1. Ingeniería

2015 Comprehensive Preferred Drug List (PDL)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN
YOUR PLAN. SELECT DRUGS ON THIS LIST MAY BE EXCLUDED UNDER YOUR SPECIFIC PLAN
DESIGN. PLEASE REFER TO YOUR COVERAGE DOCUMENTS TO DETERMINE SPECIFIC BENEFIT
LEVELS.
PLEASE NOTE: This list is subject to change and is not all-inclusive. Please review this document and
contact Medica Customer Service with questions.
The coverage level for prescription drugs is generally higher when a member receives them at an innetwork pharmacy, and, for some plans, members must use network pharmacies to receive prescription
drug benefits. Plan terms vary and members should consult their benefit plan documents for specific
coverage information.
Prior authorization may be required to obtain coverage for select drugs on this list. Brand name drugs
are listed in CAPITAL letters. Generic drugs are listed in lower case letters. The coverage level of brand
name drugs may change when a generic equivalent becomes available.
If you have questions, please call the Medica Customer Service number listed on the back of your ID
card.
1
What is a Preferred Drug List (PDL)?
The Medica PDL is comprised of drugs that meet the medical needs of our members and have proven
safety and effectiveness. It includes both brand name and generic drugs. The drugs on this list have been
approved by the Food and Drug Administration (FDA). A team of physicians and pharmacists meets
regularly to review and update the list. Your doctor can use this list to select medications for your health
care needs, while helping you maximize your prescription drug benefit.
Does the PDL ever change?
The Medica PDL can change during the course of a calendar year. Medica strives to limit these changes.
More frequent changes may occur when a new, less expensive generic drug becomes available or when
new adverse information about the safety or effectiveness of a drug is released.
Select drugs on the PDL may be excluded under your specific plan design. Please refer to your benefit
plan documents to determine specific benefit levels.
How do I use the PDL?
There are two ways to find your drug within the PDL:
Medical Condition
The PDL begins on Page 11. The drugs in this PDL are grouped into categories depending on the
type of medical conditions that they are used to treat. For example, drugs used to treat a heart
condition are listed under the category, “Beta-adrenergic Blocking Agents”. If you know what
your drug is used for, look for the category name in the list that begins on Page 11. Then look
under the category name for your drug.
Alphabetical Listing
The PDL Index provides an alphabetical list of all of the drugs included in this document. Both
brand name drugs and generic drugs are listed in the Index. Look in the Index and find your
drug. Next to your drug, you will see the page number where you can find coverage information.
Turn to the page listed in the Index and find the name of your drug in the first column of the list.
Note: To Search the PDL, use ctrl + F on your keyboard and type in the search term.
2
Are both brand name and generic drugs on the list?
Yes. The PDL includes brand name and generic drugs from all therapeutic categories.
What are generic drugs?
The Medica PDL includes both brand name drugs and generic drugs. A generic drug is approved by the
FDA as having the same active ingredient(s) as the brand name drug. Generally, generic drugs are more
cost effective than brand name drugs.
Please Note: Your benefit plan defines the level of coverage.
Remember, just because a drug that you take is listed on the PDL does not mean that your benefit plan
covers that medication. Also, you may have different copayments for drugs that are on the PDL and
drugs that are not. If you have questions, please refer to your benefit plan documents or call the Medica
Customer Service phone number listed on the back of your ID card to determine what level of coverage
you have.
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements and
limits may include:
Prior Authorization: To ensure appropriate utilization, drugs noted with “PA” must be reviewed
prior to being covered. Drugs are selected for prior authorization due to the likelihood of
misuse or overuse that may be of a clinical and/or cost concern. Medica will approve coverage
of these drugs only if certain criteria are met. The Medication Request Form (MRF) that needs
to be filled out as well as the Prior Authorization Medication Request Guidelines are posted on
medica.com.
Step Therapy: With Step Therapy (ST), certain drugs are grouped in a logical series of steps that
a doctor can follow when treating your condition. Generic drugs are typically identified as
preferred, or Step 1, treatments. Step 2 drugs would be covered for members who have already
tried and failed a Step 1 treatment alternative. This series of steps follows current medical
guidelines and best practice standards. Keep in mind multiple steps can be incorporated into a
Step Therapy program.
Quantity Limits: A quantity limit (QL) is the maximum quantity allowed per prescription over a
specific period of time. This is based on a pharmaceutical manufacturer’s packaging, FDA
recommendations, and appropriate clinical guidelines.
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Can I request an exception to the coverage restrictions?
Yes. Your healthcare provider can obtain the Minnesota Uniform Formulary Exception and Prior
Authorization Form on-line from medica.com under Medication Request Forms or by calling 1-800-7882949. This form must be returned to MedImpact at the fax number or address listed on the document.
To facilitate a thorough review, Medica asks that all information requested in the form be provided,
including documentation of which medications have been tried and failed, including the dosages used,
and the identified reason for failure (e.g. side effects, lack of efficacy).
Specialty Program
Medications with a notation of “Specialty Preferred Drug List (PDL)” are available through your Specialty
Pharmacy benefit. Specialty medications are high-technology, high cost, oral or injectable drugs used
for the treatment of certain diseases that require complex therapies. Many specialty medications
require special handling and in most cases are prescribed by a specialist.
In order to receive a specialty medication, you must utilize one of Medica’s designated specialty
pharmacy: Fairview Specialty Pharmacy.
Limited Distribution Drugs
In certain circumstances, select medications may only be available on a limited distribution
basis. Limited distribution drugs (LDD) are medications that may have special dosing or lab
monitoring requirements that need to be followed very closely. Because of this, the
manufacturer sometimes chooses to limit the distribution of its drug to only a few pharmacies,
or as part of the drug approval process the FDA may recommend this type of distribution in
order for the drug to be approved. This type of restricted distribution helps the manufacturer
keep track of drug inventory, properly educate dispensing pharmacists about any necessary
monitoring, and ensure that any risks that are associated with the LDD are minimized.
In order to obtain a limited distribution drug, you will need to contact the appropriate specialty
pharmacy. The names of these pharmacies, including contact information, are found on the
Specialty PDL document.
Oral Oncology Medications
Oral drugs for the treatment of cancer under your Specialty Pharmacy benefit are restricted to
the Specialty Pharmacy Network (or LDD designated pharmacy), but are not subject to the
specialty prescription drug copay. Oral oncology specialty medications are subject to the
applicable outpatient prescription drug copay as outlined in your benefit plan document.
Certain oral oncology medications may be subject to the Split Fill Program. If you are started on
one of these medications, you will initially be able to receive up to a 15 day supply. The
remainder of the prescription will be available after the initial fill. The partial fill of the
medication will continue for the initial 3 months of treatment. Your copay for the full amount of
4
medication will be divided evenly between the two split fills per month for the initial 3 months
of treatment. These drugs have the following notation of “Split Fill Program” in the
Requirements/Limits column.
PLEASE NOTE: Reference the Specialty PDL on medica.com for further information.
Coverage Limitations
Proton Pump Inhibitors (PPI): Coverage limitations apply to these medications. Preferred
status does not imply coverage. You should refer to your benefit plan documents for further
information.
Growth Hormones (GH): Coverage limitations may apply to these medications. Preferred
status does not imply coverage. You should refer to your benefit plan documents for further
information.
Non-Sedating Antihistamines (NSA): Coverage limitations may apply to these medications.
Preferred status does not imply coverage. You should refer to your benefit plan documents for
further information.
Erectile Dysfunction Drugs (ED): Coverage limitations may apply to these medications.
Preferred status does not imply coverage. You should refer to your benefit plan documents for
further information.
Infertility Drugs (INF): Coverage limitations may apply to these medications. Preferred status
does not imply coverage. You should refer to your benefit plan documents for further
information.
Preventative Drug and Supply Medications
Medications marked with “PREV” in the Tier Display are defined as preventative health services without
member cost sharing. If your benefit includes mail order, please note that some drugs and supplies may
not be available through this service.
Oral Contraceptives: All brand name oral contraceptives require Step Therapy before coverage
of the brand will be allowed. Members should refer to their benefit plan documents for further
information.
5
Abbreviations
Abbreviation/Note
PA
QL
ST
Specialty Preferred Drug List
ST1
ST2
Coverage Notes Abbreviations
Description
Explanation
Utilization Management Restrictions
Prior Authorization Restriction
Your healthcare provider is
required to get prior
authorization from Medica
before you fill your prescription
for this drug. Without prior
approval, Medica may not cover
this drug.
Quantity Limit Restriction
Medica limits the amount of this
drug that is covered per
prescription, or within a specific
time frame.
Step Therapy Restriction
Before Medica will provide
coverage for this drug, you must
first try another drug(s) to treat
your medical condition. This
drug may only be covered if the
other drug(s) does not work for
you.
Other Special Requirements for Coverage
Specialty PDL Restriction
This prescription is only available
under your Specialty Pharmacy
benefit.
Specialty Tier 1
This prescription is available at
your preferred specialty benefit.
Specialty Tier 2
This prescription is available at
your non-preferred specialty
benefit.
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ABBREVIATION
adh. patch
aer br act
aer pow
aer pow ba
aer refill
aer w/adap
ampul
blkbaginj
cap dr mp
cap ds pk
cap er 12h
cap er 24h
cap er deg
cap er pel
cap mphase
cap.sa 24h
cap.sr 12h
cap.sr 24h
cap24h pct
cap24h pel
cap sprink
cap sr pel
cap w/dev
capsule dr
capsule er
capsule sa
cmb cappad
cmb ont fm
cmb ont lt
cmb tabpad
combo. pkg
cpmp 12hr
cpmp 24hr
cpmp 30-70
cpmp 50-50
cream(g), cream(gm)
cream(ml)
cream/appl
STRENGTH AND DOSAGE FORM ABBREVIATIONS
DESCRIPTION
adhesive patch
aerosol, breath activated
aerosol, powder
aerosol powder, breath activated
aerosol refill
aerosol with adapter
ampule
bulk bag injection
capsule, delayed release multiphasic
capsule, dose pack
capsule, 12 hour extended release
capsule, 24 hour extended release
capsule, extended release degradable
capsule, extended release pellets
capsule, multiphasic
capsule, 24 hour sustained action
capsule, 12 hour sustained release
capsule, 24 hour sustained release
capsule, 24 hour controlled-onset pellets
capsule, 24 hour sustained release pellets
capsule, sprinkle
capsule sustained release pellets
capsule with device
capsule, delayed release
capsule, extended release
capsule, sustained action
combination: capsule, pad
combination: ointment, foam
combination: ointment, lotion
combination: tablet, pad
combination package
capsule, 12 hour multiphasic
capsule, 24 hour multiphasic
capsule, multiphasic, 30%-70%
capsule, multiphasic, 50%-50%
cream (grams)
cream (milliliters)
cream with applicator
7
ABBREVIATION
cream, er (g)
cream pack
dehp fr bg
dis needle
disk w/dev
disp syrin
drops susp
drps hpvis
emul adhes
emul packt
emulsn(g)
foam/appl.
froz.piggy
g
gel/pf app
gel (gm)
gel (ml)
gel md pmp
gel w/appl
gel w/pump
gran pack
hfa aer ad
infus. btl
insuln pen
ip soln
irrig soln
iv soln.
jel
jelly/app
jel/pf app
kit cl&crm
kt crm le
kt lotn ce
kt oint le
lotion, er
lozenge hd
m.ht patch
ma buc tab
mcg
DESCRIPTION
cream, extended release (grams)
cream, package
di(2-ethylhexyl)phthalate free bag
disposable needle
disk with inhalation device
disposable syringe
drops, suspension
drops, hyperviscous
emulsion adhesive
emulsion packet
emulsion (grams)
foam with applicator
frozen piggyback
gram
gel with prefilled applicator
gel (grams)
gel (milliliters)
gel in metered dose pump
gel with applicator
gel with pump
granule pack
hfa aerosol adapter
infusion bottle
insulin pen
intraperitoneal solution
irrigating solution
intravenous solution
jelly
jelly with applicator
jelly with pre-filled applicator
kit: cleanser and cream
kit: cream, lotion emollient
kit: lotion, cream emollient
kit: ointment, lotion emollient
lotion, extended release
lozenge handle
medicated heated patch
mucoadhesive buccal tablet
microgram
8
ABBREVIATION
med. pad
med. swab
med. tape
mg
ml
muc er 12h
ndl fr inj
nl fm susp
oint. (g), oint.(gm)
oral conc
oral susp
paste (g)
patch td24
patch td72
patch tdsw
patch tdwk
pca syring
pca vial
pellet(ea)
pen ij kit
pen injctr
pggybk btl
plast. bag
powd pack
sol md pmp
sol w/appl
sol/pf app
sol-gel
soln recon
soln(gram)
spray susp
spray/pump
stick(ea)
supp.rect
supp.vag
suppos.
sus er 24h
sus er rec
sus mc rec
DESCRIPTION
medicated pad
medicated swab
medicated tape
milligram
milliliter
mucoadhesive system, 12 hour extended release
needle for injection
nail film suspension
ointment (grams)
oral concentrate
oral suspension
paste (grams)
patch, 24 hour transdermal
patch, 72 hour transdermal
patch, biweekly transdermal
patch, weekly transdermal
patient-controlled analgesic syringe
patient-controlled analgesic vial
pellet (each)
pen injector kit
pen injector
piggyback bottle
plastic bag
powder pack
solution with multi-dose pump
solution with applicator
solution with pre-filled applicator
solution, gel-forming
solution, reconstituted
solution (grams)
spray, suspension
spray with pump
stick (each)
suppository, rectal
suppository, vaginal
suppository
suspension, 24 hour extended release
suspension, extended release reconstituted
suspension, microcapsule reconstituted
9
ABBREVIATION
suspdr pkt
susp recon
syringekit
tab chew
tab er 12h
tab er 24h
tab er prt
tab er seq
tab disper
tab ds pk
tab er 24
tab mphase
tab part
tab rap dr
tab rapdis
tab subl
tab.sr 12h
tab.sr 24h
tabergr24hr
tablet dr
tablet, er
tablet eff
tablet sa
tablet sol
tb er dspk
tb mp dspk
tb rd dspk
tbdspk 3mo
tbmp 12hr
tbmp 24hr
u
vag ring
DESCRIPTION
suspension, delayed release packet
suspension, reconstituted
syringe kit
tablet, chewable
tablet, 12 hour extended release
tablet, 24 hour extended release
tablet, extended release particles
tablet, extended release sequels
tablet, dispersible
tablet, dose pack
tablet, 24 hour extended release
tablet, multiphasic
tablet, particles
tablet, rapid disintegrating delayed release
tablet, rapid disintegrating
tablet, sublingual
tablet, 12 hour sustained release
tablet, 24 hour sustained release
tablet, 24 hour gradual extended release
tablet, delayed release
tablet, extended release
tablet, effervescent
tablet, sustained action
tablet, soluble
tablet, extended release dose pack
tablet, multiphasic dose pack
tablet, rapid disintegrating dose pack
tablet, 3-month dose pack
tablet, 12 hour multiphasic
tablet, 24 hour multiphasic
unit
vaginal ring
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Drug Name
Drug Tier
Requirements/Limits
Analgesics
Analgesics, Miscellaneous
acetaminophen with codeine
acetaminophen/phenyltolx
butalb/acetaminophen/caffeine
butalbit/acetamin/caff/codeine
butalbital/acetaminophen
butalbital/aspirin/caffeine
butorphanol tartrate spray
codeine sulfate
codeine/butalbital/asa/caffein
dhcodeine bt/acetaminophn/caff
dihydrocodeine/aspirin/caffein
DOLOGESIC
fentanyl citrate
fentanyl
hydrocodone/acetaminophen
hydrocodone/ibuprofen
hydromorphone hcl liquid, supp.rect, tablet
hydromorphone hcl tab er 24h
ibuprofen/oxycodone hcl
levorphanol tartrate
meperidine hcl solution, tablet
methadone hcl oral conc, solution, tablet,
tablet sol
morphine sulfate cap er pel, cpmp 24hr,
solution, supp.rect, syringe: 20mg/ml;
tablet er
MORPHINE SULFATE
opium/belladonna alkaloids
oxycodone hcl
oxycodone hcl/acetaminophen
oxycodone hcl/aspirin
oxymorphone hcl tab er 12h: 5mg, 7.5mg,
10mg, 15mg, 20mg, 30mg, 40mg; tablet
(Tylenol-Codeine
No.3)
(Dologesic)
(Fioricet)
(Fioricet with Codeine)
(Tencon)
(Fiorinal)
(Butorphanol Tartrate)
(Codeine Sulfate)
(Fiorinal with Codeine
#3)
(Dhcodeine Bt/
Acetaminophn/Caff)
(Synalgos-Dc)
(Actiq)
(Duragesic)
(Norco)
(Ibudone)
(Dilaudid)
(Exalgo)
(Ibuprofen/Oxycodone
HCl)
(Levorphanol Tartrate)
(Demerol)
(Dolophine HCl)
(Morphine Sulfate ER)
(Opium/Belladonna
Alkaloids)
(Roxicodone)
(OxycodoneAcetaminophen)
(Percodan)
(Opana)
1
1
1
1
1
1
1
1
1
QL: 17.5 in 28 days
1
1
1
1
1
1
1
1
1
1
PA, QL: 120 in 30 days
QL: 10 in 30 days
QL: 30 in 30 days
1
1
1
1
1
1
1
1
QL: 124 in 31 days
1
1
11
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
pentazocine hcl/acetaminophen
pentazocine hcl/naloxone hcl
sal-amide/acetaminophn/p-tlox
tramadol hcl
tramadol hcl/acetaminophen
BUTRANS
NUCYNTA ER
OXYCONTIN
ABSTRAL
ACTIQ
ANABAR
ASP
AVINZA
BUPAP
CAPITAL W-CODEINE
CODEINE SULFATE
CONZIP
DEMEROL syringe: 75mg/ml
DEMEROL tablet
DILAUDID liquid, tablet
DOLGIC PLUS
DOLOPHINE HCL
DURAGESIC
DURAXIN
EMBEDA
ESGIC
ESGIC-PLUS
EXALGO
FENTORA
FIORICET WITH CODEINE
FIORICET
FIORINAL WITH CODEINE #3
FIORINAL
HYCET
HYSINGLA ER
IBUDONE
KADIAN
LAZANDA
LORCET 10-650
Drug Tier
(Pentazocine HCl/
Acetaminophen)
(Pentazocine HCl/
Naloxone HCl)
(Duraxin)
(Ultram)
(Ultracet)
Requirements/Limits
1
1
1
1
1
2
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
QL: 4 in 28 days
QL: 124 in 31 days
PA, QL: 120 in 30 days
PA, QL: 120 in 30 days
QL: 10 in 30 days
QL: 30 in 30 days
PA, QL: 120 in 30 days
PA, QL: 1 in 28 days
12
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
LORCET PLUS
LORTAB
MAGNACET
MAXIDONE
METHADOSE
MS CONTIN
MSIR
NORCO
NUCYNTA
NUMORPHAN
ONSOLIS
OPANA ER
OPANA tablet
ORBIVAN CF
ORBIVAN
OXECTA
oxymorphone hcl tab er 12h: 40mg
PERCOCET
PERCODAN
PERCOLONE
PHRENILIN FORTE
PRIMLEV
RELAGESIC
ROXICODONE
RYBIX ODT
RYZOLT
STAGESIC-10
SUBSYS
SYNALGOS-DC
TENCON
TREZIX
TYLENOL-CODEINE NO.3
TYLENOL-CODEINE NO.4
TYLOX
ULTRACET
ULTRAM ER
ULTRAM
VERDROCET
VICOPROFEN
XARTEMIS XR
XODOL 10-300
Drug Tier
(Opana ER)
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Requirements/Limits
PA, QL: 120 in 30 days
QL: 124 in 31 days
QL: 124 in 31 days
QL: 124 in 31 days
PA, QL: 120 in 30 days
13
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
XODOL 5-300
XODOL 7.5-300
XOLOX
ZAMICET
ZEBUTAL
ZGESIC
ZOHYDRO ER
ZYDONE
Nonsteroidal Anti-Inflammatory Agents
aspirin tablet dr: 975mg
(Aspirin)
celecoxib
(Celebrex)
choline sal/mag salicylate
(Choline Sal/Mag
Salicylate)
COMFORT PAC-IBUPROFEN
COMFORT PAC-MELOXICAM
COMFORT PAC-NAPROXEN
diclofenac potassium
(Cataflam)
diclofenac sodium
(Diclofenac Sodium)
diclofenac sodium/misoprostol
(Arthrotec 75)
diflunisal
(Diflunisal)
etodolac
(Etodolac)
fenoprofen calcium
(Fenoprofen Calcium)
flurbiprofen
(Flurbiprofen)
ibuprofen oral susp: 100mg/5ml; tablet:
(Ibuprofen)
400mg, 600mg, 800mg
indomethacin
(Indomethacin)
ketoprofen
(Ketoprofen)
ketorolac tromethamine tablet
(Ketorolac
Tromethamine)
meclofenamate sodium
(Meclofenamate
Sodium)
mefenamic acid
(Ponstel)
meloxicam
(Mobic)
methyl salicylate
(Methyl Salicylate)
nabumetone
(Nabumetone)
naproxen sodium
(Anaprox Ds)
naproxen
(Naprosyn)
oxaprozin
(Daypro)
phenylbutazone
(Phenylbutazone)
piroxicam
(Feldene)
salsalate
(Salsalate)
Requirements/Limits
3
3
3
3
3
3
3
3
1
1
1
ST
1
1
1
1
1
1
1
1
1
1
1
1
1
1
QL: 20 per fill
1
1
1
1
1
1
1
1
1
1
1
14
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
sulindac
tolmetin sodium
INDOCIN oral susp
VIMOVO
ANAPROX DS
ANAPROX
ANSAID
ARTHROTEC 50
ARTHROTEC 75
CAMBIA
CATAFLAM
CELEBREX
CLINORIL
DAYPRO
DISALCID
DUEXIS
EC-NAPROSYN
FELDENE
FENOPROFEN CALCIUM
FLECTOR
INDOCIN supp.rect
LEVACET
MAGAN
MOBIC
NALFON
NAPRELAN CR DOSE CARD
NAPRELAN
NAPROSYN
PENNSAID
PONSTEL
SOLARAZE
SPRIX
VOLTAREN
VOLTAREN-XR
ZIPSOR
ZORVOLEX
asa/calcium carb/mag/al hydrox
Drug Tier
(Sulindac)
(Tolmetin Sodium)
(Asa/Calcium Carb/
Mag/Al Hydrox)
1
1
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
PREV
Requirements/Limits
ST, QL: 60 in 30 days
(See PPI Coverage
Limitation)
QL: 18 in 30 days
ST
QL: 5 in 30 days
QL: 12 in 1 days
15
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
aspirin supp.rect, tab chew, tablet, tablet dr: (Ecotrin)
81mg, 325mg, 500mg, 650mg
aspirin/calcium carbonate/mag
(Aspirin/Calcium
Carbonate/Mag)
Requirements/Limits
PREV
PREV
Anesthetics
Local Anesthetics
benoxinate hcl/fluorescein na
benzocaine
lidocaine hcl jel (ml), jel/pf app, solution
lidocaine oint. (g)
lidocaine/prilocaine
BUCALSEP
EMLA
FLUORESCEIN-BENOXINATE
FLURESS
FLUROX
lidocaine adh. patch
LIDODERM
ORASEP
PLIAGLIS
PONTOCAINE solution
PRE-ATTACHED LTA KIT
SYNERA
XYLOCAINE jel (ml), solution
(Flurox)
(Benzocaine)
(Lidocaine HCl)
(Lidocaine)
(EMLA)
(Lidoderm)
1
1
1
1
1
3
3
3
3
3
3
3
3
3
3
3
3
3
QL: 90 in 30 days
QL: 90 in 30 days
Anti-Addiction/Substance Abuse Treatment Agents
Anti-Addiction/Substance Abuse Treatment Agents
acamprosate calcium
(Campral)
buprenorphine hcl
(Subutex)
disulfiram
(Antabuse)
naltrexone hcl
(Naltrexone HCl)
buprenorphine hcl/naloxone hcl
(Suboxone)
SUBOXONE film
ANTABUSE
BUNAVAIL
CAMPRAL
EVZIO
REVIA
SUBOXONE tab subl
ZUBSOLV
bupropion hcl
(Zyban)
1
1
1
1
2
2
3
3
3
3
3
3
3
PREV
PA
PA
PA
PA
PA
QL: 60 in 30 days
16
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
Requirements/Limits
CHANTIX tab ds pk
PREV
CHANTIX tablet
PREV
QL: 53 in 28 days
(Limit of 6 fills and 186
day supply per calendar
year)
QL: 56 in 28 days
(Limit of 6 fills and 186
day supply per calendar
year)
(Limit of 3 fills and 93
day supply per calendar
year)
QL: 30 in 30 days
(Limit of 12-week course
(93 day supply) per
calendar year)
QL: 10 in 20 days
(Limit of 3 fills and 93
day supply per calendar
year)
QL: 168 in 10 days
(Limit of 6 fills and 186
day supply per calendar
year)
QL: 1 in 28 days
(Specialty Preferred
Drug List)
nicotine polacrilex
(Nicorette)
PREV
nicotine
(Nicoderm Cq)
PREV
NICOTROL NS
PREV
NICOTROL
PREV
VIVITROL
S-T1
Antianxiety Agents
Benzodiazepines
alprazolam
chlordiazepoxide hcl
clonazepam
clorazepate dipotassium
diazepam kit
diazepam oral conc, solution, tablet
estazolam
flurazepam hcl
lorazepam oral conc, tablet
midazolam hcl
(Xanax)
(Chlordiazepoxide
HCl)
(Klonopin)
(Tranxene T-Tab)
(Diastat Acudial)
(Valium)
(Estazolam)
(Flurazepam HCl)
(Ativan)
(Midazolam HCl)
1
1
1
1
1
1
1
1
1
1
QL: 2 per fill
17
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
oxazepam
quazepam
temazepam
triazolam
DIASTAT ACUDIAL kit: 12.5-15-20
ONFI tablet: 5mg, 10mg
ONFI oral susp
ONFI tablet: 20mg
ALPRAZOLAM INTENSOL
ATIVAN tablet
DIASTAT ACUDIAL kit: 5-7.5-10mg
DIASTAT
DORAL
HALCION
KLONOPIN
LIBRITABS
NIRAVAM
RESTORIL
TRANXENE T-TAB
VALIUM tablet
XANAX XR
XANAX
Drug Tier
(Oxazepam)
(Doral)
(Restoril)
(Halcion)
1
1
1
1
2
2
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Requirements/Limits
QL: 1 per fill
PA, QL: 30 in 30 days
PA, QL: 480 in 30 days
PA, QL: 60 in 30 days
QL: 1 per fill
QL: 1 per fill
Antibacterials
Aminoglycosides
neomycin sulfate
TOBI PODHALER
(Neomycin Sulfate)
tobramycin in 0.225% nacl
(Tobi)
1
S-T1
S-T1
BETHKIS
S-T2
TOBI
S-T2
Antibacterials, Miscellaneous
clindamycin hcl
clindamycin palmitate hcl
methen/m-blue/sal/na phos/hyos
methen/sod phos/meth blue/hyos
methenam/me blue/ba/salicy/hyo
(Cleocin HCl)
(Cleocin Palmitate)
(Uta)
(Methen/Sod Phos/
Meth Blue/Hyos)
(Methenam/Me Blue/
Ba/Salicy/Hyo)
(Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
1
1
1
1
1
18
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
methenamine hippurate
methenamine mandelate
mth/me blue/sod phos/phen/hyos
nitrofurantoin macrocrystal
nitrofurantoin monohyd/m-cryst
nitrofurantoin
trimethoprim
URETRON D-S
vancomycin hcl capsule
MACRODANTIN capsule: 25mg
ZYVOX susp recon, tablet
CLEOCIN HCL
CLEOCIN PALMITATE
FURADANTIN
HIPREX
MACROBID
MACRODANTIN capsule: 50mg, 100mg
MONUROL
PHOSPHASAL
PRIMSOL
PROSED-DS
SIVEXTRO tablet
URELLE
UREX
URIBEL
URIN D.S.
UROQID-ACID NO.2
URYL
UTA
UTIRA-C
VANCOCIN HCL
XIFAXAN tablet: 550mg
XIFAXAN tablet: 200mg
colistin (colistimethate na)
Drug Tier
(Hiprex)
(Methenamine
Mandelate)
(Mth/Me Blue/Sod
Phos/Phen/Hyos)
(Macrodantin)
(Macrobid)
(Furadantin)
(Trimethoprim)
(Vancocin HCl)
(Coly-Mycin M
Parenteral)
COLY-MYCIN M PARENTERAL
Cephalosporins
cefaclor
1
1
1
1
1
1
1
1
1
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
S-T1
S-T2
(Cefaclor)
Requirements/Limits
PA, QL: 60 in 30 days
QL: 9 per fill
(Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
1
19
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
cefadroxil
cefdinir
cefditoren pivoxil
cefpodoxime proxetil
cefprozil
ceftibuten dihydrate
cefuroxime axetil
CEFUROXIME AXETIL
cephalexin monohydrate
cephalexin
CEFTIN susp recon
SUPRAX
CEDAX
CEFTIN tablet
KEFLEX
SPECTRACEF
Macrolides
azithromycin packet, susp recon, tablet
clarithromycin
ery e-succ/sulfisoxazole
erythromycin base
erythromycin ethylsuccinate susp recon:
200mg/5ml; tablet
erythromycin stearate
ERYPED 200
ERYPED 400
ERY-TAB
KETEK
BIAXIN XL
BIAXIN
DIFICID
erythromycin ethylsuccinate susp recon:
200mg/5ml
PCE
ZITHROMAX TRI-PAK
ZITHROMAX packet, susp recon, tablet
ZMAX
Drug Tier
(Cefadroxil)
(Cefdinir)
(Spectracef)
(Cefpodoxime Proxetil)
(Cefprozil)
(Cedax)
(Ceftin)
(Cephalexin
Monohydrate)
(Keflex)
(Zithromax)
(Biaxin)
(Ery E-Succ/
Sulfisoxazole)
(Erythromycin Base)
(Erythromycin
Ethylsuccinate)
(Erythromycin
Stearate)
(Eryped 200)
Requirements/Limits
1
1
1
1
1
1
1
1
1
1
2
2
3
3
3
3
1
1
1
1
1
1
2
2
2
2
3
3
3
3
QL: 60 in 30 days
3
3
3
3
20
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
Miscellaneous B-Lactam Antibiotics
CAYSTON
Penicillins
amoxicillin
amoxicillin/potassium clav
AMOXIL tab chew
ampicillin trihydrate
dicloxacillin sodium
penicillin v potassium
AUGMENTIN susp recon: 125-31.25/
AMOXIL susp recon
AUGMENTIN ES-600
AUGMENTIN XR
AUGMENTIN susp recon: 250-62.5/5;
tablet
BACTOCILL
MOXATAG
Quinolones
ciprofloxacin hcl
ciprofloxacin
ciprofloxacin/ciprofloxa hcl
levofloxacin solution, tablet
moxifloxacin hcl
nalidixic acid
ofloxacin
AVELOX ABC PACK
AVELOX
CIPRO XR
CIPRO sus mc rec
CIPRO tablet
FACTIVE
LEVAQUIN solution, tablet
MAXAQUIN
NEGGRAM
NOROXIN
Sulfonamides
sulfadiazine
sulfamethoxazole/trimethoprim oral susp,
tablet
S-T1
(Amoxicillin)
(Augmentin)
(Ampicillin Trihydrate)
(Dicloxacillin Sodium)
(Penicillin V
Potassium)
Requirements/Limits
(Specialty Preferred
Drug List)
1
1
1
1
1
1
2
3
3
3
3
3
3
(Cipro)
(Cipro)
(Cipro XR)
(Levaquin)
(Avelox)
(Nalidixic Acid)
(Ofloxacin)
1
1
1
1
1
1
1
3
3
3
3
3
3
3
3
3
3
(Sulfadiazine)
(Bactrim DS)
1
1
21
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
sulfasalazine
AZULFIDINE
BACTRIM DS
BACTRIM
SEPTRA DS
SEPTRA
Tetracyclines
demeclocycline hcl
doxycycline hyclate capsule, capsule dr,
tablet, tablet dr
doxycycline monohydrate
minocycline hcl
tetracycline hcl
OXYTETRACYCLINE HCL
TETRACYCLINE HCL
ACTICLATE
ADOXA PAK
ADOXA
ALA-TET
ALODOX
AVIDOXY DK
AVIDOXY
DORYX
DYNACIN
MINOCIN capsule
MINOCIN combo. pkg
MONODOX
MORGIDOX capsule
MORGIDOX kit
OCUDOX
ORACEA
PERIOSTAT
SOLODYN
VIBRAMYCIN capsule
VIBRAMYCIN susp recon
VIBRAMYCIN syrup
Drug Tier
(Azulfidine)
1
3
3
3
3
3
(Demeclocycline HCl)
(Vibramycin)
1
1
(Avidoxy)
(Minocin)
(Tetracycline HCl)
1
1
1
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
(Arimidex)
(Casodex)
1
1
Requirements/Limits
Anticancer Agents
Anticancer Agents
anastrozole
bicalutamide
22
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
capecitabine
(Xeloda)
1
cyclophosphamide tablet
etoposide capsule
exemestane
floxuridine
flutamide
hydroxyurea
letrozole
leuprolide acetate
(Cyclophosphamide)
(Etoposide)
(Aromasin)
(Floxuridine)
(Flutamide)
(Hydrea)
(Femara)
(Leuprolide Acetate)
1
1
1
1
1
1
1
1
lomustine
megestrol acetate
mercaptopurine
methotrexate sodium
methotrexate sodium/pf
1
1
1
1
1
temozolomide
(Ceenu)
(Megace)
(Purinethol)
(Methotrexate Sodium)
(Methotrexate Sodium/
PF)
(Temodar)
tretinoin
(Tretinoin)
1
1
AFINITOR DISPERZ
2
AFINITOR
2
AFINITOR
2
ALKERAN tablet
BOSULIF
2
2
CAPRELSA
2
COMETRIQ
2
CYCLOPHOSPHAMIDE
EMCYT
ERIVEDGE
2
2
2
FARESTON
2
Requirements/Limits
(Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
Split Fill Program;
(Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
23
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
Requirements/Limits
GILOTRIF
2
GLEEVEC
2
HEXALEN
2
HYCAMTIN capsule
2
ICLUSIG
2
IMBRUVICA
2
INLYTA
2
JAKAFI
2
PA (Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
LEUKERAN
LYNPARZA
2
2
LYSODREN
2
MATULANE
2
MEGACE ES
MEKINIST
2
2
MYLERAN
NEXAVAR
2
2
NILANDRON
2
POMALYST
2
PURIXAN
REVLIMID capsule: 10mg
2
2
REVLIMID capsule: 2.5mg, 5mg, 15mg,
20mg, 25mg
2
PA (Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
PA (Specialty Preferred
Drug List)
Split Fill Program;
(Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
ST (Specialty Preferred
Drug List)
QL: 120 in 30 days
(Specialty Preferred
Drug List)
QL: 30 in 30 days
(Specialty Preferred
Drug List)
24
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
SPRYCEL
2
STIVARGA
2
SUTENT
2
TABLOID
TAFINLAR
2
2
TARCEVA
2
TARGRETIN
2
TARGRETIN
2
TASIGNA
2
TREXALL
TYKERB
2
2
VANDETANIB
2
VOTRIENT
2
XALKORI
2
XTANDI
2
ZELBORAF
2
ZOLINZA
2
Requirements/Limits
Split Fill Program;
(Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
Split Fill Program;
(Specialty Preferred
Drug List)
PA (Specialty Preferred
Drug List)
Split Fill Program;
(Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
Split Fill Program;
(Specialty Preferred
Drug List)
Split Fill Program;
(Specialty Preferred
Drug List)
QL: 150 in 30 days
(Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
QL: 120 in 30 days Split
Fill Program; (Specialty
Preferred Drug List)
PA, QL: 60 in 30 days
(Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
PA (Specialty Preferred
Drug List)
Split Fill Program;
(Specialty Preferred
Drug List)
25
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
Requirements/Limits
ZYDELIG
2
ZYKADIA
2
ZYTIGA
2
(Specialty Preferred
Drug List)
ST (Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
ARIMIDEX
AROMASIN
CASODEX
CEENU
DROXIA
ELIGARD
FEMARA
HYDREA
LUPRON DEPOT syringekit: 45mg
MEGACE
NOLVADEX
PURINETHOL
RHEUMATREX
SOLTAMOX
TEMODAR capsule
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
XELODA
3
tamoxifen citrate
LUPRON DEPOT syringekit: 3.75mg,
7.5mg, 11.25mg, 22.5mg, 30mg
LUPRON DEPOT-PED
(Tamoxifen Citrate)
PREV
S-T1
S-T1
TORISEL
S-T1
FIRMAGON
S-T2
TRELSTAR
S-T2
Specialty Preferred Drug
List
Specialty Preferred Drug
List
(Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
PA (Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
Anticholinergic Agents
Antimuscarinics/Antispasmodics
atropine sulfate
chlordiazepoxide/clidinium br
phenobarb/hyoscy/atropine/scop
(Atropine Sulfate)
(Librax)
(Phenobarb/Hyoscy/
Atropine/Scop)
1
1
1
26
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
propantheline bromide
Drug Tier
(Propantheline
Bromide)
ATROPEN
DONNATAL
LIBRAX
PAMINE FQ
PRO-BANTHINE
Requirements/Limits
1
3
3
3
3
3
Anticonvulsants
Anticonvulsants
carbamazepine
divalproex sodium
ethosuximide
felbamate
gabapentin
lamotrigine tab ds pk
lamotrigine tab er 24: 25mg, 50mg, 100mg,
200mg
lamotrigine tab er 24: 250mg, 300mg
lamotrigine tablet, tb chw dsp
levetiracetam solution, tab er 24h, tablet
oxcarbazepine
phenobarbital
phenytoin sodium extended
phenytoin
primidone
tiagabine hcl
topiramate
valproic acid (as sodium salt) solution
valproic acid
zonisamide
BANZEL
CELONTIN
DILANTIN capsule: 30mg
LAMICTAL tb chw dsp: 2mg
POTIGA
VIMPAT solution
VIMPAT tablet
APTIOM tablet: 200mg, 400mg, 800mg
APTIOM tablet: 600mg
CARBATROL
DEPAKENE capsule
(Tegretol)
(Depakote ER)
(Zarontin)
(Felbatol)
(Neurontin)
(Lamictal (Blue))
(Lamictal XR)
1
1
1
1
1
1
1
(Lamictal XR)
(Lamictal)
(Keppra)
(Trileptal)
(Phenobarbital)
(Dilantin)
(Dilantin)
(Mysoline)
(Gabitril)
(Topamax)
(Depakene)
(Depakene)
(Zonegran)
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
3
3
3
3
QL: 35 in 365 days
QL: 30 in 30 days
QL: 60 in 30 days
QL: 60 in 30 days
QL: 30 in 30 days
QL: 60 in 30 days
27
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
DEPAKENE solution
DEPAKOTE ER
DEPAKOTE SPRINKLE
DEPAKOTE
DILANTIN-125
DILANTIN capsule: 100mg
DILANTIN tab chew
EQUETRO
FANATREX
FELBATOL
FYCOMPA tablet: 2mg
FYCOMPA tablet: 8mg, 10mg, 12mg
FYCOMPA tablet: 6mg
FYCOMPA tablet: 4mg
GABITRIL
GRALISE
HORIZANT
KEPPRA XR
KEPPRA solution, tablet
LAMICTAL (BLUE)
LAMICTAL (GREEN)
LAMICTAL (ORANGE)
LAMICTAL ODT (BLUE)
LAMICTAL ODT (GREEN)
LAMICTAL ODT (ORANGE)
LAMICTAL ODT
LAMICTAL XR (BLUE)
LAMICTAL XR (GREEN)
LAMICTAL XR (ORANGE)
LAMICTAL XR tab er 24: 25mg, 50mg,
100mg, 200mg
LAMICTAL XR tab er 24: 250mg, 300mg
LAMICTAL tablet, tb chw dsp: 5mg,
25mg
LUMINAL SODIUM
LYRICA solution
LYRICA capsule
MYSOLINE
NEURONTIN
OXTELLAR XR
PEGANONE
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Requirements/Limits
QL: 180 in 30 days
QL: 30 in 30 days
QL: 60 in 30 days
QL: 90 in 30 days
QL: 90 in 30 days
ST, QL: 60 in 30 days
QL: 35 in 365 days
QL: 98 in 365 days
QL: 49 in 365 days
QL: 30 in 30 days
QL: 35 in 23 days
QL: 30 in 30 days
QL: 35 in 23 days
QL: 35 in 23 days
QL: 30 in 30 days
QL: 60 in 30 days
QL: 90 in 30 days
28
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
PHENYTEK
QUDEXY XR
STAVZOR
TEGRETOL XR
TEGRETOL
TOPAMAX
TRILEPTAL
TROKENDI XR
ZARONTIN
ZONEGRAN
SABRIL
3
3
3
3
3
3
3
3
3
3
S-T1
Requirements/Limits
QL: 180 in 30 days
(Specialty Preferred
Drug List)
Antidementia Agents
Antidementia Agents
donepezil hcl
galantamine hbr
rivastigmine tartrate
EXELON patch td24
NAMENDA XR cap spr 24
NAMENDA XR cap24 dspk
NAMENDA solution
NAMENDA tab ds pk
NAMENDA tablet
ARICEPT ODT
ARICEPT
EXELON capsule, solution
RAZADYNE ER
RAZADYNE
(Aricept)
(Razadyne)
(Exelon)
1
1
1
2
2
2
2
2
2
3
3
3
3
3
QL: 30 in 30 days
QL: 28 in 28 days
QL: 49 in 28 days
QL: 60 in 30 days
Antidepressants
Antidepressants
amitrip hcl/chlordiazepoxide
amitriptyline hcl
amoxapine
bupropion hcl tab er 24h, tablet, tablet er:
100mg, 150mg, 200mg
citalopram hydrobromide
clomipramine hcl
desipramine hcl
desvenlafaxine
(Amitrip HCl/
Chlordiazepoxide)
(Amitriptyline HCl)
(Amoxapine)
(Wellbutrin XL)
1
(Celexa)
(Anafranil)
(Norpramin)
(Desvenlafaxine)
1
1
1
1
1
1
1
ST
29
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
doxepin hcl
duloxetine hcl
escitalopram oxalate
fluoxetine hcl
fluvoxamine maleate
imipramine hcl
imipramine pamoate
maprotiline hcl
mirtazapine
nefazodone hcl
nortriptyline hcl
olanzapine/fluoxetine hcl
paroxetine hcl
perphenazine/amitriptyline hcl
phenelzine sulfate
protriptyline hcl
sertraline hcl
tranylcypromine sulfate
trazodone hcl
trimipramine maleate
