1. Healthcare

Providence prescription drug coverage
Providence Health Plan wants to help you to make the most of your prescription drug coverage.
That’s why we strive to provide you with the information you need to make smart decisions about
medications.
Know more, save more
We encourage you to be knowledgeable about your prescription drug benefits. Information is
available on your benefit summary, in your member handbook and on the Providence Health Plan
website.
When you require a prescription, be sure to let your doctor know cost matters to you. Choosing a
generic when possible can help manage your costs.
Retail pharmacies
You have access to more than 25,000 participating pharmacies nationwide at discounted rates.
Search the provider directory to locate participating pharmacies near you.
Preventive drugs
Preventive drugs are those prescribed for the purpose of avoiding a condition or disease in
individuals with risk factors. They may also be prescribed for the prevention of a reoccurrence of a
disease or condition. Preventive medications are labeled as such in the “status” column of the
formulary.
Maintenance drugs
Maintenance medications are those typically prescribed to treat long-term or chronic conditions,
such as diabetes, high blood pressure and high cholesterol. A 90-day supply of maintenance
medication is available through participating mail-order pharmacies, as well as through preferred
retail pharmacies. Your 90-day supply copay or coinsurance applies. Not all covered prescription
drugs are available in a 90-day supply.
Learn more about mail-order pharmacies and preferred retail pharmacies.
Specialty drugs
Specialty drugs are prescriptions that require special delivery, handling, administration and
monitoring by your pharmacist. These drugs are listed in the Providence formulary with a status of
“Specialty,” and are available through Providence Specialty Pharmacy Services.
Learn more about specialty drugs.
Generic drugs
Making the switch from brand to generic medication can save you money. Generic drugs, which are
available only after the brand-name patent expires:
Providence Health & Services Prescription Drug Plan | i
1
•
•
Have the same active ingredient formula as the brand-name drug and
Are tested by the Food and Drug Administration (FDA) to be as safe and effective as the
brand-name drug.
There are two types of generic drugs:
•
Generic equivalent - A generic equivalent is a generic drug that has the same active
ingredient, dosage form and strength as its brand-name counterpart. The FDA assures
sameness between brand-name and generic equivalent products. Generic equivalents are an
important option to brand-name prescription drugs because they cost less.
Example: Zocor®, a brand-name drug commonly used to treat high cholesterol, is now
available in generic form under the name simvastatin. Zocor® and simvastatin are identical
drugs – the only difference is that one costs more than the other.
•
Generic alternative - A generic alternative is a generic drug used to treat the same
condition as a brand-name drug. It is not, however, the exact same medication as the brandname drug. According to clinical evidence, a generic alternative can be expected to treat the
same condition as well as the brand-name option.
Example: Simvastatin, the generic form of Zocor®, may be prescribed instead of Crestor® in
the treatment of high cholesterol. Generic alternatives are an important option for
prescription drugs for which there is no generic available.
Visit the Consumer Reports Best-Buy Drug website for more information regarding safe and effective
drug treatment options.
The Providence formulary
Your prescription drug plan provides coverage for medications listed on the Providence formulary.
Developed in collaboration with Providence Health Plans, physicians and pharmacists, the formulary
includes FDA-approved prescription generic, brand-name and specialty medications. The formulary
can help you and your physician choose effective, quality medications that minimize your out-ofpocket expense.
Search the formulary
There are two ways to search the formulary. They include:
1. By medical condition category (e.g., drugs used to treat heart conditions are listed under the
category, Cardiovascular Agents); and
2. By index (provides an alphabetical listing of drugs included in the formulary).
Formulary updates
The formulary is updated every two months. Providence’s Oregon Regional Pharmacy and
Therapeutics committee (comprised of doctors and pharmacists who practice in the communities we
Providence Health & Services Prescription Drug Plan | ii
2
serve) continuously reviews the latest evidence to identify opportunities to promote safe, effective
and affordable drug therapy. Generally, the formulary status of a drug covered by your Providence
Health Plan prescription drug coverage will not change during the year unless:
•
•
•
The medication becomes available in generic form;
There are safety or effectiveness concerns raised about the prescription drug; or
The Pharmacy and Therapeutics committee determines that changes to the formulary would
be in the best overall interest of Providence Health Plan members.
If a change to the formulary results in a reduction of benefits or an increase in member copay,
affected individuals are notified in writing.
Formulary brand-name drugs
The Providence formulary includes prescription drugs that are proven safe, effective and that offer
value. Refer to your benefit summary for your brand-name drug copay or coinsurance amount.
Remember, even if a generic equivalent is not yet available, safe and effective generic alternatives may
be available to treat most common conditions. Using these options can provide cost savings.
Non-approved drugs
Your prescription drug benefit covers only FDA-approved prescription drugs. It is possible for
medications to be on the market without FDA approval. The FDA is taking action to ensure these
drugs become approved or are removed from the market. In the meantime, many remain on
pharmacy shelves. If the drug you are taking is not FDA approved, know that there are likely
approved prescription drugs available to treat your condition. We encourage you to discuss
alternative medications with your doctor. Should you and your doctor determine that there is no
covered alternative and you choose to continue to take a medication that is not FDA approved, your
health plan will not cover that expense.
More information regarding medications that are not FDA approved can be found on our website,
in the related article and in the FAQ document, which includes links to the FDA website. You may
also call the Providence Health Plan pharmacy team for more information and to discuss potential
alternatives.
Prior authorization
Prior authorization is a process to review a prescription drug for coverage before it is dispensed. The
prior authorization process is initiated by the prescribing medical provider.
Many factors – including the potential for serious health risks, FDA-approved indications and costeffectiveness – are considered before making the decision to require prior authorization of a
prescription medication. A limited number of medications require prior authorization review; any
medications requiring prior authorization are indicated as such in the Providence formulary.
Providence Health & Services Prescription Drug Plan | iii
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Keep in mind, the formulary may contain other suitable options. You and your doctor may wish to
discuss the possibility of changing your prescription to an effective formulary alternative. Otherwise,
your doctor may submit a prior authorization request on your behalf.
Formulary exceptions
There may be times that you require a medication that is not on the Providence formulary. If you
currently take a prescription drug that is not on the formulary, contact customer service to confirm
that drug is not covered. If the prescription drug is not covered, your doctor may request a formulary
exception.
Step therapy
Step therapy is a form of prior authorization. Its purpose is to confirm if drugs generally considered
"first-line" therapy based on clinical evidence already have been tried. If they have, the drug
requiring prior authorization will automatically be approved. In the event these drugs are not tried
first, cannot be tried first or the individual’s prescription medication history is not part of Providence
Health Plan claims history, prior authorization is required.
Quantity limit
For certain drugs, Providence Health Plan limits the amount of the drug covered for a specified
time frame [e.g., Providence Health Plan provides two inhalers per 30 days for Proair® or
Proventil® HFA (albuterol HFA)]. Quantity limits are in place to ensure safe and appropriate use of a
drug.
Answers to frequently asked questions
Learn more about your prescription drug coverage by reviewing answers to frequently asked
questions.
Providence Health & Services Prescription Drug Plan | iv
4
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
Analgesics
alagesic lq
Generic
butalbital/acetaminophen
Generic
butalbital/acetaminophen/caffeine (50325-40 capsule, 50-325-40 tablet, 50500-40 tablet)
Generic
butalbital/aspirin/caffeine
Generic
capacet
Generic
fioricet 50-325-40 mg tablet
Generic
tencon 50-325 mg tablet
Generic
tramadol hcl/acetaminophen
Generic
QL (240 PER 30 DAYS)
celecoxib (50 mg capsule, 100 mg
capsule, 200 mg capsule)
Generic
PA, QL (60 PER 30 DAYS)
celecoxib 400 mg capsule
Generic
PA, QL (30 PER 30 DAYS)
diclofenac potassium
Generic
diclofenac sodium (25 mg tablet dr, 50
mg tablet dr, 75 mg tablet dr, 100 mg
tab er 24h)
Generic
diflunisal
Generic
etodolac (200 mg capsule, 300 mg
capsule, 400 mg tab er 24h, 400 mg
tablet, 500 mg tab er 24h, 500 mg
tablet, 600 mg tab er 24h)
Generic
fenoprofen calcium 600 mg tablet
Generic
flurbiprofen (50 mg tablet, 100 mg
tablet)
Generic
ibuprofen (400 mg tablet, 600 mg
tablet, 800 mg tablet)
Generic
ibuprofen/oxycodone hcl
Generic
Nonsteroidal Anti-inflammatory Drugs
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
5
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
indomethacin (25 mg capsule, 50 mg
capsule, 75 mg capsule er)
Generic
ketoprofen (50 mg capsule, 75 mg
capsule, 200 mg cap24h pel)
Generic
ketorolac tromethamine 10 mg tablet
Generic
meclofenamate sodium (50 mg capsule,
100 mg capsule)
Generic
meloxicam (7.5 mg tablet, 7.5 mg/5ml
oral susp, 15 mg tablet)
Generic
nabumetone (500 mg tablet, 750 mg
tablet)
Generic
NAPRELAN CR 500 MG TABLET
Brand
naproxen (125 mg/5ml oral susp, 250
mg tablet, 375 mg tablet, 375 mg tablet
dr, 500 mg tablet, 500 mg tablet dr)
Generic
naproxen sodium (275 mg tablet, 550
mg tablet)
Generic
oxaprozin
Generic
piroxicam (10 mg capsule, 20 mg
capsule)
Generic
sulindac (150 mg tablet, 200 mg tablet)
Generic
tolmetin sodium
Generic
Requirements/Limits
Opioid Analgesics, Long-acting
fentanyl (12 mcg/hr, 25mcg/hr,
50mcg/hr, 75mcg/hr, 100 mcg/hr)
Generic
levorphanol tartrate 2 mg tablet
Generic
methadone hcl (5 mg tablet, 5 mg/5 ml
solution, 10 mg tablet, 10 mg/5 ml
solution, 10 mg/ml oral conc, 40 mg
tablet sol)
Generic
methadone intensol
Generic
methadose 40 mg tablet dispr
Generic
QL (15 PER 30 DAYS)
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
6
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
morphine sulfate (5 mg supp.rect, 10
mg supp.rect, 15 mg tablet er, 20 mg
supp.rect, 30 mg supp.rect, 30 mg
tablet er, 60 mg tablet er, 100 mg
tablet er, 200 mg tablet er)
Generic
oxycodone hcl (10 mg tab er, 20 mg tab
er, 40 mg tab er, 80 mg tab er)
Generic
PA, QL (90 PER 30 DAYS)
OXYCONTIN (15 MG TABLET, 30 MG
TABLET, 60 MG TABLET)
Brand
PA, QL (90 PER 30 DAYS)
tramadol hcl (100 mg tab er 24h, 100
mg tbmp 24hr, 200 mg tab er 24h, 200
mg tbmp 24hr, 300 mg tab er 24h, 300
mg tbmp 24hr)
Generic
Opioid Analgesics, Short-acting
acetaminophen with codeine phosphate
(120-12mg/5 solution, 240-24/10
solution, 300mg-15mg tablet, 300mg30mg tablet, 300mg-60mg tablet,
300mg/12.5 solution, 360-36/15
solution)
Generic
ascomp with codeine
Generic
butalbit/acetamin/caff/codeine 50-32530 capsule
Generic
butorphanol tartrate 10 mg/ml spray
Generic
co-gesic
Generic
codeine
phosphate/butalbital/aspirin/caffeine
Generic
codeine phosphate/carisoprodol/aspirin
Generic
codeine sulfate (15 mg tablet, 30 mg
tablet, 60 mg tablet)
Generic
dihydrocodeine
bitartrate/acetaminophen/caffeine
Generic
endocet (5-325 tablet, 7.5-325 mg
tablet, 7.5-500 mg tablet, 10-325 mg
tablet, 10-650 mg tablet)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
7
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
endodan
Generic
hydrocodone bitartrate/acetaminophen
(2.5-167/5 solution, 2.5-500 mg tablet,
5 mg-500mg tablet, 5-334mg/10
solution, 5mg-325mg tablet, 7.5-325/15
solution, 7.5-325mg tablet, 7.5-500/15
solution, 7.5-500mg tablet, 7.5-650 mg
tablet, 7.5-750mg tablet, 10-660mg
tablet, 10-750mg tablet, 10mg-325mg
tablet, 10mg-500mg tablet, 10mg650mg tablet)
Generic
hydrocodone/ibuprofen
Generic
hydromorphone hcl (1 mg/ml liquid, 2
mg tablet, 3 mg supp.rect, 4 mg tablet,
8 mg tablet)
Generic
ibudone 5-200 mg tablet
Generic
lorcet
Generic
lorcet hd
Generic
lorcet plus 7.5-325 mg tablet
Generic
lortab (5-325 mg tablet, 5-500 tablet,
7.5-325 mg tablet, 10-325 mg tablet)
Generic
meperidine hcl (50 mg tablet, 100 mg
tablet)
Generic
meperitab
Generic
morphine sulfate (10 mg/5 ml solution,
15 mg tablet, 20 mg/5 ml solution, 30
mg tablet, 100 mg/5ml solution)
Generic
oxycodone hcl (5 mg capsule, 5 mg
tablet, 5 mg/5 ml solution, 10 mg
tablet, 15 mg tablet, 20 mg tablet, 20
mg/ml oral conc, 30 mg tablet)
Generic
oxycodone hcl/acetaminophen (5 mg500mg capsule, 5mg-325mg tablet, 7.5325mg tablet, 7.5-500mg tablet, 10mg325mg tablet, 10mg-650mg tablet)
Generic
Requirements/Limits
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
8
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
oxycodone hcl/aspirin
Generic
oxymorphone hcl (5 mg tablet, 10 mg
tablet)
Generic
reprexain 10-200 mg tablet
Generic
ROXICET 5-325 ORAL SOLUTION
Brand
roxicet 5-325 tablet
Generic
stagesic
Generic
tramadol hcl 50 mg tablet
Generic
xylon 10
Generic
Requirements/Limits
PA
Anesthetics
Local Anesthetics
glydo
Generic
lidocaine 5 % oint. (g)
Generic
lidocaine 5%(700mg) adh. patch
Generic
lidocaine hcl (2 % jel (ml), 2 % jel/pf
app, 2 % solution, 4 % solution, 40
mg/ml solution)
Generic
lidocaine/prilocaine (2.5 %-2.5% cream
(g), 2.5 %-2.5% kit)
Generic
PA, QL (90 PER 30 DAYS)
Anti-Addiction/Substance Abuse Treatment Agents
Alcohol Deterrents/Anti-craving
acamprosate calcium
Generic
disulfiram (250 mg tablet, 500 mg
tablet)
Generic
buprenorphine hcl/naloxone hcl
Generic
SUBOXONE (2 MG-0.5 MG, 8 MG-2 MG)
Brand
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
9
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
buprenorphine hcl (2 mg tab, 8 mg tab)
Generic
QL (90 PER 30 DAYS)
depade
Generic
naltrexone hcl 50 mg tablet
Generic
revia
Generic
Opioid Antagonists
Smoking Cessation Agents
buproban
Generic
CHANTIX
Brand
Anti-inflammatory Agents
Glucocorticoids
alclometasone dipropionate
Generic
amcinonide 0.1 % cream (g)
Generic
apexicon e
Generic
betamethasone dipropionate (0.05 %
cream (g), 0.05 % gel (gram), 0.05 %
lotion, 0.05 % oint. (g))
Generic
betamethasone dipropionate/propylene
glycol (0.05 % cream (g), 0.05 % lotion,
0.05 % oint. (g))
Generic
betamethasone valerate (0.1 % cream
(g), 0.1 % lotion, 0.1 % oint. (g))
Generic
clobetasol propionate (0.05 % cream
(g), 0.05 % foam, 0.05 % gel (gram),
0.05 % oint. (g), 0.05 % shampoo, 0.05
% solution)
Generic
clobetasol propionate/emoll 0.05 %
cream (g)
Generic
clobetasol propionate/emoll 0.05 %
foam
Generic
clodan 0.05% shampoo
Generic
PA
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
10
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
cormax
Generic
cortisone acetate 25 mg tablet
Generic
desonide (0.05 % cream (g), 0.05 %
lotion, 0.05 % oint. (g))
Generic
desoximetasone
Generic
diflorasone diacetate
Generic
fludrocortisone acetate 0.1 mg tablet
Generic
fluocinolone acetonide (0.01 % cream
(g), 0.01 % solution, 0.025 % cream (g),
0.025 % oint. (g))
Generic
fluocinonide (0.05 % cream (g), 0.05 %
gel (gram), 0.05 % oint. (g), 0.05 %
solution)
Generic
fluocinonide/emollient base
Generic
fluticasone propionate (0.005 % oint.
(g), 0.05 % cream (g), 0.05 % lotion)
Generic
halobetasol propionate
Generic
hydrocortisone (2.5 % cream (g), 2.5 %
lotion, 2.5 % oint. (g))
Generic
hydrocortisone butyrate 0.1 % cream
(g)
Generic
millipred 5 mg tablet
Generic
millipred dp
Generic
nystatin/triamcinolone acetonide
Generic
oralone
Generic
prednisolone 15 mg/5 ml solution
Generic
prednisolone sod phosphate (5 mg/5 ml
solution, 10 mg tab rapdis, 15 mg tab
rapdis, 15 mg/5 ml solution, 30 mg tab
rapdis)
Generic
Requirements/Limits
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
11
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
prednisone (1 mg tablet, 2.5 mg tablet,
5 mg tab ds pk, 5 mg tablet, 5 mg/5 ml
solution, 10 mg tab ds pk, 10 mg tablet,
20 mg tablet, 50 mg tablet)
Generic
prednisone intensol
Generic
triamcinolone acetonide (0.025 %
cream (g), 0.025 % lotion, 0.025 % oint.
