Download Formulary with Specialty Drug Tier

Kaiser Permanente Point-of-Service Drug
Formulary with Specialty Drug Tier
For California Point-of-Service (POS) Plans*
Effective January 1, 2016
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION REGARDING THE DRUGS
THAT ARE COVERED WHEN YOU PARTICIPATE IN OUR POS HEALTH INSURANCE
PLAN(S) AND USE A MEDIMPACT PHARMACY. IF YOU BELONG TO OUR POS PLAN
AND YOU INTEND TO FILL YOUR PRESCRIPTIONS AT A KAISER PERMANENTE
PHARMACY, PLEASE VISIT KP.ORG/FORMULARY FOR DETAILS ON THE DRUGS
COVERED THROUGH YOUR TIER 1 BENEFIT.
This formulary was updated on December 22, 2015, and is effective on January 1, 2016. For
more recent information or other questions, please call MedImpact 24 hours a day, 7 days a
week (closed holidays), at 1-800-788-2949. You can also view the Kaiser Permanente Point-ofService (POS) Formulary with Specialty Drug Tier on our website at kp.org/kpic.
What is the Kaiser Permanente Point-of-Service (POS) Formulary with Specialty Drug
Tier?
The Kaiser Permanente POS Formulary with Specialty Drug Tier is an open formulary of
unrestricted drugs that are covered under your POS health insurance plan’s Tier 2 benefit. The
formulary consists of generic, brand, and specialty drugs when you use a MedImpact pharmacy.
Unless specifically excluded under your plan, all FDA-approved drugs are part of your plan’s
open formulary.
What drugs are covered?
Kaiser Permanente will generally cover prescribed generic, brand-name, and specialty drugs
listed on the Kaiser Permanente POS Formulary with Specialty Drug Tier as long as the drug is
medically necessary, the prescription is filled at a MedImpact pharmacy, and other coverage
rules are followed.
POS Formulary with Specialty Tier – Last revised 12/22/2015, 1
Additionally, your plan covers certain preventive drugs at no cost share when prescribed by a
physician. Contraceptives for women, tobacco-cessation drugs, and certain over-the-counter
drugs (such as aspirin, iron supplements, folic acid supplements, vitamin D, and oral fluoride
supplements) are covered at no cost share regardless of the drug tier indicated on the Kaiser
Permanente POS Formulary with Specialty Drug Tier. For more information about coverage of
preventive drugs, please refer to the “Preventive Care under the General Benefits” section of
your Certificate of Insurance.
What drugs are not covered?
Drugs not listed on the Kaiser Permanente POS Formulary with Specialty Drug Tier are not
covered.
Are there any restrictions on the drugs covered on the Kaiser Permanente POS
Formulary with Specialty Drug Tier?
There are no step therapy or prior authorization requirements for any drugs covered under your
plan. However, for certain drugs, Kaiser Permanente may limit the amount of the drug
dispensed to a certain days’ supply. Generic and brand drugs are limited to 100 days of supply
and specialty drugs are limited to 30 days of supply.
What is a generic drug?
A generic drug is approved by the FDA as having the same active ingredient as the brand-name
drug. Generally, generic drugs cost less than brand-name drugs. Under your POS Plan, you will
pay different amounts for preferred generic drugs and non-preferred generic drugs. Preferred
drugs cost you less than non-preferred drugs.
What is a brand-name drug?
Brand-name drugs are usually manufactured and sold by the drug company that originally
researched and developed the drug. When the patent on a brand-name drug expires, other drug
companies may manufacture and sell an FDA-approved generic version of the drug with the
same active ingredient(s) at lower prices.
Under your POS Plan, you will pay different amounts for preferred brand drugs and nonpreferred brand drugs. Preferred drugs cost you less than non-preferred drugs.
If you request a brand-name drug when a generic drug is prescribed, you may be responsible
for paying the brand-name copay plus the difference in cost between the generic drug and the
brand-name drug. Please see your Certificate of Insurance for details.
POS Formulary with Specialty Tier – Last revised 12/22/2015, 2
What is a specialty drug?
Specialty drugs are high-cost prescription medications that are used to treat complex and
chronic conditions, such as multiple sclerosis, rheumatoid arthritis, and hepatitis C. Specialty
drugs often require special handling, administration, or monitoring. Under your POS Plan, you
will pay different amounts for preferred specialty drugs and non-preferred specialty drugs.
Preferred drugs cost you less than non-preferred drugs.
What drugs are eligible to be mailed from the mail-order pharmacy?
This drug formulary only applies to drugs obtained at a MedImpact retail pharmacy. There is no
mail-order pharmacy coverage available through MedImpact pharmacies. Mail-order pharmacy
coverage is provided by the Kaiser Permanente mail-order pharmacy. Please refer to your
Evidence of Coverage or visit kp.org/formulary for details of this benefit.
Kaiser Permanente POS Formulary with Specialty Drug Tier
The most current drug formulary list begins on page 4. It provides information about the drugs
covered by Kaiser Permanente. All dosage forms and strengths for a particular drug may not
appear on the formulary. Some drugs have multiple dosage forms. In such cases, some
dosages may be listed on the formulary and others may not. In cases where a particular drug
has multiple dosage forms and/or strengths, the drug may be associated with multiple drug tiers.
You can call MedImpact at 1-800-788-2949 to confirm which cost-sharing tier applies for the
specific dosage form and strength you want.
Kaiser Permanente may add or remove drugs from the Kaiser Permanente POS Formulary with
Specialty Drug Tier during the year. These changes to the formulary are based on new
information or new drugs that become available.
Tier designations
The table below identifies drugs based on their drug category – preferred generic (Tier 1),
preferred brand (Tier 2), non-preferred generic or brand (Tier 3), preferred specialty (Tier 4), or
non-preferred specialty (Tier 5). Typically, you will pay a copay for generic and brand drugs and
a coinsurance for specialty drugs as shown in your Schedule of Coverage. Certain preventive
drugs, however, are covered at no cost to you. Those drugs are indicated with a “+” (for
example, 1+ or 2+).
*Kaiser Foundation Health Plan, Inc. (KFHP), underwrites the HMO portion of the Kaiser Permanente POS Plan and
Kaiser Permanente Insurance Company (KPIC), a subsidiary of KFHP, underwrites the PPO and Out-of-Network
portions of the Kaiser Permanente POS Plan.
POS Formulary with Specialty Tier – Last revised 12/22/2015, 3
DRUG CATEGORY & NAME
ALLERGY
2ND GEN ANTIHISTAMINE & DECONGESTANT COMBINATIONS
CLARINEX-D 12 HOUR
SEMPREX-D
ALLERGENIC EXTRACTS, THERAPEUTICS
ASPERGILLUS FUMIGATUS
GRASTEK
ORALAIR
RAGWITEK
ANTIHISTAMINES - 1ST GENERATION
CARBINOXAMINE MALEATE
CLEMASTINE FUMARATE
CYPROHEPTADINE HCL
DIPHENHYDRAMINE HCL
HYDROXYZINE HCL
HYDROXYZINE PAMOATE
KARBINAL ER
PROMETHAZINE HCL
VISTARIL
ANTIHISTAMINES - 2ND GENERATION
CETIRIZINE HCL
CLARINEX
DESLORATADINE
FEXOFENADINE HCL
LEVOCETIRIZINE DIHYDROCHLORIDE
XYZAL
ZYRTEC
NASAL ANTIHISTAMINE
ASTEPRO
AZELASTINE HCL
OLOPATADINE HCL
PATANASE
NASAL ANTIHISTAMINE & ANTI-INFLAM. STEROID COMB.
DYMISTA
NASAL ANTI-INFLAMMATORY STEROIDS
BECONASE AQ
BUDESONIDE
FLUNISOLIDE
FLUTICASONE PROPIONATE
NASONEX
OMNARIS
QNASL
QNASL CHILDREN
RHINOCORT AQUA
TRIAMCINOLONE ACETONIDE
VERAMYST
ZETONNA
DRUG TIER
2
2
2
2
2
2
1
1, 2
1
1
1
1, 2
2
1, 2
2
1
2
1
1
1
2
2
2
1
1
2
2
2
1
1
1
2
2
2
2
2
1
2
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 4
DRUG CATEGORY & NAME
ANTIEMESIS/ANTIVERTIGO
ANTIEMETIC/ANTIVERTIGO AGENTS
AKYNZEO
ANTIVERT
ANZEMET
CESAMET
COMPAZINE
DEXTROSE/FRUCTOSE/SODIUM CIT
DICLEGIS
DRONABINOL
EMEND
GRANISETRON HCL
MARINOL
MECLIZINE HCL
ONDANSETRON
ONDANSETRON HCL
PROCHLORPERAZINE
PROCHLORPERAZINE MALEATE
PROMETHAZINE HCL
SANCUSO
TIGAN
TRANSDERM-SCOP
TRIMETHOBENZAMIDE HCL
ZOFRAN
ZOFRAN ODT
ZUPLENZ
ASTHMA AND COPD
5-LIPOXYGENASE INHIBITORS
ZILEUTON
ZYFLO
ZYFLO CR
ADRENERGIC AGENTS,CATECHOLAMINES
EPINEPHRINE
BETA-ADRENERGIC AGENTS
ALBUTEROL SULFATE
ARCAPTA NEOHALER
BROVANA
FORADIL
LEVALBUTEROL HCL
METAPROTERENOL SULFATE
PERFOROMIST
PROAIR HFA
PROAIR RESPICLICK
PROVENTIL HFA
SEREVENT DISKUS
STRIVERDI RESPIMAT
TERBUTALINE SULFATE
DRUG TIER
2
2
2
2
2
1
2
1
2
1
2
1
1
1
1
1
1
2
2
2
1
2
2
2
4
4
4
1
1
2
2
2
1
2
2
2
2
2
2
2
1
POS Formulary with Specialty Tier – Last revised 12/22/2015, 5
DRUG CATEGORY & NAME
VENTOLIN HFA
VOSPIRE ER
XOPENEX
XOPENEX CONCENTRATE
XOPENEX HFA
BETA-ADRENERGIC AND ANTICHOLINERGIC COMBINATIONS
ANORO ELLIPTA
COMBIVENT RESPIMAT
IPRATROPIUM/ALBUTEROL SULFATE
STIOLTO RESPIMAT
BETA-ADRENERGIC AND GLUCOCORTICOID COMBINATIONS
ADVAIR DISKUS
ADVAIR HFA
BREO ELLIPTA
DULERA
SYMBICORT
GENERAL BRONCHODILATOR AGENTS
ATROVENT HFA
INCRUSE ELLIPTA
IPRATROPIUM BROMIDE
SPIRIVA
SPIRIVA RESPIMAT
TUDORZA PRESSAIR
GLUCOCORTICOIDS, ORALLY INHALED
AEROSPAN
ALVESCO
ARNUITY ELLIPTA
ASMANEX
ASMANEX HFA
BUDESONIDE
FLOVENT DISKUS
FLOVENT HFA
PULMICORT
PULMICORT FLEXHALER
QVAR
LEUKOTRIENE RECEPTOR ANTAGONISTS
ACCOLATE
MONTELUKAST SODIUM
SINGULAIR
ZAFIRLUKAST
MAST CELL STABILIZERS
CROMOLYN SODIUM
GASTROCROM
MONOCLONAL ANTIBODIES TO IMMUNOGLOBULIN E(IGE)
OMALIZUMAB
XOLAIR
PHOSPHODIESTERASE-4 (PDE4) INHIBITORS
DRUG TIER
2
2
2
2
2
2
2
1
2
2
2
2
2
2
2
2
1
2
2
2
2
2
2
2
2
1
2
2
2
2
2
2
1
2
1
1, 2, 4
4
4
4
POS Formulary with Specialty Tier – Last revised 12/22/2015, 6
DRUG CATEGORY & NAME
DALIRESP
RESPIRATORY AIDS,DEVICES,EQUIPMENT
ACE AEROSOL CLOUD ENHANCER
AEROBIKA
AEROCHAMBER MINI
AEROCHAMBER MV
AEROCHAMBER PLUS FLOW-VU
AEROCHAMBER PLUS Z STAT
AEROCHAMBER WITH FLOWSIGNAL
AEROCHAMBER Z-STAT PLUS
AEROECLIPSE
AEROECLIPSE II
AEROGEAR ASTHMA ACTION KIT
AERONEB GO NEBULISER
AEROTRACH PLUS
ALTERA NEBULIZER
ASTHMAPACK CHILDREN'S
BABY NEBULIZER
BREATHERITE
BREATHRITE
COMPACT SPACE CHAMBER PLUS
COMP-AIR ELITE COMPRESSOR SYST
COMP-AIR NEBULIZER COMPRESSOR
DEVILBISS PULMO-AIDE
DEVILBISS PULMONEB LT COMP-NEB
DEVILBISS TRAVELER
EASIVENT
ERAPID NEBULIZER
E-Z SPACER
FLEXICHAMBER
FLUTTER
INNOSPIRE DELUXE
INNOSPIRE ELEGANCE
INNOSPIRE ESSENCE
INNOSPIRE MINI
INSPIRACHAMBER
INSPIRATION
INSPIRATION ELITE
LC D NEBULIZER SET
LC PLUS
LC SPRINT NEBULIZER
LC STAR
LITEAIRE
LITETOUCH
MICRO ELITE
MICRO PLUS
MICROCHAMBER
DRUG TIER
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 7
DRUG CATEGORY & NAME
MICROSPACER
MINI PLUS NEBULIZER
MINIELITE
MINI-WRIGHT PEAK FLOW METER
MONAGHAN Z STAT
NASONEB NASAL NEBULIZER
OPTICHAMBER
OPTICHAMBER DIAMOND
PARI LC SPRINT SINUS
PARI SINUS AEROSOL SYSTEM
PFLEX TRAINER
POCKET CHAMBER
PRIMEAIRE
PROCHAMBER
PRODIGY MINI-MIST
PRONEB ULTRA II
PROVENT
PULMO-AIDE
QUAKE
RITEFLO
SAMI THE SEAL
SIDESTREAM
SIDESTREAM NEBULIZER
SIDESTREAM PLUS
SILICONE MASK
SINUSTAR
SPACE CHAMBER PLUS
SUNRISE COMPRESSOR-NEBULIZER
THRESHOLD IMT
THRESHOLD PEP
TREK S COMBO PACK
TREK S COMPACT COMPRESSOR
TRUZONE PEAK FLOW METER
VIOS AEROSOL DELIVERY SYSTEM
VORTEX
VORTEX VHC FROG MASK
VORTEX VHC LADYBUG MASK
XANTHINES
CAFFEINE CITRATED
ELIXOPHYLLIN
THEO-24
THEOPHYLLINE
THEOPHYLLINE ANHYDROUS
AUTONOMIC NERVOUS SYSTEM DISORDERS
ALZHEIMER'S THERAPY, NMDA RECEPTOR ANTAGONISTS
MEMANTINE HCL
NAMENDA
DRUG TIER
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
2
2
2
1
1
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 8
DRUG CATEGORY & NAME
NAMENDA XR
ALZHEIMER'S THX,NMDA RECEPT ANTAG & CHOLINES INHIB
NAMZARIC
CHOLINESTERASE INHIBITORS
ARICEPT
DONEPEZIL HCL
EXELON
GALANTAMINE HBR
GALANTAMINE HYDROBROMIDE
MESTINON
PYRIDOSTIGMINE BROMIDE
RAZADYNE
RAZADYNE ER
RIVASTIGMINE TARTRATE
BEHAVIORAL HEALTH - ANTIDEPRESSANTS
ALPHA-2 RECEPTOR ANTAGONIST ANTIDEPRESSANTS
MIRTAZAPINE
REMERON
MAOIS - NON-SELECTIVE & IRREVERSIBLE
MARPLAN
NARDIL
PARNATE
PHENELZINE SULFATE
TRANYLCYPROMINE SULFATE
NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIB (NDRIS)
APLENZIN
BUPROPION HCL
FORFIVO XL
WELLBUTRIN
WELLBUTRIN SR
WELLBUTRIN XL
SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS)
BRISDELLE
CELEXA
CITALOPRAM HYDROBROMIDE
ESCITALOPRAM OXALATE
FLUOXETINE HCL
FLUVOXAMINE MALEATE
LEXAPRO
PAROXETINE HCL
PAXIL
PAXIL CR
PEXEVA
PROZAC
PROZAC WEEKLY
SARAFEM
SERTRALINE HCL
DRUG TIER
2
2
2
1
2
1
2
2
1
2
2
1
1
2
2
2
2
1
1
2
1
2
2
2
2
2
2
1
1
1, 2
1
2
1
2
2
2
2
2
2
1
POS Formulary with Specialty Tier – Last revised 12/22/2015, 9
DRUG CATEGORY & NAME
ZOLOFT
SEROTONIN-2 ANTAGONIST/REUPTAKE INHIBITORS (SARIS)
NEFAZODONE HCL
OLEPTRO ER
TRAZODONE HCL
SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS)
CYMBALTA
DESVENLAFAXINE ER
DESVENLAFAXINE FUMARATE ER
DULOXETINE HCL
EFFEXOR XR
FETZIMA
IRENKA
KHEDEZLA
PRISTIQ ER
VENLAFAXINE HCL
VENLAFAXINE HCL ER
SSRI & 5HT1A PARTIAL AGONIST ANTIDEPRESSANT
VIIBRYD
SSRI & SEROTONIN RECEPTOR MODULATOR ANTIDEPRESSANT
BRINTELLIX
TRICYCLIC ANTIDEPRESSANT/BENZODIAZEPINE COMBINATNS
CHLORDIAZEPOXIDE-AMITRIPTYLINE