venlafaxine hcl
BRINTELLIX
FETZIMA
VIIBRYD
ANAFRANIL
APLENZIN
BRISDELLE
CELEXA
CYMBALTA
DESVENLAFAXINE ER tab er 24h:
100mg
DESVENLAFAXINE ER tab er 24h:
50mg
DESVENLAFAXINE FUMARATE ER
tab er 24: 100mg
DESVENLAFAXINE FUMARATE ER
tab er 24: 50mg
EFFEXOR XR
EMSAM
Drug Tier
(Doxepin HCl)
(Cymbalta)
(Lexapro)
(Prozac)
(Fluvoxamine Maleate)
(Tofranil)
(Tofranil-Pm)
(Maprotiline HCl)
(Remeron)
(Nefazodone HCl)
(Pamelor)
(Symbyax)
(Paxil)
(Perphenazine/
Amitriptyline HCl)
(Nardil)
(Vivactil)
(Zoloft)
(Parnate)
(Trazodone HCl)
(Trimipramine
Maleate)
(Effexor XR)
Requirements/Limits
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
3
3
3
3
3
3
ST
ST
ST
ST, QL: 120 in 30 days
3
ST, QL: 60 in 30 days
3
ST, QL: 120 in 30 days
3
ST, QL: 60 in 30 days
3
3
QL: 30 in 30 days
30
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
FORFIVO XL
KHEDEZLA
LEXAPRO
LUVOX CR
MARPLAN
NARDIL
NORPRAMIN
OLEPTRO ER
PAMELOR
PARNATE
PAXIL CR
PAXIL
PEXEVA
PRISTIQ ER tab er 24h: 100mg
PRISTIQ ER tab er 24h: 50mg
PROZAC WEEKLY
PROZAC
REMERON
SARAFEM
SILENOR
SURMONTIL
SYMBYAX
TOFRANIL
TOFRANIL-PM
VENLAFAXINE HCL ER
VIVACTIL
WELLBUTRIN SR
WELLBUTRIN XL
WELLBUTRIN
ZOLOFT
bupropion hcl tablet er: 150mg
Drug Tier
(Wellbutrin SR)
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
PREV
Requirements/Limits
ST, QL: 120 in 30 days
ST, QL: 60 in 30 days
QL: 60 in 30 days
Antidiabetic Agents
Antidiabetic Agents, Miscellaneous
acarbose
(Precose)
metformin hcl
(Glucophage)
nateglinide
(Starlix)
pioglitazone hcl
(Actos)
pioglitazone hcl/glimepiride
(Duetact)
pioglitazone hcl/metformin hcl
(Actoplus Met)
repaglinide
(Prandin)
AVANDAMET
1
1
1
1
1
1
1
2
QL: 30 in 30 days
31
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
AVANDIA tablet: 8mg
AVANDIA tablet: 2mg, 4mg
BYDUREON PEN
BYDUREON
BYETTA
CYCLOSET
GLYSET
INVOKAMET
INVOKANA
JENTADUETO
RIOMET
SYMLIN
SYMLINPEN 120
SYMLINPEN 60
TRADJENTA
ACTOPLUS MET XR
ACTOPLUS MET
ACTOS
AVANDARYL
DUETACT
FARXIGA
FORTAMET
GLUCOPHAGE XR
GLUCOPHAGE
GLUMETZA
JANUMET XR
JANUMET
JANUVIA
JARDIANCE
JUVISYNC
KAZANO
KOMBIGLYZE XR
NESINA
ONGLYZA
OSENI
PRANDIMET
PRANDIN
PRECOSE
STARLIX
TANZEUM
TRULICITY
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Requirements/Limits
QL: 30 in 30 days
QL: 60 in 30 days
QL: 30 in 30 days
ST
ST
ST
ST
ST
ST
ST
ST
ST
ST
32
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
VICTOZA 3-PAK
XIGDUO XR
KORLYM
Insulins
HUMALOG MIX 50-50
HUMALOG MIX 75-25
HUMALOG
HUMULIN 70/30 KWIKPEN
HUMULIN 70-30
HUMULIN N KWIKPEN
HUMULIN N
HUMULIN R
LANTUS SOLOSTAR
LANTUS
NOVOLIN 70-30
NOVOLIN N
NOVOLIN R
NOVOLOG FLEXPEN
NOVOLOG MIX 70-30 FLEXPEN
NOVOLOG MIX 70-30
NOVOLOG
AFREZZA
APIDRA SOLOSTAR
APIDRA
LEVEMIR FLEXTOUCH
LEVEMIR
Sulfonylureas
chlorpropamide
glimepiride
glipizide
glipizide/metformin hcl
glyburide
glyburide,micronized
glyburide/metformin hcl
tolazamide
tolbutamide
AMARYL
DIABETA
GLUCOTROL XL
3
3
S-T2
Requirements/Limits
ST
PA (Specialty Preferred
Drug List)
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
3
3
3
3
3
(Chlorpropamide)
(Amaryl)
(Glucotrol)
(Glipizide/Metformin
HCl)
(Glyburide)
(Glynase)
(Glucovance)
(Tolazamide)
(Tolbutamide)
1
1
1
1
1
1
1
1
1
3
3
3
33
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
GLUCOTROL
GLUCOVANCE
GLYNASE
Requirements/Limits
3
3
3
Antifungals
Antifungals
ciclopirox olamine
ciclopirox
ciclopirox/ure/camph/menth/euc
clotrimazole
clotrimazole/betamethasone dip
econazole nitrate
fluconazole
flucytosine
griseofulvin ultramicrosize
griseofulvin, microsize
itraconazole
ketoconazole
miconazole nitrate
nystatin
nystatin/triamcin
NYSTATIN
terbinafine hcl
triacetin
voriconazole tablet: 50mg
voriconazole susp recon
voriconazole tablet: 200mg
KETODAN combo. pkg
NOXAFIL oral susp
SPORANOX solution
ALA-QUIN
ANCOBON
CICLODAN combo. pkg
CICLODAN cream (g)
CICLODAN solution: 8%
CICLODAN solution: 8%
CNL 8
DIFLUCAN
ECOZA
ERTACZO
EXELDERM
(Ciclodan)
(Penlac)
(Ciclodan)
(Clotrimazole)
(Lotrisone)
(Econazole Nitrate)
(Diflucan)
(Ancobon)
(Gris-Peg)
(Griseofulvin,
Microsize)
(Sporanox)
(Ketoconazole)
(Monistat 3)
(Nystatin)
(Nystatin/Triamcin)
(Lamisil)
(Triacetin)
(Vfend)
(Vfend)
(Vfend)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
3
3
3
3
3
3
3
3
3
3
3
PA
QL: 180 in 30 days
QL: 375 in 30 days
QL: 60 in 30 days
PA
34
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
EXTINA
FIRST-BXN
FIRST-DUKE'S
FIRST-MARY'S
FULVICIN U/F
FUNGOID AND HC
GRIFULVIN V
GRIS-PEG
JUBLIA
KERYDIN
KETODAN foam
KURIC
LAMISIL
LOPROX
LOTRIMIN
LOTRISONE
LUZU
MENTAX
MONISTAT-DERM
MYCELEX
NAFTIN
NIZORAL
NOXAFIL tablet dr
ONMEL
ORAVIG
OXISTAT
PEDIADERM AF
PEDIPIROX-4
PENLAC
SPORANOX capsule
TERBINEX
VFEND
VUSION
XOLEGEL
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Requirements/Limits
PA
PA
PA
Antihistamines
Antihistamines
carbinoxamine maleate
cetirizine hcl solution: 1mg/ml
chlorpheniramine maleate
(Palgic)
(Cetirizine HCl)
1
1
(Chlorpheniramine
Maleate)
1
(See NSA Coverage
Limitation)
35
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
clemastine fumarate
cyproheptadine hcl
desloratadine
(Clemastine Fumarate)
(Cyproheptadine HCl)
(Clarinex)
1
1
1
dexchlorpheniramine maleate
(Dexchlorpheniramine
Maleate)
(Diphenhydramine
HCl)
(Doxylamine
Succinate)
(Allegra)
1
(Allegra-D 12 Hour)
1
(Xyzal)
1
levocetirizine dihydrochloride tablet
(Xyzal)
1
p-epd tan/chlor-tan
p-ephed hcl/chlor-mal/bell alk
(P-Epd Tan/Chlor-Tan)
(P-Ephed HCl/ChlorMal/Bell Alk)
(Phenylephrine HCl/
Prometh HCl)
(Phenylephrine/
Brompheniramin)
(Tussanil)
1
1
(Phenylephrine/
Pyrilamine Ma/Cp)
(Promethazine HCl)
(Tripelennamine HCl)
1
diphenhydramine hcl capsule: 50mg; elixir
doxylamine succinate liquid
fexofenadine hcl tablet: 30mg, 60mg,
180mg
fexofenadine/pseudoephedrine tab er 12h:
60mg-120mg; tab er 24h
levocetirizine dihydrochloride solution
phenylephrine hcl/prometh hcl
phenylephrine/brompheniramin
phenylephrine/chlorpheniramine drops:
2mg-1mg/ml; liquid: 10-4mg/5ml
phenylephrine/pyrilamine ma/cp
promethazine hcl
tripelennamine hcl
ALLEGRA ODT
Requirements/Limits
(See NSA Coverage
Limitation)
1
1
1
(See NSA Coverage
Limitation)
(See NSA Coverage
Limitation)
(See NSA Coverage
Limitation)
QL: 30 in 30 days (See
NSA Coverage
Limitation)
1
1
1
1
1
3
ALLEGRA
3
ALLEGRA-D 12 HOUR tab er 12h:
60mg-120mg
ALLEGRA-D 24 HOUR tab er 24h: 180240mg
BROVEX SR
3
3
(See NSA Coverage
Limitation)
(See NSA Coverage
Limitation)
(See NSA Coverage
Limitation)
(See NSA Coverage
Limitation)
3
36
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
cetirizine hcl/pseudoephedrine
Drug Tier
(Zyrtec-D)
3
CLARINEX syrup, tab rapdis: 2.5mg;
tablet
CLARINEX-D 12 HOUR
3
CLARINEX-D 24 HOUR
3
CLARINEX tab rapdis: 5mg
3
CODIMAL-A
DICOPANOL
KARBINAL ER
PALGIC
POLY HIST DHC
PROTID
PYRIL D
RICOBID
RICOBID-H
SEMPREX-D
SLOFED 60
STAHIST
XYZAL solution
3
3
3
3
3
3
3
3
3
3
3
3
3
XYZAL tablet
3
ZYRTEC-D
3
3
Requirements/Limits
(See NSA Coverage
Limitation)
(See NSA Coverage
Limitation)
(See NSA Coverage
Limitation)
(See NSA Coverage
Limitation)
QL: 4 in 28 days (See
NSA Coverage
Limitation)
(See NSA Coverage
Limitation)
QL: 30 in 30 days (See
NSA Coverage
Limitation)
(See NSA Coverage
Limitation)
Anti-infectives (Skin and Mucous Membrane)
Anti-infectives (Skin and Mucous Membrane)
clindamycin phosphate
(Cleocin)
metronidazole
(Metrogel-Vaginal)
sod propion/inositol/aa14/urea
(Sod Propion/Inositol/
Aa14/Urea)
terconazole
(Terazol 7)
CLEOCIN supp.vag
VANDAZOLE
AVC
CLEOCIN cream/appl
1
1
1
1
2
2
3
3
37
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
CLINDESSE
FEM PH
GYNAZOLE 1
METROGEL-VAGINAL
RELAGARD
TERAZOL 3
TERAZOL 7
Requirements/Limits
3
3
3
3
3
3
3
Antimigraine Agents
Antimigraine Agents
dihydroergotamine mesylate ampul
dihydroergotamine mesylate spray/pump
ergotamine tartrate/caffeine
isomethept/dichlphn/acetaminop
isomethepten/caf/acetaminophen
MIGERGOT
naratriptan hcl
rizatriptan benzoate
sumatriptan succinate tablet
sumatriptan succinate cartridge: 6mg/0.5ml
sumatriptan succinate cartridge: 4mg/
0.5ml; syringe, vial
sumatriptan
zolmitriptan
ALSUMA
AMERGE
AXERT
CAFERGOT
D.H.E.45
ERGOMAR
FROVA
IMITREX spray
IMITREX tablet
IMITREX cartridge, pen injctr
IMITREX vial
MAXALT MLT
MAXALT
MIGRANAL
PRODRIN
(D.H.E.45)
(Migranal)
(Ergotamine Tartrate/
Caffeine)
(Isomethept/Dichlphn/
Acetaminop)
(Isomethepten/Caf/
Acetaminophen)
(Amerge)
(Maxalt)
(Imitrex)
(Imitrex)
(Imitrex)
(Imitrex)
(Zomig)
1
1
1
QL: 4 in 1 days
QL: 24 in 31 days
1
1
1
1
1
1
1
1
1
1
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
QL: 18 in 30 days
QL: 18 in 30 days
QL: 18 in 30 days
QL: 3 in 30 days
QL: 6 in 30 days
QL: 12 in 30 days
QL: 12 in 30 days
QL: 3 in 30 days
QL: 18 in 30 days
QL: 12 in 30 days
QL: 18 in 30 days
QL: 12 in 30 days
QL: 18 in 30 days
QL: 3 in 30 days
QL: 6 in 30 days
QL: 18 in 30 days
QL: 18 in 30 days
QL: 24 in 31 days
38
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
RELPAX
SUMAVEL DOSEPRO
TREXIMET
ZOMIG ZMT
ZOMIG
3
3
3
3
3
Requirements/Limits
QL: 12 in 30 days
QL: 3 in 30 days
QL: 18 in 30 days
QL: 12 in 30 days
QL: 12 in 30 days
Antimycobacterials
Antimycobacterials
cycloserine
dapsone
ethambutol hcl
isoniazid solution, tablet
pyrazinamide
rifabutin
rifampin capsule
rifampin/isoniazid
PRIFTIN
RIFATER
MYAMBUTOL
MYCOBUTIN
PASER
RIFADIN capsule
RIFAMATE
RIMACTANE
SEROMYCIN
SIRTURO
TRECATOR
(Seromycin)
(Dapsone)
(Myambutol)
(Isoniazid)
(Pyrazinamide)
(Mycobutin)
(Rifadin)
(Rifampin/Isoniazid)
1
1
1
1
1
1
1
1
2
2
3
3
3
3
3
3
3
3
3
PA
Antinausea Agents
Antinausea Agents
dronabinol
granisetron hcl tablet
granisetron hcl solution
meclizine hcl tablet: 12.5mg, 25mg
ondansetron hcl
ondansetron
prochlorperazine maleate
promethazine hcl supp.rect, tablet
scopolamine hydrobromide
trimethobenzamide hcl
EMEND capsule: 125mg
(Marinol)
(Granisetron HCl)
(Granisetron HCl)
(Meclizine HCl)
(Zofran)
(Zofran Odt)
(Prochlorperazine
Maleate)
(Promethazine HCl)
(Scopolamine
Hydrobromide)
(Tigan)
1
1
1
1
1
1
1
PA, QL: 60 in 30 days
QL: 2 per fill
QL: 30 per fill
1
1
1
2
QL: 2 in 28 days
39
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
EMEND capsule: 80mg
EMEND capsule: 40mg
EMEND cap ds pk
AKYNZEO
ANTIVERT
ANZEMET tablet
CESAMET
COMPAZINE supp.rect, tablet
COMPAZINE syrup
DICLEGIS
MARINOL
PHENERGAN supp.rect
SANCUSO
TIGAN capsule
TRANSDERM-SCOP
ZOFRAN ODT
ZOFRAN solution, tablet
ZUPLENZ
2
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Requirements/Limits
QL: 4 in 28 days
QL: 5 per fill
QL: 6 in 28 days
QL: 1 per fill
PA, QL: 120 in 30 days
PA, QL: 60 in 30 days
Antiparasite Agents
Antiparasite Agents
atovaquone
atovaquone/proguanil hcl
chloroquine phosphate
hydroxychloroquine sulfate
ivermectin
mebendazole
mefloquine hcl
metronidazole
paromomycin sulfate
quinine sulfate
tinidazole
ALBENZA
ALINIA
DARAPRIM
FLAGYL ER
HALFAN
METRONIDAZOLE BENZOATE
NEBUPENT
PRIMAQUINE
YODOXIN
(Mepron)
(Malarone)
(Chloroquine
Phosphate)
(Plaquenil)
(Stromectol)
(Mebendazole)
(Mefloquine HCl)
(Flagyl)
(Paromomycin Sulfate)
(Qualaquin)
(Tindamax)
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
40
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
ARALEN PHOSPHATE
BILTRICIDE
COARTEM
FLAGYL
MALARONE
MEPRON
PLAQUENIL
QUALAQUIN
STROMECTOL
TINDAMAX
Requirements/Limits
3
3
3
3
3
3
3
3
3
3
Antiparkinsonian Agents
Antiparkinsonian Agents
amantadine hcl
benztropine mesylate tablet
bromocriptine mesylate
cabergoline
carbidopa
carbidopa/levodopa
carbidopa/levodopa/entacapone
entacapone
pramipexole di-hcl
ropinirole hcl tab er 24h
ropinirole hcl tablet
selegiline hcl
trihexyphenidyl hcl
AZILECT
NEUPRO patch td24: 1mg/24hr
NEUPRO patch td24: 2mg/24hr, 3mg/
24hr, 4mg/24hr, 6mg/24hr, 8mg/24hr
COMTAN
ELDEPRYL
LODOSYN
MIRAPEX ER
MIRAPEX
PARCOPA
PARLODEL
REQUIP XL
REQUIP
SINEMET 10-100
SINEMET 25-100
(Amantadine HCl)
(Benztropine Mesylate)
(Bromocriptine
Mesylate)
(Cabergoline)
(Lodosyn)
(Sinemet 25-100)
(Stalevo 200)
(Comtan)
(Mirapex)
(Requip XL)
(Requip)
(Eldepryl)
(Trihexyphenidyl HCl)
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
3
3
3
3
3
3
3
3
3
3
3
QL: 30 in 30 days
QL: 30 in 30 days
QL: 30 in 30 days
41
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
SINEMET 25-250
SINEMET CR
STALEVO 100
STALEVO 125
STALEVO 150
STALEVO 200
STALEVO 50
STALEVO 75
TASMAR
ZELAPAR
APOKYN
3
3
3
3
3
3
3
3
3
3
S-T1
Requirements/Limits
PA (Specialty Preferred
Drug List)
Antipsychotic Agents
Antipsychotic Agents
chlorpromazine hcl oral conc., tablet
clozapine
fluphenazine decanoate
fluphenazine hcl
haloperidol decanoate
haloperidol lactate oral conc
haloperidol
loxapine succinate
olanzapine vial
olanzapine tab rapdis: 10mg; tablet: 10mg
olanzapine tab rapdis: 5mg; tablet: 2.5mg,
5mg
olanzapine tab rapdis: 15mg, 20mg; tablet:
7.5mg, 15mg, 20mg
perphenazine
quetiapine fumarate
risperidone tab rapdis: 4mg
risperidone tab rapdis: 3mg
risperidone tab rapdis: 2mg
risperidone tab rapdis: 0.5mg, 1mg
risperidone solution, tab rapdis: 0.25mg
risperidone tablet: 4mg
risperidone tablet: 3mg
risperidone tablet: 2mg
risperidone tablet: 0.25mg, 0.5mg, 1mg
(Chlorpromazine HCl)
(Clozaril)
(Fluphenazine
Decanoate)
(Fluphenazine HCl)
(Haloperidol
Decanoate)
(Haloperidol Lactate)
(Haloperidol)
(Loxitane)
(Zyprexa)
(Zyprexa)
(Zyprexa)
1
1
1
1
1
1
1
1
1
QL: 120 in 30 days
QL: 30 in 30 days
(Zyprexa)
1
QL: 60 in 30 days
(Perphenazine)
(Seroquel)
(Risperdal M-Tab)
(Risperdal M-Tab)
(Risperdal M-Tab)
(Risperdal M-Tab)
(Risperdal)
(Risperdal)
(Risperdal)
(Risperdal)
(Risperdal)
1
1
1
1
1
1
1
1
1
1
1
1
1
QL: 112 in 28 days
QL: 140 in 28 days
QL: 56 in 28 days
QL: 84 in 28 days
QL: 120 in 30 days
QL: 150 in 30 days
QL: 60 in 30 days
QL: 90 in 30 days
42
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
thioridazine hcl
thiothixene
trifluoperazine hcl
ziprasidone hcl capsule: 20mg, 40mg,
60mg
ziprasidone hcl capsule: 80mg
ABILIFY DISCMELT
ABILIFY MAINTENA
ABILIFY solution, vial
ABILIFY tablet: 2mg, 5mg, 10mg, 15mg
ABILIFY tablet: 20mg, 30mg
GEODON vial
LATUDA
MOBAN
ORAP
RISPERDAL CONSTA
SEROQUEL XR tab er 24h: 150mg,
200mg
SEROQUEL XR tab er 24h: 50mg
SEROQUEL XR tab er 24h: 300mg,
400mg
CLOZARIL
FANAPT
FAZACLO
GEODON capsule: 20mg, 40mg, 60mg
GEODON capsule: 80mg
HALDOL DECANOATE 100
HALDOL DECANOATE 50
INVEGA SUSTENNA
INVEGA tab er 24: 1.5mg, 3mg, 9mg
INVEGA tab er 24: 6mg
LOXITANE
NAVANE
RISPERDAL M-TAB tab rapdis: 4mg
RISPERDAL M-TAB tab rapdis: 3mg
RISPERDAL M-TAB tab rapdis: 2mg
RISPERDAL M-TAB tab rapdis: 0.5mg,
1mg
RISPERDAL solution
RISPERDAL tablet: 4mg
RISPERDAL tablet: 3mg
Drug Tier
Requirements/Limits
(Thioridazine HCl)
(Navane)
(Trifluoperazine HCl)
(Geodon)
1
1
1
1
(Geodon)
1
2
2
2
2
2
2
2
2
2
2
2
QL: 90 in 30 days
QL: 30 in 30 days
2
2
QL: 60 in 30 days
QL: 90 in 30 days
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
QL: 60 in 30 days
QL: 30 in 30 days
QL: 60 in 30 days
QL: 30 in 30 days
QL: 30 in 30 days
QL: 60 in 30 days
QL: 90 in 30 days
QL: 30 in 30 days
QL: 60 in 30 days
QL: 112 in 28 days
QL: 140 in 28 days
QL: 56 in 28 days
QL: 84 in 28 days
QL: 120 in 30 days
QL: 150 in 30 days
43
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
RISPERDAL tablet: 2mg
RISPERDAL tablet: 0.25mg, 0.5mg, 1mg
SAPHRIS
SEROQUEL
VERSACLOZ
ZYPREXA RELPREVV
ZYPREXA ZYDIS tab rapdis: 10mg
ZYPREXA ZYDIS tab rapdis: 5mg
ZYPREXA ZYDIS tab rapdis: 15mg,
20mg
ZYPREXA vial
ZYPREXA tablet: 10mg
ZYPREXA tablet: 2.5mg, 5mg
ZYPREXA tablet: 7.5mg, 15mg, 20mg
3
3
3
3
3
3
3
3
3
3
3
3
3
Requirements/Limits
QL: 60 in 30 days
QL: 90 in 30 days
QL: 60 in 30 days
QL: 120 in 30 days
QL: 30 in 30 days
QL: 60 in 30 days
QL: 120 in 30 days
QL: 30 in 30 days
QL: 60 in 30 days
Antivirals (Systemic)
Antiretrovirals
abacavir sulfate
abacavir/lamivudine/zidovudine
didanosine
lamivudine solution, tablet: 150mg, 300mg
lamivudine/zidovudine
nevirapine
stavudine
zidovudine
APTIVUS capsule
APTIVUS solution
ATRIPLA
COMPLERA
CRIXIVAN
EDURANT
EMTRIVA
EPZICOM
INTELENCE
INVIRASE
ISENTRESS
KALETRA
LEXIVA
NORVIR
PREZISTA
RESCRIPTOR
REYATAZ
(Ziagen)
(Trizivir)
(Videx EC)
(Epivir Hbv)
(Combivir)
(Viramune)
(Zerit)
(Retrovir)
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
QL: 30 in 30 days
44
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
SELZENTRY
STRIBILD
SUSTIVA
TIVICAY
TRIUMEQ
TRUVADA
VIRACEPT
VIRAMUNE XR tab er 24h: 100mg
VIREAD
ZIAGEN solution
COMBIVIR
EPIVIR
RETROVIR capsule, syrup, tablet
TRIZIVIR
VIDEX EC
VIDEX
VIRAMUNE XR tab er 24h: 400mg
VIRAMUNE
ZERIT
ZIAGEN tablet
FUZEON
lamivudine tablet: 100mg
2
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
S-T1
(Epivir Hbv)
EPIVIR HBV
Antivirals, Miscellaneous
rimantadine hcl
RELENZA
TAMIFLU
FLUMADINE
HCV Antivirals
INCIVEK
S-T1
S-T2
(Rimantadine HCl)
1
2
2
3
S-T1
OLYSIO
S-T1
SOVALDI
S-T1
HARVONI
S-T2
Requirements/Limits
PA (Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
QL: 20 in 30 days
PA (Specialty Preferred
Drug List)
PA (Specialty Preferred
Drug List)
PA (Specialty Preferred
Drug List)
PA (Specialty Preferred
Drug List)
45
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
Requirements/Limits
VICTRELIS
S-T2
VIEKIRA PAK
S-T2
PA (Specialty Preferred
Drug List)
PA (Specialty Preferred
Drug List)
Interferons
INFERGEN
S-T1
INTRON A
S-T1
PEGASYS PROCLICK
S-T1
PEGASYS
S-T1
PEGINTRON REDIPEN
S-T1
PEGINTRON
S-T1
SYLATRON
S-T1
ALFERON N
S-T2
Nucleosides And Nucleotides
acyclovir
famciclovir
valacyclovir hcl tablet: 1000mg
valacyclovir hcl tablet: 500mg
valganciclovir hcl
VALCYTE soln recon
FAMVIR
SITAVIG
VALCYTE tablet
VALTREX tablet: 1000mg
VALTREX tablet: 500mg
ZOVIRAX
adefovir dipivoxil
(Zovirax)
(Famvir)
(Valtrex)
(Valtrex)
(Valcyte)
(Hepsera)
BARACLUDE solution
entecavir
1
1
1
1
1
2
3
3
3
3
3
3
S-T1
S-T1
(Baraclude)
S-T1
(Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
PA (Specialty Preferred
Drug List)
PA (Specialty Preferred
Drug List)
PA (Specialty Preferred
Drug List)
PA (Specialty Preferred
Drug List)
PA (Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
QL: 90 in 30 days
QL: 90 in 30 days
QL: 90 in 30 days
QL: 90 in 30 days
(Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
46
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
REBETOL solution
ribavirin
S-T1
(Ribasphere)
S-T1
BARACLUDE tablet
S-T2
COPEGUS
S-T2
HEPSERA
S-T2
MODERIBA
S-T2
REBETOL capsule
S-T2
RIBATAB
S-T2
TYZEKA
S-T2
VIRAZOLE
S-T2
Requirements/Limits
(Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
Blood Products/Modifiers/Volume Expanders
Anticoagulants
enoxaparin sodium
fondaparinux sodium
heparin sodium,porcine vial: 5000/ml,
10000/ml, 20000/ml
heparin sodium,porcine/pf syringe: 5000/
0.5ml; vial
warfarin sodium
FRAGMIN
PRADAXA
XARELTO
ARIXTRA
COUMADIN tablet
ELIQUIS
IPRIVASK
LOVENOX
Blood Formation Modifiers
ARANESP
(Lovenox)
(Arixtra)
(Heparin
Sodium,Porcine)
(Monoject Prefill
Advanced)
(Coumadin)
1
1
1
1
1
2
2
2
3
3
3
3
3
S-T1
QL: 60 in 30 days
PA (Specialty Preferred
Drug List)
47
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
Requirements/Limits
CINRYZE
S-T1
EPOGEN
S-T1
GRANIX
S-T1
LEUKINE
S-T1
NEULASTA
S-T1
NEUMEGA
S-T1
NEUPOGEN
S-T1
PROCRIT
S-T1
PROMACTA
S-T1
PA (Specialty Preferred
Drug List)
PA (Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
PA (Specialty Preferred
Drug List)
PA (Specialty Preferred
Drug List)
Hematologic Agents, Miscellaneous
aminocaproic acid solution, tablet
(Amicar)
anagrelide hcl
(Agrylin)
thrombin (bovine) spray, vial
(Thrombin (Bovine))
tranexamic acid tablet
(Lysteda)
AGRYLIN
LYSTEDA
Platelet-Aggregation Inhibitors
cilostazol
(Pletal)
clopidogrel bisulfate tablet: 75mg
(Plavix)
clopidogrel bisulfate tablet: 300mg
(Plavix)
dipyridamole
(Persantine)
pentoxifylline
(Pentoxifylline)
ticlopidine hcl
(Ticlopidine HCl)
EFFIENT
AGGRENOX
BRILINTA
PERSANTINE
PLAVIX tablet: 75mg
PLAVIX tablet: 300mg
PLETAL
TRENTAL
ZONTIVITY
1
1
1
1
3
3
1
1
1
1
1
1
2
3
3
3
3
3
3
3
3
QL: 2 per fill
QL: 30 in 30 days
QL: 60 in 30 days
QL: 2 per fill
48
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
Requirements/Limits
Caloric Agents
Caloric Agents
nut. tx for pku with iron #10
nut. tx for pku with iron #27
nut. tx for pku with iron #6
nut. tx for pku, #8
nutritional tx for pku #31
PKU 2
PKU 3
PKU COOLER 15
PKU COOLER 20
PKU EXPRESS15
ADD-INS
CAMINO PRO 15 oral susp: 0.11g-1.06
CAMINO PRO 15 oral susp: 0.11g-1.06
CAMINO PRO BETTERMILK powd
pack: 15g-190/50
CAMINO PRO BETTERMILK powd
pack: 27g-375
CAMINO PRO RESTORE LITE
CAMINO-PRO RESTORE liquid: 2g-34/
100
CAMINO-PRO RESTORE liquid: 2g-36/
100
dextrose
EAA
GLYTACTIN 10 PE BETTERMILK
GLYTACTIN 15 PE BETTERMILK
GLYTACTIN RESTORE 10 PE LITE
GLYTACTIN RESTORE 10 PE
GLYTACTIN RTD 10 PE
GLYTACTIN RTD 15 PE
LANAFLEX
LOPHLEX
PERIFLEX ADVANCE
PERIFLEX INFANT
PERIFLEX JUNIOR
(Nut. Tx For Pku with
Iron #10)
(Nut. Tx For Pku with
Iron #27)
(Nut. Tx For Pku with
Iron #6)
(Nut. Tx For Pku, #8)
(Nutritional Tx For Pku
#31)
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
(Dextrose)
2
2
2
2
2
2
2
2
2
2
2
2
2
49
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
PERIFLEX LQ PKU
PHENEX-1
PHENEX-2
PHENYLADE AMINO ACID bar: 10g270
PHENYLADE AMINO ACID bar: 10g270
PHENYLADE ESSENTIAL
PHENYLADE PHEBLOC powd pack
PHENYLADE PHEBLOC tablet
PHENYLADE RTD PKU 10
PHENYLADE60
PHENYL-FREE 2
PHENYL-FREE 2HP
PHLEXY-10
PKU COOLER 10
PKU EASY
PKU EXPRESS20
PKU GEL
PKU LOPHLEX liquid pkt: 20-115/125
PKU LOPHLEX liquid pkt: 20-116/125
PKU PERIFLEX JUNIOR PLUS
PKU TRIO
XPHE MAXAMAID
XPHE MAXAMUM
Requirements/Limits
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
3
3
Cardiovascular Agents
Alpha-Adrenergic Agents
clonidine hcl
clonidine hcl/chlorthalidone
clonidine
doxazosin mesylate
guanabenz acetate
guanfacine hcl
methyldopa
methyldopa/hydrochlorothiazide
midodrine hcl
prazosin hcl
PROAMATINE tablet: 5mg
ALDOMET
(Catapres)
(Clonidine HCl/
Chlorthalidone)
(Catapres-Tts 3)
(Cardura)
(Guanabenz Acetate)
(Tenex)
(Methyldopa)
(Methyldopa/
Hydrochlorothiazide)
(Midodrine HCl)
(Minipress)
1
1
1
1
1
1
1
1
QL: 4 in 28 days
1
1
1
3
50
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
ALDORIL-D50
CARDURA XL
CARDURA
CATAPRES
CATAPRES-TTS 1
CATAPRES-TTS 2
CATAPRES-TTS 3
DIBENZYLINE
MINIPRESS
NORTHERA
PROAMATINE tablet: 2.5mg, 10mg
TENEX
Angiotensin II Receptor Antagonists
candesartan cilexetil
(Atacand)
candesartan/hydrochlorothiazid
(Atacand HCT)
eprosartan mesylate
(Teveten)
irbesartan
(Avapro)
irbesartan/hydrochlorothiazide
(Avalide)
losartan potassium
(Cozaar)
losartan/hydrochlorothiazide
(Hyzaar)
telmisartan
(Micardis)
telmisartan/amlodipine
(Twynsta)
telmisartan/hydrochlorothiazid
(Micardis HCT)
valsartan
(Diovan)
valsartan/hydrochlorothiazide
(Diovan HCT)
ATACAND HCT
ATACAND
AVALIDE
AVAPRO
BENICAR HCT
BENICAR
COZAAR
DIOVAN HCT
DIOVAN
EDARBI
EDARBYCLOR
HYZAAR
MICARDIS HCT
MICARDIS
TEVETEN HCT
TEVETEN tablet: 600mg
3
3
3
3
3
3
3
3
3
3
3
3
Requirements/Limits
QL: 4 in 28 days
QL: 4 in 28 days
QL: 4 in 28 days
1
1
1
1
1
1
1
1
1
1
1
1
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
51
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
TRIBENZOR
TWYNSTA
Angiotensin-Converting Enzyme Inhibitors
benazepril hcl
(Lotensin)
benazepril/hydrochlorothiazide
(Lotensin HCT)
captopril
(Captopril)
captopril/hydrochlorothiazide
(Captopril/
Hydrochlorothiazide)
enalapril maleate
(Vasotec)
enalapril/hydrochlorothiazide
(Vaseretic)
fosinopril sodium
(Fosinopril Sodium)
fosinopril/hydrochlorothiazide
(Fosinopril/
Hydrochlorothiazide)
lisinopril
(Zestril)
lisinopril/hydrochlorothiazide
(Zestoretic)
moexipril hcl
(Univasc)
moexipril/hydrochlorothiazide
(Uniretic)
perindopril erbumine
(Aceon)
quinapril hcl
(Accupril)
quinapril/hydrochlorothiazide
(Accuretic)
ramipril
(Altace)
trandolapril
(Mavik)
ACCUPRIL
ACCURETIC
ACEON
ALTACE
CAPOTEN
EPANED
LOTENSIN HCT
LOTENSIN
MAVIK
PRINIVIL
PRINZIDE
TARKA
UNIRETIC
UNIVASC
VASERETIC
VASOTEC
ZESTORETIC
ZESTRIL
Requirements/Limits
3
3
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
52
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Antiarrhythmic Agents
amiodarone hcl tablet
disopyramide phosphate
flecainide acetate
mexiletine hcl
procainamide hcl capsule, tablet sa
propafenone hcl
quinidine gluconate tablet er
quinidine sulfate
MULTAQ
TIKOSYN
CORDARONE
NORPACE CR
NORPACE
PRONESTYL
RYTHMOL SR
RYTHMOL
TAMBOCOR
Beta-Adrenergic Blocking Agents
acebutolol hcl
atenolol
atenolol/chlorthalidone
betaxolol hcl
bisoprolol fumarate
bisoprolol fumarate/hctz
carvedilol
labetalol hcl tablet
metoprolol succinate
metoprolol tartrate tablet
metoprolol/hydrochlorothiazide
nadolol
nadolol/bendroflumethiazide
pindolol
propranolol hcl cap sa 24h, solution, tablet
propranolol/hydrochlorothiazid
sotalol hcl
timolol maleate
BETAPACE AF
BETAPACE
BYSTOLIC
Drug Tier
(Cordarone)
(Norpace)
(Tambocor)
(Mexiletine HCl)
(Procainamide HCl)
(Rythmol)
(Quinidine Gluconate)
(Quinidine Sulfate)
1
1
1
1
1
1
1
1
2
2
3
3
3
3
3
3
3
(Sectral)
(Tenormin)
(Tenoretic 50)
(Kerlone)
(Zebeta)
(Ziac)
(Coreg)
(Trandate)
(Toprol XL)
(Lopressor)
(Lopressor HCT)
(Corgard)
(Corzide)
(Pindolol)
(Propranolol HCl)
(Propranolol/
Hydrochlorothiazid)
(Betapace AF)
(Timolol Maleate)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Requirements/Limits
1
1
3
3
3
53
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
COREG CR
COREG
CORGARD
CORZIDE
DUTOPROL
HEMANGEOL
INDERAL LA
INNOPRAN XL
KERLONE
LEVATOL
LOPRESSOR HCT
LOPRESSOR tablet
SECTRAL
TENORETIC 100
TENORETIC 50
TENORMIN
TOPROL XL
TRANDATE tablet
ZEBETA
ZIAC
Calcium-Channel Blocking Agents
diltiazem hcl cap er 12h, cap er 24h, cap er (Cardizem CD)
deg, capsule er, tab er 24h, tablet
verapamil hcl cap24h pct, cap24h pel,
(Calan SR)
tablet, tablet er
CALAN SR
CALAN
CARDIZEM CD
CARDIZEM LA
CARDIZEM SR
CARDIZEM
COVERA-HS
DILACOR XR
ISOPTIN SR
TIAZAC
VERELAN PM
VERELAN
Cardiovascular Agents, Miscellaneous
digoxin tablet
(Lanoxin)
epinephrine auto injct: 0.15/0.15
(Adrenaclick)
hydralazine hcl
(Hydralazine HCl)
Requirements/Limits
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
1
1
3
3
3
3
3
3
3
3
3
3
3
3
1
1
1
54
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
hydralazine/hydrochlorothiazid
hydralazine/reserpin/hctz
isoxsuprine hcl
papaverine hcl capsule er, tablet
reserpine
reserpine/hydrochlorothiazide
Drug Tier
(Hydralazine/
Hydrochlorothiazid)
(Hydralazine/Reserpin/
Hctz)
(Isoxsuprine HCl)
(Papaverine HCl)
(Reserpine)
(Reserpine/
Hydrochlorothiazide)
DIGOXIN
EPIPEN 2-PAK
EPIPEN JR 2-PAK
LANOXIN tablet: 62.5mcg, 187.5mcg
ADRENACLICK auto injct: 0.15/0.15
ADRENACLICK auto injct: 0.3mg/0.3
AUVI-Q
DEMSER
LANOXIN tablet: 125mcg, 250mcg
RANEXA tab er 12h: 500mg
RANEXA tab er 12h: 1000mg
TWINJECT
VECAMYL
FIRAZYR
Dihydropyridines
amlodipine besylate
amlodipine besylate/benazepril
amlodipine/valsartan
amlodipine/valsartan/hcthiazid
felodipine
isradipine
nicardipine hcl capsule
nifedipine
nimodipine
nisoldipine
ADALAT CC
AZOR
CARDENE SR
DYNACIRC CR
EXFORGE HCT
EXFORGE
1
1
1
1
1
1
2
2
2
2
3
3
3
3
3
3
3
3
3
S-T1
(Norvasc)
(Lotrel)
(Exforge)
(Exforge HCT)
(Felodipine)
(Isradipine)
(Nicardipine HCl)
(Procardia XL)
(Nimodipine)
(Sular)
Requirements/Limits
ST
ST
QL: 120 in 30 days
QL: 60 in 30 days
ST
PA (Specialty Preferred
Drug List)
1
1
1
1
1
1
1
1
1
1
3
3
3
3
3
3
55
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
LOTREL
NIMOTOP
NORVASC
NYMALIZE
PROCARDIA XL
PROCARDIA
SULAR
Diuretics
amiloride hcl
amiloride/hydrochlorothiazide
bumetanide tablet
chlorothiazide
chlorthalidone
furosemide solution, tablet
hydrochlorothiazide
indapamide
methyclothiazide
metolazone
torsemide tablet
triamterene/hydrochlorothiazid
EDECRIN
DEMADEX
DIURIL
DYAZIDE
DYRENIUM
LASIX
MAXZIDE-25 MG
MAXZIDE
MICROZIDE
MIDAMOR
NATURETIN-5
SALURON
SAMSCA
THALITONE
ZAROXOLYN
Dyslipidemics
amlodipine/atorvastatin
atorvastatin calcium
cholestyramine (with sugar)
cholestyramine/aspartame
Drug Tier
Requirements/Limits
3
3
3
3
3
3
3
(Midamor)
(Amiloride/
Hydrochlorothiazide)
(Bumetanide)
(Chlorothiazide)
(Chlorthalidone)
(Lasix)
(Microzide)
(Indapamide)
(Methyclothiazide)
(Zaroxolyn)
(Demadex)
(Maxzide-25 Mg)
1
1
(Caduet)
(Lipitor)
(Questran)
(Questran Light)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
56
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
colestipol hcl
fenofibrate nanocrystallized
fenofibrate
fenofibrate,micronized
fenofibric acid (choline)
fenofibric acid
fluvastatin sodium
gemfibrozil
lovastatin
niacin tab er 24h, tablet: 500mg
omega-3 acid ethyl esters
omega-3 fatty acids/fish oil
pravastatin sodium
simvastatin
LIPTRUZET
VASCEPA
ZETIA
ADVICOR
ALTOPREV
ANTARA
CADUET
COLESTID
CRESTOR
FENOGLIDE
FIBRICOR
LESCOL XL
LESCOL
LIPITOR
LIPOFEN
LIVALO
LOFIBRA capsule
LOFIBRA tablet
LOPID
LOVAZA
MEVACOR
NIASPAN
PRAVACHOL
QUESTRAN
SIMCOR
TRICOR
TRIGLIDE
Drug Tier
(Colestid)
(Tricor)
(Lofibra)
(Antara)
(Trilipix)
(Fibricor)
(Lescol)
(Lopid)
(Mevacor)
(Niaspan)
(Lovaza)
(Fish Oil Omega-3)
(Pravachol)
(Zocor)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Requirements/Limits
QL: 120 in 30 days
ST
QL: 30 in 30 days
57
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
TRILIPIX
VYTORIN
WELCHOL
ZOCOR
JUXTAPID
3
3
3
3
S-T1
KYNAMRO
S-T1
Renin-Angiotensin-Aldosterone System Inhibitors
eplerenone tablet: 25mg
(Inspra)
eplerenone tablet: 50mg
(Inspra)
spironolact/hydrochlorothiazid
(Aldactazide)
spironolactone
(Aldactone)
AMTURNIDE
TEKAMLO
TEKTURNA HCT
TEKTURNA
ALDACTAZIDE
ALDACTONE
INSPRA tablet: 25mg
INSPRA tablet: 50mg
Vasodilators
isosorbide dinitrate
(Isordil Titradose)
isosorbide mononitrate
(Imdur)
minoxidil
(Minoxidil)
nitroglycerin capsule er, patch td24, spray (Nitro-Dur)
nylidrin hcl
(Nylidrin HCl)
DILATRATE-SR
NITRO-BID
NITRO-DUR patch td24: 0.3mg/hr
NITROSTAT
BIDIL
IMDUR
ISOCHRON
ISORDIL TITRADOSE
ISORDIL
MONOKET
NITRO-DUR patch td24: 0.1mg/hr,
0.2mg/hr, 0.4mg/hr, 0.6mg/hr, 0.8mg/hr
NITROLINGUAL
NITROMIST
1
1
1
1
2
2
2
2
3
3
3
3
Requirements/Limits
PA (Specialty Preferred
Drug List)
PA (Specialty Preferred
Drug List)
QL: 30 in 30 days
QL: 60 in 30 days
QL: 30 in 30 days
QL: 30 in 30 days
QL: 30 in 30 days
QL: 30 in 30 days
QL: 30 in 30 days
QL: 60 in 30 days
1
1
1
1
1
2
2
2
2
3
3
3
3
3
3
3
3
3
58
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
PROGLYCEM
Requirements/Limits
3
Central Nervous System Agents
Central Nervous System Agents
ADDERALL XR
benzphetamine hcl
caffeine citrated solution
clonidine hcl
dexmethylphenidate hcl
dextroamphetamine sulfate capsule er,
solution, tablet: 5mg, 10mg
dextroamphetamine/amphetamine tablet
guanfacine hcl
lithium carbonate
lithium citrate
methamphetamine hcl
methylphenidate hcl
riluzole
FOCALIN XR cpbp 50-50: 5mg, 10mg,
20mg, 25mg, 35mg
NUEDEXTA
QUILLIVANT XR
SAVELLA tab ds pk
SAVELLA tablet
STRATTERA capsule: 80mg, 100mg
STRATTERA capsule: 10mg, 18mg,
25mg, 40mg, 60mg
VYVANSE
ADDERALL
BONTRIL PDM
CAFCIT solution
CONCERTA
DAYTRANA
DESOXYN
DEXEDRINE
dextroamphetamine sulfate tablet: 5mg,
10mg
DIDREX
ESKALITH
FOCALIN XR cpbp 50-50: 15mg, 30mg,
40mg
FOCALIN
(Didrex)
(Cafcit)
(Kapvay)
(Focalin)
(Dextroamphetamine
Sulfate)
(Adderall)
(Intuniv)
(Lithium Carbonate)
(Lithium Citrate)
(Desoxyn)
(Concerta)
(Rilutek)
(Dextroamphetamine
Sulfate)
1
1
1
1
1
1
1
1
1
1
1
1
1
2
QL: 30 in 30 days
2
2
2
2
2
2
PA, QL: 60 in 30 days
2
3
3
3
3
3
3
3
3
QL: 30 in 30 days
PA, QL: 55 in 28 days
PA, QL: 60 in 30 days
QL: 30 in 30 days
QL: 60 in 30 days
QL: 30 in 30 days
3
3
3
3
59
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
INTUNIV
KAPVAY
LITHOBID
METADATE CD
METADATE ER
METHYLIN
PROCENTRA
REGIMEX
RILUTEK
RITALIN LA
RITALIN
RITALIN-SR
ZENZEDI
AMPYRA
3
3
3
3
3
3
3
3
3
3
3
3
3
S-T1
XENAZINE
S-T1
Requirements/Limits
QL: 30 in 30 days
PA, QL: 60 in 30 days
(Specialty Preferred
Drug List)
PA (Specialty Preferred
Drug List)
Contraceptives
Contraceptives
FALESSA
AMETHYST
BEYAZ
CONCEPTROL
CYCLESSA
desog-e.estradiol/e.estradiol
DESOGEN
desogestrel-ethinyl estradiol
ELLA
ESTROSTEP FE
ethinyl estradiol/drospirenone
ethynodiol d-ethinyl estradiol
FEMCAP
FEMCON FE
GENERESS FE
GYNOL II
levonorgestrel
levonorgestrel-ethin estradiol tablet: 0.150.03; tbdspk 3mo
(Mircette)
(Velivet)
(Yaz)
(Ethynodiol D-Ethinyl
Estradiol)
(Plan B One-Step)
(Levonorgestrel-Ethin
Estradiol)
3
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
ST
ST
ST
ST
QL: 1 per fill
ST
ST
ST
PA
QL: 91 in 91 days
60
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
levonorgestrel-ethin estradiol tablet: 0.10.02, 0.15-0.03, 6-5-10
l-norgest-eth estr/ethin estra
LO LOESTRIN FE
LO MINASTRIN FE
LOESTRIN 24 FE
LOESTRIN FE
LOESTRIN
LOSEASONIQUE
MINASTRIN 24 FE
MIRCETTE
MIRENA
MODICON
NATAZIA
nonoxynol 9
NORDETTE-28
norelgestromin/ethin.estradiol
noreth-ethinyl estradiol/iron
norethindrone ac-eth estradiol
norethindrone
norethindrone-e.estradiol-iron
norethindrone-ethinyl estrad
norethindrone-mestranol
norgestimate-ethinyl estradiol
norgestrel-ethinyl estradiol
Drug Tier
Requirements/Limits
(Nordette-28)
PREV
(Seasonique)
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
QL: 91 in 91 days
ST
ST
ST
ST
ST
ST, QL: 90 in 90 days
ST
ST
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
ST
ST
(Nonoxynol 9)
(Ortho Evra)
(Femcon Fe)
(Loestrin)
(Ortho Micronor)
(Loestrin 24 Fe)
(Ortho-Novum)
(Norinyl 1+50)
(Ortho Tri-Cyclen)
(Norgestrel-Ethinyl
Estradiol)
NORINYL 1+50
NOR-Q-D
NUVARING
ORTHO ALL-FLEX kit
ORTHO EVRA
ORTHO MICRONOR
ORTHO TRI-CYCLEN LO
ORTHO TRI-CYCLEN
ORTHO-CEPT
ORTHO-CYCLEN
ORTHO-NOVUM
OVCON-35
PARAGARD T 380-A
PLAN B ONE-STEP
QUARTETTE
ST
ST
ST
QL: 3 in 28 days
QL: 3 in 28 days
ST
ST
ST
ST
ST
ST
PA
ST, QL: 91 in 91 days
61
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
SAFYRAL
SEASONIQUE
SKYLA
TAKE ACTION
TODAY CONTRACEPTIVE SPONGE
TRI-NORINYL
VCF
WIDE SEAL DIAPHRAGM
YASMIN 28
YAZ
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
Requirements/Limits
ST
ST, QL: 91 in 91 days
PA
ST
ST
ST
Cough And Cold Products
Cough And Cold Products
benzonatate
bromphenira/pseudoephed/codein liquid:
1.3-10-6.3, 2-30-7.5/5
brompheniram/phenylephrine/dm liquid: 25-10mg/5
brompheniramin/pe/carbetapent
(Tessalon)
(Bromphenira/
Pseudoephed/Codein)
(Brompheniram/
Phenylephrine/Dm)
(Brompheniramin/Pe/
Carbetapent)
brompheniramine/pe/codeine
(Brompheniramine/Pe/
Codeine)
bromphenrm/pseudoeph/dihydrocd
(Bromphenrm/
Pseudoeph/Dihydrocd)
chlorphen/pseudoephed/codeine
(Chlorphen/
Pseudoephed/Codeine)
chlorpheniramine/codeine phos
(Notuss Ac)
dihydrocodeine/guaifenesin
(Dihydrocodeine/
Guaifenesin)
dm/phenyleph/chlorpheniramine drops: 3- (Dm/Phenyleph/
2-1mg/ml
Chlorpheniramine)
d-methorphan hb/p-epd hcl/bpm syrup: 10- (Endacof-Dm)
30-2/5
d-methorphan hb/prometh hcl
(D-Methorphan Hb/
Prometh HCl)
guaifenesin tablet: 200mg
(Organidin Nr)
guaifenesin/codeine phosphate capsule,
(M-Clear Wc)
liquid: 100-10mg/5, 100-6.3/5, 200-8mg/5,
225-7.5/5
guaifenesin/dm/pseudoephedrine tablet:
(Guaifenesin/Dm/
400-20-40
Pseudoephedrine)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
62
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
guaifenesin/phenylephrine hcl liquid: 2007.5/5
hydrocodone bit/homatrop me-br
(Guaifenesin/
Phenylephrine HCl)
(Hydrocodone Bit/
Homatrop Me-Br)
hydrocodone/chlorphen p-stirex
(Tussionex)
p-ephed hcl/codeine/guaifen liquid
(P-Ephed HCl/Codeine/
Guaifen)
phenylephrine/carbetapentan/gg
(Phenylephrine/
Carbetapentan/Gg)
phenylephrine/dhcodeine bt/cp
(Phenylephrine/
Dhcodeine Bt/Cp)
promethazine hcl/codeine
(Promethazine HCl/
Codeine)
promethazine/phenyleph/codeine
(Promethazine/
Phenyleph/Codeine)
pseudoephedrine hcl/codeine liquid: 30mg- (Notuss Dc)
8mg/5
REZIRA
ALA-HIST AC
ALAHIST DHC
ALLFEN CD
ALLFEN CDX
AMBIFED CD
AMBIFED CDX
AMBIFED DM
AMBIFED
AMBIFED-G CD
AMBIFED-G CDX
BROVEX CB
BROVEX CBX
BROVEX PB C
BROVEX PB CX
CAPCOF
COTAB A
COTAB AX
COTABFLU
DESPEC-EXP
DESPEC-PDC
DONATUSS DC
MAXIFED CD
MAXIFED CDX
Requirements/Limits
1
1
1
1
1
1
1
1
1
1
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
63
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
MAXIFED-G CD
MAXIFED-G CDX
MAXIFLU CD
MAXIFLU CDX
M-CLEAR WC
M-END MAX D
M-END PE
M-END WC
NOTUSS-NX
NOTUSS-NXD
PHENFLU CD
PHENFLU CDX
POLY HIST NC
POLY-TUSSIN DHC
POLY-TUSSIN EX
pseudoephed/hydrocodone/cpm
RU-TUSS DM
STATUSS GREEN
TESSALON PERLE
TESSALON
TUSNEL PEDIATRIC liquid: 50-5-15/5