(g), 0.1 % cream (g), 0.1 % lotion, 0.1 %
oint. (g), 0.1 % paste (g), 0.5 % cream
(g), 0.5 % oint. (g))
Generic
triderm
Generic
Requirements/Limits
Antibacterials
Aminoglycosides
garamycin 0.3% eye drops
Generic
gentak (0.3 % ointment, 3 mg/ml drops)
Generic
gentamicin sulfate (0.1 % cream (g), 0.1
% oint. (g), 0.3 % drops, 0.3 % oint. (g))
Generic
neomycin sulfate 500 mg tablet
Generic
TOBI PODHALER
Specialty
tobramycin 0.3 % drops
Generic
tobramycin in 0.225 % sodium chloride
Generic
TOBREX 0.3% EYE OINTMENT
Brand
LA
Antibacterials, Other
acetasol hc
Generic
acetic acid/aluminum acetate
Generic
acetic acid/hydrocortisone
Generic
bacitracin 500 unit/g oint. (g)
Generic
chlorhexidine gluconate 0.12 %
mouthwash
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
12
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
clinda-derm
Generic
clindacin etz 1% pledget
Generic
clindacin p
Generic
clindamycin hcl (75 mg capsule, 150 mg
capsule, 300 mg capsule)
Generic
clindamycin palmitate hcl
Generic
clindamycin phosphate (1 % foam, 1 %
gel (gram), 1 % lotion, 1 % med. swab, 1
% solution, 2 % cream/appl)
Generic
cycloserine 250 mg capsule
Generic
methenamine hippurate
Generic
metronidazole (0.75 % cream (g), 0.75
% gel (gram))
Generic
metronidazole (0.75 % gel w/appl, 0.75
% lotion, 250 mg tablet, 375 mg
capsule, 500 mg tablet)
Generic
MONUROL
Brand
mupirocin 2 % oint. (g)
Generic
nitrofurantoin 25 mg/5 ml oral susp
Generic
nitrofurantoin macrocrystal (50 mg
capsule, 100 mg capsule)
Generic
nitrofurantoin
monohydrate/macrocrystals
Generic
paroex
Generic
periogard
Generic
rosadan (0.75% cream, 0.75% gel)
Generic
trimethoprim 100 mg tablet
Generic
vancomycin hcl (125 mg capsule, 250
mg capsule)
Generic
vandazole
Generic
vitazol
Generic
Requirements/Limits
PA
PA
PA
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
13
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
XIFAXAN 200 MG TABLET
Brand
PA, QL (90 PER 30 DAYS)
XIFAXAN 550 MG TABLET
Brand
PA, QL (60 PER 30 DAYS)
ZYVOX (100 MG/5 ML SUSPENSION,
600 MG TABLET)
Brand
Beta-lactam, Cephalosporins
cefaclor (125 mg/5ml susp recon, 250
mg capsule, 250 mg/5ml susp recon,
375 mg/5ml susp recon, 500 mg
capsule)
Generic
cefadroxil (1 g tablet, 250 mg/5ml susp
recon, 500 mg capsule, 500 mg/5ml
susp recon)
Generic
cefdinir (125 mg/5ml susp recon, 250
mg/5ml susp recon, 300 mg capsule)
Generic
cefpodoxime proxetil (50 mg/5 ml susp
recon, 100 mg tablet, 100 mg/5ml susp
recon, 200 mg tablet)
Generic
cefprozil (125 mg/5ml susp recon, 250
mg tablet, 250 mg/5ml susp recon, 500
mg tablet)
Generic
ceftibuten dihydrate (180 mg/5ml susp
recon, 400 mg capsule)
Generic
CEFTIN (125 ML, 250 ML)
Brand
cefuroxime axetil
Generic
cephalexin (125 mg/5ml susp recon,
250 mg capsule, 250 mg tablet, 250
mg/5ml susp recon, 500 mg capsule,
500 mg tablet)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
14
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
Beta-lactam, Penicillins
amoxicillin (125 mg tab chew, 125
mg/5ml susp recon, 200 mg/5ml susp
recon, 250 mg capsule, 250 mg tab
chew, 250 mg/5ml susp recon, 400 mg
tab chew, 400 mg/5ml susp recon, 500
mg capsule, 500 mg tablet, 875 mg
tablet)
Generic
amoxicillin/potassium clavulanate (20028.5/5 susp recon, 200-28.5mg tab
chew, 250-125 mg tablet, 250-62.5/5
susp recon, 400-57mg tab chew, 40057mg/5 susp recon, 500-125 mg tablet,
600-42.9/5 susp recon, 875-125 mg
tablet, 1000-62.5 tab er 12h)
Generic
ampicillin trihydrate (250 mg capsule,
500 mg capsule)
Generic
dicloxacillin sodium
Generic
penicillin v potassium (125 mg/5ml soln
recon, 250 mg tablet, 250 mg/5ml soln
recon, 500 mg tablet)
Generic
Macrolides
AZASITE
Brand
azithromycin (1 g packet, 100 mg/5ml
susp recon, 200 mg/5ml susp recon, 250
mg tablet, 500 mg tablet, 600 mg
tablet)
Generic
clarithromycin (125 mg/5ml susp recon,
250 mg tablet, 250 mg/5ml susp recon,
500 mg tab er 24h, 500 mg tablet)
Generic
E.E.S. 200
Brand
ERY-TAB
Brand
erygel
Generic
ERYPED 200
Brand
erythromycin base (5 mg/g oint. (g),
250 mg capsule dr, 250 mg tablet, 500
mg tablet)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
15
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
erythromycin base/ethyl alcohol (2 %
gel (gram), 2 % solution)
Generic
erythromycin ethylsuccinate 400 mg
tablet
Generic
erythromycin
ethylsuccinate/sulfisoxazole acetyl
Generic
Requirements/Limits
Quinolones
ciprofloxacin hcl (0.3 % drops, 100 mg
tablet, 250 mg tablet, 500 mg tablet,
750 mg tablet)
Generic
ciprofloxacin/ciprofloxa hcl 500 mg
tbmp 24hr
Generic
levofloxacin (0.5 % drops, 250 mg
tablet, 250mg/10ml solution, 500 mg
tablet, 750 mg tablet)
Generic
moxifloxacin hcl 400 mg tablet
Generic
ofloxacin (0.3 % drops, 200 mg tablet,
300 mg tablet, 400 mg tablet)
Generic
Sulfonamides
bleph-10
Generic
silver sulfadiazine 1 % cream (g)
Generic
sulfacetamide sodium (10 % drops, 10 %
suspension)
Generic
sulfadiazine 500 mg tablet
Generic
sulfamethoxazole/trimethoprim (20040mg/5 oral susp, 400mg-80mg tablet,
800-160 mg tablet, 800-160/20 oral
susp)
Generic
sulfamide
Generic
Tetracyclines
avidoxy
Generic
demeclocycline hcl (150 mg tablet, 300
mg tablet)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
16
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
doxycycline hyclate (20 mg tablet, 50
mg capsule, 100 mg capsule, 100 mg
tablet)
Generic
doxycycline monohydrate (50 mg
capsule, 50 mg tablet, 75 mg tablet,
100 mg capsule, 100 mg tablet, 150 mg
tablet)
Generic
dynacin 100 mg tablet
Generic
minocycline hcl (50 mg capsule, 75 mg
capsule, 100 mg capsule, 100 mg
tablet)
Generic
morgidox 100 mg capsule
Generic
OCUDOX
Brand
tetracycline hcl (250 mg capsule, 500
mg capsule)
Generic
Requirements/Limits
Anticonvulsants
Anticonvulsants, Other
acetazolamide (125 mg tablet, 250 mg
tablet)
Generic
levetiracetam (100 mg/ml solution, 250
mg tablet, 500 mg tablet, 500 mg/5ml
solution, 750 mg tablet, 1000 mg
tablet)
Generic
primidone (50 mg tablet, 250 mg tablet)
Generic
Calcium Channel Modifying Agents
CELONTIN
Brand
ethosuximide (250 mg capsule, 250
mg/5ml solution)
Generic
LYRICA (20 MG/ML ORAL SOLUTION, 25
MG CAPSULE, 50 MG CAPSULE, 75 MG
CAPSULE, 100 MG CAPSULE, 150 MG
CAPSULE, 200 MG CAPSULE, 225 MG
CAPSULE, 300 MG CAPSULE)
Brand
PA
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
17
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
zonisamide
Generic
Requirements/Limits
Gamma-aminobutyric Acid (GABA) Augmenting Agents
clonazepam (0.125 mg tab rapdis, 0.25
mg tab rapdis, 0.5 mg tab rapdis, 0.5
mg tablet, 1 mg tab rapdis, 1 mg tablet,
2 mg tab rapdis, 2 mg tablet)
Generic
clorazepate dipotassium
Generic
DIASTAT
Brand
diazepam (2 mg tablet, 5 mg tablet, 5
mg/5 ml solution, 5-7.5-10mg kit, 10
mg tablet, 12.5-15-20 kit)
Generic
diazepam 2.5 mg kit
Brand
divalproex sodium
Generic
gabapentin (100 mg capsule, 250
mg/5ml solution, 300 mg capsule, 400
mg capsule, 600 mg tablet, 800 mg
tablet)
Generic
GABITRIL (12 MG TABLET, 16 MG
TABLET)
Brand
lorazepam (0.5 mg tablet, 1 mg tablet,
2 mg tablet, 2 mg/ml oral conc)
Generic
lorazepam intensol
Generic
ONFI (5 MG TABLET, 10 MG TABLET, 20
MG TABLET)
Brand
PA, QL (60 PER 30 DAYS)
ONFI 2.5 MG/ML SUSPENSION
Brand
PA
phenobarbital (15 mg tablet, 16.2 mg
tablet, 20 mg/5 ml elixir, 30 mg tablet,
32.4 mg tablet, 60 mg tablet, 64.8 mg
tablet, 97.2mg tablet, 100 mg tablet)
Generic
SABRIL
Brand
tiagabine hcl
Generic
valproic acid (as sodium salt) (valproate
sodium) (250 mg/5ml solution, 500
mg/5ml vial, 500mg/10ml solution)
Generic
LA
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
18
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
valproic acid 250 mg capsule
Generic
Requirements/Limits
Glutamate Reducing Agents
felbamate (400 mg tablet, 600 mg
tablet, 600 mg/5ml oral susp)
Generic
lamotrigine (5 mg tb chw dsp, 25 mg
tablet, 25 mg tb chw dsp, 25mg (35) tab
ds pk, 100 mg tablet, 150 mg tablet,
200 mg tablet)
Generic
QUDEXY XR 200 MG CAPSULE
Brand
topiragen
Generic
topiramate (15 mg cap sprink, 25 mg
cap sprink, 25 mg tablet, 50 mg tablet,
100 mg tablet, 200 mg tablet)
Generic
topiramate (25 mg cap 24, 50 mg cap
24, 100 mg cap 24, 150 mg cap 24)
Generic
PA
topiramate 200 mg cap spr 24
Brand
PA
APTIOM
Brand
PA
BANZEL (40 MG/ML SUSPENSION, 200
MG TABLET, 400 MG TABLET)
Brand
PA
carbamazepine (100 mg cpmp 12hr,
100 mg tab chew, 100 mg/5ml oral
susp, 200 mg cpmp 12hr, 200 mg tab er
12h, 200 mg tablet, 300 mg cpmp 12hr,
400 mg tab er 12h)
Generic
DILANTIN 30 MG CAPSULE
Brand
epitol
Generic
EQUETRO
Brand
oxcarbazepine (150 mg tablet, 300 mg
tablet, 300 mg/5ml oral susp, 600 mg
tablet)
Generic
phenytoin (50 mg tab chew, 100
mg/4ml oral susp, 125 mg/5ml oral
susp)
Generic
PA
Sodium Channel Agents
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
19
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
phenytoin sodium extended (100 mg
capsule, 200 mg capsule)
Generic
VIMPAT (10 MG/ML SOLUTION, 50 MG
TABLET, 100 MG TABLET, 150 MG
TABLET, 200 MG TABLET)
Brand
ziprasidone hcl 20 mg capsule
Generic
Requirements/Limits
PA
Antidementia Agents
Cholinesterase Inhibitors
donepezil hcl (5 mg tab rapdis, 5 mg
tablet, 10 mg tab rapdis, 10 mg tablet)
Generic
EXELON (2 MG/ML ORAL SOLUTION, 4.6
MG/24HR PATCH, 9.5 MG/24HR PATCH,
13.3 MG/24HR PATCH)
Brand
rivastigmine tartrate
Generic
N-methyl-D-aspartate (NMDA) Receptor Antagonist
NAMENDA (5 MG TABLET, 5-10 MG
TITRATION PK, 10 MG TABLET)
Brand
PA, QL (60 PER 30 DAYS)
NAMENDA 10 MG/5 ML SOLUTION
Brand
PA, QL (360 ML PER 30 DAYS)
Antidepressants
Antidepressants, Other
ABILIFY (1 MG/ML SOLUTION, 2 MG
TABLET, 5 MG TABLET, 10 MG TABLET,
15 MG TABLET, 20 MG TABLET, 30 MG
TABLET)
Brand
ABILIFY DISCMELT
Brand
budeprion sr
Generic
budeprion xl
Generic
bupropion hcl (75 mg tablet, 100 mg
tablet, 100 mg tablet er, 150 mg tab er
24h, 150 mg tablet er, 200 mg tablet er,
300 mg tab er 24h)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
20
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
maprotiline hcl 75 mg tablet
Generic
mirtazapine (7.5 mg tablet, 15 mg tab
rapdis, 15 mg tablet, 30 mg tab rapdis,
30 mg tablet, 45 mg tab rapdis, 45 mg
tablet)
Generic
nefazodone hcl
Generic
trazodone hcl (50 mg tablet, 100 mg
tablet, 150 mg tablet, 300 mg tablet)
Generic
Requirements/Limits
Monoamine Oxidase Inhibitors
MARPLAN
Brand
phenelzine sulfate 15 mg tablet
Generic
tranylcypromine sulfate
Generic
Serotonin/Norepinephrine Reuptake Inhibitors
citalopram hydrobromide (10 mg tablet,
10 mg/5 ml solution, 20 mg tablet, 40
mg tablet)
Generic
duloxetine hcl (20 mg capsule dr, 30 mg
capsule dr)
Generic
QL (60 PER 30 DAYS)
duloxetine hcl 60 mg capsule dr
Generic
QL (30 PER 30 DAYS)
escitalopram oxalate (5 mg tablet, 5
mg/5 ml solution, 10 mg tablet, 20 mg
tablet)
Generic
fluoxetine hcl (10 mg capsule, 10 mg
tablet, 20 mg capsule, 20 mg tablet, 20
mg/5 ml solution, 40 mg capsule, 60 mg
tablet, 90 mg capsule dr)
Generic
fluvoxamine maleate (25 mg tablet, 50
mg tablet, 100 mg tablet)
Generic
olanzapine/fluoxetine hcl
Generic
paroxetine hcl (10 mg tablet, 20 mg
tablet, 30 mg tablet, 40 mg tablet)
Generic
PAXIL 10 MG/5 ML SUSPENSION
Brand
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
21
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
sertraline hcl (20 mg/ml oral conc, 25
mg tablet, 50 mg tablet, 100 mg tablet)
Generic
venlafaxine hcl (25 mg tablet, 37.5 mg
cap er 24h, 37.5 mg tab er 24, 37.5 mg
tablet, 50 mg tablet, 75 mg cap er 24h,
75 mg tab er 24, 75 mg tablet, 100 mg
tablet, 150 mg cap er 24h, 150 mg tab
er 24)
Generic
venlafaxine hcl 225 mg tab er 24
Brand
Requirements/Limits
Tricyclics
amitriptyline hcl (10 mg tablet, 25 mg
tablet, 50 mg tablet, 75 mg tablet, 100
mg tablet, 150 mg tablet)
Generic
amoxapine
Generic
clomipramine hcl (25 mg capsule, 50
mg capsule, 75 mg capsule)
Generic
desipramine hcl (10 mg tablet, 25 mg
tablet, 50 mg tablet, 75 mg tablet, 100
mg tablet, 150 mg tablet)
Generic
doxepin hcl (10 mg capsule, 10 mg/ml
oral conc, 25 mg capsule, 50 mg
capsule, 75 mg capsule, 100 mg
capsule, 150 mg capsule)
Generic
imipramine hcl (10 mg tablet, 25 mg
tablet, 50 mg tablet)
Generic
imipramine pamoate
Generic
nortriptyline hcl (10 mg capsule, 10
mg/5 ml solution, 25 mg capsule, 50 mg
capsule, 75 mg capsule)
Generic
protriptyline hcl
Generic
trimipramine maleate (25 mg capsule,
50 mg capsule)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
22
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
Antiemetics
Antiemetics, Other
chlorpromazine hcl (10 mg tablet, 25
mg tablet, 50 mg tablet, 100 mg tablet,
200 mg tablet)
Generic
COMPRO
Preventive
DICLEGIS
Preventive
hydroxyzine hcl (10 mg tablet, 10 mg/5
ml syrup, 25 mg tablet, 50 mg tablet)
Generic
hydroxyzine pamoate (25 mg capsule,
50 mg capsule, 100 mg capsule)
Generic
metoclopramide hcl (5 mg tablet, 5
mg/5 ml solution, 10 mg tablet, 10
mg/10ml solution)
Generic
perphenazine (2 mg tablet, 4 mg tablet,
8 mg tablet, 16 mg tablet)
Generic
PHENADOZ
Preventive
prochlorperazine maleate (5 mg tablet,
10 mg tablet, 25 mg supp.rect)
Preventive
promethazine hcl (12.5 mg, 25 mg, 50
mg)
Preventive
promethazine hcl (6.25mg/5ml syrup,
12.5 mg tablet, 25 mg tablet, 50 mg
tablet)
Generic
PROMETHEGAN
Preventive
TRANSDERM-SCOP
Preventive
trimethobenzamide hcl 300 mg capsule
Preventive
QL (60 PER 30 DAYS)
Emetogenic Therapy Adjuncts
EMEND (80 MG CAPSULE, 125 MG
CAPSULE, TRIFOLD PACK)
Preventive
QL (4 PER 30 DAYS)
granisetron hcl 1 mg tablet
Preventive
PA, QL (8 PER 30 DAYS)
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
23
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
ondansetron
Preventive
ondansetron hcl (4 mg tablet, 4 mg/5
ml solution, 8 mg tablet)
Preventive
Requirements/Limits
Antifungals
ciclodan 0.77% cream
Generic
ciclopirox (0.77 % gel (gram), 1 %
shampoo)
Generic
ciclopirox olamine (0.77 % cream (g),
0.77 % suspension)
Generic
clotrimazole 10 mg troche
Generic
clotrimazole/betamethasone
dipropionate (1 %-0.05 % cream (g), 1
%-0.05 % lotion)
Generic
econazole nitrate 1 % cream (g)
Generic
fluconazole (10 mg/ml susp recon, 40
mg/ml susp recon, 50 mg tablet, 100
mg tablet, 150 mg tablet, 200 mg
tablet)
Generic
griseofulvin ultramicrosize 250 mg
tablet
Generic
griseofulvin, microsize (125 mg/5ml oral
susp, 500 mg tablet)
Generic
itraconazole 100 mg capsule
Generic
ketoconazole (2 % cream (g), 2 %
shampoo)
Generic
LAMISIL 187.5 MG GRANULES PACK
Brand
NATACYN
Brand
NOXAFIL 40 MG/ML SUSPENSION
Brand
nyamyc
Generic
PA
PA
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
24
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
nystatin (50mm unit powder(ea),
150mm unit powder(ea), 500k unit
tablet, 500mm unit powder(ea),
100000/g cream (g), 100000/g oint. (g),
100000/g powder, 100000/ml oral
susp)
Generic
nystop
Generic
pedi-dri
Generic
SPORANOX 10 MG/ML SOLUTION
Brand
terbinafine hcl 250 mg tablet
Generic
terconazole (0.4 % cream/appl, 0.8 %
cream/appl, 80 mg supp.vag)
Generic
voriconazole 200 mg/5ml susp recon
Generic
Requirements/Limits
PA
Antigout Agents
allopurinol (100 mg tablet, 300 mg
tablet)
Generic
colchicine/probenecid
Generic
COLCRYS
Brand
probenecid
Generic
QL (60 PER 30 DAYS)
Antimigraine Agents
Ergot Alkaloids
cafergot
Generic
dihydroergotamine mesylate
0.5mg/spry spray/pump
Brand
ergotamine tartrate/caffeine
Generic
migergot
