Download Criteria, Step Therapy and Quantity Coverage Rules Effective

Portfolio High Formulary
October 2014
Pharmacy and Therapeutics Committee. MedImpact approves such multisource drugs for addition to the MAC list based on the following criteria:
• A multi-source drug product manufactured by at least one (1) nationally
marketed company.
• At least one (1) of the generic manufacturer’s products must have an “A”
rating or the generic product has been determined to be unassociated with
efficacy, safety or bioequivalency concerns by the MedImpact P & T
Committee.
• Drug product will be approved for generic substitution by the MedImpact
P & T Committee.
Foreword
This document represents the efforts of the MedImpact Healthcare Systems
Pharmacy and Therapeutics (P & T) and Formulary Committees to provide physicians
and pharmacists with a method to evaluate the safety, efficacy and cost-effectiveness
of commercially available drug products. A structured approach to the drug selection
process is essential in ensuring continuing patient access to rational drug therapies.
The ultimate goal of the Portfolio Formulary is to provide a process and framework to
support the dynamic evolution of this document to guide prescribing decisions that
reflect the most current clinical consensus associated with drug therapy decisions.
This is accomplished through the auspices of the MedImpact P & T and Formulary
Committees. These committees meet quarterly and more often as warranted to ensure
clinical relevancy of the Formulary. To accommodate changes to this document,
updates are made accessible as necessary.
This list is reviewed and updated periodically based on the clinical literature and
pharmacokinetic characteristics of currently available versions of these drug
products.
As you use this Formulary, you are encouraged to review the information and provide
your input and comments to the MedImpact P & T and Formulary Committees.
If a member or physician requests a brand name product in lieu of an approved
generic, the member, based upon their coverage, will typically be required to pay
the difference in cost between the brand and the generic. If a physician
determines that there is a documented medical need for the brand equivalent, a
request for coverage may be made using the medication request process.
The MedImpact P & T and Formulary Committees use the following criteria in the
evaluation of drug selection for the PortfolioFormulary:
• Drug safety profile
• Drug efficacy
• Comparison of relevant therapeutic benefits to current formulary agents of
similar use, and to minimize therapeutic duplication where possible
• Cost-effectiveness relative to comparable therapies
2. Three TierBenefit
The Formulary may be applied to a three tier benefit design, where the
member shares the cost of prescription drug therapy at three levels of
copayment. In most instances, generically available drugs will be covered
under the first or lowest copay tier, branded drugs listed on the Formulary
will be covered under the second copay tier, and branded drugs not on the
Formulary will be covered under the third or highest copay tier.
How to Use the Formulary
The Formulary is a list of medications available to MedImpact members under
their pharmacy benefit. All drugs are listed by their generic names and most
common proprietary (branded) name. The Formulary may be accessed by using
the index, either by generic or proprietary name (in capital letters) and by
therapeutic drug category. In situations where an FDA approved generic
equivalent is available, brand names are listed for reference purposes only, and
do not denote coverage for the brand, unless specifically noted. Any drug not
found in this Formulary listing, or any Formulary updates published by
MedImpact shall be considered a Non-Formulary drug.
3. Medication RequestProcess
Depending upon plan benefit design, a medication request process may apply
as follows:
A. Formulary Agents
Drugs that are listed in the Formulary with associated Prior Authorization
(PA) require evaluation, per MedImpact P & T Committee Prior
Authorization guidelines prior to dispensing at a network pharmacy. Each
request will be reviewed on an individual patient need basis. If the request
does not meet the guidelines established by the P & T Committee, the
request will not be approved and alternative therapy may be
recommended.
All drugs are listed in each category in alphabetical order by generic name. Where an
FDA approved generic is available for the listed generic name, the generic name is
bolded.
B. Non-Formulary Agents
For members with 2-tier closed Formulary benefits: Any drug not found in
the Formulary listing, or any Formulary updates published by MedImpact,
shall be considered a Non-Formulary drug. Coverage for non-formulary
agents may be applied for in advance. When a member gives a
prescription order for a non-formulary drug to a pharmacist, the pharmacist
will evaluate the patient’s drug history and contact the physician to
determine if there is a reasonable medical need for a non-formulary drug.
Each request will be reviewed on an individual patient need basis.
Approval will be given if a documented medical need exists. The following
basic guidelines are used:
• The use of Formulary Drugs is contraindicated in the patient.
• The patient has failed an appropriate trial of Formulary or related
agents.
• The choices available in the Formulary are not suited for the present
patient care need, and the drug selected is required for patient
safety.
• The use of a Formulary drug may provoke an underlying condition,
which would be detrimental to patient care.
For certain agents within the Formulary, a recommended prescribing guideline may
apply. These are denoted throughout the document using the following symbols:
AGE
CU
G
MD
PA
QL
ST
Age Edit
Concurrent
Use Edit
Gender Edit
Physician
Specialty
Edit
Prior
Authorizatio
n
Quantity
Limit
Step
Therapy
Coverage may depend on patient age
Coverage or lack thereof may depend upon
concurrent use of another drug
Coverage may depend on patient gender
Coverage may depend on prescribing physician’s
specialty or board certification
Requires specific physician request process
Coverage may be limited to specific quantities
per prescription and/or time period
Coverage may depend on previous use of another
drug
Please refer to the prescribing guideline appendix within this document for details
regarding specific agents.
If the request does not meet the guidelines established by the P & T
Committee, the request will not be approved and alternative therapy may
be recommended.
Benefit Coverage and Limitations
This printed Formulary does not provide information regarding the specific coverage
and limitations an individual member may be subject to. Many members have specific
benefit inclusions, exclusions, copays, or a lack of coverage, which are not reflected in
the Formulary.
C. Obtaining Coverage
Coverage, questions or information regarding the medication request
or formulary process may be obtained by:
1. Faxing a completed Medication Request Form to MedImpact at
(858) 790-7100.
2. Contacting MedImpact at (800) 788-2949 and providing all
necessary information requested.
The Formulary applies only to outpatient drugs provided to members, and does not
apply to medications used in inpatient settings. If a member has any specific
questions regarding their coverage, they should contact their Plan Sponsor or
MedImpact at (800) 788-2949.
MedImpact will provide an authorization number, specific for the medical
need, for all approved requests.
Non-approved requests may be
appealed. The prescriber must provide information to support the appeal
on the basis of medical necessity. Prior Authorization is generally not
available for drugs that are specifically excluded by benefit design.
Depending upon a member’s specific benefit parameters, the following topics
may apply:
1. Generic Substitution
When available, FDA approved generic drugs are to be used in all situations,
regardless of the brand name indicated. The generic names are bolded in the
formulary listing wherever an FDA approved generic drug product is available.
Greater economy is realized through the use of generic equivalents. This policy
is not meant to preclude or supplant any state statutes that may exist. All drugs
that are or become available generically are subject to review by MedImpact’s
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4. General Exclusions
A. Over the Counter (OTC) medications or their equivalents, unless otherwise
specified in the Formulary listing.
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B. Nicotine Smoking Cessation products (i.e., transdermal nicotine, nicotine
gum, nicotine inhaler).
C. Drugs specifically listed as not covered.
D. Any drug products used for cosmetic purposes.
E. Experimental drug products or any drug product used in an experimental
manner.
F. Replacement of lost or stolen medication.
G. Non self-administered injectable drug products unless otherwise specified
in the Formulary listing.
H. Foreign sourced drugs or drugs not approved by the United States Food &
Drug Administration.
The P & T and Formulary Committees recognize that not all medical needs can
be met with this document and encourage inquiries about alternative therapies.
Medication Request Information (please complete each section of this form prior
to transmittal)
Patient Name (required):
Patient’s Health Plan (required):
Patient ID # (required):
Physician Name/Specialty:
Physician ID#/DEA#:
Patient DOB (required):
Diagnosis (required):
5. Pharmacist and Physician Communication
The Formulary is a tool to promote cost-effective prescription drug use. The P &
T and Formulary Committees have made every attempt to create a document
that meets all therapeutic needs; however, the art of medicine makes this a
formidable task.
MedImpact welcomes the participation of physicians,
pharmacists, and ancillary medical providers, in this dynamic process.
Physicians and pharmacists are highly encouraged to direct any suggestions,
comments or formulary additions to MedImpact at the following address:
Chairperson, Pharmacy & Therapeutics Committee
MedImpact Healthcare Systems, Inc.
10680 Treena Street, Suite 500
San Diego, CA 92131
Physician:
Pharmacy:
Patient:
Attn: Prior Authorization
Department
10680 Treena Street, Ste
500
San Diego, CA 92131
Phone: 1-800-788-2949
Fax: 858-790-7100
Dose:
Length of Treatment (please be
specific):
Dosage Form (e.g., Oral, Injection):
Reason for Medication Request (please be specific, give detail):
Other Medications Tried and/or Failed (please be specific, give detail including
reason for failure):
Other Pertinent History (relative or pertaining to this request):
DO NOT WRITE IN
BLOCKED AREAS
FOR INTERNAL USE
ONLY
Approved:
Denied:
Returned:
PA #:
Instructions:
This form is to be used by participating physicians and providers to obtain coverage
for a non-formulary drug for which there is no suitable alternative available. Please
complete this form and fax to MedImpact Healthcare Systems, Inc. at (858) 790-7100
or please call (800) 788-2949 with this information. If you have any questions
regarding this process, please contact MedImpact’s Customer Service at (800) 7882949.
Review Criteria:
The following guidelines are used in reviewing medication requests:
1.
The use of Formulary Drug Products is contraindicated in the patient.
2.
The patient has failed an appropriate trial of Formulary or related agents.
3.
The choices available in the Formulary are not suited for the present patient care
need and the drug selected is required for patient safety.
4.
The use of a Formulary Drug Product may provoke an underlying medical
condition, which would be detrimental to patient care.
PortfolioHigh Formulary – October 2014
Drug Requested:
Strength:
Medication Request Form (MRF)
MedImpact Healthcare Systems, Inc.
DO NOT WRITE IN
BLOCKED AREAS
FOR INTERNAL USE
ONLY
Contacted:
Pharmacy used by Member:
Physician Area Code and Telephone
Number:
(
)
Physician Area Code and Fax Number
(required):
(
)
Pharmacy Area Code and Telephone
Number:
(
)
Quantity (per month):
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Foreword ............................................................................................................. i
1.
Generic Substitution ......................................................................... i
2.
Three TierBenefit .............................................................................. i
3.
Medication RequestProcess ............................................................ i
4.
General Exclusions .......................................................................... i
5.
Pharmacist and Physician Communication .....................................ii
ALLERGY ................................................................................................................. 1
2nd Geneneration Antihistamine & Decongestant Combinations ..................... 1
Antihistamines - 1st Generation ......................................................................... 1
Antihistamines - 2nd Generation ....................................................................... 1
Nasal Anti-Inflammatory Steroids ...................................................................... 1
Nasal Antihistamine ........................................................................................... 1
ANTIEMESIS/ANTIVERTIGO .................................................................................. 1
Antiemetic/Antivertigo Agents ............................................................................ 1
ASTHMA ................................................................................................................... 1
Beta-Adrenergic Agents ..................................................................................... 1
Beta-Adrenergic & Anticholinergic Combinations .............................................. 1
Beta-Adrenergic & Glucocorticoid Combinations .............................................. 1
General Bronchodilator Agents .......................................................................... 1
Leukotriene Receptor Antagonists ..................................................................... 1
Mast Cell Stabilizers........................................................................................... 1
Oral Inhaled Corticosteroids .............................................................................. 1
Phosphodiesterase-4 (PDE4) Inhibitors ............................................................ 1
Xanthines ........................................................................................................... 1
AUTONOMIC NERVOUS SYSTEM DISORDERS .................................................. 1
Alzheimer's Therapy, Nmda Receptor Antagonists ........................................... 1
Cholinesterase Inhibitors ................................................................................... 1
BEHAVIORAL HEALTH - ANTIDEPRESSANTS .................................................... 1
Alpha-2 Receptor Antagonist Antidepressants .................................................. 1
Maois - Non-Selective & Irreversible ................................................................. 1
Norepinephrine & Dopamine Reuptake Inhibitors (NDRIs) ............................... 1
Selective Serotonin Reuptake Inhibitors (SSRIs) .............................................. 1
SSRI & Antipsycho, Atyp, Dopamine & Serotonin Antag Comb ....................... 1
Serotonin-2 Antagonist/Reuptake Inhibitors (SARIs) ........................................ 1
Serotonin-Norepinephrine Reuptake-Inhib (SNRIs) .......................................... 1
Tricyclic Antidepressants & Rel. Non-Sel. Ru-Inhib .......................................... 1
BEHAVIORAL HEALTH - OTHER ........................................................................... 1
Adrenergics, Aromatic, Non-Catecholamine ..................................................... 1
Anti-Alcoholic Preparations ................................................................................ 2
Anti-Anxiety Drugs ............................................................................................. 2
Anti-Mania Drugs ............................................................................................... 2
Antipsychotics, Phenothiazines ......................................................................... 2
Antipsychotics, Atypical, D2 Partial Agonist/5HT Mixed.................................... 2
Antipsychotics, Dopamine & Serotonin Antagonists ......................................... 2
Antipsychotics, Atypical, Dopamine, & Serotonin Antagonists .......................... 2
Antipsychotics, Dopamine Antagonists, Thioxanthenes .................................... 2
Antipsychotics, Dopamine Antagonists, Butyrophenones ................................. 2
Barbiturates ........................................................................................................ 2
Narcotic Antagonists .......................................................................................... 2
Sedative-Hypnotics, Non-Barbiturate ................................................................ 2
Treatment for Attention Deficit-Hyperactivity (ADHD)/Narcolepsy .................... 2
Treatment for Attention Deficit-Hyperactivity (ADHD), Nri-Type ....................... 2
CARDIOVASCULAR DISEASE - ARRHYTHMIA .................................................... 2
Antiarrhythmics .................................................................................................. 2
CARDIOVASCULAR DISEASE - CARDIAC STIMULANTS ................................... 2
Digitalis Glycosides ............................................................................................ 2
CARDIOVASCULAR DISEASE - HYPERTENSION ............................................... 2
ACE Inhibitor/Calcium Channel Blocker Combinations ..................................... 2
ACE Inhibitor/Thiazide & Thiazide-Like Diuretics .............................................. 2
Alpha-Adrenergic Blocking Agents .................................................................... 2
Alpha/Beta-Adrenergic Blocking Agents ............................................................ 2
Angiotensin Receptor Antagonist/Calcium Channel Blocker/Thiazide
Combinations ..................................................................................................... 2
Angiotensin Receptor Antagonist/Thiazide Diuretic Combinations ................... 2
Angiotensin Receptor Antagonist & Calcium Channel Blockers ....................... 2
Antihypertensives, ACE Inhibitors ..................................................................... 2
Antihypertensives, Angiotensin Receptor Antagonist........................................ 3
Antihypertensives, Sympatholytic ...................................................................... 3
Antihypertensives, Vasodilators ......................................................................... 3
Beta-Adrenergic Blocking Agents ...................................................................... 3
Beta-Adrenergic Blocking Agents/Thiazide & Related ...................................... 3
Calcium Channel Blocking Agents ..................................................................... 3
Loop Diuretics .................................................................................................... 3
Potassium Sparing Diuretics .............................................................................. 3
Potassium Sparing Diuretics in Combination .................................................... 3
Pulmonary Anti-HTN, Sel. C-GMP Phosphodiesterase T5 Inhibitors ............... 3
Pulmonary Anti-HTN, Endothelin Receptor Antagonists ................................... 3
Pulmonary Anti-HTN, Soluble Guanylate Cyclase Stimulators ......................... 3
Thiazide & Related Diuretics.............................................................................. 3
CARDIOVASCULAR DISEASE - LIPID IRREGULARITY ....................................... 3
Antihyperlipidemic - HMG CoA Reductase Inhibitors ........................................ 3
Antihyperlipidemic-HMG CoA Reductase Inhibitors & Niacin ........................... 3
Antihyperlipidemic - APO B-100 Synthesis Inhibitor ......................................... 3
Antihyperlipidemic-MTP Inhibitors ..................................................................... 3
Bile Salt Sequestrants ........................................................................................ 3
Lipotropics .......................................................................................................... 3
Niacin Preparations ............................................................................................ 3
PortfolioHigh Formulary – October 2014
CARDIOVASCULAR DISEASE - MISCELLANEOUS AGENTS ............................. 3
Adrenergic Vasopressor Agents ........................................................................ 3
Antianginal & Anti-Ischemic Agents, Non-Hemodynamic ................................. 3
Antihyperlipidemia - HMG-CoA & Calcium Channel Blocker Combinations ..... 3
CARDIOVASCULAR DISEASE - VASODILATION ................................................. 3
Vasodilators, Coronary ...................................................................................... 3
CONTRACEPTION/OXYTOCICS............................................................................ 4
Contraceptives, Intravaginal, Systemic ............................................................. 4
Contraceptives, Oral .......................................................................................... 4
Contraceptives, Transdermal ............................................................................. 4
Oxytocics ............................................................................................................ 4
COUGH AND COLD ................................................................................................ 4
1st Generation Antihistamine & Decongestant Combinations .......................... 4
Narcotic Antitussive-1st Geneneration Antihistamine-Decongestants .............. 4
Narcotic Antitussive-Decongestant-Expectorant Combinations ........................ 4
Narcotic Antitussive-1st Generation Antihistamines.......................................... 4
Narcotic Antitussive-Expectorant Combinations ............................................... 4
Non-Narcotic Antitussive-1st Generation Antihistamine Combinations ............ 4
Non-Narcotic Antitussive & Expectorant Combinations .................................... 4
DERMATOLOGY - ACNE ........................................................................................ 4
Acne Agents, Systemic ...................................................................................... 4
Acne Agents, Topical ......................................................................................... 4
Keratolytic-Glucocorticoid Combinations ........................................................... 4
Keratolytics......................................................................................................... 4
Rosacea Agents, Topical ................................................................................... 4
Topical Preparations, Antibacterials .................................................................. 4
Vitamin A Derivatives ......................................................................................... 4
DERMATOLOGY - ANTIINFECTIVE ....................................................................... 4
Topical Antibiotics .............................................................................................. 4
Topical Antifungals ............................................................................................. 4
Topical Antiparasitics ......................................................................................... 4
Topical Antivirals ................................................................................................ 5
Topical Sulfonamides......................................................................................... 5
DERMATOLOGY - ANTIINFLAMMATORY ............................................................. 5
Topical Anti-Inflammatory Steroidal ................................................................... 5
Topical Anti-Inflammatory, NSAIDs ................................................................... 5
Topical Antibiotics/Antiinflammatory, Steroidal ................................................. 5
DERMATOLOGY - MISCELLANEOUS ................................................................... 5
Antiperspirants ................................................................................................... 5
Antiseborrheic Agents ........................................................................................ 5
Topical Antineoplastic & Premalignant Lesion Agents ...................................... 5
Topical Local Anesthetics .................................................................................. 5
DERMATOLOGY - PIGMENTATION DISORDERS ................................................ 5
Topical Hyperpigmentation Agents .................................................................... 5
DERMATOLOGY - PSORIASIS/ECZEMA .............................................................. 5
Antipsoriatic Agents, Systemic .......................................................................... 5
Antipsoriatics Agents ......................................................................................... 5
Topical Immunosuppressive Agents .................................................................. 5
DIABETES ................................................................................................................ 5
Antihyperglycemic, Alpha-Glucosidase Inhibitors (Non-Sulfonylurea) .............. 5
Antihyperglycemic, Amylin Analog-Type ........................................................... 5
Antihyperglycemic, DPP-4 Inhibitors ................................................................. 5
Antihyperglycemic, DPP-4 Inhibitor & Biguanide Combinations ....................... 5
Antihyperglycemic, Incretin Mimetic (GLP-1 Receptor Agonists) ..................... 5
Antihyperglycemic, Insulin-Release Stimulant Type ......................................... 5
Antihyperglycemic, Insulin-Response Enhancer (Non-Sulfonylurea) ............... 5
Antihyperglycemic, Biguanide Type (Non-Sulfonylurea) ................................... 5
Antihyperglycemic, Insulin-Rel Stim.& Biguanide Combinations ...................... 5
Antihyperglycemic, Insulin-Response & Release Combinations ...................... 5
Antihyperglycemic Insul-Resp. Enhancer & Biguanide Combinations .............. 5
Antihyperglycemic-Glucocorticoid Receptor Blockers ....................................... 5
Antihyperglycemic-Sod/Gluc Cotransport2 (SGLT2) Inhibitors ......................... 6
Diabetic Supplies ............................................................................................... 6
Diabetic Ulcer Preparations, Topical ................................................................. 6
Hyperglycemics .................................................................................................. 6
Insulins ............................................................................................................... 6
Syringes & Accessories ..................................................................................... 6
EAR - GENERAL DISORDERS ............................................................................... 6
Ear Preparations, Misc. Anti-Infectives .............................................................. 6
Ear Preparations, Antibiotics ............................................................................. 6
Otic Preparations, Anti-Inflammatory-Antibiotics ............................................... 6
Otic Preparations, Local anesthetics ................................................................. 6
ELECTROLYTE REGULATION ............................................................................... 6
Electrolyte Depleters .......................................................................................... 6
Potassium Replacement .................................................................................... 6
ENDOCRINE DISORDER - FERTILITY .................................................................. 6
Drugs to Treat Impotency .................................................................................. 6
Fertility Stimulating Preparations, Non-FSH ...................................................... 6
Follicle Stimulating / Luteinizing Hormones ....................................................... 6
Pregnancy Facilitating/Maintaining Agents, Hormonal ...................................... 6
ENDOCRINE DISORDER - OTHER........................................................................ 6