TUSNEL
TUSSICAPS
TUSSIGON
TUSSIONEX
TUSSI-PRES PEDIATRIC
VANACOF CD
VITUZ
ZODRYL AC 25
ZODRYL AC 30
ZODRYL AC 35
ZODRYL AC 40
ZODRYL AC 50
ZODRYL AC 60
ZODRYL AC 80
ZONATUSS
ZOTEX-GP
ZUTRIPRO
Drug Tier
(Zutripro)
Requirements/Limits
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Dental And Oral Agents
Dental And Oral Agents
cevimeline hcl
(Evoxac)
1
64
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
chlorhexidine gluconate
pilocarpine hcl
sodium fluoride
stannous fluoride
triamcinolone acetonide
Drug Tier
(Peridex)
(Salagen)
(Prevident 5000 Plus)
(Gel-Kam)
(Triamcinolone
Acetonide)
APHTHASOL
ARESTIN
EVOXAC
PERIDEX
PHOS-FLUR
PREVIDENT 5000 PLUS
PREVIDENT 5000 SENSITIVE
PREVIDENT
SALAGEN
Requirements/Limits
1
1
1
1
1
3
3
3
3
3
3
3
3
3
Dermatological Agents
Dermatological Agents, Other
acyclovir
aluminum acetate
aluminum chloride
ammonium lactate
benzoyl peroxide and skin cleansr5
benzoyl peroxide microspheres
benzoyl peroxide cleanser: 4%, 6%, 7%,
8%, 9%; foam, gel (gram): 2.5%, 4%, 5%,
8%, 10%; kit, towelette
benzoyl peroxide/aloe vera
BP WASH cleanser: 5%, 7%, 10%
calcipotriene
calcipotriene/betamethasone
calcitriol
CHLORHEXIDINE GLUCONATE
ethyl chloride
fluorouracil
imiquimod
iodine/potassium iodide solution
isotretinoin
(Zovirax)
(Aluminum Acetate)
(Drysol)
(Lac-Hydrin)
(Benzoyl Peroxide and
Skin Cleansr5)
(Benzoyl Peroxide
Microspheres)
(Brevoxyl-4)
1
1
1
1
1
(Benzoyl Peroxide/
Aloe Vera)
1
(Dovonex)
(Taclonex)
(Vectical)
(Ethyl Chloride)
(Carac)
(Aldara)
(Iodine/Potassium
Iodide)
(Isotretinoin)
1
1
1
1
1
1
1
1
1
1
1
1
65
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
lactic acid
lidocaine hcl
mafenide acetate
methoxsalen, rapid
oxybenzone/octinox/h-quinone
podofilox
podophyllum resin
potassium hydroxide
salicylic acid cream (g), foam, gel (gram):
6%; liq-film, liquid: 26%; lotion: 6%;
shampoo: 6%
salicylic acid/ammon lact/aloe
salicylic acid/ceramide cmb #1
silver nitrate applicator
sodium thiosulfate/sal acid
sulfacetamide sod/sulfur/urea
sulfacetamide sodium
sulfacetamide sodium/sulfur
sulfacetamide sodium/urea
sulfacetm na/avobenzone/sulfur
tetracaine/benzocaine/butamben
trichloroacetic acid
urea
urea/hyaluronate sodium
urea/lactic ac/zn undecylenate
Drug Tier
(Lactic Acid)
(Lidamantle)
(Sulfamylon)
(Oxsoralen-Ultra)
(Oxybenzone/Octinox/
H-Quinone)
(Condylox)
(Podophyllum Resin)
(Potassium Hydroxide)
(Virasal)
1
1
1
1
1
(Salkera)
(Salex)
(Silver Nitrate
Applicator)
(Sodium Thiosulfate/
Sal Acid)
(Claris)
(Sulfacetamide
Sodium)
(Avar)
(Rosula Ns)
(Sulfacetm Na/
Avobenzone/Sulfur)
(Tetracaine/
Benzocaine/Butamben)
(Trichloroacetic Acid)
(Aluvea)
(Urea/Hyaluronate
Sodium)
(Urea/Lactic Ac/Zn
Undecylenate)
1
1
1
8-MOP
CONDYLOX gel (gram)
FINACEA PLUS
FINACEA
OXSORALEN
PANRETIN
REGRANEX
SANTYL
Requirements/Limits
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
QL: 15 per fill
66
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
SULFAMYLON cream (g)
TACLONEX suspension
VALCHLOR
2
2
2
ABSORICA
ACZONE
ALCORTIN A
ALDARA
ALOQUIN
ALUVEA
ANACAINE
AVAR LS
AVAR
AVAR-E GREEN
AVAR-E LS
AZELEX
BENSAL HP
BENZAC AC
BENZEFOAM ULTRA
BENZEFOAM
benzoyl peroxide cleanser: 2.5%, 5%, 10%
BICHLORACETIC ACID
BP WASH ACNE TREATMENT
BP WASH cleanser: 2.5%
CARAC
CETACAINE ANESTHETIC
CETACAINE MEDICAL KIT E
CETACAINE
CLARIFOAM EF
CLARIS
CONDYLOX solution
DELOS
DENAVIR
DERMA-CAS
DERMASORB XM
DESQUAM-X
DOVONEX
DRITHOCREME HP
DRYSOL
EFUDEX
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
(Delos)
Requirements/Limits
(Specialty Preferred
Drug List); (Specialty
Preferred Drug List)
67
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
FLUOROPLEX
GORDOFILM
GORDO-UREA
HYDRO 35
HYDRO 40
INOVA 4-1
INOVA 8-2
INOVA
IODOFLEX
IODOSORB
KERAFOAM
KERALAC
KERALYT SCALP
KERALYT gel (gram): 6%
KEROL AD
KEROL ZX
KEROL emulsn(g)
KEROL suspension
LAC-HYDRIN
LEVULAN
LIDOVIR
METVIXIA
MIRVASO
NEOBENZ MICRO
NUOX
OVACE PLUS WASH
OVACE PLUS
OXALIS
OXSORALEN-ULTRA
PACNEX HP
PACNEX LP
PACNEX MX
PACNEX
PAIN EASE
PICATO
PLEXION
PRUDOXIN
PYROGALLIC ACID
REA LO 39
REA LO 40
RIAX
Requirements/Limits
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
68
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
ROSANIL
SALACYN
SALEX combo. pkg, kit clcmer
SALEX shampoo
SALKERA
SALVAX DUO PLUS
SORIATANE capsule: 22.5mg
SORILUX
SPRAY AND STRETCH
SULFAMYLON packet
SUMADAN
SUMAXIN TS
SUMAXIN
TACLONEX oint. (g)
ULTRASAL-ER
UMECTA PD
UMECTA
URAMAXIN GT
URAMAXIN
UTOPIC
VANOXIDE-HC
VECTICAL
VEREGEN
VIRASAL
VYTONE
XERAC AC
XERESE
X-VIATE
ZENCIA
ZITHRANOL
ZITHRANOL-RR
ZONALON
ZOVIRAX
ZYCLARA
acitretin
Drug Tier
(Soriatane)
SORIATANE capsule: 10mg, 17.5mg,
25mg
Dermatological Antibacterials
clindamycin phos/benzoyl perox gel (gram): (Duac)
1%-5%
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
S-T1
S-T2
Requirements/Limits
(Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
1
69
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
clindamycin phosphate foam, gel (gram),
lotion, med. swab: 1%; solution
erythromycin base/ethanol
erythromycin/benzoyl peroxide
gentamicin sulfate
metronidazole
mupirocin calcium
mupirocin
neomy sulf/polymyxin b sulfate
selenium sulfide
silver nitrate
silver sulfadiazine
sulfacetamide sodium
sulfacetamide sodium/urea
Drug Tier
(Cleocin T)
1
(Emgel)
(Benzamycin)
(Gentamicin Sulfate)
(Metrogel)
(Bactroban)
(Bactroban)
(Neosporin G.U.
Irrigant)
(Selenium Sulfide)
(Silver Nitrate)
(Silvadene)
(Klaron)
(Sulfacetamide
Sodium/Urea)
1
1
1
1
1
1
1
METROGEL combo. pkg
ACANYA
AKNE-MYCIN
ALTABAX
BACTROBAN NASAL
BACTROBAN cream (g)
BACTROBAN oint. (g)
BENOXYLDOXY 30
BENOXYLDOXY 60
BENZACLIN
BENZAMYCINPAK
CENTANY AT
CENTANY
CLEOCIN T
CLINDACIN PAC
CLINDACIN P
CLINDAGEL
clindamycin phos/benzoyl perox gel (gram): (Duac)
1.2(1)%-5%
CORTISPORIN cream (g)
CORTISPORIN oint. (g)
DEL-MYCIN
DUAC CS
DUAC
ERYGEL
Requirements/Limits
1
1
1
1
1
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
70
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
EVOCLIN
FURACIN
KLARON
METROCREAM
METROGEL gel (gram)
METROLOTION
NEO-SYNALAR
NORITATE
NYDAMAX
ONEXTON
OVACE PLUS
PHISOHEX
ROSADAN gel (gram)
ROSADAN kit cl and crm
SILVADENE
SS 10-2
TERSI FOAM
THERMAZENE
VELTIN
ZIANA
Dermatological Anti-Inflammatory Agents
alclometasone dipropionate
(Aclovate)
amcinonide
(Amcinonide)
betamethasone dipropionate
(Betamethasone
Dipropionate)
betamethasone valerate
(Betamethasone
Valerate)
betamethasone/propylene glyc
(Diprolene AF)
clobetasol propionate
(Temovate)
clocortolone pivalate
(Cloderm)
desonide cream (g), lotion, oint. (g): 0.05% (Desowen)
desoximetasone
(Topicort)
diflorasone diacetate
(Apexicon)
fluocinolone acetonide
(Synalar)
fluocinolone/shower cap
(Derma-Smoothe-Fs)
fluocinonide
(Vanos)
fluticasone propionate
(Cutivate)
halobetasol propionate
(Ultravate)
halobetasol/ammonium lactate
(Ultravate Pac)
hydrocort/pramoxin/emol/pram#1
(Analpram E)
Requirements/Limits
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
71
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
hydrocort/pramoxn/skn clnsr#16
hydrocortisone ac/lidocaine
hydrocortisone acetate supp.rect
hydrocortisone acetate/aloe v
hydrocortisone acetate/urea
hydrocortisone butyrate
hydrocortisone valerate
hydrocortisone cream (g): 1%, 2.5%;
cream(gm), cream/appl, enema, lotion:
0.5%, 1%, 2%, 2.5%; oint. (g): 1%, 2.5%
hydrocortisone/iodoquinol
hydrocortisone/lidocaine/aloe
hydrocortisone/pramoxine
mometasone furoate
prednicarbate
tacrolimus
triamcinolone acetonide
Drug Tier
(Hydrocort/Pramoxn/
Skn Clnsr#16)
(Hydrocortisone Ac/
Lidocaine)
(Anusol-HC)
(Nuzon)
(Hydrocortisone
Acetate/Urea)
(Hydrocortisone
Butyrate)
(Hydrocortisone
Valerate)
(Anusol-HC)
1
(Hydrocortisone/
Iodoquinol)
(Hydrocortisone/
Lidocaine/Aloe)
(Analpram HC)
(Elocon)
(Dermatop)
(Protopic)
(Triamcinolone
Acetonide)
1
CORTIFOAM
ELIDEL
HYDROCORTISONE ACETATE
HYDROCORTISONE
PROCTOFOAM-HC
PROTOPIC
ACLOVATE
ANA-LEX
ANALPRAM E
ANALPRAM HC
ANUSOL-HC cream (g)
ANUSOL-HC supp.rect
APEXICON E
APEXICON
AQUA GLYCOLIC HC
AQUAPHILIC W/TRIAMCINOLONE
Requirements/Limits
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
QL: 4 in 28 days
QL: 8 in 28 days
72
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
CAPEX SHAMPOO
CARMOL HC
CLOBEX
CLODAN kt shm cln
CLODAN shampoo
CLODERM
CORDRAN SP
CORDRAN
CORTENEMA
CUTIVATE
DERMA-SMOOTHE-FS
DERMASORB HC
DERMASORB TA
DERMATOP
DESONATE
desonide oint. (g): 0.05%
DESOWEN cream (g), lotion
DESOWEN kt crm le, kt oint le
DESOWEN kt lotn ce
DIPROLENE AF
DIPROLENE
DIPROSONE
ELOCON
ENOVARX-IBUPROFEN
EPIFOAM
FIRST-HYDROCORTISONE
HALOG
HALONATE PAC
HALONATE
KENALOG
LACTICARE-HC
LIDAMANTLE HC
LOCOID
LUXIQ
MOMEXIN
NOVACORT
NUCORT
OLUX-E
PANDEL
PEDIADERM HC
PEDIADERM TA
Drug Tier
(Desonide)
Requirements/Limits
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
73
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
PRAMCORT
PRAMOSONE E
PRAMOSONE
PROCORT
PROCTOCORT cream (g)
PROCTOCORT supp.rect
PROCTOCREAM-HC
RECTACORT-HC
REDERM
SCALACORT DK
SCALACORT
SYNALAR TS
SYNALAR cmb ont cr, cream (g): 0.025%
SYNALAR cream (g): 0.025%; oint. (g),
solution
TEMOVATE
TEXACORT
TOPICORT
TRIDERM
TRIDESILON
ULTRAVATE PAC
ULTRAVATE X
ULTRAVATE
VANOS
VERDESO
WESTCORT
ZYPRAM
Dermatological Retinoids
adapalene
tretinoin microspheres
tretinoin
tretinoin/emollient base
Drug Tier
Requirements/Limits
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
(Differin)
(Retin-A Micro)
(Retin-A)
(Tretinoin/Emollient
Base)
TAZORAC
ATRALIN
AVAGE
DIFFERIN cream (g), gel (gram), lotion
EPIDUO
FABIOR
RETIN-A MICRO PUMP
RETIN-A MICRO
1
1
1
1
2
3
3
3
3
3
3
3
Age must be <= 36, PA
Age must be <= 36, PA
Age must be <= 36, PA
Age must be <= 36, PA
Age must be <= 36, PA
Age must be <= 36, PA
74
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
RETIN-A
TRETIN-X combo. pkg: 0.01%, 0.025%
TRETIN-X combo. pkg: 0.025%, 0.05%,
0.1%
TRETIN-X cream (g)
Scabicides And Pediculicides
lindane
malathion
permethrin
spinosad
EURAX
ELIMITE
NATROBA
OVIDE
SKLICE
SOOLANTRA
(Lindane)
(Ovide)
(Elimite)
(Natroba)
Drug Tier
Requirements/Limits
3
3
3
Age must be <= 36, PA
Age must be <= 36, PA
Age must be <= 36, PA
3
Age must be <= 36, PA
1
1
1
1
2
3
3
3
3
3
Devices
Devices
1ST CHOICE LANCETS
1ST TIER UNILET COMFORTOUCH
ACCU-CHEK ACTIVE
ACCU-CHEK AVIVA PLUS each
ACCU-CHEK AVIVA PLUS strip
ACCU-CHEK AVIVA
ACCU-CHEK COMFORT CURVE
ACCU-CHEK COMPACT BLUE
CONTROL
ACCU-CHEK COMPACT PLUS
CONTROL
ACCU-CHEK COMPACT PLUS
ACCU-CHEK FASTCLIX each
ACCU-CHEK FASTCLIX kit
ACCU-CHEK NANO SMARTVIEW
ACCU-CHEK SAFE-T-PRO PLUS
ACCU-CHEK SAFE-T-PRO
ACCU-CHEK SMARTVIEW each
ACCU-CHEK SMARTVIEW strip
ACCU-CHEK SOFTCLIX each
ACCU-CHEK SOFTCLIX kit
ACCU-CHEK VOICEMATE
ACCU-CHEK combo. pkg
2
2
2
2
2
2
2
2
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
2
2
2
2
2
2
2
2
2
2
2
2
2
QL: 360 in 30 days
QL: 360 in 30 days
75
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
ACCU-CHEK each: n/a
ACCU-CHEK each: n/a
ACCU-CHEK kit: n/a
ACCU-CHEK kit: n/a
ACCU-CHEK kit: n/a
ACCUTREND GLUCOSE each
ACCUTREND GLUCOSE strip
ACE AEROSOL CLOUD ENHANCER
ACTI-LANCE
ADJUSTABLE LANCING DEVICE
ADVANCED LANCING DEVICE
ADVANCED TRAVEL LANCETS
ADVOCATE LANCET
ADVOCATE LANCETS
ADVOCATE LANCING DEVICE
AEROCHAMBER MINI
AEROCHAMBER MV
AEROCHAMBER PLUS FLOW-VU
AEROCHAMBER PLUS Z STAT
AEROCHAMBER WITH FLOWSIGNAL
AEROCHAMBER Z-STAT PLUS
AEROTRACH PLUS
ALTERNATE SITE LANCETS
ALTERNATE SITE LANCING DEVICE
AQUA LANCE LANCING DEVICE
ASSURE HAEMOLANCE PLUS each:
1.2mm
ASSURE HAEMOLANCE PLUS each:
18gauge, 21gauge, 25gauge, 28gauge
ASSURE LANCE
AUTO INJECTOR
AUTO-LANCET MINI
AUTOLET IMPRESSION
AUTOLET LANCING DEVICE
AUTOLET LITE CLINISAFE
AUTOLET MINI
AUTOLET MKII CLINISAFE
BREATHERITE
BREATHRITE
BREEZE 2 each: n/a
BREEZE 2 each: n/a
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
Requirements/Limits
QL: 360 in 30 days
2
2
2
2
2
2
2
2
2
2
2
2
2
76
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
BREEZE 2 each: n/a
BREEZE 2 kit
BREEZE 2 strip
BULLSEYE MINI SAFETY LANCETS
CAREONE each: n/a
CAREONE each: n/a
CLEVER CHEK LANCETS
CLINITEST REAGENT
COAGUCHEK XS strip
COAGUCHEK each
COAGUCHEK strip
COLOR LANCETS
COMFORT LANCETS
COMPACT SPACE CHAMBER PLUS
CONTOUR LINK
CONTOUR NEXT CONTROL
SOLUTION each: n/a
CONTOUR NEXT CONTROL
SOLUTION each: n/a
CONTOUR NEXT EZ
CONTOUR NEXT LINK
CONTOUR NEXT USB
CONTOUR NEXT each
CONTOUR NEXT strip
CONTOUR USB
CONTOUR each: n/a
CONTOUR each: n/a
CONTOUR each: n/a
CONTOUR kit
CONTOUR strip
DROPLET LANCETS
DROPLET LANCING DEVICE
EASIVENT each
EASIVENT spacer
EASY CLICK
EASY COMFORT
EASY TOUCH LANCETS
EASY TOUCH LANCING DEVICE
EASY TOUCH each: 21gauge, 23gauge,
26gauge, 28gauge, 30gauge, 32gauge,
33gauge
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
Requirements/Limits
QL: 360 in 30 days
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
QL: 360 in 30 days
QL: 360 in 30 days
77
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
ECLIPSE LUER-LOK SYRINGE disp
syrin: 27gx1/2"
E-Z JECT LANCETS
EZ SMART LANCETS
E-Z SPACER
E-ZJECT LANCETS
FIFTY50 SAFETY SEAL LANCETS
FINE 30 UNIVERSAL LANCETS
FINGERSTIX
FORA LANCING DEVICE
FORACARE LANCETS
FREESTYLE UNISTIK 2
GLUCOCARD X-METER CONTROL
GLUCOCARD X-METER
GLUCOCOM BLOOD GLUCOSE
GLUCOCOM CONTROL SOLUTION
each: n/a
GLUCOCOM CONTROL SOLUTION
each: n/a
GLUCOCOM LANCETS
GLUCOCOM
GLUCOLET 2
GLUCOSE CONTROL SOLUTION
GLUCOSE CONTROL
GLUCOSOURCE each: n/a
GLUCOSOURCE each: n/a
HAEMOLANCE PLUS
HAEMOLANCE, RETRACTABLE
HAEMOLANCE
HEALTHY ACCENTS AUTOLET
HEALTHY ACCENTS UNILET LANCET
HYPOLANCE
INCONTROL LANCING DEVICE
INCONTROL SUPER THIN LANCETS
INCONTROL ULTRA THIN LANCETS
INJECT EASE LANCETS
INVACARE LANCETS
KINNEY BRAND LANCETS
LANCET DEVICE
LANCETS THIN each: 28gauge
LANCETS
Requirements/Limits
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
78
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
LANCING DEVICE each
LANCING DEVICE kit
LANCING SYSTEM
LITE TOUCH each: 30gauge, 33gauge
LITE TOUCH each: n/a
LITEAIRE
LITETOUCH
MEDI-LANCE
MEDISENSE GLUCOSE KETONE
CONTR
MEDISENSE GLUCOSE KETONE
MEDISENSE THIN LANCETS
MEDLANCE PLUS
MICROCHAMBER
MICROLET 2
MICROLET
MICROSPACER
MICROTAINER LANCETS
MONAGHAN Z STAT
MONOLET LANCETS
MOUTHPIECE each: n/a
MULTI-LANCET DEVICE
MYGLUCOHEALTH CONTROL
SOLUTION
MYGLUCOHEALTH LANCETS
needles, insulin disp., safety
needles, insulin disposable
Drug Tier
Requirements/Limits
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
(Needles, Insulin Disp.,
Safety)
(Needles, Insulin
Disposable)
NESSI SPACER
NOVA SAFETY LANCETS
ONE WAY MOUTHPIECE
ONETOUCH FINEPOINT LANCETS
OPTICHAMBER each
OPTICHAMBER spacer
OPTIHALER
PANDA MASK
PEDIATRIC MASK
PEDIATRIC PANDA MASK
PENLET PLUS BLOOD SAMPLER
POCKET CHAMBER
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
79
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
PRESSURE ACTIVATED LANCETS
PRIMEAIRE
PROCHAMBER
PRODIGY LANCETS
PRODIGY LANCING DEVICE
PRODIGY TWIST TOP LANCET
RENEW ADVANCED LANCING
SYSTEM
RENEW ADVANCED MICROLANCETS
RIGHTEST GD500
RIGHTEST GL300 LANCETS
RITEFLO
SAFE-CLIP
SAFETY LANCETS
SAFETY SEAL LANCETS
SAFETY-LET
SIDESTREAM PEDIATRIC
SINGLE-LET
SMART SENSE LANCETS
SMART SENSE
SMARTDIABETES VANTAGE each:
30gauge
SMARTDIABETES VANTAGE each: n/a
SMARTEST LANCET
SOFT TOUCH
SOFTCLIX
SOLUS V2 LANCETS
SOLUS V2 LANCING DEVICE
SPACE CHAMBER PLUS
STERILANCE TL
SUPER THIN LANCETS
SURE COMFORT LANCETS
SURE COMFORT LANCING PEN
SUREFLEX each
SUREFLEX kit
SURE-LANCE
SURE-PEN
SURE-TOUCH
syring w-ndl,disp,insul,0.3 ml
(Syring WNdl,Disp,Insul,0.3 Ml)
2
2
2
2
2
2
2
Requirements/Limits
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
80
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
syring w-ndl,disp,insul,0.5 ml
syringe and needle,insulin,1 ml
Drug Tier
(Syring WNdl,Disp,Insul,0.5 Ml)
(Syringe and
Needle,Insulin,1 Ml)
TECHLITE BLOOD LANCET
TECHLITE
TOPCARE UNIVERSAL1 THIN
LANCET
TRUEDRAW
TRUEPLUS LANCETS
ULTICARE each
ULTI-LANCE each
ULTI-LANCE kit
ULTILET BASIC
ULTILET CLASSIC
ULTILET LANCETS
ULTILET SAFETY
ULTRA THIN LANCETS
ULTRA THIN PLUS LANCETS
ULTRA THIN PLUS
ULTRALANCE
ULTRA-THIN II
ULTRATLC LANCETS
UNILET COMFORTOUCH
UNILET EXCELITE II
UNILET EXCELITE
UNILET GP LANCET
UNILET LANCET
UNILET LANCETS
UNISTIK 2 EXTRA
UNISTIK 2 NORMAL
UNISTIK 2
UNISTIK 3 COMFORT
UNISTIK 3 EXTRA
UNISTIK 3 NEONATAL
UNISTIK 3 each
UNISTIK 3 kit
UNISTIK CZT
UNISTIK
UNIVERSAL 1
VORTEX FROG MASK
Requirements/Limits
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
81
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
VORTEX LADYBUG MASK
VORTEX each
VORTEX spacer
WATCHHALER
2TEK each
2TEK kit
ACURA CONTROL SOLUTION LOW
ACURA CONTROL SOLUTION
NORMAL
ACURA CONTROL SOLUTION
ACURA METER KIT
ACURA PLUS
ACURA STARTER KIT
ACURA TEST STRIPS
ADVANCE INTUITION each
ADVANCE INTUITION kit
ADVANCE TEST STRIPS
ADVANCED GLUCOSE METER
ADVANCED GLUCOSE TEST STRIPS
ADVOCATE BLOOD GLUCOSE
MONITOR
ADVOCATE CONTROL SOLUTION
each: n/a
ADVOCATE CONTROL SOLUTION
each: n/a
ADVOCATE DUO
ADVOCATE RAPID-SAFE
ADVOCATE REDI-CODE DUO
ADVOCATE REDI-CODE+ CTRL SOLN
each: n/a
ADVOCATE REDI-CODE+ CTRL SOLN
each: n/a
ADVOCATE REDI-CODE+ each
ADVOCATE REDI-CODE+ strip
ADVOCATE REDI-CODE each, kit
ADVOCATE REDI-CODE strip
ADVOCATE TEST STRIP
AGAMATRIX AMP each
AGAMATRIX AMP strip
AGAMATRIX CONTROL each: n/a
AGAMATRIX CONTROL each: n/a
Requirements/Limits
2
2
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
QL: 360 in 30 days
QL: 360 in 30 days
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
82
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
ASSURE 4 combo. pkg
ASSURE 4 each
ASSURE 4 strip
ASSURE DOSE each: n/a
ASSURE DOSE each: n/a
ASSURE PLATINUM each
ASSURE PLATINUM strip
ASSURE PRO kit
ASSURE PRO strip
ASTHMAPACK CHILDREN'S
ASTHMAPACK I
ASTHMAPACK II
ASTHMAPACK III
AURORA SUPER THIN LANCETS
BD MICROTAINER LANCETS
BD ULTRA-FINE II
BD ULTRA-FINE
BG-STAR
BLOOD GLUCOSE CONTROL
BLOOD GLUCOSE METER
BLOOD GLUCOSE MONITOR
BLOOD GLUCOSE MONITORING
BLOOD GLUCOSE TEST STRIP
BLOOD GLUCOSE TEST
BLOOD-GLUCOSE CONTROL
BLOOD-GLUCOSE METER
CARELANCE ULT LANCING DEVICE
CARESENS N VOICE
CARESENS N each, kit
CARESENS N strip
CARESENS PREM LANCING DEVICE
CARESENS each: n/a
CARESENS each: n/a
CHOICEDM CLARUS CONTROL SOLN
CHOICEDM CLARUS TEST STRIPS
CHOICEDM CLARUS
CHOICEDM G20 kit
CHOICEDM G20 strip
CLEVER CHOICE BLOOD GLUC SYS
CLEVER CHOICE CONTROL
SOLUTION each: n/a
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Requirements/Limits
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
83
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
CLEVER CHOICE CONTROL
SOLUTION each: n/a
CLEVER CHOICE CONTROL
SOLUTION each: n/a
CLEVER CHOICE HD GLUCOSE SYST
CLEVER CHOICE MICRO TEST STRIP
CLEVER CHOICE MICRO
CLEVER CHOICE PRO each
CLEVER CHOICE PRO strip
CLEVER CHOICE TALK each
CLEVER CHOICE TALK strip
CLEVER CHOICE TEST STRIPS
CLEVER CHOICE VOICE+ TST STRIP
CLEVER CHOICE
COMFORT EZ
CONTROL G3
CONTROL SOLUTION each: n/a
CONTROL SOLUTION each: n/a
CONTROL SOLUTION each: n/a
CONTROL kit
CONTROL strip
diabetic supplies,miscell
Drug Tier
Requirements/Limits
3
3
(Diabetic
Supplies,Miscell)
DIATRUE PLUS each
DIATRUE PLUS strip
DIATRUE each: n/a
DIATRUE each: n/a
DIATRUE each: n/a
EASY CHECK CONTROL SOLUTION
each: n/a
EASY CHECK CONTROL SOLUTION
each: n/a
EASY CHECK TEST STRIP
EASY CHECK each: n/a
EASY CHECK each: n/a; kit
EASY GLUCO G2
EASY PLUS II each: n/a
EASY PLUS II each: n/a
EASY PLUS II each: n/a
EASY PLUS II strip
EASY PLUS each, kit
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
QL: 360 in 30 days
QL: 360 in 30 days
84
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
EASY PLUS strip
EASY STEP each: n/a
EASY STEP each: n/a
EASY STEP each: n/a
EASY STEP each: n/a; kit
EASY STEP strip
EASY TALK each: n/a
EASY TALK each: n/a
EASY TALK each: n/a; kit
EASY TALK strip
EASY TOUCH GLUCOSE MONITOR
EASY TOUCH each: n/a
EASY TOUCH strip
EASY TRAK each: n/a
EASY TRAK each: n/a
EASY TRAK each: n/a
EASY TRAK each: n/a; kit
EASY TRAK strip
EASY TWIST AND CAP LANCETS
EASYGLUCO PLUS CONTROL
NORMAL
EASYGLUCO PLUS kit
EASYGLUCO PLUS strip
EASYGLUCO kit
EASYGLUCO strip
EASYMAX 15 each: n/a
EASYMAX 15 each: n/a
EASYMAX 15 strip
EASYMAX L
EASYMAX N
EASYMAX NG
EASYMAX V SPEAKING
EASYMAX V2
EASYMAX V
EASYMAX each: n/a
EASYMAX each: n/a
EASYMAX each: n/a
EASYMAX strip
EASYPLUS R13N
EASYPLUS V
EASYPLUS
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Requirements/Limits
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
85
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
ECLIPSE CONTROL SOLUTION each:
n/a
ECLIPSE CONTROL SOLUTION each:
n/a
ECLIPSE each: n/a
ECLIPSE each: n/a
ECLIPSE strip
ELEMENT BLOOD GLUCOSE METER
ELEMENT COMPACT CONTROL SOLN
each: n/a
ELEMENT COMPACT CONTROL SOLN
each: n/a
ELEMENT COMPACT each
ELEMENT COMPACT strip
ELEMENT CONTROL SOLUTION each:
n/a
ELEMENT CONTROL SOLUTION each:
n/a
ELEMENT CONTROL SOLUTION each:
n/a
ELEMENT PLUS CONTROL SOLUTION
each: n/a
ELEMENT PLUS CONTROL SOLUTION
each: n/a
ELEMENT PLUS CONTROL SOLUTION
each: n/a
ELEMENT PLUS kit
ELEMENT PLUS strip
ELEMENT TEST STRIPS
EMBRACE EVO each: n/a
EMBRACE EVO each: n/a
EMBRACE EVO kit
EMBRACE EVO strip
EMBRACE GLUCOSE CONTROL SOLN
EMBRACE PRO each: n/a
EMBRACE PRO each: n/a
EMBRACE PRO strip
EMBRACE each: 30gauge
EMBRACE each: n/a
EMBRACE each: n/a; kit
EMBRACE strip
Requirements/Limits
3
3
3
3
3
3
3
QL: 360 in 30 days
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
86
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
ENLITE
ENVISION each: n/a
ENVISION each: n/a
ENVISION each: n/a
ENVISION kit
ENVISION strip
EVENCARE G2 each: n/a
EVENCARE G2 each: n/a
EVENCARE G2 strip
EVENCARE G3 each
EVENCARE G3 kit
EVENCARE G3 strip
EVENCARE each
EVENCARE kit
EVENCARE strip
EVOLUTION BLOOD GLUCOSE
METER
EVOLUTION CONTROL SOLUTION
EVOLUTION TEST STRIPS
EZ SMART PLUS kit
EZ SMART PLUS strip
EZ SMART each: n/a
EZ SMART each: n/a
EZ SMART each: n/a
EZ SMART kit
EZ SMART strip
FIFTY50 TEST STRIP
FORA D10 kit
FORA D10 strip
FORA D15C
FORA D15G
FORA D15Z
FORA D20 kit
FORA D20 strip
FORA G20 kit
FORA G20 strip
FORA G30A each
FORA G30A strip
FORA G71A kit
FORA G71A strip
FORA G90 each
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Requirements/Limits
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
87
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
FORA G90 strip
FORA GD50 TEST STRIPS
FORA GD50
FORA TEST N'GO TEST STRIPS
FORA TEST N'GO VOICE
FORA TEST STRIP
FORA V10 kit
FORA V10 strip
FORA V12 each, kit
FORA V12 strip
FORA V20 kit
FORA V20 strip
FORA V22 each
FORA V22 strip
FORA V30A each, kit
FORA V30A strip
FORACARE GD20 each
FORACARE GD20 strip
FORACARE GD40A
FORACARE GD40B
FORACARE GD40
FORACARE GDH each: n/a
FORACARE GDH each: n/a
FORACARE GDH each: n/a
FORTISCARE BLOOD GLUCOSE SYST
FORTISCARE GLUCOSE TEST STRIPS
FORTISCARE
FREESTYLE CONTROL SOLUTION
each: n/a
FREESTYLE CONTROL SOLUTION
each: n/a
FREESTYLE FLASH SYSTEM
FREESTYLE FREEDOM LITE
FREESTYLE FREEDOM
FREESTYLE INSULINX TEST STRIPS
FREESTYLE INSULINX each
FREESTYLE INSULINX strip
FREESTYLE LANCETS
FREESTYLE LITE METER
FREESTYLE LITE STRIPS
FREESTYLE LITE TEST STRIPS
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Requirements/Limits
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
3
3
3
3
3
3
3
3
3
3
3
QL: 1 in 1 days
QL: 1 in 1 days
QL: 1 in 1 days
QL: 360 in 30 days
88
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
FREESTYLE NAVIGATOR
FREESTYLE SIDEKICK II
FREESTYLE SYSTEM
FREESTYLE TEST STRIPS
G-4 kit
G-4 strip
GDRIVE
GE100 BLOOD GLUCOSE SYSTEM
GE100 BLOOD GLUCOSE TEST STRIP
GE100 CONTROL SOLUTION
NORMAL
GENSTRIP
GLUCO NAVII kit
GLUCO NAVII strip
GLUCOCARD 01 CONTROL each: n/a
GLUCOCARD 01 CONTROL each: n/a
GLUCOCARD 01 SENSOR
GLUCOCARD 01
GLUCOCARD 01-MINI
GLUCOCARD EXPRESSION each: n/a
GLUCOCARD EXPRESSION each: n/a;
kit
GLUCOCARD EXPRESSION strip
GLUCOCARD VITAL SENSOR
GLUCOCARD VITAL
GLUCOCARD X-SENSOR
GLUCOCOM GLUCOSE
GLUCOLAB CONTROL each: n/a
GLUCOLAB CONTROL each: n/a
GLUCOLAB CONTROL each: n/a
GLUCOLAB kit
GLUCOLAB strip
GLUCOSE TEST STRIP
GMATE CONTROL SOLUTION each: n/
a
GMATE CONTROL SOLUTION each: n/
a
GMATE LANCING DEVICE
GMATE SMART METER
GMATE SMART STARTER
GMATE TEST STRIPS
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Requirements/Limits
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
3
3
3
3
3
89
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
GMATE VOICE METER
GMATE VOICE STARTER
GMATE
HEALTHPRO GLUCOSE CONTROL
SOLN
HEALTHPRO GLUCOSE MONITOR
HEALTHPRO TEST STRIPS
IBG-STAR
INFINITY CONTROL SOLUTION each:
n/a
INFINITY CONTROL SOLUTION each:
n/a
INFINITY CONTROL SOLUTION each:
n/a
INFINITY TEST STRIPS
INFINITY
KEYNOTE PRO
KEYNOTE each
KEYNOTE strip
LANCETS THIN each: 23gauge
LANCETS ULTRA THIN
LIBERTY BLOOD GLUCOSE METER
LIBERTY CONTROL SOLUTION each:
n/a
LIBERTY CONTROL SOLUTION each:
n/a
LIBERTY LEV 1 GLUCOSE CONTROL
LIBERTY MONITOR
LIBERTY TEST STRIPS
MAXIMA
MEDISENSE CONTROL
MEDISENSE combo. pkg
MEDISENSE each
MEDLANCE PLUS SPECIAL BLADE
METER-CHECK
MICRO THIN LANCETS
MICRO kit
MICRODOT XTRA
MICRODOT each: n/a
MICRODOT each: n/a
MICRODOT each: n/a; kit
Requirements/Limits
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
QL: 360 in 30 days
QL: 360 in 30 days
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
90
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
MICRODOT strip
MICRO strip
MINI LANCING DEVICE
MONOLET THIN LANCETS
MYGLUCOHEALTH kit
MYGLUCOHEALTH strip
NEUTEK 2TEK TEST STRIPS
NOVA MAX BLOOD GLUCOSE
METER
NOVA MAX GLUCOSE CONTROL
SOLN
NOVA MAX GLUCOSE TEST STRIPS
NOVA SUREFLEX
NOVAMAX PLUS GLU-KET
NOVAMAX PLUS
ON CALL EXPRESS CONTROL SOLN
ON CALL EXPRESS METER
ON CALL EXPRESS TEST STRIP
ON CALL LANCET
ON CALL LANCING DEVICE
ON CALL PLUS CONTROL
ON CALL PLUS LANCET
ON CALL PLUS LANCING DEVICE
ON CALL PLUS METER
ON CALL PLUS TEST STRIP
ON CALL VIVID CONTROL
ON CALL VIVID METER
ON CALL VIVID PAL
ON CALL VIVID TEST STRIP
ONE TOUCH DELICA each
ONE TOUCH DELICA kit
ONE TOUCH GLUCOSE CONTROL
SOLN
ONE TOUCH LANCETS
ONE TOUCH SURESOFT
ONE TOUCH ULTRA 2
ONE TOUCH ULTRA CONTROL SOLN
ONE TOUCH ULTRA SYSTEM
ONE TOUCH ULTRA TEST STRIPS
ONE TOUCH ULTRALINK
ONE TOUCH ULTRAMINI
3
3
3
3
3
3
3
3
Requirements/Limits
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
QL: 360 in 30 days
3
3
3
3
3
3
3
3
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
91
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
ONE TOUCH VERIO IQ
ONE TOUCH VERIO SYNC
ONE TOUCH VERIO each: n/a
ONE TOUCH VERIO each: n/a
ONE TOUCH VERIO each: n/a
ONE TOUCH VERIO strip
ON-THE-GO
OPTIUM EZ
OPTIUM
OPTUMRX each: n/a
OPTUMRX each: n/a; kit
OPTUMRX strip
PHARMACIST CHOICE each
PHARMACIST CHOICE strip
POCKETCHEM EZ kit
POCKETCHEM EZ strip
PRECISION GLUCOSE CONTROL
PRECISION PCX PLUS
PRECISION PCX
PRECISION POINT OF CARE
PRECISION Q-I-D
PRECISION XTRA each
PRECISION XTRA strip: n/a
PRECISION XTRA strip: n/a
PRECISION combo. pkg
PRECISION each
PREMIUM BLOOD GLUCOSE TEST
PREMIUM BLOOD GLUCOSE
PREMIUM V10 each
PREMIUM V10 strip
PRESTIGE SMART SYSTEM
PRESTO PRO
PRODIGY AUTOCODE PRO
PRODIGY AUTOCODE
PRODIGY CONTROL SOLUTION
PRODIGY NO CODING
PRODIGY POCKET PRO
PRODIGY POCKET
PRODIGY VOICE PRO
PRODIGY VOICE
PRODIGY
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Requirements/Limits
PA
PA
PA, QL: 4 in 1 days
PA
PA
PA
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
92
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
QUINTET AC each
QUINTET AC strip
QUINTET each
QUINTET strip
REFUAH PLUS GLUCOSE CONTROL
REFUAH PLUS kit
REFUAH PLUS strip
RELIAMED MINI LANCING DEVICE
RELIAMED SAFETY SEAL LANCETS
RELIAMED each: 23gauge, 30gauge
RELION CONFIRM
RELION CONFIRM-MICRO
RELION MICRO
RELION PRIME TEST STRIPS
RELION PRIME
RELION THIN
REVEAL BLOOD GLUCOSE METER
REVEAL TEST STRIP
RIGHTEST CONTROL SOLUTION
each: n/a
RIGHTEST CONTROL SOLUTION
each: n/a
RIGHTEST GC250S CONTROL SOLN
RIGHTEST GM100 SYSTEM
RIGHTEST GM250S METER
RIGHTEST GM260 METER
RIGHTEST GM300 SYSTEM
RIGHTEST GM550 SYSTEM
RIGHTEST GS100 TEST STRIPS
RIGHTEST GS250S TEST STRIPS
RIGHTEST GS260 TEST STRIPS
RIGHTEST GS300 TEST STRIPS
RIGHTEST GS550 TEST STRIPS
RIGHTSOURCE
SEVEN PLUS each: n/a
SEVEN SYSTEM SENSOR
SIDEKICK
SMART CARESENS N kit
SMART CARESENS N strip
SMART SENSE MONITORING
SYSTEM
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Requirements/Limits
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
93
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
SMART SENSE TEST STRIPS
SMARTDIABETES XPRES kit
SMARTDIABETES XPRES strip
SMARTEST EJECT
SMARTEST PERSONA
SMARTEST PRONTO
SMARTEST PROTEGE
SMARTEST SMART CODE
SMARTEST TALKING
SMARTEST TEST
SMARTEST
SMS GLUCOSE CONTROL
SOF-SENSOR
SOLUS V2 CONTROL SOLUTION each:
n/a
SOLUS V2 CONTROL SOLUTION each:
n/a
SOLUS V2 TEST STRIPS
SOLUS V2 each: 28gauge
SOLUS V2 each: n/a; kit
SURE EDGE BLOOD GLUCOSE
METER
SURE EDGE GLUCOSE CONTROL
SOLN each: n/a
SURE EDGE GLUCOSE CONTROL
SOLN each: n/a
SURE EDGE GLUCOSE CONTROL
SOLN each: n/a
SURE EDGE TEST STRIPS
SURECHEK GLUCOSE CONTROL
SURECHEK TEST STRIPS
SURESTEP CONTROL SOLUTION
SURESTEP PRO each: n/a
SURESTEP PRO each: n/a
SURESTEP PRO each: n/a
SURESTEP PRO kit
SURESTEP PRO strip
SURE-TEST EASYPLUS MINI each: n/a
SURE-TEST EASYPLUS MINI each: n/a
SURE-TEST EASYPLUS MINI strip
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Requirements/Limits
QL: 360 in 30 days
QL: 360 in 30 days
3
3
3
3
3
QL: 360 in 30 days
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
94
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
TD GOLD BLOOD GLUCOSE
MONITOR
TD GOLD LEVEL 1 CONTROL SOL
TD GOLD LEVEL 2 CONTROL SOL
TD GOLD LEVEL 3 CONTROL SOL
TD GOLD TEST STRIP
TD GOLD VOICE GLUCOSE MONITOR
TECHLITE LANCETS
TELCARE BGM
TELCARE CONTROL SOLUTION
TELCARE each
TELCARE kit
TELCARE strip
TEST N'GO each
TEST N'GO strip
THIN LANCETS
TRUE METRIX BLOOD GLUCOSE
MTR
TRUE METRIX GLUCOSE TEST STRIP
TRUE METRIX each: n/a
TRUE METRIX each: n/a
TRUE METRIX each: n/a
TRUE2GO BLOOD GLUCOSE SYSTEM
TRUECONTROL
TRUERESULT BLOOD GLUCOSE
SYSTM
TRUETEST GLUCOSE CONTROL
TRUETEST TEST STRIPS
TRUETRACK BLOOD GLUCOSE
SYSTEM
TRUETRACK SMART SYSTEM kit
TRUETRACK SMART SYSTEM strip
TRUETRACK TEST STRIP
TRUETRACK
ULTIMA each
ULTIMA strip
ULTRATRAK PRO
ULTRATRAK ULTIMATE each: n/a
ULTRATRAK ULTIMATE each: n/a
ULTRATRAK ULTIMATE strip
ULTRATRAK each: n/a
Requirements/Limits
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
QL: 360 in 30 days
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
95
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
ULTRATRAK each: n/a
ULTRATRAK each: n/a
ULTRATRAK strip
UNISTRIP1
UNISTRIP each: n/a
UNISTRIP each: n/a
VICTORY each: n/a
VICTORY each: n/a
VICTORY strip
VOCAL POINT GLUCOSE CONTROL
VOCAL POINT
VOCALPOINT GLUCOSE CONTROL
WAVESENSE AMP
WAVESENSE CONTROL SOLUTION
WAVESENSE JAZZ kit
WAVESENSE JAZZ strip
WAVESENSE PRESTO each, kit
WAVESENSE PRESTO strip
XPRES
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Requirements/Limits
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
QL: 360 in 30 days
Enzyme Replacement/Modifiers
Enzyme Replacement/Modifiers
lipase/protease/amylase
CREON
CYSTAGON
LINZESS
CHENODAL
LOTRONEX tablet: 1mg
LOTRONEX tablet: 0.5mg
ORFADIN
PANCREAZE
PERTZYE
ULTRESA
VIOKACE
ZAVESCA
ZENPEP
KUVAN
(Zenpep)
1
2
2
2
3
3
3
3
3
3
3
3
3
3
S-T1
PULMOZYME
S-T1
ADAGEN
S-T2
QL: 30 in 30 days
QL: 60 in 30 days
(Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
96
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
Requirements/Limits
CIMZIA
S-T2
SUCRAID
S-T2
PA (Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
Eye, Ear, Nose, Throat Agents
Eye, Ear, Nose, Throat Agents, Miscellaneous
apraclonidine hcl
(Iopidine)
atropine sulfate
(Isopto Atropine)
azelastine hcl spray/pump
(Astepro)
azelastine hcl drops
(Optivar)
carteolol hcl
(Carteolol HCl)
cromolyn sodium
(Cromolyn Sodium)
cyclopentolate hcl
(Cyclogyl)
epinastine hcl
(Elestat)
homatropine hbr
(Isopto Homatropine)
ipratropium bromide
(Atrovent)
naphazoline hcl drops: 0.1%
(Naphazoline HCl)
naphazoline hcl/antazoline
(Naphazoline HCl/
Antazoline)
olopatadine hcl
(Patanase)
phenylephrine hcl
(Mydfrin)
proparacaine hcl
(Proparacaine HCl)
proparacaine/fluorescein sod
(Proparacaine/
Fluorescein Sod)
tropicamide
(Mydral)
ALAMAST
IOPIDINE droperette
PATADAY
PATANOL
ADRENALIN CHLORIDE
AKTEN
ALOMIDE
ASTELIN
ASTEPRO
ATROVENT
BEPREVE
CYCLOGYL
CYCLOMYDRIL
DYMISTA
ELESTAT
EMADINE
1
1
1
1
1
1
1
1
1
1
1
1
QL: 30 in 25 days
1
1
1
1
1
2
2
2
2
3
3
3
3
3
3
3
3
3
3
3
3
QL: 30 in 25 days
QL: 30 in 25 days
97
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
FRESHKOTE
GELFILM
IOPIDINE drops
ISOPTO ATROPINE
ISOPTO HOMATROPINE
ISOPTO HYOSCINE
LACRISERT
LASTACAFT
LATISSE
MYDFRIN
MYDRIACYL
OPTIVAR
OTICIN
PAREMYD
PATANASE
TETCAINE
TETRAVISC FORTE
TYZINE
CYSTARAN
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
S-T1
Eye, Ear, Nose, Throat Anti-Infectives Agents
aa/antipyrn/bcaine/polico#1/al
(Auralgan)
aa/antpy/bcaine/polico/al acet
(Aa/Antpy/Bcaine/
Polico/Al Acet)
acetic acid
(Vosol)
acetic acid/aluminum acetate
(Acetic Acid/
Aluminum Acetate)
acetic acid/hydrocortisone
(Vosol HC)
antipyrine/benzocaine
(Antipyrine/
Benzocaine)
bacitracin
(Bacitracin)
bacitracin/polymyxin b sulfate
(Bacitracin/Polymyxin
B Sulfate)
ciprofloxacin hcl
(Ciloxan)
CORTISPORIN drops susp: 3.5-10k-1
cresyl acetate
(Cresyl Acetate)
erythromycin base
(Erythromycin Base)
gatifloxacin
(Zymaxid)
gentamicin sulfate
(Garamycin)
levofloxacin
(Quixin)
neo/polymyx b sulf/dexameth
(Maxitrol)
Requirements/Limits
(Specialty Preferred
Drug List)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
98
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
neomy sulf/bacitra/polymyxin b
neomy sulf/bacitrac zn/poly/hc
neomycin sulfate/dex na ph
neomycin/polymyxin b sulf/hc
neomycin/polymyxn b/gramicidin
ofloxacin
polymyxin b sulf/trimethoprim
sulfacetamide sodium
sulfacetamide/prednisolone sp
tobramycin
tobramycin/dexamethasone
trifluridine
BLEPHAMIDE S.O.P.
BLEPHAMIDE
CILOXAN oint. (g)
CIPRODEX
COLY-MYCIN S
CORTISPORIN-TC
MOXEZA
TOBRADEX oint. (g)
TOBREX oint. (g)
VIGAMOX
ZIRGAN
AZASITE
BESIVANCE
CETRAXAL
CILOXAN drops
CIPRO HC
CORTISPORIN drops susp: n/a
CORTISPORIN solution
FLOXIN
GARAMYCIN
ILOTYCIN
IQUIX
MAXITROL
NATACYN
NEO-POLYCIN
Drug Tier
(Triple Antibiotic)
(Neomy Sulf/Bacitrac
Zn/Poly/HC)
(Neomycin Sulfate/Dex
Na Ph)
(Cortisporin)
(Neosporin)
(Ocuflox)
(Polytrim)
(Sulfacetamide
Sodium)
(Sulfacetamide/
Prednisolone Sp)
(Tobrex)
(Tobradex)
(Viroptic)
Requirements/Limits
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
QL: 5 in 28 days
99
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
NEOSPORIN drops
NEOSPORIN oint.(gm)
OCUFLOX
OPTIMYD
OTICIN HC
OTOZIN
POLYTRIM
PRED-G
QUIXIN
TERAK
TERRAMYCIN WITH POLYMYXIN
TOBRADEX ST
TOBRADEX drops susp
TOBREX drops
VIROPTIC
VOSOL HC
VOSOL
ZYLET
ZYMAR
ZYMAXID
Eye, Ear, Nose, Throat Anti-Inflammatory Agents
bromfenac sodium
(Bromfenac Sodium)
budesonide
(Rhinocort Aqua)
chloroxylenol/benzoc/hydrocort
(Chloroxylenol/
Benzoc/Hydrocort)
dexamethasone sod phosphate
(Dexasol)
diclofenac sodium
(Diclofenac Sodium)
flunisolide spray: 25mcg
(Flunisolide)
flunisolide spray: 29mcg
(Flunisolide)
fluocinolone acetonide oil
(Dermotic)
fluorometholone
(FML)
flurbiprofen sodium
(Ocufen)
fluticasone propionate
(Flonase)
hc/pramoxine hcl/chloroxylenol
(Oticin HC)
ketorolac tromethamine
(Acular LS)
prednisolone acetate
(Pred Forte)
prednisolone sod phosphate
(Prednisol)
triamcinolone acetonide
(Nasacort Aq)
CHILDREN'S QNASL
FLAREX
FML FORTE
Requirements/Limits
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
QL: 75 in 30 days
QL: 75 in 31 days
QL: 33 in 30 days
100
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
FML S.O.P.
ILEVRO
LOTEMAX
NASONEX
NEVANAC
PRED MILD
QNASL
RESTASIS
ACULAR LS
ACULAR
ACUVAIL
ALOCRIL
ALREX
BECONASE AQ
BROMDAY
CORTANE-B
DECADRON
DERMOTIC
DEXASOL
DUREZOL
FLONASE
FML
MAXIDEX
NASACORT AQ
OCUFEN
OMNARIS
OMNIPRED
OTICIN HC
PRED FORTE
PROLENSA
RHINOCORT AQUA
TRIOXIN
VERAMYST
VEXOL
VOLTAREN
