1. No category

777 Bannock, MC 6000
Denver, CO 80204
Formulario completo del 2015
Lista de medicamentos cubiertos
IMPORTANTE LEER: ESTE DOCUMENTO CONTIENE INFORMACIÓN
SOBRE LOS MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN
ID del formulario: 00015452, versión: 8
Este formulario se actualizó el 02/25/2015. Para obtener información más reciente o si tiene
preguntas, comuníquese con Servicios al miembro de Denver Health Medical Plan, Inc.,
llamando al 1-877-956-2111. Los usuarios de TTY pueden llamar al 1-866-538-5288.
Nuestro horario de atención es de 8 a. m. a 8 p. m., los siete días de la semana, también puede
visitar
www.denverhealthmedicalplan.org.
Nota para aquellos que ya son miembros:
Este formulario presenta cambios respecto del año pasado. Sírvase revisar este
documento para asegurarse de que todavía contenga
los medicamentos que usted toma.
Esta información está disponible de manera gratuita en otros idiomas. Para obtener más información, llame a
nuestro departamento de Servicios al miembro al 303-602-2111 o al teléfono gratuito 1-877-956-2111. Los
usuarios TTY/TDD deben llamar al 303-602-2129 o al teléfono gratuito 1-866-538-5288. Nuestro horario de
atención es de 8 a. m. a 8 p. m. los siete días de la semana.
Denver Health Medical Plan, Inc. es un plan HMO (Organización para el Mantenimiento de la Salud)
aprobado por Medicare y tiene un contrato con el programa Colorado Medicaid Program. La inscripción en
un plan Denver Health Medical Plan, Inc. depende de la renovación del contrato.
H5608_1085_CF15_SP_accepted
1
Cuando en esta lista de medicamentos (formulario) figuran los términos "nosotros", “a nosotros” o
"nuestro", se hace referencia a Denver Health Medical Plan, Inc. Donde dice “plan” o “nuestro plan”,
significa Medicare Select HMO o Medicare Choice HMO SNP.
En este documento se incluye una lista de los medicamentos (formulario) de nuestro plan que entrará
en vigencia el 03/01/2015. Para obtener un formulario actualizado, comuníquese con nosotros. Nuestra
información de contacto, junto con la fecha de la última vez que actualizamos el formulario, aparece
en las páginas de portada y contraportada.
En general, usted debe utilizar farmacias de la red para utilizar su beneficio de medicamentos
recetados. Los beneficios, la lista de medicamentos, la red de farmacias, y/o los copagos/coseguros
pueden cambiar el 1 de enero del 2016 y de vez en cuando durante el año.
¿Qué es el Formulario completo de Denver Health Medical Plan, Inc.?
Un formulario es una lista de medicamentos cubiertos seleccionados por nosotros en colaboración con un
equipo de proveedores de atención de la salud, que representa los tratamientos recetados que se consideran
parte necesaria de un programa de tratamiento de calidad. En general, cubriremos los medicamentos
incluidos en nuestro formulario, siempre y cuando el medicamento sea médicamente necesario, el
medicamento se adquiera en una farmacia de la red de Denver Health Medical Plan, Inc., y se sigan otras
reglas del plan. Para obtener más información sobre cómo obtener sus medicamentos recetados, revise su
Evidencia de cobertura.
¿Puede modificarse el Formulario (lista de medicamentos)?
En general, si usted está tomando un medicamento de nuestro formulario del 2015 que estaba cubierto a
principios del año, no vamos a interrumpir ni a reducir la cobertura del medicamento durante el año de
cobertura 2015, excepto cuando un medicamento genérico nuevo y menos costoso esté disponible o se
publique nueva información adversa sobre la seguridad o eficacia de un medicamento. Otros tipos de
cambios en el formulario, tales como eliminar un medicamento de nuestro formulario, no afectarán a los
miembros que actualmente están tomando el medicamento. Seguirá estando disponible al mismo costo
compartido para aquellos miembros que lo tomen durante el resto del año de cobertura. Creemos que es
importante que usted tenga acceso continuo durante el resto del año de cobertura a los medicamentos del
formulario que estaban disponibles cuando eligió nuestro plan, excepto en los casos en los que usted puede
ahorrar dinero adicional o podamos garantizar su seguridad.
Si eliminamos medicamentos de nuestro formulario, o añadimos los requisitos de autorización previa, límites
de cantidad o restricciones de terapia escalonada para un medicamento, o movemos un medicamento a un
nivel de costo compartido más alto, debemos notificar a los miembros afectados acerca del cambio al menos
60 días antes de que el cambio entre en vigencia, o en el momento que el afiliado solicite una renovación del
medicamento, momento en el cual el miembro recibirá un suministro para 60 días del medicamento. Si la
Administración de Medicamentos y Alimentos considera que un medicamento en nuestro formulario no es
seguro o el fabricante del medicamento retira el medicamento del mercado, vamos a retirar inmediatamente
el medicamento de nuestro formulario y notificaremos a los miembros que toman el medicamento. El
formulario que se adjunta entra en vigencia a partir del 03/01/2015. Para obtener información actualizada
2
sobre los medicamentos que cubrimos, comuníquese con nosotros. Nuestra información de contacto aparece
en las páginas de portada y contraportada.
Los futuros cambios en el formulario se le enviarán a usted con su Explicación de beneficios mensual de la
Parte D. Si la Administración de Medicamentos y Alimentos considera que un medicamento en nuestro
formulario no es seguro o si el fabricante del medicamento retira el medicamento del mercado, los miembros
afectados recibirán una notificación aparte. En nuestro sitio web, puede encontrar una lista de los cambios
que ya se han hecho a nuestro formulario.
¿Cómo uso el Formulario de medicamentos?
Hay dos maneras de encontrar un medicamento en el formulario:
Afección médica
El formulario comienza en la página 14. Los medicamentos en este formulario están agrupados en
categorías que dependen del tipo de afección médica para la que se usan como tratamiento. Por ejemplo,
los medicamentos utilizados para tratar una afección cardíaca aparecen bajo la categoría "Medicamentos
cardiovasculares". Si usted conoce para qué se utiliza su medicamento, busque el nombre de la categoría
en la lista que comienza en la página 14. Luego busque su medicamento en esa categoría.
Lista en orden alfabético
Si no sabe con certeza qué categoría buscar, debe buscar su medicamento en el índice que comienza en la
página I-1. El índice ofrece una lista en orden alfabético de todos los medicamentos incluidos en este
documento. Tanto los medicamentos de marca como los genéricos aparecen en el índice. Busque en el
índice y encuentre su medicamento. Junto a su medicamento, verá el número de página donde puede
encontrar información sobre la cobertura. Vaya a la página indicada en el índice y busque el nombre de
su medicamento en la primera columna de la lista.
¿Qué son los medicamentos genéricos?
Nuestro plan cubre tanto medicamentos de marca como genéricos. Un medicamento genérico está
aprobado por la FDA porque se considera que tiene los mismos ingredientes activos que el medicamento
de marca. En general, los medicamentos genéricos tienen un costo menor que los de marca.
¿Hay alguna restricción en mi cobertura?
Algunos medicamentos cubiertos pueden tener requisitos adicionales o límites de cobertura. Estos requisitos
y límites pueden ser, entre otros, los siguientes:
•
Autorización previa: Nuestro plan exige que usted o su médico obtengan una autorización previa
para obtener ciertos medicamentos. Esto significa que usted tendrá que obtener nuestra aprobación
antes de adquirir sus medicamentos recetados. Si usted no obtiene la aprobación, es posible que no
cubramos el medicamento.
3
•
Límites de cantidad: Para ciertos medicamentos, limitamos la cantidad del medicamento que
cubriremos. Por ejemplo, nuestro plan ofrece 90 cápsulas por receta para LYRICA. Esto puede ser
además del suministro estándar de un mes o tres meses.
•
Terapia escalonada: En algunos casos, requerimos que usted primero pruebe ciertos medicamentos
para tratar su afección médica antes de que cubramos otro medicamento para esa afección. Por
ejemplo, si el medicamento A y el medicamento B tratan su afección médica, es posible que no
cubramos el medicamento B a menos que usted pruebe el medicamento A primero. Si el
medicamento A no funciona para usted, cubriremos el Medicamento B.
Puede averiguar si su medicamento tiene requisitos o límites adicionales buscando en el formulario que
comienza en la página 14. También puede obtener más información sobre las restricciones que se aplican a
medicamentos cubiertos específicos en nuestro sitio web. Hemos publicado documentos en línea que
explican nuestras restricciones de autorización previa y terapia escalonada. También puede solicitarnos que
le enviemos una copia. Nuestra información de contacto, junto con la fecha de la última vez que
actualizamos el formulario, aparece en las páginas de portada y contraportada.
Puede pedirnos que hagamos una excepción a estas restricciones o límites, o puede solicitarnos una lista de
otros medicamentos similares que puedan tratar su estado de salud. Para obtener información sobre cómo
solicitar una excepción, consulte la sección, "¿Cómo puedo solicitar una excepción respecto del formulario
de Denver Health Medical Plan?" en la parte inferior de esta página.
¿Qué pasa si mi medicamento no figura en el Formulario?
Si su medicamento no está incluido en este formulario (lista de medicamentos cubiertos), primero debe
comunicarse con Servicios al miembro y preguntar si su medicamento está cubierto.
Si usted se entera de que nuestro plan no cubre su medicamento, usted tiene dos opciones:
•
Puede solicitar a Servicios al miembro una lista de medicamentos similares que cubramos. Cuando
reciba la lista, muéstresela a su médico y pídale que le recete un medicamento similar que esté
cubierto por nuestro plan.
•
Puede pedirnos que hagamos una excepción y que cubramos su medicamento. Consulte la
información que figura más abajo sobre cómo solicitar una excepción.
¿Cómo solicito una excepción respecto del Formulario de medicamentos de Denver
Health Medical Plan, Inc.?
Puede pedirnos que hagamos una excepción respecto de nuestras reglas de cobertura. Hay varios tipos de
excepciones que usted puede solicitar.
•
Usted puede solicitarnos que cubramos un medicamento, incluso si no está en nuestro formulario. Si
se aprueba, este medicamento se cubrirá en un nivel de costo compartido predeterminado, y no podrá
solicitarnos que le proporcionemos el medicamento a un nivel de costo compartido más bajo.
4
•
•
Usted puede solicitarnos que cubramos un medicamento del formulario en un nivel de costo
compartido menor si este medicamento no está en el nivel de especialidad. Si esto se aprueba,
reduciría el monto que debe pagar por su medicamento.
Puede pedirnos que anulemos las restricciones o los límites de cobertura de su medicamento. Por
ejemplo, para ciertos medicamentos, nuestro plan limita la cantidad de medicamento que cubriremos.
Si su medicamento tiene un límite de cantidad, puede pedirnos que anulemos el límite y que
cubramos una cantidad mayor.
Generalmente, solo aprobaremos su solicitud de excepción si los medicamentos alternativos incluidos en el
formulario del plan, el medicamento de costo compartido más bajo o las restricciones adicionales de
utilización no resultaran tan eficaces para tratar su afección o le causaran efectos médicos adversos.
Usted debe comunicarse con nosotros para solicitar una decisión de cobertura inicial para obtener una
excepción respecto del formulario, el nivel o la restricción de utilización. Cuando usted solicita una
excepción respecto del formulario, el nivel o la restricción de utilización, debe presentar una
declaración del proveedor o médico, que respalde su solicitud. En general, debemos tomar una decisión
dentro de las 72 horas de recibir la declaración de respaldo de su médico. Usted puede solicitar una
excepción acelerada (rápida) si usted o su médico creen que su salud podría verse seriamente afectada si
espera las 72 horas que lleva tomar la decisión. Si se le concede su petición de acelerar la decisión, debemos
darle una decisión a más tardar 24 horas después de recibir la declaración de respaldo de su médico u otro
proveedor.
¿Qué debo hacer antes de que pueda hablar con mi médico acerca de cambiar mis
medicamentos o solicitar una excepción?
Como miembro nuevo o continuo en nuestro plan, usted puede tomar medicamentos que no están en nuestro
formulario. O bien, usted puede tomar un medicamento que está en nuestro formulario pero su capacidad
para obtenerlo es limitada. Por ejemplo, es posible que necesite una autorización previa antes de que pueda
adquirir su medicamento recetado. Usted debe hablar con su médico para decidir si usted debe cambiar a un
medicamento adecuado que cubramos o solicitar una excepción al formulario para que cubramos el
medicamento que usted toma. Mientras habla con su médico para determinar el curso de acción correcto para
usted, podemos cubrir su medicamento en ciertos casos durante los primeros 90 días que usted sea miembro
de nuestro plan.
Para cada uno de sus medicamentos que no está en nuestro formulario o si su capacidad para obtener sus
medicamentos es limitada, cubriremos un suministro temporal de 30 días (a menos que tenga una receta por
menos días) cuando vaya a una farmacia de la red. Después de su primer suministro de 30 días, no
pagaremos por estos medicamentos, incluso si usted ha sido miembro del plan por menos de 90 días.
Si usted es residente de un centro de atención a largo plazo, vamos a permitir que usted vuelva a renovar su
receta hasta que le hayamos proporcionado un suministro de transición de 91 días, de acuerdo con el
incremento de dispensación, (a menos que tenga una receta por menos días). Cubriremos más de una
renovación de estos medicamentos durante los primeros 90 días que usted sea miembro de nuestro plan. Si
necesita un medicamento que no está en nuestro formulario o si su capacidad para obtener sus medicamentos
es limitada, pero ya han pasado los primeros 90 días de membresía en nuestro plan, cubriremos un suministro
de emergencia para 31 días de ese medicamento (a menos que tenga una receta por menos días) mientras
solicita una excepción al formulario.
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Si se le presenta un cambio en el nivel de atención, como ser ingresado o dado de alta de un centro de
atención a largo plazo y se encuentra fuera de los primeros 90 días de su cobertura, Denver Health Medical
Plan Inc. le proporcionará por una sola vez medicamentos de la Parte D que no figuran en el formulario,
como se describió anteriormente.
6
Para obtener más información
Para obtener información más detallada sobre la cobertura de medicamentos recetados que ofrece nuestro
plan, consulte su Evidencia de cobertura y otros materiales del plan.
Si tiene preguntas sobre nuestro plan, comuníquese con nosotros. Nuestra información de contacto, junto con
la fecha de la última vez que actualizamos el formulario, aparece en las páginas de portada y contraportada.
Si tiene preguntas generales sobre la cobertura de medicamentos recetados de Medicare, llame a Medicare al
1-800-MEDICARE (1-800-633-4227), disponible 24 horas al día, los 7 días de la semana. Los usuarios de
TTY deben llamar al 1-877-486-2048. O bien, visite http://www.medicare.gov.
Formulario de Denver Health Medical Plan, Inc.
El formulario completo que comienza en la página 14 proporciona información sobre la cobertura de los
medicamentos que cubre nuestro plan. Si tiene inconvenientes para encontrar su medicamento en la lista,
consulte el índice que comienza en la página I-1.
La primera columna de la tabla indica el nombre del medicamento. Los medicamentos de marca están en
mayúsculas (por ejemplo, ADVAIR DISKUS) y los medicamentos genéricos aparecen en letra cursiva en
minúsculas con un nombre de medicamento de marca de referencia que aparece junto al nombre genérico del
fármaco (por ejemplo, amoxicillin (Amoxil)). Los medicamentos genéricos en cursiva con nombres de marca
de referencia entre paréntesis indican que sólo el medicamento genérico está en el formulario.
A continuación se muestra una tabla para ayudarle a entender su copago o coseguro por cada nivel*
VENTA HASTA 31 DÍAS
ENVÍO POR CORREO HASTA 90
DÍAS
PLAN
Nivel
1
Nivel
2
Nivel
3
Nivel
4
Nivel
5
Nivel
1
Nivel
2
Nivel
3
Nivel
4
Nivel
5
Medicare Choice
25%
25%
25%
25%
25%
25%
25%
25%
25%
25%
Medicare Select
$3
$6
25%
50%
26%
$6
$12
25%
50%
26%
*Su copago y coseguro pueden variar en función del subsidio por bajos ingresos (Low-Income Subsidy, LIS).
La información en la columna de Requisitos/Límites le indica si Denver Health Medical Plan Inc. tiene algún
requisito especial para la cobertura de su medicamento.
7
En este documento pueden encontrarse las abreviaturas que figuran a continuación.
ABREVIATURAS SOBRE NOTAS DE COBERTURA
ABREVIATURA
DESCRIPCIÓN
EXPLICACIÓN
Restricciones sobre la Administración de la Utilización de Servicios
Se requiere autorización
previa
Usted (o su médico) tiene la obligación de obtener
autorización previa de Denver Health Medical Plan
(DHMP), Inc. antes de obtener el medicamento de su
receta. Sin autorización previa, Denver Health Medical
Plan Inc. no puede cubrir este medicamento.
Se requiere autorización
previa para
una determinación de
Parte B frente a Parte D
Este medicamento puede ser elegible para el pago bajo la
Parte B o la Parte D de Medicare. Usted (o su médico)
tiene la obligación de obtener una autorización previa de
Denver Health Medical Plan, Inc. para determinar que este
medicamento esté cubierto por la Parte D de Medicare
antes de obtener el medicamento indicado en su receta. Sin
autorización previa, Denver Health Medical Plan, Inc. no
puede cubrir este medicamento.
Se requiere autorización
previa para
medicamentos de alto
riesgo
Este medicamento ha sido considerado por CMS como
potencialmente perjudicial y, por lo tanto, como
medicamento de alto riesgo para los beneficiarios de
Medicare de 65 años o más. Los miembros de 65 años o
más tienen la obligación de obtener una autorización previa
de Denver Health Medical Plan, Inc. antes de obtener su
medicamento recetado. Sin autorización previa, Denver
Health Medical Plan Inc. no puede cubrir este
medicamento.
PA NSO
Se requiere autorización
previa para nuevos
miembros solamente
Si usted es un miembro nuevo o si usted no ha tomado este
medicamento antes, usted (o su médico) tiene la obligación
de obtener una autorización previa de Denver Health
Medical Plan, Inc. antes de obtener el medicamento que
figura en su receta. Sin aprobación previa, DHMP no
cubrirá este medicamento.
QL
Existe una limitación
respecto de la cantidad
Denver Health Medical Plan, Inc. establece un límite de
cobertura respecto de la cantidad de este medicamento por
receta o por un marco de tiempo específico.
ST
Restricción de terapia
escalonada
Antes de que Denver Health Medical Plan Inc. proporcione
cobertura para este medicamento, usted debe primero
probar otro(s) medicamento(s) para el tratamiento de su
afección médica. Este medicamento sólo será cubierto si
otro(s) fármaco(s) no funciona(n) para usted.
LA
Medicamento de acceso
limitado
Este medicamento puede que sólo esté disponible en
algunas farmacias. Para obtener más información consulte
PA
PA BvD
PA-HRM
8
ABREVIATURA
DESCRIPCIÓN
EXPLICACIÓN
su Directorio de farmacias o llame a Servicios al miembro
al 1-877-956-2111, de 8 a. m., los siete días de la semana.
Los usuarios de TTY/TDD deben llamar al 1-866-5385288.
9
ABREVIATURA DE DOSIS Y PRESENTACIÓN
ABREVIATURA
adh. patch
aer br act
aer pow
aer pow ba
aer refill
aer w/adap
ampul
blkbaginj
cap dr mp
cap ds pk
cap er 12h
cap er 24h
cap er deg
cap er pel
cap mphase
cap.sa 24h
cap.sr 12h
cap.sr 24h
cap24h pct
cap24h pel
cap sprink
cap sr pel
cap w/dev
capsule dr
capsule er
capsule sa
cmb cappad
cmb ont fm
cmb ont lt
cmb tabpad
combo. pkg
cpmp 12hr
cpmp 24hr
cpmp 30-70
cpmp 50-50
cream(g), cream(gm)
cream(ml)
cream/appl
cream, er (g)
cream pack
dehp fr bg
dis needle
disk w/dev
DESCRIPCIÓN
parche adhesivo
aerosol, activado por aliento
aerosol, polvo
polvo aerosol, activado por aliento
repuesto de aerosol
aerosol con adaptador
ampolla
inyección en bolsas a granel
cápsula, multifásica de liberación prolongada
cápsula, paquete de dosis
cápsula, 12 horas liberación prolongada
cápsula, 24 horas liberación prolongada
capsule, liberación prolongada degradable
cápsula, pellets liberación prolongada
cápsula, multifásica
cápsula, 24 horas acción sostenida
cápsula, 12 horas liberación sostenida
cápsula, 24 horas liberación sostenida
cápsula, 24 horas pellets de inicio controlado
cápsula, 24 horas pellets liberación sostenida
cápsula, dispersable
cápsula pellets liberación sostenida
cápsula con dispositivo
cápsula, liberación retardada
cápsula, liberación prolongada
cápsula, acción sostenida
combinación: cápsula almohadilla
combinación: ungüento, espuma
combinación: ungüento, loción
combinación: comprimido, almohadilla
paquete combinado
cápsula, 12 horas multifásica
cápsula, 24 horas multifásica
cápsula, multifásica, 30%-70%
cápsula, multifásica, 50%-50%
crema (gramos)
crema (mililitros)
crema con aplicador
crema, liberación prolongada (gramos)
crema, paquete
bolsa sin di(2-etilhexil) ftalato
aguja desechable
disco con dispositivo para inhalación
10
ABREVIATURA
disp syrin
drops susp
drps hpvis
emul adhes
emul packt
emulsn(g)
foam/appl.
froz.piggy
g
gel/pf app
gel (gm)
gel (ml)
gel md pmp
gel w/appl
gel w/pump
gran pack
hfa aer ad
infus. btl
insuln pen
ip soln
irrig soln
iv soln.
jel
jelly/app
jel/pf app
kit cl&crm
kt crm le
kt lotn ce
kt oint le
lotion, er
lozenge hd
m.ht patch
ma buc tab
mcg
med. pad
med. swab
med. tape
mg
ml
muc er 12h
ndl fr inj
nl fm susp
oint. (g), oint.(gm)
oral conc
oral susp
DESCRIPCIÓN
jeringa desechable
gotas, suspensión
gotas, hiperviscosas
adhesivo emulsión
paquete de emulsión
emulsión (gramos)
espuma con aplicador
accesorio congelado
gramo
gel con aplicador precargado
gel (gramos)
gel (mililitros)
gel en bomba con dosis medida
gel con aplicador
gel con bomba
paquete de gránulos
adaptador para aerosol hfa
frasco para infusión
pluma de insulina
solución intraperitoneal
solución para irrigación
solución intravenosa
jalea
jalea con aplicador
jalea con aplicador precargado
kit: limpiador y crema
kit: crema, loción emoliente
kit: loción, crema emoliente
kit: ungüento, loción emoliente
loción, liberación prolongada
pastillas con soporte
parche de calor con medicamento
comprimidos bucales mucoadhesivos
microgramo
almohadilla con medicamento
hisopo con medicamento
cinta adhesiva con medicamento
miligramo
mililitro
sistema mucoadhesivo, 12 horas liberación prolongada
aguja para inyección
suspensión para cubierta de uñas
ungüento (gramos)
concentrado oral
suspensión oral
11
ABREVIATURA
paste (g)
patch td24
patch td72
patch tdsw
patch tdwk
pca syring
pca vial
pellet(ea)
pen ij kit
pen injctr
pggybk btl
plast. bag
powd pack
sol md pmp
sol w/appl
sol/pf app
sol-gel
soln recon
soln(gram)
spray susp
spray/pump
stick(ea)
supp.rect
supp.vag
suppos.
