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Transcript 
STATE OF MICHIGAN COMMERCIAL FORMULARY
APRIL 2016
TABLE OF CONTENTS
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 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 accessable as necessary.
Search for a specific drug by visiting https://mp.medimpact.com/som
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.
The MedImpact P & T and Formulary Committees use the following criteria in the
evaluation of drug selection for the Formulary:
 Drug safety profile
 Drug efficacy
 Comparison of relevant therapeutic benefits to current formulary agents of
similar use, and to minimize therapeutic duplication where possible
 Cost-effectiveness relative to comparable therapies
How to Use the Formulary
The Formulary is a list of medications available to 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.
All drugs are listed in each category in alphabetical order by generic name.
Where an FDA approved generic is available for the listed generic name, the
generic name is bolded.
For certain agents within the Formulary, a recommended prescribing guideline
may apply. These are denoted throughout the document using the following
symbols:
AGE
CU
G
MD
PA
QL
SCC
ST
Age Edit
Concurrent Use
Edit
Gender Edit
Physician
Specialty Edit
Prior
Authorization
Quantity Limit
Split Cycle CoPay
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
Products are available for 15 day supply charging
the member ½ of the typical co-pay
Coverage may depend on previous use of another
drug
Please refer to the prescribing guideline appendix within this document for details
regarding specific agents.
Benefit Coverage and Limitations
This printed Formulary does not provide information regarding the specific
coverage and limitations an individual member may be subject to. Many members
have specific benefit inclusions, exclusions, copays, or a lack of coverage, which
are not reflected in the Formulary.
The Formulary applies only to outpatient drugs provided to members, and does
not apply to medications used in inpatient settings. If a member has any specific
questions regarding their coverage, they should contact their Plan Sponsor or
MedImpact at (800) 788-2949.
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 Pharmacy and Therapeutics
Committee. MedImpact approves such multi-source drugs for addition to
the MAC list based on the following criteria:
 A multi-source drug product manufactured by at least one (1)
nationally marketed company.
 At least one (1) of the generic manufacturer’s products must have an
“A” rating or the generic product has been determined to be
unassociated with efficacy, safety or bioequivalency concerns by the
MedImpact P & T Committee.
 Drug product will be approved for generic substitution by the
MedImpact P & T Committee.
This list is reviewed and updated periodically based on the clinical literature
and pharmacokinetic characteristics of currently available versions of these
drug products.
If a member or physician requests a brand name product in lieu of an
approved generic, the member, based upon their coverage, will typically be
required to pay the difference in cost between the brand and the generic. If
a physician determines that there is a documented medical need for the
brand equivalent, a request for coverage may be made using the medication
request process.
2. Three Tier Benefit
The Formulary may be applied to a three tier benefit design, where the
member shares the cost of prescription drug therapy at three levels of
copayment. In most instances, generically available drugs will be covered
under the first or lowest copay tier, branded drugs listed on the Formulary
will be covered under the second copay tier, and branded drugs not on the
Formulary will be covered under the third or highest copay tier.
3. Medication Request Process
Depending upon plan benefit design, a medication request process may
apply as follows:
A. Formulary Agents
Drugs that are listed in the Formulary with associated Prior
Authorization (PA) require evaluation, per 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.
B. Non-Formulary Agents
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.
If the request does not meet the guidelines established by the P & T
Committee, the request will not be approved and alternative therapy
may be recommended.
C. Obtaining Coverage
Coverage, questions or information regarding the medication request
or formulary process may be obtained by:
1. Faxing a completed Medication Request Form to MedImpact
at (858) 790-7100.
2. Contacting MedImpact at (800) 788-2949 and providing all
necessary information requested.
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
STATE OF MICHIGAN COMMERCIAL FORMULARY
APRIL 2016
TABLE OF CONTENTS
generally not available for drugs that are specifically excluded by
benefit design.
Medication Request Information (please complete each section of this form
4. General Exclusions
A. Over the Counter (OTC) medications or their equivalents, unless
otherwise specified in the Formulary listing.
B. Nicotine Smoking Cessation products (i.e., transdermal nicotine,
nicotine gum, nicotine inhaler).
C. Drugs specifically listed as not covered.
D. Any drug products used for cosmetic purposes.
E. Experimental drug products or any drug product used in an
experimental manner.
F. Replacement of lost or stolen medication.
G. Non self-administered injectable drug products unless otherwise
specified in the Formulary listing.
H. Foreign sourced drugs or drugs not approved by the United States
Food & Drug Administration.
Pharmacy used by Member:
Drug Requested:
Dose:
Strength:
Length of Treatment (please be
specific):
Dosage Form (e.g., Oral, Injection):
Other Medications Tried and/or Failed (please be specific, give detail including
reason for failure):
Other Pertinent History (relative or pertaining to this request):
prior to transmittal):
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) 788-2949.
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.
804PA, apr 2016
Physician Area Code and Telephone
Number:
(
)
Physician Area Code and Fax Number
(required):
(
)
Pharmacy Area Code and Telephone
Number:
(
)
Quantity (per month):
Reason for Medication Request (please be specific, give detail):
Medication Request Form (MRF)
MedImpact Healthcare Systems, Inc.
10680 Treena Street, Ste
500
San Diego, CA 92131
Phone: 1-800-788-2949
Fax: 858-790-7100
Physician Name/Specialty:
Diagnosis (required):
Chairperson, Pharmacy & Therapeutics Committee
MedImpact Healthcare Systems, Inc.
10181 Scripps Gateway Court
San Diego, CA 92131
Physician:
Pharmacy:
Patient:
Patient ID # (required):
Patient DOB (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:
Attn: Prior
Authorization
Department
Patient’s Health Plan (required):
Physician ID#/DEA#:
The P & T and Formulary Committees recognize that not all medical needs
can be met with this document and encourage inquiries about alternative
therapies.
DO NOT WRITE IN
BLOCKED AREAS
FOR INTERNAL USE
ONLY
Contacted:
Patient Name (required):
i
STATE OF MICHIGAN COMMERCIAL FORMULARY
APRIL 2016
TABLE OF CONTENTS
Foreword ..............................................................................................................
1.
Generic Substitution ..........................................................................
2.
Three Tier Benefit ..............................................................................
3.
Medication Request Process ............................................................
4.
General Exclusions .......................................................................... i
5.
Pharmacist and Physician Communication ..................................... i
ALLERGY ................................................................................................................. 5
2nd Gen Antihistamine & Decongestant Combinations .................................... 5
Antihistamines - 1st Generation ......................................................................... 5
Antihistamines - 2nd Generation ....................................................................... 5
Nasal Anti-Inflammatory Steroids ...................................................................... 5
Nasal Antihistamine ........................................................................................... 5
ANTIEMESIS/ANTIVERTIGO .................................................................................. 5
Antiemetic/Antivertigo Agents ............................................................................ 5
ASTHMA ................................................................................................................... 5
Beta-Adrenergic Agents ..................................................................................... 5
Beta-Adrenergic & Anticholinergic Combinations .............................................. 5
Beta-Adrenergic & Glucocorticoid Combinations .............................................. 5
General Bronchodilator Agents .......................................................................... 5
Leukotriene Receptor Antagonists ..................................................................... 5
Mast Cell Stabilizers........................................................................................... 5
Phosphodiesterase-4 (PD-4) Inhibitors.............................................................. 5
Monoclonal Antibodies To Immunoglobulin E(ige) ............................................ 5
Oral Inhaled Corticosteroids .............................................................................. 5
Xanthines ........................................................................................................... 5
AUTONOMIC NERVOUS SYSTEM DISORDERS .................................................. 5
Alzheimer's Therapy, Nmda Receptor Antagonists ........................................... 5
Cholinesterase Inhibitors ................................................................................... 5
BEHAVIORAL HEALTH - ANTIDEPRESSANTS .................................................... 5
Alpha-2 Receptor Antagonist Antidepressants .................................................. 5
Maois - Non-Selective & Irreversible ................................................................. 5
Norepinephrine & Dopamine Reuptake Inhib (ndris) ......................................... 5
Selective Serotonin Reuptake Inhibitors (SSRIs) .............................................. 5
SSRI & Antipsychotic,ATYP,(DA & Serotonin) Comb. ...................................... 5
Serotonin-2 Antagonist/Reuptake Inhibitors (SARIs) ........................................ 5
Serotonin-Norepinephrine Reuptake-Inhib (SNRIs) .......................................... 5
Tricyclic Antidepressants & Rel. Non-Sel. Ru-Inhib .......................................... 6
BEHAVIORAL HEALTH - OTHER ........................................................................... 6
Adrenergics, Aromatic, Non-Catecholamine ..................................................... 6
Anti-Alcoholic Preparations ................................................................................ 6
Anti-Anxiety Drugs ............................................................................................. 6
Anti-Mania Drugs ............................................................................................... 6
Anti-Psychotics, Phenothiazines ........................................................................ 6
Antipsychotics, Atyp, D2 Partial Agonist/5HT Mixed ......................................... 6
Antipsychotics, Dopamine & Serotonin Antagonists ......................................... 6
Antipsychotics, Atypical, Dopamine,& Serotonin Antag .................................... 6
Antipsychotics, Dopamine Antagonists, Thioxanthenes .................................... 6
Antipsychotics, Dopamine Antagonists, Butyrophenones ................................. 6
Barbiturates ........................................................................................................ 6
Narcotic Antagonists .......................................................................................... 6
Sedative-Hypnotics, Non-Barbiturate ................................................................ 6
Tx For Attention Deficit-Hyperact (ADHD)/Narcolepsy...................................... 6
Tx For Attention Deficit-Hyperact.(ADHD), NRI-Type ....................................... 6
CARDIOVASCULAR DISEASE - ARRHYTHMIA .................................................... 6
Antiarrhythmics .................................................................................................. 6
CARDIOVASCULAR DISEASE - CARDIAC STIMULANT ...................................... 6
Digitalis Glycosides ............................................................................................ 6
CARDIOVASCULAR DISEASE - HYPERTENSION ............................................... 6
Ace Inhibitor/Calcium Channel Blocker Combination ........................................ 6
Ace Inhibitor/Thiazide & Thiazide-Like Diuretic ................................................. 6
Alpha-Adrenergic Blocking Agents .................................................................... 6
Alpha/Beta-Adrenergic Blocking Agents ............................................................ 6
Angioten. Receptr Antag./Cal. Chanl Blkr/Thiazide Comb ................................ 7
Angiotensin Receptor Antag./Thiazide Diuretic Comb ...................................... 7
Angiotensin Receptor Antgnst & Calc. Channel Blockr ..................................... 7
Antihypertensives, ACE Inhibitors ..................................................................... 7
Antihypertensives, Angiotensin Receptor Antagonist ........................................ 7
Antihypertensives, Sympatholytic ...................................................................... 7
Antihypertensives, Vasodilators ......................................................................... 7
Beta-Adrenergic Blocking Agents ...................................................................... 7
Beta-Adrenergic Blocking Agents/Thiazide & Related ...................................... 7
Calcium Channel Blocking Agents ..................................................................... 7
Loop Diuretics .................................................................................................... 7
Potassium Sparing Diuretics .............................................................................. 7
Potassium Sparing Diuretics In Combination .................................................... 7
Pulm. Anti-HTN, Sel. C-GMP Phosphodiesterase T5 Inhib .............................. 7
Pulmonary Anti-HTN, Endothelin Receptor Antagonist ..................................... 7
Thiazide & Related Diuretics.............................................................................. 7
CARDIOVASCULAR DISEASE - LIPID IRREGULARITY ....................................... 7
Antihyperlipidemic – Apo-B 100 synthesis Inhibitor .......................................... 7
Antihyperlipidemic - HMG CoA Reductase Inhibitors ........................................ 7
Antihyperlipidemic-HMG CoA Reductase Inhib. & Niacin ................................. 7
Antihyperlipidemic- MTP Inhibitor ...................................................................... 7
Bile Salt Sequestrants ........................................................................................ 7
804PA, apr 2016
Lipotropics .......................................................................................................... 7
Niacin Preparations ............................................................................................ 8
CARDIOVASCULAR DISEASE - MISCELLANEOUS AGENTS ............................. 8
Adrenergic Vasopressor Agents ........................................................................ 8
Antianginal & Anti-Ischemic Agents, Non-Hemodynamic ................................. 8
Antihyperlip - HMG-CoA & Calcium Channel Blocker Comb ............................ 8
CARDIOVASCULAR DISEASE - VASODILATION ................................................. 8
Vasodilators, Coronary ...................................................................................... 8
CONTRACEPTION/OXYTOCICS ............................................................................ 8
Contraceptives, Injectable ................................................................................. 8
Contraceptives, Oral .......................................................................................... 8
Contraceptives, Transdermal ............................................................................. 8
Oxytocics ............................................................................................................ 8
COUGH AND COLD ................................................................................................ 8
1st Gen Antihistamine & Decongestant Combinations ..................................... 8
Narcotic Antituss-1st Gen. Antihistamine-Decongest ....................................... 8
Narcotic Antituss-Decongestant-Expectorant Comb ......................................... 8
Narcotic Antitussive-1st Generation Antihistamine ........................................... 8
Narcotic Antitussive-Expectorant Combination ................................................. 8
Non-Narcotic Antitussive-1st Gen Antihistamine Combination ......................... 8
Non-Narcotic Antitussive & Expectorant Comb. ................................................ 8
DERMATOLOGY - ACNE ........................................................................................ 8
Acne Agents, Systemic ...................................................................................... 8
Acne Agents, Topical ......................................................................................... 8
Keratolytic-Glucocorticoid Combinations ........................................................... 8
Keratolytics......................................................................................................... 8
Rosacea Agents, Topical ................................................................................... 8
Topical Preparations, Antibacterials .................................................................. 8
Vitamin A Derivatives ......................................................................................... 8
DERMATOLOGY - ANTIINFECTIVE ....................................................................... 8
Topical Antibiotics .............................................................................................. 8
Topical Antifungals ............................................................................................. 8
Topical Antiparasitics ......................................................................................... 9
Topical Antivirals ................................................................................................ 9
Topical Sulfonamides......................................................................................... 9
DERMATOLOGY - ANTIINFLAMMATORY ............................................................. 9
Topical Anti-Inflammatory Steroidal ................................................................... 9
Topical Anti-Inflammatory, NSAIDs ................................................................... 9
Topical Antibiotics/Antiinflammatory,Steroidal .................................................. 9
DERMATOLOGY - MISCELLANEOUS ................................................................... 9
Antiperspirants ................................................................................................... 9
Antiseborrheic Agents ........................................................................................ 9
Topical Antineoplastic & Premalignant Lesion Agnts ........................................ 9
Topical Local Anesthetics .................................................................................. 9
DERMATOLOGY - PIGMENTATION DISORDERS ................................................ 9
Topical Hyperpigmentation Agents .................................................................... 9
DERMATOLOGY - PSORIASIS/ECZEMA .............................................................. 9
Antipsoriatic Agents, Systemic .......................................................................... 9
Antipsoriatics Agents ......................................................................................... 9
Topical Immunosuppressive Agents .................................................................. 9
DIABETES ................................................................................................................ 9
Antihyperglycemic, Alpha-Glucosidase Inhib (Non-Sulfonylurea) ..................... 9
Antihyperglycemic, Amylin Analog-Type ........................................................... 9
Antihyperglycemic, DPP-4 Inhibitors ................................................................. 9
Antihyperglycemic DPP-4 Inhibitor & Biguanide Combination .......................... 9
Antihyperglycemic DPP-4 Inhibitor & Statin Combination ................................. 9
Antihyperglycemic,Glucocorticoid Receptor Antagonist .................................... 9
Antihyperglycemic, Incretin Mimetic (GLP-1 Recep. Agonist) ........................... 9
Antihyperglycemic, Insulin-Release Stimulant Type ......................................... 9
Antihyperglycemic, Insulin-Response Enhancer (Non-Sulfonylurea) ............... 9
Antihyperglycemic, Biguanide Type (Non-Sulfonylurea) ................................... 9
Antihyperglycemic, Insulin-Rel Stim.& Biguanide Comb ................................. 10
Antihyperglycemic, Insulin-Response & Release Comb. ................................ 10
Antihyperglycemic Insul-Resp. Enhancer & Biguanide Comb ........................ 10
Blood Sugar Diagnostics ................................... Error! Bookmark not defined.
Diabetic Supplies ............................................... Error! Bookmark not defined.
Diabetic Ulcer Preparations, Topical ............................................................... 10
Hyperglycemics ................................................................................................ 10
Insulins ............................................................................................................. 10
Syringes & Accessories ................................................................................... 10
EAR - GENERAL DISORDERS ............................................................................. 10
Ear Preparations, Misc. Anti-Infectives ............................................................ 10
Ear Preparations, Antibiotics ........................................................................... 10
Otic Preparations, Anti-Inflammatory-Antibiotics ............................................. 10
Otic Preparations, Local anesthetics ............................................................... 10
ELECTROLYTE REGULATION ............................................................................. 10
Electrolyte Depleters ........................................................................................ 10
Potassium Replacement .................................................................................. 10
ENDOCRINE DISORDER - FERTILITY ................................................................ 10
Drugs To Treat Impotency ............................................................................... 10
Fertility Stimulating Preparations, Non-FSH .................................................... 10
Follicle Stim./Luteinizing Hormones ................................................................ 10
Pregnancy Facilitating/Maintaining Agent, Hormonal ..................................... 10
ENDOCRINE DISORDER - OTHER...................................................................... 10
ii
STATE OF MICHIGAN COMMERCIAL FORMULARY
APRIL 2016
TABLE OF CONTENTS
Antidiuretic & Vasopressor Hormones ............................................................. 10
Bone Formation Stim. Agents - Parathyroid Hormone .................................... 10
Bone Resorption Inhibitor & Calcium Combinations ....................................... 10
Bone Resorption Inhibitor & Vitamin D Combinations ..................................... 10
Bone Resorption Inhibitors ............................................................................... 10
Growth Hormone Receptor Antagonists .......................................................... 11
Growth Hormones ............................................................................................ 11
Hyperparathyroid Tx Agents,Vitamin D Analog-Type ...................................... 11
LHRH (GnRH) Antagonist, Pituitary Suppressant Agents ............................... 11
Luteinizing Hormone Releasing Hormone –LHRH (GnRH) ............................ 11
Pituitary Suppressive Agents ........................................................................... 11
ENDOCRINE DISORDER - THYROID .................................................................. 11
Antithyroid Preparations ................................................................................... 11
Iodine Containing Agents ................................................................................. 11
Thyroid Hormones............................................................................................ 11
EYE - GENERAL DISORDERS ............................................................................. 11
Eye Antibiotic-Corticoid Combinations............................................................. 11
Eye Antihistamines........................................................................................... 11
Eye Antiinflammatory Agents ........................................................................... 11
Eye Antivirals ................................................................................................... 11
Eye Sulfonamides ............................................................................................ 11
Ophthalmic Anti-Inflammatory Immunomodulator-Type .................................. 11
Ophthalmic Antibiotics ..................................................................................... 11
Ophthalmic Mast Cell Stabilizers ..................................................................... 11
EYE - GLAUCOMA ................................................................................................ 11
Carbonic Anhydrase Inhibitors ......................................................................... 11
Miotics/Other Intraoc. Pressure Reducers ....................................................... 11
Mydriatics ......................................................................................................... 11
GOUT AND RELATED DISEASES ....................................................................... 11
Colchicine ......................................................................................................... 11
Hyperuricemia Tx - Purine Inhibitors ............................................................... 12
Uricosuric Agents ............................................................................................. 12
HEMATOLOGICAL DISORDERS .......................................................................... 12
Anticoagulants, Coumarin Type ....................................................................... 12
Direct Factor XA Inhibitors ............................................................................... 12
Hematinics, Other ............................................................................................ 12
Hemorrheologic Agents ................................................................................... 12
Heparin & Related Preparations ...................................................................... 12
Leukocyte (WBC) Stimulants ........................................................................... 12
Platelet Aggregation Inhibitors ......................................................................... 12
Platelet Reducing Agents ................................................................................. 12
Thrombopoietin Receptor Agonists ................................................................. 12
Vitamin K Preparations .................................................................................... 12
HORMONAL DEFICIENCY .................................................................................... 12
Androgenic Agents ........................................................................................... 12
Estrogen/Androgen Combinations ................................................................... 12
Estrogenic Agents ............................................................................................ 12
Progestational Agents ...................................................................................... 12
IMMUNOSUPPRESSION/MODULATION ............................................................. 12
Immunomodulators .......................................................................................... 12
Immunosuppressives ....................................................................................... 12