TRICYCLIC ANTIDEPRESSANT/PHENOTHIAZINE COMBINATNS
PERPHENAZINE-AMITRIPTYLINE
TRICYCLIC ANTIDEPRESSANTS & REL. NON-SEL. RU-INHIB
AMITRIPTYLINE HCL
AMOXAPINE
ANAFRANIL
CLOMIPRAMINE HCL
DESIPRAMINE HCL
DOXEPIN HCL
IMIPRAMINE HCL
IMIPRAMINE PAMOATE
MAPROTILINE HCL
NORPRAMIN
NORTRIPTYLINE HCL
PAMELOR
PROTRIPTYLINE HCL
SURMONTIL
TOFRANIL
TOFRANIL-PM
BEHAVIORAL HEALTH - OTHER
ADRENERGICS, AROMATIC, NON-CATECHOLAMINE
ADDERALL
ADDERALL XR
DESOXYN
DRUG TIER
2
1, 2
2
1
2
2
2
1, 2
2
2
2
2
2
1
2
2
2
2
2
1
2
2
1
1
1, 2
1
1
2
2
1, 2
2
1
2
2
2
2
2
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 10
DRUG CATEGORY & NAME
DEXEDRINE
DEXTROAMPHETAMINE SULFATE
DEXTROAMPHETAMINE/AMPHETAMINE
EVEKEO
METHAMPHETAMINE HCL
PROCENTRA
VYVANSE
ZENZEDI
ANTI-ALCOHOLIC PREPARATIONS
ACAMPROSATE CALCIUM
ANTABUSE
DISULFIRAM
ANTI-ANXIETY DRUGS
ALPRAZOLAM
ALPRAZOLAM INTENSOL
ATIVAN
BUSPIRONE HCL
CHLORDIAZEPOXIDE HCL
CLORAZEPATE DIPOTASSIUM
DIAZEPAM
LORAZEPAM
LORAZEPAM INTENSOL
MEPROBAMATE
OXAZEPAM
TRANXENE T-TAB
VALIUM
XANAX
XANAX XR
ANTI-MANIA DRUGS
EQUETRO
LITHIUM
LITHIUM CARBONATE
LITHOBID
ANTI-NARCOLEPSY & ANTI-CATAPLEXY,SEDATIVE-TYPE AGT
SODIUM OXYBATE
XYREM
ANTIPSYCH,DOPAMINE ANTAG.,DIPHENYLBUTYLPIPERIDINES
ORAP
ANTIPSYCHOTICS, ATYP, D2 PARTIAL AGONIST/5HT MIXED
ABILIFY
ARIPIPRAZOLE
REXULTI
ANTIPSYCHOTICS, DOPAMINE & SEROTONIN ANTAGONISTS
ADASUVE
LOXAPINE SUCCINATE
ANTIPSYCHOTICS,ATYPICAL,DOPAMINE,& SEROTONIN ANTAG
CLOZAPINE
DRUG TIER
2
1
1
2
1
2
2
2
1
2
1
1
2
2
1
1
1
1, 2
1
2
1
1
2
2
2
2
2
2
1, 2
2
4
4
2
2
1
2
2
1
1
POS Formulary with Specialty Tier – Last revised 12/22/2015, 11
DRUG CATEGORY & NAME
CLOZAPINE ODT
CLOZARIL
FANAPT
FAZACLO
GEODON
INVEGA
LATUDA
OLANZAPINE
QUETIAPINE FUMARATE
RISPERDAL
RISPERDAL M-TAB
RISPERIDONE
SAPHRIS
SEROQUEL
SEROQUEL XR
VERSACLOZ
ZIPRASIDONE HCL
ZYPREXA
ZYPREXA ZYDIS
ANTIPSYCHOTICS,DOPAMINE ANTAGONISTS, THIOXANTHENES
THIOTHIXENE
ANTIPSYCHOTICS,DOPAMINE ANTAGONISTS,BUTYROPHENONES
HALOPERIDOL
HALOPERIDOL LACTATE
ANTI-PSYCHOTICS,PHENOTHIAZINES
CHLORPROMAZINE HCL
FLUPHENAZINE HCL
PERPHENAZINE
THIORIDAZINE HCL
TRIFLUOPERAZINE HCL
BARBITURATES
BUTISOL SODIUM
PHENOBARBITAL
SECONAL SODIUM
HYPNOTICS, MELATONIN MT1/MT2 RECEPTOR AGONISTS
HETLIOZ
ROZEREM
TASIMELTEON
MONOAMINE OXIDASE(MAO) INHIBITORS
EMSAM
NARCOLEPSY AND SLEEP DISORDER THERAPY AGENTS
MODAFINIL
NUVIGIL
PROVIGIL
NARCOTIC ANTAGONISTS
NALTREXONE HCL
REVIA
DRUG TIER
2
2
2
2
2
2
2
1
1
2
2
1
2
2
2
2
1
2
2
1
1
1
1
1, 2
1
1
1
2
1, 2
2
4
2
4
2
1
2
2
1
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 12
DRUG CATEGORY & NAME
SEDATIVE-HYPNOTICS,NON-BARBITURATE
AMBIEN
AMBIEN CR
BELSOMRA
EDLUAR
ESTAZOLAM
ESZOPICLONE
FLURAZEPAM HCL
HALCION
INTERMEZZO
LUNESTA
MIDAZOLAM HCL
RESTORIL
SILENOR
SONATA
TEMAZEPAM
TRIAZOLAM
ZALEPLON
ZOLPIDEM TARTRATE
ZOLPIMIST
SSRI &ANTIPSYCH,ATYP,DOPAMINE&SEROTONIN ANTAG COMB
OLANZAPINE/FLUOXETINE HCL
SYMBYAX
TX FOR ADHD - SELECTIVE ALPHA-2A RECEPTOR AGONIST
CLONIDINE HCL
GUANFACINE HCL
INTUNIV
KAPVAY
TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY
APTENSIO XR
CONCERTA
DAYTRANA
DEXMETHYLPHENIDATE HCL
FOCALIN
FOCALIN XR
METADATE CD
METHYLIN
METHYLPHENIDATE ER
METHYLPHENIDATE HCL
QUILLIVANT XR
RITALIN
RITALIN LA
TX FOR ATTENTION DEFICIT-HYPERACT.(ADHD), NRI-TYPE
STRATTERA
CARDIOVASCULAR DISEASE - ARRHYTHMIA
ANTIARRHYTHMICS
AMIODARONE HCL
DRUG TIER
2
2
2
2
1
1
2
2
2
2
1
2
2
2
1
1
1
1
2
1
2
1
1
2
2
2
2
2
1
2
2
2
2
2
1
2
2
2
2
1
POS Formulary with Specialty Tier – Last revised 12/22/2015, 13
DRUG CATEGORY & NAME
CORDARONE
DISOPYRAMIDE PHOSPHATE
FLECAINIDE ACETATE
MEXILETINE HCL
MULTAQ
NORPACE
NORPACE CR
PROPAFENONE HCL
QUINIDINE GLUCONATE
QUINIDINE SULFATE
RYTHMOL
RYTHMOL SR
TIKOSYN
CARDIOVASCULAR DISEASE - CARDIAC STIMULANT
DIGITALIS GLYCOSIDES
DIGOXIN
LANOXIN
CARDIOVASCULAR DISEASE - HYPERTENSION
ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATION
AMLODIPINE BESYLATE/BENAZEPRIL
LOTREL
PRESTALIA
TARKA
TRANDOLAPRIL/VERAPAMIL HCL
ACE INHIBITOR/THIAZIDE & THIAZIDE-LIKE DIURETIC
ACCURETIC
BENAZEPRIL/HYDROCHLOROTHIAZIDE
CAPTOPRIL-HYDROCHLOROTHIAZIDE
ENALAPRIL/HYDROCHLOROTHIAZIDE
FOSINOPRIL/HYDROCHLOROTHIAZIDE
LISINOPRIL/HYDROCHLOROTHIAZIDE
LOTENSIN HCT
MOEXIPRIL/HYDROCHLOROTHIAZIDE
QUINAPRIL/HYDROCHLOROTHIAZIDE
VASERETIC
ZESTORETIC
ALPHA/BETA-ADRENERGIC BLOCKING AGENTS
CARVEDILOL
COREG
COREG CR
LABETALOL HCL
TRANDATE
ALPHA-ADRENERGIC BLOCKING AGENTS
CARDURA
CARDURA XL
DIBENZYLINE
DOXAZOSIN MESYLATE
DRUG TIER
2
1
1
1
2
2
2
1
1
1, 2
2
2
2
1, 2
2
1
2
2
2
1
2
1
2
1
1
1
2
1
1
2
2
1
2
2
1
2
2
2
2
1
POS Formulary with Specialty Tier – Last revised 12/22/2015, 14
DRUG CATEGORY & NAME
MINIPRESS
PHENOXYBENZAMINE HCL
PRAZOSIN HCL
TERAZOSIN HCL
ANGIOTEN.RECEPTR ANTAG./CAL.CHANL BLKR/THIAZIDE CB
AMLODIPINE/VALSARTAN/HCTHIAZID
EXFORGE HCT
TRIBENZOR
ANGIOTENSIN RECEPTOR ANTAG./THIAZIDE DIURETIC COMB
ATACAND HCT
AVALIDE
BENICAR HCT
CANDESARTAN/HYDROCHLOROTHIAZID
DIOVAN HCT
EDARBYCLOR
HYZAAR
IRBESARTAN/HYDROCHLOROTHIAZIDE
LOSARTAN/HYDROCHLOROTHIAZIDE
MICARDIS HCT
TELMISARTAN/HYDROCHLOROTHIAZID
TEVETEN HCT
VALSARTAN/HYDROCHLOROTHIAZIDE
ANGIOTENSIN RECEPTOR ANTGNST & CALC.CHANNEL BLOCKR
AMLODIPINE/VALSARTAN
AZOR
EXFORGE
TELMISARTAN/AMLODIPINE
TWYNSTA
ANTIHYPERTENSIVES, ACE INHIBITORS
ACCUPRIL
ACEON
ALTACE
BENAZEPRIL HCL
CAPTOPRIL
ENALAPRIL MALEATE
EPANED
FOSINOPRIL SODIUM
LISINOPRIL
LOTENSIN
MAVIK
MOEXIPRIL HCL
PERINDOPRIL ERBUMINE
PRINIVIL
QUINAPRIL HCL
RAMIPRIL
TRANDOLAPRIL
VASOTEC
DRUG TIER
2
1
1
1
1
2
2
2
2
2
1
2
2
2
1
1
2
1
2
1
1
2
2
1
2
2
2
2
1
1
1
2
1
1
2
2
1
1
2
1
1
1
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 15
DRUG CATEGORY & NAME
ZESTRIL
ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONIST
ATACAND
AVAPRO
BENICAR
CANDESARTAN CILEXETIL
COZAAR
DIOVAN
EDARBI
EPROSARTAN MESYLATE
IRBESARTAN
LOSARTAN POTASSIUM
MICARDIS
TELMISARTAN
VALSARTAN
ANTIHYPERTENSIVES, GANGLIONIC BLOCKERS
MECAMYLAMINE HCL
VECAMYL
ANTIHYPERTENSIVES, MISCELLANEOUS
DEMSER
ANTIHYPERTENSIVES, SYMPATHOLYTIC
CATAPRES
CATAPRES-TTS 1
CATAPRES-TTS 2
CATAPRES-TTS 3
CLONIDINE
CLONIDINE HCL
CLORPRES
GUANFACINE HCL
METHYLDOPA
METHYLDOPA-HYDROCHLOROTHIAZIDE
RESERPINE
TENEX
ANTIHYPERTENSIVES, VASODILATORS
HYDRALAZINE HCL
MINOXIDIL
BETA-ADRENERGIC BLOCKING AGENTS
ACEBUTOLOL HCL
ATENOLOL
BETAPACE
BETAPACE AF
BETAXOLOL HCL
BISOPROLOL FUMARATE
BYSTOLIC
CORGARD
HEMANGEOL
INDERAL LA
DRUG TIER
2
2
2
2
1
2
2
2
2
1
1
2
1
1
4
4
2
2
2
2
2
1
1
2
1
1
2
2
2
1
1
1
1
2
2
1
1
2
2
2
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 16
DRUG CATEGORY & NAME
INDERAL XL
INNOPRAN XL
LEVATOL
LOPRESSOR
METOPROLOL SUCCINATE
METOPROLOL TARTRATE
NADOLOL
PINDOLOL
PROPRANOLOL HCL
SECTRAL
SOTALOL HCL
SOTYLIZE
TENORMIN
TIMOLOL MALEATE
TOPROL XL
ZEBETA
BETA-ADRENERGIC BLOCKING AGENTS/THIAZIDE & RELATED
ATENOLOL/CHLORTHALIDONE
BISOPROLOL FUMARATE/HCTZ
CORZIDE
DUTOPROL
LOPRESSOR HCT
METOPROLOL/HYDROCHLOROTHIAZIDE
NADOLOL/BENDROFLUMETHIAZIDE
PROPRANOLOL-HYDROCHLOROTHIAZID
TENORETIC 100
TENORETIC 50
ZIAC
CALCIUM CHANNEL BLOCKING AGENTS
ADALAT CC
AMLODIPINE BESYLATE
CALAN
CALAN SR
CARDENE SR
CARDIZEM
CARDIZEM CD
CARDIZEM LA
DILTIAZEM HCL
FELODIPINE
FELODIPINE ER
ISRADIPINE
NICARDIPINE HCL
NIFEDIPINE
NIMODIPINE
NISOLDIPINE
NORVASC
NYMALIZE
DRUG TIER
2
2
2
2
1
1
1
1
1, 2
2
1
2
2
2
2
2
1
1
2
2
2
1
1
2
2
2
2
2
1
2
2
2
2
2
2
1
1
2
1
1
1
1
1, 2
2
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 17
DRUG CATEGORY & NAME
PROCARDIA
PROCARDIA XL
SULAR
TIAZAC
VERAPAMIL HCL
VERELAN
VERELAN PM
LOOP DIURETICS
BUMETANIDE
DEMADEX
EDECRIN
FUROSEMIDE
LASIX
TORSEMIDE
OSMOTIC DIURETICS
RESECTISOL
POTASSIUM SPARING DIURETICS
ALDACTONE
AMILORIDE HCL
DYRENIUM
EPLERENONE
INSPRA
SPIRONOLACTONE
POTASSIUM SPARING DIURETICS IN COMBINATION
ALDACTAZIDE
AMILORIDE/HYDROCHLOROTHIAZIDE
DYAZIDE
MAXZIDE
MAXZIDE-25 MG
SPIRONOLACT/HYDROCHLOROTHIAZID
TRIAMTERENE/HYDROCHLOROTHIAZID
TRIAMTERENE-HYDROCHLOROTHIAZID
PULM ANTI-HTN,SOLUBLE GUANYLATE CYCLASE STIMULATOR
ADEMPAS
RIOCIGUAT
PULM.ANTI-HTN,SEL.C-GMP PHOSPHODIESTERASE T5 INHIB
ADCIRCA
REVATIO
SILDENAFIL CITRATE
TADALAFIL
PULMONARY ANTI-HTN, ENDOTHELIN RECEPTOR ANTAGONIST
AMBRISENTAN
BOSENTAN
LETAIRIS
MACITENTAN
OPSUMIT
TRACLEER
DRUG TIER
2
2
2
2
1, 2
2
2
1
2
2
1, 2
2
1
2
2
1
2
1
2
1
2
1
2
2
2
1
1
2
4
4
4
2, 4
1, 4
4
4
4
4
4
4
4
POS Formulary with Specialty Tier – Last revised 12/22/2015, 18
DRUG CATEGORY & NAME
PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPE
ILOPROST TROMETHAMINE
ORENITRAM ER
TREPROSTINIL DIOLAMINE
TYVASO
VENTAVIS
RENIN INHIBITOR, DIRECT
TEKTURNA
RENIN INHIBITOR, DIRECT & CALCIUM CHANNEL BLOCKER
TEKAMLO
RENIN INHIBITOR, DIRECT/THIAZIDE DIURETIC COMB
TEKTURNA HCT
THIAZIDE AND RELATED DIURETICS
CHLOROTHIAZIDE
CHLORTHALIDONE
DIURIL
HYDROCHLOROTHIAZIDE
INDAPAMIDE
METHYCLOTHIAZIDE
METOLAZONE
MICROZIDE
VASODILATORS, COMBINATION
BIDIL
CARDIOVASCULAR DISEASE - LIPID IRREGULARITY
ANTIHYPERLIP.HMG COA REDUCT INHIB&CHOLEST.AB.INHIB
LIPTRUZET
VYTORIN
ANTIHYPERLIPIDEMIC - APO B-100 SYNTHESIS INHIBITOR
KYNAMRO
MIPOMERSEN SODIUM
ANTIHYPERLIPIDEMIC - HMG COA REDUCTASE INHIBITORS
ALTOPREV
ATORVASTATIN CALCIUM
CRESTOR
FLUVASTATIN SODIUM
LESCOL
LESCOL XL
LIPITOR
LIVALO
LOVASTATIN
PRAVACHOL
PRAVASTATIN SODIUM
SIMVASTATIN
ZOCOR
ANTIHYPERLIPIDEMIC - MTP INHIBITOR
JUXTAPID
LOMITAPIDE MESYLATE
DRUG TIER
4
4
4
2
4
2
2
2
1, 2
2
2
1
1
2
1
2
2
2
2
4
4
2
1
2
1
2
2
2
2
1
2
1
1
2
2, 4
4
POS Formulary with Specialty Tier – Last revised 12/22/2015, 19
DRUG CATEGORY & NAME
ANTIHYPERLIPIDEMIC - PCSK9 INHIBITORS
PRALUENT PEN
PRALUENT SYRINGE
ANTIHYPERLIPIDEMIC-HMG COA REDUCTASE INHIB.&NIACIN
ADVICOR
SIMCOR
BILE SALT SEQUESTRANTS
CHOLESTYRAMINE (WITH SUGAR)
CHOLESTYRAMINE/ASPARTAME
COLESTID
COLESTIPOL HCL
QUESTRAN
QUESTRAN LIGHT
WELCHOL
LIPOTROPICS
ANTARA
FENOFIBRATE
FENOFIBRATE NANOCRYSTALLIZED
FENOFIBRATE,MICRONIZED
FENOFIBRIC ACID
FENOFIBRIC ACID (CHOLINE)
FENOGLIDE
FIBRICOR
GEMFIBROZIL
LIPOCHOL PLUS
LIPOFEN
LOFIBRA
LOPID
LOVAZA
NIACIN
NIACOR
NIASPAN
OMEGA-3 ACID ETHYL ESTERS
TRICOR
TRIGLIDE
TRILIPIX
VASCAZEN
VASCEPA
VAYAROL
ZETIA
CARDIOVASCULAR DISEASE - MISCELLANEOUS AGENTS
ADRENERGIC VASOPRESSOR AGENTS
DROXIDOPA
MIDODRINE HCL
NORTHERA
ANGIOTENSIN RECEPT-NEPRILYSIN INHIBITOR COMB(ARNI)
ENTRESTO
DRUG TIER
2
2
2
2
1
1
2
1
2
2
2
2
1, 2
1
1
2
1
2
2
1
2
2
2
2
2
1
2
2
1
2
2
2
2
2
2
2
4
1
4
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 20
DRUG CATEGORY & NAME
ANTIANGINAL & ANTI-ISCHEMIC AGENTS,NON-HEMODYNAMIC
RANEXA
ANTIANGINAL, HEART RATE REDUCING, I(F) INHIBITOR
CORLANOR
ANTIHYPERLIP - HMG-COA&CALCIUM CHANNEL BLOCKER CB
AMLODIPINE/ATORVASTATIN
CADUET
CARDIOVASCULAR DISEASE - VASODILATION
VASODILATORS,CORONARY
DILATRATE-SR
ISORDIL
ISORDIL TITRADOSE
ISOSORBIDE DINITRATE
ISOSORBIDE MONONITRATE
NITRO-BID
NITRO-DUR
NITROGLYCERIN
NITROLINGUAL
NITROMIST
NITROSTAT
VASODILATORS,PERIPHERAL
ERGOLOID MESYLATES
ISOXSUPRINE HCL
CONTRACEPTION/OXYTOCICS
CONTRACEPTIVES, INTRAVAGINAL, SYSTEMIC
NUVARING
CONTRACEPTIVES,IMPLANTABLE
NEXPLANON
CONTRACEPTIVES,INTRAVAGINAL
CONCEPTROL
GYNOL II
TODAY CONTRACEPTIVE SPONGE
VCF
CONTRACEPTIVES,ORAL
BEYAZ
BREVICON
CYCLESSA
DESOG-E.ESTRADIOL/E.ESTRADIOL
DESOGEN
DESOGESTREL-ETHINYL ESTRADIOL
ELLA
ESTROSTEP FE
ETHINYL ESTRADIOL/DROSPIRENONE
ETHYNODIOL D-ETHINYL ESTRADIOL
FEMCON FE
GENERESS FE
LEVONORGESTREL
DRUG TIER
2
2
1
2
2
2
2
1, 2
1
2
2
1, 2
2
2
2
2
1, 2
2+
2+
2+
2+
2+
2+
2+
2+
2+
1+
2+
1+
2+
2+
1+
1+
2+
2+
1+
POS Formulary with Specialty Tier – Last revised 12/22/2015, 21
DRUG CATEGORY & NAME
LEVONORGESTREL-ETHIN ESTRADIOL
L-NORGEST/E.ESTRADION-E.ESTRAD
LO LOESTRIN FE
LOESTRIN
LOESTRIN FE
LOSEASONIQUE
MINASTRIN 24 FE
MIRCETTE
MODICON
NATAZIA
NECON
NORETH-ETHINYL ESTRADIOL/IRON
NORETHINDRONE
NORETHINDRONE AC-ETH ESTRADIOL
NORETHINDRONE-E.ESTRADIOL-IRON
NORETHINDRONE-ETHINYL ESTRAD
NORGESTIMATE-ETHINYL ESTRADIOL
NORGESTREL-ETHINYL ESTRADIOL
NORINYL 1+35
NORINYL 1+50
NOR-Q-D
OGESTREL
ORTHO MICRONOR
ORTHO TRI-CYCLEN
ORTHO TRI-CYCLEN LO
ORTHO-CEPT
ORTHO-CYCLEN
ORTHO-NOVUM
OVCON-35
PLAN B ONE-STEP
QUARTETTE
SAFYRAL
SEASONIQUE
TRI-NORINYL
YASMIN 28
YAZ
ZOVIA 1-50E
CONTRACEPTIVES,TRANSDERMAL
ORTHO EVRA
XULANE
DIAPHRAGMS/CERVICAL CAP
CAYA CONTOURED
FEMCAP
WIDE SEAL DIAPHRAGM
OXYTOCICS
CERVIDIL
METHYLERGONOVINE MALEATE
DRUG TIER
1+
1+
2+
2+
2+
2+
2+
2+
2+
2+
2+
1+
1+
1+
1+
1+
1+
1+
2+
2+
2+
2+
2+
2+
2+
2+
2+
2+
2+
2+
2+
2+
2+
2+
2+
2+
2+
2+
2+
2+
2+
2+
2
1
POS Formulary with Specialty Tier – Last revised 12/22/2015, 22
DRUG CATEGORY & NAME
PREPIDIL
PROSTIN E2 VAGINAL SUPPOSITORY
COUGH AND COLD
1ST GEN ANTIHISTAMINE & DECONGESTANT COMBINATIONS
PHENYLEPHRINE HCL/PROMETH HCL
PHENYLEPHRINE/CHLORPHENIRAMINE
1ST GEN ANTIHIST-DECONGEST-ANTICHOLINERGIC COMB
RESPA A.R.
ANTITUSSIVES,NON-NARCOTIC
BENZONATATE
TESSALON PERLE
ZONATUSS
NARCOTIC ANTITUSS-1ST GEN. ANTIHISTAMINE-DECONGEST
PROMETHAZINE VC-CODEINE
PROMETHAZINE/PHENYLEPH/CODEINE
PSEUDOEPHED/HYDROCODONE/CPM
ZUTRIPRO
NARCOTIC ANTITUSS-DECONGESTANT-EXPECTORANT COMB
HYCOFENIX
NARCOTIC ANTITUSSIVE-1ST GENERATION ANTIHISTAMINE
HYDROCODONE/CHLORPHEN P-STIREX
PROMETHAZINE HCL/CODEINE
TUSSICAPS
TUSSIONEX
TUZISTRA XR
VITUZ
NARCOTIC ANTITUSSIVE-ANTICHOLINERGIC COMB.
