lantus vial Solostar
40mL (4 vials) per 28 days 30mL (10 pens) per 28 days
Latuda 20mg, 40mg, 60mg, 120mg 80mg
Lexiva suspension tablet
30 tablets per 30 days 60 tablets per 30 days 1800mL (8 bottles) per 30 days 120 tablets per 30 days
Linzess 30 capsules per 30 days
Livalo 30 tablets per 30 days
Lovaza 120 capsules per 30 days
Lovenox 30mg/0.3mL 40mg/0.4mL 60mg/0.6mL 80mg/0.8mL 100mg/1mL 120mg/0.8mL 150mg/1mL 300mg/3mL
6mL (20 syringes) per 30 days 8mL (20 syringes) per 30 days 12mL (20 syringes) per 30 days 16mL (20 syringes) per 30 days 20mL (20 syringes) per 30 days 16mL (20 syringes) per 30 days 20mL (20 syringes) per 30 days 30mL (10 vials) per 30 days
Lumigan 2.5ml per 30 days
Lunesta 30 tablets per 30 days
Lynparza 16 capsules per day
Marinol 60 capsules per 30 days
Maxalt/ Maxalt MLT
18 tablets per 30 days
Metadate CD 30mg 10mg, 20mg, 40mg, 60mg
60 tablets per 30 days 30 tablets per 30 days
Metadate ER 90 tablets per 30 days
Methadone HCl injection solution
120mL (6 vials) per 30 days
Methylin chewable tablet 90 tablets per 30 days
Migergot 20 units per 28 days
Morgidox 50mg, 100mg
60 capsules per 30 days
Movantik 30 tablets per 30 days
MS Contin 90 tablets per 30 days
Namenda tablets titration pack solution
60 tablets per 30 days 49 tablets per 28 days 300mLper 30 days
Namenda XR capsules titration pack
30 capsules per 30 days 28 capsules per 28 days
Namzaric capsules titration pack
30 capsules per 30 days 28 capsules per 28 days
Narcan Nasal 2 boxes (4 nasal sprays per 30 days
Nasacort AQ 16.5g (1 canister) per 30 days
Nasarel 25ml (1 bottle) per 30 days
Nasonex 17g (1 canister) per 30 days
Neupro 30 patches per 30 days
Nexium capsules
packets
30 capsules per 30 days 30 packets per 30 days
Nilandron 150mg tablet 60 tablets for first 30 days, then 30 tablets per 30 days thereafter
Norvir
oral solution capsules/tablets
480mL (2 bottles) per 30 days 360 capsules/tablets per 30 days
Nucynta 180 tablets per 30 days
Nucynta ER 60 tablets per 30 days
Nuvaring 1 ring per 28 days
Odefsey 30 tablets per 30 days
Ortho Evra 3 patches per 28 days
Otrexup 1.6mL per 28 days
Oxycodone HCl/acetaminophen (maximum of 4gm acetaminophen per day):
325mg 325mg/5ml soln
12 tablets per 1 day supply 61mL per 1 day supply
Oxycontin 10mg, 15mg, 20mg, 30mg, 40mg, 60mg
80mg
60 tablets per 30 days 120 tablets per 30 days
Perforomist 120mL per 30 days
Picato 0.015% gel 0.05% gel
3 tubes per 56 days 2 tubes per 56 days
Plavix 300mg tablet 4 tablets per 30 days
Potiga 50mg 200mg, 300mg, 400mg
Prezcobix
270 tablets per 30 days 90 tablets per 30 days 30 tablets per 30 days
Prezista oral suspension 75mg 150mg 400mg, 600mg 800mg
400mL (2 bottles) per 30 days 480 tablets per 30 days 240 tablets per 30 days 60 tablets per 30 days 30 tablets per 30 days
Pristiq 30 tablets per 30 days
Promacta 30 tablets per 30 days
Pulmicort Flexhaler 1 inhaler per 30 days
Pulmicort Respules 60mL (30 respules) per 30 days
Qnasl 8.7g (1 canister) per 30 days
Qnasl Children 4.9g (1 canister) per 30 days
Quillivant XR 60mL 120mL 150mL
180mL
60mL (1 bottle) per 30 days 240mL (2 bottles) per 30 days 300mL (2 bottles) per 30 days 360mL (2 bottles) per 30 days
QVAR 17.4g (2 inhalers) per 30 days
Ranexa 500mg
1000mg
120 tablets per 30 days 60 tablets per 30 days
Rayaldee
Requip XL
60 capsules per 30 days 30 tablets per 30 days
Restasis SDV
Restasis MDV
60 single use vials per 30 days 1 multidose vial per 30 days
Retrovir syrup capsules tablets
1920mL (8 bottles) per 30 days 180 capsules per 30 days 60 tablets per 30 days
Revlimid
Risperdal tablets/ODT solution
30 capsules per 30 days 60 tablets per 30 days 240mL per 30 days
Rexulti
Reyataz 150mg, 200mg 300mg 50mg
30 tablets per 30 days 60 capsules per 30 days 30 capsules per 30 days 150 packets per 30 days
Ritalin 90 tablets per 30 days
Ritalin LA 10mg, 20mg, 40mg, 60mg
30mg
30 capsules per 30 days 60 capsules per 30 days
Ritalin SR 90 tablets per 30 days
Saphris
Seasonale
60 tablets per 30 days 91 tablets per 84 days
Selzentry 75mg, 150mg 25mg, 300mg
60 tablets per 30 days 120 tablets per 30 days
Serevent 60 doses (1 diskus) per 30 days
MedPerform High Formulary
37014 MedPerform High Formulary – April 2017 22
Seroquel 90 tablets per 30 days
Spiriva 30 capsules per 30 days
Spiriva Respimat 1 inhaler per 30 days
Sonata 30 capsules per 30 days
Stiolto Respimat 4g (60 inhalations) per 30 days
Strattera 10mg, 18mg, 25mg, 40mg 60mg, 80mg, 100mg
60 capsules per 30 days 30 capsules per 30 days
Stribild 30 tablets per 30 days
Striverdi Respimat 4g (60 inhalations) per 30 days
Symbicort
Symbyax
1 inhaler per 30 days (10.2 grams) 30 capsules per 30 days
Synjardy 60 capsules per 30 days
Tagrisso 1 tablet per day
Tamiflu 30mg tablets 45mg, 75mg tablets suspension
Trintellix
Trokendi XR 25mg, 50mg, 100mg 200mg
40 tablets per 183 days 20 tablets per 183 days 360mL per 183 days 30 tablets per 30 days 30 capsules per 30 days 60 capsules per 30 days
Vibramycin 100mg 60 capsules per 30 days
Vimpat 50mg, 100mg, 150mg, 200mg
10mg/ml oral solution
60 tablets per 30 days 1200mL per 30 days
Vraylar All Strengths Titration Pack
30 capsules per 30 days 7 blisters (1 dose-pack) per 28 days
NOTE: The FDA recommends a maximum of 5 days of therapy with this drug
Tarceva 30 tablets per 30 days
Tivicay 30 tablets per 30 days
Toradol 20 tablets per fill
Toujeo 13.5mL (9 prefilled pens) per 28 days
Tradjenta 30 tablets per 30 days
Travatan/Travatan Z 2.5ml per 30 days
Triumeq 30 tablets per 30 days
Trizivir 60 tablets per 30 days
Trulicity 2mL (4 pens) per 28 days
Truvada 30 tablets per 30 days
Tybost 30 tablets per 30 days
Uloric 30 tablets per 30 days
Vascepa 0.5g 1g
240 capsules per 30 days 120 capsules per 30 days
Vancocin Oral 125mg and 250mg
40 capsules per 30 days
Viagra 6 tablets per 30 days
Vibra-Tabs 60 tablets per 30 days
Victoza 9mL (3 pens) per 30 days
Videx 600mL (six 2g bottles or three 4g bottles) per 30 days
Videx EC 125mg, 200mg 250mg, 400mg
Viibryd
60 capsules per 30 days 30 capsules per 30 days 30 tablets per 30 days
Viramune solution tablets
1200mL (5 bottles) per 30 days 60 tablets per 30 days
Viramune XR 100mg
400mg
90 tablets per 30 days 30 tablets per 30 days
Viread powder tablets
Vistogard granules
240g powder per 30 days 30 tablets per 30 days 24 packets per 14 days
Vivelle Dot 8 patches per 30 days
Vyvanse
Xalkori
30 capsules/tablets per 30 days 60 capsules per 30 days
Xarelto
10mg, 20mg 15mg loading dose
30 tablets per 30 days 42 tablets per 21 days, followed by 30 tablets per 30 days
Xiidra 60 vials per 30 days
Zenzedi 2.5mg, 5mg, 7.5mg, 15mg 10mg 20mg, 30mg
90 tablets per 30 days 180 tablets per 30 days 60 tablets per 30 days
Zerit oral solution capsules
2400mL (12 bottles) per 30 days 60 tablets per 30 days
Zetia 30 tablets per 30 days
Ziagen solution tablets
960mL (4 bottles) per 30 days 60 tablets per 30 days
Zofran oral solution 4mg/5ml oral solution
50ml per 15 days
Zomig/Zomig ZMT Tablets Nasal Spray
12 tablets per 30 days 12 units per 30 days
Zubsolv 0.7mg/0.18mg 1.4/0.36mg 2.9/0.71mg 5.7/1.4mg
11.4/2.9mg 8.6/2.1mg
Zurampic
Zyprexa/Zyprexa Zydis
30 sublingual tablets per 30 days 60 sublingual tablets per 30 days 30 tablets per 30 days 30 tablets per 30 days
4. QUANTITY RESTRICTIONS (NON FORMULARY) Aciphex 30 tablets per 30 days
Aciphex Sprinkle 30 capsules per 30 days
Acticlate 75mg, 100mg 60 tablets per 30 days
Actonel 5mg, 30mg 35mg
150mg
30 tablets per 30 days 4 tablets per 28 days 1 tablet per 28 days
Aerospan 17.8g (2 inhalers) per 30 days
Afrezza 4 unit
30-4 unit + 60-8 unit 60-4 unit + 30-8 unit
60-8 unit + 30-12 unit Titration pack
180 cartridges (2 kits) per 28 days 360 cartridges (4 kits) per 28 days 360 cartridges (4 kits) per 28 days 360 cartridges (4 kits) per 28 days 180 cartridges (1 kit) per 28 days
Allegra 30mg/5ml oral susp
300ml per 30 days
Alsuma 4 units per 28 days
Amitiza
Anoro Ellipta
60 capsules per 30 days 60 blister packs per 30 days
Anzemet 50mg 100mg
8 tablets per fill 4 tablets per fill
Aplenzin 30 tablets per 30 days
Aptiom 200mg, 400mg
600mg, 800mg
30 tablets per 30 days 60 tablets per 30 days
Arcapta 30 capsules per 30 days
Arnuity Ellipta 30 blister packs per 30 days
Atelvia
Auryxia
4 tablets per 28 days 12 tablets per day
Avidoxy 60 tablets per 30 days
Axert 12 tablets per 30 days
Banzel 200mg 400mg 40mg/ml suspension
480 tablets per 30 days 240 tablets per 30 days 2400ml per 30 days
Belsomra 30 tablets per 30 days
Benoxyldoxy 1 kit per 30 days
Brisdelle
Briviact tablet oral solution
30 capsules per 30 days 60 tablets per 30 days 600mL per 30 days
Brovana 120mL per 30 days
Bupap 180 tablets per 30 days
MedPerform High Formulary
37014 MedPerform High Formulary – April 2017 23
Cambia 9 packets per 30 days
Caverject 1 dose per 5 days
Cesamet 180 capsules per 30 days
Chantix 56 tablets per 28 days
Cialis 2.5mg, 5mg
10mg, 20mg
30 tablets per 30 days 6 tablets per 30 days
Clarinex
2.5mg, 5mg reditab 5mg 5mg/10ml syrup
30 tablets per 30 days 30 tablets per 30 days 300ml per 30 days
Clarinex-D 12 hour 60 tablets per 30 days
Clarinex-D 24 hour 30 tablets per 30 days
Climara Pro 4 patches per 30 days
Clozapine ODT
Conzip
90 tablets per 30 days 30 capsules per 30 days
Cosopt PF 60 droperettes per 30 days
Daytrana 30 patches per 30 days
Demerol solution
tablets
900mL per 30 days 180 tablets per 30 days
Depo-Provera 1mL per 84 days
Depo-subQ Provera 104 0.65mL per 84 days
DermasilkRx SDS 1 kit per 30 days
Desoxyn 150 tablets per 30 days
Desvenlafaxine ER (fumarate)
30 tablets per 30 days
D.H.E.45 30 ampules per 28 days
Diclegis
Doryx 50mg
200mg
120 tablets per 30 days 60 tablets per 30 days 30 tablets per 30 days
Doryx MPC 120mg tablets
Dyanavel XRs
60 tablets per 30 days 240mL per 30 days
Dymista 23g (1 bottle) per 30 days
Edex 1 dose per 5 days
Embeda 20-0.8mg, 30-1.2mg, 50-2mg, 60-2.4mg, 80-3.2mg
100-4mg
2 capsules per day 4 capsules per day
Emsam 30 patches per 30 days
Entresto 60 tablets per 30 days
Epaned 1200mL (8 bottles) per 30 days
Ergomar SL 40 tablets per 28 days
Esomeprazole Strontium 24.65mg 49.3mg
30 capsules per 30 days 120 capsules per 30 days
Estring 1 ring per 90 days
Fanapt Tablets Titration Pack
60 tablets per 30 days 1 pack per 28 days
Fazaclo 90 tablets per 30 days
Felbatol 400mg 600mg 600mg/5ml solution
270 tablets per 30 days 180 tablets per 30 days 900mL per 30 days
Firmagon 80mg/vial 1 vial per 30 days
Firmagon 120mg/vial 2 vials per 365 days
Foradil 60 capsules per 30 days
Frova 18 tablets per 30 days
Fulyzaq 60 tablets per 30 days
Fycompa 2mg 4mg, 6mg 8mg, 10mg, 12mg 0.5mg/mL suspension
120 tablets per 30 days 60 tablets per 30 days 30 tablets per 30 days 680mL (2 bottles) per 28 days
Gabitril 2mg, 4mg, 12mg 16mg
120 tablets per 30 days 90 tablets per 30 days
Granisol solution 60mL per 30 days
Hemangeol 360mL (3 bottles) per 30 days
Hydrocodone bit/ acetaminophen
(max 4gm per day)
Incruse Ellipta 30 blisters per 30 days
Intuniv 30 tablets per 30 days
Invega 1.5mg, 3mg, 9mg 6mg
30 tablets per 30 days 60 tablets per 30 days
Iprivask 6 syringes per 30 days
Kapvay 120 tablets per 30 days
Karbinal ER 960mL (2 bottles) per 30 days
Kytril 8 tablets per 30 days
Lamictal ODT 25mg, 50mg 100mg
200mg
180 tablets per 30 days 90 tablets per 30 days 60 tablets per 30 days
Lamictal XR 25mg, 50mg 100mg 200mg, 250mg, 300mg
180 tablets per 30 days 90 tablets per 30 days 60 tablets per 30 days
Lescol 60 tablets per 30 days
Liptruzet 30 tablets per 30 days
LoSeasonique 91 tablets per 84 days
Luvox CR 60 capsules per 30 days
Luzu 60g (1 tube) per 28 days
Menostar 4 patches per 30 days
Migranal 8 vials per 28 days
Mirapex ER 30 tablets per 30 days
Mitigare 60 capsules per 30 days
Moban 25mg 10mg 5mg
270 tablets per 30 days 240 tablets per 30 days 120 tablets per 30 days
Mondoxyne NL 50mg, 75mg, 100mg
Monodox 50mg, 75mg, 100mg
Muse
60 capsules per 30 days 60 capsules per 30 days 1 dose per 5 days
Myalept 11.3mg vial 30 vials per 30 days
Nicotrol cartridge 1008 cartridges (6 inhalers) per 90 days
Nicotrol NS 160mL (4 packs) per 90 days
Obredon 600mL per 10 days
Oleptro ER 150mg 300mg
45 tablets per 30 days 30 tablets per 30 days
Onfi Tablets (5mg, 10mg, 20mg) Suspension (2.5 mg/mL)s
60 tablets per 30 days 480mL per 30 days
Opana ER 5mg,7.5mg,10mg,15mg,
20mg 30mg, 40mg
60 tablets per 30 days 120 tablets per 30 day
Oracea 30 capsules per 30 days
Osphena 30 tablets per 30 days
Oxycodone HCl/acetaminophen (maximum of 4gm acetaminophen per day):
300mg 325mg
13 tablets per 1 day supply 12 tablets per 1 day supply
Oxtellar XR 150mg, 300mg
600mg
30 tablets per 30 days 120 tablets per 30 days
Patanase 30.5g (1 bottle) per 30 days
Pradaxa 60 capsules per 30 days
Procentra
Qbrelis
1800mL per 30 days 1200mL (8 bottles) per 30 days
Qudexy XR 25mg, 50mg, 100mg 150mg, 200mg
30 capsules per 30 days 60 capsules per 30 days
Quillichew 20mg, 40mg 30mg
1 tablet per day 2 tablets per day
Rasuvo
MedPerform High Formulary
37014 MedPerform High Formulary – April 2017 24
7.5mg/0.15mL 10mg/0.2mL 12.5mg/0.25mL 15mg/0.3mL 17.5mg/0.35mL 22.5mg/0.46mL 25mg/0.5mL 27.5mg/0.55mL 30mg/0.6mL
1.6mL (4 syringes) per 28 days 0.8mL (4 syringes) per 28 days 1mL (4 syringes) per 28 days 1.2mL (4 syringes) per 28 days 1.4mL (4 syringes) per 28 days 1.8mL (4 syringes) per 28 days 2mL (4 syringes) per 28 days 2.2mL (4 syringes) per 28 days 2.4mL (4 syringes) per 28 days
Razadyne Tablets Solution
60 tablets per 30 days 200mL (2 bottles) per 30 days
Razadyne ER 30 capsules per 30 days
Relenza 2 boxes (#20 diskhalers/box) per 183 days
Relpax 12 tablets per 30 days
Rescula 10mL (2 bottles) per 30 days
Rhinocort Aqua 17.2g (2 canisters) per 30 days
Risperdal/Risperdal M-Tab 60 tablets per 30 days
Rubraca 120 tablets per 30 days
Rytary 300 capsules per 30 days
Ryzodeg 70/30 30mL (10 pens) per 28 days
Sabril 180 tablets per 30 days
Samsca 15mg tablets 30mg tablets
30 tablets per 365 days 60 tablets per 365 days
SanadermRX 1 kit per 30 days
Sancuso 4 patches per 28 days
Savaysa 30 tablets per 30 days
Seasonique 91 tablets per 84 days
Seroquel XR 30 tablets per 30 days
Silenor 30 tablets per 30 days
Sitavig 4 tablets per 365 days
Solodyn 30 tablets per 30 days
Sotylize 250mL 480mL
2000mL (8 bottles) per 30 days 3840mL (8 bottles) per 30 days
Spritam 250/500/750mg 1000mg
120 tablets per 30 days 60 tablets per 30 days
Sprix 5 bottles per 30 days
Sumavel DosePro 4 units per 28 days
Targadox
Tasmar
120 tablets per 30 days 90 tablets per 30 days
Timoptic Ocudose 60 droperettes per 30 days
Trezix 10 capsules per day
Trulance
Tuzistra XR
30 tablets per 30 days 600mL per 30 days
Varubi 2 tablets per 14 days
Veltassa
Vemlidy
Versacloz
1 packet per day 30 tablets per 30 days 540mL per 30 days
Vytorin 30 tablets per 30 days
Xartemis XR 360 tablets per 30 days
Xerese 10gm (2 tubes) per 365 days
Xifaxan 200mg 9 tablets per fill
Xodol 5-300mg
Xyzal solution
13 tablets per 1 day supply 300mL per 30 days
Zamicet Soln 325mg/15ml
Zecuity
184mL per 1 day supply 1 carton per 28 days
Zegerid Packets Capsules
30 packets per 30 days 30 capsules per 30 days
Zelapar 60 tablets per 30 days
Zohydro ER 60 capsules per 30 days
Zontivity 30 tablets per 30 days
Zyclara 2.5% 3.75% pump 3.75% packet
7.5 grams (1 bottle) per 28 days 7.5 grams (1 bottle) per 28 days 28 packets per 28 days
6. STEP THERAPY EDITS (FORMULARY)
Abilify Discmelt Abilify Solution
Trial of two generic SSRI’s, SNRIs or generic atypical anti-psychotics (risperidone, olanzapine, ziprasidone, quetiapine or aripiprazole tablets) within the past 365 days.