Generic
MIGRANAL
Brand
QL (3.5 ML PER 30 DAYS)
QL (3.5 ML PER 30 DAYS)
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
25
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
Serotonin (5-HT) 1b/1d Receptor Agonists
rizatriptan benzoate
Generic
QL (24 PER 30 DAYS)
sumatriptan (5 mg, 20 mg)
Generic
QL (6 PER 30 DAYS)
sumatriptan succinate (25 mg tablet, 50
mg tablet, 100 mg tablet)
Generic
QL (18 PER 30 DAYS)
sumatriptan succinate (4 cartridge, 4
pen injctr, 6 cartridge, 6 pen injctr, 6
syringe, 6 vial)
Generic
QL (2 ML PER 30 DAYS)
zolmitriptan (2.5 mg tab rapdis, 2.5 mg
tablet, 5 mg tab rapdis, 5 mg tablet)
Generic
QL (12 PER 30 DAYS)
ZOMIG (2.5 MG, 5 MG)
Brand
QL (12 PER 30 DAYS)
Antimyasthenic Agents
Parasympathomimetics
guanidine hcl
Generic
MESTINON (60 MG/5 ML SYRUP, 180
MG TIMESPAN)
Brand
pyridostigmine bromide 60 mg tablet
Generic
Antimycobacterials
Antimycobacterials, Other
dapsone (25 mg tablet, 100 mg tablet)
Generic
rifabutin
Generic
Antituberculars
ethambutol hcl
Generic
isonarif
Generic
isoniazid (50 mg/5 ml solution, 100 mg
tablet, 300 mg tablet)
Generic
PRIFTIN
Brand
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
26
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
rifampin (150 mg capsule, 300 mg
capsule)
Generic
RIFATER
Brand
SIRTURO
Specialty
TRECATOR
Brand
Requirements/Limits
LA
Antineoplastics
Alkylating Agents
ALKERAN 2 MG TABLET
Brand
CEENU
Brand
cyclophosphamide capsules
Generic
cyclophosphamide tablets
Generic
LEUKERAN
Brand
lomustine
Brand
MATULANE
Specialty
Antiangiogenic Agents
REVLIMID
Specialty
THALOMID
Specialty
PA, LA
Antiestrogens/Modifiers
EMCYT
Specialty
FARESTON
Brand
SOLTAMOX
Brand
tamoxifen citrate (10 mg tablet, 20 mg
tablet)
Generic
Antimetabolites
capecitabine
Generic
decitabine
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
27
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
DROXIA
Brand
hydroxyurea 500 mg capsule
Generic
mercaptopurine 50 mg tablet
Generic
methotrexate sodium (2.5 mg tablet, 25
mg/ml vial)
Generic
methotrexate sodium/pf (1 g vial, 25
mg/ml vial)
Generic
PURIXAN
Brand
RHEUMATREX
Brand
Requirements/Limits
Antineoplastics, Other
HEXALEN
Specialty
imiquimod 5 % cream pack
Generic
leucovorin calcium (5 mg tablet, 10 mg
tablet, 15 mg tablet, 25 mg tablet)
Generic
MESNEX 400 MG TABLET
Brand
temozolomide
Specialty
PA
VALCHLOR
Specialty
PA, LA
Aromatase Inhibitors, 3rd Generation
anastrozole 1 mg tablet
Generic
exemestane
Generic
letrozole 2.5 mg tablet
Generic
Enzyme Inhibitors
GILOTRIF
Specialty
PA, LA
HYCAMTIN 0.25 MG CAPSULE
Brand
PA
HYCAMTIN 1 MG CAPSULE
Specialty
PA
IRESSA
Specialty
PA
JAKAFI
Specialty
PA, LA
MEKINIST
Specialty
PA
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
28
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
TAFINLAR
Specialty
PA
VOTRIENT
Specialty
PA
ZYDELIG
Specialty
PA, QL (60 PER 30 DAYS)
ZYTIGA
Specialty
PA
AFINITOR (2.5 MG TABLET, 5 MG
TABLET, 10 MG TABLET)
Specialty
PA, QL (30 PER 30 DAYS)
AFINITOR 7.5 MG TABLET
Brand
PA, QL (30 PER 30 DAYS)
AFINITOR DISPERZ
Specialty
PA, QL (30 PER 30 DAYS)
BOSULIF
Specialty
PA
CAPRELSA 100 MG TABLET
Specialty
PA
CAPRELSA 300 MG TABLET
Brand
PA
COMETRIQ
Specialty
PA, LA
ERIVEDGE
Specialty
PA, LA
GLEEVEC
Specialty
PA
ICLUSIG
Specialty
PA, LA
IMBRUVICA
Specialty
PA, LA
INLYTA
Specialty
PA, LA
NEXAVAR
Specialty
PA
SPRYCEL
Specialty
PA
STIVARGA
Specialty
PA
SUTENT
Specialty
PA
TARCEVA
Specialty
PA
TASIGNA
Specialty
PA
TYKERB
Specialty
PA
vandetanib
Specialty
PA
ZELBORAF
Specialty
PA
Molecular Target Inhibitors
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
29
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
ZOLINZA
Specialty
PA
ZYKADIA
Specialty
PA
Retinoids
PANRETIN
Brand
TARGRETIN (1% GEL, 75 MG CAPSULE,
75 MG SOFTGEL)
Specialty
PA
tretinoin 10 mg capsule
Specialty
PA
Antiparasitics
Anthelmintics
ALBENZA
Brand
ivermectin 3 mg tablet
Generic
Antiprotozoals
ALINIA (100 MG/5 ML SUSPENSION,
500 MG TABLET)
Brand
atovaquone
Generic
PA
chloroquine phosphate (250 mg tablet,
500 mg tablet)
Generic
PA
DARAPRIM
Brand
PA
hydroxychloroquine sulfate 200 mg
tablet
Generic
mefloquine hcl
Generic
PA
tinidazole (250 mg tablet, 500 mg
tablet)
Generic
PA
Pediculicides/Scabicides
elimite
Generic
lindane
Generic
permethrin 5 % cream (g)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
30
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
ULESFIA
Brand
Requirements/Limits
Antiparkinson Agents
Anticholinergics
benztropine mesylate (0.5 mg tablet, 1
mg tablet, 2 mg tablet)
Generic
trihexyphenidyl hcl (2 mg tablet, 5 mg
tablet)
Generic
Antiparkinson Agents, Other
amantadine hcl (50 mg/5 ml syrup, 100
mg capsule, 100 mg tablet)
Preventive
carbidopa/levodopa/entacapone
Preventive
entacapone
Preventive
Dopamine Agonists
bromocriptine mesylate (2.5 mg tablet,
5 mg capsule)
Preventive
pramipexole di-hcl
Preventive
ropinirole hcl (0.25 mg tablet, 0.5 mg
tablet, 1 mg tablet, 2 mg tablet, 3 mg
tablet, 4 mg tablet, 5 mg tablet)
Preventive
Dopamine Precursors/ L-Amino Acid Decarboxylase Inhibitors
carbidopa 25 mg tablet
Generic
carbidopa/levodopa (10mg-100mg
tablet, 25mg-100mg tablet, 25mg100mg tablet er, 25mg-250mg tablet,
50mg-200mg tablet er)
Preventive
Monoamine Oxidase B (MAO-B) Inhibitors
AZILECT
Preventive
selegiline hcl (5 mg capsule, 5 mg
tablet)
Preventive
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
31
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
Antipsychotics
1st Generation/Typical
fluphenazine hcl (1 mg tablet, 2.5 mg
tablet, 5 mg tablet, 10 mg tablet)
Generic
haloperidol (0.5 mg tablet, 1 mg tablet,
2 mg tablet, 5 mg tablet, 10 mg tablet,
20 mg tablet)
Generic
haloperidol lactate 2 mg/ml oral conc
Generic
loxapine succinate (5 mg capsule, 10
mg capsule, 25 mg capsule, 50 mg
capsule)
Generic
ORAP
Brand
perphenazine/amitriptyline hcl
Generic
thioridazine hcl (10 mg tablet, 25 mg
tablet, 50 mg tablet, 100 mg tablet)
Generic
thiothixene
Generic
trifluoperazine hcl
Generic
2nd Generation/Atypical
INVEGA
Brand
LATUDA
Brand
olanzapine (2.5 mg tablet, 5 mg tab
rapdis, 5 mg tablet, 7.5 mg tablet, 10
mg tab rapdis, 10 mg tablet, 15 mg tab
rapdis, 15 mg tablet, 20 mg tab rapdis,
20 mg tablet)
Generic
quetiapine fumarate
Generic
RISPERDAL CONSTA 12.5 MG SYR
Brand
risperidone (0.25 mg tablet, 0.5 mg
tablet, 1 mg tablet, 1 mg/ml solution, 2
mg tablet, 3 mg tab rapdis, 3 mg tablet,
4 mg tablet)
Generic
PA, QL (30 PER 30 DAYS)
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
32
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
SAPHRIS
Brand
PA
ziprasidone hcl (40 mg capsule, 60 mg
capsule, 80 mg capsule)
Generic
Treatment-Resistant
clozapine
Generic
FAZACLO (150 MG ODT, 200 MG ODT)
Brand
VERSACLOZ
Brand
Antispasticity Agents
baclofen (10 mg tablet, 20 mg tablet)
Generic
dantrolene sodium (25 mg capsule, 50
mg capsule)
Generic
MYRBETRIQ
Brand
tizanidine hcl (2 mg tablet, 4 mg tablet)
Generic
PA
Antivirals
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors
EDURANT
Brand
INTELENCE
Brand
nevirapine (200 mg tablet, 400 mg tab
er 24h)
Generic
SUSTIVA
Brand
VIRAMUNE XR 100 MG TABLET
Brand
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors
abacavir sulfate
Generic
abacavir sulfate/lamivudine/zidovudine
Generic
didanosine
Generic
EMTRIVA (10 MG/ML SOLUTION, 200
MG CAPSULE)
Brand
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
33
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
EPZICOM
Brand
lamivudine (150 mg tablet, 300 mg
tablet)
Generic
lamivudine/zidovudine
Generic
stavudine (20 mg capsule, 30 mg
capsule, 40 mg capsule)
Generic
TRUVADA
Brand
VIREAD (150 MG TABLET, 200 MG
TABLET, 250 MG TABLET, 300 MG
TABLET, POWDER)
Brand
zidovudine (100 mg capsule, 300 mg
tablet)
Generic
Requirements/Limits
Anti-HIV Agents, Other
ATRIPLA
Brand
COMPLERA
Brand
FUZEON
Brand
ISENTRESS (100 MG POWDER PACKET,
400 MG TABLET)
Brand
SELZENTRY
Brand
STRIBILD
Brand
TIVICAY
Brand
Anti-HIV Agents, Protease Inhibitors
APTIVUS (100 MG/ML SOLUTION, 250
MG CAPSULE)
Brand
CRIXIVAN 400 MG CAPSULE
Brand
INVIRASE
Brand
KALETRA (100-25 MG TABLET, 200-50
MG TABLET)
Brand
LEXIVA (50 MG/ML SUSPENSION, 700
MG TABLET)
Brand
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
34
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
NORVIR (100 MG SOFTGEL CAP, 100
MG TABLET)
Brand
PREZISTA (75 MG TABLET, 100 MG/ML
SUSPENSION, 150 MG TABLET, 400 MG
TABLET, 600 MG TABLET, 800 MG
TABLET)
Brand
REYATAZ
Brand
VIRACEPT
Brand
Requirements/Limits
Anti-cytomegalovirus (CMV) Agents
VALCYTE 50 MG/ML SOLUTION
Brand
valganciclovir hcl
Generic
ZIRGAN
Brand
QL (60 PER 30 DAYS)
Anti-influenza Agents
rimantadine hcl
Generic
TAMIFLU (6 MG/ML SUSPENSION, 30
MG CAPSULE, 45 MG CAPSULE, 75 MG
CAPSULE)
Preventive
Antihepatitis Agents
adefovir dipivoxil
Specialty
BARACLUDE 0.05 MG/ML SOLUTION
Specialty
entecavir
Specialty
EPIVIR HBV 25 MG/5 ML SOLN
Brand
INCIVEK
Specialty
INFERGEN
Specialty
INTRON A (6 MILLION UNIT/ML VL, 10
MILLION UNIT/ML, 10 MILLION UNITS
VIL, 18 MILLION UNITS VIL, 50 MILLION
UNITS VIL)
Specialty
lamivudine 100 mg tablet
Generic
MODERIBA
Specialty
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
35
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
OLYSIO
Specialty
PA
PEGASYS (180 MCG/0.5 ML SYRINGE,
180 MCG/ML VIAL)
Specialty
PEGASYS PROCLICK
Specialty
PEGINTRON
Specialty
PEGINTRON REDIPEN
Specialty
REBETOL 40 MG/ML SOLUTION
Specialty
RIBAPAK
Specialty
RIBASPHERE
Specialty
RIBATAB
Specialty
ribavirin (200 mg capsule, 200 mg
tablet, 400 mg tablet, 600 mg tablet)
Specialty
SOVALDI
Specialty
PA
SYLATRON
Specialty
PA, QL (1 PER 28 DAYS)
SYLATRON 4-PACK
Specialty
PA, QL (1 PER 28 DAYS)
TYZEKA
Brand
VICTRELIS
Specialty
PA
Antiherpetic Agents
acyclovir (200 mg capsule, 200 mg/5ml
oral susp, 400 mg tablet, 800 mg tablet)
Generic
DENAVIR
Brand
famciclovir
Generic
trifluridine 1 % drops
Generic
valacyclovir hcl (500 mg tablet, 1000
mg tablet)
Generic
PA
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
36
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
Anxiolytics
Anxiolytics, Other
alprazolam (0.25 mg tablet, 0.5 mg tab
er 24h, 0.5 mg tablet, 1 mg tab er 24h,
1 mg tablet, 2 mg tab er 24h, 2 mg
tablet, 3 mg tab er 24h)
Generic
buspirone hcl (5 mg tablet, 7.5 mg
tablet, 10 mg tablet, 15 mg tablet, 30
mg tablet)
Generic
chlordiazepoxide hcl
Generic
meprobamate 400 mg tablet
Generic
oxazepam
Generic
Bipolar Agents
Mood Stabilizers
lithium carbonate (150 mg capsule, 300
mg capsule, 300 mg tablet, 300 mg
tablet er, 450 mg tablet er, 600 mg
capsule)
Generic
lithium citrate
Generic
Blood Glucose Regulators
Antidiabetic Agents
acarbose
Preventive
ACTOPLUS MET XR
Preventive
BYDUREON
Preventive
PA
BYDUREON PEN
Brand
PA
BYETTA
Preventive
PA
chlorpropamide
Preventive
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
37
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
FARXIGA
Brand
PA
glimepiride
Preventive
glipizide (2.5 mg tab er 24, 5 mg tab er
24, 5 mg tablet, 10 mg tab er 24, 10 mg
tablet)
Preventive
glipizide/metformin hcl
Preventive
glyburide
Preventive
glyburide,micronized
Preventive
glyburide/metformin hcl
Preventive
INVOKANA
Brand
PA
JANUMET
Preventive
PA
JANUMET XR
Preventive
PA
JANUVIA
Preventive
PA
JENTADUETO
Preventive
PA
JUVISYNC (50-10 MG TABLET, 50-20 MG
TABLET, 50-40 MG TABLET)
Preventive
KAZANO
Preventive
PA
KOMBIGLYZE XR
Preventive
PA
metformin hcl (500 mg tab er 24h, 500
mg tablet, 750 mg tab er 24h, 850 mg
tablet, 1000 mg tablet)
Preventive
nateglinide
Preventive
NESINA
Preventive
PA
ONGLYZA
Preventive
PA
OSENI
Preventive
PA
pioglitazone hcl
Preventive
pioglitazone hcl/glimepiride
Preventive
pioglitazone hcl/metformin hcl
Preventive
RIOMET
Preventive
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
38
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
SYMLINPEN 120
Preventive
PA
SYMLINPEN 60
Preventive
PA
TRADJENTA
Preventive
PA
VICTOZA 2-PAK
Preventive
PA
VICTOZA 3-PAK
Preventive
PA
Glycemic Agents
GLUCAGEN
Brand
GLUCAGON EMERGENCY KIT
Brand
PROGLYCEM
Brand
Insulins
APIDRA
Preventive
APIDRA SOLOSTAR
Preventive
HUMALOG
Preventive
HUMALOG MIX 50-50
Preventive
HUMALOG MIX 75-25
Preventive
HUMULIN R
Preventive
LANTUS
Preventive
LANTUS SOLOSTAR
Preventive
LEVEMIR
Preventive
LEVEMIR FLEXPEN
Preventive
LEVEMIR FLEXTOUCH
Preventive
NOVOLOG
Preventive
NOVOLOG FLEXPEN
Preventive
NOVOLOG MIX 70-30
Preventive
NOVOLOG MIX 70-30 FLEXPEN
Preventive
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
39
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
Blood Products/Modifiers/ Volume Expanders
Anticoagulants
ELIQUIS
Preventive
enoxaparin sodium (30mg/0.3ml,
40mg/0.4ml, 60mg/0.6ml, 80mg/0.8ml,
100 mg/ml, 120mg/.8ml, 150 mg/ml)
Preventive
fondaparinux sodium
Preventive
FRAGMIN
Preventive
JANTOVEN
Preventive
PRADAXA
Preventive
warfarin sodium (1 mg tablet, 2 mg
tablet, 2.5 mg tablet, 3 mg tablet, 4 mg
tablet, 5 mg tablet, 6 mg tablet, 7.5 mg
tablet, 10 mg tablet)
Preventive
XARELTO
Preventive
Blood Formation Modifiers
anagrelide hcl
Generic
ARANESP
Specialty
PA
EPOGEN
Specialty
PA
GRANIX
Brand
LEUKINE (250 MCG VIAL, 500 MCG/ML
VIAL)
Specialty
NEULASTA
Specialty
NEUMEGA
Specialty
NEUPOGEN
Specialty
PROCRIT
Specialty
PA
PROMACTA
Specialty
PA
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
40
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
Coagulants
tranexamic acid 650 mg tablet
Generic
Platelet Modifying Agents
AGGRENOX
Preventive
BRILINTA
Preventive
cilostazol
Preventive
clopidogrel bisulfate 75 mg tablet
Preventive
dipyridamole (25 mg tablet, 50 mg
tablet, 75 mg tablet)
Preventive
EFFIENT
Preventive
ticlopidine hcl
Preventive
Cardiovascular Agents
Alpha-adrenergic Agonists
clonidine
Preventive
clonidine hcl (0.1 mg tablet, 0.2 mg
tablet, 0.3 mg tablet)
Preventive
guanfacine hcl (1 mg tablet, 2 mg
tablet)
Preventive
methyldopa
Preventive
methyldopa/hydrochlorothiazide
Preventive
midodrine hcl
Generic
Alpha-adrenergic Blocking Agents
doxazosin mesylate
Preventive
prazosin hcl (1 mg capsule, 2 mg
capsule, 5 mg capsule)
Preventive
terazosin hcl
Preventive
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
41
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
Angiotensin II Receptor Antagonists
candesartan cilexetil
Preventive
irbesartan
Preventive
irbesartan/hydrochlorothiazide
Preventive
losartan potassium
Preventive
losartan potassium/hydrochlorothiazide
Preventive
valsartan
Preventive
valsartan/hydrochlorothiazide
Preventive
Angiotensin-converting Enzyme (ACE) Inhibitors
benazepril hcl (5 mg tablet, 10 mg
tablet, 20 mg tablet, 40 mg tablet)
Preventive
benazepril hcl/hydrochlorothiazide
Preventive
captopril (12.5 mg tablet, 25 mg tablet,
50 mg tablet, 100 mg tablet)
Preventive
captopril/hydrochlorothiazide
Preventive
enalapril maleate (2.5 mg tablet, 5 mg
tablet, 10 mg tablet, 20 mg tablet)
Preventive
enalapril maleate/hydrochlorothiazide
Preventive
EPANED
Preventive
fosinopril sodium
Preventive
fosinopril sodium/hydrochlorothiazide
Preventive
lisinopril (2.5 mg tablet, 5 mg tablet, 10
mg tablet, 20 mg tablet, 30 mg tablet,
40 mg tablet)
Preventive
lisinopril/hydrochlorothiazide
Preventive
moexipril hcl
Preventive
moexipril hcl/hydrochlorothiazide
Preventive
perindopril erbumine
Preventive
quinapril hcl
Preventive
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