HYDROCODONE BIT/HOMATROP ME-BR
NARCOTIC ANTITUSSIVE-DECONGESTANT COMBINATIONS
REZIRA
NARCOTIC ANTITUSSIVE-EXPECTORANT COMBINATION
FLOWTUSS
OBREDON
NON-NARC ANTITUSS-1ST GEN. ANTIHISTAMINE-DECONGEST
DM/PHENYLEPH/CHLORPHENIRAMINE
D-METHORPHAN HB/P-EPD HCL/BPM
NON-NARC ANTITUSSIVE-1ST GEN ANTIHISTAMINE COMB.
PROMETHAZINE/DEXTROMETHORPHAN
NON-NARCOTIC ANTITUSS-DECONGESTANT-EXPECTORANT CMB
TUSNEL PEDIATRIC
NOSE PREPARATIONS, VASOCONSTRICTORS (RX)
ADRENALIN CHLORIDE
TYZINE
DERMATOLOGY - ACNE
ACNE AGENTS,SYSTEMIC
ABSORICA
ISOTRETINOIN
DRUG TIER
2
2
1
1
2
1
2
2
2
1
1
2
2
1
1
2
2
2
2
1
2
2
2
1
1
1
2
2
2
2
1
POS Formulary with Specialty Tier – Last revised 12/22/2015, 23
DRUG CATEGORY & NAME
ACNE AGENTS,TOPICAL
ACANYA
ACZONE
AZELEX
BENZACLIN
CLINDAMYCIN PHOS/BENZOYL PEROX
DUAC
EPIDUO
EPIDUO FORTE
KLARON
NEUAC
ONEXTON
SULFACETAMIDE SODIUM
VELTIN
ZIANA
ANTICORROSIVE AGENTS
BUTYLATED HYDROXYTOLUENE(BHT)
KERATOLYTIC-GLUCOCORTICOID COMBINATIONS
VANOXIDE-HC
ROSACEA AGENTS, TOPICAL
FINACEA
METROCREAM
METROGEL
METROLOTION
METRONIDAZOLE
MIRVASO
NORITATE
ROSADAN
SOOLANTRA
TOPICAL PREPARATIONS,ANTIBACTERIALS
ALA-QUIN
ALCORTIN A
ALOQUIN
DERMASORB AF
HYDROCORTISONE/IODOQUINOL
HYDROCORTISONE/IODOQUINOL/ALOE
IODINE/POTASSIUM IODIDE
IODOFLEX
IODOSORB
NORMLGEL AG
SILVER NITRATE
SILVRSTAT
VYTONE
VITAMIN A DERIVATIVES
ADAPALENE
ATRALIN
DIFFERIN
DRUG TIER
2
2
2
2
1
2
2
2
2
2
2
1
2
2
2
2
2
2
2
2
1
2
2
2
2
2
2
2
2
1
1
1
2
2
2
2
2
2
1, 2
2
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 24
DRUG CATEGORY & NAME
RETIN-A
RETIN-A MICRO
RETIN-A MICRO PUMP
TRETINOIN
TRETINOIN MICROSPHERES
TRETIN-X
VITAMIN A DERIVATIVES, TOPICAL ACNE AGENTS
FABIOR
VITAMIN A DERIVATIVES, TOPICAL COSMETIC AGENTS
AVAGE
REFISSA
RENOVA
RENOVA PUMP
TRETINOIN
DERMATOLOGY - ANTIINFECTIVE
ANTIPARASITICS
ALINIA
TOPICAL ANTIBIOTICS
BACTROBAN
BENZAMYCIN
BENZAMYCINPAK
CENTANY
CENTANY AT
CLEOCIN T
CLINDACIN ETZ
CLINDACIN PAC
CLINDAGEL
CLINDAMYCIN PHOSPHATE
ERYGEL
ERYTHROMYCIN BASE/ETHANOL
ERYTHROMYCIN/BENZOYL PEROXIDE
EVOCLIN
GENTAMICIN SULFATE
MUPIROCIN
MUPIROCIN CALCIUM
TOPICAL ANTIFUNGAL/ANTIINFLAMMATORY,STERIOD AGENT
CLOTRIMAZOLE/BETAMETHASONE DIP
LOTRISONE
TOPICAL ANTIFUNGALS
CICLODAN
CICLOPIROX
CICLOPIROX OLAMINE
CICLOPIROX/URE/CAMPH/MENTH/EUC
CLOTRIMAZOLE
CNL 8
ECONAZOLE NITRATE
ECOZA
DRUG TIER
2
2
2
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
2
1
1
2
2
1
1
1
2
2
1
1
1
1
2
1
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 25
DRUG CATEGORY & NAME
ERTACZO
EXELDERM
EXODERM
EXTINA
JUBLIA
KERYDIN
KETOCONAZOLE
LOPROX
LUZU
MENTAX
NAFTIFINE HCL
NAFTIN
NIZORAL
NYSTATIN
NYSTATIN/TRIAMCIN
OXISTAT
PEDIADERM AF
PENLAC
TRIPLE DYE
VUSION
XOLEGEL
TOPICAL ANTIPARASITICS
ELIMITE
EURAX
LINDANE
LYCELLE
MALATHION
NATROBA
OVIDE
PERMETHRIN
SKLICE
SPINOSAD
ULESFIA
TOPICAL ANTIVIRALS
ACYCLOVIR
DENAVIR
ZOVIRAX
TOPICAL ANTIVIRALS/ANTIINFLAMMATORY, STEROID AGENT
XERESE
TOPICAL GENITAL WART-HPV TREATMENT AGENTS
VEREGEN
TOPICAL PLEUROMUTILIN DERIVATIVES
ALTABAX
TOPICAL SULFONAMIDES
AVAR
AVAR LS
AVAR-E LS
DRUG TIER
2
2
2
2
2
2
1
2
2
2
1
2
2
1
1
2
2
2
2
2
2
2
2
1
2
1
2
2
1
2
2
2
1
2
2
2
2
2
2
2
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 26
DRUG CATEGORY & NAME
CLARIFOAM EF
CLEANSING WASH
PLEXION
ROSULA
SILVADENE
SILVER SULFADIAZINE
SODIUM SULFACETAMIDE-SULFUR
SULFACETAMIDE SODIUM/SULFUR
SULFACETAMIDE/SULFUR/CLEANSR23
SULFACT SOD/SULUR/AVOB/OTN/OCT
SULFAMYLON
SUMADAN
SUMADAN XLT
SUMAXIN
SUMAXIN CP
SUMAXIN TS
DERMATOLOGY - ANTIINFLAMMATORY
TOPICAL ANTIBIOTICS/ANTIINFLAMMATORY,STEROIDAL
CORTISPORIN
NEO-SYNALAR
TOPICAL ANTI-INFLAMMATORY STEROIDAL
ADV ALLERGY COLLECTION KIT
ALA-SCALP
ALCLOMETASONE DIPROPIONATE
AMCINONIDE
APEXICON E
AQUA GLYCOLIC HC
BETAMETHASONE DIPROPIONATE
BETAMETHASONE VALERATE
BETAMETHASONE/PROPYLENE GLYC
CAPEX SHAMPOO
CLOBETASOL PROPIONATE
CLOBETASOL PROPIONATE/EMOLL
CLOBEX
CLOCORTOLONE PIVALATE
CLODAN
CLODERM
CORDRAN
CUTIVATE
DERMACINRX SILAPAK
DERMASILKRX SDS
DERMA-SMOOTHE-FS
DERMASORB HC
DERMASORB TA
DERMATOP
DESONATE
DESONIDE
DRUG TIER
2
2
2
2
2
1
2
1
1
1
2
2
2
2
2
2
2
2
2
2
1
1, 2
2
2
1
1
1
2
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
1
POS Formulary with Specialty Tier – Last revised 12/22/2015, 27
DRUG CATEGORY & NAME
DESOWEN
DESOXIMETASONE
DIFLORASONE DIACETATE
DIPROLENE
DIPROLENE AF
ELOCON
FLUOCINOLONE ACETONIDE
FLUOCINOLONE/SHOWER CAP
FLUOCINONIDE
FLUOCINONIDE/EMOLLIENT BASE
FLUTICASONE PROPIONATE
HALOBETASOL PROPIONATE
HALOG
HC/MINERAL OIL/PETROLAT,WHT
HYDROCORTISONE
HYDROCORTISONE ACETATE/ALOE V
HYDROCORTISONE BUTYRATE
HYDROCORTISONE BUTYRATE/EMOLL
HYDROCORTISONE VALERATE
KENALOG
LOCOID
LOCOID LIPOCREAM
LUXIQ
MOMETASONE FUROATE
OLUX
OLUX-E
PANDEL
PEDIADERM HC
PEDIADERM TA
PREDNICARBATE
PSORCON
SCALACORT DK
SYNALAR
SYNALAR TS
TEMOVATE
TEMOVATE EMOLLIENT
TEXACORT
TOPICORT
TRIAMCINOLONE ACETONIDE
TRIANEX
U-CORT
ULTRAVATE
ULTRAVATE X
VANOS
VERDESO
TOPICAL ANTI-INFLAMMATORY, NSAIDS
DICLOFENAC SODIUM
DRUG TIER
2
1, 2
2
2
2
2
1
1
1
1
1
1
2
1
1
1
1
1
1
2
2
2
2
1
2
2
2
2
2
1
2
2
2
2
2
2
2
2
1, 2
2
2
2
2
2
2
1
POS Formulary with Specialty Tier – Last revised 12/22/2015, 28
DRUG CATEGORY & NAME
FLECTOR
PENNSAID
VOLTAREN
DERMATOLOGY - ANTIPRURITIC DRUGS
ANTIPRURITICS,TOPICAL
ALEVICYN
PRUDOXIN
ZONALON
DERMATOLOGY - MISCELLANEOUS
ANTIPERSPIRANTS
DRYSOL
ANTISEBORRHEIC AGENTS
LOUTREX
OVACE
OVACE PLUS
OVACE PLUS WASH
PROMISEB
PROMISEB COMPLETE
SELENIUM SULFIDE
SELRX
SODIUM SULFACETAMIDE
SULFACETAMIDE SODIUM
TERSI FOAM
ANTISEPTICS,MISCELLANEOUS
GUAIACOL
EMOLLIENTS
ALEVICYN ANTIPRURITIC SG
AMMONIUM LACTATE
ATOPICLAIR
ATRAPRO CP
ATRAPRO HYDROGEL
AURSTAT
AVO CREAM
BIAFINE
ELETONE
EMOLLIENT COMBINATION NO.60
EMULSION SB
EPICERAM
HPR
HPR PLUS
HPR PLUS HYDROGEL
HPR PLUS-MB HYDROGEL
HYLATOPIC
HYLATOPIC PLUS
LACTIC ACID
MB HYDROGEL
NEOSALUS
DRUG TIER
2
2
2
2
2
2
2
2
2
2
2
2
2
1
2
2
1
2
2
2
1
2
2
2
2
2
2
2
1
2
2
2
2
2
2
2
2
1
2
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 29
DRUG CATEGORY & NAME
NEOSALUS CP
NIVATOPIC PLUS
PRESERA
PRUCLAIR
PRUMYX
PRUTECT
SONAFINE
TL-CERMIDE
TROPAZONE
XCLAIR
HYPERTRICHOTIC AGENTS, SYSTEMIC/INCL. COMBINATIONS
FINASTERIDE
PROPECIA
IRRIGANTS
ACETIC ACID
NEOMYCIN SU/POLYMYX B SULF
NEOSPORIN G.U. IRRIGANT
PHYSIOLOGICAL IRRIG SOL CMB #1
PHYSIOSOL
RINGERS SOLUTION
RINGERS SOLUTION,LACTATED
SODIUM CHLOR/HYPOCHLOROUS ACID
SODIUM CHLORIDE IRRIG SOLUTION
SORBITOL
SORBITOL-MANNITOL
WATER FOR IRRIGATION,STERILE
IRRITANTS/COUNTER-IRRITANTS
CAPTRACIN
MAC
NEUVAXIN
PAIN RELIEF
QROXIN
QUTENZA
RELYYT
RENOVO
SINELEE
SOLAICE
KERATOLYTICS
ALUVEA
BENSAL HP
BENZEFOAM
BENZEFOAM ULTRA
BENZOYL PEROXIDE
BENZOYL PEROXIDE MICROSPHERES
BPO
CEM-UREA
CONDYLOX
DRUG TIER
2
2
2
2
2
2
2
2
2
2
1
2
1
1
2
1
2
1
1
1
1
2
2
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
1
2
2
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 30
DRUG CATEGORY & NAME
DERMASORB XM
GORDO-UREA
HYDRO 35
HYDRO 40
INOVA
INOVA 4-1
INOVA 8-2
KERAFOAM
KERALAC
KERALYT
KERALYT SCALP
NUOX
PACNEX HP
PACNEX LP
PACNEX MX
PODOCON-25
PODOFILOX
POTASSIUM HYDROXIDE
SALEX
SALICYLIC ACID
SALICYLIC ACID/CERAMIDE CMB #1
SALKERA
SALVAX
SALVAX DUO PLUS
SILVER NITRATE
SILVER NITRATE APPLICATOR
ULTRASAL-ER
UMECTA
UMECTA PD
URAMAXIN
URAMAXIN GT
UREA
UREA/LACTIC AC/ZN UNDECYLENATE
UREA/LACTIC ACID/SALICYLIC AC
UREVAZ
UTOPIC
VIRASAL
OXIDIZING AGENTS
ALEVICYN
ATRAPRO DERMAL SPRAY
PROTECTIVES
BEAU RX
BIONECT
GENADUR
NUVAIL
PR CREAM
RADIAPLEXRX
DRUG TIER
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
2
2
1, 2
1
2
2
2
2
1, 2
2
2
2
2
2
1, 2
1
1
2
2
2
2
2
2
2
2
2
2
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 31
DRUG CATEGORY & NAME
RECEDO
TETRIX
VASELINE WHITE PETROLEUM
TOPICAL ANTI-INFLAMMATORY STEROID-LOCAL ANESTHETIC
EPIFOAM
HYDROCORTISONE/PRAMOXINE
LIDOCAINE/HYDROCORTISONE AC
NOVACORT
PRAMOSONE
PRAMOSONE E
TOPICAL ANTINEOPLASTIC & PREMALIGNANT LESION AGNTS
ALITRETINOIN
BEXAROTENE
CARAC
DICLOFENAC SODIUM
EFUDEX
FLUOROPLEX
FLUOROURACIL
MECHLORETHAMINE HCL
PANRETIN
PICATO
SOLARAZE
TARGRETIN
VALCHLOR
TOPICAL LOCAL ANESTHETICS
ADAZIN
ANACAINE
CETACAINE
CETACAINE ANESTHETIC
COCAINE HCL
EMLA
ETHYL CHLORIDE
LIDOCAINE
LIDOCAINE HCL
LIDOCAINE HCL/MENTHOL
LIDOCAINE/MENTHOL
LIDOCAINE/PRILOCAINE
LIDOCAINE-TETRACAINE
LIDODERM
LIDOPIN
LIDORX
LIDOVEX
PAIN EASE
PAIN RELIEF
PLIAGLIS
PONTOCAINE
PRE-ATTACHED LTA KIT
DRUG TIER
2
2
2
2
1
1
2
2
2
4
4
2
1
2
2
1, 2
4
4
2
2
4
4
2
2
2
2
2
2
2
1
1, 2
1
1
1
2
2
2
2
2
2
2
2
2
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 32
DRUG CATEGORY & NAME
REGENECARE
RELYYKS
SCAR
SILVERA
SPRAY AND STRETCH
SYNERA
SYNVEXIA TC
VELMA
VEXA
TOPICAL PREPARATIONS,MISCELLANEOUS
BETADINE
TOPICAL/MUCOUS MEMBR./SUBCUT. ENZYMES
GRANULEX
SANTYL
DERMATOLOGY - PIGMENTATION DISORDERS
HYPOPIGMENTATION AGENTS
ACLARO
C-CLARIFYING SERUM
C-THERAPY NIGHT CREAM
ELASTIDERM
HYDROQUINONE
HYDROQUINONE MICROSPHERES
HYDROQUINONE/FERRIC OXIDE
LUSTRA
LUSTRA-AF
LUSTRA-ULTRA
MELQUIN-3
NU-DERM SUNFADER
OXYBENZONE/OCTINOX/H-QUINONE
TRI-LUMA
TOPICAL HYPERPIGMENTATION AGENTS
OXSORALEN
DERMATOLOGY - PSORIASIS/ECZEMA
ANTIPSORIATIC AGENTS,SYSTEMIC
8-MOP
ACITRETIN
COSENTYX (2 SYRINGES)
COSENTYX PEN
COSENTYX PEN (2 PENS)
COSENTYX SYRINGE
METHOXSALEN, RAPID
OXSORALEN-ULTRA
SECUKINUMAB
SORIATANE
ANTIPSORIATICS AGENTS
CALCIPOTRIENE
CALCITRIOL
DRUG TIER
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
1
1
2
2
2
2
2
1
2
2
2
1, 4
4
4
4
4
1
2
4
4
1
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 33
DRUG CATEGORY & NAME
DOVONEX
DRITHOCREME HP
SORILUX
TAZORAC
VECTICAL
ZITHRANOL
ZITHRANOL-RR
HAIR GROWTH REDUCTION AGENTS
VANIQA
TOPICAL AGENTS,MISCELLANEOUS
GORDO-UREA
PYROGALLIC ACID
UREA
TOPICAL IMMUNOSUPPRESSIVE AGENTS
ELIDEL
PROTOPIC
TACROLIMUS
TOPICAL VIT D ANALOG/ANTIINFLAMMATORY, STEROIDAL
CALCIPOTRIENE/BETAMETHASONE
TACLONEX
DIABETES
ANTIHYPERGLY, (DPP-4) INHIBITOR & BIGUANIDE COMB.
JANUMET
JANUMET XR
JENTADUETO
KAZANO
KOMBIGLYZE XR
ANTIHYPERGLY,DPP-4 ENZYME INHIB &THIAZOLIDINEDIONE
OSENI
ANTIHYPERGLY,INCRETIN MIMETIC(GLP-1 RECEP.AGONIST)
BYDUREON
BYDUREON PEN
BYETTA
TANZEUM
TRULICITY
VICTOZA 2-PAK
VICTOZA 3-PAK
ANTIHYPERGLYCEMC-SOD/GLUC COTRANSPORT2(SGLT2)INHIB
FARXIGA
INVOKANA
JARDIANCE
ANTIHYPERGLYCEMIC - DOPAMINE RECEPTOR AGONISTS
CYCLOSET
ANTIHYPERGLYCEMIC, ALPHA-GLUCOSIDASE INHIB (N-S)
ACARBOSE
GLYSET
PRECOSE
DRUG TIER
2
2
2
2
2
2
2
2
2
2
1
2
2
1
1, 4
2, 4
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
2
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 34
DRUG CATEGORY & NAME
ANTIHYPERGLYCEMIC, AMYLIN ANALOG-TYPE
SYMLINPEN 120
SYMLINPEN 60
ANTIHYPERGLYCEMIC, DPP-4 INHIBITORS
JANUVIA
NESINA
ONGLYZA
TRADJENTA
ANTIHYPERGLYCEMIC, INSULIN-RELEASE STIMULANT TYPE
AMARYL
CHLORPROPAMIDE
DIABETA
GLIMEPIRIDE
GLIPIZIDE
GLUCOTROL
GLUCOTROL XL
GLYBURIDE
GLYBURIDE,MICRONIZED
GLYNASE
NATEGLINIDE
PRANDIN
REPAGLINIDE
STARLIX
TOLAZAMIDE
TOLBUTAMIDE
ANTIHYPERGLYCEMIC, INSULIN-RESPONSE ENHANCER (N-S)
ACTOS
AVANDIA
PIOGLITAZONE HCL
ANTIHYPERGLYCEMIC, SGLT-2 & DPP-4 INHIBITOR COMB.
GLYXAMBI
ANTIHYPERGLYCEMIC,BIGUANIDE TYPE(NON-SULFONYLUREA)
FORTAMET
GLUCOPHAGE
GLUCOPHAGE XR
GLUMETZA
METFORMIN HCL
RIOMET
ANTIHYPERGLYCEMIC,INSULIN-REL STIM.& BIGUANIDE CMB
GLIPIZIDE/METFORMIN HCL
GLUCOVANCE
GLYBURIDE/METFORMIN HCL
PRANDIMET
ANTIHYPERGLYCEMIC,INSULIN-RESPONSE & RELEASE COMB.
