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Formulario Buena Salud de Rocky Mountain Health Plans (RMHP)
La familia de planes médicos de RMHP incluye estas entidades:
Rocky Mountain Health Maintenance Organization
Rocky Mountain HealthCare Options
www.rmhp.org
Revised 01/25/2016
Descarte todas las copias anteriores del formulario
Los beneficiarios deben usar las farmacias en red para tener acceso a sus beneficios de
medicamentos con receta médica.
¿Qué es el formulario
El formulario es una lista de medicamentos cubiertos seleccionados por Rocky Mountain Health Plans
(RMHP), en consulta con un equipo de proveedores de atención médica, que representa las terapias
recetadas que se consideran necesarias como parte de un programa de tratamiento de calidad. RMHP
generalmente cubrirá los medicamentos incluídos en nuestro formulario siempre y cuando el medicamento
sea médicamente necesario, la receta sea surtida en una farmacia en red y se sigan otras reglas del plan.
Para más información acerca de cómo rellenar sus prescripciones, por favor revise su Evidencia de Cobertura.
¿Puede cambiar el formulario?
Sí. El formulario no es una lista estática, pero continúa siendo revisado y modificado. RMHP se reserva
el derecho de cambiar la cobertura de un medicamento en cualquier momento apropiado y necesario
para permanecer al paso de las terapias actuales de drogas y de la medicina basada en evidencias. Si
retiramos medicamentos de nuestro formulario, añadimos requisitos de autorización previa o límites de
cantidad o cambiamos un medicamento a un nivel superior de costo compartido, informaremos de estos
cambios a los Miembros afectados. El estado genérico o de marca de cualquier medicamento está sujeto
a cambios en cualquier momento y no está sujeto a la notificación a los Miembros. Si la Administración
Federal de Alimentos y Medicamentos (FDA, por sus siglas en inglés) de los Estados Unidos considera
que un medicamento que se encuentra en nuestro formulario no es seguro o el fabricante del
medicamento lo retira del mercado, eliminaremos inmediatamente dicho medicamento de nuestro
formulario y le enviaremos un aviso a los Miembros que lo toman. El formulario adjunto está vigente a
partir del 02/01/2016. El formulario se actualiza constantemente. Para obtener información actualizada
sobre los medicamentos que cubre RMHP, por favor llame al Centro de Atención a Clientes.
Miembros Individuales y Miembros de Plan Grupal llamar al 970-243-7050 ó 800-346-4643
Miembros de Medicaid llamar al 970-244-7860 ó 888-282-8801
FORM-Good Health-February 2016
¿Cómo utilizo el formulario?
Existen dos formas de encontrar su medicamento en el formulario:
Por Condición Médica
Los medicamentos que se encuentran en este formulario se agrupan en categorías dependiendo del tipo de
enfermedad en que se utilizan. Por ejemplo, los medicamentos utilizados para tratar una enfermedad cardiaca
se detallan en la categoría “Agentes cardiovasculares”. Entonces busque su medicamento en esa categoría.
Por orden Alfabético
El índice presenta una lista alfabética de todos los medicamentos incluidos en este documento. En dicho
índice se detallan los medicamentos de marca y los genéricos. Busque su medicamento en el índice. Junto a
su medicamento, verá el número de página donde podrá encontrar información sobre la cobertura. Vaya a la
página que se indica en el índice y encuentre el nombre de su medicamento en la primera columna de la lista.
El formulario contiene información sobre la cobertura de algunos de los medicamentos cubiertos por el plan
médico. Si tiene problemas para encontrar su medicamento en la lista, consulte el índice.
La primera columna del cuadro indica el nombre del medicamento. Los medicamentos de marca aparecen en
mayúsculas (por ejemplo, ALLEGRA) y los medicamentos genéricos se describen en letra minúscula (por
ejemplo, amoxicilina).
La información que se encuentra en la columna Cobertura indica si el plan médico tiene algún requisito
especial para la cobertura de su medicamento. Consulte la siguiente clave de abreviaturas del formulario.
Consulte la sección “¿Existen restricciones sobre mi cobertura?”, donde encontrará información para obtener
autorización previa.
¿Qué son los medicamentos genéricos?
Un medicamento genérico contiene el mismo ingrediente activo que contiene un medicamento de marca. Los
medicamentos genéricos generalmente cuestan menos que los medicamentos de marca y han sido
aprobados por la Administración de Alimentos y Medicamentos de los Estados Unidos (FDA, por sus siglas en
inglés), organismo que asegura que se cumplan las siguientes condiciones:
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El medicamento genérico debe contener los mismos principios activos, tener la misma potencia y la
misma forma de dosificación que el medicamento de marca.
La FDA ha otorgado una calificación de “A” en comparación con el medicamento de marca homólogo
y, por lo tanto, ha determinado que el genérico es bioequivalente en términos terapéuticos.
Cuando se cumplen los dos criterios mencionados anteriormente, los medicamentos de marca pueden
sustituirse por genéricos con la plena certeza de que el producto sustituto tendrá el mismo efecto
clínico y perfil de seguridad que el producto recetado.
¿Qué es una sustitución genérica?
Algunos medicamentos se venden en una versión genérica que cuesta menos. Los medicamentos que tienen
una versión genérica disponible por lo general se surten en la farmacia en la versión genérica en lugar de la
de marca, salvo que su médico o usted soliciten el de marca.
Los medicamentos genéricos generalmente están incluidos en el nivel 1. Si un medicamento genérico no
ofrece ahorros financieros sobre la versión de marca, lo puede colocar en un nivel superior. Los
medicamentos que tienen un equivalente genérico se presentan en minúsculas. Cuando sale a la venta una
versión genérica de un medicamento de marca, el medicamento de marca se clasificará en un nivel superior.
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Es probable que los Miembros tengan que pagar más por una receta cuando adquieran el producto de marca
que se corresponde a un nivel superior. El pago que deberá efectuar el Miembro queda determinado por el
plan de beneficios de farmacia. Cuando el sustituto genérico entra en conflicto con los reglamentos o
restricciones estatales, el farmacéutico debe obtener primero la aprobación del médico tratante u otro
profesional de la salud para sustituir el medicamento de marca por el genérico equivalente.
¿Qué es intercambio terapéutico?
Rocky Mountain Health Plans admite, pero no requiere necesariamente el uso del intercambio terapéutico
como parte de una estrategia integral de tratamiento del paciente que sea económica y de calidad. El
intercambio terapéutico es la práctica de sustituir, con autorización del médico tratante, un medicamento que
originalmente se prescribió a un paciente por un medicamento con una composición química diferente. Se
espera que los medicamentos utilizados en los programas de intercambio terapéutico produzcan niveles
similares de eficacia clínica y resultados médicos sólidos, con base en los datos científicos disponibles.
La Academy of Managed Care Pharmacy describe el intercambio terapéutico como programas elaborados por
un equipo de médicos, farmacéuticos y otros profesionales médicos que son expertos en el diagnóstico y
tratamiento de las enfermedades. Estos programas se diseñan para funcionar en conjunto con otras
herramientas que los profesionales de la salud usan para promover resultados médicos de calidad.
El uso del intercambio terapéutico ofrece varias ventajas:
Valor para los pacientes: cuando el intercambio terapéutico tiene lugar es porque los médicos y otros expertos
de la salud han determinado que los pacientes experimentarán resultados clínicos similares o mejores con las
medicinas de reemplazo. Puede ser más cómodo para el paciente tomar el medicamento de reemplazo. Por
ejemplo, es más probable que el paciente tome el medicamento recetado si se le proporciona un producto
terapéuticamente equivalente que sólo necesita tomar dos veces al día en lugar de cuatro. Un medicamento
que tiene muchas probabilidades de causar efectos secundarios puede sustituirse por otro que tenga menos
probabilidades de causarlos. Un nuevo medicamento que ofrece mejores resultados terapéuticos puede
sustituir a otro anterior. Por lo general, hay menos probabilidades de que el paciente omita la dosis y, en
consecuencia, puede recibir todo el beneficio clínico del medicamento si le resulta práctico tomarlo, le causa
menos efectos secundarios o le proporciona mayor control o alivio de la enfermedad.
Asequibilidad: un medicamento de reemplazo que es equivalente en términos terapéuticos simplemente
puede costar menos. Una vez que se determina que dos medicamentos producen los mismos resultados
positivos para el paciente, conviene que el hospital, el plan médico o la red de farmacias usen la alternativa
menos cara. Además, esto puede dar por resultado desembolsos personales menores para el paciente debido
a las reducciones de los copagos. En los casos en que dos medicamentos son equivalentes terapéuticos, la
AMCP no admite los programas de intercambio terapéutico que dan por resultado costos más altos para los
pacientes o los patrocinadores del plan.
Sin embargo, el intercambio terapéutico no siempre se relaciona con costos menores de los medicamentos. El
intercambio terapéutico ocurre a menudo cuando es posible ahorrar en la atención médica en general. La
sustitución de un medicamento por otro más caro puede dar origen a menos fallas del tratamiento, mejor
observancia del plan de tratamiento por parte del paciente, menos efectos secundarios y mejores resultados
clínicos. Este uso eficiente de los recursos médico contribuye a reducir los gastos médicos, mejora el acceso
del paciente a atención médica más asequible y mejora la calidad de vida del paciente
¿Existe alguna restricción en mi cobertura?
Algunos medicamentos cubiertos pueden tener requisitos adicionales o limitaciones en la cobertura. Dichos
requisitos y limitaciones pueden incluir:
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 Autorización Previa: RMHP requiere que usted o su médico obtengan autorización previa para ciertos
medicamentos. Esto significa que deberá obtener la aprobación de RMHP antes de surtir sus recetas.
Si no obtiene dicha aprobación, el plan médico puede no cubrir el medicamento. Los 4 medicamentos
que están sujetos a autorización previa tienen un símbolo “PA” al lado del nombre del medicamento.
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Médicos y farmacias, favor llamar al 970-248-5031 or 800-641-8921
Fax: 858-357-2538
 Límites de Cantidad: En el caso de ciertos medicamentos, el plan de salud limita la cantidad del
medicamento que ser. Por ejemplo, el plan médico proporciona 12 dosis por receta de Imitrex en
tabletas. Esto puede ser adicional a la provisión normal para uno o tres meses. Los medicamentos que
están sujetos a límites de cantidad tienen un símbolo “QL” al lado del nombre del medicamento.
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Limitaciones de Reposición: las recetas pueden volver a surtirse cuando se ha
consumido 70% o más de la provisión diaria.
 Terapia escalonada: En algunos casos, el Plan de Salud exige que primero pruebe ciertos
medicamentos para tratar su enfermedad antes de que cubramos su su enfermedad antes de que
cubramos otro medicamento para dicha enfermedad. Por ejemplo, si el medicamento A y el medicamento
B sirven para tratar su enfermedad, es posible que no proporcionemos cobertura del medicamento B a
menos que usted pruebe primero el medicamento A. Si el medicamento A no le funciona, entonces
cubriremos el medicamento B. Los medicamentos que están sujetos a tratamiento escalonado tienen un
símbolo “ST” al lado del nombre del medicamento.
 Límite de edad: En algunos casos, los medicamentos sólo están disponibles para un Miembro que
pertenece a una categoría de edad seleccionada. Los medicamentos que están sujetos a límites de
edad tienen un símbolo “AGE” al lado del nombre del medicamento.
 Límite de género: Algunos medicamentos sólo están disponibles para Miembros de cierto género. Los
medicamentos que están disponibles sólo para cierto género tienen un símbolo “GM”/”GF” (Hombre /
Mujer) al lado del nombre del medicamento.
Para averiguar si su medicamento tiene algún requisito o límite adicional, busque dicho medicamento
en el formulario a partir de la página 9.
Medicamentos Especializados
Ciertas condiciones de salud crónica o difícil requieren el uso de medicamentos especializados. Esto es lo que
necesita saber acerca de estos medicamentos:
¿Qué hace que los medicamentos especializados sean diferentes?
Los medicamentos especializados por lo general requieren un manejo especial de administración o de
supervisión. Por lo general son muy caros y a menudo son prescritos por especialistas y podrían requerir la
aprobación previa de RMHP antes de poder surtir su receta. Es posible que tenga que ordenar a través de
una farmacia especializada.
¿Cómo sé si mi medicamento es un medicamento de especialidad?
Los medicamentos especializados se enumeran en los Niveles 4 y 5 en el formulario. El nivel 6 también
incluye algunos medicamentos especializados.
¿Dónde consigo los medicamentos especializados?
Usted puede conseguir algunos medicamentos especializados en una farmacia minorista. No todas las
farmacias despachan recetas para medicamentos de especialidad, así que consulte primero. Algunos
medicamentos especializados son de Distribución Limitada y sólo se pueden obtener de una farmacia
especializada RMHP. Estos incluyen la Modern Health, Diplomat, CVS, Accredo, y otros. Revise la lista de
medicamentos especiales para ver si un medicamento especializado es de Distribución Limitada.
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¿Puedo obtener un suministro de 90 días de medicamentos especializados como mi otra medicación?
Debido a que estos medicamentos pueden ser frágiles y pueden requerir un manejo especial o monitoreo,
sólo se puede solicitar un suministro para 30 días de medicamentos especializados. Algunos medicamentos
especializados son las inyecciones que duran 3 meses o 6 meses por inyección. Estos han sido aprobados
para esa duración.
Para preguntas acerca de los medicamentos especializados y nuestras farmacias especializadas, por favor
póngase en contacto con la oficina de asistencia farmacéutica de RMHP al 970-248-5031 (1-800-640-8921).
Exclusiones del formulario
RMHP se reserva el derecho de excluir cualquier medicamento del formulario de RMHP, en cualquier
momento, por motivos de salud y seguridad o por otras razones que RMHP determine a su exclusivo criterio.
Los siguientes medicamentos están excluidos del formulario de RMHP:
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Todo medicamento que por disposición de la FDA lleve la leyenda: “Precaución, limitado por la ley
federal al uso en investigación”
Medicamentos que no estén disponibles, no se comercialicen o no se vendan en los Estados Unidos.
Medicamentos obtenidos de una farmacia o proveedor situado fuera de los Estados Unidos, excepto
medicamentos obtenidos en relación con una emergencia médica.
Todo medicamento que no esté aprobado por la FDA.
Todo medicamento que se use en relación con un servicio o suministro que no sea un beneficio (por
ejemplo, los medicamentos empleados para la atención dental no están cubiertos).
Medicamentos perdidos o robados: RMHP no cubrirá reposiciones de recetas por medicamentos
perdidos, robados o dañados
Adicionalmente, todos los medicamentos de las siguientes categorías se excluyen de la cobertura del
formulario de RMHP:
Nombre o categoría genérica del medicamento
Anorexígenos/medicamentos para bajar de peso.
Ejemplo
Medicamentos compuestos que se emplean para indicaciones o
por vías de administración que no han sido autorizadas por la FDA.
Neurontin tópico y
bloqueadores de canales
de calcio de uso tópico.
Medicamentos compuestos para los cuales existe un fármaco
aprobado por la FDA en la potencia y dosis prescritas.
Hormonas compuestas no aprobadas por la FDA.*
Tri-est, Bi-est
Medicamentos compuestos inyectables para la disfunción eréctil.
Trimix, prostaglandins
Medicamentos compuestos que utilizan polvos. [Excepciones:
sulfonato de poliestireno (Kayexalate), ácido salicílico, nistatina,
cafeína]
Fármacos cosméticos.
Propecia, Renova, Vaniqa,
Lustra, Botox Cosmetic
DHEA
Medicamentos dentales.
Monodox, Periostat
Suplementos dietéticos
Deplin, Metanx, Limbrel,
Vayarin, Hypertensa,
Theramine
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Nombre o categoría genérica del medicamento
Soluciones nebulizadas compuestas a partir de polvo
Ejemplo
triamcinolone
Medicamentos que requieran receta médica para los cuales exista
un equivalente disponible de Venta Libre. Ciertos medicamentos de
Venta Libre están cubiertos bajo la Ley de protección al paciente y
del Cuidado de Salud a Bajo Precio para Grupos Comerciales y
Miembros Individuales solamente.
Claritin, lac-hydrin
* La progesterona en la inyección de aceite no está dentro de estas exclusiones.
Medicamentos venta libre: Los Medicamentos de Venta Libre, con la excepción de la insulina, no están
cubiertos. Para los pacientes con diálisis renales : antiácidos, todas las multi-vitaminas, reemplazo de calcio,
Proferrin y Proferrin Forte están cubiertos con una autorización previa. Los Medicamentos de Venta Libre para
dejar de fumar están cubiertos por Medicaid con autorización previa, los ejemplos incluyen el parche Nicoderm
y la goma de mascar Nicorette.
Los Medicamentos de Venta Libre cubiertos bajo la Ley de protección al paciente y del Cuidado de
Salud a Bajo Precio (PPACA por sus siglas en Inglés): requiere que los planes de salud cubran el costo de
algunos productos de venta libre para grupos comerciales y miembros de grupos individuales solamente. Se
requiere una receta de su médico para este reembolso. Estos productos incluyen:
Suplementos de Ácido fólico de venta libre: El costo de suplementos de ácido fólico de venta libre
que contenga 0,4 mg a 0,8 mg de ácido fólico será reembolsado para las mujeres de 18 años y mayores
que tengan planes o sean capaces de embarazo. Los miembros serán reembolsados hasta un suministro
de 90 días por encargo.
Aspirina de Venta Libre: El costo de la aspirina de venta libre utilizado en régimen de terapia de aspirina
para la salud cardiovascular será reembolsado a los miembros femeninos de edades 55-79 y miembros
masculinos de edades 45-79. Los miembros serán reembolsados hasta un suministro de 90 días por
encargo.
Suplementos de hierro de Venta Libre: El costo de los suplementos de hierro de venta libre será
reembolsado para los niños de 6-12 meses de edad que están en riesgo incrementado de anemia por
deficiencia de hierro. . Los miembros serán reembolsados hasta un suministro de 90 días por encargo.
Anticonceptivos de Venta libre: El costo de esponjas de venta libre, espermicidas y condones
femeninos se le reembolsará a las mujeres (No aplicable para las mujeres que participen o sean
beneficiarias en planes de salud grupales patrocinado por empleadores religiosos) capaces de quedar
embarazadas pero que quieran prevenir un embarazo. Los miembros serán reembolsados hasta un
suministro de 90 días por encargo. Vitamina D de Venta Libre: El costo de suplementos de vitamina D de venta libre se reembolsará en la
comunidad-residencia para adultos de 65 años de edad o mayores que estén en mayor riesgo de caídas.
Los miembros serán reembolsados hasta un suministro de 90 días por solicitud.
Para solicitar el reembolso de alguno de estos artículos de venta libre, contacte a Servicio al Cliente y
confirme que usted es elegible para el reembolso. Si es elegible, debe completar el formulario de Reembolso
Directo al Miembro.
¿Qué sucede si mi medicamento no se encuentra en el Formulario?
Miembros: Si su medicamento no está incluido en este formulario, debe comunicarse primero con Atención a
clientes y confirmar que su medicamento no está cubierto. Si averigua que RMHP no cubre su medicamento,
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puede solicitarnos que hagamos una excepción a nuestras reglas, restricciones o limitaciones de cobertura.
Llame al centro de atención a clientes para solicitar una revisión de excepción 6 al formulario, o encontrará un
formulario de solicitud de excepción al formulario en https://www.rmhp.org/members/rx-info/formularyexceptions-requests-commercial.
Existen distintos tipos de excepciones que usted nos puede solicitar.

Nos puede pedir que cubramos su medicamento aun cuando el mismo no se encuentre en nuestro
formulario.

Puede pedirnos que anulemos las restricciones o limitaciones de cobertura con respecto a su
medicamento. Por ejemplo, para ciertos medicamentos, RMHP limita la cantidad del medicamento que
cubriremos. Si su medicamento tiene un límite de cantidad, puede pedirnos que anulemos dicho límite y
cubramos más.
Generalmente, RMHP sólo aprobará su solicitud de una excepción si los medicamentos alternativos incluidos
en el formulario del plan, el medicamento de nivel más bajo o las restricciones adicionales a la utilización no
fueran tan eficaces para tratar su enfermedad y/o causaran efectos médicos adversos.
Información para proveedores:
SOLICITUDES DE EXCEPCIÓN AL FORMULARIO: Para solicitar cobertura de un medicamento excluido,
comuníquese con la oficina de asistencia farmacéutica de RMHP al 970-248-5031 (1-800-640-8921). Se le
enviará por fax un formulario de solicitud de excepción al formulario, mismo que deberá llenar por completo y
devolverlo por fax a RMHP al 970-248-5034.
AUTORIZACIÓN PREVIA: Algunos medicamentos requieren autorización previa para que RMHP los cubra.
Consulte los criterios específicos de PA para todos los medicamentos que requieren autorización previa en
nuestro sitio web: http://www.rmhp.org/providers/prior-authorization/prior-authorizationpharmacy. También
puede llamar a la oficina de asistencia farmacéutica de RMHP al 970-248-5031 (800-640-8921) y ellos le
enviarán por fax un formulario de solicitud de autorización previa. Llene este formulario, adjunte el historial
médico pertinente y devuélvalo por fax a la oficina de asistencia farmacéutica de RMHP.
Indicadores de la Política del Formulario
T1
Medicamentos de alto costo (copago más bajo). Puede contener medicamentos
genéricos y de marca.
T2
Medicamentos preferidos (bajo copago). Contiene medicamentos genéricos y de
marca.
T3
Medicamentos no preferidos (copago medio). Contiene medicamentos genéricos y
de marca.
T4
Medicamentos especializados (copago más alto). Contiene medicamentos de
marca y medicamentos especializados genéricos de alto costo.
T5
Medicamentos especializados no preferentes (copago más alto). Contiene
medicamentos de marca y medicamentos especializados genéricos de alto costo.
T6
Beneficio Médico
PA
Requiere Autorización Previa.
PA NSO
Requiere Autorización Previa. – Salud Preventiva de la Mujer.
QL
Límites de Cantidad
ST
Tratamiento Escalonado
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T1
AGE
GM/GF
Medicamentos de alto costo (copago más bajo). Puede contener medicamentos
genéricos y de marca.
Límite de Edad
Límite de Género (Hombre / Mujer)
EX
Medicamento Excluido
minúscula cursiva
Medicamento Genérico
MAYÚSCULAS
Medicamentos de marca
POLÍTICA DE REVISIÓN
Los formularios de RMHP se revisan por lo menos cada trimestre. La cobertura de medicamentos puede
cambiar entre revisiones.
EDITOR
Agradecemos sus comentarios y sugerencias, ya que mejoramos y actualizamos el formulario de manera
contínua. No dude en comunicarse con Heather Carwin, Pharm D (970-248-8743, 800-843-0719 ext. 8743) or
Steve Nolan, Pharm D (970-248-5182, 800-843-0719 ext. 5182) RMHP, 2775 Crossroads Blvd., Grand
Junction, CO 81506.
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Drug Name
Drug Tier
Requirements/Limits
Analgesics
Analgesics, Miscellaneous
acetaminophen with codeine
butalb/acetaminophen/caffeine capsule,
tablet
butalbit/acetamin/caff/codeine
butalbital/acetaminophen
butalbital/aspirin/caffeine
butorphanol tartrate spray
CEPHADYN
codeine sulfate tablet
codeine/butalbital/asa/caffein
ESGIC capsule
fentanyl citrate
fentanyl patch td72: 12mcg/hr, 25mcg/hr,
50mcg/hr, 75mcg/hr, 100mcg/hr
hydrocodone/acetaminophen solution,
tablet: 2.5-325mg, 5mg-300mg, 5mg325mg, 7.5-300mg, 7.5-325mg, 10mg300mg, 10mg-325mg
hydrocodone/ibuprofen tablet: 7.5-200mg
hydromorphone hcl liquid, tablet
ibuprofen/oxycodone hcl
LORTAB tablet
meperidine hcl tablet
methadone hcl oral conc, solution, tablet,
tablet sol
morphine sulfate cap er pel, cpmp 24hr,
solution: 10mg/5ml, 20mg/5ml; tablet er
oxycodone hcl capsule, oral conc, tablet
oxycodone hcl/acetaminophen tablet
oxycodone hcl/aspirin
oxymorphone hcl
pentazocine hcl/naloxone hcl
tramadol hcl tab er 24h
tramadol hcl tab
(Tylenol-Codeine
No.3)
(Fioricet)
T1
(Fioricet with Codeine)
(Cephadyn)
(Fiorinal)
(Butorphanol Tartrate)
T1
T1
T1
T1
T1
T1
T1
(Codeine Sulfate)
(Fiorinal with Codeine
#3)
T1
(Actiq)
(Duragesic)
T1
T1
T1
(Norco)
T1
(Ibudone)
(Dilaudid)
(Ibuprofen/Oxycodone
HCl)
T1
T1
T1
(Demerol)
(Dolophine HCl)
T1
T1
T1
(Morphine Sulfate ER)
T1
(Roxicodone)
(OxycodoneAcetaminophen)
(Percodan)
(Opana)
(Pentazocine HCl/
Naloxone HCl)
(Ultram ER)
(Ultram)
T1
T1
PA
QL: 15 in 30 days
T1
T1
T1
T1
T1
9
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
tramadol hcl/acetaminophen
VERDROCET
ZAMICET
butalb/acetaminophen/caffeine solution
CAPITAL W-CODEINE
codeine sulfate solution
dihydrocodeine/aspirin/caffein
FENTORA
hydromorphone hcl supp.rect
levorphanol tartrate
meperidine hcl solution
morphine sulfate solution: 100mg/5ml;
supp.rect
MORPHINE SULFATE tablet
NUCYNTA
OPANA ER
opium/belladonna alkaloids
oxycodone hcl tab er 12h
oxycodone hcl/acetaminophen solution
OXYCONTIN
SYNALGOS-DC
AVINZA
BUPAP
DEMEROL tablet
DILAUDID liquid, tablet
DOLOPHINE HCL
DURAGESIC
ESGIC tablet
FIORICET WITH CODEINE
FIORICET
FIORINAL WITH CODEINE #3
FIORINAL
HYCET
hydrocodone/acetaminophen tablet: 5mg300mg, 7.5-300mg, 10mg-300mg
KADIAN
METHADOSE
Drug Tier
(Ultracet)
(Butalb/
Acetaminophen/
Caffeine)
(Codeine Sulfate)
(Synalgos-Dc)
(Hydromorphone HCl)
(Levorphanol Tartrate)
(Meperidine HCl)
(Morphine Sulfate)
(Opium/Belladonna
Alkaloids)
(Oxycodone HCl)
(Oxycodone HCl/
Acetaminophen)
T1
T1
T1
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
PA
QL: 60 in 30 days
T2
T2
T2
T2
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
(Norco)
Requirements/Limits
QL: 15 in 30 days
T3
T3
10
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
MS CONTIN
NORCO
NUCYNTA ER tab er 12h: 50mg, 100mg
NUCYNTA ER tab er 12h: 150mg,
200mg, 250mg
OPANA tablet
oxycodone hcl solution
PERCOCET
PERCODAN
ROXICODONE
SEDAPAP
TYLENOL-CODEINE NO.3
TYLENOL-CODEINE NO.4
ULTRACET
ULTRAM ER
ULTRAM
VICOPROFEN
ZOHYDRO ER
LAZANDA
alfentanil hcl
Drug Tier
T3
T3
T3
T3
(Oxycodone HCl)
(Alfentanil HCl)
BUPRENEX
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T4
T6
T6
buprenorphine hcl
(Buprenorphine HCl)
T6
butorphanol tartrate vial
(Butorphanol Tartrate)
T6
clonidine hcl/pf
(Clonidine HCl/PF)
T6
DEMEROL ampul, syringe
T6
DEMEROL vial
T6
DEPODUR
T6
DILAUDID ampul
T6
DILAUDID-HP
T6
DURACLON
T6
Requirements/Limits
QL: 120 in 30 days
QL: 60 in 30 days
QL: 60 in 30 days
PA
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
11
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
DURAMORPH
Drug Tier
Requirements/Limits
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
fentanyl citrate/pf
(Fentanyl Citrate/PF)
T6
hydromorphone hcl syringe, vial
(Hydromorphone HCl)
T6
hydromorphone hcl/pf
(Hydromorphone HCl/
PF)
T6
INFUMORPH
T6
meperidine hcl cartridge
(Meperidine HCl)
T6
meperidine hcl/pf
(Meperidine HCl/PF)
T6
methadone hcl vial
(Methadone HCl)
T6
morphine sulfate cartridge, pen injctr,
syringe: 10mg/ml; vial
morphine sulfate/d5w
(Morphine Sulfate)
T6
T6
morphine sulfate/pf
(Morphine Sulfate/
D5W)
(Morphine Sulfate/PF)
nalbuphine hcl
(Nalbuphine HCl)
T6
T6
OFIRMEV
T6
OPANA ampul
T6
PRIALT
T6
SUBLIMAZE
T6
sufentanil citrate
(Sufentanil Citrate)
T6
TALWIN
T6
ULTIVA
T6
ABSTRAL
acetaminophen/phenyltolx
ACTIQ
BUTRANS patch tdwk: 7.5mcg/hr
EX
EX
EX
EX
(Relagesic)
12
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
CONZIP
EMBEDA
EXALGO
fentanyl patch td72: 37.5mcg/hr, 62.5mcg/ (Duragesic)
hr, 87.5mcg/hr
hydrocodone/ibuprofen tablet: 2.5-200mg, (Ibudone)
5mg-200mg, 10mg-200mg
hydromorphone hcl tab er 24h
(Exalgo)
HYSINGLA ER
IBUDONE
LORTAB solution
OXECTA
PRIMLEV
RELAGESIC tablet: 650mg-50mg
SUBSYS
tramadol hcl cpbp 17-83, cpbp 25-75
(Conzip)
tramadol hcl cpbp 17-83, cpbp 25-75
(Conzip)
TREZIX
XARTEMIS XR
XODOL 10-300
XODOL 5-300
XODOL 7.5-300
Nonsteroidal Anti-Inflammatory Agents
(Celebrex)
celecoxib
(Choline Sal/Mag
choline sal/mag salicylate
Salicylate)
(Cataflam)
diclofenac potassium
diclofenac sodium gel (gram), tab er 24h,
(Diclofenac Sodium)
tablet dr
(Arthrotec 75)
diclofenac sodium/misoprostol
(Diflunisal)
diflunisal
(Etodolac)
etodolac
(Flurbiprofen)
flurbiprofen
(Ibuprofen)
ibuprofen
(Indomethacin)
indomethacin
ketoprofen capsule
(Ketoprofen)
ketorolac tromethamine tablet
(Ketorolac
Tromethamine)
(Ponstel)
mefenamic acid
meloxicam tablet
(Mobic)
(Nabumetone)
nabumetone
Requirements/Limits
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
13
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
naproxen sodium
naproxen
oxaprozin
piroxicam
salsalate
sulindac
tolmetin sodium
fenoprofen calcium
FENOPROFEN CALCIUM
INDOCIN
ketoprofen cap24h pel
LEVACET
meclofenamate sodium
meloxicam oral susp
NALFON
ANAPROX DS
ANAPROX
ARTHROTEC 50
ARTHROTEC 75
CAMBIA
CATAFLAM
DAYPRO
EC-NAPROSYN
FELDENE
MOBIC
NAPRELAN
NAPROSYN
PONSTEL
SOLARAZE
VOLTAREN
Drug Tier
(Anaprox Ds)
(Naprosyn)
(Daypro)
(Feldene)
(Salsalate)
(Sulindac)
(Tolmetin Sodium)
(Fenoprofen Calcium)
(Ketoprofen)
(Meclofenamate
Sodium)
(Mobic)
VOLTAREN-XR
CALDOLOR
Requirements/Limits
T1
T1
T1
T1
T1
T1
T1
T2
T2
T2
T2
T2
T2
T2
T2
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T6
indomethacin sodium
(Indomethacin Sodium)
T6
ketorolac tromethamine cartridge, vial
(Ketorolac
Tromethamine)
T6
QL: 9 in 30 days
(Gel; NOT COVERED
FOR MEDICAID:
Covered Alternatives
Available)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
14
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
Requirements/Limits
NEOPROFEN
T6
(Non-self administerable
injectable)
CELEBREX
COMFORT PAC-IBUPROFEN
COMFORT PAC-MELOXICAM
COMFORT PAC-NAPROXEN
diclofenac sodium drops
DUEXIS
ENOVARX-NAPROXEN
FLECTOR
NAPRODERM
PENNSAID
SPRIX
VIMOVO
ZIPSOR
ZORVOLEX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
(Pennsaid)
Anesthetics
Local Anesthetics
cocaine hcl
lidocaine hcl cream (g), jel (ml), jel/pf app,
solution
lidocaine
lidocaine/hydrocortisone ac
lidocaine/prilocaine cream (g)
lidocaine/tetracaine
benzocaine
BUCALSEP
PONTOCAINE solution
EMLA
lidocaine/prilocaine kit
LIDODERM
LIDORX
PLIAGLIS
PRE-ATTACHED LTA KIT
SYNERA
XYLOCAINE solution
bupivacaine hcl/epinephrine bi
bupivacaine hcl/epinephrine
(Cocaine HCl)
(Lidocaine HCl)
T1
T1
(Lidoderm)
(Lidocaine/
Hydrocortisone Ac)
(EMLA)
(Pliaglis)
(Benzocaine)
T1
T1
(Lidocaine/Prilocaine)
(Bupivacaine HCl/
Epinephrine Bi)
(Bupivacaine HCl/
Epinephrine)
T1
T1
T2
T2
T2
T3
T3
T3
T3
T3
T3
T3
T3
T6
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
15
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
bupivacaine hcl/epinephrine/pf
bupivacaine hcl/pf
(Bupivacaine HCl/
Epinephrine/PF)
(Sensorcaine-MPF)
CARBOCAINE
chloroprocaine hcl/pf
Drug Tier
Requirements/Limits
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
T6
T6
(Chloroprocaine HCl/
PF)
EXPAREL
T6
T6
lidocaine hcl vial
(Xylocaine)
T6
lidocaine hcl/epinephrine bit
(Lidocaine HCl/
Epinephrine Bit)
(Xylocaine with
Epinephrine)
(Lidocaine HCl/
Epinephrine/PF)
(Lidocaine HCl/PF)
T6
lidocaine hcl/epinephrine
lidocaine hcl/epinephrine/pf
lidocaine hcl/pf
T6
T6
T6
LIDOCAINE-EPINEPHRINE
T6
MARCAINE
T6
MARCAINE-EPINEPHRINE
T6
mepivacaine hcl/pf
(Mepivacaine HCl/PF)
T6
NAROPIN
T6
NESACAINE
T6
NESACAINE-MPF
T6
PONTOCAINE ampul
T6
ropivacaine hcl/pf
(Ropivacaine HCl/PF)
T6
SENSORCAINE-MPF EPINEPHRINE
T6
SENSORCAINE-MPF
T6
16
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
tetracaine hcl/pf
(Tetracaine HCl/PF)
Drug Tier
Requirements/Limits
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
XYLOCAINE WITH EPINEPHRINE
vial: 0.5-1:200k, 1%-1:100k
XYLOCAINE WITH EPINEPHRINE
vial: 2%-1:200k
XYLOCAINE vial
T6
XYLOCAINE-MPF WITH
EPINEPHRINE
XYLOCAINE-MPF ampul: 15mg/ml
T6
T6
XYLOCAINE-MPF ampul: 40mg/ml; vial
T6
LETS KIT
PRO DNA MEDICATED COLLECTION
RELADOR PAK
EX
EX
EX
T6
T6
Anti-Addiction/Substance Abuse Treatment Agents
acamprosate calcium
buprenorphine hcl
buprenorphine hcl/naloxone hcl
disulfiram
naltrexone hcl tablet: 50mg
SUBOXONE
ANTABUSE
CAMPRAL
EVZIO
REVIA
ZYBAN
naloxone hcl
(Campral)
(Subutex)
(Buprenorphine HCl/
Naloxone HCl)
(Antabuse)
(Naltrexone HCl)
(Naloxone HCl)
VIVITROL
T1
T1
T1
T1
T1
T2
T3
T3
T3
T3
T3
T6
QL: 0.8 in 365 days
(Self Administerable
(Select) Injectable)
(Non-self administerable
injectable)
EX
Antianxiety Agents
Benzodiazepines
alprazolam
chlordiazepoxide hcl
clonazepam
(Xanax)
(Chlordiazepoxide
HCl)
(Klonopin)
T1
T1
T1
17
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
clorazepate dipotassium
diazepam tablet
estazolam
flurazepam hcl
lorazepam oral conc, tablet
midazolam hcl syrup
oxazepam
temazepam
triazolam
ALPRAZOLAM INTENSOL
DIASTAT ACUDIAL
DIASTAT
diazepam kit, oral conc, solution
DORAL
ONFI tablet
ONFI oral susp
quazepam
ATIVAN tablet
HALCION
KLONOPIN
RESTORIL
TRANXENE T-TAB
VALIUM
XANAX XR
XANAX
ATIVAN vial
Drug Tier
(Tranxene T-Tab)
(Valium)
(Estazolam)
(Flurazepam HCl)
(Ativan)
(Midazolam HCl)
(Oxazepam)
(Restoril)
(Halcion)
(Diastat Acudial)
(Doral)
T1
T1
T1
T1
T1
T1
T1
T1
T1
T2
T2
T2
T2
T2
T2
T2
T2
T3
T3
T3
T3
T3
T3
T3
T3
T6
diazepam syringe
(Diazepam)
T6
lorazepam syringe, vial
(Ativan)
T6
midazolam hcl vial
(Midazolam HCl)
T6
midazolam hcl/pf syringe: 2mg/2ml; vial
(Midazolam HCl/PF)
T6
midazolam hcl in 0.9 % nacl/pf
(Midazolam Hcl In 0.9
% Nacl/PF)
EX
(Neomycin Sulfate)
T1
T4
Requirements/Limits
Age must be >= 2, PA
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
Antibacterials
Aminoglycosides
neomycin sulfate
TOBI PODHALER
18
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
tobramycin in 0.225% nacl
TOBI
amikacin sulfate
(Tobi)
gentamicin in nacl, iso-osm
(Gentamicin In Nacl,
Iso-Osm)
(Gentamicin Sulfate)
T6
T6
streptomycin sulfate
(Gentamicin Sulfate/
PF)
(Streptomycin Sulfate)
T6
tobramycin sulfate
(Tobramycin Sulfate)
T6
tobramycin/sodium chloride
(Tobramycin/Sodium
Chloride)
T6
gentamicin sulfate
gentamicin sulfate/pf
(Amikacin Sulfate)
Antibacterials, Miscellaneous
clindamycin hcl
clindamycin palmitate hcl
methenamine hippurate
methenamine mandelate tablet: 1g
(Cleocin HCl)
(Cleocin Palmitate)
(Hiprex)
(Methenamine
Mandelate)
(Flagyl)
metronidazole
mth/me blue/sod phos/phen/hyos tablet: 81- (Urelle)
0.12mg, 81.6-10.8
(Macrodantin)
nitrofurantoin macrocrystal
(Macrobid)
nitrofurantoin monohyd/m-cryst
(Furadantin)
nitrofurantoin
PHOSPHASAL
(Trimethoprim)
trimethoprim
URETRON D-S
URIN D.S.
URYL
vancomycin hcl capsule
(Vancocin HCl)
methen/sod phos/meth blue/hyos tablet:
(Methen/Sod Phos/
81.6-.12mg
Meth Blue/Hyos)
methenamine mandelate tablet: 500mg
(Methenamine
Mandelate)
MONUROL
POLYMYXIN B SULFATE powder(ea):
100mmunit
T4
T5
T6
T6
Requirements/Limits
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T2
T2
T2
T2
19
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
PRIMSOL
UROQID-ACID NO.2
XIFAXAN tablet: 200mg
CLEOCIN HCL
CLEOCIN PALMITATE
FLAGYL ER
FLAGYL
FURADANTIN
HIPREX
MACROBID
MACRODANTIN
methen/m-blue/sal/na phos/hyos
URELLE
UTIRA-C
VANCOCIN HCL
linezolid susp recon, tablet
XIFAXAN tablet: 550mg
ZYVOX susp recon, tablet
bacitracin
chloramphenicol sod succ
Drug Tier
(Methen/M-Blue/Sal/
Na Phos/Hyos)
(Zyvox)
(Bacitracin)
(Chloramphenicol Sod
Succ)
T2
T2
T2
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T4
T4
T5
T6
T6
CLEOCIN PHOSPHATE IN D5W
T6
CLEOCIN PHOSPHATE
T6
clindamycin phosphate
(Cleocin Phosphate)
T6
clindamycin phosphate/d5w
(Cleocin Phosphate In
D5w)
(Coly-Mycin M
Parenteral)
T6
colistin (colistimethate na)
T6
COLY-MYCIN M PARENTERAL
T6
CUBICIN
T6
LINCOCIN
T6
linezolid iv soln
(Zyvox)
Requirements/Limits
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
20
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
Requirements/Limits
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
metronidazole/sodium chloride
(Metro IV)
T6
moxifloxacin/sod.ace,sul/water
(Moxifloxacin/
Sod.Ace,Sul/Water)
(Polymyxin B Sulfate)
T6
polymyxin b sulfate
SYNERCID
T6
T6
vancomycin hcl vial
(Vancomycin HCl)
T6
vancomycin hcl/d5w froz.piggy
(Vancomycin HCl/
D5W)
T6
ZYVOX iv soln
T6
VIBATIV
Cephalosporins
cefaclor capsule
cefadroxil
cefdinir
cefixime
cefpodoxime proxetil
cefprozil
cefuroxime axetil
CEFUROXIME AXETIL
cephalexin capsule, susp recon
cefaclor tab er 12h
cephalexin tablet
KEFLEX capsule: 750mg
SUPRAX
CEDAX
cefaclor susp recon
ceftibuten
CEFTIN
KEFLEX capsule: 250mg, 500mg
cefazolin sodium
EX
(Cefaclor)
(Cefadroxil)
(Cefdinir)
(Suprax)
(Cefpodoxime Proxetil)
(Cefprozil)
(Ceftin)
(Keflex)
(Cefaclor)
(Cephalexin)
(Cefaclor)
(Cedax)
(Cefazolin Sodium)
CEFAZOLIN SODIUM
cefazolin sodium/dextrose,iso
T1
T1
T1
T1
T1
T1
T1
T1
T1
T2
T2
T2
T2
T3
T3
T3
T3
T3
T6
T6
(Cefazolin Sodium/
Dextrose, Iso)
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
21
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
cefepime hcl
(Maxipime)
Drug Tier
Requirements/Limits
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
CEFEPIME
T6
CEFEPIME-DEXTROSE
T6
cefotaxime sodium
(Claforan)
T6
cefotetan disod/dextrose,iso
T6
cefotetan disodium
(Cefotetan Disod/
Dextrose, Iso)
(Cefotetan Disodium)
T6
cefoxitin sodium
(Cefoxitin Sodium)
T6
cefoxitin sodium/dextrose,iso
(Cefoxitin Sodium/
Dextrose, Iso)
(Fortaz)
T6
ceftazidime
CEFTAZIDIME
ceftriaxone na/dextrose,iso
ceftriaxone sodium
T6
(Ceftriaxone Na/
Dextrose, Iso)
(Ceftriaxone Sodium)
CEFTRIAXONE
cefuroxime sodium
T6
T6
T6
T6
(Zinacef)
T6
CLAFORAN GALAXY
T6
CLAFORAN
T6
FORTAZ
T6
MEFOXIN
T6
ROCEPHIN
T6
TEFLARO
T6
ZINACEF
T6
22
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
MAXIPIME
SPECTRACEF
Macrolides
azithromycin susp recon, tablet
clarithromycin
erythromycin base capsule dr
erythromycin ethylsuccinate susp recon,
tablet: 400mg
ERYPED 200
ERYPED 400
ERY-TAB
erythromycin base tablet, tablet dr
erythromycin ethylsuccinate tablet: 400mg
erythromycin stearate
PCE
azithromycin packet
BIAXIN XL
BIAXIN
DIFICID
KETEK
ZITHROMAX TRI-PAK
ZITHROMAX packet, susp recon, tablet
ZMAX
azithromycin vial
Drug Tier
EX
EX
(Zithromax)
(Biaxin)
(Erythromycin Base)
(Eryped 200)
(Erythromycin Base)
(Erythromycin
Ethylsuccinate)
(Erythromycin
Stearate)
(Zithromax)
(Zithromax)
T1
T1
T1
T1
T2
T2
T2
T2
T2
T2
T2
T3
T3
T3
T3
T3
T3
T3
T3
T6
ERYTHROCIN LACTOBIONATE
T6
ZITHROMAX vial
T6
Miscellaneous B-Lactam Antibiotics
CAYSTON
AZACTAM
T4
T6
AZACTAM-ISO-OSMOTIC DEXTROSE
T6
aztreonam
Requirements/Limits
(Azactam)
DORIBAX
T6
T6
PA
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
23
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
imipenem/cilastatin sodium
(Primaxin)
INVANZ
Drug Tier
Requirements/Limits
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
T6
meropenem
(Merrem)
T6
meropenem-0.9% sodium chloride
(Meropenem-0.9%
Sodium Chloride)
T6
MERREM
T6
PRIMAXIN
T6
Penicillins
amoxicillin capsule, susp recon, tab chew,
tablet
amoxicillin/potassium clav
ampicillin trihydrate
dicloxacillin sodium
penicillin v potassium
(Amoxicillin)
T1
(Augmentin)
(Ampicillin Trihydrate)
(Dicloxacillin Sodium)
(Penicillin V
Potassium)
T1
T1
T1
T1
AUGMENTIN ES-600
AUGMENTIN XR
AUGMENTIN
ampicillin sodium
(Ampicillin Sodium)
T3
T3
T3
T6
ampicillin sodium/sulbactam na
(Unasyn)
T6
BICILLIN C-R
T6
BICILLIN L-A
T6
T6
nafcillin sodium
(Nafcillin In
Dextrose,Iso-Osm)
(Nafcillin Sodium)
oxacillin sodium
(Oxacillin Sodium)
T6
oxacillin sodium/dextrose,iso
(Oxacillin Sodium/
Dextrose, Iso)
(Pen G Pot/DextroseWater)
T6
nafcillin in dextrose,iso-osm
pen g pot/dextrose-water
T6
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
24
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
Requirements/Limits
T6
penicillin g procaine
(Penicillin G
Potassium)
(Penicillin G Procaine)
penicillin g sodium
(Penicillin G Sodium)
T6
piperacillin sodium/tazobactam
(Zosyn)
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
penicillin g potassium
T6
TIMENTIN
T6
UNASYN
T6
ZOSYN froz.piggy
T6
ZOSYN vial
T6
amoxicillin tbmp 24hr
MOXATAG
Quinolones
ciprofloxacin hcl
ciprofloxacin
ciprofloxacin/ciprofloxa hcl
levofloxacin solution, tablet
moxifloxacin hcl
ofloxacin
CIPRO sus mc rec
AVELOX ABC PACK
AVELOX
CIPRO tablet: 250mg, 500mg
FACTIVE
LEVAQUIN solution, tablet
NOROXIN
AVELOX IV
(Moxatag)
EX
EX
(Cipro)
(Cipro)
(Ciprofloxacin/
Ciprofloxa HCl)
(Levaquin)
(Avelox)
(Ofloxacin)
T1
T1
T1
CIPRO I.V.