Actoplus Met Actoplus Met XR
Trial of metformin, metformin ER, sulfonylurea (e.g., glyburide, glipizide) or pioglitazone within the past 120 days
Ambien CR Trial of Ambien IR within the past 180 days
Astepro Trial of Astelin (azelastine) within the past 120 days
Avodart Trial of Proscar, alfuzosin, doxazosin, prazosin, silodosin, tamsulosin or terazosin within the past 120 days
Azor Trial of ACE inhibitor, ACE inhibitor combination, formulary generic ARB, or formulary generic ARB combination within the past 120 days
Benicar Benicar HCT
Trial of ACE inhibitor, ACE inhibitor combination, formulary generic ARB, or formulary generic ARB combination within the past 120 days
Daliresp Trial of Spiriva, Serevent, Breo Ellipta, Advair Diskus, or Dulera within the past 120 days
Desvenlafaxine ER (Ranbaxy Brand)
Trial of two of the following: paroxetine, fluoxetine, citalopram, sertraline, escitalopram, mirtazapine, bupropion, venlafaxine IR/ER within the past 365 days
Detrol Detrol LA
Trial of oxybutynin or oxybutynin ER within the past 120 days
Dificid Trial of vancomycin capsules within the past 120 days
Dovonex Trial of a topical corticosteroid within the past 120 days
Drithocreme HP Trial of a topical corticosteroid within the past 120 days
Duetact
Elidel
Trial of metformin, metformin ER, sulfonylurea (e.g., glyburide, glipizide) or pioglitazone within the past 120 days Trial of a topical corticosteroid within the past 120 days
Epiduo, Epiduo Forte
Trial of adapalene 0.1% gel within the past 120 days
Exforge, Exforge HCT
Trial of ACE inhibitor, ACE inhibitor combination, formulary generic ARB, or formulary generic ARB combination within the past 120 days
Fenoglide
Fetzima
Trial of gemfibrozil or generic fenofibrate within the past 120 days Trial of two of the following; paroxetine, fluoxetine, citalopram, sertraline, escitalopram, mirtazapine, bupropion or venlafaxine IR/ER within the past 365 days
Gianvi Trial of two different non-drospirenone oral contraceptives (containing levonorgestrel, norethindrone, norgestimate, norgestrel, desogestrel, or ethinynodiol ace.) within the past 365 days.
Glyxambi Trial of metformin (IR/ER), a sulfonylurea, pioglitazone or a combination product containing any two of the three agents above within the past 120 days.
Invokamet Trial of metformin (IR/ER), a sulfonylurea, pioglitazone or a combination product containing any two of the three agents above within the past 120 days.
Invokamet XR Trial of metformin (IR/ER), a sulfonylurea, pioglitazone or a combination product containing any two of the three agents above within the past 120 days.
Invokana Trial of metformin (IR/ER), a sulfonylurea, pioglitazone or a combination product containing any two of the three agents above within the past 120 days.
MedPerform High Formulary
37014 MedPerform High Formulary – April 2017 25
Jalyn Trial of finasteride 5mg, alfuzosin, doxazosin, prazosin, tamsulosin or terazosin within the past 120 days
Jardiance Trial of metformin (IR/ER), a sulfonylurea, pioglitazone, or a combination product containing any two of the three agents above within the past 120 days.
Latuda
Loestrin FE
Trial of two generic atypical anti-psychotics, risperidone, olanzapine, ziprasidone, quetiapine, clozapine, or aripiprazole in the past 365 days Trial of one generic contraceptive within the past 120 days
Loestrin FE24 Trial of two generic oral contraceptives within the past 365 days
Lo Loestrin FE Trial of two generic oral contraceptives within the past 365 days
Loryna Trial of two different non-drospirenone oral contraceptives (containing levonorgestrel, norethindrone, norgestimate, norgestrel, desogestrel, or ethinynodiol ace.) within the past 365 days.
Marinol Trial of ondansetron, corticosteroids and Emend within the past 365 days
Methadone HCl injection solution
Trial of lower strength oral methadone tablets or solution within the past 120 days
Myrbetriq Trial of oxybutynin IR/ER within the past 120 days
Neupro Trial of pramipexole IR or ropinirole IR within the past 120 days
Nexium Nexium Suspension
Trial of omeprazole, lansoprazole or pantoprazole within the past 120 days
Namzaric Trial of donepezil and memantine within the past 365 days
Niaspan Trial of generic/multisource statin (atorvastatin, lovastatin, pravastatin, or simvastatin), or generic/multisource gemfibrozil or fenofibrate within the past 365 days
Ocella Trial of two different non-drospirenone oral contraceptives (containing levonorgestrel, norethindrone, norgestimate, norgestrel, desogestrel, or ethinynodiol ace.) within the past 365 days.
Onexton
Otrexup
Trial of generic benzaclin gel required within the past 120 days Trial of methotrexate tablet or solution for injection within the past 120 days
Prevacid Solutabs Trial of lansoprazole, omeprazole or pantoprazole within the past 120 days
Pristiq Trial of two of the following: generic paroxetine, fluoxetine, citalopram, sertraline, escitalopram, mirtazapine, bupropion, or venlafaxine IR/ER within the past 365 days
Potiga
Protonix Suspension
Trial of two of the following: carbamazepine, gabapentin, lamotrigine, levetiracetam IR or ER, oxcarbazepine, valproic acid, divalproex, topiramate, or zonisamide within the past 365 days Trial of Prilosec OTC or omeprazole within the past 120 days
Purixan Trial of mercaptopurine tablet within the past 120 days
Qnasl Trial of fluticasone or flunisolide within the past 120 days
Qnasl Children Trial of fluticasone or flunisolide within the past 120 days
Quillivant XR Trial of Metadate CD or Ritalin LA within the past 120 days
Requip XL Trial of pramipexole IR or ropinirole IR within the past 120 days
Rexulti
Trial of two generic atypical antipsychotics , SSRIs or SNRIs within the past 365 days
Sanctura Trial of oxybutynin or oxybutynin ER within the past 120 days
Saphris
Syeda
Trial of two generic atypical antipsychotics within the past 365 days Trial of two different non-drospirenone oral contraceptives (containing levonorgestrel, norethindrone, norgestimate, norgestrel, desogestrel, or ethinynodiol ace.) within the past 365 days.
Synjardy Trial of metformin (IR/ER), a sulfonylurea, pioglitazone, or a combination product containing any two of the three agents above within the past 120 days.
Tribenzor
Trintellix
Trial of ACE inhibitor, ACE inhibitor combination, formulary generic ARB or ARB combination within the past 120 days Trial of two of the following generic/multisource products: paroxetine, venlafaxine ER or IR, fluoxetine, citalopram, sertraline, escitalopram, mirtazapine or bupropion within the past 365 days
Toviaz Trial of oxybutynin or oxybutynin ER within the past 120 days
Triglide
Trokendi XR
Trial of gemfibrozil or generic fenofibrate within the past 120 days Trial of topiramate IR within the past 120 days
Trulicity Trial of metformin (IR/ER), a sulfonylurea, pioglitazone or a combination product containing any two of the three agents above within the past 120 days.
Uloric Trial of allopurinol within the past 120 days
Vectical Trial of a topical corticosteroid within the past 120 days
Vesicare Trial of oxybutynin or oxybutynin ER within the past 120 days
Vestura Trial of two different non-drospirenone oral contraceptives (containing levonorgestrel, norethindrone, norgestimate, norgestrel, desogestrel, or ethinynodiol ace.) within the past 365 days.
Vibra-Tabs
Viibryd
Trial of generic doxycycline monohydrate capsules within the past 120 days Trial of two of the following: paroxetine, fluoxetine, citalopram, sertraline, escitalopram, mirtazapine, bupropion, venlafaxine IR/ER within the past 365 days
Victoza
Trial of metformin (IR/ER), a sulfonylurea, pioglitazone or a combination product containing any two of the three agents above within the past 120 days.
Vimpat
Vimpat oral solution
Trial of two of the following: carbamazepine, gabapentin, lamotrigine, levetiracetam IR or ER, oxcarbazepine, valproic acid, divalproex, topiramate or zonisamide within the past 365 days
Vraylar
Vyvanse
Trial of two generic atypical antipsychotics within the past 365 days Trial of one of the following: SSRI (sertraline, escitalopram, citalopram, fluoxetine, fluvoxamine, paroxetine), topiramate, generic/multisource mixed amphetamine salts (Adderall IR/XR), or methylphenidate (IR, ER, LA, CD) within the past 120 days.
Yasmin 28 Trial of two different non-drospirenone oral contraceptives (containing levonorgestrel, norethindrone, norgestimate, norgestrel, desogestrel, or ethinynodiol ace.) within the past 365 days.
Yaz Trial of two different non-drospirenone oral contraceptives (containing levonorgestrel, norethindrone, norgestimate, norgestrel, desogestrel, or ethinynodiol ace.) within the past 365 days.
Zarah Trial of two different non-drospirenone oral
MedPerform High Formulary
37014 MedPerform High Formulary – April 2017 26
contraceptives (containing levonorgestrel, norethindrone, norgestimate, norgestrel, desogestrel, or ethinynodiol ace.) within the past 365 days.
Zenzedi (2.5mg, 7.5mg)
Trial of a multisource Dextroamphetamine sulfate tablet or dextroamphetamine solution within the past 120 days
Zocor (80mg only) Trial of simvastatin 80mg or Vytorin 10/80mg within the past 365 days
Zolpidem ER Trial of zolpidem IR within the past 120 days.
Zomig Zomig ZMT
Trial of sumatriptan or rizatriptan within the past 180 days
Zurampic Trial of allopurinol or Uloric (febuxostat) within the past 120 days
7. STEP THERAPY EDITS (NON FORMULARY)
Absorica Trial of generic isotretinoin within the past 120 days
Acanya
Aciphex
Trial of generic benzaclin gel required within the past 120 days Trial of two of the following; omeprazole, lansoprazole or pantoprazole or rabeprazole within the past 365 days
Aciphex Sprinkle Trial of two of the following; omeprazole, lansoprazole, pantoprazole or rabeprazole within the past 365 days
Acticlate 75mg Trial of generic doxycycline monohydrate 75mg tablets within the past 120 days
Acticlate 150mg
Actonel
Trial of generic doxycycline monohydrate 150mg tablets within the past 120 days Trial of alendronate and ibandronate within the past 365 days
Adzenys XR-ODT Trial of Adderall XR in the past 120 days
Aerospan Trial of at least two of the following: QVAR, Asmanex or Pulmicort within the past 365 days
Amitiza
Anoro Ellipta
Trial of Linzess or Movantik within the past 120 days. Trial of Stiolto Respimat and one of the following: Spiriva, Striverdi or Serevent within the past 365 days
Anzemet Trial of ondansetron tablets or ODT within the past 120 days
Aplenzin Trial of bupropion HCl SR or XL within the past 120 days
Aptiom Trial of two of the following; carbamazepine, gabapentin, lamotrigine, levetiracetam IR or ER, oxcarbazepine, valproic acid or divalproex, topiramate, or zonisamide within the past 365 days
Arcapta Trial of Serevent Diskus or Striverdi Respimat within the past 120 days
Arnuity Ellipta Trial of at least two of the following: Asmanex, Pulmicort, or QVAR within the past 365 days
Atelvia Trial of alendronate and ibandronate within the past 365 days
Avandia/ Avandaryl/ Avandamet
Trial of metformin (IR/ER), a sulfonylurea, pioglitazone, or a combination product containing any two of the three agents above within the past 120 days.
