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Download Kaiser Permanente Insurance Company Formulary with Specialty
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Kaiser Permanente Insurance Company Formulary with Specialty Drug Tier For California PPO and Out-of-Area plans with a specialty drug tier* Effective January 1, 2016 PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION REGARDING THE DRUGS THAT ARE COVERED WHEN YOU PARTICIPATE IN OUR PPO AND OUT-OF-AREA HEALTH INSURANCE PLAN(S) OFFERED BY KAISER PERMANENTE INSURANCE COMPANY. This formulary was updated on October 16, 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 access the Kaiser Permanente Insurance Company (KPIC) formulary on our website at kp.org/kpic. What is the Kaiser Permanente Insurance Company (KPIC) Formulary with Specialty Drug Tier? The KPIC Formulary is an open formulary of unrestricted drugs that are covered under your KPIC health insurance plan. The formulary consists of generic, brand, and specialty drugs. Unless specifically excluded under your plan, all FDA-approved drugs are part of your plan’s open formulary. What drugs are covered? KPIC will generally cover prescribed generic, brand, and specialty drugs listed on the KPIC 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. In addition to the drugs listed on the KPIC Formulary with Specialty Drug Tier, the following over-thecounter drugs are also covered when prescribed by a physician. These drugs are preventive drugs covered with no cost share. For more information about coverage of the following over-the-counter drugs, please refer to the “Preventive Care under the General Benefits” section of your Certificate of Insurance. 1. 2. 3. 4. 5. Aspirin Iron Supplementation Folic Acid Supplementation Vitamin D Oral Fluoride Supplementation PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 1 What drugs are not covered? Aside from the exceptions noted above, drugs not listed on the KPIC Formulary with Specialty Drug Tier are not covered. There are, however, drugs that may not be covered under your plan but are listed in the formulary. The Excluded Drug Categories table below identifies the categories of drugs that are excluded for different plan types. Please note that qualified religious employers may exclude coverage for contraceptive services. If you are uncertain which plan type applies to you, you can reference the “Outpatient Prescription Drug Benefits, Limitations & Exclusions” section of your Certificate of Insurance for details of any excluded drug categories, or call KPIC Customer Service at 1-800-788-0710. Excluded Drug Categories Weight Loss Drugs Sexual Dysfunction Drugs Standard PPO Plans (not including Metal PPO Plans) x X Out-of-Area Plans x X Are there any restrictions on the drugs covered on the KPIC Formulary? There are no step therapy or prior authorization requirements for any drugs covered under your plan. However, for certain drugs, KPIC may limit the amount of the drug dispensed to a certain days’ supply. Generic and brand drugs are limited to 100 days of supply, while specialty drugs are limited to 30 days of supply. Episodic drugs prescribed for the treatment of sexual dysfunction disorders, when covered, are limited to a maximum of 8 doses in any 30-day period or up to 27 doses in any 100-day period. 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. 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. If you request a brand-name drug when a generic drug is prescribed, you may be responsible for paying the brand-name copayment plus the difference in cost between the generic drug and the brand-name drug. Please refer to your Certificate of Insurance for details. PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 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. What drugs are eligible to be mailed from the mail-order pharmacy? Most maintenance drugs can be mailed from our mail-order pharmacy. Drugs eligible for mail order, however, cannot be mailed outside the United States. Specialty drugs are not eligible for mail order. You can order refills through our mail-order service online at walgreensmail.com or by phone. There is no extra charge for mail order. The appropriate cost share (according to your prescription drug benefit) will apply. Please refer to your Certificate of Insurance for complete details of your prescription drug benefit or call KPIC Customer Service at 1-800-788-0710. KPIC Formulary with Specialty Drug Tier The most current drug formulary list begins on page 4; it provides coverage information about the drugs covered by KPIC. All dosage forms and strengths for a particular drug listed may not be on the KPIC Formulary. Some drugs have multiple dosage forms. In such cases, some dosages may be on the KPIC Formulary and others may not. KPIC may add or remove drugs from the KPIC Formulary 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 – generic (Tier 1), brand (Tier 2), or specialty (Tier 3). Typically, you will pay a generic-drug copayment for generic drugs, a brand-drug copayment for brand drugs, and a coinsurance with per prescription maximum for specialty drugs as shown in your Schedule of Coverage. There are, however, certain preventive drugs that are covered at no cost share. Those drugs are indicated with a ‘+’ (e.g. 1+ or 2+). *Kaiser Permanente Insurance Company (KPIC) underwrites the PPO and Out-of-Area plans. KPIC is a subsidiary of Kaiser Foundation Health Plan, Inc. (KFHP). PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 3 DRUG CATEGORY & NAME DRUG TIER ALLERGY 2ND GEN ANTIHISTAMINE & DECONGESTANT COMBINATIONS CLARINEX‐D 12 HOUR SEMPREX‐D ALLERGENIC EXTRACTS, THERAPEUTICS GRASTEK ORALAIR RAGWITEK ANTIHISTAMINES ‐ 1ST GENERATION CARBINOXAMINE MALEATE CLEMASTINE FUMARATE CYPROHEPTADINE HCL HYDROXYZINE HCL HYDROXYZINE PAMOATE KARBINAL ER PROMETHAZINE HCL VISTARIL ANTIHISTAMINES ‐ 2ND GENERATION CETIRIZINE HCL CLARINEX DESLORATADINE FEXOFENADINE HCL LEVOCETIRIZINE DIHYDROCHLORIDE XYZAL NASAL ANTIHISTAMINE ASTEPRO AZELASTINE HCL OLOPATADINE HCL PATANASE NASAL ANTIHISTAMINE & ANTI‐INFLAM. STEROID COMB. DYMISTA NASAL ANTI‐INFLAMMATORY STEROIDS BECONASE AQ FLUNISOLIDE FLUTICASONE PROPIONATE NASONEX OMNARIS QNASL QNASL CHILDREN RHINOCORT AQUA TRIAMCINOLONE ACETONIDE VERAMYST ZETONNA 2 2 2 2 2 1 1 1 1 1 2 1 2 1 2 1 1 1 2 2 1 1 2 2 2 1 1 2 2 2 2 2 1 2 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 4 DRUG CATEGORY & NAME ANTIEMESIS/ANTIVERTIGO ANTIEMETIC/ANTIVERTIGO AGENTS AKYNZEO ALOXI ANTIVERT ANZEMET CESAMET COMPAZINE DICLEGIS DRONABINOL EMEND GRANISETRON HCL MARINOL MECLIZINE HCL ONDANSETRON ONDANSETRON HCL ONDANSETRON HCL IN 0.9 % NACL ONDANSETRON HCL IN D5W PHENERGAN PROCHLORPERAZINE PROCHLORPERAZINE EDISYLATE 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 ADRENALIN DOPAMINE HCL DOPAMINE HCL/D5W EPINEPHRINE EPINEPHRINE HCL IN 0.9 % NACL EPINEPHRINE HCL/D5W EPINEPHRINE IN 0.9% NACL/PF DRUG TIER 2 2 2 2 2 2 2 1 2 1 2 1 1 1 1 1 2 1 1 1 1 2 2 2 1 2 2 2 3 3 3 2 1 1 2 1 1 1 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 5 DRUG CATEGORY & NAME ISUPREL LEVOPHED BITARTRATE NOREPI BIT IN 0.9 % NACL/PF NOREPINEPHRINE BIT/0.9 % NACL NOREPINEPHRINE BITARTRATE NOREPINEPHRINE BITARTRATE/D5W 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 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 SPIRIVA SPIRIVA RESPIMAT TUDORZA PRESSAIR GLUCOCORTICOIDS, ORALLY INHALED DRUG TIER 2 2 1 1 1 1 1 2 2 2 1 1 2 2 2 2 2 2 1 2 2 2 2 2 2 2 1 2 2 2 2 2 2 2 2 2 2 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 6 DRUG CATEGORY & NAME 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 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 DRUG TIER 2 2 2 2 2 1 2 2 2 2 2 2 1 2 1 3 3 3 3 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 7 DRUG CATEGORY & NAME 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 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 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 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 8 DRUG CATEGORY & NAME 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 AMINOPHYLLINE CAFCIT CAFFEINE AND SODIUM BENZOATE CAFFEINE CITRATED THEO‐24 THEOPHYLLINE ANHYDROUS THEOPHYLLINE/D5W AUTONOMIC NERVOUS SYSTEM DISORDERS ALZHEIMER'S THERAPY, NMDA RECEPTOR ANTAGONISTS MEMANTINE HCL NAMENDA NAMENDA XR ALZHEIMER'S THX,NMDA RECEPT ANTAG & CHOLINES INHIB NAMZARIC CHOLINESTERASE INHIBITORS ARICEPT BLOXIVERZ DONEPEZIL HCL EDROPHONIUM CHLORIDE/ATROPINE ENLON EXELON DRUG TIER 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1 2 2 1 2 1 1 1 2 2 2 2 2 1 1 2 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 9 DRUG CATEGORY & NAME GALANTAMINE HBR MESTINON NEOSTIGMINE METHYLSULFATE PHYSOSTIGMINE SALICYLATE PYRIDOSTIGMINE BROMIDE RAZADYNE RAZADYNE ER REGONOL 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 ZOLOFT DRUG TIER 1 2 1 1 1 2 2 2 1 1 2 2 2 2 1 1 2 1 2 2 2 2 2 2 1 1 1 1 2 1 2 2 2 2 2 2 1 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 10 DRUG CATEGORY & NAME SEROTONIN‐2 ANTAGONIST/REUPTAKE INHIBITORS (SARIS) NEFAZODONE HCL OLEPTRO ER TRAZODONE HCL SEROTONIN‐NOREPINEPHRINE REUPTAKE‐INHIB (SNRIS) CYMBALTA DESVENLAFAXINE DESVENLAFAXINE FUMARATE ER DULOXETINE HCL EFFEXOR XR FETZIMA IRENKA KHEDEZLA PRISTIQ ER VENLAFAXINE HCL SSRI & 5HT1A PARTIAL AGONIST ANTIDEPRESSANT VIIBRYD SSRI & SEROTONIN RECEPTOR MODULATOR ANTIDEPRESSANT BRINTELLIX TRICYCLIC ANTIDEPRESSANT/BENZODIAZEPINE COMBINATNS AMITRIP HCL/CHLORDIAZEPOXIDE TRICYCLIC ANTIDEPRESSANT/PHENOTHIAZINE COMBINATNS PERPHENAZINE/AMITRIPTYLINE HCL 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 DRUG TIER 1 2 1 2 1 2 1 2 2 2 2 2 1 2 2 1 1 1 1 2 1 1 1 1 1 1 2 1 2 1 2 2 2 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 11 DRUG CATEGORY & NAME ADDERALL XR DESOXYN DEXEDRINE DEXTROAMPHETAMINE SULFATE DEXTROAMPHETAMINE/AMPHETAMINE EVEKEO METHAMPHETAMINE HCL PROCENTRA VYVANSE ANTI‐ALCOHOLIC PREPARATIONS ACAMPROSATE CALCIUM ANTABUSE DISULFIRAM VIVITROL ANTI‐ANXIETY DRUGS ALPRAZOLAM ALPRAZOLAM INTENSOL ATIVAN BUSPIRONE HCL CHLORDIAZEPOXIDE HCL CLORAZEPATE DIPOTASSIUM DIAZEPAM LORAZEPAM MEPROBAMATE OXAZEPAM TRANXENE T‐TAB VALIUM XANAX XANAX XR ANTI‐MANIA DRUGS EQUETRO LITHIUM CARBONATE LITHIUM CITRATE LITHOBID ANTI‐NARCOLEPSY & ANTI‐CATAPLEXY,SEDATIVE‐TYPE AGT SODIUM OXYBATE XYREM ANTIPSYCH,DOPAMINE ANTAG.,DIPHENYLBUTYLPIPERIDINES ORAP ANTIPSYCHOTICS, ATYP, D2 PARTIAL AGONIST/5HT MIXED ABILIFY ABILIFY MAINTENA ARIPIPRAZOLE DRUG TIER 2 2 2 1 1 2 1 2 2 1 2 1 2 1 2 2 1 1 1 1 1 1 1 2 2 2 2 2 1 1 2 3 3 2 2 2 1 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 12 DRUG CATEGORY & NAME REXULTI ANTIPSYCHOTICS, DOPAMINE & SEROTONIN ANTAGONISTS ADASUVE LOXAPINE SUCCINATE ANTIPSYCHOTICS,ATYPICAL,DOPAMINE,& SEROTONIN