T1
T1
T1
T2
T3
T3
T3
T3
T3
T3
T6
T6
ciprofloxacin lactate
(Ciprofloxacin Lactate)
T6
ciprofloxacin lactate/d5w
(Ciprofloxacin Lactate/
D5W)
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
25
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
LEVAQUIN piggyback
Drug Tier
Requirements/Limits
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
levofloxacin vial
(Levofloxacin)
T6
levofloxacin/d5w
(Levofloxacin/D5W)
T6
CIPRO XR
Sulfonamides
sulfamethoxazole/trimethoprim oral susp,
tablet
sulfasalazine
sulfadiazine
AZULFIDINE
BACTRIM DS
BACTRIM
sulfamethoxazole/trimethoprim vial
Tetracyclines
demeclocycline hcl
doxycycline hyclate capsule, tablet: 100mg
doxycycline monohydrate capsule: 50mg,
100mg; susp recon, tablet: 100mg
minocycline hcl capsule
tetracycline hcl
ALODOX
doxycycline monohydrate cap ir dr
VIBRAMYCIN syrup
MINOCIN capsule
MINOCIN combo. pkg
MONODOX capsule: 50mg, 100mg
OCUDOX
ORACEA
VIBRAMYCIN capsule
VIBRAMYCIN susp recon
doxycycline hyclate vial
EX
(Bactrim DS)
T1
(Azulfidine)
(Sulfadiazine)
T1
T2
T3
T3
T3
T6
(Sulfamethoxazole/
Trimethoprim)
(Demeclocycline HCl)
(Vibramycin)
(Avidoxy)
T1
T1
T1
(Minocin)
(Tetracycline HCl)
T1
T1
T2
T2
T2
T3
T3
T3
T3
T3
T3
T3
T6
(Oracea)
(Doxycycline Hyclate)
MINOCIN vial
T6
TYGACIL
T6
ADOXA
EX
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
26
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
AVIDOXY DK
AVIDOXY
DORYX
doxycycline hyclate tablet: 20mg; tablet dr
doxycycline monohydrate capsule: 75mg,
150mg; tablet: 50mg, 75mg, 150mg
minocycline hcl tab er 24h, tablet
MONDOXYNE NL
MONODOX capsule: 75mg
MORGIDOX capsule
MORGIDOX kit
SOLODYN
Drug Tier
(Doryx)
(Avidoxy)
Requirements/Limits
EX
EX
EX
EX
EX
(Minocycline HCl)
EX
EX
EX
EX
EX
EX
(Arimidex)
(Casodex)
(Cyclophosphamide)
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
Anticancer Agents
anastrozole
bicalutamide
cyclophosphamide tablet
CYCLOPHOSPHAMIDE
exemestane
flutamide
hydroxyurea
letrozole
megestrol acetate
mercaptopurine
methotrexate sodium tablet
tamoxifen citrate tablet: 10mg
tamoxifen citrate tablet: 20mg
ALKERAN tablet
DROXIA
EMCYT
FARESTON
HEXALEN
LEUKERAN
lomustine
LYSODREN
MATULANE
MYLERAN
NILANDRON
RHEUMATREX
(Aromasin)
(Flutamide)
(Hydrea)
(Femara)
(Megestrol Acetate)
(Purinethol)
(Methotrexate Sodium)
(Tamoxifen Citrate)
(Tamoxifen Citrate)
(Lomustine)
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
(Oral Cancer Drug)
(Oral Cancer Drug)
(Oral Cancer Drug)
(Oral Cancer Drug)
(Oral Cancer Drug)
(Oral Cancer Drug)
(Oral Cancer Drug)
(Oral Cancer Drug)
(Oral Cancer Drug)
(Oral Cancer Drug)
(Oral Cancer Drug)
(Oral Cancer Drug)
PA NSO (PA Req'd,
Women's Preventive
Healthcare); (Oral
Cancer Drug)
(Oral Cancer Drug)
(Oral Cancer Drug)
(Oral Cancer Drug)
(Oral Cancer Drug)
(Oral Cancer Drug)
(Oral Cancer Drug)
(Oral Cancer Drug)
(Oral Cancer Drug)
(Oral Cancer Drug)
(Oral Cancer Drug)
(Oral Cancer Drug)
(Oral Cancer Drug)
27
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
TABLOID
TREXALL
AFINITOR DISPERZ
AFINITOR
ARIMIDEX
AROMASIN
bexarotene
BOSULIF
capecitabine
CAPRELSA
CASODEX
COMETRIQ
ERIVEDGE
etoposide capsule
FARYDAK
FEMARA
GILOTRIF
GLEEVEC
HYCAMTIN capsule
HYDREA
IBRANCE
ICLUSIG
IMBRUVICA
INLYTA
IRESSA
LENVIMA
LONSURF
MEKINIST
NEXAVAR
POMALYST
PURINETHOL
REVLIMID
SPRYCEL
STIVARGA
SUTENT
TAFINLAR
TARCEVA
TARGRETIN capsule
TASIGNA
TEMODAR capsule
temozolomide
(Targretin)
(Xeloda)
(Etoposide)
(Temodar)
Drug Tier
Requirements/Limits
T2
T2
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
(Oral Cancer Drug)
(Oral Cancer Drug)
PA (Oral Cancer Drug)
PA (Oral Cancer Drug)
(Oral Cancer Drug)
(Oral Cancer Drug)
(Oral Cancer Drug)
PA (Oral Cancer Drug)
(Oral Cancer Drug)
PA (Oral Cancer Drug)
(Oral Cancer Drug)
PA (Oral Cancer Drug)
PA (Oral Cancer Drug)
(Oral Cancer Drug)
PA (Oral Cancer Drug)
(Oral Cancer Drug)
PA (Oral Cancer Drug)
(Oral Cancer Drug)
(Oral Cancer Drug)
(Oral Cancer Drug)
PA (Oral Cancer Drug)
PA (Oral Cancer Drug)
PA (Oral Cancer Drug)
PA (Oral Cancer Drug)
PA (Oral Cancer Drug)
PA (Oral Cancer Drug)
PA (Oral Cancer Drug)
PA (Oral Cancer Drug)
PA (Oral Cancer Drug)
PA (Oral Cancer Drug)
(Oral Cancer Drug)
PA (Oral Cancer Drug)
PA (Oral Cancer Drug)
PA (Oral Cancer Drug)
PA (Oral Cancer Drug)
PA (Oral Cancer Drug)
PA (Oral Cancer Drug)
(Oral Cancer Drug)
PA (Oral Cancer Drug)
(Oral Cancer Drug)
(Oral Cancer Drug)
28
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
tretinoin
TYKERB
VOTRIENT
XALKORI
XELODA
XTANDI
ZELBORAF
ZOLINZA
ZYDELIG
ZYKADIA
ZYTIGA
JAKAFI
TARGRETIN gel (gram)
ABRAXANE
(Tretinoin)
Drug Tier
Requirements/Limits
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T4
T4
T6
(Oral Cancer Drug)
PA (Oral Cancer Drug)
PA (Oral Cancer Drug)
PA (Oral Cancer Drug)
(Oral Cancer Drug)
PA (Oral Cancer Drug)
PA (Oral Cancer Drug)
PA (Oral Cancer Drug)
PA (Oral Cancer Drug)
PA (Oral Cancer Drug)
PA (Oral Cancer Drug)
PA (Oral Cancer Drug)
ADCETRIS
T6
ALIMTA
T6
ALKERAN vial
T6
ARRANON
T6
ARZERRA
T6
AVASTIN
T6
azacitidine
(Vidaza)
T6
BELEODAQ
T6
BEXXAR vial: 14mg/ml
T6
BEXXAR vial: 5.6mci/ml
T6
BICNU
T6
(Non-self administerable
injectable)
PA (Non-self
administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self
administerable
injectable)
PA (Non-self
administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self
administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
29
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
bleomycin sulfate
(Bleomycin Sulfate)
Drug Tier
Requirements/Limits
T6
(Non-self administerable
injectable)
PA (Non-self
administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self
administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
BLINCYTO
T6
BUSULFEX
T6
CAMPTOSAR
T6
carboplatin
(Carboplatin)
CERUBIDINE
T6
T6
cisplatin
(Cisplatin)
T6
cladribine
(Cladribine)
T6
CLOLAR
T6
COSMEGEN
T6
cyclophosphamide vial
(Cyclophosphamide)
CYRAMZA
T6
T6
cytarabine
(Cytarabine)
T6
cytarabine/pf
(Cytarabine/PF)
T6
dacarbazine
(Dacarbazine)
T6
DACOGEN
T6
dactinomycin
(Dactinomycin)
T6
daunorubicin hcl
(Daunorubicin HCl)
T6
DAUNOXOME
decitabine
T6
(Dacogen)
T6
30
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
Requirements/Limits
DEPOCYT
T6
DOCEFREZ
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self
administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self
administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
docetaxel
(Taxotere)
DOXIL
T6
T6
doxorubicin hcl peg-liposomal
(Doxil)
T6
doxorubicin hcl
(Doxorubicin HCl)
T6
ELIGARD
T6
ELLENCE
T6
ELOXATIN
T6
ELSPAR
T6
epirubicin hcl
(Ellence)
T6
ERBITUX
T6
ERWINAZE
T6
ETOPOPHOS
T6
etoposide vial
(Etoposide)
T6
FASLODEX
T6
FIRMAGON
T6
floxuridine
(Floxuridine)
T6
fludarabine phosphate
(Fludara)
T6
fluorouracil
(Fluorouracil)
T6
31
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
Requirements/Limits
FOLOTYN
T6
GAZYVA
T6
PA (Non-self
administerable
injectable)
PA (Non-self
administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self
administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self
administerable
injectable)
PA (Non-self
administerable
injectable)
PA (Non-self
administerable
injectable)
gemcitabine hcl
(Gemzar)
T6
GEMZAR
T6
GLIADEL
T6
HALAVEN
T6
HERCEPTIN
T6
HYCAMTIN vial
T6
IDAMYCIN PFS
T6
idarubicin hcl
(Idamycin Pfs)
IFEX
T6
T6
ifosfamide
(Ifex)
T6
ifosfamide/mesna
(Ifosfamide/Mesna)
T6
irinotecan hcl
(Camptosar)
T6
ISTODAX
T6
IXEMPRA
T6
JEVTANA
T6
32
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
Requirements/Limits
KADCYLA
T6
KEYTRUDA
T6
KYPROLIS
T6
PA (Non-self
administerable
injectable)
PA (Non-self
administerable
injectable)
PA (Non-self
administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self
administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self
administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
leuprolide acetate
(Leuprolide Acetate)
T6
LUPRON DEPOT
T6
MARQIBO
T6
melphalan hcl
(Alkeran)
T6
methotrexate sodium vial
(Methotrexate Sodium)
T6
methotrexate sodium/pf
T6
mitomycin
(Methotrexate Sodium/
PF)
(Mitomycin)
T6
mitoxantrone hcl
(Mitoxantrone HCl)
T6
MUSTARGEN
T6
NAVELBINE
T6
NIPENT
T6
ONCASPAR
T6
OPDIVO
T6
oxaliplatin
(Eloxatin)
T6
paclitaxel
(Paclitaxel)
T6
33
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
pentostatin
(Pentostatin)
Drug Tier
Requirements/Limits
T6
(Non-self administerable
injectable)
PA (Non-self
administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self
administerable
injectable)
PA (Non-self
administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self
administerable
injectable)
PA (Non-self
administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
Age must be <= 18
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PERJETA
T6
PHOTOFRIN
T6
PROLEUKIN
T6
RITUXAN
T6
SYLVANT
T6
SYNRIBO
T6
TAXOTERE
T6
TEMODAR vial
T6
teniposide
(Teniposide)
T6
thiotepa
(Thiotepa)
T6
topotecan hcl
(Hycamtin)
T6
TORISEL
T6
TREANDA
T6
TRELSTAR
T6
TRISENOX
T6
UNITUXIN
T6
VALSTAR
T6
34
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
Requirements/Limits
VECTIBIX
T6
VELCADE
T6
VIDAZA
T6
PA (Non-self
administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
vinblastine sulfate
(Vinblastine Sulfate)
T6
vincristine sulfate
(Vincristine Sulfate)
T6
vinorelbine tartrate
(Navelbine)
T6
YERVOY
T6
ZANOSAR
T6
ZEVALIN kit: 3.2mg/2ml
T6
ZEVALIN kit: 3.2mg/2ml
T6
ZOLADEX
T6
GLEOSTINE
LYNPARZA
ODOMZO
SOLTAMOX
ZALTRAP
EX
EX
EX
EX
EX
Anticholinergic Agents
Antimuscarinics/Antispasmodics
chlordiazepoxide/clidinium br
phenobarb/hyoscy/atropine/scop
DONNATAL elixir, tablet er
propantheline bromide
(Librax)
(Phenobarb/Hyoscy/
Atropine/Scop)
(Propantheline
Bromide)
STIOLTO RESPIMAT
DONNATAL tablet
LEVBID
LIBRAX
PAMINE FQ
T1
T1
T2
T2
T2
T3
T3
T3
T3
QL: 4 in 30 days
35
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
ATROPEN
atropine sulfate
(Atropine Sulfate)
ENLON-PLUS
Drug Tier
Requirements/Limits
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
T6
T6
Anticonvulsants
carbamazepine
divalproex sodium
ethosuximide
felbamate
gabapentin
lamotrigine tab er 24, tablet, tb chw dsp
levetiracetam solution, tab er 24h, tablet
oxcarbazepine
phenobarbital elixir, tablet: 15mg, 16.2mg,
30mg, 32.4mg, 60mg, 100mg
phenytoin sodium extended
phenytoin
primidone
tiagabine hcl
topiramate cap sprink, tablet
valproic acid (as sodium salt) solution
valproic acid
zonisamide
APTIOM
BANZEL
CELONTIN
DILANTIN capsule: 30mg
EQUETRO
FYCOMPA
GABITRIL tablet: 12mg, 16mg
LAMICTAL tb chw dsp: 2mg
lamotrigine tab rapdis, tb rd dspk
PEGANONE
phenobarbital tablet: 64.8mg, 97.2mg
POTIGA
(Tegretol)
(Depakote ER)
(Zarontin)
(Felbatol)
(Neurontin)
(Lamictal)
(Keppra)
(Trileptal)
(Phenobarbital)
T1
T1
T1
T1
T1
T1
T1
T1
T1
(Dilantin)
(Dilantin)
(Mysoline)
(Gabitril)
(Topamax)
(Depakene)
(Depakene)
(Zonegran)
T1
T1
T1
T1
T1
T1
T1
T1
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
(Lamictal Odt)
(Phenobarbital)
TEGRETOL XR tab er 12h: 100mg
VIMPAT solution, tablet
CARBATROL
Age must be >= 12, PA
Age must be >= 18, PA,
QL: 90 in 30 days
T2
T2
T3
36
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
DEPAKENE capsule
DEPAKENE solution
DEPAKOTE ER
DEPAKOTE SPRINKLE
DEPAKOTE
DILANTIN-125
DILANTIN capsule: 100mg
DILANTIN tab chew
FELBATOL
GABITRIL tablet: 2mg, 4mg
HORIZANT
KEPPRA XR
KEPPRA solution, tablet
LAMICTAL (BLUE)
LAMICTAL (GREEN)
LAMICTAL (ORANGE)
LAMICTAL ODT (BLUE)
LAMICTAL ODT (GREEN)
LAMICTAL ODT (ORANGE)
LAMICTAL ODT
LAMICTAL XR (BLUE)
LAMICTAL XR (GREEN)
LAMICTAL XR (ORANGE)
LAMICTAL XR
LAMICTAL tablet, tb chw dsp: 5mg,
25mg
LYRICA
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
MYSOLINE
NEURONTIN
PHENYTEK
STAVZOR
TEGRETOL XR tab er 12h: 200mg,
400mg
TEGRETOL
TOPAMAX
TRILEPTAL
ZARONTIN
ZONEGRAN
SABRIL
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T4
Requirements/Limits
(Prior Authorization
Criteria Requirements
apply to Medicaid Only)
PA
37
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
DEPACON
fosphenytoin sodium
(Fosphenytoin Sodium)
KEPPRA vial
levetiracetam in nacl (iso-os)
levetiracetam vial
Drug Tier
Requirements/Limits
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
T6
T6
(Levetiracetam In Nacl
(Iso-Os))
(Keppra)
LUMINAL SODIUM
T6
T6
T6
phenobarbital sodium
(Phenobarbital Sodium)
T6
phenytoin sodium
(Phenytoin Sodium)
T6
valproic acid (as sodium salt) vial
(Depacon)
T6
VIMPAT vial
T6
CEREBYX
GRALISE
OXTELLAR XR
TROKENDI XR
EX
EX
EX
EX
Antidementia Agents
donepezil hcl tab rapdis, tablet: 5mg, 10mg
galantamine hbr
memantine hcl
rivastigmine tartrate
NAMENDA tab ds pk, tablet
rivastigmine
ARICEPT ODT
ARICEPT tablet: 5mg, 10mg
EXELON capsule
EXELON patch td24
NAMENDA XR
NAMENDA solution
RAZADYNE ER
RAZADYNE
ARICEPT tablet: 23mg
donepezil hcl tablet: 23mg
(Aricept)
(Razadyne)
(Namenda)
(Exelon)
(Exelon)
(Aricept)
T1
T1
T1
T1
T2
T2
T3
T3
T3
T3
T3
T3
T3
T3
EX
EX
38
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
NAMZARIC
Requirements/Limits
EX
Antidepressants
amitrip hcl/chlordiazepoxide
amitriptyline hcl
bupropion hcl
citalopram hydrobromide
clomipramine hcl
desipramine hcl
doxepin hcl
duloxetine hcl
escitalopram oxalate
fluoxetine hcl capsule, solution, tablet
fluvoxamine maleate tablet
imipramine hcl
imipramine pamoate
mirtazapine
nefazodone hcl
nortriptyline hcl
paroxetine hcl tablet
phenelzine sulfate
protriptyline hcl
sertraline hcl
tranylcypromine sulfate
trazodone hcl
venlafaxine hcl cap er 24h, tablet
amoxapine
maprotiline hcl
MARPLAN
PAXIL oral susp
perphenazine/amitriptyline hcl
trimipramine maleate
(Amitrip HCl/
Chlordiazepoxide)
(Amitriptyline HCl)
(Wellbutrin XL)
(Celexa)
(Anafranil)
(Norpramin)
(Doxepin HCl)
(Cymbalta)
(Lexapro)
(Prozac)
(Fluvoxamine Maleate)
(Tofranil)
(Tofranil-Pm)
(Remeron)
(Nefazodone HCl)
(Pamelor)
(Paxil)
(Nardil)
(Protriptyline HCl)
(Zoloft)
(Parnate)
(Trazodone HCl)
(Effexor XR)
(Amoxapine)
(Maprotiline HCl)
(Perphenazine/
Amitriptyline HCl)
(Trimipramine
Maleate)
ANAFRANIL
BRINTELLIX
CELEXA
CYMBALTA
EFFEXOR XR
FETZIMA
LEXAPRO
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T2
T2
T2
T2
T2
T2
T3
T3
T3
T3
T3
T3
T3
ST
ST
39
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
NARDIL
NORPRAMIN
PAMELOR
PARNATE
PAXIL tablet
PROZAC
REMERON
SURMONTIL
TOFRANIL
TOFRANIL-PM
VIIBRYD
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
VIIBRYD
VIVACTIL
WELLBUTRIN SR
WELLBUTRIN XL
WELLBUTRIN
ZOLOFT
APLENZIN
BRISDELLE
DESVENLAFAXINE ER
DESVENLAFAXINE FUMARATE ER
desvenlafaxine
EMSAM
ENOVARX-AMITRIPTYLINE
fluoxetine hcl capsule dr
FLUOXETINE HCL
fluvoxamine maleate cap er 24h
FORFIVO XL
KHEDEZLA
LUVOX CR
olanzapine/fluoxetine hcl
OLEPTRO ER
paroxetine hcl tab er 24h
PAXIL CR
PEXEVA
PRISTIQ ER
PROZAC WEEKLY
SARAFEM
SILENOR
T3
T3
T3
T3
T3
T3
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
(Desvenlafaxine)
(Prozac Weekly)
(Luvox CR)
(Symbyax)
(Paxil CR)
Requirements/Limits
(NOT COVERED FOR
MEDICAID: Covered
Alternatives Available)
40
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
SYMBYAX
venlafaxine hcl tab er 24
Drug Tier
(Venlafaxine Hcl ER)
Requirements/Limits
EX
EX
Antidiabetic Agents
Antidiabetic Agents, Miscellaneous
(Precose)
acarbose
metformin hcl tab er 24h, tablet
(Glucophage)
nateglinide
pioglitazone hcl
pioglitazone hcl/metformin hcl
repaglinide
repaglinide/metformin hcl
ACTOPLUS MET XR
GLYXAMBI
INVOKAMET
INVOKANA
JANUMET XR
JANUMET
JANUVIA
JARDIANCE
JENTADUETO
MIFEPREX
RIOMET
SYMLINPEN 120
SYMLINPEN 60
SYNJARDY
TRADJENTA
TRULICITY
(Starlix)
(Actos)
(Actoplus Met)
(Prandin)
(Prandimet)
T1
T1
T1
T1
T1
T1
T1
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
VICTOZA 3-PAK
T2
ACTOPLUS MET
ACTOS
AVANDAMET
AVANDARYL
AVANDIA
BYDUREON PEN
T3
T3
T3
T3
T3
T3
(Generic Glucophage,
Glucophage XR)
QL: 60 in 30 days
ST
ST
QL: 60 in 30 days
(Self Administerable
(Select) Injectable)
(Self Administerable
(Select) Injectable)
QL: 4 in 28 days (Self
Administerable (Select)
Injectable)
41
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
BYDUREON
T3
BYETTA
T3
DUETACT
FARXIGA
GLUCOPHAGE XR
GLUCOPHAGE
GLUMETZA
GLYSET
pioglitazone hcl/glimepiride
PRANDIMET
PRANDIN
PRECOSE
STARLIX
TANZEUM
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
(Duetact)
XIGDUO XR tab bp 24h: 5mg-500mg, 101000mg, 10mg-500mg
XIGDUO XR tab bp 24h: 5mg-1000mg
KORLYM
FORTAMET
KAZANO
KOMBIGLYZE XR
metformin hcl tab er 24
(Fortamet)
NESINA
ONGLYZA
OSENI
Insulins
HUMALOG KWIKPEN U-100
HUMALOG KWIKPEN U-200
HUMALOG MIX 50-50 KWIKPEN
HUMALOG MIX 50-50
HUMALOG MIX 75-25 KWIKPEN
HUMALOG MIX 75-25
HUMALOG
HUMULIN 70/30 KWIKPEN
HUMULIN 70-30
HUMULIN N KWIKPEN
HUMULIN N
T3
T3
T5
EX
EX
EX
EX
EX
EX
EX
Requirements/Limits
QL: 4 in 28 days (Self
Administerable (Select)
Injectable)
(Self Administerable
(Select) Injectable)
ST
(Self Administerable
(Select) Injectable)
QL: 30 in 30 days
QL: 60 in 30 days
PA
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
42
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
HUMULIN R U-500
HUMULIN R
LANTUS SOLOSTAR
LANTUS
LEVEMIR FLEXTOUCH
LEVEMIR
NOVOLIN 70-30
NOVOLIN N
NOVOLIN R
NOVOLOG FLEXPEN
NOVOLOG MIX 70-30 FLEXPEN
NOVOLOG MIX 70-30
NOVOLOG
AFREZZA
APIDRA SOLOSTAR
APIDRA
TOUJEO SOLOSTAR
Sulfonylureas
glimepiride
glipizide
glipizide/metformin hcl
glyburide
glyburide,micronized
glyburide/metformin hcl
tolazamide tablet: 250mg
chlorpropamide
tolazamide tablet: 500mg
tolbutamide
AMARYL
DIABETA
GLUCOTROL XL
GLUCOTROL
GLUCOVANCE
GLYNASE
Drug Tier
Requirements/Limits
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T3
T3
T3
T3
(Amaryl)
(Glucotrol)
(Glipizide/Metformin
HCl)
(Glyburide)
(Glynase)
(Glucovance)
(Tolazamide)
(Chlorpropamide)
(Tolazamide)
(Tolbutamide)
T1
T1
T1
T1
T1
T1
T1
T2
T2
T2
T3
T3
T3
T3
T3
T3
Antifungals
CICLODAN cream (g)
CICLODAN solution: 8%
ciclopirox olamine
ciclopirox
clotrimazole
(Ciclopirox Olamine)
(Penlac)
(Clotrimazole)
T1
T1
T1
T1
T1
43
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
clotrimazole/betamethasone dip
econazole nitrate
fluconazole
flucytosine
griseofulvin ultramicrosize
griseofulvin, microsize
itraconazole
ketoconazole cream (g), shampoo, tablet
naftifine hcl
nystatin
nystatin/triamcin
terbinafine hcl
FIRST-DUKE'S
FIRST-MARY'S
gentian viol/brlnt grn/proflav
miconazole nitrate supp.vag
NOXAFIL oral susp, tablet dr
NYSTATIN
SPORANOX solution
ALA-QUIN
ANCOBON
ciclopirox/ure/camph/menth/euc
DERMASORB AF
DIFLUCAN
ERTACZO
EXELDERM
FIRST-BXN
GRIFULVIN V
GRIS-PEG
KETOCON
LAMISIL
LOPROX
LOTRISONE cream (g)
MENTAX
NAFTIN
NIZORAL
OXISTAT
PEDIADERM AF
PENLAC
Drug Tier
(Lotrisone)
(Econazole Nitrate)
(Diflucan)
(Ancobon)
(Gris-Peg)
(Griseofulvin,
Microsize)
(Sporanox)
(Ketoconazole)
(Naftin)
(Nystatin)
(Nystatin/Triamcin)
(Lamisil)
(Gentian Viol/Brlnt
Grn/Proflav)
(Monistat 3)
(Ciclodan)
Requirements/Limits
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T2
T2
T2
T2
T2
T2
T2
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
44
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
SPORANOX capsule
TERBINEX
VUSION
VFEND
voriconazole susp recon, tablet
ABELCET
Drug Tier
T3
T3
T3
T4
T4
T6
(Vfend)
AMBISOME
amphotericin b
T6
(Amphotericin B)
T6
CANCIDAS
T6
ERAXIS (WATER DILUENT)
T6
fluconazole in nacl,iso-osm
(Fluconazole In
Nacl,Iso-Osm)
T6
MYCAMINE
T6
NOXAFIL vial
T6
VFEND IV
T6
voriconazole vial
CICLODAN combo. pkg
CICLODAN solution: 8%
CNL 8
EXTINA
JUBLIA
KERYDIN
ketoconazole foam
KETODAN
LUZU
ONMEL
PEDIPIROX-4
XOLEGEL
(Vfend IV)
(Ketoconazole)
T6
Requirements/Limits
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
Antihistamines
carbinoxamine maleate liquid: 4mg/5ml;
tablet
clemastine fumarate syrup, tablet: 2.68mg
(Carbinoxamine
Maleate)
(Clemastine Fumarate)
T1
T1
45
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
cyproheptadine hcl
desloratadine tablet
(Cyproheptadine HCl)
(Clarinex)
T1
T1
diphenhydramine hcl elixir
(Diphenhydramine
HCl)
(Phenylephrine HCl/
Prometh HCl)
(Promethazine HCl)
T1
phenylephrine hcl/prometh hcl
promethazine hcl
ALLERX 10
ALLERX 30
ALLERX PE
carbinoxamine maleate liquid: 4mg/5ml
doxylamine succinate
PALGIC
p-ephed hcl/chlor-mal/bell alk
POLY HIST DHC
SEMPREX-D
diphenhydramine hcl syringe, vial
cetirizine hcl
CLARINEX
CLARINEX-D 12 HOUR
CLARINEX-D 24 HOUR
DELTUSS DMX
desloratadine tab rapdis
fexofenadine hcl
fexofenadine/pseudoephedrine
levocetirizine dihydrochloride
PHENAGIL
phenylephrine/brompheniramine
phenylephrine/chlorpheniramine drops:
2mg-1mg/ml; liquid: 10-4mg/5ml; tablet:
10mg-4mg
V-HIST
XYZAL
ZYRTEC-D
(Carbinoxamine
Maleate)
(Doxylamine
Succinate)
(P-Ephed HCl/ChlorMal/Bell Alk)
(Diphenhydramine
HCl)
(Cetirizine HCl)
(Desloratadine)
(Fexofenadine HCl)
(Fexofenadine/
Pseudoephedrine)
(Xyzal)
(Phenylephrine/
Brompheniramine)
(Phenylephrine/
Chlorpheniramine)
Requirements/Limits
T1
T1
T3
T3
T3
T3
T3
T3
T3
T3
T3
T6
(Non-self administerable
injectable)
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
46
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
Requirements/Limits
Anti-infectives (Skin and Mucous Membrane)
clindamycin phosphate
metronidazole
terconazole
VANDAZOLE
AVC
CLEOCIN supp.vag
CLINDESSE
CLEOCIN cream/appl
FEM PH
GYNAZOLE 1
METROGEL-VAGINAL
RELAGARD
TERAZOL 3
TERAZOL 7
(Cleocin)
(Metrogel-Vaginal)
(Terazol 7)
T1
T1
T1
T1
T2
T2
T2
T3
T3
T3
T3
T3
T3
T3
Antimigraine Agents
(Ergotamine Tartrate/
Caffeine)
(Isomethept/Dichlphn/
isomethept/dichlphn/acetaminop
Acetaminop)
isomethepten/caf/acetaminophen tablet: 65- (Isomethepten/Caf/
20-325, 130-20-500
Acetaminophen)
(Amerge)
naratriptan hcl
ergotamine tartrate/caffeine
T1
T1
T1
T1
rizatriptan benzoate
(Maxalt)
T1
sumatriptan succinate tablet
(Imitrex)
T1
sumatriptan succinate cartridge, pen injctr, (Imitrex)
vial
T1
(Zomig)
T1
zolmitriptan
QL: 12 in 30 days (QL
applies to all oral
Antimigraine agents
combined)
QL: 12 in 30 days (QL
applies to all oral
Antimigraine agents
combined)
QL: 12 in 30 days (QL
applies to all oral
Antimigraine agents
combined)
QL: 6 in 30 days (Self
Administerable (Select)
Injectable)
QL: 12 in 30 days (QL
applies to all oral
Antimigraine agents
combined)
47
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
almotriptan malate
CAFERGOT
dihydroergotamine mesylate spray/pump
ERGOMAR
IMITREX spray
MIGERGOT
MIGRANAL
sumatriptan
Drug Tier
(Axert)
(Migranal)
(Imitrex)
T2
T2
T2
T2
T2
T2
T2
T2
AMERGE
T3
AXERT
T3
FROVA
T3
IMITREX tablet
T3
IMITREX cartridge, pen injctr, vial
T3
isomethepten/caf/acetaminophen tablet: 65- (Isomethepten/Caf/
20-325
Acetaminophen)
MAXALT MLT
T3
T3
Requirements/Limits
QL: 12 in 30 days
QL: 12 in 30 days (QL
applies to all oral
Antimigraine agents
combined)
QL: 12 in 30 days (QL
applies to all oral
Antimigraine agents
combined)
QL: 12 in 30 days (QL
applies to all oral
Antimigraine agents
combined)
QL: 12 in 30 days (QL
applies to all oral
Antimigraine agents
combined)
QL: 12 in 30 days (QL
applies to all oral
Antimigraine agents
combined)
QL: 12 in 30 days (QL
applies to all oral
Antimigraine agents
combined)
QL: 6 in 30 days (Self
Administerable (Select)
Injectable)
QL: 12 in 30 days (QL
applies to all oral
Antimigraine agents
combined)
48
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
MAXALT
T3
PRODRIN
RELPAX
T3
T3
ZOMIG ZMT
T3
ZOMIG
ZOMIG
T3
T3
D.H.E.45
T6
dihydroergotamine mesylate ampul
(D.H.E.45)
ALSUMA
SUMAVEL DOSEPRO
TREXIMET
T6
Requirements/Limits
QL: 12 in 30 days (QL
applies to all oral
Antimigraine agents
combined)
QL: 12 in 30 days (QL
applies to all oral
Antimigraine agents
combined)
QL: 12 in 30 days (QL
applies to all oral
Antimigraine agents
combined)
QL: 12 in 30 days
QL: 12 in 30 days (QL
applies to all oral
Antimigraine agents
combined)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
EX
EX
EX
Antimycobacterials
ethambutol hcl
isoniazid tablet
pyrazinamide
rifabutin
rifampin capsule
cycloserine
dapsone
isoniazid solution
PASER
PRIFTIN
RIFAMATE
RIFATER
TRECATOR
MYAMBUTOL
MYCOBUTIN
(Myambutol)
(Isoniazid)
(Pyrazinamide)
(Mycobutin)
(Rifadin)
(Cycloserine)
(Dapsone)
(Isoniazid)
T1
T1
T1
T1
T1
T2
T2
T2
T2
T2
T2
T2
T2
T3
T3
49
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
RIFADIN capsule
CAPASTAT SULFATE
isoniazid vial
T3
T6
(Isoniazid)
RIFADIN vial
rifampin vial
T6
T6
(Rifadin)
SIRTURO
T6
Requirements/Limits
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
EX
Antinausea Agents
COMPAZINE supp.rect
dronabinol
granisetron hcl tablet
ondansetron hcl
ondansetron
PHENERGAN supp.rect: 25mg
prochlorperazine maleate
prochlorperazine
promethazine hcl supp.rect, tablet
trimethobenzamide hcl capsule
ANZEMET tablet
CESAMET
EMEND cap ds pk, capsule
granisetron hcl solution
TRANSDERM-SCOP
COMPAZINE tablet
MARINOL
PHENERGAN supp.rect: 12.5mg, 50mg
SANCUSO
TIGAN capsule
ZOFRAN ODT
ZOFRAN solution, tablet
ALOXI
(Marinol)
(Granisetron HCl)
(Zofran)
(Zofran Odt)
(Prochlorperazine
Maleate)
(Prochlorperazine)
(Promethazine HCl)
(Tigan)
(Granisetron HCl)
ANZEMET vial
dimenhydrinate
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T2
T2
T2
T2
T2
T3
T3
T3
T3
T3
T3
T3
T6
T6
(Dimenhydrinate)
T6
PA
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
50
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
EMEND vial
Drug Tier
Requirements/Limits
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
granisetron hcl vial
(Granisetron HCl)
T6
granisetron hcl/pf
(Granisetron HCl/PF)
T6
ondansetron hcl/pf
(Ondansetron HCl/PF)
T6
PHENERGAN ampul
prochlorperazine edisylate
promethazine hcl ampul, vial
scopolamine hydrobromide
T6
(Prochlorperazine
Edisylate)
(Phenergan)
(Scopolamine
Hydrobromide)
TIGAN vial
trimethobenzamide hcl vial
T6
T6
T6
T6
(Trimethobenzamide
HCl)
T6
ZOFRAN vial
T6
ANTIVERT
DICLEGIS
meclizine hcl
ZUPLENZ
EX
EX
EX
EX
(Meclizine HCl)
Antiparasite Agents
atovaquone/proguanil hcl
chloroquine phosphate
hydroxychloroquine sulfate
ivermectin
mefloquine hcl
paromomycin sulfate
quinine sulfate
tinidazole
ALBENZA
ALINIA
BILTRICIDE
COARTEM
DARAPRIM
(Malarone)
(Chloroquine
Phosphate)
(Plaquenil)
(Stromectol)
(Mefloquine HCl)
(Paromomycin Sulfate)
(Qualaquin)
(Tindamax)
T1
T1
T1
T1
T1
T1
T1
T1
T2
T2
T2
T2
T2
51
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
NEBUPENT
PRIMAQUINE
YODOXIN
MALARONE
PLAQUENIL
QUALAQUIN
STROMECTOL
TINDAMAX
atovaquone
MEPRON
PENTAM 300
Drug Tier
(Mepron)
T2
T2
T2
T3
T3
T3
T3
T3
T4
T4
T6
Requirements/Limits
(Non-self administerable
injectable)
Antiparkinsonian Agents
amantadine hcl
benztropine mesylate tablet
bromocriptine mesylate
cabergoline
carbidopa
carbidopa/levodopa
carbidopa/levodopa/entacapone
entacapone
pramipexole di-hcl tablet
ropinirole hcl
selegiline hcl
trihexyphenidyl hcl
AZILECT
LODOSYN
pramipexole di-hcl tab er 24h
tolcapone
ZELAPAR
COMTAN
ELDEPRYL
MIRAPEX ER
MIRAPEX
NEUPRO
PARCOPA
PARLODEL
REQUIP XL
REQUIP
RYTARY
(Amantadine HCl)
(Benztropine Mesylate)
(Bromocriptine
Mesylate)
(Cabergoline)
(Lodosyn)
(Sinemet 25-100)
(Stalevo 200)
(Comtan)
(Mirapex)
(Requip)
(Eldepryl)
(Trihexyphenidyl HCl)
(Mirapex ER)
(Tasmar)
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T2
T2
T2
T2
T2
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
QL: 30 in 30 days
52
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
SINEMET 10-100
SINEMET 25-100
SINEMET 25-250
SINEMET CR
STALEVO 100
STALEVO 125
STALEVO 150
STALEVO 200
STALEVO 50
STALEVO 75
TASMAR
APOKYN
benztropine mesylate ampul
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T5
(Cogentin)
COGENTIN
T6
T6
Requirements/Limits
PA (Self Administerable
(Select) Injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
Antipsychotic Agents
aripiprazole
chlorpromazine hcl tablet
clozapine tablet
fluphenazine hcl tablet
haloperidol lactate oral conc
haloperidol
loxapine succinate
molindone hcl
olanzapine tab rapdis, tablet
perphenazine
quetiapine fumarate
risperidone
thioridazine hcl
thiothixene
trifluoperazine hcl
ziprasidone hcl
fluphenazine hcl elixir, oral conc
pimozide
SEROQUEL XR
ABILIFY DISCMELT
ABILIFY solution, tablet
CLOZARIL
FANAPT
(Abilify Discmelt)
(Chlorpromazine HCl)
(Clozaril)
(Fluphenazine HCl)
(Haloperidol Lactate)
(Haloperidol)
(Loxapine Succinate)
(Moban)
(Zyprexa)
(Perphenazine)
(Seroquel)
(Risperdal)
(Thioridazine HCl)
(Thiothixene)
(Trifluoperazine HCl)
(Geodon)
(Fluphenazine HCl)
(Orap)
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T2
T2
T2
T3
T3
T3
T3
53
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
GEODON capsule
LATUDA
LOXITANE
ORAP
RISPERDAL M-TAB
RISPERDAL
SAPHRIS
SEROQUEL
ZYPREXA ZYDIS
ZYPREXA tablet
ABILIFY MAINTENA suser syr: 300mg,
400mg; suser vial
ABILIFY vial
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T6
T6
chlorpromazine hcl ampul
(Chlorpromazine HCl)
T6
fluphenazine decanoate
(Fluphenazine
Decanoate)
(Fluphenazine HCl)
T6
fluphenazine hcl vial
T6
GEODON vial
T6
HALDOL DECANOATE 100
T6
HALDOL DECANOATE 50
T6
HALDOL
T6
haloperidol decanoate
haloperidol lactate vial
(Haloperidol
Decanoate)
(Haloperidol Lactate)
T6
T6
INVEGA SUSTENNA
T6
INVEGA TRINZA
T6
olanzapine vial
(Zyprexa)
RISPERDAL CONSTA
T6
T6
Requirements/Limits
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
ST (Non-self
administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
54
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
Requirements/Limits
ZYPREXA RELPREVV
T6
ZYPREXA vial
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
clozapine tab rapdis
FAZACLO
INVEGA
paliperidone
REXULTI
(Fazaclo)
(Invega)
EX
EX
EX
EX
EX
Antivirals (Systemic)
Antiretrovirals
abacavir sulfate
didanosine
lamivudine
lamivudine/zidovudine
nevirapine tab er 24h, tablet
stavudine
zidovudine
abacavir/lamivudine/zidovudine
APTIVUS capsule
APTIVUS solution
COMBIVIR
CRIXIVAN
EDURANT
EMTRIVA
EPIVIR HBV solution
EPZICOM
EVOTAZ
INTELENCE
INVIRASE
ISENTRESS
KALETRA
nevirapine oral susp
NORVIR
PREZCOBIX
RESCRIPTOR
REYATAZ
SELZENTRY
SUSTIVA
TRUVADA
VIDEX
(Ziagen)
(Videx EC)
(Epivir Hbv)
(Combivir)
(Viramune)
(Zerit)
(Zidovudine)
(Trizivir)
(Viramune)
T1
T1
T1
T1
T1
T1
T1
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
55
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
VIRACEPT
VIREAD
ZIAGEN
EPIVIR HBV tablet
EPIVIR
RETROVIR capsule, syrup
TIVICAY
VIDEX EC
VIRAMUNE XR
VIRAMUNE
ZERIT
ATRIPLA
COMPLERA
LEXIVA
PREZISTA
STRIBILD
TRIUMEQ
TRIZIVIR
FUZEON
T2
T2
T2
T3
T3
T3
T3
T3
T3
T3
T3
T4
T4
T4
T4
T4
T4
T4
T5
VITEKTA
RETROVIR vial
T5
T6
Antivirals, Miscellaneous
rimantadine hcl
RELENZA
TAMIFLU
FLUMADINE
foscarnet sodium
(Rimantadine HCl)
(Foscavir)
T1
T2
T2
T3
T6
FOSCAVIR
T6
SYNAGIS
T6
HCV Antivirals
HARVONI
INCIVEK
SOVALDI
OLYSIO
VICTRELIS
T5
T5
T5
EX
EX
Requirements/Limits
(Self Administerable
(Select) Injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self
administerable
injectable)
PA
PA
56
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
VIEKIRA PAK
Interferons
INTRON A
EX
PEGASYS PROCLICK
T5
PEGASYS
T5
PEGINTRON REDIPEN
T5
PEGINTRON
T5
SYLATRON
T5
ALFERON N
T6
Nucleosides and Nucleotides
acyclovir
famciclovir
valacyclovir hcl
FAMVIR
VALTREX
ZOVIRAX
adefovir dipivoxil
BARACLUDE
COPEGUS
entecavir
HEPSERA
REBETOL
RIBATAB
ribavirin
TYZEKA
VALCYTE
valganciclovir hcl
VIRAZOLE
acyclovir sodium
cidofovir
T5
(Zovirax)
(Famvir)
(Valtrex)
(Acyclovir Sodium)
T1
T1
T1
T3
T3
T3
T4
T4
T4
T4
T4
T4
T4
T4
T4
T4
T4
T4
T6
(Vistide)
T6
(Hepsera)
(Baraclude)
(Rebetol)
(Valcyte)
CYTOVENE
T6
Requirements/Limits
(Self Administerable
(Select) Injectable)
(Self Administerable
(Select) Injectable)
(Self Administerable
(Select) Injectable)
(Self Administerable
(Select) Injectable)
(Self Administerable
(Select) Injectable)
(Self Administerable
(Select) Injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
57
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
ganciclovir sodium
(Cytovene)
Drug Tier
Requirements/Limits
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
VISTIDE
T6
MODERIBA
EX
Blood Products/Modifiers/Volume Expanders
Anticoagulants
warfarin sodium
sodium citrate
COUMADIN tablet
ELIQUIS
PRADAXA
XARELTO tab ds pk, tablet: 15mg, 20mg
XARELTO tablet: 10mg
enoxaparin sodium
fondaparinux sodium
(Coumadin)
(Sodium Citrate)
(Lovenox)
T1
T2
T3
T3
T3
T3
T3
T4
(Arixtra)
T4
IPRIVASK
T4
ARIXTRA
T5
FRAGMIN
T5
LOVENOX
T5
ANGIOMAX
T6
ARGATROBAN
T6
ARGATROBAN-0.9% NACL
T6
bivalirudin
(Angiomax)
T6
CEPROTIN
T6
COUMADIN vial
T6
heparin sod,porcine/0.9 % nacl iv soln, kit
(Heparin Sod,Porcine/
0.9 % NaCl)
T6
(Includes Jantoven)
QL: 94 in 365 days
(Self Administerable
(Select) Injectable)
(Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
(Self Administerable
(Select) Injectable)
(Self Administerable
(Select) Injectable)
(Self Administerable
(Select) Injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
58
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
heparin sod,pork in 0.45% nacl
(Heparin Sod,Pork In
0.45% NaCl)
HEPARIN SODIUM IN 0.45% NACL
heparin sodium,porcine
heparin sodium,porcine/d5w
heparin sodium,porcine/ns/pf
heparin sodium,porcine/pf
Drug Tier
Requirements/Limits
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
T6
(Heparin
Sodium,Porcine)
(Heparin
Sodium,Porcine/D5W)
(Heparin
Sodium,Porcine/Ns/PF)
(Monoject Prefill
Advanced)
T6
T6
T6
T6
MONOJECT PREFILL ADVANCED
T6
THROMBATE III
T6
SAVAYSA
Blood Formation Modifiers
PROMACTA
NEUMEGA
EX
ARANESP
T6
BERINERT
T6
CINRYZE
T6
EPOGEN
T6
GRANIX
T6
LEUKINE
T6
MOZOBIL
T6
NEULASTA
T6
NEUPOGEN
T6
OMONTYS
T6
T4
T5
(Self Administerable
(Select) Injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self
administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
59
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
Requirements/Limits
PROCRIT
T6
(Non-self administerable
injectable)
Hematologic Agents, Miscellaneous
aminocaproic acid solution, tablet: 500mg (Aminocaproic Acid)
(Agrylin)
anagrelide hcl
AGRYLIN
AMICAR tablet
aminocaproic acid tablet: 1000mg
(Aminocaproic Acid)
AVITENE
GELFOAM
OXYCEL
RECOTHROM
TACHOSIL
(Thrombin (Bovine))
thrombin (bovine)
tranexamic acid tablet
(Lysteda)
ULTRAFOAM
ACTIVASE
T1
T1
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T6
ADVATE
T6
ADYNOVATE
T6
ALPHANATE
T6
ALPHANINE SD
T6
aminocaproic acid vial
(Aminocaproic Acid)
T6
BEBULIN
T6
BENEFIX
T6
CATHFLO ACTIVASE
T6
COAGADEX
T6
CORIFACT
T6
CYKLOKAPRON
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
60
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
Requirements/Limits
ELOCTATE
T6
FEIBA NF
T6
HELIXATE FS
T6
HEMOFIL M
T6
HUMATE-P
T6
IXINITY
T6
KCENTRA
T6
KOATE-DVI
T6
KOGENATE FS
T6
MONOCLATE-P
T6
MONONINE
T6
NOVOEIGHT
T6
NOVOSEVEN RT
T6
NUWIQ
T6
OBIZUR
T6
PRAXBIND
T6
PROFILNINE
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
protamine sulfate
(Protamine Sulfate)
T6
RECOMBINATE
T6
RETAVASE
T6
RIASTAP
T6
61
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
Requirements/Limits
RIXUBIS
T6
TNKASE
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
tranexamic acid vial
(Tranexamic Acid)
T6
WILATE
T6
XYNTHA SOLOFUSE
T6
XYNTHA
T6
ALPROLIX
ARTISS
LYSTEDA
TISSEEL VHSD
Platelet-Aggregation Inhibitors
aspirin/dipyridamole
cilostazol
clopidogrel bisulfate
dipyridamole
pentoxifylline
ticlopidine hcl
AGGRENOX
BRILINTA
EFFIENT
PERSANTINE
PLAVIX
PLETAL
AGGRASTAT
EX
EX
EX
EX
eptifibatide
(Aggrenox)
(Pletal)
(Plavix)
(Persantine)
(Pentoxifylline)
(Ticlopidine HCl)
(Integrilin)
T1
T1
T1
T1
T1
T1
T3
T3
T3
T3
T3
T3
T6
T6
INTEGRILIN
T6
REOPRO
T6
ZONTIVITY
Volume Expanders
ALBUKED-25
EX
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
62
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
Requirements/Limits
ALBUKED-5
T6
ALBUMIN (HUMAN)
T6
ALBUMINAR-25
T6
ALBUMINAR-5
T6
ALBURX
T6
ALBUTEIN
T6
BUMINATE
T6
FLEXBUMIN
T6
KEDBUMIN
T6
OCTAPLAS plast. bag: 45to70mg
T6
OCTAPLAS plast. bag: 45to70mg
T6
OCTAPLAS plast. bag: 45to70mg
T6
OCTAPLAS plast. bag: 45to70mg
T6
PLASBUMIN-25
T6
PLASBUMIN-5
T6
PLASMANATE
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
Caloric Agents
PROTECT PLUS
AMINO ACIDS
T3
T6
AMINOSYN II WITH ELECTROLYTES
T6
AMINOSYN II iv soln: 10%
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
63
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
Requirements/Limits
AMINOSYN II iv soln: 15%
T6
AMINOSYN II iv soln: 7%
T6
AMINOSYN II iv soln: 8.5%
T6
AMINOSYN M
T6
AMINOSYN WITH ELECTROLYTES iv
soln: 7%
AMINOSYN WITH ELECTROLYTES iv
soln: 8.5%
AMINOSYN iv soln: 10%
T6
AMINOSYN iv soln: 3.5%
T6
AMINOSYN iv soln: 7%
T6
AMINOSYN iv soln: 8.5%
T6
AMINOSYN-HBC
T6
AMINOSYN-PF iv soln: 10%
T6
AMINOSYN-PF iv soln: 7%
T6
AMINOSYN-RF
T6
CLINIMIX E iv soln: 2.75%
T6
CLINIMIX E iv soln: 2.75%
T6
CLINIMIX E iv soln: 4.25%
T6
CLINIMIX E iv soln: 4.25%
T6
CLINIMIX E iv soln: 4.25%
T6
CLINIMIX E iv soln: 5%
T6
CLINIMIX E iv soln: 5%
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
T6
T6
64
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
Requirements/Limits
CLINIMIX E iv soln: 5%
T6
CLINIMIX iv soln: 2.75%
T6
CLINIMIX iv soln: 4.25%
T6
CLINIMIX iv soln: 4.25%
T6
CLINIMIX iv soln: 4.25%
T6
CLINIMIX iv soln: 4.25%
T6
CLINIMIX iv soln: 5%
T6
CLINIMIX iv soln: 5%
T6
CLINIMIX iv soln: 5%
T6
CLINISOL
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
cysteine hcl
(Cysteine HCl)
T6
dextrose 10 % and 0.9 % nacl
(Dextrose 10 % and 0.9
% NaCl)
(Dextrose 10 % in
Water)
(Dextrose 2.5 % in
Water)
(Dextrose 20 % in
Water)
(Dextrose 25 % in
Water)
(Dextrose 30 % in
Water)
(Dextrose 40 % in
Water)
(Dextrose 5 % in
Water)
(Dextrose 5% In
Ringers)
(Dextrose 50 % in
Water)
T6
dextrose 10 % in water
dextrose 2.5 % in water
dextrose 20 % in water
dextrose 25 % in water
dextrose 30 % in water
dextrose 40 % in water
dextrose 5 % in water
dextrose 5% in ringers
dextrose 50 % in water
T6
T6
T6
T6
T6
T6
T6
T6
T6
65
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
dextrose 70 % in water
(Dextrose 70 % in
Water)
Drug Tier
Requirements/Limits
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
FREAMINE HBC
T6
FREAMINE III
T6
HEPATAMINE
T6
HEPATASOL
T6
INTRALIPID
T6
KABIVEN
T6
LIPOSYN II
T6
LIPOSYN III
T6
NEPHRAMINE
T6
NUTRILIPID
T6
PERIKABIVEN
T6
PREMASOL iv soln: 10%
T6
PREMASOL iv soln: 6%
T6
PROCALAMINE
T6
PROSOL
T6
TRAVASOL
T6
TROPHAMINE iv soln: 10%
T6
TROPHAMINE iv soln: 6%
T6
AXONA
GLYTACTIN 10 PE BETTERMILK
GLYTACTIN 15 PE BETTERMILK
EX
EX
EX
66
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
Requirements/Limits
Cardiac Function
THALLOUS CHLORIDE TL-201
EX
Cardiovascular Agents
Alpha-Adrenergic Agents
clonidine hcl
clonidine
doxazosin mesylate
guanfacine hcl
methyldopa
midodrine hcl
prazosin hcl
clonidine hcl/chlorthalidone
methyldopa/hydrochlorothiazide
phenoxybenzamine hcl
CARDURA
CATAPRES
CATAPRES-TTS 1
CATAPRES-TTS 2
CATAPRES-TTS 3
MINIPRESS
TENEX
NORTHERA
methyldopate hcl
(Catapres)
(Catapres-Tts 3)
(Cardura)
(Tenex)
(Methyldopa)
(Midodrine HCl)
(Minipress)
(Clorpres)
(Methyldopa/
Hydrochlorothiazide)
(Dibenzyline)
(Methyldopate HCl)
NEO-SYNEPHRINE
phenylephrine hcl
T1
T1
T1
T1
T1
T1
T1
T2
T2
T2
T3
T3
T3
T3
T3
T3
T3
T4
T6
T6
(Phenylephrine HCl)
T6
VAZCULEP
T6
CARDURA XL
DIBENZYLINE
Angiotensin II Receptor Antagonists
(Atacand)
candesartan cilexetil
(Atacand HCT)
candesartan/hydrochlorothiazid
(Teveten)
eprosartan mesylate
(Avapro)
irbesartan
(Avalide)
irbesartan/hydrochlorothiazide
(Cozaar)
losartan potassium
(Hyzaar)
losartan/hydrochlorothiazide
EX
EX
QL: 4 in 28 days
QL: 4 in 28 days
QL: 4 in 28 days
QL: 4 in 28 days
PA, QL: 180 in 30 days
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
T1
T1
T1
T1
T1
T1
T1
67
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
(Micardis)
telmisartan
(Micardis HCT)
telmisartan/hydrochlorothiazid
(Diovan)
valsartan
(Diovan HCT)
valsartan/hydrochlorothiazide
ATACAND HCT
ATACAND
AVALIDE
AVAPRO
BENICAR HCT
BENICAR
COZAAR
DIOVAN HCT
DIOVAN
EDARBI
EDARBYCLOR
ENTRESTO
HYZAAR
MICARDIS HCT
MICARDIS
TEVETEN HCT
TEVETEN
(Twynsta)
telmisartan/amlodipine
TWYNSTA
Angiotensin-Converting Enzyme Inhibitors
(Lotensin)
benazepril hcl
(Lotensin HCT)
benazepril/hydrochlorothiazide
(Captopril)
captopril
(Captopril/
captopril/hydrochlorothiazide
Hydrochlorothiazide)
(Vasotec)
enalapril maleate
(Vaseretic)
enalapril/hydrochlorothiazide
(Fosinopril Sodium)
fosinopril sodium
(Fosinopril/
fosinopril/hydrochlorothiazide
Hydrochlorothiazide)
(Zestril)
lisinopril
(Zestoretic)
lisinopril/hydrochlorothiazide
(Univasc)
moexipril hcl
(Uniretic)
moexipril/hydrochlorothiazide
(Aceon)
perindopril erbumine
(Accupril)
quinapril hcl
(Accuretic)
quinapril/hydrochlorothiazide