Axert Trial of sumatriptan or rizatriptan within the past 180 days
Banzel Trial of lamotrigine, valproic acid or topiramate within the past 120 days
Belsomra Trial of zolpidem IR (Ambien), zaleplon (Sonata) or eszopiclone (Lunesta) within the past 120 days
Benoxyldoxy Trial of generic doxycycline monohydrate 100mg capsules within the past 120 days
Beyaz Trial of two different non-drospirenone oral contraceptives (containing levonorgestrel, norethindrone, norgestimate, norgestrel, desogestrel, or ethinynodiol ace.) within the past 365 days
Bravelle Trial of Gonal-F or Gonal-F-RFF required within the past 120 days
Brisdelle
Briviact
Trial of paroxetine or venlafaxine within the past 120 days Trial of two of the following: carbamazepine, gabapentin, lamotrigine, levetiracetam IR or ER, oxcarbazepine, valproic acid or divalproex, topiramate, or zonisamide within the past 365 days
Bupap Trial of generic butalbital/acetaminophen combination product required within the last 120 days
Cesamet Trial of ondansetron tablet or ODT within the past 120 days
Clarinex Reditabs/ Clarinex syrup/ Clarinex D
Trial of desloratadine or levocetirizine tablet within the past 120 days
Clindagel
Clozapine ODT
Conzip
Trial of generic clindamycin gel required within the past 120 days Trial of 2 of the following: olanzapine, quetiapine, risperidone, or ziprasidone in the past 365 days. Trial of tramadol ER (Ultram ER) within the past 120 days
Cosopt PF Trial of dorzolamide/timolol within the past 120 days
Cycloset Trial of metformin (Glucophage), metformin ER, glyburide/metformin (Glucovance), or glipizide/metformin (Metaglip) within the past 180 days
Daytrana Trial of methylphenidate CD, ER, or LA formulation or methylphenidate suspension/solution within the past 120 days
DermasilkRx SDS Trial of all three individual ingredients: triamcinolone 0.1% (RX), dimethicone 5% (OTC) and silicone tape (OTC) within the past 365 days
Desvenlafaxine ER (fumarate)
Trial of two of the following; generic paroxetine, fluoxetine, citalopram, sertraline, escitalopram, venlafaxine ER or IR, mirtazapine or bupropion within the past 365 days
Doryx 50mg tabs
Doryx 200mg tabs
Doryx MPC 120mg tablets
Trial of generic doxycycline monohydrate 50mg capsule or tablet or doxycycline hyclate 50mg capsule within the past 120 days Trial of generic doxycycline hyclate 100mg tablets/capsules or doxycycline monohydrate 100mg tablets or capsules within the past 120 days Trial of generic doxycycline hyclate 100mg tablets /capsules or doxycycline monohydrate 100mg tablets or capsules within the past 120 days
Dyanavel XR Trial of extended-release amphetamine/dextroamphetamine oral capsules within the past 120 days
Dymista Trial of fluticasone or flunisolide within the past 365 days
Edarbi Trial of ACE inhibitor, ACE inhibitor combination, formulary generic ARB, or formulary generic ARB combination within the past 120 days
Edarbyclor Trial of ACE inhibitor, ACE inhibitor
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37014 MedPerform High Formulary – April 2017 27
combination, formulary generic ARB, or formulary generic ARB combination within the past 120 days
Enstilar Trial of topical corticosteroid within the past 120 days
Epaned If age ≥ 12 years, trial of enalapril tablets within the past 120 days
Esomeprazole Strontium
Trial of omeprazole, lansoprazole or pantoprazole within the past 120 days
Eucrisa Trial of topical corticosteroid and Elidel required within the past 365 days
Fanapt Trial of two generic atypical antipsychotics within the past 365 days
Fazaclo Trial of two generic atypical antipsychotics within the past 365 days
Felbatol
Trial of lamotrigine or topiramate within the past 120 days
Follistim AQ Trial of Gonal-F or Gonal-F-RFF required within the past 120 days
Foradil Trial of Serevent Diskus or Striverdi Respimat within the past 120 days
Fortamet Trial of generic metformin ER (Glucophage XR) within the past 120 days
Frova Trial of sumatriptan or rizatriptan within the past 180 days
Fulyzaq Trial of antiretroviral therapy within the past 120 days
Fycompa tablets and suspension
Trial of two of the following: carbamazepine, gabapentin, lamotrigine, levetiracetam IR or ER, oxcarbazepine, valproic acid, divalproex, topiramate or zonisamide within the past 365 days
Gabitril Trial of two of the following: carbamazepine, gabapentin, lamotrigine, levetiracetam IR or ER, oxcarbazepine, valproic acid, divalproex, topiramate or zonisamide within the past 365 days
Giazo Trial of balsalazide or Apriso within the past 120 days
Hemangeol For age over 1 year, trial of generic propranolol oral solution within the past 120 days
Incruse Ellipta Trial of preferred LAMA (Spiriva) within the past 120 days
Inderal XL Trial of Inderal LA within the past 120 days
Innopran XL Trial of Inderal LA within the past 120 days
Invega Trial of two generic atypical antipsychotics within the past 365 days.
Karbinal ER Trial of generic immediate-release carbinoxamine maleate within the past 120 days
Kytril Trial of ondansetron tablets or ODT within the past 120 days
Lamictal ODT/XR Trial of lamotrigine IR within the past 120 days
Lescol/XL Trial of two of the following: atorvastatin, lovastatin, pravastatin or simvastatin within the past 365 days
Liptruzet 10/10mg 10/20mg, 10/40mg, 10/80mg
Trial of 2 of the following: atorvastatin, simvastatin, pravastatin or lovastatin within the past 365 days Trial of 40mg atorvastatin or 80mg atorvastatin within the past 120 days
Loestrin 24 Fe Trial of two generic oral contraceptives within the past 365 days
Luvox CR Trial of generic paroxetine, fluoxetine, citalopram, sertraline, escitalopram, mirtazapine, or fluvoxamine IR within the past 120 days
Luzu Trial of ketoconazole and clotrimazole cream within the past 365 days
Mirapex ER Trial of pramipexole IR or ropinirole IR within the past 120 days
Moderiba Dosepak Trial of ribavirin 200mg capsule or tablet within the past 120 days
Natazia Trial of two generic oral contraceptives within the past 365 days
Neo-Synalar Trial of fluocinolone and bacitracin within the past 365 days
Obredon Trial of hydrocodone/homatropine methylbromide within the past 120 days
Oleptro ER Trial of immediate release trazodone within the past 120 days
Onfi Trial of lamotrigine or topiramate within the past 120 days
Oracea Trial of generic doxycycline monohydrate 50mg capsule within the past 120 days
Ovace Plus Lotion Trial of ketoconazole shampoo/cream or ciclopirox shampoo/gel within the past 120 days
Oxtellar XR Trial of two of the following: carbamazepine, gabapentin, lamotrigine, levetiracetam IR or ER, oxcarbazepine, valproic acid, divalproex, topiramate, or zonisamide within the past 365 days
Patanase Trial of Astelin (azelastine) within the past 120 days
Pradaxa Trial of Eliquis and Xarelto within the past 365 days
Qbrelis If age ≥ 12 years, trial of lisinopril tablets within the past 120 days
Qudexy XR Trial of topiramate immediate release within the past 120 days
Quillichew Trial of Ritalin LA or Metadate CD within the past 120 days
Rapaflo Trial of finasteride 5mg, alfuzosin, doxazosin, prazosin, tamsulosin or terazosin within the past 120 days
Rasuvo Trial of Otrexup and methotrexate tablet or solution for injection within the past 365 days.
Relpax Trial of sumatriptan or rizatriptan within the past 180 days
Rescula Trial of latanoprost and Lumigan or Travatan Z within the past 365 days
Retin-A Micro Pump 0.08%
Trial of generic tretinoin microspheres 0.04% AND generic tretinoin microspheres 0.10% within the past 365 days
Rhinocort Aqua Trial of fluticasone or flunisolide within the past 365 days
Ribasphere 400mg, 600mg, RibaPak
Trial of ribavirin 200mg capsule or tablet within the past 120 days
Rytary Trial of Sinemet IR or CR within the past 120 days
Ryzodeg 70/30 Trial of preferred long acting insulin and preferred pre-mixed insulin) within the past 365 days
Safyral Trial of two different non-drospirenone oral contraceptives (containing levonorgestrel, norethindrone, norgestimate, norgestrel, desogestrel, or ethinynodiol ace.) within the past 365 days.
Savaysa Trial of Eliquis and Xarelto within the past 365 days
SanadermRX Trial of all three individual ingredients: triamcinolone 0.1% (RX), dimethicone 5% (OTC) and silicone tape (OTC) within the past 365 days
Sernivo Trial of Kenalog (triamcinolone acetonide) 0.147mg/g spray within the past 120 days
Seroquel XR Trial of two generic atypical anti-psychotics, SSRIs, or SNRIs within the past 365 days
Sancuso Trial of ondansetron tablet or ODT within the past 120 days
Silenor Trial of zolpidem IR (Ambien), zaleplon (Sonata) or eszopiclone (Lunesta) within
MedPerform High Formulary
37014 MedPerform High Formulary – April 2017 28
the past 120 days Sitavig Trial of oral acyclovir, valacyclovir or
famciclovir within the past 120 days Solodyn Trial of generic minocycline immediate
release within the past 120 days Sorilux Trial of a topical corticosteroid within
the past 120 days Sotylize Trial of sotolol tablets within the past
120 days Spritam Trial of generic levetiracetam 100mg/mL
solution required within the last 120 days Sumavel Dose-Pro Trial of generic/multisource injectable
sumatriptan or nasal sumatriptan (Imitrex or equivalent) within the past 180 days
Taclonex Taclonex Scalp
Trial of a topical corticosteroid within the past 120 days
Targadox Trial of generic doxycycline monohydrate 50mg capsule or generic doxycycline hyclate 50mg capsule within the past 120 days
Tasmar Trial of Comtan within the past 120 days
Teveten Teveten HCT
Trial of ACE inhibitor, ACE inhibitor combination, formulary generic ARB, or formulary generic ARB combination within the past 120 days
Timoptic Ocudose Trial of timolol drops within the past 120 days
Topicort Spray
Trial of mometasone 0.1% ointment, fluocinonide 0.05% cream/ointment/ gel, desoximetasone 0.25% cream, or betamethasone dipropionate 0.05% cream within the past 120 days
Trulance
Tuzistra XR
Trial of Linzess within the past 120 days Trial of promethazine with codeine syrup within the past 120 days
Uceris rectal foam Trial of mesalamine enema within the past 120 days
Uceris tablet Trial of balsalazide within the past 120 days
Versacloz Trial of two generic atypical antipsychotics within the past 365 days.
Vytorin: 10/10mg
Trial of two of the following: atorvastatin, lovastatin, pravastatin or simvastatin within the past 365 days
10/20mg, 10/40mg Trial of atorvastatin 40mg or atorvastatin 80mg within the past 120 days
10/80mg Trial of simvastatin 80mg or Vytorin 10/80mg within the past 365 days
Xerese Trial of oral acyclovir, valacyclovir or famciclovir within the past 120 days
Xyzal Solution Trial of desloratadine or levocetirizine tablet within the past 120 days
Zecuity Trial of generic/multisource sumatriptan and nasal sumatriptan within the past 365 days
Zegerid Trial of omeprazole, lansoprazole or pantoprazole within the past 120 days
Zithranol Zithranol RR
Trial of a topical corticosteroid within the past 120 days
8. PRIOR AUTHORIZATION RESTRICTIONS (FORMULARY) Actiq Adcirca Adempas Afinitor /Afinitor Disperz Aldara Alecensa Androgel Avonex Avonex Admin Pack Axiron Bosulif
Cabometyx Cayston
Cometriq
Copaxone
Corlanor
Cosentyx
Cotellic
Cystaran
Daraprim
Delatestryl
Depen
Depo-Testosterone
Duragesic
Eligard
Emverm
Enbrel
Epclusa
Erivedge
Esbriet
Fareston Farydak Firazyr Gattex Gilenya Gilotrif Gleevec
Grastek
Harvoni
Humira Ibrance Iclusig Imbruvica
Impavido Inlyta
Intron A Iressa Jakafi
Juxtapid
Kalydeco
Keveyis Korlym
Kynamro
Lenvima
Letairis
Leukine Lonsurf Lynparza Mekinist Neulasta Neupogen Nexavar
Ninlaro Norditropin Odomzo Ofev Omnitrope Opsumit Oralair Orfadin Orkambi Pegasys Plegridy Plegridy Pen Pomalyst
Praluent Procrit Procysbi Promacta Provigil Pulmozyme
Ragwitek
Rebif
Rebif Rebidose
Repatha Revatio tablets
MedPerform High Formulary
37014 MedPerform High Formulary – April 2017 29
Revlimid Sivextro Sovaldi Sprycel Stivarga
Stelara SC
Strensiq Suboxone Subutex Sutent Tafinlar Tagrisso
Tarceva Targretin Tasigna Tecfidera Temodar capsules Thalomid Tobi Tobi Podhaler Tracleer Tykerb
Uptravi Valchlor
Venclexta Votrient Xalkori
Xeljanz
Xeljanz XR Xeloda Xenazine Xifaxan 550mg Xtandi
Xuriden Zelboraf
Zubsolv Zydelig Zykadia Zytiga Zyvox
9. PRIOR AUTHORIZATION RESTRICTIONS (NON FORMULARY) Abraxane* Actemra IV* Actemra SC
Adcetris*
Addyi
Afrezza
Alimta*
Ampyra
Amturnide
Anadrol-50
Androderm
Apokyn
Aranesp
Arzerra*
Aubagio
Avastin*
Beleodaq*
Belviq
Belviq XR
Berinert
Betaseron
Bethkis
Bivigam*
Blincyto*
Botox*
Bunavail
Caprelsa
Carimune NF Nanofiltered*
Cerezyme*
Cholbam
Cialis
Cinqair
Cinryze
Contrave
Cuprimine
Cuvitru
Cyramza*
Darzalex*
Duopa
Dysport*
Egrifta
Elelyso*
Elspar*
Empliciti*
Entresto
Entyvio*
Epogen
Erbitux*
Erwinase*
Euflexxa*
Evekeo
Exalgo
Exondys 51*
Eylea*
Faslodex*
Flebogamma DIF*
Flolan*
Gamastan S-D*
Gammagard Liquid
Gammagard S-D*
Gammaked
Gammaplex*
Gamunex-C
Gazyva*
Gleostine
Gel-One*
Granix*
H.P. Acthar*
Halaven*
Herceptin*
Hetlioz
Hizentra
Hyalgan*
Hymovis*
Hyqvia IG Component
Ilaris*
Imlygic*
Incivek
Increlex
Inflectra*
Iprivask
Istodax*
Ixempra*
Jublia
Kadcyla*
Kalbitor*
Kanuma*
Keytruda*
Kineret
Kitabis Pak
Kyprolis*
Lartruvo*
Lemtrada*
Lucentis*
Lumizyme*
Macugen*
Makena
Marqibo*
Mircera
MedPerform High Formulary
37014 MedPerform High Formulary – April 2017 30
Monovisc*
Mozobil*
M Myobloc*
N Natpara
N Neulasta Delivery Kit*
Northera
Novantrone*
Nucala*
Nuedexta
Nuplazid
Nutropin
Nuvigil
Nymalize
Ocaliva
Octagam*
Olysio
Opdivo*
Orencia IV*
Orencia SC
Orenitram ER
Orthovisc*
Otezla
Oxandrin
Pegintron
Pegintron Redipen
Perjeta*
Photofrin*
Portrazza*
Privigen*
Prolia*
P Provigil
Qutenza
Ravicti
Relistor
Remicade*
Remodulin
Revatio vial*
Revatio suspension
Rituxan*
Rubraca
Saxenda
Serostim
Signifor
Simponi SC
Simponi Aria IV*
Sirturo
Solaraze
Soliris*
Spinraza*
Stelara IV*
Stivarga
Striant
Sucraid
Supartz*
Suprenza ODT
Sylatron
Sylvant*
Synagis*
Synribo*
Synvisc*
Synvisc-One*
Taltz
Tecentriq*
Veltassa
Yervoy*
Yondelis*
Zaltrap*
Zarxio
Zavesca
Zepatier
Zoladex*
Zorbtive
Zyclara * = Dependent on plan benefit. If covered under pharmacy benefit, then
non-formulary with prior authorization
10. CONCURRENT USE EDITS (FORMULARY) Suboxone
Subutex
Zubsolv
11. CONCURRENT USE EDITS (NON FORMULARY) Bunavail
MedPerform High Formulary INDEX
37014 MedPerform High Formulary – April 2017 31
5-grass pollen extract ........................................... 6 8-MOP ................................................................ 10 abacavir sulfate ................................................ 15 abacavir sulfate/lamivudine ............................ 14 abacavir/dolutegravir/lamivudine ....................... 14 abacavir/lamivudine/zidovudine ..................... 14 ABBOTT DIABETIC SUPPLIES......................... 11 ABILIFY DISCMELT ............................................. 7 ABILIFY SOLUTION............................................. 7 ABILIFY TABLET ................................................. 7 abiraterone acetate ............................................ 16 acarbose ............................................................ 10 ACCUPRIL ........................................................... 8 ACCURETIC......................................................... 8 acebutolol hcl ..................................................... 8 acetaminophen with codeine .......................... 18 acetazolamide ................................................... 12 acetic acid ......................................................... 11 acetic acid/aluminum acetate ......................... 11 acetic acid/hydrocortisone .............................. 11 acetylcysteine ................................................... 17 acitretin .............................................................. 10 ACLOVATE ........................................................ 10 ACTIGALL .......................................................... 16 ACTIQ ................................................................. 17 ACTOPLUS MET ............................................... 11 ACTOPLUS MET XR ......................................... 11 ACTOS ............................................................... 11 ACULAR ............................................................. 12 ACULAR LS........................................................ 12 acyclovir ...................................................... 10, 14 ADALAT CC ......................................................... 8 adalimumab ........................................................ 15 adapalene .......................................................... 10 ADCIRCA ............................................................. 8 ADDERALL........................................................... 7 ADDERALL XR .................................................... 7 ADEMPAS ............................................................ 8 ADVAIR DISKUS .................................................. 6 ADVAIR HFA ........................................................ 6 afatinib ................................................................ 16 AFINITOR ........................................................... 17 AFTERA ............................................................... 9 AGRYLIN ............................................................ 13 AK-TRACIN ........................................................ 12 AKYNZEO ............................................................ 6 ALAMAST ........................................................... 12 ALA-TET ............................................................. 14 ALAWAY OTC .................................................... 12 albuterol sulfate .................................................. 6 ALBUTEROL SULFATE ....................................... 6 alclometasone dipropionate ........................... 10 ALDACTONE ....................................................... 8 ALDARA ............................................................. 13 ALDOMET ............................................................ 8 ALECENSA ........................................................ 16 alectinib hydrochloride........................................ 16 alendronate sodium ......................................... 12 alendronate sodium solution .......................... 12 alendronate sodium/vitamin d3 .......................... 11 alfuzosin ............................................................ 19 alirocumab ............................................................ 9 ALKERAN ........................................................... 16 allopurinol ......................................................... 13
ALOCRIL ............................................................ 12 ALOMIDE ........................................................... 12 ALORA ............................................................... 13 ALPHAGAN P .................................................... 12 alprazolam ........................................................... 7 ALPRAZOLAM INTENSOL .................................. 7 ALREX ................................................................ 12 ALTACE ................................................................ 8 altretamine .......................................................... 16 aluminum chloride ........................................... 10 ALUPENT ............................................................. 6 amantadine hcl ................................................. 18 AMARYL ............................................................. 11 AMBIEN ................................................................ 7 ambrisentan .......................................................... 8 amcinonide........................................................ 10 AMERGE ............................................................ 17 AMINOPHYLLIN ................................................... 6 aminophylline ..................................................... 6 amiodarone hcl ................................................... 7
amitriptyline hcl .................................................. 7 amlodipine bes/olmesartan med ...................... 8 amlodipine besylate ........................................... 8 amlodipine besylate/benazepril ........................ 8 amlodipine/atorvast cal ..................................... 9 amlodipine/valsartan.......................................... 8 amlodipine/valsartan/hctz ................................. 8 AMNESTEEM ....................................................... 9 amox tr/potassium clavulanate ...................... 14 amoxapine ........................................................... 7 amoxicillin trihydrate ....................................... 14 AMOXIL .............................................................. 14 amphet asp/amphet/d-amphet .......................... 7 ampicillin trihydrate ......................................... 14 amylase/lipase/protease .................................. 18 ANAFRANIL ......................................................... 7 anagrelide hcl ................................................... 13 ANALPRAM HC ................................................. 15 ANAPROX .......................................................... 15 ANAPROX DS .................................................... 15 ANASPAZ ........................................................... 18 anastrozole........................................................ 16 ANDROGEL ....................................................... 13 ANDROID ........................................................... 13 ANDROXY .......................................................... 13 ANSAID .............................................................. 15 ANTABUSE .......................................................... 7 anthralin .............................................................. 10 Antipsychotics, Atypical, D3/D2 Partial
Agonist/5HT Mixed ......................................... 7 antipyrine/benzocaine otic .................................. 11 ANTIVERT ............................................................ 6 ANUSOL-HC ...................................................... 16 APEXICON ......................................................... 10 APEXICON E ..................................................... 10 apixaban ............................................................. 13 aprepitant ............................................................ 6 APRESOLINE ...................................................... 8 APRISO .............................................................. 15 APTIVUS ............................................................ 14 ARALEN PHOSPHATE ...................................... 14 ARAVA ............................................................... 15 ARICEPT .............................................................. 6 ARICEPT ODT ..................................................... 6 ARIMIDEX .......................................................... 16 aripiprazole ......................................................... 7 ARIXTRA ............................................................ 13 ARMOUR THYROID .......................................... 12 AROMASIN ........................................................ 16 ARTANE ............................................................. 18 ASACOL ............................................................. 15 ASENDIN .............................................................. 7 asfotase alfa., STRENSIQ ................................. 17 ASMANEX ............................................................ 6 ASMANEX HFA .................................................... 6 ASTELIN ............................................................... 6 ASTEPRO ............................................................ 6 ATARAX ............................................................... 6 atazanavir sulfate ............................................... 15 atazanavir sulfate/cobicistat ............................... 15 atenolol ................................................................ 8 atenolol/chlorthalidone ...................................... 8 ATIVAN ................................................................. 7 atomoxetine hcl .................................................... 7 atorvastatin calcium........................................... 9 ATRIPLA ............................................................. 15 atropine sulfate ................................................. 13 ATROVENT .................................................... 6, 17 ATROVENT HFA .................................................. 6 AUGMENTIN ...................................................... 14 AUGMENTIN ES-600 ......................................... 14 AUGMENTIN XR ................................................ 14 AVALIDE .............................................................. 8 AVAPRO ............................................................... 8 AVC .................................................................... 19 AVELOX ............................................................. 14 AVELOX ABC PACK .......................................... 14 AVIANE-28 ........................................................... 9 AVINZA ............................................................... 17 AVLOSULFON ................................................... 14 AVODART .......................................................... 19 AVONEX ............................................................. 17 AVONEX ADMINISTRATION PACK ................. 17 AXID ................................................................... 18