ZETONNA
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Requirements/Limits
QL: 34 in 30 days
QL: 64 in 30 days
QL: 50 in 30 days
QL: 33 in 30 days
Gastrointestinal Agents
Antiulcer Agents And Acid Suppressants
ACIPHEX
1
ST, QL: 60 in 30 days
(See PPI Coverage
Limitation)
101
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
cimetidine hcl solution
cimetidine
famotidine oral susp, tablet
FIRST-OMEPRAZOLE
(Cimetidine HCl)
(Cimetidine)
(Pepcid)
1
1
1
1
lansoprazole capsule dr: 15mg, 30mg; tab
rap dr
(Prevacid)
1
lansoprazole/amoxiciln/clarith
(Prevpac)
1
misoprostol
nizatidine
omeprazole capsule dr: 20mg
(Cytotec)
(Axid)
(Prilosec)
1
1
1
omeprazole capsule dr: 10mg, 40mg
(Prilosec)
1
omeprazole/sodium bicarbonate
(Zegerid)
1
pantoprazole sodium tablet dr
(Protonix)
1
rabeprazole sodium
(Aciphex)
1
ranitidine hcl capsule, syrup, tablet:
150mg, 300mg
sucralfate
FIRST-LANSOPRAZOLE
(Zantac)
1
(Carafate)
1
2
PREVACID tab rap dr: 30mg
2
PROTONIX tablet dr: 40mg
2
ACIPHEX SPRINKLE
3
Requirements/Limits
(See PPI Coverage
Limitation)
QL: 60 in 30 days (See
PPI Coverage
Limitation)
QL: 112 per fill (See
PPI Coverage
Limitation)
QL: 120 in 30 days (See
PPI Coverage
Limitation)
QL: 60 in 30 days (See
PPI Coverage
Limitation)
QL: 60 in 30 days (See
PPI Coverage
Limitation)
QL: 60 in 30 days (See
PPI Coverage
Limitation)
ST, QL: 60 in 30 days
(See PPI Coverage
Limitation)
(See PPI Coverage
Limitation)
QL: 60 in 30 days (See
PPI Coverage
Limitation)
ST, QL: 60 in 30 days
(See PPI Coverage
Limitation)
ST, QL: 60 in 30 days
(See PPI Coverage
Limitation)
102
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
AXID
CARAFATE
CYTOTEC
DEPRIZINE
DEXILANT
3
3
3
3
3
ESOMEPRAZOLE STRONTIUM
3
NEXIUM 24HR
3
NEXIUM
3
OMECLAMOX-PAK
3
PEPCID RPD
PEPCID oral susp, tablet: 20mg
PEPCID tablet: 40mg
PREVACID 24HR
3
3
3
3
PREVACID capsule dr, tab rap dr: 15mg
3
PREVPAC
3
PRILOSEC capsule dr: 20mg
3
PRILOSEC suspdr pkt
3
PRILOSEC capsule dr: 10mg, 40mg
3
PROTONIX granpkt dr, tablet dr: 20mg
3
Requirements/Limits
ST, QL: 60 in 30 days
(See PPI Coverage
Limitation)
(See PPI Coverage
Limitation)
ST, QL: 60 in 30 days
(See PPI Coverage
Limitation)
ST, QL: 60 in 30 days
(See PPI Coverage
Limitation)
ST, QL: 80 per fill (See
PPI Coverage
Limitation)
ST, QL: 60 in 30 days
ST, QL: 60 in 30 days
(See PPI Coverage
Limitation)
ST, QL: 60 in 30 days
(See PPI Coverage
Limitation)
QL: 112 per fill (See
PPI Coverage
Limitation)
ST, QL: 120 in 30 days
(See PPI Coverage
Limitation)
ST, QL: 120 in 30 days
(See PPI Coverage
Limitation)
ST, QL: 60 in 30 days
(See PPI Coverage
Limitation)
ST, QL: 60 in 30 days
(See PPI Coverage
Limitation)
103
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
TAGAMET
ZANTAC 25
ZANTAC syrup, tablet: 150mg, 300mg;
vial
ZEGERID
Gastrointestinal Agents, Other
cromolyn sodium
dicyclomine hcl capsule, solution, tablet
diphenoxylate hcl/atropine
glycopyrrolate
hyoscyamine sulfate
isopropamide/prochlorperazine
lactulose
loperamide hcl
methscopolamine bromide
metoclopramide hcl solution, tablet
opium tincture
paregoric
ursodiol
ACTIGALL
AMITIZA
ANASPAZ
BENTYL
BUPHENYL tablet
CANTIL
CESINEX
CUVPOSA
DIGEX NF
FULYZAQ
GASTRINEX NF
GASTROCROM
GLYCATE
HELIDAC
KRISTALOSE
LEVBID
LEVSIN tablet
LEVSIN-SL
LOMOTIL
Requirements/Limits
3
3
3
3
(Gastrocrom)
(Bentyl)
(Lomotil)
(Robinul)
(Levsin-Sl)
(Isopropamide/
Prochlorperazine)
(Lactulose)
(Loperamide HCl)
(Pamine)
(Reglan)
(Opium Tincture)
(Paregoric)
(Actigall)
ST, QL: 60 in 30 days
(See PPI Coverage
Limitation)
1
1
1
1
1
1
1
1
1
1
1
1
1
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
QL: 60 in 30 days
PA
104
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
METOCLOPRAMIDE HCL INTENSOL
METOZOLV ODT
MOTOFEN
NULEV
PAMINE FORTE
PAMINE
PYLERA
REGLAN
ROBINUL FORTE
ROBINUL tablet
SYMAX
SYMAX-SL
SYMAX-SR
UCEPHAN
URSO FORTE
URSO
XENICAL
CARBAGLU
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
S-T1
RAVICTI
S-T1
RELISTOR
S-T1
RELISTOR
S-T1
Laxatives
peg 3350/na sulf,bicarb,cl/kcl
PEG 3350-GRX
polyethylene glycol 3350
sodium chloride/nahco3/kcl/peg
(Golytely)
(Polyethylene Glycol
3350)
(Nulytely with Flavor
Packs)
GOLYTELY powd pack
MOVIPREP
COLYTE WITH FLAVOR PACKS
GOLYTELY soln recon
HALFLYTELY-BISACODYL
NULYTELY WITH FLAVOR PACKS
OSMOPREP
PREPOPIK
Requirements/Limits
PA (Specialty Preferred
Drug List)
PA (Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
(Specialty Preferred
Drug List); (Specialty
Preferred Drug List)
1
1
1
1
2
2
3
3
3
3
3
3
105
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
SUCLEAR
SUPREP
VISICOL
Phosphate Binders
calcium acetate capsule, tablet: 667mg
calcium carbonate/mag carb/fa
sevelamer carbonate
sodium polystyrene sulfonate
Drug Tier
Requirements/Limits
3
3
3
(Phoslo)
(Calcium Carbonate/
Mag Carb/Fa)
(Renvela)
(Sodium Polystyrene
Sulfonate)
RENAGEL
RENVELA powd pack
AURYXIA
FOSRENOL
KAYEXALATE
PHOSLO
PHOSLYRA
RENVELA tablet
VELPHORO
1
1
1
1
2
2
3
3
3
3
3
3
3
Genitourinary Agents
Antispasmodics, Urinary
flavoxate hcl
oxybutynin chloride tab er 24: 15mg
oxybutynin chloride syrup, tab er 24: 5mg,
10mg; tablet
tolterodine tartrate
trospium chloride cap er 24h
trospium chloride tablet
TOVIAZ
VESICARE
DETROL LA
DETROL
DITROPAN XL tab er 24: 5mg, 10mg
DITROPAN XL tab er 24: 15mg
ENABLEX
GELNIQUE gel packet
GELNIQUE gel md pmp
MYRBETRIQ
SANCTURA XR
SANCTURA
(Flavoxate HCl)
(Ditropan XL)
(Oxybutynin Chloride)
1
1
1
(Detrol)
(Sanctura XR)
(Sanctura)
1
1
1
2
2
3
3
3
3
3
3
3
3
3
3
QL: 60 in 30 days
QL: 30 in 30 days
QL: 60 in 30 days
QL: 30 in 30 days
QL: 30 in 30 days
QL: 60 in 30 days
QL: 60 in 30 days
QL: 30 in 30 days
QL: 92 in 30 days
QL: 30 in 30 days
QL: 60 in 30 days
106
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
Genitourinary Agents, Miscellaneous
alfuzosin hcl
(Uroxatral)
phenazopy hcl/hyoscy/butabarb
(Phenazopy HCl/
Hyoscy/Butabarb)
phenazopyridine hcl
(Phenazopyridine HCl)
tamsulosin hcl
(Flomax)
terazosin hcl
(Terazosin HCl)
FLOMAX
RAPAFLO
UROXATRAL
Requirements/Limits
1
1
1
1
1
3
3
3
QL: 30 in 30 days
Heavy Metal Antagonists
Heavy Metal Antagonists
CHEMET
CUPRIMINE
DEPEN
FERRIPROX
GALZIN
SYPRINE
EXJADE
2
2
2
3
3
3
S-T1
(Specialty Preferred
Drug List)
Hormonal Agents, Stimulant/Replacement/Modifying
Androgens
danazol
estrogen,ester/me-testosterone
fluoxymesterone
oxandrolone
testosterone cypionate
testosterone enanthate
testosterone gel (gram), gel md pmp:
1.25g(1%); gel packet
ANDRODERM
ANDROID
AXIRON
DIHYDROTESTOSTERONE
PROPIONATE
METHITEST
METHYLTESTOSTERONE
MICRONIZED
TESTOSTERONE CYPIONATE MICRO
(Danazol)
(Estrogen,Ester/MeTestosterone)
(Fluoxymesterone)
(Oxandrin)
(Testosterone
Cypionate)
(Delatestryl)
(Androgel)
1
1
1
1
1
1
1
2
2
2
2
2
2
2
107
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
TESTOSTERONE ENANTHATE
TESTOSTERONE PROPIONATE
TESTOSTERONE
TESTRED
ANADROL-50
ANDROGEL
AVEED
DELATESTRYL
DEPO-TESTOSTERONE
FIRST-TESTOSTERONE MC
FIRST-TESTOSTERONE
FORTESTA
OXANDRIN
STRIANT
TESTIM
testosterone gel md pmp: 10mg(2%)
VOGELXO
Estrogens and Antiestrogens
clomiphene citrate
estradiol patch tdwk
estradiol tablet
estradiol patch tdsw
estradiol/norethindrone acet tablet: 0.50.1mg, 1mg-0.5mg
estropipate tablet: 0.75mg, 1.5mg
estropipate tablet: 3mg
norethindrone ac-eth estradiol
COMBIPATCH
DIVIGEL
DUAVEE
ESTRACE cream/appl
ESTRADERM
ESTRADIOL BENZOATE
ESTRADIOL CYPIONATE
ESTRADIOL MICRONIZED
ESTRADIOL VALERATE
ESTRING
ETHINYL ESTRADIOL
OSPHENA
PREMARIN cream/appl, tablet
Drug Tier
(Androgel)
Requirements/Limits
2
2
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
(Clomiphene Citrate)
1
(Climara)
(Estrace)
(Vivelle-Dot)
(Activella)
1
1
1
1
(Estropipate)
(Estropipate)
(Femhrt)
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
(See INF Coverage
Limitation)
QL: 4 in 28 days
QL: 8 in 28 days
QL: 30 in 30 days
QL: 30 in 30 days
QL: 8 in 28 days
ST
108
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
PREMPHASE
PREMPRO
VAGIFEM
VIVELLE-DOT
ACTIVELLA
ALORA
CENESTIN
CLIMARA PRO
CLIMARA
ELESTRIN
ENJUVIA
ESTRACE tablet
ESTRASORB
ESTROGEL
EVAMIST
EVISTA
FEMHRT
FEMRING
FEMTRACE
MENEST
MENOSTAR
MINIVELLE
OGEN
PREFEST
SEROPHENE
2
2
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
ANGELIQ
estradiol/norethindrone acet tablet: 0.5(Activella)
0.1mg, 1mg-0.5mg
raloxifene hcl
(Evista)
Glucocorticoids/Mineralocorticoids
cortisone acetate
(Cortisone Acetate)
dexamethasone acetate
(Dexamethasone
Acetate)
dexamethasone sod phosphate
(Dexamethasone Sod
Phosphate)
dexamethasone
(Dexamethasone)
fludrocortisone acetate
(Fludrocortisone
Acetate)
hydrocortisone
(Cortef)
methylprednisolone
(Medrol)
PREV
PREV
Requirements/Limits
QL: 8 in 28 days
QL: 8 in 28 days
QL: 4 in 28 days
QL: 98 in 28 days
QL: 4 in 28 days
QL: 8 in 28 days
(See INF Coverage
Limitation)
ST
PREV
1
1
1
1
1
1
1
109
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
prednisolone sod phosphate
prednisolone
prednisone
A-HYDROCORT
DEXAMETHASONE INTENSOL
MILLIPRED DP
MILLIPRED solution
MILLIPRED tablet
PREDNISONE INTENSOL
SOLU-CORTEF vial: 1000mg/8ml
TRIAMCINOLONE DIACETATE
TRIAMCINOLONE
ARISTOCORT
CELESTONE solution
CELESTONE vial
CORTEF
DEPO-MEDROL
DEXPAK
FLO-PRED
MEDROL
ORAPRED ODT
ORAPRED
PEDIAPRED
RAYOS
VERIPRED 20
Pituitary
desmopressin acetate solution, spray/pump,
tablet
STIMATE
DDAVP solution, tablet
DDAVP spray/pump
METOPIRONE
BRAVELLE
Drug Tier
(Orapred)
(Prednisolone)
(Prednisone)
1
1
1
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
(DDAVP)
1
2
3
3
3
S-T1
CETROTIDE
S-T1
FOLLISTIM AQ
S-T1
Requirements/Limits
(Specialty Preferred
Drug List/See INF
Coverage Limitation)
(Specialty Preferred
Drug List/See INF
Coverage Limitation)
(Specialty Preferred
Drug List/See INF
Coverage Limitation)
110
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
Requirements/Limits
INCRELEX
S-T1
MENOPUR
S-T1
PA (Specialty Preferred
Drug List)
(Specialty Preferred
Drug List/See INF
Coverage Limitation)
(Specialty Preferred
Drug List)
PA (Specialty Preferred
Drug List/See GH
Coverage Limitation)
(Specialty Preferred
Drug List/See INF
Coverage Limitation)
(Specialty Preferred
Drug List/See INF
Coverage Limitation)
(Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
(Specialty Preferred
Drug List/See INF
Coverage Limitation)
PA (Specialty Preferred
Drug List)
PA (Specialty Preferred
Drug List/See GH
Coverage Limitation)
(Specialty Preferred
Drug List/See INF
Coverage Limitation)
(Specialty Preferred
Drug List/See INF
Coverage Limitation)
(Specialty Preferred
Drug List/See INF
Coverage Limitation)
PA (Specialty Preferred
Drug List/See GH
Coverage Limitation)
octreotide acetate
(Sandostatin)
S-T1
OMNITROPE
S-T1
PREGNYL
S-T1
REPRONEX
S-T1
SANDOSTATIN LAR
S-T1
SOMATULINE DEPOT
S-T1
CHORIONIC GONADOTROPIN
S-T2
EGRIFTA
S-T2
GENOTROPIN
S-T2
GONAL-F RFF REDI-JECT
S-T2
GONAL-F RFF
S-T2
GONAL-F
S-T2
HUMATROPE
S-T2
111
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
Requirements/Limits
NORDITROPIN FLEXPRO
S-T2
NORDITROPIN NORDIFLEX
S-T2
NOVAREL
S-T2
NUTROPIN AQ NUSPIN
S-T2
NUTROPIN AQ NUSPIN
S-T2
NUTROPIN AQ
S-T2
NUTROPIN
S-T2
OVIDREL
S-T2
SAIZEN
S-T2
SANDOSTATIN
S-T2
SEROSTIM
S-T2
SOMAVERT
S-T2
TEV-TROPIN
S-T2
ZORBTIVE
S-T2
PA (Specialty Preferred
Drug List/See GH
Coverage Limitation)
PA (Specialty Preferred
Drug List/See GH
Coverage Limitation)
(Specialty Preferred
Drug List/See INF
Coverage Limitation)
PA (Specialty Preferred
Drug List)
PA (Specialty Preferred
Drug List/See GH
Coverage Limitation)
PA (Specialty Preferred
Drug List/See GH
Coverage Limitation)
PA (Specialty Preferred
Drug List/See GH
Coverage Limitation)
(Specialty Preferred
Drug List/See INF
Coverage Limitation)
PA (Specialty Preferred
Drug List/See GH
Coverage Limitation)
(Specialty Preferred
Drug List)
PA (Specialty Preferred
Drug List/See GH
Coverage Limitation)
(Specialty Preferred
Drug List)
PA (Specialty Preferred
Drug List/See GH
Coverage Limitation)
PA (Specialty Preferred
Drug List/See GH
Coverage Limitation)
Progestins
medroxyprogesterone acet
(Medroxyprogesterone
Acet)
1
112
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
medroxyprogesterone acetate
norethindrone acetate
progesterone
progesterone,micronized
CRINONE
Drug Tier
(Provera)
(Aygestin)
(Progesterone)
(Prometrium)
1
1
1
1
2
ENDOMETRIN
FIRST-PROGESTERONE VGS 100
FIRST-PROGESTERONE VGS 200
FIRST-PROGESTERONE VGS 25
FIRST-PROGESTERONE VGS 400
FIRST-PROGESTERONE VGS 50
HYDROXYPROGESTERONE
CAPROATE
MEDROXYPROGESTERONE AC
MICRO
PROCHIEVE
2
2
2
2
2
2
2
PROGESTERONE MICRONIZED
PROGESTERONE
AYGESTIN
DEPO-PROVERA
DEPO-SUBQ PROVERA 104
PROMETRIUM
PROVERA
MAKENA
2
2
3
3
3
3
3
S-T1
Thyroid and Antithyroid Agents
IODINE
levothyroxine sodium tablet
liothyronine sodium tablet
methimazole
potassium iodide
potassium iodide/iodine
propylthiouracil
thyroid,pork
LEVOTHYROXINE SODIUM
LIOTHYRONINE SODIUM
PCCA T3 SODIUM DILUTION
Requirements/Limits
(See INF Coverage
Limitation)
2
2
(Synthroid)
(Cytomel)
(Tapazole)
(Potassium Iodide)
(Potassium Iodide/
Iodine)
(Propylthiouracil)
(Thyroid,Pork)
(See INF Coverage
Limitation)
QL: 5 in 30 days
(Specialty Preferred
Drug List)
1
1
1
1
1
1
1
1
2
2
2
113
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
PCCA T4 SODIUM DILUTION
ARMOUR THYROID
CYTOMEL
LEVOTHROID
LEVOXYL
SYNTHROID
TAPAZOLE
THYROLAR-1/2
THYROLAR-1/4
THYROLAR-1
THYROLAR-2
THYROLAR-3
TIROSINT
UNITHROID
Requirements/Limits
2
3
3
3
3
3
3
3
3
3
3
3
3
3
Immunological Agents
Immunological Agents
azathioprine
cyclosporine capsule, solution
cyclosporine, modified
leflunomide
mycophenolate mofetil
mycophenolate sodium
sirolimus
tacrolimus
RAPAMUNE solution
RIDAURA
SANDIMMUNE solution
ZORTRESS
ARAVA
ASTAGRAF XL
AZASAN
CELLCEPT capsule, susp recon, tablet
HECORIA
IMURAN
MYFORTIC
NEORAL
PROGRAF capsule
RAPAMUNE tablet
SANDIMMUNE capsule
VARIZIG
(Imuran)
(Sandimmune)
(Neoral)
(Arava)
(Cellcept)
(Myfortic)
(Rapamune)
(Prograf)
1
1
1
1
1
1
1
1
2
2
2
2
3
3
3
3
3
3
3
3
3
3
3
PREV
QL: 30 in 30 days
QL: 30 in 30 days
114
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
Requirements/Limits
ARCALYST
S-T1
AUBAGIO
S-T1
PA (Specialty Preferred
Drug List)
ST, QL: 30 in 30 days
(Specialty Preferred
Drug List)
PA (Specialty Preferred
Drug List)
PA (Specialty Preferred
Drug List)
PA (Specialty Preferred
Drug List)
PA (Specialty Preferred
Drug List)
PA (Specialty Preferred
Drug List)
PA (Specialty Preferred
Drug List)
PA (Specialty Preferred
Drug List)
PA (Specialty Preferred
Drug List)
azathioprine sodium
(Azathioprine Sodium)
S-T1
cyclosporine ampul
(Sandimmune)
S-T1
ENBREL
S-T1
HUMIRA
S-T1
ILARIS
S-T1
KINERET
S-T1
ORENCIA syringe
S-T1
PROGRAF ampul
S-T1
Vaccines
ACTHIB
ADACEL TDAP
AFLURIA 2012-2013 syringe
AFLURIA 2012-2013 vial
AFLURIA 2013-2014 syringe
AFLURIA 2013-2014 vial
AFLURIA 2014-2015 syringe
AFLURIA 2014-2015 vial
BCG VACCINE (TICE STRAIN)
BIOTHRAX
BOOSTRIX TDAP
CERVARIX
COMVAX
DAPTACEL DTAP
DIPHTHERIA-TETANUS TOXOID
DIPHTHERIA-TETANUS TOXOIDSPED
ENGERIX-B ADULT
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
115
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
ENGERIX-B PEDIATRICADOLESCENT
FLUARIX 2012-2013
FLUARIX 2013-2014
FLUARIX 2014-2015
FLUARIX QUAD 2013-2014
FLUARIX QUAD 2014-2015
FLUBLOK 2013-2014
FLUBLOK 2014-2015
FLUCELVAX 2014-2015
FLUCELVAX
FLULAVAL 2012-2013
FLULAVAL 2013-2014
FLULAVAL 2014-2015 syringe
FLULAVAL 2014-2015 vial
FLULAVAL QUAD 2013-2014
FLULAVAL QUAD 2014-2015
FLUMIST QUAD 2014-2015
FLUMIST nas sp syr: 10e6.5-7.5
FLUMIST nas sp syr: 10e6.5-7.5
FLUVIRIN 2012-2013
FLUVIRIN 2013-2014
FLUVIRIN 2014-2015 syringe
FLUVIRIN 2014-2015 vial
FLUZONE 2012-2013 vial: 45mcg/.5ml
FLUZONE 2012-2013 vial: 45mcg/.5ml
FLUZONE 2013-2014 vial: 45mcg/.5ml
FLUZONE 2013-2014 vial: 45mcg/.5ml
FLUZONE 2014-2015 syringe
FLUZONE 2014-2015 vial
FLUZONE HIGH-DOSE 2012-13
FLUZONE HIGH-DOSE 2013-2014
FLUZONE HIGH-DOSE 2014-2015
FLUZONE INTRADERM QUAD 2014-15
FLUZONE INTRADERMAL 2012-2013
FLUZONE INTRADERMAL 2013-2014
FLUZONE INTRADERMAL 2014-2015
FLUZONE PEDI 2012-2013
FLUZONE PEDI 2013-2014
FLUZONE QUAD 2013-2014
FLUZONE QUAD PEDI 2014-2015
Requirements/Limits
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
116
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
GARDASIL 9
GARDASIL
HAVRIX
IMOVAX RABIES VACCINE
INFANRIX DTAP
IPOL
IXIARO
JE-VAX
KINRIX
MENACTRA
MENHIBRIX
MENOMUNE-A-C-Y-W-135
MENVEO A-C-Y-W-135-DIP
M-M-R II VACCINE
PEDIARIX
PEDVAXHIB
PENTACEL ACTHIB COMPONENT
PENTACEL DTAP-IPV COMPONENT
PENTACEL
PHYSICIANS EZ USE FLU 2012-13
PNEUMOVAX 23
PREVNAR 13
PROQUAD
RABAVERT
RECOMBIVAX HB
ROTARIX
ROTATEQ
SINGLE USE EZ FLU 2012-2013
SINGLE USE EZ FLU 2013-2014
syringekit: 45mcg/.5ml
SINGLE USE EZ FLU 2013-2014
syringekit: 60mcg/.5ml
TE ANATOXAL BERNA
TENIVAC
TETANUS DIPHTHERIA TOXOIDS
TETANUS TOXOID ADSORBED
THERACYS
TRIPEDIA
TRUMENBA
TWINRIX
TYPHIM VI
Requirements/Limits
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
PREV
117
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
VAQTA
VARIVAX VACCINE
VIVOTIF BERNA
YF-VAX
ZOSTAVAX
Requirements/Limits
PREV
PREV
PREV
PREV
PREV
Inflammatory Bowel Disease Agents
Inflammatory Bowel Disease Agents
balsalazide disodium
(Colazal)
budesonide
(Entocort EC)
mesalamine
(Sfrowasa)
ASACOL HD
ASACOL
CANASA
DELZICOL
DIPENTUM
APRISO
COLAZAL
ENTOCORT EC
GIAZO
LIALDA
PENTASA
ROWASA
UCERIS foam/appl
UCERIS tabdr and er
1
1
1
2
2
2
2
2
3
3
3
3
3
3
3
3
3
QL: 180 in 30 days
QL: 180 in 30 days
QL: 120 in 30 days
QL: 30 in 30 days
Irrigating Solutions
Irrigating Solutions
acetic acid
GLYCINE
mannitol/sorbitol solution
ringers solution
sodium chloride irrig solution
sorbitol solution
water for irrigation,sterile
(Acetic Acid)
(Mannitol/Sorbitol
Solution)
(Ringers Solution)
(Sodium Chloride Irrig
Solution)
(Sorbitol Solution)
(Water For
Irrigation,Sterile)
IRRIGATING SOLUTION G
LACTATED RINGERS
PHYSIOLYTE
PHYSIOSOL
RENACIDIN
1
1
1
1
1
1
1
3
3
3
3
3
118
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
RESECTISOL
TIS-U-SOL
UROLOGIC SOLUTION G
Requirements/Limits
3
3
3
Metabolic Bone Disease Agents
Metabolic Bone Disease Agents
alendronate sodium solution
alendronate sodium tablet: 5mg, 10mg,
40mg
alendronate sodium tablet: 35mg, 70mg
calcitonin,salmon,synthetic
calcitriol capsule, solution
doxercalciferol capsule
etidronate disodium
ibandronate sodium tablet
paricalcitol
risedronate sodium
FOSAMAX PLUS D
MIACALCIN vial
ACTONEL tablet: 150mg
ACTONEL tablet: 35mg
ACTONEL tablet: 5mg, 30mg
ACTONEL tablet: 35mg
ATELVIA
BINOSTO
BONIVA tablet
DIDRONEL
FORTICAL
FOSAMAX solution, tablet: 5mg, 10mg,
35mg
FOSAMAX tablet: 70mg
HECTOROL capsule
MIACALCIN spray/pump
ROCALTROL
SKELID
ZEMPLAR capsule
FORTEO
(Alendronate Sodium)
(Fosamax)
1
1
(Fosamax)
(Miacalcin)
(Rocaltrol)
(Hectorol)
(Etidronate Disodium)
(Boniva)
(Zemplar)
(Actonel)
1
1
1
1
1
1
1
1
2
2
3
3
3
3
3
3
3
3
3
3
QL: 4 in 28 days
3
3
3
3
3
3
S-T1
QL: 4 in 28 days
PROLIA
S-T1
QL: 30 in 30 days
QL: 1 in 28 days
QL: 1 in 28 days
QL: 4 in 28 days
QL: 1 in 28 days
QL: 12 in 84 days
QL: 30 in 30 days
QL: 4 in 28 days
QL: 4 in 28 days
QL: 1 in 28 days
PA, QL: 2.4 in 28 days
(Specialty Preferred
Drug List)
PA, QL: 1 in 180 days
(Specialty Preferred
Drug List)
119
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
XGEVA
Drug Tier
Requirements/Limits
S-T1
PA (Specialty Preferred
Drug List)
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
allopurinol
bethanechol chloride
buspirone hcl
chloral hydrate
citrate phosphate dextros soln
colchicine/probenecid
ergoloid mesylates
finasteride tablet: 5mg
glutethimide
guanidine hcl
hydrogen peroxide solution: 35%
hydroxyzine hcl syrup, tablet
hydroxyzine pamoate
leucovorin calcium tablet
levocarnitine (with sugar)
levocarnitine tablet
meprobamate
methylergonovine maleate tablet
ORA PLUS
probenecid
pyridostigmine bromide
2-METHOXYESTRADIOL
AVODART
(Zyloprim)
(Urecholine)
(Vanspar)
(Chloral Hydrate)
(Citrate Phosphate
Dextros Soln)
(Colchicine/
Probenecid)
(Ergoloid Mesylates)
(Proscar)
1
1
1
1
1
(Glutethimide)
(Guanidine HCl)
(Hydrogen Peroxide)
(Hydroxyzine HCl)
(Vistaril)
(Leucovorin Calcium)
(Carnitor)
(Carnitor)
(Meprobamate)
(Methylergonovine
Maleate)
1
1
1
1
1
1
1
1
1
1
(Probenecid)
(Mestinon)
CHEMSTRIP
COLCRYS
ELMIRON
GLUCAGEN
GLUCAGON EMERGENCY KIT
LYCELLE
MESNEX tablet
MESTINON syrup, tablet er
PROSTIGMIN
1
1
1
1
1
1
2
2
PA (for non-cosmetic
use)
Age must be >= 45,
GM, PA
2
2
2
2
2
2
2
2
2
120
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
RECTIV
SENSIPAR
THALOMID
2
2
2
TYBOST
ACD-A
ASTRINGYN
CARNITOR solution
CARNITOR tablet
GRASTEK
JALYN
LIMBREL
LIPOCHOL PLUS
LITHOSTAT
MESTINON tablet
MILTOWN
MITIGARE
MYTELASE
ORAFATE
ORALAIR
OTREXUP
PLACIDYL
POTABA
PROSCAR
RAGWITEK
RASUVO
THIOLA
ULESFIA
ULORIC
URECHOLINE
VANSPAR
VISTARIL
ZYLOPRIM
ZYTAZE
ACTIMMUNE
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
S-T1
AVONEX ADMINISTRATION PACK
S-T1
AVONEX
S-T1
Requirements/Limits
(Specialty Preferred
Drug List); (Specialty
Preferred Drug List)
PA
(Specialty Preferred
Drug List)
ST (Specialty Preferred
Drug List)
ST (Specialty Preferred
Drug List)
121
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
Requirements/Limits
BETASERON
S-T1
COPAXONE
S-T1
EXTAVIA
S-T1
GILENYA
S-T1
PLEGRIDY PEN
S-T1
PLEGRIDY
S-T1
REBIF REBIDOSE
S-T1
REBIF
S-T1
SYNAREL
S-T1
TECFIDERA
S-T1
ACTEMRA syringe
S-T2
CERDELGA
S-T2
H.P. ACTHAR
S-T2
LUPANETA PACK
S-T2
MIFEPREX
S-T2
MYALEPT
S-T2
OTEZLA
S-T2
PROCYSBI
S-T2
SIGNIFOR
S-T2
SIMPONI
S-T2
ST (Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
ST (Specialty Preferred
Drug List)
QL: 28 in 28 days
(Specialty Preferred
Drug List)
ST (Specialty Preferred
Drug List)
ST (Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
QL: 60 in 30 days
(Specialty Preferred
Drug List)
PA (Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
PA (Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
PA (Specialty Preferred
Drug List)
PA (Specialty Preferred
Drug List)
PA (Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
PA (Specialty Preferred
Drug List)
PA (Specialty Preferred
Drug List)
122
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
Requirements/Limits
STELARA
S-T2
XELJANZ
S-T2
PA (Specialty Preferred
Drug List)
PA (Specialty Preferred
Drug List)
Ophthalmic Agents
Antiglaucoma Agents
acetazolamide
betaxolol hcl
brimonidine tartrate
dorzolamide hcl
dorzolamide hcl/timolol maleat
latanoprost
levobunolol hcl
methazolamide
metipranolol
pilocarpine hcl
timolol maleate
travoprost (benzalkonium)
(Acetazolamide)
(Betaxolol HCl)
(Alphagan P)
(Trusopt)
(Cosopt)
(Xalatan)
(Betagan)
(Neptazane)
(Metipranolol)
(Isopto Carpine)
(Timoptic)
(Travoprost
(Benzalkonium))
ALPHAGAN P drops: 0.1%
AZOPT
BETOPTIC S
ISOPTO CARBACHOL
ISOPTO CARPINE drops: 8%
PHOSPHOLINE IODIDE
PILOPINE HS
SIMBRINZA
ALPHAGAN P drops: 0.15%
BETAGAN
BETIMOL
COMBIGAN
COSOPT PF
COSOPT
DIAMOX SEQUELS
HUMORSOL
ISOPTO CARPINE drops: 1%, 2%, 4%
ISTALOL
LUMIGAN
NEPTAZANE
OPTIPRANOLOL
RESCULA
1
1
1
1
1
1
1
1
1
1
1
1
QL: 2.5 in 25 days
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
123
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
TIMOPTIC OCUDOSE
TIMOPTIC-XE
TRAVATAN Z
TRUSOPT
XALATAN
ZIOPTAN
3
3
3
3
3
3
Requirements/Limits
QL: 2.5 in 25 days
Replacement Preparations
Replacement Preparations
citric acid/sodium citrate
phosphorus #1
pot chloride/pot bicarb/cit ac
potassium bicarbonate/cit ac
potassium chloride capsule er, liquid,
packet, tab er prt, tablet er, tablet sa
potassium citrate
potassium citrate/citric acid packet: 33001002; solution
potassium gluconate
SHOHL'S MODIFIED
sod/pot/k cit/sod cit/cit acid
zinc sulfate capsule: 220(50)mg
ORACIT
EFFER-K
KAOCHLOR
KAOCHLOR-EFF
KAON-CL 10
K-LOR
K-PHOS NEUTRAL
K-PHOS NO.2
K-PHOS ORIGINAL
K-SOL
K-TAB ER
MICRO-K
QUIC-K
UROCIT-K
(Citric Acid/Sodium
Citrate)
(K-Phos Neutral)
(Pot Chloride/Pot
Bicarb/Cit Ac)
(Potassium
Bicarbonate/Cit Ac)
(Potassium Chloride)
1
(Urocit-K)
(Potassium Citrate/
Citric Acid)
(Potassium Gluconate)
1
1
(Sod/Pot/K Cit/Sod Cit/
Cit Acid)
(Zinc Sulfate)
1
1
1
1
1
1
1
1
2
3
3
3
3
3
3
3
3
3
3
3
3
3
124
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
Requirements/Limits
Respiratory Tract Agents
Anti-Inflammatories, Inhaled Corticosteroids
budesonide
(Pulmicort)
DULERA
FLOVENT DISKUS
FLOVENT HFA aer w/adap: 44mcg
FLOVENT HFA aer w/adap: 110mcg,
220mcg
PULMICORT ampul-neb: 1mg/2ml
QVAR
ADVAIR DISKUS blst w/dev: 10050mcg, 250-50mcg, 500-50mcg
ADVAIR HFA hfa aer ad: 45-21mcg, 11521mcg, 230-21mcg
AEROBID-M
AEROSPAN
ALVESCO
ARNUITY ELLIPTA
ASMANEX HFA
ASMANEX aer pow ba: 110mcg(30),
220mcg(30), 220mcg(60), 220mcg120
BREO ELLIPTA
PULMICORT FLEXHALER
PULMICORT ampul-neb: 0.25mg/2ml,
0.5mg/2ml
SYMBICORT hfa aer ad: 80-4.5mcg, 1604.5mcg
Antileukotrienes
montelukast sodium
(Singulair)
zafirlukast
(Accolate)
ACCOLATE
SINGULAIR
ZYFLO CR
ZYFLO
Bronchodilators
albuterol sulfate
(Accuneb)
aminophylline liquid, tablet
(Aminophylline)
ipratropium bromide
(Ipratropium Bromide)
ipratropium/albuterol sulfate
(Duoneb)
isoetharine hcl
(Isoetharine HCl)
levalbuterol hcl
(Xopenex)
1
2
2
2
2
QL: 240 in 30 days
QL: 26 in 30 days
QL: 120 in 30 days
QL: 22 in 30 days
QL: 36 in 30 days
2
2
3
QL: 240 in 30 days
3
ST, QL: 24 in 30 days
ST, QL: 120 in 30 days
3
3
3
3
3
3
3
3
3
QL: 240 in 30 days
3
ST, QL: 21 in 30 days
1
1
3
3
3
3
1
1
1
1
1
1
125
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
metaproterenol sulfate
terbutaline sulfate tablet
theophylline anhydrous
Drug Tier
(Metaproterenol
Sulfate)
(Terbutaline Sulfate)
(Theophylline
Anhydrous)
1
1
1
ATROVENT HFA
BROVANA
2
2
COMBIVENT RESPIMAT
COMBIVENT
FORADIL
MAXAIR AUTOHALER
SEREVENT DISKUS blst w/dev: 50mcg
SPIRIVA RESPIMAT
SPIRIVA
VENTOLIN HFA hfa aer ad: 90mcg
VENTOLIN HFA hfa aer ad: 90mcg
ACCUNEB
ANORO ELLIPTA
ARCAPTA NEOHALER
DUONEB
INCRUSE ELLIPTA
LUFYLLIN
PERFOROMIST
PROAIR HFA
PROVENTIL HFA
STRIVERDI RESPIMAT
THEO-24
TUDORZA PRESSAIR
VOSPIRE ER
XOPENEX HFA
XOPENEX
Respiratory Tract Agents, Other
acetylcysteine vial: 100mg/ml, 200mg/ml
cromolyn sodium
guaifen/theop anhyd/p-ephed
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
guaifenesin/dyphylline
sodium chloride for inhalation vial-neb:
3%, 7%, 10%
DALIRESP
(Acetadote)
(Cromolyn Sodium)
(Guaifen/Theop Anhyd/
P-Ephed)
(Dilex-G 400)
(Hyper-Sal)
Requirements/Limits
Age must be >= 39, PA,
QL: 120 in 30 days
QL: 120 in 30 days
QL: 36 in 30 days
QL: 48 in 30 days
ST
QL: 240 in 30 days
ST, QL: 17 in 30 days
ST, QL: 13 in 30 days
ST
ST
1
1
1
1
1
2
126
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
DYLIX
HYPER-SAL
NEBUSAL
PULMOSAL
KALYDECO
3
3
3
3
S-T1
XOLAIR
S-T1
ESBRIET
S-T2
OFEV
S-T2
Requirements/Limits
PA (Specialty Preferred
Drug List)
PA (Specialty Preferred
Drug List)
PA (Specialty Preferred
Drug List)
PA (Specialty Preferred
Drug List)
Skeletal Muscle Relaxants
Skeletal Muscle Relaxants
baclofen
carisoprodol
carisoprodol/aspirin
chlorzoxazone
chlorzoxazone/acetaminophen
codeine/carisoprodol/aspirin
COMFORT PAC-CYCLOBENZAPRINE
COMFORT PAC-TIZANIDINE
cyclobenzaprine hcl
dantrolene sodium capsule
metaxalone
methocarbamol tablet
orphenadrine citrate tablet er
orphenadrine/aspirin/caffeine
tizanidine hcl
AMRIX
DANTRIUM capsule
FEXMID
FLEXERIL
LORZONE
PARAFON FORTE DSC
ROBAXIN-750
ROBAXIN tablet
SKELAXIN
(Baclofen)
(Soma)
(Carisoprodol/Aspirin)
(Parafon Forte DSC)
(Chlorzoxazone/
Acetaminophen)
(Codeine/Carisoprodol/
Aspirin)
(Fexmid)
(Dantrium)
(Skelaxin)
(Robaxin-750)
(Orphenadrine Citrate)
(Orphenadrine/Aspirin/
Caffeine)
(Zanaflex)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
3
3
3
3
3
3
3
3
3
127
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
SOMA
ZANAFLEX
Requirements/Limits
3
3
Sleep Disorder Agents
Sleep Disorder Agents
eszopiclone
zaleplon
zolpidem tartrate tab mphase
zolpidem tartrate tablet
AMBIEN CR
AMBIEN
BELSOMRA
BUTISOL SODIUM
EDLUAR
INTERMEZZO
LUNESTA
modafinil tablet: 200mg
modafinil tablet: 100mg
NUVIGIL tablet: 150mg, 200mg, 250mg
NUVIGIL tablet: 50mg
PROVIGIL tablet: 200mg
PROVIGIL tablet: 100mg
ROZEREM
SECONAL SODIUM
SONATA
ZOLPIMIST
XYREM
(Lunesta)
(Sonata)
(Ambien CR)
(Ambien)
(Provigil)
(Provigil)
HETLIOZ
1
1
1
1
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
S-T1
S-T2
QL: 30 in 30 days
QL: 60 in 30 days
QL: 30 in 30 days
QL: 30 in 30 days
QL: 30 in 30 days
QL: 30 in 30 days
ST, QL: 30 in 30 days
ST, QL: 60 in 30 days
QL: 30 in 30 days
QL: 60 in 30 days
ST, QL: 30 in 30 days
ST, QL: 60 in 30 days
QL: 30 in 30 days
QL: 60 in 30 days
(Specialty Preferred
Drug List)
PA (Specialty Preferred
Drug List)
Urine And Feces Contents
Ketones
CHEMSTRIP K
DIASCREEN 1K REAGENT
KETONE CARE
KETONE
KETOSTIX REAGENT
Sugar
DIASCREEN 1G REAGENT
DIASTIX REAGENT
Urine And Feces Contents
CHEMSTRIP UGK
2
2
2
2
2
2
2
3
128
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
DIASCREEN 10
DIASCREEN 2GK REAGENT
DIASCREEN 3 REAGENT
DIASCREEN 4OBL
DIASCREEN 5
DIASCREEN 6
DIASCREEN 7
DIASCREEN 8
DIASCREEN 9
KETO-DIASTIX REAGENT
Requirements/Limits
3
3
3
3
3
3
3
3
3
3
QL: 1 in 1 days
Vasodilating Agents
CAVERJECT
2
MUSE
2
CIALIS tablet: 2.5mg, 5mg
3
CIALIS tablet: 10mg, 20mg
3
LEVITRA
3
STAXYN
3
STENDRA
3
VIAGRA
3
QL: 6 in 30 days (See
ED Coverage
Limitation)
QL: 6 in 30 days (See
ED Coverage
Limitation)
QL: 30 in 30 days (See
ED Coverage
Limitation)
QL: 6 in 30 days (See
ED Coverage
Limitation)
QL: 6 in 30 days (See
ED Coverage
Limitation)
QL: 6 in 30 days (See
ED Coverage
Limitation)
QL: 6 in 30 days (See
ED Coverage
Limitation)
QL: 6 in 30 days (See
ED Coverage
Limitation)
PA (Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
QL: 1 in 1 days
Vasodilating Agents
ADCIRCA
S-T1
ADEMPAS
S-T1
129
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
Drug Tier
Requirements/Limits
OPSUMIT
S-T1
REVATIO susp recon
S-T1
(Specialty Preferred
Drug List)
PA (Specialty Preferred
Drug List)
PA (Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
(Specialty Preferred
Drug List)
PA (Specialty Preferred
Drug List)
sildenafil citrate
(Revatio)
S-T1
TRACLEER
S-T1
LETAIRIS
S-T2
ORENITRAM ER
S-T2
REVATIO tablet
S-T2
Vitamins and Minerals
Vitamins and Minerals
b complex and c no.20/folic acid capsule:
1mg
b12/levomefolate calcium/b-6
cyanocobalamin (vitamin b-12) vial
ergocalciferol (vitamin d2) capsule
pnv with ca,no.71/iron/fa
pnv119/iron fumarate/fa/dss
sodium fluoride tab chew
MEPHYTON
ACTIVE FE
b complex and c no.20/folic acid capsule:
1mg
DHT
DRISDOL capsule
FER-IN-SOL
FOLGARD OS
LOZI-FLUR
LYSIPLEX PLUS
NASCOBAL
NEPHROCAPS QT
PURALOR CI
ferrous sulfate drops, liquid
(Nephrocaps)
1
(Foltx)
(Cyanocobalamin
(Vitamin B-12))
(Drisdol)
(Pnv with Ca,No.71/
Iron/Fa)
(Pnv119/Iron Fumarate/
Fa/Dss)
(Ludent Fluoride)
1
1
(B Complex and C
No.20/Folic Acid)
(Fer-In-Sol)
1
1
1
1
2
3
3
3
3
3
3
3
3
3
3
3
PREV
130
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
Drug Name
folic acid tablet: 0.8mg, 1mg
iron,carbonyl oral susp
pedi mvi no.12/sodium fluoride
sodium fluoride drops
Drug Tier
(Folic Acid)
(Icar)
(Mvc-Fluoride)
(Sodium Fluoride)
Requirements/Limits
PREV
PREV
PREV
PREV
131
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
INDEX
1ST CHOICE LANCETS ..... 75
1ST TIER UNILET
COMFORTOUCH ............ 75
2-METHOXYESTRADIOL 120
2TEK ..................................... 82
8-MOP................................... 66
aa/antipyrn/bcaine/polico#1/al
........................................... 98
aa/antpy/bcaine/polico/al acet
........................................... 98
abacavir sulfate ..................... 44
abacavir/lamivudine/zidovudine
........................................... 44
ABILIFY ............................... 43
ABILIFY DISCMELT .......... 43
ABILIFY MAINTENA ........ 43
ABSORICA .......................... 67
ABSTRAL ............................ 12
acamprosate calcium ............ 16
ACANYA ............................. 70
acarbose ................................ 31
ACCOLATE ....................... 125
ACCU-CHEK ................. 75, 76
ACCU-CHEK ACTIVE........ 75
ACCU-CHEK AVIVA ......... 75
ACCU-CHEK AVIVA PLUS
........................................... 75
ACCU-CHEK COMFORT
CURVE ............................. 75
ACCU-CHEK COMPACT
BLUE CONTROL ............ 75
ACCU-CHEK COMPACT
PLUS ................................. 75
ACCU-CHEK COMPACT
PLUS CONTROL ............. 75
ACCU-CHEK FASTCLIX ... 75
ACCU-CHEK NANO
SMARTVIEW .................. 75
ACCU-CHEK SAFE-T-PRO 75
ACCU-CHEK SAFE-T-PRO
PLUS ................................. 75
ACCU-CHEK SMARTVIEW
........................................... 75
ACCU-CHEK SOFTCLIX ... 75
ACCU-CHEK VOICEMATE75
ACCUNEB ......................... 126
ACCUPRIL ........................... 52
ACCURETIC ........................ 52
ACCUTREND GLUCOSE... 76
ACD-A ................................ 121
ACE AEROSOL CLOUD
ENHANCER ..................... 76
acebutolol hcl ........................ 53
ACEON ................................. 52
acetaminophen with codeine . 11
acetaminophen/phenyltolx .... 11
acetazolamide ..................... 123
acetic acid ..................... 98, 118
acetic acid/aluminum acetate 98
acetic acid/hydrocortisone .... 98
acetylcysteine ...................... 126
ACIPHEX ........................... 101
ACIPHEX SPRINKLE ....... 102
acitretin ................................. 69
ACLOVATE ......................... 72
ACTEMRA ......................... 122
ACTHIB .............................. 115
ACTICLATE ........................ 22
ACTIGALL......................... 104
ACTI-LANCE....................... 76
ACTIMMUNE .................... 121
ACTIQ .................................. 12
ACTIVE FE ........................ 130
ACTIVELLA ...................... 109
ACTONEL .......................... 119
ACTOPLUS MET ................ 32
ACTOPLUS MET XR .......... 32
ACTOS ................................. 32
ACULAR ............................ 101
ACULAR LS ...................... 101
ACURA CONTROL
SOLUTION....................... 82
ACURA CONTROL
SOLUTION LOW ............ 82
ACURA CONTROL
SOLUTION NORMAL .... 82
ACURA METER KIT .......... 82
ACURA PLUS ...................... 82
ACURA STARTER KIT ...... 82
ACURA TEST STRIPS ........ 82
ACUVAIL........................... 101
acyclovir .......................... 46, 65
ACZONE .............................. 67
ADACEL TDAP ................. 115
ADAGEN .............................. 96
ADALAT CC ........................ 55
adapalene .............................. 74
ADCIRCA........................... 129
ADDERALL ......................... 59
ADDERALL XR .................. 59
ADD-INS .............................. 49
adefovir dipivoxil .................. 46
ADEMPAS ......................... 129
ADJUSTABLE LANCING
DEVICE ............................ 76
ADOXA ................................ 22
ADOXA PAK ....................... 22
ADRENACLICK .................. 55
ADRENALIN CHLORIDE .. 97
ADVAIR DISKUS.............. 125
ADVAIR HFA .................... 125
ADVANCE INTUITION...... 82
ADVANCE TEST STRIPS .. 82
ADVANCED GLUCOSE
METER ............................. 82
ADVANCED GLUCOSE
TEST STRIPS ................... 82
ADVANCED LANCING
DEVICE ............................ 76
I-1
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
ADVANCED TRAVEL
LANCETS......................... 76
ADVICOR ............................ 57
ADVOCATE BLOOD
GLUCOSE MONITOR .... 82
ADVOCATE CONTROL
SOLUTION....................... 82
ADVOCATE DUO ............... 82
ADVOCATE LANCET ........ 76
ADVOCATE LANCETS...... 76
ADVOCATE LANCING
DEVICE ............................ 76
ADVOCATE RAPID-SAFE 82
ADVOCATE REDI-CODE .. 82
ADVOCATE REDI-CODE
DUO .................................. 82
ADVOCATE REDI-CODE+ 82
ADVOCATE REDI-CODE+
CTRL SOLN ..................... 82
ADVOCATE TEST STRIP .. 82
AEROBID-M ...................... 125
AEROCHAMBER MINI ...... 76
AEROCHAMBER MV ........ 76
AEROCHAMBER PLUS
FLOW-VU ........................ 76
AEROCHAMBER PLUS Z
STAT................................. 76
AEROCHAMBER WITH
FLOWSIGNAL................. 76
AEROCHAMBER Z-STAT
PLUS ................................. 76
AEROSPAN ....................... 125
AEROTRACH PLUS ........... 76
AFINITOR ............................ 23
AFINITOR DISPERZ ........... 23