INFECTIOUS DISEASE - BACTERIAL ................................................................. 12
Absorbable Sulfonamides ................................................................................ 12
Beta lactams, inhaled ....................................................................................... 12
Cephalosporins - 1st Generation ..................................................................... 12
Cephalosporins - 2nd Generation .................................................................... 12
Cephalosporins - 3rd Generation ..................................................................... 12
Chemotherapeutics, Antibacterial, Misc. ......................................................... 12
Ketolides........................................................................................................... 12
Macrolides ........................................................................................................ 12
Nitrofuran Derivatives ...................................................................................... 13
Oxazolidinones ................................................................................................. 13
Penicillins ......................................................................................................... 13
Quinolones ....................................................................................................... 13
Tetracyclines .................................................................................................... 13
INFECTIOUS DISEASE - FUNGAL ....................................................................... 13
Antifungal Agents ............................................................................................. 13
Antifungal Antibiotics ........................................................................................ 13
INFECTIOUS DISEASE - MISCELLANEOUS ....................................................... 13
Rifamycin and Related Derivative Antibiotics ........................................................ 13
Aminoglycosides .............................................................................................. 13
Anti-Mycobacterium Agents ............................................................................. 13
Antileprotics ...................................................................................................... 13
Antitubercular Antibiotics ................................................................................. 13
Vancomycin & Derivatives ............................................................................... 13
INFECTIOUS DISEASE - PARASITIC .................................................................. 13
Amebacides ..................................................................................................... 13
Anaerobic Antiprotozoal-Antibacterial Agents ................................................. 13
Anthelmintics .................................................................................................... 13
Antimalarial Drugs ............................................................................................ 13
Antiprotozoal Drugs, Miscellaneous ................................................................ 13
INFECTIOUS DISEASE - VIRAL ........................................................................... 13
All oral, non-experimental antiviral agents used for the treatment of AIDS or HIVrelated diseases are considered a formulary benefit. ............................................ 13
804PA, apr 2016
Antivirals, General ............................................................................................ 13
Antivirals, HIV-Spec, Non-Peptidic Protease Inhib .......................................... 13
Antivirals, HIV-Spec, Nucleoside-Nucleotide Analog ...................................... 13
Antivirals, HIV-Spec., Nucleoside Analog, RTI Comb ..................................... 13
Antivirals, HIV-Specific, CCR5 Co-Receptor Antag. ....................................... 13
Antivirals, HIV-Specific, Fusion Inhibitors ........................................................ 13
Antivirals, HIV-Specific, Non-Nucleoside, RTI ................................................. 13
Antivirals, HIV-Specific, Nucleoside Analog, RTI ............................................ 13
Antivirals, HIV-Specific, Nucleotide Analog, RTI ............................................. 14
Antivirals, HIV-Specific, Protease Inhibitor Comb ........................................... 14
Antivirals, HIV-Specific, Protease Inhibitors .................................................... 14
Antivirals, HIV-1 Integrase Strand Transfer Inhibtr.......................................... 14
Antiviral Comb Nucleoside, Nucleotide & Non-Nucleoside RTI ...................... 14
ARV CMB-NRTI, N(T)RTI, Integrase Inhibitor ................................................. 14
Hepatitis B Treatment Agents .......................................................................... 14
Hepatitis C Treatment Agents .......................................................................... 14
INFLAMMATORY DISEASE .................................................................................. 14
Anti-Arthritic & Chelating Agents ..................................................................... 14
Anti-Arthritic, Folate Antagonist Agents ........................................................... 14
Anti-Inflammatory,Tumor Necrosis Factor Inhibitor ......................................... 14
Anti-Inflammatory, Bradykinin B2 receptor antagonists .................................. 14
Anti-Inflammatory, Pyrimidine Synthesis Inhibitor ........................................... 14
Glucocorticoids ................................................................................................ 14
Mineralocorticoids ............................................................................................ 14
NSAIDs, Cyclooxygenase Inhibitor-Type ........................................................ 14
LOCAL ANESTHESIA ............................................................................................ 14
Local Anesthetics ............................................................................................. 14
LOWER GASTROINTESTINAL DISORDERS - BOWEL INFLAMMAT ................ 14
Bowel Antiinflamatory Agents .......................................................................... 14
Chronic Inflam. Colon Dx, 5-A-Salicylat, Rectal Tx ......................................... 14
Drug Tx-Chronic Inflam. Colon Dx, 5-Aminosalicylat ...................................... 14
Irritable Bowel Agents, Guanylate Cyclase-C Agonist .................................... 14
Hemorrhoidal Preparations .............................................................................. 14
Rectal Preparations ......................................................................................... 14
Rectal/Lower Bowel Prep., Glucocort. (Non-Hemorr) ..................................... 14
LOWER GASTROINTESTINAL DISORDERS - OTHER ...................................... 14
Ammonia Inhibitors .......................................................................................... 14
Antidiarrheals ................................................................................................... 14
Bile Salts .......................................................................................................... 15
Glucagon-like Peptide-2 (GLP-2) Analogs ...................................................... 15
Laxatives & Cathartics ..................................................................................... 15
Narcotic Antagonists, Peripherally-Acting ....................................................... 15
MISCELLANEOUS AGENTS ................................................................................. 15
Anaphylaxis Therapy Agents ........................................................................... 15
Parasympathetic Agents .................................................................................. 15
NEOPLASTIC DISEASE ........................................................................................ 15
Alkylating Agents ............................................................................................. 15
Antiandrogenic Agents ..................................................................................... 15
Antimetabolites ................................................................................................ 15
Antineoplastic Aromatase Inhibitors ................................................................ 15
Antineoplastic, Hedgehog Pathway Inhibitor ................................................... 15
Antineoplastic, Janus Kinase (JAK) Inhibitors ................................................. 15
Antineoplastic - Topoisomerase I Inhibitors..................................................... 15
Antineoplastic Immunomodulator Agents ........................................................ 15
Antineoplastic Systemic Enzyme Inhibitors ..................................................... 15
Antineoplastic, Histone Deacetylase Inhibitors, HDIS ..................................... 15
Antineoplastics, Miscellaneous ........................................................................ 15
Chemotherapy Rescue/Antidote Agents ......................................................... 15
Selective Estrogen Receptor Modulators (SERM) .......................................... 15
Selective Retinoid X Receptor Agonists (RXR) ............................................... 16
Steroid Antineoplastics .................................................................................... 16
NEUROLOGICAL DISEASE - MISCELLANEOUS ................................................ 16
Agents To Treat Multiple Sclerosis .................................................................. 16
Fibromyalgia Agents, Serotonin-Norepineph RU Inhib ................................... 16
ORAL/PHARYNGEAL DISORDERS ..................................................................... 16
Dental Aids & Preparations .............................................................................. 16
Nose Preparations, Antibiotics ......................................................................... 16
Nose Preparations, Miscellaneous (Rx) .......................................................... 16
OTHER DRUGS ..................................................................................................... 16
Appetite Stim. For Anorexia, Cachexia, Wasting Synd. .................................. 16
Needles/Needleless Devices ........................................................................... 16
Somatostatic Agents ........................................................................................ 16
Mucolytics ........................................................................................................ 16
PAIN MANAGEMENT - ANALGESICS ................................................................. 16
Analgesic, Non-Salicylate & Barbiturate Comb. .............................................. 16
Analgesic, Salicylate, Barbiturate & Xanthine Comb ...................................... 16
Analgesic, Non-Salicylate, Barbiturate & Xanthine Comb ............................... 16
Analgesic/Antipyretics, Salicylates .................................................................. 16
Analgesics, Narcotics....................................................................................... 16
Antimigraine Preparations ............................................................................... 16
Narc. & Non-Sal. Analgesic, Barbiturate & Xanthine Comb ............................ 16
Narcotic & Salicylate Analgesics, Barb. & Xanthine ........................................ 16
Narcotic Analgesic & Non-Salicylate Analgesic Comb .................................... 17
PARKINSONS DISEASE ....................................................................................... 17
iii
STATE OF MICHIGAN COMMERCIAL FORMULARY
APRIL 2016
TABLE OF CONTENTS
Antiparkinsonism Drugs, Anticholinergic ......................................................... 17
Antiparkinsonism Drugs, Other ........................................................................ 17
Decarboxylase Inhibitors .................................................................................. 17
SEIZURE DISORDER ............................................................................................ 17
Anticonvulsants ................................................................................................ 17
SKELETAL MUSCLE DISORDER ......................................................................... 17
Skeletal Muscle Relaxants ............................................................................... 17
UPPER GASTROINTESTINAL DISORDERS - DIGESTIVE ................................ 17
Pancreatic Enzymes ........................................................................................ 17
UPPER GASTROINTESTINAL DISORDERS - SPASTIC DISEASE ................... 17
Anticholinergics/Antispasmodics ..................................................................... 17
Belladonna Alkaloids ........................................................................................ 17
UPPER GASTROINTESTINAL DISORDERS - ULCER DISEASE ....................... 17
Anti-Ulcer Preparations .................................................................................... 17
Anti-Ulcer-H.pylori Agents ................................................................................ 17
Anticholinergics, Quaternary Ammonium ........................................................ 17
Histamine H2-Receptor Inhibitors .................................................................... 17
Intestinal Motility Stimulants............................................................................. 17
Proton-Pump Inhibitors .................................................................................... 17
URINARY TRACT - FUNCTIONAL DISORDERS ................................................. 17
Benign Prostatic Hypertrophy/Micturition Agents ............................................ 17
Benign Prostatic Hypertrophy, 5-alpha red. Inhib & alpha-1 antag combination
agents ............................................................................................................... 17
Urinary Tract Analgesic Agents ....................................................................... 17
Urinary Tract Anesthetic/Analgesic Agent (Azo-Dye) ...................................... 17
Urinary Tract Antispasmodic, M(3) Selective Antag. ....................................... 17
Urinary Tract Antispasmodic/Antiincontinence Agent ..................................... 18
VAGINAL DISORDERS ......................................................................................... 18
Vaginal Antibiotics ............................................................................................ 18
Vaginal Antifungals .......................................................................................... 18
Vaginal Estrogen Preparations ........................................................................ 18
Vaginal Sulfonamides ...................................................................................... 18
VITAMIN AND/OR MINERAL DEFICIENCY ......................................................... 18
Fluoride Preparations ....................................................................................... 18
Folic Acid Preparations .................................................................................... 18
Multivitamin Preparations ................................................................................. 18
Pediatric Vitamin Preparations ........................................................................ 18
Prenatal Vitamin Preparations ......................................................................... 18
Vitamin B Preparations .................................................................................... 18
Vitamin D Preparations .................................................................................... 18
804PA, apr 2016
iv
STATE OF MICHIGAN COMMERCIAL FORMULARY
APRIL 2016
ALLERGY
Allergenic extracts
PA 5-grass pollen extract
ORALAIR
PA short ragweed pollen extract
RAGWITEK
PA timothy grass pollen extract
GRASTEK
2nd Gen Antihistamine & Decongestant Combinations
p-ephed hcl/cetirizine hcl (OTC) ZYRTEC-D (OTC)
p-ephed hcl/fexofenadine hcl
ALLEGRA-D 12 HOUR
p-ephed sul/loratadine
CLARITIN-D 12 HOUR
CLARITIN-D 24 HOUR
p-ephed hcl/fexofenadine hcl
ALLEGRA-D 24 HOUR
Antihistamines - 1st Generation
chlorpheniramine maleate
CHLOR-TRIMETON
chlorpheniramine tannate
PEDIATAN
dexchlorpheniramine maleate
hydroxyzine hcl
hydroxyzine pamoate
promethazine hcl
Antihistamines - 2nd Generation
cetirizine tablets (OTC)
cetirizine solution (OTC)
fexofenadine hcl tablet
loratadine (OTC)
levocetirizine dihydrochloride
Nasal Anti-Inflammatory Steroids
flunisolide
QL
fluticasone propionate
QL
triamcinolone acetonide
QL
QL + beclomethasone dipropionate
ST
QL
mometasone furoate
Nasal Antihistamine
azelastine hcl
QL
azelastine hcl
QL
ANTIEMESIS/ANTIVERTIGO
Antiemetic/Antivertigo Agents
dronabinol
meclizine hcl
QL tiotropium br/olodaterol hcl
STIOLTO RESPIMAT
Beta-Adrenergic & Glucocorticoid Combinations
QL fluticasone/salmeterol
ADVAIR DISKUS
ADVAIR HFA
QL fluticasone/vilanterol
BREO ELLIPTA
QL
mometasone/formoterol
DULERA
General Bronchodilator Agents
ipratropium bromide
ATROVENT
QL
ipratropium bromide
ATROVENT HFA
QL
tiotropium bromide
SPIRIVA
Leukotriene Receptor Antagonists
montelukast sodium
SINGULAIR
Mast Cell Stabilizers
cromolyn sodium
INTAL
Phosphodiesterase-4 (PD-4) Inhibitors
QL
roflumilast
DALIRESP
Monoclonal Antibodies To Immunoglobulin E(ige)
Oral Inhaled Corticosteroids
QL
beclomethasone dipropionate
QVAR
budesonide
QL
PULMICORT RESPULES
QL
budesonide
PULMICORT FLEXHALER
QL
mometasone furoate
ASMANEX
Xanthines
aminophylline
AMINOPHYLLIN
theophylline anhydrous
UNIPHYL
theophylline anhydrous
THEO-24
AUTONOMIC NERVOUS SYSTEM DISORDERS
Alzheimer's Therapy, Nmda Receptor Antagonists
memantine hcl
NAMENDA
memantine hcl
NAMENDA XR
Alzheimer's Therapy, Nmda Receptor Antagonists & Cholines
Inhibitors
memantine hcl/donepezil hcl
NAMZARIC
Cholinesterase Inhibitors
donepezil hcl
ARICEPT, ARICEPT ODT
galantamine hydrobromide
RAZADYNE
pyridostigmine bromide
MESTINON
neostigmine bromide
PROSTIGMIN
rivastigmine patch
EXELON PATCH
rivastigmine tartrate
EXELON
BEHAVIORAL HEALTH - ANTIDEPRESSANTS
Alpha-2 Receptor Antagonist Antidepressants
mirtazapine
REMERON
Maois - Non-Selective & Irreversible
tranylcypromine sulfate
PARNATE
phenelzine sulfate
NARDIL
Norepinephrine & Dopamine Reuptake Inhib (ndris)
bupropion hcl
WELLBUTRIN
WELLBUTRIN SR
WELLBUTRIN XL
Selective Serotonin Reuptake Inhibitors (SSRIs)
citalopram hydrobromide
CELEXA
escitalopram oxalate
LEXAPRO
fluoxetine hcl
PROZAC
PROZAC WEEKLY
fluvoxamine maleate
LUVOX
paroxetine hcl
PAXIL
POLARAMINE
ATARAX
VISTARIL
PHENERGAN
ZYRTEC (OTC)
ZYRTEC SOLUTION
(OTC)
ALLEGRA
CLARITIN (OTC)
XYZAL
NASAREL
FLONASE
NASACORT AQ
QNASL
NASONEX
ASTELIN
ASTEPRO
MARINOL
ANTIVERT 12.5MG,
25MG
ondansetron
ZOFRAN ODT
ondansetron hcl (QL on solution ZOFRAN
only)
prochlorperazine maleate
COMPAZINE
promethazine hcl
PHENERGAN
netupitant/palonosetron hcl
AKYNZEO
aprepitant
EMEND
meclizine hcl
ANTIVERT 50MG
prochlorperazine edisylate
COMPAZINE SYRUP
ASTHMA
Beta-Adrenergic Agents
albuterol sulfate
ALBUTEROL SULFATE
metaproterenol sulfate
ALUPENT
terbutaline sulfate
BRETHINE
albuterol sulfate
PROAIR HFA
PROAIR RESPICLICK
VENTOLIN HFA
QL
formoterol fumarate
PERFOROMIST
QL olodaterol hcl
STRIVERDI RESPIMAT
QL
salmeterol xinafoate
SEREVENT DISKUS
Beta-Adrenergic & Anticholinergic Combinations
ipratropium/albuterol sulfate
DUONEB
ipratropium/albuterol sulfate
COMBIVENT
ipratropium/albuterol sulfate
COMBIVENT RESPIMAT
804PA, apr 2016
sertraline hcl
ZOLOFT
SSRI & Antipsychotic,ATYP,(DA & Serotonin) Comb.
olanzapine/fluoxetine HCl
SYMBYAX
Serotonin-2 Antagonist/Reuptake Inhibitors (SARIs)
trazodone hcl
DESYREL 300MG
Serotonin-Norepinephrine Reuptake-Inhib (SNRIs)
venlafaxine hcl
EFFEXOR
desvenlafaxine succinate
PRISTIQ
5
STATE OF MICHIGAN COMMERCIAL FORMULARY
APRIL 2016
Narcotic Antagonists
naltrexone hcl
REVIA
QL
naloxone hcl
NARCAN NASAL
Sedative-Hypnotics, Non-Barbiturate
chloral hydrate
NOCTEC
estazolam
PROSOM
QL eszopiclone
LUNESTA
flurazepam hcl
DALMANE
temazepam
RESTORIL
triazolam
HALCION
zolpidem tartrate
QL
AMBIEN
zaleplon
QL
SONATA
QL + zolpidem tartrate CR
AMBIEN CR
ST
Tx For Attention Deficit-Hyperact (ADHD)/Narcolepsy
PA modafinil
PROVIGIL
dexmethylphenidate hcl
FOCALIN ,FOCALIN XR
methylphenidate hcl
METADATE ER
METADATE CD
RITALIN
RITALIN-SR
RITALIN LA
methylphenidate hcl
CONCERTA
METHYLIN
METHYLIN CHEW TABS
methylphenidate hcl ER
QUILLIVANT XR
suspension
desvenlafaxine
DESVENLAFAXINE
ER(RANBAXY)
duloxetine hcl
CYMBALTA
venlafaxine hcl
EFFEXOR XR
Tricyclic Antidepressants & Rel. Non-Sel. Ru-Inhib
amitriptyline hcl
ELAVIL
amoxapine
ASENDIN
clomipramine hcl
ANAFRANIL
desipramine hcl
NORPRAMIN
doxepin hcl
SINEQUAN
imipramine hcl
TOFRANIL
maprotiline hcl
LUDIOMIL
nortriptyline hcl
PAMELOR
BEHAVIORAL HEALTH - OTHER
Adrenergics, Aromatic, Non-Catecholamine
amphet asp/amphet/d-amphet
ADDERALL
ADDERALL XR
dextroamphetamine sulfate
DEXEDRINE
dextroamphetamine sulfate
ZENZEDI 5mg, 10mg
dextroamphetamine sulfate
ZENZEDI 2.5mg, 7.5mg
lisdexamfetamine dimesylate
VYVANSE
Anti-Alcoholic Preparations
disulfiram
ANTABUSE
Anti-Anxiety Drugs
alprazolam
XANAX
ALPRAZOLAM INTENSOL
buspirone hcl
BUSPAR
VANSPAR
chlordiazepoxide hcl
LIBRIUM
clorazepate dipotassium
TRANXENE T-TAB
diazepam
VALIUM
lorazepam
ATIVAN
LORAZEPAM INTENSOL
meprobamate
MILTOWN
oxazepam
SERAX
Anti-Mania Drugs
lithium carbonate
ESKALITH
LITHOBID
lithium citrate
CIBALITH-S
Anti-Psychotics, Phenothiazines
chlorpromazine hcl
THORAZINE
fluphenazine hcl
PROLIXIN
perphenazine
TRILAFON
thioridazine hcl
MELLARIL
trifluoperazine hcl
STELAZINE
Antipsychotics, Atyp, D2 Partial Agonist/5HT Mixed
aripiprazole
ABILIFY
aripiprazole
ABILIFY DISCMELT
Antipsychotics, Dopamine & Serotonin Antagonists
loxapine succinate
LOXITANE
Antipsychotics, Atypical, Dopamine,& Serotonin Antag
clozapine
CLOZARIL
olanzapine
ZYPREXA
olanzapine ODT
ZYPREXA ZYDIS
risperidone
RISPERDAL
risperidone ODT
RISPERDAL M-TAB
quetiapine fumarate
SEROQUEL
Tx For Attention Deficit-Hyperact.(ADHD), NRI-Type
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 STIMULANT
Digitalis Glycosides
digoxin
LANOXIN
DIGOXIN ORAL SOLN.
CARDIOVASCULAR DISEASE - HYPERTENSION
Ace Inhibitor/Calcium Channel Blocker Combination
amlodipine besylate/benazepril LOTREL
Ace Inhibitor/Thiazide & Thiazide-Like Diuretic
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
ziprasidone hcl
GEODON
Antipsychotics, Dopamine Antagonists, Thioxanthenes
thiothixene
NAVANE
Antipsychotics, Dopamine Antagonists, Butyrophenones
haloperidol
HALDOL
haloperidol lactate
HALDOL ORAL CONC.
Barbiturates
phenobarbital
PHENOBARBITAL
804PA, apr 2016
6
STATE OF MICHIGAN COMMERCIAL FORMULARY
APRIL 2016
labetalol hcl
TRANDATE
carvedilol phosphate
COREG CR
Angioten. Receptr Antag./Cal. Chanl Blkr/Thiazide Comb
amlodipine/valsartan/hctz
ST
EXFORGE HCT
ST
olmesartan/amlodipin/hcthiazid
TRIBENZOR
Angiotensin Receptor Antag./Thiazide Diuretic Comb
irbesartan/ hydrochlorothiazide AVALIDE
losartan/hydrochlorothiazide
HYZAAR
valsartan/hydrochlorothiazide DIOVAN HCT
ST
olmesartan/hydrochlorothiazide
BENICAR HCT
Angiotensin Receptor Antgnst & Calc. Channel Blockr
amlodipine/valsartan
ST
EXFORGE
ST
amlodipine bes/olmesartan med
AZOR
Antihypertensives, ACE Inhibitors
benazepril hcl
LOTENSIN
captopril
CAPOTEN
enalapril maleate
VASOTEC
fosinopril sodium
MONOPRIL
lisinopril
PRINIVIL
ZESTRIL
moexipril hcl
UNIVASC
quinapril hcl
ACCUPRIL
ramipril
ALTACE
trandolapril
MAVIK
Antihypertensives, Angiotensin Receptor Antagonist
irbesartan
AVAPRO
losartan potassium
COZAAR
ST
olmesartan medoxomil
BENICAR
valsartan
ST
DIOVAN
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
nimodipine
verapamil hcl
Loop Diuretics
bumetanide
BUMEX
furosemide
LASIX
torsemide
DEMADEX
Potassium Sparing Diuretics
eplerenone
INSPRA
spironolactone
ALDACTONE
Potassium Sparing Diuretics In Combination
triamterene/hydrochlorothiazid DYAZIDE
MAXZIDE
MAXZIDE-25MG
Pulm. Anti-HTN, Sel. C-GMP Phosphodiesterase T5 Inhib
sildenafil citrate
PA
REVATIO TABLET
PA
tadalafil
ADCIRCA
Pulmonary Anti-HTN, Endothelin Receptor Antagonist
PA
ambrisentan
LETAIRIS
PA
bosentan
TRACLEER
PA macitentan
OPSUMIT
Pulmonary Anti-HTN, Prostacyclin-Type
PA selexipag
UPTRAVI
Pulmonary Anti-HTN, Soluble Guanylate Cyclase Stimulators
PA riociguat
ADEMPAS
Thiazide & Related Diuretics
chlorthalidone
HYGROTON
hydrochlorothiazide
MICROZIDE
indapamide
LOZOL
metolazone
ZAROXOLYN
chlorthalidone
THALITONE
CARDIOVASCULAR DISEASE - LIPID IRREGULARITY
Antihyperlipidemic – Apo-B 100 synthesis Inhibitor
PA
mipomersen sodium
KYNAMRO
Antihyperlipidemic - HMG CoA Reductase Inhibitors
atorvastatin
LIPITOR
lovastatin
MEVACOR
pravastatin sodium
PRAVACHOL
simvastatin
ZOCOR
QL
rosuvastatin calcium
CRESTOR
Antihyperlipidemic-HMG CoA Reductase Inhib. & Niacin
QL
niacin/simvastatin
SIMCOR
Antihyperlipidemic- MTP Inhibitor
PA+ lomitapide mesylate
JUXTAPID
QL
Bile Salt Sequestrants
cholestyramine/aspartame
QUESTRAN LIGHT
cholestyramine/sucrose
QUESTRAN
colestipol
COLESTID
COLESTID GRANULES
colesevelam hcl
WELCHOL
WELCHOL POWDER
PACKETS
Lipotropics
fenofibrate
LOFIBRA TABS
FENOGLIDE
fenofibrate
TRIGLIDE
fenofibrate, micronized
LOFIBRA CAPS
gemfibrozil
LOPID
QL
ezetimibe
ZETIA
fenofibrate nanocrystallized
TRICOR
QL
icosapent ethyl
VASCEPA
niacin
NIASPAN
QL
omega-3 acid ethyl esters
LOVAZA
Beta-Adrenergic Blocking Agents/Thiazide & Related
atenolol/chlorthalidone
TENORETIC 100
TENORETIC 50
bisoprolol fumarate/hctz
ZIAC
metoprolol/hctz
LOPRESSOR HCT
propranolol/hydrochlorothiazid INDERIDE-40/25
Calcium Channel Blocking Agents
amlodipine besylate
NORVASC
diltiazem hcl
CARDIZEM
CARDIZEM CD
DILACOR XR
TIAZAC
felodipine
PLENDIL
isradipine IR capsules
ISRADIPINE
nicardipine hcl IR
NICARDIPINE HCL
nifedipine
ADALAT CC
804PA, apr 2016
PROCARDIA
PROCARDIA XL
NIMOTOP
CALAN SR
VERELAN
VERELAN PM
7
STATE OF MICHIGAN COMMERCIAL FORMULARY
APRIL 2016
Niacin Preparations
niacin
SLO-NIACIN
CARDIOVASCULAR DISEASE - MISCELLANEOUS AGENTS
Adrenergic Vasopressor Agents
midodrine hcl
PROAMATINE
Antianginal & Anti-Ischemic Agents, Non-Hemodynamic
QL
ranolazine
RANEXA
Antihyperlip - HMG-CoA & Calcium Channel Blocker Comb
amlodipine/atorvastatin
QL
CADUET
Heart Rate Reducing, Selective I(F) Current Inhib.
PA + ivabradine hcl
CORLANOR
QL
CARDIOVASCULAR DISEASE - VASODILATION
Vasodilators, Combination
isosorb dinit/hydralazine hcl
BIDIL
Vasodilators, Coronary
isosorbide dinitrate
ISOCHRON
ISORDIL
ISORDIL TITRADOSE
isosorbide mononitrate
IMDUR
ISMO
MONOKET
nitroglycerin
NITRO-DUR
nitroglycerin
NITRO-BID
NITROLINGUAL
NITROSTAT
CONTRACEPTION/OXYTOCICS
QL
etonogestrel/ethinyl estradiol
NUVARING
Contraceptives, Injectable
medroxyprogesterone acet
DEPO-PROVERA
Contraceptives, Oral
desog-et estra/ethin estra
MIRCETTE
desogestrel-ethinyl estradiol
CYCLESSA
DESOGEN
ORTHO-CEPT
ethinyl estradiol/drospirenone YASMIN 28
YAZ
ethynodiol d-ethinyl estradiol
DEMULEN 1-50-21
levonorgestrel
PLAN B
levonorgestrel-eth estra
NORDETTE-28
QL
SEASONALE
noreth a-et estra/fe fumarate
LOESTRIN FE
norethindrone
NOR-Q-D
ORTHO MICRONOR
norethindrone a-e estradiol
LOESTRIN
norethindrone-ethinyl estrad
NORINYL 1+35
ORTHO-NOVUM
TRI-NORINYL
norethindrone-mestranol
NORINYL 1+50
norgestimate-ethinyl estradiol ORTHO TRI-CYCLEN
ORTHO TRI-CYCLEN LO
ORTHO-CYCLEN
norgestrel-ethinyl estradiol
LO-OVRAL-28
Contraceptives, Transdermal
QL
norelgestromin/ethin.estradiol
ORTHO EVRA
Oxytocics
methylergonovine maleate
METHERGINE
COUGH AND COLD
1st Gen Antihistamine & Decongestant Combinations
phenylephrine hcl/prometh hcl PHENERGAN VC
phenylephrine/brompheniramin BROMFED
e
BROMFED-PD
phenylephrine/chlor-tan
RYNATAN
RYNATAN PEDIATRIC
phenylephrine/pyril tan/cp
NALEX A 12
pseudoephedrine hcl/chlor-mal DECONAMINE
KLERIST-D
Narcotic Antituss-1st Gen. Antihistamine-Decongest
804PA, apr 2016
p-ephed hcl/cod/chlorphenir
NOVAHISTINE DH
phenylephrine hcl/cod/prometh PHENERGAN VC
W/CODEINE
phenylephrine/hydrocodone/cp MAXI-TUSS HCX
Narcotic Antituss-Decongestant-Expectorant Comb
p-ephed hcl/codeine/guaifen
SUTTAR-2
SUTTAR-SF
TUSNEL C
Narcotic Antitussive-1st Generation Antihistamine
codeine/promethazine hcl
PHENERGAN
W/CODEINE
hydrocodone/chlorphen polis
TUSSIONEX
Narcotic Antitussive-Anticholinergic Comb.
hydrocodone/homatrop me-br
HYCODAN
Narcotic Antitussive-Expectorant Combination
guaifenesin/codeine phos
MYCI-GC
Non-Narcotic Antitussive-1st Gen Antihistamine Combination
d-methorphan hb/prometh hcl PHENERGAN
W/DEXTROMETHORPHA
Non-Narcotic Antitussive & Expectorant Comb.
guaifenesin/d-methorphan hb
TUSNEL DIABETIC
DERMATOLOGY - ACNE
Acne Agents, Systemic
isotretinoin
ACCUTANE
Acne Agents, Topical
clindamycin phos/benzoyl perox BENZACLIN
sulfacetamide sodium
KLARON
clindamycin phos/benzoyl perox
ACANYA
clindamycin/benzoyl prx/skn #5
DUAC CS
clindamycin/tretinoin
ZIANA
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
BACTROBAN
CENTANY
clindamycin phosphate
EVOCLIN
erythromycin base/benz per
BENZAMYCIN PAK
mupirocin calcium
BACTROBAN
Topical Antifungals