sus er 24h
sus er rec
sus mc rec
suspdr pkt
susp recon
syringekit
tab chew
tab er 12h
tab er 24h
tab er prt
tab er seq
tab disper
tab ds pk
tab er 24
tab mphase
tab part
tab rap dr
tab rapdis
tab subl
tab.sr 12h
DESCRIPCIÓN
pasta (gramos)
parche, 24 horas transdérmico
parche, 72 horas transdérmico
parche, 2 veces por semana transdérmico
parche, 1 vez por semana transdérmico
jeringa analgésica controlada por paciente
vial analgésico controlado por paciente
pellet (cada uno)
kit con pluma para inyección
pluma para inyección
frasco accesorio
bolsa plástica
paquete de polvo
solución con bomba multidosis
solución con aplicador
solución con aplicador precargado
solución, formadora de gel
solución, reconstituida
solución (gramos)
atomizador, suspensión
atomizador con bomba
varilla (cada una)
supositorio, rectal
supositorio, vaginal
supositorio
suspensión, 24 horas liberación prolongada
suspensión, reconstituida de liberación prolongada
suspensión, microcápsula reconstituida
suspensión, paquete de liberación retardada
suspensión, reconstituida
kit de jeringa
comprimido, masticable
comprimido, 12 horas liberación prolongada
comprimido, 24 horas liberación prolongada
comprimido, partículas de liberación prolongada
comprimido, sequels de liberación prolongada
comprimido, dispersable
comprimido, paquete de dosis
comprimido, 24 horas liberación prolongada
comprimido, multifásico
comprimido, partículas
comprimido, liberación retardada de desintegración rápida
comprimido, desintegración rápida
comprimido, sublingual
comprimido, 12 horas liberación sostenida
12
ABREVIATURA
tab.sr 24h
tabergr24hr
tablet dr
tablet, er
tablet eff
tablet sa
tablet sol
tb er dspk
tb mp dspk
tb rd dspk
tbdspk 3mo
tbmp 12hr
tbmp 24hr
u
vag ring
DESCRIPCIÓN
comprimido, 24 horas liberación sostenida
comprimido, 24 horas liberación prolongada gradual
comprimido, liberación retardada
comprimido, liberación prolongada
comprimido, efervescente
comprimido, acción sostenida
comprimido, soluble
comprimido, paquete de dosis de liberación prolongada
comprimido, paquete de dosis multifásica
comprimido, paquete de dosis de desintegración rápida
comprimido, paquete de dosis de 3 meses
comprimido, 12 horas multifásico
comprimido, 24 horas multifásico
unidad
anillo vaginal
13
Drug Name
Drug Tier
Requirements/Limits
Analgesics
Analgesics, Miscellaneous
acetaminophen with codeine solution
(Acetaminophen with
Codeine)
acetaminophen with codeine tablet: 300mg- (Vopac)
60mg
acetaminophen with codeine tablet: 300mg- (Vopac)
15mg, 300mg-30mg
(Buprenorphine HCl)
buprenorphine hcl
butalb/acetaminophen/caffeine tablet
(Esgic)
2
QL: 2700 in 30 days
2
QL: 180 in 30 days
2
QL: 360 in 30 days
2
2
(injectable)
PA-HRM, QL: 180 in 30
days
PA-HRM, QL: 180 in 30
days
PA-HRM, QL: 180 in 30
days
PA-HRM, QL: 180 in 30
days
QL: 5 in 28 days
QL: 4 in 28 days
QL: 180 in 30 days
PA-HRM, QL: 180 in 30
days
butalbit/acetamin/caff/codeine
(Fioricet with Codeine)
2
butalbital/acetaminophen tablet: 50mg325mg
butalbital/aspirin/caffeine
(Tencon)
2
(Fiorinal)
2
butorphanol tartrate spray
BUTRANS
codeine sulfate tablet
codeine/butalbital/asa/caffein
(Butorphanol Tartrate)
2
3
2
2
DURAMORPH
fentanyl citrate
fentanyl patch td72: 12mcg/hr, 25mcg/hr,
50mcg/hr, 75mcg/hr
fentanyl patch td72: 100mcg/hr
hydrocodone/acetaminophen solution: 2.5167/5, 10-325/15
hydrocodone/acetaminophen solution: 7.5325/15
hydrocodone/acetaminophen tablet: 2.5325mg, 5mg-325mg, 7.5-325mg, 10mg325mg
hydrocodone/acetaminophen tablet: 5mg300mg, 7.5-300mg, 10mg-300mg
hydrocodone/ibuprofen
(Codeine Sulfate)
(Fiorinal w/Codeine
#3)
(Actiq)
(Duragesic)
4
5
2
PA, QL: 120 in 30 days
PA, QL: 10 in 30 days
(Duragesic)
(Hycet)
2
2
PA, QL: 20 in 30 days
QL: 2700 in 30 days
(Hycet)
2
QL: 2700 in 30 days
(Norco)
2
QL: 360 in 30 days
(Norco)
2
(Ibudone)
2
QL: 390 in 30 days
(includes Vicodin,
Vicodin ES and Vicodin
HP)
QL: 150 in 30 days
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
14
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
hydromorphone hcl liquid
hydromorphone hcl tablet: 2mg, 4mg
hydromorphone hcl tablet: 8mg
hydromorphone hcl syringe, vial
hydromorphone hcl/pf ampul
hydromorphone hcl/pf vial
LAZANDA
levorphanol tartrate
methadone hcl vial
methadone hcl solution
methadone hcl tablet
methadone hcl tablet sol: 40mg
morphine sulfate cartridge: 15mg/ml; pen
injctr, supp.rect, syringe, vial: 8mg/ml,
10mg/ml, 15mg/ml, 25mg/ml, 50mg/ml
morphine sulfate cartridge: 2mg/ml, 4mg/
ml, 8mg/ml, 10mg/ml
morphine sulfate tablet er: 30mg, 60mg,
100mg
morphine sulfate tablet er: 15mg, 200mg
morphine sulfate solution: 100mg/5ml
morphine sulfate solution: 20mg/5ml
morphine sulfate solution: 10mg/5ml
MORPHINE SULFATE tablet
NUCYNTA ER
NUCYNTA
oxycodone hcl oral conc, tablet
oxycodone hcl solution
oxycodone hcl/acetaminophen tablet:
10mg-650mg
oxycodone hcl/acetaminophen tablet: 5mg500mg, 7.5-500mg
oxycodone hcl/acetaminophen tablet: 2.5325mg, 5mg-325mg, 7.5-325mg, 10mg325mg
oxycodone hcl/acetaminophen solution
oxycodone hcl/aspirin
Drug Tier
(Dilaudid)
(Dilaudid)
(Dilaudid)
(Hydromorphone HCl)
(Dilaudid)
(Hydromorphone HCl/
PF)
Requirements/Limits
2
2
2
2
2
2
QL: 1200 in 30 days
QL: 180 in 30 days
QL: 240 in 30 days
(Levo-dromoran)
(Methadone HCl)
(Methadone HCl)
(Methadose)
(Methadose)
(Morphine Sulfate)
5
2
2
2
2
2
2
PA, QL: 30 in 30 days
QL: 180 in 30 days
(Morphine Sulfate)
2
(MS Contin)
2
QL: 120 in 30 days
(MS Contin)
(MSIR)
(MSIR)
(MSIR)
(Dazidox)
(Oxycodone HCl)
(Alcet)
2
2
2
2
2
3
3
2
2
2
QL: 180 in 30 days
QL: 200 in 30 days
QL: 300 in 30 days
QL: 700 in 30 days
QL: 180 in 30 days
QL: 60 in 30 days
QL: 181 in 30 days
QL: 180 in 30 days
QL: 1300 in 30 days
QL: 180 in 30 days
(Alcet)
2
QL: 240 in 30 days
(Alcet)
2
QL: 360 in 30 days
(Oxycodone HCl/
acetaminophen)
(Endodan)
2
QL: 1800 in 30 days
2
QL: 360 in 30 days
QL: 1800 in 30 days
QL: 360 in 30 days
QL: 90 in 30 days
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
15
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
Drug Tier
Requirements/Limits
OXYCONTIN tab er 12h: 80mg
OXYCONTIN tab er 12h: 10mg, 15mg,
20mg, 30mg, 40mg, 60mg
oxymorphone hcl tab er 12h: 30mg, 40mg (Opana ER)
oxymorphone hcl tab er 12h: 5mg, 7.5mg, (Opana ER)
10mg, 15mg, 20mg
oxymorphone hcl tablet
(Opana)
tramadol hcl tablet
(Ultram)
(Ultracet)
tramadol hcl/acetaminophen
Nonsteroidal Anti-inflammatory Agents
CALDOLOR
CELEBREX
(Celebrex)
celecoxib
(Choline Sal/mag
choline sal/mag salicylate
Salicylate)
(Cataflam)
diclofenac potassium
diclofenac sodium gel (gram)
(Solaraze)
diclofenac sodium tab er 24h, tablet dr
(Voltaren)
(Arthrotec 50)
diclofenac sodium/misoprostol
(Diflunisal)
diflunisal
(Etodolac)
etodolac
(Fenoprofen Calcium)
fenoprofen calcium
FLECTOR
(Ansaid)
flurbiprofen
ibuprofen oral susp
(Ibuprofen)
ibuprofen tablet
(Motrin)
(Indocin I.v.)
indomethacin sodium
indomethacin capsule er
(Indocin SR)
2
5
2
2
2
2
2
3
2
2
1
2
2
indomethacin capsule: 50mg
(Indomethacin)
2
indomethacin capsule: 25mg
(Indomethacin)
2
ketoprofen
ketorolac tromethamine vial: 15mg/ml
(Ketoprofen)
(Ketorolac
Tromethamine)
(Toradol)
2
2
QL: 40 in 30 days
2
QL: 20 in 30 days
ketorolac tromethamine cartridge: 30mg/
ml; syringe
3
3
QL: 120 in 30 days
QL: 60 in 30 days
2
2
QL: 120 in 30 days
QL: 60 in 30 days
2
2
2
QL: 180 in 30 days
QL: 240 in 30 days
QL: 240 in 30 days
4
3
2
2
QL: 60 in 30 days
QL: 60 in 30 days
PA
PA-HRM
PA-HRM, QL: 60 in 30
days
PA-HRM, QL: 120 in 30
days
PA-HRM, QL: 240 in 30
days
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
16
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
ketorolac tromethamine tablet, vial: 30mg/
ml
ketorolac tromethamine cartridge: 15mg/ml
mefenamic acid
meloxicam tablet
meloxicam oral susp
nabumetone
naproxen sodium
naproxen tablet
naproxen oral susp, tablet dr
piroxicam
salsalate
sulindac
tolmetin sodium
VOLTAREN
Drug Tier
Requirements/Limits
(Toradol)
2
QL: 20 in 30 days
(Toradol)
(Ponstel)
(Mobic)
(Mobic)
(Relafen)
(Anaprox)
(Naprosyn)
(Naprosyn)
(Feldene)
(Salflex)
(Clinoril)
(Tolmetin Sodium)
2
2
1
2
2
1
1
2
2
2
2
2
3
QL: 40 in 30 days
(Topical Gel)
Anesthetics
Local Anesthetics
lidocaine hcl disp syrin, solution: 4%
lidocaine hcl jel (ml), jel/pf app, solution:
2%, 40mg/ml
lidocaine hcl vial: 10mg/ml
lidocaine hcl vial: 20mg/ml
(Xylocaine)
(Xylocaine)
2
2
(Xylocaine)
2
(Xylocaine)
2
4
PA BvD
Only)
PA BvD
Only)
PA BvD
Only)
PA BvD
Only)
PA BvD
Only)
PA
PA BvD
Only)
PA
2
2
2
PA, QL: 90 in 30 days
PA, QL: 90 in 30 days
lidocaine hcl/pf ampul: 15mg/ml, 40mg/ml (Xylocaine-MPF)
2
lidocaine hcl/pf vial: 5mg/ml
(Xylocaine-MPF)
2
lidocaine oint. (g)
(Lidocaine)
2
lidocaine adh. patch
lidocaine/prilocaine
(Lidoderm)
(EMLA)
2
2
LIDODERM
(PA for ESRD
(PA for ESRD
(PA for ESRD
(PA for ESRD
(PA for ESRD
(PA for ESRD
Anti-addiction/substance Abuse Treatment Agents
Anti-addiction/substance Abuse Treatment Agents
(Campral)
acamprosate calcium
(Subutex)
buprenorphine hcl
(Suboxone)
buprenorphine hcl/naloxone hcl
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
17
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
Drug Tier
Requirements/Limits
CHANTIX tablet: 0.5mg, 1mg
CHANTIX tab ds pk
3
3
CHANTIX tablet: 1mg
3
QL: 168 in 84 days
QL: 53 in 28 days
(Chantix - first month of
therapy)
QL: 56 in 28 days
(Chantix - continuing
months of therapy)
2
2
2
2
4
3
PA, QL: 90 in 30 days
(Xanax XR)
(Xanax)
2
2
QL: 60 in 30 days
QL: 90 in 30 days
(Librium)
(Klonopin)
(Klonopin)
2
2
2
QL: 120 in 30 days
QL: 300 in 30 days
QL: 90 in 30 days
(Tranxene T-tab)
(Tranxene T-tab)
2
2
QL: 120 in 30 days
QL: 60 in 30 days
(Diastat)
(Diazepam)
(Diazepam)
(Valium)
(Prosom)
4
2
2
2
2
2
estazolam tablet: 1mg
(Prosom)
2
flurazepam hcl capsule: 30mg
(Dalmane)
2
flurazepam hcl capsule: 15mg
(Dalmane)
2
lorazepam syringe, vial
(Ativan)
2
disulfiram
naloxone hcl syringe: 0.4mg/ml; vial
naloxone hcl syringe: 1mg/ml
naltrexone hcl
NICOTROL
ZUBSOLV
(Antabuse)
(Naloxone HCl)
(Naloxone HCl)
(Revia)
Antianxiety Agents
Benzodiazepines
alprazolam tab er 24h: 1mg, 2mg, 3mg
alprazolam tab er 24h: 0.5mg; tab rapdis,
tablet
chlordiazepoxide hcl
clonazepam tab rapdis: 2mg; tablet: 2mg
clonazepam tab rapdis: 0.125mg, 0.25mg,
0.5mg, 1mg; tablet: 0.5mg, 1mg
clorazepate dipotassium tablet: 15mg
clorazepate dipotassium tablet: 3.75mg,
7.5mg
DIASTAT ACUDIAL kit: 12.5-15-20
diazepam kit
diazepam vial
diazepam oral conc, solution
diazepam tablet
estazolam tablet: 2mg
QL: 10 in 28 days
QL: 1200 in 30 days
QL: 120 in 30 days
PA-HRM, QL: 30 in 30
days
PA-HRM, QL: 60 in 30
days
PA-HRM, QL: 30 in 30
days
PA-HRM, QL: 60 in 30
days
QL: 2 in 30 days
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
18
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
lorazepam tablet
lorazepam oral conc
midazolam hcl syrup
midazolam hcl vial
midazolam hcl/pf
ONFI oral susp
(Ativan)
(Lorazepam)
(Midazolam HCl)
(Midazolam HCl)
(Midazolam HCl/PF)
ONFI tablet
Drug Tier
Requirements/Limits
2
2
2
2
2
4
QL: 90 in 30 days
QL: 150 in 30 days
QL: 10 in 30 days
QL: 2 in 30 days
QL: 2 in 30 days
PA NSO, QL: 480 in 30
days
PA NSO, QL: 60 in 30
days
PA-HRM, QL: 120 in 30
days
PA-HRM, QL: 30 in 30
days
PA-HRM, QL: 120 in 30
days
PA-HRM, QL: 60 in 30
days
4
temazepam capsule: 7.5mg
(Restoril)
2
temazepam capsule: 15mg, 22.5mg, 30mg
(Restoril)
2
triazolam tablet: 0.125mg
(Halcion)
2
triazolam tablet: 0.25mg
(Halcion)
2
Antibacterials
Aminoglycosides
BETHKIS
gentamicin in nacl, iso-osm piggyback:
100mg/50ml
gentamicin in nacl, iso-osm piggyback:
70mg/50ml, 80mg/100ml, 80mg/50ml,
90mg/100ml, 100mg/0.1l, 120mg/0.1l
gentamicin sulfate
gentamicin sulfate/pf
neomycin sulfate
streptomycin sulfate
TOBI PODHALER
tobramycin in 0.225% nacl
tobramycin sulfate
tobramycin/sodium chloride piggyback:
60mg/50ml
tobramycin/sodium chloride piggyback:
80mg/100ml
Antibacterials, Miscellaneous
bacitracin vial: 50000unit
(Gentamicin In Nacl,
Iso-osm)
(Gentamicin In Nacl,
Iso-osm)
(Garamycin)
(Gentamicin Sulfate/
PF)
(Neomycin Sulfate)
(Streptomycin Sulfate)
(Tobi)
(Nebcin)
(Tobramycin/sodium
Chloride)
(Tobramycin/sodium
Chloride)
(Bacitracin)
5
2
PA BvD
2
2
2
2
2
5
5
2
2
QL: 224 in 28 days
PA BvD
2
2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
19
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
chloramphenicol sod succ
clindamycin hcl
clindamycin palmitate hcl
clindamycin phosphate vial port
clindamycin phosphate/d5w
colistin (colistimethate na)
Drug Tier
(Chloramphenicol Sod
Succ)
(Cleocin HCl)
(Cleocin Palmitate)
(Cleocin Phosphate)
(Cleocin Phosphate In
D5w)
(Coly-mycin M
Parenteral)
CUBICIN
linezolid
methenamine hippurate
nitrofurantoin macrocrystal
2
2
2
2
2
2
5
(Zyvox)
(Urex)
(Macrodantin/
Macrobid)
5
2
2
SYNERCID
trimethoprim
vancomycin hcl capsule
vancomycin hcl vial: 5g, 10g
(Trimethoprim)
(Vancocin HCl)
(Vancomycin HCl)
5
2
5
2
vancomycin hcl vial: 750mg
(Vancomycin HCl)
2
vancomycin hcl/d5w
(Vancomycin HCl/
D5W)
2
VANCOMYCIN HCL
XIFAXAN tablet: 200mg
XIFAXAN tablet: 550mg
ZYVOX
Cephalosporins
cefaclor capsule, susp recon
cefadroxil
cefazolin sodium
4
5
5
5
(Ceclor)
(Cefadroxil)
(Ancef)
Requirements/Limits
PA BvD (PA for ESRD
Only)
PA-HRM, QL: 120 in 30
days (High Risk Med.
QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use of
nitrofurantoin drugs)
PA BvD (PA for ESRD
Only)
PA BvD (PA for ESRD
Only)
(IV Piggyback)
PA, QL: 9 in 30 days
ST, QL: 60 in 30 days
2
2
2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
20
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
cefazolin sodium/dextrose,iso
cefdinir
cefditoren pivoxil tablet: 200mg
cefditoren pivoxil tablet: 400mg
cefepime hcl
CEFEPIME
CEFEPIME-DEXTROSE
cefotaxime sodium vial: 10g
cefotaxime sodium vial: 1g, 2g, 500mg
cefoxitin sodium
cefoxitin sodium/dextrose,iso
cefpodoxime proxetil
cefprozil
ceftazidime pentahydrate vial port
ceftazidime pentahydrate vial: 2g, 6g,
500mg
ceftazidime pentahydrate vial: 1g
ceftibuten dihydrate
ceftriaxone na/dextrose,iso
ceftriaxone sodium
cefuroxime axetil
cefuroxime sodium
cefuroxime sodium/dextrose,iso
cephalexin
MEFOXIN froz.piggy
SUPRAX tab chew, tablet
TAZICEF IN DEXTROSE
TEFLARO
Macrolides
azithromycin
clarithromycin
DIFICID
ERY-TAB
ERYTHROCIN LACTOBIONATE vial
port: 1g
Drug Tier
(Cefazolin Sodium/
dextrose, Iso)
(Omnicef)
(Spectracef)
(Spectracef)
(Maxipime)
(Claforan)
(Claforan)
(Mefoxin)
(Cefoxitin Sodium/
dextrose, Iso)
(Vantin)
(Cefzil)
(Fortaz)
(Fortaz)
(Fortaz)
(Cedax)
(Ceftriaxone Na/
dextrose, Iso)
(Rocephin)
(Ceftin)
(Zinacef)
(Cefuroxime Sodium/
dextrose, Iso)
(Keflex)
(Zithromax)
(Biaxin)
Requirements/Limits
2
2
2
2
2
4
4
2
2
2
2
2
2
2
2
4
2
2
2
2
2
2
1
4
4
4
4
2
2
5
2
4
QL: 20 in 10 days
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
21
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
ERYTHROCIN LACTOBIONATE vial
port: 500mg
erythromycin base capsule dr
erythromycin base tablet, tablet dr
erythromycin ethylsuccinate susp recon:
200mg/5ml
erythromycin ethylsuccinate tablet
erythromycin stearate
Drug Tier
Requirements/Limits
4
(Eryc)
(Erythromycin Base)
(Eryped 200)
2
2
2
(Erythromycin
Ethylsuccinate)
(Erythromycin
Stearate)
2
Miscellaneous B-lactam Antibiotics
(Azactam)
aztreonam
CAYSTON
(Primaxin)
imipenem/cilastatin sodium
INVANZ vial
INVANZ vial port
(Merrem)
meropenem
Penicillins
amoxicillin capsule, susp recon, tab chew, (Amoxil)
tablet
(Augmentin)
amoxicillin/potassium clav
ampicillin sodium vial
(Totacillin-N)
ampicillin sodium vial port
(Totacillin-N)
ampicillin sodium/sulbactam na vial
(Unasyn)
ampicillin sodium/sulbactam na vial port
(Unasyn)
(Ampicillin Trihydrate)
ampicillin trihydrate
BICILLIN C-R
BICILLIN L-A
(Dicloxacillin Sodium)
dicloxacillin sodium
(Nafcillin In
nafcillin in dextrose,iso-osm
Dextrose,iso-osm)
nafcillin sodium vial
(Unipen)
nafcillin sodium vial port
(Unipen)
(Oxacillin Sodium)
oxacillin sodium
(Oxacillin Sodium/
oxacillin sodium/dextrose,iso
dextrose, Iso)
pen g pot/dextrose-water froz.piggy: 1mm/ (Pen G Pot/dextrose50ml
water)
2
2
5
2
4
4
2
LA
1
2
2
2
2
2
1
4
4
2
4
2
2
2
2
2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
22
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
Drug Tier
pen g pot/dextrose-water froz.piggy: 2mm/ (Pen G Pot/dextrose50ml, 3mm/50ml
water)
(Penicillin G
penicillin g potassium
Potassium)
(Penicillin G
penicillin g potassium/d5w
Potassium/D5W)
penicillin g procaine syringe: 1.2mm/2ml (Penicillin G Procaine)
penicillin g procaine syringe: 600000/ml
(Penicillin G Procaine)
(Veetids 500)
penicillin v potassium
(Zosyn)
piperacillin sodium/tazobactam
Quinolones
(Cipro)
ciprofloxacin hcl
(Cipro I.V.)
ciprofloxacin lactate
(Cipro I.V.)