Antineoplastic LHRH (GNRH) Agonists, Pituitary Suppressants ...................... 6
Antidiuretic & Vasopressor Hormones ............................................................... 6
Bone Formation Stim. Agents - Parathyroid Hormone ...................................... 6
Bone Resorption Inhibitor & Vitamin D Combinations ....................................... 6
Bone Resorption Inhibitors ................................................................................ 6
Growth Hormone Receptor Antagonists ............................................................ 6
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Growth Hormones .............................................................................................. 6
Hyperparathyroid Tx Agent, Vitamin D Analog-Type ........................................ 6
LHRH (GnRH) Antagonist, Pituitary Suppressant Agents ................................. 6
Luteinizing Hormone Releasing Hormone –LHRH (GnRH) .............................. 6
Pituitary Suppressive Agents ............................................................................. 6
ENDOCRINE DISORDER - THYROID .................................................................... 7
Antithyroid Preparations ..................................................................................... 7
Iodine Containing Agents ................................................................................... 7
Thyroid Hormones.............................................................................................. 7
EYE - GENERAL DISORDERS ............................................................................... 7
Eye Antibiotic-Corticoid Combinations............................................................... 7
Eye Antihistamines............................................................................................. 7
Eye Antiinflammatory Agents ............................................................................. 7
Eye Antivirals ..................................................................................................... 7
Eye Sulfonamides .............................................................................................. 7
EYE - MISCELLANEOUS ........................................................................................ 7
Ophthalmic Cystine Delpleting Agents .............................................................. 7
Ophthalmic Anti-Inflammatory Immunomodulator-Type .................................... 7
Ophthalmic Antibiotics ....................................................................................... 7
Ophthalmic Mast Cell Stabilizers ....................................................................... 7
EYE - GLAUCOMA .................................................................................................. 7
Carbonic Anhydrase Inhibitors ........................................................................... 7
Miotics/Other Intraoccula Pressure Reducers ................................................... 7
Mydriatics ........................................................................................................... 7
GOUT AND RELATED DISEASES ......................................................................... 7
Colchicine ........................................................................................................... 7
Hyperuricemia Treatment - Purine Inhibitors ..................................................... 7
Uricosuric Agents ............................................................................................... 7
HEMATOLOGICAL DISORDERS ............................................................................ 7
Anticoagulants, Coumarin Type ......................................................................... 7
Hematinics, Other .............................................................................................. 7
Hemorrheologic Agents ..................................................................................... 7
Heparin & Related Preparations ........................................................................ 7
Leukocyte (WBC) Stimulants ............................................................................. 8
Platelet Aggregation Inhibitors ........................................................................... 8
Platelet Reducing Agents ................................................................................... 8
Thrombopoietin Receptor Agonists ................................................................... 8
Vitamin K Preparations ...................................................................................... 8
HORMONAL DEFICIENCY...................................................................................... 8
Androgenic Agents ............................................................................................. 8
Estrogen/Androgen Combinations ..................................................................... 8
Estrogenic Agents .............................................................................................. 8
Progestational Agents ........................................................................................ 8
IMMUNOSUPPRESSION/MODULATION ............................................................... 8
Immunomodulators ............................................................................................ 8
Immunosuppressives ......................................................................................... 8
INFECTIOUS DISEASE - BACTERIAL ................................................................... 8
Absorbable Sulfonamides .................................................................................. 8
Betalactams ....................................................................................................... 8
Cephalosporins - 1st Generation ....................................................................... 8
Cephalosporins - 2nd Generation ...................................................................... 8
Cephalosporins - 3rd Generation ....................................................................... 8
Chemotherapeutics, Antibacterial, Miscellaneous ............................................. 8
Ketolides............................................................................................................. 8
Lincosamides ..................................................................................................... 8
Macrolides .......................................................................................................... 8
Nitrofuran Derivatives ........................................................................................ 8
Oxazolidinones ................................................................................................... 8
Penicillins ........................................................................................................... 8
Quinolones ......................................................................................................... 8
Tetracyclines ...................................................................................................... 9
INFECTIOUS DISEASE - FUNGAL ......................................................................... 9
Antifungal Agents ............................................................................................... 9
Antifungal Antibiotics .......................................................................................... 9
INFECTIOUS DISEASE - MISCELLANEOUS ......................................................... 9
Aminoglycosides ................................................................................................ 9
Anti-Mycobacterium Agents ............................................................................... 9
Antileprotics ........................................................................................................ 9
Antitubercular Antibiotics ................................................................................... 9
Rifamycins and Related Derivative Antibiotics .................................................. 9
Vancomycin & Derivatives ................................................................................. 9
INFECTIOUS DISEASE - PARASITIC .................................................................... 9
Amebacides ....................................................................................................... 9
Anaerobic Antiprotozoal-Antibacterial Agents ................................................... 9
Anthelmintics ...................................................................................................... 9
Antimalarial Drugs .............................................................................................. 9
Antiprotozoal Drugs, Miscellaneous .................................................................. 9
INFECTIOUS DISEASE - VIRAL ............................................................................. 9
Antivirals, HIV-Spec, Non-Peptidic Protease Inhib ............................................ 9
Antivirals, HIV-Spec, Nucleoside-Nucleotide Analog ........................................ 9
Antivirals, HIV-Spec., Nucleoside Analog, RTI Comb ....................................... 9
Antivirals, HIV-Specific, CCR5 Co-Receptor Antag. ......................................... 9
Antivirals, HIV-Specific, Fusion Inhibitors .......................................................... 9
Antivirals, HIV-Specific, Non-Nucleoside, RTI ................................................... 9
Antivirals, HIV-Specific, Nucleoside Analog, RTI .............................................. 9
Antivirals, HIV-Specific, Nucleotide Analog, RTI ............................................... 9
Antivirals, HIV-Specific, Protease Inhibitor Comb ............................................. 9
Antivirals, HIV-Specific, Protease Inhibitors ...................................................... 9
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Antivirals, HIV-1 Integrase Strand Transfer Inhibtors ........................................ 9
Antiviral Combination Nucleoside, Nucleotide & Non-Nucleoside RTI ............. 9
Hepatitis B Treatment Agents ............................................................................ 9
Hepatitis C Treatment Agents ............................................................................ 9
INFLAMMATORY DISEASE .................................................................................. 10
Anti-Arthritic & Chelating Agents ..................................................................... 10
Anti-Arthritic, Folate Antagonist Agents ........................................................... 10
Anti-Inflammatory Tumor Necrosis Factor Inhibitor ......................................... 10
Anti-Inflammatory, Pyrimidine Synthesis Inhibitors ......................................... 10
Bradykinin B2 Receptor Antagonists ............................................................... 10
Glucocorticoids ................................................................................................ 10
Mineralocorticoids ............................................................................................ 10
NSAIDs, COX Inhibitor-Type & Proton Pump Inhibitor Combinations ............ 10
NSAIDs, Cyclooxygenase Inhibitor-Type ........................................................ 10
LOCAL ANESTHESIA ............................................................................................ 10
Local Anesthetics ............................................................................................. 10
LOWER GASTROINTESTINAL DISORDERS - BOWEL INFLAMMAT ................ 10
Bowel Antiinflamatory Agents .......................................................................... 10
Chronic Inflam. Colon Dx, 5-A-Salicylat, Rectal Tx ......................................... 10
Drug Tx-Chronic Inflam. Colon Dx, 5-Aminosalicylat ...................................... 10
Hemorrhoidal Preparations .............................................................................. 10
Rectal Preparations ......................................................................................... 10
Rectal/Lower Bowel Prep., Glucocort. (Non-Hemorr) ..................................... 10
LOWER GASTROINTESTINAL DISORDERS - OTHER ...................................... 10
Ammonia Inhibitors .......................................................................................... 10
Antidiarrheals ................................................................................................... 10
Bile Salts .......................................................................................................... 10
Laxatives & Cathartics ..................................................................................... 10
Narcotic Antagonists, Peripherally-Acting ....................................................... 10
MISCELLANEOUS AGENTS ................................................................................. 10
Anaphylaxis Therapy Agents ........................................................................... 10
Parasympathetic Agents .................................................................................. 10
NEOPLASTIC DISEASE ........................................................................................ 10
Alkylating Agents ............................................................................................. 10
Antiandrogenic Agents ..................................................................................... 11
Antimetabolites ................................................................................................ 11
Antineoplastic - Aromatase Inhibitors .............................................................. 11
Antineoplastic – Hedgehog Pathway Inhibitors ............................................... 11
Antineoplastic – Janus Kinase (JAK) Inhibitors ............................................... 11
Antineoplastic - Topoisomerase I Inhibitors..................................................... 11
Antineoplastic - Immunomodulator Agents ...................................................... 11
Antineoplastic - Systemic Enzyme Inhibitors ................................................... 11
Antineoplastic, Histone Deacetylase Inhibitors, HDIS ..................................... 11
Antineoplastics, Miscellaneous ........................................................................ 11
Chemotherapy Rescue/Antidote Agents ......................................................... 11
Selective Estrogen Receptor Modulators (SERM) .......................................... 11
Selective Retinoid X Receptor Agonists (RXR) ............................................... 11
Steroid Antineoplastics .................................................................................... 11
NEUROLOGICAL DISEASE - MISCELLANEOUS ................................................ 11
Agents to Treat Multiple Sclerosis ................................................................... 11
Fibromyalgia Agents, Serotonin-Norepineph RU Inhibitor .............................. 11
ORAL/PHARYNGEAL DISORDERS ..................................................................... 11
Dental Aids & Preparations .............................................................................. 11
Nose Preparations, Antibiotics ......................................................................... 11
Nose Preparations, Miscellaneous (Rx) .......................................................... 11
OTHER DRUGS ..................................................................................................... 11
Appetite Stimulators for Anorexia, Cachexia, Wasting Syndrome .................. 11
General Inhalation Agents ............................................................................... 11
Needles/Needleless Devices ........................................................................... 11
Somatostatic Agents ........................................................................................ 11
OTHER RESPIRATORY DISORDERS ................................................................. 11
Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) Potentiators
......................................................................................................................... 11
Mucolytics ........................................................................................................ 11
PAIN MANAGEMENT - ANALGESICS ................................................................. 11
Analgesic, Non-Salicylate & Barbiturate Combinations .................................. 11
Analgesic, Salicylate, Barbiturate & Xanthine Combinations .......................... 11
Analgesic, Non-Salicylate, Barbiturate & Xanthine Combinations .................. 11
Analgesic/Antipyretics, Salicylates .................................................................. 11
Analgesics, Narcotics....................................................................................... 11
Antimigraine Preparations ............................................................................... 12
Narcotic & Non-Salicylate Analgesic, Barbiturate & Xanthine Combinations . 12
Narcotic & Salicylate Analgesics, Barbiturates & Xanthines ........................... 12
Narcotic Analgesic & Non-Salicylate Analgesic Combinations ....................... 12
PARKINSON’S DISEASE ...................................................................................... 12
Antiparkinsonism Drugs, Anticholinergic ......................................................... 12
Antiparkinsonism Drugs, Other ........................................................................ 12
Decarboxylase Inhibitors ................................................................................. 12
SEIZURE DISORDER ............................................................................................ 12
Anticonvulsants ................................................................................................ 12
SKELETAL MUSCLE DISORDER ......................................................................... 12
Skeletal Muscle Relaxants ............................................................................... 12
UPPER GASTROINTESTINAL DISORDERS - DIGESTIVE ................................ 12
Pancreatic Enzymes ........................................................................................ 12
UPPER GASTROINTESTINAL DISORDERS - SPASTIC DISEASE ................... 13
Anticholinergics/Antispasmodics ..................................................................... 13
Belladonna Alkaloids........................................................................................ 13
UPPER GASTROINTESTINAL DISORDERS - ULCER DISEASE ...................... 13
iv
PortfolioHigh Formulary
Anti-Ulcer Preparations .................................................................................... 13
Anti-Ulcer-H.pylori Agents ................................................................................ 13
Anticholinergics, Quaternary Ammonium ........................................................ 13
Histamine H2-Receptor Inhibitors .................................................................... 13
Intestinal Motility Stimulants............................................................................. 13
Proton-Pump Inhibitors .................................................................................... 13
URINARY TRACT - FUNCTIONAL DISORDERS ................................................. 13
Benign Prostatic Hypertrophy/Micturition Agents ............................................ 13
Urinary Tract Analgesic Agents ....................................................................... 13
Urinary Tract Anesthetic/Analgesic Agents (Azo-Dye) .................................... 13
Urinary Tract Antispasmodic, M(3) Selective Antagonists .............................. 13
Urinary Tract Antispasmodic/Antiincontinence Agents .................................... 13
VAGINAL DISORDERS ......................................................................................... 13
Vaginal Antibiotics ............................................................................................ 13
Vaginal Antifungals .......................................................................................... 13
Vaginal Estrogen Preparations ........................................................................ 13
Vaginal Sulfonamides ...................................................................................... 13
VITAMIN AND/OR MINERAL DEFICIENCY ......................................................... 13
Fluoride Preparations ....................................................................................... 13
Folic Acid Preparations .................................................................................... 13
Multivitamin Preparations ................................................................................. 13
Pediatric Vitamin Preparations ........................................................................ 13
Prenatal Vitamin Preparations ......................................................................... 13
Vitamin B Preparations .................................................................................... 13
Vitamin D Preparations .................................................................................... 13
SPECIALTY INJECTABLE CROSS REFERENCE LISTING ................................ 14
PortfolioHigh Formulary – October 2014
v
PortfolioHigh Formulary
ALLERGY
2nd Geneneration Antihistamine & Decongestant Combinations
p-ephed hcl/cetirizine hcl (OTC) ZYRTEC-D (OTC)
p-ephed sul/loratadine (OTC)
CLARITIN-D 12 HOUR
(OTC)
CLARITIN-D 24 HOUR
(OTC)
Antihistamines - 1st Generation
hydroxyzine hcl
ATARAX
hydroxyzine pamoate
VISTARIL
promethazine hcl
PHENERGAN
Antihistamines - 2nd Generation
cetirizine hcl (OTC)
ZYRTEC (OTC)
levocetirizine dihydrochloride
XYZAL TABS
loratadine (OTC)
CLARITIN (OTC)
Nasal Anti-Inflammatory Steroids
QL flunisolide
NASAREL
QL fluticasone propionate
FLONASE
QL triamcinolone acetonide
NASACORT AQ
QL + betamethasone dipropionate
QNASL
ST
QL mometasone furoate
NASONEX
Nasal Antihistamine
QL azelastine hcl
ASTELIN
QL +
ASTEPRO
ST
ANTIEMESIS/ANTIVERTIGO
Antiemetic/Antivertigo Agents
QL + dronabinol
MARINOL
ST
meclizine hcl
ANTIVERT
ondansetron
ZOFRAN ODT
QL ondansetron hcl (QL on solution) ZOFRAN
prochlorperazine maleate
COMPAZINE
promethazine hcl
PHENERGAN
QL aprepitant
EMEND
prochlorperazine edisylate
COMPAZINE SYRUP
ASTHMA
Beta-Adrenergic Agents
albuterol sulfate
ALBUTEROL SULFATE
metaproterenol sulfate
ALUPENT
terbutaline sulfate
BRETHINE
albuterol sulfate
PROAIR HFA
VENTOLIN HFA
QL formoterol fumarate
PERFOROMIST
QL salmeterol xinafoate
SEREVENT DISKUS
Beta-Adrenergic & Anticholinergic Combinations
ipratropium/albuterol sulfate
DUONEB
ipratropium/albuterol sulfate
COMBIVENT
COMBIVENT RESPIMAT
QL umeclidinium brm/vilanterol tr
ANORO ELLIPTA
Beta-Adrenergic & Glucocorticoid Combinations
QL fluticasone/salmeterol
ADVAIR DISKUS
QL
ADVAIR HFA
QL fluticasone/vilanterol
BREO ELLIPTA
QL mometasone/formoterol
DULERA
General Bronchodilator Agents
ipratropium bromide
ATROVENT
QL aclidinium bromide
TUDORZA
QL ipratropium bromide
ATROVENT HFA
QL tiotropium bromide
SPIRIVA
Leukotriene Receptor Antagonists
montelukast sodium
SINGULAIR
Mast Cell Stabilizers
cromolyn sodium
INTAL
Oral Inhaled Corticosteroids
QL budesonide
PULMICORT RESPULES
QL beclomethasone dipropionate
QVAR
PortfolioHigh Formulary – October 2014
QL
fluticasone propionate
FLOVENT DISKUS
FLOVENT HFA
Phosphodiesterase-4 (PDE4) Inhibitors
QL + roflumilast
DALIRESP
ST
Xanthines
aminophylline
AMINOPHYLLIN
theophylline anhydrous
UNIPHYL
theophylline anhydrous
THEO-24
AUTONOMIC NERVOUS SYSTEM DISORDERS
Alzheimer's Therapy, Nmda Receptor Antagonists
QL memantine hcl
NAMENDA
QL
NAMENDA XR
Cholinesterase Inhibitors
donepezil hcl
ARICEPT
ARICEPT ODT
QL galantamine hydrobromide
RAZADYNE
QL
RAZADYNE ER
pyridostigmine bromide
MESTINON
rivastigmine tartrate
EXELON CAPSULE
neostigmine bromide
PROSTIGMIN
QL rivastigmine patch
EXELON PATCH
rivastigmine tartrate
EXELON SOLUTION
BEHAVIORAL HEALTH - ANTIDEPRESSANTS
Alpha-2 Receptor Antagonist Antidepressants
mirtazapine
REMERON
Maois - Non-Selective & Irreversible
tranylcypromine sulfate
PARNATE
phenelzine sulfate
NARDIL
Norepinephrine & Dopamine Reuptake Inhibitors (NDRIs)
bupropion hcl
WELLBUTRIN
WELLBUTRIN SR
WELLBUTRIN XL
Selective Serotonin Reuptake Inhibitors (SSRIs)
citalopram hydrobromide
CELEXA
escitalopram oxalate
LEXAPRO
fluoxetine hcl
PROZAC
fluoxetine er
PROZAC WEEKLY
paroxetine hcl
PAXIL
sertraline hcl
ZOLOFT
SSRI & Antipsycho, Atyp, Dopamine & Serotonin Antag Comb
QL olanzapine/fluoxetine
SYMBYAX
Serotonin-2 Antagonist/Reuptake Inhibitors (SARIs)
trazodone hcl
DESYREL 300MG
Serotonin-Norepinephrine Reuptake-Inhib (SNRIs)
QL duloxetine hcl
CYMBALTA
venlafaxine hcl
EFFEXOR
EFFEXOR XR
QL + desvenlafaxine ER (Ranbaxy)
DESVENLAFAXINE ER
ST
(RANBAXY BRAND)
QL + desvenlafaxine succinate
PRISTIQ
ST
Tricyclic Antidepressants & Rel. Non-Sel. Ru-Inhib
amitriptyline hcl
ELAVIL
amoxapine
ASENDIN
clomipramine hcl
ANAFRANIL
desipramine hcl
NORPRAMIN
doxepin hcl
SINEQUAN
imipramine hcl
TOFRANIL
maprotiline hcl
LUDIOMIL
nortriptyline hcl
PAMELOR
BEHAVIORAL HEALTH - OTHER
Adrenergics, Aromatic, Non-Catecholamine
QL amphet asp/amphet/d-amphet
ADDERALL
QL
ADDERALL XR
QL dextroamphetamine sulfate
DEXEDRINE
QL dextroamphetamine capsule
DEXEDRINE SPANSULE
QL dextroamphetamine tablet (5mg, ZENZEDI
1
PortfolioHigh Formulary
10mg)
QL + dextroamphetamine tablet (2.5mg,
ST 7.5mg)
QL dextroamphetamine tablet (15mg,
20mg, 30mg)
QL + lisdexamfetamine dimesylate
ST
Anti-Alcoholic Preparations
disulfiram
Anti-Anxiety Drugs
alprazolam
buspirone hcl
chlordiazepoxide hcl
clorazepate dipotassium
diazepam
lorazepam
meprobamate
oxazepam
Anti-Mania Drugs
lithium carbonate
FOCALIN XR
METADATE CD
METADATE ER
METHYLIN
METHLYIN ER
RITALIN
RITALIN LA
RITALIN SR
armodafinil
NUVIGIL
methylphenidate chewable
METHYLIN CHEW TAB
methylphenidate ER Susp
QUILLIVANT XR
methylphenidate hcl
CONCERTA
METHYLIN
Treatment for Attention Deficit-Hyperactivity (ADHD), Nri-Type
QL atomoxetine hcl
STRATTERA
CARDIOVASCULAR DISEASE - ARRHYTHMIA
Antiarrhythmics
amiodarone hcl
CORDARONE
disopyramide phosphate
NORPACE
flecainide acetate
TAMBOCOR
mexiletine hcl
MEXITIL
procainamide hcl
PRONESTYL
propafenone hcl
RYTHMOL
quinidine gluconate
QUINAGLUTE
quinidine sulfate
QUINIDEX
disopyramide phosphate
NORPACE CR
dofetilide
TIKOSYN
dronedarone hcl
MULTAQ
propafenone hcl
RYTHMOL SR
CARDIOVASCULAR DISEASE - CARDIAC STIMULANTS
Digitalis Glycosides
digoxin
LANOXIN
DIGOXIN ORAL SOLN.
CARDIOVASCULAR DISEASE - HYPERTENSION
ACE Inhibitor/Calcium Channel Blocker Combinations
amlodipine besylate/benazepril LOTREL
ACE Inhibitor/Thiazide & Thiazide-Like Diuretics
benazepril/hydrochlorothiazide LOTENSIN HCT
captopril/hydrochlorothiazide
CAPOZIDE
enalapril/hydrochlorothiazide
VASERETIC
fosinopril/hydrochlorothiazide
MONOPRIL HCT
lisinopril/hydrochlorothiazide
PRINZIDE
ZESTORETIC
moexipril/hydrochlorothiazide
UNIRETIC
quinapril/hydrochlorothiazide
ACCURETIC
Alpha-Adrenergic Blocking Agents
doxazosin mesylate
CARDURA
prazosin hcl
MINIPRESS
terazosin hcl
HYTRIN
phenoxybenzamine hcl
DIBENZYLINE
Alpha/Beta-Adrenergic Blocking Agents
carvedilol
COREG
labetalol hcl
TRANDATE
carvedilol phosphate
COREG CR
Angiotensin Receptor Antagonist/Calcium Channel
Blocker/Thiazide Combinations
ST amlodipine/valsartan/hctz
EXFORGE HCT
Angiotensin Receptor Antagonist/Thiazide Diuretic Combinations
irbesartan/hydrochlorithiazide
AVALIDE
losartan/hydrochlorothiazide
HYZAAR
valsartan/hydrochlorothiazide
DIOVAN HCT
ST olmesartan/hydrochlorothiazide
BENICAR HCT
Angiotensin Receptor Antagonist & Calcium Channel Blockers
ST amlodipine/valsartan
EXFORGE
Antihypertensives, ACE Inhibitors
benazepril hcl
LOTENSIN
captopril
CAPOTEN
enalapril maleate
VASOTEC
ZENZEDI
QL
QL
QL
QL
QL
QL
QL
PA
QL
QL
QL
ZENZEDI
VYVANSE
ANTABUSE
XANAX
ALPRAZOLAM
INTENSOL
BUSPAR
VANSPAR
LIBRIUM
TRANXENE T-TAB
VALIUM
ATIVAN
LORAZEPAM INTENSOL
MILTOWN
SERAX
ESKALITH
LITHOBID
CIBALITH-S
lithium citrate
Antipsychotics, Phenothiazines
chlorpromazine hcl
THORAZINE
fluphenazine hcl
PROLIXIN
perphenazine
TRILAFON
thioridazine hcl
MELLARIL
trifluoperazine hcl
STELAZINE
Antipsychotics, Atypical, D2 Partial Agonist/5HT Mixed
ST + aripiprazole
ABILIFY
QL
ABILIFY DISCMELT
Antipsychotics, Dopamine & Serotonin Antagonists
loxapine succinate
LOXITANE
Antipsychotics, Atypical, Dopamine, & Serotonin Antagonists
QL clozapine
CLOZARIL
QL olanzapine
ZYPREXA
QL olanzapine ODT
ZYPREXA ZYDIS
QL quetiapine fumarate
SEROQUEL
QL risperidone
RISPERDAL
QL risperidone ODT
RISPERDAL M-TAB
QL ziprasidone hcl
GEODON
QL + quetiapine fumarate XR
SEROQUEL XR
ST