AXIRON .............................................................. 13 axitinib ................................................................ 16 AYGESTIN ......................................................... 13 azathioprine ...................................................... 13 azelastine hcl ................................................ 6, 12 AZILECT ............................................................. 18 azithromycin ............................................... 13, 14 AZOPT ................................................................ 12 AZOR .................................................................... 8 aztreonam lysine ................................................ 13 AZULFIDINE....................................................... 15 bacitracin........................................................... 12 bacitracin/polymyxin b sulfate........................ 12 baclofen ............................................................. 18 BACTRIM DS ..................................................... 13 BACTROBAN ..................................................... 10 BACTROBAN NASAL ........................................ 17 balsalazide disodium ....................................... 15 BARACLUDE ..................................................... 15 becaplermin ........................................................ 11 beclomethasone dipropionate .............................. 6 belladonna alkaloids/phenobarb .................... 18 benazepril hcl ..................................................... 8 benazepril/hydrochlorothiazide ........................ 8 BENEMID ........................................................... 13 BENICAR .............................................................. 8 BENICAR HCT ..................................................... 8 BENTYL .............................................................. 18 BENZACLIN ......................................................... 9 BENZAMYCIN .................................................... 10 BENZAMYCIN PAK ............................................ 10 BENZOTIC ......................................................... 11 benzoyl peroxide .............................................. 10 benzoyl peroxide/hydrocortison ........................... 9 benztropine mesylate ...................................... 18 besifloxacin hcl drops susp 0.6% ....................... 12 BESIVANCE ....................................................... 12 BETAGAN .......................................................... 12 betamet diprop/prop gly .................................. 10
betamethasone dipropionate.......................... 6, 10 betamethasone valerate .................................. 10 BETAPACE .......................................................... 8 BETAPACE AF ..................................................... 8 betaxolol hcl ..................................................... 12 bethanechol chloride ....................................... 16 BETIMOL ............................................................ 12 BETOPTIC.......................................................... 12 BETOPTIC S ...................................................... 12 bexarotene.................................................... 10, 17 BIAXIN ................................................................ 13 BIAXIN XL .......................................................... 13 bicalutamide ..................................................... 16 BIDIL ..................................................................... 9 BILTRICIDE ........................................................ 14 bimatoprost 0.01% ............................................. 12 bimatoprost 0.03% ............................................. 12 bimonidine/timolol ............................................... 12 bisoprolol fumarate ............................................ 8 bisoprolol fumarate/hctz ................................... 8 BLEPHAMIDE .................................................... 12 BLEPHAMIDE S.O.P.......................................... 12 BLOCADREN ....................................................... 8 blood sugar diagnostic ....................................... 11 blood-glucose calib. control ................................ 11 blood-glucose meter ........................................... 11 BONIVA .............................................................. 12 bosentan ............................................................... 8 BOSULIF ............................................................ 16 bosutinib ............................................................. 16 BREO ELLIPTA .................................................... 6 BRETHINE ........................................................... 6 BREVOXYL-4 ..................................................... 10 BREVOXYL-8 ..................................................... 10 BRILINTA ........................................................... 13 brimonidine tartrate ......................................... 12 brinzolamide ....................................................... 12 brinzolamide/brimonidine ................................... 12 bromocriptine mesylate ................................... 18 budesonide ................................................... 6, 15 BUDESONIDE .................................................... 15 bumetanide ......................................................... 8 BUMEX ................................................................. 8 BUPHENYL POWDER ....................................... 16 BUPHENYL TABLET ......................................... 16
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buprenorphine .................................................... 17 bupropion hcl ..................................................... 6 BUSPAR ............................................................... 7 buspirone hcl ...................................................... 7 busulfan .............................................................. 16 butalb/acetaminophen/caffeine ...................... 17 butalbital/acetaminophen ................................ 17 butalbital/aspirin/caffeine ................................ 17 butoconazole nitrate ........................................... 19 BUTRANS .......................................................... 17 BYSTOLIC ............................................................ 8 BYVALSON .......................................................... 8 cabergoline ....................................................... 12 CABOMETYX ..................................................... 16 cabozanitinib ...................................................... 16 cabozantinib s-malate ........................................ 16 CADUET ............................................................... 9 CAFERGOT........................................................ 17 CALAN .................................................................. 8 CALAN SR............................................................ 8 calcipotriene ..................................................... 10 calcitriol ............................................................. 19 calcium acetate ................................................. 11 canagliflozin ........................................................ 11 canagliflozin/metformin hcl ................................. 11 CANASA ............................................................. 15 capecitabine ...................................................... 16 CAPITAL W-CODEINE ...................................... 18 CAPOTEN ............................................................ 8 CAPOZIDE ........................................................... 8 captopril .............................................................. 8 captopril/hydrochlorothiazide........................... 8 CARAFATE ........................................................ 18 carbachol ............................................................ 12 carbamazepine ................................................. 18
CARBATROL ..................................................... 18 carbidopa .......................................................... 18 carbidopa/levodopa ......................................... 18 carbidopa/levodopa/entacapone .................... 18 CARDENE ............................................................ 8 CARDIZEM ........................................................... 8 CARDIZEM CD .................................................... 8 CARDURA ............................................................ 8 carisoprodol ...................................................... 18 carisoprodol/aspirin ......................................... 18 CARMOL HC ...................................................... 10 carteolol hcl ...................................................... 12 carvedilol ............................................................. 8
carvedilol phosphate ............................................ 8 CASODEX .......................................................... 16 CATAPRES .......................................................... 8 CAYSTON .......................................................... 13 CECLOR ............................................................. 13 CEENU ............................................................... 16 cefaclor .............................................................. 13 cefadroxil hydrate ............................................ 13 cefdinir ............................................................... 13 cefixime .............................................................. 13 cefpodoxime proxetil ....................................... 13 cefprozil ............................................................. 13 CEFTIN ............................................................... 13 cefuroxime axetil .............................................. 13 CEFZIL ............................................................... 13 CELEBREX ........................................................ 15 celecoxib ........................................................... 15 CELEXA ............................................................... 6 CELLCEPT ......................................................... 13 CENTANY .......................................................... 10 cephalexin monohydrate ................................. 13 ceritinib ............................................................... 16 cetirizine hcl (OTC)............................................. 6 cetrorelix acetate ................................................ 12 CETROTIDE ....................................................... 12 cevimeline hcl ................................................... 16 chloral hydrate .................................................... 7 chlorambucil ....................................................... 16 chlordiazepoxide hcl .......................................... 7 chlordiazepoxide/clidinium br ............................. 18 chlorhexidine gluconate .................................. 17 chloroquine phosphate ................................... 14 chlorpromazine hcl ............................................ 7 chlorpropamide ................................................ 11 chlorthalidone ..................................................... 8 chlorzoxazone .................................................. 18 cholestyramine/aspartame ................................ 9 cholestyramine/sucrose .................................... 9
CHRONULAC ..................................................... 16 CIBALITH-S .......................................................... 7 CICLODAN ......................................................... 10 ciclopirox 8% solution ..................................... 10 ciclopirox olamine ............................................ 10 cilostazol ........................................................... 13 CILOXAN ............................................................ 12 cimetidine hcl ................................................... 18 CIPRO ................................................................ 14 CIPRO ORAL SUSPENSION ............................ 14 CIPRODEX ......................................................... 11 ciprofloxacin ..................................................... 14 ciprofloxacin hcl ......................................... 12, 14 ciprofloxacin hcl/dexameth ................................. 11 citalopram hydrobromide .................................. 6 CLARAVIS ............................................................ 9 clarithromycin ................................................... 13 CLARITIN (OTC) .................................................. 6 CLARITIN-D 12 HOUR......................................... 6 CLARITIN-D 24 HOUR......................................... 6 CLEOCIN HCL ................................................... 13 CLEOCIN PALMITATE ...................................... 13 CLEOCIN T ........................................................ 10 CLIMARA ............................................................ 13 clindamycin ....................................................... 13 clindamycin palmitate ...................................... 13 clindamycin phos/benzoyl perox ..................... 9 clindamycin phosphate ................................... 10 clindamycin/tretinoin ............................................. 9 CLINORIL ........................................................... 15 clobetasol propionate ...................................... 10 clobetasol propionate/emoll ........................... 10 CLOBEX ............................................................. 10 CLOMID .............................................................. 11 clomiphene citrate ............................................ 11 clomipramine hcl ................................................ 7 clonazepam ....................................................... 18 clonidine hcl ....................................................... 8 clopidogrel bisulfate ........................................ 13 clorazepate dipotassium ................................... 7 clotrimazole....................................................... 14 clotrimazole/betamet diprop ........................... 10 clozapine ............................................................. 7 CLOZARIL ............................................................ 7 cobicistat ............................................................. 15 cobimetinib fumarate .......................................... 16 codeine phos/carisoprodol/asa ...................... 17 codeine/butalbit/acetamin/caff........................ 18 codeine/butalbital/asa/caffein ......................... 18 codeine/promethazine hcl ................................. 9 COGENTIN......................................................... 18 COLAZAL ........................................................... 15 COL-BENEMID .................................................. 13 colchicine .......................................................... 13 colchicine/probenecid ..................................... 13 COLCRYS .......................................................... 13 colesevelam hcl .................................................... 9 COLESTID............................................................ 9 COLESTID GRANULES ...................................... 9 colestipol ............................................................... 9 COLYTE WITH FLAVOR PACKETS ................. 16 COMBIGAN ........................................................ 12 COMBIPATCH ................................................... 13 COMBIVENT ........................................................ 6 COMBIVENT RESPIMAT .................................... 6 COMBIVIR .......................................................... 14 COMETRIQ ........................................................ 16 COMPAZINE ........................................................ 6 COMPAZINE SYRUP........................................... 6 COMPLERA ....................................................... 15 COMTAN ............................................................ 18 CONCERTA ......................................................... 7 CONDYLOX ....................................................... 10 COPAXONE ....................................................... 17 COPEGUS.......................................................... 15 CORDARONE ...................................................... 7 CORDRAN ......................................................... 10 CORDRAN SP ................................................... 10 COREG ................................................................ 8 COREG CR .......................................................... 8 CORGARD ........................................................... 8 CORLANOR ......................................................... 9 CORTEF ............................................................. 15 CORTENEMA .................................................... 16 cortisone acetate .............................................. 15 CORTISPORIN CREAM .................................... 10
CORTISPORIN OINTMENT .............................. 10 CORTISPORIN OPHTH SUSPENSION ............ 12 CORTISPORIN OTIC ......................................... 11 CORTONE ACETATE ........................................ 15 COSENTYX ........................................................ 10 COSOPT ............................................................ 12 COTELLIC .......................................................... 16 COUMADIN ........................................................ 13 COZAAR ............................................................... 8 CREON ............................................................... 18 CRESTOR ............................................................ 9 CRINONE ........................................................... 11 CRIXIVAN........................................................... 15 crizotinib ............................................................. 16 cromolyn sodium ......................................... 6, 12 crotamiton ........................................................... 10 CUPRIMINE ....................................................... 15 CUTIVATE .......................................................... 10 cyanocobalamin/fa/pyridoxine ............................ 19 CYCLESSA .......................................................... 9 cyclobenzaprine hcl ......................................... 18 CYCLOCORT ..................................................... 10 CYCLOGYL ........................................................ 13 cyclopentolate hcl ............................................ 13 cyclophosphamide ........................................... 16
cyclosporine.................................................. 12, 13 cyclosporine, modified .................................... 13 CYMBALTA .......................................................... 7 CYSTARAN ........................................................ 12 cysteamine ......................................................... 12 cysteamine bitartrate .......................................... 19 CYTOMEL .......................................................... 12 CYTOTEC .......................................................... 18 CYTOVENE ........................................................ 14 CYTOXAN .......................................................... 16 dabrafanib........................................................... 16 DALIRESP ............................................................ 6 DALMANE ............................................................ 7 dalteparin sodium,porcine .................................. 13 danazol .............................................................. 12 DANOCRINE ...................................................... 12 DANTRIUM......................................................... 18 dantrolene sodium ........................................... 18 dapsone ............................................................. 14 DARAPRIM......................................................... 14 darunavir ethanolate........................................... 14 darunavir/cobicistat ............................................ 14 dasatinib ............................................................. 16 DAYPRO ............................................................ 15 DDAVP ............................................................... 11 DECADRON ....................................................... 15 DELATESTRYL .................................................. 13 delavirdine mesylate........................................... 15 DEL-BETA .......................................................... 10 DELTASONE ...................................................... 15 DEMADEX ............................................................ 8 DEMULEN 1-50-21 .............................................. 9 DEPAKENE CAPSULES ................................... 18 DEPAKENE SYRUP .......................................... 18 DEPAKOTE ........................................................ 18 DEPAKOTE ER .................................................. 18 DEPAKOTE SPRINKLE ..................................... 18 DEPEN ............................................................... 15 DEPO-TESTOSTERONE .................................. 13 DESCOVY .......................................................... 14 desipramine hcl .................................................. 7 desmopressin (nonrefrigerated) ..................... 11 DESOGEN............................................................ 9 desogestrel-ethinyl estradiol ............................ 9 desog-et estra/ethin estra ................................. 9 desonide ............................................................ 10 DESOWEN ......................................................... 10 desoximetasone ............................................... 10 DESVENLAFAXINE ER (RANBAXY BRAND) .... 7 desvenlafaxine ER (Ranbaxy).............................. 7 desvenlafaxine succinate .................................. 7 DESYREL 300MG ................................................ 6 DETROL ............................................................. 19 DETROL LA........................................................ 19 dexamethasone ................................................ 15 DEXEDRINE......................................................... 7 DEXEDRINE SPANSULE .................................... 7 dexmethylphenidate hcl .................................... 7 dextroamphetamine capsule............................. 7 dextroamphetamine sulfate .............................. 7 dextroamphetamine tablet ................................ 7
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DIABETA ............................................................ 11 DIABINESE ........................................................ 11 DIAMOX SEQUELS ........................................... 12 DIASTAT ............................................................ 18 diazepam ....................................................... 7, 18 DIBENZYLINE ...................................................... 8 dichlorphenamide ............................................... 18 diclofenac sodium ................................ 10, 12, 15 dicloxacillin sodium ......................................... 14 dicyclomine hcl ................................................ 18 didanosine......................................................... 15 DIDRONEL ......................................................... 12 DIFFERIN ........................................................... 10 DIFICID ............................................................... 14 diflorasone diacetate ....................................... 10 diflorasone diacetate/emoll ................................ 10 DIFLUCAN.......................................................... 14 diflunisal ............................................................ 17 difluprednate ....................................................... 12 digoxin ................................................................. 8 DIGOXIN ORAL SOLN......................................... 8 DILACOR XR ....................................................... 8 DILANTIN ........................................................... 18 DILANTIN CHEW TAB ....................................... 18 DILANTIN-125 .................................................... 18 DILAUDID ........................................................... 17 DILAUDID-5........................................................ 17 diltiazem hcl ........................................................ 8 dimethyl fumarate ............................................... 17 DIOVAN ................................................................ 8 DIOVAN HCT ....................................................... 8 diphenoxylate hcl/atrop sulf ........................... 16 dipivefrin hcl........................................................ 13 DIPROLENE ....................................................... 10 DIPROLENE AF ................................................. 10 DIPROSONE ...................................................... 10 dipyridamole ..................................................... 13 DISALCID ........................................................... 17 disopyramide phosphate ............................... 7, 8 disulfiram .............................................................. 7 DITROPAN XL ................................................... 19 divalproex sodium ............................................ 18 d-methorphan hb/prometh hcl .......................... 9 dofetilide .............................................................. 8 DOLOBID ........................................................... 17 DOLOPHINE HCL .............................................. 17 dolutegravir ......................................................... 15 DOMEBORO ...................................................... 11 donepezil hcl ....................................................... 6 DONNATAL ........................................................ 18 dornase alfa ........................................................ 17 dorzolamide hcl ................................................ 12 dorzolamide hcl/timolol maleat ...................... 12 DOSTINEX ......................................................... 12 DOVONEX.......................................................... 10 doxazosin mesylate ........................................... 8 doxepin hcl.......................................................... 7 doxycycline calcium ............................................ 14 doxycycline hyclate ......................................... 14 DOXYCYCLINE MONOHYDRATE 150MG
TABLET ........................................................ 14 DRISDOL ............................................................ 19 DRITHOCREME HP........................................... 10 DRITHO-SCALP ................................................. 10 dronabinol ........................................................... 6 dronedarone hcl ................................................... 8 DRYSOL ............................................................. 10 DUAVEE ............................................................. 13 DUETACT ........................................................... 11 DULERA ............................................................... 6 duloxetine hcl ..................................................... 7 DUONEB .............................................................. 6 DURAGESIC ...................................................... 17 DUREZOL .......................................................... 12 DURICEF ............................................................ 13 dutasteride ........................................................ 19 dutasteride/tamsulosin .................................... 19 DYAZIDE .............................................................. 8 DYNACIN ........................................................... 14 DYNACIRC ........................................................... 8 EC-NAPROSYN ................................................. 15 EDURANT .......................................................... 15 efavirenz ............................................................. 15 efavirenz/emtricitab/tenofovir ............................. 15 EFFEXOR............................................................. 7 EFFEXOR XR ...................................................... 7