ANTAG CLOZAPINE CLOZARIL FANAPT FAZACLO GEODON INVEGA INVEGA SUSTENNA INVEGA TRINZA LATUDA OLANZAPINE PALIPERIDONE PALMITATE QUETIAPINE FUMARATE RISPERDAL RISPERDAL CONSTA RISPERDAL M‐TAB RISPERIDONE SAPHRIS SEROQUEL SEROQUEL XR VERSACLOZ ZIPRASIDONE HCL ZYPREXA ZYPREXA RELPREVV ZYPREXA ZYDIS ANTIPSYCHOTICS,DOPAMINE ANTAGONISTS, THIOXANTHENES THIOTHIXENE ANTIPSYCHOTICS,DOPAMINE ANTAGONISTS,BUTYROPHENONES DROPERIDOL HALDOL HALDOL DECANOATE 100 HALDOL DECANOATE 50 HALOPERIDOL HALOPERIDOL DECANOATE HALOPERIDOL LACTATE ANTI‐PSYCHOTICS,PHENOTHIAZINES CHLORPROMAZINE HCL FLUPHENAZINE DECANOATE FLUPHENAZINE HCL DRUG TIER 2 2 1 1 2 2 2 2 2 3 2 2 1 3 1 2 2 2 1 2 2 2 2 1 2 2 2 1 1 2 2 2 1 1 1 1 1 1 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 13 DRUG CATEGORY & NAME PERPHENAZINE THIORIDAZINE HCL TRIFLUOPERAZINE HCL BARBITURATES AMYTAL SODIUM BUTISOL SODIUM LUMINAL SODIUM NEMBUTAL SODIUM PHENOBARBITAL PHENOBARBITAL SODIUM PHENOBARBITAL/0.9 % SOD CHLOR SECONAL SODIUM BENZODIAZEPINE ANTAGONISTS FLUMAZENIL CENTRAL NERVOUS SYSTEM STIMULANTS DOPRAM DOXAPRAM HCL 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 EVZIO NALOXONE HCL NALTREXONE HCL REVIA SEDATIVE‐HYPNOTICS,NON‐BARBITURATE AMBIEN AMBIEN CR BELSOMRA DEXMEDETOMIDINE HCL EDLUAR ESTAZOLAM ESZOPICLONE FLURAZEPAM HCL HALCION INTERMEZZO DRUG TIER 1 1 1 2 2 2 2 1 1 1 2 1 2 2 3 2 3 2 1 2 2 2 1 1 2 2 2 2 1 2 1 1 1 2 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 14 DRUG CATEGORY & NAME LORAZEPAM/0.9% SODIUM CHLORIDE LORAZEPAM/D5W LUNESTA MIDAZOLAM HCL PRECEDEX 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 HCL QUILLIVANT XR RITALIN RITALIN LA TX FOR ATTENTION DEFICIT‐HYPERACT.(ADHD), NRI‐TYPE STRATTERA CARDIOVASCULAR DISEASE ‐ ARRHYTHMIA ANTIARRHYTHMICS ADENOCARD AMIODARONE HCL AMIODARONE HCL/D5W CORDARONE CORVERT DRUG TIER 1 1 2 1 2 2 2 2 1 1 1 1 2 1 2 1 1 2 2 2 2 2 1 2 2 2 2 1 2 2 2 2 2 1 1 2 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 15 DRUG CATEGORY & NAME DISOPYRAMIDE PHOSPHATE FLECAINIDE ACETATE IBUTILIDE FUMARATE LIDOCAINE HCL/D5W/PF LIDOCAINE HCL/PF MEXILETINE HCL MULTAQ NEXTERONE NORPACE NORPACE CR PROCAINAMIDE HCL PROPAFENONE HCL QUINIDINE GLUCONATE QUINIDINE SULFATE RYTHMOL RYTHMOL SR TIKOSYN CARDIOVASCULAR DISEASE ‐ CARDIAC STIMULANT DIGITALIS GLYCOSIDES DIGOXIN LANOXIN LANOXIN PEDIATRIC INOTROPIC DRUGS DOBUTAMINE HCL DOBUTAMINE HCL/D5W MILRINONE IN 5% DEXTROSE MILRINONE LACTATE 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 DRUG TIER 1 1 1 1 1 1 2 2 2 2 1 1 1 1 2 2 2 1 2 2 1 1 2 1 1 2 2 2 1 2 1 1 1 1 1 2 1 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 16 DRUG CATEGORY & NAME 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 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 DRUG TIER 1 2 2 1 2 2 1 2 2 2 2 1 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 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 17 DRUG CATEGORY & NAME ACCUPRIL ACEON ALTACE BENAZEPRIL HCL CAPTOPRIL ENALAPRIL MALEATE ENALAPRILAT DIHYDRATE EPANED FOSINOPRIL SODIUM LISINOPRIL LOTENSIN MAVIK MOEXIPRIL HCL PERINDOPRIL ERBUMINE PRINIVIL QUINAPRIL HCL RAMIPRIL TRANDOLAPRIL VASOTEC 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 NITROPRESS ANTIHYPERTENSIVES, SYMPATHOLYTIC CATAPRES CATAPRES‐TTS 1 DRUG TIER 2 2 2 1 1 1 1 2 1 1 2 2 1 1 2 1 1 1 2 2 2 2 2 1 2 2 2 1 1 1 2 1 1 3 3 2 2 2 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 18 DRUG CATEGORY & NAME CATAPRES‐TTS 2 CATAPRES‐TTS 3 CLONIDINE CLONIDINE HCL/CHLORTHALIDONE GUANFACINE HCL METHYLDOPA METHYLDOPA/HYDROCHLOROTHIAZIDE METHYLDOPATE HCL RESERPINE TENEX ANTIHYPERTENSIVES, VASODILATORS CORLOPAM HYDRALAZINE HCL MINOXIDIL BETA‐ADRENERGIC BLOCKING AGENTS ACEBUTOLOL HCL ATENOLOL BETAPACE BETAPACE AF BETAXOLOL HCL BISOPROLOL FUMARATE BREVIBLOC BYSTOLIC CORGARD ESMOLOL HCL HEMANGEOL INDERAL LA INDERAL XL INNOPRAN XL LEVATOL LOPRESSOR METOPROLOL SUCCINATE METOPROLOL TARTRATE NADOLOL PINDOLOL PROPRANOLOL HCL SECTRAL SOTALOL HCL SOTYLIZE TENORMIN TIMOLOL MALEATE TOPROL XL ZEBETA DRUG TIER 2 2 1 1 1 1 1 1 1 2 2 1 1 1 1 2 2 1 1 2 2 2 1 2 2 2 2 2 2 1 1 1 1 1 2 2 2 2 1 2 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 19 DRUG CATEGORY & NAME 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 I.V. CARDENE SR CARDIZEM CARDIZEM CD CARDIZEM LA CLEVIPREX DILTIAZEM HCL DILTIAZEM HCL IN 0.9% NACL DILTIAZEM HCL/D5W FELODIPINE ISRADIPINE NICARDIPINE HCL NICARDIPINE IN D5W NIFEDIPINE NIMODIPINE NISOLDIPINE NORVASC NYMALIZE PROCARDIA PROCARDIA XL SULAR TIAZAC VERAPAMIL HCL VERELAN VERELAN PM INORGANIC SALT DIURETICS DRUG TIER 1 1 2 2 2 1 1 1 2 2 2 2 1 2 2 2 2 2 2 2 2 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 1 2 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 20 DRUG CATEGORY & NAME AMMONIUM CHLORIDE LOOP DIURETICS BUMETANIDE DEMADEX EDECRIN ETHACRYNATE SODIUM FUROSEMIDE FUROSEMIDE IN 0.9 % NACL LASIX SODIUM EDECRIN TORSEMIDE OSMOTIC DIURETICS MANNITOL OSMITROL 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 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 DRUG TIER 1 1 2 2 1 1 1 2 2 1 1 2 2 2 1 2 1 2 1 2 1 2 2 2 1 1 3 3 3 2 1 3 3 3 3 3 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 21 DRUG CATEGORY & NAME OPSUMIT TRACLEER PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN‐TYPE EPOPROSTENOL SODIUM (GLYCINE) FLOLAN ILOPROST TROMETHAMINE ORENITRAM ER REMODULIN TREPROSTINIL DIOLAMINE TREPROSTINIL SODIUM TYVASO VELETRI 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 CHLOROTHIAZIDE SODIUM CHLORTHALIDONE DIURIL HYDROCHLOROTHIAZIDE INDAPAMIDE METHYCLOTHIAZIDE METOLAZONE MICROZIDE SODIUM DIURIL VASODILATORS, COMBINATION BIDIL VASODILATORS,MISCELLANEOUS ALPROSTADIL PROSTIN VR PEDIATRIC 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 DRUG TIER 3 3 1 2 3 3 3 3 3 2 2 3 2 2 2 1 1 1 2 1 1 1 1 2 2 2 2 2 2 2 3 3 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 22 DRUG CATEGORY & NAME ALTOPREV ATORVASTATIN CALCIUM CRESTOR FLUVASTATIN SODIUM LESCOL LESCOL XL LIPITOR LIVALO LOVASTATIN PRAVACHOL PRAVASTATIN SODIUM SIMVASTATIN ZOCOR ANTIHYPERLIPIDEMIC ‐ MTP INHIBITOR JUXTAPID 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 NANOCRYSTALLIZED FENOFIBRIC ACID (CHOLINE) FENOGLIDE FIBRICOR GEMFIBROZIL LIPOCHOL PLUS LIPOFEN LOFIBRA LOPID LOVAZA NIACIN NIASPAN DRUG TIER 2 1 2 1 2 2 2 2 1 2 1 1 2 2 2 2 2 2 1 1 2 1 2 2 2 2 1 1 2 2 1 2 2 2 2 2 1 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 23 DRUG CATEGORY & NAME 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 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 CARDIOVASCULAR DIAGNOSTICS,NON‐RADIOPAQUE AGENTS ADENOSCAN ADENOSINE DEFINITY LEXISCAN OPTISON CARDIOVASCULAR DIAGNOSTICS‐RADIOPAQUE ABLAVAR CARDIOLITE ISOVUE‐200 ISOVUE‐250 ISOVUE‐300 ISOVUE‐370 ISOVUE‐M 200 ISOVUE‐M 300 KIT FOR TC 99M/SESTAMIBI NO.1 MYOVIEW OMNIPAQUE OPTIRAY 300 OPTIRAY 320 DRUG TIER 1 2 2 2 2 2 2 2 3 1 3 2 2 2 1 2 2 1 2 2 2 2 2 2 2 2 2 2 2 1 2 2 2 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 24 DRUG CATEGORY & NAME OPTIRAY 350 OXILAN‐350 TC99M PYROPHOSPHATE PREP THALLOUS CHLORIDE TL‐201 ULTRAVIST VISIPAQUE VASODILATORS,CORONARY DILATRATE‐SR ISOCHRON ISORDIL ISORDIL TITRADOSE ISOSORBIDE DINITRATE ISOSORBIDE MONONITRATE NITRO‐BID NITRO‐DUR NITROGLYCERIN NITROGLYCERIN IN D5W NITROLINGUAL NITROMIST NITRONAL NITROSTAT VASODILATORS,PERIPHERAL ERGOLOID MESYLATES ISOXSUPRINE HCL PAPAVERINE HCL CONTRACEPTION/OXYTOCICS CONTRACEPTIVES, INTRAVAGINAL, SYSTEMIC NUVARING CONTRACEPTIVES,IMPLANTABLE NEXPLANON CONTRACEPTIVES,INJECTABLE DEPO‐PROVERA DEPO‐SUBQ PROVERA 104 CONTRACEPTIVES,INTRAVAGINAL CONCEPTROL GYNOL II NONOXYNOL 9 TODAY CONTRACEPTIVE SPONGE CONTRACEPTIVES,ORAL AFTERA AMETHYST BEYAZ CYCLESSA DRUG TIER 2 2 2 2 2 2 2 2 2 2 1 1 2 2 1 2 2 2 2 2 1 1 1 2+ 2+ 2+ 2+ 2+ 2+ 1+ 2+ 2+ 2+ 2+ 2+ PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 25 DRUG CATEGORY & NAME DESOG‐E.ESTRADIOL/E.ESTRADIOL DESOGEN DESOGESTREL‐ETHINYL ESTRADIOL ELLA ESTROSTEP FE ETHINYL ESTRADIOL/DROSPIRENONE ETHYNODIOL D‐ETHINYL ESTRADIOL FEMCON FE GENERESS FE LEVONORGESTREL LEVONORGESTREL‐ETHIN ESTRADIOL L‐NORGEST/E.ESTRADION‐E.ESTRAD LO LOESTRIN FE LOESTRIN LOESTRIN FE LOSEASONIQUE MINASTRIN 24 FE MIRCETTE MODICON NATAZIA NORETH‐ETHINYL ESTRADIOL/IRON NORETHINDRONE NORETHINDRONE AC‐ETH ESTRADIOL NORETHINDRONE‐E.ESTRADIOL‐IRON NORETHINDRONE‐ETHINYL ESTRAD NORGESTIMATE‐ETHINYL ESTRADIOL NORGESTREL‐ETHINYL ESTRADIOL NORINYL 1+50 NOR‐Q‐D ORTHO MICRONOR ORTHO TRI‐CYCLEN ORTHO TRI‐CYCLEN LO ORTHO‐CEPT ORTHO‐CYCLEN ORTHO‐NOVUM OVCON‐35 PLAN B ONE‐STEP QUARTETTE SAFYRAL SEASONIQUE TAKE ACTION TRI‐NORINYL YASMIN 28 DRUG TIER 1+ 2+ 1+ 2+ 2+ 1+ 1+ 2+ 2+ 1+ 1+ 1+ 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+ PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 26 DRUG CATEGORY & NAME YAZ CONTRACEPTIVES,TRANSDERMAL NORELGESTROMIN/ETHIN.ESTRADIOL ORTHO EVRA DIAPHRAGMS/CERVICAL CAP CAYA CONTOURED FEMCAP WIDE SEAL DIAPHRAGM OXYTOCICS CERVIDIL HEMABATE METHYLERGONOVINE MALEATE OXYTOCIN OXYTOCIN/0.9 % SODIUM CHLORIDE OXYTOCIN/D5LR OXYTOCIN/RINGERS LACTATE OXYTOCIN‐D5W PITOCIN 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 P‐EPHED HCL/CHLOR‐MAL/BELL ALK ANTITUSSIVES,NON‐NARCOTIC BENZONATATE TESSALON PERLE ZONATUSS NARCOTIC ANTITUSS‐1ST GEN. ANTIHISTAMINE‐DECONGEST 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 DRUG TIER 2+ 1+ 2+ 2+ 2+ 2+ 2 2 1 2 1 1 1 2 2 2 2 1 1 1 1 2 2 1 1 2 2 1 1 2 2 2 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 27 DRUG CATEGORY & NAME NARCOTIC ANTITUSSIVE‐ANTICHOLINERGIC COMB. HYDROCODONE BIT/HOMATROP ME‐BR TUSSIGON 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 SYMPATHOMIMETIC AGENTS EPHEDRINE SULFATE EPHEDRINE SULFATE IN 0.9% NACL PHENYLEPHRINE HCL IN 0.9% NACL PHENYLEPHRINE HCL/D5W/PF VAZCULEP DERMATOLOGY ‐ ACNE ACNE AGENTS,SYSTEMIC ABSORICA ISOTRETINOIN ACNE AGENTS,TOPICAL ACANYA ACZONE AZELEX BENZACLIN CLINDAMYCIN PHOS/BENZOYL PEROX DUAC EPIDUO EPIDUO FORTE KLARON ONEXTON SULFACETAMIDE SODIUM VELTIN ZIANA ANTIBIOTICS, MISCELLANEOUS, OTHER DRUG TIER 1 2 2 2 2 1 1 1 2 2 2 1 1 1 1 2 2 1 2 2 2 2 1 2 2 2 2 2 1 2 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 28 DRUG CATEGORY & NAME BACITRACIN ANTICORROSIVE AGENTS BUTYLATED HYDROXYTOLUENE(BHT) KERATOLYTIC‐GLUCOCORTICOID COMBINATIONS VANOXIDE‐HC ROSACEA AGENTS, TOPICAL FINACEA METROCREAM METROGEL METROLOTION METRONIDAZOLE MIRVASO NORITATE 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 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 RENOVA DRUG TIER 1 2 2 2 2 2 2 1 2 2 2 2 2 2 2 1 1 1 2 2 2 1 2 2 1 2 2 2 2 2 1 1 2 2 2 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 29 DRUG CATEGORY & NAME RENOVA PUMP TRETINOIN/EMOLLIENT BASE DERMATOLOGY ‐ ANTIINFECTIVE ANTIPARASITICS ALINIA TOPICAL ANTIBIOTICS BACTROBAN BENZAMYCIN BENZAMYCINPAK CENTANY