Antipsychotics, Dopamine Antagonists, Thioxanthenes
thiothixene
NAVANE
Antipsychotics, Dopamine Antagonists, Butyrophenones
haloperidol
HALDOL
haloperidol lactate
HALDOL ORAL CONC.
Barbiturates
phenobarbital
PHENOBARBITAL
Narcotic Antagonists
naltrexone hcl
REVIA
Sedative-Hypnotics, Non-Barbiturate
chloral hydrate
NOCTEC
estazolam
PROSOM
flurazepam hcl
DALMANE
temazepam
RESTORIL
triazolam
HALCION
QL zaleplon
SONATA
QL zolpidem tartrate
AMBIEN
QL +
AMBIEN CR
ST
Treatment for Attention Deficit-Hyperactivity (ADHD)/Narcolepsy
QL dexmethylphenidate hcl
FOCALIN
PortfolioHigh Formulary – October 2014
2
methylphenidate hcl
PortfolioHigh Formulary
fosinopril sodium
lisinopril
Pulmonary Anti-HTN, Sel. C-GMP Phosphodiesterase T5
Inhibitors
QL sildenafil citrate
REVATIO
PA tadalafil
ADCIRCA
Pulmonary Anti-HTN, Endothelin Receptor Antagonists
PA ambrisentan
LETAIRIS
PA bosentan
TRACLEER
PA macitentan
OPSUMIT
Pulmonary Anti-HTN, Soluble Guanylate Cyclase Stimulators
PA riociguat
ADEMPAS
Thiazide & Related Diuretics
chlorthalidone
HYGROTON
hydrochlorothiazide
MICROZIDE
indapamide
LOZOL
metolazone
ZAROXOLYN
chlorthalidone
THALITONE
CARDIOVASCULAR DISEASE - LIPID IRREGULARITY
Antihyperlipidemic - HMG CoA Reductase Inhibitors
atorvastatin calcium
LIPITOR
lovastatin
MEVACOR
pravastatin sodium
PRAVACHOL
simvastatin
ZOCOR
ST simvastatin (80mg only)
QL + rosuvastatin calcium
CRESTOR
ST
Antihyperlipidemic-HMG CoA Reductase Inhibitors & Niacin
QL + niacin/simvastatin
SIMCOR
ST
Antihyperlipidemic - APO B-100 Synthesis Inhibitor
PA mipomersin sodium
KYNAMRO
Antihyperlipidemic-MTP Inhibitors
PA lomitapide
JUXTAPID
Bile Salt Sequestrants
cholestyramine/aspartame
QUESTRAN LIGHT
cholestyramine/sucrose
QUESTRAN
colesevelam hcl
WELCHOL
WELCHOL POWDER
PACKETS
colestipol
COLESTID
COLESTID GRANULES
Lipotropics
fenofibrate
LOFIBRA
TRIGLIDE 160MG
fenofibrate, micronized
LOFIBRA
fenofibrate nanocrystallized
TRICOR
gemfibrozil
LOPID
ST niacin
NIASPAN
QL omega-3 acid ethyl esters
LOVAZA
QL ezetimibe
ZETIA
fenofibrate
FENOGLIDE
TRIGLIDE 50MG
QL icosapent ethyl
VASCEPA
Niacin Preparations
niacin
SLO-NIACIN
CARDIOVASCULAR DISEASE - MISCELLANEOUS AGENTS
Adrenergic Vasopressor Agents
midodrine hcl
PROAMATINE
Antianginal & Anti-Ischemic Agents, Non-Hemodynamic
QL ranolazine
RANEXA
Antihyperlipidemia - HMG-CoA & Calcium Channel Blocker
Combinations
QL amlodipine/atorvast cal
CADUET
CARDIOVASCULAR DISEASE - VASODILATION
Vasodilators, Coronary
isosorbide dinitrate
ISOCHRON
ISORDIL
ISORDIL TITRADOSE
isosorbide mononitrate
IMDUR
MONOPRIL
PRINIVIL
ZESTRIL
moexipril hcl
UNIVASC
quinapril hcl
ACCUPRIL
ramipril
ALTACE
trandolapril
MAVIK
Antihypertensives, Angiotensin Receptor Antagonist
irbesartan
AVAPRO
losartan potassium
COZAAR
valsartan
DIOVAN
ST olmesartan medoxomil
BENICAR
Antihypertensives, Sympatholytic
clonidine hcl
CATAPRES
guanfacine hcl
TENEX
methyldopa
ALDOMET
reserpine
SERPASIL
Antihypertensives, Vasodilators
hydralazine hcl
APRESOLINE
Beta-Adrenergic Blocking Agents
acebutolol hcl
SECTRAL
atenolol
TENORMIN
bisoprolol fumarate
ZEBETA
metoprolol succinate
TOPROL XL
metoprolol tartrate
LOPRESSOR
nadolol
CORGARD
pindolol
VISKEN
propranolol hcl
INDERAL LA
sotalol hcl
BETAPACE
BETAPACE AF
timolol maleate
BLOCADREN
nebivolol hcl
BYSTOLIC
Beta-Adrenergic Blocking Agents/Thiazide & Related
atenolol/chlorthalidone
TENORETIC 100
TENORETIC 50
bisoprolol fumarate/hctz
ZIAC
metoprolol/hctz
LOPRESSOR HCT
propranolol/hydrochlorothiazide INDERIDE-40/25
Calcium Channel Blocking Agents
amlodipine besylate
NORVASC
diltiazem hcl
CARDIZEM
CARDIZEM CD
DILACOR XR
TIAZAC
felodipine
PLENDIL
isradipine IR capsules
DYNACIRC
nicardipine hcl
CARDENE
nifedipine
ADALAT CC
PROCARDIA
PROCARDIA XL
nimodipine
NIMOTOP
verapamil hcl
CALAN
VERELAN
verapamil hcl ER
CALAN SR
VERELAN PM
Loop Diuretics
bumetanide
BUMEX
furosemide
LASIX
torsemide
DEMADEX
Potassium Sparing Diuretics
eplerenone
INSPRA
spironolactone
ALDACTONE
Potassium Sparing Diuretics in Combination
triamterene/hydrochlorothiazide DYAZIDE
MAXZIDE
MAXZIDE-25MG
PortfolioHigh Formulary – October 2014
3
PortfolioHigh Formulary
nitroglycerin
nitroglycerin
CONTRACEPTION/OXYTOCICS
Contraceptives, Intravaginal, Systemic
QL + etonogestrel/ethinyl estradiol
ST
Contraceptives, Oral
desog-et estra/ethin estra
desogestrel-ethinyl estradiol
ST
ST
ST
ST
ST
ST
ST
ST
ethinyl estradiol/drospirenone
ethynodiol d-ethinyl estradiol
levonorgestrel-eth estra
QL
ST
noreth a-et estra/fe fumarate
norethindrone
norethindrone a-e estradiol
norethindrone-ethinyl estrad
norethindrone-mestranol
norgestimate-ethinyl estradiol
norgestrel-ethinyl estradiol
noreth a-et estra/fe fumarate
Narcotic Antitussive-1st Generation Antihistamines
codeine/promethazine hcl
PHENERGAN
W/CODEINE
AGE hydrocodone/chlorphen polis
TUSSIONEX
Narcotic Antitussive-Expectorant Combinations
guaifenesin/codeine phos
MYCI-GC
Non-Narcotic Antitussive-1st Generation Antihistamine
Combinations
d-methorphan hb/prometh hcl
PHENERGAN W/
DEXTROMETHORPHAN
Non-Narcotic Antitussive & Expectorant Combinations
guaifenesin/d-methorphan hb
TUSNEL DIABETIC
DERMATOLOGY - ACNE
Acne Agents, Systemic
isotretinoin
AMNESTEEM
CLARAVIS
MYORISAN
SOTRET
ZENATANE
Acne Agents, Topical
clindamycin phos/benzoyl perox BENZACLIN
sulfacetamide sodium
KLARON
clindamycin/benzoyl prx/skn #5
DUAC CS
Keratolytic-Glucocorticoid Combinations
benzoyl peroxide/hydrocortison
VANOXIDE-HC
Keratolytics
benz perox/hc/skin clnsr no.14 VANOXIDE HC
benzoyl peroxide
BREVOXYL-4
BREVOXYL-8
TRIAZ
podofilox
CONDYLOX
benzoyl peroxide shave cream
BENZASHAVE
benzoyl peroxide gel
CLINAC BPO
Rosacea Agents, Topical
metronidazole
METROCREAM
METROLOTION
Topical Preparations, Antibacterials
hydrocortisone/iodoquinol
VYTONE
Vitamin A Derivatives
AGE adapalene
DIFFERIN
AGE tazorotene foam
FABIOR
DERMATOLOGY - ANTIINFECTIVE
Topical Antibiotics
clindamycin phosphate
CLEOCIN T
erythromycin base/benz per
BENZAMYCIN
erythromycin base/ethanol
EMGEL
ERYGEL
gentamicin sulfate
GARAMYCIN
mupirocin ointment
BACTROBAN
CENTANY
mupirocin calcium cream
BACTROBAN
clindamycin phosphate
EVOCLIN
erythromycin base/benz per
BENZAMYCIN PAK
Topical Antifungals
ciclopirox olamine
LOPROX
ciclopirox 8% solution
CICLODAN
clotrimazole/betamet diprop
LOTRISONE
ketoconazole
KURIC
NIZORAL
nystatin
MYCOSTATIN
nystatin/triamcin
MYCOLOG II
naftifine hcl
NAFTIN
sulconazole nitrate
EXELDERM
terbinafine hcl
LAMISIL
Topical Antiparasitics
lindane
KWELL
malathion
OVIDE
permethrin
ELIMITE
ISMO
MONOKET
NITRO-DUR
NITROLINGUAL
NITRO-BID
NITROSTAT
NUVARING
MIRCETTE
CYCLESSA
DESOGEN
ORTHO-CEPT
GIANVI
LORYNA
OSCELLA
SYEDA
VESTURA
YASMIN 28
YAZ
ZARAH
DEMULEN 1-50-21
NORDETTE-28
SEASONALE
AVIANE-28
LESSINA
LUTERA
ORSYTHIA
SRONYX
LOESTRIN FE
LOESTRIN FE24
NOR-Q-D
ORTHO MICRONOR
LOESTRIN
NORINYL 1+35
ORTHO-NOVUM
TRI-NORINYL
NORINYL 1+50
ORTHO TRI-CYCLEN
ORTHO-CYCLEN
LO-OVRAL-28
LO LOESTRIN FE
LO MINASTRIN FE
ORTHO TRI-CYCLEN LO
ST norgestimate-ethinyl estradiol
Contraceptives, Transdermal
ST norelgestromin/ethin.estradiol
ORTHO EVRA
Oxytocics
methylergonovine maleate
METHERGINE
COUGH AND COLD
1st Generation Antihistamine & Decongestant Combinations
p-ephed hcl/brompheniramin
LODRANE
phenylephrine hcl/prometh hcl PHENERGAN VC
phenylephrine/brompheniramine BROMFED
BROMFED-PD
phenylephrine/chlor-tan
RYNATAN
RYNATAN PEDIATRIC
phenylephrine/pyril tan/cp
NALEX A 12
pseudoephedrine hcl/chlor-mal DECONAMINE
KLERIST-D
Narcotic Antitussive-1st Geneneration AntihistamineDecongestants
p-ephed hcl/cod/chlorphenir
NOVAHISTINE DH
phenylephrine hcl/cod/prometh PHENERGAN VC
W/CODEINE
AGE phenylephrine/hydrocodone/cp MAXI-TUSS HCX
Narcotic Antitussive-Decongestant-Expectorant Combinations
p-ephed hcl/codeine/guaifen
SUTTAR-2
SUTTAR-SF
TUSNEL C
PortfolioHigh Formulary – October 2014
4
PortfolioHigh Formulary
crotamiton
Topical Antivirals
acyclovir
acyclovir
Topical Sulfonamides
silver sulfadiazine
DERMATOLOGY - PIGMENTATION DISORDERS
Topical Hyperpigmentation Agents
methoxsalen
OXSORALEN
DERMATOLOGY - PSORIASIS/ECZEMA
Antipsoriatic Agents, Systemic
acitretin
SORIATANE
methoxsalen, rapid
OXSORALEN-ULTRA
methoxsalen
8-MOP
Antipsoriatics Agents
ST calcipotriene
DOVONEX
anthralin
DRITHO-SCALP
ST anthralin
DRITHOCREME HP
tazarotene
TAZORAC
Topical Immunosuppressive Agents
AGE tacrolimus
PROTOPIC
+ ST
DIABETES
Antihyperglycemic, Alpha-Glucosidase Inhibitors (NonSulfonylurea)
acarbose
PRECOSE
Antihyperglycemic, Amylin Analog-Type
pramlintide acetate
SYMLIN
SYMLINPEN 120
SYMLINPEN 60
Antihyperglycemic, DPP-4 Inhibitors
QL linagliptin
TRADJENTA
QL sitagliptin phosphate
JANUVIA
Antihyperglycemic, DPP-4 Inhibitor & Biguanide Combinations
QL linagliptin/metformin hcl
JENTADUETO
QL sitagliptin phos/metformin hcl
JANUMET
QL sitagliptin phos/metformin hcl
JANUMET XR
Antihyperglycemic, Incretin Mimetic (GLP-1 Receptor Agonists)
QL + exenatide
BYETTA
ST
QL + exenatide micropheres
BYDUREON
ST
QL + liraglutide
VICTOZA
ST
Antihyperglycemic, Insulin-Release Stimulant Type
chlorpropamide
DIABINESE
glimepiride
AMARYL
glipizide
GLUCOTROL
GLUCOTROL XL
glipizide/metformin hcl
METAGLIP
glyburide
MICRONASE
nateglinide
STARLIX
repaglinide
PRANDIN
tolazamide
TOLINASE
tolbutamide
ORINASE
glyburide
DIABETA
Antihyperglycemic, Insulin-Response Enhancer (NonSulfonylurea)
pioglitazone hcl
ACTOS
Antihyperglycemic, Biguanide Type (Non-Sulfonylurea)
metformin hcl
GLUCOPHAGE
GLUCOPHAGE XR
metformin hcl
RIOMET
Antihyperglycemic, Insulin-Rel Stim.& Biguanide Combinations
glyburide, micro/metformin hcl GLUCOVANCE
repaglinide/metformin hcl
PRANDIMET
Antihyperglycemic, Insulin-Response & Release Combinations
ST pioglitazone/glimepiride
DUETACT
Antihyperglycemic Insul-Resp. Enhancer & Biguanide
Combinations
ST pioglitazone hcl/metformin hcl
ACTOPLUS MET
ST pioglitazone hcl/metformin hcl
ACTOPLUS MET XR
Antihyperglycemic-Glucocorticoid Receptor Blockers
PA mifepristone
KORLYM
EURAX
ZOVIRAX OINTMENT
ZOVIRAX CREAM
SILVADENE
THERMAZENE
DERMATOLOGY - ANTIINFLAMMATORY
Topical Anti-Inflammatory Steroidal
alclometasone dipropionate
ACLOVATE
amcinonide
CYCLOCORT
betamet diprop/prop gly
DIPROLENE
DIPROLENE AF
betamethasone dipropionate
DEL-BETA
DIPROSONE
betamethasone valerate
VALISONE
clobetasol propionate
OLUX
TEMOVATE
clobetasol propionate/emoll
TEMOVATE EMOLLIENT
desonide
DESOWEN
TRIDESILON
desoximetasone
TOPICORT
TOPICORT LP
diflorasone diacetate
APEXICON
fluocinolone acetonide
SYNALAR
fluocinonide
LIDEX
VANOS
fluocinonide/emollient
LIDEX-E
fluticasone propionate
CUTIVATE
halobetasol propionate
ULTRAVATE
hydrocortisone
LACTICARE-HC
REDERM
SCALACORT
hydrocortisone acetate/urea
CARMOL HC
hydrocortisone butyrate
LOCOID
hydrocortisone valerate
WESTCORT
mometasone furoate
ELOCON
triamcinolone acetonide
KENALOG
TRIDERM
clobetasol propionate
CLOBEX
diflorasone diacetate/emoll
APEXICON E
flurandrenolide
CORDRAN
CORDRAN SP
hydrocort/sal acid/sulf/shmp#1
SCALACORT DK
hydrocortisone
FIRSTHYDROCORTISONE
TEXACORT
hydrocortisone butyrate/emoll
LOCOID LIPOCREAM
hydrocortisone probutate
PANDEL
Topical Anti-Inflammatory, NSAIDs
diclofenac sodium
VOLTAREN GEL
Topical Antibiotics/Antiinflammatory, Steroidal
neomy sulf/polymyx b sulf/hc
CORTISPORIN CREAM
neomycin/bacitra/polymyxin/hc
CORTISPORIN
OINTMENT
DERMATOLOGY - MISCELLANEOUS
Antiperspirants
aluminum chloride
DRYSOL
Antiseborrheic Agents
selenium sulfide
SELSUN RX
sulfacetamide sodium
OVACE PLUS
SUSPENSION
Topical Antineoplastic & Premalignant Lesion Agents
fluorouracil
EFUDEX
PA bexarotene
TARGRETIN
QL ingenol
PICATO
PA mechlorethamine gel
VALCHLOR
Topical Local Anesthetics
hc acetate/pramoxine hcl
PRAMOSONE
PortfolioHigh Formulary – October 2014
5
PortfolioHigh Formulary
Antihyperglycemic-Sod/Gluc Cotransport2 (SGLT2) Inhibitors
QL + canagliflozin
INVOKANA
ST
Diabetic Supplies
blood-glucose calib. control
ALL ABBOTT CONTROL
PRODUCTS (e.g.,
FREESTYLE,
PRECISION)
blood-glucose meter
blood sugar diagnostics
lancing device/lancets
Diabetic Ulcer Preparations, Topical
becaplermin
Hyperglycemics
glucagon,human recombinant
Insulins
hum insulin nph/reg insulin hm
hum insulin nph/reg insulin hm
insulin aspart
insuln asp prt/insulin aspart
insulin glargine,hum.rec.anlog
insulin lispro
insulin npl/insulin lispro
insulin regular, human
nph, human insulin isophane
Syringes & Accessories
syringes & needles
EAR - GENERAL DISORDERS
Ear Preparations, Misc. Anti-Infectives
acetic acid
acetic acid/aluminum acetate
acetic acid/hydrocortisone
Ear Preparations, Antibiotics
neomy sulf/polymyx b sulf/hc
ELECTROLYTE REGULATION
Electrolyte Depleters
calcium acetate
sevelamer carbonate
sodium polystyrene sulfonate
sevelamer hcl
Potassium Replacement
potassium bicarbonate/cit ac
pot chloride/pot bicarb/cit ac
potassium chloride
ALL LIFESCAN
CONTROL PRODUCTS
(e.g., ONETOUCH)
ALL ABBOTT
METERS(e.g.,
FREESTYLE,
PRECISION)
K-LYTE
K-LYTE-CL
K-DUR
K-TAB
MICRO-K
ENDOCRINE DISORDER - FERTILITY
Drugs to Treat Impotency
QL + sildenafil citrate
VIAGRA
GEN
QL + tadalafil
CIALIS
GEN
QL + vardenafil hcl
STAXYN
GEN
Fertility Stimulating Preparations, Non-FSH
clomiphene citrate
CLOMID
SEROPHENE
Follicle Stimulating / Luteinizing Hormones
follitropin alpha, recomb
GONAL-F
GONAL-F RFF
follitropin beta, recomb
FOLLISTIM AQ
gonadotropin,chorionic, human
NOVAREL
PREGNYL
PROFASI
hcg alpha, recombinant
OVIDREL
menotropins
MENOPUR
REPRONEX
urofollitropin (fsh)
BRAVELLE
FERTINEX
Pregnancy Facilitating/Maintaining Agents, Hormonal
progesterone, micronized
CRINONE
ENDOMETRIN
PROCHIEVE
ENDOCRINE DISORDER - OTHER
Antineoplastic LHRH (GNRH) Agonists, Pituitary Suppressants
PA leuprolide
ELIGARD
Antidiuretic & Vasopressor Hormones
desmopressin (nonrefrigerated) DDAVP
Bone Formation Stim. Agents - Parathyroid Hormone
QL teriparatide
FORTEO
Bone Resorption Inhibitor & Vitamin D Combinations
alendronate sodium/vitamin d3
FOSAMAX PLUS D
Bone Resorption Inhibitors
alendronate sodium tablet
FOSAMAX
QL alendronate sodium solution
FOSAMAX SOLUTION
etidronate disodium
DIDRONEL
ibandronate
BONIVA
QL raloxifene hcl
EVISTA
Growth Hormone Receptor Antagonists
pegvisomant
SOMAVERT
Growth Hormones
PA somatropin
OMNITROPE
Hyperparathyroid Tx Agent, Vitamin D Analog-Type
paricalcitol
ZEMPLAR
LHRH (GnRH) Antagonist, Pituitary Suppressant Agents
cetrorelix acetate
CETROTIDE
ganirelix acetate
GANIRELIX ACETATE
Luteinizing Hormone Releasing Hormone –LHRH (GnRH)
gonadorelin acetate
LUTREPULSE
Pituitary Suppressive Agents
cabergoline
DOSTINEX
danazol
DANOCRINE
ALL LIFESCAN METERS
(e.g., ONETOUCH)
ALL ABBOTT TEST
STRIPS (e.g.,
FREESTYLE,
PRECISION)
ALL LIFESCAN TEST
STRIPS (e.g.,
ONETOUCH)
ALL ABBOTT AND
LIFESCAN(e.g.,
ONETOUCH) LANCETS
REGRANEX
GLUCAGON
EMERGENCY KIT
HUMULIN 70-30
NOVOLIN 70-30
NOVOLIN 70-30
INNOLET
HUMULIN 50-50
NOVOLOG
NOVOLOG MIX 70-30
LANTUS
LANTUS SOLOSTAR
HUMALOG
HUMALOG MIX 50-50
HUMALOG MIX 75-25
HUMULIN R
NOVOLIN R
HUMULIN N
NOVOLIN N
NOVOLIN N INNOLET
ALL COMMERCIALLY
AVAILABLE SYRINGES
AND NEEDLES
VOSOL
DOMEBORO
VOSOL HC
CORTISPORIN OTIC
OTICIN HC
ofloxacin
FLOXIN
Otic Preparations, Anti-Inflammatory-Antibiotics
ciprofloxacin hcl/dexameth
CIPRODEX
Otic Preparations, Local anesthetics
antipyrine/benzocaine otic
A/B OTIC
PortfolioHigh Formulary – October 2014
PHOSLO
RENVELA
KAYEXALATE
RENAGEL
6
PortfolioHigh Formulary
ENDOCRINE DISORDER - THYROID
Antithyroid Preparations
methimazole
propylthiouracil
Iodine Containing Agents
potassium iodide
Thyroid Hormones
levothyroxine sodium
liothyronine sodium
thyroid, pork
EYE - GENERAL DISORDERS
Eye Antibiotic-Corticoid Combinations
neo/polymyx b sulf/dexameth
neomy sulf/bacitrac zn/poly/hc
neomy sulf/polymyx b sulf/hc
neomycin sulfate/dex na ph
tobramycin sulfate/dexameth
neomy sulf/polymyx b sulf/pred
tobramycin/lotepred etab
Eye Antihistamines
azelastine hcl
ketotifen fumarate (OTC)
olopatadine hcl
Eye Antiinflammatory Agents
diclofenac sodium
fluorometholone
flurbiprofen sodium
ketorolac tromethamine
prednisolone acetate
prednisolone sod phosphate
difluprednate
fluorometholone
fluorometholone acetate
loteprednol etabonate
nepafenac
prednisolone acetate
Eye Antivirals
trifluridine
ganciclovir
Eye Sulfonamides
na sulfacetm/prednis sp
sulfacetamide sodium
na sulfacetm/prednisol ac
neomycin/bacitracin/polymyxin
neomycin/polymyxn
b/gramicidin
ofloxacin
polymyxin b sulfate/tmp
tobramycin sulfate
besifloxacin hcl drops susp 0.6%
moxifloxacin hcl
Ophthalmic Mast Cell Stabilizers
cromolyn sodium
OPTICROM
lodoxamide tromethamine
ALOMIDE
nedocromil sodium
ALOCRIL
pemirolast potassium
ALAMAST
EYE - GLAUCOMA
Carbonic Anhydrase Inhibitors
acetazolamide
DIAMOX SEQUELS
methazolamide
NEPTAZANE
Miotics/Other Intraoccula Pressure Reducers
betaxolol hcl
BETOPTIC
brimonidine tartrate
ALPHAGAN P
carteolol hcl
OCUPRESS
dorzolamide hcl
TRUSOPT
dorzolamide hcl/timolol maleat COSOPT
latanoprost
XALATAN
levobunolol hcl
BETAGAN
metipranolol
OPTIPRANOLOL
pilocarpine hcl
ISOPTO CARPINE
timolol maleate
TIMOPTIC
TIMOPTIC-XE
QL travoprost (benzalkonium)
TRAVATAN
betaxolol hcl
BETOPTIC S
QL bimatoprost
LUMIGAN
bimonidine/timolol
COMBIGAN
brinzolamide
AZOPT
brinzolamide/brimonidine
SIMBRINZA
carbachol
ISOPTO CARBACHOL
timolol
BETIMOL
timolol maleate
TIMOPTIC
QL travoprost
TRAVATAN Z
Mydriatics
atropine sulfate
ISOPTO ATROPINE
cyclopentolate hcl
CYCLOGYL
homatropine hbr
ISOPTO HOMATROPINE
dipivefrin hcl
PROPINE
GOUT AND RELATED DISEASES
Colchicine
colchicine
COLCRYS
colchicine/probenecid
COL-BENEMID
Hyperuricemia Treatment - Purine Inhibitors
allopurinol
ZYLOPRIM
QL + febuxostat
ULORIC
ST
Uricosuric Agents
probenecid
BENEMID
HEMATOLOGICAL DISORDERS
Anticoagulants, Coumarin Type
warfarin sodium
COUMADIN
Direct Factor XA Inhibitors
QL apixaban
ELIQUIS
QL rivaroxaban
XARELTO
Hematinics, Other
PA epoetin alfa
PROCRIT
Hemorrheologic Agents
pentoxifylline
TRENTAL
Heparin & Related Preparations
QL enoxaparin sodium
LOVENOX
TAPAZOLE
PROPYLTHIOURACIL
POTASSIUM IODIDE
LEVOTHROID
LEVOXYL
SYNTHROID
CYTOMEL
ARMOUR THYROID
NATURE-THROID
WESTHROID
MAXITROL
CORTISPORIN OPHTH
OINTMENT
CORTISPORIN OPHTH
SUSPENSION
NEODECADRON
TOBRADEX
POLY-PRED
ZYLET
OPTIVAR
ALAWAY (OTC)
PATADAY
PATANOL
VOLTAREN
FML
OCUFEN
ACULAR
ACULAR LS
OMNIPRED
PRED FORTE
PREDNISOL
DUREZOL
FML FORTE
FML S.O.P.
FLAREX
ALREX
LOTEMAX
ILEVRO
NEVANAC
PRED MILD
VIROPTIC
ZIRGAN
VASOCIDIN
SULFAC
BLEPHAMIDE
BLEPHAMIDE S.O.P.
EYE - MISCELLANEOUS
Ophthalmic Cystine Delpleting Agents
PA cysteamine
CYSTARAN
Ophthalmic Anti-Inflammatory Immunomodulator-Type
QL cyclosporine
RESTASIS
Ophthalmic Antibiotics
bacitracin
AK-TRACIN
bacitracin/polymyxin b sulfate
POLYCIN-B
ciprofloxacin hcl
CILOXAN
erythromycin base
ROMYCIN
gatifloxacin
ZYMAXID
gentamicin sulfate
GARAMYCIN
PortfolioHigh Formulary – October 2014
NEOSPORIN OPHTH
OINTMENT
NEOSPORIN OPHTH
DROPS
OCUFLOX
POLYTRIM
TOBREX
BESIVANCE
VIGAMOX
7
PortfolioHigh Formulary
heparin sodium, porcine
heparin sodium, porcine/pf
QL dalteparin sodium, porcine
QL fondaparinux sodium
Leukocyte (WBC) Stimulants
PA filgrastim
PA pegfilgrastim
PA sargramostim
Platelet Aggregation Inhibitors
cilostazol
clopidogrel bisulfate
QL clopidogrel bisulfate 300mg
dipyridamole
QL prasugrel hcl
QL ticagrelor
Platelet Reducing Agents
anagrelide hcl
Thrombopoietin Receptor Agonists
PA eltrombopag olamine
Vitamin K Preparations
phytonadione
HORMONAL DEFICIENCY
Androgenic Agents
QL fluoxymesterone
PA testosterone cypionate
PA testosterone enanthate
methyltestosterone
sulfamethoxazole/trimethoprim
HEP-LOCK
HEPARIN LOCK
HEP-LOCK
FRAGMIN
ARIXTRA
sulfisoxazole acetyl
Betalactams
PA aztreonam lysine
CAYSTON
Cephalosporins - 1st Generation
cefadroxil hydrate
DURICEF
cephalexin monohydrate
KEFLEX
Cephalosporins - 2nd Generation
cefaclor
CECLOR
cefprozil
CEFZIL
cefuroxime axetil
CEFTIN
Cephalosporins - 3rd Generation
cefdinir
OMNICEF
cefpodoxime proxetil
VANTIN
cefixime
SUPRAX
Chemotherapeutics, Antibacterial, Miscellaneous
trimethoprim
PROLOPRIM
meth/meth blue/ba/salicy/hyos PROSED-DS
mth/me blue/salicy/na phos/hyo
URETRON D-S
URIN D.S.
trimethoprim
PRIMSOL
Ketolides
telithromycin
KETEK
Lincosamides
clindamycin hcl capsules
CLEOCIN HCL
clindamycin palmitate
CLEOCIN PALMITATE
Macrolides
azithromycin
ZITHROMAX
ZITHROMAX TRI-PAK
clarithromycin
BIAXIN
BIAXIN XL
ery e-succ/sulfisoxazole
PEDIAZOLE
erythromycin base
ERYC
erythromycin ethylsuccinate
ERYPED 200
erythromycin stearate
ERYTHROCIN
STEARATE
azithromycin
ZMAX
ZMAX PEDIATRIC
erythromycin base
ERY-TAB
PCE
erythromycin ethylsuccinate
E.E.S. 200
ERYPED 200
ERYPED 400
QL + fidaxomicin
DIFICID
ST
Nitrofuran Derivatives
nitrofurantoin macrocrystal
MACRODANTIN
nitrofurantoin/nitrofuran mac
MACROBID
furazolidone
FUROXONE
nitrofurantoin
FURADANTIN
Oxazolidinones
PA linezolid
ZYVOX
PA tedizolid phosphate tablet
SIVEXTRO TABLET
Penicillins
amox tr/potassium clavulanate AUGMENTIN
AUGMENTIN ES-600
AUGMENTIN XR
amoxicillin trihydrate
AMOXIL
ampicillin trihydrate
POLYCILLIN
dicloxacillin sodium
PATHOCIL
penicillin v potassium
V-CILLIN K
Quinolones
ciprofloxacin
CIPRO ORAL
SUSPENSION
ciprofloxacin hcl
CIPRO
levofloxacin
LEVAQUIN
NEUPOGEN
NEULASTA
LEUKINE
PLETAL
PLAVIX 75MG
PLAVIX 300MG
PERSANTINE
EFFIENT
BRILINTA
AGRYLIN
PROMACTA
MEPHYTON
ANDROXY
DEPO-TESTOSTERONE
DELATESTRYL
ANDROID
METHITEST
TESTRED
ANDROGEL
AXIRON
PA testosterone
PA testosterone solution
Estrogen/Androgen Combinations
estrogen, ester/me-testosterone ESTRATEST H.S.
Estrogenic Agents
estradiol
CLIMARA
ESTRACE
estropipate
OGEN
estradiol
ALORA
ESTRADERM
QL
VIVELLE-DOT
QL estradiol/noreth ac
COMBIPATCH
estrogens, conj/bazedoxifene
DUAVEE
estrogen, con/m-progest acet
PREMPHASE
PREMPRO
estrogens, conjugated
PREMARIN
estrogens, esterified
MENEST
norethind ac/ethinyl estradiol
FEMHRT
Progestational Agents
medroxyprogesterone acet
PROVERA
norethindrone acetate
AYGESTIN
progesterone, micronized
PROMETRIUM
IMMUNOSUPPRESSION/MODULATION
Immunomodulators
PA imiquimod
ALDARA
PA interferon alfa-2b, recomb.
INTRON A
Immunosuppressives
azathioprine
IMURAN
cyclosporine
SANDIMMUNE
cyclosporine, modified
NEORAL
mycophenolate mofetil
CELLCEPT
sirolimus
RAPAMUNE
tacrolimus anhydrous
PROGRAF
everolimus
ZORTRESS
INFECTIOUS DISEASE - BACTERIAL
Absorbable Sulfonamides
sulfadiazine
SULFADIAZINE
PortfolioHigh Formulary – October 2014
BACTRIM DS
SEPTRA
SEPTRA DS
GANTRISIN
8
PortfolioHigh Formulary
moxifloxacin hcl
ofloxacin
Tetracyclines
doxycycline hyclate
doxycycline monohydrate
minocycline hcl
AVELOX
AVELOX ABC PACK
FLOXIN
benefit.
acyclovir
ZOVIRAX
ganciclovir
CYTOVENE
valacyclovir hcl
VALTREX
QL elvitegravir/cobicistat,
STRIBILD
emtricitabine/tenofovir disoproxil
fumarate
QL oseltamivir phosphate
TAMIFLU
ribavirin
VIRAZOLE
Antivirals, HIV-Spec, Non-Peptidic Protease Inhib
QL darunavir ethanolate
PREZISTA
PA tipranavir
APTIVUS
PA tipranavir/vitamin e tpgs
APTIVUS
Antivirals, HIV-Spec, Nucleoside-Nucleotide Analog
QL emtricitabine/tenofovir
TRUVADA
Antivirals, HIV-Spec., Nucleoside Analog, RTI Comb
PA abacavir/lamivudine/zidovudine TRIZIVIR
QL abacavir sulfate/lamivudine
EPZICOM
QL lamivudine/zidovudine
COMBIVIR
Antivirals, HIV-Specific, CCR5 Co-Receptor Antag.
PA maraviroc
SELZENTRY
Antivirals, HIV-Specific, Fusion Inhibitors
QL + enfuvirtide
FUZEON
ST
Antivirals, HIV-Specific, Non-Nucleoside, RTI
QL nevirapine
VIRAMUNE
nevirapine ER
VIRAMUNE XR
delavirdine mesylate
RESCRIPTOR
efavirenz
SUSTIVA
PA etravirine
INTELENCE
PA rilpivirine
EDURANT
Antivirals, HIV-Specific, Nucleoside Analog, RTI
QL abacavir sulfate
ZIAGEN
QL didanosine
VIDEX EC
QL stavudine
ZERIT
QL zidovudine
RETROVIR
QL didanosine
VIDEX
QL emtricitabine
EMTRIVA
QL lamivudine
EPIVIR
Antivirals, HIV-Specific, Nucleotide Analog, RTI
QL tenofovir disoproxil fumarate
VIREAD
Antivirals, HIV-Specific, Protease Inhibitor Comb
QL lopinavir/ritonavir
KALETRA
Antivirals, HIV-Specific, Protease Inhibitors
atazanavir sulfate
REYATAZ
PA fosamprenavir calcium
LEXIVA
indinavir sulfate
CRIXIVAN
nelfinavir mesylate
VIRACEPT
QL ritonavir
NORVIR
QL + saquinavir mesylate
INVIRASE
ST
Antivirals, HIV-1 Integrase Strand Transfer Inhibtors
PA dolutegravir
TIVICAY
raltegravir potassium
ISENTRESS
Antiviral Combination Nucleoside, Nucleotide & Non-Nucleoside
RTI
QL efavirenz/emtricitab/tenofovir
ATRIPLA
PA emtricitab/rilpivirine/tenofovir
COMPLERA
Hepatitis B Treatment Agents
adefovir dipivoxil
HEPSERA
lamivudine
EPIVIR HBV
entecavir
BARACLUDE
telbivudine
TYZEKA
Hepatitis C Treatment Agents
ribavirin 200mg
COPEGUS
REBETOL
PA peginterferon alfa-2a
PEGASYS
VIBRA-TABS
VIBRAMYCIN
VIBRAMYCIN ORAL
SUSPENSION
DYNACIN
MINOCIN
ALA-TET
VIBRAMYCIN SYRUP
tetracycline hcl
doxycycline calcium
INFECTIOUS DISEASE - FUNGAL
Antifungal Agents
clotrimazole
MYCELEX
fluconazole
DIFLUCAN
itraconazole
SPORANOX
ketoconazole
NIZORAL
terbinafine hcl
LAMISIL
voriconazole
VFEND
terbinafine hcl
LAMISIL GRANULES
Antifungal Antibiotics
griseofulvin ultramicrosize
GRIS-PEG
nystatin
MYCOSTATIN
griseofulvin suspension
GRISEOFULVIN V
INFECTIOUS DISEASE - MISCELLANEOUS
Aminoglycosides
neomycin sulfate
MYCIFRADIN
PA tobramycin
TOBI
PA tobramycin inhalation powder
TOBI PODHALER
Anti-Mycobacterium Agents
ethambutol hcl
MYAMBUTOL
isoniazid
NYDRAZID
pyrazinamide
PYRAZINAMIDE
Antileprotics
dapsone
AVLOSULFON
PA thalidomide
THALOMID
Antitubercular Antibiotics
rifampin
RIFADIN
rifampin/isoniazid
RIFAMATE
Rifamycins and Related Derivative Antibiotics
QL rifaximin 550mg
XIFAXAN
Vancomycin & Derivatives
QL vancomycin hcl
VANCOCIN HCL
INFECTIOUS DISEASE - PARASITIC
Amebacides
paromomycin sulfate
HUMATIN
iodoquinol
YODOXIN
Anaerobic Antiprotozoal-Antibacterial Agents
metronidazole
FLAGYL
metronidazole
FLAGYL ER
Anthelmintics
mebendazole
VERMOX
praziquantel
BILTRICIDE
Antimalarial Drugs
chloroquine phosphate
ARALEN PHOSPHATE
hydroxychloroquine sulfate
PLAQUENIL
mefloquine hcl
LARIAM
quinine sulfate
QUALAQUIN
primaquine phosphate
PRIMAQUINE
pyrimethamine
DARAPRIM
pyrimethamine/sulfadoxine
FANSIDAR
Antiprotozoal Drugs, Miscellaneous
pentamidine isethionate
NEBUPENT
INFECTIOUS DISEASE - VIRAL
All oral, non-experimental antiviral agents used for the treatment
of AIDS or HIV-related diseases are considered a formulary
PortfolioHigh Formulary – October 2014
9
PortfolioHigh Formulary
PA
peginterferon alfa-2b
PA simeprevir
PA sofosbuvir
INFLAMMATORY DISEASE
Anti-Arthritic & Chelating Agents
penicillamine
LOCAL ANESTHESIA
Local Anesthetics
lidocaine hcl
XYLOCAINE
LOWER GASTROINTESTINAL DISORDERS - BOWEL INFLAMMAT
Bowel Antiinflamatory Agents
sulfasalazine
AZULFIDINE
Chronic Inflam. Colon Dx, 5-A-Salicylat, Rectal Tx
mesalamine
SFROWASA
mesalamine w/cleansing wipes ROWASA
mesalamine
CANASA
Drug Tx-Chronic Inflam. Colon Dx, 5-Aminosalicylat
balsalazide disodium
COLAZAL
mesalamine
APRISO
ASACOL
Hemorrhoidal Preparations
hc acetate/pramoxine hcl
PROCTOCREAM-HC
hc acetate/pramoxine hcl
ANALPRAM HC
Irritable Bowel Agents, Guanylate Cylase-C Agonists
QL linaclotide
LINZESS
Rectal Preparations
hydrocortisone
PROCTO-KIT
PROCTOCORT
PROCTOCREAM-HC
hydrocortisone acetate
ANUSOL-HC
PROCTOCORT
hc acetate/pramoxine hcl
PROCTOFOAM-HC
Rectal/Lower Bowel Prep., Glucocort. (Non-Hemorr)
hydrocortisone
CORTENEMA
LOWER GASTROINTESTINAL DISORDERS - OTHER
Ammonia Inhibitors
lactulose
CHRONULAC
sodium phenylbutyrate
BUPHENYL POWDER
sodium phenylbutyrate
BUPHENYL TABLET
Antidiarrheals
diphenoxylate hcl/atrop sulf
LOMOTIL
Bile Salts
ursodiol
ACTIGALL
URSO
URSO FORTE
Laxatives & Cathartics
peg 3350/na sulf,bicarb,cl/kcl
COLYTE WITH FLAVOR
PACKETS
polyethylene glycol 3350
MIRALAX
sod chloride/nahco3/kcl/peg's
NULYTELY WITH
FLAVOR PACKS
lactulose
KRISTALOSE
QL lubiprostone
AMITIZA
peg 3350/na sulf,bicarb,cl/kcl
GOLYTELY
OCL
Narcotic Antagonists, Peripherally-Acting
PA methylnaltrexone bromide
RELISTOR
Glucagon-Like Peptide (GLP-2) Analogs
PA teduglutide [rDNA origin]
GATTEX
MISCELLANEOUS AGENTS
Anaphylaxis Therapy Agents
epinephrine
EPIPEN
TWINJECT
epinephrine
EPIPEN JR
Parasympathetic Agents
bethanechol chloride
URECHOLINE
cevimeline hcl
EVOXAC
pilocarpine hcl
SALAGEN
NEOPLASTIC DISEASE
Alkylating Agents
cyclophosphamide
CYTOXAN
hydroxyurea
HYDREA
lomustine
CEENU
PA temozolomide
TEMODAR
PEGASYS
CONVENIENCE PACK
PEGASYS PROCLICK
CONVENIENCE PACK
PEGINTRON
PEGINTRON REDIPEN
OLYSIO
SOVALDI
CUPRIMINE
DEPEN
Anti-Arthritic, Folate Antagonist Agents
methotrexate sodium
RHEUMATREX
Anti-Inflammatory Tumor Necrosis Factor Inhibitor
PA adalimumab
HUMIRA
PA etanercept
ENBREL
Anti-Inflammatory, Pyrimidine Synthesis Inhibitors
leflunomide
ARAVA
Bradykinin B2 Receptor Antagonists
PA
icatibant acetate
FIRAZYR
Glucocorticoids
budesonide
BUDESONIDE
cortisone acetate
CORTONE ACETATE
dexamethasone tablet, elixir
DECADRON
hydrocortisone
CORTEF
methylprednisolone
MEDROL
prednisolone
MILLIPRED
MILLIPRED DP
prednisolone sod phosphate
ORAPRED
PEDIAPRED
prednisone
DELTASONE
PREDNISONE
INTENSOL
budesonide
ENTOCORT EC
Mineralocorticoids
fludrocortisone acetate
FLORINEF ACETATE
NSAIDs, COX Inhibitor-Type & Proton Pump Inhibitor
Combinations
naproxen/esomeprazole mag
VIMOVO
NSAIDs, Cyclooxygenase Inhibitor-Type
diclofenac sodium
VOLTAREN
VOLTAREN-XR
etodolac
LODINE
fenoprofen calcium
NALFON TABLET
flurbiprofen
ANSAID
ibuprofen
MOTRIN
indomethacin
INDOCIN
INDOCIN SR
ketoprofen
ORUVAIL
QL ketorolac tromethamine
TORADOL
meclofenamate sodium
MECLOMEN
meloxicam
MOBIC
nabumetone
RELAFEN
naproxen
EC-NAPROSYN
NAPROSYN
naproxen sodium
ANAPROX
ANAPROX DS
oxaprozin
DAYPRO
piroxicam
FELDENE
sulindac
CLINORIL
tolmetin sodium
TOLECTIN 600
celecoxib
CELEBREX
fenoprofen calcium
NALFON CAPSULE
indomethacin
INDOCIN SUPPOS.
INDOCIN ORAL SUSP.