Requirements/Limits
T1
T1
T1
T1
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
EX
EX
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
68
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
ramipril
trandolapril
trandolapril/verapamil hcl
ACCUPRIL
ACCURETIC
ACEON
ALTACE
LOTENSIN HCT
LOTENSIN
MAVIK
PRINIVIL
TARKA
UNIRETIC
UNIVASC
VASERETIC
VASOTEC
ZESTORETIC
ZESTRIL
enalaprilat dihydrate
EPANED
Antiarrhythmic Agents
amiodarone hcl tablet
disopyramide phosphate
flecainide acetate
mexiletine hcl
propafenone hcl
quinidine gluconate tablet er
quinidine sulfate tablet: 300mg
NORPACE CR
quinidine sulfate tablet: 200mg; tablet er
TIKOSYN
CORDARONE
MULTAQ
NORPACE
RYTHMOL SR
RYTHMOL
ADENOCARD
adenosine
Drug Tier
(Altace)
(Mavik)
(Tarka)
(Enalaprilat Dihydrate)
T1
T1
T2
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T6
Requirements/Limits
(Non-self administerable
injectable)
EX
(Cordarone)
(Norpace)
(Tambocor)
(Mexiletine HCl)
(Rythmol)
(Quinidine Gluconate)
(Quinidine Sulfate)
(Quinidine Sulfate)
(Adenosine)
T1
T1
T1
T1
T1
T1
T1
T2
T2
T2
T3
T3
T3
T3
T3
T6
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
69
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
amiodarone hcl ampul, syringe, vial
(Amiodarone HCl)
CORVERT
Drug Tier
Requirements/Limits
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
T6
ibutilide fumarate
(Corvert)
T6
lidocaine hcl/d5w/pf
(Lidocaine HCl/D5w/
PF)
(Lidocaine HCl/D7.5w/
PF)
(Lidocaine HCl/PF)
T6
lidocaine hcl/d7.5w/pf
lidocaine hcl/pf
NEXTERONE
T6
T6
T6
procainamide hcl
(Procainamide HCl)
T6
quinidine gluconate vial
(Quinidine Gluconate)
T6
(Sectral)
(Tenormin)
(Tenoretic 50)
(Kerlone)
(Zebeta)
(Ziac)
(Coreg)
(Trandate)
(Toprol XL)
(Lopressor)
(Lopressor HCT)
(Corgard)
(Corzide)
(Pindolol)
(Propranolol HCl)
(Propranolol/
Hydrochlorothiazid)
(Betapace AF)
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
Beta-Adrenergic Blocking Agents
acebutolol hcl
atenolol
atenolol/chlorthalidone
betaxolol hcl
bisoprolol fumarate
bisoprolol fumarate/hctz
carvedilol
labetalol hcl tablet
metoprolol succinate
metoprolol tartrate tablet
metoprolol/hydrochlorothiazide
nadolol
nadolol/bendroflumethiazide
pindolol
propranolol hcl cap sa 24h, tablet
propranolol/hydrochlorothiazid
sotalol hcl
BYSTOLIC
DUTOPROL
LEVATOL
propranolol hcl solution
(Propranolol HCl)
T1
T2
T2
T2
T2
70
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
timolol maleate
BETAPACE AF
BETAPACE
COREG
CORGARD
CORZIDE
INDERAL LA
INNOPRAN XL
LOPRESSOR HCT
LOPRESSOR tablet
SECTRAL
TENORETIC 100
TENORETIC 50
TENORMIN
TOPROL XL
TRANDATE
ZEBETA
ZIAC
BREVIBLOC
(Timolol Maleate)
esmolol hcl
(Esmolol HCl)
T6
labetalol hcl vial
(Labetalol HCl)
T6
LOPRESSOR ampul
T2
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T6
T6
metoprolol tartrate vial
(Metoprolol Tartrate)
T6
propranolol hcl vial
(Propranolol HCl)
T6
SOTALOL HCL
T6
COREG CR
Calcium-Channel Blocking Agents
diltiazem hcl cap er 12h, cap er 24h, cap er (Cardizem CD)
deg, capsule er, tab er 24h, tablet
verapamil hcl cap24h pct, cap24h pel,
(Calan SR)
tablet, tablet er
CALAN SR
CALAN
CARDIZEM CD
EX
Requirements/Limits
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
T1
T1
T3
T3
T3
71
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
CARDIZEM LA
CARDIZEM
DILACOR XR
TIAZAC
VERELAN PM
VERELAN
diltiazem hcl vial, vial port
(Diltiazem HCl)
T3
T3
T3
T3
T3
T3
T6
verapamil hcl syringe, vial
(Verapamil HCl)
T6
Cardiovascular Agents, Miscellaneous
digoxin tablet
(Lanoxin)
hydralazine hcl tablet
(Hydralazine HCl)
(Isoxsuprine HCl)
isoxsuprine hcl
papaverine hcl capsule er
(Papaverine HCl)
ADRENACLICK
T1
T1
T1
T1
T2
AUVI-Q
T2
DEMSER
DIGOXIN
epinephrine auto injct
T2
T2
T2
(Adrenaclick)
EPIPEN 2-PAK
T2
EPIPEN JR 2-PAK
T2
reserpine
LANOXIN tablet
RANEXA
FIRAZYR
(Reserpine)
T2
T3
T3
T5
ADRENALIN
T6
CORLOPAM
T6
DIGIFAB
T6
digoxin ampul
(Lanoxin)
T6
Requirements/Limits
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Self Administerable
(Select) Injectable)
(Self Administerable
(Select) Injectable)
(Self Administerable
(Select) Injectable)
(Self Administerable
(Select) Injectable)
(Self Administerable
(Select) Injectable)
Age must be >= 18, PA
(Self Administerable
(Select) Injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
72
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
Requirements/Limits
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
dipyridamole
(Dipyridamole)
T6
dobutamine hcl
(Dobutamine HCl)
T6
dobutamine hcl/d5w
T6
dopamine hcl
(Dobutamine HCl/
D5W)
(Dopamine HCl)
dopamine hcl/d5w
(Dopamine HCl/D5W)
T6
ephedrine sulfate
(Ephedrine Sulfate)
T6
epinephrine hcl/pf
(Epinephrine HCl/PF)
T6
epinephrine ampul, syringe
(Epinephrine)
T6
ethanolamine oleate
(Ethanolamine Oleate)
T6
hydralazine hcl vial
(Hydralazine HCl)
T6
T6
LANOXIN PEDIATRIC
T6
LANOXIN ampul
T6
LEVOPHED BITARTRATE
T6
milrinone lactate
(Milrinone Lactate)
T6
milrinone lactate/d5w
(Milrinone Lactate/
D5W)
T6
NATRECOR
T6
NITROPRESS
T6
norepinephrine bitartrate
(Levophed Bitartrate)
T6
papaverine hcl vial
(Papaverine HCl)
T6
VECAMYL
Dihydropyridines
amlodipine besylate
amlodipine besylate/benazepril
EX
(Norvasc)
(Lotrel)
T1
T1
73
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
felodipine
nicardipine hcl capsule
nifedipine
nimodipine
nisoldipine tab er 24h: 8.5mg, 17mg, 34mg
CARDENE SR
isradipine
nisoldipine tab er 24h: 20mg, 30mg, 40mg
ADALAT CC
LOTREL
nisoldipine tab er 24h: 25.5mg
NORVASC
PROCARDIA XL
PROCARDIA
SULAR
CARDENE I.V. ampul
Drug Tier
(Felodipine)
(Nicardipine HCl)
(Procardia XL)
(Nimodipine)
(Sular)
(Isradipine)
(Sular)
(Sular)
CARDENE I.V. piggyback
nicardipine hcl in 0.9% nacl
nicardipine hcl vial
amlodipine/valsartan
amlodipine/valsartan/hcthiazid
AZOR
CLEVIPREX
EXFORGE HCT
EXFORGE
Diuretics
amiloride hcl
amiloride/hydrochlorothiazide
bumetanide tablet
chlorothiazide
chlorthalidone
furosemide solution: 10mg/ml; tablet
hydrochlorothiazide
indapamide
metolazone
torsemide tablet
T1
T1
T1
T1
T1
T2
T2
T2
T3
T3
T3
T3
T3
T3
T3
T6
T6
(Nicardipine Hcl In
0.9% NaCl)
(Nicardipine HCl)
T6
(Exforge)
(Exforge HCT)
EX
EX
EX
EX
EX
EX
(Midamor)
(Amiloride/
Hydrochlorothiazide)
(Bumetanide)
(Chlorothiazide)
(Chlorthalidone)
(Lasix)
(Microzide)
(Indapamide)
(Zaroxolyn)
(Demadex)
T1
T1
T6
Requirements/Limits
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
T1
T1
T1
T1
T1
T1
T1
T1
74
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
triamterene/hydrochlorothiazid capsule:
37.5-25mg; tablet
DIURIL
DYRENIUM
EDECRIN
furosemide solution: 40mg/5ml
methyclothiazide
triamterene/hydrochlorothiazid capsule:
50mg-25mg
DEMADEX
DYAZIDE
LASIX
MAXZIDE-25 MG
MAXZIDE
MICROZIDE
ZAROXOLYN
SAMSCA
bumetanide vial
(Maxzide-25 Mg)
T1
(Furosemide)
(Methyclothiazide)
(Dyazide)
T2
T2
T2
T2
T2
T2
(Bumetanide)
T3
T3
T3
T3
T3
T3
T3
T4
T6
chlorothiazide sodium
(Sodium Diuril)
T6
ethacrynate sodium
(Sodium Edecrin)
T6
furosemide syringe, vial
(Furosemide)
T6
mannitol
(Mannitol)
T6
OSMITROL
T6
SODIUM DIURIL
T6
SODIUM EDECRIN
T6
torsemide vial
(Torsemide)
VAPRISOL-5% DEXTROSE
Dyslipidemics
atorvastatin calcium
cholestyramine (with sugar)
cholestyramine/aspartame
T6
T6
(Lipitor)
(Questran)
(Questran Light)
Requirements/Limits
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
T1
T1
T1
75
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
colestipol hcl
fenofibrate nanocrystallized
fenofibrate tablet
fenofibrate,micronized
fluvastatin sodium capsule
gemfibrozil
lovastatin
niacin tab er 24h
pravastatin sodium
simvastatin
CRESTOR
fluvastatin sodium tab er 24h
niacin tablet
SIMCOR
VYTORIN
WELCHOL
ADVICOR
amlodipine/atorvastatin
ANTARA
CADUET
COLESTID
fenofibrate capsule
fenofibric acid (choline)
(Colestid)
(Tricor)
(Fenoglide)
(Antara)
(Lescol)
(Lopid)
(Mevacor)
(Niaspan)
(Pravachol)
(Zocor)
fenofibric acid
FENOGLIDE
FIBRICOR
LESCOL XL
LESCOL
LIPOFEN
LOFIBRA capsule
LOFIBRA tablet
LOPID
MEVACOR
NIASPAN
PRAVACHOL
QUESTRAN
TRICOR
TRIGLIDE
(Fibricor)
(Lescol XL)
(Niacin)
(Caduet)
(Lipofen)
(Trilipix)
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T2
T2
T2
T2
T2
T2
T3
T3
T3
T3
T3
T3
T3
Requirements/Limits
(NOT COVERED FOR
MEDICAID: Covered
Alternatives Available)
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
76
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
TRILIPIX
T3
ZETIA
ZOCOR
PRALUENT PEN
T3
T3
T4
PRALUENT SYRINGE
T4
REPATHA SURECLICK
T4
REPATHA SYRINGE
T4
ALTOPREV
JUXTAPID
KYNAMRO
LIPICHOL 540
LIPITOR
LIPTRUZET
LIVALO
LOVAZA
(Lovaza)
omega-3 acid ethyl esters
VASCAZEN
VASCEPA
Renin-Angiotensin-Aldosterone System Inhibitors
(Inspra)
eplerenone
(Aldactazide)
spironolact/hydrochlorothiazid
(Aldactone)
spironolactone
ALDACTAZIDE
ALDACTONE
INSPRA
AMTURNIDE
TEKTURNA HCT
TEKTURNA
Sclerosing Agents
ASCLERA
VARITHENA
Vasodilators
ISOCHRON
isosorbide dinitrate tablet, tablet er
(Isordil Titradose)
(Imdur)
isosorbide mononitrate
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
Requirements/Limits
(NOT COVERED FOR
MEDICAID: Covered
Alternatives Available)
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
T1
T1
T1
T3
T3
T3
EX
EX
EX
EX
EX
T1
T1
T1
77
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
minoxidil
nitroglycerin patch td24
nitroglycerin capsule er
BIDIL
ISORDIL
isosorbide dinitrate tab subl
NITRO-BID
nitroglycerin spray
NITROLINGUAL
NITROMIST
NITROSTAT
PROGLYCEM
DILATRATE-SR
IMDUR
ISORDIL TITRADOSE
NITRO-DUR
nitroglycerin vial
(Minoxidil)
(Nitro-Dur)
(Nitroglycerin)
(Nitroglycerin)
T1
T1
T1
T2
T2
T2
T2
T2
T2
T2
T2
T2
T3
T3
T3
T3
T6
nitroglycerin/d5w
(Nitroglycerin/D5W)
T6
(Isosorbide Dinitrate)
(Nitrolingual)
NITRONAL
T6
Requirements/Limits
QL: 30 in 30 days
QL: 30 in 30 days
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
Central Nervous System Agents
caffeine citrated solution
DEXEDRINE tablet
dexmethylphenidate hcl
dextroamphetamine sulfate
dextroamphetamine/amphetamine
lithium carbonate
methamphetamine hcl
methylphenidate hcl
riluzole
lithium citrate
RITALIN LA cpbp 50-50: 10mg
ADDERALL XR
ADDERALL
CAFCIT solution
CONCERTA
DESOXYN
DEXEDRINE capsule er
(Cafcit)
(Focalin)
(Dextroamphetamine
Sulfate)
(Adderall)
(Lithium Carbonate)
(Desoxyn)
(Concerta)
(Rilutek)
(Lithium Citrate)
T1
T1
T1
T1
T1
T1
T1
T1
T1
T2
T2
T3
T3
T3
T3
T3
T3
PA
PA
78
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
FOCALIN XR
FOCALIN
guanfacine hcl
INTUNIV
Drug Tier
(Intuniv)
T3
T3
T3
T3
LITHOBID
METADATE CD
METHYLIN
PROCENTRA
RILUTEK
RITALIN LA cpbp 50-50: 20mg, 30mg,
40mg, 60mg
RITALIN
RITALIN-SR
SAVELLA
T3
T3
T3
STRATTERA
VYVANSE
ZENZEDI
tetrabenazine
XENAZINE
BREVITAL SODIUM
T3
T3
T3
T4
T5
T6
(Xenazine)
T6
caffeine citrated vial
(Cafcit)
T6
caffeine/sodium benzoate
(Caffeine/Sodium
Benzoate)
(Romazicon)
T6
ADDYI
ADIPEX-P
AMPYRA
BELVIQ
benzphetamine hcl
BONTRIL SLOW-RELEASE
clonidine hcl
DAYTRANA
(NOT COVERED FOR
MEDICAID: Covered
Alternatives Available)
T3
T3
T3
T3
T3
T3
CAFCIT vial
flumazenil
Requirements/Limits
(Didrex)
(Kapvay)
T6
(NOT COVERED FOR
MEDICAID: Covered
Alternatives Available)
PA
PA
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
EX
EX
EX
EX
EX
EX
EX
EX
79
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
DIDREX
diethylpropion hcl
KAPVAY
NUEDEXTA
phentermine hcl
QSYMIA
QUILLIVANT XR
REGIMEX
SUPRENZA ODT
Drug Tier
(Adipex-P)
EX
EX
EX
EX
EX
EX
EX
EX
EX
desog-e.estradiol/e.estradiol
(Mircette)
T1
desogestrel-ethinyl estradiol
(Velivet)
T1
ethinyl estradiol/drospirenone
(Yaz)
T1
ethynodiol d-ethinyl estradiol
(Ethynodiol D-Ethinyl
Estradiol)
T1
levonorgestrel
(Plan B One-Step)
T1
levonorgestrel-ethin estradiol
(Amethyst)
T1
(Diethylpropion HCl)
Requirements/Limits
Contraceptives
(Women's Preventive
Healthcare; see
Appendix A for list of
covered generic
contraceptives)
(Women's Preventive
Healthcare; see
Appendix A for list of
covered generic
contraceptives)
(Women's Preventive
Healthcare; see
Appendix A for list of
covered generic
contraceptives)
(Women's Preventive
Healthcare; see
Appendix A for list of
covered generic
contraceptives)
(Women's Preventive
Healthcare; see
Appendix A for list of
covered generic
contraceptives)
(Women's Preventive
Healthcare; see
Appendix A for list of
covered generic
contraceptives)
80
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
l-norgest/e.estradion-e.estrad
(Seasonique)
T1
norelgestromin/ethin.estradiol
(Ortho Evra)
T1
noreth-ethinyl estradiol/iron tab chew: 0.4- (Generess Fe)
35(21)
T1
norethindrone ac-eth estradiol
(Loestrin)
T1
norethindrone
(Ortho Micronor)
T1
norethindrone-e.estradiol-iron
(Loestrin Fe)
T1
norethindrone-ethinyl estrad
(Ortho-Novum)
T1
norethindrone-mestranol
(Norinyl 1+50)
T1
Requirements/Limits
(Women's Preventive
Healthcare; see
Appendix A for list of
covered generic
contraceptives)
QL: 3 in 28 days
(Women's Preventive
Healthcare; see
Appendix A for list of
covered generic
contraceptives)
(Women's Preventive
Healthcare; see
Appendix A for list of
covered generic
contraceptives)
(Women's Preventive
Healthcare; see
Appendix A for list of
covered generic
contraceptives)
(Women's Preventive
Healthcare; see
Appendix A for list of
covered generic
contraceptives)
(Women's Preventive
Healthcare; see
Appendix A for list of
covered generic
contraceptives)
(Women's Preventive
Healthcare; see
Appendix A for list of
covered generic
contraceptives)
(Women's Preventive
Healthcare; see
Appendix A for list of
covered generic
contraceptives)
81
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
norgestimate-ethinyl estradiol
(Ortho Tri-Cyclen)
T1
norgestrel-ethinyl estradiol
(Norgestrel-Ethinyl
Estradiol)
T1
AMETHYST
ELLA
T2
T2
MINASTRIN 24 FE
NORINYL 1+50
NUVARING
T2
T2
T2
ORTHO TRI-CYCLEN LO
CYCLESSA
DEMULEN 1-50-21
DESOGEN
ESTROSTEP FE
FEMCON FE
LOESTRIN FE
LOESTRIN
LOSEASONIQUE
MIRCETTE
MODICON
NATAZIA
NOR-Q-D
ORTHO EVRA
ORTHO MICRONOR
ORTHO TRI-CYCLEN
ORTHO-CEPT
ORTHO-CYCLEN
ORTHO-NOVUM
OVCON-35
PLAN B ONE-STEP
SEASONIQUE
TAKE ACTION
T2
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
Requirements/Limits
(Women's Preventive
Healthcare; see
Appendix A for list of
covered generic
contraceptives)
(Women's Preventive
Healthcare; see
Appendix A for list of
covered generic
contraceptives)
(Women's Preventive
Healthcare)
QL: 1 in 28 days
(Women's Preventive
Healthcare)
QL: 3 in 28 days
82
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
TRI-NORINYL
YASMIN 28
YAZ
CAYA CONTOURED
T3
T3
T3
T6
MIRENA
T6
NEXPLANON
T6
ORTHO ALL-FLEX
T6
PARAGARD T 380-A
T6
SKYLA
T6
WIDE SEAL DIAPHRAGM
T6
BEYAZ
GENERESS FE
LO LOESTRIN FE
MICROGESTIN 24 FE
QUARTETTE
SAFYRAL
EX
EX
EX
EX
EX
EX
Requirements/Limits
(Women's Preventive
Healthcare)
QL: 1 in 365 days
(Women's Preventive
Healthcare)
(Women's Preventive
Healthcare)
(Women's Preventive
Healthcare)
QL: 1 in 365 days
(Women's Preventive
Healthcare)
(Women's Preventive
Healthcare)
QL: 3 in 365 days
(Women's Preventive
Healthcare)
Cough And Cold Products
benzonatate capsule: 100mg, 200mg
chlorpheniramine/codeine phos liquid:
2mg-10mg/5
d-methorphan hb/p-epd hcl/bpm syrup: 1030-2/5
guaifenesin/codeine phosphate liquid: 10010mg/5, 200-8mg/5, 225-7.5/5
hydrocodone bit/homatrop me-br
hydrocodone/chlorphen p-stirex
p-ephed hcl/cod/chlorphenir
p-ephed hcl/codeine/guaifen
(Zonatuss)
(Chlorpheniramine/
Codeine Phos)
(D-Methorphan Hb/PEpd HCl/Bpm)
(M-Clear Wc)
(Hydrocodone Bit/
Homatrop Me-Br)
(Hydrocodone/
Chlorphen P-Stirex)
(P-Ephed HCl/Cod/
Chlorphenir)
(Tusnel C)
T1
T1
T1
T1
T1
T1
T1
T1
83
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
promethazine hcl/codeine
promethazine/dextromethorphan
promethazine/phenyleph/codeine
pseudoephed/hydrocodone/cpm
TUSSIGON
ALA-HIST AC
ALAHIST DHC
ALLFEN CD
ALLFEN CDX
COTABFLU
DESPEC-PDC
GILPHEX TR
LORTUSS EX
MAXIFED CD
MAXIFLU CD
MAXIFLU CDX
M-END MAX D
PHENFLU CD
PHENFLU CDX
POLY HIST NC
POLY-TUSSIN DHC
POLY-TUSSIN EX
PRO-CLEAR CAPS
REZIRA
TESSALON PERLE
TESSALON
TUSNEL
TUSSICAPS
TUSSIONEX
ZOTEX-GP
Z-TUSS AC
Z-TUSS E
ZUTRIPRO
benzonatate capsule: 150mg
bromphenrm/pseudoeph/dihydrocd
dihydrocodeine/guaifenesin
Drug Tier
(Promethazine HCl/
Codeine)
(Promethazine/
Dextromethorphan)
(Promethazine/
Phenyleph/Codeine)
(Zutripro)
(Zonatuss)
(Bromphenrm/
Pseudoeph/Dihydrocd)
(Dihydrocodeine/
Guaifenesin)
Requirements/Limits
T1
T1
T1
T1
T1
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
EX
EX
EX
84
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
ZONATUSS
Requirements/Limits
EX
Dental And Oral Agents
cevimeline hcl
chlorhexidine gluconate
pilocarpine hcl
sodium borate
triamcinolone acetonide
CAPHOSOL
DEBACTEROL
FIRST-MOUTHWASH BLM
NEUTRASAL
EVOXAC
GELCLAIR
GELX
PERIDEX
SALAGEN
AQUORAL
ARESTIN
CLINPRO 5000
PREVIDENT 5000 PLUS
PREVIDENT 5000 SENSITIVE
PREVIDENT
sodium fluoride cream (g), gel (gram),
solution
sodium fluoride/potassium nit
stannous fluoride
(Evoxac)
(Peridex)
(Salagen)
(Sodium Borate)
(Triamcinolone
Acetonide)
(Prevident 5000 Plus)
(Sodium Fluoride/
Potassium Nit)
(Stannous Fluoride)
T1
T1
T1
T1
T1
T2
T2
T2
T2
T3
T3
T3
T3
T3
EX
EX
EX
EX
EX
EX
EX
EX
EX
Dermatological Agents
Dermatological Agents, Other
acyclovir
alcohol antiseptic pads
aluminum chloride
AVAR cleanser
AVAR-E
BENZIQ
benzoyl peroxide cleanser, gel (gram): 5%,
10%; lotion
BP WASH
calcipotriene
(Zovirax)
(Alcohol Antiseptic
Pads)
(Aluminum Chloride)
T1
T1
(Benzoyl Peroxide)
T1
T1
T1
T1
T1
(Dovonex)
T1
T1
85
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
CLARIS
fluorouracil
imiquimod
lactic acid
mafenide acetate
podofilox
REA LO 39
REA LO 40
ROSANIL
salicylic acid cream (g), foam: 6%; gel
(gram), liq-film: 27.5%; shampoo
salicylic acid/ceramide cmb #1
sodium thiosulfate/sal acid
Drug Tier
(Carac)
(Aldara)
(Lactic Acid)
(Mafenide Acetate)
(Condylox)
(Virasal)
(Salex)
(Sodium Thiosulfate/
Sal Acid)
sulfacetamide sod/sulfur/urea cleanser
(Claris)
(Sulfacetamide
sulfacetamide sodium
Sodium)
sulfacetamide sodium/sulfur various dosage (Sumadan)
and/or strengths are available
(Sulfacetm Na/
sulfacetm na/avobenzone/sulfur
Avobenzone/Sulfur)
trypsin/balsam peru/castor oil oint. (g)
(Xenaderm)
urea cream (g), foam: 40%; gel (ml): 40%; (Aluvea)
lotion: 40%; sol/pf app
urea/lactic ac/zn undecylenate emulsn(g)
(Urea/Lactic Ac/Zn
Undecylenate)
X-VIATE
ZENCIA
DENAVIR
iodine/potassium iodide solution
(Iodine/Potassium
Iodide)
LUGOL'S
(Oxsoralen-Ultra)
methoxsalen, rapid
PHENOL liquid: 89%
PICATO
ZOVIRAX cream (g)
8-MOP
ACZONE
ALDARA
(Aluminum Acetate)
aluminum acetate
ALUVEA
Requirements/Limits
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T2
T2
T2
T2
T2
T2
T2
T3
T3
T3
T3
T3
86
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
ANACAINE
APOP
AVAR LS
AVAR med. pad
AVAR-E LS
AZELEX
BENSAL HP
BENZAC AC
benzoyl peroxide microspheres kit cl and
crm
benzoyl peroxide gel (gram): 4%, 8%; kit
BREVOXYL-4
BREVOXYL-8
calcitriol
CARAC
CETACAINE
CLARIFOAM EF
CONDYLOX
DELOS
DESQUAM-X
DOVONEX
DRITHOCREME HP
DRYSOL
EFUDEX
emollient combination no.53
ethyl chloride
FINACEA
FLUOROPLEX
GORDOFILM
GORDO-UREA
HYDRO 40
hydrocortisone/lidocaine/aloe
Drug Tier
(Benzoyl Peroxide
Microspheres)
(Benzoyl Peroxide)
(Vectical)
(Emollient
Combination No.53)
(Ethyl Chloride)
(Hydrocortisone/
Lidocaine/Aloe)
INOVA 4-1
INOVA 8-2
INOVA
KERAFOAM
KERALAC
KERALYT
KEROL
Requirements/Limits
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
87
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
LEVULAN
MIRVASO
NUOX
OPTASE
OVACE PLUS WASH
OVACE PLUS
OXSORALEN
OXSORALEN-ULTRA
PACNEX MX
PACNEX
PANRETIN
PLEXION med. pad: 10%-5%
podophyllum resin
protect cmb2/ceramide 1,3,6-11
PRUDOXIN
PYROGALLIC ACID
RADIAPLEXRX
REGENECARE
REGRANEX
SALACYN
SALEX combo. pkg, kit clcmer
SALEX shampoo
salicylic acid foam: 6%; lotion
SALKERA
SANTYL
SILVASORB
SILVRSTAT
SORILUX
sulfacetamide sod/sulfur/urea gel (gram)
sulfacetamide sodium/sulfur foam: 10%4%
SULFAMYLON
SUMADAN
SUMAXIN TS
SUMAXIN
trichloroacetic acid
trypsin/balsam peru/castor oil spray
Drug Tier
(Podophyllum Resin)
(Protect Cmb2/
Ceramide 1,3,6-11)
(Salicylic Acid)
(Sulfacetamide Sod/
Sulfur/Urea)
(Clarifoam Ef)
(Trichloroacetic Acid)
(Trypsin/Balsam Peru/
Castor Oil)
UMECTA
Requirements/Limits
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
88
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
URAMAXIN cream (g), gel (ml)
urea gel/pf app
(Uramaxin Gt)
urea/lactic ac/zn undecylenate eml md pmp (Urea/Lactic Ac/Zn
Undecylenate)
UTOPIC
VALCHLOR
VECTICAL
VENELEX
VEREGEN
VIRASAL
XENADERM
XERAC AC
ZITHRANOL
ZITHRANOL-RR
ZONALON
ZOVIRAX oint. (g)
(Soriatane)
acitretin
(Isotretinoin)
isotretinoin
SORIATANE
RIMSO-50
T3
T3
T3
UVADEX
T6
ABSORICA
ammonium lactate
BENZEFOAM ULTRA
BENZEFOAM
benzoin/aloe vera/storax/tolu
benzoyl peroxide foam, med. pad,
towelette: 3%, 6%, 9%
calcipotriene/betamethasone
CHLORHEXIDINE GLUCONATE
dioxybenzone/pdo/hydroquinone gel
(gram): 3%-5%-4%
ENOVARX-BACLOFEN
FINACEA PLUS
HYDRO 35
hydroquinone cream (g): 4%
LAC-HYDRIN
LIDOVIR
(Lac-Hydrin)
(Benzoin/Aloe Vera/
Storax/Tolu)
(Benzoyl Peroxide)
(Taclonex)
(Dioxybenzone/Pdo/
Hydroquinone)
(Hydroquinone)
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T4
T4
T4
T6
Requirements/Limits
PA
(Non-self administerable
injectable)
(Non-self administerable
injectable)
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
89
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
LUSTRA
NEOBENZ MICRO
PACNEX HP
PACNEX LP
PLEXION SCT
PLEXION cleanser, cream (g), lotion,
med. pad: 9.8%-4.8%
QUTENZA
RADIGEL
RIAX
sulfacetamide sodium/sulfur cleanser:
9.8%-4.8%; cream (g): 9.8%-4.8%; lotion:
9.8%-4.8%
sulfacetamide sodium/urea
TACLONEX
TRI-LUMA
URAMAXIN foam, lotion
urea foam: 35%; gel (ml): 45%; lotion:
45%
VANIQA
VANOXIDE-HC
vite ac/grape/hyaluronic acid
XERESE
ZYCLARA
Dermatological Antibacterials
CLINDACIN P
clindamycin phos/benzoyl perox
clindamycin phosphate
erythromycin base/ethanol
erythromycin/benzoyl peroxide
gentamicin sulfate
metronidazole
mupirocin calcium
mupirocin
neomycin su/polymyx b sulf
ROSADAN gel (gram)
selenium sulfide suspension
silver sulfadiazine
sulfacetamide sodium
Drug Tier
Requirements/Limits
EX
EX
EX
EX
EX
EX
(Sumadan)
(Sulfacetamide
Sodium/Urea)
(Hydro 40)
(Atopiclair)
(Duac)
(Cleocin T)
(Emgel)
(Benzamycin)
(Gentamicin Sulfate)
(Metrogel)
(Bactroban)
(Bactroban)
(Neosporin G.U.
Irrigant)
(Selenium Sulfide)
(Silvadene)
(Klaron)
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
90
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
THERMAZENE
BACTROBAN NASAL
METROGEL combo. pkg
NORITATE
ACANYA
AKNE-MYCIN
BACTROBAN cream (g)
BACTROBAN oint. (g)
BENZACLIN
BENZAMYCINPAK
CENTANY AT
CENTANY
CLEOCIN T
CLINDACIN PAC
CLINDAGEL
CORTISPORIN cream (g)
CORTISPORIN oint. (g)
DUAC
ERYGEL
EVOCLIN
KLARON
METROCREAM
METROGEL gel (gram)
METROLOTION
NEOSPORIN G.U. IRRIGANT
NEO-SYNALAR
OVACE PLUS
ROSADAN kit cl and crm
selenium sulfide shampoo
(Selenium Sulfide)
SELRX
SILVADENE
(Silver Nitrate)
silver nitrate
VELTIN
ZIANA
ALTABAX
CLINDAREACH
NEUAC
TERSI FOAM
Dermatological Anti-Inflammatory Agents
(Aclovate)
alclometasone dipropionate
amcinonide cream (g)
(Amcinonide)
Requirements/Limits
T1
T2
T2
T2
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
EX
EX
EX
EX
T1
T1
91
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
betamethasone dipropionate
betamethasone valerate
betamethasone/propylene glyc
clobetasol propionate
CLODAN shampoo
desonide
desoximetasone cream (g): 0.25%; gel
(gram), oint. (g): 0.25%
diflorasone diacetate oint. (g)
fluocinolone acetonide
fluocinolone/shower cap
fluocinonide
fluticasone propionate
halobetasol propionate
HALONATE PAC
hydrocort/pramoxin/emol/pram#1
hydrocortisone acetate
hydrocortisone acetate/aloe v
hydrocortisone butyrate
hydrocortisone valerate
hydrocortisone cream (g): 1%, 2.5%;
cream/appl, enema: 100mg/60ml; lotion:
2.5%; oint. (g)
hydrocortisone/iodoquinol
hydrocortisone/pramoxine
lidocaine/hydrocortisone ac
mometasone furoate
PRAMCORT
PRAM-HCA
prednicarbate
RECTACORT-HC
SCALACORT
tacrolimus
triamcinolone acetonide cream (g), lotion,
oint. (g): 0.025%, 0.1%
Drug Tier
(Betamethasone
Dipropionate)
(Betamethasone
Valerate)
(Diprolene AF)
(Temovate)
(Desowen)
(Topicort)
(Apexicon)
(Synalar)
(Derma-Smoothe-Fs)
(Vanos)
(Cutivate)
(Ultravate)
(Analpram E)
(Anusol-HC)
(Hydrocortisone
Acetate/Aloe V)
(Locoid)
(Hydrocortisone
Valerate)
(Anusol-HC)
(Hydrocortisone/
Iodoquinol)
(Analpram HC)
(Lidocaine/
Hydrocortisone Ac)
(Elocon)
(Dermatop)
(Protopic)
(Triamcinolone
Acetonide)
Requirements/Limits
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
92
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
CORTIFOAM
triamcinolone acetonide aerosol
ACLOVATE
amcinonide lotion, oint. (g)
ANALPRAM ADVANCED
ANALPRAM HC
ANUSOL-HC cream (g)
ANUSOL-HC supp.rect
APEXICON E
CAPEX SHAMPOO
CLOBEX
clocortolone pivalate
CLODERM
CORDRAN
CORTENEMA
CUTIVATE
DERMA-SMOOTHE-FS
DERMASORB TA
DERMATOP
DESONATE
DESOWEN cream (g), lotion
DESOWEN kt oint le
desoximetasone cream (g): 0.05%; oint. (g):
0.05%
diflorasone diacetate cream (g)
DIPROLENE AF
DIPROLENE
ELIDEL
ELOCON
EPIFOAM
FIRST-HYDROCORTISONE
HALOG
hydrocort/pramoxn/skn clnsr#16
hydrocortisone acetate/urea
hydrocortisone enema: 100mg/60ml;
lotion: 2%
KENALOG
LOCOID
LUXIQ
Drug Tier
(Kenalog)
(Amcinonide)
(Cloderm)
(Topicort)
(Diflorasone Diacetate)
(Hydrocort/Pramoxn/
Skn Clnsr#16)
(Hydrocortisone
Acetate/Urea)
(Cortenema)
Requirements/Limits
T2
T2
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
93
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
NOVACORT
NUCORT
OLUX
PANDEL
PEDIADERM TA
PRAMOSONE E
PRAMOSONE
PROCORT
PROCTOCORT cream (g)
PROCTOCORT supp.rect
PROCTOFOAM-HC
PROTOPIC
PSORCON
SYNALAR TS
SYNALAR cmb ont cr, cream (g): 0.025%
SYNALAR cream (g): 0.025%; oint. (g),
solution
TEMOVATE
TEXACORT
TOPICORT
triamcinolone acetonide oint. (g): 0.05%,
(Triamcinolone
0.5%
Acetonide)
ULTRAVATE PAC
ULTRAVATE X
ULTRAVATE
VANOS
VERDESO
AQUA GLYCOLIC HC
CLODAN kt shm cln
DERMASORB HC
HALONATE
(Hydrocortisone/
hydrocortisone/lidocaine/aloe
Lidocaine/Aloe)
MOMEXIN
NAPRO
PEDIADERM HC
SCALACORT DK
ZYPRAM
Dermatological Retinoids
(Differin)
adapalene
(Retin-A Micro)
tretinoin microspheres
Requirements/Limits
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
T1
T1
Age must be <= 49, PA
94
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
tretinoin cream (g), gel (gram): 0.01%,
0.025%
(Retin-A)
Drug Tier
Requirements/Limits
T1
Age must be <= 49, PA
DIFFERIN
T3
EPIDUO
T3
FABIOR
T3
RETIN-A MICRO
T3
Age must be <= 49, PA
RETIN-A
T3
Age must be <= 49, PA
TAZORAC
T3
TRETIN-X combo. pkg
T3
Age must be <= 49, PA
TRETIN-X cream (g)
T3
Age must be <= 49, PA
ATRALIN
EX
AVAGE
EX
DERMAPAK PLUS
EX
RENOVA
EX
tretinoin gel (gram): 0.05%
(Retin-A)
EX
tretinoin/emollient base
(Tretinoin/Emollient
Base)
EX
95
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Scabicides and Pediculicides
lindane
malathion
permethrin
ELIMITE
EURAX
OVIDE
NATROBA
SKLICE
spinosad
Drug Tier
(Lindane)
(Ovide)
(Elimite)
(Natroba)
Requirements/Limits
T1
T1
T1
T3
T3
T3
EX
EX
EX
Devices
NUMOISYN liquid
APLIGRAF
BIAFINE
DERMAGRAFT
ELETONE
emollient combination no.10
emollient combination no.32
emollient combination no.43
emollient combination no.85
ENDOFORM sheet: 2"x2", 4"x5"
ENDOFORM sheet: 2"x2", 4"x5"
EPICERAM
EPISIL
GELFOAM COMPRESSED
GELFOAM
MUGARD
NUMOISYN lozenge
OASIS ULTRA
PROMISEB
TETRIX
WOUND MATRIX
0.9 % sodium chloride
(Biafine)
(Emollient
Combination No.32)
(Emollient
Combination No.43)
(Emollient
Combination No.85)
(0.9 % Sodium
Chloride)
T2
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T6
DISCOVISC
T6
DUOVISC
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
96
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
Requirements/Limits
VISCOAT
T6
(Non-self administerable
injectable)
A.I.R.S. NEBULIZER
ACE AEROSOL CLOUD ENHANCER
ADAPTER
ADULT AEROSOL MASK
AEROCHAMBER MINI
AEROCHAMBER MV
AEROCHAMBER PLUS FLOW-VU
AEROCHAMBER PLUS Z STAT
AEROCHAMBER WITH FLOWSIGNAL
AEROCHAMBER Z-STAT PLUS
AEROECLIPSE II
AEROECLIPSE
AEROGEAR ASTHMA ACTION KIT
AERONEB GO NEBULIZER
AERONEB GO
AEROTRACH PLUS
AIR FILTER
AIR TUBE WITH AIR PLUGS
AIRS ADULT AEROSOL MASK
AIRS DISPOSABLE NEBULIZER
AIRZONE PEAK FLOW METER
ALL FLOW 1000
ALL FLOW 2000
ALL FLOW 3000 KIT
ALL FLOW 3000 PFT
ALL FLOW 4000
ALL FLOW 5000
ALL FLOW 6000
ALL FLOW 7000
ALTERA NEBULIZER
ASSESS
ASTHMA CHECK
ASTHMAMENTOR
ASTHMAPACK CHILDREN'S
ASTHMAPACK I
ASTHMAPACK II
BABY CONVERSION KIT
BABY CONVERSION PACK 1
BABY CONVERSION PACK 2
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
97
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
BABY NEBULIZER
BREATHERITE
BREATHRITE
BUBBLES THE FISH II
CO MONITOR REPLACEMENT T
CO MONITOR
COMPACT COMPRESSOR NEBULIZER
COMPACT SPACE CHAMBER PLUS
COMPACT ULTRASONIC NEBULIZER
COMP-AIR ELITE COMPRESSOR SYST
COMP-AIR NEBULIZER COMPRESSOR
COMPMIST COMPRESSOR
NEBULIZER
DEVILBISS DISPOSABLE NEBULIZER
DEVILBISS PULMO-AIDE
DEVILBISS PULMONEB LT COMPNEB
DEVILBISS TRAVELER
EASIVENT each
EASIVENT spacer
ERAPID NEBULIZER HANDSET
ERAPID NEBULIZER
EXPIRATORY
E-Z SPACER PEDSPAK
E-Z SPACER
FILTER PAD
FILTER, VALVE SET FOR LL AND LC
FILTERS REPLACEMENT
FLEXICHAMBER
FLUTTER
IN-CHECK DIAL
IN-CHECK NASAL WITH MASK
IN-CHECK ORAL
INNOSPIRE DELUXE
INNOSPIRE ELEGANCE
INNOSPIRE ESSENCE
INNOSPIRE MINI
INNOSPIRE REPLACEMENT FILTER
INSPIRACHAMBER
INSPIRATION ELITE FILTER
INSPIRATION ELITE each: n/a
Requirements/Limits
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
98
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
INSPIRATION ELITE each: n/a
INSPIRATION
INSPIREASE each
INSPIREASE spacer
LC D NEBULIZER SET
LC PLUS
LC SPRINT NEBULIZER
LC STAR
LITEAIRE
LITETOUCH
MASK SET WITH Y-PIECE
MASK VORTEX
MICRO AIR
MICRO ELITE REPLACEMENT FILTER
MICRO ELITE each: n/a
MICRO ELITE each: n/a
MICRO PLUS
MICROCHAMBER
MICROLIFE PEAK FLOW
MICROSPACER
MINI ELITE FILTER REPLACEMENT
MINI PLUS NEBULIZER
MINICOMP COMPRESSOR
NEBULIZER
MINIELITE each: n/a
MINIELITE each: n/a
MINI-WRIGHT PEAK FLOW METER
MISTASSIST
MONAGHAN Z STAT
MOUTHPIECE each: n/a
MOUTHPIECE each: n/a
NESSI SPACER
NOSE CLIP
ONE FLOW FVC each
ONE FLOW FVC kit
ONE WAY MOUTHPIECE
OPTICHAMBER DIAMOND
OPTICHAMBER each
OPTICHAMBER spacer
OPTIHALER
OPTIONHOME
Requirements/Limits
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
99
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
PANDA MASK
PARI SINUS AEROSOL SYSTEM
PEAK-AIR
PEDIATRIC MASK
PEDIATRIC PANDA MASK
PERSONAL BEST
PFLEX TRAINER
PIKO 1
PILLOW MASK FOR CHILDREN
PILLOW MASK each: n/a
PILLOW MASK each: n/a
POCKET CHAMBER
POCKET PEAK
PRIMEAIRE
PROCHAMBER
PRODIGY MINI-MIST
PRONEB ULTRA II
PRONEB ULTRA
PULMO-AIDE
PULMONEB LT COMPRESSOR NEBUL
QUAKE
REUSABLE NEBULIZER KIT
RITEFLO
RUBBER MOUTHPIECE
SAMI THE SEAL FILTER
SAMI THE SEAL MASK
SAMI THE SEAL
SIDESTREAM MASK
SIDESTREAM NEBULIZER
SIDESTREAM PEDIATRIC
SIDESTREAM PLUS
SIDESTREAM
SILICONE MASK each: n/a
SILICONE MASK each: n/a
SMARTMASK KIDS
SOOTHE NEB
SPACE CHAMBER PLUS
SUNRISE COMPRESSOR-NEBULIZER
THRESHOLD IMT
THRESHOLD PEP
TREK S COMBO PACK
Requirements/Limits
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
100
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
TREK S COMPACT COMPRESSOR
TREK S PORTABLE PWR KIT
TRUZONE PEAK FLOW METER
VIOS AEROSOL DELIVERY SYSTEM
VORTEX FROG MASK
VORTEX LADYBUG MASK
VORTEX each
VORTEX spacer
WATCHHALER
WINDMILL TRAINER
WING TIP TUBING
1ST CHOICE LANCETS
1ST TIER UNILET COMFORTOUCH
ACCU-CHEK FASTCLIX
ACCU-CHEK SAFE-T-PRO PLUS
ACCU-CHEK SAFE-T-PRO
ACCU-CHEK SOFTCLIX
ACCU-CHEK each
ACTI-LANCE
ADVANCED TRAVEL LANCETS
ADVOCATE LANCET
ADVOCATE LANCETS
ALTERNATE SITE LANCETS
ASSURE HAEMOLANCE PLUS each:
18gauge, 21gauge, 25gauge, 28gauge
ASSURE LANCE PLUS
ASSURE LANCE
BD MICROTAINER LANCETS
BD ULTRA-FINE II
BD ULTRA-FINE
BLOOD LANCETS
BREEZE 2 each: n/a
BREEZE 2 each: n/a
BREEZE 2 each: n/a
BREEZE 2 strip
BREEZE 2 kit
BULLSEYE MINI SAFETY LANCETS
CAREONE
CARESENS
CLEVER CHEK LANCETS
COAGUCHEK
Requirements/Limits
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
QL: 1 in 365 days
101
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
COLOR LANCETS
COMFORT EZ
COMFORT LANCETS
CONTOUR LINK
CONTOUR NEXT CONTROL
SOLUTION each: n/a
CONTOUR NEXT CONTROL
SOLUTION each: n/a
CONTOUR NEXT EZ
CONTOUR NEXT LINK
CONTOUR NEXT USB
CONTOUR NEXT strip
CONTOUR NEXT each
CONTOUR USB
CONTOUR each: n/a
CONTOUR each: n/a
CONTOUR each: n/a
CONTOUR strip
CONTOUR each: n/a
DROPLET LANCETS
EASY COMFORT
EASY TOUCH LANCETS
EASY TOUCH each
EASY TWIST AND CAP LANCETS
EMBRACE each: 30gauge
E-Z JECT LANCETS
EZ SMART LANCETS
E-ZJECT LANCETS
FIFTY50 SAFETY SEAL LANCETS
FINE 30 UNIVERSAL LANCETS
FINGERSTIX
FORA LANCETS
FORACARE LANCETS
FREESTYLE LANCETS
FREESTYLE UNISTIK 2
GLUCOCOM LANCETS
GLUCOCOM
GLUCOLET 2
GLUCOSOURCE
GMATE
HAEMOLANCE, RETRACTABLE
T6
T6
T6
T6
T6
Requirements/Limits
QL: 1 in 365 days
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
QL: 1 in 365 days
QL: 1 in 365 days
QL: 1 in 365 days
QL: 1 in 365 days
QL: 1 in 365 days
QL: 1 in 365 days
102
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
HEALTHY ACCENTS UNILET LANCET
INCONTROL SUPER THIN LANCETS
INCONTROL ULTRA THIN LANCETS
INJECT EASE LANCETS
INVACARE LANCETS
KINNEY BRAND LANCETS
LANCETS THIN
LANCETS ULTRA THIN
LANCETS
LITE TOUCH
MEDI-LANCE
MEDISENSE THIN LANCETS
MEDLANCE PLUS
MICRO THIN LANCETS
MICROLET 2
MICROLET
MONOLET LANCETS
MONOLET THIN LANCETS
MYGLUCOHEALTH LANCETS
NOVA SAFETY LANCETS
NOVA SUREFLEX
ON CALL LANCET
ON CALL PLUS LANCET
ONETOUCH DELICA each
ONETOUCH DELICA kit
ONETOUCH FINEPOINT LANCETS
ONETOUCH LANCETS
ONETOUCH SURESOFT
ONETOUCH ULTRA CONTROL SOLN
ONETOUCH ULTRA SMART
ONETOUCH ULTRA SYSTEM
ONETOUCH ULTRA TEST STRIPS
ONETOUCH ULTRA2
ONETOUCH ULTRALINK
ONETOUCH ULTRAMINI
ONETOUCH VERIO FLEX
ONETOUCH VERIO IQ
ONETOUCH VERIO SYNC
ONETOUCH VERIO each: n/a
ONETOUCH VERIO each: n/a
ONETOUCH VERIO strip
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
Requirements/Limits
QL: 1 in 365 days
QL: 1 in 365 days
QL: 1 in 365 days
QL: 1 in 365 days
QL: 1 in 365 days
QL: 1 in 365 days
QL: 1 in 365 days
QL: 1 in 365 days
103
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
ONETOUCH VERIO each: n/a
ON-THE-GO
pen needle, diabetic
pen needle, diabetic, safety
PENLET PLUS BLOOD SAMPLER
PRESSURE ACTIVATED LANCETS
PRODIGY LANCETS
PRODIGY TWIST TOP LANCET
PUSH BUTTON SAFETY LANCETS
RELIAMED SAFETY SEAL LANCETS
RELIAMED
RELION THIN
RIGHTEST GL300 LANCETS
SAFETY LANCETS
SAFETY SEAL LANCETS
SAFETY-LET
SINGLE-LET
SMART SENSE LANCETS
SMART SENSE
SMARTDIABETES VANTAGE
SMARTEST LANCET
SOFT TOUCH
SOLUS V2 LANCETS
SOLUS V2 each: 28gauge
STERILANCE TL
SUPER THIN LANCETS
SURE COMFORT LANCETS
SURE-LANCE
SURESTEP CONTROL SOLUTION
SURESTEP PRO each: n/a
SURESTEP PRO each: n/a
SURESTEP PRO each: n/a
SURESTEP PRO strip
SURESTEP PRO kit
SURE-TOUCH
syring w-ndl,disp,insul,0.3 ml
syring w-ndl,disp,insul,0.5 ml
Drug Tier
(Pen Needle, Diabetic)
(Pen Needle, Diabetic,
Safety)
(Syring WNdl,Disp,Insul,0.3 Ml)
(Syring WNdl,Disp,Insul,0.5 Ml)
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
Requirements/Limits
QL: 1 in 365 days
QL: 1 in 365 days
T6
104
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
syringe and needle,insulin,1 ml
Drug Tier
(Syringe and
Needle,Insulin,1 Ml)
TECHLITE LANCETS
TELCARE each
THIN LANCETS
TOPCARE UNIVERSAL1 THIN
LANCET
TRUEPLUS LANCETS
ULTILET BASIC
ULTILET CLASSIC
ULTILET LANCETS
ULTILET SAFETY
ULTRA THIN LANCETS
ULTRA THIN PLUS LANCETS
ULTRA THIN PLUS
ULTRALANCE
ULTRA-THIN II
ULTRATLC LANCETS
UNILET COMFORTOUCH
UNILET EXCELITE II
UNILET EXCELITE
UNILET GP LANCET
UNILET LANCET
UNILET LANCETS
UNISTIK 3 EXTRA
UNISTIK 3
UNISTIK CZT
UNISTIK SAFETY
UNIVERSAL 1
EASY TOUCH disp syrin
EXEL HYPODERMIC NEEDLE
EXEL SYRINGE
FLOW-EZE
HYPODERMIC NEEDLE
INTEGRA NEEDLE
LIFESHIELD BLUNT CANNULA
LUER-LOK SYRINGE-NEEDLE
MEDSAVER
MONOJECT SYRINGE
NEEDLE
NEEDLES
Requirements/Limits
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
105
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
NOKOR ADMIX NEEDLE
PRECISIONGLIDE dis needle
PRECISIONGLIDE disp syrin
REGULAR BEVEL NEEDLES
SAFETYGLIDE SYRINGE
SHORT BEVEL NEEDLES
SPECIALTY USE NEEDLES
SYRINGE
TERUMO SYRINGE
THIN WALL NEEDLES
VANISHPOINT disp syrin: 20gx1",
21gx11/2", 25gx1"
YALE NEEDLES
ACCU-CHEK ACTIVE
ACCU-CHEK AVIVA PLUS each
ACCU-CHEK AVIVA PLUS strip
ACCU-CHEK AVIVA
ACCU-CHEK COMFORT CURVE
ACCU-CHEK COMPACT PLUS
ACCU-CHEK NANO SMARTVIEW
ACCU-CHEK SMARTVIEW
ACCU-CHEK VOICEMATE
ACCU-CHEK kit: n/a
ACCU-CHEK kit: n/a
ACCUTREND GLUCOSE
ACURA METER KIT
ACURA PLUS
ACURA STARTER KIT
ACURA TEST STRIPS
ADVANCE INTUITION
ADVANCE TEST STRIPS
ADVOCATE BLOOD GLUCOSE
MONITOR
ADVOCATE REDI-CODE+ each
ADVOCATE REDI-CODE+ strip
ADVOCATE REDI-CODE each, kit
ADVOCATE REDI-CODE strip
ADVOCATE TEST STRIP
AGAMATRIX AMP each
AGAMATRIX AMP strip
ASSURE 4 each
Requirements/Limits
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
106
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
ASSURE 4 strip
ASSURE PLATINUM each
ASSURE PLATINUM strip
ASSURE PRO kit
ASSURE PRO strip
ATRAPRO CP
AURSTAT
BG-STAR
BLOOD GLUCOSE METER
BLOOD GLUCOSE MONITOR
BLOOD GLUCOSE MONITORING
BLOOD GLUCOSE TEST STRIP
BLOOD GLUCOSE TEST
BLOOD-GLUCOSE METER
CARESENS N VOICE
CARESENS N each
CARESENS N strip
CHOICEDM G20 kit
CHOICEDM G20 strip
CLEVER CHOICE BLOOD GLUC SYS
CLEVER CHOICE HD GLUCOSE SYST
CLEVER CHOICE MICRO TEST STRIP
CLEVER CHOICE MICRO
CLEVER CHOICE PRO each
CLEVER CHOICE PRO strip
CLEVER CHOICE TEST STRIPS
CLEVER CHOICE VOICE+ TST STRIP
CLEVER CHOICE
CONTROL G3
CONTROL kit
CONTROL strip
CURITY
DEXCOM G4 each: n/a
DEXCOM G4 each: n/a
DEXCOM G4 each: n/a
DEXCOM G5-G4 SENSOR
DIATRUE PLUS each
DIATRUE PLUS strip
EASY GLUCO G2
EASY PLUS II each
EASY PLUS II strip
Requirements/Limits
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
107
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
EASY STEP each, kit
EASY STEP strip
EASY TALK each, kit
EASY TALK strip
EASY TOUCH GLUCOSE MONITOR
EASY TOUCH strip
EASY TRAK kit
EASY TRAK strip
EASYGLUCO kit
EASYGLUCO strip
EASYMAX 15
EASYMAX L
EASYMAX N
EASYMAX NG
EASYMAX V SPEAKING
EASYMAX V2
EASYMAX V
EASYMAX
EASYPLUS R13N
EASYPLUS V
EASYPLUS
ECLIPSE each
ECLIPSE strip
ELEMENT BLOOD GLUCOSE METER
ELEMENT COMPACT each
ELEMENT COMPACT strip
ELEMENT PLUS kit
ELEMENT PLUS strip
ELEMENT TEST STRIPS
em#53/namgf/cyc/phos/nahc/nacl
EMBRACE EVO kit
EMBRACE EVO strip
EMBRACE PRO each
EMBRACE PRO strip
EMBRACE each: n/a; kit
EMBRACE strip
emol53/namgfs/ha/nahypochlorit cmb gel
fm, kt crm gel: 96.53%-3%
emollient combination no.35
emollient combination no.53
ENVISION kit
Drug Tier
(Aurstat)
(Emol53/Namgfs/Ha/
Nahypochlorit)
(Mimyx)
(Hylatopic Plus)
Requirements/Limits
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
108
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
ENVISION strip
EPIFIX AMNIOTIC MEMBRANE
EVENCARE G2 each
EVENCARE G2 strip
EVENCARE G3 kit
EVENCARE G3 strip
EVENCARE kit
EVENCARE strip
EVOLUTION BLOOD GLUCOSE
METER
EVOLUTION TEST STRIPS
EZ SMART PLUS kit
EZ SMART PLUS strip
EZ SMART kit
EZ SMART strip
FIFTY50 TEST STRIP
FORA D10
FORA D15C
FORA D15G
FORA D15Z
FORA D20
FORA G20 kit
FORA G20 strip
FORA G30A each
FORA G30A strip
FORA G71A kit
FORA G71A strip
FORA G90 each
FORA G90 strip
FORA TEST STRIP
FORA V10 kit
FORA V10 strip
FORA V10-V12-D10-D20
FORA V12 each, kit
FORA V12 strip
FORA V20 kit
FORA V20 strip
FORA V22 each
FORA V22 strip
FORA V30A each, kit
FORA V30A strip
Requirements/Limits
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
109
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
FORACARE GD20 each
FORACARE GD20 strip
FORACARE GD40A
FORACARE GD40B
FORACARE GD40
FREESTYLE FLASH SYSTEM
FREESTYLE FREEDOM LITE
FREESTYLE FREEDOM
FREESTYLE INSULINX TEST STRIPS
FREESTYLE INSULINX each
FREESTYLE INSULINX strip
FREESTYLE LITE TEST STRIPS
FREESTYLE SIDEKICK II
FREESTYLE SYSTEM
FREESTYLE TEST STRIPS
G-4 kit
G-4 strip
GE100 BLOOD GLUCOSE SYSTEM
GE100 BLOOD GLUCOSE TEST STRIP
GENADUR kit
GENADUR liquid
GLUCO NAVII kit
GLUCO NAVII strip
GLUCOCARD 01 SENSOR PLUS
GLUCOCARD 01
GLUCOCARD 01-MINI
GLUCOCARD EXPRESSION each, kit
GLUCOCARD EXPRESSION strip
GLUCOCARD VITAL SENSOR
GLUCOCARD VITAL
GLUCOCARD X-SENSOR
GLUCOCOM BLOOD GLUCOSE
GLUCOCOM GLUCOSE
GLUCOLAB kit
GLUCOLAB strip
GLUCOSE TEST STRIP
GMATE TEST STRIPS
GMATE VOICE METER
GRAFIX CORE
GRAFIX PRIME
GUARDIAN REAL-TIME