ciclopirox olamine
LOPROX
ciclopirox 8% solution
CICLOPIROX
clotrimazole/betamet diprop
LOTRISONE
ketoconazole
KURIC
NIZORAL
nystatin
MYCOSTATIN
8
STATE OF MICHIGAN COMMERCIAL FORMULARY
APRIL 2016
nystatin/triamcin
naftifine hcl
sulconazole nitrate
terbinafine hcl
Topical Antiparasitics
lindane
malathion
permethrin
crotamiton
Topical Antivirals
acyclovir
Topical Sulfonamides
silver sulfadiazine
sulfacetamide sodium
MYCOLOG II
NAFTIN
EXELDERM
LAMISIL
OVACE PLUS
SUSPENSION
Topical Antineoplastic & Premalignant Lesion Agnts
fluorouracil
EFUDEX
PA + bexarotene
TARGRETIN
SCC
QL
ingenol
PICATO
PA mechlorethamine gel
VALCHLOR
Topical Local Anesthetics
hc acetate/pramoxine hcl
PRAMOSONE
DERMATOLOGY - PIGMENTATION DISORDERS
Topical Hyperpigmentation Agents
methoxsalen
OXSORALEN
DERMATOLOGY - PSORIASIS/ECZEMA
Antipsoriatic Agents, Systemic
acitretin
SORIATANE
methoxsalen
8-MOP
methoxsalen, rapid
OXSORALEN-ULTRA
PA secukinumab
COSENTYX
Antipsoriatics Agents
calcipotriene
DOVONEX
anthralin
DRITHO-SCALP
anthralin
DRITHOCREME HP
calcitriol
VECTICAL
tazarotene
TAZORAC
Topical Immunosuppressive Agents
tacrolimus
PROTOPIC
DIABETES
Antihyperglycemic, Alpha-Glucosidase Inhib (Non-Sulfonylurea)
acarbose
PRECOSE
Antihyperglycemic, Amylin Analog-Type
pramlintide acetate
SYMLIN
SYMLINPEN 120
SYMLINPEN 60
Antihyperglycemic, DPP-4 Inhibitors
QL
linagliptin
TRADJENTA
QL
sitagliptin
JANUVIA
Antihyperglycemic DPP-4 Inhibitor & Biguanide Combination
QL
linagliptin/metformin
JENTADUETO
QL
sitagliptin/metformin hcl
JANUMET
QL
sitagliptin/metformin ER
JANUMET XR
Antihyperglycemic DPP-4 Inhibitor & Statin Combination
sitagliptin/simvastatin
JUVISYNC
Antihyperglycemic,Glucocorticoid Receptor Antagonist
PA + mifepristone
KORLYM
QL
Antihyperglycemic, Incretin Mimetic (GLP-1 Recep. Agonist)
KWELL
OVIDE
ELIMITE
EURAX
ZOVIRAX
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
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
fluocinonide
VANOS
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
804PA, apr 2016
QL
dulaglutide
TRULICITY
QL liraglutide
VICTOZA
Antihyperglycemic, Insulin-Release Stimulant Type
chlorpropamide
DIABINESE
glimepiride
AMARYL
glipizide
GLUCOTROL
GLUCOTROL XL
glipizide/metformin hcl
METAGLIP
glyburide
DIABETA
glyburide
MICRONASE
nateglinide
STARLIX
repaglinide
PRANDIN
tolazamide
TOLINASE
tolbutamide
ORINASE
Antihyperglycemic, Insulin-Response Enhancer (NonSulfonylurea)
pioglitazone hcl
ACTOS
Antihyperglycemic, Biguanide Type (Non-Sulfonylurea)
metformin hcl
GLUCOPHAGE
9
STATE OF MICHIGAN COMMERCIAL FORMULARY
APRIL 2016
acetic acid
acetic acid/aluminum acetate
acetic acid/hydrocortisone
Ear Preparations, Antibiotics
neomy sulf/polymyx b sulf/hc
GLUCOPHAGE XR
metformin hcl
RIOMET
Antihyperglycemic, Insulin-Rel Stim.& Biguanide Comb
glyburide, micro/metformin hcl GLUCOVANCE
repaglinide/metformin hcl
PRANDIMET
Antihyperglycemic, Insulin-Response & Release Comb.
pioglitazone/glimepiride
DUETACT
Antihyperglycemic Insul-Resp. Enhancer & Biguanide Comb
pioglitazone hcl/metformin hcl ACTOPLUS MET
pioglitazone hcl/metformin hcl ER ACTOPLUS MET XR
Antihyperglycemic, Sodium/Glucose Cotransport-2 (SGLT2)
Inhibitor
QL
canagliflozin
INVOKANA
QL empagliflozin
JARDIANCE
Antihyperglycemic, Sodium/Glucose Cotransport-2 (SGLT2)
Inhibitor and Biguanide Combination
QL canagliflozin/metformin hcl
INVOKAMET
QL empagliflozin/metformin hcl
SYNJARDY
Antihyperglycemic, SGLT-2 & DPP-4 Inhibitor Combination
QL
empagliflozin/linagliptin
GLYXAMBI
Diabetic Supplies
blood-glucose calib. control
ALL ABBOTT CONTROL
PRODUCTS (e.g.,
FREESTYLE,
PRECISION)
blood-glucose meter
ALL LIFESCAN
CONTROL PRODUCTS
(e.g., ONETOUCH)
ALL ABBOTT
METERS(e.g.,
FREESTYLE,
PRECISION)
blood sugar diagnostics
ALL LIFESCAN METERS
(e.g., ONETOUCH)
ALL ABBOTT TEST
STRIPS (e.g.,
FREESTYLE,
PRECISION)
lancing device/lancets
Diabetic Ulcer Preparations, Topical
becaplermin
Hyperglycemics
glucagon,human recombinant
Insulins
QL
hum insulin nph/reg insulin hm
QL
hum insulin nph/reg insulin hm
QL
insulin glargine,hum.rec.anlog
QL
QL
insulin lispro
QL
insulin npl/insulin lispro
QL
insulin regular, human
QL
nph, human insulin isophane
Syringes & Accessories
syringes & needles
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
ELECTROLYTE REGULATION
Electrolyte Depleters
calcium acetate
PHOSLO
sodium polystyrene sulfonate
KAYEXALATE
sevelamer carbonate
RENVELA
sevelamer hcl
RENAGEL
Potassium Replacement
pot chloride/pot bicarb/cit ac
K-LYTE-CL
potassium bicarbonate/cit ac
K-LYTE
potassium chloride
K-DUR
K-TAB
MICRO-K
ENDOCRINE DISORDER - FERTILITY
Drugs to Treat Impotency
QL + sildenafil citrate
VIAGRA
GEN
QL+ tadalafil
CIALIS
GEN
Fertility Stimulating Preparations, Non-FSH
clomiphene citrate
CLOMID
SEROPHENE
Follicle Stim./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 Agent, Hormonal
progesterone, micronized
CRINONE
PROCHIEVE
progesterone, micronized
CRINONE
ENDOMETRIN
PROCHIEVE
ENDOCRINE DISORDER - OTHER
Antidiuretic & Vasopressor Hormones
desmopressin (nonrefrigerated) DDAVP
Antineoplastic LHRH (GNRH) agonist, Pituitary Suppressant
PA
leuprolide
ELIGARD
Bone Formation Stim. Agents - Parathyroid Hormone
QL
teriparatide
FORTEO
Bone Resorption Inhibitor & Calcium Combinations
ALL LIFESCAN TEST
STRIPS (e.g.,
ONETOUCH)
ALL ABBOTT AND
LIFESCAN (e.g.,
ONETOUCH) LANCETS
REGRANEX
GLUCAGEN
GLUCAGON
EMERGENCY KIT
HUMULIN 70-30
HUMULIN 50-50
LANTUS
TOUJEO
HUMALOG
HUMALOG MIX 50-50
HUMALOG MIX 75-25
HUMULIN R
HUMULIN N
Bone Resorption Inhibitor & Vitamin D Combinations
alendronate sodium/vitamin d3
FOSAMAX PLUS D
Bone Resorption Inhibitors
alendronate sodium
FOSAMAX
etidronate disodium
DIDRONEL
ibandronate
BONIVA
raloxifene hcl
QL
EVISTA
ALL COMMERCIALLY
AVAILABLE SYRINGES
AND NEEDLES
EAR - GENERAL DISORDERS
Ear Preparations, Misc. Anti-Infectives
804PA, apr 2016
VOSOL
DOMEBORO
VOSOL HC
10
STATE OF MICHIGAN COMMERCIAL FORMULARY
APRIL 2016
Growth Hormone Receptor Antagonists
pegvisomant
SOMAVERT
Growth Hormones
PA somatropin
NORDITROPIN
NORDITROPIN
FLEXPRO
NORDITROPIN
NORDIFLEX
PA
somatropin
OMNITROPE
Hyperparathyroid Tx Agents, 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
ENDOCRINE DISORDER - THYROID
Antithyroid Preparations
methimazole
TAPAZOLE
propylthiouracil
PROPYLTHIOURACIL
Iodine Containing Agents
potassium iodide
POTASSIUM IODIDE
Thyroid Hormones
levothyroxine sodium
LEVOTHROID
LEVOXYL
SYNTHROID
liothyronine sodium
CYTOMEL
thyroid, pork
ARMOUR THYROID
thyroid, pork
NATURE-THROID
EYE - GENERAL DISORDERS
Eye Antibiotic-Corticoid Combinations
neo/polymyx b sulf/dexameth
MAXITROL
neomy sulf/bacitrac zn/poly/hc CORTISPORIN OPHTH
OINTMENT
neomy sulf/polymyx b sulf/hc
CORTISPORIN OPHTH
SUSPENSION
neomycin sulfate/dex na ph
NEODECADRON
tobramycin sulfate/dexameth
TOBRADEX
neomy sulf/polymyx b sulf/pred
POLY-PRED
tobramycin/lotepred etab
ZYLET
Eye Antihistamines
azelastine hcl
OPTIVAR
ketotifen fumarate (OTC)
ALAWAY OTC
olopatadine hcl
PATADAY
PATANOL
Eye Antiinflammatory Agents
diclofenac sodium
VOLTAREN
fluorometholone
FML
flurbiprofen sodium
OCUFEN
ketorolac tromethamine
ACULAR
ACULAR LS
prednisolone acetate
OMNIPRED
PRED FORTE
prednisolone sod phosphate
PREDNISOL
difluprednate
DUREZOL
fluorometholone
FML FORTE
FML S.O.P.
fluorometholone acetate
FLAREX
loteprednol etabonate
ALREX
LOTEMAX
nepafenac
ILEVRO
nepafenac
NEVANAC
prednisolone acetate
PRED MILD
Eye Antivirals
804PA, apr 2016
trifluridine
ganciclovir
Eye Sulfonamides
na sulfacetm/prednis sp
sulfacetamide sodium
na sulfacetm/prednisol ac
VIROPTIC
ZIRGAN
VASOCIDIN
SULFAC
BLEPHAMIDE
BLEPHAMIDE S.O.P.
Ophthalmic Anti-Inflammatory Immunomodulator-Type
cyclosporine
RESTASIS
Ophthalmic Antibiotics
bacitracin
AK-TRACIN
bacitracin/polymyxin b sulfate POLYCIN-B
ciprofloxacin hcl
CILOXAN
erythromycin base
ROMYCIN
gentamicin sulfate
GARAMYCIN
neomycin/bacitracin/polymyxin NEOSPORIN OPHTH
OINTMENT
neomycin/polymyxn
NEOSPORIN OPHTH
b/gramicidin
DROPS
ofloxacin
OCUFLOX
polymyxin b sulfate/tmp
POLYTRIM
tobramycin sulfate
TOBREX
gatifloxacin
ZYMAR
ZYMAXID
moxifloxacin hcl
VIGAMOX
Ophthalmic Mast Cell Stabilizers
cromolyn sodium
OPTICROM
lodoxamide tromethamine
ALOMIDE
nedocromil sodium
ALOCRIL
pemirolast potassium
ALAMAST
EYE - GLAUCOMA
Carbonic Anhydrase Inhibitors
acetazolamide
DIAMOX SEQUELS
methazolamide
NEPTAZANE
Miotics/Other Intraoc. Pressure Reducers
betaxolol hcl
BETOPTIC
brimonidine tartrate
ALPHAGAN P
carteolol hcl
OCUPRESS
dorzolamide hcl
TRUSOPT
dorzolamide hcl/timolol maleat COSOPT
levobunolol hcl
BETAGAN
metipranolol
OPTIPRANOLOL
pilocarpine hcl
ISOPTO CARPINE
timolol maleate
TIMOPTIC(except
Ocudose)
TIMOPTIC-XE
betaxolol hcl
BETOPTIC S
bimatoprost 0.03%
LUMIGAN
bimatoprost 0.01%
brimonidine/timolol
COMBIGAN
brinzolamide
AZOPT
brinzolamide/brimonidine
SIMBRINZA
carbachol
ISOPTO CARBACHOL
latanoprost
XALATAN
timolol
BETIMOL
travoprost
TRAVATAN Z
travoprost (benzalkonium)
TRAVATAN
Mydriatics
atropine sulfate
ISOPTO ATROPINE
cyclopentolate hcl
CYCLOGYL
homatropine hbr
ISOPTO HOMATROPINE
dipivefrin hcl
PROPINE
Eye Miscellaneous
PA
cysteamine HCl
CYSTARAN
GOUT AND RELATED DISEASES
Colchicine
11
STATE OF MICHIGAN COMMERCIAL FORMULARY
APRIL 2016
colchicine
colchicine/probenecid
Hyperuricemia Tx - Purine Inhibitors
allopurinol
febuxostat
Uricosuric Agents
probenecid
HEMATOLOGICAL DISORDERS
Anticoagulants, Coumarin Type
warfarin sodium
Direct Factor XA Inhibitors
QL
apixaban
QL
rivaroxaban
Hematinics, Other
PA
epoetin alfa
Hemorrheologic Agents
pentoxifylline
Heparin & Related Preparations
heparin sodium, porcine
heparin sodium, porcine/pf
QL
dalteparin sodium, porcine
enoxaparin sodium
QL
fondaparinux sodium
QL
Leukocyte (WBC) Stimulants
PA
filgrastim
PA
pegfilgrastim
PA
sargramostim
Platelet Aggregation Inhibitors
cilostazol
dipyridamole
clopidogrel bisulfate
QL clopidogrel bisulfate 300mg
QL
prasugrel hcl
QL
ticagrelor
Platelet Reducing Agents
anagrelide hcl
Thrombopoietin Receptor Agonists
PA
eltrombopag olamine
Vitamin K Preparations
phytonadione
HORMONAL DEFICIENCY
Androgenic Agents
fluoxymesterone
testosterone cypionate
QL
testosterone enanthate
QL
methyltestosterone
testosterone 1%
testosterone gel 1.62%
QL
testosterone solution
Estrogen/Androgen Combinations
estrogen, ester/me-testosterone
Estrogenic Agents
estradiol patch
QL
estradiol tablet
estropipate
estradiol patch
QL
QL
QL
QL
estradiol/noreth ac
estrogens, conj/bazedoxifene
estrogen, con/m-progest acet
QL
estrogens, conjugated
804PA, apr 2016
COLCRYS
COL-BENEMID
estrogens, esterified
norethind ac/ethinyl estradiol
Progestational Agents
medroxyprogesterone acet
norethindrone acetate
progesterone, micronized
IMMUNOSUPPRESSION/MODULATION
Immunomodulators
PA, imiquimod
QL
PA
interferon alfa-2b, recomb.
Immunosuppressives
azathioprine
cyclosporine
cyclosporine, modified
mycophenolate mofetil
tacrolimus anhydrous
everolimus
sirolimus
INFECTIOUS DISEASE - BACTERIAL
Absorbable Sulfonamides
sulfadiazine
sulfamethoxazole/trimethoprim
ZYLOPRIM
ULORIC
BENEMID
COUMADIN
ELIQUIS
XARELTO
PROCRIT
TRENTAL
HEP-LOCK
HEPARIN LOCK
HEP-LOCK
FRAGMIN
LOVENOX
ARIXTRA
sulfisoxazole acetyl
Beta lactams, inhaled
PA + aztreonam lysine, inhaled
QL
Cephalosporins - 1st Generation
cefadroxil hydrate
cephalexin monohydrate
Cephalosporins - 2nd Generation
cefaclor
cefprozil
cefuroxime axetil
Cephalosporins - 3rd Generation
cefdinir
cefpodoxime proxetil
cefixime
Chemotherapeutics, Antibacterial, Misc.
trimethoprim
meth/meth blue/ba/salicy/hyos
mth/me blue/salicy/na phos/hyo
NEUPOGEN
NEULASTA
LEUKINE
PLETAL
PERSANTINE
PLAVIX
PLAVIX 300MG
EFFIENT
BRILINTA
AGRYLIN
PROMACTA
MEPHYTON
ANDROXY, HALOTESTIN
DEPO-TESTOSTERONE
DELATESTRYL
ANDROID
METHITEST
trimethoprim
Ketolides
telithromycin
Lincosamides
clindamycin hcl capsules
clindamycin palmitate solution
Macrolides
azithromycin
ANDROGEL
ANDROGEL
AXIRON
ESTRATEST H.S.
clarithromycin
CLIMARA
ESTRACE
OGEN
ALORA
ESTRADERM
VIVELLE-DOT
COMBIPATCH
DUAVEE
PREMPHASE
PREMPRO
PREMARIN
ery e-succ/sulfisoxazole
erythromycin base
erythromycin ethylsuccinate
erythromycin stearate
azithromycin
erythromycin base
erythromycin ethylsuccinate
12
MENEST
FEMHRT
PROVERA
AYGESTIN
PROMETRIUM
ALDARA
INTRON A
IMURAN
SANDIMMUNE
NEORAL
CELLCEPT
PROGRAF
ZORTRESS
RAPAMUNE
SULFADIAZINE
BACTRIM DS
SEPTRA
SEPTRA DS
GANTRISIN
CAYSTON
DURICEF
KEFLEX
CECLOR
CEFZIL
CEFTIN
OMNICEF
VANTIN
SUPRAX
PROLOPRIM
PROSED-DS
URETRON D-S
URIN D.S.
PRIMSOL
KETEK
CLEOCIN HCL
CLEOCIN PALMITATE
ZITHROMAX
ZITHROMAX TRI-PAK
BIAXIN
BIAXIN XL
PEDIAZOLE
ERYC
ERYPED 200
ERYTHROCIN
STEARATE
ZMAX
ZMAX PEDIATRIC
ERY-TAB
PCE
E.E.S. 200
ERYPED 200
STATE OF MICHIGAN COMMERCIAL FORMULARY
APRIL 2016
fidaxomicin
Nitrofuran Derivatives
nitrofurantoin macrocrystal
nitrofurantoin/nitrofuran mac
furazolidone
nitrofurantoin
Oxazolidinones
linezolid
PA
PA tedizolid phosphate tablet
Penicillins
amox tr/potassium clavulanate
amoxicillin trihydrate
ampicillin trihydrate
dicloxacillin sodium
penicillin v potassium
amox tr/potassium clavulanate
Quinolones
ciprofloxacin hcl
levofloxacin
ofloxacin
ciprofloxacin
moxifloxacin hcl
Tetracyclines
doxycycline hyclate
doxycycline monohydrate
doxycycline monohydrate
minocycline hcl
Antitubercular Antibiotics
rifampin
RIFADIN
rifampin/isoniazid
RIFAMATE
Vancomycin & Derivatives
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
ERYPED 400
DIFICID
MACRODANTIN
MACROBID
FUROXONE
FURADANTIN
ZYVOX
SIVEXTRO TABLET
AUGMENTIN
AUGMENTIN ES-600
AMOXIL
POLYCILLIN
PATHOCIL
V-CILLIN K
AUGMENTIN XR
Antimalarial Drugs
chloroquine phosphate
ARALEN PHOSPHATE
hydroxychloroquine sulfate
PLAQUENIL
mefloquine hcl
LARIAM
primaquine phosphate
PRIMAQUINE
PA
pyrimethamine
DARAPRIM
pyrimethamine/sulfadoxine
FANSIDAR
quinine sulfate
QUALAQUIN
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
benefit.
Antivirals, General
acyclovir
ZOVIRAX
ganciclovir
CYTOVENE
valacyclovir hcl
VALTREX
oseltamivir phosphate
TAMIFLU
ribavirin
VIRAZOLE
Antivirals, HIV-Spec, Non-Peptidic Protease Inhib
darunavir ethanolate
PREZISTA
darunavir/cobicistat
PREZCOBIX
tipranavir
APTIVUS
tipranavir/vitamin e tpgs
APTIVUS
Antivirals, HIV-Spec, Nucleoside-Nucleotide Analog
emtricitabine/tenofovir
TRUVADA
Antivirals, HIV-Spec., Nucleoside Analog, RTI Comb
abacavir sulfate/lamivudine
EPZICOM
abacavir/lamivudine/zidovudine TRIZIVIR
lamivudine/zidovudine
COMBIVIR
Antivirals, HIV-Specific, CCR5 Co-Receptor Antag.
maraviroc
SELZENTRY
Antivirals, HIV-Specific, Fusion Inhibitors
ST
enfuvirtide
FUZEON
Antivirals, HIV-Specific, Non-Nucleoside, RTI
delavirdine mesylate
RESCRIPTOR
efavirenz
SUSTIVA
etravirine
INTELENCE
nevirapine
VIRAMUNE
nevirapine
Viramune XR
rilpivirine
EDURANT
Antivirals, HIV-Specific, Nucleoside Analog, RTI
didanosine
VIDEX EC
stavudine
ZERIT
zidovudine
RETROVIR
abacavir sulfate
ZIAGEN
didanosine
VIDEX
emtricitabine
EMTRIVA
lamivudine
EPIVIR
CIPRO
LEVAQUIN
FLOXIN
CIPRO ORAL
SUSPENSION
AVELOX
AVELOX ABC PACK
VIBRA-TABS
VIBRAMYCIN
ADOXA
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
terbinafine hcl
LAMISIL GRANULES
voriconazole
VFEND
Antifungal Antibiotics
griseofulvin suspension
GRISEOFULVIN
nystatin
MYCOSTATIN
griseofulvin ultramicrosize
GRIS-PEG
INFECTIOUS DISEASE - MISCELLANEOUS
Rifamycin and Related Derivative Antibiotics
rifaximin 550mg
XIFAXAN
Aminoglycosides
neomycin sulfate
MYCIFRADIN
PA + tobramycin for inhalation
TOBI
QL
PA + tobramycin for inhalation(cap)
TOBI PODHALER
QL
Anti-Mycobacterium Agents
ethambutol hcl
MYAMBUTOL
isoniazid
NYDRAZID
pyrazinamide
PYRAZINAMIDE
Antileprotics
dapsone
AVLOSULFON
PA
thalidomide
THALOMID
804PA, apr 2016
13
STATE OF MICHIGAN COMMERCIAL FORMULARY
APRIL 2016
Antivirals, HIV-Specific, Nucleotide Analog, RTI
tenofovir disoproxil fumarate
VIREAD
Antivirals, HIV-Specific, Protease Inhibitor Comb
lopinavir/ritonavir
KALETRA
Antivirals, HIV-Specific, Protease Inhibitors
atazanavir sulfate
REYATAZ
atazanavir sulfate/cobicistat
EVOTAZ
fosamprenavir calcium
LEXIVA
indinavir sulfate
CRIXIVAN
nelfinavir mesylate
VIRACEPT
ritonavir
NORVIR
ST
saquinavir mesylate
INVIRASE
Antivirals, HIV-1 Integrase Strand Transfer Inhibtr
dolutegravir
TIVICAY
ST
elvitegravir
VITEKTA
raltegravir potassium
ISENTRESS
Antiviral Comb Nucleoside, Nucleotide & Non-Nucleoside RTI
efavirenz/emtricitab/tenofovir
ATRIPLA
emtricit/rilpivirine/tenofovir
COMPLERA
Cytochrome P450 Inhibitors
PA
cobicistat
TYBOST
ARV CMB-NRTI, N(T)RTI, Integrase Inhibitor
abacavir/dolutegravir/lamivudine TRIUMEQ
elvitegravir, cobicistat,
STRIBILD
emtricitabine, tenofovir disoproxil
fumarate
elviteg/cobi/emtric/tenofo ala
GENVOYA
Hepatitis B Treatment Agents
adefovir dipivoxil
HEPSERA
entecavir
BARACLUDE
lamivudine
EPIVIR HBV
lamivudine
EPIVIR HBV SOLUTION
telbivudine
TYZEKA
Hepatitis C Combination Agents
PA ledipasvir/sofosbuvir
HARVONI
Hepatitis C Treatment Agents
ribavirin 200mg
COPEGUS
REBETOL
PA
peginterferon alfa-2a
PEGASYS
PEGASYS PROCLICK
PA sofosbuvir
SOVALDI
INFLAMMATORY DISEASE
Anti-Arthritic & Chelating Agents
penicillamine
CUPRIMINE
DEPEN
Anti-Arthritic, Folate Antagonist Agents
methotrexate sodium
RHEUMATREX
QL methotrexate
OTREXUP
Anti-Inflammatory,Tumor Necrosis Factor Inhibitor
PA
adalimumab
HUMIRA
PA etanercept
ENBREL
Anti-Inflammatory, Bradykinin B2 receptor antagonists
PA icatibant acetate
FIRAZYR
Anti-Inflammatory, Pyrimidine Synthesis Inhibitor
leflunomide
ARAVA
Glucocorticoids
budesonide
BUDESONIDE
cortisone acetate
CORTONE ACETATE
dexamethasone
DEXAMETHASONE
TABLET/ELIXIR
hydrocortisone
CORTEF
methylprednisolone
MEDROL
prednisolone
MILLIPRED
MILLIPRED DP
prednisolone sod phosphate
ORAPRED
PEDIAPRED
804PA, apr 2016
prednisone
DELTASONE
PREDNISONE INTENSOL
ENTOCORT EC
budesonide
Mineralocorticoids
fludrocortisone acetate
FLORINEF ACETATE
Monoclonal antibody-human interleukin
PA ustekinumab
STELARA
NSAIDs, Cyclooxygenase Inhibitor-Type
diclofenac sodium
VOLTAREN
VOLTAREN-XR
etodolac
LODINE
fenoprofen calcium
NALFON TABLETS
flurbiprofen
ANSAID
ibuprofen
MOTRIN
indomethacin
INDOCIN
INDOCIN SR
ketoprofen
ORUVAIL
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 CAPSULES
indomethacin
INDOCIN SUPPOS.
INDOCIN ORAL SUSP.
LOCAL ANESTHESIA
Local Anesthetics
lidocaine hcl
XYLOCAINE
LOWER GASTROINTESTINAL DISORDERS - BOWEL INFLAMMAT
Bowel Antiinflamatory Agents
sulfasalazine
AZULFIDINE
Chronic Inflam. Colon Dx, 5-A-Salicylat, Rectal Tx
mesalamine
SFROWASA
mesalamine w/cleansing wipes ROWASA
mesalamine
CANASA
Drug Tx-Chronic Inflam. Colon Dx, 5-Aminosalicylat
balsalazide disodium
COLAZAL
mesalamine
APRISO,
LIALDA
PENTASA
Irritable Bowel Agents, Guanylate Cyclase-C Agonist
linaclotide
LINZESS
Hemorrhoidal Preparations
hc acetate/pramoxine hcl
PROCTOCREAM-HC
hc acetate/pramoxine hcl
ANALPRAM HC
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
Antidiarrheals
14
STATE OF MICHIGAN COMMERCIAL FORMULARY
APRIL 2016
diphenoxylate hcl/atrop sulf
Bile Salts
ursodiol
Antineoplastic, Janus Kinase (JAK) Inhibitors
PA+ ruloxitinib
JAKAFI
SCC
Antineoplastic - MEK1 and MEK2 Kinase Inhibitors
PA + cobimetinib fumarate
COTELLIC
QL
Antineoplastic - Topoisomerase I Inhibitors
topotecan hcl
HYCAMTIN
Antineoplastic Immunomodulator Agents
PA+ lenalidomide
REVLIMID
QL
PA
pomalidomide
POMALYST
Antineoplastic Systemic Enzyme Inhibitors
PA+ imatinib mesylate
GLEEVEC
SCC
PA afatinib
GILOTRIF
PA+ alectinib hydrochloride
ALECENSA
QL
PA+ axitinib
INLYTA
SCC
PA
bosutinib
BOSULIF
PA
cabozantinib
COMETRIQ
PA ceritinib
ZYKADIA
PA+ crizotinib
XALKORI
SCC
PA
dabrafenib
TAFINLAR
PA+ dasatinib
SPRYCEL
SCC
PA+ erlotinib hcl
TARCEVA
SCC
PA gefitinib
IRESSA
PA ibrutinib
IMBRUVICA
PA idelalisib
ZYDELIG
PA ixazomib citrate
NINLARO
PA
lapatinib ditosylate
TYKERB
PA lenvatinib mesylate
LENVIMA
PA+ nilotinib hydrochloride
TASIGNA
SCC
PA + olaparib
LYNPARZA
QL
PA + osimertinib mesylate
TAGRISSO
QL
PA + pazopanib hydrochloride
VOTRIENT
SCC
PA palbociclib
IBRANCE
PA
ponatinib
ICLUSIG
PA
regorafenib
STIVARGA
PA+ sorafenib tosylate
NEXAVAR
SCC
PA+ sunitinib malate
SUTENT
SCC
PA
tramtinib dimethyl sulfoxide
MEKINIST
PA+ vemurafinib
ZELBORAF
SCC
Antineoplastic, Histone Deacetylase Inhibitors, HDIS
PA panobinostat lactate
FARYDAK
SCC vorinostat
ZOLINZA
Antineoplastics, Miscellaneous
etoposide
VEPESID
mitotane
LYSODREN
procarbazine hcl
MATULANE
tretinoin
VESANOID
PA + everolimus
AFINITOR, AFINITOR
SCC
DISPERZ
Chemotherapy Rescue/Antidote Agents
leucovorin calcium
LEUCOVORIN CALCIUM
Selective Estrogen Receptor Modulators (SERM)
tamoxifen citrate
NOLVADEX
LOMOTIL
ACTIGALL
URSO
URSO FORTE
Glucagon-like Peptide-2 (GLP-2) Analogs
PA
teduglutide
GATTEX
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
lubiprostone
AMITIZA
peg 3350/na sulf,bicarb,cl/kcl
GOLYTELY
OCL
Narcotic Antagonists, Peripherally-Acting
naloxegol oxalate
MOVANTIK
methylnaltrexone bromide
RELISTOR
MISCELLANEOUS AGENTS
Anaphylaxis Therapy Agents
epinephrine
EPIPEN
EPIPEN JR
TWINJECT
Parasympathetic Agents
bethanechol chloride
URECHOLINE
cevimeline hcl
EVOXAC
pilocarpine hcl
SALAGEN
Pku Tx Agent-Cofactor Of Phenylalanine Hydroxylase
PA sapropterin dihydrochloride
KUVAN
NEOPLASTIC DISEASE
Alkylating Agents
cyclophosphamide
CYTOXAN
hydroxyurea
HYDREA
altretamine
HEXALEN
busulfan
MYLERAN
chlorambucil
LEUKERAN
lomustine
CEENU
melphalan
ALKERAN
temozolomide
PA
TEMODAR
Antiandrogenic Agents
bicalutamide
CASODEX
flutamide
EULEXIN
PA+ abiraterone
ZYTIGA
SCC
PA
enzalutamide
XTANDI
QL
nilutamide
NILANDRON
Antimetabolites
mercaptopurine
PURINETHOL
methotrexate sodium
METHOTREXATE
TABLET
methotrexate sodium
METHOTREXATE VIAL
thioguanine
THIOGUANINE
PA
capecitabine
XELODA
fludarabine phosphate
OFORTA
mercaptopurine
PURIXAN
methotrexate sodium
TREXALL
PA trifluridine/tipiracil hcl
LONSURF
Antineoplastic Aromatase Inhibitors
anastrozole
ARIMIDEX
exemestane
AROMASIN
letrozole
FEMARA
Antineoplastic, Hedgehog Pathway Inhibitor
PA + vismodegib
ERIVEDGE
SCC
PA
sonidegib phosphate
ODOMZO
804PA, apr 2016
15
STATE OF MICHIGAN COMMERCIAL FORMULARY
APRIL 2016
Analgesic, Non-Salicylate, Barbiturate & Xanthine Comb
butalb/acetaminophen/caffeine ESGIC
FIORICET
Analgesic/Antipyretics, Salicylates
diflunisal
DOLOBID
salsalate
DISALCID
Analgesics, Narcotics
buprenorphine hcl
PA
SUBUTEX
codeine phos/carisoprodol/asa SOMA COMPOUND WITH
CODEINE
Fentanyl patch
PA
DURAGESIC
QL fentanyl citrate lozenge
ACTIQ
hydrocodone bit/acetaminophen VICODIN,VICODIN ES,
QL
(300mg)
VICODIN HP
hydrocodone bit/acetaminophen LORCET
QL
(325mg)
LORCET PLUS
LORTAB
NORCO
hydrocodone bit/acetaminophen LORTAB ELIXIR
QL
oral elixir (300mg/15ml)
QL
hydrocodone bit/acetaminophen HYCET
(325mg/15ml) oral solution
hydromorphone hcl
DILAUDID
methadone hcl
DOLOPHINE HCL
morphine sulfate
QL
AVINZA
morphine sulfate
QL
MS CONTIN
PA
toremifene citrate
FARESTON
Selective Retinoid X Receptor Agonists (RXR)
PA + bexarotene
TARGRETIN
SCC
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
REBIF
PA
peginterferon beta-1a
PLEGRIDY
PA
PLEGRIDY PEN
Fibromyalgia Agents, Serotonin-Norepineph RU Inhib
milnacipran hcl
SAVELLA
Movement Disorders (Drug Therapy)
PA tetrabenazine
XENAZINE
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 Stim. For Anorexia, Cachexia, Wasting Synd.
megestrol acetate
MEGACE
megestrol acetate
MEGACE ES
General Inhalation Agents
sodium chloride for inhalation
HYPER-SAL 7%
Metabolic disease enzyme replace, hypophosphatasia
PA asfotase alfa
STRENSIQ
Needles/Needleless Devices
needles, insulin disp., safety
NOVOFINE
NOVOFINE 32 PEN
NEEDLE
needles, insulin disp., safety
NOVOFINE AUTOCOVER
Somatostatic Agents
octreotide acetate
SANDOSTATIN
lanreotide acetate
SOMATULINE DEPOT
octreotide acetate
SANDOSTATIN LAR
Antifibrotic Therapy – Pyridone Analogs
PA
pirfenidone
ESBRIET
OTHER RESPIRATORY DISORDERS
Cystic Fibrosis-Cftr Potentiator & Corrector Comb.
PA lumacaftor/ivacaftor
ORKAMBI
Cystic Fibrosis Transmembrane Conduct. Regulator (CFTR)
Potentiator
PA + ivacaftor
KALYDECO
QL
Mucolytics
acetylcysteine
MUCOMYST-10
PA + dornase alfa for inhalation
PULMOZYME
QL
Pulmonary Fibrosis – Systemic Enzyme Inhibitors
PA
nintedanib esylate
OFEV
PAIN MANAGEMENT - ANALGESICS
Analgesic, Non-Salicylate & Barbiturate Comb.
butalbital/acetaminophen
PHRENILIN
butalbital/acetaminophen
PHRENILIN FORTE
Analgesic, Salicylate, Barbiturate & Xanthine Comb
butalbital/aspirin/caffeine
FIORINAL
804PA, apr 2016
morphine sulfate
oxycodone hcl
MSIR
ORAMORPH SR
ROXANOL
PERCOLONE
ROXICODONE
ROXICODONE
INTENSOL
PERCOCET
oxycodone hcl/acetaminophen
(325mg)
oxycodone hcl/acetaminophen ROXICET
QL
(325mg/5ml)
oxycodone hcl/aspirin
PERCODAN
tramadol hcl
ULTRAM
tramadol/acetaminophen
ULTRACET
buprenorphine transdermal
BUTRANS
PA
buprenorphine hcl/naloxone hcl
SUBOXONE
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
NUCYNTA ER
Antimigraine Preparations
ergotamine tartrate/caffeine
CAFERGOT
MIGERGOT
isomethept/acetaminop/dichlph MIDRIN
n
naratriptan
QL
AMERGE
sumatriptan
QL
IMITREX NASAL SPRAY
sumatriptan succinate
QL
IMITREX TABLET
QL
IMITREX INJECTION
rizatriptan benzoate
QL
MAXALTMAXALT MLT
QL + zolmitriptan
ZOMIG
ST
QL +
ZOMIG ZMT
ST
Narc. & Non-Sal. Analgesic, Barbiturate & Xanthine Comb
codeine/butalbit/acetamin/caff FIORICET WITH
CODEINE
Narcotic & Salicylate Analgesics, Barb. & Xanthine
QL
16
STATE OF MICHIGAN COMMERCIAL FORMULARY
APRIL 2016
codeine/butalbital/asa/caffein
methocarbamol
FIORINAL WITH
CODEINE #3
Narcotic Analgesic & Non-Salicylate Analgesic Comb
acetaminophen with codeine
TYLENOL-CODEINE
NO.3
TYLENOL-CODEINE
NO.4
acetaminophen with codeine
TYLENOL-CODEINE
NO.4
acetaminophen with codeine
CAPITAL W-CODEINE
PARKINSONS 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
ropinirole hcl
REQUIP XL
selegiline hcl
ELDEPRYL
rasagiline mesylate
AZILECT
rotigotine
NEUPRO
Decarboxylase Inhibitors
carbidopa
LODOSYN
SEIZURE DISORDER
Anticonvulsants
carbamazepine
CARBATROL
TEGRETOL
TEGRETOL XR
clonazepam
KLONOPIN
QL
diazepam (rectal)
DIASTAT
divalproex sodium
DEPAKOTE
DEPAKOTE ER
DEPAKOTE SPRINKLE
ethosuximide
ZARONTIN
gabapentin
NEURONTIN
lamotrigine
LAMICTAL
levetiracetam
KEPPRA
oxcarbazepine
TRILEPTAL
phenytoin
DILANTIN-125
phenytoin sodium extended
DILANTIN
PHENYTEK
primidone
MYSOLINE
topiramate
TOPAMAX
TOPAMAX SPRINKLE
valproate sodium
DEPAKENE SYRUP
valproic acid
DEPAKENE CAPSULES
zonisamide
ZONEGRAN
phenytoin
DILANTIN CHEW TAB
pregabalin
LYRICA
SKELETAL MUSCLE DISORDER
Agents To Treat Periodic Paralysis
PA dichlorphenamide
KEVEYIS
Skeletal Muscle Relaxants
baclofen
LIORESAL
carisoprodol
SOMA
carisoprodol/aspirin
SOMA COMPOUND
chlorzoxazone
PARAFON FORTE DSC
cyclobenzaprine hcl
FLEXERIL
dantrolene sodium
DANTRIUM
metaxalone
SKELAXIN
804PA, apr 2016
ROBAXIN
ROBAXIN-750
orphenadrine citrate
NORFLEX
orphenadrine/aspirin/caffeine
NORGESIC FORTE
tizanidine hcl
ZANAFLEX
UPPER GASTROINTESTINAL DISORDERS - DIGESTIVE
Pancreatic Enzymes
amylase/lipase/protease
PANCRELIPASE 5,000
amylase/lipase/protease
CREON
ULTRASE
ULTRASE MT
ZENPEP
UPPER GASTROINTESTINAL DISORDERS - SPASTIC DISEASE
Anticholinergics/Antispasmodics
dicyclomine hcl
BENTYL
Belladonna Alkaloids
belladonna alkaloids/phenobarb DONNATAL
hyoscyamine sulfate
ANASPAZ
LEVBID
LEVSIN-SL
UPPER GASTROINTESTINAL DISORDERS - ULCER DISEASE
Anti-Ulcer Preparations
misoprostol
CYTOTEC
sucralfate
CARAFATE
Anti-Ulcer-H.pylori Agents
lansoprazole/amox tr/clarith
PREVPAC
Anticholinergics, Quaternary Ammonium
chlordiazepoxide/clidinium br
LIBRAX
Histamine H2-Receptor Inhibitors
cimetidine hcl
TAGAMET
famotidine
PEPCID
nizatidine
AXID
ranitidine hcl
TALADINE
ZANTAC
famotidine
PEPCID RPD
ranitidine hcl
ZANTAC 25
Intestinal Motility Stimulants
metoclopramide hcl
REGLAN
METOCLOPRAMIDE HCL
INTENSOL
Proton-Pump Inhibitors
esomeprazole magnesium
NEXIUM
lansoprazole
ST
PREVACID
omeprazole
PRILOSEC
omeprazole magnesium
PRILOSEC OTC
pantoprazole sodium
PROTONIX
ST
lansoprazole
PREVACID SOLUTABS
URINARY TRACT - FUNCTIONAL DISORDERS
Benign Prostatic Hypertrophy/Micturition Agents
alfuzosin
UROXATRAL
GEN finasteride
PROSCAR
tamsulosin hcl
FLOMAX
GEN, dutasteride
AVODART
ST
Benign Prostatic Hypertrophy, 5-alpha red. Inhib & alpha-1
antag combination agents
GEN, dutasteride/tamsulosin
JALYN
ST
Kidney Stone Agents
PA cysteamine bitartrate
PROCYSBI
Overactive Bladder Agents, Beta-3 Adrenergic Recep
mirabegron
MYRBETRIQ
Urinary Tract Analgesic Agents
pentosan polysulfate sodium
ELMIRON
Urinary Tract Anesthetic/Analgesic Agent (Azo-Dye)
phenazopyridine hcl
PYRIDIUM
Urinary Tract Antispasmodic, M(3) Selective Antag.
17
STATE OF MICHIGAN COMMERCIAL FORMULARY
APRIL 2016
solifenacin succinate
VESICARE
Urinary Tract Antispasmodic/Antiincontinence Agent
oxybutynin chloride
DITROPAN XL
tolterodine tartrate (IR)
DETROL
tolterodine tartrate (LA)
DETROL LA
fesoterodine fumarate
TOVIAZ
VAGINAL DISORDERS
Vaginal Antibiotics
metronidazole
METROGEL-VAGINAL
VANDAZOLE
Vaginal Antifungals
miconazole nitrate
MONISTAT 3
butoconazole nitrate
GYNAZOLE-1
Vaginal Estrogen Preparations
estradiol
ESTRACE
estradiol vaginal tablets
VAGIFEM
estrogens, conjugated
PREMARIN
Vaginal Sulfonamides
sulfanilamide
AVC
VITAMIN AND/OR MINERAL DEFICIENCY
Fluoride Preparations
sodium fluoride
FLUORITAB
FLURA-DROPS
FLURA-TABS
LURIDE
Folic Acid Preparations
folic acid
FOLIC ACID
Multivitamin Preparations
folic acid/mu-vits-min th
VICON FORTE
multivitamins with min no.7/fa 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 w/fe fum/fa
PRENAVITE (proteincoated) (OTC)
Vitamin B Preparations
cyanocobalamin/fa/pyridoxine
FOLGARD RX
Vitamin D Preparations
calcitriol
ROCALTROL
ergocalciferol
DRISDOL
dihydrotachysterol
DHT
804PA, apr 2016
18
STATE OF MICHIGAN COMMERCIAL FORMULARY
APRIL 2016
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 12
HEPATITIS C
Hepatitis C Treatment Agents
Page 14
HUMAN GROWTH FACTORS
Growth Hormones
Page 11
LOW MOLECULAR WEIGHT HEPARINS
Heparin and Related Preparations
Page 12
MULTIPLE SCLEROSIS
Agents to Treat Multiple Sclerosis
Page 16
RHEUMATOID ARTHRITIS
Anti-Inflammatory, TNF Inhibitors and Others
Page 14