AFLURIA 2012-2013 ......... 115
AFLURIA 2013-2014 ......... 115
AFLURIA 2014-2015 ......... 115
AFREZZA............................. 33
AGAMATRIX AMP ............ 82
AGAMATRIX CONTROL .. 82
AGGRENOX ........................ 48
AGRYLIN............................. 48
A-HYDROCORT ............... 110
AKNE-MYCIN ..................... 70
AKTEN ................................. 97
AKYNZEO ........................... 40
ALA-HIST AC...................... 63
ALAHIST DHC .................... 63
ALAMAST ........................... 97
ALA-QUIN ........................... 34
ALA-TET .............................. 22
ALBENZA ............................ 40
albuterol sulfate .................. 125
alclometasone dipropionate .. 71
ALCORTIN A ...................... 67
ALDACTAZIDE .................. 58
ALDACTONE ...................... 58
ALDARA .............................. 67
ALDOMET ........................... 50
ALDORIL-D50 ..................... 51
alendronate sodium............. 119
ALFERON N ........................ 46
alfuzosin hcl ........................ 107
ALINIA ................................. 40
ALKERAN ........................... 23
ALLEGRA ............................ 36
ALLEGRA ODT ................... 36
ALLEGRA-D 12 HOUR ...... 36
ALLEGRA-D 24 HOUR ...... 36
ALLFEN CD ......................... 63
ALLFEN CDX ...................... 63
allopurinol........................... 120
ALOCRIL ........................... 101
ALODOX .............................. 22
ALOMIDE ............................ 97
ALOQUIN ............................ 67
ALORA ............................... 109
ALPHAGAN P ................... 123
alprazolam ............................ 17
ALPRAZOLAM INTENSOL18
ALREX ............................... 101
ALSUMA .............................. 38
ALTABAX ........................... 70
ALTACE ............................... 52
ALTERNATE SITE LANCETS
........................................... 76
ALTERNATE SITE LANCING
DEVICE ............................ 76
ALTOPREV .......................... 57
aluminum acetate .................. 65
aluminum chloride ................ 65
ALUVEA .............................. 67
ALVESCO .......................... 125
amantadine hcl ...................... 41
AMARYL ............................. 33
AMBIEN ............................. 128
AMBIEN CR ...................... 128
AMBIFED............................. 63
AMBIFED CD ...................... 63
AMBIFED CDX ................... 63
AMBIFED DM ..................... 63
AMBIFED-G CD .................. 63
AMBIFED-G CDX ............... 63
amcinonide ............................ 71
AMERGE .............................. 38
AMETHYST ......................... 60
amiloride hcl ......................... 56
amiloride/hydrochlorothiazide
........................................... 56
aminocaproic acid ................ 48
aminophylline ...................... 125
amiodarone hcl ..................... 53
AMITIZA ............................ 104
amitrip hcl/chlordiazepoxide 29
amitriptyline hcl .................... 29
amlodipine besylate .............. 55
amlodipine besylate/benazepril
........................................... 55
amlodipine/atorvastatin ........ 56
amlodipine/valsartan ............ 55
amlodipine/valsartan/hcthiazid
........................................... 55
ammonium lactate ................. 65
amoxapine ............................. 29
amoxicillin............................. 21
amoxicillin/potassium clav.... 21
AMOXIL............................... 21
I-2
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
ampicillin trihydrate ............. 21
AMPYRA ............................. 60
AMRIX ............................... 127
AMTURNIDE....................... 58
ANABAR .............................. 12
ANACAINE .......................... 67
ANADROL-50 .................... 108
ANAFRANIL ....................... 30
anagrelide hcl ....................... 48
ANA-LEX ............................. 72
ANALPRAM E ..................... 72
ANALPRAM HC.................. 72
ANAPROX ........................... 15
ANAPROX DS ..................... 15
ANASPAZ .......................... 104
anastrozole ............................ 22
ANCOBON ........................... 34
ANDRODERM ................... 107
ANDROGEL....................... 108
ANDROID .......................... 107
ANGELIQ ........................... 109
ANORO ELLIPTA ............. 126
ANSAID ............................... 15
ANTABUSE ......................... 16
ANTARA .............................. 57
antipyrine/benzocaine ........... 98
ANTIVERT........................... 40
ANUSOL-HC ....................... 72
ANZEMET ........................... 40
APEXICON .......................... 72
APEXICON E ....................... 72
APHTHASOL ....................... 65
APIDRA ................................ 33
APIDRA SOLOSTAR .......... 33
APLENZIN ........................... 30
APOKYN .............................. 42
apraclonidine hcl .................. 97
APRISO .............................. 118
APTIOM ............................... 27
APTIVUS .............................. 44
AQUA GLYCOLIC HC ....... 72
AQUA LANCE LANCING
DEVICE ............................ 76
AQUAPHILIC W/
TRIAMCINOLONE ......... 72
ARALEN PHOSPHATE ...... 41
ARANESP ............................ 47
ARAVA .............................. 114
ARCALYST ....................... 115
ARCAPTA NEOHALER ... 126
ARESTIN .............................. 65
ARICEPT .............................. 29
ARICEPT ODT ..................... 29
ARIMIDEX........................... 26
ARISTOCORT ................... 110
ARIXTRA ............................. 47
ARMOUR THYROID ........ 114
ARNUITY ELLIPTA ......... 125
AROMASIN ......................... 26
ARTHROTEC 50.................. 15
ARTHROTEC 75.................. 15
asa/calcium carb/mag/al hydrox
........................................... 15
ASACOL............................. 118
ASACOL HD ...................... 118
ASMANEX ......................... 125
ASMANEX HFA ................ 125
ASP ....................................... 12
aspirin ............................. 14, 16
aspirin/calcium carbonate/mag
........................................... 16
ASSURE 4 ............................ 83
ASSURE DOSE .................... 83
ASSURE HAEMOLANCE
PLUS ................................. 76
ASSURE LANCE ................. 76
ASSURE PLATINUM.......... 83
ASSURE PRO ...................... 83
ASTAGRAF XL ................. 114
ASTELIN .............................. 97
ASTEPRO ............................. 97
ASTHMAPACK CHILDREN'S
........................................... 83
ASTHMAPACK I................. 83
ASTHMAPACK II ............... 83
ASTHMAPACK III .............. 83
ASTRINGYN ..................... 121
ATACAND ........................... 51
ATACAND HCT .................. 51
ATELVIA ........................... 119
atenolol ................................. 53
atenolol/chlorthalidone ......... 53
ATIVAN ............................... 18
atorvastatin calcium.............. 56
atovaquone ............................ 40
atovaquone/proguanil hcl ..... 40
ATRALIN ............................. 74
ATRIPLA .............................. 44
ATROPEN ............................ 27
atropine sulfate ............... 26, 97
ATROVENT ......................... 97
ATROVENT HFA .............. 126
AUBAGIO .......................... 115
AUGMENTIN ...................... 21
AUGMENTIN ES-600 ......... 21
AUGMENTIN XR ................ 21
AURORA SUPER THIN
LANCETS......................... 83
AURYXIA .......................... 106
AUTO INJECTOR................ 76
AUTO-LANCET MINI ........ 76
AUTOLET IMPRESSION ... 76
AUTOLET LANCING
DEVICE ............................ 76
AUTOLET LITE CLINISAFE
........................................... 76
AUTOLET MINI .................. 76
AUTOLET MKII CLINISAFE
........................................... 76
AUVI-Q ................................ 55
AVAGE................................. 74
AVALIDE ............................. 51
AVANDAMET ..................... 31
AVANDARYL ..................... 32
AVANDIA ............................ 32
AVAPRO .............................. 51
AVAR ................................... 67
AVAR LS.............................. 67
AVAR-E GREEN ................. 67
I-3
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
AVAR-E LS .......................... 67
AVC ...................................... 37
AVEED ............................... 108
AVELOX .............................. 21
AVELOX ABC PACK ......... 21
AVIDOXY ............................ 22
AVIDOXY DK ..................... 22
AVINZA ............................... 12
AVODART ......................... 120
AVONEX ............................ 121
AVONEX
ADMINISTRATION PACK
......................................... 121
AXERT ................................. 38
AXID................................... 103
AXIRON ............................. 107
AYGESTIN......................... 113
AZASAN ............................ 114
AZASITE .............................. 99
azathioprine ........................ 114
azathioprine sodium ............ 115
azelastine hcl ......................... 97
AZELEX ............................... 67
AZILECT .............................. 41
azithromycin .......................... 20
AZOPT ................................ 123
AZOR .................................... 55
AZULFIDINE ....................... 22
b complex and c no.20/folic
acid .................................. 130
b12/levomefolate calcium/b-6
......................................... 130
bacitracin .............................. 98
bacitracin/polymyxin b sulfate
........................................... 98
baclofen ............................... 127
BACTOCILL ........................ 21
BACTRIM ............................ 22
BACTRIM DS ...................... 22
BACTROBAN ...................... 70
BACTROBAN NASAL........ 70
balsalazide disodium........... 118
BANZEL ............................... 27
BARACLUDE ................ 46, 47
BCG VACCINE TICE
STRAIN .......................... 115
BD MICROTAINER
LANCETS......................... 83
BD ULTRA-FINE ................ 83
BD ULTRA-FINE II ............. 83
BECONASE AQ ................. 101
BELSOMRA ....................... 128
benazepril hcl ........................ 52
benazepril/hydrochlorothiazide
........................................... 52
BENICAR ............................. 51
BENICAR HCT .................... 51
benoxinate hcl/fluorescein na 16
BENOXYLDOXY 30 ........... 70
BENOXYLDOXY 60 ........... 70
BENSAL HP ......................... 67
BENTYL ............................. 104
BENZAC AC ........................ 67
BENZACLIN ........................ 70
BENZAMYCINPAK ............ 70
BENZEFOAM ...................... 67
BENZEFOAM ULTRA ........ 67
benzocaine............................. 16
benzonatate ........................... 62
benzoyl peroxide ............. 65, 67
benzoyl peroxide and skin
cleansr5 ............................. 65
benzoyl peroxide microspheres
........................................... 65
benzoyl peroxide/aloe vera ... 65
benzphetamine hcl ................. 59
benztropine mesylate ............. 41
BEPREVE ............................. 97
BESIVANCE ........................ 99
BETAGAN ......................... 123
betamethasone dipropionate . 71
betamethasone valerate ........ 71
betamethasone/propylene glyc
........................................... 71
BETAPACE .......................... 53
BETAPACE AF .................... 53
BETASERON ..................... 122
betaxolol hcl .................. 53, 123
bethanechol chloride ........... 120
BETHKIS .............................. 18
BETIMOL ........................... 123
BETOPTIC S ...................... 123
BEYAZ ................................. 60
BG-STAR ............................. 83
BIAXIN................................. 20
BIAXIN XL .......................... 20
bicalutamide .......................... 22
BICHLORACETIC ACID .... 67
BIDIL .................................... 58
BILTRICIDE ........................ 41
BINOSTO ........................... 119
BIOTHRAX ........................ 115
bisoprolol fumarate............... 53
bisoprolol fumarate/hctz ....... 53
BLEPHAMIDE ..................... 99
BLEPHAMIDE S.O.P. ......... 99
BLOOD GLUCOSE
CONTROL........................ 83
BLOOD GLUCOSE METER83
BLOOD GLUCOSE
MONITOR ........................ 83
BLOOD GLUCOSE
MONITORING ................. 83
BLOOD GLUCOSE TEST ... 83
BLOOD GLUCOSE TEST
STRIP ................................ 83
BLOOD-GLUCOSE
CONTROL........................ 83
BLOOD-GLUCOSE METER
........................................... 83
BONIVA ............................. 119
BONTRIL PDM.................... 59
BOOSTRIX TDAP ............. 115
BOSULIF .............................. 23
BP WASH ....................... 65, 67
BP WASH ACNE
TREATMENT .................. 67
BRAVELLE ........................ 110
BREATHERITE ................... 76
I-4
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
BREATHRITE ...................... 76
BREEZE 2 ...................... 76, 77
BREO ELLIPTA ................. 125
BRILINTA ............................ 48
brimonidine tartrate ............ 123
BRINTELLIX ....................... 30
BRISDELLE ......................... 30
BROMDAY ........................ 101
bromfenac sodium ............... 100
bromocriptine mesylate ......... 41
bromphenira/pseudoephed/
codein ................................ 62
brompheniram/phenylephrine/
dm...................................... 62
brompheniramin/pe/carbetapent
........................................... 62
brompheniramine/pe/codeine 62
bromphenrm/pseudoeph/
dihydrocd .......................... 62
BROVANA ......................... 126
BROVEX CB ........................ 63
BROVEX CBX ..................... 63
BROVEX PB C..................... 63
BROVEX PB CX .................. 63
BROVEX SR ........................ 36
BUCALSEP .......................... 16
budesonide .......... 100, 118, 125
BULLSEYE MINI SAFETY
LANCETS......................... 77
bumetanide ............................ 56
BUNAVAIL.......................... 16
BUPAP .................................. 12
BUPHENYL ....................... 104
buprenorphine hcl ................. 16
buprenorphine hcl/naloxone hcl
........................................... 16
bupropion hcl ............ 16, 29, 31
buspirone hcl ....................... 120
butalb/acetaminophen/caffeine
........................................... 11
butalbit/acetamin/caff/codeine
........................................... 11
butalbital/acetaminophen ..... 11
butalbital/aspirin/caffeine ..... 11
BUTISOL SODIUM ........... 128
butorphanol tartrate.............. 11
BUTRANS ............................ 12
BYDUREON ........................ 32
BYDUREON PEN ................ 32
BYETTA ............................... 32
BYSTOLIC ........................... 53
cabergoline ........................... 41
CADUET .............................. 57
CAFCIT ................................ 59
CAFERGOT ......................... 38
caffeine citrated .................... 59
CALAN ................................. 54
CALAN SR ........................... 54
calcipotriene ......................... 65
calcipotriene/betamethasone 65
calcitonin,salmon,synthetic . 119
calcitriol ........................ 65, 119
calcium acetate ................... 106
calcium carbonate/mag carb/fa
......................................... 106
CAMBIA............................... 15
CAMINO PRO 15................. 49
CAMINO PRO BETTERMILK
........................................... 49
CAMINO PRO RESTORE
LITE .................................. 49
CAMINO-PRO RESTORE .. 49
CAMPRAL ........................... 16
CANASA ............................ 118
candesartan cilexetil ............. 51
candesartan/hydrochlorothiazid
........................................... 51
CANTIL .............................. 104
CAPCOF ............................... 63
capecitabine .......................... 23
CAPEX SHAMPOO ............. 73
CAPITAL W-CODEINE ...... 12
CAPOTEN ............................ 52
CAPRELSA .......................... 23
captopril ................................ 52
captopril/hydrochlorothiazide
........................................... 52
CARAC ................................. 67
CARAFATE ....................... 103
CARBAGLU....................... 105
carbamazepine ...................... 27
CARBATROL ...................... 27
carbidopa .............................. 41
carbidopa/levodopa .............. 41
carbidopa/levodopa/entacapone
........................................... 41
carbinoxamine maleate ......... 35
CARDENE SR ...................... 55
CARDIZEM .......................... 54
CARDIZEM CD ................... 54
CARDIZEM LA ................... 54
CARDIZEM SR .................... 54
CARDURA ........................... 51
CARDURA XL..................... 51
CARELANCE ULT LANCING
DEVICE ............................ 83
CAREONE ............................ 77
CARESENS .......................... 83
CARESENS N ...................... 83
CARESENS N VOICE ......... 83
CARESENS PREM LANCING
DEVICE ............................ 83
carisoprodol ........................ 127
carisoprodol/aspirin ........... 127
CARMOL HC ....................... 73
CARNITOR ........................ 121
carteolol hcl .......................... 97
carvedilol .............................. 53
CASODEX ............................ 26
CATAFLAM......................... 15
CATAPRES .......................... 51
CATAPRES-TTS 1............... 51
CATAPRES-TTS 2............... 51
CATAPRES-TTS 3............... 51
CAVERJECT ...................... 129
CAYSTON............................ 21
CEDAX ................................. 20
CEENU ................................. 26
I-5
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
cefaclor ................................. 19
cefadroxil .............................. 20
cefdinir .................................. 20
cefditoren pivoxil .................. 20
cefpodoxime proxetil ............. 20
cefprozil................................. 20
ceftibuten dihydrate .............. 20
CEFTIN................................. 20
cefuroxime axetil ................... 20
CEFUROXIME AXETIL ..... 20
CELEBREX .......................... 15
celecoxib ............................... 14
CELESTONE ...................... 110
CELEXA ............................... 30
CELLCEPT ......................... 114
CELONTIN........................... 27
CENESTIN ......................... 109
CENTANY ........................... 70
CENTANY AT ..................... 70
cephalexin ............................. 20
cephalexin monohydrate ....... 20
CERDELGA ....................... 122
CERVARIX ........................ 115
CESAMET ............................ 40
CESINEX ............................ 104
CETACAINE ........................ 67
CETACAINE ANESTHETIC
........................................... 67
CETACAINE MEDICAL KIT
E ........................................ 67
cetirizine hcl .......................... 35
cetirizine hcl/pseudoephedrine
........................................... 37
CETRAXAL ......................... 99
CETROTIDE ...................... 110
cevimeline hcl........................ 64
CHANTIX............................. 17
CHEMET ............................ 107
CHEMSTRIP ...................... 120
CHEMSTRIP K .................. 128
CHEMSTRIP UGK ............ 128
CHENODAL......................... 96
CHILDREN'S QNASL ....... 100
chloral hydrate .................... 120
chlordiazepoxide hcl ............. 17
chlordiazepoxide/clidinium br
........................................... 26
chlorhexidine gluconate ........ 65
CHLORHEXIDINE
GLUCONATE .................. 65
chloroquine phosphate .......... 40
chlorothiazide ....................... 56
chloroxylenol/benzoc/hydrocort
......................................... 100
chlorphen/pseudoephed/codeine
........................................... 62
chlorpheniramine maleate .... 35
chlorpheniramine/codeine phos
........................................... 62
chlorpromazine hcl ............... 42
chlorpropamide ..................... 33
chlorthalidone ....................... 56
chlorzoxazone ..................... 127
chlorzoxazone/acetaminophen
......................................... 127
CHOICEDM CLARUS ........ 83
CHOICEDM CLARUS
CONTROL SOLN ............ 83
CHOICEDM CLARUS TEST
STRIPS ............................. 83
CHOICEDM G20 ................. 83
cholestyramine (with sugar) . 56
cholestyramine/aspartame .... 56
choline sal/mag salicylate ..... 14
CHORIONIC
GONADOTROPIN ......... 111
CIALIS ................................ 129
CICLODAN .......................... 34
ciclopirox .............................. 34
ciclopirox olamine ................ 34
ciclopirox/ure/camph/menth/euc
........................................... 34
cilostazol ............................... 48
CILOXAN............................. 99
cimetidine ............................ 102
cimetidine hcl ...................... 102
CIMZIA ................................ 97
CINRYZE ............................. 48
CIPRO ................................... 21
CIPRO HC ............................ 99
CIPRO XR ............................ 21
CIPRODEX........................... 99
ciprofloxacin ......................... 21
ciprofloxacin hcl ............. 21, 98
ciprofloxacin/ciprofloxa hcl .. 21
citalopram hydrobromide ..... 29
citrate phosphate dextros soln
......................................... 120
citric acid/sodium citrate .... 124
CLARIFOAM EF ................. 67
CLARINEX .......................... 37
CLARINEX-D 12 HOUR ..... 37
CLARINEX-D 24 HOUR ..... 37
CLARIS ................................ 67
clarithromycin ....................... 20
clemastine fumarate .............. 36
CLEOCIN ............................. 37
CLEOCIN HCL .................... 19
CLEOCIN PALMITATE...... 19
CLEOCIN T .......................... 70
CLEVER CHEK LANCETS 77
CLEVER CHOICE ............... 84
CLEVER CHOICE BLOOD
GLUC SYS ....................... 83
CLEVER CHOICE CONTROL
SOLUTION................. 83, 84
CLEVER CHOICE HD
GLUCOSE SYST ............. 84
CLEVER CHOICE MICRO . 84
CLEVER CHOICE MICRO
TEST STRIP ..................... 84
CLEVER CHOICE PRO ...... 84
CLEVER CHOICE TALK ... 84
CLEVER CHOICE TEST
STRIPS ............................. 84
CLEVER CHOICE VOICE+
TST STRIP........................ 84
CLIMARA .......................... 109
CLIMARA PRO ................. 109
I-6
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
CLINDACIN P ..................... 70
CLINDACIN PAC ................ 70
CLINDAGEL ........................ 70
clindamycin hcl ..................... 18
clindamycin palmitate hcl ..... 18
clindamycin phos/benzoyl perox
..................................... 69, 70
clindamycin phosphate.... 37, 70
CLINDESSE ......................... 38
CLINITEST REAGENT ....... 77
CLINORIL ............................ 15
clobetasol propionate............ 71
CLOBEX............................... 73
clocortolone pivalate ............ 71
CLODAN .............................. 73
CLODERM ........................... 73
clomiphene citrate ............... 108
clomipramine hcl .................. 29
clonazepam ........................... 17
clonidine ................................ 50
clonidine hcl .................... 50, 59
clonidine hcl/chlorthalidone . 50
clopidogrel bisulfate ............. 48
clorazepate dipotassium........ 17
clotrimazole........................... 34
clotrimazole/betamethasone dip
........................................... 34
clozapine ............................... 42
CLOZARIL ........................... 43
CNL 8.................................... 34
COAGUCHEK ..................... 77
COAGUCHEK XS ............... 77
COARTEM ........................... 41
codeine sulfate ...................... 11
CODEINE SULFATE .......... 12
codeine/butalbital/asa/caffein11
codeine/carisoprodol/aspirin
......................................... 127
CODIMAL-A ........................ 37
COLAZAL .......................... 118
colchicine/probenecid ......... 120
COLCRYS .......................... 120
COLESTID ........................... 57
colestipol hcl ......................... 57
colistin (colistimethate na) .... 19
COLOR LANCETS .............. 77
COLY-MYCIN M
PARENTERAL................. 19
COLY-MYCIN S .................. 99
COLYTE WITH FLAVOR
PACKS............................ 105
COMBIGAN ....................... 123
COMBIPATCH .................. 108
COMBIVENT ..................... 126
COMBIVENT RESPIMAT 126
COMBIVIR........................... 45
COMETRIQ .......................... 23
COMFORT EZ ..................... 84
COMFORT LANCETS ........ 77
COMFORT PACCYCLOBENZAPRINE .. 127
COMFORT PAC-IBUPROFEN
........................................... 14
COMFORT PACMELOXICAM .................. 14
COMFORT PAC-NAPROXEN
........................................... 14
COMFORT PACTIZANIDINE .................. 127
COMPACT SPACE
CHAMBER PLUS ............ 77
COMPAZINE ....................... 40
COMPLERA ......................... 44
COMTAN ............................. 41
COMVAX ........................... 115
CONCEPTROL .................... 60
CONCERTA ......................... 59
CONDYLOX .................. 66, 67
CONTOUR ........................... 77
CONTOUR LINK ................. 77
CONTOUR NEXT................ 77
CONTOUR NEXT CONTROL
SOLUTION....................... 77
CONTOUR NEXT EZ .......... 77
CONTOUR NEXT LINK ..... 77
CONTOUR NEXT USB ....... 77
CONTOUR USB .................. 77
CONTROL............................ 84
CONTROL G3 ...................... 84
CONTROL SOLUTION ....... 84
CONZIP ................................ 12
COPAXONE ....................... 122
COPEGUS ............................ 47
CORDARONE ...................... 53
CORDRAN ........................... 73
CORDRAN SP...................... 73
COREG ................................. 54
COREG CR........................... 54
CORGARD ........................... 54
CORTANE-B ...................... 101
CORTEF ............................. 110
CORTENEMA ...................... 73
CORTIFOAM ....................... 72
cortisone acetate ................. 109
CORTISPORIN ........ 70, 98, 99
CORTISPORIN-TC .............. 99
CORZIDE ............................. 54
COSOPT ............................. 123
COSOPT PF ........................ 123
COTAB A ............................. 63
COTAB AX .......................... 63
COTABFLU ......................... 63
COUMADIN......................... 47
COVERA-HS ........................ 54
COZAAR .............................. 51
CREON ................................. 96
CRESTOR............................. 57
cresyl acetate ........................ 98
CRINONE ........................... 113
CRIXIVAN ........................... 44
cromolyn sodium ... 97, 104, 126
CUPRIMINE....................... 107
CUTIVATE........................... 73
CUVPOSA .......................... 104
cyanocobalamin (vitamin b-12)
......................................... 130
CYCLESSA .......................... 60
cyclobenzaprine hcl ............ 127
CYCLOGYL ......................... 97
I-7
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
CYCLOMYDRIL ................. 97
cyclopentolate hcl ................. 97
cyclophosphamide ................. 23
CYCLOPHOSPHAMIDE..... 23
cycloserine ............................ 39
CYCLOSET .......................... 32
cyclosporine ................ 114, 115
cyclosporine, modified ........ 114
CYMBALTA ........................ 30
cyproheptadine hcl ................ 36
CYSTAGON ......................... 96
CYSTARAN ......................... 98
CYTOMEL ......................... 114
CYTOTEC .......................... 103
D.H.E.45 ............................... 38
DALIRESP ......................... 126
danazol ................................ 107
DANTRIUM ....................... 127
dantrolene sodium ............... 127
dapsone ................................. 39
DAPTACEL DTAP ............ 115
DARAPRIM ......................... 40
DAYPRO .............................. 15
DAYTRANA ........................ 59
DDAVP ............................... 110
DECADRON ...................... 101
DELATESTRYL ................ 108
DEL-MYCIN ........................ 70
DELOS .................................. 67
DELZICOL ......................... 118
DEMADEX........................... 56
demeclocycline hcl ................ 22
DEMEROL ........................... 12
DEMSER .............................. 55
DENAVIR............................. 67
DEPAKENE ................... 27, 28
DEPAKOTE ......................... 28
DEPAKOTE ER ................... 28
DEPAKOTE SPRINKLE ..... 28
DEPEN................................ 107
DEPO-MEDROL ................ 110
DEPO-PROVERA .............. 113
DEPO-SUBQ PROVERA 104
......................................... 113
DEPO-TESTOSTERONE .. 108
DEPRIZINE ........................ 103
DERMA-CAS ....................... 67
DERMA-SMOOTHE-FS ...... 73
DERMASORB HC ............... 73
DERMASORB TA ............... 73
DERMASORB XM .............. 67
DERMATOP......................... 73
DERMOTIC ........................ 101
desipramine hcl ..................... 29
desloratadine......................... 36
desmopressin acetate .......... 110
desog-e.estradiol/e.estradiol . 60
DESOGEN ............................ 60
desogestrel-ethinyl estradiol . 60
DESONATE ......................... 73
desonide .......................... 71, 73
DESOWEN ........................... 73
desoximetasone ..................... 71
DESOXYN ........................... 59
DESPEC-EXP ....................... 63
DESPEC-PDC....................... 63
DESQUAM-X....................... 67
desvenlafaxine ....................... 29
DESVENLAFAXINE ER..... 30
DESVENLAFAXINE
FUMARATE ER .............. 30
DETROL ............................. 106
DETROL LA ...................... 106
dexamethasone .................... 109
dexamethasone acetate ....... 109
DEXAMETHASONE
INTENSOL ..................... 110
dexamethasone sod phosphate
................................. 100, 109
DEXASOL .......................... 101
dexchlorpheniramine maleate36
DEXEDRINE ........................ 59
DEXILANT ........................ 103
dexmethylphenidate hcl ......... 59
DEXPAK ............................ 110
dextroamphetamine sulfate ... 59
dextroamphetamine/
amphetamine ..................... 59
dextrose ................................. 49
dhcodeine bt/acetaminophn/caff
........................................... 11
DHT .................................... 130
DIABETA ............................. 33
diabetic supplies,miscell ....... 84
DIAMOX SEQUELS.......... 123
DIASCREEN 10 ................. 129
DIASCREEN 1G REAGENT
......................................... 128
DIASCREEN 1K REAGENT
......................................... 128
DIASCREEN 2GK REAGENT
......................................... 129
DIASCREEN 3 REAGENT 129
DIASCREEN 4OBL ........... 129
DIASCREEN 5 ................... 129
DIASCREEN 6 ................... 129
DIASCREEN 7 ................... 129
DIASCREEN 8 ................... 129
DIASCREEN 9 ................... 129
DIASTAT ............................. 18
DIASTAT ACUDIAL .......... 18
DIASTIX REAGENT ......... 128
DIATRUE ............................. 84
DIATRUE PLUS .................. 84
diazepam ............................... 17
DIBENZYLINE .................... 51
DICLEGIS ............................ 40
diclofenac potassium ............. 14
diclofenac sodium ......... 14, 100
diclofenac sodium/misoprostol
........................................... 14
dicloxacillin sodium .............. 21
DICOPANOL ....................... 37
dicyclomine hcl ................... 104
didanosine ............................. 44
DIDREX ............................... 59
DIDRONEL ........................ 119
DIFFERIN............................. 74
I-8
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
DIFICID ................................ 20
diflorasone diacetate ............. 71
DIFLUCAN .......................... 34
diflunisal ............................... 14
DIGEX NF .......................... 104
digoxin................................... 54
DIGOXIN ............................. 55
dihydrocodeine/aspirin/caffein
........................................... 11
dihydrocodeine/guaifenesin .. 62
dihydroergotamine mesylate . 38
DIHYDROTESTOSTERONE
PROPIONATE ................ 107
DILACOR XR ...................... 54
DILANTIN ..................... 27, 28
DILANTIN-125 .................... 28
DILATRATE-SR .................. 58
DILAUDID ........................... 12
diltiazem hcl .......................... 54
DIOVAN ............................... 51
DIOVAN HCT ...................... 51
DIPENTUM ........................ 118
diphenhydramine hcl ............. 36
diphenoxylate hcl/atropine.. 104
DIPHTHERIA-TETANUS
TOXOID ......................... 115
DIPHTHERIA-TETANUS
TOXOIDS-PED .............. 115
DIPROLENE ........................ 73
DIPROLENE AF .................. 73
DIPROSONE ........................ 73
dipyridamole ......................... 48
DISALCID ............................ 15
disopyramide phosphate ....... 53
disulfiram .............................. 16
DITROPAN XL .................. 106
DIURIL ................................. 56
divalproex sodium ................. 27
DIVIGEL ............................ 108
dm/phenyleph/
chlorpheniramine .............. 62
d-methorphan hb/p-epd hcl/bpm
........................................... 62
d-methorphan hb/prometh hcl62
DOLGIC PLUS ..................... 12
DOLOGESIC ........................ 11
DOLOPHINE HCL ............... 12
DONATUSS DC ................... 63
donepezil hcl ......................... 29
DONNATAL ........................ 27
DORAL ................................. 18
DORYX ................................ 22
dorzolamide hcl ................... 123
dorzolamide hcl/timolol maleat
......................................... 123
DOVONEX ........................... 67
doxazosin mesylate................ 50
doxepin hcl ............................ 30
doxercalciferol .................... 119
doxycycline hyclate ............... 22
doxycycline monohydrate...... 22
doxylamine succinate ............ 36
DRISDOL ........................... 130
DRITHOCREME HP............ 67
dronabinol ............................. 39
DROPLET LANCETS.......... 77
DROPLET LANCING
DEVICE ............................ 77
DROXIA ............................... 26
DRYSOL............................... 67
DUAC ................................... 70
DUAC CS ............................. 70
DUAVEE ............................ 108
DUETACT ............................ 32
DUEXIS ................................ 15
DULERA ............................ 125
duloxetine hcl ........................ 30
DUONEB ............................ 126
DURAGESIC ........................ 12
DURAXIN ............................ 12
DUREZOL .......................... 101
DUTOPROL ......................... 54
DYAZIDE ............................. 56
DYLIX ................................ 127
DYMISTA ............................ 97
DYNACIN ............................ 22
DYNACIRC CR ................... 55
DYRENIUM ......................... 56
EAA ...................................... 49
EASIVENT ........................... 77
EASY CHECK...................... 84
EASY CHECK CONTROL
SOLUTION....................... 84
EASY CHECK TEST STRIP 84
EASY CLICK ....................... 77
EASY COMFORT ................ 77
EASY GLUCO G2 ............... 84
EASY PLUS ................... 84, 85
EASY PLUS II...................... 84
EASY STEP .......................... 85
EASY TALK ........................ 85
EASY TOUCH ............... 77, 85
EASY TOUCH GLUCOSE