Requirements/Limits
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
110
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
GUARDIAN RT STARTER KIT
HEALTHPRO GLUCOSE MONITOR
HEALTHPRO TEST STRIPS
HPR PLUS
HPR
HYLATOPIC PLUS
HYLATOPIC
IBG-STAR
INFINITY TEST STRIPS
INFINITY
KEYNOTE PRO
KEYNOTE each
KEYNOTE strip
LIBERTY BLOOD GLUCOSE METER
LIBERTY MONITOR
LIBERTY TEST STRIPS
MAXIMA
MEDIHONEY bandage: 2"x2", 4"x5"
MICRO kit
MICRO strip
MICRODOT each
MICRODOT strip
MIMYX
MYGLUCOHEALTH kit
MYGLUCOHEALTH strip
NASONEB NASAL NEBULIZER each:
n/a
NASONEB NASAL NEBULIZER each:
n/a
NEOSALUS CP
NEOSALUS cream (g), lotion
NEOSALUS foam
NEUTEK 2TEK TEST STRIPS
NOVA MAX BLOOD GLUCOSE
METER
NOVA MAX GLUCOSE TEST STRIPS
NUVAIL
ON CALL EXPRESS METER
ON CALL EXPRESS TEST STRIP
ON CALL PLUS METER
ON CALL PLUS TEST STRIP
Requirements/Limits
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
111
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
ON CALL VIVID METER
ON CALL VIVID PAL
ON CALL VIVID TEST STRIP
OPTIUM EZ
OPTIUM
OPTUMRX each, kit
OPTUMRX strip
PHARMACIST CHOICE each
PHARMACIST CHOICE strip
POCKETCHEM EZ kit
POCKETCHEM EZ strip
PRECISION PCX PLUS
PRECISION PCX
PRECISION POINT OF CARE
PRECISION Q-I-D
PRECISION XTRA each
PRECISION XTRA strip
PREMIUM BLOOD GLUCOSE TEST
PREMIUM BLOOD GLUCOSE
PREMIUM V10 each
PREMIUM V10 strip
PRESERA
PRESTO PRO
PRODIGY AUTOCODE PRO
PRODIGY AUTOCODE
PRODIGY NO CODING
PRODIGY POCKET PRO
PRODIGY POCKET
PRODIGY VOICE PRO
PRODIGY VOICE
PRODIGY
PROMISEB COMPLETE
QUINTET AC each
QUINTET AC strip
QUINTET each
QUINTET strip
REFUAH PLUS kit
REFUAH PLUS strip
RELION CONFIRM
RELION CONFIRM-MICRO
RELION MICRO
Requirements/Limits
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
112
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
RELION PRIME TEST STRIPS
RELION PRIME
RESTORE
REVEAL BLOOD GLUCOSE METER
REVEAL TEST STRIP
RIGHTEST GM100 SYSTEM
RIGHTEST GM300 SYSTEM
RIGHTEST GM550 SYSTEM
RIGHTEST GS100 TEST STRIPS
RIGHTEST GS300 TEST STRIPS
RIGHTEST GS550 TEST STRIPS
SEVEN PLUS
SINUSTAR each: n/a
SINUSTAR each: n/a
SMART SENSE MONITORING
SYSTEM
SMART SENSE TEST STRIPS
SMARTDIABETES XPRES kit
SMARTDIABETES XPRES strip
SMARTEST EJECT
SMARTEST PERSONA
SMARTEST PRONTO
SMARTEST PROTEGE
SMARTEST TEST
SOLUS V2 TEST STRIPS
SOLUS V2 each: n/a; kit
SURE EDGE BLOOD GLUCOSE
METER
SURE EDGE TEST STRIPS
SURECHEK TEST STRIPS
SURE-TEST EASYPLUS MINI each
SURE-TEST EASYPLUS MINI strip
TELCARE kit
TELCARE strip
TEST N'GO each
TEST N'GO strip
thromb-ca-cell-dressing, hemos
thrombin/ca/cmc/gel/dress, hem
Drug Tier
Requirements/Limits
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
(Thromb-Ca-CellDressing, Hemos)
(Thrombin/Ca/Cmc/
Gel/Dress, Hem)
TROPAZONE cream (g)
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
113
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
TROPAZONE lotion
TRUE2GO BLOOD GLUCOSE SYSTEM
TRUERESULT BLOOD GLUCOSE
METER
TRUERESULT BLOOD GLUCOSE
SYSTM
TRUETEST TEST STRIPS
TRUETRACK BLOOD GLUCOSE
SYSTEM
TRUETRACK SMART SYSTEM kit
TRUETRACK SMART SYSTEM strip
TRUETRACK TEST STRIP
ULTIMA each
ULTIMA strip
ULTRATRAK PRO
ULTRATRAK ULTIMATE each
ULTRATRAK ULTIMATE strip
ULTRATRAK each
ULTRATRAK strip
UNISTRIP1
VICTORY each
VICTORY strip
VOCAL POINT
WAVESENSE AMP
WAVESENSE JAZZ kit
WAVESENSE JAZZ strip
WAVESENSE PRESTO each, kit
WAVESENSE PRESTO strip
Requirements/Limits
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
Diagnostic Agents
INDIUM IN-111 DTPA
T6
(Non-self administerable
injectable)
Disinfectants (For Non-Dermatologic Use)
GLUTARALDEHYDE
T3
Enzyme Replacement/Modifiers
CREON
CYSTAGON
lipase/protease/amylase
PANCREAZE
PERTZYE
SUCRAID
ULTRESA
(Zenpep)
T2
T2
T2
T2
T2
T2
T2
114
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
VIOKACE
ZENPEP
KUVAN
ORFADIN
PULMOZYME
ZAVESCA
ADAGEN
T2
T2
T4
T4
T4
T4
T6
ALDURAZYME
T6
AMPHADASE
T6
CEREZYME
T6
ELAPRASE
T6
ELELYSO
T6
ELITEK
T6
FABRAZYME
T6
HYLENEX
T6
KRYSTEXXA
T6
LUMIZYME
T6
MYOZYME
T6
NAGLAZYME
T6
VITRASE
T6
VPRIV
T6
XIAFLEX
T6
Requirements/Limits
PA
PA
(Non-self administerable
injectable)
PA (Non-self
administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self
administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self
administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self
administerable
injectable)
115
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
CHENODAL
Requirements/Limits
EX
Eye, Ear, Nose, Throat Agents
Eye, Ear, Nose, Throat Agents, Miscellaneous
(Iopidine)
apraclonidine hcl
atropine sulfate drops
(Isopto Atropine)
azelastine hcl drops
(Optivar)
(Carteolol HCl)
carteolol hcl
(Pramotic)
chloroxylenol/pramoxine hcl
(Cromolyn Sodium)
cromolyn sodium
(Cyclogyl)
cyclopentolate hcl
(Elestat)
epinastine hcl
(Isopto Homatropine)
homatropine hbr
(Atrovent)
ipratropium bromide
olopatadine hcl spray/pump
(Patanase)
olopatadine hcl drops
(Patanol)
(Mydfrin)
phenylephrine hcl
proparacaine hcl drops: 0.5%
(Proparacaine HCl)
TETCAINE
(Tetracaine HCl)
tetracaine hcl
TETRAVISC FORTE
(Mydriacyl)
tropicamide
ADRENALIN CHLORIDE
ALOMIDE
atropine sulfate oint. (g)
(Atropine Sulfate)
azelastine hcl spray/pump
(Astepro)
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T2
T2
T2
T2
CYCLOMYDRIL
EMADINE
ISOPTO HYOSCINE
LASTACAFT
naphazoline hcl
PATADAY
TYZINE
AKTEN
ASTELIN
T2
T2
T2
T2
T2
T2
T2
T3
T3
(Naphazoline HCl)
ASTEPRO
T3
QL: 5 in 30 days
QL: 5 in 30 days
QL: 60 in 30 days
(Quantity listed is 2
bottles)
QL: 2.5 in 30 days
QL: 60 in 30 days
(Quantity listed is 2
bottles)
QL: 60 in 30 days
(Quantity listed is 2
bottles)
116
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
ATROVENT
BSS
T3
T3
CYCLOGYL
DYMISTA
ELESTAT
IOPIDINE
ISOPTO ATROPINE
ISOPTO HOMATROPINE
MYDRIACYL
OPTIVAR
PATANASE
PATANOL
proparacaine hcl drops: 0.5%
LACRISERT
0.9 % sodium chloride
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T4
T6
balanced salt irrig soln no.2
(Proparacaine HCl)
(0.9 % Sodium
Chloride)
(Bss)
T6
BSS PLUS
T6
CELLUGEL
T6
EYLEA
T6
JETREA
T6
LUCENTIS
T6
MACUGEN
T6
OCUCOAT
T6
OZURDEX
T6
RETISERT
T6
Requirements/Limits
(Self Administerable
(Select) Injectable)
QL: 5 in 30 days
QL: 60 in 30 days
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self
administerable
injectable)
PA (Non-self
administerable
injectable)
PA (Non-self
administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
117
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
Requirements/Limits
VISUDYNE
T6
(Non-self administerable
injectable)
BEPREVE
CYSTARAN
LATISSE
ZINOTIC ES
ZINOTIC
Eye, Ear, Nose, Throat Anti-Infectives Agents
(Acetic Acid)
acetic acid
(Vosol HC)
acetic acid/hydrocortisone
(Antipyrine/
antipyrine/benzocaine
Benzocaine)
(Bacitracin/Polymyxin
bacitracin/polymyxin b sulfate
B Sulfate)
ciprofloxacin hcl drops
(Ciloxan)
(Erythromycin Base)
erythromycin base
GARAMYCIN oint. (g)
(Zymaxid)
gatifloxacin
(Garamycin)
gentamicin sulfate
ILOTYCIN
(Levofloxacin)
levofloxacin
(Maxitrol)
neo/polymyx b sulf/dexameth
(Neomycin Su/Baci Zn/
neomycin su/baci zn/poly/hc
Poly/HC)
(Neomycin Su/Bacitra/
neomycin su/bacitra/polymyxin
Polymyxin)
neomycin/polymyxin b sulf/hc drops susp:
(Cortisporin)
3.5-10k-1; solution
(Neosporin)
neomycin/polymyxn b/gramicidin
(Ocuflox)
ofloxacin
(Polytrim)
polymyxin b sulf/trimethoprim
sulfacetamide sodium drops: 10%
(Sulfacetamide
Sodium)
(Sulfacetamide/
sulfacetamide/prednisolone sp
Prednisolone Sp)
(Tobrex)
tobramycin
(Tobradex)
tobramycin/dexamethasone
(Viroptic)
trifluridine
AZASITE
(Bacitracin)
bacitracin
BETADINE
EX
EX
EX
EX
EX
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T2
T2
T2
QL: 20 in 30 days
QL: 5 in 30 days
118
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
BLEPHAMIDE S.O.P.
BLEPHAMIDE
CILOXAN oint. (g)
CIPRO HC
CIPRODEX
COLY-MYCIN S
CORTISPORIN-TC
cresyl acetate
NATACYN
neomycin/polymyxin b sulf/hc drops susp:
3.5-10k-10
PRED-G
sulfacetamide sodium oint. (g)
TOBRADEX oint. (g)
TOBREX oint. (g)
VIGAMOX
ZIRGAN
ZYLET
aa/antipyrn/bcaine/polico#1/al
BESIVANCE
CETRAXAL
CILOXAN drops
ciprofloxacin hcl droperette
CORTISPORIN
GARAMYCIN drops
MAXITROL
MOXEZA
NEOSPORIN
NEOTIC
OCUFLOX
OTOZIN
POLYTRIM
sulfacetamide sodium drops: 10%
Drug Tier
(Cresyl Acetate)
(Cortisporin)
(Sulfacetamide
Sodium)
(Aa/Antipyrn/Bcaine/
Polico#1/Al)
(Cetraxal)
(Sulfacetamide
Sodium)
TOBRADEX drops susp
TOBREX drops
VIROPTIC
VOSOL HC
ZYMAXID
Requirements/Limits
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
QL: 20 in 30 days
119
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
Requirements/Limits
VITRASERT
T6
(Non-self administerable
injectable)
TOBRADEX ST
Eye, Ear, Nose, Throat Anti-Inflammatory Agents
(Dexasol)
dexamethasone sod phosphate
(Diclofenac Sodium)
diclofenac sodium
(Flunisolide)
flunisolide
EX
T1
T1
T1
fluocinolone acetonide oil
fluorometholone
flurbiprofen sodium
fluticasone propionate
(Dermotic)
(FML)
(Ocufen)
(Flonase)
T1
T1
T1
T1
hc/pramoxine hcl/chloroxylenol drops: 1010-1/ml
ketorolac tromethamine
prednisolone acetate
triamcinolone acetonide
(Oticin HC)
T1
(Acular LS)
(Pred Forte)
(Nasacort Aq)
T1
T1
T1
(Bromfenac Sodium)
(Rhinocort Aqua)
T2
T2
T2
T2
ALOCRIL
ALREX
bromfenac sodium
budesonide
FLAREX
FML FORTE
FML S.O.P.
ILEVRO
LOTEMAX
MAXIDEX
NASONEX
T2
T2
T2
T2
T2
T2
T2
NEVANAC
PRED MILD
prednisolone sod phosphate
T2
T2
T2
(Prednisolone Sod
Phosphate)
QL: 5 in 30 days
QL: 50 in 30 days
(Quantity listed is 2
bottles)
QL: 32 in 30 days
(Quantity listed is 2
bottles)
QL: 33 in 30 days
(Quantity listed is 2
bottles)
QL: 17.2 in 30 days
(Quantity listed is 2
bottles)
QL: 34 in 30 days
(Quantity listed is 2
bottles)
120
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
RESTASIS
VEXOL
ZETONNA
T2
T2
T2
ACULAR LS
ACULAR
BECONASE AQ
T3
T3
T3
CORTANE-B
DERMOTIC
DUREZOL
FLONASE
T3
T3
T3
T3
FML
hc/pramoxine hcl/chloroxylenol drops: 1010-1/ml
NASACORT AQ
T3
T3
(Oticin HC)
T3
OCUFEN
OMNARIS
T3
T3
OMNIPRED
OTICIN HC
PRED FORTE
PROLENSA
QNASL CHILDREN
QNASL
RHINOCORT AQUA
T3
T3
T3
T3
T3
T3
T3
VERAMYST
TRIESENCE
T3
T6
chloroxylenol/benzoc/hydrocort
(Chloroxylenol/
Benzoc/Hydrocort)
TRIOXIN
Requirements/Limits
QL: 60 in 30 days
(NOT COVERED FOR
MEDICAID: Covered
Alternatives Available)
QL: 50 in 30 days
(Quantity listed is 2
bottles)
QL: 32 in 30 days
(Quantity listed is 2
bottles)
QL: 33 in 30 days
(Quantity listed is 2
bottles)
(NOT COVERED FOR
MEDICAID: Covered
Alternatives Available)
QL: 17.2 in 30 days
(Quantity listed is 2
bottles)
(Non-self administerable
injectable)
EX
EX
121
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
Requirements/Limits
Gastrointestinal Agents
Antiulcer Agents And Acid Suppressants
(Cimetidine HCl)
cimetidine hcl
(Cimetidine)
cimetidine
famotidine oral susp, tablet
(Pepcid)
(Prevacid)
lansoprazole
(Prevpac)
lansoprazole/amoxiciln/clarith
(Cytotec)
misoprostol
(Axid)
nizatidine
(Prilosec)
omeprazole
pantoprazole sodium tablet dr
(Protonix)
(Aciphex)
rabeprazole sodium
ranitidine hcl capsule, syrup, tablet
(Zantac)
(Carafate)
sucralfate
CARAFATE oral susp
DEXILANT
(Nexium)
esomeprazole magnesium
FIRST-LANSOPRAZOLE
FIRST-OMEPRAZOLE
PREVACID tab rap dr
AXID
CARAFATE tablet
CYTOTEC
NEXIUM suspdr pkt
PEPCID
PREVACID capsule dr
PREVPAC
PRILOSEC capsule dr
PROTONIX
ZANTAC tablet
(Nexium I.V.)
esomeprazole sodium
famotidine in nacl,iso-osm/pf
famotidine vial
(Famotidine In
Nacl,Iso-Osm/PF)
(Famotidine)
NEXIUM I.V.
pantoprazole sodium vial
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T2
T2
T2
T2
T2
T2
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T6
T6
T6
T6
(Pantoprazole Sodium)
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
122
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
PROTONIX IV
ranitidine hcl vial
(Zantac)
Drug Tier
Requirements/Limits
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
T6
ZANTAC vial
T6
ACIPHEX SPRINKLE
ACIPHEX
esomeprazole strontium
EX
EX
EX
NEXIUM capsule dr
omeprazole/sodium bicarbonate
PEPCID RPD
ZEGERID
Gastrointestinal Agents, Other
cromolyn sodium
dicyclomine hcl capsule, tablet
diphenoxylate hcl/atropine tablet
glycopyrrolate tablet
hyoscyamine sulfate
lactulose
loperamide hcl
methscopolamine bromide
metoclopramide hcl solution, tablet
NULEV
opium tincture
sodium phenylbutyrate
sodium polystyrene sulfonate
SYMAX
SYMAX-SL
SYMAX-SR
ursodiol
BUPHENYL tablet
CANTIL
CUVPOSA
dicyclomine hcl solution
diphenoxylate hcl/atropine liquid
(Esomeprazole
Strontium)
(Zegerid)
(Gastrocrom)
(Bentyl)
(Lomotil)
(Robinul)
(Levsin-Sl)
(Lactulose)
(Loperamide HCl)
(Pamine)
(Reglan)
(Opium Tincture)
(Buphenyl)
(Sodium Polystyrene
Sulfonate)
(Actigall)
(Dicyclomine HCl)
(Diphenoxylate HCl/
Atropine)
KRISTALOSE
MOTOFEN
EX
EX
EX
EX
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T2
T2
T2
T2
T2
T2
T2
123
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
NUTRESTORE
paregoric
PYLERA
ACTIGALL
AMITIZA
ANASPAZ
BENTYL capsule, tablet
BUPHENYL powder
DIGEX NF
GASTRINEX NF
GASTROCROM
KAYEXALATE
l.acidophilus/b.bifidum and longum
Drug Tier
(Paregoric)
(L.Acidophilus/
B.Bifidum and
Longum)
T2
T2
T2
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
LEVSIN tablet
LEVSIN-SL
LINZESS
LOMOTIL
PAMINE FORTE
PAMINE
REGLAN
ROBINUL FORTE
ROBINUL tablet
URSO FORTE
URSO
RELISTOR
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T4
CARBAGLU
LOTRONEX
BENTYL ampul
T5
T5
T6
glycopyrrolate vial
(Robinul)
LEVSIN ampul
metoclopramide hcl vial
T6
T6
(Metoclopramide HCl)
Requirements/Limits
T6
ROBINUL vial
T6
CESINEX
EX
ST (Self Administerable
(Select) Injectable)
PA
PA
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
124
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
ENTEREG
FULYZAQ
GLYCATE
metoclopramide hcl tab rapdis
METOZOLV ODT
RAVICTI
VSL#3 DS
XENICAL
Laxatives
peg 3350/na sulf,bicarb,cl/kcl
sodium chloride/nahco3/kcl/peg
COLYTE WITH FLAVOR PACKETS
GOLYTELY powd pack
MOVIPREP
OSMOPREP
PREPOPIK
SUPREP
GOLYTELY soln recon
NULYTELY WITH FLAVOR PACKS
SUCLEAR
polyethylene glycol 3350
Phosphate Binders
calcium acetate capsule, tablet: 667mg
calcium carbonate/mag carb/fa
FOSRENOL
PHOSLYRA
RENAGEL
RENVELA
sevelamer carbonate
calcium acetate tablet: 667mg
PHOSLO
AURYXIA
Drug Tier
(Metozolv Odt)
(Golytely)
(Nulytely with Flavor
Packs)
(Polyethylene Glycol
3350)
(Phoslo)
(Calcium Carbonate/
Mag Carb/Fa)
(Sevelamer Carbonate)
(Calcium Acetate)
Requirements/Limits
EX
EX
EX
EX
EX
EX
EX
EX
T1
T1
T2
T2
T2
T2
T2
T2
T3
T3
T3
EX
T1
T2
T2
T2
T2
T2
T2
T3
T3
EX
General Anesthetics
General Anesthetics, Miscellaneous
AMIDATE
T6
DIPRIVAN
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
125
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
etomidate
(Etomidate)
KETALAR
ketamine hcl
Drug Tier
Requirements/Limits
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
T6
(Ketalar)
LUSEDRA
T6
T6
propofol
(Propofol)
T6
propofol/pf
(Propofol/PF)
T6
ketamine hcl in 0.9 % nacl
(Ketamine Hcl In 0.9 %
NaCl)
EX
(Enflurane)
EX
EX
EX
EX
EX
EX
Inhalation Anesthetics
enflurane
ETHRANE
FORANE
isoflurane
sevoflurane
ULTANE
(Isoflurane)
(Ultane)
Genitourinary Agents
Antispasmodics, Urinary
(Flavoxate HCl)
flavoxate hcl
(Oxybutynin Chloride)
oxybutynin chloride
(Detrol)
tolterodine tartrate
(Sanctura)
trospium chloride
OXYTROL
DETROL LA
DETROL
DITROPAN XL
ENABLEX
GELNIQUE gel md pmp
GELNIQUE gel packet
MYRBETRIQ
SANCTURA XR
SANCTURA
TOVIAZ
VESICARE
Genitourinary Agents, Miscellaneous
(Uroxatral)
alfuzosin hcl
T1
T1
T1
T1
T2
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
QL: 8 in 28 days
ST
T1
126
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
methen/m-blue/sal/na phos/hyos capsule:
120-0.12mg
methenam/me blue/ba/salicy/hyo tablet:
81.6-0.12
mth/me blue/sod phos/phen/hyos
phenazopyridine hcl
tamsulosin hcl
terazosin hcl
FLOMAX
PROSED-DS
PYRIDIUM
RAPAFLO
Drug Tier
(Uta)
T1
(Methenam/Me Blue/
Ba/Salicy/Hyo)
(Uribel)
(Phenazopyridine HCl)
(Flomax)
(Terazosin HCl)
T1
URIBEL
UROXATRAL
T1
T1
T1
T1
T3
T3
T3
T3
Requirements/Limits
(NOT COVERED FOR
MEDICAID: Covered
Alternatives Available)
T3
T3
Heavy Metal Antagonists
CA-DTPA
CHEMET
CUPRIMINE
DEPEN
GALZIN
SYPRINE
ZN-DTPA
EXJADE
FERRIPROX tablet
BAL IN OIL
T2
T2
T2
T2
T2
T2
T2
T3
T5
T6
CALCIUM DISODIUM VERSENATE
T6
deferoxamine mesylate
(Desferal)
DESFERAL
sodium thiosulfate
T6
T6
(Sodium Thiosulfate)
T6
PA
PA
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
Hormonal Agents, Stimulant/Replacement/Modifying
Androgens
danazol
estrogen,ester/me-testosterone
(Danazol)
(Estrogen,Ester/MeTestosterone)
T1
T1
127
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
oxandrolone
ANADROL-50
ANDRODERM
ANDROID
AXIRON
FIRST-TESTOSTERONE MC
FIRST-TESTOSTERONE
fluoxymesterone
FORTESTA
METHITEST
methyltestosterone
STRIANT
testosterone gel md pmp: 10mg(2%); gel
packet
ANDROGEL
OXANDRIN
TESTIM
testosterone gel (gram), gel md pmp:
1.25g(1%)
TESTRED
VOGELXO
DELATESTRYL
Drug Tier
(Oxandrin)
(Androgel)
T1
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
(Testim)
T3
T3
T3
T3
(Fluoxymesterone)
(Android)
T3
T3
T6
DEPO-TESTOSTERONE
T6
TESTOPEL
T6
testosterone cypionate
(Depo-Testosterone)
T6
testosterone enanthate
(Delatestryl)
T6
Estrogens and Antiestrogens
clomiphene citrate
estradiol patch tdwk
estradiol tablet
estradiol patch tdsw
(Clomiphene Citrate)
(Climara)
(Estrace)
(Vivelle-Dot)
T1
T1
T1
T1
Requirements/Limits
GM, QL: 30 in 30 days
GM, QL: 180 in 30 days
GM, QL: 300 in 30 days
GM, QL: 300 in 30 days
GM
GM
GM
GM
GM
GM
GM
GM (Non-self
administerable
injectable)
GM (Non-self
administerable
injectable)
GM (Non-self
administerable
injectable)
GM (Non-self
administerable
injectable)
GM (Non-self
administerable
injectable)
PA
QL: 4 in 28 days
QL: 8 in 28 days
128
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
estradiol/norethindrone acet
(Activella)
T1
estradiol/norethindrone acet
estropipate
norethindrone ac-eth estradiol
(Activella)
(Estropipate)
(Femhrt)
T1
T1
T1
raloxifene hcl
(Evista)
T1
SEROPHENE
ANGELIQ
CLIMARA PRO
COMBIPATCH
DIVIGEL
DUAVEE
ELESTRIN
ESTRACE cream/appl
ESTRING
EVAMIST
FEMRING
MENEST
MENOSTAR
PREMARIN cream/appl, tablet
PREMPHASE
PREMPRO
VAGIFEM
ACTIVELLA
ALORA
CENESTIN
CLIMARA
ESTRACE tablet
ESTRASORB
ESTROGEL
EVISTA
FEMHRT
T1
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T3
T3
T3
T3
T3
T3
T3
T3
T3
Requirements/Limits
(Women's Preventive
Healthcare; see
Appendix A for list of
covered generic
contraceptives)
(Women's Preventive
Healthcare; see
Appendix A for list of
covered generic
contraceptives)
PA NSO (PA Req'd
WomenÆs Preventive
Healthcare)
PA
QL: 4 in 28 days
QL: 8 in 28 days
QL: 1 in 90 days
QL: 1 in 90 days
QL: 4 in 28 days
QL: 8 in 28 days
QL: 4 in 28 days
129
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
JEVANTIQUE LO
JEVANTIQUE
MINIVELLE
OSPHENA
PREFEST
VIVELLE-DOT
DELESTROGEN
T3
T3
T3
T3
T3
T3
T6
DEPO-ESTRADIOL
T6
estradiol valerate
(Delestrogen)
T6
PREMARIN vial
T6
ENJUVIA
OGEN
Glucocorticoids/Mineralocorticoids
ASMALPRED
(Dexamethasone)
dexamethasone
(Fludrocortisone
fludrocortisone acetate
Acetate)
(Cortef)
hydrocortisone
(Medrol)
methylprednisolone
prednisolone sod phosphate solution: 5mg/ (Orapred)
5ml; tab rapdis
(Prednisolone)
prednisolone
prednisone solution, tab ds pk, tablet: 1mg, (Prednisone)
2.5mg, 5mg, 10mg, 20mg, 50mg
(Cortisone Acetate)
cortisone acetate
DEXAMETHASONE INTENSOL
DEXPAK
MILLIPRED solution
prednisolone sod phosphate solution:
(Orapred)
25mg/5ml
PREDNISONE INTENSOL
VERIPRED 20
ASMALPRED PLUS
CORTEF
MEDROL
MILLIPRED DP
MILLIPRED tablet
EX
EX
Requirements/Limits
QL: 8 in 28 days
QL: 8 in 28 days
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
T1
T1
T1
T1
T1
T1
T1
T1
T2
T2
T2
T2
T2
T2
T2
T3
T3
T3
T3
T3
130
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
ORAPRED ODT
ORAPRED
PEDIAPRED
A-METHAPRED
T3
T3
T3
T6
ARISTOSPAN
T6
betamet acet/betamet na ph
(Celestone)
T6
CELESTONE
T6
DEPO-MEDROL
T6
dexamethasone sod phosphate
hydrocortisone sod succinate
(Dexamethasone Sod
Phosphate)
(Solu-Cortef)
T6
T6
KENALOG-10
T6
KENALOG-40
T6
methylprednisolone acetate
(Depo-Medrol)
T6
methylprednisolone sod succ
(Solu-Medrol)
T6
SOLU-CORTEF
T6
SOLU-MEDROL vial: 2g
T6
SOLU-MEDROL vial: 40mg/ml, 125mg/
2ml, 1000mg/8ml
triamcinolone acetonide
T6
(Triamcinolone
Acetonide)
EZ USE JOINT-TUNNEL-TRIGGER
FLO-PRED
RAYOS
Pituitary
desmopressin acetate solution, spray/pump, (DDAVP)
tablet
DDAVP solution, tablet
DDAVP spray/pump
T6
Requirements/Limits
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
EX
EX
EX
T1
T3
T3
131
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
STIMATE
SAIZEN
T3
T4
SEROSTIM
T4
ZORBTIVE
T4
BRAVELLE
T5
CHORIONIC GONADOTROPIN
T5
FOLLISTIM AQ cartridge
T5
GENOTROPIN
T5
HUMATROPE
T5
INCRELEX
T5
MENOPUR
T5
NORDITROPIN FLEXPRO
T5
NOVAREL
T5
NUTROPIN AQ NUSPIN
T5
NUTROPIN AQ
T5
OMNITROPE
T5
PREGNYL
T5
REPRONEX
T5
SOMAVERT
T5
TEV-TROPIN
T5
ZOMACTON
T5
Requirements/Limits
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
Age must be >= 2, PA
(Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
132
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
Requirements/Limits
CETROTIDE
T6
DDAVP ampul
T6
PA (Non-self
administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self
administerable
injectable)
PA (Non-self
administerable
injectable)
PA (Non-self
administerable
injectable)
PA (Non-self
administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self
administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self
administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
desmopressin acetate ampul
(DDAVP)
T6
FOLLISTIM AQ vial
T6
GONAL-F RFF REDI-JECT
T6
GONAL-F RFF
T6
GONAL-F
T6
LUPRON DEPOT-PED
T6
LUVERIS
T6
octreotide acetate
(Sandostatin)
T6
OVIDREL
T6
PITRESSIN
T6
SANDOSTATIN LAR
T6
SANDOSTATIN
T6
SUPPRELIN LA
T6
VANTAS
T6
vasopressin
(Pitressin)
EGRIFTA
T6
EX
133
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
SOMATULINE DEPOT
Progestins
medroxyprogesterone acetate tablet
megestrol acetate
norethindrone acetate
progesterone,micronized
CRINONE
ENDOMETRIN
FIRST-PROGESTERONE VGS 100
FIRST-PROGESTERONE VGS 200
FIRST-PROGESTERONE VGS 25
FIRST-PROGESTERONE VGS 400
FIRST-PROGESTERONE VGS 50
AYGESTIN
MEGACE ES
MEGACE
PROMETRIUM
PROVERA
DEPO-PROVERA
Drug Tier
EX
(Provera)
(Megace Es)
(Aygestin)
(Prometrium)
T1
T1
T1
T1
T2
T2
T2
T2
T2
T2
T2
T3
T3
T3
T3
T3
T6
DEPO-SUBQ PROVERA 104
T6
MAKENA
T6
medroxyprogesterone acetate syringe, vial
(Depo-Provera)
T6
progesterone
(Progesterone)
T6
(Synthroid)
T1
T1
T1
T1
T1
T1
T1
T2
T2
T2
Thyroid and Antithyroid Agents
levothyroxine sodium tablet
LEVOXYL
liothyronine sodium tablet
methimazole
propylthiouracil
thyroid,pork
UNITHROID
ARMOUR THYROID
potassium iodide
potassium iodide/iodine
Requirements/Limits
(Cytomel)
(Tapazole)
(Propylthiouracil)
(Thyroid,Pork)
(Potassium Iodide)
(Potassium Iodide/
Iodine)
(Oral Cancer Drug)
PA
PA
(Oral Cancer Drug)
(Oral Cancer Drug)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self
administerable
injectable)
(Women's Preventive
Healthcare)
(Non-self administerable
injectable)
134
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
THYROLAR-1/2
THYROLAR-1/4
THYROLAR-1
THYROLAR-2
THYROLAR-3
CYTOMEL
SYNTHROID
TAPAZOLE
TIROSINT
levothyroxine sodium vial
liothyronine sodium vial
Drug Tier
(Levothyroxine
Sodium)
(Liothyronine Sodium)
T2
T2
T2
T2
T2
T3
T3
T3
T3
T6
T6
THYROGEN
T6
TRIOSTAT
T6
Requirements/Limits
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
Immunological Agents
azathioprine
cyclosporine capsule
cyclosporine, modified capsule: 25mg,
100mg; solution
HECORIA
leflunomide
mycophenolate mofetil
mycophenolate sodium
sirolimus
tacrolimus
ASTAGRAF XL
CELLCEPT susp recon
cyclosporine, modified capsule: 50mg
ENVARSUS XR
RAPAMUNE solution
RIDAURA
SANDIMMUNE solution
ARAVA
CELLCEPT capsule, tablet
IMURAN
MYFORTIC
NEORAL
PROGRAF capsule
(Imuran)
(Sandimmune)
(Neoral)
(Arava)
(Cellcept)
(Myfortic)
(Rapamune)
(Prograf)
(Neoral)
T1
T1
T1
T1
T1
T1
T1
T1
T1
T2
T2
T2
T2
T2
T2
T2
T3
T3
T3
T3
T3
T3
135
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
RAPAMUNE tablet
SANDIMMUNE capsule
ENBREL
T3
T3
T4
HUMIRA PEN CROHN'S-UC-HS
T4
HUMIRA PEN
T4
HUMIRA
T4
ZORTRESS
ARCALYST
T4
T5
CIMZIA syringekit
T5
HIZENTRA
T5
HYQVIA
T5
KINERET
T5
ORENCIA syringe
T5
ANASCORP
T6
ANTIVENIN LATRODECTUS
MACTANS
ANTIVENIN MICRURUS FULVIUS
T6
T6
ATGAM
T6
azathioprine sodium
(Azathioprine Sodium)
T6
BIVIGAM
T6
CARIMUNE NF NANOFILTERED
T6
CELLCEPT vial
T6
Requirements/Limits
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
Age must be >= 12, PA
(Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
(Self Administerable
(Select) Injectable)
(Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
136
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
Requirements/Limits
CIMZIA kit
T6
CROFAB
T6
PA (Non-self
administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
Age must be >= 12, PA
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
cyclosporine ampul
(Sandimmune)
T6
CYTOGAM
T6
FLEBOGAMMA DIF vial: 10%
T6
FLEBOGAMMA DIF vial: 5%
T6
GAMASTAN S-D
T6
GAMMAGARD LIQUID
T6
GAMMAKED
T6
GAMMAPLEX
T6
GAMUNEX-C
T6
HEPAGAM B
T6
HYPERHEP B S-D
T6
HYPERRAB S-D
T6
HYPERRHO S-D
T6
HYPERTET S-D
T6
ILARIS
T6
IMOGAM RABIES-HT
T6
MICRHOGAM ULTRA-FILTERED
PLUS
NABI-HB
T6
T6
137
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
Requirements/Limits
OCTAGAM
T6
(Non-self administerable
injectable)
ORENCIA vial
T6
PRIVIGEN
T6
PA (Non-self
administerable
injectable)
(Non-self administerable
injectable)
PROGRAF ampul
T6
(Non-self administerable
injectable)
RHOGAM ULTRA-FILTERED PLUS
T6
(Non-self administerable
injectable)
RHOPHYLAC
T6
(Non-self administerable
injectable)
SANDIMMUNE ampul
T6
(Non-self administerable
injectable)
THYMOGLOBULIN
T6
(Non-self administerable
injectable)
TYSABRI
T6
WINRHO SDF
T6
PA (Non-self
administerable
injectable)
(Non-self administerable
injectable)
AUBAGIO
EX
AZASAN
EX
138
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
Vaccines
ACTHIB
ADACEL TDAP
AFLURIA 2015-2016 syringe
AFLURIA 2015-2016 vial
BCG (TICE STRAIN)
BEXSERO
BIOTHRAX
BOOSTRIX TDAP
CERVARIX
COMVAX
DAPTACEL DTAP
DIPHTHERIA-TETANUS TOXOIDSPED
ENGERIX-B ADULT
ENGERIX-B PEDIATRICADOLESCENT
FLUARIX QUAD 2015-2016
FLUBLOK 2015-2016
FLUCELVAX 2015-2016
FLULAVAL QUAD 2015-2016
FLUMIST QUAD 2015-2016
FLUVIRIN 2015-2016 syringe
FLUVIRIN 2015-2016 vial
FLUZONE 2015-2016
FLUZONE HIGH-DOSE 2015-2016
FLUZONE INTRADERM QUAD 2015-16
FLUZONE QUAD 2015-2016
GARDASIL 9
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
GARDASIL
T6
HAVRIX
IMOVAX RABIES VACCINE
INFANRIX DTAP
IPOL
KINRIX
MENACTRA
MENHIBRIX
MENOMUNE-A-C-Y-W-135
MENVEO A-C-Y-W-135-DIP
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
Requirements/Limits
GF, PA
T6
T6
Age must be >= 65, PA
Age must be >= 9, PA
(Restricted to ages 9-26)
Age must be >= 9, PA
(Restricted to ages 9-26)
139
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
MENVEO MENA COMPONENT
MENVEO MENCYW-135 COMPONENT
M-M-R II VACCINE
PEDIARIX
PEDVAXHIB
PENTACEL ACTHIB COMPONENT
PENTACEL
PNEUMOVAX 23
PREVNAR 13
PROQUAD
QUADRACEL DTAP-IPV
RABAVERT
RECOMBIVAX HB
ROTARIX
ROTATEQ
TENIVAC
TETANUS DIPHTHERIA TOXOIDS
TETANUS TOXOID ADSORBED
THERACYS
TRUMENBA
TWINRIX
VAQTA
VARIVAX VACCINE
ZOSTAVAX
Drug Tier
Requirements/Limits
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
Age must be >= 50, PA
Inflammatory Bowel Disease Agents
balsalazide disodium
budesonide
mesalamine
APRISO
CANASA
DIPENTUM
PENTASA
ASACOL HD
COLAZAL
DELZICOL
ENTOCORT EC
LIALDA
ROWASA
UCERIS tabdr and er
alosetron hcl
GIAZO
(Colazal)
(Entocort EC)
(Sfrowasa)
(Alosetron HCl)
T1
T1
T1
T2
T2
T2
T2
T3
T3
T3
T3
T3
T3
T3
T4
EX
PA
PA
140
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
Requirements/Limits
Irrigating Solutions
acetic acid
glycine urologic solution
LACTATED RINGERS
PHYSIOLYTE
ringers solution
sodium chloride irrig solution
water for irrigation,sterile
mannitol/sorbitol solution
RESECTISOL
sorbitol solution
VIASPAN BELZER-UW
PHYSIOSOL
DELFLEX WITH 1.5% DEXTROSE ip
soln: 2.5meq(ca)
DELFLEX WITH 1.5% DEXTROSE ip
soln: 3.5meq(ca)
DELFLEX WITH 2.5% DEXTROSE
(Acetic Acid)
(Glycine Urologic
Solution)
(Ringers Solution)
(Sodium Chloride Irrig
Solution)
(Water For
Irrigation,Sterile)
(Mannitol/Sorbitol
Solution)
(Sorbitol Solution)
T1
T1
T1
T1
T1
T1
T1
T2
T2
T2
T2
T3
T6
T6
T6
DELFLEX WITH 4.25% DEXTROSE
T6
DIANEAL PD-2 W-1.5% DEXTROSE
T6
DIANEAL PD-2 W-2.5% DEXTROSE
T6
DIANEAL PD-2 W-4.25% DEXTROSE
T6
DIANEAL WITH 1.5% DEXTROSE
T6
DIANEAL WITH 2.5% DEXTROSE
T6
DIANEAL WITH 4.25% DEXTROSE
T6
EXTRANEAL ICODEXTRIN DIALYSIS
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
Liver Function
EOVIST
EX
141
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
Requirements/Limits
Metabolic Bone Disease Agents
alendronate sodium tablet: 5mg, 10mg
alendronate sodium tablet: 35mg, 70mg
calcitonin,salmon,synthetic
calcitriol capsule, solution
doxercalciferol capsule
ibandronate sodium tablet
paricalcitol
risedronate sodium tablet: 5mg, 30mg
risedronate sodium tablet: 150mg
risedronate sodium tablet: 35mg
alendronate sodium tablet: 40mg
etidronate disodium
FORTICAL
ACTONEL tablet: 5mg, 30mg
ACTONEL tablet: 150mg
ACTONEL tablet: 35mg
alendronate sodium solution
BONIVA tablet
FOSAMAX PLUS D
FOSAMAX
HECTOROL capsule
MIACALCIN spray/pump
ROCALTROL
ZEMPLAR capsule
FORTEO
(Fosamax)
(Fosamax)
(Miacalcin)
(Rocaltrol)
(Hectorol)
(Boniva)
(Zemplar)
(Actonel)
(Actonel)
(Actonel)
(Fosamax)
(Etidronate Disodium)
(Alendronate Sodium)
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T2
T2
T2
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T5
MIACALCIN vial
T5
BONIVA syringe
T6
calcitriol ampul
(Calcitriol)
T6
doxercalciferol ampul
(Doxercalciferol)
T6
HECTOROL vial
ibandronate sodium syringe, vial
T6
(Ibandronate Sodium)
T6
QL: 4 in 28 days
QL: 1 in 28 days
QL: 1 in 28 days
QL: 4 in 28 days
QL: 1 in 28 days
QL: 4 in 28 days
QL: 300 in 28 days
QL: 1 in 28 days
QL: 4 in 28 days
QL: 4 in 28 days
PA (Self Administerable
(Select) Injectable)
(Self Administerable
(Select) Injectable)
QL: 3 in 90 days (Nonself administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
QL: 3 in 90 days (Nonself administerable
injectable)
142
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
pamidronate disodium
(Pamidronate
Disodium)
Drug Tier
Requirements/Limits
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self
administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self
administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PARICALCITOL
T6
PROLIA
T6
RECLAST
T6
XGEVA
T6
ZEMPLAR vial
T6
zoledronic acid
(Zometa)
T6
zoledronic acid/mannitol and water
(Reclast)
T6
ZOMETA infus. btl
T6
ZOMETA vial
T6
ATELVIA
BINOSTO
risedronate sodium tablet dr
EX
EX
EX
(Atelvia)
Miscellaneous Therapeutic Agents
(Acetylcysteine)
(Zyloprim)
(Urecholine)
(Buspirone HCl)
(Colchicine/
Probenecid)
(Avodart)
dutasteride
(Jalyn)
dutasteride/tamsulosin hcl
(Ergoloid Mesylates)
ergoloid mesylates
finasteride tablet: 5mg
(Propecia)
hydroxyzine hcl solution, tablet
(Hydroxyzine HCl)
hydroxyzine pamoate capsule: 25mg, 50mg (Vistaril)
leucovorin calcium tablet: 5mg, 25mg
(Leucovorin Calcium)
(Carnitor)
levocarnitine (with sugar)
levocarnitine tablet
(Carnitor)
acetylcysteine
allopurinol
bethanechol chloride
buspirone hcl
colchicine/probenecid
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
GM
143
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
meprobamate
methylergonovine maleate tablet
probenecid
pyridostigmine bromide
CERVIDIL
ELMIRON
GLUCAGEN
GLUCAGON EMERGENCY KIT
guanidine hcl
hydroxyzine pamoate capsule: 100mg
leucovorin calcium tablet: 10mg, 15mg
LITHOSTAT
MESTINON syrup
MINERAL OIL
POTABA
PREPIDIL
PROSTIN E2 VAGINAL SUPPOSITORY
SENSIPAR
SYNAREL
THIOLA
TRICHLOROACETIC ACID soln recon:
25%
TRICITRASOL
TYBOST
ULORIC
ASTRINGYN
AVODART
b3/azel ac/zinc/b6/copper/fa
BIONECT
BIOSTEP AG
BIOSTEP
CARNITOR solution
CARNITOR tablet
CARRASYN HYDROGEL WOUND
colchicine tablet
COLCRYS
ENDO-AVITENE
GELFILM
GRASTEK
HYLASE
Drug Tier
(Meprobamate)
(Methylergonovine
Maleate)
(Probenecid)
(Mestinon)
(Guanidine HCl)
(Vistaril)
(Leucovorin Calcium)
(Nicazel)
(Colcrys)
Requirements/Limits
T1
T1
T1
T1
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
ST
PA
144
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
JALYN
KENDALL
MESTINON tablet, tablet er
MONSEL'S
NICAZEL FORTE
NICAZEL
ORALAIR
PROSCAR
RAGWITEK
REZYST
SILVERSEAL HYDROGEL
SPECTRAGEL
SYRINGE AVITENE
THALOMID
ULESFIA
URECHOLINE
VISTARIL
XCLAIR
ZYLOPRIM
BETASERON
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T4
COPAXONE syringe: 40mg/ml
T4
glatiramer acetate
(Copaxone)
T4
MESNEX tablet
ACTEMRA syringe
T4
T5
ACTIMMUNE
T5
AVONEX ADMINISTRATION PACK
T5
AVONEX PEN
T5
AVONEX
T5
COPAXONE syringe: 20mg/ml
T5
CYSTADANE
EXTAVIA
T5
T5
Requirements/Limits
PA
GM
PA
(Oral Cancer Drug)
(Self Administerable
(Select) Injectable)
(Self Administerable
(Select) Injectable)
(Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
(Self Administerable
(Select) Injectable)
(Self Administerable
(Select) Injectable)
(Self Administerable
(Select) Injectable)
(Self Administerable
(Select) Injectable)
(Self Administerable
(Select) Injectable)
(Self Administerable
(Select) Injectable)
145
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
Requirements/Limits
GANIRELIX ACETATE
T5
PA (Self Administerable
(Select) Injectable)
GILENYA
PLEGRIDY PEN
T5
T5
PLEGRIDY
T5
RADIOGARDASE
REBIF REBIDOSE
T5
T5
REBIF
T5
SIMPONI
T5
TECFIDERA
XELJANZ
ACTEMRA vial
T5
T5
T6
allopurinol sodium
(Allopurinol Sodium)
ALOPRIM
T6
T6
ammonium chloride
(Amifostine
Crystalline)
(Ammonium Chloride)
T6
amobarbital sodium
(Amobarbital Sodium)
T6
amifostine crystalline
T6
AMVISC PLUS
T6
AMVISC
T6
BENLYSTA
T6
BLOXIVERZ
T6
BOTOX
T6
(Self Administerable
(Select) Injectable)
(Self Administerable
(Select) Injectable)
(Self Administerable
(Select) Injectable)
(Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
PA
PA (Non-self
administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self
administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self
administerable
injectable)
146
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
Requirements/Limits
CARNITOR vial
T6
CARTICEL
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self
administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self
administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self
administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self
administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self
administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self
administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
dexrazoxane hcl
(Totect)
T6
droperidol
(Droperidol)
T6
DUODOTE
T6
DYSPORT
T6
ELLIOTTS B
T6
ENTYVIO
T6
ethyl alcohol
(Ethyl Alcohol)
EUFLEXXA
fomepizole
T6
T6
(Fomepizole)
T6
FUSILEV
T6
HEMABATE
T6
HYALGAN
T6
hydroxyzine hcl vial
(Hydroxyzine HCl)
T6
KALBITOR
T6
KEPIVANCE
T6
leucovorin calcium vial
(Leucovorin Calcium)
T6
147
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
Requirements/Limits
(Non-self administerable
injectable)
PA (Non-self
administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self
administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
levocarnitine vial
(Carnitor)
T6
levoleucovorin calcium
(Levoleucovorin
Calcium)
T6
mesna
(Mesnex)
T6
MESNEX vial
T6
methylene blue
(Methylene Blue)
T6
methylergonovine maleate vial
(Methylergonovine
Maleate)
T6
MYOBLOC
neostigmine methylsulfate
T6
(Neostigmine
Methylsulfate)
T6
NEXAVIR
T6
NITHIODOTE
T6
NPLATE
T6
OXYTOCIN
T6
PANHEMATIN
T6
PHYSICIANS EZ USE M-PRED
T6
physostigmine salicylate
(Physostigmine
Salicylate)
T6
PITOCIN
T6
PRALIDOXIME CHLORIDE
T6
PROSTASCINT
T6
PROTOPAM CHLORIDE
T6
148
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
Requirements/Limits
PROVENGE
T6
PROVISC
T6
REGONOL
T6
REMICADE
T6
SCLEROSOL
T6
SIMPONI ARIA
T6
SIMULECT
T6
PA (Non-self
administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self
administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self
administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self
administerable
injectable)
PA (Non-self
administerable
injectable)
PA (Non-self
administerable
injectable)
PA (Non-self
administerable
injectable)
PA (Non-self
administerable
injectable)
(Non-self administerable
injectable)
sodium morrhuate
(Sodium Morrhuate)
T6
sodium nitrite
(Sodium Nitrite)
T6
sodium tetradecyl sulfate
(Sodium Tetradecyl
Sulfate)
T6
SOTRADECOL
T6
STELARA
T6
SUPARTZ FX
T6
SUPARTZ
T6
SYNVISC-ONE
T6
SYNVISC
T6
talc
(Talc)
T6
149
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
Requirements/Limits
THAM
T6
TOTECT
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
TRIFERIC
VORAXAZE
T6
T6
XEOMIN
T6
ZINECARD
T6
aa8/a-carnitin/grp/cocoa/hc126
aa9/a-carnitin/dex/cocoa/hc127
AQUAFLO
ATRAPRO DERMAL SPRAY
AURSTAT
borage and fish oil/fruct/soy lec
BOTOX COSMETIC
colchicine capsule
ENTERAGAM
finasteride tablet: 1mg
fish oil/om-3/dl-e/fa/b6-b12
formaldehyde
FORMALDEHYDE
FORMA-RAY
FOSTEUM
FOVEX
genistein/cit zn bisgly/vit d3
H.P. ACTHAR
HYPERTENSA
LIMBREL250
LIMBREL500
LIMBREL
LISTER-V
MITIGARE
MYALEPT
(Aa8/A-Carnitin/Grp/
Cocoa/Hc126)
(Aa9/A-Carnitin/Dex/
Cocoa/Hc127)
(Borage and Fish Oil/
Fruct/Soy Lec)
(Colchicine)
(Propecia)
(Fish Oil/Om-3/Dl-E/
Fa/B6-B12)
(Formaldehyde)
(Fosteum)
(Non-self administerable
injectable)
PA (Non-self
administerable
injectable)
(Non-self administerable
injectable)
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
150
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
ORAFATE
ORTHOVISC
OTEZLA
OTREXUP
PERCURA
PREFLIN
PROCYSBI
PROPECIA
PROTEOLIN
PROTHELIAL
RASUVO
RECTIV
RESTORE CALCIUM ALGINATE
RESTORE CONTACT LAYER SILVER
RESTORE
SANARE SCAR THERAPY BASE
SENTRA PM
SIGNIFOR
SOLIRIS
TEGADERM AG MESH
THERAMINE
TREPADONE
VAYACOG
VAYARIN
VAYAROL
VERTIGOHEEL
VP-PRECIP
Requirements/Limits
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
Ocular Disorders
MEMBRANEBLUE
T6
VISIONBLUE
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
Ophthalmic Agents
Antiglaucoma Agents
acetazolamide
betaxolol hcl
brimonidine tartrate
dorzolamide hcl
dorzolamide hcl/timolol maleat
latanoprost
levobunolol hcl drops: 0.5%
(Acetazolamide)
(Betaxolol HCl)
(Alphagan P)
(Trusopt)
(Cosopt)
(Xalatan)
(Betagan)
T1
T1
T1
T1
T1
T1
T1
QL: 5 in 30 days
QL: 10 in 30 days
QL: 10 in 30 days
QL: 2.5 in 30 days
QL: 5 in 30 days
151
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
methazolamide
pilocarpine hcl
timolol maleate drops: 0.25%
timolol maleate drops: 0.5%; sol-gel
ALPHAGAN P drops: 0.1%
BETOPTIC S
COMBIGAN
ISOPTO CARBACHOL
levobunolol hcl drops: 0.25%
LUMIGAN
metipranolol
PHOSPHOLINE IODIDE
SIMBRINZA
TIMOPTIC OCUDOSE
TIMOPTIC
ALPHAGAN P drops: 0.15%
AZOPT
BETAGAN
BETIMOL
COSOPT PF
COSOPT
DIAMOX SEQUELS
ISOPTO CARPINE
ISTALOL
NEPTAZANE
TIMOPTIC-XE
TRAVATAN Z
travoprost (benzalkonium)
TRUSOPT
XALATAN
ZIOPTAN
acetazolamide sodium
Drug Tier
(Neptazane)
(Isopto Carpine)
(Timolol Maleate)
(Timolol Maleate)
(Betagan)
(Metipranolol)
(Travoprost
(Benzalkonium))
(Acetazolamide
Sodium)
T1
T1
T1
T1
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T6
MIOCHOL-E
T6
MIOSTAT
T6
MITOSOL
T6
bimatoprost
(Bimatoprost)
Requirements/Limits
QL: 15 in 30 days
QL: 5 in 30 days
QL: 10 in 30 days
QL: 10 in 30 days
QL: 10 in 30 days
QL: 5 in 30 days
QL: 5 in 60 days
QL: 10 in 30 days
QL: 10 in 30 days
QL: 5 in 30 days
QL: 10 in 30 days
QL: 60 in 30 days
QL: 10 in 30 days
QL: 15 in 30 days
QL: 5 in 30 days
QL: 5 in 30 days
QL: 5 in 60 days
QL: 5 in 60 days
QL: 2.5 in 30 days
QL: 30 in 30 days
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
EX
152
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
RESCULA
Requirements/Limits
EX
Parasympathomimetics (Cholinergic Agents)
pyridostigmine bromide
(Pyridostigmine
Bromide)
T1
Radioactive Agents
AMYVID
T6
INDICLOR
T6
METASTRON
T6
QUADRAMET
T6
XOFIGO
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self
administerable
injectable)
Replacement Preparations
cardioplegic solution no.1
citric acid/sodium citrate
KLOR-CON 8
KLOR-CON
phosphorus #1
pot chloride/pot bicarb/cit ac
potassium bicarbonate/cit ac
potassium chloride capsule er, liquid,
packet, tab er prt, tablet er
potassium citrate
potassium citrate/citric acid packet,
solution: 1100-334/5
zinc sulfate capsule
K-PHOS M.F.