ciprofloxacin lactate/d5w
(Cipro)
ciprofloxacin
levofloxacin tablet
(Levaquin)
levofloxacin solution, vial
(Levaquin)
(Levaquin)
levofloxacin/d5w
(Avelox)
moxifloxacin hcl
(Nalidixic Acid)
nalidixic acid
(Floxin)
ofloxacin
Sulfonamides
(Sulfadiazine)
sulfadiazine
sulfamethoxazole/trimethoprim tablet
(Septra)
sulfamethoxazole/trimethoprim oral susp,
(Sulfamethoxazole/
vial
trimethoprim)
(Azulfidine)
sulfasalazine
Tetracyclines
doxycycline hyclate capsule: 100mg; tablet: (Morgidox)
100mg
doxycycline hyclate capsule: 50mg; tablet: (Morgidox)
20mg; vial
doxycycline monohydrate capsule: 50mg
(Adoxa)
doxycycline monohydrate capsule: 75mg,
(Adoxa)
100mg, 150mg; susp recon, tablet
minocycline hcl capsule, tablet
(Dynacin)
tetracycline hcl capsule
(Ala-tet)
tetracycline hcl oral susp
(Tetracycline HCl)
TYGACIL
2
Requirements/Limits
2
2
2
2
2
2
1
2
2
2
1
2
2
2
2
2
2
1
2
2
2
2
2
2
2
2
2
5
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
23
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
Drug Tier
Requirements/Limits
Anticancer Agents
Anticancer Agents
ABRAXANE
ADCETRIS
5
5
AFINITOR DISPERZ
5
AFINITOR tablet: 2.5mg, 5mg, 7.5mg
5
AFINITOR tablet: 10mg
5
ALIMTA
anastrozole
ARRANON
ARZERRA
AVASTIN
azacitidine
BELEODAQ
bicalutamide
bleomycin sulfate
BOSULIF tablet: 100mg
5
2
5
5
5
5
5
2
2
5
(Arimidex)
(Vidaza)
(Casodex)
(Bleomycin Sulfate)
BOSULIF tablet: 500mg
5
CAPRELSA tablet: 300mg
5
CAPRELSA tablet: 100mg
5
carboplatin
cisplatin
COMETRIQ
(Carboplatin)
(Cisplatin)
cyclophosphamide tablet
cyclophosphamide vial
CYCLOPHOSPHAMIDE
CYRAMZA
cytarabine
cytarabine/pf vial: 2g/20ml
cytarabine/pf vial: 500mg
(Cyclophosphamide)
(Cytoxan)
(Tarabine Pfs)
(Cytarabine/PF)
(Cytarabine/PF)
2
2
5
2
2
4
5
2
2
2
PA NSO, QL: 4 in 21
days
PA NSO, QL: 112 in 28
days
PA NSO, QL: 28 in 28
days
PA NSO, QL: 56 in 28
days
PA NSO
PA NSO
PA NSO
PA BvD
PA NSO, QL: 120 in 30
days
PA NSO, QL: 30 in 30
days
PA NSO, QL: 30 in 30
days
PA NSO, QL: 60 in 30
days
PA NSO, QL: 112 in 28
days
PA BvD, ST
PA BvD
PA BvD, ST
PA NSO
PA BvD
PA BvD
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
24
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
dacarbazine
dactinomycin
decitabine
doxorubicin hcl peg-liposomal
doxorubicin hcl vial: 10mg
DROXIA
ELIGARD syringe: 30mg
ELIGARD syringe: 7.5mg
ELIGARD syringe: 22.5mg
ELIGARD syringe: 45mg
EMCYT
epirubicin hcl
ERBITUX
ERIVEDGE
ETOPOPHOS
etoposide
exemestane
FARESTON
FASLODEX
FIRMAGON
floxuridine
fludarabine phosphate
fluorouracil vial: 500mg/10ml
fluorouracil vial: 500mg/10ml
flutamide
GAZYVA
gemcitabine hcl
GILOTRIF
Drug Tier
(Dtic-Dome IV)
(Dactinomycin)
(Dacogen)
(Doxil)
(Adriamycin RDF)
(Ellence)
(Etoposide)
(Aromasin)
(FUDR)
(Fludara)
(Fluorouracil)
(Fluorouracil)
(Flutamide)
(Gemzar)
2
2
5
5
2
3
4
4
4
5
3
2
5
5
4
2
2
5
5
4
2
2
2
2
2
5
5
5
GLEEVEC tablet: 400mg
5
GLEEVEC tablet: 100mg
5
HALAVEN
5
HERCEPTIN
HEXALEN
5
5
Requirements/Limits
PA BvD
PA BvD
QL: 1 in 112 days
QL: 1 in 28 days
QL: 1 in 84 days
QL: 1 in 168 days
PA NSO
PA NSO, QL: 30 in 30
days
PA BvD
PA BvD
PA BvD
PA NSO, QL: 40 in 28
days
PA NSO, QL: 30 in 30
days
PA NSO, QL: 60 in 30
days
PA NSO, QL: 90 in 30
days
PA NSO, QL: 24 in 28
days
PA NSO
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
25
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
hydroxyurea
ICLUSIG tablet: 45mg
Drug Tier
(Hydrea)
ICLUSIG tablet: 15mg
ifosfamide
ifosfamide/mesna kit: 1g-1g, 3g-1g
IMBRUVICA
2
5
5
(Ifex)
(Ifex-mesnex)
2
5
5
INLYTA tablet: 1mg
5
INLYTA tablet: 5mg
5
ISTODAX
IXEMPRA
JAKAFI
5
5
5
JEVTANA
KADCYLA
KEYTRUDA
KYPROLIS
5
5
5
5
letrozole
LEUKERAN
leuprolide acetate
lomustine
LUPRON DEPOT syringekit: 45mg
LUPRON DEPOT syringekit: 3.75mg,
7.5mg
LUPRON DEPOT syringekit: 11.25mg,
22.5mg
LUPRON DEPOT-PED kit
LUPRON DEPOT-PED syringekit
LYSODREN
MARQIBO
MATULANE
MEGACE ES
megestrol acetate
(Femara)
(Leuprolide Acetate)
(Ceenu)
(Megestrol Acetate)
Requirements/Limits
PA NSO, QL: 30 in 30
days
PA NSO, QL: 60 in 30
days
PA BvD
PA BvD
PA NSO, QL: 120 in 30
days
PA NSO, QL: 180 in 30
days
PA NSO, QL: 60 in 30
days
PA NSO
PA NSO, QL: 60 in 30
days
PA NSO
PA NSO
PA NSO, QL: 6 in 28
days
2
4
2
2
5
5
QL: 1 in 168 days
QL: 1 in 28 days
5
QL: 1 in 84 days
5
5
3
5
QL: 1 in 28 days
QL: 1 in 84 days
PA NSO, QL: 4 in 28
days
5
5
2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
26
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
Drug Tier
MEKINIST tablet: 2mg
5
MEKINIST tablet: 0.5mg
5
melphalan hcl
mercaptopurine
methotrexate sodium
methotrexate sodium/pf
mitomycin
mitoxantrone hcl
MUSTARGEN
NEXAVAR
NILANDRON
ONCASPAR
oxaliplatin
paclitaxel
PERJETA
POMALYST
(Alkeran)
(Purinethol)
(Methotrexate Sodium)
(Methotrexate Sodium/
PF)
(Mitomycin)
(Novantrone)
(Eloxatin)
(Taxol)
5
2
2
2
2
2
3
5
3
5
5
2
5
5
PROLEUKIN
PURIXAN
REVLIMID
5
5
5
RITUXAN
SOLTAMOX
SPRYCEL tablet: 50mg, 70mg, 80mg,
100mg, 140mg
SPRYCEL tablet: 20mg
5
4
5
STIVARGA
5
SUTENT
5
SYLVANT vial: 100mg
SYLVANT vial: 400mg
SYNRIBO
5
5
5
5
Requirements/Limits
PA NSO, QL: 30 in 30
days
PA NSO, QL: 90 in 30
days
PA BvD, ST
PA BvD
PA BvD
PA NSO, QL: 120 in 30
days
PA NSO
PA NSO
PA NSO, QL: 21 in 28
days
LA, PA NSO, QL: 21 in
28 days
PA NSO
PA NSO, QL: 30 in 30
days
PA NSO, QL: 60 in 30
days
PA NSO, QL: 84 in 28
days
PA NSO, QL: 30 in 30
days
PA NSO
PA NSO
PA NSO, QL: 28 in 28
days
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
27
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
Drug Tier
TABLOID
TAFINLAR
tamoxifen citrate
TARCEVA tablet: 25mg, 100mg
3
5
(Nolvadex)
2
5
TARCEVA tablet: 150mg
5
TARGRETIN capsule
5
TARGRETIN gel (gram)
5
TASIGNA
5
TEMODAR
topotecan hcl
TORISEL
5
5
5
TREANDA vial: 180mg/2ml
TREANDA vial: 45mg/0.5ml, 100mg
TRELSTAR syringe: 22.5mg/2ml
TRELSTAR syringe: 3.75mg/2ml
TRELSTAR syringe: 11.25/2ml
tretinoin
TREXALL
TYKERB
VALSTAR
VECTIBIX
VELCADE
vinblastine sulfate
vincristine sulfate
vinorelbine tartrate
VOTRIENT
(Hycamtin)
(Tretinoin)
(Vinblastine Sulfate)
(Vincristine Sulfate)
(Navelbine)
5
5
5
5
5
5
4
5
5
5
5
2
2
2
5
XALKORI
5
XTANDI
5
YERVOY
5
Requirements/Limits
PA NSO, QL: 120 in 30
days
PA NSO, QL: 60 in 30
days
PA NSO, QL: 90 in 30
days
PA NSO, QL: 420 in 30
days
PA NSO, QL: 60 in 28
days
PA NSO, QL: 112 in 28
days
PA NSO (vial only)
PA BvD, QL: 4 in 28
days
QL: 1 in 168 days
QL: 1 in 28 days
QL: 1 in 84 days
(capsule: 10mg)
PA BvD, ST
PA NSO
PA NSO
PA BvD
PA BvD
PA NSO, QL: 120 in 30
days
PA NSO, QL: 60 in 30
days
PA NSO, QL: 120 in 30
days
PA NSO
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
28
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
Drug Tier
Requirements/Limits
ZALTRAP
ZELBORAF
5
5
ZOLADEX implant: 3.6mg
ZOLADEX implant: 10.8mg
ZOLINZA
ZYDELIG
4
4
5
5
PA NSO
PA NSO, QL: 240 in 30
days
QL: 1 in 28 days
QL: 1 in 84 days
ZYKADIA
5
ZYTIGA
5
PA NSO, QL: 60 in 30
days
PA NSO, QL: 140 in 28
days
PA NSO, QL: 120 in 30
days
Anticholinergic Agents
Antimuscarinics/Antispasmodics
atropine sulfate syringe: 0.05mg/ml,
0.1mg/ml
atropine sulfate vial: 0.4mg/ml
propantheline bromide
(Atropine Sulfate)
2
(Atropine Sulfate)
(Propantheline
Bromide)
2
2
Anticonvulsants
Anticonvulsants
APTIOM
BANZEL
carbamazepine
CELONTIN
DILANTIN capsule: 30mg
divalproex sodium
ethosuximide
felbamate
fosphenytoin sodium
FYCOMPA
gabapentin
GABITRIL tablet: 12mg, 16mg
LAMICTAL tb chw dsp: 2mg
lamotrigine tab ds pk
lamotrigine tab er 24, tablet, tb chw dsp
levetiracetam
LUMINAL SODIUM
LYRICA capsule
(Tegretol)
(Depakote ER)
(Zarontin)
(Felbatol)
(Cerebyx)
(Neurontin)
(Lamictal (blue))
(Lamictal)
(Keppra)
4
4
2
3
3
2
2
2
2
4
2
3
4
2
2
2
4
3
ST
ST
ST
QL: 2 in 30 days
QL: 90 in 30 days
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
29
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
LYRICA solution
oxcarbazepine
OXTELLAR XR
PEGANONE
phenobarbital sodium
phenobarbital elixir
phenobarbital tablet: 30mg
phenobarbital tablet: 15mg, 16.2mg,
32.4mg, 60mg, 64.8mg, 97.2mg, 100mg
phenytoin sodium extended
phenytoin sodium syringe
phenytoin sodium vial
phenytoin
POTIGA tablet: 50mg
POTIGA tablet: 200mg, 300mg, 400mg
primidone
QUDEXY XR
SABRIL
tiagabine hcl
topiramate
TRILEPTAL oral susp
TROKENDI XR
valproic acid (as sodium salt)
valproic acid
VIMPAT solution
VIMPAT vial
VIMPAT tablet
zonisamide
Drug Tier
(Trileptal)
(Phenobarbital Sodium)
(Phenobarbital)
(Phenobarbital)
(Phenobarbital)
(Dilantin)
(Phenytoin Sodium)
(Phenytoin Sodium)
(Dilantin)
(Mysoline)
(Gabitril)
(Topamax)
(Depakene)
(Depakene)
(Zonegran)
3
2
4
3
2
2
2
2
2
2
2
2
4
4
2
4
5
2
2
4
4
2
2
4
4
4
2
Requirements/Limits
QL: 900 in 30 days
ST
QL: 2 in 30 days
QL: 1500 in 30 days
QL: 200 in 30 days
QL: 90 in 30 days
ST, QL: 270 in 30 days
ST, QL: 90 in 30 days
ST
ST
ST, QL: 1200 in 30 days
ST, QL: 200 in 5 days
ST, QL: 60 in 30 days
Antidementia Agents
Antidementia Agents
donepezil hcl
EXELON patch td24: 4.6mg/24hr, 9.5mg/
24hr
galantamine hbr cap24h pel
galantamine hbr solution
galantamine hbr tablet
NAMENDA XR cap24 dspk
NAMENDA XR cap spr 24
NAMENDA solution
(Aricept)
2
2
QL: 30 in 30 days
QL: 30 in 30 days
(Razadyne ER)
(Razadyne)
(Razadyne)
2
2
2
3
3
3
QL: 30 in 30 days
QL: 200 in 30 days
QL: 60 in 30 days
QL: 28 in 28 days
QL: 30 in 30 days
QL: 360 in 30 days
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
30
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
NAMENDA tab ds pk
NAMENDA tablet
rivastigmine tartrate
Drug Tier
(Exelon)
Requirements/Limits
3
3
2
QL: 49 in 28 days
QL: 60 in 30 days
QL: 60 in 30 days
2
2
4
2
1
2
2
2
2
2
2
4
2
4
1
2
2
2
2
4
2
4
2
2
2
2
2
4
2
PA-HRM
Antidepressants
Antidepressants
amitriptyline hcl
amoxapine
BRINTELLIX
bupropion hcl
citalopram hydrobromide tablet
citalopram hydrobromide solution
clomipramine hcl
desipramine hcl
doxepin hcl
duloxetine hcl capsule dr: 30mg
duloxetine hcl capsule dr: 20mg, 60mg
EMSAM
escitalopram oxalate
FETZIMA
fluoxetine hcl capsule
fluoxetine hcl capsule dr, solution, tablet
fluvoxamine maleate
imipramine hcl
imipramine pamoate
KHEDEZLA
maprotiline hcl
MARPLAN
mirtazapine
nefazodone hcl
nortriptyline hcl
olanzapine/fluoxetine hcl
paroxetine hcl
PAXIL oral susp
perphenazine/amitriptyline hcl
phenelzine sulfate
PRISTIQ ER
protriptyline hcl
sertraline hcl tablet
(Amitriptyline HCl)
(Amoxapine)
(Wellbutrin XL)
(Celexa)
(Celexa)
(Anafranil)
(Norpramin)
(Doxepin HCl)
(Cymbalta)
(Cymbalta)
(Lexapro)
(Prozac)
(Rapiflux)
(Fluvoxamine Maleate)
(Tofranil)
(Tofranil-PM)
(Maprotiline HCl)
(Remeron)
(Nefazodone HCl)
(Pamelor)
(Symbyax)
(Paxil)
(Perphenazine/
amitriptyline HCl)
(Nardil)
(Vivactil)
(Zoloft)
2
4
2
1
ST
QL: 30 in 30 days
PA-HRM
PA-HRM
QL: 30 in 30 days
QL: 60 in 30 days
QL: 30 in 30 days
ST
PA-HRM
PA-HRM
ST, QL: 30 in 30 days
PA-HRM
ST, QL: 30 in 30 days
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
31
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
sertraline hcl oral conc
SILENOR
SURMONTIL
tranylcypromine sulfate
trazodone hcl
venlafaxine hcl
VIIBRYD
Drug Tier
(Zoloft)
(Parnate)
(Trazodone HCl)
(Effexor XR)
2
3
4
2
1
2
4
Requirements/Limits
QL: 30 in 30 days
PA-HRM
Antidiabetic Agents
Antidiabetic Agents, Miscellaneous
(Precose)
acarbose
BYDUREON PEN
BYDUREON
BYETTA pen injctr: 5mcg/0.02
BYETTA pen injctr: 10mcg/0.04
CYCLOSET
INVOKAMET tablet: 50mg-500mg
INVOKAMET tablet: 50-1000mg, 1501000mg, 150-500mg
INVOKANA tablet: 300mg
INVOKANA tablet: 100mg
JANUMET XR tbmp 24hr: 50mg-500mg,
100-1000mg
JANUMET XR tbmp 24hr: 50-1000mg
JANUMET
JANUVIA
JARDIANCE
JENTADUETO
KORLYM
metformin hcl tab er 24h: 500mg
(Fortamet)
metformin hcl tab er 24
(Fortamet)
metformin hcl tab er 24h: 750mg
(Fortamet)
metformin hcl tablet: 500mg
(Glucophage)
metformin hcl tablet: 1000mg
(Glucophage)
metformin hcl tablet: 850mg
(Glucophage)
(Starlix)
nateglinide
(Actos)
pioglitazone hcl
(Duetact)
pioglitazone hcl/glimepiride
(Actoplus Met)
pioglitazone hcl/metformin hcl
PRANDIMET
2
3
3
3
3
4
3
3
QL: 90 in 30 days
QL: 4 in 28 days
QL: 4 in 28 days
QL: 1.2 in 28 days
QL: 2.4 in 28 days
QL: 180 in 30 days
ST, QL: 120 in 30 days
ST, QL: 60 in 30 days
3
3
3
ST, QL: 30 in 30 days
ST, QL: 60 in 30 days
QL: 30 in 30 days
3
3
3
3
3
5
2
2
2
1
1
1
2
2
2
2
3
QL: 60 in 30 days
QL: 60 in 30 days
QL: 30 in 30 days
ST, QL: 30 in 30 days
QL: 60 in 30 days
PA, QL: 112 in 28 days
QL: 120 in 30 days
QL: 60 in 30 days
QL: 90 in 30 days
QL: 120 in 30 days
QL: 60 in 30 days
QL: 90 in 30 days
QL: 90 in 30 days
QL: 30 in 30 days
QL: 30 in 30 days
QL: 90 in 30 days
QL: 150 in 30 days
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
32
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
repaglinide
SYMLINPEN 120
SYMLINPEN 60
TRADJENTA
TRULICITY
VICTOZA 3-PAK
Insulins
HUMALOG MIX 50-50 insuln pen
HUMALOG MIX 50-50 vial
HUMALOG MIX 75-25 insuln pen
HUMALOG MIX 75-25 vial
HUMALOG cartridge
HUMALOG vial
HUMULIN 70/30 KWIKPEN
HUMULIN 70-30
HUMULIN N KWIKPEN
HUMULIN N
HUMULIN R
LANTUS SOLOSTAR
LANTUS
NOVOLIN 70-30 cartridge
NOVOLIN 70-30 vial
NOVOLIN N cartridge
NOVOLIN N vial
NOVOLIN R cartridge
NOVOLIN R vial
NOVOLOG FLEXPEN
NOVOLOG MIX 70-30 FLEXPEN
NOVOLOG MIX 70-30
NOVOLOG
Sulfonylureas
glimepiride tablet: 1mg, 2mg
glimepiride tablet: 4mg
glipizide tab er 24: 2.5mg, 5mg
glipizide tab er 24: 10mg
glipizide tablet: 10mg
glipizide tablet: 5mg
glipizide/metformin hcl tablet: 2.5-500mg,
5mg-500mg
(Prandin)
(Amaryl)
(Amaryl)
(Glucotrol XL)
(Glucotrol XL)
(Glucotrol)
(Glucotrol)
(Metaglip)
Drug Tier
Requirements/Limits
2
4
4
3
3
4
QL: 240 in 30 days
PA, QL: 10.8 in 28 days
PA, QL: 6 in 28 days
QL: 30 in 30 days
PA, QL: 4 in 28 days
PA, QL: 9 in 28 days
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
QL: 30 in 28 days
QL: 40 in 28 days
QL: 30 in 28 days
QL: 40 in 28 days
QL: 30 in 28 days
QL: 40 in 28 days
QL: 30 in 28 days
QL: 40 in 28 days
QL: 30 in 28 days
QL: 40 in 28 days
QL: 40 in 28 days
QL: 30 in 28 days
QL: 40 in 28 days
QL: 30 in 28 days
QL: 40 in 28 days
QL: 30 in 28 days
QL: 40 in 28 days
QL: 30 in 28 days
QL: 40 in 28 days
QL: 30 in 28 days
QL: 30 in 28 days
QL: 40 in 28 days
QL: 40 in 28 days
1
1
2
2
1
1
2
QL: 30 in 30 days
QL: 60 in 30 days
QL: 30 in 30 days
QL: 60 in 30 days
QL: 120 in 30 days
QL: 60 in 30 days
QL: 120 in 30 days
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
33
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
Drug Tier
Requirements/Limits
QL: 60 in 30 days
PA-HRM, QL: 120 in 30
days
PA-HRM, QL: 240 in 30
days
PA-HRM, QL: 280 in 30
days
PA-HRM, QL: 120 in 30
days
PA-HRM, QL: 180 in 30
days
PA-HRM, QL: 400 in 30
days
PA-HRM, QL: 120 in 30
days
PA-HRM, QL: 240 in 30
days
QL: 120 in 30 days
QL: 60 in 30 days
QL: 180 in 30 days
glipizide/metformin hcl tablet: 2.5-250mg
glyburide tablet: 5mg
(Metaglip)
(Micronase)
2
2
glyburide tablet: 2.5mg
(Micronase)
2
glyburide tablet: 1.25mg
(Micronase)
2
glyburide,micronized tablet: 6mg
(Glynase)
2
glyburide,micronized tablet: 3mg
(Glynase)
2
glyburide,micronized tablet: 1.5mg
(Glynase)
2
glyburide/metformin hcl tablet: 2.5-500mg, (Glucovance)
5mg-500mg
glyburide/metformin hcl tablet: 1.25-250mg (Glucovance)
2
tolazamide tablet: 250mg
tolazamide tablet: 500mg
tolbutamide
2
2
2
(Tolazamide)
(Tolazamide)
(Tolbutamide)
2
Antifungals
Antifungals
ABELCET
AMBISOME
amphotericin b
CANCIDAS
ciclopirox olamine
ciclopirox
clotrimazole
clotrimazole/betamethasone dip
econazole nitrate
fluconazole in nacl,iso-osm
fluconazole
flucytosine
griseofulvin, microsize tablet
itraconazole
ketoconazole
miconazole nitrate
NOXAFIL oral susp, tablet dr
(Amphotericin B)
(Loprox)
(Penlac)
(Mycelex)
(Lotrisone)
(Spectazole)
(Diflucan in Saline)
(Diflucan)
(Ancobon)
(Grifulvin V)
(Sporanox)
(Kuric)
(Monistat 3)
5
5
2
5
2
2
2
2
2
2
2
5
2
2
2
2
5
PA BvD
PA BvD
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
34
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
nystatin
nystatin/triamcin
terbinafine hcl
voriconazole vial
voriconazole susp recon, tablet
Drug Tier
(Nystatin)
(Mycogen II)
(Lamisil)
(Vfend IV)
(Vfend)
2
2
2
2
5
(Clemastine Fumarate)
(Clemastine Fumarate)
(Cyproheptadine HCl)
(Benadryl)
(Diphenhydramine
HCl)
(Xyzal)
(P-epd Tan/chlor-tan)
(Promethazine HCl)
2
2
2
2
2
Requirements/Limits
Antihistamines
Antihistamines
clemastine fumarate syrup, tablet: 2.68mg
clemastine fumarate tablet: 1.34mg
cyproheptadine hcl
diphenhydramine hcl vial
diphenhydramine hcl syringe
levocetirizine dihydrochloride
p-epd tan/chlor-tan
promethazine hcl
2
2
2
PA-HRM
PA-HRM
PA-HRM
PA-HRM
Anti-infectives (Skin and Mucous Membrane)
Anti-infectives (Skin and Mucous Membrane)
AVC
(Cleocin)
clindamycin phosphate
(Metrogel-vaginal)
metronidazole
(Sod Propion/inositol/
sod propion/inositol/aa14/urea
aa14/urea)
(Terazol 3)
terconazole
3
2
2
2
2
Antimigraine Agents
Antimigraine Agents
dihydroergotamine mesylate ampul
dihydroergotamine mesylate spray/pump
ERGOMAR
naratriptan hcl
rizatriptan benzoate
sumatriptan succinate tablet
sumatriptan succinate pen injctr: 4mg/
0.5ml
sumatriptan succinate pen injctr: 6mg/
0.5ml; vial
sumatriptan
zolmitriptan
(D.H.E. 45)
(Migranal)
(Amerge)
(Maxalt Mlt)
(Imitrex)
(Imitrex)
2
2
4
2
2
2
2
QL: 30 in 28 days
QL: 4 in 28 days
QL: 40 in 28 days
QL: 18 in 28 days
QL: 18 in 28 days
QL: 18 in 28 days
QL: 4 in 28 days
(Imitrex)
2
QL: 4 in 28 days
(Imitrex)
(Zomig)
2
2
QL: 12 in 28 days
QL: 12 in 28 days
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
35
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
Drug Tier
Requirements/Limits
Antimycobacterials
Antimycobacterials
CAPASTAT SULFATE
dapsone
ethambutol hcl
isoniazid tablet
isoniazid solution
PASER
PRIFTIN
pyrazinamide
rifabutin
rifampin
RIFATER
SIRTURO
TRECATOR
(Dapsone)
(Myambutol)
(Isoniazid)
(Isoniazid)
(Pyrazinamide)
(Mycobutin)
(Rifadin)
4
2
2
1
2
4
4
2
2
2
4
5
4
PA, QL: 188 in 168 days
Antinausea Agents
Antinausea Agents
dimenhydrinate
dronabinol
EMEND capsule: 40mg, 125mg
EMEND capsule: 80mg
EMEND cap ds pk
EMEND vial
granisetron hcl vial
granisetron hcl tablet
granisetron hcl/pf
meclizine hcl
ondansetron hcl
ondansetron hcl/pf
ondansetron
prochlorperazine edisylate
prochlorperazine maleate tablet
prochlorperazine maleate supp.rect
promethazine hcl supp.rect, tablet
TRANSDERM-SCOP
(Dimenhydrinate)
(Marinol)
(Kytril)
(Kytril)
(Kytril)
(Antivert)
(Zofran)
(Zofran)
(Zofran Odt)
(Compazine)
(Compazine)
(Compazine)
(Promethazine HCl)
2
2
4
4
4
4
2
2
2
2
2
2
2
2
1
2
2
4
PA BvD, QL: 1 per fill
PA BvD, QL: 2 per fill
PA BvD, QL: 3 per fill
QL: 2 in 28 days
PA BvD
PA BvD
PA BvD
PA-HRM
QL: 10 in 30 days
Antiparasite Agents
Antiparasite Agents
ALBENZA
4
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
36
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
ALINIA
atovaquone
atovaquone/proguanil hcl
BILTRICIDE
chloroquine phosphate
COARTEM
DARAPRIM
hydroxychloroquine sulfate
ivermectin
mefloquine hcl
metronidazole
metronidazole/sodium chloride
NEBUPENT
paromomycin sulfate
PENTAM 300
pentamidine isethionate
PRIMAQUINE
quinine sulfate
STROMECTOL
Drug Tier
(Mepron)
(Malarone)
(Aralen Phosphate)
(Plaquenil)
(Stromectol)
(Lariam)
(Flagyl)
(Metro IV)
(Paromomycin Sulfate)
(Pentamidine
Isethionate)
(Qualaquin)
4
5
2
4
2
4
4
2
2
2
2
2
4
2
4
2
4
2
3
Requirements/Limits
PA BvD
QL: 90 in 30 days
PA, QL: 42 in 7 days
Antiparkinsonian Agents
Antiparkinsonian Agents
amantadine hcl
APOKYN
AZILECT
benztropine mesylate tablet
bromocriptine mesylate
cabergoline
carbidopa
carbidopa/levodopa tablet, tablet er
carbidopa/levodopa/entacapone
entacapone
NEUPRO
pramipexole di-hcl
ropinirole hcl
selegiline hcl
trihexyphenidyl hcl
(Amantadine HCl)
(Benztropine Mesylate)
(Parlodel)
(Cabergoline)
(Lodosyn)
(Sinemet 10-100)
(Stalevo 50)
(Comtan)
(Mirapex)
(Requip)
(Eldepryl)
(Trihexyphenidyl HCl)
2
5
3
2
2
2
2
2
2
2
3
2
2
2
2
QL: 60 in 30 days
PA-HRM
ST, QL: 30 in 30 days
PA-HRM
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
37
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
Drug Tier
Requirements/Limits
Antipsychotic Agents
Antipsychotic Agents
ABILIFY DISCMELT tab rapdis: 15mg
ABILIFY DISCMELT tab rapdis: 10mg
ABILIFY MAINTENA
ABILIFY vial
ABILIFY tablet: 5mg, 10mg, 15mg, 20mg,
30mg
ABILIFY tablet: 2mg
ABILIFY solution
chlorpromazine hcl ampul, tablet
chlorpromazine hcl oral conc.