CENTANY AT CLEOCIN T CLINDACIN ETZ CLINDACIN P CLINDACIN PAC CLINDAGEL CLINDAMYCIN PHOSPHATE ERYGEL ERYTHROMYCIN BASE/ETHANOL ERYTHROMYCIN/BENZOYL PEROXIDE EVOCLIN MUPIROCIN TOPICAL ANTIFUNGAL/ANTIINFLAMMATORY,STERIOD AGENT CLOTRIMAZOLE/BETAMETHASONE DIP LOTRISONE TOPICAL ANTIFUNGALS CICLODAN CICLOPIROX OLAMINE CNL 8 ECONAZOLE NITRATE ECOZA ERTACZO EXELDERM EXTINA GENTIAN VIOL/BRLNT GRN/PROFLAV JUBLIA KERYDIN KETOCONAZOLE LOPROX LUZU MENTAX NAFTIFINE HCL NAFTIN DRUG TIER 2 1 2 2 2 2 2 2 2 2 2 2 2 1 2 1 1 2 1 1 2 2 1 2 1 2 2 2 2 1 2 2 1 2 2 2 1 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 30 DRUG CATEGORY & NAME NIZORAL NYSTATIN NYSTATIN/TRIAMCIN OXISTAT PEDIADERM AF PENLAC SODIUM THIOSULFATE/SAL ACID VUSION XOLEGEL TOPICAL ANTIPARASITICS ELIMITE EURAX LINDANE LYCELLE MALATHION NATROBA OVIDE PERMETHRIN SKLICE SPINOSAD ULESFIA TOPICAL ANTIVIRALS DENAVIR TOPICAL ANTIVIRALS/ANTIINFLAMMATORY, STEROID AGENT XERESE TOPICAL GENITAL WART‐HPV TREATMENT AGENTS VEREGEN TOPICAL PLEUROMUTILIN DERIVATIVES ALTABAX TOPICAL SULFONAMIDES AVAR AVAR LS AVAR‐E AVAR‐E GREEN AVAR‐E LS CLARIFOAM EF PLEXION ROSANIL ROSULA SILVADENE SILVER SULFADIAZINE SS 10‐2 SULFACETAMIDE SOD/SULFUR/UREA DRUG TIER 2 1 1 2 2 2 1 2 2 2 2 1 2 1 2 2 1 2 1 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1 2 1 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 31 DRUG CATEGORY & NAME SULFACETAMIDE SODIUM/SULFUR SULFAMYLON SUMADAN SUMADAN XLT SUMAXIN SUMAXIN CP SUMAXIN TS THERMAZENE ZENCIA DERMATOLOGY ‐ ANTIINFLAMMATORY TOPICAL ANTIBIOTICS/ANTIINFLAMMATORY,STEROIDAL CORTISPORIN NEO‐SYNALAR TOPICAL ANTI‐INFLAMMATORY STEROIDAL ALCLOMETASONE DIPROPIONATE AMCINONIDE APEXICON E AQUA GLYCOLIC HC BETAMETHASONE VALERATE BETAMETHASONE/PROPYLENE GLYC CAPEX SHAMPOO CLOBETASOL PROPIONATE CLOBETASOL PROPIONATE/EMOLL CLOBEX CLOCORTOLONE PIVALATE CLODAN CLODERM CORDRAN CUTIVATE DERMACINRX SILAPAK DERMA‐SMOOTHE‐FS DERMASORB HC DERMASORB TA DERMATOP DESONATE DESONIDE DESOWEN DESOXIMETASONE DIFLORASONE DIACETATE DIPROLENE DIPROLENE AF ELOCON FLUOCINOLONE ACETONIDE DRUG TIER 1 2 2 2 2 2 2 2 2 2 2 1 1 2 2 1 1 2 1 1 2 1 2 2 2 2 2 2 2 2 2 2 1 2 1 1 2 2 2 1 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 32 DRUG CATEGORY & NAME FLUOCINONIDE FLUOCINONIDE/EMOLLIENT BASE HALOBETASOL PROPIONATE HALOG HYDROCORTISONE HYDROCORTISONE ACETATE/UREA HYDROCORTISONE BUTYRATE HYDROCORTISONE VALERATE KENALOG LOCOID LOCOID LIPOCREAM LUXIQ MOMETASONE FUROATE NUCORT OLUX OLUX‐E PANDEL PEDIADERM HC PEDIADERM TA PREDNICARBATE PSORCON SCALACORT SCALACORT DK SYNALAR SYNALAR TS TEMOVATE TEMOVATE EMOLLIENT TEXACORT TOPICORT TRIAMCINOLONE ACET/DIMETHICONE TRIAMCINOLONE ACETONIDE ULTRAVATE ULTRAVATE X VANOS VERDESO TOPICAL ANTI‐INFLAMMATORY, NSAIDS FLECTOR PENNSAID VOLTAREN DERMATOLOGY ‐ ANTIPRURITIC DRUGS ANTIPRURITICS,TOPICAL PRUDOXIN ZONALON DRUG TIER 1 1 1 2 1 1 1 1 2 2 2 2 1 2 2 2 2 2 2 1 2 2 2 2 2 2 2 2 2 1 1 2 2 2 2 2 2 2 2 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 33 DRUG CATEGORY & NAME DERMATOLOGY ‐ MISCELLANEOUS ANTIPERSPIRANTS DRYSOL ANTISEBORRHEIC AGENTS EMOLLIENT COMBINATION NO.85 OVACE OVACE PLUS OVACE PLUS WASH PROMISEB PROMISEB COMPLETE SELENIUM SULFIDE SELRX SULFACETAMIDE SODIUM TERSI FOAM ANTISEPTICS,MISCELLANEOUS GUAIACOL EMOLLIENTS ALEVICYN ANTIPRURITIC SG AMMONIUM LACTATE ATOPICLAIR ATRAPRO CP ATRAPRO HYDROGEL AURSTAT BIAFINE CELACYN ELETONE EM#53/NAMGF/CYC/PHOS/NAHC/NACL EMOL53/NAMGFS/HA/NAHYPOCHLORIT EMOLLIENT COMBINATION NO.10 EMOLLIENT COMBINATION NO.32 EMOLLIENT COMBINATION NO.35 EMOLLIENT COMBINATION NO.53 EPICERAM HPR HYLATOPIC HYLATOPIC PLUS LACTIC ACID NEOSALUS NEOSALUS CP PRESERA TROPAZONE VITE AC/GRAPE/HYALURONIC ACID XCLAIR DRUG TIER 2 1 2 2 2 2 2 1 2 1 2 2 2 1 2 2 2 2 2 2 2 1 1 1 1 1 1 2 2 2 2 1 2 2 2 2 1 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 34 DRUG CATEGORY & NAME HYPERTRICHOTIC AGENTS, SYSTEMIC/INCL. COMBINATIONS PROPECIA IRRIGANTS ACETIC ACID LACTATED RINGERS MANNITOL/SORBITOL SOLUTION NEOMYCIN SU/POLYMYX B SULF NEOSPORIN G.U. IRRIGANT PHYSIOLYTE PHYSIOSOL RINGERS SOLUTION SODIUM CHLORIDE IRRIG SOLUTION SORBITOL SOLUTION VASHE WOUND THERAPY VIASPAN BELZER‐UW WATER FOR IRRIGATION,STERILE IRRITANTS/COUNTER‐IRRITANTS CAPSAICIN/MENTHOL MAC NEUVAXIN PAIN RELIEF QROXIN QUTENZA RELYYT RENOVO SINELEE SOLAICE KERATOLYTICS ALUVEA BENSAL HP BENZEFOAM BENZEFOAM ULTRA BENZOYL PEROXIDE BENZOYL PEROXIDE MICROSPHERES CONDYLOX DERMASORB XM HYDRO 35 HYDRO 40 INOVA INOVA 4‐1 INOVA 8‐2 KERAFOAM KERALAC DRUG TIER 2 1 2 1 1 2 2 2 1 1 1 2 2 1 1 2 2 2 2 2 2 2 2 2 2 2 2 2 1 1 2 2 2 2 2 2 2 2 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 35 DRUG CATEGORY & NAME KERALYT KERALYT SCALP NUOX PACNEX PACNEX HP PACNEX LP PACNEX MX PODOFILOX PODOPHYLLUM RESIN POTASSIUM HYDROXIDE REA LO 39 REA LO 40 SALEX SALICYLIC ACID SALICYLIC ACID/AMMON LACT/ALOE SALICYLIC ACID/CERAMIDE CMB #1 SALVAX DUO PLUS SILVER NITRATE APPLICATOR ULTRASAL‐ER 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 PETROLATUM,WHITE PROTECT CMB2/CERAMIDE 1,3,6‐11 RADIAPLEXRX RECEDO TETRIX TOPICAL ANTI‐INFLAMMATORY STEROID‐LOCAL ANESTHETIC EPIFOAM DRUG TIER 2 2 2 2 2 2 2 1 1 1 2 2 2 1 1 1 2 1 2 2 2 2 1 1 1 2 2 2 2 2 2 2 2 2 1 1 2 2 2 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 36 DRUG CATEGORY & NAME HYDROCORTISONE/PRAMOXINE 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/MENTHOL LIDOCAINE/PRILOCAINE LIDOCAINE/TETRACAINE LIDODERM LIDODEXTRAPINE LIDOPIN LIDORX LIDOVEX LIVIXIL PAK LORENZA PAIN EASE PLIAGLIS PONTOCAINE PRE‐ATTACHED LTA KIT PROVENZA RECIPHEXAMINE DRUG TIER 1 2 2 2 3 3 2 1 2 2 1 3 3 2 2 3 3 2 2 2 2 1 2 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2 2 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 37 DRUG CATEGORY & NAME REGENECARE RELADOR PAK RELADOR PAK PLUS RELYYKS SCAR SILVERA SPRAY AND STRETCH SYNERA SYNVEXIA SYNVEXIA TC VELMA VEXA ZERUVIA TOPICAL PREPARATIONS,MISCELLANEOUS BETADINE TOPICAL/MUCOUS MEMBR./SUBCUT. ENZYMES HYLENEX SANTYL TRYPSIN/BALSAM PERU/CASTOR OIL VITRASE DERMATOLOGY ‐ PIGMENTATION DISORDERS HYPOPIGMENTATION AGENTS ACLARO BLANCHE C‐CLARIFYING SERUM C‐THERAPY NIGHT CREAM ELASTIDERM HYDROQUINONE HYDROQUINONE/FERRIC OXIDE LUSTRA LUSTRA‐AF LUSTRA‐ULTRA NU‐DERM 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) DRUG TIER 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1 2 2 2 2 2 2 1 1 2 2 2 2 2 1 2 2 2 3 3 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 38 DRUG CATEGORY & NAME COSENTYX PEN COSENTYX PEN (2 PENS) COSENTYX SYRINGE METHOXSALEN, RAPID OXSORALEN‐ULTRA SECUKINUMAB SORIATANE ANTIPSORIATICS AGENTS CALCIPOTRIENE 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 DRUG TIER 3 3 3 1 2 3 3 1 2 2 2 2 2 2 2 2 2 2 1 2 2 1 1 2 2 2 2 2 2 2 2 2 2 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 39 DRUG CATEGORY & NAME 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 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. DRUG TIER 2 2 2 2 2 2 2 1 2 2 2 2 2 2 2 2 2 1 2 1 1 2 2 1 1 2 1 2 1 2 1 1 2 2 1 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 40 DRUG CATEGORY & NAME 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 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 ULCER PREPARATIONS,TOPICAL BECAPLERMIN REGRANEX HYPERGLYCEMICS DIAZOXIDE GLUCAGEN GLUCAGON EMERGENCY KIT PROGLYCEM INSULINS AFREZZA APIDRA APIDRA SOLOSTAR HUMALOG HUMALOG KWIKPEN HUMALOG MIX 50‐50 HUMALOG MIX 50‐50 KWIKPEN DRUG TIER 2 2 2 2 2 1 2 1 2 1 2 2 1 3 3 2 2 2 2 2 1 3 3 3 2 2 3 2 2 2 2 2 2 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 41 DRUG CATEGORY & NAME 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 INSULIN ASPART INSULIN ASPART PROTAM & ASPART INSULIN DETEMIR INSULIN LISPRO INSULIN NPH HUM/REG INSULIN HM INSULIN NPH HUMAN ISOPHANE INSULIN NPL/INSULIN LISPRO INSULIN REGULAR, HUMAN LANTUS LANTUS SOLOSTAR NOVOLIN 70‐30 NOVOLIN N NOVOLIN R TOUJEO SOLOSTAR EAR ‐ GENERAL DISORDERS EAR PREPARATIONS ANTI‐INFLAMMATORY DERMOTIC FLUOCINOLONE ACETONIDE OIL EAR PREPARATIONS, MISC. ANTI‐INFECTIVES ACETIC ACID/ALUMINUM ACETATE ACETIC ACID/HYDROCORTISONE CORTANE‐B EAR PREPARATIONS,ANTIBIOTICS CETRAXAL COLY‐MYCIN S CORTISPORIN‐TC NEOMYCIN/POLYMYXIN B SULF/HC OTIC PREPARATIONS,ANTI‐INFLAMMATORY‐ANTIBIOTICS CIPRO HC CIPRODEX ELECTROLYTE REGULATION ARGININE VASOPRESSIN (AVP) RECEPTOR ANTAGONISTS SAMSCA TOLVAPTAN VAPRISOL DRUG TIER 2 2 2 2 2 2 2 2 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 1 1 1 2 2 2 2 1 2 2 3 3 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 42 DRUG CATEGORY & NAME VAPRISOL‐5% DEXTROSE BICARBONATE PRODUCING/CONTAINING AGENTS NEUT SODIUM ACETATE SODIUM BICARBONATE IN D5W SODIUM LACTATE DRUGS USED TO TREAT ACIDOSIS THAM ELECTROLYTE DEPLETERS AURYXIA CALCIUM ACETATE CALCIUM CARBONATE/MAG CARB/FA FOSRENOL KALEXATE KAYEXALATE PHOSLO PHOSLYRA RENAGEL RENVELA SODIUM POLYSTYRENE SULFONATE VELPHORO ELECTROLYTE MAINTENANCE ELECTROLYTE‐48 SOLUTION/D5W HYPERLYTE CR IONOSOL B WITH DEXTROSE 5% IONOSOL MB‐DEXTROSE 5% ISOLYTE P WITH DEXTROSE ISOLYTE S NORMOSOL‐M AND DEXTROSE NORMOSOL‐R NORMOSOL‐R AND DEXTROSE NORMOSOL‐R PH 7.4 NUTRILYTE PLASMA‐LYTE 148 PLASMA‐LYTE 56 IN DEXTROSE PLASMA‐LYTE A PH 7.4 RINGERS SOLUTION TPN ELECTROLYTES TPN ELECTROLYTES II PHOSPHATE REPLACEMENT POTASSIUM PHOS IN 0.9 % NACL POTASSIUM PHOSPHATE POTASSIUM PHOSPHATE/D5W DRUG TIER 2 2 2 1 1 2 2 1 1 2 2 2 2 2 2 2 1 2 1 2 2 2 2 2 2 2 2 2 2 2 2 2 1 2 2 1 2 1 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 43 DRUG CATEGORY & NAME SODIUM GLYCEROPHOSPHATE SODIUM PHOSPHATE SODIUM PHOSPHATE IN 0.9 % NACL POTASSIUM REPLACEMENT KLOR‐CON KLOR‐CON 10 KLOR‐CON 8 KLOR‐CON‐EF K‐SOL K‐TAB ER POTASSIUM ACETATE POTASSIUM BICARBONATE/CIT AC POTASSIUM CHLORIDE POTASSIUM CHLORIDE IN 0.9%NACL POTASSIUM CHLORIDE IN D5W POTASSIUM CHLORIDE IN LR‐D5 POTASSIUM CHLORIDE/D5‐0.2%NACL POTASSIUM CHLORIDE/D5‐0.3%NACL POTASSIUM CHLORIDE/D5‐0.45NACL POTASSIUM CHLORIDE/D5‐0.9%NACL POTASSIUM CHLORIDE‐0.45% NACL POTASSIUM CL/LIDO/0.9 % NACL SODIUM/SALINE PREPARATIONS 0.9 % SODIUM CHLORIDE MONOJECT 0.9% SODIUM CHLORIDE MONOJECT PREFILL MONOJECT PREFILL ADVANCED SWABFLUSH ENDOCRINE DISORDER ‐ FERTILITY DRUGS TO TREAT IMPOTENCY CAVERJECT CIALIS EDEX LEVITRA MUSE STAXYN STENDRA VIAGRA FERTILITY STIMULATING PREPARATIONS,NON‐FSH CLOMIPHENE CITRATE SEROPHENE FOLLICLE STIM./LUTEINIZING HORMONES MENOPUR DRUG TIER 1 2 1 2 2 2 2 2 2 2 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2 2 1 2 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 44 DRUG CATEGORY & NAME FOLLICLE‐STIMULATING HORMONE (FSH) BRAVELLE FOLLISTIM AQ GONAL‐F GONAL‐F RFF GONAL‐F RFF REDI‐JECT HUMAN CHORIONIC GONADOTROPIN (HCG) CHORIONIC GONADOTROPIN NOVAREL OVIDREL PREGNYL PREGNANCY FACILITATING/MAINTAINING AGENT,HORMONAL ENDOMETRIN ENDOCRINE DISORDER ‐ OTHER ADRENOCORTICOTROPHIC HORMONES ACTHREL CORTICOTROPIN CORTROSYN