42
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
quinapril hcl/hydrochlorothiazide
Preventive
ramipril
Preventive
trandolapril
Preventive
Requirements/Limits
Antiarrhythmics
amiodarone hcl (100 mg tablet, 200 mg
tablet, 400 mg tablet)
Generic
disopyramide phosphate
Generic
flecainide acetate
Generic
mexiletine hcl (150 mg capsule, 200 mg
capsule, 250 mg capsule)
Generic
MULTAQ
Brand
NORPACE CR
Brand
pacerone 200 mg tablet
Generic
propafenone hcl
Generic
quinidine gluconate 324 mg tablet er
Generic
quinidine sulfate (200 mg tablet, 300
mg tablet, 300 mg tablet er)
Generic
SORINE
Preventive
sotalol hcl (80 mg tablet, 120 mg tablet,
160 mg tablet, 240 mg tablet)
Preventive
TIKOSYN
Brand
verapamil hcl (40 mg tablet, 80 mg
tablet, 120 mg tablet)
Preventive
Beta-adrenergic Blocking Agents
acebutolol hcl (200 mg capsule, 400 mg
capsule)
Preventive
atenolol (25 mg tablet, 50 mg tablet,
100 mg tablet)
Preventive
atenolol/chlorthalidone
Preventive
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
43
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
betaxolol hcl (10 mg tablet, 20 mg
tablet)
Preventive
bisoprolol fumarate
Preventive
bisoprolol
fumarate/hydrochlorothiazide
Preventive
carvedilol
Preventive
COREG CR
Preventive
labetalol hcl (100 mg tablet, 200 mg
tablet, 300 mg tablet)
Preventive
LEVATOL
Preventive
metoprolol succinate
Preventive
metoprolol tartrate (25 mg tablet, 50
mg tablet, 100 mg tablet)
Preventive
metoprolol
tartrate/hydrochlorothiazide
Preventive
nadolol (20 mg tablet, 40 mg tablet, 80
mg tablet)
Preventive
nadolol/bendroflumethiazide
Preventive
pindolol
Preventive
propranolol hcl (10 mg tablet, 20 mg
tablet, 40 mg tablet, 40mg/5ml
solution, 60 mg cap sa 24h, 60 mg
tablet, 80 mg cap sa 24h, 80 mg tablet,
120 mg cap sa 24h, 160 mg cap sa 24h)
Preventive
propranolol hcl/hydrochlorothiazide
Preventive
timolol maleate (5 mg tablet, 10 mg
tablet, 20 mg tablet)
Preventive
Requirements/Limits
Calcium Channel Blocking Agents
AFEDITAB CR
Preventive
amlodipine besylate (2.5 mg tablet, 5
mg tablet, 10 mg tablet)
Preventive
amlodipine besylate/benazepril hcl
Preventive
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
44
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
CARTIA XT
Preventive
DILT-CD
Preventive
DILT-XR
Preventive
DILTIA XT
Preventive
diltiazem hcl (30 mg tablet, 60 mg cap
er 12h, 60 mg tablet, 90 mg cap er 12h,
90 mg tablet, 120 mg cap er 12h, 120
mg cap er 24h, 120 mg cap er deg, 120
mg capsule er, 120 mg tablet, 180 mg
cap er 24h, 180 mg cap er deg, 180 mg
capsule er, 180 mg tab er 24h, 240 mg
cap er 24h, 240 mg cap er deg, 240 mg
capsule er, 240 mg tab er 24h, 300 mg
cap er 24h, 300 mg capsule er, 300 mg
tab er 24h, 360 mg cap er 24h, 360 mg
capsule er, 360 mg tab er 24h, 420mg
capsule er, 420mg tab er 24h)
Preventive
DILTZAC ER
Preventive
felodipine
Preventive
isradipine
Preventive
MATZIM LA
Preventive
nicardipine hcl (20 mg capsule, 30 mg
capsule)
Preventive
NIFEDIAC CC
Preventive
NIFEDICAL XL
Preventive
nifedipine (30 mg tab er 24, 30 mg
tablet er, 60 mg tab er 24, 60 mg tablet
er, 90 mg tab er 24, 90 mg tablet er)
Preventive
nimodipine 30 mg capsule
Preventive
nisoldipine
Preventive
TAZTIA XT
Preventive
Requirements/Limits
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
45
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
verapamil hcl (100 mg cap24h pct, 120
mg cap24h pel, 120 mg tablet er, 180
mg cap24h pel, 180 mg tablet er, 200
mg cap24h pct, 240 mg cap24h pel, 240
mg tablet er, 300 mg cap24h pct, 360
mg cap24h pel)
Preventive
Requirements/Limits
Cardiovascular Agents, Other
amlodipine besylate/atorvastatin
calcium
Preventive
digitek
Generic
digox
Generic
digoxin (50 mcg/ml solution, 125 mcg
tablet, 250 mcg tablet)
Generic
LANOXIN (62.5 MCG TABLET, 187.5
MCG TABLET)
Brand
pentoxifylline 400 mg tablet er
Preventive
RANEXA
Brand
Diuretics, Carbonic Anhydrase Inhibitors
acetazolamide 500 mg capsule er
Generic
methazolamide (25 mg tablet, 50 mg
tablet)
Generic
Diuretics, Loop
bumetanide (0.5 mg tablet, 1 mg tablet,
2 mg tablet)
Preventive
EDECRIN
Preventive
furosemide (10 mg/ml solution, 20 mg
tablet, 40 mg tablet, 80 mg tablet)
Preventive
torsemide (5 mg tablet, 10 mg tablet,
20 mg tablet, 100 mg tablet)
Preventive
Diuretics, Potassium-sparing
amiloride hcl 5 mg tablet
Preventive
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
46
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
amiloride hcl/hydrochlorothiazide
Preventive
DYRENIUM
Preventive
eplerenone
Preventive
spironolactone (25 mg tablet, 50 mg
tablet, 100 mg tablet)
Preventive
spironolactone/hydrochlorothiazide
Preventive
triamterene/hydrochlorothiazide
Preventive
Requirements/Limits
Diuretics, Thiazide
chlorothiazide
Preventive
chlorthalidone
Preventive
hydrochlorothiazide (12.5 mg capsule,
12.5 mg tablet, 25 mg tablet, 50 mg
tablet)
Preventive
indapamide
Preventive
methyclothiazide
Preventive
metolazone
Preventive
Dyslipidemics, Fibric Acid Derivatives
fenofibrate (54 mg tablet, 160 mg
tablet)
Preventive
fenofibrate nanocrystallized
Preventive
fenofibrate,micronized (67 mg capsule,
134mg capsule, 200 mg capsule)
Preventive
fenofibric acid
Preventive
fenofibric acid (choline)
Preventive
gemfibrozil 600 mg tablet
Preventive
LOFIBRA
Preventive
TRIGLIDE 160 MG TABLET
Preventive
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
47
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
Dyslipidemics, HMG CoA Reductase Inhibitors
atorvastatin calcium
Preventive
fluvastatin sodium
Preventive
lovastatin
Preventive
pravastatin sodium
Preventive
simvastatin (5 mg tablet, 10 mg tablet,
20 mg tablet, 40 mg tablet)
Preventive
Dyslipidemics, Other
cholestyramine (with sugar) (suar) 4
powd pack, suar) 4 powder)
Preventive
cholestyramine/aspartame (4 powd
pack, 4 powder)
Preventive
COLESTID (, FLAVORED)
Preventive
colestipol hcl (1 tablet, 5 packet, 5
ranules)
Preventive
JUXTAPID
Specialty
PA, LA
KYNAMRO
Specialty
PA, LA
PREVALITE (PACKET, POWDER)
Preventive
Vasodilators, Direct-acting Arterial
hydralazine hcl (10 mg tablet, 25 mg
tablet, 50 mg tablet, 100 mg tablet)
Generic
minoxidil (2.5 mg tablet, 10 mg tablet)
Generic
RECTIV
Brand
Vasodilators, Direct-acting Arterial/Venous
DILATRATE-SR
Brand
isochron
Generic
isosorbide dinitrate
Generic
isosorbide mononitrate
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
48
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
minitran
Generic
NITRO-BID
Brand
NITRO-DUR (0.3, 0.8)
Brand
nitro-time
Generic
nitroglycerin (0.1mg/hr patch td24,
0.2mg/hr patch td24, 0.4mg/hr patch
td24, 0.6mg/hr patch td24, 2.5 mg
capsule er, 6.5 mg capsule er, 9 mg
capsule er, 400mcg/spr spray)
Generic
NITROSTAT
Brand
Requirements/Limits
Central Nervous System Agents
Attention Deficit Hyperactivity Disorder Agents, Amphetamines
dextroamphetamine sulfsaccharate/amphetamine sulfaspartate
Generic
dextroamphetamine sulfate (5 mg
capsule er, 10 mg capsule er, 15 mg
capsule er)
Generic
dextroamphetamine sulfate (5 mg
tablet, 10 mg tablet)
Generic
VYVANSE
Brand
zenzedi (5 mg tablet, 10 mg tablet)
Generic
PA
PA
Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines
DAYTRANA
Brand
PA, QL (30 PER 30 DAYS)
dexmethylphenidate hcl (2.5 mg tablet,
5 mg tablet, 10 mg tablet)
Generic
dexmethylphenidate hcl (5 mg, 15 mg,
30 mg, 40 mg)
Generic
PA
FOCALIN XR (10 MG CAPSULE, 20 MG
CAPSULE, 25 MG CAPSULE, 35 MG
CAPSULE)
Brand
PA
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
49
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
guanfacine hcl (1 mg tab er, 2 mg tab
er, 3 mg tab er, 4 mg tab er)
Generic
PA, QL (30 PER 30 DAYS)
metadate er
Generic
methylphenidate hcl (5 mg tablet, 5
mg/5 ml solution, 10 mg cpbp 30-70, 10
mg tablet, 10 mg tablet er, 10 mg/5 ml
solution, 18 mg tab er 24, 20 mg cpbp
30-70, 20 mg cpbp 50-50, 20 mg tablet,
20 mg tablet er, 27 mg tab er 24, 30 mg
cpbp 30-70, 30 mg cpbp 50-50, 36 mg
tab er 24, 40 mg cpbp 30-70, 40 mg
cpbp 50-50, 50 mg cpbp 30-70, 54 mg
tab er 24, 60 mg cpbp 30-70)
Generic
RITALIN LA 10 MG CAPSULE
Brand
STRATTERA
Brand
PA, QL (30 PER 30 DAYS)
NUEDEXTA
Brand
PA
riluzole
Generic
XENAZINE
Specialty
PA
SAVELLA (12.5 MG TABLET, 25 MG
TABLET, 50 MG TABLET, 100 MG
TABLET)
Brand
PA, QL (60 PER 30 DAYS)
SAVELLA TITRATION PACK
Brand
PA, QL (55 PER 30 DAYS)
AMPYRA
Specialty
PA, LA, QL (60 PER 30 DAYS)
AUBAGIO
Specialty
PA, LA, QL (30 PER 30 DAYS)
AVONEX (30 MCG, 30 MCG KT)
Specialty
AVONEX ADMINISTRATION PACK
Specialty
AVONEX PEN
Specialty
BETASERON 0.3 MG KIT
Specialty
Central Nervous System Agents, Other
Fibromyalgia Agents
Multiple Sclerosis Agents
PA, QL (14 PER 30 DAYS)
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
50
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
BETASERON 0.3 MG VIAL
Specialty
PA, QL (15 PER 30 DAYS)
COPAXONE 20 MG/ML SYRINGE
Specialty
QL (30 ML PER 30 DAYS)
COPAXONE 40 MG/ML SYRINGE
Specialty
QL (12 ML PER 28 DAYS)
EXTAVIA 0.3 MG KIT
Specialty
PA, QL (14 PER 30 DAYS)
EXTAVIA 0.3 MG VIAL
Specialty
PA, QL (15 PER 30 DAYS)
FIRAZYR
Specialty
PA, QL (9 ML PER 30 DAYS)
GILENYA
Specialty
PA, QL (30 PER 30 DAYS)
PLEGRIDY
Specialty
QL (1 ML PER 28 DAYS)
PLEGRIDY PEN
Specialty
QL (1 ML PER 28 DAYS)
REBIF (22 ML, 44 ML)
Specialty
QL (6 ML PER 30 DAYS)
REBIF REBIDOSE (22 ML, 44 ML)
Specialty
QL (6 ML PER 30 DAYS)
REBIF REBIDOSE TITRATION PACK
Specialty
QL (4.2 ML PER 30 DAYS)
REBIF TITRATION PACK
Specialty
QL (4.2 ML PER 30 DAYS)
TECFIDERA
Specialty
QL (60 PER 30 DAYS)
Dental and Oral Agents
pilocarpine hcl (5 mg tablet, 7.5 mg
tablet)
Generic
Dermatological Agents
acitretin
Generic
adapalene (0.1 % cream (g), 0.1 % gel
(gram), 0.3 % gel (gram))
Generic
adapalene 0.3 % gel w/pump
Brand
amnesteem
Generic
avita 0.025% cream
Generic
calcipotriene (0.005 % cream (g), 0.005
% solution)
Generic
claravis
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
51
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
clindamycin phos/benzoyl perox 1 %-5
% gel (gram)
Generic
DIFFERIN 0.3% GEL PUMP
Brand
ELIDEL
Brand
EPIFOAM
Brand
erythromycin base/benzoyl peroxide
Generic
FINACEA
Brand
FLUOROPLEX
Brand
fluorouracil (0.5 % cream (g), 2 %
solution, 5 % cream (g), 5 % solution)
Generic
gengraf 100 mg capsule
Generic
hypercare
Generic
methoxsalen, rapid
Specialty
mometasone furoate (0.1 % cream (g),
0.1 % oint. (g), 0.1 % solution)
Generic
myorisan
Generic
OTEZLA
Specialty
OXSORALEN
Brand
PICATO
Brand
podofilox 0.5 % solution
Generic
refissa
Generic
REGRANEX
Brand
PA
SANTYL
Brand
QL (30 GM PER 30 DAYS)
STELARA 45 MG/0.5 ML SYRINGE
Specialty
PA, QL (0.5 ML PER 90 DAYS)
STELARA 90 MG/ML SYRINGE
Specialty
PA, QL (1 ML PER 90 DAYS)
tacrolimus (0.03 %, 0.1 %)
Generic
PA
TAZORAC
Brand
tretinoin (0.01 % gel (gram), 0.025 %
cream (g), 0.025 % gel (gram), 0.05 %
cream (g), 0.1 % cream (g))
Generic
PA
PA
PA, QL (60 PER 30 DAYS)
PA
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
52
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
tretinoin/emollient base
Generic
trianex
Generic
VOLTAREN
Brand
zenatane
Generic
Requirements/Limits
Enzyme Replacement/ Modifiers
ADAGEN
Specialty
BUPHENYL 500 MG TABLET
Specialty
CARBAGLU
Brand
CEREZYME 400 UNITS VIAL
Brand
CREON
Brand
ELELYSO
Specialty
KUVAN
Specialty
ORFADIN
Specialty
pancrelipase 5,000
Generic
RAVICTI
Specialty
sodium phenylbutyrate 0.94 g/g powder
Specialty
SUCRAID
Specialty
ZAVESCA
Specialty
ZENPEP (DR 10,000 CAPSULE, DR
15,000 CAPSULE, DR 20,000 CAPSULE,
DR 25,000 CAPSULE, DR 3,000 CAPSULE,
DR 40,000 CAPSULE)
Brand
PA, LA
LA
Gastrointestinal Agents
Antispasmodics, Gastrointestinal
CUVPOSA
Brand
dicyclomine hcl (10 mg capsule, 10
mg/5 ml solution, 20 mg tablet)
Generic
PA
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
53
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
glycopyrrolate (1 mg tablet, 2 mg
tablet)
Generic
Requirements/Limits
Gastrointestinal Agents, Other
APRISO
Brand
ASACOL
Brand
ASACOL HD
Brand
CANASA
Brand
DELZICOL
Brand
diphenoxylate hcl/atropine sulfate (2.5.025/5 liquid, 2.5-.025mg tablet)
Generic
FULYZAQ
Brand
PA
GATTEX
Specialty
PA, LA
gavilyte-c
Generic
gavilyte-g
Generic
gavilyte-n
Generic
GOLYTELY PACKET
Brand
LIALDA
Brand
mesalamine 4 g/60 ml enema
Generic
mesalamine with cleansing wipes
Generic
nulytely with flavor packs
Generic
peg 3350/sod sulf/sod bicarbonate/sod
chloride/potassium chl
Generic
PENTASA
Brand
propantheline bromide 15 mg tablet
Generic
PYLERA
Brand
sodium chloride/sodium
bicarbonate/potassium chloride/peg
Generic
sulfasalazine (500 mg tablet, 500 mg
tablet dr)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
54
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
sulfazine
Generic
sulfazine ec
Generic
trilyte with flavor packets
Generic
ursodiol (250 mg tablet, 300 mg
capsule, 500 mg tablet)
Generic
Requirements/Limits
Histamine2 (H2) Receptor Antagonists
cimetidine (300 mg tablet, 400 mg
tablet, 800 mg tablet)
Generic
cimetidine hcl
Generic
famotidine 40 mg tablet
Generic
nizatidine (150 mg capsule, 300 mg
capsule)
Generic
ranitidine hcl (15 mg/ml syrup, 300 mg
tablet)
Generic
Irritable Bowel Syndrome Agents
LOTRONEX
Brand
PA
Laxatives
constulose
Generic
enulose
Generic
generlac
Generic
lactulose
Generic
MOVIPREP
Brand
SUPREP
Brand
Protectants
misoprostol (100 mcg tablet, 200 mcg
tablet)
Generic
sucralfate (1 g tablet, 1 g/10 ml oral
susp)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
55
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
Proton Pump Inhibitors
FIRST-LANSOPRAZOLE
Brand
FIRST-OMEPRAZOLE
Brand
lansoprazole 30 mg capsule dr
Generic
lansoprazole/amoxicillin
trihydrate/clarithromycin
Generic
omeprazole (10 mg capsule dr, 20 mg
capsule dr, 40 mg capsule dr)
Generic
OMEPRAZOLE+SYRSPEND SF ALKA
Brand
pantoprazole sodium (20 mg tablet dr,
40 mg tablet dr)
Generic
PROTONIX 40 MG SUSPENSION
Brand
rabeprazole sodium
Generic
Genitourinary Agents
Antispasmodics, Urinary
flavoxate hcl
Generic
oxybutynin chloride (5 mg tab er 24, 5
mg tablet, 5 mg/5 ml syrup, 10 mg tab
er 24, 15 mg tab er 24)
Generic
OXYTROL
Brand
tolterodine tartrate
Generic
trospium chloride 20 mg tablet
Generic
Benign Prostatic Hypertrophy Agents
alfuzosin hcl
Generic
finasteride 5 mg tablet
Generic
tamsulosin hcl
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
56
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
Genitourinary Agents, Other
bethanechol chloride (5 mg tablet, 10
mg tablet, 25 mg tablet, 50 mg tablet)
Generic
CUPRIMINE
Brand
CYSTAGON
Specialty
DEPEN
Brand
ELMIRON
Brand
PROCYSBI
Brand
THIOLA
Brand
PA
PA, LA
Phosphate Binders
calcium acetate 667 mg capsule
Generic
RENAGEL
Brand
PA
RENVELA
Brand
PA
sevelamer carbonate
Brand
PA
Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal)
Glucocorticoids/Mineralocorticoids
betamethasone
acetate/betamethasone sodium
phosphate
Generic
budesonide 3 mg capdr - er
Generic
CELESTONE 0.6 MG/5 ML SOLUTION
Brand
dexamethasone (0.5 mg tablet, 0.5
mg/5ml elixir, 0.5 mg/5ml solution, 0.75
mg tablet, 1 mg tablet, 1.5 mg tablet, 2
mg tablet, 4 mg tablet, 6 mg tablet)
Generic
FLAREX
Brand
fluocinolone acetonide oil
Generic
fluorometholone 0.1 % drops susp
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
57
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
fluticasone propionate 50 mcg spray
susp
Generic
FML FORTE
Brand
FML S.O.P.