DUETACT
PIOGLITAZONE HCL/GLIMEPIRIDE
ANTIHYPERGLYCEMIC-GLUCOCORTICOID RECEPTOR BLOCKER
DRUG TIER
2
2
2
2
2
2
2
2
2
1
1
2
2
1, 2
1
2
1
2
1
2
1, 2
2
2
2
1
2
2
2
2
2
1
2
1
2
1
2
2
1
POS Formulary with Specialty Tier – Last revised 12/22/2015, 35
DRUG CATEGORY & NAME
KORLYM
MIFEPRISTONE
ANTIHYPERGLYCEMIC-SGLT2 INHIBITOR & BIGUANIDE COMB
INVOKAMET
XIGDUO XR
ANTIHYPERGLYCM,INSUL-RESP.ENHANCER & BIGUANIDE CMB
ACTOPLUS MET
ACTOPLUS MET XR
AVANDAMET
PIOGLITAZONE HCL/METFORMIN HCL
DIABETIC SUPPLIES
AUTOJECT 2
AUTOPEN
HUMAPEN LUXURA HD
NOVOPEN ECHO
OMNIPOD
T:SLIM
DIABETIC ULCER PREPARATIONS,TOPICAL
BECAPLERMIN
REGRANEX
HYPERGLYCEMICS
DIAZOXIDE
PROGLYCEM
INSULINS
AFREZZA
APIDRA
APIDRA SOLOSTAR
HUMALOG
HUMALOG KWIKPEN
HUMALOG MIX 50-50
HUMALOG MIX 50-50 KWIKPEN
HUMALOG MIX 75-25
HUMALOG MIX 75-25 KWIKPEN
HUMULIN 70/30 KWIKPEN
HUMULIN 70-30
HUMULIN N
HUMULIN N KWIKPEN
HUMULIN R
HUMULIN R U-500
LANTUS
LANTUS SOLOSTAR
LEVEMIR
LEVEMIR FLEXTOUCH
NOVOLIN 70-30
NOVOLIN N
NOVOLIN R
NOVOLOG
DRUG TIER
4
4
2
2
2
2
2
1
2
2
2
2
2
2
4
4
4
4
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 36
DRUG CATEGORY & NAME
NOVOLOG FLEXPEN
NOVOLOG MIX 70-30
NOVOLOG MIX 70-30 FLEXPEN
TOUJEO SOLOSTAR
URINE GLUCOSE TEST AIDS
CLINITEST REAGENT
DIASTIX REAGENT
NO-STICK GLUCOSE
URINE GLUCOSE/ACETONE TEST AIDS,STRIPS
CHEMSTRIP UGK
KETO-DIASTIX REAGENT
EAR - GENERAL DISORDERS
EAR PREPARATIONS ANTI-INFLAMMATORY
DERMOTIC
FLUOCINOLONE ACETONIDE OIL
EAR PREPARATIONS, MISC. ANTI-INFECTIVES
ACETIC ACID
ACETIC ACID/HYDROCORTISONE
ACETIC ACID-ALUMINUM
CORTANE-B
EAR PREPARATIONS,ANTIBIOTICS
CETRAXAL
CIPROFLOXACIN HCL
COLY-MYCIN S
CORTISPORIN-TC
NEOMYCIN/POLYMYXIN B SULF/HC
OFLOXACIN
OTIC PREPARATIONS,ANTI-INFLAMMATORY-ANTIBIOTICS
CIPRO HC
CIPRODEX
ELECTROLYTE REGULATION
ARGININE VASOPRESSIN (AVP) RECEPTOR ANTAGONISTS
SAMSCA
TOLVAPTAN
ELECTROLYTE DEPLETERS
AURYXIA
CALCIUM ACETATE
ELIPHOS
FOSRENOL
KAYEXALATE
LANTHANUM CARBONATE
MAGNEBIND 400 RX
PHOSLO
PHOSLYRA
RENAGEL
RENVELA
SODIUM POLYSTYRENE SULFONATE
DRUG TIER
2
2
2
2
2
2
2
2
2
2
1
1
1
2
2
2
2
2
2
1
1
2
2
4
4
2
1
2
2, 4
2
4
2
2
2
2
2
1
POS Formulary with Specialty Tier – Last revised 12/22/2015, 37
DRUG CATEGORY & NAME
VELPHORO
POTASSIUM REPLACEMENT
EFFER-K
KLOR-CON
KLOR-CON M15
K-TAB ER
POT CHLORIDE/POT BICARB/CIT AC
POTASSIUM BICARBONATE/CIT AC
POTASSIUM CHLORIDE
ENDOCRINE DISORDER - FERTILITY
FERTILITY STIMULATING PREPARATIONS,NON-FSH
CLOMIPHENE CITRATE
FOLLICLE STIM./LUTEINIZING HORMONES
MENOPUR
FOLLICLE-STIMULATING HORMONE (FSH)
BRAVELLE
FOLLISTIM AQ
GONAL-F
GONAL-F RFF
GONAL-F RFF REDI-JECT
HUMAN CHORIONIC GONADOTROPIN (HCG)
OVIDREL
PREGNANCY FACILITATING/MAINTAINING AGENT,HORMONAL
CRINONE
ENDOMETRIN
ENDOCRINE DISORDER - OTHER
ANTIDIURETIC AND VASOPRESSOR HORMONES
DDAVP
DESMOPRESSIN (NONREFRIGERATED)
DESMOPRESSIN ACETATE
STIMATE
ANTINEOPLASTIC LHRH(GNRH) AGONIST,PITUITARY SUPPR.
ELIGARD
LEUPROLIDE ACETATE
ZOLADEX
BONE FORMATION STIM. AGENTS - PARATHYROID HORMONE
FORTEO
TERIPARATIDE
BONE RESORPTION INHIBITOR & VITAMIN D COMBINATIONS
FOSAMAX PLUS D
BONE RESORPTION INHIBITORS
ACTONEL
ALENDRONATE SODIUM
ATELVIA
BINOSTO
BONIVA
CALCITONIN,SALMON,SYNTHETIC
DRUG TIER
2
2
2
2
2
1
1
1, 2
1
2
2
2
2
2
2
2
2
2
2
1
1, 4
4
2
1
2
4
4
2
2
1, 2
2
2
2
1
POS Formulary with Specialty Tier – Last revised 12/22/2015, 38
DRUG CATEGORY & NAME
DENOSUMAB
ETIDRONATE DISODIUM
EVISTA
FORTICAL
FOSAMAX
IBANDRONATE SODIUM
MIACALCIN
PROLIA
RALOXIFENE HCL
RISEDRONATE SODIUM
XGEVA
CALCIMIMETIC,PARATHYROID CALCIUM ENHANCER
CINACALCET HCL
SENSIPAR
GROWTH HORMONE RECEPTOR ANTAGONISTS
PEGVISOMANT
SOMAVERT
GROWTH HORMONE RELEASING HORMONE (GHRH) & ANALOGS
EGRIFTA
TESAMORELIN ACETATE
GROWTH HORMONES
GENOTROPIN
HUMATROPE
NORDITROPIN FLEXPRO
NUTROPIN AQ
NUTROPIN AQ NUSPIN
OMNITROPE
SAIZEN
SEROSTIM
SOMATROPIN
ZOMACTON
ZORBTIVE
HYPERPARATHYROID TX AGENTS - VITAMIN D ANALOG-TYPE
DOXERCALCIFEROL
HECTOROL
PARICALCITOL
ZEMPLAR
INSULIN-LIKE GROWTH FACTOR-1 (IGF-1) HORMONES
INCRELEX
MECASERMIN
LEPTIN HORMONE ANALOGS
MYALEPT
LHRH(GNRH) AGONIST ANALOG PITUITARY SUPPRESSANTS
NAFARELIN ACETATE
SYNAREL
LHRH(GNRH) ANTAGONIST,PITUITARY SUPPRESSANT AGENTS
GANIRELIX ACETATE
DRUG TIER
4
2
2
2
2
1
2
2
1
1
4
4
4
4
2, 4
4
4
4
4
4
4
4
2
4
4
4
4
4
1
2
1
2
4
4
2
4
4
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 39
DRUG CATEGORY & NAME
MENOPAUSAL SYMPT SUPP-SEL ESTROGEN RECEP MODULATOR
OSPHENA
PARATHYROID HORMONES
NATPARA
PITUITARY SUPPRESSIVE AGENTS
CABERGOLINE
DANAZOL
ENDOCRINE DISORDER - THYROID
ANTITHYROID PREPARATIONS
METHIMAZOLE
PROPYLTHIOURACIL
TAPAZOLE
IODINE CONTAINING AGENTS
SSKI
STRONG IODINE
THYROID HORMONES
ARMOUR THYROID
CYTOMEL
LEVOTHYROXINE SODIUM
LIOTHYRONINE SODIUM
NATURE-THROID
SYNTHROID
THYROID,PORK
THYROLAR-1
THYROLAR-1/2
THYROLAR-1/4
THYROLAR-2
THYROLAR-3
TIROSINT
WESTHROID
WP THYROID
EYE - GENERAL DISORDERS
EYE ANTIBIOTIC-CORTICOID COMBINATIONS
MAXITROL
NEO/POLYMYX B SULF/DEXAMETH
NEOMYCIN SU/BACI ZN/POLY/HC
NEOMYCIN-POLYMYXIN-HC
PRED-G
TOBRADEX
TOBRADEX ST
TOBRAMYCIN/DEXAMETHASONE
ZYLET
EYE ANTIHISTAMINES
AZELASTINE HCL
BEPREVE
ELESTAT
EMADINE
DRUG TIER
2
2
1
1
1
1
2
2
2
2
2
1
1
2
2
1
2
2
2
2
2
2
2
2
2
1
1
2
2
2
2
1
2
1
2
2
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 40
DRUG CATEGORY & NAME
EPINASTINE HCL
LASTACAFT
PATADAY
PATANOL
PAZEO
EYE ANTIINFLAMMATORY AGENTS
ACULAR
ACULAR LS
ACUVAIL
ALREX
BROMFENAC SODIUM
DEXAMETHASONE SOD PHOSPHATE
DICLOFENAC SODIUM
DUREZOL
FLAREX
FLUOROMETHOLONE
FLURBIPROFEN SODIUM
FML
FML FORTE
FML S.O.P.
ILEVRO
KETOROLAC TROMETHAMINE
LOTEMAX
MAXIDEX
NEVANAC
OCUFEN
OMNIPRED
PRED FORTE
PRED MILD
PREDNISOLONE ACETATE
PREDNISOLONE SODIUM PHOSPHATE
PROLENSA
VEXOL
EYE ANTIVIRALS
TRIFLURIDINE
VIROPTIC
ZIRGAN
EYE LOCAL ANESTHETICS
AKTEN
ALCAINE
BENOXINATE HCL/FLUORESCEIN NA
PROPARACAINE HCL
PROPARACAINE/FLUORESCEIN SOD
TETRACAINE HCL
TETRACAINE HCL/PF
EYE SULFONAMIDES
BLEPH-10
DRUG TIER
1
2
2
2
2
2
2
2
2
1
1
1
2
2
1
1
2
2
2
2
1
2
2
2
2
2
2
2
1
2
2
2
1
2
2
2
2
1
1
1
1
1
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 41
DRUG CATEGORY & NAME
BLEPHAMIDE
BLEPHAMIDE S.O.P.
SULFACETAMIDE SODIUM
SULFACETAMIDE/PREDNISOLONE SP
EYE VASOCONSTRICTORS (RX ONLY)
NAPHAZOLINE HCL
PHENYLEPHRINE HCL
OPHTHALMIC ANTIBIOTICS
AZASITE
BACITRACIN
BACITRACIN/POLYMYXIN B SULFATE
BESIVANCE
CILOXAN
CIPROFLOXACIN HCL
ERYTHROMYCIN BASE
GARAMYCIN
GATIFLOXACIN
GENTAMICIN SULFATE
LEVOFLOXACIN
MOXEZA
NATACYN
NEOMYCIN SU/BACITRA/POLYMYXIN
NEOMYCIN/POLYMYXN B/GRAMICIDIN
NEOSPORIN
OCUFLOX
OFLOXACIN
POLYMYXIN B SULF/TRIMETHOPRIM
POLYTRIM
TOBRAMYCIN
TOBREX
VIGAMOX
ZYMAXID
OPHTHALMIC ANTI-INFLAMMATORY IMMUNOMODULATOR-TYPE
RESTASIS
OPHTHALMIC MAST CELL STABILIZERS
ALOCRIL
ALOMIDE
CROMOLYN SODIUM
OPHTHALMIC PREPARATIONS, MISCELLANEOUS
ACUICYN
AVENOVA
EYE - GLAUCOMA
CARBONIC ANHYDRASE INHIBITORS
ACETAZOLAMIDE
DIAMOX SEQUELS
METHAZOLAMIDE
NEPTAZANE
DRUG TIER
2
2
1, 2
1
2
1
2
2
1
2
2
1
1
2
1
1
1
2
2
1
1
2
2
1
1
2
1
2
2
2
2
2
2
1
2
2
1, 2
2
1
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 42
DRUG CATEGORY & NAME
MIOTICS/OTHER INTRAOC. PRESSURE REDUCERS
ALPHAGAN P
APRACLONIDINE HCL
AZOPT
BETAGAN
BETAXOLOL HCL
BETIMOL
BETOPTIC S
BIMATOPROST
BRIMONIDINE TARTRATE
CARTEOLOL HCL
COMBIGAN
COSOPT
COSOPT PF
DORZOLAMIDE HCL
DORZOLAMIDE HCL/TIMOLOL MALEAT
IOPIDINE
ISOPTO CARPINE
ISTALOL
LATANOPROST
LEVOBUNOLOL HCL
LUMIGAN
METIPRANOLOL
PHOSPHOLINE IODIDE
PILOCARPINE HCL
RESCULA
SIMBRINZA
TIMOLOL MALEATE
TIMOPTIC
TIMOPTIC OCUDOSE
TIMOPTIC-XE
TRAVATAN Z
TRAVOPROST
TRUSOPT
XALATAN
ZIOPTAN
MYDRIATICS
ATROPINE SULFATE
CYCLOGYL
CYCLOMYDRIL
CYCLOPENTOLATE HCL
HOMATROPINE HBR
ISOPTO ATROPINE
MYDRIACYL
PAREMYD
TROPICAMIDE
OPHTHALMIC ANTIFIBROTIC AGENTS
DRUG TIER
2
1
2
2
1
2
2
2
1
1
2
2
2
1
1
2
2
2
1
1
2
2
2
1
2
2
1
2
2
2
2
2
2
2
2
1, 2
2
2
1
1
2
2
2
1
POS Formulary with Specialty Tier – Last revised 12/22/2015, 43
DRUG CATEGORY & NAME
MITOSOL
EYE - MISCELLANEOUS
ARTIFICIAL TEARS
LACRISERT
EYE DIAGNOSTIC AGENTS
FLUORESCEIN SODIUM
FUL-GLO
EYE PREPARATIONS, MISCELLANEOUS (OTC)
GELFILM
OPHTHALMIC CYSTINE DEPLETING AGENTS
CYSTARAN
TOPICAL HYPERTRICHOTIC AGENTS, EYELASHES
LATISSE
GOUT AND RELATED DISEASES
COLCHICINE
COLCHICINE
COLCHICINE/PROBENECID
COLCRYS
MITIGARE
HYPERURICEMIA TX - PURINE INHIBITORS
ALLOPURINOL
ULORIC
ZYLOPRIM
URICOSURIC AGENTS
PROBENECID
HEMATOLOGICAL DISORDERS
ANTICOAGULANTS,COUMARIN TYPE
COUMADIN
WARFARIN SODIUM
ANTIFIBRINOLYTIC AGENTS
AMICAR
LYSTEDA
TRANEXAMIC ACID
CITRATES AS ANTICOAGULANTS
ACD
ACD-A
CITRATE PHOSPHATE DEXTROSE
SODIUM CITRATE
DIRECT FACTOR XA INHIBITORS
ELIQUIS
SAVAYSA
XARELTO
HEMORRHEOLOGIC AGENTS
PENTOXIFYLLINE
HEPARIN AND RELATED PREPARATIONS
ARIXTRA
ENOXAPARIN SODIUM
DRUG TIER
2
2
1
2
2
2
2
2
1
2
2
1
2
2
1
2
1
2
2
1
2
2
2
1, 2
2
2
2
1
2
1
POS Formulary with Specialty Tier – Last revised 12/22/2015, 44
DRUG CATEGORY & NAME
FONDAPARINUX SODIUM
FRAGMIN
HEPARIN SODIUM,PORCINE/PF
LOVENOX
LEUKOCYTE (WBC) STIMULANTS
FILGRASTIM
GRANIX
NEULASTA
NEUPOGEN
PEGFILGRASTIM
TBO-FILGRASTIM
PLATELET AGGREGATION INHIBITORS
AGGRENOX
ASPIRIN-DIPYRIDAMOLE ER
BRILINTA
CILOSTAZOL
CLOPIDOGREL BISULFATE
DIPYRIDAMOLE
EFFIENT
PERSANTINE
PLAVIX
PLETAL
TICLOPIDINE HCL
ZONTIVITY
PLATELET PROLIFERATION STIMULANTS
NEUMEGA
OPRELVEKIN
PLATELET REDUCING AGENTS
AGRYLIN
ANAGRELIDE HCL
SICKLE CELL ANEMIA AGENTS
DROXIA
THROMBIN INHIBITORS,SELECTIVE,DIRECT, & REVERSIBLE
PRADAXA
THROMBOPOIETIN RECEPTOR AGONISTS
ELTROMBOPAG OLAMINE
NPLATE
PROMACTA
TOPICAL HEMOSTATICS
ASTRINGYN
AVITENE
ENDO-AVITENE
GELFOAM
GELFOAM COMPRESSED
MONSEL'S
OXYCEL
RECOTHROM
DRUG TIER
1
2
1
2
4
4
2, 4
4
4
4
2
2
2
1
1
1
2
2
2
2
1
2
4
4
2
1
2
2
4
2
4
2
2
2
2
2
2
2
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 45
DRUG CATEGORY & NAME
SYRINGE AVITENE
TACHOSIL
THROMBI-GEL
THROMBIN-JMI
THROMBI-PAD
TISSEEL VHSD
ULTRAFOAM
VITAMIN K PREPARATIONS
MEPHYTON
HORMONAL DEFICIENCY
ANDROGENIC AGENTS
ANADROL-50
ANDRODERM
ANDROGEL
ANDROID
ANDROXY
AXIRON
FORTESTA
METHITEST
NATESTO
OXANDRIN
OXANDROLONE
STRIANT
TESTIM
TESTOSTERONE
TESTRED
VOGELXO
ESTROGEN & PROGESTIN WITH ANTIMINERALOCORTICOID CB
ANGELIQ
ESTROGEN & SELECTIVE ESTROGEN RECEPT MOD(SERM)COMB
DUAVEE
ESTROGEN/ANDROGEN COMBINATIONS
ESTROGEN,ESTER/ME-TESTOSTERONE
ESTROGENIC AGENTS
ACTIVELLA
ALORA
CLIMARA
CLIMARA PRO
COMBIPATCH
DIVIGEL
ELESTRIN
ENJUVIA
ESTRACE
ESTRADIOL
ESTRADIOL/NORETHINDRONE ACET
ESTROGEL
ESTROPIPATE
DRUG TIER
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
2
2
2
2
2
2
2
1
2
2
2
2
2
2
2
2
2
1
1
2
1, 2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 46
DRUG CATEGORY & NAME
EVAMIST
FEMHRT
MENEST
MENOSTAR
MINIVELLE
NORETHINDRONE AC-ETH ESTRADIOL
PREFEST
PREMARIN
PREMPHASE
PREMPRO
VIVELLE-DOT
LHRH (GNRH) AGONIST ANALOG AND PROGESTIN COMB
LUPANETA PACK
PROGESTATIONAL AGENTS
AYGESTIN
CRINONE
MEDROXYPROGESTERONE ACETATE
NORETHINDRONE ACETATE
PROGESTERONE,MICRONIZED
PROMETRIUM
PROVERA
IMMUNIZATION
ANTISERA
HYQVIA
ENTERIC VIRUS VACCINES
ROTARIX
ROTATEQ
GRAM (-) BACILLI (NON-ENTERIC) VACCINES
VIVOTIF BERNA
GRAM NEGATIVE COCCI VACCINES
MENOMUNE-A-C-Y-W-135
INFLUENZA VIRUS VACCINES
FLUMIST QUAD 2015-2016
NEUROTOXIC VIRUS VACCINES
YF-VAX
VACCINE/TOXOID PREPARATIONS,COMBINATIONS
M-M-R II VACCINE
PROQUAD
VIRAL/TUMORIGENIC VACCINES
ADENOVIRUS TYPE 4
ADENOVIRUS TYPE 4 AND TYPE 7
ADENOVIRUS TYPE 7
VARIVAX VACCINE
ZOSTAVAX
IMMUNOSUPPRESSION/MODULATION
IMMUNOMODULATORS
ACTIMMUNE
DRUG TIER
2
2
2
2
2
1
2
2
2
2
2
2
2
2
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
4
POS Formulary with Specialty Tier – Last revised 12/22/2015, 47
DRUG CATEGORY & NAME
ALDARA
IMIQUIMOD
INTERFERON GAMMA-1B,RECOMB.