COSYNTROPIN H.P. ACTHAR ANTIDIURETIC AND VASOPRESSOR HORMONES DDAVP DESMOPRESSIN ACETATE STIMATE VASOPRESSIN VASOPRESSIN IN 0.9 % NACL VASOPRESSIN IN D5W VASOSTRICT ANTINEOPLASTIC LHRH(GNRH) AGONIST,PITUITARY SUPPR. ELIGARD LEUPROLIDE ACETATE LUPRON DEPOT TRELSTAR TRELSTAR DEPOT TRELSTAR LA TRIPTORELIN PAMOATE ZOLADEX BONE FORMATION STIM. AGENTS ‐ PARATHYROID HORMONE FORTEO TERIPARATIDE BONE RESORPTION INHIBITOR & VITAMIN D COMBINATIONS FOSAMAX PLUS D BONE RESORPTION INHIBITORS DRUG TIER 2 2 2 2 2 2 2 2 2 2 2 3 2 1 3 2 3 3 1 1 1 2 2 1 2 3 2 2 3 2 3 3 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 45 DRUG CATEGORY & NAME ACTONEL ALENDRONATE SODIUM ATELVIA BINOSTO BONIVA CALCITONIN,SALMON,SYNTHETIC DENOSUMAB ETIDRONATE DISODIUM EVISTA FORTICAL FOSAMAX IBANDRONATE SODIUM MIACALCIN PAMIDRONATE DISODIUM PROLIA RALOXIFENE HCL RECLAST RISEDRONATE SODIUM XGEVA ZOLEDRONIC ACID ZOMETA 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 DRUG TIER 2 1 2 2 2 1 3 1 2 2 2 1 2 1 2 1 2 1 3 1 2 3 3 3 3 3 3 3 3 3 3 3 2 3 3 3 3 3 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 46 DRUG CATEGORY & NAME DOXERCALCIFEROL HECTOROL PARICALCITOL ZEMPLAR INSULIN‐LIKE GROWTH FACTOR‐1 (IGF‐1) HORMONES INCRELEX MECASERMIN LEPTIN HORMONE ANALOGS MYALEPT LHRH(GNRH) AGONIST ANALOG PITUITARY SUPPRESSANTS HISTRELIN AC NAFARELIN ACETATE SYNAREL VANTAS LHRH(GNRH) ANTAGONIST,PITUITARY SUPPRESSANT AGENTS CETROTIDE GANIRELIX ACETATE LHRH(GNRH)AGNST PIT.SUP‐CENTRAL PRECOCIOUS PUBERTY LUPRON DEPOT‐PED SUPPRELIN LA MENOPAUSAL SYMPT SUPP‐SEL ESTROGEN RECEP MODULATOR OSPHENA PARATHYROID HORMONES NATPARA PITUITARY SUPPRESSIVE AGENTS CABERGOLINE DANAZOL THYROID FUNCTION DIAGNOSTIC AGENTS THYROGEN ENDOCRINE DISORDER ‐ THYROID ANTITHYROID PREPARATIONS METHIMAZOLE PROPYLTHIOURACIL TAPAZOLE IODINE CONTAINING AGENTS POTASSIUM IODIDE POTASSIUM IODIDE/IODINE SODIUM IODIDE THYROID HORMONES ARMOUR THYROID CYTOMEL LEVOTHYROXINE SODIUM LEVOXYL DRUG TIER 1 2 1 2 3 3 2 3 3 3 3 2 2 2 2 2 2 1 1 2 1 1 2 1 1 1 2 2 1 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 47 DRUG CATEGORY & NAME LIOTHYRONINE SODIUM SYNTHROID THYROID,PORK THYROLAR‐1 THYROLAR‐1/2 THYROLAR‐1/4 THYROLAR‐2 THYROLAR‐3 TIROSINT TRIOSTAT UNITHROID EYE ‐ GENERAL DISORDERS EYE ANTIBIOTIC‐CORTICOID COMBINATIONS MAXITROL NEO/POLYMYX B SULF/DEXAMETH NEOMYCIN SU/BACI ZN/POLY/HC PRED‐G TOBRADEX TOBRADEX ST TOBRAMYCIN/DEXAMETHASONE ZYLET EYE ANTIHISTAMINES BEPREVE ELESTAT EMADINE EPINASTINE HCL LASTACAFT PATADAY PATANOL PAZEO EYE ANTIINFLAMMATORY AGENTS ACULAR ACULAR LS ACUVAIL ALREX BROMFENAC SODIUM DEXAMETHASONE SOD PHOSPHATE DUREZOL FLAREX FLUOROMETHOLONE FLURBIPROFEN SODIUM FML FML FORTE DRUG TIER 1 2 1 2 2 2 2 2 2 2 2 2 1 1 2 2 2 1 2 2 2 2 1 2 2 2 2 2 2 2 2 1 1 2 2 1 1 2 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 48 DRUG CATEGORY & NAME FML S.O.P. ILEVRO ILUVIEN LOTEMAX MAXIDEX NEVANAC OCUFEN OMNIPRED OZURDEX PRED FORTE PRED MILD PREDNISOLONE ACETATE PROLENSA RETISERT TRIESENCE VEXOL EYE ANTIVIRALS TRIFLURIDINE VIROPTIC ZIRGAN EYE LOCAL ANESTHETICS AKTEN BENOXINATE HCL/FLUORESCEIN NA FLUORESCEIN‐BENOXINATE FLUROX PROPARACAINE HCL PROPARACAINE/FLUORESCEIN SOD TETCAINE TETRACAINE HCL TETRACAINE HCL/PF TETRAVISC TETRAVISC FORTE EYE SULFONAMIDES BLEPHAMIDE BLEPHAMIDE S.O.P. SULFACETAMIDE SODIUM SULFACETAMIDE/PREDNISOLONE SP EYE VASOCONSTRICTORS (RX ONLY) NAPHAZOLINE HCL PHENYLEPHRINE HCL OPHTHALMIC ANTIBIOTICS AZASITE BACITRACIN DRUG TIER 2 2 2 2 2 2 2 2 2 2 2 1 2 2 2 2 1 2 2 2 1 2 2 1 1 2 1 1 2 2 2 2 1 1 1 1 2 1 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 49 DRUG CATEGORY & NAME BACITRACIN/POLYMYXIN B SULFATE BESIVANCE CILOXAN GARAMYCIN GATIFLOXACIN GENTAMICIN SULFATE ILOTYCIN MOXEZA NATACYN NEOMYCIN SU/BACITRA/POLYMYXIN NEOMYCIN/POLYMYXN B/GRAMICIDIN NEOSPORIN OCUFLOX OFLOXACIN POLYMYXIN B SULF/TRIMETHOPRIM POLYTRIM TOBREX VIGAMOX ZYMAXID OPHTHALMIC ANTI‐INFLAMMATORY IMMUNOMODULATOR‐TYPE RESTASIS OPHTHALMIC MAST CELL STABILIZERS ALOCRIL ALOMIDE CROMOLYN SODIUM OPHTHALMIC PREPARATIONS, MISCELLANEOUS ACUICYN AMVISC AMVISC PLUS AVENOVA DISCOVISC DUOVISC HEALON HEALON GV HEALON ULTIMATE DUAL PACK HEALON5 PROVISC VISCOAT OPHTHALMIC PROTEOLYTIC ENZYME AGENTS JETREA EYE ‐ GLAUCOMA CARBONIC ANHYDRASE INHIBITORS ACETAZOLAMIDE DRUG TIER 1 2 2 2 1 1 2 2 2 1 1 2 2 1 1 2 2 2 2 2 2 2 1 2 2 2 2 2 2 2 2 2 2 2 2 2 1 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 50 DRUG CATEGORY & NAME ACETAZOLAMIDE SODIUM DIAMOX SEQUELS METHAZOLAMIDE NEPTAZANE MIOTICS/OTHER INTRAOC. PRESSURE REDUCERS ALPHAGAN P APRACLONIDINE HCL AZOPT BETAGAN 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 MIOCHOL‐E MIOSTAT PHOSPHOLINE IODIDE RESCULA SIMBRINZA TIMOPTIC TIMOPTIC OCUDOSE TIMOPTIC‐XE TRAVATAN Z TRAVOPROST (BENZALKONIUM) TRUSOPT XALATAN ZIOPTAN MYDRIATICS ATROPINE SULFATE CYCLOGYL CYCLOMYDRIL DRUG TIER 1 2 1 2 2 1 2 2 2 2 1 1 1 2 2 2 1 1 2 2 2 1 1 2 1 2 2 2 2 2 2 2 2 2 1 2 2 2 1 2 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 51 DRUG CATEGORY & NAME CYCLOPENTOLATE HCL HOMATROPINE HBR ISOPTO ATROPINE MYDRIACYL PAREMYD TROPICAMIDE OPHTHALMIC ANTIFIBROTIC AGENTS MITOSOL EYE ‐ MISCELLANEOUS ARTIFICIAL TEARS LACRISERT EYE DIAGNOSTIC AGENTS AK‐FLUOR FLUORESCEIN SODIUM FLUORESCITE FUL‐GLO EYE IRRIGATIONS BALANCED SALT IRRIG SOLN NO.2 BSS BSS PLUS EYE MYDRIATIC AND NSAID COMBINATIONS OMIDRIA OCULAR PHOTOACTIVATED VESSEL‐OCCLUDING AGENTS VISUDYNE OPHTH VASC. ENDOTHELIAL GROWTH FACTOR ANTAGONISTS EYLEA MACUGEN OPHTH. VEGF‐A RECEPTOR ANTAG. RCMB MC ANTIBODY LUCENTIS 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 ALOPRIM ULORIC DRUG TIER 1 1 2 2 2 1 2 2 2 1 2 2 1 2 2 2 2 2 2 2 2 2 1 1 2 2 1 2 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 52 DRUG CATEGORY & NAME ZYLOPRIM HYPERURICEMIA TX ‐ URATE‐OXIDASE ENZYME‐TYPE ELITEK KRYSTEXXA RASBURICASE URICOSURIC AGENTS PROBENECID HEMATOLOGICAL DISORDERS ANTICOAGULANTS,COUMARIN TYPE COUMADIN WARFARIN SODIUM ANTIFIBRINOLYTIC AGENTS AMICAR AMINOCAPROIC ACID CYKLOKAPRON LYSTEDA RIASTAP TRANEXAMIC ACID ANTIHEMOPHILIC FACTORS ADVATE ADVATE H ADVATE L ADVATE M ADVATE SH ADVATE UH ALPHANATE ELOCTATE FEIBA NF HELIXATE FS HEMOFIL M HUMATE‐P KOATE‐DVI KOGENATE FS MONOCLATE‐P NOVOEIGHT NOVOSEVEN RT OBIZUR RECOMBINATE WILATE XYNTHA XYNTHA SOLOFUSE ANTIPORPHYRIA FACTORS PANHEMATIN DRUG TIER 2 3 2 3 1 2 1 2 1 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 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 53 DRUG CATEGORY & NAME BLOOD FACTORS,MISCELLANEOUS CORIFACT CITRATES AS ANTICOAGULANTS ACD ACD‐A CITRATE PHOSPHATE DEXTROS SOLN SODIUM CITRATE TRICITRASOL COAGULANTS PROTAMINE SULFATE DIRECT FACTOR XA INHIBITORS ELIQUIS SAVAYSA XARELTO FACTOR IX COMPLEX (PCC) PREPARATIONS KCENTRA FACTOR IX PREPARATIONS ALPHANINE SD ALPROLIX BEBULIN BENEFIX FACTOR IX COMPLEX (PCC) COMB.4 IXINITY MONONINE PROFILNINE RIXUBIS FACTOR XIII PREPARATIONS TRETTEN HEMATINICS,OTHER ARANESP EPOGEN MIRCERA PROCRIT HEMORRHEOLOGIC AGENTS PENTOXIFYLLINE HEPARIN AND RELATED PREPARATIONS ARIXTRA ENOXAPARIN SODIUM FONDAPARINUX SODIUM FRAGMIN HEPARIN SOD,PORK IN 0.45% NACL HEPARIN SODIUM HEPARIN SODIUM,PORCINE DRUG TIER 2 2 2 1 1 2 1 2 2 2 2 2 2 2 2 3 2 2 3 2 2 2 2 2 2 1 2 1 1 2 1 2 1 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 54 DRUG CATEGORY & NAME HEPARIN SODIUM,PORCINE/D5W HEPARIN SODIUM,PORCINE/NS/PF HEPARIN SODIUM,PORCINE/PF LOVENOX HUMAN MONOCLONAL ANTIBODY COMPLEMENT(C5) INHIBITOR SOLIRIS LEUKOCYTE (WBC) STIMULANTS FILGRASTIM GRANIX LEUKINE NEULASTA NEUPOGEN PEGFILGRASTIM SARGRAMOSTIM TBO‐FILGRASTIM PLASMA EXPANDERS HESPAN HETASTARCH IN 0.9 % NACL HEXTEND LACTATED ELECTROLYTE LMD 10% WITH 0.9% SOD CHLORIDE LMD 10% WITH 5% DEXTROSE VOLUVEN PLASMA PROTEINS ALBUKED‐25 ALBUKED‐5 ALBUMIN (HUMAN) ALBUMINAR‐25 ALBUMINAR‐5 ALBURX ALBUTEIN ATRYN BUMINATE FLEXBUMIN KEDBUMIN OCTAPLAS PLASBUMIN‐25 PLASBUMIN‐5 PLASMANATE THROMBATE III PLATELET AGGREGATION INHIBITORS AGGRASTAT AGGRENOX ASPIRIN/DIPYRIDAMOLE DRUG TIER 1 1 1 2 2 3 3 3 3 3 3 3 3 2 1 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 55 DRUG CATEGORY & NAME BRILINTA CILOSTAZOL CLOPIDOGREL BISULFATE DIPYRIDAMOLE EFFIENT EPTIFIBATIDE INTEGRILIN KENGREAL PERSANTINE PLAVIX PLETAL REOPRO TICLOPIDINE HCL ZONTIVITY PLATELET PROLIFERATION STIMULANTS NEUMEGA OPRELVEKIN PLATELET REDUCING AGENTS AGRYLIN ANAGRELIDE HCL PROTEIN C PREPARATIONS CEPROTIN SICKLE CELL ANEMIA AGENTS DROXIA THROMBIN INHIBITORS,SEL.,DIRECT,&REV.‐HIRUDIN TYPE ANGIOMAX BIVALIRUDIN IPRIVASK THROMBIN INHIBITORS,SELECTIVE,DIRECT, & REVERSIBLE ARGATROBAN ARGATROBAN‐0.9% NACL ARGATROBAN‐SODIUM CHLORIDE PRADAXA THROMBOLYTIC ENZYMES ACTIVASE CATHFLO ACTIVASE TNKASE THROMBOPOIETIN RECEPTOR AGONISTS ELTROMBOPAG OLAMINE NPLATE PROMACTA TOPICAL HEMOSTATICS ASTRINGYN DRUG TIER 2 1 1 1 2 3 3 2 2 2 2 2 1 2 3 3 2 1 2 2 2 1 2 2 2 2 2 2 2 2 3 2 3 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 56 DRUG CATEGORY & NAME AVITENE ENDO‐AVITENE FERRIC SUBSULFATE GELFOAM GELFOAM COMPRESSED OXYCEL RECOTHROM SYRINGE AVITENE TACHOSIL THROMB‐CA‐CELL‐DRESSING, HEMOS THROMBI‐GEL THROMBIN (BOVINE) TISSEEL VHSD ULTRAFOAM VITAMIN K PREPARATIONS MEPHYTON PHYTONADIONE HORMONAL DEFICIENCY ANDROGENIC AGENTS ANADROL‐50 ANDRODERM ANDROGEL ANDROID AVEED AXIRON DELATESTRYL DEPO‐TESTOSTERONE FLUOXYMESTERONE FORTESTA METHITEST NATESTO OXANDRIN OXANDROLONE STRIANT TESTIM TESTONE CIK TESTOPEL TESTOSTERONE TESTOSTERONE CYPIONATE TESTOSTERONE ENANTHATE TESTRED VOGELXO ESTROGEN & PROGESTIN WITH ANTIMINERALOCORTICOID CB DRUG TIER 2 2 1 2 2 2 2 2 2 1 2 1 2 2 2 1 2 2 2 2 2 2 2 2 1 2 2 2 2 1 2 2 2 2 1 1 1 2 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 57 DRUG CATEGORY & NAME ANGELIQ ESTROGEN & SELECTIVE ESTROGEN RECEPT MOD(SERM)COMB DUAVEE ESTROGEN/ANDROGEN COMBINATIONS ESTROGEN,ESTER/ME‐TESTOSTERONE ESTROGENIC AGENTS ACTIVELLA ALORA CLIMARA CLIMARA PRO COMBIPATCH DELESTROGEN DEPO‐ESTRADIOL DIVIGEL ELESTRIN ENJUVIA ESTRACE ESTRADIOL ESTRADIOL VALERATE ESTRADIOL/NORETHINDRONE ACET ESTROGEL ESTROPIPATE EVAMIST FEMHRT MENEST MENOSTAR MINIVELLE NORETHINDRONE AC‐ETH ESTRADIOL PREFEST PREMPHASE PREMPRO VIVELLE‐DOT LHRH (GNRH) AGONIST ANALOG AND PROGESTIN COMB LUPANETA PACK PROGESTATIONAL AGENTS AYGESTIN CRINONE HYDROXYPROGESTERONE CAPROATE MAKENA MEDROXYPROGESTERONE ACETATE NORETHINDRONE ACETATE PROGESTERONE PROGESTERONE,MICRONIZED DRUG TIER 2 2 1 2 2 2 2 2 2 2 2 2 2 2 1 1 1 2 1 2 2 2 2 2 1 2 2 2 2 2 2 2 3 3 1 1 1 1 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 58 DRUG CATEGORY & NAME PROMETRIUM PROVERA IMMUNIZATION ANTISERA ATGAM BIVIGAM BOTULISM ANTITOXIN HEPTAVALENT CARIMUNE NF NANOFILTERED CYTOGAM FLEBOGAMMA DIF GAMASTAN S‐D GAMMAGARD LIQUID GAMMAGARD S‐D GAMMAKED GAMMAPLEX GAMUNEX‐C HEPAGAM B HIZENTRA HYPERHEP B S‐D HYPERRAB S‐D HYPERRHO S‐D HYPERTET S‐D HYQVIA IMMUN GLOB G(IGG)/PRO/IGA 0‐50 IMOGAM RABIES‐HT LYMPHOCYTE