MEDICATION PRESCRIBING LIMITATIONS
1.
2.
3.
4.
5.
AGE RESTRICTION (FORMULARY)

Differin

Fabior
AGE RESTRICTIONS (NON-FORMULARY)

Oracea

Retin A

Retin A Micro

Retin A Micro Pump

Solodyn
Covered for ages:
≤ 25 years old
≥ 12 years old



Covered for ages:
> 18 years old
≤ 25 years old
≤ 25 years old
≤ 25 years old
>12 years


GENDER RESTRICTIONS (FORMULARY)
Male only

Avodart
Male only

Cialis
Male only

Jalyn
Male only

Levitra
Male only

Staxyn
Male only

Stendra
Male only

Viagra



GENDER RESTRICTIONS (NON-FORMULARY)
Male only

Rapaflo

QUANTITY RESTRICTIONS (FORMULARY)
1 unit/month
 Advair Diskus
1 unit/month

Advair HFA
24 packets per 30 days

Aldara
240 capsules per 30 days

Alecensa

Alendronate Sodium
4 tablets/month
35mg and 70mg
30 tablets/month
5mg, 10mg, 40mg
4 vials/month
Solution
30 tablets/month

Ambien
30 tablets/month

Ambien CR

Androgel
150g/month
2.5g packet
300g/month
5g packet
150g/month
Pump (1.62%)
Pump (1%)
300g/month
120tablets/30days

Androxy
1 inhaler/month
 Asmanex
10 syringes per 30 days

Arixtra
2 bottles/month

Astelin
2 bottles/month

Astepro
2 inhalers/28days

Atrovent HFA
 Avinza
30mg, 45mg, 60mg, 75mg,
1 capsule per day
90mg
804PA, apr 2016
120mg
Axiron
Azilect
Breo Ellipta
Brilinta
Caduet
Cafergot
Cayston
Cialis 2.5mg
Cialis 5mg
Cialis 10mg & 20mg
Climara Patch
Combipatch
Corlanor
Cotellic
Crestor
Daliresp
Delatestryl syringe (1mL)
Delatestryl vial (5mL)
Depo-Testosterone
1ml vial
10ml vial
Diastat
Dulera
Duragesic
Effient
Eliquis
Estradiol Patches
Estraderm Patch
Evista
Fentanyl citrate lozenge
Flonase
Flunisolide
Forteo



































19
Fragmin
Glyxambi
Hydrocodone/acetaminophen
Humulin N
Vial
Kwikpen
Humulin R
100u/mL
500u/mL
Humulin 70/30
Vial
Kwikpen
Humalog
vial
pen/cartridge
Humalog Mix 50/50 / 75/25
vial
Kwikpen
Imitrex
6mg/0.5ml Kit and Refill
Kit
6mg/0.5ml Vial
Tablet (all strengths)
Nasal Spray
Invokamet
Invokana
Janumet
Janumet XR
100-1000mg
50-1000mg
50-500mg
Januvia
Jardiance
Jentadueto
Juxtapid
Kalydeco
Korlym
Lantus
vial
Solostar
Lovaza
Lovenox
Lunesta
Lynparza
Maxalt / MLT
2 capsules per day
2 bottles/month
30 tablets/30days
60 units/30 days
60 tablets/month
30 tablets/month
40 tablets/28 days
84mL/56 days
30 tablets/month
30 tablets/month
12 tablets/month
4 patches/month
8 patches/month
60 tablets per 30 days
63 tablets per 28 days
30 tablets/30 days
30 tablets/month
2 syringes/month
1 vial/month
4 vials/month
1 vial/month
One twin pack/month
1 inhaler/month
10 patches/month
30 tablets/month
60 tablets per 30 days
4 patches/month
8 patches/month
30 tablets/month
120 lozenges/month
1 unit/month
1 unit/month
2.4mls (1 pen)/28 days with a
max duration of 2 years per
lifetime
10 syringes per 30 days
30 tablets per 30 days
Maximum of 4gm of
acetaminophen per day
40mL (4 vials) per 28 days
30mL (10 pens) per 28 days
40mL (4 vials) per 28 days
40mL (2 vials) per 28 days
40mL (4 vials) per 28 days
30mL (10 pens) per 28 days
40mL (4 vials) per 28 days
30mL (10 pens/cartridges) per
28 days
40mL (4 vials) per 28 days
30mL (10 pens) per 28 days
4 kits/month
4 vials/month
18 tablets/month
12 sprays/month
60 tablets per 30 days
30 tablets/month
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
30 tablets per 30 days
60 tablets per 30 days
30 capsules per 30 days
2 tablets/day
120 tablets/month
40mL (4 vials) per 28 days
30mL (10 pens) per 28 days
120 capsules/month
20 syringes per 30 days
30 tablets/month
16 capsules per day
18 tablets/month
STATE OF MICHIGAN COMMERCIAL FORMULARY
APRIL 2016



Migergot suppositories
MS Contin
Narcan Nasal




Nasacort AQ
Nasarel
Nasonex
Nilandron





20 units per 28 days
90 tablets per 30 days
2 boxes (4 nasal sprays per 30
days
1 unit/month
1 bottle/month
1 unit/month
2 tablets/day for the first 30
days, then 1 tablet/day
thereafter
180 tablets/30 days
60 tablets/30 days
1 ring/28 days
3 patches/28 days
Vial
Solostar/cartridge

Aptiom
200, 400mg
600, 800mg

Arcapta

Arnuity Ellipta

Atelvia

Aubagio

Auryxia

Axert

Banzel 200mg

Banzel 400mg

Banzel solution

Basaglar

Beconase AQ

Belbuca

Belsomra

Berinert

Binosto
 Brisdelle

Brovana

Butrans

Bydureon/Bydureon Pen

Byetta
5mcg
10mcg

Cambia

Caverject

Clarinex
Tablets
Syrup

Clarinex-D
12 HR
24 HR

Climara Pro Patch

Conzip

Demerol

Demerol solution

D.H.E. 45 injection

Duexis

Dymista

Edex

Edluar

Egrifta

Entresto

Epaned

Ergomar

Estring

Evzio

Farxiga

Felbatol 400mg

Felbatol 600mg

Felbatol solution

Femring

Fentora

Firmagon 80mg/vial

Firmagon 120mg/vial

Flovent Diskus
50mcg and 100mcg
250mcg

Flovent HFA
44mcg and 220 mcg
110 mcg

Foradil

Fortesta

Frova

Fycompa
2mg
4mg, 6mg

8mg, 10mg, 12mg

Gabitril 2mg, 4mg, 12mg

Gabitril 16mg

Gilenya

Gralise 300mg, 600mg

Gralise starter pack

Hemangeol

Horizant 600mg

Hycofenix

Hydrocodone/acetaminophen
Nucynta
Nucynta ER
Nuvaring
Ortho Evra
Oxycontin
10mg, 15mg, 20mg, 30mg,
60 tablets per 30 days
40mg, 60mg
120 tablets per 30 days
80mg

Oxycodone/acetaminophen [maximum of 4gm acetaminophen
per day]
60 vials/month

Perforomist
3 tubes (0.015%); 2 tubes

Picato
(0.05%)
4 tablets per 30 days

Plavix 300mg tablet
1 inhaler per 30 days

Pulmicort Flexhaler
30 units/month

Pulmicort Respules
2 ampules/day

Pulmozyme
1 canister/30 days

QNasl
1 unit/month

QVAR
120 tablets/30 days

Ranexa 500mg tablet
60 tablets/30 days

Ranexa 1000mg tablet
1 capsule per day

Revlimid
91 tablets/84 days

Seasonale
1 unit/month

Serevent Diskus

Simcor 500/20, 500/40, 1000/40 30 tablets/month
60 tablets/month

Simcor 750/20, 1000/20
30 capsules/month

Sonata
30 units/month

Spiriva
4g (60 inhalations) per 30 days

Stiolto Respimat
4g (1 inhaler) per 30 days

Striverdi Respimat
60 capsules per 30 days

Synjardy
1 tablet per day

Tagrisso
30 tablets per 30 days

Tradjenta
56 units/56 days

Tobi/Tobi Podhaler
7.5mL (5 pens) per 28 days

Toujeo
2mL (4 pens) per 28 days

Trulicity
120 capsules/month

Vascepa
12 tablets/month

Viagra
9ml(3pens)/30 days

Victoza
8 patches/month

Vivelle-DOT Patch

Xarelto
30 tablets/month
10mg and 20mg
42 tablets for the first 21 days,
15mg
followed by 30 tablets/month
30 tablets/month
 Zetia

Zomig / ZMT
12 tablets/month
Tablet
12 sprays/month
Nasal Spray
6.
QUANTITY RESTRICTIONS (NON-FORMULARY)
120 tablets/month

Abstral
120 lozenges/month

Actiq

Actonel
30 tablets/month
5mg and 30mg
1 tablet/week
35mg
1 tablet/month
150mg
30 tablets/month

Advicor 500/20 or 1000/40
60 tablets/month

Advicor 750/20 or 1000/20
17.8g (2 inhalers) per 30 days

Aerospan

Afrezza
4 unit
180 cartridges (2 kits) per 28 days
30-4 unit + 60-8 unit
360 cartridges (4 kits) per 28 days
60-4 unit + 30-8 unit
360 cartridges (4 kits) per 28 days
60-8 unit + 30-12 unit
360 cartridges (4 kits) per 28 days

Allegra
30mg/5ml oral susp

Alsuma

Altoprev

Alvesco

Androderm 2mg & 4mg patches

Anoro Ellipta
 Apidra
804PA, apr 2016
40mL (4 vials) per 28 days
30mL (10 pens/cartridges) per
28 days
300ml/month
4 units/month
30 tablets/month
2 inhalers/25 days
30 patches/month
60 blister packs per 30 days
20
30 tablets per 30 days
60 tablets per 30 days
30 capsules/month
30 blister packs per 30 days
1 tablet/week
28 tablets/28days
12 tablets/day
12 tablets/month
480 tablets/month
240 tablets/month
2400mL/month
30mL (10 pens) per 28 days
1 unit/month
2 buccal films per day
30 tablets per 30 days
4 units/365 days
4 tablets/28 days
30 capsules/30 days
60 vials/month
4 patches/28 days
4 vials or 4 pens/28 days
1.2mL (1 pen) per 30 days
2.4mL (1 pen) per 30 days
9 packets/30 days
1 unit/5 days
30 tablets/month
300ml/month
60 tablets/month
30 tablets/month
4 patches/month
30 capsules/month
180 tablets/month
900mL/30 days
30 units/28 days
90 tablets/month
1 bottle/month
1 unit/3 days
30 tablets/month
60 vials/30 days
60 tablets per 30 days
1200mL per 30 days
40 tablets/28 days
1 unit/90 days
0.8mL (2 syringes) per 365 days
30 tablets per 30 days
270 tablets/month
180 tablets/month
900mL/month
1 ring/90 days
120 tablets/month
1 vial/month
2 vials/365 days
1 diskus
2 diskus
2 inhalers/month
1 inhaler/month
60 units/month
2 bottles/month
18 tablets/month
120 tablets per 30 days
60 tablets per 30 days
30 tablets per 30 days
120 tablets/month
90 tablets/month
1 capsule/day
90 tablets/month
78 tablets/month
360mL (3 bottles) per 30 days
60 tablets/month
473mL (1 bottle) per 30 days
maximum of 4gm
acetaminophen per day
STATE OF MICHIGAN COMMERCIAL FORMULARY
APRIL 2016






















































Hysingla ER
Incruse Ellipta
Intermezzo
Iprivask
Kadian
10mg, 20mg, 30mg, 40mg,
50mg, 60mg, 70mg, 80mg,
100mg, 130mg, 150mg
200mg
Karbinal ER
Kazano
Kombiglyze XR
2.5-1000mg
5-500mg, 5-1000mg
30 tablets per 30 days
30 blisters per 30 days
30 tablets/month
6 syringes/30 days
Lamictal ODT 25mg or 50mg
Lamictal ODT 100
Lamictal ODT 200mg
Lamictal XR 25mg or 50mg
Lamictal XR 100
Lamictal XR 200mg, 250mg, or
300mg
Lescol
Lescol XL
Levemir
vial
Flextouch
Levitra
Liptruzet
Livalo
Lo-Seasonique
Menostar Patch
Migranal nasal spray
Muse
Nesina
Novolin N/Novolin R/ Novolin
70/30
Novolog
Vial
Flexpen/cartridge
180 tablets/month
90 tablets/month
60 tablets/month
180 tablets/month
90 tablets/month
60 tablets/month

Silenor

Sotylize
250mL
480mL

Sprix

Staxyn

Stendra

Striant

Sucraid

Sumavel DosePro

Symbicort
 Tanzeum

Testim

Tivorbex

Tresiba (100 U)

Tresiba (200 U)

Treximet

Trezix

Trokendi XR
25mg, 50mg, 100mg
200mg

Tudorza

Tuzistra XR

Utibron Neohaler
60 capsules per 30 days
120 capsules per 30 days
960mL (2 bottles) per 30 days
60 tablets per 30 days
60 tablets per 30 days
30 tablets per 30 days
60 capsules/30 days
30 tablets/30 days
40mL (4 vials) per 28 days
30mL (10 pens) per 28 days
12 tablets/month
30 tablets/30 days
30 tablets/month
91 tablets/84 days
4 patches/month
8 vials/28 days
1 unit/3 days
30 tablets per 30 days
40mL (4 vials) per 28 days











Veramyst
Vimpat
Vytorin
Xartemis XR
Xigduo XR
Xyzal 2.5mg/5ml oral soln
Zecuity
Zetonna
Zipsor
Zohydro ER
Zolpimist
 Zontivity

Zorvolex

Zyclara
40mL (4 vials) per 28 days
30mL (10 pens/cartridges) per
28 days
Novolog Mix 70/30
40mL (4 vials) per 28 days
Vial
30mL (10 pens) per 28 days
Kwikpen
600mL per 10 days
Obredon
1 unit/month
Omnaris
Onfi
60 tablets per 30 days
Tablets
480mL per 30 days
Suspension
30 tablets per 30 days
Onglyza
Opana ER
5mg, 7.5mg, 10mg, 15mg, 20mg 60 tablets per 30 days
120 tablets per 30 day
30mg, 40mg
30 tablets per 30 days
Oseni
Osphena

30 tablets/month
Otrexup

1.6mL per 28 days
Oxycodone/acetaminophen [maximum of 4gm acetaminophen per
day]
30.5g (1 bottle) per 30 days
Patanase
270 tablets/month
Potiga 50mg
90 tablets/month
Potiga 200mg, 300mg, 400mg
60 tablets/30 days
Pradaxa
Rasuvo
1.6mL (4 syringes) per 28 days
7.5mg/0.15mL
0.8mL (4 syringes) per 28 days
10mg/0.2mL
1mL (4 syringes) per 28 days
12.5mg/0.25mL
1.2mL (4 syringes) per 28 days
15mg/0.3mL
1.4mL (4 syringes) per 28 days
17.5mg/0.35mL
1.8mL (4 syringes) per 28 days
22.5mg/0.46mL
2mL (4 syringes) per 28 days
25mg/0.5mL
2.2mL (4 syringes) per 28 days
27.5mg/0.55mL
2.4mL (4 syringes) per 28 days
30mg/0.6mL
12 tablets/month
Relpax
5 canisters/75 days
Rhinocort Aqua
30 tablets/month
Rozerem
180 tablets/month
Sabril
30mL (10 pens) per 28 days
Ryzodeg 70/30
15mg tablet: 30 tablets/365
Samsca
days
30mg tablet:60 tablets/365 days
30 tablets per 30 days
Savaysa
91 tablets/84 days
Seasonique
60 blister packs (1 Seebri
Seebri Neohaler
804PA, apr 2016
inhaler) per 30 days
30 capsules/month
2000mL (8 bottles) per 30 days
3840mL (8 bottles) per 30 days
5 bottles/month
12 tablets/month
12 tablets/month
60 buccal/month
8mL/day
4 injections/month
1 unit/month
4 pens per 28 days
60 packets/month
90 capsules per 30 days
30 mL (10 pens) per 28 days
18 mL (6 pens) per 28 days
9 tablets/month
10 capsules per day
30 capsules per 30 days
60 capsules per 30 days
1 inhaler/month
600mL per 30 days
60 blister packs (Utibron
Inhaler) per 30 days
1 bottle/30 days
60 tablets/month
30 tablets/month
360 tablets per 30 days
60 tablets per 30 days
300ml/month
1 carton per 28 days
1 aerosol unit/month
120 capsules per 30 days
60 capsules per 30 days
1 pump/month
30 tablets per 30 days
90 capsules per 30 days
2.5%: 7.5 grams (1 bottle) per
28 days.
3.75% pump:7.5 grams (1
bottle) per 28 days
3.75% packet: 28 packets per
28 days
7. STEP THERAPY RESTRICTIONS (FORMULARY)


Ambien CR
Azor

Benicar /
HCT
Prior prescription for an ACE inhibitor or ACE
inhibitor combination or formulary generic ARB or
ARB combination within the past 120 days.

Diovan
Prior prescription for an ACE inhibitor or ACE
inhibitor combination or formulary generic ARB or
ARB combination within the past 120 days.