PortfolioHigh Formulary – October 2014
10
PortfolioHigh Formulary
altretamine
busulfan
chlorambucil
melphalan
Antiandrogenic Agents
bicalutamide
flutamide
PA abiraterone acetate
PA enzalutamide
QL nilutamide
Antimetabolites
PA capecitabine
mercaptopurine
methotrexate sodium
Selective Estrogen Receptor Modulators (SERM)
tamoxifen citrate
NOLVADEX
PA toremifene citrate
FARESTON
Selective Retinoid X Receptor Agonists (RXR)
PA bexarotene
TARGRETIN
Steroid Antineoplastics
megestrol acetate
MEGACE
estramustine phosphate sodium
EMCYT
NEUROLOGICAL DISEASE - MISCELLANEOUS
Agents to Treat Multiple Sclerosis
PA dimethyl fumarate
TECFIDERA
PA fingolimod hcl
GILENYA
PA glatiramer acetate
COPAXONE
PA interferon beta-1a
AVONEX
PA interferon beta-1a/albumin
AVONEX
ADMINISTRATION PACK
PA
REBIF
PA
REBIF REBIDOSE
PA interferon beta-1b
BETASERON
Fibromyalgia Agents, Serotonin-Norepineph RU Inhibitor
milnacipran hcl
SAVELLA
ORAL/PHARYNGEAL DISORDERS
Dental Aids & Preparations
chlorhexidine gluconate
PERIDEX
PERISOL
triamcinolone acetonide
KENALOG IN ORABASE
Nose Preparations, Antibiotics
mupirocin calcium
BACTROBAN NASAL
Nose Preparations, Miscellaneous (Rx)
ipratropium bromide
ATROVENT
OTHER DRUGS
Appetite Stimulators for Anorexia, Cachexia, Wasting Syndrome
megestrol acetate
MEGACE
megestrol acetate
MEGACE ES
General Inhalation Agents
sodium chloride for inhalation
HYPER-SAL 7%
Needles/Needleless Devices
needles, insulin disp., safety
NOVOFINE
NOVOFINE 32 PEN
NEEDLE
needles, insulin disp., safety
NOVOFINE AUTOCOVER
Somatostatic Agents
octreotide acetate
SANDOSTATIN
lanreotide acetate
SOMATULINE DEPOT
octreotide acetate
SANDOSTATIN LAR
OTHER RESPIRATORY DISORDERS
Cystic Fibrosis Transmembrane Conductance Regulator (CFTR)
Potentiators
PA ivacaftor
KALYDECO
Mucolytics
acetylcysteine
MUCOMYST-10
PA dornase alfa
PULMOZYME
PAIN MANAGEMENT - ANALGESICS
Analgesic, Non-Salicylate & Barbiturate Combinations
butalbital/acetaminophen
PHRENILIN
butalbital/acetaminophen
PHRENILIN FORTE
Analgesic, Salicylate, Barbiturate & Xanthine Combinations
butalbital/aspirin/caffeine
FIORINAL
Analgesic, Non-Salicylate, Barbiturate & Xanthine Combinations
butalb/acetaminophen/caffeine ESGIC
FIORICET
Analgesic/Antipyretics, Salicylates
diflunisal
DOLOBID
salsalate
DISALCID
Analgesics, Narcotics
CU + buprenorphine hcl
SUBUTEX
PA
codeine phos/carisoprodol/asa SOMA COMPOUND
HEXALEN
MYLERAN
LEUKERAN
ALKERAN
CASODEX
EULEXIN
ZYTIGA
XTANDI
NILANDRON
XELODA
PURINETHOL
METHOTREXATE 2.5MG
TABLET
METHOTREXATE VIAL
THIOGUANINE
OFORTA
PURIXAN
TREXALL
methotrexate sodium
thioguanine
fludarabine phosphate
ST mercaptopurine
methotrexate sodium
Antineoplastic - Aromatase Inhibitors
anastrozole
ARIMIDEX
PA exemestane
AROMASIN
letrozole
FEMARA
Antineoplastic – Hedgehog Pathway Inhibitors
PA
vismodegib
ERIVEDGE
Antineoplastic – Janus Kinase (JAK) Inhibitors
PA
ruxolitinib
JAKAFI
Antineoplastic - Topoisomerase I Inhibitors
topotecan hcl
HYCAMTIN
Antineoplastic - Immunomodulator Agents
PA lenalidomide
REVLIMID
PA pomalidomide
POMALYST
Antineoplastic - Systemic Enzyme Inhibitors
PA afatinib
GILOTRIF
PA axitinib
INLYTA
PA bosutinib
BOSULIF
PA cabozanitinib
COMETRIQ
PA ceritinib
ZYKADIA
PA crizotinib
XALKORI
PA dabrafanib
TAFINLAR
PA dasatinib
SPRYCEL
PA erlotinib hcl
TARCEVA
PA ibrutinib
IMBRUVICA
PA imatinib mesylate
GLEEVEC
PA lapatinib ditosylate
TYKERB
PA nilotinib hydrochloride
TASIGNA
PA pazopanib hydrochloride
VOTRIENT
PA ponatinib
ICLUSIG
PA regorafenib
STIVARGA
PA sorafenib tosylate
NEXAVAR
PA sunitinib malate
SUTENT
PA trametinib dimethyl sulfoxide
MEKINIST
PA vemurafenib
ZELBORAF
Antineoplastic, Histone Deacetylase Inhibitors, HDIS
vorinostat
ZOLINZA
Antineoplastics, Miscellaneous
etoposide
VEPESID
mitotane
LYSODREN
procarbazine hcl
MATULANE
tretinoin
VESANOID
PA everolimus
AFINITOR
PA
AFINITOR DISPERZ
Chemotherapy Rescue/Antidote Agents
leucovorin calcium
LEUCOVORIN CALCIUM
PortfolioHigh Formulary – October 2014
11
PortfolioHigh Formulary
PARKINSON’S DISEASE
Antiparkinsonism Drugs, Anticholinergic
benztropine mesylate
COGENTIN
trihexyphenidyl hcl
ARTANE
Antiparkinsonism Drugs, Other
amantadine hcl
SYMMETREL
bromocriptine mesylate
PARLODEL
carbidopa/levodopa
PARCOPA
SINEMET 25-100
SINEMET CR
carbidopa/levodopa/entacapone STALEVO
entacapone
COMTAN
pramipexole di-hcl
MIRAPEX
ropinirole hcl
REQUIP
QL +
REQUIP XL
ST
selegiline hcl
ELDEPRYL
QL rasagiline mesylate
AZILECT
QL + rotigotine
NEUPRO
ST
Decarboxylase Inhibitors
carbidopa
LODOSYN
SEIZURE DISORDER
Anticonvulsants
carbamazepine
CARBATROL
TEGRETOL
TEGRETOL XR
clonazepam
KLONOPIN
QL diazepam
DIASTAT
divalproex sodium
DEPAKOTE
DEPAKOTE ER
DEPAKOTE SPRINKLE
ethosuximide
ZARONTIN
gabapentin
NEURONTIN
lamotrigine
LAMICTAL
levetiracetam
KEPPRA
oxcarbazepine
TRILEPTAL
phenytoin
DILANTIN-125
DILANTIN CHEW TAB
phenytoin sodium extended
DILANTIN
PHENYTEK
primidone
MYSOLINE
topiramate
TOPAMAX
TOPAMAX SPRINKLE
valproate sodium
DEPAKENE SYRUP
valproic acid
DEPAKENE CAPSULES
zonisamide
ZONEGRAN
pregabalin
LYRICA
SKELETAL MUSCLE DISORDER
Skeletal Muscle Relaxants
baclofen
LIORESAL
carisoprodol
SOMA
carisoprodol/aspirin
SOMA COMPOUND
chlorzoxazone
PARAFON FORTE DSC
cyclobenzaprine hcl
FLEXERIL
dantrolene sodium
DANTRIUM
metaxalone
SKELAXIN
methocarbamol
ROBAXIN
ROBAXIN-750
orphenadrine citrate
NORFLEX
orphenadrine/aspirin/caffeine
NORGESIC FORTE
tizanidine hcl
ZANAFLEX
UPPER GASTROINTESTINAL DISORDERS - DIGESTIVE
Pancreatic Enzymes
amylase/lipase/protease
PANCRELIPASE 5,000
amylase/lipase/protease
CREON
CREON 36K
ULTRASE
ULTRASE MT
WITH CODEINE
DURAGESIC
ACTIQ
VICODIN
VICODIN ES
VICODIN HP
QL hydrocodone bit/acetaminophen LORCET
(325mg)
LORCET PLUS
LORTAB
NORCO
QL hydrocodone bit/acetaminophen LORTAB ELIXIR
(300mg/15ml) oral solution
QL hydrocodone bit/acetaminophen HYCET
oral elixir (325mg/15ml)
hydromorphone hcl
DILAUDID
methadone hcl
DOLOPHINE HCL
QL morphine sulfate
AVINZA
QL morphine sulfate
MS CONTIN
morphine sulfate
MSIR
ORAMORPH SR
ROXANOL
oxycodone hcl
PERCOLONE
ROXICODONE
ROXICODONE
INTENSOL
QL oxycodone hcl/acetaminophen PERCOCET
(325mg)
QL oxycodone hcl/acetaminophen ROXICET
(325mg/5ml)
oxycodone hcl/aspirin
PERCODAN
tramadol hcl
ULTRAM
tramadol hcl/acetaminophen
ULTRACET
QL buprenorphine
BUTRANS
CU + buprenorphine hcl/naloxone hcl
SUBOXONE
PA
QL hydrocodone bit/acetaminophen
STAGESIC-10
(250mg)
QL hydrocodone bit/acetaminophen
XODOL 10-300
(300mg)
hydromorphone hcl
DILAUDID-5
QL oxycodone hcl
OXYCONTIN
QL tapentadol hcl
NUCYNTA
QL tapentadol hcl ER
NUCYNTA ER
Antimigraine Preparations
QL ergotamine tartrate/caffeine
CAFERGOT
QL
MIGERGOT
isomethept/acetaminop/dichlphn MIDRIN
QL naratriptan
AMERGE
QL rizatriptan benzoate
MAXALT
MAXALT MLT
QL sumatriptan
IMITREX NASAL SPRAY
QL sumatriptan succinate
IMITREX TABLET
IMITREX INJECTION
QL + zolmitriptan
ZOMIG
ST
ZOMIG ZMT
Narcotic & Non-Salicylate Analgesic, Barbiturate & Xanthine
Combinations
codeine/butalbit/acetamin/caff
FIORICET WITH
CODEINE
Narcotic & Salicylate Analgesics, Barbiturates & Xanthines
codeine/butalbital/asa/caffein
FIORINAL WITH
CODEINE #3
PA
PA
QL
fentanyl
fentanyl citrate lozenge
hydrocodone bit/acetaminophen
(300mg)
Narcotic Analgesic & Non-Salicylate Analgesic Combinations
acetaminophen with codeine
TYLENOL-CODEINE
NO.3
TYLENOL-CODEINE
NO.4
acetaminophen and codeine
CAPITAL AND CODEINE
PortfolioHigh Formulary – October 2014
12
PortfolioHigh Formulary
VITAMIN AND/OR MINERAL DEFICIENCY
Fluoride Preparations
sodium fluoride
FLUORITAB
FLURA-DROPS
FLURA-TABS
LURIDE
Folic Acid Preparations
folic acid
FOLIC ACID
Multivitamin Preparations
folic acid/mu-vits-min th
VICON FORTE
Pediatric Vitamin Preparations
fluoride ion/iron/vit a,c&d
TRI-VI-FLOR W/IRON
fluoride ion/multivitamins
POLY-VI-FLOR
fluoride ion/multivits w-fe
POLY-VI-FLOR W/IRON
fluoride ion/vit a,c&d
FLUORABON BASIC
Prenatal Vitamin Preparations
prenatal vit 15/iron cb/fa/dss
TRIADVANCE
prenatal vit 16/iron cb/fa/dss
VINATE GT
prenatal vit 18/iron cb/fa/dss
VINATE ULTRA
prenatal vit 95/fe fum/fa
PRENAVITE
Vitamin B Preparations
cyanocobalamin/fa/pyridoxine
FOLGARD RX
Vitamin D Preparations
calcitriol
ROCALTROL
ST
VECTICAL
ergocalciferol
DRISDOL
dihydrotachysterol
DHT
ZENPEP
UPPER GASTROINTESTINAL DISORDERS - SPASTIC DISEASE
Anticholinergics/Antispasmodics
dicyclomine hcl
BENTYL
Belladonna Alkaloids
belladonna alkaloids/phenobarb DONNATAL
hyoscyamine sulfate
ANASPAZ
LEVBID
LEVSIN-SL
UPPER GASTROINTESTINAL DISORDERS - ULCER DISEASE
Anti-Ulcer Preparations
misoprostol
CYTOTEC
sucralfate
CARAFATE
Anti-Ulcer-H.pylori Agents
lansoprazole/amox tr/clarith
PREVPAC
Anticholinergics, Quaternary Ammonium
chlordiazepoxide/clidinium br
LIBRAX
Histamine H2-Receptor Inhibitors
cimetidine hcl
TAGAMET
famotidine
PEPCID
nizatidine
AXID
ranitidine hcl
ZANTAC
Intestinal Motility Stimulants
metoclopramide hcl
REGLAN
Proton-Pump Inhibitors
lansoprazole
PREVACID RX
omeprazole capsules (RX)
PRILOSEC CAPSULES
(RX)
omeprazole magnesium tablets PRILOSEC OTC
(OTC)
TABLETS (OTC)
pantoprazole sodium
PROTONIX
QL + esomeprazole magnesium
NEXIUM
ST
ST lansoprazole
PREVACID SOLUTABS
URINARY TRACT - FUNCTIONAL DISORDERS
Benign Prostatic Hypertrophy/Micturition Agents
alfuzosin
UROXATRAL
finasteride
G
PROSCAR
tamsulosin hcl
FLOMAX
G
dutasteride
AVODART
G + dutasteride/tamsulosin
JALYN
ST
Urinary Tract Analgesic Agents
pentosan polysulfate sodium
ELMIRON
Urinary Tract Anesthetic/Analgesic Agents (Azo-Dye)
phenazopyridine hcl
PYRIDIUM
Urinary Tract Antispasmodic, M(3) Selective Antagonists
solifenacin succinate
VESICARE
Urinary Tract Antispasmodic/Antiincontinence Agents
oxybutynin chloride
DITROPAN XL
tolterodine tartrate
DETROL
DETROL LA
fesoterodine fumarate
TOVIAZ
VAGINAL DISORDERS
Vaginal Antibiotics
metronidazole
METROGEL-VAGINAL
VANDAZOLE
Vaginal Antifungals
miconazole nitrate
butoconazole nitrate
Vaginal Estrogen Preparations
estradiol
estrogens, conjugated
Vaginal Sulfonamides
sulfanilamide
PortfolioHigh Formulary – October 2014
MONISTAT 3
GYNAZOLE-1
ESTRACE
VAGIFEM
PREMARIN
AVC
13
PortfolioHigh Formulary
•
•
•
•
•
•
•
•
•
•
•
Ambien / Ambien CR
Amerge
Amitiza
Androxy
Anoro Ellipta
Arixtra
Astelin
Astepro
Atripla
Atrovent HFA
Avinza
30mg, 45mg, 60mg,
75mg, 90mg
120mg
• Azilect
• Breo Ellipta
• Brilinta
• Butrans
• Bydureon
• Byetta
5mcg
10mcg
• Caduet
• Cafergot
• Cialis
2.5mg, 5mg
10mg, 20mg
• Clozapine (Clozaril)
• Clozaril
• Combipatch
• Combivir
• Concerta
18mg, 27mg, 54mg
36mg
• Crestor
• Cymbalta
• Daliresp
• Desvenlavaxine ER
(Ranbaxy Brand)
• Dexedrine Spansule
5mg, 10mg
15mg
• Diastat
• Dificid
• Dulera
• Effient
• Eliquis
• Emend
40mg
80mg
125mg
• Emend Trifold Pack
• Emtriva
10mg/mL oral solution
200mg capsules
• Epivir
10mg/mL oral solution
150mg tablets
300mg tablets
• Epzicom
• Evista
• Exelon Patch
• Flonase
• Flovent Diskus
50mcg, 100mcg
250mcg
• Flovent HFA
44mcg
110mcg
220mcg
• Flunisolide
• Focalin
• Focalin XR
• Forteo
SPECIALTY INJECTABLE CROSS REFERENCE LISTING
The following cross reference is being provided as a guide to
formulary choices within prominent “specialty” injectable drug
categories. General specialty categories are cross referenced to
their corresponding formulary classification status and page
number. This cross reference is not meant to be all-inclusive.
Please refer to the Table of Contents or Index to determine
formulary status of injectable medications not listed in this cross
reference (e.g., Antineoplastics, Leukocyte Stimulants, etc.).
EPO
Hematinics, Other
Page 7
HEPATITIS C
Hepatitis C Treatment Agents
Page 9
HUMAN GROWTH FACTORS
Growth Hormones
Page 6
LOW MOLECULAR WEIGHT HEPARINS
Heparin and Related Preparations
Page 7
MULTIPLE SCLEROSIS
Agents to Treat Multiple Sclerosis
Page 10
RHEUMATOID ARTHRITIS
Anti-Inflammatory, Pyrimidine Synthesis Inhibitors
Page 9
MEDICATION PRESCRIBING LIMITATIONS
1. AGE RESTRICTIONS (FORMULARY)-Covered for ages:
≤ 25 years old
• Differin
≥ 12 years old
• Fabior
≥ 6 years old
• Maxi-tuss HCX
<18years old
• Plan B
<15 years old
• Plan B One Step
• Protopic
≥ 2 years old
0.03%
≥ 15 years old
0.1%
≥ 6 years old
• Tussionex
2. AGE RESTRICTIONS (NON FORMULARY)-Covered for ages:
• All carbinoxamine containing products ≥ 2 years old
(i.e., Palgic, Tussafed, etc.)
≤ 25 years old
• Atralin
≤ 25 years old
• Avita
≥ 2 years old
• Elidel
≥ 6 years old
• Hycodan
≥ 18 years old
• Oracea
≤ 25 years old
• Refissa
≤ 25 years old
• Renova
≤ 25 years old
• Retin A
≤ 25 years old
• Retin A Micro
≤ 25 years old
• Retin A Micro Pump
≥ 12 years old
• Solodyn
≤ 25 years old
• Tretin-X
≥ 6 years old
• Tussigon
3. QUANTITY RESTRICTIONS (FORMULARY)
• Abilify
30tablets per 30 days
Tablets
900mLper 30 days
Solution
• Abilify Discmelt
90tablets per 30 days
10mg
60tablets per 30 days
15mg
60 tablets per 30 days
• Adderall
• Adderall XR
30 capsules per 30 days
5mg, 10mg, 15mg
60 capsules per 30 days
20mg, 25mg, 30mg
60 units per 30 days
• Advair Diskus
12g (1 inhaler) per 30 days
• Advair HFA
300mL per 28 days
• Alendronate solution
PortfolioHigh Formulary – October 2014
14
30 tablets per 30 days
18 tablets per 30 days
60 capsules per 30 days
120 tablets per 30 days
60 blister packs per 30 days
10 syringes per 30 days
60mL (2 bottles) per 30 days
60mL (2 bottles) per 30 days
30 tablets per 30 days
2 inhalers per 28 days
1 capsule per day
2 capsules per day
30 tablets per 30 days
60 units per 30 days
60 tablets in 30 days
4 patches per 28 days
4 vials per 28 days
1.2mL (1 pen) per 30 days
2.4mL (1 pen) per 30 days
30 tablets per 30 days
40 tablets 28 days
30 tablets per 30 days
6 tablets per 30 days
90 tablets per 30 day
90 tablets per 30 day
8 patches per 30 days
60 tablets per 30 days
30 tablets per 30 days
60 tablets per 30 days
30 tablets per 30 days
60 capsules per 30 days
30 tablets per 30 days
30 tablets per 30 days
60 capsules per 30 days
120 capsules per 30 days
1 kit per copay
20 tablets per 30 days
13g (1 inhaler) per 30 days
30 tablets per 30 days
60 tablets per 30 days
4 capsules per fill
2 capsules per fill
1 capsule per fill
1 packet per fill
720mL per 30 days
30 capsules per 30 days
900mL per 30 days
60 tablets per 30 days
30 tablets per 30 days
30 tablets per 30 days
30 tablets per 30 days
30 patches per 30 days
16gm (1 bottle) per 30 days
60 units (1 diskus) per 30 days
120 units (2 diskus) per 30 days
21.2g (2 inhalers) per 30 days
12g (1 inhaler) per 30 days
24g (2 inhalers) per 30 days
25mL (1 bottle) per 30 days
60 tablets per 30 days
30 capsules per 30 days
1 pen per 30 days
PortfolioHigh Formulary
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10 syringes per 30 days
Fragmin
1 kit per 30 days
Fuzeon
60 capsules per 30 days
Geodon (oral)
Hydrocodone bit/acetaminophen (maximum of 4gm of
acetaminophen per day):
250mg
16 tablets per 1 day supply
300mg
13 tablets per 1 day supply
325mg
12 tablets per 1 day supply
300mg/15ml soln
200ml per 1 day supply
325mg/15ml elixir
184ml per 1 day supply
Imitrex
18 tablets per 30 days
tablets (all strengths)
12 units per 30 days
nasal spray
injection (kits and vials):
4 vials per 30 days
6mg/0.5ml vial
2 kits per 30 days
6mg/0.5ml kit/refill kit
2 kits per 30 days
4mg/0.5ml kit/refill kit
Invirase
300 capsules per 30 days
200mg capsules
120 tablets per 30 days
500mg tablets
30 tablets per 30 days
Invokana
60 tablets per 30 days
Janumet
Janumet XR
30 tablets per 30 days
100-1000mg
60 tablets per 30 days
50-1000mg
60 tablets per 30 days
50-500mg
30 tablets per 30 days
Januvia
60 tablets per 30 days
Jentadueto
Juxtapid
30 capsules per 30 days
5mg, 10mg
90 capsules per 30 days
20mg
Kaletra
390mL per 30 days
oral solution
300 tablets per 30 days
100/25mg tablets
120 tablets per 30 days
200/50mg tablets
30 capsules per 30 days
Linzess
120 capsules per 30 days
Lovaza
20 syringes per 30 days
Lovenox
2.5ml per 30 days
Lumigan
60 capsules per 30 days
Marinol
18 tablets per 30 days
Maxalt
Maxalt MLT
Metadate CD
60 tablets per 30 days
30mg
30 tablets per 30 days
10mg, 20mg, 40mg,
60mg
90 tablets per 30 days
Metadate ER
90 tablets per 30 days
Methylin
90 tablets per 30 days
Methylin Chew Tab
90 tablets per 30 days
Methylin ER
20 units per 28 days
Migergot
90 tablets per 30 days
MS Contin
Namenda
60 tablets per 30 days
tablets
49 tablets per 28 days
titration pack
300mLper 30 days
solution
Namenda XR
30 capsules per 30 days
capsules
28 capsules per 28 days
titration pack
16.5g (1 canister) per 30 days
Nasacort AQ
25ml (1 bottle) per 30 days
Nasarel
17g (1 canister) per 30 days
Nasonex
30 patches per 30 days
Neupro
Nexium
Capsules (all strengths) 30 capsules per 30 days
30 packets per 30 days
Packets (all strengths)
60 tablets for first 30 days, then 30
Nilandron 150mg tablet
tablets per 30 days thereafter
Norvir
450mL per 30 days
oral solution
360 capsules/tablets per 30 days
capsules/tablets
180 tablets per 30 days
Nucynta
60 tablets per 30 days
Nucynta ER
1 ring per 28 days
Nuvaring
PortfolioHigh Formulary – October 2014
3 patches per 28 days
Ortho Evra
Oxycodone hcl/acetaminophen (maximum of 4gm
acetaminophen per day):
325mg
12 tablets per 1 day supply
325mg/5ml soln
61mL per 1 day supply
•
Oxycontin
10mg, 15mg, 20mg,
60 tablets per 30 days
30mg, 40mg, 60mg
120 tablets per 30 days
80mg
120mL per 30 days
• Perforomist
• Picato
3 tubes per 56 days
0.015% gel
2 tubes per 56 days
0.05% gel
4 tablets per 30 days
• Plavix 300mg tablet
• Prezista
240mL per 30 days
oral suspension
180 capsules per 30 days
capsules
480 tablets per 30 days
75mg tablets
240 tablets per 30 days
150mg tablets
400mg, 600mg tablets 60 tablets per 30 days
30 tablets per 30 days
800mg tablets
30 tablets per 30 days
• Pristiq
30 tablets per 30 days
• Promacta
60mL (30 respules) per 30 days
• Pulmicort Respules
8.7g (1 canister) per 30 days
• Qnasl
• Quillivant XR
1 bottle per 30 days
60mL
2 bottles per 30 days
120mL
2 bottles per 30 days
150mL
2 bottles per 30 days
180mL
17.4g (2 inhalers) per 30 days
• QVAR
•
Ranexa
120 tablets per 30 days
500mg
60 tablets per 30 days
1000mg
30 tablets per 30 days
• Requip XL
64 vials per 30 days
• Restasis
• Retrovir
1800mL per 30 days
syrup
180 capsules per 30 days
capsules
60 tablets per 30 days
tablets
90 tablets per 30 days
• Revatio
• Risperdal
60 tablets per 30 days
Tablets/ODT
240ml per 30 days
Solution
90 tablets per 30 days
• Ritalin
• Ritalin LA
10mg, 20mg and 40mg 30 capsules per 30 days
60 capsules per 30 days
30mg
90 tablets per 30 days
• Ritalin SR
91 tablets per 84 days
• Seasonale
60 doses (1 diskus) per 30 days
• Serevent
90 tablets per 30 days
• Seroquel
30 tablets per 30 days
• Seroquel XR
• Simcor
30 tablets per 30 days
500/20mg, 500/40mg
30 tablets per 30 days
1000/40mg
750/20mg, 1000/20mg 60 tablets per 30 days
30 capsules per 30 days
• Spiriva
30 capsules per 30 days
• Sonata
6 tablets per 30 days
• Staxyn
• Strattera
60 capsules per 30 days
10mg, 18mg, 25mg,
30 capsules per 30 days
40mg
60mg, 80mg, 100mg
30 tablets per 30 days
• Stribild
30 capsules per 30 days
• Symbyax
• Tamiflu
40 tablets per 183 days
30mg tablets
20 tablets per 183 days
45mg, 75mg tablets
360mL per 183 days
suspension
NOTE: The FDA recommends a maximum of 5 days of therapy with
this drug
20 tablets per fill
• Toradol
30 tablets per 30 days
• Tradjenta
15
PortfolioHigh Formulary
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Travatan
Travatan Z
Truvada
Tudorza
Uloric
Vascepa
Vancocin Oral
125mg and 250mg
Viagra
Victoza
Videx
solution
capsules
Viramune
solution
tablets
Viread
powder
tablets
Vivelle Dot
Vyvanse
Xarelto
10mg, 20mg
15mg
Xifaxan 550mg
Zenzedi
2.5mg, 5mg, 7.5mg,
15mg
10mg
20mg, 30mg
Zerit
oral solution
capsules
Zetia
Ziagen
solution
tablets
Zofran oral solution
4mg/5ml oral solution
Zomig
Zomig ZMT
Tablets
Nasal Spray
Zyprexa
Zyprexa Zydis
•
•
2.5ml per 30 days
30 tablets per 30 days
1 inhaler per 30 days
30 tablets per30 days
120 capsules per 30 days
•
•
•
•
•
•
•
•
•
•
•
40 capsules per 30 days
6 tablets per 30 days
9mL (3 pens) per 30 days
1200mL per 30 days
60 capsules per 30 days
1200mL per 30 days
60 tablets per 30 days
225g powder per 30 days
30 tablets per 30 days
8 patches per 30 days
30 tablets per 30 days
•
•
•
•
•
•
•
•
•
•
30 tablets per 30 days
42 tablets per 21 days followed by
30 tablets per 30 days
60 tablets per 30 days
90 tablets per 30 days
180 tablets per 30 days
60 tablets per 30 days
•
•
•
•
2400mL per 30 days
60 tablets per 30 days
30 tablets per 30 days
900mL per 30 days
60 tablets per 30 days
•
•
•
•
•
•
•
•
50ml per 15 days
12 tablets per 30 days
12 units per 30 days
30 tablets per 30 days
•
•
•
4. QUANTITY RESTRICTIONS (NON FORMULARY)
30 tablets per 30 days
• Aciphex
30 capsules per 30 days
• Aciphex Sprinkle
2 tablets per day
• Acticlate
• Actonel
30 tablets per 30 days
5mg, 30mg
4 tablets per 28 days
35mg
1 tablet per 28 days
150mg
60 tablets per 30 days
• Adoxa
• Advicor
500/20mg, 1000/40mg 30 tablets per 30days
60 tablets per 30 days
750/20mg, 100/20mg
17.8g (2 inhalers) per 30 days
• Aerospan
• Allegra
300ml per 30 days
30mg/5ml oral susp
4 units per 28 days
• Alsuma
30 tablets per 30 days
• Altoprev
12.2gms (2 inhalers) per 25 days
• Alvesco
• Anzemet
8 tablets per fill
50mg
4 tablets per fill
100mg
30 tablets per 30 days
• Aplenzin
• Aptiom
30 tablets per 30 days
200, 400, 800mg
60 tablets per 30 days
600mg
30 capsules per 30 days
• Arcapta
4 tablets in 28 days
• Atelvia
PortfolioHigh Formulary – October 2014
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16
Axert
Banzel
200mg
400mg
40mg/ml suspension
Asmanex
Beconase AQ
Binosto
Brintellix
Brisdelle
Brovana
Cambia
Caverject
Cesamet
Chantix
Clarinex
2.5mg, 5mg reditab
5mg
5mg/10ml syrup
Clarinex-D 12 hour
Climara Pro
Conzip
Cosopt PF
Daytrana
Demerol
Depo-Provera
Depo-subQ Provera 104
Desoxyn
Desvenlafaxine ER
(fumarate)
Dexilant
D.H.E.45
Diclegis
Doryx
75mg, 100mg, 150mg
200mg
Duexis
Dymista
Edex
Edluar
Emsam
Epaned
Ergomar SL
Esomeprazole Strontium
24.65mg
49.3mg
Estring
Evzio
Fanapt
Tablets
Titration Pack
Farxiga
Fazaclo
Felbatol
400mg
600mg
Solution
Fetzima
Firmagon 80mg/vial
Firmagon 120mg/vial
Foradil
Forfivo XL
Frova
Fulyzaq
Fycompa
2mg
4mg, 6mg
8mg, 10mg, 12mg
Gabitril
2mg, 4mg, 12mg
16mg
12 tablets per 30 days
480 tablets per 30 days
240 tablets per 30 days
2400ml per 30 days
1 canister per 30 days
25g (1 bottle) per 30 days
4 tablets per 28 days
30 tablets per 30 days
30 capsules per 30 days
120mL per 30 days
9 packets per 30 days
1 dose per 5 days
180 capsules per 30 days
56 tablets per 28 days
30 tablets per 30 days
30 tablets per 30 days
300ml per 30 days
60 tablets per 30 days
4 patches per 30 days
30 capsules per 30 days
60 droperettes per 30 days
30 patches per 30 days
180 tablets or 900mL per 30 days
1mL per 84 days
0.65mL per 84 days
150 tablets per 30 days
30 tablets per 30 days
30 capsules per 30 days
30 ampules per 28 days
120 tablets per 30 days
60 tablets per 30 days
30 tablets per 30 days
90 tablets per 30 days
23g (1 bottle) per 30 days
1 dose per 5 days
30 tablets per 30 days
30 patches per 30 days
1200mL per 30 days
40 tablets per 28 days
30 capsules per 30 days
120 capsules per 30 days
1 ring per 90 days
0.8mL (2 syringes) per 365 days
60 tablets per 30 days
1 pack per 28 days
30 tablets per 30 days
90 tablets per 30 days
270 tablets per 30 days
180 tablets per 30 days
900mL per 30 days
30 capsules per 30 days
1 vial per 30 days
2 vials per 365 days
60 capsules per 30 days
30 capsules per 30 days
18 tablets per 30 days
60 tablets per 30 days
120 tablets per 30 days
60 tablets per 30 days
30 tablets per 30 days
120 tablets per 30 days
90 tablets per 30 days
PortfolioHigh Formulary
•
Gralise
300mg tablets
600mg tablets
Starter Pack
• Granisol solution
• Hemangeol
• Horizant
300mg
600mg
• Hydrocodone
bit/acetaminophen
Xodol 5-300mg
Zamicet Soln
325mg/15ml
• Intermezzo
• Intuniv
• Invega
1.5mg, 3mg and 9mg
6mg
• Iprivask
• Kadian
10mg, 20mg, 30mg,
40mg, 50mg, 60mg,
70mg, 80mg, 100mg,
130mg, 150mg
200mg
• Kapvay
• Karbinal ER
• Kazano
• Khedezla
• Kombiglyze XR
2.5-1000mg
5-500mg
5-1000mg
• Kytril
• Lamictal ODT
25mg, 50mg
100mg
200mg
• Lamictal XR
25mg, 50mg
100mg
200mg, 250mg, 300mg
• Latuda
20mg, 40mg, 60mg
80mg
• Lescol
• Lescol XL
• Levitra
• Liptruzet
• Livalo
• LoSeasonique
• Lunesta
• Luvox CR
• Luzu
• Menostar
• Migranal
• Mirapex ER
• Mirvaso
• Monodox
• Muse
• Myalept 11.3mg vial
• Myrbetriq
• Nesina
• Nicotrol cartridge
•
•
•
•
Nicotrol NS
Oleptro ER
150mg
300mg
Omnaris
Onfi
Tablets
Suspension
PortfolioHigh Formulary – October 2014
•
•
30 tablets per 30 days
Onglyza
Opana ER
5mg, 7.5mg, 10mg,
60 tablets per 30 days
15mg, 20mg
120 tablets per 30 day
30mg, 40mg
30 capsules per 30 days
• Oracea
30 tablets per 30 days
• Oseni
30 tablets per 30 days
• Osphena
1.6mL per 28 days
• Otrexup
• Oxycodone hcl/acetaminophen (maximum of 4gm
acetaminophen per day):
300mg
13 tablets per 1 day supply
325mg
12 tablets per 1 day supply
• Oxtellar XR
30 tablets per 30 days
150mg, 300mg
120 tablets per 30 days
600mg
30.5g (1 bottle) per 30 days
• Patanase
30 tablets per 30 days
• Pexeva
• Potiga
270 tablets per 30 days
50mg
200mg, 300mg, 400mg 90 tablets per 30 days
60 capsules per 30 days
• Pradaxa
1800mL per 30 days
• Procentra
1 canister per 30 days
• Pulmicort Flexhaler
• Qudexy XR
30 capsules per 30 days
25mg, 50mg, 100mg
60 capsules per 30 days
150mg, 200mg
• Razadyne
60 tablets per 30 days
Tablets
200mL (2 bottles) per 30 days
Solution
30 capsules per 30 days
• Razadyne ER
2 boxes (#20 diskhalers/box) in 183
• Relenza
days
12 tablets per 30 days
• Relpax
10mL (2 bottles) per 30 days
• Rescula
17.2g (2 canisters) per 30 days
• Rhinocort Aqua
• Risperdal/Risperdal M-Tab 60 tablets per 30 days
30 tablets per 30 days
• Rozerem
180 tablets per 30 days
• Sabril
• Samsca
30 tablets per 365 days
15mg tablets
60 tablets per 365 days
30mg tablets
4 patches per 28 days
• Sancuso
60 tablets per 30 days
• Saphris
91 tablets per 84 days
• Seasonique
30 tablets per 30 days
• Silenor
4 tablets per 365 days
• Sitavig
30 tablets per 30 days
• Solodyn
5 bottles per 30 days
• Sprix
10.2g (1 inhaler) per 30 days
• Symbicort
6 tablets per 30 days
• Stendra
4 units per 28 days
• Sumavel Dosepro
4 pens per 28 days
• Tanzeum
90 tablets per 30 days
• Tasmar
60 droperettes per 30 days
• Timoptic Ocudose
9 tablets per 30 days
• Treximet
• Trokendi XR
30 capsules per 30 days
25mg, 50mg, 100mg
60 capsules per 30 days
200mg
10g (1 bottle) per 30 days
• Veramyst
540mL per 30 day
• Versacloz
• Viibryd 10mg, 20mg, 40mg 30 tablets per 30 days
• Vimpat
60 tablets per 30 days
Tablets
1200mL per 30 days
Solution
30 tablets per 30 days
• Vytorin
360 tablets per 30 days
• Xartemis XR
10gm (2 tubes) per 365 days
• Xerese
300mL per 30 days
• Xyzal Solution
• Zegerid
30 packets per 30 days
Powder
30 capsules per 30 days
Capsules
60 tablets per 30 days
• Zelapar
6.1g (1 bottle) per 30 days
• Zetonna
90 tablets per 30 days
90 tablets per 30 days
78 tablets per 30 days
60mL per 30 days
360mL (3 bottles) per 30 days
30 tablets per 30 days
60 tablets per 30 days
(max 4gm per day)
13 tablets per 1 day supply
184mL per 1 day supply
30 tablets per 30 days
30 tablets per 30 days
30 tablets per 30 days
60 tablets per 30 days
6 syringes per 30 days
60 capsules per 30 days
120 capsules per 30 days
120 tablets per 30 days
960mL (2 bottles) per 30 days
60 tablets per 30 days
30 tablets per 30 days
60 tablets per 30 days
30 tablets per 30 days
30 tablets per 30 days
8 tablets per 30 days
180 tablets per 30 days
90 tablets per 30 days
60 tablets per 30 days
180 tablets per 30 days
90 tablets per 30 days
60 tablets per 30 days
30 tablets per 30 days
60 tablets per 30 days
60 tablets per 30 days
30 tablets per 30 days
6 tablets per 30 days
30 tablets per 30 days
30 tablets per 30 days
91 tablets per 84 days
30 tablets per 30 days
60 capsules per 30 days
60g (1 tube) per 28 days
4 patches per 30 days
32 vials per 28 days
30 tablets per 30 days
30g (1 tube) per 30 days
60 capsules per 30 days
1 dose per 5 days
30 vials per 30 days
30 tablets per 30 days
30 tablets per 30 days
1008 cartridges (6 inhalers)per
90days
160mL (4 packs) per 90 days
45 tablets per 30 days
30 tablets per 30 days
12.5g (1 bottle) per 30 days
60 tablets per 30 days
480mL per 30 days
17
PortfolioHigh Formulary
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•
•
•
•
•
•
Zioptan
Zipsor
Zohydro ER
Zolpimist
Zontivity
Zorvolex
Zuplenz
4mg Film
8mg Film
30 droperettes per 30 days
120 capsules per 30 days
60 capsules per 30 days
1 pump per 30 days
30 tablets per 30 days
90 capsules per 30 days
20 films per 30 days
10 films per 30 days
5. STEP THERAPY EDITS (FORMULARY)
Trial of 2 of the following: olanzapine,
• Abilify
quetiapine IR, risperidone, risperidone
Abilify Discmelt
ODT, ziprasidone, sertraline, fluoxetine,
venlafaxine, paroxetine, citalopram, or
escitalopram in the past 365 days
Trial of metformin , metformin ER,
•
Actoplus Met
sulfonylurea (e.g., glyburide, glipizide
Actoplus Met XR
or pioglitazone within the past 120 days
Trial of Ambien IR within the past 180
• Ambien CR
days
Trial of Astelin (azelastine)within the
• Astepro
past 120 days
Trial of ACE inhibitor, ACE inhibitor
• Benicar
combination, formulary generic ARB, or
Benicar HCT
formulary generic ARB combination
within the past 120 days
Trial of metformin, metformin ER,
• Bydureon
glyburide/metformin,
glipizide/metformin, a formulary oral
sulfonylurea, or pioglitazone within the
past 120 days
Trial of metformin, metformin
• Byetta
ER,glyburide/metformin,
glipizide/metformin, a formulary oral
sulfonylurea, or pioglitazonewithin the
past 120 days
Trial of two of the following:
• Crestor 5mg
atorvastatin, lovastatin, pravastatin or
simvastatin within the past 365 days
Trial of atorvastatin 40mg or
• Crestor 10mg, 20mg,
atorvastatin 80mg within the past 120
40mg
days.