IMMU GLOB.,RABBIT MICRHOGAM ULTRA‐FILTERED PLUS NABI‐HB OCTAGAM PRIVIGEN RHOGAM ULTRA‐FILTERED PLUS RHOPHYLAC THYMOGLOBULIN VARIZIG WINRHO SDF ENTERIC VIRUS VACCINES IPOL ROTARIX ROTATEQ GRAM (‐) BACILLI (NON‐ENTERIC) VACCINES TYPHIM VI VIVOTIF BERNA GRAM NEGATIVE COCCI VACCINES DRUG TIER 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 3 2 2 2 2 2 3 2 3 2 2 2 2 2 2 3 2 2 2 2 2 2 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 59 DRUG CATEGORY & NAME BEXSERO MENACTRA MENOMUNE‐A‐C‐Y‐W‐135 MENVEO A‐C‐Y‐W‐135‐DIP MENVEO MENA COMPONENT MENVEO MENCYW‐135 COMPONENT TRUMENBA GRAM POSITIVE COCCI VACCINES PNEUMOVAX 23 PREVNAR 13 INFLUENZA VIRUS VACCINES AFLURIA 2015‐2016 FLUARIX QUAD 2015‐2016 FLUBLOK 2015‐2016 FLUCELVAX 2015‐2016 FLULAVAL QUAD 2015‐2016 FLUMIST QUAD 2015‐2016 FLUVIRIN 2015‐2016 FLUZONE 2015‐2016 FLUZONE HIGH‐DOSE 2015‐2016 FLUZONE INTRADERM QUAD 2015‐16 FLUZONE QUAD 2015‐2016 FLUZONE QUAD PEDI 2015‐2016 NEUROTOXIC VIRUS VACCINES IMOVAX RABIES VACCINE IXIARO RABAVERT YF‐VAX TOXIN‐PRODUCING BACILLI VACCINES/TOXOIDS BCG VACCINE (TICE STRAIN) BIOTHRAX VACCINE/TOXOID PREPARATIONS,COMBINATIONS ACTHIB ADACEL TDAP BOOSTRIX TDAP DAPTACEL DTAP DIPHTHERIA‐TETANUS TOXOIDS‐PED INFANRIX DTAP KINRIX MENHIBRIX M‐M‐R II VACCINE PEDVAXHIB PENTACEL 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 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 60 DRUG CATEGORY & NAME PENTACEL ACTHIB COMPONENT PENTACEL DTAP‐IPV COMPONENT PROQUAD QUADRACEL DTAP‐IPV TENIVAC TETANUS & DIPHTHERIA TOX,ADULT VIRAL/TUMORIGENIC VACCINES ADENOVIRUS TYPE 4 ADENOVIRUS TYPE 4 AND TYPE 7 ADENOVIRUS TYPE 7 CERVARIX COMVAX ENGERIX‐B ADULT ENGERIX‐B PEDIATRIC‐ADOLESCENT GARDASIL GARDASIL 9 HAVRIX PEDIARIX RECOMBIVAX HB TWINRIX VAQTA VARIVAX VACCINE ZOSTAVAX IMMUNOSUPPRESSION/MODULATION IMMUNOMODULATORS ACTIMMUNE ALDARA ALDESLEUKIN ALFERON N IMIQUIMOD INTERFERON ALFA‐2B,RECOMB. INTERFERON GAMMA‐1B,RECOMB. INTRON A PROLEUKIN ZYCLARA IMMUNOSUPP ‐ MONOCLONAL AB INHIBITING T LYMPH FXN BASILIXIMAB SIMULECT IMMUNOSUPPRESSIVES ASTAGRAF XL AZASAN AZATHIOPRINE BELATACEPT DRUG TIER 2 2 2 2 2 1 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 3 2 3 2 1 3 3 3 3 2 3 3 2 2 1 3 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 61 DRUG CATEGORY & NAME CELLCEPT CYCLOSPORINE, MODIFIED EVEROLIMUS IMURAN MYCOPHENOLATE MOFETIL MYCOPHENOLATE SODIUM MYFORTIC NEORAL NULOJIX PROGRAF RAPAMUNE SANDIMMUNE SIROLIMUS ZORTRESS INFECTIOUS DISEASE ‐ BACTERIAL ABSORBABLE SULFONAMIDES BACTRIM BACTRIM DS SULFAMETHOXAZOLE/TRIMETHOPRIM BETALACTAMS AZACTAM AZACTAM‐ISO‐OSMOTIC DEXTROSE AZTREONAM AZTREONAM LYSINE CAYSTON CARBAPENEMS (THIENAMYCINS) DORIBAX ERTAPENEM SODIUM IMIPENEM/CILASTATIN SODIUM INVANZ MEROPENEM MERREM PRIMAXIN CEPHALOSPORINS ‐ EXTENDED SPECTRUM, ANTI‐MRSA TEFLARO CEPHALOSPORINS ‐ 1ST GENERATION CEFADROXIL CEFAZOLIN SODIUM CEFAZOLIN SODIUM IN 0.9 % NACL CEFAZOLIN SODIUM/DEXTROSE,ISO CEPHALEXIN KEFLEX CEPHALOSPORINS ‐ 2ND GENERATION DRUG TIER 2 1 3 2 1 1 2 2 3 2 2 2 1 3 2 2 1 2 2 1 3 3 2 3 1 3 1 2 2 2 1 1 1 1 1 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 62 DRUG CATEGORY & NAME CEFACLOR CEFOTETAN DISOD/DEXTROSE,ISO CEFOTETAN DISODIUM CEFOXITIN SODIUM CEFOXITIN SODIUM/DEXTROSE,ISO CEFPROZIL CEFTIN CEFUROXIME AXETIL CEFUROXIME SODIUM MEFOXIN ZINACEF CEPHALOSPORINS ‐ 3RD GENERATION AVYCAZ CEDAX CEFDINIR CEFDITOREN PIVOXIL CEFIXIME CEFOTAXIME SODIUM CEFPODOXIME PROXETIL CEFTAZIDIME CEFTIBUTEN CEFTRIAXONE CLAFORAN FORTAZ FORTAZ IN ISO‐OSMOTIC DEXTROSE SPECTRACEF SUPRAX ZERBAXA CEPHALOSPORINS ‐ 4TH GENERATION CEFEPIME CEFEPIME HCL CEFEPIME‐DEXTROSE MAXIPIME 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 PHOSPHASAL DRUG TIER 1 1 1 1 1 1 2 2 1 2 2 2 2 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 1 2 2 2 1 1 1 1 1 2 1 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 63 DRUG CATEGORY & NAME PRIMSOL PROSED‐DS TRIMETHOPRIM URELLE URETRON D‐S URIBEL URIN D.S. URYL UTA UTIRA‐C CYCLIC LIPOPEPTIDES CUBICIN DAPTOMYCIN GLYCYLCYCLINES TIGECYCLINE TYGACIL KETOLIDES KETEK MACROLIDES AZITHROMYCIN BIAXIN CLARITHROMYCIN DIFICID ERYPED 200 ERYPED 400 ERYTHROCIN LACTOBIONATE ERYTHROMYCIN BASE ERYTHROMYCIN ETHYLSUCCINATE ERYTHROMYCIN STEARATE FIDAXOMICIN PCE ZITHROMAX ZITHROMAX TRI‐PAK ZMAX NITROFURAN DERIVATIVES FURADANTIN MACROBID MACRODANTIN NITROFURANTOIN MACROCRYSTAL NITROFURANTOIN MONOHYD/M‐CRYST OXAZOLIDINONES LINEZOLID LINEZOLID‐0.9% SODIUM CHLORIDE DRUG TIER 2 2 1 2 2 2 2 2 2 2 3 3 3 3 2 1 2 1 3 2 2 2 1 1 1 3 2 2 2 2 2 2 2 1 1 3 1 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 64 DRUG CATEGORY & NAME SIVEXTRO TEDIZOLID PHOSPHATE ZYVOX PENICILLINS AMOXICILLIN AMOXICILLIN/POTASSIUM CLAV AMPICILLIN SODIUM AMPICILLIN SODIUM/SULBACTAM NA AMPICILLIN TRIHYDRATE AUGMENTIN AUGMENTIN ES‐600 AUGMENTIN XR BICILLIN C‐R BICILLIN L‐A DICLOXACILLIN SODIUM MOXATAG NAFCILLIN IN DEXTROSE,ISO‐OSM NAFCILLIN SODIUM OXACILLIN SODIUM OXACILLIN SODIUM/DEXTROSE,ISO PEN G POT/DEXTROSE‐WATER PENICILLIN G POTASSIUM PENICILLIN G PROCAINE PENICILLIN G SODIUM PENICILLIN V POTASSIUM PFIZERPEN PIPERACILLIN SODIUM/TAZOBACTAM TIMENTIN UNASYN ZOSYN QUINOLONES AVELOX AVELOX ABC PACK AVELOX IV CIPRO CIPRO I.V. CIPRO XR CIPROFLOXACIN CIPROFLOXACIN HCL CIPROFLOXACIN LACTATE/D5W CIPROFLOXACIN/CIPROFLOXA HCL FACTIVE LEVAQUIN DRUG TIER 3 3 3 1 1 1 1 1 2 2 2 2 2 1 2 1 1 1 1 1 1 1 1 1 2 1 2 2 2 2 2 2 2 2 2 1 1 1 1 2 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 65 DRUG CATEGORY & NAME LEVOFLOXACIN LEVOFLOXACIN/D5W MOXIFLOXACIN HCL MOXIFLOXACIN/SOD.ACE,SUL/WATER STREPTOGRAMINS QUINUPRISTIN/DALFOPRISTIN SYNERCID TETRACYCLINES ACTICLATE ADOXA AVIDOXY AVIDOXY DK BENOXYLDOXY 30 BENOXYLDOXY 60 DEMECLOCYCLINE HCL DORYX DOXYCYCLINE HYCLATE DOXYCYCLINE MONOHYDRATE MINOCIN MINOCYCLINE HCL MONODOX MORGIDOX ORACEA SOLODYN TETRACYCLINE HCL VIBRAMYCIN INFECTIOUS DISEASE ‐ FUNGAL ANTIFUNGAL AGENTS ANCOBON CLOTRIMAZOLE CRESEMBA DIFLUCAN FLUCONAZOLE FLUCONAZOLE IN DEXTROSE,ISO‐OS FLUCONAZOLE IN NACL,ISO‐OSM FLUCYTOSINE ITRACONAZOLE LAMISIL NOXAFIL ONMEL ORAVIG POSACONAZOLE SPORANOX DRUG TIER 1 1 1 1 3 3 2 2 2 2 2 2 1 2 1 1 2 1 2 2 2 2 1 2 3 1 2 2 1 1 1 3 1 2 3 2 2 3 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 66 DRUG CATEGORY & NAME TERBINAFINE HCL VFEND VFEND IV VORICONAZOLE ANTIFUNGAL ANTIBIOTICS ABELCET AMBISOME AMPHOTERICIN B AMPHOTERICIN B LIPOSOME CANCIDAS CASPOFUNGIN ACETATE ERAXIS (WATER DILUENT) GRIFULVIN V GRISEOFULVIN ULTRAMICROSIZE GRISEOFULVIN, MICROSIZE GRIS‐PEG MICAFUNGIN SODIUM MYCAMINE NYSTATIN INFECTIOUS DISEASE ‐ MISCELLANEOUS AMINOGLYCOSIDES AMIKACIN SULFATE BETHKIS GENTAMICIN IN NACL, ISO‐OSM KITABIS PAK NEOMYCIN SULFATE STREPTOMYCIN SULFATE TOBI TOBI PODHALER TOBRAMYCIN TOBRAMYCIN IN 0.225% NACL TOBRAMYCIN SULFATE TOBRAMYCIN/NEBULIZER TOBRAMYCIN/SODIUM CHLORIDE ANTIBACTERIAL AGENTS,MISCELLANEOUS AMINOACETIC ACID GLYCINE UROLOGIC SOLUTION ANTILEPROTICS DAPSONE THALIDOMIDE THALOMID ANTI‐MYCOBACTERIUM AGENTS ETHAMBUTOL HCL DRUG TIER 1 3 2 3 2 3 1 3 3 3 2 2 1 1 2 3 3 1 1 3 1 3 1 1 3 3 3 3 2 3 1 2 1 1 3 3 1 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 67 DRUG CATEGORY & NAME ISONIAZID MYAMBUTOL MYCOBUTIN PASER PYRAZINAMIDE RIFABUTIN TRECATOR ANTITUBERCULAR ANTIBIOTICS BEDAQUILINE FUMARATE CAPASTAT SULFATE CYCLOSERINE PRIFTIN RIFADIN RIFAMATE RIFAMPIN RIFATER SIRTURO CHLORAMPHENICOL AND DERIVATIVES CHLORAMPHENICOL SOD SUCC LINCOSAMIDES CLEOCIN HCL CLEOCIN PALMITATE CLEOCIN PHOSPHATE CLEOCIN PHOSPHATE IN D5W CLINDAMYCIN HCL CLINDAMYCIN PALMITATE HCL CLINDAMYCIN PHOSPHATE/D5W LINCOCIN LIPOGLYCOPEPTIDE ANTIBIOTIC DALBAVANCIN HCL DALVANCE ORBACTIV ORITAVANCIN DIPHOSPHATE POLYMYXIN AND DERIVATIVES COLISTIN (COLISTIMETHATE NA) COLY‐MYCIN M PARENTERAL POLYMYXIN B SULFATE RIFAMYCINS AND RELATED DERIVATIVE ANTIBIOTICS XIFAXAN VANCOMYCIN AND DERIVATIVES VANCOCIN HCL VANCOMYCIN HCL VANCOMYCIN HCL/D5W DRUG TIER 1 2 3 2 1 3 2 3 2 1 2 2 2 1 2 3 1 2 2 2 2 1 1 1 2 3 3 3 3 1 2 1 2 3 3 1 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 68 DRUG CATEGORY & NAME VANCOMYCIN IN DEXTROSE,ISO‐OSM VANCOMYCIN/0.9% SOD CHLORIDE VIBATIV INFECTIOUS DISEASE ‐ PARASITIC 2ND GEN. ANAEROBIC ANTIPROTOZOAL‐ANTIBACTERIAL TINDAMAX TINIDAZOLE AMEBACIDES PAROMOMYCIN SULFATE ANAEROBIC ANTIPROTOZOAL‐ANTIBACTERIAL AGENTS FLAGYL FLAGYL ER METRO IV ANTHELMINTICS ALBENZA BILTRICIDE IVERMECTIN STROMECTOL ANTIMALARIAL DRUGS ATOVAQUONE/PROGUANIL HCL CHLOROQUINE PHOSPHATE COARTEM DARAPRIM HYDROXYCHLOROQUINE SULFATE MALARONE MEFLOQUINE HCL PLAQUENIL PRIMAQUINE QUALAQUIN QUININE SULFATE ANTIPROTOZOAL DRUGS,MISCELLANEOUS ATOVAQUONE MEPRON NEBUPENT PENTAM 300 INFECTIOUS DISEASE ‐ VIRAL ANTIVIRAL MONOCLONAL ANTIBODIES PALIVIZUMAB SYNAGIS ANTIVIRALS, GENERAL ACYCLOVIR ACYCLOVIR SODIUM CIDOFOVIR DRUG TIER 1 1 2 2 1 1 2 2 2 2 2 1 2 1 1 2 2 1 2 1 2 2 2 1 3 3 2 2 3 3 1 1 3 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 69 DRUG CATEGORY & NAME CYTOVENE FAMCICLOVIR FAMVIR FLUMADINE FOSCARNET SODIUM FOSCAVIR GANCICLOVIR SODIUM RAPIVAB RELENZA RIBAVIRIN RIMANTADINE HCL SITAVIG TAMIFLU VALACYCLOVIR HCL VALCYTE VALGANCICLOVIR HCL VALTREX VIRAZOLE VISTIDE 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 INTELENCE NEVIRAPINE RESCRIPTOR SUSTIVA VIRAMUNE DRUG TIER 2 1 2 2 1 2 1 2 2 3 1 2 2 1 3 3 2 3 3 2 2 2 2 2 1 2 2 1 2 2 2 2 2 1 2 2 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 70 DRUG CATEGORY & NAME VIRAMUNE XR ANTIVIRALS, HIV‐SPECIFIC, NUCLEOSIDE ANALOG, RTI ABACAVIR SULFATE DIDANOSINE EMTRIVA EPIVIR 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 HEP C VIRUS,NUCLEOTIDE ANALOG NS5B POLYMERASE INH SOFOSBUVIR DRUG TIER 2 1 1 2 2 2 1 2 2 2 2 1 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 3 2 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 71 DRUG CATEGORY & NAME 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 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 ARCALYST DRUG TIER 3 3 2 3 2 3 1 3 2 2 2 2 3 2 3 3 2 2 2 1 2 3 2 3 3 2 2 2 2 2 2 3 3 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 72 DRUG CATEGORY & NAME KINERET RILONACEPT ANTI‐INFLAMMATORY TUMOR NECROSIS FACTOR INHIBITOR ADALIMUMAB ENBREL ETANERCEPT GOLIMUMAB HUMIRA HUMIRA CROHN'S HUMIRA PEDIATRIC CROHN'S HUMIRA PSORIASIS SIMPONI SIMPONI ARIA 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. EUFLEXXA HYALGAN HYALURONATE SOD, CROSS‐LINKED MONOVISC ORTHOVISC SUPARTZ SYNVISC SYNVISC‐ONE TREPADONE ANTINFLAMMATORY, SEL.COSTIM.MOD.,T‐CELL INHIBITOR ABATACEPT/MALTOSE ORENCIA BRADYKININ B2 RECEPTOR ANTAGONISTS FIRAZYR ICATIBANT ACETATE C1 ESTERASE INHIBITORS BERINERT C1 ESTERASE INHIBITOR C1 ESTERASE INHIBITOR, RECOMB CINRYZE DRUG TIER 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 2 2 1 2 2 2 2 2 2 3 3 3 3 3 3 3 3 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 73 DRUG CATEGORY & NAME RUCONEST GLUCOCORTICOIDS ARISTOSPAN