K-PHOS NO.2
K-PHOS ORIGINAL
ORACIT
sod/pot/k cit/sod cit/cit acid
(Plegisol)
(Citric Acid/Sodium
Citrate)
(K-Phos Neutral)
(Pot Chloride/Pot
Bicarb/Cit Ac)
(Klor-Con-Ef)
(Klor-Con)
(Urocit-K)
(Potassium Citrate/
Citric Acid)
(Zinc Sulfate)
(Sod/Pot/K Cit/Sod Cit/
Cit Acid)
K-PHOS NEUTRAL
K-TAB ER
PLEGISOL
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T2
T2
T2
T2
T2
T3
T3
T3
153
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
SHOHL'S MODIFIED
UROCIT-K
0.9 % sodium chloride
Drug Tier
(Sodium Chloride)
AMMONUL
T3
T3
T6
T6
calcium chloride
(Calcium Chloride)
T6
calcium gluconate
(Calcium Gluconate)
T6
chromic chloride
(Chromic Chloride)
T6
cupric chloride
(Cupric Chloride)
T6
cupric sulfate
(Cupric Sulfate)
T6
dextrose 10 % and 0.2 % nacl
(Dextrose 10 % and 0.2
% NaCl)
(Dextrose 10 % and
0.45 % NaCl)
(Dextrose 2.5 % and
0.45 % NaCl)
(Dextrose 5 % and 0.3
% NaCl)
(Dextrose 5 % and 0.9
% NaCl)
(Dextrose 5 %-0.2 %
NaCl)
(Dextrose 5 %-0.45 %
NaCl)
(Dextrose 5%-Lactated
Ringers)
(Electrolyte-48
Solution/D5W)
T6
dextrose 10 % and 0.45 % nacl
dextrose 2.5 % and 0.45 % nacl
dextrose 5 % and 0.3 % nacl
dextrose 5 % and 0.9 % nacl
dextrose 5 %-0.2 % nacl
dextrose 5 %-0.45 % nacl
dextrose 5%-lactated ringers
electrolyte-48 solution/d5w
HESPAN
hetastarch in 0.9 % nacl
T6
T6
T6
T6
T6
T6
T6
T6
T6
(Hespan)
T6
HEXTEND LACTATED ELECTROLYTE
T6
HYPERLYTE CR
T6
Requirements/Limits
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
154
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
Requirements/Limits
IONOSOL B WITH DEXTROSE 5%
T6
IONOSOL MB-DEXTROSE 5%
T6
ISOLYTE H WITH DEXTROSE
T6
ISOLYTE M WITH DEXTROSE
T6
ISOLYTE P WITH DEXTROSE
T6
ISOLYTE S
T6
LACTATED RINGERS
T6
LMD 10% WITH 5% DEXTROSE
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
magnesium chloride
(Magnesium Chloride)
T6
magnesium sulf in 0.45% nacl
(Magnesium Sulf In
0.45% NaCl)
(Magnesium Sulfate in
Water)
(Magnesium Sulfate)
T6
magnesium sulfate in water
magnesium sulfate
T6
T6
T6
manganese chloride
(Magnesium Sulfate/
D5W)
(Manganese Chloride)
manganese sulfate
(Manganese Sulfate)
T6
molybdenum(ammonium molybdate)
(Molybdenum(Ammoni
um Molybdate))
T6
magnesium sulfate/d5w
T6
NEUT
T6
NORMOSOL-M AND DEXTROSE
T6
NORMOSOL-R AND DEXTROSE
T6
NORMOSOL-R PH 7.4
T6
NUTRILYTE II
T6
155
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
Requirements/Limits
NUTRILYTE
T6
PLASMA-LYTE 148
T6
PLASMA-LYTE 56 IN DEXTROSE
T6
PLASMA-LYTE A PH 7.4
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
potassium acetate
(Potassium Acetate)
T6
potassium chloride in 0.9%nacl
(Potassium Chloride In
0.9%NaCl)
(Potassium Chloride In
D5w)
(Potassium Chloride In
Lr-D5)
(Klor-Con)
T6
potassium chloride in d5w
potassium chloride in lr-d5
potassium chloride piggyback, vial
potassium chloride/d5-0.2%nacl
potassium chloride/d5-0.3%nacl
potassium chloride/d5-0.45nacl
potassium chloride/d5-0.9%nacl
potassium chloride-0.45% nacl
potassium phos,m-basic-d-basic
(Potassium Chloride/
D5-0.2%NaCl)
(Potassium Chloride/
D5-0.3%NaCl)
(Potassium Chloride/
D5-0.45nacl)
(Potassium Chloride/
D5-0.9%NaCl)
(Potassium Chloride0.45% NaCl)
(Potassium Phos,MBasic-D-Basic)
T6
T6
T6
T6
T6
T6
T6
T6
T6
PRISMASOL solution: 1.2meq/l
T6
PRISMASOL solution: 2.5-1.5/l
T6
PRISMASOL solution: 2-1.5meq/l
T6
PRISMASOL solution: 2-1meq/l
T6
PRISMASOL solution: 2-3.5meq/l
T6
PRISMASOL solution: 4-1.2meq/l
T6
156
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
Requirements/Limits
PRISMASOL solution: 4-1.5meq/l
T6
PRISMASOL solution: 4-2.5-1.5
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
ringers solution
(Ringers Solution)
T6
selenium
(Selenium)
T6
sodium acetate
(Sodium Acetate)
T6
sodium bicarbonate
(Sodium Bicarbonate)
T6
sodium chloride 0.45 %
T6
sodium chloride 3 %
(Sodium Chloride 0.45
%)
(Sodium Chloride 3 %)
T6
sodium chloride 5 %
(Sodium Chloride 5 %)
T6
sodium chloride
(Sodium Chloride)
T6
sodium glycerophosphate
(Sodium
Glycerophosphate)
(Sodium Lactate)
T6
sodium lactate
sodium phos,m-basic-d-basic
(Sodium Phos,MBasic-D-Basic)
T6
T6
SWABFLUSH
T6
TPN ELECTROLYTES II
T6
trace elements comb no.1
(Trace Elements Comb
No.1)
VOLUVEN
T6
T6
zinc chloride
(Zinc Chloride)
T6
zinc cl/cupric cl/mang/chrom
(Zinc Cl/Cupric Cl/
Mang/Chrom)
(Zinc Gluconate)
T6
(Zinc Sulf/Cuso4 PHyd/Mn/Cr/Se)
T6
zinc gluconate
zinc sulf/cuso4 p-hyd/mn/cr/se
T6
157
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
Requirements/Limits
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
zinc sulfate vial
(Zinc Sulfate)
T6
zn/cu/mang/selen/fluor/pot iod
(Zn/Cu/Mang/Selen/
Fluor/Pot Iod)
(Znso4/Cuso4/Mang
Su/Chromic Cl)
T6
znso4/cuso4/mang su/chromic cl
FOSTEUM PLUS
T6
EX
Respiratory Tract Agents
Anti-Inflammatories, Inhaled Corticosteroids
ASMANEX aer pow ba: 110mcg(30),
110mcg(7), 220mcg(14), 220mcg(30),
220mcg(60)
ASMANEX aer pow ba: 220mcg120
(Pulmicort)
budesonide
ADVAIR DISKUS
ADVAIR HFA
AEROSPAN
ALVESCO
ARNUITY ELLIPTA
ASMANEX HFA
BREO ELLIPTA
DULERA
FLOVENT DISKUS
FLOVENT HFA aer w/adap: 110mcg,
220mcg
FLOVENT HFA aer w/adap: 44mcg
T1
T1
T1
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
PULMICORT FLEXHALER
T2
PULMICORT ampul-neb: 1mg/2ml
QVAR
SYMBICORT
PULMICORT ampul-neb: 0.25mg/2ml,
0.5mg/2ml
Antileukotrienes
montelukast sodium
zafirlukast
ACCOLATE
SINGULAIR
T2
T2
T2
T3
(Singulair)
(Accolate)
QL: 1 in 30 days
(Quantity listed is # of
inhalers)
QL: 1 in 60 days
QL: 60 in 30 days
QL: 12 in 30 days
QL: 12.2 in 30 days
QL: 30 in 30 days
QL: 13 in 30 days
QL: 60 in 30 days
QL: 13 in 30 days
QL: 120 in 30 days
QL: 21.2 in 30 days
(Quantity listed is 2
inhalers)
QL: 2 in 30 days
(Quantity listed is # of
inhalers)
QL: 17.4 in 30 days
QL: 10.2 in 30 days
T1
T1
T3
T3
158
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
ZYFLO CR
ZYFLO
Bronchodilators
albuterol sulfate
ipratropium bromide
ipratropium/albuterol sulfate
T3
T3
(Albuterol Sulfate)
(Ipratropium Bromide)
(Ipratropium/Albuterol
Sulfate)
levalbuterol hcl vial-neb: 1.25mg/0.5
(Xopenex)
metaproterenol sulfate syrup
(Metaproterenol
Sulfate)
terbutaline sulfate tablet
(Terbutaline Sulfate)
theophylline anhydrous elixir: 80mg/15ml; (Theophylline
tab er 12h, tablet er
Anhydrous)
ANORO ELLIPTA
ARCAPTA NEOHALER
ATROVENT HFA
BROVANA
COMBIVENT RESPIMAT
FORADIL
INCRUSE ELLIPTA
levalbuterol hcl vial-neb: 0.31mg/3ml,
(Xopenex)
0.63mg/3ml
LUFYLLIN
metaproterenol sulfate tablet
(Metaproterenol
Sulfate)
PERFOROMIST
PROAIR HFA
PROAIR RESPICLICK
SEREVENT DISKUS
SPIRIVA RESPIMAT
SPIRIVA
STRIVERDI RESPIMAT
THEO-24
theophylline anhydrous elixir: 80mg/15ml
Requirements/Limits
(Theophylline
Anhydrous)
TUDORZA PRESSAIR
VENTOLIN HFA
T1
T1
T1
T1
T1
T1
T1
T2
T2
T2
T2
T2
T2
T2
T2
QL: 30 in 30 days
QL: 25.8 in 30 days
QL: 8 in 30 days
QL: 60 in 30 days
QL: 30 in 30 days
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
QL: 17 in 30 days
(Quantity listed is 2
inhalers)
QL: 2 in 30 days
QL: 60 in 30 days
QL: 4 in 30 days
QL: 36 in 30 days
(Quantity listed is 2
inhalers)
159
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
PROVENTIL HFA
T3
VOSPIRE ER
XOPENEX CONCENTRATE
XOPENEX HFA
T3
T3
T3
XOPENEX
aminophylline
(Aminophylline)
ISUPREL
T3
T6
T6
terbutaline sulfate vial
(Terbutaline Sulfate)
T6
theophylline/d5w
(Theophylline/D5W)
T6
(Acetadote)
(Cromolyn Sodium)
(Guaifenesin/
Dyphylline)
T1
T1
T1
Respiratory Tract Agents, Other
acetylcysteine vial: 100mg/ml, 200mg/ml
cromolyn sodium
guaifenesin/dyphylline
PULMOSAL
sodium chloride for inhalation
(Sodium Chloride For
Inhalation)
CUROSURF
HYPER-SAL vial-neb: 3.5%
INFASURF
NEBUSAL
SURFAXIN
SURVANTA
HYPER-SAL vial-neb: 7%
ESBRIET
KALYDECO gran pack
KALYDECO tablet
OFEV
ACETADOTE
acetylcysteine vial: 200mg/ml
QL: 13.4 in 30 days
(Quantity listed is 2
inhalers)
QL: 30 in 30 days
(Quantity listed is 2
inhalers)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
T1
T1
T2
T2
T2
T2
T2
T2
T3
T5
T5
T5
T5
T6
(Acetadote)
Requirements/Limits
T6
PA
Age must be >= 2, PA
Age must be >= 6, PA
PA
(Non-self administerable
injectable)
(Non-self administerable
injectable)
160
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
Requirements/Limits
ARALAST NP
T6
DOPRAM
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self
administerable
injectable)
(Non-self administerable
injectable)
doxapram hcl
(Doxapram HCl)
T6
GLASSIA
T6
PROLASTIN C
T6
XOLAIR
T6
ZEMAIRA
T6
DALIRESP
DYLIX
EX
EX
Roentgenography
OCTREOSCAN
T6
(Non-self administerable
injectable)
Skeletal Muscle Relaxants
baclofen
carisoprodol tablet: 350mg
carisoprodol/aspirin
chlorzoxazone
codeine/carisoprodol/aspirin
cyclobenzaprine hcl tablet: 5mg, 10mg
dantrolene sodium capsule: 25mg, 50mg
metaxalone tablet: 400mg, 800mg
methocarbamol tablet
orphenadrine citrate tablet er
orphenadrine/aspirin/caffeine tablet: 25385-30
tizanidine hcl tablet
dantrolene sodium capsule: 100mg
orphenadrine/aspirin/caffeine tablet: 50770-60
DANTRIUM capsule
PARAFON FORTE DSC
ROBAXIN-750
(Baclofen)
(Soma)
(Carisoprodol/Aspirin)
(Parafon Forte DSC)
(Codeine/Carisoprodol/
Aspirin)
(Fexmid)
(Dantrium)
(Skelaxin)
(Robaxin-750)
(Orphenadrine Citrate)
(Orphenadrine/Aspirin/
Caffeine)
(Zanaflex)
(Dantrium)
(Orphenadrine/Aspirin/
Caffeine)
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T2
T2
T3
T3
T3
161
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
ROBAXIN tablet
SKELAXIN
SOMA tablet: 350mg
ZANAFLEX
ANECTINE
T3
T3
T3
T3
T6
atracurium besylate
(Atracurium Besylate)
T6
cisatracurium besylate
(Nimbex)
T6
DANTRIUM vial
dantrolene sodium vial
T6
(Dantrium)
T6
GABLOFEN
T6
LIORESAL INTRATHECAL
T6
methocarbamol vial
(Robaxin)
NIMBEX
T6
T6
orphenadrine citrate ampul
(Orphenadrine Citrate)
T6
pancuronium bromide
(Pancuronium
Bromide)
T6
QUELICIN
T6
ROBAXIN vial
T6
rocuronium bromide
(Rocuronium Bromide)
T6
vecuronium bromide
(Vecuronium Bromide)
T6
ZEMURON
T6
AMRIX
carisoprodol tablet: 250mg
COMFORT PAC-CYCLOBENZAPRINE
COMFORT PAC-TIZANIDINE
cyclobenzaprine hcl tablet: 7.5mg
EX
EX
EX
EX
EX
(Soma)
(Fexmid)
Requirements/Limits
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
162
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
FEXMID
LORZONE
SOMA tablet: 250mg
tizanidine hcl capsule
Drug Tier
(Zanaflex)
EX
EX
EX
EX
(Lunesta)
(Provigil)
(Sonata)
(Ambien)
T1
T1
T1
T1
BUTISOL SODIUM
SECONAL SODIUM
AMBIEN
LUNESTA
PROVIGIL
ROZEREM
SONATA
zolpidem tartrate tab mphase
(Ambien CR)
T2
T2
T3
T3
T3
T3
T3
T3
XYREM
dexmedetomidine hcl
(Precedex)
T5
T6
Requirements/Limits
Sleep Disorder Agents
eszopiclone
modafinil
zaleplon
zolpidem tartrate tablet
NEMBUTAL SODIUM
T6
PRECEDEX infus. btl, vial: 80mcg/20ml
T6
PRECEDEX vial: 200mcg/2ml
T6
AMBIEN CR
BELSOMRA
EDLUAR
HETLIOZ
INTERMEZZO
NUVIGIL
ZOLPIMIST
EX
EX
EX
EX
EX
EX
EX
PA
PA
QL: 30 in 30 days (NOT
COVERED FOR
MEDICAID: Covered
Alternatives Available)
PA
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
Sympatholytic Adrenergic Blocking Agents
Alpha-Adrenergic Blocking Agents
(Phentolamine
phentolamine mesylate
Mesylate)
T6
(Non-self administerable
injectable)
163
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
Requirements/Limits
Urine And Feces Contents
Ketones
CHEMSTRIP K
KETONE CARE
KETONE
KETOSTIX REAGENT
T6
T6
T6
T6
Vasodilating Agents
sildenafil citrate tablet
VIAGRA
CAVERJECT
(Revatio)
T1
T2
T3
CIALIS tablet: 2.5mg, 5mg
CIALIS tablet: 10mg, 20mg
EDEX
T3
T3
T3
LEVITRA
STAXYN
STENDRA
ADCIRCA
ADEMPAS
LETAIRIS
OPSUMIT
TRACLEER
TYVASO ampul-neb: 1.74mg/2.9
TYVASO ampul-neb: 1.74mg/2.9
TYVASO ampul-neb: 1.74mg/2.9
VENTAVIS
ORENITRAM ER
alprostadil
(Alprostadil)
T3
T3
T3
T4
T4
T4
T4
T4
T4
T4
T4
T4
T5
T6
epoprostenol sodium (glycine)
(Flolan)
T6
FLOLAN
T6
PROSTIN VR PEDIATRIC
T6
REMODULIN
T6
QL: 8 in 30 days
PA, QL: 6 in 30 days
(Self Administerable
(Select) Injectable)
QL: 30 in 30 days
QL: 8 in 30 days
PA, QL: 6 in 30 days
(Self Administerable
(Select) Injectable)
QL: 8 in 30 days
QL: 8 in 30 days
QL: 8 in 30 days
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self
administerable
injectable)
164
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
REVATIO vial
sildenafil citrate vial
(Revatio)
Drug Tier
Requirements/Limits
T6
PA (Non-self
administerable
injectable)
PA (Non-self
administerable
injectable)
(Non-self administerable
injectable)
T6
VELETRI
T6
MUSE
REVATIO tablet
EX
EX
Vitamins and Minerals
b cmplx 4/vit d3/c/fa/zinc ox
(B Cmplx 4/Vit D3/C/
Fa/Zinc Ox)
T1
b complex and c no.20/folic acid
(Nephrocaps)
T1
calcium/mag/d3/b12/fa/b6/boron tablet
(Folgard Os)
T1
CORVITE FREE
T1
cyanocobalamin/fa/pyridoxine
(Folgard Rx)
T1
cyanocobalamin/mecobalamin
(Cyanocobalamin/
Mecobalamin)
T1
ergocalciferol (vitamin d2)
(Drisdol)
T1
fa/niacinamide/cupric ox/zn ox
(Fa/Niacinamide/
Cupric Ox/Zn Ox)
T1
fa/vit bcomp and c/se/min aa/zn
(Fa/Vit Bcomp and C/
Se/Min Aa/Zn)
T1
fe fumarate/doss/fa/bcomp,c
(Fe Fumarate/Doss/Fa/
Bcomp,C)
T1
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
165
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
Requirements/Limits
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
fe fumarate/vit c/b12/stomc
(Fe Fumarate/Vit C/
B12/Stomc)
T1
fe fumarate/vit c/b12-if/fa
(Fe Fumarate/Vit C/
B12-If/Fa)
T1
ferrous fumarate/folic acid
(Hemocyte-F)
T1
ferrous sulfate/vit c/fa
(Ferrous Sulfate/Vit C/
Fa)
T1
folic acid tablet
(Folic Acid)
T1
folic acid/b complex and c no.17
(Folic Acid/B Complex
and C No.17)
T1
folic acid/vit bcomp,c
(Folic Acid/Vit
Bcomp,C)
T1
folic acid/vit bcomp,c/cu/znox
(Folic Acid/Vit
Bcomp,C/Cu/Znox)
T1
iron bg and ps/vit c/b12/fa/ca thr
(Iron Bg and Ps/Vit C/
B12/Fa/Ca Thr)
T1
iron fum and p/fa/vit b and c no.9
(Integra Plus)
T1
iron fum and polysac#1/fa/mv no.18
(Tandem Plus)
T1
iron fum and ps cmp/fa/vit c/b3
(Integra F)
T1
iron fumarate/vit c/vit b12/fa
(Iron Fumarate/Vit C/
Vit B12/Fa)
T1
iron ps cmplx/vit b12/fa
(Niferex-150 Forte)
T1
166
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
Requirements/Limits
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
iron, carbonyl/fa/c/b-6/b12/zn
(Corvite 150)
T1
iron,carb/dss/b12if/fa/mv-mn
(Hemax)
T1
iron/fa/vit bcomp,c/minerals
(Iron/Fa/Vit Bcomp,C/
Minerals)
T1
iron/liver ext/vit bcomp,c/min
(Iron/Liver Ext/Vit
Bcomp,C/Min)
T1
LYSIPLEX PLUS
T1
multivit, min cmb#20/iron/fa
(Multivit, Min
Cmb#20/Iron/Fa)
T1
multivitamins with min no.7/fa
(Multivitamins with
Min No.7/Fa)
T1
multivit-min/fa/lycopen/lutein
(Biocel)
T1
multivits,therap w-fe,hematin tablet: 27mg- (Multivits,Therap W0.8mg
Fe,Hematin)
T1
(Mv,Min #10/Fa/D3/
Alip Acid/Lut)
T1
mv,min #10/fa/d3/alip acid/lut
NEPHROCAPS capsule: 1mg
T1
om-3/dha/epa/b12/fa/b6/phytost
(Animi-3)
T1
pnv with ca,no.72/iron/fa
(Pnv with Ca,No.72/
Iron/Fa)
T1
pnv95/ferrous fumarate/fa
(Prenatal)
T1
167
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
Requirements/Limits
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
prenatal vit#96/ferrous fum/fa
(Prenatal Vit#96/
Ferrous Fum/Fa)
T1
prenatal vit/iron fumarate/fa
(Classic Prenatal)
T1
vit b cmplx 3/fa/vit c/biotin
(Vit B Cmplx 3/Fa/Vit
C/Biotin)
T1
vit b cmplx no3/fa/c/biot/zinc
(Vit B Cmplx No3/Fa/
C/Biot/Zinc)
T1
vit b cplx #11/fa/c/biot/zn ox
(Vit B Cplx #11/Fa/C/
Biot/Zn Ox)
T1
ACTIVE FE
calcium/mag/d3/b12/fa/b6/boron wafer
T2
(Calcium/Mag/D3/B12/
Fa/B6/Boron)
T2
CENTRATEX
T2
FOLPACE RX
T2
FUSION PLUS
T2
FUSION SPRINKLES
T2
iron ag and fum/c/fa/mv cmb11/ca-t
(Iron Ag and Fum/C/
Fa/Mv Cmb11/Ca-T)
T2
iron ag/c/b12/ca/suc.acid/stom tablet: 70150-10
(Iron Ag/C/B12/Ca/
Suc.Acid/Stom)
T2
iron aspgly and ps/c/b12/fa/ca/suc capsule: (Iron Aspgly and Ps/C/
150-25-1
B12/Fa/Ca/Suc)
T2
168
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
Requirements/Limits
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
PA (See Appendix B for
list of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
iron aspgly/c/b12/fa/ca-th/suc
(Iron Aspgly/C/B12/Fa/
Ca-Th/Suc)
T2
iron fum and ag/c/b12/fa/ca/succ tablet:
151-60-1mg
(Iron Fum and Ag/C/
B12/Fa/Ca/Succ)
T2
iron polysac/iron heme/fa/b12
(Bifera Rx)
T2
iron/fa/b12/c/docusate sodium
(Iron/Fa/B12/C/
Docusate Sodium)
T2
MEPHYTON
T2
NOVAFERRUM
T2
PROFERRIN-FORTE
T2
WHEAT GERM OIL
T2
b complex with vitamin c tablet
(B Complex with
Vitamin C)
T3
BIFERA RX
T3
BIOCEL
T3
cod liver oil oil
(Cod Liver Oil)
T3
CORVITA
T3
CORVITE 150 tablet: 150-1.25mg
T3
169
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
Requirements/Limits
CORVITE 150 tablet: 150mg-1mg
T3
CORVITE FE tablet: 150mg-1mg
T3
CORVITE
T3
DIALYVITE 5000
T3
DIALYVITE SUPREME D
T3
DRISDOL
T3
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
fe fumarate/cal/e/fa/multivit
(Fe Fumarate/Cal/E/Fa/
Multivit)
T3
FERIVA FA capsule: 110mg-1mg
T3
FERIVA FA capsule: 110mg-1mg
T3
FERRALET 90
T3
FOLGARD OS
T3
FOLGARD RX
T3
FOLTRATE
T3
FORTAVIT
T3
170
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
Requirements/Limits
HEMATRON-AF
T3
HEMOCYTE PLUS
T3
HEMOCYTE-F
T3
INTEGRA F
T3
INTEGRA PLUS
T3
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
iron, carb and gluc/fa/b12/c/dss tablet: 901-50mg
(Ferralet 90)
T3
IROSPAN
T3
MAXARON FORTE
T3
METHAVER
T3
MULTICHEW
T3
multivit, iron, min #5, fa
(Multivit, Iron, Min #5,
Fa)
T3
multivitamin with minerals liquid: n/a
(Multivitamin with
Minerals)
T3
NASCOBAL
T3
NEPHROCAPS QT
T3
171
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
Requirements/Limits
NEPHRONEX-SL
T3
NICADAN
T3
NICOMIDE tablet: 0.5-750mg
T3
NICOMIDE tablet: 0.5-750mg
T3
NUTRICAP
T3
NUTRIVIT
T3
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
pnv no.118/iron fumarate/fa
(Pnv No.118/Iron
Fumarate/Fa)
T3
pnv#71/iron/folic acid/dha
(Pnv#71/Iron/Folic
Acid/Dha)
T3
pnv#79/iron/fa/lmfolate ca/dha
(Neevo Dha)
T3
prenatal #48/iron cb and glu/fa/b6
(Prenatal #48/Iron Cb
and Glu/Fa/B6)
T3
PRENATAL 19
T3
PROTECT IRON
T3
PUREVIT DUALFE PLUS
T3
REQ49+
T3
172
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
Drug Tier
Requirements/Limits
STROVITE ONE
T3
SUPERVITE EC
T3
SUPERVITE
T3
TANDEM PLUS
T3
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
(See Appendix B for list
of covered
multivitamins)
AQUASOL A
ascorbic acid
CENOLATE
cyanocobalamin (vitamin b-12)
dexpanthenol
FERAHEME
FERRLECIT
folic acid vial
hydroxocobalamin
INFED
INFUVITE ADULT
INFUVITE
INJECTAFER
iron dextran complex
M.V.I. ADULT
M.V.I. PEDIATRIC
phytonadione ampul, syringe
pyridoxine hcl
sodium ferric gluconat/sucrose
thiamine hcl
VENOFER
vitamins b1,b2,b3,b5, and b6
ANIMI-3 capsule: 500-0.5-1
ANIMI-3 capsule: 500-1000-1
b complex with vitamin c capsule
(Ascorbic Acid)
(Cyanocobalamin
(Vitamin B-12))
(Dexpanthenol)
(Folic Acid)
(Hydroxocobalamin)
(Infed)
(Phytonadione)
(Pyridoxine HCl)
(Sodium Ferric
Gluconat/Sucrose)
(Thiamine HCl)
(Vitamins
B1,B2,B3,B5, and B6)
(B Complex with
Vitamin C)
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
EX
EX
EX
173
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
b12/levomefolate calcium/b-6 tablet: 21.13-25
CALAFOL RX
CARDIOTEK-RX
CEREFOLIN NAC tablet: 6-600-2mg
CEREFOLIN
DEPLIN-ALGAL OIL
DEPLIN
DERMANIC
ENLYTE
fa/arginine hcl/b12/b6/pep ex
FERIVA
FOLTX tablet: 2-1.13-25
FOLTX tablet: 2-2.5-25mg
levomefolate calcium
levomefolate/algal oil
levomefolate/b6/b12/algal oil
lmfol ca/acetyl/mb12/algal oil
MAXFE
mecobal/levomefolat ca/b6 phos
METANX capsule
METANX tablet
methyltetrahydrofolate glucosa
mv, min cmb#43/lut/om3/dha/epa
om-3/calcium/d3/fa/mv cmb 13
om-3/dha/epa/d3/b12/fa/b-6/phy
PODIAPN
PROBARIMIN QT
PROTECT CARDIO
RELAMINE
RHEUMATE
SYNAGEX
TOZAL
UDAMIN SP
UROSEX
Drug Tier
(Foltx)
Requirements/Limits
EX
(Fa/Arginine HCl/B12/
B6/Pep Ex)
(Levomefolate
Calcium)
(Deplin-Algal Oil)
(Metanx)
(Cerefolin Nac)
(Metanx)
(Methyltetrahydrofolate
Glucosa)
(Mv, Min Cmb#43/Lut/
Om3/Dha/Epa)
(Om-3/Calcium/D3/Fa/
Mv Cmb 13)
(Animi-3)
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
174
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
Drug Name
vit a,c,e/zinc/copper/lut/zeax
vit b12/lmefolate ca/vit b6/b2
VITA-RESPA
Drug Tier
(Vit A,C,E/Zinc/
Copper/Lut/Zeax)
(Cerefolin)
Requirements/Limits
EX
EX
EX
175
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
INDEX
0.9 % sodium chloride ...... 96, 117, 154
1ST CHOICE LANCETS ................101
1ST TIER UNILET COMFORTOUCH
...................................................101
8-MOP ..............................................86
A.I.R.S. NEBULIZER ........................97
aa/antipyrn/bcaine/polico#1/al ........119
aa8/a-carnitin/grp/cocoa/hc126 ......150
aa9/a-carnitin/dex/cocoa/hc127 ......150
abacavir sulfate ................................55
abacavir/lamivudine/zidovudine........55
ABELCET .........................................45
ABILIFY ......................................53, 54
ABILIFY DISCMELT .........................53
ABILIFY MAINTENA ........................54
ABRAXANE ......................................29
ABSORICA .......................................89
ABSTRAL .........................................12
acamprosate calcium .......................17
ACANYA...........................................91
acarbose...........................................41
ACCOLATE ....................................158
ACCU-CHEK ..........................101, 106
ACCU-CHEK ACTIVE ....................106
ACCU-CHEK AVIVA ......................106
ACCU-CHEK AVIVA PLUS ............106
ACCU-CHEK COMFORT CURVE .106
ACCU-CHEK COMPACT PLUS .....106
ACCU-CHEK FASTCLIX ................101
ACCU-CHEK NANO SMARTVIEW 106
ACCU-CHEK SAFE-T-PRO ...........101
ACCU-CHEK SAFE-T-PRO PLUS .101
ACCU-CHEK SMARTVIEW ...........106
ACCU-CHEK SOFTCLIX................101
ACCU-CHEK VOICEMATE ............106
ACCUPRIL .......................................69
ACCURETIC ....................................69
ACCUTREND GLUCOSE ..............106
ACE AEROSOL CLOUD ENHANCER
.....................................................97
acebutolol hcl ...................................70
ACEON.............................................69
ACETADOTE .................................160
acetaminophen with codeine ..............9
acetaminophen/phenyltolx ................12
acetazolamide ................................151
acetazolamide sodium ....................152
acetic acid ..............................118, 141
acetic acid/hydrocortisone ..............118
acetylcysteine .........................143, 160
ACIPHEX........................................123
ACIPHEX SPRINKLE .....................123
acitretin .............................................89
ACLOVATE ......................................93
ACTEMRA.............................. 145, 146
ACTHIB .......................................... 139
ACTIGALL ...................................... 124
ACTI-LANCE .................................. 101
ACTIMMUNE ................................. 145
ACTIQ .............................................. 12
ACTIVASE ....................................... 60
ACTIVE FE..................................... 168
ACTIVELLA .................................... 129
ACTONEL ...................................... 142
ACTOPLUS MET ............................. 41
ACTOPLUS MET XR ....................... 41
ACTOS ............................................. 41
ACULAR......................................... 121
ACULAR LS ................................... 121
ACURA METER KIT....................... 106
ACURA PLUS ................................ 106
ACURA STARTER KIT .................. 106
ACURA TEST STRIPS................... 106
acyclovir ..................................... 57, 85
acyclovir sodium............................... 57
ACZONE .......................................... 86
ADACEL TDAP .............................. 139
ADAGEN ........................................ 115
ADALAT CC ..................................... 74
adapalene ........................................ 94
ADAPTER ........................................ 97
ADCETRIS ....................................... 29
ADCIRCA ....................................... 164
ADDERALL ...................................... 78
ADDERALL XR ................................ 78
ADDYI .............................................. 79
adefovir dipivoxil ............................... 57
ADEMPAS...................................... 164
ADENOCARD .................................. 69
adenosine......................................... 69
ADIPEX-P ........................................ 79
ADOXA............................................. 26
ADRENACLICK ................................ 72
ADRENALIN..................................... 72
ADRENALIN CHLORIDE ............... 116
ADULT AEROSOL MASK ................ 97
ADVAIR DISKUS ........................... 158
ADVAIR HFA.................................. 158
ADVANCE INTUITION ................... 106
ADVANCE TEST STRIPS .............. 106
ADVANCED TRAVEL LANCETS ... 101
ADVATE ........................................... 60
ADVICOR ......................................... 76
ADVOCATE BLOOD GLUCOSE
MONITOR .................................. 106
ADVOCATE LANCET .................... 101
ADVOCATE LANCETS .................. 101
ADVOCATE REDI-CODE .............. 106
ADVOCATE REDI-CODE+ ............ 106
ADVOCATE TEST STRIP.............. 106
ADYNOVATE ................................... 60
AEROCHAMBER MINI .................... 97
AEROCHAMBER MV....................... 97
AEROCHAMBER PLUS FLOW-VU . 97
AEROCHAMBER PLUS Z STAT ..... 97
AEROCHAMBER WITH
FLOWSIGNAL ............................. 97
AEROCHAMBER Z-STAT PLUS ..... 97
AEROECLIPSE ................................ 97
AEROECLIPSE II ............................. 97
AEROGEAR ASTHMA ACTION KIT 97
AERONEB GO ................................. 97
AERONEB GO NEBULIZER ............ 97
AEROSPAN ................................... 158
AEROTRACH PLUS ........................ 97
AFINITOR ........................................ 28
AFINITOR DISPERZ ........................ 28
AFLURIA 2015-2016 ...................... 139
AFREZZA......................................... 43
AGAMATRIX AMP ......................... 106
AGGRASTAT ................................... 62
AGGRENOX .................................... 62
AGRYLIN ......................................... 60
AIR FILTER...................................... 97
AIR TUBE WITH AIR PLUGS .......... 97
AIRS ADULT AEROSOL MASK ...... 97
AIRS DISPOSABLE NEBULIZER .... 97
AIRZONE PEAK FLOW METER ...... 97
AKNE-MYCIN .................................. 91
AKTEN ........................................... 116
ALA-HIST AC ................................... 84
ALAHIST DHC ................................. 84
ALA-QUIN ........................................ 44
ALBENZA......................................... 51
ALBUKED-25 ................................... 62
ALBUKED-5 ..................................... 63
ALBUMIN HUMAN ........................... 63
ALBUMINAR-25 ............................... 63
ALBUMINAR-5 ................................. 63
ALBURX........................................... 63
ALBUTEIN ....................................... 63
albuterol sulfate .............................. 159
alclometasone dipropionate ............. 91
alcohol antiseptic pads ..................... 85
ALDACTAZIDE ................................ 77
ALDACTONE ................................... 77
ALDARA........................................... 86
ALDURAZYME .............................. 115
alendronate sodium ....................... 142
alfentanil hcl ..................................... 11
ALFERON N .................................... 57
alfuzosin hcl ................................... 126
I-1
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
ALIMTA ............................................29
ALINIA ..............................................51
ALKERAN...................................27, 29
ALL FLOW 1000 ...............................97
ALL FLOW 2000 ...............................97
ALL FLOW 3000 KIT ........................97
ALL FLOW 3000 PFT .......................97
ALL FLOW 4000 ...............................97
ALL FLOW 5000 ...............................97
ALL FLOW 6000 ...............................97
ALL FLOW 7000 ...............................97
ALLERX 10.......................................46
ALLERX 30.......................................46
ALLERX PE ......................................46
ALLFEN CD......................................84
ALLFEN CDX ...................................84
allopurinol .......................................143
allopurinol sodium ..........................146
almotriptan malate ............................48
ALOCRIL ........................................120
ALODOX ..........................................26
ALOMIDE .......................................116
ALOPRIM .......................................146
ALORA ...........................................129
alosetron hcl ...................................140
ALOXI ...............................................50
ALPHAGAN P ................................152
ALPHANATE ....................................60
ALPHANINE SD ...............................60
alprazolam ........................................17
ALPRAZOLAM INTENSOL ..............18
ALPROLIX ........................................62
alprostadil .......................................164
ALREX............................................120
ALSUMA...........................................49
ALTABAX .........................................91
ALTACE ...........................................69
ALTERA NEBULIZER ......................97
ALTERNATE SITE LANCETS ........101
ALTOPREV ......................................77
aluminum acetate .............................86
aluminum chloride ............................85
ALUVEA ...........................................86
ALVESCO ......................................158
amantadine hcl .................................52
AMARYL...........................................43
AMBIEN..........................................163
AMBIEN CR ...................................163
AMBISOME ......................................45
amcinonide .................................91, 93
AMERGE ..........................................48
A-METHAPRED .............................131
AMETHYST ......................................82
AMICAR ...........................................60
AMIDATE .......................................125
amifostine crystalline ......................146
amikacin sulfate ................................19
amiloride hcl .....................................74
amiloride/hydrochlorothiazide........... 74
AMINO ACIDS ................................. 63
aminocaproic acid ............................ 60
aminophylline ................................. 160
AMINOSYN ...................................... 64
AMINOSYN II ............................. 63, 64
AMINOSYN II WITH ELECTROLYTES
..................................................... 63
AMINOSYN M .................................. 64
AMINOSYN WITH ELECTROLYTES
..................................................... 64
AMINOSYN-HBC ............................. 64
AMINOSYN-PF ................................ 64
AMINOSYN-RF ................................ 64
amiodarone hcl ........................... 69, 70
AMITIZA ......................................... 124
amitrip hcl/chlordiazepoxide ............. 39
amitriptyline hcl ................................ 39
amlodipine besylate ......................... 73
amlodipine besylate/benazepril ........ 73
amlodipine/atorvastatin .................... 76
amlodipine/valsartan ........................ 74
amlodipine/valsartan/hcthiazid ......... 74
ammonium chloride ........................ 146
ammonium lactate ............................ 89
AMMONUL ..................................... 154
amobarbital sodium ........................ 146
amoxapine........................................ 39
amoxicillin................................... 24, 25
amoxicillin/potassium clav ................ 24
AMPHADASE ................................. 115
amphotericin b .................................. 45
ampicillin sodium .............................. 24
ampicillin sodium/sulbactam na ........ 24
ampicillin trihydrate .......................... 24
AMPYRA .......................................... 79
AMRIX ............................................ 162
AMTURNIDE .................................... 77
AMVISC ......................................... 146
AMVISC PLUS ............................... 146
AMYVID ......................................... 153
ANACAINE ....................................... 87
ANADROL-50 ................................. 128
ANAFRANIL ..................................... 39
anagrelide hcl ................................... 60
ANALPRAM ADVANCED................. 93
ANALPRAM HC ............................... 93
ANAPROX........................................ 14
ANAPROX DS.................................. 14
ANASCORP ................................... 136
ANASPAZ ...................................... 124
anastrozole....................................... 27
ANCOBON ....................................... 44
ANDRODERM ................................ 128
ANDROGEL ................................... 128
ANDROID....................................... 128
ANECTINE ..................................... 162
ANGELIQ ....................................... 129
ANGIOMAX...................................... 58
ANIMI-3 .......................................... 173
ANORO ELLIPTA .......................... 159
ANTABUSE...................................... 17
ANTARA .......................................... 76
antipyrine/benzocaine .................... 118
ANTIVENIN LATRODECTUS
MACTANS ................................. 136
ANTIVENIN MICRURUS FULVIUS 136
ANTIVERT ....................................... 51
ANUSOL-HC .................................... 93
ANZEMET ........................................ 50
APEXICON E ................................... 93
APIDRA............................................ 43
APIDRA SOLOSTAR ....................... 43
APLENZIN ....................................... 40
APLIGRAF ....................................... 96
APOKYN .......................................... 53
APOP ............................................... 87
apraclonidine hcl ............................ 116
APRISO ......................................... 140
APTIOM ........................................... 36
APTIVUS.......................................... 55
AQUA GLYCOLIC HC...................... 94
AQUAFLO ...................................... 150
AQUASOL A .................................. 173
AQUORAL ....................................... 85
ARALAST NP................................. 161
ARANESP ........................................ 59
ARAVA ........................................... 135
ARCALYST .................................... 136
ARCAPTA NEOHALER ................. 159
ARESTIN ......................................... 85
ARGATROBAN ................................ 58
ARGATROBAN-0.9% NACL ............ 58
ARICEPT ......................................... 38
ARICEPT ODT ................................. 38
ARIMIDEX........................................ 28
aripiprazole ...................................... 53
ARISTOSPAN ................................ 131
ARIXTRA ......................................... 58
ARMOUR THYROID ...................... 134
ARNUITY ELLIPTA ........................ 158
AROMASIN ...................................... 28
ARRANON ....................................... 29
ARTHROTEC 50 .............................. 14
ARTHROTEC 75 .............................. 14
ARTISS ............................................ 62
ARZERRA ........................................ 29
ASACOL HD .................................. 140
ASCLERA ........................................ 77
ascorbic acid .................................. 173
ASMALPRED ................................. 130
ASMALPRED PLUS ...................... 130
ASMANEX ..................................... 158
ASMANEX HFA ............................. 158
aspirin/dipyridamole ......................... 62
ASSESS........................................... 97
I-2
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
ASSURE 4..............................106, 107
ASSURE HAEMOLANCE PLUS ....101
ASSURE LANCE ............................101
ASSURE LANCE PLUS .................101
ASSURE PLATINUM .....................107
ASSURE PRO ................................107
ASTAGRAF XL ...............................135
ASTELIN ........................................116
ASTEPRO ......................................116
ASTHMA CHECK .............................97
ASTHMAMENTOR ...........................97
ASTHMAPACK CHILDREN'S ..........97
ASTHMAPACK I ...............................97
ASTHMAPACK II ..............................97
ASTRINGYN ..................................144
ATACAND ........................................68
ATACAND HCT ................................68
ATELVIA.........................................143
atenolol .............................................70
atenolol/chlorthalidone .....................70
ATGAM...........................................136
ATIVAN ............................................18
atorvastatin calcium ..........................75
atovaquone.......................................52
atovaquone/proguanil hcl .................51
atracurium besylate ........................162
ATRALIN ..........................................95
ATRAPRO CP ................................107
ATRAPRO DERMAL SPRAY .........150
ATRIPLA ..........................................56
ATROPEN ........................................36
atropine sulfate .........................36, 116
ATROVENT ....................................117
ATROVENT HFA ............................159
AUBAGIO .......................................138
AUGMENTIN ....................................24
AUGMENTIN ES-600 .......................24
AUGMENTIN XR ..............................24
AURSTAT...............................107, 150
AURYXIA........................................125
AUVI-Q .............................................72
AVAGE .............................................95
AVALIDE ..........................................68
AVANDAMET ...................................41
AVANDARYL....................................41
AVANDIA..........................................41
AVAPRO ..........................................68
AVAR..........................................85, 87
AVAR LS ..........................................87
AVAR-E ............................................85
AVAR-E LS.......................................87
AVASTIN ..........................................29
AVC ..................................................47
AVELOX ...........................................25
AVELOX ABC PACK ........................25
AVELOX IV.......................................25
AVIDOXY .........................................27
AVIDOXY DK ...................................27
AVINZA ............................................ 10
AVITENE .......................................... 60
AVODART ...................................... 144
AVONEX ........................................ 145
AVONEX ADMINISTRATION PACK
................................................... 145
AVONEX PEN ................................ 145
AXERT ............................................. 48
AXID ............................................... 122
AXIRON ......................................... 128
AXONA............................................. 66
AYGESTIN ..................................... 134
azacitidine ........................................ 29
AZACTAM ........................................ 23
AZACTAM-ISO-OSMOTIC
DEXTROSE ................................. 23
AZASAN ......................................... 138
AZASITE ........................................ 118
azathioprine.................................... 135
azathioprine sodium ....................... 136
azelastine hcl ................................. 116
AZELEX ........................................... 87
AZILECT .......................................... 52
azithromycin ..................................... 23
AZOPT ........................................... 152
AZOR ............................................... 74
aztreonam ........................................ 23
AZULFIDINE .................................... 26
b cmplx 4/vit d3/c/fa/zinc ox ........... 165
b complex and c no.20/folic acid .... 165
b complex with vitamin c ........ 169, 173
b12/levomefolate calcium/b-6......... 174
b3/azel ac/zinc/b6/copper/fa........... 144
BABY CONVERSION KIT ................ 97
BABY CONVERSION PACK 1 ......... 97
BABY CONVERSION PACK 2 ......... 97
BABY NEBULIZER .......................... 98
bacitracin .................................. 20, 118
bacitracin/polymyxin b sulfate ........ 118
baclofen.......................................... 161
BACTRIM ......................................... 26
BACTRIM DS ................................... 26
BACTROBAN ................................... 91
BACTROBAN NASAL ...................... 91
BAL IN OIL ..................................... 127
balanced salt irrig soln no.2............ 117
balsalazide disodium ...................... 140
BANZEL ........................................... 36
BARACLUDE ................................... 57
BCG TICE STRAIN ........................ 139
BD MICROTAINER LANCETS ....... 101
BD ULTRA-FINE ............................ 101
BD ULTRA-FINE II ......................... 101
BEBULIN .......................................... 60
BECONASE AQ ............................. 121
BELEODAQ ..................................... 29
BELSOMRA ................................... 163
BELVIQ ............................................ 79
benazepril hcl ................................... 68
benazepril/hydrochlorothiazide ........ 68
BENEFIX.......................................... 60
BENICAR ......................................... 68
BENICAR HCT ................................. 68
BENLYSTA .................................... 146
BENSAL HP ..................................... 87
BENTYL ......................................... 124
BENZAC AC .................................... 87
BENZACLIN ..................................... 91
BENZAMYCINPAK .......................... 91
BENZEFOAM................................... 89
BENZEFOAM ULTRA ...................... 89
BENZIQ............................................ 85
benzocaine....................................... 15
benzoin/aloe vera/storax/tolu ........... 89
benzonatate ............................... 83, 84
benzoyl peroxide .................. 85, 87, 89
benzoyl peroxide microspheres ....... 87
benzphetamine hcl ........................... 79
benztropine mesylate ................. 52, 53
BEPREVE ...................................... 118
BERINERT ....................................... 59
BESIVANCE .................................. 119
BETADINE ..................................... 118
BETAGAN ...................................... 152
betamet acet/betamet na ph .......... 131
betamethasone dipropionate............ 92
betamethasone valerate................... 92
betamethasone/propylene glyc ........ 92
BETAPACE ...................................... 71
BETAPACE AF ................................ 71
BETASERON ................................. 145
betaxolol hcl ............................. 70, 151
bethanechol chloride ...................... 143
BETIMOL ....................................... 152
BETOPTIC S.................................. 152
bexarotene ....................................... 28
BEXSERO...................................... 139
BEXXAR .......................................... 29
BEYAZ ............................................. 83
BG-STAR ....................................... 107
BIAFINE ........................................... 96
BIAXIN ............................................. 23
BIAXIN XL ........................................ 23
bicalutamide ..................................... 27
BICILLIN C-R ................................... 24
BICILLIN L-A .................................... 24
BICNU .............................................. 29
BIDIL ................................................ 78
BIFERA RX .................................... 169
BILTRICIDE ..................................... 51
bimatoprost .................................... 152
BINOSTO ....................................... 143
BIOCEL .......................................... 169
BIONECT ....................................... 144
BIOSTEP ....................................... 144
BIOSTEP AG ................................. 144
I-3
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
BIOTHRAX .....................................139
bisoprolol fumarate ...........................70
bisoprolol fumarate/hctz ...................70
bivalirudin .........................................58
BIVIGAM ........................................136
bleomycin sulfate ..............................30
BLEPHAMIDE ................................119
BLEPHAMIDE S.O.P. .....................119
BLINCYTO .......................................30
BLOOD GLUCOSE METER ...........107
BLOOD GLUCOSE MONITOR ......107
BLOOD GLUCOSE MONITORING 107
BLOOD GLUCOSE TEST ..............107
BLOOD GLUCOSE TEST STRIP ...107
BLOOD LANCETS .........................101
BLOOD-GLUCOSE METER...........107
BLOXIVERZ ...................................146
BONIVA ..........................................142
BONTRIL SLOW-RELEASE.............79
BOOSTRIX TDAP ..........................139
borage and fish oil/fruct/soy lec ......150
BOSULIF ..........................................28
BOTOX ...........................................146
BOTOX COSMETIC .......................150
BP WASH .........................................85
BRAVELLE .....................................132
BREATHERITE ................................98
BREATHRITE...................................98
BREEZE 2 ......................................101
BREO ELLIPTA ..............................158
BREVIBLOC .....................................71
BREVITAL SODIUM .........................79
BREVOXYL-4 ...................................87
BREVOXYL-8 ...................................87
BRILINTA .........................................62
brimonidine tartrate ........................151
BRINTELLIX .....................................39
BRISDELLE......................................40
bromfenac sodium ..........................120
bromocriptine mesylate ....................52
bromphenrm/pseudoeph/dihydrocd ..84
BROVANA ......................................159
BSS ................................................117
BSS PLUS ......................................117
BUBBLES THE FISH II.....................98
BUCALSEP ......................................15
budesonide ..................... 120, 140, 158
BULLSEYE MINI SAFETY LANCETS
...................................................101
bumetanide.................................74, 75
BUMINATE .......................................63
BUPAP .............................................10
BUPHENYL ............................123, 124
bupivacaine hcl/epinephrine .............15
bupivacaine hcl/epinephrine bi .........15
bupivacaine hcl/epinephrine/pf .........16
bupivacaine hcl/pf .............................16
BUPRENEX......................................11
buprenorphine hcl ...................... 11, 17
buprenorphine hcl/naloxone hcl ....... 17
bupropion hcl.................................... 39
buspirone hcl .................................. 143
BUSULFEX ...................................... 30
butalb/acetaminophen/caffeine .... 9, 10
butalbit/acetamin/caff/codeine ............ 9
butalbital/acetaminophen ................... 9
butalbital/aspirin/caffeine .................... 9
BUTISOL SODIUM ........................ 163
butorphanol tartrate ...................... 9, 11
BUTRANS ........................................ 12
BYDUREON ..................................... 42
BYDUREON PEN ............................ 41
BYETTA ........................................... 42
BYSTOLIC ....................................... 70
cabergoline....................................... 52
CA-DTPA ....................................... 127
CADUET .......................................... 76
CAFCIT ...................................... 78, 79
CAFERGOT ..................................... 48
caffeine citrated .......................... 78, 79
caffeine/sodium benzoate ................ 79
CALAFOL RX ................................. 174
CALAN ............................................. 71
CALAN SR ....................................... 71
calcipotriene ..................................... 85
calcipotriene/betamethasone ........... 89
calcitonin,salmon,synthetic............. 142
calcitriol .................................... 87, 142
calcium acetate .............................. 125
calcium carbonate/mag carb/fa ...... 125
calcium chloride ............................. 154
CALCIUM DISODIUM VERSENATE
................................................... 127
calcium gluconate .......................... 154
calcium/mag/d3/b12/fa/b6/boron ... 165,
168
CALDOLOR ..................................... 14
CAMBIA ........................................... 14
CAMPRAL ........................................ 17
CAMPTOSAR .................................. 30
CANASA ........................................ 140
CANCIDAS....................................... 45
candesartan cilexetil ......................... 67
candesartan/hydrochlorothiazid ....... 67
CANTIL .......................................... 123
CAPASTAT SULFATE ..................... 50
capecitabine ..................................... 28
CAPEX SHAMPOO .......................... 93
CAPHOSOL ..................................... 85
CAPITAL W-CODEINE .................... 10
CAPRELSA ...................................... 28
captopril............................................ 68
captopril/hydrochlorothiazide............ 68
CARAC............................................. 87
CARAFATE .................................... 122
CARBAGLU ................................... 124
carbamazepine ................................ 36
CARBATROL ................................... 36
carbidopa ......................................... 52
carbidopa/levodopa .......................... 52
carbidopa/levodopa/entacapone ...... 52
carbinoxamine maleate .............. 45, 46
CARBOCAINE ................................. 16
carboplatin ....................................... 30
CARDENE I.V. ................................. 74
CARDENE SR ................................. 74
cardioplegic solution no.1............... 153
CARDIOTEK-RX ............................ 174
CARDIZEM ...................................... 72
CARDIZEM CD ................................ 71
CARDIZEM LA ................................. 72
CARDURA ....................................... 67
CARDURA XL .................................. 67
CAREONE ..................................... 101
CARESENS ................................... 101
CARESENS N ................................ 107
CARESENS N VOICE.................... 107
CARIMUNE NF NANOFILTERED . 136
carisoprodol ........................... 161, 162
carisoprodol/aspirin ........................ 161
CARNITOR ............................ 144, 147
CARRASYN HYDROGEL WOUND144
carteolol hcl .................................... 116
CARTICEL ..................................... 147
carvedilol .......................................... 70
CASODEX ....................................... 28
CATAFLAM ...................................... 14
CATAPRES...................................... 67
CATAPRES-TTS 1 ........................... 67
CATAPRES-TTS 2 ........................... 67
CATAPRES-TTS 3 ........................... 67
CATHFLO ACTIVASE...................... 60
CAVERJECT .................................. 164
CAYA CONTOURED ....................... 83
CAYSTON........................................ 23
CEDAX............................................. 21
cefaclor ............................................ 21
cefadroxil.......................................... 21
cefazolin sodium .............................. 21
CEFAZOLIN SODIUM...................... 21
cefazolin sodium/dextrose,iso .......... 21
cefdinir ............................................. 21
CEFEPIME....................................... 22
cefepime hcl ..................................... 22
CEFEPIME-DEXTROSE .................. 22
cefixime ............................................ 21
cefotaxime sodium ........................... 22
cefotetan disod/dextrose,iso ............ 22
cefotetan disodium ........................... 22
cefoxitin sodium ............................... 22
cefoxitin sodium/dextrose,iso ........... 22
cefpodoxime proxetil ........................ 21
cefprozil............................................ 21
ceftazidime ....................................... 22
I-4
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
CEFTAZIDIME .................................22
ceftibuten ..........................................21
CEFTIN ............................................21
CEFTRIAXONE ................................22
ceftriaxone na/dextrose,iso...............22
ceftriaxone sodium ...........................22
cefuroxime axetil ..............................21
CEFUROXIME AXETIL ....................21
cefuroxime sodium ...........................22
CELEBREX ......................................15
celecoxib ..........................................13
CELESTONE..................................131
CELEXA ...........................................39
CELLCEPT .............................135, 136
CELLUGEL.....................................117
CELONTIN .......................................36
CENESTIN .....................................129
CENOLATE ....................................173
CENTANY ........................................91
CENTANY AT...................................91
CENTRATEX..................................168
CEPHADYN .......................................9
cephalexin ........................................21
CEPROTIN .......................................58
CEREBYX ........................................38
CEREFOLIN ...................................174
CEREFOLIN NAC ..........................174
CEREZYME ...................................115
CERUBIDINE ...................................30
CERVARIX .....................................139
CERVIDIL .......................................144
CESAMET ........................................50
CESINEX........................................124
CETACAINE .....................................87
cetirizine hcl......................................46
CETRAXAL ....................................119
CETROTIDE...................................133
cevimeline hcl ...................................85
CHEMET ........................................127
CHEMSTRIP K ...............................164
CHENODAL ...................................116
chloramphenicol sod succ ................20
chlordiazepoxide hcl .........................17
chlordiazepoxide/clidinium br ...........35
chlorhexidine gluconate ....................85
CHLORHEXIDINE GLUCONATE .....89
chloroprocaine hcl/pf ........................16
chloroquine phosphate .....................51
chlorothiazide ...................................74
chlorothiazide sodium .......................75
chloroxylenol/benzoc/hydrocort ......121
chloroxylenol/pramoxine hcl ...........116
chlorpheniramine/codeine phos........83
chlorpromazine hcl .....................53, 54
chlorpropamide .................................43
chlorthalidone ...................................74
chlorzoxazone ................................161
CHOICEDM G20 ............................107
cholestyramine (with sugar) ............. 75
cholestyramine/aspartame ............... 75
choline sal/mag salicylate................. 13
CHORIONIC GONADOTROPIN .... 132
chromic chloride ............................. 154
CIALIS ............................................ 164
CICLODAN................................. 43, 45
ciclopirox .......................................... 43
ciclopirox olamine ............................. 43
ciclopirox/ure/camph/menth/euc ....... 44
cidofovir ............................................ 57
cilostazol .......................................... 62
CILOXAN ....................................... 119
cimetidine ....................................... 122
cimetidine hcl ................................. 122
CIMZIA ................................... 136, 137
CINRYZE ......................................... 59
CIPRO .............................................. 25
CIPRO HC...................................... 119
CIPRO I.V. ....................................... 25
CIPRO XR ........................................ 26
CIPRODEX .................................... 119
ciprofloxacin ..................................... 25
ciprofloxacin hcl ................ 25, 118, 119
ciprofloxacin lactate .......................... 25
ciprofloxacin lactate/d5w .................. 25
ciprofloxacin/ciprofloxa hcl ............... 25
cisatracurium besylate.................... 162
cisplatin ............................................ 30
citalopram hydrobromide .................. 39
citric acid/sodium citrate ................. 153
cladribine .......................................... 30
CLAFORAN...................................... 22
CLAFORAN GALAXY ...................... 22
CLARIFOAM EF ............................... 87
CLARINEX ....................................... 46
CLARINEX-D 12 HOUR ................... 46
CLARINEX-D 24 HOUR ................... 46
CLARIS ............................................ 86
clarithromycin ................................... 23
clemastine fumarate ......................... 45
CLEOCIN ......................................... 47
CLEOCIN HCL ................................. 20
CLEOCIN PALMITATE .................... 20
CLEOCIN PHOSPHATE .................. 20
CLEOCIN PHOSPHATE IN D5W ..... 20
CLEOCIN T ...................................... 91
CLEVER CHEK LANCETS ............ 101
CLEVER CHOICE .......................... 107
CLEVER CHOICE BLOOD GLUC SYS
CLEVER CHOICE HD GLUCOSE
SYST .......................................... 107
CLEVER CHOICE MICRO ............. 107
CLEVER CHOICE MICRO TEST
STRIP......................................... 107
CLEVER CHOICE PRO ................. 107
CLEVER CHOICE TEST STRIPS .. 107
CLEVER CHOICE VOICE+ TST
STRIP ........................................ 107
CLEVIPREX ..................................... 74
CLIMARA ....................................... 129
CLIMARA PRO .............................. 129
CLINDACIN P .................................. 90