MONITOR ........................ 85
EASY TOUCH LANCETS .. 77
EASY TOUCH LANCING
DEVICE ............................ 77
EASY TRAK ........................ 85
EASY TWIST AND CAP
LANCETS......................... 85
EASYGLUCO ...................... 85
EASYGLUCO PLUS............ 85
EASYGLUCO PLUS
CONTROL NORMAL ..... 85
EASYMAX ........................... 85
EASYMAX 15 ...................... 85
EASYMAX L ....................... 85
EASYMAX N ....................... 85
EASYMAX NG .................... 85
EASYMAX V ....................... 85
EASYMAX V SPEAKING .. 85
EASYMAX V2 ..................... 85
EASYPLUS .......................... 85
EASYPLUS R13N ................ 85
EASYPLUS V ...................... 85
ECLIPSE ............................... 86
ECLIPSE CONTROL
SOLUTION....................... 86
I-9
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
ECLIPSE LUER-LOK
SYRINGE ......................... 78
EC-NAPROSYN................... 15
econazole nitrate ................... 34
ECOZA ................................. 34
EDARBI ................................ 51
EDARBYCLOR ................... 51
EDECRIN ............................. 56
EDLUAR ............................ 128
EDURANT ........................... 44
EFFER-K ............................ 124
EFFEXOR XR ...................... 30
EFFIENT............................... 48
EFUDEX ............................... 67
EGRIFTA ............................ 111
ELDEPRYL .......................... 41
ELEMENT BLOOD
GLUCOSE METER.......... 86
ELEMENT COMPACT........ 86
ELEMENT COMPACT
CONTROL SOLN ............ 86
ELEMENT CONTROL
SOLUTION....................... 86
ELEMENT PLUS ................. 86
ELEMENT PLUS CONTROL
SOLUTION....................... 86
ELEMENT TEST STRIPS ... 86
ELESTAT ............................. 97
ELESTRIN .......................... 109
ELIDEL................................. 72
ELIGARD ............................. 26
ELIMITE............................... 75
ELIQUIS ............................... 47
ELLA .................................... 60
ELMIRON .......................... 120
ELOCON .............................. 73
EMADINE ............................ 97
EMBEDA .............................. 12
EMBRACE ........................... 86
EMBRACE EVO .................. 86
EMBRACE GLUCOSE
CONTROL SOLN ............ 86
EMBRACE PRO .................. 86
EMCYT................................. 23
EMEND .......................... 39, 40
EMLA ................................... 16
EMSAM ................................ 30
EMTRIVA ............................ 44
ENABLEX .......................... 106
enalapril maleate .................. 52
enalapril/hydrochlorothiazide
........................................... 52
ENBREL ............................. 115
ENDOMETRIN .................. 113
ENGERIX-B ADULT ........ 115
ENGERIX-B PEDIATRICADOLESCENT .............. 116
ENJUVIA ............................ 109
ENLITE................................. 87
ENOVARX-IBUPROFEN ... 73
enoxaparin sodium ................ 47
entacapone ............................ 41
entecavir ................................ 46
ENTOCORT EC ................. 118
ENVISION ............................ 87
EPANED ............................... 52
EPIDUO ................................ 74
EPIFOAM ............................. 73
epinastine hcl ........................ 97
epinephrine ........................... 54
EPIPEN 2-PAK ..................... 55
EPIPEN JR 2-PAK ............... 55
EPIVIR .................................. 45
EPIVIR HBV ........................ 45
eplerenone ............................. 58
EPOGEN ............................... 48
eprosartan mesylate .............. 51
EPZICOM ............................. 44
EQUETRO ............................ 28
ergocalciferol (vitamin d2) . 130
ergoloid mesylates .............. 120
ERGOMAR........................... 38
ergotamine tartrate/caffeine . 38
ERIVEDGE........................... 23
ERTACZO ............................ 34
ery e-succ/sulfisoxazole ........ 20
ERYGEL ............................... 70
ERYPED 200 ........................ 20
ERYPED 400 ........................ 20
ERY-TAB ............................. 20
erythromycin base ........... 20, 98
erythromycin base/ethanol .... 70
erythromycin ethylsuccinate . 20
erythromycin stearate ........... 20
erythromycin/benzoyl peroxide
........................................... 70
ESBRIET ............................ 127
escitalopram oxalate ............. 30
ESGIC ................................... 12
ESGIC-PLUS ........................ 12
ESKALITH ........................... 59
ESOMEPRAZOLE
STRONTIUM ................. 103
estazolam............................... 17
ESTRACE ................... 108, 109
ESTRADERM .................... 108
estradiol .............................. 108
ESTRADIOL BENZOATE 108
ESTRADIOL CYPIONATE108
ESTRADIOL MICRONIZED
......................................... 108
ESTRADIOL VALERATE 108
estradiol/norethindrone acet
................................. 108, 109
ESTRASORB ..................... 109
ESTRING ............................ 108
ESTROGEL ........................ 109
estrogen,ester/me-testosterone
......................................... 107
estropipate........................... 108
ESTROSTEP FE ................... 60
eszopiclone .......................... 128
ethambutol hcl ....................... 39
ETHINYL ESTRADIOL .... 108
ethinyl estradiol/drospirenone
........................................... 60
ethosuximide ......................... 27
ethyl chloride ........................ 65
ethynodiol d-ethinyl estradiol 60
I-10
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
etidronate disodium ............ 119
etodolac ................................. 14
etoposide ............................... 23
EURAX ................................. 75
EVAMIST ........................... 109
EVENCARE ......................... 87
EVENCARE G2 ................... 87
EVENCARE G3 ................... 87
EVISTA .............................. 109
EVOCLIN ............................. 71
EVOLUTION BLOOD
GLUCOSE METER.......... 87
EVOLUTION CONTROL
SOLUTION....................... 87
EVOLUTION TEST STRIPS 87
EVOXAC .............................. 65
EVZIO................................... 16
EXALGO .............................. 12
EXELDERM ......................... 34
EXELON............................... 29
exemestane ............................ 23
EXFORGE ............................ 55
EXFORGE HCT ................... 55
EXJADE ............................. 107
EXTAVIA ........................... 122
EXTINA ................................ 35
E-Z JECT LANCETS ........... 78
EZ SMART ........................... 87
EZ SMART LANCETS ........ 78
EZ SMART PLUS ................ 87
E-Z SPACER ........................ 78
E-ZJECT LANCETS ............ 78
FABIOR ................................ 74
FACTIVE .............................. 21
FALESSA ............................. 60
famciclovir ............................ 46
famotidine ........................... 102
FAMVIR ............................... 46
FANAPT ............................... 43
FANATREX ......................... 28
FARESTON .......................... 23
FARXIGA ............................. 32
FAZACLO ............................ 43
felbamate ............................... 27
FELBATOL .......................... 28
FELDENE ............................. 15
felodipine............................... 55
FEM PH ................................ 38
FEMARA .............................. 26
FEMCAP............................... 60
FEMCON FE ........................ 60
FEMHRT ............................ 109
FEMRING........................... 109
FEMTRACE ....................... 109
fenofibrate ............................. 57
fenofibrate nanocrystallized.. 57
fenofibrate,micronized .......... 57
fenofibric acid ....................... 57
fenofibric acid (choline) ........ 57
FENOGLIDE ........................ 57
fenoprofen calcium................ 14
FENOPROFEN CALCIUM . 15
fentanyl .................................. 11
fentanyl citrate ...................... 11
FENTORA ............................ 12
FER-IN-SOL ....................... 130
FERRIPROX....................... 107
ferrous sulfate ..................... 130
FETZIMA ............................. 30
FEXMID ............................. 127
fexofenadine hcl .................... 36
fexofenadine/pseudoephedrine
........................................... 36
FIBRICOR ............................ 57
FIFTY50 SAFETY SEAL
LANCETS......................... 78
FIFTY50 TEST STRIP ......... 87
FINACEA ............................. 66
FINACEA PLUS .................. 66
finasteride ........................... 120
FINE 30 UNIVERSAL
LANCETS......................... 78
FINGERSTIX ....................... 78
FIORICET............................. 12
FIORICET WITH CODEINE12
FIORINAL ............................ 12
FIORINAL WITH CODEINE
#3....................................... 12
FIRAZYR ............................. 55
FIRMAGON ......................... 26
FIRST-BXN .......................... 35
FIRST-DUKE'S .................... 35
FIRST-HYDROCORTISONE
........................................... 73
FIRST-LANSOPRAZOLE . 102
FIRST-MARY'S ................... 35
FIRST-OMEPRAZOLE ..... 102
FIRST-PROGESTERONE
VGS 100.......................... 113
FIRST-PROGESTERONE
VGS 200.......................... 113
FIRST-PROGESTERONE
VGS 25............................ 113
FIRST-PROGESTERONE
VGS 400.......................... 113
FIRST-PROGESTERONE
VGS 50............................ 113
FIRST-TESTOSTERONE .. 108
FIRST-TESTOSTERONE MC
......................................... 108
FLAGYL ............................... 41
FLAGYL ER ......................... 40
FLAREX ............................. 100
flavoxate hcl ........................ 106
flecainide acetate .................. 53
FLECTOR ............................. 15
FLEXERIL .......................... 127
FLOMAX ............................ 107
FLONASE........................... 101
FLO-PRED ......................... 110
FLOVENT DISKUS ........... 125
FLOVENT HFA ................. 125
FLOXIN ................................ 99
floxuridine ............................. 23
FLUARIX 2012-2013 ......... 116
FLUARIX 2013-2014 ......... 116
FLUARIX 2014-2015 ......... 116
FLUARIX QUAD 2013-2014
......................................... 116
I-11
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
FLUARIX QUAD 2014-2015
......................................... 116
FLUBLOK 2013-2014 ........ 116
FLUBLOK 2014-2015 ........ 116
FLUCELVAX ..................... 116
FLUCELVAX 2014-2015 .. 116
fluconazole ............................ 34
flucytosine ............................. 34
fludrocortisone acetate ....... 109
FLULAVAL 2012-2013 ..... 116
FLULAVAL 2013-2014 ..... 116
FLULAVAL 2014-2015 ..... 116
FLULAVAL QUAD 2013-2014
......................................... 116
FLULAVAL QUAD 2014-2015
......................................... 116
FLUMADINE ....................... 45
FLUMIST ........................... 116
FLUMIST QUAD 2014-2015
......................................... 116
flunisolide............................ 100
fluocinolone acetonide .......... 71
fluocinolone acetonide oil ... 100
fluocinolone/shower cap ....... 71
fluocinonide........................... 71
FLUORESCEINBENOXINATE ................. 16
fluorometholone .................. 100
FLUOROPLEX..................... 68
fluorouracil ........................... 65
fluoxetine hcl ......................... 30
fluoxymesterone .................. 107
fluphenazine decanoate ......... 42
fluphenazine hcl .................... 42
flurazepam hcl ....................... 17
flurbiprofen ........................... 14
flurbiprofen sodium............. 100
FLURESS ............................. 16
FLUROX............................... 16
flutamide ............................... 23
fluticasone propionate .. 71, 100
fluvastatin sodium ................. 57
FLUVIRIN 2012-2013........ 116
FLUVIRIN 2013-2014........ 116
FLUVIRIN 2014-2015........ 116
fluvoxamine maleate ............. 30
FLUZONE 2012-2013 ........ 116
FLUZONE 2013-2014 ........ 116
FLUZONE 2014-2015 ........ 116
FLUZONE HIGH-DOSE 201213..................................... 116
FLUZONE HIGH-DOSE 20132014................................. 116
FLUZONE HIGH-DOSE 20142015................................. 116
FLUZONE INTRADERM
QUAD 2014-15 ............... 116
FLUZONE INTRADERMAL
2012-2013 ....................... 116
FLUZONE INTRADERMAL
2013-2014 ....................... 116
FLUZONE INTRADERMAL
2014-2015 ....................... 116
FLUZONE PEDI 2012-2013
......................................... 116
FLUZONE PEDI 2013-2014
......................................... 116
FLUZONE QUAD 2013-2014
......................................... 116
FLUZONE QUAD PEDI 20142015................................. 116
FML .................................... 101
FML FORTE ....................... 100
FML S.O.P. ......................... 101
FOCALIN ............................. 59
FOCALIN XR ....................... 59
FOLGARD OS.................... 130
folic acid.............................. 131
FOLLISTIM AQ ................. 110
fondaparinux sodium ............ 47
FORA D10 ............................ 87
FORA D15C ......................... 87
FORA D15G ......................... 87
FORA D15Z.......................... 87
FORA D20 ............................ 87
FORA G20 ............................ 87
FORA G30A ......................... 87
FORA G71A ......................... 87
FORA G90 ...................... 87, 88
FORA GD50 ......................... 88
FORA GD50 TEST STRIPS 88
FORA LANCING DEVICE . 78
FORA TEST N'GO TEST
STRIPS ............................. 88
FORA TEST N'GO VOICE .. 88
FORA TEST STRIP ............. 88
FORA V10 ............................ 88
FORA V12 ............................ 88
FORA V20 ............................ 88
FORA V22 ............................ 88
FORA V30A ......................... 88
FORACARE GD20 .............. 88
FORACARE GD40 .............. 88
FORACARE GD40A............ 88
FORACARE GD40B ............ 88
FORACARE GDH................ 88
FORACARE LANCETS ...... 78
FORADIL ........................... 126
FORFIVO XL ....................... 31
FORTAMET ......................... 32
FORTEO ............................. 119
FORTESTA ........................ 108
FORTICAL ......................... 119
FORTISCARE ...................... 88
FORTISCARE BLOOD
GLUCOSE SYST ............. 88
FORTISCARE GLUCOSE
TEST STRIPS ................... 88
FOSAMAX ......................... 119
FOSAMAX PLUS D .......... 119
fosinopril sodium .................. 52
fosinopril/hydrochlorothiazide
........................................... 52
FOSRENOL ........................ 106
FRAGMIN ............................ 47
FREESTYLE CONTROL
SOLUTION....................... 88
FREESTYLE FLASH
SYSTEM ........................... 88
I-12
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
FREESTYLE FREEDOM .... 88
FREESTYLE FREEDOM LITE
........................................... 88
FREESTYLE INSULINX .... 88
FREESTYLE INSULINX
TEST STRIPS ................... 88
FREESTYLE LANCETS ..... 88
FREESTYLE LITE METER 88
FREESTYLE LITE STRIPS 88
FREESTYLE LITE TEST
STRIPS ............................. 88
FREESTYLE NAVIGATOR 89
FREESTYLE SIDEKICK II . 89
FREESTYLE SYSTEM........ 89
FREESTYLE TEST STRIPS 89
FREESTYLE UNISTIK 2 .... 78
FRESHKOTE ....................... 98
FROVA ................................. 38
FULVICIN U/F..................... 35
FULYZAQ .......................... 104
FUNGOID AND HC ............ 35
FURACIN ............................. 71
FURADANTIN..................... 19
furosemide ............................. 56
FUZEON ............................... 45
FYCOMPA ........................... 28
G-4 ........................................ 89
gabapentin............................. 27
GABITRIL ............................ 28
galantamine hbr .................... 29
GALZIN .............................. 107
GARAMYCIN ...................... 99
GARDASIL ........................ 117
GARDASIL 9 ..................... 117
GASTRINEX NF ................ 104
GASTROCROM ................. 104
gatifloxacin ........................... 98
GDRIVE ............................... 89
GE100 BLOOD GLUCOSE
SYSTEM ........................... 89
GE100 BLOOD GLUCOSE
TEST STRIP ..................... 89
GE100 CONTROL
SOLUTION NORMAL .... 89
GELFILM ............................. 98
GELNIQUE ........................ 106
gemfibrozil ............................ 57
GENERESS FE ..................... 60
GENOTROPIN ................... 111
GENSTRIP ........................... 89
gentamicin sulfate ........... 70, 98
GEODON .............................. 43
GIAZO ................................ 118
GILENYA ........................... 122
GILOTRIF ............................ 24
GLEEVEC ............................ 24
glimepiride ............................ 33
glipizide ................................. 33
glipizide/metformin hcl ......... 33
GLUCAGEN....................... 120
GLUCAGON EMERGENCY
KIT .................................. 120
GLUCO NAVII .................... 89
GLUCOCARD 01 ................. 89
GLUCOCARD 01 CONTROL
........................................... 89
GLUCOCARD 01 SENSOR 89
GLUCOCARD 01-MINI ...... 89
GLUCOCARD EXPRESSION
........................................... 89
GLUCOCARD VITAL ......... 89
GLUCOCARD VITAL
SENSOR ........................... 89
GLUCOCARD X-METER ... 78
GLUCOCARD X-METER
CONTROL........................ 78
GLUCOCARD X-SENSOR . 89
GLUCOCOM ........................ 78
GLUCOCOM BLOOD
GLUCOSE ........................ 78
GLUCOCOM CONTROL
SOLUTION....................... 78
GLUCOCOM GLUCOSE .... 89
GLUCOCOM LANCETS..... 78
GLUCOLAB ......................... 89
GLUCOLAB CONTROL ..... 89
GLUCOLET 2 ...................... 78
GLUCOPHAGE ................... 32
GLUCOPHAGE XR ............. 32
GLUCOSE CONTROL ........ 78
GLUCOSE CONTROL
SOLUTION....................... 78
GLUCOSE TEST STRIP ...... 89
GLUCOSOURCE ................. 78
GLUCOTROL ...................... 34
GLUCOTROL XL ................ 33
GLUCOVANCE ................... 34
GLUMETZA......................... 32
glutethimide......................... 120
glyburide ............................... 33
glyburide,micronized ............ 33
glyburide/metformin hcl ........ 33
GLYCATE .......................... 104
GLYCINE ........................... 118
glycopyrrolate ..................... 104
GLYNASE ............................ 34
GLYSET ............................... 32
GLYTACTIN 10 PE
BETTERMILK ................. 49
GLYTACTIN 15 PE
BETTERMILK ................. 49
GLYTACTIN RESTORE 10
PE ...................................... 49
GLYTACTIN RESTORE 10
PE LITE ............................ 49
GLYTACTIN RTD 10 PE .... 49
GLYTACTIN RTD 15 PE .... 49
GMATE ................................ 90
GMATE CONTROL
SOLUTION....................... 89
GMATE LANCING DEVICE
........................................... 89
GMATE SMART METER ... 89
GMATE SMART STARTER89
GMATE TEST STRIPS ........ 89
GMATE VOICE METER..... 90
GMATE VOICE STARTER 90
GOLYTELY ....................... 105
I-13
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
GONAL-F ........................... 111
GONAL-F RFF ................... 111
GONAL-F RFF REDI-JECT
......................................... 111
GORDOFILM ....................... 68
GORDO-UREA .................... 68
GRALISE .............................. 28
granisetron hcl ...................... 39
GRANIX ............................... 48
GRASTEK .......................... 121
GRIFULVIN V ..................... 35
griseofulvin ultramicrosize ... 34
griseofulvin, microsize .......... 34
GRIS-PEG............................. 35
guaifen/theop anhyd/p-ephed
......................................... 126
guaifenesin ............................ 62
guaifenesin/codeine phosphate
........................................... 62
guaifenesin/dm/
pseudoephedrine ............... 62
guaifenesin/dyphylline ........ 126
guaifenesin/phenylephrine hcl
........................................... 63
guanabenz acetate ................. 50
guanfacine hcl ................. 50, 59
guanidine hcl ....................... 120
GYNAZOLE 1 ...................... 38
GYNOL II ............................. 60
H.P. ACTHAR .................... 122
HAEMOLANCE................... 78
HAEMOLANCE PLUS ........ 78
HAEMOLANCE,
RETRACTABLE .............. 78
HALCION............................. 18
HALDOL DECANOATE 100
........................................... 43
HALDOL DECANOATE 50 43
HALFAN .............................. 40
HALFLYTELY-BISACODYL
......................................... 105
halobetasol propionate ......... 71
halobetasol/ammonium lactate
........................................... 71
HALOG................................. 73
HALONATE ......................... 73
HALONATE PAC ................ 73
haloperidol ............................ 42
haloperidol decanoate .......... 42
haloperidol lactate ................ 42
HARVONI ............................ 45
HAVRIX ............................. 117
hc/pramoxine hcl/chloroxylenol
......................................... 100
HEALTHPRO GLUCOSE
CONTROL SOLN ............ 90
HEALTHPRO GLUCOSE
MONITOR ........................ 90
HEALTHPRO TEST STRIPS
........................................... 90
HEALTHY ACCENTS
AUTOLET ........................ 78
HEALTHY ACCENTS
UNILET LANCET ........... 78
HECORIA ........................... 114
HECTOROL ....................... 119
HELIDAC ........................... 104
HEMANGEOL ..................... 54
heparin sodium,porcine ........ 47
heparin sodium,porcine/pf .... 47
HEPSERA ............................. 47
HETLIOZ ............................ 128
HEXALEN ............................ 24
HIPREX ................................ 19
homatropine hbr.................... 97
HORIZANT .......................... 28
HUMALOG .......................... 33
HUMALOG MIX 50-50 ....... 33
HUMALOG MIX 75-25 ....... 33
HUMATROPE .................... 111
HUMIRA ............................ 115
HUMORSOL ...................... 123
HUMULIN 70/30 KWIKPEN
........................................... 33
HUMULIN 70-30 ................. 33
HUMULIN N ........................ 33
HUMULIN N KWIKPEN .... 33
HUMULIN R ........................ 33
HYCAMTIN ......................... 24
HYCET ................................. 12
hydralazine hcl ...................... 54
hydralazine/hydrochlorothiazid
........................................... 55
hydralazine/reserpin/hctz ...... 55
HYDREA .............................. 26
HYDRO 35 ........................... 68
HYDRO 40 ........................... 68
hydrochlorothiazide .............. 56
hydrocodone bit/homatrop mebr ....................................... 63
hydrocodone/acetaminophen 11
hydrocodone/chlorphen p-stirex
........................................... 63
hydrocodone/ibuprofen ......... 11
hydrocort/pramoxin/emol/
pram#1 .............................. 71
hydrocort/pramoxn/skn
clnsr#16............................. 72
hydrocortisone .............. 72, 109
HYDROCORTISONE .......... 72
hydrocortisone ac/lidocaine.. 72
hydrocortisone acetate .......... 72
HYDROCORTISONE
ACETATE ........................ 72
hydrocortisone acetate/aloe v 72
hydrocortisone acetate/urea . 72
hydrocortisone butyrate ........ 72
hydrocortisone valerate ........ 72
hydrocortisone/iodoquinol .... 72
hydrocortisone/lidocaine/aloe
........................................... 72
hydrocortisone/pramoxine .... 72
hydrogen peroxide .............. 120
hydromorphone hcl ............... 11
hydroxychloroquine sulfate ... 40
HYDROXYPROGESTERONE
CAPROATE ................... 113
hydroxyurea .......................... 23
I-14
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
hydroxyzine hcl ................... 120
hydroxyzine pamoate .......... 120
hyoscyamine sulfate ............ 104
HYPER-SAL....................... 127
HYPOLANCE ...................... 78
HYSINGLA ER .................... 12
HYZAAR .............................. 51
ibandronate sodium ............ 119
IBG-STAR ............................ 90
IBUDONE............................. 12
ibuprofen ............................... 14
ibuprofen/oxycodone hcl ....... 11
ICLUSIG ............................... 24
ILARIS ................................ 115
ILEVRO .............................. 101
ILOTYCIN ............................ 99
IMBRUVICA ........................ 24
IMDUR ................................. 58
imipramine hcl ...................... 30
imipramine pamoate ............. 30
imiquimod ............................. 65
IMITREX .............................. 38
IMOVAX RABIES VACCINE
......................................... 117
IMURAN ............................ 114
INCIVEK .............................. 45
INCONTROL LANCING
DEVICE ............................ 78
INCONTROL SUPER THIN
LANCETS......................... 78
INCONTROL ULTRA THIN
LANCETS......................... 78
INCRELEX ......................... 111
INCRUSE ELLIPTA .......... 126
indapamide............................ 56
INDERAL LA ....................... 54
INDOCIN .............................. 15
indomethacin ......................... 14
INFANRIX DTAP .............. 117
INFERGEN ........................... 46
INFINITY ............................. 90
INFINITY CONTROL
SOLUTION....................... 90
INFINITY TEST STRIPS .... 90
INJECT EASE LANCETS ... 78
INLYTA ................................ 24
INNOPRAN XL.................... 54
INOVA .................................. 68
INOVA 4-1 ........................... 68
INOVA 8-2 ........................... 68
INSPRA ................................ 58
INTELENCE......................... 44
INTERMEZZO ................... 128
INTRON A............................ 46
INTUNIV .............................. 60
INVACARE LANCETS ....... 78
INVEGA ............................... 43
INVEGA SUSTENNA ......... 43
INVIRASE ............................ 44
INVOKAMET ...................... 32
INVOKANA ......................... 32
IODINE ............................... 113
iodine/potassium iodide ........ 65
IODOFLEX........................... 68
IODOSORB .......................... 68
IOPIDINE ....................... 97, 98
IPOL .................................... 117
ipratropium bromide ..... 97, 125
ipratropium/albuterol sulfate
......................................... 125
IPRIVASK ............................ 47
IQUIX ................................... 99
irbesartan .............................. 51
irbesartan/hydrochlorothiazide
........................................... 51
iron,carbonyl ....................... 131
IRRIGATING SOLUTION G
......................................... 118
ISENTRESS .......................... 44
ISOCHRON .......................... 58
isoetharine hcl ..................... 125
isomethept/dichlphn/
acetaminop ........................ 38
isomethepten/caf/
acetaminophen .................. 38
isoniazid ................................ 39
isopropamide/prochlorperazine
......................................... 104
ISOPTIN SR ......................... 54
ISOPTO ATROPINE ............ 98
ISOPTO CARBACHOL ..... 123
ISOPTO CARPINE ............ 123
ISOPTO HOMATROPINE .. 98
ISOPTO HYOSCINE ........... 98
ISORDIL ............................... 58
ISORDIL TITRADOSE........ 58
isosorbide dinitrate ............... 58
isosorbide mononitrate ......... 58
isotretinoin ............................ 65
isoxsuprine hcl ...................... 55
isradipine .............................. 55
ISTALOL ............................ 123
itraconazole........................... 34
ivermectin .............................. 40
IXIARO............................... 117
JAKAFI ................................. 24
JALYN ................................ 121
JANUMET ............................ 32
JANUMET XR ..................... 32
JANUVIA ............................. 32
JARDIANCE ........................ 32
JENTADUETO ..................... 32
JE-VAX............................... 117
JUBLIA ................................. 35
JUVISYNC ........................... 32
JUXTAPID ........................... 58
KADIAN ............................... 12
KALETRA ............................ 44
KALYDECO....................... 127
KAOCHLOR ...................... 124
KAOCHLOR-EFF .............. 124
KAON-CL 10...................... 124
KAPVAY .............................. 60
KARBINAL ER .................... 37
KAYEXALATE ................. 106
KAZANO .............................. 32
KEFLEX ............................... 20
KENALOG ........................... 73
KEPPRA ............................... 28
I-15
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
KEPPRA XR......................... 28
KERAFOAM ........................ 68
KERALAC ............................ 68
KERALYT ............................ 68
KERALYT SCALP .............. 68
KERLONE ............................ 54
KEROL ................................. 68
KEROL AD .......................... 68
KEROL ZX ........................... 68
KERYDIN............................. 35
KETEK ................................. 20
ketoconazole .......................... 34
KETODAN ..................... 34, 35
KETO-DIASTIX REAGENT
......................................... 129
KETONE............................. 128
KETONE CARE ................. 128
ketoprofen ............................. 14
ketorolac tromethamine 14, 100
KETOSTIX REAGENT ..... 128
KEYNOTE ............................ 90
KEYNOTE PRO ................... 90
KHEDEZLA ......................... 31
KINERET ........................... 115
KINNEY BRAND LANCETS
........................................... 78
KINRIX............................... 117
KLARON .............................. 71
KLONOPIN .......................... 18
K-LOR ................................ 124
KOMBIGLYZE XR.............. 32
KORLYM ............................. 33
K-PHOS NEUTRAL .......... 124
K-PHOS NO.2 .................... 124
K-PHOS ORIGINAL .......... 124
KRISTALOSE .................... 104
K-SOL ................................. 124
K-TAB ER .......................... 124
KURIC .................................. 35
KUVAN ................................ 96
KYNAMRO .......................... 58
labetalol hcl .......................... 53
LAC-HYDRIN ...................... 68
LACRISERT ......................... 98
LACTATED RINGERS ..... 118
lactic acid .............................. 66
LACTICARE-HC ................. 73
lactulose .............................. 104
LAMICTAL .................... 27, 28
LAMICTAL BLUE .............. 28
LAMICTAL GREEN............ 28
LAMICTAL ODT ................. 28
LAMICTAL ODT BLUE ..... 28
LAMICTAL ODT GREEN .. 28
LAMICTAL ODT ORANGE 28
LAMICTAL ORANGE ........ 28
LAMICTAL XR ................... 28
LAMICTAL XR BLUE ........ 28
LAMICTAL XR GREEN ..... 28
LAMICTAL XR ORANGE .. 28
LAMISIL .............................. 35
lamivudine ....................... 44, 45
lamivudine/zidovudine .......... 44
lamotrigine ............................ 27
LANAFLEX ......................... 49
LANCET DEVICE ............... 78
LANCETS............................. 78
LANCETS THIN ............ 78, 90
LANCETS ULTRA THIN .... 90
LANCING DEVICE ............. 79
LANCING SYSTEM ............ 79
LANOXIN ............................ 55
lansoprazole ........................ 102
lansoprazole/amoxiciln/clarith
......................................... 102
LANTUS ............................... 33
LANTUS SOLOSTAR ......... 33
LASIX ................................... 56
LASTACAFT ....................... 98
latanoprost .......................... 123
LATISSE............................... 98
LATUDA .............................. 43
LAZANDA ........................... 12
leflunomide.......................... 114
LESCOL ............................... 57
LESCOL XL ......................... 57
LETAIRIS ........................... 130
letrozole................................. 23
leucovorin calcium .............. 120
LEUKERAN ......................... 24
LEUKINE ............................. 48
leuprolide acetate.................. 23
LEVACET ............................ 15
levalbuterol hcl ................... 125
LEVAQUIN .......................... 21
LEVATOL ............................ 54
LEVBID .............................. 104
LEVEMIR ............................. 33
LEVEMIR FLEXTOUCH .... 33
levetiracetam ......................... 27
LEVITRA ........................... 129
levobunolol hcl .................... 123
levocarnitine ....................... 120
levocarnitine (with sugar) ... 120
levocetirizine dihydrochloride
........................................... 36
levofloxacin ..................... 21, 98
levonorgestrel ....................... 60
levonorgestrel-ethin estradiol
..................................... 60, 61
levorphanol tartrate .............. 11
LEVOTHROID ................... 114
levothyroxine sodium .......... 113
LEVOTHYROXINE SODIUM
......................................... 113
LEVOXYL .......................... 114
LEVSIN .............................. 104
LEVSIN-SL ........................ 104
LEVULAN ............................ 68
LEXAPRO ............................ 31
LEXIVA ................................ 44
LIALDA .............................. 118
LIBERTY BLOOD GLUCOSE
METER ............................. 90
LIBERTY CONTROL
SOLUTION....................... 90
LIBERTY LEV 1 GLUCOSE
CONTROL........................ 90
LIBERTY MONITOR .......... 90
I-16
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
LIBERTY TEST STRIPS ..... 90
LIBRAX ................................ 27
LIBRITABS .......................... 18
LIDAMANTLE HC .............. 73
lidocaine ................................ 16
lidocaine hcl .................... 16, 66
lidocaine/prilocaine .............. 16
LIDODERM ......................... 16
LIDOVIR .............................. 68
LIMBREL ........................... 121
lindane................................... 75
LINZESS............................... 96
liothyronine sodium ............ 113
LIOTHYRONINE SODIUM
......................................... 113
lipase/protease/amylase ........ 96
LIPITOR ............................... 57
LIPOCHOL PLUS .............. 121
LIPOFEN .............................. 57
LIPTRUZET ......................... 57
lisinopril ................................ 52
lisinopril/hydrochlorothiazide
........................................... 52
LITE TOUCH ....................... 79
LITEAIRE............................. 79
LITETOUCH ........................ 79
lithium carbonate .................. 59
lithium citrate ........................ 59
LITHOBID ............................ 60
LITHOSTAT....................... 121
LIVALO ................................ 57
l-norgest-eth estr/ethin estra . 61
LO LOESTRIN FE ............... 61
LO MINASTRIN FE ............ 61
LOCOID ............................... 73
LODOSYN ........................... 41
LOESTRIN ........................... 61
LOESTRIN 24 FE................. 61
LOESTRIN FE...................... 61
LOFIBRA ............................. 57
LOMOTIL........................... 104
lomustine ............................... 23
loperamide hcl .................... 104
LOPHLEX ............................ 49
LOPID ................................... 57
LOPRESSOR ........................ 54
LOPRESSOR HCT ............... 54
LOPROX............................... 35
lorazepam.............................. 17
LORCET 10-650 ................... 12
LORCET PLUS .................... 13
LORTAB............................... 13
LORZONE .......................... 127
losartan potassium ................ 51
losartan/hydrochlorothiazide 51
LOSEASONIQUE ................ 61