BETAMET ACET/BETAMET NA PH BUDESONIDE CELESTONE CORTEF CORTISONE ACETATE DEPO‐MEDROL DEXAMETHASONE DEXAMETHASONE INTENSOL DEXPAK ENTOCORT EC EZ USE JOINT‐TUNNEL‐TRIGGER FLO‐PRED HYDROCORTISONE HYDROCORTISONE SOD SUCCINATE KENALOG‐10 KENALOG‐40 MEDROL METHYLPREDNISOLONE METHYLPREDNISOLONE ACETATE METHYLPREDNISOLONE SOD SUCC MILLIPRED MILLIPRED DP ORAPRED ODT PEDIAPRED PHYSICIANS EZ USE M‐PRED PREDNISOLONE PREDNISOLONE SOD PHOSPHATE PREDNISONE PREDNISONE INTENSOL RAYOS SOLU‐CORTEF SOLU‐MEDROL VERIPRED 20 GOLD SALTS RIDAURA INTERLEUKIN‐6 (IL‐6) RECEPTOR INHIBITORS ACTEMRA TOCILIZUMAB JANUS KINASE (JAK) INHIBITORS TOFACITINIB CITRATE DRUG TIER 3 2 1 3 2 2 1 2 1 2 2 3 2 2 1 1 2 2 2 1 1 1 2 2 2 2 2 1 1 1 2 2 2 2 2 2 3 3 3 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 74 DRUG CATEGORY & NAME 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 CALDOLOR DAYPRO DICLOFENAC POTASSIUM DICLOFENAC SODIUM DYLOJECT EC‐NAPROSYN ETODOLAC FELDENE FENOPROFEN CALCIUM FLURBIPROFEN IBUPROFEN INDOCIN INDOMETHACIN KETOPROFEN KETOROLAC TROMETHAMINE MECLOFENAMATE SODIUM MEFENAMIC ACID MELOXICAM MOBIC NABUMETONE NALFON DRUG TIER 3 1 3 3 2 2 2 2 2 1 2 1 2 2 2 2 1 1 2 2 1 2 1 1 1 2 1 1 1 1 1 1 2 1 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 75 DRUG CATEGORY & NAME NAPRELAN NAPROSYN NAPROXEN NAPROXEN SODIUM OXAPROZIN PIROXICAM PONSTEL SULINDAC TIVORBEX TOLMETIN SODIUM VOLTAREN‐XR ZIPSOR ZORVOLEX PLASMA KALLIKREIN INHIBITORS KALBITOR MISCELLANEOUS COMFORT PAC‐IBUPROFEN COMFORT PAC‐MELOXICAM COMFORT PAC‐NAPROXEN LOCAL ANESTHESIA LOCAL ANESTHETICS BUCALSEP LIDOCAINE HCL 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 ROWASA SFROWASA DRUG TX‐CHRONIC INFLAM. COLON DX,5‐AMINOSALICYLAT APRISO ASACOL HD AZULFIDINE BALSALAZIDE DISODIUM COLAZAL DELZICOL DIPENTUM GIAZO DRUG TIER 2 2 1 1 1 1 2 1 2 1 2 2 2 2 2 2 2 2 1 2 1 1 2 1 2 2 2 2 2 1 2 2 3 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 76 DRUG CATEGORY & NAME LIALDA OLSALAZINE SODIUM PENTASA SULFASALAZINE DRUGS TO TX CHRONIC INFLAMM. DISEASE OF COLON CERTOLIZUMAB PEGOL CIMZIA INFLIXIMAB REMICADE HEMORRHOIDAL PREP, ANTI‐INFAM STEROID/LOCAL ANESTH ANA‐LEX ANALPRAM E ANALPRAM HC HYDROCORTISONE/PRAMOXINE LIDOCAINE/HYDROCORTISONE AC PRAMCORT PROCORT PROCTOFOAM‐HC ZYPRAM HEMORRHOIDAL PREPARATIONS ANALPRAM ADVANCED INTEGRIN RECEPTOR ANTAGONIST, MONOCLONAL ANTIBODY ENTYVIO VEDOLIZUMAB 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 DRUG TIER 2 3 2 1 3 3 3 3 2 2 2 1 1 2 2 2 2 2 3 3 2 2 2 1 1 2 2 2 1 2 2 3 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 77 DRUG CATEGORY & NAME GLYCEROL PHENYLBUTYRATE LACTULOSE LITHOSTAT RAVICTI SODIUM PHENYLBUTYRATE ANTIDIARRHEAL ‐ G.I. CHLORIDE CHANNEL INHIBITORS FULYZAQ ANTIDIARRHEALS DIPHENOXYLATE HCL/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 PEG‐PREP POLYETHYLENE GLYCOL 3350 PREPOPIK SODIUM CHLORIDE/NAHCO3/KCL/PEG SUPREP NARCOTIC ANTAGONISTS, PERIPHERALLY‐ACTING ENTEREG DRUG TIER 3 1 2 3 3 2 1 2 1 2 1 1 2 2 2 2 2 1 3 3 2 1 2 2 2 2 1 2 2 2 1 2 1 2 1 2 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 78 DRUG CATEGORY & NAME MOVANTIK RELISTOR SBS ‐ GLUCAGON‐LIKE PEPTIDE‐2 (GLP‐2) ANALOGS GATTEX TEDUGLUTIDE MEDICAL SUPPLIES BANDAGES AND RELATED SUPPLIES ACTICOAT ACTICOAT 7 ACTICOAT FLEX 3 ACTICOAT FLEX 7 ACTICOAT SURGICAL ALLEVYN ALLEVYN ADHESIVE ALLEVYN AG ALLEVYN AG ADHESIVE ALLEVYN AG GENTLE ALLEVYN HEEL ALLEVYN LIFE BIOSTEP BIOSTEP AG CURITY AMD CURITY IODOFORM HYDROFERA BLUE KERLIX AMD KERLIX AMD BANDAGE REPLICARE REPLICARE THIN REPLICARE ULTRA REPLICARE ULTRA SACRUM RESTORE RESTORE CALCIUM ALGINATE RESTORE CONTACT LAYER SILVER SILVERSEAL HYDROGEL XEROFORM XEROFORM PETROLATUM DRESSING CATHETERS AND RELATED DEVICES ADVANCE PLUS INTERMITTENT APOGEE HC INTERMITTENT CATHETER CURITY DOVER ADVANTAGE DOVER ADVANTAGE DRAINAGE DRUG TIER 2 2 3 3 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 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 79 DRUG CATEGORY & NAME DOVER LATEX FOLEY CATHETER DOVER PREMIUM DOVER RED RUBBER ROBIBSON CATH DOVER UNIVERSAL FEMALE SELF CATHETER KENGUARD 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 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 MASK SET WITH Y‐PIECE MOUTHPIECE NOSE CLIP PARI LC PLUS NEBULIZER PILLOW MASK FOR CHILDREN REUSABLE NEBULIZER KIT RUBBER MOUTHPIECE SAMI THE SEAL MASK SIDESTREAM MASK SMARTMASK KIDS TENS 504 TREK S PORTABLE PWR KIT PARENTERAL ADMINISTRATION SETS ACCU‐CHEK SPIRIT 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 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 80 DRUG CATEGORY & NAME INSYTE AUTOGUARD INSYTE IV CATHETER NEXIVA PARADIGM SILHOUETTE POLYFIN QR SAF‐T‐INTIMA IV CATHETER SILHOUETTE SYRINGES AND ACCESSORIES ALLERGIST SYRINGE ALLERGIST TRAY INTERLINK SYRINGE W‐CANNULA MAGELLAN TUBERCULIN SYRINGE MONOJECT CONTROL SYRINGE MONOJECT LUER LOCK TB SYRINGE MONOJECT MAGELLAN MONOJECT PHARMACY TRAY MONOJECT SAFETY SYRINGE MONOJECT SMARTIP CANNULA MONOJECT SYRINGE NORM‐JECT SAFETY SYRINGE WITH SHIELD SAFETY SYRINGE‐NEEDLE SAFETYGLIDE ALLERGY SYRINGE SYRING W‐NDL,DISP,INSUL,0.5 ML SYRINGE SYRINGE & NEEDLE,INSULIN,1 ML SYRINGE,NEEDLE,INSULN,SAFE,1ML SYRINGE,NEEDLE,INSULN,SF,0.3ML TERUMO SURGUARD2 TOOMEY SYRINGE ULTICARE SYRINGE TISSUE BULKING IMPLANTS SOLESTA MISCELLANEOUS AGENTS PARASYMPATHETIC AGENTS BETHANECHOL CHLORIDE CEVIMELINE HCL EVOXAC GUANIDINE HCL PILOCARPINE HCL SALAGEN URECHOLINE SYSTEMIC ENZYME INHIBITORS 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 1 2 2 2 2 1 1 2 1 1 2 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 81 DRUG CATEGORY & NAME ALPHA‐1‐PROTEINASE INHIBITOR ARALAST NP GLASSIA PROLASTIN C ZEMAIRA NEOPLASTIC DISEASE ALKYLATING AGENTS ALKERAN ALTRETAMINE BENDAMUSTINE HCL BICNU BUSULFAN BUSULFEX CARBOPLATIN CISPLATIN CYCLOPHOSPHAMIDE ELOXATIN GLEOSTINE GLIADEL HEXALEN HYDREA HYDROXYUREA IFEX IFOSFAMIDE IFOSFAMIDE/MESNA LEUKERAN LOMUSTINE MELPHALAN HCL MUSTARGEN MYLERAN OXALIPLATIN TEMODAR TEMOZOLOMIDE TREANDA ANTIANDROGENIC AGENTS ABIRATERONE ACETATE BICALUTAMIDE CASODEX ENZALUTAMIDE FLUTAMIDE NILANDRON XTANDI ZYTIGA DRUG TIER 3 3 3 3 3 2 3 3 2 3 3 1 1 2 3 2 2 3 2 1 2 1 1 2 1 1 2 2 3 3 3 3 3 1 2 3 1 2 3 3 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 82 DRUG CATEGORY & NAME ANTIBIOTIC ANTINEOPLASTICS BLEOMYCIN SULFATE COSMEGEN DACTINOMYCIN DAUNORUBICIN HCL DAUNOXOME DOXIL DOXORUBICIN HCL DOXORUBICIN HCL PEG‐LIPOSOMAL ELLENCE EPIRUBICIN HCL IDAMYCIN PFS IDARUBICIN HCL MITOMYCIN STREPTOZOCIN VALRUBICIN VALSTAR ZANOSAR ANTI‐CD20 (B LYMPHOCYTE) MONOCLONAL ANTIBODY ARZERRA GAZYVA OBINUTUZUMAB OFATUMUMAB RITUXAN RITUXIMAB ANTIMETABOLITES ALIMTA ARRANON AZACITIDINE CAPECITABINE CLADRIBINE CLOLAR CYTARABINE DACOGEN DECITABINE DEPOCYT FLOXURIDINE FLUDARABINE PHOSPHATE FLUOROURACIL FOLOTYN GEMCITABINE HCL GEMZAR MERCAPTOPURINE DRUG TIER 1 3 3 1 2 2 1 1 2 1 2 1 1 3 3 3 3 3 3 3 3 3 3 3 3 1 1 1 2 1 3 3 2 1 1 1 2 3 3 1 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 83 DRUG CATEGORY & NAME METHOTREXATE SODIUM METHOTREXATE SODIUM/PF NELARABINE NIPENT PEMETREXED DISODIUM PENTOSTATIN PURIXAN TABLOID TREXALL VIDAZA XELODA ANTINEOPLAST EGF RECEPTOR BLOCKER RCMB MC ANTIBODY CETUXIMAB ERBITUX HERCEPTIN PANITUMUMAB PERJETA PERTUZUMAB TRASTUZUMAB VECTIBIX ANTINEOPLAST HUM VEGF INHIBITOR RECOMB MC ANTIBODY AVASTIN BEVACIZUMAB ANTINEOPLASTIC AROMATASE INHIBITORS ANASTROZOLE ARIMIDEX AROMASIN EXEMESTANE FEMARA LETROZOLE ANTINEOPLASTIC ‐ EPOTHILONES AND ANALOGS IXABEPILONE IXEMPRA ANTINEOPLASTIC ‐ HALICHONDRIN B ANALOGS ERIBULIN MESYLATE HALAVEN ANTINEOPLASTIC ‐ HEDGEHOG PATHWAY INHIBITOR ERIVEDGE VISMODEGIB ANTINEOPLASTIC ‐ IMMUNOTHERAPY, THERAPEUTIC VAC PROVENGE ANTINEOPLASTIC ‐ JANUS KINASE (JAK) INHIBITORS JAKAFI DRUG TIER 1 1 3 3 3 3 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 1 2 2 1 2 1 3 3 3 3 3 3 2 3 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 84 DRUG CATEGORY & NAME RUXOLITINIB PHOSPHATE ANTINEOPLASTIC ‐ MTOR KINASE INHIBITORS AFINITOR AFINITOR DISPERZ EVEROLIMUS TEMSIROLIMUS TORISEL ANTINEOPLASTIC ‐ TOPOISOMERASE I INHIBITORS CAMPTOSAR HYCAMTIN IRINOTECAN HCL TOPOTECAN HCL ANTINEOPLASTIC ‐ VEGF‐A,B & P1GF INHIBITOR ZALTRAP ZIV‐AFLIBERCEPT ANTINEOPLASTIC ‐ VEGFR ANTAGONIST CYRAMZA RAMUCIRUMAB 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 BORTEZOMIB BOSULIF BOSUTINIB CABOZANTINIB S‐MALATE CAPRELSA CARFILZOMIB CERITINIB COMETRIQ CRIZOTINIB DABRAFENIB MESYLATE DASATINIB ERLOTINIB HCL GEFITINIB DRUG TIER 3 3 3 3 3 3 2 3 1 3 3 3 3 3 3 3 3 3 3 3 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 85 DRUG CATEGORY & NAME GILOTRIF GLEEVEC IBRANCE IBRUTINIB ICLUSIG IDELALISIB IMATINIB MESYLATE IMBRUVICA INLYTA IRESSA KYPROLIS LAPATINIB DITOSYLATE LENVATINIB MESYLATE LENVIMA LYNPARZA 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 VELCADE VEMURAFENIB VOTRIENT XALKORI ZELBORAF ZYDELIG ZYKADIA ANTINEOPLASTIC,ANTI‐PROGRAMMED DEATH‐1 (PD‐1) MAB KEYTRUDA DRUG TIER 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 86 DRUG CATEGORY & NAME NIVOLUMAB OPDIVO PEMBROLIZUMAB ANTINEOPLASTIC,HISTONE DEACETYLASE INHIBITORS,HDIS BELEODAQ BELINOSTAT FARYDAK ISTODAX PANOBINOSTAT LACTATE ROMIDEPSIN VORINOSTAT ZOLINZA ANTINEOPLASTIC‐INTERLEUKIN‐6(IL‐6)INHIB,ANTIBODY SILTUXIMAB SYLVANT ANTINEOPLASTICS ANTIBODY/ANTIBODY‐DRUG COMPLEXES ADCETRIS ADO‐TRASTUZUMAB EMTANSINE BLINATUMOMAB BLINCYTO KADCYLA UNITUXIN ZEVALIN ANTINEOPLASTICS,MISCELLANEOUS ABRAXANE ARSENIC TRIOXIDE BCG (TICE STRAIN) CABAZITAXEL DACARBAZINE DOCEFREZ DOCETAXEL ERWINAZE ETOPOPHOS ETOPOSIDE JEVTANA LYSODREN MATULANE MITOXANTRONE HCL OMACETAXINE MEPESUCCINATE ONCASPAR PACLITAXEL PACLITAXEL PROTEIN‐BOUND PEGASPARGASE DRUG TIER 3 3 3 3 3 3 3 3 3 3 3 3 3 2 3 3 3 3 2 2 3 3 2 3 1 2 3 2 2 1 3 2 3 1 3 3 1 3 3 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 87 DRUG CATEGORY & NAME PROCARBAZINE HCL SYNRIBO TAXOTERE TENIPOSIDE THERACYS TRISENOX CHEMOTHERAPY RESCUE/ANTIDOTE AGENTS AMIFOSTINE CRYSTALLINE DEXRAZOXANE HCL FUSILEV GLUCARPIDASE LEUCOVORIN CALCIUM LEVOLEUCOVORIN CALCIUM MESNA MESNEX VORAXAZE ZINECARD CYTOTOXIC T‐LYMPHOCYTE ANTIGEN(CTLA‐4)RMC ANTIBODY IPILIMUMAB YERVOY INTRAPLEURAL SCLEROSING AGENTS, ANTINEOPLAST. ADJ. SCLEROSOL TALC NEOPLASM MONOCLONAL DIAGNOSTIC AGENTS PROSTASCINT PHOTOACTIVATED, ANTINEOPLASTIC AGENTS (SYSTEMIC) PHOTOFRIN UVADEX PHOTOACTIVATED, ANTINEOPLS. & PREMALIGNANT LESIONS LEVULAN SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERM) FARESTON FASLODEX FULVESTRANT SOLTAMOX TAMOXIFEN CITRATE TOREMIFENE CITRATE SELECTIVE RETINOID X RECEPTOR AGONISTS (RXR) BEXAROTENE STEROID ANTINEOPLASTICS EMCYT ESTRAMUSTINE PHOSPHATE SODIUM VINCA ALKALOIDS DRUG TIER 3 3 3 1 2 3 1 1 2 3 1 1 1 2 3 2 3 3 2 1 2 2 2 2 3 3 3 2 1 3 1 3 3 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 88 DRUG CATEGORY & NAME MARQIBO NAVELBINE VINBLASTINE