Brand
hydrocortisone (5 mg tablet, 10 mg
tablet, 20 mg tablet)
Generic
hydrocortisone butyrate (0.1 % oint. (g),
0.1 % solution)
Generic
hydrocortisone valerate
Generic
methylprednisolone
Generic
triamcinolone acetonide 55 mcg spray
Generic
UCERIS 9 MG ER TABLET
Brand
Requirements/Limits
PA
Hormonal Agents, Stimulant/Replacement/Modifying (Other)
MYALEPT
Brand
PA, LA
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)
desmopressin acetate (0.1 mg tablet,
0.2 mg tablet, 10/spray spray/pump)
Generic
PA
desmopressin acetate (0.1 mg/ml
solution, 4mcg/ml ampul, 4mcg/ml vial)
Generic
desmopressin acetate (nonrefrigerated)
Generic
PA
EGRIFTA
Specialty
PA
GENOTROPIN
Specialty
PA
HUMATROPE
Specialty
PA
INCRELEX
Specialty
PA, LA
NORDITROPIN
Specialty
PA
NORDITROPIN FLEXPRO
Specialty
PA
NORDITROPIN NORDIFLEX (NORDIFLEX
5, NORDIFLX 10, NORDIFLX 15)
Specialty
PA
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
58
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
NUTROPIN
Specialty
PA
NUTROPIN AQ
Specialty
PA
NUTROPIN AQ NUSPIN
Specialty
PA
OMNITROPE 5 MG/1.5 ML CRTG
Specialty
PA
SAIZEN
Specialty
PA
SEROSTIM
Specialty
PA
STIMATE
Brand
TEV-TROPIN
Specialty
PA
ZORBTIVE
Specialty
PA
Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)
Anabolic Steroids
ANADROL-50
Specialty
oxandrolone 10 mg tablet
Generic
Androgens
ANDROGEL (1.62% GEL PUMP,
1.62%(1.25G) GEL PCKT, 1.62%(2.5G)
GEL PCKT)
Brand
danazol (50 mg capsule, 100 mg
capsule, 200 mg capsule)
Generic
testosterone (1.25g (1%) gel md pmp,
25mg(1%) gel packet, 50 mg (1%) gel
(gram), 50 mg (1%) gel packet)
Generic
testosterone cypionate (100 mg/ml vial,
200 mg/ml vial)
Generic
testosterone enanthate 200 mg/ml vial
Generic
Estrogens
ALTAVERA
Preventive
ALYACEN
Preventive
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
59
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
AMETHIA
Preventive
AMETHIA LO
Preventive
AMETHYST
Preventive
APRI
Preventive
ARANELLE
Preventive
AUBRA
Preventive
AVIANE
Preventive
AZURETTE
Preventive
BALZIVA
Preventive
BRIELLYN
Preventive
CAMRESE
Preventive
CAMRESE LO
Preventive
CAZIANT
Preventive
CHATEAL
Preventive
COMBIPATCH
Brand
CRYSELLE
Preventive
CYCLAFEM
Preventive
DASETTA
Preventive
DAYSEE
Preventive
DELYLA
Preventive
desogestrel-ethinyl estradiol
Preventive
desogestrel-ethinyl estradiol/ethinyl
estradiol
Preventive
DUAVEE
Brand
ELINEST
Preventive
EMOQUETTE
Preventive
ENPRESSE
Preventive
Requirements/Limits
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
60
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
ENSKYCE
Preventive
ESTARYLLA
Preventive
ESTRACE 0.01% CREAM
Brand
estradiol (.025mg/24h patch tdsw,
.025mg/24h patch tdwk, .0375mg/24
patch tdsw, .0375mg/24 patch tdwk,
0.05mg/24h patch tdsw, 0.05mg/24h
patch tdwk, 0.06mg/24h patch tdwk,
.075mg/24h patch tdsw, .075mg/24h
patch tdwk, 0.1mg/24hr patch tdsw,
0.1mg/24hr patch tdwk, 0.5 mg tablet,
1 mg tablet, 2 mg tablet)
Generic
estradiol/norethindrone acetate
Generic
ESTRING
Brand
estropipate (0.75 mg tablet, 1.5 mg
tablet, 3 mg tablet)
Generic
ethinyl estradiol/drospirenone
Preventive
FALMINA
Preventive
GIANVI
Preventive
GILDAGIA
Preventive
GILDESS
Preventive
GILDESS FE
Preventive
INTROVALE
Preventive
JOLESSA
Preventive
JUNEL
Preventive
JUNEL FE
Preventive
KARIVA
Preventive
KELNOR 1-35
Preventive
KURVELO
Preventive
LARIN
Preventive
LARIN FE
Preventive
Requirements/Limits
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
61
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
LEENA
Preventive
LESSINA
Preventive
LEVONEST
Preventive
levonorgestrel-eth estra/ethinyl
estradiol
Preventive
levonorgestrel-ethinyl estradiol
Preventive
LEVORA-28
Preventive
LOMEDIA 24 FE
Preventive
lopreeza
Generic
LORYNA
Preventive
LOW-OGESTREL
Preventive
LUTERA
Preventive
MARLISSA
Preventive
MICROGESTIN
Preventive
MICROGESTIN FE
Preventive
mimvey
Generic
mimvey lo
Generic
MONO-LINYAH
Preventive
MONONESSA
Preventive
MYZILRA
Preventive
NECON
Preventive
NIKKI
Preventive
norethindrone acetate-ethinyl estradiol
Preventive
norethindrone acetate-ethinyl
estradiol/ferrous fumarate
Preventive
norgestimate-ethinyl estradiol
Preventive
NORTREL
Preventive
NUVARING
Preventive
Requirements/Limits
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
62
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
OCELLA
Preventive
OGESTREL
Preventive
ORSYTHIA
Preventive
ORTHO TRI-CYCLEN LO
Preventive
PHILITH
Preventive
PIMTREA
Preventive
PIRMELLA
Preventive
PORTIA
Preventive
PREMARIN (0.3 MG TABLET, 0.45 MG
TABLET, 0.625 MG TABLET, 0.9 MG
TABLET, 1.25 MG TABLET, VAGINAL
CREAM-APPL)
Brand
PREMPHASE
Brand
PREMPRO
Brand
PREVIFEM
Preventive
QUASENSE
Preventive
RECLIPSEN
Preventive
SPRINTEC
Preventive
SRONYX
Preventive
SYEDA
Preventive
TARINA FE
Preventive
TILIA FE
Preventive
TRI-ESTARYLLA
Preventive
TRI-LEGEST FE
Preventive
TRI-LINYAH
Preventive
TRI-PREVIFEM
Preventive
TRI-SPRINTEC
Preventive
TRINESSA
Preventive
Requirements/Limits
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
63
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
TRIVORA-28
Preventive
VAGIFEM
Brand
VELIVET
Preventive
VESTURA
Preventive
VIORELE
Preventive
VYFEMLA
Preventive
WERA
Preventive
XULANE
Preventive
ZARAH
Preventive
ZENCHENT
Preventive
ZOVIA 1-35E
Preventive
ZOVIA 1-50E
Preventive
Requirements/Limits
Progestins
CAMILA
Preventive
DEBLITANE
Preventive
DEPO-SUBQ PROVERA 104
Brand
ERRIN
Preventive
HEATHER
Preventive
JENCYCLA
Preventive
JOLIVETTE
Preventive
LYZA
Preventive
medroxyprogesterone acetate (2.5 mg
tablet, 5 mg tablet, 10 mg tablet, 150
mg/ml syringe, 150 mg/ml vial)
Generic
megestrol acetate (20 mg tablet, 40 mg
tablet, 400mg/10ml oral susp)
Generic
NORA-BE
Preventive
norethindrone 0.35 mg tablet
Preventive
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
64
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
norethindrone acetate 5 mg tablet
Generic
NORLYROC
Preventive
progesterone,micronized (100 mg
capsule, 200 mg capsule)
Generic
SHAROBEL
Preventive
Requirements/Limits
Selective Estrogen Receptor Modifying Agents
raloxifene hcl
Preventive
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)
levothroid
Generic
levothyroxine sodium (25 mcg tablet, 50
mcg tablet, 75 mcg tablet, 88 mcg
tablet, 100 mcg tablet, 112 mcg tablet,
125 mcg tablet, 137 mcg tablet, 150
mcg tablet, 175mcg tablet, 200 mcg
tablet, 300 mcg tablet)
Generic
levoxyl
Generic
liothyronine sodium (5 mcg tablet, 25
mcg tablet, 50 mcg tablet)
Generic
unithroid (25 mcg tablet, 50 mcg tablet,
75 mcg tablet, 88 mcg tablet, 100 mcg
tablet, 112 mcg tablet, 125 mcg tablet,
150 mcg tablet, 175 mcg tablet, 200
mcg tablet, 300 mcg tablet)
Generic
Hormonal Agents, Suppressant (Adrenal)
LYSODREN
Brand
SIGNIFOR
Specialty
PA, LA
Hormonal Agents, Suppressant (Parathyroid)
calcitriol (0.25 mcg capsule, 0.5 mcg
capsule, 1 mcg/ml solution)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
65
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
paricalcitol (1 mcg capsule, 2 mcg
capsule, 4mcg capsule)
Generic
ST
SENSIPAR (30 MG TABLET, 60 MG
TABLET)
Specialty
QL (60 PER 30 DAYS)
SENSIPAR 90 MG TABLET
Specialty
Hormonal Agents, Suppressant (Pituitary)
cabergoline
Generic
ELIGARD
Brand
PA
leuprolide acetate 1 mg/0.2ml kit
Generic
PA
octreotide acetate (50 mcg/ml ampul,
50 mcg/ml vial, 100 mcg/ml ampul, 100
mcg/ml vial, 200 mcg/ml vial, 500
mcg/ml ampul, 500 mcg/ml vial,
1000mcg/ml vial)
Specialty
PA
SOMAVERT
Specialty
PA, LA
Hormonal Agents, Suppressant (Sex Hormones/Modifiers)
Antiandrogens
bicalutamide
Generic
NILANDRON
Brand
XTANDI
Specialty
PA
Hormonal Agents, Suppressant (Thyroid)
Antithyroid Agents
methimazole (5 mg tablet, 10 mg
tablet)
Generic
propylthiouracil 50 mg tablet
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
66
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
Specialty
PA, QL (3 PER 30 DAYS)
Immunological Agents
Angioedema (HAE) Agents
BERINERT 500 UNIT KIT
Immune Suppressants
ASTAGRAF XL
Brand
azathioprine 50 mg tablet
Generic
cyclosporine (25 mg capsule, 100 mg
capsule)
Generic
cyclosporine, modified (25 mg capsule,
50 mg capsule, 100 mg capsule, 100
mg/ml solution)
Generic
ENBREL (25 MG/0.5 ML SYRINGE, 50
MG/ML SURECLICK SYR, 50 MG/ML
SYRINGE)
Specialty
QL (4 ML PER 28 DAYS)
ENBREL 25 MG KIT
Specialty
QL (8 PER 28 DAYS)
gengraf (25 mg capsule, 100 mg/ml
solution)
Generic
GRASTEK
Brand
hecoria
Generic
HUMIRA
Specialty
HUMIRA PEDIATRIC
Specialty
mycophenolate mofetil (200 mg/ml
susp recon, 250 mg capsule, 500 mg
tablet)
Generic
mycophenolate sodium
Generic
ORALAIR 300 IR SUBLINGUAL TAB
Specialty
PROGRAF 5 MG/ML AMPULE
Brand
RAGWITEK
Brand
RAPAMUNE 1 MG/ML ORAL SOLN
Brand
PA
PA, LA
PA
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
67
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
RESTASIS
Brand
QL (60 PER 30 DAYS)
SANDIMMUNE 100 MG/ML SOLN
Brand
sirolimus (0.5 mg tablet, 1 mg tablet, 2
mg tablet)
Generic
tacrolimus (0.5 mg capsule, 1 mg
capsule, 5 mg capsule)
Generic
ZORTRESS
Specialty
Immunizing Agents, Passive
GAMMAGARD S-D
Brand
PA
GAMMAKED
Specialty
PA
GAMUNEX-C
Specialty
PA
ACTIMMUNE
Specialty
PA
ALFERON N
Specialty
leflunomide
Generic
Immunomodulators
Inflammatory Bowel Disease Agents
Aminosalicylates
balsalazide disodium
Generic
DIPENTUM
Brand
Glucocorticoids
anusol-hc 2.5% cream
Generic
procto-pak
Generic
proctocream-hc
Generic
PROCTOFOAM-HC
Brand
proctosol-hc
Generic
proctozone-hc
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
68
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
ACTONEL (5 MG TABLET, 30 MG
TABLET, 35 MG TABLET)
Preventive
PA
alendronate sodium (5 mg tablet, 10
mg tablet, 35 mg tablet, 40 mg tablet,
70 mg tablet, 70 mg/75ml solution)
Preventive
calcitonin,salmon,synthetic
Preventive
doxercalciferol (0.5 mcg capsule, 1 mcg
capsule, 2.5 mcg capsule)
Generic
doxercalciferol 4mcg/2ml vial
Generic
etidronate disodium
Preventive
FORTEO
Preventive
ibandronate sodium 150 mg tablet
Preventive
Metabolic Bone Disease Agents
ST
PA
Miscellaneous
Glucose Testing
ACCU-CHECK (METERS & TEST STRIPS)
DME Benefit
QL
LIFESCAN (METERS & TEST STRIPS)
DME Benefit
QL
Ophthalmic Agents
Ophthalmic Prostaglandin and Prostamide Analogs
latanoprost
Generic
LUMIGAN 0.01% EYE DROPS
Brand
ST
LUMIGAN 0.03% EYE DROPS
Brand
ST
TRAVATAN Z
Brand
travoprost (benzalkonium)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
69
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
Ophthalmic Agents, Other
ak-poly-bac
Generic
bacitracin/polymyxin b sulfate
Generic
BLEPHAMIDE
Brand
BLEPHAMIDE S.O.P.