Trial of Atrovent, Combivent, Spiriva,
• Daliresp
Arcapta, or Serevent within the past
120 days
Trial of 2 of the following: olanzapine,
• Desvenlafaxine ER
quetiapine IR, risperidone, risperidone
(Ranbaxy Brand)
ODT, ziprasidone, sertraline, fluoxetine,
or escitalopram in the past 365 days
Trial of vancomycin capsules within the
• Dificid
past 120 days
Trial of a topical corticosteroid within
• Dovonex
the past 120 days
Trial of a topical corticosteroid within
• Drithocreme HP
the past 120 days
Trial of metformin, metformin ER,
• Duetact
sulfonylurea (e.g., glyburide, glipizide)
or pioglitazone within the past 120 days
Trial of ACE inhibitor, ACE inhibitor
• Exforge
combination, formulary generic ARB, or
Exforge HCT
formulary generic ARB combination
within the past 120 days
Trial of any antiretroviral medication
• Fuzeon
within the past 30 days
Trial of two prescriptions for two
• Gianvi
different non-drospirenone oral
contraceptives (containing
levonorgestrel, norethindrone,
norgestimate, norgestrel, desogestrel,
or ethinynodiol acetate) within the past
365 days
Trial of Isentress, Reyataz, Prezista or
• Invirase
Atripla (new starts only)
Trial of metformin or metformin ER, a
• Invokana
sulfonylurea, or pioglitazone within the
PortfolioHigh Formulary – October 2014
•
Jalyn
•
Loestrin FE
•
Loestrin FE24
•
Lo Loestrin FE
•
Loryna
•
Marinol
•
Neupro
• Nexium
Nexium Suspension
• Niaspan
18
•
Nuvaring
•
Ocella
•
Ortho Evra
•
Ortho Tri-Cyclen Lo
•
Prevacid Solutabs
•
Pristiq
•
Protopic
•
Purixan
•
Qnasl
•
Requip XL
•
Seroquel XR
•
Simcor
•
Syeda
•
Uloric
•
Vectical
•
Vestura
past 120 days
Trial of finasteride 5mg, alfuzosin,
doxazosin, prazosin,tamsulosin or
terazosin within the past 120 days
Trial of one generic contraceptive
within the past 120 days
Trial of two generic oral contraceptives
within the past 365 days
Trial of two generic oral contraceptives
within the past 365 days
Trial of two prescriptions for two
different non-drospirenone oral
contraceptives (containing
levonorgestrel, norethindrone,
norgestimate, norgestrel, desogestrel,
or ethinynodiol acetate) within the past
365 days
Trial of 5HT3 antagonist,
corticosteroids, and Emend within the
past 30 days
Trial of pramipexole IR or ropinirole IR
within the past 120 days
Trial of omeprazole, lansoprazole or
pantoprazole within the past 120 days
Trial of generic/multisource statin
(atorvastatin, lovastatin, pravastatin, or
simvastatin), or generic/multisource
gemfibrozil or fenofibrate within the
past 365 days
Trial of a generic oral contraceptive
within the past 120 days
Trial of two prescriptions for two
different non-drospirenone oral
contraceptives (containing
levonorgestrel, norethindrone,
norgestimate, norgestrel, desogestrel,
or ethinynodiol acetate) within the past
365 days
Trial of a generic oral contraceptive
within the past 120 days
Trial of two generic oral contraceptives
within the past 365 days
Trial of lansoprazole, omeprazole or
pantoprazole within the past 120 days
Trial of two of the following: generic
paroxetine, fluoxetine, citalopram,
sertraline, escitalopram, mirtazapine or
bupropion, or venlafaxine IR/ER within
the past 365 days
Trial of a topical corticosteroid within
the past 120 days
Trial of mercaptopurine tablet within the
past 120 days
Trial of fluticasone or flunisolide within
the past 365 days
Trial of pramipexole IR or ropinirole IR
within the past 120 days
Trial of 2 of the following: olanzapine,
quetiapine IR, risperidone, risperidone
ODT, ziprasidone, sertraline, fluoxetine,
venlafaxine, paroxetine, citalopram,or
escitalopram in the past 365 days
Trial of two of the following;
atorvastatin, lovastatin, pravastatin or
simvastatin within the past 365 days
Trial of two prescriptions for two
different non-drospirenone oral
contraceptives (containing
levonorgestrel, norethindrone,
norgestimate, norgestrel, desogestrel,
or ethinynodiol acetate) within the past
365 days
Trial of allopurinol within the past 120
days
Trial of a topical corticosteroid within
the past 120 days
Trial of two prescriptions for two
PortfolioHigh Formulary
•
•
•
•
•
•
•
•
•
different non-drospirenone oral
contraceptives (containing
levonorgestrel, norethindrone,
norgestimate, norgestrel, desogestrel,
or ethinynodiol acetate) within the past
365 days
Trial of metformin, metformin ER,
Victoza
glyburide/metformin,
glipizide/metformin, a formulary oral
sulfonylurea, or pioglitazone within the
past 120 days
Prior trial of generic methylphenidate
Vyvanse
(Ritalin) or generic mixed amphetamine
salts (Adderall) within the past 120
days
Trial of two prescriptions for two
Yasmin
different non-drospirenone oral
contraceptives (containing
levonorgestrel, norethindrone,
norgestimate, norgestrel, desogestrel,
or ethinynodiol acetate) within the past
365 days
Trial of two prescriptions for two
Yaz
different non-drospirenone oral
contraceptives (containing
levonorgestrel, norethindrone,
norgestimate, norgestrel, desogestrel,
or ethinynodiol acetate) within the past
365 days
Trial of two prescriptions for two
Zarah
different non-drospirenone oral
contraceptives (containing
levonorgestrel, norethindrone,
norgestimate, norgestrel, desogestrel,
or ethinynodiol acetate) within the past
365 days
Zenzedi (2.5mg, 7.5mg) Trial of a multisource
dextroamphetamine sulfate tablet or
dextroamphetamine solution in the past
120 days
Trial of simvastatin 80mg or Vytorin
Zocor (80mg only)
10/80mg within the past 365 days
Trial of sumatriptan or rizatriptan within
Zomig
the past 180 days
Zomig ZMT
Trial of bupropion hcl SR or XL within
the past 120 days
Trial of two of the following;
• Aptiom
carbamazepine, gabapentin,
lamotrigine, levetiracetam IR or ER,
oxcarbazepine, valproic acid or
divalproex, topiramate, or zonisamide
within the past 365 days
Trial of Serevent within the past 120
• Arcapta
days
Trial of balsalazide or Apriso within the
• Asacol HD
past 120 days
Trial of QVAR and Flovent within the
• Asmanex
past 365 days
Trial of alendronate and ibandronate
• Atelvia
within the past 365 days
Trial of Epipen within the past 120
• Auvi-Q
days
Trial of metformin or metformin
• Avandia / Avandaryl /
combination or a formulary oral
Avandamet
sulfonylurea (i.e., glyburide, glipizide)
and pioglitazone / pioglitazone
combination (i.e.,Actos) required within
the past 120 days.
Trial of sumatriptan or rizatriptanwithin
• Axert
the past 180 days
Trial of ACE inhibitor, ACE inhibitor
• Azor
combination, formulary generic ARB,
or formulary generic ARB combination
within the past 120 days
Trial of lamotrigine, valproic acid or
• Banzel
topiramate within the past 120 days
Trial of fluticasone or flunisolide within
• Beconase AQ
the past 120 days
Previous prescriptions for two different
• Beyaz
non-drospirenone oral contraceptives
(containing levonorgestrel,
norethindrone,norgestimate,
norgestrel, desogestrel, or ethinynodiol
ace.) within the past 365 days.
Trial of generic alendronate and
• Binosto
ibandronate within the past 365 days
Trial of two of the following
• Brintellix
generic/multisource products:
paroxetine, venlafaxine ER or IR,
fluoxetine, citalopram, sertraline,
escitalopram, mirtazapine or bupropion
within the past 365 days
Trial of paroxetine or venlafaxine within
• Brisdelle
the past 120 days
Trial of ondansetron tablet or ODT
• Cesamet
within the past 120 days
Trial of desloratadine or levocetirizine
• Clarinex/Clarinex D
tablet within the past 120 days
Trial of tramadol ER (Ultram ER) within
• Conzip
the past 120 days
Trial of dorzolamide/timolol within the
• Cosopt PF
past 120 days
Trial of metformin (Glucophage),
• Cycloset
metformin ER, glyburide/metformin
(Glucovance), or glipizide/metformin
(Metaglip) within the past 180 days
Trial of methylphenidate CD, ER, or LA
• Daytrana
formulation or methylphenidate
suspension/solution in the past 120
days
Trial of balsalazide or Apriso within the
• Delzicol
past 120 days
Trial of two of the following; generic
• Desvenlafaxine ER
paroxetine, fluoxetine, citalopram,
fumarate
sertraline, escitalopram, venlafaxine
ER or IR, mirtazapine or bupropion
within the past 365 days.
Trial of omeprazole, pantoprazole, or
• Dexilant
lansoprazole within the past 120 days
• Diabetes blood glucose Trial of 1) one FreeStyle or Precision
brand test strip AND 2) one OneTouch
test strips, Bayer
6. STEP THERAPY EDITS (NON FORMULARY)
Trial of two of the following;
• Aciphex
omeprazole, lansoprazole or
pantoprazole or rabeprazole within the
past 365 days
Trial of two of the following;
• Aciphex Sprinkle
omeprazole, lansoprazole,
pantoprazole or rabeprazole within the
past 365 days
Trial of generic doxycycline hyclate
• Acticlate
within the past 120 days
Trial of alendronate and ibandronate
• Actonel
within the past 365 days
Trial of generic doxycycline hyclate
• Adoxa
within the past 120 days
Trial of Epipen within the past 120
• Adrenaclick
days.
Trial of two of the following;
• Advicor
atorvastatin, lovastatin, pravastatin or
simvastatin within the past 365 days
Trial of QVAR AND Flovent within the
• Aerospan
past 365 days
Trial of two of the following;
• Altoprev
atorvastatin, lovastatin, pravastatin or
simvastatin within the past 365 days
Trial of QVAR and Flovent within the
• Alvesco
past 365 days
Trial of gemifibrozil or generic
• Antara
fenofibrate within the past 120 days
Trial of ondansetron tablets or ODT
• Anzemet
within the past 120 days
PortfolioHigh Formulary – October 2014
19
Aplenzin
PortfolioHigh Formulary
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
brands(Contour, Breeze)
Diabetes blood glucose
test strips, Roche
brands (Accu-chek,
ChemStrip)
Dipentum
test strip within the past 365 days
Trial of 1) one FreeStyle or Precision
brand test strip AND 2) one OneTouch
test strip within the past 365 days
Trial of balsalazide or Apriso within the
past 120 days
Trial of generic doxycycline hyclate
Doryx
within the past 120 days
Trial of generic oral NSAID within the
Duexis
past 120 days
Trial of fluticasone or flunisolide within
Dymista
the past 365 days
Trial of ACE inhibitor, ACE inhibitor
Edarbi
combination, formulary generic ARB,
or formulary generic ARB combination
within the past 120 days
Trial of ACE inhibitor, ACE inhibitor
Edarbyclor
combination, formulary generic ARB,
or formulary generic ARB combination
within the past 120 days
Trial of zolpidem IR (Ambien) within
Edluar
the past 180 days
Trial of a topical corticosteroid within
Elidel
the past 120 days
If age ≥ 12 years, trial of enalapril
Epaned
tablets within the past 120 days
Esomeprazole Strontium Trial of omeprazole, lansoprazole or
pantoprazole within the past 120 days
Trial of two generic atypical
Fanapt
antipsychotics within the past 365 days
Trial of metformin, metformin ER,
Farxiga
glyburide/metformin,
glipizide/metformin, a formulary oral
sulfonylurea or pioglitazone AND
formulary SGLT2 Inhibitor within the
past 365 days
Trial of two generics of the following;
Fazaclo
olanzapine, quetiapine, risperidone or
ziprasidone within the past 365 days
Trial of lamotrigine or topiramate within
Felbatol
the past 120 days
Trial of two of the following; paroxetine,
Fetzima
fluoxetine, citalopram, sertraline,
escitalopram, mirtazapine, bupropion
or venlafaxine IR/ER within the past
365 days
Trial of Serevent within the past 120
Foradil
days
Trial of generic bupropion within the
Forfivo XL
past 120 days
Trial of generic metformin ER
Fortamet
(Glucophage XR) within the past 120
days
Trial of sumatriptan or rizatriptan in the
Frova
past 180 days
Trial of antiretroviral therapy within the
Fulyzaq
past 120 days
Trial of two of the following:
Fycompa
carbamazepine, gabapentin,
lamotrigine, levetiracetam IR or ER,
oxcarbazepine, valproic acid,
divalproex, topiramate or zonisamide
within the past 365 days
Trial of 2 of the following:
Gabitril
carbamazepine, gabapentin,
lamotrigine, levetiracetam IR or ER,
oxcarbazepine, valproic acid,
divalproex, topiramate or zonisamide
within the past 365 days
Trial of balsalazide or Apriso within the
Giazo
past 120 days
Trial of generic metformin ER
Glumetza
(Glucophage XR within the past 120
days
Trial of gabapentin (Neurontin) within
Gralise
the past 120 days
PortfolioHigh Formulary – October 2014
20
•
Hemangeol
•
Horizant
•
Inderal XL
•
Innopran XL
•
Intermezzo
•
Invega
•
Kazano
•
Karbinal ER
•
Khedezla
•
Kombiglyze XR
•
Kytril
•
Lamictal ODT
•
Lamictal XR
•
Latuda
•
Lescol
•
Lescol XL
•
•
Levemir
Lialda
•
Liptruzet
10/10mg
•
10/20mg, 10/40mg,
10/80mg
Livalo
•
Loestrin 24 Fe
•
Lunesta
•
Luvox CR
•
Luzu
•
Mirapex ER
•
Monodox
•
Myrbetriq
•
Natazia
•
Neo-Synalar
Trial of generic propranolol oral
solution within the past 120 days
Trial of pramiprexole (Mirapex),
ropinirole IR (Requip), or generic
gabapentin (Neurontin) within the past
120 days
Trial of Inderal LA within the past 120
days
Trial of Inderal LA within the past 120
days
Trial of zolpidem immediate-release
tablets within the past 120 days
Trial of two generic atypical
antipsychotics within the past 365 days
Trial of Tradjenta, Januvia, Janumet,
Janumet XR, Juvisync, or Jentadueto
within the past 120 days
Trial of generic immediate-release
carbinoxamine maleate within the past
120 days
Trial of two of the following
generic/multisource products:
paroxetine, venlafaxine ER or IR,
fluoxetine, citalopram, sertraline,
escitalopram, mirtazapine or bupropion
within the past 365 days
Trial of Tradjenta, Januvia, Janumet,
Janumet XR, Juvisync, or Jentadueto
within the past 120 days
Trial of ondansetron tablets or ODT
within the past 120 days
Trial of lamotrigine IR within the past
120 days
Trial of lamotrigine IR within the past
120 days
Trial of two generic atypical
antipsychotics (olanzapine, quetiapine
IR, risperidone, risperidone ODT or
ziprasidone) within the past 365 days
Trial of two of the following:
atorvastatin, lovastatin, pravastatin or
simvastatin within the past 365 days
Trial of two of the following:
atorvastatin, lovastatin, pravastatin or
simvastatin within the past 365 days
Trial of Lantus within the past 120 days
Trial of balsalazide or Apriso within the
past 120 days
Trial of 2 of the following: atorvastatin,
simvastatin, pravastatin or lovastatin
within the past 365 days.
Trial of 40mg atorvastatin or 80mg
atorvastatin within the past 120 days.
Trial of two of the following:
atorvastatin, lovastatin, pravastatin or
simvastatin within the past 365 days
Trial of two generic oral contraceptives
within the past 365 days
Trial of zolpidem IR (Ambien)within the
past 180 days
Trial of generic paroxetine, fluoxetine,
citalopram, sertraline, escitalopram,
mirtazapine, or fluvoxamine IR within
the past 120 days
Trial of ketoconazole AND clotrimazole
cream within the past 365 days
Trial of pramipexole IR or ropinirole IR
within the past 120 days
Trial of generic doxycycline hyclate
within the past 120 days
Trial of two anticholinergic agents
within the past 365 days
Trial of two generic oral contraceptives
within the past 365 days
Trial of fluocinolone and bacitracin
within the past 365 days
PortfolioHigh Formulary
•
Nesina
•
Oleptro ER
•
Omnaris
•
Onfi
•
Onglyza
•
Oracea
•
Oseni
•
Otrexup
•
Ovace Plus Lotion
•
Oxtellar XR
•
Patanase
•
Pennsaid
•
Pentasa
•
Pexeva
•
Potiga
•
Pulmicort Flexhaler
•
Qudexy XR
•
Rapaflo
•
Rayos
•
Relpax
•
Rescula
•
Rhinocort Aqua
•
•
Ribavirin 400mg,
600mg, and Ribapak
Rozerem
•
Safyral
•
Sancuso
•
Saphris
•
Silenor
•
Sitavig
PortfolioHigh Formulary – October 2014
Trial of Tradjenta, Januvia, Janumet,
Janumet XR, Juvisync, or Jentadueto
within the past 120 days
Trial of immediate release trazodone
within the past 120 days
Trial of fluticasone or flunisolide within
the past 365 days
Trial of lamotrigine or topiramate within
the past 120 days
Trial of Tradjenta,Januvia,Janumet,
Janumet XR, Juvisync, or Jentadueto
within the past 120 days
Trial of generic doxycycline hyclate
within the past 120 days
Trial of Tradjenta, Januvia, Janumet,
Janumet XR, Juvisync, or Jentadueto
within the past 120 days
Trial of methotrexate tablet or solution
for injection within the past 120 days
Trial of ketoconazole shampoo/cream
or ciclopirox shampoo/gel within the
past 120 days
Trial of 2 of the following;
carbamazepine, gabapentin,
lamotrigine, levetiracetam IR or ER,
oxcarbazepine, valproic acid or
divalproex, topiramate, or zonisamide
within the past 365 days
Trial of Astelin (azelastine) within the
past 120 days
Trial of Voltaren gel within the past 120
days
Trial of balsalazide or Apriso within the
past 120 days
Trial of paroxetine HCL IR within the
past 120 days
Trial of 2 of the following;
carbamazepine, gabapentin,
lamotrigine, levetiracetam IR or ER,
oxcarbazepine, valproic acid or
divalproex, topiramate, or zonisamide
within the past 365 days
Trial of QVAR and Flovent within the
past 365 days
Trial of topiramate immediate release
within the past 120 days
Trial of finasteride 5mg, alfuzosin,
doxazosin, prazosin,tamsulosin or
terazosin within the past 120 days
Trial of generic prednisone within the
past 120 days
Trial of sumatriptan or rizatriptan within
the past 180 days
Trial of latanoprost AND Lumigan or
Travatan Z within the past 365 days
Trial of fluticasone or flunisolide within
the past 365 days
Trial of ribavirin 200mg capsule or
tablet within the past 120 days
Trial of zolpidem IR (Ambien) or
zaleplon (Sonata) within the past 120
days
Previous prescriptions for two different
non-drospirenone oral contraceptives
(containing levonorgestrel,
norethindrone, norgestimate,
norgestrel, desogestrel, or ethinynodiol
ace.) within the past 365 days.
Trial of ondansetron tablet or ODT
within the past 120 days
Trial of two generic atypical
antipsychotics within the past 365 days
Trial of zolpidem IR (Ambien) or
zaleplon (Sonata) within the past 120
days
Trial of oral acyclovir, valacyclovir or
famciclovir within the past 120 days
•
Solodyn
•
Sorilux
•
Stavzor
•
Sumavel Dose-Pro
•
Symbicort
•
•
Taclonex / Taclonex
Scalp
Tanzeum
•
Tasmar
•
Teveten
Teveten HCT
•
Timoptic Ocudose
•
Topicort Spray
•
Treximet
•
Tribenzor
•
Trokendi XR
•
Uceris
•
Veramyst
•
Versacloz
•
Viibryd
•
Vimpat
•
Vytorin:
10/10mg
10/20mg, 10/40mg
10/80mg
21
•
Xerese
•
Xyzal Solution
•
Zegerid
•
Zetonna
Trial of generic minocycline within the
past 120 days
Trial of a topical corticosteroid within
the past 120 days
Trial of genericvalproic acid or
divalproex within the past 120 days
Trial of generic/multisource injectable
sumatriptan or nasal sumatriptan
(Imitrex or equivalent) within the past
180 days
Trial of Dulera or Advair or Breo Ellipta
within the past 120 days
Trial of a topical corticosteroid within
the past 120 days
Trial of metformin, metformin ER, a
sulfonylurea, a metformin/sulfonylurea
combination, pioglitazone, a
pioglitazone/metformin combination or
a pioglitazone/glimepiride combination
AND a formulary GLP-1 agonist (e.g.