EFFIENT ............................................................. 13 EFUDEX ............................................................. 10 ELAVIL ................................................................. 7 ELDEPRYL ......................................................... 18 ELIDEL ............................................................... 10 ELIGARD ............................................................ 11 ELIMITE .............................................................. 10 ELIQUIS ............................................................. 13 ELMIRON ........................................................... 19 ELOCON ............................................................ 10 eltrombopag olamine .......................................... 13 elviteg/cobi/emtric/tenofo ala .............................. 14 elvitegravir .......................................................... 15 elvitegravir/cobicistat/emtricitabine/ tenofovir
disoproxil fumarate ....................................... 14 EMCYT ............................................................... 17 EMEND ................................................................. 6 EMGEL ............................................................... 10 empagliflozin....................................................... 11 empagliflozin/linagliptin ...................................... 11 empagliflozin/metformin hcl ................................ 11 emtricitabine ....................................................... 15 emtricitabine/tenofov alafenam .......................... 14 emtricitabine/tenofovir ........................................ 14 emtrictab/rilpiviri/tenof ala .................................. 15 EMTRIVA ............................................................ 15 EMVERM ............................................................ 14 enalapril maleate ................................................ 8 enalapril/hydrochlorothiazide ........................... 8 Enbrel ................................................................. 28 ENBREL ............................................................. 15 ENDOMETRIN ................................................... 11 enfuvirtide ........................................................... 15 enoxaparin sodium .......................................... 13 entacapone........................................................ 18 entecavir ............................................................ 15 ENTOCORT EC ................................................. 15 enzalutamide ...................................................... 16 EPCLUSA ........................................................... 15 EPIDUO ................................................................ 9 EPIDUO FORTE .................................................. 9 epinephrine ....................................................... 16 EPIPEN .............................................................. 16 EPIPEN JR ......................................................... 16 EPIVIR ................................................................ 15 EPIVIR HBV SOLUTION .................................... 15 EPIVIR HBV TABLET......................................... 15 eplerenone .......................................................... 8
epoetin alfa ......................................................... 13 EPZICOM ........................................................... 14 ergocalciferol .................................................... 19 ergotamine tartrate/caffeine ............................ 17 ERIVEDGE ......................................................... 16 erlotinib hcl ......................................................... 16 ery e-succ/sulfisoxazole .................................. 14 ERYC .................................................................. 14 ERYGEL ............................................................. 10 ERYPED 200 ...................................................... 14 ERYPED 400 ...................................................... 14 ERY-TAB ............................................................ 14 ERYTHROCIN STEARATE ............................... 14 erythromycin base ..................................... 12, 14 erythromycin base/benz per ........................... 10 erythromycin base/ethanol ............................. 10 erythromycin ethylsuccinate .......................... 14 erythromycin stearate ...................................... 14 ESBRIET ............................................................ 17 escitalopram oxalate .......................................... 6
ESGIC ................................................................ 17 ESKALITH ............................................................ 7 esomeprazole magnesium .............................. 18 estazolam ............................................................ 7 ESTRACE..................................................... 13, 19 ESTRADERM ..................................................... 13 estradiol ....................................................... 13, 19 estradiol/noreth ac .............................................. 13 estramustine phosphate sodium ........................ 17 ESTRATEST H.S. .............................................. 13 estrogen, con/m-progest acet ............................ 13 estrogen, ester/me-testosterone .................... 13 estrogens, conj/bazedoxifene ............................ 13 estrogens, conjugated .................................. 13, 19 estrogens, esterified ........................................... 13 estropipate ........................................................ 13 eszopiclone ......................................................... 7 etanercept........................................................... 15
ethambutol hcl .................................................. 14 ethinyl estradiol/drospirenone.......................... 9 ethosuximide ...................................................... 18 ethynodiol d-ethinyl estradiol ........................... 9 etidronate disodium ......................................... 12 etodolac ............................................................. 15 etonogestrel/ethinyl estradiol ............................... 9 etoposide........................................................... 16 etravirine ............................................................. 15 EULEXIN ............................................................ 16 EURAX ............................................................... 10 everolimus .................................................... 13, 17 EVISTA ............................................................... 12 EVOCLIN ............................................................ 10 evolocumab .......................................................... 9 EVOTAZ ............................................................. 15 EVOXAC ............................................................. 16 EXELDERM ........................................................ 10 EXELON ............................................................... 6 EXELON PATCH .................................................. 6 exemestane ....................................................... 16 EXFORGE ............................................................ 8 EXFORGE HCT ................................................... 8 ezetimibe ............................................................. 9 FABIOR .............................................................. 10 famotidine ......................................................... 18 FARESTON ........................................................ 17 FARYDAK........................................................... 16 febuxostat ........................................................... 13 FELDENE ........................................................... 15 felodipine ............................................................. 8 FEMHRT ............................................................. 13 fenofibrate ........................................................... 9 fenofibrate nanocrystallized ............................. 9 fenofibrate, micronized ...................................... 9 fenoprofen calcium .......................................... 15 fentanyl .............................................................. 17 fentanyl citrate lozenge ................................... 17 fesoterodine fumarate ........................................ 19 FETZIMA .............................................................. 7 fidaxomicin.......................................................... 14 filgrastim ............................................................. 13 finasteride ......................................................... 19 fingolimod hcl ..................................................... 17 FIORICET ........................................................... 17 FIORICET WITH CODEINE ............................... 18 FIORINAL ........................................................... 17 FIORINAL WITH CODEINE ............................... 18 FIRAZYR ............................................................ 15 FIRST-HYDROCORTISONE ............................. 10 FLAGYL .............................................................. 14 FLAGYL ER ........................................................ 14 FLAREX .............................................................. 12 flecainide acetate ............................................... 7 FLEXERIL........................................................... 18 FLOMAX ............................................................. 19 FLONASE ............................................................. 6 FLORINEF ACETATE ........................................ 15 FLOXIN ......................................................... 11, 14 fluconazole ........................................................ 14 fludarabine phosphate ........................................ 16 fludrocortisone acetate ................................... 15 flunisolide............................................................ 6 fluocinolone acetonide .................................... 10 fluocinonide ...................................................... 10 fluocinonide/emollient ..................................... 10 FLUORABON BASIC ......................................... 19 fluoride ion/iron/vit a,c&d ................................ 19 fluoride ion/multivitamins ............................... 19 fluoride ion/multivits w-fe ................................ 19 fluoride ion/vit a,c&d ........................................ 19 FLUORITAB ....................................................... 19 fluorometholone ............................................... 12 fluorometholone acetate ..................................... 12 fluorouracil ........................................................ 10 fluoxetine er ........................................................ 6 fluoxetine hcl ...................................................... 6 fluoxymesterone ............................................... 13 fluphenazine hcl ................................................. 7 FLURA-DROPS .................................................. 19 flurandrenolide ................................................. 10 FLURA-TABS ..................................................... 19 flurazepam hcl .................................................... 7 flurbiprofen ....................................................... 15 flurbiprofen sodium ......................................... 12 flutamide ............................................................ 16
MedPerform High Formulary INDEX
37014 MedPerform High Formulary – April 2017 34
fluticasone propionate ................................. 6, 10 fluticasone/salmeterol........................................... 6 fluticasone/vilanterol ............................................. 6 FML .................................................................... 12 FML FORTE ....................................................... 12 FML S.O.P. ......................................................... 12 FOCALIN .............................................................. 7 FOCALIN XR ........................................................ 7 FOLGARD RX .................................................... 19 folic acid ............................................................ 19 FOLIC ACID ....................................................... 19 folic acid/mu-vits-min th .................................. 19 follitropin alpha,recomb ...................................... 11 fondaparinux sodium .......................................... 13 formoterol fumarate .............................................. 6 FORTEO ............................................................. 11 FOSAMAX .......................................................... 12 FOSAMAX PLUS D ............................................ 11 fosamprenavir calcium ....................................... 15 fosinopril sodium ............................................... 8 fosinopril/hydrochlorothiazide ......................... 8 FRAGMIN ........................................................... 13 FURADANTIN .................................................... 14 furazolidone ........................................................ 14 furosemide .......................................................... 8
FUROXONE ....................................................... 14 FUZEON ............................................................. 15 gabapentin ........................................................ 18 galantamine hbr .................................................. 6 ganciclovir..................................................... 12, 14 ganirelix acetate ................................................. 12 GANIRELIX ACETATE....................................... 12 GANTRISIN ........................................................ 13 GARAMYCIN ................................................ 10, 12 gatifloxacin........................................................ 12
GATTEX ............................................................. 16 gefitinib ............................................................... 16 gemfibrozil .......................................................... 9 gentamicin sulfate ...................................... 10, 12 GENVOYA .......................................................... 14 GEODON .............................................................. 7 GIANVI ................................................................. 9 GILENYA ............................................................ 17 GILOTRIF ........................................................... 16 glatiramer acetate ............................................. 17 GLEEVEC........................................................... 16 glimepiride ........................................................ 11 glipizide ............................................................. 11 glipizide/metformin hcl .................................... 11 glucagon ............................................................. 11 GLUCAGON KIT ................................................ 11 GLUCOPHAGE .................................................. 11 GLUCOPHAGE XR ............................................ 11 GLUCOTROL ..................................................... 11 GLUCOTROL XL ................................................ 11 GLUCOVANCE .................................................. 11 glyburide ........................................................... 11 glyburide, micro/metformin hcl ...................... 11 GLYXAMBI ......................................................... 11 GOLYTELY......................................................... 16 gonadotropin,chorionic, human .......................... 11 GONAL-F ............................................................ 11 GONAL-F RFF ................................................... 11 GRASTEK ............................................................ 6 griseofulvin suspension ...................................... 14 griseofulvin ultramicrosize ............................. 14 GRISEOFULVIN V ............................................. 14 GRIS-PEG .......................................................... 14 guanfacine hcl .................................................... 8 GYNAZOLE-1 ..................................................... 19 HALCION .............................................................. 7 HALDOL ............................................................... 7 HALDOL ORAL CONC......................................... 7 halobetasol propionate .................................... 10 haloperidol .......................................................... 7 haloperidol lactate .............................................. 7 HARVONI ........................................................... 15 hc acetate/pramoxine hcl .................... 10, 15, 16 hcg alpha, recombinant ...................................... 11 HEPARIN LOCK ................................................. 13 heparin sodium, porcine ................................. 13 heparin sodium, porcine/pf ............................. 13 HEP-LOCK ......................................................... 13 HEPSERA .......................................................... 15 HEXALEN ........................................................... 16 homatropine hbr ............................................... 13
HUMALOG ......................................................... 11 HUMALOG MIX 50-50........................................ 11 HUMALOG MIX 75-25........................................ 11 HUMATIN ........................................................... 14 HUMIRA ............................................................. 15 HUMULIN 70-30 ................................................. 11 HUMULIN N........................................................ 11 HUMULIN R........................................................ 11 HUMULIN R U-500 ............................................. 11 HYCAMTIN ......................................................... 16 HYCET ............................................................... 17 HYCODAN............................................................ 9 hydralazine hcl ................................................... 8 HYDREA ............................................................. 16 hydrochlorothiazide ........................................... 8 hydrocodone bit/acetaminophen ................... 17 hydrocodone bit/acetaminophen oral elixir .. 17 hydrocodone bit/acetaminophen oral solution
...................................................................... 17 hydrocodone bit/homatrop me-br .................... 9 hydrocodone bitartrate ....................................... 17 hydrocodone/chlorphen p-stirex ...................... 9
hydrocort/sal acid/sulf/shmp#1........................... 10 hydrocortisone ..................................... 10, 15, 16 hydrocortisone acetate .................................... 16 hydrocortisone acetate/urea ........................... 10 hydrocortisone butyrate .................................. 10 hydrocortisone butyrate/emoll ............................ 10 hydrocortisone probutate ................................... 10 hydrocortisone valerate .................................. 10 hydromorphone hcl.......................................... 17 hydroxychloroquine sulfate ............................ 14 hydroxyurea ...................................................... 16 hydroxyzine hcl .................................................. 6 hydroxyzine pamoate ........................................ 6
HYGROTON ......................................................... 8 hyoscyamine sulfate ........................................ 18 HYPER-SAL 7% ................................................. 17 HYSINGLA ER ................................................... 17 HYTRIN ................................................................ 8 HYZAAR ............................................................... 8 ibandronate ....................................................... 12 IBRANCE ............................................................ 16 ibrutinib ............................................................... 16 ibuprofen ........................................................... 15 icatibant .............................................................. 15 ICLUSIG ............................................................. 16 icosapent ethyl ..................................................... 9 idelalisib .............................................................. 16 ILEVRO .............................................................. 12 imatinib mesylate ............................................. 16 Imbruvica ............................................................ 28 IMBRUVICA........................................................ 16 IMDUR .................................................................. 9 imipramine hcl .................................................... 7 imiquimod ......................................................... 13 IMITREX INJECTION ......................................... 17 IMITREX NASAL SPRAY ................................... 17 IMITREX TABLET .............................................. 17 IMPAVIDO .......................................................... 14 IMURAN ............................................................. 13 indapamide.......................................................... 8 INDERAL LA......................................................... 8 INDERIDE-40/25 .................................................. 8 indinavir sulfate .................................................. 15 INDOCIN ............................................................ 15 INDOCIN ORAL SUSP. ..................................... 15 INDOCIN SR ...................................................... 15 INDOCIN SUPPOS ............................................ 15 indomethacin .................................................... 15 ingenol ................................................................ 10 INLYTA ............................................................... 16 INSPRA ................................................................ 8 insulin glargine,hum.rec.anlog ........................... 11 insulin lispro ........................................................ 11 insulin nph hum/reg insulin hm........................... 11 insulin nph human isophane .............................. 11 insulin npl/insulin lispro ...................................... 11 insulin regular, human ........................................ 11 INTAL ................................................................... 6 INTELENCE ....................................................... 15 interferon alfa-2b, recomb. ................................. 13 interferon beta-1a ............................................... 17 interferon beta-1a/albumin ................................. 17 INTRON A .......................................................... 13 INVIRASE ........................................................... 15
INVOKAMET ...................................................... 11 INVOKAMET XR ................................................ 11 INVOKANA ......................................................... 11 iodoquinol ........................................................... 14 ipratropium bromide .................................... 6, 17 ipratropium/albuterol sulfate ............................ 6 irbesartan ............................................................ 8 irbesartan/hydrochlorithiazide.......................... 8 IRESSA .............................................................. 16 ISENTRESS ....................................................... 15 ISMO .................................................................... 9 ISOCHRON .......................................................... 9 isomethept/acetaminop/dichlphn ................... 17 isoniazid ............................................................ 14 ISOPTO ATROPINE .......................................... 13 ISOPTO CARBACHOL ...................................... 12 ISOPTO CARPINE ............................................. 12 ISOPTO HOMATROPINE .................................. 13 ISORDIL ............................................................... 9 ISORDIL TITRADOSE ......................................... 9 isosorb dinit/hydralazine hcl ................................. 9 isosorbide dinitrate ............................................ 9 isosorbide mononitrate ..................................... 9 isotretinoin .......................................................... 9 isradipine IR capsules ....................................... 8 itraconazole....................................................... 14 ivabradine hcl ....................................................... 9 ivacaftor .............................................................. 17 ixazomib citrate .................................................. 16 JAKAFI ............................................................... 16 JALYN ................................................................ 19 JANUMET ........................................................... 10 JANUMET XR .................................................... 10 JANUVIA ............................................................ 10 JARDIANCE ....................................................... 11 JENTADUETO ................................................... 10 JUXTAPID ............................................................ 9 KALETRA ........................................................... 15 KALYDECO ........................................................ 17 KAYEXALATE .................................................... 11 K-DUR ................................................................ 11 KEFLEX .............................................................. 13 KENALOG .......................................................... 10 KENALOG IN ORABASE ................................... 17 KEPPRA ............................................................. 18 KETEK ................................................................ 13 ketoconazole ............................................... 10, 14 ketoprofen ......................................................... 15 ketorolac tromethamine ............................ 12, 15 ketotifen fumarate (OTC) ................................. 12 KEVEYIS ............................................................ 18 KLONOPIN ......................................................... 18 KORLYM ............................................................ 11 KRISTALOSE ..................................................... 16 K-TAB ................................................................. 11 KURIC ................................................................ 10 KUVAN ............................................................... 16 KWELL ............................................................... 10 KYNAMRO ........................................................... 8 labetalol hcl ......................................................... 8 LACTICARE-HC ................................................. 10 lactulose ............................................................ 16 LAMICTAL .......................................................... 18 LAMISIL ........................................................ 10, 14 LAMISIL GRANULES ......................................... 14 lamivudine ......................................................... 15 lamivudine/zidovudine ........................................ 14 lamotrigine ........................................................ 18