clozapine tablet: 200mg
clozapine tablet: 100mg
clozapine tablet: 25mg, 50mg
clozapine tab rapdis
FANAPT tablet
FANAPT tab ds pk
FAZACLO tab rapdis: 200mg
FAZACLO tab rapdis: 150mg
fluphenazine decanoate
fluphenazine hcl
GEODON vial
haloperidol decanoate
haloperidol lactate
haloperidol
INVEGA SUSTENNA syringe: 39mg/0.25
INVEGA SUSTENNA syringe: 78mg/
0.5ml
INVEGA SUSTENNA syringe: 117mg/
0.75
INVEGA SUSTENNA syringe: 156mg/ml
INVEGA SUSTENNA syringe: 234mg/1.5
INVEGA tab er 24: 1.5mg, 3mg, 9mg
INVEGA tab er 24: 6mg
LATUDA tablet: 20mg, 40mg, 60mg,
120mg
(Chlorpromazine HCl)
(Chlorpromazine HCl)
(Clozaril)
(Clozaril)
(Clozaril)
(Fazaclo)
(Fluphenazine
Decanoate)
(Fluphenazine HCl)
(Haloperidol
Decanoate)
(Haloperidol Lactate)
(Haloperidol)
3
3
5
3
3
QL: 60 in 30 days
QL: 90 in 30 days
QL: 1 in 28 days
QL: 161.2 in 28 days
QL: 30 in 30 days
3
3
2
2
2
2
2
2
4
4
4
4
2
QL: 60 in 30 days
QL: 900 in 30 days
2
4
2
QL: 135 in 30 days
QL: 270 in 30 days
QL: 90 in 30 days
ST, QL: 90 in 30 days
ST, QL: 60 in 30 days
ST, QL: 8 in 28 days
ST, QL: 120 in 30 days
ST, QL: 180 in 30 days
QL: 6 in 28 days
2
2
3
3
QL: 0.25 in 28 days
QL: 0.5 in 28 days
5
QL: 0.75 in 28 days
5
5
4
4
4
QL: 1 in 28 days
QL: 1.5 in 28 days
ST, QL: 30 in 30 days
ST, QL: 60 in 30 days
ST, QL: 30 in 30 days
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
38
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
LATUDA tablet: 80mg
loxapine succinate
olanzapine tab rapdis: 20mg
olanzapine tab rapdis: 5mg, 10mg, 15mg;
tablet, vial
ORAP
perphenazine
quetiapine fumarate
RISPERDAL CONSTA
risperidone tab rapdis: 3mg, 4mg
risperidone solution
risperidone tab rapdis: 0.25mg, 0.5mg,
1mg, 2mg; tablet
SAPHRIS
SEROQUEL XR tab er 24h: 200mg
SEROQUEL XR tab er 24h: 50mg,
150mg, 300mg, 400mg
thioridazine hcl oral conc.
thioridazine hcl tablet
thiothixene
trifluoperazine hcl
VERSACLOZ
ziprasidone hcl
ZYPREXA RELPREVV
Drug Tier
(Loxitane)
(Zyprexa Zydis)
(Zyprexa)
(Perphenazine)
(Seroquel)
(Risperdal M-tab)
(Risperdal)
(Risperdal)
(Thioridazine HCl)
(Thioridazine HCl)
(Navane)
(Trifluoperazine HCl)
(Geodon)
Requirements/Limits
4
2
2
2
ST, QL: 60 in 30 days
QL: 31 in 30 days
QL: 30 in 30 days
4
2
2
4
2
2
2
QL: 90 in 30 days
QL: 4 in 28 days
QL: 120 in 30 days
QL: 480 in 30 days
QL: 60 in 30 days
4
4
4
ST, QL: 60 in 30 days
ST, QL: 30 in 30 days
ST, QL: 60 in 30 days
2
2
2
2
5
2
5
PA-HRM
PA-HRM
ST, QL: 540 in 30 days
QL: 60 in 30 days
QL: 2 in 28 days
Antivirals (Systemic)
Antiretrovirals
abacavir sulfate
abacavir/lamivudine/zidovudine
APTIVUS solution
APTIVUS capsule
ATRIPLA
COMPLERA
CRIXIVAN
didanosine
EDURANT
EMTRIVA
EPIVIR HBV solution
EPIVIR solution
EPZICOM
(Ziagen)
(Trizivir)
(Videx EC)
2
5
4
5
5
5
4
2
5
3
4
4
5
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
39
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
FUZEON
INTELENCE tablet: 25mg
INTELENCE tablet: 100mg, 200mg
INVIRASE
ISENTRESS powd pack, tab chew
ISENTRESS tablet
KALETRA tablet: 100mg-25mg
KALETRA solution, tablet: 200mg-50mg
lamivudine solution
lamivudine tablet
lamivudine/zidovudine
LEXIVA oral susp
LEXIVA tablet
nevirapine
NORVIR
PREZISTA tablet: 75mg, 150mg
PREZISTA oral susp
PREZISTA tablet: 400mg
PREZISTA tablet: 600mg, 800mg
RESCRIPTOR
RETROVIR vial
REYATAZ capsule
REYATAZ powd pack
SELZENTRY
stavudine
STRIBILD
SUSTIVA capsule: 100mg
SUSTIVA capsule: 50mg, 200mg; tablet
TIVICAY
TRIUMEQ
TRUVADA
VIDEX
VIRACEPT
VIRAMUNE XR tab er 24h: 100mg
VIREAD
ZIAGEN solution
zidovudine
Antivirals, Miscellaneous
foscarnet sodium
Drug Tier
(Retrovir)
5
3
5
5
3
5
3
5
2
2
5
3
5
2
4
3
4
5
5
4
3
5
5
5
2
5
4
4
5
5
5
3
4
3
5
4
2
(Foscavir)
2
(Epivir)
(Epivir)
(Combivir)
(Viramune)
(Zerit)
Requirements/Limits
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
40
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
RELENZA
rimantadine hcl
SYNAGIS
TAMIFLU capsule: 75mg
TAMIFLU capsule: 45mg
TAMIFLU susp recon
TAMIFLU capsule: 30mg
Hcv Antivirals
HARVONI
OLYSIO
SOVALDI
VIEKIRA PAK
Interferons
INTRON A pen ij kit
INTRON A vial
PEGASYS PROCLICK
PEGASYS
PEGINTRON REDIPEN
PEGINTRON
SYLATRON 4-PACK
Nucleosides and Nucleotides
acyclovir sodium
acyclovir
adefovir dipivoxil
BARACLUDE tablet
entecavir
famciclovir
ganciclovir sodium
ribavirin capsule, tablet
TYZEKA
valacyclovir hcl
VALCYTE tablet
valganciclovir hcl
VIRAZOLE
Drug Tier
(Flumadine)
(Acyclovir Sodium)
(Zovirax)
(Hepsera)
(Baraclude)
(Famvir)
(Cytovene)
(Rebetol)
(Valtrex)
(Valcyte)
Requirements/Limits
4
2
5
3
3
3
3
QL: 42 in 180 days
QL: 48 in 180 days
QL: 540 in 180 days
QL: 84 in 180 days
5
5
5
5
PA, QL: 30 in 30 days
PA, QL: 28 in 28 days
PA, QL: 28 in 28 days
PA, QL: 112 in 28 days
4
4
5
5
5
5
5
PA NSO
PA NSO
PA
PA
PA
PA
PA NSO, QL: 4 in 28
days
2
2
5
5
5
2
2
2
5
2
5
5
5
PA BvD
PA BvD
PA BvD
Blood Products/modifiers/volume Expanders
Anticoagulants
CEPROTIN
ELIQUIS
5
3
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
41
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
enoxaparin sodium syringe: 40mg/0.4ml
enoxaparin sodium syringe: 30mg/0.3ml
enoxaparin sodium syringe: 60mg/0.6ml
enoxaparin sodium syringe: 80mg/0.8ml
enoxaparin sodium vial
enoxaparin sodium syringe: 120mg/.8ml
enoxaparin sodium syringe: 150mg/ml
enoxaparin sodium syringe: 100mg/ml
fondaparinux sodium syringe: 5mg/0.4ml
fondaparinux sodium syringe: 2.5mg/0.5
fondaparinux sodium syringe: 7.5mg/0.6
fondaparinux sodium syringe: 10mg/0.8ml
heparin sod,pork in 0.45% nacl
heparin sodium,porcine
heparin sodium,porcine/d5w iv soln:
12500/250, 25000/500
heparin sodium,porcine/d5w iv soln: 20k/
500ml
heparin sodium,porcine/ns/pf
heparin sodium,porcine/pf
IPRIVASK
PRADAXA
warfarin sodium
XARELTO
Blood Formation Modifiers
EPOGEN
GRANIX
LEUKINE
MOZOBIL
NEULASTA
NEUMEGA
NEUPOGEN
PROCRIT vial: 2000/ml, 3000/ml, 4000/
ml, 20000/2ml
PROCRIT vial: 20000/ml
Drug Tier
Requirements/Limits
(Lovenox)
(Lovenox)
(Lovenox)
(Lovenox)
(Lovenox)
(Lovenox)
(Lovenox)
(Lovenox)
(Arixtra)
(Arixtra)
(Arixtra)
(Arixtra)
(Heparin Sod,pork In
0.45% NaCl)
(Hep-lock)
2
2
2
2
2
5
5
5
2
2
2
2
2
QL: 13.6 in 30 days
QL: 18 in 30 days
QL: 20.4 in 30 days
QL: 27.2 in 30 days
QL: 36 in 30 days
QL: 27.2 in 30 days
QL: 34 in 30 days
QL: 36 in 30 days
QL: 12 in 30 days
QL: 15 in 30 days
QL: 18 in 30 days
QL: 24 in 30 days
2
PA BvD (PA for ESRD
Only)
(Heparin Sodium,
porcine/D5W)
(Heparin Sodium,
porcine/D5W)
(Heparin Sodium,
porcine/ns/PF)
(Monoject Prefill
Advanced)
2
(Coumadin)
2
2
2
5
4
1
3
PA BvD (PA for ESRD
Only)
PA, QL: 24 in 28 days
QL: 60 in 30 days
(includes Jantoven)
3
5
5
5
5
5
5
3
PA, QL: 12 in 28 days
PA, QL: 12 in 28 days
5
PA, QL: 12 in 28 days
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
42
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
Drug Tier
PROCRIT vial: 40000/ml
PROMACTA
Hematologic Agents, Miscellaneous
aminocaproic acid solution, tablet
(Amicar)
(Agrylin)
anagrelide hcl
(Protamine Sulfate)
protamine sulfate
tranexamic acid tablet
tranexamic acid vial
Platelet-aggregation Inhibitors
AGGRENOX
BRILINTA
cilostazol
clopidogrel bisulfate
EFFIENT
pentoxifylline
Volume Expanders
ALBUKED-25
ALBUKED-5
ALBUMIN (HUMAN)
ALBUMINAR-25
ALBUMINAR-5
ALBURX
ALBUTEIN
BUMINATE
FLEXBUMIN
KEDBUMIN
PLASBUMIN-25
PLASBUMIN-5
STERILE DILUENT
5
5
2
2
2
(Lysteda)
(Tranexamic Acid)
2
2
(Pletal)
(Plavix)
4
3
2
2
3
2
(Trental)
Requirements/Limits
PA, QL: 6 in 28 days
PA, QL: 30 in 30 days
PA BvD (PA for ESRD
Only)
QL: 30 in 30 days
QL: 60 in 30 days
QL: 30 in 30 days
4
4
4
4
4
4
4
4
4
4
4
4
4
Caloric Agents
Caloric Agents
AMINO ACIDS
AMINOSYN II with ELECTROLYTES
AMINOSYN II iv soln: 10%
AMINOSYN II iv soln: 15%
AMINOSYN II iv soln: 7%
AMINOSYN II iv soln: 8.5%
AMINOSYN M
4
4
4
4
4
4
4
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
43
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
AMINOSYN with ELECTROLYTES iv
soln: 7%
AMINOSYN with ELECTROLYTES iv
soln: 8.5%
AMINOSYN iv soln: 10%
AMINOSYN iv soln: 3.5%
AMINOSYN iv soln: 7%
AMINOSYN iv soln: 8.5%
AMINOSYN-HBC
AMINOSYN-PF iv soln: 10%
AMINOSYN-PF iv soln: 7%
AMINOSYN-RF
CLINIMIX E iv soln: 2.75%
CLINIMIX E iv soln: 2.75%
CLINIMIX E iv soln: 4.25%
CLINIMIX E iv soln: 4.25%
CLINIMIX E iv soln: 4.25%
CLINIMIX E iv soln: 5%
CLINIMIX E iv soln: 5%
CLINIMIX E iv soln: 5%
CLINIMIX E iv soln: 5%
CLINIMIX iv soln: 2.75%
CLINIMIX iv soln: 4.25%
CLINIMIX iv soln: 4.25%
CLINIMIX iv soln: 4.25%
CLINIMIX iv soln: 4.25%
CLINIMIX iv soln: 5%
CLINIMIX iv soln: 5%
CLINIMIX iv soln: 5%
CLINISOL
cysteine hcl
dextrose 10 % and 0.2 % nacl dehp fr bg
dextrose 10 % and 0.2 % nacl iv soln
dextrose 10 % and 0.45 % nacl
dextrose 10 % in water
Drug Tier
(Cysteine HCl)
(Dextrose 10 % and 0.2
% NaCl)
(Dextrose 10 % and 0.2
% NaCl)
(Dextrose 10 % and
0.45 % NaCl)
(Dextrose 10 % in
Water)
Requirements/Limits
4
PA BvD
4
PA BvD
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
2
2
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
2
2
2
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
44
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
dextrose 2.5 % and 0.45 % nacl
dextrose 2.5 % in water
dextrose 2.5% in half ringers
dextrose 20 % in water
dextrose 25 % in water
dextrose 40 % in water
dextrose 5 % and 0.3 % nacl
dextrose 5 % and 0.9 % nacl
dextrose 5 % in water
dextrose 5 %-0.2 % nacl
dextrose 5 %-0.45 % nacl
dextrose 5% in ringers
dextrose 5%-lactated ringers
dextrose 50 % in water
dextrose 60 % in water
dextrose 70 % in water
DEXTROSE with SODIUM CHLORIDE
FREAMINE HBC
FREAMINE III
fructose 10 %
HEPATAMINE
HEPATASOL
INTRALIPID emulsion: 10%
Drug Tier
(Dextrose 2.5 % and
0.45 % NaCl)
(Dextrose 2.5 % in
Water)
(Dextrose 2.5% In Half
Ringers)
(Dextrose 20 % in
Water)
(Dextrose 25 % in
Water)
(Dextrose 40 % in
Water)
(Dextrose 5 % and 0.3
% NaCl)
(Dextrose 5 % and 0.9
% NaCl)
(Dextrose 5 % in
Water)
(Dextrose 5 %-0.2 %
NaCl)
(Dextrose 5 %-0.45 %
NaCl)
(Dextrose 5% In
Ringers)
(Dextrose 5%-Lactated
Ringers)
(Dextrose 50 % in
Water)
(Dextrose 60 % in
Water)
(Dextrose 70 % in
Water)
(Fructose 10 %)
Requirements/Limits
2
2
PA BvD
2
2
PA BvD
2
PA BvD
2
PA BvD
2
2
2
2
2
2
2
2
PA BvD
2
PA BvD
2
PA BvD
2
4
4
2
4
4
4
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
45
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
INTRALIPID emulsion: 20%, 30%
KABIVEN
LIPOSYN II
LIPOSYN III emulsion: 10%, 20%
LIPOSYN III emulsion: 30%
NEPHRAMINE
NOVAMINE
NUTRILIPID
PERIKABIVEN
potassium chloride in lr-d5
Drug Tier
(Potassium Chloride In
Lr-d5)
PREMASOL iv soln: 10%
PREMASOL iv soln: 6%
PROCALAMINE
PROSOL
QUICK MIX with LYTES
TRAVAMULSION
TRAVASOL W/DEXTROSE
TRAVASOL W/ELECTROLYTES iv
soln.: 5.5%
TRAVASOL W/ELECTROLYTES iv
soln.: 8.5%
TRAVASOL with DEXTROSE iv soln:
8.5%
TRAVASOL with DEXTROSE iv soln:
8.5%
TRAVASOL with DEXTROSE iv soln:
8.5%
TRAVASOL with ELECTROLYTES
TRAVASOL iv soln.
TRAVASOL iv soln: 10%
TRAVASOL iv soln: 5.5%
TRAVASOL iv soln: 8.5%
TRAVERT IN NORMAL SALINE
TRAVERT iv soln: 10%
TRAVERT iv soln: 5%
TROPHAMINE iv soln: 10%
TROPHAMINE iv soln: 6%
Requirements/Limits
4
4
4
4
4
4
4
4
4
2
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
4
4
4
4
4
4
4
4
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
4
4
4
4
4
4
4
4
4
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
46
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
Drug Tier
Requirements/Limits
Cardiovascular Agents
Alpha-adrenergic Agents
clonidine hcl
clonidine hcl/chlorthalidone
(Catapres)
(Clonidine HCl/
chlorthalidone)
(Catapres-tts 1)
clonidine patch tdwk: 0.1mg/24hr, 0.2mg/
24hr
clonidine patch tdwk: 0.3mg/24hr
(Catapres-tts 1)
(Cardura)
doxazosin mesylate
(Tenex)
guanfacine hcl
(Proamatine)
midodrine hcl
NORTHERA
(Vazculep)
phenylephrine hcl
(Minipress)
prazosin hcl
Angiotensin II Receptor Antagonists
BENICAR HCT
BENICAR
(Atacand)
candesartan cilexetil
(Atacand HCT)
candesartan/hydrochlorothiazid
DIOVAN
(Avapro)
irbesartan
(Avalide)
irbesartan/hydrochlorothiazide
(Cozaar)
losartan potassium
(Hyzaar)
losartan/hydrochlorothiazide
(Micardis)
telmisartan
(Micardis HCT)
telmisartan/hydrochlorothiazid
TRIBENZOR
(Diovan)
valsartan
(Diovan HCT)
valsartan/hydrochlorothiazide
Angiotensin-Converting Enzyme Inhibitors
(Lotensin)
benazepril hcl
(Lotensin HCT)
benazepril/hydrochlorothiazide
(Capoten)
captopril
(Capozide)
captopril/hydrochlorothiazide
(Vasotec)
enalapril maleate
(Vaseretic)
enalapril/hydrochlorothiazide
(Enalaprilat Dihydrate)
enalaprilat dihydrate
(Monopril)
fosinopril sodium
(Monopril HCT)
fosinopril/hydrochlorothiazide
1
2
2
QL: 4 in 28 days
2
2
2
2
5
2
2
QL: 8 in 28 days
3
3
2
2
3
2
2
1
2
2
2
3
2
2
PA-HRM
PA, QL: 180 in 30 days
ST
ST
ST
ST
1
2
2
2
1
2
2
2
2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
47
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
lisinopril
lisinopril/hydrochlorothiazide
moexipril hcl
moexipril/hydrochlorothiazide
perindopril erbumine
quinapril hcl
quinapril/hydrochlorothiazide
ramipril
trandolapril
Antiarrhythmic Agents
amiodarone hcl tablet
disopyramide phosphate
flecainide acetate
lidocaine hcl
lidocaine hcl/d5w/pf iv soln: 2mg/ml, 8mg/
ml
lidocaine hcl/pf syringe
mexiletine hcl
MULTAQ
procainamide hcl capsule, tablet sa
procainamide hcl vial
PRONESTYL
propafenone hcl
quinidine gluconate tablet er
quinidine sulfate
TIKOSYN
Beta-Adrenergic Blocking Agents
acebutolol hcl
atenolol
atenolol/chlorthalidone
betaxolol hcl
bisoprolol fumarate
bisoprolol fumarate/hctz
BYSTOLIC
carvedilol
esmolol hcl
labetalol hcl
metoprolol succinate
metoprolol tartrate tablet
Drug Tier
(Zestril)
(Prinzide)
(Univasc)
(Uniretic)
(Aceon)
(Accupril)
(Accuretic)
(Altace)
(Mavik)
1
1
2
2
2
2
2
2
2
(Cordarone)
(Norpace)
(Tambocor)
(Lidocaine HCl)
(Lidocaine HCl/d5w/
PF)
(Lidocaine HCl/PF)
(Mexitil)
2
2
2
2
2
(Procainamide HCl)
(Procainamide HCl)
(Rythmol)
(Quinidine Gluconate)
(Quinidine Sulfate)
(Sectral)
(Tenormin)
(Tenoretic 50)
(Kerlone)
(Zebeta)
(Ziac)
(Coreg)
(Brevibloc)
(Trandate)
(Toprol XL)
(Lopressor)
Requirements/Limits
2
2
3
2
2
4
2
2
2
3
2
1
1
2
2
2
3
1
2
2
2
1
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
48
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
metoprolol tartrate vial
metoprolol/hydrochlorothiazide
nadolol
pindolol
propranolol hcl
propranolol/hydrochlorothiazid
Drug Tier
(Metoprolol Tartrate)
(Lopressor HCT)
(Corgard)
(Pindolol)
(Propranolol HCl)
(Propranolol/
hydrochlorothiazid)
(Betapace)
(Timolol Maleate)
2
2
2
2
2
2
2
2
sotalol hcl
timolol maleate
Calcium-channel Blocking Agents
diltiazem hcl tablet
(Cardizem CD)
diltiazem hcl cap er 12h, cap er 24h, cap er (Cardizem CD)
deg, capsule er, tab er 24h, vial, vial port
verapamil hcl tablet
(Calan)
verapamil hcl cap24h pct, cap24h pel,
(Calan)
tablet er
verapamil hcl syringe
(Verapamil HCl)
Cardiovascular Agents, Miscellaneous
ADRENALIN
DEMSER
digoxin syringe
(Digoxin)
digoxin tablet
(Lanoxin)
2
4
2
2
DIGOXIN
3
dobutamine hcl
dobutamine hcl/d5w
dopamine hcl
dopamine hcl/d5w
ephedrine sulfate
epinephrine ampul, auto injct: 0.15/0.15
epinephrine auto injct: 0.3mg/0.3; syringe
EPIPEN 2-PAK
EPIPEN JR 2-PAK
ethanolamine oleate
(Dobutamine HCl)
(Dobutamine HCl/
D5W)
(Dopamine HCl)
(Dopamine HCl/D5W)
(Ephedrine Sulfate)
(Adrenaclick)
(Adrenaclick)
(Ethanolamine Oleate)
Requirements/Limits
1
2
1
2
2
2
2
2
2
2
2
2
3
3
2
PA-HRM
PA-HRM, QL: 30 in 30
days (High Risk Med
for Ages 65 and Older
and Dose is Greater
Than 125mcg Per Day)
PA-HRM, QL: 300 in 30
days (solution)
PA BvD
PA BvD
PA BvD
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
49
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
FIRAZYR
hydralazine hcl
hydralazine/hydrochlorothiazid
Drug Tier
(Apresoline)
(Hydralazine/
hydrochlorothiazid)
LANOXIN tablet: 62.5mcg, 187.5mcg
milrinone lactate
milrinone lactate/d5w
norepinephrine bitartrate
papaverine hcl
RANEXA
Dihydropyridines
amlodipine besylate
amlodipine besylate/benazepril
AZOR
CLEVIPREX
EXFORGE HCT
EXFORGE
felodipine
isradipine
nicardipine hcl capsule
nifedipine tab er 24, tablet er
Diuretics
amiloride hcl
amiloride/hydrochlorothiazide
bumetanide
chlorothiazide sodium
chlorothiazide
chlorthalidone
DYRENIUM
furosemide solution, syringe: 10mg/ml; vial
furosemide syringe: 10mg/ml
furosemide tablet
hydrochlorothiazide
5
2
2
4
(Milrinone Lactate)
(Primacor in 5%
Dextrose)
(Levophed Bitartrate)
(Papaverine HCl)
5
5
(Norvasc)
(Lotrel)
1
2
3
4
2
2
2
2
2
2
(Plendil)
(Dynacirc)
(Nicardipine HCl)
(Adalat CC)
(Midamor)
(Amiloride/
hydrochlorothiazide)
(Bumex)
(Sodium Diuril)
(Chlorothiazide)
(Chlorthalidone)
(Furosemide)
(Furosemide)
(Lasix)
(Microzide)
Requirements/Limits
2
2
3
PA-HRM, QL: 30 in 30
days (High Risk Med
for Ages 65 and Older
and Dose is Greater
Than 125mcg Per Day)
PA BvD
PA BvD
PA BvD
PA
ST
ST
ST
2
2
2
2
1
1
4
2
2
1
1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
50
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
(Lozol)
indapamide
(Methyclothiazide)
methyclothiazide
(Zaroxolyn)
metolazone
torsemide tablet
(Demadex)
(Maxzide)
triamterene/hydrochlorothiazid
Dyslipidemics
(Caduet)
amlodipine/atorvastatin
(Lipitor)
atorvastatin calcium
(Questran)
cholestyramine (with sugar)
(Questran Light)
cholestyramine/aspartame
(Colestid)
colestipol hcl
CRESTOR
(Tricor)
fenofibrate nanocrystallized
fenofibrate tablet
(Lofibra)
(Antara)
fenofibrate,micronized
(Trilipix)
fenofibric acid (choline)
(Fibricor)
fenofibric acid
(Lopid)
gemfibrozil
(Mevacor)
lovastatin
(Niaspan)
niacin
(Lovaza)
omega-3 acid ethyl esters
(Pravachol)
pravastatin sodium
(Zocor)
simvastatin
VASCEPA
WELCHOL
ZETIA
Renin-Angiotensin-Aldosterone System Inhibitors
(Inspra)
eplerenone
(Aldactazide)
spironolact/hydrochlorothiazid
(Aldactone)
spironolactone
Vasodilators
isosorbide dinitrate tablet, tablet er
(Isordil)
isosorbide dinitrate tab subl
(Isosorbide Dinitrate)
(Imdur)
isosorbide mononitrate
(Minoxidil)
minoxidil
NITRO-BID
nitroglycerin patch td24: 0.1mg/hr, 0.2mg/ (Nitro-dur)
hr, 0.6mg/hr
Drug Tier
Requirements/Limits
1
2
2
2
2
2
2
2
2
2
3
2
2
2
2
2
2
1
2
2
1
1
3
3
4
QL: 30 in 30 days
2
2
2
2
1
2
2
3
2
QL: 30 in 30 days
(includes Minitran)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
51
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
Drug Tier
nitroglycerin patch td24: 0.4mg/hr
(Nitro-dur)
2
nitroglycerin vial: 50mg/10ml
nitroglycerin vial: 5mg/ml
nitroglycerin/d5w
NITROSTAT
PROGLYCEM
(Nitroglycerin)
(Nitroglycerin)
(Nitroglycerin/D5W)
2
2
2
3
4
Requirements/Limits
QL: 60 in 30 days
(includes Minitran)
Central Nervous System Agents
Central Nervous System Agents
AMPYRA
caffeine citrated
caffeine/sodium benzoate
clonidine hcl
dexmethylphenidate hcl tablet
dextroamphetamine sulfate capsule er
dextroamphetamine sulfate tablet: 5mg,
10mg
dextroamphetamine/amphetamine cap er
24h: 5mg, 10mg, 15mg
dextroamphetamine/amphetamine cap er
24h: 20mg, 25mg, 30mg; tablet
flumazenil
guanfacine hcl
INTUNIV
lithium carbonate
lithium citrate
methylphenidate hcl cpbp 30-70, cpbp 5050: 40mg; tab er 24: 18mg, 27mg, 54mg
methylphenidate hcl cpbp 50-50: 30mg; tab
er 24: 36mg
methylphenidate hcl solution
methylphenidate hcl tablet, tablet er
NUEDEXTA
QUILLIVANT XR
riluzole
SAVELLA
STRATTERA
XENAZINE
5
2
2
PA, QL: 60 in 30 days
(Cafcit)
(Caffeine/sodium
Benzoate)
(Kapvay)
(Focalin)
(Dexedrine)
(Dexedrine)
2
2
2
2
QL: 60 in 30 days
QL: 120 in 30 days
QL: 180 in 30 days
(Adderall XR)
2
QL: 30 in 30 days
(Adderall)
2
QL: 60 in 30 days
(Romazicon)
(Intuniv)
(Eskalith)
(Lithium Citrate)
(Concerta)
2
2
4
2
2
2
QL: 30 in 30 days
(Concerta)
2
QL: 60 in 30 days
(Methylin)
(Ritalin)
2
2
3
3
2
3
3
5
QL: 900 in 30 days
QL: 90 in 30 days
QL: 60 in 30 days
(Rilutek)
QL: 30 in 30 days
QL: 60 in 30 days
PA, QL: 112 in 28 days
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
52
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
Drug Tier
Requirements/Limits
Contraceptives
Contraceptives
desog-e.estradiol/e.estradiol
desogestrel-ethinyl estradiol
ELLA
ethinyl estradiol/drospirenone
ethynodiol d-ethinyl estradiol
levonorgestrel
levonorgestrel-ethin estradiol tablet: 0.10.02, 0.15-0.03, 6-5-10
levonorgestrel-ethin estradiol tbdspk 3mo
l-norgest-eth estr/ethin estra tbdspk 3mo:
100-20(84)
l-norgest-eth estr/ethin estra tbdspk 3mo:
150-30(84)
norelgestromin/ethin.estradiol
noreth-ethinyl estradiol/iron
norethindrone ac-eth estradiol
norethindrone
norethindrone-e.estradiol-iron
norethindrone-ethinyl estrad tablet: 0.40.035, 0.5-0.035, 1mg-35mcg, 7-9-5,
7daysx3, 10-11
norethindrone-mestranol
norgestimate-ethinyl estradiol
norgestrel-ethinyl estradiol
NUVARING
(Mircette)
(Desogen)
(Yaz)
(Demulen 1/50-28)
(Plan B)
(Nordette-28)
2
2
3
2
2
2
2
(Seasonale)
(Seasonique)
2
2
QL: 91 in 84 days
QL: 91 in 84 days
(Seasonique)
2
QL: 91 in 84 days
(Ortho Evra)
(Femcon Fe)
(Loestrin)
(Nor-Q-D)
(Loestrin Fe)
(Modicon)
2
2
2
2
2
2
QL: 3 in 28 days
(Ortho-novum)
(Ortho-cyclen)
(Ovral-21)
2
2
2
3
ST, QL: 1 in 28 days
Dental And Oral Agents
Dental And Oral Agents
cevimeline hcl
chlorhexidine gluconate
pilocarpine hcl
triamcinolone acetonide
(Evoxac)
(Peridex)
(Salagen)
(Kenalog In Orabase)
2
2
2
2
(Soriatane)
(Zovirax)
4
5
2
Dermatological Agents
Dermatological Agents, Other
8-MOP
acitretin
acyclovir
QL: 30 in 30 days
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
53
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
alcohol antiseptic pads
aluminum chloride
ammonium lactate
ANACAINE
calcipotriene
calcitriol
CONDYLOX gel (gram)
FLUOROPLEX
fluorouracil
imiquimod
isotretinoin capsule: 10mg, 20mg, 40mg
mafenide acetate
methoxsalen, rapid
PANRETIN
PICATO gel (ea): 0.05%
PICATO gel (ea): 0.015%
podofilox
podophyllum resin
potassium hydroxide
SANTYL
silver nitrate applicator
VALCHLOR
ZOVIRAX cream (g)
Dermatological Antibacterials
clindamycin phosphate gel (gram), lotion,
med. swab, solution
erythromycin base/ethanol
gentamicin sulfate
metronidazole
mupirocin calcium
mupirocin
neomy sulf/polymyxin b sulfate
selenium sulfide suspension
selenium sulfide shampoo
silver nitrate
Drug Tier
(Alcohol Antiseptic
Pads)
(Drysol)
(Lac-hydrin)
(Dovonex)
(Vectical)
(Carac)
(Aldara)
(Accutane)
(Sulfamylon)
(Oxsoralen-ultra)
(Condylox)
(Pododerm)
(Potassium Hydroxide)
(Silver Nitrate
Applicator)
Requirements/Limits
1
2
2
4
2
2
4
4
2
2
2
2
5
5
3
3
2
2
2
4
2
5
3
(Cleocin T)
2
(A-T-S)
(Gentamicin Sulfate)
(Nydamax)
(Bactroban)
(Centany)
(Neosporin G.U.