Brand
CYSTARAN
Brand
gatifloxacin
Generic
LACRISERT
Brand
MOXEZA
Brand
naphazoline hcl 0.1 % drops
Generic
neo-polycin
Generic
neo-polycin hc
Generic
neomycin sulfate/bacitracin
zinc/polymyxin b/hydrocortisone
Generic
neomycin sulfate/bacitracin/polymyxin
b
Generic
neomycin sulfate/polymyxin b
sulfate/gramicidin d
Generic
neomycin/polymyxin b sulf/hc 3.5-10k10 drops susp
Generic
neomycin/polymyxin b
sulfate/dexamethasone (0.1 % drops
susp, 3.5-10k-.1 oint. (g))
Generic
neosporin
Generic
polycin
Generic
polymyxin b sulfate/trimethoprim
Generic
sulfacetamide sodium/prednisolone
sodium phosphate
Generic
TOBRADEX EYE OINTMENT
Brand
TOBRADEX ST
Brand
PA, LA, QL (60 ML PER 30 DAYS)
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
70
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
tobramycin/dexamethasone
Generic
tropicamide (0.5 % drops, 1 % drops)
Generic
VIGAMOX
Brand
ZYLET
Brand
Requirements/Limits
Ophthalmic Anti-allergy Agents
ALOMIDE
Brand
azelastine hcl 0.05 % drops
Generic
cromolyn sodium 4 % drops
Generic
PATANOL
Brand
PA
Ophthalmic Anti-inflammatories
ALREX
Brand
bromfenac sodium
Generic
dexamethasone sod phosphate 0.1 %
drops
Generic
diclofenac sodium 0.1 % drops
Generic
flurbiprofen sodium
Generic
ketorolac tromethamine (0.4 % drops,
0.5 % drops)
Generic
LOTEMAX (0.5% EYE DROPS, 0.5% EYE
OINTMENT, 0.5% OPHTHALMIC GEL)
Brand
prednisolone acetate 1 % drops susp
Generic
prednisolone sod phosphate 1 % drops
Generic
VEXOL
Brand
Ophthalmic Antiglaucoma Agents
ALPHAGAN P 0.1% DROPS
Brand
AZOPT
Brand
betaxolol hcl 0.5 % drops
Generic
BETIMOL
Brand
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
71
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
BETOPTIC S
Brand
brimonidine tartrate (0.15 % drops, 0.2
% drops)
Generic
carteolol hcl
Generic
dorzolamide hcl
Generic
dorzolamide hcl/timolol maleate
Generic
ISTALOL
Brand
levobunolol hcl
Generic
metipranolol
Generic
pilocarpine hcl (1 % drops, 2 % drops, 4
% drops)
Generic
PILOPINE HS
Brand
timolol maleate (0.25 % drops, 0.25 %
sol-gel, 0.5 % drops, 0.5 % sol-gel)
Generic
Requirements/Limits
Otic Agents
antipyrine/benzocaine 5.4 %-1.4% drops
Generic
aurodex
Generic
auroguard
Generic
CIPRO HC
Brand
CIPRODEX
Brand
ciprofloxacin hcl 0.2 % droperette
Generic
neomycin sulfate/polymyxin b
sulfate/hydrocortisone (drops susp,
solution)
Generic
otic care
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
72
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
Respiratory Tract Agents
Anti-inflammatories, Inhaled Corticosteroids
ADVAIR DISKUS
Preventive
ADVAIR HFA
Preventive
AEROSPAN
Preventive
ALVESCO
Preventive
ASMANEX
Preventive
ASMANEX HFA
Preventive
BREO ELLIPTA
Preventive
budesonide (0.25mg/2ml, 0.5 mg/2ml)
Preventive
budesonide 32mcg spray/pump
Generic
FLOVENT DISKUS
Preventive
FLOVENT HFA
Preventive
flunisolide (25 mcg, 29mcg)
Generic
NASONEX
Brand
PULMICORT 1 MG/2 ML RESPULE
Preventive
PULMICORT FLEXHALER
Preventive
QVAR
Preventive
QL (17 GM PER 30 DAYS)
Antihistamines
azelastine hcl 137 mcg spray/pump
Generic
clemastine fumarate (0.67mg/5ml
syrup, 2.68 mg tablet)
Generic
cyproheptadine hcl (2 mg/5 ml syrup, 4
mg tablet)
Generic
levocetirizine dihydrochloride (2.5
mg/5ml solution, 5 mg tablet)
Generic
promethazine hcl/codeine
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
73
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
promethazine/phenylephrine
hcl/codeine
Generic
Requirements/Limits
Antileukotrienes
montelukast sodium (4 mg gran pack, 4
mg tab chew, 5 mg tab chew, 10 mg
tablet)
Preventive
zafirlukast
Preventive
ZYFLO CR
Preventive
QL (60 PER 30 DAYS)
Bronchodilators, Anticholinergic
ATROVENT HFA
Brand
COMBIVENT
Brand
QL (14.7 GM PER 30 DAYS)
COMBIVENT RESPIMAT
Brand
QL (4 GM PER 30 DAYS)
hydrocodone bit/homatrop me-br 5-1.5
mg/5 syrup
Generic
hydromet
Generic
ipratropium bromide (0.2 mg/ml
solution, 21 mcg spray, 42mcg spray)
Generic
ipratropium bromide/albuterol sulfate
Generic
SPIRIVA
Brand
Bronchodilators, Phosphodiesterase Inhibitors (Xanthines)
THEOCHRON
Preventive
theophylline anhydrous (100 mg tab er
12h, 200 mg tab er 12h, 300 mg tab er
12h, 400 mg tablet er, 450 mg tab er
12h, 600 mg tablet er)
Preventive
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
74
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
Bronchodilators, Sympathomimetic
albuterol sulfate (0.63mg/3ml vial-neb,
1.25mg/3ml vial-neb, 2 mg tablet, 2
mg/5 ml syrup, 2.5 mg/0.5 vial-neb, 2.5
mg/3ml vial-neb, 4 mg tab er 12h, 4 mg
tablet, 5 mg/ml solution, 8 mg tab er
12h)
Preventive
EPIPEN 2-PAK
Brand
EPIPEN JR 2-PAK
Brand
levalbuterol hcl (0.31mg/3ml,
0.63mg/3ml, 1.25mg/0.5, 1.25mg/3ml)
Preventive
PROAIR HFA
Preventive
SEREVENT DISKUS
Preventive
terbutaline sulfate (2.5 mg tablet, 5 mg
tablet)
Preventive
VENTOLIN HFA
Preventive
XOPENEX HFA
Preventive
QL (17 GM PER 30 DAYS)
QL (36 GM PER 30 DAYS)
Mast Cell Stabilizers
cromolyn sodium (20 mg/2 ml ampulneb, 20 mg/ml solution)
Generic
Pulmonary Antihypertensives
ADCIRCA
Specialty
PA, QL (60 PER 30 DAYS)
ADEMPAS
Specialty
PA
LETAIRIS
Specialty
PA
OPSUMIT
Specialty
PA, LA
ORENITRAM ER
Specialty
PA, LA
sildenafil citrate 20 mg tablet
Specialty
PA, QL (90 PER 30 DAYS)
TRACLEER
Specialty
PA, LA
VELETRI 0.5 MG VIAL
Specialty
VENTAVIS
Specialty
PA
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
75
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
Respiratory Tract Agents, Other
ANORO ELLIPTA
Brand
benzonatate
Generic
dextromethorphan hbr/promethazine
hcl
Generic
HYPER-SAL 3.5% VIAL
Brand
KALYDECO
Specialty
phenylephrine hcl/promethazine hcl
Generic
pulmosal
Generic
PULMOZYME
Specialty
sodium chloride for inhalation 7 % vialneb
Generic
sski
Generic
SYMBICORT
Preventive
TYZINE
Brand
PA, LA, QL (60 PER 30 DAYS)
Skeletal Muscle Relaxants
carisoprodol (250 mg tablet, 350 mg
tablet)
Generic
carisoprodol/aspirin
Generic
chlorzoxazone
Generic
cyclobenzaprine hcl (5 mg tablet, 7.5
mg tablet, 10 mg tablet)
Generic
metaxalone
Generic
methocarbamol (500 mg tablet, 750 mg
tablet)
Generic
orphenadrine citrate 100 mg tablet er
Generic
orphenadrine/aspirin/caffeine 50-77060 tablet
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
76
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
Sleep Disorder Agents
GABA Receptor Modulators
estazolam
Generic
eszopiclone
Generic
flurazepam hcl
Generic
temazepam
Generic
triazolam
Generic
zaleplon
Generic
QL (30 PER 30 DAYS)
zolpidem tartrate (5 mg tablet, 10 mg
tablet)
Generic
QL (30 PER 30 DAYS)
modafinil
Generic
PA, QL (30 PER 30 DAYS)
ROZEREM
Brand
PA, QL (30 PER 30 DAYS)
XYREM
Specialty
PA, LA, QL (540 ML PER 30 DAYS)
QL (30 PER 30 DAYS)
Sleep Disorders, Other
Therapeutic Nutrients/ Minerals/ Electrolytes
Electrolyte/Mineral Modifiers
EXJADE
Specialty
kionex 15 gm/60 ml suspension
Generic
sodium polystyrene sulfonate
(15g/60ml oral susp, 30g/120ml enema,
50g/200ml enema)
Generic
sps 15 gm/60 ml suspension
Generic
SYPRINE
Brand
Electrolyte/Mineral Replacement
cyanocobalamin (vitamin b-12)
1000mcg/ml vial
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
77
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
ergocalciferol (vitamin d2) 50000 unit
capsule
Generic
FLUOR-A-DAY (0.25 MG TAB, 0.5 MG
TAB, 1 MG TABLET)
Preventive
fluoride/iron/vitamins a,c,and d
Preventive
FLUORITAB 0.5 MG TABLET CHEW
Preventive
FLURA-DROPS
Preventive
klor-con 10
Generic
klor-con 8
Generic
klor-con m10
Generic
klor-con m20
Generic
levocarnitine 330 mg tablet
Generic
LUDENT FLUORIDE
Preventive
MATERNITY
Preventive
pediatric multivitamin combination
no.2/sodium fluoride
Preventive
pediatric multivitamins a,c,& d3 no.21
with sodium fluoride
Preventive
pediatric multivitamins no.16 with
sodium fluoride
Preventive
pediatric multivitamins no.17 with
sodium fluoride
Preventive
pediatric multivitamins no.82 with
sodium fluoride
Preventive
PNV-VP-U
Preventive
potassium chloride (8 meq capsule er, 8
meq tablet er, 10 meq capsule er, 10
meq tab er prt, 10 meq tablet er, 20
meq tab er prt, 20 meq tablet er,
20meq/15ml liquid, 40meq/15ml liquid)
Generic
potassium citrate (5 tablet er, 10 tablet
er)
Generic
Requirements/Limits
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
78
LAST UPDATE 01/2015
2015 Providence Health Plan Formulary
(with designated preventive drugs)
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
PRENAPLUS
Preventive
prenatal vitamins comb no.115/iron
fumarate/folic acid
Preventive
prenatal vitamins comb no.115/iron
fumarate/folic acid/dss
Preventive
prenatal vitamins combo no.60/ferrous
fumarate/folic acid
Preventive
prenatal vits with calcium #72/ferrous
fumarate/folic acid
Preventive
prenatal vits with calcium
#72/iron,carbonyl/folic acid
Preventive
prenatal vits without calc no5/ferrous
fumarate/folic acid
Preventive
PREPLUS
Preventive
QUFLORA (0.25 MG/ML, 0.5 MG/ML)
Brand
sodium fluoride (0.25(0.55) tab chew,
0.5 mg/ml drops, 0.5(1.1)mg tab chew,
1mg(2.2mg) tab chew, 1mg(2.2mg)
tablet)
Preventive
TL FOLATE
Preventive
TL-FLUORIVITE
Preventive
TRICARE
Preventive
TRINATAL RX 1
Preventive
TRIVEEN-U
Preventive
VINATE ONE
Preventive
VINATE-M
Preventive
VOL-PLUS
Preventive
Requirements/Limits
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
79
LAST UPDATE 01/2015
Non-Formulary Drugs That Require Prior Authorization
ABSTRAL
ACANYA
ACIPHEX SPRINKLE
ACTIQ
ACTONEL 150 MG TABLET
ACYCLOVIR 5% OINTMENT
ACZONE
ADOXA
ALTABAX
AMBIEN CR
AMITIZA
AMRIX
ANZEMET 50 MG TABLET
ANZEMET 100 MG TABLET
APLENZIN
APOKYN
ARICEPT 23 MG TABLET
ARTHROTEC 50
ARTHROTEC 75
ASTEPRO
ATELVIA
ATOVAQUONE-PROGUANIL HCL
ATRALIN
AVINZA
AZACITIDINE
AZELASTINE 0.15% NASAL SPRAY
BENICAR 20 MG TABLET
BENICAR 5 MG TABLET
BENICAR HCT
BENZACLIN GEL 35G PUMP
BENZACLIN GEL 50G PUMP
BEPREVE
BIDIL
BINOSTO
BRINTELLIX
BRISDELLE
BUTALB-ACETAMIN-CAFF 50-300-40
BUTRANS 15 MCG/HR PATCH
BUTRANS 10 MCG/HR PATCH
BUTRANS 20 MCG/HR PATCH
BUTRANS 5 MCG/HR PATCH
BYSTOLIC
CALCIPOTRIENE-BETAMETHASONE DP
CALCITRIOL 3 MCG/G OINTMENT
CAMBIA
CARDIZEM LA 120 MG TABLET
CARDURA XL
CENTANY AT
CESAMET
CIALIS 5 MG TABLET
CIMZIA
CLARINEX
CLARINEX-D 12 HOUR
CLARINEX-D 24 HOUR
CLOBEX 0.05% SPRAY
CLONIDINE HCL ER
COARTEM
COMBIGAN
CONZIP
CRESTOR
CRINONE
CYCLOSET
DALIRESP
DERMASORB HC
DERMASORB TA
DESLORATADINE
DESONATE
DESVENLAFAXINE FUMARATE ER
DEXILANT
DICLOFENAC SODIUM 3% GEL
DICLOFENAC 1.5% TOPICAL SOLN
DICLOFENAC SODIUM-MISOPROSTOL
DIFFERIN 0.1% LOTION
DIFICID
DONEPEZIL HCL 23 MG TABLET
DORYX
DOXYCYCLINE HYC DR 150 MG TAB
DOXYCYCLINE HYC DR 75 MG TAB
DOXYCYCLINE HYC DR 100 MG TAB
DOXYCYCLINE IR-DR
DOXYCYCLINE MONO 75 MG CAPSULE
DOXYCYCLINE MONO 150 MG CAP
80
DRONABINOL
DUEXIS
ECOZA
EDARBI
EDARBYCLOR
EDLUAR
ENABLEX
ENDOMETRIN
EPIDUO
EPROSARTAN MESYLATE
ESOMEPRAZOLE STRONTIUM
EXALGO
FENOFIBRATE 50 MG CAPSULE
FENOFIBRATE 150 MG CAPSULE
FENTANYL CIT OTFC 1
200 MCG
FENTANYL CITRATE OTFC 800 MCG
FENTANYL CITRATE OTFC 600 MCG
FENTANYL CITRATE OTFC 200 MCG
FENTANYL CITRATE OTFC 400 MCG
FENTANYL CIT OTFC 1
600 MCG
FENTORA
FETZIMA
FIORICET 50-300-40 MG CAPSULE
FLECTOR
FLO-PRED
FLUOCINONIDE 0.1% CREAM
FLUVOXAMINE MALEATE ER
FORFIVO XL
FORTAMET
FOSAMAX PLUS D
FOSRENOL
FYCOMPA
GELNIQUE
GLUMETZA
GRALISE
HETLIOZ
HORIZANT
HYDROMORPHONE ER
INTERMEZZO
INTUNIV
JALYN
KAPVAY
KETEK
KORLYM
LAMICTAL ODT
LAMICTAL ODT (BLUE)
LAMICTAL ODT (GREEN)
LAMICTAL ODT (ORANGE)
LASTACAFT
LAZANDA
LIPOFEN
LIPTRUZET
LIVALO
LOVAZA
LUPRON DEPOT
LUPRON DEPOT-PED
LUVOX CR
MALARONE
MARINOL
METFORMIN HCL ER 500 MG OSM-TB
METFORMIN ER 1
000 MG OSM-TAB
METOZOLV ODT
METROGEL
METRONIDAZOLE TOPICAL 1% GEL
MICARDIS
MICARDIS HCT
MIRAPEX ER
MONODOX 75 MG CAPSULE
MORGIDOX 1X100 MG KIT
MORGIDOX 2X100 MG KIT
MORPHINE SULFATE ER 45 MG CAP
MORPHINE SULFATE ER 30 MG CAP
MORPHINE SULFATE ER 75 MG CAP
MORPHINE SULFATE ER 120 MG CAP
MORPHINE SULFATE ER 60 MG CAP
MORPHINE SULFATE ER 90 MG CAP
MOZOBIL
NAMENDA XR
NATROBA
81
NEXIUM
NIACIN ER
NIASPAN
NORDITROPIN NORDIFLEX 30 MG/3
NUCYNTA
NUCYNTA ER
NUVIGIL
OCTREOTIDE ACET 50 MCG/ML SYR
OCTREOTIDE ACET 500 MCG/ML SYR
OCTREOTIDE ACET 100 MCG/ML SYR
OLEPTRO ER
OLOPATADINE HCL
OMEGA-3 ACID ETHYL ESTERS
OMNARIS
OMNITROPE 10 MG/1.5 ML CRTG
OMNITROPE 5.8 MG VIAL
ONEXTON
ONSOLIS
OPANA ER
ORACEA
ORALAIR 300 IR STARTER PACK
ORALAIR 100 IR STARTER PACK
ORBIVAN
OXECTA
OXTELLAR XR
OXYMORPHONE HCL ER
PAROXETINE ER 37.5 MG TABLET
PAROXETINE CR 37.5 MG TABLET
PAROXETINE CR 12.5 MG TABLET
PAROXETINE CR 25 MG TABLET
PATADAY
PATANASE
PAXIL CR
PENNSAID
PEXEVA
POMALYST
POTIGA
PRIMAQUINE
PRISTIQ ER
QUALAQUIN
QUININE SULFATE 324 MG CAPSULE
QUTENZA
RAPAFLO
RELISTOR
RENOVA
RENOVA PUMP
REQUIP XL
RETIN-A MICRO
RETIN-A MICRO PUMP
RISEDRONATE SODIUM
ROPINIROLE HCL ER 6 MG TABLET
ROPINIROLE HCL ER 4 MG TABLET
ROPINIROLE HCL ER 2 MG TABLET
ROPINIROLE HCL ER 12 MG TABLET
ROPINIROLE HCL ER 8 MG TABLET
ROSADAN 0.75% CREAM KIT
ROSADAN 0.75% GEL KIT
SAMSCA
SANCTURA XR
SANCUSO
SEROQUEL XR
SILENOR
SIMPONI
SIMPONI ARIA
SIMVASTATIN 80 MG TABLET
SOLARAZE
SOLODYN ER 80 MG TABLET
SOLODYN ER 105 MG TABLET
SOLODYN ER 55 MG TABLET
SOLODYN ER 65 MG TABLET
SOLODYN ER 115 MG TABLET
SORILUX
SPINOSAD
STAVZOR
SUBSYS
SUMAVEL DOSEPRO
SYNALAR 0.025% OINTMENT KIT
SYNALAR 0.025% CREAM KIT
SYNALAR TS
TACLONEX
TELMISARTAN
TELMISARTAN-AMLODIPINE
82
TELMISARTAN-HYDROCHLOROTHIAZID
TEVETEN
TEVETEN HCT
TIZANIDINE HCL 6 MG CAPSULE
TIZANIDINE HCL 4 MG CAPSULE
TIZANIDINE HCL 2 MG CAPSULE
TOPICORT 0.25% SPRAY
TOVIAZ
TRAMADOL HCL ER 150 MG CAPSULE
TRETIN-X
TRETINOIN MICROSPHERE
TREXIMET
TRIBENZOR
TROSPIUM CHLORIDE ER
TWYNSTA
TYVASO INHALATION REFILL KIT
TYVASO 1.74 MG/2.9 ML SOLUTION
TYVASO INHALATION STARTER KIT
ULORIC
ULTRAVATE X CREAM COMBO PACK
VANOS
VASCEPA
VECTICAL
VELPHORO
VELTIN
VERAMYST
VERDESO
VESICARE
VIDAZA
VIIBRYD
VIMOVO
VYTORIN
WELCHOL
XALKORI
XARTEMIS XR
XERESE
XOLEGEL
ZANAFLEX 6 MG CAPSULE
ZANAFLEX 4 MG CAPSULE
ZANAFLEX 2 MG CAPSULE
ZELAPAR
ZENZEDI 2.5 MG TABLET
ZENZEDI 15 MG TABLET
ZENZEDI 7.5 MG TABLET
ZENZEDI 20 MG TABLET
ZENZEDI 30 MG TABLET
ZETIA
ZETONNA
ZIANA
ZIPSOR
ZMAX
ZOCOR 80 MG TABLET
ZOHYDRO ER
ZOLPIDEM TARTRATE ER
ZOLPIMIST
ZORVOLEX
ZOVIRAX 5% CREAM
ZOVIRAX 5% OINTMENT
ZUPLENZ
ZYCLARA 3.75% CREAM
ZYCLARA 3.75% CREAM PUMP
83
Alphabetical Listing
A
allopurinol
25
ALOMIDE
71
abacavir sulfate
33
ALPHAGAN P
71
abacavir sulfate/lamivudine/zidovudine
33
alprazolam
37
ABILIFY
20
ALREX
71
ABILIFY DISCMELT
20
ALTAVERA
59
acamprosate calcium
9
ALVESCO
73
acarbose
37
ALYACEN
59
acebutolol hcl
43
amantadine hcl
31
amcinonide
10
AMETHIA
60
AMETHIA LO
60
acetaminophen with codeine phosphate
acetasol hc
acetazolamide
7
12
17,46
acetic acid/aluminum acetate
12
AMETHYST
60
acetic acid/hydrocortisone
12
amiloride hcl
46
acitretin
51
amiloride hcl/hydrochlorothiazide
47
ACTIMMUNE
68
amiodarone hcl
43
ACTONEL
69
amitriptyline hcl
22
ACTOPLUS MET XR
37
amlodipine besylate
44
acyclovir
36
amlodipine besylate/atorvastatin calcium
46
ADAGEN
53
amlodipine besylate/benazepril hcl
44
adapalene
51
amnesteem
51
ADCIRCA
75
amoxapine
22
adefovir dipivoxil
35
amoxicillin
15
ADEMPAS
75
amoxicillin/potassium clavulanate
15
ADVAIR DISKUS
73
ampicillin trihydrate
15
ADVAIR HFA
73
AMPYRA
50
AEROSPAN
73
ANADROL-50
59
AFEDITAB CR
44
anagrelide hcl
40
AFINITOR
29
anastrozole
28
AFINITOR DISPERZ
29
ANDROGEL
59
AGGRENOX
41
ANORO ELLIPTA
76
ak-poly-bac
70
antipyrine/benzocaine
72
alagesic lq
5
anusol-hc
68
ALBENZA
30
apexicon e
10
albuterol sulfate
75
APIDRA
39
alclometasone dipropionate
10
APIDRA SOLOSTAR
39
alendronate sodium
69
APRI
60
ALFERON N
68
APRISO
54
alfuzosin hcl
56
APTIOM
19
ALINIA
30
APTIVUS
34
ALKERAN
27
ARANELLE
60
84
ARANESP
40
benzonatate
76
ASACOL
54
benztropine mesylate
31
ASACOL HD
54
BERINERT
67
ascomp with codeine
7
betamethasone acetate/betamethasone sodium
ASMANEX
73
phosphate
57
ASMANEX HFA
73
betamethasone dipropionate
10
ASTAGRAF XL
67
betamethasone dipropionate/propylene glycol
10
atenolol
43
betamethasone valerate
10
atenolol/chlorthalidone
43
BETASERON
50,51
atorvastatin calcium
48
betaxolol hcl
44,71
atovaquone
30
bethanechol chloride
57
ATRIPLA
34
BETIMOL
71
ATROVENT HFA
74
BETOPTIC S
72
AUBAGIO
50
bicalutamide
66
AUBRA
60
bisoprolol fumarate
44
aurodex
72
bisoprolol fumarate/hydrochlorothiazide
44
auroguard
72
bleph-10
16
AVIANE
60
BLEPHAMIDE
70
avidoxy
16
BLEPHAMIDE S.O.P.