LOTEMAX ......................... 101
LOTENSIN ........................... 52
LOTENSIN HCT .................. 52
LOTREL ............................... 56
LOTRIMIN ........................... 35
LOTRISONE ........................ 35
LOTRONEX ......................... 96
lovastatin ............................... 57
LOVAZA .............................. 57
LOVENOX ........................... 47
loxapine succinate ................. 42
LOXITANE .......................... 43
LOZI-FLUR ........................ 130
LUFYLLIN ......................... 126
LUMIGAN .......................... 123
LUMINAL SODIUM ........... 28
LUNESTA .......................... 128
LUPANETA PACK ............ 122
LUPRON DEPOT ................. 26
LUPRON DEPOT-PED ........ 26
LUVOX CR .......................... 31
LUXIQ .................................. 73
LUZU .................................... 35
LYCELLE ........................... 120
LYNPARZA ......................... 24
LYRICA ................................ 28
LYSIPLEX PLUS ............... 130
LYSODREN ......................... 24
LYSTEDA ............................ 48
MACROBID ......................... 19
MACRODANTIN................. 19
mafenide acetate ................... 66
MAGAN ............................... 15
MAGNACET ........................ 13
MAKENA ........................... 113
MALARONE ........................ 41
malathion .............................. 75
mannitol/sorbitol solution ... 118
maprotiline hcl ...................... 30
MARINOL ............................ 40
MARPLAN ........................... 31
MATULANE ........................ 24
MAVIK ................................. 52
MAXAIR AUTOHALER ... 126
MAXALT ............................. 38
MAXALT MLT .................... 38
MAXAQUIN ........................ 21
MAXIDEX .......................... 101
MAXIDONE ......................... 13
MAXIFED CD ...................... 63
MAXIFED CDX ................... 63
MAXIFED-G CD.................. 64
MAXIFED-G CDX ............... 64
MAXIFLU CD ...................... 64
MAXIFLU CDX ................... 64
MAXIMA ............................. 90
MAXITROL ......................... 99
MAXZIDE ............................ 56
MAXZIDE-25 MG ............... 56
M-CLEAR WC ..................... 64
mebendazole .......................... 40
meclizine hcl.......................... 39
meclofenamate sodium .......... 14
MEDI-LANCE ...................... 79
MEDISENSE ........................ 90
MEDISENSE CONTROL .... 90
MEDISENSE GLUCOSE
KETONE........................... 79
MEDISENSE GLUCOSE
KETONE CONTR ............ 79
MEDISENSE THIN LANCETS
........................................... 79
MEDLANCE PLUS.............. 79
I-17
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
MEDLANCE PLUS SPECIAL
BLADE ............................. 90
MEDROL............................ 110
MEDROXYPROGESTERONE
AC MICRO ..................... 113
medroxyprogesterone acet .. 112
medroxyprogesterone acetate
......................................... 113
mefenamic acid ..................... 14
mefloquine hcl ....................... 40
MEGACE .............................. 26
MEGACE ES ........................ 24
megestrol acetate .................. 23
MEKINIST ........................... 24
meloxicam ............................. 14
MENACTRA ...................... 117
M-END MAX D ................... 64
M-END PE ............................ 64
M-END WC .......................... 64
MENEST............................. 109
MENHIBRIX ...................... 117
MENOMUNE-A-C-Y-W-135
......................................... 117
MENOPUR ......................... 111
MENOSTAR....................... 109
MENTAX ............................. 35
MENVEO A-C-Y-W-135-DIP
......................................... 117
meperidine hcl ....................... 11
MEPHYTON ...................... 130
meprobamate....................... 120
MEPRON .............................. 41
mercaptopurine ..................... 23
mesalamine ......................... 118
MESNEX ............................ 120
MESTINON ................ 120, 121
METADATE CD .................. 60
METADATE ER .................. 60
metaproterenol sulfate ........ 126
metaxalone .......................... 127
METER-CHECK .................. 90
metformin hcl ........................ 31
methadone hcl ....................... 11
METHADOSE ...................... 13
methamphetamine hcl ........... 59
methazolamide .................... 123
methen/m-blue/sal/na phos/hyos
........................................... 18
methen/sod phos/meth blue/hyos
........................................... 18
methenam/me blue/ba/salicy/
hyo ..................................... 18
methenamine hippurate ......... 19
methenamine mandelate........ 19
methimazole ........................ 113
METHITEST ...................... 107
methocarbamol ................... 127
methotrexate sodium ............. 23
methotrexate sodium/pf ......... 23
methoxsalen, rapid ................ 66
methscopolamine bromide .. 104
methyclothiazide ................... 56
methyl salicylate.................... 14
methyldopa ............................ 50
methyldopa/
hydrochlorothiazide .......... 50
methylergonovine maleate .. 120
METHYLIN .......................... 60
methylphenidate hcl .............. 59
methylprednisolone ............. 109
METHYLTESTOSTERONE
MICRONIZED ............... 107
metipranolol ........................ 123
metoclopramide hcl ............. 104
METOCLOPRAMIDE HCL
INTENSOL ..................... 105
metolazone ............................ 56
METOPIRONE ................... 110
metoprolol succinate ............. 53
metoprolol tartrate ................ 53
metoprolol/hydrochlorothiazide
........................................... 53
METOZOLV ODT ............. 105
METROCREAM .................. 71
METROGEL ................... 70, 71
METROGEL-VAGINAL ..... 38
METROLOTION .................. 71
metronidazole ............ 37, 40, 70
METRONIDAZOLE
BENZOATE ..................... 40
METVIXIA ........................... 68
MEVACOR........................... 57
mexiletine hcl ........................ 53
MIACALCIN ...................... 119
MICARDIS ........................... 51
MICARDIS HCT .................. 51
miconazole nitrate ................. 34
MICRO ........................... 90, 91
MICRO THIN LANCETS .... 90
MICROCHAMBER .............. 79
MICRODOT ................... 90, 91
MICRODOT XTRA ............. 90
MICRO-K ........................... 124
MICROLET .......................... 79
MICROLET 2 ....................... 79
MICROSPACER .................. 79
MICROTAINER LANCETS 79
MICROZIDE ........................ 56
MIDAMOR ........................... 56
midazolam hcl ....................... 17
midodrine hcl ........................ 50
MIFEPREX ......................... 122
MIGERGOT ......................... 38
MIGRANAL ......................... 38
MILLIPRED ....................... 110
MILLIPRED DP ................. 110
MILTOWN ......................... 121
MINASTRIN 24 FE .............. 61
MINI LANCING DEVICE ... 91
MINIPRESS .......................... 51
MINIVELLE ....................... 109
MINOCIN ............................. 22
minocycline hcl ..................... 22
minoxidil ............................... 58
MIRAPEX............................. 41
MIRAPEX ER ...................... 41
MIRCETTE........................... 61
MIRENA ............................... 61
mirtazapine ........................... 30
I-18
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
MIRVASO ............................ 68
misoprostol.......................... 102
MITIGARE ......................... 121
M-M-R II VACCINE .......... 117
MOBAN ................................ 43
MOBIC ................................. 15
modafinil ............................. 128
MODERIBA ......................... 47
MODICON ........................... 61
moexipril hcl ......................... 52
moexipril/hydrochlorothiazide
........................................... 52
mometasone furoate .............. 72
MOMEXIN ........................... 73
MONAGHAN Z STAT ........ 79
MONISTAT-DERM ............. 35
MONODOX .......................... 22
MONOKET........................... 58
MONOLET LANCETS ........ 79
MONOLET THIN LANCETS
........................................... 91
montelukast sodium ............. 125
MONUROL .......................... 19
MORGIDOX......................... 22
morphine sulfate.................... 11
MORPHINE SULFATE ....... 11
MOTOFEN ......................... 105
MOUTHPIECE ..................... 79
MOVIPREP ........................ 105
MOXATAG .......................... 21
MOXEZA ............................. 99
moxifloxacin hcl .................... 21
MS CONTIN ......................... 13
MSIR ..................................... 13
mth/me blue/sod phos/phen/
hyos ................................... 19
MULTAQ ............................. 53
MULTI-LANCET DEVICE . 79
mupirocin .............................. 70
mupirocin calcium ................ 70
MUSE ................................. 129
MYALEPT .......................... 122
MYAMBUTOL .................... 39
MYCELEX ........................... 35
MYCOBUTIN ...................... 39
mycophenolate mofetil ........ 114
mycophenolate sodium ........ 114
MYDFRIN ............................ 98
MYDRIACYL ...................... 98
MYFORTIC ........................ 114
MYGLUCOHEALTH .......... 91
MYGLUCOHEALTH
CONTROL SOLUTION ... 79
MYGLUCOHEALTH
LANCETS......................... 79
MYLERAN ........................... 24
MYRBETRIQ ..................... 106
MYSOLINE .......................... 28
MYTELASE ....................... 121
nabumetone ........................... 14
nadolol .................................. 53
nadolol/bendroflumethiazide 53
NAFTIN ................................ 35
NALFON .............................. 15
nalidixic acid ......................... 21
naltrexone hcl........................ 16
NAMENDA .......................... 29
NAMENDA XR.................... 29
naphazoline hcl ..................... 97
naphazoline hcl/antazoline ... 97
NAPRELAN ......................... 15
NAPRELAN CR DOSE CARD
........................................... 15
NAPROSYN ......................... 15
naproxen ............................... 14
naproxen sodium ................... 14
naratriptan hcl ...................... 38
NARDIL ............................... 31
NASACORT AQ ................ 101
NASCOBAL ....................... 130
NASONEX ......................... 101
NATACYN ........................... 99
NATAZIA ............................. 61
nateglinide............................. 31
NATROBA ........................... 75
NATURETIN-5 .................... 56
NAVANE .............................. 43
NEBUPENT .......................... 40
NEBUSAL .......................... 127
needles, insulin disp., safety .. 79
needles, insulin disposable.... 79
nefazodone hcl ...................... 30
NEGGRAM .......................... 21
neo/polymyx b sulf/dexameth 98
NEOBENZ MICRO .............. 68
neomy sulf/bacitra/polymyxin b
........................................... 99
neomy sulf/bacitrac zn/poly/hc
........................................... 99
neomy sulf/polymyxin b sulfate
........................................... 70
neomycin sulfate.................... 18
neomycin sulfate/dex na ph ... 99
neomycin/polymyxin b sulf/hc 99
neomycin/polymyxn b/
gramicidin ......................... 99
NEO-POLYCIN .................... 99
NEORAL ............................ 114
NEOSPORIN ...................... 100
NEO-SYNALAR .................. 71
NEPHROCAPS QT ............ 130
NEPTAZANE ..................... 123
NESINA ................................ 32
NESSI SPACER ................... 79
NEULASTA ......................... 48
NEUMEGA........................... 48
NEUPOGEN ......................... 48
NEUPRO............................... 41
NEURONTIN ....................... 28
NEUTEK 2TEK TEST STRIPS
........................................... 91
NEVANAC ......................... 101
nevirapine ............................. 44
NEXAVAR ........................... 24
NEXIUM............................. 103
NEXIUM 24HR .................. 103
niacin..................................... 57
NIASPAN ............................. 57
nicardipine hcl ...................... 55
I-19
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
nicotine.................................. 17
nicotine polacrilex ................ 17
NICOTROL .......................... 17
NICOTROL NS .................... 17
nifedipine............................... 55
NILANDRON ....................... 24
nimodipine............................. 55
NIMOTOP ............................ 56
NIRAVAM ........................... 18
nisoldipine ............................. 55
NITRO-BID .......................... 58
NITRO-DUR......................... 58
nitrofurantoin ........................ 19
nitrofurantoin macrocrystal .. 19
nitrofurantoin monohyd/m-cryst
........................................... 19
nitroglycerin .......................... 58
NITROLINGUAL................. 58
NITROMIST ......................... 58
NITROSTAT ........................ 58
nizatidine ............................. 102
NIZORAL ............................. 35
NOLVADEX ........................ 26
nonoxynol 9 ........................... 61
NORCO................................. 13
NORDETTE-28 .................... 61
NORDITROPIN FLEXPRO112
NORDITROPIN NORDIFLEX
......................................... 112
norelgestromin/ethin.estradiol
........................................... 61
noreth-ethinyl estradiol/iron . 61
norethindrone........................ 61
norethindrone acetate ......... 113
norethindrone ac-eth estradiol
................................... 61, 108
norethindrone-e.estradiol-iron
........................................... 61
norethindrone-ethinyl estrad 61
norethindrone-mestranol ...... 61
norgestimate-ethinyl estradiol
........................................... 61
norgestrel-ethinyl estradiol ... 61
NORINYL 1+50 ................... 61
NORITATE........................... 71
NOROXIN ............................ 21
NORPACE ............................ 53
NORPACE CR...................... 53
NORPRAMIN....................... 31
NOR-Q-D .............................. 61
NORTHERA ......................... 51
nortriptyline hcl .................... 30
NORVASC ........................... 56
NORVIR ............................... 44
NOTUSS-NX ........................ 64
NOTUSS-NXD ..................... 64
NOVA MAX BLOOD
GLUCOSE METER.......... 91
NOVA MAX GLUCOSE
CONTROL SOLN ............ 91
NOVA MAX GLUCOSE TEST
STRIPS ............................. 91
NOVA SAFETY LANCETS 79
NOVA SUREFLEX .............. 91
NOVACORT ........................ 73
NOVAMAX PLUS ............... 91
NOVAMAX PLUS GLU-KET
........................................... 91
NOVAREL ......................... 112
NOVOLIN 70-30 .................. 33
NOVOLIN N ........................ 33
NOVOLIN R ......................... 33
NOVOLOG ........................... 33
NOVOLOG FLEXPEN ........ 33
NOVOLOG MIX 70-30 ........ 33
NOVOLOG MIX 70-30
FLEXPEN ......................... 33
NOXAFIL ....................... 34, 35
NUCORT .............................. 73
NUCYNTA ........................... 13
NUCYNTA ER ..................... 12
NUEDEXTA ......................... 59
NULEV ............................... 105
NULYTELY WITH FLAVOR
PACKS............................ 105
NUMORPHAN ..................... 13
NUOX ................................... 68
nut. tx for pku with iron #10.. 49
nut. tx for pku with iron #27.. 49
nut. tx for pku with iron #6.... 49
nut. tx for pku, #8 .................. 49
nutritional tx for pku #31 ...... 49
NUTROPIN ........................ 112
NUTROPIN AQ.................. 112
NUTROPIN AQ NUSPIN .. 112
NUVARING ......................... 61
NUVIGIL ............................ 128
NYDAMAX .......................... 71
nylidrin hcl ............................ 58
NYMALIZE .......................... 56
nystatin .................................. 34
NYSTATIN........................... 34
nystatin/triamcin ................... 34
octreotide acetate ................ 111
OCUDOX ............................. 22
OCUFEN............................. 101
OCUFLOX .......................... 100
OFEV .................................. 127
ofloxacin .......................... 21, 99
OGEN ................................. 109
olanzapine ............................. 42
olanzapine/fluoxetine hcl ...... 30
OLEPTRO ER ...................... 31
olopatadine hcl...................... 97
OLUX-E ................................ 73
OLYSIO ................................ 45
OMECLAMOX-PAK ......... 103
omega-3 acid ethyl esters...... 57
omega-3 fatty acids/fish oil ... 57
omeprazole .......................... 102
omeprazole/sodium bicarbonate
......................................... 102
OMNARIS .......................... 101
OMNIPRED ........................ 101
OMNITROPE ..................... 111
ON CALL EXPRESS
CONTROL SOLN ............ 91
ON CALL EXPRESS METER
........................................... 91
I-20
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
ON CALL EXPRESS TEST
STRIP ................................ 91
ON CALL LANCET............. 91
ON CALL LANCING DEVICE
........................................... 91
ON CALL PLUS CONTROL91
ON CALL PLUS LANCET .. 91
ON CALL PLUS LANCING
DEVICE ............................ 91
ON CALL PLUS METER .... 91
ON CALL PLUS TEST STRIP
........................................... 91
ON CALL VIVID CONTROL
........................................... 91
ON CALL VIVID METER .. 91
ON CALL VIVID PAL ........ 91
ON CALL VIVID TEST STRIP
........................................... 91
ondansetron........................... 39
ondansetron hcl ..................... 39
ONE TOUCH DELICA ........ 91
ONE TOUCH GLUCOSE
CONTROL SOLN ............ 91
ONE TOUCH LANCETS..... 91
ONE TOUCH SURESOFT... 91
ONE TOUCH ULTRA 2 ...... 91
ONE TOUCH ULTRA
CONTROL SOLN ............ 91
ONE TOUCH ULTRA
SYSTEM ........................... 91
ONE TOUCH ULTRA TEST
STRIPS ............................. 91
ONE TOUCH ULTRALINK 91
ONE TOUCH ULTRAMINI 91
ONE TOUCH VERIO .......... 92
ONE TOUCH VERIO IQ ..... 92
ONE TOUCH VERIO SYNC92
ONE WAY MOUTHPIECE . 79
ONETOUCH FINEPOINT
LANCETS......................... 79
ONEXTON ........................... 71
ONFI ..................................... 18
ONGLYZA ........................... 32
ONMEL ................................ 35
ONSOLIS .............................. 13
ON-THE-GO......................... 92
OPANA ................................. 13
OPANA ER ........................... 13
opium tincture ..................... 104
opium/belladonna alkaloids .. 11
OPSUMIT ........................... 130
OPTICHAMBER .................. 79
OPTIHALER ........................ 79
OPTIMYD .......................... 100
OPTIPRANOLOL .............. 123
OPTIUM ............................... 92
OPTIUM EZ ......................... 92
OPTIVAR ............................. 98
OPTUMRX ........................... 92
ORA PLUS ......................... 120
ORACEA .............................. 22
ORACIT .............................. 124
ORAFATE .......................... 121
ORALAIR ........................... 121
ORAP .................................... 43
ORAPRED .......................... 110
ORAPRED ODT................. 110
ORASEP ............................... 16
ORAVIG ............................... 35
ORBIVAN ............................ 13
ORBIVAN CF ...................... 13
ORENCIA ........................... 115
ORENITRAM ER ............... 130
ORFADIN ............................. 96
orphenadrine citrate ........... 127
orphenadrine/aspirin/caffeine
......................................... 127
ORTHO ALL-FLEX ............. 61
ORTHO EVRA ..................... 61
ORTHO MICRONOR .......... 61
ORTHO TRI-CYCLEN ........ 61
ORTHO TRI-CYCLEN LO .. 61
ORTHO-CEPT ...................... 61
ORTHO-CYCLEN ............... 61
ORTHO-NOVUM ................ 61
OSENI ................................... 32
OSMOPREP ....................... 105
OSPHENA .......................... 108
OTEZLA ............................. 122
OTICIN ................................. 98
OTICIN HC ................ 100, 101
OTOZIN .............................. 100
OTREXUP .......................... 121
OVACE PLUS ................ 68, 71
OVACE PLUS WASH ......... 68
OVCON-35 ........................... 61
OVIDE .................................. 75
OVIDREL ........................... 112
OXALIS ................................ 68
OXANDRIN ....................... 108
oxandrolone ........................ 107
oxaprozin............................... 14
oxazepam............................... 18
oxcarbazepine ....................... 27
OXECTA .............................. 13
OXISTAT ............................. 35
OXSORALEN ...................... 66
OXSORALEN-ULTRA ........ 68
OXTELLAR XR ................... 28
oxybenzone/octinox/h-quinone
........................................... 66
oxybutynin chloride ............. 106
oxycodone hcl........................ 11
oxycodone hcl/acetaminophen
........................................... 11
oxycodone hcl/aspirin ........... 11
OXYCONTIN ....................... 12
oxymorphone hcl ............. 11, 13
OXYTETRACYCLINE HCL22
PACNEX............................... 68
PACNEX HP ........................ 68
PACNEX LP ......................... 68
PACNEX MX ....................... 68
PAIN EASE .......................... 68
PALGIC ................................ 37
PAMELOR ........................... 31
PAMINE ............................. 105
PAMINE FORTE................ 105
PAMINE FQ ......................... 27
I-21
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
PANCREAZE ....................... 96
PANDA MASK .................... 79
PANDEL ............................... 73
PANRETIN ........................... 66
pantoprazole sodium ........... 102
papaverine hcl ....................... 55
PARAFON FORTE DSC ... 127
PARAGARD T 380-A .......... 61
PARCOPA ............................ 41
paregoric ............................. 104
PAREMYD ........................... 98
paricalcitol .......................... 119
PARLODEL .......................... 41
PARNATE ............................ 31
paromomycin sulfate ............. 40
paroxetine hcl........................ 30
PASER .................................. 39
PATADAY ........................... 97
PATANASE .......................... 98
PATANOL ............................ 97
PAXIL ................................... 31
PAXIL CR ............................ 31
PCCA T3 SODIUM
DILUTION ..................... 113
PCCA T4 SODIUM
DILUTION ..................... 114
PCE ....................................... 20
pedi mvi no.12/sodium fluoride
......................................... 131
PEDIADERM AF ................. 35
PEDIADERM HC ................. 73
PEDIADERM TA ................. 73
PEDIAPRED....................... 110
PEDIARIX .......................... 117
PEDIATRIC MASK ............. 79
PEDIATRIC PANDA MASK
........................................... 79
PEDIPIROX-4 ...................... 35
PEDVAXHIB ..................... 117
peg 3350/na sulf,bicarb,cl/kcl
......................................... 105
PEG 3350-GRX .................. 105
PEGANONE ......................... 28
PEGASYS ............................. 46
PEGASYS PROCLICK ........ 46
PEGINTRON ........................ 46
PEGINTRON REDIPEN ...... 46
penicillin v potassium ........... 21
PENLAC ............................... 35
PENLET PLUS BLOOD
SAMPLER ........................ 79
PENNSAID ........................... 15
PENTACEL ........................ 117
PENTACEL ACTHIB
COMPONENT................ 117
PENTACEL DTAP-IPV
COMPONENT................ 117
PENTASA........................... 118
pentazocine hcl/acetaminophen
........................................... 12
pentazocine hcl/naloxone hcl 12
pentoxifylline ......................... 48
PEPCID ............................... 103
PEPCID RPD ...................... 103
p-epd tan/chlor-tan ............... 36
p-ephed hcl/chlor-mal/bell alk
........................................... 36
p-ephed hcl/codeine/guaifen . 63
PERCOCET .......................... 13
PERCODAN ......................... 13
PERCOLONE ....................... 13
PERFOROMIST ................. 126
PERIDEX .............................. 65
PERIFLEX ADVANCE ....... 49
PERIFLEX INFANT ............ 49
PERIFLEX JUNIOR ............. 49
PERIFLEX LQ PKU............. 50
perindopril erbumine ............ 52
PERIOSTAT ......................... 22
permethrin ............................. 75
perphenazine ......................... 42
perphenazine/amitriptyline hcl
........................................... 30
PERSANTINE ...................... 48
PERTZYE ............................. 96
PEXEVA ............................... 31
PHARMACIST CHOICE ..... 92
phenazopy hcl/hyoscy/butabarb
......................................... 107
phenazopyridine hcl ............ 107
phenelzine sulfate .................. 30
PHENERGAN ...................... 40
PHENEX-1 ........................... 50
PHENEX-2 ........................... 50
PHENFLU CD ...................... 64
PHENFLU CDX ................... 64
phenobarb/hyoscy/atropine/
scop ................................... 26
phenobarbital ........................ 27
PHENYLADE AMINO ACID
........................................... 50
PHENYLADE ESSENTIAL 50
PHENYLADE PHEBLOC ... 50
PHENYLADE RTD PKU 10 50
PHENYLADE60................... 50
phenylbutazone ..................... 14
phenylephrine hcl .................. 97
phenylephrine hcl/prometh hcl
........................................... 36
phenylephrine/brompheniramin
........................................... 36
phenylephrine/carbetapentan/
gg....................................... 63
phenylephrine/
chlorpheniramine .............. 36
phenylephrine/dhcodeine bt/cp
........................................... 63
phenylephrine/pyrilamine ma/
cp ....................................... 36
PHENYL-FREE 2 ................. 50
PHENYL-FREE 2HP............ 50
PHENYTEK ......................... 29
phenytoin ............................... 27
phenytoin sodium extended ... 27
PHISOHEX ........................... 71
PHLEXY-10 ......................... 50
PHOS-FLUR ......................... 65
PHOSLO ............................. 106
PHOSLYRA ....................... 106
I-22
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
PHOSPHASAL ..................... 19
PHOSPHOLINE IODIDE .. 123
phosphorus #1 ..................... 124
PHRENILIN FORTE ............ 13
PHYSICIANS EZ USE FLU
2012-13 ........................... 117
PHYSIOLYTE .................... 118
PHYSIOSOL....................... 118
PICATO ................................ 68
pilocarpine hcl .............. 65, 123
PILOPINE HS ..................... 123
pindolol ................................. 53
pioglitazone hcl ..................... 31
pioglitazone hcl/glimepiride . 31
pioglitazone hcl/metformin hcl
........................................... 31
piroxicam .............................. 14
PKU 2.................................... 49
PKU 3.................................... 49
PKU COOLER 10................. 50
PKU COOLER 15................. 49
PKU COOLER 20................. 49
PKU EASY ........................... 50
PKU EXPRESS15 ................ 49
PKU EXPRESS20 ................ 50
PKU GEL .............................. 50
PKU LOPHLEX ................... 50
PKU PERIFLEX JUNIOR
PLUS ................................. 50
PKU TRIO ............................ 50
PLACIDYL ......................... 121
PLAN B ONE-STEP............. 61
PLAQUENIL ........................ 41
PLAVIX ................................ 48
PLEGRIDY ......................... 122
PLEGRIDY PEN ................ 122
PLETAL ................................ 48
PLEXION ............................. 68
PLIAGLIS ............................. 16
PNEUMOVAX 23 .............. 117
pnv with ca,no.71/iron/fa .... 130
pnv119/iron fumarate/fa/dss 130
POCKET CHAMBER .......... 79
POCKETCHEM EZ.............. 92
podofilox ............................... 66
podophyllum resin ................. 66
POLY HIST DHC ................. 37
POLY HIST NC .................... 64
polyethylene glycol 3350..... 105
polymyxin b sulf/trimethoprim
........................................... 99
POLYTRIM ........................ 100
POLY-TUSSIN DHC ........... 64
POLY-TUSSIN EX .............. 64
POMALYST ......................... 24
PONSTEL ............................. 15
PONTOCAINE ..................... 16
pot chloride/pot bicarb/cit ac
......................................... 124
POTABA............................. 121
potassium bicarbonate/cit ac
......................................... 124
potassium chloride .............. 124
potassium citrate ................. 124
potassium citrate/citric acid 124
potassium gluconate............ 124
potassium hydroxide ............. 66
potassium iodide ................. 113
potassium iodide/iodine ...... 113
POTIGA ................................ 27
PRADAXA ........................... 47
PRAMCORT......................... 74
pramipexole di-hcl ................ 41
PRAMOSONE ...................... 74
PRAMOSONE E .................. 74
PRANDIMET ....................... 32
PRANDIN ............................. 32
PRAVACHOL ...................... 57
pravastatin sodium ................ 57
prazosin hcl ........................... 50
PRE-ATTACHED LTA KIT 16
PRECISION .......................... 92
PRECISION GLUCOSE
CONTROL........................ 92
PRECISION PCX ................. 92
PRECISION PCX PLUS ...... 92
PRECISION POINT OF CARE
........................................... 92
PRECISION Q-I-D ............... 92
PRECISION XTRA .............. 92
PRECOSE ............................. 32
PRED FORTE ..................... 101
PRED MILD ....................... 101
PRED-G .............................. 100
prednicarbate ........................ 72
prednisolone........................ 110
prednisolone acetate ........... 100
prednisolone sod phosphate100,
110
prednisone ........................... 110
PREDNISONE INTENSOL 110
PREFEST ............................ 109
PREGNYL .......................... 111
PREMARIN ........................ 108
PREMIUM BLOOD
GLUCOSE ........................ 92
PREMIUM BLOOD
GLUCOSE TEST.............. 92
PREMIUM V10 .................... 92
PREMPHASE ..................... 109
PREMPRO .......................... 109
PREPOPIK .......................... 105
PRESSURE ACTIVATED
LANCETS......................... 80
PRESTIGE SMART SYSTEM
........................................... 92
PRESTO PRO ....................... 92
PREVACID................. 102, 103
PREVACID 24HR .............. 103
PREVIDENT ........................ 65
PREVIDENT 5000 PLUS .... 65
PREVIDENT 5000
SENSITIVE ...................... 65
PREVNAR 13 ..................... 117
PREVPAC........................... 103
PREZISTA ............................ 44
PRIFTIN ............................... 39
PRILOSEC .......................... 103
PRIMAQUINE ..................... 40
I-23
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
PRIMEAIRE ......................... 80
primidone .............................. 27
PRIMLEV ............................. 13
PRIMSOL ............................. 19
PRINIVIL ............................. 52
PRINZIDE ............................ 52
PRISTIQ ER ......................... 31
PROAIR HFA ..................... 126
PROAMATINE .............. 50, 51
PRO-BANTHINE ................. 27
probenecid........................... 120
procainamide hcl .................. 53
PROCARDIA ....................... 56
PROCARDIA XL ................. 56
PROCENTRA ....................... 60
PROCHAMBER ................... 80
PROCHIEVE ...................... 113
prochlorperazine maleate ..... 39
PROCORT ............................ 74
PROCRIT .............................. 48
PROCTOCORT .................... 74
PROCTOCREAM-HC.......... 74
PROCTOFOAM-HC ............ 72
PROCYSBI ......................... 122
PRODIGY ............................. 92
PRODIGY AUTOCODE ...... 92
PRODIGY AUTOCODE PRO
........................................... 92
PRODIGY CONTROL
SOLUTION....................... 92
PRODIGY LANCETS .......... 80
PRODIGY LANCING
DEVICE ............................ 80
PRODIGY NO CODING ..... 92
PRODIGY POCKET ............ 92
PRODIGY POCKET PRO ... 92
PRODIGY TWIST TOP
LANCET ........................... 80
PRODIGY VOICE................ 92
PRODIGY VOICE PRO ....... 92
PRODRIN ............................. 38
progesterone ....................... 113
PROGESTERONE ............. 113
PROGESTERONE
MICRONIZED ............... 113
progesterone,micronized ..... 113
PROGLYCEM ...................... 59
PROGRAF .................. 114, 115
PROLENSA ........................ 101
PROLIA .............................. 119
PROMACTA ........................ 48
promethazine hcl ............. 36, 39
promethazine hcl/codeine ..... 63
promethazine/phenyleph/
codeine .............................. 63
PROMETRIUM .................. 113
PRONESTYL ....................... 53
propafenone hcl .................... 53
propantheline bromide .......... 27
proparacaine hcl ................... 97
proparacaine/fluorescein sod 97
propranolol hcl ..................... 53
propranolol/hydrochlorothiazid
........................................... 53
propylthiouracil .................. 113
PROQUAD ......................... 117
PROSCAR .......................... 121
PROSED-DS ......................... 19
PROSTIGMIN .................... 120
PROTID ................................ 37
PROTONIX ................ 102, 103
PROTOPIC ........................... 72
protriptyline hcl .................... 30
PROVENTIL HFA ............. 126
PROVERA .......................... 113
PROVIGIL .......................... 128
PROZAC ............................... 31
PROZAC WEEKLY ............. 31
PRUDOXIN .......................... 68
pseudoephed/hydrocodone/cpm
........................................... 64
pseudoephedrine hcl/codeine 63
PULMICORT ..................... 125
PULMICORT FLEXHALER
......................................... 125
PULMOSAL ....................... 127
PULMOZYME ..................... 96
PURALOR CI ..................... 130
PURINETHOL ..................... 26
PURIXAN ............................. 24
PYLERA ............................. 105
pyrazinamide ......................... 39
pyridostigmine bromide ...... 120
PYRIL D ............................... 37
PYROGALLIC ACID .......... 68
QNASL ............................... 101
QUALAQUIN....................... 41
QUARTETTE ....................... 61
quazepam .............................. 18
QUDEXY XR ....................... 29
QUESTRAN ......................... 57
quetiapine fumarate .............. 42
QUIC-K............................... 124
QUILLIVANT XR................ 59
quinapril hcl .......................... 52
quinapril/hydrochlorothiazide
........................................... 52
quinidine gluconate ............... 53
quinidine sulfate .................... 53
quinine sulfate ....................... 40
QUINTET ............................. 93
QUINTET AC ....................... 93
QUIXIN .............................. 100
QVAR ................................. 125
RABAVERT ....................... 117
rabeprazole sodium ............. 102
RAGWITEK ....................... 121
raloxifene hcl ...................... 109
ramipril ................................. 52
RANEXA .............................. 55
ranitidine hcl ....................... 102
RAPAFLO .......................... 107
RAPAMUNE ...................... 114
RASUVO ............................ 121