CLINDACIN PAC ............................. 91
CLINDAGEL ..................................... 91
clindamycin hcl ................................. 19
clindamycin palmitate hcl ................. 19
clindamycin phos/benzoyl perox ...... 90
clindamycin phosphate......... 20, 47, 90
clindamycin phosphate/d5w ............. 20
CLINDAREACH ............................... 91
CLINDESSE ..................................... 47
CLINIMIX ......................................... 65
CLINIMIX E ................................ 64, 65
CLINISOL......................................... 65
CLINPRO 5000 ................................ 85
clobetasol propionate ....................... 92
CLOBEX .......................................... 93
clocortolone pivalate ........................ 93
CLODAN .................................... 92, 94
CLODERM ....................................... 93
CLOLAR........................................... 30
clomiphene citrate .......................... 128
clomipramine hcl .............................. 39
clonazepam...................................... 17
clonidine ........................................... 67
clonidine hcl ............................... 67, 79
clonidine hcl/chlorthalidone .............. 67
clonidine hcl/pf ................................. 11
clopidogrel bisulfate ......................... 62
clorazepate dipotassium .................. 18
clotrimazole ...................................... 43
clotrimazole/betamethasone dip ...... 44
clozapine .................................... 53, 55
CLOZARIL ....................................... 53
CNL 8 ............................................... 45
CO MONITOR.................................. 98
CO MONITOR REPLACEMENT T ... 98
COAGADEX..................................... 60
COAGUCHEK ................................ 101
COARTEM ....................................... 51
cocaine hcl ....................................... 15
cod liver oil ..................................... 169
codeine sulfate ............................. 9, 10
codeine/butalbital/asa/caffein ............. 9
codeine/carisoprodol/aspirin .......... 161
COGENTIN
107
...................................... 53
COLAZAL....................................... 140
colchicine ............................... 144, 150
colchicine/probenecid .................... 143
COLCRYS...................................... 144
COLESTID ....................................... 76
colestipol hcl .................................... 76
colistin (colistimethate na) ................ 20
COLOR LANCETS ......................... 102
I-5
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
COLY-MYCIN M PARENTERAL ......20
COLY-MYCIN S .............................119
COLYTE WITH FLAVOR PACKETS
...................................................125
COMBIGAN ....................................152
COMBIPATCH ...............................129
COMBIVENT RESPIMAT ...............159
COMBIVIR........................................55
COMETRIQ ......................................28
COMFORT EZ................................102
COMFORT LANCETS ....................102
COMFORT PACCYCLOBENZAPRINE ................162
COMFORT PAC-IBUPROFEN .........15
COMFORT PAC-MELOXICAM ........15
COMFORT PAC-NAPROXEN..........15
COMFORT PAC-TIZANIDINE ........162
COMPACT COMPRESSOR
NEBULIZER .................................98
COMPACT SPACE CHAMBER PLUS
.....................................................98
COMPACT ULTRASONIC
NEBULIZER .................................98
COMP-AIR ELITE COMPRESSOR
SYST ............................................98
COMP-AIR NEBULIZER
COMPRESSOR ...........................98
COMPAZINE ....................................50
COMPLERA .....................................56
COMPMIST COMPRESSOR
NEBULIZER .................................98
COMTAN ..........................................52
COMVAX ........................................139
CONCERTA .....................................78
CONDYLOX .....................................87
CONTOUR .....................................102
CONTOUR LINK ............................102
CONTOUR NEXT ...........................102
CONTOUR NEXT CONTROL
SOLUTION .................................102
CONTOUR NEXT EZ .....................102
CONTOUR NEXT LINK ..................102
CONTOUR NEXT USB ..................102
CONTOUR USB .............................102
CONTROL ......................................107
CONTROL G3 ................................107
CONZIP ............................................13
COPAXONE ...................................145
COPEGUS .......................................57
CORDARONE ..................................69
CORDRAN .......................................93
COREG ............................................71
COREG CR ......................................71
CORGARD .......................................71
CORIFACT .......................................60
CORLOPAM .....................................72
CORTANE-B ..................................121
CORTEF.........................................130
CORTENEMA .................................. 93
CORTIFOAM.................................... 93
cortisone acetate ............................ 130
CORTISPORIN ........................ 91, 119
CORTISPORIN-TC ........................ 119
CORVERT........................................ 70
CORVITA ....................................... 169
CORVITE ....................................... 170
CORVITE 150 ........................ 169, 170
CORVITE FE.................................. 170
CORVITE FREE ............................. 165
CORZIDE ......................................... 71
COSMEGEN .................................... 30
COSOPT ........................................ 152
COSOPT PF .................................. 152
COTABFLU ...................................... 84
COUMADIN...................................... 58
COZAAR .......................................... 68
CREON .......................................... 114
CRESTOR........................................ 76
cresyl acetate ................................. 119
CRINONE....................................... 134
CRIXIVAN ........................................ 55
CROFAB ........................................ 137
cromolyn sodium ............ 116, 123, 160
CUBICIN .......................................... 20
cupric chloride ................................ 154
cupric sulfate .................................. 154
CUPRIMINE ................................... 127
CURITY .......................................... 107
CUROSURF ................................... 160
CUTIVATE ....................................... 93
CUVPOSA...................................... 123
cyanocobalamin (vitamin b-12) ...... 173
cyanocobalamin/fa/pyridoxine ........ 165
cyanocobalamin/mecobalamin ....... 165
CYCLESSA ...................................... 82
cyclobenzaprine hcl ................ 161, 162
CYCLOGYL.................................... 117
CYCLOMYDRIL ............................. 116
cyclopentolate hcl ........................... 116
cyclophosphamide ..................... 27, 30
CYCLOPHOSPHAMIDE .................. 27
cycloserine ....................................... 49
cyclosporine ........................... 135, 137
cyclosporine, modified .................... 135
CYKLOKAPRON .............................. 60
CYMBALTA ...................................... 39
cyproheptadine hcl ........................... 46
CYRAMZA........................................ 30
CYSTADANE ................................. 145
CYSTAGON ................................... 114
CYSTARAN.................................... 118
cysteine hcl ...................................... 65
cytarabine......................................... 30
cytarabine/pf..................................... 30
CYTOGAM ..................................... 137
CYTOMEL ...................................... 135
CYTOTEC ...................................... 122
CYTOVENE ..................................... 57
D.H.E.45 .......................................... 49
dacarbazine ..................................... 30
DACOGEN ....................................... 30
dactinomycin .................................... 30
DALIRESP ..................................... 161
danazol .......................................... 127
DANTRIUM ............................ 161, 162
dantrolene sodium ................. 161, 162
dapsone ........................................... 49
DAPTACEL DTAP ......................... 139
DARAPRIM ...................................... 51
daunorubicin hcl ............................... 30
DAUNOXOME ................................. 30
DAYPRO .......................................... 14
DAYTRANA ..................................... 79
DDAVP................................... 131, 133
DEBACTEROL ................................. 85
decitabine......................................... 30
deferoxamine mesylate .................. 127
DELATESTRYL ............................. 128
DELESTROGEN ............................ 130
DELFLEX WITH 1.5% DEXTROSE141
DELFLEX WITH 2.5% DEXTROSE141
DELFLEX WITH 4.25% DEXTROSE
................................................... 141
DELOS ............................................. 87
DELTUSS DMX ............................... 46
DELZICOL ..................................... 140
DEMADEX ....................................... 75
demeclocycline hcl ........................... 26
DEMEROL ................................. 10, 11
DEMSER.......................................... 72
DEMULEN 1-50-21 .......................... 82
DENAVIR ......................................... 86
DEPACON ....................................... 38
DEPAKENE ..................................... 37
DEPAKOTE ..................................... 37
DEPAKOTE ER ............................... 37
DEPAKOTE SPRINKLE ................... 37
DEPEN........................................... 127
DEPLIN .......................................... 174
DEPLIN-ALGAL OIL ...................... 174
DEPOCYT........................................ 31
DEPODUR ....................................... 11
DEPO-ESTRADIOL ....................... 130
DEPO-MEDROL ............................ 131
DEPO-PROVERA .......................... 134
DEPO-SUBQ PROVERA 104 ........ 134
DEPO-TESTOSTERONE .............. 128
DERMAGRAFT ................................ 96
DERMANIC .................................... 174
DERMAPAK PLUS .......................... 95
DERMA-SMOOTHE-FS ................... 93
DERMASORB AF ............................ 44
DERMASORB HC ............................ 94
DERMASORB TA ............................ 93
I-6
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
DERMATOP .....................................93
DERMOTIC ....................................121
DESFERAL ....................................127
desipramine hcl ................................39
desloratadine ....................................46
desmopressin acetate ............131, 133
desog-e.estradiol/e.estradiol ............80
DESOGEN .......................................82
desogestrel-ethinyl estradiol .............80
DESONATE......................................93
desonide ...........................................92
DESOWEN .......................................93
desoximetasone .........................92, 93
DESOXYN ........................................78
DESPEC-PDC ..................................84
DESQUAM-X....................................87
desvenlafaxine .................................40
DESVENLAFAXINE ER ...................40
DESVENLAFAXINE FUMARATE ER
.....................................................40
DETROL .........................................126
DETROL LA ...................................126
DEVILBISS DISPOSABLE
NEBULIZER .................................98
DEVILBISS PULMO-AIDE................98
DEVILBISS PULMONEB LT COMPNEB ..............................................98
DEVILBISS TRAVELER ...................98
dexamethasone ..............................130
DEXAMETHASONE INTENSOL ....130
dexamethasone sod phosphate ....120,
131
DEXCOM G4 ..................................107
DEXCOM G5-G4 SENSOR ............107
DEXEDRINE ....................................78
DEXILANT ......................................122
dexmedetomidine hcl .....................163
dexmethylphenidate hcl ....................78
DEXPAK .........................................130
dexpanthenol ..................................173
dexrazoxane hcl .............................147
dextroamphetamine sulfate ..............78
dextroamphetamine/amphetamine ...78
dextrose 10 % and 0.2 % nacl ........154
dextrose 10 % and 0.45 % nacl ......154
dextrose 10 % and 0.9 % nacl ..........65
dextrose 10 % in water .....................65
dextrose 2.5 % and 0.45 % nacl .....154
dextrose 2.5 % in water ....................65
dextrose 20 % in water .....................65
dextrose 25 % in water .....................65
dextrose 30 % in water .....................65
dextrose 40 % in water .....................65
dextrose 5 % and 0.3 % nacl ..........154
dextrose 5 % and 0.9 % nacl ..........154
dextrose 5 % in water .......................65
dextrose 5 %-0.2 % nacl.................154
dextrose 5 %-0.45 % nacl...............154
dextrose 5% in ringers...................... 65
dextrose 5%-lactated ringers .......... 154
dextrose 50 % in water ..................... 65
dextrose 70 % in water ..................... 66
DIABETA .......................................... 43
DIALYVITE 5000 ............................ 170
DIALYVITE SUPREME D............... 170
DIAMOX SEQUELS ....................... 152
DIANEAL PD-2 W-1.5% DEXTROSE
................................................... 141
DIANEAL PD-2 W-2.5% DEXTROSE
................................................... 141
DIANEAL PD-2 W-4.25% DEXTROSE
................................................... 141
DIANEAL WITH 1.5% DEXTROSE 141
DIANEAL WITH 2.5% DEXTROSE 141
DIANEAL WITH 4.25% DEXTROSE
................................................... 141
DIASTAT .......................................... 18
DIASTAT ACUDIAL ......................... 18
DIATRUE PLUS ............................. 107
diazepam.......................................... 18
DIBENZYLINE .................................. 67
DICLEGIS ........................................ 51
diclofenac potassium ........................ 13
diclofenac sodium .............. 13, 15, 120
diclofenac sodium/misoprostol ......... 13
dicloxacillin sodium .......................... 24
dicyclomine hcl ............................... 123
didanosine ........................................ 55
DIDREX............................................ 80
diethylpropion hcl ............................. 80
DIFFERIN......................................... 95
DIFICID ............................................ 23
diflorasone diacetate .................. 92, 93
DIFLUCAN ....................................... 44
diflunisal ........................................... 13
DIGEX NF ...................................... 124
DIGIFAB ........................................... 72
digoxin .............................................. 72
DIGOXIN .......................................... 72
dihydrocodeine/aspirin/caffein .......... 10
dihydrocodeine/guaifenesin.............. 84
dihydroergotamine mesylate ...... 48, 49
DILACOR XR ................................... 72
DILANTIN ................................... 36, 37
DILANTIN-125 .................................. 37
DILATRATE-SR ............................... 78
DILAUDID .................................. 10, 11
DILAUDID-HP .................................. 11
diltiazem hcl ............................... 71, 72
dimenhydrinate ................................. 50
DIOVAN ........................................... 68
DIOVAN HCT ................................... 68
dioxybenzone/pdo/hydroquinone ..... 89
DIPENTUM .................................... 140
diphenhydramine hcl ........................ 46
diphenoxylate hcl/atropine.............. 123
DIPHTHERIA-TETANUS TOXOIDSPED............................................ 139
DIPRIVAN ...................................... 125
DIPROLENE .................................... 93
DIPROLENE AF ............................... 93
dipyridamole ............................... 62, 73
DISCOVISC ..................................... 96
disopyramide phosphate .................. 69
disulfiram.......................................... 17
DITROPAN XL ............................... 126
DIURIL ............................................. 75
divalproex sodium ............................ 36
DIVIGEL ......................................... 129
d-methorphan hb/p-epd hcl/bpm ...... 83
dobutamine hcl ................................. 73
dobutamine hcl/d5w ......................... 73
DOCEFREZ ..................................... 31
docetaxel.......................................... 31
DOLOPHINE HCL ............................ 10
donepezil hcl .................................... 38
DONNATAL ..................................... 35
dopamine hcl .................................... 73
dopamine hcl/d5w ............................ 73
DOPRAM ....................................... 161
DORAL............................................. 18
DORIBAX ......................................... 23
DORYX ............................................ 27
dorzolamide hcl .............................. 151
dorzolamide hcl/timolol maleat ....... 151
DOVONEX ....................................... 87
doxapram hcl ................................. 161
doxazosin mesylate ......................... 67
doxepin hcl ....................................... 39
doxercalciferol ................................ 142
DOXIL .............................................. 31
doxorubicin hcl ................................. 31
doxorubicin hcl peg-liposomal .......... 31
doxycycline hyclate .................... 26, 27
doxycycline monohydrate........... 26, 27
doxylamine succinate ....................... 46
DRISDOL ....................................... 170
DRITHOCREME HP ........................ 87
dronabinol ........................................ 50
droperidol ....................................... 147
DROPLET LANCETS..................... 102
DROXIA ........................................... 27
DRYSOL .......................................... 87
DUAC ............................................... 91
DUAVEE ........................................ 129
DUETACT ........................................ 42
DUEXIS............................................ 15
DULERA ........................................ 158
duloxetine hcl ................................... 39
DUODOTE ..................................... 147
DUOVISC......................................... 96
DURACLON ..................................... 11
DURAGESIC .................................... 10
DURAMORPH ................................. 12
I-7
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
DUREZOL ......................................121
dutasteride......................................143
dutasteride/tamsulosin hcl ..............143
DUTOPROL .....................................70
DYAZIDE ..........................................75
DYLIX .............................................161
DYMISTA .......................................117
DYRENIUM ......................................75
DYSPORT ......................................147
EASIVENT........................................98
EASY COMFORT ...........................102
EASY GLUCO G2 ..........................107
EASY PLUS II ................................107
EASY STEP ...................................108
EASY TALK ....................................108
EASY TOUCH ................ 102, 105, 108
EASY TOUCH GLUCOSE MONITOR
...................................................108
EASY TOUCH LANCETS...............102
EASY TRAK ...................................108
EASY TWIST AND CAP LANCETS
...................................................102
EASYGLUCO .................................108
EASYMAX ......................................108
EASYMAX 15 .................................108
EASYMAX L ...................................108
EASYMAX N ..................................108
EASYMAX NG ................................108
EASYMAX V...................................108
EASYMAX V SPEAKING ...............108
EASYMAX V2.................................108
EASYPLUS ....................................108
EASYPLUS R13N ..........................108
EASYPLUS V .................................108
ECLIPSE ........................................108
EC-NAPROSYN ...............................14
econazole nitrate ..............................44
EDARBI ............................................68
EDARBYCLOR .................................68
EDECRIN .........................................75
EDEX..............................................164
EDLUAR .........................................163
EDURANT ........................................55
EFFEXOR XR ..................................39
EFFIENT ..........................................62
EFUDEX ...........................................87
EGRIFTA ........................................133
ELAPRASE ....................................115
ELDEPRYL.......................................52
electrolyte-48 solution/d5w .............154
ELELYSO .......................................115
ELEMENT BLOOD GLUCOSE
METER .......................................108
ELEMENT COMPACT....................108
ELEMENT PLUS ............................108
ELEMENT TEST STRIPS ..............108
ELESTAT .......................................117
ELESTRIN ......................................129
ELETONE ........................................ 96
ELIDEL ............................................. 93
ELIGARD ......................................... 31
ELIMITE ........................................... 96
ELIQUIS ........................................... 58
ELITEK ........................................... 115
ELLA ................................................ 82
ELLENCE ......................................... 31
ELLIOTTS B ................................... 147
ELMIRON ....................................... 144
ELOCON .......................................... 93
ELOCTATE ...................................... 61
ELOXATIN ....................................... 31
ELSPAR ........................................... 31
em#53/namgf/cyc/phos/nahc/nacl .. 108
EMADINE ....................................... 116
EMBEDA .......................................... 13
EMBRACE ............................. 102, 108
EMBRACE EVO ............................. 108
EMBRACE PRO ............................. 108
EMCYT............................................. 27
EMEND ...................................... 50, 51
EMLA ............................................... 15
emol53/namgfs/ha/nahypochlorit ... 108
emollient combination no.10............. 96
emollient combination no.32............. 96
emollient combination no.35........... 108
emollient combination no.43............. 96
emollient combination no.53..... 87, 108
emollient combination no.85............. 96
EMSAM ............................................ 40
EMTRIVA ......................................... 55
ENABLEX....................................... 126
enalapril maleate .............................. 68
enalapril/hydrochlorothiazide............ 68
enalaprilat dihydrate ......................... 69
ENBREL ......................................... 136
ENDO-AVITENE ............................ 144
ENDOFORM .................................... 96
ENDOMETRIN ............................... 134
enflurane ........................................ 126
ENGERIX-B ADULT ....................... 139
ENGERIX-B PEDIATRICADOLESCENT ........................... 139
ENJUVIA ........................................ 130
ENLON-PLUS .................................. 36
ENLYTE ......................................... 174
ENOVARX-AMITRIPTYLINE ........... 40
ENOVARX-BACLOFEN ................... 89
ENOVARX-NAPROXEN .................. 15
enoxaparin sodium ........................... 58
entacapone ...................................... 52
entecavir........................................... 57
ENTERAGAM ................................ 150
ENTEREG ...................................... 125
ENTOCORT EC ............................. 140
ENTRESTO...................................... 68
ENTYVIO ....................................... 147
ENVARSUS XR ............................. 135
ENVISION .............................. 108, 109
EOVIST .......................................... 141
EPANED .......................................... 69
ephedrine sulfate ............................. 73
EPICERAM ...................................... 96
EPIDUO ........................................... 95
EPIFIX AMNIOTIC MEMBRANE ... 109
EPIFOAM ......................................... 93
epinastine hcl ................................. 116
epinephrine ................................ 72, 73
epinephrine hcl/pf ............................. 73
EPIPEN 2-PAK ................................ 72
EPIPEN JR 2-PAK ........................... 72
epirubicin hcl .................................... 31
EPISIL .............................................. 96
EPIVIR ............................................. 56
EPIVIR HBV ............................... 55, 56
eplerenone ....................................... 77
EPOGEN.......................................... 59
epoprostenol sodium (glycine) ....... 164
eprosartan mesylate ........................ 67
eptifibatide........................................ 62
EPZICOM......................................... 55
EQUETRO ....................................... 36
ERAPID NEBULIZER....................... 98
ERAPID NEBULIZER HANDSET .... 98
ERAXIS WATER DILUENT.............. 45
ERBITUX ......................................... 31
ergocalciferol (vitamin d2) .............. 165
ergoloid mesylates ......................... 143
ERGOMAR ...................................... 48
ergotamine tartrate/caffeine ............. 47
ERIVEDGE ...................................... 28
ERTACZO ........................................ 44
ERWINAZE ...................................... 31
ERYGEL .......................................... 91
ERYPED 200 ................................... 23
ERYPED 400 ................................... 23
ERY-TAB ......................................... 23
ERYTHROCIN LACTOBIONATE..... 23
erythromycin base .................... 23, 118
erythromycin base/ethanol ............... 90
erythromycin ethylsuccinate ............. 23
erythromycin stearate....................... 23
erythromycin/benzoyl peroxide ........ 90
ESBRIET........................................ 160
escitalopram oxalate ........................ 39
ESGIC .......................................... 9, 10
esmolol hcl ....................................... 71
esomeprazole magnesium ............. 122
esomeprazole sodium .................... 122
esomeprazole strontium ................. 123
estazolam......................................... 18
ESTRACE ...................................... 129
estradiol ......................................... 128
estradiol valerate ............................ 130
estradiol/norethindrone acet........... 129
I-8
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
ESTRASORB .................................129
ESTRING .......................................129
ESTROGEL ....................................129
estrogen,ester/me-testosterone......127
estropipate......................................129
ESTROSTEP FE ..............................82
eszopiclone ....................................163
ethacrynate sodium ..........................75
ethambutol hcl ..................................49
ethanolamine oleate .........................73
ethinyl estradiol/drospirenone...........80
ethosuximide ....................................36
ETHRANE ......................................126
ethyl alcohol ...................................147
ethyl chloride ....................................87
ethynodiol d-ethinyl estradiol ............80
etidronate disodium ........................142
etodolac ............................................13
etomidate........................................126
ETOPOPHOS...................................31
etoposide ....................................28, 31
EUFLEXXA.....................................147
EURAX .............................................96
EVAMIST........................................129
EVENCARE....................................109
EVENCARE G2 ..............................109
EVENCARE G3 ..............................109
EVISTA...........................................129
EVOCLIN..........................................91
EVOLUTION BLOOD GLUCOSE
METER .......................................109
EVOLUTION TEST STRIPS...........109
EVOTAZ ...........................................55
EVOXAC ..........................................85
EVZIO...............................................17
EXALGO...........................................13
EXEL HYPODERMIC NEEDLE......105
EXEL SYRINGE .............................105
EXELDERM......................................44
EXELON ...........................................38
exemestane ......................................27
EXFORGE ........................................74
EXFORGE HCT ...............................74
EXJADE .........................................127
EXPAREL .........................................16
EXPIRATORY ..................................98
EXTAVIA ........................................145
EXTINA ............................................45
EXTRANEAL ICODEXTRIN DIALYSIS
...................................................141
EYLEA ............................................117
E-Z JECT LANCETS ......................102
EZ SMART .....................................109
EZ SMART LANCETS ....................102
EZ SMART PLUS ...........................109
E-Z SPACER ....................................98
E-Z SPACER PEDSPAK ..................98
EZ USE JOINT-TUNNEL-TRIGGER
................................................... 131
E-ZJECT LANCETS ....................... 102
fa/arginine hcl/b12/b6/pep ex ......... 174
fa/niacinamide/cupric ox/zn ox ....... 165
fa/vit bcomp and c/se/min aa/zn ..... 165
FABIOR ............................................ 95
FABRAZYME ................................. 115
FACTIVE .......................................... 25
famciclovir ........................................ 57
famotidine....................................... 122
famotidine in nacl,iso-osm/pf .......... 122
FAMVIR............................................ 57
FANAPT ........................................... 53
FARESTON...................................... 27
FARXIGA ......................................... 42
FARYDAK ........................................ 28
FASLODEX ...................................... 31
FAZACLO......................................... 55
fe fumarate/cal/e/fa/multivit ............ 170
fe fumarate/doss/fa/bcomp,c .......... 165
fe fumarate/vit c/b12/stomc ............ 166
fe fumarate/vit c/b12-if/fa ................ 166
FEIBA NF ......................................... 61
felbamate ......................................... 36
FELBATOL ....................................... 37
FELDENE......................................... 14
felodipine .......................................... 74
FEM PH............................................ 47
FEMARA .......................................... 28
FEMCON FE .................................... 82
FEMHRT ........................................ 129
FEMRING....................................... 129
fenofibrate ........................................ 76
fenofibrate nanocrystallized.............. 76
fenofibrate,micronized ...................... 76
fenofibric acid ................................... 76
fenofibric acid (choline) .................... 76
FENOGLIDE .................................... 76
fenoprofen calcium ........................... 14
FENOPROFEN CALCIUM ............... 14
fentanyl......................................... 9, 13
fentanyl citrate .................................... 9
fentanyl citrate/pf .............................. 12
FENTORA ........................................ 10
FERAHEME ................................... 173
FERIVA .......................................... 174
FERIVA FA..................................... 170
FERRALET 90 ............................... 170
FERRIPROX .................................. 127
FERRLECIT ................................... 173
ferrous fumarate/folic acid .............. 166
ferrous sulfate/vit c/fa ..................... 166
FETZIMA .......................................... 39
FEXMID.......................................... 163
fexofenadine hcl ............................... 46
fexofenadine/pseudoephedrine ........ 46
FIBRICOR ........................................ 76
FIFTY50 SAFETY SEAL LANCETS
................................................... 102
FIFTY50 TEST STRIP ................... 109
FILTER PAD .................................... 98
FILTER, VALVE SET FOR LL AND LC
..................................................... 98
FILTERS REPLACEMENT .............. 98
FINACEA ......................................... 87
FINACEA PLUS ............................... 89
finasteride .............................. 143, 150
FINE 30 UNIVERSAL LANCETS ... 102
FINGERSTIX ................................. 102
FIORICET ........................................ 10
FIORICET WITH CODEINE ............. 10
FIORINAL ........................................ 10
FIORINAL WITH CODEINE #3 ........ 10
FIRAZYR.......................................... 72
FIRMAGON...................................... 31
FIRST-BXN ...................................... 44
FIRST-DUKE'S ................................ 44
FIRST-HYDROCORTISONE ........... 93
FIRST-LANSOPRAZOLE............... 122
FIRST-MARY'S ................................ 44
FIRST-MOUTHWASH BLM ............. 85
FIRST-OMEPRAZOLE................... 122
FIRST-PROGESTERONE VGS 100
................................................... 134
FIRST-PROGESTERONE VGS 200
................................................... 134
FIRST-PROGESTERONE VGS 25 134
FIRST-PROGESTERONE VGS 400
................................................... 134
FIRST-PROGESTERONE VGS 50 134
FIRST-TESTOSTERONE .............. 128
FIRST-TESTOSTERONE MC........ 128
fish oil/om-3/dl-e/fa/b6-b12............. 150
FLAGYL ........................................... 20
FLAGYL ER ..................................... 20
FLAREX ......................................... 120
flavoxate hcl ................................... 126
FLEBOGAMMA DIF ....................... 137
flecainide acetate ............................. 69
FLECTOR ........................................ 15
FLEXBUMIN .................................... 63
FLEXICHAMBER ............................. 98
FLOLAN ......................................... 164
FLOMAX ........................................ 127
FLONASE ...................................... 121
FLO-PRED ..................................... 131
FLOVENT DISKUS ........................ 158
FLOVENT HFA .............................. 158
FLOW-EZE .................................... 105
floxuridine......................................... 31
FLUARIX QUAD 2015-2016 .......... 139
FLUBLOK 2015-2016..................... 139
FLUCELVAX 2015-2016 ................ 139
fluconazole ....................................... 44
fluconazole in nacl,iso-osm .............. 45
I-9
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
flucytosine ........................................44
fludarabine phosphate ......................31
fludrocortisone acetate ...................130
FLULAVAL QUAD 2015-2016 ........139
FLUMADINE.....................................56
flumazenil .........................................79
FLUMIST QUAD 2015-2016...........139
flunisolide .......................................120
fluocinolone acetonide ......................92
fluocinolone acetonide oil ...............120
fluocinolone/shower cap ...................92
fluocinonide ......................................92
fluorometholone ..............................120
FLUOROPLEX .................................87
fluorouracil ..................................31, 86
fluoxetine hcl ..............................39, 40
FLUOXETINE HCL ...........................40
fluoxymesterone .............................128
fluphenazine decanoate ...................54
fluphenazine hcl .........................53, 54
flurazepam hcl ..................................18
flurbiprofen .......................................13
flurbiprofen sodium .........................120
flutamide ...........................................27
fluticasone propionate ..............92, 120
FLUTTER .........................................98
fluvastatin sodium .............................76
FLUVIRIN 2015-2016 .....................139
fluvoxamine maleate ..................39, 40
FLUZONE 2015-2016 ....................139
FLUZONE HIGH-DOSE 2015-2016
...................................................139
FLUZONE INTRADERM QUAD 201516 ...............................................139
FLUZONE QUAD 2015-2016 .........139
FML ................................................121
FML FORTE ...................................120
FML S.O.P......................................120
FOCALIN ..........................................79
FOCALIN XR ....................................79
FOLGARD OS ................................170
FOLGARD RX ................................170
folic acid .................................166, 173
folic acid/b complex and c no.17 ....166
folic acid/vit bcomp,c ......................166
folic acid/vit bcomp,c/cu/znox .........166
FOLLISTIM AQ.......................132, 133
FOLOTYN ........................................32
FOLPACE RX.................................168
FOLTRATE.....................................170
FOLTX ............................................174
fomepizole ......................................147
fondaparinux sodium ........................58
FORA D10 ......................................109
FORA D15C ...................................109
FORA D15G ...................................109
FORA D15Z....................................109
FORA D20 ......................................109
FORA G20 ..................................... 109
FORA G30A ................................... 109
FORA G71A ................................... 109
FORA G90 ..................................... 109
FORA LANCETS ............................ 102
FORA TEST STRIP ....................... 109
FORA V10 ...................................... 109
FORA V10-V12-D10-D20 ............... 109
FORA V12 ...................................... 109
FORA V20 ...................................... 109
FORA V22 ...................................... 109
FORA V30A ................................... 109
FORACARE GD20 ......................... 110
FORACARE GD40 ......................... 110
FORACARE GD40A ...................... 110
FORACARE GD40B ...................... 110
FORACARE LANCETS .................. 102
FORADIL........................................ 159
FORANE ........................................ 126
FORFIVO XL .................................... 40
formaldehyde ................................. 150
FORMALDEHYDE ......................... 150
FORMA-RAY.................................. 150
FORTAMET ..................................... 42
FORTAVIT ..................................... 170
FORTAZ ........................................... 22
FORTEO ........................................ 142
FORTESTA .................................... 128
FORTICAL ..................................... 142
FOSAMAX...................................... 142
FOSAMAX PLUS D ........................ 142
foscarnet sodium .............................. 56
FOSCAVIR ....................................... 56
fosinopril sodium .............................. 68
fosinopril/hydrochlorothiazide ........... 68
fosphenytoin sodium ........................ 38
FOSRENOL ................................... 125
FOSTEUM...................................... 150
FOSTEUM PLUS ........................... 158
FOVEX ........................................... 150
FRAGMIN......................................... 58
FREAMINE HBC .............................. 66
FREAMINE III................................... 66
FREESTYLE FLASH SYSTEM ...... 110
FREESTYLE FREEDOM ............... 110
FREESTYLE FREEDOM LITE ....... 110
FREESTYLE INSULINX ................. 110
FREESTYLE INSULINX TEST
STRIPS ...................................... 110
FREESTYLE LANCETS ................. 102
FREESTYLE LITE TEST STRIPS .. 110
FREESTYLE SIDEKICK II.............. 110
FREESTYLE SYSTEM................... 110
FREESTYLE TEST STRIPS .......... 110
FREESTYLE UNISTIK 2 ................ 102
FROVA ............................................. 48
FULYZAQ....................................... 125
FURADANTIN .................................. 20
furosemide ................................. 74, 75
FUSILEV ........................................ 147
FUSION PLUS ............................... 168
FUSION SPRINKLES .................... 168
FUZEON .......................................... 56
FYCOMPA ....................................... 36
G-4 ................................................. 110
gabapentin ....................................... 36
GABITRIL................................... 36, 37
GABLOFEN ................................... 162
galantamine hbr ............................... 38
GALZIN .......................................... 127
GAMASTAN S-D ............................ 137
GAMMAGARD LIQUID .................. 137
GAMMAKED .................................. 137
GAMMAPLEX ................................ 137
GAMUNEX-C ................................. 137
ganciclovir sodium ........................... 58
GANIRELIX ACETATE .................. 146
GARAMYCIN ......................... 118, 119
GARDASIL ..................................... 139
GARDASIL 9 .................................. 139
GASTRINEX NF ............................ 124
GASTROCROM ............................. 124
gatifloxacin ..................................... 118
GAZYVA .......................................... 32
GE100 BLOOD GLUCOSE SYSTEM
................................................... 110
GE100 BLOOD GLUCOSE TEST
STRIP ........................................ 110
GELCLAIR ....................................... 85
GELFILM........................................ 144
GELFOAM ................................. 60, 96
GELFOAM COMPRESSED ............. 96
GELNIQUE .................................... 126
GELX ............................................... 85
gemcitabine hcl ................................ 32
gemfibrozil........................................ 76
GEMZAR.......................................... 32
GENADUR ..................................... 110
GENERESS FE ............................... 83
genistein/cit zn bisgly/vit d3............ 150
GENOTROPIN ............................... 132
gentamicin in nacl, iso-osm .............. 19
gentamicin sulfate .............. 19, 90, 118
gentamicin sulfate/pf ........................ 19
gentian viol/brlnt grn/proflav ............. 44
GEODON ......................................... 54
GIAZO ............................................ 140
GILENYA ....................................... 146
GILOTRIF ........................................ 28
GILPHEX TR.................................... 84
GLASSIA........................................ 161
glatiramer acetate .......................... 145
GLEEVEC ........................................ 28
GLEOSTINE .................................... 35
GLIADEL .......................................... 32
glimepiride........................................ 43
I-10
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
glipizide ............................................43
glipizide/metformin hcl ......................43
GLUCAGEN ...................................144
GLUCAGON EMERGENCY KIT ....144
GLUCO NAVII ................................110
GLUCOCARD 01 ...........................110
GLUCOCARD 01 SENSOR PLUS .110
GLUCOCARD 01-MINI ...................110
GLUCOCARD EXPRESSION ........110
GLUCOCARD VITAL .....................110
GLUCOCARD VITAL SENSOR .....110
GLUCOCARD X-SENSOR .............110
GLUCOCOM ..................................102
GLUCOCOM BLOOD GLUCOSE ..110
GLUCOCOM GLUCOSE ................110
GLUCOCOM LANCETS .................102
GLUCOLAB ....................................110
GLUCOLET 2 .................................102
GLUCOPHAGE ................................42
GLUCOPHAGE XR ..........................42
GLUCOSE TEST STRIP ................110
GLUCOSOURCE ...........................102
GLUCOTROL ...................................43
GLUCOTROL XL ..............................43
GLUCOVANCE ................................43
GLUMETZA ......................................42
GLUTARALDEHYDE .....................114
glyburide ...........................................43
glyburide,micronized ........................43
glyburide/metformin hcl ....................43
GLYCATE.......................................125
glycine urologic solution .................141
glycopyrrolate .........................123, 124
GLYNASE ........................................43
GLYSET ...........................................42
GLYTACTIN 10 PE BETTERMILK ...66
GLYTACTIN 15 PE BETTERMILK ...66
GLYXAMBI .......................................41
GMATE...........................................102
GMATE TEST STRIPS...................110
GMATE VOICE METER .................110
GOLYTELY ....................................125
GONAL-F .......................................133
GONAL-F RFF ...............................133
GONAL-F RFF REDI-JECT ............133
GORDOFILM....................................87
GORDO-UREA .................................87
GRAFIX CORE ...............................110
GRAFIX PRIME ..............................110
GRALISE ..........................................38
granisetron hcl ............................50, 51
granisetron hcl/pf ..............................51
GRANIX............................................59
GRASTEK ......................................144
GRIFULVIN V ...................................44
griseofulvin ultramicrosize ................44
griseofulvin, microsize ......................44
GRIS-PEG ........................................44
guaifenesin/codeine phosphate........ 83
guaifenesin/dyphylline .................... 160
guanfacine hcl ............................ 67, 79
guanidine hcl .................................. 144
GUARDIAN REAL-TIME ................ 110
GUARDIAN RT STARTER KIT ...... 111
GYNAZOLE 1................................... 47
H.P. ACTHAR ................................ 150
HAEMOLANCE, RETRACTABLE .. 102
HALAVEN ........................................ 32
HALCION ......................................... 18
HALDOL ........................................... 54
HALDOL DECANOATE 100............. 54
HALDOL DECANOATE 50............... 54
halobetasol propionate ..................... 92
HALOG............................................. 93
HALONATE ...................................... 94
HALONATE PAC ............................. 92
haloperidol........................................ 53
haloperidol decanoate ...................... 54
haloperidol lactate ...................... 53, 54
HARVONI ......................................... 56
HAVRIX .......................................... 139
hc/pramoxine hcl/chloroxylenol ..... 120,
121
HEALTHPRO GLUCOSE MONITOR
................................................... 111
HEALTHPRO TEST STRIPS ......... 111
HEALTHY ACCENTS UNILET
LANCET ..................................... 103
HECORIA ....................................... 135
HECTOROL ................................... 142
HELIXATE FS .................................. 61
HEMABATE ................................... 147
HEMATRON-AF ............................. 171
HEMOCYTE PLUS ........................ 171
HEMOCYTE-F ............................... 171
HEMOFIL M ..................................... 61
HEPAGAM B .................................. 137
heparin sod,porcine/0.9 % nacl ........ 58
heparin sod,pork in 0.45% nacl ........ 59
HEPARIN SODIUM IN 0.45% NACL 59
heparin sodium,porcine .................... 59
heparin sodium,porcine/d5w ............ 59
heparin sodium,porcine/ns/pf ........... 59
heparin sodium,porcine/pf ................ 59
HEPATAMINE .................................. 66
HEPATASOL.................................... 66
HEPSERA ........................................ 57
HERCEPTIN .................................... 32
HESPAN ........................................ 154
hetastarch in 0.9 % nacl ................. 154
HETLIOZ ........................................ 163
HEXALEN ........................................ 27
HEXTEND LACTATED
ELECTROLYTE ......................... 154
HIPREX ............................................ 20
HIZENTRA ..................................... 136
homatropine hbr ............................. 116
HORIZANT....................................... 37
HPR ............................................... 111
HPR PLUS ..................................... 111
HUMALOG ....................................... 42
HUMALOG KWIKPEN U-100 ........... 42
HUMALOG KWIKPEN U-200 ........... 42
HUMALOG MIX 50-50 ..................... 42
HUMALOG MIX 50-50 KWIKPEN .... 42
HUMALOG MIX 75-25 ..................... 42
HUMALOG MIX 75-25 KWIKPEN .... 42
HUMATE-P ...................................... 61
HUMATROPE ................................ 132
HUMIRA ......................................... 136
HUMIRA PEN ................................ 136
HUMIRA PEN CROHN'S-UC-HS ... 136
HUMULIN 70/30 KWIKPEN ............. 42
HUMULIN 70-30 .............................. 42
HUMULIN N ..................................... 42
HUMULIN N KWIKPEN.................... 42
HUMULIN R ..................................... 43
HUMULIN R U-500 .......................... 43
HYALGAN ...................................... 147
HYCAMTIN ................................ 28, 32
HYCET ............................................. 10
hydralazine hcl ........................... 72, 73
HYDREA .......................................... 28
HYDRO 35 ....................................... 89
HYDRO 40 ....................................... 87
hydrochlorothiazide .......................... 74
hydrocodone bit/homatrop me-br ..... 83
hydrocodone/acetaminophen ....... 9, 10
hydrocodone/chlorphen p-stirex ....... 83
hydrocodone/ibuprofen ................ 9, 13
hydrocort/pramoxin/emol/pram#1 .... 92
hydrocort/pramoxn/skn clnsr#16 ...... 93
hydrocortisone ................... 92, 93, 130
hydrocortisone acetate ..................... 92
hydrocortisone acetate/aloe v .......... 92
hydrocortisone acetate/urea............. 93
hydrocortisone butyrate.................... 92
hydrocortisone sod succinate......... 131
hydrocortisone valerate .................... 92
hydrocortisone/iodoquinol ................ 92
hydrocortisone/lidocaine/aloe..... 87, 94
hydrocortisone/pramoxine ................ 92
hydromorphone hcl .......... 9, 10, 12, 13
hydromorphone hcl/pf ...................... 12
hydroquinone ................................... 89
hydroxocobalamin .......................... 173
hydroxychloroquine sulfate .............. 51
hydroxyurea ..................................... 27
hydroxyzine hcl ...................... 143, 147
hydroxyzine pamoate ............. 143, 144
HYLASE ......................................... 144
HYLATOPIC................................... 111
HYLATOPIC PLUS ........................ 111
HYLENEX ...................................... 115
I-11
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
hyoscyamine sulfate .......................123
HYPERHEP B S-D .........................137
HYPERLYTE CR ............................154
HYPERRAB S-D ............................137
HYPERRHO S-D ............................137
HYPER-SAL ...................................160
HYPERTENSA ...............................150
HYPERTET S-D .............................137
HYPODERMIC NEEDLE ................105
HYQVIA ..........................................136
HYSINGLA ER .................................13
HYZAAR ...........................................68
ibandronate sodium ........................142
IBG-STAR ......................................111
IBRANCE .........................................28
IBUDONE .........................................13
ibuprofen ..........................................13
ibuprofen/oxycodone hcl ....................9
ibutilide fumarate ..............................70
ICLUSIG ...........................................28
IDAMYCIN PFS ................................32
idarubicin hcl ....................................32
IFEX .................................................32
ifosfamide .........................................32
ifosfamide/mesna .............................32
ILARIS ............................................137
ILEVRO ..........................................120
ILOTYCIN .......................................118
IMBRUVICA .....................................28
IMDUR..............................................78
imipenem/cilastatin sodium ..............24
imipramine hcl ..................................39
imipramine pamoate .........................39
imiquimod .........................................86
IMITREX ...........................................48
IMOGAM RABIES-HT ....................137
IMOVAX RABIES VACCINE ..........139
IMURAN .........................................135
IN-CHECK DIAL ...............................98
IN-CHECK NASAL WITH MASK ......98
IN-CHECK ORAL .............................98
INCIVEK ...........................................56
INCONTROL SUPER THIN LANCETS
...................................................103
INCONTROL ULTRA THIN LANCETS
...................................................103
INCRELEX .....................................132
INCRUSE ELLIPTA ........................159
indapamide .......................................74
INDERAL LA ....................................71
INDICLOR ......................................153
INDIUM IN-111 DTPA ....................114
INDOCIN ..........................................14
indomethacin ....................................13
indomethacin sodium .......................14
INFANRIX DTAP ............................139
INFASURF .....................................160
INFED.............................................173
INFINITY ........................................ 111
INFINITY TEST STRIPS ................ 111
INFUMORPH ................................... 12
INFUVITE ....................................... 173
INFUVITE ADULT .......................... 173
INJECT EASE LANCETS............... 103
INJECTAFER ................................. 173
INLYTA............................................. 28
INNOPRAN XL ................................. 71
INNOSPIRE DELUXE ...................... 98
INNOSPIRE ELEGANCE ................. 98
INNOSPIRE ESSENCE ................... 98
INNOSPIRE MINI ............................. 98
INNOSPIRE REPLACEMENT FILTER
..................................................... 98
INOVA .............................................. 87
INOVA 4-1 ........................................ 87
INOVA 8-2 ........................................ 87
INSPIRACHAMBER ......................... 98
INSPIRATION .................................. 99
INSPIRATION ELITE ................. 98, 99
INSPIRATION ELITE FILTER .......... 98
INSPIREASE.................................... 99
INSPRA ............................................ 77
INTEGRA F .................................... 171
INTEGRA NEEDLE ........................ 105
INTEGRA PLUS ............................. 171
INTEGRILIN ..................................... 62
INTELENCE ..................................... 55
INTERMEZZO ................................ 163
INTRALIPID ..................................... 66
INTRON A ........................................ 57
INTUNIV ........................................... 79
INVACARE LANCETS ................... 103
INVANZ ............................................ 24
INVEGA............................................ 55
INVEGA SUSTENNA ....................... 54
INVEGA TRINZA .............................. 54
INVIRASE ........................................ 55
INVOKAMET .................................... 41
INVOKANA....................................... 41
iodine/potassium iodide .................... 86
IONOSOL B WITH DEXTROSE 5%
................................................... 155
IONOSOL MB-DEXTROSE 5% ..... 155
IOPIDINE ....................................... 117
IPOL ............................................... 139
ipratropium bromide ............... 116, 159
ipratropium/albuterol sulfate ........... 159
IPRIVASK......................................... 58
irbesartan ......................................... 67
irbesartan/hydrochlorothiazide ......... 67
IRESSA ............................................ 28
irinotecan hcl .................................... 32
iron ag and fum/c/fa/mv cmb11/ca-t
................................................... 168
iron ag/c/b12/ca/suc.acid/stom ....... 168
iron aspgly and ps/c/b12/fa/ca/suc . 168
iron aspgly/c/b12/fa/ca-th/suc ........ 169
iron bg and ps/vit c/b12/fa/ca thr .... 166
iron dextran complex ...................... 173
iron fum and ag/c/b12/fa/ca/succ ... 169
iron fum and p/fa/vit b and c no.9 ... 166
iron fum and polysac#1/fa/mv no.18
................................................... 166
iron fum and ps cmp/fa/vit c/b3 ...... 166
iron fumarate/vit c/vit b12/fa ........... 166
iron polysac/iron heme/fa/b12 ........ 169
iron ps cmplx/vit b12/fa .................. 166
iron, carb and gluc/fa/b12/c/dss ..... 171
iron, carbonyl/fa/c/b-6/b12/zn ......... 167
iron,carb/dss/b12if/fa/mv-mn .......... 167
iron/fa/b12/c/docusate sodium ....... 169
iron/fa/vit bcomp,c/minerals ........... 167
iron/liver ext/vit bcomp,c/min .......... 167
IROSPAN ....................................... 171
ISENTRESS..................................... 55