Irrigant)
(Selenium Sulfide)
(Selseb)
(Silver Nitrate)
2
2
2
2
2
2
PA NSO, QL: 24 in 30
days
QL: 2 in 56 days
QL: 3 in 56 days
QL: 15 in 30 days
2
2
2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
54
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
Drug Tier
(Silvadene)
silver sulfadiazine
(Klaron)
sulfacetamide sodium
Dermatological Anti-inflammatory Agents
(Aclovate)
alclometasone dipropionate
(Del-beta)
betamethasone dipropionate
(Betamethasone
betamethasone valerate
Valerate)
(Diprolene AF)
betamethasone/propylene glyc
clobetasol propionate cream (g), foam, gel (Temovate)
(gram), lotion, oint. (g), shampoo, solution
(Cloderm)
clocortolone pivalate
CORDRAN oint. (g)
desonide cream (g), oint. (g)
(Desowen)
(Topicort)
desoximetasone
ELIDEL
fluocinonide cream (g): 0.05%; gel (gram), (Vanos)
oint. (g), solution
fluticasone propionate cream (g), oint. (g) (Cutivate)
(Ultravate)
halobetasol propionate
(Nuzon)
hydrocortisone acetate/aloe v
(Carmol HC)
hydrocortisone acetate/urea
(Hydrocortisone
hydrocortisone butyrate
Butyrate)
(Hydrocortisone
hydrocortisone valerate
Valerate)
hydrocortisone cream(gm)
(Hydrocortisone)
hydrocortisone cream (g), cream/appl,
(Hytone)
enema, lotion, oint. (g)
(Elocon)
mometasone furoate
(Dermatop)
prednicarbate
PROTOPIC
2
2
4
PROTOPIC
4
tacrolimus
triamcinolone acetonide cream (g), lotion,
oint. (g): 0.025%, 0.1%, 0.5%
triamcinolone acetonide oint. (g): 0.05%
(Protopic)
(Triamcinolone
Acetonide)
(Triderm)
Requirements/Limits
2
2
2
2
2
2
2
2
4
2
2
3
2
PA (PA for Ages < 2)
2
2
2
2
2
2
2
2
PA (0.03%; PA for
Ages < 2)
PA (0.1%; PA for Ages
< 15)
2
2
2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
55
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
Dermatological Retinoids
adapalene cream (g), gel (gram): 0.1%
TAZORAC cream (g)
tretinoin microspheres
tretinoin cream (g): 0.025%, 0.05%, 0.1%;
gel (gram): 0.01%, 0.025%
Scabicides and Pediculicides
malathion
permethrin
Drug Tier
(Differin)
(Retin-a Micro)
(Retin-A)
2
4
2
2
(Ovide)
(Elimite)
2
2
(Needles, Insulin
Disposable)
(Syring Wndl,disp,insul,0.3 Ml)
(Syring Wndl,disp,insul,0.5 Ml)
(Syringe &
Needle,insulin,1 Ml)
2
Requirements/Limits
PA
PA
Devices
Devices
needles, insulin disposable
syring w-ndl,disp,insul,0.3 ml
syring w-ndl,disp,insul,0.5 ml
syringe & needle,insulin,1 ml
2
2
2
Enzyme Replacement/modifiers
Enzyme Replacement/modifiers
ADAGEN
ALDURAZYME
CEREZYME
CIMZIA
CREON
ELAPRASE
ELITEK
FABRAZYME
KRYSTEXXA
KUVAN
LINZESS
lipase/protease/amylase
LOTRONEX
LUMIZYME
MYOZYME
NAGLAZYME
ORFADIN
PULMOZYME
(Zenpep)
5
5
5
5
3
5
5
5
5
5
3
2
5
5
5
5
5
5
PA
QL: 30 in 30 days
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
56
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
VIMIZIM
VPRIV
ZAVESCA
ZENPEP
Drug Tier
5
5
5
3
Requirements/Limits
PA
QL: 90 in 30 days
Eye, Ear, Nose, Throat Agents
Eye, Ear, Nose, Throat Agents, Miscellaneous
AKTEN
(Iopidine)
apraclonidine hcl
atropine sulfate oint. (g)
(Atropine Sulfate)
atropine sulfate drops
(Isopto Atropine)
azelastine hcl spray/pump
(Astelin)
azelastine hcl drops
(Optivar)
(Carteolol HCl)
carteolol hcl
(Cromolyn Sodium)
cromolyn sodium
CYCLOGYL drops: 0.5%
(Cyclogyl)
cyclopentolate hcl
CYSTARAN
(Elestat)
epinastine hcl
(Isopto Homatropine)
homatropine hbr
ipratropium bromide spray: 42mcg
(Atrovent)
ipratropium bromide spray: 21mcg
(Atrovent)
LACRISERT
(Naphazoline HCl/
naphazoline hcl/antazoline
antazoline)
(Patanase)
olopatadine hcl
PATADAY
PATANOL
(Mydfrin)
phenylephrine hcl
(Ophthetic)
proparacaine hcl
(Proparacaine/
proparacaine/fluorescein sod
fluorescein Sod)
(Tetcaine)
tetracaine hcl
Eye, Ear, Nose, Throat Anti-infectives Agents
(Vosol)
acetic acid
(Bacitracin)
bacitracin
(Polycin-b)
bacitracin/polymyxin b sulfate
CIPRODEX
ciprofloxacin hcl droperette
(Cetraxal)
ciprofloxacin hcl drops
(Ciloxan)
4
2
2
2
2
2
2
2
3
2
5
2
2
2
2
3
2
2
3
3
2
2
2
QL: 30 in 25 days
QL: 15 in 10 days
QL: 30 in 28 days
QL: 30.5 in 30 days
ST
ST
2
2
2
2
3
2
2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
57
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
COLY-MYCIN S
erythromycin base
gatifloxacin
gentamicin sulfate
levofloxacin
MOXEZA
NATACYN
neo/polymyx b sulf/dexameth
neomy sulf/bacitra/polymyxin b
neomy sulf/bacitrac zn/poly/hc
neomycin sulfate/dex na ph
neomycin/polymyxin b sulf/hc
neomycin/polymyxn b/gramicidin
ofloxacin
polymyxin b sulf/trimethoprim
sulfacetamide sodium
sulfacetamide/prednisolone sp
Drug Tier
(Ilotycin)
(Zymaxid)
(Garamycin)
(Quixin)
(Maxitrol)
(Neo-polycin)
(Triple Antibiotic HC)
(Neomycin Sulfate/dex
Na Ph)
(Oticin HC)
(Neosporin)
(Floxin)
(Polytrim)
(Sulfac)
(Sulfacetamide/
prednisolone Sp)
TOBRADEX ST
(Tobrex)
tobramycin
(Viroptic)
trifluridine
VIGAMOX
ZYLET
Eye, Ear, Nose, Throat Anti-inflammatory Agents
ALREX
(Bromfenac Sodium)
bromfenac sodium
dexamethasone sod phosphate drops
(Ak-dex)
(Voltaren)
diclofenac sodium
DUREZOL
(FML)
fluorometholone
(Ocufen)
flurbiprofen sodium
(Flonase)
fluticasone propionate
ILEVRO
(Acular)
ketorolac tromethamine
LOTEMAX
NASONEX
NEVANAC
(Prednisol)
prednisolone sod phosphate
Requirements/Limits
4
2
2
2
2
3
3
2
2
2
2
2
2
2
2
2
2
3
2
2
3
3
3
2
2
2
3
2
2
2
3
2
3
4
3
2
QL: 16 in 30 days
QL: 34 in 28 days
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
58
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
PROLENSA
RESTASIS
Drug Tier
3
3
Requirements/Limits
QL: 60 in 30 days
Gastrointestinal Agents
Antiulcer Agents And Acid Suppressants
CARAFATE oral susp
(Cimetidine HCl)
cimetidine hcl
(Tagamet)
cimetidine
(Tagamet)
cimetidine
(Nexium I.v.)
esomeprazole sodium
(Famotidine In
famotidine in nacl,iso-osm/pf
Nacl,iso-osm/PF)
famotidine tablet
(Pepcid)
famotidine tablet
(Pepcid)
(Famotidine/PF)
famotidine/pf
(Prevacid)
lansoprazole
(Prevpac)
lansoprazole/amoxiciln/clarith
(Cytotec)
misoprostol
(Prilosec)
omeprazole
(Protonix)
pantoprazole sodium
ranitidine hcl tablet
(Zantac)
ranitidine hcl syrup, vial
(Zantac)
ranitidine hcl syrup, vial
(Zantac)
sucralfate tablet
(Carafate)
sucralfate oral susp
(Sucralfate)
Gastrointestinal Agents, Other
AMITIZA
BUPHENYL tablet
(Gastrocrom)
cromolyn sodium
(Bentyl)
dicyclomine hcl
(Lomotil)
diphenoxylate hcl/atropine
(Robinul)
glycopyrrolate
(Isopropamide/
isopropamide/prochlorperazine
prochlorperazine)
lactulose solution: 10; syrup
(Lactulose)
lactulose solution: 10g/15ml
(Lactulose)
(Loperamide HCl)
loperamide hcl
(Pamine)
methscopolamine bromide
metoclopramide hcl disp syrin
(Metoclopramide HCl)
metoclopramide hcl solution, vial
(Metoclopramide HCl)
3
2
2
2
2
2
(Rx Product Only)
1
1
2
2
2
2
2
2
1
2
2
2
2
(Rx Product Only)
3
5
5
2
2
2
2
QL: 60 in 30 days
(Rx Product Only)
(Rx Product Only)
(Rx Product Only)
2
2
2
2
2
2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
59
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
metoclopramide hcl tablet
NUTRESTORE
RELISTOR syringe: 12mg/0.6ml
RELISTOR syringe: 8mg/0.4ml
ursodiol
Laxatives
MOVIPREP
peg 3350/na sulf,bicarb,cl/kcl
polyethylene glycol 3350
sodium chloride/nahco3/kcl/peg
Phosphate Binders
calcium acetate
calcium carbonate/mag carb/fa
PHOSLYRA
RENAGEL
RENVELA
sodium polystyrene sulfonate oral susp
sodium polystyrene sulfonate enema
Drug Tier
(Reglan)
(Actigall)
(Golytely)
(Gavilyte-N)
(Nulytely with Flavor
Packs)
(Phoslo)
(Calcium Carbonate/
mag Carb/fa)
(Sodium Polystyrene
Sulfonate)
(Sps)
1
4
4
4
2
Requirements/Limits
PA, QL: 28 in 28 days
PA, QL: 28 in 28 days
3
2
2
2
2
2
4
3
3
2
2
Genitourinary Agents
Antispasmodics, Urinary
oxybutynin chloride tab er 24, tablet
(Ditropan)
(Detrol LA)
tolterodine tartrate
TOVIAZ
(Sanctura)
trospium chloride
Genitourinary Agents, Miscellaneous
(Uroxatral)
alfuzosin hcl
(Flomax)
tamsulosin hcl
(Hytrin)
terazosin hcl
2
2
3
2
2
2
1
Heavy Metal Antagonists
Heavy Metal Antagonists
deferoxamine mesylate
DEPEN
edetate disodium
EXJADE tab disper: 125mg
EXJADE tab disper: 250mg, 500mg
FERRIPROX
(Desferal)
(Edetate Disodium)
2
4
2
4
5
5
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
60
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
sodium thiosulfate
SYPRINE
Drug Tier
(Sodium Thiosulfate)
Requirements/Limits
2
5
Hormonal Agents, Stimulant/replacement/modifying
Androgens
ANDRODERM
ANDROGEL gel md pmp: 20.25/1.25
ANDROGEL gel packet: 1.25g-1.62, 2.5g1.62%
ANDROGEL gel md pmp: 1.25g(1%); gel
packet: 25mg(1%), 50mg(1%)
danazol
fluoxymesterone
oxandrolone
testosterone cypionate
testosterone enanthate
testosterone gel packet
Estrogens and Antiestrogens
COMBIPATCH
(Danocrine)
(Fluoxymesterone)
(Oxandrin)
(Testosterone
Cypionate)
(Delatestryl)
(Androgel)
3
3
3
PA, QL: 30 in 30 days
PA, QL: 150 in 30 days
PA, QL: 150 in 30 days
3
PA, QL: 300 in 30 days
2
2
2
2
PA
2
2
PA, QL: 5 in 28 days
PA, QL: 150 in 30 days
3
PA-HRM, QL: 8 in 28
days
PA-HRM
DUAVEE
ESTRACE cream/appl
estradiol valerate vial: 10mg/ml
estradiol valerate vial: 20mg/ml, 40mg/ml
estradiol patch tdwk
(Delestrogen)
(Delestrogen)
(Climara)
3
3
2
2
2
estradiol tablet
estradiol patch tdsw
(Estrace)
(Vivelle-dot)
2
2
estradiol/norethindrone acet tablet: 0.50.1mg, 1mg-0.5mg
ESTRASORB
(Activella)
2
estropipate
FEMRING
MENEST
norethindrone ac-eth estradiol
PREMARIN cream/appl, vial
PREMARIN tablet
(Ogen)
4
(Femhrt)
2
4
4
2
3
3
PA-HRM, QL: 4 in 28
days
PA-HRM
PA-HRM, QL: 8 in 28
days
PA-HRM
PA-HRM, QL: 97.44 in
28 days
PA-HRM
QL: 1 in 84 days
PA-HRM
PA-HRM
PA-HRM
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
61
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
PREMPHASE
PREMPRO
raloxifene hcl
VAGIFEM
VIVELLE-DOT
Drug Tier
(Evista)
Glucocorticoids/mineralocorticoids
A-HYDROCORT
(Celestone)
betamet acet/betamet na ph
(Cortisone Acetate)
cortisone acetate
(Dexamethasone
dexamethasone acetate
Acetate)
(Dexamethasone Sod
dexamethasone sod phosphate
Phosphate)
dexamethasone tablet
(Dexamethasone)
dexamethasone elixir
(Dexamethasone)
(Fludrocortisone
fludrocortisone acetate
Acetate)
(Hydrocortisone Sod
hydrocortisone sod succinate
Succinate)
(Cortef)
hydrocortisone
(Depo-medrol)
methylprednisolone acetate
methylprednisolone sod succ vial: 40mg,
(A-methapred)
125mg
methylprednisolone sod succ vial: 500mg, (A-methapred)
1000mg
(Medrol)
methylprednisolone
(Prednisolone Acetate)
prednisolone acetate
prednisolone sod phosphate solution
(Orapred)
prednisone tablet
(Prednisone)
prednisone solution
(Prednisone)
prednisone tab ds pk
(Sterapred Ds)
SOLU-CORTEF vial: 100mg/2ml
(Triamcinolone
triamcinolone acetonide
Acetonide)
Pituitary
desmopressin acetate tablet, vial
(DDAVP)
desmopressin acetate solution
(Desmopressin Acetate)
desmopressin acetate spray/pump
(Desmopressin Acetate)
Requirements/Limits
3
3
2
3
3
PA-HRM
PA-HRM
4
2
2
2
PA BvD
PA BvD
PA BvD
PA BvD
2
PA BvD
1
2
2
PA BvD
PA BvD
2
PA BvD
2
2
2
PA BvD
PA BvD
PA BvD
2
PA BvD
2
2
2
1
2
2
4
2
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
2
2
2
QL: 18 in 28 days
PA-HRM, QL: 8 in 28
days
QL: 15 in 30 days
QL: 15 in 30 days
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
62
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
GENOTROPIN syringe: 0.2mg/0.25
GENOTROPIN various dosage and/or
strengths are available
HUMATROPE
INCRELEX
NORDITROPIN FLEXPRO
NORDITROPIN NORDIFLEX
NUTROPIN AQ NUSPIN
NUTROPIN
octreotide acetate syringe, vial: 100mcg/
ml, 200mcg/ml
octreotide acetate vial: 1000mcg/ml
OMNITROPE cartridge: 10mg/1.5ml
OMNITROPE cartridge: 5mg/1.5ml; vial
PREGNYL
SAIZEN cartridge, vial: 5mg
SAIZEN vial: 8.8mg
SANDOSTATIN LAR
SEROSTIM
SOMATULINE DEPOT
SOMAVERT
SUPPRELIN LA
TEV-TROPIN
vasopressin
Progestins
DEPO-PROVERA vial: 400mg/ml
medroxyprogesterone acet
medroxyprogesterone acetate syringe
medroxyprogesterone acetate vial
medroxyprogesterone acetate tablet
norethindrone acetate
progesterone
progesterone,micronized
Thyroid and Antithyroid Agents
levothyroxine sodium vial: 100mcg
levothyroxine sodium vial: 200mcg,
500mcg
Drug Tier
(Sandostatin)
(Sandostatin)
(Pitressin)
(Medroxyprogesterone
Acet)
(Depo-provera)
(Depo-provera)
(Provera)
(Aygestin)
(Progesterone)
(Prometrium)
(Levothyroxine
Sodium)
(Levothyroxine
Sodium)
Requirements/Limits
4
5
PA
PA
5
5
5
5
5
5
2
PA
5
4
5
4
5
5
5
5
5
5
5
4
2
PA
PA
PA
PA
PA
PA
PA
PA
PA
QL: 1 in 28 days
QL: 1 in 360 days
PA
4
2
QL: 10 in 28 days
2
2
2
2
2
2
QL: 1 in 84 days
QL: 1 in 84 days
2
2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
63
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
levothyroxine sodium tablet
liothyronine sodium tablet
methimazole tablet: 20mg
methimazole tablet: 5mg, 10mg
propylthiouracil
Drug Tier
(Levoxyl)
(Cytomel)
(Tapazole)
(Tapazole)
(Propylthiouracil)
Requirements/Limits
1
2
2
2
2
Immunological Agents
Immunological Agents
ARCALYST
ASTAGRAF XL
AUBAGIO
azathioprine sodium
azathioprine
CARIMUNE NF NANOFILTERED
CELLCEPT vial
CELLCEPT susp recon
cyclosporine
cyclosporine, modified
ENBREL
FLEBOGAMMA DIF
GAMASTAN S-D
GAMMAGARD LIQUID
GAMMAPLEX
GAMUNEX-C
HUMIRA
HUMIRA
HYPERRAB S-D
HYQVIA
ILARIS
IMOGAM RABIES-HT
KINERET
leflunomide
mycophenolate mofetil capsule, tablet
mycophenolate mofetil susp recon
mycophenolate sodium
NULOJIX
OCTAGAM
ORENCIA syringe
ORENCIA vial
(Azathioprine Sodium)
(Imuran)
(Sandimmune)
(Neoral)
(Arava)
(Cellcept)
(Cellcept)
(Myfortic)
5
4
5
2
2
5
4
5
2
2
5
5
3
5
5
5
5
5
4
5
5
4
5
2
2
5
2
5
5
5
5
PA BvD
PA, QL: 28 in 28 days
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA
PA (Starter Kit)
PA BvD
PA
PA, QL: 18.76 in 28
days
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA, QL: 4 in 28 days
PA
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
64
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
PRIVIGEN
PROGRAF ampul
RAPAMUNE solution, tablet: 1mg, 2mg
RIDAURA
sirolimus tablet: 0.5mg, 1mg
sirolimus tablet: 2mg
tacrolimus
TYSABRI
Drug Tier
(Rapamune)
(Rapamune)
(Hecoria)
5
4
5
5
2
5
2
5
ZORTRESS tablet: 0.25mg
4
ZORTRESS tablet: 0.5mg, 0.75mg
5
Vaccines
ACTHIB
3
ADACEL TDAP syringe
3
ADACEL TDAP vial
3
BCG VACCINE (TICE STRAIN)
3
BOOSTRIX TDAP
3
CERVARIX
3
COMVAX
3
DAPTACEL DTAP
3
DIPHTHERIA-TETANUS TOXOIDSPED
ENGERIX-B ADULT
3
3
Requirements/Limits
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
LA, PA, QL: 15 in 28
days
PA BvD, QL: 120 in 30
days
PA BvD, QL: 120 in 30
days