SULFATE VINCRISTINE SULFATE VINCRISTINE SULFATE LIPOSOMAL VINORELBINE TARTRATE NEUROLOGICAL DISEASE ‐ MISCELLANEOUS AGENTS TO TREAT MULTIPLE SCLEROSIS AUBAGIO AVONEX AVONEX ADMINISTRATION PACK AVONEX PEN BETASERON COPAXONE EXTAVIA GILENYA GLATIRAMER ACETATE LEMTRADA PLEGRIDY PLEGRIDY PEN REBIF REBIF REBIDOSE TECFIDERA AGTS TX NEUROMUSC TRANSMISSION DIS,POT‐CHAN BLKR AMPYRA DALFAMPRIDINE AMYOTROPHIC LATERAL SCLEROSIS AGENTS RILUTEK RILUZOLE FIBROMYALGIA AGENTS,SEROTONIN‐NOREPINEPH RU INHIB SAVELLA LEUKOCYTE ADHESION INHIB,ALPHA4‐MEDIAT IGG4K MC AB TYSABRI MOVEMENT DISORDERS(DRUG THERAPY) HORIZANT TETRABENAZINE XENAZINE POSTHERPETIC NEURALGIA AGENTS GRALISE PSEUDOBULBAR AFFECT (PBA) AGENTS, NMDA ANTAGONISTS NUEDEXTA ORAL/PHARYNGEAL DISORDERS DENTAL AIDS AND PREPARATIONS DRUG TIER 3 2 1 1 3 1 2 2 2 2 2 2 2 2 1 2 2 2 2 2 2 3 3 3 3 2 2 2 3 3 2 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 89 DRUG CATEGORY & NAME CHLORHEXIDINE GLUCONATE PERIDEX TRIAMCINOLONE ACETONIDE KERATINOCYTE GROWTH FACTOR (KGF) KEPIVANCE PALIFERMIN NOSE PREPARATIONS ANTIBIOTICS BACTROBAN NASAL NOSE PREPARATIONS, MISCELLANEOUS (RX) ATROVENT IPRATROPIUM BROMIDE 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 TRICHLOROACETIC ACID VITAMIN E ACETATE CARDIOPLEGIC SOLUTIONS CARDIOPLEGIC SOLUTION NO.1 CARDIOPLEGIC SOLUTION NO.10 PLEGISOL CHELATING AGENTS GLUTATHIONE GLUTATHIONE‐L CXCR4 CHEMOKINE RECEPTOR ANTAGONIST MOZOBIL DRUG TIER 1 2 1 3 3 2 2 1 2 2 2 2 2 2 2 2 2 1 2 2 2 2 2 2 1 1 2 2 2 3 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 90 DRUG CATEGORY & NAME PLERIXAFOR DIETARY SUPPLEMENT, MISCELLANEOUS AA8/A‐CARNITIN/GRP/COCOA/HC126 AA9/A‐CARNITIN/DEX/COCOA/HC127 APPTRIM APPTRIM‐D B3/AZEL AC/ZINC/B6/COPPER/FA B3/AZEL/QUER/TUR/FA/B6/ZN/COPP CERENX DERMANIC ENTERAGAM FISH OIL/OM‐3/DL‐E/FA/B6‐B12 FOSTEUM FOSTEUM PLUS GENISTEIN/CIT ZN BISGLY/VIT D3 HYPERTENSA LIMBREL LIMBREL250 LIMBREL500 LISTER‐V MEDI‐10 MV, MIN CMB#43/LUT/OM3/DHA/EPA NICADAN NICAZEL NICAZEL FORTE PERCURA RHEUMATE SENTRA PM THERAMINE THERAMINE PLUS TOZAL VAYACOG VAYARIN DILUENT SOLUTIONS DILUENT FOR ROTARIX DRUGS TO TREAT HEREDITARY TYROSINEMIA NITISINONE ORFADIN DRUGS TO TX GAUCHER DX‐TYPE 1, SUBSTRATE REDUCING CERDELGA ELIGLUSTAT TARTRATE MIGLUSTAT ZAVESCA DRUG TIER 3 1 1 2 2 1 1 2 2 2 1 2 2 1 2 2 2 2 2 2 1 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 91 DRUG CATEGORY & NAME FLAVORING AGENTS ETHYL ACETATE GENERAL ANESTHETICS,INHALANT ENFLURANE FORANE ISOFLURANE SEVOFLURANE SUPRANE ULTANE GENERAL INHALATION AGENTS HYPER‐SAL NEBUSAL PULMOSAL HERBAL DRUGS VP‐PRECIP HOMEOPATHIC DRUGS AURUMHEEL CANTHARIS COMPOSITUM CRALONIN EYE LAMIOFLUR PLANTAGO‐HOMACCORD POPULUS COMPOSITUM PSORINOHEEL RENEEL SABAL‐HOMACCORD SYZYGIUM COMPOSITUM VERTIGOHEEL IMMUNOMODULATOR,B‐LYMPHOCYTE STIM(BLYS)‐SPEC INHIB BELIMUMAB BENLYSTA JOINT TISSUE REPLACEMENT CARTICEL METABOLIC DEFICIENCY AGENTS BETAINE CARNITOR CARNITOR SF CYSTADANE LEVOCARNITINE (WITH SUGAR) SULFZIX METABOLIC DISEASE ENZYME REPLACEMENT, FABRY'S DX AGALSIDASE BETA FABRAZYME DRUG TIER 2 1 2 1 1 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 3 3 2 3 2 2 3 1 2 3 3 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 92 DRUG CATEGORY & NAME METABOLIC DISEASE ENZYME REPLACEMENT, GAUCHER'S DX CEREZYME ELELYSO IMIGLUCERASE TALIGLUCERASE ALFA VELAGLUCERASE ALFA VPRIV METABOLIC DISEASE ENZYME REPLACEMENT,POMPE DISEASE ALGLUCOSIDASE ALFA LUMIZYME MYOZYME METABOLIC DX ENZYME REPLACE, MUCOPOLYSACCHARIDOSIS ALDURAZYME ELAPRASE ELOSULFASE ALFA GALSULFASE IDURSULFASE LARONIDASE NAGLAZYME VIMIZIM METALLIC POISON,AGENTS TO TREAT CHEMET DEFERASIROX DEFERIPRONE EXJADE FERRIPROX GALZIN JADENU RADIOGARDASE SUCCIMER SYPRINE NEEDLES/NEEDLELESS DEVICES HYPODERMIC NEEDLE NUTRITIONAL THERAPY, MED COND SPECIAL FORMULATION NUTRESTORE OINTMENT/CREAM BASES RADIAGEL ORAL MUCOSITIS/STOMATITIS AGENTS GELCLAIR GELX MUGARD ORAMAGICRX ORAL MUCOSITIS/STOMATITIS ANTI‐INFLAMMATORY AGENT DRUG TIER 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 2 2 2 3 2 2 2 2 2 2 2 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 93 DRUG CATEGORY & NAME EPISIL MUCOSITIS & STOMATITIS COMBO 1 PHARMACEUTICAL ADJUVANTS, TABLETING MICROCRYSTALLINE CELLULOSE PKU TX AGENT‐COFACTOR OF PHENYLALANINE HYDROXYLASE KUVAN PRESERVATIVES FORMA‐RAY PROTEIN REPLACEMENT LYSIPLEX PLUS RADIOPHARMACEUTICALS ELEMENTS INDICLOR SALIVA SUBSTITUTE AGENTS AQUORAL CAPHOSOL NEUTRASAL NUMOISYN SKIN TISSUE REPLACEMENT APLIGRAF DERMAGRAFT ENDOFORM EPIFIX AMNIOTIC MEMBRANE GRAFIX CORE GRAFIX PRIME MATRISTEM MATRISTEM MICROMATRIX SOLVENTS MURI‐LUBE MINERAL OIL PROPYLENE GLYCOL SODIUM SUCCINATE SOMATOSTATIC AGENTS LANREOTIDE ACETATE OCTREOTIDE ACETATE,MI‐SPHERES PASIREOTIDE DIASPARTATE PASIREOTIDE PAMOATE SANDOSTATIN LAR SIGNIFOR SIGNIFOR LAR SOMATULINE DEPOT SUSPENDING AGENTS GELFILM SWEETENERS SACCHARIN DRUG TIER 2 1 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 2 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 94 DRUG CATEGORY & NAME TISSUE/WOUND ADHESIVES ARTISS TOPICAL ANTISEPTIC DRYING AGENTS FORMALDEHYDE MISCELLANEOUS CRYOSERV VEHICLES CITRIC ACID WOUND HEALING AGENTS, LOCAL DERMACINRX SURGICAL PHARMAPAK RADIGEL VENELEX OTHER RESPIRATORY DISORDERS ANTIFIBROTIC THERAPY ‐ PYRIDONE ANALOGS ESBRIET PIRFENIDONE CYSTIC FIB.TRANSMEMB CONDUCT.REG.(CFTR)POTENTIATOR 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 DRUG TIER 2 1 2 2 2 2 2 3 3 2 2 2 2 2 2 1 3 3 3 3 2 1 1 2 1 2 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 95 DRUG CATEGORY & NAME VANATOL LQ ANALGESIC/ANTIPYRETICS, SALICYLATES CHOLINE SAL/MAG SALICYLATE DIFLUNISAL DISALCID LEVACET SALSALATE ANALGESIC/ANTIPYRETICS,NON‐SALICYLATE OFIRMEV ANALGESICS NARCOTIC, ANESTHETIC ADJUNCT AGENTS ALFENTA ALFENTANIL HCL SUBLIMAZE SUFENTA SUFENTANIL CITRATE ULTIVA ANALGESICS, NARCOTIC AGONIST AND NSAID COMBINATION HYDROCODONE/IBUPROFEN IBUDONE IBUPROFEN/OXYCODONE HCL VICOPROFEN ANALGESICS, NEURONAL‐TYPE CALCIUM CHANNEL BLOCKERS PRIALT ANALGESICS, NON‐NARCOTICS CLONIDINE HCL/PF DURACLON ANALGESICS,NARCOTICS ABSTRAL ACTIQ BUTORPHANOL TARTRATE BUTRANS CODEINE SULFATE CODEINE/CARISOPRODOL/ASPIRIN CONZIP DEMEROL DHCODEINE BT/ACETAMINOPHN/CAFF DIHYDROCODEINE/ASPIRIN/CAFFEIN DILAUDID DISKETS DOLOPHINE HCL DURAGESIC EMBEDA EXALGO DRUG TIER 2 1 1 2 2 1 2 2 1 2 2 1 2 1 2 1 2 2 1 2 2 2 1 2 1 1 2 2 1 1 2 2 2 2 2 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 96 DRUG CATEGORY & NAME FENTANYL FENTANYL CITRATE FENTANYL/BUPIVACAINE/NS/PF FENTORA HYCET HYDROCODONE/ACETAMINOPHEN HYDROMORPHONE HCL HYSINGLA ER IONSYS KADIAN LAZANDA LEVORPHANOL TARTRATE LORTAB MEPERIDINE HCL METHADONE HCL MORPHINE SULFATE MS CONTIN NORCO NUCYNTA NUCYNTA ER OPANA OPANA ER OPIUM/BELLADONNA ALKALOIDS OXECTA OXYCODONE HCL OXYCODONE HCL/ACETAMINOPHEN OXYCODONE HCL/ASPIRIN OXYCONTIN OXYMORPHONE HCL PENTAZOCINE HCL/NALOXONE HCL PERCOCET PRIMLEV ROXICODONE SUBSYS SYNALGOS‐DC TRAMADOL HCL TRAMADOL HCL/ACETAMINOPHEN TREZIX ULTRACET ULTRAM ULTRAM ER VERDROCET XARTEMIS XR DRUG TIER 1 1 1 2 2 1 1 2 2 2 2 1 2 1 1 1 2 2 2 2 2 2 1 2 1 1 1 2 1 1 2 2 2 2 2 1 1 2 2 2 2 2 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 97 DRUG CATEGORY & NAME 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 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 DRUG TIER 2 2 2 2 2 1 2 2 2 2 2 2 1 2 2 2 1 1 2 2 2 2 1 2 1 1 1 2 2 1 2 2 1 2 1 2 1 2 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 98 DRUG CATEGORY & NAME TYLENOL‐CODEINE NO.4 NARCOTIC WITHDRAWAL THERAPY AGENTS BUNAVAIL BUPRENEX BUPRENORPHINE HCL BUPRENORPHINE HCL/NALOXONE HCL SUBOXONE ZUBSOLV PARKINSONS DISEASE ANTIPARKINSONISM DRUGS,ANTICHOLINERGIC BENZTROPINE MESYLATE COGENTIN TRIHEXYPHENIDYL HCL ANTIPARKINSONISM DRUGS,OTHER AMANTADINE HCL APOKYN APOMORPHINE HCL AZILECT BROMOCRIPTINE MESYLATE CARBIDOPA/LEVODOPA CARBIDOPA/LEVODOPA/ENTACAPONE COMTAN DUOPA ELDEPRYL ENTACAPONE MIRAPEX MIRAPEX ER NEUPRO PARLODEL 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 DRUG TIER 2 2 2 1 1 2 2 1 2 1 1 3 3 2 1 1 1 2 2 2 1 2 2 2 2 1 2 2 1 2 1 2 2 2 2 2 2 2 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 99 DRUG CATEGORY & NAME STALEVO 50 STALEVO 75 TASMAR TOLCAPONE ZELAPAR DECARBOXYLASE INHIBITORS CARBIDOPA LODOSYN SEIZURE DISORDER ANTICONVULSANTS APTIOM BANZEL CARBAMAZEPINE CARBATROL CELONTIN CEREBYX CLONAZEPAM DEPACON DEPAKENE DEPAKOTE DEPAKOTE ER DEPAKOTE SPRINKLE DIASTAT DIASTAT ACUDIAL DILANTIN DILANTIN‐125 DIVALPROEX SODIUM ESLICARBAZEPINE ACETATE ETHOSUXIMIDE FELBAMATE FELBATOL FOSPHENYTOIN SODIUM FYCOMPA GABAPENTIN GABITRIL KEPPRA KEPPRA XR KLONOPIN LAMICTAL LAMICTAL (BLUE) LAMICTAL (GREEN) LAMICTAL (ORANGE) LAMICTAL ODT DRUG TIER 2 2 3 3 2 1 2 3 3 1 2 2 2 1 2 2 2 2 2 2 2 2 2 1 3 1 3 3 1 2 1 2 2 2 2 2 2 2 2 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 100 DRUG CATEGORY & NAME LAMICTAL ODT (BLUE) LAMICTAL ODT (GREEN) LAMICTAL ODT (ORANGE) LAMICTAL XR LAMICTAL XR (BLUE) LAMICTAL XR (GREEN) LAMICTAL XR (ORANGE) LAMOTRIGINE LEVETIRACETAM LEVETIRACETAM IN NACL (ISO‐OS) LYRICA MYSOLINE NEURONTIN ONFI OXCARBAZEPINE OXTELLAR XR PEGANONE PHENYTEK PHENYTOIN PHENYTOIN SODIUM PHENYTOIN SODIUM EXTENDED POTIGA PRIMIDONE QUDEXY XR RUFINAMIDE SABRIL TEGRETOL TEGRETOL XR TIAGABINE HCL TOPAMAX TOPIRAMATE TRILEPTAL TROKENDI XR VALPROIC ACID (AS SODIUM SALT) VIGABATRIN VIMPAT ZARONTIN ZONEGRAN ZONISAMIDE SKELETAL MUSCLE DISORDER JOINT CONTRACTURE THERAPY, COLLAGENASE ENZYME XIAFLEX SKELETAL MUSCLE RELAXANTS DRUG TIER 2 2 2 2 2 2 2 1 1 1 2 2 2 2 1 2 2 2 1 1 1 2 1 2 3 3 2 2 1 2 1 2 2 1 3 2 2 2 1 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 101 DRUG CATEGORY & NAME AMRIX BACLOFEN CARISOPRODOL CARISOPRODOL/ASPIRIN CHLORZOXAZONE CYCLOBENZAPRINE HCL DANTRIUM DANTROLENE SODIUM FEXMID GABLOFEN LIORESAL INTRATHECAL LORZONE METAXALONE METHOCARBAMOL ORPHENADRINE CITRATE PARAFON FORTE DSC ROBAXIN ROBAXIN‐750 RYANODEX SKELAXIN SOMA TIZANIDINE HCL ZANAFLEX MISCELLANEOUS COMFORT PAC‐CYCLOBENZAPRINE COMFORT PAC‐TIZANIDINE SMOKING CESSATION SMOKING DETERRENT AGENTS (GANGLIONIC STIM,OTHERS) NICODERM CQ NICOTINE 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 DRUG TIER 2 1 1 1 1 1 2 1 2 2 2 2 1 1 1 2 2 2 2 2 2 1 2 2 2 2+ 1+ 1+ 2+ 2+ 2+ 1+ 2+ 2 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 102 DRUG CATEGORY & NAME LIPASE/PROTEASE/AMYLASE PANCREAZE PERTZYE ULTRESA VIOKACE ZENPEP UPPER GASTROINTESTINAL DISORDERS ‐ SPASTIC DISEASE ANTICHOLINERGICS/ANTISPASMODICS BENTYL DICYCLOMINE HCL BELLADONNA ALKALOIDS ANASPAZ ATROPINE SULFATE IN 0.9% NACL DONNATAL HYOSCYAMINE SULFATE LEVBID LEVSIN LEVSIN‐SL METHSCOPOLAMINE BROMIDE NULEV PHENOBARB/HYOSCY/ATROPINE/SCOP SCOPOLAMINE HYDROBROMIDE SYMAX SYMAX DUOTAB SYMAX‐SL SYMAX‐SR 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 DRUG TIER 1 2 2 2 2 2 2 1 2 1 2 1 2 2 2 1 2 1 1 2 2 2 2 2 1 2 1 2 1 2 2 2 2 1 1 1 