ZYCLARA
IMMUNOSUPPRESSIVES
ASTAGRAF XL
AZASAN
AZATHIOPRINE
CELLCEPT
CYCLOSPORINE
CYCLOSPORINE MODIFIED
CYCLOSPORINE, MODIFIED
EVEROLIMUS
IMURAN
MYCOPHENOLATE MOFETIL
MYCOPHENOLATE SODIUM
MYFORTIC
NEORAL
PROGRAF
RAPAMUNE
SANDIMMUNE
SIROLIMUS
TACROLIMUS
ZORTRESS
INFECTIOUS DISEASE - BACTERIAL
ABSORBABLE SULFONAMIDES
BACTRIM
BACTRIM DS
SULFAMETHOXAZOLE/TRIMETHOPRIM
BETALACTAMS
AZTREONAM LYSINE
CAYSTON
CEPHALOSPORINS - 1ST GENERATION
CEFADROXIL
CEPHALEXIN
KEFLEX
CEPHALOSPORINS - 2ND GENERATION
CEFACLOR
CEFACLOR ER
CEFPROZIL
CEFTIN
CEFUROXIME AXETIL
CEPHALOSPORINS - 3RD GENERATION
CEDAX
CEFDINIR
CEFDITOREN PIVOXIL
CEFIXIME
DRUG TIER
2
1
4
2
2, 4
2
1
2
1
2
1
4
2
1
1
2
2
2
2
2
1
1, 4
4
2
2
1
4
4
1
1, 2
2
1, 2
2
1
2
1
2
1
2
1
POS Formulary with Specialty Tier – Last revised 12/22/2015, 48
DRUG CATEGORY & NAME
CEFPODOXIME PROXETIL
CEFTIBUTEN
SPECTRACEF
SUPRAX
CHEMOTHERAPEUTICS, ANTIBACTERIAL, MISC.
HIPREX
METHEN/M-BLUE/SAL/NA PHOS/HYOS
METHEN/SOD PHOS/METH BLUE/HYOS
METHENAM/ME BLUE/BA/SALICY/HYO
METHENAMINE HIPPURATE
METHENAMINE MANDELATE
MONUROL
MTH/ME BLUE/SOD PHOS/PHEN/HYOS
PRIMSOL
PROSED-DS
TRIMETHOPRIM
URIMAR-T
UROGESIC-BLUE
KETOLIDES
KETEK
MACROLIDES
AZITHROMYCIN
BIAXIN
CLARITHROMYCIN
DIFICID
E.E.S. 200
E.E.S. 400
ERYPED 200
ERYPED 400
ERY-TAB
ERYTHROCIN STEARATE
ERYTHROMYCIN
ERYTHROMYCIN BASE
ERYTHROMYCIN ETHYLSUCCINATE
FIDAXOMICIN
PCE
ZITHROMAX
ZITHROMAX TRI-PAK
ZMAX
NITROFURAN DERIVATIVES
FURADANTIN
MACROBID
MACRODANTIN
NITROFURANTOIN
NITROFURANTOIN MACROCRYSTAL
NITROFURANTOIN MONOHYD/M-CRYST
OXAZOLIDINONES
DRUG TIER
1
2
2
2
2
1
1
1
1
1, 2
2
1
2
2
1
2
2
2
1, 2
2
1
4
2
2
2
2
2
2
2
1
1, 2
4
2
2
2
2
2
2
2
1
1
1
POS Formulary with Specialty Tier – Last revised 12/22/2015, 49
DRUG CATEGORY & NAME
LINEZOLID
SIVEXTRO
TEDIZOLID PHOSPHATE
ZYVOX
PENICILLINS
AMOXICILLIN
AMOXICILLIN ER
AMOXICILLIN/POTASSIUM CLAV
AMPICILLIN TRIHYDRATE
AUGMENTIN
AUGMENTIN ES-600
AUGMENTIN XR
DICLOXACILLIN SODIUM
MOXATAG
PENICILLIN V POTASSIUM
QUINOLONES
AVELOX
AVELOX ABC PACK
CIPRO
CIPRO XR
CIPROFLOXACIN
CIPROFLOXACIN HCL
CIPROFLOXACIN/CIPROFLOXA HCL
FACTIVE
LEVAQUIN
LEVOFLOXACIN
MOXIFLOXACIN HCL
OFLOXACIN
TETRACYCLINES
ACTICLATE
ADOXA
AVIDOXY DK
BENOXYLDOXY 30
BENOXYLDOXY 60
DEMECLOCYCLINE HCL
DORYX
DOXYCYCLINE HYCLATE
DOXYCYCLINE IR-DR
DOXYCYCLINE MONOHYDRATE
MINOCIN
MINOCYCLINE HCL
MONODOX
MORGIDOX
ORACEA
SOLODYN
TETRACYCLINE HCL
VIBRAMYCIN
DRUG TIER
1, 4
4
4
4
1, 2
2
1
1, 2
2
2
2
1
2
1
2
2
2
2
1
1, 2
1
2
2
1
1
2
2
2
2
2
2
1
2
1
2
1
2
1
2
2
2
2
1, 2
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 50
DRUG CATEGORY & NAME
INFECTIOUS DISEASE - FUNGAL
ANTIFUNGAL AGENTS
ANCOBON
CLOTRIMAZOLE
CRESEMBA
DIFLUCAN
FLUCONAZOLE
FLUCYTOSINE
ITRACONAZOLE
KETOCONAZOLE
LAMISIL
NOXAFIL
ONMEL
ORAVIG
POSACONAZOLE
SPORANOX
TERBINAFINE HCL
VFEND
VORICONAZOLE
ANTIFUNGAL ANTIBIOTICS
GRIFULVIN V
GRISEOFULVIN ULTRAMICROSIZE
GRISEOFULVIN, MICROSIZE
GRIS-PEG
NYSTATIN
INFECTIOUS DISEASE - MISCELLANEOUS
AMINOGLYCOSIDES
BETHKIS
GENTAMICIN IN NACL, ISO-OSM
GENTAMICIN SULFATE IN NS
GENTAMICIN SULFATE/PF
KITABIS PAK
NEOMYCIN SULFATE
TOBI
TOBI PODHALER
TOBRAMYCIN
TOBRAMYCIN IN 0.225% NACL
TOBRAMYCIN SULFATE IN NS
TOBRAMYCIN/NEBULIZER
ANTIBACTERIAL AGENTS,MISCELLANEOUS
GLYCINE UROLOGIC SOLUTION
ANTILEPROTICS
DAPSONE
THALIDOMIDE
THALOMID
ANTI-MYCOBACTERIUM AGENTS
ETHAMBUTOL HCL
DRUG TIER
4
1
2
2
1
1, 4
1
1
2
4
2
2
4
2
1
4
1, 4
2
1
1
2
1
4
1
2
1
4
1
4
4
4
1, 4
2
4
1
2
4
4
1
POS Formulary with Specialty Tier – Last revised 12/22/2015, 51
DRUG CATEGORY & NAME
ISONIAZID
MYAMBUTOL
MYCOBUTIN
PASER
PYRAZINAMIDE
RIFABUTIN
TRECATOR
ANTITUBERCULAR ANTIBIOTICS
BEDAQUILINE FUMARATE
CYCLOSERINE
PRIFTIN
RIFADIN
RIFAMATE
RIFAMPIN
RIFATER
SIRTURO
LINCOSAMIDES
CLEOCIN HCL
CLEOCIN PALMITATE
CLINDAMYCIN HCL
CLINDAMYCIN PALMITATE HCL
RIFAMYCINS AND RELATED DERIVATIVE ANTIBIOTICS
XIFAXAN
VANCOMYCIN AND DERIVATIVES
VANCOCIN HCL
VANCOMYCIN HCL
INFECTIOUS DISEASE - PARASITIC
2ND GEN. ANAEROBIC ANTIPROTOZOAL-ANTIBACTERIAL
TINDAMAX
TINIDAZOLE
AMEBACIDES
PAROMOMYCIN SULFATE
ANAEROBIC ANTIPROTOZOAL-ANTIBACTERIAL AGENTS
FLAGYL
FLAGYL ER
METRO IV
METRONIDAZOLE
METRONIDAZOLE/SODIUM CHLORIDE
ANTHELMINTICS
ALBENZA
BILTRICIDE
IVERMECTIN
STROMECTOL
ANTIMALARIAL DRUGS
ATOVAQUONE/PROGUANIL HCL
CHLOROQUINE PHOSPHATE
COARTEM
DRUG TIER
1, 2
2
4
2
1
1, 4
2
4
2
2
2
2
1
2
4
2
2
1
1
2
4
1, 4
2
1
1
2
2
2
1
1
2
2
1
2
1
1
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 52
DRUG CATEGORY & NAME
DARAPRIM
HYDROXYCHLOROQUINE SULFATE
MALARONE
MEFLOQUINE HCL
PLAQUENIL
PRIMAQUINE
QUALAQUIN
QUININE SULFATE
ANTIPROTOZOAL DRUGS,MISCELLANEOUS
ATOVAQUONE
MEPRON
NEBUPENT
INFECTIOUS DISEASE - VIRAL
ANTIVIRALS, GENERAL
ACYCLOVIR
FAMCICLOVIR
FAMVIR
FLUMADINE
RELENZA
RIBAVIRIN
RIMANTADINE HCL
SITAVIG
TAMIFLU
VALACYCLOVIR HCL
VALCYTE
VALGANCICLOVIR HCL
VALTREX
VIRAZOLE
ZOVIRAX
ANTIVIRALS, HIV-SPEC, NON-PEPTIDIC PROTEASE INHIB
APTIVUS
PREZCOBIX
PREZISTA
ANTIVIRALS, HIV-SPEC, NUCLEOSIDE-NUCLEOTIDE ANALOG
TRUVADA
ANTIVIRALS, HIV-SPEC., NUCLEOSIDE ANALOG, RTI COMB
ABACAVIR/LAMIVUDINE/ZIDOVUDINE
COMBIVIR
EPZICOM
LAMIVUDINE/ZIDOVUDINE
TRIZIVIR
ANTIVIRALS, HIV-SPECIFIC, CCR5 CO-RECEPTOR ANTAG.
SELZENTRY
ANTIVIRALS, HIV-SPECIFIC, FUSION INHIBITORS
FUZEON
ANTIVIRALS, HIV-SPECIFIC, NON-NUCLEOSIDE, RTI
EDURANT
DRUG TIER
2
1
2
1
2
2
2
1
1, 4
4
2
1
1
2
2
2
4
1
2
2
1
4
1, 4
2
4
2
2
2
2
2
1
2
2
1
2
2
2
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 53
DRUG CATEGORY & NAME
INTELENCE
NEVIRAPINE
RESCRIPTOR
SUSTIVA
VIRAMUNE
VIRAMUNE XR
ANTIVIRALS, HIV-SPECIFIC, NUCLEOSIDE ANALOG, RTI
ABACAVIR SULFATE
DIDANOSINE
EMTRIVA
EPIVIR
LAMIVUDINE
RETROVIR
STAVUDINE
VIDEX
VIDEX EC
ZERIT
ZIAGEN
ZIDOVUDINE
ANTIVIRALS, HIV-SPECIFIC, NUCLEOTIDE ANALOG, RTI
VIREAD
ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITOR COMB
KALETRA
ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORS
CRIXIVAN
EVOTAZ
INVIRASE
LEXIVA
NORVIR
REYATAZ
VIRACEPT
ANTIVIRALS,HIV-1 INTEGRASE STRAND TRANSFER INHIBTR
ISENTRESS
TIVICAY
VITEKTA
ARTV CMB NUCLEOSIDE,NUCLEOTIDE,&NON-NUCLEOSIDE RTI
ATRIPLA
COMPLERA
ARV CMB-NRTI,N(T)RTI, INTEGRASE INHIBITOR
STRIBILD
ARV COMB-NRTIS & INTEGRASE INHIBITOR
TRIUMEQ
CYTOCHROME P450 INHIBITORS
TYBOST
HEP C VIRUS - NS5A & NS5B POLYMERASE INHIB. COMBO.
HARVONI
LEDIPASVIR/SOFOSBUVIR
DRUG TIER
2
1, 2
2
2
2
2
1
1
2
2
1
2
1
2
2
2
2
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
4
4
POS Formulary with Specialty Tier – Last revised 12/22/2015, 54
DRUG CATEGORY & NAME
HEP C VIRUS,NUCLEOTIDE ANALOG NS5B POLYMERASE INH
SOFOSBUVIR
SOVALDI
HEPATITIS B TREATMENT AGENTS
ADEFOVIR DIPIVOXIL
BARACLUDE
ENTECAVIR
EPIVIR HBV
HEPSERA
LAMIVUDINE
TELBIVUDINE
TYZEKA
HEPATITIS C TREATMENT AGENTS
COPEGUS
MODERIBA
PEGASYS
PEGASYS PROCLICK
PEGINTERFERON ALFA-2A
PEGINTERFERON ALFA-2B
PEGINTRON
PEGINTRON REDIPEN
REBETOL
RIBASPHERE
RIBASPHERE RIBAPAK
RIBATAB
RIBAVIRIN
HEPATITIS C VIRUS - NS5A REPLICATION COMPLEX INHIB
DAKLINZA
HEPATITIS C VIRUS - NS5A, NS3/4A, NS5B INHIB CMB.
OMBITA/PARITAP/RITON/DASABUVIR
VIEKIRA PAK
HEPATITIS C VIRUS NS3/4A SERINE PROTEASE INHIB.
OLYSIO
SIMEPREVIR SODIUM
HEPATITIS C VIRUS- NS5A AND NS3/4A INHIBITOR COMB
TECHNIVIE
INFLAMMATORY DISEASE
ANTI-ARTHRITIC AND CHELATING AGENTS
CUPRIMINE
DEPEN
ANTI-ARTHRITIC, FOLATE ANTAGONIST AGENTS
OTREXUP
RASUVO
RHEUMATREX
ANTI-FLAM. INTERLEUKIN-1 RECEPTOR ANTAGONIST
ANAKINRA
KINERET
DRUG TIER
4
4
1, 4
4
1, 4
2
4
1
4
4
2
2
4
4
4
4
4
4
2
2
2
2
1
2
4
4
4
4
2
2
2
2
2
2
4
4
POS Formulary with Specialty Tier – Last revised 12/22/2015, 55
DRUG CATEGORY & NAME
ANTI-INFLAMMATORY TUMOR NECROSIS FACTOR INHIBITOR
ADALIMUMAB
ENBREL
ETANERCEPT
GOLIMUMAB
HUMIRA
HUMIRA CROHN'S
HUMIRA PEDIATRIC CROHN'S
HUMIRA PSORIASIS
SIMPONI
ANTI-INFLAMMATORY, INTERLEUKIN-1 BETA BLOCKERS
CANAKINUMAB/PF
ILARIS
ANTI-INFLAMMATORY, PYRIMIDINE SYNTHESIS INHIBITOR
ARAVA
LEFLUNOMIDE
ANTI-INFLAMMATORY,PHOSPHODIESTERASE-4(PDE4) INHIB.
APREMILAST
OTEZLA
ANTI-INFLAMMATORY/ANTIARTHRITICS AGENTS, MISC.
TREPADONE
ANTINFLAMMATORY, SEL.COSTIM.MOD.,T-CELL INHIBITOR
ABATACEPT
ORENCIA
GLUCOCORTICOIDS
BUDESONIDE
CORTEF
CORTISONE ACETATE
DEXAMETHASONE
DEXAMETHASONE INTENSOL
DEXPAK
ENTOCORT EC
FLO-PRED
HYDROCORTISONE
MEDROL
METHYLPREDNISOLONE
MILLIPRED
MILLIPRED DP
ORAPRED ODT
PEDIAPRED
PREDNISOLONE
PREDNISOLONE SOD PHOSPHATE
PREDNISOLONE SODIUM PHOSPHATE
PREDNISONE
PREDNISONE INTENSOL
RAYOS
SOLU-CORTEF
DRUG TIER
4
4
4
4
2, 4
4
4
4
4
4
4
4
1, 4
4
4
2
4
4
1, 4
2
2
1, 2
2
2
4
2
1
2
1
2
2
2
2
1
1
2
1, 2
2
2
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 56
DRUG CATEGORY & NAME
UCERIS
VERIPRED 20
GOLD SALTS
RIDAURA
JANUS KINASE (JAK) INHIBITORS
TOFACITINIB CITRATE
XELJANZ
MINERALOCORTICOIDS
FLUDROCORTISONE ACETATE
MONOCLONAL ANTIBODY-HUMAN INTERLEUKIN 12/23 INHIB
STELARA
USTEKINUMAB
NASAL NSAIDS, COX NON-SELECTIVE,SYSTEMIC ANALGESIC
SPRIX
NSAID & HISTAMINE H2 RECEPTOR ANTAGONIST COMB.