(Vaccine for
Haemophilus B
Conjugate)
(Vaccine for Tetanus,
Diphtheria, and Pertussis
[Tdap])
(Vaccine for Tetanus,
Diphtheria, and Pertussis
[Tdap])
PA BvD (Vaccine for
Tuberculosis)
(Vaccine for Tetanus,
Diphtheria, and Pertussis
[Tdap])
(Vaccine for Human
Papillomavirus 16, 18)
(Vaccine for
Haemophilus B
Conjugate/Hepatitis B)
(Vaccine for Pertussis,
Diphtheria, and Tetanus
[Dtap])
(Vaccine for Tetanus and
Diphtheria [DT])
PA BvD (Vaccine for
Hepatitis B)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
65
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
Drug Tier
ENGERIX-B PEDIATRICADOLESCENT
GARDASIL 9
GARDASIL
3
3
3
HAVRIX syringe: 1440/ml
HAVRIX syringe: 720/0.5ml; vial
HAVRIX syringe: 720/0.5ml; vial
IMOVAX RABIES VACCINE
3
3
3
3
INFANRIX DTAP
3
IPOL
IXIARO
3
3
KINRIX
3
MENACTRA
3
MENHIBRIX
3
MENOMUNE-A-C-Y-W-135
3
MENVEO A-C-Y-W-135-DIP
3
M-M-R II VACCINE
3
PEDIARIX
3
PEDVAXHIB
3
Requirements/Limits
PA BvD (Vaccine for
Hepatitis B)
(Vaccine for Human
Papillomavirus 6, 11, 16,
18)
(Vaccine for Hepatitis A)
(Vaccine for Hepatitis A)
PA BvD (Vaccine for
Rabies)
(Vaccine for Tetanus,
Diphtheria, and Pertussis
[Td/Tdap])
(Vaccine for Polio)
(Vaccine for Japanese
Encephalitis)
(Vaccine for Diphtheria/
Tetanus/Pertussis/Polio)
(Vaccine for
Meningococcal
Diphtheria)
(Vaccine for
Haemophilus B/Tetanus
Toxoid Conjugate)
(Vaccine for
Meningococcal
Polysaccharide)
(Vaccine for
Meningococcal
Oligosaccharide/
Diphtheria)
(Vaccine for Measles/
Mumps/Rubella)
(Vaccine for Diphtheria/
Tetanus/Pertussis/
Hepatitis B/Polio)
(Vaccine for
Haemophilis B
Conjugate)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
66
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
Drug Tier
Requirements/Limits
PENTACEL ACTHIB COMPONENT
3
PENTACEL DTAP-IPV COMPONENT
3
PENTACEL
3
PROQUAD
3
RABAVERT
3
RECOMBIVAX HB
3
ROTARIX
ROTATEQ
TE ANATOXAL BERNA
3
3
3
TENIVAC
3
TETANUS DIPHTHERIA TOXOIDS
3
TETANUS TOXOID ADSORBED
3
(Vaccine for Diphtheria/
Haemophilis B/Pertussis/
Polio/Tetanus)
(Vaccine for Diphtheria/
Haemophilis B/Pertussis/
Polio/Tetanus)
(Vaccine for Diphtheria/
Haemophilis B/Pertussis/
Polio/Tetanus)
(Vaccine for Measles/
Mumps/Rubella/
Varicella)
PA BvD (Vaccine for
Rabies)
PA BvD (Vaccine for
Hepatitis B)
(Vaccine for Rotavirus)
(Vaccine for Rotavirus)
PA BvD (Vaccine for
Tetanus)
(Vaccine for Tetanus and
Diphtheria [Td])
(Vaccine for Tetanus and
Diphtheria [Td])
PA BvD (Vaccine for
Tetanus)
TRUMENBA
TWINRIX syringe
3
3
TWINRIX vial
3
TYPHIM VI
3
VAQTA
VARIVAX VACCINE
YF-VAX
3
3
3
ZOSTAVAX
3
(Vaccine for Hepatitis A/
Hepatitis B)
(Vaccine for Hepatitis A/
Hepatitis B)
(Vaccine for Typhoid
VI)
(Vaccine for Hepatitis A)
(Vaccine for Varicella)
(Vaccine for Yellow
Fever)
QL: 1 in 365 days
(Vaccine for Shingles)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
67
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
Drug Tier
Requirements/Limits
Inflammatory Bowel Disease Agents
Inflammatory Bowel Disease Agents
APRISO
ASACOL HD
(Colazal)
balsalazide disodium
(Entocort EC)
budesonide
DELZICOL
DIPENTUM
3
3
2
5
3
4
ST
Irrigating Solutions
Irrigating Solutions
acetic acid
GLYCINE
LACTATED RINGERS
mannitol/sorbitol solution
ringers solution
sodium chloride irrig solution
sorbitol solution
urologic solution-g
water for irrigation,sterile
(Acetic Acid)
(Mannitol/sorbitol
Solution)
(Tis-u-sol)
(Sodium Chloride Irrig
Solution)
(Sorbitol Solution)
(Urologic Solution-g)
(Water for Irrigation,
Sterile)
2
2
3
2
2
2
2
3
2
Metabolic Bone Disease Agents
Metabolic Bone Disease Agents
alendronate sodium tablet: 5mg, 10mg,
40mg
alendronate sodium tablet: 35mg, 70mg
alendronate sodium solution
calcitonin,salmon,synthetic
calcitriol
(Fosamax)
1
(Fosamax)
(Fosamax)
(Miacalcin)
(Rocaltrol)
1
2
2
2
doxercalciferol
(Hectorol)
2
etidronate disodium
FORTEO
FORTICAL
ibandronate sodium tablet
(Didronel)
2
4
4
2
(Boniva)
QL: 4 in 28 days
QL: 300 in 28 days
QL: 3.7 in 28 days
PA BvD (PA for ESRD
Only)
PA BvD (PA for ESRD
Only)
PA, QL: 2.4 in 28 days
QL: 3.7 in 28 days
QL: 1 in 28 days
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
68
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
ibandronate sodium vial
(Ibandronate Sodium)
MIACALCIN vial
paricalcitol
PROLIA
risedronate sodium
XGEVA
ZEMPLAR vial
Drug Tier
Requirements/Limits
2
PA BvD, QL: 3 in 84
days (PA for ESRD
Only)
PA BvD (PA for ESRD
Only)
PA BvD (PA for ESRD
Only)
QL: 1 in 180 days
QL: 1 in 28 days
PA, QL: 1.7 in 28 days
PA BvD (PA for ESRD
Only)
3
(Zemplar)
(Actonel)
(Zometa)
zoledronic acid
zoledronic acid/mannitol&water infus. btl (Reclast)
zoledronic acid/mannitol&water piggyback (Zoledronic Acid/
mannitol&water)
ZOMETA infus. btl
2
3
2
5
3
2
2
2
QL: 100 in 300 days
5
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
ACTEMRA syringe
ACTEMRA vial
ACTIMMUNE
allopurinol
amifostine crystalline
AVODART
AVONEX ADMINISTRATION PACK
AVONEX
BENLYSTA
BETASERON
bethanechol chloride
BOTOX vial: 200unit
BOTOX vial: 100unit
buspirone hcl
CERDELGA
citrate phosphate dextros soln
colchicine tablet
colchicine/probenecid
(Zyloprim)
(Ethyol)
(Urecholine)
(Buspar)
(Citrate Phosphate
Dextros Soln)
(Colcrys)
(Colchicine/
probenecid)
5
5
5
1
2
3
5
5
5
5
2
4
4
2
5
2
PA, QL: 3.6 in 28 days
PA, QL: 40 in 30 days
ST
ST
PA
ST
PA, QL: 1 in 90 days
PA, QL: 4 in 90 days
PA
2
2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
69
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
COLCRYS
COPAXONE
CYSTADANE
droperidol
ELMIRON
ergoloid mesylates tablet
EXTAVIA
finasteride
fomepizole
FUSILEV
gauze bandage
GILENYA
GLUCAGEN
GLUCAGON EMERGENCY KIT
glutethimide
guanidine hcl
hydroxyzine hcl
hydroxyzine pamoate
JALYN
leucovorin calcium
levocarnitine (with sugar)
Drug Tier
(Leucovorin Calcium)
(Carnitor)
3
5
5
2
4
2
5
2
5
5
1
5
3
4
2
2
2
2
3
2
2
levocarnitine tablet
(Carnitor)
2
mesna
MESNEX tablet
MESTINON syrup, tablet er
OTEZLA
PLEGRIDY PEN pen injctr: 125mcg/0.5
PLEGRIDY PEN pen injctr: 63-94mcg
PLEGRIDY
probenecid
PROCYSBI
pyridostigmine bromide
REBIF REBIDOSE
REBIF
REMICADE
SENSIPAR tablet: 30mg
SENSIPAR tablet: 60mg, 90mg
(Mesnex)
2
5
4
5
5
5
5
2
5
2
5
5
5
3
5
(Inapsine)
(Ergoloid Mesylates)
(Proscar)
(Antizol)
(Dermacea)
(Glutethimide)
(Guanidine HCl)
(Hydroxyzine HCl)
(Vistaril)
(Probenecid)
(Mestinon)
Requirements/Limits
ST
PA, QL: 28 in 28 days
PA-HRM
PA-HRM
QL: 30 in 30 days
PA BvD (PA for ESRD
Only)
PA BvD (PA for ESRD
Only)
PA, QL: 60 in 30 days
ST
ST
ST
PA
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
70
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
SIMPONI ARIA
SIMPONI pen injctr: 50mg/0.5ml
SIMPONI pen injctr: 100mg/ml
sodium morrhuate
SOLIRIS
STELARA
SYNAREL
TECFIDERA capsule dr: 120mg
TECFIDERA capsule dr: 120-240mg,
240mg
THALOMID
Drug Tier
(Sodium Morrhuate)
5
5
5
2
5
5
5
5
5
5
TYBOST
ULORIC
XELJANZ
4
3
5
Requirements/Limits
PA, QL: 12 in 28 days
PA, QL: 0.5 in 28 days
PA, QL: 3 in 28 days
PA
PA, QL: 14 in 30 days
PA, QL: 60 in 30 days
PA NSO, QL: 60 in 30
days
QL: 30 in 30 days
ST, QL: 30 in 30 days
PA, QL: 60 in 30 days
Ophthalmic Agents
Antiglaucoma Agents
acetazolamide sodium
acetazolamide
ALPHAGAN P drops: 0.1%
AZOPT
betaxolol hcl
brimonidine tartrate
COMBIGAN
dorzolamide hcl
dorzolamide hcl/timolol maleat
ISOPTO CARPINE drops: 8%
latanoprost
levobunolol hcl drops: 0.25%
levobunolol hcl drops: 0.5%
LUMIGAN
methazolamide
metipranolol
PHOSPHOLINE IODIDE
pilocarpine hcl
SIMBRINZA
timolol maleate
TRAVATAN Z
(Acetazolamide
Sodium)
(Acetazolamide)
(Betaxolol HCl)
(Alphagan P)
(Trusopt)
(Cosopt)
(Xalatan)
(Betagan)
(Betagan)
(Neptazane)
(Optipranolol)
(Isopto Carpine)
(Timoptic)
2
2
3
3
2
2
3
2
2
3
2
2
2
3
2
2
3
2
3
2
3
(drops: 0.15%, 0.20%)
QL: 2.5 in 25 days
QL: 2.5 in 25 days
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
71
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
travoprost (benzalkonium)
Drug Tier
(Travatan)
2
(0.9 % Sodium
Chloride)
(Calcium Chloride)
(Calcium Gluconate)
2
Requirements/Limits
QL: 2.5 in 25 days
Replacement Preparations
Replacement Preparations
0.9 % sodium chloride
calcium chloride
calcium gluconate
citric acid/sodium citrate
dex 2.5%-half str lact.ringers
DEXTROSE W/ELECTROLYTE A
DEXTROSE W/ELECTROLYTE B
electrolyte-48 solution/d5w
electrolyte-48/fructose 10 %
electrolyte-48/fructose 5 %
electrolyte-75 solution/d5w
electrolyte-75/fructose 5 %
HYPERLYTE CR
HYPERLYTE R
IONOSOL B with DEXTROSE 5%
IONOSOL MB-DEXTROSE 5%
IONOSOL T-DEXTROSE 5%
ISOLYTE E
ISOLYTE H with DEXTROSE
ISOLYTE M with DEXTROSE
ISOLYTE P with DEXTROSE
ISOLYTE S with DEXTROSE
ISOLYTE S
KLOR-CON 10
KLOR-CON 8
KLOR-CON
KLOR-CON-EF
magnesium chloride
(Bicitra)
(Dex 2.5%-half Str
Lact.ringers)
(Electrolyte-48
Solution/D5W)
(Electrolyte-48/fructose
10 %)
(Electrolyte-48/fructose
5 %)
(Electrolyte-75
Solution/D5W)
(Electrolyte-75/fructose
5 %)
(Magnesium Chloride)
2
2
PA BvD (PA for ESRD
Only)
2
2
4
4
2
2
2
2
2
4
4
4
4
4
4
4
4
4
4
4
2
2
2
2
2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
72
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
magnesium sulfate in water
magnesium sulfate
magnesium sulfate/d5w
NORMOSOL-M and DEXTROSE
NORMOSOL-R PH 7.4
NUTRILYTE II
NUTRILYTE
phosphorus #1
PLASMA-LYTE 148
PLASMA-LYTE 56 IN DEXTROSE
PLASMA-LYTE A PH 7.4
PLASMA-LYTE M IN DEXTROSE
pot chloride/pot bicarb/cit ac
Drug Tier
(Magnesium Sulfate in
Water)
(Magnesium Sulfate)
(Magnesium Sulfate/
D5W)
(K-phos Neutral)
(Pot Chloride/pot
Bicarb/cit Ac)
(Potassium Acetate)
potassium acetate
(Klor-con-ef)
potassium bicarbonate/cit ac
(Potassium Chlorid/
potassium chlorid/d10-0.2%nacl
d10-0.2%NaCl)
(Potassium Chloride In
potassium chloride in 0.9%nacl
0.9%NaCl)
potassium chloride in d5w iv soln: 20meq/l, (Potassium Chloride In
40meq/l
D5w)
potassium chloride in d5w iv soln: 30meq/l (Potassium Chloride In
D5w)
potassium chloride capsule er, piggyback: (K-dur)
10meq/0.1l, 10meq/50ml, 20meq/50ml;
syringe, tab er prt, tablet er
potassium chloride liquid, packet,
(K-sol)
piggyback: 30meq/0.1l; tablet sa
potassium chloride/d5-0.2%nacl iv soln:
(Potassium Chloride/
10meq/l, 30meq/l, 40meq/l
d5-0.2%NaCl)
potassium chloride/d5-0.2%nacl iv soln:
(Potassium Chloride/
20meq/l
d5-0.2%NaCl)
(Potassium Chloride/
potassium chloride/d5-0.25ns
D5-0.25 NS)
(Potassium Chloride/
potassium chloride/d5-0.3%nacl
d5-0.3%NaCl)
Requirements/Limits
2
2
2
4
4
4
4
2
4
4
4
4
2
2
2
2
2
2
2
2
2
2
2
2
2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
73
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
potassium chloride/d5-0.45nacl
potassium chloride/d5-0.9%nacl
potassium chloride/d5w
potassium chloride-0.45% nacl
potassium citrate/citric acid
potassium gluconate
potassium phos,m-basic-d-basic
ringers solution
sod/pot/k cit/sod cit/cit acid
sodium acetate
sodium bicarbonate
sodium chloride 0.45 %
sodium chloride 3 %
sodium chloride 5 %
sodium chloride vial: 2.5meq/ml
sodium chloride vial: 4meq/ml
sodium lactate iv soln
sodium lactate vial
sodium phos,m-basic-d-basic
Drug Tier
(Potassium Chloride/
d5-0.45NaCl)
(Potassium Chloride/
d5-0.9%NaCl)
(Potassium Chloride/
D5W)
(Potassium Chloride0.45% NaCl)
(Polycitra-k)
(Potassium Gluconate)
(Potassium Phos,mbasic-d-basic)
(Ringers Solution)
(Polycitra-lc)
(Sodium Acetate)
(Sodium Bicarbonate)
(Sodium Chloride 0.45
%)
(Sodium Chloride 3 %)
(Sodium Chloride 5 %)
(Sodium Chloride)
(Sodium Chloride)
(Sodium Lactate)
(Sodium Lactate)
(Sodium Phos,m-basicd-basic)
TPN ELECTROLYTES II
TRAVERT-ELECTROLYTE NO.1
TRAVERT-ELECTROLYTE NO.2 iv
soln: 10%
TRAVERT-ELECTROLYTE NO.2 iv
soln: 5%
TRAVERT-ELECTROLYTE NO.3
TRAVERT-ELECTROLYTE NO.4
Requirements/Limits
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
4
4
4
4
4
4
Respiratory Tract Agents
Anti-inflammatories, Inhaled Corticosteroids
ADVAIR DISKUS
ADVAIR HFA
BREO ELLIPTA
3
3
3
QL: 60 in 30 days
QL: 12 in 28 days
QL: 60 in 30 days
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
74
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
DULERA
FLOVENT DISKUS blst w/dev: 250mcg
FLOVENT DISKUS blst w/dev: 50mcg,
100mcg
FLOVENT HFA aer w/adap: 110mcg
FLOVENT HFA aer w/adap: 44mcg
FLOVENT HFA aer w/adap: 220mcg
QVAR
Antileukotrienes
montelukast sodium
zafirlukast
Bronchodilators
albuterol sulfate solution, vial-neb
albuterol sulfate syrup, tab er 12h, tablet
ANORO ELLIPTA
ATROVENT HFA
COMBIVENT RESPIMAT
metaproterenol sulfate
PROAIR HFA
SEREVENT DISKUS
SPIRIVA RESPIMAT
SPIRIVA
terbutaline sulfate
theophylline anhydrous solution, tab er
12h, tablet er
theophylline/d5w
TUDORZA PRESSAIR
Respiratory Tract Agents, Other
acetylcysteine
ARALAST NP
cromolyn sodium
DALIRESP
KALYDECO
XOLAIR
ZEMAIRA
Drug Tier
Requirements/Limits
3
3
3
QL: 13 in 28 days
QL: 120 in 30 days
QL: 60 in 30 days
3
3
3
3
QL: 12 in 28 days
QL: 21.2 in 28 days
QL: 24 in 28 days
QL: 17.4 in 25 days
(Singulair)
(Accolate)
2
2
(Accuneb)
(Albuterol Sulfate)
2
2
3
3
3
2
PA BvD
3
3
3
3
2
2
QL: 17 in 25 days
QL: 60 in 30 days
QL: 4 in 30 days
QL: 30 in 30 days
(Metaproterenol
Sulfate)
(Brethine)
(Theochron)
(Theophylline/D5W)
(Acetadote)
(Intal)
2
3
2
5
2
3
5
5
5
QL: 60 in 30 days
QL: 25.8 in 28 days
QL: 8 in 30 days
QL: 1 in 28 days
PA BvD
PA BvD
QL: 30 in 30 days
PA, QL: 60 in 30 days
PA, QL: 6 in 28 days
Skeletal Muscle Relaxants
Skeletal Muscle Relaxants
baclofen
(Baclofen)
2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
75
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
Drug Tier
Requirements/Limits
PA-HRM, QL: 120 in 30
days
PA-HRM, QL: 120 in 30
days
PA-HRM
PA-HRM
carisoprodol tablet: 250mg
(Soma)
2
carisoprodol tablet: 350mg
(Soma)
2
chlorzoxazone
chlorzoxazone/acetaminophen
(Parafon Forte DSC)
(Chlorzoxazone/
acetaminophen)
(Fexmid)
(Dantrium)
(Dantrium)
(Skelaxin)
(Robaxin)
(Zanaflex)
2
2
2
2
2
2
2
2
Sleep Disorder Agents
NUVIGIL
ROZEREM
XYREM
zaleplon
(Sonata)
3
3
5
2
zolpidem tartrate
(Ambien)
2
cyclobenzaprine hcl tablet: 5mg, 10mg
dantrolene sodium capsule
dantrolene sodium vial
metaxalone
methocarbamol tablet
tizanidine hcl
PA-HRM
PA-HRM
PA-HRM
Sleep Disorder Agents
PA
LA
PA-HRM, QL: 60 in 30
days (High Risk Med.
QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use with any
non-benzodiazepine
hypnotic drug)
PA-HRM, QL: 30 in 30
days (High Risk Med.
QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use with any
non-benzodiazepine
hypnotic drug)
Sympatholytic Adrenergic Blocking Agents
Alpha-Adrenergic Blocking Agents
PHENTOLAMINE MESYLATE
2
PA
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
76
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Drug Name
Drug Tier
Requirements/Limits
Vasodilating Agents
Vasodilating Agents
ADCIRCA
ADEMPAS
epoprostenol sodium (glycine) vial: 0.5mg (Flolan)
epoprostenol sodium (glycine) vial: 1.5mg (Flolan)
LETAIRIS
OPSUMIT
ORENITRAM ER tablet er: 0.125mg
ORENITRAM ER tablet er: 0.25mg, 1mg,
2.5mg
REMODULIN
REVATIO vial
(Revatio)
sildenafil citrate
TRACLEER
TYVASO
VENTAVIS
5
5
2
5
5
5
3
5
PA, QL: 60 in 30 days
PA, QL: 90 in 30 days
PA BvD
PA BvD
PA, QL: 30 in 30 days
PA, QL: 30 in 30 days
PA
PA
5
5
2
5
PA BvD
PA, QL: 37.5 in 1 day
PA, QL: 90 in 30 days
LA, PA, QL: 60 in 30
days
PA BvD
PA BvD
5
5
Vitamins and Minerals
Vitamins and Minerals
ped mv a,c,d3 #21 w-fluoride
pnv with ca,no.72/iron/fa
(Ped Mv A,c,d3 #21
W-fluoride)
(Pnv with Ca,no.72/
iron/fa)
2
3
(All Rx Prenatal
Vitamins Covered)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
77
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
INDEX
0.9 % sodium chloride .......... 72
8-MOP................................... 53
abacavir sulfate..................... 39
abacavir/lamivudine/zidovudine
........................................... 39
ABELCET............................. 34
ABILIFY............................... 38
ABILIFY DISCMELT.......... 38
ABILIFY MAINTENA ........ 38
ABRAXANE ........................ 24
acamprosate calcium ............ 17
acarbose................................ 32
acebutolol hcl........................ 48
acetaminophen with codeine. 14
acetazolamide ....................... 71
acetazolamide sodium........... 71
acetic acid ....................... 57, 68
acetylcysteine ........................ 75
acitretin ................................. 53
ACTEMRA ........................... 69
ACTHIB................................ 65
ACTIMMUNE...................... 69
acyclovir.......................... 41, 53
acyclovir sodium ................... 41
ADACEL TDAP................... 65
ADAGEN.............................. 56
adapalene.............................. 56
ADCETRIS ........................... 24
ADCIRCA............................. 77
adefovir dipivoxil .................. 41
ADEMPAS ........................... 77
ADRENALIN ....................... 49
ADVAIR DISKUS................ 74
ADVAIR HFA ...................... 74
AFINITOR............................ 24
AFINITOR DISPERZ........... 24
AGGRENOX ........................ 43
A-HYDROCORT ................. 62
AKTEN ................................. 57
ALBENZA............................ 36
ALBUKED-25 ...................... 43
ALBUKED-5 ........................ 43
ALBUMIN HUMAN............ 43
ALBUMINAR-25 ................. 43
ALBUMINAR-5 ................... 43
ALBURX .............................. 43
ALBUTEIN........................... 43
albuterol sulfate .................... 75
alclometasone dipropionate.. 55
alcohol antiseptic pads ......... 54
ALDURAZYME................... 56
alendronate sodium............... 68
alfuzosin hcl .......................... 60
ALIMTA ............................... 24
ALINIA................................. 37
allopurinol............................. 69
ALPHAGAN P ..................... 71
alprazolam ............................ 18
ALREX ................................. 58
aluminum chloride ................ 54
amantadine hcl...................... 37
AMBISOME ......................... 34
amifostine crystalline ............ 69
amiloride hcl ......................... 50
amiloride/hydrochlorothiazide
........................................... 50
AMINO ACIDS .................... 43
aminocaproic acid ................ 43
AMINOSYN ......................... 44
AMINOSYN II ..................... 43
AMINOSYN II with
ELECTROLYTES ............ 43
AMINOSYN M .................... 43
AMINOSYN with
ELECTROLYTES ............ 44
AMINOSYN-HBC ............... 44
AMINOSYN-PF ................... 44
AMINOSYN-RF................... 44
I-1
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
amiodarone hcl ..................... 48
AMITIZA.............................. 59
amitriptyline hcl .................... 31
amlodipine besylate .............. 50
amlodipine besylate/benazepril
........................................... 50
amlodipine/atorvastatin ........ 51
ammonium lactate................. 54
amoxapine ............................. 31
amoxicillin............................. 22
amoxicillin/potassium clav.... 22
amphotericin b ...................... 34
ampicillin sodium.................. 22
ampicillin sodium/sulbactam na
........................................... 22
ampicillin trihydrate ............. 22
AMPYRA ............................. 52
ANACAINE.......................... 54
anagrelide hcl ....................... 43
anastrozole............................ 24
ANDRODERM..................... 61
ANDROGEL......................... 61
ANORO ELLIPTA ............... 75
APOKYN.............................. 37
apraclonidine hcl .................. 57
APRISO ................................ 68
APTIOM ............................... 29
APTIVUS.............................. 39
ARALAST NP ...................... 75
ARCALYST ......................... 64
ARRANON........................... 24
ARZERRA............................ 24
ASACOL HD........................ 68
ASTAGRAF XL ................... 64
atenolol ................................. 48
atenolol/chlorthalidone......... 48
atorvastatin calcium.............. 51
atovaquone............................ 37
atovaquone/proguanil hcl ..... 37
Effective: March 01, 2015
ATRIPLA.............................. 39
atropine sulfate ............... 29, 57
ATROVENT HFA ................ 75
AUBAGIO ............................ 64
AVASTIN ............................. 24
AVC ...................................... 35
AVODART ........................... 69
AVONEX.............................. 69
AVONEX
ADMINISTRATION PACK
........................................... 69
azacitidine ............................. 24
azathioprine .......................... 64
azathioprine sodium.............. 64
azelastine hcl......................... 57
AZILECT.............................. 37
azithromycin.......................... 21
AZOPT.................................. 71
AZOR.................................... 50
aztreonam.............................. 22
bacitracin ........................ 19, 57
bacitracin/polymyxin b sulfate
........................................... 57
baclofen................................. 75
balsalazide disodium............. 68
BANZEL............................... 29
BARACLUDE ...................... 41
BCG VACCINE TICE
STRAIN ............................ 65
BELEODAQ ......................... 24
benazepril hcl........................ 47
benazepril/hydrochlorothiazide
........................................... 47
BENICAR ............................. 47
BENICAR HCT .................... 47
BENLYSTA.......................... 69
benztropine mesylate............. 37
betamet acet/betamet na ph .. 62
betamethasone dipropionate. 55
betamethasone valerate ........ 55
betamethasone/propylene glyc
........................................... 55
BETASERON ....................... 69
betaxolol hcl.................... 48, 71
bethanechol chloride............. 69
BETHKIS.............................. 19
bicalutamide.......................... 24
BICILLIN C-R...................... 22
BICILLIN L-A...................... 22
BILTRICIDE ........................ 37
bisoprolol fumarate............... 48
bisoprolol fumarate/hctz ....... 48
bleomycin sulfate .................. 24
BOOSTRIX TDAP ............... 65
BOSULIF.............................. 24
BOTOX................................. 69
BREO ELLIPTA................... 74
BRILINTA............................ 43
brimonidine tartrate.............. 71
BRINTELLIX ....................... 31
bromfenac sodium................. 58
bromocriptine mesylate......... 37
budesonide ............................ 68
bumetanide............................ 50
BUMINATE ......................... 43
BUPHENYL ......................... 59
buprenorphine hcl........... 14, 17
buprenorphine hcl/naloxone hcl
........................................... 17
bupropion hcl ........................ 31
buspirone hcl......................... 69
butalb/acetaminophen/caffeine
........................................... 14
butalbit/acetamin/caff/codeine
........................................... 14
butalbital/acetaminophen ..... 14
butalbital/aspirin/caffeine..... 14
butorphanol tartrate.............. 14
BUTRANS............................ 14
BYDUREON ........................ 32
BYDUREON PEN................ 32
BYETTA............................... 32
BYSTOLIC ........................... 48
cabergoline ........................... 37
I-2
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
caffeine citrated .................... 52
caffeine/sodium benzoate ...... 52
calcipotriene ......................... 54
calcitonin,salmon,synthetic... 68
calcitriol.......................... 54, 68
calcium acetate ..................... 60
calcium carbonate/mag carb/fa
........................................... 60
calcium chloride.................... 72
calcium gluconate ................. 72
CALDOLOR......................... 16
CANCIDAS .......................... 34
candesartan cilexetil ............. 47
candesartan/hydrochlorothiazid
........................................... 47
CAPASTAT SULFATE ....... 36
CAPRELSA .......................... 24
captopril................................ 47
captopril/hydrochlorothiazide
........................................... 47
CARAFATE ......................... 59
carbamazepine ...................... 29
carbidopa .............................. 37
carbidopa/levodopa .............. 37
carbidopa/levodopa/entacapone
........................................... 37
carboplatin............................ 24
CARIMUNE NF
NANOFILTERED ............ 64
carisoprodol.......................... 76
carteolol hcl .......................... 57
carvedilol .............................. 48
CAYSTON............................ 22
cefaclor ................................. 20
cefadroxil .............................. 20
cefazolin sodium.................... 20
cefazolin sodium/dextrose,iso 21
cefdinir .................................. 21
cefditoren pivoxil .................. 21
CEFEPIME ........................... 21
cefepime hcl .......................... 21
CEFEPIME-DEXTROSE ..... 21
Effective: March 01, 2015
cefotaxime sodium................. 21
cefoxitin sodium .................... 21
cefoxitin sodium/dextrose,iso 21
cefpodoxime proxetil............. 21
cefprozil................................. 21
ceftazidime pentahydrate ...... 21
ceftibuten dihydrate .............. 21
ceftriaxone na/dextrose,iso ... 21
ceftriaxone sodium ................ 21
cefuroxime axetil................... 21
cefuroxime sodium ................ 21
cefuroxime sodium/dextrose,iso
........................................... 21
CELEBREX.......................... 16
celecoxib ............................... 16
CELLCEPT........................... 64
CELONTIN........................... 29
cephalexin ............................. 21
CEPROTIN ........................... 41
CERDELGA ......................... 69
CEREZYME ......................... 56
CERVARIX .......................... 65
cevimeline hcl........................ 53
CHANTIX............................. 18
chloramphenicol sod succ..... 20
chlordiazepoxide hcl ............. 18
chlorhexidine gluconate........ 53
chloroquine phosphate.......... 37
chlorothiazide ....................... 50
chlorothiazide sodium........... 50
chlorpromazine hcl ............... 38
chlorthalidone ....................... 50
chlorzoxazone ....................... 76
chlorzoxazone/acetaminophen
........................................... 76
cholestyramine (with sugar) . 51
cholestyramine/aspartame .... 51
choline sal/mag salicylate..... 16
ciclopirox .............................. 34
ciclopirox olamine ................ 34
cilostazol ............................... 43
cimetidine.............................. 59
cimetidine hcl ........................ 59
CIMZIA ................................ 56
CIPRODEX........................... 57
ciprofloxacin ......................... 23
ciprofloxacin hcl ............. 23, 57
ciprofloxacin lactate ............. 23
ciprofloxacin lactate/d5w...... 23
cisplatin................................. 24
citalopram hydrobromide ..... 31
citrate phosphate dextros soln
........................................... 69
citric acid/sodium citrate ...... 72
clarithromycin....................... 21
clemastine fumarate .............. 35
CLEVIPREX......................... 50
clindamycin hcl ..................... 20
clindamycin palmitate hcl ..... 20
clindamycin phosphate... 20, 35,
54
clindamycin phosphate/d5w.. 20
CLINIMIX ............................ 44
CLINIMIX E......................... 44
CLINISOL ............................ 44
clobetasol propionate............ 55
clocortolone pivalate ............ 55
clomipramine hcl .................. 31
clonazepam ........................... 18
clonidine................................ 47
clonidine hcl.................... 47, 52
clonidine hcl/chlorthalidone . 47
clopidogrel bisulfate ............. 43
clorazepate dipotassium........ 18
clotrimazole........................... 34
clotrimazole/betamethasone dip
........................................... 34
clozapine ............................... 38
COARTEM ........................... 37
codeine sulfate ...................... 14
codeine/butalbital/asa/caffein14
colchicine .............................. 69
colchicine/probenecid ........... 69
COLCRYS ............................ 70
I-3
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
colestipol hcl ......................... 51
colistin (colistimethate na).... 20
COLY-MYCIN S.................. 58
COMBIGAN......................... 71
COMBIPATCH .................... 61
COMBIVENT RESPIMAT .. 75
COMETRIQ.......................... 24
COMPLERA......................... 39
COMVAX............................. 65
CONDYLOX ........................ 54
COPAXONE......................... 70
CORDRAN ........................... 55
cortisone acetate ................... 62
CREON ................................. 56
CRESTOR............................. 51
CRIXIVAN ........................... 39
cromolyn sodium....... 57, 59, 75
CUBICIN .............................. 20
cyclobenzaprine hcl .............. 76
CYCLOGYL......................... 57
cyclopentolate hcl ................. 57
cyclophosphamide................. 24
CYCLOPHOSPHAMIDE..... 24
CYCLOSET.......................... 32
cyclosporine .......................... 64
cyclosporine, modified .......... 64
cyproheptadine hcl................ 35
CYRAMZA........................... 24
CYSTADANE ...................... 70
CYSTARAN ......................... 57
cysteine hcl............................ 44
cytarabine ............................. 24
cytarabine/pf ......................... 24
dacarbazine........................... 25
dactinomycin ......................... 25
DALIRESP ........................... 75
danazol.................................. 61
dantrolene sodium................. 76
dapsone ................................. 36
DAPTACEL DTAP .............. 65
DARAPRIM ......................... 37
decitabine.............................. 25
Effective: March 01, 2015
deferoxamine mesylate.......... 60
DELZICOL ........................... 68
DEMSER .............................. 49
DEPEN.................................. 60
DEPO-PROVERA ................ 63
desipramine hcl..................... 31
desmopressin acetate ............ 62
desog-e.estradiol/e.estradiol. 53
desogestrel-ethinyl estradiol. 53
desonide ................................ 55
desoximetasone ..................... 55
dex 2.5%-half str lact.ringers 72
dexamethasone...................... 62
dexamethasone acetate ......... 62
dexamethasone sod phosphate
..................................... 58, 62
dexmethylphenidate hcl......... 52
dextroamphetamine sulfate ... 52
dextroamphetamine/
amphetamine ..................... 52
dextrose 10 % and 0.2 % nacl
........................................... 44
dextrose 10 % and 0.45 % nacl
........................................... 44
dextrose 10 % in water ......... 44
dextrose 2.5 % and 0.45 % nacl
........................................... 45
dextrose 2.5 % in water ........ 45
dextrose 2.5% in half ringers 45
dextrose 20 % in water ......... 45
dextrose 25 % in water ......... 45
dextrose 40 % in water ......... 45
dextrose 5 % and 0.3 % nacl 45
dextrose 5 % and 0.9 % nacl 45
dextrose 5 % in water ........... 45
dextrose 5 %-0.2 % nacl ....... 45
dextrose 5 %-0.45 % nacl ..... 45
dextrose 5% in ringers .......... 45
dextrose 5%-lactated ringers 45
dextrose 50 % in water ......... 45
dextrose 60 % in water ......... 45
dextrose 70 % in water ......... 45
DEXTROSE W/
ELECTROLYTE A .......... 72
DEXTROSE W/
ELECTROLYTE B........... 72
DEXTROSE with SODIUM
CHLORIDE ...................... 45
DIASTAT ACUDIAL .......... 18
diazepam ............................... 18
diclofenac potassium............. 16
diclofenac sodium ........... 16, 58
diclofenac sodium/misoprostol
........................................... 16
dicloxacillin sodium .............. 22
dicyclomine hcl ..................... 59
didanosine ............................. 39
DIFICID................................ 21
diflunisal ............................... 16
digoxin................................... 49
DIGOXIN ............................. 49
dihydroergotamine mesylate. 35
DILANTIN ........................... 29
diltiazem hcl .......................... 49
dimenhydrinate ..................... 36
DIOVAN............................... 47
DIPENTUM.......................... 68
diphenhydramine hcl............. 35
diphenoxylate hcl/atropine.... 59
DIPHTHERIA-TETANUS
TOXOIDS-PED ................ 65
disopyramide phosphate ....... 48
disulfiram .............................. 18
divalproex sodium................. 29
dobutamine hcl...................... 49
dobutamine hcl/d5w .............. 49
donepezil hcl ......................... 30
dopamine hcl......................... 49
dopamine hcl/d5w ................. 49
dorzolamide hcl..................... 71
dorzolamide hcl/timolol maleat
........................................... 71
doxazosin mesylate................ 47
doxepin hcl ............................ 31
I-4
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
doxercalciferol ...................... 68
doxorubicin hcl ..................... 25
doxorubicin hcl peg-liposomal
........................................... 25
doxycycline hyclate ............... 23
doxycycline monohydrate...... 23
dronabinol............................. 36
droperidol ............................. 70
DROXIA ............................... 25
DUAVEE .............................. 61
DULERA .............................. 75
duloxetine hcl ........................ 31
DURAMORPH ..................... 14
DUREZOL............................ 58
DYRENIUM ......................... 50
econazole nitrate................... 34
edetate disodium ................... 60
EDURANT ........................... 39
EFFIENT............................... 43
ELAPRASE .......................... 56
electrolyte-48 solution/d5w... 72
electrolyte-48/fructose 10 % . 72
electrolyte-48/fructose 5 % ... 72
electrolyte-75 solution/d5w... 72
electrolyte-75/fructose 5 % ... 72
ELIDEL................................. 55
ELIGARD ............................. 25
ELIQUIS ............................... 41
ELITEK................................. 56
ELLA .................................... 53
ELMIRON ............................ 70
EMCYT................................. 25
EMEND ................................ 36
EMSAM................................ 31
EMTRIVA ............................ 39
enalapril maleate .................. 47
enalapril/hydrochlorothiazide
........................................... 47
enalaprilat dihydrate ............ 47
ENBREL ............................... 64
ENGERIX-B ADULT .......... 65
Effective: March 01, 2015
ENGERIX-B PEDIATRICADOLESCENT ................ 66
enoxaparin sodium................ 42
entacapone ............................ 37
entecavir................................ 41
ephedrine sulfate................... 49
epinastine hcl ........................ 57
epinephrine ........................... 49
EPIPEN 2-PAK..................... 49
EPIPEN JR 2-PAK ............... 49
epirubicin hcl ........................ 25
EPIVIR.................................. 39
EPIVIR HBV ........................ 39
eplerenone............................. 51
EPOGEN............................... 42
epoprostenol sodium (glycine)
........................................... 77
EPZICOM ............................. 39
ERBITUX ............................. 25
ergoloid mesylates ................ 70
ERGOMAR........................... 35
ERIVEDGE........................... 25
ERY-TAB ............................. 21
ERYTHROCIN
LACTOBIONATE...... 21, 22
erythromycin base........... 22, 58
erythromycin base/ethanol.... 54
erythromycin ethylsuccinate . 22
erythromycin stearate ........... 22
escitalopram oxalate............. 31
esmolol hcl ............................ 48
esomeprazole sodium ............ 59
estazolam............................... 18
ESTRACE............................. 61
estradiol ................................ 61
estradiol valerate .................. 61
estradiol/norethindrone acet. 61
ESTRASORB ....................... 61
estropipate............................. 61
ethambutol hcl....................... 36
ethanolamine oleate .............. 49
ethinyl estradiol/drospirenone
........................................... 53
ethosuximide ......................... 29
ethynodiol d-ethinyl estradiol 53
etidronate disodium .............. 68
etodolac................................. 16
ETOPOPHOS ....................... 25
etoposide ............................... 25
EXELON............................... 30
exemestane ............................ 25
EXFORGE ............................ 50
EXFORGE HCT ................... 50
EXJADE ............................... 60
EXTAVIA............................. 70
FABRAZYME...................... 56
famciclovir ............................ 41
famotidine ............................. 59
famotidine in nacl,iso-osm/pf 59
famotidine/pf ......................... 59
FANAPT ............................... 38
FARESTON.......................... 25
FASLODEX.......................... 25
FAZACLO ............................ 38
felbamate............................... 29
felodipine............................... 50
FEMRING............................. 61
fenofibrate ............................. 51
fenofibrate nanocrystallized.. 51
fenofibrate,micronized .......... 51
fenofibric acid ....................... 51
fenofibric acid (choline)........ 51
fenoprofen calcium................ 16
fentanyl.................................. 14
fentanyl citrate ...................... 14
FERRIPROX......................... 60
FETZIMA ............................. 31
finasteride ............................. 70
FIRAZYR ............................. 50
FIRMAGON ......................... 25
FLEBOGAMMA DIF........... 64
flecainide acetate .................. 48
FLECTOR............................. 16
I-5
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
FLEXBUMIN ....................... 43
FLOVENT DISKUS............. 75
FLOVENT HFA ................... 75
floxuridine ............................. 25
fluconazole ............................ 34
fluconazole in nacl,iso-osm... 34
flucytosine ............................. 34
fludarabine phosphate .......... 25
fludrocortisone acetate ......... 62
flumazenil.............................. 52
fluocinonide........................... 55
fluorometholone .................... 58
FLUOROPLEX..................... 54
fluorouracil ..................... 25, 54
fluoxetine hcl......................... 31
fluoxymesterone .................... 61
fluphenazine decanoate......... 38
fluphenazine hcl .................... 38
flurazepam hcl....................... 18
flurbiprofen ........................... 16
flurbiprofen sodium............... 58
flutamide ............................... 25
fluticasone propionate .... 55, 58
fluvoxamine maleate ............. 31
fomepizole ............................. 70
fondaparinux sodium ............ 42
FORTEO ............................... 68
FORTICAL ........................... 68
foscarnet sodium ................... 40
fosinopril sodium .................. 47
fosinopril/hydrochlorothiazide
........................................... 47
fosphenytoin sodium.............. 29
FREAMINE HBC................. 45
FREAMINE III ..................... 45
fructose 10 % ........................ 45
furosemide............................. 50
FUSILEV .............................. 70
FUZEON............................... 40
FYCOMPA ........................... 29
gabapentin............................. 29
GABITRIL............................ 29
Effective: March 01, 2015
galantamine hbr .................... 30
GAMASTAN S-D ................ 64
GAMMAGARD LIQUID..... 64
GAMMAPLEX..................... 64
GAMUNEX-C ...................... 64
ganciclovir sodium................ 41
GARDASIL .......................... 66
GARDASIL 9 ....................... 66
gatifloxacin ........................... 58
gauze bandage ...................... 70
GAZYVA.............................. 25
gemcitabine hcl ..................... 25
gemfibrozil ............................ 51
GENOTROPIN ..................... 63
gentamicin in nacl, iso-osm .. 19
gentamicin sulfate ..... 19, 54, 58
gentamicin sulfate/pf............. 19
GEODON.............................. 38
GILENYA............................. 70
GILOTRIF ............................ 25
GLEEVEC ............................ 25
glimepiride ............................ 33
glipizide................................. 33
glipizide/metformin hcl ... 33, 34
GLUCAGEN......................... 70
GLUCAGON EMERGENCY
KIT.................................... 70
glutethimide........................... 70
glyburide ............................... 34
glyburide,micronized ............ 34
glyburide/metformin hcl........ 34
GLYCINE ............................. 68
glycopyrrolate ....................... 59
granisetron hcl ...................... 36
granisetron hcl/pf.................. 36
GRANIX ............................... 42
griseofulvin, microsize .......... 34
guanfacine hcl................. 47, 52
guanidine hcl......................... 70
HALAVEN ........................... 25
halobetasol propionate ......... 55
haloperidol............................ 38
haloperidol decanoate .......... 38
haloperidol lactate ................ 38
HARVONI ............................ 41
HAVRIX ............................... 66
heparin sod,pork in 0.45% nacl
........................................... 42
heparin sodium,porcine ........ 42
heparin sodium,porcine/d5w. 42
heparin sodium,porcine/ns/pf 42
heparin sodium,porcine/pf .... 42
HEPATAMINE..................... 45
HEPATASOL ....................... 45
HERCEPTIN......................... 25
HEXALEN............................ 25
homatropine hbr.................... 57
HUMALOG .......................... 33
HUMALOG MIX 50-50 ....... 33
HUMALOG MIX 75-25 ....... 33
HUMATROPE...................... 63
HUMIRA .............................. 64
HUMULIN 70/30 KWIKPEN
........................................... 33
HUMULIN 70-30 ................. 33
HUMULIN N........................ 33
HUMULIN N KWIKPEN .... 33
HUMULIN R ........................ 33
hydralazine hcl...................... 50
hydralazine/hydrochlorothiazid
........................................... 50
hydrochlorothiazide .............. 50
hydrocodone/acetaminophen 14
hydrocodone/ibuprofen ......... 14
hydrocortisone ................ 55, 62
hydrocortisone acetate/aloe v55
hydrocortisone acetate/urea . 55
hydrocortisone butyrate ........ 55
hydrocortisone sod succinate 62
hydrocortisone valerate ........ 55
hydromorphone hcl ............... 15
hydromorphone hcl/pf........... 15
hydroxychloroquine sulfate... 37
hydroxyurea .......................... 26
I-6
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
hydroxyzine hcl ..................... 70
hydroxyzine pamoate ............ 70
HYPERLYTE CR................. 72
HYPERLYTE R.................... 72
HYPERRAB S-D.................. 64
HYQVIA............................... 64
ibandronate sodium ........ 68, 69
ibuprofen ............................... 16
ICLUSIG............................... 26
ifosfamide.............................. 26
ifosfamide/mesna................... 26
ILARIS.................................. 64
ILEVRO................................ 58
IMBRUVICA........................ 26
imipenem/cilastatin sodium .. 22
imipramine hcl ...................... 31
imipramine pamoate ............. 31
imiquimod ............................. 54
IMOGAM RABIES-HT........ 64
IMOVAX RABIES VACCINE
........................................... 66
INCRELEX........................... 63
indapamide............................ 51
indomethacin......................... 16
indomethacin sodium ............ 16
INFANRIX DTAP ................ 66
INLYTA................................ 26
INTELENCE......................... 40
INTRALIPID .................. 45, 46
INTRON A............................ 41
INTUNIV.............................. 52
INVANZ ............................... 22
INVEGA ............................... 38
INVEGA SUSTENNA ......... 38
INVIRASE............................ 40
INVOKAMET ...................... 32
INVOKANA ......................... 32
IONOSOL B with DEXTROSE
5% ..................................... 72
IONOSOL MB-DEXTROSE
5% ..................................... 72
Effective: March 01, 2015
IONOSOL T-DEXTROSE 5%
........................................... 72
IPOL...................................... 66
ipratropium bromide............. 57
IPRIVASK ............................ 42
irbesartan.............................. 47
irbesartan/hydrochlorothiazide
........................................... 47
ISENTRESS.......................... 40
ISOLYTE E .......................... 72
ISOLYTE H with DEXTROSE
........................................... 72
ISOLYTE M with DEXTROSE
........................................... 72
ISOLYTE P with DEXTROSE
........................................... 72
ISOLYTE S........................... 72
ISOLYTE S with DEXTROSE
........................................... 72
isoniazid ................................ 36
isopropamide/prochlorperazine
........................................... 59
ISOPTO CARPINE .............. 71
isosorbide dinitrate ............... 51
isosorbide mononitrate ......... 51
isotretinoin ............................ 54
isradipine .............................. 50
ISTODAX ............................. 26
itraconazole........................... 34
ivermectin.............................. 37
IXEMPRA............................. 26
IXIARO................................. 66
JAKAFI................................. 26
JALYN.................................. 70
JANUMET............................ 32
JANUMET XR ..................... 32
JANUVIA ............................. 32
JARDIANCE ........................ 32
JENTADUETO..................... 32
JEVTANA............................. 26
KABIVEN............................. 46
KADCYLA ........................... 26
KALETRA............................ 40
KALYDECO......................... 75
KEDBUMIN ......................... 43
ketoconazole.......................... 34
ketoprofen ............................. 16
ketorolac tromethamine . 16, 17,
58
KEYTRUDA......................... 26
KHEDEZLA ......................... 31
KINERET ............................. 64
KINRIX................................. 66
KLOR-CON.......................... 72
KLOR-CON 10..................... 72
KLOR-CON 8....................... 72
KLOR-CON-EF.................... 72
KORLYM ............................. 32
KRYSTEXXA ...................... 56
KUVAN ................................ 56
KYPROLIS ........................... 26