lancing device/lancets ........................................ 11 LANOXIN .............................................................. 8 lansoprazole ..................................................... 18 lansoprazole/amox tr/clarith ........................... 18 LANTUS ............................................................. 11 lapatinib ditosylate .............................................. 16 LARIAM .............................................................. 14 LASIX ................................................................... 8 latanoprost .......................................................... 12 LATUDA ............................................................... 7 ledipasvir/sofosbuvir ........................................... 15 leflunomide ....................................................... 15 lenalidomide ....................................................... 16 lenvatinib mesylate ............................................. 16 LENVIMA ............................................................ 16 LESSINA .............................................................. 9 LETAIRIS .............................................................. 8 LEUKERAN ........................................................ 16
MedPerform High Formulary INDEX
37014 MedPerform High Formulary – April 2017 35
LEUKINE ............................................................ 13 leuprolide ............................................................ 11 LEVAQUIN ......................................................... 14 LEVBID ............................................................... 18 levetiracetam .................................................... 18 levobunolol hcl ................................................. 12 levocetirizine ....................................................... 6 levofloxacin ....................................................... 14 levonorgestrel ..................................................... 9 levonorgestrel-eth estra .................................... 9 LEVOTHROID .................................................... 12 levothyroxine sodium ...................................... 12 LEVOXYL ........................................................... 12 LEVSIN-SL ......................................................... 18 LEXAPRO............................................................. 6 LEXIVA ............................................................... 15 LIBRAX ............................................................... 18 LIBRIUM ............................................................... 7 LIDEX ................................................................. 10 LIDEX-E .............................................................. 10 lidocaine hcl ...................................................... 15 linaclotide ............................................................ 15 linagliptin ............................................................. 10 linagliptin/metformin hcl ...................................... 10 lindane ............................................................... 10 linezolid ............................................................. 14 LINZESS ............................................................. 15 LIORESAL .......................................................... 18 liothyronine sodium ......................................... 12 LIPITOR ................................................................ 9 liraglutide ............................................................ 11 lisdexamfetamine dimesylate ............................... 7 lisinopril ............................................................... 8 lisinopril/hydrochlorothiazide ........................... 8 lithium carbonate ............................................... 7 lithium citrate ...................................................... 7 LITHOBID ............................................................. 7 LIVALO ................................................................. 9 LO LOESTRIN FE ................................................ 9 LO MINASTRIN FE .............................................. 9 LOCOID .............................................................. 10 LOCOID LIPOCREAM ....................................... 10 LODINE .............................................................. 15 LODOSYN .......................................................... 18 lodoxamide tromethamine .................................. 12 LOESTRIN............................................................ 9 LOESTRIN FE ...................................................... 9 LOESTRIN FE24 .................................................. 9 LOFIBRA .............................................................. 9 lomitapide ............................................................. 9 LOMOTIL ............................................................ 16 lomustine........................................................... 16 LONSURF .......................................................... 16 LO-OVRAL-28 ...................................................... 9 LOPID ................................................................... 9 lopinavir/ritonavir ............................................. 15 LOPRESSOR ....................................................... 8 LOPRESSOR HCT ............................................... 8 LOPROX ............................................................. 10 loratadine (OTC) ................................................. 6 lorazepam ............................................................ 7
LORAZEPAM INTENSOL .................................... 7 LORCET ............................................................. 17 LORCET PLUS .................................................. 17 LORTAB ............................................................. 17 LORTAB ELIXIR ................................................. 17 LORYNA ............................................................... 9 losartan potassium ............................................ 8 losartan/hydrochlorothiazide ............................ 8 LOTEMAX .......................................................... 12 LOTENSIN............................................................ 8 LOTENSIN HCT ................................................... 8 loteprednol etabonate......................................... 12 LOTREL ................................................................ 8 LOTRISONE ....................................................... 10 lovastatin ............................................................. 9 LOVAZA ............................................................... 9 LOVENOX .......................................................... 13 loxapine succinate ............................................. 7 LOXITANE ............................................................ 7 LOZOL .................................................................. 8 LUDIOMIL............................................................. 7 lumacaftor/ivacaftor ............................................ 17 LUMIGAN ........................................................... 12 LUNESTA ............................................................. 7 LURIDE .............................................................. 19
LUTERA ............................................................... 9 LYNPARZA......................................................... 16 LYRICA ............................................................... 18 LYSODREN ........................................................ 16 macitentan ............................................................ 8 MACROBID ........................................................ 14 MACRODANTIN ................................................. 14 malathion........................................................... 10 maprotiline hcl .................................................... 7
maraviroc ............................................................ 14 MARINOL ............................................................. 6 MATULANE ........................................................ 16 MAVIK .................................................................. 8 MAXALT ............................................................. 17 MAXALT MLT ..................................................... 17 MAXITROL ......................................................... 12 MAXZIDE .............................................................. 8 MAXZIDE-25MG .................................................. 8 mechlorethamine ................................................ 10 meclizine hcl ....................................................... 6 meclofenamate sodium ................................... 15 MECLOMEN ....................................................... 15 MEDROL ............................................................ 15 medroxyprogesterone acet ............................. 13 mefloquine hcl .................................................. 14
MEGACE ............................................................ 17 megestrol acetate ............................................. 17 MEKINIST........................................................... 16 MELLARIL ............................................................ 7 meloxicam ......................................................... 15 melphalan ........................................................... 16 memantine hcl .................................................... 6 memantine hcl/donepezil hcl ................................ 6 MENEST ............................................................. 13 MENOPUR ......................................................... 11 menotropins ........................................................ 11 MEPHYTON ....................................................... 13 meprobamate ...................................................... 7 mercaptopurine ................................................ 16 mesalamine ....................................................... 15 mesalamine w/cleansing wipes ...................... 15 MESTINON........................................................... 6 METADATE CD .................................................... 7 METADATE ER .................................................... 7 METAGLIP ......................................................... 11 metaproterenol sulfate ...................................... 6 metaxalone ........................................................ 18 metformin hcl .................................................... 11
meth/meth blue/ba/salicy/hyos ........................... 13 methadone hcl .................................................. 17 methadone HCl injection solution .................. 17 methazolamide ................................................. 12 METHERGINE ..................................................... 9 methimazole ...................................................... 12 METHITEST ....................................................... 13 METHLYIN SOLN ................................................ 7 methocarbamol ................................................. 18 methotrexate ..................................................... 15 methotrexate sodium ................................. 15, 16 METHOTREXATE TABLET ............................... 16 METHOTREXATE VIAL ..................................... 16 methoxsalen ....................................................... 10 methoxsalen, rapid........................................... 10 methyldopa ......................................................... 8 methylergonovine maleate ................................ 9 METHYLIN CHEW TAB ....................................... 7 methylphenidate ER Susp .................................... 7 methylphenidate hcl........................................... 7 methylprednisolone ......................................... 15 methyltestosterone .......................................... 13 metipranolol ...................................................... 12 metoclopramide hcl ......................................... 18 METOCLOPRAMIDE HCL INTENSOL .............. 18 metolazone .......................................................... 8 metoprolol succinate ......................................... 8 metoprolol tartrate ............................................. 8 metoprolol/hctz ................................................... 8 METROCREAM ................................................. 10 METROGEL-VAGINAL ...................................... 19 METROLOTION ................................................. 10 metronidazole ....................................... 10, 14, 19 MEVACOR ........................................................... 9 mexiletine hcl ...................................................... 7 MEXITIL ................................................................ 7 miconazole nitrate ............................................ 19 MICRO-K ............................................................ 11
MICRONASE ...................................................... 11 MICROZIDE ......................................................... 8 midodrine hcl ...................................................... 9
MIDRIN ............................................................... 17 mifepristone ........................................................ 11 MIGERGOT ........................................................ 17 MILLIPRED......................................................... 15 MILLIPRED DP .................................................. 15 milnacipran hcl ................................................... 17 miltefosine .......................................................... 14 MILTOWN ............................................................. 7 MINIPRESS .......................................................... 8 MINOCIN ............................................................ 14 minocycline hcl ................................................ 14 mipomersen sodium ............................................. 8 mirabegron ......................................................... 19 MIRALAX ............................................................ 16 MIRAPEX ........................................................... 18 MIRCETTE ........................................................... 9 mirtazapine.......................................................... 6 misoprostol ....................................................... 18 mitotane .............................................................. 16 MOBIC ................................................................ 15 modafinil .............................................................. 7 moexipril hcl ....................................................... 8 moexipril/hydrochlorothiazide .......................... 8 mometasone furoate .................................... 6, 10 mometasone/formoterol ....................................... 6 MONISTAT 3 ...................................................... 19 MONOKET ........................................................... 9 MONOPRIL .......................................................... 8 MONOPRIL HCT .................................................. 8 montelukast sodium .......................................... 6 MORGIDOX 100MG CAPSULE......................... 14 MORGIDOX 50MG CAPSULE........................... 14 morphine sulfate .............................................. 17 MOTRIN ............................................................. 15 MOVANTIK ......................................................... 16 moxifloxacin hcl ............................................ 12, 14 MSIR ................................................................... 17 mth/me blue/salicy/na phos/hyo ......................... 13 MUCOMYST-10 ................................................. 17 MULTAQ ............................................................... 8 mupirocin .......................................................... 10 mupirocin calcium ...................................... 10, 17 MYAMBUTOL ..................................................... 14 MYCELEX .......................................................... 14 MYCIFRADIN ..................................................... 14 MYCOLOG II ...................................................... 10 mycophenolate mofetil .................................... 13 MYCOSTATIN .............................................. 10, 14 MYLERAN .......................................................... 16 MYORISAN .......................................................... 9 MYRBETRIQ ...................................................... 19 MYSOLINE ......................................................... 18 na sulfacetm/prednis sp .................................. 12 na sulfacetm/prednisol ac .................................. 12 nabumetone ...................................................... 15 nadolol ................................................................. 8 naftifine hcl ....................................................... 10 NAFTIN ............................................................... 10 NALFON CAPSULE ........................................... 15 NALFON TABLET .............................................. 15 naloxegol oxalate ............................................... 16 naltrexone hcl ..................................................... 7 NAMENDA............................................................ 6 NAMENDA XR ..................................................... 6 NAMZARIC ........................................................... 6 NAPROSYN ....................................................... 15 naproxen ........................................................... 15 naproxen sodium ............................................. 15 naratriptan ......................................................... 17 NARCAN NASAL ................................................. 7 Narcotic Withdrawal Therapy Agents ................. 18 NARDIL ................................................................ 6 NASACORT AQ ................................................... 6 NASAREL ............................................................. 6 NASONEX ............................................................ 6 nateglinide......................................................... 11 NATURE-THROID .............................................. 12 NAVANE ............................................................... 7 nebivolol hcl .......................................................... 8 NEBUPENT ........................................................ 14 nedocromil sodium ............................................. 12 needles, insulin disp., safety .............................. 17 nelfinavir mesylate .............................................. 15
MedPerform High Formulary INDEX
37014 MedPerform High Formulary – April 2017 36
neo/polymyx b sulf/dexameth ......................... 12 neomy sulf/bacitrac zn/poly/hc ....................... 12 neomy sulf/polymyx b sulf/hc ................. 10, 11, 12 neomycin sulfate .............................................. 14 neomycin/bacitra/polymyxin/hc .......................... 10 neomycin/bacitracin/polymyxin ..................... 12 neomycin/polymyxn b/gramicidin .................. 12 NEO-POLYCIN HC OPHTH OINTMENT........... 12 NEORAL ............................................................. 13 NEOSPORIN OPHTH DROPS .......................... 12 NEOSPORIN OPHTH OINTMENT .................... 12 neostigmine bromide ............................................ 6 nepafenac ........................................................... 12 NEPTAZANE ...................................................... 12 netupitant/palonosetron hcl .................................. 6 NEULASTA......................................................... 13 NEUPOGEN ....................................................... 13 NEUPRO ............................................................ 18 NEURONTIN ...................................................... 18 NEVANAC .......................................................... 12 nevirapine.......................................................... 15 nevirapine ER ................................................... 15
NEXAVAR .......................................................... 16 NEXIUM .............................................................. 18 niacin ................................................................... 9
NIASPAN .............................................................. 9 nicardipine .......................................................... 8 nifedipine ............................................................. 8 NILANDRON ...................................................... 16 nilotinib hydrochloride......................................... 16 nilutamide.......................................................... 16 nimodipine .......................................................... 8 NIMOTOP ............................................................. 8 NINLARO ............................................................ 16 nintedanib esylate .............................................. 17 NITRO-BID ........................................................... 9 NITRO-DUR ......................................................... 9 nitrofurantoin ...................................................... 14 nitrofurantoin macrocrystal ............................ 14 nitrofurantoin/nitrofuran mac ......................... 14 nitroglycerin ........................................................ 9 NITROLINGUAL ................................................... 9 NITROSTAT ......................................................... 9 nizatidine ........................................................... 18 NIZORAL ...................................................... 10, 14 NOCTEC .............................................................. 7 NOLVADEX ........................................................ 17 NORCO .............................................................. 17 NORDETTE-28 .................................................... 9 NORDITROPIN .................................................. 12 NORDITROPIN FLEXPRO ................................ 12 NORDITROPIN NORDIFLEX ............................ 12 norelgestromin/ethin.estradiol ......................... 9 noreth a-et estra/fe fumarate............................. 9 norethindrone ..................................................... 9 norethindrone acetate ..................................... 13 norethindrone ac-eth estradiol ....................... 13 norethindrone a-e estradiol ............................... 9 norethindrone-ethinyl estrad ............................ 9 norethindrone-mestranol .................................. 9 NORFLEX........................................................... 18 NORGESIC FORTE ........................................... 18 norgestimate-ethinyl estradiol .......................... 9 norgestrel-ethinyl estradiol ............................... 9 NORINYL 1+35 .................................................... 9 NORINYL 1+50 .................................................... 9 NORPACE ............................................................ 7 NORPACE CR ..................................................... 8 NORPRAMIN ....................................................... 7 NOR-Q-D .............................................................. 9 nortriptyline hcl .................................................. 7 NORVASC ............................................................ 8 NORVIR .............................................................. 15 NOVAREL .......................................................... 11 NUCYNTA .......................................................... 17 NUCYNTA ER .................................................... 17 NULYTELY WITH FLAVOR PACKS .................. 16 NUVARING........................................................... 9 NYDRAZID ......................................................... 14 nystatin ........................................................ 10, 14 nystatin/triamcin ............................................... 10 OCL .................................................................... 16 octreotide acetate ............................................. 17 OCUFEN ............................................................ 12 OCUFLOX .......................................................... 12 OCUPRESS ....................................................... 12