Exforge /
HCT
Prior prescription for an ACE inhibitor or ACE
inhibitor combination or formulary generic ARB or
ARB combination within the past 120 days.
 Fuzeon
 Invirase
 Prevacid
Solutabs

QNasl

21
Previous prescription for zolpidem within the past
180 days is required.
Prior prescription for an ACE inhibitor or ACE
inhibitor combination or formulary generic ARB or
ARB combination within the past 120 days.
Tribenzor

Vitekta

Zomig /
ZMT and
Zomig
Nasal
Trial of any antiretroviral medication within the
past 30 days
Trial of Isentress, Reyataz, Prezista or Atripla
(new starts only)
Trial of lansoprazole, omeprazole or pantoprazole
within the past 120 days
Previous prescription for fluticasone or flunisolide
nasal product within the past 365 days.
Prior prescription for an ACE inhibitor or ACE
inhibitor combination or formulary generic ARB or
ARB combination within the past 120 days.
Trial of previous HIV anti-retroviral therapy within
the past 120 days
Previous prescription for sumatriptan or rizatriptan
within the past 180 days is required.
STATE OF MICHIGAN COMMERCIAL FORMULARY
APRIL 2016
 Treximet
8. STEP THERAPY
RESTRICTIONS (NONFORMULARY)
 Aciphex
 Aciphex Sprinkle
 Actonel
 Atelvia
 Axert
 Beconase AQ
 Belsomra
 Binosto
 Dexilant/Kapidex
 Dymista
 Edarbi
 Edarbyclor
 Edluar
 Epaned
 Esomeprazole Strontium
 Frova
 Hemangeol
 Intermezzo

 Neo-Synalar
 Omnaris
 Relpax
 Rhinocort Aqua
 Rozerem
 Silenor
 Sitavig
 Sotylize
 Sumavel DosePro
 Teveten / HCT
804PA, apr 2016
 Veramyst
Previous prescription for omeprazole,
lansoprazole, pantoprazole or
rabeprazole within the past 120 days.
Trial of two of the following; omeprazole,
lansoprazole, pantoprazole or
rabeprazole within the past 365 days
Previous prescription for alendronate and
ibandronate within the past 365 days is
required.
Previous prescription for alendronate and
ibandronate within the past 365 days is
required.
Previous prescription for sumatriptan or
rizatriptan within the past 180 days
required.
Previous prescription for fluticasone or
flunisolide nasal product within the past
365 days.
Trial of zolpidem IR (Ambien), zaleplon
(Sonata) or eszopiclone (Lunesta) within
the past 120 days
Previous prescription for alendronate and
ibandronate within the last 365 days
required.
Previous prescription for omeprazole,
lansoprazole or pantoprazole within the
past 120 days
Previous prescription for fluticasone or
flunisolide nasal product within the past
365 days.
Prior prescription for an ACE inhibitor or
ACE inhibitor combination or formulary
generic ARB or ARB combination within
the past 120 days.
Prior prescription for an ACE inhibitor or
ACE inhibitor combination or formulary
generic ARB or ARB combination within
the past 120 days.
Previous prescription for zolpidem within
the past 180 days is required.
If age ≥ 12 years, trial of enalapril tablets
within the past 120 days
Trial of omeprazole, lansoprazole or
pantoprazole within the past 120 days
Previous prescription for sumatriptan or
rizatriptan within the past 180 days is
required.
For age over 1 year, trial of generic
propranolol oral solution within the past
120 days
Previous prescription for zolpidem IR
(Ambien) within the past 120 days.
 Vimovo
 Xerese
 Zecuity
 Zegerid
 Zetonna
 Zolpmist
9.
Trial of fluocinolone and bacitracin within
the past 365 days
Previous prescription for fluticasone or
flunisolide nasal product within the past
365 days.
Previous prescription for sumatriptan or
rizatriptan in the past 180 days is
required.
Previous prescription for fluticasone or
flunisolide nasal product within the past
365 days.
Trial of zolpidem IR (Ambien), zaleplon
(Sonata) or eszopiclone (Lunesta) within
the past 120 days
Trial of zolpidem IR (Ambien), zaleplon
(Sonata) or eszopiclone (Lunesta) within
the past 120 days
Trial of oral acyclovir, valacyclovir or
famciclovir within the past 120 days
Trial of sotolol tablets within the past 120
days
Previous prescription for generic or
multisource injectable or nasal
sumatriptan (Imitrex or equivalent) within
the past 180 days.
Prior prescription for an ACE inhibitor or
ACE inhibitor combination or formulary
generic ARB or ARB combination within
the past 120 days.
22
Previous prescription for sumatriptan
within the past 180 days is required.
Previous prescription for fluticasone or
flunisolide nasal product within the past
365 days.
Previous prescription for generic
naproxen required in the past 120 days.
Trial of oral acyclovir, valacyclovir or
famciclovir within the past 120 days
Trial of generic/multisource sumatriptan
and nasal sumatriptan within the past
365 days
Previous prescription for omeprazole,
lansoprazole, or pantoprazole within the
past 120 days is required.
Previous prescription for fluticasone or
flunisolide nasal product within the past
365 days.
Previous prescription for zolpidem IR
within the past 120 days is required.
PA RESTRICTIONS (FORMULARY)

Adcirca

Adempas

Afinitor, Afinitor Disperz

Aldara

Alecensa

Avonex

Bosulif

Cayston

Cometriq

Copaxone

Corlanor

Cosentyx

Cystaran

Daraprim

Duragesic

Eligard

Enbrel

Erivedge

Esbriet

Fareston

Farydak

Fentanyl citrate lozenge

Firazyr

Gattex

Gilenya

Gilotrif

Gleevec

Grastek

Harvoni

Humira

Ibrance

Iclusig

Imbruvica

Inlyta

Intron A

Iressa

Jakafi

Juxtapid

Kalydeco

Keveyis

Korlym

Kynamro

Kuvan

Lenvima

Letairis

Leukine

Lonsurf

Lynparza

Menkinist

Neulasta

Neupogen

Nexavar

Ninlaro

Norditropin, Norditropin Flexpro, Norditropin
Nordiflex

Odomzo

Ofev

Omnitrope

Opsumit

Oralair

Orkambi
STATE OF MICHIGAN COMMERCIAL FORMULARY
APRIL 2016












































10.

















































































Pegasys
Plegridyl, Plegridyl Pen
Pomalyst
Procrit
Procysbi
Promacta
Provigil
Pulmozyme
Revlimid
Ragwitek
Rebif
Revatio tablet
Sovaldi
Sivextro
Sprycel
Stelara
Stivarga
Strensiq
Suboxone
Subutex Sutent
Tafinlar
Tagrisso
Tarceva
Targretin
Tasigna
Tecfidera
Temodar capsules
Thalomid
Tobi/Tobi Podhaler
Tracleer
Tybost
Tykerb
Uptravi
Valchlor
Votrient
Xalkori
Xeloda
Xenazine
Xtandi
Zelboraf
Zydelig
Zykadia
Zytiga
Zyvox
PA RESTRICTIONS (NON-FORMULARY)

Abraxane

Abstral

Actemra Iv

Actemra Sc

Actiq

Adcetris

Addyi

Alimta

Amevive

Ampyra

Apokyn

Aranesp

Arzerra

Avastin

Aubagio

Beleodaq

Belviq

Berinert

Betaseron

Bethkis

Bivigam

Blincyto

Bunavail

Caprelsa

Carimune Nf Nanofiltered

Cerezyme

Cholbam

Cimzia

Cinryze

Contrave

Cosentyx

Cyramza

Daklinza
804PA, apr 2016
23
Darzalex
Duopa
Dysport
Egrifta
Elelyso
Elspar
Empliciti
Entresto
Entyvio
Epogen
Erbitux
Erwinaze
Evekeo
Exalgo
Extavia
Faslodex
Fentora
Flebogamma Dif
Flolan/Veletri
Gamastan S-D
Gammagard
Gammagard S-D
Gammaked
Gammaplex
Gamunex-C
Gazyva
Genotropin
Granix
Halaven
Herceptin
Hetlioz
Hizentra
H.P. Acthar
Humatrope
Imlygic
Increlex
Istodax
Ixempra
Jublia
Kadcyla
Kalbitor
Kanuma
Kitabis Pak
Keytruda
Kineret
Kyprolis
Lazanda
Lemtrada
Lumizyme
Marqibo
Mircera
Mozobil
Natpara
Novatrone
Nucala
Nuedexta
Nutropin, Nutropin Aq, Nutropin Aq Nuspin
Nuvigil
Nymalize
Octagam
Olysio
Omontys
Oncaspar
Onivyde
Onsolis
Opdivo
Orencia IV
Orencia SC
Orenitram
Otezla
Pegintron
Perjeta
Photofrin
Portrazza
Praluent
Privigen
Prolia
Qutenza
Qsymia
Ravicti
Remicade
STATE OF MICHIGAN COMMERCIAL FORMULARY
APRIL 2016


















































11.
Remodulin
Repatha
Revatio Liquid
Revatio Vial
Rituxan
Saizen
Saxenda
Serostim
Simponi SC
Simponi Aria IV
Solaraze
Soliris
Stelara
Subsys
Sucraid
Suprenza ODT
Sylatron
Sylvant
Synagis
Synribo
Technivie
Temodar (Vial)
Tev-Tropin
Thyrogen
Torisel
Tysabri
Tyvaso
Unituxin
Vecamyl
Vectibix
Velcade
Ventavis
Viekira Pak
Vimizim
Vpriv
Xeljanz
Xeomin
Xgeva
Xolair
Xyrem
Yervoy
Yondelis
Zaltrap
Zarxio
Zavesca
Zepatier
Zoladex
Zorbtive
Zubsolv
Zyclara
SHORT CYCLE COPAY PRODUCTS