DUEXIS
NSAID, COX INHIBITOR-TYPE & PROTON PUMP INHIB COMB
VIMOVO
NSAIDS (COX NON-SPECIFIC INHIB)& PROSTAGLANDIN CMB
ARTHROTEC 50
ARTHROTEC 75
DICLOFENAC SODIUM/MISOPROSTOL
NSAIDS, CYCLOOXYGENASE 2 INHIBITOR - TYPE
CELEBREX
CELECOXIB
NSAIDS, CYCLOOXYGENASE INHIBITOR-TYPE
ANAPROX
ANAPROX DS
CELEBREX
CELECOXIB
DAYPRO
DICLOFENAC POTASSIUM
DICLOFENAC SODIUM
EC-NAPROSYN
ETODOLAC
FELDENE
FENOPROFEN CALCIUM
FLURBIPROFEN
IBUPROFEN
INDOCIN
INDOMETHACIN
KETOPROFEN
KETOROLAC TROMETHAMINE
MECLOFENAMATE SODIUM
MEFENAMIC ACID
MELOXICAM
MOBIC
DRUG TIER
4
2
2
4
4
1
4
4
2
2
2
2
2
1
2
1
2
2
2
1
2
1
1
2
1
2
2
1
1
2
1
1, 2
1
2
1
1, 2
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 57
DRUG CATEGORY & NAME
NABUMETONE
NALFON
NAPRELAN
NAPROSYN
NAPROXEN
NAPROXEN SODIUM
OXAPROZIN
PIROXICAM
PONSTEL
SULINDAC
TIVORBEX
TOLMETIN SODIUM
VOLTAREN-XR
ZIPSOR
ZORVOLEX
PLASMA KALLIKREIN INHIBITORS
KALBITOR
UNKNOWN
COMFORT PAC-IBUPROFEN
COMFORT PAC-MELOXICAM
COMFORT PAC-NAPROXEN
LOCAL ANESTHESIA
LOCAL ANESTHETICS
ADVANCED DNA MEDICATED COLLECT
BUCALSEP
DYNAMIC
LIDOCAINE HCL
PRO DNA COLLECTION
XYLOCAINE
LOWER GASTROINTESTINAL DISORDERS - BOWEL INFLAMMAT
ABSORBABLE SULFONAMIDES
SULFAMETHOXAZOLE/TRIMETHOPRIM
BOWEL ANTIINFLAMATORY AGENTS
SULFADIAZINE
CHRONIC INFLAM. COLON DX, 5-A-SALICYLAT,RECTAL TX
CANASA
MESALAMINE
MESALAMINE W/CLEANSING WIPES
ROWASA
SFROWASA
DRUG TX-CHRONIC INFLAM. COLON DX,5-AMINOSALICYLAT
APRISO
ASACOL HD
AZULFIDINE
BALSALAZIDE DISODIUM
COLAZAL
DELZICOL
DRUG TIER
1
2
2
2
1, 2
1
1
1
2
1
2
1, 2
2
2
2
2
2
2
2
2
2
2
1
2
2
1
2
2
1
1
2
2
2
2
2
1
2
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 58
DRUG CATEGORY & NAME
DIPENTUM
GIAZO
LIALDA
OLSALAZINE SODIUM
PENTASA
SULFASALAZINE
DRUGS TO TX CHRONIC INFLAMM. DISEASE OF COLON
CERTOLIZUMAB PEGOL
CIMZIA
HEMORRHOIDAL PREP, ANTI-INFAM STEROID/LOCAL ANESTH
ANALPRAM E
ANALPRAM HC
HYDROCORT/PRAMOXIN/EMOL/PRAM#1
HYDROCORTISONE/LIDOCAINE/ALOE
HYDROCORTISONE/PRAMOXINE
LIDOCAINE/HYDROCORTISONE AC
LIDOCAINE-HYDROCORTISONE
PROCORT
PROCTOFOAM-HC
ZYPRAM
HEMORRHOIDAL PREPARATIONS
ANALPRAM ADVANCED
IRRITABLE BOWEL AGENTS,GUANYLATE CYLASE-C AGONIST
LINZESS
LOCAL ANORECTAL NITRATE PREPARATIONS
RECTIV
RECTAL PREPARATIONS
ANUSOL-HC
HYDROCORTISONE
HYDROCORTISONE ACETATE
PROCTOCORT
RECTAL/LOWER BOWEL PREP.,GLUCOCORT. (NON-HEMORR)
CORTENEMA
CORTIFOAM
HYDROCORTISONE
UCERIS
LOWER GASTROINTESTINAL DISORDERS - OTHER
AMMONIA INHIBITORS
AMMONUL
BUPHENYL
CARBAGLU
GLYCEROL PHENYLBUTYRATE
LACTULOSE
LITHOSTAT
RAVICTI
SODIUM PHENYLBUTYRATE
ANTIDIARRHEAL - G.I. CHLORIDE CHANNEL INHIBITORS
DRUG TIER
4
2
2
4
2
1
4
4
2
2
1
1
1
1
2
2
2
2
2
2
2
2
1
1
2
2
2
1
2
2
4
2
4
1
2
4
1, 4
POS Formulary with Specialty Tier – Last revised 12/22/2015, 59
DRUG CATEGORY & NAME
FULYZAQ
ANTIDIARRHEALS
DIPHENOXYLATE HCL/ATROPINE
DIPHENOXYLATE-ATROPINE
LOMOTIL
LOPERAMIDE HCL
MOTOFEN
OPIUM TINCTURE
PAREGORIC
BILE SALTS
ACTIGALL
CHENODAL
CHOLBAM
URSO
URSO FORTE
URSODIOL
IRRITABLE BOWEL SYND. AGENT,5HT-3 ANTAGONIST-TYPE
ALOSETRON HCL
LOTRONEX
LAXATIVES AND CATHARTICS
AMITIZA
BISAC/NACL/NAHCO3/KCL/PEG 3350
COLYTE WITH FLAVOR PACKETS
COLYTE WITH FLAVOR PACKS
GOLYTELY
KRISTALOSE
LACTULOSE
MOVIPREP
NULYTELY WITH FLAVOR PACKS
OSMOPREP
PEG 3350/NA SULF,BICARB,CL/KCL
POLYETHYLENE GLYCOL 3350
PREPOPIK
SODIUM CHLORIDE/NAHCO3/KCL/PEG
SUPREP
NARCOTIC ANTAGONISTS, PERIPHERALLY-ACTING
ENTEREG
MOVANTIK
RELISTOR
MEDICAL SUPPLIES
BANDAGES AND RELATED SUPPLIES
ACTICOAT
ACTICOAT 7
ACTICOAT FLEX 3
ACTICOAT FLEX 7
ACTICOAT SURGICAL
ALLEVYN
DRUG TIER
2
1
2
2
1
2
1
2
2
2
2
2
2
1
1, 4
4
2
1
2
2
2
2
1
2
2
2
1
1, 2
2
1
2
2
2
2
2
2
2
2
2
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 60
DRUG CATEGORY & NAME
ALLEVYN ADHESIVE
ALLEVYN AG
ALLEVYN AG ADHESIVE
ALLEVYN AG GENTLE
ALLEVYN HEEL
ALLEVYN LIFE
BIOSTEP
BIOSTEP AG
CARRASYN HYDROGEL WOUND
CURAFIL
CURITY AMD
CURITY IODOFORM
HYDROFERA BLUE
HYDROFERA BLUE READY
KERLIX AMD
KERLIX AMD BANDAGE
OASIS ULTRA
REPLICARE
REPLICARE THIN
REPLICARE ULTRA
REPLICARE ULTRA SACRUM
RESTORE
RESTORE CALCIUM ALGINATE
RESTORE CONTACT LAYER SILVER
SILVERSEAL HYDROGEL
SPECTRAGEL
VASCUDERM HYDROGEL WOUND
WOUND MATRIX
XEROFORM
XEROFORM PETROLATUM DRESSING
BLOOD ADMINISTRATION SETS
HEMA ACCESS PORT
CATHETERS AND RELATED DEVICES
ADVANCE PLUS INTERMITTENT
APOGEE HC INTERMITTENT
CATHETER
CURITY
DOVER ADVANTAGE
DOVER ADVANTAGE DRAINAGE
DOVER COATED LATEX FOLEY
DOVER LATEX FOLEY CATHETER
DOVER PREMIUM
DOVER RED RUBBER ROBIBSON CATH
DOVER UNIVERSAL
FEMALE SELF CATHETER
KENGUARD
MONO-FLO
DRUG TIER
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 61
DRUG CATEGORY & NAME
ROBINSON CLEAR VINYL CATHETER
TOUCH-TROL
DURABLE MEDICAL EQUIPMENT,MISC
AERONEB GO
AIR FILTER
ALL FLOW 1000
ALL FLOW 2000
ALL FLOW 3000 KIT
ALL FLOW 3000 PFT
ALL FLOW 4000
ALL FLOW 5000
ALL FLOW 6000
ALL FLOW 7000
AMIELLE VAGINAL TRAINER
ARGYLE
BABY CONVERSION KIT
BABY CONVERSION PACK 1
BABY CONVERSION PACK 2
ERAPID NEBULIZER HANDSET
E-Z SPACER PEDSPAK
FILTER PAD
FILTER, VALVE SET FOR LL & LC
INNOSPIRE REPLACEMENT FILTER
INSPIRATION ELITE FILTER
JETCO-SPRAY CANNULA
MASK SET WITH Y-PIECE
MICRO ELITE
MINIELITE
MOUTHPIECE
NOSE CLIP
PARI LC PLUS NEBULIZER
PILLOW MASK FOR CHILDREN
PRO-CEPTION FERTILITY PAK
RECONSTITUBE
REUSABLE NEBULIZER KIT
RUBBER MOUTHPIECE
SAMI THE SEAL MASK
SIDESTREAM MASK
SILICONE MASK
SMARTMASK KIDS
STERILE EMPTY VIAL
T.E.D. SEQUNT COMPRESS DEVICE
TENS 502
TENS 504
TREK S PORTABLE PWR KIT
DURABLE MEDICAL EQUIPMENT,MISC(GROUP 2)
RELIEFBAND
DRUG TIER
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 62
DRUG CATEGORY & NAME
FEEDING DEVICES
ARGYLE
KANGAROO 924 SAFETY SCREW
KANGAROO EPUMP SET
KANGAROO GRAVITY SET
INCONTINENCE SUPPLIES
FLEXI-SEAL SIGNAL FMS
MEDICAL SUPPLIES,MISCELLANEOUS
VARITHENA ADMINISTRATION PACK
MEDICAL SUPPLIES,MISCELLANEOUS(GROUP 2)
EAR POPPER
FREEDOM PRECISION AIRLESS
PCCA ACCUPEN-15
ZYMOGENETICS SPRAY APPLICATOR
MEDICAL SUPPLIES,MISCELLANEOUS(GROUP 3)
CONT EPIDURAL W-BUPIV-EPI
CONT EPIDURAL W-LIDOCAINE-EPI
MYELOGRAM TRAY
SPINAL ANESTHESIA TRAY
SPINAL-22 W-BUPIV-EPI-EPHED
OSTOMY SUPPLIES
ASSURA
NUTRIPORT BALLOON
SENSURA CLICK OSTOMY POUCH
SENSURA FLEX OSTOMY BASE PLATE
SENSURA FLEX OSTOMY POUCH
SENSURA OSTOMY BASE PLATE
SYRINGES AND ACCESSORIES
ADVOCATE SYRINGES
ALLERGIST SYRINGE
ALLERGIST SYRINGE TRAY
ALLERGIST SYRINGE WITH NEEDLE
ALLERGIST TRAY
ALLERGIST TRAY SYR-DETACH NDL
ALLERGIST TRAY SYR-PERM NEEDLE
ALLERGY SYRINGE
ASEPTO BULB SYRINGE GLASS TIP
ASSURE ID INSULIN SAFETY
BULK SYRINGE
CANNULA
COMFORT EZ
CORNWALL METAL PIPETING HOLDER
CORNWALL SYRINGE TIP CONNECTOR
CORNWALL SYRINGES LUER-LOK TIP
DAVOL IRRIGATION SYRINGE
EASY COMFORT INSULIN SYRINGE
EASY TOUCH
DRUG TIER
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 63
DRUG CATEGORY & NAME
EASY TOUCH FLURINGE
EASY TOUCH FLURINGE FLU TRAY
EASY TOUCH INSULIN SAFETY
EASY TOUCH INSULIN SYRINGE
EASY TOUCH SYR ALLERGY TRAY
EASY-TOUCH INSULIN SYRINGE
ECLIPSE LUER-LOK SYRINGE
ECLIPSE SYRINGE
ECLIPSE SYRINGE-NEEDLE
EXEL ALLERGY SYRINGE
EXEL SYRINGE
EXEL TB WITH NEEDLE
EXEL TUBERCULIN SYRINGE
FIFTY50 RESERVOIR
FILTER, MILLEX-OR SYRINGE
FINGER GRIP EXTENDER
FREESTYLE PRECISION
GLASPAK
INJECT-EASE
INPERSOL PERITONEAL CATH. 11FR
INSULIN SYRINGE
INTEGRA SYRINGE
INTERLINK SYRINGE
INTERLINK SYRINGE W-CANNULA
IRRIGATION SYRINGE
KENDALL DISINFECTANT CAP
LEVER LOCK CANNULA
LIFESHIELD BLUNT CANNULA
LITE TOUCH
LUER LOCK SYRINGE
LUER SLIP TIP CAP
LUER SLIP TIP SYRINGE TRAY
LUER-LOCK SYRINGE
LUER-LOK SYRINGE
LUER-LOK SYRINGE-NEEDLE
LUER-LOK TIP SYRINGE
LUERSLIP SYRINGE
MAGELLAN INSULIN SAFETY SYRNG
MAGELLAN INSULIN SYRINGE
MAGELLAN TUBERCULIN SYRINGE
MAXI-COMFORT
MEDSAVER
MINIMED RESERVOIR
MONOJECT
MONOJECT ALLERGY TRAY-NEEDLE
MONOJECT CONTROL SYRINGE
MONOJECT INSULIN SAFETY SYRNG
DRUG TIER
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 64
DRUG CATEGORY & NAME
MONOJECT INSULIN SYRINGE
MONOJECT LUER LOCK TB SYRINGE
MONOJECT MAGELLAN
MONOJECT MEGELLAN TB SYRINGE
MONOJECT PHARMACY TRAY
MONOJECT SAFETY SYR TIP CAP
MONOJECT SAFETY SYRINGE
MONOJECT SMARTIP CANNULA
MONOJECT SYRINGE
MONOJECT SYRINGE PHARMACY TRAY
MONOJECT TB
MONOJECT TB SYRINGE
MONOJECT TUBERCULIN SAFETY SYR
MONOJECT TUBERCULIN SYRINGE
NORM-JECT
NUTRIMIX
PARADIGM
PRECISIONGLIDE
PRODIGY COUNT-A-DOSE
PRODIGY INSULIN SYRINGE
SAFE-CLIP
SAFESNAP ALLERGY SYRINGE
SAFESNAP INSULIN SYRINGE
SAFESNAP SYRINGE
SAFESNAP TUBERCULIN SYRINGE
SAFETY SYRINGE WITH SHIELD
SAFETY SYRINGE-NEEDLE
SAFETYGLIDE ALLERGY
SAFETYGLIDE ALLERGY SYRINGE
SAFETYGLIDE INSULIN SYRINGE
SAFETYGLIDE SYRINGE
SAFETYGLIDE TB SYRINGE
SAFETY-LOK SAFETY SYRINGE
SAFETY-LOK SAFETY SYRINGES
SAFETY-LOK SYRINGES
SLIP-TIP SYRINGE
SUPOR
SURE COMFORT
SURE-JECT INSULIN SYRINGE
SYRINGE
SYRINGE BULK
SYRINGE CATHETER TIP
SYRINGE FILTER, MILLEX-GP
SYRINGE FILTER, MILLEX-GS
SYRINGE STORAGE BIN
SYRINGE TIP CAP
SYRINGE WITH NEEDLE DISP
DRUG TIER
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 65
DRUG CATEGORY & NAME
SYRINGE WITHOUT NEEDLE
SYRINGE, DISPOSABLE, 20 ML
SYRINGE, DISPOSABLE, 30 ML
SYRINGE-LUER TIP CAP
SYRINGE-NEEDLE
SYRINGE-PRECISIONGLIDE NEEDLE
TB SYRINGE
TERUMO ALLERGY SYRINGE
TERUMO HYPODERMIC NEEDLE-SYRIN
TERUMO INSULIN SYRINGE
TERUMO SURGUARD2
TERUMO SYRINGE
THINPRO INSULIN SYRINGE
THINSET
TOOMEY SYRINGE
TOPCARE ULTRA COMFORT
TRUEPLUS INSULIN SYRINGE
TUBERCULIN SYRINGE
TUBERCULIN SYRINGE-NEEDLE
TWINPAK DUAL CANNULA
ULTICARE
ULTICARE SYRINGE
ULTILET INSULIN SYRINGE
ULTRA COMFORT
ULTRA-THIN II
UNIVERSAL SYRINGE TIP ADAPTOR
VANISHPOINT
YALE GLASS TB SYRINGE
YALE SYRINGE
MISCELLANEOUS AGENTS
PARASYMPATHETIC AGENTS
BETHANECHOL CHLORIDE
CEVIMELINE HCL
EVOXAC
GUANIDINE HCL
PILOCARPINE HCL
SALAGEN
URECHOLINE
NEOPLASTIC DISEASE
ALKYLATING AGENTS
ALKERAN
ALTRETAMINE
BENDAMUSTINE HCL
BICNU
BUSULFAN
BUSULFEX
CARBOPLATIN
DRUG TIER
2
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
1
2
2
1
2
2
2
4
4
2
4
4
1, 2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 66
DRUG CATEGORY & NAME
CISPLATIN
CYCLOPHOSPHAMIDE
ELOXATIN
GLEOSTINE
GLIADEL
HEXALEN
HYDREA
HYDROXYUREA
IFEX
IFOSFAMIDE
IFOSFAMIDE-MESNA
LEUKERAN
LOMUSTINE
MELPHALAN HCL
MYLERAN
OXALIPLATIN
TEMODAR
TEMOZOLOMIDE
TREANDA
ANTIANDROGENIC AGENTS
ABIRATERONE ACETATE
BICALUTAMIDE
CASODEX
ENZALUTAMIDE
FLUTAMIDE
NILANDRON
XTANDI
ZYTIGA
ANTIMETABOLITES
CAPECITABINE
MERCAPTOPURINE
METHOTREXATE SODIUM
METHOTREXATE SODIUM/PF
PURIXAN
TABLOID
TREXALL
XELODA
ANTINEOPLASTIC AROMATASE INHIBITORS
ANASTROZOLE
ARIMIDEX
AROMASIN
EXEMESTANE
FEMARA
LETROZOLE
ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITOR
ERIVEDGE
VISMODEGIB
DRUG TIER
1, 2
1, 2
4
2
2
4
2
1
2
1, 2
2
2
2
1
2
1, 4
4
1, 4
2, 4
4
1
2
4
1
2
4
4
1
1
1
1
2
2
2
2
1
2
2
1
2
1
4
4
POS Formulary with Specialty Tier – Last revised 12/22/2015, 67
DRUG CATEGORY & NAME
ANTINEOPLASTIC - JANUS KINASE (JAK) INHIBITORS
JAKAFI
RUXOLITINIB PHOSPHATE
ANTINEOPLASTIC - MTOR KINASE INHIBITORS
AFINITOR
AFINITOR DISPERZ
EVEROLIMUS
ANTINEOPLASTIC - TOPOISOMERASE I INHIBITORS
HYCAMTIN
TOPOTECAN HCL
ANTINEOPLASTIC IMMUNOMODULATOR AGENTS
LENALIDOMIDE
PEGINTERFERON ALFA-2B
POMALIDOMIDE
POMALYST
REVLIMID
SYLATRON
ANTINEOPLASTIC LHRH(GNRH) ANTAGONIST,PITUIT.SUPPRS
FIRMAGON
ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS
AFATINIB DIMALEATE
AXITINIB
BOSULIF
BOSUTINIB
CABOZANTINIB S-MALATE
CAPRELSA
CERITINIB
COMETRIQ
CRIZOTINIB
DABRAFENIB MESYLATE
DASATINIB
ERLOTINIB HCL
GEFITINIB
GILOTRIF
GLEEVEC
IBRANCE
IBRUTINIB
ICLUSIG
IDELALISIB
IMATINIB MESYLATE
IMBRUVICA
INLYTA
IRESSA
LAPATINIB DITOSYLATE
LENVATINIB MESYLATE
LENVIMA
LYNPARZA
DRUG TIER
4
4
4
4
4
4
4
4
4
4
4
4
4
2
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
POS Formulary with Specialty Tier – Last revised 12/22/2015, 68
DRUG CATEGORY & NAME
MEKINIST
NEXAVAR
NILOTINIB HCL
OLAPARIB
PALBOCICLIB
PAZOPANIB HCL
PONATINIB HCL
REGORAFENIB
SORAFENIB TOSYLATE
SPRYCEL
STIVARGA
SUNITINIB MALATE
SUTENT
TAFINLAR
TARCEVA
TASIGNA
TRAMETINIB DIMETHYL SULFOXIDE
TYKERB
VANDETANIB
VEMURAFENIB
VOTRIENT
XALKORI
ZELBORAF
ZYDELIG
ZYKADIA
ANTINEOPLASTIC,HISTONE DEACETYLASE INHIBITORS,HDIS
FARYDAK
PANOBINOSTAT LACTATE
VORINOSTAT
ZOLINZA
ANTINEOPLASTICS,MISCELLANEOUS
ETOPOSIDE
LYSODREN
MATULANE
OMACETAXINE MEPESUCCINATE
PROCARBAZINE HCL
SYNRIBO
TRETINOIN
CHEMOTHERAPY RESCUE/ANTIDOTE AGENTS
LEUCOVORIN CALCIUM
MESNEX
PHOTOACTIVATED, ANTINEOPLS. & PREMALIGNANT LESIONS
LEVULAN
SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERM)
FARESTON
SOLTAMOX
TAMOXIFEN CITRATE
DRUG TIER
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
2
2
4
4
4
4
1
1, 2
2
2
4
2
1
POS Formulary with Specialty Tier – Last revised 12/22/2015, 69
DRUG CATEGORY & NAME
TOREMIFENE CITRATE
SELECTIVE RETINOID X RECEPTOR AGONISTS (RXR)
BEXAROTENE
TARGRETIN
STEROID ANTINEOPLASTICS
EMCYT
ESTRAMUSTINE PHOSPHATE SODIUM
MEGESTROL ACETATE
NEUROLOGICAL DISEASE - MISCELLANEOUS
AGENTS TO TREAT MULTIPLE SCLEROSIS
AUBAGIO
AVONEX
AVONEX ADMINISTRATION PACK
AVONEX PEN
BETASERON
COPAXONE
DIMETHYL FUMARATE
EXTAVIA
FINGOLIMOD HCL
GILENYA
GLATIRAMER ACETATE
INTERFERON BETA-1A
INTERFERON BETA-1A/ALBUMIN
PEGINTERFERON BETA-1A
PLEGRIDY
PLEGRIDY PEN
REBIF
REBIF REBIDOSE
TECFIDERA
TERIFLUNOMIDE
AGTS TX NEUROMUSC TRANSMISSION DIS,POT-CHAN BLKR
AMPYRA
DALFAMPRIDINE
AMYOTROPHIC LATERAL SCLEROSIS AGENTS
RILUTEK
RILUZOLE
FIBROMYALGIA AGENTS,SEROTONIN-NOREPINEPH RU INHIB
SAVELLA
MOVEMENT DISORDERS(DRUG THERAPY)
HORIZANT
TETRABENAZINE
XENAZINE
POSTHERPETIC NEURALGIA AGENTS
GRALISE
PSEUDOBULBAR AFFECT (PBA) AGENTS, NMDA ANTAGONISTS
NUEDEXTA
ORAL/PHARYNGEAL DISORDERS
DRUG TIER
4
1, 4
4
4
4
1
4
2, 4
4
4
2
4
4
2
4
4
1, 4
4
4
4
4
4
2
2
4
4
4
4
4
1, 4
2
2
1, 4
4
2
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 70
DRUG CATEGORY & NAME
DENTAL AIDS AND PREPARATIONS
CHLORHEXIDINE GLUCONATE
PERIDEX
Q-CARE RX
TRIAMCINOLONE ACETONIDE
NOSE PREPARATIONS ANTIBIOTICS
BACTROBAN NASAL
NOSE PREPARATIONS, MISCELLANEOUS (RX)
ATROVENT
IPRATROPIUM BROMIDE
PERIODONTAL COLLAGENASE INHIBITORS
DOXYCYCLINE HYCLATE
PERIODONTAL TETRACYCLINE ANTIINFECTIVE, LOCAL
ARESTIN
OTHER DRUGS
ABORTIFACIENT,PROGESTERONE RECEPTOR ANTAGONIST-TYP
MIFEPREX
AGENTS FOR STOMATOLOGICAL USE
DEBACTEROL
ORAFATE
PROTHELIAL
ANTIDIARRHEAL MICROORGANISMS AGENTS
RESTORA RX
VSL#3 DS
APPETITE STIM. FOR ANOREXIA,CACHEXIA,WASTING SYND.