ODEFSEY .......................................................... 15 ODOMZO ........................................................... 16 OFEV .................................................................. 17 ofloxacin ................................................ 11, 12, 14 OFORTA ............................................................. 16 OGEN ................................................................. 13 olanzapine ........................................................... 7 olanzapine ODT .................................................. 7 olanzapine/fluoxetine ......................................... 6
olaparib ............................................................... 16 olmesartan medoxomil ...................................... 8 olmesartan/amlodipin/hcthiazid ....................... 8 olmesartan/hydrochlorothiazide ...................... 8 olodaterol hcl ........................................................ 6 olopatadine hcl ................................................. 12 OLUX .................................................................. 10 omega-3 acid ethyl esters ................................. 9 omeprazole........................................................ 18 omeprazole magnesium .................................. 18 OMNICEF ........................................................... 13 OMNIPRED ........................................................ 12 OMNITROPE ...................................................... 12 ondansetron ........................................................ 6 ondansetron hcl ................................................. 6 ONEXTON ............................................................ 9 OPSUMIT ............................................................. 8 OPTICROM ........................................................ 12 OPTIPRANOLOL ............................................... 12 OPTIVAR ............................................................ 12 ORALAIR .............................................................. 6 ORAMORPH SR ................................................ 17 ORAPRED .......................................................... 15 ORFADIN ........................................................... 17 ORINASE ........................................................... 11 ORKAMBI ........................................................... 17 orphenadrine citrate......................................... 18 orphenadrine/aspirin/caffeine ......................... 18 ORSYTHIA ........................................................... 9 ORTHO EVRA ...................................................... 9 ORTHO MICRONOR ........................................... 9 ORTHO TRI-CYCLEN .......................................... 9 ORTHO TRI-CYCLEN LO .................................... 9 ORTHO-CEPT ...................................................... 9 ORTHO-CYCLEN ................................................. 9 ORTHO-NOVUM .................................................. 9 ORUVAIL ............................................................ 15 OSCELLA ............................................................. 9 oseltamivir phosphate ..................................... 14
osimertinib mesylate........................................... 16 OTICIN HC ......................................................... 11 OTREXUP .......................................................... 15 OVACE PLUS SUSPENSION............................ 10 OVIDE ................................................................ 10 OVIDREL ............................................................ 11 oxaprozin........................................................... 15 oxazepam ............................................................ 7 oxcarbazepine .................................................. 18 OXSORALEN ..................................................... 10 OXSORALEN-ULTRA ........................................ 10 oxybutynin chloride ......................................... 19 oxycodone hcl .................................................. 17 oxycodone hcl/acetaminophen ...................... 17 oxycodone hcl/aspirin ..................................... 17 OXYCONTIN ...................................................... 17 palbociclib ........................................................... 16 PAMELOR ............................................................ 7 PANCRELIPASE 5,000 ...................................... 18 PANDEL ............................................................. 10 panobinostat lactate ........................................... 16 pantoprazole sodium ....................................... 18 PARAFON FORTE DSC .................................... 18 PARCOPA .......................................................... 18 paricalcitol......................................................... 12 PARLODEL ........................................................ 18 PARNATE............................................................. 6 paromomycin sulfate ....................................... 14 paroxetine hcl ..................................................... 6 PATADAY ........................................................... 12 PATANOL ........................................................... 12 PATHOCIL.......................................................... 14 PAXIL ................................................................... 6 pazopanib hydrochloride .................................... 16 PCE .................................................................... 14 PEDIAPRED ....................................................... 15 PEDIAZOLE ....................................................... 14 peg 3350/na sulf,bicarb,cl/kcl ......................... 16
PEGASYS .......................................................... 15 PEGASYS PROCLICK ....................................... 15 pegfilgrastim ....................................................... 13 peginterferon alfa-2a .......................................... 15 peginterferon beta-1a ......................................... 17 pegvisomant ....................................................... 12 pemirolast potassium ......................................... 12 penicillamine ....................................................... 15 penicillin v potassium ...................................... 14
pentamidine isethionate ..................................... 14 pentosan polysulfate sodium .............................. 19 pentoxifylline .................................................... 13 PEPCID .............................................................. 18 p-ephed hcl/cetirizine hcl (OTC) ....................... 6 p-ephed sul/loratadine ....................................... 6 PERCOCET........................................................ 17 PERCODAN ....................................................... 17 PERCOLONE ..................................................... 17 PERFOROMIST ................................................... 6 PERIDEX ............................................................ 17 PERISOL ............................................................ 17 permethrin ......................................................... 10 perphenazine ...................................................... 7 PERSANTINE .................................................... 13 phenazopyridine hcl......................................... 19
phenelzine sulfate ................................................ 6 PHENERGAN ....................................................... 6 PHENERGAN VC ................................................. 9 PHENERGAN VC W/CODEINE........................... 9 PHENERGAN W/CODEINE ................................. 9 PHENERGAN W/DEXTROMETHORPHAN ........ 9 phenobarbital ...................................................... 7 PHENOBARBITAL ............................................... 7 phenoxybenzamine hcl ...................................... 8 phenylephrine hcl/cod/prometh ....................... 9 phenylephrine hcl/prometh hcl ......................... 9 PHENYTEK ........................................................ 18 phenytoin .......................................................... 18 phenytoin sodium extended ........................... 18 PHOSLO ............................................................. 11 PHRENILIN ........................................................ 17 PHRENILIN FORTE ........................................... 17 phytonadione ...................................................... 13 PICATO .............................................................. 10 pilocarpine hcl ............................................ 12, 16 pindolol ................................................................ 8 pioglitazone hcl ................................................ 11 pioglitazone hcl/metformin hcl ............................ 11 pioglitazone/glimepiride .................................. 11 pirfenidone .......................................................... 17 piroxicam........................................................... 15 PLAN B ONE-STEP ............................................. 9 PLAQUENIL ....................................................... 14 PLAVIX ............................................................... 13 PLAVIX 300MG .................................................. 13 PLEGRIDY ......................................................... 17 PLEGRIDY PEN ................................................. 17 PLENDIL ............................................................... 8 PLETAL .............................................................. 13 PODHALER ........................................................ 14 podofilox ........................................................... 10
POLYCILLIN ....................................................... 14 POLYCIN-B ........................................................ 12 polyethylene glycol 3350 ................................. 16 polymyxin b sulfate/tmp .................................. 12 POLYTRIM ......................................................... 12 POLY-VI-FLOR .................................................. 19 POLY-VI-FLOR W/IRON .................................... 19 pomalidomide ..................................................... 16 POMALYST ........................................................ 16 ponatinib ............................................................. 16 potassium chloride .......................................... 11 potassium iodide .............................................. 12 POTASSIUM IODIDE ......................................... 12 POTIGA .............................................................. 18 PRALUENT .......................................................... 9 pramipexole di-hcl ............................................ 18 pramlintide acetate ............................................. 10 PRAMOSONE .................................................... 10 PRANDIMET ...................................................... 11 PRANDIN ........................................................... 11 prasugrel hcl ....................................................... 13 PRAVACHOL ....................................................... 9 pravastatin sodium ............................................ 9 praziquantel ........................................................ 14 prazosin hcl......................................................... 8
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37014 MedPerform High Formulary – April 2017 37
PRECOSE .......................................................... 10 PRED FORTE .................................................... 12 PRED MILD ........................................................ 12 PREDNISOL ....................................................... 12 prednisolone ..................................................... 15 prednisolone acetate ....................................... 12 prednisolone sod phosphate .................... 12, 15 prednisone ........................................................ 15 PREDNISONE INTENSOL ................................ 15 pregabalin ........................................................... 18 PREGNYL .......................................................... 11 PREMARIN................................................... 13, 19 PREMPHASE ..................................................... 13 PREMPRO ......................................................... 13 prenatal vit 15/iron cb/fa/dss........................... 19 prenatal vit 16/iron cb/fa/dss........................... 19 prenatal vit 18/iron cb/fa/dss........................... 19 prenatal vit 95/fe fum/fa ................................... 19 PRENATE GT .................................................... 19 PRENAVITE ....................................................... 19 PREVACID ......................................................... 18 PREVACID SOLUTABS ..................................... 18 PREVPAC .......................................................... 18 PREZCOBIX ....................................................... 14 PREZISTA .......................................................... 14 PRILOSEC ......................................................... 18 PRILOSEC OTC ................................................. 18 PRIMAQUINE ..................................................... 14 primaquine phosphate ........................................ 14 primidone .......................................................... 18 PRIMSOL ........................................................... 13 PRINIVIL ............................................................... 8 PRINZIDE ............................................................. 8 PRISTIQ ............................................................... 7 PROAIR HFA ....................................................... 6 PROAIR RESPICLICK ......................................... 6 PROAMATINE ...................................................... 9 probenecid ........................................................ 13 procainamide hcl ................................................ 7 procarbazine hcl ................................................. 16 PROCARDIA ........................................................ 8 PROCARDIA XL ................................................... 8 PROCHIEVE ...................................................... 11 prochlorperazine edisylate ................................... 6 prochlorperazine maleate .................................. 6 PROCRIT ........................................................... 13 PROCTOCORT .................................................. 16 PROCTOCREAM-HC......................................... 16 PROCTOFOAM-HC ........................................... 16 PROCTO-KIT ..................................................... 16 PROCYSBI ......................................................... 19 PROFASI ............................................................ 11 progesterone, micronized ............................. 11, 13 PROGRAF .......................................................... 13 PROLIXIN ............................................................. 7 PROLOPRIM ...................................................... 13 PROMACTA ....................................................... 13 promethazine hcl ................................................ 6 PROMETRIUM ................................................... 13 PRONESTYL ........................................................ 7 propafenone hcl ............................................. 7, 8
PROPINE ........................................................... 13 propranolol hcl ................................................... 8 propranolol/hydrochlorothiazid ........................ 8 propylthiouracil ................................................... 12 PROPYLTHIOURACIL ....................................... 12 PROSCAR .......................................................... 19 PROSED-DS ...................................................... 13 PROSOM .............................................................. 7 PROSTIGMIN ....................................................... 6 PROTONIX ......................................................... 18 PROTOPIC ......................................................... 10 PROVERA .......................................................... 13 PROVIGIL............................................................. 7 PROZAC ............................................................... 6 PROZAC WEEKLY .............................................. 6 PULMICORT FLEXHALER .................................. 6 PULMICORT RESPULES .................................... 6 PULMOZYME ..................................................... 17 PURINETHOL .................................................... 16 PURIXAN ............................................................ 16 pyrazinamide .................................................... 14 PYRAZINAMIDE ................................................ 14 PYRIDIUM .......................................................... 19 pyridostigmine bromide .................................... 6 pyrimethamine .................................................... 14
QNASL ................................................................. 6 QNASL CHILDREN .............................................. 6 QUALAQUIN ...................................................... 14 QUESTRAN.......................................................... 9 QUESTRAN LIGHT .............................................. 9 quetiapine fumarate ........................................... 7 QUILLIVANT XR .................................................. 7 QUINAGLUTE ...................................................... 7 quinapril hcl ........................................................ 8 quinapril/hydrochlorothiazide........................... 8 QUINIDEX ............................................................ 8 quinidine gluconate ........................................... 7 quinidine sulfate ................................................. 8 quinine sulfate .................................................. 14 QVAR ................................................................... 6 RAGWITEK .......................................................... 6 raloxifene hcl .................................................... 12 raltegravir potassium .......................................... 15 ramipril ................................................................ 8 RANEXA ............................................................... 9 ranitidine hcl ..................................................... 18 ranolazine ............................................................. 9 RAPAMUNE ....................................................... 13 rasagiline mesylate .......................................... 18 RAYALDEE ........................................................ 12 RAZADYNE .......................................................... 6 RAZADYNE ER .................................................... 6 REBETOL ........................................................... 15 REBIF ................................................................. 17 REBIF REBIDOSE ............................................. 17 REDERM ............................................................ 10 REGLAN ............................................................. 18 regorafenib ......................................................... 16 REGRANEX ....................................................... 11 RELAFEN ........................................................... 15 REMERON ........................................................... 6 RENAGEL .......................................................... 11 RENVELA ........................................................... 11 repaglinide ........................................................ 11 repaglinide/metformin hcl ............................... 11 REPATHA............................................................. 9 REPRONEX ....................................................... 11 REQUIP .............................................................. 18 REQUIP XL ........................................................ 18 RESCRIPTOR .................................................... 15 reserpine ............................................................. 8
RESTASIS .......................................................... 12 RESTASIS MULTIDOSE ................................... 12 RESTORIL............................................................ 7 RETROVIR ......................................................... 15 REVATIO TABLET ............................................... 8 REVIA ................................................................... 7 REVLIMID........................................................... 16 REXULTI .............................................................. 7 REYATAZ ........................................................... 15 RHEUMATREX .................................................. 15 ribavirin ....................................................... 14, 15 RIFADIN ............................................................. 14 RIFAMATE ......................................................... 14 rifampin ............................................................. 14 rifampin/isoniazid ............................................. 14
rifaximin .............................................................. 14 rilpivirine ............................................................. 15 rilpivirine/ emtricitabine/ tenofovir disoproxil
fumarate ....................................................... 15 riociguat ................................................................ 8 RIOMET .............................................................. 11 RISPERDAL ......................................................... 7 RISPERDAL M-TAB ............................................. 7 risperidone .......................................................... 7 risperidone ODT ................................................. 7 RITALIN ................................................................ 7 RITALIN LA .......................................................... 7 RITALIN-SR.......................................................... 7 ritonavir ............................................................... 15 rivaroxaban ......................................................... 13 rivastigmine ........................................................ 6 rivastigmine tartrate ........................................... 6 rizatriptan benzoate ......................................... 17 ROBAXIN ........................................................... 18 ROBAXIN-750 .................................................... 18 ROCALTROL ..................................................... 19 roflumilast ............................................................. 6 ROMYCIN ........................................................... 12 ropinirole hcl ..................................................... 18 rosuvastatin calcium.......................................... 9
rotigotine ............................................................. 18 ROWASA ............................................................ 15 ROXANOL .......................................................... 17 ROXICET ............................................................ 17 ROXICODONE ................................................... 17 ROXICODONE INTENSOL ................................ 17 RYTHMOL ............................................................ 7 RYTHMOL SR ...................................................... 8 SALAGEN........................................................... 16 salmeterol xinafoate ............................................. 6 salsalate ............................................................ 17 SANDIMMUNE ................................................... 13 SANDOSTATIN .................................................. 17 SAPHRIS .............................................................. 7 sapropterin dihydrochloride ................................ 16 saquinavir mesylate............................................ 15 sargramostim ...................................................... 13 SAVELLA ............................................................ 17 SCALACORT ..................................................... 10 SCALACORT DK ............................................... 10 SEASONALE ........................................................ 9 SECTRAL ............................................................. 8 secukinumab .................................................... 10 selegiline hcl ..................................................... 18 selenium sulfide ............................................... 10
selexipag .............................................................. 8 SELSUN RX ....................................................... 10 SELZENTRY ...................................................... 14 SEPTRA ............................................................. 13 SEPTRA DS ....................................................... 13 SERAX ................................................................. 7 SEREVENT DISKUS............................................ 6 SEROPHENE ..................................................... 11 SEROQUEL.......................................................... 7 SERPASIL ............................................................ 8 sertraline hcl ....................................................... 6 sevelamer carbonate .......................................... 11 sevelamer hcl ..................................................... 11 SFROWASA ....................................................... 15 short ragweed pollen extract ................................ 6 sildenafil citrate ............................................ 8, 11 SILVADENE ....................................................... 10 silver sulfadiazine ............................................ 10 SIMBRINZA ........................................................ 12 simvastatin .......................................................... 9 simvastatin (80mg only) .................................... 9
SINEMET 25-100 ............................................... 18 SINEMET CR ..................................................... 18 SINEQUAN ........................................................... 7 SINGULAIR .......................................................... 6 sirolimus ............................................................ 13 sitagliptin phos/metformin hcl ............................. 10 sitagliptin phosphate........................................... 10 SIVEXTRO ......................................................... 14 SKELAXIN .......................................................... 18 SLO-NIACIN ......................................................... 9 sod chloride/nahco3/kcl/peg's ........................ 16 sodium chloride for inhalation ............................ 17 sodium fluoride ................................................ 19 sodium phenylbutyrate .................................... 16 sodium polystyrene sulfonate ........................ 11