Afinitor

Erivedge

Gleevec

Inlyta

Jakafi

Nexavar

Xalkori

Sprycel

Sutent

Tarceva

Targretin

Tasigna

Votrient

Zelboraf

Zolinza

Zytiga
804PA, apr 2016
24
STATE OF MICHIGAN COMMERCIAL FORMULARY
APRIL 2016
INDEX
1st Gen Antihistamine & Decongestant
Combinations ................................................. 8
2nd Gen Antihistamine & Decongestant
Combinations ................................................. 5
5-grass pollen extract ........................................... 5
8-MOP .................................................................. 9
abacavir sulfate ................................................ 13
abacavir sulfate/lamivudine ................................ 13
abacavir/dolutegravir/lamivudine ....................... 14
abacavir/lamivudine/zidovudine ..................... 13
ABBOTT DIABETIC SUPPLIES......................... 10
ABILIFY ................................................................ 6
abiraterone ......................................................... 15
Absorbable Sulfonamides .................................. 12
ACANYA ............................................................... 8
acarbose .............................................................. 9
ACCUPRIL ........................................................... 7
ACCURETIC......................................................... 6
ACCUTANE .......................................................... 8
Ace Inhibitor/Calcium Channel Blocker
Combination ................................................... 6
Ace Inhibitor/Thiazide & Thiazide-Like Diuretic ... 6
acebutolol hcl ..................................................... 7
acetaminophen with codeine .......................... 17
acetazolamide ................................................... 11
acetic acid ......................................................... 10
acetic acid/aluminum acetate ......................... 10
acetic acid/hydrocortisone .............................. 10
acetylcysteine ................................................... 16
acitretin ................................................................. 9
ACLOVATE .......................................................... 9
Acne Agents, Systemic ........................................ 8
Acne Agents, Topical ........................................... 8
ACTIGALL .......................................................... 15
ACTIQ ................................................................. 16
ACTOPLUS MET ............................................... 10
ACTOPLUS MET XR ......................................... 10
ACTOS ................................................................. 9
ACULAR ............................................................. 11
ACULAR LS........................................................ 11
acyclovir .......................................................... 9, 13
ADALAT CC ......................................................... 7
adalimumab ........................................................ 14
adapalene ............................................................ 8
ADCIRCA ............................................................. 7
ADDERALL........................................................... 6
ADDERALL XR .................................................... 6
adefovir dipivoxil ................................................. 14
ADEMPAS ............................................................ 7
ADOXA ............................................................... 13
Adrenergic Vasopressor Agents .......................... 8
Adrenergics, Aromatic, Non-Catecholamine ........ 6
ADVAIR DISKUS .................................................. 5
ADVAIR HFA ........................................................ 5
afatinib ................................................................ 15
AFINITOR ........................................................... 15
AFINITOR DISPERZ .......................................... 15
Agents To Treat Multiple Sclerosis .................... 16
AGRYLIN ............................................................ 12
AK-TRACIN ........................................................ 11
AKYNZEO ............................................................ 5
ALAMAST ........................................................... 11
ALA-TET ............................................................. 13
ALAWAY OTC .................................................... 11
albuterol sulfate .................................................. 5
ALBUTEROL SULFATE ....................................... 5
alclometasone dipropionate ............................. 9
ALDACTONE ....................................................... 7
ALDARA ............................................................. 12
ALDOMET ............................................................ 7
ALECENSA ........................................................ 15
alectinib hydrochloride........................................ 15
alendronate sodium ......................................... 10
alendronate sodium/vitamin d3 .......................... 10
alfuzosin ............................................................. 17
ALKERAN ........................................................... 15
Alkylating Agents ................................................ 15
ALLEGRA ............................................................. 5
ALLEGRA-D 12 HOUR ........................................ 5
ALLEGRA-D 24 HOUR ........................................ 5
ALLERGY ............................................................. 5
allopurinol ......................................................... 12
804PA, apr 2016
ALOCRIL ............................................................ 11
ALOMIDE ........................................................... 11
ALORA ............................................................... 12
Alpha/Beta-Adrenergic Blocking Agents .............. 6
Alpha-2 Receptor Antagonist Antidepressants .... 5
Alpha-Adrenergic Blocking Agents ...................... 6
ALPHAGAN P .................................................... 11
alprazolam ........................................................... 6
ALPRAZOLAM INTENSOL .................................. 6
ALREX ................................................................ 11
ALTACE................................................................ 7
altretamine .......................................................... 15
aluminum chloride ............................................. 9
ALUPENT ............................................................. 5
Alzheimer's Therapy, Nmda Receptor Antagonists
........................................................................ 5
amantadine hcl ................................................. 17
AMARYL ............................................................... 9
AMBIEN ................................................................ 6
AMBIEN CR.......................................................... 6
ambrisentan .......................................................... 7
amcinonide.......................................................... 9
Amebacides ........................................................ 13
AMERGE ............................................................ 16
Aminoglycosides ................................................ 13
AMINOPHYLLIN ................................................... 5
aminophylline ..................................................... 5
amiodarone hcl ................................................... 6
AMITIZA ............................................................. 15
amitriptyline hcl .................................................. 6
amlodipine bes/olmesartan med .......................... 7
amlodipine besylate ........................................... 7
amlodipine besylate/benazepril ........................ 6
amlodipine/atorvast cal ..................................... 8
amlodipine/valsartan.......................................... 7
amlodipine/valsartan/hctz ................................. 7
Ammonia Inhibitors ............................................. 14
amox tr/potassium clavulanate ...................... 13
amoxapine ........................................................... 6
amoxicillin trihydrate ....................................... 13
AMOXIL .............................................................. 13
amphet asp/amphet/d-amphet .......................... 6
ampicillin trihydrate ......................................... 13
amylase/lipase/protease .................................. 17
Anaerobic Antiprotozoal-Antibacterial Agents ... 13
ANAFRANIL ......................................................... 6
anagrelide hcl ................................................... 12
Analgesic, Non-Salicylate & Barbiturate Comb. 16
Analgesic, Non-Salicylate, Barbiturate & Xanthine
Comb ............................................................ 16
Analgesic, Salicylate, Barbiturat & Xanthine Comb
...................................................................... 16
Analgesic/Antipyretics, Salicylates ..................... 16
Analgesics, Narcotics ......................................... 16
ANALPRAM HC ................................................. 14
Anaphylaxis Therapy Agents ............................. 15
ANAPROX .......................................................... 14
ANAPROX DS .................................................... 14
ANASPAZ ........................................................... 17
anastrozole ......................................................... 15
ANDROGEL ....................................................... 12
Androgenic Agents ............................................. 12
ANDROID ........................................................... 12
ANDROXY .......................................................... 12
Angioten. Receptr Antag./Cal. Chanl Blkr/Thiazide
Comb .............................................................. 7
Angiotensin Receptor Antag./Thiazide Diuretic
Comb .............................................................. 7
Angiotensin Receptor Antgnst & Calc. Channel
Blockr ............................................................. 7
ANSAID .............................................................. 14
ANTABUSE .......................................................... 6
Anthelmintics ...................................................... 13
anthralin ................................................................ 9
Anti-Alcoholic Preparations .................................. 6
Antiandrogenic Agents ....................................... 15
Antianginal & Anti-Ischemic Agents, NonHemodynamic ................................................ 8
Anti-Anxiety Drugs ................................................ 6
Antiarrhythmics ..................................................... 6
Anti-Arthritic & Chelating Agents ........................ 14
Anti-Arthritic, Folate Antagonist Agents ............. 14
25
Anticholinergics, Quaternary Ammonium........... 17
Anticholinergics/Antispasmodics ........................ 17
Anticoagulants, Coumarin Type ......................... 12
Anticonvulsants .................................................. 17
Antidiarrheals ..................................................... 14
Antidiuretic & Vasopressor Hormones ............... 10
ANTIEMESIS/ANTIVERTIGO .............................. 5
Antiemetic/Antivertigo Agents .............................. 5
Antifungal Agents ............................................... 13
Antifungal Antibiotics .......................................... 13
Antihistamines - 1st Generation ........................... 5
Antihistamines - 2nd Generation .......................... 5
Antihypergly, (DPP-4) Inhibitor & Biguanide
Comb. ............................................................. 9
Antihyperglycemic Insul-Resp. Enhancer &
Biguanide Comb ........................................... 10
Antihyperglycemic, Alpha-Glucosidase Inhib
(Non-Sulfonylurea) ......................................... 9
Antihyperglycemic, Amylin Analog-Type.............. 9
Antihyperglycemic, DPP-4 Inhibitors .................... 9
Antihyperglycemic, Insulin-Rel Stim.& Biguanide
Comb ............................................................ 10
Antihyperglycemic, Insulin-Release Stimulant
Type ............................................................... 9
Antihyperglycemic, Insulin-Response & Release
Comb. ........................................................... 10
Antihyperglycemic, Insulin-Response Enhancer
(Non-Sulfonylurea) ......................................... 9
Antihyperglycemic, Sodium/Glucose Cotransport2 (SGLT2) Inhibitor....................................... 10
Antihyperglycemic,Biguanide Type(NonSulfonylurea) .................................................. 9
Antihyperglycemic,Glucocorticoid Receptor
Antagonist ...................................................... 9
Antihyperglycemics, DPP-4 & Statin Combo ....... 9
Antihyperglycemics, Incretin Mimetic ................... 9
Antihyperlip - HMG-CoA & Calcium Channel
Blocker Comb ................................................. 8
Antihyperlipidemic - HMG CoA Reductase
Inhibitors ......................................................... 7
Antihyperlipidemic-Apo B 100 synthesis inhibitor 7
Antihyperlipidemic-HMG CoA Reductase Inhib. &
Niacin ............................................................. 7
Antihypertensives, ACE Inhibitors ........................ 7
Antihypertensives, Angiotensin Receptor
Antagonist ...................................................... 7
Antihypertensives, Sympatholytic ........................ 7
Antihypertensives, Vasodilators ........................... 7
Anti-inflam, Bradykinin B2 receptor antagonists 14
Anti-Inflammatory Tumor Necrosis Factor Inhibitor
...................................................................... 14
Anti-Inflammatory, Pyrimidine Synthesis Inhibitor
...................................................................... 14
Antileprotics ........................................................ 13
Antimalarial Drugs .............................................. 13
Anti-Mania Drugs .................................................. 6
Antimetabolites ................................................... 15
Antimigraine Preparations .................................. 16
Anti-Mycobacterium Agents ............................... 13
Antineoplastic - Topoisomerase I Inhibitors ....... 15
Antineoplastic Aromatase Inhibitors ................... 15
Antineoplastic Immunomodulator Agents .......... 15
Antineoplastic Systemic Enzyme Inhibitors ....... 15
Antineoplastic, Hedgehog Pathway Inhibitor ..... 15
Antineoplastic, Histone Deacetylase Inhibitors,
HDIS ............................................................. 15
Antineoplastic, Januse Kinase Inhib. ................. 15
Antineoplastics, Miscellaneous .......................... 15
Antiparkinsonism Drugs, Anticholinergic............ 17
Antiparkinsonism Drugs, Other .......................... 17
Antiperspirants ..................................................... 9
Antiprotozoal Drugs, Miscellaneous ................... 13
Antipsoriatic Agents, Systemic ............................. 9
Antipsoriatics Agents ............................................ 9
Antipsychotics, Atyp, D2 Partial Agonist/5HT
Mixed .............................................................. 6
Antipsychotics, Atypical, Dopamine,& Serotonin
Antag .............................................................. 6
Antipsychotics, Dopamine & Serotonin
Antagonists .................................................... 6
Antipsychotics, Dopamine Antagonists,
Butyrophenones ............................................. 6
STATE OF MICHIGAN COMMERCIAL FORMULARY
APRIL 2016
INDEX
Antipsychotics, Dopamine Antagonists,
Thioxanthenes ................................................ 6
Anti-Psychotics, Phenothiazines .......................... 6
antipyrine/benzocaine otic .................................. 10
Antiseborrheic Agents .......................................... 9
Antithyroid Preparations ..................................... 11
Antitubercular Antibiotics .................................... 13
Anti-Ulcer Preparations ...................................... 17
Anti-Ulcer-H.pylori Agents .................................. 17
ANTIVERT 12.5MG, 25MG .................................. 5
ANTIVERT 50MG ................................................. 5
Antiviral Comb Nucleoside, Nucleotide & NonNucleoside RTI............................................. 14
Antivirals, General .............................................. 13
Antivirals, HIV-1 Integrase Strand Transfer Inhibtr
...................................................................... 14
Antivirals, HIV-Spec, Non-Peptidic Protease Inhib
...................................................................... 13
Antivirals, HIV-Spec, Nucleoside-Nucleotide
Analog .......................................................... 13
Antivirals, HIV-Spec., Nucleoside Analog, RTI
Comb ............................................................ 13
Antivirals, HIV-Specific, CCR5 Co-Receptor
Antag. ........................................................... 13
Antivirals, HIV-Specific, Fusion Inhibitors .......... 13
Antivirals, HIV-Specific, Non-Nucleoside, RTI ... 13
Antivirals, HIV-Specific, Nucleoside Analog, RTI
...................................................................... 13
Antivirals, HIV-Specific, Nucleotide Analog, RTI 14
Antivirals, HIV-Specific, Protease Inhibitor Comb
...................................................................... 14
Antivirals, HIV-Specific, Protease Inhibitors ...... 14
ANUSOL-HC ...................................................... 14
APEXICON ........................................................... 9
APEXICON E ....................................................... 9
apixaban ............................................................. 12
Appetite Stim. For Anorexia, Cachexia, Wasting
Synd. ............................................................ 16
aprepitant .............................................................. 5
APRESOLINE ...................................................... 7
APRISO .............................................................. 14
APTIVUS ............................................................ 13
ARALEN PHOSPHATE ...................................... 13
ARAVA ............................................................... 14
ARICEPT .............................................................. 5
ARICEPT ODT ..................................................... 5
ARIMIDEX .......................................................... 15
aripiprazole ......................................................... 6
ARIXTRA ............................................................ 12
ARMOUR THYROID .......................................... 11
AROMASIN ........................................................ 15
ARTANE ............................................................. 17
ASENDIN .............................................................. 6
asfotase alfa., ..................................................... 16
ASMANEX ............................................................ 5
ASTELIN ............................................................... 5
ASTEPRO ............................................................ 5
ASTHMA ............................................................... 5
ATARAX ............................................................... 5
atazanavir sulfate ............................................... 14
atazanavir sulfate/cobicistat ............................... 14
atenolol ................................................................ 7
atenolol/chlorthalidone ...................................... 7
ATIVAN ................................................................. 6
atomoxetine hcl .................................................... 6
atorvastatin ......................................................... 7
ATRIPLA ............................................................. 14
atropine sulfate ................................................. 11
ATROVENT .................................................... 5, 16
ATROVENT HFA .................................................. 5
AUGMENTIN ...................................................... 13
AUGMENTIN ES-600 ......................................... 13
AUGMENTIN XR ................................................ 13
AUTONOMIC NERVOUS SYSTEM DISORDERS
........................................................................ 5
AVALIDE .............................................................. 7
AVAPRO............................................................... 7
AVC .................................................................... 18
AVELOX ............................................................. 13
AVELOX ABC PACK .......................................... 13
AVINZA ............................................................... 16
AVLOSULFON ................................................... 13
AVODART .......................................................... 17
AVONEX............................................................. 16
AXID ................................................................... 17
804PA, apr 2016
axitinib ................................................................ 15
AYGESTIN ......................................................... 12
azathioprine ...................................................... 12
azelastine hcl ................................................ 5, 11
AZILECT ............................................................. 17
azithromycin ..................................................... 12
AZOPT ................................................................ 11
AZOR .................................................................... 7
aztreonam, inhaled ............................................. 12
AZULFIDINE....................................................... 14
bacitracin........................................................... 11
bacitracin/polymyxin b sulfate........................ 11
baclofen ............................................................. 17
BACTRIM DS ..................................................... 12
BACTROBAN ....................................................... 8
BACTROBAN NASAL ........................................ 16
balsalazide disodium ....................................... 14
BARACLUDE ..................................................... 14
Barbiturates .......................................................... 6
becaplermin ........................................................ 10
beclomethasone dipropionate .............................. 5
BEHAVIORAL HEALTH - ANTIDEPRESSANTS 5
BEHAVIORAL HEALTH - OTHER ....................... 6
Belladonna Alkaloids .......................................... 17
belladonna alkaloids/phenobarb .................... 17
benazepril hcl ..................................................... 7
benazepril/hydrochlorothiazide ........................ 6
BENEMID ........................................................... 12
BENICAR .............................................................. 7
BENICAR HCT ..................................................... 7
Benign Prostatic Hypertrophy/Micturition Agents
...................................................................... 17
BENTYL .............................................................. 17
benz perox/hc/skin clnsr no.14 ......................... 8
BENZACLIN ......................................................... 8
BENZAMYCIN ...................................................... 8
BENZAMYCIN PAK .............................................. 8
BENZASHAVE ..................................................... 8
benzoyl peroxide ................................................ 8
benzoyl peroxide gel ............................................ 8
benzoyl peroxide shave cream ............................ 8
benzoyl peroxide/hydrocortison ........................... 8
benztropine mesylate ...................................... 17
Beta lactams, inhaled ......................................... 12
Beta-Adrenergic & Anticholinergic Combinations 5
Beta-Adrenergic & Glucocorticoid Combinations. 5
Beta-Adrenergic Agents ....................................... 5
Beta-Adrenergic Blocking Agents ........................ 7
Beta-Adrenergic Blocking Agents/Thiazide &
Related ........................................................... 7
BETAGAN .......................................................... 11
betamet diprop/prop gly .................................... 9
betamethasone dipropionate ............................ 9
betamethasone valerate .................................... 9
BETAPACE .......................................................... 7
BETAPACE AF ..................................................... 7
betaxolol hcl ..................................................... 11
bethanechol chloride ....................................... 15
BETIMOL ............................................................ 11
BETOPTIC.......................................................... 11
BETOPTIC S ...................................................... 11
bexarotene...................................................... 9, 16
BIAXIN ................................................................ 12
BIAXIN XL .......................................................... 12
bicalutamide ..................................................... 15
BIDIL ..................................................................... 8
Bile Salt Sequestrants .......................................... 7
Bile Salts ............................................................. 15
BILTRICIDE ........................................................ 13
bimatoprost ......................................................... 11
bisoprolol fumarate ............................................ 7
bisoprolol fumarate/hctz ................................... 7
BLEPHAMIDE .................................................... 11
BLEPHAMIDE S.O.P.......................................... 11
BLOCADREN ....................................................... 7
blood sugar diagnostic ....................................... 10
blood-glucose calib. control ................................ 10
blood-glucose meter ........................................... 10
Bone Formation Stim. Agents - Parathyroid
Hormone....................................................... 10
Bone Resorption Inhibitor & Calcium
Combinations ............................................... 10
Bone Resorption Inhibitor & Vitamin D
Combinations ............................................... 10
Bone Resorption Inhibitors ................................. 10
26
BONIVA .............................................................. 10
bosentan ............................................................... 7
BOSULIF ............................................................ 15
bosutinib ............................................................. 15
Bowel Antiinflamatory Agents ............................ 14
BRAVELLE ......................................................... 10
BREO ELLIPTA .................................................... 5
BRETHINE ........................................................... 5
BREVOXYL-4 ....................................................... 8
BREVOXYL-8 ....................................................... 8
BRILINTA ........................................................... 12
brimonidine tartrate ......................................... 11
brimonidine/timolol ............................................. 11
brinzolamide ....................................................... 11
brinzolamide/brimonidine ................................... 11
BROMFED............................................................ 8
BROMFED-PD ..................................................... 8
bromocriptine mesylate ................................... 17
budesonide ................................................... 5, 14
BUDESONIDE .................................................... 14
bumetanide ......................................................... 7
BUMEX ................................................................. 7
BUPHENYL ........................................................ 14
buprenorphine .................................................... 16
buprenorphine hcl ............................................ 16
buprenorphine hcl/naloxone hcl ......................... 16
bupropion hcl ..................................................... 5
BUSPAR ............................................................... 6
buspirone hcl ...................................................... 6
busulfan .............................................................. 15
butalb/acetaminophen/caffeine ...................... 16
butalbital/acetaminophen ................................ 16
butalbital/aspirin/caffeine ................................ 16
butoconazole nitrate ........................................... 18
BUTRANS .......................................................... 16
BYSTOLIC ............................................................ 7
cabergoline ....................................................... 11
cabozantinib ....................................................... 15
CADUET ............................................................... 8
CAFERGOT........................................................ 16
CALAN SR............................................................ 7
calcipotriene ....................................................... 9
calcitriol ........................................................... 9, 18
calcium acetate ................................................. 10
Calcium Channel Blocking Agents ....................... 7
CANAGLIFLOZIN ............................................... 10
canagliflozin/metformin hcl ................................. 10
CANASA ............................................................. 14
capecitabine ....................................................... 15
CAPITAL W-CODEINE ...................................... 17
CAPOTEN ............................................................ 7
CAPOZIDE ........................................................... 6
captopril .............................................................. 7
captopril/hydrochlorothiazide........................... 6
CARAFATE ........................................................ 17
carbachol ............................................................ 11
carbamazepine ................................................. 17
carbidopa ............................................................ 17
carbidopa/levodopa ......................................... 17
Carbonic Anhydrase Inhibitors ........................... 11
CARDIOVASCULAR DISEASE - ARRHYTHMIA 6
CARDIOVASCULAR DISEASE - CARDIAC
STIMULANT ................................................... 6
CARDIOVASCULAR DISEASE HYPERTENSION ........................................... 6
CARDIOVASCULAR DISEASE - LIPID
IRREGULARITY............................................. 7
CARDIOVASCULAR DISEASE MISCELLANEOUS AGENTS......................... 8
CARDIOVASCULAR DISEASE - VASODILATION
........................................................................ 8
CARDIZEM ........................................................... 7
CARDIZEM CD .................................................... 7
CARDURA ............................................................ 6
carisoprodol ...................................................... 17
carisoprodol/aspirin ......................................... 17
CARMOL HC ........................................................ 9
carteolol hcl ...................................................... 11
carvedilol ............................................................. 6
carvedilol phosphate ............................................ 7
CASODEX .......................................................... 15
CATAPRES .......................................................... 7
CAYSTON .......................................................... 12
CECLOR ............................................................. 12
CEENU ............................................................... 15
STATE OF MICHIGAN COMMERCIAL FORMULARY
APRIL 2016
INDEX
cefaclor .............................................................. 12
cefadroxil hydrate ............................................ 12
cefdinir ............................................................... 12
cefixime .............................................................. 12
cefpodoxime proxetil ....................................... 12
cefprozil ............................................................. 12
CEFTIN ............................................................... 12
cefuroxime axetil .............................................. 12
CEFZIL ............................................................... 12
CELEBREX ........................................................ 14
celecoxib ........................................................... 14
CELEXA ............................................................... 5
CELLCEPT ......................................................... 12
CENTANY ............................................................ 8
cephalexin monohydrate ................................. 12
Cephalosporins - 1st Generation ....................... 12
Cephalosporins - 2nd Generation ...................... 12
Cephalosporins - 3rd Generation ....................... 12
ceritinib ............................................................... 15
cetirizine hcl (OTC)............................................. 5
cetrorelix acetate ................................................ 11
CETROTIDE ....................................................... 11
cevimeline hcl ................................................... 15
Chemotherapeutics, Antibacterial, Misc............. 12
Chemotherapy Rescue/Antidote Agents ............ 15
chloral hydrate .................................................... 6
chlorambucil ....................................................... 15
chlordiazepoxide hcl .......................................... 6
chlordiazepoxide/clidinium br ............................. 17
chlorhexidine gluconate .................................. 16
chloroquine phosphate ................................... 13
chlorpheniramine maleate ................................. 5
chlorpheniramine tannate ................................. 5
chlorpromazine hcl ............................................ 6
chlorpropamide .................................................. 9
chlorthalidone ..................................................... 7
CHLOR-TRIMETON ............................................. 5
chlorzoxazone .................................................. 17
cholestyramine/aspartame ................................ 7
cholestyramine/sucrose .................................... 7
Cholinesterase Inhibitors ...................................... 5
Chronic Inflam. Colon Dx, 5-A-Salicylat, Rectal Tx
...................................................................... 14
CHRONULAC ..................................................... 14
CIALIS ................................................................ 10
CIBALITH-S .......................................................... 6
ciclopirox............................................................... 8
ciclopirox olamine .............................................. 8
cilostazol ........................................................... 12
CILOXAN ............................................................ 11
cimetidine hcl ................................................... 17
CIPRO ................................................................ 13
CIPRO ORAL SUSPENSION ............................ 13
CIPRODEX ......................................................... 10
ciprofloxacin........................................................ 13
ciprofloxacin hcl ......................................... 11, 13
ciprofloxacin hcl/dexameth ................................. 10
citalopram hydrobromide .................................. 5
clarithromycin ................................................... 12
CLARITIN (OTC) .................................................. 5
CLARITIN-D 12 HOUR......................................... 5
CLARITIN-D 24 HOUR......................................... 5
CLEOCIN ............................................................ 12
CLEOCIN T .......................................................... 8
CLIMARA ............................................................ 12
CLINAC BPO ........................................................ 8
clindamycin capsules ......................................... 12
clindamycin palmitate solution ........................... 12
clindamycin phos/benzoyl perox ..................... 8
clindamycin phosphate ..................................... 8
clindamycin/benzoyl prx/skn #5 ........................... 8
clindamycin/tretinoin ............................................. 8
CLINORIL ........................................................... 14
clobetasol propionate ........................................ 9
clobetasol propionate/emoll ............................. 9
CLOBEX ............................................................... 9
CLOMID .............................................................. 10
clomiphene citrate ............................................ 10
clomipramine hcl ................................................ 6
clonazepam ....................................................... 17
clonidine hcl ....................................................... 7
clopidogrel bisulfate ........................................ 12
clopidogrel bisulfate 300mg............................ 12
clorazepate dipotassium ................................... 6
clotrimazole....................................................... 13
804PA, apr 2016
clotrimazole/betamet diprop ............................. 8
clozapine ............................................................. 6
CLOZARIL ............................................................ 6
cobicistat ............................................................. 14
cobimetinib fumarate .......................................... 15
codeine phos/carisoprodol/asa ...................... 16
codeine/butalbit/acetamin/caff........................ 16
codeine/butalbital/asa/caffein ......................... 17
codeine/promethazine hcl ................................. 8
COGENTIN......................................................... 17
COLAZAL ........................................................... 14
COL-BENEMID .................................................. 12
colchicine .......................................................... 12
Colchicine ........................................................... 11
colchicine/probenecid ..................................... 12
COLCRYS .......................................................... 12
colesevelam hcl .................................................... 7
COLESTID............................................................ 7
colestipol ............................................................... 7
COLYTE WITH FLAVOR PACKETS ................. 15
COMBIGAN ........................................................ 11
COMBIPATCH ................................................... 12
COMBIVENT ........................................................ 5
COMBIVENT RESPIMAT .................................... 5
COMBIVIR .......................................................... 13
COMETRIQ ........................................................ 15
COMPAZINE ........................................................ 5
COMPAZINE SYRUP........................................... 5
COMTAN ............................................................ 17
CONCERTA ......................................................... 6
CONDYLOX ......................................................... 8
CONTRACEPTION/OXYTOCICS ........................ 8
Contraceptives, Injectable .................................... 8
Contraceptives, Oral............................................. 8
Contraceptives, Transdermal ............................... 8
COPAXONE ....................................................... 16
COPEGUS.......................................................... 14
CORDARONE ...................................................... 6
CORDRAN ........................................................... 9
CORDRAN SP ..................................................... 9
COREG ................................................................ 6
COREG CR .......................................................... 7
CORGARD ........................................................... 7
CORLANOR ......................................................... 8
CORTEF ............................................................. 14
CORTENEMA .................................................... 14
cortisone acetate .............................................. 14
CORTISPORIN CREAM ...................................... 9
CORTISPORIN OINTMENT ................................ 9
CORTISPORIN OPHTH OINTMENT ................. 11
CORTISPORIN OPHTH SUSPENSION ............ 11
CORTISPORIN OTIC ......................................... 10
CORTONE ACETATE ........................................ 14
COSENTYX .......................................................... 9
COSOPT ............................................................ 11
COTELLIC .......................................................... 15
COUGH AND COLD ............................................ 8
COUMADIN ........................................................ 12
COZAAR ............................................................... 7
CREON ............................................................... 17
CRESTOR ............................................................ 7
CRINONE ........................................................... 10
CRIXIVAN........................................................... 14
crizotinib ............................................................. 15
cromolyn sodium ......................................... 5, 11
crotamiton ............................................................. 9
CUPRIMINE ....................................................... 14
CUTIVATE ............................................................ 9
cyanocobalamin/fa/pyridoxine ............................ 18
CYCLESSA .......................................................... 8
cyclobenzaprine hcl ......................................... 17
CYCLOCORT ....................................................... 9
CYCLOGYL ........................................................ 11
cyclopentolate hcl ............................................ 11
cyclophosphamide ........................................... 15
cyclosporine.................................................. 11, 12
cyclosporine, modified .................................... 12
CYMBALTA .......................................................... 6
cyproheptadine hcl ............................................ 5
CYSTARAN ........................................................ 11
cysteamine bitartrate .......................................... 17
cysteamine HCL ................................................. 11
Cystic Fibrosis Transmembrane Conduct.
Regulator (CFTR) Potentiator ................... 16
CYTOMEL .......................................................... 11
27
CYTOTEC .......................................................... 17
CYTOVENE ........................................................ 13
CYTOXAN .......................................................... 15
dabrafenib........................................................... 15
DALIRESP ............................................................ 5
DALMANE ............................................................ 6
dalteparin sodium,porcine .................................. 12
danazol .............................................................. 11
DANOCRINE ...................................................... 11
DANTRIUM......................................................... 17
dantrolene sodium ........................................... 17
dapsone ............................................................. 13
DARAPRIM......................................................... 13
darunavir ethanolate..................................... 13, 14
darunavir/cobicistat ............................................ 13
dasatinib ............................................................. 15
DAYPRO ............................................................ 14
DDAVP ............................................................... 10
Decarboxylase Inhibitors .................................... 17
DECONAMINE ..................................................... 8
DELATESTRYL .................................................. 12
delavirdine mesylate........................................... 13
DEL-BETA ............................................................ 9
DELTASONE ...................................................... 14
DEMADEX ............................................................ 7
DEMULEN 1-50-21 .............................................. 8
Dental Aids & Preparations ................................ 16
DEPAKENE CAPSULES ................................... 17
DEPAKENE SYRUP .......................................... 17
DEPAKOTE ........................................................ 17
DEPAKOTE ER .................................................. 17
DEPAKOTE SPRINKLE ..................................... 17
DEPEN ............................................................... 14
DEPO-PROVERA ................................................ 8
DEPO-TESTOSTERONE .................................. 12
DERMATOLOGY - ACNE .................................... 8
DERMATOLOGY - ANTIINFECTIVE ................... 8
DERMATOLOGY - ANTIINFLAMMATORY ......... 9
DERMATOLOGY - MISCELLANEOUS ............... 9
DERMATOLOGY - PIGMENTATION
DISORDERS .................................................. 9
DERMATOLOGY - PSORIASIS/ECZEMA .......... 9
desipramine hcl .................................................. 6
desmopressin (nonrefrigerated) ..................... 10
DESOGEN............................................................ 8
desogestrel-ethinyl estradiol ............................ 8
desog-et estra/ethin estra ................................. 8
desonide .............................................................. 9
DESOWEN ........................................................... 9
desoximetasone ................................................. 9
desvenlafaxine ..................................................... 6
DESVENLAFAXINE ER (RANBAXY) .................. 6
desvenlafaxine succinate ..................................... 5
DESYREL 300MG ................................................ 5
DETROL ............................................................. 18
dexamethasone .................................................. 14
dexchlorpheniramine maleate .......................... 5
DEXEDRINE......................................................... 6
dexmethylphenidate hcl .................................... 6
dextroamphetamine sulfate .............................. 6
DHT .................................................................... 18
DIABETA .............................................................. 9
DIABETES ............................................................ 9
Diabetic Ulcer Preparations, Topical .................. 10
DIABINESE .......................................................... 9
DIAMOX SEQUELS ........................................... 11
DIASTAT ............................................................ 17
diazepam ............................................................. 6
diazepam (rectal) ................................................ 17
DIBENZYLINE ...................................................... 6
dichlorphenamide ............................................... 17
diclofenac sodium .................................. 9, 11, 14
dicloxacillin sodium ......................................... 13
dicyclomine hcl ................................................ 17
didanosine......................................................... 13
DIDRONEL ......................................................... 10
DIFFERIN ............................................................. 8
DIFICID ............................................................... 13
diflorasone diacetate ......................................... 9
diflorasone diacetate/emoll .................................. 9
DIFLUCAN.......................................................... 13
diflunisal ............................................................ 16
difluprednate ....................................................... 11
Digitalis Glycosides .............................................. 6
digoxin ................................................................. 6
STATE OF MICHIGAN COMMERCIAL FORMULARY
APRIL 2016
INDEX
DIGOXIN ORAL SOLN......................................... 6
dihydrotachysterol .............................................. 18
DILACOR XR ....................................................... 7
DILANTIN ........................................................... 17
DILANTIN CHEW TAB ....................................... 17
DILANTIN-125 .................................................... 17
DILAUDID ........................................................... 16
DILAUDID-5........................................................ 16
diltiazem hcl ........................................................ 7
dimethyl fumarate ............................................... 16
DIOVAN ................................................................ 7
DIOVAN HCT ....................................................... 7
diphenoxylate hcl/atrop sulf ........................... 15
dipivefrin hcl........................................................ 11
DIPROLENE ......................................................... 9
DIPROLENE AF ................................................... 9
DIPROSONE ........................................................ 9
dipyridamole ..................................................... 12
DISALCID ........................................................... 16
disopyramide phosphate ................................... 6
disulfiram .............................................................. 6
DITROPAN XL ................................................... 18
divalproex sodium ............................................ 17
d-methorphan hb/prometh hcl .......................... 8
dofetilide ............................................................... 6
DOLOBID ........................................................... 16
DOLOPHINE HCL .............................................. 16
dolutegravir ......................................................... 14
DOMEBORO ...................................................... 10
DONNATAL ........................................................ 17
dornase alfa for inhalation .................................. 16
dorzolamide hcl ................................................ 11
dorzolamide hcl/timolol maleat ...................... 11
DOSTINEX ......................................................... 11
DOVONEX............................................................ 9
doxazosin mesylate ........................................... 6
doxepin hcl.......................................................... 6
doxycycline calcium ............................................ 13
doxycycline hyclate ......................................... 13
doxycycline monohydrate ............................... 13
DRISDOL ............................................................ 18
DRITHOCREME HP............................................. 9
DRITHO-SCALP ................................................... 9
dronabinol ........................................................... 5
dronedarone hcl ................................................... 6
Drug Tx-Chronic Inflam. Colon Dx, 5Aminosalicylat .............................................. 14
Drugs To Treat Impotency ................................. 10
DRYSOL ............................................................... 9
DUAC CS ............................................................. 8
DUAVEE ............................................................. 12
DUETACT........................................................... 10
DULERA ............................................................... 5
duloxetine hcl ..................................................... 6
DUONEB .............................................................. 5
DURAGESIC ...................................................... 16
DUREZOL .......................................................... 11
DURICEF ............................................................ 12
dutasteride ........................................................ 17
dutasteride/tamsulosin ....................................... 17
DYAZIDE .............................................................. 7
DYNACIN ........................................................... 13
E.E.S. 200 .......................................................... 12
EAR - GENERAL DISORDERS ......................... 10
Ear Preparations, Antibiotics .............................. 10
Ear Preparations, Misc. Anti-Infectives .............. 10
EC-NAPROSYN ................................................. 14
efavirenz ............................................................. 13
efavirenz/emtricitab/tenofovir ............................. 14
EFFEXOR............................................................. 5
EFFEXOR XR ...................................................... 6
EFFIENT ............................................................. 12
EFUDEX ............................................................... 9
ELAVIL ................................................................. 6
ELDEPRYL ......................................................... 17
Electrolyte Depleters .......................................... 10
ELECTROLYTE REGULATION ......................... 10
ELIGARD ............................................................ 10
ELIMITE ................................................................ 9
ELIQUIS ............................................................. 12
ELMIRON ........................................................... 17
ELOCON .............................................................. 9
eltrombopag olamine .......................................... 12
elviteg/cobi/emtric/tenofo ala .............................. 14
elvitegravir .......................................................... 14
804PA, apr 2016
elvitegravir, cobicistat, emtricitabine, tenofovir
disoproxil fumarate ....................................... 14
EMCYT ............................................................... 16
EMEND ................................................................. 5
EMGEL ................................................................. 8
empagliflozin....................................................... 10
empagliflozin/linagliptin ...................................... 10
empagliflozin/metformin hcl ................................ 10
emtricitabine ....................................................... 13
emtricitabine/tenofovir ........................................ 13
EMTRIVA ............................................................ 13
enalapril maleate ................................................ 7
enalapril/hydrochlorothiazide ........................... 6
ENBREL ............................................................. 14
ENDOCRINE DISORDER - FERTILITY ............ 10
ENDOCRINE DISORDER - OTHER .................. 10
ENDOCRINE DISORDER - THYROID .............. 11
ENDOMETRIN ................................................... 10
enfuvirtide ........................................................... 13
enoxaparin sodium .......................................... 12
entacapone........................................................ 17
entecavir ............................................................ 14
ENTOCORT EC ................................................. 14
enzalutamide ...................................................... 15
epinephrine ......................................................... 15
EPIPEN .............................................................. 15
EPIPEN JR ......................................................... 15
EPIVIR ................................................................ 13
EPIVIR HBV ....................................................... 14
EPIVIR HBV SOLUTION .................................... 14
eplerenone .......................................................... 7
epoetin alfa ......................................................... 12
EPZICOM ........................................................... 13
ergocalciferol .................................................... 18
ergotamine tartrate/caffeine ............................ 16
ERIVEDGE ......................................................... 15
erlotinib hcl ......................................................... 15
ery e-succ/sulfisoxazole .................................. 12
ERYC .................................................................. 12
ERYGEL ............................................................... 8