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 103 DRUG CATEGORY & NAME OMECLAMOX‐PAK PREVPAC PYLERA HISTAMINE H2‐RECEPTOR INHIBITORS CIMETIDINE FAMOTIDINE NIZATIDINE PEPCID RANITIDINE HCL ZANTAC INTESTINAL MOTILITY STIMULANTS METOCLOPRAMIDE HCL METOZOLV ODT REGLAN PROTON‐PUMP INHIBITORS ACIPHEX ACIPHEX SPRINKLE DEXILANT ESOMEPRAZOLE MAGNESIUM ESOMEPRAZOLE SODIUM LANSOPRAZOLE NEXIUM NEXIUM I.V. OMEPRAZOLE OMEPRAZOLE/SODIUM BICARBONATE PANTOPRAZOLE SODIUM PREVACID PRILOSEC PROTONIX PROTONIX IV 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 DRUG TIER 2 2 2 1 1 1 2 1 2 1 2 2 2 2 2 1 1 1 2 2 1 1 1 2 2 2 2 1 2 1 2 1 2 2 2 1 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 104 DRUG CATEGORY & NAME JALYN KIDNEY STONE AGENTS CYSTAGON CYSTEAMINE BITARTRATE PROCYSBI THIOLA OVERACTIVE BLADDER AGENTS, BETA‐3 ADRENERGIC RECEP MYRBETRIQ URINARY PH MODIFIERS CITRIC ACID/SODIUM CITRATE K‐PHOS NEUTRAL K‐PHOS NO.2 K‐PHOS ORIGINAL ORACIT PHOSPHORUS #1 POTASSIUM CITRATE POTASSIUM CITRATE/CITRIC ACID RENACIDIN SHOHL'S MODIFIED SOD/POT/K CIT/SOD CIT/CIT ACID UROCIT‐K UROQID‐ACID NO.2 URINARY TRACT ANALGESIC AGENTS ELMIRON RIMSO‐50 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 DRUG TIER 2 2 3 3 2 2 1 2 2 2 2 1 1 1 2 2 1 2 2 2 2 1 2 2 2 2 2 2 1 2 1 2 1 2 1 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 105 DRUG CATEGORY & NAME VAGINAL ANTIBIOTICS CLEOCIN CLINDESSE METROGEL‐VAGINAL NUVESSA VANDAZOLE VAGINAL ANTIFUNGALS GYNAZOLE 1 MICONAZOLE NITRATE TERAZOL 3 TERAZOL 7 TERCONAZOLE VAGINAL ANTISEPTICS FEM PH RELAGARD VAGINAL ESTROGEN PREPARATIONS ESTRING FEMRING PREMARIN VAGIFEM VAGINAL SULFONAMIDES AVC VITAMIN AND/OR MINERAL DEFICIENCY ANTIOXIDANT MULTIVITAMIN COMBINATIONS MACUVEX MACUZIN OCUVEL BIOFLAVONOIDS VASCULERA CALCIUM REPLACEMENT CAL CARB/MGOX/D3/B12/FA/B6/BOR CALCIUM CHLORIDE CALCIUM GLUCONATE IN 0.9% NACL CALCIUM GLUCONATE/D5W FOLGARD OS FLUORIDE PREPARATIONS CLINPRO 5000 FLORIVA FLUORABON FLUOR‐A‐DAY FLUORITAB FLURA‐DROPS LUDENT FLUORIDE DRUG TIER 2 2 2 2 2 2 1 2 2 1 2 2 2 2 2 2 2 2 2 2 2 1 2 1 1 2 2 2 2 2 2 2 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 106 DRUG CATEGORY & NAME PREVIDENT PREVIDENT 5000 PREVIDENT 5000 ENAMEL PROTECT PREVIDENT 5000 PLUS PREVIDENT 5000 SENSITIVE SODIUM FLUORIDE SODIUM FLUORIDE/POTASSIUM NIT FOLIC ACID PREPARATIONS DEPLIN‐ALGAL OIL ENLYTE LEVOMEFOLATE CALCIUM LEVOMEFOLATE/ALGAL OIL PURALOR CI GERIATRIC VITAMIN PREPARATIONS REQ49+ IRON REPLACEMENT ACTIVE FE BIFERA RX CENTRATEX CORVITE 150 CORVITE FE FE FUMARATE/CAL/E/FA/MULTIVIT FE FUMARATE/DOSS/FA/BCOMP&C FE FUMARATE/VIT C/B12/STOMC FE FUMARATE/VIT C/B12‐IF/FA FERAHEME FERIVA FERIVA 21‐7 FERIVA FA FERRALET 90 FERRLECIT FERROUS FUMARATE/FOLIC ACID FUSION PLUS HEMATRON HEMATRON‐AF HEMAX HEMOCYTE PLUS HEMOCYTE‐F INFED INJECTAFER INTEGRA F INTEGRA PLUS IRON AG&FUM/C/FA/MV CMB11/CA‐T DRUG TIER 2 2 2 2 2 1 1 2 2 1 1 2 2 2 2 2 2 2 1 1 1 1 2 2 2 2 2 2 1 2 2 2 2 2 2 2 2 2 2 1 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 107 DRUG CATEGORY & NAME IRON AG/C/B12/CA/SUC.ACID/STOM IRON ASPGLY&PS/C/B12/FA/CA/SUC IRON ASPGLY/C/B12/FA/CA‐TH/SUC IRON BG&PS/VIT C/B12/FA/CA THR IRON FUM & AG/C/B12/FA/CA/SUCC IRON FUM & P/FA/VIT B & C NO.9 IRON FUM & PS CMP/FA/VIT C/B3 IRON FUM&POLYSAC#1/FA/MV NO.18 IRON FUMARATE/VIT C/VIT B12/FA IRON POLYSAC/IRON HEME/FA/B12 IRON PS CMPLX/VIT B12/FA IRON, CARB & GLUC/FA/B12/C/DSS IRON, CARBONYL/FA/C/B‐6/B12/ZN IRON,CARB/DSS/B12IF/FA/MV‐MN IRON/FA/B12/C/DOCUSATE SODIUM IRON/FA/VITAMIN B COMP W‐C/MIN IROSPAN MAXARON FORTE MAXFE PROFERRIN‐FORTE PUREVIT DUALFE PLUS SODIUM FERRIC GLUCONAT/SUCROSE TANDEM PLUS VENOFER MAGNESIUM SALTS REPLACEMENT MAGNESIUM CHLORIDE MAGNESIUM SULF/RINGERS LACTATE MAGNESIUM SULFATE MAGNESIUM SULFATE IN 0.9% NACL MAGNESIUM SULFATE/D5W MINERAL REPLACEMENT,MISCELLANEOUS CHROMIC CHLORIDE CUPRIC CHLORIDE MANGANESE CHLORIDE TRACE ELEMENTS COMB NO.1 ZINC SULF/CUSO4 P‐HYD/MN/CR/SE ZN/CU/MANG/SELEN/FLUOR/POT IOD ZNSO4/CUSO4/MANG SU/CHROMIC CL MULTIVITAMIN PREPARATIONS ANIMI‐3 CORVITA CORVITE CORVITE FREE DRUG TIER 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 1 2 2 2 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 108 DRUG CATEGORY & NAME ELDERCAPS FE FUMARATE/FA/VIT BCOMP&C FORTAVIT INFUVITE ADULT M.V.I. ADULT M.V.I.‐12 MULTICHEW MULTIVIT, IRON, MIN #5, FA MULTIVIT, MIN CMB#20/IRON/FA MULTIVITAMINS WITH MIN NO.7/FA MULTIVITS,THERAP W‐FE,HEMATIN NICOMIDE NUTRICAP OM‐3/CA CARB/D3/FA/MV CMB 13 OM‐3/DHA/EPA/B12/FA/B6/PHYTOST OM‐3/DHA/EPA/D3/B12/FA/B‐6/PHY PROTECT IRON STROVITE ONE SUPERVITE EC UDAMIN SP PEDIATRIC VITAMIN PREPARATIONS COMPLETE FORMULATION D3000 COMPLETE FORMULATION PEDIATRIC ESCAVITE ESCAVITE D ESCAVITE LQ FLUORIDE/IRON/VIT A,C&D INFUVITE M.V.I. PEDIATRIC MYKIDZ IRON FL PED MV A,C,D3 #21 W‐FLUORIDE PEDI M.VIT NO.17 WITH FLUORIDE PEDI MULTIVIT #65/VIT D3/VIT K PEDI MULTIVIT NO.2 W‐FLUORIDE PEDI MV #45/FLUORIDE/IRON PEDI MV #75/FLUORIDE/IRON PEDI MV NO.83 WITH FLUORIDE PEDI MVI NO.12/SODIUM FLUORIDE PEDI MVI NO.82 WITH FLUORIDE POLY‐VI‐FLOR POLY‐VI‐FLOR FS POLY‐VI‐FLOR WITH IRON TEXAVITE LQ DRUG TIER 2 1 2 2 2 2 2 1 1 1 1 2 2 1 1 1 2 2 2 2 2 2 2 2 2 1 2 2 2 1 1 1 1 1 1 1 1 1 2 2 2 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 109 DRUG CATEGORY & NAME TRI‐VI‐FLOR PRENATAL VITAMIN PREPARATIONS ACTIVE OB ATABEX EC CADEAU DHA CITRANATAL 90 DHA CITRANATAL ASSURE CITRANATAL B‐CALM CITRANATAL DHA CITRANATAL HARMONY CITRANATAL RX COMPLETE NATAL DHA CONCEPT DHA CONCEPT OB DUET DHA 400 DUET DHA BALANCED ELITE‐OB ENBRACE HR FOLET DHA FOLET ONE IRON,CARBONYL/VIT C/VIT B12/FA MAXINATE M‐VIT NATACHEW NATALVIT NATELLE ONE NEEVODHA NESTABS NESTABS ABC NESTABS DHA NEXA PLUS OB COMPLETE OB COMPLETE ONE OB COMPLETE PETITE OB COMPLETE PREMIER OB COMPLETE WITH DHA OBSTETRIX EC OBTREX DHA PN VIT.W‐O CA #7, IRON,FA,DHA PNV #14/FERROUS FUM/FOLIC ACID PNV #19/IRON PS&HEME/FOLIC/DHA PNV #8/IRON PS CMP&ASPG/FA/DHA PNV #87/IRON BISGLY/FA/DHA DRUG TIER 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 2 2 2 2 2 2 2 1 1 1 1 1 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 110 DRUG CATEGORY & NAME PNV 11‐IRON FUM‐FOLIC ACID‐OM3 PNV COMB.NO.44/IRON/FOLIC ACID PNV COMBO #22/IRON/FA/OM3/DHA PNV COMBO#47/IRON/FA #1/DHA PNV NO.15/IRON FUM & PS CMP/FA PNV NO.22/IRON CBN&GLUC/FA/DSS PNV NO.66/IRON,CARBONYL/FA/DHA PNV NO10/IRON FUM&P/FA/OMEGA‐3 PNV NO12/IRON,CARB/FA/DSS/OM‐3 PNV OB+DHA PNV W‐CA #40/IRON FUM/FA CMB#1 PNV W‐CA NO.37/IRON/FA/OMEGA‐3 PNV W‐CA8/IRON/FA/LMEFOLATE CA PNV WITH CA #68/IRON/FA#1/DHA PNV WITH CA NO.65/IRON POLY/FA PNV WITH CA,NO.62/IRON/FA/DHA PNV WITH CA,NO.70/IRON/FA/DHA PNV WITH CA,NO.72/IRON/FA PNV WITH CA,NO.74/IRON/FA PNV WITH CA,NO63/IRON/FA/B6 PNV W‐O CA NO5/FE FUMARATE/FA PNV#16/IRON FUM & PS/FA/OM‐3 PNV#21/IRON PS& HEME POLYP/FA PNV#64/IRON/LMFOLATE/ALGAL/SOY PNV#71/IRON/FOLIC ACID/DHA PNV#79/IRON/FA/LMFOLATE CA/DHA PNV,CA,NO.35/IRON/FA/DS/OMEG‐3 PNV,CA42/IRON/FA/LMEFOL CA/DHA PNV/FERROUS FUMARATE/DOSS/FA PNV/FERROUS FUMARATE/FA/SE PNV100/IRON EDTA&PS/FA/OMEGA3 PNV115/IRON FUMARATE/FA/DSS PNV119/IRON FUMARATE/FA/DSS PNV17/IRON/FA/FISH OIL/DHA/OM PNV19/IRON BG HC&SUCC‐P/FA/OM3 PNV34/IRON,CARBONYL/FA/DSS/DHA PNV39/IRON FUMARATE/FA/DSS/DHA PNV53/IRON B‐G HCL‐P/FA/OMEGA3 PNV54/IRON B‐G HCL‐P/FA/OMEGA3 PNV55/IRON BG HC&SUCC‐P/FA/OM3 PNV59/IRON,CARBONYL/FA/DSS/DHA PNV66/IRON FUMARATE/FA/DSS/DHA PNV69/IRON,CARBONYL/FA/DSS/DHA DRUG TIER 1 1 1 1 1 1 1 1 1 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 111 DRUG CATEGORY & NAME PNV7/FE ASP GLY/DOCUSATE/FA PNV72/IRON,CARB&GLU/FA/DSS/DHA PNV73/IRON,CARB&GLU/FA/DSS/DHA PNV77/SOD IRON EDTA& PS/FA/OM3 PNV80/IRON FUMARATE/FA/DSS/DHA PNV81/SOD IRON EDTA& PS/FA/OM3 PREFERA OB PREFERA‐OB ONE PREFERA‐OB PLUS DHA PRENAT VIT COMB.10/IRON/FA/DHA PRENATA PRENATAL #57/IRON/FA/DSS/DHA PRENATAL COMB NO.42/FOLIC ACID PRENATAL NO.52/IRON/FA/DHA PRENATAL NO.75/IRON/FOLATE #1 PRENATAL NO.82/IRON/FOLATE #2 PRENATAL VIT #76/IRON,CARB/FA PRENATAL VIT 15/IRON CB/FA/DSS PRENATAL VIT 16/IRON CB/FA/DSS PRENATAL VIT 18/IRON CB/FA/DSS PRENATAL VIT NO.109/IRON/FA PRENATAL VIT NO.73/IRON/FA PRENATAL VIT NO.78/IRON/FA PRENATAL VIT#4/IRON FUM &PS/FA PRENATAL VIT#86/IRON BISGLY/FA PRENATAL VIT/IRON BISGLYCIN/FA PRENATAL VIT/IRON FUMARATE/FA PRENATAL VIT27&CALCIUM/IRON/FA PRENATAL VITS#4/IRON FUM/FA PRENATE AM PRENATE CHEWABLE PRENATE DHA PRENATE ELITE PRENATE ENHANCE PRENATE ESSENTIAL PRENATE MINI PRENATE PIXIE PRENATE RESTORE PRENATE STAR PREQUE 10 PROVIDA DHA PROVIDA OB PV W‐O CAL/IRON PS CPLX/FA DRUG TIER 1 1 1 1 1 1 2 2 2 1 2 1 1 1 1 1 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 1 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 112 DRUG CATEGORY & NAME SELECT‐OB + DHA TRICARE TRICARE PRENATAL DHA ONE TRINATAL RX 1 TRISTART DHA TRUST NATAL DHA VITAFOL ULTRA VITAFOL‐OB VITAFOL‐ONE VITAMEDMD ONE RX VITAMEDMD PLUS RX VITAMEDMD REDICHEW RX VITAPEARL PRENATAL VITAMINS WITHOUT IRON PNV W‐O IRON/FA/CALCIUM/B6/B12 PNV/FA/B6/CALCIUM CARB/GINGER PNV/FA/B6/CALCIUM PHOS/GINGER VITAMIN A PREPARATIONS AQUASOL A VITAMIN B PREPARATIONS ACETYL/METHYL‐B12/LMEFOLATE CA B CMPLX 4/VIT D3/C/FA/ZINC OX B COMPLEX & C NO.20/FOLIC ACID B12/LEVOMEFOLATE CALCIUM/B‐6 B‐COMPLEX CARDIOTEK‐RX CEREFOLIN CEREFOLIN NAC CYANOCOBALAMIN/FA/PYRIDOXINE DIALYVITE 5000 DIALYVITE SUPREME D FA/VIT BCOMP&C/SE/MIN AA/ZN FOLGARD RX FOLIC ACID/B COMPLEX & C NO.17 FOLIC ACID/VIT BCOMP&C/CU/ZNOX FOLIC ACID/VITAMIN B COMP W‐C FOLTX LEVOMEFOLATE/B6/B12/ALGAL OIL LMFOL CA/ACETYL/MB12/ALGAL OIL METANX METHYL‐B12/L‐MEFOLATE/B6 PHOS NEPHROCAPS QT NIVA‐FOL DRUG TIER 2 2 2 2 2 2 2 2 2 2 2 2 2 1 1 1 2 1 1 1 1 2 2 2 2 1 2 2 1 2 1 1 1 2 1 1 2 1 2 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 113 DRUG CATEGORY & NAME PODIAPN POTABA SUPERVITE VIT B CMPLX 3/FA/VIT C/BIOTIN VIT B CMPLX NO3/FA/C/BIOT/ZINC VIT B CPLX #11/FA/C/BIOT/ZN OX VIT B12/LMEFOLATE CA/VIT B6/B2 VITA‐RESPA VITAMIN B12 PREPARATIONS CYANOCOBALAMIN (VITAMIN B‐12) CYANOCOBALAMIN/MECOBALAMIN ELIGEN B12 FOLTRATE HYDROXOCOBALAMIN NASCOBAL PHYSICIANS EZ USE B‐12 VITAMIN D PREPARATIONS CALCITRIOL CIFEREX DURACHOL ERGOCALCIFEROL (VITAMIN D2) ORTHO D REVESTA ROCALTROL ZINC REPLACEMENT ZINC CHLORIDE WEIGHT REDUCTION ANOREXIC AGENTS ADIPEX‐P BENZPHETAMINE HCL BONTRIL PDM DIETHYLPROPION HCL PHENDIMETRAZINE TARTRATE PHENTERMINE HCL QSYMIA REGIMEX SUPRENZA ODT ANTI‐OBESITY ‐ OPIOID ANTAG/NOREPI & DA REUP INHIB CONTRAVE ANTI‐OBESITY GLUCAGON‐LIKE PEPTIDE‐1 RECEP AGONIST SAXENDA FAT ABSORPTION DECREASING AGENTS XENICAL DRUG TIER 2 2 2 1 1 1 1 2 1 1 2 2 2 2 2 1 2 2 1 2 2 2 1 2 1 2 1 1 1 2 2 2 2 2 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 114 DRUG CATEGORY & NAME SEROTONIN 2C RECEPTOR AGONISTS BELVIQ DRUG TIER 2 PPO & OOA Formulary with Specialty ‐ Last revised 10/16/2015, 115
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