MEGACE
MEGACE ES
MEGESTROL ACETATE
BULK CHEMICALS
DIMETHYL SULFOXIDE
HYDROCHLORIC ACID
HYDROGEN PEROXIDE
HYDROXYETHYL METHACRYLATE
LACTIC ACID
TRI-CHLOR
TRICHLOROACETIC ACID
VITAMIN E ACETATE
CARBOHYDRATES
GLUTOL
CHELATING AGENTS
GLUTATHIONE
GLUTATHIONE-L
CONCEPTION ASSISTANCE SUPPLIES
CONCEPTION
CXCR4 CHEMOKINE RECEPTOR ANTAGONIST
MOZOBIL
PLERIXAFOR
DRUG TIER
1
2
2
1
2
2
1
1
2
2
2
2
2
2
2
2
2
1
2
2
2
2
2
2
2
2
2
2
2
2
4
4
POS Formulary with Specialty Tier – Last revised 12/22/2015, 71
DRUG CATEGORY & NAME
DIAGNOSTIC PREPARATIONS,MISC.
ISOSULFAN BLUE
LYMPHAZURIN
PROVOCHOLINE
TC99M SULFUR COLLOID PREP
TOXICOLOGY SALIVA COLLECTION
DIETARY SUPPLEMENT, MISCELLANEOUS
APPTRIM
APPTRIM-D
B3/AZEL/QUER/TUR/FA/B6/ZN/COPP
CARDIOVID PLUS
CITICOLINE SODIUM
DERMANIC
ENTERAGAM
FOSTEUM
FOSTEUM PLUS
GABADONE
HYPERTENSA
LIMBREL
LIMBREL250
LIMBREL500
LISTER-V
MEDI-10
NICADAN
NICAZEL
NICAZEL FORTE
PERCURA
RHEUMATE
SENTRA AM
SENTRA PM
THERAMINE
THERAMINE PLUS
TL-ICARE
TOZAL
VAYACOG
VAYARIN
VP-GSTN
VP-ZEL
DILUENT SOLUTIONS
DILUENT FOR MENOMUNE
DILUENT FOR ROTARIX
DILUENT FOR YF-VAX
DILUENT-MERCK LIVE VIRUS VACC
DRUGS TO TREAT HEREDITARY TYROSINEMIA
NITISINONE
ORFADIN
DRUGS TO TX GAUCHER DX-TYPE 1, SUBSTRATE REDUCING
DRUG TIER
2
2
2
2
2
2
2
1
2
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
4
4
POS Formulary with Specialty Tier – Last revised 12/22/2015, 72
DRUG CATEGORY & NAME
CERDELGA
ELIGLUSTAT TARTRATE
MIGLUSTAT
ZAVESCA
FLAVORING AGENTS
ETHYL ACETATE
GASTROINTESTINAL RADIOPAQUE DIAGNOSTICS
ENTERO VU
E-Z DISK
E-Z-CAT
E-Z-HD
E-Z-PAQUE
E-Z-PASTE
GASTROMARK
LIQUID E-Z PAQUE
LIQUID POLIBAR PLUS
POLIBAR ACB
READI-CAT 2
SITZMARKS
TAGITOL
VARIBAR HONEY
VARIBAR NECTAR
VARIBAR PUDDING
VARIBAR THIN HONEY
VARIBAR THIN LIQUID
VOLUMEN
GENERAL ANESTHETICS,INHALANT
ENFLURANE
FORANE
ISOFLURANE
SEVOFLURANE
SUPRANE
ULTANE
GENERAL INHALATION AGENTS
HYPER-SAL
NEBUSAL
SODIUM CHLORIDE FOR INHALATION
HERBAL DRUGS
FLAXSEED/EVENING PRIM/BILBERRY
HOMEOPATHIC DRUGS
AURUMHEEL
CANTHARIS COMPOSITUM
CRALONIN
EYE
HOMEOPATHIC DRUGS
LAMIOFLUR
PLANTAGO-HOMACCORD
DRUG TIER
4
4
4
4
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
2
1
1
2
2
2
2
1
1
2
2
2
2
1
2
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 73
DRUG CATEGORY & NAME
POPULUS COMPOSITUM
PSORINOHEEL
RENEEL
SABAL-HOMACCORD
SYZYGIUM COMPOSITUM
VERTIGOHEEL
INTRA-UTERINE DEVICES (IUD'S)
LILETTA
MIRENA
PARAGARD T 380-A
SKYLA
METABOLIC DEFICIENCY AGENTS
BETAINE
CARNITOR
CARNITOR SF
CYSTADANE
LEVOCARNITINE
LEVOCARNITINE (WITH SUGAR)
SULFZIX
METABOLIC FUNCTION DIAGNOSTICS
METOPIRONE
METALLIC POISON,AGENTS TO TREAT
CHEMET
DEFERASIROX
DEFERIPRONE
EXJADE
FERRIPROX
GALZIN
JADENU
RADIOGARDASE
SUCCIMER
SYPRINE
NUTRITIONAL THERAPY, MED COND SPECIAL FORMULATION
BOOST GLUCOSE CONTROL
DIABETISOURCE AC
GLUCERNA
GLUCERNA 1 CAL
GLUCERNA 1.2 CAL
GLUCERNA 1.5 CAL
GLUCERNA ADVANCE
GLUCERNA CRISPY DELIGHTS
GLUCERNA HUNGER SMART
GLUCERNA MINI SNACKS
GLUCO BURST
GLYTROL
GLYTROL WITH PREBIO1
NUTRESTORE
DRUG TIER
2
2
2
2
2
2
2
2
2
2
4
2
2
4
1
1
2
2
4
4
4
4
4
2
2
2
4
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 74
DRUG CATEGORY & NAME
OINTMENT/CREAM BASES
RADIAGEL
ORAL MUCOSITIS/STOMATITIS AGENTS
GELCLAIR
GELX
MUGARD
ORAMAGICRX
ORAL MUCOSITIS/STOMATITIS ANTI-INFLAMMATORY AGENT
EPISIL
MUCOTROL
PHARMACEUTICAL ADJUVANTS, TABLETING
MICROCRYSTALLINE CELLULOSE
PKU TX AGENT-COFACTOR OF PHENYLALANINE HYDROXYLASE
KUVAN
PRESERVATIVES
FORMA-RAY
PROTEIN REPLACEMENT
LYSINE/VIT E/FA/VIT BCOMP&C/ZN
RADIOPHARMACEUTICALS ELEMENTS
INDICLOR
RUBBER SYRINGES
CHILD EAR SYRINGE
EAR SYRINGE
ENEMA SYRINGE
FEMININE BULB SYRINGE
FEMININE COMBINATION SYRINGE
FEMININE COMPACT TRAVEL SYRNGE
FEMININE FOLDING SYRINGE
INFANT EAR SYRINGE
NASAL ASPIRATOR
RECTAL SYRINGE
SALIVA STIMULANT AGENTS
NUMOISYN
SALIVA SUBSTITUTE AGENTS
AQUORAL
CAPHOSOL
NEUTRASAL
NUMOISYN
SEXUAL DYSFUNCTION DEVICES
RAPPORT VACUUM THERAPY
SKIN TISSUE REPLACEMENT
APLIGRAF
DERMAGRAFT
ENDOFORM
EPIFIX AMNIOTIC MEMBRANE
GRAFIX CORE
GRAFIX PRIME
DRUG TIER
2
2
2
2
2
2
2
2
2
2
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 75
DRUG CATEGORY & NAME
MATRISTEM
MATRISTEM MICROMATRIX
SOLVENTS
MURI-LUBE MINERAL OIL
PROPYLENE GLYCOL
SODIUM SUCCINATE
SOMATOSTATIC AGENTS
LANREOTIDE ACETATE
SOMATULINE DEPOT
SUPPORT HOSIERY
T.E.D. ANTI-EMBOLISM STOCKING
SUSPENDING AGENTS
GELFILM
SWEETENERS
SACCHARIN
TISSUE/WOUND ADHESIVES
ARTISS
TOPICAL ANTISEPTIC DRYING AGENTS
FORMALDEHYDE
UNKNOWN
CRYOSERV
URINARY TRACT RADIOPAQUE DIAGNOSTICS
CYSTO-CONRAY II
CYSTOGRAFIN
CYSTOGRAFIN-DILUTE
DIATRIZOATE MEGLU/DIATRIZO SOD
GASTROGRAFIN
URINE ACETONE TEST AIDS
ACETEST REAGENT
CHEMSTRIP K
KETONE
KETONE CARE
KETOSTIX REAGENT
URINE TEST AIDS,MISCELLANEOUS
ALBUSTIX REAGENT
CHEMSTRIP MICRAL
ICTOTEST
MICRO-BUMINTEST
VEHICLES
CITRIC ACID
SORBITOL
WOUND HEALING AGENTS, LOCAL
DERMACINRX SURGICAL PHARMAPAK
RADIGEL
VENELEX
OTHER RESPIRATORY DISORDERS
ANTIFIBROTIC THERAPY - PYRIDONE ANALOGS
DRUG TIER
2
2
2
2
2
4
4
2
2
2
2
1
2
2
2
2
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 76
DRUG CATEGORY & NAME
ESBRIET
PIRFENIDONE
CYSTIC FIB.TRANSMEMB CONDUCT.REG.(CFTR)POTENTIATOR
IVACAFTOR
KALYDECO
CYSTIC FIBROSIS-CFTR POTENTIATOR & CORRECTOR COMB.
ORKAMBI
LUNG SURFACTANTS
CUROSURF
INFASURF
SURFAXIN
SURVANTA
MUCOLYTICS
ACETYLCYSTEINE
DORNASE ALFA
PULMOZYME
PULMONARY FIBROSIS - SYSTEMIC ENZYME INHIBITORS
NINTEDANIB ESYLATE
OFEV
PAIN MANAGEMENT - ANALGESICS
ANALGESIC, NON-SALICYLATE & BARBITURATE COMB.
BUPAP
BUTALBITAL/ACETAMINOPHEN
ANALGESIC, SALICYLATE, BARBITURATE,& XANTHINE CMB
BUTALBITAL/ASPIRIN/CAFFEINE
FIORINAL
ANALGESIC,NON-SALICYLATE,BARBITURATE,&XANTHINE CMB
BUTALB/ACETAMINOPHEN/CAFFEINE
ESGIC
FIORICET
VANATOL LQ
ANALGESIC/ANTIPYRETICS, SALICYLATES
ASPIRIN
ASPIRIN EC
CHOLINE SAL/MAG SALICYLATE
DIFLUNISAL
DISALCID
ECOTRIN
LEVACET
SALSALATE
ANALGESIC/ANTIPYRETICS,NON-SALICYLATE
OFIRMEV
ANALGESICS NARCOTIC, ANESTHETIC ADJUNCT AGENTS
FENTANYL CITRATE/PF
SUFENTA
SUFENTANIL CITRATE
ULTIVA
DRUG TIER
4
4
4
2, 4
2
2
2
2
2
1
4
4
4
4
2
1
1
2
1
2
2
2
1
2
1
1
2
2
2
1
2
1
2
1
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 77
DRUG CATEGORY & NAME
ANALGESICS, NARCOTIC AGONIST AND NSAID COMBINATION
HYDROCODONE/IBUPROFEN
IBUDONE
IBUPROFEN/OXYCODONE HCL
REPREXAIN
VICOPROFEN
ANALGESICS,NARCOTICS
ABSTRAL
ACTIQ
ASPIRIN-CAFFEINE-DIHYDROCODEIN
BELLADONNA-OPIUM
BUTORPHANOL TARTRATE
BUTRANS
CODEINE SULFATE
CODEINE/CARISOPRODOL/ASPIRIN
CONZIP
DEMEROL
DHCODEINE BT/ACETAMINOPHN/CAFF
DILAUDID
DOLOPHINE HCL
DURAGESIC
EMBEDA
EXALGO
FENTANYL
FENTANYL CITRATE
FENTORA
HYCET
HYDROCODONE/ACETAMINOPHEN
HYDROCODONE-ACETAMINOPHEN
HYDROMORPHONE ER
HYDROMORPHONE HCL
HYSINGLA ER
IONSYS
KADIAN
LAZANDA
LEVORPHANOL TARTRATE
LORTAB
MEPERIDINE HCL
METHADONE HCL
METHADOSE
MORPHINE SULFATE
MORPHINE SULFATE ER
MS CONTIN
NORCO
NUCYNTA
NUCYNTA ER
OPANA
DRUG TIER
1
2
1
2
2
2
2
2
2
1
2
1, 2
1
2
2
1
2
2
2
2
2
1, 2
1
2
2
1
2
2
1, 2
2
2
2
2
2
2
1, 2
1, 2
2
1, 2
2
2
2
2
2
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 78
DRUG CATEGORY & NAME
OPANA ER
OXECTA
OXYCODONE HCL
OXYCODONE HCL ER
OXYCODONE HCL/ACETAMINOPHEN
OXYCODONE HCL/ASPIRIN
OXYCONTIN
OXYMORPHONE HCL
PENTAZOCINE HCL/NALOXONE HCL
PERCOCET
PRIMLEV
ROXICODONE
SUBSYS
SYNALGOS-DC
TRAMADOL HCL
TRAMADOL HCL ER
TRAMADOL HCL/ACETAMINOPHEN
TREZIX
ULTRACET
ULTRAM
ULTRAM ER
XARTEMIS XR
XODOL 10-300
XODOL 5-300
XODOL 7.5-300
ZAMICET
ZOHYDRO ER
ANTIMIGRAINE PREPARATIONS
ALMOTRIPTAN MALATE
ALSUMA
AMERGE
AXERT
CAFERGOT
CAMBIA
D.H.E.45
DIHYDROERGOTAMINE MESYLATE
ERGOMAR
FROVA
IMITREX
ISOMETHEPT/DICHLPHN/ACETAMINOP
ISOMETHEPTEN/CAF/ACETAMINOPHEN
MAXALT
MAXALT MLT
MIGERGOT
MIGRANAL
NARATRIPTAN HCL
PRODRIN
DRUG TIER
2
2
1, 2
2
1
1
2
1
1
2
2
2
2
2
1
2
1
2
2
2
2
2
2
2
2
2
2
1
2
2
2
2
2
2
1, 2
2
2
2
1
1
2
2
2
2
1
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 79
DRUG CATEGORY & NAME
RELPAX
RIZATRIPTAN BENZOATE
SUMATRIPTAN
SUMATRIPTAN SUCCINATE
SUMAVEL DOSEPRO
TREXIMET
ZOLMITRIPTAN
ZOMIG
ZOMIG ZMT
NARC.& NON-SAL.ANALGESIC,BARBITURATE &XANTHINE CMB
BUTALBIT/ACETAMIN/CAFF/CODEINE
FIORICET WITH CODEINE
NARCOTIC & SALICYLATE ANALGESICS, BARB.& XANTHINE
CODEINE/BUTALBITAL/ASA/CAFFEIN
FIORINAL WITH CODEINE #3
NARCOTIC ANALGESIC & NON-SALICYLATE ANALGESIC COMB
ACETAMINOPHEN WITH CODEINE
CAPITAL W-CODEINE
TYLENOL-CODEINE NO.3
TYLENOL-CODEINE NO.4
NARCOTIC WITHDRAWAL THERAPY AGENTS
BUNAVAIL
BUPRENORPHINE HCL
BUPRENORPHINE HCL/NALOXONE HCL
SUBOXONE
ZUBSOLV
PARKINSONS DISEASE
ANTIPARKINSONISM DRUGS,ANTICHOLINERGIC
BENZTROPINE MESYLATE
TRIHEXYPHENIDYL HCL
ANTIPARKINSONISM DRUGS,OTHER
AMANTADINE
AMANTADINE HCL
APOKYN
APOMORPHINE HCL
AZILECT
BROMOCRIPTINE MESYLATE
CARBIDOPA/LEVODOPA
CARBIDOPA-LEVODOPA-ENTACAPONE
COMTAN
DUOPA
ELDEPRYL
ENTACAPONE
MIRAPEX
MIRAPEX ER
NEUPRO
PARLODEL
DRUG TIER
2
1
2
1, 2
2
2
1
2
2
1
2
1
2
1
2
2
2
2
1
1
2
2
1
1
2
1
4
4
2
1
1
2
2
2
2
1
2
2
2
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 80
DRUG CATEGORY & NAME
PRAMIPEXOLE DI-HCL
REQUIP
REQUIP XL
ROPINIROLE HCL
RYTARY
SELEGILINE HCL
SINEMET 10-100
SINEMET 25-100
SINEMET 25-250
SINEMET CR
STALEVO 100
STALEVO 125
STALEVO 150
STALEVO 200
STALEVO 50
STALEVO 75
TASMAR
TOLCAPONE
ZELAPAR
DECARBOXYLASE INHIBITORS
CARBIDOPA
LODOSYN
SEIZURE DISORDER
ANTICONVULSANTS
APTIOM
BANZEL
CARBAMAZEPINE
CARBATROL
CELONTIN
CLONAZEPAM
DEPAKENE
DEPAKOTE
DEPAKOTE ER
DEPAKOTE SPRINKLE
DIASTAT
DIASTAT ACUDIAL
DIAZEPAM
DILANTIN
DILANTIN-125
DIVALPROEX SODIUM
ESLICARBAZEPINE ACETATE
ETHOSUXIMIDE
FELBAMATE
FELBATOL
FYCOMPA
GABAPENTIN
GABITRIL
DRUG TIER
1
2
2
1
2
1
2
2
2
2
2
2
2
2
2
2
4
1, 4
2
1
2
4
4
1
2
2
1
2
2
2
2
2
2
2
2
2
1
4
1
1, 4
4
2
1
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 81
DRUG CATEGORY & NAME
KEPPRA
KEPPRA XR
KLONOPIN
LAMICTAL
LAMICTAL (BLUE)
LAMICTAL (GREEN)
LAMICTAL (ORANGE)
LAMICTAL ODT
LAMICTAL ODT (BLUE)
LAMICTAL ODT (GREEN)
LAMICTAL ODT (ORANGE)
LAMICTAL XR
LAMICTAL XR (BLUE)
LAMICTAL XR (GREEN)
LAMICTAL XR (ORANGE)
LAMOTRIGINE
LEVETIRACETAM
LYRICA
MYSOLINE
NEURONTIN
ONFI
OXCARBAZEPINE
OXTELLAR XR
PEGANONE
PHENYTEK
PHENYTOIN
PHENYTOIN SODIUM EXTENDED
POTIGA
PRIMIDONE
QUDEXY XR
RUFINAMIDE
SABRIL
TEGRETOL
TEGRETOL XR
TIAGABINE HCL
TOPAMAX
TOPIRAMATE
TOPIRAMATE ER
TRILEPTAL
TROKENDI XR
VALPROIC ACID
VALPROIC ACID (AS SODIUM SALT)
VIGABATRIN
VIMPAT
ZARONTIN
ZONEGRAN
ZONISAMIDE
DRUG TIER
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
1
2
2
2
2
1
2
2
2
1
1
2
1
2
4
4
2
2
1
2
1
2
2
2
1
1
4
2
2
2
1
POS Formulary with Specialty Tier – Last revised 12/22/2015, 82
DRUG CATEGORY & NAME
SKELETAL MUSCLE DISORDER
SKELETAL MUSCLE RELAXANTS
AMRIX
BACLOFEN
CARISOPRODOL
CARISOPRODOL/ASPIRIN
CHLORZOXAZONE
CYCLOBENZAPRINE HCL
DANTRIUM
DANTROLENE SODIUM
FEXMID
LORZONE
METAXALONE
METHOCARBAMOL
ORPHENADRINE CITRATE
PARAFON FORTE DSC
ROBAXIN
ROBAXIN-750
SKELAXIN
SOMA
TIZANIDINE HCL
ZANAFLEX
UNKNOWN
COMFORT PAC-CYCLOBENZAPRINE
COMFORT PAC-TIZANIDINE
SMOKING CESSATION
SMOKING DETERRENT AGENTS (GANGLIONIC STIM,OTHERS)
NICODERM CQ
NICORETTE
NICOTINE
NICOTINE LOZENGE
NICOTINE PATCH
NICOTINE POLACRILEX
NICOTROL
NICOTROL NS
SMOKING DETERRENT-NICOTINIC RECEPT.PARTIAL AGONIST
CHANTIX
SMOKING DETERRENTS, OTHER
BUPROPION HCL
ZYBAN
UPPER GASTROINTESTINAL DISORDERS - DIGESTIVE
GASTRIC ENZYMES
SUCRAID
PANCREATIC ENZYMES
CREON
PANCREAZE
PANCRELIPASE 5,000
DRUG TIER
2
1
1, 2
1
1
1
2
1, 2
2
2
1, 2
1
1
2
2
2
2
2
1
2
2
2
2+
2+
1+
2+
2+
1+
2+
2+
2+
1+
2+
2
2
2
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 83
DRUG CATEGORY & NAME
PERTZYE
ULTRESA
VIOKACE
ZENPEP
UPPER GASTROINTESTINAL DISORDERS - SPASTIC DISEASE
ANTICHOLINERGICS/ANTISPASMODICS
BENTYL
DICYCLOMINE HCL
BELLADONNA ALKALOIDS
ANASPAZ
DONNATAL
HYOSCYAMINE SULFATE
LEVBID
LEVSIN
LEVSIN-SL
METHSCOPOLAMINE BROMIDE
PHENOBARB/HYOSCY/ATROPINE/SCOP
SYMAX DUOTAB
UPPER GASTROINTESTINAL DISORDERS - ULCER DISEASE
ANTICHOLINERGICS,QUATERNARY AMMONIUM
CANTIL
CHLORDIAZEPOXIDE/CLIDINIUM BR
CUVPOSA
GLYCOPYRROLATE
LIBRAX
PROPANTHELINE BROMIDE
ROBINUL
ROBINUL FORTE
ANTI-ULCER PREPARATIONS
CARAFATE
CYTOTEC
MISOPROSTOL
SUCRALFATE
ANTI-ULCER-H.PYLORI AGENTS
LANSOPRAZOLE/AMOXICILN/CLARITH
OMECLAMOX-PAK
PREVPAC
PYLERA
HISTAMINE H2-RECEPTOR INHIBITORS
CIMETIDINE
CIMETIDINE HCL
FAMOTIDINE
NIZATIDINE
PEPCID
RANITIDINE HCL
ZANTAC
INTESTINAL MOTILITY STIMULANTS
DRUG TIER
2
2
2
2
2
1
2
2
1
2
2
2
1
1
2
2
1
2
1
2
2
2
2
2
2
1
1, 2
1
2
2
2
1
1
1
1
2
1
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 84
DRUG CATEGORY & NAME
METOCLOPRAMIDE HCL
METOZOLV ODT
REGLAN
PROTON-PUMP INHIBITORS
ACIPHEX
ACIPHEX SPRINKLE
DEXILANT
ESOMEPRAZOLE MAGNESIUM
LANSOPRAZOLE
NEXIUM
OMEPRAZOLE
OMEPRAZOLE/SODIUM BICARBONATE
PANTOPRAZOLE SODIUM
PREVACID
PRILOSEC
PROTONIX
RABEPRAZOLE SODIUM
ZEGERID
URINARY TRACT - FUNCTIONAL DISORDERS
BENIGN PROSTATIC HYPERTROPHY/MICTURITION AGENTS
ALFUZOSIN HCL
AVODART
FINASTERIDE
FLOMAX
PROSCAR
RAPAFLO
TAMSULOSIN HCL
UROXATRAL
BPH AGENTS,5-ALPHA-RED INH & ALPHA-1-ADR ANTG CMB
JALYN
KIDNEY STONE AGENTS
CYSTAGON
CYSTEAMINE BITARTRATE
PROCYSBI
THIOLA
OVERACTIVE BLADDER AGENTS, BETA-3 ADRENERGIC RECEP
MYRBETRIQ
URINARY PH MODIFIERS
CITRIC ACID/SODIUM CITRATE
CYTRA-3
K-PHOS NEUTRAL
K-PHOS NO.2
K-PHOS ORIGINAL
ORACIT
PHOSPHORUS #1
POTASSIUM CITRATE
POTASSIUM CITRATE/CITRIC ACID
DRUG TIER
1
2
2
2
2
2
1
1
2
1
1
1
2
2
2
1
2
1
2
1
2
2
2
1
2
2
2
4
4
2
2
1
2
2
2
2
2
1
1
1
POS Formulary with Specialty Tier – Last revised 12/22/2015, 85
DRUG CATEGORY & NAME
RENACIDIN
SHOHL'S MODIFIED
SOD/POT/K CIT/SOD CIT/CIT ACID
UROCIT-K
UROQID-ACID NO.2
URINARY TRACT ANALGESIC AGENTS
ELMIRON
URINARY TRACT ANESTHETIC/ANALGESIC AGNT (AZO-DYE)
PHENAZOPYRIDINE HCL
PYRIDIUM
URINARY TRACT ANTISPASMODIC, M(3) SELECTIVE ANTAG.