Byetta, Bydureon or Victoza) within the
past 365 days
Trial of Comtan within the past 120
days
Trial of ACE inhibitor, ACE inhibitor
combination, formulary generic ARB,
or formulary generic ARB combination
within the past 120 days
Trial of timolol drops within the past
120 days
Trial of mometasone 0.1% ointment,
fluocinonide 0.05%
cream/ointment/gel, desoximetasone
0.25% cream, or betamethasone
dipropionate 0.05% cream within the
past 120 days
Trial of sumatriptan within the past 180
days
Trial of ACE inhibitor, ACE inhibitor
combination, formulary generic ARB,
or formulary generic ARB combination
within the past 120 days
Trial of topiramate IR within the past
120 days
Trial of balsalazide within the past 120
days
Trial of fluticasone or flunisolide within
the past 365 days
Trial of two generics of the following;
olanzapine, quetiapine, risperidone or
ziprasidone within the past 365 days
Trial of two of the following: paroxetine,
fluoxetine, citalopram, sertraline,
escitalopram, mirtazapine, bupropion,
venlafaxine IR/ERwithin the past 365
days
Trial of 2 of the following;
carbamazepine, gabapentin,
lamotrigine, levetiracetam IR or ER,
oxcarbazepine, valproic acid,
divalproex, topiramate or zonisamide
within the past 365 days
Trial of two of the following:
atorvastatin, lovastatin, pravastatin or
simvastatin within the past 365 days
Trial of atorvastatin 40mg or
atorvastatin 80mg within the past 120
days
Trial of simvastatin 80mg or Vytorin
10/80mg within the past 365 days
Trial of oral acyclovir, valacyclovir or
famciclovir within the past 120 days
Trial of desloratadine or levocetirizine
tablet within the past 120 days
Trial of omeprazole, lansoprazole or
pantoprazole within the past 120 days
Trial of fluticasone or flunisolide within
PortfolioHigh Formulary
•
Zioptan
•
Zipsor
•
Zithranol / Zithranol RR
•
Zolpimist
•
Zorvolex
•
Zuplenz
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
the past 365 days
Trial of latanoprost AND Lumigan or
Travatan Z within the past 365 days
Trial of diclofenac sodium within the
past 120 days
Trial of a topical corticosteroid within
the past 120 days
Trial of zolipem IR (Ambien) within the
past 180 days
Trial of diclofenac sodium within the
past 120 days
Trial of ondansetron tablet or ODT
within the past 120 days
7. GENDER EDITS (FORMULARY)
Male only
• Avodart
Male only
• Cialis
Male only
• Jalyn
Male only
• Proscar
Male only
• Staxyn
Male only
• Viagra
8. GENDER EDITS (NON-FORMULARY)
Male only
• Levitra
Male only
• Rapaflo
Male only
• Stendra
9. PRIOR AUTHORIZATION RESTRICTIONS (FORMULARY)
• Actiq
• Adcirca
• Adempas
• Afinitor /Afinitor Disperz
• Aldara
• Androgel
• Aptivus
• Aromasin
• Avonex
• Avonex Admin Pack
• Axiron
• Betaseron
• Bosulif
• Cayston
• Cometriq
• Complera
• Copaxone
• Cystaran
• Delatestryl
• Depo-Testosterone
• Duragesic
• Edurant
• Eligard
• Enbrel
• Erivedge
• Fareston
• Firazyr
• Gattex
• Gilenya
• Gilotrif
• Gleevec
• Humira
• Iclusig
• Imbruvica
• Inlyta
• Intelence
• Intron A
• Jakafi
• Juxtapid
• Kalydeco
• Korlym
• Kynamro
• Letairis
• Leukine
PortfolioHigh Formulary – October 2014
Lexiva
Mekinist
Neulasta
Neupogen
Nexavar
Nuvigil
Olysio
Omnitrope
Opsumit
Pegasys
PegIntron
Pomalyst
Procrit
Promacta
Pulmozyme
Rebif
Relistor
Revlimid
Selzentry
Sivextro
Sovaldi
Sprycel
Stivarga
Suboxone
Subutex
Sutent
Tafinlar
Tarceva
Targretin
Tasigna
Tecfidera
Temodar capsules
Thalomid
Tivicay
Tobi
Tobi Podhaler
Tracleer
Trizivir
Tykerb
Valchlor
Votrient
Xalkori
Xeloda
Xtandi
Zelboraf
Zykadia
Zytiga
Zyvox
10. PRIOR AUTHORIZATION RESTRICTIONS (NON FORMULARY)
• Abraxane*
• Abstral
• Actemra IV*
• Actemra SC
•
Adcetris*
•
Alimta*
•
Ampyra
•
Amturnide
•
Androderm
•
Apokyn
•
Aranesp
•
Arzerra*
•
Aubagio
•
Avastin*
•
Beleodaq*
•
Belviq
•
Berinert
•
Bethkis
•
Botox*
•
Bunavail
•
Caprelsa
•
Cimzia
22
PortfolioHigh Formulary
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Cinryze
Cyramza*
Dysport*
Egrifta
Elspar*
Entyvio*
Epogen
Erbitux*
Erwinase*
Euflexxa*
Exalgo
Extavia
Eylea*
Faslodex*
Fentora
Flolan*
Fortesta
Gammagard Liquid
Gammaked
Gamunex-C
Gazyva*
Gel-One*
Genotropin
Granix*
Grastek
H.P. Acthar*
Halaven*
Herceptin*
Hetlioz
Hizentra
Humatrope
Hyalgan*
Ilaris*
Incivek
Increlex
Iprivask
Istodax*
Ixempra*
Jublia
Kadcyla*
Kalbitor*
Kineret
Kyprolis*
Lazanda
Lucentis*
Macugen*
Makena
Marqibo*
Monovisc*
Mozobil*
Myobloc*
Norditropin
Norditropin FlexPro
Norditropin Nordiflex
Northera
Novantrone*
Nuedexta
Nutropin
Nutropin AQ
Nutropin AQ NuSpin
Nymalize
Omontys
Oncaspar*
Onsolis
Oralair
Orencia IV*
Orencia SC
Orenitram ER
Orthovisc*
Otezla
Perjeta*
Photofrin*
PortfolioHigh Formulary – October 2014
Pradaxa
Procysbi
Provigil
Qsymia
Qutenza
Ragwitek
Ravicti
Remicade*
Remodulin
Rituxan*
Saizen
Serostim
Signifor
Simponi SC
Simponi IVAria*
Sirturo
Solaraze
Soliris*
Stelara
Stivarga
Striant
Subsys
Sucraid
Supartz*
Suprenza
Sylatron
Sylvant*
Synagis*
Synribo*
Synvisc*
Synvisc-One*
Tekamlo
Tekturna
Tekturna HCT
Temodar Vial*
Testim
Tev-Tropin
Thyrogen*
Torisel*
Tysabri*
Tyvaso
Valturna
Vecamy
Vectibix*
Velcade*
Veletri*
Ventavis
Victrelis
Vimizim*
Vogelxo
Xeljanz
Xeomin*
Xgeva*
Xolair*
Xyrem
Yervoy*
Zaltrap*
Zavesca
Zoladex*
Zorbtive
Zubsolv
Zyclara
Zydelig*
* = Dependent on plan benefit. If covered under pharmacy benefit, then
non-formulary with prior authorization
11. CONCURRENT USE EDITS(FORMULARY)
• Suboxone
• Subutex
23
PortfolioHigh Formulary
12. CONCURRENT USE EDITS (NON FORMULARY)
• Zubsolv
PortfolioHigh Formulary – October 2014
24
PortfolioHigh Formulary
INDEX
8-MOP .................................................................. 5
A/B OTIC .............................................................. 6
abacavir sulfate .................................................. 9
abacavir sulfate/lamivudine .................................. 9
abacavir/lamivudine/zidovudine ....................... 9
ABBOTT DIABETIC SUPPLIES........................... 6
ABILIFY ................................................................ 2
ABILIFY DISCMELT ............................................. 2
abiraterone acetate ............................................ 11
acarbose .............................................................. 5
ACCUPRIL ........................................................... 3
ACCURETIC......................................................... 2
acebutolol hcl ..................................................... 3
acetaminophen with codeine .......................... 12
acetazolamide ..................................................... 7
acetic acid ........................................................... 6
acetic acid/aluminum acetate ........................... 6
acetic acid/hydrocortisone ................................ 6
acetylcysteine ................................................... 11
acitretin................................................................ 5
aclidinium bromide ............................................... 1
ACLOVATE .......................................................... 5
ACTIGALL .......................................................... 10
ACTIQ ................................................................. 12
ACTOPLUS MET ................................................. 5
ACTOPLUS MET XR ........................................... 5
ACTOS ................................................................. 5
ACULAR ............................................................... 7
ACULAR LS.......................................................... 7
acyclovir .......................................................... 5, 9
ADALAT CC ......................................................... 3
adalimumab ........................................................ 10
adapalene ............................................................ 4
ADCIRCA ............................................................. 3
ADDERALL........................................................... 1
ADDERALL XR .................................................... 1
ADEMPAS ............................................................ 3
ADVAIR DISKUS .................................................. 1
ADVAIR HFA ........................................................ 1
afatinib ................................................................ 11
AFINITOR ........................................................... 11
AFINITOR DISPERZ .......................................... 11
AGRYLIN .............................................................. 8
AK-TRACIN .......................................................... 7
ALAMAST ............................................................. 7
ALA-TET ............................................................... 9
ALAWAY OTC ...................................................... 7
albuterol sulfate.................................................. 1
ALBUTEROL SULFATE ....................................... 1
alclometasone dipropionate ............................. 5
ALDACTONE ....................................................... 3
ALDARA ............................................................... 8
ALDOMET ............................................................ 3
alendronate sodium ........................................... 6
alendronate sodium solution ............................ 6
alendronate sodium/vitamin d3 ............................ 6
alfuzosin ............................................................ 13
ALKERAN ........................................................... 11
allopurinol ........................................................... 7
ALOCRIL .............................................................. 7
ALOMIDE ............................................................. 7
ALORA ................................................................. 8
ALPHAGAN P ...................................................... 7
alprazolam ........................................................... 2
ALPRAZOLAM INTENSOL .................................. 2
ALREX .................................................................. 7
ALTACE................................................................ 3
altretamine .......................................................... 11
aluminum chloride ............................................. 5
ALUPENT ............................................................. 1
amantadine hcl ................................................. 12
AMARYL ............................................................... 5
AMBIEN ................................................................ 2
AMBIEN CR.......................................................... 2
ambrisentan .......................................................... 3
amcinonide.......................................................... 5
AMERGE ............................................................ 12
AMINOPHYLLIN ................................................... 1
aminophylline ..................................................... 1
amiodarone hcl ................................................... 2
AMITIZA ............................................................. 10
amitriptyline hcl .................................................. 1
amlodipine besylate ........................................... 3
amlodipine besylate/benazepril ........................ 2
PortfolioHigh Formulary – October 2014
amlodipine/atorvast cal ........................................ 3
amlodipine/valsartan ............................................ 2
amlodipine/valsartan/hctz ..................................... 2
AMNESTEEM....................................................... 4
amox tr/potassium clavulanate ........................ 8
amoxapine ........................................................... 1
amoxicillin trihydrate ......................................... 8
AMOXIL ................................................................ 8
amphet asp/amphet/d-amphet .......................... 1
ampicillin trihydrate ........................................... 8
amylase/lipase/protease .................................. 12
ANAFRANIL ......................................................... 1
anagrelide hcl ..................................................... 8
ANALPRAM HC ................................................. 10
ANAPROX .......................................................... 10
ANAPROX DS .................................................... 10
ANASPAZ ........................................................... 13
anastrozole........................................................ 11
ANDROGEL ......................................................... 8
ANDROID ............................................................. 8
ANDROXY ............................................................ 8
ANORO ELLIPTA ................................................. 1
ANSAID .............................................................. 10
ANTABUSE .......................................................... 2
anthralin ................................................................ 5
antipyrine/benzocaine otic .................................... 6
ANTIVERT ............................................................ 1
ANUSOL-HC ...................................................... 10
APEXICON ........................................................... 5
APEXICON E ....................................................... 5
apixaban ............................................................... 7
aprepitant .............................................................. 1
APRESOLINE ...................................................... 3
APRISO .............................................................. 10
APTIVUS .............................................................. 9
ARALEN PHOSPHATE ........................................ 9
ARAVA ............................................................... 10
ARICEPT .............................................................. 1
ARICEPT ODT ..................................................... 1
ARIMIDEX .......................................................... 11
aripiprazole ........................................................... 2
ARIXTRA .............................................................. 8
armodafinil ............................................................ 2
ARMOUR THYROID ............................................ 7
AROMASIN ........................................................ 11
ARTANE ............................................................. 12
ASACOL ............................................................. 10
ASENDIN .............................................................. 1
ASTELIN ............................................................... 1
ASTEPRO ............................................................ 1
ATARAX ............................................................... 1
atazanavir sulfate ................................................. 9
atenolol ................................................................ 3
atenolol/chlorthalidone ...................................... 3
ATIVAN ................................................................. 2
atomoxetine hcl .................................................... 2
atorvastatin calcium........................................... 3
ATRIPLA ............................................................... 9
atropine sulfate ................................................... 7
ATROVENT .................................................... 1, 11
ATROVENT HFA .................................................. 1
AUGMENTIN ........................................................ 8
AUGMENTIN ES-600 ........................................... 8
AUGMENTIN XR .................................................. 8
AVALIDE .............................................................. 2
AVAPRO............................................................... 3
AVC .................................................................... 13
AVELOX ............................................................... 9
AVELOX ABC PACK ............................................ 9
AVIANE-28 ........................................................... 4
AVINZA ............................................................... 12
AVLOSULFON ..................................................... 9
AVODART .......................................................... 13
AVONEX............................................................. 11
AVONEX ADMINISTRATION PACK ................. 11
AXID ................................................................... 13
AXIRON ................................................................ 8
axitinib ................................................................ 11
AYGESTIN ........................................................... 8
azathioprine ........................................................ 8
azelastine hcl .................................................. 1, 7
AZILECT ............................................................. 12
azithromycin ....................................................... 8
AZOPT .................................................................. 7
25
aztreonam lysine .................................................. 8
AZULFIDINE....................................................... 10
bacitracin............................................................. 7
bacitracin/polymyxin b sulfate.......................... 7
baclofen ............................................................. 12
BACTRIM DS ....................................................... 8
BACTROBAN ....................................................... 4
BACTROBAN NASAL ........................................ 11
balsalazide disodium ....................................... 10
BARACLUDE ....................................................... 9
becaplermin .......................................................... 6
beclomethasone dipropionate .............................. 1
belladonna alkaloids/phenobarb .................... 13
benazepril hcl ..................................................... 2
benazepril/hydrochlorothiazide ........................ 2
BENEMID ............................................................. 7
BENICAR .............................................................. 3
BENICAR HCT ..................................................... 2
BENTYL .............................................................. 13
benz perox/hc/skin clnsr no.14 ......................... 4
BENZACLIN ......................................................... 4
BENZAMYCIN ...................................................... 4
BENZAMYCIN PAK.............................................. 4
BENZASHAVE ..................................................... 4
benzoyl peroxide ................................................ 4
benzoyl peroxide gel ............................................ 4
benzoyl peroxide shave cream ............................ 4
benzoyl peroxide/hydrocortison ........................... 4
benztropine mesylate ...................................... 12
besifloxacin hcl drops susp 0.6% ......................... 7
BESIVANCE ......................................................... 7
BETAGAN ............................................................ 7
betamet diprop/prop gly .................................... 5
betamethasone dipropionate............................ 1, 5
betamethasone valerate .................................... 5
BETAPACE .......................................................... 3
BETAPACE AF..................................................... 3
BETASERON ..................................................... 11
betaxolol hcl ....................................................... 7
bethanechol chloride ....................................... 10
BETIMOL .............................................................. 7
BETOPTIC............................................................ 7
BETOPTIC S ........................................................ 7
bexarotene...................................................... 5, 11
BIAXIN .................................................................. 8
BIAXIN XL ............................................................ 8
bicalutamide ..................................................... 11
BILTRICIDE .......................................................... 9
bimatoprost ........................................................... 7
bimonidine/timolol ................................................. 7
bisoprolol fumarate ............................................ 3
bisoprolol fumarate/hctz ................................... 3
BLEPHAMIDE ...................................................... 7
BLEPHAMIDE S.O.P............................................ 7
BLOCADREN ....................................................... 3
blood sugar diagnostic ......................................... 6
blood-glucose calib. control .................................. 6
blood-glucose meter ............................................. 6
BONIVA ................................................................ 6
bosentan ............................................................... 3
BOSULIF ............................................................ 11
bosutinib ............................................................. 11
BRAVELLE ........................................................... 6
BREO ELLIPTA .................................................... 1
BRETHINE ........................................................... 1
BREVOXYL-4 ....................................................... 4
BREVOXYL-8 ....................................................... 4
BRILINTA ............................................................. 8
brimonidine tartrate ........................................... 7
brinzolamide ......................................................... 7
brinzolamide/brimonidine ..................................... 7
BROMFED............................................................ 4
BROMFED-PD ..................................................... 4
bromocriptine mesylate ................................... 12
budesonide ................................................... 1, 10
BUDESONIDE .................................................... 10
bumetanide ......................................................... 3
BUMEX ................................................................. 3
BUPHENYL POWDER ....................................... 10
BUPHENYL TABLET ......................................... 10
buprenorphine .................................................... 12
buprenorphine hcl ............................................ 11
buprenorphine hcl/naloxone hcl ......................... 12
bupropion hcl ..................................................... 1
PortfolioHigh Formulary
INDEX
BUSPAR ............................................................... 2
buspirone hcl ...................................................... 2
busulfan .............................................................. 11
butalb/acetaminophen/caffeine ...................... 11
butalbital/acetaminophen ................................ 11
butalbital/aspirin/caffeine ................................ 11
butoconazole nitrate ........................................... 13
BUTRANS .......................................................... 12
BYDUREON ......................................................... 5
BYETTA................................................................ 5
BYSTOLIC ............................................................ 3
cabergoline ......................................................... 6
cabozanitinib ...................................................... 11
CADUET ............................................................... 3
CAFERGOT........................................................ 12
CALAN .................................................................. 3
CALAN SR............................................................ 3
calcipotriene ....................................................... 5
calcitriol ............................................................. 13
calcium acetate................................................... 6
canagliflozin .......................................................... 6
CANASA ............................................................. 10
capecitabine ...................................................... 11
CAPITAL W-CODEINE ...................................... 12
CAPOTEN ............................................................ 2
CAPOZIDE ........................................................... 2
captopril .............................................................. 2
captopril/hydrochlorothiazide........................... 2
CARAFATE ........................................................ 13
carbachol .............................................................. 7
carbamazepine ................................................. 12
CARBATROL ..................................................... 12
carbidopa .......................................................... 12
carbidopa/levodopa ......................................... 12
carbidopa/levodopa/entacapone .................... 12
CARDENE ............................................................ 3
CARDIZEM ........................................................... 3
CARDIZEM CD .................................................... 3
CARDURA ............................................................ 2
carisoprodol ...................................................... 12
carisoprodol/aspirin ......................................... 12
CARMOL HC ........................................................ 5
carteolol hcl ........................................................ 7
carvedilol ............................................................. 2
carvedilol phosphate ............................................ 2
CASODEX .......................................................... 11
CATAPRES .......................................................... 3
CAYSTON ............................................................ 8
CECLOR ............................................................... 8
CEENU ............................................................... 10
cefaclor ................................................................ 8
cefadroxil hydrate .............................................. 8
cefdinir ................................................................. 8
cefixime ................................................................ 8
cefpodoxime proxetil ......................................... 8
cefprozil ............................................................... 8
CEFTIN ................................................................. 8
cefuroxime axetil ................................................ 8
CEFZIL ................................................................. 8
CELEBREX ........................................................ 10
celecoxib............................................................. 10
CELEXA ............................................................... 1
CELLCEPT ........................................................... 8
CENTANY ............................................................ 4
cephalexin monohydrate ................................... 8
ceritinib ............................................................... 11
cetirizine hcl (OTC)............................................. 1
cetrorelix acetate .................................................. 6
CETROTIDE ......................................................... 6
cevimeline hcl ................................................... 10
chloral hydrate .................................................... 2
chlorambucil ....................................................... 11
chlordiazepoxide hcl .......................................... 2
chlordiazepoxide/clidinium br ............................. 13
chlorhexidine gluconate .................................. 11
chloroquine phosphate ..................................... 9
chlorpromazine hcl ............................................ 2
chlorpropamide .................................................. 5
chlorthalidone ..................................................... 3
chlorzoxazone .................................................. 12
cholestyramine/aspartame ................................ 3
cholestyramine/sucrose .................................... 3
CHRONULAC ..................................................... 10
CIALIS .................................................................. 6
CIBALITH-S .......................................................... 2
CICLODAN ........................................................... 4
PortfolioHigh Formulary – October 2014
ciclopirox 8% solution ....................................... 4
ciclopirox olamine .............................................. 4
cilostazol ............................................................. 8
CILOXAN .............................................................. 7
cimetidine hcl ................................................... 13
CIPRO .................................................................. 8
CIPRO ORAL SUSPENSION .............................. 8
CIPRODEX ........................................................... 6
ciprofloxacin ....................................................... 8
ciprofloxacin hcl ............................................. 7, 8
ciprofloxacin hcl/dexameth ................................... 6
citalopram hydrobromide .................................. 1
CLARAVIS ............................................................ 4
clarithromycin ..................................................... 8
CLARITIN (OTC) .................................................. 1
CLARITIN-D 12 HOUR......................................... 1
CLARITIN-D 24 HOUR......................................... 1
CLEOCIN HCL ..................................................... 8
CLEOCIN PALMITATE ........................................ 8
CLEOCIN T .......................................................... 4
CLIMARA .............................................................. 8
CLINAC BPO ........................................................ 4
clindamycin ......................................................... 8
clindamycin palmitate ........................................ 8
clindamycin phos/benzoyl perox ..................... 4
clindamycin phosphate ..................................... 4
clindamycin/benzoyl prx/skn #5 ........................... 4
CLINORIL ........................................................... 10
clobetasol propionate ........................................ 5
clobetasol propionate/emoll ............................. 5
CLOBEX ............................................................... 5
CLOMID ................................................................ 6
clomiphene citrate.............................................. 6
clomipramine hcl ................................................ 1
clonazepam ....................................................... 12
clonidine hcl ....................................................... 3
clopidogrel bisulfate .......................................... 8
clorazepate dipotassium ................................... 2
clotrimazole......................................................... 9
clotrimazole/betamet diprop ............................. 4
clozapine ............................................................. 2
CLOZARIL ............................................................ 2
codeine phos/carisoprodol/asa ...................... 11
codeine/butalbit/acetamin/caff........................ 12
codeine/butalbital/asa/caffein ......................... 12
codeine/promethazine hcl ................................. 4
COGENTIN......................................................... 12
COLAZAL ........................................................... 10
COL-BENEMID .................................................... 7
colchicine ............................................................ 7
colchicine/probenecid ....................................... 7
COLCRYS ............................................................ 7
colesevelam hcl .................................................... 3
COLESTID............................................................ 3
COLESTID GRANULES ...................................... 3
colestipol ............................................................... 3
COLYTE WITH FLAVOR PACKETS ................. 10
COMBIGAN .......................................................... 7
COMBIPATCH ..................................................... 8
COMBIVENT ........................................................ 1
COMBIVENT RESPIMAT .................................... 1
COMBIVIR ............................................................ 9
COMETRIQ ........................................................ 11
COMPAZINE ........................................................ 1
COMPAZINE SYRUP........................................... 1
COMPLERA ......................................................... 9
COMTAN ............................................................ 12
CONCERTA ......................................................... 2
CONDYLOX ......................................................... 4
COPAXONE ....................................................... 11
COPEGUS............................................................ 9
CORDARONE ...................................................... 2
CORDRAN ........................................................... 5
CORDRAN SP ..................................................... 5
COREG ................................................................ 2
COREG CR .......................................................... 2
CORGARD ........................................................... 3
CORTEF ............................................................. 10
CORTENEMA .................................................... 10
cortisone acetate .............................................. 10
CORTISPORIN CREAM ...................................... 5
CORTISPORIN OINTMENT ................................ 5
CORTISPORIN OPHTH OINTMENT ................... 7
CORTISPORIN OPHTH SUSPENSION .............. 7
CORTISPORIN OTIC ........................................... 6
CORTONE ACETATE ........................................ 10
26
COSOPT .............................................................. 7
COUMADIN .......................................................... 7
COZAAR ............................................................... 3
CREON ............................................................... 12
CREON 36K ....................................................... 12
CRESTOR ............................................................ 3
CRINONE ............................................................. 6
CRIXIVAN............................................................. 9
crizotinib ............................................................. 11
cromolyn sodium ........................................... 1, 7
crotamiton ............................................................. 5
CUPRIMINE ....................................................... 10
CUTIVATE ............................................................ 5
cyanocobalamin/fa/pyridoxine ............................ 13
CYCLESSA .......................................................... 4
cyclobenzaprine hcl ......................................... 12
CYCLOCORT ....................................................... 5
CYCLOGYL .......................................................... 7
cyclopentolate hcl .............................................. 7
cyclophosphamide ........................................... 10
cyclosporine...................................................... 7, 8
cyclosporine, modified ...................................... 8
CYMBALTA .......................................................... 1
CYSTARAN .......................................................... 7
cysteamine ........................................................... 7
CYTOMEL ............................................................ 7
CYTOTEC .......................................................... 13
CYTOVENE .......................................................... 9
CYTOXAN .......................................................... 10
dabrafanib........................................................... 11
DALIRESP ............................................................ 1
DALMANE ............................................................ 2
dalteparin sodium,porcine .................................... 8
danazol ................................................................ 6
DANOCRINE ........................................................ 6
DANTRIUM......................................................... 12
dantrolene sodium ........................................... 12
dapsone ............................................................... 9
DARAPRIM........................................................... 9
darunavir ethanolate............................................. 9
dasatinib ............................................................. 11
DAYPRO ............................................................ 10
DDAVP ................................................................. 6
DECADRON ....................................................... 10
DECONAMINE ..................................................... 4
DELATESTRYL .................................................... 8
delavirdine mesylate............................................. 9
DEL-BETA ............................................................ 5
DELTASONE ...................................................... 10
DEMADEX ............................................................ 3
DEMULEN 1-50-21 .............................................. 4
DEPAKENE CAPSULES ................................... 12
DEPAKENE SYRUP .......................................... 12
DEPAKOTE ........................................................ 12
DEPAKOTE ER .................................................. 12
DEPAKOTE SPRINKLE ..................................... 12
DEPEN ............................................................... 10
DEPO-TESTOSTERONE .................................... 8
desipramine hcl .................................................. 1
desmopressin (nonrefrigerated) ....................... 6
DESOGEN............................................................ 4
desogestrel-ethinyl estradiol ............................ 4
desog-et estra/ethin estra ................................. 4
desonide .............................................................. 5
DESOWEN ........................................................... 5
desoximetasone ................................................. 5
DESVENLAFAXINE ER (RANBAXY BRAND) .... 1
desvenlafaxine ER (Ranbaxy).............................. 1
desvenlafaxine succinate ..................................... 1
DESYREL 300MG ................................................ 1
DETROL ............................................................. 13
DETROL LA........................................................ 13
dexamethasone ................................................ 10
DEXEDRINE......................................................... 1
DEXEDRINE SPANSULE .................................... 1
dexmethylphenidate hcl .................................... 2
dextroamphetamine capsule............................. 1
dextroamphetamine sulfate .............................. 1
dextroamphetamine tablet ............................ 1, 2
DHT .................................................................... 13
DIABETA .............................................................. 5
DIABINESE .......................................................... 5
DIAMOX SEQUELS ............................................. 7
DIASTAT ............................................................ 12
diazepam ....................................................... 2, 12
DIBENZYLINE ...................................................... 2
PortfolioHigh Formulary
INDEX
diclofenac sodium ....................................... 5, 7, 10
dicloxacillin sodium ........................................... 8
dicyclomine hcl ................................................ 13
didanosine........................................................... 9
DIDRONEL ........................................................... 6
DIFFERIN ............................................................. 4
DIFICID ................................................................. 8
diflorasone diacetate ......................................... 5
diflorasone diacetate/emoll .................................. 5
DIFLUCAN............................................................ 9
diflunisal ............................................................ 11
difluprednate ......................................................... 7
digoxin ................................................................. 2
DIGOXIN ORAL SOLN......................................... 2
dihydrotachysterol .............................................. 13
DILACOR XR ....................................................... 3
DILANTIN ........................................................... 12
DILANTIN CHEW TAB ....................................... 12
DILANTIN-125 .................................................... 12
DILAUDID ........................................................... 12
DILAUDID-5........................................................ 12
diltiazem hcl ........................................................ 3
dimethyl fumarate ............................................... 11
DIOVAN ................................................................ 3
DIOVAN HCT ....................................................... 2
diphenoxylate hcl/atrop sulf ........................... 10
dipivefrin hcl.......................................................... 7
DIPROLENE ......................................................... 5
DIPROLENE AF ................................................... 5
DIPROSONE ........................................................ 5
dipyridamole ....................................................... 8
DISALCID ........................................................... 11
disopyramide phosphate ................................... 2
disulfiram .............................................................. 2
DITROPAN XL ................................................... 13
divalproex sodium............................................ 12
d-methorphan hb/prometh hcl .......................... 4
dofetilide ............................................................... 2
DOLOBID ........................................................... 11
DOLOPHINE HCL .............................................. 12
dolutegravir ........................................................... 9
DOMEBORO ........................................................ 6
donepezil hcl ....................................................... 1
DONNATAL ........................................................ 13
dornase alfa ........................................................ 11
dorzolamide hcl .................................................. 7
dorzolamide hcl/timolol maleat ........................ 7
DOSTINEX ........................................................... 6
DOVONEX............................................................ 5
doxazosin mesylate ........................................... 2
doxepin hcl.......................................................... 1
doxycycline calcium.............................................. 9
doxycycline hyclate ........................................... 9
doxycycline monohydrate ................................. 9
DRISDOL ............................................................ 13
DRITHOCREME HP............................................. 5
DRITHO-SCALP ................................................... 5
dronabinol ........................................................... 1
dronedarone hcl ................................................... 2
DRYSOL ............................................................... 5
DUAC CS ............................................................. 4
DUAVEE ............................................................... 8
DUETACT............................................................. 5
DULERA ............................................................... 1
duloxetine hcl ..................................................... 1
DUONEB .............................................................. 1
DURAGESIC ...................................................... 12
DUREZOL ............................................................ 7
DURICEF.............................................................. 8
dutasteride .......................................................... 13
dutasteride/tamsulosin ....................................... 13
DYAZIDE .............................................................. 3
DYNACIN ............................................................. 9
DYNACIRC ........................................................... 3
E.E.S. 200 ............................................................ 8
EC-NAPROSYN ................................................. 10
EDURANT ............................................................ 9
efavirenz ............................................................... 9
efavirenz/emtricitab/tenofovir ............................... 9
EFFEXOR............................................................. 1
EFFEXOR XR ...................................................... 1
EFFIENT ............................................................... 8
EFUDEX ............................................................... 5
ELAVIL ................................................................. 1
ELDEPRYL ......................................................... 12
ELIGARD .............................................................. 6
PortfolioHigh Formulary – October 2014
ELIMITE ................................................................ 4
ELIQUIS ............................................................... 7
ELMIRON ........................................................... 13
ELOCON .............................................................. 5
eltrombopag olamine ............................................ 8
elvitegravir/ cobicistat/emtricitabine/tenofovir
disoproxil fumarate ......................................... 9
EMCYT ............................................................... 11
EMEND ................................................................. 1
EMGEL ................................................................. 4
emtricitab/rilpivirine/tenofovir................................ 9
emtricitabine ......................................................... 9
emtricitabine/tenofovir .......................................... 9
EMTRIVA .............................................................. 9
enalapril maleate ................................................ 2
enalapril/hydrochlorothiazide ........................... 2
ENBREL ............................................................. 10
ENDOMETRIN ..................................................... 6
enfuvirtide ............................................................. 9
enoxaparin sodium ............................................ 7
entacapone........................................................ 12
entecavir ............................................................... 9
ENTOCORT EC ................................................. 10
enzalutamide ...................................................... 11
epinephrine ....................................................... 10
EPIPEN .............................................................. 10
EPIVIR .................................................................. 9
EPIVIR HBV ......................................................... 9
eplerenone .......................................................... 3
epoetin alfa ........................................................... 7
EPZICOM ............................................................. 9
ergocalciferol .................................................... 13
ergotamine tartrate/caffeine ............................ 12
ERIVEDGE ......................................................... 11
erlotinib hcl ......................................................... 11
ery e-succ/sulfisoxazole .................................... 8
ERYC .................................................................... 8
ERYGEL ............................................................... 4
ERYPED 200 ........................................................ 8
ERYPED 400 ........................................................ 8
ERY-TAB .............................................................. 8
ERYTHROCIN STEARATE ................................. 8
erythromycin base ......................................... 7, 8
erythromycin base/benz per ............................. 4
erythromycin base/ethanol ............................... 4
erythromycin ethylsuccinate ............................ 8
erythromycin stearate ........................................ 8
escitalopram oxalate .......................................... 1
ESGIC ................................................................ 11
ESKALITH ............................................................ 2
esomeprazole magnesium ................................. 13
estazolam ............................................................ 2