70
avita
51
blood sugar diagnostic
69
AVONEX
50
BOSULIF
29
AVONEX ADMINISTRATION PACK
50
BREO ELLIPTA
73
AVONEX PEN
50
BRIELLYN
60
AZASITE
15
BRILINTA
41
azathioprine
67
brimonidine tartrate
72
bromfenac sodium
71
azelastine hcl
71,73
AZILECT
31
bromocriptine mesylate
31
azithromycin
15
budeprion sr
20
AZOPT
71
budeprion xl
20
AZURETTE
60
budesonide
57,73
bumetanide
46
BUPHENYL
53
10
B
bacitracin
12
buprenorphine hcl
bacitracin/polymyxin b sulfate
70
buprenorphine hcl/naloxone hcl
baclofen
33
buproban
10
balsalazide disodium
68
bupropion hcl
20
BALZIVA
60
buspirone hcl
37
BANZEL
19
butalbital/acetaminophen
5
BARACLUDE
35
butalbital/acetaminophen/caffeine
5
benazepril hcl
42
butalbital/acetaminophen/caffeine/codeine phosphate 7
benazepril hcl/hydrochlorothiazide
42
butalbital/aspirin/caffeine
85
9
5
butorphanol tartrate
7
cefuroxime axetil
14
BYDUREON
37
celecoxib
BYDUREON PEN
37
CELESTONE
57
BYETTA
37
CELONTIN
17
cephalexin
14
CEREZYME
53
C
5
cabergoline
66
CHANTIX
10
cafergot
25
CHATEAL
60
calcipotriene
51
chlordiazepoxide hcl
37
calcitonin,salmon,synthetic
69
chlorhexidine gluconate
12
calcitriol
65
chloroquine phosphate
30
calcium acetate
57
chlorothiazide
47
CAMILA
64
chlorpromazine hcl
23
CAMRESE
60
chlorpropamide
37
CAMRESE LO
60
chlorthalidone
47
CANASA
54
chlorzoxazone
76
candesartan cilexetil
42
cholestyramine (with sugar)
48
5
cholestyramine/aspartame
48
capacet
capecitabine
27
ciclodan
24
CAPRELSA
29
ciclopirox
24
captopril
42
ciclopirox olamine
24
captopril/hydrochlorothiazide
42
cilostazol
41
CARBAGLU
53
cimetidine
55
carbamazepine
19
cimetidine hcl
55
carbidopa
31
CIPRO HC
72
carbidopa/levodopa
31
CIPRODEX
72
carbidopa/levodopa/entacapone
31
ciprofloxacin hcl
carisoprodol
76
ciprofloxacin/ciprofloxacin hcl
16
carisoprodol/aspirin
76
citalopram hydrobromide
21
carteolol hcl
72
claravis
51
CARTIA XT
45
clarithromycin
15
carvedilol
44
clemastine fumarate
73
CAZIANT
60
clinda-derm
13
CEENU
27
clindacin etz
13
cefaclor
14
clindacin p
13
cefadroxil
14
clindamycin hcl
13
cefdinir
14
clindamycin palmitate hcl
13
cefpodoxime proxetil
14
clindamycin phosphate
13
cefprozil
14
clindamycin phosphate/benzoyl peroxide
52
ceftibuten dihydrate
14
clobetasol propionate
10
CEFTIN
14
clobetasol propionate/emollient base
10
86
16,72
clodan
10
cyclosporine
67
clomipramine hcl
22
cyclosporine, modified
67
clonazepam
18
cyproheptadine hcl
73
clonidine
41
CYSTAGON
57
clonidine hcl
41
CYSTARAN
70
clopidogrel bisulfate
41
clorazepate dipotassium
18
D
clotrimazole
24
danazol
59
clotrimazole/betamethasone dipropionate
24
dantrolene sodium
33
clozapine
33
dapsone
26
co-gesic
7
DARAPRIM
30
codeine phosphate/butalbital/aspirin/caffeine
7
DASETTA
60
codeine phosphate/carisoprodol/aspirin
7
DAYSEE
60
codeine sulfate
7
DAYTRANA
49
colchicine/probenecid
25
DEBLITANE
64
COLCRYS
25
decitabine
27
COLESTID
48
DELYLA
60
colestipol hcl
48
DELZICOL
54
COMBIPATCH
60
demeclocycline hcl
16
COMBIVENT
74
DENAVIR
36
COMBIVENT RESPIMAT
74
depade
10
COMETRIQ
29
DEPEN
57
COMPLERA
34
DEPO-SUBQ PROVERA 104
64
COMPRO
23
desipramine hcl
22
constulose
55
desmopressin acetate
58
COPAXONE
51
desmopressin acetate (non-refrigerated)
58
COREG CR
44
desogestrel-ethinyl estradiol
60
cormax
11
desogestrel-ethinyl estradiol/ethinyl estradiol
60
cortisone acetate
11
desonide
11
CREON
53
desoximetasone
11
CRIXIVAN
34
dexamethasone
57
dexamethasone sod phosphate
71
49
cromolyn sodium
71,75
CRYSELLE
60
dexmethylphenidate hcl
CUPRIMINE
57
dextroamphetamine sulf-saccharate/amphetamine sulf-
CUVPOSA
53
aspartate
49
cyanocobalamin (vitamin b-12)
77
dextroamphetamine sulfate
49
CYCLAFEM
60
dextromethorphan hbr/promethazine hcl
76
cyclobenzaprine hcl
76
DIASTAT
18
cyclophosphamide capsules
27
diazepam
18
cyclophosphamide tablets
27
DICLEGIS
23
cycloserine
13
diclofenac potassium
87
5
diclofenac sodium
5,71
econazole nitrate
24
dicloxacillin sodium
15
EDECRIN
46
dicyclomine hcl
53
EDURANT
33
didanosine
33
EFFIENT
41
DIFFERIN
52
EGRIFTA
58
diflorasone diacetate
11
ELELYSO
53
ELIDEL
52
diflunisal
5
digitek
46
ELIGARD
66
digox
46
elimite
30
digoxin
46
ELINEST
60
7
ELIQUIS
40
dihydrocodeine bitartrate/acetaminophen/caffeine
dihydroergotamine mesylate
25
ELMIRON
57
DILANTIN
19
EMCYT
27
DILATRATE-SR
48
EMEND
23
DILT-CD
45
EMOQUETTE
60
DILT-XR
45
EMTRIVA
33
DILTIA XT
45
enalapril maleate
42
diltiazem hcl
45
enalapril maleate/hydrochlorothiazide
42
DILTZAC ER
45
ENBREL
67
DIPENTUM
68
endocet
7
diphenoxylate hcl/atropine sulfate
54
endodan
8
dipyridamole
41
enoxaparin sodium
40
disopyramide phosphate
43
ENPRESSE
60
9
ENSKYCE
61
divalproex sodium
18
entacapone
31
donepezil hcl
20
entecavir
35
dorzolamide hcl
72
enulose
55
dorzolamide hcl/timolol maleate
72
EPANED
42
doxazosin mesylate
41
EPIFOAM
52
doxepin hcl
22
EPIPEN 2-PAK
75
doxercalciferol
69
EPIPEN JR 2-PAK
75
doxycycline hyclate
17
epitol
19
doxycycline monohydrate
17
EPIVIR HBV
35
DROXIA
28
eplerenone
47
DUAVEE
60
EPOGEN
40
duloxetine hcl
21
EPZICOM
34
dynacin
17
EQUETRO
19
DYRENIUM
47
ergocalciferol (vitamin d2)
78
ergotamine tartrate/caffeine
25
ERIVEDGE
29
ERRIN
64
disulfiram
E
E.E.S. 200
15
88
ERY-TAB
15
fenoprofen calcium
5
erygel
15
fentanyl
6
ERYPED 200
15
FINACEA
52
erythromycin base
15
finasteride
56
erythromycin base/benzoyl peroxide
52
fioricet
erythromycin base/ethyl alcohol
16
FIRAZYR
51
erythromycin ethylsuccinate
16
FIRST-LANSOPRAZOLE
56
erythromycin ethylsuccinate/sulfisoxazole acetyl
16
FIRST-OMEPRAZOLE
56
escitalopram oxalate
21
FLAREX
57
ESTARYLLA
61
flavoxate hcl
56
estazolam
77
flecainide acetate
43
ESTRACE
61
FLOVENT DISKUS
73
estradiol
61
FLOVENT HFA
73
estradiol/norethindrone acetate
61
fluconazole
24
ESTRING
61
fludrocortisone acetate
11
estropipate
61
flunisolide
73
eszopiclone
77
fluocinolone acetonide
11
ethambutol hcl
26
fluocinolone acetonide oil
57
ethinyl estradiol/drospirenone
61
fluocinonide
11
ethosuximide
17
fluocinonide/emollient base
11
etidronate disodium
69
FLUOR-A-DAY
78
fluoride/iron/vitamins a,c,and d
78
5
etodolac
5
EXELON
20
FLUORITAB
78
exemestane
28
fluorometholone
57
EXJADE
77
FLUOROPLEX
52
EXTAVIA
51
fluorouracil
52
fluoxetine hcl
21
fluphenazine hcl
32
F
FALMINA
61
FLURA-DROPS
78
famciclovir
36
flurazepam hcl
77
famotidine
55
flurbiprofen
FARESTON
27
flurbiprofen sodium
FARXIGA
38
fluticasone propionate
FAZACLO
33
fluvastatin sodium
48
felbamate
19
fluvoxamine maleate
21
felodipine
45
FML FORTE
58
fenofibrate
47
FML S.O.P.