sofosbuvir ........................................................... 15 sofosbuvir/velpatasvir ......................................... 15 SOFTCLIX .......................................................... 11 SOMA ................................................................. 18 SOMA COMPOUND .......................................... 18 SOMA COMPOUND WITH CODEINE .............. 17 somatropin .......................................................... 12 SOMAVERT ....................................................... 12 SONATA ............................................................... 7 sonidegib phosphate .......................................... 16 sorafenib tosylate ............................................... 16 SORIATANE ....................................................... 10 sotalol hcl ............................................................ 8
SOTRET ............................................................... 9 SOVALDI ............................................................ 15 SPIRIVA ............................................................... 6 SPIRIVA RESPIMAT ............................................ 6 spironolactone .................................................... 8 SPORANOX ....................................................... 14 SPRYCEL ........................................................... 16 STAGESIC-10 .................................................... 17 STALEVO ........................................................... 18 STARLIX ............................................................. 11 stavudine ........................................................... 15 STELARA ........................................................... 15
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STELAZINE .......................................................... 7 STIOLTO RESPIMAT........................................... 6 STIVARGA ......................................................... 16 STRATTERA ........................................................ 7 STRIBILD ........................................................... 14 STRIVERDI RESPIMAT ....................................... 6 sucralfate........................................................... 18 sulconazole nitrate ............................................. 10 SULFAC ............................................................. 12 sulfacetamide sodium ............................... 10, 12 sulfadiazine ....................................................... 13 SULFADIAZINE .................................................. 13 sulfamethoxazole/trimethoprim ...................... 13 sulfanilamide....................................................... 19 sulfasalazine ..................................................... 15 sulfisoxazole acetyl ............................................ 13 sulindac ............................................................. 15 sumatriptan ....................................................... 17 sumatriptan succinate ..................................... 17 sunitinib malate .................................................. 16 SUPRAX ............................................................. 13 SUSTIVA ............................................................ 15 SUTENT ............................................................. 16 SYEDA ................................................................. 9 SYMBICORT ........................................................ 6 SYMBYAX ............................................................ 6 SYMLIN .............................................................. 10 SYMLINPEN 120 ................................................ 10 SYMLINPEN 60 .................................................. 10 SYMMETREL ..................................................... 18 SYNALAR ........................................................... 10 SYNJARDY ........................................................ 11 SYNTHROID ...................................................... 12 syringes & needles ............................................. 11 tacrolimus ......................................................... 10 tacrolimus anhydrous ...................................... 13 tadalafil ................................................................. 8 TAFINLAR .......................................................... 16 TAGAMET .......................................................... 18 TAGRISSO ......................................................... 16 TAKE ACTION ..................................................... 9 TALADINE .......................................................... 18 TAMBOCOR ......................................................... 7 TAMIFLU ............................................................ 14 tamoxifen citrate ............................................... 17 tamsulosin hcl .................................................. 19
TAPAZOLE ......................................................... 12 tapentadol ........................................................... 17 tapentadol hcl ER ............................................... 17 TARCEVA........................................................... 16 TARGRETIN ................................................. 10, 17 TASIGNA ............................................................ 16 tazarotene........................................................... 10 TAZORAC .......................................................... 10 tazorotene foam ................................................. 10 TECFIDERA ....................................................... 17 tedizolid phosphate ............................................ 14 teduglutide [rDNA origin] .................................... 16 TEGRETOL ........................................................ 18 TEGRETOL XR .................................................. 18 telbivudine .......................................................... 15 telithromycin ....................................................... 13 temazepam .......................................................... 7 TEMODAR.......................................................... 16 TEMOVATE ........................................................ 10 TEMOVATE EMOLLIENT .................................. 10 temozolomide ................................................... 16 TENEX .................................................................. 8 tenofovir disoproxil fumarate .............................. 15 TENORETIC 100 .................................................. 8 TENORETIC 50 .................................................... 8 TENORMIN .......................................................... 8 terazosin hcl ....................................................... 8 terbinafine hcl ............................................... 10, 14 terbutaline sulfate .............................................. 6 teriparatide.......................................................... 11 testosterone ...................................................... 13 testosterone 1% ................................................ 13 testosterone cypionate .................................... 13 testosterone gel 1.62% ...................................... 13 testosterone solution .......................................... 13 TESTRED ........................................................... 13 tetrabenazine ...................................................... 17 tetracycline hcl ................................................. 14 TEXACORT ........................................................ 10 thalidomide ......................................................... 14
THALITONE ......................................................... 8 THALOMID ......................................................... 14 THEO-24 .............................................................. 6 theophylline anhydrous ..................................... 6 THERMAZENE ................................................... 10 thioguanine ....................................................... 16 THIOGUANINE .................................................. 16 thioridazine hcl ................................................... 7 thiothixene .......................................................... 7
THORAZINE ......................................................... 7 thyroid, pork ........................................................ 12 TIAZAC ................................................................. 8 ticagrelor ............................................................. 13 TIKOSYN .............................................................. 8 timolol ................................................................. 12 timolol maleate ............................................. 8, 12 TIMOPTIC .......................................................... 12 TIMOPTIC-XE .................................................... 12 timothy grass pollen extract ................................. 6 tiotropium br/olodaterol hcl ................................... 6 tiotropium bromide ................................................ 6 tipranavir ............................................................. 14 tipranavir/vitamin e tpgs ..................................... 14 TIVICAY .............................................................. 15 tizanidine hcl ..................................................... 18
TOBI ................................................................... 14 TOBRADEX ........................................................ 12 tobramycin for inhalation ................................ 14 tobramycin sulfate ........................................... 12 tobramycin sulfate/dexameth ......................... 12 tobramycin/lotepred etab .................................... 12 TOBREX ............................................................. 12 tofacitinib citrate ................................................. 16 tofacitinib citrate XR ........................................... 16 TOFRANIL ............................................................ 7 tolazamide ......................................................... 11 tolbutamide ....................................................... 11 TOLECTIN 600 ................................................... 15 TOLINASE .......................................................... 11 tolmetin sodium ................................................ 15 tolterodine tartrate ........................................... 19 TOPAMAX .......................................................... 18 TOPAMAX SPRINKLE ....................................... 18 TOPICORT ......................................................... 10 TOPICORT LP ................................................... 10 topiramate........................................................... 18 topotecan hcl ...................................................... 16 TOPROL XL ......................................................... 8 TORADOL .......................................................... 15 toremifene citrate ................................................ 17 torsemide ............................................................ 8 TOUJEO ............................................................. 11 TOVIAZ ............................................................... 19 TRACLEER .......................................................... 8 TRADJENTA ...................................................... 10 tramadol hcl ...................................................... 17 tramadol hcl/acetaminophen .......................... 17 trametinib dimethyl sulfoxide .............................. 16 TRANDATE .......................................................... 8 trandolapril .......................................................... 8 TRANXENE T-TAB .............................................. 7 tranylcypromine sulfate ..................................... 6 TRAVATAN ........................................................ 12 TRAVATAN Z ..................................................... 13 travoprost ............................................................ 13 travoprost (benzalkonium) .............................. 12 trazodone hcl ...................................................... 6 TRENTAL ........................................................... 13 tretinoin ............................................................... 17 TREXALL ............................................................ 16 triamcinolone acetonide ........................ 6, 10, 17 triamterene/hydrochlorothiazid ........................ 8 TRIAZ ................................................................. 10 triazolam .............................................................. 7
TRIBENZOR ......................................................... 8 TRICOR ................................................................ 9 TRIDERM ........................................................... 10 TRIDESILON ...................................................... 10 trifluoperazine hcl .............................................. 7 trifluridine .......................................................... 12 trifluridine/tipiracil hcl .......................................... 16 TRIGLIDE 160MG ................................................ 9 trihexyphenidyl hcl........................................... 18 TRILAFON ............................................................ 7 TRILEPTAL ........................................................ 18 trimethoprim ..................................................... 13
TRI-NORINYL ...................................................... 9 TRINTELLIX ......................................................... 6 TRIUMEQ ........................................................... 14 TRI-VI-FLOR W/IRON ........................................ 19 TRIZIVIR ............................................................. 14 TROKENDI XR ................................................... 18 TRUSOPT .......................................................... 12 TRUVADA .......................................................... 14 TUSSIONEX ......................................................... 9 TYBOST ............................................................. 15 TYKERB ............................................................. 16 TYLENOL-CODEINE ......................................... 18 TYZEKA .............................................................. 15 ULORIC .............................................................. 13 ULTRACET......................................................... 17 ULTRAM ............................................................. 17 ULTRASE ........................................................... 18 ULTRASE MT ..................................................... 18 ULTRAVATE ...................................................... 10 UNIPHYL .............................................................. 6 UNIRETIC ............................................................. 8 UNIVASC .............................................................. 8 UPTRAVI .............................................................. 8 URECHOLINE .................................................... 16 URETRON D-S .................................................. 13 uridine triacetate ................................................. 17 URIN D.S. ........................................................... 13 UROXATRAL ..................................................... 19 URSO ................................................................. 16 URSO FORTE .................................................... 16 ursodiol ............................................................. 16 ustekinumab ....................................................... 15 VAGIFEM ........................................................... 19 valacyclovir hcl ................................................. 14 VALCHLOR ........................................................ 10 VALISONE.......................................................... 10 VALIUM ................................................................ 7 valproate sodium .............................................. 18 valproic acid ..................................................... 18 valsartan .............................................................. 8 valsartan/hydrochlorothiazide .......................... 8 VALTREX ........................................................... 14 VANCOCIN HCL ................................................ 14 vancomycin hcl ................................................ 14 VANDAZOLE ...................................................... 19 VANOS ............................................................... 10 VANOXIDE-HC .................................................... 9 VANSPAR ............................................................ 7 VANTIN .............................................................. 13 VASCEPA............................................................. 9 VASERETIC ......................................................... 8 VASOCIDIN ........................................................ 12 VASOTEC ............................................................ 8 V-CILLIN K ......................................................... 14 VECTICAL .......................................................... 19 vemurafenib ........................................................ 16 VENCLEXTA ...................................................... 16 venetoclax .......................................................... 16 venlafaxine hcl .................................................... 7 VENTOLIN HFA ................................................... 6 VEPESID ............................................................ 16 verapamil hcl ...................................................... 8 verapamil hcl ER ................................................ 8 VERELAN ............................................................. 8 VERELAN PM ...................................................... 8 VESANOID ......................................................... 17 VESTURA............................................................. 9 VFEND ............................................................... 14 VIAGRA .............................................................. 11 VIBRAMYCIN ..................................................... 14 VIBRAMYCIN SYRUP........................................ 14 VIBRAMYCIN 100MG CAPSULE ...................... 14 VICODIN ............................................................. 17 VICODIN ES ....................................................... 17 VICODIN HP....................................................... 17 VICON FORTE ................................................... 19 VICTOZA ............................................................ 11 VIDEX ................................................................. 15 VIDEX EC ........................................................... 15 VIGAMOX ........................................................... 12 Viibryd ................................................................. 22 VIIBRYD ............................................................... 6 VIMPAT .............................................................. 18 VIRACEPT.......................................................... 15 VIRAMUNE......................................................... 15 VIRAMUNE XR .................................................. 15
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VIRAZOLE .......................................................... 14 VIREAD .............................................................. 15 VIROPTIC........................................................... 12 VISKEN ................................................................ 8 vismodegib ......................................................... 16 VISTARIL .............................................................. 6 VISTOGARD ...................................................... 17 VIVELLE-DOT .................................................... 13 VOLTAREN .................................................. 12, 15 VOLTAREN GEL ................................................ 10 VOLTAREN-XR .................................................. 15 voriconazole ..................................................... 14 vorinostat ............................................................ 16 VOSOL ............................................................... 11 VOSOL HC ......................................................... 11 VOTRIENT ......................................................... 16 VRAYLAR ............................................................. 7 VYVANSE............................................................. 7 warfarin sodium ................................................ 13 WELCHOL ............................................................ 9 WELCHOL POWDER PACKETS ........................ 9 WELLBUTRIN ...................................................... 6 WELLBUTRIN SR ................................................ 6 WELLBUTRIN XL ................................................. 6 WESTCORT ....................................................... 10 WESTHROID...................................................... 12 XALATAN ........................................................... 12 XALKORI ............................................................ 16 XANAX ................................................................. 7 XARELTO ........................................................... 13 XELJANZ ............................................................ 16 XELJANZ XR ...................................................... 16 XELODA ............................................................. 16
XENAZINE.......................................................... 17 XIFAXAN 550MG ............................................... 14 XIIDRA ................................................................ 12 XODOL 10-300 ................................................... 17 XTANDI .............................................................. 16 XURIDEN ........................................................... 17 XYLOCAINE ....................................................... 15 XYZAL TABS ........................................................ 6 YASMIN 28 ........................................................... 9 YAZ ....................................................................... 9 YODOXIN ........................................................... 14 zaleplon ............................................................... 7 ZANAFLEX ......................................................... 18 ZANTAC ............................................................. 18 ZARAH ................................................................. 9 ZARONTIN ......................................................... 18 ZAROXOLYN ....................................................... 8 ZEBETA ................................................................ 8 ZELBORAF......................................................... 16 ZEMPLAR........................................................... 12 ZENATANE .......................................................... 9 ZENPEP ............................................................. 18 ZENZEDI .............................................................. 7 ZERIT ................................................................. 15 ZESTORETIC ....................................................... 8 ZESTRIL ............................................................... 8 ZETIA ................................................................... 9 ZIAC ..................................................................... 8 ZIAGEN .............................................................. 15 ZIANA ................................................................... 9 zidovudine ......................................................... 15 ziprasidone hcl ................................................... 7 ZIRGAN .............................................................. 12
ZITHROMAX ...................................................... 13 ZITHROMAX TRI-PAK ....................................... 13 ZMAX .................................................................. 14 ZMAX PEDIATRIC ............................................. 14 ZOCOR ................................................................. 9 ZOFRAN ............................................................... 6 ZOFRAN ODT ...................................................... 6 ZOLINZA ............................................................ 16 zolmitriptan ....................................................... 17
ZOLOFT ............................................................... 6 zolpidem tartrate ................................................ 7 ZOLPIDEM TARTRATE ER ................................. 7 ZOMIG ................................................................ 17 ZOMIG ZMT ....................................................... 17 ZONEGRAN ....................................................... 18 zonisamide ........................................................ 18 ZORTRESS ........................................................ 13 ZOVIRAX ............................................................ 14 ZOVIRAX CREAM .............................................. 10 ZOVIRAX OINTMENT ........................................ 10 ZUBSOLV ........................................................... 18 ZURAMPIC ......................................................... 13 ZYDELIG ............................................................ 16 ZYKADIA ............................................................ 16 ZYLET ................................................................ 12 ZYLOPRIM ......................................................... 13 ZYMAXID ............................................................ 12 ZYPREXA ............................................................. 7 ZYPREXA ZYDIS ................................................. 7 ZYRTEC (OTC) .................................................... 6 ZYRTEC-D (OTC) ................................................ 6 ZYTIGA ............................................................... 16 ZYVOX ............................................................... 14