ISOCHRON...................................... 77
isoflurane ....................................... 126
ISOLYTE H WITH DEXTROSE ..... 155
ISOLYTE M WITH DEXTROSE ..... 155
ISOLYTE P WITH DEXTROSE ...... 155
ISOLYTE S .................................... 155
isomethept/dichlphn/acetaminop ...... 47
isomethepten/caf/acetaminophen ... 47,
48
isoniazid ..................................... 49, 50
ISOPTO ATROPINE ...................... 117
ISOPTO CARBACHOL .................. 152
ISOPTO CARPINE ........................ 152
ISOPTO HOMATROPINE .............. 117
ISOPTO HYOSCINE ...................... 116
ISORDIL........................................... 78
ISORDIL TITRADOSE ..................... 78
isosorbide dinitrate ..................... 77, 78
isosorbide mononitrate ..................... 77
isotretinoin........................................ 89
isoxsuprine hcl ................................. 72
isradipine.......................................... 74
ISTALOL ........................................ 152
ISTODAX ......................................... 32
ISUPREL........................................ 160
itraconazole...................................... 44
ivermectin......................................... 51
IXEMPRA ......................................... 32
IXINITY ............................................ 61
JAKAFI ............................................. 29
JALYN ............................................ 145
JANUMET ........................................ 41
JANUMET XR .................................. 41
JANUVIA .......................................... 41
JARDIANCE ..................................... 41
JENTADUETO ................................. 41
JETREA ......................................... 117
JEVANTIQUE ................................ 130
JEVANTIQUE LO ........................... 130
I-12
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
JEVTANA .........................................32
JUBLIA .............................................45
JUXTAPID ........................................77
KABIVEN ..........................................66
KADCYLA.........................................33
KADIAN ............................................10
KALBITOR......................................147
KALETRA .........................................55
KALYDECO ....................................160
KAPVAY ...........................................80
KAYEXALATE ................................124
KAZANO...........................................42
KCENTRA ........................................61
KEDBUMIN ......................................63
KEFLEX............................................21
KENALOG ........................................93
KENALOG-10 .................................131
KENALOG-40 .................................131
KENDALL .......................................145
KEPIVANCE ...................................147
KEPPRA .....................................37, 38
KEPPRA XR .....................................37
KERAFOAM .....................................87
KERALAC.........................................87
KERALYT .........................................87
KEROL .............................................87
KERYDIN .........................................45
KETALAR .......................................126
ketamine hcl ...................................126
ketamine hcl in 0.9 % nacl ..............126
KETEK..............................................23
KETOCON........................................44
ketoconazole ..............................44, 45
KETODAN ........................................45
KETONE.........................................164
KETONE CARE ..............................164
ketoprofen ..................................13, 14
ketorolac tromethamine ...... 13, 14, 120
KETOSTIX REAGENT ...................164
KEYNOTE ......................................111
KEYNOTE PRO .............................111
KEYTRUDA ......................................33
KHEDEZLA ......................................40
KINERET ........................................136
KINNEY BRAND LANCETS ...........103
KINRIX ...........................................139
KLARON...........................................91
KLONOPIN .......................................18
KLOR-CON ....................................153
KLOR-CON 8 .................................153
KOATE-DVI ......................................61
KOGENATE FS ................................61
KOMBIGLYZE XR ............................42
KORLYM ..........................................42
K-PHOS M.F. .................................153
K-PHOS NEUTRAL ........................153
K-PHOS NO.2 ................................153
K-PHOS ORIGINAL .......................153
KRISTALOSE................................. 123
KRYSTEXXA .................................. 115
K-TAB ER....................................... 153
KUVAN ........................................... 115
KYNAMRO ....................................... 77
KYPROLIS ....................................... 33
l.acidophilus/b.bifidum and longum 124
labetalol hcl ................................ 70, 71
LAC-HYDRIN ................................... 89
LACRISERT ................................... 117
LACTATED RINGERS ........... 141, 155
lactic acid ......................................... 86
lactulose ......................................... 123
LAMICTAL.................................. 36, 37
LAMICTAL BLUE ............................. 37
LAMICTAL GREEN .......................... 37
LAMICTAL ODT ............................... 37
LAMICTAL ODT BLUE ..................... 37
LAMICTAL ODT GREEN ................. 37
LAMICTAL ODT ORANGE............... 37
LAMICTAL ORANGE ....................... 37
LAMICTAL XR .................................. 37
LAMICTAL XR BLUE ....................... 37
LAMICTAL XR GREEN .................... 37
LAMICTAL XR ORANGE ................. 37
LAMISIL ........................................... 44
lamivudine ........................................ 55
lamivudine/zidovudine ...................... 55
lamotrigine........................................ 36
LANCETS....................................... 103
LANCETS THIN ............................. 103
LANCETS ULTRA THIN................. 103
LANOXIN ................................... 72, 73
LANOXIN PEDIATRIC ..................... 73
lansoprazole ................................... 122
lansoprazole/amoxiciln/clarith ........ 122
LANTUS ........................................... 43
LANTUS SOLOSTAR ...................... 43
LASIX ............................................... 75
LASTACAFT .................................. 116
latanoprost ..................................... 151
LATISSE ........................................ 118
LATUDA ........................................... 54
LAZANDA......................................... 11
LC D NEBULIZER SET .................... 99
LC PLUS .......................................... 99
LC SPRINT NEBULIZER ................. 99
LC STAR .......................................... 99
leflunomide ..................................... 135
LENVIMA ......................................... 28
LESCOL ........................................... 76
LESCOL XL...................................... 76
LETAIRIS ....................................... 164
letrozole............................................ 27
LETS KIT.......................................... 17
leucovorin calcium .......... 143, 144, 147
LEUKERAN ...................................... 27
LEUKINE .......................................... 59
leuprolide acetate ............................. 33
LEVACET......................................... 14
levalbuterol hcl ............................... 159
LEVAQUIN ................................. 25, 26
LEVATOL ......................................... 70
LEVBID ............................................ 35
LEVEMIR ......................................... 43
LEVEMIR FLEXTOUCH................... 43
levetiracetam.............................. 36, 38
levetiracetam in nacl (iso-os) ........... 38
LEVITRA ........................................ 164
levobunolol hcl ....................... 151, 152
levocarnitine ........................... 143, 148
levocarnitine (with sugar) ............... 143
levocetirizine dihydrochloride ........... 46
levofloxacin ........................ 25, 26, 118
levofloxacin/d5w ............................... 26
levoleucovorin calcium ................... 148
levomefolate calcium...................... 174
levomefolate/algal oil ..................... 174
levomefolate/b6/b12/algal oil.......... 174
levonorgestrel .................................. 80
levonorgestrel-ethin estradiol ........... 80
LEVOPHED BITARTRATE .............. 73
levorphanol tartrate .......................... 10
levothyroxine sodium ............. 134, 135
LEVOXYL....................................... 134
LEVSIN .......................................... 124
LEVSIN-SL..................................... 124
LEVULAN......................................... 88
LEXAPRO ........................................ 39
LEXIVA ............................................ 56
LIALDA........................................... 140
LIBERTY BLOOD GLUCOSE METER
................................................... 111
LIBERTY MONITOR ...................... 111
LIBERTY TEST STRIPS ................ 111
LIBRAX ............................................ 35
lidocaine ........................................... 15
lidocaine hcl ............................... 15, 16
lidocaine hcl/d5w/pf .......................... 70
lidocaine hcl/d7.5w/pf ....................... 70
lidocaine hcl/epinephrine.................. 16
lidocaine hcl/epinephrine bit ............. 16
lidocaine hcl/epinephrine/pf.............. 16
lidocaine hcl/pf ........................... 16, 70
lidocaine/hydrocortisone ac........ 15, 92
lidocaine/prilocaine .......................... 15
lidocaine/tetracaine .......................... 15
LIDOCAINE-EPINEPHRINE ............ 16
LIDODERM ...................................... 15
LIDORX............................................ 15
LIDOVIR........................................... 89
LIFESHIELD BLUNT CANNULA .... 105
LIMBREL........................................ 150
LIMBREL250 .................................. 150
LIMBREL500 .................................. 150
LINCOCIN ........................................ 20
I-13
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
lindane ..............................................96
linezolid ............................................20
LINZESS ........................................124
LIORESAL INTRATHECAL ............162
liothyronine sodium ................134, 135
lipase/protease/amylase .................114
LIPICHOL 540 ..................................77
LIPITOR ...........................................77
LIPOFEN ..........................................76
LIPOSYN II .......................................66
LIPOSYN III ......................................66
LIPTRUZET ......................................77
lisinopril ............................................68
lisinopril/hydrochlorothiazide ............68
LISTER-V .......................................150
LITE TOUCH ..................................103
LITEAIRE .........................................99
LITETOUCH .....................................99
lithium carbonate ..............................78
lithium citrate ....................................78
LITHOBID .........................................79
LITHOSTAT....................................144
LIVALO .............................................77
LMD 10% WITH 5% DEXTROSE ...155
lmfol ca/acetyl/mb12/algal oil..........174
l-norgest/e.estradion-e.estrad...........81
LO LOESTRIN FE ............................83
LOCOID............................................93
LODOSYN ........................................52
LOESTRIN .......................................82
LOESTRIN FE ..................................82
LOFIBRA ..........................................76
LOMOTIL........................................124
lomustine ..........................................27
LONSURF ........................................28
loperamide hcl ................................123
LOPID...............................................76
LOPRESSOR ...................................71
LOPRESSOR HCT ...........................71
LOPROX ..........................................44
lorazepam.........................................18
LORTAB .......................................9, 13
LORTUSS EX...................................84
LORZONE ......................................163
losartan potassium ...........................67
losartan/hydrochlorothiazide.............67
LOSEASONIQUE .............................82
LOTEMAX ......................................120
LOTENSIN .......................................69
LOTENSIN HCT ...............................69
LOTREL ...........................................74
LOTRISONE.....................................44
LOTRONEX....................................124
lovastatin ..........................................76
LOVAZA ...........................................77
LOVENOX ........................................58
loxapine succinate ............................53
LOXITANE........................................54
LUCENTIS ..................................... 117
LUER-LOK SYRINGE-NEEDLE ..... 105
LUFYLLIN ...................................... 159
LUGOL'S .......................................... 86
LUMIGAN ....................................... 152
LUMINAL SODIUM .......................... 38
LUMIZYME..................................... 115
LUNESTA....................................... 163
LUPRON DEPOT ............................. 33
LUPRON DEPOT-PED .................. 133
LUSEDRA ...................................... 126
LUSTRA ........................................... 90
LUVERIS ........................................ 133
LUVOX CR ....................................... 40
LUXIQ .............................................. 93
LUZU ................................................ 45
LYNPARZA ...................................... 35
LYRICA ............................................ 37
LYSIPLEX PLUS ............................ 167
LYSODREN ..................................... 27
LYSTEDA ......................................... 62
M.V.I. ADULT ................................. 173
M.V.I. PEDIATRIC .......................... 173
MACROBID ...................................... 20
MACRODANTIN .............................. 20
MACUGEN ..................................... 117
mafenide acetate .............................. 86
magnesium chloride ....................... 155
magnesium sulf in 0.45% nacl........ 155
magnesium sulfate ......................... 155
magnesium sulfate in water............ 155
magnesium sulfate/d5w.................. 155
MAKENA ........................................ 134
MALARONE ..................................... 52
malathion.......................................... 96
manganese chloride ....................... 155
manganese sulfate ......................... 155
mannitol............................................ 75
mannitol/sorbitol solution ................ 141
maprotiline hcl .................................. 39
MARCAINE ...................................... 16
MARCAINE-EPINEPHRINE ............. 16
MARINOL ......................................... 50
MARPLAN ........................................ 39
MARQIBO ........................................ 33
MASK SET WITH Y-PIECE.............. 99
MASK VORTEX ............................... 99
MATULANE...................................... 27
MAVIK .............................................. 69
MAXALT ........................................... 49
MAXALT MLT................................... 48
MAXARON FORTE ........................ 171
MAXFE ........................................... 174
MAXIDEX ....................................... 120
MAXIFED CD ................................... 84
MAXIFLU CD ................................... 84
MAXIFLU CDX ................................. 84
MAXIMA ......................................... 111
MAXIPIME ....................................... 23
MAXITROL..................................... 119
MAXZIDE ......................................... 75
MAXZIDE-25 MG ............................. 75
meclizine hcl .................................... 51
meclofenamate sodium .................... 14
mecobal/levomefolat ca/b6 phos .... 174
MEDIHONEY ................................. 111
MEDI-LANCE ................................. 103
MEDISENSE THIN LANCETS ....... 103
MEDLANCE PLUS ......................... 103
MEDROL........................................ 130
medroxyprogesterone acetate ....... 134
MEDSAVER ................................... 105
mefenamic acid ................................ 13
mefloquine hcl .................................. 51
MEFOXIN......................................... 22
MEGACE ....................................... 134
MEGACE ES.................................. 134
megestrol acetate .................... 27, 134
MEKINIST ........................................ 28
meloxicam .................................. 13, 14
melphalan hcl ................................... 33
memantine hcl .................................. 38
MEMBRANEBLUE ......................... 151
MENACTRA ................................... 139
M-END MAX D ................................. 84
MENEST ........................................ 129
MENHIBRIX ................................... 139
MENOMUNE-A-C-Y-W-135 ........... 139
MENOPUR..................................... 132
MENOSTAR................................... 129
MENTAX .......................................... 44
MENVEO A-C-Y-W-135-DIP .......... 139
MENVEO MENA COMPONENT .... 140
MENVEO MENCYW-135
COMPONENT ............................ 140
meperidine hcl ........................ 9, 10, 12
meperidine hcl/pf .............................. 12
MEPHYTON................................... 169
mepivacaine hcl/pf ........................... 16
meprobamate ................................. 144
MEPRON ......................................... 52
mercaptopurine ................................ 27
meropenem ...................................... 24
meropenem-0.9% sodium chloride .. 24
MERREM ......................................... 24
mesalamine.................................... 140
mesna ............................................ 148
MESNEX ................................ 145, 148
MESTINON ............................ 144, 145
METADATE CD ............................... 79
METANX ........................................ 174
metaproterenol sulfate ................... 159
METASTRON ................................ 153
metaxalone .................................... 161
metformin hcl ............................. 41, 42
methadone hcl ............................. 9, 12
I-14
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
METHADOSE...................................10
methamphetamine hcl ......................78
METHAVER ...................................171
methazolamide ...............................152
methen/m-blue/sal/na phos/hyos .....20,
127
methen/sod phos/meth blue/hyos .....19
methenam/me blue/ba/salicy/hyo ...127
methenamine hippurate ....................19
methenamine mandelate ..................19
methimazole ...................................134
METHITEST ...................................128
methocarbamol .......................161, 162
methotrexate sodium ..................27, 33
methotrexate sodium/pf ....................33
methoxsalen, rapid ...........................86
methscopolamine bromide .............123
methyclothiazide ...............................75
methyldopa .......................................67
methyldopa/hydrochlorothiazide .......67
methyldopate hcl ..............................67
methylene blue ...............................148
methylergonovine maleate .....144, 148
METHYLIN .......................................79
methylphenidate hcl .........................78
methylprednisolone ........................130
methylprednisolone acetate............131
methylprednisolone sod succ .........131
methyltestosterone .........................128
methyltetrahydrofolate glucosa.......174
metipranolol ....................................152
metoclopramide hcl ........ 123, 124, 125
metolazone .......................................74
metoprolol succinate ........................70
metoprolol tartrate ......................70, 71
metoprolol/hydrochlorothiazide.........70
METOZOLV ODT ...........................125
METROCREAM ...............................91
METROGEL .....................................91
METROGEL-VAGINAL.....................47
METROLOTION ...............................91
metronidazole ....................... 19, 47, 90
metronidazole/sodium chloride .........21
MEVACOR .......................................76
mexiletine hcl....................................69
MIACALCIN ....................................142
MICARDIS ........................................68
MICARDIS HCT ...............................68
miconazole nitrate ............................44
MICRHOGAM ULTRA-FILTERED
PLUS ..........................................137
MICRO ...........................................111
MICRO AIR ......................................99
MICRO ELITE ..................................99
MICRO ELITE REPLACEMENT
FILTER .........................................99
MICRO PLUS ...................................99
MICRO THIN LANCETS.................103
MICROCHAMBER ........................... 99
MICRODOT.................................... 111
MICROGESTIN 24 FE ..................... 83
MICROLET..................................... 103
MICROLET 2.................................. 103
MICROLIFE PEAK FLOW ................ 99
MICROSPACER .............................. 99
MICROZIDE ..................................... 75
midazolam hcl .................................. 18
midazolam hcl in 0.9 % nacl/pf ......... 18
midazolam hcl/pf .............................. 18
midodrine hcl .................................... 67
MIFEPREX ....................................... 41
MIGERGOT...................................... 48
MIGRANAL ...................................... 48
MILLIPRED .................................... 130
MILLIPRED DP .............................. 130
milrinone lactate ............................... 73
milrinone lactate/d5w ....................... 73
MIMYX ........................................... 111
MINASTRIN 24 FE ........................... 82
MINERAL OIL ................................ 144
MINI ELITE FILTER REPLACEMENT
..................................................... 99
MINI PLUS NEBULIZER .................. 99
MINICOMP COMPRESSOR
NEBULIZER ................................. 99
MINIELITE........................................ 99
MINIPRESS ..................................... 67
MINIVELLE .................................... 130
MINI-WRIGHT PEAK FLOW METER
..................................................... 99
MINOCIN.......................................... 26
minocycline hcl ........................... 26, 27
minoxidil ........................................... 78
MIOCHOL-E ................................... 152
MIOSTAT ....................................... 152
MIRAPEX ......................................... 52
MIRAPEX ER ................................... 52
MIRCETTE ....................................... 82
MIRENA ........................................... 83
mirtazapine....................................... 39
MIRVASO......................................... 88
misoprostol ..................................... 122
MISTASSIST .................................... 99
MITIGARE ...................................... 150
mitomycin ......................................... 33
MITOSOL ....................................... 152
mitoxantrone hcl ............................... 33
M-M-R II VACCINE ........................ 140
MOBIC ............................................. 14
modafinil ......................................... 163
MODERIBA ...................................... 58
MODICON ........................................ 82
moexipril hcl ..................................... 68
moexipril/hydrochlorothiazide ........... 68
molindone hcl ................................... 53
molybdenum(ammonium molybdate)
................................................... 155
mometasone furoate ........................ 92
MOMEXIN ........................................ 94
MONAGHAN Z STAT....................... 99
MONDOXYNE NL ............................ 27
MONOCLATE-P ............................... 61
MONODOX ................................ 26, 27
MONOJECT PREFILL ADVANCED 59
MONOJECT SYRINGE .................. 105
MONOLET LANCETS .................... 103
MONOLET THIN LANCETS .......... 103
MONONINE ..................................... 61
MONSEL'S ..................................... 145
montelukast sodium ....................... 158
MONUROL....................................... 19
MORGIDOX ..................................... 27
morphine sulfate .................... 9, 10, 12
MORPHINE SULFATE..................... 10
morphine sulfate/d5w ....................... 12
morphine sulfate/pf .......................... 12
MOTOFEN ..................................... 123
MOUTHPIECE ................................. 99
MOVIPREP .................................... 125
MOXATAG ....................................... 25
MOXEZA ........................................ 119
moxifloxacin hcl ................................ 25
moxifloxacin/sod.ace,sul/water ........ 21
MOZOBIL ......................................... 59
MS CONTIN ..................................... 11
mth/me blue/sod phos/phen/hyos ... 19,
127
MUGARD ......................................... 96
MULTAQ .......................................... 69
MULTICHEW ................................. 171
multivit, iron, min #5, fa .................. 171
multivit, min cmb#20/iron/fa ........... 167
multivitamin with minerals .............. 171
multivitamins with min no.7/fa ........ 167
multivit-min/fa/lycopen/lutein .......... 167
multivits,therap w-fe,hematin ......... 167
mupirocin ......................................... 90
mupirocin calcium ............................ 90
MUSE............................................. 165
MUSTARGEN .................................. 33
mv, min cmb#43/lut/om3/dha/epa .. 174
mv,min #10/fa/d3/alip acid/lut......... 167
MYALEPT ...................................... 150
MYAMBUTOL .................................. 49
MYCAMINE...................................... 45
MYCOBUTIN ................................... 49
mycophenolate mofetil ................... 135
mycophenolate sodium .................. 135
MYDRIACYL .................................. 117
MYFORTIC .................................... 135
MYGLUCOHEALTH ....................... 111
MYGLUCOHEALTH LANCETS ..... 103
MYLERAN........................................ 27
I-15
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
MYOBLOC .....................................148
MYOZYME .....................................115
MYRBETRIQ ..................................126
MYSOLINE .......................................37
NABI-HB .........................................137
nabumetone .....................................13
nadolol ..............................................70
nadolol/bendroflumethiazide.............70
nafcillin in dextrose,iso-osm .............24
nafcillin sodium .................................24
naftifine hcl .......................................44
NAFTIN ............................................44
NAGLAZYME .................................115
nalbuphine hcl ..................................12
NALFON ...........................................14
naloxone hcl .....................................17
naltrexone hcl ...................................17
NAMENDA .......................................38
NAMENDA XR .................................38
NAMZARIC.......................................39
naphazoline hcl ..............................116
NAPRELAN ......................................14
NAPRO.............................................94
NAPRODERM ..................................15
NAPROSYN .....................................14
naproxen ..........................................14
naproxen sodium ..............................14
naratriptan hcl ...................................47
NARDIL ............................................40
NAROPIN .........................................16
NASACORT AQ .............................121
NASCOBAL ....................................171
NASONEB NASAL NEBULIZER ....111
NASONEX ......................................120
NATACYN ......................................119
NATAZIA ..........................................82
nateglinide ........................................41
NATRECOR .....................................73
NATROBA ........................................96
NAVELBINE .....................................33
NEBUPENT ......................................52
NEBUSAL.......................................160
NEEDLE .........................................105
NEEDLES.......................................105
nefazodone hcl .................................39
NEMBUTAL SODIUM.....................163
neo/polymyx b sulf/dexameth .........118
NEOBENZ MICRO ...........................90
neomycin su/baci zn/poly/hc...........118
neomycin su/bacitra/polymyxin.......118
neomycin su/polymyx b sulf..............90
neomycin sulfate ..............................18
neomycin/polymyxin b sulf/hc .118, 119
neomycin/polymyxn b/gramicidin ....118
NEOPROFEN...................................15
NEORAL.........................................135
NEOSALUS ....................................111
NEOSALUS CP ..............................111
NEOSPORIN.................................. 119
NEOSPORIN G.U. IRRIGANT ......... 91
neostigmine methylsulfate .............. 148
NEO-SYNALAR ............................... 91
NEO-SYNEPHRINE ......................... 67
NEOTIC.......................................... 119
NEPHRAMINE ................................. 66
NEPHROCAPS .............................. 167
NEPHROCAPS QT ........................ 171
NEPHRONEX-SL ........................... 172
NEPTAZANE.................................. 152
NESACAINE .................................... 16
NESACAINE-MPF ............................ 16
NESINA ............................................ 42
NESSI SPACER ............................... 99
NEUAC............................................. 91
NEULASTA ...................................... 59
NEUMEGA ....................................... 59
NEUPOGEN..................................... 59
NEUPRO .......................................... 52
NEURONTIN .................................... 37
NEUT ............................................. 155
NEUTEK 2TEK TEST STRIPS ....... 111
NEUTRASAL.................................... 85
NEVANAC ...................................... 120
nevirapine......................................... 55
NEXAVAR ........................................ 28
NEXAVIR ....................................... 148
NEXIUM ................................. 122, 123
NEXIUM I.V. ................................... 122
NEXPLANON ................................... 83
NEXTERONE ................................... 70
niacin ................................................ 76
NIASPAN ......................................... 76
NICADAN ....................................... 172
nicardipine hcl .................................. 74
nicardipine hcl in 0.9% nacl .............. 74
NICAZEL ........................................ 145
NICAZEL FORTE ........................... 145
NICOMIDE ..................................... 172
nifedipine .......................................... 74
NILANDRON .................................... 27
NIMBEX ......................................... 162
nimodipine ........................................ 74
NIPENT ............................................ 33
nisoldipine ........................................ 74
NITHIODOTE ................................. 148
NITRO-BID ....................................... 78
NITRO-DUR ..................................... 78
nitrofurantoin .................................... 19
nitrofurantoin macrocrystal ............... 19
nitrofurantoin monohyd/m-cryst ........ 19
nitroglycerin ...................................... 78
nitroglycerin/d5w .............................. 78
NITROLINGUAL ............................... 78
NITROMIST ..................................... 78
NITRONAL ....................................... 78
NITROPRESS .................................. 73
NITROSTAT..................................... 78
nizatidine ........................................ 122
NIZORAL ......................................... 44
NOKOR ADMIX NEEDLE .............. 106
NORCO............................................ 11
NORDITROPIN FLEXPRO ............ 132
norelgestromin/ethin.estradiol .......... 81
norepinephrine bitartrate .................. 73
noreth-ethinyl estradiol/iron .............. 81
norethindrone ................................... 81
norethindrone acetate .................... 134
norethindrone ac-eth estradiol . 81, 129
norethindrone-e.estradiol-iron .......... 81
norethindrone-ethinyl estrad ............ 81
norethindrone-mestranol .................. 81
norgestimate-ethinyl estradiol .......... 82
norgestrel-ethinyl estradiol ............... 82
NORINYL 1+50 ................................ 82
NORITATE ....................................... 91
NORMOSOL-M AND DEXTROSE . 155
NORMOSOL-R AND DEXTROSE . 155
NORMOSOL-R PH 7.4 .................. 155
NOROXIN ........................................ 25
NORPACE ....................................... 69
NORPACE CR ................................. 69
NORPRAMIN ................................... 40
NOR-Q-D ......................................... 82
NORTHERA ..................................... 67
nortriptyline hcl ................................. 39
NORVASC ....................................... 74
NORVIR ........................................... 55
NOSE CLIP ...................................... 99
NOVA MAX BLOOD GLUCOSE
METER ...................................... 111
NOVA MAX GLUCOSE TEST STRIPS
................................................... 111
NOVA SAFETY LANCETS ............ 103
NOVA SUREFLEX ......................... 103
NOVACORT..................................... 94
NOVAFERRUM ............................. 169
NOVAREL ...................................... 132
NOVOEIGHT ................................... 61
NOVOLIN 70-30 ............................... 43
NOVOLIN N ..................................... 43
NOVOLIN R ..................................... 43
NOVOLOG ....................................... 43
NOVOLOG FLEXPEN...................... 43
NOVOLOG MIX 70-30 ..................... 43
NOVOLOG MIX 70-30 FLEXPEN .... 43
NOVOSEVEN RT ............................ 61
NOXAFIL.................................... 44, 45
NPLATE ......................................... 148
NUCORT.......................................... 94
NUCYNTA........................................ 10
NUCYNTA ER .................................. 11
NUEDEXTA ..................................... 80
NULEV ........................................... 123
I-16
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
NULYTELY WITH FLAVOR PACKS
...................................................125
NUMOISYN ......................................96
NUOX ...............................................88
NUTRESTORE ...............................124
NUTRICAP .....................................172
NUTRILIPID .....................................66
NUTRILYTE ...................................156
NUTRILYTE II ................................155
NUTRIVIT .......................................172
NUTROPIN AQ ..............................132
NUTROPIN AQ NUSPIN ................132
NUVAIL ..........................................111
NUVARING ......................................82
NUVIGIL .........................................163
NUWIQ .............................................61
nystatin .............................................44
NYSTATIN........................................44
nystatin/triamcin ...............................44
OASIS ULTRA..................................96
OBIZUR ............................................61
OCTAGAM .....................................138
OCTAPLAS ......................................63
OCTREOSCAN ..............................161
octreotide acetate ...........................133
OCUCOAT .....................................117
OCUDOX..........................................26
OCUFEN ........................................121
OCUFLOX ......................................119
ODOMZO .........................................35
OFEV..............................................160
OFIRMEV .........................................12
ofloxacin ...................................25, 118
OGEN .............................................130
olanzapine ..................................53, 54
olanzapine/fluoxetine hcl ..................40
OLEPTRO ER ..................................40
olopatadine hcl ...............................116
OLUX................................................94
OLYSIO ............................................56
om-3/calcium/d3/fa/mv cmb 13.......174
om-3/dha/epa/b12/fa/b6/phytost .....167
om-3/dha/epa/d3/b12/fa/b-6/phy ....174
omega-3 acid ethyl esters ................77
omeprazole.....................................122
omeprazole/sodium bicarbonate ....123
OMNARIS.......................................121
OMNIPRED ....................................121
OMNITROPE..................................132
OMONTYS .......................................59
ON CALL EXPRESS METER.........111
ON CALL EXPRESS TEST STRIP 111
ON CALL LANCET .........................103
ON CALL PLUS LANCET...............103
ON CALL PLUS METER ................111
ON CALL PLUS TEST STRIP ........111
ON CALL VIVID METER ................112
ON CALL VIVID PAL ......................112
ON CALL VIVID TEST STRIP ........ 112
ONCASPAR ..................................... 33
ondansetron ..................................... 50
ondansetron hcl ................................ 50
ondansetron hcl/pf ............................ 51
ONE FLOW FVC .............................. 99
ONE WAY MOUTHPIECE ............... 99
ONETOUCH DELICA ..................... 103
ONETOUCH FINEPOINT LANCETS
................................................... 103
ONETOUCH LANCETS ................. 103
ONETOUCH SURESOFT .............. 103
ONETOUCH ULTRA CONTROL
SOLN ......................................... 103
ONETOUCH ULTRA SMART ........ 103
ONETOUCH ULTRA SYSTEM ...... 103
ONETOUCH ULTRA TEST STRIPS
................................................... 103
ONETOUCH ULTRA2 .................... 103
ONETOUCH ULTRALINK .............. 103
ONETOUCH ULTRAMINI .............. 103
ONETOUCH VERIO .............. 103, 104
ONETOUCH VERIO FLEX............. 103
ONETOUCH VERIO IQ .................. 103
ONETOUCH VERIO SYNC............ 103
ONFI................................................. 18
ONGLYZA ........................................ 42
ONMEL ............................................ 45
ON-THE-GO................................... 104
OPANA....................................... 11, 12
OPANA ER....................................... 10
OPDIVO ........................................... 33
opium tincture................................. 123
opium/belladonna alkaloids .............. 10
OPSUMIT ....................................... 164
OPTASE........................................... 88
OPTICHAMBER ............................... 99
OPTICHAMBER DIAMOND ............. 99
OPTIHALER ..................................... 99
OPTIONHOME ................................. 99
OPTIUM ......................................... 112
OPTIUM EZ.................................... 112
OPTIVAR ....................................... 117
OPTUMRX ..................................... 112
ORACEA .......................................... 26
ORACIT.......................................... 153
ORAFATE ...................................... 151
ORALAIR ....................................... 145
ORAP ............................................... 54
ORAPRED ..................................... 131
ORAPRED ODT ............................. 131
ORENCIA ............................... 136, 138
ORENITRAM ER ............................ 164
ORFADIN ....................................... 115
orphenadrine citrate ............... 161, 162
orphenadrine/aspirin/caffeine ......... 161
ORTHO ALL-FLEX ........................... 83
ORTHO EVRA ................................. 82
ORTHO MICRONOR ....................... 82
ORTHO TRI-CYCLEN...................... 82
ORTHO TRI-CYCLEN LO ................ 82
ORTHO-CEPT ................................. 82
ORTHO-CYCLEN ............................ 82
ORTHO-NOVUM ............................. 82
ORTHOVISC.................................. 151
OSENI .............................................. 42
OSMITROL ...................................... 75
OSMOPREP .................................. 125
OSPHENA ..................................... 130
OTEZLA ......................................... 151
OTICIN HC..................................... 121
OTOZIN ......................................... 119
OTREXUP...................................... 151
OVACE PLUS ............................ 88, 91
OVACE PLUS WASH ...................... 88
OVCON-35....................................... 82
OVIDE .............................................. 96
OVIDREL ....................................... 133
oxacillin sodium ................................ 24
oxacillin sodium/dextrose,iso ........... 24
oxaliplatin ......................................... 33
OXANDRIN .................................... 128
oxandrolone ................................... 128
oxaprozin ......................................... 14
oxazepam ........................................ 18
oxcarbazepine .................................. 36
OXECTA .......................................... 13
OXISTAT.......................................... 44
OXSORALEN................................... 88
OXSORALEN-ULTRA ...................... 88
OXTELLAR XR ................................ 38
oxybutynin chloride ........................ 126
OXYCEL .......................................... 60
oxycodone hcl ........................ 9, 10, 11
oxycodone hcl/acetaminophen..... 9, 10
oxycodone hcl/aspirin ........................ 9
OXYCONTIN.................................... 10
oxymorphone hcl ................................ 9
OXYTOCIN .................................... 148
OXYTROL ...................................... 126
OZURDEX ..................................... 117
paclitaxel .......................................... 33
PACNEX .......................................... 88
PACNEX HP .................................... 90
PACNEX LP ..................................... 90
PACNEX MX .................................... 88
PALGIC ............................................ 46
paliperidone ..................................... 55
PAMELOR ....................................... 40
pamidronate disodium .................... 143
PAMINE ......................................... 124
PAMINE FORTE ............................ 124
PAMINE FQ ..................................... 35
PANCREAZE ................................. 114
pancuronium bromide .................... 162
PANDA MASK ............................... 100
I-17
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
PANDEL ...........................................94
PANHEMATIN ................................148
PANRETIN .......................................88
pantoprazole sodium ......................122
papaverine hcl ............................72, 73
PARAFON FORTE DSC ................161
PARAGARD T 380-A .......................83
PARCOPA ........................................52
paregoric ........................................124
PARI SINUS AEROSOL SYSTEM .100
paricalcitol ......................................142
PARICALCITOL .............................143
PARLODEL ......................................52
PARNATE ........................................40
paromomycin sulfate ........................51
paroxetine hcl .............................39, 40
PASER .............................................49
PATADAY.......................................116
PATANASE ....................................117
PATANOL.......................................117
PAXIL .........................................39, 40
PAXIL CR .........................................40
PCE ..................................................23
PEAK-AIR.......................................100
PEDIADERM AF ..............................44
PEDIADERM HC ..............................94
PEDIADERM TA ..............................94
PEDIAPRED...................................131
PEDIARIX.......................................140
PEDIATRIC MASK .........................100
PEDIATRIC PANDA MASK ............100
PEDIPIROX-4...................................45
PEDVAXHIB ...................................140
peg 3350/na sulf,bicarb,cl/kcl .........125
PEGANONE .....................................36
PEGASYS ........................................57
PEGASYS PROCLICK .....................57
PEGINTRON ....................................57
PEGINTRON REDIPEN ...................57
pen g pot/dextrose-water ..................24
pen needle, diabetic .......................104
pen needle, diabetic, safety ............104
penicillin g potassium .......................25
penicillin g procaine ..........................25
penicillin g sodium ............................25
penicillin v potassium .......................24
PENLAC ...........................................44
PENLET PLUS BLOOD SAMPLER104
PENNSAID .......................................15
PENTACEL ....................................140
PENTACEL ACTHIB COMPONENT
...................................................140
PENTAM 300 ...................................52
PENTASA.......................................140
pentazocine hcl/naloxone hcl .............9
pentostatin ........................................34
pentoxifylline.....................................62
PEPCID ..........................................122
PEPCID RPD ................................. 123
p-ephed hcl/chlor-mal/bell alk ........... 46
p-ephed hcl/cod/chlorphenir ............. 83
p-ephed hcl/codeine/guaifen ............ 83
PERCOCET ..................................... 11
PERCODAN ..................................... 11
PERCURA...................................... 151
PERFOROMIST ............................. 159
PERIDEX ......................................... 85
PERIKABIVEN ................................. 66
perindopril erbumine ........................ 68
PERJETA ......................................... 34
permethrin ........................................ 96
perphenazine ................................... 53
perphenazine/amitriptyline hcl .......... 39
PERSANTINE .................................. 62
PERSONAL BEST ......................... 100
PERTZYE....................................... 114
PEXEVA ........................................... 40
PFLEX TRAINER ........................... 100
PHARMACIST CHOICE ................. 112
PHENAGIL ....................................... 46
phenazopyridine hcl ....................... 127
phenelzine sulfate ............................ 39
PHENERGAN ............................ 50, 51
PHENFLU CD .................................. 84
PHENFLU CDX ................................ 84
phenobarb/hyoscy/atropine/scop ..... 35
phenobarbital ................................... 36
phenobarbital sodium ....................... 38
PHENOL .......................................... 86
phenoxybenzamine hcl .................... 67
phentermine hcl................................ 80
phentolamine mesylate .................. 163
phenylephrine hcl ..................... 67, 116
phenylephrine hcl/prometh hcl ......... 46
phenylephrine/brompheniramine ...... 46
phenylephrine/chlorpheniramine ...... 46
PHENYTEK ...................................... 37
phenytoin.......................................... 36
phenytoin sodium ............................. 38
phenytoin sodium extended ............. 36
PHOSLO ........................................ 125
PHOSLYRA.................................... 125
PHOSPHASAL ................................. 19
PHOSPHOLINE IODIDE ................ 152
phosphorus #1 ............................... 153
PHOTOFRIN .................................... 34
PHYSICIANS EZ USE M-PRED .... 148
PHYSIOLYTE................................. 141
PHYSIOSOL .................................. 141
physostigmine salicylate................. 148
phytonadione.................................. 173
PICATO ............................................ 86
PIKO 1............................................ 100
PILLOW MASK .............................. 100
PILLOW MASK FOR CHILDREN ... 100
pilocarpine hcl .......................... 85, 152
pimozide........................................... 53
pindolol............................................. 70
pioglitazone hcl ................................ 41
pioglitazone hcl/glimepiride .............. 42
pioglitazone hcl/metformin hcl .......... 41
piperacillin sodium/tazobactam ........ 25
piroxicam.......................................... 14
PITOCIN ........................................ 148
PITRESSIN .................................... 133
PLAN B ONE-STEP ......................... 82
PLAQUENIL ..................................... 52
PLASBUMIN-25 ............................... 63
PLASBUMIN-5 ................................. 63
PLASMA-LYTE 148 ....................... 156
PLASMA-LYTE 56 IN DEXTROSE 156
PLASMA-LYTE A PH 7.4 ............... 156
PLASMANATE ................................. 63
PLAVIX ............................................ 62
PLEGISOL ..................................... 153
PLEGRIDY ..................................... 146
PLEGRIDY PEN ............................ 146
PLETAL............................................ 62
PLEXION ................................... 88, 90
PLEXION SCT ................................. 90
PLIAGLIS ......................................... 15
PNEUMOVAX 23 ........................... 140
pnv no.118/iron fumarate/fa ........... 172
pnv with ca,no.72/iron/fa ................ 167
pnv#71/iron/folic acid/dha .............. 172
pnv#79/iron/fa/lmfolate ca/dha ....... 172
pnv95/ferrous fumarate/fa .............. 167
POCKET CHAMBER ..................... 100
POCKET PEAK .............................. 100
POCKETCHEM EZ ........................ 112
PODIAPN ....................................... 174
podofilox........................................... 86
podophyllum resin ............................ 88
POLY HIST DHC ............................. 46
POLY HIST NC ................................ 84
polyethylene glycol 3350 ................ 125
polymyxin b sulf/trimethoprim......... 118
polymyxin b sulfate .......................... 21
POLYMYXIN B SULFATE................ 19
POLYTRIM..................................... 119
POLY-TUSSIN DHC ........................ 84
POLY-TUSSIN EX ........................... 84
POMALYST ..................................... 28
PONSTEL ........................................ 14
PONTOCAINE ........................... 15, 16
pot chloride/pot bicarb/cit ac .......... 153
POTABA ........................................ 144
potassium acetate .......................... 156
potassium bicarbonate/cit ac.......... 153
potassium chloride ................. 153, 156
potassium chloride in 0.9%nacl ...... 156
potassium chloride in d5w .............. 156
potassium chloride in lr-d5 ............. 156
potassium chloride/d5-0.2%nacl .... 156
I-18
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
potassium chloride/d5-0.3%nacl .....156
potassium chloride/d5-0.45nacl ......156
potassium chloride/d5-0.9%nacl .....156
potassium chloride-0.45% nacl.......156
potassium citrate ............................153
potassium citrate/citric acid ............153
potassium iodide ............................134
potassium iodide/iodine ..................134
potassium phos,m-basic-d-basic ....156
POTIGA ............................................36
PRADAXA ........................................58
PRALIDOXIME CHLORIDE ...........148
PRALUENT PEN ..............................77
PRALUENT SYRINGE .....................77
PRAMCORT .....................................92
PRAM-HCA ......................................92
pramipexole di-hcl ............................52
PRAMOSONE ..................................94
PRAMOSONE E ...............................94
PRANDIMET ....................................42
PRANDIN .........................................42
PRAVACHOL ...................................76
pravastatin sodium ...........................76
PRAXBIND .......................................61
prazosin hcl ......................................67
PRE-ATTACHED LTA KIT ...............15
PRECEDEX....................................163
PRECISION PCX ...........................112
PRECISION PCX PLUS .................112
PRECISION POINT OF CARE .......112
PRECISION Q-I-D ..........................112
PRECISION XTRA .........................112
PRECISIONGLIDE .........................106
PRECOSE ........................................42
PRED FORTE ................................121
PRED MILD ....................................120
PRED-G .........................................119
prednicarbate ...................................92
prednisolone ...................................130
prednisolone acetate ......................120
prednisolone sod phosphate ..120, 130
prednisone......................................130
PREDNISONE INTENSOL .............130
PREFEST .......................................130
PREFLIN ........................................151
PREGNYL ......................................132
PREMARIN ............................129, 130
PREMASOL .....................................66
PREMIUM BLOOD GLUCOSE ......112
PREMIUM BLOOD GLUCOSE TEST
...................................................112
PREMIUM V10 ...............................112
PREMPHASE .................................129
PREMPRO .....................................129
prenatal #48/iron cb and glu/fa/b6 ..172
PRENATAL 19 ...............................172
prenatal vit#96/ferrous fum/fa .........168
prenatal vit/iron fumarate/fa ............168
PREPIDIL ....................................... 144
PREPOPIK ..................................... 125
PRESERA ...................................... 112
PRESSURE ACTIVATED LANCETS
................................................... 104
PRESTO PRO................................ 112
PREVACID ..................................... 122
PREVIDENT..................................... 85
PREVIDENT 5000 PLUS ................. 85
PREVIDENT 5000 SENSITIVE ........ 85
PREVNAR 13 ................................. 140
PREVPAC ...................................... 122
PREZCOBIX .................................... 55
PREZISTA........................................ 56
PRIALT............................................. 12
PRIFTIN ........................................... 49
PRILOSEC ..................................... 122
PRIMAQUINE .................................. 52
PRIMAXIN ........................................ 24
PRIMEAIRE ................................... 100
primidone ......................................... 36
PRIMLEV ......................................... 13
PRIMSOL ......................................... 20
PRINIVIL .......................................... 69
PRISMASOL .......................... 156, 157
PRISTIQ ER ..................................... 40
PRIVIGEN ...................................... 138
PRO DNA MEDICATED
COLLECTION .............................. 17
PROAIR HFA ................................. 159
PROAIR RESPICLICK ................... 159
PROBARIMIN QT .......................... 174
probenecid ..................................... 144
procainamide hcl .............................. 70
PROCALAMINE ............................... 66
PROCARDIA .................................... 74
PROCARDIA XL .............................. 74
PROCENTRA................................... 79
PROCHAMBER ............................. 100
prochlorperazine .............................. 50
prochlorperazine edisylate ............... 51
prochlorperazine maleate ................. 50
PRO-CLEAR CAPS ......................... 84
PROCORT ....................................... 94
PROCRIT ......................................... 60
PROCTOCORT ................................ 94
PROCTOFOAM-HC ......................... 94
PROCYSBI..................................... 151
PRODIGY....................................... 112
PRODIGY AUTOCODE ................. 112
PRODIGY AUTOCODE PRO......... 112
PRODIGY LANCETS ..................... 104
PRODIGY MINI-MIST .................... 100
PRODIGY NO CODING ................. 112
PRODIGY POCKET ....................... 112
PRODIGY POCKET PRO .............. 112
PRODIGY TWIST TOP LANCET ... 104
PRODIGY VOICE .......................... 112
PRODIGY VOICE PRO.................. 112
PRODRIN ........................................ 49
PROFERRIN-FORTE..................... 169
PROFILNINE ................................... 61
progesterone .................................. 134
progesterone,micronized................ 134
PROGLYCEM .................................. 78
PROGRAF ............................. 135, 138
PROLASTIN C ............................... 161
PROLENSA ................................... 121
PROLEUKIN .................................... 34
PROLIA .......................................... 143
PROMACTA..................................... 59
promethazine hcl .................. 46, 50, 51
promethazine hcl/codeine ................ 84
promethazine/dextromethorphan ..... 84
promethazine/phenyleph/codeine .... 84
PROMETRIUM .............................. 134
PROMISEB ...................................... 96
PROMISEB COMPLETE ............... 112