58
fenofibrate nanocrystallized
47
FOCALIN XR
49
fenofibrate,micronized
47
fondaparinux sodium
40
fenofibric acid
47
FORTEO
69
fenofibric acid (choline)
47
fosinopril sodium
42
89
5
71
11,58
fosinopril sodium/hydrochlorothiazide
42
GOLYTELY
54
FRAGMIN
40
granisetron hcl
23
FULYZAQ
54
GRANIX
40
furosemide
46
GRASTEK
67
FUZEON
34
griseofulvin ultramicrosize
24
griseofulvin, microsize
24
G
guanfacine hcl
gabapentin
18
GABITRIL
18
GAMMAGARD S-D
68
H
GAMMAKED
68
halobetasol propionate
11
GAMUNEX-C
68
haloperidol
32
garamycin
12
haloperidol lactate
32
gatifloxacin
70
HEATHER
64
GATTEX
54
hecoria
67
gavilyte-c
54
HEXALEN
28
gavilyte-g
54
HUMALOG
39
gavilyte-n
54
HUMALOG MIX 50-50
39
gemfibrozil
47
HUMALOG MIX 75-25
39
generlac
55
HUMATROPE
58
HUMIRA
67
gengraf
52,67
guanidine hcl
41,50
26
GENOTROPIN
58
HUMIRA PEDIATRIC
67
gentak
12
HUMULIN R
39
gentamicin sulfate
12
HYCAMTIN
28
GIANVI
61
hydralazine hcl
48
GILDAGIA
61
hydrochlorothiazide
47
GILDESS
61
hydrocodone bitartrate/acetaminophen
GILDESS FE
61
hydrocodone bitartrate/homatropine methylbromide 74
GILENYA
51
hydrocodone/ibuprofen
GILOTRIF
28
hydrocortisone
11,58
GLEEVEC
29
hydrocortisone butyrate
11,58
glimepiride
38
hydrocortisone valerate
58
glipizide
38
hydromet
74
glipizide/metformin hcl
38
hydromorphone hcl
GLUCAGEN
39
hydroxychloroquine sulfate
30
GLUCAGON EMERGENCY KIT
39
hydroxyurea
28
glyburide
38
hydroxyzine hcl
23
glyburide,micronized
38
hydroxyzine pamoate
23
glyburide/metformin hcl
38
HYPER-SAL
76
glycopyrrolate
54
hypercare
52
glydo
9
90
8
8
8
I
ibandronate sodium
69
JANTOVEN
40
JANUMET
38
JANUMET XR
38
ibudone
8
JANUVIA
38
ibuprofen
5
JENCYCLA
64
ibuprofen/oxycodone hcl
5
JENTADUETO
38
ICLUSIG
29
JOLESSA
61
IMBRUVICA
29
JOLIVETTE
64
imipramine hcl
22
JUNEL
61
imipramine pamoate
22
JUNEL FE
61
imiquimod
28
JUVISYNC
38
INCIVEK
35
JUXTAPID
48
INCRELEX
58
indapamide
47
indomethacin
6
K
KALETRA
34
INFERGEN
35
KALYDECO
76
INLYTA
29
KARIVA
61
INTELENCE
33
KAZANO
38
INTRON A
35
KELNOR 1-35
61
INTROVALE
61
ketoconazole
24
INVEGA
32
ketoprofen
INVIRASE
34
ketorolac tromethamine
INVOKANA
38
kionex
77
ipratropium bromide
74
klor-con 10
78
ipratropium bromide/albuterol sulfate
74
klor-con 8
78
irbesartan
42
klor-con m10
78
irbesartan/hydrochlorothiazide
42
klor-con m20
78
IRESSA
28
KOMBIGLYZE XR
38
ISENTRESS
34
KURVELO
61
isochron
48
KUVAN
53
isonarif
26
KYNAMRO
48
isoniazid
26
isosorbide dinitrate
48
L
isosorbide mononitrate
48
labetalol hcl
44
isradipine
45
LACRISERT
70
ISTALOL
72
lactulose
55
itraconazole
24
LAMISIL
24
ivermectin
30
lamivudine
J
JAKAFI
28
91
6
6,71
34,35
lamivudine/zidovudine
34
lamotrigine
19
LANOXIN
46
lansoprazole
56
liothyronine sodium
65
lansoprazole/amoxicillin trihydrate/clarithromycin
56
lisinopril
42
LANTUS
39
lisinopril/hydrochlorothiazide
42
LANTUS SOLOSTAR
39
lithium carbonate
37
LARIN
61
lithium citrate
37
LARIN FE
61
LOFIBRA
47
latanoprost
69
LOMEDIA 24 FE
62
LATUDA
32
lomustine
27
LEENA
62
lopreeza
62
leflunomide
68
lorazepam
18
LESSINA
62
lorazepam intensol
18
LETAIRIS
75
lorcet
8
letrozole
28
lorcet hd
8
leucovorin calcium
28
lorcet plus
8
LEUKERAN
27
lortab
8
LEUKINE
40
LORYNA
62
leuprolide acetate
66
losartan potassium
42
levalbuterol hcl
75
losartan potassium/hydrochlorothiazide
42
LEVATOL
44
LOTEMAX
71
LEVEMIR
39
LOTRONEX
55
LEVEMIR FLEXPEN
39
lovastatin
48
LEVEMIR FLEXTOUCH
39
LOW-OGESTREL
62
levetiracetam
17
loxapine succinate
32
levobunolol hcl
72
LUDENT FLUORIDE
78
levocarnitine
78
LUMIGAN
69
levocetirizine dihydrochloride
73
LUTERA
62
levofloxacin
16
LYRICA
17
LEVONEST
62
LYSODREN
65
levonorgestrel-eth estra/ethinyl estradiol
62
LYZA
64
levonorgestrel-ethinyl estradiol
62
LEVORA-28
62
levorphanol tartrate
6
M
maprotiline hcl
21
levothroid
65
MARLISSA
62
levothyroxine sodium
65
MARPLAN
21
levoxyl
65
MATERNITY
78
LEXIVA
34
MATULANE
27
LIALDA
54
MATZIM LA
45
lidocaine
9
meclofenamate sodium
lidocaine hcl
9
medroxyprogesterone acetate
64
lidocaine/prilocaine
9
mefloquine hcl
30
megestrol acetate
64
lindane
30
92
6
MEKINIST
28
millipred
11
meloxicam
6
millipred dp
11
meperidine hcl
8
mimvey
62
meperitab
8
mimvey lo
62
meprobamate
37
minitran
49
mercaptopurine
28
minocycline hcl
17
mesalamine
54
minoxidil
48
mesalamine with cleansing wipes
54
mirtazapine
21
MESNEX
28
misoprostol
55
MESTINON
26
modafinil
77
metadate er
50
MODERIBA
35
metaxalone
76
moexipril hcl
42
metformin hcl
38
moexipril hcl/hydrochlorothiazide
42
methadone hcl
6
mometasone furoate
52
methadone intensol
6
MONO-LINYAH
62
methadose
6
MONONESSA
62
methazolamide
46
montelukast sodium
74
methenamine hippurate
13
MONUROL
13
methimazole
66
morgidox
17
methocarbamol
76
morphine sulfate
7,8
methotrexate sodium
28
MOVIPREP
55
methotrexate sodium/pf
28
MOXEZA
70
methoxsalen, rapid
52
moxifloxacin hcl
16
methyclothiazide
47
MULTAQ
43
methyldopa
41
mupirocin
13
methyldopa/hydrochlorothiazide
41
MYALEPT
58
methylphenidate hcl
50
mycophenolate mofetil
67
methylprednisolone
58
mycophenolate sodium
67
metipranolol
72
myorisan
52
metoclopramide hcl
23
MYRBETRIQ
33
metolazone
47
MYZILRA
62
metoprolol succinate
44
metoprolol tartrate
44
N
metoprolol tartrate/hydrochlorothiazide
44
nabumetone
metronidazole
13
nadolol
44
mexiletine hcl
43
nadolol/bendroflumethiazide
44
MICROGESTIN
62
naltrexone hcl
10
MICROGESTIN FE
62
NAMENDA
20
midodrine hcl
41
naphazoline hcl
70
migergot
25
NAPRELAN
6
MIGRANAL
25
naproxen
6
93
6
naproxen sodium
6
NORDITROPIN
58
NASONEX
73
NORDITROPIN FLEXPRO
58
NATACYN
24
NORDITROPIN NORDIFLEX
58
nateglinide
38
norethindrone
64
NECON
62
norethindrone acetate
65
nefazodone hcl
21
norethindrone acetate-ethinyl estradiol
62
neo-polycin
70
norethindrone acetate-ethinyl estradiol/ferrous
neo-polycin hc
70
fumarate
62
neomycin sulfate
12
norgestimate-ethinyl estradiol
62
NORLYROC
65
neomycin sulfate/bacitracin zinc/polymyxin
b/hydrocortisone
70
NORPACE CR
43
neomycin sulfate/bacitracin/polymyxin b
70
NORTREL
62
neomycin sulfate/polymyxin b sulfate/gramicidin d
70
nortriptyline hcl
22
NORVIR
35
NOVOLOG
39
neomycin sulfate/polymyxin b
sulfate/hydrocortisone
70,72
neomycin/polymyxin b sulfate/dexamethasone
70
NOVOLOG FLEXPEN
39
neosporin
70
NOVOLOG MIX 70-30
39
NESINA
38
NOVOLOG MIX 70-30 FLEXPEN
39
NEULASTA
40
NOXAFIL
24
NEUMEGA
40
NUEDEXTA
50
NEUPOGEN
40
nulytely with flavor packs
54
nevirapine
33
NUTROPIN
59
NEXAVAR
29
NUTROPIN AQ
59
nicardipine hcl
45
NUTROPIN AQ NUSPIN
59
NIFEDIAC CC
45
NUVARING
62
NIFEDICAL XL
45
nyamyc
24
nifedipine
45
nystatin
25
NIKKI
62
nystatin/triamcinolone acetonide
11
NILANDRON
66
nystop
25
nimodipine
45
nisoldipine
45
O
NITRO-BID
49
OCELLA
63
NITRO-DUR
49
octreotide acetate
66
nitro-time
49
OCUDOX
17
nitrofurantoin
13
ofloxacin
16
nitrofurantoin macrocrystal
13
OGESTREL
63
nitrofurantoin monohydrate/macrocrystals
13
olanzapine
32
nitroglycerin
49
olanzapine/fluoxetine hcl
21
NITROSTAT
49
OLYSIO
36
nizatidine
55
omeprazole
56
NORA-BE
64
OMEPRAZOLE+SYRSPEND SF ALKA
56
94
OMNITROPE
59
pedi-dri
25
ondansetron
24
pediatric multivitamin combination no.2/sodium
ondansetron hcl
24
fluoride
ONFI
18
pediatric multivitamins a,c,& d3 no.21 with sodium
ONGLYZA
38
fluoride
78
OPSUMIT
75
pediatric multivitamins no.16 with sodium fluoride
78
ORALAIR
67
pediatric multivitamins no.17 with sodium fluoride
78
oralone
11
pediatric multivitamins no.82 with sodium fluoride
78
ORAP
32
peg 3350/sod sulf/sod bicarbonate/sod
ORENITRAM ER
75
chloride/potassium chl
54
ORFADIN
53
PEGASYS
36
orphenadrine citrate
76
PEGASYS PROCLICK
36
orphenadrine citrate/aspirin/caffeine
76
PEGINTRON
36
ORSYTHIA
63
PEGINTRON REDIPEN
36
ORTHO TRI-CYCLEN LO
63
penicillin v potassium
15
OSENI
38
PENTASA
54
OTEZLA
52
pentoxifylline
46
otic care
72
perindopril erbumine
42
oxandrolone
59
periogard
13
oxaprozin
6
permethrin
30
oxazepam
37
perphenazine
23
oxcarbazepine
19
perphenazine/amitriptyline hcl
32
OXSORALEN
52
PHENADOZ
23
oxybutynin chloride
56
phenelzine sulfate
21
oxycodone hcl
7,8
phenobarbital
18
78
oxycodone hcl/acetaminophen
8
phenylephrine hcl/promethazine hcl
76
oxycodone hcl/aspirin
9
phenytoin
19
OXYCONTIN
7
phenytoin sodium extended
20
oxymorphone hcl
9
PHILITH
63
56
PICATO
52
OXYTROL
P
pilocarpine hcl
51,72
PILOPINE HS
72
pacerone
43
PIMTREA
63
pancrelipase 5,000
53
pindolol
44
PANRETIN
30
pioglitazone hcl
38
pantoprazole sodium
56
pioglitazone hcl/glimepiride
38
paricalcitol
66
pioglitazone hcl/metformin hcl
38
paroex
13
PIRMELLA
63
paroxetine hcl
21
piroxicam
PATANOL
71
PLEGRIDY
51
PAXIL
21
PLEGRIDY PEN
51
95
6
PNV-VP-U
78
procto-pak
68
podofilox
52
proctocream-hc
68
polycin
70
PROCTOFOAM-HC
68
polymyxin b sulfate/trimethoprim
70
proctosol-hc
68
PORTIA
63
proctozone-hc
68
potassium chloride
78
PROCYSBI
57
potassium citrate
78
progesterone,micronized
65
PRADAXA
40
PROGLYCEM
39
pramipexole di-hcl
31
PROGRAF
67
pravastatin sodium
48
PROMACTA
40
prazosin hcl
41
promethazine hcl
23
prednisolone
11
promethazine hcl/codeine
73
prednisolone acetate
71
promethazine/phenylephrine hcl/codeine
74
PROMETHEGAN
23
prednisolone sod phosphate
11,71
prednisone
12
propafenone hcl
43
prednisone intensol
12
propantheline bromide
54
PREMARIN
63
propranolol hcl
44
PREMPHASE
63
propranolol hcl/hydrochlorothiazide
44
PREMPRO
63
propylthiouracil
66
PRENAPLUS
79
PROTONIX
56
protriptyline hcl
22
PULMICORT
73
PULMICORT FLEXHALER
73
pulmosal
76
PULMOZYME
76
PURIXAN
28
PYLERA
54
pyridostigmine bromide
26
prenatal vitamins comb no.115/iron fumarate/folic
acid
79
prenatal vitamins comb no.115/iron fumarate/folic
acid/dss
79
prenatal vitamins combo no.60/ferrous fumarate/folic
acid
79
prenatal vits with calcium #72/ferrous fumarate/folic
acid
79
prenatal vits with calcium #72/iron,carbonyl/folic acid 79
prenatal vits without calc no5/ferrous fumarate/folic
Q
acid
79
QUASENSE
63
PREPLUS
79
QUDEXY XR
19
PREVALITE
48
quetiapine fumarate
32
PREVIFEM
63
QUFLORA
79
PREZISTA
35
quinapril hcl
42
PRIFTIN
26
quinapril hcl/hydrochlorothiazide
43
primidone
17
quinidine gluconate
43
PROAIR HFA
75
quinidine sulfate
43
probenecid
25
QVAR
73
prochlorperazine maleate
23
PROCRIT
40
96
rosadan
R
13
ROXICET
9
9
rabeprazole sodium
56
roxicet
RAGWITEK
67
ROZEREM
raloxifene hcl
65
ramipril
43
S
RANEXA
46
SABRIL
18
ranitidine hcl
55
SAIZEN
59
RAPAMUNE
67
SANDIMMUNE
68
RAVICTI
53
SANTYL
52
REBETOL
36
SAPHRIS
33
REBIF
51
SAVELLA
50
REBIF REBIDOSE
51
selegiline hcl
31
RECLIPSEN
63
SELZENTRY
34
RECTIV
48
SENSIPAR
66
refissa
52
SEREVENT DISKUS
75
REGRANEX
52
SEROSTIM
59
RENAGEL
57
sertraline hcl
22
RENVELA
57
sevelamer carbonate
57
reprexain
9
SHAROBEL
65
77
RESTASIS
68
SIGNIFOR
65
revia
10
sildenafil citrate
75
REVLIMID
27
silver sulfadiazine
16
REYATAZ
35
simvastatin
48
RHEUMATREX
28
sirolimus
68
RIBAPAK
36
SIRTURO
27
RIBASPHERE
36
sodium chloride for inhalation
76
RIBATAB
36
sodium chloride/sodium bicarbonate/potassium
ribavirin
36
chloride/peg
54
rifabutin
26
sodium fluoride
79
rifampin
27
sodium phenylbutyrate
53
RIFATER
27
sodium polystyrene sulfonate
77
riluzole
50
SOLTAMOX
27
rimantadine hcl
35
SOMAVERT
66
RIOMET
38
SORINE
43
RISPERDAL CONSTA
32
sotalol hcl
43
risperidone
32
SOVALDI
36
RITALIN LA
50
SPIRIVA
74
rivastigmine tartrate
20
spironolactone
47
rizatriptan benzoate
26
spironolactone/hydrochlorothiazide
47
ropinirole hcl
31
SPORANOX
25
97
SPRINTEC
63
TAMIFLU
35
SPRYCEL
29
tamoxifen citrate
27
sps
77
tamsulosin hcl
56
SRONYX
63
TARCEVA
29
sski
76
TARGRETIN
30
9
TARINA FE
63
stagesic
stavudine
34
TASIGNA
29
STELARA
52
TAZORAC
52
STIMATE
59
TAZTIA XT
45
STIVARGA
29
TECFIDERA
51
STRATTERA
50
temazepam
77
STRIBILD
34
temozolomide
28
SUBOXONE
9
tencon
5
SUCRAID
53
terazosin hcl
41
sucralfate
55
terbinafine hcl
25
sulfacetamide sodium
16
terbutaline sulfate
75
terconazole
25
sulfacetamide sodium/prednisolone sodium
phosphate
70
testosterone
59
sulfadiazine
16
testosterone cypionate
59
sulfamethoxazole/trimethoprim
16
testosterone enanthate
59
sulfamide
16
tetracycline hcl
17
sulfasalazine
54
TEV-TROPIN
59
sulfazine
55
THALOMID
27
sulfazine ec
55
THEOCHRON
74
theophylline anhydrous
74
sulindac
6
sumatriptan
26
THIOLA
57
sumatriptan succinate
26
thioridazine hcl
32
SUPREP
55
thiothixene
32
SUSTIVA
33
tiagabine hcl
18
SUTENT
29
ticlopidine hcl
41
SYEDA
63
TIKOSYN
43
SYLATRON
36
TILIA FE
63
SYLATRON 4-PACK
36
timolol maleate
SYMBICORT
76
tinidazole
30
SYMLINPEN 120
39
TIVICAY
34
SYMLINPEN 60
39
tizanidine hcl
33
SYPRINE
77
TL FOLATE
79
TL-FLUORIVITE
79
TOBI PODHALER
12
TOBRADEX
70
TOBRADEX ST
70
T
tacrolimus
52,68
TAFINLAR
29
98
44,72
tobramycin
12
trimipramine maleate
22
tobramycin in 0.225 % sodium chloride
12
TRINATAL RX 1
79
tobramycin/dexamethasone
71
TRINESSA
63
TOBREX
12
TRIVEEN-U
79
6
TRIVORA-28
64
tolmetin sodium
tolterodine tartrate
56
tropicamide
71
topiragen
19
trospium chloride
56
topiramate
19
TRUVADA
34
torsemide
46
TYKERB
29
TRACLEER
75
TYZEKA
36
TRADJENTA
39
TYZINE
76
tramadol hcl
7,9
tramadol hcl/acetaminophen
5
U
trandolapril
43
UCERIS
58
tranexamic acid
41
ULESFIA
31
TRANSDERM-SCOP
23
unithroid
65
tranylcypromine sulfate
21
ursodiol
55
TRAVATAN Z
69
travoprost (benzalkonium)
69
V
trazodone hcl
21
VAGIFEM
64
TRECATOR
27
valacyclovir hcl
36
VALCHLOR
28
tretinoin
30,52
tretinoin/emollient base
53
VALCYTE
35
TRI-ESTARYLLA
63
valganciclovir hcl
35
TRI-LEGEST FE
63
valproic acid
19
TRI-LINYAH
63
valproic acid (as sodium salt) (valproate sodium)
18
TRI-PREVIFEM
63
valsartan
42
TRI-SPRINTEC
63
valsartan/hydrochlorothiazide
42
vancomycin hcl
13
triamcinolone acetonide
12,58
triamterene/hydrochlorothiazide
47
vandazole
13
trianex
53
vandetanib
29
triazolam
77
VELETRI
75
TRICARE
79
VELIVET
64
triderm
12
venlafaxine hcl
22
trifluoperazine hcl
32
VENTAVIS
75
trifluridine
36
VENTOLIN HFA
75
TRIGLIDE
47
verapamil hcl
43,46
trihexyphenidyl hcl
31
VERSACLOZ
33
trilyte with flavor packets
55
VESTURA
64
trimethobenzamide hcl
23
VEXOL
71
trimethoprim
13
VICTOZA 2-PAK
39
99
VICTOZA 3-PAK
39
zenzedi
49
VICTRELIS
36
zidovudine
34
VIGAMOX
71
ziprasidone hcl
VIMPAT
20
ZIRGAN
35
VINATE ONE
79
ZOLINZA
30
VINATE-M
79
zolmitriptan
26
VIORELE
64
zolpidem tartrate
77
VIRACEPT
35
ZOMIG
26
VIRAMUNE XR
33
zonisamide
18
VIREAD
34
ZORBTIVE
59
vitazol
13
ZORTRESS
68
VOL-PLUS
79
ZOVIA 1-35E
64
VOLTAREN
53
ZOVIA 1-50E
64
voriconazole
25
ZYDELIG
29
VOTRIENT
29
ZYFLO CR
74
VYFEMLA
64
ZYKADIA
30
VYVANSE
49
ZYLET
71
ZYTIGA
29
ZYVOX
14
W
warfarin sodium
40
WERA
64
X
XARELTO
40
XENAZINE
50
XIFAXAN
14
XOPENEX HFA
75
XTANDI
66
XULANE
64
xylon 10
9
XYREM
77
Z
zafirlukast
74
zaleplon
77
ZARAH
64
ZAVESCA
53
ZELBORAF
29
zenatane
53
ZENCHENT
64
ZENPEP
53
100
20,33
Category Listing
Analgesics
Anesthetics
Anti-Addiction/Substance Abuse Treatment Agents
Anti-inflammatory Agents
Antibacterials
Anticonvulsants
Antidementia Agents
Antidepressants
Antiemetics
Antifungals
Antigout Agents
Antimigraine Agents
Antimyasthenic Agents
Antimycobacterials
Antineoplastics
Antiparasitics
Antiparkinson Agents
Antipsychotics
Antispasticity Agents
Antivirals
Anxiolytics
Bipolar Agents
Blood Glucose Regulators
Blood Products/Modifiers/ Volume Expanders
Cardiovascular Agents
Central Nervous System Agents
Dental and Oral Agents
Dermatological Agents
Enzyme Replacement/ Modifiers
Gastrointestinal Agents
Genitourinary Agents
Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal)
Hormonal Agents, Stimulant/Replacement/Modifying (Other)
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)
Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)
Hormonal Agents, Suppressant (Adrenal)
Hormonal Agents, Suppressant (Parathyroid)
Hormonal Agents, Suppressant (Pituitary)
Hormonal Agents, Suppressant (Sex Hormones/Modifiers)
Hormonal Agents, Suppressant (Thyroid)
Immunological Agents
101
5
9
9
10
12
17
20
20
23
24
25
25
26
26
27
30
31
32
33
33
37
37
37
40
41
49
51
51
53
53
56
57
58
58
59
65
65
65
66
66
66
67
Inflammatory Bowel Disease Agents
Metabolic Bone Disease Agents
Miscellaneous
Ophthalmic Agents
Otic Agents
Respiratory Tract Agents
Skeletal Muscle Relaxants
Sleep Disorder Agents
Therapeutic Nutrients/ Minerals/ Electrolytes
68
69
69
69
72
73
76
77
77
102