ESTRACE....................................................... 8, 13
ESTRADERM ....................................................... 8
estradiol ......................................................... 8, 13
estradiol/noreth ac ................................................ 8
estramustine phosphate sodium ........................ 11
ESTRATEST H.S. ................................................ 8
estrogen, con/m-progest acet .............................. 8
estrogen, ester/me-testosterone ...................... 8
estrogens, conj/bazedoxifene .............................. 8
estrogens, conjugated .................................... 8, 13
estrogens, esterified ............................................. 8
estropipate .......................................................... 8
etanercept........................................................... 10
ethambutol hcl .................................................... 9
ethinyl estradiol/drospirenone.......................... 4
ethosuximide .................................................... 12
ethynodiol d-ethinyl estradiol ........................... 4
etidronate disodium ........................................... 6
etodolac ............................................................. 10
etonogestrel/ethinyl estradiol ............................... 4
etoposide........................................................... 11
etravirine ............................................................... 9
EULEXIN ............................................................ 11
EURAX ................................................................. 5
everolimus ...................................................... 8, 11
EVISTA ................................................................. 6
EVOCLIN .............................................................. 4
EVOXAC ............................................................. 10
EXELDERM .......................................................... 4
EXELON CAPSULE ............................................. 1
EXELON PATCH .................................................. 1
EXELON SOLUTION ........................................... 1
exemestane ....................................................... 11
exenatide .............................................................. 5
27
exenatide micropheres ......................................... 5
EXFORGE ............................................................ 2
EXFORGE HCT ................................................... 2
ezetimibe .............................................................. 3
FABIOR ................................................................ 4
famotidine ......................................................... 13
FANSIDAR ........................................................... 9
FARESTON ........................................................ 11
febuxostat ............................................................. 7
FELDENE ........................................................... 10
felodipine............................................................. 3
FEMARA ............................................................. 11
FEMHRT ............................................................... 8
fenofibrate ........................................................... 3
fenofibrate nanocrystallized ............................. 3
fenofibrate, micronized ...................................... 3
FENOGLIDE ......................................................... 3
fenoprofen calcium .......................................... 10
fentanyl .............................................................. 12
fentanyl citrate lozenge ................................... 12
FERTINEX ............................................................ 6
fesoterodine fumarate ........................................ 13
fidaxomicin............................................................ 8
filgrastim ............................................................... 8
finasteride ......................................................... 13
fingolimod hcl ..................................................... 11
FIORICET ........................................................... 11
FIORICET WITH CODEINE ............................... 12
FIORINAL ........................................................... 11
FIORINAL WITH CODEINE ............................... 12
FIRAZYR ............................................................ 10
FIRST-HYDROCORTISONE ............................... 5
FLAGYL ................................................................ 9
FLAGYL ER .......................................................... 9
FLAREX................................................................ 7
flecainide acetate ............................................... 2
FLEXERIL........................................................... 12
FLOMAX ............................................................. 13
FLONASE ............................................................. 1
FLORINEF ACETATE ........................................ 10
FLOVENT DISKUS .............................................. 1
FLOVENT HFA ..................................................... 1
FLOXIN ............................................................. 6, 9
fluconazole .......................................................... 9
fludarabine phosphate ........................................ 11
fludrocortisone acetate ................................... 10
flunisolide............................................................ 1
fluocinolone acetonide ...................................... 5
fluocinonide ........................................................ 5
fluocinonide/emollient ....................................... 5
FLUORABON BASIC ......................................... 13
fluoride ion/iron/vit a,c&d ................................ 13
fluoride ion/multivitamins ............................... 13
fluoride ion/multivits w-fe................................ 13
fluoride ion/vit a,c&d ........................................ 13
FLUORITAB ....................................................... 13
fluorometholone ................................................. 7
fluorometholone acetate ....................................... 7
fluorouracil .......................................................... 5
fluoxetine er ........................................................ 1
fluoxetine hcl ...................................................... 1
fluoxymesterone ................................................. 8
fluphenazine hcl ................................................. 2
FLURA-DROPS .................................................. 13
flurandrenolide ...................................................... 5
FLURA-TABS ..................................................... 13
flurazepam hcl .................................................... 2
flurbiprofen ....................................................... 10
flurbiprofen sodium ........................................... 7
flutamide............................................................ 11
fluticasone propionate ................................... 1, 5
fluticasone/salmeterol........................................... 1
fluticasone/vilanterol ............................................. 1
FML ...................................................................... 7
FML FORTE ......................................................... 7
FML S.O.P. ........................................................... 7
FOCALIN .............................................................. 2
FOCALIN XR ........................................................ 2
FOLGARD RX .................................................... 13
folic acid ............................................................ 13
FOLIC ACID ....................................................... 13
folic acid/mu-vits-min th .................................. 13
FOLLISTIM AQ ..................................................... 6
follitropin alpha,recomb ........................................ 6
follitropin beta,recomb .......................................... 6
fondaparinux sodium ............................................ 8
PortfolioHigh Formulary
INDEX
formoterol fumarate .............................................. 1
FORTEO ............................................................... 6
FOSAMAX ............................................................ 6
FOSAMAX PLUS D .............................................. 6
fosamprenavir calcium ......................................... 9
fosinopril sodium ............................................... 3
fosinopril/hydrochlorothiazide ......................... 2
FRAGMIN ............................................................. 8
FURADANTIN ...................................................... 8
furazolidone .......................................................... 8
furosemide .......................................................... 3
FUROXONE ......................................................... 8
FUZEON ............................................................... 9
gabapentin ........................................................ 12
galantamine hbr .................................................. 1
ganciclovir......................................................... 7, 9
ganirelix acetate ................................................... 6
GANIRELIX ACETATE......................................... 6
GANTRISIN .......................................................... 8
GARAMYCIN .................................................... 4, 7
gatifloxacin.......................................................... 7
GATTEX ............................................................. 10
gemfibrozil .......................................................... 3
gentamicin sulfate .......................................... 4, 7
GEODON .............................................................. 2
GIANVI ................................................................. 4
GILENYA ............................................................ 11
GILOTRIF ........................................................... 11
glatiramer acetate............................................... 11
GLEEVEC........................................................... 11
glimepiride .......................................................... 5
glipizide ............................................................... 5
glipizide/metformin hcl ...................................... 5
glucagon ............................................................... 6
GLUCAGON KIT .................................................. 6
GLUCOPHAGE .................................................... 5
GLUCOPHAGE XR .............................................. 5
GLUCOTROL ....................................................... 5
GLUCOTROL XL .................................................. 5
GLUCOVANCE .................................................... 5
glyburide ............................................................. 5
glyburide, micro/metformin hcl ........................ 5
GOLYTELY......................................................... 10
gonadorelin acetate .............................................. 6
gonadotropin,chorionic, human ............................ 6
GONAL-F.............................................................. 6
GONAL-F RFF ..................................................... 6
griseofulvin suspension ........................................ 9
griseofulvin ultramicrosize ............................... 9
GRISEOFULVIN V ............................................... 9
GRIS-PEG ............................................................ 9
guaifenesin/codeine phos ................................. 4
guaifenesin/d-methorphan hb........................... 4
guanfacine hcl .................................................... 3
GYNAZOLE-1 ..................................................... 13
HALCION .............................................................. 2
HALDOL ............................................................... 2
HALDOL ORAL CONC......................................... 2
halobetasol propionate ...................................... 5
haloperidol .......................................................... 2
haloperidol lactate.............................................. 2
hc acetate/pramoxine hcl ............................ 5, 10
hcg alpha, recombinant ........................................ 6
HEPARIN LOCK ................................................... 8
heparin sodium, porcine ................................... 8
heparin sodium, porcine/pf ............................... 8
HEP-LOCK ........................................................... 8
HEPSERA ............................................................ 9
HEXALEN ........................................................... 11
homatropine hbr ................................................. 7
hum insulin nph/reg insulin hm............................. 6
HUMALOG ........................................................... 6
HUMALOG MIX 50-50.......................................... 6
HUMALOG MIX 75-25.......................................... 6
HUMATIN ............................................................. 9
HUMIRA ............................................................. 10
HUMULIN 50-50 ................................................... 6
HUMULIN 70-30 ................................................... 6
HUMULIN N.......................................................... 6
HUMULIN R.......................................................... 6
HYCAMTIN ......................................................... 11
HYCET ............................................................... 12
hydralazine hcl ................................................... 3
HYDREA ............................................................. 10
hydrochlorothiazide ........................................... 3
hydrocodone bit/acetaminophen ................... 12
PortfolioHigh Formulary – October 2014
hydrocodone bit/acetaminophen oral elixir .. 12
hydrocodone bit/acetaminophen oral solution
...................................................................... 12
hydrocodone/chlorphen polis ............................... 4
hydrocort/sal acid/sulf/shmp#1............................. 5
hydrocortisone ............................................. 5, 10
hydrocortisone acetate .................................... 10
hydrocortisone acetate/urea ............................. 5
hydrocortisone butyrate .................................... 5
hydrocortisone butyrate/emoll .............................. 5
hydrocortisone probutate ..................................... 5
hydrocortisone valerate .................................... 5
hydrocortisone/iodoquinol ................................ 4
hydromorphone hcl.......................................... 12
hydroxychloroquine sulfate .............................. 9
hydroxyurea ...................................................... 10
hydroxyzine hcl .................................................. 1
hydroxyzine pamoate ........................................ 1
HYGROTON ......................................................... 3
hyoscyamine sulfate ........................................ 13
HYPER-SAL 7% ................................................. 11
HYTRIN ................................................................ 2
HYZAAR ............................................................... 2
ibandronate ......................................................... 6
ibrutinib ............................................................... 11
ibuprofen ........................................................... 10
icatibant .............................................................. 10
ICLUSIG ............................................................. 11
icosapent ethyl ..................................................... 3
ILEVRO ................................................................ 7
imatinib mesylate................................................ 11
IMBRUVICA........................................................ 11
IMDUR .................................................................. 3
imipramine hcl .................................................... 1
imiquimod ........................................................... 8
IMITREX INJECTION ......................................... 12
IMITREX NASAL SPRAY ................................... 12
IMITREX TABLET .............................................. 12
IMURAN ............................................................... 8
indapamide.......................................................... 3
INDERAL LA......................................................... 3
INDERIDE-40/25 .................................................. 3
indinavir sulfate .................................................... 9
INDOCIN ............................................................ 10
INDOCIN ORAL SUSP. ..................................... 10
INDOCIN SR ...................................................... 10
INDOCIN SUPPOS ............................................ 10
indomethacin .................................................... 10
ingenol .................................................................. 5
INLYTA ............................................................... 11
INSPRA ................................................................ 3
insulin aspart ........................................................ 6
insulin glargine,hum.rec.anlog ............................. 6
insulin lispro .......................................................... 6
insulin npl/insulin lispro ........................................ 6
insulin regular, human .......................................... 6
insuln asp prt/insulin aspart.................................. 6
INTAL ................................................................... 1
INTELENCE ......................................................... 9
interferon alfa-2b, recomb. ................................... 8
interferon beta-1a ............................................... 11
interferon beta-1a/albumin ................................. 11
interferon beta-1b ............................................... 11
INTRON A ............................................................ 8
INVIRASE ............................................................. 9
INVOKANA ........................................................... 6
iodoquinol ............................................................. 9
ipratropium bromide .................................... 1, 11
ipratropium/albuterol sulfate ............................ 1
irbesartan ............................................................ 3
irbesartan/hydrochlorithiazide.......................... 2
ISENTRESS ......................................................... 9
ISMO .................................................................... 3
ISOCHRON .......................................................... 3
isomethept/acetaminop/dichlphn ................... 12
isoniazid .............................................................. 9
ISOPTO ATROPINE ............................................ 7
ISOPTO CARBACHOL ........................................ 7
ISOPTO CARPINE ............................................... 7
ISOPTO HOMATROPINE .................................... 7
ISORDIL ............................................................... 3
ISORDIL TITRADOSE ......................................... 3
isosorbide dinitrate ............................................ 3
isosorbide mononitrate ..................................... 3
isotretinoin .......................................................... 4
isradipine IR capsules ....................................... 3
28
itraconazole......................................................... 9
ivacaftor .............................................................. 11
JAKAFI ............................................................... 11
JALYN ................................................................ 13
JANUMET............................................................. 5
JANUMET XR ...................................................... 5
JANUVIA .............................................................. 5
JENTADUETO ..................................................... 5
JUXTAPID ............................................................ 3
KALETRA ............................................................. 9
KALYDECO ........................................................ 11
KAYEXALATE ...................................................... 6
K-DUR .................................................................. 6
KEFLEX ................................................................ 8
KENALOG ............................................................ 5
KENALOG IN ORABASE ................................... 11
KEPPRA ............................................................. 12
KETEK .................................................................. 8
ketoconazole ................................................... 4, 9
ketoprofen ......................................................... 10
ketorolac tromethamine .............................. 7, 10
ketotifen fumarate (OTC) ................................... 7
KLARON ............................................................... 4
KLERIST-D ........................................................... 4
KLONOPIN ......................................................... 12
K-LYTE ................................................................. 6
K-LYTE-CL ........................................................... 6
KORLYM .............................................................. 5
KRISTALOSE ..................................................... 10
K-TAB ................................................................... 6
KURIC .................................................................. 4
KWELL ................................................................. 4
KYNAMRO ........................................................... 3
labetalol hcl ......................................................... 2
LACTICARE-HC ................................................... 5
lactulose ............................................................ 10
LAMICTAL .......................................................... 12
LAMISIL ............................................................ 4, 9
LAMISIL GRANULES ........................................... 9
lamivudine ............................................................ 9
lamivudine/zidovudine .......................................... 9
lamotrigine ........................................................ 12
lancing device/lancets .......................................... 6
LANOXIN .............................................................. 2
lanreotide acetate ............................................... 11
lansoprazole ..................................................... 13
lansoprazole/amox tr/clarith ........................... 13
LANTUS ............................................................... 6
LANTUS SOLOSTAR........................................... 6
lapatinib ditosylate .............................................. 11
LARIAM ................................................................ 9
LASIX ................................................................... 3
latanoprost ............................................................ 7
leflunomide ....................................................... 10
lenalidomide ....................................................... 11
LESSINA .............................................................. 4
LETAIRIS .............................................................. 3
letrozole ............................................................. 11
leucovorin calcium ........................................... 11
LEUCOVORIN CALCIUM .................................. 11
LEUKERAN ........................................................ 11
LEUKINE .............................................................. 8
leuprolide .............................................................. 6
LEVAQUIN ........................................................... 8
LEVBID ............................................................... 13
levetiracetam .................................................... 12
levobunolol hcl ................................................... 7
levocetirizine ....................................................... 1
levofloxacin ......................................................... 8
levonorgestrel-eth estra .................................... 4
LEVOTHROID ...................................................... 7
levothyroxine sodium ........................................ 7
LEVOXYL ............................................................. 7
LEVSIN-SL ......................................................... 13
LEXAPRO............................................................. 1
LEXIVA ................................................................. 9
LIBRAX ............................................................... 13
LIBRIUM ............................................................... 2
LIDEX ................................................................... 5
LIDEX-E ................................................................ 5
lidocaine hcl ...................................................... 10
LIFESCAN DIABETIC SUPPLIES ....................... 6
linaclotide ............................................................ 10
linagliptin............................................................... 5
linagliptin/metformin hcl ........................................ 5
lindane ................................................................. 4
PortfolioHigh Formulary
INDEX
linezolid ................................................................. 8
LINZESS ............................................................. 10
LIORESAL .......................................................... 12
liothyronine sodium ........................................... 7
LIPITOR ................................................................ 3
liraglutide .............................................................. 5
lisdexamfetamine dimesylate ............................... 2
lisinopril ............................................................... 3
lisinopril/hydrochlorothiazide ........................... 2
lithium carbonate ............................................... 2
lithium citrate ...................................................... 2
LITHOBID ............................................................. 2
LO LOESTRIN FE ................................................ 4
LO MINASTRIN FE .............................................. 4
LOCOID ................................................................ 5
LOCOID LIPOCREAM ......................................... 5
LODINE .............................................................. 10
LODOSYN .......................................................... 12
lodoxamide tromethamine .................................... 7
LODRANE ............................................................ 4
LOESTRIN............................................................ 4
LOESTRIN FE ...................................................... 4
LOESTRIN FE24 .................................................. 4
LOFIBRA .............................................................. 3
lomitapide ............................................................. 3
LOMOTIL ............................................................ 10
lomustine........................................................... 10
LO-OVRAL-28 ...................................................... 4
LOPID ................................................................... 3
lopinavir/ritonavir .................................................. 9
LOPRESSOR ....................................................... 3
LOPRESSOR HCT............................................... 3
LOPROX............................................................... 4
loratadine (OTC) ................................................. 1
lorazepam ............................................................ 2
LORAZEPAM INTENSOL .................................... 2
LORCET ............................................................. 12
LORCET PLUS .................................................. 12
LORTAB ............................................................. 12
LORTAB ELIXIR ................................................. 12
LORYNA ............................................................... 4
losartan potassium ............................................ 3
losartan/hydrochlorothiazide ............................ 2
LOTEMAX ............................................................ 7
LOTENSIN............................................................ 2
LOTENSIN HCT ................................................... 2
loteprednol etabonate........................................... 7
LOTREL................................................................ 2
LOTRISONE ......................................................... 4
lovastatin ............................................................. 3
LOVAZA ............................................................... 3
LOVENOX ............................................................ 7
loxapine succinate ............................................. 2
LOXITANE ............................................................ 2
LOZOL .................................................................. 3
lubiprostone ........................................................ 10
LUDIOMIL............................................................. 1
LUMIGAN ............................................................. 7
LURIDE .............................................................. 13
LUTERA ............................................................... 4
LUTREPULSE ...................................................... 6
LYRICA ............................................................... 12
LYSODREN ........................................................ 11
macitentan ............................................................ 3
MACROBID .......................................................... 8
MACRODANTIN ................................................... 8
malathion............................................................. 4
maprotiline hcl .................................................... 1
maraviroc .............................................................. 9
MARINOL ............................................................. 1
MATULANE ........................................................ 11
MAVIK .................................................................. 3
MAXALT ............................................................. 12
MAXALT MLT ..................................................... 12
MAXITROL ........................................................... 7
MAXI-TUSS HCX ................................................. 4
MAXZIDE .............................................................. 3
MAXZIDE-25MG .................................................. 3
mebendazole ....................................................... 9
mechlorethamine .................................................. 5
meclizine hcl ....................................................... 1
meclofenamate sodium ................................... 10
MECLOMEN ....................................................... 10
Medication Request Form (MRF) .......................ii
MEDROL ............................................................ 10
medroxyprogesterone acet ............................... 8
PortfolioHigh Formulary – October 2014
mefloquine hcl .................................................... 9
MEGACE ............................................................ 11
MEGACE ES ...................................................... 11
megestrol acetate ............................................. 11
MEKINIST........................................................... 11
MELLARIL ............................................................ 2
meloxicam ......................................................... 10
melphalan ........................................................... 11
memantine hcl ...................................................... 1
MENEST............................................................... 8
MENOPUR ........................................................... 6
menotropins .......................................................... 6
MEPHYTON ......................................................... 8
meprobamate ...................................................... 2
mercaptopurine ................................................ 11
mesalamine ....................................................... 10
mesalamine w/cleansing wipes ...................... 10
MESTINON........................................................... 1
METADATE CD .................................................... 2
METADATE ER .................................................... 2
METAGLIP ........................................................... 5
metaproterenol sulfate ...................................... 1
metaxalone ........................................................ 12
metformin hcl ...................................................... 5
meth/meth blue/ba/salicy/hyos ............................. 8
methadone hcl .................................................. 12
methazolamide ................................................... 7
METHERGINE ..................................................... 4
methimazole ........................................................ 7
METHITEST ......................................................... 8
METHLYIN ER ..................................................... 2
methocarbamol ................................................. 12
methotrexate sodium ................................. 10, 11
METHOTREXATE TABLET ............................... 11
METHOTREXATE VIAL ..................................... 11
methoxsalen ......................................................... 5
methoxsalen, rapid............................................. 5
methyldopa ......................................................... 3
methylergonovine maleate ................................... 4
METHYLIN ........................................................... 2
METHYLIN CHEW TAB ....................................... 2
methylnaltrexone bromide .................................. 10
methylphenidate chewable................................... 2
methylphenidate ER Susp.................................... 2
methylphenidate hcl........................................... 2
methylprednisolone ......................................... 10
methyltestosterone ............................................... 8
metipranolol ........................................................ 7
metoclopramide hcl ......................................... 13
METOCLOPRAMIDE HCL INTENSOL .............. 13
metolazone .......................................................... 3
metoprolol succinate ......................................... 3
metoprolol tartrate ............................................. 3
metoprolol/hctz ................................................... 3
METROCREAM ................................................... 4
METROGEL-VAGINAL ...................................... 13
METROLOTION ................................................... 4
metronidazole ........................................... 4, 9, 13
MEVACOR ........................................................... 3
mexiletine hcl ...................................................... 2
MEXITIL................................................................ 2
miconazole nitrate ............................................ 13
MICRO-K .............................................................. 6
MICRONASE ........................................................ 5
MICROZIDE ......................................................... 3
midodrine hcl ...................................................... 3
MIDRIN ............................................................... 12
mifepristone .......................................................... 5
MIGERGOT ........................................................ 12
MILLIPRED......................................................... 10
MILLIPRED DP .................................................. 10
milnacipran hcl ................................................... 11
MILTOWN............................................................. 2
MINIPRESS .......................................................... 2
MINOCIN .............................................................. 9
minocycline hcl .................................................. 9
mipomersin sodium ........................................... 3
MIRALAX ............................................................ 10
MIRAPEX ........................................................... 12
MIRCETTE ........................................................... 4
mirtazapine.......................................................... 1
misoprostol ....................................................... 13
mitotane .............................................................. 11
MOBIC ................................................................ 10
moexipril hcl ....................................................... 3
moexipril/hydrochlorothiazide .......................... 2
29
mometasone furoate ........................................ 1, 5
mometasone/formoterol ....................................... 1
MONISTAT 3 ...................................................... 13
MONOKET ........................................................... 3
MONOPRIL .......................................................... 3
MONOPRIL HCT .................................................. 2
montelukast sodium .......................................... 1
morphine sulfate .............................................. 12
MOTRIN ............................................................. 10
moxifloxacin hcl ................................................ 7, 9
MSIR ................................................................... 12
mth/me blue/salicy/na phos/hyo ........................... 8
MUCOMYST-10 ................................................. 11
MULTAQ ............................................................... 2
mupirocin ............................................................ 4
mupirocin calcium........................................ 4, 11
MYAMBUTOL ....................................................... 9
MYCELEX ............................................................ 9
MYCIFRADIN ....................................................... 9
MYCI-GC .............................................................. 4
MYCOLOG II ........................................................ 4
mycophenolate mofetil ...................................... 8
MYCOSTATIN .................................................. 4, 9
MYLERAN .......................................................... 11
MYORISAN .......................................................... 4
MYSOLINE ......................................................... 12
na sulfacetm/prednis sp .................................... 7
na sulfacetm/prednisol ac .................................... 7
nabumetone ...................................................... 10
nadolol ................................................................. 3
naftifine hcl ........................................................... 4
NAFTIN ................................................................. 4
NALEX A 12 ......................................................... 4
NALFON CAPSULE ........................................... 10
NALFON TABLET .............................................. 10
naltrexone hcl ..................................................... 2
NAMENDA............................................................ 1
NAMENDA XR ..................................................... 1
NAPROSYN ....................................................... 10
naproxen ........................................................... 10
naproxen sodium ............................................. 10
naproxen/esomeprazole mag............................. 10
naratriptan ......................................................... 12
NARDIL ................................................................ 1
NASACORT AQ ................................................... 1
NASAREL ............................................................. 1
NASONEX ............................................................ 1
nateglinide........................................................... 5
NATURE-THROID ................................................ 7
NAVANE ............................................................... 2
nebivolol hcl .......................................................... 3
NEBUPENT .......................................................... 9
nedocromil sodium ............................................... 7
needles, insulin disp., safety .............................. 11
nelfinavir mesylate................................................ 9
neo/polymyx b sulf/dexameth ........................... 7
NEODECADRON ................................................. 7
neomy sulf/bacitrac zn/poly/hc ......................... 7
neomy sulf/polymyx b sulf/hc ....................... 5, 6, 7
neomy sulf/polymyx b sulf/pred ............................ 7
neomycin sulfate ................................................ 9
neomycin sulfate/dex na ph .............................. 7
neomycin/bacitra/polymyxin/hc ............................ 5
neomycin/bacitracin/polymyxin ....................... 7
neomycin/polymyxn b/gramicidin .................... 7
NEORAL ............................................................... 8
NEOSPORIN OPHTH DROPS ............................ 7
NEOSPORIN OPHTH OINTMENT ...................... 7
neostigmine bromide ............................................ 1
nepafenac ............................................................. 7
NEPTAZANE ........................................................ 7
NEULASTA........................................................... 8
NEUPOGEN ......................................................... 8
NEUPRO ............................................................ 12
NEURONTIN ...................................................... 12
NEVANAC ............................................................ 7
nevirapine............................................................ 9
nevirapine ER ..................................................... 9
NEXAVAR .......................................................... 11
NEXIUM.............................................................. 13
niacin ................................................................... 3
niacin/simvastatin ................................................. 3
NIASPAN .............................................................. 3
nicardipine .......................................................... 3
nifedipine............................................................. 3
NILANDRON ...................................................... 11
PortfolioHigh Formulary
INDEX
nilotinib hydrochloride......................................... 11
nilutamide ........................................................... 11
nimodipine .......................................................... 3
NIMOTOP ............................................................. 3
NITRO-BID ........................................................... 4
NITRO-DUR ......................................................... 4
nitrofurantoin ........................................................ 8
nitrofurantoin macrocrystal .............................. 8
nitrofurantoin/nitrofuran mac ........................... 8
nitroglycerin ........................................................ 4
NITROLINGUAL ................................................... 4
NITROSTAT ......................................................... 4
nizatidine ........................................................... 13
NIZORAL .......................................................... 4, 9
NOCTEC .............................................................. 2
NOLVADEX ........................................................ 11
NORCO .............................................................. 12
NORDETTE-28 .................................................... 4
norelgestromin/ethin.estradiol ......................... 4
noreth a-et estra/fe fumarate............................. 4
norethind ac/ethinyl estradiol ............................... 8
norethindrone ..................................................... 4
norethindrone acetate ....................................... 8
norethindrone a-e estradiol ............................... 4
norethindrone-ethinyl estrad ............................ 4
norethindrone-mestranol .................................. 4
NORFLEX........................................................... 12
NORGESIC FORTE ........................................... 12
norgestimate-ethinyl estradiol .......................... 4
norgestrel-ethinyl estradiol ............................... 4
NORINYL 1+35 .................................................... 4
NORINYL 1+50 .................................................... 4
NORPACE ............................................................ 2
NORPACE CR ..................................................... 2
NORPRAMIN ....................................................... 1
NOR-Q-D .............................................................. 4
nortriptyline hcl .................................................. 1
NORVASC ............................................................ 3
NORVIR ................................................................ 9
NOVAHISTINE DH ............................................... 4
NOVAREL ............................................................ 6
NOVOFINE ......................................................... 11
NOVOFINE AUTOCOVER ................................. 11
NOVOLIN 70-30 ................................................... 6
NOVOLIN 70-30 INNOLET .................................. 6
NOVOLIN N .......................................................... 6
NOVOLIN N INNOLET ......................................... 6
NOVOLIN R .......................................................... 6
NOVOLOG ........................................................... 6
NOVOLOG MIX 70-30.......................................... 6
nph, human insulin isophane ............................... 6
NUCYNTA .......................................................... 12
NUCYNTA ER .................................................... 12
NULYTELY WITH FLAVOR PACKS .................. 10
NUVARING........................................................... 4
NUVIGIL ............................................................... 2
NYDRAZID ........................................................... 9
nystatin ............................................................ 4, 9
nystatin/triamcin................................................. 4
OCL .................................................................... 10
octreotide acetate............................................. 11
OCUFEN .............................................................. 7
OCUFLOX ............................................................ 7
OCUPRESS ......................................................... 7
ofloxacin ...................................................... 6, 7, 9
OFORTA............................................................. 11
OGEN ................................................................... 8
olanzapine ........................................................... 2
olanzapine ODT .................................................. 2
olanzapine/fluoxetine ......................................... 1
olmesartan medoxomil ......................................... 3
olmesartan/hydrochlorothiazide ........................... 2
olopatadine hcl ..................................................... 7
OLUX .................................................................... 5
OLYSIO .............................................................. 10
omega-3 acid ethyl esters ................................. 3
omeprazole........................................................ 13
omeprazole magnesium .................................. 13
OMNICEF ............................................................. 8
OMNIPRED .......................................................... 7
OMNITROPE ........................................................ 6
ondansetron ........................................................ 1
ondansetron hcl ................................................. 1
OPSUMIT ............................................................. 3
OPTICROM .......................................................... 7
OPTIPRANOLOL ................................................. 7
PortfolioHigh Formulary – October 2014
OPTIVAR .............................................................. 7
ORAMORPH SR ................................................ 12
ORAPRED .......................................................... 10
ORINASE ............................................................. 5
orphenadrine citrate......................................... 12
orphenadrine/aspirin/caffeine ......................... 12