RAVICTI ............................ 105
RAYOS ............................... 110
RAZADYNE......................... 29
RAZADYNE ER .................. 29
REA LO 39 ........................... 68
I-24
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
REA LO 40 ........................... 68
REBETOL............................. 47
REBIF ................................. 122
REBIF REBIDOSE ............. 122
RECOMBIVAX HB ........... 117
RECTACORT-HC ................ 74
RECTIV .............................. 121
REDERM .............................. 74
REFUAH PLUS .................... 93
REFUAH PLUS GLUCOSE
CONTROL........................ 93
REGIMEX ............................ 60
REGLAN ............................ 105
REGRANEX ......................... 66
RELAGARD ......................... 38
RELAGESIC......................... 13
RELENZA ............................ 45
RELIAMED .......................... 93
RELIAMED MINI LANCING
DEVICE ............................ 93
RELIAMED SAFETY SEAL
LANCETS......................... 93
RELION CONFIRM ............. 93
RELION CONFIRM-MICRO
........................................... 93
RELION MICRO .................. 93
RELION PRIME ................... 93
RELION PRIME TEST
STRIPS ............................. 93
RELION THIN ..................... 93
RELISTOR ......................... 105
RELPAX ............................... 39
REMERON ........................... 31
RENACIDIN....................... 118
RENAGEL .......................... 106
RENEW ADVANCED
LANCING SYSTEM ........ 80
RENEW ADVANCED
MICRO-LANCETS .......... 80
RENVELA .......................... 106
repaglinide ............................ 31
REPRONEX ....................... 111
REQUIP ................................ 41
REQUIP XL .......................... 41
RESCRIPTOR ...................... 44
RESCULA .......................... 123
RESECTISOL ..................... 119
reserpine ............................... 55
reserpine/hydrochlorothiazide
........................................... 55
RESTASIS .......................... 101
RESTORIL ........................... 18
RETIN-A............................... 75
RETIN-A MICRO ................ 74
RETIN-A MICRO PUMP .... 74
RETROVIR........................... 45
REVATIO ........................... 130
REVEAL BLOOD GLUCOSE
METER ............................. 93
REVEAL TEST STRIP ........ 93
REVIA .................................. 16
REVLIMID ........................... 24
REYATAZ ............................ 44
REZIRA ................................ 63
RHEUMATREX ................... 26
RHINOCORT AQUA ......... 101
RIAX ..................................... 68
RIBATAB ............................. 47
ribavirin ................................ 47
RICOBID .............................. 37
RICOBID-H .......................... 37
RIDAURA .......................... 114
rifabutin................................. 39
RIFADIN .............................. 39
RIFAMATE .......................... 39
rifampin ................................. 39
rifampin/isoniazid ................. 39
RIFATER .............................. 39
RIGHTEST CONTROL
SOLUTION....................... 93
RIGHTEST GC250S
CONTROL SOLN ............ 93
RIGHTEST GD500 .............. 80
RIGHTEST GL300 LANCETS
........................................... 80
RIGHTEST GM100 SYSTEM
........................................... 93
RIGHTEST GM250S METER
........................................... 93
RIGHTEST GM260 METER 93
RIGHTEST GM300 SYSTEM
........................................... 93
RIGHTEST GM550 SYSTEM
........................................... 93
RIGHTEST GS100 TEST
STRIPS ............................. 93
RIGHTEST GS250S TEST
STRIPS ............................. 93
RIGHTEST GS260 TEST
STRIPS ............................. 93
RIGHTEST GS300 TEST
STRIPS ............................. 93
RIGHTEST GS550 TEST
STRIPS ............................. 93
RIGHTSOURCE................... 93
RILUTEK ............................. 60
riluzole .................................. 59
RIMACTANE ....................... 39
rimantadine hcl ..................... 45
ringers solution ................... 118
RIOMET ............................... 32
risedronate sodium.............. 119
RISPERDAL ................... 43, 44
RISPERDAL CONSTA ........ 43
RISPERDAL M-TAB ........... 43
risperidone ............................ 42
RITALIN............................... 60
RITALIN LA ........................ 60
RITALIN-SR ........................ 60
RITEFLO .............................. 80
rivastigmine tartrate ............. 29
rizatriptan benzoate .............. 38
ROBAXIN .......................... 127
ROBAXIN-750 ................... 127
ROBINUL ........................... 105
ROBINUL FORTE ............. 105
ROCALTROL..................... 119
ropinirole hcl ........................ 41
I-25
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
ROSADAN ........................... 71
ROSANIL ............................. 69
ROTARIX ........................... 117
ROTATEQ .......................... 117
ROWASA ........................... 118
ROXICODONE .................... 13
ROZEREM ......................... 128
RU-TUSS DM ...................... 64
RYBIX ODT ......................... 13
RYTHMOL ........................... 53
RYTHMOL SR ..................... 53
RYZOLT ............................... 13
SABRIL ................................ 29
SAFE-CLIP ........................... 80
SAFETY LANCETS ............ 80
SAFETY SEAL LANCETS . 80
SAFETY-LET ....................... 80
SAFYRAL ............................ 62
SAIZEN .............................. 112
SALACYN ............................ 69
SALAGEN ............................ 65
sal-amide/acetaminophn/p-tlox
........................................... 12
SALEX .................................. 69
salicylic acid ......................... 66
salicylic acid/ammon lact/aloe
........................................... 66
salicylic acid/ceramide cmb #1
........................................... 66
SALKERA ............................ 69
salsalate ................................ 14
SALURON ............................ 56
SALVAX DUO PLUS .......... 69
SAMSCA .............................. 56
SANCTURA ....................... 106
SANCTURA XR ................ 106
SANCUSO ............................ 40
SANDIMMUNE ................. 114
SANDOSTATIN................. 112
SANDOSTATIN LAR........ 111
SANTYL ............................... 66
SAPHRIS .............................. 44
SARAFEM ............................ 31
SAVELLA ............................ 59
SCALACORT ....................... 74
SCALACORT DK ................ 74
scopolamine hydrobromide... 39
SEASONIQUE ..................... 62
SECONAL SODIUM ......... 128
SECTRAL ............................. 54
selegiline hcl ......................... 41
selenium sulfide..................... 70
SELZENTRY ........................ 45
SEMPREX-D ........................ 37
SENSIPAR .......................... 121
SEPTRA................................ 22
SEPTRA DS.......................... 22
SEREVENT DISKUS ......... 126
SEROMYCIN ....................... 39
SEROPHENE ..................... 109
SEROQUEL.......................... 44
SEROQUEL XR ................... 43
SEROSTIM ......................... 112
sertraline hcl ......................... 30
sevelamer carbonate ........... 106
SEVEN PLUS ....................... 93
SEVEN SYSTEM SENSOR. 93
SHOHL'S MODIFIED ........ 124
SIDEKICK ............................ 93
SIDESTREAM PEDIATRIC 80
SIGNIFOR .......................... 122
sildenafil citrate .................. 130
SILENOR .............................. 31
SILVADENE ........................ 71
silver nitrate .......................... 70
silver nitrate applicator ........ 66
silver sulfadiazine ................. 70
SIMBRINZA....................... 123
SIMCOR ............................... 57
SIMPONI ............................ 122
simvastatin ............................ 57
SINEMET 10-100 ................. 41
SINEMET 25-100 ................. 41
SINEMET 25-250 ................. 42
SINEMET CR ....................... 42
SINGLE USE EZ FLU 20122013................................. 117
SINGLE USE EZ FLU 20132014................................. 117
SINGLE-LET ........................ 80
SINGULAIR ....................... 125
sirolimus.............................. 114
SIRTURO ............................. 39
SITAVIG............................... 46
SIVEXTRO ........................... 19
SKELAXIN......................... 127
SKELID .............................. 119
SKLICE................................. 75
SKYLA ................................. 62
SLOFED 60 .......................... 37
SMART CARESENS N ....... 93
SMART SENSE.................... 80
SMART SENSE LANCETS. 80
SMART SENSE
MONITORING SYSTEM 93
SMART SENSE TEST STRIPS
........................................... 94
SMARTDIABETES
VANTAGE ....................... 80
SMARTDIABETES XPRES 94
SMARTEST.......................... 94
SMARTEST EJECT ............. 94
SMARTEST LANCET ......... 80
SMARTEST PERSONA ...... 94
SMARTEST PRONTO......... 94
SMARTEST PROTEGE....... 94
SMARTEST SMART CODE 94
SMARTEST TALKING ....... 94
SMARTEST TEST ............... 94
SMS GLUCOSE CONTROL 94
sod propion/inositol/aa14/urea
........................................... 37
sod/pot/k cit/sod cit/cit acid 124
sodium chloride for inhalation
......................................... 126
sodium chloride irrig solution
......................................... 118
I-26
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
sodium chloride/nahco3/kcl/peg
......................................... 105
sodium fluoride ..... 65, 130, 131
sodium polystyrene sulfonate
......................................... 106
sodium thiosulfate/sal acid ... 66
SOF-SENSOR....................... 94
SOFT TOUCH ...................... 80
SOFTCLIX ........................... 80
SOLARAZE .......................... 15
SOLODYN ........................... 22
SOLTAMOX ........................ 26
SOLU-CORTEF ................. 110
SOLUS V2 ............................ 94
SOLUS V2 CONTROL
SOLUTION....................... 94
SOLUS V2 LANCETS ......... 80
SOLUS V2 LANCING
DEVICE ............................ 80
SOLUS V2 TEST STRIPS ... 94
SOMA ................................. 128
SOMATULINE DEPOT ..... 111
SOMAVERT....................... 112
SONATA ............................ 128
SOOLANTRA ...................... 75
sorbitol solution .................. 118
SORIATANE ........................ 69
SORILUX ............................. 69
sotalol hcl .............................. 53
SOVALDI ............................. 45
SPACE CHAMBER PLUS .. 80
SPECTRACEF...................... 20
spinosad ................................ 75
SPIRIVA ............................. 126
SPIRIVA RESPIMAT ........ 126
spironolact/hydrochlorothiazid
........................................... 58
spironolactone....................... 58
SPORANOX ................... 34, 35
SPRAY AND STRETCH ..... 69
SPRIX ................................... 15
SPRYCEL ............................. 25
SS 10-2 .................................. 71
STAGESIC-10 ...................... 13
STAHIST .............................. 37
STALEVO 100 ..................... 42
STALEVO 125 ..................... 42
STALEVO 150 ..................... 42
STALEVO 200 ..................... 42
STALEVO 50 ....................... 42
STALEVO 75 ....................... 42
stannous fluoride................... 65
STARLIX .............................. 32
STATUSS GREEN ............... 64
stavudine ............................... 44
STAVZOR ............................ 29
STAXYN ............................ 129
STELARA........................... 123
STENDRA .......................... 129
STERILANCE TL ................ 80
STIMATE ........................... 110
STIVARGA .......................... 25
STRATTERA ....................... 59
STRIANT ............................ 108
STRIBILD............................. 45
STRIVERDI RESPIMAT ... 126
STROMECTOL .................... 41
SUBOXONE ......................... 16
SUBSYS ............................... 13
SUCLEAR .......................... 106
SUCRAID ............................. 97
sucralfate............................. 102
SULAR ................................. 56
sulfacetamide sod/sulfur/urea 66
sulfacetamide sodium 66, 70, 99
sulfacetamide sodium/sulfur . 66
sulfacetamide sodium/urea .. 66,
70
sulfacetamide/prednisolone sp
........................................... 99
sulfacetm na/avobenzone/sulfur
........................................... 66
sulfadiazine ........................... 21
sulfamethoxazole/trimethoprim
........................................... 21
SULFAMYLON ............. 67, 69
sulfasalazine.......................... 22
sulindac ................................. 15
SUMADAN .......................... 69
sumatriptan ........................... 38
sumatriptan succinate ........... 38
SUMAVEL DOSEPRO ........ 39
SUMAXIN ............................ 69
SUMAXIN TS ...................... 69
SUPER THIN LANCETS .... 80
SUPRAX ............................... 20
SUPREP .............................. 106
SURE COMFORT LANCETS
........................................... 80
SURE COMFORT LANCING
PEN ................................... 80
SURE EDGE BLOOD
GLUCOSE METER.......... 94
SURE EDGE GLUCOSE
CONTROL SOLN ............ 94
SURE EDGE TEST STRIPS 94
SURECHEK GLUCOSE
CONTROL........................ 94
SURECHEK TEST STRIPS . 94
SUREFLEX .......................... 80
SURE-LANCE ...................... 80
SURE-PEN ........................... 80
SURESTEP CONTROL
SOLUTION....................... 94
SURESTEP PRO .................. 94
SURE-TEST EASYPLUS
MINI ................................. 94
SURE-TOUCH ..................... 80
SURMONTIL ....................... 31
SUSTIVA .............................. 45
SUTENT ............................... 25
SYLATRON ......................... 46
SYMAX .............................. 105
SYMAX-SL ........................ 105
SYMAX-SR ........................ 105
SYMBICORT ..................... 125
SYMBYAX........................... 31
SYMLIN ............................... 32
SYMLINPEN 120 ................. 32
I-27
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
SYMLINPEN 60 ................... 32
SYNALAR ............................ 74
SYNALAR TS ...................... 74
SYNALGOS-DC .................. 13
SYNAREL .......................... 122
SYNERA............................... 16
SYNTHROID ..................... 114
SYPRINE ............................ 107
syring w-ndl,disp,insul,0.3 ml 80
syring w-ndl,disp,insul,0.5 ml 81
syringe and needle,insulin,1 ml
........................................... 81
TABLOID ............................. 25
TACLONEX ................... 67, 69
tacrolimus ..................... 72, 114
TAFINLAR ........................... 25
TAGAMET ......................... 104
TAKE ACTION .................... 62
TAMBOCOR ........................ 53
TAMIFLU ............................. 45
tamoxifen citrate ................... 26
tamsulosin hcl ..................... 107
TANZEUM ........................... 32
TAPAZOLE ........................ 114
TARCEVA............................ 25
TARGRETIN ........................ 25
TARKA ................................. 52
TASIGNA ............................. 25
TASMAR .............................. 42
TAZORAC ............................ 74
TD GOLD BLOOD GLUCOSE
MONITOR ........................ 95
TD GOLD LEVEL 1
CONTROL SOL ............... 95
TD GOLD LEVEL 2
CONTROL SOL ............... 95
TD GOLD LEVEL 3
CONTROL SOL ............... 95
TD GOLD TEST STRIP ....... 95
TD GOLD VOICE GLUCOSE
MONITOR ........................ 95
TE ANATOXAL BERNA .. 117
TECFIDERA....................... 122
TECHLITE ........................... 81
TECHLITE BLOOD LANCET
........................................... 81
TECHLITE LANCETS ........ 95
TEGRETOL .......................... 29
TEGRETOL XR ................... 29
TEKAMLO ........................... 58
TEKTURNA ......................... 58
TEKTURNA HCT ................ 58
TELCARE............................. 95
TELCARE BGM .................. 95
TELCARE CONTROL
SOLUTION....................... 95
telmisartan ............................ 51
telmisartan/amlodipine ......... 51
telmisartan/hydrochlorothiazid
........................................... 51
temazepam............................. 18
TEMODAR ........................... 26
TEMOVATE......................... 74
temozolomide ........................ 23
TENCON .............................. 13
TENEX ................................. 51
TENIVAC ........................... 117
TENORETIC 100 ................. 54
TENORETIC 50 ................... 54
TENORMIN ......................... 54
TERAK ............................... 100
TERAZOL 3 ......................... 38
TERAZOL 7 ......................... 38
terazosin hcl ........................ 107
terbinafine hcl ....................... 34
TERBINEX ........................... 35
terbutaline sulfate ............... 126
terconazole ............................ 37
TERRAMYCIN WITH
POLYMYXIN................. 100
TERSI FOAM ....................... 71
TESSALON .......................... 64
TESSALON PERLE ............. 64
TEST N'GO........................... 95
TESTIM .............................. 108
testosterone ................. 107, 108
TESTOSTERONE .............. 108
testosterone cypionate ......... 107
TESTOSTERONE
CYPIONATE MICRO .... 107
testosterone enanthate ........ 107
TESTOSTERONE
ENANTHATE ................ 108
TESTOSTERONE
PROPIONATE ................ 108
TESTRED ........................... 108
TETANUS DIPHTHERIA
TOXOIDS ....................... 117
TETANUS TOXOID
ADSORBED ................... 117
TETCAINE ........................... 98
tetracaine/benzocaine/
butamben ........................... 66
tetracycline hcl ...................... 22
TETRACYCLINE HCL ....... 22
TETRAVISC FORTE ........... 98
TEVETEN............................. 51
TEVETEN HCT.................... 51
TEV-TROPIN ..................... 112
TEXACORT ......................... 74
THALITONE ........................ 56
THALOMID ....................... 121
THEO-24............................. 126
theophylline anhydrous ....... 126
THERACYS ....................... 117
THERMAZENE ................... 71
THIN LANCETS .................. 95
THIOLA .............................. 121
thioridazine hcl ..................... 43
thiothixene ............................. 43
thrombin (bovine).................. 48
thyroid,pork......................... 113
THYROLAR-1 ................... 114
THYROLAR-1/2 ................ 114
THYROLAR-1/4 ................ 114
THYROLAR-2 ................... 114
THYROLAR-3 ................... 114
tiagabine hcl.......................... 27
TIAZAC ................................ 54
I-28
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
ticlopidine hcl........................ 48
TIGAN .................................. 40
TIKOSYN ............................. 53
timolol maleate.............. 53, 123
TIMOPTIC OCUDOSE ...... 124
TIMOPTIC-XE ................... 124
TINDAMAX ......................... 41
tinidazole ............................... 40
TIROSINT .......................... 114
TIS-U-SOL ......................... 119
TIVICAY .............................. 45
tizanidine hcl ....................... 127
TOBI ..................................... 18
TOBI PODHALER ............... 18
TOBRADEX ................. 99, 100
TOBRADEX ST ................. 100
tobramycin ............................ 99
tobramycin in 0.225% nacl ... 18
tobramycin/dexamethasone... 99
TOBREX....................... 99, 100
TODAY CONTRACEPTIVE
SPONGE ........................... 62
TOFRANIL ........................... 31
TOFRANIL-PM .................... 31
tolazamide ............................. 33
tolbutamide ........................... 33
tolmetin sodium ..................... 15
tolterodine tartrate .............. 106
TOPAMAX ........................... 29
TOPCARE UNIVERSAL1
THIN LANCET ................ 81
TOPICORT ........................... 74
topiramate ............................. 27
TOPROL XL ......................... 54
TORISEL .............................. 26
torsemide ............................... 56
TOVIAZ .............................. 106
TRACLEER ........................ 130
TRADJENTA ....................... 32
tramadol hcl .......................... 12
tramadol hcl/acetaminophen 12
TRANDATE ......................... 54
trandolapril ........................... 52
tranexamic acid ..................... 48
TRANSDERM-SCOP........... 40
TRANXENE T-TAB ............ 18
tranylcypromine sulfate ........ 30
TRAVATAN Z ................... 124
travoprost (benzalkonium) .. 123
trazodone hcl ......................... 30
TRECATOR ......................... 39
TRELSTAR .......................... 26
TRENTAL ............................ 48
tretinoin ........................... 23, 74
tretinoin microspheres .......... 74
tretinoin/emollient base ........ 74
TRETIN-X ............................ 75
TREXALL ............................ 25
TREXIMET .......................... 39
TREZIX ................................ 13
triacetin ................................. 34
TRIAMCINOLONE ........... 110
triamcinolone acetonide. 65, 72,
100
TRIAMCINOLONE
DIACETATE .................. 110
triamterene/hydrochlorothiazid
........................................... 56
triazolam ............................... 18
TRIBENZOR ........................ 52
trichloroacetic acid ............... 66
TRICOR ................................ 57
TRIDERM............................. 74
TRIDESILON ....................... 74
trifluoperazine hcl ................. 43
trifluridine ............................. 99
TRIGLIDE ............................ 57
trihexyphenidyl hcl ................ 41
TRILEPTAL ......................... 29
TRILIPIX .............................. 58
trimethobenzamide hcl .......... 39
trimethoprim ......................... 19
trimipramine maleate ............ 30
TRI-NORINYL ..................... 62
TRIOXIN ............................ 101
TRIPEDIA .......................... 117
tripelennamine hcl ................ 36
TRIUMEQ ............................ 45
TRIZIVIR ............................. 45
TROKENDI XR.................... 29
tropicamide ........................... 97
trospium chloride ................ 106
TRUE METRIX .................... 95
TRUE METRIX BLOOD
GLUCOSE MTR .............. 95
TRUE METRIX GLUCOSE
TEST STRIP ..................... 95
TRUE2GO BLOOD
GLUCOSE SYSTEM ....... 95
TRUECONTROL ................. 95
TRUEDRAW ........................ 81
TRUEPLUS LANCETS ....... 81
TRUERESULT BLOOD
GLUCOSE SYSTM .......... 95
TRUETEST GLUCOSE
CONTROL........................ 95
TRUETEST TEST STRIPS .. 95
TRUETRACK....................... 95
TRUETRACK BLOOD
GLUCOSE SYSTEM ....... 95
TRUETRACK SMART
SYSTEM ........................... 95
TRUETRACK TEST STRIP 95
TRULICITY ......................... 32
TRUMENBA ...................... 117
TRUSOPT ........................... 124
TRUVADA ........................... 45
TUDORZA PRESSAIR ...... 126
TUSNEL ............................... 64
TUSNEL PEDIATRIC ......... 64
TUSSICAPS ......................... 64
TUSSIGON ........................... 64
TUSSIONEX ........................ 64
TUSSI-PRES PEDIATRIC ... 64
TWINJECT ........................... 55
TWINRIX ........................... 117
TWYNSTA ........................... 52
TYBOST ............................. 121
TYKERB............................... 25
I-29
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
TYLENOL-CODEINE NO.3 13
TYLENOL-CODEINE NO.4 13
TYLOX ................................. 13
TYPHIM VI ........................ 117
TYZEKA............................... 47
TYZINE ................................ 98
UCEPHAN .......................... 105
UCERIS .............................. 118
ULESFIA ............................ 121
ULORIC .............................. 121
ULTICARE ........................... 81
ULTI-LANCE ....................... 81
ULTILET BASIC ................. 81
ULTILET CLASSIC ............. 81
ULTILET LANCETS ........... 81
ULTILET SAFETY .............. 81
ULTIMA ............................... 95
ULTRA THIN LANCETS .... 81
ULTRA THIN PLUS ............ 81
ULTRA THIN PLUS
LANCETS......................... 81
ULTRACET .......................... 13
ULTRALANCE .................... 81
ULTRAM .............................. 13
ULTRAM ER........................ 13
ULTRASAL-ER ................... 69
ULTRA-THIN II................... 81
ULTRATLC LANCETS ....... 81
ULTRATRAK ................ 95, 96
ULTRATRAK PRO.............. 95
ULTRATRAK ULTIMATE . 95
ULTRAVATE....................... 74
ULTRAVATE PAC .............. 74
ULTRAVATE X ................... 74
ULTRESA............................. 96
UMECTA.............................. 69
UMECTA PD........................ 69
UNILET COMFORTOUCH 81
UNILET EXCELITE ............ 81
UNILET EXCELITE II ........ 81
UNILET GP LANCET ......... 81
UNILET LANCET ............... 81
UNILET LANCETS ............. 81
UNIRETIC ............................ 52
UNISTIK............................... 81
UNISTIK 2............................ 81
UNISTIK 2 EXTRA ............. 81
UNISTIK 2 NORMAL ......... 81
UNISTIK 3............................ 81
UNISTIK 3 COMFORT ....... 81
UNISTIK 3 EXTRA ............. 81
UNISTIK 3 NEONATAL ..... 81
UNISTIK CZT ...................... 81
UNISTRIP............................. 96
UNISTRIP1........................... 96
UNITHROID ...................... 114
UNIVASC ............................. 52
UNIVERSAL 1 ..................... 81
URAMAXIN......................... 69
URAMAXIN GT .................. 69
urea ....................................... 66
urea/hyaluronate sodium ...... 66
urea/lactic ac/zn undecylenate
........................................... 66
URECHOLINE ................... 121
URELLE ............................... 19
URETRON D-S .................... 19
UREX.................................... 19
URIBEL ................................ 19
URIN D.S. ............................. 19
UROCIT-K ......................... 124
UROLOGIC SOLUTION G 119
UROQID-ACID NO.2 .......... 19
UROXATRAL .................... 107
URSO .................................. 105
URSO FORTE .................... 105
ursodiol ............................... 104
URYL.................................... 19
UTA ...................................... 19
UTIRA-C .............................. 19
UTOPIC ................................ 69
VAGIFEM .......................... 109
valacyclovir hcl ..................... 46
VALCHLOR ......................... 67
VALCYTE ............................ 46
valganciclovir hcl.................. 46
VALIUM............................... 18
valproic acid ......................... 27
valproic acid (as sodium salt)27
valsartan ............................... 51
valsartan/hydrochlorothiazide
........................................... 51
VALTREX ............................ 46
VANACOF CD ..................... 64
VANCOCIN HCL ................ 19
vancomycin hcl...................... 19
VANDAZOLE ...................... 37
VANDETANIB .................... 25
VANOS ................................. 74
VANOXIDE-HC................... 69
VANSPAR .......................... 121
VAQTA............................... 118
VARIVAX VACCINE ....... 118
VARIZIG ............................ 114
VASCEPA ............................ 57
VASERETIC......................... 52
VASOTEC ............................ 52
VCF ....................................... 62
VECAMYL ........................... 55
VECTICAL ........................... 69
VELPHORO ....................... 106
VELTIN ................................ 71
venlafaxine hcl ...................... 30
VENLAFAXINE HCL ER ... 31
VENTOLIN HFA ............... 126
VERAMYST....................... 101
verapamil hcl ........................ 54
VERDESO ............................ 74
VERDROCET....................... 13
VEREGEN ............................ 69
VERELAN ............................ 54
VERELAN PM ..................... 54
VERIPRED 20 .................... 110
VERSACLOZ ....................... 44
VESICARE ......................... 106
VEXOL ............................... 101
VFEND ................................. 35
VIAGRA ............................. 129
VIBRAMYCIN ..................... 22
I-30
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
VICOPROFEN ..................... 13
VICTORY ............................. 96
VICTOZA 3-PAK ................. 33
VICTRELIS .......................... 46
VIDEX .................................. 45
VIDEX EC ............................ 45
VIEKIRA PAK ..................... 46
VIGAMOX ........................... 99
VIIBRYD .............................. 30
VIMOVO .............................. 15
VIMPAT ............................... 27
VIOKACE............................. 96
VIRACEPT ........................... 45
VIRAMUNE ......................... 45
VIRAMUNE XR .................. 45
VIRASAL ............................. 69
VIRAZOLE........................... 47
VIREAD ............................... 45
VIROPTIC .......................... 100
VISICOL ............................. 106
VISTARIL .......................... 121
VITUZ................................... 64
VIVACTIL ............................ 31
VIVELLE-DOT .................. 109
VIVITROL ............................ 17
VIVOTIF BERNA .............. 118
VOCAL POINT .................... 96
VOCAL POINT GLUCOSE
CONTROL........................ 96
VOCALPOINT GLUCOSE
CONTROL........................ 96
VOGELXO ......................... 108
VOLTAREN ................. 15, 101
VOLTAREN-XR .................. 15
voriconazole .......................... 34
VORTEX .............................. 82
VORTEX FROG MASK ...... 81
VORTEX LADYBUG MASK
........................................... 82
VOSOL ............................... 100
VOSOL HC ......................... 100
VOSPIRE ER ...................... 126
VOTRIENT........................... 25
VUSION ............................... 35
VYTONE .............................. 69
VYTORIN............................. 58
VYVANSE ........................... 59
warfarin sodium .................... 47
WATCHHALER................... 82
water for irrigation,sterile .. 118
WAVESENSE AMP............. 96
WAVESENSE CONTROL
SOLUTION....................... 96
WAVESENSE JAZZ ............ 96
WAVESENSE PRESTO ...... 96
WELCHOL ........................... 58
WELLBUTRIN..................... 31
WELLBUTRIN SR ............... 31
WELLBUTRIN XL .............. 31
WESTCORT ......................... 74
WIDE SEAL DIAPHRAGM 62
XALATAN ......................... 124
XALKORI............................. 25
XANAX ................................ 18
XANAX XR.......................... 18
XARELTO ............................ 47
XARTEMIS XR.................... 13
XELJANZ ........................... 123
XELODA .............................. 26
XENAZINE .......................... 60
XENICAL ........................... 105
XERAC AC .......................... 69
XERESE ............................... 69
XGEVA............................... 120
XIFAXAN............................. 19
XIGDUO XR ........................ 33
XODOL 10-300 .................... 13
XODOL 5-300 ...................... 14
XODOL 7.5-300 ................... 14
XOLAIR ............................. 127
XOLEGEL ............................ 35
XOLOX................................. 14
XOPENEX .......................... 126
XOPENEX HFA ................. 126
XPHE MAXAMAID ............ 50
XPHE MAXAMUM ............. 50
XPRES .................................. 96
XTANDI ............................... 25
X-VIATE .............................. 69
XYLOCAINE ....................... 16
XYREM .............................. 128
XYZAL ................................. 37
YASMIN 28 .......................... 62
YAZ ...................................... 62
YF-VAX ............................. 118
YODOXIN ............................ 40
zafirlukast............................ 125
zaleplon ............................... 128
ZAMICET ............................. 14
ZANAFLEX ....................... 128
ZANTAC ............................ 104
ZANTAC 25 ....................... 104
ZARONTIN .......................... 29
ZAROXOLYN ...................... 56
ZAVESCA ............................ 96
ZEBETA ............................... 54
ZEBUTAL ............................ 14
ZEGERID ........................... 104
ZELAPAR............................. 42
ZELBORAF .......................... 25
ZEMPLAR .......................... 119
ZENCIA ................................ 69
ZENPEP ................................ 96
ZENZEDI .............................. 60
ZERIT ................................... 45
ZESTORETIC....................... 52
ZESTRIL............................... 52
ZETIA ................................... 57
ZETONNA .......................... 101
ZGESIC................................. 14
ZIAC ..................................... 54
ZIAGEN ................................ 45
ZIANA .................................. 71
zidovudine ............................. 44
zinc sulfate .......................... 124
ZIOPTAN ........................... 124
ziprasidone hcl ...................... 43
ZIPSOR ................................. 15
ZIRGAN ............................... 99
I-31
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
ZITHRANOL ........................ 69
ZITHRANOL-RR ................. 69
ZITHROMAX....................... 20
ZITHROMAX TRI-PAK ...... 20
ZMAX ................................... 20
ZOCOR ................................. 58
ZODRYL AC 25 ................... 64
ZODRYL AC 30 ................... 64
ZODRYL AC 35 ................... 64
ZODRYL AC 40 ................... 64
ZODRYL AC 50 ................... 64
ZODRYL AC 60 ................... 64
ZODRYL AC 80 ................... 64
ZOFRAN............................... 40
ZOFRAN ODT ..................... 40
ZOHYDRO ER ..................... 14
ZOLINZA ............................. 25
zolmitriptan ........................... 38
ZOLOFT ............................... 31
zolpidem tartrate ................. 128
ZOLPIMIST ........................ 128
ZOMIG ................................. 39
ZOMIG ZMT ........................ 39
ZONALON ........................... 69
ZONATUSS .......................... 64
ZONEGRAN......................... 29
zonisamide............................. 27
ZONTIVITY ......................... 48
ZORBTIVE ......................... 112
ZORTRESS......................... 114
ZORVOLEX ......................... 15
ZOSTAVAX ....................... 118
ZOTEX-GP ........................... 64
ZOVIRAX....................... 46, 69
ZUBSOLV ............................ 16
ZUPLENZ ............................. 40
ZUTRIPRO ........................... 64
ZYCLARA ............................ 69
ZYDELIG ............................. 26
ZYDONE .............................. 14
ZYFLO ................................ 125
ZYFLO CR ......................... 125
ZYKADIA ............................ 26
ZYLET ................................ 100
ZYLOPRIM ........................ 121
ZYMAR .............................. 100
ZYMAXID .......................... 100
ZYPRAM .............................. 74
ZYPREXA ............................ 44
ZYPREXA RELPREVV ...... 44
ZYPREXA ZYDIS ............... 44
ZYRTEC-D ........................... 37
ZYTAZE ............................. 121
ZYTIGA ................................ 26
ZYVOX................................. 19
I-32
EHB_Non-HSA 2015 Preferred Drug List
Formulary ID: 82107.000, Version: 1Q2015
Effective: February 01, 2015
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