ERYPED 200 ...................................................... 12
ERYPED 400 ...................................................... 12
ERY-TAB ............................................................ 12
ERYTHROCIN STEARATE ............................... 12
erythromycin base ..................................... 11, 12
erythromycin base/benz per ............................. 8
erythromycin base/ethanol ............................... 8
erythromycin ethylsuccinate .......................... 12
erythromycin stearate ...................................... 12
ESBRIET ............................................................ 16
escitalopram ......................................................... 5
ESGIC ................................................................ 16
ESKALITH ............................................................ 6
esomeprazole magnesium .............................. 17
estazolam ............................................................ 6
ESTRACE..................................................... 12, 18
ESTRADERM ..................................................... 12
estradiol ....................................................... 12, 18
estradiol tablet .................................................. 12
estradiol/noreth ac .............................................. 12
estramustine phosphate sodium ........................ 16
ESTRATEST H.S. .............................................. 12
estrogen, con/m-progest acet ............................ 12
estrogen, ester/me-testosterone .................... 12
Estrogen/Androgen Combinations ..................... 12
Estrogenic Agents .............................................. 12
estrogens, conj/bazedoxifene ............................ 12
estrogens, conjugated .................................. 12, 18
estrogens, esterified ........................................... 12
estropipate ........................................................ 12
eszopiclone ......................................................... 6
etanercept........................................................... 14
ethambutol hcl .................................................. 13
ethinyl estradiol/drospirenone.......................... 8
ethosuximide .................................................... 17
ethynodiol d-ethinyl estradiol ........................... 8
etidronate disodium ......................................... 10
etodolac ............................................................. 14
etonogestrel/ethinyl estradiol ............................... 8
etoposide........................................................... 15
etravirine ............................................................. 13
EULEXIN ............................................................ 15
EURAX ................................................................. 9
everolimus .................................................... 12, 15
EVISTA ............................................................... 10
28
EVOCLIN .............................................................. 8
EVOTAZ ............................................................. 14
EVOXAC ............................................................. 15
EXELDERM .......................................................... 9
EXELON ............................................................... 5
EXELON PATCH .................................................. 5
exemestane ........................................................ 15
EXFORGE ............................................................ 7
EXFORGE HCT ................................................... 7
EYE - GENERAL DISORDERS ......................... 11
EYE - GLAUCOMA ............................................ 11
Eye Antibiotic-Corticoid Combinations ............... 11
Eye Antihistamines ............................................. 11
Eye Antiinflammatory Agents ............................. 11
Eye Antivirals ...................................................... 11
Eye Miscellaneous ............................................. 11
Eye Sulfonamides .............................................. 11
ezetimibe .............................................................. 7
FABIOR ................................................................ 8
famotidine ......................................................... 17
FANSIDAR ......................................................... 13
FARESTON ........................................................ 16
FARYDAK........................................................... 15
febuxostat ........................................................... 12
FELDENE ........................................................... 14
felodipine ............................................................. 7
FEMARA ............................................................. 15
FEMHRT ............................................................. 12
fenofibrate ........................................................... 7
fenofibrate nanocrystallized ............................. 7
fenofibrate, micronized ...................................... 7
FENOGLIDE ......................................................... 7
fenoprofen calcium .......................................... 14
fentanyl citrate .................................................. 16
fentanyl patch ................................................... 16
Fertility Stimulating Preparations, Non-FSH ...... 10
FERTINEX .......................................................... 10
fesoterodine fumarate ........................................ 18
fexofenadine hcl tablet ...................................... 5
Fibromyalgia Agents, Serotonin-Norepineph RU
Inhib .............................................................. 16
fidaxomicin.......................................................... 13
filgrastim ............................................................. 12
finasteride ......................................................... 17
fingolimod hcl ..................................................... 16
FIORICET ........................................................... 16
FIORICET WITH CODEINE ............................... 16
FIORINAL ........................................................... 16
FIORINAL WITH CODEINE #3 .......................... 17
FIRAZYR ............................................................ 14
FIRST-HYDROCORTISONE ............................... 9
FLAGYL .............................................................. 13
FLAGYL ER ........................................................ 13
FLAREX.............................................................. 11
flecainide acetate ............................................... 6
FLEXERIL........................................................... 17
FLOMAX ............................................................. 17
FLONASE ............................................................. 5
FLORINEF ACETATE ........................................ 14
FLOXIN ......................................................... 10, 13
fluconazole ........................................................ 13
fludarabine phosphate ........................................ 15
fludrocortisone acetate ................................... 14
flunisolide............................................................ 5
fluocinolone acetonide ...................................... 9
fluocinonide ........................................................ 9
fluocinonide/emollient ....................................... 9
FLUORABON BASIC ......................................... 18
fluoride ion/iron/vit a,c&d ................................ 18
fluoride ion/multivitamins ............................... 18
fluoride ion/multivits w-fe ................................ 18
fluoride ion/vit a,c&d ........................................ 18
Fluoride Preparations ......................................... 18
FLUORITAB ....................................................... 18
fluorometholone ............................................... 11
fluorometholone acetate ..................................... 11
fluorouracil .......................................................... 9
fluoxetine hcl ...................................................... 5
fluoxymesterone ............................................... 12
fluphenazine hcl ................................................. 6
FLURA-DROPS .................................................. 18
flurandrenolide ...................................................... 9
FLURA-TABS ..................................................... 18
flurazepam hcl .................................................... 6
flurbiprofen ....................................................... 14
STATE OF MICHIGAN COMMERCIAL FORMULARY
APRIL 2016
INDEX
flurbiprofen sodium ......................................... 11
flutamide ............................................................ 15
fluticasone propionate ................................... 5, 9
fluticasone/salmeterol........................................... 5
fluticasone/vilanterol ............................................. 5
fluvoxamine maleate .......................................... 5
FML .................................................................... 11
FML FORTE ....................................................... 11
FML S.O.P. ......................................................... 11
FOCALIN .............................................................. 6
FOLGARD RX .................................................... 18
folic acid ............................................................ 18
FOLIC ACID ....................................................... 18
Folic Acid Preparations ...................................... 18
folic acid/mu-vits-min th .................................. 18
Follicle Stim./Luteinizing Hormones ................... 10
FOLLISTIM AQ ................................................... 10
follitropin alpha,recomb ...................................... 10
follitropin beta,recomb ........................................ 10
fondaparinux sodium ....................................... 12
formoterol fumarate .............................................. 5
FORTEO ............................................................. 10
FOSAMAX .......................................................... 10
FOSAMAX PLUS D ............................................ 10
fosamprenavir calcium ....................................... 14
fosinopril sodium ............................................... 7
fosinopril/hydrochlorothiazide ......................... 6
FRAGMIN ........................................................... 12
FURADANTIN .................................................... 13
furazolidone ........................................................ 13
furosemide .......................................................... 7
FUROXONE ....................................................... 13
FUZEON ............................................................. 13
gabapentin ........................................................ 17
galantamine .......................................................... 5
ganciclovir..................................................... 11, 13
ganirelix acetate ................................................. 11
GANIRELIX ACETATE....................................... 11
GANTRISIN ........................................................ 12
GARAMYCIN .................................................. 8, 11
gatifloxacin.......................................................... 11
GATTEX ............................................................. 15
gefitinib ............................................................... 15
gemfibrozil .......................................................... 7
General Bronchodilator Agents ............................ 5
gentamicin sulfate ........................................ 8, 11
GENVOYA .......................................................... 14
GEODON .............................................................. 6
GILENYA ............................................................ 16
GILOTRIF ........................................................... 15
glatiramer acetate ............................................... 16
GLEEVEC........................................................... 15
glimepiride .......................................................... 9
glipizide ............................................................... 9
glipizide/metformin hcl ...................................... 9
GLUCAGEN ....................................................... 10
GLUCAGON EMERGENCY KIT ........................ 10
glucagon,human recombinant ............................ 10
Glucocorticoids ................................................... 14
GLUCOPHAGE .................................................... 9
GLUCOPHAGE XR .............................................. 9
GLUCOTROL ....................................................... 9
GLUCOTROL XL .................................................. 9
GLUCOVANCE .................................................. 10
glyburide ............................................................... 9
glyburide, micro/metformin hcl ...................... 10
GLYXAMBI ......................................................... 10
GOLYTELY......................................................... 15
gonadorelin acetate ............................................ 11
gonadotropin,chorionic, human .......................... 10
GONAL-F............................................................ 10
GONAL-F RFF ................................................... 10
GOUT AND RELATED DISEASES ................... 11
GRASTEK ............................................................ 5
griseofulvin suspension ...................................... 13
griseofulvin ultramicrosize .................................. 13
GRIS-PEG .......................................................... 13
Growth Hormone Receptor Antagonists ............ 11
Growth Hormones .............................................. 11
guaifenesin/codeine phos ................................. 8
guaifenesin/d-methorphan hb........................... 8
guanfacine hcl .................................................... 7
GYNAZOLE-1 ..................................................... 18
HALCION .............................................................. 6
HALDOL ............................................................... 6
804PA, apr 2016
HALDOL ORAL CONC......................................... 6
halobetasol propionate ...................................... 9
haloperidol .......................................................... 6
haloperidol lactate .............................................. 6
HALOTESTIN ..................................................... 12
HARVONI ........................................................... 14
hc acetate/pramoxine hcl ............................ 9, 14
hcg alpha, recombinant ...................................... 10
Hematinics, Other ............................................... 12
HEMATOLOGICAL DISORDERS ...................... 12
Hemorrheologic Agents ...................................... 12
Hemorrhoidal Preparations ................................ 14
Heparin & Related Preparations ........................ 12
HEPARIN LOCK ................................................. 12
heparin sodium, porcine ................................. 12
heparin sodium, porcine/pf ............................. 12
Hepatitis B Treatment Agents ............................ 14
Hepatitis C Treatment Agents ............................ 14
HEP-LOCK ......................................................... 12
HEPSERA .......................................................... 14
HEXALEN ........................................................... 15
Histamine H2-Receptor Inhibitors ...................... 17
homatropine hbr ............................................... 11
HORMONAL DEFICIENCY ................................ 12
hum insulin nph/reg insulin hm........................... 10
HUMALOG ......................................................... 10
HUMALOG MIX 50-50........................................ 10
HUMALOG MIX 75-25........................................ 10
HUMATIN ........................................................... 13
HUMIRA ............................................................. 14
HUMULIN 50-50 ................................................. 10
HUMULIN 70-30 ................................................. 10
HUMULIN N........................................................ 10
HUMULIN R........................................................ 10
HYCAMTIN ......................................................... 15
HYCET ............................................................... 16
HYCODAN............................................................ 8
hydralazine hcl ................................................... 7
HYDREA ............................................................. 15
hydrochlorothiazide ........................................... 7
hydrocodone bit/acetaminophen (250mg) ......... 16
hydrocodone bit/acetaminophen (300mg) .... 16
hydrocodone bit/acetaminophen (325mg) .... 16
hydrocodone bit/acetaminophen (325mg/15ml)
oral solution .................................................. 16
hydrocodone bit/acetaminophen oral elixir
(300mg/15ml) .............................................. 16
hydrocodone bit/homatrop me-br .................... 8
hydrocodone/chlorphen polis ............................... 8
hydrocort/sal acid/sulf/shmp#1............................. 9
hydrocortisone ............................................. 9, 14
hydrocortisone acetate .................................... 14
hydrocortisone acetate/urea ............................. 9
hydrocortisone butyrate .................................... 9
hydrocortisone butyrate/emoll .............................. 9
hydrocortisone probutate ..................................... 9
hydrocortisone valerate .................................... 9
hydrocortisone/iodoquinol ................................ 8
hydromorphone hcl.......................................... 16
hydroxychloroquine sulfate ............................ 13
hydroxyurea ...................................................... 15
hydroxyzine hcl .................................................. 5
hydroxyzine pamoate ........................................ 5
HYGROTON ......................................................... 7
hyoscyamine sulfate ........................................ 17
Hyperglycemics .................................................. 10
HYPER-SAL 7% ................................................. 16
Hyperuricemia Tx - Purine Inhibitors .................. 12
HYTRIN ................................................................ 6
HYZAAR ............................................................... 7
ibandronate ....................................................... 10
IBRANCE ............................................................ 15
ibrutinib ............................................................... 15
ibuprofen ........................................................... 14
icatibant .............................................................. 14
ICLUSIG ............................................................. 15
icosapent ethyl ..................................................... 7
idelalisib .............................................................. 15
ILEVRO .............................................................. 11
imatinib mesylate ............................................. 15
IMBRUVICA........................................................ 15
IMDUR .................................................................. 8
imipramine hcl .................................................... 6
imiquimod ......................................................... 12
IMITREX INJECTION ......................................... 16
29
IMITREX NASAL SPRAY ................................... 16
IMITREX TABLET .............................................. 16
Immunomodulators ............................................. 12
IMMUNOSUPPRESSION/MODULATION ......... 12
Immunosuppressives ......................................... 12
IMURAN ............................................................. 12
indapamide.......................................................... 7
INDERAL LA......................................................... 7
INDERIDE-40/25 .................................................. 7
indinavir sulfate .................................................. 14
INDOCIN ............................................................ 14
INDOCIN ORAL SUSP. ..................................... 14
INDOCIN SR ...................................................... 14
INDOCIN SUPPOS ............................................ 14
indomethacin .................................................... 14
INFECTIOUS DISEASE - BACTERIAL ............. 12
INFECTIOUS DISEASE - FUNGAL ................... 13
INFECTIOUS DISEASE - MISCELLANEOUS ... 13
INFECTIOUS DISEASE - PARASITIC .............. 13
INFECTIOUS DISEASE - VIRAL ....................... 13
INFLAMMATORY DISEASE .............................. 14
ingenol .................................................................. 9
INLYTA ............................................................... 15
INSPRA ................................................................ 7
insulin glargine,hum.rec.anlog ........................... 10
insulin lispro ........................................................ 10
insulin npl/insulin lispro ...................................... 10
insulin regular, human ........................................ 10
Insulins ............................................................... 10
INTAL ................................................................... 5
INTELENCE ....................................................... 13
interferon alfa-2b, recomb. ................................. 12
interferon beta-1a ............................................... 16
interferon beta-1a/albumin ................................. 16
Intestinal Motility Stimulants ............................... 17
INTRON A .......................................................... 12
INVIRASE ........................................................... 14
INVOKAMET ...................................................... 10
INVOKANA ......................................................... 10
Iodine Containing Agents ................................... 11
iodoquinol ........................................................... 13
ipratropium bromide .................................... 5, 16
ipratropium/albuterol sulfate ............................ 5
irbesartan ............................................................ 7
irbesartan/ hydrochlorothiazide ....................... 7
IRESSA .............................................................. 15
ISENTRESS ....................................................... 14
ISMO .................................................................... 8
ISOCHRON .......................................................... 8
isomethept/acetaminop/dichlphn ................... 16
isoniazid ............................................................ 13
ISOPTO ATROPINE .......................................... 11
ISOPTO CARBACHOL ...................................... 11
ISOPTO CARPINE ............................................. 11
ISOPTO HOMATROPINE .................................. 11
ISORDIL ............................................................... 8
ISORDIL TITRADOSE ......................................... 8
isosorb dinit/hydralazine hcl ................................. 8
isosorbide dinitrate ............................................ 8
isosorbide mononitrate ..................................... 8
isotretinoin .......................................................... 8
isradipine .............................................................. 7
itraconazole....................................................... 13
ivabradine hcl ....................................................... 8
ivacaftor .............................................................. 16
ixazomib citrate .................................................. 15
JAKAFI ............................................................... 15
JALYN ................................................................ 17
JANUMET ............................................................. 9
JANUMET XR ...................................................... 9
JANUVIA .............................................................. 9
JARDIANCE ....................................................... 10
JENTADUETO ..................................................... 9
JUVISYNC ............................................................ 9
JUXTAPID ............................................................ 7
KALETRA ........................................................... 14
KALYDECO ........................................................ 16
KAYEXALATE .................................................... 10
K-DUR ................................................................ 10
KEFLEX .............................................................. 12
KENALOG ............................................................ 9
KENALOG IN ORABASE ................................... 16
KEPPRA ............................................................. 17
Keratolytic-Glucocorticoid Combinations ............. 8
Keratolytics ........................................................... 8
STATE OF MICHIGAN COMMERCIAL FORMULARY
APRIL 2016
INDEX
KETEK ................................................................ 12
ketoconazole ................................................. 8, 13
Ketolides ............................................................. 12
ketoprofen ......................................................... 14
ketorolac tromethamine ............................ 11, 14
ketotifen fumarate (OTC) ................................. 11
KEVEYIS ............................................................ 17
KLARON ............................................................... 8
KLERIST-D ........................................................... 8
KLONOPIN ......................................................... 17
K-LYTE ............................................................... 10
K-LYTE-CL ......................................................... 10
KORLYM .............................................................. 9
KRISTALOSE ..................................................... 15
K-TAB ................................................................. 10
KURIC .................................................................. 8
KUVAN ............................................................... 15
KWELL ................................................................. 9
KYNAMRO ........................................................... 7
labetalol hcl ......................................................... 7
LACTICARE-HC ................................................... 9
lactulose ...................................................... 14, 15
LAMICTAL .......................................................... 17
LAMISIL .......................................................... 9, 13
LAMISIL GRANULES ......................................... 13
lamivudine ................................................... 13, 14
lamivudine/zidovudine ........................................ 13
lamotrigine ........................................................ 17
lancing device/lancets ........................................ 10
LANOXIN .............................................................. 6
lanreotide acetate ............................................... 16
lansoprazole ..................................................... 17
lansoprazole/amox tr/clarith ............................... 17
LANTUS ............................................................. 10
lapatinib ditosylate .............................................. 15
LARIAM .............................................................. 13
LASIX ................................................................... 7
latanoprost .......................................................... 11
Laxatives & Cathartics........................................ 15
ledipasvir/sofosbuvir ........................................... 14
leflunomide ....................................................... 14
lenalidomide ....................................................... 15
lenvatinib mesylate ............................................. 15
LENVIMA ............................................................ 15
LETAIRIS .............................................................. 7
letrozole .............................................................. 15
leucovorin calcium ........................................... 15
LEUCOVORIN CALCIUM .................................. 15
LEUKERAN ........................................................ 15
LEUKINE ............................................................ 12
Leukocyte (WBC) Stimulants ............................. 12
Leukotriene Receptor Antagonists ....................... 5
leuprolide ............................................................ 10
LEVAQUIN ......................................................... 13
LEVBID ............................................................... 17
levetiracetam .................................................... 17
levobunolol hcl ................................................. 11
levocetirizine dihydrochloride ............................... 5
levofloxacin ....................................................... 13
levonorgestrel ..................................................... 8
levonorgestrel-eth estra .................................... 8
LEVOTHROID .................................................... 11
levothyroxine sodium ...................................... 11
LEVOXYL ........................................................... 11
LEVSIN-SL ......................................................... 17
LEXAPRO............................................................. 5
LEXIVA ............................................................... 14
LHRH (GnRH) Antagonist, Pituitary Suppressant
Agents .......................................................... 11
LIALDA ............................................................... 14
LIBRAX ............................................................... 17
LIBRIUM ............................................................... 6
LIDEX ................................................................... 9
LIDEX-E ................................................................ 9
lidocaine hcl ...................................................... 14
LIFESCAN DIABETIC SUPPLIES ..................... 10
linaclotide ............................................................ 14
lindane ................................................................. 9
linezolid ............................................................. 13
LINZESS ............................................................. 14
LIORESAL .......................................................... 17
liothyronine sodium ......................................... 11
LIPITOR ................................................................ 7
Lipotropics ............................................................ 7
liraglutide .............................................................. 9
804PA, apr 2016
lisdexamfetamine dimesylate ............................... 6
lisinopril ............................................................... 7
lisinopril/hydrochlorothiazide ........................... 6
lithium carbonate ............................................... 6
lithium citrate ...................................................... 6
LITHOBID ............................................................. 6
LOCAL ANESTHESIA ........................................ 14
Local Anesthetics ............................................... 14
LOCOID ................................................................ 9
LOCOID LIPOCREAM ......................................... 9
LODINE .............................................................. 14
LODOSYN .......................................................... 17
lodoxamide tromethamine .................................. 11
LOESTRIN............................................................ 8
LOESTRIN FE ...................................................... 8
LOFIBRA CAPS ................................................... 7
LOFIBRA TABS .................................................... 7
lomitapide mesylate.............................................. 7
LOMOTIL ............................................................ 15
lomustine ............................................................ 15
LONSURF .......................................................... 15
Loop Diuretics ...................................................... 7
LO-OVRAL-28 ...................................................... 8
LOPID ................................................................... 7
lopinavir/ritonavir ................................................ 14
LOPRESSOR ....................................................... 7
Lopressor HCT ..................................................... 7
LOPROX............................................................... 8
loratadine (OTC .................................................. 5
lorazepam ............................................................ 6
LORAZEPAM INTENSOL .................................... 6
LORCET ............................................................. 16
LORCET PLUS .................................................. 16
LORTAB ............................................................. 16
LORTAB ELIXIR ................................................. 16
losartan potassium ............................................ 7
losartan/hydrochlorothiazide ............................ 7
LOTEMAX .......................................................... 11
LOTENSIN............................................................ 7
LOTENSIN HCT ................................................... 6
loteprednol etabonate......................................... 11
LOTREL ................................................................ 6
LOTRISONE ......................................................... 8
lovastatin ............................................................. 7
LOVAZA ............................................................... 7
LOVENOX .......................................................... 12
LOWER GASTROINTESTINAL DISORDERS BOWEL INFLAMMAT .................................. 14
LOWER GASTROINTESTINAL DISORDERS OTHER ......................................................... 14
loxapine succinate ............................................. 6
LOXITANE ............................................................ 6
LOZOL .................................................................. 7
lubiprostone ........................................................ 15
LUDIOMIL............................................................. 6
lumacaftor/ivacaftor ............................................ 16
LUMIGAN ........................................................... 11
LUNESTA ............................................................. 6
LURIDE .............................................................. 18
Luteinizing Hormone Releasing Hormone –LHRH
(GnRH) ......................................................... 11
LUTREPULSE .................................................... 11
LUVOX ................................................................. 5
LYNPARZA......................................................... 15
LYRICA ............................................................... 17
LYSODREN ........................................................ 15
macitentan ............................................................ 7
MACROBID ........................................................ 13
MACRODANTIN ................................................. 13
Macrolides .......................................................... 12
malathion............................................................. 9
Maois - Non-Selective & Irreversible .................... 5
maprotiline hcl .................................................... 6
maraviroc ............................................................ 13
MARINOL ............................................................. 5
Mast Cell Stabilizers ............................................. 5
MATULANE ........................................................ 15
MAVIK .................................................................. 7
MAXALT ............................................................. 16
MAXALT MLT ..................................................... 16
MAXITROL ......................................................... 11
MAXI-TUSS HCX ................................................. 8
MAXZIDE .............................................................. 7
MAXZIDE-25MG .................................................. 7
mebendazole ..................................................... 13
30
mechlorethamine .................................................. 9
meclizine hcl ....................................................... 5
meclofenamate sodium ................................... 14
MECLOMEN ....................................................... 14
MEDICATION PRESCRIBING LIMITATIONS .. 19
Medication Request Form (MRF) ....................... i
MEDROL ............................................................ 14
medroxyprogesterone acet ......................... 8, 12
mefloquine hcl .................................................. 13
MEGACE ............................................................ 16
MEGACE ES ...................................................... 16
megestrol acetate ............................................. 16
MEKINIST........................................................... 15
MELLARIL ............................................................ 6
meloxicam ......................................................... 14
melphalan ........................................................... 15
memantine hcl .................................................... 5
memantine hcl/donepezil hcl ................................ 5
MENEST............................................................. 12
MENOPUR ......................................................... 10
menotropins ........................................................ 10
MEPHYTON ....................................................... 12
meprobamate ...................................................... 6
mercaptopurine ................................................ 15
mesalamine ....................................................... 14
mesalamine w/cleansing wipes ...................... 14
MESTINON........................................................... 5
METADATE CD .................................................... 6
METADATE ER .................................................... 6
METAGLIP ........................................................... 9
metaproterenol sulfate ...................................... 5
metaxalone ........................................................ 17
metformin hcl ................................................ 9, 10
meth/meth blue/ba/salicy/hyos ........................... 12
methadone hcl .................................................. 16
methazolamide ................................................. 11
METHERGINE ..................................................... 8
methimazole ...................................................... 11
METHITEST ....................................................... 12
methocarbamol ................................................. 17
methotrexate ..................................................... 14
METHOTREXATE 2.5MG TABLET ................... 15
methotrexate sodium ................................. 14, 15
METHOTREXATE VIAL ..................................... 15
methoxsalen ......................................................... 9
methoxsalen, rapid ............................................... 9
methyldopa ......................................................... 7
methylergonovine maleate ................................... 8
METHYLIN ........................................................... 6
METHYLIN CHEW TABS ..................................... 6
methylnaltrexone bromide .................................. 15
methylphenidate hcl........................................... 6
methylphenidate hcl ER suspension .................... 6
methylprednisolone ......................................... 14
methyltestosterone ............................................. 12
metipranolol ...................................................... 11
metoclopramide hcl ......................................... 17
METOCLOPRAMIDE HCL INTENSOL .............. 17
metolazone .......................................................... 7
metoprolol succinate ......................................... 7
metoprolol tartrate ............................................. 7
metoprolol/hctz ..................................................... 7
METROCREAM ................................................... 8
METROGEL-VAGINAL ...................................... 18
METROLOTION ................................................... 8
metronidazole ......................................... 8, 13, 18
MEVACOR ........................................................... 7
mexiletine hcl ...................................................... 6
MEXITIL................................................................ 6
miconazole nitrate ............................................ 18
MICRO-K ............................................................ 10
MICRONASE ........................................................ 9
MICROZIDE ......................................................... 7
midodrine hcl ...................................................... 8
MIDRIN ............................................................... 16
mifepristone .......................................................... 9
MIGERGOT ........................................................ 16
MILLIPRED......................................................... 14
MILLIPRED DP .................................................. 14
milnacipran hcl ................................................... 16
MILTOWN............................................................. 6
Mineralocorticoids .............................................. 14
MINIPRESS .......................................................... 6
MINOCIN ............................................................ 13
minocycline hcl ................................................ 13
STATE OF MICHIGAN COMMERCIAL FORMULARY
APRIL 2016
INDEX
Miotics/Other Intraoc. Pressure Reducers ......... 11
mipomersen sodium ............................................. 7
mirabegron ......................................................... 17
MIRALAX ............................................................ 15
MIRAPEX ........................................................... 17
MIRCETTE ........................................................... 8
mirtazapine.......................................................... 5
MISCELLANEOUS AGENTS ............................. 15
misoprostol ....................................................... 17
mitotane .............................................................. 15
MOBIC ................................................................ 14
modafinil .............................................................. 6
moexipril hcl ....................................................... 7
moexipril/hydrochlorothiazide .......................... 6
mometasone furoate ........................................ 5, 9
mometasone/formoterol ....................................... 5
MONISTAT 3 ...................................................... 18
Monoclonal Antibodies To Immunoglobulin E(ige)
........................................................................ 5
MONOKET ........................................................... 8
MONOPRIL .......................................................... 7
MONOPRIL HCT .................................................. 6
montelukast sodium .......................................... 5
morphine sulfate .............................................. 16
MOTRIN ............................................................. 14
MOVANTIK ......................................................... 15
moxifloxacin hcl ............................................ 11, 13
MS CONTIN ....................................................... 16
MSIR ................................................................... 16
mth/me blue/salicy/na phos/hyo ......................... 12
Mucolytics ........................................................... 16
MUCOMYST-10 ................................................. 16
MULTAQ ............................................................... 6
Multivitamin Preparations ................................... 18
multivitamins with min no.7/fa ........................ 18
mupirocin ............................................................ 8
mupirocin calcium ........................................... 8, 16
MYAMBUTOL ..................................................... 13
MYCELEX .......................................................... 13
MYCIFRADIN ..................................................... 13
MYCI-GC .............................................................. 8
MYCOLOG II ........................................................ 9
mycophenolate mofetil .................................... 12
MYCOSTATIN ................................................ 8, 13
Mydriatics ........................................................... 11
MYLERAN .......................................................... 15
MYRBETRIQ ...................................................... 17
MYSOLINE ......................................................... 17
na sulfacetm/prednis sp .................................. 11
na sulfacetm/prednisol ac .................................. 11
nabumetone ...................................................... 14
nadolol ................................................................. 7
naftifine hcl ......................................................... 9
NAFTIN ................................................................. 9
NALEX A 12 ......................................................... 8
NALFON CAPSULES......................................... 14
NALFON TABLETS ............................................ 14
naltrexone hcl ..................................................... 6
NAMENDA............................................................ 5
NAMENDA XR ..................................................... 5
NAMZARIC ........................................................... 5
NAPROSYN ....................................................... 14
naproxen ........................................................... 14
naproxen sodium ............................................. 14
naratriptan .......................................................... 16
Narc. & Non-Sal. Analgesic, Barbiturate &
Xanthine Comb ............................................ 16
NARCAN NASAL ................................................. 6
Narcotic & Salicylate Analgesics, Barb. &
Xanthine ....................................................... 16
Narcotic Analgesic & Non-Salicylate Analgesic
Comb ............................................................ 17
Narcotic Antagonists ............................................ 6
Narcotic Antagonists, Peripherally-Acting .......... 15
Narcotic Antituss-1st Gen. AntihistamineDecongest ...................................................... 8
Narcotic Antituss-Decongestant-Expectorant
Comb .............................................................. 8
Narcotic Antitussive-1st Generation Antihistamine
........................................................................ 8
Narcotic Antitussive-Expectorant Combination .... 8
NARDIL ................................................................ 5
NASACORT AQ ................................................... 5
Nasal Antihistamine.............................................. 5
Nasal Anti-Inflammatory Steroids ........................ 5
804PA, apr 2016
NASAREL ............................................................. 5
NASONEX ............................................................ 5
nateglinide........................................................... 9
NAVANE ............................................................... 6
nebivolol hcl .......................................................... 7
NEBUPENT ........................................................ 13
nedocromil sodium ............................................. 11
needles, insulin disp., safety .............................. 16
Needles/Needleless Devices ............................. 16
nelfinavir mesylate .............................................. 14
neo/polymyx b sulf/dexameth ......................... 11
NEODECADRON ............................................... 11
neomy sulf/bacitrac zn/poly/hc ....................... 11
neomy sulf/polymyx b sulf/hc ................... 9, 10, 11
neomy sulf/polymyx b sulf/pred .......................... 11
neomycin sulfate .............................................. 13
neomycin sulfate/dex na ph ............................ 11
neomycin/bacitra/polymyxin/hc ............................ 9
neomycin/bacitracin/polymyxin ..................... 11
neomycin/polymyxn b/gramicidin .................. 11
NEOPLASTIC DISEASE .................................... 15
NEORAL ............................................................. 12
NEOSPORIN OPHTH DROPS .......................... 11
NEOSPORIN OPHTH OINTMENT .................... 11
neostigmine bromide ............................................ 5
nepafenac ........................................................... 11
NEPTAZANE ...................................................... 11
netupitant/palonosetron hcl .................................. 5
NEULASTA......................................................... 12
NEUPOGEN ....................................................... 12
NEUPRO ............................................................ 17
NEUROLOGICAL DISEASE - MISCELLANEOUS
...................................................................... 16
NEURONTIN ...................................................... 17
NEVANAC .......................................................... 11
nevirapine.......................................................... 13
NEXAVAR .......................................................... 15
NEXIUM .............................................................. 17
niacin ............................................................... 7, 8
Niacin Preparations .............................................. 8
niacin/simvastatin ................................................. 7
NIASPAN .............................................................. 7
nicardipine ............................................................ 7
nifedipine ............................................................. 7
NILANDRON ...................................................... 15
nilotinib hydrochloride......................................... 15
nilutamide ........................................................... 15
nimodipine .......................................................... 7
NIMOTOP ............................................................. 7
NINLARO ............................................................ 15
nintedanib esylate .............................................. 16
NITRO-BID ........................................................... 8
NITRO-DUR ......................................................... 8
Nitrofuran Derivatives ......................................... 13
nitrofurantoin ...................................................... 13
nitrofurantoin macrocrystal ............................ 13
nitrofurantoin/nitrofuran mac ......................... 13
nitroglycerin ........................................................ 8
NITROLINGUAL ................................................... 8
NITROSTAT ......................................................... 8
nizatidine ........................................................... 17
NIZORAL ........................................................ 8, 13
NOCTEC .............................................................. 6
NOLVADEX ........................................................ 15
Non-Narc Antitussive-1st Gen Antihistamine
Comb. ............................................................. 8
Non-Narcotic Antitussive & Expectorant Comb. .. 8
NORCO .............................................................. 16
NORDETTE-28 .................................................... 8
NORDITROPIN .................................................. 11
NORDITROPIN FLEXPRO ................................ 11
NORDITROPIN NORDIFLEX ............................ 11
norelgestromin/ethin.estradiol .............................. 8
Norepinephrine & Dopamine Reuptake Inhib
(ndris) ............................................................. 5
noreth a-et estra/fe fumarate............................. 8
norethind ac/ethinyl estradiol ......................... 12
norethindrone ..................................................... 8
norethindrone acetate ..................................... 12
norethindrone a-e estradiol ............................... 8
norethindrone-ethinyl estrad ............................ 8
norethindrone-mestranol .................................. 8
NORFLEX........................................................... 17
NORGESIC FORTE ........................................... 17
norgestimate-ethinyl estradiol .......................... 8
31
norgestrel-ethinyl estradiol ............................... 8
NORINYL 1+35 .................................................... 8
NORINYL 1+50 .................................................... 8
NORPACE ............................................................ 6
NORPACE CR ..................................................... 6
NORPRAMIN ....................................................... 6
NOR-Q-D .............................................................. 8
nortriptyline hcl .................................................. 6
NORVASC ............................................................ 7
NORVIR .............................................................. 14
Nose Preparations, Antibiotics ........................... 16
Nose Preparations, Miscellaneous (Rx)............. 16
NOVAHISTINE DH ............................................... 8
NOVAREL .......................................................... 10
NOVOFINE ......................................................... 16
NOVOFINE AUTOCOVER ................................. 16
nph, human insulin isophane ............................. 10
NSAIDs, Cyclooxygenase Inhibitor-Type ........... 14
NUCYNTA .......................................................... 16
NULYTELY WITH FLAVOR PACKS .................. 15
NUVARING........................................................... 8
NYDRAZID ......................................................... 13
nystatin .......................................................... 8, 13
nystatin/triamcin ................................................. 9
OCL .................................................................... 15
octreotide acetate ............................................. 16
OCUFEN ............................................................ 11
OCUFLOX .......................................................... 11
OCUPRESS ....................................................... 11
ODOMZO ........................................................... 15
OFEV .................................................................. 16
ofloxacin ................................................ 10, 11, 13
OFORTA............................................................. 15
OGEN ................................................................. 12
olanzapine ............................................................ 6
olanzapine/fluoxetine HCl ................................. 5
olaparib ............................................................... 15
olmesartan medoxomil ......................................... 7
olmesartan/amlodipin/hcthiazid ............................ 7
olmesartan/hydrochlorothiazide ........................... 7
olodaterol hcl ........................................................ 5
olopatadine hcl ................................................. 11
OLUX .................................................................... 9
omega-3 acid ethyl esters .................................... 7
omeprazole........................................................ 17
omeprazole magnesium .................................. 17
OMNICEF ........................................................... 12
OMNIPRED ........................................................ 11
OMNITROPE ...................................................... 11
ondansetron ........................................................ 5
ondansetron hcl ................................................. 5
Ophthalmic Antibiotics ........................................ 11
Ophthalmic Anti-Inflammatory ImmunomodulatorType ............................................................. 11