ENABLEX
VESICARE
URINARY TRACT ANTISPASMODIC/ANTIINCONTINENCE AGENT
DETROL
DETROL LA
DITROPAN XL
FLAVOXATE HCL
GELNIQUE
OXYBUTYNIN CHLORIDE
OXYTROL
TOLTERODINE TARTRATE
TOVIAZ
TROSPIUM CHLORIDE
VAGINAL DISORDERS
VAGINAL ANTIBIOTICS
CLEOCIN
CLINDAMYCIN PHOSPHATE
CLINDESSE
METROGEL-VAGINAL
METRONIDAZOLE
NUVESSA
VAGINAL ANTIFUNGALS
GYNAZOLE 1
MICONAZOLE 3
TERAZOL 3
TERAZOL 7
TERCONAZOLE
VAGINAL ANTISEPTICS
FEM PH
RELAGARD
VAGINAL ESTROGEN PREPARATIONS
ESTRACE
ESTRING
FEMRING
PREMARIN
VAGIFEM
DRUG TIER
2
2
1
2
2
2
1
2
2
2
2
2
2
1
2
1
2
1
2
1
2
1
2
2
1
2
2
2
2
2
1
2
2
2
2
2
2
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 86
DRUG CATEGORY & NAME
VAGINAL SULFONAMIDES
AVC
VITAMIN AND/OR MINERAL DEFICIENCY
ANTIOXIDANT MULTIVITAMIN COMBINATIONS
MACUVEX
MACUZIN
OCUVEL
BIOFLAVONOIDS
VASCULERA
CALCIUM REPLACEMENT
CALCIUM-FOLIC ACID PLUS D
FOLGARD OS
TL G-FOL OS
FLUORIDE PREPARATIONS
FLORIVA
FLUORABON
FLUOR-A-DAY
FLURA-DROPS
GEL-KAM
PHOS-FLUR
PREVIDENT
PREVIDENT 5000
PREVIDENT 5000 ENAMEL PROTECT
PREVIDENT 5000 PLUS
PREVIDENT 5000 SENSITIVE
SODIUM FLUORIDE
SODIUM FLUORIDE/POTASSIUM NIT
STANNOUS FLUORIDE
FOLIC ACID PREPARATIONS
DEPLIN-ALGAL OIL
ENLYTE
FA/MULTIVIT-MIN/YHBK/GIN/DAM
FA-8
FOLIC ACID
LEVOMEFOLATE CALCIUM-ALGAL
L-METHYLFOLATE
L-METHYLFOLATE CALCIUM
L-METHYLFOLATE FORMULA
L-METHYLFOLATE FORTE
MULTIVIT-MIN/FA/LYCOPENE/LUT
PURALOR CI
GERIATRIC VITAMIN PREPARATIONS
REQ49+
IRON REPLACEMENT
ACTIVE FE
APETIGEN PLUS
APETIGEN-PLUS
DRUG TIER
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
1
1
2
2
1
2
1, 2
2
2
2
2
2
1
2
2
2
2
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 87
DRUG CATEGORY & NAME
BIFERA RX
CENTRATEX
CHEWABLE IRON
CHOLECALCIFEROL (VITAMIN D3)
CORVITE 150
CORVITE FE
DUOFER
FE FUMARATE/LIVER EXT/BCOMP&C
FE FUMARATE/VIT C/B12/STOMC
FE FUMARATE/VIT C/B12-IF/FA
FEOSOL
FERGON
FER-IN-SOL
FERIVA
FERIVA 21-7
FERIVA FA
FERRACTIV IRON
FERRALET 90
FERRAPLUS 90
FERRETTS
FERRETTS IPS
FERREX 150 FORTE PLUS
FERREX 150 PLUS
FERREX 28
FERRIC AMCIT/LYS/VIT B COMP/FA
FERRIMIN 150
FERROUS FUMARATE
FERROUS FUMARATE/DOCUSATE NA
FERROUS FUMARATE/FOLIC ACID
FERROUS GLUCONATE
FERROUS SULFATE
FERROUS SULFATE, DRIED
FOCALGIN DSS
FOLITAB 500
FOLIVANE-F
FOLIVANE-PLUS
FUSION
FUSION PLUS
HEMATOGEN FA
HEMATRON-AF
HEMETAB
HEMOCYTE
HEMOCYTE PLUS
I.L.X. B-12
ICAR
ICAR-C
INTEGRA
DRUG TIER
2
2
2
1
2
2
2
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
2
1, 2
1
1
1, 2
1, 2
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 88
DRUG CATEGORY & NAME
INTEGRA F
INTEGRA PLUS
IRON
IRON 21/7
IRON CHEWS
IRON FUM&POLYSAC#1/FA/MV NO.18
IRON FUMARATE/VIT C/VIT B12/FA
IRON POLYSACCHARIDE COMPLEX
IRON PS CMPLX/VIT B12/FA
IRON, CARBONYL/FA/C/B-6/B12/ZN
IRON,CARB/DSS/B12IF/FA/MV-MN
IRON,CARBONYL
IRON,CARBONYL/ASCORBIC ACID
IRON,CARBONYL/VIT C/VIT B12/FA
IRON/FA/C/E/B12/BIO/COPPER/DSS
IRON/FA/VIT B CMPLX #16/MAG/ZN
IRON/FA/VITAMIN B COMP W-C/MIN
IRON/MULTIVITS,STRESS FORMULA
IRONUP
IRO-PLEX
IROSPAN
LYDIA PINKHAM HERBAL
MAXARON FORTE
MAXFE
MULTIGEN
MULTIGEN FOLIC
MULTIGEN PLUS
MYKIDZ IRON 10
NEPHRON FA
NOVAFERRUM
NOVAFERRUM 125
NOVAFERRUM 50
PERFECT IRON
PRO FE
PROFERRIN
PROFERRIN-FORTE
SIDEROL
SLOW RELEASE IRON
TANDEM DUAL ACTION
TANDEM PLUS
TARON FORTE
VIT B COMP/C/FA/IRON SULF/VITE
VIT B COMP/C/FA/IRON/VIT E
VITAFOL
VITRON-C
MULTIVITAMIN PREPARATIONS
ADVANCED AM/PM
DRUG TIER
2
2
2
2
2
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
1
2
2
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 89
DRUG CATEGORY & NAME
ANIMI-3
BACMIN
BP VIT 3 PLUS
CORVITE
DIALYVITE 800 WITH IRON
FA/MU-VITS-MIN TH/LYCOPENE/LUT
FORTAVIT
MULTICHEW
MULTIVITAMIN NO.44/VIT D3/K
MULTIVITAMINS WITH MIN NO.5/FA
MULTIVITAMINS WITH MIN NO.7/FA
MULTIVITS,THERAP W-FE,HEMATIN
MV, MIN CMB #6/FA/LUT/LYCO/Q10
NICOMIDE
NUTRICAP
PARVLEX
PROTECT IRON
STROVITE FORTE
STROVITE ONE
SUPERVITE EC
UDAMIN SP
VIT 3
PEDIATRIC VITAMIN PREPARATIONS
COMPLETE FORMULATION D3000
COMPLETE FORMULATION PEDIATRIC
ESCAVITE
ESCAVITE D
ESCAVITE LQ
FLORIVA
MYKIDZ IRON FL
PED MV A,C,D3 #21 W-FLUORIDE
PEDI M.VIT NO.17 WITH FLUORIDE
PEDI MULTIVIT #22/VIT D3/VIT K
PEDI MULTIVIT #65/VIT D3/VIT K
PEDI MULTIVIT NO.2 W-FLUORIDE
PEDI MV #45/FLUORIDE/IRON
PEDI MV #75/FLUORIDE/IRON
PEDI MVI NO.12/SODIUM FLUORIDE
PEDI MVI NO.16 WITH FLUORIDE
PEDI MVI NO.82 WITH FLUORIDE
POLY-VI-FLOR
POLY-VI-FLOR FS
POLY-VI-FLOR WITH IRON
QUFLORA
TEXAVITE LQ
TRI-VI-FLOR
TRI-VIT WITH FLUORIDE-IRON
DRUG TIER
2
2
2
2
2
1
2
2
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 90
DRUG CATEGORY & NAME
PRENATAL VITAMIN PREPARATIONS
ACTIVE OB
ATABEX EC
BAL-CARE DHA
BAL-CARE DHA ESSENTIAL
CALCIUM PNV
CITRANATAL 90 DHA
CITRANATAL ASSURE
CITRANATAL B-CALM
CITRANATAL DHA
CITRANATAL HARMONY
CITRANATAL RX
C-NATE DHA
COMPLETE NATAL DHA
COMPLETENATE
CONCEPT DHA
CONCEPT OB
DOTHELLE DHA
DUET DHA 400
DUET DHA BALANCED
ELITE OB DHA
ELITE-OB
ELITE-OB 400
ENBRACE HR
EXTRA-VIRT PLUS DHA
FOCALGIN 90 DHA
FOCALGIN CA
FOLET DHA
FOLET ONE
FOLIVANE-OB
HEMENATAL OB
HEMENATAL OB + DHA
ICAR-C PLUS
INATAL ADVANCE
INATAL ULTRA
INFANATE BALANCE
IRON,CARBONYL/VIT C/VIT B12/FA
LEVOMEFOLATE DHA
MACNATAL CN DHA
MARNATAL-F
MAXINATE
M-VIT
MYNATAL
MYNATAL ADVANCE
MYNATAL PLUS
MYNATAL-Z
MYNATE 90 PLUS
DRUG TIER
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
2
2
2
2
2
2
2
2
2
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 91
DRUG CATEGORY & NAME
NATACHEW
NATALVIT
NATELLE ONE
NEEVODHA
NESTABS
NESTABS ABC
NESTABS DHA
NEWGEN
NEXA PLUS
NIVA-PLUS
OB COMPLETE
OB COMPLETE ONE
OB COMPLETE PETITE
OB COMPLETE PREMIER
OB COMPLETE WITH DHA
OBSTETRIX DHA
OBSTETRIX EC
OBTREX DHA
O-CAL FA
O-CAL PRENATAL
PAIRE OB PLUS DHA
PNV 29-1
PNV NO12/IRON,CARB/FA/DSS/OM-3
PNV OB+DHA
PNV W-CA8/IRON/FA/LMEFOLATE CA
PNV,CA42/IRON/FA/LMEFOL CA/DHA
PNV-DHA
PNV-DHA + DOCUSATE
PNV-FERROUS FUMARATE-DOCU-FA
PNV-OMEGA
PNV-SELECT
PNV-TOTAL
PNV-VP-U
PR NATAL 400
PR NATAL 400 EC
PR NATAL 430
PR NATAL 430 EC
PREFERA OB
PREFERA-OB ONE
PREFERA-OB PLUS DHA
PRENA1 CHEW
PRENA1 PEARL
PRENAISSANCE
PRENAISSANCE BALANCE
PRENAISSANCE PLUS
PRENATA
PRENATABS FA
DRUG TIER
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
2
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 92
DRUG CATEGORY & NAME
PRENATABS RX
PRENATAL 19
PRENATAL LOW IRON
PRENATAL PLUS
PRENATAL VIT #83/IRON/FA#6/DHA
PRENATAL VITAMINS LOW IRON
PRENATAL-U
PRENATE AM
PRENATE CHEWABLE
PRENATE DHA
PRENATE ELITE
PRENATE ENHANCE
PRENATE ESSENTIAL
PRENATE MINI
PRENATE PIXIE
PRENATE RESTORE
PRENATE STAR
PREPLUS
PREQUE 10
PRETAB
PROVIDA DHA
PROVIDA OB
PUREFE OB PLUS
PUREFE PLUS
RELNATE DHA
R-NATAL OB
RULAVITE DHA
SELECT-OB
SELECT-OB + DHA
SE-NATAL 19
SE-TAN DHA
TARON-BC
TARON-C DHA
TARON-PREX PRENATAL
THRIVITE 19
TL FOLATE
TL-SELECT
TRIADVANCE
TRICARE
TRICARE PRENATAL DHA ONE
TRINATAL GT
TRINATAL RX 1
TRINATE
TRISTART DHA
TRI-TABS DHA
TRIVEEN-DUO DHA
TRIVEEN-ONE
DRUG TIER
2
2
2
2
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 93
DRUG CATEGORY & NAME
TRIVEEN-PRX RNF
TRIVEEN-U
TRUST NATAL DHA
ULTIMATECARE ONE
ULTIMATECARE ONE NF
VEMAVITE-PRX 2
VENA-BAL DHA
VENATAL COMPLETE DHA
VINACAL
VINATE CARE
VINATE DHA
VINATE DHA RF
VINATE GT
VINATE II
VINATE ONE
VINATE PN CARE
VINATE ULTRA
VINATE-M
VIRT NATE
VIRT-ADVANCE
VIRT-C DHA
VIRT-CARE ONE
VIRT-PN
VIRT-PN DHA
VIRT-PN PLUS
VIRTPREX
VIRT-SELECT
VIRT-VITE GT
VITAFOL NANO
VITAFOL ULTRA
VITAFOL-OB
VITAFOL-OB+DHA
VITAFOL-ONE
VITAMEDMD ONE RX
VITAMEDMD PLUS RX
VITAMEDMD REDICHEW RX
VITAPEARL
VITASPIRE
VIVA DHA
VOL-NATE
VOL-PLUS
VOL-TAB RX
VP-CH PLUS
VP-CH-PNV
VP-HEME OB
VP-HEME OB + DHA
VP-HEME ONE
DRUG TIER
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 94
DRUG CATEGORY & NAME
VP-PNV-DHA
ZATEAN-CH
ZATEAN-PN DHA
ZATEAN-PN PLUS
PRENATAL VITAMINS WITHOUT IRON
FOLBECAL
FOLINATAL PLUS B
PRENAISSANCE NEXT
PRENAISSANCE NEXT-B
VP-GGR-B6
ZINGIBER
VITAMIN A & D PREPARATIONS
VIT A & D3 IN COD LIVER OIL
VITAMIN B PREPARATIONS
B COMPLEX & C NO.20/FOLIC ACID
CARDIOTEK-RX
CEREFOLIN
CEREFOLIN NAC
CYANOCOBALAMIN/FA/PYRIDOXINE
DIALYVITE 3000
DIALYVITE 5000
DIALYVITE SUPREME D
DIALYVITE ZINC
FOLBIC RF
FOLGARD RX
FOLIC ACID/B COMPLEX & C NO.17
FOLIC ACID/VIT BCOMP&C/CU/ZNOX
FOLIC ACID/VITAMIN B COMP W-C
FOLTANX
FOLTANX RF
FOLTX
LEVOMEFOLATE-NAC-MECOBAL-ALGAL
LEVOMEFOL-PYRIDOXAL-MEC-ALGAL
L-METHYL-B6-B12
L-METHYLFOLATE CA P-5-P ME-CBL
L-METHYLFOLATE-MECOBALAMIN-NAC
L-METHYL-MC
L-METHYL-MC NAC
LMTHF-PYRIDOXINE-CYANOCOBAL
METAFOLBIC
METAFOLBIC PLUS
METAFOLBIC PLUS RF
METANX
NEPHPLEX RX
NEPHROCAPS
NEPHROCAPS QT
NEPHRO-VITE RX
DRUG TIER
2
2
2
2
2
2
2
2
2
2
1
1
2
2
2
1
2
2
2
2
2
2
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 95
DRUG CATEGORY & NAME
PODIAPN
POTABA
SUPERVITE
VIT B CMPLX 3/FA/VIT C/BIOTIN
VITAL-D RX
VITA-RESPA
VITAMIN B12 PREPARATIONS
ELIGEN B12
FOLTRATE
NASCOBAL
NEURIN-SL
VITAMIN D PREPARATIONS
CALCITRIOL
CHILDREN'S REPLESTA
CHOLECALCIFEROL (VITAMIN D3)
CIFEREX
COD LIVER OIL
D3 + K2 DOTS
DECARA
DIALYVITE VITAMIN D3 MAX
DRISDOL
DURACHOL
D-VI-SOL
ERGOCALCIFEROL (VITAMIN D2)
FISH OIL/DHA/EPA
ISO D3
K2 PLUS D3
ORTHO D
REPLESTA
REPLESTA NX
REVESTA
ROCALTROL
SUPER DAILY D3
THERA-D
VITAMIN D
VITAMIN D2
VITAMIN D3
DRUG TIER
2
2
2
1
2
2
2
2
2
2
1
2
1
2
1, 2
2
2
2
2
2
2
1
1
2
2
2
2
2
2
2
2
2
2
2
2
POS Formulary with Specialty Tier – Last revised 12/22/2015, 96