labetalol hcl .......................... 48
LACRISERT......................... 57
LACTATED RINGERS ....... 68
lactulose ................................ 59
LAMICTAL.......................... 29
lamivudine............................. 40
lamivudine/zidovudine .......... 40
lamotrigine............................ 29
LANOXIN ............................ 50
lansoprazole.......................... 59
lansoprazole/amoxiciln/clarith
........................................... 59
LANTUS............................... 33
LANTUS SOLOSTAR ......... 33
latanoprost ............................ 71
LATUDA ........................ 38, 39
LAZANDA ........................... 15
leflunomide............................ 64
LETAIRIS............................. 77
letrozole................................. 26
leucovorin calcium................ 70
LEUKERAN ......................... 26
LEUKINE ............................. 42
I-7
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
leuprolide acetate.................. 26
levetiracetam......................... 29
levobunolol hcl...................... 71
levocarnitine ......................... 70
levocarnitine (with sugar)..... 70
levocetirizine dihydrochloride
........................................... 35
levofloxacin ..................... 23, 58
levofloxacin/d5w ................... 23
levonorgestrel ....................... 53
levonorgestrel-ethin estradiol53
levorphanol tartrate .............. 15
levothyroxine sodium ...... 63, 64
LEXIVA................................ 40
lidocaine................................ 17
lidocaine hcl.................... 17, 48
lidocaine hcl/d5w/pf.............. 48
lidocaine hcl/pf................ 17, 48
lidocaine/prilocaine .............. 17
LIDODERM ......................... 17
linezolid................................. 20
LINZESS............................... 56
liothyronine sodium .............. 64
lipase/protease/amylase........ 56
LIPOSYN II .......................... 46
LIPOSYN III......................... 46
lisinopril................................ 48
lisinopril/hydrochlorothiazide
........................................... 48
lithium carbonate .................. 52
lithium citrate........................ 52
l-norgest-eth estr/ethin estra. 53
lomustine ............................... 26
loperamide hcl ...................... 59
lorazepam........................ 18, 19
losartan potassium ................ 47
losartan/hydrochlorothiazide 47
LOTEMAX ........................... 58
LOTRONEX ......................... 56
lovastatin............................... 51
loxapine succinate................. 39
LUMIGAN............................ 71
Effective: March 01, 2015
LUMINAL SODIUM ........... 29
LUMIZYME ......................... 56
LUPRON DEPOT................. 26
LUPRON DEPOT-PED........ 26
LYRICA.......................... 29, 30
LYSODREN ......................... 26
mafenide acetate ................... 54
magnesium chloride .............. 72
magnesium sulfate................. 73
magnesium sulfate in water .. 73
magnesium sulfate/d5w......... 73
malathion .............................. 56
mannitol/sorbitol solution..... 68
maprotiline hcl ...................... 31
MARPLAN ........................... 31
MARQIBO............................ 26
MATULANE ........................ 26
meclizine hcl.......................... 36
medroxyprogesterone acet .... 63
medroxyprogesterone acetate63
mefenamic acid ..................... 17
mefloquine hcl....................... 37
MEFOXIN ............................ 21
MEGACE ES ........................ 26
megestrol acetate .................. 26
MEKINIST ........................... 27
meloxicam ............................. 17
melphalan hcl........................ 27
MENACTRA ........................ 66
MENEST............................... 61
MENHIBRIX........................ 66
MENOMUNE-A-C-Y-W-135
........................................... 66
MENVEO A-C-Y-W-135-DIP
........................................... 66
mercaptopurine ..................... 27
meropenem............................ 22
mesna .................................... 70
MESNEX .............................. 70
MESTINON.......................... 70
metaproterenol sulfate .......... 75
metaxalone ............................ 76
metformin hcl ........................ 32
methadone hcl ....................... 15
methazolamide ...................... 71
methenamine hippurate......... 20
methimazole .......................... 64
methocarbamol ..................... 76
methotrexate sodium ............. 27
methotrexate sodium/pf......... 27
methoxsalen, rapid................ 54
methscopolamine bromide .... 59
methyclothiazide ................... 51
methylphenidate hcl .............. 52
methylprednisolone ............... 62
methylprednisolone acetate .. 62
methylprednisolone sod succ 62
metipranolol.......................... 71
metoclopramide hcl......... 59, 60
metolazone ............................ 51
metoprolol succinate............. 48
metoprolol tartrate.......... 48, 49
metoprolol/hydrochlorothiazide
........................................... 49
metronidazole............ 35, 37, 54
metronidazole/sodium chloride
........................................... 37
mexiletine hcl ........................ 48
MIACALCIN........................ 69
miconazole nitrate................. 34
midazolam hcl ....................... 19
midazolam hcl/pf................... 19
midodrine hcl ........................ 47
milrinone lactate ................... 50
milrinone lactate/d5w ........... 50
minocycline hcl ..................... 23
minoxidil ............................... 51
mirtazapine ........................... 31
misoprostol............................ 59
mitomycin.............................. 27
mitoxantrone hcl ................... 27
M-M-R II VACCINE............ 66
moexipril hcl ......................... 48
I-8
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
moexipril/hydrochlorothiazide
........................................... 48
mometasone furoate .............. 55
montelukast sodium............... 75
morphine sulfate.................... 15
MORPHINE SULFATE ....... 15
MOVIPREP .......................... 60
MOXEZA ............................. 58
moxifloxacin hcl .................... 23
MOZOBIL ............................ 42
MULTAQ ............................. 48
mupirocin .............................. 54
mupirocin calcium ................ 54
MUSTARGEN...................... 27
mycophenolate mofetil .......... 64
mycophenolate sodium.......... 64
MYOZYME.......................... 56
nabumetone ........................... 17
nadolol .................................. 49
nafcillin in dextrose,iso-osm . 22
nafcillin sodium..................... 22
NAGLAZYME ..................... 56
nalidixic acid......................... 23
naloxone hcl .......................... 18
naltrexone hcl........................ 18
NAMENDA .................... 30, 31
NAMENDA XR.................... 30
naphazoline hcl/antazoline ... 57
naproxen ............................... 17
naproxen sodium................... 17
naratriptan hcl ...................... 35
NASONEX ........................... 58
NATACYN ........................... 58
nateglinide............................. 32
NEBUPENT.......................... 37
needles, insulin disposable.... 56
nefazodone hcl ...................... 31
neo/polymyx b sulf/dexameth 58
neomy sulf/bacitra/polymyxin b
........................................... 58
neomy sulf/bacitrac zn/poly/hc
........................................... 58
Effective: March 01, 2015
neomy sulf/polymyxin b sulfate
........................................... 54
neomycin sulfate.................... 19
neomycin sulfate/dex na ph... 58
neomycin/polymyxin b sulf/hc58
neomycin/polymyxn b/
gramicidin ......................... 58
NEPHRAMINE .................... 46
NEULASTA ......................... 42
NEUMEGA........................... 42
NEUPOGEN ......................... 42
NEUPRO............................... 37
NEVANAC ........................... 58
nevirapine ............................. 40
NEXAVAR ........................... 27
niacin..................................... 51
nicardipine hcl ...................... 50
NICOTROL .......................... 18
nifedipine............................... 50
NILANDRON....................... 27
NITRO-BID .......................... 51
nitrofurantoin macrocrystal.. 20
nitroglycerin.................... 51, 52
nitroglycerin/d5w.................. 52
NITROSTAT ........................ 52
NORDITROPIN FLEXPRO. 63
NORDITROPIN NORDIFLEX
........................................... 63
norelgestromin/ethin.estradiol
........................................... 53
norepinephrine bitartrate...... 50
noreth-ethinyl estradiol/iron. 53
norethindrone........................ 53
norethindrone acetate ........... 63
norethindrone ac-eth estradiol
..................................... 53, 61
norethindrone-e.estradiol-iron
........................................... 53
norethindrone-ethinyl estrad 53
norethindrone-mestranol ...... 53
norgestimate-ethinyl estradiol
........................................... 53
norgestrel-ethinyl estradiol... 53
NORMOSOL-M and
DEXTROSE...................... 73
NORMOSOL-R PH 7.4 ........ 73
NORTHERA......................... 47
nortriptyline hcl .................... 31
NORVIR ............................... 40
NOVAMINE......................... 46
NOVOLIN 70-30 .................. 33
NOVOLIN N ........................ 33
NOVOLIN R......................... 33
NOVOLOG........................... 33
NOVOLOG FLEXPEN ........ 33
NOVOLOG MIX 70-30........ 33
NOVOLOG MIX 70-30
FLEXPEN ......................... 33
NOXAFIL ............................. 34
NUCYNTA ........................... 15
NUCYNTA ER..................... 15
NUEDEXTA......................... 52
NULOJIX.............................. 64
NUTRESTORE..................... 60
NUTRILIPID ........................ 46
NUTRILYTE ........................ 73
NUTRILYTE II .................... 73
NUTROPIN .......................... 63
NUTROPIN AQ NUSPIN .... 63
NUVARING ......................... 53
NUVIGIL.............................. 76
nystatin.................................. 35
nystatin/triamcin ................... 35
OCTAGAM .......................... 64
octreotide acetate.................. 63
ofloxacin.......................... 23, 58
olanzapine ............................. 39
olanzapine/fluoxetine hcl ...... 31
olopatadine hcl...................... 57
OLYSIO................................ 41
omega-3 acid ethyl esters...... 51
omeprazole............................ 59
OMNITROPE ....................... 63
ONCASPAR ......................... 27
I-9
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
ondansetron........................... 36
ondansetron hcl..................... 36
ondansetron hcl/pf ................ 36
ONFI ..................................... 19
OPSUMIT ............................. 77
ORAP.................................... 39
ORENCIA............................. 64
ORENITRAM ER................. 77
ORFADIN............................. 56
OTEZLA ............................... 70
oxacillin sodium .................... 22
oxacillin sodium/dextrose,iso 22
oxaliplatin ............................. 27
oxandrolone .......................... 61
oxcarbazepine ....................... 30
OXTELLAR XR................... 30
oxybutynin chloride............... 60
oxycodone hcl........................ 15
oxycodone hcl/acetaminophen
........................................... 15
oxycodone hcl/aspirin ........... 15
OXYCONTIN....................... 16
oxymorphone hcl................... 16
paclitaxel............................... 27
PANRETIN........................... 54
pantoprazole sodium............. 59
papaverine hcl....................... 50
paricalcitol............................ 69
paromomycin sulfate............. 37
paroxetine hcl........................ 31
PASER .................................. 36
PATADAY ........................... 57
PATANOL............................ 57
PAXIL................................... 31
ped mv a,c,d3 #21 w-fluoride 77
PEDIARIX............................ 66
PEDVAXHIB ....................... 66
peg 3350/na sulf,bicarb,cl/kcl60
PEGANONE ......................... 30
PEGASYS............................. 41
PEGASYS PROCLICK ........ 41
PEGINTRON........................ 41
Effective: March 01, 2015
PEGINTRON REDIPEN ...... 41
pen g pot/dextrose-water. 22, 23
penicillin g potassium ........... 23
penicillin g potassium/d5w ... 23
penicillin g procaine ............. 23
penicillin v potassium ........... 23
PENTACEL .......................... 67
PENTACEL ACTHIB
COMPONENT.................. 67
PENTACEL DTAP-IPV
COMPONENT.................. 67
PENTAM 300 ....................... 37
pentamidine isethionate ........ 37
pentoxifylline......................... 43
p-epd tan/chlor-tan ............... 35
PERIKABIVEN.................... 46
perindopril erbumine ............ 48
PERJETA.............................. 27
permethrin............................. 56
perphenazine ......................... 39
perphenazine/amitriptyline hcl
........................................... 31
phenelzine sulfate.................. 31
phenobarbital........................ 30
phenobarbital sodium ........... 30
PHENTOLAMINE
MESYLATE ..................... 76
phenylephrine hcl............ 47, 57
phenytoin............................... 30
phenytoin sodium .................. 30
phenytoin sodium extended ... 30
PHOSLYRA ......................... 60
PHOSPHOLINE IODIDE .... 71
phosphorus #1....................... 73
PICATO ................................ 54
pilocarpine hcl ................ 53, 71
pindolol ................................. 49
pioglitazone hcl..................... 32
pioglitazone hcl/glimepiride . 32
pioglitazone hcl/metformin hcl
........................................... 32
piperacillin sodium/tazobactam
........................................... 23
piroxicam .............................. 17
PLASBUMIN-25 .................. 43
PLASBUMIN-5 .................... 43
PLASMA-LYTE 148............ 73
PLASMA-LYTE 56 IN
DEXTROSE...................... 73
PLASMA-LYTE A PH 7.4... 73
PLASMA-LYTE M IN
DEXTROSE...................... 73
PLEGRIDY........................... 70
PLEGRIDY PEN .................. 70
pnv with ca,no.72/iron/fa ...... 77
podofilox ............................... 54
podophyllum resin................. 54
polyethylene glycol 3350....... 60
polymyxin b sulf/trimethoprim
........................................... 58
POMALYST ......................... 27
pot chloride/pot bicarb/cit ac 73
potassium acetate.................. 73
potassium bicarbonate/cit ac 73
potassium chlorid/d100.2%nacl ........................... 73
potassium chloride ................ 73
potassium chloride in 0.9%nacl
........................................... 73
potassium chloride in d5w .... 73
potassium chloride in lr-d5... 46
potassium chloride/d50.2%nacl ........................... 73
potassium chloride/d5-0.25ns73
potassium chloride/d50.3%nacl ........................... 73
potassium chloride/d5-0.45nacl
........................................... 74
potassium chloride/d50.9%nacl ........................... 74
potassium chloride/d5w ........ 74
potassium chloride-0.45% nacl
........................................... 74
I-10
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
potassium citrate/citric acid . 74
potassium gluconate.............. 74
potassium hydroxide ............. 54
potassium phos,m-basic-d-basic
........................................... 74
POTIGA................................ 30
PRADAXA ........................... 42
pramipexole di-hcl ................ 37
PRANDIMET ....................... 32
pravastatin sodium................ 51
prazosin hcl........................... 47
prednicarbate........................ 55
prednisolone acetate ............. 62
prednisolone sod phosphate. 58,
62
prednisone............................. 62
PREGNYL ............................ 63
PREMARIN.......................... 61
PREMASOL ......................... 46
PREMPHASE ....................... 62
PREMPRO............................ 62
PREZISTA............................ 40
PRIFTIN ............................... 36
PRIMAQUINE ..................... 37
primidone .............................. 30
PRISTIQ ER ......................... 31
PRIVIGEN............................ 65
PROAIR HFA....................... 75
probenecid............................. 70
procainamide hcl .................. 48
PROCALAMINE.................. 46
prochlorperazine edisylate.... 36
prochlorperazine maleate ..... 36
PROCRIT........................ 42, 43
PROCYSBI ........................... 70
progesterone ......................... 63
progesterone,micronized....... 63
PROGLYCEM...................... 52
PROGRAF ............................ 65
PROLENSA.......................... 59
PROLEUKIN........................ 27
PROLIA ................................ 69
Effective: March 01, 2015
PROMACTA ........................ 43
promethazine hcl............. 35, 36
PRONESTYL ....................... 48
propafenone hcl .................... 48
propantheline bromide.......... 29
proparacaine hcl................... 57
proparacaine/fluorescein sod 57
propranolol hcl ..................... 49
propranolol/hydrochlorothiazid
........................................... 49
propylthiouracil .................... 64
PROQUAD ........................... 67
PROSOL ............................... 46
protamine sulfate .................. 43
PROTOPIC ........................... 55
protriptyline hcl .................... 31
PULMOZYME ..................... 56
PURIXAN............................. 27
pyrazinamide......................... 36
pyridostigmine bromide ........ 70
QUDEXY XR ....................... 30
quetiapine fumarate .............. 39
QUICK MIX with LYTES.... 46
QUILLIVANT XR................ 52
quinapril hcl.......................... 48
quinapril/hydrochlorothiazide
........................................... 48
quinidine gluconate............... 48
quinidine sulfate.................... 48
quinine sulfate....................... 37
QVAR ................................... 75
RABAVERT ......................... 67
raloxifene hcl ........................ 62
ramipril ................................. 48
RANEXA.............................. 50
ranitidine hcl......................... 59
RAPAMUNE ........................ 65
REBIF ................................... 70
REBIF REBIDOSE............... 70
RECOMBIVAX HB ............. 67
RELENZA ............................ 41
RELISTOR ........................... 60
REMICADE.......................... 70
REMODULIN....................... 77
RENAGEL............................ 60
RENVELA............................ 60
repaglinide ............................ 33
RESCRIPTOR ...................... 40
RESTASIS ............................ 59
RETROVIR........................... 40
REVATIO ............................. 77
REVLIMID ........................... 27
REYATAZ............................ 40
ribavirin ................................ 41
RIDAURA ............................ 65
rifabutin................................. 36
rifampin................................. 36
RIFATER.............................. 36
riluzole .................................. 52
rimantadine hcl ..................... 41
ringers solution ............... 68, 74
risedronate sodium................ 69
RISPERDAL CONSTA........ 39
risperidone ............................ 39
RITUXAN............................. 27
rivastigmine tartrate ............. 31
rizatriptan benzoate .............. 35
ropinirole hcl ........................ 37
ROTARIX............................. 67
ROTATEQ............................ 67
ROZEREM ........................... 76
SABRIL ................................ 30
SAIZEN ................................ 63
salsalate ................................ 17
SANDOSTATIN LAR.......... 63
SANTYL............................... 54
SAPHRIS .............................. 39
SAVELLA ............................ 52
selegiline hcl ......................... 37
selenium sulfide..................... 54
SELZENTRY........................ 40
SENSIPAR............................ 70
SEREVENT DISKUS........... 75
SEROQUEL XR ................... 39
I-11
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
SEROSTIM........................... 63
sertraline hcl ................... 31, 32
sildenafil citrate .................... 77
SILENOR.............................. 32
silver nitrate .......................... 54
silver nitrate applicator ........ 54
silver sulfadiazine ................. 55
SIMBRINZA......................... 71
SIMPONI .............................. 71
SIMPONI ARIA ................... 71
simvastatin ............................ 51
sirolimus................................ 65
SIRTURO ............................. 36
sod propion/inositol/aa14/urea
........................................... 35
sod/pot/k cit/sod cit/cit acid .. 74
sodium acetate ...................... 74
sodium bicarbonate............... 74
sodium chloride..................... 74
sodium chloride 0.45 % ........ 74
sodium chloride 3 % ............. 74
sodium chloride 5 % ............. 74
sodium chloride irrig solution
........................................... 68
sodium chloride/nahco3/kcl/peg
........................................... 60
sodium lactate ....................... 74
sodium morrhuate ................. 71
sodium phos,m-basic-d-basic 74
sodium polystyrene sulfonate 60
sodium thiosulfate ................. 61
SOLIRIS ............................... 71
SOLTAMOX ........................ 27
SOLU-CORTEF ................... 62
SOMATULINE DEPOT....... 63
SOMAVERT......................... 63
sorbitol solution .................... 68
sotalol hcl.............................. 49
SOVALDI ............................. 41
SPIRIVA ............................... 75
SPIRIVA RESPIMAT .......... 75
Effective: March 01, 2015
spironolact/hydrochlorothiazid
........................................... 51
spironolactone....................... 51
SPRYCEL ............................. 27
stavudine ............................... 40
STELARA............................. 71
STERILE DILUENT ............ 43
STIVARGA .......................... 27
STRATTERA ....................... 52
streptomycin sulfate .............. 19
STRIBILD............................. 40
STROMECTOL.................... 37
sucralfate............................... 59
sulfacetamide sodium...... 55, 58
sulfacetamide/prednisolone sp
........................................... 58
sulfadiazine ........................... 23
sulfamethoxazole/trimethoprim
........................................... 23
sulfasalazine.......................... 23
sulindac ................................. 17
sumatriptan ........................... 35
sumatriptan succinate ........... 35
SUPPRELIN LA................... 63
SUPRAX............................... 21
SURMONTIL ....................... 32
SUSTIVA.............................. 40
SUTENT ............................... 27
SYLATRON 4-PACK .......... 41
SYLVANT............................ 27
SYMLINPEN 120................. 33
SYMLINPEN 60................... 33
SYNAGIS ............................. 41
SYNAREL ............................ 71
SYNERCID........................... 20
SYNRIBO ............................. 27
SYPRINE.............................. 61
syring w-ndl,disp,insul,0.3 ml56
syring w-ndl,disp,insul,0.5 ml56
syringe & needle,insulin,1 ml 56
TABLOID ............................. 28
tacrolimus ....................... 55, 65
TAFINLAR........................... 28
TAMIFLU............................. 41
tamoxifen citrate ................... 28
tamsulosin hcl ....................... 60
TARCEVA............................ 28
TARGRETIN........................ 28
TASIGNA ............................. 28
TAZICEF IN DEXTROSE ... 21
TAZORAC............................ 56
TE ANATOXAL BERNA.... 67
TECFIDERA......................... 71
TEFLARO............................. 21
telmisartan ............................ 47
telmisartan/hydrochlorothiazid
........................................... 47
temazepam............................. 19
TEMODAR........................... 28
TENIVAC ............................. 67
terazosin hcl .......................... 60
terbinafine hcl ....................... 35
terbutaline sulfate ................. 75
terconazole............................ 35
testosterone ........................... 61
testosterone cypionate........... 61
testosterone enanthate .......... 61
TETANUS DIPHTHERIA
TOXOIDS ......................... 67
TETANUS TOXOID
ADSORBED ..................... 67
tetracaine hcl ........................ 57
tetracycline hcl...................... 23
TEV-TROPIN ....................... 63
THALOMID ......................... 71
theophylline anhydrous......... 75
theophylline/d5w ................... 75
thioridazine hcl ..................... 39
thiothixene............................. 39
tiagabine hcl.......................... 30
TIKOSYN ............................. 48
timolol maleate................ 49, 71
TIVICAY .............................. 40
tizanidine hcl......................... 76
I-12
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
TOBI PODHALER............... 19
TOBRADEX ST ................... 58
tobramycin ............................ 58
tobramycin in 0.225% nacl ... 19
tobramycin sulfate................. 19
tobramycin/sodium chloride . 19
tolazamide ............................. 34
tolbutamide ........................... 34
tolmetin sodium..................... 17
tolterodine tartrate................ 60
topiramate ............................. 30
topotecan hcl......................... 28
TORISEL .............................. 28
torsemide............................... 51
TOVIAZ................................ 60
TPN ELECTROLYTES II.... 74
TRACLEER.......................... 77
TRADJENTA ....................... 33
tramadol hcl .......................... 16
tramadol hcl/acetaminophen 16
trandolapril ........................... 48
tranexamic acid..................... 43
TRANSDERM-SCOP........... 36
tranylcypromine sulfate ........ 32
TRAVAMULSION............... 46
TRAVASOL ......................... 46
TRAVASOL W/DEXTROSE
........................................... 46
TRAVASOL W/
ELECTROLYTES ............ 46
TRAVASOL with DEXTROSE
........................................... 46
TRAVASOL with
ELECTROLYTES ............ 46
TRAVATAN Z ..................... 71
TRAVERT ............................ 46
TRAVERT IN NORMAL
SALINE ............................ 46
TRAVERT-ELECTROLYTE
NO.1.................................. 74
TRAVERT-ELECTROLYTE
NO.2.................................. 74
Effective: March 01, 2015
TRAVERT-ELECTROLYTE
NO.3.................................. 74
TRAVERT-ELECTROLYTE
NO.4.................................. 74
travoprost (benzalkonium) .... 72
trazodone hcl......................... 32
TREANDA ........................... 28
TRECATOR ......................... 36
TRELSTAR .......................... 28
tretinoin........................... 28, 56
tretinoin microspheres .......... 56
TREXALL ............................ 28
triamcinolone acetonide. 53, 55,
62
triamterene/hydrochlorothiazid
........................................... 51
triazolam ............................... 19
TRIBENZOR ........................ 47
trifluoperazine hcl................. 39
trifluridine ............................. 58
trihexyphenidyl hcl................ 37
TRILEPTAL ......................... 30
trimethoprim ......................... 20
TRIUMEQ ............................ 40
TROKENDI XR.................... 30
TROPHAMINE .................... 46
trospium chloride .................. 60
TRULICITY ......................... 33
TRUMENBA ........................ 67
TRUVADA ........................... 40
TUDORZA PRESSAIR........ 75
TWINRIX ............................. 67
TYBOST ............................... 71
TYGACIL ............................. 23
TYKERB............................... 28
TYPHIM VI .......................... 67
TYSABRI ............................. 65
TYVASO .............................. 77
TYZEKA............................... 41
ULORIC................................ 71
urologic solution-g................ 68
ursodiol ................................. 60
VAGIFEM ............................ 62
valacyclovir hcl..................... 41
VALCHLOR......................... 54
VALCYTE............................ 41
valganciclovir hcl.................. 41
valproic acid ......................... 30
valproic acid (as sodium salt)30
valsartan ............................... 47
valsartan/hydrochlorothiazide
........................................... 47
VALSTAR ............................ 28
vancomycin hcl...................... 20
VANCOMYCIN HCL .......... 20
vancomycin hcl/d5w.............. 20
VAQTA................................. 67
VARIVAX VACCINE ......... 67
VASCEPA ............................ 51
vasopressin............................ 63
VECTIBIX............................ 28
VELCADE............................ 28
venlafaxine hcl ...................... 32
VENTAVIS........................... 77
verapamil hcl ........................ 49
VERSACLOZ ....................... 39
VICTOZA 3-PAK................. 33
VIDEX .................................. 40
VIEKIRA PAK ..................... 41
VIGAMOX ........................... 58
VIIBRYD.............................. 32
VIMIZIM .............................. 57
VIMPAT ............................... 30
vinblastine sulfate ................. 28
vincristine sulfate .................. 28
vinorelbine tartrate ............... 28
VIRACEPT ........................... 40
VIRAMUNE XR .................. 40
VIRAZOLE........................... 41
VIREAD ............................... 40
VIVELLE-DOT .................... 62
VOLTAREN ......................... 17
voriconazole.......................... 35
VOTRIENT........................... 28
I-13
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
VPRIV................................... 57
warfarin sodium .................... 42
water for irrigation,sterile .... 68
WELCHOL ........................... 51
XALKORI............................. 28
XARELTO............................ 42
XELJANZ ............................. 71
XENAZINE .......................... 52
XGEVA................................. 69
XIFAXAN............................. 20
XOLAIR ............................... 75
XTANDI ............................... 28
XYREM ................................ 76
YERVOY.............................. 28
YF-VAX ............................... 67
zafirlukast.............................. 75
zaleplon ................................. 76
ZALTRAP............................. 29
ZAVESCA ............................ 57
ZELBORAF.......................... 29
ZEMAIRA ............................ 75
ZEMPLAR............................ 69
ZENPEP................................ 57
ZETIA ................................... 51
ZIAGEN................................ 40
zidovudine ............................. 40
ziprasidone hcl ...................... 39
ZOLADEX............................ 29
zoledronic acid...................... 69
zoledronic acid/
mannitol&water ................ 69
ZOLINZA ............................. 29
zolmitriptan ........................... 35
zolpidem tartrate................... 76
ZOMETA.............................. 69
zonisamide............................. 30
ZORTRESS........................... 65
ZOSTAVAX ......................... 67
ZOVIRAX............................. 54
ZUBSOLV ............................ 18
ZYDELIG ............................. 29
ZYKADIA ............................ 29
Effective: March 01, 2015
ZYLET.................................. 58
ZYPREXA RELPREVV ...... 39
ZYTIGA................................ 29
ZYVOX................................. 20
I-14
Denver Health Medical Plan, Inc. 2015 Part D Formulary
Formulary ID: 15452.000, Version: 8
Effective: March 01, 2015
Este formulario se actualizó el 02/25/2015. Para obtener información más reciente
o si tiene otras preguntas, comuníquese con Servicios al miembro de Denver
Health Medical Plan, Inc. llamando al 1-877-956-2111.
Los usuarios de TTY pueden llamar al 1-866-538-5288.
Nuestro horario de atención es de 8 a. m. a 8 p. m., los siete días de la semana, o
puede visitar el sitio web www.denverhealthmedicalplan.org.