PRONEB ULTRA ........................... 100
PRONEB ULTRA II ........................ 100
propafenone hcl ............................... 69
propantheline bromide ..................... 35
proparacaine hcl .................... 116, 117
PROPECIA .................................... 151
propofol .......................................... 126
propofol/pf ...................................... 126
propranolol hcl ........................... 70, 71
propranolol/hydrochlorothiazid ......... 70
propylthiouracil ............................... 134
PROQUAD ..................................... 140
PROSCAR ..................................... 145
PROSED-DS .................................. 127
PROSOL .......................................... 66
PROSTASCINT ............................. 148
PROSTIN E2 VAGINAL
SUPPOSITORY ......................... 144
PROSTIN VR PEDIATRIC ............. 164
protamine sulfate ............................. 61
PROTECT CARDIO ....................... 174
protect cmb2/ceramide 1,3,6-11 ...... 88
PROTECT IRON ............................ 172
PROTECT PLUS ............................. 63
PROTEOLIN .................................. 151
PROTHELIAL................................. 151
PROTONIX .................................... 122
PROTONIX IV ................................ 123
PROTOPAM CHLORIDE ............... 148
PROTOPIC ...................................... 94
protriptyline hcl ................................. 39
PROVENGE................................... 149
PROVENTIL HFA .......................... 160
PROVERA ..................................... 134
PROVIGIL ...................................... 163
PROVISC ....................................... 149
PROZAC .......................................... 40
PROZAC WEEKLY .......................... 40
I-19
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
PRUDOXIN ......................................88
pseudoephed/hydrocodone/cpm ......84
PSORCON .......................................94
PULMICORT ..................................158
PULMICORT FLEXHALER ............158
PULMO-AIDE .................................100
PULMONEB LT COMPRESSOR
NEBUL .......................................100
PULMOSAL ....................................160
PULMOZYME.................................115
PUREVIT DUALFE PLUS ..............172
PURINETHOL ..................................28
PUSH BUTTON SAFETY LANCETS
...................................................104
PYLERA .........................................124
pyrazinamide ....................................49
PYRIDIUM ......................................127
pyridostigmine bromide ..........144, 153
pyridoxine hcl .................................173
PYROGALLIC ACID .........................88
QNASL ...........................................121
QNASL CHILDREN ........................121
QSYMIA ...........................................80
QUADRACEL DTAP-IPV................140
QUADRAMET ................................153
QUAKE ...........................................100
QUALAQUIN ....................................52
QUARTETTE....................................83
quazepam.........................................18
QUELICIN ......................................162
QUESTRAN .....................................76
quetiapine fumarate ..........................53
QUILLIVANT XR ..............................80
quinapril hcl ......................................68
quinapril/hydrochlorothiazide ............68
quinidine gluconate ....................69, 70
quinidine sulfate ...............................69
quinine sulfate ..................................51
QUINTET........................................112
QUINTET AC..................................112
QUTENZA ........................................90
QVAR .............................................158
RABAVERT ....................................140
rabeprazole sodium ........................122
RADIAPLEXRX ................................88
RADIGEL..........................................90
RADIOGARDASE ..........................146
RAGWITEK ....................................145
raloxifene hcl ..................................129
ramipril..............................................69
RANEXA...........................................72
ranitidine hcl ...........................122, 123
RAPAFLO.......................................127
RAPAMUNE ...........................135, 136
RASUVO ........................................151
RAVICTI .........................................125
RAYOS ...........................................131
RAZADYNE ......................................38
RAZADYNE ER ................................ 38
REA LO 39 ....................................... 86
REA LO 40 ....................................... 86
REBETOL ........................................ 57
REBIF............................................. 146
REBIF REBIDOSE ......................... 146
RECLAST....................................... 143
RECOMBINATE ............................... 61
RECOMBIVAX HB ......................... 140
RECOTHROM.................................. 60
RECTACORT-HC ............................ 92
RECTIV .......................................... 151
REFUAH PLUS .............................. 112
REGENECARE ................................ 88
REGIMEX......................................... 80
REGLAN ........................................ 124
REGONOL ..................................... 149
REGRANEX ..................................... 88
REGULAR BEVEL NEEDLES........ 106
RELADOR PAK ................................ 17
RELAGARD ..................................... 47
RELAGESIC..................................... 13
RELAMINE ..................................... 174
RELENZA......................................... 56
RELIAMED ..................................... 104
RELIAMED SAFETY SEAL LANCETS
................................................... 104
RELION CONFIRM ........................ 112
RELION CONFIRM-MICRO ........... 112
RELION MICRO ............................. 112
RELION PRIME ............................. 113
RELION PRIME TEST STRIPS ..... 113
RELION THIN ................................ 104
RELISTOR ..................................... 124
RELPAX ........................................... 49
REMERON ....................................... 40
REMICADE .................................... 149
REMODULIN.................................. 164
RENAGEL ...................................... 125
RENOVA .......................................... 95
RENVELA ...................................... 125
REOPRO.......................................... 62
repaglinide........................................ 41
repaglinide/metformin hcl ................. 41
REPATHA SURECLICK ................... 77
REPATHA SYRINGE ....................... 77
REPRONEX ................................... 132
REQ49+ ......................................... 172
REQUIP ........................................... 52
REQUIP XL ...................................... 52
RESCRIPTOR.................................. 55
RESCULA ...................................... 153
RESECTISOL ................................ 141
reserpine .......................................... 72
RESTASIS ..................................... 121
RESTORE .............................. 113, 151
RESTORE CALCIUM ALGINATE .. 151
RESTORE CONTACT LAYER
SILVER ...................................... 151
RESTORIL ....................................... 18
RETAVASE ...................................... 61
RETIN-A........................................... 95
RETIN-A MICRO .............................. 95
RETISERT ..................................... 117
RETROVIR ...................................... 56
REUSABLE NEBULIZER KIT ........ 100
REVATIO ....................................... 165
REVEAL BLOOD GLUCOSE METER
................................................... 113
REVEAL TEST STRIP ................... 113
REVIA .............................................. 17
REVLIMID ........................................ 28
REXULTI .......................................... 55
REYATAZ ........................................ 55
REZIRA ............................................ 84
REZYST ......................................... 145
RHEUMATE ................................... 174
RHEUMATREX ................................ 27
RHINOCORT AQUA ...................... 121
RHOGAM ULTRA-FILTERED PLUS
................................................... 138
RHOPHYLAC ................................. 138
RIASTAP.......................................... 61
RIAX................................................. 90
RIBATAB.......................................... 57
ribavirin ............................................ 57
RIDAURA ....................................... 135
rifabutin ............................................ 49
RIFADIN........................................... 50
RIFAMATE ....................................... 49
rifampin ...................................... 49, 50
RIFATER.......................................... 49
RIGHTEST GL300 LANCETS........ 104
RIGHTEST GM100 SYSTEM ........ 113
RIGHTEST GM300 SYSTEM ........ 113
RIGHTEST GM550 SYSTEM ........ 113
RIGHTEST GS100 TEST STRIPS . 113
RIGHTEST GS300 TEST STRIPS . 113
RIGHTEST GS550 TEST STRIPS . 113
RILUTEK .......................................... 79
riluzole.............................................. 78
rimantadine hcl ................................. 56
RIMSO-50 ........................................ 89
ringers solution ....................... 141, 157
RIOMET ........................................... 41
risedronate sodium ................ 142, 143
RISPERDAL ..................................... 54
RISPERDAL CONSTA ..................... 54
RISPERDAL M-TAB ........................ 54
risperidone ....................................... 53
RITALIN ........................................... 79
RITALIN LA ................................ 78, 79
RITALIN-SR ..................................... 79
RITEFLO ........................................ 100
RITUXAN ......................................... 34
I-20
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
rivastigmine ......................................38
rivastigmine tartrate ..........................38
RIXUBIS ...........................................62
rizatriptan benzoate ..........................47
ROBAXIN .......................................162
ROBAXIN-750 ................................161
ROBINUL .......................................124
ROBINUL FORTE ..........................124
ROCALTROL .................................142
ROCEPHIN ......................................22
rocuronium bromide .......................162
ropinirole hcl .....................................52
ropivacaine hcl/pf .............................16
ROSADAN..................................90, 91
ROSANIL..........................................86
ROTARIX .......................................140
ROTATEQ ......................................140
ROWASA .......................................140
ROXICODONE .................................11
ROZEREM .....................................163
RUBBER MOUTHPIECE................100
RYTARY ...........................................52
RYTHMOL ........................................69
RYTHMOL SR ..................................69
SABRIL.............................................37
SAFETY LANCETS ........................104
SAFETY SEAL LANCETS ..............104
SAFETYGLIDE SYRINGE..............106
SAFETY-LET..................................104
SAFYRAL .........................................83
SAIZEN ..........................................132
SALACYN.........................................88
SALAGEN ........................................85
SALEX ..............................................88
salicylic acid ...............................86, 88
salicylic acid/ceramide cmb #1 .........86
SALKERA .........................................88
salsalate ...........................................14
SAMI THE SEAL ............................100
SAMI THE SEAL FILTER ...............100
SAMI THE SEAL MASK .................100
SAMSCA ..........................................75
SANARE SCAR THERAPY BASE .151
SANCTURA....................................126
SANCTURA XR ..............................126
SANCUSO........................................50
SANDIMMUNE ............... 135, 136, 138
SANDOSTATIN ..............................133
SANDOSTATIN LAR ......................133
SANTYL ...........................................88
SAPHRIS..........................................54
SARAFEM ........................................40
SAVAYSA.........................................59
SAVELLA .........................................79
SCALACORT ...................................92
SCALACORT DK .............................94
SCLEROSOL .................................149
scopolamine hydrobromide ..............51
SEASONIQUE ................................. 82
SECONAL SODIUM ....................... 163
SECTRAL......................................... 71
SEDAPAP ........................................ 11
selegiline hcl..................................... 52
selenium ......................................... 157
selenium sulfide ......................... 90, 91
SELRX ............................................. 91
SELZENTRY .................................... 55
SEMPREX-D .................................... 46
SENSIPAR ..................................... 144
SENSORCAINE-MPF ...................... 16
SENSORCAINE-MPF EPINEPHRINE
..................................................... 16
SENTRA PM .................................. 151
SEREVENT DISKUS...................... 159
SEROPHENE ................................. 129
SEROQUEL ..................................... 54
SEROQUEL XR ............................... 53
SEROSTIM .................................... 132
sertraline hcl ..................................... 39
sevelamer carbonate ...................... 125
SEVEN PLUS ................................. 113
sevoflurane..................................... 126
SHOHL'S MODIFIED ..................... 154
SHORT BEVEL NEEDLES ............ 106
SIDESTREAM ................................ 100
SIDESTREAM MASK ..................... 100
SIDESTREAM NEBULIZER ........... 100
SIDESTREAM PEDIATRIC ............ 100
SIDESTREAM PLUS ..................... 100
SIGNIFOR ...................................... 151
sildenafil citrate ...................... 164, 165
SILENOR ......................................... 40
SILICONE MASK ........................... 100
SILVADENE ..................................... 91
SILVASORB ..................................... 88
silver nitrate ...................................... 91
silver sulfadiazine ............................. 90
SILVERSEAL HYDROGEL ............ 145
SILVRSTAT...................................... 88
SIMBRINZA.................................... 152
SIMCOR ........................................... 76
SIMPONI ........................................ 146
SIMPONI ARIA ............................... 149
SIMULECT ..................................... 149
simvastatin ....................................... 76
SINEMET 10-100 ............................. 53
SINEMET 25-100 ............................. 53
SINEMET 25-250 ............................. 53
SINEMET CR ................................... 53
SINGLE-LET .................................. 104
SINGULAIR .................................... 158
SINUSTAR ..................................... 113
sirolimus ......................................... 135
SIRTURO ......................................... 50
SKELAXIN...................................... 162
SKLICE ............................................ 96
SKYLA ............................................. 83
SMART SENSE ............................. 104
SMART SENSE LANCETS ............ 104
SMART SENSE MONITORING
SYSTEM .................................... 113
SMART SENSE TEST STRIPS ..... 113
SMARTDIABETES VANTAGE ....... 104
SMARTDIABETES XPRES............ 113
SMARTEST EJECT ....................... 113
SMARTEST LANCET .................... 104
SMARTEST PERSONA ................. 113
SMARTEST PRONTO ................... 113
SMARTEST PROTEGE ................. 113
SMARTEST TEST ......................... 113
SMARTMASK KIDS ....................... 100
sod/pot/k cit/sod cit/cit acid ............ 153
sodium acetate ............................... 157
sodium bicarbonate ........................ 157
sodium borate .................................. 85
sodium chloride .............................. 157
sodium chloride 0.45 % .................. 157
sodium chloride 3 % ....................... 157
sodium chloride 5 % ....................... 157
sodium chloride for inhalation ........ 160
sodium chloride irrig solution.......... 141
sodium chloride/nahco3/kcl/peg ..... 125
sodium citrate ................................... 58
SODIUM DIURIL .............................. 75
SODIUM EDECRIN ......................... 75
sodium ferric gluconat/sucrose ...... 173
sodium fluoride ................................. 85
sodium fluoride/potassium nit........... 85
sodium glycerophosphate .............. 157
sodium lactate ................................ 157
sodium morrhuate .......................... 149
sodium nitrite .................................. 149
sodium phenylbutyrate ................... 123
sodium phos,m-basic-d-basic ........ 157
sodium polystyrene sulfonate......... 123
sodium tetradecyl sulfate ............... 149
sodium thiosulfate .......................... 127
sodium thiosulfate/sal acid ............... 86
SOFT TOUCH ................................ 104
SOLARAZE ...................................... 14
SOLIRIS ......................................... 151
SOLODYN ....................................... 27
SOLTAMOX ..................................... 35
SOLU-CORTEF ............................. 131
SOLU-MEDROL ............................. 131
SOLUS V2 ............................. 104, 113
SOLUS V2 LANCETS .................... 104
SOLUS V2 TEST STRIPS ............. 113
SOMA .................................... 162, 163
SOMATULINE DEPOT .................. 134
SOMAVERT ................................... 132
SONATA ........................................ 163
SOOTHE NEB ............................... 100
sorbitol solution .............................. 141
I-21
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
SORIATANE.....................................89
SORILUX..........................................88
sotalol hcl .........................................70
SOTALOL HCL .................................71
SOTRADECOL ...............................149
SOVALDI ..........................................56
SPACE CHAMBER PLUS ..............100
SPECIALTY USE NEEDLES..........106
SPECTRACEF .................................23
SPECTRAGEL ...............................145
spinosad ...........................................96
SPIRIVA .........................................159
SPIRIVA RESPIMAT ......................159
spironolact/hydrochlorothiazid ..........77
spironolactone ..................................77
SPORANOX ...............................44, 45
SPRIX...............................................15
SPRYCEL.........................................28
STALEVO 100 ..................................53
STALEVO 125 ..................................53
STALEVO 150 ..................................53
STALEVO 200 ..................................53
STALEVO 50 ....................................53
STALEVO 75 ....................................53
stannous fluoride ..............................85
STARLIX ..........................................42
stavudine ..........................................55
STAVZOR ........................................37
STAXYN .........................................164
STELARA .......................................149
STENDRA ......................................164
STERILANCE TL............................104
STIMATE ........................................132
STIOLTO RESPIMAT .......................35
STIVARGA .......................................28
STRATTERA ....................................79
streptomycin sulfate .........................19
STRIANT ........................................128
STRIBILD .........................................56
STRIVERDI RESPIMAT .................159
STROMECTOL ................................52
STROVITE ONE .............................173
SUBLIMAZE .....................................12
SUBOXONE .....................................17
SUBSYS ...........................................13
SUCLEAR ......................................125
SUCRAID .......................................114
sucralfate ........................................122
sufentanil citrate ...............................12
SULAR .............................................74
sulfacetamide sod/sulfur/urea.....86, 88
sulfacetamide sodium . 86, 90, 118, 119
sulfacetamide sodium/sulfur . 86, 88, 90
sulfacetamide sodium/urea...............90
sulfacetamide/prednisolone sp .......118
sulfacetm na/avobenzone/sulfur .......86
sulfadiazine ......................................26
sulfamethoxazole/trimethoprim.........26
SULFAMYLON ................................. 88
sulfasalazine .................................... 26
sulindac ............................................ 14
SUMADAN ....................................... 88
sumatriptan ...................................... 48
sumatriptan succinate ...................... 47
SUMAVEL DOSEPRO ..................... 49
SUMAXIN ......................................... 88
SUMAXIN TS ................................... 88
SUNRISE COMPRESSORNEBULIZER ............................... 100
SUPARTZ ...................................... 149
SUPARTZ FX ................................. 149
SUPER THIN LANCETS ................ 104
SUPERVITE ................................... 173
SUPERVITE EC ............................. 173
SUPPRELIN LA ............................. 133
SUPRAX .......................................... 21
SUPRENZA ODT ............................. 80
SUPREP ........................................ 125
SURE COMFORT LANCETS......... 104
SURE EDGE BLOOD GLUCOSE
METER....................................... 113
SURE EDGE TEST STRIPS .......... 113
SURECHEK TEST STRIPS ........... 113
SURE-LANCE ................................ 104
SURESTEP CONTROL SOLUTION
................................................... 104
SURESTEP PRO ........................... 104
SURE-TEST EASYPLUS MINI ...... 113
SURE-TOUCH ............................... 104
SURFAXIN ..................................... 160
SURMONTIL .................................... 40
SURVANTA.................................... 160
SUSTIVA .......................................... 55
SUTENT ........................................... 28
SWABFLUSH ................................. 157
SYLATRON ...................................... 57
SYLVANT ......................................... 34
SYMAX........................................... 123
SYMAX-SL ..................................... 123
SYMAX-SR .................................... 123
SYMBICORT .................................. 158
SYMBYAX ........................................ 41
SYMLINPEN 120 ............................. 41
SYMLINPEN 60 ............................... 41
SYNAGEX ...................................... 174
SYNAGIS ......................................... 56
SYNALAR ........................................ 94
SYNALAR TS ................................... 94
SYNALGOS-DC ............................... 10
SYNAREL ...................................... 144
SYNERA .......................................... 15
SYNERCID....................................... 21
SYNJARDY ...................................... 41
SYNRIBO ......................................... 34
SYNTHROID .................................. 135
SYNVISC ....................................... 149
SYNVISC-ONE .............................. 149
SYPRINE ....................................... 127
syring w-ndl,disp,insul,0.3 ml ......... 104
syring w-ndl,disp,insul,0.5 ml ......... 104
SYRINGE ....................................... 106
syringe and needle,insulin,1 ml ...... 105
SYRINGE AVITENE ...................... 145
TABLOID.......................................... 28
TACHOSIL ....................................... 60
TACLONEX...................................... 90
tacrolimus................................. 92, 135
TAFINLAR........................................ 28
TAKE ACTION ................................. 82
talc ................................................. 149
TALWIN ........................................... 12
TAMIFLU.......................................... 56
tamoxifen citrate ............................... 27
tamsulosin hcl ................................ 127
TANDEM PLUS ............................. 173
TANZEUM........................................ 42
TAPAZOLE .................................... 135
TARCEVA ........................................ 28
TARGRETIN .............................. 28, 29
TARKA ............................................. 69
TASIGNA ......................................... 28
TASMAR .......................................... 53
TAXOTERE...................................... 34
TAZORAC ........................................ 95
TECFIDERA................................... 146
TECHLITE LANCETS .................... 105
TEFLARO ........................................ 22
TEGADERM AG MESH ................. 151
TEGRETOL...................................... 37
TEGRETOL XR .......................... 36, 37
TEKTURNA...................................... 77
TEKTURNA HCT ............................. 77
TELCARE .............................. 105, 113
telmisartan ....................................... 68
telmisartan/amlodipine ..................... 68
telmisartan/hydrochlorothiazid ......... 68
temazepam ...................................... 18
TEMODAR ................................. 28, 34
TEMOVATE ..................................... 94
temozolomide ................................... 28
TENEX ............................................. 67
teniposide......................................... 34
TENIVAC ....................................... 140
TENORETIC 100 ............................. 71
TENORETIC 50 ............................... 71
TENORMIN ...................................... 71
TERAZOL 3 ..................................... 47
TERAZOL 7 ..................................... 47
terazosin hcl ................................... 127
terbinafine hcl ................................... 44
TERBINEX ....................................... 45
terbutaline sulfate ................... 159, 160
terconazole ...................................... 47
TERSI FOAM ................................... 91
I-22
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
TERUMO SYRINGE .......................106
TESSALON ......................................84
TESSALON PERLE .........................84
TEST N'GO ....................................113
TESTIM ..........................................128
TESTOPEL.....................................128
testosterone....................................128
testosterone cypionate ...................128
testosterone enanthate ...................128
TESTRED.......................................128
TETANUS DIPHTHERIA TOXOIDS
...................................................140
TETANUS TOXOID ADSORBED ...140
TETCAINE......................................116
tetrabenazine....................................79
tetracaine hcl ..................................116
tetracaine hcl/pf ................................17
tetracycline hcl ..................................26
TETRAVISC FORTE ......................116
TETRIX.............................................96
TEVETEN .........................................68
TEVETEN HCT ................................68
TEV-TROPIN..................................132
TEXACORT ......................................94
THALLOUS CHLORIDE TL-201.......67
THALOMID .....................................145
THAM .............................................150
THEO-24 ........................................159
theophylline anhydrous ..................159
theophylline/d5w .............................160
THERACYS ....................................140
THERAMINE ..................................151
THERMAZENE .................................91
thiamine hcl ....................................173
THIN LANCETS .............................105
THIN WALL NEEDLES...................106
THIOLA ..........................................144
thioridazine hcl .................................53
thiotepa.............................................34
thiothixene ........................................53
THRESHOLD IMT ..........................100
THRESHOLD PEP .........................100
THROMBATE III ...............................59
thromb-ca-cell-dressing, hemos .....113
thrombin (bovine) .............................60
thrombin/ca/cmc/gel/dress, hem .....113
THYMOGLOBULIN ........................138
THYROGEN ...................................135
thyroid,pork.....................................134
THYROLAR-1.................................135
THYROLAR-1/2 ..............................135
THYROLAR-1/4 ..............................135
THYROLAR-2.................................135
THYROLAR-3.................................135
tiagabine hcl .....................................36
TIAZAC.............................................72
ticlopidine hcl ....................................62
TIGAN ........................................50, 51
TIKOSYN ......................................... 69
TIMENTIN ........................................ 25
timolol maleate ......................... 71, 152
TIMOPTIC ...................................... 152
TIMOPTIC OCUDOSE ................... 152
TIMOPTIC-XE ................................ 152
TINDAMAX....................................... 52
tinidazole .......................................... 51
TIROSINT ...................................... 135
TISSEEL VHSD ............................... 62
TIVICAY ........................................... 56
tizanidine hcl .......................... 161, 163
TNKASE ........................................... 62
TOBI ................................................. 19
TOBI PODHALER ............................ 18
TOBRADEX ................................... 119
TOBRADEX ST .............................. 120
tobramycin...................................... 118
tobramycin in 0.225% nacl ............... 19
tobramycin sulfate ............................ 19
tobramycin/dexamethasone ........... 118
tobramycin/sodium chloride.............. 19
TOBREX ........................................ 119
TOFRANIL ....................................... 40
TOFRANIL-PM ................................. 40
tolazamide ........................................ 43
tolbutamide....................................... 43
tolcapone.......................................... 52
tolmetin sodium ................................ 14
tolterodine tartrate .......................... 126
TOPAMAX........................................ 37
TOPCARE UNIVERSAL1 THIN
LANCET ..................................... 105
TOPICORT....................................... 94
topiramate ........................................ 36
topotecan hcl .................................... 34
TOPROL XL ..................................... 71
TORISEL .......................................... 34
torsemide ................................... 74, 75
TOTECT ......................................... 150
TOUJEO SOLOSTAR ...................... 43
TOVIAZ .......................................... 126
TOZAL............................................ 174
TPN ELECTROLYTES II ................ 157
trace elements comb no.1 .............. 157
TRACLEER .................................... 164
TRADJENTA .................................... 41
tramadol hcl.................................. 9, 13
tramadol hcl/acetaminophen ............ 10
TRANDATE ...................................... 71
trandolapril ....................................... 69
trandolapril/verapamil hcl ................. 69
tranexamic acid .......................... 60, 62
TRANSDERM-SCOP ....................... 50
TRANXENE T-TAB .......................... 18
tranylcypromine sulfate .................... 39
TRAVASOL ...................................... 66
TRAVATAN Z ................................. 152
travoprost (benzalkonium).............. 152
trazodone hcl ................................... 39
TREANDA ........................................ 34
TRECATOR ..................................... 49
TREK S COMBO PACK ................. 100
TREK S COMPACT COMPRESSOR
................................................... 101
TREK S PORTABLE PWR KIT ...... 101
TRELSTAR ...................................... 34
TREPADONE................................. 151
tretinoin ...................................... 29, 95
tretinoin microspheres ...................... 94
tretinoin/emollient base .................... 95
TRETIN-X ........................................ 95
TREXALL ......................................... 28
TREXIMET ....................................... 49
TREZIX ............................................ 13
triamcinolone acetonide 85, 92, 93, 94,
120, 131
triamterene/hydrochlorothiazid ......... 75
triazolam .......................................... 18
trichloroacetic acid ........................... 88
TRICHLOROACETIC ACID ........... 144
TRICITRASOL ............................... 144
TRICOR ........................................... 76
TRIESENCE .................................. 121
TRIFERIC ...................................... 150
trifluoperazine hcl ............................. 53
trifluridine ....................................... 118
TRIGLIDE ........................................ 76
trihexyphenidyl hcl ........................... 52
TRILEPTAL ...................................... 37
TRILIPIX .......................................... 77
TRI-LUMA ........................................ 90
trimethobenzamide hcl ............... 50, 51
trimethoprim ..................................... 19
trimipramine maleate ....................... 39
TRI-NORINYL .................................. 83
TRIOSTAT ..................................... 135
TRIOXIN ........................................ 121
TRISENOX....................................... 34
TRIUMEQ ........................................ 56
TRIZIVIR .......................................... 56
TROKENDI XR ................................ 38
TROPAZONE......................... 113, 114
TROPHAMINE ................................. 66
tropicamide .................................... 116
trospium chloride ............................ 126
TRUE2GO BLOOD GLUCOSE
SYSTEM .................................... 114
TRUEPLUS LANCETS .................. 105
TRUERESULT BLOOD GLUCOSE
METER ...................................... 114
TRUERESULT BLOOD GLUCOSE
SYSTM....................................... 114
TRUETEST TEST STRIPS ............ 114
TRUETRACK BLOOD GLUCOSE
SYSTEM .................................... 114
I-23
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
TRUETRACK SMART SYSTEM ....114
TRUETRACK TEST STRIP ............114
TRULICITY .......................................41
TRUMENBA ...................................140
TRUSOPT ......................................152
TRUVADA ........................................55
TRUZONE PEAK FLOW METER...101
trypsin/balsam peru/castor oil .....86, 88
TUDORZA PRESSAIR ...................159
TUSNEL ...........................................84
TUSSICAPS .....................................84
TUSSIGON.......................................84
TUSSIONEX.....................................84
TWINRIX ........................................140
TWYNSTA ........................................68
TYBOST .........................................144
TYGACIL ..........................................26
TYKERB ...........................................29
TYLENOL-CODEINE NO.3 ..............11
TYLENOL-CODEINE NO.4 ..............11
TYSABRI ........................................138
TYVASO .........................................164
TYZEKA ...........................................57
TYZINE...........................................116
UCERIS ..........................................140
UDAMIN SP ...................................174
ULESFIA ........................................145
ULORIC ..........................................144
ULTANE .........................................126
ULTILET BASIC .............................105
ULTILET CLASSIC .........................105
ULTILET LANCETS .......................105
ULTILET SAFETY ..........................105
ULTIMA ..........................................114
ULTIVA .............................................12
ULTRA THIN LANCETS .................105
ULTRA THIN PLUS ........................105
ULTRA THIN PLUS LANCETS ......105
ULTRACET ......................................11
ULTRAFOAM ...................................60
ULTRALANCE ................................105
ULTRAM...........................................11
ULTRAM ER.....................................11
ULTRA-THIN II ...............................105
ULTRATLC LANCETS ...................105
ULTRATRAK ..................................114
ULTRATRAK PRO .........................114
ULTRATRAK ULTIMATE ...............114
ULTRAVATE ....................................94
ULTRAVATE PAC ............................94
ULTRAVATE X .................................94
ULTRESA .......................................114
UMECTA ..........................................88
UNASYN ..........................................25
UNILET COMFORTOUCH .............105
UNILET EXCELITE ........................105
UNILET EXCELITE II .....................105
UNILET GP LANCET .....................105
UNILET LANCET ........................... 105
UNILET LANCETS ......................... 105
UNIRETIC ........................................ 69
UNISTIK 3 ...................................... 105
UNISTIK 3 EXTRA ......................... 105
UNISTIK CZT ................................. 105
UNISTIK SAFETY .......................... 105
UNISTRIP1 .................................... 114
UNITHROID ................................... 134
UNITUXIN ........................................ 34
UNIVASC ......................................... 69
UNIVERSAL 1 ................................ 105
URAMAXIN ................................ 89, 90
urea ...................................... 86, 89, 90
urea/lactic ac/zn undecylenate ... 86, 89
URECHOLINE ................................ 145
URELLE ........................................... 20
URETRON D-S ................................ 19
URIBEL .......................................... 127
URIN D.S. ........................................ 19
UROCIT-K ...................................... 154
UROQID-ACID NO.2 ........................ 20
UROSEX ........................................ 174
UROXATRAL ................................. 127
URSO ............................................. 124
URSO FORTE................................ 124
ursodiol........................................... 123
URYL................................................ 19
UTIRA-C........................................... 20
UTOPIC............................................ 89
UVADEX .......................................... 89
VAGIFEM ....................................... 129
valacyclovir hcl ................................. 57
VALCHLOR ...................................... 89
VALCYTE ......................................... 57
valganciclovir hcl .............................. 57
VALIUM ............................................ 18
valproic acid ..................................... 36
valproic acid (as sodium salt) ..... 36, 38
valsartan........................................... 68
valsartan/hydrochlorothiazide........... 68
VALSTAR ......................................... 34
VALTREX ......................................... 57
VANCOCIN HCL .............................. 20
vancomycin hcl........................... 19, 21
vancomycin hcl/d5w ......................... 21
VANDAZOLE ................................... 47
VANIQA............................................ 90
VANISHPOINT ............................... 106
VANOS............................................. 94
VANOXIDE-HC ................................ 90
VANTAS ......................................... 133
VAPRISOL-5% DEXTROSE ............ 75
VAQTA ........................................... 140
VARITHENA..................................... 77
VARIVAX VACCINE ....................... 140
VASCAZEN ...................................... 77
VASCEPA ........................................ 77
VASERETIC..................................... 69
vasopressin .................................... 133
VASOTEC ........................................ 69
VAYACOG ..................................... 151
VAYARIN ....................................... 151
VAYAROL ...................................... 151
VAZCULEP ...................................... 67
VECAMYL ........................................ 73
VECTIBIX......................................... 35
VECTICAL ....................................... 89
vecuronium bromide ...................... 162
VELCADE ........................................ 35
VELETRI ........................................ 165
VELTIN ............................................ 91
VENELEX ........................................ 89
venlafaxine hcl ........................... 39, 41
VENOFER...................................... 173
VENTAVIS ..................................... 164
VENTOLIN HFA ............................. 159
VERAMYST ................................... 121
verapamil hcl .............................. 71, 72
VERDESO ....................................... 94
VERDROCET .................................. 10
VEREGEN ....................................... 89
VERELAN ........................................ 72
VERELAN PM .................................. 72
VERIPRED 20 ................................ 130
VERTIGOHEEL ............................. 151
VESICARE ..................................... 126
VEXOL ........................................... 121
VFEND ............................................. 45
VFEND IV ........................................ 45
V-HIST ............................................. 46
VIAGRA ......................................... 164
VIASPAN BELZER-UW ................. 141
VIBATIV ........................................... 21
VIBRAMYCIN................................... 26
VICOPROFEN ................................. 11
VICTORY ....................................... 114
VICTOZA 3-PAK .............................. 41
VICTRELIS ...................................... 56
VIDAZA ............................................ 35
VIDEX .............................................. 55
VIDEX EC ........................................ 56
VIEKIRA PAK................................... 57
VIGAMOX ...................................... 119
VIIBRYD........................................... 40
VIMOVO........................................... 15
VIMPAT...................................... 36, 38
vinblastine sulfate ............................ 35
vincristine sulfate ............................. 35
vinorelbine tartrate ........................... 35
VIOKACE ....................................... 115
VIOS AEROSOL DELIVERY SYSTEM
................................................... 101
VIRACEPT ....................................... 56
VIRAMUNE ...................................... 56
VIRAMUNE XR ................................ 56
I-24
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
VIRASAL ..........................................89
VIRAZOLE........................................57
VIREAD ............................................56
VIROPTIC ......................................119
VISCOAT..........................................97
VISIONBLUE ..................................151
VISTARIL .......................................145
VISTIDE ...........................................58
VISUDYNE .....................................118
vit a,c,e/zinc/copper/lut/zeax ..........175
vit b cmplx 3/fa/vit c/biotin...............168
vit b cmplx no3/fa/c/biot/zinc...........168
vit b cplx #11/fa/c/biot/zn ox ...........168
vit b12/lmefolate ca/vit b6/b2 ..........175
vitamins b1,b2,b3,b5, and b6 .........173
VITA-RESPA ..................................175
vite ac/grape/hyaluronic acid ............90
VITEKTA ..........................................56
VITRASE ........................................115
VITRASERT ...................................120
VIVACTIL .........................................40
VIVELLE-DOT ................................130
VIVITROL .........................................17
VOCAL POINT ...............................114
VOGELXO ......................................128
VOLTAREN ......................................14
VOLTAREN-XR ................................14
VOLUVEN ......................................157
VORAXAZE ....................................150
voriconazole .....................................45
VORTEX.........................................101
VORTEX FROG MASK ..................101
VORTEX LADYBUG MASK ...........101
VOSOL HC .....................................119
VOSPIRE ER .................................160
VOTRIENT .......................................29
VP-PRECIP ....................................151
VPRIV.............................................115
VSL#3 DS.......................................125
VUSION............................................45
VYTORIN .........................................76
VYVANSE ........................................79
warfarin sodium ................................58
WATCHHALER ..............................101
water for irrigation,sterile ................141
WAVESENSE AMP ........................114
WAVESENSE JAZZ .......................114
WAVESENSE PRESTO .................114
WELCHOL........................................76
WELLBUTRIN ..................................40
WELLBUTRIN SR ............................40
WELLBUTRIN XL .............................40
WHEAT GERM OIL ........................169
WIDE SEAL DIAPHRAGM ...............83
WILATE ............................................62
WINDMILL TRAINER .....................101
WING TIP TUBING ........................101
WINRHO SDF ................................138
WOUND MATRIX ............................. 96
XALATAN ....................................... 152
XALKORI.......................................... 29
XANAX ............................................. 18
XANAX XR ....................................... 18
XARELTO ........................................ 58
XARTEMIS XR ................................. 13
XCLAIR .......................................... 145
XELJANZ ....................................... 146
XELODA........................................... 29
XENADERM ..................................... 89
XENAZINE ....................................... 79
XENICAL ........................................ 125
XEOMIN ......................................... 150
XERAC AC ....................................... 89
XERESE........................................... 90
XGEVA ........................................... 143
XIAFLEX ........................................ 115
XIFAXAN .......................................... 20
XIGDUO XR ..................................... 42
XODOL 10-300 ................................ 13
XODOL 5-300 .................................. 13
XODOL 7.5-300 ............................... 13
XOFIGO ......................................... 153
XOLAIR .......................................... 161
XOLEGEL ........................................ 45
XOPENEX ...................................... 160
XOPENEX CONCENTRATE.......... 160
XOPENEX HFA .............................. 160
XTANDI ............................................ 29
X-VIATE ........................................... 86
XYLOCAINE............................... 15, 17
XYLOCAINE WITH EPINEPHRINE . 17
XYLOCAINE-MPF ............................ 17
XYLOCAINE-MPF WITH
EPINEPHRINE ............................. 17
XYNTHA........................................... 62
XYNTHA SOLOFUSE ...................... 62
XYREM .......................................... 163
XYZAL .............................................. 46
YALE NEEDLES ............................ 106
YASMIN 28 ...................................... 83
YAZ .................................................. 83
YERVOY .......................................... 35
YODOXIN......................................... 52
zafirlukast ....................................... 158
zaleplon .......................................... 163
ZALTRAP ......................................... 35
ZAMICET ......................................... 10
ZANAFLEX..................................... 162
ZANOSAR ........................................ 35
ZANTAC ................................. 122, 123
ZARONTIN ....................................... 37
ZAROXOLYN ................................... 75
ZAVESCA ...................................... 115
ZEBETA ........................................... 71
ZEGERID ....................................... 123
ZELAPAR ......................................... 52
ZELBORAF ...................................... 29
ZEMAIRA ....................................... 161
ZEMPLAR .............................. 142, 143
ZEMURON ..................................... 162
ZENCIA ............................................ 86
ZENPEP......................................... 115
ZENZEDI.......................................... 79
ZERIT............................................... 56
ZESTORETIC .................................. 69
ZESTRIL .......................................... 69
ZETIA ............................................... 77
ZETONNA ...................................... 121
ZEVALIN .......................................... 35
ZIAC ................................................. 71
ZIAGEN............................................ 56
ZIANA .............................................. 91
zidovudine ........................................ 55
ZINACEF.......................................... 22
zinc chloride ................................... 157
zinc cl/cupric cl/mang/chrom .......... 157
zinc gluconate ................................ 157
zinc sulf/cuso4 p-hyd/mn/cr/se ....... 157
zinc sulfate ............................. 153, 158
ZINECARD..................................... 150
ZINOTIC......................................... 118
ZINOTIC ES ................................... 118
ZIOPTAN ....................................... 152
ziprasidone hcl ................................. 53
ZIPSOR............................................ 15
ZIRGAN ......................................... 119
ZITHRANOL..................................... 89
ZITHRANOL-RR .............................. 89
ZITHROMAX .................................... 23
ZITHROMAX TRI-PAK ..................... 23
ZMAX ............................................... 23
zn/cu/mang/selen/fluor/pot iod ....... 158
ZN-DTPA ....................................... 127
znso4/cuso4/mang su/chromic cl ... 158
ZOCOR ............................................ 77
ZOFRAN .................................... 50, 51
ZOFRAN ODT .................................. 50
ZOHYDRO ER ................................. 11
ZOLADEX ........................................ 35
zoledronic acid ............................... 143
zoledronic acid/mannitol and water 143
ZOLINZA .......................................... 29
zolmitriptan....................................... 47
ZOLOFT ........................................... 40
zolpidem tartrate ............................ 163
ZOLPIMIST .................................... 163
ZOMACTON .................................. 132
ZOMETA ........................................ 143
ZOMIG ............................................. 49
ZOMIG ZMT ..................................... 49
ZONALON........................................ 89
ZONATUSS ..................................... 85
ZONEGRAN..................................... 37
zonisamide ....................................... 36
I-25
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
ZONTIVITY.......................................62
ZORBTIVE .....................................132
ZORTRESS ....................................136
ZORVOLEX ......................................15
ZOSTAVAX ....................................140
ZOSYN .............................................25
ZOTEX-GP .......................................84
ZOVIRAX.............................. 57, 86, 89
Z-TUSS AC ......................................84
Z-TUSS E .........................................84
ZUPLENZ ......................................... 51
ZUTRIPRO ....................................... 84
ZYBAN ............................................. 17
ZYCLARA......................................... 90
ZYDELIG .......................................... 29
ZYFLO............................................ 159
ZYFLO CR ..................................... 159
ZYKADIA .......................................... 29
ZYLET ............................................ 119
ZYLOPRIM ..................................... 145
ZYMAXID ....................................... 119
ZYPRAM .......................................... 94
ZYPREXA .................................. 54, 55
ZYPREXA RELPREVV .................... 55
ZYPREXA ZYDIS ............................. 54
ZYRTEC-D ....................................... 46
ZYTIGA ............................................ 29
ZYVOX ....................................... 20, 21
I-26
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 1Q2016
Effective: February 1, 2016
APPENDIX A
Covered Generic Contraceptives
Name
Tier
ALTAVERA
ALYACEN
AMETHIA
AMETHIA LO
APRI
ARANELLE
AUBRA
AVIANE
AZURETTE
BALZIVA
BRIELLYN
CAMILA
CAMRESE
CAMRESE LO
CAZIANT
CHATEAL
CRYSELLE
CYCLAFEM
DASETTA
DAYSEE
DEBLITANE
DELYLA
DESOGESTREL-ETHINYL ESTRADIOL
DESOGESTR-ETH ESTRAD ETH ESTRA
DROSPIRENONE-ETHINYL ESTRADIOL
ELINEST
EMOQUETTE
ENPRESSE
ENSKYCE
ERRIN
ESTARYLLA
FALLBACK SOLO
FALMINA
GIANVI
GILDAGIA
GILDESS
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
Notes Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Covered Generic Contraceptives
Name
Tier
GILDESS FE
HEATHER
INTROVALE
JENCYCLA
JOLESSA
JOLIVETTE
JUNEL
JUNEL FE
KARIVA
KELNOR 1-35
KURVELO
LARIN
LARIN FE
LEENA
LESSINA
LEVONEST
LEVONORGESTREL
LEVONORGESTREL-ETH ESTRADIOL
LEVONORG-ETH ESTRAD ETH ESTRAD
LEVORA-28
LORYNA
LOW-OGESTREL
LUTERA
LYZA
MARLISSA
MICROGESTIN
MICROGESTIN FE
MIMVEY LO
MONO-LINYAH
MONONESSA
MY WAY
MYZILRA
NECON
NEXT CHOICE
NEXT CHOICE ONE DOSE
NIKKI
NORA-BE
NORETHINDRONE
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
Notes Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Covered Generic Contraceptives
Name
NORETHINDRON-ETHINYL ESTRADIOL
NORETHIN-ETH ESTRA FERROUS FUM
NORGESTIMATE-ETHINYL ESTRADIOL
NORGESTREL-ETHINY ESTRA
NORLYROC
NORTREL
OCELLA
ORSYTHIA
PHILITH
PIMTREA
PIRMELLA
PORTIA
PREVIFEM
QUASENSE
RECLIPSEN
SHAROBEL
SOLIA
SPRINTEC
SRONYX
SYEDA
TARINA FE
TILIA FE
TRI-ESTARYLLA
TRI-LEGEST FE
TRI-LINYAH
TRINESSA
TRI-PREVIFEM
TRI-SPRINTEC
TRIVORA-28
VELIVET
VESTURA
VIORELE
VYFEMLA
WERA
WYMZYA FE
XULANE
ZARAH
ZENCHENT
Tier
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
Notes Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
Covered Generic Contraceptives
Name
ZENCHENT FE
ZEOSA
ZOVIA 1-35E
Tier
T1
T1
T1
Notes Women’s Preventive Healthcare
Women’s Preventive Healthcare
Women’s Preventive Healthcare
APPENDIX B
Covered Multivitamins
Name
B-PLEX
CHOICE-TABS
CORVITA 150
CORVITE FREE
DIALYVITE
DUALVIT F
DUALVIT PLUS
FABB
FAC-X
FEROTRIN
FEROTRINSIC
FERREX 150 FORTE
FERROCITE PLUS
FERROGELS FORTE
FOLBEE
FOLBEE PLUS
FOLBEE PLUS CZ
FOLCAPS
FOLIC ACID
FOLIC ACID-VIT B6-VIT B12
FOLITAB 500
FOLPLEX 2.2
HEMATINIC PLUS
HEMATINIC WITH FOLIC ACID
HEMATOGEN
HEMATOGEN FORTE
IFEREX 150 FORTE
LYSIPLEX PLUS
MYFERON-150 FORTE
NEPHROCAPS
NICOTINAMIDE-ZINC-COPPER-FA
POLY-IRON 150 FORTE
PRENAPLUS
PRENATAL
PRENATAL FORMULA
PRENATAL MULTIVITAMINS
PRENATAL VITAMINS
RECAL D
RENA-VITE RX
RENO CAPS
Tier
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
Notes
Covered Multivitamins
Name
Tier
REOCYTE PLUS
RIGHT STEP PRENATAL VITAMINS
SE-TAN PLUS
SIDEROL
STROVITE PLUS
STUART PRENATAL
THEROBEC
THEROBEC PLUS
TL GARD RX
TL ICON
TL NICOTINAMIDE
TL-FOL 500
TL-HEM 150
TRIGELS-F FORTE
V-C FORTE
VICA-FORTE
VICAP FORTE
VIC-FORTE
VIRT-CAPS
VIRT-VITE
VIRT-VITE PLUS
VIT 3
VITA S FORTE
VITACEL
VITAMIN D2
VOL-CARE RX
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
ACTIVE FE
CALCIUM-FOLIC ACID PLUS D
CENTRATEX
FE 90 PLUS
FERRAPLUS 90
FERREX 150 FORTE PLUS
FERREX 28
FETRIN
FOLPACE RX
FUSION PLUS
GLUTOFAC-MX
HEMATOGEN FA
HEMETAB
IRCON-FA
MEPHYTON
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
Notes
Covered Multivitamins
Name
Tier
MULTIGEN
MULTIGEN FOLIC
MULTIGEN PLUS
NATALVIRT FLT
NEPHRON FA
NEURIN-SL
NOVAFERRUM
PROFERRIN-FORTE
WHEAT GERM OIL
T2
T2
T2
T2
T2
T2
T2
T2
T2
ANIMI-3
BACMIN
B-COMPLEX WITH VITAMIN C
BIFERA RX
BIOCEL
CALCIFOLIC-D
COD LIVER OIL
CORVITA
CORVITE
CORVITE 150
CORVITE FE
DIALYVITE 3000
DIALYVITE 5000
DIALYVITE SUPREME D
DIALYVITE ZINC
DIATX ZN
DRISDOL
FERIVAFA
FERRALET 90
FOLGARD OS
FOLGARD RX
FOLIVANE-F
FOLIVANE-PLUS
FOLTRATE
FORTAVIT
GLUTOFAC-ZX
HEMATRON-AF
HEMOCYTE PLUS
HEMOCYTE-F
INTEGRA F
INTEGRA PLUS
IRON
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
Notes
Prior Authorization Required
Covered Multivitamins
Name
IROSPAN
MAXARON FORTE
MULTICHEW
NASCOBAL
NATELLE-EZ
NEPHPLEX RX
NEPHROCAPS QT
NEPHRONEX-SL
NEPHRO-VITE RX
NICADAN
NICOMIDE
NIRON KOMPLETE
NUTRICAP
NUTRIVIT
PRENA1 PEARL
PRENATAL 19
PROMAR
PROTECT BONE
PROTECT IRON
PROTECT PLUS NR
PUREVIT DUALFE PLUS
RENAX
REQ49+
STROVITE
STROVITE ADVANCE
STROVITE FORTE
STROVITE ONE
SUPERVITE
SUPERVITE EC
SUPPORT
TANDEM PLUS
TARON FORTE
TL G-FOL OS
UDAMIN
VINACAL B
VINATE DHA
VITAFOL
VITAL-D RX
Tier
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
Notes