Ophthalmic Mast Cell Stabilizers ....................... 11
OPSUMIT ............................................................. 7
OPTICROM ........................................................ 11
OPTIPRANOLOL ............................................... 11
OPTIVAR ............................................................ 11
Oral Inhaled Corticosteroids ................................. 5
ORAL/PHARYNGEAL DISORDERS ................. 16
ORALAIR .............................................................. 5
ORAMORPH SR ................................................ 16
ORAPRED .......................................................... 14
ORINASE ............................................................. 9
ORKAMBI ........................................................... 16
orphenadrine citrate......................................... 17
orphenadrine/aspirin/caffeine ......................... 17
ORTHO EVRA ...................................................... 8
ORTHO MICRONOR ........................................... 8
ORTHO TRI-CYCLEN .......................................... 8
ORTHO TRI-CYCLEN LO .................................... 8
ORTHO-CEPT ...................................................... 8
ORTHO-CYCLEN ................................................. 8
ORTHO-NOVUM .................................................. 8
ORUVAIL ............................................................ 14
oseltamivir phosphate ........................................ 13
osimertinib mesylate........................................... 15
OTHER DRUGS ................................................. 16
Otic Preparations, Anti-Inflammatory-Antibiotics 10
Otic Preparations, Local anesthetics ................. 10
OTICIN HC ......................................................... 10
OTREXUP .......................................................... 14
OVACE PLUS SUSPENSION.............................. 9
OVIDE .................................................................. 9
STATE OF MICHIGAN COMMERCIAL FORMULARY
APRIL 2016
INDEX
OVIDREL ............................................................ 10
oxaprozin........................................................... 14
oxazepam ............................................................ 6
Oxazolidinones ................................................... 13
oxcarbazepine .................................................. 17
OXSORALEN ....................................................... 9
OXSORALEN-ULTRA .......................................... 9
oxybutynin chloride ......................................... 18
oxycodone hcl .................................................. 16
oxycodone hcl/acetaminophen (325mg) ....... 16
oxycodone hcl/acetaminophen (325mg/15ml)
...................................................................... 16
oxycodone hcl/aspirin ..................................... 16
OXYCONTIN ...................................................... 16
Oxytocics .............................................................. 8
PAIN MANAGEMENT - ANALGESICS .............. 16
palbociclib ........................................................... 15
PAMELOR ............................................................ 6
Pancreatic Enzymes........................................... 17
PANCRELIPASE 5,000 ...................................... 17
PANDEL ............................................................... 9
panobinostat lactate ........................................... 15
pantoprazole sodium ....................................... 17
PARAFON FORTE DSC .................................... 17
Parasympathetic Agents .................................... 15
PARCOPA .......................................................... 17
paricalcitol........................................................... 11
PARKINSONS DISEASE ................................... 17
PARLODEL ........................................................ 17
PARNATE............................................................. 5
paromomycin sulfate ....................................... 13
paroxetine hcl ..................................................... 5
PATADAY ........................................................... 11
PATANOL ........................................................... 11
PATHOCIL.......................................................... 13
PAXIL ................................................................... 5
PAXIL CR ............................................................. 5
pazopanib hydrochloride .................................... 15
PCE .................................................................... 12
PEDIAPRED ....................................................... 14
PEDIATAN............................................................ 5
Pediatric Vitamin Preparations ........................... 18
PEDIAZOLE ....................................................... 12
peg 3350/na sulf,bicarb,cl/kcl ......................... 15
PEGASYS .......................................................... 14
pegfilgrastim ....................................................... 12
peginterferon alfa-2a .......................................... 14
peginterferon beta-1a ......................................... 16
pegvisomant ....................................................... 11
pemirolast potassium ......................................... 11
penicillamine ....................................................... 14
penicillin v potassium ...................................... 13
Penicillins ............................................................ 13
pentamidine isethionate ..................................... 13
PENTASA ........................................................... 14
pentosan polysulfate sodium .............................. 17
pentoxifylline .................................................... 12
PEPCID .............................................................. 17
PEPCID RPD ..................................................... 17
p-ephed hcl/cetirizine hcl (OTC) ....................... 5
p-ephed hcl/cod/chlorphenir ............................. 8
p-ephed hcl/codeine/guaifen............................. 8
p-ephed hcl/fexofenadine hcl............................ 5
p-ephed sul/loratadine ....................................... 5
PERCOCET........................................................ 16
PERCODAN ....................................................... 16
PERCOLONE ..................................................... 16
PERFOROMIST ................................................... 5
PERIACTIN .......................................................... 5
PERIDEX ............................................................ 16
PERISOL ............................................................ 16
permethrin ........................................................... 9
perphenazine ...................................................... 6
PERSANTINE .................................................... 12
phenazopyridine hcl......................................... 17
phenelzine sulfate ................................................ 5
PHENERGAN ....................................................... 5
PHENERGAN VC ................................................. 8
PHENERGAN VC W/CODEINE........................... 8
PHENERGAN W/CODEINE ................................. 8
PHENERGAN W/DEXTROMETHORPHAN ........ 8
phenobarbital ...................................................... 6
PHENOBARBITAL ............................................... 6
phenoxybenzamine hcl ...................................... 6
phenylephrine hcl/cod/prometh ....................... 8
804PA, apr 2016
phenylephrine hcl/prometh hcl ......................... 8
phenylephrine/brompheniramine ..................... 8
phenylephrine/chlor-tan .................................... 8
phenylephrine/hydrocodone/cp ....................... 8
phenylephrine/pyril tan/cp ................................ 8
PHENYTEK ........................................................ 17
phenytoin .......................................................... 17
phenytoin sodium extended ........................... 17
PHOSLO ............................................................. 10
Phosphodiesterase-4 (PD-4) Inhibitors ................ 5
PHRENILIN ........................................................ 16
PHRENILIN FORTE ........................................... 16
phytonadione ...................................................... 12
PICATO ................................................................ 9
pilocarpine hcl ............................................ 11, 15
pindolol ................................................................ 7
pioglitazone hcl .................................................. 9
pioglitazone hcl/metformin hcl ............................ 10
pioglitazone/glimepiride ...................................... 10
pirfenidone .......................................................... 16
piroxicam........................................................... 14
Pituitary Suppressive Agents ............................. 11
PLAN B ................................................................. 8
PLAQUENIL ....................................................... 13
Platelet Aggregation Inhibitors ........................... 12
Platelet Reducing Agents ................................... 12
PLAVIX ............................................................... 12
PLAVIX 300MG .................................................. 12
PLEGRIDY ......................................................... 16
PLEGRIDY PEN ................................................. 16
PLENDIL ............................................................... 7
PLETAL .............................................................. 12
podofilox ............................................................. 8
POLARAMINE ...................................................... 5
POLYCILLIN ....................................................... 13
POLYCIN-B ........................................................ 11
polyethylene glycol 3350 ................................. 15
polymyxin b sulfate/tmp .................................. 11
POLY-PRED ....................................................... 11
POLYTRIM ......................................................... 11
POLY-VI-FLOR .................................................. 18
POLY-VI-FLOR W/IRON .................................... 18
pomalidomide ..................................................... 15
POMALYST ........................................................ 15
ponatinib ............................................................. 15
pot chloride/pot bicarb/cit ac .......................... 10
potassium bicarbonate/cit ac.......................... 10
potassium chloride .......................................... 10
potassium iodide .............................................. 11
POTASSIUM IODIDE ......................................... 11
Potassium Replacement .................................... 10
Potassium Sparing Diuretics ................................ 7
Potassium Sparing Diuretics In Combination ...... 7
pramipexole di-hcl ............................................ 17
pramlintide acetate ............................................... 9
PRAMOSONE ...................................................... 9
PRANDIMET ...................................................... 10
PRANDIN ............................................................. 9
prasugrel hcl ....................................................... 12
PRAVACHOL ....................................................... 7
pravastatin sodium ............................................ 7
praziquantel ........................................................ 13
prazosin hcl......................................................... 6
PRECOSE ............................................................ 9
PRED FORTE .................................................... 11
PRED MILD ........................................................ 11
PREDNISOL ....................................................... 11
prednisolone ..................................................... 14
prednisolone acetate ....................................... 11
prednisolone sod phosphate .................... 11, 14
prednisone ........................................................ 14
PREDNISONE INTENSOL ................................ 14
pregabalin ........................................................... 17
Pregnancy Facilitating/Maintaining Agent,
Hormonal ...................................................... 10
PREGNYL .......................................................... 10
PREMARIN................................................... 12, 18
PREMPHASE ..................................................... 12
PREMPRO ......................................................... 12
prenatal vit 15/iron cb/fa/dss........................... 18
prenatal vit 16/iron cb/fa/dss........................... 18
prenatal vit 18/iron cb/fa/dss........................... 18
Prenatal Vitamin Preparations ........................... 18
PRENATE GT .................................................... 18
PREVACID ......................................................... 17
32
PREVACID SOLUTABS ..................................... 17
PREVPAC .......................................................... 17
PREZCOBIX ....................................................... 13
PREZISTA .................................................... 13, 14
PRILOSEC ......................................................... 17
PRILOSEC OTC ................................................. 17
PRIMAQUINE ..................................................... 13
primaquine phosphate ........................................ 13
primidone .......................................................... 17
PRIMSOL ........................................................... 12
PRINIVIL ............................................................... 7
PRINZIDE ............................................................. 6
PRISTIQ ............................................................... 5
PROAIR HFA ....................................................... 5
PROAIR RESPICLICK ......................................... 5
PROAMATINE ...................................................... 8
probenecid ........................................................ 12
procainamide hcl ................................................ 6
procarbazine hcl ................................................. 15
PROCARDIA ........................................................ 7
PROCARDIA XL ................................................... 7
PROCHIEVE ...................................................... 10
prochlorperazine edisylate ................................... 5
prochlorperazine maleate .................................. 5
PROCRIT ........................................................... 12
PROCTOCORT .................................................. 14
PROCTOCREAM-HC......................................... 14
PROCTOFOAM-HC ........................................... 14
PROCTO-KIT ..................................................... 14
PROCYSBI ......................................................... 17
PROFASI ............................................................ 10
Progestational Agents ........................................ 12
progesterone, micronized ............................. 10, 12
PROGRAF .......................................................... 12
PROLIXIN ............................................................. 6
PROLOPRIM ...................................................... 12
PROMACTA ....................................................... 12
promethazine hcl ................................................ 5
PROMETRIUM ................................................... 12
PRONESTYL ........................................................ 6
propafenone hcl ................................................. 6
PROPINE ........................................................... 11
propranolol hcl ................................................... 7
propranolol/hydrochlorothiazid ........................ 7
propylthiouracil ................................................... 11
PROPYLTHIOURACIL ....................................... 11
PROSCAR .......................................................... 17
PROSED-DS ...................................................... 12
PROSOM.............................................................. 6
PROSTIGMIN ....................................................... 5
PROTONIX ......................................................... 17
Proton-Pump Inhibitors ...................................... 17
PROTOPIC ........................................................... 9
PROVERA .......................................................... 12
PROVIGIL............................................................. 6
PROZAC ............................................................... 5
PROZAC WEEKLY .............................................. 5
pseudoephedrine hcl/chlor-mal ........................ 8
Pulm. Anti-HTN, Sel. C-GMP Phosphodiesterase
T5 Inhib .......................................................... 7
PULMICORT FLEXHALER .................................. 5
PULMICORT RESPULES .................................... 5
Pulmonary Anti-HTN, Endothelin Receptor
Antagonist ...................................................... 7
Pulmonary Anti-HTN, Soluble Guanylate Cyclase
Stimulators ..................................................... 7
PULMOZYME ..................................................... 16
PURINETHOL .................................................... 15
PURIXAN ............................................................ 15
pyrazinamide .................................................... 13
PYRAZINAMIDE ................................................ 13
PYRIDIUM .......................................................... 17
pyridostigmine bromide .................................... 5
pyrimethamine .................................................... 13
pyrimethamine/sulfadoxine ................................ 13
QNASL ................................................................. 5
QUALAQUIN ...................................................... 13
QUESTRAN.......................................................... 7
QUESTRAN LIGHT .............................................. 7
quetiapine fumarate ........................................... 6
QUILLIVANT XR .................................................. 6
QUINAGLUTE ...................................................... 6
quinapril hcl ........................................................ 7
quinapril/hydrochlorothiazide........................... 6
QUINIDEX ............................................................ 6
STATE OF MICHIGAN COMMERCIAL FORMULARY
APRIL 2016
INDEX
quinidine gluconate ........................................... 6
quinidine sulfate ................................................. 6
quinine sulfate .................................................... 13
Quinolones ......................................................... 13
QVAR ................................................................... 5
RAGWITEK .......................................................... 5
raloxifene hcl .................................................... 10
raltegravir potassium .......................................... 14
ramipril ................................................................ 7
RANEXA ............................................................... 8
ranitidine hcl ..................................................... 17
ranolazine ............................................................. 8
RAPAMUNE ....................................................... 12
rasagiline mesylate............................................. 17
RAZADYNE .......................................................... 5
REBETOL ........................................................... 14
REBIF ................................................................. 16
Rectal Preparations ............................................ 14
Rectal/Lower Bowel Prep., Glucocort. (NonHemorr) ........................................................ 14
REDERM .............................................................. 9
REGLAN ............................................................. 17
regorafenib ......................................................... 15
REGRANEX ....................................................... 10
RELAFEN ........................................................... 14
RELISTOR.......................................................... 15
REMERON ........................................................... 5
RENAGEL .......................................................... 10
RENVELA ........................................................... 10
repaglinide .......................................................... 9
repaglinide/metformin hcl ............................... 10
REPRONEX ....................................................... 10
REQUIP .............................................................. 17
REQUIP XL ........................................................ 17
RESCRIPTOR .................................................... 13
reserpine ............................................................. 7
RESTASIS .......................................................... 11
RESTORIL............................................................ 6
RETROVIR ......................................................... 13
REVATIO TABLET ............................................... 7
REVIA ................................................................... 6
REVLIMID........................................................... 15
REYATAZ ........................................................... 14
RHEUMATREX .................................................. 14
ribavirin ......................................................... 13, 14
RIFADIN ............................................................. 13
RIFAMATE ......................................................... 13
rifampin ............................................................. 13
rifampin/isoniazid ............................................. 13
Rifamycin and Related Derivative Antibiotics .... 13
rifaximin .............................................................. 13
riociguat ................................................................ 7
RIOMET .............................................................. 10
RISPERDAL ......................................................... 6
RISPERDAL M TAB ............................................. 6
risperidone .......................................................... 6
RITALIN ................................................................ 6
RITALIN LA .......................................................... 6
RITALIN-SR.......................................................... 6
ritonavir ............................................................... 14
rivaroxaban ......................................................... 12
rivastigmine patch .............................................. 5
rivastigmine tartrate ........................................... 5
rizatriptan benzoate ......................................... 16
ROBAXIN ........................................................... 17
ROBAXIN-750 .................................................... 17
ROCALTROL ..................................................... 18
roflumilast ............................................................. 5
ROMYCIN ........................................................... 11
ropinirole hcl ..................................................... 17
Rosacea Agents, Topical ..................................... 8
rosuvastatin calcium ............................................. 7
rotigotine ............................................................. 17
ROWASA............................................................ 14
ROXANOL .......................................................... 16
ROXICET ............................................................ 16
ROXICODONE ................................................... 16
ROXICODONE INTENSOL ................................ 16
ruloxitinib ............................................................ 15
RYNATAN ............................................................ 8
RYNATAN PEDIATRIC ........................................ 8
RYTHMOL ............................................................ 6
RYTHMOL SR ...................................................... 6
SALAGEN........................................................... 15
salmeterol xinafoate ............................................. 5
804PA, apr 2016
salsalate ............................................................ 16
SANDIMMUNE ................................................... 12
SANDOSTATIN .................................................. 16
SANDOSTATIN LAR .......................................... 16
sapropterin dihydrochloride ................................ 15
saquinavir mesylate............................................ 14
sargramostim ...................................................... 12
SAVELLA............................................................ 16
SCALACORT ....................................................... 9
SCALACORT DK ................................................. 9
SEASONALE ........................................................ 8
SECTRAL ............................................................. 7
secukinumab ...................................................... 9
Sedative-Hypnotics, Non-Barbiturate ................... 6
SEIZURE DISORDER ........................................ 17
Selective Estrogen Receptor Modulators (SERM)
...................................................................... 15
Selective Retinoid X Receptor Agonists (RXR) . 16
Selective Serotonin Reuptake Inhibitors (SSRIs) 5
selegiline hcl ..................................................... 17
selenium sulfide ................................................. 9
selexipag .............................................................. 7
SELSUN RX ......................................................... 9
SELZENTRY ...................................................... 13
SEPTRA ............................................................. 12
SEPTRA DS ....................................................... 12
SERAX ................................................................. 6
SEREVENT DISKUS............................................ 5
SEROPHENE ..................................................... 10
SEROQUEL.......................................................... 6
Serotonin-2 Antagonist/Reuptake Inhibitors
(SARIs) ........................................................... 5
Serotonin-Norepinephrine Reuptake-Inhib
(SNRIs) ........................................................... 5
SERPASIL ............................................................ 7
sertraline hcl ....................................................... 5
sevelamer carbonate .......................................... 10
sevelamer hcl ..................................................... 10
SFROWASA ....................................................... 14
short ragweed pollen extract ................................ 5
sildenafil citrate ............................................ 7, 10
SILVADENE ......................................................... 9
silver sulfadiazine .............................................. 9
SIMBRINZA ........................................................ 11
SIMCOR ............................................................... 7
simvastatin .......................................................... 7
SINEMET 25-100 ............................................... 17
SINEMET CR ..................................................... 17
SINEQUAN ........................................................... 6
SINGULAIR .......................................................... 5
sirolimus ............................................................. 12
sitagliptin phos/metformin hcl ............................... 9
sitagliptin phosphate............................................. 9
sitagliptin/simvastatin ........................................... 9
SIVEXTRO ......................................................... 13
SKELAXIN .......................................................... 17
SKELETAL MUSCLE DISORDER ..................... 17
Skeletal Muscle Relaxants ................................. 17
SLO-NIACIN ......................................................... 8
sod chloride/nahco3/kcl/peg's ........................ 15
sodium chloride for inhalation ............................ 16
sodium fluoride ................................................... 18
sodium phenylbutyrate ....................................... 14
sodium polystyrene sulfonate ........................ 10
sofosbuvir ........................................................... 14
SOMA ................................................................. 17
SOMA COMPOUND .......................................... 17
SOMA COMPOUND WITH CODEINE .............. 16
Somatostatic Agents .......................................... 16
somatropin .......................................................... 11
SOMATULINE DEPOT....................................... 16
SOMAVERT ....................................................... 11
SONATA ............................................................... 6
sonidegib phosphate .......................................... 15
sorafenib tosylate ............................................... 15
SORIATANE ......................................................... 9
sotalol hcl ............................................................ 7
SOVALDI ............................................................ 14
SPECIALTY INJECTABLE CROSS
REFERENCE LISTING ................................ 19
SPIRIVA ............................................................... 5
spironolactone .................................................... 7
SPORANOX ....................................................... 13
SPRYCEL ........................................................... 15
33
SSRI & Antipsychotic,ATYP,(DA & Serotonin)
Comb. ............................................................. 5
STAGESIC-10 .................................................... 16
STARLIX............................................................... 9
stavudine ........................................................... 13
STELARA ........................................................... 14
STELAZINE .......................................................... 6
Steroid Antineoplastics ....................................... 16
STIOLTO RESPIMAT........................................... 5
STIVARGA ......................................................... 15
STRATTERA ........................................................ 6
STRENSIQ ......................................................... 16
STRIBILD ........................................................... 14
STRIVERDI RESPIMAT ....................................... 5
SUBOXONE ....................................................... 16
SUBUTEX........................................................... 16
sucralfate........................................................... 17
sulconazole nitrate ............................................... 9
SULFAC ............................................................. 11
sulfacetamide sodium ............................. 8, 9, 11
sulfadiazine ....................................................... 12
SULFADIAZINE .................................................. 12
sulfamethoxazole/trimethoprim ...................... 12
sulfanilamide....................................................... 18
sulfasalazine ..................................................... 14
sulfisoxazole acetyl ............................................ 12
sulindac ............................................................. 14
sumatriptan ....................................................... 16
sumatriptan succinate ..................................... 16
sunitinib malate .................................................. 15
SUPRAX ............................................................. 12
SUSTIVA ............................................................ 13
SUTENT ............................................................. 15
SUTTAR-2 ............................................................ 8
SUTTAR-SF ......................................................... 8
SYMBYAX ............................................................ 5
SYMLIN ................................................................ 9
SYMLINPEN 120 .................................................. 9
SYMLINPEN 60 .................................................... 9
SYMMETREL ..................................................... 17
SYNALAR ............................................................. 9
SYNJARDY ........................................................ 10
SYNTHROID ...................................................... 11
Syringes & Accessories ..................................... 10
syringes & needles ............................................. 10
tacrolimus ............................................................. 9
tacrolimus anhydrous ...................................... 12
tadalafil ........................................................... 7, 10
TAFINLAR .......................................................... 15
TAGAMET .......................................................... 17
TAGRISSO ......................................................... 15
TALADINE .......................................................... 17
TAMBOCOR ......................................................... 6
TAMIFLU ............................................................ 13
tamoxifen citrate ............................................... 15
tamsulosin hcl .................................................. 17
TAPAZOLE ......................................................... 11
tapentadol hcl ..................................................... 16
TARCEVA........................................................... 15
TARGRETIN ................................................... 9, 16
TASIGNA ............................................................ 15
tazarotene............................................................. 9
TAZORAC ............................................................ 9
tazorotene foam ................................................... 8
TECFIDERA ....................................................... 16
tedizolid phosphate ............................................ 13
teduglutide .......................................................... 15
TEGRETOL ........................................................ 17
TEGRETOL XR .................................................. 17
telbivudine .......................................................... 14
telithromycin ....................................................... 12
temazepam .......................................................... 6
TEMODAR.......................................................... 15
TEMOVATE .......................................................... 9
TEMOVATE EMOLLIENT .................................... 9
temozolomide ................................................... 15
TENEX.................................................................. 7
tenofovir disoproxil fumarate .............................. 14
TENORETIC 100 .................................................. 7
TENORETIC 50 .................................................... 7
TENORMIN .......................................................... 7
terazosin hcl ....................................................... 6
terbinafine hcl ................................................. 9, 13
terbutaline sulfate .............................................. 5
teriparatide.......................................................... 10
STATE OF MICHIGAN COMMERCIAL FORMULARY
APRIL 2016
INDEX
testosterone cypionate .................................... 12
testosterone enanthate .................................... 12
testosterone gel .................................................. 12
tetrabenazine ...................................................... 16
tetracycline hcl ................................................. 13
Tetracyclines ...................................................... 13
TEXACORT .......................................................... 9
thalidomide ......................................................... 13
THALITONE ......................................................... 7
THALOMID ......................................................... 13
THEO-24 .............................................................. 5
theophylline anhydrous ..................................... 5
THERMAZENE ..................................................... 9
Thiazide & Related Diuretics ................................ 7
thioguanine ....................................................... 15
THIOGUANINE .................................................. 15
thioridazine hcl ................................................... 6
thiothixene .......................................................... 6
THORAZINE ......................................................... 6
Thrombopoietin Receptor Agonists .................... 12
Thyroid Hormones .............................................. 11
thyroid, pork ........................................................ 11
TIAZAC ................................................................. 7
ticagrelor ............................................................. 12
TIKOSYN .............................................................. 6
timolol ................................................................. 11
timolol maleate ............................................. 7, 11
TIMOPTIC .......................................................... 11
TIMOPTIC-XE .................................................... 11
timothy grass pollen extract ................................. 5
tiotropium br/olodaterol hcl ................................... 5
tiotropium bromide ................................................ 5
tipranavir ............................................................. 13
tipranavir/vitamin e tpgs ..................................... 13
TIVICAY.............................................................. 14
tizanidine hcl ..................................................... 17
TOBI ................................................................... 13
TOBI PODHALER .............................................. 13
TOBRADEX ........................................................ 11
tobramycin for inhalation ................................ 13
tobramycin for inhalation (cap) ........................... 13
tobramycin sulfate ........................................... 11
tobramycin sulfate/dexameth ......................... 11
tobramycin/lotepred etab .................................... 11
TOBREX ............................................................. 11
TOFRANIL ............................................................ 6
tolazamide ........................................................... 9
tolbutamide ......................................................... 9
TOLECTIN 600 ................................................... 14
TOLINASE ............................................................ 9
tolmetin sodium ................................................ 14
tolterodine tartrate ........................................... 18
TOPAMAX .......................................................... 17
TOPAMAX SPRINKLE ....................................... 17
Topical Antibiotics ................................................ 8
Topical Antibiotics/Antiinflammatory,Steroidal ..... 9
Topical Antifungals ............................................... 8
Topical Anti-Inflammatory Steroidal ..................... 9
Topical Anti-Inflammatory, NSAIDs ..................... 9
Topical Antineoplastic & Premalignant Lesion
Agnts .............................................................. 9
Topical Antiparasitics ........................................... 9
Topical Antivirals .................................................. 9
Topical Hyperpigmentation Agents ...................... 9
Topical Immunosuppressive Agents .................... 9
Topical Local Anesthetics .................................... 9
Topical Preparations, Antibacterials .................... 8
Topical Sulfonamides ........................................... 9
TOPICORT ........................................................... 9
TOPICORT LP ..................................................... 9
topiramate ......................................................... 17
topotecan hcl ...................................................... 15
TOPROL XL ......................................................... 7
TORADOL .......................................................... 14
toremifene citrate ................................................ 16
torsemide ............................................................ 7
TOUJEO ............................................................. 10
TOVIAZ ............................................................... 18
TRACLEER .......................................................... 7
tramadol hcl ...................................................... 16
tramtinib dimethyl sulfoxide ................................ 15
TRANDATE .......................................................... 7
trandolapril .......................................................... 7
TRANXENE T-TAB .............................................. 6
tranylcypromine sulfate ..................................... 5
804PA, apr 2016
TRAVATAN ........................................................ 11
TRAVATAN Z ..................................................... 11
travoprost ............................................................ 11
travoprost (benzalkonium) .................................. 11
trazodone hcl ...................................................... 5
TRENTAL ........................................................... 12
tretinoin ............................................................... 15
TREXALL ............................................................ 15
triamcinolone acetonide .......................... 5, 9, 16
triamterene/hydrochlorothiazid ........................ 7
TRIAZ ................................................................... 8
triazolam .............................................................. 6
TRIBENZOR ......................................................... 7
TRICOR ................................................................ 7
Tricyclic Antidepressants & Rel. Non-Sel. RuInhib ................................................................ 6
TRIDERM ............................................................. 9
TRIDESILON ........................................................ 9
trifluoperazine hcl .............................................. 6
trifluridine .......................................................... 11
trifluridine/tipiracil hcl .......................................... 15
TRIGLIDE ............................................................. 7
trihexyphenidyl hcl........................................... 17
TRILAFON ............................................................ 6
TRILEPTAL ........................................................ 17
trimethoprim ..................................................... 12
TRI-NORINYL ...................................................... 8
TRIUMEQ ........................................................... 14
TRI-VI-FLOR W/IRON ........................................ 18
TRIZIVIR ............................................................. 13
TRUSOPT .......................................................... 11
TRUVADA .......................................................... 13
TUSNEL C ............................................................ 8
TUSNEL DIABETIC .............................................. 8
TUSSIONEX ......................................................... 8
TWINJECT ......................................................... 15
Tx For Attention Deficit-Hyperact
(ADHD)/Narcolepsy........................................ 6
Tx For Attention Deficit-Hyperact.(ADHD), NriType ............................................................... 6
TYBOST ............................................................. 14
TYKERB ............................................................. 15
TYLENOL-CODEINE NO.3 ................................ 17
TYLENOL-CODEINE NO.4 ................................ 17
TYZEKA .............................................................. 14
ULORIC .............................................................. 12
ULTRAM ............................................................. 16
ULTRASE ........................................................... 17
ULTRASE MT ..................................................... 17
ULTRAVATE ........................................................ 9
UNIPHYL .............................................................. 5
UNIRETIC ............................................................. 6
UNIVASC .............................................................. 7
UPPER GASTROINTESTINAL DISORDERS DIGESTIVE .................................................. 17
UPPER GASTROINTESTINAL DISORDERS SPASTIC DISEASE ..................................... 17
UPPER GASTROINTESTINAL DISORDERS ULCER DISEASE ........................................ 17
UPTRAVI .............................................................. 7
URECHOLINE .................................................... 15
URETRON D-S .................................................. 12
Uricosuric Agents ............................................... 12
URIN D.S. ........................................................... 12
URINARY TRACT - FUNCTIONAL DISORDERS
...................................................................... 17
Urinary Tract Analgesic Agents.......................... 17
Urinary Tract Anesthetic/Analgesic Agnt (AzoDye) .............................................................. 17
Urinary Tract Antispasmodic, M(3) Selective
Antag. ........................................................... 17
Urinary Tract Antispasmodic/Antiincontinence
Agent ............................................................ 18
urofollitropin (fsh) ................................................ 10
UROXATRAL ..................................................... 17
URSO ................................................................. 15
URSO FORTE .................................................... 15
ursodiol ............................................................. 15
ustekinumab ..................................................... 14
VAGIFEM ........................................................... 18
Vaginal Antibiotics .............................................. 18
Vaginal Antifungals ............................................. 18
VAGINAL DISORDERS ..................................... 18
Vaginal Estrogen Preparations .......................... 18
Vaginal Sulfonamides......................................... 18
34
valacyclovir hcl ................................................. 13
VALCHLOR .......................................................... 9
VALISONE............................................................ 9
VALIUM ................................................................ 6
valproate sodium .............................................. 17
valproic acid ..................................................... 17
valsartan .............................................................. 7
valsartan/hydrochlorothiazide .......................... 7
VALTREX ........................................................... 13
VANCOCIN HCL ................................................ 13
Vancomycin & Derivatives ................................. 13
vancomycin hcl ................................................ 13
VANDAZOLE ...................................................... 18
VANOS ................................................................. 9
VANOXIDE HC ..................................................... 8
VANOXIDE-HC .................................................... 8
VANSPAR ............................................................ 6
VANTIN .............................................................. 12
VASCEPA............................................................. 7
VASERETIC ......................................................... 6
VASOCIDIN ........................................................ 11
Vasodilators, Coronary ......................................... 8
VASOTEC ............................................................ 7
V-CILLIN K ......................................................... 13
VECTICAL ............................................................ 9
vemurafinib ......................................................... 15
venlafaxine hcl ................................................ 5, 6
VENTOLIN HFA ................................................... 5
VEPESID ............................................................ 15
verapamil hcl ...................................................... 7
VERELAN ............................................................. 7
VERELAN PM ...................................................... 7
VERMOX ............................................................ 13
VESANOID ......................................................... 15
VFEND ............................................................... 13
VIAGRA .............................................................. 10
VIBRAMYCIN ..................................................... 13
VIBRAMYCIN ORAL SUSPENSION ................. 13
VIBRAMYCIN SYRUP........................................ 13
VIBRA-TABS ...................................................... 13
VICODIN ............................................................. 16
VICODIN ES ....................................................... 16
VICODIN HP....................................................... 16
VICON FORTE ................................................... 18
VICTOZA .............................................................. 9
VIDEX ................................................................. 13
VIDEX EC ........................................................... 13
VIGAMOX ........................................................... 11
VIRACEPT.......................................................... 14
VIRAMUNE......................................................... 13
VIRAZOLE .......................................................... 13
VIREAD .............................................................. 14
VIROPTIC........................................................... 11
VISKEN ................................................................ 7
vismodegib ......................................................... 15
VISTARIL .............................................................. 5
Vitamin A Derivatives ........................................... 8
VITAMIN AND/OR MINERAL DEFICIENCY ..... 18
Vitamin B Preparations ...................................... 18
Vitamin D Preparations ...................................... 18
Vitamin K Preparations ...................................... 12
VITEKTA....................................................... 13, 14
VIVELLE-DOT .................................................... 12
VOLTAREN .................................................. 11, 14
VOLTAREN GEL .................................................. 9
VOLTAREN-XR .................................................. 14
voriconazole ....................................................... 13
vorinostat ............................................................ 15
VOSOL ............................................................... 10
VOSOL HC ......................................................... 10
VOTRIENT ......................................................... 15
VYTONE ............................................................... 8
VYVANSE............................................................. 6
warfarin sodium ................................................ 12
WELCHOL ............................................................ 7
WELCHOL POWDER PACKETS ........................ 7
WELLBUTRIN ...................................................... 5
WELLBUTRIN SR ................................................ 5
WELLBUTRIN XL ................................................. 5
WESTCORT ......................................................... 9
XALATAN ........................................................... 11
XALKORI ............................................................ 15
XANAX ................................................................. 6
Xanthines .............................................................. 5
XARELTO ........................................................... 12
STATE OF MICHIGAN COMMERCIAL FORMULARY
APRIL 2016
INDEX
XELODA ............................................................. 15
XENAZINE.......................................................... 16
xifaxan ................................................................ 13
XODOL 10-300 ................................................... 16
XTANDI .............................................................. 15
XYLOCAINE ....................................................... 14
XYZAL .................................................................. 5
YASMIN 28 ........................................................... 8
YAZ ....................................................................... 8
YODOXIN ........................................................... 13
zaleplon ................................................................ 6
ZANAFLEX ......................................................... 17
ZANTAC ............................................................. 17
ZANTAC 25 ........................................................ 17
ZARONTIN ......................................................... 17
ZAROXOLYN ....................................................... 7
ZEBETA ................................................................ 7
ZELBORAF......................................................... 15
ZEMPLAR........................................................... 11
ZENPEP ............................................................. 17
ZENZEDI .............................................................. 6
804PA, apr 2016
ZERIT ................................................................. 13
ZESTORETIC ....................................................... 6
ZESTRIL ............................................................... 7
ZETIA ................................................................... 7
ZIAC ..................................................................... 7
ZIAGEN .............................................................. 13
ZIANA ................................................................... 8
zidovudine ......................................................... 13
ziprasidone hcl ................................................... 6
ZIRGAN .............................................................. 11
ZITHROMAX ...................................................... 12
ZITHROMAX TRI-PAK ....................................... 12
ZMAX .................................................................. 12
ZMAX PEDIATRIC ............................................. 12
ZOCOR ................................................................. 7
ZOFRAN ............................................................... 5
ZOFRAN ODT ...................................................... 5
ZOLINZA ............................................................ 15
zolmitriptan ......................................................... 16
ZOLOFT ............................................................... 5
zolpidem tartrate ................................................ 6
35
zolpidem tartrate CR .......................................... 6
ZOMIG ................................................................ 16
ZOMIG ZMT ....................................................... 16
ZONEGRAN ....................................................... 17
zonisamide ........................................................ 17
ZORTRESS ........................................................ 12
ZOVIRAX ........................................................ 9, 13
ZYDELIG ............................................................ 15
ZYKADIA ............................................................ 15
ZYLET ................................................................ 11
ZYLOPRIM ......................................................... 12
ZYMAR ............................................................... 11
ZYMAXID ............................................................ 11
ZYPREXA ............................................................. 6
ZYPREXA ZYDIS ................................................. 6
ZYRTEC (OTC) .................................................... 5
ZYRTEC-D (OTC) ................................................ 5
ZYTIGA ............................................................... 15
ZYVOX ............................................................... 13
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