ORSYTHIA ........................................................... 4
ORTHO EVRA ...................................................... 4
ORTHO MICRONOR ........................................... 4
ORTHO TRI-CYCLEN .......................................... 4
ORTHO TRI-CYCLEN LO .................................... 4
ORTHO-CEPT ...................................................... 4
ORTHO-CYCLEN ................................................. 4
ORTHO-NOVUM .................................................. 4
ORUVAIL ............................................................ 10
OSCELLA ............................................................. 4
oseltamivir phosphate .......................................... 9
OTICIN HC ........................................................... 6
OVACE PLUS SUSPENSION.............................. 5
OVIDE .................................................................. 4
OVIDREL .............................................................. 6
oxaprozin........................................................... 10
oxazepam ............................................................ 2
oxcarbazepine .................................................. 12
OXSORALEN ....................................................... 5
OXSORALEN-ULTRA .......................................... 5
oxybutynin chloride ......................................... 13
oxycodone hcl .................................................. 12
oxycodone hcl/acetaminophen ...................... 12
oxycodone hcl/aspirin ..................................... 12
OXYCONTIN ...................................................... 12
PAMELOR ............................................................ 1
PANCRELIPASE 5,000 ...................................... 12
PANDEL ............................................................... 5
pantoprazole sodium ....................................... 13
PARAFON FORTE DSC .................................... 12
PARCOPA .......................................................... 12
paricalcitol........................................................... 6
PARLODEL ........................................................ 12
PARNATE............................................................. 1
paromomycin sulfate ......................................... 9
paroxetine hcl ..................................................... 1
PATADAY ............................................................. 7
PATANOL ............................................................. 7
PATHOCIL............................................................ 8
PAXIL ................................................................... 1
pazopanib hydrochloride .................................... 11
PCE ...................................................................... 8
PEDIAPRED ....................................................... 10
PEDIAZOLE ......................................................... 8
peg 3350/na sulf,bicarb,cl/kcl ......................... 10
PEGASYS ............................................................ 9
PEGASYS CONVENIENCE PACK ...................... 9
PEGASYS PROCLICK CONVENIENCE PACK .. 9
pegfilgrastim ......................................................... 8
peginterferon alfa-2a ............................................ 9
peginterferon alfa-2b .......................................... 10
PEGINTRON ...................................................... 10
PEGINTRON REDIPEN ..................................... 10
pegvisomant ......................................................... 6
pemirolast potassium ........................................... 7
penicillamine ....................................................... 10
penicillin v potassium ........................................ 8
pentamidine isethionate ....................................... 9
pentosan polysulfate sodium.............................. 13
pentoxifylline ...................................................... 7
PEPCID .............................................................. 13
p-ephed hcl/brompheniramin............................ 4
p-ephed hcl/cetirizine hcl (OTC) ....................... 1
p-ephed hcl/cod/chlorphenir ............................. 4
p-ephed hcl/codeine/guaifen............................. 4
p-ephed sul/loratadine ....................................... 1
PERCOCET........................................................ 12
PERCODAN ....................................................... 12
PERCOLONE ..................................................... 12
PERFOROMIST ................................................... 1
PERIDEX ............................................................ 11
PERISOL ............................................................ 11
permethrin ........................................................... 4
perphenazine ...................................................... 2
PERSANTINE ...................................................... 8
phenazopyridine hcl......................................... 13
phenelzine sulfate ................................................ 1
PHENERGAN ....................................................... 1
PHENERGAN VC ................................................. 4
PHENERGAN VC W/CODEINE........................... 4
30
PHENERGAN W/CODEINE ................................. 4
PHENERGAN W/DEXTROMETHORPHAN ........ 4
phenobarbital ...................................................... 2
PHENOBARBITAL ............................................... 2
phenoxybenzamine hcl ........................................ 2
phenylephrine hcl/cod/prometh ....................... 4
phenylephrine hcl/prometh hcl ......................... 4
phenylephrine/brompheniramine ..................... 4
phenylephrine/chlor-tan .................................... 4
phenylephrine/hydrocodone/cp ....................... 4
phenylephrine/pyril tan/cp ................................ 4
PHENYTEK ........................................................ 12
phenytoin .......................................................... 12
phenytoin sodium extended ........................... 12
PHOSLO ............................................................... 6
PHRENILIN ........................................................ 11
PHRENILIN FORTE ........................................... 11
phytonadione ........................................................ 8
PICATO ................................................................ 5
pilocarpine hcl .............................................. 7, 10
pindolol ................................................................ 3
pioglitazone hcl .................................................. 5
pioglitazone hcl/metformin hcl .............................. 5
pioglitazone/glimepiride .................................... 5
piroxicam........................................................... 10
PLAQUENIL ......................................................... 9
PLAVIX ................................................................. 8
PLAVIX 300MG .................................................... 8
PLENDIL ............................................................... 3
PLETAL ................................................................ 8
PODHALER .......................................................... 9
podofilox ............................................................. 4
POLYCILLIN ......................................................... 8
POLYCIN-B .......................................................... 7
polyethylene glycol 3350 ................................. 10
polymyxin b sulfate/tmp .................................... 7
POLY-PRED ......................................................... 7
POLYTRIM ........................................................... 7
POLY-VI-FLOR .................................................. 13
POLY-VI-FLOR W/IRON .................................... 13
pomalidomide ..................................................... 11
POMALYST ........................................................ 11
ponatinib ............................................................. 11
pot chloride/pot bicarb/cit ac ............................ 6
potassium bicarbonate/cit ac............................ 6
potassium chloride ............................................ 6
potassium iodide ................................................ 7
POTASSIUM IODIDE ........................................... 7
pramipexole di-hcl ............................................ 12
pramlintide acetate ............................................... 5
PRAMOSONE ...................................................... 5
PRANDIMET ........................................................ 5
PRANDIN ............................................................. 5
prasugrel hcl ......................................................... 8
PRAVACHOL ....................................................... 3
pravastatin sodium ............................................ 3
praziquantel .......................................................... 9
prazosin hcl......................................................... 2
PRECOSE ............................................................ 5
PRED FORTE ...................................................... 7
PRED MILD .......................................................... 7
PREDNISOL ......................................................... 7
prednisolone ..................................................... 10
prednisolone acetate ......................................... 7
prednisolone sod phosphate ...................... 7, 10
prednisone ........................................................ 10
PREDNISONE INTENSOL ................................ 10
pregabalin ........................................................... 12
PREGNYL ............................................................ 6
PREMARIN..................................................... 8, 13
PREMPHASE ....................................................... 8
PREMPRO ........................................................... 8
prenatal vit 15/iron cb/fa/dss........................... 13
prenatal vit 16/iron cb/fa/dss........................... 13
prenatal vit 18/iron cb/fa/dss........................... 13
prenatal vit 95/fe fum/fa ................................... 13
PRENATE GT .................................................... 13
PRENAVITE ....................................................... 13
PREVACID ......................................................... 13
PREVACID SOLUTABS ..................................... 13
PREVPAC .......................................................... 13
PREZISTA ............................................................ 9
PRILOSEC ......................................................... 13
PRILOSEC OTC ................................................. 13
PRIMAQUINE ....................................................... 9
primaquine phosphate .......................................... 9
PortfolioHigh Formulary
INDEX
primidone .......................................................... 12
PRIMSOL ............................................................. 8
PRINIVIL............................................................... 3
PRINZIDE ............................................................. 2
PRISTIQ ............................................................... 1
PROAIR HFA ....................................................... 1
PROAMATINE ...................................................... 3
probenecid .......................................................... 7
procainamide hcl ................................................ 2
procarbazine hcl ................................................. 11
PROCARDIA ........................................................ 3
PROCARDIA XL ................................................... 3
PROCHIEVE ........................................................ 6
prochlorperazine edisylate ................................... 1
prochlorperazine maleate .................................. 1
PROCRIT ............................................................. 7
PROCTOCORT .................................................. 10
PROCTOCREAM-HC......................................... 10
PROCTOFOAM-HC ........................................... 10
PROCTO-KIT ..................................................... 10
PROFASI .............................................................. 6
progesterone, micronized ................................. 6, 8
PROGRAF ............................................................ 8
PROLIXIN ............................................................. 2
PROLOPRIM ........................................................ 8
PROMACTA ......................................................... 8
promethazine hcl ................................................ 1
PROMETRIUM ..................................................... 8
PRONESTYL ........................................................ 2
propafenone hcl ................................................. 2
PROPINE ............................................................. 7
propranolol hcl ................................................... 3
propranolol/hydrochlorothiazid ........................ 3
propylthiouracil ..................................................... 7
PROPYLTHIOURACIL ......................................... 7
PROSCAR .......................................................... 13
PROSED-DS ........................................................ 8
PROSOM.............................................................. 2
PROSTIGMIN ....................................................... 1
PROTONIX ......................................................... 13
PROTOPIC ........................................................... 5
PROVERA ............................................................ 8
PROZAC ............................................................... 1
PROZAC WEEKLY .............................................. 1
pseudoephedrine hcl/chlor-mal ........................ 4
PULMICORT RESPULES .................................... 1
PULMOZYME ..................................................... 11
PURINETHOL .................................................... 11
PURIXAN ............................................................ 11
pyrazinamide ...................................................... 9
PYRAZINAMIDE .................................................. 9
PYRIDIUM .......................................................... 13
pyridostigmine bromide .................................... 1
pyrimethamine ...................................................... 9
pyrimethamine/sulfadoxine .................................. 9
QNASL ................................................................. 1
QUALAQUIN ........................................................ 9
QUESTRAN.......................................................... 3
QUESTRAN LIGHT .............................................. 3
quetiapine fumarate ........................................... 2
QUILLIVANT XR .................................................. 2
QUINAGLUTE ...................................................... 2
quinapril hcl ........................................................ 3
quinapril/hydrochlorothiazide........................... 2
QUINIDEX ............................................................ 2
quinidine gluconate ........................................... 2
quinidine sulfate ................................................. 2
quinine sulfate .................................................... 9
QVAR ................................................................... 1
raloxifene hcl ...................................................... 6
raltegravir potassium ............................................ 9
ramipril ................................................................ 3
RANEXA ............................................................... 3
ranitidine hcl ..................................................... 13
ranolazine ............................................................. 3
RAPAMUNE ......................................................... 8
rasagiline mesylate............................................. 12
RAZADYNE .......................................................... 1
RAZADYNE ER .................................................... 1
REBETOL ............................................................. 9
REBIF ................................................................. 11
REBIF REBIDOSE ............................................. 11
REDERM .............................................................. 5
REGLAN ............................................................. 13
regorafenib ......................................................... 11
REGRANEX ......................................................... 6
PortfolioHigh Formulary – October 2014
RELAFEN ........................................................... 10
RELISTOR.......................................................... 10
REMERON ........................................................... 1
RENAGEL ............................................................ 6
RENVELA ............................................................. 6
repaglinide .......................................................... 5
repaglinide/metformin hcl ..................................... 5
REPRONEX ......................................................... 6
REQUIP .............................................................. 12
REQUIP XL ........................................................ 12
RESCRIPTOR ...................................................... 9
reserpine ............................................................. 3
RESTASIS ............................................................ 7
RESTORIL............................................................ 2
RETROVIR ........................................................... 9
REVATIO .............................................................. 3
REVIA ................................................................... 2
REVLIMID........................................................... 11
REYATAZ ............................................................. 9
RHEUMATREX .................................................. 10
ribavirin ................................................................. 9
RIFADIN ............................................................... 9
RIFAMATE ........................................................... 9
rifampin ............................................................... 9
rifampin/isoniazid ............................................... 9
rifaximin ................................................................ 9
rilpivirine ............................................................... 9
riociguat ................................................................ 3
RIOMET ................................................................ 5
RISPERDAL ......................................................... 2
RISPERDAL M-TAB ............................................. 2
risperidone .......................................................... 2
risperidone ODT ................................................. 2
RITALIN ................................................................ 2
RITALIN LA .......................................................... 2
RITALIN-SR.......................................................... 2
ritonavir ................................................................. 9
rivaroxaban ........................................................... 7
rivastigmine patch ................................................ 1
rivastigmine tartrate ........................................... 1
rizatriptan benzoate ......................................... 12
ROBAXIN ........................................................... 12
ROBAXIN-750 .................................................... 12
ROCALTROL ..................................................... 13
roflumilast ............................................................. 1
ROMYCIN ............................................................. 7
ropinirole hcl ..................................................... 12
rosuvastatin calcium ............................................. 3
rotigotine ............................................................. 12
ROWASA............................................................ 10
ROXANOL .......................................................... 12
ROXICET............................................................ 12
ROXICODONE ................................................... 12
ROXICODONE INTENSOL ................................ 12
ruxolitinib ............................................................ 11
RYNATAN ............................................................ 4
RYNATAN PEDIATRIC ........................................ 4
RYTHMOL ............................................................ 2
RYTHMOL SR ...................................................... 2
SALAGEN........................................................... 10
salmeterol xinafoate ............................................. 1
salsalate ............................................................ 11
SANDIMMUNE ..................................................... 8
SANDOSTATIN .................................................. 11
SANDOSTATIN LAR .......................................... 11
saquinavir mesylate.............................................. 9
sargramostim ........................................................ 8
SAVELLA............................................................ 11
SCALACORT ....................................................... 5
SCALACORT DK ................................................. 5
SEASONALE ........................................................ 4
SECTRAL ............................................................. 3
selegiline hcl ..................................................... 12
selenium sulfide ................................................. 5
SELSUN RX ......................................................... 5
SELZENTRY ........................................................ 9
SEPTRA ............................................................... 8
SEPTRA DS ......................................................... 8
SERAX ................................................................. 2
SEREVENT DISKUS............................................ 1
SEROPHENE ....................................................... 6
SEROQUEL.......................................................... 2
SEROQUEL XR ................................................... 2
SERPASIL ............................................................ 3
sertraline hcl ....................................................... 1
sevelamer carbonate.......................................... 6
31
sevelamer hcl ....................................................... 6
SFROWASA ....................................................... 10
sildenafil citrate .............................................. 3, 6
SILVADENE ......................................................... 5
silver sulfadiazine .............................................. 5
SIMBRINZA .......................................................... 7
SIMCOR ............................................................... 3
simeprevir ........................................................... 10
simvastatin .......................................................... 3
simvastatin (80mg only) .................................... 3
SINEMET 25-100 ............................................... 12
SINEMET CR ..................................................... 12
SINEQUAN ........................................................... 1
SINGULAIR .......................................................... 1
sirolimus .............................................................. 8
sitagliptin phos/metformin hcl ............................... 5
sitagliptin phosphate............................................. 5
SIVEXTRO ........................................................... 8
SKELAXIN .......................................................... 12
SLO-NIACIN ......................................................... 3
sod chloride/nahco3/kcl/peg's ........................ 10
sodium chloride for inhalation ............................ 11
sodium fluoride ................................................ 13
sodium phenylbutyrate .................................... 10
sodium polystyrene sulfonate .......................... 6
sofosbuvir ........................................................... 10
SOFTCLIX ............................................................ 6
SOMA ................................................................. 12
SOMA COMPOUND .......................................... 12
SOMA COMPOUND WITH CODEINE .............. 11
somatropin ............................................................ 6
SOMATULINE DEPOT....................................... 11
SOMAVERT ......................................................... 6
SONATA ............................................................... 2
sorafenib tosylate ............................................... 11
SORIATANE ......................................................... 5
sotalol hcl ............................................................ 3
SOTRET ............................................................... 4
SOVALDI ............................................................ 10
SPIRIVA ............................................................... 1
spironolactone .................................................... 3
SPORANOX ......................................................... 9
SPRYCEL ........................................................... 11
STAGESIC-10 .................................................... 12
STALEVO ........................................................... 12
STARLIX............................................................... 5
stavudine ............................................................. 9
STAXYN ............................................................... 6
STELAZINE .......................................................... 2
STIVARGA ......................................................... 11
STRATTERA ........................................................ 2
STRIBILD ............................................................. 9
SUBOXONE ....................................................... 12
SUBUTEX........................................................... 11
sucralfate........................................................... 13
sulconazole nitrate ............................................... 4
SULFAC ............................................................... 7
sulfacetamide sodium ............................... 4, 5, 7
sulfadiazine ......................................................... 8
SULFADIAZINE .................................................... 8
sulfamethoxazole/trimethoprim ........................ 8
sulfanilamide....................................................... 13
sulfasalazine ..................................................... 10
sulfisoxazole acetyl .............................................. 8
sulindac ............................................................. 10
sumatriptan ....................................................... 12
sumatriptan succinate ..................................... 12
sunitinib malate .................................................. 11
SUPRAX ............................................................... 8
SUSTIVA .............................................................. 9
SUTENT ............................................................. 11
SUTTAR-2 ............................................................ 4
SUTTAR-SF ......................................................... 4
SYEDA ................................................................. 4
SYMBYAX ............................................................ 1
SYMLIN ................................................................ 5
SYMLINPEN 120 .................................................. 5
SYMLINPEN 60 .................................................... 5
SYMMETREL ..................................................... 12
SYNALAR ............................................................. 5
SYNTHROID ........................................................ 7
syringes & needles ............................................... 6
tacrolimus ............................................................. 5
tacrolimus anhydrous ........................................ 8
tadalafil ............................................................. 3, 6
TAFINLAR .......................................................... 11
PortfolioHigh Formulary
INDEX
TAGAMET .......................................................... 13
TALADINE .......................................................... 13
TAMBOCOR ......................................................... 2
TAMIFLU .............................................................. 9
tamoxifen citrate............................................... 11
tamsulosin hcl .................................................. 13
TAPAZOLE ........................................................... 7
tapentadol ........................................................... 12
tapentadol hcl ER ............................................... 12
TARCEVA........................................................... 11
TARGRETIN ................................................... 5, 11
TASIGNA ............................................................ 11
tazarotene............................................................. 5
TAZORAC ............................................................ 5
tazorotene foam ................................................... 4
TECFIDERA ....................................................... 11
tedizolid phosphate .............................................. 8
teduglutide [rDNA origin] .................................... 10
TEGRETOL ........................................................ 12
TEGRETOL XR .................................................. 12
telbivudine ............................................................ 9
telithromycin ......................................................... 8
temazepam .......................................................... 2
TEMODAR.......................................................... 10
TEMOVATE .......................................................... 5
TEMOVATE EMOLLIENT .................................... 5
temozolomide ................................................... 10
TENEX.................................................................. 3
tenofovir disoproxil fumarate ................................ 9
TENORETIC 100 .................................................. 3
TENORETIC 50 .................................................... 3
TENORMIN .......................................................... 3
terazosin hcl ....................................................... 2
terbinafine hcl ................................................... 4, 9
terbutaline sulfate .............................................. 1
teriparatide............................................................ 6
testosterone ........................................................ 8
testosterone cypionate ...................................... 8
testosterone solution ............................................ 8
TESTRED ............................................................. 8
tetracycline hcl ................................................... 9
TEXACORT .......................................................... 5
thalidomide ........................................................... 9
THALITONE ......................................................... 3
THALOMID ........................................................... 9
THEO-24 .............................................................. 1
theophylline anhydrous ..................................... 1
THERMAZENE ..................................................... 5
thioguanine ....................................................... 11
THIOGUANINE .................................................. 11
thioridazine hcl ................................................... 2
thiothixene .......................................................... 2
THORAZINE ......................................................... 2
thyroid, pork .......................................................... 7
TIAZAC ................................................................. 3
ticagrelor ............................................................... 8
TIKOSYN .............................................................. 2
timolol ................................................................... 7
timolol maleate ............................................... 3, 7
timolol maleate/pf ................................................. 7
TIMOPTIC ............................................................ 7
TIMOPTIC-XE ...................................................... 7
tiotropium bromide................................................ 1
tipranavir ............................................................... 9
tipranavir/vitamin e tpgs ....................................... 9
TIVICAY................................................................ 9
tizanidine hcl ..................................................... 12
TOBI ..................................................................... 9
TOBRADEX .......................................................... 7
tobramycin .......................................................... 9
tobramycin inhalation powder .............................. 9
tobramycin sulfate ............................................. 7
tobramycin sulfate/dexameth ........................... 7
tobramycin/lotepred etab ...................................... 7
TOBREX ............................................................... 7
TOFRANIL ............................................................ 1
tolazamide ........................................................... 5
tolbutamide ......................................................... 5
TOLECTIN 600 ................................................... 10
TOLINASE ............................................................ 5
tolmetin sodium ................................................ 10
tolterodine tartrate ........................................... 13
TOPAMAX .......................................................... 12
TOPAMAX SPRINKLE ....................................... 12
TOPICORT ........................................................... 5
TOPICORT LP ..................................................... 5
PortfolioHigh Formulary – October 2014
topiramate ......................................................... 12
topotecan hcl ...................................................... 11
TOPROL XL ......................................................... 3
TORADOL .......................................................... 10
toremifene citrate................................................ 11
torsemide ............................................................ 3
TOVIAZ............................................................... 13
TRACLEER .......................................................... 3
TRADJENTA ........................................................ 5
tramadol hcl ...................................................... 12
tramadol hcl/acetaminophen .......................... 12
trametinib dimethyl sulfoxide .............................. 11
TRANDATE .......................................................... 2
trandolapril .......................................................... 3
TRANXENE T-TAB .............................................. 2
tranylcypromine sulfate ..................................... 1
TRAVATAN .......................................................... 7
TRAVATAN Z ....................................................... 7
travoprost .............................................................. 7
travoprost (benzalkonium) ................................ 7
trazodone hcl ...................................................... 1
TRENTAL ............................................................. 7
tretinoin ............................................................... 11
TREXALL ............................................................ 11
triamcinolone acetonide .......................... 1, 5, 11
triamterene/hydrochlorothiazid ........................ 3
TRIAZ ................................................................... 4
triazolam .............................................................. 2
TRICOR ................................................................ 3
TRIDERM ............................................................. 5
TRIDESILON ........................................................ 5
trifluoperazine hcl .............................................. 2
trifluridine ............................................................ 7
TRIGLIDE 160MG ................................................ 3
TRIGLIDE 50MG .................................................. 3
trihexyphenidyl hcl........................................... 12
TRILAFON ............................................................ 2
TRILEPTAL ........................................................ 12
trimethoprim ....................................................... 8
TRI-NORINYL ...................................................... 4
TRI-VI-FLOR W/IRON ........................................ 13
TRIZIVIR ............................................................... 9
TRUSOPT ............................................................ 7
TRUVADA ............................................................ 9
TUDORZA ............................................................ 1
TUSNEL C ............................................................ 4
TUSNEL DIABETIC .............................................. 4
TUSSIONEX ......................................................... 4
TWINJECT ......................................................... 10
TYKERB ............................................................. 11
TYLENOL-CODEINE ......................................... 12
TYZEKA ................................................................ 9
ULORIC ................................................................ 7
ULTRACET......................................................... 12
ULTRAM ............................................................. 12
ULTRASE ........................................................... 12
ULTRASE MT ..................................................... 12
ULTRAVATE ........................................................ 5
umeclidinium brm/vilanterol tr .............................. 1
UNIPHYL .............................................................. 1
UNIRETIC ............................................................. 2
UNIVASC .............................................................. 3
URECHOLINE .................................................... 10
URETRON D-S .................................................... 8
URIN D.S. ............................................................. 8
urofollitropin (fsh).................................................. 6
UROXATRAL ..................................................... 13
URSO ................................................................. 10
URSO FORTE .................................................... 10
ursodiol ............................................................. 10
VAGIFEM ........................................................... 13
valacyclovir hcl ................................................... 9
VALCHLOR .......................................................... 5
VALISONE............................................................ 5
VALIUM ................................................................ 2
valproate sodium .............................................. 12
valproic acid ..................................................... 12
valsartan .............................................................. 3
valsartan/hydrochlorothiazide .......................... 2
VALTREX ............................................................. 9
VANCOCIN HCL .................................................. 9
vancomycin hcl .................................................. 9
VANDAZOLE ...................................................... 13
VANOS ................................................................. 5
VANOXIDE HC ..................................................... 4
VANOXIDE-HC .................................................... 4
32
VANSPAR ............................................................ 2
VANTIN ................................................................ 8
vardenafil hcl ........................................................ 6
VASCEPA............................................................. 3
VASERETIC ......................................................... 2
VASOCIDIN .......................................................... 7
VASOTEC ............................................................ 2
V-CILLIN K ........................................................... 8
VECTICAL .......................................................... 13
vemurafenib ........................................................ 11
venlafaxine hcl .................................................... 1
VENTOLIN HFA ................................................... 1
VEPESID ............................................................ 11
verapamil hcl ...................................................... 3
verapamil hcl ER ................................................ 3
VERELAN ............................................................. 3
VERELAN PM ...................................................... 3
VERMOX .............................................................. 9
VESANOID ......................................................... 11
VESTURA............................................................. 4
VFEND ................................................................. 9
VIAGRA ................................................................ 6
VIBRAMYCIN ....................................................... 9
VIBRAMYCIN ORAL SUSPENSION ................... 9
VIBRAMYCIN SYRUP.......................................... 9
VIBRA-TABS ........................................................ 9
VICODIN ............................................................. 12
VICODIN ES ....................................................... 12
VICODIN HP....................................................... 12
VICON FORTE ................................................... 13
VICTOZA .............................................................. 5
VIDEX ................................................................... 9
VIDEX EC ............................................................. 9
VIGAMOX ............................................................. 7
VIMOVO ............................................................. 10
VIRACEPT............................................................ 9
VIRAMUNE........................................................... 9
VIRAMUNE XR .................................................... 9
VIRAZOLE ............................................................ 9
VIREAD ................................................................ 9
VIROPTIC............................................................. 7
VISKEN ................................................................ 3
vismodegib ......................................................... 11
VISTARIL .............................................................. 1
VIVELLE-DOT ...................................................... 8
VOLTAREN .................................................... 7, 10
VOLTAREN GEL .................................................. 5
VOLTAREN-XR .................................................. 10
voriconazole ....................................................... 9
vorinostat ............................................................ 11
VOSOL ................................................................. 6
VOSOL HC ........................................................... 6
VOTRIENT ......................................................... 11
VYTONE ............................................................... 4
VYVANSE............................................................. 2
warfarin sodium .................................................. 7
WELCHOL ............................................................ 3
WELCHOL POWDER PACKETS ........................ 3
WELLBUTRIN ...................................................... 1
WELLBUTRIN SR ................................................ 1
WELLBUTRIN XL ................................................. 1
WESTCORT ......................................................... 5
WESTHROID........................................................ 7
XALATAN ............................................................. 7
XALKORI ............................................................ 11
XANAX ................................................................. 2
XARELTO ............................................................. 7
XELODA ............................................................. 11
XIFAXAN .............................................................. 9
XODOL 10-300 ................................................... 12
XTANDI .............................................................. 11
XYLOCAINE ....................................................... 10
XYZAL TABS ........................................................ 1
YASMIN 28 ........................................................... 4
YAZ ....................................................................... 4
YODOXIN ............................................................. 9
zaleplon ............................................................... 2
ZANAFLEX ......................................................... 12
ZANTAC ............................................................. 13
ZARAH ................................................................. 4
ZARONTIN ......................................................... 12
ZAROXOLYN ....................................................... 3
ZEBETA................................................................ 3
ZELBORAF......................................................... 11
ZEMPLAR............................................................. 6
ZENATANE .......................................................... 4
PortfolioHigh Formulary
INDEX
ZENPEP ............................................................. 12
ZENZEDI .......................................................... 1, 2
ZERIT ................................................................... 9
ZESTORETIC ....................................................... 2
ZESTRIL ............................................................... 3
ZETIA ................................................................... 3
ZIAC ..................................................................... 3
ZIAGEN ................................................................ 9
zidovudine ........................................................... 9
ziprasidone hcl ................................................... 2
ZIRGAN ................................................................ 7
ZITHROMAX ........................................................ 8
ZITHROMAX TRI-PAK ......................................... 8
ZMAX .................................................................... 8
PortfolioHigh Formulary – October 2014
ZMAX PEDIATRIC ............................................... 8
ZOCOR ................................................................. 3
ZOFRAN ............................................................... 1
ZOFRAN ODT ...................................................... 1
ZOLINZA ............................................................ 11
zolmitriptan ....................................................... 12
ZOLOFT ............................................................... 1
zolpidem tartrate ................................................ 2
ZOMIG ................................................................ 12
ZOMIG ZMT ....................................................... 12
ZONEGRAN ....................................................... 12
zonisamide ........................................................ 12
ZORTRESS .......................................................... 8
ZOVIRAX .............................................................. 9
33
ZOVIRAX CREAM................................................ 5
ZOVIRAX OINTMENT .......................................... 5
ZYKADIA ............................................................ 11
ZYLET .................................................................. 7
ZYLOPRIM ........................................................... 7
ZYMAXID .............................................................. 7
ZYPREXA ............................................................. 2
ZYPREXA ZYDIS ................................................. 2
ZYRTEC (OTC) .................................................... 1
ZYRTEC-D (OTC) ................................................ 1
ZYTIGA ............................................................... 11
ZYVOX ................................................................. 8